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  • 1
    Online Resource
    Online Resource
    Empirical Anti-MRSA vs Standard Antibiotic Therapy and Risk of 30-Day Mortality in Patients Hospitalized for Pneumonia
    American Medical Association (AMA) ; 2020
    In:  JAMA Internal Medicine Vol. 180, No. 4 ( 2020-04-01), p. 552-
    Details
    In: JAMA Internal Medicine, American Medical Association (AMA), Vol. 180, No. 4 ( 2020-04-01), p. 552-
    Type of Medium: Online Resource
    ISSN: 2168-6106
    URL: Article
    DOI: 10.1001/jamainternmed.2019.7495
    Language: English
    Publisher: American Medical Association (AMA)
    Publication Date: 2020
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  • 2
    Online Resource
    Online Resource
    145. Comparing Antibiotic Use Across Inpatient Facilities with Different Antibiotic Stewardship Typologies using Machine Learning and Joint Modeling Approach
    Oxford University Press (OUP) ; 2021
    In:  Open Forum Infectious Diseases Vol. 8, No. Supplement_1 ( 2021-12-04), p. S185-S185
    Details
    In: Open Forum Infectious Diseases, Oxford University Press (OUP), Vol. 8, No. Supplement_1 ( 2021-12-04), p. S185-S185
    Abstract: Hospital antibiotic stewardship programs (ASP) aim to promote the appropriate use of antimicrobials (including antibiotics) and play a critical role in controlling antibiotic costs and antibiotic-resistant bacterial infection risk, and improving patient outcomes. However, unlike other health care quality improvement intervention programs, the ASP implementation strategies vary among healthcare facilities, and little is known about whether different types of ASP implementation will lead to the shifting of antibiotic drug use from one class to another. Methods We proposed an analytical framework using unsupervised machine learning and joint model approach to 1) develop a typology of ASP strategies in facilities from the Veterans Health Administration, America’s largest integrated health care system; and 2) simultaneously evaluate the impacts of different ASP types on the annual antibiotic use rates across multiple drug classes. The unsupervised machine learning method was used to leverage the structural components in the surveys conducted by the Veteran Affair (VA) Healthcare Analysis and Information group and the Consolidated Framework for Implementation Research experts from Boston University, and reveal the underlying ASP patterns in the VA facilities in 2016. Results We identified 4 groups in the VA facilities in terms of enthusiasm and implementation level of antibiotic control in our ASP typology. We found the facilities with high implementation level and high enthusiasm in ASP and those with high implementation level but low enthusiasm had statistically significant 30% (p-value=0.002) and 22% (p-value=0.031) lower antibiotic use rates in broad-spectrum agents used for community infections, respectively than those with low implementation level and low enthusiasm. However, the facilities with high implementation and high enthusiasm also marginally increased antibiotic use rates in beta-lactam antibiotics (p-value=0.096). Conclusion The developed analytical framework in the study provided an approach to the granular assessment of the impact of the healthcare intervention programs and might be informative for future health service policy development. Disclosures Matthew B. Goetz, MD, Nothing to disclose
    Type of Medium: Online Resource
    ISSN: 2328-8957
    URL: Article
    DOI: 10.1093/ofid/ofab466.347
    Language: English
    Publisher: Oxford University Press (OUP)
    Publication Date: 2021
    detail.hit.zdb_id: 2757767-3
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  • 3
    Online Resource
    Online Resource
    Simulated Adoption of 2019 Community-Acquired Pneumonia Guidelines Across 114 Veterans Affairs Medical Centers: Estimated Impact on Culturing and Antibiotic Selection in Hospitalized Patients
    Oxford University Press (OUP) ; 2021
    In:  Clinical Infectious Diseases Vol. 72, No. Supplement_1 ( 2021-01-29), p. S59-S67
    Details
    In: Clinical Infectious Diseases, Oxford University Press (OUP), Vol. 72, No. Supplement_1 ( 2021-01-29), p. S59-S67
    Abstract: The 2019 American Thoracic Society/Infectious Diseases Society of America guidelines for community-acquired pneumonia (CAP) revised recommendations for culturing and empiric broad-spectrum antibiotics. We simulated guideline adoption in Veterans Affairs (VA) inpatients. Methods For all VA acute hospitalizations for CAP from 2006–2016 nationwide, we compared observed with guideline-expected proportions of hospitalizations with initial blood and respiratory cultures obtained, empiric antibiotic therapy with activity against methicillin-resistant Staphylococcus aureus (anti-MRSA) or Pseudomonas aeruginosa (antipseudomonal), empiric “overcoverage” (receipt of anti-MRSA/antipseudomonal therapy without eventual detection of MRSA/P. aeruginosa on culture), and empiric “undercoverage” (lack of anti-MRSA/antipseudomonal therapy with eventual detection on culture). Results Of 115 036 CAP hospitalizations over 11 years, 17 877 (16%) were admitted to an intensive care unit (ICU). Guideline adoption would slightly increase respiratory culture (30% to 36%) and decrease blood culture proportions (93% to 36%) in hospital wards and increase both respiratory (40% to 100%) and blood (95% to 100%) cultures in ICUs. Adoption would decrease empiric selection of anti-MRSA (ward: 27% to 1%; ICU: 61% to 8%) and antipseudomonal (ward: 25% to 1%; ICU: 54% to 9%) therapies. This would correspond to greatly decreased MRSA overcoverage (ward: 27% to 1%; ICU: 56% to 8%), slightly increased MRSA undercoverage (ward: 0.6% to 1.3%; ICU: 0.5% to 3.3%), with similar findings for P. aeruginosa. For all comparisons, P  & lt; .001. Conclusions Adoption of the 2019 CAP guidelines in this population would substantially change culturing and empiric antibiotic selection practices, with a decrease in overcoverage and slight increase in undercoverage for MRSA and P. aeruginosa.
    Type of Medium: Online Resource
    ISSN: 1058-4838 , 1537-6591
    URL: Article
    DOI: 10.1093/cid/ciaa1604
    RVK:
    XA 10000
    Language: English
    Publisher: Oxford University Press (OUP)
    Publication Date: 2021
    detail.hit.zdb_id: 2002229-3
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  • 4
    Online Resource
    Online Resource
    1020. Variations in inpatient and outpatient antibiotic use – opportunities for improvement and facility-level feedback
    Oxford University Press (OUP) ; 2019
    In:  Open Forum Infectious Diseases Vol. 6, No. Supplement_2 ( 2019-10-23), p. S359-S359
    Details
    In: Open Forum Infectious Diseases, Oxford University Press (OUP), Vol. 6, No. Supplement_2 ( 2019-10-23), p. S359-S359
    Abstract: Participation in the Antibiotic Use (AU) option of the National Health Safety Network (NHSN), provides medical facilities with the Standardized Antibiotic Administration Ratio (SAAR), a normalized ratio of facility antibiotic use. However, the range of antibiotic use by similar facilities is not provided and thus the opportunity to “nudge” behavior by comparing use with “best facilities” is lost. We developed reports of variations of antibiotic use that allow comparisons of local antibiotic use with that of 107 other VA facilities. Methods Data for 2018 were extracted from the VA Corporate Data Warehouse. Antibiotic use in CY2018 on acute inpatient care units was assessed as days of therapy (using CDC-defined drug classes) per 1000 days-present. In addition, we assessed the proportion of patients with pneumonia, urinary tract infections or skin-soft-tissue infections (collectively, PUS) who received anti-MRSA therapy or ß-lactam therapy directed against multi-drug-resistant and hospital GNR (anti-MDRGNR) during hospital days 0–2 (CHOICE, a timeframe representing empiric therapy). Results Rates of total antibiotic use by VA facility varied over two-fold from 460 to 965 days of therapy (DOT)/1000 days-present (DP); anti-MRSA and anti-MDRGNR varied over four-fold, from 44 to 184 and, 55 to 262, respectively. Fluoroquinolone variation was even higher, ranging over 8-fold, from 17 to 145 DOT/1000 DP (Figure 1). Substantial variations were also observed in the frequency of administration of anti-MRSA and anti-MDRGNR therapy for PUS during CHOICE (14 to 49% and 15 to 65%, respectively; Figure 2). Conclusion The large variations in the use of total antibiotic therapy, anti-MRSA, anti-MDRGNR and fluoroquinolone therapies are greater than can be readily explained by known variations in antibiotic resistance or differences in case-mix within the VA. Efforts are underway in the VA to strengthen antimicrobial stewardship programs. In other work, we have shown improvements in antimicrobial use among sites that have access to reports that provide the data described herein and that participate in group collaboratives. Our group is now making these data available to all VA facilities. Disclosures All authors: No reported disclosures.
    Type of Medium: Online Resource
    ISSN: 2328-8957
    URL: Article
    DOI: 10.1093/ofid/ofz360.884
    Language: English
    Publisher: Oxford University Press (OUP)
    Publication Date: 2019
    detail.hit.zdb_id: 2757767-3
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  • 5
    Online Resource
    Online Resource
    Perspectives of Physician and Pharmacist Stewards on Successful Antibiotic Stewardship Program Implementation: A Qualitative Study
    Oxford University Press (OUP) ; 2020
    In:  Open Forum Infectious Diseases Vol. 7, No. 7 ( 2020-07-01)
    Details
    In: Open Forum Infectious Diseases, Oxford University Press (OUP), Vol. 7, No. 7 ( 2020-07-01)
    Abstract: Antibiotic stewardship programs (ASPs) are required at every hospital regardless of size. We conducted a qualitative study across different hospital settings to examine perspectives of physician and pharmacist stewards about the dynamics within their team and contextual factors that facilitate the success of their programs. Methods Semistructured interviews were conducted in March–November 2018 with 46 ASP stewards, 30 pharmacists, and 16 physicians, from 39 hospitals within 2 large hospital systems. Results We identified 5 major themes: antibiotic stewards were enthusiastic about their role, committed to the goals of stewardship for their patients and as a public-health imperative, and energized by successful interventions; responsibilities of pharmacist and physician stewards are markedly different, and pharmacy stewards performed the majority of the day-to-day stewardship work; collaborative teamwork is important to improving care, the pharmacists and physicians supported each other, and pharmacists believed that having a strong physician leader was essential; provider engagement strategies are a critical component of stewardship, and recommendations must be communicated in a collegial manner that did not judge the provider competence, preferably through face-to-face interactions; and hospital leadership support for ASP goals and for protected time for ASP activities is critical for success. Conclusions The physician-pharmacist team is essential for ASPs; most have pharmacists leading and performing day-to-day activities with physician support. Collaborative, persuasive approaches for ASP interventions were the norm. Stewards were careful not to criticize or judge inappropriate antibiotic prescribing. Further research should examine whether this persuasive approach undercuts provider appreciation of stewardship as a public health mandate.
    Type of Medium: Online Resource
    ISSN: 2328-8957
    URL: Article
    DOI: 10.1093/ofid/ofaa229
    Language: English
    Publisher: Oxford University Press (OUP)
    Publication Date: 2020
    detail.hit.zdb_id: 2757767-3
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  • 6
    Online Resource
    Online Resource
    1058. Decreases in Antibiotic Use Associated with the Implementation of Electronic Antibiotic Visualization Tools for Stewards at Eight Veterans Affairs (VA) Healthcare Facilities
    Oxford University Press (OUP) ; 2019
    In:  Open Forum Infectious Diseases Vol. 6, No. Supplement_2 ( 2019-10-23), p. S374-S374
    Details
    In: Open Forum Infectious Diseases, Oxford University Press (OUP), Vol. 6, No. Supplement_2 ( 2019-10-23), p. S374-S374
    Abstract: To identify areas for improved antibiotic use, we developed and pilot-tested visualization tools to quantify antibiotic use at 8 VA facilities. These tools allow a facility to review its patterns of total use, and use by antibiotic class, compared with patterns of use at VA facilities with similar (or user-selected) complexity levels. Methods Antibiotic stewards from 8 VA facilities participated in iterative report development and implementation, with the final product consisting of two components: an interactive web-based antibiotic dashboard and a standardized antibiotic usage report updated at user-selected intervals. Stewards also participated in monthly learning collaboratives. The percent change in average monthly antimicrobial use (all antibiotics; anti-methicillin-resistant S. aureus agents (anti-MRSA); and broad-spectrum agents predominantly used for hospital-onset/multi-drug-resistant organisms (anti-MDRO)) was analyzed using a pre-post (January 2014–January 2016 vs. July 2016–January 2018) with un-involved controls (all other inpatient VA facilities, n = 132) design modeled using Generalized Estimation Equations segmented regression. Results Intervention sites had a 2.1% decrease (95% CI = [−5.7%,1.6%]) in all antibiotic use pre-post-intervention, vs. a 2.5% increase (95% CI = [0.8%, 4.1%] ) in nonintervention sites (P = 0.025 for difference). Anti-MRSA antibiotic use decreased 11.3% (95% CI = [−16.0%,−6.3%]) at intervention sites vs. a 6.6% decrease (95% CI=[−9.1%, −3.9%] ) at nonintervention sites (P = 0.092 for difference). Anti-MDRO antibiotic use decreased 3.4% (95% CI = [−8.2%,1.7%]) at intervention sites vs. a 3.6% increase (95% CI = [0.8%,6.5%] ) at nonintervention sites (P = 0.018 for difference) (Figure 1). Examples of graphs include overall antibacterial use (Figure 2), and usage of broad-spectrum Gram-negative therapy (Figure 3) in intensive care units. Conclusion The use of data visualization tools use and participation in monthly learning collaboratives by antimicrobial stewards in a pilot implementation project at eight VA facilities was associated with decreases in antimicrobial use relative to uninvolved sites. Disclosures All authors: No reported disclosures.
    Type of Medium: Online Resource
    ISSN: 2328-8957
    URL: Article
    DOI: 10.1093/ofid/ofz360.922
    Language: English
    Publisher: Oxford University Press (OUP)
    Publication Date: 2019
    detail.hit.zdb_id: 2757767-3
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  • 7
    Online Resource
    Online Resource
    2218. Feasibility of Automated Prediction of Drug Resistance in Pneumonia in the Veteran Population.
    Oxford University Press (OUP) ; 2019
    In:  Open Forum Infectious Diseases Vol. 6, No. Supplement_2 ( 2019-10-23), p. S756-S757
    Details
    In: Open Forum Infectious Diseases, Oxford University Press (OUP), Vol. 6, No. Supplement_2 ( 2019-10-23), p. S756-S757
    Abstract: To enhance antimicrobial decision-making in community-onset pneumonia, several manually calculable clinical scores have been proposed to predict drug-resistant organisms (DRPs), most commonly methicillin-resistant Staphylococcus aureus or Pseudomonas aeruginosa. The Drug Resistance in Pneumonia (DRIP) score includes 10 features that can be calculated by providers at the bedside but is potentially automatically extractable from an electronic health record (EHR). We aimed to explore the feasibility of calculating an automated “eDRIP” score from the EHR in the Veteran’s Affairs (VA) population. Methods We extracted patient characteristics, features relevant to the DRIP score, and detection of DRPs among all inpatient admissions for pneumonia between August 29, 2010 and July 31, 2013 at VA hospitals nationwide using EHR data from the VA corporate data warehouse. We calculated an eDRIP score for each admission. We compared the prevalence of each electronically extracted feature to that reported in a separate study of manually extracted factors performed at the Salt Lake City VA by Babbel et al, and to the original DRIP score validation cohort from Webb et al. Results Among 101,462 pneumonia admissions across 114 VA hospitals, 4% had a DRP detected on culture, 25% had an eDRIP ≥ 4, and 50% received broad-spectrum antibiotics. The Salt Lake City VA demonstrated slightly lower prevalence of eDRIP factors than the national population (table). Within the Salt Lake City VA, the EHR cohort and manually extracted Babbel cohort demonstrated similar prevalence of detected DRP’s, DRIP ≥ 4, and 8 of 10 features involved in the DRIP score (table). The eDRIP identified fewer hospitalizations with poor functional status and residence in long-term facilities. Conclusion In a large population of veterans admitted for community-onset pneumonia, automated extraction of an eDRIP score from the EHR was promising, though in need of revision. While some extracted features had similar prevalence to manual review, others differed by a factor of 10 or more, which may reflect issues with data extraction. Further work is needed to optimize feature extraction and compare electronic to manual DRIP scores to determine its utility within the VA population. Disclosures All authors: No reported disclosures.
    Type of Medium: Online Resource
    ISSN: 2328-8957
    URL: Article
    DOI: 10.1093/ofid/ofz360.1896
    Language: English
    Publisher: Oxford University Press (OUP)
    Publication Date: 2019
    detail.hit.zdb_id: 2757767-3
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  • 8
    Online Resource
    Online Resource
    152. Applying A Difference-in-Difference Analysis to Assess Effect of Antimicrobial Stewardship Strategies on Changes in Antimicrobial Use
    Oxford University Press (OUP) ; 2020
    In:  Open Forum Infectious Diseases Vol. 7, No. Supplement_1 ( 2020-12-31), p. S86-S86
    Details
    In: Open Forum Infectious Diseases, Oxford University Press (OUP), Vol. 7, No. Supplement_1 ( 2020-12-31), p. S86-S86
    Abstract: About 30–50% of inpatient antimicrobial therapy is sub-optimal. Health care facilities have utilized various antimicrobial stewardship (AS) strategies to optimize appropriate antimicrobial use, improve health outcomes, and promote patient safety. However, little evidence exists to assess relationships between AS strategies and antimicrobial use. This study examined the impact of changes in AS strategies on antimicrobial use over time. Methods This study used data from the Veterans Affairs (VA) Healthcare Analysis & Informatics Group (HAIG) AS survey, administered at 130 VA facilities in 2012 and 2015, and antimicrobial utilization from VA Corporate Data Warehouse. Four AS strategies were examined: having an AS team, feedback mechanism on antimicrobial use, infectious diseases (ID) attending physicians, and clinical pharmacist on wards. Change in AS strategies were computed by taking the difference in the presence of a given strategy in a facility between 2012–2015. The outcome was the difference between antimicrobial use per 1000 patient days in 2012–2013 and 2015–2016. Employing multiple regression analysis, changes in antimicrobial use was estimated as a function of changes in AS strategies, controlling for ID human resources in and organizational complexity. Results Of the 4 strategies, only change in availability of AS teams had an impact on antimicrobial use. Compared to facilities with no AS teams at both time points, antibiotic use decreased by 63.9 uses per 1000 patient days in facilities that did not have a AS team in 2012 but implemented one in 2015 (p=0.0183). Facilities that had an AS team at both time points decreased use by 62.2 per 1000 patient days (p=0.0324). Conclusion The findings showed that AS teams reduced inpatient antibiotic use over time. While changes in having feedback on antimicrobial use and clinical pharmacist on wards showed reduced antimicrobial use between 2012–2015, the differences were not statistically significant. These strategies may already be a part of a comprehensive AS program and employed by AS teams. In further development of stewardship programs within healthcare organizations, the association between AS teams and antibiotic use should inform program design and implementation. Disclosures All Authors: No reported disclosures
    Type of Medium: Online Resource
    ISSN: 2328-8957
    URL: Article
    DOI: 10.1093/ofid/ofaa439.197
    Language: English
    Publisher: Oxford University Press (OUP)
    Publication Date: 2020
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  • 9
    Online Resource
    Online Resource
    Comparative Effectiveness of Vancomycin and Metronidazole for the Prevention of Recurrence and Death in Patients With Clostridium difficile Infection
    American Medical Association (AMA) ; 2017
    In:  JAMA Internal Medicine Vol. 177, No. 4 ( 2017-04-01), p. 546-
    Details
    In: JAMA Internal Medicine, American Medical Association (AMA), Vol. 177, No. 4 ( 2017-04-01), p. 546-
    Type of Medium: Online Resource
    ISSN: 2168-6106
    URL: Article
    DOI: 10.1001/jamainternmed.2016.9045
    Language: English
    Publisher: American Medical Association (AMA)
    Publication Date: 2017
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  • 10
    Online Resource
    Online Resource
    Variation in Empiric Coverage Versus Detection of Methicillin-Resistant Staphylococcus aureus and Pseudomonas aeruginosa in Hospitalizations for Community-Onset Pneumonia Across 128 US Veterans Affairs Medical Centers
    Cambridge University Press (CUP) ; 2017
    In:  Infection Control & Hospital Epidemiology Vol. 38, No. 8 ( 2017-08), p. 937-944
    Details
    In: Infection Control & Hospital Epidemiology, Cambridge University Press (CUP), Vol. 38, No. 8 ( 2017-08), p. 937-944
    Abstract: To examine variation in antibiotic coverage and detection of resistant pathogens in community-onset pneumonia. DESIGN Cross-sectional study. SETTING A total of 128 hospitals in the Veterans Affairs health system. PARTICIPANTS Hospitalizations with a principal diagnosis of pneumonia from 2009 through 2010. METHODS We examined proportions of hospitalizations with empiric antibiotic coverage for methicillin-resistant Staphylococcus aureus (MRSA) and Pseudomonas aeruginosa (PAER) and with initial detection in blood or respiratory cultures. We compared lowest- versus highest-decile hospitals, and we estimated adjusted probabilities (AP) for patient- and hospital-level factors predicting coverage and detection using hierarchical regression modeling. RESULTS Among 38,473 hospitalizations, empiric coverage varied widely across hospitals (MRSA lowest vs highest, 8.2% vs 42.0%; PAER lowest vs highest, 13.9% vs 44.4%). Detection rates also varied (MRSA lowest vs highest, 0.5% vs 3.6%; PAER lowest vs highest, 0.6% vs 3.7%). Whereas coverage was greatest among patients with recent hospitalizations (AP for anti-MRSA, 54%; AP for anti-PAER, 59%) and long-term care (AP for anti-MRSA, 60%; AP for anti-PAER, 66%), detection was greatest in patients with a previous history of a positive culture (AP for MRSA, 7.9%; AP for PAER, 11.9%) and in hospitals with a high prevalence of the organism in pneumonia (AP for MRSA, 3.9%; AP for PAER, 3.2%). Low hospital complexity and rural setting were strong negative predictors of coverage but not of detection. CONCLUSIONS Hospitals demonstrated widespread variation in both coverage and detection of MRSA and PAER, but probability of coverage correlated poorly with probability of detection. Factors associated with empiric coverage (eg, healthcare exposure) were different from those associated with detection (eg, microbiology history). Providing microbiology data during empiric antibiotic decision making could better align coverage to risk for resistant pathogens and could promote more judicious use of broad-spectrum antibiotics. Infect Control Hosp Epidemiol 2017;38:937–944
    Type of Medium: Online Resource
    ISSN: 0899-823X , 1559-6834
    URL: Article
    DOI: 10.1017/ice.2017.98
    Language: English
    Publisher: Cambridge University Press (CUP)
    Publication Date: 2017
    detail.hit.zdb_id: 2106319-9
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