Background:Clostridioides difficile infection (CDI) is a major source of morbidity and mortality. Even after recovery, recurrent CDI (rCDI) occurs frequently, and concomitant antibiotic use for treatment of a concurrent non–C. difficile infection is a major risk factor. Treatment with fidaxomicin versus vancomycin is associated with similar rate of cure and lower recurrence risk. However, the comparative efficacy of these 2 agents remains unclear in those receiving concomitant antibiotics. Methods: We conducted a randomized, controlled, open-label trial at the University of Michigan and St. Joseph Mercy hospitals in Ann Arbor, Michigan. Patients provided written informed consent at enrollment. We included all hospitalized patients aged ≥18 years with a positive test for toxigenic C. difficile, >3 unformed stools per 24 hours, and ≥1 qualifying concomitant antibiotic with a planned treatment of an infection for ≥5 days after enrollment. We excluded patients with complicated CDI, allergy to vancomycin–fidaxomicin, planned adjunctive CDI treatments, CDI treatment for >24 hours prior to enrollment, concomitant laxative use, current or planned colostomy or ileostomy, and/or planned long-term (>12 weeks) concomitant antibiotic use. Clinical cure was defined as resolution of diarrhea for 2 consecutive days maintained until the end of therapy and for 2 days afterward. rCDI was defined as recurrent diarrhea with positive testing within 30 days of initial treatment. Patients were randomized (stratified by ICU status) to fidaxomicin 200 mg twice daily or vancomycin 125 mg orally 4 times daily for 10 days. If concomitant antibiotic treatment continued >10 days, the study drug continued until the concomitant antibiotic ended. Bivariable statistics included t tests and χ2 tests. Results: After screening 5,101 patients for eligibility (May 2017–May 2021), 144 were included and randomized (Fig. 1). Study characteristics and outcomes are noted in Table 1. Baseline characteristics were similar between groups. Most patients were aged <65 years, were on a proton-pump inhibitor (PPI), and were not in the ICU. The mean duration of concomitant antibiotic was 18.4 days. In the intention-to-treat population, clinical cure (73% vs 62.9%; P =.195), and rCDI (3.3% vs 4.0%; P >.99) were similar for fidaxomicin and vancomycin, respectively. Conclusions: In this study of patients with CDI receiving a concomitant antibiotic, a numerically higher proportion were cured with fidaxomicin versus vancomycin, but this result did not reach statistical significance. Overall recurrence was lower than anticipated in both arms compared to previous studies in which duration of CDI treatment was not extended during concomitant antibiotic treatment. Future studies are needed to ascertain whether clinical cure is higher with fidaxomicin than vancomycin during concomitant antibiotic exposure, and whether extending the duration of CDI treatment reduces recurrence.

Funding: Merck & Co.

Disclosures: None

We retrospectively reviewed the records of 136 veterans with a penicillin allergy label during a quality improvement initiative. We identified 82 inpatients eligible for removal of penicillin allergy by oral amoxicillin challenge, including 40 out of 82 (48%) still eligible after accounting for other limiting factors.

Background: The IDSA recommends that when determining empiric treatment for a given patient, clinicians should consider previous organisms and associated antibiotic susceptibility data in the prior 6 months when multidrug-resistant/extended-spectrum β-lactamase gram-negative rods (MDR /ESBL GNR) is suspected. The presence of MDR GN in cultures on previous hospitalization or in surveillance cultures leads to use of broader-spectrum empiric antibiotic in subsequent admissions. We sought to determine whether the presence of an MDRO in 1 hospital admission dictates the need for broader-spectrum antibiotic use in subsequent hospitalizations when a different site is considered the source of infection. Methods: The study was conducted at a 700-bed tertiary-care level I trauma center. Infection control records were reviewed for patients aged 21–99 years admitted between July 1, 2013, through January 31, 2014, who had any ESBL or MDR GNR at any site including surveillance culture. The charts were surveyed until January 31, 2016, for ESBL or MDR gram-negative organisms at any site during subsequent hospitalizations. The CDC definition of MDR/ESBL was applied. Results: Of the 50 people followed, 34 patients (68%) had ESBL/MDR recovered at a single sentinel site, 6 patients (12%) had ESBL/MDR in multiple sites, and in 10 patients (20%) had ESBL/MDR only in surveillance cultures during their primary hospitalization. In 34 patients with a single sentinel site MDRO/ESBL in their primary hospitalization, 16 (47%) were identified in urine, 13 (38%) were identified by bronchoalveolar lavage (lung), 4 (12%) were identified on skin or MS, and 1 (3%) was identified at another site. When lung and urine were the sole sites of recovery of MDRO/ESBL in primary hospitalization, respectively, 3 patients (23%) and 2 patients (12.5%) subsequently developed MDROs in a secondary site on subsequent admissions. Overall, 10 bacteremia episodes occurred in 8 patients among 189 total admissions. MDRO/ESBL Klebsiella spp were identified in the cultures of 5 patients (50%), MDRO Acinetobacter spp were identified in the cultures of 3 patients (30%), and ESBL E. coli was identified in the cultures of 2 patients (20%). The organism causing bacteremia was present at a different sites during the same admission in only 3 (30%) of these cases: 2 were cultured from urine and 1 was cultured from a pulmonary source. Conclusions: The presence of MDRO at 1 site in a previous hospitalization may not be sufficient evidence to justify very broad antibiotics for patients during subsequent admissions, especially when another site is considered the source of infection. More studies are needed on natural history of MDRO in different patient populations with different risk factors.

Funding: None

Disclosures: None

In a prospective cohort of healthcare personnel (HCP), we measured severe acute respiratory syndrome coronavirus virus 2 (SARS-CoV-2) nucleocapsid IgG antibodies after SARS-CoV-2 infection. Among 79 HCP, 68 (86%) were seropositive 14–28 days after their positive PCR test, and 54 (77%) of 70 were seropositive at the 70–180-day follow-up. Many seropositive HCP (95%) experienced an antibody decline by the second visit.

Background: Urinalysis and urine culture are frequently ordered diagnostic tests among hospitalized patients, often for nonspecific symptoms. Diagnostic testing stewardship with urinalysis with reflex culture (UARC) is a practice shown to reduce institutional culture rates by selecting patients who are more likely to have a true infection. Optimal reflex criteria are not well established, and downstream effects, such as antibiotic use, have not been well studied. Methods: We compared outcomes in the preimplementation period (December 2018 – October 2019) and postintervention period (November 2019–October 2020) at an academic medical center. The intervention was changing the UARC reflex criteria. The primary outcomes were urine-culture rate per 1,000 patient days, urine-culture positivity, antibiotic prescription for suspected urinary tract infection (UTI) and catheter-associated urinary tract infection (CAUTI) rate per 1,000 Foley catheter days. Analysis was performed using interrupted time-series negative binomial regression or Poisson regression where appropriate. Results: We detected a significant decrease in the rate of cultures performed (32.5 cultures per 1,000 patient days before the intervention vs 8.6 cultures per 1,000 patient days after the intervention; P = 0.10). Fig. 1 summarizes these results graphically. In an adverse events analysis, of 646 patients in the postintervention period, 130 patients were reviewed for the outcome of sepsis secondary to a urinary tract infection, with only 1 patient meeting criteria for this diagnosis. Conclusions: Changing the UARC reflex criteria resulted in the expected decrease in rate of cultures performed with increase in culture positivity, and the stricter criteria appeared to more effectively identify true UTIs. Minimal adverse events were associated with the UARC criteria change, demonstrating that these criteria are also safe. We detected a significant change in antibiotic prescriptions, but much of the decrease occurred during the preintervention period, which likely reflected educational and stewardship interventions performed at that time. Although the intervention affected culture performance, which does decrease institutional costs, continued provider education is needed to influence clinical outcomes.

Funding: None

Disclosures: None

We describe severe acute respiratory coronavirus virus 2 (SARS-CoV-2) IgG seroprevalence and antigenemia among patients at a medical center in January–March 2021 using residual clinical blood samples. The overall seroprevalences were 17% by infection and 16% by vaccination. Spent or residual samples are a feasible alternative for rapidly estimating seroprevalence or monitoring trends in infection and vaccination.

Antimicrobial use during the coronavirus disease 2019 (COVID-19) pandemic at a tertiary-care center was analyzed using interrupted time-series analysis. Among intravenous antimicrobials, the use of azithromycin and third-generation cephalosporins significantly decreased during the current pandemic. Similarly, the use of oral antimicrobials, including azithromycin and fluoroquinolones, also decreased.

In many developing countries, antimicrobials are available without prescriptions in pharmacies and stores. We performed a survey to describe antimicrobial availability, training, and use recommendations for common symptoms in the Dominican Republic. Pharmacy recommendations varied, whereas aminopenicillins are routinely recommended at bodegas. Frontline staff are gatekeepers and potential targets for stewardship education.

Background: Emergency departments (EDs) are complex, sociotechnical, high-paced, safety-critical work systems that have been disproportionately affected by the COVID-19 pandemic. Despite training, consistent compliance with recommended PPE use during COVID-19 pandemic has been challenging. Healthcare workers (HCWs) have had adapt to overcome these challenges to ensure their own safety and patient safety. We sought to identify barriers in the work system that impede the recommended COVID-19 PPE use in EDs. Methods: We conducted semistructured, in-depth interviews over ZoomTM from August 2020–May 2021 with 45 HCWs from the ED (ie, physicians, nurses, ancillary support staff, etc) affiliated with a large, tertiary-care, academic medical center. These audio-recorded interviews were transcribed and analyzed using a hybrid (inductive and deductive) qualitative coding approach in NVivo software. The deductive portion was guided by the SEIPS work system model, a well-known human-factors conceptual framework. Results: We identified multiple work-system factors in the ED that impede compliance with the recommended COVID-19 PPE use. In addition, ED HCWs have reported making a variety of adaptations or developing strategies to overcome these barriers. Some of these adaptations were made to the PPE physically (eg, trimming portions of PPE), and others were related to the tasks and/or processes associated with PPE, such as filming their own training video demonstrating PPE donning and doffing techniques, and environment services staff checking a patient’s status with nurses prior to entering the patient’s room when there was no COVID-19 signage on the door. Conclusions: Consistent compliance with COVID-19 PPE use in ED clinical practice is challenging and can be negatively affected by a variety of work system factors. Resilience strategies developed by HCWs can provide critical information with regards to HCW needs and potential directions for innovation. Future efforts should focus on not only changing individual HCW behavior through training but also on improving the PPE and ED work system design.

Funding: US CDC

Disclosures: The authors gratefully acknowledge the US CDC for funding this work. This material is based upon work supported by the Naval Sea Systems Command (under contract no. N00024-13-D-6400, task order NH076). Any opinions, findings, and conclusions or recommendations expressed in this material are those of the authors and do not necessarily reflect the views of the Naval Sea Systems Command (NAVSEA) or the US CDC.

COVID-19 therapies were challenging to deploy due to evolving literature and conflicting guidelines. Antimicrobial stewardship can help optimize drug use. We conducted a survey to understand the role of stewardship and formulary restrictions during the pandemic. Restrictions for COVID-19 therapies were common and approval by infectious disease physicians often required.

Background: Blood cultures are commonly ordered for patients with low risk of bacteremia. Liberal blood-culture ordering increases the risk of false-positive results, which can lead to increased length of stay, excess antibiotics, and unnecessary diagnostic procedures. We implemented a blood-culture indication algorithm with data feedback and assessed the impact on ordering volume and percent positivity. Methods: We performed a prospective cohort study from February 2022 to November 2022 using historical controls from February 2020 to January 2022. We introduced the blood-culture algorithm (Fig. 1) in 2 adult surgical intensive care units (ICUs). Clinicians reviewed charts of eligible patients with blood cultures weekly to determine whether the blood-culture algorithm was followed. They provided feedback to the unit medical directors weekly. We defined a blood-culture event as ≥1 blood culture within 24 hours. We excluded patients aged <18 years, absolute neutrophil count <500, and heart and lung transplant recipients at the time of blood-culture review. Results: In total, 7,315 blood-culture events in the preintervention group and 2,506 blood-culture events in the postintervention group met eligibility criteria. The average monthly blood-culture rate decreased from 190 blood cultures per 1,000 patient days to 142 blood cultures per 1,000 patient days (P < .01) after the algorithm was implemented. (Fig. 2) The average monthly blood-culture positivity increased from 11.7% to 14.2% (P = .13). Average monthly days of antibiotic therapy (DOT) was lower in the postintervention period than in the preintervention period (2,200 vs 1,940; P < .01). (Fig. 3) The ICU length of stay did not change before the intervention compared to after the intervention: 10 days (IQR, 5–18) versus 10 days (IQR, 5–17; P = .63). The in-hospital mortality rate was lower during the postintervention period, but the difference was not statistically significant: 9.24% versus 8.34% (P = .17). The all-cause 30-day mortality was significantly lower during the intervention period: 11.9% versus 9.7% (P < .01). The unplanned 30-day readmission percentage was significantly lower during the intervention period (10.6% vs 7.6%; P < .01). Over the 9-month intervention, we reviewed 916 blood-culture events in 452 unique patients. Overall, 74.6% of blood cultures followed the algorithm. The most common reasons overall for ordering blood cultures were severe sepsis or septic shock (37%), isolated fever and/or leukocytosis (19%), and documenting clearance of bacteremia (15%) (Table 1). The most common indications for inappropriate blood cultures were isolated fever and/or leukocytosis (53%). Conclusions: We introduced a blood-culture algorithm with data feedback in 2 surgical ICUs and observed decreases in blood-culture volume without a negative impact on ICU LOS or mortality rate.

Disclosure: None