73. Identification of Novel Factors Associated with Inappropriate Treatment of Asymptomatic Bacteriuria Treatment in Acute and Long-term Care

Abstract Background Inappropriate treatment of asymptomatic bacteriuria (ASB) is a major driver of antibiotic overuse. Demographic and laboratory factors associated with inappropriate antibiotic treatment include older age, pyuria, leukocytosis and dementia. To gain a deeper understanding of inappropriate ASB treatment, we performed an in-depth review of provider documentation capturing a broader range of misleading factors associated with ASB treatment. Methods We reviewed a random sample of 10 positive urine cultures per month per facility from acute or long-term care wards at eight Veteran’s Administration (VA) facilities from 2017-2019 (n=960). Trained chart reviewers classified cultures as UTI or ASB and as treated or untreated. Charts were searched specifically for mention of 8 categories of potentially misleading symptoms that often lead to overtreatment of ASB (e.g. “prior history of UTI”) (Figure legend). We also created a ‘suspected systemic inflammatory response syndrome (SIRS)’ category that included any mention of leukocytosis, tachycardia, tachypnea, subjective or low-grade fever, or hypothermia. Generalized estimating equations logistic regression was used for analysis. Results Our study included 575 cultures from patients that were primarily white (71%) males (94%) from acute medicine units (75.7%) with a mean age of 76. Twenty-eight percent (n=159) of ASB cases received antibiotics. In addition to the usual known predictors, multiple new misleading symptoms were found to be associated with ASB treatment (Table). Novel, independent predictors of ASB treatment included behavioral issues, such as falls or fatigue (odds ratio (OR): 1.8; 95% CI: 1.05-3.07), urine characteristics, such as cloudy or odorous urine (OR: 1.41; 95% CI: 1.13-1.75), voiding issues (OR: 1.86; 95% CI: 1.43-2.41), and a single, free text mention of a SIRS criteria (OR: 1.63; 95% CI: 1.16-2.3). P-values extracted from multivariate regression model (ASB-asymptomatic bacteriuria; NS-not significant; SIRS- systemic inflammatory response syndrome). The following signs or symptoms compose each category: abnormal laboratory findings: acute kidney injury, abnormal creatinine, leukocytosis, pyuria/positive urinalysis, hyperglycemia; abnormal vital sign: bradycardia, tachycardia, atrial fibrillation, hypotension, hypertension, hypoxia, tachypnea, subjective fever or low-grade fever, syncope; behavior issues: falls, confusion lethargy, fatigue, weakness; nonspecific signs or symptoms: nonspecific gastrointestinal, genitourinary, neurological symptoms; voiding issues: decreased urine output, urinary retention, urinary incontinence; urine characteristics: change in color, foul smell, cloudy urine, sediment; SIRS: ordinal variable characterizing if 1 or ≥ 2 of the following were documented by the provider: leukocytosis, tachycardia, tachypnea, subjective or low-grade fever, hypothermia. Conclusion Our in-depth chart review, with attention to misleading symptoms and any documentation of the provider thought process, highlights new factors associated with inappropriate ASB treatment. Patients with even a single SIRS criteria are at risk for unnecessary treatment of ASB; this finding can help design antibiotic stewardship interventions. Disclosures Barbara Trautner, MD, PhD, Genentech (Consultant, Scientific Research Study Investigator)


Evaluation of Acclerate Pheno™ on Clinical and Antimicrobial Outcomes in Patients with Methicillin Susceptible Staphylococcus aureus Bloodstream Infections
Deanna Berg, PharmD Candidate 1 ; William P. DePasquale, PharmD Candidate 2 ; Mary L. Staicu, PharmD 3 ; Sean Stainton, PharmD 3 ; Mindee Hite, PharmD 3 ; Maryrose R. Laguio-Vila, MD 4 ; 1 Wegmans School of Pharmacy, Rochester Regional Hospital, Penfield, New York; 2 Wegmans School of Pharmacy, Rochester General Hospital, Victor, New York; 3 Rochester General Hospital, Rochester, New York; 4 Rochester Regional Health, Rochester, NY Session: P-05. Antimicrobial Stewardship: Diagnostics/Diagnostic Stewardship Background. Anti-staphylococcal beta-lactams (BL) are treatment of choice for methicillin-susceptible Staphylococcus aureus (MSSA) bloodstream infections (BSI) as they have superior MSSA bacteremia clearance. Based on the hypothesis that earlier initiation of anti-staphylococcal BL may improve clinical outcomes, this study compared clinical and microbiologic features of patients with MSSA BSI pre-and post-implementation of Accelerate Pheno™ (AXDX).
Methods. This was a case-control analysis of adult inpatients with MSSA BSI analyzed using AXDX compared to traditional laboratory methods. Cases were prospectively identified by the antimicrobial stewardship team between August and October 2020 post implementation of AXDX in July 2020. Patients were matched with historical controls (July 2018-July 2020) based on age (±4 years), gender, organism, and source of infection. The primary outcome was time to antibiotic (abx) deescalation to an anti-staphylococcal beta-lactam. Secondary outcomes included hospital length of stay (LOS), 30-day allcause mortality and hospital readmission, and 60-day C. difficile infection.
Results. A total of 25 cases with MSSA BSI were identified, of which 18 (72%) were matched to historical controls. Of these patients, 12 (67%) were male with an average age of 67 years (SD ±12). Other demographics were similar between groups. The median time to species identification [21.3 hours in cases (IQR 14-31.9) vs 33.3 hours in controls (29-41.7), p=0.046] and abx susceptibilities [22.5 hours (18.8 -42) vs 60.1 hours (46-61.9), p< 0.001] were significantly shorter in cases. The average time to abx deescalation from time to organism susceptibility was 1.7 days (±1.9) for cases compared to 2.7 days (±1.5) for controls (p = 0.129). There were no significant differences detected in hospital LOS, 30-day mortality or readmission, and 60-day C.difficile infection.
Conclusion. Although time to organism identification and abx susceptibilities was significantly shorter in cases, AXDX was not associated with a statistically significant reduction in time to anti-staphylococcal BL initiation nor a difference in associated clinical outcomes. A trend in shorter time to abx de-escalation was observed and warrants further investigation in a larger population.
Disclosures. Background. Inappropriate treatment of asymptomatic bacteriuria (ASB) is a major driver of antibiotic overuse. Demographic and laboratory factors associated with inappropriate antibiotic treatment include older age, pyuria, leukocytosis and dementia. To gain a deeper understanding of inappropriate ASB treatment, we performed an in-depth review of provider documentation capturing a broader range of misleading factors associated with ASB treatment.
Methods. We reviewed a random sample of 10 positive urine cultures per month per facility from acute or long-term care wards at eight Veteran's Administration (VA) facilities from 2017-2019 (n=960). Trained chart reviewers classified cultures as UTI or ASB and as treated or untreated. Charts were searched specifically for mention of 8 categories of potentially misleading symptoms that often lead to overtreatment of ASB (e.g. "prior history of UTI") ( Figure legend). We also created a 'suspected systemic inflammatory response syndrome (SIRS)' category that included any mention of leukocytosis, tachycardia, tachypnea, subjective or low-grade fever, or hypothermia. Generalized estimating equations logistic regression was used for analysis.