A urinary tract infection is amongst the most common bacterial infections in the community and hospital setting and accounts for an estimated 1.6 to 2.14 billion in national healthcare expenditure. Despite its financial impact, the diagnosis is challenging with urine cultures and antibiotics often inappropriately ordered for non-specific symptoms or asymptomatic bacteriuria. In an attempt to limit unnecessary laboratory testing and antibiotic overutilization, several diagnostic stewardship initiatives have been described in the literature. We conducted a systematic review with a focus on the application of molecular and microbiological diagnostics, clinical decision support, and implementation of diagnostic stewardship initiatives for urinary tract infections. The most successful strategies utilized a bundled, multidisciplinary, and multimodal approach involving nursing and physician education and feedback, indication requirements for urine culture orders, reflex urine culture programs, cascade reporting, and urinary antibiograms. Implementation of antibiotic stewardship initiatives across the various phases of laboratory testing (i.e., pre-analytic, analytic, post-analytic) can effectively decrease the rate of inappropriate ordering of urine cultures and antibiotic prescribing in patients with clinically ambiguous symptoms that are unlikely to be a urinary tract infection.
Background In an effort to reduce strain on healthcare systems with patient hospitalizations and deaths due to COVID-19, the US Food and Drug Administration (FDA) issued an Emergency Use Authorization (EUA) for 2 monoclonal antibodies for the treatment of COVID-19 in November 2020: bamlanivimab (BAM) and casirivmab-imdevimab (CAS-IMD). While clinical trial data demonstrated reductions in hospitalization rate, real-world data at the time of approval was vastly limited. Methods A retrospective chart review of non-hospitalized patients who received either BAM or CAS-IMD from November 27th, 2020 to February 16th, 2021. Variables included timing of monoclonal antibody infusion, adverse events, and 30-day hospitalization rate. Descriptive statistics were calculated for all data. Results 101 patients received either BAM (75.2%) or CAS-IMD (24.8%) at a median of 6 days (IQR 4-7) from reported symptom onset. The most commonly reported symptoms of COVID-19 at time of referral were cough (57.4%), fever (29.7%), and myalgia (27.7%). All patients (100%) had at least 1 documented EUA defined risk factor for severe COVID-19 (Table 1). Following transfusion, 7/101 (6.9%) and 3/101 (3.0%) experienced mild to moderate and severe adverse events, respectively (Table 2). At day 30, 5 patients (5.0%) were hospitalized with COVID-19 at a median of 7 days (IQR 3-8) post monoclonal antibody infusion. Conclusion We observed a higher frequency of hospitalization compared to 1.6% for BAM in BLAZE-1 and 3% for CAS-IMD in REGN-COV-2. This observation may reflect our higher risk population as all patients presented with at least 1 risk factor for severe disease compared to 69.6% and 65.0% in BAM and CAS-IMD clinical trials, respectively. Additionally, patients presented with longer durations of symptoms prior to infusion in our study population compared to 3 days reported in BAM and 4 days reported in CAS-IMD trials. Since the conclusion of this study, the FDA revoked the EUA for BAM administered alone based on increased observations of resistant variants to BAM monotherapy. However, our observations highlight the need for further exploration in the prevention of hospitalization in high risk populations as well as the optimal timing of monoclonal antibody therapy. Disclosures All Authors: No reported disclosures
Background Unnecessary use of broad-spectrum antibiotics due to false antibiotic allergy labels leads to an increase in drug resistant and health care associated infections. Therefore, allergy assessments to de-label patients not truly allergic is an important antimicrobial stewardship (AMS) tool. The purpose of this study was to assess the effectiveness of a pharmacy-led questionnaire and AMS rounds in improving the accuracy of beta-lactam allergy labels (BLA). Methods AMS piloted BLA de-labeling rounds three times a week from November 1, 2021 to April 1, 2022. Rounds consisted of an infectious disease physician and an AMS pharmacist that reviewed allergy questionnaires conducted by trained pharmacy personnel. The questionnaire was provided to patients 18 years or older with a documented BLA and an admission stay of two or more nights. Patients were excluded if unable to participate or did not have a representative available for interview. The primary outcomes evaluated were: (i) direct de-labelling (ii) future de-labeling upon patient consent (iii) allergy profile changes. The secondary outcomes were potential days of therapy (DOTs) saved for anti-MRSA agents (vancomycin, linezolid, clindamycin) and fluoroquinolones (ciprofloxacin, levofloxacin) and PEN-FAST scores for those with a penicillin-specific allergy. Results 93 of 96 patients interviewed (96.9%) had their allergy profile updated to include type, severity, or timing of reaction. 82 of 96 patients (85.4%) were classified as low-risk allergies in which 11 patients (13.4%) were successfully de-labeled and 18 patients (22.0%) were eligible for de-labeling upon patient consent. The remaining patients were eligible for further interrogation with an oral challenge (Figure 1). Potential DOTs saved were 131 and 67 days for anti-MRSA agents and fluoroquinolones, respectively. Average PEN-FAST scores for those de-labeled and eligible for oral challenge was 0.5 (SD 0.85) and 1.08 (SD 1.20), respectively. Conclusion AMS BLA assessments can decrease the prevalence of false BLA labels and prescribing of unnecessary broad-spectrum agents. PEN-FAST scores less than 2 suggests that allergy assessments help identify patients with low-risk penicillin allergies. Disclosures All Authors: No reported disclosures.
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