bluuebunny/crossref_metadata_2025 huggingface dataset:
171. Effectiveness and Feasibility of Pharmacist-Driven Penicillin Allergy De-Labeling Pilot Program
Authors: Song Youchan , Nelson Zachary , Gens Krista
Published: January 2021

Background

Prevalence of true hypersensitivity to penicillins is low (0.5–2%). Documented penicillin allergies have been associated with an increased risk of adverse outcomes, including methicillin resistant Staphylococcus aureus infections, Clostridioides difficile infections, and surgical site infections. “De-labeling” of inappropriately documented allergies can decrease the use of unnecessary broad-spectrum antibiotics and prevent negative outcomes, but labor-intensive skin testing and oral challenges can be a barrier to program implementation. The goal of this project is to assess the effectiveness and feasibility of a pharmacist-led penicillin allergy de-labeling process that does not involve skin testing or oral challenges.

Methods

Adult patients with penicillin allergies were identified using a report within the electronic health record during a 3-month pilot period. Patients identified were interviewed by an infectious diseases pharmacy resident, and an allergy history was assessed utilizing a standardized checklist. The patients’ answers determined the ability to de-label via pharmacist utilization of an evidence-based and standardized checklist developed for this project. All documentation included a detailed patient allergy history along with a beta-lactam cross-reactivity chart to help guide future antibiotic choices.

Results

66 patients were interviewed during the pilot. 12 patients (18%) met criteria for de-labeling and consented to the removal of the allergy. 4 patients (6%) met criteria for de-labeling but declined the removal of the allergy. Average time spent during patient interview was 5.2 minutes per patient. 58.3% of patients (7/12) who were de-labeled were subsequently prescribed a beta-lactam, and 100% (7/7) were able to tolerate the agents. 1 out of 4 patients (25%) who declined de-labeling but had their allergy updated to reflect intolerance was prescribed beta-lactams and was able to tolerate the agents (1/1, 100%).

Conclusion

A pharmacist-led penicillin allergy de-labeling process utilizing a standardized checklist is an effective method for removing penicillin allergies in patients who do not have a true allergy to penicillins. This pharmacist-led process is a feasible method for sites unable to perform oral challenges or skin testing.

Disclosures

All Authors: No reported disclosures
172. Evaluation of Multifaceted Antimicrobial Stewardship Interventions on The Treatment of Asymptomatic Bacteriuria
Authors: Pham Tho H , Huang Angela , Huang Vanthida , Hall Scott T
Published: January 2021

Background

Treatment of asymptomatic bacteriuria (ASB) and asymptomatic candiduria (ASC) is a leading cause of inappropriate use of antimicrobial therapy in many healthcare facility, and has been associated with undesirable outcomes such as Clostridium difficile infection, longer length of stay, long-term antibiotic resistance, and delayed time back to baseline activity. This evaluation was designed to utilize a pharmacy-driven multifaceted antimicrobial stewardship intervention to reduce the number of antibiotic treatment days in patients with ASB/ASC

Methods

This retrospective single-center study included hospitalized adult patients with a positive urinalysis and/or a positive urine culture with or without antimicrobial therapy from January-March 2019, compared to patients from January-March 2020 after initiation of a multifaceted antimicrobial stewardship intervention, including daily prospective audit and feedback. The primary outcome was the number of antibiotic treatment days in patients with ASB/ASC before and after implementation of the targeted antimicrobial stewardship interventions

Results

189 patients were identified upon retrospective chart review in the pre-group and 110 patients were included in the post-group. Baseline characteristics were well-matched between groups, except that the pre-group had a higher percentage of patients coming from nursing facilities while the post-group had a significantly higher percentage of patients with positive urine cultures. Antibiotic treatment days were significantly lower in the post- versus pre-group 0 (IQR 0–3) vs. 3 (IQR 1–7), p< 0.001. Incidence of ASB/ASC treatment was also significantly lower in the post- versus pre-group 45.5 vs 72.5%, p< 0.001. There was no statistical difference between the two groups in 30-day mortality, 30-day hospital readmission, and hospital length of stay. There was one case of Clostridium difficile infection among patients being inappropriately managed with antibiotics in each groups

Conclusion

A multifaceted antimicrobial stewardship interventions successfully reduced antimicrobial treatment days in patients with ASB/ASC, as well as overall incidence of inappropriate treatment of ASB/ASC without increasing mortality or readmission rate

Disclosures

All Authors: No reported disclosures
175. Impact of Infectious Diseases Pharmacist Interventions on Appropriateness of Antibiotics Prescribed at Hospital Discharge
Authors: Malik Luke , Ebert Steven C , Hurley Evan
Published: January 2021

Background

Hospital discharge is an important opportunity for antimicrobial stewardship. Despite inpatient stewardship efforts, antibiotics ordered at discharge are frequently prescribed inappropriately. Discharge antibiotic therapy may be too broad or narrow in spectrum, inappropriately dosed, or for an unnecessarily long duration. The purpose of this study was to assess the inappropriateness of antimicrobial prescribing on discharge and to measure the effect of infectious diseases pharmacist (IDP) intervention on antibiotics prescribed at discharge from the inpatient setting.

Methods

Analyses were completed before and after implementation of an IDP intervention at hospital discharge. IDPs were alerted to patients discharged on antimicrobial therapy for community-acquired pneumonia (CAP), skin and soft tissue infections (SSTIs), and urinary tract infections (UTIs). IDPs reviewed patient and laboratory data and made recommendations for modifications of antibiotics prior to patients leaving the hospital. Prescribing algorithms were created and used to standardize the assessment of discharge antibiotics using local antibiograms and IDSA guidelines. The primary outcome was the composite of appropriateness including antibiotic dose, duration, and spectrum. Secondary outcomes included appropriateness of the individual components of the primary outcome as well as the mean total duration of antibiotic therapy per disease state.

Results

A total of 77 patients were assessed during the study period occurring December 2019 through February 2020. Intervention increased the rate of appropriate prescribing for the composite of antibiotic dose, duration, and spectrum from 48.1% at baseline to 84.4% (P < 0.05). By subset, intervention increased the proportion of patients receiving antibiotics of appropriate duration from 59.7% at baseline to 85.7% (P < 0.001), and proportion of patients receiving antibiotics of appropriate spectrum from 90.9% at baseline to 100% (P < 0.05). The mean duration of therapy for CAP decreased by 0.6 days (6.8 vs 7.4 days, P < 0.05).

Conclusion

IDP intervention improved appropriateness of prescribing consistent with guideline recommendations and local antibiogram data.

Disclosures

All Authors: No reported disclosures
179. Integrating Antibiotic Stewardship Core Elements into Nurse Residency Programs
Authors: Straley Amy L , Wirtz Ann , Monsees Elizabeth
Published: January 2021

Background

Background: In the 2019 Centers for Disease Control and Prevention Core Elements of Hospital Antibiotic Stewardship (AS) Programs, 3 elements outline opportunities for nurse engagement:

• Leadership Commitment, securing resources to support AS endeavors, including quality/safety work

• Action, identifying new categories of nursing-based interventions

• Education, engaging nurses in patient education

Nurse Residency Programs (NRPs) enculturate newly licensed nurses (NLNs) into the profession and provide a platform for integrating NLNs into organizational initiatives, including AS.

Methods

Methods: To determine if NRPs were an avenue to integrate core elements, nursing leaders committed to using the NRP to engage NLNs in development of unit-based AS projects. Tenured nurses mentored NLNs on evidence-based quality improvement projects with an AS nurse serving as content expert. Over 2 years, 4 cohorts, 2 in Pediatric Intensive Care Unit (PICU) and 2 in Cardiology, applied a Lean problem-solving approach (A3) to identify and implement nurse-led AS projects.

Results

Results: Four A3s were completed; data collection varied by group (Figure 1). Year 1, PICU developed a handoff tool, and improved frequency of nurse to nurse communication regarding the indication, duration, and day of therapy for prescribed antibiotics. Year 2, PICU developed a tool to increase parent education encounters; frequency of interactions did not change. Year 1, Cardiology implemented educational initiatives; increased awareness of nurses’ role in AS (Figure 2). Year 2, Cardiology piloted a handoff tool to promote AS; nurse communication increased. In total, 4 NLN projects were presented to leaders and clinical staff exposing 18 NLNs, 6 tenured nurses, and over 400 clinical nurses to AS. Each cohort expressed challenges integrating AS into established processes during debriefing.

Figure 1: Cohort Overview

Figure 2: Example of Nursing-Driven A3

Conclusion

Conclusions: Commitment by unit-leaders is crucial to mitigate challenges during the development of nurse-driven projects. NRPs serve as a central location to reach a large subset of nurses and shows potential for facilitating nursing-based AS interventions. Elements were integrated, through challenges remain with maintaining a standard data collection process and analysis within and across NLN cohorts.

Disclosures

All Authors: No reported disclosures
182. Missed Opportunities to Discontinue Unnecessary Vancomycin During Pharmacist Therapeutic Monitoring
Authors: Medler Corey J , Whitney Mary , Galvan-Cruz Juan , Kendall Ron , Kenney Rachel , Davis Susan L , Davis Susan L
Published: January 2021

Background

Unnecessary and prolonged IV vancomycin exposure increases risk of adverse drug events, notably nephrotoxicity, which may result in prolonged hospital length of stay. The purpose of this study is to identify areas of improvement in antimicrobial stewardship for vancomycin appropriateness by clinical pharmacists at the time of therapeutic drug monitoring (TDM).

Methods

Retrospective, observational cohort study at an academic medical center and a community hospital. Inclusion: patient over 18 years, received at least three days of IV vancomycin where the clinical pharmacy TDM service assessed for appropriate continuation for hospital admission between June 19, 2019 and June 30, 2019. Exclusion: vancomycin prophylaxis or administered by routes other than IV. Primary outcome was to determine the frequency and clinical components of inappropriate vancomycin continuation at the time of TDM. Inappropriate vancomycin continuation was defined as cultures positive for methicillin-susceptible Staphylococcus aureus (MRSA), vancomycin-resistant bacteria, and non-purulent skin and soft tissue infection (SSTI) in the absence of vasopressors. Data was reported using descriptive statistics and measures of central tendency.

Results

167 patients met inclusion criteria with 38.3% from the ICU. SSTIs were most common indication 39 (23.4%) cases, followed by pneumonia and blood with 34 (20.4%) cases each. At time of vancomycin TDM assessment, vancomycin continuation was appropriate 59.3% of the time. Mean of 4.22 ± 2.69 days of appropriate vancomycin use, 2.18 ± 2.47 days of inappropriate use, and total duration 5.42 ± 2.94. 16.4% patients developed an AKI. Majority of missed opportunities were attributed to non-purulent SSTI (28.2%) and missed MRSA nares swabs in 21% pneumonia cases (table 1).

Conclusion

Vancomycin is used extensively for empiric treatment of presumed infections. Appropriate de-escalation of vancomycin therapy is important to decrease the incidence of adverse effects, decreasing hospital length of stay, and reduce development of resistance. According to the mean duration of inappropriate therapy, there are opportunities for pharmacy and antibiotic stewardship involvement at the time of TDM to optimize patient care (table 1).

Missed opportunities for vancomycin de-escalation

Disclosures

All Authors: No reported disclosures
184. Pharmacist role in antimicrobial stewardship research: a 30-year experience
Authors: Pillinger Kelly E , Jariwala Ripal , Mercuro PharmD; Nicholas J , Cwengros Laura N , Davis Susan L , Davis Susan L , Appaneal Haley
Published: January 2021

Background

Antimicrobial stewardship program (ASP) guidance from the Centers for Disease Control and Prevention recommends co-leadership of both an infectious-diseases (ID) physician and ID-trained pharmacist. Pharmacists play a key role in the therapeutic management, administration, and implementation of ASP interventions. The purpose of this study, conducted on behalf of the Society of Infectious Diseases Pharmacists, was to describe the involvement of pharmacists in publications of ASP interventional research.

Methods

A PubMed search was conducted to identify publications in the United States and Canada from 1990–2019 including “antimicrobial (or antibiotic) stewardship” or “antimicrobial (or antibiotic) intervention.” Articles were screened for active interventions with comparator arms. A random subset of 100 pharmacist-authored manuscripts were selected using a time-based clustering strategy to review specific study designs, populations, interventions, and endpoints.

Results

Of 1,426 publications, 340 met inclusion. Two-thirds (228/340) of all interventional antimicrobial stewardship studies included a pharmacist author. Pharmacists were lead authors in 59% (135/228) of studies that included a pharmacist. Among the randomized subset of pharmacist-authored manuscripts (n=100), the average impact factor of journals with pharmacists as the first author was 3.52, compared to 5.25 as middle authors. Most studies were inpatient focused (89%), included adults (81%), and conducted in a single-site setting (84%). Pediatrics, immunocompromised, post-acute care, and ambulatory populations comprised less than 10% of the publications. The most common interventions described were audit and feedback (55%), guideline implementation (49%), and education (40%). Endpoints included drug utilization (66%), clinical outcomes (57%), safety events (46%), cost (40%), and appropriateness of therapy (35%).

Figure 1.

Conclusion

Pharmacists have an integral role in publication and dissemination of ASP research. Opportunities exist in multi-site collaboration as well as research in ambulatory, pediatric, and immunocompromised groups. Future research endpoints should be practical, generalizable, and patient-centered.

Disclosures

Kelly E. Pillinger, PharmD, BCIDP, Pharmacy Times (Other Financial or Material Support, Speaker) Haley Appaneal, PharmD, Shionogi (Grant/Research Support)
185. Pilot of a Face-to-Face Model of Stewardship (Handshake Stewardship) in a General Medicine Ward
Authors: Morita Kazumi , Mueller Daniel
Published: January 2021

Background

Handshake stewardship (HS) is an antibiotic stewardship strategy that includes a more in-person approach to prospective audit and feedback (PAF). It has emerged as an effective form of PAF, enhancing trust and collaboration between the antibiotic stewardship team (AST) and the prescribers. However, resources can be a barrier to implementation. We sought to describe our experience of a HS pilot implementation at our institution.

Methods: Our HS model was implemented as a pilot among five attending-only hospital medicine teams at Temple University Hospital. All antimicrobials administered to patients on these teams were reviewed by the AST pharmacist on weekdays from 2/4/19 to 3/4/19. The AST physician and pharmacist then physically located each team to discuss recommendations and answered questions. Number and types of AST recommendations were recorded along with the outcome. As patients on all five teams were centralized in one patient care unit (PCU), antibiotic utilization of this PCU, measured as days of therapy per 1000 patient days (DOT/1000 PD) was collected from January to March 2019. An anonymous survey of hospitalists involved in this pilot was also performed to determine their perceptions toward the HS model.

Results: During the pilot period, 108 recommendations were made on 63 unique patients. On average, 20 patients were on antimicrobials on a given day, and AST spent 2 hours per day reviewing data and interacting with the teams. The most common recommendation was a change in antibiotic regimen (39%), mostly for de-escalation of therapy, with an overall acceptance rate of 91%. Overall antibiotic usage was numerically lower in the pilot month (February; 622 DOT/1000 PD) compared to the two adjacent non-pilot months; January (824 DOT/1000 PD) and March (728 DOT/1000 PD). The difference was mostly explained by the decrease in anti-pseudomonal beta-lactam use. The HS model was widely accepted among the surveyed hospitalists, who preferred it over the current PAF model completed via telecommunication.

Conclusion: The HS model appears to be effective and well accepted by our hospitalists. Strategies to expand this face-to-face approach may provide additional opportunities for antimicrobial optimization while increasing provider satisfaction.

Disclosures

All Authors: No reported disclosures
186. Prescriber-Led Antibiotic Timeout Alert Responses: A Retrospective Multicenter Study
Authors: Smoke Steven , Secaras Ellen , Crossen Melissa , Patel Gargi , Brophy Alison , Clark Alexander , Elbaga Yasmine , Raja Karan , Shah Monica , Stone Elizabeth , Lew Indu
Published: January 2021

Background

An antibiotic time out is when a clinician is prompted to reevaluate antibiotic therapy for appropriateness after 48–72 hrs. The purpose of this study is to evaluate the impact of a prescriber-led electronic antibiotic timeout alert.

Methods

This was a retrospective cohort study conducted at seven hospitals of a health system. The alert prompts prescribers to reevaluate antibiotic therapy after > 72 hours upon opening the electronic chart. Prescribers can then choose to “Continue”, “Renew”, “Discontinue” or “Defer” for each antibiotic. The alert fires for every time the chart is opened, for every prescriber, every time any antibiotic has been active for > 72 hours and no action response (i.e., “Continue”, “Renew”, “Discontinue”) has been selected. This was a 6 month study from November 1, 2018 – April 30, 2019. The primary outcome measure was the percentage of patients having > 1 antibiotic discontinued via the electronic antibiotic timeout alert. Secondary outcomes included frequency of timeout alerts per patient, and percentage of discontinuations per response, by drug, by indication and by patient age.

Results

A total of 213950 alerts fired for 13263 patients during the study period. 94.2% and 0.4% of responses were “Defer” and “Discontinue”, respectively. The average number of alerts per patient was 16.1. The percentage of patients who had at least one discontinuation was 5.3%. 38.2% of patients had no response other than “Defer”. There were a total of 10306 action responses, 4.8% of which were “Discontinue”. Among action responses, discontinue rates for the indications of “COPD exacerbation”, “Prophylaxis, Surgical/Procedural”, “Prophylaxis, Immunosuppression”, “Osteomyelitis” were 9.6%, 12%, 1.3% and 1%, respectively. Azithromycin and trimethoprim/sulfamethoxazole had discontinuation rates of 9.3% and 0.9%, respectively. Patient age had a significant impact on discontinuation rates with rates of 4.7%, 3.5%, and 10.9% for patients > 18, 2–17 and < 2 years of age (p< 0.001).

Conclusion

An electronic antibiotic timeout alert implemented at seven hospitals was largely ignored. This alert may be refined by limiting it to antibiotic orders with specific features associated with higher rates of discontinuation.

Disclosures

All Authors: No reported disclosures
187. Significant Decline in Carbapenem Use with Multifaceted Antimicrobial Stewardship Program (ASP) Interventions
Authors: Kaushik Ashlesha , Gupta Sandeep , Lettow Erin , Lundsgaard Jenna , Thieman Corey , Fullas Fekadu , Padomek Michael
Published: January 2021

Background

Per World Health Organization, carbapenems should be key targets for antibiotic stewardship programs.

Methods

A multifaceted antimicrobial stewardship program (ASP) was implemented in January 2018 at a 160-bed tertiary care center serving the tristate area of Iowa, South Dakota and Nebraska. Carbapenem use during pre ASP intervention period (P1: 07/01/2016-12/31/2017) was compared with ASP intervention period (P2: 01/01/2018-06/30/2019). ASP interventions included: providing educational pearls in monthly physician newsletter; educational posters in high-traffic provider areas; suppression of carbapenem results on microbiology susceptibility reports; distributing monthly carbapenem use data to providers; provider counseling for appropriate ordering; creating carbapenem alternative alert in order-entry software; generating pharmacy decision-support software algorithms to aid in identifying intervention opportunities; removing carbapenems from order-sets where appropriate. Additional ASP pharmacist interventions: limiting double antibiotic coverage for pseudomonas/anaerobes; de-escalation recommendations.

Results

Carbapenem use declined significantly from a mean of 64.81 days of therapy (DOT) per 1000 patient days during P1 to 8.91 DOT per 1000 patient days in P2 (p< 0.001). All hospital units showed a significant decrease in carbapenem use, with intensive care step-down unit noting 85.7% reduction (p < 0.00001); floors (medicine, pediatric, surgery) with 61.6% reduction (p< 0.00001); and intensive care units with 52% reduction (p< 0.00001) during P2 compared to P1. Defined daily doses per 1000 patient days decreased from 314.9 in P1 to 93.4 in P2 (p< 0.00001). During P2, 58.3% (132/228) of carbapenem orders were found to be appropriate compared to 37.5% (190/506) in P1 (p< 0.00001). Sensitivity profile for Pseudomonas aeruginosa improved from 86% carbapenem sensitivity during P1 to 89% in P2. No Carbapenem Resistant Enterobacteriaceae isolates were identified. Cost savings of $643 per 1000 patient days were recognized in P2 as a result of reduced carbapenem use.

Conclusion

There was a significant decline in total carbapenem utilization, an increase in proportion of appropriate use and considerable cost savings as a result of ASP interventions.

Disclosures

All Authors: No reported disclosures
193. Adding Insalt to Injury: Evaluating the Consequences of Sepsis Protocols on Patients with Heart Failure
Authors: Fornaro Rachyl , Sandhu Kamaldeep , Escobar Zahra
Published: January 2021

Background

Inpatients with acute decompensated heart failure (ADHF) frequently meet sepsis criteria defined by the systemic inflammatory response syndrome (SIRS). To meet CMS guidelines, they receive a fluid bolus and broad-spectrum antibiotics, like piperacillin/tazobactam (pip/tazo), within 3 hours of presentation. A daily regimen of pip/tazo can contain as much as 1040 mg, or half the recommended dietary intake, of sodium. The objective of this investigation was to evaluate volume overloading and clinical consequences of sepsis protocols in patients with ADHF.

Methods

We reviewed inpatients ≥18 years old with ADHF per ICD-10 codes and an IV loop diuretic order who were initiated on a sepsis bundle, identified by IV fluid bolus and IV antibiotic orders. Patients who received ≥16 g of pip/tazo consecutively were compared to those who received other antibiotics. Outcomes included change in fluid homeostasis defined by increase in diuretic dose or frequency, or a weight increase ≥1 kg within a calendar day after receiving antibiotics; discharge disposition, length of stay (LOS), and 30-day readmission.

Results

We identified 95 patients admitted from 2/1/19 – 8/1/19. Thirty-four received pip/tazo, 61 received other antibiotics. Average age was 75, and 70% of patients had an infectious diseases diagnosis on discharge. Fluid homeostasis was poorer in the pip/tazo group compared to the other antibiotics group, demonstrated by weight increase ≥ 1kg (42% vs. 38%) and/or increase in diuretic intensity (65% vs. 51%). 30-day readmission rate was 2.9% in the pip/tazo group and 4.9% in the other antibiotics group. Median LOS was 11.5 vs. 7 days for the pip/tazo group and other antibiotics group, respectively. Rate of mortality was 32.6% during this encounter.

Conclusion

Early initiation of fluids and antibiotics may be detrimental in those without an infectious syndrome based on disrupted fluid homeostasis. Given lower sodium burden associated with other antibiotic selections, this has implications for antimicrobial stewardship.

Disclosures

All Authors: No reported disclosures
197. Bridging the Divide Between Antimicrobial Stewardship and Surgical Services: Successful Use of Handshake Stewardship with Hepato-Pancreato-Biliary Surgical Services in Adult Patients at a Large Academic Medical Center
Authors: Meredith Jacqueline , Roshdy Danya , Jaffa Rupal K , Medaris Leigh A , Aviles Cesar , Cochran Allyson , Fischer Kristin , Shastry Vivek , Davidson Lisa
Published: January 2021

Background

Handshake stewardship has displayed promise in engaging providers in the pediatric population but literature in adults are lacking. Face-to-face interactions are proposed to improve antibiotic stewardship (ASP) efforts in challenging services that have low ASP acceptance and commonly utilize broad-spectrum antibiotics (BSA) such as Hepato-Pancreato-Biliary surgical services (HPBSS).

Methods

Handshake stewardship was initiated by the Antimicrobial Support Network (ASN) with the HPBSS at the Carolinas Medical Center in January 2019. In-person rounding was completed. Treatment algorithms were created to assist in standardizing antibiotic selection and de-escalation for common HPB infections. To evaluate the impact of handshake stewardship, we assessed antimicrobial utilization of BSA by measuring days of therapy (DOT) per 1000 patient days (PD), comparing the pre- (Jan – Dec 2018) and post-intervention period (Jan – Dec 2019). ASN intervention acceptance rates and rates of hospital-acquired (HA) carbapenem-resistant Enterobacterales (CRE) infections/colonization and C. difficile infections (CDI) were also collected.

Results

After implementation of handshake stewardship, antipseudomonal use decreased significantly by 32.5 DOT/1000 PD as compared to the pre-intervention period (174.4 vs 141.9 DOT/1000 PD, p = 0.04). A numeric decrease in carbapenem use was also observed (21.7 vs 57.5 DOT/1000 PD, p = 0.275). ASN intervention acceptance rates significantly increased by 31% (p < 0.01). HA-CRE infections, CRE colonization and CDI decreased by 87.7%, 66% and 38.8%, respectively (p = ns).

Figure 1: HPB Antibiotic Utilization

FIgure 2: ASN Intervention Rates with HPB

Table 1. Rates of CRE and C. difficile Infections

Conclusion

Use of handshake stewardship assisted in reducing BSA use, improving provider acceptance of ASN interventions and decreasing HA-infection rates. Based on these findings, handshake stewardship may be useful in services that display challenges in implementing ASP due to their complex patient populations, such as HPBSS.

Disclosures

All Authors: No reported disclosures
201. Healthcare utilization outcomes of patients prescribed fluoroquinolones on discharge from the hospital to nursing homes
Authors: Lantz Tyler L , Noble Brie N , Crnich Christopher J , McGregor Jessina C , Chan Dominic , Furuno Jon P , Furuno Jon P , Bearden David T
Published: January 2021

Background

Fluoroquinolones (FQs) are frequently prescribed in nursing homes (NHs) despite concerns regarding broad spectrum antibiotic selective pressure, increased risk of Clostridioides difficile infection, and other adverse events. NH antibiotics are also frequently initiated in hospitals prior to NH admission. We quantified the frequency and outcomes of patients prescribed FQs on discharge from the hospital to NHs.

Methods

This was a retrospective cohort study of adult (age ≥ 18 years) inpatients prescribed a FQ on discharge from Oregon Health & Science University Hospital (OHSU) to a NH between 1/1/2016 and 12/31/2018. Study data were collected from a repository of electronic health record data. The outcome of interest was a composite of 30-day hospital readmission or emergency department (ED) visit to OHSU. Associations were quantified using odds ratios (ORs) and 95% confidence intervals (CIs).

Results

Among 9,546 patients discharged to a NH, 2,410 (25%) were prescribed at least one antibiotic and 423 (17.6%) were prescribed a FQ. Of these patients, 36.9% were age ≤ 65, 53% were male, 11.6% received a specialty infectious diseases consultation, 34.8% had a surgical diagnosis, and 49.7% had a hospital length of stay > 7 days. The most prevalent comorbidities were cancer (30.5%), chronic obstructive pulmonary disease (29.6%), and renal disease (26%). The most prevalent FQs prescribed were ciprofloxacin (56.7%), levofloxacin (40.2%), and moxifloxacin (3.1%). Duration of NH therapy > 7 days occurred in 37.6% of patients. The most common infectious diagnoses were bloodstream infection and endocarditis (39%), pneumonia (17%), and urinary tract infection (14.2%). Of patients prescribed a FQ, 276 (65.3%) had an ED visit or hospital admission to index facility within 30 days of discharge. Patients who were ≤ 65 years old (OR 2.3, 95% CI 1.4–3.5), male (OR 1.6, 95% CI 1.1–2.5), had comorbid renal disease (OR 1.8, 95% CI 1.1–2.9), or osteomyelitis as infectious diagnosis (OR 2.4, 95% CI 1.0–5.7) were more likely to have a 30-day ED visit or hospital admission.

Conclusion

Patients prescribed FQs on discharge to NHs frequently returned to the hospital for an ED visit or inpatient admission within 30 days of discharge.

Disclosures

All Authors: No reported disclosures
202. Implementation of an Outpatient Parenteral Antimicrobial Therapy (OPAT) Collaborative for Patients with Staphylococcus aureus or Gram-Negative Bacilli Bacteremia Requiring Home Infusion: The PANTHIR Program
Authors: Ross Jennifer K , Boeser Kimberly D , Simonson Dana , Hain Malia , Killelea Kristi , Galdys Alison
Published: January 2021

Background

Staphylococcus aureus (SA) and Gram-negative bacilli (GNB) bacteremia often require prolonged treatment courses due to high morbidity and mortality risk. Outpatient parenteral antibiotic therapy (OPAT) has emerged as a preferred delivery method. Few data have been published regarding the follow-up and adverse event rates among OPAT patients. We describe outcomes in patients with SA or GNB bacteremia transitioning from an academic medical center to home infusion, prompting the implementation of the Parenteral ANtimicrobial therapy Transitions to Home Infusion Review (PANTHIR) program.

Methods

A retrospective chart review of adult patients with SA or GNB bacteremia at the University of Minnesota Medical Center requiring home infusion represent a 26-month period. Baseline outcomes, including 30-day hospital readmissions and adverse drug events (ADEs), were calculated. The PANTHIR program was launched as an interdisciplinary collaborative with an infectious diseases (ID) provider, pharmacists, and home infusion specialists. Core program elements include inpatient identification, ID pharmacist review, care plan documentation and communication, and OPAT program measures.

Results

The retrospective cohort included 69 patients. 23.2% experienced a hospitalization within 30 days of discharge and 26.1% experienced an ADE (Table 1). The mean duration of therapy was 22 days. No patient received aminoglycosides and one required vancomycin. A primary goal was to improve the continuity of care for potentially life-threatening bacteremia during the vulnerable inpatient to outpatient transition. Electronic health record functionality allowed for creation of an OPAT navigator for infectious diseases (ID) pharmacist transition plan documentation, electronic communication with designated provider and home infusion pharmacist, and retrieval of focal data points for ongoing program evaluation. 28 patients have been enrolled in the PANTHIR program with outcomes data collection underway.

Table 1. Retrospective data among University of Minnesota Medical Center patients hospitalized with SA or GNB bacteremia requiring home infusion on discharge.

Conclusion

Hospital readmission rates and ADEs are frequent among patients with SA or GNB bacteremia requiring OPAT via home infusion. An ID pharmacist-directed program in collaboration with an ID provider is feasible for OPAT transitions and may serve as a roadmap for other institutions.

Disclosures

Dana Simonson, PharmD, BCPS, Janssen (Advisor or Review Panel member, Other Financial or Material Support, Webinar Series Speaker Fall 2019)
205. Rectal Stool Surveillance Cultures to Guide Empiric Antibiotic Therapy in Patients with Hematologic Malignancies with or without Hematopoietic Stem Cell Transplantation
Authors: Sait Afrah S , Patole Shalom S , Dzintars Kathryn , Cosgrove Sara E , Steinke Seema Mehta
Published: January 2021

Background

Patients with hematologic malignancies (HM) or hematopoietic stem cell transplant (HSCT) commonly receive broad-spectrum antimicrobials, often leading to the development of multidrug resistant organisms (MDRO). At our institution, rectal stool surveillance cultures (SSC) are done weekly on admitted adult patients with HMs or HSCT. The objective of this study is to determine the role of SSCs in predicting the development of a sterile site infection (StSI) with the same MDRO as identified in the SSC.

Methods

We retrospectively evaluated StSIs (blood, CSF, sputum/respiratory, pleural fluid, and urine) and SSC data from 242 adult patients admitted to the adult oncology ward at a large academic tertiary care center from 6/1/2017 to 2/28/2019. Demographics, SSC data, and StSIs in a 3-month period following the last SSC for each patient were collected from electronic medical records. SSCs were cultured on HardyCHROM ESBL™ media. MDRO similarity between SSC and StSI was determined by comparing susceptibility profiles. JMPÒ Pro 14.3.0 and RStudio were used for statistical analyses.

Results

Two hundred forty-two patients yielded 732 SSCs. We eliminated SSCs with incomplete (< 3 months of follow up) data. Thus, 579 SSCs were included in the analyses. 64% of patients were male. Leukemias (55.4%), lymphomas (21.9%), and multiple myeloma (10.3%) were the most common HMs. HSCT recipients comprised 50.4%. SSCs were positive for a MDRO in 251 cases (vancomycin-resistant enterococci, 52.2%; extended-spectrum beta-lactamase (ESBL) producing organisms, 22.2%; and carbapenamase producing organisms, 4.4%). There were 54 StSIs documented where the MDRO was the same as the SSC MDRO. The NPV of the SSC was 95.1% (95%CI 0.93,0.97). The positive likelihood ratio of the SSC was 2.5 (95%CI 2.07,3.02).

Conclusion

Our results suggest that a negative SSC is associated with a lower probability of identifying a StSI with an MDRO. Clinically, this can be useful in providing the opportunity to judiciously guide antimicrobial therapy, thereby avoiding the unnecessary usage of broad-spectrum antimicrobials when no MDRO is identified in the SSC.

Disclosures

All Authors: No reported disclosures
206. The Utility of Lactate as a Biomarker for Sepsis in Cancer Patients
Authors: Mathew Suji , Whitman Leah
Published: January 2021

Background

Serum lactate is included in the initial assessment of patients with sepsis. However, cancer patients develop lactic acidosis for a variety of reasons and are underrepresented in most studies. Therefore, elevated lactate levels may lead to overdiagnosis of sepsis and excessive antibiotic use. The purpose of this study is to evaluate the utility of lactate as a biomarker for sepsis in cancer patients. The primary endpoint is the rate of 24-hour lactate clearance between infectious and non-infectious causes of lactic acidosis in cancer patients. Secondary objectives explore the duration of antibiotic therapy (DOT), the impact of liver metastasis on serum lactate levels, and the role of procalcitonin in distinguishing between infectious and non-infectious causes of lactic acidosis.

Methods

Retrospective chart review by Antimicrobial Stewardship team

Figure 1: Study design

Results

Preliminary data from a random subset of our sample (45/150) suggests there is no difference in mean serum lactate levels between infectious and non-infectious groups (4.6 vs 6.4). However, a substantial difference exists in the rate of 24h lactate clearance, although the difference was not statistically significant (58.3% vs 33%; p=0.13) (Fig2). There was a significant difference in antibiotic DOT (12.6 vs 3.3; p< 0.0001) presumably due to robust antimicrobial stewardship practices. Consistent with previous studies, there was a significant difference in procalcitonin levels between groups (27.2 vs 1.5, p=0.04).

A sub-analysis of non-infectious patients with liver metastasis revealed a statistically significant difference in the rate of lactate clearance (21% vs 61.5%, p=0.03) (Fig3) suggesting that liver involvement impacts lactate clearance. Antibiotic DOT were also longer in non-infectious patients with liver metastasis (4.53 vs 1.38, p=0.02).

Comparing end points between cancer patients with and witthout infection.

Liver involvement affecting Lactate clearance in patients without infection.

Conclusion

Cancer patients often manifest SIRS criteria at baseline which may lead to the overdiagnosis of infection and excessive antibiotic usage. Our observation is that lactate clearance as opposed to degree of lactic acidosis may be a more accurate indicator of infection in cancer patients especially those with liver involvement. This information may mitigate unnecessary antibiotic use in cancer patients with persistent lactic acidosis unrelated to infection.

Disclosures

All Authors: No reported disclosures
213. An Analysis of the Impact of Gastrointestinal Polymerase Chain Reaction Panel Use on Antimicrobial use at a Tertiary Care Academic Medical Center
Authors: Nlandu Zola , Piccicacco Nicholas , Zeitler Kristen , Jariwala Ripal , Montero Jose
Published: January 2021

Background

Gastrointestinal Polymerase Chain Reaction (GI PCR) panels are increasingly utilized in place of conventional stool testing methods. Several studies have noted GI PCR testing is associated with a reduction in antibiotic prescribing. As it relates to the appropriate timing to order this test in hospitalized patients, one study showed decreased utility when ordered more than 72 hours into admission. At Tampa General Hospital, we utilize the BioFire® FilmArray® GI PCR panel. Since implementation in March 2015, its impact on antimicrobial use has not been formally assessed. Our aim was to evaluate the impact of the GI PCR panel and determine its usefulness as a potential tool for antimicrobial stewardship.

Methods

We conducted an IRB approved retrospective chart review in adult patients admitted to our institution who were ordered the GI PCR panel between 1/1/2018 and 12/31/19. Our primary objective was to assess antimicrobial prescribing patterns; secondary objectives included determining the quantity of tests ordered after 72 hours of admission and inpatient length of stay.

Results

Our initial chart review of 50 patients who were ordered the GI PCR panel revealed 60 % (n = 30) females with an overall median age of 55 years (interquartile range (IQR): 40.75,66.75). GI PCRs were ordered a median of 1 day into the hospital admission (IQR: 1,3) with 6 patients having a test ordered longer than 72 hours into their admission. The median length of stay was 5 days (IQR: 3,7). Testing was negative for 82 % of patients. For patients with positive tests, the most common pathogen identified was E coli (EPEC). Five out of 50 patients (10%) had antimicrobial therapy modified after GI PCR results. Internal medicine providers ordered the majority of tests in these patients (n = 26 (52 %)).

Conclusion

Our findings suggest the majority of GI PCRs were ordered within 72 hours of admission. However, changes in antimicrobial therapy were minimal. A limitation of our study includes patients who were on antimicrobials for other indications.

Disclosures

All Authors: No reported disclosures
214. Antibiotic Use for Common Infections in British Columbia: A Review of Outpatient Prescribing from 2000 - 2018
Authors: Saatchi Ariana , Patrick David M , Morris Andrew , Silverman Michael , Povitz Marcus , Shariff Salimah , Marra Fawziah
Published: January 2021

Background

Antimicrobial resistance continues to jeopardize the future of modern medicine; as 92% of all antibiotics are used in the community, it is imperative to parse outpatient prescribing. In British Columbia (BC), efforts to curb the use of these essential medications have included: stewardship campaigns, practitioner guidelines, and vaccine scheduling amendments. This study reviews the trends in antibiotic use over the past two decades to identify new targets for Provincial stewardship and intervention.

Methods

Antibiotic prescription information was extracted from PharmaNet, a centralized data system that links all pharmacies with prescriptions dispensed in the community setting. The Medical Service Plan records reimbursement claims submitted by physicians for services provided, including diagnostic codes. Antibiotic prescriptions were extracted from PharmaNet and then matched to the billing system using anonymized patient identifiers. Prescription rates were calculated, and trends were examined by major anatomical therapeutic chemical (ATC) classification.

Results

Our study included 3,564,258 individuals over an 18-year period, with a total of 26,108,576 antibiotic prescriptions issued, for common infections. Overall antibiotic utilization decreased 18% (from 228 to 187 prescriptions per 1000 population) over the course of the study period. This trend was reflected in both Beta-Lactam (-37%) and Macrolide (-50%) antibiotics; two of the most common classes prescribed in the outpatient setting. A significant outlier was the J01X class of Other Antibacterials, which increased by a staggering 218%, by 2018. Further analyses are currently underway to stratify these changes in magnitude by demographic variables to identify specific, new targets for stewardship.

Rates of outpatient antibiotic prescriptions, for common infections, per 1000 population, by major ATC class, over time.

Conclusion

Outpatient antibiotic prescribing has decreased steadily since 2000. These promising results can be ascribed to the various Provincial initiatives to quell the misuse of these medications. However, many of the indications tied to these prescriptions do not warrant the use of antibiotics, and further analyses are necessary to evaluate prescribing quality to fully delineate the state of antibiotic use in BC. Next steps also include comparing BC rates with Ontario, another large province of Canada.

Disclosures

All Authors: No reported disclosures
220. Comparing Antibiotic Prescription Practices, and Provider’s Perceptions of Such Rates, Among Urgent Care and Non-Urgent Care Clinicians at One of the Nation’s Largest Federally Qualified Health Centers
Authors: Ben-Yelles Ramzi W , Hopkins Brittany , Brown Sherrill , Saluja Sonali
Published: January 2021

Background

Inappropriate antibiotic prescribing practices, and the resulting development of antibiotic resistance, contribute to a growing health emergency worldwide. In reviewing data from 2010–2011, it was estimated that over 30% of ambulatory antibiotic prescriptions in the United States are non-essential.1 Altamed, one of the nation’s largest federally qualified health centers, operates 21 clinics across Southern California and serves the primary care needs of a high-volume, socioeconomically disadvantaged, predominantly Hispanic population.

Citation 1

Methods

We conducted an evaluation on the inappropriate antibiotic prescribing rate for Upper Respiratory Infections (URI) among all providers at Altamed (n=400). We limited our scope of encounters to cases of uncomplicated, acute bronchitis (URI) that occurred between January and December 2018. ICD 10 codes identified URIs, with exclusion criteria limiting confounding variables, charting errors, and dual diagnoses. Additionally, provider perceptions and mechanism for their antibiotic prescription practices were assessed with a de-identified 17 question, Likert-scale assessment (n=90).

Results

Of the encounters for URI seen by urgent care providers, 11.09% had inappropriate antibiotic prescriptions written. This is significantly different from encounters by non-urgent care providers, where 9.13% were deemed inappropriate (p=0.016). Despite this, providers were not uniform in believing their own antibiotic prescription rates to be as successful, with many estimating that their rate of CDC guideline concordance to fall below 90%. However, in their survey responses, providers as a whole report following healthy prescribing practices, identifying needs in their communities to recognize when it was inappropriate to prescribe an antibiotic, though they requested increased access to and education on antibiograms.

Graph 1

Table 1

Graph 2

Conclusion

Our study limitations included uneven or incomplete charting, the narrow time frame of the study, and the limited survey response rate of Altamed providers. Nevertheless, we are able to ascertain that inappropriate prescribing practices continue to be a challenge in the outpatient setting and are of greater concern among urgent care providers.

Disclosures

All Authors: No reported disclosures
221. Comparison of dental antibiotic prescribing between Australia, England, the United States and British Columbia in 2017
Authors: Teoh Leanne , Thompson Wendy , Hubbard Colin , Patrick David M , Marra Fawziah , Mamun Abdullah A , Campbell Allen , Suda Katie
Published: January 2021

Background

Antibiotic resistance is recognised as a major public health burden. Dentists overprescribe antibiotics and prescribe for unnecessary indications. Tracking and investigating prescribing practices by healthcare professionals provides insights needed to inform targeted antibiotic stewardship interventions. It is unclear how dental antibiotic prescribing patterns differs between countries. The aim of this study was to compare antibiotic prescribing by dentists in Australia, England the United States (US) and British Columbia (BC).

Methods

This was a cross-sectional study of dispensed dental antibiotic prescriptions between January 1 and December 31, 2017, from Australia, England, US and BC. Dispensed dental antibiotic prescriptions included those from outpatient pharmacies and healthcare settings. Outcome measures included the proportion of dental antibiotic prescriptions by location and prescribing rates by population.

Results

English dentists prescribed 1.6 times more antibiotics than those in Australia, and dentists in BC and US prescribed around twice more than Australian dentists. (Australia: 33.2 prescriptions/1000population; England: 53.5 prescriptions/1000population; US: 72.6 prescriptions/1000 population; BC: 65.0 prescriptions/1000 population). The types of antibiotics prescribed were similar across all countries, where penicillins were the predominant class prescribed (66.8–80.5% of antibiotic prescriptions). US dentists and dentists in BC prescribed more clindamycin compared to the dentists in other countries.

Conclusion

Dentists in the US, England and BC prescribed at relatively higher rates than Australian dentists. The findings from this study should initiate an evaluation by dentists of their prescribing practices and responsibilities regarding their contribution towards antibiotic resistance. Further investigations can be aimed at determining country-specific factors that influence dental antibiotic prescription.

Disclosures

Leanne Teoh, BDSc(Hons) BPharm(Hons), Australian Government Research Training Program Scholarship (Other Financial or Material Support, Scholarship awarded for the PhD candidature)