bluuebunny/crossref_metadata_2025_split huggingface dataset:
170. Development of Key Indicators for Appropriate Antibiotic Use in Republic of Korea: a Systematic Review followed by Delphi Procedure
Authors: Kim Bongyoung , Lee Myung Jin , Park Se Yoon , Moon Song Mi , Song Kyung Ho , Kim Tae Hyong , Kim Eu Suk , Kim Hong Bim 
Published: January 2021

Abstract

Background
The aim of this study was to develop a set of key quality indicators (QIs) for application to nationwide point surveillance of appropriateness of antibiotic usage in Republic of Korea.

Methods
A systematic literature review was performed in order to retrieve a list of potential key QIs. These candidates were evaluated by multidisciplinary expert panel using a RAND-modified Delphi procedure, using two online questionnaires and a face-to-face meeting between them. Twenty-five expert panels with diverse backgrounds (infectious diseases specialist, urologist, laboratory medicine doctors, pediatric infectious disease specialists, otorhinolaryngology doctors, gastrointestinal doctors, pulmonologist, general surgeon, and researcher in National Evidence-Based Healthcare Collaborating Agency) participated in the consensus procedure. A Likert scale (ranging 1–7) was used for the evaluation of appropriateness of the potential key QIs and items with median score 6 or 7 were accepted if there was no disagreement. In addition, we grade each QI into admission, outward, or surgical prophylaxis using the Likert scale. If the score was 6 or 7, we considered it as appropriate application.

Results
The systematic literature review identified 23 potential QIs, from 21 studies. Ultimately, 17 key indicators were retained, with a high level of agreement (13 QIs for admitted patients, 7 for outward patients and 3 for surgical prophylaxis) (Figue 1). After sum of importance score and applicability, 6 key QIs [6 QIs (1–6) for admitted patients and 3 (1, 2 and 5) for outward patients] were finally selected: (1) prescribe empirical antibiotic therapy according to guideline, (2) change empirical to pathogen-directed therapy, (3) take cultures from suspected sites of infection, (4) take 2 blood cultures, (5) adapt antibiotic dosage to renal function, and (6) document antibiotic plan (Table 1). In surgical prophylaxis, prescribe according to guideline and initiate antibiotics one hour before incision was finally selected (Table 2).
Figure 1. Flowchart of the study

Table 1. Ranking in key indicators for admitted and out patients and applicability in point surveillance study.

Table 2. Ranking in key indicators for surgical prophylaxis and applicability in point surveillance study.

Conclusion
We identified key QIs to measure the appropriateness of antibiotics. These QIs can be used to identify targets for improvement and to evaluate the effects of antibiotic stewardship intervention.

Disclosures
All Authors: No reported disclosures
173. Identification of Inappropriate Antibiotic Orders During a Pharmacy-Supported Antimicrobial Stewardship Program in the Primary Care Setting: A Retrospective Analysis
Authors: Eckardt Paula , Mohammed Sheerida Hosein , Singh-Franco Devada , Wolowich William R 
Published: January 2021

Abstract

Background
In Florida, the number of antibiotic prescriptions has increased from 710–779 prescription/1000 population in 2012 to 748–839 prescription/1000 population in 2017. Antimicrobial stewardship in the outpatient setting is a suggested solution to combat antibiotics misuse in ambulatory practices.

Methods
This was a retrospective review of oral antimicrobial orders generated by primary care providers. The research protocol received approval from Memorial Healthcare System’s Institutional Review Board prior to any research related analysis being conducted. Orders from January 1-December 31, 2018 were reviewed for appropriateness by pharmacy based on IDSA guidelines. Appropriateness was assessed based on the need to prescribe the antibiotic for indication, selection, dose and duration of therapy. Descriptive statistics were used to analyze data.

Results
Of 2995 orders, 50.2% were inappropriate. The most common infections associated with inappropriate antibiotic use were upper/lower respiratory tract infections (URTIs (65%) and LRTIs (61%)), oral cavity infections (61%), and skin/soft tissue infections (SSTI (54%)). Inappropriately-prescribed antibiotics were penicillin (62%), cephalosporins (56%), quinolones (50%), macrolides (49%), and sulfamethoxazole/trimethoprim (46%). Penicillin use for URTIs were inappropriate (406 orders) for the following reasons: duration of therapy only 116/137 (85%); dose and duration 36/58 (62%), drug and dose 12/58 (21%) and all three (drug, dose, duration 85/93 (91%)).

Conclusion
Implementation of a pharmacist-driven antibiotic stewardship program in the primary care setting identified a significant proportion of orders that were inappropriate for type of antibiotic, dose, and duration of therapy in the management of patients with URTIs. These results serve as an avenue to implement the audit feedback process to promote appropriate use of antibiotics. A process improvement plan will include sharing of the findings, educating primary care physicians per IDSA guidelines and continuous review of prescribing trends. A programmatic evaluation will continue on an on-going basis to decrease the number of inappropriately prescribed antibiotics.

Disclosures
All Authors: No reported disclosures
174. Impact of Cascade Reporting of Antimicrobial Susceptibility on Antimicrobial Consumption at a Veterans Affairs Medical Center
Authors: Vissichelli Nicole C , Orndahl Christine M , Cecil Jane A , Hill Emily , Sabo Roy T , Stevens Michael , Tassone Daniel , Vaughan Leroy , Markley John D , Hitchcock Matthew M 
Published: January 2021

Abstract

Background
Cascade reporting (CR) is a strategy of reporting antimicrobial susceptibility test results in which secondary agents are only reported if an organism is resistant to primary, narrow spectrum agents within a drug class. A multidisciplinary team developed CR algorithms for Gram-negative bacteria based on the local antibiogram and infectious diseases practice guidelines.

Methods
CR was implemented at a 399-bed tertiary care VAMC in March 2018. In a quasi-experimental study, antimicrobial use data across 8 inpatient units were extracted from the CDC’s NHSN AU module from April 2017 – March 2019 (12 months pre- and post-implementation of CR), reported as antimicrobial days of therapy (DOT) per 1000 days present (DP). T-tests and linear mixed models accounting for seasonal and random unit effects were used to compare antimicrobial use pre- and post-CR implementation.
Figure 1A. Cascade reporting algorithm for antimicrobial susceptibility reporting for Enterobacteriaceae

Figure 1B. Cascade reporting algorithm for antimicrobial susceptibility reporting for Pseudomonas aeruginosa

Results
Following CR implementation, mean monthly meropenem (p=0.005) and piperacillin/tazobactam (p=0.002) use decreased, while cefepime use increased (p&lt; 0.001). The slope of ciprofloxacin use decreased by 2.16 DOTs/1,000 DP per month (SE=0.25, p&lt; 0.001). The slope of cefpodoxime and moxifloxacin use decreased by 18% (p&lt; 0.001), and 7% (p&lt; 0.001), respectively. The slope of cephalexin use decreased by 0.55 DOTs/1,000 DP (SE=0.26, p&lt; 0.001). The slope of ceftriaxone and cefepime use increased by 1.51 (SE=0.59, p=0.011) and 1.06 (SE=.32, p=0.002) DOTs/1000 DP per month, respectively. There were no significant changes in the slope of amoxicillin/clavulanate, levofloxacin, or meropenem consumption. Rates of Clostridioides difficile infection did not significantly change.
Figure 2A. Average monthly use of oral antibiotics across all units in average days of therapy (DOTs) per 1000 days present. CR = Cascade reporting. *For Cefpodoxime and moxifloxacin medians were reported as data was not normally distributed.

Figure 2B. Average monthly use of intravenous antibiotics across all units in average days of therapy (DOTs) per 1000 days present. CR = Cascade reporting.

Table 1. Slope of Antimicrobial Utilization Pre and Post-Cascade Reporting Implementation.

Conclusion
After implementation of CR, the slope of ciprofloxacin use decreased and mean monthly meropenem use decreased. CR is a valuable tool that can be employed by ASPs to encourage optimal use of antibiotics.

Disclosures
All Authors: No reported disclosures
176. Impact of pharmacist electronic communication on the appropriateness of antimicrobial therapy at renewal time
Authors: Taqi Ahmad , Elarabi Salwa , Fleisher Jorge 
Published: January 2021

Abstract

Background
Inappropriate antibiotic use increases the risk of antimicrobial resistance and adverse events. Our institution adopts all elements recommended by the CDC to improve antimicrobial stewardship (AMS). Compliance with such elements requires education, coaching and decision support tools. The objective of the study intervention is to engage prescribers to critically evaluate and improve antibiotic utilization through renewal communication in the electronic medical record (EMR).

Methods
This is a single center study with a retrospective phase and prospective phase. During the intervention period from October 1st, 2019 to January 1st, 2020 the pharmacist monitored targeted antibiotics and initiated an AMS EMR note. Prescribers were then requested to evaluate the appropriateness of therapy utilizing pre-defined criteria developed in agreement with the infectious disease (ID) service at 48 hours, in-line with the EMR time-out alert. Adults receiving vancomycin (VAN), piperacillin/tazobactam (TAZ), cefepime (CEF) or meropenem (MPN) for at least 48 hours were included. The historical group included patients on the targeted antibiotics between July 1st, 2019 and September 30th, 2019. The primary outcome was median days of therapy (DOT). Secondary outcomes were median DOT per antibiotic, percentage of ID consults and percentage of antibiotic optimization. Statistical analyses were conducted using T-test and chi-square test for continuous and categorical variables respectively.

Results
A total of 81 and 72 patients were included in the intervention and historical groups respectively. No statistical difference in the primary outcome of median DOT was observed (4.5 vs 4, p=0.5). However, Non-significant numerical reductions in DOT were observed for VAN (3 vs 3.5, p=0.5), CEF (3 vs 4, p=0.6) and TAZ (3 vs 4, p=0.3), but not for MPN (6 vs 5, p=0.6). The intervention resulted in more ID consults when prescribing targeted antibiotics (59.3% vs 41.6%, p=0.03). In the intervention group, antibiotic treatment was optimized in 87.7% of patient, in which 39.6% were treatment de-escalation and discontinuation.

Conclusion
Pharmacist clinical guidance through the electronic medical record can provide a powerful educational tool to promote adherence to antimicrobials best practice

Disclosures
All Authors: No reported disclosures
177. Implementation of Pharmacist-Driven Penicillin Allergy Evaluation and Testing with a Focus on Bypassing Penicillin Skin Testing at an Academic Medical Center
Authors: Ham YoungYoon , Joshi Shyam , Sukerman Ellie , Tucker Kendall J , Yu Diana , Lewis James 
Published: January 2021

Abstract

Background
Penicillin allergies are reported by approximately 10% of the US population; however, studies reveal that &gt;90% of those patients can tolerate penicillins. Penicillin allergies are associated with negative health outcomes, both clinical and financial, due to reduced efficacy and increased adverse effects of alternative antibiotics. Patient interview, penicillin skin testing (PST) and/or an oral graded challenge can be used to evaluate penicillin allergies. Different facilities use various algorithms for testing. The objective of this project was to determine whether a pharmacist-driven penicillin allergy evaluation and testing protocol which largely bypasses PST could safely de-label patients.

Methods
Adult patients (≥18 years) admitted with a penicillin allergy were evaluated for eligibility between September 2019 and June 2020. Pregnant patients, critically-ill patients, and patients receiving test-invalidating medication were excluded. Patients were evaluated and tested using institutional protocols, which allowed for the majority of patients to be challenged without PST. Allergies were removed with standardized documentation, and patients were given a pamphlet and counseled to discourage relabeling. Data collected included but were not limited to, the number of patients challenged and de-labeled, number of patients who were relabeled, and number of patients whose change in allergy status resulted in change of therapy.

Results
Forty-eight patients were interviewed and evaluated. One patient was evaluated by PST and oral graded challenge while 27 patients underwent an oral graded challenge only. Twenty patients were de-labeled as a result of patient interview. One patient failed oral challenge with minor itching that did not require any treatment, while 27 patients passed. Forty-seven allergies were removed or modified. Two patients who were de-labeled were relabeled with no record of a new reaction. Of de-labeled patients, 50% received a penicillin following removal of the allergy.

Conclusion
Penicillin allergies can be evaluated and removed using a pharmacy-driven algorithm that prioritizes direct challenges when appropriate. Risks of a reaction are low, and removal leads to change in treatment in a significant portion of patients.

Disclosures
All Authors: No reported disclosures
180. Leveraging the Electronic Medical Record as a Method of Antibiotic Stewardship
Authors: Kaul Christina M , Molina Eric , Armellino Donna , Schilling Mary Ellen , Jarrett Mark 
Published: January 2021

Abstract

Background
Overutilization of antibiotics remains an issue in the inpatient setting. What is more, many protocols geared toward curbing improper antibiotic use rely heavily on resource- and personnel-intensive interventions. Thus, the potential for using the EMR to facilitate antibiotic stewardship remains largely unexplored.

Methods
We implemented a novel change for ordering certain antibiotics in our EMR: ceftriaxone, daptomycin, ertapenem, imipenem, meropenem, and piperacillin-tazobactam. When ordering one of these antibiotics, providers had to note a usage indication, which assigned a usage duration as per our Antibiotic Stewardship Committee guidelines. Pre-intervention, manual discontinuation was required if a provider did not enter a duration. The intervention was enacted August 2019 in 13 hospitals. Data was collected from January 2018 to February 2020. Antibiotic usage was reported monthly as rate per 1000-patient days. Monthly pre- and post-intervention rates were averaged, respectively. Paired samples t-tests were used to compare pre- and post-intervention rates per unit type per hospital. A p-value of less than 0.05 was considered significant. Units with minimal usage, as defined by a pre- or post-intervention mean of 0, were excluded from analysis.
Example of Ordering an Antibiotic Prior to Intervention

Example of Ordering an Antibiotic After Intervention

Results
Ertapenem was noted to have a statistically significant decrease in utilization in seven units at three hospitals. Piperacillin-tazobactam was found to have a decrease in utilization in 19 units at eight hospitals. Daptomycin was found to have a decrease in utilization in one unit. Significant decreases in the utilization of ceftriaxone, imipenem, and meropenem were not noted.
Example of Statistically Significant Decreased Utilization in Piperacillin-Tazobactam on a Medical-Surglcal Unit

Conclusion
Our study showed a statistically significant decrease in use of ertapenem, piperacillin-tazobactam and daptomycin using a simple built-in EMR prompt that curtails provider error. This should allow for an increased ease of integration, as the protocol does not require a host of resources for maintenance. Of note is decreased utilization of piperacillin-tazobactam and ertapenem across multiple hospitals, most notably on the medical and surgical wards. Thus, usage of the EMR without personnel-intensive protocols is a viable method for augmenting antibiotic stewardship in health systems.

Disclosures
All Authors: No reported disclosures
181. Limited Effectiveness of an EMR Alert-Based Antibiotic Timeout Procedure in Solid Tumor Cancer Patients
Authors: Hyak Jonathan M , Mohajer Mayar Al , Musher Benjamin 
Published: January 2021

Abstract

Background
Computer-based antibiotic time-outs, in which providers receive automated electronic medical record (EMR) alerts regarding continuation of inpatient antibiotics (Anb), are common stewardship initiatives. We assessed the efficacy of such an intervention in oncology patients (pts), who frequently receive Anb when hospitalized.

Methods
An EMR alert triggered 48 hours after starting vancomycin (vanc), cefepime (cef), piperacillin-tazobactam (pip-tazo), meropenem (mero), and fluoroquinolones (flq) was initiated in a tertiary care hospital in November 2018. To assess the efficacy of the intervention in adults with solid tumor malignancies, demographic, vital sign, laboratory, and treatment data were extracted retrospectively from the EMR. Pts with neutropenic fever, organ transplant, trauma, and cardiopulmonary arrest were excluded. We compared length of therapy [LOT; days of therapy per 1000 patient-days (DOT/1000 pd)] via t-test and incidence rate ratio (IRR) for 3- and 12-month periods preceding and following the intervention. November 2018 was excluded as a washout period.

Results
The groups did not differ by age, sex, length of stay, or rate of bacteremia (Table 1). Comparing the 3 months before and after the intervention, neither mean LOT (2.9 ± 0.20 vs 2.6 ± 0.14 DOT/1000 pd, p=0.31) nor rate of Anb use changed (IRR 0.97, p=0.32). However, when considering only the Anb targeted by the intervention, cef usage was 1.4 times higher post- intervention (p=0.002), while use of other Anb was similar (Table 2). Comparing 12 months before to 12 months after the intervention, mean LOT was longer after (0.74 ± 0.018) than before (0.68 ± 0.020 DOT/1000 pd; p=0.03), and Anb use increased (IRR 1.3, p&lt; 0.0001). Specifically, mero (IRR 1.8, p&lt; 0.0001) and cef (1.6, p&lt; 0.0001) were used more frequently after the intervention while none were used less (table 2).
Table 1: Study Group Characteristics

Table 2: Antibiotic Use Three Months Before and After, and Twelve Months Before and After, the Intervention

Conclusion
Despite wide adoption and efficacy in other populations, an EMR-based Anb time-out did not mitigate the continuation of Anb among inpatients with solid tumors. The intervention may require additional measures, such as an active role for pharmacy, to be effective. However, qualitative studies may also be required to understand why providers are hesitant to limit Anb use in this population.

Disclosures
All Authors: No reported disclosures
183. Optimization of an Outpatient Antimicrobial Stewardship Process for Patients Discharged from the Emergency Department at an Academic Medical Center
Authors: Kafisheh Hannah , Hinton Matthew , Binkley Amanda , Cimino Christo , Edwards Christopher 
Published: January 2021

Abstract

Background
Suboptimal antimicrobial therapy has resulted in the emergence of multi-drug resistant organisms. The objective of this study was to optimize the time to antimicrobial therapy modification for patients discharged from the emergency department (ED) of an academic medical center through implementation of a pharmacist-driven outpatient antimicrobial stewardship initiative (ASI).

Methods
This was a pre-post, quasi-experimental study that evaluated the impact of a pharmacist-driven outpatient antimicrobial stewardship initiative at a single academic medical center. The pre-cohort was evaluated through manual electronic medical record (EMR) review, while the post-cohort involved a real-time notification alert system through an electronic clinical surveillance application. The difference in time from positive culture result to antimicrobial therapy optimization before and after implementation of the pharmacist-driven ASI was collected and analyzed.

Results
A total of 166 cultures were included in the analysis. Of these, 12/72 (16%) in the pre-cohort and 11/94 (12%) in the post-cohort required antimicrobial therapy modification, with a 21.9-hour reduction in median time from positive culture result to antimicrobial optimization in the post-cohort (43 h vs. 21.1 h; p &lt; 0.01). Similarly, the median time from positive culture result to review was reduced by 20 hours with pharmacist-driven intervention (21.1 h vs. 1.4 h; p &lt; 0.01).

Conclusion
The implementation of a pharmacist-driven outpatient antimicrobial stewardship initiative resulted in a significant reduction in time to positive culture review and therapy optimization for patients discharged from the ED of an academic medical center set in Philadelphia, PA.

Disclosures
All Authors: No reported disclosures
189. Validating a Hospitalist-Specific Antibiotic Prescribing Metric across Four Acute Care Hospitals
Authors: Howard-Anderson Jessica , Nys Cara , Kubes Julianne N , Dube William C , Albrecht Benjamin , Jones K Ashley , Shabbir Hasan , Jacob Jesse T , Zanthia Wiley , Fridkin Scott 
Published: January 2021

Abstract

Background
Peer comparison reduces unnecessary outpatient antibiotic prescribing, but no prescribing metric has been validated for inpatient comparison. We aimed to evaluate if an electronically derived antibiotic prescribing metric correlated with indicated antibiotic days in hospitalized patients.

Methods
We previously created a hospitalist-specific adjusted antibiotic use metric (observed:expected [O:E]) for National Healthcare Safety Network-defined broad-spectrum antibiotics. From May-Oct 2019 at four Emory Healthcare hospitals, we identified outlier hospitalists prescribing in the top (high O:E) and bottom (low O:E) 15th percentile. We randomly selected 10 days of antibiotic administration from each outlier and reviewed days with &gt; 2 days of consecutive days of antibiotics. For pneumonia, chronic obstructive pulmonary disease (COPD), or urinary tract infection (UTI) we determined if each day of antibiotics was indicated, assuming the diagnosis was accurate. We compared high vs. low O:E providers and used regression modeling to determine if the metric predicted indicated days of antibiotics.

Results
Among 997 days, 510 (51%) were from high and 487 (49%) from low O:E providers. High O:E providers had a greater proportion of days with &gt; 2 prior days of antibiotics (60%) compared to low O:E providers (54%, p = 0.03). In the subset of days with &gt; 2 prior days of antibiotics (n = 569), high O:E providers had more patient-days with longer hospital stays, diabetes and Charlson comorbidity index (CCI) &gt;3, and fewer days supervising (resident/advanced practice provider, Table 1). The primary diagnosis was pneumonia, COPD exacerbation or UTI in 260 (25%) days; 91% were indicated based on duration with no difference between high and low O:E providers (88% vs. 94%, p = 0.1). After controlling for days of hospitalization, CCI, immunocompromised status, and supervisory role, a high O:E was not associated with indicated antibiotic use (OR 0.5, 95% CI 0.2 – 1.3).
Description of days with a patient on greater than two days of antibiotics, comparing high- versus low-metric providers

Conclusion
A high hospitalist antibiotic prescribing metric correlated with patients receiving &gt; 2 consecutive days of antibiotics on any given day but did not predict unindicated antibiotic use for a subset of diagnoses. Evaluating indicated use by validating diagnoses may improve metric performance.

Disclosures
Jessica Howard-Anderson, MD, Antibacterial Resistance Leadership Group (ARLG) (Other Financial or Material Support, The ARLG fellowship provides salary support for ID fellowship and mentored research training)