Asymptomatic bacteriuria in critical-access hospitals: Prevalence and patient characteristics driving treatment

We evaluated the prevalence and treatment of asymptomatic bacteriuria (ASB) in 17 critical-access hospitals. Among 891 patients with urine cultures from September 2021 to June 2022, 170 (35%) had ASB. Also, 76% of patients with ASB received antibiotics for a median duration of 7 days, demonstrating opportunities for antimicrobial stewardship.

Clinical outcomes and frequency of persistent infection among immunosuppressed patients treated with bebtelovimab for COVID-19 infection at an ambulatory cancer center

BACKGROUND

There are limited data on clinical outcomes associated with the use of bebtelovimab for the treatment of coronavirus disease 2019 (COVID-19) among cancer patients. We aimed to define the clinical characteristics and outcomes among patients receiving bebtelovimab as part of the COVID-19 therapeutics program at our cancer center.

METHODS

This is a retrospective cohort study of immunosuppressed adult patients who received bebtelovimab at Fred Hutchinson Cancer Center between March 2022, and November 2022. We reviewed medical records to capture the date of the first positive COVID-19 test, clinical characteristics, outcomes, and follow-up COVID-19 testing for 60 days after the first positive. Persistent infection was defined as a positive test beyond day 30; these patients were reviewed beyond day 60.

RESULTS

Among 93 patients who received bebtelovimab, 64 (69%) had hematologic malignancy. Sixty-nine (74%) patients received bebtelovimab within 2 days after diagnosis. Two (2%) patients were hospitalized, none required ICU care, and one patient died on day 52; although it is unknown if death was directly related to COVID-19. Ten (11%) patients had persistent COVID-19 infection; of these, four received additional COVID-19 therapy with either nirmatrelvir/ritonavir or remdesivir, and five out of six patients with sequencing data available had spike protein mutations associated with bebtelovimab resistance.

CONCLUSION

A coordinated systems-based approach led to prompt initiation of bebtelovimab within two days of testing positive in most patients. We observed few hospitalizations or deaths. Persistent infection was noted in 11% of patients with four requiring additional therapies, highlighting a need for novel strategies to manage immunosuppressed patients.

Health System and Tele-Antimicrobial Stewardship: The Role of Building Networks

Tele-antimicrobial stewardship programs (tele-ASPs) use technology and remote access to resources and clinical expertise to expand antimicrobial services within and outside of health systems. Models of tele-ASPs are workforce multiplying and workforce extending, depending on how they are structured. Building rapport and strong interpersonal networks are essential for successful ASPs. The available evidence suggests that an optimal model for tele-ASP includes hands-on involvement from remote infectious disease (ID) expertise with implementation by local pharmacists. However, this model remains limited by the available time and cost of ID-trained specialists.

Antimicrobials in patients with hematologic malignancies and recipients of hematopoietic cell transplantation and other cellular therapies

BACKGROUND

Appropriate use of antimicrobials for hematologic malignancy, hematopoietic stem cell transplant recipients, and other cellular therapies is vital, with infection causing significant morbidity and mortality in this unique population of immunocompromised hosts. However, often in this population the choice and management of antimicrobial therapy is complex. When selecting an antimicrobial agent, key considerations include the need for dose adjustments due to renal or hepatic impairment, managing drug interactions, the potential for additive drug toxicity among those receiving polypharmacy and therapeutic drug monitoring. Other factors include leveraging pharmacodynamic principles to enable optimization of directed therapy against challenging pathogens, as well as judicious use of antimicrobials to limit drug resistance and adverse drug reactions.

SUMMARY

This review summarizes the clinical considerations for commonly used antimicrobials in this setting, including antibacterial, antiviral, and antifungal agents.

Successful Treatment of Persistent Symptomatic Coronavirus Disease 19 Infection With Extended-Duration Nirmatrelvir-Ritonavir Among Outpatients With Hematologic Cancer

Persistent symptomatic coronavirus disease 2019 (COVID-19) is a distinct clinical entity among patients with hematologic cancer and/or profound immunosuppression. The optimal medical management is unknown. We describe 2 patients who had symptomatic COVID-19 for almost 6 months and were successfully treated in the ambulatory setting with extended courses of nirmatrelvir-ritonavir.

A single-centre experience rolling out an antibiotic stewardship intervention prior to and during the SARS-CoV-2 pandemic 2019-2022

Background

Antibiotics are prescribed to nearly one-half of patients with viral respiratory tract infections (RTI) in outpatient settings. This use is ineffective and may cause undue harm and excess cost from unnecessary antibiotic exposure. We implemented a multifaceted intervention to address inappropriate antibiotic prescribing for viral RTI. Here, we discuss the impact over 4 years, before and during the SARS-CoV-2 pandemic.

Methods

This observational study describes the implementation and initial impact of a multimodal stewardship intervention on inappropriate antibiotic prescribing for viral RTIs in outpatient care settings at a single centre. We tracked the rate of visits for viral RTI as well as antibiotic prescribing for viral RTIs in urgent care, primary care and the emergency department between January 2018 and March 2022. Data were collected 1 year prior to implementation and 3 years after implementation. The primary outcome - the rate of inappropriate antibiotics prescribed for viral RTIs - was described by calendar year (CY) to review changes after the stewardship intervention.

Results

In CY2018, the year prior to implementation of targeted RTI antimicrobial stewardship, the rate of inappropriate RTI antibiotics prescribed was 10% in urgent care, 11% in primary care and 18% in the emergency department (ED). During the first CY of the intervention, rates were 8% in urgent care, 10% in primary care and 16% in the ED. In CY2020, the second year of the intervention, inappropriate RTI antibiotics were prescribed in 5% of urgent care and 3% primary care RTI visits and 15% of ED RTI visits. These rates were similar in CY2021 and the first 3 months of CY2022. Over 30,000 visits for RTIs were seen annually in CY2018 and CY2019. Annual RTI visits dropped to 20,222 in CY2020 and 14,172 in CY2021.

Conclusion

Although total visits for non-COVID RTIs decreased by approximately 50% during the first 2 years of the SARS-CoV-2 pandemic, an antimicrobial stewardship intervention was associated with decreases in inappropriate antibiotic prescribing for RTIs. This was maintained throughout 2 years of the pandemic.This article is part of the Antibiotic stewardship Special Issue: https://www.drugsincontext.com/special_issues/antimicrobial-stewardship-a-focus-on-the-need-for-moderation.

Doing More With Less: Pragmatic Implementation of Vancomycin Area-Under-the-Curve (AUC) Monitoring

Universal area-under-the-curve (AUC) guided vancomycin therapeutic drug monitoring (TDM) is resource-intensive, cost-prohibitive, and presents a paradigm shift that leaves institutions with the quandary of defining the preferred and most practical method for TDM. We report a step-by-step quality improvement process using 4 plan-do-study-act (PDSA) cycles to provide a framework for development of a hybrid model of trough and AUC-based vancomycin monitoring. We found trough-based monitoring a pragmatic strategy as a first-tier approach when anticipated use is short-term. AUC-guided monitoring was most impactful and cost-effective when reserved for patients with high-risk for nephrotoxicity. We encourage others to consider quality improvement tools to locally adopt AUC-based monitoring.

Experience with two antimicrobial prescribing tools in ambulatory care settings

We compared experiences with The Multifaceted Intervention to Improve Prescribing for Acute Respiratory Infection for Adult and Children in Emergency Department and Urgent Care Settings versus Choosing Wisely to evaluate inappropriate antimicrobial prescribing in ambulatory care. Both identified the same clinics, diagnoses, and antibiotics for high-yield antibiotic stewardship interventions.

Contemporary Perspective on the Treatment of Acinetobacter baumannii Infections: Insights from the Society of Infectious Diseases Pharmacists

The purpose of this narrative review is to bring together the most recent epidemiologic, preclinical, and clinical findings to offer our perspective on best practices for managing patients with A. baumannii infections with an emphasis on carbapenem-resistant A. baumannii (CRAB). To date, the preferred treatment for CRAB infections has not been defined. Traditional agents with retained in vitro activity (aminoglycosides, polymyxins, and tetracyclines) are limited by suboptimal pharmacokinetic characteristics, emergence of resistance, and/or toxicity. Recently developed and US Food and Drug Administration (FDA)-approved β-lactam/β-lactamase inhibitor agents do not provide enhanced activity against CRAB. On balance, cefiderocol and eravacycline demonstrate potent in vitro activity and are well tolerated, but clinical data for patients with CRAB infections do not yet support widespread use. Given that CRAB has the capacity to infect vulnerable patients and preferred regimens have not been identified, we advocate for combination therapy. Our preferred regimen for critically ill patients infected, or considered to be at high risk for CRAB, includes meropenem, polymyxin B, and ampicillin/sulbactam. Importantly, site of infection, severity of illness, and local epidemiology are essential factors to be considered in selecting combination therapies. Molecular mechanisms of resistance may unveil preferred combinations at individual centers; however, such data are often unavailable to treating clinicians and have not been linked to improved clinical outcomes. Combination strategies may also pose an increased risk for antibiotic toxicity and Clostridioides difficile infection, and should therefore be balanced by understanding patient goals of care and underlying health conditions. Promising therapies that are in clinical development and/or under investigation include durlobactam-sulbactam, cefiderocol combination regimens, and bacteriophage therapy, which may over time eliminate the need for the continued use of polymyxins. Future goals for CRAB management include pathogen-focused treatment paradigms that are based on molecular mechanisms of resistance, local susceptibility rates, and the availability of well-tolerated, effective treatment options.

136. Don’t Sweat the Small Stuff: Solutions for Large-Scale Stewardship Obstacles

Background

In an effort to support stewardship endeavors, the MITIGATE (a Multifaceted Intervention to Improve Prescribing for Acute Respiratory Infection for Adult and Children in Emergency Department and Urgent Care Settings) Toolkit was published in 2018, aiming to reduce unnecessary antibiotics for viral respiratory tract infections (RTIs). At the University of Washington, we have incorporated strategies from this toolkit at our urgent care clinics. This study aims to address solutions to some of the challenges we experienced.

Challenges and Solutions

Methods

This was a retrospective observational study conducted at Valley Medical Center (Sept 2019-Mar 2020) and the University of Washington (Jan 2019-Feb 2020) urgent care clinics. Patients were identified through ICD-10 diagnosis codes included in the MITIGATE toolkit. The primary outcome was identifying challenges and solutions developed during this process.

Results

We encountered five challenges during our roll-out of MITIGATE. First, using both ICD-9 and ICD-10 codes can lead to inaccurate data collection. Second, technical support for coding a complex data set is essential and should be accounted for prior to beginning stewardship interventions of this scale. Third, unintentional incorrect diagnosis selection was common and may require reeducation of prescribers on proper selection. Fourth, focusing on singular issues rather than multiple outcomes is more feasible and can offer several opportunities for stewardship interventions. Lastly, changing prescribing behavior can cause unintended tension during implementation. Modifying benchmarks measured, allowing for bi-directional feedback, and identifying provider champions can help maintain open communication.

Conclusion

Resources such as the MITIGATE toolkit are helpful to implement standardized data driven stewardship interventions. We have experienced some challenges including a complex data build, errors with diagnostic coding, providing constructive feedback while maintaining positive stewardship relationships, and choosing feasible outcomes to measure. We present solutions to these challenges with the aim to provide guidance to those who are considering using this toolkit for outpatient stewardship interventions.

Disclosures

All Authors: No reported disclosures

143. Initial Impact of COVID-19 on Ambulatory Antibiotic Prescribing for Respiratory Viral Infections

Background

Between 15–50% of patients seen in ambulatory settings are prescribed an antibiotic. At least one third of this usage is considered unnecessary. In 2019, our institution implemented the MITIGATE Toolkit, endorsed by the Centers for Disease Control and Prevention to reduce inappropriate antibiotic prescribing for viral respiratory infections in emergency and urgent care settings. In February 2020 we identified our first hospitalized patient with SARS-CoV(2). In March, efforts to limit person-to-person contact led to shelter in place orders and substantial reorganization of our healthcare system. During this time we continued to track rates of unnecessary antibiotic prescribing.

Methods

This was a single center observational study. Electronic medical record data were accessed to determine antibiotic prescribing and diagnosis codes. We provided monthly individual feedback to urgent care prescribers, (Sep 2019-Mar 2020), primary care, and ED providers (Jan 2020 – Mar 2020) notifying them of their specific rate of unnecessary antibiotic prescribing and labeling them as a top performer or not a top performer compared to their peers. The primary outcome was rate of inappropriate antibiotic prescribing.

Results

Pre toolkit intervention, 14,398 patient visits met MITIGATE inclusion criteria and 12% received an antibiotic unnecessarily in Jan-April 2019. Post-toolkit intervention, 12,328 patient visits met inclusion criteria and 7% received an antibiotic unnecessarily in Jan-April 2020. In April 2020, patient visits dropped to 10–50% of what they were in March 2020 and April 2019. During this time the unnecessary antibiotic prescribing rate doubled in urgent care to 7.8% from 3.6% the previous month and stayed stable in primary care and the ED at 3.2% and 11.8% respectively in April compared to 4.6% and 10.4% in the previous month.

Conclusion

Rates of inappropriate antibiotic prescribing were reduced nearly in half from 2019 to 2020 across 3 ambulatory care settings. The increase in prescribing in April seen in urgent care and after providers stopped receiving their monthly feedback is concerning. Many factors may have contributed to this increase, but it raises concerns for increased inappropriate antibacterial usage as a side effect of the SARS-CoV(2) pandemic.

Disclosures

All Authors: No reported disclosures

621. Reporting Behaviors and Perceptions Towards the National Healthcare Safety Network Antimicrobial Use (AU) and Antimicrobial Resistance (AR) Options

Background

Antibiotic use (AU) and antibiotic resistance (AR; AUR) reporting to National Healthcare Safety Network (NHSN) is suboptimal by US hospitals. The Society of Infectious Diseases Pharmacists (SIDP) and the Society for Healthcare Epidemiology of America (SHEA) conducted a survey of their membership to 1) Identify characteristics of US health systems that report AUR data 2) Determine how NHSN AUR data are used by health systems and 3) Identify barriers to AUR reporting.

Methods

An anonymous survey was posted on SurveyMonkey from 1/21- 2/21/2020 and links were emailed to SIDP and SHEA Research Network members. Data were analyzed in Excel and RStudio. Respondent and hospital data were reported as frequencies and percentages. Fisher’s Exact test was used to compare survey responses from NHSN AUR reporters to non-reporters.

Results

A total of 238 individuals from 43 states responded to our survey. Respondents were primarily pharmacists (84%), from urban (45%), non-profit medical centers (80%) with >250 beds (65%). 62% of respondents reported to the AU option while 19% reported to the AR option. Respondents not using software for local AU or AR tracking were less likely than those using any software for local tracking to report to AU (19% vs 64%) and AR (2% vs 30%) options (P< 0.0001). Among AU and AR reporters 41% and 54% used clinical decision support software to aggregate compile data for upload while 54% and 38% used their electronic health record, and 5% and 8% used another method. Over half of AU (56%) and AR (51%) reporters upload data manually. Regular use of the NHSN data analysis tools was reported by 36% and 9% of those reporting AU and AR data respectively. The most common barriers to reporting were related to technical issues (software, IT support, data formatting) and time/salary support. Among non-reporters, increased expectations to report and better software solutions were most commonly identified as the best ways to increase reporting.

Conclusion

Efforts to improve AUR reporting should focus on software solutions and increasing the utility of AUR analytical tools. Increasing expectations to report may also help to improve reporting rates. The lower rate of AR vs AU reporting suggests that interventions should also target the AR option.

Disclosures

Brian J. Werth, PharmD, Shionogi Inc. (Grant/Research Support) Kerry LaPlante, PharmD, Merck (Advisor or Review Panel member, Research Grant or Support)Ocean Spray Cranberries, Inc. (Research Grant or Support)Pfizer Pharmaceuticals (Research Grant or Support)Shionogi, Inc. (Research Grant or Support)