"Electronic Phenotyping" Antimicrobials to Facilitate Outpatient Stewardship for Asymptomatic Bacteriuria and Urinary Tract Infection in Renal Transplant

Asymptomatic bacteriuria and urinary tract infection in renal transplant are important antimicrobial stewardship targets but are difficult to identify within electronic medical records. We validated an "electronic phenotype" of antibacterials prescribed for these indications. This may be more useful than billing data in assessing antibiotic indication in this outpatient setting.

Utilization of Immunization Information Systems (IIS) among independently owned community pharmacies: A national survey

BACKGROUND/OBJECTIVE

Immunization information systems (IIS) consolidate provider-submitted immunization information. We reassessed independently owned community pharmacies' IIS enrollment, verification of immunizations needs via IIS records retrieval, and immunization records reporting to IISs following post-pandemic shifts in community pharmacy operations.

METHODS

A cross-sectional online survey of National Community Pharmacists Association pharmacist, pharmacy owner, and pharmacy technician members was conducted in Fall 2022.

RESULTS

202 complete responses were analyzed. Margin of error was an estimated 7 %. Respondents were: 53.2 % female, ∼87 % White, 69.8 % managers, and 86.1 % practicing in standalone community pharmacies. Almost all (91.6 %) were enrolled in IIS. About two-thirds frequently or always utilized IIS to retrieve immunization records prior to immunization. On average, 81.2 % of influenza and 83.5 % of non-COVID/non-influenza vaccination records were submitted.

CONCLUSIONS

Enrollment rates are high among studied pharmacies, as are records reporting rates. However, records retrieval rates are suboptimal. Future work should focus on addressing suboptimal retrieval rates within immunization-providing pharmacies.

Pharmacy-based immunization in rural USA during the COVID-19 pandemic: A survey of community pharmacists from five southeastern states

INTRODUCTION

Immunization rates for seasonal and non-seasonal vaccines dropped during the COVID-19 pandemic. Little is known about the extent to which community pharmacies in the USA continued to serve as immunization sites during the pandemic. This study compared 1) the types and perceived changes in non-COVID-19 vaccine doses administered at rural community pharmacies in 2020 (during the pandemic) to 2019 (pre-pandemic) and 2) the delivery of non-COVID-19 immunization services in 2020 to 2019.

METHODS

A mixed-mode (paper/electronic) survey of a convenience sample of 385 community pharmacies operating in rural settings and have administered ≥1 vaccine in 2019 and 2020 was distributed in May-August 2021. Survey development was informed by relevant literature, pre-tested with three individuals, and pilot-tested with 20 pharmacists. Non-response bias was assessed, and survey responses were analyzed using descriptive and bivariate statistics.

RESULTS

Of the 385 community pharmacies, 86 qualified pharmacies completed the survey (Response Rate = 23.8%). The percentage of pharmacies offering a given vaccine in 2019 and 2020 were similar; with one exception, a higher percentage of pharmacies reported having MMR administered for adults in the pharmacy in 2020 (McNemar's test; p-value = 0.0253). For each given vaccine, the majority of respondents did not perceive a change in the number of doses administered in 2020 compared to 2019. Further, the majority reported no difference in how they delivered immunization services during and pre-pandemic. However, a small percentage of respondents (6.0-22.0%) adapted their services by adopting several measures to ensure the safety and continuity of immunizations during the pandemic.

CONCLUSION

Findings highlight the importance of community pharmacies as immunization sites during the pandemic. Community pharmacies continued immunization delivery at community pharmacies during the pandemic with almost no noticeable change to types and doses of vaccines compared to pre-pandemic nor the process of vaccine delivery.

Piperacillin/tazobactam versus cefepime or carbapenems for cefoxitin-non-susceptible Enterobacter cloacae, Klebsiella aerogenes, Citrobacter freundii, Serratia marcescens and Morganella morganii bacteraemia in immunocompromised patients

BACKGROUND

The role of piperacillin/tazobactam for treatment of serious infections due to AmpC-producing organisms remains debatable, particularly in immunocompromised patients.

METHODS

This was a retrospective cohort study in immunocompromised patients that investigated the effect of definitive treatment with either piperacillin/tazobactam versus cefepime or carbapenems for bacteraemia caused by cefoxitin-non-susceptible Enterobacterales. The primary endpoint was a composite of clinical and microbiological failure. A logistic regression model was constructed to assess the impact of definitive treatment choice on the primary endpoint.

RESULTS

A total of 81 immunocompromised patients with blood cultures positive for cefoxitin-non-susceptible Enterobacterales were included for analysis. There was more microbiological failure in the piperacillin/tazobactam arm compared with the cefepime/carbapenem arm (11.4% versus 0.0%, P = 0.019). Definitive treatment with cefepime or a carbapenem was associated with a decreased odds of clinical or microbiological failure (OR 0.303, 95% CI 0.093-0.991, P = 0.048) when controlling for baseline characteristics.

CONCLUSIONS

In immunocompromised patients with bacteraemia due to cefoxitin-non-susceptible Enterobacterales, definitive treatment with piperacillin/tazobactam was associated with an increased risk of microbiological failure and higher odds of clinical or microbiological failure compared with cefepime or carbapenems.

Validity of Coronavirus Disease 2019 International Classification of Diseases, Tenth Revision in the Urgent Care Setting and Impact on Antibiotic Prescribing Rates

We validated  different coronavirus disease 2019 (COVID-19) International Classification of Diseases, Tenth Edition (ICD-10) encounter definitions across 2 urgent care clinics. Sensitivity of definitions varied throughout the pandemic. Inclusion of COVID-19 and COVID-19-like illness (CLI) ICD-10s rendered highest sensitivity but lowest specificity. Antibiotic prescribing rates were low for COVID-19 ICD-10 encounters, increasing with CLI ICD-10 encounters.

Risk factors and outcomes associated with persistent vancomycin resistant Enterococcal Bacteremia

Background

Prior studies have identified that vancomycin resistant enterococcus (VRE) bacteremia that persists for four days or more is an independent predictor of mortality. Despite this, there is no published data to identify those patients at highest risk of developing persistent VRE bacteremia.

Methods

This was a single center, retrospective, case-control study of adult patients with a VRE bloodstream infection (BSI). Case patients were those with persistent bacteremia (≥ 4 days despite VRE-directed therapy) and control patients were those with non-persistent bacteremia. Logistic regression was used to assess risk factors associated with persistent VRE BSIs. Secondary outcomes included in-hospital mortality, recurrent bacteremia, and breakthrough bacteremia.

Results

During the study period, 24/108 (22%) patients had persistently positive blood cultures. Risk factors for persistent bacteremia included severe neutropenia (OR 2.13), 4 out of 4 positive index blood cultures (OR 11.29) and lack of source control (OR 11.88). In an unadjusted analysis, no statistically significant differences in in-hospital mortality (58% versus 40%; p = 0.121), recurrent bacteremia (17% versus 6%; p = 0.090), or breakthrough bacteremia (13% versus 7%; p = 0.402) were observed between groups.

Conclusion

Patients with severe neutropenia, 4 out of 4 positive index blood culture bottles, and lack of source control were more likely to develop persistent VRE bacteremia despite directed antibiotic treatment.

Determinants to immunization information system implementation in independent community pharmacies in rural Alabama

BACKGROUND

Immunization information systems (IISs) facilitate consolidated vaccination data within each state. Many have limited pharmacy participation, especially Alabama. As pharmacists increasingly engage in delivery of vaccines recommended across the life span, it is critical to understand the barriers to IIS implementation, particularly in rural community pharmacies where access to primary care may be limited.

OBJECTIVE

The purpose of this study was to identify barriers and facilitators to IIS implementation in rural, independent community pharmacies in Alabama.

METHODS

Qualitative interviews with rural, independent community pharmacy personnel and IIS experts in both states with high IIS participation and Alabama (state with low IIS participation) were conducted. States with high participation were identified as those with ≥75% of adults recorded in their respective state IIS. Less than 25% of Alabama adults were recorded in the state IIS at the time of this study. Deductive coding using CFIR constructs was conducted with a second coder to ensure inter-rater reliability. CFIR Rating Rules were applied to the coded data to allow for identification of constructs that have the greatest impact on implementation.

RESULTS

A total of twenty-five participants (16 pharmacy personnel; 9 IIS experts) were interviewed. During interviews, 32 of 39 CFIR constructs were mentioned and 11 constructs with a strong influence (+2 or -2) were identified. These included, "adaptability", "complexity", "compatibility", "available resources", "access to knowledge and information", "needs and resources of those served by the organization", "peer pressure", "external policy and initiatives", "knowledge and beliefs about the innovation", "engaging key stakeholders", and "engaging innovation participants".

CONCLUSIONS

This qualitative study explored perceived barriers and facilitators to IIS implementation in the rural, independent community pharmacy setting from the perspectives of pharmacy personnel and IIS experts. Factors identified can be used to inform the development of resources and implementation strategies to improve IIS uptake and participation.

Sustained Reduction in Urgent Care Antibiotic Prescribing During the COVID-19 pandemic: An Academic Medical Center’s Experience

We compared antibiotic prescribing before and during the ­coronavirus disease 2019 (COVID-19) pandemic at 2 academic urgent care clinics and found a sustained decrease in prescribing driven by respiratory encounters and despite transitioning to telemedicine. Antibiotics were rarely prescribed during encounters for COVID-19 or COVID-19 symptoms. COVID-19 revealed opportunities for outpatient stewardship programs.

Successful fidaxomicin hospital discharges of adult patients with Clostridioides difficile infections post 2021 guidelines - are economic barriers finally coming down?

We reviewed C.difficile positive patients discharged on fidaxomicin after local adoption of 2021C.difficile infection (CDI) guidelines. From June 14 - Oct 3, 2021, 80% (12/15) had copayments $0-$35, and 27% (4/15) required prior authorization. The 30-day CDI recurrence was 7%.

Procedural Skills Training in Emergency Medicine Physicians Within the Edmonton Zone: A Needs Assessment

OBJECTIVES

The objectives were to describe the current procedural skill practices, attitudes toward procedural skill competency, and the role for educational skills training sessions among emergency medicine (EM) physicians within a geographic health zone.

METHODS

This is a multicenter descriptive cross-sectional survey of all EM physicians working at 12 emergency departments (EDs) within the Edmonton Zone in 2019. Survey items addressed current procedural skill performance frequency; perceived importance and confidence; current methods to maintain competence; barriers and facilitating factors to participation in a curriculum; preferred teaching methods; and desired frequency of practice for each procedural skill.

RESULTS

Survey response rate was 53.6%. Variability in frequency of performed procedures was seen across the type of hospital sites. For the majority of skills, there was a significantly positive correlation between the frequency at which a skill was performed and the perceived confidence performing said skill. There was inconsistency and no significant correlation with perceived importance, perceived confidence or frequency performing a given skill, and the desired frequency of training for that skill. Course availability (76.2%) and time (72.8%) are the most common identified barriers to participation in procedural skills training.

CONCLUSIONS

This study summarized the current ED procedural skill practices among EM physicians in the Edmonton Zone and attitudes toward an educational curriculum for procedural skill competency. This represents a step toward targeted continuing professional development in staff physicians.

Oral Health Inequalities among Indigenous and Non-Indigenous Children

INTRODUCTION

Our ability to address child oral health inequalities would be greatly facilitated by a more nuanced understanding of whether underlying disease experience or treatment opportunities account for a larger share of differences between social groups. This is particularly relevant in the context of population subgroups who are socially marginalized, such as Australia's Indigenous population. The decayed, missing, and filled (dmf) surfaces index is at once a reflection of dental caries experience (d) and its management (m and f).

OBJECTIVES

To 1) describe socioeconomic inequalities in dental caries experience and its management among Indigenous and non-Indigenous children and 2) compare these inequalities using absolute and relative measures.

METHODS

Data were from the Australian National Child Oral Health Study 2012-2014. Absolute and relative income inequalities were assessed for overall dmfs and its individual components (ds, ms, fs) using adjusted means and health disparity indices (Slope Index of Inequality [SII] and Relative Index of Inequality [RII]).

RESULTS

Mean dmfs among Indigenous children aged 5 to 10 y was 6.4 (95% confidence interval [CI], 5.4-7.4), ranging from 2.3 in the highest to 9.1 in the lowest income group. Mean dmfs among non-Indigenous children was 2.9 (95% CI, 2.8-3.1), ranging from 1.9 in the highest to 4.2 in the lowest income group. Age- and gender-adjusted social gradients for Indigenous children were evident across all dmfs components but were particularly notable for ds (SII = -4.6, RII = -1.7) and fs (SII = -3.2, RII = -1.5). The social gradients for non-Indigenous children were much lower in magnitude: ds (SII = -1.8, RII = -1.6) and fs (SII = -0.7, RII = -0.5).

CONCLUSION

Our findings suggest that socioeconomic disadvantage may translate into both higher disease experience and increased use of dental services for both Indigenous and non-Indigenous groups, with the social gradients being much more amplified among Indigenous children.

KNOWLEDGE TRANSFER STATEMENT

The findings of this study demonstrate the magnitude of disparities in dental caries among children by population groups in Australia. Our results suggest that the relationship between socioeconomic disadvantage and poor oral health is more deleterious among Indigenous than non-Indigenous children. Tackling upstream determinants of health might not only affect population patterns of health and disease but also mitigate the overwhelming racial inequalities in oral health between Indigenous and non-Indigenous Australians.

Baloxavir Marboxil: A New Antiviral for Acute Influenza

Baloxavir is a newly approved, single-dose, oral influenza antiviral indicated for acute uncomplicated influenza in patients 12 years and older if symptomatic for less than 48 hours. The purpose of this article is to review currently available literature on the mechanism of action, pharmacokinetics, safety, and clinical and virologic efficacy of baloxavir. Its novel mechanism of action prevents influenza replication by targeting the viral cap-dependent endonuclease enzyme. In clinical trials baloxavir was shown to be superior to placebo and comparable to oseltamivir with regard to time to alleviation of symptoms and viral titer reduction and was well tolerated with minimal adverse effects. Baloxavir is a viable treatment option for acute uncomplicated influenza in certain age groups.

Enhancing pharmacy personnel immunization-related confidence, perceived barriers, and perceived influence: The We Immunize program

OBJECTIVES

Pharmacy personnel need practical strategies to incorporate nonseasonal vaccination services into pharmacy workflow. The objective of this study was to evaluate participants' confidence, perceived barriers and facilitators, and perceived influence on decision-making related to immunization services before and after the We Immunize program to assess program effectiveness.

DESIGN

Randomized controlled trial.

SETTING AND PARTICIPANTS

A total of 62 pharmacist-technician pairs from community pharmacies in Alabama and California participated in the randomized controlled trial. All participants were offered a 1-hour live immunization update. Intervention participants were also offered a 2-hour enhanced training at the beginning of the study period and tailored monthly feedback for 6 months.

OUTCOME MEASURES

A survey was administered at baseline and after the intervention. Likert-type scales were used to rank level of agreement and differences were analyzed using paired-sample t tests and 2-way mixed analysis of variance.

RESULTS

Sixty-seven participants completed both baseline and postintervention surveys (37 intervention; 30 control). Within the intervention group, participants' confidence in determining pneumococcal vaccine appropriateness (P = 0.027), confidence in pneumococcal vaccine-related patient interactions (P = 0.041), perceived external support (P = 0.016), and perceived influence on immunization services (P < 0.001) significantly improved. No change was observed within the control group. Compared to control participants, intervention participants showed a greater degree of change in perceived external support (P = 0.023) and influence on immunization services (P = 0.005) from baseline to post intervention. Neither confidence related to the herpes zoster vaccine nor marketing activities improved over the study period in either the intervention or control groups.

CONCLUSION

Immunization training, including educational interventions and tailored feedback, can be used to positively impact pharmacy personnel's confidence in providing pneumococcal vaccinations and perceptions related to environmental support and influence on immunization services. This, in turn, may increase immunization activities within community settings.

Reinforcement Learning for Improving Agent Design

In many reinforcement learning tasks, the goal is to learn a policy to manipulate an agent, whose design is fixed, to maximize some notion of cumulative reward. The design of the agent's physical structure is rarely optimized for the task at hand. In this work, we explore the possibility of learning a version of the agent's design that is better suited for its task, jointly with the policy. We propose an alteration to the popular OpenAI Gym framework, where we parameterize parts of an environment, and allow an agent to jointly learn to modify these environment parameters along with its policy. We demonstrate that an agent can learn a better structure of its body that is not only better suited for the task, but also facilitates policy learning. Joint learning of policy and structure may even uncover design principles that are useful for assisted-design applications.

2085. Bedside Nurses Improve Antimicrobial Stewardship and Infection Prevention Outcomes: Results of a 3.5-Year Study in Three Hospital Telemetry Units

Background

Minimal literature exists to demonstrate the quantitative impact of bedside nurses in antimicrobial stewardship (AMS). We initiated bedside nurse-driven AMS and infection prevention (AMS/IP) rounds on three inpatient telemetry units of a community regional medical center. Rounds were nurse-driven, involved an infectious diseases (ID) pharmacist and infection preventionist, and were designed to complement traditional ID pharmacist and ID physician AMS rounds. Rounds were focused on use of antibiotics, urinary catheters (UCs), and central venous catheters (CVCs). Recommendations from rounds were communicated by the bedside nurse either directly to providers or to the ID pharmacist and ID physician for intervention.

Methods

This was an observational, multiple-group, quasi-experimental study conducted over 3.5 years (July 2015 to December 2018) to characterize the impact of bedside nurse-driven AMS/IP rounds on antibiotic, urinary catheter and CVC use, hospital-onset C. difficile infection (CDI), catheter-associated urinary tract infections (CAUTI), and central line-associated bloodstream infections (CLABSI). Outcomes were assessed in two cohorts based on time of AMS/IP rounds implementation (Cohort 1 implemented on one telemetry unit in July 2016, Cohort 2 implemented in two telemetry units in January 2018).

Results

A total of 2,273 patient therapy reviews occurred (Cohort 1: 1,736; Cohort 2: 537). Of these reviews, 1,209 (53%) were antibiotics, 879 (39%) were urinary catheters, and 185 (8%) were CVCs. Pre- vs. post-intervention, significant reductions were observed in both cohorts for mean monthly antibiotic days of therapy per 1,000 patient-days (Cohort 1: 791 vs. 688, P < 0.001; Cohort 2: 615 vs. 492, P < 0.001), UC days per patient day (Cohort 1: 0.25 vs. 0.16, P < 0.001; Cohort 2: 0.19 vs. 0.14, P < 0.001), CVC days per patient day (Cohort 1: 0.15 vs. 0.11, = 0.002; Cohort 2: 0.09 vs. 0.07, p = 0.005), and CDI per 10,000 patient-days (Cohort 1: 17.8 vs. 7.1, p = 0.035; Cohort 2: 19.1 vs. 5.4, p = 0.003). Numerical reductions were observed in CAUTI and CLABSI per 10,000 patient-days.

Conclusion

Bedside nurses can improve AMS and IP outcomes in a scalable fashion when supported by an interdisciplinary AMS/IP team and are complimentary to traditional AMS and IP practices.

Disclosures

All authors: No reported disclosures.

542. Los Angeles County Acute Care Regional Antibiogram Suggests Changing Landscape of MDRO Threats Between 2015 and 2017

Background

National surveillance for multidrug-resistant organisms (MDRO) are limited by narrow geographic sampling, few hospitals, and failure to account for local epidemiology. A Los Angeles County (LAC) regional antibiogram was created to inform public health interventions and provide a baseline for susceptibility patterns countywide. We present data to compare the 2015 and 2017 LAC regional antibiogram.

Methods

We conducted a cross-sectional survey of cumulative facility-level antibiograms from all hospitals in LAC; 83 hospitals (AH) and 9 Long-term Acute Care (LTAC). For 2015, submission was voluntary, 2017 data were collected by public health order. Non-respondents were contacted by phone and in person. Isolates from sterile sources were pooled. Countywide susceptibility was calculated by weighting each facility’s isolate count by its reported susceptibility rate with minimum–maximim observed (2015) and Interquartile range (IQR) for 2017. Change from 2015 mean susceptibility is reported.

Results

Seventy-five (75) facilities submitted antibiograms for 2015 and 86 facilities for 2017. Among non-respondents in 2017, two facilities could not provide an adequate antibiogram and 4 were specialty hospitals with too few cultures to create an antibiogram. Regional summmary tables are presented in Tables 1–4. Klebsiella pneumoniae (n = 50 hospitals/19,382 isolates) % S to meropenem was 97% (IQR 94–100%), no change from 2015. Pseudomonas aeruginosa (PA) (n = 52 hospitals/17,770 isolates)% S to meropenem was 84% (IQR 74–93%), no change from 2015. Susceptibility to Acinetobacter baumannii (AB) was reported by 48 hospitals, including 1,4361 isolates,% S to meropenem was 39% (IQR 25–75%), 14% lower than 2015. Streptococcus agalactiae (n = 13 hospitals/647 isolates)% S to clindamycin was 43% (IQR 13–59%), a 22% increase from 2015.

Conclusion

LAC regional antibiograms identified stable patterns of antimicrobial resistance for most pathogens, but concerning results with AB and PA. Analysis of highly drug-resistant pathogens such as AB and PA would be improved with patient-level data to generate a combination antibiogram. We favor presenting IQR %S as done for 2017. Ongoing analysis will include multivariable analysis of observed changed S controlling for hospital characteristics.

Disclosures

All authors: No reported disclosures.

578. Microbiology Laboratory-Driven Standardized Urine Culture Reporting Increases Aminopenicillin Prescribing in Vancomycin-Resistant Enterococci Urinary Infections

Background

Vancomycin-resistant Enterococcus (VRE) urinary tract infections (UTI) are traditionally treated with therapies like linezolid or daptomycin. Multiple recent studies have demonstrated that aminopencillins (APs) have equivalent clinical efficacy outcomes as these therapies are able to achieve high urinary drug concentrations and may also have favorable comparative safety profiles and lower costs. Our institution implemented a standardized microbiology report for urine cultures positive for VRE which encouraged prescribing of APs and blinded sensitivity results.

Methods

This was a single-center, retrospective, observational study evaluating the impact of this microbiology report on prescribing outcomes in patients being treated for VRE UTI at a community regional medical center. The study was conducted over 7.5 years with January 2011 to September 2014 representing the pre-intervention cohort and October 2014 to July 2018 representing the post-intervention cohort. Patients were included if they were 18 years or older and received antibiotic therapy for a diagnosed VRE UTI. The primary outcome measure was terminal antibiotic therapy.

Results

Out of 388 patients with VRE positive urine cultures, 102 were included for analysis, 38 in the pre-intervention cohort and 64 in the post-intervention cohort. Cohorts were similar in terms of age, Charlson Comorbidity Index (CCI), β-lactam allergy, ID consultation, and urologic abnormalities. AP prescribing significantly increased from 3% (1/38) in the pre-intervention cohort to 44% (28/64) in the post-intervention cohort both in univariate (OR 29.8, 95% CI 3.7–222.8) and multivariate (OR 38.7, 95% CI 4.8–312.3) analyses. In the post-intervention cohort, age, gender, CCI, β-lactam allergy, and urologic abnormalities were not significantly associated with differences in aminopenicillin prescribing. There was no difference in in-hospital mortality between cohorts.

Conclusion

The results from this study demonstrate that a simple microbiology report for VRE positive urine cultures encouraging AP prescribing is significantly associated with an increase in AP prescribing for diagnosed VRE UTI and should be considered as a supplementary antimicrobial stewardship intervention.

Disclosures

All authors: No reported disclosures.

781. Nurse-Driven Time-of-Triage Sepsis Screening Tool Improves Timely Intervention in Ambulatory Emergency Department (ED) Patients with Suspected Sepsis

Background

Sepsis is a potentially life-threatening, systemic complication of infection. Rapid intervention is critical to reduce morbidity and mortality; however, early recognition of sepsis is challenging due to a highly variable and nonspecific presentation. Recognition is particularly problematic in ambulatory (walk-in) patients who receive minimal to no medical attention prior to ED presentation. There is limited literature addressing sepsis intervention among the ambulatory population in the ED. Our organization has employed an electronic, nurse-driven sepsis screening tool into the triage process for all ambulatory patients who present to the ED.

Methods

This was a retrospective, quasi-experimental study conducted from November 2015 to May 2018 in three consecutive timeframes: pre-implementation (12 months), implementation (7 months), and post-implementation (12 months). Adult ambulatory ED patients were included if they had a coded diagnosis of sepsis, septic shock, or an infectious syndrome, had fever or hypothermia and systemic inflammatory response syndrome signs on presentation. The primary outcome measure was hourly time interval to antibiotic administration from time of ED registration.

Results

A total of 902 patients were included with 286, 208, and 408 patients in the pre-implementation, implementation and post-implementation cohorts, respectively. Baseline characteristics including comorbid conditions and infection source were similar between cohorts. The primary outcome of hourly time interval to antibiotic administration was significantly different (P = 0.044) between the three cohorts with the most substantial increase in administration specifically in the less than 1-hour interval. Between the pre-implementation, implementation, and post-implementation cohorts, significant decreases were observed in mean time to fluids (3.6, 3.0, and 2.5 hours, respectively, P = 0.003) and average length of stay (5.5, 5.8, and 4.2 days, respectively, P < 0.001) and a significant increase was observed in ED sepsis alert activations (26%, 48%, 51%, respectively, P < 0.001).

Conclusion

A nurse-driven electronic time-of-triage sepsis screening tool improved timely recognition and intervention in ambulatory ED patients with suspected sepsis.

Disclosures

All authors: No reported disclosures.

2088. Cross-sectional Analysis of Administrative Structure and Practices for Hospital Antimicrobial Stewardship Programs (ASPs) in a Large Metropolitan City

Background

Methods

Results

Conclusion

Disclosures

Assessing barriers and increasing use of immunization information systems in independent community pharmacies: Study protocol for a randomized controlled trial

BACKGROUND

As the number of providers administering vaccines increases, including pharmacists, there is a concern of fragmented immunization records in state and regional immunization information systems (IIS). In order for IIS to have complete records, it is critical that each provider administering vaccines, including pharmacists, participate and update the IIS each time a vaccine is administered to a patient. In Alabama, provider participation in the state IIS is not mandatory; as a result, less than 25% of adults over the age of 19 have immunization data recorded. IIS participation among independent pharmacies is of particular concern as approximately 40% of Alabama pharmacies are independently owned, but only 27% of these are enrolled in the IIS.

OBJECTIVE

The objective of this report is to describe a study protocol to assess the impact of an IIS training program among community pharmacies' IIS enrollment and actual participation rates.

METHODS

The research design is a randomized controlled trial. Study participants are Alabama pharmacists who work in independently owned pharmacies that currently provide at least one type of non-seasonal vaccine and are not currently enrolled in the Alabama IIS. Multiple outcomes including awareness, knowledge, attitudes, intention, IIS enrollment, and IIS participation will be compared between intervention and control groups across three time points (baseline, one-month, and three-months). Individual and organizational factors will be measured to identify any possible associations with outcomes.

IMPLICATIONS

The expected outcome is to create an effective training program that is scalable and ready for dissemination. If successful, this training program can be replicated and used to significantly impact the completeness and accuracy of IIS across the U.S., providing the potential for IIS to be used consistently in assessing immunization status and recommending additional vaccines in the pharmacy setting, thereby improving vaccination coverage and making the provision of immunizations safe and efficient.

607. Group B Streptococcus Resistance to Clindamycin: Regional Antibiogram Surveillance in Los Angeles County

Background

Intrapartum antibiotic prophylaxis (IAP) prevents neonatal mortality from Group B Streptococcus (GBS). Clindamycin resistance among GBS isolates complicates IAP for GBS-positive women allergic to penicillin and cephalosporins. GBS screening by nucleic acid amplification tests (NAATs) provides rapid results, but no susceptibility data to inform IAP. We sought to estimate burden of clindamycin resistance among GBS in Los Angeles County (LAC).

Methods

Hospital antibiogram data were gathered from all LAC acute care hospitals from 2015 to 2016. Weighted averages for GBS resistance to clindamycin, erythromycin, penicillin, and TMP/SMX were calculated. Facilities which reported clindamycin susceptibilities were interviewed regarding antimicrobial susceptibility testing methods.

Results

A total of 2,339 GBS isolates from 22 hospitals were reported between 2015 and 2016. Thirteen hospitals tested GBS for clindamycin (nine reported in 2015 and 2016, four hospitals reported in 2016 only). Clindamycin resistance was found in 61.7% of 1,794 GBS isolates (79.3% of 891 in 2015, 44.3% of 903 in 2016). Erythromycin resistance was 42% in 735 isolates reported, 0.1% penicillin of 1,916 isolates reported, and 1.5% TMP/SMX of = 135 isolates reported. Facilities tested GBS by manual minimum inhibitory concentration (MIC) broth dilution (n = 1), automated MIC dilution (n = 4), agar plate diffusion (n = 1), and MIC dilution followed by agar plate diffusion (n = 1). Two hospitals did not perform testing on-site.

Conclusion

The 62% prevalence of clindamycin-resistant GBS in LAC is three-fold higher than national CDC estimates and complicates IAP for GBS-positive women allergic to penicillin and cephalosporins. These data support CDC recommendations for susceptibility testing in addition to NAAT screening which does not include assays for common determinants of clindamycin resistance, erm-methylase, mef, and isa. There is an opportunity for diagnostic manufacturers and clinical labs to help clinicians choose appropriate IAP and prevent neonatal mortality. The CDC and public health should be aware of regional variations in clindamycin resistance. Clinicians should be aware of local resistance to inform IAP stewardship recommendations.

Disclosures

S. Butler-Wu, BioFire (bioMerieux): Investigator, Research support.

Galectin isolated from parasite inhibits remission of experimental autoimmune encephalomyelitis by up-regulating autoantibody

Recently, parasite infections or parasite-derived products have been suggested as a therapeutic strategy with suppression of immunopathology, which involves the induction of regulatory T cells or/and T helper type 2 (Th2) responses. In a recent study, researchers reported that constructed recombinant galectin (rTl-gal) isolated from an adult worm of the gastrointestinal nematode parasite Toxascaris leonina attenuated clinical symptoms of inflammatory bowel disease in mice treated with dextran sulphate sodium. Noting the role of rTl-gal in inflammatory disease, we attempted to investigate the effect of the parasite via its rTl-gal on neuronal autoimmune disease using experimental autoimmune encephalomyelitis (EAE), a mouse inflammatory and demyelinating autoimmune disease model of human multiple sclerosis. In this model, rTl-gal-treated experimental autoimmune encephalomyelitis (EAE) mice failed to recover after the peak of the disease, leading to persistent central nervous system (CNS) damage, such as demyelination, gliosis and axonal damage. Further, rTl-gal-treated EAE mice markedly increased the number of CD45R/B220(+) B cells in both infiltrated inflammation and the periphery, along with the increased production of autoantibody [anti-myelin oligodendrocyte glycoprotein (MOG)35-55 ] in serum at chronic stage. Upon antigen restimulation, rTl-gal treatment affected the release of overall cytokines, especially interferon (IFN)-γ and tumour necrosis factor (TNF)-α. Our results suggest that galectin isolated from a gastrointestinal parasite can deliver a harmful effect to EAE contrary to its beneficial effect on inflammatory bowel disease.

Greater inequalities in dental treatment than in disease experience

This study aimed to (1) describe social gradients in dental caries in a population-level survey and (2) examine whether inequalities are greater in disease experience or in its treatment. Using data from Australia's National Survey of Adult Oral Health 2004-2006, we examined absolute and relative income inequalities for DMFT and its separate components (DT, MT, FT) using adjusted proportions, means, and health disparity indices [Slope Index of Inequality (SII) and Relative Index of Inequality (RII)]. Approximately 90% of Australian adults had experienced caries, with prevalence ranging from 89.7% in the highest to 96.6% in the lowest income group. Social gradients in caries were evident across all components of DMFT, but particularly notable in Missing (SII = -15.5, RII = -0.3) and untreated Decay (SII = -23.7, RII = -0.9). Analysis of age- and gender-adjusted data indicated less variation in levels of disease experienced (DMFT) than in the health outcomes of its management (missing teeth). The findings indicate that social gradients for dental caries have a greater effect on how the disease was treated than on lifetime disease experience.

Neuraxial anesthesia for cardiac surgery: thoracic epidural and high spinal anesthesia - why is it different?

Anesthesiologists can offer much more then stable blood pressure and heart rate in the intraoperative period. By choosing appropriate anesthetic techniques they can tremendously influence perioperative stress. This may positively impact on the overall surgical outcome. One of the most intriguing aspects of neuraxial anesthesia is its ability to attenuate the stress response to surgery. At present there is no agreement on the clinical importance of such a response but there is substantial indirect evidence that it may play an important role in a patient's outcome. Neuraxial anesthesia supplemented by general anesthesia is justified and can be safely used in cardiac surgery. The authors of this expert opinion prefer spinal anesthesia to thoracic epidural anesthesia and have been using it routinely for the last 20 years without any neurological complications. The risk of spinal hematoma from a 27G spinal needle prior to full heparinization is unknown but in our opinion is remote. Both epidural and spinal techniques can and should have a place in modern cardiac anesthesia practice and should be further investigated.

Evaluation of wheelchair sling seat and sling back crashworthiness

Many wheelchairs are used as vehicle seats by those who cannot transfer to a vehicle seat. Although ANSI/RESNA WC-19 has been recently adopted as a standard to evaluate crashworthiness of the wheelchairs used as motor vehicle seats, replacement or after-market seats may not be tested to this standard. This study evaluated the crashworthiness of two specimens each of three unique sling backs and three unique sling seats using a static test procedure intended to simulate crash loading conditions. To pass the test, a sling back is required to withstand a 2290 lb load, and a sling seat should be capable of withstanding a 3750 lb load. All, but two sling back specimens which failed at 1567 lb and 1787 lb, withstood the test criterion load. Two of six tested sling seats failed to pass the test: one failed at 3123 lb and the other failed to sustain the load for 5 s although it reached the test criterion load. Most of the failures occurred at the seams of the side openings of upholsteries where the wheelchair frame inserts for attachment.

Wheelchairs used as motor vehicle seats: seat loading in frontal impact sled testing

Wheelchairs are not typically designed to function as motor vehicle seats. However, many wheelchair users are unable to transfer to a vehicle seat and instead travel seated in their wheelchair. ANSI/RESNA WC19: Wheelchairs Used as Seats in Motor Vehicles provides design and testing requirements, but does not provide wheelchair manufacturers with design guidance related to expected loads imposed upon wheelchair components during a crash. To provide manufacturers with crashworthy design guidance, our study measured wheelchair seat loading during 20g/48kph frontal impact sled tests with a 50th percentile male test dummy. Loading conditions were assessed using two different rear securement point positions. Results of four sled impact tests revealed downward loads ranging from 17 019 to 18 682 N, depending upon rear securement point configuration. Maximum fore/aft shear loads ranged from 4424 to 6717 N across the tests.

Wheelchair integrated occupant restraints: feasibility in frontal impact

Individuals often use their wheelchair as a motor vehicle seat when traveling in motor vehicles. The current use of fixed vehicle-mounted wheelchair occupant restraint systems (FWORSs) often results in poor belt fit and discomfort. Additionally, satisfaction, usability and usage rate of FWORSs during transit use are often low. The automotive industry has shown improved occupant restraint usage, belt fit and injury protection when integrating the upper torso and pelvic restraint in a motor vehicle seat. This study compared occupant injury measures of a FWORS to a concept wheelchair integrated restraint system (WIRS) using a 20g frontal sled impact test with a 30 mph change in velocity. Neck loads, neck moments, head, pelvis and chest acceleration, sternum compression and knee and head excursion data were recorded from the wheelchair seated 50th percentile male hybrid III anthropomorphic test dummy (ATD). The WIRS resulted in a lower head injury criteria (HIC) value, lower sternum compression and a lower upper-torso restraint load than the FWORS. Compared with the FWORS, increased head, knee and wheelchair excursions and higher neck loads and moments were measured in the WIRS test. Both restraint scenario injury parameters were complied with occupant injury criteria based on General Motors Injury Assessment Reference Values (GM-IARVs) and occupant kinematic requirements defined by the Society of Automotive Engineers (SAE) voluntary standard, J2249. A higher motion criteria index was calculated for the WIRS scenario and a comparable combined injury criteria index was calculated for both restraint scenarios. The sled impact test showed WIRS concept feasibility, facilitating further development by industrial manufacturers who might further want to pursue this restraint principle to increase wheelchair occupant safety and comfort during transport in motor vehicles.

Evaluation of wheelchair drop seat crashworthiness

Wheelchair seating crash performance is critical to protecting wheelchair users who remain seated in their wheelchairs during transportation. Relying upon computer simulation and sled testing seat loads associated with a 20 g/48 kph (20 g/30 mph) frontal impact and 50th percentile male occupant were estimated to develop test criteria. Using a static test setup we evaluated the performance of various types of commercially available drop seats against the loading test criteria. Five different types of drop seats (two specimens each) constructed of various materials (i.e. plastics, plywood, metal) were evaluated. Two types of drop seats (three of the total 10 specimens) met the 16650 N (3750 lb) frontal impact test criteria. While additional validation of the test protocol is necessary, this study suggests that some drop seat designs may be incapable of withstanding crash level loads.

Evaluation of wheelchair seating system crashworthiness: "drop hook"-type seat attachment hardware

OBJECTIVE

To evaluate the crashworthiness of commercially available hardware that attaches seat surfaces to the wheelchair frame.

DESIGN

A low cost static crashworthiness test procedure that simulates a frontal impact motor vehicle crash.

SETTING

Safety testing laboratory.

SPECIMENS

Eleven unique sets of drop-hook hardware made of carbon steel (4), stainless steel (4), and aluminum (3).

INTERVENTIONS

Replicated seat-loading conditions associated with a 20g/48 kph frontal impact. Test criterion for seat loading was 16,680 N (3750 lb).

MAIN OUTCOME MEASURES

Failure load and deflection of seat surface.

RESULTS

None of the hardware sets tested met the crashworthiness test criterion. All failed at less than 50% of the load that seating hardware could be exposed to in a 20g/48 kph frontal impact. The primary failure mode was excessive deformation, leading to an unstable seat support surface.

CONCLUSIONS

Results suggest that commercially available seating drop hooks may be unable to withstand loading associated with a frontal crash and may not be the best option for use with transport wheelchairs.

Configurational analysis of chiral acids as O-trifluoroacetylated (-)-menthyl esters by achiral dual-capillary column gas chromatography

The simultaneous enantiomeric separation of 30 racemic acids including 24 hydroxy acids in a single analysis is described for the determination of their absolute configurations. It involves the conversion of each enantiomer into diastereomeric O-trifluoroacetylated (-)-menthyl ester for the direct separation by gas chromatography on achiral dual-capillary columns of different polarities, with subsequent identification and chiral discrimination by retention index (I) library matching. Among the acids studied, the enantiomers of 27 acids were discriminatively resolved on both non-polar DB-5 and the intermediate-polar DB-17 columns with resolution factors in the range of 0.7-7.7 and separation factors in the range of 1.002-1.021. Enantiomers of 3-hydroxybutyric and alpha-methoxyphenylacetic acids were partially resolved on DB-5 (resolution factor of 0.9), but not resolved on DB-17, while the baseline resolution for 3-hydroxydecanoic acid and the minimal separation on the peak top (resolution factor less than 0.7) for 2-hydroxyglutaric acid were achieved on DB-17 but not on DB-5. The temperature-programmed I values measured on both columns were characteristic of each enantiomer and thus simple I matching with the reference values was useful in cross-checking for their chemical identification and the chiral discrimination as well. When applied to a clinical urine sample, the present method allowed positive identification of endogenous (S)-lactic acid and (S)-2-hydroxybutyric acid along with (R)-3-hydroxybutyric acid.

Cs(2)CO(3)-promoted efficient carbonate and carbamate synthesis on solid phase

[reaction: see text] Mild and efficient preparation of alkyl carbonates and carbamates on solid supports is described herein. Alcohols or amines were coupled with Merrifield's resin through a CO(2) linker in the presence of cesium carbonate and tetrabutylammonium iodide (TBAI).

Evaluation of wheelchair back support crashworthiness: combination wheelchair back support surfaces and attachment hardware

Automotive seats are tested for compliance with federal motor vehicle safety standards (FMVSS) to assure safety during impact. Many wheelchair users rely upon their wheelchairs to serve as vehicle seats. However, the crashworthiness of these wheelchairs during impact is often unknown. This study evaluated the crashworthiness of five combinations of wheelchair back support surfaces and attachment hardware using a static test procedure simulating crash loading conditions. The crashworthiness was tested by applying a simulated rearward load to each seat-back system. The magnitude of the applied load was established through computer simulation and biodynamic calculations. None of the five tested wheelchair back supports withstood the simulated crash loads. All failures were associated with attachment hardware.

Enantiomeric separation and discrimination of 2-hydroxy acids as O-trifluoroacetylated (S)-(+)-3-methyl-2-butyl esters by achiral dual-capillary column gas chromatography

An efficient method is described for the simultaneous enantiomeric separation of 18 different racemic 2-hydroxy acids for the determination of their absolute configurations. It involves the conversion of each enantiomer into a diastereomeric O-trifluoroacetylated (S)-(+)-3-methyl-2-butyl ester for the direct separation by achiral dual-capillary column gas chromatography with subsequent identification and determination of its chirality by retention index (I) library matching. The enantiomers of each acid were well separated with high resolution values (R > or = 1.4) on DB-5 and DB-17 columns of different polarity. When temperature-programmed I values of 2-hydroxy acid enantiomers as their diastereomeric derivatives were measured on both columns, the I values were characteristic of each enantiomer. Simple I matching with the reference values was thus useful in cross-checking each acid enantiomer for the identification and chiral discrimination. When applied to urine samples, the present method allowed positive identification of most of the spiked 2-hydroxy acids from normal urine and for endogenous (S)-lactic acid and (S)-2-hydroxybutyric acid from a clinical urine specimen.

[Relationship between genotype of angiotensin converting enzyme gene and left ventricular hypertrophy in Chinese hypertensives]

OBJECTIVE

To search into the relationship between genotype of angiotensin-converting enzyme (ACE) gene and left ventricular hypertrophy(LVH) in Chinese hypertensives.

METHODS

ACE genotyping with polymerase chain reaction (PCR) was performed in 33 unrelated hypertensives with LVH, 55 hypertensives without cardio-cerebrovascular diseases and 62 healthy controls.

RESULTS

The frequencies of DD genotype (0.394) and deletion allele (0.606) among hypertensives with LVH were significantly higher than those (0.129 and 0.387) among controls and those (0.128 and 0.400) among hypertensives without cardio-cerebrovascular diseases.

CONCLUSION

A deletion polymorphism of ACE gene probably increases the risk for left ventricular hypertrophy in Chinese hypertensives.

Junctional epidermolysis bullosa with pyloric atresia: A case with favourable outcome

BACKGROUND

Pyloric atresia is a rare but serious condition that can occur with junctional epidermolysis bullosa (PA-JEB). Early recognition is necessary for timely intervention, but prognosis can be serious and mortality is high.

OBJECTIVE

We describe the case of a patient with PA-JEB who not only survived past infancy, but showed improvement in cutaneous blistering as she grew older.

CONCLUSION

With early surgical intervention, some patients with PA-JEB can survive and look forward to a favourable prognosis, with improvement of cutaneous blistering by early childhood.