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Introduction: Plastic surgeons frequently take facial trauma calls, and their responsibilities may include infection care. The head and neck is a site of presentation for necrotizing fasciitis which requires a high level of suspicion and prompt acti2on for diagnosis and treatment. We performed a meta-analysis of the literature on necrotizing fasciitis of the head and neck (HNnf) to summarize clinical factors, causative organisms, and treatment, and included 2 cases presenting to our institution. Methods: A meta-analysis of the literature from 1990 to 2021 was completed on HNnf. After institutional review board approval, medical records of 2 patients presenting with a diagnosis of HNnf to an academic plastic surgery center between July and September 2021 were retrospectively reviewed. Systematic reviews and articles without comprehensive individualized patient data were excluded. Results: A systematic review was performed including 2 cases presenting to our institution. A total of 149 individual cases of HNnf spanning a 30-year period were included. The most common associated comorbidity was diabetes mellitus. The most frequent source of infection was odontogenic. Most patients required serial debridements in addition to IV antibiotics. Streptococcus pyogenes was the most frequent pathogen; however, most infections were polymicrobial. Infections in the periorbital region were significantly monomicrobial ( P = .011). Acute reconstructive surgery requirements: 27 patients had skin grafting, 9 had flap reconstruction. Mortality rate was 12.3%. Increasing age was a significant predictor of mortality ( P = .01). Patients with diabetes were significantly more likely to die from HNnf (52.6%, P = .039) and require multiple debridements ( P = .001) for HNnf as compared to patients without diabetes. Infections initially arising from the submandibular region were found to be an independent negative predictor of mortality ( P = .029). Conclusion: Our experience with HNnf along with meta-analysis of the literature revealed trends in demographics, presentation, organisms, and outcomes, increasing the collective knowledge of this rare entity.

Background Clindamycin utilization has provoked gram-positive and anaerobic bacterial resistance and is associated with Clostridioides difficile infections (CDI). The purpose of this study was to evaluate if implementing local clindamycin-focused stewardship initiatives impacts clindamycin utilization and outcome metrics. Methods This multicenter, retrospective quasi-experimental study was conducted in adult hospitalized patients who received clindamycin from 2018 to 2020. Outcomes were compared in three phases between an intervention and control group (Figure 1). The primary outcome was inappropriate utilization: a resistant pathogen, concurrent antibiotic(s) with pathogen activity, a non-necrotizing infection, an alternative agent was preferred, or alternative reasons per expert discretion. Secondary outcomes included clindamycin duration of therapy per 1000 patient hospital days (DOT/1000 PD), 30-day CDI, 30-day readmission, and in-hospital mortality. Outcomes were compared between groups using the chi-square, Fisher’s exact, or Kruskal-Wallis tests as appropriate. Figure 1.Study DesignID: infectious diseases, I: intervention group, C: control group Results The study included 481 patients (Table 1). Inappropriate clindamycin use in the intervention group was highest in Phase 1 (94%), then decreased in Phase 2 (72%) and Phase 3 (74%) (p< 0.01). Comparing Phase 1, Phase 2, and Phase 3 between the intervention and control groups, respectively, the primary outcome occurred in 94% vs 93% (p=0.80), 72% vs 88% (p=0.02), and 74% vs 89% (p=0.03). The DOT/1000 PD was 10 in Phase 1, 9.2 in Phase 2, and 6.2 in Phase 3. Initiatives were not associated with significant reductions in 30-day CDI (1% in Phase 1, 0% in Phase 2, 0% in Phase 3, p=0.64), 30-day readmission (18% in Phase 1, 31% in Phase 2, 22% in Phase 3, p=0.13), or in-hospital mortality (0% in Phase 1, 2% in Phase 2, 0% in Phase 3, p=0.33). Table 1.OutcomesI: intervention group, C: control group, DOT/1000 PD: days of therapy per 1000 patient days, CDI: Clostridioides difficile infection Conclusion Clindamycin-focused stewardship initiatives reduced inappropriate prescribing patterns by approximately 20% but still remained high in Phase 3. Clindamycin was primarily ordered in the emergency department (ED). Additional initiatives may include formal criteria for use and removing clindamycin from automated dispensing cabinets in the ED. Our initiatives may serve as a model for other institutions to reduce clindamycin utilization and its associated complications. Disclosures All Authors: No reported disclosures.

BackgroundAlthough important in clinical care, reports of inappropriate peripherally inserted central catheter (PICC) use are growing.ObjectiveTo test whether implementation of the Michigan Appropriateness Guide for Intravenous Catheters (MAGIC) can improve PICC use and patient outcomes.DesignQuasi-experimental, interrupted time series design at one study site with nine contemporaneous external controls.SettingTen hospitals participating in a state-wide quality collaborative from 1 August 2014 to 31 July 2016.Patients963 hospitalised patients who received a PICC at the study site vs 6613 patients at nine control sites.InterventionA multimodal intervention (tool, training, electronic changes, education) derived from MAGIC.MeasurementsAppropriateness of PICC use and rates of PICC-associated complications. Segmented Poisson regression was used for analyses.ResultsAbsolute rates of inappropriate PICC use decreased substantially at the study site versus controls (91.3% to 65.3% (−26.0%) vs 72.2% to 69.6% (−2.6%); PLimitationsNon-randomised design limits inference; the most effective component of the multimodal intervention is unknown; effects following implementation were modest.ConclusionsIn a multihospital quality improvement project, implementation of MAGIC improved PICC appropriateness and reduced complications to a modest extent. Given the size and resources required for this study, future work should consider cost-to-benefit ratio of similar approaches.

In a 2016 survey of 46 Michigan hospitals, we identified four key needs for antibiotic stewardship: clinically-relevant antibiotic data, monitoring compliance, syndrome-specific interventions, and discharge stewardship. A stewardship initiative now addresses these needs within the Michigan Hospital Medicine Safety Consortium.

Background Fluoroquinolones increase the risk of Clostridioides difficile infection and antibiotic resistance, but are frequently used for hospitalized patients with bacteriuria. We assessed patterns and predictors of inappropriate fluoroquinolone (FQ) use among hospitalized patients with asymptomatic bacteriuria (ASB) and cystitis. Methods This is a retrospective cohort study of non-ICU medicine patients with ASB or cystitis (complicated or uncomplicated) from January 2018 to March 2019 at 43 Michigan hospitals. Patients with concomitant infections, bacteremia, or pyelonephritis were excluded. Each day of FQ (ciprofloxacin, levofloxacin) use (inpatient and post discharge) was assessed for appropriateness. FQ use was inappropriate if: (A) ASB, (B) urine culture with an FQ-resistant bacteria, (C) a safer alternative empiric or definitive antibiotic (treatment ≥2 days after urine culture collection) based on disease severity, cultures, allergies, and renal function, or (D) excess duration (>7 days complicated cystitis; >3 days uncomplicated cystitis). Hospitals were also surveyed on existing stewardship (ASP) practices targeting FQ use. ASP practices associated with inappropriate FQ use were evaluated using logistic generalized estimated equation models adjusting for patient factors and hospital clustering. Results Of 4849 included patients with ASB (39.7%) or cystitis (60.3%), 21.9% (n = 1,061) received an FQ and 92.7% (n = 984) received a, FQ inappropriately (Figure 1). Of 5,465 FQ days of therapy (DOT), 90.7% (n = 4,959) were inappropriate. Definitive treatment of complicated cystitis led to the greatest proportion of inappropriate FQ DOTs (50.6%), followed by ASB (36.4%) (Table 1). Hospitals varied (Figure 2), but those with cascade reporting of antibiotic susceptibilities, urinary tract infection (UTI) treatment guideline or an ASP performing prospective audit and feedback on FQ use had lower inappropriate FQ treatment rates (Table 2). Conclusion Hospitalized patients with ASB and cystitis often receive an FQ. Most FQ use is inappropriate due to ASB treatment or FQ use for complicated cystitis despite the option of an alternative antibiotic. Prospective audit and feedback, UTI guidelines, and cascade reporting of antibiotic susceptibilities can be used by ASP to reduce inappropriate FQ use. Disclosures All authors: No reported disclosures.

Objective.To determine whether increases in contact isolation precautions are associated with decreased adherence to isolation practices among healthcare workers (HCWs).Design.Prospective cohort study from February 2009 to October 2009.Setting.Eleven teaching hospitals.Participants.HCWs.Methods.One thousand thirteen observations conducted on HCWs. Additional data included the number of persons in isolation, types of HCWs, and hospital-specific contact precaution practices. Main outcome measures included compliance with individual components of contact isolation precautions (hand hygiene before and after patient encounter, donning of gown and glove upon entering a patient room, and doffing upon exiting) and overall compliance (all 5 measures together) during varying burdens of isolation.Results.Compliance with hand hygiene was as follows: prior to donning gowns/gloves, 37.2%; gowning, 74.3%; gloving, 80.1%; doffing of gowns/gloves, 80.1%; after gown/glove removal, 61%. Compliance with all components was 28.9%. As the burden of isolation increased (20% or less to greater than 60%), a decrease in compliance with hand hygiene (43.6%—4.9%) and with all 5 components (31.5%—6.5%) was observed. In multivariable analysis, there was an increase in noncompliance with all 5 components of the contact isolation precautions bundle (odds ratio [OR], 6.6 [95% confidence interval (CI), 1.15-37.44];P= .03) and in noncompliance with hand hygiene prior to donning gowns and gloves (OR, 10.1 [95% CI, 1.84—55.54];P= .008) associated with increasing burden of isolation.Conclusions.As the proportion of patients in contact isolation increases, compliance with contact isolation precautions decreases. Placing 40% of patients under contact precautions represents a tipping point for noncompliance with contact isolation precautions measures.

Background Broad-spectrum (BS) antibiotics directed against Pseudomonas aeruginosa and methicillin-resistant Staphylococcus aureus (MRSA) are commonly used for health-care associated pneumonia (HCAP) treatment. Many patients with HCAP do not have a microbiologically confirmed diagnosis. The goal of this study was to evaluate the impact of antibiotic de-escalation on clinical outcomes in patients with HCAP without a microbiological diagnosis. Methods This is a retrospective cohort study of adult, non-ICU, medical patients hospitalized with HCAP between January 2016 and February 2018 at 46 Michigan hospitals. Exclusions included extrapulmonary infection, severe immune suppression, or clinical instability on day 4. Included patients: (1) lacked any positive culture (blood/sputum); (2) started on empiric anti-P. aeruginosa and anti-MRSA therapy by hospital day 2; (3) switched to a narrow-spectrum (NS) regimen (no anti-P. aeruginosa or anti-MRSA coverage) or maintained on BS antibiotics (anti-P. aeruginosa ± anti-MRSA) by therapy day 4 (Figure 1). Mortality, readmission, Clostridium difficile infection, and adverse events from antibiotics were compared between the BS and NS groups. Data were analyzed using logistic generalized estimating equation models and inverse probability of treatment weighting. Results Of 363 patients with HCAP included, 73 (20%) were switched to an NS regimen. Of 290 patients maintained on anti-PSA BS regimens, 47.6% also continued anti-MRSA therapy. The median age was 72 (IQR, 61–81) and Charlson comorbidity index was 4 (IQR, 2–6) of the entire cohort. Baseline characteristics were similar between BS and NS groups, except more patients had chronic kidney disease in the BS group. On multivariable analysis, no other baseline factors were found to be associated with use of BS antibiotics on day 4. Both total and IV antibiotic duration were longer in the BS group (10 vs. 8 days, P = 0.002, and 4 vs. 3 days, P < 0.001, respectively). On adjusted analysis, there were no differences in patient outcomes (Figure 2). Conclusion Among patients with HCAP started on empiric MRSA and PSA coverage without microbiological diagnosis, clinical outcomes were similar in patients switched to an NS antibiotic and those maintained on BS antibiotics. Our findings suggest a potential role for antimicrobial stewardship in promoting antibiotic de-escalation in this population. Disclosures All authors: No reported disclosures.

Background Treatment of asymptomatic bacteriuria (ASB) is a major driver of inappropriate antibiotic use and an important target for antimicrobial stewardship. We identified patient- and hospital-level factors associated with treatment of ASB and its impact on patient outcomes. Methods In this retrospective cohort study, detailed data were abstracted from the medical record of adult non-ICU patients hospitalized with a positive urine culture (Ucx) between January 2016 and February 2018 at 46 Michigan hospitals. Exclusions included pregnancy, urologic surgery or abnormality, immune-compromise, or concomitant infection. ASB was defined as a positive Ucx without signs or symptoms attributable to a urinary tract infection (UTI). The treatment group received ≥1 antibiotic dose. Patient outcomes included mortality, readmissions, Clostridium difficile infection, and emergency room visits. Patient and hospital factors associated with ASB treatment were evaluated using logistic generalized estimating equation models; patient outcomes were inverse probability of treatment weighted. Results Of 2,733 included patients with ASB, 82.9% (n = 2,266) were treated with antibiotics for a median 7 days (IQR 4,9). Ceftriaxone (71.1%) was the most frequent initial therapy; fluoroquinolones (33.2%) were most common at discharge. In the multivariable model, patient variables associated with ASB treatment included: increased age, dementia, positive urinalysis, incontinence, indwelling urinary catheter, and nonambulatory status (Figure 1). Hospitals varied (Figure 2), but those that required a documented indication for antibiotics in the order or medical record had lower ASB treatment rates (OR = 0.5). There was no difference in patient outcomes for patients treated vs. not treated with antibiotics. Conclusion Antibiotic treatment of ASB, often broad-spectrum, is widespread. Certain patient characteristics (including advanced age, nonambulatory, dementia, and incontinence) and the misinterpretation of test results (including overemphasis of the urinalysis) drive clinicians to treat ASB. Requiring documentation of antibiotic indication may decrease inappropriate treatment. Future interventions may be more effective by incorporating these drivers of ASB treatment. Disclosures All authors: No reported Disclosures.

Importance Treatment of asymptomatic bacteriuria (ASB) with antibiotics is a common factor in inappropriate antibiotic use, but risk factors and outcomes associated with treatment of ASB in hospitalized patients are not well defined. Objective To evaluate factors associated with treatment of ASB among hospitalized patients and the possible association between treatment and clinical outcomes. Design, Setting, and Participants A retrospective cohort study was conducted from January 1, 2016, through February 1, 2018, at 46 hospitals participating in the Michigan Hospital Medicine Safety Consortium. A total of 2733 hospitalized medical patients with ASB, defined as a positive urine culture without any documented signs or symptoms attributable to urinary tract infection, were included in the analysis. Exposures One or more antibiotic dose for treatment of ASB. Main Outcomes and Measures Estimators of antibiotic treatment of ASB. Secondary outcomes included 30-day mortality, 30-day hospital readmission, 30-day emergency department visit, discharge to post–acute care settings,Clostridioides difficileinfection (formerly known asClostridium difficile) at 30 days, and duration of hospitalization after urine testing. Results Of 2733 patients with ASB, 2138 were women (78.2%); median age was 77 years (interquartile range [IQR], 66-86 years). A total of 2259 patients (82.7%) were treated with antibiotics for a median of 7 days (IQR, 4-9 days). Factors associated with ASB treatment included older age (odds ratio [OR], 1.10 per 10-year increase; 95% CI, 1.02-1.18), dementia (OR, 1.57; 95% CI, 1.15-2.13), acutely altered mental status (OR, 1.93; 95% CI, 1.23-3.04), urinary incontinence (OR, 1.81; 95% CI, 1.36-2.41), leukocytosis (white blood cell count >10 000/μL) (OR, 1.55; 95% CI, 1.21-2.00), positive urinalysis (presence of leukocyte esterase or nitrite, or >5 white blood cells per high-power field) (OR, 2.83; 95% CI, 2.05-3.93), and urine culture with a bacterial colony count greater than 100 000 colony-forming units per high-power field (OR, 2.30; 95% CI, 1.83-2.91). Treatment of ASB was associated with longer duration of hospitalization after urine testing (4 vs 3 days; relative risk, 1.37; 95% CI, 1.28-1.47). No other differences in secondary outcomes were identified after propensity weighting. Conclusions and Relevance Hospitalized patients with ASB commonly receive inappropriate antibiotic therapy. Antibiotic treatment did not appear to be associated with improved outcomes; rather, treatment may be associated with longer duration of hospitalization after urine testing. To possibly reduce inappropriate antibiotic use, stewardship efforts should focus on improving urine testing practices and management strategies for elderly patients with altered mental status.

Background Randomized trials demonstrate no benefit from antibiotic treatment exceeding the shortest effective duration. Objective To examine predictors and outcomes associated with excess duration of antibiotic treatment. Design Retrospective cohort study. Setting 43 hospitals in the Michigan Hospital Medicine Safety Consortium. Patients 6481 general care medical patients with pneumonia. Measurements The primary outcome was the rate of excess antibiotic treatment duration (excess days per 30-day period). Excess days were calculated by subtracting each patient's shortest effective (expected) treatment duration (based on time to clinical stability, pathogen, and pneumonia classification [community-acquired vs. health care-associated]) from the actual duration. Negative binomial generalized estimating equations (GEEs) were used to calculate rate ratios to assess predictors of 30-day rates of excess duration. Patient outcomes, assessed at 30 days via the medical record and telephone calls, were evaluated using logit GEEs that adjusted for patient characteristics and probability of treatment. Results Two thirds (67.8% [4391 of 6481]) of patients received excess antibiotic therapy. Antibiotics prescribed at discharge accounted for 93.2% of excess duration. Patients who had respiratory cultures or nonculture diagnostic testing, had a longer stay, received a high-risk antibiotic in the prior 90 days, had community-acquired pneumonia, or did not have a total antibiotic treatment duration documented at discharge were more likely to receive excess treatment. Excess treatment was not associated with lower rates of any adverse outcomes, including death, readmission, emergency department visit, or Clostridioides difficile infection. Each excess day of treatment was associated with a 5% increase in the odds of antibiotic-associated adverse events reported by patients after discharge. Limitation Retrospective design; not all patients could be contacted to report 30-day outcomes. Conclusion Patients hospitalized with pneumonia often receive excess antibiotic therapy. Excess antibiotic treatment was associated with patient-reported adverse events. Future interventions should focus on whether reducing excess treatment and improving documentation at discharge improves outcomes. Primary funding source Blue Cross Blue Shield of Michigan (BCBSM) and Blue Care Network as part of the BCBSM Value Partnerships program.

Background Community-acquired pneumonia (CAP) guidelines recommend transition to an oral (PO) β-lactam (BL) regimen or fluoroquinolone (FQ) when patients are clinically stable. Due to collateral damage associated with FQs, stewardship efforts often focus on reducing initial FQ use for CAP therapy. We hypothesized that FQ use remains prevalent in CAP treatment despite initial intravenous (IV) BL therapy, and examined factors associated with switching to a PO BL vs. an FQ and the impact on outcomes. Methods In this retrospective cohort study, data were collected from January 2016 through February 2018 on non-ICU medical patients admitted with CAP at 46 Michigan hospitals. Patients were included if they received IV BL (ceftriaxone or ampicillin-sulbactam) plus macrolide/doxycycline by hospital day 2 and switched to a PO respiratory FQ or BL by therapy day 4. Exclusions included positive culture, concomitant infection, HCAP, unstable on day 4, or severe immune deficiency. Data were analyzed using logistic generalized estimating equation models, accounting for hospital-level clustering; outcomes were adjusted using the inverse probability of treatment weighting by propensity scores. Results. Of 555 included patients, 54.4% were switched to a PO BL vs. 45.6% to an FQ by day 4 of therapy. The groups had similar durations of therapy (8 days), time to clinical stability, prior antibiotics, and COPD, but the BL group was older, with a higher Pneumonia Severity Index, CURB-65, and more cardiovascular (CV) disease (Figure 1). In multivariable analysis, CV disease and higher CURB-65 were more common and diabetes (DM) less common in the PO BL group (Figure 2). Sharing antibiotic use data with providers were associated with less FQ use (83.1% vs. 70.8%, OR 0.51, 95% CI 0.27, 0.97, P = 0.04). On adjusted analysis there were no differences in patient outcomes (Figure 3). Conclusion. Among CAP patients started on an IV BL regimen, nearly half were switched to a PO FQ by therapy day 4, including more patients with DM. Although there were sicker patients in the BL group, there were no differences in outcomes between cohorts. To reduce FQ use, stewardship programs should share antibiotic use data and provide guidance for step-down therapy in clinically stable CAP patients. Disclosures All authors: No reported disclosures.

Background Over 90% of annual deaths caused by Clostridium difficile infection (CDI) occur in persons aged ≥65 years. However, no large-scale studies have been conducted to investigate predictors of CDI-related mortality among older adults. Methods This case-control study included 540 CDI patients aged ≥60 years admitted to a tertiary care hospital in Detroit, Michigan, between January 2005 and December 2012. Cases were CDI patients who died within 30 days of CDI date. Controls were CDI patients who survived >30 days after CDI date. Cases were matched to controls on a 1:3 ratio based on age and hospital acquisition of CDI. Results One-hundred and thirty cases (25%) were compared with 405 controls (75%). Independent predictors of CDI-related mortality included admission from another acute hospital (odds ratio [OR], 8.25; P = .001) or a long-term care facility (OR, 13.12; P = .012), McCabe score ≥2 (OR, 12.19; P P = .021). The regression model was adjusted for the confounding effect of limited activity of daily living score, total number of antibiotic days prior to CDI, ileus on abdominal radiograph, low albumin (≤2.5 g/dL), elevated white blood cell count (>15 × 1,000/mm 3 ), and admission to intensive care unit because of CDI. Conclusions Predictors of CDI-related mortality reported in this study could be applied to the development of a bedside scoring system for older adults with CDI.

Tigecycline is one of the few remaining therapeutic options for extensively drug-resistant (XDR) Gram-negative bacilli (GNB). MICs of tigecycline to Acinetobacter baumannii have been reported to be elevated when determined by the Etest compared to determinations by the broth microdilution (BMD) method. The study aim was to compare the susceptibility of GNB to tigecycline by four different testing methods. GNB were collected from six health care systems (25 hospitals) in southeast Michigan from January 2010 to September 2011. Tigecycline MICs among A. baumannii , carbapenem-resistant Enterobacteriaceae (CRE), extended-spectrum β-lactamase (ESBL)-producing Enterobacteriaceae , and susceptible Enterobacteriaceae isolates were determined by Etest, BMD, Vitek-2, and MicroScan. Nonsusceptibility was categorized as a tigecycline MIC of ≥4 μg/ml for both A. baumannii and Enterobacteriaceae . The study included 4,427 isolates: 2,065 ESBL-producing Enterobacteriaceae , 1,105 A. baumannii , 888 susceptible Enterobacteriaceae , and 369 CRE isolates. Tigecycline nonsusceptibility among A. baumannii isolates was significantly more common as determined by Etest compared to that determined by BMD (odds ratio [OR], 10.3; P < 0.001), MicroScan (OR, 12.4; P < 0.001), or Vitek-2 (OR, 9.4; P < 0.001). These differences were not evident with the other pathogens. Tigecycline MICs varied greatly according to the in vitro testing methods among A. baumannii isolates. Etest should probably not be used by laboratories for tigecycline MIC testing of A. baumannii isolates, since MICs are significantly elevated with Etest compared to those determined by the three other methods.