Background: Incorporating diversity, equity, inclusion, and justice into healthcare ensures equitable opportunity to achieve optimal health. Infectious diseases, antimicrobial stewardship, and infection prevention teams rely on consultative recommendations to improve patient care which may be influenced by implicit and explicit biases of the recipient treatment teams. Little is known about how race, ethnicity, and other characteristics impact stewardship and infection control recommendations. Methods: A survey of infectious diseases, antimicrobial stewardship, and infection prevention practitioners was developed through the Society of Healthcare Epidemiology of America (SHEA) Antimicrobial Stewardship Committee. The survey was sent electronically to members of the SHEA Research Network and was promoted to attendees of two sessions at IDWeek 2022 and SHEA Spring 2023. Survey questions included demographics, awareness of (and participation in) unconscious bias and microaggression training at their institutions, antibiotic prescribing bias observations, and perceptions of how race, ethnicity, and other characteristics have influenced participants' antimicrobial stewardship and infection prevention recommendations. Descriptive statistics were performed using SAS V.9.4 . Results: Among 175 survey respondents, 75% (n=129) were White, 16% (n=27) were Asian, 4% (n=7) were Black, 85% (n=150) were non-Hispanic, 5% (n=8) were Hispanic, and 3% (n=5) reported ethnicity as multiethnic. 76% of respondents identified as female, and 2% as non-binary or gender-fluid. 29% of respondents had a medical degree, 12% had a nursing degree, 7% had a pharmacy degree, and 52% had a degree listed as other (7% had a PhD, 23% had an MPH/MSPH degree, and 15% had an MS degree). 65% and 49% of respondents had participated in unconscious bias and microaggression training, respectively. 18% (n=22) of White respondents, 43% (n=3) of Black respondents, and 30% (n=8) of Asian respondents reported witnessing antimicrobial prescribing influenced by race, ethnicity, or other characteristics. 17% and 15% of respondents felt that their antimicrobial stewardship and infection prevention recommendations, respectively, had not been accepted due to their race, ethnicity, gender identity, or other personal identifiers. Conclusion: This survey showed demographic characteristics of professionals working in infectious diseases and their perceptions of how certain aspects of their identity have influenced their recommendations. Differences between racial groups were observed in how frequently respondents witnessed inequities in antimicrobial prescribing, and many respondents felt their recommendations had not been accepted due to their identity. A limitation of this analysis is that few Black individuals completed the survey, which makes comparisons by race difficult; however, the respondents were consistent with SHEA membership demographics.

Background: Inequities in healthcare-associated infections (HAI) incidence and prevention measures are critically important to understand (Chen,2021). While evaluations are beginning to characterize these disparities by infection type (Gettler, 2023), our work expands this by characterizing disparities by prevention strategies. By better understanding how evidence-based prevention strategies are implemented at the patient level, infection preventionists and hospital epidemiologists can better design strategies that provide equitable care to all patients. Methods: Beginning January 2023, gender, race, ethnicity, spoken language, and age group fields were added to daily chlorhexidine gluconate (CHG) treatment and C. difficile test order compliance data captured via electronic medical record. In July 2023, fields on recorded race, ethnicity, and gender were added to well-established foley and vascular access real-time peer audit tools that are used by infection preventionists (IPs). Each prevention strategy variable was summarized by demographic variables and differences in compliance were measured using chi-square tests. Results: 899 vascular audits and 420 foley audits were completed by IPs between July – December 2023. In 2023, there were 114,066 opportunities for CHG Treatment and 1,991 C. difficile test orders. Missing data varied by metric but ranged from 0-60%. Statistically significant differences by race were found in 3 of 8 components (i.e., intact seal, secured catheter and absence of dependent loop) in the foley audit (p < 0 .01) and compliance with C. difficile test ordering (p < 0 .01). No differences in race were found in vascular access audits or CHG treatment. No differences in gender or ethnicity were noted in foley, vascular access audits, CHG treatment compliance, or C. difficile testing. Differences in gender and age were found in CHG treatment compliance (p < 0 .001). Conclusions: By focusing more on patient level process measures rather than only presenting stratified outcomes data, we can identify targeted opportunities for improvement in health equity before our patients develop an HAI. Further evaluations should also focus on assessing the clinical relevance of statistical findings to better inform intervention strategies. Separately, efforts are needed to improve completeness and integrity of demographic data in the electronic medical record.

Background: Among children who start antibiotics for suspected urinary tract infection (UTI) in emergency departments (EDs), 40-60% have negative urine cultures or other results inconsistent with UTI. Practices contributing to excess antibiotic exposure are not well understood. The goal of this study was to understand diagnostic and post-encounter follow-up processes in children who received antibiotics, in order to define targets for intervention. Methods: We identified encounters by children evaluated in two pediatric EDs, over 2 months in the first ED and 9 months in the second ED, to balance different visit volumes. Children 2 months-17 years old were included if they had a urinalysis (UA) and/or urine culture performed, were assigned a primary or secondary diagnosis code for UTI, and initiated antibiotics. Patients were excluded if they received antibiotics prior to the encounter, had prior urologic surgery or device placement, or were immunocompromised or pregnant. Data abstracted by chart review included demographics, documented symptoms, test results, and documented urine culture review and management. Possible UTI symptoms per pediatric criteria included fever, dysuria, urinary frequency, urgency, or hesitancy, suprapubic, abdominal or flank pain, foul smelling urine, or new urinary incontinence. In both EDs, nurses review urine cultures and document changes to treatment plans. Final urine culture results were considered inconsistent with UTI if there was 1) no growth or 2) only mixed growth reported with quantity < 1 00,000 colony forming units/ml. Results: Of 150 eligible children, 146 (97%) had at least one UTI symptom and 146 (97%) had abnormal UA Results: Urine cultures were not performed in 27 (18%) children. Of 123 encounters with urine cultures performed, 71 (58%) had results inconsistent with UTI. Though 67/71 cultures were marked as reviewed, 43/67 (64%) of the patients who could have stopped antibiotics per guideline recommendations did not have documented plans to stop. In those who had documented plans to stop antibiotics, nurses reached 20/23 (87%) caregivers by phone to communicate these recommendations. Conclusion: Many children suspected to have UTI at the time of ED evaluation do not meet criteria for UTI. We found that the most frequent departures from evidence-based practice recommendations were 1) not sending urine cultures, and 2) not stopping antibiotics when culture results did not support the suspected UTI diagnosis. Further investigation should explore barriers and facilitators to these evidence-based practices to develop population- and context-specific diagnostic stewardship strategies.

Background: The Streptococcal pneumoniae urine antigen (SPUA) test was developed to increase microbiologic diagnosis of pneumonia. Concerns have been raised about the test’s low sensitivity and failure to alter outcomes by de-escalating antibiotics (PMID:31956656). However, the cost-effectiveness and real-world clinical utility of the test remain unclear. Methods: From June 1, 2022 - May 31, 2023, all patients with a SPUA test in the MUSC Health System were identified via Epic SlicerDicer. Those with a positive test underwent chart review. Antibiotics were classified as a “broad” or “targeted” regimen for S. pneumoniae. Targeted regimens included penicillins without beta-lactamase inhibitors, 1st-3rd generation cephalosporins, doxycycline, levofloxacin or moxifloxacin (with or without azithromycin), as well as azithromycin monotherapy. Broad regimens included 4th generation or higher cephalosporins, carbapenems, penicillins with beta-lactamase inhibitors, and vancomycin. Results: In one year, 1,518 patients had a SPUA test ordered. 62 (4%) patients had a positive test. Of those 62 patients, 14 patients were discharged before the test resulted (Table). The average turnaround time for the test was 2.2 days. When comparing antibiotic therapy on the day before the SPUA test resulted to two days after the test resulted, only 7 additional patients were switched to a targeted regimen (Figure). Conclusion: Of 1,518 SPUA tests ordered in a year, most (1,456 or 96%) were negative, with minimal changes to antibiotic therapy based on positive Results: These results are similar to other real-world studies, which showed a positive test prevalence between 4-8% (PMID:30265290) with 15-30% of patients changed to targeted antibiotics following a positive result (PMID:23111919, PMID: 28053969). The SPUA test cost approximately $44,022 (based on $29 test price) but has limited utility in a real-world setting.

Disclosure: Krutika Hornback: Speaker’s Bureau - Cepheid Diagnostics

Beta-lactam therapeutic drug monitoring has been growing in prevalence in the acute care hospital setting. Expansion of its use to outpatient parenteral antimicrobial therapy requires careful consideration of potential logistical and therapeutic barriers.

Background: Multiplex molecular tests for infectious diseases can provide highly sensitive results rapidly; however, these tests may more readily detect asymptomatic colonization. There are reports of non-FDA approved laboratory-developed multiplex tests for the diagnosis of urinary tract infections (UTI). Differentiating UTI from asymptomatic bacteriuria is challenging, especially in older adults. The increased sensitivity of multiplex tests may exacerbate this challenge. We sought to describe the use of multiplex testing for UTIs in Medicare claims. Methods: Multiplex testing was identified using carrier claims submitted by non-institutional providers using the Chronic Conditions Warehouse for 2016 – 2022. Because there are no CPT-4 codes specifying UTI multiplex testing, we included claims as described in Figure 1 and categorized claims based on the primary ICD-10-CM diagnosis. The payment amounts for line items related to testing for infectious agents were summed. Laboratories were counted using CLIA numbers listed on corresponding claims. Beneficiaries residing in a nursing home at the time of their claim were identified using stay information derived from the Minimum Dataset 3.0. For comparison, similar characteristics among carrier claims with a CPT-4 code indicating urine culture were also described. Results: Claims for unspecified multiplex molecular tests overall have increased, driven by increases in claims with a primary UTI diagnosis (from 8,521 in 2016 to 386,943 in 2022), while urine cultures have not (Figure 1). In 2022, 65% of all unspecified multiplex tests were linked to a diagnosis of UTI; UTI multiplex claims were associated with 647 laboratories. For UTI claims, the median cost per claim for line items related to multiplex testing was $589 compared to $13 for urine culture-related line items. Overall, 8% of UTI multiplex claims were for beneficiaries residing in a nursing home. Conclusions: Claims for non-FDA approved unspecified multiplex tests associated with a primary diagnosis of UTI have increased >45-times between 2016-2021 and have >45-times higher median costs than urine cultures. The use of this testing in the Medicare population, including nursing home residents, is of potential concern given that inappropriate treatment of asymptomatic bacteriuria has been described to be common in older adults. Research is needed to outline use cases where UTI multiplex testing may be beneficial. Appropriate use of diagnostic testing is important to minimize diagnostic errors and avoid unnecessary antibiotic use.

Background: Clostridioides difficile infection (CDI) is associated with 500,000 infections and 30,000 deaths per year. Inappropriate testing and treatment of patients with asymptomatic colonization occurs frequently (between 15% and 41%). The VA CDI guidelines emphasize avoidance of CDI testing in patients with laxative use within the previous 48 hours due to the high likelihood of non-infectious diarrhea. The objective of this study was to assess laxative administration among inpatients tested for CDI in VA hospitals and identify factors associated with guideline discordance. Methods: Adults hospitalized in Illinois, Wisconsin, and Michigan VA Medical Centers from January 2019-December 2022 with a CDI test performed during the admission were included. CDI tests included Toxin B gene Polymerase Chain Reaction or Toxin Enzyme Immunoassay. Tests were defined as positive, negative, or cancelled according to the diagnostic protocols of the VA testing laboratories. Laxative use, patient demographics, admission data, and comorbidities were collected from the VA Corporate Data Warehouse. Guideline discordant testing was defined as a diagnostic test for CDI ordered within 48 hours of a recorded laxative dose. Factors associated with discordant testing were analyzed using clustered binomial logistic regression models. Analyses were completed using SAS 9.4. Results: There were 7,326 tests ordered for 4,888 patients during the study. Patients were predominantly White (61.8%), male (95.6%), and elderly (mean age=70.0 standard deviation=12.1). Most (59.0%) patients had received at least one dose of laxative in the 48 hours preceding their CDI test. Being Black (Odds Ratio (OR)=0.86 (95%Confidence Interval (95%CI) =0.76,0.98) or Hispanic (OR (95%CI) =0.62(0.48,0.82) vs White) was associated with a decreased likelihood of inappropriate testing due to recent laxative use. Being tested at a rural facility (OR (95%CI) =1.23 (1.07,1.41) vs urban), within a long-term care (LTC) unit (OR (95%CI) =1.67 (1.41,1.97) vs inpatient), or within an intensive care unit (ICU) (OR (95%CI) =1.40 (1.24,1.59)) were all associated with an increased likelihood of being inappropriately tested. Guideline discordant tests were more likely to have negative results (OR (95%CI) =1.25 (1.05,1.49)) compared to guideline concordant tests. Discussion: Laxative administration in the 48 hours preceding CDI testing was common among hospitalized Veterans and associated with a lower likelihood of positive Results: This echoes non-VA studies where laxative use was reported at 44%. An increased likelihood of guideline discordant testing in ICU and LTC settings suggests the need for greater diagnostic stewardship interventions. Additionally, further work to determine negative outcomes associated with inappropriate testing are needed.

We assessed adverse events in hospitalized patients receiving selected vesicant antibiotics or vasopressors administered through midline catheters or peripherally inserted central catheters (PICC). The rates of catheter-related bloodstream infections, thrombosis, and overall events were similar across the two groups, while occlusion was higher in the PICC group.

Background: Carbapenem-resistant Acinetobacter baumannii (CRAB) and Pseudomonas aeruginosa (CRPA) are drug-resistant pathogens causing high mortality rates with limited treatment options. Understanding the incidence of these organisms and laboratory knowledge of testing protocols is important for controlling their spread in healthcare settings. This project assessed how often Veterans Affairs (VA) healthcare facilities identify CRAB and CRPA and testing practices used. Method: An electronic survey was distributed to 126 VA acute care facilities September-October 2023. The survey focused on CRAB and CRPA incidence, testing and identification, and availability of testing resources. Responses were analyzed by complexity of patients treated at VA facilities (High, Medium, Low) using Fisher’s exact tests. Result: 77 (61.1%) facilities responded, most in urban settings (85.4%). Most respondents were lead or supervisory laboratory technologists (84.2%) from high complexity facilities (69.0%). Few facilities detected CRAB ≥ once/month (4.4%), with most reporting that they have not seen CRAB at their facility (55.0%). CRPA was detected more frequently: 19% of facilities with isolates ≥ once/month, 29.2% a few times per year, and 26.9% reporting had not seen the organism. No differences in CRAB or CRPA incidence was found by facility complexity. Nearly all facilities, regardless of complexity, utilize the recommended methods of MIC or disk diffusion to identify CRAB or CRPA (91.9%) with remaining facilities reporting that testing is done off-site (7.8%). More high complexity facilities perform on-site testing compared to low complexity facilities (32.0% vs 2.7%, p=0.04). 83% of laboratories test for Carbapenemase production, with one-fourth using off-site reference labs. One-fourth of facilities perform additional antibiotic susceptibility testing for CRAB and CRPA isolates, most of which test for susceptibility to combination antibiotics; no differences between complexities were found. Agreement that sufficient laboratory and equipment resources were available was higher in high complexity than in medium complexity facilities (70.7% vs 33.3%, p=0.01), but not low complexity facilities (43.8%). Conclusion: Having timely and accurate testing protocols for CRAB and CRPA are important to quickly control spread and reduce associated mortality. This study shows that most VA protocols follow recommended testing and identification guidelines. Interestingly, there was no difference in CRAB or CRPA incidence for facilities providing higher vs lower complexity of care. While high and low complexity facilities generally reported sufficient resources for CRAB and CRPA evaluation, some medium-complexity labs, who may feel more compelled than low-complexity labs to bring testing in house, reported that additional resources would be required.

Experts recommend standing orders for hospital-administered vaccines to improve adult immunization rates. We implemented an admission assessment tool to offer pneumococcal vaccine to eligible hospitalized patients. We retrospectively reviewed vaccines for guideline concordance and found that immunization rates increased but less than half of study patients received the correct vaccine.

Background: Clinically non-indicated asymptomatic bacteriuria (ASB) identification precipitates higher reported catheter-associated urinary tract infection (CAUTI) rates and urinary tract infection (UTI)-directed antimicrobial overuse. Published diagnostic stewardship interventions to reduce ASB were mostly tested individually and heterogeneously; hence the optimal bundle approach is yet to be defined. Methods: We performed a single-center sequential quasi-experimental study involving hospitalized, emergency, and long-term care patients at a VA healthcare facility, retrospectively comparing standard of care (period 1: 1/1/2022-6/30/2022) to adding dedicated provider education on facility-approved urine-culturing indications (period 2: 7/1/2022-1/19/2023), then adding an electronic clinical decision support (CDS) tool (Figure 1) mandating urine-culturing indications selections (period 3: 1/20/2023-6/30/2023), then prospectively adding real-time case-based physician-generated audit/feedback emails on ordering appropriateness (period 4: 7/1/2023-12/31/2023). We randomly sampled approximately 500 orders from each period and measured the impact on the rate of urine reflex/culture orders, the percentage of non-indicated orders and ASB, UTI-directed antimicrobial usage, and facility-wide CAUTI rates. Results: We analyzed 2140 urine reflex/culture orders (Table 1 and Figure 2). The mean monthly orders per 1000 bed-days and percentage of non-indicated orders decreased with each intervention to one-fourth of the initial values by period 4 (p=0.0002). The ASB rate among positive cultures was unchanged from periods 1 to 2 but started to decrease in period 3 with the biggest impact in period 4 (p=0.01). Non-indicated and ASB-directed antimicrobial courses both followed the previous pattern, dropping from 28% and 26% baseline to 6% and 4% by the study conclusion (p=0.015 and 0.008), respectively. Estimated UTI-directed antimicrobials decreased by 34% (363/551) with antimicrobial-days saved from 4093 to 2846 per 6-month period. CAUTI rate relatively declined with each intervention, along with a reduction in ASB-attributed CAUTI’s from 45% (5/11) initially to 20% (1/5) in period 4. Conclusion: A stepwise urine-culturing diagnostic stewardship approach of clinical education, electronic CDS tool, plus real-time audit/feedback decreased overall urine reflex/cultures, non-indicated ordering, ASB identification, unnecessary antimicrobials, and CAUTI rates, with the greatest impact after bundling all interventions including order appropriateness audit/feedback.

Background: Infectious Diseases Society of America guidelines recommend antibiotic prescribing for urinary tract infections (UTIs) when there is a positive culture and signs and symptoms of infection. Despite these guidelines, prescribing for asymptomatic bacteriuria remains prevalent. We conducted a chart review of UTI outpatient encounters to determine the prevalence of antibiotic prescribing as well as patient and provider factors associated with inappropriate prescribing for UTIs. Methods: Patients who were seen at any Department of Veterans Affairs (VA) outpatient clinic with a positive urine culture from 1/1/2019-12/31/2022 were evaluated for inclusion. Exclusion criteria were pregnancy, neutropenia, neurogenic bladder, spinal cord injury/disorder, chronic kidney disease stage III and above, and those undergoing urologic surgical procedures within 7 days. Inappropriate prescribing was defined as an antibiotic prescription given for UTI treatment when no signs or symptoms of infection were recorded during the patient encounter. Chi-square, Fisher’s exact and t-tests were used to evaluate the association between patient and provider characteristics and antibiotic prescribing. Results: Among 341 visits, most patients were male (70%), White (40%), older (mean age of 65.8 ± 15.9 years) and treated at an urban facility (57%). Antibiotics were prescribed for 67% (229/341) of visits. Of the 229 antibiotic courses prescribed, 119 (52%) were appropriate; issued to patients with > = 1 sign or symptom consistent with a urinary tract infection. The most common symptom recorded was dysuria, followed by frequency, urgency, and hematuria (Figure 1). The remaining 110 (48%) antibiotic prescriptions were inappropriate; given to patients without documented UTI-related signs or symptoms. The proportion of inappropriate prescribing was higher among advanced practice practitioners (39/56; 69%) compared to physicians (68/113; 60%; P < 0 .0001). Prescribing of an antibiotic did not differ by gender (p-value=0.3779), race (p-value=0.3972), age (p-value=0.7461) or urban versus rural geography (p-value=0.3647). Discussion: In outpatient clinics, nearly half of antibiotics prescribed to patients with a positive urine culture occurred in the absence of documented of signs or symptoms of a UTI. These results suggest that interventions to improve antibiotic use for UTI-related concerns in the outpatient setting should address UTI-related signs and symptoms as well as asymptomatic bacteriuria. Advanced practice practitioners were more likely to prescribe without documentation of relevant signs or symptoms than physicians. Improving meaningful documentation about the presence or absence of signs and symptoms of a UTI may help reduce inappropriate antibiotic prescriptions in the outpatient setting.

Disclosure: Robin Jump: Research support to my institution from Merck and Pfizer; Advisory boards for Pfizer

Background: Inappropriate diagnosis and treatment of urinary tract infections (UTI) contributes to antibiotic overuse. The Inappropriate Diagnosis of UTI (ID-UTI) measure—which quantifies the percentage of treated bacteriuria that is asymptomatic (ASB) using a standard definition of UTI—has been validated in acute care hospitals, but not in critical access hospitals (CAHs) where resources differ. Methods: From October 2022-July 2023, ten CAHs participated in a program to reduce ASB treatment, including education, coaching, and hospital feedback using the ID-UTI measure. Our primary aim was to assess performance characteristics of the ID-UTI standard definition and measure in CAHs (Figure 1). Non-physician abstractors from each CAH submitted clinical data (e.g., signs/symptoms) via REDCap for consecutive adult patients who were admitted or discharged from the emergency department and received antibiotics for bacteriuria. The case abstraction goal for each CAH was 5-6 cases/month. To assess feasibility, we evaluated the ability of each CAH to achieve goal case abstractions. To assess validity and reliability of the ID-UTI standard definition, two physicians reviewed 10% of submitted cases using deidentified patient notes and assessed agreement with the standard ID-UTI definition and consensus clinical opinion. Based on submitted data, we provided bi-monthly feedback reports to CAHs including the hospital-level ID-UTI measure to benchmark progress and for peer comparison. We measured monthly change in the ID-UTI measure using a mixed-effects logistic regression model (Figure 1, Figure 2). Results: Among 10 CAHs, 4 (40%) submitted >59 cases over 10 months (goal) while 3 (30%) submitted >35 cases (secondary goal). Physician reviewers assessed 9.5% (58/608) of cases. Utilizing the ID-UTI standard definition, there was high agreement (93%) in ASB vs UTI designation between each physician reviewer and the CAH’s REDCap assessment (Figure 3). Compared to clinical opinion, the ID-UTI standard definition identified 48% (16/33) of ASB cases and 100% (25/25) of UTI cases (Figure 4). Over the program, the percentage of cases treated for UTI that were ASB decreased from 28.4% (range 0-63%) to 18.6% (range, 0-33%; p=0.055) (Figure 5). Conclusions: Case abstraction with use of the ID-UTI measure was feasible and reliable to implement with modifications for CAHs. Data collection by untrained staff was as reliable as physician adjudication. Though the ID-UTI standard definition undercounted ASB cases (low sensitivity), cases reported as ASB were always ASB when adjudicated (high specificity). The program, including performance feedback using the ID-UTI measure, was associated with a trend toward lower treatment of ASB.

In this study, we examined the impact of the number and type of arterial grafts, and surgical dressing type, on deep and organ/space surgical site infection following coronary artery bypass graft procedures. Bilateral internal mammary artery grafts and negative pressure wound therapy were associated with higher odds of infection.