bluuebunny/crossref_metadata_2025_split huggingface dataset:
2020. Impact of Local Antimicrobial Stewardship Guidelines through a Cellphone App to Lower Hospital-acquired MDR Infections in a Private Hospital in Mexico City
Authors: Villanueva Reza Marco , Lanz-Zubiria Lorena , Rojas de Ita Israel , Castañeda-Méndez Paulo , Aleman Aguilar Esperanza , Aguilar-Zapata Daniel , Soto-Ramirez Luis E , Reyes Mar Javier , Lorena Cabrera Ruiz Maria 
Published: October 2019

Abstract

Background
Hospital-acquired multi-drug-resistant organisms (HA-MDRO) infections are associated with increased cost, length of stay, morbidity, and mortality. The prevalence of HA-MDRO has been increasing worldwide. We look to describe how the implementation of local guidelines as an app available for tablets or cellphones in our hospital in 2014 decrease the prevalence of HA-MDRO.

Methods
Local guidelines were implemented as an electronic application available and intended for hospital staff only. This app gives local patterns of resistance for bacteria with treatment recommendations alongside suggested antimicrobial drugs for empiric treatment. Descriptive statistics were performed.

Results
In 2013, before implementing the app, HA-MDRO were reported in 25% of hospital-acquired infection. After the introduction of the app, compliance in 2014 was 56.7% with HA-MDRO reported in 20%, 2015 use was 60.7% and HA-MDRO in 18%, 2016 compliance 68.7% and HA-MDRO in 16%, 2017 compliance in 73.7% and HA-MDRO in 14%, lastly in 2018 prevalence was 15% of HA-MDRO while use of local guidelines was 78.7%. Different type of infections (VAP, HAP, UTI, SSI, BSI) also decreased while following guidelines recommendations.

Conclusion
These programs are needed as a part of the healthcare program to control the HA-MDRO morbidity and complications. Simple friendly-user electronic applications such as the one implemented in our hospital led to higher compliance and lower hospital-acquired infections. Antimicrobial stewardship programs and local guidelines should be part of the standard of care of all hospitals.

Disclosures
All authors: No reported disclosures.
2028. A Survey of Antimicrobial Availability, Training, and Antimicrobial Recommendations by Staff in Pharmacies and Non-pharmacy Stores in the Dominican Republic
Authors: Mena Lora Alfredo J , Almonte Marcos , Jimenez Mariel , Rodriguez Abreu Julia , Rojas Fermin Rita , Bleasdale Susan C 
Published: October 2019

Abstract

Background
Antimicrobial resistance (AMR) is a rising global health challenge. Antimicrobial use (AU) is a key factor in the development of AMR, but knowledge gaps remain on AU and dispensation in low- and middle-income countries (LMICs). AU can be purchased without prescriptions in many LMICs and are available in pharmacies and non-pharmacy stores. We seek to describe the availability, training and AU recommendations in pharmacies and non-pharmacy stores in the Dominican Republic (DR).

Methods
We conducted a survey of pharmacies and non-pharmacy stores that dispense antimicrobials from March to April 2019 in randomly selected locations throughout metropolitan Santo Domingo. Data on the availability of antimicrobials and training on AU was obtained. Antimicrobial of choice for common symptoms such as dysuria, throat pain, diarrhea, fever, and cough were queried, and data tabulated. Availability of antimicrobials by phone and online delivery was assessed.

Results
A total of 35 stores were surveyed. Ten pharmacies and 15 nonpharmacy stores agreed to participate. Ten refused and were excluded. Fifty AU recommendations were given in pharmacies and 16 in non-pharmacy stores. The most common type of antimicrobial recommended were aminopenicillins (Figure 1). Staff received prior training on antimicrobials in 70% of pharmacies and 0% of non-pharmacy stores. Antimicrobial recommendations by symptom in pharmacies and non-pharmacy stores are seen in Figure 2 and 3. Antimicrobials are available for phone delivery in 100% of pharmacies and 90% of non-pharmacy stores. No antimicrobials were available via online delivery apps.

Conclusion
Antimicrobials are widely available in the DR without prescriptions and can be purchased in person or via phone delivery. Aminopenicillins are commonly prescribed and may contribute to high rates of ESBL in the DR. Pharmacy staff gave more specific symptom-based recommendations than non-pharmacy staff and commonly had prior training on antibiotic use. In LMICs with easy access to antimicrobials, frontline staff in pharmacies and non-pharmacy stores are gatekeepers for AU and may benefit from further education and training. Further studies on attitudes and perceptions related to antimicrobial use in the community are needed.

Disclosures
All authors: No reported disclosures.
2030. Impact of an Antimicrobial Stewardship Program on Carbapenem Susceptibility in a National Hospital in Bhutan
Authors: Chuki Pem , Bianchini Monica L , Tshering Thupten , Sharma Ragunath , Yangzom Pema , Dema Ugyen , Kenney Rachel , Maki Gina , Zervos Marcus 
Published: October 2019

Abstract

Background
The overuse of broad-spectrum antibiotics drives antimicrobial resistance (AMR), and the prevalence of highly-resistant Gram-negative infections is increasing across the world, especially in low- and middle-income countries (LMIC). Carbapenem resistance is of particular concern since these are often the last line agents. Antimicrobial restriction is an antimicrobial stewardship intervention (AMS) that aims to reduce the use of broad-spectrum antibiotics to preserve antimicrobial susceptibility.

Methods
This is retrospective, observational study of antibiotic consumption and prevalence of antibiotic resistance of bacterial isolates from inpatients at Jigme Dorji Wangchuck National Referral Hospital, a 350-bed multi-specialty hospital in Thimphu, Bhutan. Antibiotic consumption and antimicrobial susceptibility were monitored from January 2015 to December 2017 by the pharmacy department and the microbiology lab, respectively. Antibiotic consumption was measured using defined daily doses (DDD) and expressed as DDDs per 1,000 persons per day. The antibiotic susceptibility was determined using the Clinical Laboratory Standards Institute (CLSI) guideline. A hospital AMS program with multidisciplinary team and good hospital managerial/ leadership support were initiated in 2016 and interventions included antimicrobial restrictions, educations, guidelines for use, post prescription review, de-escalation, audit and feedback.

Results
From 2015 to 2016, the DDDs of carbapenems and piperacillin–tazobactam (PTZ) increased while ceftriaxone decreased (Figure 1). After the AMS program was implemented in 2016, the annual DDDs of carbapenems decreased while PTZ and ceftriaxone increased. Antimicrobial susceptibility of Klebsiella pneumoniae and Escheriachia coli blood isolates to carbapenems and ceftriaxone increased from 2016 to 2017: 50/61 (82%) vs. 45/49 (92%) and 24/91 (26%) vs. 31/92 (34%), respectively.

Conclusion
Implementing an AMS program that restricted the use of carbapenems resulted in a decrease in carbapenem use and increased antimicrobial susceptibility for carbapenems and ceftriaxone. AMS interventions can be successful to decrease carbapenem-resistance in LMIC.
2035. Clinical and Economic Outcomes in Patients with Complicated Urinary Tract Infection (cUTI) and Complicated Intra-Abdominal Infection (cIAI) in Perú: Impact of Gram-Negative Organisms (GNO) Resistant to Antibiotics
Authors: Hercilla Luis , Perez Giancarlo , Illescas Ricardo , Hidalgo Jose , Ramirez Eresvita , Moreno Vanesa , Galdos-Cardenas Gerson , Gutierrez-Rodriguez Raul , Rodriguez Lourdes , Carlos Orengo Juan , Monsanto Homero 
Published: October 2019

Abstract

Background
Delays in appropriate therapy of infections affect clinical outcomes. The aim of this study was to compare the clinical and economic outcomes of patients with cUTI and cIAI due to cephalosporin- and carbapenem-resistant GNOs to similar infections caused by nonresistant GNOs.

Methods
A retrospective cohort study of patients admitted to two tertiary care hospitals in Lima-Callao, Peru between January and December 2017. Patients with resistant strains were compared with those with nonresistant strains for the failure of initial antibiotic regimen (defined as worsened clinical status, change of initial antibiotic treatment, or in-hospital mortality), median length of stay (LOS), hospitalization ward cost and total hospitalization cost.

Results
A sample of 500 consecutive culture-positive patients were included: 429 (86%) with cUTI and 71 (14%) with cIAI (table).

Conclusion
cUTI caused by GNOs resistant to cephalosporins or carbapenems are associated with an incremental clinical and economic burden. The proportion of inappropriate therapy in patients with resistant infections is high. The cost of care for carbapenem-resistant cUTI was highest. The appropriate initial antibiotic choice may minimize the impact of GNO resistance on outcomes of patients with cIAI and cUTI.

Disclosures
All authors: No reported disclosures.
2036. A Quasi-Experimental Survey Study of Antimicrobial Stewardship Education for Registered Nurses
Authors: Santarossa Maressa , Walk Christina , Joyce Cara J , Albarillo Fritzie S 
Published: October 2019

Abstract

Background
Antimicrobial stewardship (AS) efforts have led to improved patient outcomes, reduction in unnecessary costs, and decrease in antimicrobial resistance (AR). Loyola University Medical Center (LUMC) is a quaternary care-system that has a comprehensive multidisciplinary Antimicrobial Stewardship Program (ASP). Registered nurses (RNs) have been shown to be a vital part of ASP; however their role and engagement in ASP should continue to be investigated and explored.

Methods
In February 2018, a voluntary online survey was created and disseminated to all RNs at LUMC to evaluate their baseline knowledge and perception of AS and AR, as well as to further investigate their role in AS at LUMC. Based on the results of the survey, our AS team implemented a multi-faceted education program. This included a series of lectures which were emailed to all RNs, as well as live education sessions by the AS team during nursing huddles. In March 2019, a second survey was distributed to all nurses with the primary goal of evaluating changes in the knowledge and perception of AS and AR after targeted education efforts. The secondary goal was to gather feedback to target further efforts of engaging RNs in AS.

Results
A total of 179 RNs completed the first survey and 117 completed the second survey. In both surveys, over 90% of RNs agree that they play an important role in AS, and that AS can decrease AR and adverse effects of antimicrobials. The majority in both surveys also agreed that AR can be caused by misuse/overuse of antimicrobials and this can be harmful to patients. Unfamiliarity with AS practices among RNs remains an issue, however this increased from 70% strongly agree/agree in the first survey to 74% in the second survey. Sixty-nine percent of RNs recalled reading the PowerPoint education slides, while only 38% recalled being educated in person by the AS team. A similar number of RNs (58% and 60%, respectively) prefer to be educated in person vs. through email.

Conclusion
Hospital-specific surveys on nurses’ perception and knowledge on AS and AR can be used to guide future ASP interventions, as well as to evaluate the effectiveness of these interventions. Our ASP at LUMC implemented strategies to improve nursing education and engagement in AS and evaluated this strategy using a pre-/post-survey.

Disclosures
All authors: No reported disclosures.
2044. An Assessment and Feedback Model Bringing Antimicrobial Stewardship Program Expertise to Long-Term Care Facilities
Authors: Chung Philip , Tyner Kate , Bergman Scott , Micheels Teresa , Rupp Mark E , Schwedhelm Michelle , Tierney Maureen , Van Schooneveld Trevor C , Ashraf M Salman 
Published: October 2019

Abstract

Background
Long-term care facilities (LTCF) often struggle with implementation of antimicrobial stewardship programs (ASP) that meet all CDC core elements (CE). The CDC recommends partnership with infectious diseases (ID)/ASP experts to guide ASP implementation. The Nebraska Antimicrobial Stewardship Assessment and Promotion Program (ASAP) is an initiative funded by NE DHHS via a CDC grant to assist healthcare facilities with ASP implementation.

Methods
ASAP performed on-site baseline evaluation of ASP in 5 LTCF (42–293 beds) in the spring of 2017 using a 64-item questionnaire based on CDC CE. After interviewing ASP members, ASAP provided prioritized facility-specific recommendations for ASP implementation. LTCF were periodically contacted in the next 12 months to provide implementation support and evaluate progress. The number of CE met, recommendations implemented, antibiotic starts (AS) and days of therapy (DOT)/1000 resident-days (RD), and incidence of facility-onset Clostridioides difficile infections (FO-CDI) were compared 6 to 12 months before and after on-site visits. Paired t-test and Wilcoxon signed rank test were used for statistical analyses.

Results
Multidisciplinary ASP existed in all 5 facilities at baseline with medical directors (n = 2) or directors of nursing (n = 3) designated as team leads. Median CE implemented increased from 3 at baseline to 6 at the end of follow-up (P = 0.06). No LTCF had all 7 CE at baseline. By the end of one year, 2 facilities implemented all 7 CE with the remaining implementing 6 CE. LTCF not meeting all CE were only deficient in reporting ASP metrics to providers and staff. Among the 38 recommendations provided by ASAP, 82% were partially or fully implemented. Mean AS/1000 RD reduced by 19% from 10.1 at baseline to 8.2 post-intervention (P = 0.37) and DOT/1000 RD decreased by 21% from 91.7 to 72.5 (P = 0.20). The average incidence of FO-CDI decreased by 75% from 0.53 to 0.13 cases/10,000 RD (P = 0.25).

Conclusion
Assessment of LTCF ASP along with feedback for improvement by ID/ASP experts resulted in more programs meeting all 7 CE. Favorable reductions in antimicrobial use and CDI rates were also observed. Moving forward, the availability of these services should be expanded to all LTCFs struggling with ASP implementation.

Disclosures
All authors: No reported disclosures.
2051. Frequency of Inappropriate Antibiotic Prescribing in Nursing Homes
Authors: Kanchagar Chitra , Noble Brie N , Crnich Christopher , McGregor Jessina C , Bearden David T , Furuno Jon P 
Published: October 2019

Abstract

Background
Antibiotics are among the most prescribed medications in nursing homes (NHs). The increasing incidence of multidrug-resistant and C. Difficile infections due to antibiotic overuse has driven the requirement for NHs to establish antibiotic stewardship programs (ASPs). However, estimates of the frequency of inappropriate antibiotic prescribing in NHs have varied considerably between studies. We evaluated the frequency of inappropriate antibiotic prescribing in a multi-state sample of NHs.

Methods
We utilized a retrospective, (20%) random sample of residents of 17 for-profit NHs in Oregon, California, and Nevada who received antibiotics between January 1, 2017 and May 31, 2018. Study NHs ranged in size from 50 to 188 beds and offered services including subacute care, long-term care, ventilator care, and Alzheimer’s/memory care. Data were collected from residents’ electronic medical records. Antibiotic appropriateness was defined using Loeb Minimum Criteria for initiation of antibiotics for residents with indications for lower respiratory tract infection (LRTI), urinary tract infection (UTI) and skin and soft-tissue infection (SSTI). Residents with other types of infections were excluded from the study.

Results
Among 232 antibiotic prescriptions reviewed, 61% (141/232) were initiated in the NH. Of these, 65% were for female residents and 81% were for residents above the age of 65. Nearly 70% (98/141) of antibiotic prescriptions were for an indication of an LRTI, UTI, or SSTI of which 51% (57% of LRTIs, 52% of UTIs, and 35% of SSTIs) did not meet the Loeb Minimum Criteria and were determined to be inappropriate. Among antibiotics that did not meet the Loeb Minimum Criteria, more than half were cephalosporins (40%) or fluoroquinolones (14%) and the median (interquartile range) duration of therapy was 7 (5–10) days.

Conclusion
These data from a multi-state sample of NHs suggest the continued need for improvement in antibiotic prescribing practices and the importance of ASPs in NHs.

Disclosures
All authors: No reported disclosures.
2060. Evaluation of a Pharmacist’s Impact on Antimicrobial Prescribing in an Urgent Care Center
Authors: Fabian Amy , Linnertz Sara , Avery Lisa 
Published: October 2019

Abstract

Background
The urgent care center (UC) setting is an opportunity for pharmacists to promote antimicrobial stewardship (AS). The primary objective is to determine compliance with antibiotic prescribing recommendations for the treatment of urinary tract infections (UTIs), skin and soft-tissue infections (SSTIs), upper respiratory tract infections (URIs), and lower respiratory tract infections (LRTIs) before, during, and after the presence of an AS pharmacist in an UC.

Methods
Single-center, retrospective, observational, pre (December 10, 2018–January 6, 2019), intervention (January 7–February 3, 2019), and post-intervention (February 4–March 3, 2019) study. All non-pregnant, adult patients with a chief complaint consistent with UTI, SSTI, URI, or LRTI were included. Patients transferred to another facility, presented for a follow-up visit, with multiple sites of infection, or treated for a bite, wound, or surgical site infection were excluded. Noncompliance (NC) was a composite endpoint of non-guideline adherent antibiotic prescribing for viral infections, inappropriate empiric selection, duration, and/or dosage. Secondary outcomes include composite outcome components and subgroup analysis of disease states.

Results
A total of 1,930 patients were screened with 439,440, and 430 patients included in the pre, intervention, and post-intervention group. Demographics were similar between groups, except for age (P = 0.001) and influenza diagnoses (P < 0.001). NC decreased from 43.3% to 31.1% (P = 0.0002) pre-intervention to intervention and from 31.1% to 26.5% (P = 0.14) post-intervention. Pre-intervention to intervention resulted in a change in composite outcome components of non-compliant prescribing (18.9% to 13%, P = 0.02), empiric selection (8.7% to 5.9%, P = 0.12), duration (4.1% to 5.9%, P = 0.28), dosage (3.4% to 0.5%, P = 0.001), and multiple components for NC (8.2% to 6.4%, P = 0.3). Reductions in NC were seen for UTI (83.3% to 69.2%, P = 0.26), SSTI (45.7% to 42.9%, P = 1.0), URI (23.5% to 23.2%, P = 1.0), and LRTI (82.1% to 51.6%, P = 0.0004).

Conclusion
An AS pharmacist’s presence in a UC significantly reduced NC to antibiotic prescribing recommendations. The largest impact was in reducing antibiotic treatment of viral infections and optimizing antibiotic dosing.

Disclosures
All authors: No reported disclosures.
2073. Apples and Oranges: Comparing Toolkits to Track Antimicrobial Prescribing in Ambulatory Care Settings
Authors: Kassamali Zahra , Bryson-Cahn Chloe , Bouchard Todd , Min Lee Kyung , G. Lansang Jose Mari , Thomassen Scott , Lynch John B , Lynch John B , May Larissa , Kvak Staci , D’Angeli Marisa A 
Published: October 2019

Abstract

Background
Between 15–50% of patients seen in ambulatory settings are prescribed an antibiotic. At least one-third of this usage is considered unnecessary. Multiple tools have emerged to evaluate antibiotic prescribing in ambulatory settings. The toolkits, MITIGATE and Choosing Wisely, have been funded by the Centers for Disease Control and Prevention and promoted by the American Board of Internal Medicine, respectively, but use different reporting criteria. Notably, the target rate of antibiotic prescribing in the MITIGATE framework is zero, whereas the target rate for Choosing Wisely is not zero because it includes diagnoses for which an antibiotic may be appropriate. We compared both to evaluate prescribing in primary care and specialty clinics, urgent care, and the emergency department.

Methods
This was a single-center observational study. Electronic medical record data were accessed to determine antibiotic prescribing and diagnosis codes. The primary outcome was rate of inappropriate antibiotic prescribing overall and in each of the individual settings.

Results
Between March 2018 and April 2019, 42,650 patient visits met MITIGATE inclusion criteria and 11% received an antibiotic unnecessarily. In the same time-period, 23,366 patient visits met Choosing Wisely inclusion criteria and 17% received an antibiotic unnecessarily. Within the MITIGATE framework, inappropriate prescribing was highest in the ED (17%), followed by primary care (12%), urgent care (10%), and specialty care (5%). Choosing Wisely, inappropriate prescribing was highest in primary care (23%), followed by urgent care (15%), and specialty care (8%). The ED was not included in the Choosing Wisely technical specifications. The top coded diagnosis in both frameworks was acute respiratory infection, unspecified.

Conclusion
Rates of inappropriate antibiotic prescribing varied widely depending upon the toolkit used. Inappropriate antibiotic prescribing in primary care by Choosing Wisely framework was double that of MITIGATE. Careful consideration of the differences and goals of using these toolkits is needed both on the local level for individual provider feedback and more broadly, when comparing prescribing rates between institutions.

Disclosures
All authors: No reported disclosures.
2080. Impact of an Emergency Department Post-discharge Blood Culture Follow-up Program
Authors: Vazquez Deida Axel , Salazar Veronica , Lee Lilly , Abbo Lilian 
Published: October 2019

Abstract

Background
Blood cultures are the gold standard in the identification of laboratory confirmed bloodstream infections (LCBI) but contamination can lead to unnecessary interventions. This study sought to assess the number of unwarranted admissions in patients with contaminated blood cultures post-discharge and at low risk for LCBI before and after the implementation of a multidisciplinary emergency department (ED) blood culture follow-up program.

Methods
This was a two-phase retrospective cohort study at a tertiary care, 1,550-bed, academic hospital and level I trauma center in southeast Florida. Phase 1 assessed interventions made on patients 18 years of age or older discharged from the ED or a hospital observation unit with a positive blood culture result post-discharge from March 2018 to July 2018. Phase 2 assessed interventions made from December 2018 to March 2019 post-implementation of the multidisciplinary follow-up program. The criteria for low risk of LCBI were lack of risk factors for infection and < 2 positive blood cultures with a commensal bacteria with no symptoms of fever or hypotension on the date of specimen collection and 3 days before or after such date.

Results
Among patients at low risk for LCBI (46% of 24 patients in phase 1 vs. 59% of 22 patients in phase 2), unwarranted admissions due to contaminated blood cultures occurred in 27.3% of patients in phase 1 vs. 0% of patients in phase 2 (P = 0.08). Phase 1 represented a period in which systematic reporting and evaluation of positive results and patient follow-up were not in place. Phase 2 consisted of daily pharmacist-led blood culture reviews with callback nurse follow-up and therapeutic care plan development with ED physicians. The number of contaminant isolates was relatively high (Figures 1 and 2). Pharmacist-led interventions were diverse (Figure 3). The program led to an estimated total cost avoidance of $16,410.80 in a median of 4.5 months due to unnecessary admissions.

Conclusion
Implementation of a multidisciplinary ED post-discharge blood culture follow-up program can be an effective strategy in improving patient care and avoiding unnecessary antibiotic therapy. Further interventions aimed at reducing blood culture contamination could have a direct impact on improving ED antimicrobial stewardship.

Disclosures
All authors: No reported disclosures.