Indirect impact of childhood 13-valent pneumococcal conjugate vaccine (PCV13) in Canadian older adults: a Canadian Immunization Research Network (CIRN) retrospective observational study

BACKGROUND

13-valent pneumococcal conjugate vaccine (PCV13) has been part of publicly funded childhood immunisation programmes in Ontario and British Columbia (BC) since 2010. We assessed the indirect impact of infant PCV13 programmes on invasive pneumococcal disease (IPD) and all-cause pneumonia hospitalisation in older adults (aged ≥65 years) using a retrospective observational study.

METHODS

We extracted monthly IPD and all-cause pneumonia cases from laboratory and health administrative databases between January 2005 and December 2018. Using a quasi-experimental difference-in-differences design, we calculated the ratio of risk ratios (RRRs) using incidence rates of IPD or all-cause pneumonia cases before (pre-PCV13 period) and after (PCV13 period) 2010 with rates of fractures as controls.

RESULTS

The rates of all IPD or PCV serotype-specific IPD for older adults in both Ontario and BC did not change in 8 years after childhood PCV13 programme implementation. All-cause pneumonia increased in Ontario (RRR 1.38, 95% CI 1.11 to 1.71) but remained unchanged in BC.

CONCLUSIONS

Indirect community protection of older adults from hospitalisation with pneumococcal disease stalled despite maturation of childhood PCV13 vaccination programmes in two Canadian provinces.

Enhancing the nutritional value of sweet bell pepper through moderate NaCl salinity

Salinity presents a significant obstacle to crop productivity, particularly in dry and semi-arid regions. Sweet bell pepper (Capsicum annuum L.), a widely grown and consumed horticultural crop, is especially vulnerable to salinity. Consequently, it is vital to determine the salinity threshold that impacts bell pepper growth and quality, enabling sustainable production in salinized areas. This study aimed to evaluate the effects of varying sodium chloride concentrations (0, 50, and 75 mM) on bell pepper growth, nutritional value, and phytochemical composition, aiming to identify the adaptable threshold in salinized environments. The results suggested that the application of 75 mM NaCl not only had no adverse impact on fruit quality in terms of biomolecules and phytochemicals but also led to significant improvements. Specifically, under these conditions, there was a remarkable increase, in respect to control, in total protein (TPRO by 50 %), total carbohydrates (TCARB by 18 %), lycopene (LIC by 68 %), total Carotenoids (TCAR by 13 %), and total phenols (TPHE by 18 %) in terms of antioxidants.In contrast, the content of ascorbic acid and antioxidant activities remained consistent. Moderate salt stress exhibited the most positive influence on sweet bell pepper quality, leading to higher concentrations of essential nutrients and nutraceutical compounds, including minerals, phenolic acids, and flavonoids.

Quality of antibiotic prescribing for pediatric community-acquired Pneumonia in outpatient care

BACKGROUND

Antibiotics remain the primary treatment for community acquired pneumonia (CAP), however rising rates of antimicrobial resistance may jeopardize their future efficacy. With higher rates of disease reported in the youngest populations, effective treatment courses for pediatric pneumonia are of paramount importance. This study is the first to examine the quality of pediatric antibiotic use by agent, dose and duration.

METHODS

A retrospective cohort study included all outpatient/primary care physician visits for pediatric CAP (aged < 19 years) between January 1 2014 to December 31 2018. Relevant practice guidelines were identified, and treatment recommendations extracted. Amoxicillin was the primary first-line agent for pediatric CAP. Categories of prescribing included: guideline adherent, effective but unnecessary (excess dose and/or duration), under treatment (insufficient dose and/or duration), and not recommended. Proportions of attributable-antibiotic use were examined by prescribing category, and then stratified by age and sex.

RESULT(S)

A total of 42,452 episodes of pediatric CAP were identified. Of those, 31,347 (76%) resulted in an antibiotic prescription. Amoxicillin accounted for 51% of all prescriptions. Overall, 27% of prescribing was fully guideline adherent, 19% effective but unnecessary, 10% under treatment, and 44% not recommended by agent. Excessive duration was the hallmark of effective but unnecessary prescribing (97%) Macrolides accounted for the majority on non-first line agent use, with only 32% of not recommended prescribing preceded by a previous course of antibiotics.

CONCLUSION(S)

This study is the first in Canada to examine prescribing quality for pediatric CAP by agent, dose and duration. Utilizing first-line agents, and shorter-course treatments are targets for stewardship.

Retrospective cohort analysis of outpatient antibiotic prescribing for community-acquired pneumonia in Canadian older adults

BACKGROUND

This retrospective cohort study is the first in North America to examine population-level appropriate antibiotic use for community-acquired pneumonia (CAP) in older adults, by agent, dose and duration. With the highest rates of CAP reported in the elderly populations, appropriate antibiotic use is essential to improve clinical outcomes. Given the ongoing crisis of antimicrobial resistance, understanding inappropriate antibiotic prescribing is integral to direct community stewardship efforts.

METHODS

All outpatient primary care visits for CAP (aged ≥65 years) were identified using physician billing codes between January 1 2014 to December 31 2018 in British Columbia (BC) and Ontario (ON). Categories of prescribing were derived from existing literature, and constructed for clinical relevance using Canadian and international guidelines available during the study period. Categories were mutually exclusive and included: guideline adherent (first-line agent, adherent dose/duration), clinically appropriate (non-first line agent, presence of comorbidities), effective but unnecessary (first-line agent, excess dose/duration), undertreatment (first-line agent, subtherapeutic dose/duration), and not recommended (non-first line agent, absence of comorbidities). Proportions of prescribing were examined by category. Temporal trends in prescribing were examined using Poisson regression.

RESULTS

A total of 436,441 episodes of CAP were identified, with 46% prescribed an antibiotic in BC, and 52% in Ontario. Guideline adherent prescribing was minimal for both provinces (BC: 2%; ON: 1%) however the largest magnitude of increase was reported in this category by the final study year (BC-Rate Ratio [RR]: 3.4, 95% Confidence Interval [CI]: 2.7-4.3; ON-RR: 4.62, 95% CI: 3.4-6.5). Clinically appropriate prescribing accounted for the most antibiotics issued, across all study years (BC: 61%; ON: 74%) (BC-RR: 0.8, 95% CI: 0.8-0.8; ON-RR: 0.9, 95% CI: 0.8-0.9). Excess duration of therapy was the hallmark characteristic for effective but unnecessary prescribing (BC: 92%; ON: 99%). The most common duration prescribed was 7 days, followed by 10. Not recommended prescribing was minimal in both provinces (BC: 4%; ON: 7%) and remained stable by the final study year (BC-RR: 1.1, 95% CI: 0.9-1.2; ON-RR: 0.9, 95% CI: 0.9-1.1).

CONCLUSION

Three quarters of antibiotic prescribing for CAP was appropriate in Ontario, but only two thirds in BC. Shortening durations-in line with evidence for 3 to 5-day treatment presents a focused target for stewardship efforts.

Detection of carbapenemase- and ESBL-producing Klebsiella pneumoniae from bovine bulk milk and comparison with clinical human isolates in Italy

Klebsiella pneumoniae is the most common Klebsiella species infecting animals and is one of the causing agents of mastitis in cows. The rise of antimicrobial resistance in K. pneumoniae, particularly in strains producing extended-spectrum β-lactamases (ESBLs) and/or carbapenemases, is of concern worldwide. Recently (Regulation UE No 2022/1255), carbapenems and cephalosporins in combination with β-lactamase inhibitors have been reserved only to human treatments in the European Union. The aim of this study was to investigate the role of cattle as carrier of human pathogenic carbapenem-resistant (CR) and ESBL-producing K. pneumoniae. On this purpose, a study involving 150 dairy farms in Parma province (Northern Italy) and 14 non replicate K. pneumoniae isolates from patients admitted at Parma University-Hospital was planned. Four multidrug resistant (MDR) K. pneumoniae strains were detected from 258 milk filters collected between 2019 and 2021. One carbapenemase KPC-3-positive K. pneumoniae ST307 (0.4 %; 95 % CI - 0.07 - 2.2) was detected in milk filters. The isolate also harboured OXA-9, CTX-M-15 and SHV-106 determinants, together with genes conferring resistance to aminoglycosides (aac(3')-IIa, aph (3″)-Ib, aph (6)-Id), fluoroquinolones (oqxA, oqxB, qnrB1), phosphonic acids (fosA6), sulphonamides (sul2), tetracyclines (tet(A)6) and trimethoprim (dfrA14). One KPC-3-producing K. pneumoniae ST307 was identified also among the human isolates, thus suggesting a possible circulation of pathogens out of the clinical settings. The remaining three bovine isolates were MDR ESBL-producing K. pneumoniae characterized by different genomic profiles: CTX-M-15, TEM-1B and SHV-187 genes (ST513); CTX-M-15 and SHV-145 (ST307); SHV-187 and DHA-1 (ST307). Occurrence of ESBL-producing K. pneumoniae in milk filters was 1.2 % (95 % CI 0.4-3.4). All the isolates showed resistance to aminoglycosides, 3rd-generation cephalosporins, and fluoroquinolones. Among the human isolates, two multidrug resistant ESBL-producing K. pneumoniae ST307 were found, thus confirming the circulation of this high-risk lineage between humans and cattle. Our findings suggest that food-producing animals can carry human pathogenic microorganisms harboring resistance genes against carbapenems and 3rd-generation cephalosporins, even if not treated with such antimicrobials. Moreover, on the MDR K. pneumoniae farms, the antimicrobial use was much higher than the Italian median value, thus highlighting the importance of a more prudent use of antibiotics in animal productions.

Atezolizumab plus bevacizumab versus lenvatinib or sorafenib in non-viral unresectable hepatocellular carcinoma: an international propensity score matching analysis

BACKGROUND

A growing body of evidence suggests that non-viral hepatocellular carcinoma (HCC) might benefit less from immunotherapy.

MATERIALS AND METHODS

We carried out a retrospective analysis of prospectively collected data from consecutive patients with non-viral advanced HCC, treated with atezolizumab plus bevacizumab, lenvatinib, or sorafenib, in 36 centers in 4 countries (Italy, Japan, Republic of Korea, and UK). The primary endpoint was overall survival (OS) with atezolizumab plus bevacizumab versus lenvatinib. Secondary endpoints were progression-free survival (PFS) with atezolizumab plus bevacizumab versus lenvatinib, and OS and PFS with atezolizumab plus bevacizumab versus sorafenib. For the primary and secondary endpoints, we carried out the analysis on the whole population first, and then we divided the cohort into two groups: non-alcoholic fatty liver disease (NAFLD)/non-alcoholic steatohepatitis (NASH) population and non-NAFLD/NASH population.

RESULTS

One hundred and ninety patients received atezolizumab plus bevacizumab, 569 patients received lenvatinib, and 210 patients received sorafenib. In the whole population, multivariate analysis showed that treatment with lenvatinib was associated with a longer OS [hazard ratio (HR) 0.65; 95% confidence interval (CI) 0.44-0.95; P = 0.0268] and PFS (HR 0.67; 95% CI 0.51-0.86; P = 0.002) compared to atezolizumab plus bevacizumab. In the NAFLD/NASH population, multivariate analysis confirmed that lenvatinib treatment was associated with a longer OS (HR 0.46; 95% CI 0.26-0.84; P = 0.0110) and PFS (HR 0.55; 95% CI 0.38-0.82; P = 0.031) compared to atezolizumab plus bevacizumab. In the subgroup of non-NAFLD/NASH patients, no difference in OS or PFS was observed between patients treated with lenvatinib and those treated with atezolizumab plus bevacizumab. All these results were confirmed following propensity score matching analysis. By comparing patients receiving atezolizumab plus bevacizumab versus sorafenib, no statistically significant difference in survival was observed.

CONCLUSIONS

The present analysis conducted on a large number of advanced non-viral HCC patients showed for the first time that treatment with lenvatinib is associated with a significant survival benefit compared to atezolizumab plus bevacizumab, in particular in patients with NAFLD/NASH-related HCC.

Healthcare Costs for Pneumococcal Disease in the Era of Infant Immunization With 13-Valent Pneumococcal Conjugate Vaccine: A Population-Based Study

OBJECTIVES

Invasive pneumococcal disease (IPD) and a variety of clinical syndromes caused by pneumococci, such as acute otitis media (AOM), acute sinusitis (AS), and community-acquired pneumonia (CAP), cause a substantial burden on healthcare systems. Few studies have explored the short-term financial burden of pneumococcal disease after the 13-valent pneumococcal conjugate vaccine (PCV13) introduction in the infant immunization programs. This population-based study evaluated changes in costs associated with healthcare utilization for pneumococcal disease after the PCV13 introduction in the infant immunization program in British Columbia, Canada.

METHODS

Individuals with pneumococcal disease were identified using provincial administrative data for the 2000 to 2018 period. Total direct healthcare costs were determined using case-mix methodology for hospitalization and fee-for-service codes for outpatient visits and medications dispensed. Costs were adjusted to 2018 Canadian dollars. Changes in the annual healthcare costs were evaluated across vaccine eras (pre-PCV13, 2000-2010; PCV13, 2011-2018) using generalized linear models, adjusting for the 7-valent pneumococcal conjugate vaccine program (2004-2010).

RESULTS

During the 19-year study period, pneumococcal disease resulted in 6.3 million cases among 85 million total patient-years, resulting in total healthcare costs of $7.9 billion. More than 6.2 million cases were treated in outpatient setting, costing $0.65 billion (8% of total costs associated with pneumococcal disease treatment), whereas 370 000 hospitalized cases were 3% of all cases, which accrued $7.25 billion (92% of total costs) in costs. Healthcare costs for all studied infections nearly doubled over the study period from $248 million in 2000 to $476 million in 2018 (P = .003). In contrast, there were large declines in total annual costs in the PCV13 era for IPD (adjusted relative rate (aRR) 0.73; 95% confidence interval [CI] 0.56-0.95; P = .032), AOM (aRR 0.70; 95% CI 0.59-0.83; P = .001), and AS (aRR 0.68; 95% CI 0.54-0.85; P = .004) compared with the pre-PCV13 era. Total costs increased marginally in the PCV13 era for all-cause CAP (aRR 1.04; 95% CI 0.94-1.15; P = .484).

CONCLUSIONS

This study confirms a temporal association in declining economic burden for IPD, AOM, and AS after the PCV13 introduction. Nevertheless, the total economic burden continues to be high in the PCV13 era, mainly driven by increasing CAP costs.

Estimating population-based incidence of community-acquired pneumonia and acute otitis media in children and adults in Ontario and British Columbia using health administrative data, 2005-2018: a Canadian Immunisation Research Network (CIRN) study

Background

There is a paucity of data on the burden of the full spectrum of community-acquired pneumonia (CAP) and acute otitis media (AOM) from outpatient and inpatient settings across the age spectrum.

Methods

We conducted a population-based retrospective study in Ontario and British Columbia (BC), Canada, to estimate the incidence rate of CAP and AOM in children and adults over a 14-year period using health administrative databases. CAP and AOM cases were identified from outpatient physician consultation and hospitalisation data in both provinces, and from emergency department visit data in Ontario.

Results

During 2005–2018, Ontario had 3 607 124 CAP, 172 290 bacterial CAP, 7814 pneumococcal pneumonia, and 8 026 971 AOM cases. The incidence rate of CAP declined from 3077/100 000 in 2005 to 2604/100 000 in 2010 before increasing to 2843/100 000 in 2018; bacterial CAP incidence rate also declined from 178/100 000 in 2005 to 112/100 000 in 2010 before increasing to 149/100 000 in 2018. The incidence rate of AOM decreased from 4192/100 000 in 2005 to 3178/100 000 in 2018. BC had 970 455 CAP, 317 913 bacterial CAP, 35 287 pneumococcal pneumonia and 2 022 871 AOM cases. The incidence rate of CAP in BC decreased from 2214/100 000 in 2005 to 1964/100 000 in 2010 before increasing to 2176/100 000 in 2018; bacterial CAP incidence rate increased from 442/100 000 in 2005 to 981/100 000 in 2018. The incidence rate of AOM decreased from 3684/100 000 in 2005 to 2398/100 000 in 2018. The incidence rate of bacterial CAP increased with age in older adults (≥65 years) with the highest burden in the oldest cohort aged ≥85 years both before and after 13-valent pneumococcal conjugate vaccine (PCV13) programme in both provinces. Hospitalised pneumococcal pneumonia decreased slightly but non-hospitalised pneumococcal pneumonia increased in BC during PCV13 period. No consistent direct benefit of PCV13 on CAP was observed in the paediatric population.

Conclusions

There is a substantial burden of CAP and AOM in Ontario and BC. Indirect benefits from childhood PCV vaccination and polysaccharide vaccination of older adults have not substantially decreased the burden of pneumococcal pneumonia in older adults.

A population-based analysis to determine the impact of the 13-valent pneumococcal conjugate vaccine on community-acquired pneumonia in British Columbia, Canada

BACKGROUND

Pneumonia is a leading cause of morbidity and mortality globally. We determined the impact of 13-valent pneumococcal conjugate vaccine (PCV13) use on community-acquired pneumonia (CAP) rates eight years after the vaccine was introduced in the infant immunization program.

METHODS

Using diagnostic codes from administrative databases, we calculated the overall and age-specific CAP incidence per month (2000-2018). Changes in the CAP incidence before and after the PCV13 vaccine program introduction were evaluated using negative binomial regression model adjusting for 7-valent pneumococcal conjugate vaccine program.

RESULTS

The PCV13 vaccine infant immunization program was associated with declining CAP incidence among children aged 0-2 years (adjusted Incidence Rate Ratio (aIRR): 0.91; 95% CI: 0.87-0.96). Overall CAP incidence did not decrease in those aged 3-5 years (0.98; 95% CI: 0.93-1.04), 6-17 years (1.02; 95% CI: 0.97-1.08), 18-49 years (1.02; 95% CI:0.98-1.05), 50-64 years (1.07; 95% CI: 1.04-1.11), ≥65 years (1.05; 95% CI:1.02-1.08).

CONCLUSIONS

The PCV13 infant immunization program is temporally associated with a reduction in CAP incidence in vaccine target age group. However, no significant decrease in CAP incidence in other age groups warrants further study of the etiology of CAP to develop and implement effective prevention programs.

Population-based incidence of invasive pneumococcal disease in children and adults in Ontario and British Columbia, 2002-2018: A Canadian Immunization Research Network (CIRN) study

BACKGROUND

Invasive pneumococcal disease (IPD) burden, evaluated in Canada using reported confirmed cases in surveillance systems, is likely underestimated due to underreporting. We estimated the burden of IPD in Ontario and British Columbia (BC) by combining surveillance data with health administrative databases.

METHODS

We established a cohort of 27,525 individuals in Ontario and BC. Laboratory-confirmed IPD cases were identified from Ontario's integrated Public Health Information System and the BC Centre for Disease Control Public Health Laboratory. Possible IPD cases were identified from hospitalization data in both provinces, and from emergency department visit data in Ontario. We estimated the age and sex adjusted annual incidence of IPD and pneumococcal conjugate/polysaccharide vaccine (PCV/PPV) serotype-specific IPD using Poisson regression models.

RESULTS

In Ontario, 20,205 overall IPD cases, including 15,299 laboratory-confirmed cases, were identified with relatively stable age- and sex-adjusted annual incidence rates ranging from 13.7/100,000 (2005) to 13.6/100,000 (2018). In BC, 7,320 overall IPD cases, including 5,932 laboratory-confirmed cases were identified; annual incidence rates increased from 10.9/100,000 (2002) to 13.2/100,000 (2018). Older adults aged ≥ 85 years had the highest incidence rates. During 2007-2018 the incidence of PCV7 serotypes and additional PCV13 serotypes decreased while the incidence of unique PPV23 and non-vaccine serotypes increased in both provinces.

CONCLUSIONS

IPD continues to cause a substantial public health burden in Canada despite publicly funded pneumococcal vaccination programs, resulting in part from an increase in unique PPV23 and non-vaccine serotypes.

Recycling agricultural, municipal and industrial pollutant wastes into fertilizers for a sustainable healthy food production

This work was focused on recycling different typology of pollutant wastes (olive pomace and orange residues; municipal wastes and sulphur residue of hydrocarbon refining processes) with the triple objectives of limiting wastes in landfill, reducing greenhouse gas emission and producing organic-mineral fertilizers. The environmental risks and benefits of the whole process have been considered. The specific objectives were: 1) innovation in waste management techniques by reducing the accumulation of different typology of wastes using a unique process 2) verifying efficiency of the obtained organic-mineral fertilizers on soil and plant growth 3) improving soil and crop quality relating wastes to food, economy and environment. Sulphur-based pads improved soil quality mostly when contained orange residues. Onion and Garlic grew better in presence of sulphur-based pads (+20%), and mostly when pads contained orange residues (+45%). Onion and Garlic quality, in terms of antioxidant compounds and antioxidant capacity, increased in presence of sulphur-based pads (+30%) mostly when orange residues were present in the pads (+90%). In short, in addition to the environmental advantages, numerous economic benefits coming from the decrease in the production and use of chemical fertilizers, the reduction of costs for landfilling and the gain rising from the sale of the new fertilizers produced, emerged.

1211. Incidence of All-Cause Community-Acquired Pneumonia in Ontario and British Columbia, Canada, 2002-2018; a Canadian Immunization Research Network (CIRN) study

Background

Community-acquired pneumonia (CAP) causes substantial morbidity and mortality. There is a lack of data on the comprehensive burden of CAP across the life span in Canada. We estimated the incidence of all-cause CAP in all age groups in Ontario and British Columbia (BC), Canada.

Methods

We identified hospitalized and outpatient CAP episodes from the Discharge Abstract Database (DAD) and physician billing claims databases (Ontario Health Insurance Plan in Ontario and Medical Services Plan in BC) in both provinces. The National Ambulatory Care Reporting System was used to identify CAP episodes from emergency department visits in Ontario. CAP recorded with a primary or secondary diagnosis was identified using International Classification of Diseases 9 (480–486, 510, 513) and 10 (J10.0, J11.0, J12–J18, J86.9, J85.1) codes. We estimated the age and sex adjusted annual incidence of CAP overall, and by age groups (0–4, 5–17, 18–39, 40–64, 65–74, 75–84 and ≥85 years) according to routine childhood pneumococcal conjugate vaccine (PCV) immunization periods from 2005–2018 in Ontario and from 2002–2018 in BC. Poisson regression models were fitted with population denominators from Statistics Canada to estimate the incidence rates.

Results

Ontario had 3,607,186 CAP episodes from 2005–2015 with a mean annual incidence of 2,801 (95% confidence interval [CI]: 2,748, 2,854) per 100,000 population; incidence declined from 3,077/100,000 in 2005 to 2,604/100,000 in 2010 before increasing to 2,843/100,000 in 2018. BC had 1,146,172 CAP episodes from 2002–2008, with a mean annual incidence of 2,146 (95% CI: 2105, 2189); the incidence increased from 2,005 /100,000 in 2002 to 2,199/100,000 in 2018. A high incidence of CAP was observed in children aged 0–4 years and older adults, particularly in adults aged ≥85 years in both provinces across all PCV program periods (Figure 1).

Figure 1: Age group-specific incidence of all-cause community-acquired pneumonia according to childhood pneumococcal conjugate vaccine (PCV) program periods in Ontario (PCV7 [1 Jan 2005–30 Sep 2009]), PCV10 [1 Oct 2009–31 Oct 2010] and PCV13 [1 Nov 2010–31 Dec 2018]) and British Columbia (PCV7 [1 Sep 2003–31 May 2010] and PCV13 [1 Jun 2010–31 Dec 2018]), Canada

Conclusion

CAP continues to be a public health burden in Canada despite publicly funded pneumococcal vaccination programs. Ontario seems to have higher CAP burden than British Columbia that warrants further investigation. The youngest cohort of children and older adults contribute significantly to the CAP burden.

Disclosures

Manish Sadarangani, BM BCh, DPhil, GlaxoSmithKline (Grant/Research Support)Merck (Grant/Research Support)Pfizer (Grant/Research Support)Sanofi Pasteur (Grant/Research Support)Seqirus (Grant/Research Support)Symvivo (Grant/Research Support)VBI Vaccines (Research Grant or Support) Allison McGeer, MSc,MD,FRCPC,FSHEA, GlaxoSmithKline (Advisor or Review Panel member)Merck (Advisor or Review Panel member, Research Grant or Support)Pfizer (Grant/Research Support, Scientific Research Study Investigator, Advisor or Review Panel member) James D. Kellner, MD, FRCPC, FIDSA, Pfizer, Merck, GSK, Moderna (Grant/Research Support) Shaun Morris, MD, MPH, DTM&H, FRCPC, FAAP, GSK (Speaker’s Bureau)Pfizer (Advisor or Review Panel member)Pfizer (Grant/Research Support) Shaza A. Fadel, PhD MPH, Merck (Other Financial or Material Support, Salary is paid by the University of Toronto via a donation by Merck to the Centre for Vaccine Preventable Diseases to support educational and operational activities.) Fawziah Marra, BSc(Pharm), PharmD, Pfizer Canada (Research Grant or Support)

143. Antibiotic Use for Common Infections in British Columbia and Ontario: A Review of Outpatient Prescribing to Seniors from 2000 – 2018

Background

Antimicrobials remain among the most prescribed medications in Canada, with over 90% prescribed in outpatient settings. Older adults (aged ≥65 years) prescribed antimicrobials are particularly vulnerable to adverse drug events and antimicrobial resistance. This study compared annual rates of indication-associated, outpatient prescribing to seniors across two Canadian provinces.

Methods

All outpatient, oral antimicrobials dispensed to older adults (≥65 years) were identified from administrative health databases, from 2000 to 2018. Antimicrobials were limited to outpatient use only and linked to an indication using a 3-tiered diagnostic hierarchy. When possible, a record of dispensation was matched to a tier 1 indication (always require antibiotics) first. In the absence of a tier 1 indication, priority was given to tier 2 (sometimes require antibiotics), then 3 (never require antibiotics). Prescription rates were calculated per 1000 population, and trends were examined overall, by drug class, and patient demographics.

Results

Our study included over 18 million individuals (aged ≥65 years) with a total of 23,773,552 antibiotic prescriptions issued to seniors, for common infections. In both provinces, prescribing for tier 1 diagnoses increased over the study period (BC: 44%; ON: 28%). Urinary tract infections accounted for most prescriptions within this tier (ON: 89 prescriptions/1000, BC: 129 prescriptions/1000 population by 2018). Pneumonia-associated prescribing increased by roughly 10% in both provinces. In any given study year, for both provinces, tier 3 diagnosis was the most common reason for antibiotic use, accounting for 50% of all indication-associated antibiotic prescribing. As diagnoses within this tier do not warrant prescribing all antibiotics issued are therefore inappropriate prescriptions.

Figure 1. Rates of indication-associated antibiotic use in Canadian seniors, from 2000 to 2018.

Conclusion

Elevated prescribing to seniors continues across Canadian outpatient settings. Antibiotic prescribing remains an issue of high concern with 50% of all antimicrobials prescribed to seniors, for common infections, used inappropriately.

Disclosures

All Authors: No reported disclosures

Appropriateness of Outpatient Antibiotic Use in Seniors across Two Canadian Provinces

Antimicrobials are among the most prescribed medications in Canada, with over 90% of antibiotics prescribed in outpatient settings. Seniors prescribed antimicrobials are particularly vulnerable to adverse drug events and antimicrobial resistance. The extent of inappropriate antibiotic prescribing in outpatient Canadian medical practice, and the potential long-term trends in this practice, are unknown. This study is the first in Canada to examine prescribing quality across two large-scale provincial healthcare systems to compare both quantity and quality of outpatient antibiotic use in seniors. Population-based analyses using administrative health databases were conducted in British Columbia (BC) and Ontario (ON), and all outpatient, oral antimicrobials dispensed to seniors (≥65 years) from 1 January 2000 to 31 December 2018 were identified. Antimicrobials were linked to an indication using a 3-tiered hierarchy. Tier 1 indications, which always require antibiotics, were given priority, followed by Tier 2 indications that sometimes require antibiotics, then Tier 3, which never require antibiotics. Prescription rates were calculated per 1000 population, and trends were examined overall, by drug class, and by patient demographics. Prescribing remained steady in both provinces, with 11,166,401 prescriptions dispensed overall in BC, and 27,656,014 overall in ON. BC prescribed at slightly elevated rates (range: 790 to 930 per 1000 residents), in comparison to ON (range: 745 to 785 per 1000 residents), throughout the study period. For both provinces, a Tier 3 diagnosis was the most common reason for antibiotic use, accounting for 50% of all indication-associated antibiotic prescribing. Although Tier 3 indications remained the most prescribed-for diagnoses throughout the study period, a declining trend over time is encouraging, with much room for improvement remaining. Elevated prescribing to seniors continues across Canadian outpatient settings, and prescribing quality is of high concern, with 50% of all antimicrobials prescribed inappropriately for common infections that do not require antimicrobials.

Nonalcoholic steatohepatitis in hepatocarcinoma: new insights about its prognostic role in patients treated with lenvatinib

BACKGROUND

Hepatocellular carcinoma (HCC) treatment remains a big challenge in the field of oncology. The liver disease (viral or not viral) underlying HCC turned out to be crucial in determining the biologic behavior of the tumor, including its response to treatment. The aim of this analysis was to investigate the role of the etiology of the underlying liver disease in survival outcomes.

PATIENTS AND METHODS

We conducted a multicenter retrospective study on a large cohort of patients treated with lenvatinib as first-line therapy for advanced HCC from both Eastern and Western institutions. Univariate and multivariate analyses were performed.

RESULTS

Among the 1232 lenvatinib-treated HCC patients, 453 (36.8%) were hepatitis C virus positive, 268 hepatitis B virus positive (21.8%), 236 nonalcoholic steatohepatitis (NASH) correlate (19.2%) and 275 had other etiologies (22.3%). The median progression-free survival (mPFS) was 6.2 months [95% confidence interval (CI) 5.9-6.7 months] and the median overall survival (mOS) was 15.8 months (95% CI 14.9-17.2 months). In the univariate analysis for OS NASH-HCC was associated with longer mOS [22.2 versus 15.1 months; hazard ratio (HR) 0.69; 95% CI 0.56-0.85; P = 0.0006]. In the univariate analysis for PFS NASH-HCC was associated with longer mPFS (7.5 versus 6.5 months; HR 0.84; 95% CI 0.71-0.99; P = 0.0436). The multivariate analysis confirmed NASH-HCC (HR 0.64; 95% CI 0.48-0.86; P = 0.0028) as an independent prognostic factor for OS, along with albumin-bilirubin (ALBI) grade, extrahepatic spread, neutrophil-to-lymphocyte ratio, portal vein thrombosis, Eastern Cooperative Oncology Group (ECOG) performance status and alpha-fetoprotein. An interaction test was performed between sorafenib and lenvatinib cohorts and the results highlighted the positive predictive role of NASH in favor of the lenvatinib arm (P = 0.0047).

CONCLUSION

NASH has been identified as an independent prognostic factor in a large cohort of patients with advanced HCC treated with lenvatinib, thereby suggesting the role of the etiology in the selection of patients for tyrosine kinase treatment. If validated, this result could provide new insights useful to improve the management of these patients.

Quantifying the Gap between Expected and Actual Rates of Antibiotic Prescribing in British Columbia, Canada

Despite decades of stewardship efforts to combat antimicrobial resistance and quantify changes in use, the quality of antibiotic use in British Columbia (BC) remains unknown. As the overuse and misuse of antibiotics drives antibiotic resistance, it is imperative to expand surveillance efforts to examine the quality of antibiotic prescriptions. In late 2019, Canadian expected rates of antibiotic prescribing were developed for common infections. These rates were utilized to quantify the gap between the observed rates of prescribing and Canadian expected rates for antibiotic use for the province of BC. The prescribing data were extracted and matched to physician billing systems using anonymized patient identifiers from 1 January 2000 to 31 December 2018. Outpatient prescribing was further subdivided into community and emergency department settings and stratified by the following age groups: <2 years, 2-18 years, and ≥19 years. The proportions of physician visits that received antibiotic prescription were compared against the Canadian expected rates to quantify the unnecessary use for 18 common indications. Respiratory tract infections (RTI), including acute bronchitis, acute sinusitis, and acute pharyngitis, reported significant levels of overprescribing. Across all ages and health care settings, prescribing for RTI indications occurred at rates 2-8 times higher than the expected rates recommended by a group of expert Canadian physicians. Understanding the magnitude of unnecessary prescribing is a first step in delineating the provincial prescribing quality. The quantification of antibiotic overuse offers concrete targets for provincial stewardship efforts to reduce unnecessary prescribing by an average of 30% across both outpatient and emergency care settings.

Outpatient antibiotic use in British Columbia, Canada: reviewing major trends since 2000

BACKGROUND

With 90% of all antibiotics in Canada being used in the community setting, tracking outpatient prescribing is integral to mitigate the issue of antimicrobial resistance. In 2005, a provincial programme was launched in British Columbia (BC) to disseminate information regarding the judicious use of antibiotics. These efforts include educational campaigns, updated practitioner guidelines and academic detailing. The impact of provincial stewardship on community prescribing requires ongoing evaluation.

OBJECTIVES

This study examines outpatient prescribing to quantify rates of antibiotic use, evaluate major trends over time and identify new targets for stewardship.

METHODS

A retrospective cohort design using population-level data.

RESULTS

This study included over 3.5 million unique individuals with a total of 51 367 938 oral antibiotic prescriptions dispensed over a 19 year period (2000-18). Overall antibiotic utilization decreased by 23% over the course of the study period. This trend in the reduction of antibiotic prescription was observed across all major antibiotic classes, apart from the class of other antibacterials, which was mostly related to use of nitrofurantoin. The largest magnitudes of decreased prescribing were observed in the paediatric population. Prescribing across two distinct eras of provincial stewardship reaffirmed preliminary findings of programme efficacy, when compared with pre-stewardship levels of antibiotic use.

CONCLUSIONS

Outpatient prescribing in BC is decreasing overall, and this study confirms an association between provincial stewardship interventions and improvements in antibiotic use. Pronounced declines in paediatric populations are promising, and further research is underway to examine prescribing quality.

Characterization of raft-forming alginate suspensions formed in HCl or model food systems at varying pH levels to better simulate gastric postprandial conditions

OBJECTIVE

Elucidate properties of raft-forming alginates in vitro with varying composition, a system in which the raft was formed (HCl solution; tomato soup; protein-rich beverage), and pH levels for a more accurate representation of postprandial gastric conditions.

SIGNIFICANCE

Knowledge of the impact of the food system and pH on properties of raft-forming alginates may aid in formulation optimization. Recommendations may be made on food that is consumed prior to their consumption to optimize efficacy as a therapeutic agent.

METHODS

Dispersions of sodium alginate, calcium carbonate, and sodium bicarbonate were prepared with levels similar to commercial formulations. Rafts were formed in HCl solution, tomato soup, and a protein-rich beverage at pH 1-4 to assess raft properties.

RESULTS

Significant differences (p < 0.05) in raft mass, strength, resilience, and ability to buffer acid were observed depending on the system in which the rafts were formed. The highest mass was obtained in tomato soup (48.5 ± 9.8 g) compared to the protein-rich beverage and HCl solution (32.5 ± 4.5 g and 23.4 ± 4.8 g, respectively) at pH 1. Rafts formed in the protein-rich beverage exhibited the highest strength. Rafts formed in both food systems had a greater ability to buffer added acid compared to rafts formed in HCl solution.

CONCLUSIONS

In vitro testing of raft forming alginates in HCl solution at low pH may not be sufficient to describe in vivo events, as a strong matrix effect was observed when rafts were formed in model meal systems at representative postprandial pH levels.

Regional variation in the potentially inappropriate first-line use of fluoroquinolones in Canada as a key to antibiotic stewardship? A drug utilization review study

Background

Serious adverse effects of fluoroquinolone antibiotics have been described for more than decade. Recently, several drug regulatory agencies have advised restricting their use in milder infections for which other treatments are available, given the potential for disabling and possibly persistent side effects. We aimed to describe variations in fluoroquinolone use for initial treatment of urinary tract infection (UTI), acute bacterial sinusitis (ABS), and acute exacerbation of chronic obstructive pulmonary disease (AECOPD) in the outpatient setting across Canada.

Methods

Using administrative health data from six provinces, we identified ambulatory visits with a diagnosis of uncomplicated UTI, uncomplicated AECOPD or ABS. Antibiotic exposure was determined by the first antibiotic dispensed within 5 days of the visit.

Results

We identified 4,303,144 uncomplicated UTI events among 2,170,027 women; the proportion of events treated with fluoroquinolones, mostly ciprofloxacin, varied across provinces, ranging from 18.6% (Saskatchewan) to 51.6% (Alberta). Among 3,467,678 ABS events (2,087,934 patients), between 2.2% (Nova Scotia) and 11.2% (Ontario) were dispensed a fluoroquinolone. For 1,319,128 AECOPD events among 598,347 patients, fluoroquinolones, mostly levofloxacin and moxifloxacin, ranged from 5.8% (Nova Scotia) to 35.6% (Ontario). The proportion of uncomplicated UTI and ABS events treated with fluoroquinolones declined over time, whereas it remained relatively stable for AECOPD.

Conclusions

Fluoroquinolones were commonly used as first-line therapies for uncomplicated UTI and AECOPD. However, their use varied widely across provinces. Drug insurance formulary criteria and enforcement may be a key to facilitating better antibiotic stewardship and limiting potentially inappropriate first-line use of fluoroquinolones.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12879-021-06467-z.

Identification of lenvatinib prognostic index via recursive partitioning analysis in advanced hepatocellular carcinoma

BACKGROUND

After the advent of new treatment options for advanced hepatocellular carcinoma (HCC), the identification of prognostic factors is crucial for the selection of the most appropriate therapy for each patient.

PATIENTS AND METHODS

With the aim to fill this gap, we applied recursive partitioning analysis (RPA) to a cohort of 404 patients treated with lenvatinib.

RESULTS

The application of RPA resulted in a classification based on five variables that originated a new prognostic score, the lenvatinib prognostic index (LEP) index, identifying three groups: low risk [patients with prognostic nutritional index (PNI) >43.3 and previous trans-arterial chemoembolization (TACE)]; medium risk [patients with PNI >43.3 but without previous TACE and patients with PNI <43.3, albumin-bilirubin (ALBI) grade 1 and Barcelona Clinic Liver Cancer stage B (BCLC-B)]; high risk [patients with PNI <43.3 and ALBI grade 2 and patients with PNI <43.3, albumin-bilirubin (ALBI) grade 1 and Barcelona Clinic Liver Cancer stage C (BCLC-C)]. Median overall survival was 29.8 months [95% confidence interval (CI) 22.8-29.8 months] in low risk patients (n = 128), 17.0 months (95% CI 15.0-24.0 months) in medium risk (n = 162) and 8.9 months (95% CI 8.0-10.7 months) in high risk (n = 114); low risk hazard ratio (HR) 1 (reference group), medium risk HR 1.95 (95% CI 1.38-2.74), high risk HR 4.84 (95% CI 3.16-7.43); P < 0.0001. The LEP index was validated in a cohort of 127 Italian patients treated with lenvatinib. While the same classification did not show a prognostic value in a cohort of 311 patients treated with sorafenib, we also show a possible predictive role in favor of lenvatinib in the low risk group.

CONCLUSIONS

LEP index is a promising, easy-to-use tool that may be used to stratify patients undergoing systemic treatment of advanced HCC.

Outpatient prescribing and prophylactic antibiotic use for recurrent urinary tract infections in British Columbia, Canada

INTRODUCTION

Urinary tract infections (UTI) are one of the most common infections, have frequent recurrences, and may debilitate quality of life. UTI is considered recurrent if there are three individual cases of UTI within 12 months. The objective of this study was to set a baseline for recurrent urinary tract infections (rUTI) in women, and rUTI-associated antibiotic prescribing in the presence of antimicrobial stewardship efforts.

METHODS

Data for rUTI in women were organized through a provincial prescription database, physician billing system, and a consolidation file to combine antibiotic prescribing, diagnoses and patient demographics. Rates of rUTI cases and prescriptions were examined, and trends of antibiotics were separated by major anatomical therapeutic chemical classes.

RESULTS

A total of 2 234 903 rUTI-associated prescriptions were dispensed for 674 785 rUTI cases from 2008-2018; 2 205 703 prescriptions were for treatment and 29 310 prescriptions were for prophylaxis of rUTI. The prevalence of rUTI cases declined by 59%, while overall rUTI-associated antibiotic prescribing decreased by 73%. The greatest decrease was seen in quinolones (87%), while nitrofurantoin became the most common rUTI-antibiotic dispensed, accounting for 42% of prescriptions overall.

CONCLUSIONS

Implementation of numerous antimicrobial stewardship efforts may have contributed to the decrease in antibiotic prescribing, particularly for quinolones. In line with local antibiograms and guidelines, nitrofurantoin is the most used antibiotic for rUTI by far, distinctly preferred over other antibiotics secondary to the lack of E. coli resistance.

Impact of the 13-valent pneumococcal conjugate vaccine on acute otitis media and acute sinusitis epidemiology in British Columbia, Canada

BACKGROUND

Numerous studies have characterized the 13-valent pneumococcal conjugate vaccine (PCV13) programme's beneficial effects on acute otitis media (AOM) and acute sinusitis (AS) rates in children; however, few studies have examined the impact on adults.

OBJECTIVES

This retrospective cohort study evaluates the overall effect of the PCV13 immunization programme on the incidence of AOM and AS at the population level.

METHODS

Health administrative databases were linked to assess outpatient visits, hospitalizations and antibiotic utilization from 2000 to 2018. Multivariable Poisson regression was used to evaluate the impact of the PCV13 vaccine programme (2011-18) compared with the pre-PCV13 era (2000-10), overall and by age.

RESULTS

From 2000 to 2018, the incidence of AOM decreased by 50% (62 to 31 per 1000 population) while sinusitis decreased by 18% (33 to 27 per 1000 population). In the PCV13 era, the incidence of AOM declined [incidence rate ratio (IRR): 0.70; 95% CI: 0.70-0.70], in parallel with decreased incidence of antibiotic utilization (IRR: 0.65; 95% CI: 0.64-0.65). A reduction was also observed in the incidence of AS during the PCV13 era compared with the pre-PCV13 era (IRR: 0.88; 95% CI: 0.88-0.88), mainly driven by declines among those younger than 65 years of age. In contrast, an increase in AS incidence was noted in individuals aged ≥65 years (IRR: 1.03; 95% CI: 1.02-1.03). A decrease in antibiotic prescription rates for sinusitis was observed for those under 65 years of age.

CONCLUSIONS

The PCV13 immunization programme is associated with a reduction in the incidence of AOM and AS. Moreover, the associated use of antibiotics for these diagnoses has comparably decreased across paediatric, as well as adult populations.

Community Antibiotic Use at the Population Level During the SARS-CoV-2 Pandemic in British Columbia, Canada

Background

The objective of this study was to examine the aggregate rates of antibiotic use at the population level and compare these rates over time against historical averages to identify the effect of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and the resulting control measures on community prescribing.

Methods

We collected antibiotic prescriptions and physician office visits from January 1, 2016, to July 21, 2020. We calculated monthly prescription rates stratified by sex, age group, profession, diagnosis type, and antibiotic class. We looked at monthly prescription rate as a moving average over time. Using the interrupted time series analysis method, we estimated the changes in prescription rates after March 2020.

Results

The moving average of overall monthly prescription rates during January–June 2020 was below the minimum of the historical years’ moving averages (2016–2019). We observed a >30% reduction in overall monthly prescription rates in April, May, and July of 2020 compared with the same months of 2019. We observed that overall monthly prescription rates experienced a significant level change of –12.79 (P < .001) during the coronavirus disease 2019 pandemic after March 2020, with the greatest level change being –18.02 among children 1–4 years of age (P < .001). We estimated an average –5.94 (P < .001) change in respiratory tract infection (RTI)–associated monthly prescription rates after March 2020. Overall prescription rates comparing January–July 2019 and their 2020 counterparts showed a decrease in monthly prescribing ranging from –1 to –5 for amoxicillin, amoxicillin and enzyme inhibitors, azithromycin, clarithromycin, and sulfamethoxazole.

Conclusions

In British Columbia, Canada, overall and RTI-specific monthly antibiotic prescription rates declined significantly during April–July 2020 compared with the same months in prepandemic years.

CT volume of enhancement of disease (VED) can predict the early response to treatment and overall survival in patients with advanced HCC treated with sorafenib

OBJECTIVES

To analyse the predictive value of the volume of enhancement of disease (VED), based on the CT arterial enhancement coefficient (ΔArt%), in the evaluation of the sorafenib response in patients with advanced hepatocellular carcinoma (HCC).

METHODS

Patients with sorafenib-treated advanced HCC, who underwent a multiphase contrast-enhanced CT before (T0) and after 60-70 days of starting therapy (T1), were included. The same target lesions utilised for the response evaluation according to modified Response Evaluation Criteria in Solid Tumors criteria were retrospectively used for the ΔArt% calculation ([(HUarterial phase - HUunenhanced phase) / HUunenhanced phase] × 100). ΔArt% was weighted for the lesion volume to obtain the VED. We compared VEDT0 and VEDT1 values in patients with clinical benefit (CB) or progressive disease (PD). The impact of VED, ancillary imaging findings, and blood chemistries on survival probability was evaluated.

RESULTS

Thirty-two patients (25 men, mean age 65.8 years) analysed between 2012 and 2016 were selected. At T1, 8 patients had CB and 24 had PD. VEDT0 was > 70% in 8/8 CB patients compared with 12/24 PD patients (p = 0.011). Patients with VEDT0 > 70% showed a significantly higher median survival than those with lower VEDT0 (451.5 days vs. 209.5 days, p = 0.032). Patients with VEDT0 > 70% and alpha-fetoproteinT0 ≤ 400 ng/ml had significantly longer survival than all other three combinations. In multivariate analysis, VEDT0 > 70% emerged as the only factor independently associated with survival (p = 0.037).

CONCLUSION

In patients with advanced HCC treated with sorafenib, VED is a novel radiologic parameter obtained by contrast-enhanced CT, which could be helpful in selecting patients who are more likely to respond to sorafenib, and with a longer survival.

KEY POINTS

• To achieve the best results of treatment with sorafenib in advanced HCC, a strict selection of patients is needed. • New radiologic parameters predictive of the response to sorafenib would be essential. • Volume of enhancement of disease (VED) is a novel radiologic parameter obtained by contrast-enhanced CT, which could be helpful in selecting patients who are more likely to respond to therapy, and with a longer survival.

221. Comparison of dental antibiotic prescribing between Australia, England, the United States and British Columbia in 2017

Background

Antibiotic resistance is recognised as a major public health burden. Dentists overprescribe antibiotics and prescribe for unnecessary indications. Tracking and investigating prescribing practices by healthcare professionals provides insights needed to inform targeted antibiotic stewardship interventions. It is unclear how dental antibiotic prescribing patterns differs between countries. The aim of this study was to compare antibiotic prescribing by dentists in Australia, England the United States (US) and British Columbia (BC).

Methods

This was a cross-sectional study of dispensed dental antibiotic prescriptions between January 1 and December 31, 2017, from Australia, England, US and BC. Dispensed dental antibiotic prescriptions included those from outpatient pharmacies and healthcare settings. Outcome measures included the proportion of dental antibiotic prescriptions by location and prescribing rates by population.

Results

English dentists prescribed 1.6 times more antibiotics than those in Australia, and dentists in BC and US prescribed around twice more than Australian dentists. (Australia: 33.2 prescriptions/1000population; England: 53.5 prescriptions/1000population; US: 72.6 prescriptions/1000 population; BC: 65.0 prescriptions/1000 population). The types of antibiotics prescribed were similar across all countries, where penicillins were the predominant class prescribed (66.8–80.5% of antibiotic prescriptions). US dentists and dentists in BC prescribed more clindamycin compared to the dentists in other countries.

Conclusion

Dentists in the US, England and BC prescribed at relatively higher rates than Australian dentists. The findings from this study should initiate an evaluation by dentists of their prescribing practices and responsibilities regarding their contribution towards antibiotic resistance. Further investigations can be aimed at determining country-specific factors that influence dental antibiotic prescription.

Disclosures

Leanne Teoh, BDSc(Hons) BPharm(Hons), Australian Government Research Training Program Scholarship (Other Financial or Material Support, Scholarship awarded for the PhD candidature)

1462. The protective effect of pneumococcal vaccination on cardiovascular disease in adults: A systematic review and meta-analysis

Background

Epidemiological studies suggest a link between pneumococcal infection and an adverse cardiovascular outcome such as myocardial infarction. Therefore, studies have evaluated the protective effect of the 23-valent polysaccharide pneumococcal vaccination (PPV23), but results have varied. We conducted a meta-analysis to summarize the available evidence on the impact of PPV23 on cardiovascular disease

Methods

A literature search from January 1946 to September 2019 was conducted in Embase, Medline and Cochrane. All studies evaluating PPV23 compared to a control (placebo, no vaccine or another vaccine) for any cardiovascular events including myocardial infarction (MI), heart failure, cerebrovascular events were included. Risk ratios (RRs) were pooled using random effects models.

Results

Eighteen studies were included, with a total of 716,108 participants. Vaccination with PPV23 was associated with decreased risk of any cardiovascular event (RR: 0.91;95% CI: 0.84-0.99), and MI (RR of 0.88; 95% CI:0.79-0.98) in all age groups, with a significant effect in those 65 years and older, but not in the younger age group. Similarly, PPV23 vaccine was associated with significant risk reduction in all-cause mortality in all ages (RR: 0.78; 95%CI: 0.68-0.88), specifically in those aged 65 years and older (RR: 0.71; 95%CI: 0.60-0.84). A significant risk reduction in cerebrovascular disease was not observed following pneumococcal vaccination.

Conclusion

Polysaccharide pneumococcal vaccination decreases the risk of a cardiovascular event, specifically acute MI in the vaccinated population, particularly those 65 years of age and older. It would be highly beneficial to vaccinate the population who is at greater risk for cardiovascular diseases.

Disclosures

Fawziah Marra, BSc (Pharm), PharmD, Pfizer Inc (Research Grant or Support) Nirma Khatri Vadlamudi, BA, BS, MPH, Pfizer Inc (Research Grant or Support)

214. Antibiotic Use for Common Infections in British Columbia: A Review of Outpatient Prescribing from 2000 - 2018

Background

Antimicrobial resistance continues to jeopardize the future of modern medicine; as 92% of all antibiotics are used in the community, it is imperative to parse outpatient prescribing. In British Columbia (BC), efforts to curb the use of these essential medications have included: stewardship campaigns, practitioner guidelines, and vaccine scheduling amendments. This study reviews the trends in antibiotic use over the past two decades to identify new targets for Provincial stewardship and intervention.

Methods

Antibiotic prescription information was extracted from PharmaNet, a centralized data system that links all pharmacies with prescriptions dispensed in the community setting. The Medical Service Plan records reimbursement claims submitted by physicians for services provided, including diagnostic codes. Antibiotic prescriptions were extracted from PharmaNet and then matched to the billing system using anonymized patient identifiers. Prescription rates were calculated, and trends were examined by major anatomical therapeutic chemical (ATC) classification.

Results

Our study included 3,564,258 individuals over an 18-year period, with a total of 26,108,576 antibiotic prescriptions issued, for common infections. Overall antibiotic utilization decreased 18% (from 228 to 187 prescriptions per 1000 population) over the course of the study period. This trend was reflected in both Beta-Lactam (-37%) and Macrolide (-50%) antibiotics; two of the most common classes prescribed in the outpatient setting. A significant outlier was the J01X class of Other Antibacterials, which increased by a staggering 218%, by 2018. Further analyses are currently underway to stratify these changes in magnitude by demographic variables to identify specific, new targets for stewardship.

Rates of outpatient antibiotic prescriptions, for common infections, per 1000 population, by major ATC class, over time.

Conclusion

Outpatient antibiotic prescribing has decreased steadily since 2000. These promising results can be ascribed to the various Provincial initiatives to quell the misuse of these medications. However, many of the indications tied to these prescriptions do not warrant the use of antibiotics, and further analyses are necessary to evaluate prescribing quality to fully delineate the state of antibiotic use in BC. Next steps also include comparing BC rates with Ontario, another large province of Canada.

Disclosures

All Authors: No reported disclosures

1397. Long term impact of the 13-valent pneumococcal conjugate vaccine use in infant immunization program on all-cause pneumonia hospitalizations in British Columbia, Canada: a time series analysis

Background

Pneumonia is a leading cause of hospitalization and in-patient mortality globally. We determined the impact of 13-valent pneumococcal conjugate vaccine (PCV13) use on all-cause pneumonia hospitalization rates eight years after the vaccine was introduced in British Columbia, Canada.

Methods

Routine administrative databases, such as, hospital discharge abstract databases, registry and demographics were used to build the cohort. Overall and age-specific all-cause pneumonia hospital admissions per month (Jan 2000 to Dec 2018) for those aged &lt; 2 years, 2-5 years, 6-17 years, 18-64 years and ≥ 65 years were obtained using International Classification of Diseases 9 and 10 codes (480-486, J12-J18). Changes in the all-cause pneumonia hospitalization incidence rates before and after the PCV13 vaccine program introduction were evaluated using a negative binomial regression and time-series modelling while adjusting for seasonality, influenza-likeness illnesses, 7-valent pneumococcal conjugate vaccine (PCV7) program and pre-PCV13 vaccine secular trends.

Results

Long term use of the PCV13 vaccine in the infant immunization program was associated with significant declines in all-cause pneumonia hospitalization rates among all children, &lt; 2 years (IRR: 0.63; 95% Confidence Interval (CI): 0.59-0.67), 2-5 years (IRR: 0.82; 95%CI: 0.77-0.87) and 6-17 years (IRR: 0.73; 95%CI: 0.69-0.78). All-cause pneumonia rates did not change significantly in those aged 18-64 years (IRR: 0.98; 95%CI: 0.96-1), whereas a modest increase was observed in those 65 years and over (IRR: 1.05; 95%CI: 1.02-1.07). Consequently, we did not observe significant change in the overall rate (IRR: 1.02; 95%CI: 1-1.02).

Conclusion

Significant reduction in all-cause pneumonia hospitalization rates in children demonstrates long term beneficial effect of PCV13 use. A modest increase in all-cause pneumonia hospitalization rates in adults aged 65 years and over indicates a need for further microbial investigation.

Disclosures

Nirma Khatri Vadlamudi, BA, BS, MPH, Pfizer Inc (Research Grant or Support) Fawziah Marra, BSc (Pharm), PharmD, Pfizer Inc (Research Grant or Support)

Incidence of invasive pneumococcal disease after introduction of the 13-valent conjugate pneumococcal vaccine in British Columbia: A retrospective cohort study

BACKGROUND

A significant reduction in invasive pneumococcal disease (IPD) has been reported, across all ages, following the implementation of 7-valent conjugate pneumococcal vaccine (PCV7) globally, as part of infant immunization programs. We explored the additional impact of PCV13 on IPD over a 14-year period.

METHODS

Using provincial laboratory surveillance and hospitalization data (N = 5791), we calculated the annual incidence of IPD following the implementation of PCV13 vaccine. Poisson regression was used to evaluate changes in the overall incidence of IPD, and serotype-specific IPD between PCV7 (2004-10) and PCV13 (2011-2015) eras.

RESULTS

Overall, IPD rates have seen a modest decline in the PCV13 compared to the PCV7 era (IRR 0.84; 95% CI: 0.79-0.89); this was seen in children ≤2 years of age, and the majority of the adult cohort. Rates of vaccine-type IPD (PCV7 and PCV13) also decreased in the PCV13 era. In contrast, IPD incidence related to non-PCV13 (IRR: 1.56; 95%CI:1.43-1.72) and non-vaccine serotypes (IRR: 2.12; 95%CI:1.84-2.45) increased in the PCV13 era compared to the PCV7 era.

CONCLUSIONS

A modest reduction in IPD from the PCV13 vaccine was observed, with gains limited to the immunized cohort and adults. However, a significant increase in non-vaccine serotypes emphasizes the need for continued surveillance.

Estimated Impact of World Health Organization Latent Tuberculosis Screening Guidelines in a Region With a Low Tuberculosis Incidence: Retrospective Cohort Study

BACKGROUND

Latent tuberculosis infection (LTBI) screening and treatment is a key component of the World Health Organization (WHO) EndTB Strategy, but the impact of LTBI screening and treatment at a population level is unclear. We aimed to estimate the impact of LTBI screening and treatment in a population of migrants to British Columbia (BC), Canada.

METHODS

This retrospective cohort included all individuals (N = 1 080 908) who immigrated to Canada as permanent residents between 1985 and 2012 and were residents in BC at any time up to 2013. Multiple administrative databases were linked to identify people with risk factors who met the WHO strong recommendations for screening: people with tuberculosis (TB) contact, with human immunodeficiency virus, on dialysis, with tumor necrosis factor-alpha inhibitors, who had an organ/haematological transplant, or with silicosis. Additional TB risk factors included immunosuppressive medications, cancer, diabetes, and migration from a country with a high TB burden. We defined active TB as preventable if diagnosed ≥6 months after a risk factor diagnosis. We estimated the number of preventable TB cases, given optimal LTBI screening and treatment, based on these risk factors.

RESULTS

There were 16 085 people (1.5%) identified with WHO strong risk factors. Of the 2814 people with active TB, 118 (4.2%) were considered preventable through screening with WHO risk factors. Less than half (49.4%) were considered preventable with expanded screening to include people migrating from countries with high TB burdens, people who had been prescribed immunosuppressive medications, or people with diabetes or cancer.

CONCLUSIONS

The application of WHO LTBI strong recommendations for screening would have minimally impacted the TB incidence in this population. Further high-risk groups must be identified to develop an effective LTBI screening and treatment strategy for low-incidence regions.

Impact of the 13-Valent Pneumococcal Conjugate Vaccine Among Adults: A Systematic Review and Meta-analysis

BACKGROUND

A notable reduction of the pneumococcal disease burden among adults was observed after the introduction of a 7-valent pneumococcal conjugate vaccine (PCV7) in childhood immunization programs. In 2010, a 13-valent pneumococcal conjugate vaccine (PCV13) replaced PCV7 in many jurisdictions; a comparative assessment of PCV13's impact was missing. Our objective was to summarize the available data and assess the change in the incidence of invasive pneumococcal disease (IPD) in adults after the introduction of PCV13 in childhood immunization programs.

METHODS

We conducted a systematic literature search from January 1946 to May 2017 of randomized, controlled trials and observational studies OBS reporting the incidence of IPD, non-invasive pneumococcal disease, hospitalizations, and mortality in adults for the periods before and after the introduction of PCV13. Incidence rate ratios (IRRs) were pooled across studies using restricted, maximum-likelihood, random-effects models.

RESULTS

From 3306 records,we included 29 OBS studies and 2033961 cases. Significantly lower IPD rates were seen after PCV13 introduction in adults aged <65 years (IRR 0.78, 95% confidence interval [CI] 0.72-0.85) and those aged ≥65 years (IRR 0.86, 95% CI 0.81-0.91). Lower rates of IPD were seen with PCV7 (IRR 0.45, 95% CI 0.38-0.54) and PCV13 serotypes (IRR 0.60, 95% CI 0.54-0.68). A significantly higher IRR of 1.10 (95% CI 1.04-1.17) for non-vaccine serotypes was observed, especially among those aged 65 years and older (IRR 1.20, 95% CI 1.11-1.29).

CONCLUSIONS

PCV13 use in children had a moderate impact on reducing the overall and vaccine-type IPDs, but there was a significant increase in non-vaccine type IPDs among adults, especially in those over 65 years.

Increasing paediatric prescribing rates in British Columbian children: cause for concern?

OBJECTIVES

Antibiotic prescribing in paediatric care is highly prevalent, and quite often, children are prescribed for conditions, like upper respiratory tract infections, which are self-limiting and viral in aetiology. The purpose of this study was to identify potential new targets for provincial antimicrobial stewardship efforts.

METHODS

Antibiotic prescription data for children were extracted from a provincial prescription database, linked to physician billing data in order to obtain diagnostic information, and then combined with demographic data in order to obtain patient age, sex and geographic location. Prescription rates were calculated, and trends were examined by major anatomical therapeutic chemical (ATC) classification.

RESULTS

Our cohort included an average of 271,134 children per year and 1,767,652 antibiotic prescriptions. Antibiotic utilization increased 4.5% (from 453 to 474 prescriptions per 1000 population). The greatest increases in prescribing were seen in children aged 0-2 years. Increased indication-specific rates of prescribing were observed in children aged 0-2 years, across every category. Although antibiotic use for upper respiratory tract infections decreased, prescribing rates remain as high as 5 times more than other indications.

CONCLUSION

Past studies have widely illustrated decreasing or static rates of prescribing in British Columbia. However, these results signal a potential problem in the sphere of paediatric antibiotic prescribing, wherein rates have been increasing since 2013. Despite the success of provincial efforts in reducing the use of broad-spectrum penicillins, marked surges in the use of classes like tetracyclines, quinolones and other antibacterials identify a new potential target for provincial stewardship.

The protective effect of pneumococcal vaccination on cardiovascular disease in adults: A systematic review and meta-analysis

BACKGROUND

Epidemiological studies suggest that there is a link between pneumococcal infection and adverse cardiovascular outcomes such as myocardial infarction. Multiple studies have evaluated the protective effect of the 23-valent polysaccharide pneumococcal vaccination (PPV23), but results have varied. Therefore, a meta-analysis was conducted to summarize available evidence on the impact of PPV23 on cardiovascular disease.

METHODS

A literature search from January 1946 to September 2019 was conducted across Embase, Medline and Cochrane. All studies were included that evaluated PPV23 compared with a control (placebo, no vaccine or another vaccine) for any cardiovascular events, including: myocardial infarction (MI), heart failure and cerebrovascular events. Risk ratios (RRs) were pooled using random effects models.

RESULTS

Eighteen studies were included, with a total of 716,108 participants. Vaccination with PPV23 was associated with decreased risk of any cardiovascular event (RR: 0.91; 95% CI: 0.84-0.99), and MI (RR: 0.88; 95% CI: 0.79-0.98) in all age groups, with a significant effect in those aged ≥65 years, but not in the younger age group. Similarly, PPV23 vaccine was associated with significant risk reduction in all-cause mortality in all ages (RR: 0.78; 95% CI: 0.68-0.88), specifically in those aged ≥65 years (RR: 0.71; 95% CI: 0.60-0.84). A significant risk reduction in cerebrovascular disease was not observed following pneumococcal vaccination.

CONCLUSIONS

Polysaccharide pneumococcal vaccination decreased the risk for some adverse cardiovascular events, specifically acute MI in the vaccinated population, particularly for those individuals aged ≥65 years. It would be highly beneficial to vaccinate the population who is at greater risk of cardiovascular diseases.

Anomalous Last Interglacial Tyrrhenian sea levels and Neanderthal settling at Guattari and Moscerini caves (central Italy)

We present a geological-stratigraphical study aimed to provide chronologic constraints to the sea-level markers occurring at two coastal caves of central Italy (Grotta Guattari and Grotta dei Moscerini) and to the Neanderthal frequentation of these caves, in the light of recent archaeological and geomorphological-geochronological studies suggesting similar sea levels during MIS 5.5 and MIS 5.3, and only few m below the Present during MIS 5.1 in this region. Based on the review of previous literature data, combined with new stratigraphic observations at Grotta Guattari and re-analysis of archive material including unpublished field notes from Grotta dei Moscerini, we reconstruct a plausible sea-level history accounting for the lithological and paleoenvironmental features of their sedimentary fillings. In particular, we outline the abundant occurrence of well-rounded pumice clasts within the sedimentary deposits of Moscerini Cave, attesting for the proximity to the beach where this pumice was gathered by wave action. Through the petrographic and geochemical analysis of this pumice we evidence provenance from Phlegraean Fields and Ischia Island volcanic districts, framing their chronology in the time span 118–40 ka, consistent with literature ESR-U/Th dates providing ages ranging 101 ± 5–74 ± 7 ka for the sedimentary filling of both Moscerini and Guattari caves.

Monti Sabatini and Colli Albani: the dormant twin volcanoes at the gates of Rome

This multi-disciplinary work provides an updated assessment of possible future eruptive scenarios for the city of Rome. Seven new ⁴⁰Ar/³⁹Ar ages from selected products of the Monti Sabatini and Vulsini volcanic districts, along with a compilation of all the literature ages on the Colli Albani and Vico products, are used to reconstruct and compare the eruptive histories of the Monti Sabatini and Colli Albani over the last 900 ka, in order to define their present state of activity. Petrographic analyses of the dated units characterize the crystal cargo, and Advanced-InSAR analysis highlights active deformation in the MS. We also review the historical and instrumental seismicity affecting this region. Based on the chronology of the most recent phases and the time elapsed between the last eruptions, we conclude that the waning/extinguishment of eruptive activity shifted progressively from NW to SE, from northern Latium toward the Neapolitan area, crossing the city of Rome. Although Monti Sabatini is unaffected by the unrest indicators presently occurring at the Colli Albani, it should be regarded as a dormant volcanic district, as the time of 70 kyr elapsed since the last eruption is of the same order of the longest dormancies occurred in the past.

Decreasing antibiotic use, the gut microbiota, and asthma incidence in children: evidence from population-based and prospective cohort studies

BACKGROUND

Childhood asthma incidence is decreasing in some parts of Europe and North America. Antibiotic use in infancy has been associated with increased asthma risk. In the present study, we tested the hypothesis that decreases in asthma incidence are linked to reduced antibiotic prescribing and mediated by changes in the gut bacterial community.

METHODS

This study comprised population-based and prospective cohort analyses. At the population level, we used administrative data from British Columbia, Canada (population 4·7 million), on annual rates of antibiotic prescriptions and asthma diagnoses, to assess the association between antibiotic prescribing (at age <1 year) and asthma incidence (at age 1-4 years). At the individual level, 2644 children from the Canadian Healthy Infant Longitudinal Development (CHILD) prospective birth cohort were examined for the association of systemic antibiotic use (at age <1 year) with the diagnosis of asthma (at age 5 years). In the same cohort, we did a mechanistic investigation of 917 children with available 16S rRNA gene sequencing data from faecal samples (at age ≤1 year), to assess how composition of the gut microbiota relates to antibiotic exposure and asthma incidence.

FINDINGS

At the population level between 2000 and 2014, asthma incidence in children (aged 1-4 years) showed an absolute decrease of 7·1 new diagnoses per 1000 children, from 27·3 (26·8-28·3) per 1000 children to 20·2 (19·5-20·8) per 1000 children (a relative decrease of 26·0%). Reduction in incidence over the study period was associated with decreasing antibiotic use in infancy (age <1 year), from 1253·8 prescriptions (95% CI 1219·3-1288·9) per 1000 infants to 489·1 (467·6-511·2) per 1000 infants (Spearman's r=0·81; p<0·0001). Asthma incidence increased by 24% with each 10% increase in antibiotic prescribing (adjusted incidence rate ratio 1·24 [95% CI 1·20-1·28]; p<0·0001). In the CHILD cohort, after excluding children who received antibiotics for respiratory symptoms, asthma diagnosis in childhood was associated with infant antibiotic use (adjusted odds ratio [aOR] 2·15 [95% CI 1·37-3·39]; p=0·0009), with a significant dose-response; 114 (5·2%) of 2182 children unexposed to antibiotics had asthma by age 5 years, compared with 23 (8·1%) of 284 exposed to one course, five (10·2%) of 49 exposed to two courses, and six (17·6%) of 34 exposed to three or more courses (aOR 1·44 [1·16-1·79]; p=0·0008). Increasing α-diversity of the gut microbiota, defined as an IQR increase (25th to 75th percentile) in the Chao1 index, at age 1 year was associated with a 32% reduced risk of asthma at age 5 years (aOR for IQR increase 0·68 [0·46-0·99]; p=0·046). In a structural equation model, we found the gut microbiota at age 1 year, characterised by α-diversity, β-diversity, and amplicon sequence variants modified by antibiotic exposure, to be a significant mediator between outpatient antibiotic exposure in the first year of life and asthma diagnosis at age 5 years (β=0·08; p=0·027).

INTERPRETATION

Our findings suggest that the reduction in the incidence of paediatric asthma observed in recent years might be an unexpected benefit of prudent antibiotic use during infancy, acting via preservation of the gut microbial community.

FUNDING

British Columbia Ministry of Health, Pharmaceutical Services Branch; Canadian Institutes of Health Research; Allergy, Genes and Environment (AllerGen) Network of Centres of Excellence; Genome Canada; and Genome British Columbia.

Unsupported Ni metal catalyst in hydrothermal liquefaction of oak wood: Effect of catalyst surface modification

Hydrothermal liquefaction of oak wood was carried out in tubular micro reactors at different temperatures (280-330 °C), reaction times (10-30 min), and catalyst loads (10-50 wt%) using metallic Ni catalysts. For the first time, to enhance the catalytic activity of Ni particles, a coating technique producing a nanostructured surface was used, maintaining anyway the micrometric dimension of the catalyst, necessary for an easier recovery. The optimum conditions for non-catalytic liquefaction tests were determined to be 330 °C and 10 min with the bio-crude yield of 32.88%. The addition of metallic Ni catalysts (Commercial Ni powder and nanostructured surface-modified Ni particle) increased the oil yield and inhibited the char formation through hydrogenation action. Nano modified Ni catalyst resulted in a better catalytic activity in terms of bio-crude yield (36.63%), thanks to the higher surface area due to the presence of flower-like superficial nanostructures. Also, bio-crude quality resulted improved with the use of the two catalysts, with a decrease of C/H ratio and a corresponding increase of the high heating value (HHV). The magnetic recovery of the catalysts and their reusability was also investigated with good results.

Risk Factors for Herpes Zoster Infection: A Meta-Analysis

Background

The burden of herpes zoster (HZ) is significant worldwide, with millions affected and the incidence rising. Current literature has identified some risk factors for this disease; however, there is yet to be a comprehensive study that pools all evidence to provide estimates of risk. Therefore, the purpose of this study is to identify various risk factors, excluding immunosuppressive medication, that may predispose an individual to developing HZ.

Methods

The literature search was conducted in MEDLINE, EMBASE, and Cochrane Central, yielding case control, cohort, and cross-sectional studies that were pooled from January 1966 to September 2017. Search terms included the following: zoster OR herpe* OR postherpe* OR shingle* AND risk OR immunosupp* OR stress OR trauma OR gender OR ethnicity OR race OR age OR diabetes OR asthma OR chronic obstructive pulmonary disease OR diabetes. Risk ratios (RRs) for key risk factors were calculated via natural logarithms and pooled using random-effects modeling.

Results

From a total of 4417 identified studies, 88 were included in analysis (N = 3, 768 691 HZ cases). Immunosuppression through human immunodeficiency virus/acquired immune deficiency syndrome (RR = 3.22; 95% confidence interval [CI], 2.40–4.33) or malignancy (RR = 2.17; 95% CI, 1.86–2.53) significantly increased the risk of HZ compared with controls. Family history was also associated with a greater risk (RR = 2.48; 95% CI, 1.70–3.60), followed by physical trauma (RR = 2.01; 95% CI, 1.39–2.91) and older age (RR = 1.65; 95% CI, 1.37–1.97). A slightly smaller risk was seen those with psychological stress, females, and comorbidities such as diabetes, rheumatoid arthritis, cardiovascular diseases, renal disease, systemic lupus erythematosus, and inflammatory bowel disease compared with controls (RR range, 2.08–1.23). We found that black race had lower rates of HZ development (RR = 0.69; 95% CI, 0.56–0.85).

Conclusions

This study demonstrated a number of risk factors for development of HZ infection. However, many of these characteristics are known well in advance by the patient and clinician and may be used to guide discussions with patients for prevention by vaccination.

Cost-effectiveness of Latent Tuberculosis Infection Screening before Immigration to Low-Incidence Countries

Prospective migrants to countries where the incidence of tuberculosis (TB) is low (low-incidence countries) receive TB screening; however, screening for latent TB infection (LTBI) before immigration is rare. We evaluated the cost-effectiveness of mandated and sponsored preimmigration LTBI screening for migrants to low-incidence countries. We used discrete event simulation to model preimmigration LTBI screening coupled with postarrival follow-up and treatment for those who test positive. Preimmigration interferon-gamma release assay screening and postarrival rifampin treatment was preferred in deterministic analysis. We calculated cost per quality-adjusted life-year gained for migrants from countries with different TB incidences. Our analysis provides evidence of the cost-effectiveness of preimmigration LTBI screening for migrants to low-incidence countries. Coupled with research on sustainability, acceptability, and program implementation, these results can inform policy decisions.

Cost-benefit analysis of a population-based education program on the wise use of antibiotics

OBJECTIVE

In 2005, the Do Bugs Need Drugs (DBND) program was imported to British Columbia (BC) from Alberta with the goal of reducing unnecessary antibiotic use in the community. The objective of this study was to estimate the impact of the program on antibiotic-associated costs and cost-benefit.

METHODS

We used data on antibiotic prescription and costs from BC PharmaNet for the period of 1996 to 2014. We conducted interrupted time series regression to formally interpret the impact of the DBND program.

RESULTS

The average monthly prescription rate fell by 14.5%, from 54.3 to 46.4 per 1000 population between 2005 and 2014. The proportionate contribution of macrolide prescription decreased from 19.2% in 2005 to 13.2% in 2014 and for quinolones decreased from 13.1% in 2005 to 12% in 2014. The proportion of prescriptions for both penicillins and tetracyclines increased by > 35.5%. Before the program, the average monthly cost of antibiotics was increasing by CAD $8.12 per 1000 population (p < 0.001). After program introduction, average monthly cost decreased by CAD $18.19 per 1000 population (p < 0.001), creating an annual savings for BC in 2014 of CAD $83.6 million. In 2014, one Canadian dollar spent on the DBND program was associated with conservative savings of CAD $76.20.

CONCLUSION

Significant cost savings have been observed in association with a community antimicrobial stewardship program focused on both public and prescribers. Such programs are an effective strategy in cost-benefit terms and should therefore be considered for universal adoption in Canadian healthcare systems.

The use and misuse of antibiotics in dentistry: A scoping review

BACKGROUND

To describe antibiotic prescribing behaviors in dentistry, including clinical and nonclinical indications for their use, the type and regimen of antibiotics prescribed, and factors influencing their prescription, the authors conducted a scoping review.

TYPES OF STUDIES REVIEWED

The authors conducted a scoping review of published literature by searching multiple databases. Key search terms included dentist, antibiotic, antimicrobial, antibacterial, prophylaxis, prescription, pattern, habit, knowledge, and practice. Two authors independently reviewed titles and abstracts by using detailed eligibility criteria. The authors placed no restrictions on study design or publication year. The authors qualitatively assessed studies by using a modified version of the Center for Evidence-Based Management's critical appraisal of a survey checklist.

RESULTS

The authors identified 1,912 studies but considered only 118 studies eligible for review. Most included studies were either cross-sectional surveys (81 studies) or prescription audits (25 studies) from various geographic locations. Publication dates ranged from 1982 through 2017. The authors examined prophylactic and therapeutic antibiotic use in 48 and 29 studies, respectively. Another 29 studies examined the use of both prophylactic and therapeutic antibiotics in dentistry. Overall, dentists prescribed a wide variety of antibiotic regimens for various clinical and nonclinical indications. Dentists have acquired their prescribing knowledge from a variety of sources and have changed their antibiotic prescribing practices throughout their careers for various reasons.

CONCLUSIONS AND PRACTICAL IMPLICATIONS

Considering the seriousness of antibiotic resistance, the authors highlight trends in antibiotic prescribing practices, characterize factors contributing to the use and misuse of antibiotics in dentistry, provide insight into the importance of antibiotic stewardship in the oral health setting, and encourage dentists to reflect on their antibiotic prescription practices.

2302. A Meta-Analysis of Risk Factors for Herpes Zoster Infection

Background

The burden of herpes zoster (HZ) is significant worldwide, with millions affected and the incidence rising. Current literature has identified some risk factors for this disease; however, there is yet to be a comprehensive study that pools all evidence to provide estimates of risk. Therefore, The purpose of this study was to identify various risk factors, excluding immunosuppressive medication, that may predispose an individual to developing herpes zoster.

Methods

The literature search was conducted in MEDLINE, EMBASE, Cochrane Central, Cochrane Systematic Reviews, Web of Science, CAB Direct, yielding case–control, cohort and cross-sectional studies that were pooled from January 1966 to September 2018. Search terms included: zoster OR herpe*OR postherpe*OR shingle*AND riskOR immunosupp*OR stress OR trauma OR gender OR ethnicity OR race OR age OR diabetes OR asthma OR chronic obstructive pulmonary disease OR diabetes. Risk ratios for key risk factors were calculated via natural logarithms and pooled using random effects modeling.

Results

From a total of 4417 identified studies, 93 were included in analysis (n = 3826134 HZ cases). Immunosuppression through HIV/AIDS (RR 3.25; 95% CI 2.47–4.27) or malignancy (RR 2.17; 95% CI 1.86–2.53) significantly increased the risk of HZ compared with controls. Family history was also associated with a greater risk (RR 2.48; 95% CI 1.70–3.60), followed by physical trauma (RR 2.01; 95% CI 1.39–2.91) and older age (RR 1.68; 95% CI 1.41–2.01). A slightly smaller risk was seen those with psychological stress, females, and comorbidities such as diabetes, rheumatoid arthritis, cardiovascular diseases, renal disease, SLE, and IBD compared with controls (RR range: 2.08 to 1.25). We found that black race had lower rates of HZ development RR 0.69 (95% CI 0.56–0.85).

Conclusion

This study demonstrated patients with family history of HZ, older age, female sex, have particular comorbidities or are immunosuppressed have an elevated risk of herpes zoster. Patients with these characteristics are prime candidates for vaccination.

Disclosures

All authors: No reported disclosures.

1118. Trends of Paediatric Prescribing for Common Infections in British Columbia

Background

Antibiotic prescribing in pediatric care is highly prevalent, and quite often children are prescribed for conditions which are commonly self-limiting and viral in etiology. The purpose of this study was to examine the scope of pediatric antibiotic prescribing by indication, from 2013 to 2016, and identify potential new targets for provincial antimicrobial stewardship efforts.

Methods

Antibiotic prescription data for children were extracted from a provincial prescription database, and linked to physician billing data in order to obtain diagnostic information. Prescription rates were then calculated, and trends were examined by indication. Major categories included: upper respiratory tract infection, acute otitis media, lower respiratory tract, skin and soft tissue, and urinary tract infections.

Results

Our database included an average of 244,763 children per year, and 5,896,173 total antibiotic prescriptions. Increased indication-specific rates of prescribing were observed in children aged 0–2 years, for every category. Children aged 3–18 years experienced decreased prescribing across all indications, with the exception of urinary tract infections for those aged between 10–18 years. Urinary tract infections increased by 134% for children aged 0–2 years, and 75% for those aged 10–18 years, from 2013 to 2016. Although antibiotic use for upper respiratory tract infections decreased by 11% for all ages, these diagnoses continue to be prescribed for at rates 2 – 5 times higher than other conditions.

Conclusion

Although this study found a decrease in prescribing over time across all indications, antibiotic use continues to be a concern for upper respiratory tract infections in pediatric care. These diagnoses generally do not require antibiotics, and inappropriate prescribing is a major factor in antimicrobial resistance. The increased prescribing rates in the youngest age group (0–2 years) offers a new target for provincial stewardship efforts.

Disclosures

All authors: No reported disclosures.

1146. Antibiotic Use in Infants Predicts Asthma Rate in Children 1–4 years at Fine Geographic Scale

Background

Early-life exposure to antibiotics is associated with childhood asthma. We previously reported that a dramatic drop in infant antibiotic use is correlated with a decline in asthma incidence in children in British Columbia (BC). This study aims to see whether antibiotic exposure predicts asthma at a fine geographic scale after adjustment for known covariates.

Methods

We used prescribing data from BC PharmaNet, a population-based database capturing all outpatient prescribing for BC population (n = 4.7 million). Prescribing rates for infants <1 year were calculated as prescriptions per 1000 population per year using age and sex-specified denominator estimates. Age-adjusted aggregate asthma incidence data for children 1–4 years were obtained from the BC Ministry of Health Chronic Disease Registry. The disease identification uses a standard case definition making using of diagnostic codes (ICD9-493 and ICD10-J45) in BC’s universal hospital and physician billing databases and relevant asthma-specific drug data from BC PharmaNet. We modeled the association between antibiotic prescribing rate and asthma incidence in 91 Local Health Areas using multivariable Poisson regression employing a generalized linear mixed-effects model adjusting for covariates.

Results

Between 2000 and 2014, the annual asthma incidence (ages 1–4 years) fell 26% from 27.3 (95% CI: 26.5–28.0) to 20.2 (95% CI: 19.5–20.8) per 1000 population. For children aged 1–4 years in 2000, the average proportion of infants exposed to one or more courses of antibiotics fell from 66.9 to 32.1% over the same interval. Antibiotic was a significant predictor of asthma rate (IRR=1.24 per 10% absolute increase in antibiotic prescribing; 95% CI: 1.19–1.27). Other covariates that remained significant in the model included male sex (IRR=1.56; 95% CI: 1.53–1.58), and atmospheric particulate matter PM 2.5 (IRR=1.08 per interquartile increase; 95% CI: 1.06–1.10).

Conclusion

Our findings suggest that antibiotic exposure in the first year of life increases the risk of being diagnosed with asthma later in childhood. This is congruent with similar findings at the individual level in a prospective cohort of Canadian children that also points to a pathway through altered gut microbiota.

Disclosures

All authors: No reported disclosures.

1117. A Retrospective Analysis of Paediatric Prescribing in British Columbia from 2013 to 2016

Background

Antibiotic prescribing in pediatric care is highly prevalent. Often children are prescribed antibiotics for conditions that are commonly self-limiting and viral in etiology such as upper respiratory tract infections. The purpose of this study was to examine the scope of pediatric antibiotic prescribing in British Columbia from 2013 to 2016 and identify potential new provincial antimicrobial stewardship targets.

Methods

Antibiotic prescription data for children were extracted from a provincial prescription database, and linked to demographic files in order to obtain patient age, sex and geographic location. Prescription rates were then calculated, and trends were examined by major anatomical therapeutic chemical (ATC) classification.

Results

Our cohort included an average of 271,134 children per year and 1,767,652 antibiotic prescriptions. Over the 4 years, rates of antibiotic prescribing increased 4.5% (from 453 to 474 prescriptions per 1,000 population per year). The greatest increase, across all classes of antibiotics, was seen in children aged 0–2 years of age. By 2016, the greatest increase in prescribing, by class, was observed in J01X (e.g., nitrofurantoin, fosfomycin) with a 1360% increase for children aged 3–9. Across all ages, quinolones (J01M) increased 98%. Remaining classes, including β lactams (J01C), and macrolides (J01F), experienced modest reductions in the older age groups.

Conclusion

Past studies have illustrated decreasing or static rates of antibiotic prescribing in British Columbia. However, we have identified a paradoxical (4.5%) increase in pediatric antibiotic prescribing since 2013. Although it appears that provincial efforts have been successful in reducing the use of broad-spectrum penicillins (J01C), marked surges in the use of classes like tetracylines (J01A), quinolones (J01M), and other antibacterials (J01X) identify a new potential target for provincial stewardship.

Disclosures

All authors: No reported disclosures.

2706. Indirect Effects of Infant 13-valent Conjugate Pneumococcal Vaccination Program on Invasive Pneumococcal Disease in Adults in British Columbia, Canada

Background

Many jurisdictions report a significant reduction in invasive pneumococcal disease (IPD) in adults following implementation of the pneumococcal conjugate vaccines, 7-valent (PCV7) and 13-valent (PCV13) in childhood immunization programs. This study evaluates the indirect effect of conjugate vaccines on IPD in British Columbia, Canada over a 14 year period (2002–2015).

Methods

Using provincial IPD laboratory surveillance data, we calculated the annual incidence following implementation of PCV7 (September 2004), and PCV13 (September 2010) in adults 18 years of age and older. We also compared incidence rate ratios (IRR) against pre-PCV13 (2004–2010) and pre-PCV7 (2002–2003) baselines for overall and age-specific IPD rates using Poisson regression.

Results

A total of 3793 cases were reported over the 14 year period. The overall annual incidence increased from 4.32 cases per 100,000 population in 2002 to 8.61 cases per 100,000 population in 2015. Overall, IPD has increased by 80% (IRR: 1.80; 95% CI: 1.59–2.04) compared with baseline, especially in adults ≥ 85 years of age (PCV13 vs baseline: IRR: 1.90; 95% CI: 1.25–03.05). This increase was the highest after introduction of PCV7 (IRR: 1.87; 95% CI: 1.65–2.11); the incremental change after introduction of PCV13 was non-significant (IRR 0.96; 95% CI: 0.90–1.03). While PCV7 type IPD plummeted by 76% (IRR 0.24; 95% CI: 0.18–0.31) since introduction of PCV7 compared with baseline, a modest decline in PCV13 type IPD of 20% was seen (IRR 0.80; 95% CI: 0.71–0.89) since introduction of PCV13.

Conclusion

Although PCV7-type IPD has decreased substantially, only a modest reduction in IPD from the additional 6 serotypes in the PCV13 vaccine was observed.

Disclosures

All authors: No reported disclosures.