Background: Approximately half of antibiotics used in nursing home (NHs) are initiated in acute care hospitals prior to NH admission. Optimizing antibiotic prescribing on hospital discharge to these facilities presents an opportunity to improve NH antibiotic use. We aimed to identify intervention targets to optimize antibiotic use on discharge from the hospital to NHs. Methods: This was a multicenter, cross-sectional study across 9 acute care hospitals in Oregon, Wisconsin, and Washington. We selected a 20% random sample of adult (age >18) inpatients prescribed at least one antibiotic on discharge from the hospital to a NH between 2016-2018. We excluded patients discharged from the emergency department or an intensive care unit. Study data were electronically extracted from patients’ electronic health records and supplemented with manual chart review. Antibiotic optimization opportunities were determined by an infectious diseases (ID) physician or ID pharmacist and classified as definitely, possibly, or unlikely. Expert reviewers also recorded the type of optimization opportunity and the rationale for each determination. A gamma lasso algorithm was used to identify patient-level characteristics associated with definite optimization opportunity, which were then included in a logistic regression model. Results: There were 2761 antibiotic prescriptions among 2215 patients. Mean (standard deviation) age was 71.9 (14.3) years and 48.8% were male. Most discharges (83.1%) were prescribed one antibiotic, 15.2% were prescribed two antibiotics, and 1.8% were prescribed three antibiotics. The most frequently prescribed antibiotics were cephalexin (10.4%), vancomycin (9.8%), and amoxicillin clavulanate (8.4%). Among the 2761 antibiotic prescriptions, expert reviewers determined that 18.4% could definitely be optimized, 36.0% could possibly be optimized, and 45.3% unlikely could have been optimized. Among the 508 definite antibiotic optimization opportunities, 25.2% were to subtract the antibiotic, 56.3% were to change the antibiotic, 11.0% were to change the dose, 25.0% were to change the duration, 0.8% were to change the route, and 1.8% were to change the schedule. Patient-level characteristics found to be associated with definite antibiotic optimization opportunity included age over 80 years (odds ratio (OR)=1.44, 95% confidence interval (CI): [1.14, 1.82]), length of stay < 8 days (OR=1.40, 95% CI: [1.09, 1.81]), discharge with multiple antibiotic prescriptions (OR=1.92, 95% CI: [1.39, 2.63]), and discharge with prescription for oral vs intravenous (IV) antibiotics (OR=2.08, 95% CI: [1.49, 2.95]). Conclusion: We identified several patient and antibiotic characteristics which may serve as intervention targets to optimize antibiotic prescribing on discharge from the hospital to nursing homes.

Background: Healthcare settings without access to infectious diseases experts may struggle to implement effective antibiotic stewardship programs. We previously described a successful pilot project using the Veterans Affairs (VA) telehealth system to form a Videoconference Antimicrobial Stewardship Team (VAST) that connected multidisciplinary teams from rural VA medical centers (VAMCs) with infectious diseases experts at geographically distant locations. VASTs discussed patients from the rural VAMC, with the overarching goal of supporting antibiotic stewardship. This project is currently ongoing. Here, we describe preliminary outcomes describing the cases discussed, recommendations made, and acceptance of those recommendations among 4 VASTs. Methods: Cases discussed at any of the 4 participating intervention sites were independently reviewed by study staff, noting the infectious disease diagnoses, recommendations made by infectious diseases experts and, when applicable, acceptance of those recommendations at the rural VAMC within 1 week. Discrepancies between independent reviewers were discussed and, when consensus could not be reached, discrepancies were discussed with an infectious diseases clinician. Results: The VASTs serving 4 different rural VAMCs discussed 96 cases involving 92 patients. Overall, infection of the respiratory tract was the most common syndrome discussed by VASTs (Fig. 1). The most common specific diagnoses among discussed cases were cellulitis (n = 11), acute cystitis (n = 11), wounds (n = 11), and osteomyelitis (n = 10). Of 172 recommendations, 41 (24%) related to diagnostic imaging or laboratory results and 38 (22%) were to change the antibiotic agent, dose, or duration (Fig. 2). Of the 151 recommendations that could be assessed via chart review, 122 (81%) were accepted within 1 week. Conclusions: These findings indicate successful implementation of telehealth to connect clinicians at rural VAMCs with an offsite infectious diseases expert. The cases represented an array of common infectious syndromes. The most frequent recommendations pertained to getting additional diagnostic information and to adjusting, but not stopping, antibiotic therapy. These results suggest that many of the cases discussed warrant antibiotics and that VASTs may use the results of diagnostic studies to tailor that therapy. The high rate of acceptance suggests that the VASTs are affecting patient care. Future work will describe VAST implementation at 4 additional VAMCs, and we will assess whether using telehealth to disseminate infectious diseases expertise to rural VAMCs supports changes in antibiotic use that align with principles of antimicrobial stewardship.

Disclosures: None

ABSTRACT IMPACT: Successful implementation of this control strategy will result in a commercially available ivermectin-treated birdfeed that the public can use to protect themselves from infection with West Nile virus (WNV) by reducing mosquito survival and thereby suppressing WNV transmission around their homes. OBJECTIVES/GOALS: We assessed the efficacy and feasibility of ivermectin (IVM)-treated birds as a mosquito control strategy for local reduction of West Nile virus (WNV) transmission. We conducted a randomized field trial in backyard chickens and developed a mathematical model informed by field data to predict the impact of treated wild birds on transmission. METHODS/STUDY POPULATION: We placed 48 chickens in four treated and four untreated control flocks in backyards coops across Davis, CA and administered IVM daily in feed to treated flocks (Jul-Sep 2019). We assessed entomological indices weekly (i.e. Culex mosquito abundance, WNV infection prevalence, and parity rate) around each coop, monitored serum IVM levels in treated chickens, and tested for WNV antibodies in all chickens. Shifting our focus to wild birds, we developed a spatially-implicit mathematical model of WNV transmission near IVM-treated birdfeeders. Model parameters for bird movement were based on our telemetry of 27 birds in Fort Collins, CO (Aug-Sep 2020). Using the model, we predicted optimal deployment of treated feeders to provide local WNV control. RESULTS/ANTICIPATED RESULTS: WNV seroconversions were reduced in treated vs. untreated flocks, indicating a reduction in WNV transmission intensity at treated coops (P = 0.03). A sustained, but insignificant reduction in number of infected mosquitoes was observed near treated coops (P = 0.59); small sample sizes and below normal WNV prevalence in the study area limited our power. We anticipate that optimal spacing and number of IVM-treated birdfeeders required for effective WNV control in neighborhoods will depend on feeder usage rates by common bird species irrespective of WNV competence; broad availability of IVM-treated bloodmeals to mosquitoes will be more effective in reducing transmission than targeting the few species responsible for viral amplification. DISCUSSION/SIGNIFICANCE OF FINDINGS: IVM is a novel method for controlling zoonotic pathogens in the US and has the potential for targeted mosquito control to reduce pesticide usage. Evaluating spatial deployment of IVM-treated bird feed for local reduction in WNV transmission is a stepping stone to commercial deployment of this WNV control strategy.

Using the panel data of 89 economies from 1995–2012, this study examines the major drivers of agricultural emissions while considering affluence, energy intensity, agriculture value added and economic integration. We find long-run cointegration among the variables. Furthermore, our empirical results based on a dynamic fixed effects autoregressive distributed lag model show that the increases in income and economic integration – proxied by trade and foreign direct investment (FDI) – are the major contributors to higher greenhouse gas (GHG) emissions from agriculture in the short run. Additionally, the increases in income, agriculture value added and energy consumption are the major drivers of agricultural emissions in the long run. Notably, trade openness and FDI inflows have significantly negative effects on GHG emissions from agriculture in the long run. These results apply to methane and nitrous oxide emissions. The empirical findings vary across three subsamples of countries at different development stages.

OBJECTIVES/GOALS: We conducted a randomized field trail to evaluate the efficacy and safety of a novel vector control strategy that involves treating urban backyard chickens with ivermectin (IVM), a widely used antiparasitic and mosquitocial drug. The goal was to reduce vector mosquito populations and West Nile virus (WNV) transmission. METHODS/STUDY POPULATION: We placed eight flocks—four treated and four untreated control—of six Lohmann brown chickens (16 month-old) each in backyard coops across Davis, CA and administered IVM in feed daily at treated coops (200 mg IVM/kg feed) for eleven weeks. We monitored entomological indices weekly (i.e. mosquito abundance, WNV infection prevalence, and parity rate) in Culex mosquito populations near (10 m) and far (150 m) from each coop location for the peak WNV transmission season (Jul-Sep 2019). We also monitored serum IVM levels in treated chickens and tested for WNV antibodies in all chickens throughout the study. RESULTS/ANTICIPATED RESULTS: Since IVM impacts only mosquitoes that live long enough to take a bloodmeal from a treated chicken, we do not expect to find a marked difference in adult Culex abundance between the two treatment arms, but we expect to find a reduction in WNV infection prevalence and a shift in female mosquito age structure towards younger, uninfected individuals at treated coops. We also anticipate seroconversions in treated chickens to occur at lower rates versus untreated control chickens indicating a reduction in WNV transmission intensity at treated coops. We observed no negative health outcomes from the long-term ingestion of IVM by study chickens. A pathological investigation is underway to compare histological findings between treated and untreated chickens. DISCUSSION/SIGNIFICANCE OF IMPACT: IVM provides the potential for targeted mosquito control. Reduced WNV transmission dynamics here is a stepping stone to a commercial WNV control strategy; IVM-treated feed for wild birds for homeowners’ use to combat WNV transmission in their neighborhoods.

Augmented reality (AR) superimposes computer-generated virtual objects onto the user’s view of the real world. Among medical disciplines, neurosurgery has long been at the forefront of image-guided surgery, and it continues to push the frontiers of AR technology in the operating room. In this systematic review, we explore the history of AR in neurosurgery and examine the literature on current neurosurgical applications of AR. Significant challenges to surgical AR exist, including compounded sources of registration error, impaired depth perception, visual and tactile temporal asynchrony, and operator inattentional blindness. Nevertheless, the ability to accurately display multiple three-dimensional datasets congruently over the area where they are most useful, coupled with future advances in imaging, registration, display technology, and robotic actuation, portend a promising role for AR in the neurosurgical operating room.

We calculated hospital-onset methicillin-resistant Staphylococcus aureus (HO-MRSA) rates for Orange County, California, hospitals using survey and state data. Numerators were variably defined as HO-MRSA occurring more than 48 hours (37%), more than 2 days (30%), and more than 3 days (33%) postadmission. Survey-reported denominators differed from state-reported patient-days. Numerator and denominator choices substantially impacted HO-MRSA rates.

RED is a technique we have developed for stand-off detection of trace explosives using infrared (IR) photo-thermal imaging [1,2,3]. RED incorporates compact IR quantum cascade lasers tuned to strong characteristic absorption bands and may be used to illuminate explosives present as particles on a surface. An IR focal plane array is used to image the surface and detect any small increase in the thermal emission upon laser illumination. We have previously demonstrated the technique at several meters to 10’s of meters of stand-off distance indoors and in field tests [4,5], while operating the lasers below the eye-safe intensity limit (100 mWcm2) [6]. Sensitivity to traces of explosives as small as a nanogram has been demonstrated. By varying the incident wavelength slightly, we can readily show selectivity between individual explosives such as TNT and RDX. Using a sequence of lasers at different wavelengths, we increase both sensitivity and selectivity. A complete detection protocol can be performed in a sub-second time domain. More recently, RED has been used to emphasize measurements with cooled detectors in addition to examining the utility of filtering the collected thermal emission signal which is rich in analyte-specific spectroscopic information. A next generation RED system and detection algorithm is being developed to take advantage of these more powerful features. This manuscript will include an overview of the approach and recent experimental results.