bluuebunny/crossref_metadata_2025_split huggingface dataset:
1053. De-Implementing Low-Value Antibiotic Prescribing Across Levels of Care
Authors: Gupta Kalpana , Hartmann Christine , Schweizer Marin L 
Published: October 2019

Abstract

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

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

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

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

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

Abstract

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

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

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

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

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

Abstract

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

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

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

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

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

Abstract

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

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

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

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

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

Abstract

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

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

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

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

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

Abstract

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

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

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

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

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

Abstract

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

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

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

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

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

Abstract

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

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

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

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

Disclosures
All authors: No reported disclosures.
1104. Antibiotic Prophylaxis for the Endoscopic Endonasal Approach
Authors: DeKerlegand Alaina , Vilar Jason , Persaud Rosemary 
Published: October 2019

Abstract

Background
Evidence available to guide perioperative antibiotic prophylaxis for endoscopic endonasal (EEN) procedures remains limited. The primary objective of this study was to characterize the impact of antibiotic prophylaxis on the incidence of post-operative central nervous system (CNS) or sinonasal infections in patients undergoing EEN procedures.

Methods
This was an IRB-approved descriptive analysis including patients >18 years of age who underwent EEN surgery at AdventHealth Orlando over a 3-year period. Patients were excluded if they had an infection present prior to surgery, ongoing antibiotic treatment (other than surgical prophylaxis) at the time of surgery, or a basic sinonasal surgery which lacked CNS penetration. The primary endpoint assessed was the rate of CNS or sinonasal infection within 30 days of EEN procedure.

Results
After screening 160 patient encounters, a total of 118 patients were included. The most common antibiotic prophylaxis utilized was ceftriaxone, followed by cefazolin, or alternative/combination therapy (72.8% vs. 13.6% vs. 13.6% of cases, respectively). There were 4 total patients who met the primary endpoint, and all 4 cases were due to a diagnosis of meningitis (overall rate 3.4%). Infection rate by antibiotic prophylaxis was 2.4% for ceftriaxone, 0% for cefazolin, and 14.3% for alternative/combination therapy. Based upon the retrospective nature of this study, we were unable to account for provider preference in selection of surgical prophylaxis or other surgeon-specific factors.

Conclusion
In this retrospective descriptive analysis, rates of CNS or sinonasal infections occurred at a rate similar to previously published literature. Larger, prospective studies are warranted to evaluate the impact of antibiotic selection on the rate of CNS or sinonasal infections post-EEN procedures.

Disclosures
All authors: No reported disclosures.
1107. Impact of Routine Education and Data Feedback on the Durability of an Antimicrobial Stewardship Intervention for Outpatient Urinary Tract Infections
Authors: Funaro Jason , Moehring Rebekah W , Liu Beiyu , Lee Hui-Jie , Sarubbi Christina , Anderson Deverick J , Wrenn Rebekah 
Published: October 2019

Abstract

Background
Achieving lasting, sustainable effects in outpatient AS interventions has been a challenge for many programs. Our group observed an initial benefit of an outpatient AS intervention focused on diagnosis and management of urinary tract infections (UTIs). However, prescribing habits trended back toward baseline over time. This study aimed to evaluate the impact of routine education and comparative data feedback on the durability of an outpatient AS intervention for UTIs.

Methods
We conducted a prospective quasi-experimental study at one primary care (PC) and one urgent care (UC) clinic to evaluate the durability of an outpatient AS intervention implemented in August 2017 and November 2017, respectively. Clinicians who treated adult patients with a diagnosis of acute UTI at either clinic participated in the study. The initial intervention (phase 1) included development of clinic-specific antibiograms and UTI diagnosis and treatment guidelines. Approximately 12 months after the initial intervention, routine education along with clinic- and comparative provider-specific feedback reports were emailed to clinicians at regular intervals (phase 2). The primary outcome was percent of encounters in which first- or second-line antibiotics were prescribed. Pre- and post-intervention phase and trend changes were assessed using an interrupted time-series approach.

Results
Data were collected on 792 and 3,720 UTI encounters at PC and UC, respectively. In the 12 months after the initial intervention, rates of guideline concordance were 73% at PC and 57% at UC (Figures 1 and 2). After routine data feedback was provided for approximately 7 months at PC and 5 months at UC, rates of guideline concordance remained relatively stable at 75% for PC and 61% at UC. An initial 37% relative reduction in fluoroquinolone (FQ) use was observed during phase 1 which was further reduced by an additional 18% during phase 2.

Conclusion
Routine provision of clinic-specific feedback and peer comparisons sustained rates of guideline-concordant prescribing at two outpatient clinics. This intervention required significant resources for data analysis and delivery, but it was successful in decreasing rates of FQ prescribing and maintaining clinician engagement.

Disclosures
All authors: No reported disclosures.