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

The coronavirus disease 2019 (COVID-19) pandemic has strained antimicrobial stewardship programs (ASPs) but offered new opportunities. This review summarizes the impact of the COVID-19 pandemic on ASPs, review the contributions ASPs have made in the pandemic response, and highlight the potential role of ASPs in future pandemics.

Background: The COVID-19 pandemic has made a significant impact on antimicrobial use patterns across health systems. We have described antibiotic use patterns at an academic medical center in Richmond, Virginia, before and after the onset of COVID-19. We also examined the impact on the proportional consumption of carbapenems (PoCC) metric. PoCC represents meropenem utilization relative to the narrower-spectrum antipseudomonal agents cefepime and piperacillin-tazobactam. Our institution practices antimicrobial restriction for meropenem. All other antibiotics included in the study data can be freely ordered by any provider. Methods: We evaluated antimicrobial use data from September 2018 through August 2021 using days of therapy (DOT) per 1,000 patient days. We included 18 months of data before and after the first recorded COVID-19 admission at our institution in March 2020. Mean comparisons were performed using the Welch 2-sample t test. The Bonferonni correction for multiple comparisons was utilized to determine significance with an initial baseline α of 0.05. All data analyses were performed using R software (R Foundation for Statistical Computing, Vienna, Austria, 2021). Results: Normality was evaluated with QQ-plots and all data demonstrated normality. Bonferroni correction produced an adjusted α value of 0.007. We detected significant increases in the use of cefepime, piperacillin-tazobactam, ceftriaxone, and azithromycin following the onset of the COVID-19 pandemic. We noted a significant decrease in the PoCC metric during this period. No significant change was noted for levofloxacin or meropenem. Conclusions: The COVID-19 pandemic produced significant changes in antimicrobial use patterns at our institution. We noted statistically significant increases in bacterial community-acquired pneumonia-focused antibiotics (ceftriaxone and azithromycin). We observed significant increases for cefepime and piperacillin-tazobactam. Interestingly, relative utilization of carbapenems as measured by the PoCC metric continued to decrease during this time. This trend was primarily driven by increases in cefepime and piperacillin-tazobactam utilization while meropenem utilization remained relatively constant. This study highlights the importance of looking at normalized antibiotic consumption data and not relative-use data alone.

Funding: None

Disclosures: None

The Centers for Medicare and Medicaid mandated that nursing homes implement antibiotic stewardship programs (ASPs) by November 2017. We conducted surveys of Wisconsin nursing-home stewardship practices before and after this mandate. Our comparison of these surveys shows an overall increase in ASP implementation efforts, but it also highlights areas for further improvement.

Background: Antimicrobials are frequently used during end-of-life care and may be prescribed without a clear clinical indication. Overuse of antimicrobials is a major public health concern because of the development of multidrug resistant organisms (MDROs). Antimicrobial stewardship programs are associated with reductions in antibiotic resistance and antibiotic-associated adverse events. We sought to identify and describe opportunities to successfully incorporate stewardship strategies into end-of-life care. Methods: We completed semistructured interviews with 15 healthcare providers at 2 VA medical centers, 1 inpatient setting and 1 long-term care setting. Interviews were conducted via telephone between November 2020 and June 2021 and covered topics related to antibiotic prescribing for hospice and palliative-care patients, including how to improve antimicrobial stewardship during the end-of-life period. We targeted healthcare providers who are involved in prescribing antibiotics during the end-of-life period, including hospitalists, infectious disease physicians, palliative care and hospice physicians, and pharmacists. All interviews were recorded, transcribed, and analyzed using consensus-based inductive and deductive coding. Results: End-of-life care, particularly hospice care, was described as an underutilized resource for patients, who are often enrolled in their final days of life rather than earlier in the dying process. Even at facilities with established antimicrobial stewardship programs, healthcare providers interviewed believed that opportunities for antimicrobial stewardship in the hospice and palliative care settings were missed. Recommendations for how stewardship should be incorporated in end-of-life care included receiving feedback on antimicrobial prescribing, increasing pharmacist involvement in prescribing decisions, and targeted education for providers on end-of-life care, including the value of shared decision making with patients around antibiotic use. Conclusions: Improved antibiotic prescribing during end-of-life care is critical in the effort to combat antimicrobial resistance. Healthcare providers discussed antimicrobial stewardship activities during end-of-life patient care as a potential avenue to improve appropriate antibiotic prescribing. Future research should evaluate the feasibility and effectiveness of incorporating these strategies into end-of-life patient care.

Funding: None

Disclosures: None

We developed and validated a set of fully automated surveillance algorithms for healthcare-onset CDI using electronic health records. In a validation data set of 750 manually annotated admissions, the algorithm based on International Classification of Disease, Tenth Revision (ICD-10) code A04.7 had insufficient sensitivity. Algorithms based on microbiological test results with or without addition of symptoms performed well.

Background: Bacterial coinfections with COVID-19 appear to be rare, yet antibiotic use in this population is high. Limited guidance is available regarding the use of antibiotics in these patients. In response, a multidisciplinary group of physicians and pharmacists from 5 VISN9 facilities developed a guideline for the use of antibiotics with COVID-19 in July 2021. This guideline created a network-wide standard for antibiotic use and facilitates the assessment of antibiotic appropriateness in hospitalized veterans with COVID-19. Methods: In this observational, cross-sectional study, we reviewed veterans diagnosed with COVID-19 from August 1 through September 30, 2021, who were admitted to VISN9 facilities. Use of antibiotics was assessed during the first 4 days of admission. If antibiotics were prescribed, their use was determined to be appropriate or inappropriate based on the presence or absence of a finding concerning for bacterial coinfection as outlined in the guideline (Table 1). Additional data including procalcitonin results as well as positive sputum cultures were collected. Results: In total, 377 veterans were admitted for COVID-19 during the study period. Among them, 42 veterans (11%) received antibiotics for nonrespiratory infections and were removed from this analysis. Of the remaining 335 veterans, 229 (68%) received antibiotics and 116 (51%) of those met guideline criteria that were concerning for bacterial coinfection. Additionally, 32 (14%) of the 229 veterans who received antibiotics had >1 finding concerning for bacterial coinfection. Procalcitonin levels were obtained in 97 (42%) of 229. Only 33 veterans (14%) who received antibiotics had an elevated procalcitonin, and only 19 (8%) had a positive sputum culture. Conclusions: Antibiotic use was common in hospitalized veterans with COVID-19 in VISN9 facilities. This results are comparable to findings in the published literature. Among those receiving antibiotics early in their hospitalization, half were considered appropriate based on our guideline. Quality improvement initiatives are needed to improve implementation of the network guideline to reduce the overuse of antibiotics for management of COVID-19. Additionally, procalcitonin may be a helpful tool for hospitalized veterans with COVID-19.

Funding: None

Disclosures: None

External urinary collection devices (ECDs) are increasingly used in female patients, however, their impact on bacteriuria and antimicrobial use is unclear. Comparing the periods before and after the implementation of an ECD use policy, we found an overall decrease in bacteriuria but no significant decrease in trend of monthly rates. Antimicrobial use for genitourinary indications did not change.

Background: Cefepime has a known association with neurotoxicity due to its ability to cross the blood–brain barrier. The symptoms of neurotoxicity are highly variable. It has been postulated that cefepime neurotoxicity is associated with elevated levels of the drug. However, studies assessing for an association between serum drug level and the incidence of neurotoxicity have yet to establish a consistent threshold. We assessed serum cefepime levels and incidence of neurotoxicity to help develop a dosing strategy to minimize adverse effects. Method: In total, 32 inpatients admitted from January 2019 to November 2021 who received cefepime according to institutional standard dosing regimens for at least 72 hours were reviewed by infectious diseases pharmacists who obtained serum cefepime levels and performed pharmacokinetic analyses to obtain percentage free trough levels. Cefepime percentage free trough levels were defined as therapeutic if they were above the known minimum inhibitory concentration (MIC) of the treated organism and were <40 μg/mL. Patient charts were reviewed for clinical findings consistent with cefepime-induced neurotoxicity. Numerical and statistical analyses were performed to assess factors with a significant association with neurotoxicity. Results: Overall, 16 (47.1%) patients showed some evidence of neurotoxicity, 9 (56.3%) of whom had a likely alternate clinical cause of symptoms (Table 1). We did observe that patients with creatinine clearance <60 mL/min were more likely to have symptoms concerning for neurotoxicity. Conclusions: Cefepime percentage free trough levels were highly variable, and no association with neurotoxicity was observed. Patients with decreased creatinine clearance were significantly more likely to develop neurologic findings consistent with cefepime-induced neurotoxicity. Further study is needed to establish a relationship between cefepime pharmacokinetic values and incidence of neurotoxicity.

Funding: None

Disclosures: None

Background: In May 2018, The Joint Commission, The Pew Charitable Trusts, and the CDC cosponsored a meeting of experts who identified 6 evidence-based leading practices that antimicrobial stewardship programs (ASPs) should be doing beyond having basic infrastructure for improving antibiotic prescribing. The Joint Commission Department of Research working with external experts in 2020 conducted a prevalence study to assess what proportion of Joint Commission-accredited hospitals had implemented the 6 leading practices identified (results presented at SHEA Spring 2021). In this qualitative study, we collected information about how hospitals implemented ASP leading practices to identify facilitators and barriers to implementation among diverse hospitals. Methods: We conducted in-depth telephone interviews with a subset of ASP leaders from hospitals that participated in the 2020 prevalence study. We used purposive sampling to select 30 hospitals from 288 hospitals based on leading practices implemented, hospital size, and system membership. An experienced qualitative researcher (M.K.) not previously affiliated with the Joint Commission interviewed all participants using a semistructured interview guide. The framework method of analysis was used to review and organize data. We used the constant comparative approach to ensure that factors were not missed. Each transcript was reviewed by at least 2 researchers who compared coded findings in group discussion sessions. Two researchers independently identified key factors and combined findings following discussion and review. We focused on super factors that are relevant to implementing multiple leading practices. Results: ASP leaders from 30 hospitals were interviewed. Participating hospitals were evenly distributed across hospital size (10 small, 10 medium, 10 large) and membership in a health system (16 system, 14 nonsystem). At least 14, (46.7%) interviewees had pharmacist in their title; 11 (36.7%) had pharmacist-antimicrobial stewardship; and 5 (16.6%) had other titles (eg, infection preventionist). Super factors included ASP team capacity, ID expertise, having a physician champion, relationships with clinicians and relevant departments, structure of electronic health records, adequate software, and information technology resources. Small and rural nonsystem hospitals often lacked resources related to ID expertise, dedicated staff, and software tools, whereas hospitals that belong to a system benefit from centralized ID expertise and technical infrastructure provided. Conclusions: Specific factors related to personnel, relationships and IT resources have an outsized impact on implementing multiple leading antimicrobial stewardship practices in hospitals. Hospital ASPs could benefit by targeting resources toward these areas.

Funding: None

Disclosures: None

Background: Urinary tract infections (UTIs) are common indications for antibiotics in ambulatory setting, and inappropriate use is prevalent. Fluoroquinolones account for 40% of antibiotics prescribed for uncomplicated UTIs, despite clinical guidance against their use as firstline agents. We conducted a systematic review to determine which antibiotic stewardship intervention(s) are effective in improving antibiotic prescribing for UTIs in the ambulatory setting. Methods: Following PRISMA guidelines, English-language literature from 1995 to September 21, 2021, was searched for articles about antimicrobial stewardship, UTI, and ambulatory setting from PubMed, Embase, and Central. Additional articles were identified from authors’ collections and references of pertinent articles. Studies were included if the authors implemented intervention targeting adults 18 years and older in outpatient setting (excluding emergency departments). Interventions were categorized into Guideline Development and Dissemination (GDD), Audit and Feedback, Clinical Decision Support System (CDSS), and Multimodal Interventions. Results: The literature search identified 1,899 papers; 14 papers were included in this review; and 4 additional papers were identified from other sources. The main interventions were GDD in 6 studies, audit and feedback in 3 studies, CDSS in 4 studies, and multimodal interventions in 5 stidues. These studies had heterogeneity of the practice settings and interventions. Moreover, 11 studies targeted primary care, 2 studies targeted urgent care, 1 study targeted both primary and urgent care, 2 studies were conducted in spinal cord injury clinics, and 2 studies were conducted in hospital-wide outpatient sites. Outcomes included (1) statistically significant increase in guideline-concordant antibiotic prescribing in 12 studies (range, 4.6%–246%); (2) statistically significant decrease in fluoroquinolone prescriptions (range, 9.1%–86.3%) in 7 of 9 studies focusing on fluoroquinolones; (3) significant decreases in drug resistance in urine pathogens in 2 studies that evaluated this. Provider education, in conjunction with passive CDSS tools, such as integrating order sets for UTI prescriptions with prefilled instructions into electronic medical records appeared most beneficial. Several studies have investigated negative impact and have found no increase in retreatment rates or worse outcomes. Conclusions: Our systematic literature review identified a limited number of studies with a variety of interventions that improved antibiotic use for UTIs in the ambulatory care setting. Provider education, in conjunction with CDSS tools, can be less time-consuming than audit and feedback and can target a large number of providers and practices. Future studies need to address sustainability over longer periods and should target specialty clinic populations because they have high burden of patients with multidrug-resistant UTI organisms.

Funding: None

Disclosures: None

We performed severe acute respiratory coronavirus virus 2 (SARS-CoV-2) antinucleocapsid IgG testing on 5,557 healthcare providers and found a seroprevalence of 3.9%. African Americans were more likely to test positive than Whites, and HCWs with household exposure and those working on COVID-19 cohorting units were more likely to test positive than their peers.

Background: Child absenteeism from childcare or school leads to economic loss from parental work absenteeism, overutilization of acute-care resources, and excess medicalization of children with minor illnesses. We sought to determine the difference in days missed from childcare or school and days of illness for children with influenza-like illness (ILI) in the emergency department (ED) who are or are not prescribed an antibiotic. Methods: We conducted a secondary data analysis of a prospective randomized control trial evaluating the impact of rapid molecular testing on provider decision making. The study included children aged 2 months–12 years attending childcare or school seen in the ED from December 2018 through December 2019 with ILI (CDC definition) with parental survey completion 10 days after their ED visit. The primary exposure was receipt of antibiotics over the course of illness, which was assessed by chart review and parent survey. The primary outcome was number of days missed from class. The secondary outcome was number of days of illness after initial ED visit. Wilcoxon tests were used to compare missed class days or illness days by antibiotic receipt. Multivariable negative binomial regression was used to analyze outcomes, controlling for clinically important patient characteristics. Results: Of 251 children included in this study, the median age was 4.2 years (IQR, 1.6–7.0); 52% were male, 40% were White, 54% were Hispanic, and 75% had government insurance. Antibiotics were prescribed in 26% of ILI encounters. There was no statistically significant association between antibiotic receipt and number missed class days (2.0 days [IQR, 1.0–4.0] vs 3.0 days [IQR, 1.0–5.0]; P = .08) or illness days (4.0 days [IQR, 3.0–7.0] vs 5.0 days [IQR, 3.0–7.0]; P = .13) after the initial ED visit. After adjusting for covariates, there was no significant difference in missed class days or illness days for patients prescribed antibiotics in relation to days sick before ED visit. The rates of missed class days and illness days were 87% and 30% greater, respectively, in patients with additional medical visits during the course of illness. Conclusions: Days sick prior to ED presentation and receipt of an antibiotic for ILI had no influence on child absenteeism or illness duration. However, children missed more class and received more antibiotics if they had multiple medical visits during an illness. Further study is needed on sociobehavioral factors leading to medicalization of children with minor illnesses and its impact on the unnecessary use of antibiotics.

Funding: None

Disclosures: None

Background: An estimated 30% of antibiotic prescriptions in outpatient settings may be inappropriate. Antibiotic exposure increases an individual’s risk of Clostridioides difficile infection (CDI). To assess the prevalence of community-acquired CDI (CA-CDI) among patients without recent hospitalization and to examine the influence of outpatient antibiotic exposure on the risk of acquiring CA-CDI in this population, we examined a 2-year cohort of patients seen in primary care clinics at VA community-based outpatient clinics (CBOCs) associated with a large VA medical center. Methods: All primary care visits and nonvisit antibiotic prescriptions were identified in calendar years 2018–2019 as encounters of interest. Encounters occurring Results: We identified 84,787 patients with visits meeting our criteria. In this cohort, 3,533 patients were prescribed antibiotics at their encounter of whom 5 (0.14%) developed CA-CDI. Among the 81,254 patients who were not prescribed antibiotics, 15 (0.02%) developed CA-CDI, yielding an unadjusted CA-CDI odds ratio of 7.68 (95% CI, 2.50–19.82). p Conclusions: Although CA-CDI episodes were infrequent among VA outpatients with a CBOC visit in 2018–2019, the odds of CA-CDI were 7-fold greater in outpatients with antibiotic exposure than outpatients without antibiotic exposure. Antibiotic stewardship interventions that emphasize adverse events as a result of care provided in the outpatient setting, rather than as events limited to acute-care settings, may mitigate CDI risk.

Funding: This work was supported by the Merck Investigator Studies Program (MISP 59266 to F.P. and R.J.), and funds and facilities were provided by the Cleveland Geriatric Research Education and Clinical Center (GRECC) at the VA Northeast Ohio Healthcare System. The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Disclosures:. All authors report no conflicts of interest relevant to this article. R.J. has received research funding from Pfizer; she has also participated in advisory boards for Pfizer and Merck.

Background:Clostridioides difficile infection (CDI) is the leading cause of healthcare-associated diarrhea. Significant risk factors for CDI include antibiotic use and healthcare exposure. Antibiotics are often administered before, during and/or after surgery to prevent postsurgical infection. The contribution of surgery-related antibiotics to the overall CDI burden has not been well described, and assessment of the appropriateness of surgical antibiotic use is complicated by complex clinical guidelines. We have described surgical antibiotic prophylaxis history among adult with CDI in Minnesota in 2018. Method: The Minnesota Department of Health (MDH) performs 5-county active population- and laboratory-based CDI surveillance as a CDC Emerging Infections Program site. Incident CDI was defined as stool positive for C. difficile by toxin or molecular assay from a person aged ≥18 years with no positive test in the preceding 8 weeks. History of CDI was defined as having had a previous CDI episode in the 2009–2018 surveillance data set. Medical records were reviewed for 12 weeks prior to incident CDI test date to identify antibiotic prescriptions. Antibiotics with documented indication for surgical-site infection prevention or surgical prophylaxis were classified as “surgical antibiotic prophylaxis” (SPPX). SPPX type (eg, intraoperative, postoperative), appropriateness of SPPX, and clinical guideline adherence were not assessed. Results: During 2018, 812 incident CDIs were reported to MDH among 736 patients. SPPX preceded 84 (10.3%) cases, non-SPPX antibiotic use preceded 465 cases (57.3%), and 263 cases (32.4%) had no documented prior antibiotic use. The median age of incident CDIs with preceding SPPX was 68 years (IQR, 54–79.5). In 25 incident CDI cases with preceding SPPX (29.8%), there were no other antibiotic exposures. Among incident CDIs with preceding SPPX, 11 (13.1%) had >1 surgery event with SPPX. Prior CDI was identified for 13 (15.7%) with SPPX. Among 99 procedures with preceding SPPX, orthopedic surgeries (n = 27, 27.3%), gastrointestinal surgeries (n = 26, 26.3%), and cardiovascular surgeries (n = 22, 22.2%) were most common. In total 18 SPPX prescriptions (18.2%) originated in outpatient settings. SPPX drugs included cefazolin (n = 67, 67.7%), ceftriaxone (n = 7, 7.1%), ertapenem (n = 6, 6.1%), and clindamycin (n = 6, 6.1%). Median SPPX duration was 1 day (IQR, 1–2), and the median number days between surgery and specimen collection date was 19 (IQR, 7–49). Conclusions: Antibiotic stewardship programs should assess surgical prescribing, including in outpatient centers. Even short antibiotic duration for surgery could put patients at risk for CDI. More data are needed to evaluate the appropriateness of SPPX prescribing and to describe the impact of SPPX on CDI.

Funding: None

Disclosures: None