bluuebunny/crossref_metadata_2025 huggingface dataset:
1198. More is not Merrier: Mitigating Meropenem Misuse in the ICU at an Academic Medical Center
Authors: Huang Angela , Sacco Alicia , Skolnik Aaron , Siebeneck Eric , Ilges Dan , Seville Maria T
Published: November 2023

Background

Inappropriate use of carbapenems is a major driver of antimicrobial resistance. The intensive care unit (ICU) at Mayo Clinic Arizona had a higher meropenem (MER) days of therapy (DOT) per 1000 patient days (PD) compared to other Mayo Clinic Enterprise sites, despite low rates of Pseudomonal resistance to narrower spectrum anti-pseudomonal beta-lactams.

Methods

A multidisciplinary team of infectious diseases (ID) and critical care medicine (CCM) physicians and pharmacists was created to reduce inappropriate use of MER in the ICU. The baseline rate of appropriateness was determined by evaluating all MER days in the ICU during Q4 2019 and Q4 2020. Each MER day was designated as appropriate or inappropriate based on pre-determined criteria after review by at least one ID and one CCM member. Discordant days were evaluated by the whole team to achieve consensus. The team provided education to the CCM department on the initiative, baseline data, and strategies to reduce inappropriate MER use. The active intervention included prospective audit and feedback of all patients on MER performed by the ID clinical pharmacists Mon-Fri 0700-1530 in Q4 2022. DOT/1000 PD was assessed for the pre-intervention and intervention periods.

Results

The baseline rate of inappropriate MER use in the ICU was 52% (442/846 days). The two most common reasons for inappropriate MER use in the baseline period were: susceptible organism for which a narrower agent could have been used (93/442, 21%), and infectious workup/cultures negative (89/442, 20%). During the intervention period, the inappropriate rate of MER use was reduced to 23%, below the pre-determined goal of 30%. The MER DOT/1000 PD in the baseline period were 103.9 (Q4 2019) and 151.5 (Q4 2020) versus 66.1 (Q4 2022) in the intervention period. There was no difference in ICU sepsis-related mortality in the pre-intervention vs intervention period (13.4 vs 0%, p=0.04).

Conclusion

A multidisciplinary team approach, including education and prospective audit and feedback, reduced inappropriate MER use in the ICU of an academic medical center from 52 to 23%. An associated decrease in MER DOT/1000 patient days was also observed.

Disclosures

All Authors: No reported disclosures
1201. Putting a CAP on Discharge Antimicrobial Therapy: Evaluation of a Systematic Transitions of Care Process for Patients with Community Acquired Pneumonia (CAP) and Chronic Obstructive Pulmonary Disease (COPD)
Authors: Belza Ana Christine , Efta Jessica , MacDonald Nancy , Kenney Rachel M , Patel Nisha
Published: November 2023

Background

Prescribing excess antibiotic duration at hospital discharge is common. A collaborative, pharmacist-led Antimicrobial Stewardship Transition of Care (ASP TOC) intervention implemented in our hospital was associated with improved discharge prescribing and reduced patient harm. However, the sustainability of this pharmacy service was challenging. To improve sustainability, the electronic scoring system (ESS) in the electronic medical record, used by inpatient pharmacists to prioritize patient care and identify interventions, had implemented an ASP TOC decision support in 2023. The purpose of this study was to evaluate the implementation of ASP TOC in the ESS.

Methods

This IRB-approved retrospective quasi-experiment included patients discharged on oral antibiotics for community-acquired pneumonia or chronic obstructive pulmonary disease exacerbation (LRTI) from 11/2021 to 2/2022 (pre-intervention) or 11/2022 to 2/2023 (post-intervention). The primary endpoint was optimized discharge antimicrobial regimen, defined as guideline concordant selection, dose, and duration. 194 patients were required to achieve 80% power and detect 20% reduction of non-optimized therapy. Multivariable logistic regression was used to identify factors associated with optimized regimens.

Results

200 patients were included. Similar baseline demographics were found in both the pre-intervention group and post-intervention group (Table 1). Optimized discharge regimens improved from 69% in the pre-intervention group to 82% in the post-intervention group (p = 0.033). ASP TOC interventions by the pharmacist increased from 4% to 25% in the post-intervention group (p < 0.001). After adjustment for the type of LRTI, ASP TOC intervention was independently associated with optimized discharge regimens (aOR 6.57; 95% CI 1.51-28.63).Table 1.Baseline Demographics

Conclusion

After launch of the ASP TOC decision support, there was an increase in optimized discharge regimens and ASP TOC interventions completed. Pharmacist use of ASP TOC decision support through an ESS can aid in improving discharge prescribing by the primary medical team, leading to improved outcomes.

Disclosures

All Authors: No reported disclosures
1204. Evaluation Of An Antimicrobial Stewardship Scorecard For Hospitalized Patients With Community-Acquired Pneumonia
Authors: Klatt Megan , Wilson Nicole , Lamberton Kathryn
Published: November 2023

Background

Community-acquired pneumonia (CAP) is a common infectious disease state that provides multiple opportunities for antimicrobial stewardship interventions to optimize therapy management.

Methods

This retrospective cohort study evaluated the impact of a service-level scorecard (Figure 1) with prescribing feedback on the rate of guideline concordant therapy and order set utilization in non-immunocompromised, adult patients with CAP and admitted to internal medicine and family medicine services. Scorecards were shared with teams as part of a larger antimicrobial stewardship “bundle” that included order set and guideline development, and clinician education. The primary outcome was the proportion of guideline concordant therapy defined as meeting three of our four scorecard domains: appropriate duration of therapy, appropriate empiric therapy, and inpatient IV to PO transition. Secondary outcomes included individual scorecard components of appropriate treatment duration, empiric therapy, inpatient IV to PO transition, and order set utilization.Figure 1:Monthly Scorecard Example

Results

239 patients were included consisting of 182 in the pre-dissemination of scorecard group (December 2022 – February 2023) and 57 in the post-dissemination group (March 2023). Median age in both groups were 68-69 years with 49% males in the pre-dissemination group and 63% males in the post-dissemination group. The majority of patients were treated under the internal medicine service (Table 1). Proportion of guideline concordant therapy in the pre-dissemination group was 9% (n=16) and 25% (n=14) in the post-dissemination group (p=.007). Appropriate empiric therapy was utilized in 77% (n=140) patients in the pre-dissemination group and in 95% (n=54) in the post-dissemination group (p=.003) (Table 2).

Conclusion

Service-level scorecard distribution increased the rate of guideline concordant therapy amongst internal medicine and family medicine services and provided insight into creative solutions to optimize future disease state-based antimicrobial stewardship interventions.

Disclosures

All Authors: No reported disclosures
1205. Antibiotic-prescribing for all respiratory tract diagnoses across a network of walk-in clinics: clinician-level variation and correlation with other performance metrics
Authors: Livorsi Daniel J , Clore Gosia , Ince Dilek , Percival Kelly M , O’Shea Amy , Shaw Nathan , Dukes Kimberly , Sherlock Stacey Hockett , Perencevich Eli
Published: November 2023

Background

It is unclear which stewardship metrics are most effective for audit and feedback to outpatient clinicians. In this study, we explored a metric that captures antibiotic-prescribing for all respiratory tract diagnoses to determine if it could serve as an appropriate metric for feedback.

Methods

We performed a retrospective cohort study of in-person visits to the 7 walk-in clinics, including 3 Urgent Care locations, within University of Iowa Health Care during 2018-2022. Visits were categorized as respiratory visits (RVs) if a respiratory tract diagnosis was coded and the patient lacked complicating factors, such as a concomitant non-respiratory infection or certain comorbidities. We built a hierarchical logistic regression model that adjusted for antibiotic appropriateness tiers (1-3) to identify factors associated with antibiotic-prescribing for RVs. Using Spearman’s correlation, we compared the frequency at which clinicians prescribed antibiotics for RVs and other types of visits.

Results

There were 331,496 visits, and 96,546 (29.1%) led to an antibiotic prescription; 44,498 (46.1%) of these were for RVs (Tables 1 and 2). At the clinician-level (n=89), the mean frequency of antibiotic-prescribing for RVs was 36.4% (standard deviation 11.6). Factors at the visit-level associated with an increased odds of antibiotic use for RVs included age ≥ 65 (OR=1.5; 95% CI=1.4-1.6) and having at least one comorbidity (OR=1.2; 95% CI=1.1-1.2). The frequency at which a clinician prescribed antibiotics for RVs was strongly correlated with antibiotic use for all visits (r=0.77, p< 0.001). Clinicians who more often prescribed antibiotics for RVs also more often prescribed antibiotics for respiratory infections that are always viral (r=0.73, p< 0.001), sinusitis (r=0.49, p< 0.001), and non-streptococcal pharyngitis (r=0.69, p< 0.001). There was no correlation between antibiotic-prescribing for RVs and the frequency of return visits within 30 days (r=0.11, p=0.29).

Conclusion

A metric that quantifies the frequency of antibiotic-prescribing for all respiratory tract diagnoses correlated strongly with clinicians who over-use antibiotics for walk-in visits. Future studies should assess whether this type of metric is acceptable to clinicians and an effective tool for feedback.

Disclosures

Daniel J. Livorsi, MD, Merck: Grant/Research Support Kelly M. Percival, PharmD, Gilead Sciences Inc: Advisor/Consultant
1207. Impact of a switch from ciprofloxacin to ceftriaxone on infectious complications after transrectal ultrasound-guided biopsy of the prostate
Authors: Hecker Michelle T , Donskey Curtis , Mendo-Lopez Rafael , Lengu Irma , Nguyen Carvell
Published: November 2023

Background

Transrectal ultrasound-guided biopsy of the prostate (TRUBP), first described in the 1980s, remains a commonly performed procedure. Since approximately 2010, increasing infection rates due to fluoroquinolone-resistant E. coli have been reported. These data prompted a change in our recommended antibiotic prophylaxis in March 2014 from ciprofloxacin to ceftriaxone. Limited data are available on whether this strategy leads to improved outcomes or contributes to emergence of infections due to ceftriaxone-resistant organisms.

Methods

We conducted a retrospective, single-center cohort study comparing patients who received ciprofloxacin monotherapy from 1/1/2011 through 2/28/2014 and patients who received ceftriaxone monotherapy from 3/1/2014 through 12/31/2022 as prophylaxis for TRUBP. The primary outcomes were the percentage of procedures with positive blood cultures within 30 days after the procedure and the percentage of urinary tract infections (UTI), defined as a positive urine culture, within 30 days after the procedure. Secondary outcomes included the percentage of procedures with UTI due to specific organisms, including E. coli, fluoroquinolone-resistant E. coli, and extended-spectrum beta-lactamase producing (ESBL) E. coli within 30 days after the procedure.

Results

Of 2,910 total TRUBP procedures, ciprofloxacin was used for prophylaxis in 653 procedures in 578 patients, and ceftriaxone was used for 2,257 procedures in 1,794 patients. As shown in Table 1, patients receiving ceftriaxone prophylaxis had significantly fewer positive blood and urine cultures in the 30 days after the procedure and significant reductions in positive urine cultures with E. coli, fluoroquinolone-resistant E. coli, and non-E. coli Enterobacteriaceae.

Conclusion

Our findings suggest that in the setting of increasing rates of fluoroquinolone resistance in E. coli, switching from ciprofloxacin to ceftriaxone for TRUBP prophylaxis may result in fewer infectious complications without increasing the risk for emergence of infections due to ceftriaxone-resistant organisms.

Disclosures

All Authors: No reported disclosures
1211. Impact of Gram-Negative Rod Bacteremia Rapid Diagnostic Testing and Real-Time Clinical Staff Pharmacist Review
Authors: Kremer Abby , Orvin Alison
Published: November 2023

Background

Although Rapid Diagnostic Testing (RDT) enables optimization of antimicrobial therapy, there is no consensus on how to integrate utilization into clinical practice. At our institution, the BIOFIRE® Blood Culture Identification 2 (BCID2) RDT was implemented in September 2021 in conjunction with real-time clinical staff pharmacist result notification and review. The objective of this study was to determine the impact of RDT plus real-time clinical staff pharmacist review on the management of gram-negative rod (GNR) bacteremia.

Methods

This retrospective, matched cohort study included patients with a positive blood culture for a GNR on the BCID2 panel from September 2020 to August 2021 (historical) and October 2021 to September 2022 (interventional). Exclusion criteria were polymicrobial bacteremia, discrepant RDT results from traditional culture, 24-hour mortality, and comfort care or not admitted at the time of RDT result. Patients were randomly screened to include 120 patients in each group and matched based on age, pathogen, and resistance mechanism. The primary endpoint was time from Gram stain to appropriate antibiotic therapy. Secondary endpoints included time to first pathogen-directed change in therapy, days of anti-pseudomonal therapy, length of stay (LOS), and inpatient mortality.

Results

The study population was predominantly female (61%) and the majority were over 70 years old (55%). Escherichia coli was isolated in 71% of patients with extended-spectrum beta-lactamase-producing organisms isolated in 8%. The median time to appropriate therapy was 0 hours for both groups, indicating patients were on appropriate therapy at the time of Gram stain result (p=0.28). There was a statistically significant decrease in time to first pathogen-directed change in therapy (40 vs. 11 hours; p< 0.01). There was no difference in days of anti-pseudomonal therapy, LOS, or inpatient mortality between groups.

Conclusion

Implementation of RDT plus real-time clinical staff pharmacist intervention did not impact time to appropriate therapy in patients with GNR bacteremia but did significantly reduce time to pathogen-directed antibiotic changes. RDT plus real-time clinical staff pharmacist intervention is a practical method of utilizing technology to improve patient care.

Disclosures

All Authors: No reported disclosures
1217. Game of Trophs: Stenotrophomonas maltophilia Management 2.0: Before and After an Antimicrobial Stewardship Intervention
Authors: Son Andrea H , Hecker Michelle T
Published: November 2023

Background

IDSA guidance on the treatment of Stenotrophomonas maltophilia infections version 2.0 recommends caution in the use of levofloxacin, reserving its use as a second line option for mild infections and using it only as a component of combination therapy for moderate to severe infections. The use of ceftazidime is not recommended. In July 2022 we implemented a multifaceted intervention including suppression of levofloxacin and removal of ceftazidime susceptibility reporting in the electronic medical record, education to ID providers, and prospective audit and feedback (PAF). We herein describe S. maltophilia treatment and outcomes before and after this intervention.

Methods

This was a retrospective single center cohort study including all patients from whom S. maltophilia was isolated in culture between 7/1/2021 – 6/31/2022 (before) and 7/1/2022 – 3/31/2023 (after). The primary objective was to describe the rates of adherence to the recommended use of levofloxacin and ceftazidime for each period. The secondary objective was to describe clinical outcomes.

Results

One hundred eleven patients were included in the study. The respiratory tract was the most common culture source. Levofloxacin susceptibility data were visible to providers in 100% and 2% of cultures in the before and after periods, respectively. Ceftazidime susceptibility data were visible to providers in 20% and 7% in the before and after periods, respectively (table 1). ID was consulted more often in the after period (30% before vs 47% after). Adherence to recommended treatment overall was greater in the after period. Fewer patients received levofloxacin monotherapy and no patients received IV ceftazidime in the after period (table 2). S. maltophilia was isolated in subsequent cultures in 12% and 13% of patients and levofloxacin resistance developed in 3% and 2% of isolates during the before and after periods respectively (table 3).

Conclusion

A stewardship intervention including changes in susceptibility reporting, education, and PAF was associated with an increase in the percentage of patients receiving appropriate therapy. Clinical outcomes did not change.

Disclosures

All Authors: No reported disclosures
1220. Comparing Breakthrough Fungal Infections in Acute Myeloid Leukemia (AML) and Myelodysplastic Syndrome (MDS) Patients Receiving Prophylaxis with Different Azoles
Authors: Chen Catherine , Tverdek Frank P , Escobar Zahra , Liu Catherine , Simmons William F , Bui Hanh
Published: November 2023

Background

Posaconazole is recommended for primary prophylaxis in neutropenic patients with acute myeloid leukemia (AML) or myelodysplastic syndrome (MDS) receiving induction chemotherapy. Despite prophylaxis, breakthrough invasive fungal infections (bIFIs) still arise. Initiating posaconazole is not always feasible, and may necessitate use of alternative azoles. The primary objective of this study was to evaluate the rate of bIFIs in patients receiving prophylaxis with posaconazole versus alternative azoles. The secondary objective reviewed reasons for alternative azole use.

Methods

A retrospective chart review was conducted at University of Washington Medical Center (UWMC) and Fred Hutchinson Cancer Center (FHCC). Patients who received induction chemotherapy for AML/MDS from March 2021 to November 2022 and received a prophylactic azole for at least 7 days during neutropenia were included. Outcomes were evaluated with Chi-Square. The incidence of bIFI was evaluated up to 12 weeks from induction chemotherapy, or until consolidation chemotherapy or hematopoietic stem cell transplant, whichever came first.

Results

The initial query yielded 175 patients with AML/MDS. Of these, 88 patients were included: 74 received posaconazole and 14 received an alternate azole (Table 1). BIFIs occurred in 9 patients (posaconazole (n=7, 9.5%), alternative azole (n=2, voriconazole, 14.2%); p=0.631) (Figure 1). The most common reason for initiating an alternative azole was insurance restrictions/high cost (Figure 2).

Conclusion

Numerically, we found reduced incidence of bIFIs among patients receiving posaconazole compared to alternative azoles. Insurance restrictions/cost was the most common reason for alternative azole utilization. This barrier may increase risk of bIFIs, and additional efforts should be considered to use posaconazole over alternative azoles.

Disclosures

Catherine Liu, MD, Pfizer: Site Investigator|SNIPR BIOME: Advisor/Consultant
1221. Non-severe, non-immune mediated intolerances: simple targets for direct non-invasive delabeling opportunities of beta-lactam antibiotic allergy labels (BAAL)
Authors: Polisetty Radhika S , Dickens Michael , Tran Hoang , Khankan Nour , Weslander Erin , Bertram Christie M , Moore William J , Wang Sheila K
Published: November 2023

Background

Majority of patients with a BAALs can tolerate a β-lactam without concerns for a severe IgE-mediated reaction. Many BAALs are confirmed to be intolerances or adverse events versus a true allergy. False BAALs can result in the use of alternative non-BLs, posing risk for collateral health consequences. Current strategies to delabel a false BAAL can be restricted, time consuming and invasive, requiring skin and drug provocation testing. An alternative approach involves direct delabeling of reported BL allergies in patients with non-severe, non-immune mediated intolerances. This method of assessment relies on the review of the electronic medical record (EMR) versus invasive assessments. The aim of this study was to identify the prevalence of reported non-severe, non-immune mediated intolerances across a system of hospitals for prospective non-invasive delabeling opportunities.

Methods

Eligible patients seen within the Northwestern Medicine Healthcare System (NMHS) between 8/1/20 and 8/1/22 were included. Eligible patients: 18 years and older, admitted to a NMHS hospital with > 1 overnight stay, and a BAAL in the allergy profile of the EMR. Examples of non-severe, non-immune mediated intolerances were GI upset, rash w/o pruritus, headache, and pharmacologically predictable reactions. Demographic and allergy data reported in the allergy profile of the EMR was retrospectively obtained through from the Epic Enterprise Data Warehouse.

Results

Over the study period, 25,768 unique patients were eligible for inclusion. During this time, the NMHS admitted 194,670 patients, suggesting a BAAL prevalence rate of 13.2% system-wide. Included patients were mostly White (81%), female (65%) with a median age of 64 (18-109). Of the 25,768 BAALs, 16,561 (64%) were reported as immune mediated reactions, 2,534 (9.8%) as non-severe, non-immune mediated intolerances, 3,405 (13.2%) as indeterminant, and 3,268 (12.7%) had no reaction type reported in the allergy profile of the EMR.

Conclusion

Our prevalence of BAAL across NMHS hospitals was 13.2%. At least 2,534 BAALs reported as a non-severe, non-immune mediated intolerance could be directly delabeled using a non-invasive approach, possibly offering a simpler and broader approach compared to current (invasive) strategies.

Disclosures

All Authors: No reported disclosures
1223. Utilizing Multiple Antimicrobial Stewardship Metrics to Trend Vancomycin Use in an Implementation Study
Authors: Wolfe Kaleb H , Smiley Casey , Hasse Eileen , Millman Nina , Chambers Michael , Hendrickson Sage , Parvaz Parmida , Lokant Matthew , Patel Nishant , Pellegrino Rachael , Okafor Kimberly C , Vojtek Christina , Staub Milner , Fiske Christina T , Norwood Jamison
Published: November 2023

Background

Inpatient IV vancomycin use is often inappropriately prolonged. Methicillin-resistant Staphylococcus aureus (MRSA) polymerase chain reaction (PCR) nares swabs have shown high negative predictive values for many infections and can guide appropriate vancomycin de-escalation. Antibiotic stewardship programs (ASPs) often monitor vancomycin use in days of therapy (DoT) per 1000 patient days present (PDP). This measure can be affected, especially for smaller facilities, by changes in bed capacity and prolonged stays and thus may not accurately reflect vancomycin use. We evaluated whether alternative metrics of vancomycin use would show different impacts during a multi-step ASP intervention to reduce inappropriate vancomycin use at Veterans Affairs Tennessee Valley Healthcare System.

Figure 1

Run chart of vancomycin DoT/1000 PDP at the Tennessee Valley Healthcare System (TVHS) in two years prior to intervention.

Methods

In September 2021, the ASP, with multiple stakeholders, initiated use of MRSA nasal swabs to inform vancomycin de-escalation. From 7/2022 to 3/2023, we performed iterative Plan-Do-Study-Act intervention cycles including educating medicine and surgical divisions on MRSA swab result interpretation, educating nurses on timely swab collection, replacing MRSA culture swabs with PCR swabs, and adding MRSA swab orders to vancomycin order sets. In April 2022, in addition to DoT/1000 PDP, we began measuring mean, median, and mode DoT per vancomycin course initiated by start week.

Results

Despite multiple interventions beginning July 2022, vancomycin use in DoT/1000 PDP increased to a peak of 106 DoT/1000 PDP in September 2022. In that same period, median and mode DoT per vancomycin initiation remained steady at 2 days and 1 day, respectively.

Figure 2

Run chart of vancomycin DoT/1000 PDP at the TVHS from April 2022 to March 2023. Specific ASP interventions are annotated on the dates they occur.

Figure 3

Run chart of mean, median, and mode days of vancomycin therapy per vancomycin course initiated at the TVHS from April 2022 to March 2023. Specific ASP interventions are annotated on the dates they occur.

Conclusion

DoT/1000 PDP may not be the best metric to evaluate efforts to reduce inappropriate vancomycin use. By tracking mean, median, and mode of DoT per individual vancomycin course, we determined that most providers already practice rapid de-escalation, minimizing patient vancomycin exposure. This method also allows us to quickly detect changes in prescribing patterns and determine whether interventions were warranted. More evaluation of antibiotic use metric appropriateness based on desired outcome is needed in ASPs.

Disclosures

Milner Staub, MD, MPH, Gilead: Stocks/Bonds|Johnson & Johnson: Stocks/Bonds
1228. Evaluation of the Practice of Switching from Intravenous to Oral Antimicrobial Therapy at King Abdulaziz University Hospital
Authors: Alharbi Reem , Baghdady Nour
Published: November 2023

Background

Conversion from intravenous (IV) antibiotics to an oral (PO) in eligible patients is an important antimicrobial stewardship strategy. Recently, King Abdul-Aziz University Hospital (KAUH) in updated its IV to PO conversion policy. This policy describes eligibility criteria for patients to be switched to oral therapy from IV and it suggests PO alternative to IV medications. The aim of this prospective observational study is to observe IV to PO conversion practices on selected antimicrobials in selected ward after updating and implementing this policy.

Methods

Adult patients admitted to the medical, surgical, and hematology/oncology wards who received either metronidazole, ciprofloxacin or clindamycin IV were evaluated for antibiotic need and for eligibility for IV to PO conversion according to the policy. Evaluation period spanned from November 2021 – December 2022.

Results

194 patients were evaluated. Of them, 154 (80%) had a clear indication for the antibiotic of which 98 (63%) required IV administration for the following reasons: impaired oral route (59%), impaired gastrointestinal absorption (15.3%), acute treatment phase of the infection (15.3%), and other reasons such as surgical prophylaxis (3%) and severe sepsis/septic shock (2%). The remaining 56 (36.7%) met the policy’s eligibility criteria for IV to PO conversion.

Conclusion

We found that most patients received antibiotics appropriately in the appropriate route for an existing indication. However, there are plenty of opportunities for improvement in discontinuing unnecessary antibiotics and de-escalating from IV to PO. Ideally, this discussion should be had while rounding on the patient for collective decision making at the point of care.

Disclosures

Nour Baghdady, PharmD, BCPS, MPH, BCIDP, CSL Seqirus: Advisor/Consultant|CSL Seqirus: Stocks/Bonds
1230. Optimization of a Public-Facing Health System Antimicrobial Stewardship Website
Authors: Bertram Christie M , Wang Sheila K , Moore William J , Borkowski Jaime , Weslander Erin
Published: November 2023

Background

Following health system integration of an academic medical center and 10 community hospitals, efforts were made to unify the individual antimicrobial stewardship programs (ASP) and standardize resources within a system-wide Antimicrobial and Diagnostic Stewardship Program (NM ADSP). We assessed the impact of optimizing our public-facing website with updated resources, improving platform usability and convenience, and promoting the new ADSP website to stakeholders.

Methods

Previously conducted focus group sessions of the general public and internal questionnaires to clinicians were used to assess the value of antimicrobial stewardship (AS) and available resources/education. Our system ADSP team worked to assess and merge existing AS resources across each site. Concurrently, the ADSP team partnered with marketing specialists and digital content creators at our institution to produce and launch the new ADSP website. Tracking of total website pageviews per week for 3 months before and 3 months after the ADSP website optimization was evaluated.

Results

Feedback from focus groups and clinical users confirmed the value of a website as a convenient and accessible platform in disseminating important AS resources and education to a broad audience. From these assessments, we identified and prioritized high-use AS resources and education content across the system (e.g. allergy, antibiograms, antimicrobial dosing, COVID-19, and guidelines/protocols) and prioritized these on the home page. Other information identified as useful included site-specific practice guidance, about us, clinical & patient education, news/events, and residency/fellowship information, which were also posted on the home page. A significant difference in the median unique website views per week was observed after optimization and launch of the new ADSP website (pre: 347; post: 524, p < 0.001).

NM ADSP Website Resources

Conclusion

Antimicrobial stewardship is a collective effort. Establishing an organized and resourceful AS public-facing website that is user-friendly and reliable for our stakeholders betters our chances of improving the use of anti-infectives and reducing the threat of antimicrobial resistance. Our experience may be useful to identify educational best practices for enhanced ASP impact at other institutions.

Disclosures

All Authors: No reported disclosures
1232. Incorporation of Theory to Develop and Implement a Multi-Faceted Antimicrobial Stewardship Intervention for Hospitalized Adults with Bacteriuria
Authors: Black Emily , MacLean Dianne M , Bell Madison , Bonnar Paul , Kent Andrea J , Abbass Kim A , Murphy Valerie , Neville Heather L , Ramsey Tasha , Helwig Melissa , Kits Olga , Campbell Samuel G , Coulson Keri , LeBlanc Constance , Johnston B Lynn , Sketris Ingrid
Published: November 2023

Background

Inappropriate treatment of bacteriuria is commonly reported. While evidence to support antimicrobial stewardship (AMS) interventions has been published, few studies justify intervention components or incorporate theory into designing interventions. The objective of the study was to develop a theory-informed multifaceted AMS intervention to improve management of bacteriuria in adults admitted to hospital.

Methods

We used the 4-step approach described by French and colleagues to develop a theory informed intervention. A systematic review of AMS interventions to improve antibiotic use for bacteriuria was completed. In addition, local barriers to improving antimicrobial use in hospitalized adults with bacteriuria were assessed through a qualitative study using focus groups with health care providers. Barriers identified through the qualitative study were mapped to the Theoretical Domains Framework and the COM-B model then linked to the Behaviour Change Wheel. Published literature, focus group results, and practical considerations were used by our team to identify and rank possible solutions. Consensus on which interventions to implement locally was achieved using the Nominal Group Technique.

Results

Ten interventions that could address local challenges with antimicrobial prescribing for bacteriuria were identified. The highest-ranking interventions were audit and feedback (to individuals or teams), active educational sessions, development of clinical order sets, and incorporating clinical decision support with culture results. A multifaceted intervention that included monthly audit and feedback on management of bacteriuria to multidisciplinary teams in combination with case-based virtual education sessions was developed and is currently being piloted at four tertiary and community hospitals.

Conclusion

Use of theory to identify local barriers and facilitators to improving antimicrobial use in combination with evidence and practical considerations should be incorporated into design and implementation of AMS interventions. Further work will evaluate impact of this theory-informed AMS intervention on antimicrobial prescribing for bacteriuria in hospitalized adults.

Disclosures

Emily Black, BSc(Pharm), PharmD, Drug Evaluation Alliance of Nova Scotia: Grant/Research Support|Research Nova Scotia: Grant/Research Support Paul Bonnar, MD, BioMerieux: Honoraria|Paladin Labs: Honoraria Samuel G. Campbell, FRCP (Edin), Astra Zeneca: Board Member
1234. Three Year, Statewide, Assessment of Impact of Time to Sepsis Bundle Completion on Mortality in Patients with Severe Sepsis and Septic Shock
Authors: Carreno Joseph , Nero Alexa , Weber Mckayla , Racz Michael
Published: November 2023

Background

In 2013 New York State regulations mandated that all hospitals implement methods for rapidly identifying and treating patients with severe sepsis and septic shock. This study evaluates the impact of those regulations on patients with sepsis between 2016 and 2019.

Methods

Retrospective, statewide, cohort study of all patients in New York State Sepsis Clinical Dataset with severe sepsis or septic shock between 2016 and 2019. Patients were included if they were admitted through the emergency department (ED), had their 3-hour sepsis bundle (blood culture taken prior to antibiotics, antibiotics given within 1 hour, lactate level taken) started within 6 hours of presentation to the ED, and had their sepsis bundle completed within 12 hours of bundle initiation. The main exposure of interest was time to bundle completion from triage in ED. The main outcome of interest was all-cause inpatient mortality. Multilevel logistic regression was used to account for intra-hospital clustering. P-values < 0.05 were considered statistically significant.

Sepsis Clinical Data Disclaimer

The data used to produce this publication was provided by the New York State Department of Health (NYSDOH). However, the conclusions derived, and views expressed herein are those of the author(s) and do not reflect the conclusions or views of NYSDOH. NYSDOH, its employees, officers, and agents make no representation, warranty or guarantee as to the accuracy, completeness, currency, or suitability of the information provided here.

Results

The weighted sample included 64,119 patients. Baseline characteristics are presented in Table 1. Most individuals (73.6%) had their bundles completed within 3-hours. The median (IQR) time to bundle completion was 1.83 h (1.07 – 3.12), the median (IQR) time to antibiotics was 1.72 h (1.00 – 2.83). Bundle completion within 3-hours from triage was associated with decreased risk of mortality in univariable analysis (17.07% vs. 18.59%, ≤ 3 hrs vs. > 3 hrs, respectively, p < 0.0001). In the multivariable analysis, delayed bundle completion ( >3 h from triage) was associated with increased adjusted odds ratio (aOR, 95% CI) for mortality (1.097 [1.041 – 1.155], P < 0.0001). Delayed antibiotics administration ( > 3 h from triage) was associated increased odds of mortality (aOR [95% CI]: 1.089 [1.031 - 1.151], P < 0.0001). Subgroup analyses are presented in Figure 1 and 2.

Figure 2. Impact of Delayed Antibiotics on Mortality in Subgroups

Data are for adjusted odds ratios and indicate adjusted odds ratios for > 3 delay on mortality within subgroup.

Conclusion

Rapid (≤ 3h) completion of sepsis bundle was associated with decreased risk of mortality. This association was also observed for rapid administration of antibiotics. These data suggest that statewide mandates may improve outcomes for patients hospitalized with sepsis.

Disclosures

All Authors: No reported disclosures
1238. Evaluating the Impact of an Automatic Antibiotic De-escalation Protocol at an Acute Care Hospital
Authors: Diep Albert , Leonard Jacob , Cho Jonathan , Chromi Stephen E , Kronsberg Kelli
Published: November 2023

Background

Previously, pharmacist-led stewardship programs have been shown to result in more timely de-escalation of antibiotics and lack of adverse outcomes in patients treated for pneumonia in the intensive care unit (ICU). This study evaluated the effects of an automatic pharmacist-led antimicrobial de-escalation policy outside of the ICU.

Methods

This was a retrospective pre- and post-implementation study at a 425-bed tertiary care hospital in Las Vegas, Nevada. Inclusion criteria consisted of patients admitted from October 2017 to October 2021 who had Escherichia sp., Proteus sp., Klebsiella sp., Pseudomonas sp., or Enterococcus sp. isolated from specified sites that were susceptible to certain antibiotics included in the de-escalation policy. Exclusion criteria included concomitant infections, polymicrobial infections with organisms outside of those mentioned in the inclusion criteria, deep-seated infections, or hemodynamic instability. The primary outcome was time to de-escalation, which was calculated by determining elapsed time between culture susceptibility results and start of the new antibiotic if de-escalated. If de-escalation did not occur, then time to de-escalation was calculated by comparing time of susceptibility results to antibiotic discontinuation. Secondary outcomes evaluated included rates of antibiotic de-escalation, occurrence of readmission at 30- and 90-days, incidence of all-cause inpatient mortality, length of stay, incidence of Clostridioides difficile infection, and time to clinical resolution. Time to clinical resolution was defined by when patient met pre-specified laboratory values following the first antibiotic dose.

Results

A total of 174 patients were included in the pre-group and 52 in the post-group. The results are shown in Table 1; there was a statistically significant decrease in time to de-escalation, rates of de-escalation, and 90-day readmission rates favoring the post-intervention group, with no differences seen in the other outcomes.

Conclusion

An automatic de-escalation protocol can significantly shorten time to de-escalation in addition to improving rates of de-escalation outside of the ICU without negatively impacting patients.

Disclosures

All Authors: No reported disclosures
1254. DoD Adherence to CDC Core Elements of Hospital Antibiotic Stewardship Programs
Authors: Lynch LeeAnne C , Tribble David R , Tribble David R , Mende Katrin
Published: November 2023

Background

In response to the 2014 Executive Order on Combating Antibiotic-Resistant Bacteria, the Centers for Disease Control and Prevention (CDC) released “Core Elements of Hospital Antibiotic Stewardship Programs” in 2014 and updated it in 2019. In 2017, the Department of Defense (DoD) required hospitals to establish antimicrobial stewardship programs (ASPs) that include CDC Core Elements (CEs). DoD ASPs are often evaluated at the facility level but have not yet been assessed system-wide. This study aims to analyze DoD ASPs as an enterprise to inform future quality improvement.

Methods

Data from the CDC’s National Healthcare Safety Network (NHSN) hospital annual survey, which includes self-reported responses about facility characteristics and various hospital programs (including ASPs), were analyzed in Stata/IC 16.1. A framework analysis was conducted to determine how ASPs are structured, using CDC CEs as a guide. DoD adherence for each individual and all CEs was compared to national data for 2017-2021 and averaged over the same time frame. Adherence was measured using CDC methodology: a positive response to > 1 question within a CE was categorized as that CE being met.

Results

From 2017-2021, between 4,940 and 5,053 hospitals responded to the NHSN annual survey, including 46 to 48 DoD hospitals (1.0% of reporting facilities). Reporting facility participation varies year-to-year, but average percent CE adherence nationally and for the DoD showed education, reporting, and tracking had the lowest adherence (Table 1; Figure 1). DoD differed from national adherence for the CEs of education (-1.9%) and action and tracking (-1.3%). All CEs were met for 82.7% of DoD hospitals compared to 87.2% of hospitals nationally.

Conclusion

National and DoD CEs adherence levels both showed the largest 2017-2021 average deficiencies in education, followed by tracking and reporting. Differences between national and DoD adherence levels were observed for several CEs. The DoD sample size is small and adherence was variable. However, these findings suggest that the CEs where DoD lags national adherence - education, action, and tracking - present opportunities for the DoD to improve its ASPs. A similar comparison with national adherence percentages may also prove useful for other health systems to undertake.

Disclosures

All Authors: No reported disclosures
1255. Filipino Health Care Professionals’ Knowledge, Attitude and Perception regarding Drug-Susceptible and Drug-Resistant Tuberculosis in a High TB Burden City in Central Luzon: A Cross- Sectional Study
Authors: MANZANO J E R O M E G , Redondo-Samin Divina Cristy
Published: November 2023

Background

Tuberculosis (TB) is one of the major diseases responsible for the public health and economic crisis in low-income countries, with the Philippines as one of the eight countries in 2020 that accounted for two thirds of the new TB cases worldwide. Its three most populous regions which are the National Capital Region, Calabarzon and the Central Luzon Region reported the highest number of TB cases in 2015. One important consideration is that health care providers’ knowledge, attitude and perception regarding TB largely affects the success of TB treatment.

Methods

This study assessed the knowledge, attitude and perception among health care professionals who manage tuberculosis, using a validated questionnaire regarding drug-susceptible and drug-resistant tuberculosis in Cabanatuan City, Nueva Ecija. Cross-sectional study was used in this research. All health care professionals assigned in each identified health facility were asked to participate in the study. After obtaining informed consent, a self-administered questionnaire was given to all participants to answer. Descriptive statistics and Chi-square tests were used in data analysis.

Figure 1

Selection of Study Participants through Purposive Sampling

Results

Table 1

Socio-Demographic Profile of HCPs in Cabanatuan City Nueva Ecija

Table 2

Knowledge of HCPs on Diagnosis and Nature of Tuberculosis

Table 3

Attitude of HCPs towards Patients with Tuberculosis and the TB Control Systems

Conclusion

The lack of training may have largely contributed to the poor knowledge of HCPs which may possibly hinder the success of providing TB treatment. It is therefore a paramount consideration that prior to the HCP’s assignment in TB DOTS centers, all HCPs must first undergo training in order to manage TB treatment properly and successfully.

Table 4

Perception of HCPs towards Tuberculosis

Table 5.1

Significant Difference between overall TB Knowledge of HCPs and the Socio-Demographic Profile

Table 5.2

Significant Difference between MDR-TB Knowledge of HCPs and the Socio-Demographic Profile

Disclosures

All Authors: No reported disclosures
1260. A Retrospective Observational Study on Assessing the Use of Antibiotic Prophylaxis for Outpatients in the Dental and Ophthalmic Department in a Tertiary Care Hospital
Authors: Dorairajan Suresh Kumar , Rajakumar Ratheesh , Basha Safiya Banu Sadik
Published: November 2023

Background

Antibiotics are most commonly used in outpatient setting when compared to inpatient setting. Inappropriate antibiotics prescribing in dental and ophthalmic outpatient setting without following any proper guidelines has been identified as a potential driver for antimicrobial resistance especially in the developing world. As there is no sufficient data in India regarding efficient prophylactic use of antibiotics in dental and ophthalmic department, this study is aimed to address this by assessing the antibiotic prophylaxis among outpatients.

Methods

This retrospective observational study was conducted in the Dental and Ophthalmic outpatient’s department in a tertiary care hospital in South India for 3 months from April 2022 to June 2022. The data regarding the Antibiotic prophylaxis were collected from records of the patients’ prescription and analyzed using simple statistics.

Results

A total of 395 prescriptions are collected. Mean age was found to be 53.5 years. The key findings are summarized in Table 1 below.

Conclusion

85% of patients were prescribed with antibiotics in Dental OP whereas 90% of patients were prescribed with antibiotics in Ophthalmic OP in which 56% of patients were found to have inappropriate duration of Antibiotic therapy. Understanding the current patterns of antibiotic prophylaxis in outpatient setting is necessary to implement antibiotic stewardship and large multicentric studies in the future will help to reduce unnecessary antibiotic use in the developing world.

Disclosures

All Authors: No reported disclosures
1262. The Impact of Antimicrobial Stewardship on Antimicrobial Consumption and Resistance Trends at a Tertiary Care Center in Beirut
Authors: Haddad Nisrine , Abdallah Tamara , Rizk Nesrine , Zeenny Rony , Kanj Souha S
Published: November 2023

Background

Antimicrobial Resistance (AMR) is a threat to public health, causing increased morbidity and mortality particularly among hospitalized patients. The COVID-19 pandemic has further worsened the situation globally, causing a surge in the number of critically ill patients, and an increase in antimicrobial consumption resulting in the spread of infections with multidrug-resistant organisms (MDROs). Antimicrobial Stewardship Programs (ASP) play a crucial role in optimizing antimicrobial consumption to fight AMR. In this study, we evaluate the impact of ASP interventions on antibiotic consumption and trends of AMR among bacterial pathogens at a tertiary care center in Beirut before and after the pandemic.

Methods

ASP team recommendations are labeled as interventions. We compiled the ASP interventions from January 2019 until December 2021. Data on antimicrobial consumption, expressed as defined daily dose (DDD) per 100 patient days, for all anti-infectives and restricted anti-infectives was collected per quarter. Data on MDRO resistance trends were obtained from the clinical microbiology laboratory from 2019 to 2022.

Results

The number of ASP recommendations is reported in Figure 1. There is a noticeable correlation between COVID-19 surges in Lebanon and the number of ASP interventions. We note an increase in all antimicrobial consumption after the onset of the pandemic, with a peak in Q4 2020 (142.8 DDD/100 patient days) (Figure 2), and in Q1 2021 for restricted antimicrobials (79.1 DDD/100 patient days) (Figure 3). Importantly, there were no noteworthy changes in resistance patterns for MDR gram-negative organisms, except for MDR Acinetobacter baumannii and Carbapenem resistant Klebsiella spp., which decreased by 27% and 8%, respectively. We witnessed a rise in Gram-positive resistance trends for Methicillin-resistant Staphylococcus aureus and Vancomycin-resistant Enterococcus (f29% to 33% and 9% to 14% in 2019 to 2022, respectively).Figure 1.Number of ASP Interventions Pre- and During COVID-19Figure 2.All Antimicrobials Defined Daily Dose per 100 Patient Days and Resistance Trends of MDROsFigure 3.Restricted Antimicrobials Defined Daily Dose per 100 Patient Days and Resistance Trends of MDROs

Conclusion

This study highlights the importance of ASP activities despite and during a pandemic. The results emphasize the role of ASP to mitigate the impact of the pandemic on antimicrobial resistance. The ASP team maintained its operations, monitoring antibiotic consumption and providing recommendations to limit antibiotic misuse.

Disclosures

Souha S Kanj, MD, Gilead: Advisor/Consultant|Menarini: Advisor/Consultant|MSD: Advisor/Consultant|Pfizer: Advisor/Consultant