Real-World Effectiveness of Intravenous and Oral Antibiotic Stepdown Strategies for Gram-Negative Complicated Urinary Tract Infection With Bacteremia

Background

Robust data are lacking regarding the optimal route, duration, and antibiotic choice for gram-negative bloodstream infection from a complicated urinary tract infection source (GN-BSI/cUTI).

Methods

In this multicenter observational cohort study, we simulated a 4-arm registry trial using a causal inference method to compare effectiveness of the following regimens for GN-BSI/cUTI: complete course of an intravenous β-lactam (IVBL) or oral stepdown therapy within 7 days using fluoroquinolones (FQs), trimethoprim-sulfamethoxazole (TMP-SMX), or high-bioavailability β-lactams (HBBLs). Adults treated between January 2016 and December 2022 for Escherichia coli or Klebsiella species GN-BSI/cUTI were included. Propensity weighting was used to balance characteristics between groups. The 60-day recurrence was compared using a multinomial Cox proportional hazards model with probability of treatment weighting.

Results

Of 2571 patients screened, 759 (30%) were included. Characteristics were similar between groups. Compared with IVBLs, we did not observe a difference in effectiveness for FQs (adjusted hazard ratio, 1.09 [95% confidence interval, .49-2.43]) or TMP-SMX (1.44 [.54-3.87]), and the effectiveness of TMP-SMX/FQ appeared to be optimal at durations of >10 days. HBBLs were associated with nearly 4-fold higher risk of recurrence (adjusted hazard ratio, 3.83 [95% confidence interval, 1.76-8.33]), which was not mitigated by longer treatment durations. Most HBBLs (67%) were not optimally dosed for bacteremia. Results were robust to multiple sensitivity analyses.

Conclusions

These real-world data suggest that oral stepdown therapy with FQs or TMP-SMX have similar effectiveness as IVBLs. HBBLs were associated with higher recurrence rates, but dosing was suboptimal. Further data are needed to define optimal dosing and duration to mitigate treatment failures.

Oral β-Lactams, Fluoroquinolones, or Trimethoprim-Sulfamethoxazole for Definitive Treatment of Uncomplicated Escherichia coli or Klebsiella Species Bacteremia From a Urinary Tract Source

Background

Fluoroquinolones (FQs) are effective for oral step-down therapy for gram-negative bloodstream infections but are associated with unfavorable toxic effects. Robust data are lacking for trimethoprim-sulfamethoxazole (TMP-SMX) and high-bioavailability β-lactams (HBBLs).

Methods

In this multicenter observational cohort study, we simulated a 3-arm registry trial using causal inference methods to compare the effectiveness of FQs, TMP-SMX, or HBBLs for gram-negative bloodstream infections oral step-down therapy. The study included adults treated between January 2016 and December 2022 for uncomplicated Escherichia coli or Klebsiella species bacteremia of urinary tract origin who were who were transitioned to an oral regimen after ≤4 days of effective intravenous antibiotics. Propensity weighting was used to balance characteristics between groups. 60-day recurrence was compared using a multinomial Cox proportional hazards model with probability of treatment weighting.

Results

Of 2571 patients screened, 648 (25%) were included. Their median age (interquartile range) was 67 (45-78) years, and only 103 (16%) were male. Characteristics were well balanced between groups. Compared with FQs, TMP-SMX had similar effectiveness (adjusted hazard ratio, 0.91 [95% confidence interval, .30-2.78]), and HBBLs had a higher risk of recurrence (2.19 [.95-5.01]), although this difference was not statistically significant. Most HBBLs (70%) were not optimally dosed for bacteremia. A total antibiotic duration ≤8 days was associated with a higher recurrence rate in select patients with risk factors for failure.

Conclusions

FQs and TMP-SMX had similar effectiveness in this real-world data set. HBBLs were associated with higher recurrence rates but suboptimal dosing may have contributed. Further studies are needed to define optimal BL dosing and duration to mitigate treatment failures.

Effect of RMGI Roughness and Dentin Bonding Primer on Shear Bond Strength of Sandwich-type Restorations

BACKGROUND

The open sandwich technique is a reliable alternative to amalgam placement in deep proximal box preparations, where proper isolation and enamel bonding may not be possible. It is often difficult to prepare the box for composite placement without affecting the resin-modified glass ionomer (RMGI) that has been placed in the gingival portion. We hypothesized that RMGI surfaces that are roughened or those that use all steps in the manufacturing bonding protocol, including the priming solution, applied before placing a bonded composite increment, would have greater composite/RMGI shear bond strength.

DESIGN AND METHODS

Shear bond strengths (SBS) of RMGI tested in the presence and absence of SiC roughening and primer-coating were tested using a fourth-generation dentin bonding agent to composite after thermocycling. Twenty specimens for four test conditions were fabricated and investigated. Data were subjected to a two-way ANOVA and the Holm-Sidak post-hoc test.

RESULTS

Placing dentin primer on unabraded RMGI provided a statistically significant improvement in SBS, but only modestly. Furthermore, because bond failure consistently occurred within the RMGI itself, none of the surface modifications have a clinically relevant impact on SBS at the RMGI to the composite interface.

CONCLUSIONS

Clinicians should be aware that they need not avoid RMGI abrasion and do not need to incorporate all components of a fourth-generation bonding system when covering an RMGI sandwich layer with composite.

Childhood-Onset Lupus Nephritis in the Childhood Arthritis and Rheumatology Research Alliance Registry: Short-Term Kidney Status and Variation in Care

OBJECTIVE

The goal was to characterize short-term kidney status and describe variation in early care utilization in a multicenter cohort of patients with childhood-onset systemic lupus erythematosus (cSLE) and nephritis.

METHODS

We analyzed previously collected prospective data from North American patients with cSLE with kidney biopsy-proven nephritis enrolled in the Childhood Arthritis and Rheumatology Research Alliance (CARRA) Registry from March 2017 through December 2019. We determined the proportion of patients with abnormal kidney status at the most recent registry visit and applied generalized linear mixed models to identify associated factors. We also calculated frequency of medication use, both during induction and ever recorded.

RESULTS

We identified 222 patients with kidney biopsy-proven nephritis, with 64% class III/IV nephritis on initial biopsy. At the most recent registry visit at median (interquartile range) of 17 (8-29) months from initial kidney biopsy, 58 of 106 patients (55%) with available data had abnormal kidney status. This finding was associated with male sex (odds ratio [OR] 3.88, 95% confidence interval [95% CI] 1.21-12.46) and age at cSLE diagnosis (OR 1.23, 95% CI 1.01-1.49). Patients with class IV nephritis were more likely than class III to receive cyclophosphamide and rituximab during induction. There was substantial variation in mycophenolate, cyclophosphamide, and rituximab ever use patterns across rheumatology centers.

CONCLUSION

In this cohort with predominately class III/IV nephritis, male sex and older age at cSLE diagnosis were associated with abnormal short-term kidney status. We also observed substantial variation in contemporary medication use for pediatric lupus nephritis between pediatric rheumatology centers. Additional studies are needed to better understand the impact of this variation on long-term kidney outcomes.

Outcomes of patients with bacteriuria/pyuria of clinically undetermined significance (BPCUS) treated with antibiotics in 23 community hospital emergency departments

The optimal management of bacteriuria/pyuria of clinically undetermined significance (BPCUS) is unknown. Among 220 emergency department patients prescribed antibiotics for BPCUS, we found frequent readmissions, which were mitigated by outpatient follow-up visits. Observation and follow-up for an unknown diagnosis should be emphasized over antibiotics due to high likelihood of readmissions.

Impact of a Multifaceted Intervention on Antibiotic Prescribing for Cystitis and Asymptomatic Bacteriuria in 23 Community Hospital Emergency Departments

Background: Urinary tract infections (UTIs) are over-diagnosed and over-treated in the emergency department (ED) leading to unnecessary antibiotic exposure and avoidable side effects. However, data describing effective large-scale antimicrobial stewardship program (ASP) interventions to improve UTI and asymptomatic bacteriuria (ASB) management in the ED are lacking. Methods: We implemented a multifaceted intervention across 23 community hospital EDs in Utah and Idaho consisting of in-person education for ED prescribers, updated electronic order sets, and implementation/dissemination of UTI guidelines for our healthcare system. We compared ED UTI antibiotic prescribing in 2021 (post-intervention) to baseline data from 2017 (pre-intervention). The primary outcomes were the percent of cystitis patients prescribed fluoroquinolones or prolonged antibiotic durations (>7 days). Secondary outcomes included the percent of patients treated for UTI who met ASB criteria, and 14-day UTI-related readmissions. Results: There was a significant decrease in prolonged treatment duration for cystitis (29% vs 12%, P < .01) and treatment of cystitis with a fluoroquinolone (32% vs 7%, P < .01). The percent of patients treated for UTI who met ASB criteria did not change following the intervention (28% pre-intervention versus 29% post-intervention, P  = .97). A subgroup analysis indicated that ASB prescriptions were highly variable by facility (range 11%-53%) and provider (range 0%-71%) and were driven by a few high prescribers. Conclusions: The intervention was associated with improved antibiotic selection and duration for cystitis, but future interventions to improve urine testing and provide individualized prescriber feedback are likely needed to improve ASB prescribing practice.

554. Discharge Antibiotic Prescribing at Children’s Hospitals with Established Antimicrobial Stewardship Programs

Background

Antibiotic stewardship programs optimize antibiotic use in hospitalized children, but most do not routinely review antibiotic prescriptions at discharge. Up to 30% of discharged children receive additional days of antibiotics, and one single-center study found that 27% of discharge prescriptions were suboptimal.

Methods

We conducted a retrospective cohort study to evaluate duration of therapy (DOT) and antibiotic choice for children < 18 years admitted to 4 children’s hospitals from January 1, 2019 - December 31, 2019 and prescribed antibiotics at discharge for uncomplicated community-acquired pneumonia (CAP), skin and soft tissue infection (SSTI), or urinary tract infection (UTI). We excluded children with complex medical conditions, > 1 infection requiring antibiotics, > 7 day hospital stay, or intensive care unit stay. The primary outcomes were the percentage of subjects prescribed optimal (1) total (inpatient plus outpatient) DOT (4-6 days for CAP and SSTI, ≤8 days for UTI), and (2) antibiotic choice (CAP: amoxicillin; SSTI: clindamycin, amoxicillin-clavulanate, cephalexin, or trimethoprim-sulfamethoxazole (TMP/SMX); UTI: cephalexin, amoxicillin, amoxicillin-clavulanate, TMP/SMX, or nitrofurantoin) based on current national guidelines and available evidence.

Results

2105 encounters were included: 783 CAP, 916 SSTI, and 406 UTI. Median age was 4 years and 49% were female. DOT for each condition are shown in Figure 1 and antibiotic choice in Figure 2. Antibiotic choice was optimal for 66% with CAP, 98% with SSTI, and 88% with UTI. DOT was optimal for 11% with CAP, 4% with SSTI, and 21% with UTI. Both DOT and choice were optimal for 2% with CAP, 4% with SSTI, and 19% with UTI. For all indications, antibiotic choice was optimal for 84% and DOT was optimal for 10%, while only 6% of antibiotic courses included both optimal DOT and antibiotic choice.

Total duration of therapy for 2105 children discharged with antibiotics for community-acquired pneumonia, urinary tract infection, and skin and soft tissue infection. Figure 1.

560. Meningitis/encephalitis PCR panel result and antimicrobial use in children

Background

The meningitis/encephalitis multiplex polymerase chain reaction panel (ME PCR) detects common pathogens associated with community acquired CNS infections. The impact of this test on antimicrobial use in children is not well characterized.

Methods

We performed a retrospective, observational study in children &lt; 18 years of age who had ME PCR performed on CSF collected within 24 hours of admission to the hospital, presentation to the ED, or outpatient encounter from January 2018 to April 2022. Decision to order ME PCR was determined by the treating team. There are no restrictions on ordering ME PCR at our institution. The total calendar days of antimicrobial use from 24 hours prior to CSF collection to 7 days after CSF collection was evaluated. Our primary objective was to compare antimicrobial duration between subgroups based on ME PCR results: negative, virus positive, bacteria positive, and positive for both.

Results

Of 1282 ME PCR tests performed, 806 were done within the first 24 hours of the encounter. 190 (23.6%) patients never received antimicrobials for empiric treatment of meningitis/encephalitis and were excluded from subsequent analyses. Demographics and antimicrobial use are summarized for patients receiving at least one dose of an antimicrobial in Tables 1 and 2. CSF WBC was highest in bacteria positive CSF (p&lt; 0.001) followed by viral positive (p=0.0066). A positive bacterial result was associated with a longer duration of ceftriaxone, vancomycin and penicillin G and a shorter duration of acyclovir compared to viral and negative results (Table 2). A positive viral result was associated with a shorter length of total antimicrobial treatment (LOT) than negative (p=0.041) and bacterial positive (p&lt; 0.001).

Conclusion

Positive ME PCR results for bacteria may promote faster initiation of targeted therapy. Positive viral tests were associated with shorter LOT than both negative and bacteria positive ME PCR. Median LOT for negative testing was still 2 days suggesting rapid negative testing does not impact LOT. Prioritizing ME PCR for use in CSF samples with high pretest probability of a positive test may increase its effect on antimicrobial use.

Disclosures

Anne J. Blaschke, MD, PhD, BioFire Diagnostics/Biomerieux: Advisor/Consultant|BioFire Diagnostics/Biomerieux: Grant/Research Support|BioFire Diagnostics/Biomerieux: IP licensed to BioFire Diagnostics through the University of Utah and royalties received through the University of Utah related to the FilmArray|Merck: Advisor/Consultant.

Intraarticular steroids as DMARD-sparing agents for juvenile idiopathic arthritis flares: Analysis of the Childhood Arthritis and Rheumatology Research Alliance Registry

BACKGROUND

Children with juvenile idiopathic arthritis (JIA) who achieve a drug free remission often experience a flare of their disease requiring either intraarticular steroids (IAS) or systemic treatment with disease modifying anti-rheumatic drugs (DMARDs). IAS offer an opportunity to recapture disease control and avoid exposure to side effects from systemic immunosuppression. We examined a cohort of patients treated with IAS after drug free remission and report the probability of restarting systemic treatment within 12 months.

METHODS

We analyzed a cohort of patients from the Childhood Arthritis and Rheumatology Research Alliance (CARRA) Registry who received IAS for a flare after a period of drug free remission. Historical factors and clinical characteristics and of the patients including data obtained at the time of treatment were analyzed.

RESULTS

We identified 46 patients who met the inclusion criteria. Of those with follow up data available 49% had restarted systemic treatment 6 months after IAS injection and 70% had restarted systemic treatment at 12 months. The proportion of patients with prior use of a biologic DMARD was the only factor that differed between patients who restarted systemic treatment those who did not, both at 6 months (79% vs 35%, p < 0.01) and 12 months (81% vs 33%, p < 0.05).

CONCLUSION

While IAS are an option for all patients who flare after drug free remission, it may not prevent the need to restart systemic treatment. Prior use of a biologic DMARD may predict lack of success for IAS. Those who previously received methotrexate only, on the other hand, are excellent candidates for IAS.

Staphylococcal scalded skin syndrome: Clinical features, ancillary testing, and patient management

BACKGROUND/OBJECTIVES

The utility of ancillary testing in improving diagnostic precision or improving patient outcomes in staphylococcal scalded skin syndrome (SSSS) is unclear. Similarly, an optimal antibiotic regimen has yet to be established. Our goal was to describe clinical characteristics and ancillary work-up of SSSS, report bacterial resistance patterns, and examine patient outcomes under varying therapeutic strategies with the aim of developing an evidence-based management algorithm.

METHODS

We performed a retrospective review of pediatric patients diagnosed with SSSS at Intermountain Healthcare facilities between 2010 and 2021. A Kruskal-Wallis rank sum test was used to assess median length of stay between different antibiotic regimens.

RESULTS

Eighty-five cases were identified. The most common ancillary tests obtained were a complete blood count (88%), followed by chemistry analysis (80%). Blood cultures were collected in more patients (79%) compared to aerobic cultures (60%). No blood culture was positive for Staphylococcus aureus. All S. aureus isolates were methicillin-sensitive. Of those found resistant to clindamycin (36%), all demonstrated macrolide-induced clindamycin resistance. None were constitutively resistant to clindamycin. There was no statistical difference between antibiotic regimen and length of stay (p = .691). Receiving opiate medications was the only risk factor associated with prolonged hospitalization (p = .001).

CONCLUSIONS

Ancillary testing does not improve diagnostic precision and can be reduced. Clindamycin does not improve patient outcomes, suggesting beta-lactams should be considered first line. Susceptibility patterns in our cohort demonstrate inducible clindamycin resistance as opposed to constitutive.

Impact of Early Oral Antibiotic Therapy in Infants With Bacteremic Urinary Tract Infections

OBJECTIVES

To determine the effect of early conversion to oral antibiotics in infants ≤90 days with gram-negative bacteremia and concomitant urinary tract infection on hospital length of stay (LOS) and 30-day revisits for urinary tract infection.

DESIGN

This retrospective cohort study included infants ≤ 90 days who had concomitant positive blood and urine cultures with gram-negative bacteremia at 22 hospitals from January 1, 2002 through January 31, 2020. Early oral conversion was defined as a maximum intravenous (IV) duration of 4 days. We conducted a noninferiority test to compare early oral conversion to long IV therapy. A propensity score framework was used to assess comparisons in survey-weighted regression models using matched weights.

RESULTS

Among 174 infants, 73 infants received early oral conversion. The LOS was shorter in infants receiving early oral conversion compared to long IV therapy (median 2 days [interquartile range 2, 3] vs 4 days [3, 5]), descriptively (P < .001) and in noninferiority analysis (ratio = 0.43; 90% CI 0.35, 0.53, P < .001). Thirty-day revisits occurred in 5 of 174 (2.8%) of total patients. Early oral conversion did not meet our noninferiority criteria for the 30-day revisits (odds ratio: 4.22, 90%; confidence interval: 0.83, 21.34, P = .91).

CONCLUSIONS

Early oral conversion was associated with shorter LOS. The rate of 30-day revisit rates overall was low.

Medication and Fluid Management of Pediatric Sepsis and Septic Shock

Sepsis is a life-threatening response to infection that contributes significantly to neonatal and pediatric morbidity and mortality worldwide. The key tenets of care include early recognition of potential sepsis, rapid intervention with appropriate fluids to restore adequate tissue perfusion, and empiric antibiotics to cover likely pathogens. Vasoactive/inotropic agents are recommended if tissue perfusion and hemodynamics are inadequate following initial fluid resuscitation. Several adjunctive therapies have been suggested with theoretical benefit, though definitive recommendations are not yet supported by research reports. This review focuses on the recommendations for medication and fluid management of pediatric sepsis and septic shock, highlighting issues related to antibiotic choices and antimicrobial stewardship, selection of intravenous fluids for resuscitation, and selection and use of vasoactive/inotropic medications. Controversy remains regarding resuscitation fluid volume and type, antibiotic choices depending upon infectious risks in the patient's community, and adjunctive therapies such as vitamin C, corticosteroids, intravenous immunoglobulin, and methylene blue. We include best practice recommendations based on international guidelines, a review of primary literature, and a discussion of ongoing clinical trials and the nuances of therapeutic choices.

Social determinants of health influence disease activity and functional disability in Polyarticular Juvenile Idiopathic Arthritis

BACKGROUND

Social determinants of health (SDH) greatly influence outcomes during the first year of treatment in rheumatoid arthritis, a disease similar to polyarticular juvenile idiopathic arthritis (pJIA). We investigated the correlation of community poverty level and other SDH with the persistence of moderate to severe disease activity and functional disability over the first year of treatment in pJIA patients enrolled in the Childhood Arthritis and Rheumatology Research Alliance Registry.

METHODS

In this cohort study, unadjusted and adjusted generalized linear mixed effects models analyzed the effect of community poverty and other SDH on disease activity, using the clinical Juvenile Arthritis Disease Activity Score-10, and disability, using the Child Health Assessment Questionnaire, measured at baseline, 6, and 12 months.

RESULTS

One thousand six hundred eighty-four patients were identified. High community poverty (≥20% living below the federal poverty level) was associated with increased odds of functional disability (OR 1.82, 95% CI 1.28-2.60) but was not statistically significant after adjustment (aOR 1.23, 95% CI 0.81-1.86) and was not associated with increased disease activity. Non-white race/ethnicity was associated with higher disease activity (aOR 2.48, 95% CI: 1.41-4.36). Lower self-reported household income was associated with higher disease activity and persistent functional disability. Public insurance (aOR 1.56, 95% CI 1.06-2.29) and low family education (aOR 1.89, 95% CI 1.14-3.12) was associated with persistent functional disability.

CONCLUSION

High community poverty level was associated with persistent functional disability in unadjusted analysis but not with persistent moderate to high disease activity. Race/ethnicity and other SDH were associated with persistent disease activity and functional disability.

National Healthcare Safety Network 2018 Baseline Neonatal Standardized Antimicrobial Administration Ratios

BACKGROUND

The microbiologic etiologies, clinical manifestations, and antimicrobial treatment of neonatal infections differ substantially from infections in adult and pediatric patient populations. In 2019, the Centers for Disease Control and Prevention developed neonatal-specific (Standardized Antimicrobial Administration Ratios SAARs), a set of risk-adjusted antimicrobial use metrics that hospitals participating in the National Healthcare Safety Network's (NHSN's) antimicrobial use surveillance can use in their antibiotic stewardship programs (ASPs).

METHODS

The Centers for Disease Control and Prevention, in collaboration with the Vermont Oxford Network, identified eligible patient care locations, defined SAAR agent categories, and implemented neonatal-specific NHSN Annual Hospital Survey questions to gather hospital-level data necessary for risk adjustment. SAAR predictive models were developed using 2018 data reported to NHSN from eligible neonatal units.

RESULTS

The 2018 baseline neonatal SAAR models were developed for 7 SAAR antimicrobial agent categories using data reported from 324 neonatal units in 304 unique hospitals. Final models were used to calculate predicted antimicrobial days, the SAAR denominator, for level II neonatal special care nurseries and level II/III, III, and IV NICUs.

CONCLUSIONS

NHSN's initial set of neonatal SAARs provides a way for hospital ASPs to assess whether antimicrobial agents in their facility are used at significantly higher or lower rates compared with a national baseline or whether an individual SAAR value is above or below a specific percentile on a given SAAR distribution, which can prompt investigations into prescribing practices and inform ASP interventions.

77. Opportunity for Improved Use of a Commercially Available Meningitis/Encephalitis Panel in Pediatric Patients

Background

The BioFire® FilmArray Meningitis/Encephalitis (ME) panel delivers timely CSF analysis when meningitis or encephalitis is suspected and has the potential for earlier optimization of patient care. It is unclear if the M/E panel provides incremental benefit over standard microbiologic methods such as culture and cell counts, especially in the absence of significant pleocytosis. We evaluated the clinical utility of the ME panel with respect to CSF white blood cell count per high power field (WBC/hpf) and patient age.

Methods

We identified paired CSF ME panels and CSF cultures collected throughout a large healthcare system from 2016–May 2021 in children &lt; 18 years of age. CSF results from the same calendar day were included in the dataset. We reviewed standalone HSV and Enterovirus (EV) CSF studies to determine frequency of duplicative testing. Results were stratified by CSF WBC/hpf and patient age (&lt; 14 days, 14–60 days, &gt; 60 days and &lt; 5 years, and &gt; 5 years).

Results

1045 paired cultures and ME panels were identified. Of those, 921 (88%) ME panels were negative, but 5 of those cultures grew bacteria. Of 124 (12%) positive ME panel results, 66% were viral: 46 (37%) EV, 22 (18%) HHV-6 and 6 (5%) parechovirus. In 498 cases, ME panels were sent when CSF had &lt; 10 WBC/hpf, resulting in only 2 (0.4%) PCRs positive for bacteria, one which was gram stain positive and the other was considered a false positive (Table 1). In addition to a ME panel, standalone PCRs for enterovirus and HSV were sent in 134 (13%) and 213 (20%) of cases, respectively, with &lt; 2% discordance. Pathogen distribution by ME panel did not vary with age (Table 2).

Conclusion

In our cohort, the ME panels were overwhelmingly negative. Only 12% of ME panels were positive, mostly with self-limited viral pathogens (e.g., EV, parechovirus). Performance was worse when samples had &lt; 10 WBC/hpf. Duplicative testing was common and had no benefit. Performance was similar across age groups. More targeted use of the ME panel could improve the utility and efficacy of this test.

Disclosures

Anne Bonkowsky, MD/PhD, BioFire Diagnostics (Consultant, Grant/Research Support, Other Financial or Material Support, I have intellectual property through the University of Utah in BioFire Diagnostics and the FilmArray and receive royalties through the University of Utah.)Merck (Advisor or Review Panel member)

Follow-Up Blood Cultures in Young Infants With Bacteremic Urinary Tract Infections

BACKGROUND AND OBJECTIVES

Researchers in previous studies suggest that the clinical yield of follow-up blood cultures (FUBCs) is low in infants with bacteremic urinary tract infection (UTI) because persistent bacteremia is rare; however, no researchers have analyzed the practice of routinely obtaining FUBCs. In our study, we evaluate outcomes in infants with FUBCs, examine opportunities for improvement of blood culture practices, and add important information to inform both clinical practice as well as further study.

DESIGN

This retrospective cohort study included infants <90 days of age with bacteremia and UTI with the same pathogen at 22 hospitals that make up Intermountain Healthcare between 2002 to 2020. Infants with culture proven meningitis, osteomyelitis, central line infection, and infections occurring during NICU hospitalization were excluded.

RESULTS

Total number of patients with bacteremic UTI was 174, 153 (88%) patients had at least 1 FUBC, 14 of 153 (9%) had a positive FUBC with same organism, and 4 of 153 (3%) were contaminants. The length of stay was longer for patients with positive FUBCs. Patients with Escherichia coli are more likely to have a negative FUBC. Readmissions within 30 days were similar among infants with positive FUBCs, negative FUBCs, and no FUBCs.

CONCLUSIONS

FUBCs in infants with bacteremic UTI should not be routinely performed, especially for E coli, and it is unclear whether FUBCs improve outcomes.

Coagulopathy, Bleeding Events, and Outcome According to Rotational Thromboelastometry in Patients With Acute Liver Injury/Failure

BACKGROUND AND AIMS

Patients with acute liver injury or failure (ALI/ALF) experience bleeding complications uncommonly despite an abnormal hemostatic profile. Rotational thromboelastometry (ROTEM), which assesses clot formation in whole blood, was used to determine the nature of abnormal hemostasis and whether it contributes to bleeding events, illness severity, or survival.

APPROACH AND RESULTS

A total of 200 patients were recruited from sites of the ALF Study Group. Blood collected daily for up to 5 days was analyzed using ROTEM delta devices. Consistent with standard laboratory evidence of hypocoagulability (median international normalized ratio = 2.9 and platelet count = 144 × 109 /L), patients frequently exhibited ROTEM parameters outside the normal range (73% and 62% had abnormalities in clot formation from extrinsic and intrinsic clotting cascades, respectively); however, measures of clot stability were generally normal. Eighteen patients (9%) experienced bleeding events, in whom clot initiation, assembly, and firmness were more severely deranged than patients without bleeding. Abnormal ROTEM parameters were more frequently observed in patients with non-acetaminophen ALI/ALF than those with acetaminophen ALI/ALF (clot initiation [P < 0.001], assembly [P = 0.02], firmness at 10 minutes [P = 0.05], and maximal firmness [P = 0.06]). Patients with more severe systemic complications (high-grade hepatic encephalopathy and need for renal replacement therapy) also had a higher incidence of abnormal ROTEM parameters. Finally, more hypocoagulable ROTEM parameters (clot initiation (P = 0.005), stiffness at 10 minutes (P = 0.05), and maximal stiffness by fibrin assembly (P = 0.004)) were observed in patients who died or underwent liver transplantation than those who survived with their native liver.

CONCLUSIONS

In patients with ALI/ALF, abnormal ROTEM parameters are frequent and proportional to disease severity. Whether the increased bleeding risk associated with abnormal ROTEM indicates hemostatic failure or is a proxy for disease severity requires additional study.

Ion Heating and Flow Driven by an Instability Found in Plasma Couette Flow

We present the first observation of instability in weakly magnetized, pressure dominated plasma Couette flow firmly in the Hall regime. Strong Hall currents couple to a low frequency electromagnetic mode that is driven by high-β (>1) pressure profiles. Spectroscopic measurements show heating (factor of 3) of the cold, unmagnetized ions via a resonant Landau damping process. A linear theory of this instability is derived that predicts positive growth rates at finite β and shows the stabilizing effect of very large β, in line with observations.

Laboratory Resolved Structure of Supercritical Perpendicular Shocks

Supermagnetosonic perpendicular flows are magnetically driven by a large radius theta-pinch experiment. Fine spatial resolution and macroscopic coverage allow the full structure of the plasma-piston coupling to be resolved in laboratory experiment for the first time. A moving ambipolar potential is observed to reflect unmagnetized ions to twice the piston speed. Magnetized electrons balance the radial potential via Hall currents and generate signature quadrupolar magnetic fields. Electron heating in the reflected ion foot is adiabatic.

The impact of beta-lactam allergy labels on hospitalized children

BACKGROUND AND OBJECTIVES

Antibiotic allergy labels are common and are frequently inaccurate. Previous studies among adults demonstrate that β-lactam allergy labels may lead to adverse outcomes, including prescription of broader-spectrum antibiotics, increased costs, and increased lengths of stay, among others. However, data among pediatric patients are lacking, especially in the United States. In this study, we sought to determine the impact of β-lactam allergy labels in hospitalized children with regards to clinical and economic outcomes.

METHOD

This retrospective cohort study included pediatric patients 30 days to 17 years old, hospitalized at Intermountain Healthcare facilities from 2007 to 2017, who received ≥1 dose of an antibiotic during their admission. Patients with β-lactam allergies were matched to nonallergic patients based on age, sex, clinical service line, admission date, academic children's hospital or other hospital admission, and the presence of chronic, comorbid conditions. Outcomes included receipt of broader-spectrum antibiotics, clinical outcomes including length of stay and readmission, and antibiotic and hospitalization costs.

RESULTS

In total, 38,906 patients were identified. The prevalence of antibiotic allergy increased from 0.9% among those < 1 year peaked at 10.6% by age 17. Patients with β-lactam allergy received broader-spectrum antibiotics and experienced higher antibiotic costs than nonallergic controls. However, there were no differences in the length of stay, readmission rates, or total number of days of antibiotics between allergic and nonallergic patients.

CONCLUSIONS

Hospitalized pediatric patients with β-lactam allergy labels receive broader-spectrum antibiotics and experience increased antibiotic costs. This represents an important opportunity for allergy delabeling and antibiotic stewardship.

Oral Step-Down Therapy With Levofloxacin for Febrile Neutropenia in Children With Cancer

BACKGROUND

Although febrile neutropenia (FN) is a frequent complication in children with cancer receiving chemotherapy, there remains significant variability in selection of route (intravenous [IV] vs oral) and length of therapy. We implemented a guideline with a goal to change practice from using IV antibiotics after hospital discharge to the use of step-down oral therapy with levofloxacin for most children with FN until absolute neutrophil count > 500. The objectives of this study were to determine the impact of this guideline on home IV antibiotic use, and to evaluate the safety of implementation of this guideline.

METHODS

We performed a quasi-experimental, pre-post study of discharge FN treatment at a stand-alone children's hospital in patients without bacteremia discharged between January 2013 and October 2018. In January 2015, a multidisciplinary team created a guideline to switch most children with FN to oral levofloxacin, which was formally implemented as of September 2017. Discharges during the postintervention period (after September 2017) were compared to discharges in the preintervention period (between January 2013 and December 2014).

RESULTS

In adjusted multivariable regression analyses, the postimplementation period was associated with a decrease in home IV antibiotics (adjusted risk ratio [aRR], 0.07 [95% confidence interval {CI}, .03-.13]) and fewer IV antibiotic initiations within 24 hours of a new healthcare encounter up to 7 days after discharge (aRR, 0.39 [95% CI, .17-.93]) compared to the preintervention time period.

CONCLUSIONS

Step-down oral levofloxacin for children with FN who are afebrile with an ANC ≤ 500 at discharge is feasible and resulted in similar clinical outcomes compared to home IV antibiotics.

Implementing harm reduction in non-urban communities affected by opioids and polysubstance use: A qualitative study exploring challenges and mitigating strategies

BACKGROUND

Harm reduction services, which typically provide overdose education and prevention with distribution of naloxone and other supplies related to safer drug use, help reduce opioid-related overdose and infectious disease transmission. However, structural stigma and the ongoing criminalization of drug use have limited the expansion of harm reduction services into many non-urban communities in the United States that have been increasingly affected by the health consequences of opioid and polysubstance use.

METHODS

We conducted qualitative interviews with 22 professionals working with people who use drugs in cities and towns across Rhode Island and Massachusetts to understand challenges and strategies for engaging communities in accepting harm reduction perspectives and services.

RESULTS

Our thematic analysis identified several interrelated challenges to implementing harm reduction services in non-urban communities, including: (1) limited understandings of harm reduction practice and preferential focus on substance use treatment and primary prevention, (2) community-level stigma against people who use drugs as well as the agencies supporting them, (3) data reporting and aggregating leading to inaccurate perceptions about local patterns of substance use and related health consequences, and (4) a "prosecutorial mindset" against drug use and harm reduction. From key informants' narratives, we also identified specific strategies that communities could use to address these challenges, including: (1) identifying local champions to advocate for harm reduction strategies, (2) proactively educating communities about harm reduction approaches before they are implemented, (3) improving the visibility of harm reduction services within communities, and (4) obtaining "buy-in" from a wide range of local stakeholders including law enforcement and local government.

CONCLUSION

These findings carry important implications for expanding harm reduction services, including syringe service programs and safe injection sites, into non-urban communities that have a demonstrated need for evidence-based interventions to reduce drug-related overdose and infectious disease transmission.

Antibiotic prescribing for adult bacteriuria and pyuria in community hospital emergency departments

OBJECTIVE

To describe emergency department (ED) antibiotic prescribing for urinary tract infections (UTIs) and asymptomatic bacteriuria (ASB) and to identify improvement opportunities.

METHODS

Patients treated for UTI in 16 community hospital EDs were reviewed to identify prescribing that was unnecessary (any treatment for ASB, duration >7 days for cystitis or >14 days for pyelonephritis) or suboptimal [ineffective antibiotics (nitrofurantoin/fosfomycin) or duration <7 days for pyelonephritis]. Duration criteria were based on recommendations for complicated UTI since criteria for uncomplicated UTI were not reviewed. 14-day repeat ED visits were evaluated.

RESULTS

Of 250,788 ED visits, UTI was diagnosed in 13,466 patients (5%), and 1427 of these (11%) were manually reviewed. 286/1427 [20%, 95% CI: 18-22%] met criteria for ASB and received 2068 unnecessary antibiotic days [mean (±SD) 7 (2) days]. Mean treatment duration was 7 (2) days for cystitis and 9 (2) days for pyelonephritis. Of 446 patients with cystitis, 128 (29%) were prescribed >7 days (total 396 unnecessary). Of 422 pyelonephritis patients, 0 (0%) were prescribed >14 days, 20 (5%) were prescribed <7 days, and 9 (2%) were given ineffective antibiotics. Overall, prescribing was unnecessary or suboptimal in 443/1427 [31%, 95% CI: 29-33%] resulting in 2464/11,192 (22%) unnecessary antibiotic days and 8 (0.5%) preventable ED visits.

CONCLUSIONS

Among reviewed patients, poor UTI prescribing in 16 EDs resulted in unnecessary antibiotic days and preventable readmissions. Key areas for improvement include non-treatment of ASB and shorter durations for cystitis.

Weakly Magnetized, Hall Dominated Plasma Couette Flow

A novel plasma equilibrium in the high-β, Hall regime that produces centrally peaked, high Mach number Couette flow is described. Flow is driven using a weak, uniform magnetic field and large, cross field currents. Large magnetic field amplification (factor 20) due to the Hall effect is observed when electrons are flowing radially inward, and near perfect field expulsion is observed when the flow is reversed. A dynamic equilibrium is reached between the amplified (removed) field and extended density gradients.

Vacant lot to community garden conversion and crime in Milwaukee: a difference-in-differences analysis

BACKGROUND

Vacant lots generate the perception of neglect and are often opportunistic locations for crime. Evidence is building to suggest that greening vacant lots, especially through community engaged approaches, is associated with reductions in some types of crime.

METHODS

Using a retrospective quasi-experimental approach, we compared the conversion of vacant lots into community gardens (n=53) with a group of matched control lots (n=159) to examine the effect of this intervention on police reported theft, violent and nuisance crime in Milwaukee, Wisconsin. Conversions often involved the addition of planter boxes to create a garden, and sometimes included benches, paths, works of art or other landscaping features. Public crime data were used to generate crime rates within 100 m and 250 m around each lot.

RESULTS

Violent and nuisance crime rates are lower near treatment lots based on an unadjusted difference-in-differences analysis of means and two Poisson regression models. While no substantial effects were observed among theft crimes, the most consistent crime rate reductions were found among violent crime within 250 m, ranging between 3.7% and 6.4% across analyses.

CONCLUSIONS

Despite the small number of interventions, community-driven vacant lot to garden conversions were associated with slight reductions in crime. Urban greening initiatives may be a promising strategy to reduce urban crime and warrant further study.

Intravenous Vancomycin Therapeutic Drug Monitoring in Children: Evaluation of a Pharmacy-Driven Protocol and Collaborative Practice Agreement

BACKGROUND

Vancomycin optimization is challenging, requiring careful therapeutic drug monitoring (TDM) to avoid toxicity and ensure an efficacious concentration. Most prescriptions are empiric and often discontinued within 72 hours, which makes early TDM unnecessary. Although TDM using trough levels is common, the area under the concentration-time curve (AUC) is the preferred pharmacodynamic target. We studied the effect of a pharmacy-driven vancomycin collaborative practice agreement (CPA) at a children's hospital that delayed TDM up to 72 hours and targeted a 2-point 24-hour AUC of ≥400 mg × h/L.

METHODS

We retrospectively reviewed vancomycin courses in patients aged ≥30 days who received vancomycin between April 1, 2011, and August 30, 2017. We implemented the CPA on June 1, 2014. Outcomes included CPA use, use of TDM, dosage adjustments, and development of acute kidney injury; we compared courses given while monitoring only trough levels (TO-TDM) with those given while using the CPA (AUC-TDM). We performed interrupted time series analyses to account for preintervention trends.

RESULTS

We included 2379 courses in the TO-TDM period and 2155 in the AUC-TDM period. During AUC-TDM, 87% of the courses were managed by the CPA. In adjusted interrupted time series analyses, CPA implementation was associated with an initial change in level of -0.265 (95% confidence interval [CI], -0.336 to -0.189) TDM and an initial change in level of -0.332 (95% CI, -0.506 to -0.163) dosage adjustments. The 1-year risk of acute kidney injury decreased after CPA implementation (odds ratio, 0.695 [95% CI, 0.539-0.91]).

CONCLUSION

The pharmacy-driven vancomycin CPA resulted in less monitoring and fewer dose adjustments without increasing AKI.

Antibiotic Timing in Pediatric Septic Shock

BACKGROUND AND OBJECTIVES

National guidelines advocate for the administration of antibiotics within 1 hour to children with septic shock, although there is variance in the pediatric evidence-based literature supporting this benchmark. Our objective for this study was to describe the association of target time to antibiotic administration (TTAA) with outcomes of children treated for suspected septic shock in a pediatric emergency department. Septic shock is suspected when signs of perfusion and/or hypotension are present. The primary outcome was mortality. Secondary outcomes included PICU admission, hospital and PICU length of stay, and organ dysfunction resolution by hospital day 2.

METHODS

We conducted a retrospective study of children <18 years of age admitted from the pediatric emergency department and treated for suspected septic shock between February 1, 2007, and December 31, 2015. Associations between TTAA and outcomes were evaluated by using multivariable linear and logistic regression models obtained from stepwise selection.

RESULTS

Of 1377 patients, 47% were boys with a median age of 4.0 (interquartile range 1.4-11.6) years, 1.5% (20) died, 90% were compliant with TTAA goals, 40% required PICU admission, 38% had ≥2 unique complex chronic conditions, 71% received antibiotics in ≤2 hours, and 30% had a culture-positive bacterial etiology. There were no significant associations between TTAA and outcomes.

CONCLUSIONS

We found no association with TTAA and any clinical outcomes, adding to the growing body of literature questioning the timing benchmark of antibiotic administration. Although the importance of antibiotics is not in question, elucidating the target TTAA may improve resource use and decrease inappropriate or unnecessary antibiotic exposure.

Evaluation of Discharge Antibiotic Prescribing at a Freestanding Children's Hospital: Opportunities for Stewardship

We conducted a retrospective study to evaluate suboptimal discharge antibiotic prescribing at a children's hospital and found that 27% of the prescriptions were suboptimal. Thirty-three percent of the patients who might have qualified for solid dosage forms received liquid dosages instead. Our findings suggest that opportunities exist for discharge antibiotic-stewardship and pill-swallowing programs.

2109. Liposomal Amphotericin B-associated Nephrotoxicity in Obese and Non-obese Patients

Background

Liposomal amphotericin B (L-amb) is an important antifungal agent which exhibits significant rates of dose-dependent nephrotoxicity. Animal studies demonstrate only small amounts of L-amb distribute into adipose tissue and obese animals show greater risk of nephrotoxicity with L-amb administration. This study aims to determine whether obese patients are at a higher risk of nephrotoxicity with weight-based doses of L-amb.

Methods

We performed a multi-center, retrospective cohort study of nephrotoxicity with L-amb in obese (BMI > 30) and non-obese adult patients at University of Utah Health and Intermountain Healthcare from January 1, 2014 through December 31, 2018. Our primary outcome was the rate of nephrotoxicity as determined by AKIN criteria. Patients receiving at least one dose of L-amb were identified for inclusion. Patients were excluded if they were already on a renal replacement at the time of L-amb initiation or they received L-amb prior to admission.

Results

We included 221 patients, 47 (21%) were obese and 174 (79%) were non-obese. Median total body weight was 109 kg in obese patients compared with 70 kg in non-obese patients. Dosage based on ideal body weight was higher in the obese group (median 6.9 mg/kg vs. 4.9 mg/kg). Obese patients were significantly more likely to experience acute kidney injury (AKI) than non-obese patients (55% vs. 37%, P = 0.03). Patients who experienced nephrotoxicity received a higher average daily dose than those who did not (365 mg vs. 333 mg, P = 0.03), had a higher median cumulative dose (3,130 mg vs. 1,700 mg, P < 0.001), and had a higher median total body weight (79.6 kg vs. 71.9 kg, P = 0.04.). Additionally, daily dose normalized to total body weight was not associated with AKI (median 4.7 mg/kg in patients with AKI vs. 4.8 mg/kg in patients without AKI, P = 0.86). However, daily dose normalized to ideal body weight was associated with AKI (median 5.5 mg/kg in patients with AKI vs. 4.9 mg/kg in patients without AKI, P = 0.02).

Conclusion

We identified a higher rate of nephrotoxicity among obese patients receiving L-amb compared with non-obese patients. These data suggest that dosing L-amb based on total body weight places obese patients at a higher risk of nephrotoxicity. This should be considered when assessing the risks and benefits of this dosing strategy in obese patients.

Disclosures

All authors: No reported disclosures.

1511. Effect of Discharge Antibiotic Route on Clinical Outcomes in Children with Methicillin-Resistant Staphylococcus aureus (MRSA) Osteomyelitis with Bacteremia

Background

Children with osteomyelitis transitioned to oral step-down therapy experience similar outcomes to those treated with outpatient parenteral antibiotic therapy (OPAT). Compared with OPAT, oral therapy has lower costs and avoids catheter complications. However, few studies have specifically compared patient outcomes between those receiving oral therapy vs. OPAT for osteomyelitis with associated bacteremia caused by MRSA.

Methods

We performed a retrospective cohort study comparing early oral therapy (EOT), defined as transition to oral therapy at or prior to discharge vs. use of OPAT at discharge. We identified hospitalized children <19 years of age with MRSA osteomyelitis with bacteremia between 2007 and 2014 from three children’s hospitals. The primary outcome was treatment failure within 6 months of discharge, defined as unplanned change in antibiotic after discharge, development of chronic osteomyelitis, need for an operative procedure after discharge, or recrudescence of bacteremia. The secondary outcome was treatment-related events, defined as documented adverse drug events in the medical record and/or central venous catheter complications. Between-group comparisons were made using Fisher exact test for binomial distributions and the Wilcoxon rank-sum test for continuous variables.

Results

We included 61 patients with MRSA osteomyelitis with bacteremia. Twenty-five patients (41%) received EOT and 36 (59%) received OPAT. Duration of bacteremia and hospital length of stay was similar between groups (Table 1). Clindamycin was the most commonly used antibiotic in both the EOT (24/25; 96%) and OPAT (22/36; 61%) groups. Clinical failure occurred in 1/25 (4%) children receiving EOT and in 5/36 (14%) in the OPAT group (95% CI of difference: −29 to 6%; P = 0.38, Table 1). Treatment-related adverse events occurred in 1/25 (4%) children receiving EOT compared with 9/36 (25%) receiving OPAT (95% CI of difference: −49 to –7%; P = 0.04, Table 1).

Conclusion

Children receiving EOT for MRSA osteomyelitis with bacteremia did not experience higher rates of clinical failure and had fewer treatment-related complications compared with OPAT. Oral step-down therapy can be considered for children with MRSA osteomyelitis with bacteremia.

Disclosures

All authors: No reported disclosures.

2059. Antimicrobial Stewardship of Community Parenteral Antimicrobial Therapy: A Health System Approach

Background

Community parenteral antimicrobial therapy (CoPAT) allows patients to receive intravenous (IV) antimicrobials outside the hospital; however, inappropriate use occurs and can lead to adverse outcomes. In addition, these patients are at high risk of readmission. Our objective was to assess the quality of CoPAT in a large healthcare system in order to guide implementation of an intervention requiring mandatory review by antimicrobial stewardship.

Methods

We identified patients with orders for IV antimicrobials at discharge between January 1 and December 10, 2018. Patients were excluded if transferred to an acute care facility, left against medical advice, or died. 250 patients were selected using a random number generator and reviewed consecutively until 100 confirmed CoPAT encounters were identified. Each encounter was evaluated for evidence of ID consultation, opportunities for stewardship interventions in seven categories (See Table 1), and adverse events such as emergency room (ER) visits and readmissions.

Results

The query identified 4,642 potential CoPAT discharges from 22 hospitals (see Table 2). 117 encounters were reviewed to reach 100 true CoPAT discharges (85% query accuracy). Of these, 55 (55%) received a formal ID consult, 6 (6%) had an ID pharmacist or ID physician curbside, and 5 (5%) had an ID clinic follow-up appointment scheduled without formal ID consult. Opportunity for stewardship intervention was found in 50 (50%) patients (see Table 1). There were 31 (31%) patients who were seen in the ER (n = 21) and/or re-admitted (n = 19) to the hospital during or shortly after completion of CoPAT, of which 25 (81%) were potentially related to CoPAT, including abnormal laboratory findings, PICC-line complications, and signs or symptoms of infection.

Conclusion

CoPAT patients are complex with high healthcare utilization. Mandatory ID review of patients receiving CoPAT has the potential to impact 2,000 lives annually in a large health system.

Disclosures

All authors: No reported disclosures.

1957. Impact of β-Lactam Antibiotic Allergy on Antimicrobial Use, Clinical Outcomes, and Costs for Hospitalized Children

Background

Methods

Results

Conclusion

Disclosures

Brain Computer Interfaces in Rehabilitation Medicine

One innovation currently influencing physical medicine and rehabilitation is brain-computer interface (BCI) technology. BCI systems used for motor control record neural activity associated with thoughts, perceptions, and motor intent; decode brain signals into commands for output devices; and perform the user's intended action through an output device. BCI systems used for sensory augmentation transduce environmental stimuli into neural signals interpretable by the central nervous system. Both types of systems have potential for reducing disability by facilitating a user's interaction with the environment. Investigational BCI systems are being used in the rehabilitation setting both as neuroprostheses to replace lost function and as potential plasticity-enhancing therapy tools aimed at accelerating neurorecovery. Populations benefitting from motor and somatosensory BCI systems include those with spinal cord injury, motor neuron disease, limb amputation, and stroke. This article discusses the basic components of BCI for rehabilitation, including recording systems and locations, signal processing and translation algorithms, and external devices controlled through BCI commands. An overview of applications in motor and sensory restoration is provided, along with ethical questions and user perspectives regarding BCI technology.

Culturally Adapted Mobile Technology Improves Environmental Health Literacy in Laurentian, Great Lakes Native Americans (Anishinaabeg)

The presence of persistent bioaccumulative toxics (PBT) in aquatic food chains complicates decision processes of people with a strong culture of fish consumption. This environmental contamination is especially problematic for Native American populations in the Laurentian Great Lakes region (Anishinaabeg). Pursuing the growing discipline of environmental health literacy (EHL) may help reduce toxic exposures, support healthy decision-making, and combat health deficits. Our goals for this research were first to improve environmental health literacy using novel technologies and second to help define environmental health literacy metrics that can be tracked over time, especially regarding culturally-contextualized health interests. We recently reported that a mobile app (Gigiigoo'inaan App) presenting personalized, culturally-contextualized fish consumption advice may improve EHL for the Anishinaabeg. Gigiigoo'inaan App safely supports desired fish consumption rates by putting local data into the hands of the Anishinaabeg. We conducted a pre-test post-test evaluation with 103 Aninishinaabe adults. Participants estimated their current fish meal consumption over a hypothetical month before exposure to the software and then planned their future consumption of fish meals in a month after using the mobile app. Significantly more monthly traditional fish meals on average (Median: 4 vs 2, p=0.0005) were selected when using the app versus pre-exposure to the app. Significantly more traditional grams of fish were also selected during use of the app relative to the pretest (Median: 680.39g vs 453.59g, p=0.0007). These increases were accompanied by widespread (97%) adherence to conventional advice that minimizes PBT exposure health effects (ATSDR minimum risk levels).

Abstract P1-11-09: Sleep disturbance and quality of life among breast cancer survivors

Introduction: Breast cancer survivors are at risk for substantial sleep disturbance, which can negatively affect quality of life. Sleep disturbance can be exacerbated by co-occurring emotional concerns such as depressive symptoms and anxiety. Prior research has largely focused on linkages between sleep disturbance and emotional concerns among individuals with early stage disease. To dive deeper, we examined sleep disturbance and its correlates among breast cancer survivors with and without metastatic disease.

Methods: 631 female breast cancer survivors (168 ever experiencing metastatic disease [MBC]; 463 never metastatic [BC]) enrolled in the Cancer Support Community's online Cancer Experience Registry, provided socio-demographic information, and reported cancer-related distress (CancerSupportSource®, a 25-item measure with depression and anxiety risk screening subscales) and levels of pain interference (PI) and sleep disturbance (PROMIS-29 subscales). We examined associations between risk for depression/anxiety, PI, and worse sleep disturbance with multivariate regression, adjusting for metastatic disease, treatment history, and number of comorbidities.

Results: Participants were 84% non-Hispanic White; mean age=54.8 years, SD=12.2; mean time since diagnosis=4.4 years, SD=5.5. 72% ever received chemotherapy; 60% radiation therapy; 56% hormone therapy; 91% had surgery for their cancer. 47% reported moderate to very serious concern about sleep problems; concern about sleep did not differ by metastatic history. 20% of participants reported a level of sleep disturbance that was significantly worse (&gt;1SD) than the U.S. population average and 18% reported PI that was significantly worse (&gt;1SD) than the U.S. population average; these did not differ by metastatic history. Using CancerSupportSource anxiety and depression risk screening subscales, 47% of participants were identified as at risk for clinically significant levels of anxiety, and 35% at risk for clinically significant levels of depression. Participants with MBC were more likely to be at risk for clinically significant levels of anxiety (χ2=.7.98, p&lt;.01). Depression risk did not differ between MBC and BC survivors. Greater sleep disturbance was associated with having ever received radiation therapy (r=.11, p&lt;.01), number of reported comorbidities (r=.37, p&lt;.001), greater PI (r=.46, p&lt;.001), and greater risk for clinically significant depression (r=.38, p&lt;.001) and anxiety (r=.35, p&lt;.001). In multivariate analysis, risk for clinically significant levels of depression (semipartial r=.12, p&lt; .005), anxiety (semipartial r=.05, p&lt; .05), and greater PI (semipartial r=.24, p&lt; .001) remained associated with greater sleep disturbance after controlling for treatment history, metastatic status, and number of comorbidities, (R2=.28, F(4,588)=56.26, p&lt;.001).

Conclusion: Being at risk for clinically significant levels of depression and anxiety and experiencing greater pain interference are associated with worse sleep disturbance among breast cancer survivors across the illness trajectory. Health care providers are encouraged to discuss with patients how they can address sleep disturbance concerns, including referrals to integrative therapies that address the constellation of affective, pain, and sleep symptoms.

Citation Format: McManus S, Zaleta AK, Miller MF, Olson J, Saxton MC, Stein K. Sleep disturbance and quality of life among breast cancer survivors [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P1-11-09.

An Evaluation of Vancomycin Area Under the Curve Estimation Methods for Children Treated for Acute Pulmonary Exacerbations of Cystic Fibrosis Due to Methicillin-Resistant Staphylococcus aureus

The prevalence of pulmonary methicillin-resistant Staphylococcus aureus infections in patients with cystic fibrosis (CF) has increased over the last 2 decades. Two concentrations-a postdistributive and a trough-are currently used to estimate the area under the curve (AUC) of vancomycin, an antibiotic routinely used to treat these infections, to achieve the target AUC/minimum inhibitory concentration of ≥400 mg·h/L in ensuring optimal dosing of this drug. This study evaluated precision and bias in estimating vancomycin AUCs obtained either from a population pharmacokinetic (PK) model by using a single trough concentration or from standard PK equation-based 2-point monitoring approach. AUCs were either obtained from a single trough concentration-fitted model or derived from a model fitted by 2 concentration points. Children ≥2 years of age with CF received intravenous vancomycin at 2 centers from June 2012 to December 2014. A population PK model was developed in Pmetrics to quantify the between-subject variability in vancomycin PK parameters, define the sources of PK variability, and leverage information from the population to improve individual AUC estimates. Twenty-three children with CF received 27 courses of vancomycin. The median age was 12.3 (interquartile range [IQR] 8.5-16.6) years. From the individual vancomycin PK parameter estimates from the population PK model, median AUC was 622 (IQR 529-680) mg·h/L. Values were not significantly different from the AUC calculated using the standard PK equation-based approach (median 616 [IQR 540-663] mg·h/L) (P = .89). A standard PK equation-based approach using 2 concentrations and a population PK model-based approach using a single trough concentration yielded unbiased and precise AUC estimates. Findings suggest that options exist to implement AUC-based pediatric vancomycin dosing in patients with CF. The findings of this study reveal that several excellent options exist for centers to implement AUC-based pediatric vancomycin dosing for patients with CF.

Fatty Acids in Ten Species of Fish Commonly Consumed by the Anishinaabe of the Upper Great Lakes

The Chippewa Ottawa Resource Authority (CORA) in Sault Ste. Marie, Michigan, has been monitoring contaminant concentrations in the fillet portions of fish from the 1836 treaty-ceded waters of lakes Superior, Huron, and Michigan since 1991. The goal is to provide up to date consumption advice for their CORA member tribes. For the first time since the program started, CORA has included fatty acid analysis in 2016 monitoring of fish in Lake Superior. Ten species were targeted by CORA based on 25 years of experience and regular discussions with Anishinaabe fish consumers. This paper reports these results and presents some preliminary discussion of the consequences for consumption advice for the CORA member tribes who inhabit the Great Lakes region. Six of the species were sampled from Lake Huron and Lake Superior and four were sampled from supermarkets. Wild caught fish are an important link to the culture of Great Lakes Native American tribes and important sources of food and omega-3 polyunsaturated fatty acids (PUFA N-3). While some PUFA N-3 data from the Great Lakes is available, this dataset provides an important supplement and is specific to the 1836-treaty ceded waters of CORA. This paper confirms the presence of PUFA N-3s in Great Lakes fish traditionally harvested by the CORA tribes.

Outpatient Parenteral Antimicrobial Therapy in Young Infants

We examined clinical outcomes for 53 young infants (<3 months of age) treated with outpatient parenteral antimicrobial therapy after discharge from a freestanding children's hospital. None of the patients experienced treatment failure or disease progression; 9% of them experienced a catheter-related complication, but this percentage is not different than that for older children.

Sharing Antimicrobial Reports for Pediatric Stewardship (SHARPS): A Quality Improvement Collaborative

BACKGROUND

Although many children's hospitals have established antimicrobial stewardship programs (ASPs), data-driven benchmarks for optimizing antimicrobial use across centers are lacking. We developed a multicenter quality improvement collaborative focused on sharing data reports and benchmarking antimicrobial use to improve antimicrobial prescribing among hospitalized children.

METHODS

A national antimicrobial stewardship collaborative among children's hospitals, Sharing Antimicrobial Reports for Pediatric Stewardship (SHARPS), was established in 2013. Characteristics of the hospitals and their ASPs were obtained through a standardized survey. Antimicrobial-use data reports were developed on the basis of input from the participating hospitals. Collaborative learning opportunities were provided through monthly webinars and annual meetings.

RESULTS

Since 2013, 36 US hospitals have participated in the SHARPS collaborative. The median full-time equivalent (pharmacist and physician) dedicated to 30 of these ASPs was 0.75 (interquartile range, 0.45-1.4). To date, the collaborative has developed 26 data reports that include benchmarking reports according to specific antimicrobial agents, indications, and clinical service lines. The collaborative has conducted 27 webinars and 3 in-person meetings to highlight the stewardship work being conducted in the hospitals. The data reports and learning opportunities have resulted in approximately 36 distinct stewardship interventions.

CONCLUSION

A pediatric antimicrobial stewardship collaborative has been successful in promoting the development of and innovation among pediatric ASPs. Additional research is needed to determine the impact of these efforts.

Oxidative Stress and Cardiovascular Risk in Type 1 Diabetes Mellitus: Insights From the DCCT/EDIC Study

Background

Hyperglycemia leading to increased oxidative stress is implicated in the increased risk for the development of macrovascular and microvascular complications in patients with type 1 diabetes mellitus.

Methods and Results

A random subcohort of 349 participants was selected from the DCCT / EDIC (Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications) cohort. This included 320 controls and 29 cardiovascular disease cases that were augmented with 98 additional known cases to yield a case cohort of 447 participants (320 controls, 127 cases). Biosamples from DCCT baseline, year 1, and closeout of DCCT , and 1 to 2 years post‐ DCCT ( EDIC years 1 and 2) were measured for markers of oxidative stress, including plasma myeloperoxidase, paraoxonase activity, urinary F 2α isoprostanes, and its metabolite, 2,3 dinor‐8 iso prostaglandin F 2α . Following adjustment for glycated hemoblobin and weighting the observations inversely proportional to the sampling selection probabilities, higher paraoxonase activity, reflective of antioxidant activity, and 2,3 dinor‐8 iso prostaglandin F 2α , an oxidative marker, were significantly associated with lower risk of cardiovascular disease (−4.5% risk for 10% higher paraoxonase, P <0.003; −5.3% risk for 10% higher 2,3 dinor‐8 iso prostaglandin F 2α , P =0.0092). In contrast, the oxidative markers myeloperoxidase and F 2α isoprostanes were not significantly associated with cardiovascular disease after adjustment for glycated hemoblobin. There were no significant differences between DCCT intensive and conventional treatment groups in the change in all biomarkers across time segments.

Conclusions

Heightened antioxidant activity (rather than diminished oxidative stress markers) is associated with lower cardiovascular disease risk in type 1 diabetes mellitus, but these biomarkers did not change over time with intensification of glycemic control.

Clinical Trial Registration

URL : https://www.clinicaltrials.gov . Unique identifiers: NCT 00360815 and NCT 00360893.

Impact of Antimicrobial Stewardship for Pediatric Outpatient Parenteral Antibiotic Therapy

We developed an outpatient parenteral antibiotic therapy (OPAT) stewardship program in a freestanding children's hospital to improve the appropriateness of OPAT prescribing. Introduction of the program enabled expert review of nearly 90% of the patients being prepared for discharge with OPAT and was associated with a 24% reduction in OPAT use.

Pharmacodynamic studies of voriconazole: informing the clinical management of invasive fungal infections

INTRODUCTION

Voriconazole is a broad-spectrum antifungal agent commonly used to treat invasive fungal infections (IFI), including aspergillosis, candidiasis, Scedosporium infection, and Fusarium infection. IFI often occur in immunocompromised patients, leading to increased morbidity and mortality.

AREAS COVERED

The objective of this review is to summarize the pharmacodynamic properties of voriconazole and to provide considerations for potential optimal dosing strategies. Studies have demonstrated superior clinical response when an AUC/MIC >25 or Cmin/MIC >1 is attained in adult patients, correlating to a trough concentration range as narrow as 2-4.5 mg/L; however, these targets are poorly established in the pediatric population. Topics in this discussion include voriconazole use in multiple age groups, predisposing patient factors for IFI, and considerations for clinicians managing IFI. Expert commentary: The relationship between voriconazole dosing and exposure is not well defined due to the large inter- and intra-subject variability. Development of comprehensive decision support tools for individualizing dosing, particularly in children who require higher dosing, will help to increase the probability of achieving therapeutic efficacy and decrease sub-therapeutic dosing and adverse events.