Background: Patients with recurrent urinary tract infections (rUTI) experience frequent exposure to antimicrobial regimens, leaving them at higher risk for developing antibiotic resistance. Little information on the prevalence of antibiotic resistance among patients with rUTI has been published. Although the IDSA recommends using a prior culture to guide empiric treatment, studies have not examined the predictive ability of a prior culture among patients meeting rUTI criteria. We constructed an antibiogram and evaluated test metrics, including sensitivity, specificity, and positive predictive value (PPV) and negative predictive values (NPV) of a prior culture (any organism), on predicting resistance (PPV) or susceptibility (NPV) of a future culture among patients with uncomplicated rUTI in an outpatient setting. Methods: We retrospectively extracted electronic health record data from outpatients aged ≥18 years who had an ICD-10 code for cystitis listed twice in 6 months or thrice in 12 months between November 1, 2016, and December 31, 2018. Patients sought care at either urology or primary care practices within an academic medical center in Houston, Texas. Patients with functional or structural abnormalities of the genitourinary tract, signs or symptoms of pyelonephritis, or pregnancy were excluded. Antibiogram data were reported for uropathogens with ≥30 isolates, and intermediate results were considered resistant. Test metrics and Bayes’ PPV and NPV were calculated using standard formulas. Results: We included 597 visits from 232 unique patients. Most were White (63%) and female (92%), and the cohort had a median age of 58 (IQR, 41–68). Among 310 rUTI episodes with a urine culture, 189 (61%) had at least 1 uropathogen isolated, and Escherichia coli (n = 130, 66%) was most common among all 196 uropathogens. E. coli isolates had >20% resistance to 10 of 18 antibiotics (Fig. 1). E. coli resistance to ciprofloxacin was 27.9%, resistance to nitrofurantoin was 5.5%, and resistance to trimethoprim-sulfamethoxazole was 38.0%. The PPVs for predicting resistance were highest for ceftriaxone (0.86; 95% CI, 0.60–0.96), ciprofloxacin (0.84; 95% CI, 0.63–0.94), and levofloxacin (0.84; 95% CI, 0.63–0.94). NPVs of resistance were highest for gentamicin (0.97; 95% CI, 0.83–1.00), ceftriaxone (0.94; 95% CI, 0.86–0.98), and cefepime (0.94; 95% CI, 0.84–0.98), whereas NPVs for cefuroxime, ciprofloxacin, levofloxacin, and nitrofurantoin were all >0.83. Conclusions: We detected considerable antibiotic resistance among patients with rUTI to commonly prescribed antibiotics. Prior urine culture susceptibility demonstrated moderate-to-high PPVs for predicting future resistance to ceftriaxone and fluoroquinolones as well as high NPVs for several cephalosporins and fluoroquinolones, which could inform empiric prescribing choices.

Funding: This investigator-initiated research study was funded by Rebiotix, a Ferring Company.

Disclosures: None

Background: Antibiotic overuse and the resulting patient outcomes span all hospitals. However, although antibiotic stewardship can improve antibiotic use, effective stewardship programs require expertise and an infrastructure that are not present in all hospitals. Rural hospitals have less access to resources, infectious disease expertise, and participation in academic research. Thus, we compared antibiotic overuse at discharge between rural and nonrural hospitals for patients diagnosed with community-associated pneumonia (CAP) or urinary tract infection (UTI)—the 2 most common hospital infections. Methods: To determine whether antibiotic overuse at discharge was higher among rural versus nonrural hospitals, we analyzed data from a 41-hospital prospective cohort of patients treated for CAP or UTI between July 1, 2017, and July 30, 2019, in Michigan. Antibiotic overuse was defined as treatment that was unnecessary (ie, patient did not have an infection), excessive (ie, duration >4 days for CAP), or included suboptimal fluoroquinolone use (ie, safer alternative available). Overuse was determined based on patient risk factors, symptoms, allergies, diagnostic results, and time to stability. Hospital rurality was defined using the Rural–Urban Continuum Codes (RUCC) score. We defined rural as a score ≥4 and very rural as a score of 7–9. We used t tests to compare the mean percentage of patients with antibiotic overuse at discharge between nonrural and rural (and very rural) hospitals. Results: Across 41 hospitals, we included 23,449 patients with CAP or UTI. There were 5 rural (and 3 very rural) hospitals with 2,039 (and 1,082) patients. Antibiotic overuse at discharge was present in 43.1% of patient cases in nonrural hospitals, 52.5% in rural hospitals (P = .04 vs nonrural) and 58.1% in very rural hospitals (P = .007 vs nonrural). Compared to nonrural hospitals, the mean percentage of cases with antibiotic overuse at discharge in rural hospitals was 9.4% higher (15.1% higher in very rural hospitals). Results were similar in a subgroup analysis of only patients with UTI (47.0% in rural vs 37.5% in nonrural, mean difference, 9.5%; P = .03) but were not statistically significant in patients with CAP (53.8% vs 48.0%, respectively; mean difference, 5.8%; P = 0.23). Conclusions: In this retrospective study, rural hospitals—especially very rural hospitals, had higher rates of antibiotic overuse at discharge than nonrural hospitals. Our findings suggest that antibiotic stewardship interventions tailored toward the unique differences in infrastructure, resources, and needs of rural hospitals are essential to community health.

Disclosures: None

Background: Antibiotic use was common in patients with suspected or confirmed COVID-19 infection; however, data emerged demonstrating low rates of bacterial coinfection (6%–10%). Antimicrobial stewardship best practice was challenged during this time, requiring new strategies and education to limit the inappropriate use of antibiotics. At the Veterans’ Affairs Maryland Healthcare System, we evaluated the use of community acquired pneumonia (CAP) specific antibiotics in COVID-19–positive patients after successive interventions. Methods: We conducted a pre–post evaluation of common CAP antibiotics (ceftriaxone IV/IM, cefpodoxime PO, azithromycin PO/IV, ampicillin/sulbactam IV, amoxicillin-clavulanate PO, levofloxacin) during the COVID-19 pandemic. The preintervention period was April–October 2020 and the postintervention period was November 2020–April 2021. During the preintervention period, intervention A was carried out as follows: (1) inpatient weekly virtual interdisciplinary COVID-19 rounds were led by an antimicrobial stewardship champion, (2) χprocalcitonin was implemented in clinical decision making, and (3) inpatient audit and feedback of active antibiotics was conducted by the antimicrobial stewardship team. In the postintervention period, intervention B was added as follows: (1) weekly educational COVID-19 virtual seminars were conducted for providers, and (2) targeted education was provided to emergency department and hospitalist directors. Comparisons of the proportions of antibiotics prescribed were made between the pre- and postintervention periods using X2 statistic, and data were stratified by location. The rates of CAP antibiotic prescription per 100 COVID-19–positive patients were also compared using Poisson distribution. Results: During the study period, 814 unique patients had COVID-19 infection: 182 (22.4%) patients admitted to the acute-care center, 66 (8.1%) long-term care residents, and 566 (69.5%) were managed outside the hospital. Of these 814 patients, 211 (25%) were prescribed a CAP antibiotic. Of the antibiotics prescribed, 223 (61%) were ceftriaxone, cefpodoxime, amoxicillin-clavulanate, or ampicillin-sulbactam; 123 (34%) were azithromycin; and 16 (4.4%) were levofloxacin. We observed a decrease in the frequency of all antibiotic prescriptions after intervention B was added: 32% (86 of 273) vs 23% (125 of 541) (P = .01). Decreases in antibiotic prescriptions were observed in all locations: acute care (57% vs 44%), long-term care (53% vs 41%) and outpatient care (19% vs 15%). The rates of CAP antibiotic prescribing per 100 COVID-19–positive patients were 114 in the preintervention period and 45 in the postintervention period, a rate difference of −70 antibiotics per 100 COVID-19–positive patients (pConclusions: Curbing antibiotic use for CAP indication during the COVID-19 pandemic was a challenge. A multifaceted approach focusing on education was an impactful intervention leading to significant decreases in antibiotic prescribing despite COVID-19 cases increasing.

Funding: None

Disclosures: None

Background: Pediatric patients often require central venous catheters (CVCs) for a variety of clinical indications, including medication administration, parenteral nutrition, and venous blood sampling. Patients with CVCs are at risk for central-line–associated bloodstream infections (CLABSI). These hospital-acquired infections are often preventable and may lead to increased morbidity and mortality. Clinicians at a 477-bed, freestanding pediatric academic hospital completed a quality improvement project to identify factors that place pediatric patients at increased risk for CLABSI and to outline strategies aimed at CLABSI reduction for our highest-risk patients. Methods: Project leaders completed a literature review to evaluate current research on the topic and then assembled a project team. The team completed a retrospective analysis and categorization of CLABSI cases and reviewed internal CLABSI root-cause analysis data. The group then completed a case–control analysis to identify risk factors in patients with CVCs who developed CLABSIs, compared to patients with CVCs who did not develop CLABSI. Following this analysis, the team created a CLABSI risk-factor tool for use by bedside nurses. This tool described patients with CLABSI risk factors and outlined best practices for CLABSI prevention. Results: Based upon literature review, root-cause analysis data, and retrospective CLABSI case review over the period from 2017 to 2021, an initial list of 9 potential CLABSI risk factors was compiled. A case–control analysis was performed comparing 97 CLABSI cases with 103 matched controls. Univariate, multivariate, and additional covariate analyses were employed to identify 3 factors placing pediatric patients at increased risk for CLABSI. These included (1) multiple enteral devices (ie, 2 or more devices, including gastrostomy tube, jejunostomy tube, gastrostomy or jejunostomy tube, ostomy, and peritoneal drain); (2) multiple CVC entries (ie, CVC used for medications and venous sampling); and (3) long-term CVC plus parenteral nutrition (CVC in place for >21 days and receiving parenteral nutrition and/or intralipids). Conclusions: Pediatric patients with central venous access are vulnerable to CLABSI, and certain patients may be at increased risk. Frontline clinicians may be able to identify these patients and adopt best practices to prevent infection. A tool for use by bedside nurses can be a useful adjunct to existing CLABSI prevention practices.

Disclosures: None

Background: Inappropriate antimicrobial use continues to threaten modern medicine. The ongoing pandemic likely exacerbated this problem because COVID-19 presents similarly to bacterial pneumonia, confusion exists regarding treatment guidelines, and testing turnaround times (TATs) are slow. Our primary object was to quantify antimicrobial use changes during the pandemic to rates before the crisis. A subanalysis within the COVID-19 cohort was completed based on SARS-CoV-2 status. Methods: The pre–COVID-19 period was January–May 2019 and the COVID-19 period was January–May 2020. Subanalyses were used to explore differences in antibiotics use between persons not under investigation (non-PUIs), SARS-CoV-2–negative PUIs, and SARS-CoV-2–positive PUIs. Non-PUI patients were those without respiratory symptoms and/or fever. The χ2 and Wilcoxon signed rank-sum tests were used for analysis. Results: During the 2019 and 2020 study periods, 7,909 and 7,283 patients received >1 antimicrobial, respectively (Figure 1). Overall, antibiotic therapy per 1,000 patient days increased from 633.1 before COVID-19 to 678.5 during COVID-19, a 7.2% increase (Table 1). Notably, broad-spectrum respiratory antibiotics demonstrated a significant increase between pre–COVID-19 and COVID-19 cohorts (p < 0.001). Of the 7,283 patients within the COVID-19 cohort, 34.7% (n = 2,532) were PUI and 13.8% (n = 1,002) of these patients tested SARS-CoV-2 positive. Again, broad-spectrum respiratory antibiotics use was significantly increased for COVID-19 patients (p < 0.001). Of note, the proportion of patients receiving respiratory antibiotics steadily decreased over time (R2 = 0.99). Conclusions: There was a significant increase in antibiotic use during the COVID-19 pandemic. Encouragingly, antimicrobial use decreased over time, likely due to (1) faster TATs, (2) real-time education to clinicians and subsequent de-escalation of unnecessary antimicrobials, and (3) development of treatment guidelines as new research emerged.

Funding: No

Disclosures: None

Figure 1.

Table 1.

Background: Candida spp can cause a variety of infections known as candidiasis, ranging from severe invasive infections to superficial mucosal infections of the mouth and vagina. Fluconazole, a triazole antifungal, is commonly prescribed to treat candidiasis but increasing fluconazole resistance is a growing concern for several Candida spp. Although C. albicans has historically been the most common cause of candidiasis, other species are increasingly common and antifungal resistance is more prevalent in these non-albicans species, including C. glabrata, C. parapsilosis, and C. tropicalis, which were the focus of this analysis. Methods: We used the PINC AI healthcare data (PHD) database to examine fluconazole resistance for inpatient isolates between 2012 and 2021 from 187 US acute-care hospitals with at least 1 Candida spp culture with a fluconazole susceptibility result over the entire period. We calculated annual percentage fluconazole resistance for C. glabrata, C. tropicalis, and C. parapsilosis isolates using the clinical laboratory interpretation for resistance. Results: We identified 4,264 C. glabrata, 2,482 C. parapsilosis, and 2,283 C. tropicalis isolates between 2012 and 2021 with susceptibility results. The percentage of C. glabrata isolates resistant to fluconazole doubled between 2020 and 2021 (14.6% vs 29.3%) (Fig. 1a). The percentage of C. parapsilosis isolates resistant to fluconazole steadily increased since 2017 (Fig. 1b), with an 82% increase in 2021 compared with 2020 (3.8% in 2020 vs 6.9% in 2021). Fluconazole resistance among C. tropicalis isolates varied over the years, with a 0.3% decrease in 2021 from 2020 (Fig. 1c). Of hospitals reporting at least 1 result each year 2020–2021, 44% observed an increase in the proportion of C. glabrata isolates resistant to fluconazole in 2021 compared to 2020. Conclusions: Our analysis highlights a concerning increase in fluconazole resistance among C. glabrata and C. parapsilosis isolates in 2021 compared with previous years. Further investigation of the observed increases in fluconazole resistance among these Candida spp could provide further insight on potential drivers of resistance or limitations in reported results from large databases. More analyses are needed to understand rates, sites of Candida infections, and risk factors (eg, antifungal exposure) associated with resistance.

Disclosures: None

Background: Clinical pharmacists are a critical part of antibiotic stewardship. Stewardship often relies on relationships and persuasion, which may be affected by gender bias. Thus, we aimed to assess the association of sex with the acceptance of antibiotic stewardship recommendations. Methods: Between May and October 2019, medicine pharmacists at single hospital reviewed patients on antibiotics and–when a discharge was anticipated–led an antibiotic discussion (or “timeout”) prior to discharge. To explore differences in antibiotic timeout effectiveness by gender, we assessed the association of pharmacist sex with suggestion and acceptance of antibiotic changes using logistic regression controlling for patient characteristics. We also assessed whether hospitalist sex was associated with or moderated the effect of pharmacist sex on acceptance of timeout recommendations. Results: Between May 1, 2019, and October 31, 2019, pharmacists conducted 295 timeouts (patient characteristics in Fig. 1). Overall, 54% of timeouts were conducted by 12 female pharmacists and the remaining 46% were conducted by 8 male pharmacists. Overall, 82 (29%) of 295 timeouts resulted in a pharmacist recommending an antibiotic change, and male pharmacists were more likely to recommend a change: 52 (38%) of 137 versus 30 (19%) 158 (P Conclusions: In this discharge antibiotic intervention, timeouts conducted by women were less likely to result in an antibiotic change than those conducted by men. The difference in effectiveness resulted both from female pharmacists being less likely to recommend a change and from hospitalists being less likely to accept recommendations from a female pharmacist. These findings suggest that gender bias may play a role acceptance of antibiotic stewardship recommendations, which could affect antibiotic use, pharmacist job satisfaction, and patient outcomes.

Funding: None

Disclosures: None

Altering the appearance of a computerized physician order entry (CPOE) interface reduces misuse of an HIV diagnostic test by 87%, demonstrating that CPOE design is a key component of diagnostic stewardship. Collaboration between infectious disease providers, clinical laboratorians, and information technology (IT) professionals can result in improved quality and decreased costs.

Catheter-related infections increased during surges of coronavirus disease 2019 (COVID-19) in an 11-hospital system in New York City. A disproportionate number of central-line infections occurred in larger hospitals. Patients with COVID-19 had shorter times from catheter insertion to infection and a higher incidence of infections with enterococci.

Background: Sink drains can act as breeding grounds for multidrug-resistant (MDR) bacteria, leading to outbreaks. Drains provide a protected humid environment where nutrient-rich substances are available. Recent and growing installation of water and energy conservation devices have led to increased frequency of drain blockage due to biofilm accumulation. Ineffective drainage may lead to backflow and accumulation of water in the sink during use, increasing the risk of contaminated aerosols formation or direct contamination of surrounding material and equipment. Cleaning and disinfection procedures of sink drains need to be improved to prevent amplification and dispersion of MDR bacteria. The objective of this study was to investigate alternatives to reduce the biofilm and risk of contamination through aerosols. Methods: Sink drains from patient rooms were randomly selected in the neonatal intensive care unit of a 450-bed pediatric hospital. We tested 4 approaches: (1) new drain; (2) self-disinfecting heating-vibration drain; (3) chemical disinfection with 20 ppm chlorine for 30 minutes; and (4) thermal disinfection with > 90°C water for 30 minutes. A special device was used during disinfection to increase the disinfectant contact time with the biofilm. Treatments were conducted weekly, with prior sampling of drain water. Other drains were also sampled weekly, including a control drain with no intervention. Bacterial loads were evaluated using flow cytometry and heterotrophic plate counts. The drains were made of stainless steel, a heat-conductive material. Results: Preliminary results show that chlorine disinfection had a small impact (<1 log) on culturable bacteria at 48 hours after disinfection but not after a week or repeated weekly disinfection. Thermal disinfection using boiling water is promising, showing an important decrease of 4 log in culturable cells after 48 hours and a concentration still 100× lower 1 week after the disinfection. Repeated weekly thermal disinfection maintained lower culturable levels in the drain. No culturable cells were detected in water from the self-disinfecting drain 2 months after installation, whereas the new drain became fully colonized to concentrations similar to those of drains prior to interventions during the same period. Conclusions: Thermal disinfection of drains is a promising alternative to chlorine. This solution is interesting because it is nontoxic and easy to perform, requiring a small volume of hot water. The rapid recolonization of the new drain suggests that replacing contaminated drains is not a sustainable solution and would need to be paired with a thermal disinfection program to maintain low culturable cells.

Funding: No

Disclosures: None

Background: Central-line–associated bloodstream infections (CLABSIs) significantly burden the US population and healthcare system. Reporting facilities in Tennessee consistently omit race and ethnicity data in the NHSN despite having the option to enter. Racial and ethnic disparities are well documented across many health outcomes, including patient safety. CLABSIs were compared among 3 racial groups to better understand the impact of race on CLABSI incidence in Tennessee. Methods: CLABSI data from NHSN were linked with records from the TN Hospital Discharge Data System (HDDS) for 2018–2021. A multivariable linear regression model was used to determine relative risk (RR) between racial groups for contracting a CLABSI after controlling for confounding variables including Charlson comorbidity index (CCI) and social vulnerability index (SVI) scores. Statistical significance was set at P < .05. Data linkage and statistical analyses were performed in SAS version 9.4 software. Results: In Tennessee between 2018 and 2021, 342 (17.2%) of the 1,980 CLABSI events had race documented, and no ethnicity variables exist in the NHSN. The data linkage process yielded a 72% match (1,426 CLABSIs). The remaining 28% were excluded from the analysis. Per 1,000 central-line days (CL days) for all races, white patients had the highest CLABSI rate (17.5), followed by Black patients (1.36), and Native American or Alaskan Native patients (0.68). Per 1,000 admissions by race, Black patients had a higher CLABSI rate (1.26) than Native American/Alaskan Native patients (0.85) and white patients (0.75). The risk of contracting a CLABSI was 79% higher in Black patients than in white patients (RR, 1.79; 95% CI, 1.55–2.07; P < .0001) when controlling for CCI, age group, and SVI. Conclusions: These results suggest that racial disparities between Black and white patients are present in Tennessee hospitals regarding CLABSIs. Although most CLABSI events were linked to HDDS patients, there were limitations in the ability to match all cases and calculate CL days by race. This study highlights the need for complete race and ethnicity data in the NHSN. Further studies should examine infection types at the regional and facility levels to target interventions for reducing HAI inequities in Tennessee.

Disclosures: None

Background: Antibiotics targeted against Clostridioides difficile bacteria are necessary, but insufficient, to achieve a durable clinical response because they have no effect on C. difficile spores that germinate within a disrupted microbiome. ECOSPOR-III evaluated SER-109, an investigational, biologically derived microbiome therapeutic of purified Firmicute spores for treatment of rCDI. Herein, we present the interim analysis in the ITT population at 8 and 12 weeks. Methods: Adults ≥18 years with rCDI (≥3 episodes in 12 months) were screened at 75 US and CAN sites. CDI was defined as ≥3 unformed stools per day for <48 hours with a positive C. difficile assay. After completion of 10–21 days of vancomycin or fidaxomicin, adults with symptom resolution were randomized 1:1 to SER-109 (4 capsules × 3 days) or matching placebo and stratified by age (≥ or <65 years) and antibiotic received. Primary objectives were safety and efficacy at 8 weeks. Primary efficacy endpoint was rCDI (recurrent toxin+ diarrhea requiring treatment); secondary endpoints included efficacy at 12 weeks after dosing. Results: Overall, 287 participants were screened and 182 were randomized (59.9% female; mean age, 65.5 years). The most common reason for screen failure was a negative C. difficile toxin assay. A significantly lower proportion of SER-109 participants had rCDI after dosing compared to placebo at week 8 (11.1% vs 41.3%, respectively; relative risk [RR], 0.27; 95% confidence interval [CI], 0.15–0.51; p-value <0.001). Efficacy rates were significantly higher with SER-109 vs placebo in both stratified age groups (Figure 1). SER-109 was well-tolerated with a safety profile similar to placebo. The most common treatment-emergent adverse events (TEAEs) were gastrointestinal and were mainly mild to moderate. No serious TEAEs, infections, deaths, or drug discontinuations were deemed related to study drug. Conclusions: SER-109, an oral live microbiome therapeutic, achieved high rates of sustained clinical response with a favorable safety profile. By enriching for Firmicute spores, SER-109 achieves high efficacy while mitigating risk of transmitting infectious agents, beyond donor screening alone. SER-109 represents a major paradigm shift in the clinical management of patients with recurrent CDI. Clinicaltrials.gov Identifier NCT03183128. These data were previously presented as a late breaker at American College of Gastroenterology 2020.

Funding: Seres Therapeutics

Disclosures: None

Figure 1.

Objectives: Antimicrobial resistance is a serious threat to health and economic well-being worldwide. The impact of antibiotic-resistant infections is reflected by higher mortality, increased lengths of hospital stay (LOS), and increased healthcare costs. We analyzed the direct healthcare costs attributable to treating patients infected with methicillin-resistant Staphylococcus aureus (MRSA) and carbapenem-resistant Enterobacterales (CRE) in a tertiary-care referral hospital in Vietnam. Methods: A retrospective descriptive cross-sectional study was conducted in an intensive care unit (ICU) in the University Medical Center in Ho Chi Minh City from June 2018 to September 2019. Participants were ICU patients diagnosed with either MRSA or CRE infection, and patients infected with non–multidrug-resistant organisms (non-MDROs) were used as the comparison group. Medical records were obtained to collect data on medical services expenditures such as medications, diagnostic testing, medical procedures, and hospital rooms. Statistical significance was determined using the Mann-Whitney and Kruskal-Wallis tests for comparing the average costs and the χ2 test for comparing the proportions. Results: In total, 227 patients, including 37 MRSA-infected patients, 97 CRE-infected patients, and 93 non–MDRO-infected patients, were included in the study. The additional average healthcare costs for a treatment episode of a CRE infection case (367.7 million VND or ~US $16,000) and of a MRSA infection case (139.1 million VND or ~US $6,043) were 3.8 times higher (P < .001) and 1.5 times higher (P < .001), respectively, than the average cost for a non-MDRO case (94.8 million VND or ~US $4,121). Resource use for a CRE infection was higher than that for MRSA infection, with longer antibiotic treatment (13.4 additional days), greater LOS (15.8 additional days), and higher costs (additional 228.6 million VND or ~US $9,939). Conclusions: Multidrug-resistant infections create a heavy economic burden in a low- to middle-income country like Vietnam. The elevated cost was mainly due to longer antibiotic treatment and increased LOS.