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Background The burden of vancomycin-associated acute kidney injury (V-AKI) is unclear because it is not systematically monitored. The objective of this study was to develop and validate an electronic algorithm to identify cases of V-AKI, and to determine its incidence. Methods Adults and children admitted to one of five health system hospitals from January 2018 to December 2019 who received at least one dose of intravenous (IV) vancomycin were included. A subset of charts was reviewed using a V-AKI assessment framework to classify cases as unlikely, possible, or probable events. Based on review, an electronic algorithm was developed and then validated using another subset of charts. Percent agreement and kappa coefficients were calculated. Sensitivity and specificity were determined at various cutoffs, using chart review as the reference standard. For courses ≥48 hours, the incidence of possible or probable V-AKI events was assessed. Results The algorithm was developed using 494 cases and validated using 200 cases. The percent agreement between the electronic algorithm and chart review was 92.5% and the weighted kappa was 0.95. The electronic algorithm was 89.7% sensitive and 98.2% specific in detecting possible or probable V-AKI events. For the 11,073 courses of ≥48 hours of vancomycin among 8,963 patients, the incidence of possible or probable V-AKI events was 14.0%; the V-AKI incidence rate was 22.8 per 1,000 days of IV vancomycin therapy. Conclusions An electronic algorithm demonstrated substantial agreement with chart review and had excellent sensitivity and specificity in detecting possible or probable V-AKI events. The electronic algorithm may be useful for informing future interventions to reduce V-AKI.

BackgroundDeclines in outpatient antibiotic prescribing were reported during the beginning of the coronavirus disease 2019 (COVID-19) pandemic in the United States; however, the overall impact of COVID-19 cases on antibiotic prescribing remains unclear.MethodsThis was an ecological study using random-effects panel regression of monthly reported COVID-19 county case and antibiotic prescription data, controlling for seasonality, urbanicity, health care access, nonpharmaceutical interventions (NPIs), and sociodemographic factors.ResultsAntibiotic prescribing fell 26.8% in 2020 compared with prior years. Each 1% increase in county-level monthly COVID-19 cases was associated with a 0.009% (95% CI, 0.007% to 0.012%; P < .01) increase in prescriptions per 100 000 population dispensed to all ages and a 0.012% (95% CI, −0.017% to −0.008%; P < .01) decrease in prescriptions per 100 000 children. Counties with schools open for in-person instruction were associated with a 0.044% (95% CI, 0.024% to 0.065%; P < .01) increase in prescriptions per 100 000 children compared with counties that closed schools. Internal movement restrictions and requiring facemasks were also associated with lower prescribing among children.ConclusionsThe positive association of COVID-19 cases with prescribing for all ages and the negative association for children indicate that increases in prescribing occurred primarily among adults. The rarity of bacterial coinfection in COVID-19 patients suggests that a fraction of these prescriptions may have been inappropriate. Facemasks and school closures were correlated with reductions in prescribing among children, possibly due to the prevention of other upper respiratory infections. The strongest predictors of prescribing were prior years’ prescribing trends, suggesting the possibility that behavioral norms are an important driver of prescribing practices.

ObjectiveTo explore an approach to identify the risk of local prevalence of extended-spectrum beta-lactamase producing Enterobacterales (ESBL-E) on ESBL-E colonization or infection, and reassess known risk factors.DesignCase-control study.SettingJohns Hopkins Health System emergency departments (EDs) in the Baltimore-Washington, D.C. region.PatientsPatients aged ≥18 years with a culture growing Enterobacterales between 4/2019-12/2021. Cases had a culture growing an ESBL-E.MethodsAddresses were linked to Census Block Groups and placed into communities using a clustering algorithm. Prevalence in each community was estimated by the proportion of ESBL-E among Enterobacterales isolates. Logistic regression was used to determine risk factors for ESBL-E colonization or infection.ResultsESBL-E were detected in 1167 of 11,229 patients (10.4%). Risk factors included a history of ESBL-E in the prior year (OR, 15.62; 95% CI, 11.25-21.68), and exposure to a skilled nursing or long term care facility (OR, 1.66; 95% CI, 1.39-1.99), 3rd generation cephalosporin (OR, 1.83; 95% CI, 1.50-2.23), carbapenem (OR, 2.01; 95% CI, 1.46-2.78) or trimethoprim-sulfamethoxazole (OR, 1.53; 95% CI, 1.05-2.22) within the prior 6 months. Patients were at lower risk if their community had a prevalence thpercentile in the prior 3 months (OR, 0.84; 95% CI, 0.71-0.98), 6 months (OR, 0.84; 95% CI, 0.71-0.99) or 12 months (OR, 0.81; 95% CI, 0.69-0.96). There was no association between being in a community >75thpercentile and the outcome.ConclusionsThis method of defining the recent local prevalence of ESBL-E may partially capture differences in the likelihood of a patient having an ESBL-E.

Background HIV-positive men who have sex with men (MSM) are recommended to have anal Pap tests annually to screen for high-grade anal squamous intraepithelial lesions (HSIL). In this population, removal of HSIL reduces the risk of progression to anal cancer. This study aims to assess the effectiveness of the anal dysplasia screening cascade in a single-center outpatient clinic. Methods We conducted a single-center retrospective cohort study at Johns Hopkins. All adult HIV-positive MSM patients who had in-person encounters in the Bartlett Clinic between October 1, 2019-April 30, 2021 were included. Clinical information and dates of anal pap smears and HRAs were provided via an Epic data extraction. Manual chart review was conducted for anal pap and HRA pathology results. Descriptive analysis was performed. The primary outcome was successful navigation of the institutional anal dysplasia screening cascade, defined as annual anal Pap testing and completion of HRA if pap results were abnormal. This study was IRB exempt. Results 779 HIV-positive MSM patients were seen for in-person visits during the study period. 24% (190/779) of patients underwent at least one screening anal Pap, with 29 having multiple anal pap smears leading to a total of 219 anal pap smears done. 40% (87/219) were abnormal. Among those with an abnormal pap, 72% (63/87) had a referral for HRA placed but only 26% (23/87) underwent HRA. 39% (9/23) of HRAs identified HSIL in patients with lower-grade lesions on Pap test and one patient with HSIL on Pap had anal cancer detected on HRA. In total, 120 patients navigated the anal cancer screening cascade appropriately. This compromised 15% (120/779) of eligible MSM patients seen for at least one in-person clinic visit and 63% (120/190) of patients who underwent an anal Pap. Conclusion Completion of a screening cascade for anal dysplasia among HIV-positive MSM at our clinic was low. The largest gaps were seen in initiating annual anal Pap screening and scheduling referrals for HRA in surgical subspecialty clinics. Increased attention and clinic resources should be directed toward narrowing these gaps to ensure HSIL and anal cancers are detected early within this high-risk population. Disclosures All Authors: No reported disclosures.

Background Pseudomonas aeruginosa has the ability to exhibit resistance to a broad range of antibiotics, highlighting the importance of identifying alternative or adjunctive treatment options, such as phages. Patients and methods We report the case of a 25-year-old male who experienced an accidental electrocution resulting in exposed calvarium in the left parieto-temporal region, complicated by a difficult-to-treat P. aeruginosa (DTR-P. aeruginosa) infection. Cefiderocol was the sole antibiotic with consistent activity against six bacterial isolates obtained from the infected region over a 38 day period. Results WGS analysis identified a blaGES-1 gene as well as the MDR efflux pumps MexD and MexX in all six of the patient’s ST235 DTR-P. aeruginosa isolates, when compared with the reference genome P. aeruginosa PA01 and a P. aeruginosa ST235 isolate from an unrelated patient. After debridement of infected scalp and bone, the patient received approximately 6 weeks of cefiderocol in conjunction with IV phage Pa14NPøPASA16. Some improvement was observed after the initiation of cefiderocol; however, sustained local site improvement and haemodynamic stability were not achieved until phage was administered. No medication-related toxicities were observed. The patient remains infection free more than 12 months after completion of therapy. Conclusions This report adds to the growing literature that phage therapy may be a safe and effective approach to augment antibiotic therapy for patients infected with drug-resistant pathogens. Furthermore, it highlights the importance of the GES β-lactamase family in contributing to inactivation of a broad range of β-lactam antibiotics in P. aeruginosa, including ceftolozane/tazobactam, ceftazidime/avibactam and imipenem/relebactam.

Aims Nocturia, or waking up at night to void, is a highly prevalent and bothersome lower urinary tract symptom. However, the applied treatment modalities do not improve symptoms in about half of the patients. The aim of this report is to generate new ideas for future nocturia research, with special emphasis on the role of sleep physiology and sleep disorders. Methods The following is a report of the presentations and subsequent discussion of the Nocturia Think Tank session at the annual meeting of the International Consultation on Incontinence Research Society (ICI-RS), which took place in September 2015 in Bristol. General information about the organization of the ICI-RS meeting can be found on the website "www.ici-rs.org." An overview of challenges within the existing evidence, future research ideas, and results of research with regard to nocturia and sleep were presented. Results and conclusion In order to optimize the management of nocturia and nocturnal polyuria (NP), future research has to focus on the development of unambiguous terminology regarding nocturia and NP, the role of renal function profiles and simplified frequency volume charts as guidance of individualized therapy and the role of sleep disorders such as periodic limb movements during sleep and habitual voiding as a response to awakening. Neurourol. Urodynam. 37:2048-2052, 2018. © 2016 Wiley Periodicals, Inc.

Nocturia, or waking up at night to void, is a highly prevalent and bothersome lower urinary tract symptom. However, the applied treatment modalities do not improve symptoms in about half of the patients. The aim of this report is to generate new ideas for future nocturia research, with special emphasis on the role of sleep physiology and sleep disorders.The following is a report of the presentations and subsequent discussion of the Nocturia Think Tank session at the annual meeting of the International Consultation on Incontinence Research Society (ICI-RS), which took place in September 2015 in Bristol. General information about the organization of the ICI-RS meeting can be found on the website "www.ici-rs.org." An overview of challenges within the existing evidence, future research ideas, and results of research with regard to nocturia and sleep were presented.In order to optimize the management of nocturia and nocturnal polyuria (NP), future research has to focus on the development of unambiguous terminology regarding nocturia and NP, the role of renal function profiles and simplified frequency volume charts as guidance of individualized therapy and the role of sleep disorders such as periodic limb movements during sleep and habitual voiding as a response to awakening. Neurourol. Urodynam. 37:2048-2052, 2018. © 2016 Wiley Periodicals, Inc.