Ambulatory amoxicillin use for common acute respiratory infections during a national shortage: Results from the SHARPS-OP benchmarking collaborative

We quantified antibiotic prescribing for ambulatory pediatric acute respiratory illness at 22 institutions in "pre-shortage" (Jan 2019-Sep 2022) and "shortage" (Oct 2022-Mar 2023) periods for amoxicillin. While acute respiratory illness prescribing increased across settings, the proportion of amoxicillin prescriptions decreased. Variation was seen within and between institutions.

Utility of Methicillin-Resistant Staphylococcus aureus Nasal PCR Testing in Pediatric Patients With Suspected Respiratory Infections

Observational studies in adults suggest nasal methicillin-resistant Staphylococcus aureus (MRSA) swabs have a high negative predictive value (NPV) for ruling out MRSA pneumonia, however, pediatric data are limited. This retrospective study of 505 pediatric patients found a 99.8% NPV among children with suspected respiratory infections.

Opportunistic dried blood spot sampling validates and optimizes a pediatric population pharmacokinetic model of metronidazole

Pharmacokinetic models rarely undergo external validation in vulnerable populations such as critically ill infants, thereby limiting the accuracy, efficacy, and safety of model-informed dosing in real-world settings. Here, we describe an opportunistic approach using dried blood spots (DBS) to evaluate a population pharmacokinetic model of metronidazole in critically ill preterm infants of gestational age (GA) ≤31 weeks from the Metronidazole Pharmacokinetics in Premature Infants (PTN_METRO, NCT01222585) study. First, we used linear correlation to compare 42 paired DBS and plasma metronidazole concentrations from 21 preterm infants [mean (SD): post natal age 28.0 (21.7) days, GA 26.3 (2.4) weeks]. Using the resulting predictive equation, we estimated plasma metronidazole concentrations (ePlasma) from 399 DBS collected from 122 preterm and term infants [mean (SD): post natal age 16.7 (15.8) days, GA 31.4 (5.1) weeks] from the Antibiotic Safety in Infants with Complicated Intra-Abdominal Infections (SCAMP, NCT01994993) trial. When evaluating the PTN_METRO model using ePlasma from the SCAMP trial, we found that the model generally predicted ePlasma well in preterm infants with GA ≤31 weeks. When including ePlasma from term and preterm infants with GA >31 weeks, the model was optimized using a sigmoidal Emax maturation function of postmenstrual age on clearance and estimated the exponent of weight on volume of distribution. The optimized model supports existing dosing guidelines and adds new data to support a 6-hour dosing interval for infants with postmenstrual age >40 weeks. Using an opportunistic DBS to externally validate and optimize a metronidazole population pharmacokinetic model was feasible and useful in this vulnerable population.

A chemical screen identifies structurally diverse metal chelators with activity against the fungal pathogen Candida albicans

Candida albicans, one of the most prevalent human fungal pathogens, causes diverse diseases extending from superficial infections to deadly systemic mycoses. Currently, only three major classes of antifungal drugs are available to treat systemic infections: azoles, polyenes, and echinocandins. Alarmingly, the efficacy of these antifungals against C. albicans is hindered both by basal tolerance toward the drugs and the development of resistance mechanisms such as alterations of the drug's target, modulation of stress responses, and overexpression of efflux pumps. Thus, the need to identify novel antifungal strategies is dire. To address this challenge, we screened 3,049 structurally-diverse compounds from the Boston University Center for Molecular Discovery (BU-CMD) chemical library against a C. albicans clinical isolate and identified 17 molecules that inhibited C. albicans growth by >80% relative to controls. Among the most potent compounds were CMLD013360, CMLD012661, and CMLD012693, molecules representing two distinct chemical scaffolds, including 3-hydroxyquinolinones and a xanthone natural product. Based on structural insights, CMLD013360, CMLD012661, and CMLD012693 were hypothesized to exert antifungal activity through metal chelation. Follow-up investigations revealed all three compounds exerted antifungal activity against non-albicans Candida, including Candida auris and Candida glabrata, with the xanthone natural product CMLD013360 also displaying activity against the pathogenic mould Aspergillus fumigatus. Media supplementation with metallonutrients, namely ferric or ferrous iron, rescued C. albicans growth, confirming these compounds act as metal chelators. Thus, this work identifies and characterizes two chemical scaffolds that chelate iron to inhibit the growth of the clinically relevant fungal pathogen C. albicansIMPORTANCEThe worldwide incidence of invasive fungal infections is increasing at an alarming rate. Systemic candidiasis caused by the opportunistic pathogen Candida albicans is the most common cause of life-threatening fungal infection. However, due to the limited number of antifungal drug classes available and the rise of antifungal resistance, an urgent need exists for the identification of novel treatments. By screening a compound collection from the Boston University Center for Molecular Discovery (BU-CMD), we identified three compounds representing two distinct chemical scaffolds that displayed activity against C. albicans. Follow-up analyses confirmed these molecules were also active against other pathogenic fungal species including Candida auris and Aspergillus fumigatus. Finally, we determined that these compounds inhibit the growth of C. albicans in culture through iron chelation. Overall, this observation describes two novel chemical scaffolds with antifungal activity against diverse fungal pathogens.

Teams in Transition: Increasing Role of Advanced Practice Providers in Antimicrobial Use and Infectious Diseases Consultation

Background

Advanced practice providers (APPs) have taken on increasing responsibilities as primary team members in acute care hospitals, but the impact of this practice shift on antimicrobial prescribing and infectious diseases (ID) consultation requests is unknown. Here we describe longitudinal trends in antimicrobial days of therapy (DOT) and ID consultation by attributed provider type in 3 hospitals.

Methods

We performed a retrospective time series analysis of antimicrobial use and ID consultation from July 2015 to June 2022 at a major university hospital and 2 community hospitals. We evaluated antimicrobial DOT and ID consultation over time and assessed attribution to 3 groups of providers: attending physicians, trainees, and APPs. We used multinomial logistic regression to measure changes in percentage of DOT and ID consultation across the clinician groups over time using physicians as the referent.

Results

Baseline distribution of antimicrobial DOT and ID consultation varied by practice setting, but all subgroups showed increases in the proportion attributable to APPs. Large increases were seen in the rate of ID consultation, increasing by >30% during the study period. At our university hospital, by study end >40% of new ID consults and restricted antimicrobial days were attributed to APPs.

Conclusions

Hospitals had differing baseline patterns of DOT attributed to provider groups, but all experienced increases in DOT attributed to APPs. Similar increases were seen in changes to ID consultation. APPs have increasing involvement in antimicrobial use decisions in the inpatient setting and should be engaged in future antimicrobial stewardship initiatives.

Demonstrating the reliability of in vivo metabolomics based chemical grouping: towards best practice

While grouping/read-across is widely used to fill data gaps, chemical registration dossiers are often rejected due to weak category justifications based on structural similarity only. Metabolomics provides a route to robust chemical categories via evidence of shared molecular effects across source and target substances. To gain international acceptance, this approach must demonstrate high reliability, and best-practice guidance is required. The MetAbolomics ring Trial for CHemical groupING (MATCHING), comprising six industrial, government and academic ring-trial partners, evaluated inter-laboratory reproducibility and worked towards best-practice. An independent team selected eight substances (WY-14643, 4-chloro-3-nitroaniline, 17α-methyl-testosterone, trenbolone, aniline, dichlorprop-p, 2-chloroaniline, fenofibrate); ring-trial partners were blinded to their identities and modes-of-action. Plasma samples were derived from 28-day rat tests (two doses per substance), aliquoted, and distributed to partners. Each partner applied their preferred liquid chromatography-mass spectrometry (LC-MS) metabolomics workflows to acquire, process, quality assess, statistically analyze and report their grouping results to the European Chemicals Agency, to ensure the blinding conditions of the ring trial. Five of six partners, whose metabolomics datasets passed quality control, correctly identified the grouping of eight test substances into three categories, for both male and female rats. Strikingly, this was achieved even though a range of metabolomics approaches were used. Through assessing intrastudy quality-control samples, the sixth partner observed high technical variation and was unable to group the substances. By comparing workflows, we conclude that some heterogeneity in metabolomics methods is not detrimental to consistent grouping, and that assessing data quality prior to grouping is essential. We recommend development of international guidance for quality-control acceptance criteria. This study demonstrates the reliability of metabolomics for chemical grouping and works towards best-practice.

Pediatric Antimicrobial Stewardship Programs Reduce Antibiotic Use at Combined Adult-Pediatric Hospitals

Implementation of dedicated pediatric antimicrobial stewardship programs (ASPs) at two combined adult-pediatric hospitals with existing ASPs was associated with sustained decreases in pediatric antibiotic use (AU) out of proportion to declines seen in adult inpatient units. ASPs in combined hospitals may not detect excessive pediatric AU without incorporating pediatric expertise.

What medical-legal partnerships can do for trauma patients and trauma care

ABSTRACT

Trauma patients are particularly vulnerable to the impact of preexisting social and legal determinants of health postinjury. Trauma patients have a wide range of legal needs, including housing, employment, debt, insurance coverage, and access to federal and state benefits. Legal support could provide vital assistance to address the social determinants of health for injured patients. Medical legal partnerships (MLPs) embed legal professionals within health care teams to improve health by addressing legal needs that affect health. Medical legal partnerships have a successful track record in oncology, human immunodeficiency virus/acquired immune deficiency syndrome, and pediatrics, but have been little used in trauma. We conducted a scoping review to describe the role of MLPs and their potential to improve health outcomes for patients with traumatic injuries. We found that MLPs use legal remedies to address a variety of social and structural conditions that could affect patient health across several patient populations, such as children with asthma and patients with cancer. Legal intervention can assist patients in obtaining stable and healthy housing, employment opportunities, debt relief, access to public benefits, and immigration assistance. Medical legal partnership structure varies across institutions. In some, MLP lawyers are employed directly by a health care institution. In others, MLPs function as partnerships between a health system and an external legal organization. Medical legal partnerships have been found to reduce hospital readmissions, increase treatment utilization by patients, decrease patient stress levels, and benefit health systems financially. This scoping review outlines the potential of MLPs to improve outcomes for injured patients. Establishing trauma-focused MLPs could be a feasible intervention for trauma centers around the country seeking to improve health outcomes and reduce disparities for injured patients.

Variations in antibiotic prescribing among children enrolled in North Carolina Medicaid, 2013-2019

PURPOSE

The majority of pediatric antibiotic prescribing occurs in the outpatient setting and inappropriate use contributes to antimicrobial resistance. There are regional variations in outpatient antibiotic use with the highest rates occurring in the Southern states, including in Appalachia. The purpose of this study was to describe the rates and risk factors for inappropriate antibiotic prescription among pediatric patients enrolled in North Carolina (NC) Medicaid.

METHODS

We used Medicaid prescription claims data from 2013 to 2019 to describe patterns of pediatric antibiotic prescription in NC. We assessed patient and provider factors to identify variations in prescribing.

FINDINGS

Children who were less than 2 years of age, non-Hispanic White, and living in a rural area had the highest overall rates of antibiotic prescription. Compared to pediatricians, the risk of inappropriate antibiotic prescription was highest among other specialists and general practioners and lowest among nurse practitioners. Rural areas of NC had the highest rates of inappropriate antibiotic prescribing, and the risk for non-Hispanic Black children compared to children of other races/ethnicities was compounded by rurality.

CONCLUSIONS

Prescribing practices in NC differ compared to neighboring states with a lower overall risk of inappropriate prescription in Appalachian regions; however, disparities by race and rurality exist. Outpatient stewardship efforts in NC should focus on ensuring health equity by appreciating racial and geographic variations in prescribing patterns and providing education to all health care providers.

Immunogenicity and safety of varying dosages of a fifth-wave influenza A/H7N9 inactivated vaccine given with and without AS03 adjuvant in healthy adults

BACKGROUND

Human infections with the avian influenza A(H7N9) virus were first reported in China in 2013 and continued to occur in annual waves. In the 2016/2017 fifth wave, Yangtze River Delta (YRD) lineage viruses, which differed antigenically from those of earlier waves, predominated.

METHODS

In this phase 2 double-blinded trial we randomized 720 adults ≥ 19 years of age to receive two injections of a YRD lineage inactivated A/Hong Kong/125/2017 fifth-wave H7N9 vaccine, given 21 days apart, at doses of 3.75, 7.5, and 15 µg of hemagglutinin (HA) with AS03A adjuvant and at doses of 15 and 45 µg of HA without adjuvant.

RESULTS

Two doses of adjuvanted vaccine were required to induce HA inhibition (HI) antibody titers ≥ 40 in most participants. After two doses of the 15 µg H7N9 formulation, given with or without AS03 adjuvant, the proportion achieving a HI titer ≥ 40 against the vaccine strain at 21 days after the second vaccination was 65 % (95 % CI, 57 %-73 %) and 0 % (95 % CI, 0 %-4%), respectively. Among those who received two doses of the 15 µg adjuvanted formulation the proportion with HI titer ≥ 40 at 21 days after the second vaccination was 76 % (95 % CI, 66 %-84 %) in those 19-64 years of age and 49 % (95 % CI, 37 %-62 %) in those ≥ 65 years of age. Responses to the adjuvanted vaccine formulations did not vary by HA content. Antibody responses declined over time and responses against drifted H7N9 strains were diminished. Overall, the vaccines were well tolerated but, as expected, adjuvanted vaccines were associated with more frequent solicited systemic and local adverse events.

CONCLUSIONS

AS03 adjuvant improved the immune responses to an inactivated fifth-wave H7N9 influenza vaccine, particularly in younger adults, but invoked lower responses to drifted H7N9 strains. These findings may inform future influenza pandemic preparedness strategies.

Prehospital Sepsis Recognition and Outcomes for Patients with Sepsis by Race and Ethnicity

BACKGROUND

First medical contact for patients with sepsis often initiates in the prehospital setting, yet limited studies have explored the EMS sepsis recognition-mortality relationship. Racial and ethnic minority patients often have worse sepsis outcomes, yet the role of prehospital recognition in this inequity has not been explored. Our objective was to describe prehospital sepsis recognition and hospital mortality, with analysis by patient race and ethnicity.

METHODS

Using linked EMS and hospital records from the 2021 ESO Data Collaborative, we retrospectively analyzed 9-1-1 EMS transports for adult patients with emergency department ICD-10 sepsis diagnosis codes. EMS sepsis recognition was defined as a primary or secondary sepsis impression, use of an electronic health record specialty sepsis form, or a prehospital sepsis alert. We used multivariable logistic regression to assess the association between EMS sepsis recognition and hospital mortality, adjusting for age, sex, race and ethnicity, scene socioeconomic status, and documented clinical characteristics: altered mental status, hypotension, tachypnea, tachycardia, fever. We conducted a secondary analysis of patients who were positive for the quick sequential organ failure assessment (qSOFA) using first prehospital vital signs.

RESULTS

We analyzed 20,172 records for EMS-transported patients with diagnosed sepsis. Overall, 8% of patients were Black, 8% were Hispanic, and 72% were White. Prehospital sepsis recognition was 18%. Prehospital sepsis recognition was similar across racial and ethnic groups (Black: 17.2%, Hispanic: 17.4%, White: 18.1%) and adjusted odds of sepsis recognition did not differ between racial and ethnic groups. Overall mortality was 11% (2,186). Prehospital sepsis recognition was associated with a 18% reduction in adjusted odds of mortality (OR: 0.82, 95% CI: 0.70-0.94). Of patients who were qSOFA positive in the field (n = 2,168), EMS sepsis recognition was 32% and was similar across race and ethnicities. Adjusted odds of mortality were 0.68 (95% CI: 0.53-0.88) when sepsis was recognized in the prehospital setting.

CONCLUSION

EMS identified sepsis in fewer than one in three patients even after limiting to those positive for qSOFA, without differences by race and ethnicity. EMS sepsis recognition was associated with reduced odds of mortality; however, Black patients remained at greater odds of death suggesting additional factors that warrant investigation.

Ultrasound image guided injection of botulinum toxin for the management of spasticity: A Delphi study to develop recommendations for a scope of practice, competency, and governance framework

Objective

To establish a scope of practice, competency (through education) and governance framework for ultrasound image guided injection of botulinum toxin in the management of spasticity.

Design

Delphi study.

Setting

International, web-based survey.

Participants

A purposively selected multidisciplinary (physicians, physiotherapists, occupational therapists) panel of experts (n=15) in the use of ultrasound image guided injection of botulinum toxin for management of spasticity. Panel members were predominantly based in the UK (11/15).

Interventions

In round 1, open-ended questions were posed relating to potential scope of practice for 'ultrasound imaging in spasticity management'; (specifically relating to ultrasound image guided injection of Botulinum Toxin) education/competency and governance considerations. In round 2, respondents were asked to rate their level of agreement with the statements generated.

Outcome measures

5-point Likert scale used for rating the statements. Threshold for consensus agreement was set at 70% or above.

Results

Three different scopes of practice relating to ultrasound imaging in spasticity management were accepted. The primary scope of practice was the use of ultrasound imaging to guide safe and accurate delivery of botulinum toxin. Relating to this primary scope, 7 competency requirements were agreed relating to areas including image optimization and interpretation, needle visualization and safety. A singular, broad governance statement was generated.

Conclusion

Relating specifically to guided injection of botulinum toxin for management of spasticity, we present a scope of practice, competency, and governance framework. These are integrated within a framework approach to provide a mechanism for increased patient access to accurate, safe, and effective focal spasticity treatment. The framework supports focused training routes, greater inter-profession communication and wider clinical community engagement in spasticity management using this modality.

Use of the Child Opportunity Index to Examine Racial Variations in Outpatient Antibiotic Prescribing to Children

To examine further racial and ethnic variations in antibiotic prescribing to children, we used the Child Opportunity Index. Black children were less likely to be prescribed an antibiotic. Low- and moderate-opportunity areas were associated with greater rates of antibiotic prescribing, after adjusting for race and other factors.

Comparison of bivalent and monovalent SARS-CoV-2 variant vaccines: the phase 2 randomized open-label COVAIL trial

Vaccine protection against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection wanes over time, requiring updated boosters. In a phase 2, open-label, randomized clinical trial with sequentially enrolled stages at 22 US sites, we assessed safety and immunogenicity of a second boost with monovalent or bivalent variant vaccines from mRNA and protein-based platforms targeting wild-type, Beta, Delta and Omicron BA.1 spike antigens. The primary outcome was pseudovirus neutralization titers at 50% inhibitory dilution (ID50 titers) with 95% confidence intervals against different SARS-CoV-2 strains. The secondary outcome assessed safety by solicited local and systemic adverse events (AEs), unsolicited AEs, serious AEs and AEs of special interest. Boosting with prototype/wild-type vaccines produced numerically lower ID50 titers than any variant-containing vaccine against all variants. Conversely, boosting with a variant vaccine excluding prototype was not associated with decreased neutralization against D614G. Omicron BA.1 or Beta monovalent vaccines were nearly equivalent to Omicron BA.1 + prototype or Beta + prototype bivalent vaccines for neutralization of Beta, Omicron BA.1 and Omicron BA.4/5, although they were lower for contemporaneous Omicron subvariants. Safety was similar across arms and stages and comparable to previous reports. Our study shows that updated vaccines targeting Beta or Omicron BA.1 provide broadly crossprotective neutralizing antibody responses against diverse SARS-CoV-2 variants without sacrificing immunity to the ancestral strain. ClinicalTrials.gov registration: NCT05289037 .

Inappropriate Prescribing of Antibiotics to Pediatric Patients Receiving Medicaid: Comparison of High-Volume and Non-High-Volume Antibiotic Prescribers-Kentucky, 2019

Inappropriate antibiotic prescribing to pediatric Medicaid patients was compared among high-volume and non-high-volume prescribers. High-volume prescribers had a higher percentage of inappropriate prescriptions than non-high-volume prescribers (17.2% versus 15.8%, p = 0.005). Targeting high-volume prescribers for stewardship efforts is a practical approach to reducing outpatient antibiotic prescribing that also captures inappropriate use.

Benchmarking of Outpatient Pediatric Antibiotic Prescribing: Results of a Multicenter Collaborative

BACKGROUND

Most antibiotic use occurs in ambulatory settings. No benchmarks exist for pediatric institutions to assess their outpatient antibiotic use and compare prescribing rates to peers. We aimed to share pediatric outpatient antibiotic use reports and benchmarking metrics nationally.

METHODS

We invited institutions from the Sharing Antimicrobial Reports for Pediatric Stewardship OutPatient (SHARPS-OP) Collaborative to contribute quarterly aggregate reports on antibiotic use from January 2019 through June 2022. Outpatient settings included emergency departments (ED), urgent care centers (UCC), primary care clinics (PCC) and telehealth encounters. Benchmarking metrics included the percentage of 1) all acute encounters resulting in antibiotic prescriptions; 2) acute respiratory infection (ARI) encounters resulting in antibiotic prescriptions; and among ARI encounters receiving antibiotics, 3) the percentage receiving amoxicillin ("Amoxicillin index"); and 4) the percentage receiving azithromycin ("Azithromycin index"). We collected rates of antibiotic prescriptions with durations ≤7 days and >10 days from institutions able to provide validated duration data.

RESULTS

Twenty-one institutions submitted aggregate reports. Percent ARI encounters receiving antibiotics were highest in the UCC (40.2%), and lowest in telehealth (19.1%). Amoxicillin index was highest for the ED (76.2%), and lowest for telehealth (55.8%), while azithromycin index was similar for ED, UCC and PCC (3.8%, 3.7% and 5.0% respectively). Antibiotic duration of ≤7 days varied substantially (46.4% for ED, 27.8% UCC, 23.7% telehealth, 16.4% PCC).

CONCLUSIONS

We developed a benchmarking platform for key pediatric outpatient antibiotic use metrics drawing data from multiple pediatric institutions nationally. These data may serve as a baseline measurement for future improvement work.

Racial Inequities in Sepsis Mortality Among Children in the United States

BACKGROUND

Racial inequities influence health outcomes in the United States, but their impact on sepsis outcomes among children is understudied. We aimed to evaluate for racial inequities in sepsis mortality using a nationally representative sample of pediatric hospitalizations.

METHODS

This population-based, retrospective cohort study used the 2006, 2009, 2012 and 2016 Kids' Inpatient Database. Eligible children 1 month to 17 years old were identified using sepsis-related International Classification of Diseases, Ninth Revision or International Classification of Diseases, Tenth Revision codes. We used modified Poisson regression to evaluate the association between patient race and in-hospital mortality, clustering by hospital and adjusting for age, sex and year. We used Wald tests to assess for modification of associations between race and mortality by sociodemographic factors, geographic region and insurance status.

RESULTS

Among 38,234 children with sepsis, 2555 (6.7%) died in-hospital. Compared with White children, mortality was higher among Hispanic (adjusted relative risk: 1.09; 95% confidence interval: 1.05-1.14), Asian/Pacific Islander (1.17, 1.08-1.27) and children from other racial minority groups (1.27, 1.19-1.35). Black children had similar mortality to White children overall (1.02, 0.96-1.07), but higher mortality in the South (7.3% vs. 6.4%; P < 0.0001). Hispanic children had higher mortality than White children in the Midwest (6.9% vs. 5.4%; P < 0.0001), while Asian/Pacific Islander children had higher mortality than all other racial categories in the Midwest (12.6%) and South (12.0%). Mortality was higher among uninsured children than among privately insured children (1.24, 1.17-1.31).

CONCLUSIONS

Risk of in-hospital mortality among children with sepsis in the United States differs by patient race, geographic region and insurance status.

Astronomia ex machina: a history, primer and outlook on neural networks in astronomy

In this review, we explore the historical development and future prospects of artificial intelligence (AI) and deep learning in astronomy. We trace the evolution of connectionism in astronomy through its three waves, from the early use of multilayer perceptrons, to the rise of convolutional and recurrent neural networks, and finally to the current era of unsupervised and generative deep learning methods. With the exponential growth of astronomical data, deep learning techniques offer an unprecedented opportunity to uncover valuable insights and tackle previously intractable problems. As we enter the anticipated fourth wave of astronomical connectionism, we argue for the adoption of GPT-like foundation models fine-tuned for astronomical applications. Such models could harness the wealth of high-quality, multimodal astronomical data to serve state-of-the-art downstream tasks. To keep pace with advancements driven by Big Tech, we propose a collaborative, open-source approach within the astronomy community to develop and maintain these foundation models, fostering a symbiotic relationship between AI and astronomy that capitalizes on the unique strengths of both fields.

Abstract 2871: Spatial landscape of the tumor microenvironment in pancreatic ductal adenocarcinoma using multiplexed imaging and AI based analysis

Pancreatic tumors are highly heterogenous, often with more aggressive regions that are responsible for invasion and metastasis. These aggressive pancreatic ductal adenocarcinoma (PDAC) cells undergo epithelial to mesenchymal transition and create subregions in the tumor that evade treatments and provide a critical support niche for continued tumor growth and metastasis. Conventional chemotherapy plus radiation, or in advanced disease chemotherapy plus targeted drug therapy can lengthen patient survival. However, even in patients with local disease, the 5-year survival rate remains at around 40%, demonstrating that there is need for improved conventional and immune therapies for all pancreatic cancer patients. In this study, dozens of biomarkers have been used to probe tumor heterogeneity in pancreatic ductal adenocarcinoma (PDAC) tissue. We rely on the published finding that hypoxia gene expression is consistent in PDAC, regardless of tumor location, whether primary tumor or metastasis. With the spatial biology solution, Cell DIVETM and proprietary Spatial AI analytics software, dozens of biomarkers can be used to computationally reduce tumor heterogeneity, and to spatially define cells in the microenvironment within hypoxic and normoxic regions of PDAC, and in normal pancreas. We found that these hypoxic PDAC regions are devoid of immune cells in general, with the appearance of spatially co-localized populations of cell types consistent with tumor desmoplasia and inflammation. Taken together, multiplexed whole slide imaging and analysis enables spatially resolved whole tissue analysis of the tumor microenvironment, including new insights into spatial biology in the hypoxic PDAC environment.

Citation Format: Michael J. Smith, Chi-Chou Huang, Tuan H. Phan, Hideki Sasaki, Katie O. White, Richard A. Heil-Chapdelaine, Melinda Angus-Hill. Spatial landscape of the tumor microenvironment in pancreatic ductal adenocarcinoma using multiplexed imaging and AI based analysis [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 2871.

Abstract 4701: Spatial resolution of tumor and immune cell lineages in the hypoxic microenvironment of pancreatic ductal adenocarcinoma (PDAC)

Understanding how the tumor microenvironment (TME) evolves during tumorigenesis and therapeutic response is crucial to developing personalized treatments with the goal of improving cancer therapy. With robust and comprehensive multiplexed imaging technologies, immune biomarker antibodies can be used to interrogate immune cell lineages and structures. When combined with specific oncology biomarker antibodies, this approach can capture the immune response within the TME in a variety of neoplasms. The Cell DIVETM Multiplex Imaging Solution allows probing and imaging of dozens of biomarkers on a whole single tissue section using an iterative staining and dye inactivation workflow. The broad portfolio of robust IHC-validated antibodies from Cell Signaling Technology (CST) enables the detection of key proteins in the TME, allowing immune cell detection and phenotyping in tissue. Here, we demonstrate multiplexed Cell DIVE imaging using a novel CST panel to probe pancreatic ductal adenocarcinoma (PDAC). These biomarker antibodies define the immune cell landscape in the hypoxic tumor. Development of the antibody panel required minimal optimization, enabled the identification of complex cell types and revealed their cell-to-cell interactions within the tumor microenvironment. The availability of cell type specific biomarkers, combined with the ability to interrogate using multiplexed tissue imaging, provides unprecedented and novel insights and spatial resolution of immune cell populations with many cell types in the TME.

Citation Format: Lisa Arvidson, Reginaldo Prioli, Samuel Jensen, Michael J. Smith, Katie O. White, Richard A. Heil-Chapdelaine, Chi-Chou Huang, Tuan H. Phan, Hideki Sasaki, Melinda L. Angus-Hill. Spatial resolution of tumor and immune cell lineages in the hypoxic microenvironment of pancreatic ductal adenocarcinoma (PDAC). [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 4701.

Abstract 4698: Reproducibility in spatial biology: reducing variables to improve the reliability of insight generation

There is an ongoing crisis in reproducibility in scientific studies, and studies in spatial biology are no exception. Cell DIVETM Multiplex imaging solution (Leica Microsystems) provides reliable workflow solutions to minimize variability from study to study. Cell DIVE allows probing and imaging of dozens of biomarkers on a whole tissue section with an iterative staining and dye inactivation workflow. At its core, Cell DIVE is designed to provide methods reproducibility, from tissue preparation, antigen retrieval, and sample imaging and slide storage. Cell DIVE is designed to work with directly conjugated primary antibodies, another source of variability. However, conjugated antibodies from Cell Signaling Technology (CST) are rigorously validated using stringent acceptance criteria to reduce variability. In addition, the use of recombinant antibodies, the consistent conjugate brightness and antibody degree-of-labeling reduce lot to lot variability, ensuring reliable conjugated antibodies for spatial biology studies. High resolution imaging results are obtained by consistent round to round imaging, consistent calibration and corrections, and reduction of human error using the BAB 200 liquid handling solution (Advanced Solutions Life Sciences). We present here, an iterative biomarker study using adjacent tissue sections probed with distinct lots of CST antibody panels, imaged in temporally separated batches using a Cell DIVE imager fitted with a BAB200 liquid handler. Following robust analysis (segmentation, phenotyping and statistical analysis), we report the reproducibility findings across parameters. Methods and results reproducibility in spatial biology is essential for reliable insight generation, giving confidence in the quality of future studies aimed at improving patient outcomes.

Citation Format: Lisa Arvidson, Reginaldo Prioli, Samuel Jensen, James B. Hoying, Michael W. Golway, Michael J. Smith, Katie O. White, Richard A. Heil-Chapdelaine, Chi-Chou Huang, Tuan H. Phan, Hideki Sasaki, Melinda Angus-Hill. Reproducibility in spatial biology: reducing variables to improve the reliability of insight generation. [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 4698.

Health Effects of Policing in Hospitals: a Narrative Review

IMPORTANCE

Law enforcement activity, in the form of outside agencies or hospital security forces, is increasingly common in American healthcare. Little is known about the potential effects of this prevalent, modifiable exposure on hospital staff and patient health. This narrative review characterizes existing evidence on the direct and indirect health effects of law enforcement activity in hospitals.

OBSERVATIONS

Law enforcement activity in hospitals can affect health outcomes through four mechanisms: (1) physical health effects related to workplace violence, restraint use, excessive force, and weapon use; (2) mental health effects involving perceptions of safety and psychological distress; (3) social effects related to the patient-provider relationship, mistrust, and bias and discrimination; and (4) legal and ethical considerations affecting overall well-being.

CONCLUSIONS AND RELEVANCE

Unchecked law enforcement activity in hospitals may risk patient physical and mental health, reduce patient trust, result in bias and discrimination, and contribute to legal and ethical rights violations. Importantly, law enforcement activity in hospitals may also contribute to staff perceptions of safety. To fill knowledge gaps on the measurable impact of law enforcement activity in the hospital on staff and patients, hospitals should collect and publicly share robust data on law enforcement activity in their facilities, create and adopt patient-centered policies to ensure safety and protect patient health and privacy, and implement evidence-based interventions that safely reduce law enforcement involvement with patients.

Law Enforcement and Patient Privacy Among Survivors of Violence: A Nationwide Mixed-Methods Study

INTRODUCTION

During the emergent treatment of violently injured patients, law enforcement (LE) officers and health care providers frequently interact. Both have duties to protect patient health, rights, and public health, however, the balance of these duties may feel at odds. The purpose of this study is to assess hospital-based violence intervention program (HVIP) representatives' experiences with LE officers among survivors of violence and the impact of hospital policies on interactions with LE officers.

MATERIALS AND METHODS

A nationwide survey was distributed to the 35 HVIPs that form the Health Alliance for Violence Intervention. Data regarding respondent affiliation, programs, and perceptions of hospital policies outlining LE activity were collected. Follow-up video interviews were open coded and qualitatively analyzed using grounded theory.

RESULTS

Respondents from 32 HVIPs completed the survey (91%), and 22 interviews (63%) were conducted. Common themes from interviews were: police-patient interactions; racism, bias, and victims' treatment as suspects; and training and education. Only 39% of respondents knew that policies existed and were familiar with them. Most representatives believed their hospitals' existing policies were inadequate, ineffective, or biased. Programs that reported good working relationships with LE officers offered insight on how their programs maintain these partnerships and work with LE officers towards a common goal.

CONCLUSIONS

Unclear or inadequate policies relating to LE activity may jeopardize the health and privacy of violently injured patients. Primary areas identified for improvement include clarifying and revising hospital policies, education of staff and LE officers, and improved communication between health care providers and LE officers to better protect patient rights.

Addressing Legal Needs as Violence Prevention: A National Survey of Legal Services Offered through Hospital-based Violence Intervention Programs

Hospital-based violence intervention programs (HVIPs) provide comprehensive services to survivors of community violence to address social determinants of health (SDOH) as risks factors for future violence. Medical-legal partnerships (MLPs) integrate lawyers into health care teams to address SDOH through the application of the law. Despite shared purposes, it is unknown if HVIP-MLPs exist. We sought to quantify the existing landscape of legal services provided by HVIPs, identify HVIP-MLPs, and characterize barriers to formation. Surveys and interviews were conducted in 2020 with 35 HVIPs of the Health Alliance for Violence Intervention (HAVI) concerning civil legal services. Most HVIPs screened for civil legal needs though none had an official MLP. Common civil legal needs included housing, mental health, and education. Barriers included no memorandum of understanding, legal confusion, funding, and overwhelming need. In 2021, no HVIP-MLP partnerships existed within HAVI. Establishing HVIP-MLPs may further support survivors of violence and address health inequity.

961. Pandemic Hits: Evaluation of an Antimicrobial Stewardship Program Website for Hospital Communication During the COVID-19 Pandemic

Background

Antibiotic Stewardship Programs (ASPs) assist front-line clinicians in synthesizing emerging data and establishing best practices. Our ASP team directly maintained and edited an internal web application, Duke CustomID^®, to disseminate updated guideline, policy, and drug information during COVID-19. We aimed to describe website engagement and maintenance during the dynamic pandemic period.

Methods

We performed a descriptive, time-series analysis using Google Analytics software to measure engagement with Duke CustomID^® during a 1-year pre-pandemic period through the Omicron surge: January 2019 to March 2022. We measured total page views (or “hits”), COVID-specific page hits, and days requiring COVID-specific page edits by week. Given fluctuations in hospitalization rates, we defined the primary outcome as the rate of hits divided by total hospitalizations. Weekly data were assessed graphically with positive COVID tests and COVID hospitalizations. We used negative binomial regression to quantify the association between COVID hospitalizations and hit rates and to trend engagement over time, adjusted for seasonality. We stratified data by COVID page and calculated a hit/edit ratio.

Results

Engagement with CustomID® increased during the pandemic period, especially during surges (Figure). Hits in the pre-pandemic period were median 1707 (range 1165-2354) per week, and hit rates median 1.95 per hospitalization (range 1.40-2.86). Peaks were observed in March 2020 (hit rate 4.59) and January 2022 (hit rate 3.87). On average, for every 100 COVID hospitalizations, the hit rate increased by 0.08 (0.004-0.16, p=0.04). Engagement slowly increased over the study period (relative rate week 1 versus 170: 1.15, 95% confidence interval 1.02-1.28, p=0.02). COVID page edits per week had a median of 2 (range 0-12). Adult Inpatient Guidelines and COVID Monoclonal Antibody pages had highest use (Table).

Duke CustomID Hits and Maintenance Efforts over the Pandemic

Top: COVID-specific CustomID hits per week (Green), Positive COVID tests per week (Blue) over time

Middle: Total custom ID page hits relative to total hospitalizations per week (teal), COVID hospitalizations (Red)

Bottom: Number of edits to COVID-specific CustomID pages per week, stratified by management pages and drug pages

Several dates of significance are highlighted including the Emergency Use Authorizations (EUA) for remdesivir, the COVID Vaccines, and Paxlovid

Duke CustomID COVID-19 Page Hits and Edits

COVID specific pages on Duke CustomID with total hits, edits, and ratio over the pandemic

Conclusion

Our ASP’s website was a highly utilized, practical tool for disseminating practice-changing information during the pandemic. Use increased over time and especially during surges. An electronic reference customized for local practice and rapidly updated by ASPs offers critical support for front-line clinicians.

Disclosures

Martha B. Adams, M.D., Custom Clinical Decision Support, Inc: Board Member|Custom Clinical Decision Support, Inc: Ownership Interest Richard H. Drew, PharmD MS, American College of Clinical Pharmacists: Publication royalties|Takeda: Advisor/Consultant|UpToDate: publication royalties Rebekah W. Moehring, MD, MPH, FIDSA, FSHEA, UpToDate, Inc.: Author Royalties Michael J. Smith, M.D., M.S.C.E, Merck: Grant/Research Support|Pfizer: Grant/Research Support.

Recurrent Antibiotic Use in Kentucky Children With 6 Years of Continuous Medicaid Enrollment

BACKGROUND

Little is known about the distribution of antibiotic use in individual children over time. The amoxicillin index is a recently proposed metric to assess first-line antibiotic prescribing to children.

METHODS

We constructed a cohort of continuously enrolled Medicaid children using enrollment claims from 2012 to 2017. Pharmacy claims were used to identify antibiotic prescription data.

RESULTS

Among 169 724 children with 6 years of Medicaid enrollment, 10 804 (6.4%) had no antibiotic prescription claims during the study period; 43 473 (25.6%) had 1-3 antibiotics; 34 318 (20.2%) had 4-6 antibiotics; 30 994 (18.3%) had 7-10; 35 018 (20.6%) had 11-20; and 15 117 (8.9%) children had more than 20 antibiotic prescriptions. Overall, the population had a median total of 6 antibiotic prescriptions during the study period, but use was higher in certain patient groups: younger age (8 antibiotic fills over the 6-year period, [IQR 4-14]), White children (7 [IQR 3-13], compared to 3 [IQR 1-6] in Black children), rural settings (9 [IQR 4-15]) and chronic conditions (8 [IQR 4-15]). Higher-use groups also had lower rates of amoxicillin fills, reported as amoxicillin indices.

CONCLUSIONS

Antibiotic use is common among most children insured by Kentucky Medicaid. A number of fills over time were higher in younger children, and in White children, children living in rural settings and children with chronic conditions. Patients with higher recurrent antibiotic use are important targets for designing high-impact antibiotic stewardship efforts.

Epstein-Barr Virus DNAemia and post-transplant lymphoproliferative disorder in pediatric solid organ transplant recipients

BACKGROUND

Pediatric solid organ transplant (SOT) recipients commonly have Epstein-Barr virus (EBV) DNAemia and are at risk of developing post-transplant lymphoproliferative disorder (PTLD). EBV DNAemia has not been analyzed on a continuous scale in this population.

METHODS

All children ≤ 18 years of age who underwent SOT at a single center between January 1, 2007 and July 31, 2018 were included in this retrospective study. Transplant episodes in which PTLD occurred were compared to transplant episodes without PTLD. Multivariable logistic regression was used to identify factors associated with the development of EBV DNAemia and maximum height of EBV DNAemia. A Cox proportional hazards model was used to calculate hazard ratios for time to PTLD.

RESULTS

Of 275 total transplant recipients and 294 transplant episodes, there were 14 episodes of PTLD. Intestinal and multivisceral transplant were strongly associated with PTLD (p = 0.002). Risk factors for the development of EBV DNAemia include donor and recipient positive EBV serologies (p = 0.001) and older age (p = 0.001). Maximum level of EBV DNAemia was significantly associated with development of PTLD (p<0.0001). Every one log (log10) increase in the maximum level of EBV DNAemia was associated with a more than doubling of the hazard on developing PTLD (HR: 2.18, 95% CI 1.19-3.99).

CONCLUSIONS

Transplant type was strongly associated with development of PTLD in pediatric SOT recipients. EBV serologies and age were associated with the development of EBV DNAemia and height of DNAemia. High levels of EBV DNAemia were strongly associated with an increased hazard for PTLD.

Prescriber and employee utilization of a health sciences center campus outpatient pharmacy: A qualitative analysis

DISCLAIMER

In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time.

PURPOSE

The college of pharmacy has operated pharmacies on campus for over 26 years. Employees and patients are users of the pharmacies; however, utilization across the campus has been limited. This paper describes a process, as well as results, that was used to gather input from employees on a large university health sciences center campus on pharmacy needs and related behaviors on campus pharmacy utilization.

METHODS

Two focus groups of staff and 4 focus groups of prescribers were conducted over 1 month. Participants were selected through purposive sampling via email within an academic health sciences center campus over a 1-month period. The sessions were moderated by one investigator using a preconstructed discussion guide and lasted 1 hour. Two additional investigators observed sessions for nonverbal communication; all sessions were audio recorded for subsequent transcription. An open-coding process was performed on verbatim transcripts using NVivo12. The investigator team then developed, refined, and grouped themes during subsequent group discussions.

RESULTS

A total of 44 participants took part in 6 focus groups. Participants included prescribers (physicians, nurses, physician assistants) and staff (nonprescribers). Two major themes identified were (1) factors related to on-campus pharmacies and (2) qualities valued in a pharmacy. There was an equal split (8% for each group) on awareness of the on-campus pharmacies. Almost 11% of participants commented on the accessibility of a pharmacy being a quality valued in a pharmacy.

CONCLUSION

Focus groups provided insights for the administration team regarding additional value-added services that would be helpful for the campus community, as well as various approaches to increase utilization of the on-campus pharmacies. Focus group methodology is an effective approach to engage employees of a large university campus to garner new ideas to enhance existing policies or services, as well as to gather thoughts on preliminary strategic plans before implementation.

Percutaneous cryoablation for desmoid fibromatosis: initial experience at a UK centre

AIM

To report the first UK experience of cryoablation in desmoid fibromatosis (DF) with particular focus on technique, safety, and efficacy.

MATERIALS AND METHODS

Patients were selected at multidisciplinary tumour board meetings at a specialist cancer hospital. Radiation dose, procedure duration, and number of cryoprobes were compared for small versus large tumours (>10 cm long axis). Response at magnetic resonance imaging (MRI) was evaluated using different criteria, and percentage agreement with clinical response as assessed in oncology clinic calculated.

RESULTS

Thirteen procedures were performed in 10 patients (eight women, median age 51 years, IQR 42-69 years) between February 2019 and August 2021. Procedures for large tumours had higher radiation dose (2,012 ± 1,012 versus 1,076 ± 519 mGy·cm, p=0.048) used more cryoprobes (13 ± 7 versus 4 ± 2, p=0.009), and were more likely to have residual unablated tumour (38 ± 37% versus 7.5 ± 10%, p=0.045). Adverse events were minor apart from one transient radial nerve palsy. Eight of 10 patients had symptomatic benefit at clinical follow-up (median 353 days, IQR 86-796 days), and three started systemic therapy mean 393 days later. All patients who had complete ablation demonstrated symptomatic response, with no instances of repeat treatment, recurrence, or need for systemic therapy during the study period. All progression occurred outside ablation zones.

CONCLUSION

Cryoablation for symptomatic DF is a reproducible technique with low, transient toxicity, where one or two treatments can achieve a meaningful response. Where possible, the ablation ice ball should fully cover DF tumours.

SARS-CoV-2 Variant Vaccine Boosters Trial: Preliminary Analyses

Background

Protection from SARS-CoV-2 vaccines wanes over time and is compounded by emerging variants including Omicron subvariants. This study evaluated safety and immunogenicity of SARS-CoV-2 variant vaccines.

Methods

This phase 2 open-label, randomized trial enrolled healthy adults previously vaccinated with a SARS-CoV-2 primary series and a single boost. Eligible participants were randomized to one of six Moderna COVID19 mRNA vaccine arms (50µg dose): Prototype (mRNA-1273), Omicron BA.1+Beta (1 or 2 doses), Omicron BA.1+Delta, Omicron BA.1 monovalent, and Omicron BA.1+Prototype. Neutralization antibody titers (ID 50 ) were assessed for D614G, Delta, Beta and Omicron BA.1 variants and Omicron BA.2.12.1 and BA.4/BA.5 subvariants 15 days after vaccination.

Results

From March 30 to May 6, 2022, 597 participants were randomized and vaccinated. Median age was 53 years, and 20% had a prior SARS-CoV-2 infection. All vaccines were safe and well-tolerated. Day 15 geometric mean titers (GMT) against D614G were similar across arms and ages, and higher with prior infection. For uninfected participants, Day 15 Omicron BA.1 GMTs were similar across Omicron-containing vaccine arms (3724-4561) and higher than Prototype (1,997 [95%CI:1,482-2,692]). The Omicron BA.1 monovalent and Omicron BA.1+Prototype vaccines induced a geometric mean ratio (GMR) to Prototype for Omicron BA.1 of 2.03 (97.5%CI:1.37-3.00) and 1.56 (97.5%CI:1.06-2.31), respectively. A subset of samples from uninfected participants in four arms were also tested in a different laboratory at Day 15 for neutralizing antibody titers to D614G and Omicron subvariants BA.1, BA.2.12.2 and BA.4/BA.5. Omicron BA.4/BA.5 GMTs were approximately one third BA.1 GMTs (Prototype 517 [95%CI:324-826] vs. 1503 [95%CI:949-2381]; Omicron BA.1+Beta 628 [95%CI:367-1,074] vs. 2125 [95%CI:1139-3965]; Omicron BA.1+Delta 765 [95%CI:443-1,322] vs. 2242 [95%CI:1218-4128] and Omicron BA.1+Prototype 635 [95%CI:447-903] vs. 1972 [95%CI:1337-2907).

Conclusions

Higher Omicron BA.1 titers were observed with Omicron-containing vaccines compared to Prototype vaccine and titers against Omicron BA.4/BA.5 were lower than against BA.1 for all candidate vaccines.

Clinicaltrialsgov

NCT05289037.

Quality of antibiotic prescribing to children through the coronavirus disease 2019 (COVID-19) pandemic

OBJECTIVE

To describe pediatric outpatient visits and antibiotic prescribing during the coronavirus disease 2019 (COVID-19) pandemic.

DESIGN

An observational, retrospective control study from January 2019 to October 2021.

SETTING

Outpatient clinics, including 27 family medicine clinics, 27 pediatric clinics, and 26 urgent or prompt care clinics.

PATIENTS

Children aged 0-19 years receiving care in an outpatient setting.

METHODS

Data were extracted from the electronic health record. The COVID-19 era was defined as April 1, 2020, to October 31, 2021. Virtual visits were identified by coded encounter or visit type variables. Visit diagnoses were assigned using a 3-tier classification system based on appropriateness of antibiotic prescribing and a subanalysis of respiratory visits was performed to compare changes in the COVID-19 era compared to baseline.

RESULTS

Through October 2021, we detected an overall sustained reduction of 18.2% in antibiotic prescribing to children. Disproportionate changes occurred in the percentages of antibiotic visits in respiratory visits for children by age, race or ethnicity, practice setting, and prescriber type. Virtual visits were minimal during the study period but did not result in higher rates of antibiotic visits or in-person follow-up visits.

CONCLUSIONS

These findings suggest that reductions in antibiotic prescribing have been sustained despite increases in outpatient visits. However, additional studies are warranted to better understand disproportionate rates of antibiotic visits.

School Masking Policies and Secondary SARS-CoV-2 Transmission

OBJECTIVES

Throughout the COVID-19 pandemic, masking has been a widely used mitigation practice in kindergarten through 12th grade (K-12) school districts to limit within-school transmission. Prior studies attempting to quantify the impact of masking have assessed total cases within schools; however, the metric that more optimally defines effectiveness of mitigation practices is within-school transmission, or secondary cases. We estimated the impact of various masking practices on secondary transmission in a cohort of K-12 schools.

METHODS

We performed a multistate, prospective, observational, open cohort study from July 26, 2021 to December 13, 2021. Districts reported mitigation practices and weekly infection data. Districts that were able to perform contact tracing and adjudicate primary and secondary infections were eligible for inclusion. To estimate the impact of masking on secondary transmission, we used a quasi-Poisson regression model.

RESULTS

A total of 1 112 899 students and 157 069 staff attended 61 K-12 districts across 9 states that met inclusion criteria. The districts reported 40 601 primary and 3085 secondary infections. Six districts had optional masking policies, 9 had partial masking policies, and 46 had universal masking. In unadjusted analysis, districts that optionally masked throughout the study period had 3.6 times the rate of secondary transmission as universally masked districts; and for every 100 community-acquired cases, universally masked districts had 7.3 predicted secondary infections, whereas optionally masked districts had 26.4.

CONCLUSIONS

Secondary transmission across the cohort was modest (<10% of total infections) and universal masking was associated with reduced secondary transmission compared with optional masking.

Utilization of West Virginia Pediatric Medicaid Claims Data to Guide Outpatient Antimicrobial Stewardship Interventions

West Virginia consistently ranks in the top two nationally for per capita antibiotic prescription rates in both pediatric and adult outpatient populations. We present the first descriptive analysis evaluating outpatient prescription rates within the WV pediatric Medicaid population, which demonstrated significant antibiotic prescribing variability by provider type, specialty, and geography.

Prevention of pneumococcal infections in childhood: two decades of progress

PURPOSE OF REVIEW

This review highlights progress in combating pediatric pneumococcal disease in the era of pneumococcal conjugate vaccines (PCVs). This review is timely given the development of increased valency PCVs for potential use in children.

RECENT FINDINGS

Countries implementing vaccination programs with PCVs have witnessed dramatic reductions in cases of childhood invasive pneumococcal disease (IPD). In the US, the largest decline of IPD followed the introduction of 7-valent PCV with additional decreases following the switch to 13-valent PCV (PCV13). Despite these gains, IPD still occurs in the US but at much lower rates. Likewise, pneumonia hospitalizations and office visits for otitis media have decreased. Nasopharyngeal colonization with pneumococci has persisted due to replacement by nonvaccine serotypes: colonizing non-PCV13 serotypes have less invasive potential. The PCV era has also been marked by reductions in the proportions of pneumococcus showing nonsusceptibility or resistance to some antimicrobial agents. Furthermore, PCVs have an excellent safety profile.

SUMMARY

Despite proven safety and efficacy, childhood vaccination programs in some countries do not include PCVs, resulting in the majority of global deaths attributable to pneumococcus. Increased worldwide vaccination of children and the development of higher valency vaccines holds additional promise for further reductions in childhood IPD.

Severe Congenital Syphilis in the Neonatal Intensive Care Unit: A Retrospective Case Series

BACKGROUND

There has been a 291% relative increase in congenital syphilis (CS) cases in the United States from 2015 to 2019. Although the majority of affected fetuses/infants are stillborn or are asymptomatic, a subset is born with severe clinical illness. We describe a series of severe CS cases in the neonatal intensive care unit.

METHODS

Retrospective review of infants with CS, admitted to the Duke Intensive Care Nursery from June 2016 to February 2020. We recorded birthweight, gestational age, medications, procedures, diagnoses, laboratory data and outcomes. Severe symptoms included: birth depression, hypoxic ischemic encephalopathy (HIE), disseminated intravascular coagulopathy and/or persistent pulmonary hypertension (PPHN).

RESULTS

Seven infants with CS were identified and 5 with severe presentations were included. Median gestational age was 35.1 weeks (range: 29-37 weeks, median: 35 weeks). All infants required intubation at birth, 2 required chest compressions and epinephrine in the delivery room. One had hydrops fetalis and died in the delivery room. All 4 surviving infants had HIE, severe PPHN, hepatitis and seizures. All infants had a positive rapid plasma reagin, and were treated with penicillin G. Maternal rapid plasma reagin was pending for 3 of 5 infants at delivery, and later returned positive; 2 were positive during pregnancy but not treated. Other infectious work-up was negative. Three infants survived to discharge.

CONCLUSION

CS can be associated with HIE, PPHN and disseminated intravascular coagulopathy in affected infants. Clinicians should have a high index of suspicion and include CS in their differential diagnoses. This study also highlights the importance of adequate treatment of identified cases and screening during the third trimester and at delivery.

Secondary Transmission of COVID-19 in K-12 Schools: Findings From 2 States

OBJECTIVES

We evaluated the impact of distancing practices on secondary transmission of severe acute respiratory syndrome coronavirus 2 and the degree of sports-associated secondary transmission across a large diverse cohort of schools during spring 2021.

METHODS

Participating districts in North Carolina and Wisconsin and North Carolina charter schools offering in-person instruction between March 15, 2021 and June 25, 2021 reported on distancing policies, community- and school-acquired infections, quarantines, and infections associated with school-sponsored sports. We calculated the ratio of school-acquired to community-acquired infection, secondary attack rates, and the proportion of secondary transmission events associated with sports. To estimate the effect of distancing and bus practices on student secondary transmission, we used a quasi-Poisson regression model with the number of primary student cases as the denominator.

RESULTS

During the study period, 1 102 039 students and staff attended in-person instruction in 100 North Carolina school districts, 13 Wisconsin school districts, and 14 North Carolina charter schools. Students and staff had 7865 primary infections, 386 secondary infections, and 48 313 quarantines. For every 20 community-acquired infections, there was 1 within-school transmission event. Secondary transmissions associated with school sports composed 46% of secondary transmission events in middle and high schools. Relaxed distancing practices (<3 ft, 3 ft) and increased children per bus seat were not associated with increased relative risk of secondary transmission.

CONCLUSIONS

With universal masking, in-person education was associated with low rates of secondary transmission, even with less stringent distancing and bus practices. Given the rates of sports-associated secondary transmission, additional mitigation may be warranted.

A School-Based SARS-CoV-2 Testing Program: Testing Uptake and Quarantine Length After In-School Exposures

OBJECTIVES

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-related quarantines, which are required after close contact with infected individuals, have substantially disrupted in-person education for kindergarten through 12th grade (K-12) students. In recent recommendations, shortened durations of quarantine are allowed if a negative SARS-CoV-2 test result is obtained at 5 to 7 days postexposure, but access to testing remains limited. We hypothesized that providing access to in-school SARS-CoV-2 testing postexposure would increase testing and reduce missed school days.

METHODS

This prospective cohort study was conducted in one large public K-12 school district in North Carolina and included 2 periods: preimplementation (March 15, 2021, to April 21, 2021) and postimplementation (April 22, 2021, to June 4, 2021), defined around initiation of an in-school SARS-CoV-2 testing program in which on-site access to testing is provided. Number of quarantined students and staff, testing uptake, test results, and number of missed school days were analyzed and compared between the preimplementation and postimplementation periods.

RESULTS

Twenty-four schools, including 12 251 in-person learners, participated in the study. During preimplementation, 446 close contacts were quarantined for school-related exposures; 708 close contacts were quarantined postimplementation. Testing uptake after school-related exposures increased from 6% to 40% (95% confidence interval: 23% to 45%) after implementation, and 89% of tests were conducted in-school. After in-school testing implementation, close contacts missed ∼1.5 fewer days of school (95% confidence interval: -2 to -1).

CONCLUSIONS

Providing access to in-school testing may be a worthwhile mechanism to increase testing uptake after in-school exposures and minimize missed days of in-person learning, thereby mitigating the pandemic's ongoing impact on children.

Myocarditis Cases Reported After mRNA-Based COVID-19 Vaccination in the US From December 2020 to August 2021

IMPORTANCE

Vaccination against COVID-19 provides clear public health benefits, but vaccination also carries potential risks. The risks and outcomes of myocarditis after COVID-19 vaccination are unclear.

OBJECTIVE

To describe reports of myocarditis and the reporting rates after mRNA-based COVID-19 vaccination in the US.

DESIGN, SETTING, AND PARTICIPANTS

Descriptive study of reports of myocarditis to the Vaccine Adverse Event Reporting System (VAERS) that occurred after mRNA-based COVID-19 vaccine administration between December 2020 and August 2021 in 192 405 448 individuals older than 12 years of age in the US; data were processed by VAERS as of September 30, 2021.

EXPOSURES

Vaccination with BNT162b2 (Pfizer-BioNTech) or mRNA-1273 (Moderna).

MAIN OUTCOMES AND MEASURES

Reports of myocarditis to VAERS were adjudicated and summarized for all age groups. Crude reporting rates were calculated across age and sex strata. Expected rates of myocarditis by age and sex were calculated using 2017-2019 claims data. For persons younger than 30 years of age, medical record reviews and clinician interviews were conducted to describe clinical presentation, diagnostic test results, treatment, and early outcomes.

RESULTS

Among 192 405 448 persons receiving a total of 354 100 845 mRNA-based COVID-19 vaccines during the study period, there were 1991 reports of myocarditis to VAERS and 1626 of these reports met the case definition of myocarditis. Of those with myocarditis, the median age was 21 years (IQR, 16-31 years) and the median time to symptom onset was 2 days (IQR, 1-3 days). Males comprised 82% of the myocarditis cases for whom sex was reported. The crude reporting rates for cases of myocarditis within 7 days after COVID-19 vaccination exceeded the expected rates of myocarditis across multiple age and sex strata. The rates of myocarditis were highest after the second vaccination dose in adolescent males aged 12 to 15 years (70.7 per million doses of the BNT162b2 vaccine), in adolescent males aged 16 to 17 years (105.9 per million doses of the BNT162b2 vaccine), and in young men aged 18 to 24 years (52.4 and 56.3 per million doses of the BNT162b2 vaccine and the mRNA-1273 vaccine, respectively). There were 826 cases of myocarditis among those younger than 30 years of age who had detailed clinical information available; of these cases, 792 of 809 (98%) had elevated troponin levels, 569 of 794 (72%) had abnormal electrocardiogram results, and 223 of 312 (72%) had abnormal cardiac magnetic resonance imaging results. Approximately 96% of persons (784/813) were hospitalized and 87% (577/661) of these had resolution of presenting symptoms by hospital discharge. The most common treatment was nonsteroidal anti-inflammatory drugs (589/676; 87%).

CONCLUSIONS AND RELEVANCE

Based on passive surveillance reporting in the US, the risk of myocarditis after receiving mRNA-based COVID-19 vaccines was increased across multiple age and sex strata and was highest after the second vaccination dose in adolescent males and young men. This risk should be considered in the context of the benefits of COVID-19 vaccination.

A Policy Analysis of Preparedness for Hurricane Evacuations in the United States, 1990 to 2019: Implementation in Coastal States

Hurricane or typhoon evacuations in the United States are typically managed by state, territorial, or tribal emergency management officials with federal, state, and local agency operational support. The evacuation process may involve issuing mandatory or "voluntary" evacuation orders to alert the community and mitigate loss of life and injury. We conducted an analysis of state and local hurricane evacuation policies identified through a literature review (January 1990 to June 2019) and key informant interviews with state public health and emergency management officials in Florida, Georgia, Louisiana, Mississippi, North Carolina, South Carolina, and Texas in October and November 2019. Findings from the literature review show that most gaps in hurricane evacuation preparedness-based on 44 policy-related publications identified in the review-could be categorized into 4 themes: shelters, evacuation decisionmaking, at-risk populations, and transportation. Findings from key informant interviews for 7 states revealed that coastal states have been able to address most of these gaps since Hurricane Katrina in 2005. However, an important remaining gap in preparedness is providing timely warnings to at-risk populations during hurricane evacuations.

1129. Outpatient Prescribing During the COVID-19 Pandemic

Background

The Joint Commission requires ambulatory healthcare systems to collect, analyze and report antimicrobial prescribing data. Duke University Health System (DUHS) piloted a dashboard to capture outpatient prescribing for pediatric patients with URI. Implementation in 2020 allowed for an assessment of antibiotic prescribing during the pandemic.

Methods

We included patients 0 - < 19 years seen at DUHS for URI and pharyngitis from 1/1/2019 -2/21/2021. Patient characteristics included: age, sex, race, ethnicity, Pediatric Medical Complexity Algorithm (PMCA) score and insurance status (public versus private). Provider characteristics included: type (physician, NP, PA) and specialty (pediatrics, family medicine, internal medicine, other). We compared pre- and post-COVID ( March 1, 2020) prescribing and prescribing during telehealth versus in-person visits. A logistic regression model was used to identify factors independently associated with antibiotic prescribing.

Results

62,447 children were seen during the study period, 29% of whom received an antibiotic. Amoxicillin was the most commonly prescribed antibiotic (64.4%), followed by cefdinir (11%) amoxicillin-clavulanic acid (10%) and azithromycin (8%). Factors associated with antibiotic prescribing are shown in Table 1. White race, private insurance, visits with nurse practitioners and visits with non-pediatric providers were associated with high prescribing. Higher PMCA scores, indicating greater medical complexity, were associated with decreased likelihood of prescribing. Although the total number of outpatient visits plummeted during the COVID period, rates of prescribing only decreased mildly from 31% to 25% (Figure 1).

Table 1. Factors Associated with Antibiotic Prescribing in Logistic Regression Model

Conclusion

Outpatient prescribing was associated with multiple patient and provider characteristics. Similar to other studies, white race, private insurance, and visits with non-physician, non-pediatric providers were associated with antibiotic prescription. Despite a large decrease in the number of outpatient visits during the pandemic, rates of prescribing for URI decreased minimally. A better understanding of factors associated with antibiotic prescribing during the pandemic may identify priority targets for outpatient stewardship as mitigation strategies are relaxed.

Disclosures

Michael J. Smith, MD, M.S.C.E, Merck (Grant/Research Support)Pfizer (Grant/Research Support)

384. SARS-CoV-2 Surveillance Testing Patterns among Hospitalized Pediatric Patients in a Single Academic Medical Center

Background

Children infected with SARS-CoV-2 often have mild or no symptoms, making symptom screening an ineffective tool for determining isolation precautions. As an infection control measure, universal pre-procedural and admission SARS-CoV-2 testing for pediatric patients was implemented in April and August 2020, respectively. Limited data exist on the utility screening programs in the pediatric population.

Methods

We performed a retrospective cohort study of pediatric patients (birth to 18 years) admitted to a tertiary care academic medical center from April 2020 to May 2021 that had one or more SARS-CoV-2 point-of-care or polymerase chain reaction tests performed. We describe demographic data, positivity rates and repeat testing trends observed in our cohort.

Results

A total of 2,579 SARS-CoV-2 tests were performed among 1,027 pediatric inpatients. Of these, 51 tests (2%) from 45 patients (4.3%) resulted positive. Community infection rates ranged from 4.5-60 cases/100,000 persons/day during the study period. Hispanic patients comprised 16% of the total children tested, but were disproportionately overrepresented (40%) among those testing positive (Figure1). Of 654 children with repeated tests, 7 (0.1%) converted to positive from a prior negative result. Median days between repeat tests was 12 (IQR 6-45), not necessarily performed during the same hospital stay. Five of these 7 patients had tests repeated < 3 days from a negative result, of which only 2 had no history of recent infection by testing performed at an outside facility. Pre-procedural tests accounted for 35% of repeat testing, of which 0.9% were positive. Repeated tests were most frequently ordered for patients in hematology/oncology (35%) and solid organ transplant/surgical (33%) wards, each with < 3% positive conversion rate. Notably, no hematopoietic stem cell transplant patients tested positive for SARS-CoV-2 during the study period.

Pediatric SARS-CoV-2 Testing Distributed by Race/Ethnicity

Conclusion

The positivity rate of universal pre-procedural and admission SARS-CoV-2 testing in pediatric patients was low in our inpatient cohort. Tests repeated < 3 days from a negative result were especially low yield, suggesting limited utility of this practice. Diagnostic testing stewardship in certain populations may be useful, especially as community infection rates decline.

Disclosures

Michael J. Smith, MD, M.S.C.E, Merck (Grant/Research Support)Pfizer (Grant/Research Support) Rebekah W. Moehring, MD, MPH, UpToDate, Inc. (Other Financial or Material Support, Author Royalties)

1123. Appropriateness of Antibiotic Prescribing Through the COVID-19 Pandemic and Associated Telehealth Visits

Background

The COVID-19 pandemic and resulting mitigation strategies have impacted rates of outpatient infections and delivery of care to pediatric patients. Virtual healthcare was rapidly implemented but much is unknown about the quality of care provided in telehealth visits. We sought to describe changes in visits throughout the pandemic and evaluate the appropriateness of antibiotic prescribing.

Methods

We utilized EHR data from a large health care system that provides primary care via pediatric, family medicine, and urgent care clinics. We included outpatient visits from 1/1/19 - 4/30/21 for children &lt; 20 years. The COVID-19 era was defined as after March 2020. Visits were labeled as virtual according to coded encounter or visit type variables. The appropriateness of antibiotic prescriptions was assigned using a previously published ICD-10 classification scheme that defines each prescription as appropriate, potentially appropriate, or inappropriate (Chua, et al. BMJ, 2019).

Results

There were 805,130 outpatient visits during the study period. The mean rate of antibiotic prescriptions in the pre-pandemic period was 23% (range 17-26% per month) and 11% (range 9-15%) in the COVID-19 era. Mean rates of inappropriate prescribing were 17% (range 14-20% per month) and 20% (range 19-22%), respectively (Figure 1). Coded virtual visits during the COVID-19 era were uncommon (1-2%) with the exception of April and May 2020 (11% and 5%, respectively). During the COVID-19 era, approximately 9% of telehealth visits resulted in antibiotics, compared to 11% of in-person visits (Table 1). Virtual visits had lower rates of inappropriate and appropriate prescribing, but higher rates of potentially appropriate prescribing (Table 1).

Visits and associated antibiotic prescribing in the pre-pandemic and COVID-19 era

Conclusion

Rates and volume of antibiotic prescribing in outpatient pediatric visits have declined in the COVID-19 era, while rates of inappropriate prescribing have increased slightly. Our study suggests use of telehealth for pediatric visits was minimal and led to higher prescribing rates for “potentially appropriate” indications. This could be explained by a lack of clinical certainty in conditions such as otitis media and pharyngitis in virtual visits.

Disclosures

Bethany A. Wattles, PharmD, MHA, Merck (Grant/Research Support, Research Grant or Support) Yana Feygin, Master of Science, Merck (Grant/Research Support, Research Grant or Support) Michelle D. Stevenson, MD, MS, Merck (Grant/Research Support) Michael J. Smith, MD, M.S.C.E, Merck (Grant/Research Support)Pfizer (Grant/Research Support)

412. Estimating the Impact of School Classroom Sizes on the Probability of Severe Acute Respiratory Syndrome Coronavirus-2 Infectivity or Exposure

Background

Despite schools reopening across the United States in communities with low and high Coronavirus disease 2019 (COVID-19) prevalence, data remain scarce about the effect of classroom size on the transmission of severe acute respiratory syndrome coronavirus-2 (SARS-COV-2) within schools. This study estimates the effect of classroom size on the risk of COVID-19 infection in a closed classroom cohort for varying age groups locally in Durham, North Carolina. Total number of Coronavirus Disease 2019 (COVID-19) infections over a 28-day follow-up period for varying classroom reproduction number (R0) and varying classroom cohort sizes of 15 students, 30 students and 100 students in Durham County, North Carolina.

Methods

Using publicly available population and COVID-19 case count data from Durham County, we calculated a weekly average number of new confirmed COVID-19 cases per week between May 3, 2020 and August 22, 2020 according to age categories: < 5 years, 5-9 years, 10-14 years, and 15-19 years. We collated average classroom cohort sizes and enrollment data for each age group by grade level of education for the first month of the 2019-2020 academic school year. Then, using a SEIR compartmental model, we calculated the number of susceptible (S), exposed (E), infectious (I) and recovered (R) students in a cohort size of 15, 30 and 100 students, modelling for classroom reproduction number (R₀) of 0.5, 1.5 and 2.5 within a closed classroom cohort over a 14-day and 28-day follow-up period using age group-specific COVID-19 prevalence rates.

Results

The SEIR model estimated that the increase in cohort size resulted in up to 5 new COVID-19 infections per 10,000 students whereas the classroom R₀ had a stronger effect, with up to 88 new infections per 10,000 students in a closed classroom cohort over time. When comparing different follow-up periods in a closed cohort with R₀ of 0.5, we estimated 12 more infected students per 10,000 students over 28 days as compared to 14 days irrespective of cohort size. With a R₀ of 2.5, there were 49 more infected students per 10,000 students over 28 days as compared to 14 days.

Conclusion

Classroom R₀ had a stronger impact in reducing school-based COVID-19 transmission events as compared to cohort size. Additionally, earlier isolation of newly infected students in a closed cohort resulted in fewer new COVID-19 infections within that group. Mitigation strategies should target promoting safe practices within the school setting including early quarantine of newly identified contacts and minimizing COVID-19 community prevalence.

Disclosures

Michael J. Smith, MD, M.S.C.E, Merck (Grant/Research Support)Pfizer (Grant/Research Support)

Community SARS-CoV-2 Surge and Within-School Transmission

OBJECTIVES

When the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic began, experts raised concerns about in-person instruction in the setting of high levels of community transmission. We describe secondary transmission of SARS-CoV-2 within North Carolina kindergarten through 12th-grade school districts during a winter surge to determine if mitigation strategies can hinder within-school transmission.

METHODS

From October 26, 2020, to February 28, 2021, 13 North Carolina school districts participating in The ABC Science Collaborative were open for in-person instruction, adhered to basic mitigation strategies, and tracked community- and school-acquired SARS-CoV-2 cases. Public health officials adjudicated each case. We combined these data with that from August 2020 to evaluate the effect of the SARS-CoV-2 winter surge on infection rates as well as weekly community- and school-acquired cases. We evaluated the number of secondary cases generated by each primary case as well as the role of athletic activities in school-acquired cases.

RESULTS

More than 100 000 students and staff from 13 school districts attended school in person; of these, 4969 community-acquired SARS-CoV-2 infections were documented by molecular testing. Through contact tracing, North Carolina local health department staff identified an additional 209 infections among >26 000 school close contacts (secondary attack rate <1%). Most within-school transmissions in high schools (75%) were linked to school-sponsored sports. School-acquired cases slightly increased during the surge; however, within-school transmission rates remained constant, from presurge to surge, with ∼1 school-acquired case for every 20 primary cases.

CONCLUSIONS

With adherence to basic mitigation strategies, within-school transmission of SARS-CoV-2 can be interrupted, even during a surge of community infections.