Overdiagnosis of urinary tract infection linked to overdiagnosis of pneumonia: a multihospital cohort study

Urinary tract infection (UTI) and community-acquired pneumonia (CAP) are the most common infections treated in hospitals. UTI and CAP are also commonly overdiagnosed, resulting in unnecessary antibiotic use and diagnostic delays. While much is known individually about overdiagnosis of UTI and CAP, it is not known whether hospitals with higher overdiagnosis of one also have higher overdiagnosis of the other. Correlation of overdiagnosis of these two conditions may indicate underlying hospital-level contributors, which in turn may represent targets for intervention. To evaluate the association of overdiagnosis of UTI and CAP, we first determined the proportion of hospitalised patients treated for CAP or UTI at 46 hospitals in Michigan who were overdiagnosed according to national guideline definitions. Then, we used Pearson’s correlation coefficient to compare hospital proportions of overdiagnosis of CAP and UTI. Finally, we assessed for ‘diagnostic momentum’ (ie, accepting a previous diagnosis without sufficient scepticism) by determining how often overdiagnosed patients remained on antibiotics on day 3 of hospitalisation. We included 14 085 patients treated for CAP (11.4% were overdiagnosed) and 10 398 patients treated for UTI (27.8% were overdiagnosed) across 46 hospitals. Within hospitals, the proportion of patients overdiagnosed with UTI was moderately correlated with the proportion of patients overdiagnosed with CAP (r=0.53, p<0.001). Over 80% (81.8% (n=952/1164) of UTI; 89.9% (n=796/885) of CAP) of overdiagnosed patients started on antibiotics by an emergency medicine clinician remained on antibiotics on day 3 of hospitalisation. In conclusion, we found overdiagnosis of UTI and CAP to be correlated at the hospital level. Reducing overdiagnosis of these two common infections may benefit from systematic interventions.

Clinical profile, etiology, type and outcome of neonatal seizures: a hospital-based study

Background: Our study was undertaken to study the etiological factor, clinical profile, types and outcome of newborn with neonatal seizures (NNS).Methods: Our study was hospital based prospective study was done in Sheri Kashmir institute of medical sciences (SKIMS) Bemina from April 2013 to April 2015 in NICU, after obtaining ethical clearance from institutional ethical committee. All neonates fulfilling inclusion criteria were included in our study.Results: In our study, 80 neonates with seizures were included in our study, among them 48 were males and 32 were females. Majority of neonates (57.5%) developed seizures during first 72 hours of life due to birth asphyxia. Commonest types of neonatal seizures observed in our study were subtle observed in 46 cases, followed by tonic (21.2 %), clonic (14.9 %) and mixed (6.2%) seizures. Birth asphyxia was commonest cause (57.5%) of NNS, sepsis with meningitis (18.7%) followed by hypoglycemia (13.7%) and hypocalcemia (5%). Cases of birth asphyxia were associated with higher mortality (58.3%) as compared to cases with metabolic seizures.Conclusions: From our study we conclude that commonest cause of neonatal seizure was birth asphyxia occurring within 72 hours of birth. Sepsis and meningitis were also common infections resulting in neonatal seizure, while as hypoglycaemia and hypocalcemia were common biochemical abnormalities leading to NNS. Early identification and treatment are likely important for long-term outcomes in acute symptomatic seizure.

Common Infections and Antibiotic Prescribing during the First Year of the COVID-19 Pandemic: A Primary Care-Based Observational Cohort Study

Presentation and antibiotic prescribing for common infectious disease episodes decreased substantially during the first COVID-19 pandemic wave in Dutch general practice. We set out to determine the course of these variables during the first pandemic year. We conducted a retrospective observational cohort study using routine health care data from the Julius General Practitioners’ Network. All patients registered in the pre-pandemic year (n = 425,129) and/or during the first pandemic year (n = 432,122) were included. Relative risks for the number of infectious disease episodes (respiratory tract/ear, urinary tract, gastrointestinal, and skin), in total and those treated with antibiotics, and proportions of episodes treated with antibiotics (prescription rates) were calculated. Compared to the pre-pandemic year, primary care presentation for common infections remained lower during the full first pandemic year (RR, 0.77; CI, 0.76–0.78), mainly attributed to a sustained decline in respiratory tract/ear and gastrointestinal infection episodes. Presentation for urinary tract and skin infection episodes declined during the first wave, but returned to pre-pandemic levels during the second and start of the third wave. Antibiotic prescription rates were lower during the full first pandemic year (24%) as compared to the pre-pandemic year (28%), mainly attributed to a 10% lower prescription rate for respiratory tract/ear infections; the latter was not accompanied by an increase in complications. The decline in primary care presentation for common infections during the full first COVID-19 pandemic year, together with lower prescription rates for respiratory tract/ear infections, resulted in a substantial reduction in antibiotic prescribing in Dutch primary care.

Two Cases of Leigh Syndrome in One Family: Diagnostic Challenges and Clinical Management Experience in Latvia

Leigh syndrome is a neurodegenerative disorder with an incidence of 1 : 40,000 live births. The clinical presentation of LS is highly variable with heterogeneity in the disease-associated symptoms of cerebellar, motor, and extrapyramidal dysfunction and common infections. There is no effective treatment for this condition; as such, the prognosis of this condition is very poor with death occurring within the first few years of life. In this study, we report the first LS case in Latvia with SURF1 pathogenic variants in two siblings. The difficulties encountered establishing a diagnosis for the first proband and the effective prenatal diagnosis for the second offspring that led to termination of the pregnancy are discussed.

Exploring Primary Care Clinicians’ Views about How Best to Implement a Potential Trial around Point-of-Care Tests for Common Infections in South Africa

Optimisation of antibiotic prescribing is critical to combat antimicrobial resistance. Point-of-care tests (POCTs) for common infections could be a valuable tool to achieve this in primary care. Currently, their use has primarily been studied in high-income countries. Trials in low-and-middle-income countries face challenges unique to their setting. This study aims to explore the barriers and facilitators for a future trial of POCTs for common infections in South Africa. Twenty-three primary care clinicians in the Western Cape Metropole were interviewed. Interview transcripts were analysed using thematic analysis. We identified three key themes. These themes focused on clinicians’ views about proposed trial design and novel POCTs, clinicians’ perspectives about trial set-up, and specific trial procedures. Participants were overall positive about the proposed trial and POCTs. Potential issues centred around the limited space and technology available and participant retention to follow-up. Additionally, impact on clinic workload was an important consideration. These insights will be invaluable in informing the design of a feasibility trial of POCTs in this setting.

143. Antibiotic Use for Common Infections in British Columbia and Ontario: A Review of Outpatient Prescribing to Seniors from 2000 – 2018

Background Antimicrobials remain among the most prescribed medications in Canada, with over 90% prescribed in outpatient settings. Older adults (aged ≥65 years) prescribed antimicrobials are particularly vulnerable to adverse drug events and antimicrobial resistance. This study compared annual rates of indication-associated, outpatient prescribing to seniors across two Canadian provinces. Methods All outpatient, oral antimicrobials dispensed to older adults (≥65 years) were identified from administrative health databases, from 2000 to 2018. Antimicrobials were limited to outpatient use only and linked to an indication using a 3-tiered diagnostic hierarchy. When possible, a record of dispensation was matched to a tier 1 indication (always require antibiotics) first. In the absence of a tier 1 indication, priority was given to tier 2 (sometimes require antibiotics), then 3 (never require antibiotics). Prescription rates were calculated per 1000 population, and trends were examined overall, by drug class, and patient demographics. Results Our study included over 18 million individuals (aged ≥65 years) with a total of 23,773,552 antibiotic prescriptions issued to seniors, for common infections. In both provinces, prescribing for tier 1 diagnoses increased over the study period (BC: 44%; ON: 28%). Urinary tract infections accounted for most prescriptions within this tier (ON: 89 prescriptions/1000, BC: 129 prescriptions/1000 population by 2018). Pneumonia-associated prescribing increased by roughly 10% in both provinces. In any given study year, for both provinces, tier 3 diagnosis was the most common reason for antibiotic use, accounting for 50% of all indication-associated antibiotic prescribing. As diagnoses within this tier do not warrant prescribing all antibiotics issued are therefore inappropriate prescriptions. Figure 1. Rates of indication-associated antibiotic use in Canadian seniors, from 2000 to 2018. Conclusion Elevated prescribing to seniors continues across Canadian outpatient settings. Antibiotic prescribing remains an issue of high concern with 50% of all antimicrobials prescribed to seniors, for common infections, used inappropriately. Disclosures All Authors: No reported disclosures

111. Assessment of Empiric Management Practices of Common Infections in Solid Organ Transplant Recipients at a Canadian Tertiary Care Centre - A Retrospective Cohort Study

Background Post-transplant infections remain a leading cause of morbidity and mortality in solid organ transplant recipients (SOTR). Standardized antimicrobial treatment guidelines for infectious syndromes may contribute to improved clinical care. Our study seeks to assess the rate of therapeutic compliance with local standard guidelines in the treatment of common infections in SOTR, and their associated outcomes. Methods Consecutive adult SOTR admitted to the transplant floor from January–May 2020 for treatment of an infectious syndrome of interest were reviewed for study inclusion. Patients were followed until discharge or for 30 days following the date of diagnosis, whichever was shorter. Data was extracted from electronic medical records. Results 475 SOTR were admitted to the transplant floor, of which 156 patients (33%) were admitted with infectious syndromes. Guidelines were applicable to 117 patients, constituting the following 122 syndromes: 51 pneumonias; 34 urinary tract infections (UTI); 22 bacteremias and 15 intra-abdominal infections (Fig. 1). Intra-abdominal infections occurred earliest at a median time of 9 months post-transplant followed by bacteremias, pneumonias, and UTIs (medians 10, 38 and 54 months respectively) (Table 1). 47% of patients were empirically treated with a regimen compliant with guidelines and 66% were provided compliant tailored therapies. Non-compliance with empiric management guidelines resulted in a significantly higher proportion of patients requiring ICU transfer when compared to compliance (25% vs. 9%; P = .02) (Table 2). Non-compliance with tailoring protocols resulted in an increased overall length of stay (medians 11 days vs. 8 days; P = .04). Within 30 days of discharge, no differences in readmission, development of Clostridium difficile infection, rejection, graft loss or death were observed between patients receiving compliant or non-compliant regimens. Figure 1. Study Flow Diagram Table 1. Baseline Characteristics of Patient Cohort Table 2. Outcomes of compliant vs. non-compliant treatment in patients receiving antimicrobial therapy for an infectious syndrome Conclusion Non-compliance with locally developed antimicrobial management guidelines resulted in a higher proportion of patients being transferred to the ICU and an increased length of stay in our cohort, highlighting the benefits of adherence. Future studies will assess long-term outcomes associated with compliance to infection management guidelines. Disclosures All Authors: No reported disclosures

Epidemiology, management and the associated burden of mental health illness, atopic and autoimmune conditions, and common infections in alopecia areata: protocol for an observational study series

IntroductionAlopecia areata (AA) is a common cause of immune-mediated non-scarring hair loss. Links between AA and common mental health, autoimmune and atopic conditions, and common infections have previously been described but remain incompletely elucidated and contemporary descriptions of the epidemiology of AA in the UK are lacking.Methods and analysisRetrospective study series using a large population-based cohort (5.2 million) from the Oxford Royal College of General Practitioners (RCGP) Research and Surveillance Centre (RSC) database, exploring four themes: AA epidemiology, mental health comorbidities, autoimmune/atopic associations and common infections.In the epidemiology theme, we will describe the incidence and point prevalence of AA overall and by age, sex and sociodemographic factors. Healthcare utilisation (primary care visits and secondary care referrals) and treatments for AA will also be assessed. In the mental health theme, we will explore the prevalence and incidence of mental health conditions (anxiety, depressive episodes, recurrent depressive disorder, adjustment disorder, agoraphobia, self-harm and parasuicide) in people with AA compared with matched controls. We will also explore the mental health treatment patterns (medication and psychological interventions), time off work and unemployment rates. Within the autoimmune/atopic associations theme, we will examine the prevalence of atopic (atopic dermatitis, allergic rhinitis, asthma) and autoimmune conditions (Crohn’s disease, ulcerative colitis, coeliac disease, type 1 diabetes, Hashimoto’s thyroiditis, Graves’ disease, rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, systemic lupus erythematosus (SLE), polymyalgia rheumatica, Sjögren’s syndrome, psoriasis, vitiligo, multiple sclerosis, pernicious anaemia) in people with AA compared with matched controls. We will also estimate the incidence of new-onset atopic and autoimmune conditions after AA diagnosis. Within the common infections theme, we will examine the incidence of common infections (respiratory tract infection, pneumonia, acute bronchitis, influenza, skin infection, urinary tract infection, genital infections, gastrointestinal infection, herpes simplex, herpes zoster, meningitis, COVID-19) in people with AA compared with matched controls.Ethics and disseminationThe Health Research Authority decision tool classed this a study of usual practice, ethics approval was not required. Study approval was granted by the RCGP RSC Study Approval Committee. Results will be disseminated through peer-reviewed publications.Observational study registration numberNCT04239521.

100. Assessment of Emergency Department Prescribing Practices for Outpatient Treatment of Urinary Tract Infection, Community-Acquired Pneumonia, and Skin and Soft Tissue Infections

Background Studies have found a need for improved antimicrobial stewardship in the outpatient setting. The literature is limited by the populations and disease states studied as many focus on viral infections. This study focuses on the adult emergency departments (EDs) in a large healthcare system and quantifies the proportion of antibiotic prescriptions deemed inappropriate for common outpatient infections. Methods A retrospective study was conducted in patients with selected common infections treated as an outpatient from the ED. Patients were reviewed for eligibility based on the inclusion and exclusion criteria in Table 1. Appropriateness was analyzed based on: need for antimicrobial therapy; agent choice, dose, duration, and directions in concordance with national guidelines and local resistance patterns; and no clinically relevant drug interactions, unnecessary dual coverage, or a better or safer alternative available. The entire prescription was marked inappropriate if any factor was deemed inappropriate. Table 1. Inclusion and Exclusion Criteria Based on the Epic report generated, a random sample of patients were selected for manual review. Only patients who met the following criteria were eligible for inclusion in the final analysis. Results Of the 318 patients reviewed, 274 were included. Treatment was deemed inappropriate 64% (174/274) of the time, significantly above the estimated 30% (p &lt; 0.001). The agent selection, duration, and dose were the most the frequent factors deeming a prescription inappropriate. The most inappropriately used agents were fluoroquinolones and azithromycin. A positive culture required modification of therapy 31% (22/70) of the time and more so when the drug was guideline recommended. For example, when empiric antibiotic selection was per urinary tract infection guidelines, 31% (14/53) required modification compared to 19% (3/16) when the agent was not. This was most apparent when cephalexin was used. Conclusion The use of antibiotics at the studied EDs was not in concordance with guidelines in the study period. However, the cultures were sensitive less often to agents deemed appropriate per guidelines for empiric therapy. It is possible that the ideal treatments of bacterial infections in this community are not representative of national resistance patterns. Using ED-specific antibiograms to create order panels for common infections, as well as prospective pharmacist review at ED discharge, could increase appropriate utilization of preferred agents. Disclosures All Authors: No reported disclosures