Towards the mechanical characterisation of unruptured intracranial aneurysms: Numerical modelling of interactions between a deformation device and the aneurysm wall

Intracranial aneurysm is a critical pathology related to the arterial wall deterioration. This work is an essential aspect of a large scale project aimed at providing clinicians with a non-invasive patient-specific decision support tool regarding the rupture risk assessment. A machine learning algorithm links the aneurysm shape observed and a database of UIA clinical images associated with in vivo wall mechanical properties and rupture characterisation. The database constitution is derived from a device prototype coupled with medical imaging. It provides the mechanical characterisation of the aneurysm from the wall deformation obtained by inverse analysis based on the variation of luminal volume. Before performing in vivo tests of the device on small animals, a numerical model was built to quantify the device's impact on the aneurysm wall under natural blood flow conditions. As the clinician will never be able to precisely situate the device, several locations were considered. In preparation for the inverse analysis procedure, artery material laws of increasing complexity were studied (linear elastic, hyper elastic Fung-like). Considering all the device locations and material laws, the device induced relative displacements to the Systole peak (worst case scenario with the highest mechanical stimulus linked to the blood flow) ranging from 375 μm to 1.28 mm. The variation of luminal volume associated with the displacements was between 0.95 % and 4.3 % compared to the initial Systole volume of the aneurysm. Significant increase of the relative displacements and volume variations were found with the study of different cardiac cycle moments between the blood flow alone and the device application. For forthcoming animal model studies, Spectral Photon CT Counting, with a minimum spatial resolution of 250 μm, was selected as the clinical imaging technique. Based on this preliminary study, the displacements and associated volume variations (baseline for inverse analyse), should be observable and exploitable.

Implementation of a multi-modal intervention adopting new technologies, clinical services, and feedback improves catheter-associated urinary tract infections

OBJECTIVES

Catheter-associated urinary tract infections (CAUTI) are a significant cause of morbidity and financial burden to healthcare systems. The aim of this study was to develop and implement a program designed to reduce Foley catheter use days and associated CAUTI rates.

METHODS

A retrospective evaluation of a multi-modal program aimed toward reducing Foley catheter use days and associated CAUTI rates across the Indiana University Health (IUH) system was conducted. IUH is comprised of 16 hospitals and 2,703 available beds. The program included the adoption of new technologies with evidence-based clinical training materials based on change management and feedback from clinicians. National Healthcare Safety Network Standardized Infection Ratio (SIR), Standardized Utilization Ratio (SUR), and Incidence Density Ratio (IDR) rates were assessed.

RESULTS

Implementation of the multi-modal program resulted in a significant reduction in SIR, SUR, and IDR in the post-implementation compared to the baseline periods.

CONCLUSIONS

Through CAUTI bundle workflow assessments, education, and interventions designed to standardize practice variation, the program was successfully implemented and resulted in a significant decrease in Foley Catheter use days, and associated CAUTI rates.

Catheter-associated urinary tract infections (CAUTIs) and non-CAUTI hospital-onset urinary tract infections: Relative burden, cost, outcomes and related hospital-onset bacteremia and fungemia infections

OBJECTIVE

To describe the relative burden of catheter-associated urinary tract infections (CAUTIs) and non-CAUTI hospital-onset urinary tract infections (HOUTIs).

METHODS

A retrospective observational study of patients from 43 acute-care hospitals was conducted. CAUTI cases were defined as those reported to the National Healthcare Safety Network. Non-CAUTI HOUTI was defined as a positive, non-contaminated, non-commensal culture collected on day 3 or later. All HOUTIs were required to have a new antimicrobial prescribed within 2 days of the first positive urine culture. Outcomes included secondary hospital-onset bacteremia and fungemia (HOB), total hospital costs, length of stay (LOS), readmission risk, and mortality.

RESULTS

Of 549,433 admissions, 434 CAUTIs and 3,177 non-CAUTI HOUTIs were observed. The overall rate of HOB likely secondary to HOUTI was 3.7%. Total numbers of secondary HOB were higher in non-CAUTI HOUTIs compared to CAUTI (101 vs 34). HOB secondary to non-CAUTI HOUTI was more likely to originate outside the ICU compared to CAUTI (69.3% vs 44.1%). CAUTI was associated with adjusted incremental total hospital cost and LOS of $9,807 (P < .0001) and 3.01 days (P < .0001) while non-CAUTI HOUTI was associated with adjusted incremental total hospital cost and LOS of $6,874 (P < .0001) and 2.97 days (P < .0001).

CONCLUSION

CAUTI and non-CAUTI HOUTI were associated with deleterious outcomes. Non-CAUTI HOUTI occurred more often and was associated with a higher facility aggregate volume of HOB than CAUTI. Patients at risk for UTIs in the hospital represent a vulnerable population who may benefit from surveillance and prevention efforts, particularly in the non-ICU setting.

Prevalence, regional distribution, and trends of antimicrobial resistance among female outpatients with urine Klebsiella spp. isolates: a multicenter evaluation in the United States between 2011 and 2019

BACKGROUND

Antimicrobial resistance research in uncomplicated urinary tract infection typically focuses on the main causative pathogen, Escherichia coli; however, little is known about the antimicrobial resistance burden of Klebsiella species, which can also cause uncomplicated urinary tract infections. This retrospective cohort study assessed the prevalence and geographic distribution of antimicrobial resistance among Klebsiella species and antimicrobial resistance trends for K. pneumoniae in the United States (2011-2019).

METHODS

K. pneumoniae and K. oxytoca urine isolates (30-day, non-duplicate) among female outpatients (aged ≥ 12 years) with presumed uUTI at 304 centers in the United States were classified by resistance phenotype(s): not susceptible to nitrofurantoin, trimethoprim/sulfamethoxazole, or fluoroquinolone, extended-spectrum β-lactamase-positive/not susceptible; and multidrug-resistant based on ≥ 2 and ≥ 3 resistance phenotypes. Antimicrobial resistance prevalence by census division and age, as well as antimicrobial resistance trends over time for Klebsiella species, were assessed using generalized estimating equations.

RESULTS

270,552 Klebsiella species isolates were evaluated (250,719 K. pneumoniae; 19,833 K. oxytoca). The most frequent resistance phenotypes in 2019 were nitrofurantoin not susceptible (Klebsiella species: 54.0%; K. pneumoniae: 57.3%; K. oxytoca: 15.1%) and trimethoprim/sulfamethoxazole not susceptible (Klebsiella species: 10.4%; K. pneumoniae: 10.6%; K. oxytoca: 8.6%). Extended-spectrum β-lactamase-positive/not susceptible prevalence was 5.4%, 5.3%, and 6.8%, respectively. K. pneumoniae resistance phenotype prevalence varied (p < 0.0001) geographically and by age, and increased over time (except for the nitrofurantoin not susceptible phenotype, which was stable and > 50% throughout).

CONCLUSIONS

There is a high antimicrobial resistance prevalence and increasing antimicrobial resistance trends among K. pneumoniae isolates from female outpatients in the United States with presumed uncomplicated urinary tract infection. Awareness of K. pneumoniae antimicrobial resistance helps to optimize empiric uncomplicated urinary tract infection treatment.

Favorable Survival after Definitive Ablative RT in Surgically Resectable Pancreatic Cancer Patients

PURPOSE/OBJECTIVE(S)

Surgical resection has been considered the only curative option for patients with pancreatic adenocarcinoma (PDAC). Ablative RT ≥100Gy BED10 (A-RT) is associated with favorable survival in patients with locally advanced unresectable disease. We sought to evaluate A-RT outcomes in patients with technically resectable disease who did not undergo surgery.

MATERIALS/METHODS

Our prospectively maintained database of patients treated with A-RT was queried for consecutive patients with radiographic T1/T2 resectable PDAC. Patients were treated with a standardized technique within a large academic cancer center regional network. Ablative RT using several hypofractionated regimens was delivered on either standard Linacs with respiratory motion management, CBCT image guidance and selective adaptive replanning or MR-Linac with compression belt and daily on-line adaptive replanning. Freedom from local progression (FFLP), distant metastasis-free and overall survival (DMFS and OS, respectively) were analyzed using the Kaplan Meier estimates.

RESULTS

Between 2016 and 2022, 28 patients (54% male) with radiographically resectable PDAC received definitive A-RT. Median age was 80 (interquartile range, 77-84) years and 23 (82.1%) had KPS of 80 or below. Eighteen patients (64.3%) had T2 cancer, 5 (17.9%) were node positive, and 23 (82.1%) had head location. Median size was 2.6 (range, 1.6-4.0) cm with a median carbohydrate antigen 19-9 (CA19-9) of 160.5 (0-1823) U/mL. Twenty patients (71.4%) received induction chemotherapy for a median of 2.4 (0-6.2) months. RT regimens delivered on conventional Linacs unless otherwise indicated included 75Gy in 25 fractions (n = 15), 67.5Gy in 15 fractions (n = 10), 50Gy in 5 (N = 2, MR Linac), 60Gy in 10 (n = 1). 24-month FFLP and DMFS were 78.8% (52.3-91.7%) and 17.7% (95% CI, 5.8%-34.8%), respectively. 24-month and 48-month rate of OS from A-RT were 49.1% (95% CI, 27.53-67.5%) and 36.3 (95%16.0-57.1%). Grade 3 acute and late GI toxicity was noted in 3 and 1 patients, respectively, including 2 bleeding events treated with transfusions. There were no ≥ grade 4 events.

CONCLUSION

In patients with surgically resectable PDAC we found that definitive A-RT following multiagent induction therapy was associated with oncologic outcomes similar to resection with minimal toxicity.

Genome-wide gene expression responses to experimental manipulation of Saccharomyces cerevisiae repressor activator protein 1 (Rap1) expression level

Precise regulation of transcription in gene expression is critical for all aspects of normal organism form, fitness, and function and even minor alterations in the level, location, and timing of gene expression can result in phenotypic variation within and between species including evolutionary innovations and human disease states. Eukaryotic transcription is regulated by a complex interplay of multiple factors working both at a physical and molecular levels influencing this process. In Saccharomyces cerevisiae, the TF with the greatest number of putative regulatory targets is the essential gene Repressor Activator Protein 1 (RAP1). While much is known about the roles of Rap1 in gene regulation and numerous cellular processes, the response of Rap1 target genes to systematic titration of RAP1 expression level remains unknown. To fill this knowledge gap, we used a strain with a tetracycline-titratable promoter replacing wild-type regulatory sequences of RAP1 to systematically reduce the expression level of RAP1 and followed this with RNA sequencing (RNA-seq) to measure genome-wide gene expression responses. Previous research indicated that Rap1 plays a significant regulatory role in particular groups of genes including telomere-proximal genes, homothallic mating (HM) loci, glycolytic genes, DNA repair genes, and ribosomal protein genes; therefore, we focused our analyses on these groups and downstream targets to determine how they respond to reductions in RAP1 expression level. Overall, despite being known as both an activator and as a repressor of its target genes, we found that Rap1 acts as an activator for more target genes than as a repressor. Additionally, we found that Rap1 functions as an activator of ribosomal protein genes and a repressor of the silent mating locus genes consistent with predictions from the literature. Unexpectedly, we found that Rap1 functions as a repressor of glycolytic enzyme genes contrary to prior reports of it having the opposite effect. We also compared the expression of RAP1 to five different genes related to DNA repair pathway and found that decreasing RAP1 downregulated four of those five genes. Finally, we found no effect of RAP1 depletion on telomere-proximal genes despite its functioning to silence telomeric repeat-containing RNAs. Together our results enrich our understanding of this important transcriptional regulator. The graphical abstract is provided as a supplementary fig. (S-Fig 1).

Bacterial antibiotic resistance among cancer inpatients in China: 2016-20

BACKGROUND

The incidence of infections among cancer patients is as high as 23.2-33.2% in China. However, the lack of information and data on the number of antibiotics used by cancer patients is an obstacle to implementing antibiotic management plans.

AIM

This study aimed to investigate bacterial infections and antibiotic resistance in Chinese cancer patients to provide a reference for the rational use of antibiotics.

DESIGN

This was a 5-year retrospective study on the antibiotic resistance of cancer patients.

METHODS

In this 5-year surveillance study, we collected bacterial and antibiotic resistance data from 20 provincial cancer diagnosis and treatment centers and three specialized cancer hospitals in China. We analyzed the resistance of common bacteria to antibiotics, compared to common clinical drug-resistant bacteria, evaluated the evolution of critical drug-resistant bacteria and conducted data analysis.

FINDINGS

Between 2016 and 2020, 216 219 bacterial strains were clinically isolated. The resistance trend of Escherichia coli and Klebsiella pneumoniae to amikacin, ciprofloxacin, cefotaxime, piperacillin/tazobactam and imipenem was relatively stable and did not significantly increase over time. The resistance of Pseudomonas aeruginosa strains to all antibiotics tested, including imipenem and meropenem, decreased over time. In contrast, the resistance of Acinetobacter baumannii strains to carbapenems increased from 4.7% to 14.7%. Methicillin-resistant Staphylococcus aureus (MRSA) significantly decreased from 65.2% in 2016 to 48.9% in 2020.

CONCLUSIONS

The bacterial prevalence and antibiotic resistance rates of E. coli, K. pneumoniae, P. aeruginosa, A. baumannii, S. aureus and MRSA were significantly lower than the national average.

Sparse ensemble neural code for a complete vocal repertoire

The categorization of animal vocalizations into distinct behaviorally relevant groups for communication is an essential operation that must be performed by the auditory system. This auditory object recognition is a difficult task that requires selectivity to the group identifying acoustic features and invariance to renditions within each group. We find that small ensembles of auditory neurons in the forebrain of a social songbird can code the bird's entire vocal repertoire (∼10 call types). Ensemble neural discrimination is not, however, correlated with single unit selectivity, but instead with how well the joint single unit tunings to characteristic spectro-temporal modulations span the acoustic subspace optimized for the discrimination of call types. Thus, akin to face recognition in the visual system, call type recognition in the auditory system is based on a sparse code representing a small number of high-level features and not on highly selective grandmother neurons.

Morbidity and mortality of hospitalised patients with candidemia during the various severe acute respiratory syndrome coronavirus 2 pandemic waves: A multicentre evaluation of 248 US hospitals

BACKGROUND

Studies evaluating outcomes of COVID-19 patients with candidemia are limited and have only evaluated a single timepoint during the pandemic.

OBJECTIVES

To compare the prevalence and outcomes associated with candidemia in patients based on severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) status and through the various pandemic waves (1 March 2020-5 March 2022).

PATIENTS/METHODS

Multicentre, retrospective cohort analysis of data from 248 US medical facilities using the BD Insights Research Database (Becton, Dickinson and Company, Franklin Lakes, New Jersey, USA). Eligible patients were adults aged ≥18 years who were hospitalised for >1 day, had a SARS-CoV-2 test and a positive blood culture for Candida spp.

RESULTS

During the study time frame, there were 2,402,879 hospital admissions; 234,903 (9.7%) and 2,167,976 (90.3%) patients were SARS-CoV-2 positive and negative, respectively. A significantly higher rate of candidemia/1000 admissions was observed in SARS-CoV-2-positive patients compared to SARS-CoV-2-negative patients (3.18 vs. 0.99; p < .001). The highest candidemia rate for SARS-CoV-2-positive patients was observed during the Alpha SARS-CoV-2 wave (June 2020-August 2020) with the lowest candidemia rate during the Omicron wave. Hospital mortality was significantly higher in SARS-CoV-2-positive patients compared to SARS-CoV-2-negative patients with candidemia (59.6% vs. 30.8%; p < .001). When evaluating the mortality rate through the various pandemic waves, the rate for the overall population did not change.

CONCLUSIONS

Our study indicates high morbidity and mortality for hospitalised patients with COVID-19 and candidemia which was consistent throughout the pandemic. Patients with COVID-19 are at an increased risk for candidemia; importantly, the magnitude of which may differ based on the circulating variant.

Impact of a Statewide Livestock Antibiotic Use Policy on Resistance in Human Urine Escherichia coli Isolates: A Synthetic Control Analysis

BACKGROUND

On 1 January 2018, California implemented Senate Bill 27 (SB27), banning, for the first time in the United States, routine preventive use of antibiotics in food-animal production and any antibiotic use without a veterinarian's prescription.

OBJECTIVES

Our objective was to assess whether SB27 was associated with decreased antimicrobial resistance among E. coli isolated from human urine.

METHODS

We used U.S. nationwide monthly state-level data from BD Insights Research Database (Becton, Dickinson, and Co.) spanning 1 January 2013 to 30 June 2021 on antibiotic-resistance patterns of 30-d nonduplicate E. coli isolated from urine. Tested antibiotic classes included aminoglycosides, extended-spectrum cephalosporins (ESC), fluoroquinolones, and tetracyclines. Counts of tested and not-susceptible (resistant and intermediate, hereafter resistant) urine isolates were available by sex, age group (<65, 65+ year), month, and state. We applied a synthetic control approach to estimate the causal effect of SB27 on resistance patterns. Our approach created a synthetic California based on a composite of other states without the policy change and contrasted its counterfactual postpolicy trends with the observed postpolicy trends in California.

FINDINGS

We included 7.1 million E. coli urine isolates, 90% among women, across 33 states. From 2013 to 2017, the median (interquartile range) resistance percentages in California were 11.9% (7.4, 17.6), 13.8% (5.8, 20.0), 24.6% (9.6, 36.4), 7.9% (2.1, 13.1), for aminoglycosides, ESC, fluoroquinolones, and tetracyclines, respectively. SB27 was associated with a 7.1% reduction in ESC resistance (p-value for joint null: <0.01), but no change in resistance to aminoglycosides, fluoroquinolones, or tetracyclines.

DISCUSSION

Further research is needed to determine the role of SB27 in the observed reduction in ESC resistance E. coli in human populations, particularly as additional states implement similar legislation. https://doi.org/10.1289/EHP11221.

2227. Prevalence, Regional Distribution, and Trends of Antimicrobial Resistance Among Female Outpatients With Urine Klebsiella pneumoniae Isolates: A Multicenter Evaluation

Background

Infections caused by extended spectrum β-lactamase producing Enterobacterales (ESBLs), as well as antimicrobial resistance (AMR) and multi-drug resistance among uncomplicated urinary tract infections (uUTIs) in outpatients have risen in the past decade. The study objective was to determine the prevalence and geographic distribution of AMR among Klebsiella pneumoniae (K. pneumoniae) isolates in urine from female outpatients in the United States (US).

Methods

A retrospective, cross-sectional study of non-duplicate urine isolates from female outpatients (≥ 12 years of age) at 304 facilities, with ≥ 3 months of data, including initial isolates with distinct susceptibility patterns within 30 days of index urine samples, were used to assess regional AMR in 2019, and AMR trends from 2011 to 2019 (BD Insights Research Database, Franklin Lakes, NJ). K. pneumoniae isolates were identified as ESBL-positive (ESBL+) (confirmed by commercial panel or not susceptible [NS] to ceftriaxone, cefotaxime, ceftazidime, or cefepime), or NS if intermediate/resistant to any of the following: nitrofurantoin (NFT), trimethoprim/sulfamethoxazole (SXT), or fluoroquinolones (FQs). AMR prevalence and variation across US census regions was evaluated using logistic regression (with covariate adjustment) and generalized estimating equations.

Results

44,056 non-duplicate K. pneumoniae isolates were evaluated in 2019 (Figure). For all microbiological phenotypes, there was significant variation in resistance for K. pneumoniae across all US census regions (p&lt; 0.0001). Among 250,719 isolates evaluated from 2011 to 2019, AMR prevalence increased for all studied antimicrobials except for NFT NS (all p&lt; 0.0041; Table). There was an increase in adjusted AMR rates by age groups with higher AMR rates for females ≥ 55 versus &lt; 55, except for NFT, which showed the highest resistance in those aged &lt; 55. Figure.Prevalence of antimicrobial resistance in Klebsiella pneumoniae isolates in 2019Abbreviations: ESBL+, extended spectrum β-lactamase-positive or not susceptible to ceftriaxone, cefotaxime, ceftazidime, or cefepime; FQ, fluoroquinolone; FQ, fluoroquinolone; NFT, nitrofurantoin; NS, not susceptible; SXT, trimethoprim/sulfamethoxazole.Table.Klebsiella pneumoniae: model-estimated trends of relative average annual percentage change of antimicrobial resistance over time (2011 to 2019), by patient age, and by census region (N=250,719 isolates)All p values were p&lt; 0.0001 apart from NFT trend over years, which was p=0.0041.*Relative average annual percentage change in resistance rate.Abbreviations: CDC, Centers for Disease Control and Prevention; CI, confidence interval; ESBL+, extended spectrum β-lactamase-positive or not susceptible to ceftriaxone, cefotaxime, ceftazidime, or cefepime; FQ, fluoroquinolone; NFT, nitrofurantoin; NS, not susceptible; SXT, trimethoprim/sulfamethoxazole.

Conclusion

AMR prevalence in 2019 among non-duplicate K. pneumoniae isolates from urine in outpatients was notable. There were significant regional differences in resistance rates, which were higher in those aged ≥ 55 years, except for NFT. These analyses inform, and may be used to optimize, empiric treatment of uUTI.

Disclosures

Keith S. Kaye, MD, MPH, Allecra: Advisor/Consultant|GlaxoSmithKline plc.: Receiving symposia honoraria|GlaxoSmithKline plc.: GlaxoSmithKline plc.-sponsored study 212502|Merck: Advisor/Consultant|qpex: Advisor/Consultant|Shionogi: Grant/Research Support|Spero: Advisor/Consultant Vikas Gupta, PharmD, Becton, Dickinson and Company: Employee of, and shareholder in, Becton, Dickinson and Company, and the company received funding from GlaxoSmithKline plc. to conduct this study|GlaxoSmithKline plc.: GlaxoSmithKline plc.-sponsored study 212502 Aruni Mulgirigama, MBBS, GlaxoSmithKline plc.: Employee and shareholder|GlaxoSmithKline plc.: GlaxoSmithKline plc.-sponsored study 212502 Ashish V. Joshi, PhD, GlaxoSmithKline plc.: Employee and shareholder|GlaxoSmithKline plc.: GlaxoSmithKline plc.-sponsored study Nicole E. Scangarella-Oman, MS, GlaxoSmithKline plc.: Employee and shareholder Kalvin Yu, MD, FIDSA, Becton, Dickinson and Company: Employee of, and shareholder in, Becton, Dickinson and Company, and the company received funding from GlaxoSmithKline plc. to conduct this study|GlaxoSmithKline plc.: GlaxoSmithKline plc.-sponsored study 212502 Gang Ye, PhD, Becton, Dickinson and Company: Employee of Becton, Dickinson and Company, and received funding from GlaxoSmithKline plc. to conduct this study|GlaxoSmithKline plc.: GlaxoSmithKline plc.-sponsored study 212502 Fanny S. Mitrani-Gold, MPH, GlaxoSmithKline plc.: Employee and shareholder|GlaxoSmithKline plc.: GlaxoSmithKline plc.-sponsored study 212502.

2225. Analysis of Co-Resistance Among Escherichia coli Urine Isolates From Female Outpatients in the United States

Background

In the past 10 years, there has been a substantial increase in antimicrobial resistance among uropathogens in community-acquired uncomplicated urinary tract infections (uUTIs), including extended spectrum β-lactamase producing (ESBL+) Enterobacterales and multidrug resistance. This study examined urine isolates from female outpatients in the United States (US) for co-resistance among Escherichia coli (E. coli).

Methods

This was a retrospective, cross-sectional study of 30-day non-duplicate E. coli urine isolates (first isolates collected within a 30-day period) from female outpatients (≥ 12 years of age) at 304 US facilities. Included patients had ≥ 3 months of data from 2011 to 2019 (Becton, Dickinson and Company [BD] Insights Research Database). Urine-isolated E. coli were defined as ESBL+ by 1) commercial panel or 2) not susceptible (NS; intermediate/resistant) to ceftriaxone, cefotaxime, ceftazidime, or cefepime), or NS to any of: fluoroquinolones (FQs), trimethoprim/sulfamethoxazole (SXT), or nitrofurantoin (NFT). Microbiological co-resistance phenotypes were characterized in isolates NS to ≥ 2 of the 4 resistance phenotypes assessed.

Results

In total, 856,918 unique isolates were evaluated. Co-resistance data are shown in the Table. Of ESBL+ isolates (96,306), 72.4% were co-resistant to FQ, 56.7% to SXT, and 11.9% to NFT; 6.8% had all 4 phenotypes. For FQ NS isolates (319,354), 21.8% were also ESBL+, 51.6% were co-resistant to SXT, 8.0% were co-resistant to NFT, and 2.0% had all 4 phenotypes. Among SXT NS isolates (384,304), 14.2% were also ESBL+, 42.9% were co-resistant to FQ, 6.8% were co-resistant to NFT, and 1.7% had all 4 phenotypes. Finally, for NFT NS isolates (56,954), 20.1% were ESBL+, 44.7% were co-resistant to FQ, 46.0% were co-resistant to SXT, and 11.5% had all 4 phenotypes. Table.

426. Trends in carbapenem non-susceptible (Carb-NS) Enterobacterales from hospitalized patients in the US from 2014-2020: A comparison between organisms with and without concerns for chromosomal ampC beta-lactamase hyperproduction

Background

Carbapenem-resistant Enterobacterales (ENT) were designated an “Urgent Threat” by the CDC, underscoring need for understanding epidemiological trends over time with these pathogens. We evaluated trends in non-susceptibility to carbapenems (Carb-NS) in ENT in the inpatient setting from 2014-2020 across 314 US facilities nation-wide, with a focus on comparisons between ENT with and without concerns for chromosomal ampC beta-lactamase hyperproduction. Table:Model-estimated inpatient-setting Carb NS % and trends from 2014-2020.Figure:Trends in inpatient % Carb-NS ENT from 2014-2020.

Methods

All adults with a positive ENT culture (first isolate of a species per 30-day period from blood, respiratory, urine, skin/wound, intra-abdominal, or other) in the inpatient setting from 314 US hospitals from 2014 - 2020 were evaluated (BD Insights Research Database, Becton, Dickinson & Company). Carb-NS was defined as intermediate or resistant to ertapenem, imipenem, meropenem or doripenem per commercial panels. Organisms were classified as concerning for hyperproduction of chromosomal ampC b-lactamase (K. aerogenes, E. cloacae, C. freundii; ampC-ENT) and those without such concerns (E coli [EC], K. pneumoniae [KPN], P mirabilis [PM]); non-ampC ENT). Other ENT were excluded. Time series models were used to evaluate the monthly patterns of resistance trends in proportion per isolates tested.

Results

2,513,392 inpatient non-duplicate ENT isolates were evaluated across 314 facilities of which 31,628 (1.3%) were Carb-NS. For Carb-NS ENT, 60.9% (19,277/31,628) were from non-ampC ENT and 30.7% (9,717/31,628) were in ampC ENT; together, these groups made up 91.6% of ENT evaluated. There were significant decreases in overall trends in inpatient ENT by % Carb-NS and % Carb-NS KPN (p &lt; 0.001 for both). There were significant increases (see Table) in inpatient % Carb NS for PM and ampC-ENT (p &lt; 0.0001 for both).

Conclusion

There was significant decrease in overall inpatient % Carb-NS ENT and % Carb-NS KPN from 2014-2020. However, significant increases in % Carb-NS were seen in organisms concerning for hyperproduction of chromosomal ampC. PM, in particular, should be further evaluated for genotypic resistance. Surveillance of Carb-NS isolates should include a broader set of pathogens beyond KPN and EC.

Disclosures

Vikas Gupta, PharmD, Becton, Dickinson and Company: Employee of, and shareholder in, Becton, Dickinson and Company, and the company received funding from GlaxoSmithKline plc. to conduct this study|GlaxoSmithKline plc.: GlaxoSmithKline plc.-sponsored study 212502 Kalvin Yu, MD, FIDSA, Becton, Dickinson and Company: Employee of, and shareholder in, Becton, Dickinson and Company, and the company received funding from GlaxoSmithKline plc. to conduct this study|GlaxoSmithKline plc.: GlaxoSmithKline plc.-sponsored study 212502 jason M. Pogue, PharmD, consultant to Venatorx, Merck, Shionogi, QPex Biopharma, Utility, GSK, and Entasis.: Advisor/Consultant Janet Watts, PhD, Becton, Dickinson and Company: Employee of Becton, Dickinson and Company, and the company received funding from GlaxoSmithKline plc. to conduct this study|GlaxoSmithKline plc.: GlaxoSmithKline plc.-sponsored study 212502 Cornelius J. Clancy, MD, receives research funding paid to his institution from Astellas and Merck: Grant/Research Support|serves as an advisory Board member for Astellas, Cidara, and Scynexis, served on the advisory board for Merck, Qpex Biopharma, and Shionogi: Advisor/Consultant|Venatorx and Needham & Associates: Advisor/Consultant.

2237. Enterbacterales Resistance Patterns for Extended-spectrum beta-lactamases (ESBL) Positive and Multidrug Resistance (MDR) Urine Isolates Collected and Tested from 295 Outpatient US Facilities in 2019

Background

Approximately 3 million cases of complicated Urinary Tract Infections (cUTI) occur annually in the U.S. with over 80% being diagnosed in the community setting. Antimicrobial resistance (AMR) and MDR are a growing threat. ESBL producing Enterbacterales (ENT) alone have increased by 53% from 2012 to 2017. Agents commonly used for treatment are becoming ineffective due to higher baseline resistance, resulting in treatment failures and unnecessary hospitalizations.

Methods

In total, 669,664 ENT (E. coli, K. pneumoniae, K. oxytoca, P. mirabilis) urine isolates were collected and tested from 295 US facilities (BD database) in 2019. All 30-day non-duplicate isolates collected were from adult outpatients (OPs). Antimicrobial susceptibility was done by each facility reference lab. The total number of isolates tested, and total non-susceptible (NS) isolates were tested and identified at the county level. Only counties with ≥ 30 tested isolates were reported. Those with < 30 isolates tested were indicated as < 1% NS (e.g., insufficient isolates tested). Counties without susceptibility results were populated to the nearest county either within or across state lines. We sought to examine both ESBL and ≥ 3 drug NS rates in the OP setting.

Results

Among all isolates, ESBL + and ≥ 3 drug NS rates represented 8.5% and 4.9%, respectively. A total of 14 states (28%) had resistance rates ≥20% for ESBL producing ENT. MO had the highest rate (28.6%), followed by 24.7% for KY, NC, TN, VA, and WV. GA was at 23.7%, while AZ, NM and TX were∼ 21.2%, and FL at 20.2%. The remain states DE, MD, and NJ were all at 20% (Figure 1). MDR (≥ 3 drug NS) rates ≥ 10% were noted for 11 states (22%). States in rank order included: MO (20%), KY, NC, TN, VA, and WV all at 14.7%. KY ranged from 14.7% to 10.1%, whereas GA was at 11.5% with 10.7% for both AL and FL. The remaining states included CA and HI both at ∼10% (Figure 2). Figure 1.Figure 2.

Conclusion

Important regional differences are noted for ESBL + and ≥ 3 drug resistance to urine isolates in the OP setting complicating oral antibiotic therapy. Certain states with higher resistance rates require education for the guideline selection of appropriate antibiotics. The approval of newer agents that overcome AMR are warranted and offer an alternative to limited existing oral therapy.

Disclosures

Mauricio Rodriguez, PharmD, MS-HEOR, BCPS, BCCCP, BCIDP, Spero Therapeutics: Employee Kalvin Yu, MD, FIDSA, Becton, Dickinson and Company: Employee of, and shareholder in, Becton, Dickinson and Company, and the company received funding from GlaxoSmithKline plc. to conduct this study|GlaxoSmithKline plc.: GlaxoSmithKline plc.-sponsored study 212502 Vikas Gupta, PharmD, Becton, Dickinson and Company: Employee of, and shareholder in, Becton, Dickinson and Company, and the company received funding from GlaxoSmithKline plc. to conduct this study|GlaxoSmithKline plc.: GlaxoSmithKline plc.-sponsored study 212502.

1204. Catheter-Associated Urinary Tract Infections (CAUTIs) and Secondary Hospital-Onset Bloodstream Infections (HO-BSIs)… Only the Tip of the Iceberg?

Background

HO-BSIs – secondary to urinary tract infections (UTIs) – can result in substantial morbidity and mortality. The Centers for Disease Control and Prevention report that CAUTIs are the leading cause of secondary BSIs. However, more than 70% of hospital-onset UTIs (HO-UTIs) may be non-device associated. If that is the case, are a substantial number of HO-BSIs caused by non-CAUTI HO-UTIs?

Methods

A retrospective cohort analysis of nosocomial infections from 37 US hospitals was conducted using de-identified, real-world data from an electronic infection surveillance system. The analytic cohort included adults ≥ 18 years, without an infection diagnosis, and hospital length of stay ≥ 2 days, between October 2015 and June 2019. HO-UTI subjects presented with a non-contaminated positive urine culture on day 3 or later. Clinically meaningful HO-UTIs, were those with antimicrobials ordered ±2 days of the positive urine culture. CAUTI was defined per the National Healthcare Safety Network definition. Non-CAUTI HO-UTI were HO-UTIs not meeting the CAUTI definition. Secondary HO-BSIs were defined as non-contaminated, positive blood cultures occurring 2 days before or 4 days after the positive urine specimen, requiring an antimicrobial susceptibility test, and presenting with the same pathogen.

Results

Of the 568,293 inpatient admissions, 465,246 met the inclusion criteria. The vast majority of CAUTIs (401 of 436; 92%) and 75% of non-CAUTI HO-UTIs (3,256 of 4,374) were clinically meaningful. The relative burden of secondary HO-BSI was greater in patients with CAUTI (8%) compared to non-CAUTI HO-UTI (3%). However, the absolute risk of secondary HO-BSI was 3-times greater in non-CAUTI HO-UTI compared to CAUTI (96 cases vs 32 cases, respectively). 56% of secondary HO-BSI in CAUTI, and only 31% of secondary HO-BSI in non-CAUTI HO-UTI, likely originated in the intensive care unit (ICU).

Case Tree

Frequency of CAUTI and non-CAUTI HO-UTI. Frequency of secondary HO-BSI. Location of HO-UTI.

Conclusion

This retrospective, observational study found clinically meaningful non-CAUTI HO-UTIs to be 10-fold higher than the number of CAUTIs. In addition, the absolute burden of secondary HO-BSI is substantially higher in these non-CAUTI HO-UTIs and more likely to be associated with the non-ICU setting. The data suggests that evaluating CAUTI alone may underestimate the true burden of clinically meaningful HO-UTI.

Disclosures

ChinEn Ai, MPH, BD - Becton, Dickinson and Company: Employee|BD - Becton, Dickinson and Company: Stocks/Bonds Molly Jung, MPH, BD - Becton, Dickinson and Company: Employee|BD - Becton, Dickinson and Company: Stocks/Bonds Timothy Kelly, MS, MBA, BD - Becton, Dickinson and Company: Employee|BD - Becton, Dickinson and Company: Stocks/Bonds Kalvin Yu, MD, FIDSA, Becton, Dickinson and Company: Employee of, and shareholder in, Becton, Dickinson and Company, and the company received funding from GlaxoSmithKline plc. to conduct this study|GlaxoSmithKline plc.: GlaxoSmithKline plc.-sponsored study 212502.

Impact of prior failed irrigation and debridement on outcomes of subsequent two-stage revision arthroplasty: a systematic review and meta-analysis

OBJECTIVE

This study aimed at examining if prior failed debridement, antibiotics, and implant retention (DAIR) for prosthetic joint infection have an impact on the success of subsequent two-stage revision arthroplasty (2SRA).

MATERIALS AND METHODS

Search was conducted on PubMed, Embase, and Google Scholar up to 14th April 2022 for studies comparing 2SRA with and without a history of DAIR.

RESULTS

Six retrospective studies were included. The success of 2SRA was defined as either absence of additional surgical intervention for infection or absence of antibiotic suppression or both. We noted no statistically significant difference in the odds of success between failed DAIR and no DAIR group, albeit with an inclination of reduced success with prior failed DAIR (OR 0.63 95% CI 0.33, 1.19 I2=66% p=0.16). Five studies reported adjusted outcomes. The meta-analysis demonstrated no statistically significant difference in the odds of success between failed DAIR and no DAIR groups (OR 0.57 95% CI 0.26, 1.26 I2=66% p=0.17). During sensitivity analysis, the removal of a single study changed the effect size indicating significantly lower success rates in failed DAIR group.

CONCLUSIONS

Our results indicate that patients undergoing 2SRA after failed DAIR may have a non-significant tendency of lower success rates as compared to patients directly undergoing 2SRA. However, current evidence is scarce and fraught with several limitations and there is a need for further research to delineate the impact of failed DAIR on the success of 2SRA.

Risk Factors Associated With Antimicrobial Resistance and Adverse Short-Term Health Outcomes Among Adult and Adolescent Female Outpatients With Uncomplicated Urinary Tract Infection

Background

Increasing antimicrobial resistance makes treating uncomplicated urinary tract infections (uUTIs) difficult. We compared whether adverse short-term outcomes among US female patients were more common when initial antimicrobial therapy did not cover the causative uropathogen.

Methods

This retrospective cohort study used data from female outpatients aged ≥12 years, with a positive urine culture and dispensing of an oral antibiotic ±1 day from index culture. Isolate susceptibility to the antimicrobial initially dispensed, patient age, and history of antimicrobial exposure, resistance, and all-cause hospitalization within 12 months of index culture were evaluated for associations with adverse outcomes during 28-day follow-up. Outcomes assessed were new antimicrobial dispensing, all-cause hospitalization, and all-cause outpatient emergency department (ED)/clinic visits.

Results

Of 2366 uUTIs, 1908 (80.6%) were caused by isolates susceptible and 458 (19.4%) by isolates not susceptible (intermediate/resistant) to initial antimicrobial treatment. Within 28 days, patients with episodes caused by not susceptible isolates were 60% more likely to receive a new antimicrobial versus episodes with susceptible isolates (29.0% versus 18.1%; 95% CI 1.3–2.1; P &lt; .0001). Other variables associated with new antibiotic dispenses within 28 days were older age, prior antimicrobial exposure, or prior nitrofurantoin-not susceptible uropathogens (P &lt; .05). Older age, prior antimicrobial-resistant urine isolates and prior hospitalization were associated with all-cause hospitalization (P &lt; .05). Prior fluoroquinolone-not susceptible isolates or oral antibiotic dispensing within 12 months of index culture were associated with subsequent all-cause outpatient visits (P &lt; .05).

Conclusions

New antimicrobial dispensing within the 28-day follow-up period was associated with uUTIs where the uropathogen was not susceptible to initial antimicrobial treatment. Older age and prior antimicrobial exposure, resistance, and hospitalization also identified patients at risk of adverse outcomes.

Current census of oncology critical care medicine in China

OBJECTIVE

The purposes of this survey were to show the current situation of oncology critical care medicine in China by questionnaire, to understand the resource distribution of oncology critical care medicine and to analyze and evaluate the existing resources and reserve capacity of oncology critical care medicine in China.

METHODS

We conducted the survey mainly in the form of an online questionnaire. The Committee of Cancer Critical Care Medicine of the Chinese Anticancer Association (CACA) initiated the survey on 1 November 2017, and 36 member hospitals nationwide participated in the survey. The questionnaire included 10 items: investigator information, hospital information, general information of oncology critical care department, staffing of oncology critical care department, management in oncology critical care department, technical skills in oncology critical care department, patient source in oncology critical care department, equipment configuration in oncology critical care department, special skills in oncology critical care department and summary of the information.

RESULTS

The survey results included information from 28 member units, all of which were tertiary hospitals, distributed in 20 provinces and 4 direct-controlled municipalities. The results are as follows. (i) The total ratio of beds in the oncology critical care department to hospital beds was 1.06%, and the average number of beds in the oncology critical care department was 16.36. (ii) The ratio of physicians in the oncology critical care department to beds was ∼0.62:1, and the ratio of nurses to beds was ∼1.98:1. (iii) According to the census of the population and gross domestic product (GDP) of different regions conducted by the State Statistics Bureau in 2017, the ratio of beds in the oncology critical care department for tumor patients to the population was 4.55 beds per 10 million people, and the ratio of beds in the oncology critical care department to GDP was 8.00 beds per RMB 100 billion, on average. (iv) According to the requirements of the guidelines for the development and management of critical care medicine in China, the facilities in departments of oncology critical care medicine meet the requirements, and the technical skills of medical staff are competent.

CONCLUSION

The development of oncology critical care in China is becoming better, but there is still a certain gap compared with the intensive care unit standards in China and the average level of the nationwide. The development of oncology critical care medicine is urgent.

[Suppression of HMGB1 inhibits neuronal autophagy and apoptosis to improve neurological deficits in rats following intracerebral hemorrhage]

OBJECTIVE

To investigate the effect of suppressing high-mobility group box 1 (HMGB1) on neuronal autophagy and apoptosis in rats after intracerebral hemorrhage (ICH) in rats.

METHODS

Rat models of ICH induced by intracerebral striatum injection of 0.2 U/mL collagenase Ⅳ were treated with 1 mg/kg anti-HMGB1 mAb or a control anti-IgG mAb injected via the tail immediately and at 6 h after the operation (n=5). The rats in the sham-operated group (with intracranial injection of 2 μL normal saline) and ICH model group (n=5) were treated with PBS in the same manner after the operation. The neurological deficits of the rats were evaluated using modified neurological severity score (mNSS). TUNEL staining was used to detect apoptosis of the striatal neurons, and the expressions of HMGB1, autophagy-related proteins (Beclin-1, LC3-Ⅱ and LC3-Ⅰ) and apoptosis-related proteins (Bcl-2, Bax and cleaved caspase-3) in the brain tissues surrounding the hematoma were detected using Western blotting. The expression of HMGB1 in the striatum was detected by immunohistochemistry, and serum level of HMGB1 was detected with ELISA.

RESULTS

The rat models of ICH showed significantly increased mNSS (P < 0.05), which was markedly lowered after treatment with anti- HMGB1 mAb (P < 0.05). ICH caused a significant increase of apoptosis of the striatal neurons (P < 0.05), enhanced the expressions of beclin-1, LC3-Ⅱ, Bax and cleaved caspase-3 (P < 0.05), lowered the expressions of LC3-Ⅰ and Bcl-2 (P < 0.05), and increased the content of HMGB1 (P < 0.05). Treatment with anti-HMGB1 mAb obviously lowered the apoptosis rate of the striatal neurons (P < 0.05), decreased the expressions of Beclin-1, LC3-Ⅱ, Bax and cleaved caspase-3 (P < 0.05), increased the expressions of LC3-Ⅰ and Bcl-2 (P < 0.05), and reduced the content of HMGB1 in ICH rats (P < 0.05).

CONCLUSION

Down- regulation of HMGB1 by anti-HMGB1 improves neurological functions of rats after ICH possibly by inhibiting autophagy and apoptosis of the neurons.

Outcomes during delivery hospitalisations with inflammatory bowel disease

OBJECTIVE

To characterise inflammatory bowel disease (IBD) trends and associated risk during delivery hospitalisations.

DESIGN

Cross-sectional.

SETTING

US delivery hospitalisations.

POPULATION

Delivery hospitalisations in the 2000-2018 National Inpatient Sample.

METHODS

This study analysed a nationally representative hospital discharge database based on the presence of IBD. Temporal trends in IBD were analysed using joinpoint regression to estimate the average annual percent change (AAPC). IBD severity was characterised by the presence of diagnoses such as penetrating and stricturing disease and history of bowel resection. Risks for adverse outcomes were analysed based on presence of IBD. Poisson regression models were performed with unadjusted and adjusted risk ratios (aRR) as measures of effect.

MAIN OUTCOME MEASURE

Prevalence of IBD and associated adverse outcomes.

RESULTS

Of 73 109 790 delivery hospitalisations, 89 965 had a diagnosis of IBD. IBD rose from 0.06% in 2000 to 0.21% in 2018 (AAPC 7.3%, 95% CI 6.7-7.9%). Among deliveries with IBD, IBD severity diagnoses increased from 4.1% to 8.1% from 2000 to 2018. In adjusted analysis, IBD was associated with increased risk for preterm delivery (aRR 1.50, 95% CI 1.47-1.53), severe maternal morbidity (aRR 1.93, 95% CI 1.83-2.04), venous thrombo-embolism (aRR 2.76, 95% CI 2.39-3.18) and surgical injury during caesarean delivery hospitalisation (aRR 5.03, 95% CI 4.76-5.31). In the presence of a severe IBD diagnosis, risk was further increased for all adverse outcomes.

CONCLUSION

IBD is increasing in the obstetric population and is associated with adverse outcomes. Risk is increased in the presence of a severe IBD diagnosis.

TWEETABLE ABSTRACT

Deliveries among women with inflammatory bowel disease are increasing. Disease severity is associated with adverse outcomes.

A plain language summary of how lefamulin alone can be used to treat pneumonia caught outside of the hospital due to common bacterial causes, including drug-resistant bacteria

What is this summary about?

Bacterial pneumonia is an infection of the lung caused by bacteria that is potentially deadly, costly, and affects millions of people worldwide every year. Treatment is becoming more challenging—many current treatments no longer work well because some strains of bacteria that cause pneumonia have become resistant to current antibiotics. Many of the antibiotics that do still work have undesirable side effects. Therefore, new antibiotics that work differently are needed to treat bacterial pneumonia.

Lefamulin (brand name, Xenleta^®) is an antibiotic that was approved to treat bacterial pneumonia caught outside a hospital (also called community-acquired bacterial pneumonia, or CABP) based on results of two clinical studies. In both studies, participants started treatment with lefamulin before the type of bacteria causing the infection was known. Lefamulin was well tolerated and worked well in 5 to 7 days to kill the bacteria causing the infection and to improve symptoms in almost all participants with CABP.

What were the results?

After the studies were completed, the researchers looked back at what kinds of bacteria were identified from the study participants. Lefamulin worked well to kill bacteria and to improve CABP symptoms for most kinds of infecting bacteria, including bacteria resistant to many current antibiotics.

What do the results mean?

These results suggest that lefamulin, by itself, provides a much-needed treatment option for CABP that covers most of the key bacteria causing this infection.

[Application of totally visceral sac separation in abdominal wall hernia]

To investigate the application of totally visceral sac separation (TVS) in the treatment of ventral hernia, to summarize the operation procedure and to analyze its safety and effectiveness. Twenty-one consecutive primary and secondary ventral hernias cases were repaired using the TVS procedure from December 2019 to December 2020. A large mesh should be placed in retrorectus sublay or underlay preperitoneal using the minimally invasive procedure. The indications for this procedure include umbilical, incisional hernia, linea alba hernia, lumbar hernia, and parastomal hernia. All the operations were successful, of which 2 cases were converted to laparotomy because of the failure of anterior peritoneal cavity construction and the difficulty of anterior defect closure. The mean operation time was 140 mins (70-260 min), postoperative pain was mild, and the mean visual analogue scale(VAS) was 2.5 (1-4) on the first postoperative day. There were no recurrent cases during the follow-up for more than 6 months. TVS procedure is safe and highly reproducible. Without expensive anti-adhesion mesh and fixation tacker, the technology of TVS is a good technique for the surgical treatment of ventral hernia.

Do Inpatient Antimicrobial Stewardship Programs Help Us in the Battle Against Antimicrobial Resistance?

BACKGROUND

Antibiotic stewardship programs (ASPs) have demonstrated success at reducing costs, yet there is limited quality evidence of their effectiveness in reducing infections of high-profile drug-resistant organisms.

METHODS

This retrospective, cohort study included all Kaiser Permanente Southern California (KPSC) members aged ≥18 years hospitalized in 9 KPSC hospitals from 1 January 2008 to 31 December 2016. We measured the impact of staggered ASP implementation on consumption of 18 ASP-targeted antibiotics using generalized linear mixed-effects models. We used multivariable generalized linear mixed-effects models to estimate the adjusted effect of an ASP on rates of infection with drug-resistant organisms. Analyses were adjusted for confounding by time, cluster effects, and patient- and hospital-level characteristics.

RESULTS

We included 765 111 hospitalizations (288 257 pre-ASP, 476 854 post-ASP). By defined daily dose, we found a 6.1% (-7.5% to -4.7%) overall decrease antibiotic use post-ASP; by days of therapy, we detected a 4.3% (-5.4% to -3.1%) decrease in overall use of antibiotics. The number of prescriptions increased post-ASP (1.04 [1.03-1.05]). In adjusted analyses, we detected an overall increase in vancomycin-resistant enterococci infections post-ASP (1.37 [1.10-1.69]). We did not detect a change in the rates of extended-spectrum beta-lactamase, carbapenem-resistant Enterobacteriaceae, and multidrug-resistant Pseudomonas aeruginosa infections post-ASP.

CONCLUSIONS

ASPs with successful reductions in consumption of targeted antibiotics may not see changes in infection rates with antibiotic-resistant organisms in the 2 to 6 years post-implementation. There are likely differing timescales for reversion to susceptibility across organisms and antibiotics, and unintended consequences from compensatory prescribing may occur.

221. Evaluation of Rates of Culture Positive Blood Stream Pathogens Prior to and During the SARS-CoV-2 Pandemic: A Multicenter Evaluation

Background

Bacterial co-infections or super-infections are well-characterized complications of viral infections, further increasing morbidity and mortality of global viral pandemics. We evaluated trends in the incidence of culture positive gram-negative (GN), gram-positive (GP), and fungal/yeast pathogens from a blood source in hospitalized patients at US hospitals before and during the SARS-CoV-2 pandemic.

Table: Incidence and rate of blood pathogens in the pre and post SARS-CoV-2 period.

Results

There were 2,001,793 admissions in the pre-SARS-CoV-2 period (7/2019-2/2020) and 2,875,219 admissions during the SARS-CoV-2 pandemic. Incidence of GN/GP blood stream pathogens was significantly higher prior to the SARS-CoV-2 pandemic than during the pandemic. Higher rates of blood stream pathogens occurred in those who were tested for SARS-CoV-2, but all non-tested patients had significantly lower rates than pre-pandemic. Rates of Candida spp., Enterococcus spp., Serratia marcescens, and Enterobacter cloacae were higher in SARS-CoV-2 positive patients compared to pre-pandemic patients. Compared to the prior pandemic period, the incidence of B. fragilis, Streptococcus, Enterococcus and Candida were higher among those tested for SARS-CoV-2 but were negative.

Conclusion

In general, rates of positive blood cultures for bacterial pathogens were either lower or similar during the SARS-CoV-2 period compared to the pre-SARS-CoV-2 pandemic period. The patients that were tested for SARS-CoV-2 but were positive who had higher rates of infection than prior may indicate the similarity in viral and bacterial clinical presentation. Further evaluation of higher rates of Enterococcus and Candida in the pandemic period are warranted.

Disclosures

Laura A. Puzniak, PhD, Merck & Co., Inc. (Employee) Karri A. Bauer, PharmD, Merck & Co., Inc. (Employee, Shareholder) Kalvin Yu, MD, BD (Employee) Pamela Moise, PharmD, Merck (Employee) Vikas Gupta, PharmD, BCPS, Becton, Dickinson and Company (Employee, Shareholder)

156. Evaluation of Trends in Antimicrobial Use and Proportion of Culture Positive Gram-Negative/Gram-Positive Pathogens Comparing Prior to and During the SARS-CoV-2 Pandemic: A Multicenter Evaluation

Background

Increased risk for bacterial co-infections has been described in the pathogenesis of primary viral infections. We evaluated trends in incidence of antibiotic use (abx) and culture positive Gram negative/Gram positive (GN/GP) pathogens in US hospitalized patients prior to and quarterly during the SARS-CoV-2 pandemic.

Table. Trends in antimicrobial use, duration, and positive GN/GP pathogen results.

Methods

We conducted a multi-center, retrospective cohort analysis of all hospitalized patients from 241 US acute care facilities with >1-day inpatient admission between 7/1/19-5/15/21 in the BD Insights Research Database (Franklin Lakes, NJ USA). SARS-CoV-2 infection was defined as a positive PCR during or ≤7 days prior to hospitalization. Admissions with abx prescribed ≥24 hrs and a GN/GP non-contaminant, positive culture were evaluated.

Results

During the pre-pandemic period (7/19 – 2/20) 30% (600,116/2,001,793) admissions were prescribed abx ≥ 24 hrs and 5.3% were positive for a GN/GP pathogen (Table 1). During the SARS-CoV-2 pandemic, abx use ≥ 24 hrs (66.2%) and positive GN/GP culture (8.4%) was highest in SARS-CoV-2 positive patients followed by patients negative for SARS-CoV-2 (abx ≥ 24 hrs 36.7%; GN/GP pathogens 6.8%), and SARS-CoV-2 not tested (abx ≥ 24 hrs 27.5%; GN/GP pathogens 4.5%). GN/GP positive culture was consistent by quarter during the pandemic for SARS-CoV-2 positive patients, whereas SARS-CoV-2 negative and not tested patients had the highest proportion of antibiotics received and positive pathogens in the first three months of pandemic. SARS-CoV-2 positive patients with positive GN/GP culture had the longest median abx duration. (Table 1) The prevalence of abx usage was highest in all groups for all abx during the early pandemic and then declined over time with the largest declines in SARS-CoV-2 positive patients. (Table 2)

Conclusion

This study highlights the impact of viral infections on both prescribing practices and prevalence of bacterial pathogens. Approximately two-thirds of SARS-CoV-2 positive patients received an antibiotic despite a low percentage of positive cultures, however aggregate antimicrobial use overall was similar prior to compared to during the SARS-CoV-2 pandemic. These data may inform opportunities for stewardship programs and antibiotic prescribing in the current and future viral pandemics.

Disclosures

Laura A. Puzniak, PhD, Merck & Co., Inc. (Employee) Karri A. Bauer, PharmD, Merck & Co., Inc. (Employee, Shareholder) Kalvin Yu, MD, BD (Employee) Vikas Gupta, PharmD, BCPS, Becton, Dickinson and Company (Employee, Shareholder)

786. Facility Reported vs. CLSI MIC Breakpoint Comparison of Carbapenem Non-susceptible (Carb-NS) Pseudomonas aeruginosa (PSA) From 2016-2019: A Multicenter Evaluation

Background

CLSI lowered Pseudomonas aeruginosa (PSA) Carbapenem (Carb) interpretive breakpoint minimum inhibitory concentrations (MICs) in 2012. It often takes several years for commercial test manufacturers and microbiology labs to incorporate revised breakpoints. We compare facility-reported rates of Carb-NS PSA to the 2012 CLSI MIC breakpoints, using a large nationwide database for isolates tested in 2016-2020 at United States (US) facilities.

Table. Imipenem (IPM)/meropenem (MEM)/doripenem (DOR) interpretation (evaluable isolates) results for PSA.

Methods

All adults with a positive non-contaminant PSA culture (first isolate per 30-day period from blood, respiratory, urine, skin/wound, intra-abdominal, or other) in ambulatory and inpatient settings from 298 US hospitals from Q1 2016-Q4 2020 were evaluated (BD Insights Research Database, Becton, Dickinson & Company). Facility-reported Carb-non susceptible (NS) was defined as lab information system feed designations of susceptible (S), intermediate (I) or resistant (R) to imipenem (IPM), meropenem (MEM) and/or doripenem (DOR) per commercial panels. Where available, MICs were interpreted using CLSI 2012 Carb breakpoints (µg/ml) of ≤2 (S), 4 (I), ≥8 (R) for IPM/MEM/DOR. For evaluable PSA isolates we compared susceptibility results as reported by the facility to those using CLSI MIC breakpoints.

Results

Overall, 86.9% (255,844/294,426) of non-duplicate PSA isolates with facility-reported IPM/MEM/DOR susceptibility interpretations also had interpretable MIC results. S rates were 84.9% and 83.3% as reported by facilities and determined by CLSI criteria, respectively (Table). Facilities under-reported Carb-NS by 9.8%, using CLSI criteria as the standard (10.4% and 7.7% of R and I isolates, respectively, were missed by facility reporting).

Conclusion

Systematic application of CLSI breakpoints in 2016-20 would have had minimal impact on PSA S rates in the US. However, facility reporting failed to identify ~10% of Carb-NS isolates. The clinical implications of this observation are unknown. Facilities should know their local epidemiology, decide if under-reporting might be an issue, and assess if there is any impact on their patients.

Disclosures

Vikas Gupta, PharmD, BCPS, Becton, Dickinson and Company (Employee, Shareholder) Kalvin Yu, MD, BD (Employee) Jason M Pogue, PharmD, BCPS, BCIDP, Merck (Consultant)QPex (Consultant)Shionogi (Consultant)Utility Therapeutics (Consultant)VenatoRX (Consultant) Janet Weeks, PhD, Becton, Dickinson and Company (Employee) Cornelius J. Clancy, MD, Merck (Grant/Research Support)

176. Antibiotic Resistance Patterns, Seasonality, and Correlation with the Influenza Season in the United States: A Multicenter Evaluation Reveals Surprising Association Between Influenza Season and Gram Negative Pathogens

Background

Influenza infection may affect bacterial transmission dynamics and seasonality of antimicrobial resistance (AMR). There is a paucity of data on the association of influenza season and AMR rates. We aimed to describe trends of AMR and their correlation with the influenza season in ambulatory and inpatient settings in the United States (US).

Methods

We used the BD Insights Research Database (Franklin Lakes, NJ USA) to identify 30 day non-duplicate isolates collected from patients &gt;17 years old with susceptibility profile of Gram-negative (GN) (Enterobacterales (ENT), P. aeruginosa (PSA), A. baumannii spp. (ACB), and S. maltophilia (Sm)) and Gram-positive (GP) pathogens (S. aureus (SA), and S. pneumoniae (Sp)) in up to 257 US healthcare institutions from 2011-19. We defined the outcomes as rates per 100 admissions and % of non-susceptibility (NS), stratified by community and inpatient settings, resistance type (resistance to carbapenem (Carb-NS), quinolone (FQ-NS), macrolide (Macr NS), penicillin (PCN NS), and extended spectrum cephalosporin (ESC NS)) and isolate origin (respiratory and non-respiratory). Influenza data were presented as the % of positive laboratory tests. We used descriptive statistics and generalized estimating equations models to evaluate the monthly trends of AMR outcomes and correlation with the influenza season.

Results

We identified 16 576 274 confirmed non-duplicate pathogens, of which 154 841 were GN Carb-NS, 1 502 796 GN FQ-NS, 498 012 methicillin resistant SA (MRSA), and 44 131 Macr-NS, PCN-NS, and ESC-NS Sp. Among the Carb-NS pathogens, Influenza rate was correlated with % ACB-NS [β= 0.205, p&lt; .001]. In the FQ-NS group, influenza was associated with overall % ENT-NS [β= 0.041 p&lt; .001] and % PSA-NS [β= 0.039, p = .015]. For the GP pathogens, all Sp. rates were correlated with increased influenza positivity % (See Table). Only MRSA rates of respiratory source were associated with influenza [β= .066, p=.028].

Summary of Multivariate regressions of AMR and % Flu by Source and Setting (controlling for hospital level factors): 2011-2019

Conclusion

Our study revealed surprising association between influenza epidemics and GN resistance and corroborated the evidence of correlation between respiratory GP and influenza infections. These insights may help inform targeted antimicrobial stewardship initiatives during influenza season.

Disclosures

Amine Amiche, PhD, Sanofi (Employee, Shareholder) Heidi Kabler, MD, Sanofi Pasteur (Employee) Janet Weeks, PhD, Becton, Dickinson and Company (Employee) Kalvin Yu, MD, BD (Employee) Vikas Gupta, PharmD, BCPS, Becton, Dickinson and Company (Employee, Shareholder)

642. Facility Reported vs. CLSI MIC Breakpoint Comparison of Carbapenem Non-susceptible (Carb-NS) Enterobacteriaceae (ENT) from 2016-2019: A Multicenter Evaluation

Background

Carbapenem (Carb) minimum inhibitory concentration (MIC) breakpoints were lowered by CLSI in 2010 and recognized by FDA in 2012. Adoption of revised breakpoints is often slow, which may lead to under-reporting of Carb non-susceptibility (NS) by facilities. We compare facility-reported rates of Carb-NS ENT to the CLSI MIC breakpoints for a large nationwide collection of isolates in the United States (US) from 2016-2019.

Methods

All adults with a positive non-contaminant ENT culture (first isolate of a species per 30-day period from blood, respiratory, urine, skin/wound, intra-abdominal, or other) in ambulatory/inpatient settings from up to 300 US hospitals from 2016-2019 were evaluated (BD Insights Research Database). Facility-reported Carb-NS was defined as: susceptible (S), intermediate (I) or R to ertapenem (ETP), imipenem (IPM), meropenem (MEM) and/or doripenem (DOR) per commercial panels. Where available, MICs were interpreted using CLSI 2010 MIC breakpoints (µg/ml): ≤ 0.5 (S), 1 (I), ≥ 2 (R) for ETP and ≤1 (S), 2 (I), and ≥ 4 (R) for IPM/MEM/DOR. For evaluable ENT isolates we compared susceptibility results as reported by the facility to CLSI MIC breakpoints.

Results

Overall, 77.4% (937,926/1,211,845) and 90.6% (2,157,785/2,381,824) non-duplicate ENT isolates with facility-reported susceptibility results also had interpretable MIC results for ETP and IPM/MEM/DOR, respectively (Tables). ETP S rates were 99.3% and 99.1% as reported by facilities and using CLSI criteria, respectively. S rates of other Carbs were 98.9% and 98.4% by facility reporting and CLSI criteria, respectively. Systematic application of CLSI breakpoints under-reported EPT-I and –R isolates by 24.2% and 16.4%, respectively, and identification of IPM/MEM/DOR-I and –R isolates by 31.3% and 22.7%, respectively.

Conclusion

Systematic application of CLSI breakpoints in 2016-19 would have had minimal impact on ENT S rates in the US. However, facility reporting failed to identify 18.8% of ETP I or R and 26.5% of IPM/MEM/DOR I or R isolates. The clinical implications of this observation are unknown. Facilities should know their local epidemiology, decide if under-reporting might be an issue, and assess if there is any impact on their patients.

Disclosures

Vikas Gupta, PharmD, BCPS, Becton, Dickinson and Company (Employee, Shareholder) Kalvin Yu, MD, BD (Employee) Jason M Pogue, PharmD, BCPS, BCIDP, Merck (Consultant)QPex (Consultant)Shionogi (Consultant)Utility Therapeutics (Consultant)VenatoRX (Consultant) Janet Weeks, PhD, Becton, Dickinson and Company (Employee) Cornelius J. Clancy, MD, Merck (Grant/Research Support)

The Quality of Care of Transgender and Gender Nonconforming Patients: The Provider Perspective

BACKGROUND

Transgender and gender-nonconforming (TGNC) patients have inadequate quality of care. Few studies have examined the issues related to quality of care from the perspective of providers. The purpose of this pilot study was to understand the barriers and facilitators of quality TGNC care and develop recommendations for health systems.

METHODS

We used phenomenological methods in the form of qualitative semistructured interviews to allow provider participants to elaborate about issues not covered in the script questions. Audio files from 11 provider interviews were transcribed and summarized by common themes. Thematic analysis was conducted in an iterative process to extract insights from the data.

RESULTS

Six main subthemes resulted from our qualitative review regarding "barriers to quality care": 1) provider training and knowledge of TGNC care, 2) provider and staff interactions with TGNC patients, 3) case management, 4) misgendering, 5) access and continuity of care, and 6) bias and discrimination. Four subthemes were identified as "facilitators of quality care" for TGNC patients: 1) skilled staff, 2) continuity of care and electronic health records, 3) organizational support, and 4) provider-patient interactions. Additional needs were also suggested.

CONCLUSIONS

Findings were distilled into 3 recommendations to improve the quality of TGNC care: 1) establish a dedicated case-management team; 2) provide access to more in-depth and meaningful training for providers, clinic staff, and administrative staff (and mandate certain basic training); and 3) allocate financial resources and enforce a policy of nondiscrimination.

The efficacy, challenges, and facilitators of telemedicine in post-treatment cancer survivorship care: an overview of systematic reviews

BACKGROUND

Telemedicine services have been increasingly used to facilitate post-treatment cancer survivorship care, including improving access; monitoring health status, health behaviors, and symptom management; enhancing information exchange; and mitigating the costs of care delivery, especially since the COVID-19 pandemic. To inform guidance for the use of telemedicine in the post-COVID era, the aim of this overview of systematic reviews (SRs) was to evaluate the efficacy of, and survivor engagement in, telemedicine interventions in the post-treatment survivorship phase, and to consider implementation barriers and facilitators.

METHODS

PubMed, Cochrane CENTRAL, CINAHL, Embase, and Web of Science databases were searched. SRs that examined the use of telemedicine in the post-treatment phase of cancer survivorship, published between January 2010 and April 2021, were included. Efficacy data were synthesized narratively. Implementation barriers and facilitators were synthesized using the Consolidated Framework for Implementation Research.

RESULTS

Twenty-nine SRs were included. A substantive body of evidence found telemedicine to benefit the management of psychosocial and physical effects, particularly for improving fatigue and cognitive function. There was a lack of evidence on the use of telemedicine in the prevention and surveillance for recurrences and new cancers as well as management of chronic medical conditions. This overview highlights a range of diverse barriers and facilitators at the patient, health service, and system levels.

CONCLUSIONS

This review highlights the benefits of telemedicine in addressing psychosocial and physical effects, but not in other areas of post-treatment cancer survivorship care. This large review provides practical guidance for use of telemedicine in post-treatment survivorship care.

Hourglass Body Shape Ideal Scale and disordered eating

Disordered eating research has long considered the negative consequences of internalizing sociocultural appearance ideals (e.g., thin ideal, muscular ideal). However, the implications of internalizing a curvy or "hourglass" body shape remains unclear. The Hourglass Body Shape Ideal Scale (HBSIS) is a new self-report questionnaire that was developed and evaluated to appropriately measure the extent women subscribe to an hourglass body shape ideal. The measure was administered to a community and undergraduate sample of women via two separate online studies. Study 1 (N = 916) provided support for the factor structure as well as the convergent and discriminant validity of the HBSIS. The HBSIS was correlated with measures of appearance orientation, overweight preoccupation, and disordered eating. HBSIS was associated with disordered eating even after controlling for age, BMI, thin ideal and muscular ideal internalization. Further, higher HBSIS scores were associated with increased likelihood of having clinical levels of disordered eating symptoms. There were no racial and ethnic group differences on HBSIS. Study 2 (N = 195) replicated the factor structure of Study 1, in addition to its convergent and discriminant validity. The HBSIS allows for more precise examination of appearance-ideal internalization, capturing a unique construct understudied within eating pathology literature.

Antimicrobial Resistance Trends in Urine Escherichia coli Isolates From Adult and Adolescent Females in the United States From 2011-2019: Rising ESBL Strains and Impact on Patient Management

Background

Uncomplicated urinary tract infection (uUTI) is predominantly caused by Escherichia coli, which has increasing antimicrobial resistance (AMR) at the United States (US)-community level. As uUTI is often treated empirically, assessing AMR is challenging, and there are limited contemporary data characterizing period prevalence in the US.

Methods

This was a retrospective study of AMR using Becton, Dickinson and Company Insights Research Database (Franklin Lakes, New Jersey, US) data collected 2011–2019. Thirty-day, nonduplicate Escherichia coli urine isolates from US female outpatients (aged ≥12 years) were included. Isolates were evaluated for nonsusceptibility (intermediate/resistant) to trimethoprim-sulfamethoxazole, fluoroquinolones, or nitrofurantoin, and assessed for extended-spectrum β-lactamase production (ESBL+) and for ≥2 or ≥3 drug-resistance phenotypes. Generalized estimating equations were used to model AMR trends over time and by US census region.

Results

Among 1 513 882 E. coli isolates, the overall prevalence of isolates nonsusceptible to trimethoprim-sulfamethoxazole, fluoroquinolones, and nitrofurantoin was 25.4%, 21.1%, and 3.8%, respectively. Among the isolates, 6.4% were ESBL+, 14.4% had ≥2 drug-resistance phenotypes, and 3.8% had ≥3. Modeling demonstrated a relative average yearly increase of 7.7% (95% confidence interval [CI], 7.2–8.2%) for ESBL+ isolates and 2.7% (95% CI, 2.2–3.2%) for ≥3 drug-phenotypes (both P < .0001). Modeling also demonstrated significant variation in AMR prevalence between US census regions (P < .001).

Conclusions

Period prevalence of AMR among US outpatient urine-isolated E. coli was high, and for multidrug-resistance phenotypes increased during the study period with significant variation between census regions. Knowledge of regional AMR rates helps inform empiric treatment of community-onset uUTI and highlights the AMR burden to physicians.

[Speckle-type POZ protein up-regulates c-Jun protein expression and promotes proliferation and invasion of renal carcinoma cells]

OBJECTIVE

To investigate the effect of speckle-type POZ protein (SPOP) on proliferation, apoptosis, migration and invasion of renal cell carcinoma (RCC) and explore the potential mechanisms.

OBJECTIVE

Renal carcinoma cell lines (786-O, A704, and Caki-2) cultured in vitro were transfected with a SPOP-overexpressing plasmid, and the changes in proliferation of the cells were detected using colony formation and MTT assay; TUNEL assay was used to assess apoptosis of the cells. The changes in migration and invasion abilities of the cells were examined using wound healing assay and Transwell assay. The mRNA and protein levels of SPOP and c-Jun in the transfected cells were measured using real-time PCR and Western blotting.

OBJECTIVE

SPOP over-expression obviously promoted the proliferation, migration and invasion of 786-O, A704 and Caki-2 cells (P < 0.05). Compared with the control cells, 786-o and Caki-2 cells over-expressing SPOP exhibited significantly lowered apoptosis rates (P < 0.05). The results of real-time PCR demonstrated that the transfected cells did not show obvious changes in the mRNA level of c-Jun, but the protein expressions of SPOP and c-jun increased significantly as shown by Western blotting (P < 0.05).

OBJECTIVE

SPOP can promote proliferation, migration, and invasion and suppress apoptosis of renal carcinoma cells possibly by promoting the expression of c-Jun.

Untargeted Metabolomic Profiling of the Correlation Between Prognosis Differences and PD-1 Expression in Sepsis: A Preliminary Study

Objectives: The mortality rate of sepsis remains very high. Metabolomic techniques are playing increasingly important roles in diagnosis and treatment in critical care medicine. The purpose of our research was to use untargeted metabolomics to identify and analyze the common differential metabolites among patients with sepsis with differences in their 7-day prognosis and blood PD-1 expression and analyze their correlations with environmental factors.

Methods: Plasma samples from 18 patients with sepsis were analyzed by untargeted LC-MS metabolomics. Based on the 7-day prognoses of the sepsis patients or their levels of PD-1 expression on the surface of CD4+ T cells in the blood, we divided the patients into two groups. We used a combination of multidimensional and monodimensional methods for statistical analysis. At the same time, the Spearman correlation analysis method was used to analyze the correlation between the differential metabolites and inflammatory factors.

Results: In the positive and negative ionization modes, 16 and 8 differential metabolites were obtained between the 7-day death and survival groups, respectively; 5 and 8 differential metabolites were obtained between the high PD-1 and low PD-1 groups, respectively. We identified three common differential metabolites from the two groups, namely, PC (P-18:0/14:0), 2-ethyl-2-hydroxybutyric acid and glyceraldehyde. Then, we analyzed the correlations between environmental factors and the common differences in metabolites. Among the identified metabolites, 2-ethyl-2-hydroxybutyric acid was positively correlated with the levels of IL-2 and lactic acid (Lac) (P < 0.01 and P < 0.05, respectively).

Conclusions: These three metabolites were identified as common differential metabolites between the 7-day prognosis groups and the PD-1 expression level groups of sepsis patients. They may be involved in regulating the expression of PD-1 on the surface of CD4+ T cells through the action of related environmental factors such as IL-2 or Lac, which in turn affects the 7-day prognosis of sepsis patients.

Mortality Among US Patients Hospitalized With SARS-CoV-2 Infection in 2020

IMPORTANCE

Mortality is an important measure of the severity of a pandemic. This study aimed to understand how mortality by age of hospitalized patients who were tested for SARS-CoV-2 has changed over time.

OBJECTIVE

To evaluate trends in in-hospital mortality among patients who tested positive for SARS-CoV-2.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study included patients who were hospitalized for at least 1 day at 1 of 209 US acute care hospitals of variable size, in urban and rural areas, between March 1 and November 21, 2020. Eligible patients had a SARS-CoV-2 polymerase chain reaction (PCR) or antigen test within 7 days of admission or during hospitalization, and a record of discharge or in-hospital death.

EXPOSURE

SARS-CoV-2 positivity.

MAIN OUTCOMES AND MEASURES

SARS-CoV-2 infection was defined as a positive SARS-CoV-2 PCR or antigen test within 7 days before admission or during hospitalization. Mortality was extracted from electronically available data.

RESULTS

Among 503 409 admitted patients, 42 604 (8.5%) had SARS-CoV-2-positive tests. Of those with SARS-CoV-2-positive tests, 21 592 (50.7%) were male patients. Hospital admissions among patients with SARS-CoV-2-positive tests were highest in the group aged 65 years or older (19 929 [46.8%]), followed by those aged 50 to 64 years (11 602 [27.2%]) and 18 to 49 years (10 619 [24.9%]). Hospital admissions among patients 18 to 49 years of age increased from 1099 of 5319 (20.7%) in April to 1266 of 4184 (30.3%) in June and 2156 of 7280 (29.6%) in July, briefly exceeding those in the group 50 to 64 years of age (June: 1194 of 4184 [28.5%]; 2039 of 7280 [28.0%]). Patients with SARS-CoV-2-positive tests had higher in-hospital mortality than patients with SARS-CoV-2-negative tests (4705 [11.0%] vs 11 707 of 460 805 [2.5%]; P < .001). In-hospital mortality rates increased with increasing age for both patients with SARS-CoV-2-negative tests and SARS-CoV-2-positive tests. In patients with SARS-CoV-2-negative tests, mortality increased from 45 of 11 255 (0.4%) in those younger than 18 years to 4812 of 107 394 (4.5%) in those older than 75 years. In patients with SARS-CoV-2-positive tests, mortality increased from 1 of 454 (0.2%) of those younger than 18 years to 2149 of 10 287 (20.9%) in those older than 75 years. In-hospital mortality rates among patients with SARS-CoV-2-negative tests were similar for male and female patients (6273 of 209 086 [3.0%] vs 5538 of 251 719 [2.2%]) but higher mortality was observed among male patients with SARS-CoV-2-positive tests (2700 of 21 592 [12.5%]) compared with female patients with SARS-CoV-2-positive tests (2016 of 21 012 [9.60%]). Overall, in-hospital mortality increased from March to April (63 of 597 [10.6%] to 1047 of 5319 [19.7%]), then decreased significantly to November (499 of 5350 [9.3%]; P = .04), with significant decreases in the oldest age groups (50-64 years: 197 of 1542 [12.8%] to 73 of 1341 [5.4%]; P = .02; 65-75 years: 269 of 1182 [22.8%] to 137 of 1332 [10.3%]; P = .006; >75 years: 535 of 1479 [36.2%] to 262 of 1505 [17.4%]; P = .03).

CONCLUSIONS AND RELEVANCE

This nationally representative study supported the findings of smaller, regional studies and found that in-hospital mortality declined across all age groups during the period evaluated. Reductions were unlikely because of a higher proportion of younger patients with lower in-hospital mortality in the later period.

Association between fluoroquinolone utilization rates and susceptibilities of gram-negative bacilli: Results from an 8-year intervention by an antibiotic stewardship program in an inner-city United States hospital

This study evaluated an antibiotic stewardship program (ASP) intervention aimed at reducing inpatient fluoroquinolone (FQ) use and examined its impact on ciprofloxacin susceptibilities of gram-negative bacteria in a large 611-bed community hospital. A two-step ASP intervention was implemented: an electronic medical record algorithm that prompted physicians to re-evaluate FQ use shortly after admission and changed institutional UTI/pneumonia guidelines that recommended options alternate to FQs for first-line empiric antibiotic therapy in 2010 and 2011 respectively. Between 2007 and 2017 FQ use and ciprofloxacin susceptibilities of all non-duplicate cultured isolates of Escherichia coli, Klebsiella pneumoniae, Proteus mirabilis, and Pseudomonas aeruginosa obtained ≥72 h after admission were reviewed. Ambulatory care isolates served as a comparison group. FQ utilization rates and relationships to ciprofloxacin susceptibility were evaluated using interrupted time series models. Over the 11-year period, FQ use decreased from 110.0 (2007) to 26.2 (2017) days of therapy/1000 days at risk (p < 0.001). Compared to pre-intervention, the estimated (post-intervention) reduction in FQ utilization was 28.4 (95% CI: 10.9-46) days of therapy/1000 days at risk. Reduced FQ utilization was correlated with increase susceptibilities to ciprofloxacin of hospital onset isolates of Escherichia coli, Klebsiella pneumoniae, Proteus mirabilis (p < 0.02), and Pseudomonas aeruginosa (p = 0.07). No significant susceptibility change was observed in the ambulatory care isolates. Persuasive interventions by an ASP successfully modified physicians' inpatient empiric antibiotic use, produced a sustained reduction in FQ utilization rates and increased ciprofloxacin susceptibility to four commonly encountered gram-negative bacteria in a community hospital.

1699. Variation of antimicrobial resistance by age groups for outpatient UTI isolates in US females: A multicenter evaluation from 2011 to 2019

Background

An estimated 12% of women experience ≥ 1 episode of urinary tract infection (UTI) annually. Incidence is bimodal, with peaks occurring in young, sexually active women (18–24 years) and in post-menopausal women. Previous studies suggest the prevalence of antimicrobial resistance (AMR) in UTI is rising; however recent AMR data for community-acquired UTI are lacking. We estimated the prevalence of AMR among US females with outpatient UTI in 2011–2019, stratified by age.

Methods

A retrospective, multicenter, cohort study of AMR among non-duplicate urine isolates in US females (≥ 12 years of age) from 296 institutions from 2011–2019 (BD Insights Research Database, Franklin Lakes, NJ). Phenotypes examined for Enterobacterales (ENT) were: extended spectrum β-lactamase positive (ESBL+; determined by commercial panels or intermediate/resistant to ceftriaxone, cefotaxime, ceftazidime or cefepime); nitrofurantoin (NFT) not-susceptible (NS); fluoroquinolone (FQ) NS; trimethoprim-sulfamethoxazole (TMP-SMX) NS; and NS to ≥ 2 or ≥ 3 drug classes (including ESBL+). Gram-positive phenotypes were, methicillin resistant S. aureus and S. saprophyticus and vancomycin-resistant Enterococcus. Isolates were stratified by patient age (≥ 12 to < 18, ≥ 18 to < 55, ≥ 55 to < 65, ≥ 65 to < 75, ≥ 75 years). Chi-square tests were used to evaluate AMR difference between groups.

Results

In total, urine isolates were collected from 106 to 296 (2011–2019) US sites. Overall, the prevalence of antimicrobial NS increased with age for all E. coli phenotypes (all P< 0.001; Table 1), and for non-E. coli ENT (all P< 0.001), except NFT NS, which decreased from 70.6% to 59.7% (P=0.002; Table 2). The greatest difference between age groups in prevalence of resistance was observed for FQ NS E.coli: 5.8% (≥ 12 to < 18 years) vs 34.5% (≥ 75 years). For the multi-drug resistant E. coli phenotypes, resistance increased with age, ranging from 4.8–22.4% and 0.9–6.5% for ≥ 2 and ≥ 3 drug NS, respectively. Overall, the prevalence of resistance for Gram-positive phenotypes increased with age (all P< 0.001; Table 3).

Table 1. Prevalence of antimicrobial resistance among E. coli isolates in US females with outpatient UTI by age group.

Table 2. Prevalence of antimicrobial resistance among non-E. coli ENT isolates in US females with outpatient UTI by age group.

Table 3. Prevalence of antimicrobial resistance among Gram-positive isolates in US females with outpatient UTI by age group.

Conclusion

The prevalence of AMR in E. coli and non-E. coli ENT increased with age among US females presenting for care in the outpatient setting overall. A similar trend increase by age is also seen in Gram-positive isolates.

Disclosures

Vikas Gupta, PharmD, BCPS, Becton, Dickinson and Company (Employee, Shareholder)GlaxoSmithKline plc. (Other Financial or Material Support, Funding) Aruni Mulgirigama, MBBS, GlaxoSmithKline plc. (Employee, Shareholder) Ashish V. Joshi, PhD, GlaxoSmithKline plc. (Employee, Shareholder) Nicole Scangarella-Oman, MS, GlaxoSmithKline plc. (Employee, Shareholder) Kalvin Yu, MD, Becton, Dickinson and Company (Employee)GlaxoSmithKline plc. (Other Financial or Material Support, Funding) Gang Ye, PhD, Becton, Dickinson and Company (Employee)GlaxoSmithKline plc. (Other Financial or Material Support, Funding) Fanny S. Mitrani-Gold, MPH, GlaxoSmithKline plc. (Employee, Shareholder)

187. Regional Distribution of Antimicrobial Resistance Among Outpatient Urine e. Coli Isolates in US Females ≥12 Years of age: a Multicenter Evaluation in 2019

Background

The 2019 CDC Threats Report lists extended spectrum β-lactamase (ESBL) producing Enterobacterales as a serious health threat. While the clinical epidemiology of uncomplicated urinary tract infection (uUTI) has remained stable, there has been a notable increase in antimicrobial resistance (AMR) among community-acquired uUTIs. Urine cultures are seldom ordered for uUTI as treatment is often empiric; local surveillance data may therefore be lacking. The study objective was to determine the prevalence and geographic distribution of AMR in urine E. coli isolates from females in the US outpatient setting.

Methods

A retrospective cross-sectional study of E. coli ambulatory urine isolates identified from females (≥ 12 years of age) at 296 facilities, with ≥ 1 quarter of data in 2019 (BD Insights Research Database, Franklin Lakes, NJ). Initial isolates representing each distinct susceptibility pattern within 30 days of index urine were included. E. coli isolates were identified as not-susceptible (NS) if intermediate/resistant to trimethoprim-sulfamethoxazole (TMP-SMX), fluoroquinolone (FQ), nitrofurantoin (NFT), ESBL+ (by commercial panels or intermediate/resistant to ceftriaxone, cefotaxime, ceftazidime or cefepime), and multi-drug resistant, defined as NS to ≥ 2 or ≥ 3 of FQ, TMP-SMX, NFT or ESBL+. Logistic regression models were used to evaluate resistance prevalence and variation across US census regions.

Results

Of 267,524 non-duplicate E. coli isolates evaluated, 25.1% (67,189) were TMP-SMX NS, 20.3% (54,359) were FQ NS, 7.3% (19,576) were ESBL+, 3.5% (9,453) were NFT NS, 14.0% (37,328) were NS to ≥ 2 drugs and 4.0% (10,814) were NS to ≥ 3 drugs. For all phenotypes, there was significant variation in resistance across census regions (all P< 0.001) with the highest in the East South Central region and lowest in the New England region of the US (Table). The figure shows regional prevalence of ESBL+ E. coli in 2019.

Table. Antimicrobial resistance data from 30-day non-duplicate urine E. coli isolates in females ≥12 years old in 2019, by US census region.

Figure. Heat map of the overall US geographic distribution of ESBL+ E. coli (30-day non-duplicate urine isolates) from females across 296 acute care facilities in 2019.

Conclusion

The 2019 prevalence of AMR in non-duplicate ambulatory E. coli urine isolates was notable: TMP-SMX NS and FQ NS were > 20%. In addition, there were significant regional differences in resistance, with the highest in the East South Central region of the US, for all NS phenotypes. These analyses inform, and may optimize, empiric treatment of uUTI and patient outcomes.

Disclosures

Vikas Gupta, PharmD, BCPS, Becton, Dickinson and Company (Employee, Shareholder)GlaxoSmithKline plc. (Other Financial or Material Support, Funding) Aruni Mulgirigama, MBBS, GlaxoSmithKline plc. (Employee, Shareholder) Ashish V. Joshi, PhD, GlaxoSmithKline plc. (Employee, Shareholder) Nicole Scangarella-Oman, MS, GlaxoSmithKline plc. (Employee, Shareholder) Kalvin Yu, MD, Becton, Dickinson and Company (Employee)GlaxoSmithKline plc. (Other Financial or Material Support, Funding) Anthony Boyles, MSc, Becton, Dickinson and Company (Employee)GlaxoSmithKline plc. (Other Financial or Material Support, Funding) Fanny S. Mitrani-Gold, MPH, GlaxoSmithKline plc. (Employee, Shareholder)

1698. Trends in antimicrobial resistance among outpatient urine E. coli isolates in US females ≥12 years of age: A multicenter evaluation from 2011 to 2019

Background

E. coli is the predominant uropathogen isolated in uncomplicated urinary tract infections (UTI). Surveillance data suggest increasing antimicrobial resistance (AMR), although recent data from the outpatient setting are limited. Treatment is typically empiric and should be guided by local resistance rates; however, this is challenging in the absence of routine culture and assessment of regional AMR. We characterized AMR trends for E. coli isolated from females with outpatient UTI in the US, from 2011 to 2019.

Methods

A retrospective multicenter cohort study of antimicrobial susceptibility using data from the BD Insights Research Database (Franklin Lakes, NJ) was conducted. The first E. coli urine culture isolates representing each distinct susceptibility pattern within 30 days of index urine from 2011–2019 were included from females ≥ 12 years old. E. coli isolates were identified as not-susceptible (NS) if intermediate or resistant to trimethoprim-sulfamethoxazole (TMP-SMX NS), fluoroquinolone (FQ NS), nitrofurantoin (NFT NS), ESBL+ (by commercial panels or intermediate/resistant to ceftriaxone, cefotaxime, ceftazidime or cefepime), and multi-drug resistant (MDR), defined as NS to ≥ 2 or ≥ 3 of FQ, TMP-SMX, NFT or ESBL+. Descriptive analyses characterized AMR (%) over time and generalized estimating equations were used to statistically assess AMR trends over time.

Results

A total of 1,513,882 E. coli isolates were tested at 106 to 295 US centers between 2011 and 2019. Over the study period, AMR remained persistently high (> 20%) for FQ and TMP-SMX and increased for the MDR (≥ 3 drugs) phenotype (from 3.1% to 4.0%) (Table). Prevalence of the ESBL+ phenotype increased year-on-year (from 4.1% to 7.3%). Modeling confirmed a significant increasing trend for the ESBL+ (7.7%/year) and MDR (≥ 3 drugs) phenotypes (2.7%/year) (P< 0.001), with decreasing or no trend change for NFT NS and other AMR phenotypes (Table).

Table. Descriptive Statistics and Model-estimated Annual Change of AMR (count and % not-susceptible out of isolates tested) in E. coli among US Females (≥12 years of age) with Outpatient UTI

Conclusion

Characterization of AMR trends for E. coli over the last decade, in outpatient E. coli isolates in US females, shows persistently high AMR to FQ and TMP-SMX, and increasing AMR trends for the ESBL+ and MDR (≥ 3 drugs) phenotypes.

Disclosures

Vikas Gupta, PharmD, BCPS, Becton, Dickinson and Company (Employee, Shareholder)GlaxoSmithKline plc. (Other Financial or Material Support, Funding) Aruni Mulgirigama, MBBS, GlaxoSmithKline plc. (Employee, Shareholder) Ashish V. Joshi, PhD, GlaxoSmithKline plc. (Employee, Shareholder) Nicole Scangarella-Oman, MS, GlaxoSmithKline plc. (Employee, Shareholder) Kalvin Yu, MD, Becton, Dickinson and Company (Employee)GlaxoSmithKline plc. (Other Financial or Material Support, Funding) Gang Ye, PhD, Becton, Dickinson and Company (Employee)GlaxoSmithKline plc. (Other Financial or Material Support, Funding) Fanny S. Mitrani-Gold, MPH, GlaxoSmithKline plc. (Employee, Shareholder)

590. Vancomycin Infusion: Algorithmic Analysis of Unstructured Real-World Data Captured from Automated Infusion Devices

Background

Large scale research on antimicrobial usage in real-world populations traditionally does not consist of infusion data. With automation, detailed infusion events are captured in device systems, providing opportunities to harness them for patient safety studies. However, due to the unstructured nature of infusion data, the scale-up of data ingestion, cleansing, and processing is challenging.

Figure 1. Illustration of dosing complexity

Methods

We applied algorithmic techniques to quantitate and visualize vancomycin administration data captured in real-time by automated infusion devices from 3 acute care hospitals. The device data included timestamped infusion events – infusion started, paused, restarted, alarmed, and stopped. We used time density-based segmentation algorithms to depict infusion sessions as bursts of event activity. We examined clinical interpretability of the cluster-defined sessions in defining infusion events, dosing intensity, and duration.

Results

The algorithms identified 13,339 vancomycin infusion sessions from 2,417 unique patients (mean = 5.5 sessions per patient). Clustering captured vancomycin infusion sessions consistently with correct event labels in >98% of cases. It disentangled ambiguity associated with unexpected events (e.g. multiple stopped/started events within a single infusion session). Segmentation of vancomycin infusion events on an example patient timeline is illustrated in Figure 1. The median duration of infusion sessions was 1.55 (1^st, 3^rd quartiles: 1.14, 2.02) hours, demonstrating clinical plausibility.

Conclusion

Passively captured vancomycin administration data from automated infusion device systems provide ramifications for real-time bed-side patient care practice. With large volume of data, temporal event segmentation can be an efficient approach to generate clinically interpretable insights. This method scales up accuracy and consistency in handling longitudinal dosing data. It can enable real-time population surveillance and patient-specific clinical decision support for large patient populations. Better understanding of infusion data may also have implications for vancomycin pharmacokinetic dosing.

Disclosures

David L. Bostick, PhD, Becton, Dickinson and Co. (Employee) Kalvin Yu, MD, Becton, Dickinson and Company (Employee)GlaxoSmithKline plc. (Other Financial or Material Support, Funding) Cynthia Yamaga, PharmD, BD (Employee) Ann Liu-Ferrara, PhD, Becton, Dickinson and Co. (Employee) Didier Morel, PhD, Becton, Dickinson and Co. (Employee) Ying P. Tabak, PhD, Becton, Dickinson and Co. (Employee)

379. Epidemiology of Antimicrobial Use Among SARS-CoV-2 Positive and Negative Admissions in the US: A Multicenter Evaluation

Background

SARS-CoV-2, a novel coronavirus, emerged in Wuhan, China in December of 2019, and became a pandemic. Increases in bacterial/fungal co-infections have occurred during influenza pandemics and early data from this pandemic indicate high utilization of antimicrobial therapy. We compared the utilization of antimicrobials and health outcomes between SARS-CoV-2 positive and negative patients.

Methods

Patients hospitalized at 271 US acute care facilities from 3/1/20–5/30/20 with ≥1 day length of stay (LOS) and ≥24 hours of antimicrobial therapy tested for SARS-CoV-2 were included in the study (BD Insights Research Database [Becton, Dickinson & Company, Franklin Lakes, NJ]). Demographics, antimicrobial utilization, duration of antimicrobial therapy, hospital LOS and ICU LOS data were analyzed by SARS-CoV-2 test results.

Results

142,054 patients were tested for SARS CoV-2 and 12% (n=17,075) were SARS-CoV-2 positive. SARS-CoV-2 negative and positive patients did not differ regarding presence of a positive bacterial culture. Total LOS, % ICU admission, and ICU LOS were higher among SARS-CoV-2 positive patients (Table). In total 48% of admissions were prescribed antimicrobial therapy; rates were higher in SARS-CoV-2 positive versus negative admissions (68% vs. 46%). The most common antimicrobials and classes are in Table.

Antimicrobial therapy and outcomes in hospitalized SARS-CoV-2 tested patients.

Conclusion

Almost half of patients tested for SARS-CoV-2 were prescribed antimicrobials, with antimicrobial use higher among those with SARS-CoV-2, despite similar rates of positive cultures. On average, antimicrobials were prescribed within 10 hours from the time to admission among patients tested. These treatment patterns may highlight the difficulties in making treatment decisions and concerns over potential bacterial superinfection in SARS-CoV-2, but also indicate potential overuse of antimicrobials. Collateral damage from antimicrobial overuse include increase selection of antimicrobial resistance, adverse effects of drugs, and unnecessary treatment costs. It will be important to continue to evaluate the utilization and appropriateness of antimicrobial use among SARS-CoV-2 patients.

Disclosures

Laura A. Puzniak, PhD, Merck (Employee) Karri A. Bauer, PharmD, Merck Research Laboratories (Employee) Lyn Finelli, DrPH, MS, Merck & Co Inc, (Employee) Carisa De Anda, PharmD, Merck & Co Inc, (Employee) Pamela Moise, PharmD, Merck & Co., Inc. (Employee, Shareholder) Kalvin Yu, MD, Becton, Dickinson and Company (Employee)GlaxoSmithKline plc. (Other Financial or Material Support, Funding) Latha Vankeepuram, MS, BD (Employee) Prashant Parikh, n/a, Becton, Dickinson and Company (Employee) Vikas Gupta, PharmD, BCPS, Becton, Dickinson and Company (Employee, Shareholder)GlaxoSmithKline plc. (Other Financial or Material Support, Funding)