bluuebunny/crossref_metadata_2025_split huggingface dataset:
2016. Antibiotic Misuse of Rural Residents and Pilot Project of Antibiotic Take-Back Program
Authors: Wang Weiyi , Wang Xiaomin , Cai Jingjing , Yao Tingting , Zhou Xudong 
Published: October 2019

Abstract

Background
Self-medication with antibiotics (SMA) is a major form of antibiotic misuse behaviors contributing to increasing antimicrobial resistance (AMR). The main source of SMA usually comes from in-home leftover antibiotics which usually disposed as household waste without classification. Therefore, an antibiotic take-back program (ATBP) is urgently needed.

Methods
A pilot ATBP was launched in Liantang Village, Zhejiang Province from January to March, 2019. A total of 50 households were randomly selected for the baseline survey. A questionnaire was used to investigate their knowledge and antibiotic use behaviors. Health education leaflets and posters were distributed to each household. A village Wechat group was set up for health communication. Residents were encouraged to hand over those unused or expired antibiotics at home to the village clinic to redeem a commodity. The pilot ATBP was implemented for 30 days. The type, name, and amount of antibiotics were collected as after intervention data.

Results
All of 50 households finished the questionnaire. Although 27 (52.9%) agreed that keeping antibiotics at home would potentially increase risk of SMA, there were still 32 (64.0%) residents reported that they kept antibiotics at home and 25 (49%) residents indicated that their leftover antibiotics usually disposed as household waste. After the 30-day intervention, 10 (20.0%) households handed their in-home antibiotics or medicine to the village clinic. In total, 32 boxes of medicine including 17 (53.1%) boxes of antibiotics were recycled. All of 32 boxes of medicine could be classified into 19 specific types, of which there were 8 (42.1%) types of antibiotics, belonging to four broad categories: Cephalosporins, Penicillins, Macrolides, and Nitroimidazoles. In addition, there were also antifungal drug, antiviral agent, anti-inflammatory drug, and paracetamol tablets handed over by the villagers as antibiotics.

Conclusion
Using leaflets and social media to promote health education can reduce the risk of keeping antibiotics at home. Rural residents could not identify commonly used antibiotics even after health education. To conduct a broader intervention to recycle antibiotics, further study needs to focus on improving the antibiotic identification among the rural residents.

Disclosures
All authors: No reported disclosures.
2024. A Multifaceted Intervention to Improve Oral Antimicrobial Prescription at the Emergency Department at a Japanese Tertiary Care Center
Authors: Tagashira Yasuaki , Honda Hitoshi 
Published: October 2019

Abstract

Background
The emergency department (ED) is one of the most important settings where antimicrobials are frequently prescribed in developed countries, and at least 30% of antimicrobials prescribed at the ED are inappropriate. Some studies revealed that various factors, especially the physician-related factors were associated with inappropriate antimicrobial use. Implementing effective strategies to modify prescribing practice is needed to optimize antimicrobial therapy at the ED.

Methods
We implemented a multifaceted intervention to patients discharged with oral antimicrobial agents in the ED at a Japanese tertiary care center from October 2018 to March 2019. The intervention included (1) an educational didactic session to physicians, (2) an evidence-based tool book regarding antimicrobial use for common diagnoses, (3) antimicrobial order sets for common diagnoses, (4) monthly reports of the appropriateness of antimicrobial use, and (5) post-prescription review and feedback by an infectious diseases physician. The proportion of appropriate discharge antimicrobial prescription at ED, and changes in the prescription density, measured as the number of prescription per 1,000 patient visits between pre- and post-intervention were evaluated.

Results
The total number of patient visits at the ED during the study period was 52,274. With the intervention, the mean monthly discharge antimicrobial prescription decreased from 42.7 to 34.2 per 1,000 visits (proportional reduction 0.20; P < 0.01). Overall, appropriate prescription rate significantly increased from 47.7% (742/1,555) to 77.4% (421/544) (P < 0.01). The rate of unnecessary and inappropriate discharge antimicrobial prescription accounted from 27.5% (428/1,555) and 21.7% (337/1,555) to 8.5% (46/544) and 10.7% (58/544), respectively. A substantial improvement in discharge antimicrobial prescription against intra-abdominal infections and odontogenic infections during the intervention period was observed (changes in the proportion of appropriate prescription was 0.37 [P < 0.01] and 0.51 [P < 0.01], respectively.

Conclusion
An evidence-based, multifaceted intervention led to decreasing unnecessary prescription and optimizing physicians’ antimicrobial prescriptions at the ED.

Disclosures
All authors: No reported disclosures.
2055. Action: A Year in the Lives of Consultant Pharmacists Working on Antimicrobial Stewardship in Long-Term Care Facilities
Authors: Chung Philip , Neukirch Alex , Ortmeier Rebecca J , Bergman Scott , Rupp Mark E , Van Schooneveld Trevor C , Ashraf M Salman 
Published: October 2019

Abstract

Background
The CDC recommends consultant pharmacists (CP) support antimicrobial stewardship (AS) activities in long-term care facilities (LTCF) by reviewing antimicrobial appropriateness. We initiated a project training CP from a regional long-term care pharmacy to support AS implementation in LTCF.

Methods
CP were trained to evaluate the appropriateness of all systemic antimicrobial therapy (AT) and provide prescriber feedback during their monthly drug regimen review (DRR). An electronic database was developed to facilitate data reporting. Antimicrobial use (AU) and adverse events (AE) from 32 LTCF were analyzed for 2018 using descriptive statistics.

Results
A total of 5327 courses of AT with a median duration of 7 days (IQR 5–10) were reviewed. The majority of AT was started in the LTCF (55%) but was also initiated in hospitals (24%), clinics (11%) and emergency departments (2%). Of 2926 AT started in LTCF, 36% were based on nurse evaluation (NE) while 33% began after prescriber evaluation (PE). Fluoroquinolones (FQ) and first-generation cephalosporins were the most commonly prescribed agents (Table 1). Treatment or prophylaxis of urinary tract infections accounted for 40% of AU (Figure 1). Diagnostic testing was associated with 37% of AT courses. Urine cultures were the most frequent test performed (81%). Overall, 41% of AT was determined to be inappropriate resulting in > 800 feedback letters sent to prescribers. Unnecessary antibiotic starts (based on revised Mc Geer or Loeb’s criteria) were identified as the most common reason (Figure 2). AT appropriateness varied depending on the setting in which it was initiated. A majority (87%) of AT initiated in hospitals was found to be appropriate with 56% and 46% appropriate for ED and clinic starts. Appropriateness of LTCF initiated AT was 49% (59% after PE and 42% after NE). AE were associated with 3% of AT with allergic reactions and Clostridioides difficile infections occurring with 0.4% and 0.7% of AT, respectively. AE were most frequently associated with folate antagonists (5%) and FQ (3%).

Conclusion
This study demonstrates many AU improvement opportunities exist in LTCF and CP can play an important role in identifying them if trained in AS principles. CP should review all AU for appropriateness and provide data to inform AS efforts in LTCF.

Disclosures
All authors: No reported disclosures.
2066. Development and Implementation of Prescribing Algorithms for Antibiotics on Discharge from the Emergency Department
Authors: Stoll Kristin , Feltz Erik , Ebert Steven C 
Published: October 2019

Abstract

Background
In the emergency department (ED), rapid decision-making and frequent distractions are often challenging to implementing effective antimicrobial stewardship. The purpose of this project is to improve guideline adherence and promote optimal use of outpatient antibiotic therapy for community-acquired infections.

Methods
Prescribing algorithms were developed to integrate clinical practice guideline recommendations with emergency department-specific antibiogram data. Algorithms for treating community-acquired pneumonia (CAP), skin and soft-tissue infections (SSTI), and urinary tract infections (UTI) were made available throughout the ED. Outcomes were evaluated through a chart review of patients prescribed empiric outpatient antibiotics for CAP, SSTI, or UTI by ED providers. Patients were excluded if they were <18 years old, pregnant, or taking antibiotics prior to arrival. The primary outcome was rate of adherence to clinical practice guidelines, defined as the selection of an appropriate antibiotic agent, dose, and duration of therapy for each patient discharged. Secondary outcomes included the rate of fluoroquinolone use, as well as all-cause 30-day returns to the ED or urgent care.

Results
When compared with patients discharged from the ED prior to algorithm implementation (N = 325), the post-implementation group (N = 172) received more antibiotic prescriptions that were completely guideline adherent (57.0% vs. 11.7%, P < 0.01). Post-implementation discharge orders demonstrated improvement in the selection of an appropriate agent (86.6% vs. 45.5%, P < 0.01), dose (89.0% vs. 77.2%, P < 0.01), and duration of therapy (63.4% vs. 39.1%, P < 0.01). Additionally, fluoroquinolone prescribing rates in this population were reduced (2.9% vs. 12.3%, P < 0.01). In the post-implementation patients who presented at least 30 days prior to analysis (N = 124), a reduction in all-cause 30-day returns to the ED or urgent care was observed (12.9% vs. 21.5%, P < 0.05).

Conclusion
Implementation of antibiotic prescribing algorithms improved guideline adherence in the outpatient treatment of CAP, SSTI, and UTI. By developing prescribing algorithms, pharmacists may reduce the unnecessary use of broad-spectrum antibiotics and prevent patient returns to the ED.

Disclosures
All authors: No reported disclosures.
2072. Do ID and Non-ID Clinicians Agree on IV to PO Switch Criteria? Results from Phase I of the INForming IV to ORal MEdication Report (INFORMER) Project
Authors: Bosma Rachael , Haj Reem , Dai David , Mamdani Muhammad , Young Michaelia , Gough Kevin , Langford Bradley J , Downing Mark , Schwartz Kevin L , Topolovec-Vranic Jane , Mccall Michele , Taggart Linda R , Leung Elizabeth 
Published: October 2019

Abstract

Background
Converting intravenous (IV) antibiotics to an oral (PO) route is an important stewardship activity to reduce patient harm, including extravasation, thrombophlebitis, and catheter-related infections. The INFORMER Project aims to develop a “smart” electronic tool to streamline IV to PO conversion in eligible patients using an algorithm derived from patient-level data. In designing the algorithm, we noted significant clinician subjectivity in reviewing PO eligibility criteria. To support algorithm development and frontline clinician buy in for future e-tool use, an initial step of our project explored agreement level for IV to PO switch between general internal medicine (GIM) vs. ID clinicians.

Methods
A convenience sample of GIM patients (tertiary teaching hospital) were reviewed in a 4-month pilot. Patients were still on the ward and received a target IV antibiotic (fluoroquinolone, sulfamethoxazole/trimethoprim, clindamycin, metronidazole, linezolid, fluconazole, voriconazole, azithromycin). To mimic real-time decision-making, clinicians (MD and PharmDs) retrospectively assessed IV to PO eligibility of the last IV antibiotic dose on admission for (1) GI/absorption, (2) clinical stability and (3) global review (but not given specific thresholds/criteria). Agreement level was compared for ID vs. non-ID reviews.

Results
Overall, 52 patients’ IV to PO eligibility was assessed by multiple clinicians; 5 GIM teams and 6 ID MDs or PharmDs participated. ID vs. GIM respective assessment of Global eligibility was 61% vs. 48% (agreement in 71% of cases). ID vs. GIM assessment of acceptable absorption was 82% vs. 67%; acceptable clinical stability was 64% vs. 62% (Fig 1). Clinician comments were reviewed to identify algorithm improvements and areas for frontline education.

Conclusion
Our results are consistent with prior data suggesting up to 40–50% of patients may be eligible for IV to PO conversion, even at institutions that have IV to PO protocols. Our data also shows that overall, ID clinicians were more likely to assess a patient as ready for PO antibiotics vs. non-ID clinicians. Our findings are important as understanding cases of non-agreement and obtaining GIM consensus for tool utility are important for our next step, assessing INFORMER implementation on realtime IV to PO conversion rates.

Disclosures
All authors: No reported disclosures.
2082. Evaluation of Outpatient Parenteral Antimicrobial Therapy (OPAT) Processes and Outcomes Among Patients Within an Integrated Health System
Authors: Brown Brittany , Dilworth Thomas J , Cook Margaret , Brummitt Charles F 
Published: October 2019

Abstract

Background
Successful management of outpatient parenteral antimicrobial therapy (OPAT) optimizes outcomes and reduces cost. We examined (i) local OPAT processes and outcomes, (ii) whether OPAT constraints favoring once daily antibiotics promoted suboptimal therapeutic choices, and (iii) whether these data could drive OPAT improvements.

Methods
Patients ≥ 18 years of age who received > 48 hours of OPAT at five infusion centers within a single health-system from January 1, 2018 to March 1, 2018 were eligible for review. The following patient- and treatment-level data were collected: age, gender, drug allergies, laboratory studies and frequency, OPAT indication, infection source, pathogen(s), antibiotic sensitivities, antibiotic therapy and duration, electronic order set used, prescriber specialty, evidence of failed prior oral or intravenous (IV) therapy and IV access type. The primary outcome was OPAT success: the clinical resolution of the infection without relapse within 30 days of antibiotic therapy completion. Secondary outcomes included change in antibiotic therapy due to lack of clinical improvement, adverse drug reactions and IV access complications. A sub-analysis of patients who received daptomycin and/or ertapenem was also performed. OPAT practice was compared with 2018 Infectious Diseases Society of America OPAT guidelines (Norris et al. Clin Infect Dis. 2019;68(1):e1-e35).

Results
A total of 108 patients were evaluated. Patient demographics, treatment and outcomes are shown in Table 1. The most common OPAT indications were bone/joint, bacteremia and skin infection. Third-generation cephalosporins, carbapenems and daptomycin were most commonly prescribed. In 34.3% and 24.2% of daptomycin and ertapenem cases, respectively, β-lactam therapy could have been utilized. Assessment of prior failed antibiotic therapy, patient allergies and pathogen-site pairing found 28.7% of patients were eligible for oral therapy upon OPAT initiation.

Conclusion
Several components of our local OPAT aligned with current guidelines. Initial OPAT patient selection may benefit from added scrutiny. Given the high volume of once daily antibiotics administered for convenience there is an internal opportunity to facilitate multi-daily infusions.

Disclosures
All authors: No reported disclosures.
2084. Implementation of a Diagnostic Stewardship Algorithm by Bedside Nurses to Reduce Unnecessary Urinary Cultures in Hospitalized Adult Patients
Authors: Fabre Valeria , Pleiss Ashley , Demko Zoe , Sick-Samuels Anna , Hicks Lauri , Neuhauser Melinda M , Srinivasan Arjun , Cosgrove Sara E , Cosgrove Sara E 
Published: October 2019

Abstract

Background
Urine cultures (UCx) are often ordered in patients without symptoms of urinary tract infection. A pilot study was conducted to assess the impact of a nurse-driven UCx diagnostic stewardship intervention for adult inpatients.

Methods
We interviewed eight nurses to determine the feasibility of a nurse-driven UCx stewardship intervention. Based on their feedback, an algorithm with appropriate indications for UCx was developed (Figure 1) and approved by physicians and nurses for piloting on a 24-bed medicine unit at The Johns Hopkins Hospital. UCx orders/100 patient-days (PD) were trended with statistical process charts in the intervention and a control unit. Nurses used the algorithm to guide discussions with ordering providers and to suggest instances where UCx may be unnecessary (“intervention”). Nurses were educated on an antibiotic (abx) use safety and appropriate testing during live sessions prior to algorithm implementation. Two study team members reviewed all UCx ordered in the intervention unit 12 months before and 6 months after the intervention for appropriateness based on algorithm criteria. Feedback on UCx order appropriateness and case-based discussion were provided to nurses via in-person meetings post intervention. Data were compared using the χ 2 or the Mann–Whitney test as appropriate. The rate of UCx orders before and after the intervention were compared using a standard incident ratio (IRR).

Results
With algorithm implementation, the mean rate of UCx orders/100 PD decreased from 2.7 to 1.8 (39% decrease) in the intervention unit (IRR 0.61, 95% confidence intervals (CI) 0.45–0.82, P = .16). Mean UCx order rates in the control unit were 2.49 and 2.99, respectively (Figure 2). Characteristics of patients reviewed for appropriateness were similar between the two study periods: median age 63 (IQR 39, 74) vs. 56 (IQR 45, 76), female sex 65% vs. 61%, on hemodialysis 7% vs. 11%, urinary catheter present 20% vs. 29%. The proportion of inappropriate UCx decreased from 59% (98/165) to 50% (32/64) (P = 0.16). There were 8 and 1 cases of asymptomatic bacteriuria inappropriately treated in the pre- and post-intervention periods, respectively (42 and 7 abx days).

Conclusion
With the appropriate training and tools, nurses can steward UCx and reduce unnecessary testing and abx use

Disclosures
Sara E. Cosgrove, MD, MS, Basilea: Consultant; Theravance: Consultant.
2095. Antimicrobial Stewardship (ASP) in Rural and Critical Access Hospitals (CAHs) Using TeleStewardship® Services
Authors: Ased Sumaya J , Horne John , Vivekanandan Renuga , Destache Christopher J 
Published: October 2019

Abstract

Background
MDstewardship® is a physician-owned company that uses TeleStewardship® services, which consist of telephone and HIPPA-compliant teleconferencing and texting, to provide rural and critical access hospital (CAH) ASP services, ensuring facilities remain compliant with Joint Commission ASP requirements. MDstewardship® also provides monthly webinars to all participating hospital personnel for continuing education. Webinars are live, interactive, and contain topics based on IDSA guidelines. MDstewardship® personnel discuss antibiotics with the hospital staff using a HIPPA-compliant secure audio-video feed, phone conference, or secure-text. CAH pharmacists discuss the antibiotics currently being given in their institution and MDstewardship® personnel provide further ASP recommendations. ASP recommendations are provided by MDstewardship® clinically-trained infectious disease pharmacists and infectious disease physicians, and are communicated to on-site pharmacists or directly with providers.

Methods
MDstewardship® is active with many rural CAHs in Nebraska, and over 20 hospitals nationally. Here we report our ASP results for 10 CAHs in Nebraska from August 2018 to April 2019. A total of 401 ASP recommendations were given over that time.

Results
The top three most common infectious diseases diagnoses involving recommendations were UTI (16.7%), pneumonia (15.2%), and bacteremia (13.7%). Most common ASP interventions included alternative therapy (15.7%), additional therapy (13.7%), oral step-down therapy (12.7%), and further laboratory monitoring (12.5%). Additional daily antimicrobial stewardship assistance includes: development of hospital protocols, order-sets, antibiograms and guideline adherence. Total acceptance of ASP recommendations averages > 90%. Reimbursement is based on a contract over 12 months.

Conclusion
The use of TeleStewardship® services allow CAHs to have 24/7 infectious disease specialist and clinically trained antimicrobial stewardship pharmacist support with a high number of interventions and a high acceptance of recommendations. The goal of this program is to give the right antibiotic, right dose, for the right duration, for each patient.

Disclosures
All authors: No reported disclosures.
2096. System-Wide Multi-Pronged Approach Leads to Successful Reduction of Fluoroquinolone Use Across a Large Health System
Authors: Sebastian Danielle , Daragjati Florian , Saake Karl , Fakih Mohamad G 
Published: October 2019

Abstract

Background
Overuse of fluoroquinolones has been associated with increased rates of Clostridioides difficile infections, MRSA, and resistant Gram-negative infections due to selective pressure on normal flora. In addition, the FDA has issued several safety alerts regarding systemic use of fluoroquinolone antibiotics due to concerns for serious adverse events and antimicrobial resistance. Considerable variability in the utilization of this antibiotic class across the system resulted in a system-wide initiative to reduce inappropriate prescribing.

Methods
A national initiative included the integration of system-wide approved adult criteria for use into electronic health record order sets and pharmacy clinical decision support systems. System-wide education on the initiative involved learning modules, education toolkits and webinars. Fluoroquinolone utilization rates were reported monthly to help facilities determine the success of initiatives to improve performance.

Results
The fluoroquinolone criteria for use were integrated into several disease-specific order sets system-wide to include: pneumonia, acute exacerbation of COPD, chronic bronchitis, sepsis, acute pyelonephritis, and skin and soft-tissue infection. The learning modules were assigned to all acute care pharmacists resulting in 1,783 completions. Education toolkits were utilized by antimicrobial stewardship teams for provider education. A significant reduction in fluoroquinolone utilization rates, defined by days of therapy (DOT) per 1000 patient-days, was seen across 94 facilities (Figure 1). This resulted in a 45.84% reduction in fluoroquinolone rates from 2017 (56.96, 95% CI 56.72, 57.21) to 2018 (30.85, 95% CI 30.66, 31.04).

Conclusion
Developing and implementing a multi-pronged approach to maximize the effective use of fluoroquinolones can result in significant reductions in utilization across a diverse health system.

Disclosures
All authors: No reported disclosures.