bluuebunny/crossref_metadata_2025_split huggingface dataset:
171. Effectiveness and Feasibility of Pharmacist-Driven Penicillin Allergy De-Labeling Pilot Program
Authors: Song Youchan , Nelson Zachary , Gens Krista 
Published: January 2021

Abstract

Background
Prevalence of true hypersensitivity to penicillins is low (0.5–2%). Documented penicillin allergies have been associated with an increased risk of adverse outcomes, including methicillin resistant Staphylococcus aureus infections, Clostridioides difficile infections, and surgical site infections. “De-labeling” of inappropriately documented allergies can decrease the use of unnecessary broad-spectrum antibiotics and prevent negative outcomes, but labor-intensive skin testing and oral challenges can be a barrier to program implementation. The goal of this project is to assess the effectiveness and feasibility of a pharmacist-led penicillin allergy de-labeling process that does not involve skin testing or oral challenges.

Methods
Adult patients with penicillin allergies were identified using a report within the electronic health record during a 3-month pilot period. Patients identified were interviewed by an infectious diseases pharmacy resident, and an allergy history was assessed utilizing a standardized checklist. The patients’ answers determined the ability to de-label via pharmacist utilization of an evidence-based and standardized checklist developed for this project. All documentation included a detailed patient allergy history along with a beta-lactam cross-reactivity chart to help guide future antibiotic choices.

Results
66 patients were interviewed during the pilot. 12 patients (18%) met criteria for de-labeling and consented to the removal of the allergy. 4 patients (6%) met criteria for de-labeling but declined the removal of the allergy. Average time spent during patient interview was 5.2 minutes per patient. 58.3% of patients (7/12) who were de-labeled were subsequently prescribed a beta-lactam, and 100% (7/7) were able to tolerate the agents. 1 out of 4 patients (25%) who declined de-labeling but had their allergy updated to reflect intolerance was prescribed beta-lactams and was able to tolerate the agents (1/1, 100%).

Conclusion
A pharmacist-led penicillin allergy de-labeling process utilizing a standardized checklist is an effective method for removing penicillin allergies in patients who do not have a true allergy to penicillins. This pharmacist-led process is a feasible method for sites unable to perform oral challenges or skin testing.

Disclosures
All Authors: No reported disclosures
172. Evaluation of Multifaceted Antimicrobial Stewardship Interventions on The Treatment of Asymptomatic Bacteriuria
Authors: Pham Tho H , Huang Angela , Huang Vanthida , Hall Scott T 
Published: January 2021

Abstract

Background
Treatment of asymptomatic bacteriuria (ASB) and asymptomatic candiduria (ASC) is a leading cause of inappropriate use of antimicrobial therapy in many healthcare facility, and has been associated with undesirable outcomes such as Clostridium difficile infection, longer length of stay, long-term antibiotic resistance, and delayed time back to baseline activity. This evaluation was designed to utilize a pharmacy-driven multifaceted antimicrobial stewardship intervention to reduce the number of antibiotic treatment days in patients with ASB/ASC

Methods
This retrospective single-center study included hospitalized adult patients with a positive urinalysis and/or a positive urine culture with or without antimicrobial therapy from January-March 2019, compared to patients from January-March 2020 after initiation of a multifaceted antimicrobial stewardship intervention, including daily prospective audit and feedback. The primary outcome was the number of antibiotic treatment days in patients with ASB/ASC before and after implementation of the targeted antimicrobial stewardship interventions

Results
189 patients were identified upon retrospective chart review in the pre-group and 110 patients were included in the post-group. Baseline characteristics were well-matched between groups, except that the pre-group had a higher percentage of patients coming from nursing facilities while the post-group had a significantly higher percentage of patients with positive urine cultures. Antibiotic treatment days were significantly lower in the post- versus pre-group 0 (IQR 0–3) vs. 3 (IQR 1–7), p&lt; 0.001. Incidence of ASB/ASC treatment was also significantly lower in the post- versus pre-group 45.5 vs 72.5%, p&lt; 0.001. There was no statistical difference between the two groups in 30-day mortality, 30-day hospital readmission, and hospital length of stay. There was one case of Clostridium difficile infection among patients being inappropriately managed with antibiotics in each groups

Conclusion
A multifaceted antimicrobial stewardship interventions successfully reduced antimicrobial treatment days in patients with ASB/ASC, as well as overall incidence of inappropriate treatment of ASB/ASC without increasing mortality or readmission rate

Disclosures
All Authors: No reported disclosures
175. Impact of Infectious Diseases Pharmacist Interventions on Appropriateness of Antibiotics Prescribed at Hospital Discharge
Authors: Malik Luke , Ebert Steven C , Hurley Evan 
Published: January 2021

Abstract

Background
Hospital discharge is an important opportunity for antimicrobial stewardship. Despite inpatient stewardship efforts, antibiotics ordered at discharge are frequently prescribed inappropriately. Discharge antibiotic therapy may be too broad or narrow in spectrum, inappropriately dosed, or for an unnecessarily long duration. The purpose of this study was to assess the inappropriateness of antimicrobial prescribing on discharge and to measure the effect of infectious diseases pharmacist (IDP) intervention on antibiotics prescribed at discharge from the inpatient setting.

Methods
Analyses were completed before and after implementation of an IDP intervention at hospital discharge. IDPs were alerted to patients discharged on antimicrobial therapy for community-acquired pneumonia (CAP), skin and soft tissue infections (SSTIs), and urinary tract infections (UTIs). IDPs reviewed patient and laboratory data and made recommendations for modifications of antibiotics prior to patients leaving the hospital. Prescribing algorithms were created and used to standardize the assessment of discharge antibiotics using local antibiograms and IDSA guidelines. The primary outcome was the composite of appropriateness including antibiotic dose, duration, and spectrum. Secondary outcomes included appropriateness of the individual components of the primary outcome as well as the mean total duration of antibiotic therapy per disease state.

Results
A total of 77 patients were assessed during the study period occurring December 2019 through February 2020. Intervention increased the rate of appropriate prescribing for the composite of antibiotic dose, duration, and spectrum from 48.1% at baseline to 84.4% (P &lt; 0.05). By subset, intervention increased the proportion of patients receiving antibiotics of appropriate duration from 59.7% at baseline to 85.7% (P &lt; 0.001), and proportion of patients receiving antibiotics of appropriate spectrum from 90.9% at baseline to 100% (P &lt; 0.05). The mean duration of therapy for CAP decreased by 0.6 days (6.8 vs 7.4 days, P &lt; 0.05).

Conclusion
IDP intervention improved appropriateness of prescribing consistent with guideline recommendations and local antibiogram data.

Disclosures
All Authors: No reported disclosures
179. Integrating Antibiotic Stewardship Core Elements into Nurse Residency Programs
Authors: Straley Amy L , Wirtz Ann , Monsees Elizabeth 
Published: January 2021

Abstract

Background
Background: In the 2019 Centers for Disease Control and Prevention Core Elements of Hospital Antibiotic Stewardship (AS) Programs, 3 elements outline opportunities for nurse engagement:
• Leadership Commitment, securing resources to support AS endeavors, including quality/safety work
• Action, identifying new categories of nursing-based interventions
• Education, engaging nurses in patient education
Nurse Residency Programs (NRPs) enculturate newly licensed nurses (NLNs) into the profession and provide a platform for integrating NLNs into organizational initiatives, including AS.

Methods
Methods: To determine if NRPs were an avenue to integrate core elements, nursing leaders committed to using the NRP to engage NLNs in development of unit-based AS projects. Tenured nurses mentored NLNs on evidence-based quality improvement projects with an AS nurse serving as content expert. Over 2 years, 4 cohorts, 2 in Pediatric Intensive Care Unit (PICU) and 2 in Cardiology, applied a Lean problem-solving approach (A3) to identify and implement nurse-led AS projects.

Results
Results: Four A3s were completed; data collection varied by group (Figure 1). Year 1, PICU developed a handoff tool, and improved frequency of nurse to nurse communication regarding the indication, duration, and day of therapy for prescribed antibiotics. Year 2, PICU developed a tool to increase parent education encounters; frequency of interactions did not change. Year 1, Cardiology implemented educational initiatives; increased awareness of nurses’ role in AS (Figure 2). Year 2, Cardiology piloted a handoff tool to promote AS; nurse communication increased. In total, 4 NLN projects were presented to leaders and clinical staff exposing 18 NLNs, 6 tenured nurses, and over 400 clinical nurses to AS. Each cohort expressed challenges integrating AS into established processes during debriefing.
Figure 1: Cohort Overview

Figure 2: Example of Nursing-Driven A3

Conclusion
Conclusions: Commitment by unit-leaders is crucial to mitigate challenges during the development of nurse-driven projects. NRPs serve as a central location to reach a large subset of nurses and shows potential for facilitating nursing-based AS interventions. Elements were integrated, through challenges remain with maintaining a standard data collection process and analysis within and across NLN cohorts.

Disclosures
All Authors: No reported disclosures
182. Missed Opportunities to Discontinue Unnecessary Vancomycin During Pharmacist Therapeutic Monitoring
Authors: Medler Corey J , Whitney Mary , Galvan-Cruz Juan , Kendall Ron , Kenney Rachel , Davis Susan L , Davis Susan L 
Published: January 2021

Abstract

Background
Unnecessary and prolonged IV vancomycin exposure increases risk of adverse drug events, notably nephrotoxicity, which may result in prolonged hospital length of stay. The purpose of this study is to identify areas of improvement in antimicrobial stewardship for vancomycin appropriateness by clinical pharmacists at the time of therapeutic drug monitoring (TDM).

Methods
Retrospective, observational cohort study at an academic medical center and a community hospital. Inclusion: patient over 18 years, received at least three days of IV vancomycin where the clinical pharmacy TDM service assessed for appropriate continuation for hospital admission between June 19, 2019 and June 30, 2019. Exclusion: vancomycin prophylaxis or administered by routes other than IV. Primary outcome was to determine the frequency and clinical components of inappropriate vancomycin continuation at the time of TDM. Inappropriate vancomycin continuation was defined as cultures positive for methicillin-susceptible Staphylococcus aureus (MRSA), vancomycin-resistant bacteria, and non-purulent skin and soft tissue infection (SSTI) in the absence of vasopressors. Data was reported using descriptive statistics and measures of central tendency.

Results
167 patients met inclusion criteria with 38.3% from the ICU. SSTIs were most common indication 39 (23.4%) cases, followed by pneumonia and blood with 34 (20.4%) cases each. At time of vancomycin TDM assessment, vancomycin continuation was appropriate 59.3% of the time. Mean of 4.22 ± 2.69 days of appropriate vancomycin use, 2.18 ± 2.47 days of inappropriate use, and total duration 5.42 ± 2.94. 16.4% patients developed an AKI. Majority of missed opportunities were attributed to non-purulent SSTI (28.2%) and missed MRSA nares swabs in 21% pneumonia cases (table 1).

Conclusion
Vancomycin is used extensively for empiric treatment of presumed infections. Appropriate de-escalation of vancomycin therapy is important to decrease the incidence of adverse effects, decreasing hospital length of stay, and reduce development of resistance. According to the mean duration of inappropriate therapy, there are opportunities for pharmacy and antibiotic stewardship involvement at the time of TDM to optimize patient care (table 1).
Missed opportunities for vancomycin de-escalation

Disclosures
All Authors: No reported disclosures
184. Pharmacist role in antimicrobial stewardship research: a 30-year experience
Authors: Pillinger Kelly E , Jariwala Ripal , Mercuro PharmD; Nicholas J , Cwengros Laura N , Davis Susan L , Davis Susan L , Appaneal Haley 
Published: January 2021

Abstract

Background
Antimicrobial stewardship program (ASP) guidance from the Centers for Disease Control and Prevention recommends co-leadership of both an infectious-diseases (ID) physician and ID-trained pharmacist. Pharmacists play a key role in the therapeutic management, administration, and implementation of ASP interventions. The purpose of this study, conducted on behalf of the Society of Infectious Diseases Pharmacists, was to describe the involvement of pharmacists in publications of ASP interventional research.

Methods
A PubMed search was conducted to identify publications in the United States and Canada from 1990–2019 including “antimicrobial (or antibiotic) stewardship” or “antimicrobial (or antibiotic) intervention.” Articles were screened for active interventions with comparator arms. A random subset of 100 pharmacist-authored manuscripts were selected using a time-based clustering strategy to review specific study designs, populations, interventions, and endpoints.

Results
Of 1,426 publications, 340 met inclusion. Two-thirds (228/340) of all interventional antimicrobial stewardship studies included a pharmacist author. Pharmacists were lead authors in 59% (135/228) of studies that included a pharmacist. Among the randomized subset of pharmacist-authored manuscripts (n=100), the average impact factor of journals with pharmacists as the first author was 3.52, compared to 5.25 as middle authors. Most studies were inpatient focused (89%), included adults (81%), and conducted in a single-site setting (84%). Pediatrics, immunocompromised, post-acute care, and ambulatory populations comprised less than 10% of the publications. The most common interventions described were audit and feedback (55%), guideline implementation (49%), and education (40%). Endpoints included drug utilization (66%), clinical outcomes (57%), safety events (46%), cost (40%), and appropriateness of therapy (35%).
Figure 1.

Conclusion
Pharmacists have an integral role in publication and dissemination of ASP research. Opportunities exist in multi-site collaboration as well as research in ambulatory, pediatric, and immunocompromised groups. Future research endpoints should be practical, generalizable, and patient-centered.

Disclosures
Kelly E. Pillinger, PharmD, BCIDP, Pharmacy Times (Other Financial or Material Support, Speaker) Haley Appaneal, PharmD, Shionogi (Grant/Research Support)
185. Pilot of a Face-to-Face Model of Stewardship (Handshake Stewardship) in a General Medicine Ward
Authors: Morita Kazumi , Mueller Daniel 
Published: January 2021

Abstract

Background
Handshake stewardship (HS) is an antibiotic stewardship strategy that includes a more in-person approach to prospective audit and feedback (PAF). It has emerged as an effective form of PAF, enhancing trust and collaboration between the antibiotic stewardship team (AST) and the prescribers. However, resources can be a barrier to implementation. We sought to describe our experience of a HS pilot implementation at our institution.
Methods: Our HS model was implemented as a pilot among five attending-only hospital medicine teams at Temple University Hospital. All antimicrobials administered to patients on these teams were reviewed by the AST pharmacist on weekdays from 2/4/19 to 3/4/19. The AST physician and pharmacist then physically located each team to discuss recommendations and answered questions. Number and types of AST recommendations were recorded along with the outcome. As patients on all five teams were centralized in one patient care unit (PCU), antibiotic utilization of this PCU, measured as days of therapy per 1000 patient days (DOT/1000 PD) was collected from January to March 2019. An anonymous survey of hospitalists involved in this pilot was also performed to determine their perceptions toward the HS model.
Results: During the pilot period, 108 recommendations were made on 63 unique patients. On average, 20 patients were on antimicrobials on a given day, and AST spent 2 hours per day reviewing data and interacting with the teams. The most common recommendation was a change in antibiotic regimen (39%), mostly for de-escalation of therapy, with an overall acceptance rate of 91%. Overall antibiotic usage was numerically lower in the pilot month (February; 622 DOT/1000 PD) compared to the two adjacent non-pilot months; January (824 DOT/1000 PD) and March (728 DOT/1000 PD). The difference was mostly explained by the decrease in anti-pseudomonal beta-lactam use. The HS model was widely accepted among the surveyed hospitalists, who preferred it over the current PAF model completed via telecommunication.
Conclusion: The HS model appears to be effective and well accepted by our hospitalists. Strategies to expand this face-to-face approach may provide additional opportunities for antimicrobial optimization while increasing provider satisfaction.

Disclosures
All Authors: No reported disclosures
186. Prescriber-Led Antibiotic Timeout Alert Responses: A Retrospective Multicenter Study
Authors: Smoke Steven , Secaras Ellen , Crossen Melissa , Patel Gargi , Brophy Alison , Clark Alexander , Elbaga Yasmine , Raja Karan , Shah Monica , Stone Elizabeth , Lew Indu 
Published: January 2021

Abstract

Background
An antibiotic time out is when a clinician is prompted to reevaluate antibiotic therapy for appropriateness after 48–72 hrs. The purpose of this study is to evaluate the impact of a prescriber-led electronic antibiotic timeout alert.

Methods
This was a retrospective cohort study conducted at seven hospitals of a health system. The alert prompts prescribers to reevaluate antibiotic therapy after &gt; 72 hours upon opening the electronic chart. Prescribers can then choose to “Continue”, “Renew”, “Discontinue” or “Defer” for each antibiotic. The alert fires for every time the chart is opened, for every prescriber, every time any antibiotic has been active for &gt; 72 hours and no action response (i.e., “Continue”, “Renew”, “Discontinue”) has been selected. This was a 6 month study from November 1, 2018 – April 30, 2019. The primary outcome measure was the percentage of patients having &gt; 1 antibiotic discontinued via the electronic antibiotic timeout alert. Secondary outcomes included frequency of timeout alerts per patient, and percentage of discontinuations per response, by drug, by indication and by patient age.

Results
A total of 213950 alerts fired for 13263 patients during the study period. 94.2% and 0.4% of responses were “Defer” and “Discontinue”, respectively. The average number of alerts per patient was 16.1. The percentage of patients who had at least one discontinuation was 5.3%. 38.2% of patients had no response other than “Defer”. There were a total of 10306 action responses, 4.8% of which were “Discontinue”. Among action responses, discontinue rates for the indications of “COPD exacerbation”, “Prophylaxis, Surgical/Procedural”, “Prophylaxis, Immunosuppression”, “Osteomyelitis” were 9.6%, 12%, 1.3% and 1%, respectively. Azithromycin and trimethoprim/sulfamethoxazole had discontinuation rates of 9.3% and 0.9%, respectively. Patient age had a significant impact on discontinuation rates with rates of 4.7%, 3.5%, and 10.9% for patients &gt; 18, 2–17 and &lt; 2 years of age (p&lt; 0.001).

Conclusion
An electronic antibiotic timeout alert implemented at seven hospitals was largely ignored. This alert may be refined by limiting it to antibiotic orders with specific features associated with higher rates of discontinuation.

Disclosures
All Authors: No reported disclosures
187. Significant Decline in Carbapenem Use with Multifaceted Antimicrobial Stewardship Program (ASP) Interventions
Authors: Kaushik Ashlesha , Gupta Sandeep , Lettow Erin , Lundsgaard Jenna , Thieman Corey , Fullas Fekadu , Padomek Michael 
Published: January 2021

Abstract

Background
Per World Health Organization, carbapenems should be key targets for antibiotic stewardship programs.

Methods
A multifaceted antimicrobial stewardship program (ASP) was implemented in January 2018 at a 160-bed tertiary care center serving the tristate area of Iowa, South Dakota and Nebraska. Carbapenem use during pre ASP intervention period (P1: 07/01/2016-12/31/2017) was compared with ASP intervention period (P2: 01/01/2018-06/30/2019). ASP interventions included: providing educational pearls in monthly physician newsletter; educational posters in high-traffic provider areas; suppression of carbapenem results on microbiology susceptibility reports; distributing monthly carbapenem use data to providers; provider counseling for appropriate ordering; creating carbapenem alternative alert in order-entry software; generating pharmacy decision-support software algorithms to aid in identifying intervention opportunities; removing carbapenems from order-sets where appropriate. Additional ASP pharmacist interventions: limiting double antibiotic coverage for pseudomonas/anaerobes; de-escalation recommendations.

Results
Carbapenem use declined significantly from a mean of 64.81 days of therapy (DOT) per 1000 patient days during P1 to 8.91 DOT per 1000 patient days in P2 (p&lt; 0.001). All hospital units showed a significant decrease in carbapenem use, with intensive care step-down unit noting 85.7% reduction (p &lt; 0.00001); floors (medicine, pediatric, surgery) with 61.6% reduction (p&lt; 0.00001); and intensive care units with 52% reduction (p&lt; 0.00001) during P2 compared to P1. Defined daily doses per 1000 patient days decreased from 314.9 in P1 to 93.4 in P2 (p&lt; 0.00001). During P2, 58.3% (132/228) of carbapenem orders were found to be appropriate compared to 37.5% (190/506) in P1 (p&lt; 0.00001). Sensitivity profile for Pseudomonas aeruginosa improved from 86% carbapenem sensitivity during P1 to 89% in P2. No Carbapenem Resistant Enterobacteriaceae isolates were identified. Cost savings of $643 per 1000 patient days were recognized in P2 as a result of reduced carbapenem use.

Conclusion
There was a significant decline in total carbapenem utilization, an increase in proportion of appropriate use and considerable cost savings as a result of ASP interventions.

Disclosures
All Authors: No reported disclosures