Background: Antimicrobial resistance (AMR) is a global public health crisis. A key strategy to combat AMR is to use targeted antibiotics, which is difficult in patients who report an allergy to penicillin. Increased risk for resistant infections, mortality, and healthcare costs are associated with penicillin allergies; however, up to 90% of those with a reported penicillin allergy do not have a true allergy. We investigated racial and ethnic differences related to penicillin allergy delabeling by analyzing rates of penicillin allergy reporting and referral for allergist consultation. Methods: Tufts Medical Center is a teaching medical center in Boston, Massachusetts. This study cohort contains all patients seen in 2019 by clinicians at Primary Care Boston, the main primary care practice at Tufts Medical Center. Demographic data, documented allergies, and referral history were collected from the electronic medical record. We performed univariate and multivariable analyses using logistic regression models. Covariates found to be statistically significant (P < .05) in the univariate analyses were included in the multivariable model. Results:In total, 2,391 (11%) patients reported a penicillin allergy, but only 249 (10%) were referred to an allergist (Table 1). Black patients and Asian patients were less likely to report a penicillin allergy than White patients. We detected no differences related to Hispanic ethnicity. Black patients with penicillin allergy were more likely to be referred to an allergist. Conclusions: There were low rates of allergist referral for penicillin allergy delabeling in this cohort. We identified racial differences in both penicillin allergy reporting and allergist referral. Allergist consultation is an important opportunity to combat AMR and should be considered for all patients reporting a penicillin allergy. Future work should evaluate equitable access to allergy delabeling resources.

Funding: None

Disclosures: None

Transmission of bacteria between animals and humans in domestic households is increasingly recognized. We evaluated the presence of antimicrobial-resistant fecal bacteria in 8 dog-owner–dog pairs before and after the dog received amoxicillin-clavulanate. The study identified shared flora in the humans and dogs that were affected by antimicrobial administration.

We describe our experience implementing an intensive quality improvement cohort pilot focused on managing asymptomatic bacteriuria in 19 critical access hospitals. Participation in the pilot was high, and almost all sites identified an improvement goal and collected clinical data. Barriers to implementation included staffing shortages, turnover, and lack of bandwidth.

Background: Nasal decolonization significantly decreases the incidence of Staphylococcus aureus surgical-site infections (SSIs). Patient adherence with self-administration of a decolonization ointment (ie, mupirocin) is low, especially among patients having urgent surgery. Povidone-iodine decolonization may overcome patient adherence challenges because povidone-iodine needs to be applied only on the day of surgery. We assessed the effectiveness and acceptability of povidone-iodine decolonization given on the day of surgery among patients having orthopedic trauma surgery. Methods: Adult patients who underwent operative fixation of traumatic lower extremity fractures were consented to receive 10% intranasal povidone-iodine solution. Povidone-iodine was applied ~1 hour before surgical incision and was reapplied the evening after surgery. Patients were tested for S. aureus nasal colonization before surgery, the evening after surgery (before povidone-iodine reapplication), and the day after surgery. Swabs were inoculated into Dey-Engley neutralizer and processed in a vortexer. A series of dilutions were performed and plated on mannitol salt agar plates. S. aureus cultures were quantitatively assessed to determine the reduction in S. aureus after povidone-iodine use. Reductions in S. aureus nasal growth were evaluated using the Skillings-Mack test. SSIs manifesting within 30 and 90 days of surgery were identified using NHSN definitions. A survey was administered the morning after surgery to determine the acceptability of intranasal povidone-iodine. Results: In total, 51 patients participated in this pilot study between February 2020 and June 2021. Nasal samples from 12 participants (23.5%) grew S. aureus. The S. aureus concentration decreased significantly across the time points (P = .03) (Fig. 1). No SSIs were identified within 30 days of surgery. One SSI occurred within 90 days of surgery; this patient did not carry S. aureus, and cultures from the infected site were negative. Also, 31% of patients reported at least 1 mild side effect while using povidone-iodine: dripping (n = 7), itching (n = 6), dryness (n = 4), stinging (n = 4), staining (n = 3), unpleasant taste (n = 3), runny nose (n = 2), burning (n = 1), sneezing (n = 1), sore throat (n = 1), tickling (n = 1), and/or cough (n = 1). Also, 86% of patients stated that povidone-iodine felt neutral, pleasant, or very pleasant, and only 14% stated that it felt unpleasant or very unpleasant. Discussion: In this pilot study, 2 applications of nasal povidone-iodine on the day of surgery were acceptable for patients, and this protocol significantly reduced S. aureus concentration in nares of patients. Future large clinical trials should evaluate whether this 2-application regimen of povidone-iodine significantly decreases rates of SSI among orthopedic trauma surgery patients.

Funding: PDI Healthcare

Disclosures: None

Background: Antibiotics alone are often insufficient to treat recurrent C. difficile infection (rCDI) because they have no activity against C. difficile spores that germinate within a disrupted microbiome. SER-109, an investigational, oral, microbiome therapeutic comprised of purified Firmicutes spores, was designed to reduce rCDI through microbiome repair. We report an integrated efficacy analysis through week 24 for SER-109 from phase 3 studies, ECOSPOR III and ECOSPOR IV. Methods: ECOSPOR III was a randomized, placebo-controlled phase 3 trial conducted at 56 US or Canadian sites that included 182 participants with ≥2 CDI recurrences, confirmed via toxin EIA testing. Participants were stratified by age (<65 years or ≥65 years) and antibiotic regimen (vancomycin, fidaxomicin) and were randomized 1:1 to placebo or SER-109 groups. ECOSPOR IV was an open-label, single-arm study conducted at 72 US or Canadian sites including 263 participants with rCDI enrolled in 2 cohorts: (1) rollover participants from ECOSPOR III who experienced on-study recurrence diagnosed by toxin EIA (n = 29) and (2) participants with ≥1 CDI recurrence (diagnosed by PCR or toxin EIA), inclusive of the current episode (n = 234). In both studies, the investigational product was administered orally as 4 capsules over 3 consecutive days following symptom resolution after standard-of-care antibiotics. The primary efficacy end point was rCDI (recurrent toxin-positive diarrhea requiring treatment) through week 8. Other end points included CDI recurrence rates and safety through 24 weeks. Results: These 349 participants received at least 1 dose of SER-109 in ECOSPOR III or ECOSPOR IV (mean age 64.2; 68.8% female). Overall, 77 participants (22.1%) enrolled with their first CDI recurrence. Four participants received blinded SER-109 in ECOSPOR III followed by a second dose of open-label SER-109 in ECOSPOR IV. Overall, the proportion of participants who received any dose of SER-109 with rCDI at week 8 was 9.5% (33 of 349; 95% CI, 6.6 %–13.0%), and the CDI recurrence rate remained low through 24 weeks (15.2%, 53 of 349; 95% CI, 11.6%–19.4%), corresponding to sustained clinical response rates of 90.5% (95% CI, 87.0%–93.4%) and 84.8% (95% CI, 80.6%–88.4%), respectively (Fig. 1). Most rollover participants (25 of 29, 86.2%) were from the placebo arm; 13.8% had rCDI by week 8. Conclusions: In this integrated analysis, the rates of rCDI were low and durable in participants who received the investigational microbiome therapeutic SER-109, with sustained clinical response rates of 90.5% and 84.8% at weeks 8 and 24, respectively. These data further support the potential benefit of microbiome repair with SER-109 following antibiotics for rCDI to prevent recurrence in high-risk patients.

Financial support: This study was funded by Seres Therapeutics.

Disclosure: None

Using point-prevalence methodology and the World Health Organization (WHO) Access, Watch, and Reserve Classification, we measured antibiotic use in 5 hospitals in Okinawa, Japan, on October 1, 2020. Overall, 29% of patients were prescribed an antibiotic on the survey date and the 3 most used antibiotics in the “Watch” category were cefazolin, ampicillin-sulbactam, and ampicillin.

Refugee and migrant populations have increased vulnerability to antimicrobial resistance, yet stewardship guidance is lacking. We addressed this gap through a cross-sectional survey, finding that these populations and immigrants from low and middle-income countries had lower health literacy on the issue compared to native-born Americans and those from high-income countries.

Background: Nationally, a decrease in total antibiotic use in nursing homes during the COVID-19 pandemic was observed with an increase in select agents used for respiratory infections. Currently there is minimal data on antibiotic use in long-term care facilities (LTCFs) in Tennessee. To address this issue, the Tennessee Department of Health (TDH) developed a monthly point-prevalence survey of antibiotic use. Utilizing this tool, we sought to determine the effect the pandemic had on antibiotic use in Tennessee LTCFs. Method: We developed a REDCap questionnaire to collect information on selected antibiotics administered in Tennessee LTCFs. Antibiotic use percentage was determined by dividing the number of residents who received an antibiotic on the day of survey by facilities’ average censuses. Data were divided into a prepandemic period (January 2019–February 2020) and a period during the pandemic (March 2020–December 2021). Antibiotic prescriptions were grouped into 4 classes according to their most common uses: Clostridium difficile infections, urinary tract infections, skin and soft-tissue infections (SSTIs), and respiratory infections. Average percentage of residents on antibiotics were compared between study periods. Results: In total, 37 facilities participated in the survey during the prepandemic period and 32 facilities participated during the pandemic period; 14 participated during both periods. The average percentage of residents on antimicrobials before the pandemic was 16.3%, which decreased to 11.5% during the pandemic period (P = .04). During the prepandemic period, 40.2% of antibiotics prescribed were in the common for SSTI category and 38.3% were in the common for respiratory infections category (P = .01); during the pandemic period, 64.3% of antibiotics prescribed were in the common for SSTI category and 45.8% were in the common for respiratory infections category (P = .01). The 3 most prescribed antibiotics in the prepandemic period were amoxicillin (148 prescriptions), doxycycline (140 prescriptions), and levofloxacin (135 prescriptions). The 3 most prescribed antibiotics during the pandemic were doxycycline (141 prescriptions), levofloxacin (125 prescriptions), and trimethoprim–sulfamethoxazole (115 prescriptions). Conclusions: Survey results revealed that antibiotic prescriptions commonly used for respiratory infections increased 7.5% during the pandemic study period. Additionally, the average percentage of residents on antimicrobials fell 4.8% during this period. Both statistics reflect what has been seen nationally with a decrease in antibiotic use with an increase in respiratory antibiotics. This could be due to multiple factors including decreased reporting, a change in healthcare delivery during the pandemic, and facilities seeing an increase of respiratory tract infections. These data will be used to guide future TDH antibiotic stewardship efforts in the long-term care setting.

Funding: None

Disclosures: None

Background: Fungemia is associated with high rates of morbidity, mortality, and increase in length of hospital stay. Several studies have recognized increased rates of candidemia since the COVID-19 pandemic. Methods: Patients with candidemia during January through May 2020 were identified through Theradoc. Patient demographics, comorbidities, hospital management, and microbiology were extracted by medical chart review. Patients were divided into cohorts based on COVID-19 status. The Fisher exact and Satterthwaite tests were used for analyses of categorical and continuous variables, respectively. Results: Overall, 31 patients developed candidemia and 12 (38.7%) patients tested SARS-CoV-2 positive. Candida glabrata was the most prevalent causative organism in both groups. On average, COVID-19 patients developed fungemia 12.1 days from admission, compared to 17.8 days in the COVID-19 negative or untested cohort (P = .340). Additionally, COVID-19 patients with a fungemia coinfection were significantly more likely to expire; 10 COVID-19 patients (83.3%) died, compared to 7 (36.8%) in the COVID-19–negative or untested cohort (P = .025). The cohorts did not demonstrate statistically significant differences in terms of demographic, comorbidities, hospital management, or coinfections. Conclusions: The prevalence of fungemia in COVID-19 patients is significantly greater than historically reported figures. Known risk factors for candidemia, such as use of corticosteroid, use of central venous catheters, and prolonged ICU length of stay were higher in the SARS-CoV-2–positive cohort in this period, which likely contributed to increased fungemia rates, as these factors are also more pronounced in those with COVID-19. Patients who developed candidemia in the COVID-19 cohort had poorer outcomes than those who were SARS-CoV-2 negative or were untested. Further investigation should be conducted in larger studies.

Funding: No

Disclosures: None

Table 1.

Over 3 months, we provided monthly education to internal medicine residents and distributed resources regarding penicillin-allergy history taking. Allergy information in the electronic record was updated more often during the intervention compared to the period before the intervention (16.1% vs 10.9%; P = .02). Education and interdepartmental collaboration have the potential to affect provider behavior.

Background: Clinical antibiotic susceptibility testing (AST) interpretations based on minimum inhibitory concentrations (MIC) breakpoints are important for both clinical decision making and some reportable condition criteria. Standardization of MIC breakpoints across clinical laboratories is lacking; AST instruments are often validated for outdated Clinical and Laboratory Standards Institute (CLSI) MIC breakpoint guidelines. In this study, we analyzed the agreement between the reported clinical laboratory AST interpretations and the guideline CLSI interpretation. Methods: Clinical laboratory AST data collected from the Multisite Gram-Negative Surveillance Initiative (MuGSI) carbapenem-resistant Enterobacterales (CRE) surveillance program in Tennessee between 2019 and 2021 were utilized. MIC values from the clinical instrument were used to calculate CLSI standard interpretations following the 2019–2021 CLSI M100 guidelines. Agreement between the clinical laboratory and CLSI interpretations of the reported MIC values were measured using a weighted Cohen κ calculated in SAS version 9.4 software. Total matches were isolates with identical CLSI and clinical laboratory interpretations. Results: In total, 14 antibiotics were assessed. Of those, 9 antibiotics had at least moderate agreement (κ > 0.41) between interpretations. Agreement between the clinical laboratory and the CLSI interpretations were near perfect (κ > 0.81) for 3 antibiotics. Agreement between the clinical laboratory and the CLSI interpretations were poor for cefazolin (0.06) and ertapenem (0.14). Cefotaxime (−0.07) was the only antibiotic that suggested no agreement. Conclusions: Of the antibiotics included in the analysis, 36% had less than moderate agreement between clinical laboratory and CLSI AST interpretations. Given the increases in antimicrobial resistance globally and the emphasis placed on antibiotic stewardship, standardization across clinical AST panels should be prioritized. Inconsistencies have the potential to contribute to inappropriate antibiotic use in addition to under- or overidentification of reportable conditions, including CRE.

Disclosures: None

Background: COVID-19 has presented hospitals with unique challenges. An SHEA Research Network survey showed that 40% reported “limited” or worse levels of personal protective equipment (PPE) and that 13% were self-producing PPE to address those deficits, including 3D-printed items. However, we do not know how efficiently, if at all, 3D-printed materials can be disinfected. Additionally, 2 filaments, PLACTIVE and PUREMENT, claim to be antimicrobial; they use copper nanocomposites and silver ions to reduce bacterial populations. We assessed how PLACTIVE and PUREMENT may be contaminated and how well they reduce contamination, and how readily polylactic acid (PLA), a standard 3D-printed material, may be disinfected. Methods: We grew methicillin-resistant and -susceptible Staphylococcus aureus, Escherichia coli, and Klebsiella pneumoniae on 3D-printed disks and conducted bacterial survival assays to determine whether bacteria grow on PLA, PLACTIVE, and PUREMENT. We performed a time series (with 3- and 24-hour dry times) followed by serial dilutions to attain colony-forming unit (CFU) averages for each strain per disk. To determine whether 3D-printed material can be cleaned, we used 70% EtOH on PLA only. We conducted the same time series followed by a disinfectant time series (with dry times 30 seconds, 2.5, minutes, 5 minutes, and 10 minutes). Again, serial dilutions were performed to attain the PLA CFU averages with disinfectant. The CFU averages from the control group (PLA) and testing group (PLACTIVE and PUREMENT) were compared to see how well the antimicrobial material decreased bacterial load. We also compared the CFU averages of PLA with and without disinfectant to see how well 70% EtOH decreased bacterial load. Results: 3D-printed material is readily contaminated with bacteria common in hospitals and can sustain that contamination. Antimicrobial materials, PLACTIVE and PUREMENT, had lower levels of bacterial contamination when compared to PLA. However, disinfected disks had lower overall CFU averages than those that were not, but the level of disinfection was variable and bacterial populations recovered hours after disinfection application. Conclusions: Proper disinfection and using appropriate 3D-printed materials are essential to limiting bacterial contamination. 3D printers and their products can be invaluable for hospitals, especially when supplies are low and healthcare worker safety is paramount. Environmental services should be made aware of the presence of antimicrobial 3D-printed materials, and patients should be discouraged from printing their own items for use in hospital environments.

Disclosures: None

The standardized antibiotic administration ratio (SAAR) enables comparison of antibiotic use (AU) within and between hospitals and identifies target locations and antimicrobials for stewardship interventions. Thousands of institutions have already been submitting AU to the National Healthcare Safety Network. We highlight the benefits and meaningful utilization of SAAR in conjunction with antimicrobial stewardship interventions to improve antimicrobial prescribing in the clinical setting.