Developing the Common Marmoset as a Translational Geroscience Model to Study the Microbiome and Healthy Aging

Emerging data support associations between the depletion of the healthy gut microbiome and aging-related physiological decline and disease. In humans, fecal microbiota transplantation (FMT) has been used successfully to restore gut microbiome structure and function and to treat C. difficile infections, but its application to healthy aging has been scarcely investigated. The marmoset is an excellent model for evaluating microbiome-mediated changes with age and interventional treatments due to their relatively shorter lifespan and many social, behavioral, and physiological functions that mimic human aging. Prior work indicates that FMT is safe in marmosets and may successfully mediate gut microbiome function and host health. This narrative review (1) provides an overview of the rationale for FMT to support healthy aging using the marmoset as a translational geroscience model, (2) summarizes the prior use of FMT in marmosets, (3) outlines a protocol synthesized from prior literature for studying FMT in aging marmosets, and (4) describes limitations, knowledge gaps, and future research needs in this field.

Changes in oral health during aging in a novel non-human primate model

Oral health plays a significant role in the quality of life and overall well-being of the aging population. However, age-related changes in oral health are not well understood due to challenges with current animal models. In this study, we analyzed the oral health and microbiota of a short-lived non-human primate (i.e., marmoset), as a step towards establishing a surrogate for studying the changes that occur in oral health during human aging. We investigated the oral health of marmosets using cadaveric tissues in three different cohorts: young (aged ≤6 years), middle-aged, and older (>10 years) and assessed the gingival bacterial community using analyses of the V3-V4 variable region of 16S rRNA gene. The oldest cohort had a significantly higher number of dental caries, increased dental attrition/erosion, and deeper periodontal pocket depth scores. Oral microbiome analyses showed that older marmosets had a significantly greater abundance of Escherichia-Shigella and Propionibacterium, and a lower abundance of Agrobacterium/Rhizobium at the genus level. Alpha diversity of the microbiome between the three groups showed no significant differences; however, principal coordinate analysis and non-metric multidimensional scaling analysis revealed that samples from middle-aged and older marmosets were more closely clustered than the youngest cohort. In addition, linear discriminant analysis effect size (LEFSe) identified a higher abundance of Esherichia-Shigella as a potential pathogenic biomarker in older animals. Our findings confirm that changes in the oral microbiome are associated with a decline in oral health in aging marmosets. The current study suggests that the marmoset model recapitulates some of the changes in oral health associated with human aging and may provide opportunities for developing new preventive strategies or interventions which target these disease conditions.

Association of Gabapentinoids With Opioid-Related Overdose in the Inpatient Setting: A Single Center Retrospective Case-Control Study

Objectives: Recent data suggest concomitant gabapentinoid use increases opioid-related overdose (ORO) risk; however, this association has not been well studied in the hospital setting. The primary objective of this study was to compare ORO risk, indicated by naloxone administration, in patients receiving opioids plus gabapentinoids versus opioids alone. Methods: In this retrospective case-control study of adults admitted to a large community hospital from 1/1/20 to 12/31/21, all cases (defined as patients who received naloxone more than 24 hours after admission) identified were matched 1:1 to randomly selected controls (defined as patients on opioids who did not receive naloxone). The primary outcome was the percentage of cases and controls with concomitant inpatient gabapentinoid use. Logistic regression was performed to determine the independent association between gabapentinoids and ORO (as evidenced by inpatient naloxone administration). Results: Baseline characteristics were similar between the 144 cases and 144 controls. Gabapentinoid exposure was greater for cases than controls (34.0%vs 20.8%, P = .0118). Median hospital length of stay (11vs 4 days, P < .0001) and mortality (19%vs 5%; P = .0018) were also higher for cases. In logistic regression analysis, ORO (adjusted OR 4.91; 95% CI 1.86-12.96) and serotonergic medication exposure (adjusted OR 4.31; 95% CI 1.50-12.38) were significantly associated with gabapentinoid use. Conclusions: Concomitant gabapentinoid use with opioids was associated with increased ORO risk in the inpatient setting. When considering prescribing gabapentinoids in conjunction with opioids in the hospital setting, potential benefits should be weighed against increased overdose risk.

Diverse Role of blaCTX-M and Porins in Mediating Ertapenem Resistance among Carbapenem-Resistant Enterobacterales

Among carbapenem-resistant Enterobacterales (CRE) are diverse mechanisms, including those that are resistant to meropenem but susceptible to ertapenem, adding further complexity to the clinical landscape. This study investigates the emergence of ertapenem-resistant, meropenem-susceptible (ErMs) Escherichia coli and Klebsiella pneumoniae CRE across five hospitals in San Antonio, Texas, USA, from 2012 to 2018. The majority of the CRE isolates were non-carbapenemase producers (NCP; 54%; 41/76); 56% of all NCP isolates had an ErMs phenotype. Among ErMs strains, E. coli comprised the majority (72%). ErMs strains carrying blaCTX-M had, on average, 9-fold higher copies of blaCTX-M than CP-ErMs strains as well as approximately 4-fold more copies than blaCTX-M-positive but ertapenem- and meropenem-susceptible (EsMs) strains (3.7 vs. 0.9, p < 0.001). Notably, carbapenem hydrolysis was observed to be mediated by strains harboring blaCTX-M with and without a carbapenemase(s). ErMs also carried more mobile genetic elements, particularly IS26 composite transposons, than EsMs (37 vs. 0.2, p < 0.0001). MGE- ISVsa5 was uniquely more abundant in ErMs than either EsMs or ErMr strains, with over 30 more average ISVsa5 counts than both phenotype groups (p < 0.0001). Immunoblot analysis demonstrated the absence of OmpC expression in NCP-ErMs E. coli, with 92% of strains lacking full contig coverage of ompC. Overall, our findings characterize both collaborative and independent efforts between blaCTX-M and OmpC in ErMs strains, indicating the need to reappraise the term "non-carbapenemase (NCP)", particularly for strains highly expressing blaCTX-M. To improve outcomes for CRE-infected patients, future efforts should focus on mechanisms underlying the emerging ErMs subphenotype of CRE strains to develop technologies for its rapid detection and provide targeted therapeutic strategies.

Infectious Inequity: How the Gut Microbiome and Social Determinants of Health May Contribute to Clostridioides difficile Infection Among Racial and Ethnic Minorities

Infectious diseases are a leading contributor to death in the United States, and racial differences in clinical outcomes have been increasingly reported. Clostridioides difficile infection (CDI) is a growing public health concern, as it causes nearly half a million infections per year and considerable excess hospital costs. Concurrent with other infectious diseases, recent literature denotes racial disparities in CDI incidence rates, mortality, and associated morbidity. Of note, investigations into CDI and causative factors suggest that inequities in health-related social needs and other social determinants of health (SDoH) may cause disruption to the gut microbiome, thereby contributing to the observed deleterious outcomes in racially and ethnically minoritized individuals. Despite these discoveries, there is limited literature that provides context for the recognized racial disparities in CDI, particularly the influence of structural and systemic barriers. Here, we synthesize the available literature describing racial inequities in CDI outcomes and discuss the interrelationship of SDoH on microbiome dysregulation. Finally, we provide actionable considerations for infectious diseases professionals to aid in narrowing CDI equity gaps.

Comparison of Droperidol and Midazolam Versus Haloperidol and Lorazepam for Acute Agitation Management in the Emergency Department

BACKGROUND

Acute agitation accounts for up to 2.6% of visits to the emergency department (ED). To date, a standard of care for the management of acute agitation has not been established. Few studies have evaluated antipsychotic and benzodiazepine combinations.

OBJECTIVE

The purpose of this study was to evaluate effectiveness and safety of combination therapy for acute agitation with intramuscular (IM) droperidol and midazolam (D+M) compared with IM haloperidol and lorazepam (H+L) in patients in the ED.

METHODS

This was a single-center, retrospective medical record review of patients presenting to a large, academic ED with acute agitation from July 2020 through October 2021. The primary outcome was percentage of patients requiring additional agitation medication within 60 minutes of combination administration. Secondary outcomes included average time to repeat dose administration and average number of repeat doses required before ED discharge.

RESULTS

A total of 306 patients were included for analysis: 102 in the D+M group and 204 in the H+L group. Repeat dose within 60 minutes occurred in 7 (6.9%) and 28 (13.8%) patients in the D+M and H+L groups, respectively (P = 0.065). A total of 28.4% of D+M patients and 30.9% of H+L patients required any repeat dose during their ED visit. Time to repeat dose was 12 and 24 minutes in the D+M and H+L, respectively (P = 0.22). The adverse event rate was 2.9% in each group.

CONCLUSION AND RELEVANCE

IM D+M resulted in a lower rate of repeat doses of acute agitation medication compared with IM H+L, though this was not statistically significant. Both therapies were safe, and the adverse event rate was low.

Comparative Effectiveness Randomized Clinical Trial Using Next-generation Microbial Sequencing to Direct Prophylactic Antibiotic Choice Before Urologic Stone Lithotripsy Using an Interprofessional Model

Background

Next-generation sequencing (NGS) methods for microbial profiling have increased sensitivity to detect urinary pathogens.

Objective

To determine whether NGS microbial profiling can be used to guide antibiotic prophylaxis and reduce infection compared with the standard of care.

Design setting and participants

A prospective randomized controlled clinical trial of patients undergoing urologic stone interventions at an academic health center from December 2019 to January 2022 was conducted. Urine was collected at the preoperative visit for standard culture and intervention NGS diagnostics. Evaluable patients were culture negative, met 2-wk follow-up, and did not cancel surgery. Of 240 individuals (control = 121, intervention = 119), 83 control and 74 intervention patients were evaluable.

Intervention

Microbial findings (paired quantitative polymerase chain reaction and NGS) were sent to an infectious disease pharmacist to recommend prophylactic antimicrobial regimen.

Outcome measurements and statistical analysis

The primary outcome was postoperative urinary infection within the follow-up period (Fisher's exact test). The primary outcome was analyzed by modified intent-to-treat (mITT) and per-protocol analyses. Secondary endpoints considered included positive culture concordance, antibiotic use, and adverse events. Additional post hoc analyses investigated factors contributing to infection (univariate logistic regression).

Results and limitations

The intervention significantly reduced postsurgical urinary infection risk by 7.1% (-0.73%, 15%) compared with the standard of care in the mITT analysis (1.4% vs 8.4%, p = 0.045) or by 8.5% (0.88%, 16%) compared with the per-protocol analysis (0% vs 8.5%, p = 0.032). NGS-guided treatment altered the distribution of antibiotics used (p = 0.025), and antibiotics poorly matched with NGS findings were associated with increased infection odds (odds ratio [OR] = 5.9, p = 0.046). Women were at greater odds to develop infection (OR = 10, p = 0.03) and possessed differentiated microbial profiles (p < 0.001).

Conclusions

Urinary microbial NGS-guided antibiotic prophylaxis before endoscopic urologic stone lithotripsy improves antibiotic selection to reduce healthcare-associated urinary infections; however, treatment efficacy may be limited by the ability to adhere to the recommended protocol.

Patient summary

We investigated whether microbial DNA sequencing could improve the selection of antibiotics before kidney stone surgery in patients not known to have any bacteria in the urine on standard culture. We found that using microbe DNA to guide antibiotic choices decreased postoperative infection rate and may encourage individualized use of available antibiotics.

A Survey of Vaping Use, Perceptions, and Access in Adolescents from South-Central Texas Schools

Despite efforts to dissuade major manufacturers and retailers from marketing and selling vape products to adolescents, the practice of vaping continues to increase in this population. Few studies have assessed adolescent perceptions of vaping, access to vaping, and use of vaping, and most rely, at least in part, on inferential conclusions drawn from data on smoking traditional combustible cigarettes. A novel electronic survey was created to assess the use of vapes, perceptions of vaping, and access to vaping among a convenience sample of adolescents (ages 12-20 years) in eleven schools in South-Central Texas from May to August 2021. The students' perceived threat of negative health outcomes due to vaping was calculated based on questions soliciting perceptions of severity (perceived danger) and susceptibility (perceived likelihood of illness). Trends were identified using descriptive and bivariate statistical tests. A total of 267 respondents were included; 26% had tried vaping. A majority (63%) did not believe vaping and smoking were synonymous. Most (70%) thought it was easy to obtain supplies and (76%) vape before and after (88%) or even during (64%) school. Respondents who vaped had a 34% lower perceived threat when compared to respondents who did not vape. In this sample of adolescents from South-Central Texas, one in four reported that they had tried vaping. Easy access to vapes and misperceptions regarding the safety of vaping might create a false sense of security with respect to vaping as an alternative to smoking, particularly among those who reported vaping, and is likely contributing to the increased use of vapes.

Durvalumab Treatment Patterns for Patients with Unresectable Stage III Non-Small Cell Lung Cancer in the Veterans Health Administration (VHA): A Nationwide, Real-World Study

BACKGROUND

Durvalumab is approved for the treatment of adults with unresectable stage III non-small cell lung cancer (NSCLC) post-chemoradiotherapy (CRT). This real-world study describes patient characteristics and durvalumab treatment patterns (number of doses and therapy duration; treatment initiation delays, interruptions, discontinuations, and associated reasons) among VHA-treated patients.

METHODS

This was a retrospective cohort study of adults with unresectable stage III NSCLC receiving durvalumab at the VHA between 1 January 2017 and 30 June 2020. Patient characteristics and treatment patterns were presented descriptively.

RESULTS

A total of 935 patients were included (median age: 69 years; 95% males; 21% Blacks; 46% current smokers; 16% ECOG performance scores ≥ 2; 50% squamous histology). Durvalumab initiation was delayed in 39% of patients (n = 367). Among the 200 patients with recorded reasons, delays were mainly due to physician preference (20%) and CRT toxicity (11%). Overall, patients received a median (interquartile range) of 16 (7-24) doses of durvalumab over 9.0 (2.9-11.8) months. Treatment interruptions were experienced by 19% of patients (n = 180), with toxicity (7.8%) and social reasons (2.6%) being the most cited reasons. Early discontinuation occurred in 59% of patients (n = 551), largely due to disease progression (24.2%) and toxicity (18.2%).

CONCLUSIONS

These real-world analyses corroborate PACIFIC study results in terms of the main reasons for treatment discontinuation in a VHA population with worse prognostic factors, including older age, predominantly male sex, and poorer performance score. One of the main reasons for durvalumab initiation delays, treatment interruptions, or discontinuations was due to toxicities. Patients could benefit from improved strategies to prevent, identify, and manage CRT and durvalumab toxicities timely and effectively.

Health Equity in Patients Receiving Durvalumab for Unresectable Stage III Non-Small Cell Lung Cancer in the US Veterans Health Administration

BACKGROUND

Real-world evidence is limited regarding the relationship between race and use of durvalumab, an immunotherapy approved for use in adults with unresectable stage III non-small cell lung cancer (NSCLC) post-chemoradiotherapy (CRT). This study aimed to evaluate if durvalumab treatment patterns differed by race in patients with unresectable stage III NSCLC in a Veterans Health Administration (VHA) population.

MATERIALS AND METHODS

This was a retrospective analysis of White and Black adults with unresectable stage III NSCLC treated with durvalumab presenting to any VHA facility in the US from January 1, 2017, to June 30, 2020. Data captured included baseline characteristics and durvalumab treatment patterns, including treatment initiation delay (TID), interruption (TI), and discontinuation (TD); defined as CRT completion to durvalumab initiation greater than 42 days, greater than 28 days between durvalumab infusions, and more than 28 days from the last durvalumab dose with no new durvalumab restarts, respectively. The number of doses, duration of therapy, and adverse events were also collected.

RESULTS

A total of 924 patients were included in this study (White = 726; Black = 198). Race was not a significant factor in a multivariate logistic regression model for TID (OR, 1.39; 95% CI, 0.81-2.37), TI (OR, 1.58; 95% CI, 0.90-2.76), or TD (OR, 0.84; 95% CI, 0.50-1.38). There were also no significant differences in median (interquartile range [IQR]) number of doses (White: 15 [7-24], Black: 18 [7-25]; P = .25) or median (IQR) duration of therapy (White: 8.7 months [2.9-11.8], Black: 9.8 months [3.6-12.0]; P = .08), although Black patients were less likely to experience an immune-related adverse event (28% vs. 36%, P = .03) and less likely to experience pneumonitis (7% vs. 14%, P < .01).

CONCLUSION

Race was not found to be linked with TID, TI, or TD in this real-world study of patients with unresectable stage III NSCLC treated with durvalumab at the VHA.

Population based cohort to examine association between geospatial antibiotic factors and urinary tract infection outcomes

INTRODUCTION

Urinary tract infections (UTIs) pose a significant health care burden. Outpatient antibiotic geospatial factors (eg, geographic prescribing and geographic resistance) may be associated with inpatient outcomes. This study examined the relationship between these factors, severe UTI, and hospitalization for severe UTI.

METHODS

The first cohort included hospitalized, female, Medicare beneficiaries, aged >50 years. The primary outcome was severe UTI (defined as CSS diagnosis code of 159 with an APR-DRG severity of illness code of 3 or 4). The association between geospatial first-line prescribing (FLP) and severe UTI was assessed. The second cohort examined the association between these geospatial FLP and risk of hospitalization with severe UTI. Multivariable regression was used to produce adjusted odds ratios and adjusted risk ratios.

RESULTS

In the first cohort (n = 14,474), low FLP was not associated with severe UTI (P = .87) in univariable analysis. In multivariable analysis, low FLP was associated with severe UTI was (aOR: 1.08 [95% CI 1.00, 1.16]). In the second cohort (n = 2,972,174), the admission rate was 47.0 and 49.8 per 10,000 (low FLP vs high FLP, respectively [P < .001]). The aRR for admission was 1.26 (95% CI 1.14, 1.39) in areas with low FLP.

CONCLUSIONS

This study suggests that geospatial antibiotic factors may influence inpatient outcomes in women aged >50 with UTI. Further research is needed to corroborate our findings.

Economic Impact of Recurrent Clostridioides difficile Infection in the USA: A Systematic Literature Review and Cost Synthesis

INTRODUCTION

Up to 35% of patients with a first episode of Clostridioides difficile infection (CDI) develop recurrent CDI (rCDI), and of those, up to 65% experience multiple recurrences. A systematic literature review (SLR) was conducted to review and summarize the economic impact of rCDI in the United States of America.

METHODS

English-language publications reporting real-world healthcare resource utilization (HRU) and/or direct medical costs associated with rCDI in the USA were searched in MEDLINE, MEDLINE In-Process, Embase, and the Cochrane Library databases over the past 10 years (2012-2022), as well as in selected scientific conferences that publish research on rCDI and its economic burden over the past 3 years (2019-2022). HRU and costs identified through the SLR were synthesized to estimate annual rCDI-attributable direct medical costs to inform the economic impact of rCDI from a US third-party payer's perspective.

RESULTS

A total of 661 publications were retrieved, and 31 of them met all selection criteria. Substantial variability was found across these publications in terms of data source, patient population, sample size, definition of rCDI, follow-up period, outcomes reported, analytic approach, and methods to adjudicate rCDI-attributable costs. Only one study reported rCDI-attributable costs over 12 months. Synthesizing across the relevant publications using a component-based cost approach, the per-patient per-year rCDI-attributable direct medical cost was estimated to range from $67,837 to $82,268.

CONCLUSIONS

While real-world studies on economic impact of rCDI in the USA suggested a high-cost burden, inconsistency in methodologies and results reporting warranted a component-based cost synthesis approach to estimate the annual medical cost burden of rCDI. Utilizing available literature, we estimated the average annual rCDI-attributable medical costs to allow for consistent economic assessments of rCDI and identify the budget impact on US payers.

Controversies in the Prevention and Treatment of Clostridioides difficile Infection in Adults: A Narrative Review

Clostridioides difficile remains a problematic pathogen resulting in significant morbidity and mortality, especially for high-risk groups that include immunocompromised patients. Both the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America (IDSA/SHEA), as well as the American College of Gastroenterology (ACG) and the European Society of Clinical Microbiology and Infectious Diseases (ESCMID) recently provided guideline updates for C. difficile infection (CDI). In this narrative review, the authors reviewed available literature regarding the prevention or treatment of CDI in adults and focused on disagreements between the IDSA/SHEA and ACG guidelines, as well as articles that have been published since the updates. Several options for primary prophylaxis are available, including probiotics and antibiotics (vancomycin, fidaxomicin). The literature supporting fidaxomicin is currently quite limited. While there are more studies evaluating probiotics and vancomycin, the optimal patient populations and regimens for their use have yet to be defined. While the IDSA/SHEA guidelines discourage metronidazole use for mild CDI episodes, evidence exists that it may remain a reasonable option for these patients. Fidaxomicin has an advantage over vancomycin in reducing recurrences, but its use is limited by cost. Despite this, recent studies suggest fidaxomicin's cost-effectiveness as a first-line therapy, though this is highly dependent on institutional contracts and payment structures. Secondary prophylaxis should focus on non-antimicrobial options to lessen the impact on the microbiome. The oral option of fecal microbiota transplantation (FMT), SER109, and the now FDA-approved RBX2660 represent exciting new options to correct dysbiosis. Bezlotoxumab is another attractive option to prevent recurrences. Further head-to-head studies of newer agents will be needed to guide selection of the optimal therapies for CDI primary and secondary prophylaxis.

264. COVID-19 Associated Pulmonary Aspergillosis in Intensive Care Patients Based on Duration of Corticosteroid Administration

Background

Coronavirus disease 2019 (COVID-19) associated pulmonary aspergillosis (CAPA) has emerged as a complication in critically ill COVID-19 patients. Corticosteroids are standard of care for COVID-19 patients. Prolonged corticosteroids have been associated with an increased risk of CAPA, but duration of use associated with this risk remains unknown. The objective of this study was to evaluate if the duration of corticosteroid therapy ≤ 10 days vs > 10 days affects the risk of developing CAPA.

Methods

This single-center, retrospective, cohort study included patients ≥ 18 years old admitted to University Hospital between March 2020 and December 2021, diagnosed with severe COVID-19 pneumonia requiring mechanical ventilation, and who received at least 3 days of corticosteroid treatment. CAPA was defined according to 2020 European Confederation of Medical Mycology and the International Society for Human and Animal Mycology consensus guideline. Baseline characteristics, CAPA, and secondary outcomes were compared using appropriate bivariable analyses. Steroid duration was evaluated as an independent predictor of CAPA in a logistic regression model.

Results

Final analysis included 278 patients (n=169 ≤ 10 days steroid duration; n=109 > 10 day steroid duration). Baseline characteristics were similar between groups, with the exception of acute kidney injury and solid organ transplantation. Median duration of steroids was 6 days in the ≤ 10 day group vs 18 days in the > 10 day group. In total, 20/278 (7.2%) patients developed CAPA. Patients treated with > 10 days of corticosteroid therapy had significantly higher incidence of CAPA (12% vs 4.1%; p = 0.0156) and duration was independently associated with CAPA (OR 3.25, 95% CI 1.03-10.24). Secondary outcomes including inpatient mortality (43.2% vs 77.1%; p < 0.0001), mechanical ventilation free days at 28 (1.5 vs 0; p < 0.0001) and secondary infections (28.4% vs 44.9% p = 0.0220) were all significantly worse for > 10 day corticosteroid cohort.

Conclusion

Duration of corticosteroid treatment > 10 days in critically ill patients is associated with an increased risk of CAPA. Though patients may require corticosteroids for non-COVID-19 indications, clinicians should attempt to limit prolonged courses of corticosteroids in COVID-19 patients.

Disclosures

All Authors: No reported disclosures.

2014. Central Line - Associated Bloodstream Infections and Their Increase With the COVID-19 Pandemic at Veterans Affairs in San Antonio, Texas

Background

Coronavirus disease-19 (COVID-19) has been associated with an increase in healthcare-associated infections (HAI). This increase is likely multifactorial (i.e. higher hospitalization rates, COVID-19 and post-COVID-19 complications, lower staffing, delayed care among others). The objective of this study was to determine the association between COVID-19 hospitalization rates and central line- associated blood stream infections (CLABSI).

Methods

We conducted a retrospective study in acute care unit hospitalizations in a Veterans Affairs (VA) hospital in San Antonio, Texas from October 2017 to December 2021. Individuals over 18 years of age admitted with a new diagnosis of COVID-19, determined by the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) polymerase chain reaction (PCR) were included in the study. CLABSIs were defined by the National Healthcare Safety Network (NHSN) criteria for laboratory confirmed bloodstream infections. Pearson correlation was used to determine correlation of CLABSI and COVID-19 disease hospitalization rates. CLABSI rates were also compared pre-COVID-19 (Oct 2017-Feb 2020) to COVID-19 (Mar 2020-Dec 2021) periods using the chi-square test.

Results

During the study period, a total of 0.69 CLABSIs per 1,000 central line days occurred in the pre-COVID-19 period compared to 1.98 per 1,000 in the COVID-19 period (p=0.004). There was a significant correlation between CLABSI and ICU COVID-19 hospitalization rates (R=0.459; p=0.001) as well as CLABSI and acute care COVID-19 hospitalization rates (R=0.341; p=0.014). During the COVID-19 period only, there continued to be a significant correlation between CLABSI and COVID-19 ICU hospitalization rates (R=0.426; p=0.048).

Conclusion

CLABSI rates significantly increased during the COVID-19 period compared to the pre-COVID-19 period and CLABSI rates were significantly correlated with COVID-19 ICU and acute care hospitalizations. Accounting for this variable allows us to factor in impact of post-COVID-19 related complications and association with CLABSI rate. We urge for careful implementation of HAI prevention strategies during the pandemic. Awareness of anticipated increase is important in allocating resources essential for prevention of HAIs.

Disclosures

All Authors: No reported disclosures.

911. Impact of Intensified Clindamycin Stewardship Initiatives in Three Phases: A Quasi-Experimental Study

Background

Clindamycin utilization has provoked gram-positive and anaerobic bacterial resistance and is associated with Clostridioides difficile infections (CDI). The purpose of this study was to evaluate if implementing local clindamycin-focused stewardship initiatives impacts clindamycin utilization and outcome metrics.

Methods

This multicenter, retrospective quasi-experimental study was conducted in adult hospitalized patients who received clindamycin from 2018 to 2020. Outcomes were compared in three phases between an intervention and control group (Figure 1). The primary outcome was inappropriate utilization: a resistant pathogen, concurrent antibiotic(s) with pathogen activity, a non-necrotizing infection, an alternative agent was preferred, or alternative reasons per expert discretion. Secondary outcomes included clindamycin duration of therapy per 1000 patient hospital days (DOT/1000 PD), 30-day CDI, 30-day readmission, and in-hospital mortality. Outcomes were compared between groups using the chi-square, Fisher’s exact, or Kruskal-Wallis tests as appropriate. Figure 1.

2045. IVAC Plus in the Time of COVID-19: An Imperfect Metric?

Background

Prior to the COVID-19 pandemic, the incidence of infection related ventilator associated complications plus possible ventilator associated pneumonias (IVAC+) was decreasing; however, as the number of COVID-19 hospitalizations increased, so did the number of IVAC+. Our goal was to investigate if there was a relationship between these two occurrences.

Methods

This was a retrospective study at the Audie Murphy VA Hospital (ALMVA) from October 2017 to December 2021. ALMVA is a level 1A facility with 232 beds and an active bone marrow transplant program in San Antonio, Texas. This study included acute care COVID-19 hospitalizations per 10,000 bed days of care and IVAC+ per 1000 ventilator days. Monthly acute and intensive care COVID-19 hospitalization rates were correlated with IVAC+ rates using Pearson correlation for the overall study period and in the subgroup of COVID pandemic months (Mar 2020-December 2021).

Results

During the overall study period, COVID-19 hospitalization rates were significantly associated with IVAC+ rates: acute care correlation 0.86 (p&lt; 0.01) and intensive care correlation 0.33 (p=0.04). During the COVID-19 pandemic months, acute care COVID-19 hospitalizations but not intensive care COVID-19 hospitalizations, were correlated with IVAC+ (correlation 0.90, p&lt; 0.01 and correlation 0.21, p=0.53, respectively). There were 0 IVAC+ before the pandemic months and this rose to 14 during (0 per 1000 ventilator days and 3.05 per 1000 ventilator days, respectively). All but 2 cases of IVAC+ had COVID-19.

COVID-19 Hospitalizations and IVAC Plus, October 2017 to December 2021

A sharp increase in COVID-19 hospitalizations correlated with a rise in patients meeting criteria for IVAC Plus.

Conclusion

The natural history of COVID-19 disease has presented challenges for IVAC+ monitoring. COVID-19 can cause persistent fevers and worsening oxygenation, and antibiotic use is common during periods of clinical deterioration. These factors can fulfill criteria for IVAC+. In this study, each IVAC+ case was traced for safety bundle compliance. These bundles were followed, along with conservative fluid management, low tidal volume ventilation, and sedation breaks. Patients met NHSN criteria for IVAC+ despite these measures and most had COVID-19. Given the common occurrence of IVAC+ in COVID-19 patients, futures studies are needed to define if IVAC+ are preventable in this population and whether IVAC+ surveillance has any value among COVID-19 patients.

Disclosures

All Authors: No reported disclosures.

The Risk and Clinical Implications of Antibiotic-Associated Acute Kidney Injury: A Review of the Clinical Data for Agents with Signals from the Food and Drug Administration’s Adverse Event Reporting System (FAERS) Database

Antibiotic-associated acute kidney injury (AA-AKI) is quite common, especially among hospitalized patients; however, little is known about risk factors or mechanisms of why AA-AKI occurs. In this review, the authors have reviewed all available literature prior to 1 June 2022, with a large number of AKI reports. Information regarding risk factors of AA-AKI, mechanisms behind AA-AKI, and treatment/management principles to decrease AA-AKI risk were collected and reviewed. Patients treated in the inpatient setting are at increased risk of AA-AKI due to common risk factors: hypovolemia, concomitant use of other nephrotoxic medications, and exacerbation of comorbid conditions. Clinicians should attempt to correct risk factors for AA-AKI, choose antibiotic therapies with decreased association of AA-AKI to protect their high-risk patients, and narrow, when clinically possible, the use of antibiotics which have decreased incidence of AKI. To treat AKI, it is still recommended to discontinue all offending nephrotoxic agents and to renally adjust all medications according to package insert recommendations to decrease patient harm.

Prevalence and Health Outcomes of Clostridioides difficile Infection during the COVID-19 Pandemic in a National Sample of United States Hospital Systems

Background

The coronavirus disease 2019 (COVID-19) pandemic resulted in unprecedented emphasis on infection control procedures; however, it is unknown whether the pandemic altered Clostridioides difficile infection (CDI) prevalence. This study investigated CDI prevalence before and during the COVID-19 pandemic in a national sample of United States (US) hospitals.

Methods

This was a retrospective cohort study using the Premier Healthcare Database. Patients with laboratory-confirmed CDI from April 2019 through March 2020 (pre–COVID-19 period) and April 2020 through March 2021 (COVID-19 period) were included. CDI prevalence (CDI encounters per 10 000 total encounters) and inpatient outcomes (eg, mortality, hospital length of stay) were compared between pre–COVID-19 and COVID-19 periods using bivariable analyses or interrupted time series analysis.

Results

A total of 25 992 CDI encounters were included representing 22 130 unique CDI patients. CDI prevalence decreased from the pre–COVID-19 to COVID-19 period (12.2 per 10 000 vs 8.9 per 10 000, P < .0001), driven by a reduction in inpatient CDI prevalence (57.8 per 10 000 vs 49.4 per 10 000, P < .0001); however, the rate ratio did not significantly change over time (RR, 1.04 [95% confidence interval, .90–1.20]). From the pre–COVID-19 to COVID-19 period, CDI patients experienced higher inpatient mortality (5.5% vs 7.4%, P < .0001) and higher median encounter cost ($10 832 vs $12 862, P < .0001).

Conclusions

CDI prevalence decreased during the COVID-19 pandemic in a national US sample, though at a rate similar to prior to the pandemic. CDI patients had higher inpatient mortality and encounter costs during the pandemic.

Racial disparities in the clinical use of durvalumab for patients with stage III unresectable non–small cell lung cancer treated at Veterans Health Administration facilities

8526

Background: Evidence from the PACIFIC study and real-world data highlight the benefit of durvalumab in patients with stage III unresectable non-small cell lung cancer (UR-NSCLC). However, limited literature exists regarding disparities in durvalumab treatment patterns such as treatment initiation delays (TID), treatment interruptions (TI), number of doses, duration of therapy (DOT), adverse effects (AEs), and treatment discontinuation (TD) in minority populations. Methods: Patients with stage III UR-NSCLC and a self-reported racial identity of Black or White treated with durvalumab following chemoradiotherapy (CRT) at any Veterans Health Administration (VHA) facility from January 1, 2017 to June 30, 2020 were included. Patients were followed from their date of durvalumab initiation through the earliest of their last VHA visit, loss to follow up, death, or end of the study; therefore, all patients had the opportunity to be treated for 12 months. Patients were excluded if durvalumab therapy was ongoing at the end of the study. Patient charts were retrospectively reviewed for baseline characteristics and durvalumab treatment patterns including TID (>42 days from end of CRT to durvalumab start), TI (>28 days between doses), number of doses, DOT, AEs, and TD. Nominal variables were compared using chi-square/Fisher’s exact tests. Continuous variables were compared using Student’s t-tests/Wilcoxon Rank Sum tests. Results: Among 924 patients, Black patients were younger than White patients (median age 67 years [IQR, 63-71] vs. 70 years [IQR, 65-73]; p<0.01), more likely to be current smokers (54% vs. 45%; p=0.03), with more chronic liver disease (22% vs. 9%; p<0.01), but less COPD (63% vs. 72%; p=0.01). Black patients experienced more TI (25% vs. 18%; p=0.03) but TID, number of doses, DOT, and TD were similar between the groups. Black patients were less likely to have an immune-related AE (irAE) (28% vs. 36%; p=0.03) (and less pneumonitis (7% vs. 14%; p<0.01)). Toxicity was the reason for TD in 12% of Black patients vs. 20% of White patients (p=0.01), with no other significant (α < 0.05) differences in reported reasons for TID, TI, or TD between the groups. Conclusions: In this real-world study, Black patients experienced similar TID, number of doses, and DOT as White patients. Black patients were less likely to experience an irAE (including pneumonitis) but experienced more TI; TD were similar but more likely to be from toxicity for White patients. Future research is needed to validate these findings.[Table: see text]

Treatment interruptions and discontinuations among patients with stage III unresectable non–small cell lung cancer treated with durvalumab at the Veterans Health Administration

8554

Background: The PD-1/PD-L1 pathway is a mechanism of immune evasion and disruption of this pathway with immune checkpoint inhibitors (ICIs) has shown clinical benefit in multiple malignancies. Based on results from the PACIFIC trial, durvalumab is approved as consolidation therapy in patients (pts) with stage III unresectable non-small cell lung cancer (UR-NSCLC) without progression following concurrent chemoradiotherapy (cCRT). Durvalumab has been used extensively in Veterans Health Administration (VHA) facilities, providing an opportunity to evaluate durvalumab treatment interruptions (TI), treatment discontinuations (TD), and the reasons for these on a national scale. Methods: Patients with stage III UR-NSCLC receiving durvalumab consolidation immunotherapy at the VHA between January 1, 2017 and June 30, 2020 with a minimum follow up for 12 months were included using ICD-10, HCPCS, and J codes and followed from their durvalumab start date through the earliest of last VHA visit, loss to follow up, death, or end of study (excluded if durvalumab therapy was ongoing at the end of the study, because the full treatment course could not be determined). TI were defined as durvalumab infusions separated by >28 days. Reasons for TI and TD are presented descriptively. Durations are reported using medians and interquartile ranges (IQR). Results: 935 pts were included (median age = 69 years; 95% males; 96% current or former smokers; 70% with COPD; histologies [squamous (50%), non-squamous (43%), other/missing (7%)]; and 77% with carboplatin-paclitaxel as their platinum-based CRT). Durvalumab TI were experienced by 19% of pts (median [IQR] number of TI = 1 [1-1], median [IQR] TI duration = 53 days [39-90]). The main reasons for TI were toxicity (8%) and social reasons (3%) (Table). The median duration of treatment (DoT) with durvalumab (TI included) was 9.0 months (IQR 2.9-11.8). Durvalumab TD occurred in 59% of pts. Top reasons for discontinuation across all 935 pts included disease progression (24%) and toxicity (18%) (Table). Conclusions: In this real world analysis of national VHA data, durvalumab DoT was similar to PACIFIC despite having a patient population with worse prognostic factors (e.g. more males, squamous, COPD) with 8% of VHA pts experiencing TI and 18% TD due to toxicity. Patients could benefit from additional efforts to prevent, identify, and manage toxicities in the UR-NSCLC population [Table: see text]

Durvalumab treatment initiation delays in patients with unresectable stage III non–small cell lung cancer treated at Veterans Health Administration facilities

8556

Background: Durvalumab is an FDA-approved immunotherapy for the treatment of adults with UnResectable stage III non-small cell lung cancer (UR-NSCLC) without disease progression following concurrent chemoradiotherapy (CRT). There are limited real-world data regarding Durvalumab treatment initiation delays (TIDs) and reasons for them in the UR-NSCLC population. Methods: Patients with stage III UR-NSCLC receiving consolidation Durvalumab at the Veterans Health Administration (VHA) between January 1, 2017 and June 30, 2020 were selected from the VHA database using ICD-10, HCPCS, and J codes. All had the opportunity to be treated for 12 months and were followed from Durvalumab initiation through the earliest of their last VHA visit, loss to follow up, death, or the study’s end (and excluded if Durvalumab therapy was ongoing at the study’s end). Trained data abstractors determined the occurrence and reasons for TIDs (> 6 weeks from end of CRT to initiation of Durvalumab as in the PACIFIC trial) by chart review. Results: 935 patients were eligible for analysis (median age = 69 years; 95% males; 16% with ECOG performance status >1). TIDs occurred in 39% of the patients (Table). Durvalumab was initiated 61 days (median) from the end of CRT in TID patients vs. 31 days for those without TIDs. There were no significant (α<0.05) differences in age, race, smoking status, histology, or ECOG performance status and no comorbidity differences (except in patients with a history of cerebrovascular accident, for whom TIDs were more likely) between the TID/No-TID patients. Patients without timely post-CRT scans were more likely to have a TID. Of the 367 patients who experienced TIDs, 200 had documented reasons for the delay, consisting of other (not categorized) (28.5%), physician preference (20%), toxicity (11%), patient preference (10.5%), decline in performance status (10%), system issues (9.5%), social reasons (9%), and progression (0.5%). Conclusions: This is one of the largest retrospective cohort studies reporting real-world data in patients with UR-NSCLC receiving Durvalumab. TIDs were associated with increased time to post-CRT scans. This potential issue can be improved with care coordination and involvement of cancer navigators. Additional studies are needed to assess the impact of TIDs on survival outcomes.[Table: see text]

Automated Susceptibility Testing With Vitek 2 Compared to MicroScan Reduces Vancomycin Alternative Therapy For Methicillin-Resistant Staphylococcus Aureus Bacteremia

OBJECTIVES

Variability in minimum inhibitory concentration (MIC) with automated susceptibility testing instruments may influence methicillin-resistant Staphylococcus aureus (MRSA) treatment. The purpose of this study was to evaluate the difference in vancomycin MIC values and the impact on vancomycin alternative therapy for MRSA bacteremia using the MicroScan and VITEK 2 automated systems.

METHODS

This was a retrospective multicenter cohort study of adult patients with MRSA bacteremia. Patients were stratified by susceptibility testing with MicroScan (May 2013-December 2016) or VITEK 2 (June 2017-February 2020). The primary outcome was vancomycin alternative therapy use. Secondary endpoints included MRSA MIC, 30-day mortality, 30- and 90-day readmission, and hospital length of stay (LOS).

RESULTS

A total of 193 patients were included for analysis: 89 in the MicroScan group and 104 in the VITEK 2 group. Vancomycin alternative therapy use was higher in the MicroScan group than the VITEK 2 group (56.2% vs 20.2%; p <0.001). Median MIC value was 2 mg/L and 1 mg/L for MicroScan and VITEK 2, respectively (p <0.001). Median hospital LOS was shorter in the VITEK 2 period (16 vs 12 days; p = 0.02). Thirty-day mortality (10.1% vs 7.7%; p = 0.555) and 90-day readmission (34.8% vs 29.8%; p = 0.457) did not significantly differ between MicroScan and VITEK 2 groups.

CONCLUSIONS

VITEK 2 use was associated with lower reported vancomycin MICs and less use of vancomycin alternative therapy.

758. Increased Prevalence of Clostridioides difficile Infection During the COVID-19 Pandemic Among Hospitalized Veterans in South Texas, USA

Background

Clostridioides difficile infection (CDI) continues to be a major global public health concern, particularly during the ongoing SARS-CoV-2 coronavirus disease 2019 (COVID-19) pandemic. Despite new social distancing guidelines and enhanced infection control procedures (e.g., masking, hand hygiene) being implemented since the beginning of COVID-19, little evidence indicates whether these changes have influenced the prevalence of CDI hospitalizations. This study aims to measure CDI prevalence before and during the COVID-19 pandemic in a local cohort of U.S. Veterans.

Methods

This was a cross-sectional study of all Veterans presenting to the South Texas Veterans Health Care System in San Antonio, Texas from Jan 1, 2019 to Apr 30, 2021. Monthly laboratory confirmed CDI events were collected overall and categorized as the following: hospital-onset, healthcare facility-associated (HO-HCFA-CDI), community-onset, healthcare facility-associated CDI (CO-HCFA-CDI), and community-associated CDI (CA-CDI). Monthly confirmed COVID-19 cases were also collected. CDI prevalence was calculated as CDI events per 10,000 bed days of care (BDOC) and was compared between pre-pandemic (Jan 2019-Feb 2020) and pandemic (Mar 2020-Apr 2021) periods.

Results

A total of 285 CDI events, 920 COVID-19 cases, and 104,220 BDOC were included in this study. The overall CDI rate increased from 20.33 per 10,000 BDOC pre-pandemic to 34.51 per 10,000 during the pandemic (p&lt; 0.0001). This was driven primarily by a rise in CO-HCFA-CDI rates (0.95 vs 2.52 per 10,000 BDOC; p&lt; 0.0001) during the pandemic, followed by increases in CA-CDI (15.58 vs. 18.61 per 10,000 BDOC; p&lt; 0.0001) and HO-HCFA-CDI (2.66 vs. 5.43 per 10,000 BDOC; p&lt; 0.0001). Lastly, CDI rates have tripled since the start of the pandemic (March-Apr 2020) compared to the current year (March-Apr 2021) (14.69 vs. 43.76 per 10,000 BDOC).

Conclusion

Overall, CDI prevalence increased during the COVID-19 pandemic, driven mostly by an increase in CO-HCFA-CDI. As COVID-19 rates increased, CDI rates also increased, likely due to greater healthcare exposures and antibiotic use. Continued surveillance of COVID-19 and CDI is warranted to further decrease infection rates

Disclosures

All Authors: No reported disclosures

185. Does an Infectious Diseases Consultation Improve Clinical Outcomes and Treatment Bundle Adherence for Enterococcal Bacteremia in a Multicenter Healthcare System?

Background

Infectious diseases consultation (IDC) for Staphylococcus aureus bacteremia has a known mortality benefit, but for other gram positive bacteremias the benefit is not known. This study examined differences in outcomes for enterococcal bacteremia when management includes IDC.

Methods

This retrospective multicenter observational cohort study included adults with at least 1 positive blood culture with Enterococcus species. Patients who died or transferred to palliative care within 2 days of positive blood cultures were excluded. The primary outcome was a composite of clinical failure, including persistent blood cultures or fever for 5 days and in-hospital mortality. Secondary outcomes included adherence to a treatment bundle (appropriate empiric/definitive antibiotics, echocardiography (ECHO), duration of treatment, and repeat blood cultures).

Results

A total of 250 patients were included. IDC was obtained in 62.0% of patients. More patients in the IDC group had endocarditis (20% vs 0%, p < 0.0001) and bone and joint infections (13.5% vs 1.1%, p = 0.001), compared to more UTI (16.8% vs 39.0%, p < 0.0001) in the non-IDC group. Patients in the IDC group had more murmurs on initial exam (21.3% vs 6.3%, p = 0.002), prosthetic device (49.7% vs 27.4%, p = 0.001), and NOVA scores of ≥ 4 (40.6% vs 18.9%, p < 0.0001). Most infections were due to E. faecalis (78.4%) and most were susceptible to vancomycin and ampicillin at 90.4% and 92.4%, respectively. The composite of clinical failure occurred in 22.6% of patients with IDC and 16.8% in the non-IDC group (p=0.274). There was higher adherence to the treatment bundle in the IDC group (Figure 1). More patients in the IDC group were treated with ampicillin (47.1% vs 22.1%, p < 0.0001), and numerically more patients received treatment with vancomycin in the non-IDC group (17.4% vs 24.2%, p = 0.068). In the multivariate analysis, vasopressors were the only independent predictor of the primary outcome (OR 9.3, 95% CI 3.5-24.8, p < 0.0001).

Figure 1. Adherence to treatment bundle. IDC = infectious diseases consultation, Echo = echocardiogram, * = p < 0.05

Conclusion

There was no difference in rates of composite failure in patients with or without IDC; however, adherence to a treatment bundle was higher in the IDC group. IDC demonstrated stewardship benefits with regards to vancomycin usage.

Disclosures

All Authors: No reported disclosures

204. Clinical Outcomes with Ceftaroline Monotherapy versus Daptomycin-Ceftaroline Combination Therapy in the Treatment of Methicillin-Resistant Staphylococcus aureus Bacteremia

Background

Methicillin-resistant Staphylococcus aureus (MRSA) bacteremia is associated with poor outcomes and increased mortality. Daptomycin (DAP) and ceftaroline (CPT) in combination has been explored as a potential treatment option and showed improved outcomes compared to vancomycin/standard therapy. CPT monotherapy has been evaluated as salvage therapy for MRSA bacteremia but, to our knowledge, not as a comparator to DAP-CPT combination therapy. The purpose of this study is to compare the clinical outcomes of DAP and CPT combination therapy to CPT monotherapy in the setting of MRSA bacteremia.

Methods

A retrospective chart review of adult patients (≥ 18 years of age) admitted to University Health from January 2017 to December 2020 with a diagnosis of MRSA bacteremia was performed. Patients received either CPT monotherapy or DAP-CPT combination therapy for a minimum of 48 hours during their course of therapy.

Results

Thirty-two patients met inclusion criteria and were evaluated. Primary source of infection was pulmonary in the CPT monotherapy group (n=7/24; 29.2%) and osteomyelitis in the DAP-CPT combination group (n= 4/8; 50.0%). Median duration of bacteremia was 8 days and 9 days in the CPT monotherapy and DAP-CPT combination group, respectively. Microbiological cure was achieved in 95.8% (n=23/24) of patients in the CPT monotherapy and 100% (n=8/8) of patients in the DAP-CPT combination group. Bacteremia relapse (30 day, p=0.62; 60 day, p=0.63), readmission rates (30 day, p=0.62; 60 day, p=0.63), and mortality rates (30 day, p=0.70; 90 day, p=0.85) were similar in both groups. There was no statistically significant difference in safety parameters, including incidence of acute kidney injury (p=1.00) and creatine kinase elevations (p=1.00). Bone marrow suppression after at least 72 hours of therapy, including anemia, leukopenia, and thrombocytopenia, was also not statistically significant between groups.

Conclusion

This study was unable to find a statistically significant difference in clinical outcomes between patients receiving CPT monotherapy or DAP-CPT combination therapy. A large prospective, randomized controlled trial to assess CPT monotherapy and DAP-CPT combination therapy for the treatment of persistent MRSA bacteremia is warranted.

Disclosures

All Authors: No reported disclosures

1402. NTM Infections; A Rising Global Health Problem/Clinical Characteristics and Outcomes of Patients with Non-Tuberculous Mycobacterial Infections at Two Tertiary Academic Medical Centers

Background

Non-Tuberculous Mycobacteria (NTM) cause infections in immunocompetent as well as immunocompromised individuals affecting pulmonary and extra pulmonary sites. These pathogens are widely distributed globally and recent reports have shown their rise in many developed countries. Our study aimed to assess the disease magnitude, describe patient characteristics and risk factors, assess diagnostic and therapeutic measures and review outcomes furthering our understanding of the overall disease process.

Methods

We conducted a retrospective, multicenter review of patients with positive NTM cultures treated at University Hospital System and South Texas Veterans Health Care System (STVHCS) from 2011 to 2018. Infections were classified as pulmonary or extrapulmonary, and we recorded demographics, microbiological data, treatment regimens, duration, complications, follow-up and mortality. All categorical variables were described using percentages and compared between groups using the chi-square test.

Results

A total of 176 patients were included for analysis, of which 111 (63.1%) met criteria for NTM disease (2020 ATS/IDSA). The most common cultured mycobacterium was M. Avium Complex (MAC). M. abscessus-chelonae was more commonly associated with clinical disease and isolated from an extra pulmonary site whereas M. simiae complex had similar distribution between the infected and un-infected groups. Over 50% of patients received treatment (80% in the infected group). Cure was seen in 47.2%, all-cause mortality was 27% at last follow-up. Median duration of therapy was 10 months. 47% of patients experienced adverse effects which led to treatment discontinuation in one third of patients. Patients who were able to achieve a cure received a longer duration of therapy (12 vs 7 months; not statistically significant) and treatment was halted more commonly in the group that did not achieve eventual cure (42.6% vs. 16.7%, p=0.007).

Conclusion

NTM infections represent a therapeutic challenge with low cure rates and high mortality. An understanding of the risk factors, treatment options and outcomes is essential to guide appropriate management. Our study highlights high rates of adverse effects and discontinuation which precludes prolonged courses of therapy required to achieve cure.

Disclosures

All Authors: No reported disclosures

Polypharmacy prevalence in older adults seen in United States physician offices from 2009 to 2016

BACKGROUND/OBJECTIVES

With an aging population suffering from increased prevalence of chronic conditions in the United States (U.S.), a large portion of these patients are on multiple medications. High-risk medications can increase the risk for drug-drug interactions and medication nonadherence. This study aims to describe the prevalence of polypharmacy and high-risk medication prescribing in U.S. physician offices.

METHODS

This was a cross-sectional study of the Centers for Disease Control and Prevention's National Ambulatory Medical Care Survey from 2009 to 2016. All patients over 65 years old were included. Polypharmacy was categorized as no polypharmacy (< 2 medications), minor polypharmacy (2-3 medications), moderate polypharmacy (4-5 medications), and major polypharmacy (>5 medications). Medications were further categorized into high-risk medication categories (anticholinergics, cardiovascular agents, central nervous system (CNS) medications, pain medications, and other). Comparisons between the degrees of polypharmacy were performed utilizing chi-square or Wilcoxon rank-sum tests with JMP Pro 14® (SAS Institute, Cary, NC).

RESULTS

Over 2 billion patient visits were included. Overall, Polypharmacy was common (65.1%): minor polypharmacy (16.2%), moderate polypharmacy (12.1%), and major polypharmacy (36.8%). Patients with major polypharmacy were older compared to those with moderate or minor polypharmacy (75 vs. 73 years, respectively) and were most frequently prescribed pain medications (477.3 per 1,000 total visits). NSAIDs were the most frequently prescribed, with 232.4 per 1,000 total visits resulting in one high-risk NSAID prescription, while 21.9 per 1,000 total visits resulted in two or more high-risk NSAIDs.

CONCLUSION

Most patients over 65 years experienced some degree of polypharmacy, with many experiencing major polypharmacy. This indicates an increased need for expanded pharmacist roles through medication therapy management and safety monitoring in this patient population.

Sexually transmitted infection laboratory testing and education trends in US outpatient physician offices, 2009-2016

OBJECTIVE

To describe national rates of sexually transmitted infection (STI) testing and education overall and among patient subgroups in US outpatient physician offices from 2009 to 2016.

DESIGN

This was a cross-sectional study of the Centers for Disease Control and Prevention's National Ambulatory Medical Care Survey from 2009 to 2016. Data weights were applied to extrapolate to national estimates.

SETTING

Data were collected from a systematic random sample of outpatient physician office visits throughout USA. Physician office types include free standing clinics, private or group setting practices, centres offering community and mental health services, family planning clinics and health maintenance organisations/other prepaid clinics.

PARTICIPANTS

All sampled patient visits were eligible for inclusion and were assessed for the provision of STI prevention education and STI testing for chlamydia, gonorrhoea, hepatitis, human papillomavirus (HPV) and HIV.

RESULTS

Of 7.6 billion total visits, 123 million included an STI test. Hepatitis was the most commonly tested STI (9.12 per 1000), followed by chlamydia (6.67 per 1000), gonorrhoea (6.00 per 1000), HIV (5.40 per 1000) and HPV (5.03 per 1000). Testing rates for the three STIs measured for the entire 8-year period increased over time and peaked in 2015 compared with 2009: chlamydia (R2=0.36), HPV (R2=0.28) and HIV (R2=0.51). Testing was highest among women (21.93 per 1000), 15-24-year olds (46.04 per 1000), non-Hispanic blacks (37.33 per 1000) and those seen by obstetrics/gynaecology specialists (103.75 per 1000). STI prevention education was provided to 4.89 per 1000 patients and remained relatively unchanged from 2013 to 2016.

CONCLUSION

STI testing in outpatient physician offices increased over the study period but varied by patient characteristics and site of care. Few patients received STI prevention education, highlighting a potential gap in resource utilisation in these settings.

Availability of buprenorphine/naloxone films and naloxone nasal spray in community pharmacies in Texas, USA

BACKGROUND AND AIMS

Patients with opioid use disorder (OUD) must be able to obtain prescribed buprenorphine/naloxone films (BUP/NX) and naloxone nasal spray (NNS) from a pharmacy promptly to reduce risk for a recurrence of use and subsequent morbidity and mortality. Telephone audits have identified concerning gaps in availability of NNS within US pharmacies, but the availability of BUP/NX has not been rigorously evaluated. This study estimated the availability of BUP/NX and NNS in the US state of Texas and compared availability by pharmacy type and metropolitan status.

DESIGN

A cross-sectional telephone audit with a secret shopper approach conducted from 18 May 2020 to 7 June 2020. Setting and Participants A random sample of 800 of 5078 (16%) community pharmacies licensed with the Texas State Board of Pharmacy.

MEASUREMENTS

Primary outcomes included availability of a 1-week supply of generic BUP/NX 8/2 mg films and a single unit of NNS 4 mg, overall and by pharmacy type. Secondary outcomes included willingness and estimated time-frame to order BUP/NX if unavailable.

FINDINGS

Data from 704 pharmacies (471 chain, 233 independent) were included for analyses. Of these, 34.1% of pharmacies (45.0% of chains versus 12.0% of independents, P < 0.0001) were willing and able to dispense a 1-week supply of generic BUP/NX and a single unit of NNS. BUP/NX alone was available in 42.2% of pharmacies (52.4% of chains versus 21.5% of independents, P < 0.0001). NNS alone was available in 60.1% of pharmacies (77.9% of chains versus 24.0% of independents, P < 0.0001). Of the 397 pharmacies with generic BUP/NX unavailable, 62.2% of pharmacies (73.9% of chains versus 48.0% of independents, P < 0.0001) indicated willingness to order.

CONCLUSIONS

Most pharmacies in Texas do not appear to be willing and able to dispense prescribed buprenorphine/naloxone films and naloxone nasal spray to patients with opioid use disorder in a timely manner. Deficiencies in availability are markedly more pronounced in independent pharmacies compared with chain pharmacies.

Gut microbiome differences among Mexican Americans with and without type 2 diabetes mellitus

PURPOSE

Type 2 diabetes mellitus (T2DM) is an urgent public health problem and disproportionately affects Mexican Americans. The gut microbiome contributes to the pathophysiology of diabetes; however, no studies have examined this association in Mexican-Americans. The objective of this study was to compare gut microbiome composition between Mexican-Americans with and without T2DM.

METHODS

This was a cross-sectional study of volunteers from San Antonio, TX. Subjects were 18 years or older and self-identified as Mexican American. Subjects were grouped by prior T2DM diagnosis. Eligible subjects attended a clinic visit to provide demographic and medical information. Thereafter, subjects recorded their dietary intake for three days and collected a stool sample on the fourth day. Stool 16s rRNA sequences were classified into operational taxonomic units (OTUs) via the mothur bayesian classifier and referenced to the Greengenes database. Shannon diversity and bacterial taxa relative abundance were compared between groups using the Wilcoxon rank sum test. Beta diversity was estimated using Bray-Curtis indices and compared between groups using PERMANOVA.

RESULTS

Thirty-seven subjects were included, 14 (38%) with diabetes and 23 (62%) without diabetes. Groups were well-matched by body mass index and comorbid conditions. Shannon diversity was not significantly different between those with and without T2DM (3.26 vs. 3.31; p = 0.341). Beta diversity was not significantly associated with T2DM diagnosis (p = 0.201). The relative abundance of the most common bacterial phyla and families did not significantly differ between groups; however, 16 OTUs were significantly different between groups.

CONCLUSIONS

Although alpha diversity was not significantly different between diabetic and non-diabetic Mexican Americans, the abundance of certain bacterial taxa were significantly different between groups.

National Prevalence of Influenza Diagnoses and Vaccination Rates Among Patients Presenting to United States Physician Offices and Hospital Outpatient Departments, 2009 to 2016

Background

Influenza health resource utilization studies are important to inform future public health policies and prevent outbreaks. This study aimed to describe influenza prevalence, vaccination, and treatment among outpatients in the United States and to evaluate population-level characteristics associated with influenza health resource utilization.

Methods

Data were extracted from the National Ambulatory and National Hospital Ambulatory Medical Care Surveys (2009 to 2016). Prevalence rates were described as influenza visits (defined by International Classification of Diseases, Ninth Revision, Clinical Modification or International Classification of Diseases, Tenth Revision code) per 1000 total visits overall and by flu year, month, region, race, and age group. Influenza vaccination and antiviral treatments were identified by Multum code(s) and presented as vaccination visits per 1000 total visits and the percentage of patients diagnosed with influenza receiving antiviral treatment.

Results

In more than 19.2 million patient visits, an influenza diagnosis was made with rates ranging from 1.2 per 1000 during 2014–2015 to 3.7 per 1000 during 2009–2010. Rates were highest in the South (3.6 per 1000), in December (5.2), among black patients (2.8), and those less than 18 years (6.8). Vaccination rates were highest during 2014–2015 (29.3 per 1000) and lowest during 2011–2012 (15.5 per 1000), in the West (23.4), in October (69.2), among “other race” patients (26.2), and age less than 18 years (51.4). Overall, 39.4% of patients with an influenza diagnosis received an antiviral.

Conclusions

Overall, there were no major changes in influenza diagnosis or vaccination rates. Patient populations with lower vaccination rates had higher influenza diagnosis rates. Future campaigns should promote influenza vaccinations particularly in underserved populations.

Comparison of rectal swab, glove tip, and participant-collected stool techniques for gut microbiome sampling

BACKGROUND

Studies of the gut microbiome are becoming increasingly important. Such studies require stool collections that can be processed or frozen in a timely manner so as not to alter the microbial content. Due to the logistical difficulties of home-based stool collection, there has been a challenge in selecting the appropriate sample collection technique and comparing results from different microbiome studies. Thus, we compared stool collection and two alternative clinic-based fecal microbiome collection techniques, including a newer glove-based collection method.

RESULTS

We prospectively enrolled 22 adult men from our prostate cancer screening cohort SABOR (San Antonio Biomarkers of Risk for prostate cancer) in San Antonio, TX, from 8/2018 to 4/2019. A rectal swab and glove tip sample were collected from each participant during a one-time visit to our clinics. A single stool sample was collected at the participant's home. DNA was isolated from the fecal material and 16 s rRNA sequencing of the V1-V2 and V3-V4 regions was performed. We found the gut microbiome to be similar in richness and evenness, noting no differences in alpha diversity among the collection methods. The stool collection method, which remains the gold-standard method for the gut microbiome, proved to have different community composition compared to swab and glove tip techniques (p< 0.001) as measured by Bray-Curtis and unifrac distances. There were no significant differences in between the swab and glove tip samples with regard to beta diversity (p> 0.05). Despite differences between home-based stool and office-based fecal collection methods, we noted that the distance metrics for the three methods cluster by participant indicating within-person similarities. Additionally, no taxa differed among the methods in a Linear Discriminant Analysis Effect Size (LEfSe) analysis comparing all-against-all sampling methods.

CONCLUSION

The glove tip method provides similar gut microbiome results as rectal swab and stool microbiome collection techniques. The addition of a new office-based collection technique could help easy and practical implementation of gut microbiome research studies and clinical practice.

Gabapentinoid misuse, abuse and non-prescribed obtainment in a United States general population sample

Background Reports of gabapentinoid (gabapentin and pregabalin) misuse are on the rise, but few studies have assessed this within the general US population. Objective Describe lifetime misuse/abuse/non-prescribed obtainment of gabapentinoids and descriptive characteristics associated with such actions in a US general population sample. Setting This cross-sectional questionnaire was administered online by Qualtrics^® research panel aggregator via quota-based sampling. Methods Data were collected from a sample of respondents that mirrored the general US population aged 18-59 years with regards to age, geographic region, ethnicity, income, and education level, based on most recent census data. Misuse/abuse/non-prescribed obtainment was collectively defined as use of a gabapentinoid for reasons other than a diagnosed medical condition, using with the intention of altering one's state of consciousness, or obtaining without a prescription. A multivariable logistic regression model was created to predict misuse/abuse/non-prescribed obtainment of gabapentinoids, incorporating relevant covariates. Main outcome measure Proportion of sample indicating lifetime misuse/abuse/non-prescribed obtainment of gabapentinoids. Results Among 1,843 respondents, 121 (6.6%) reported gabapentinoid misuse/abuse/non-prescribed obtainment. Specifically, 2.1% (n = 39) and 1.5% (n = 27) of respondents for gabapentin and pregabalin, respectively, met study criteria for abuse. Opioids were the most common medication co-administered with gabapentinoids (among 50-70% of respondents) for misuse/abuse. Previous treatment for addiction (OR: 2.61, 95% CI: 1.32-5.14, p = 0.005) and the total attitudinal risk score (OR: 1.14, 95% CI: 1.09-1.19, p < 0.001) were associated with gabapentinoid misuse/abuse/non-prescribed obtainment. Conclusion Among those surveyed, 6.6% reported previous gabapentinoid misuse/abuse/non-prescribed obtainment, providing one of the first estimates within a nationally distributed, US general population sample.

1544. Sexually Transmitted Infection Laboratory Testing and Education Trends Among Physician Office Visits in the United States, 2009-2016

Background

Rates of sexually transmitted infections (STIs) have been rising in the United States (US). Physician offices play an important role in providing both STI prevention and education, as well as STI laboratory testing options for patients who present at risk. However, few studies have documented the extent to which physician’s offices have contributed to prevention and testing efforts. We address this gap by evaluating STI testing and education provided in US physician offices from 2009 to 2016.

Methods

This was a cross-sectional study of the Centers for Disease Control and Prevention’s National Ambulatory Medical Care Survey (NAMCS) from 2009 to 2016. Data weights were applied to extrapolate sample data to national estimates. Testing for HIV, HPV, Chlamydia (2009 – 2016) and Hepatitis and Gonorrhea (2014 – 2016) were presented as testing visits per 1,000 total visits. Subgroup analyses were performed for age group, sex, and geographical region by individual STI test and receipt of STI prevention education.

Results

A total of 7.6 billion visits were included for analysis, of which 0.6% included an STI test. Testing rates increased over the study period for Chlamydia (R2=0.27), HPV (R2=0.28), and HIV (R2=0.51). Peak testing occurred in 2015 for all tests. STI prevention education was provided to 0.5% of patients. Females were tested at a higher rate for all STIs (4.2%) compared to males (0.4%). Females also received more STI prevention education overall (0.6% versus 0.4%, respectively). While the age group 25 – 24 accounted for highest Hepatitis (15.9%) and HPV (11.3%) testing rates, the 15 – 24 age group had the highest overall testing rate (9.4%). STI testing was highest in the South region (Figure 1).

Conclusion

STI testing in US physician offices increased in recent years. Females accounted for the majority of STI testing and STI prevention education. Testing was more frequent among patients 15 – 24 years old and those seen in the South region. Further research should be conducted to determine reasons for differences in testing and education amongst sex, age group, and geographic region.

Disclosures

All Authors: No reported disclosures

310. The Impact of Microscan versus Vitek-2 for Automated Susceptibility Testing on the Utilization of Vancomycin Alternatives for the Treatment of Methicillin-Resistant Staphylococcus aureus Bacteremia

Background

Automated susceptibility testing (AST) provides minimum inhibitory concentrations (MIC) to guide effective antibiotic therapy. AST is critical for methicillin-resistant Staphylococcus aureus (MRSA) bacteremia, as susceptible MIC values ≥ 1.5 µg/mL are associated with vancomycin (VAN) failure. The Microscan (MS) instrument may report elevated MIC values compared to Vitek-2 (VTK), thus impacting treatment. This study aimed to evaluate the impact of MS versus VTK on VAN alternative use in the treatment of MRSA bacteremia in a Texas health system.

Methods

This was a retrospective cohort study of patients admitted to the Ascension Seton health system in Austin, TX. Patient eligibility included: age ≥18 years, ≥1 positive MRSA blood culture, ≥72 hours of MRSA therapy, and VAN use within 48 hours of positive culture. Patients were stratified into the MS group (May 2013-Dec 2016) and VTK group (Jun 2017-Mar 2020). The primary outcome was therapy switch from VAN to VAN alternatives. Secondary endpoints include S. aureus MIC, 30-day all-cause mortality, 30 and 90-day readmission, and length of hospital stay (LOS). Outcomes were compared between groups using appropriate bivariable comparisons, as well as multivariable logistic regression and propensity score-adjusted logistic regression.

Results

A total of 199 patients were included: 91 in the MS group and 108 in the VTK group. Switch to VAN alternative was 56% vs. 19% (p< 0.0001) for MS and VTK, respectively. The median (interquartile range) MIC value reported was 2 μg/mL (2 – 2) and 1 μg/mL (0.5 – 1) for MS and VTK, respectively (p< 0.0001). Thirty-day readmission (19% vs. 20%, p=0.7647) and 30-day mortality (10% vs. 9%, p=0.5262) were comparable between MS and VTK groups, respectively. Hospital LOS significantly decreased in the VTK period (16 days vs. 12 days, p=0.0153). The MS group was the only independent positive predictor of VAN alternative therapy: logistic regression, OR 5.64 (95% CI 1.67–18.99) and propensity score adjusted, OR 4.21 (95% CI 1.32–13.48).

Conclusion

Since implementation of VTK from MS, Ascension Seton hospitals experienced a decreased median VAN MIC for MRSA bacteremia as well as therapy switches from VAN to VAN alternatives without affecting other patient health outcomes.

Disclosures

All Authors: No reported disclosures

1419. National ambulatory health resource utilization and geographic disparities of influenza in the United States, 2009 to 2016

Background

Influenza can affect up to 10% of adults and 30% of children and, in specific populations, can lead to severe illness and death. Although epidemiological surveillance on influenza patterns have been expanded since 2009, it is also imperative to observe specific trends for influenza immunization and treatment to inform and potentially prevent future outbreaks. The primary objective of this study was to describe influenza prevalence, immunization, and treatment among outpatients in the United States (US).

Methods

This was a cross-sectional study using the Centers for Disease Control and Prevention’s National Ambulatory and Hospital Ambulatory Medical Care Surveys from 2009 to 2016. All patient visits were eligible for inclusion, and prevalence rates were described as influenza visits per 1,000 patient visits. Patient visits were categorized by year, month, and US geographic region. Influenza vaccinations and treatments were defined by their respective Multum code(s) and diagnosis was identified using International Classification of Diseases, 9^th Revision, Clinical Modification (ICD-9-CM) and ICD-10 codes for the appropriate survey years. Data were presented descriptively.

Results

Over 7 billion visits were included for analysis. Overall, influenza rates varied over the study period with the highest rate in 2009 (5.0) and lowest in 2015 (0.9). Immunization rates were highest in 2014 (25.4) and lowest in 2016 (12.5). The South had the highest influenza rates (3.6) and proportion of influenza visits that included treatment (45.6%), as well as the lowest immunization rates (17.6). The Northeast had the lowest influenza rate (1.5), while the West had the lowest proportion of influenza treatment (24.9%) and highest immunization rates (23.4). December and February had the highest rates of influenza (5.2 and 5.7, respectively), while rates of immunization were the highest in September and October (48.9 and 71.7, respectively).

Conclusion

Immunization rates were highest in the fall months and influenza rates were highest in the winter months. Overall, this study found that regions with lower influenza vaccination had higher influenza rates, and vice versa. Future campaigns should promote immunizations against the influenza virus particularly in underserved regions (e.g., South).

Disclosures

All Authors: No reported disclosures

Feasibility of fecal microbiota transplantation via oral gavage to safely alter gut microbiome composition in marmosets

Disruption of microbial communities within human hosts has been associated with infection, obesity, cognitive decline, cancer risk and frailty, suggesting that microbiome-targeted therapies may be an option for improving healthspan and lifespan. The objectives of this study were to determine the feasibility of delivering fecal microbiota transplants (FMTs) to marmosets via oral gavage and to evaluate if alteration of the gut microbiome post-FMT could be achieved. This was a prospective study of marmosets housed at the Barshop Institute for Longevity and Aging Studies in San Antonio, Texas. Eligible animals included healthy young adult males (age 2-5 years) with no recent medication use. Stool from two donors was combined and administered in 0.5 ml doses to five young recipients once weekly for 3 weeks. Safety outcomes and alterations in the gut microbiome composition via 16S ribosomal RNA sequencing were compared at baseline and monthly up to 6 months post-FMT. Overall, significant differences in the percent relative abundance was seen in FMT recipients at the phylum and family levels from baseline to 1 month and baseline to 6 months post-FMT. In permutational multivariate analysis of variance analyses, treatment status (donor vs. recipient) (p = .056) and time course (p = .019) predicted β diversity (p = .056). The FMT recipients did not experience any negative health outcomes over the course of the treatment. FMT via oral gavage was safe to administer to young adult marmosets. The marmoset microbiome may be altered by FMT; however, progressive changes in the microbiome are strongly driven by the host and its baseline microbiome composition.

National outpatient medication utilization for opioid and alcohol use disorders from 2014 to 2016

BACKGROUND AND AIMS

Research has recommended a combination of pharmacotherapy and behavioral therapy to treat opioid use disorder (OUD) or alcohol use disorder (AUD). The objective of this study was to estimate the prevalence of U.S. outpatient visits in which patients had a documented OUD or AUD and in what proportion of these visits the patient was receiving medication for OUD (MOUD) or AUD (MAUD), alone or in combination with behavioral therapy.

DESIGN

Cross-sectional analysis of the National Ambulatory Medical Care Survey (NAMCS) from 2014 to 2016.

SETTING

NAMCS provides national estimates based on the latest census data, for all U.S. outpatient medical visits.

PARTICIPANTS/CASES

All visits involving patients aged ≥18 years with an OUD or AUD diagnosis.

MEASUREMENT

Medications for OUD included buprenorphine, buprenorphine/naloxone, or naltrexone; medications for AUD included acamprosate, disulfiram, or naltrexone. We defined behavioral therapy as provision of psychosocial therapy, mental health counseling, or stress management. We also compared annualized data between 2014 and 2016 using the Chi-square test.

FINDINGS

From 2014 to 2016, NAMCS recorded nearly 2.3 billion adult outpatient visits, including 17.1 million and 21.7 million visits involving patients with an OUD or AUD diagnosis, respectively. From 2014 to 2016, a decreased prevalence of annual visits involved AUD (11.7 vs. 9.9/1000, P < 0.0001), while those for OUD increased (9.3 vs. 13.3/1000, P < 0.0001). Among office visits with an OUD diagnosis, a MOUD was documented in 14.2 million (83.1%) visits and behavioral therapy was provided in 4.4 million (25.6%). Among office visits with an AUD diagnosis, an MAUD was documented in approximately 800,000 (3.6%) and behavioral therapy in 5.4 million (24.8%).

CONCLUSION

These data highlight an opportunity to increase the use of MAUD and offer behavioral therapy to those with OUD and/or AUD.

Charting the Path Forward: Development, Goals and Initiatives of the 2019 Infectious Diseases Society of America Strategic Plan

In October 2018, the Infectious Diseases Society of America (IDSA) Board of Directors (BOD) decided to develop a 2019 IDSA Strategic Plan. The IDSA BOD has invested in strategic planning at regular intervals as part of an ongoing process to review and to renew the vision and direction of IDSA. Herein, the 2018-2019 strategic planning process and outcomes are described. The 2019 IDSA Strategic Plan presents 4 key initiatives: (1) optimize the development, dissemination, and adoption of timely and relevant ID guidance and guidelines that improve the outcomes of clinical care; (2) quantify, communicate, and advocate for the value of ID physicians to increase professional fulfillment and compensation; (3) facilitate the growth and development of the ID workforce to meet emerging scientific, clinical, and leadership needs; and (4) develop and position a new tool to serve as the leading US benchmark to measure and drive national progress on antimicrobial resistance. The BOD looks forward to developing, implementing, assessing, and advancing the 2019 IDSA Strategic Plan working with member volunteers, Society partners, and IDSA staff.

GABAergic but not Antidepressant Medications Increase Risk for Clostridioides difficile Infection in a National Cohort of Veterans

Background

Clostridioides difficile infection (CDI) is primarily mediated by alterations in the host gut ecosystem. While antibiotic use is the primary risk factor for CDI, other medications that modulate the gut ecosystem, particularly those targeting the gut-brain axis, could impact CDI risk. This study aimed to investigate the association between recent antidepressant and gamma-aminobutyric acid (GABA)-ergic medication use with CDI risk in a national cohort of United States veterans.

Methods

This was a retrospective case-control study of patients seen in Veterans Health Administration facilities from October 2002 to September 2014. CDI and non-CDI control patients were propensity score matched 1:1 using a maximum caliper of 0.0001. Antidepressant and GABAergic medication use 90 days before cohort inclusion were analyzed for CDI association using bivariable and multivariable logistic regression models.

Results

A total of 85 831 patients were included, and 9287 CDI and 9287 control patients were propensity score matched. Antidepressant use overall was not significantly associated with CDI risk (odds ratio [OR], 1.05; 95% CI, 0.98-1.12), although GABAergic medication use was associated with increased risk (OR, 1.81; 95% CI, 1.70-1.92). In multivariable models of individual medications/classes, benzodiazepines had the strongest CDI association (OR, 1.91; 95% CI, 1.77-2.07). SSRIs (OR, 0.88; 95% CI, 0.81-0.95) and bupropion (OR, 0.67; 95% CI, 0.57-0.78) were negatively associated with CDI.

Conclusions

In this national study of veterans, GABAergic medication use was a positive predictor of CDI risk, though antidepressant use was not. Further research is needed to understand biological mechanisms, and confirmatory studies are needed to validate these findings.

National Trends in Oral Antibiotic Prescribing in United States Physician Offices from 2009 to 2016

BACKGROUND

Prior studies have found that outpatient antibiotics are commonly prescribed for non-bacterial conditions. It is unclear if national prescribing has changed in recent years given recent public health and antimicrobial stewardship initiatives. This study aimed to describe antibiotic prescribing in United States (U.S.) physician offices.

MATERIALS/METHODS

This was a cross-sectional study of all sampled patient visits in the Centers for Disease Control and Prevention's National Ambulatory Medical Care Survey from 2009 to 2016. Antibiotic use was defined as at least one oral antibiotic prescription during the visit as identified by Multum code(s). Patient visits were categorized by U.S. geographic region and season. ICD-9-CM and ICD-10 codes were used to assess diagnoses and categorize antibiotic use as appropriate, possibly appropriate, or inappropriate.

RESULTS

Seven billion visits were included for analysis, with 793,415,182 (11.3%) including an antibiotic. Prescribing rates were relatively stable over the study period (102.9-124.9 prescriptions per 1000 visits); however, 2016 had one of the lowest prescribing rates (107.7 per 1000 visits). The most commonly prescribed antibiotic class was macrolides (25 per 1000 visits). The South region and winter season had the highest antibiotic prescribing (118.2 and 129.7 per 1000 visits, respectively). Of patients who received an antibiotic, 55.9%, 35.7%, and 8.4% were classified as inappropriate, possibly appropriate, and appropriate, respectively. The most common conditions in which antibiotics were prescribed inappropriately included those with no indication in any of the predefined diagnosis codes (40.1%), other skin conditions (17.3%), and viral upper respiratory conditions (13.3%).

CONCLUSIONS

There was no significant reduction in outpatient antibiotic prescribing rates among U.S. outpatients from 2009 to 2016 and prescribing varied by region and season. These data suggest that more than half of antibiotics were prescribed inappropriately, with the majority of antibiotics prescribed with no indication. However, these findings need to be confirmed with robust prospective studies.

Clostridioides (Formerly Clostridium) difficile Infection During Hospitalization Increases the Likelihood of Nonhome Patient Discharge

BACKGROUND

Clostridioides (formerly Clostridium) difficile infection (CDI) is associated with significant morbidity and mortality, including frequent hospitalizations. However, the impact of CDI after hospital discharge is poorly understood. The purpose of this study was to assess patient discharge disposition and understand CDI-related risk factors for nonhome discharge.

METHODS

Using a nationally representative database of Veterans Health Administration (VHA) patients (2003-2014) and a validation database from hospitalized non-VHA patients in Houston, Texas, admission and discharge disposition was obtained for patients with CDI and matched controls. Incidence of and clinical/microbiologic risk factors for nonhome discharge were assessed using these databases.

RESULTS

A total of 15173 VHA patients with CDI and 48599 non-CDI control patients originally admitted from the community were included. Significantly more patients with CDI were discharged to a nonhome location compared with controls (18% vs 8%; P < .0001), most commonly hospice/death (12%) or nursing home/long-term care facility (6%). Results were confirmed using a propensity-matched analysis and a validation cohort of 1941 hospitalized patients with CDI in Houston, Texas. Age, comorbidities, severe CDI, and ribotypes F027, F001, and F053-163 were associated with a nonhome discharge (P < .05 for all).

CONCLUSIONS

Hospitalized patients with CDI frequently required a higher level of medical care residence at discharge compared with non-CDI patients. Risk factors for discharge to a higher level of care included CDI disease severity and variables associated with recurrent CDI.

Receipt of Substance Use Counseling Among Ambulatory Patients Prescribed Opioids in the United States

Background:

As opioid-related overdose deaths climb in the U.S., risk reduction measures are increasingly important. One such measure recommended involves provision of proactive substance use counseling regarding the risks of opioid analgesics. This is particularly important in patients at increased risk of overdose, such as those with substance use disorders (SUD) or those receiving concomitant medications that further increase the overdose risk (eg, benzodiazepines, gabapentinoids, or Z-hypnotics). However, previous research regarding the likelihood that such counseling is provided during outpatient prescriber visits is lacking.

Objectives:

To determine the percentage of U.S. ambulatory care visits in which patients taking prescription opioids received substance use counseling, and whether counseling was more common in patients with concomitant GABAergic medication(s) (benzodiazepine, gabapentinoid or Z-hypnotic) or substance use disorder (SUD) diagnosis.

Methods:

A cross-sectional analysis was conducted of all patients aged ⩾18 years identified as having a prescription opioid on their medication list within the 2014-2015 National Ambulatory Medical Care Survey data.

Results:

Among 162.7 million visits in which patients were taking opioid medication(s), substance use counseling was provided in 2.4%. During visits for patients receiving opioid(s) plus GABAergic(s), substance use counseling was marginally more common (3.1% versus 2.0%, P < .0001). Substance use counseling was also more common among visits for patients taking opioid(s) with SUD (18.9% versus 1.5%, P < .0001). Among visits in which a patient was diagnosed with SUD and taking opioid(s) plus GABAergic(s), counseling was more common (23.1% versus 1.4%, P < .0001) compared to patients taking opioid(s) plus GABAergic(s) without SUD.

Conclusions:

Among national ambulatory care visits in the United States, substance use counseling is provided infrequently for patients taking opioids, even when significant risk factors are present. Increasing patient education may help reduce opioid-related overdose mortality.

Can oral health and oral-derived biospecimens predict progression of dementia?

Growing evidence indicates that oral health and brain health are interconnected. Declining cognition and dementia coincide with lack of self‐preservation, including oral hygiene. The oral microbiota plays an important role in maintaining oral health. Emerging evidence suggests a link between oral dysbiosis and cognitive decline in patients with Alzheimer's disease. This review showcases the recent advances connecting oral health and cognitive function during aging and the potential utility of oral‐derived biospecimens to inform on brain health. Collectively, experimental findings indicate that the connection between oral health and cognition cannot be underestimated; moreover, oral biospecimens are abundant and readily obtainable without invasive procedures, which may help inform on cognitive health.