bluuebunny/crossref_metadata_2025_split huggingface dataset:
1057. The Impact of Temporary Suspensions of an Antimicrobial Stewardship Audit and Feedback Program on Antimicrobial Utilization of General Internal Medicine Inpatients
Authors: Wong Cynthia , Taggart Linda R , Leung Elizabeth 
Published: October 2019

Abstract

Background
A goal of Antimicrobial Stewardship Programs (ASP) is to optimize antimicrobial use; many using audit and feedback (AAF). Although AAF decreases unnecessary target antimicrobial use, it is resource-intensive. As a result, temporary suspensions in AAF activity may occur from human resource limitations or other factors. We describe the impact of these temporary suspensions and intensity of care on antimicrobial utilization trends.

Methods
This retrospective study describes the initiation and temporary suspensions of AAF in the General Internal Medicine (GIM) unit at an urban teaching hospital. Data were collected over 65 months. During active-AAF, a dedicated ID trained clinical pharmacist and ID physician-reviewed antimicrobial use for all GIM patients and provided patient-specific advice to physicians. Antimicrobial use was measured by Defined Daily Doses (DDD) normalized per 1,000 patient-days. To assess the impact of temporary suspensions, data were compared in two ways: 1. All nonactive-AAF time-frames were compared with active AAF 2. Pre-ASP was compared with Post-ASP Initiation which includes suspension periods. To determine whether differences in trends were seen based on acuity level of the patients (identified at admission as benefiting from frequent monitoring), analyses were repeated after stratification of patients admitted to the Step-Up unit (GIM-SU) and the regular ward (GIM-W).

Results
Comparing nonactive AAF vs. active-AAF, significant changes (P < 0.05) in mean normalized DDD were observed for total antimicrobials (-19%), antipseudomonals (-21%) fluoroquinolones (−41%) and first-generation β lactams (−30%). Pre ASP vs. Post ASP comparisons showed similar but less pronounced trends. Following stratification to GIM-SU and GIM-W, greater variation in significant changes to targeted antimicrobials between comparisons was observed. Different significant antimicrobial changes were seen in SU vs. W.

Conclusion
Our results show that the temporary suspension of ASP AAF impacts antimicrobial utilization trends. Greater sustained decreases in targeted antimicrobials utilization were associated with active AAF. Stratification by patient acuity lead to increased variation in the impact on target antimicrobials and increased the impact of suspension.

Disclosures
All authors: No reported disclosures.
1058. Decreases in Antibiotic Use Associated with the Implementation of Electronic Antibiotic Visualization Tools for Stewards at Eight Veterans Affairs (VA) Healthcare Facilities
Authors: Graber Christopher J , Jones Makoto M , Goetz Matthew B , Madaras-Kelly Karl , Zhang Yue , Butler Jorie M , Weir Charlene , Chou Ann F , Youn Sarah Y , Samore Matthew H , Glassman Peter A 
Published: October 2019

Abstract

Background
To identify areas for improved antibiotic use, we developed and pilot-tested visualization tools to quantify antibiotic use at 8 VA facilities. These tools allow a facility to review its patterns of total use, and use by antibiotic class, compared with patterns of use at VA facilities with similar (or user-selected) complexity levels.

Methods
Antibiotic stewards from 8 VA facilities participated in iterative report development and implementation, with the final product consisting of two components: an interactive web-based antibiotic dashboard and a standardized antibiotic usage report updated at user-selected intervals. Stewards also participated in monthly learning collaboratives. The percent change in average monthly antimicrobial use (all antibiotics; anti-methicillin-resistant S. aureus agents (anti-MRSA); and broad-spectrum agents predominantly used for hospital-onset/multi-drug-resistant organisms (anti-MDRO)) was analyzed using a pre-post (January 2014–January 2016 vs. July 2016–January 2018) with un-involved controls (all other inpatient VA facilities, n = 132) design modeled using Generalized Estimation Equations segmented regression.

Results
Intervention sites had a 2.1% decrease (95% CI = [−5.7%,1.6%]) in all antibiotic use pre-post-intervention, vs. a 2.5% increase (95% CI = [0.8%, 4.1%]) in nonintervention sites (P = 0.025 for difference). Anti-MRSA antibiotic use decreased 11.3% (95% CI = [−16.0%,−6.3%]) at intervention sites vs. a 6.6% decrease (95% CI=[−9.1%, −3.9%]) at nonintervention sites (P = 0.092 for difference). Anti-MDRO antibiotic use decreased 3.4% (95% CI = [−8.2%,1.7%]) at intervention sites vs. a 3.6% increase (95% CI = [0.8%,6.5%]) at nonintervention sites (P = 0.018 for difference) (Figure 1). Examples of graphs include overall antibacterial use (Figure 2), and usage of broad-spectrum Gram-negative therapy (Figure 3) in intensive care units.

Conclusion
The use of data visualization tools use and participation in monthly learning collaboratives by antimicrobial stewards in a pilot implementation project at eight VA facilities was associated with decreases in antimicrobial use relative to uninvolved sites.

Disclosures
All authors: No reported disclosures.
1068. Implementation of an Antimicrobial Stewardship Program (ASP) Managed by an Infectious Disease Physician and Pharmacists in a Community Hospital
Authors: Brady PharmD Jeanne , Poudel Mahendra 
Published: October 2019

Abstract

Background
The implementation of antimicrobial stewardship program (ASP) is one of the basis for the control of multidrug-resistant bacteria (MDR), optimization of antibiotic use, minimization of adverse events, and reduction of unnecessary costs. We demonstrate the design, development, and participation in ASP program following CDC and Prevention Core Elements strategies.1,3,4 The objective is to evaluate the impact of clinical pharmacists working in conjunction with infectious disease (ID) physician on tracking and documenting antibacterial utilization in per patient-days, pharmacist clinical interventions, prescriber practices, and antibiotic purchases.

Methods
We conducted a multidisciplinary-team project of pharmacist-led prospective-audit-with-feedback ASP from 2015 to 2018. The ID physician and clinical pharmacist conducted patient care rounds twice weekly to make recommendations that include de-escalation, intensification of treatment, alternative therapy, dose optimization, order clarification, stop date/duration, additional monitoring, education, restriction enforcement, consult, IV to PO conversion, rejection of recommendation, and total monitored interventions requiring no changes.

Results
Pharmacist tracked between 150 and 200 interventions monthly through the EMR system, reflecting both self-stewardship and during rounds with ID physician. Figures 2–8: Charts display the number of patient-days of therapy per 1,000 days at risk and yearly SVMH Antibacterial Utilization Rates compared nationally to other Teaching and Nonteaching hospitals.5 Below each graph exhibits yearly Drug Spend per patient-days of Therapy.6

Conclusion
Overall, the antibiotic utilization rates decreased over 4 years, particularly with aztreonam, meropenem, and levofloxacin.The formalization of an antimicrobial stewardship partnership between ID physician and pharmacy team led to increases in pharmacist-recommended interventions, streamlining of antimicrobial therapy, as well as decreases in antimicrobial purchasing costs. Proactively working in conjunction with hospitalists allows the pharmacists to play a critical role in sustaining a robust ASP service at our community hospital. The ASP at SVMH can serve as a model for other community hospitals with similar resources.

Disclosures
All authors: No reported disclosures.
1083. Risk Factors Associated with Treatment of Asymptomatic Bacteriuria in the Emergency Department: A Multi-Hospital Cohort Study
Authors: Petty Lindsay A , Vaughn Valerie M , Patel Twisha S , Malani Anurag N , Pogue Jason M , Dumkow Lisa , Thyagarajan Rama , Hsaiky Lama , Osterholzer Danielle , Kaye Keith S , Ratz David , McLaughlin Elizabeth , Flanders Scott A , Gandhi Tejal N 
Published: October 2019

Abstract

Background
Antimicrobial stewardship interventions to decrease testing and treatment of asymptomatic bacteriuria (ASB) have primarily focused on inpatient clinicians, however emergency medicine (EM) clinicians also test and treat ASB. We identified testing attributable to EM clinicians and patient-level factors associated with EM treatment of ASB.

Methods
Between November 2017 and March 2019, data were abstracted from medical records of adult non-ICU medical patients at 43 Michigan hospitals admitted through the Emergency Department (ED) with a positive urine culture (Ucx) collected on day 1 or 2 of hospitalization. Exclusions included pregnancy, urologic surgery or abnormality, immune-compromise, severe sepsis, or concomitant infection. ASB was defined as a positive Ucx without signs or symptoms of a urinary tract infection (UTI). The treatment group included patients receiving ≥1 antibiotic dose ordered by an EM clinician. Patient factors associated with ASB treatment by EM clinicians vs. no treatment were evaluated using logistic generalized estimating equation models.

Results
Of 1,778 patients with ASB, 74.7% (N = 1328) had a Ucx ordered by an EM clinician (Figure 1), and 74.4% (N = 1323) were treated with antibiotics (Figure 2). Of those treated for ASB, 64.3% (851/1328) had the first dose ordered by an EM clinician (Figure 2). Patient variables associated with EM treatment included nonambulatory status, incontinence, presence of a urinary catheter, acutely altered mental status (AMS), leukocytosis, and positive urinalysis (Table 1). When EM initiated treatment, most patients (80%) remained on antibiotics for ≥3 days (Figure 3), with a median treatment duration of 6 days [IQR 4–9].

Conclusion
Among patients with ASB admitted through the ED with a Ucx collected on day 1 or 2 of hospitalization, most were treated with antibiotics. The majority of testing and initial treatment for ASB was by EM clinicians. The strongest predictors of EM treatment of ASB were positive urinalysis and AMS. Once started by EM, patients often received a full course for UTI. Given the burden of ASB testing and treatment, expanding stewardship into the ED is critical and should start with addressing interpretation of urinalyses in patients without specific urinary symptoms.

Disclosures
All authors: No reported disclosures.
1087. Fluoroquinolone Prophylaxis vs. No Bacterial Prophylaxis in Hospitalized Neutropenic Patients Undergoing Induction Chemotherapy for Acute Myeloid Leukemia
Authors: Buchanan Carley , Bremmer Derek N , Koget Anna , Moffa Matthew , Shively Nathan , Patel Monank , Walsh Thomas L 
Published: October 2019

Abstract

Background
Despite evidence to support outpatient anti-pseudomonal fluoroquinolone (FQ) prophylaxis in neutropenic patients, limited data exist to support this for inpatients undergoing induction chemotherapy for acute myeloid leukemia (AML). At our institution, we implemented an initiative to replace FQ prophylaxis with a conditional order for an anti-pseudomonal β-lactam to be given if a fever occurred.

Methods
A retrospective chart review was conducted to analyze the outcome differences between patients receiving FQ prophylaxis (pre-intervention) and those who had a conditional order for an anti-pseudomonal β-lactam in place of FQ prophylaxis (post-intervention). Patients were included if they were ≥18 years of age and were newly diagnosed with AML undergoing induction chemotherapy. The primary outcome was 90-day all-cause mortality. Secondary outcomes included the number of patients requiring ICU admission and rate of bacteremic episodes caused by any pathogen and from a Gram-negative rod (GNR). Additionally, ciprofloxacin susceptibility of these pathogens was analyzed.

Results
There were 35 and 26 patients in the pre- and post-intervention groups, respectively. Between pre- and post-intervention groups, there was no difference in 90-day mortality (20.0% vs. 15.4%; P = 0.745) or ICU admissions (25.7% vs. 23.1%, P = 1), respectively. The rate of any bacteremic episode was similar between the pre- and post-intervention groups (51.4% vs. 65.4%; P = 0.307), but more patients in the post-intervention group developed GNR bacteremia (17.1% vs. 46.2%; P = 0.023). In the patients with GNR bacteremia, the number of ciprofloxacin nonsusceptible isolates was higher in the pre-intervention group (100% vs. 30.7%; P = 0.011).

Conclusion
Replacing FQ prophylaxis with a conditional order for an anti-pseudomonal β-lactam for inpatients newly diagnosed with AML receiving induction chemotherapy is a feasible option to decrease FQ exposure. Though increased episodes of GNR bacteremia were observed, there was no difference in total bacteremic episodes or clinical outcomes, and the improved ciprofloxacin susceptibility patterns will allow for an additional treatment option in this extremely vulnerable patient population.

Disclosures
All authors: No reported disclosures.
1088. Evaluating the Timing of Antimicrobial Prophylaxis in Allogeneic and Autologous Hematopoietic Stem Cell Transplant
Authors: Gawrys Gerard , Ramirez Brittney , Horowitz Justin , Lee Grace 
Published: October 2019

Abstract

Background
Hematopoietic stem cell transplant (HSCT) patients develop profound neutropenia during the transplant process and often fever, which is suggestive of infection. Antimicrobial prophylaxis (AP) during anticipated neutropenia is recommended; however, data regarding when to initiate AP is limited. A local quality improvement initiative adjusted AP initiation to target the duration of severe neutropenia, defined as ANC ≤ 500 mm3 (ANC500), which is when patients are at the greatest risk of infection. This initiative aimed to reduce antimicrobial utilization and consequences of unnecessary antimicrobial exposure while not adversely affecting patient outcomes.

Methods
A retrospective study was conducted across two cohorts over a 2-year period. The pre-intervention cohort (November 2016–2017) called for the initiation of AP on Day -1 prior to transplant. The post-intervention cohort (November 2017–2018) called for initiation of AP when patients reached ANC500. The primary outcome was frequency of febrile occurrences (temperature ≥38°C). Secondary outcomes included days of antimicrobial exposure, positive blood cultures, all-cause mortality, length of stay, graft-vs.-host disease, and Clostridioides difficile rates. Patients were excluded if they received a haploidentical transplant or inappropriate AP for the specified cohort.

Results
A total of 248 patients were included in the final analysis with 130 patients in the pre-intervention cohort and 118 patients in the post-intervention cohort. The final analysis included 40 allogeneic and 208 autologous HSCT patients. There was no difference in fever occurrences between the two groups (79% pre vs. 69% post; P = 0.078). There was a significant reduction in the mean antibacterial (10.3 vs. 4.95; P < 0.001) and antifungal (13.4 vs. 7.6; P < 0.001) prophylaxis per patient-days in the pre- and post-intervention group. No significant differences in positive blood cultures (11.5% vs. 16.9%; P = 0.222), ICU admissions, length of stay or all-cause mortality were identified.

Conclusion
Delaying antimicrobial prophylaxis (AP) until severe neutropenia showed no difference in fever occurrences or other patient outcomes. This approach is associated with a drastic reduction in antimicrobial exposure.

Disclosures
All authors: No reported disclosures.
1091. An Ethnographic Approach to Interrogating Antimicrobial Stewardship at US Teaching Hospitals
Authors: Rynkiewich Katharina , Schwartz David , Won Sarah Y , Heber Mikhail , Timmireddy Kavya , Stoner Bradley 
Published: October 2019

Abstract

Background
Hospital antimicrobial stewardship programs (ASPs) deploy variably evidence-based interventions aimed at improving antimicrobial use and reducing antimicrobial resistance. Little is known about how ASPs are perceived by hospital clinicians or how such data might inform ASP improvement. We conducted an ethnographic study of hospital ASPs and infectious diseases (ID), surgical intensive care unit (SICU) and medical intensive care unit (MICU) practitioners to identify how ASPs are understood and integrated into everyday practice by hospital staff.

Methods
A medical anthropologist performed direct observation of patient care and semi-structured interviews with ID (N = 29), SICU (N = 10), and MICU (N = 19) practitioners at two affiliated teaching hospitals in Chicago, IL, between July 2017 and September 2018, accruing >576 hours of direct observations and 48 hours of semi-structured interview data. Data collection and analysis centered on explicating the understandings and interpretations of ASPs present in diverse practice groups. Transcriptions of the data were analyzed using thematic coding aided by MAXQDA qualitative analysis software.

Results
Understandings and interpretations of ASPs varied greatly between the practice groups. ID practitioners commonly focused on “changing prescribing behavior” and “restricting inappropriate usage,” while MICU and SICU practitioners more often emphasized “following guidelines” and maintaining clinical “balance.” Additionally, direct observation data demonstrate that MICU and SICU practitioners are bounded by social and institutional determinants of antimicrobial prescribing (Table 1) that affect the pursuit of “appropriate antimicrobial use.”

Conclusion
Ethnographic interrogation found that practice groups understand and integrate ASPs differently according to everyday encounters with the social and institutional determinants of antimicrobial prescribing. ASP effectiveness might be enhanced by adopting a more mindful approach to accounting for and addressing the distinct understandings and interpretations of ASPs among diverse practice groups operating within the same institution.

Disclosures
All authors: No reported disclosures.
1097. An Antimicrobial Stewardship Intervention to Optimize Cefazolin Dosing for Surgical Prophylaxis
Authors: Neuner Elizabeth A , Wesolowski Jill , Rivard Kaitlyn R , Srinivas Pavithra , Pallotta Andrea , Athans Vasilios , Gordon Steven M , Fraser Thomas G 
Published: October 2019

Abstract

Background
Guidelines for antimicrobial prophylaxis in surgery recommend cefazolin dose be adjusted based on patient weight. Adults weighing ≥120 kg should receive a 3 g dose, all other adult patients should receive a 2 g dose pre-operatively. To promote guideline adherence, an antimicrobial stewardship pharmacist-driven dose optimization intervention was implemented.

Methods
Retrospective, pre (February 1, 2017–March 31, 2017)/post (February 1, 2018–March 31, 2018) study evaluating the impact of a pharmacist-driven cefazolin dose optimization intervention at a large health system. An alert within the electronic health record notified pharmacists during order verification when cefazolin dose from a surgical prophylaxis order set did not match weight-based recommendations. All patients with cefazolin orders for surgical prophylaxis were included; pediatric and pregnant patients were excluded.

Results
Pre-group included 9,830 patients, post-group 10,025 patients. In both groups, the mean age was 58 years, mean weight 87 kg, and 8% of patients weighed ≥120 kg. Approximately 21% of patients were seen at the academic medical center, 8% at ambulatory surgery centers, and the remainder amongst 10 community hospitals. Most common surgical procedure types were orthopedic (26%), general surgery (21%) and urologic (10%). Primary cefazolin dose was 2 g in 89.8% vs. 88.7%, followed by 3 g 6.6% vs. 6.9% and 1 g in 3.9% vs. 4.4%, pre- and post-intervention, respectively. Overall adherence to weight-based cefazolin dosing was 92.2% pre-group and 92.4% post-group. In patients weighing ≥120 kg, adherence improved from 62% (514/827) to 71% (582/817) post-intervention, P < 0.001. Adherence was better both pre- and post-intervention when an order set was used (pre: order set 95.0% vs. no order set 85.9%, P < 0.001; post: order set 96.4% vs. no order set 84.8%, P < 0.001). There were no differences between surgical services or hospital locations. Investigation of guideline nonadherent cases found order sets without updated dosing recommendations and allowed for targeted education efforts.

Conclusion
Overall adherence to cefazolin weight-based dosing recommendations for surgical prophylaxis was high, especially with the use of order sets. Pharmacist-driven dose optimization intervention improved guideline adherence in patients weighing ≥120 kg.

Disclosures
All authors: No reported disclosures.
1122. Implementation of an Outpatient Antimicrobial Stewardship Program within a Pediatric Health System
Authors: Burns Alaina , Lee Brian R , Goldman Jennifer , Myers Angela , Myers Angela , El Feghaly Rana E 
Published: October 2019

Abstract

Background
Over 60% of antibiotic expenditures occur in outpatient settings with at least 30% being unnecessary. In 2016, the Centers for Disease Control and Prevention (CDC) defined core elements for outpatient antimicrobial stewardship programs (ASP): commitment from all members of the healthcare team, action for policy and practice, tracking and reporting, and education and expertise. Quantifying local prescribing practices and frontline provider engagement are essential for successful outpatient ASP. We describe our outpatient ASP efforts at Children’s Mercy Kansas City (CM) emergency departments (ED) and urgent care clinics (UCC).

Methods
In March 2018, we created a report defining antibiotic prescribing patterns in 16 common pediatric infections using ICD-10 codes from ED and UCC encounters. Baseline data helped identify areas for targeted interventions and establish ED/UCC engagement, which we have maintained by ongoing review and sharing of data with leadership and frontline providers.

Results
Baseline data showed low antibiotic prescribing rates (<5%) for most viral infections, except a rate of 74% in otitis media with effusion (OME) (Figure 1). We also identified a higher rate of cefdinir use in acute otitis media (AOM), community-acquired pneumonia, and urinary tract infections (Figure 2). We developed and shared an outpatient antibiotic handbook facilitating diagnosis and treatment of common infections. Ongoing QI teams are focusing on increasing utilization of safety-net antibiotic prescriptions for eligible patients with AOM in EDs, decreasing antibiotic prescriptions of OME, and decreasing unnecessary rapid streptococcal testing in UCCs. Through these multiple interventions, in addition to email communications and newsletter articles, we observed early improvements in prescribing patterns, including OME antibiotic prescriptions and cefdinir use (Figures 1 and 2).

Conclusion
We used the CDC’s core elements for outpatient ASP to successfully develop interventions in our EDs and UCCs. We created a report defining baseline prescribing patterns and identifying opportunities for improvement. Data sharing with leadership and frontline providers facilitated widespread engagement in ASP efforts.

Disclosures
All authors: No reported disclosures