Background: Measuring and reporting antibiotic use are essential to antimicrobial stewardship activities. The most common metric to assess facility-level use is days of antibiotic therapy per 1000 days of care (DOT/1000 DOC). This metric may be difficult to calculate, not be readily comparable, or not provide actionable data to individual prescribers, particularly those that work in post-acute and long-term care (PALTC) settings. Here we use data from a centralized dispensing pharmacy to develop antibiotic use metrics suitable for offering individualized feedback to prescribers working in PALTC settings. Methods: We obtained medication dispensing data and resident census data for 13 PALTC settings within the same network. After omitting non-pharmacologic items and limiting the data to medications dispensed from 1/2020 – 12/2022, we determined the following metrics by month: days of antibiotic therapy (DOT), number of medications prescribed, number of antibiotic courses prescribed (antibiotic starts), and the number of individual residents issued a prescription for any medication (unique residents). These metrics were assessed for each facility (2020 – 2022) and for prescribers responsible for > 1% of prescriptions within that facility (2022 only). Prescriber-level unique residents was the number of residents issued a prescription by the given provider. We obtained facility-level census data to calculate antibiotic DOT/1000 resident days of care (DOC) as a standard to which we compared novel metrics. Results: During the 3-year study period, 1718 prescribers at 13 PALTC settings wrote for 672256 medications, including 31087 antibiotic courses. At the facility level, the correlation between monthly antibiotic starts (courses)/unique residents and antibiotic DOT/1000 DOC was 0.83 (p < 0 .0001). The correlation between monthly antibiotic DOT/unique residents and antibiotic DOT/1000 DOC was 0.98 (p < 0 .0001). Trends in monthly values of both novel metrics and DOT/1000 DOC were consistent across the examined period (Figure 1). For individual prescribers, both novel metrics permit assessment and comparison of antibiotic prescription rates over time (Figure 2). Conclusions: Pharmacy dispensing data can be used to determine antibiotic DOT/unique residents and antibiotic starts/unique residents at the facility level and for individual providers. The novel metric antibiotic DOT/unique residents demonstrated strong correlation with antibiotic DOT/1000 DOC at the facility level. In addition to supporting tracking and reporting of antibiotic use among PALTC settings, these new metrics permit visualization of the antibiotic prescribing rates of individuals prescribers, as well as peer comparison, which in turn can lead to actionable feedback that helps improve antibiotic use in the care of PALTC.

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: Optimizing antimicrobial use (AU) among post-acute and long-term care (PALTC) residents is fundamental to reducing the morbidity and mortality associated with multidrug-resistant organism (MDROs), as well as unintended social consequences related to infection prevention. Data on AU in PALTC settings remains limited. The U.S. Department of Veteran Affairs (VA) provides PALTC to over 23,000 residents at 134 community living centers (CLCs) across the United States annually. Here, we describe AU in VA CLCs, assessing both class and length of therapy. Methods: Monthly AU between January 1, 2015 and December 31, 2019 was extracted from the VA Corporate Data Warehouse across 134 VA CLCs. Antimicrobials and administration routes were based on the National Healthcare Safety Network AU Option protocol for hospitals. Rates of AU were measured as the days of therapy (DOT) per 1,000 resident-days. An antimicrobial course was defined as the same drug and route administered to the same resident with a gap of ≤ three days between administrations. Course duration was measured in days. AU Rates were measured as the days of therapy (DOT) per 1,000 resident-days. Results: The most common class of antimicrobial course administered during the study period was beta-lactam/beta-lactamase inhibitor combinations (15%) followed by fluroquinolones (14%), extended-spectrum cephalosporins (12%) and glycopeptides (11%; Figure 1). Neuraminidase inhibitors had the longest median (IQR) course duration (10 (IQR 8) days), followed by tetracyclines (8 (IQR 8) days), and then folate pathway inhibitors, nitrofurans and 1st/2nd generation cephalosporins (7 (IQR 7) days). Overall, 60% of antimicrobial courses were administered orally, with fluroquinolones the most frequently administered orally (20%). From 2015 – 2019, the annual rate of total antimicrobial use across VA CLCs decreased slightly from 213.6 to 202.5 DOT/1,000 resident-days. During the 5-year study period, fluroquinolone use decreased from 27.47 to 13.36 DOTs/1,000 resident-days. First and 2nd generation cephalosporin use remained relatively stable, but 3rd or greater generation cephalosporin use increased from 14.70 to 19.21 DOTs/1,000 resident-days (Figure 2). Conclusion: The marked decrease in the use of fluoroquinolones at VA CLCs from 2015-2019 is similar to patterns observed for VA hospitals and for non-VA PALTC facilities. The overall use of antibacterial agents at VA CLCs decreased slightly during the study period, but other broad-spectrum agents such as 3rd or greater generation cephalosporins increased over the same period. The strategies used to decrease fluroquinolone use may have application for other antibiotic classes, both in VA and non-VA PALTC settings.

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

Background: In rural areas, antimicrobial stewardship programs often have limited access to infectious disease (ID) expertise. Videoconference Antimicrobial Stewardship Teams (VASTs) pair rural Veterans Affairs (VA) medical centers with an ID expert to discuss treatment of patients with concerns for infection. In a pilot study, VASTs were effective at improving antimicrobial use. Here, we evaluated 12-month operating costs for staffing for 3 VASTs. Methods: We used the following data to describe 12 months of clinical encounters for 3 VASTs operating from January 2022 – March 2023: the number of VAST sessions completed and clinical encounters; Current Procedural Terminology (CPT) codes associated with clinical encounters; session attendees (by role) and the time spent (percent effort) on VAST-related activities. The annual operating cost was based on the annual salaries and percent effort of VAST attendees. We used these characteristics combined with private-sector and Medicare reimbursements to evaluate the cost of implementation and number of clinical encounters needed to offset those costs (breakeven) for each site. Results: Three VASTs recorded 229 clinical encounters during 117 sessions (Table 1). Based on CPT codes, the approximate revenue per patient was $516.46. Site A, the only site to break even, had the most sessions and clinical encounters as well as the lowest operating costs. For Site B, a slight increase in the clinical encounters, which might be achieved by 3 additional VAST sessions, would help achieve breakeven. For Site C, increasing the number of clinical encounters to 3-4 per session would have helped their VAST break even without requiring a decrease in operating costs. Conclusions: The frequency of VAST sessions, volume of clinical encounters, and low operating costs all contributed the VAST at Site A achieving a financial break-even point within 12 months. Consideration of the potential number of clinical encounters and sessions will help other VASTs achieve financial sustainment, independent of cost-savings related to potential decreases in expenditures for antibiotics and antibiotic-related adverse events. These results also provide insight into possible adoption and diffusion of VAST-like programs in the Medicare hospital setting.

Background: Overall, ~12% of outpatient visits result in an antibiotic prescription, and 30% of those prescriptions are inappropriate. Behavioral nudges help influence practitioner behavior. We hypothesized that peer comparison combined with a behavioral nudge (a patient alert letter) would influence prescribers to reduce antibiotic prescriptions and improve antimicrobial stewardship in the outpatient setting. We pilot-tested this intervention in outpatient primary care clinics associated with a large Veterans Affairs (VA) medical center. Methods: We conducted a clustered randomized controlled trial of 12 community-based outpatient clinics. All practitioners in the intervention arm received quarterly comparative feedback reports and, when indicated, quarterly patient alert letters. Comparative feedback reports gave personalized feedback about antibiotic prescriptions for upper respiratory tract infections, comparing the recipient’s antibiotic prescriptions to the average for all practitioners at the primary care clinics included in our study. Patient alert letters notified practitioners to patients in their panel with recently detected Clostridioides difficile or resistant organism and their antibiotic exposures. We assessed outpatient visits during the preintervention period (April–September 2020), the intervention period (October 2020–September 2021), and the postintervention period (October 2021–September 2022). A mixed-effects logistic regression model predicting antibiotic prescriptions compared the arms across these periods. Results: The outpatient populations observed in the intervention and control arms were similar during each phase of the study. Prior to the intervention, the average proportion of visits with an antibiotic prescription was lower among clinics in the intervention arm (1.4% vs 1.8% in control arm; P = .45). This difference broadened slightly during the intervention period (1.4% vs 2.1%, respectively; P = .03) and the postintervention period (1.3% vs 2.1%, respectively; P = .01) (Fig. 1). Throughout the study, clinics in the intervention arm typically used more doxycycline and azithromycin and less amoxicillin-clavulanate and sulfamethoxazole-trimethoprim compared to clinics in the control arm. (Fig. 2). In the 6-month preintervention period, which coincided with the early phase of the COVID-19 pandemic, antibiotic prescriptions in the intervention compared to control clinics were similar. During the intervention and postintervention periods, the proportion of visits with an antibiotic prescription remained steady for clinics in the intervention arm and increased for those in the control arm. These results suggest that this pilot study using a low-intensity intervention consisting of comparative feedback reports and patient alert letters was successful in influencing the antibiotic prescribing behavior of primary care clinicians practicing in community-based outpatient clinics affiliated with a VA medical center.

Financial support: This study was funded by Merck.

Disclosures: None

Background: Veterans Health Administration (VHA) community living centers (CLCs) provide postacute and long-term care. CLC veterans visit myriad locations outside their rooms (eg, rehabilitation, dialysis). Pathogen transmission during out-of-room visits is unknown. Methods: We recruited newly admitted veterans at 3 CLCs. After obtaining informed consent, we cultured nares, groin, hands, and 7 surfaces in the patient rooms. We accompanied veterans to up to 5 out-of-room visits and cultured patients’ hands and surfaces they touched. We tested for multidrug-resistant organisms (MDROs) including methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococcus (VRE), and quinolone, carbapenem, and/or ceftazidime-resistant gram-negative bacteria (R-GNB). We defined transmission as a positive culture following an initial negative culture during the same visit. Results: We enrolled 137 veterans (median follow-up, 29 days; mean, 5.9 visits); 97% were postacute patients. We conducted 539 patient-room sampling visits (mean, 3.9 per veteran; 5,490 swabs) and accompanied 97 veterans to 266 out-of-room sampling visits (mean, 2.7 per veteran; 2,360 swabs). Of 137 patients, 47 (35%) were colonized with an MDRO at enrollment and 74 (58%) of 128 patients were colonized on any follow-up patient-room visits. Of 133 patients, 55 (41%) acquired a new MDRO, most often VRE (31 of 97, 32%). In patient rooms, toilet seats [114 (21%) of 538], curtains [101 (19%) of 530] and bedrails [98 (18%) of 539] were most frequently contaminated. Among 266 out-of-room visits, 17% had surfaces contaminated with MDROs, most commonly involving dialysis [4 (31%) of 13], radiology [2 (25%) of 8], and rehabilitation therapy [29 (18%) of 159] (Fig. 1).Transmission of MDROs during out-of-room visits was common and occurred in 18% of visits with 8% (9 MRSA and 12 VRE) acquiring a new MDRO on their hands and 12% (9 MRSA and 23 VRE) of MDRO transmission occurring from hands to a surface that the patient touched (Fig. 1). In 18 (58%) of 31 cases, the organism transmitted to a surface was on patient hands at the start of the visit. Transmission was most common during visits to dialysis (3 to patients and 2 to surfaces), radiology (1 to a patient and 2 to surfaces), and rehabilitation therapy (13 to patients and 21 to surfaces) (Fig. 2). Conclusions: New MDRO acquisition during VHA CLC stay was common, and nearly one-fifth of out-of-room visits resulted in MDRO transmission. Our analyses suggest that veterans’ hands may shed MDROs (MRSA and VRE) to surfaces. Interventions to reduce MDRO transmission during visits for rehabilitation, dialysis, and other therapies are needed.

Disclosures: None

Background: In long-term care settings, practice patterns among practitioners are stronger determinants of antibiotic use than resident characteristics. In July 2021, hospitalists from the acute medicine service replaced geriatricians and assumed the care of residents in a 110-bed community living center (CLC) at a large academic Veterans Affairs (VA) medical center. We assessed changes in antibiotic use associated with that change of practitioners to guide stewardship efforts. We hypothesized that antibiotic use in the CLC would shift, reflecting the practice pattern of practitioners accustomed to treating patients in acute-care settings. Methods: We conducted a retrospective cohort study from July 1, 2020, through June 30, 2022, 1 year before and after the change of practitioners on July 1, 2021. We assessed resident characteristics and the following metrics of antibiotic use at monthly intervals: days of therapy (DOT) per 1,000 bed days of care (BDOC), antibiotic starts per 1,000 BDOC, and mean length of therapy (LOT) in days. We also compared the DOT per 1,000 BDOC for various antibiotics, in groups and individually. Results: In the years before and after the change of practitioners on July 1, 2021, the characteristics of CLC residents were comparable. Before and after July 1, 2021, monthly DOT per 1,000 BDOC (Fig. 1A), antibiotic starts per 1,000 BDOC, and mean LOT (Fig. 1B) were similar. After July 1, 2021, the use of fluoroquinolones decreased (14.31 vs 5.83 DOT per 1,000 BDOC; P < .01), and variations in anti-MRSA, narrow-spectrum, and broad-spectrum hospital agents were small, whereas the use of broad-spectrum community agents increased (29.42 vs 47.81 DOT per 1,000 BDOC; P < .01) (Fig. 2A). Within this group, there was increased use of doxycycline (7.42 vs 19.13 DOT per 1,000 BDOC; P < .01), ertapenem (2.03 vs 4.58 DOT per 1,000 BDOC; P < .01), and, modestly, azithromycin (0.40 vs 1.80 DOT per 1,000 BDOC) (Fig. 2B). Conclusions: The overall use of antibiotics, as measured by DOT, antibiotic starts, and LOT did not change after hospitalists assumed care of CLC residents. However, a notable decrease was observed in the use of fluoroquinolones, and an increase was observed in the use of doxycycline and ertapenem. Stewardship that is tailored to the type of provider and incorporates their practice patterns is needed to reinforce the prudent use of antibiotics.

Disclosures: None

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

For primary care clinics at a Veterans’ Affairs (VA) medical center, the shift from in-person to telehealth visits during the coronavirus disease 2019 (COVID-19) pandemic was associated with low rates of antibiotic prescription. Understanding contextual factors associated with antibiotic prescription practices during telehealth visits may help promote antibiotic stewardship in primary care settings.

In this large, retrospective cohort study, we used administrative data to evaluate nonpregnant adults with group B Streptococcus (GBS) bacteriuria. We found greater all-cause mortality in those with urinary tract infections compared to asymptomatic bacteriuria. Differences in patients’ baseline characteristics and the 1-year mortality rate raise the possibility that provider practices contribute to differences observed.

Background: An estimated 30% of antibiotic prescriptions in outpatient settings may be inappropriate. Antibiotic exposure increases an individual’s risk of Clostridioides difficile infection (CDI). To assess the prevalence of community-acquired CDI (CA-CDI) among patients without recent hospitalization and to examine the influence of outpatient antibiotic exposure on the risk of acquiring CA-CDI in this population, we examined a 2-year cohort of patients seen in primary care clinics at VA community-based outpatient clinics (CBOCs) associated with a large VA medical center. Methods: All primary care visits and nonvisit antibiotic prescriptions were identified in calendar years 2018–2019 as encounters of interest. Encounters occurring Results: We identified 84,787 patients with visits meeting our criteria. In this cohort, 3,533 patients were prescribed antibiotics at their encounter of whom 5 (0.14%) developed CA-CDI. Among the 81,254 patients who were not prescribed antibiotics, 15 (0.02%) developed CA-CDI, yielding an unadjusted CA-CDI odds ratio of 7.68 (95% CI, 2.50–19.82). p Conclusions: Although CA-CDI episodes were infrequent among VA outpatients with a CBOC visit in 2018–2019, the odds of CA-CDI were 7-fold greater in outpatients with antibiotic exposure than outpatients without antibiotic exposure. Antibiotic stewardship interventions that emphasize adverse events as a result of care provided in the outpatient setting, rather than as events limited to acute-care settings, may mitigate CDI risk.

Funding: This work was supported by the Merck Investigator Studies Program (MISP 59266 to F.P. and R.J.), and funds and facilities were provided by the Cleveland Geriatric Research Education and Clinical Center (GRECC) at the VA Northeast Ohio Healthcare System. The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Disclosures:. All authors report no conflicts of interest relevant to this article. R.J. has received research funding from Pfizer; she has also participated in advisory boards for Pfizer and Merck.

Background: COVID-19 has had a disproportionate effect on nursing homes residents as well as people from racial and ethnic minorities. Whether differences in mortality due to COVID-19 exists for nursing-home residents from racial and ethnic minorities is less clear, with some previous studies reporting systems-level disparities. The Department of Veterans’ Affairs (VA) has nursing homes, termed community living centers (CLCs), across the United States. We hypothesized that differences in COVID-19–related mortality among racial and ethnic minorities would be less pronounced among residents of CLCs. Methods: Using data from the VA Corporate Data Warehouse, we conducted a retrospective cohort study from April 14, 2020 (implementation of population-based testing) to December 10, 2020 (availability of a COVID-19 vaccine). Inclusion criteria were residents with a positive SARS-CoV-2 test while residing in or <48 hours before admission to a CLC. Positive tests <180 days after a prior positive test were excluded. We assessed the cohort for demographics, including self-reported race or ethnicity, clinical characteristics, and survival probability including all-cause 30-day mortality. A multivariable logistic regression model was used to estimate odds ratios (ORs) and 95% confidence intervals (CIs) for all-cause 30-day mortality that included race, ethnicity, age, and Charlson comorbidity index (CCI). Results: Among 14,759 CLC residents, 651 (4.4%) had a positive SARS-COV-2 test. Their mean age was 75.7 ± 11.3 years, and self-reported race or ethnicity was 68% White (445 of 651), 23% Black (152 of 651), and 4% Hispanic/Latinx (27 of 651). The mean CCI was lower among White residents than Black residents (4.15 ± 2.6 vs 4.61 ± 3.1, respectively). All-cause 30-day mortality for CLC residents following positive SARS-COV-2 test was 25% for White patients, 14% for Black patients, and 15% for Hispanic/Latinx patients (Fig. 1). Age (in years), but neither race or ethnicity nor CCI, was independently associated with all-cause 30-day mortality (OR, 1.07; 95% CI, 1.05–1.09) in CLC residents with COVID-19. Conclusions: Among VA CLC residents with a positive COVID-19 test, minority CLC residents did not have worse outcomes than white residents, suggesting that users of the VA healthcare system may enjoy abrogation of some aspects of health disparities.

Funding: None

Disclosures: None

Background: The Veterans’ Affairs (VA) healthcare system has had established telehealth programs for several years. Even so, the COVID-19 pandemic led to an expansion of and changes in these services. Little is known about the influence of the increased use of telehealth due to the COVID-19 pandemic on antibiotic prescriptions in outpatient settings. Here, we report on changes in visit modality and antibiotic prescribing at primary care clinics at a large VA medical center after the emergence of the COVID-19 pandemic. Methods: Using VA administrative databases, we identified primary care visits from March 2018 to November 2019 (before the COVID-19 pandemic) and March 2020 to November 2021 (during the COVID-19 pandemic), which permitted us to account for seasonality while analyzing visit modality and antibiotic trends. For primary care visits during the pre–COVID-19 and COVID-19 periods, we have described the type of visit (in-person or telehealth), diagnostic codes for any infection, and antibiotic prescriptions. Results: The patient population was primarily men (89%) with a mean age of 62.9 years (SD, ±15.3) at first visit. The most common medical conditions were diabetes mellitus (26%) and chronic lung disease (17%). Comparing visits during the pre–COVID-19 and the COVID-19 periods, the proportions of telehealth visits were 20% (17,708 of 88,565) and 74% (69,891 of 94,937), respectively (Fig. 1). The proportions of visits with an antibiotic prescription were 1.4% (1,212 of 88,565) and 0.8% (798 of 94,396), respectively. When considered by the type of visit, the rates of antibiotics prescribed were consistent during the pre–COVID-19 and COVID-19 periods, with a lower rate for telehealth visits (Fig. 2). In both periods, >50% of antibiotic prescriptions occurred during visits without an associated infectious disease diagnosis. Conclusions: Compared to the pre–COVID-19 period, primary care providers at a large VA medical center prescribed fewer antibiotics during the COVID-19 period, and they saw most of their patients via telehealth. These results suggest that some aspects of telehealth may support clinical practices consistent with antibiotic stewardship. The prescription of an antibiotic without an associated diagnostic code also suggests opportunities to improve implementation of antibiotic stewardship principles in primary care settings.

Funding: This work was supported by the Merck Investigator Studies Program (grant no. MISP 59266 to F.P. and R.J.) and by funds and facilities provided by the Cleveland Geriatric Research.

Disclosures: None

Background: Group B Streptococcus (GBS) can cause life-threating invasive infections, yet GBS is also a normal component of the intestinal and genitourinary tract. Although it is regarded as a potential urinary pathogen, the morbidity and mortality associated with recovery of GBS from urine cultures of nonpregnant adults is not well understood. We evaluated characteristics and mortality among nonpregnant adults with urine cultures that grew GBS. Methods: Using administrative data from the Veterans’ Healthcare Administration (VHA), we conducted a retrospective cohort study of VA healthcare system users from January 1, 2008, through December 31, 2017, with monomicrobial urine cultures growing ≥100,000 colony-forming units of GBS. Urinary tract infection (UTI) cases were defined as urinalysis positive for leukocyte esterase and pyuria (≥10 white blood cells), an International Classification of Diseases (ICD) code for UTI, and an antibiotic prescription. Cases with colonization were defined as negative for leukocyte esterase and pyuria, no ICD code for UTI, and no antibiotic prescription. Cases not meeting either definition were deemed unclassifiable. We compared demographics, comorbidities, and all-cause mortality among these 3 groups. Results: Over the 10-year study period, 26,848 veterans had 30,740 urine cultures positive for GBS. Applying the definitions above, there were 2,807 cases of infection, 8,789 cases of colonization, and 15,252 cases that were unclassifiable. Patients with a GBS UTI were slightly older compared to those who were colonized, with a higher Charlson comorbidity index and greater burden of chronic renal disease (Table 1). Individuals with infection versus colonization had 30-day mortality rates of 1% and 0%, respectively, and 1-year mortality rates of 9% and 4%, respectively (Figure 1). Conclusions: The association of a greater burden of illness among veterans who met our definition of UTI compared to colonization might be more reflective of providers’ responses to patients with chronic medical conditions rather than a difference in GBS as a cause of UTI. Overall, the prospect of a urine culture that grows GBS does not appear to be associated with adverse long-term outcomes.

Funding: No

Disclosures: None

Table 1.

Figure 1.

Background: The influence of increased use of telehealth during the emergence of COVID-19 on antibiotic prescriptions in outpatient settings is unknown. The VA Northeast Ohio Healthcare System has 13 community-based outpatient clinics (CBOCs) that provide primary and preventive care. We assessed changes in antibiotic prescriptions that occurred as care shifted from in-person to telehealth visits. Methods: Using VHA administrative databases, we identified all primary care CBOC visits between January 1, 2019, and December 31, 2020, that included a diagnosis for an acute respiratory infection (ARI), a urinary tract infection (UTI), or a skin or soft-tissue infection (SSTI), excluding visits with >1 of these diagnoses or with additional infectious diagnoses (eg, pneumonia, influenza). We summarized the proportion of telehealth visits and the proportion of patients prescribed antibiotics at quarterly intervals. We specifically assessed outpatient visits from April to December 2019 compared to the same months in 2020 to account for seasonality while analyzing diagnosis and antibiotic trends in the emergence of the COVID-19 pandemic. Results: The patients receiving care in April–December 2019 compared to April–December 2020 were similar (Table 1). From April through December 2019, 90% of CBOC primary care visits with a diagnosis for ARI, UTI, or SSTI were in-person, and antibiotics were prescribed at 63%, 46%, and 65% of visits in either modality, respectively (Figure 1). From April through December 2020, only 33% of CBOC primary care visits for ARI, UTI, and SSTI were in person, and antibiotics were prescribed at 46%, 38%, and 47% of visits in either modality, respectively. Comparing April–December in 2019 and 2020, the number of CBOC visits for ARI fell by 76% (2,152 visits to 509 visits), with a more modest decline of 20% and 35% observed for UTI and SSTI visits. In-person visits for ARIs and SSTIs were more likely than telehealth visits to result in an antibiotic prescription (Figure 2). Conclusions: Among the CBOCs at our healthcare system, an increase in the proportion of telehealth visits and a reduction in ARI diagnoses occurred after the emergence of COVID-19. In this setting, we observed a reduction in the proportion of visits for ARIs, UTIs, and SSTIs that included an antibiotic prescription.

Funding: Merck

Disclosures: None

Table 1.

Figure 1.

Figure 2.

Background: Outcomes among nursing home residents with asymptomatic compared to symptomatic COVID-19 are not well characterized. We assessed all-cause mortality among Veterans’ Affairs (VA) community living center (CLC) residents; we compared those residents with a negative SARS-CoV-2 test to residents with symptomatic, presymptomatic, and asymptomatic SARS-CoV-2 infections. Methods: We conducted a national retrospective cohort study of CLC residents tested for COVID-19 between March 1 and July 31, 2020, based on data compiled through the VA COVID-19 shared data resource. Among those with a positive SARS-CoV-2 test, residents were considered symptomatic if they had experienced COVID-19 symptoms in the 30 days prior to the test. Residents were considered presymptomatic if they did not experience symptoms in the 30 days prior to testing and developed a fever (>38°C) or required supplemental oxygen within 14 and 60 days, respectively, following the test. Residents were considered asymptomatic in the absence of these pre- and posttest symptoms. Results: From March 1 to July 31, 2020, of 9,052 CLC residents screened for COVID-19, 8,325 (92%) tested negative (Table 1). Among 727 residents with positive tests, 467 (64%) were symptomatic, 88 (12%) were presymptomatic, and 172 (24%) remained asymptomatic. We observed significant differences in the racial makeup of these disease groups. Among CLC residents who were symptomatic or presymptomatic, 176 (32%) of 555 were black compared to 39 (23%) of 172 who were asymptomatic and 1,810 (22%) of 8,325 who tested negative for SAR-CoV-2. All-cause 30-day mortality rates for symptomatic and presymptomatic residents were 25% and 34%, respectively, which exceeded the all-cause 30-day mortality of asymptomatic residents (12%) and residents with a negative test (6%) (Figure 1). Conclusions: More than one-third of CLC residents with COVID-19 were asymptomatic at the time of testing. This finding highlights the importance of vigilant infection prevention and control measures. Our finding that mortality among presymptomatic residents exceeded that of symptomatic residents raises consideration for enhancing supportive care measures, such as supplemental oxygen and mitigation of inflammatory reactions, as a means to reduce mortality among nursing home residents with presymptomatic SARS-CoV-2 infections.

Funding: No

Disclosures: None

Table 1.

Figure 1.