bluuebunny/crossref_metadata_2025 huggingface dataset:
1007. A novel approach to evaluate antibiotic utilization across the spectrum of inpatient and ambulatory care and implications for prioritization of antibiotic stewardship efforts
Authors: Frost Holly M , Knepper Bryan C , Shihadeh Katherine C , Jenkins Timothy C
Published: October 2019

Background

Antibiotic overuse remains a significant problem in inpatient and outpatient settings. The objective of this study was to develop a methodology to evaluate antibiotic use across inpatient and ambulatory care sites in an integrated healthcare system in order to prioritize antibiotic stewardship efforts.

Methods

We conducted an epidemiologic study of antibiotic use across an integrated healthcare system on 12 randomly-selected days between October 1, 2017 and September 30, 2018. Inpatients and perioperative patients were recorded as having received an antibiotic if they were administered ≥1 dose of a systemic antibacterial agent. Outpatients were recorded as having received an antibiotic if they were prescribed ≥1 systemic antibacterial agent.

Results

On the study days, 10.9% (95% CI 10.6–11.3%) of patients received an antibiotic. Of all antibiotics administered or prescribed, 54.1% were from ambulatory care (95% CI 52.6–55.7%), 38.0% were from the hospital, (95% CI 36.6–39.5%), and 7.8% (95% CI 7.1–7.8%) were perioperative. The emergency department/urgent care centers, adult outpatient clinics, and adult noncritical care inpatient wards accounted for 26.4% (95% CI: 25.0–27.7%), 23.8% (95% CI: 22.6–25.2), and 23.9% (95% CI 22.7–25.3) of antibiotic use, respectively. Only 9.2% (95% CI: 8.3–10.1%) of all antibiotics were administered in critical care units. Antibiotics with a broad spectrum of Gram-negative activity accounted for 30.4% (95% CI: 29.0–31.9%) of all antibiotics prescribed. Infections of the respiratory tract were the leading indication for antibiotic use.

Conclusion

In an integrated healthcare system, nearly three-quarters of antibiotic use occurred in the emergency department/urgent care centers, adult outpatient clinics, and adult noncritical care inpatient wards. Antibiotics with a broad spectrum of Gram-negative activity accounted for a large portion of antibiotic use. Analysis of antibiotic utilization across the spectrum of inpatient and ambulatory care is useful to prioritize antibiotic stewardship efforts.

Disclosures

All authors: No reported disclosures.
1010. Exploring Antimicrobial Prescriptions in a National Audit of Hematology/Oncology Inpatients Compared with the General Inpatient Population: Targeted Analysis Highlights Key Areas for Targeted Intervention
Authors: Douglas Abby , Hall Lisa , James Rodney , Worth Leon , Slavin Monica , Thursky Karin
Published: October 2019

Background

Little is known about the antimicrobial prescribing practices in hematology and oncology (haemonc) populations. We aimed to explore antimicrobial prescribing practices in haemonc patients compared with other acute inpatients, in order to target areas for intervention.

Methods

In Australia, facilities nationwide participate in an annual point-prevalence survey of antimicrobial prescribing in hospitalized patients (Hospital National Antimicrobial Prescribing Survey (Hospital NAPS)). The results for adult inpatients from 2015–2018 were analyzed. Assessments of appropriateness were undertaken by local antimicrobial stewardship teams according to a structured algorithm, and defined as: 1 (optimal); 2 (adequate); 3 (suboptimal); 4 (inadequate); 5 (not assessable). A score of 1 or 2 is considered to be”appropriate’ and 3 or 4 ‘inappropriate’; those not assessable were excluded. Antimicrobial class, indication and appropriateness were compared between haemonc and other acute inpatient populations. Using logistic regression analysis, factors associated with appropriate prescribing of antibacterials were explored.

Results

The survey comprised 95809 antibiotic prescriptions for 63668 adult inpatients (4097 haemonc, 59571 other inpatients) in 423 acute facilities. The top treatment and prophylactic indications for all classes of antimicrobials were highly disparate between haemonc and other inpatients (table). Of note in the haemonc group, vancomycin use was high, and amphotericin B was used frequently for antifungal treatment. In multivariate analysis, haemonc patients were strongly associated with antibacterial appropriateness compared with other inpatients (adjusted OR 1.72, 95% CI 1.59–1.87, P < 0.001); factors associated with inappropriate prescription included antibiotic allergies and prophylactic indications.

Conclusion

Haemonc patients were more likely to receive appropriate antimicrobials compared with other inpatients. However, we have identified key areas for targeted interventions (prophylaxis use, antimicrobial allergy labels, vancomycin and amphotericin B treatment). Separate analysis of haemonc populations is necessary to identify key areas of concern specific to this patient group.

Disclosures

All authors: No reported disclosures.
1017. Scratching the Surface with NHSN Data: Defining High Impact Stewardship Targets in Critical Care
Authors: Cowman Kelsie , Chen Victor , Saraiya Nidhi , Guo Yi , Bartash Rachel , Nori Priya
Published: October 2019

Background

The National Healthcare Safety Network (NHSN) provides risk-adjusted Standardized Antimicrobial Administration Ratios (SAAR) as a benchmark for medical and surgical intensive care units (ICU). Antibiotic use (AU) data does not provide patient-level information (e.g., antibiotic appropriateness, indications, durations, etc.). However, we hypothesize that AU data can help define high impact stewardship targets, particularly in the context of critical care Clostridioides difficile rates.

Methods

Units with high rates of AU and hospital-onset (HO) C. difficile were selected for review. A monthly AU and C. difficile dashboard was created for ICU providers, inclusive of data from May 2018 onwards. We also performed chart audits for indication, duration, and location of initiation for all medical intensive care unit (MICU) patients receiving piperacillin/tazobactam (P/T) or vancomycin (Van) during February 2019 per request of ICU stakeholders. Data were used to obtain stewardship buy-in from local MICU champions.

Results

AU data indicated that (1) all 3 MICUs consistently had SAARs >1 for broad-spectrum categories and (2) Van and P/T were the highest volume agents on these units (Figure 1). Chart audit of 135 MICU patients showed that 17 patients received P/T, 34 Van, and 84 (62%) both agents; median duration was 2 days for Van and 3 days for P/T (Figure 2). Approximately half of initiations occurred in the emergency department (ED) (50% Van, 47% P/T); most common indications were “respiratory tract infection” and “severe sepsis/septic shock” for both P/T (77%) and Van (74%) (Figure 2). HO C. difficile in MICUs accounted for 6%, 13%, and 16% of total HO C. difficile cases in campuses A, B, and C, respectively during the time frame (Figure 1).

Conclusion

We feel that NHSN data scratches the surface of the deep-rooted challenges of ICU stewardship. However, it can identify AU trends and most frequently prescribed antibiotics in the context of unit-specific C. difficile rates. Intensive stewardship audit can further uncover areas for intervention, such as ED Van and P/T overprescribing. We suggest presenting clinical stakeholders with a quarterly “stewardship dashboard” combining AU rates, patient-level data, and C. difficile rates to maximize the impact of stewardship endeavors.

Disclosures

All authors: No reported disclosures.
1019. Defining electronic patient phenotypes to inform risk-adjustment strategies in hospital antimicrobial use comparisons
Authors: Moehring Rebekah W , Phelan Matthew , Lofgren Eric , Nelson Alicia , Neuhauser Melinda M , Hicks Lauri , Dodds Ashley Elizabeth , Anderson Deverick J , Goldstein Benjamin
Published: October 2019

Background

Comparison of antimicrobial use (AU) rates among hospitals can identify areas to intervene for antimicrobial stewardship. Hospital AU interpretation is difficult without risk-adjustment for patient mix. Identifying high- or low-risk patient characteristics, or “electronic phenotypes,” for receipt of antimicrobials using data from electronic health records (EHR) could help define risk-adjustment factors AU comparisons.

Methods

We performed a retrospective study of EHR-derived data from adult and pediatric inpatients within the Duke University Health System from October 2015 to September 2017. Encounters were included if the patient spent time in an inpatient location. The analysis aimed to identify subpopulations that were high- or low-risk for antimicrobial exposure based on EHR data summarized on the encounter level. Antimicrobial days of therapy (DOT) and days present, representing the length of stay (LOS), were defined as in the 2018 NHSN AU Option. Location exposures were defined in binary variables if patients were housed at least 1 day on a hospital unit type. We compared antimicrobial-exposed to unexposed patients as well as DOT among various factors including demographics, location, nonantimicrobial medications, labs, ICD-10 codes, and diagnosis-related groups (DRG).

Results

The EHR-derived dataset included 170,294 encounters and 204 variables in one academic and two community hospitals; 80,192 (47%) received at least one antimicrobial. Distributions of both LOS and DOT were zero-inflated and skewed by long outliers (figure). Encounters with >=7 DOT made up 63% of total DOT, but only 9% of inpatient encounters. Electronic phenotypes with highest DOT included those with long lengths of stay, older age, exposures to stem cell transplant, pulmonary, and critical care units, and DRG that included transplant, respiratory, or infectious diagnoses. Zero DOT phenotypes included those with short lengths of stay, exposure to labor and delivery wards, medical wards, and DRG that included birth and pregnancy.

Conclusion

Future work in defining risk-adjustment factors for hospital AU data comparisons should determine if factors associated with low- or high-risk electronic phenotypes assist in prediction of antibiotic use.

Disclosures

All authors: No reported disclosures.
1024. Evaluation of Atovaquone Prescribing for Pneumocystis jiroveci Pneumonia (PJP) Prophylaxis
Authors: Aleissa Muneerah , Kubiak David , Nauffal Mary , Sommer Jamie , Patterson Monica , Marty Francisco M , Pearson Jeffrey
Published: October 2019

Background

Trimethoprim-sulfamethoxazole (TMP-SMX) use for PJP prophylaxis has been associated with a variety of adverse reactions including myelosuppression, hypersensitivity reactions, acute kidney injury, and hyperkalemia. Atovaquone is used as an alternative drug, but it has several disadvantages, such as breakthrough PJP risk, dysgeusia, and higher cost compared with TMP-SMX. Indications for atovaquone prophylaxis at our institutions include severe cytopenias, hypersensitivity, renal impairment, or hyperkalemia. We evaluated atovaquone use and compliance with institutional PJP prophylaxis guidelines.

Methods

This was a retrospective study of inpatient atovaquone prescribing for PJP prophylaxis at Brigham and Women’s Hospital and Dana-Farber Cancer Institute from 7/1/18 to 9/30/18. We included adult patients who received ≥1 dose of atovaquone and ≥3 months of PJP prophylaxis with any agent. The primary endpoint of this study was the proportion of patients who could have been safely switched to TMP-SMX 3 months after atovaquone initiation. Other endpoints included the incidence of breakthrough PJP, reasons for TMP-SMX avoidance, and estimated cost savings.

Results

Two-hundred and eighteen patients were evaluated and 164 were included. Most common indications for atovaquone prophylaxis were bone marrow transplant (44.5%), solid-organ transplant (30.5%) and use of immunosuppressive agents (21.9%). Atovaquone was started in 145 patients (88.4%) according to institutional guidance. Three months after initiation, 89 patients (45.7%) could have been safely switched to TMP-SMX. Failure to timely change to TMP-SMX was associated with 1,615 additional patient-days of atovaquone therapy and $103,683 in excess costs within 3 months of initiation. Major reasons for TMP-SMX avoidance were thrombocytopenia (51.3%), neutropenia (35.4%), renal impairment (31.7%), allergy history (26.8%), and hyperkalemia (19.5%). No breakthrough PJP infections were observed while patients were on atovaquone.

Conclusion

Institutional-guideline compliance was high during atovaquone initiation. However, after 3 months, many patients who could have been safely transitioned to TMP-SMX continued to receive atovaquone. This resulted in excess costs and potentially sub-optimal therapy.

Disclosures

All authors: No reported disclosures.
1028. Dalbavancin Use in Complicated Infections and-associated Cost-Savings
Authors: Streifel Amber C , Sikka Monica , Sikka Monica , Lewis James
Published: October 2019

Background

Dalbavancin is a lipoglycopeptide antibiotic active against Gram-positive organisms with an extended half-life that allows for weekly dosing. Initially approved for treating skin and soft-tissue infections, use for more complicated infections provides several potential benefits, particularly in the outpatient setting when daily intravenous antibiotics are not practical due to social or financial issues.

Methods

We conducted a retrospective study to describe dalbavancin use at our institution and to estimate resulting cost avoidance. We identified all patients aged 18 years or older who received at least one dose of dalbavancin via medication records, regardless of setting.

Results

46 patients received dalbavancin between April of 2015 and March of 2019. The most commonly treated infections were bone and joint infections (41%), complicated bacteremias (24%), and skin and soft-tissue infections (20%). The most commonly treated organism was Staphylococcus aureus (55%). A variety of dosing regimens were used, 26 patients (57%) received a single dose to complete a treatment course. The majority of doses were administered in an outpatient infusion center (61%) although 28% of doses were administered in the inpatient setting prior to discharge. Reasons for dalbavancin selection included history of intravenous drug use (35%), contraindications to alternative antibiotics (30%), prior history of nonadherence or manipulation of PICC (18%), other social issues preventing PICC (11%), and limited outpatient daily infusion options due to lack of funding (9%). 4 patients (8.7%) were lost to follow-up. 11 (24%) patients were readmitted to the hospital within 30 days, 2 (4%) of these patients were readmitted with a concern related to their infection or an adverse effect of the dalbavancin infusion. Based on a calculation of equivalent dalbavancin therapy days for each patient, 774 hospital days were saved. In total, this is estimated to be $1,885,479 in overall cost avoidance and a mean cost avoidance of $40,988 per patient.

Conclusion

As data regarding the efficacy of dalbavancin for more complicated infections continue to emerge, it should be considered as a cost-effective alternative therapy when social and financial factors limit treatment options.

Disclosures

All authors: No reported disclosures.
1035. Implementation of an Antimicrobial Stewardship Program-Led, Multifactorial Pneumonia Diagnosis and Treatment Bundle
Authors: Cua Jefferson L , Crass Ryan L , Marshall Vince , Ateya Mohammad , Nagel Jerod , Eschenauer Gregory , Gandhi Tejal N , Kaye Keith S , Petty Lindsay A , Chenoweth Carol , Baang Ji , Lew Alison , Patel Twisha S
Published: October 2019

Background

Pneumonia remains a leading cause of hospitalization and accounts for significant antibiotic use. This study aims to evaluate the impact of bundled antimicrobial stewardship program (ASP) interventions, including procalcitonin and surveillance cultures, on broad-spectrum antimicrobial use in patients with suspected pneumonia.

Methods

This is a pre-post, quasi-experimental study conducted at Michigan Medicine. During the intervention period, an ASP member reviewed adult patients admitted to 3-floor medical services with antibiotics initiated for suspected pneumonia. The ASP member (1) recommended the use of procalcitonin when clinically appropriate, (2) used institutional guidelines to guide empiric antibiotic selection based on risk for drug-resistant pathogens, and (3) ordered a methicillin-resistant Staphylococcus aureus (MRSA) surveillance culture in patients receiving empiric anti-MRSA therapy. The primary endpoint was anti-MRSA and anti-pseudomonal (PSA) antibiotic use measured as days of therapy (DOT) per 1000 days-present on the services of interest. Antibiotic use and clinical data were extracted from an electronic database. Pneumonia diagnosis codes were used to identify the study population.

Results

A total of 549 patients were included: 310 in the pre-intervention (December 1/2017 - 3/31/2018) and 239 in the intervention (December 1/2018 - 3/31/2019) periods. Baseline demographics were similar between groups (Table 1). Less than 15% of patients had a microbiological diagnosis via respiratory culture in both study periods (Table 2). Respiratory cultures were ordered less commonly in the intervention period; however, the rate of culture positivity was higher (28% vs. 48%, P < 0.01). Process measures improved in the intervention period with an increase in the proportion of patients with MRSA surveillance cultures (13% vs. 39%, P < 0.01) and procalcitonin monitoring (77% vs. 83%, P = 0.07). Compared with the pre-intervention period, anti-MRSA antibiotic use decreased from 172 to 158 DOT per 1000 days-present (Δ -8%) and the use of anti-PSA antibiotics decreased from 348 to 316 DOT per 1000 days present (Δ -9%).

Conclusion

The implementation of an ASP-led pneumonia bundle led to reductions in anti-MRSA and anti-PSA antibiotic use.

Disclosures

All authors: No reported disclosures.
1039. Forty-eight-hour Antibiotic Time-out: Impact on Antibiotic Duration and Clinical Outcomes
Authors: Pettit Natasha N , Bhagat Palak , Nguyen Cynthia T , Konold Victoria J L , Kumar Madan , Choksi Anish , Pisano Jennifer
Published: October 2019

Background

A core element of the Centers for Disease Control and Prevention Antimicrobial Stewardship standard for the inpatient setting includes a 48-hour antibiotic time-out (ATO) process to reassess antibiotic indication. We implemented an automated alert in the electronic health record (EHR) that identifies patients that have received >=48hours of antibiotic therapy. The alert requires the clinician (physician or pharmacist) to note an indication for continuation or plan for discontinuation. Within the alert, a dashboard was developed to include relevant patient information (e.g., temperature, white blood cell count, microbiology, etc). We sought to evaluate the impact of the ATO alert on the duration of therapy (DOT) of cefepime (CFP), ceftazidime (CTZ) and vancomycin (VAN), for the treatment of pneumonia (PNA) and urinary tract infections (UTI) for adult and pediatric patients.

Methods

This quasi-experimental, retrospective analysis included adult and pediatric patients that received ≥48 hours of CFP, CTZ, or VAN for UTI or PNA between April 1, 2017 and July 31, 2017 (pre-48H ATO) and October 1, 2018–December 31, 2018 (post-48H ATO). Fields at order-entry to specify an antibiotic indication were not available prior to our EHR interventions. A randomized subset from the Pre-48Hr ATO group was selected for detailed analysis. The primary endpoint was to evaluate the average DOT of CFP/CTZ combined, VAN alone, and the combination of CFP/CTZ/VAN. We also evaluated length of stay (LOS), all-cause inpatient mortality, and 30-day readmissions.

Results

A total of 157 antibiotic orders (n = 94 patients) were evaluated in the pre-48h ATO group, and 2093 antibiotic orders (n = 521 patients) post-48H ATO group. Pre-48H ATO, 85 patients received CFP/CTZ and 72 VAN. Post-48H ATO, 322 patients received CFP/CTZ and 198 VAN. PNA was the most common indication pre- and post-48H ATO. DOT significantly decreased pre- vs. post-48H ATO (Figure 1). LOS was 2 days shorter (P = 0.01) in the post-48H ATO group, mortality and 30-day readmissions was similar between groups (Table 1).

Conclusion

Average antibiotic DOT for CFP/CTZ, and VAN significantly decreased following the implementation of the 48H ATO at our medical center. LOS was reduced by 2 days, while mortality and 30-day readmissions were similar before and after.

Disclosures

All authors: No reported disclosures.
1041. Staphylococcus aureus Bacteremia Bundle Adherence Pre- and Post-Implementation of Mandatory Infectious Diseases Consultation and Antimicrobial Stewardship Pharmacist Intervention
Authors: Arensman Kellie , Dela-Pena Jennifer , Miller Jessica , LaChance Erik , Beganovic Maya , Anderson Morgan , Wieczorkiewicz Sarah
Published: October 2019

Background

Infectious diseases consult (IDC) and antimicrobial stewardship (AMS) intervention independently demonstrate improved management of Staphylococcus aureus bacteremia (SAB). However, data supporting utilizing both strategies is limited. The objective of the current study is to assess evidence-based bundle adherence for SAB in the presence and absence of mandatory IDC and AMS pharmacist review in a multi-site health system.

Methods

This retrospective study included adult inpatients with SAB from January 2016 to December 2018 at seven hospitals. Outcomes were compared between three groups: pre-mandatory IDC and AMS review (group 1), post-mandatory IDC and pre-AMS review (group 2), and post-mandatory IDC and AMS review (group 3). The primary outcome was bundle adherence defined as: appropriate intravenous antimicrobial therapy, appropriate duration of therapy, 24–48-hour surveillance cultures until documented clearance, echocardiography, and removal of indwelling intravenous catheters, if applicable. Secondary endpoints included individual bundle components, source control, length of stay (LOS), 30-day bacteremia-related readmission, and in-hospital all-cause mortality.

Results

A total of 579 patients met the final inclusion criteria for analysis. Complete bundle adherence was achieved in 65% of patients for group 1 (n = 371), 54% for group 2 (n = 87), and 76% for group 3 (n = 121). Adherence to bundle elements was significantly higher in group 3 when compared with group 1 (odds ratio [OR] 0.58, 95% confidence interval [CI] 0.37–0.93), and group 2 (OR 0.37, 95% CI 0.20 – 0.67). No difference in bundle adherence was noted between groups 1 and 2. When comparing groups 1, 2 and 3, significant differences were seen in obtaining echocardiography (91% vs. 83% vs. 100%; P = 0.0378), and hospital LOS (10.5 vs. 8.85 vs. 12.0 days; P = 0.0149), respectively. Increased hospital LOS in group 3 may be due to nonsignificant higher rates of complicated bacteremia compared with groups 2 and 1 (32% vs. 44% vs. 43%, P = 0.09), respectively. No differences were noted for readmission or mortality.

Conclusion

The addition of AMS pharmacist review to mandatory IDC significantly improved quality care bundle adherence.

Disclosures

All authors: No reported disclosures.
1047. Impact of Indication for Antibiotic Orders on Pharmacist Interventions
Authors: Scardina Tonya , Sun Shan , Kotsonis-Chiampas Lori , Patel Avani , Patel Sameer
Published: October 2019

Background

Joint Commission mandates that prescribers document indication for antibiotics at the time of prescribing. Antibiotic indications may offer opportunities for pharmacists to optimize dosing and frequency or provide alternative therapeutic options. We examined the impact of antibiotic indications during order entry on frequency and type of pharmacist interventions, time to order verification, and time to administration of antibiotics.

Methods

Number of pharmacist interventions documented in EPIC from 4/28/17 through 4/28/18 (pre-intervention) were compared with interventions from 4/29/18 through 2/28/19 (post-intervention). All pharmacist interventions involving antibiotic orders were included. For antibiotic orders involving a pharmacist intervention, data collected included antibiotic prescribed, indication for antibiotic (post-intervention only) and reason for intervention. For administered antibiotics, data collected included order time, time of arrival of order in pharmacist queue, pharmacist verification time, patient administration time. Statistical analysis involved chi-squared test (compare the reason for intervention) and t-test (compare difference in time).

Results

There were 790 orders and 638 orders that involved a pharmacist’s interventions, pre-intervention and post-intervention, respectively (Tables 1 and 2). Pre-intervention, there were 200 antibiotic orders that had a documented pharmacist intervention and were administered. Post-intervention, there were 184 orders that had a documented pharmacist intervention and were administered. Abdominal/pelvic (29 orders, 16%), sepsis (19 orders, 10%), and surgical prophylaxis (18 orders, 9.7%) were the most frequent indications selected during order entry. Average time to order verification was 119 minutes pre-intervention and 123 minutes post-intervention (P =0.97). Average time to administration of antibiotics was 313 minutes and 360 minutes pre-intervention and post-intervention, respectively (P =0.45).

Conclusion

Inclusion of the selection of antibiotic indications during order entry did not significantly impact the number of pharmacist interventions, time to order verification nor time to administration.

Disclosures

All authors: No reported disclosures.
1052. Antimicrobial Stewardship: On Board with Lean Daily Management System
Authors: Monsees Elizabeth , Monsees Elizabeth , Wirtz Ann , Myers Angela , Myers Angela , Burns Alaina , Day Chris , El Feghaly Rana E , Lee Brian R , Purandare Amol , Weddle Gina , Goldman Jennifer
Published: October 2019

Background

Limited guidance exists on how to design and measure the efficiency and effectiveness of an antimicrobial stewardship program (ASP). Our established ASP sought to broaden interprofessional accountability and enhance our programmatic efficiency by employing Lean Daily Management System (DMS) procedures.

Methods

To improve ASP communication, a visual and systematic approach to identify, address, and resolve ASP projects while quantifying nontraditional metrics measuring the efficiency and effectiveness was developed. Through shared discussions, an interdisciplinary group of stakeholders produced the following deliverables: (a) established shared programming goals/metrics; (b) improved prioritization methods and project tracking through completion; (c) developed readiness and metric boards to display achievements, current activity, and metrics; (d) identified programming threats and strategies to strengthen our provided services.

Results

At 6 months following DMS adoption, our ASP has disbanded monthly meetings in lieu of weekly, 15 minute huddles utilizing the readiness and metric boards. We achieved consistent and interprofessional representation where each member is accountable for leading huddles, providing reports, and owning projects. Using a stoplight color system to indicate status, potential ASP influencers are tracked and reported: clinical workload/demands, organizational awareness, equipment/supplies, staffing, project updates, and announcements. The visual identification allows the team to address “quick hits” or escalate resource allocation to solve “big issues” (figure). Program metrics are codified under the domains of delivery, people, quality, safety, and financial stewardship. Administrative leadership has attended huddles and provided positive and constructive feedback to foster a process of continuous improvement.

Conclusion

Integration of Lean DMS huddles provides a collaborative, interactive and interdisciplinary approach to enhance shared awareness and to broaden the reach and efficiency of our ASP. With project tracking mechanisms in place, our team is refining our problem-solving abilities to ensure a congruent plan between issues raised and established program metrics.

Disclosures

All authors: No reported disclosures.
1053. De-Implementing Low-Value Antibiotic Prescribing Across Levels of Care
Authors: Gupta Kalpana , Hartmann Christine , Schweizer Marin L
Published: October 2019

Background

Performing urinalyses and urine cultures in asymptomatic patients is one of the most common reasons for inappropriate antibiotic use. However, de-implementing this practice has been difficult, especially for clinical scenarios deemed to be high risk for infectious complications, such as among patients with delirium or those undergoing orthopedic implant surgery.

Methods

Using the dual-process theory framework “Developing De-Implementation Strategies Based on Un-Learning and Substitution,” an educational intervention citing new IDSA guidelines and providing a pneumonic “ABCs of ASB” was created and delivered didactically to providers. The goal was to increase performance of evidence-based prevention actions in place of low-value urine screening and treating of asymptomatic patients. Clinical providers and staff (MD, RN, APRN, trainees) in 3 different levels of care (acute inpatient, long-term, and outpatient) were included. A web-based anonymous and confidential pre- and post-question format was delivered to assess influence on provider behavior.

Results

Responses from a range of 250–279 unique providers were collected. For scenario #1 (patient with delirium and a positive urine culture and no other infectious symptoms), the option to give antibiotics was reduced by 45% pre to 4% post, Chi-square P < 0.01). For scenario #2 (patient having a knee replacement and positive preoperative urine culture, no other symptoms) the option to give antibiotics was reduced by the same magnitude (~50%) but a lower absolute number (67% pre and 33% post, chi-square P < 0.01). Changes in predicted behavior were similar across levels of care.

Conclusion

Substituting evidence-based practices in place of low-value practices is an appealing framework for influencing provider behavior. Our work demonstrates that education can successfully reduce the intention to use antibiotics for asymptomatic patients with positive urine cultures.

Disclosures

All authors: No reported disclosures.
1055. Addition of Antimicrobial Stewardship Program Weekend Coverage Increases Interventions while Reducing Antimicrobial Duration and Cost
Authors: Pettit Natasha N , Pisano Jennifer , Nguyen Cynthia T
Published: October 2019

Background

Expansion of Antimicrobial Stewardship Program (ASP) activities to include coverage of weekends has been shown to facilitate further optimization of antimicrobial usage. Beginning July 2018, we implemented full ASP coverage on weekends from 0700–1530 by infectious diseases (ID) clinical pharmacists and pharmacy residents. We sought to evaluate the impact of the addition of weekend ASP coverage on the number of interventions, antimicrobial duration and cost of target broad-spectrum antimicrobials.

Methods

Antimicrobials reviewed by ASP on a weekend day between July 14, 2018 and December 16, 2018 were included in the analysis. The primary outcome was the number and type of documented interventions associated with the antimicrobials reviewed. Secondary outcomes included the total duration of meropenem, daptomycin, and micafungin initiated on a weekend, estimated expenditures on these target broad-spectrum antimicrobials, and comparison of the average number of interventions performed per day by ID clinical pharmacists vs. pharmacy residents. For comparison, we also evaluated these secondary outcomes prior to ASP weekend coverage, between July 16, 2017 and December 9, 2017.

Results

A total of 688 antimicrobials were reviewed on weekend days during the included time-frame with 753 interventions (average number of interventions/day: 37). Table 1 summarizes the type of interventions. The acceptance rate for interventions was 99%. The average number of interventions per day for ID clinical pharmacists vs. pharmacy residents was 57.9 and 26.2, respectively. Table 2 shows the total duration of therapy (DOT) and total expenditures on target antimicrobials before and after ASP weekend coverage. The total DOT of target antimicrobials agents decreased from 21 days to 7 days, with an estimated 3,165 dollar decrease in expenditures during the included time-frame.

Conclusion

Expansion of ASP coverage to include weekends allowed us to provide 753 interventions over 4 months that would not otherwise have been made when no ASP coverage was available. This was associated with a reduction in broad-spectrum antimicrobial duration of therapy and expenditures when compared with weekends where ASP weekend coverage was not available.

Disclosures

All authors: No reported disclosures.
1075. The Impact of Physician Peer Comparison of a Novel Inpatient Antimicrobial Stewardship Metric: the Start-Stop Ratio (SSR)
Authors: Volk Stacy , Fagenstrom Michelle
Published: October 2019

Background

The 48-hour “Antibiotic Timeout” (ATO), one of the CDC’s interventions defined in the Core Elements of Antimicrobial Stewardship Programs (ASP), has not reliably proven to impact inpatient antibiotic use. Given the reported history of utilizing peer-comparison data to change prescribing behavior, it was hypothesized that open disclosure of individual inpatient antibiotic start-stop ratios (SSR) would be an effective tool to increase prescribers’ tendency to (1) observe patients off antibiotics upon admission while pursuing treatments perceived more likely to provide syndromic resolution and (2) discontinue antibiotics in the setting of diagnostic uncertainty at 48 hours, or possibly even earlier, without introducing harm.

Methods

In a community, nonteaching hospital, all adult systemic antibiotic orders initiated by an inpatient hospitalist with at least one administration during the baseline period of January - March of 2018 were retrieved. A prescriber-specific count of all antibiotic orders (“starts”) and discontinuations (“stops”) was collected. Each provider received a document with their baseline SSR compared with the group SSR and was assigned a visual cue that corresponded to the quartile in which they performed at baseline. The same antibiotic data were then collected and evaluated for the post-intervention period of February–April 2019 to determine whether open disclosure of inpatient SSRs impacted antibiotic prescribing.

Results

Of 19 providers that were included in both study periods, there was no significant difference in the pre- and post-intervention SSR (1.93 to 2.09, P = 0.19). However, in the pre-intervention high-ratio target group (n = 10) for whom we felt open SSR reporting would impact the most, the SSR decreased from 2.41 to 2.26 (P = 0.24). In the entire study population, 68% of providers had a reduction or no change in their SSR. Overall facility-wide antibiotic utilization decreased from 561 to 478 days of therapy per 1,000 days present (P < 0.05).

Conclusion

Open reporting of antibiotic SSRs to an inpatient provider group may be utilized as an ASP tool to reduce overall inpatient antibiotic consumption, especially by providers that are found to be high-ratio prescribers at baseline.

Disclosures

All authors: No reported disclosures.
1078. Expectations and Attitudes Toward Antimicrobial Stewardship Among Cystic Fibrosis Care Providers
Authors: Bullington Wendy , Smyth Alan , Elborn Stuart , Drevinek Pavel , Hempstead Sarah , Muhlebach Marianne
Published: October 2019

Background

Treatment of cystic fibrosis (CF) exacerbations can be challenging secondary to antimicrobial resistance due to chronic airway infection, multiple treatment courses, and frequent use of suppressive antibiotics. For these reasons, many antimicrobial stewardship (AMS) principles may not be practical for the CF population. The objective of this study was to determine perceptions of AMS among CF healthcare providers internationally.

Methods

Six questions regarding AMS were incorporated into an email survey focusing on antimicrobial resistance in CF. Healthcare providers (HCP) were identified through list-servs and CF-related organizations internationally.

Results

Three-hundred and seventy-eight HCP from 30 countries responded to the survey (see Figure 1). Within their institutions, more than half had access to a CF-specific pharmacist, infectious disease consultation, and/or written CF exacerbation guidelines. An AMS program was only available for 39% of respondents. Most HCP stated that choosing and dosing antibiotics correctly and minimizing resistance were the main goals of AMS. Stewardship activities they felt would be helpful during CF exacerbations included the following: choice of antibiotics (83%), duration of antibiotics (78%), antibiotic dosing (68%), therapeutic drug monitoring (63%), reducing drug interactions (53%), and avoiding toxicity (50%). Nine percent of HCP stated that they did not think AMS was advantageous during exacerbations.

Conclusion

Although most CF HCP have access to individual aspects of AMS, fewer had access to a formal AMS program. Help with antibiotics during exacerbations was identified as an important aspect for input from AMS programs.

Disclosures

All authors: No reported disclosures.
1080. OPAT at the End of Life?: Short- and Long-Term Mortality Following Outpatient Parenteral Antibiotic Therapy
Authors: Schranz Asher J , Kinlaw Alan C , Swartwood Michael J , Boerneke Renae A , Medlin Tenesha , Farel Claire E
Published: October 2019

Background

Outpatient parenteral antimicrobial therapy (OPAT) patients have high rates of adverse drug events, emergency visits, and readmissions. Understanding correlates of mortality during and after OPAT may clarify opportunities to enhance care and meaningfully interpret the clinical profile of patients receiving OPAT.

Methods

We analyzed a cohort of patients enrolled in our OPAT program from 2015 to 2018. Patients were followed to death or December 31, 2018, whichever came first. Using Linkplus, we linked patients to North Carolina death records by name, birth date, and sex. We performed a probabilistic linkage and reviewed any nondeterministic matches. Clinical and demographic data were extracted by chart review. Cause of death was determined by first cause in the state death data, as indexed by ICD-10 code. Mortality rates were tabulated at 90 days and 1 year after treatment start. Predictors of 1-year mortality were assessed by multivariable logistic regression and adjusted for age, sex, Staphylococcus aureus infection, early antibiotic stop, and readmission.

Results

Among 729 OPAT courses in the study, the median age was 54 (interquartile range, IQR 44–65) and 60% were male. Seventy-seven deaths occurred during the period at a median 272 days (IQR 89–462), including 7 during OPAT (figure). Mortality at 90 days and 1 year was 3.1% (19 of 617 eligible OPAT courses) and 7.1% (31 of 408), respectively. 90-day mortality was equally due to infection (37%) and cancer (37%), whereas 1-year death was most commonly due to infection (32%). The most commonly reported causes of death at any time during the period were cancer (25%), infection (19%) and cardiovascular disease (17%). Each year increase in age was associated with a 5% relative increase in odds of 1-year death (odds ratio, OR, 1.05, 95% CI 1.02–1.08), and readmission was associated with risk of 1-year death (adjusted OR 7.78, CI 3.46–17.50).

Conclusion

In this large OPAT cohort, 90-day mortality was 3% and 1-year mortality was 7%. Readmission during OPAT was a strong predictor of 1-year death. Strategies to decrease 1-year mortality may include mitigating readmissions or allocating resources after readmission. The prevalence of cancer-related death suggests an opportunity for OPAT providers and oncologists to collaborate in care of high-risk patients.

Disclosures

All authors: No reported disclosures.
1085. Impact of a Novel Infectious Diseases Pharmacy Service on Medication-Related Errors and Linkage to Care in Inpatients Living with Human Immunodeficiency Virus
Authors: Santevecchi Barbara A , Roshdy Danya , Isip Jacqueline , Hammer Katie , Jaffa Rupal K , Leonard Michael , Polk Christopher
Published: October 2019

Background

Complexity of antiretroviral therapy (ART) for human immunodeficiency virus (HIV) and lack of experience with treatment regimens by providers may lead to medication-related errors (MRE). Consequences of MRE may include loss of virologic suppression, development of ART resistance, HIV transmission, and increased morbidity and mortality. The purpose of this study was to compare ART-related MRE and linkage to care through consultation with Infectious Diseases (ID) providers as a result of ID-pharmacist review.

Methods

An ID pharmacist-led intervention incorporating prospective review of electronic medical records of adult patients admitted with an ICD-10 code for HIV was implemented. Patients not on ART were triaged for linkage to care with ID consultation, and those on ART received profile review to assess for and correct MRE. We then conducted an IRB-approved, quasi-experimental cohort study comparing adult patients living with HIV who were admitted between February 2017 to June 2017 (pre-intervention) and October 2018 to March 2019 (post-intervention). Patients on ART for indications other than the treatment of HIV were excluded. Rates of ART-related MRE and frequency of ID consultation with linkage to care were compared before and after our intervention.

Results

A total of 200 patients were included, with 100 patients in each of the intervention periods. The institutional stewardship program intervened to correct one error in the pre-intervention period, whereas 119 interventions were made in the post-intervention period with an acceptance rate of 97%. The proportion of patients who experienced an MRE decreased from 70% to 25% (absolute risk reduction 45%, P < 0.01). The total number of errors also decreased between intervention periods (102 vs. 36, P < 0.01). A description of ID pharmacist intervention type is provided in Figure 1. To link patients into care or clarify an ART regimen, the number of ID consults significantly increased from 19% to 39% (P < 0.01) as a result of the ID pharmacist-led initiative.

Conclusion

Focused ID pharmacy review of patients admitted with HIV and inpatient ART prescription as part of an antimicrobial stewardship program was successful in reducing ART-related MRE and increasing ID consultation to promote linkage to care.

Disclosures

All authors: No reported disclosures.
1086. Antimicrobial Stewardship: From Bedside to Man’s Best Friend
Authors: Reed Erica E , Feyes Emily , Diaz-Campos Dubraska , Wittum Thomas , Horne Rikki , Stevenson Kurt
Published: October 2019

Background

Antimicrobial stewardship plays an integral role in ensuring appropriate antimicrobial use in the inpatient hospital setting and is now required by The Joint Commission. Although it is well established that antimicrobial misuse and overuse has societal and ecological implications, the same regulations do not yet apply to our veterinary and agricultural counterparts.

Methods

At The Ohio State University Wexner Medical Center (OSUWMC), the Antimicrobial Stewardship Program (ASP) was created in 2007. A partnership was formed with The Ohio State University Veterinary Medical Center (OSUVMC) in 2017 and was leveraged through a pre-existing campus-wide One Health initiative. The goal was to develop a comprehensive Veterinary Hospital ASP. “The Core Elements of Hospital Antibiotic Stewardship Programs” (Centers for Disease Control and Prevention) and “The Core Principles of Antibiotic Stewardship in Veterinary Medicine” (American Veterinary Medical Association) were also referenced for guidance.

Results

Specific initiatives within the OSUVMC ASP were modeled after similar interventions in the OSUWMC including development of antibiotic use guidelines by animal type for commonly encountered infections, antimicrobial utilization tracking, antibiogram creation, and both active and passive surveillance of targeted resistant pathogens. A mobile-friendly website was created to allow providers easy access to these ASP tools. Overall antimicrobial prescriptions decreased 22.4% following the first year of program implementation. Planning is currently underway for an ASP outreach program to local veterinary practices to increase awareness of ASP and improve antimicrobial prescribing. A parallel outreach program with rural Ohio hospitals is underway at OSUWMC.

Conclusion

A comprehensive veterinary hospital ASP was successfully implemented in collaboration with OSUWMC counterparts using successful human interventions applied in the animal setting. Optimizing antimicrobial use and resistance at both sites will likely prevent resistance transmission between these geographically proximate hospitals. Sharing the details of our approach may benefit other institutions looking to expand their stewardship reach.

Disclosures

All authors: No reported disclosures.
1096. Reducing Unnecessary Postoperative Antibiotic Prophylaxis
Authors: Metjian Talene A , Gerber Jeffrey , Watson Adam , Burlingame Caroline , Gregory Heuer , Rizzi Mark , Rodman Allison , Stow Joanne N , Wertz Aileen , Mattei Peter
Published: October 2019

Background

National guidelines for the prevention of surgical site infections (SSI) recommend against antibiotic prophylaxis following wound closure for clean and clean-contaminated surgical procedures. Prolonged antibiotic prophylaxis can lead to antibiotic resistance and adverse drug events without reducing SSI rates. The objective was to reduce the rate of antibiotic prophylaxis following surgical incision closure for specified procedures in the Divisions of Neurosurgery (NRS), Otolaryngology (OTO), and General Surgery (GS) at Children’s Hospital of Philadelphia (CHOP).

Methods

We identified all NRS, OTO, and GS procedures conducted at CHOP from July 1, 2016 to June 20, 2017. Collaborative meetings between surgical quality improvement team leads and the antimicrobial stewardship program (ASP) were convened to identify procedures most suitable for the intervention, including Chiari decompressions and tethered cord repair (NRS); tympanoplasty and tracheostomy (OTO); and laparoscopic and thoracoscopic procedures (GS). The intervention, started in March 2018, included (1) education of surgeons on perioperative prescribing guidelines, (2) order set modification, and (3) individualized monthly audit with feedback reports of inappropriate postoperative prescribing (via email copying all surgeons within the division). We monitored rates utilizing SPC charts of postoperative antibiotic use (defined as administration within 24 hours of procedure end) and evaluated SSI rates pre and post-intervention with a Poisson regression.

Results

Following the intervention, postoperative antibiotic use reached special cause resulting in a mean decline for laparoscopy (19.6% to 11.7%), thoracoscopy (35.6% to 17.9%), tympanoplasty (90.5% to 11.4%), tethered cord repair (95% to 25.5%), and Chiari decompression (97% to 45.9%). There was no mean shift in postoperative antibiotic use for tracheostomy (25.5%). 30-day SSI rates did not change pre- and post-intervention (P = 0.36).

Conclusion

A quality improvement initiative conducted to implement national guidelines recommending against postoperative antibiotic prophylaxis showed a significant reduction in postoperative antibiotic prophylaxis without a concomitant rise in SSI rates.

Disclosures

All authors: No reported disclosures.