In a cross-sectional study of 20 Massachusetts long-term care (LTC) facilities, 19% (n = 449) of residents received antibiotics, with approximately one-third having a documented penicillin allergy. This documented allergy decreased the likelihood of prescribing beta-lactam antibiotics for infections. Improved penicillin allergy assessments and delabeling could optimize antibiotic prescribing in LTC settings.

The vulnerability of patients on hemodialysis (HD) to infections is evident by their increased susceptibility to infections in general and to resistant organisms in particular. Unnecessary, inappropriate, or suboptimal antimicrobial prescribing is common in dialysis units. This underscores the need for dedicated antimicrobial stewardship (AMS) interventions that can be implemented both in the inpatient and outpatient settings. In this review, we provide a comprehensive approach for clinicians with the most updated coordinated AMS principles in HD setting in six areas: prevention, diagnosis, treatment, education and empowerment, monitoring, and research.

Background: RSV is underrecognized in hospitalized adults. A better understanding of RSV in this population could help prioritize targeted viral-testing resources. Hospitalization and in-hospital outcomes are widely accepted as markers of clinical severity with respect to acute respiratory illness (ARI). We compared characteristics and clinical outcomes between adults hospitalized with ARI from October 2016 through May 2019. Methods: All hospitalized adults (≥ 18 years) who met a standardized case definition of ARI were prospectively enrolled across 3 respiratory seasons from 9 hospitals participating in the US Hospitalized Adult Influenza Vaccine Effectiveness Network (HAIVEN). Demographic data were collected during enrollment interviews, and electronic medical records (EMRs) were reviewed to extract comorbidity data. Throat and nasal swabs collected at enrollment were tested for ARI pathogens using real-time PCR assays at respective HAIVEN research laboratory sites. Characteristics and clinical outcomes of participants were compared using χ2 or nonparametric tests where appropriate. Multivariable logistic regression models were used to test associations between infection status, characteristics, and clinical outcomes, adjusting for age, sex, race, Charlson comorbidity index (CCI), body mass index (BMI), site, season, and days to admission. Results: In total, 10,311 adults were included, 22.3% (n = 2,300) were aged 18–49 years, 33.2% (n = 3,423) were aged 50–64 years, and 44.5% (n = 4,588) were aged ≥65 years. Moreover, 6% of adults tested positive for RSV (n = 622), 18.8% positive for influenza (n = 1,940), and 75.1% negative for both (n = 7,749). Obesity and age ≥65 years were significantly associated with RSV detection when compared with participants negative for both RSV and influenza. Patients aged 18–49 years and ≥65 years with RSV had significantly higher median CCI scores compared to patients with influenza (Fig. 1.). The proportion of adults with CHF or COPD was significantly (p-value Conclusions: Severe RSV illness may differ from severe influenza illness, and those infected with RSV may have different characteristics than those infected with influenza. Hospitalized adults with RSV infection were more likely to have underlying cardiopulmonary comorbidities and higher CCI scores as well as experience an extended length of hospital stay and need for mechanical ventilation. These data highlight the importance of retaining testing for RSV in older adults hospitalized with ARI.

Funding: None

Disclosures: None

Background: Urine cultures are the most common microbiological tests in the outpatient setting and heavily influence treatment of suspected urinary tract infections (UTIs). Antibiotics for UTI are usually prescribed on an empiric basis in primary care before the urine culture results are available. However, culture results may be needed to confirm a UTI diagnosis and to verify that the correct antibiotic was prescribed. Although urine cultures are considered as the gold standard for diagnosis of UTI, cultures can easily become contaminated during collection. We determined the prevalence, predictors, and antibiotic use associated with contaminated urine cultures in 2 adult safety net primary care clinics. Methods: We conducted a retrospective chart review of visits with provider-suspected UTI in which a urine culture was ordered (November 2018–March 2020). Patient demographics, culture results, and prescription orders were captured for each visit. Culture results were defined as no culture growth, contaminated (ie, mixed flora, non-uropathogens, or ≥3 bacteria isolated on culture), low-count positive (growth between 100 and 100,000 CFU/mL), and high-count positive (>100,000 CFU/mL). A multivariable multinomial logistic regression model was used to identify factors associated with contaminated culture results. Results: There were 1,265 visits with urine cultures: 264 (20.9%) had no growth, 694 (54.9%) were contaminated, 159 (12.6%) were low counts, and 148 (11.7%) were high counts. Encounter-level factors are presented in Table 1. Female gender (adjusted odds ratio [aOR], 15.8; 95% confidence interval [CI], 10.21–23.46; P < .001), pregnancy (aOR, 13.98; 95% CI, 7.93–4.67; P < .001), and obesity (aOR, 1.9; 95% CI 1.31–2.77; P < .001) were independently associated with contaminated cultures. Of 264 patients whose urine cultures showed no growth, 36 (14%) were prescribed an antibiotic. Of 694 patients with contaminated cultures, 153 (22%) were prescribed an antibiotic (Figure 1). Conclusions: More than half of urine cultures were contaminated, and 1 in 5 patients were treated with antibiotics. Reduction of contamination should improve patient care by providing a more accurate record of the organism in the urine (if any) and its susceptibilities, which are relevant to managing future episodes of UTI in that patient. Optimizing urine collection represents a diagnostic stewardship opportunity in primary care.

Funding: This study was supported by the National Institute of Allergy and Infectious Diseases of the National Institutes of Health (grant no. UM1AI104681). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Disclosures: None

Table 1.

Figure 1.

COVID-19 vaccine uptake in healthcare personnel (HCP) is poor. A cross-sectional survey study of behavioral health HCP was performed. Commonly identified reasons for vaccination were protecting others and oneself. Reasons against were a lack of perceived protection, dosing intervals, and side effects. Assessing vaccination attitudes can assist in uptake strategy.

The ability to provide feedback to a colleague is a key skill required for professional growth and patient safety. However, these conversations are limited by time constraints, differences in values, and a culture of “noninterference.” This advocacy-inquiry-identify-teach framework creates an organized approach to initiating successful “challenging” conversations with peers.

Background: SARS-CoV-2 infection of healthcare workers (HCWs) occasionally occurs via acquisition from their colleagues. Data regarding the infection rates of HCWs with close contact and non–close contacts of HCWs are limited. In addition, the protective effect of COVID-19 vaccination against transmission between HCWs is unknown. We evaluated the infection rates of HCWs with close contact and non–close contact of infected HCWs and the effect of COVID-19 vaccination on transmission among HCWs in a tertiary-care hospital in South Korea. Methods: This study was performed in a tertiary-care hospital in Korea. We analyzed the COVID-19 cases and contacts among HCWs from January to December 2021. We reviewed the vaccination status of confirmed and exposed HCWs, the type of vaccination, and the infection rate according to the contact. We performed subgroup analyses in individuals who had been diagnosed since July 2021 when the δ (delta) variant became the dominant strain in South Korea. Transmission was defined based on their spatiotemporal epidemiologic association. Results: During the study period, 173 HCWs had COVID-19, and 2,693 HCWs were exposed to them. Among them, 18 (1.52%) of 1,186 close contacts and 13 (0.86%) of 1,507 non–close contacts had a positive SARS-CoV-2 test (P = .11). When the index cases had been fully vaccinated, the infection rate of close contacts was 0.85% (7 of 820), whereas the infection rate of close contacts was 3.01% (11 of 366) when the index had not been fully vaccinated (P = .005). However, the infection rate of non–close contacts was not different according to the vaccination status of index (0.83% vs 0.89%; P = .90). During the period of δ (delta) variant being dominant, the infection rate of close contacts was significantly lower when the index case had been fully vaccinated index than in cases with a non–fully vaccinated index case (0.85% vs 5.88%; P < .001). Conclusions: Transmission to colleagues was significantly lower from vaccinated HCWs than from nonvaccinated HCWs, and this finding was more significant in the era of the δ (delta) variant. Our findings support the importance of vaccination in HCWs.

Funding: None

Disclosures: None

Background: Antimicrobial stewardship initiatives usually occur in the inpatient setting, and they are often lacking at transitions of care (TOC), including hospital discharge. We assessed the appropriateness of antibiotic treatment duration at the time of discharge from our institution. Methods: This retrospective chart review included 300 adult patients discharged on oral antibiotics for acute infections during a 3-month period in 2019. The primary outcome was the duration of antibiotic therapy (DOT). To assess appropriateness, we compared the prescribed DOT (1) to that recommended by clinical guidelines, (2) to the minimum supported by clinical trials, and (3) to the period beyond the point of clinical stability, defined as normal vital signs with improvement in symptoms present from diagnosis. Each indication and antibiotic was assessed using standards appropriate for the combination. Results: Results are shown in Tables 1 and 2 and Figure 1. Conclusions: Antibiotics were often given longer than necessary on hospital discharge. In this study, patients received a median 2 days of excess antibiotics compared to recommended guidelines and 6 days after reaching clinical stability. A pilot TOC stewardship program was initiated to address this problem.

Funding: No

Disclosures: None

Table 1.

Table 2.

Figure 1.

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

Funding: No

Disclosures: None

Table 1.

We evaluated antibiotic use in a private health insurance network in Bolivia with two different healthcare plans. The Health Maintenance Organization plan had 29% lower antibiotic consumption and fewer broad-spectrum antibiotics prescribed than the Preferred Provider Organization. Furthermore, we identified potential targets for future antibiotic stewardship efforts.

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

Funding: None

Disclosures: None

Levofloxacin prophylaxis reduces bloodstream infections in neutropenic patients with acute myeloid leukemia or relapsed acute lymphoblastic leukemia. A retrospective, longitudinal cohort study compares incidence of bacteremia, multidrug-resistant organisms (MDRO), and Clostridioides difficile (CDI) between time periods of levofloxacin prophylaxis implementation. Benefits were sustained without increasing MDRO or CDI.

In this study, we used genomic sequencing to identify variants of severe acute respiratory coronavirus virus 2 (SARS-CoV-2) in healthcare workers with coronavirus disease 2019 (COVID-19) after receiving a booster vaccination. We compared symptoms, comorbidities, exposure risks, and vaccine history between the variants. Postbooster COVID-19 cases increased as the SARS-CoV-2 omicron variant predominated.