Dierkhising, Ross

Abstract Background Optimizing antimicrobial regimens for outpatients with community-acquired pneumonia (CAP) represents an area of opportunity for ambulatory antimicrobial stewardship programs. A pre-populated, antibiotic order panel for outpatient respiratory syndromes was implemented in the Mayo Clinic Enterprise on 1/4/2021. For CAP, it provides national guideline adherent regimens (i.e., selection, dosing, and durations) by patient comorbidity and beta-lactam allergy status. We aimed to assess impacts of panel use on antibiotic prescribing in outpatients with CAP. Methods This retrospective review included Mayo Clinic outpatient encounters from Minnesota in 2021 and 2022. Eligible encounters used a CAP-related primary ICD-10 code, conveyed intention to treat CAP in encounter notes, and were performed by primary care, emergency department, or urgent care clinicians who managed ≥1 CAP patient with the panel and ≥1 without the panel during the study period. Encounters were excluded if patients were already receiving antibiotics at the time of encounter. The primary outcome was adherence (drug and duration) to guideline recommendations. Secondary outcomes included utilization rate by agent and therapy duration. Outcomes were analyzed with Kruskal-Wallis rank sum and Pearson’s chi-squared tests (α level = 0.05). Results 352 encounters (134 panel vs. 218 non-panel) were included. Prescribing was guideline adherent in 61.9% and 29.4% (p< 0.01) of panel and non-panel encounters, respectively. The most common reason for guideline non-adherence during panel use was inappropriate drug selection (n = 45/51, 88.2%). This was predominantly driven by use of the incorrect section of the treatment panel based on patient comorbidity status (n = 30/45, 66.7%). Individual antibiotic utilization rates differed between panel and non-panel cohorts (Table 1), with higher rates of amoxicillin and amoxicillin/clavulanate use and lower rates of azithromycin and doxycycline use in the panel cohort. Durations >5 days were more common in the non-panel as compared to the panel cohort (34.4% vs. 7.5%, p < 0.01). Conclusion Use of a pre-populated antimicrobial order panel in outpatients with CAP resulted in greater adherence to national guideline recommendations. Disclosures Paschalis Vergidis, MD, MSc, AbbVie: Advisor/Consultant|Ansun: Grant/Research Support|Cidara: Grant/Research Support|Scynexis: Grant/Research Support

Abstract Background The aim of this study was to evaluate the frequency of unnecessary antibiotic prescribing for Tier 3 upper respiratory infection (URI) syndromes across the Mayo Clinic Enterprise before and after a multifaceted antimicrobial stewardship intervention, and to determine ongoing factors associated with antibiotic prescribing and repeat respiratory healthcare contact in the postintervention period. Methods This was a quasi-experimental, pre/post, retrospective cohort study from 1 January 2019 through 31 December 2022, with 12-month washout during implementation from 1 July 2020 through 30 June 2021. All outpatient encounters, adult and pediatric, from primary care, urgent care, and emergency medicine specialties with a Tier 3 URI diagnosis were included. The intervention was a multifaceted outpatient antibiotic stewardship bundle. The primary outcome was the rate of antibiotic prescribing in Tier 3 encounters. Secondary outcomes included 14-day repeat healthcare contact for respiratory indications and factors associated with persistent unnecessary prescribing. Results A total of 165 658 Tier 3 encounters, 96 125 in the preintervention and 69 533 in the postintervention period, were included. Following intervention, the prescribing rate for Tier 3 encounters decreased from 21.7% to 11.2% (P < .001). Repeat 14-day respiratory healthcare contact in the no antibiotic group was lower postintervention (9.9.% vs 9.4%; P = .004). Multivariable models indicated that increasing patient age, Charlson comorbidity index, and primary diagnosis selected were the most important factors associated with persistent unnecessary antibiotic prescribing. Conclusions Outpatient antibiotic stewardship initiatives can reduce unnecessary antibiotic prescribing for Tier 3 URIs without increasing repeat respiratory healthcare contact. Advancing age and number of comorbidities remain risk factors for persistent unnecessary antibiotic prescribing.

Introduction: Medical trainees experience a high degree of stress that predisposes them to burnout. This pilot study tested a scalable approach to deliver a validated resilience program (Stress Management and Resiliency Training (SMART)) among Hematology/Oncology fellows at an academic medical center. Methods: This was a mixed-methods, prospective, single-arm clinical trial involving Hematology/Oncology fellows at Mayo Clinic in Rochester, MN, USA. Four one-hour training sessions were conducted virtually with 26 fellows. Stress, burnout, and emotional resilience were measured at baseline, three months, and six months post-intervention using the Perceived Stress Scale (PSS-10), Maslach Burnout Inventory (MBI-HSS), and Connor-Davidson Resilience Scale (CD-RISC2). Changes in mean scores were assessed using paired t-tests. Feasibility and acceptability data were obtained during a virtual focus group. Results: Statistically significant improvements in mean stress (p = 0.004) and professional achievement (p < 0.001) were seen at three months post-intervention. At six months post-intervention, mean stress (p < 0.001) and professional achievement (p = 0.032) continued to improve, while improvements in emotional exhaustion (p = 0.001) and depersonalization (p < 0.001) also became significant. Focus group participants found the program beneficial and reported improved stress and work performance as a result of participation. Conclusion: Virtual implementation of the SMART program is feasible and resulted in improvements in stress and burnout. Focus group participants found the training beneficial, reporting lower stress and improved work performance.

Background: Methicillin-resistant Staphylococcus aureus (MRSA) can cause serious infections and empiric treatment regimens in children frequently include an anti-MRSA antibiotic. Studies in adults have demonstrated a high negative predictive value (NPV) of MRSA nasal swabs (MNS) in a variety of infectious syndromes. Negative MNS have been utilized as a tool to guide de-escalation of anti-MRSA antibiotics in adults, especially in those with lower respiratory tract infections, but data in children is minimal. The primary objective of this study was to determine the NPV and positive predictive value (PPV) of MNS in children hospitalized for treatment of an infection. Methods: This was a single-site, retrospective cohort study of pediatric patients admitted with a suspected infectious diagnosis who had an MNS performed during their hospitalization between June 1, 2018 and November 25, 2022. Results: This study identified 172 patients who met the inclusion criteria. Eleven (6.4%) nasal swabs were positive for MRSA and 10 (5.8%) microbiological cultures from suspected sources of infection were identified to be positive for MRSA. The MNS was found to have a sensitivity of 20%, specificity of 94%, PPV of 18% and NPV of 95% for all sites of infection. Conclusion: MNS has a high NPV and low PPV in children. MNS can be utilized as an antimicrobial stewardship tool to guide the safe de-escalation of anti-MRSA antibiotics in children.

Background: Microscopic colitis (MC) causes chronic diarrhea. It has two histologic subtypes: lymphocytic colitis (LC) and collagenous colitis (CC). Little is known about the natural progression of disease with time and with treatment. Objectives: We aimed to assess histological changes over time. Design: We designed a retrospective study including adults diagnosed with MC from January 1992 to January 2020 at Mayo Clinic. Methods: Pathology reports were reviewed until 31 October 2020. Histological assessments at least 8 weeks apart were considered as adequate follow-up. Histological change from one subtype to the other and resolution were tracked with univariate and multivariable Cox proportional hazards models. Results: Overall, 416 patients with a median age at diagnosis of 63.9 years with >1 histopathological assessment were identified. Histology at initial diagnosis was CC in 218 (52.4%) patients and LC in 198 (47.6%). No medications were associated with a histological change. However, histological resolution was more likely with the use of aspirin [hazard ratio (HR): 2.10, 95% confidence interval (CI): 1.34–3.31, p = 0.001) and proton-pump inhibitors (PPIs; HR: 2.01, 95% CI: 1.34–3.02, p = 0.001). Histological resolution was more likely with budesonide treatment (HR: 1.86, 95% CI: 1.16–3.00, p = 0.010) and less likely with mesalamine (HR: 0.40, 95% CI: 0.19–0.83, p = 0.014), compared to medications such as prednisone, loperamide, and bismuth. Patients with CC were less likely to change their histology compared to patients with LC (HR: 0.24, 95% CI: 0.14–0.42, p < 0.001). There was no difference in histological resolution between the two subtypes (HR: 0.70, 95% CI: 0.47–1.05, p = 0.084). Conclusion: Patients with LC have a higher chance of changing their histology as compared to CC. However, histological resolution was associated with the use of PPIs and aspirin, and treatment with budesonide.

Introduction: Today’s physicians must demonstrate both professionalism and leadership skills in order to succeed in largely team-based healthcare environments. The purpose of this study was to determine if professionalism attributes, leadership style, and leadership style adaptability are associated with academic performance among first-year students early in their medical curriculum. Materials and Methods: Students were divided into 4-member dissection groups for the duration of the Gross and Developmental Anatomy course. Leadership responsibility was randomly assigned to a team member on a rotating basis every 5 weeks. After each 5-week block, student performance was measured by written and practical examinations, and each student assessed their leader’s or their own professionalism attributes and leadership style using validated survey instruments. Results: Most students demonstrated either a “selling” only (57%) or “participating” only (30%) leadership style with low to moderate leadership adaptability. “Participating” and “delegating” leadership styles have the highest average group written exam scores (89.4%, P <0.008). “Telling” only or “selling” only leaders have the lowest average group exam scores (83.5%, P <0.001). “Selling” and “participating” leaders have significantly lower average group practical exam scores than other styles (81.5%, P <0.007). Positive associations were observed between the written and practical examination scores and the leader’s integrity (P = 0.003, P = 0.002) and responsibility (P <0.001 , P = 0.037). Conclusions: This study demonstrates that various situational leadership styles and aspects of professionalism are associated with written and practical examination scores in the Gross and Developmental Anatomy course. Furthermore, it demonstrates that first-year medical students are in need of leadership skill development. Key words: Basic science, Gross anatomy, Leadership style, Medical curriculum, Teamwork, Team-based learning

Background Sexual assault survivors are at increased risk for sexually transmitted infections. Sexual Assault Nurse Examiner programs guide sexually transmitted infection treatment, monitoring, and follow-up scheduling according to guidelines by the Centers for Disease Control and Prevention (CDC). Reported low rates of provider adherence to CDC treatment guidelines and patient adherence to follow-up necessitate a review of medication prescribing and follow-up scheduling practices, especially at smaller community hospitals in the United States. Methods A retrospective medical record review was conducted to assess adherence rates to CDC guidelines for prescribing practices, scheduling, and follow-up of sexual assault survivors. We included pediatric and adult patients presenting to the emergency department (ED) and participating in the ED Sexual Assault Nurse Examiner program at a rural, community-based teaching hospital in La Crosse, WI, from January 2018 to December 2021. Descriptive statistics were used to evaluate results. Results Analysis included 103 patients. Prescribing adherence to CDC guidelines was >80% for all except human immunodeficiency virus (53.4%), trichomoniasis (68.1%), and hepatitis B (69%). Of the 38 patients who had a follow-up scheduled during their ED encounter, 78.9% attended their scheduled follow-up and 94.7% of those appointments were scheduled within the CDC-recommended time frame, leading to an overall adherence of 40%. Conclusions Adherence rates were high for most prescribing practices, and attendance of scheduled follow-up was higher than expected. Opportunities to improved adherence to CDC guidelines were identified in prescribing for 3 disease states (human immunodeficiency virus, trichomoniasis, and hepatitis B) and in scheduling of follow-up.

Abstract Background Sexual assault survivors are at increased risk for sexually transmitted infections. Due to patient vulnerability, institutions have implemented Sexual Assault Nurse Examiner (SANE) protocols to care for these patients. These protocols guide evidence collection, testing, treatment, and medical follow-up to ensure optimization of sexually transmitted infections (STIs) treatment, monitoring and follow-up. Previous gap analyses have identified decreased prescribing of prophylactic STI medications and scheduling follow-up appointments compared to guideline recommendations. The purpose of this study was to assess adherence of medication prescribing and follow-up scheduling practices to Centers for Disease Control (CDC) guidelines. Methods This study was a single-center, retrospective, observational, descriptive assessment which evaluated adherence rates to CDC guidelines, to scheduling medical follow-up, and patient attendance at scheduled appointments. Pediatric and adult patients who presented to the emergency department at Mayo Clinic Health System in La Crosse, WI from January 2018 through December 2021 were included. Data collected through chart review included demographics and laboratory data necessary for prescribing prophylactic HIV medications, antibiotics for STIs, emergency contraception, and vaccine administration. Descriptive statistics were used to evaluate results. Results One hundred three patients were evaluated. Majority of patients were female and presented within 3 days of assault. Medication adherence to CDC guidelines was ≥ 80% for chlamydia and gonorrhea whereas &lt; 80% was noted for trichomoniasis and HIV prophylaxis. Adherence to post-ED discharge follow-up was 40%. Conclusion Opportunities to improve adherence of ED-SANE protocols for medication prescribing and medical follow-up for trichomoniasis and HIV prophylaxis exist. Disclosures All Authors: No reported disclosures.