Intravenous Antimicrobial Starts among Hemodialysis Patients in the National Healthcare Safety Network Dialysis Component, 2016-2020

NHSN total IV antimicrobial start rates for patients on hemodialysis decreased from 2016 to 2020, but rates unsupported by NHSN surveillance documentation did not. There were 80% of reporting hemodialysis facilities that had ≥1 unsupported IV antimicrobial start, and the fraction of facilities with unsupported starts increased yearly. Accurate reporting and timely review of antimicrobial data is critical to understanding prescribing trends and practices in hemodialysis facilities.

Characteristics of patients associated with any outpatient antibiotic prescribing among Medicare Part D enrollees, 2007-2018

The 2007-2018 National Health Interview Survey data linked with Medicare claims were used to examine older adults' characteristics and assess their associations with receiving an antibiotic prescription. This analysis shows variation in antibiotic prescribing among adults enrolled in Medicare Part D by race and ethnicity, sex, geography, and health status.

1769. Characterizing Antibiotic Prescribing for Nursing Home Residents with SARS-CoV-2 Infection, April 2020-November 2021

Background

Increased prescribing of antibiotics commonly used for respiratory infections, including azithromycin, ceftriaxone, and doxycycline was observed in nursing homes (NH) during the COVID-19 pandemic however antibiotic prescribing was not linked to resident diagnosis. Therefore, our objective was to characterize antibiotic prescribing in residents with SARS-CoV-2 infection in a large cohort of US NHs.

Methods

We conducted a retrospective cohort study using PointClickCare (PCC) data containing longitudinal NH electronic health records. We included 4,891 NHs that reported ≥1 medication order/month from April 2020-November 2021. We identified the first onset of SARS-CoV-2 infection using ICD-10-CM diagnosis code U07.1. To validate the number of SARS-CoV-2 infections per facility captured in PCC, we compared the total number of SARS-CoV-2 infections documented in PCC to those reported to the National Healthcare Safety Network (NHSN). Antibiotic orders were determined to be associated with a SARS-CoV-2 infection if 3 days before or ≤7 days after diagnosis. We characterized the proportion of residents with a SARS-CoV-2 infection with an associated antibiotic by month.

Results

We included 2,086 (43%) NHs that had ≤20% difference in total number of SARS-CoV-2 infections documented in PCC and reported to NHSN. From April 2020-November 2021, a total of 118,180 residents with a SARS-CoV-2 infection were identified and 24% had an associated antibiotic prescription (N=27,972). The highest prescription rate (30%, 95% Confidence Interval [29%-31%]) was observed in April 2020 and varied by less than 8% from May 2020-November 2021 (Fig.1). The most commonly prescribed antibiotics were azithromycin (53%), doxycycline (13%) and ceftriaxone (10%).

Conclusion

An antibiotic prescription was linked to up to a quarter of NH residents with SARS-CoV-2 infection, highlighting potential opportunities for avoiding unnecessary antibiotic prescribing for viral infections in NHs. Appropriate antibiotic prescribing in NH populations is important to reduce potential harm when antibiotics offer no treatment benefit to the resident. Identifying facility-level characteristics that lead to variability in antibiotic prescribing is a next step to inform antibiotic stewardship interventions.

Disclosures

All Authors: No reported disclosures.

Identifying Higher-Volume Antibiotic Outpatient Prescribers Using Publicly Available Medicare Part D Data - United States, 2019

Antibiotic prescribing can lead to adverse drug events and antibiotic resistance, which pose ongoing urgent public health threats (1). Adults aged ≥65 years (older adults) are recipients of the highest rates of outpatient antibiotic prescribing and are at increased risk for antibiotic-related adverse events, including Clostridioides difficile and antibiotic-resistant infections and related deaths (1). Variation in antibiotic prescribing quality is primarily driven by prescribing patterns of individual health care providers, independent of patients' underlying comorbidities and diagnoses (2). Engaging higher-volume prescribers (the top 10% of prescribers by antibiotic volume) in antibiotic stewardship interventions, such as peer comparison audit and feedback in which health care providers receive data on their prescribing performance compared with that of other health care providers, has been effective in reducing antibiotic prescribing in outpatient settings and can be implemented on a large scale (3-5). This study analyzed data from the Centers for Medicare & Medicaid Services (CMS) Part D Prescriber Public Use Files (PUFs)* to describe higher-volume antibiotic prescribers in outpatient settings compared with lower-volume prescribers (the lower 90% of prescribers by antibiotic volume). Among the 59.4 million antibiotic prescriptions during 2019, 41% (24.4 million) were prescribed by the top 10% of prescribers (69,835). The antibiotic prescribing rate of these higher-volume prescribers (680 prescriptions per 1,000 beneficiaries) was 60% higher than that of lower-volume prescribers (426 prescriptions per 1,000 beneficiaries). Identifying health care providers responsible for a higher volume of antibiotic prescribing could provide a basis for additional assessment of appropriateness and outreach. Public health organizations and health care systems can use publicly available data to guide focused interventions to optimize antibiotic prescribing to limit the emergence of antibiotic resistance and improve patient outcomes.

88. Review of nursing home antibiotic stewardship citation deficiencies to identify opportunities to improve antibiotic stewardship implementation, 2018-2019

Background

Centers for Medicare & Medicaid Services (CMS) set standards for nursing homes (NH) and conduct inspections to assess adherence to regulatory requirements, including antibiotic stewardship implementation. NHs not meeting requirements are issued a citation. We reviewed text summaries for citations related to antibiotic stewardship to assess implementation in NHs.

Methods

We obtained publicly available antibiotic stewardship deficiency citations issued to NHs from 9/2018—7/2019 and NH characteristics data from CMS Nursing Home Compare. We used the χ2 test to compare characteristics of NHs with and without citations.

We did a qualitative review of a randomly selected subset (318/635) of antibiotic stewardship citations and classified citations into one or more of four categories based on Centers for Disease Control and Prevention’s Core Elements of Antibiotic Stewardship: 1) Leadership & Accountability, 2) Action, 3) Tracking & Reporting, 4) Education (Fig 1). We developed subcategories based on our iterative review process to further describe the citations. Each citation was reviewed by two reviewers and yielded 95% agreement in categorization. Discordant citations were reviewed by a third reviewer, and core element categories with agreement by ≥2/3 reviewers were assigned, resulting in 99% agreement.

Antibiotic Stewardship Citation Deficiency Category Common Themes and Examples from Citation Text from Qualitative Review of Antibiotic Stewardship Citation Deficiencies.

Results

There were 635 NH stewardship citation deficiencies across 44 states from 9/2018—7/2019. NHs with a citation were more likely to have < 100 beds (60% vs. 50%) and for-profit ownership (75% vs. 70%) (Table 1).

Of the 318 reviewed citations, Action was cited in 67% of NHs; 115/213 had missing or incomplete criteria documented for antibiotic initiation. Tracking & Reporting was cited in 40% of NHs; 117/126 had missing or incomplete antibiotic or infection tracking logs. Leadership & Accountability was cited in 23% of NHs; 41/72 NHs had no stewardship policy available. Education was cited in 13% of NHs (Fig 2).

Table 1. Characteristics of US Nursing Homes With and Without an Antibiotic Stewardship Citation Deficiency from 9/2018-7/2019.

Conclusion

The most common opportunities for improvement fell under appropriate assessment and documentation of criteria for antibiotic initiation at the resident and facility-level. Training NH staff to use available resources for antibiotic stewardship activities may improve implementation. Further evaluation to identify barriers to implementation is needed.

Disclosures

David Gifford, MD, MPH, American Healthcare Association (Employee)

COVID-19 Vaccine Uptake Among Residents and Staff Members of Assisted Living and Residential Care Communities-Pharmacy Partnership for Long-Term Care Program, December 2020-April 2021

OBJECTIVES

In December 2020, CDC launched the Pharmacy Partnership for Long-Term Care Program to facilitate COVID-19 vaccination of residents and staff in long-term care facilities (LTCFs), including assisted living (AL) and other residential care (RC) communities. We aimed to assess vaccine uptake in these communities and identify characteristics that might impact uptake.

DESIGN

Cross-sectional study.

SETTING AND PARTICIPANTS

AL/RC communities in the Pharmacy Partnership for Long-Term Care Program that had ≥1 on-site vaccination clinic during December 18, 2020-April 21, 2021.

METHODS

We estimated uptake using the cumulative number of doses of COVID-19 vaccine administered and normalizing by the number of AL/RC community beds. We estimated the percentage of residents vaccinated in 3 states using AL census counts. We linked community vaccine administration data with county-level social vulnerability index (SVI) measures to calculate median vaccine uptake by SVI tertile.

RESULTS

In AL communities, a median of 67 residents [interquartile range (IQR): 48-90] and 32 staff members (IQR: 15-60) per 100 beds received a first dose of COVID-19 vaccine at the first on-site clinic; in RC, a median of 8 residents (IQR: 5-10) and 5 staff members (IQR: 2-12) per 10 beds received a first dose. Among 3 states with available AL resident census data, median resident first-dose uptake at the first clinic was 93% (IQR: 85-108) in Connecticut, 85% in Georgia (IQR: 70-102), and 78% (IQR: 56-91) in Tennessee. Among both residents and staff, cumulative first-dose vaccine uptake increased with increasing social vulnerability related to housing type and transportation.

CONCLUSIONS AND IMPLICATIONS

COVID-19 vaccination of residents and staff in LTCFs is a public health priority. On-site clinics may help to increase vaccine uptake, particularly when transportation may be a barrier. Ensuring steady access to COVID-19 vaccine in LTCFs following the conclusion of the Pharmacy Partnership is critical to maintaining high vaccination coverage among residents and staff.

Trends in Prescribing of Antibiotics and Drugs Investigated for COVID-19 Treatment in U.S. Nursing Home Residents During the COVID-19 Pandemic

BACKGROUND

Trends in prescribing for nursing home (NH) residents, which may have been influenced by the COVID-19 pandemic, have not been characterized.

METHODS

Long-term care pharmacy data from 1,944 U.S. NHs were used to evaluate trends in prescribing of antibiotics and drugs that were investigated for COVID-19 treatment, including hydroxychloroquine, famotidine, and dexamethasone. To account for seasonal variability in antibiotic prescribing and decreased NH occupancy during the pandemic, monthly prevalence of residents with a prescription dispensed per 1,000 residents serviced was calculated from January - October and compared as relative percent change from 2019 to 2020.

RESULTS

In April 2020, prescribing was significantly higher in NHs for drugs investigated for COVID-19 treatment than 2019; including hydroxychloroquine (+563%, 95% confidence interval (CI) 5.87, 7.48) and azithromycin (+150%, 95% CI 2.37, 2.63). Ceftriaxone prescribing also increased (+43%, 95% CI 1.34, 1.54). Prescribing of dexamethasone was 36% lower in April (95% CI 0.55, 0.73) and 303% higher in July (95% CI 3.66, 4.45). Although azithromycin and ceftriaxone prescribing increased, total antibiotic prescribing among residents was lower from May (-5%, 95% CI 0.94, 0.97) through October (-4%, 95% CI 0.94, 0.97) in 2020 compared to 2019.

CONCLUSIONS

During the pandemic, large numbers of residents were prescribed drugs investigated for COVID-19 treatment, and an increase in prescribing of antibiotics commonly used for respiratory infections was observed. Prescribing of these drugs may increase the risk of adverse events, without providing clear benefits. Surveillance of NH prescribing practices is critical to evaluate concordance with guideline-recommended therapy and improve resident safety.

199. Evaluating long-term care pharmacy dispense data to monitor antibiotic use in U.S. nursing homes

Background

Automated reporting of antibiotic use (AU) in nursing homes (NHs) may help to identify opportunities to improve antibiotic prescribing practices and inform implementation of stewardship activities. The majority of U.S. NHs contract with long-term care (LTC) pharmacies to dispense prescriptions and provide medication monitoring and reviews. We investigated the feasibility of leveraging LTC pharmacy electronic dispensing data to describe AU in NHs.

Methods

We analyzed all NH antibiotic dispenses and monthly resident-days in 2017 reported by a large LTC pharmacy. The dispense-level data included facility and resident identifiers, antibiotic class and agent, dispense date and days of therapy (DOT) dispensed. We identified NH antibiotic courses, inclusive of both antibiotic starts and continuations from hospital-initiated courses, by collapsing dispenses of the same drug to the same resident if the subsequent dispense was within three days of the preceding end date. The course duration was the sum of DOT for all dispenses in the course. The AU rate was reported as DOT and courses per 1,000 resident-days.

Results

AU was described in 326,713 residents admitted to 1,348 NHs (9% of U.S. NHs), covering 38.1 million resident-days. There were 576,228 dispenses for a total of 3.3 million antibiotic DOT at a rate of 86 DOT/1,000 resident-days. After collapsing dispenses, 324,306 antibiotic courses were defined at a rate of 9 courses/1,000 resident-days. During the year, 45% of residents received an antibiotic. The most frequently prescribed classes by DOT and courses were cephalosporins, penicillins, urinary anti-infectives and quinolones (Fig. 1). The top agents by DOT were levofloxacin (12%), sulfamethoxazole/trimethoprim (12%) and cephalexin (11%). Most course durations were 1–7 days (54%) or 8–14 days (35%) (Fig. 2). Long-term antibiotic courses (> 30 days) contributed to 5% of courses and 30% of overall DOT. The mean duration per course was 7.5 days when courses > 30 days were excluded.

Figure 1. Distribution of antibiotic courses and days of therapy by antibiotic class for 324,306 antibiotic courses and 3.3 million days of antibiotic therapy dispensed to 1,348 nursing homes from a long-term care pharmacy in 2017

Figure 2. Distribution of antibiotic course duration and cumulative percent of total antibiotic days of therapy for 324,306 antibiotic courses dispensed to 1,348 nursing homes from a long-term care pharmacy in 2017

Conclusion

LTC pharmacy dispenses may be an accessible data source to report NH AU rates and prescribing patterns by antibiotic class and agent. Further evaluation of data sources for facility- and national-level AU reporting in NHs is needed to support stewardship implementation.

Disclosures

All Authors: No reported disclosures

178. Implementation of the Core Elements of Antibiotic Stewardship in Nursing Homes – National Healthcare Safety Network (NHSN), 2016–2018

Background

Since 2016, nursing homes (NHs) enrolled in the Centers for Disease Control and Prevention’s NHSN Long-term Care Facility (LTCF) Component have reported on their implementation of the core elements of antibiotic stewardship. In 2016, 42% of NHs reported implementing all seven core elements. Recent regulations require antibiotic stewardship programs in NHs. The objectives of this analysis were to track national progress in implementation of the core elements and evaluate how time dedicated to infection prevention and control (IPC) is associated with the implementation of the core elements.

Methods

We used the NHSN LTCF 2016–2018 Annual Surveys to assess NH characteristics and implementation of the core elements, defined as self-reported implementation of at least one corresponding stewardship activity. We reported absolute differences in percent implementation. We used log-binomial regression models to estimate the association between weekly IPC hours and the implementation of all seven core elements, while controlling for confounding by facility characteristics.

Results

We included 7,506 surveys from 2016–2018. In 2018, 71% of NHs reported implementation of all seven core elements, a 28% increase from 2016 (Fig. 1). The greatest increases in implementation from 2016–2018 were in Education (+19%), Reporting (+18%) and Drug Expertise (+15%) (Fig. 2). Ninety-eight percent of NHs had an individual responsible for antibiotic stewardship activities (Accountability), with 30% indicating that the role was fulfilled by an infection preventionist. Furthermore, 71% of NHs reported pharmacist involvement in improving antibiotic use, an increase of 27% since 2016. NHs that reported at least 20 hours of IPC activity per week were 14% more likely to implement all seven core elements, when controlling for facility ownership and affiliation, 95% CI: (1.07, 1.20).

Conclusion

NHs reported substantial progress in antibiotic stewardship implementation from 2016–2018. Improvements in accessing drug expertise, providing education and reporting antibiotic use may reflect increased stewardship awareness and use of resources among NH providers under new regulatory requirements. NHs with at least 20 hours dedicated to IPC per week may have greater capacity to implement all core elements.

Disclosures

All Authors: No reported disclosures

20. Fluoroquinolone and Overall Outpatient Antibiotic Prescribing Trends in Adults, 2011 to 2018

Background

Fluoroquinolones (FQs) are the third most commonly prescribed antibiotics among U.S. outpatients, and the second most commonly prescribed class among adults ≥ 65 years of age. However, FQ use has been associated with severe adverse events, especially among older adults. As a result, in 2016 the U.S. Food and Drug Administration (FDA) issued warnings against FQ use when other agents may be effective. We assessed changes in outpatient FQ prescribing relative to overall antibiotic prescribing from 2011 to 2018.

Methods

We estimated annual antibiotic prescription rates in adults ≥ 20 years of age for all classes and FQs using national prescription dispensing count data from IQVIA Xponent (numerator) and census estimates (denominator) for 2011 to 2018. We used Poisson models to estimate prevalence rate ratios (PRR) and 95% confidence intervals (CIs) comparing antibiotic prescription rates overall and stratified by age group from 2011 to 2018. The Chi-square test was used to compare the percent decrease in rates between age groups.

Results

From 2011 to 2018, prescription rates in adults for all antibiotics decreased by 2% (PRR 0.98, 95% CI: 0.98-0.98); FQ prescription rates decreased by 30% (PRR 0.70, 95% CI: 0.69–0.70), with the largest decline from 2015–2018 (Figure 1). Adults ≥ 65 years had the highest FQ prescription rates for 2011 to 2018, at a rate 2.37 (95% CI: 2.32,2.42) times that of adults 20–64 years (Figure 2). The FQ prescribing rate in adults 20–64 experienced a greater decrease from 2011 to 2018 than the rate in adults ≥ 65 years (p< 0.0001), with a 35% decrease (PRR 0.65, 95% CI: 0.65, 0.65) in adults 20–64 years compared to a 29% (PRR 0.71, 95% CI: 0.71-0.71) decrease in adults ≥ 65 years (Figure 2).

Decreases in total outpatient antibiotic and fluoroquinolone prescribing rates among adults in the United States from 2011 to 2018

Decreases in outpatient fluoroquinolone prescriptions per 1,000 persons by age group in the United States from 2011 to 2018

Conclusion

FQ prescribing decreased markedly compared to overall antibiotic prescribing from 2011 to 2018, which was likely due in part to FDA warnings on FQ-associated adverse events. However, FQ prescribing among older adults remained high during this period and did not decrease as much as in younger adults. Further evaluation of the diagnoses associated with prescribing may provide additional opportunities to optimize FQ prescribing practices, especially among older adults.

Disclosures

All Authors: No reported disclosures

Characterization of COVID-19 in Assisted Living Facilities - 39 States, October 2020

The coronavirus disease 2019 (COVID-19) pandemic has highlighted the vulnerability of residents and staff members in long-term care facilities (LTCFs) (1). Although skilled nursing facilities (SNFs) certified by the Centers for Medicare & Medicaid Services (CMS) have federal COVID-19 reporting requirements, national surveillance data are less readily available for other types of LTCFs, such as assisted living facilities (ALFs) and those providing similar residential care. However, many state and territorial health departments publicly report COVID-19 surveillance data across various types of LTCFs. These data were systematically retrieved from health department websites to characterize COVID-19 cases and deaths in ALF residents and staff members. Limited ALF COVID-19 data were available for 39 states, although reporting varied. By October 15, 2020, among 28,623 ALFs, 6,440 (22%) had at least one COVID-19 case among residents or staff members. Among the states with available data, the proportion of COVID-19 cases that were fatal was 21.2% for ALF residents, 0.3% for ALF staff members, and 2.5% overall for the general population of these states. To prevent the introduction and spread of SARS-CoV-2, the virus that causes COVID-19, in their facilities, ALFs should 1) identify a point of contact at the local health department; 2) educate residents, families, and staff members about COVID-19; 3) have a plan for visitor and staff member restrictions; 4) encourage social (physical) distancing and the use of masks, as appropriate; 5) implement recommended infection prevention and control practices and provide access to supplies; 6) rapidly identify and properly respond to suspected or confirmed COVID-19 cases in residents and staff members; and 7) conduct surveillance of COVID-19 cases and deaths, facility staffing, and supply information (2).

Cardiac-specific YAP activation improves cardiac function and survival in an experimental murine MI model

RATIONALE

Yes-associated protein (YAP), the terminal effector of the Hippo signaling pathway, is crucial for regulating embryonic cardiomyocyte proliferation.

OBJECTIVE

We hypothesized that YAP activation after myocardial infarction (MI) would preserve cardiac function and improve survival.

METHODS AND RESULTS

We used a cardiac-specific, inducible expression system to activate YAP in adult mouse heart. Activation of YAP in adult heart promoted cardiomyocyte proliferation and did not deleteriously affect heart function. Furthermore, YAP activation after MI preserved heart function and reduced infarct size. Using adeno-associated virus subtype 9 (AAV9) as a delivery vector, we expressed human YAP (hYAP) in the adult murine myocardium immediately after MI. We found that AAV9:hYAP significantly improved cardiac function and mouse survival. AAV9:hYAP did not exert its salutary effects by reducing cardiomyocyte apoptosis. Rather, AAV9:hYAP stimulated adult cardiomyocyte proliferation. Gene expression profiling indicated that AAV9:hYAP stimulated expression of cell cycle genes and promoted a less mature cardiac gene expression signature.

CONCLUSIONS

Cardiac-specific YAP activation after MI mitigated myocardial injury, improved cardiac function, and enhanced survival. These findings suggest that therapeutic activation of YAP or its downstream targets, potentially through AAV-mediated gene therapy, may be a strategy to improve outcome after MI.