bluuebunny/crossref_metadata_2025_split huggingface dataset:
1049. Using Alternative Alerts in the Electronic Health Record to Guide Antimicrobial Selection Decisionmaking at the Point of Order Entry
Authors: Ebert Steven C 
Published: October 2019

Abstract

Background
In a White Paper published in 2019, SHEA describes “The role of electronic health record and ‘add-on’ clinical decision support systems to enhance antimicrobial stewardship programs.” Modifications of the electronic health record and add-on clinical decision support systems are compared and contrasted. Some disadvantages of modification of the EHR include the need to include all end-user affiliates in modifications, lack of order set utilization, and heavy demands of IT staff to modify the EHR. We have utilized alternative alerts which may be customized to individual affiliates and are relatively easy to build which fire when specific medications are ordered (whether within order sets or not) and guide clinicians to more appropriate antibiotic choices.

Methods
From an antimicrobial stewardship perspective, alternative alerts are activated during the ordering of antibiotics for which routine use is discouraged (e.g., carbapenems, fluoroquinolones). When a provider enters an order, the alternative alert will pop up. The alert consists of two sections: an alert section describing the reason for the alert and a list of therapeutic options for the targeted drug; and links to orders for alternative antibiotics/combinations. The alerts may be configured to allow or not allow the orderer to continue with the original order. Different alternative alerts can be created and used at different facilities using the same EHR platform. We designed alternative alerts for fluoroquinolones, carbapenems, and fifth-generation cephalosporins that allowed providers to continue with the original order. We tested their impact on antimicrobial prescribing for 18 months after implementation, measured as quarterly days of therapy (DOT)/1000 pt-days.

Results
We noted marked reductions in quarterly DOT/1000 pt-days for fluoroquinolones (-70%) and fifth-generation cephalosporins (-90%). The impact on carbapenem prescribing was more variable.

Conclusion
Alternative alerts represent an easily created, customizable means to guide providers’ antimicrobial selections. We plan to incorporate more alternative alerts into our antimicrobial ordering process and strengthen the alert for carbapenems.

Disclosures
All authors: No reported disclosures.
1056. Evaluation of Clinical Outcomes Following Implementation of Real-Time Stewardship Team Interventions for Multi-Drug-Resistant Organisms
Authors: Xhemali Xhilda , Patel Twisha S , Eschenauer Gregory , Lew Alison , Kaye Keith S , Albin Owen , Nagel Jerod 
Published: October 2019

Abstract

Background
Infections due to multidrug-resistant organisms (MDRO) are associated with an increased risk of mortality. Accurate assessment of culture results and prompt initiation of effective antibiotic therapy have the potential to improve patient outcomes. The purpose of this study was to assess the time to effective therapy and associated clinical outcomes following the implementation of real-time stewardship alerts for infections due to MDRO.

Methods
This pre–post quasi-experimental study identified patients admitted to Michigan Medicine with a positive culture for one of 14 pre-defined MDRO. An alerting system was implemented within the institution’s electronic health record (EHR) in October 2018, which notifies the antimicrobial stewardship (ASP) pharmacist upon detection of an MDRO, regardless of source. The ASP pager is monitored 24/7 by a clinical pharmacy specialist who reviews the patient’s chart and recommends antibiotic modifications if necessary. In the pre-intervention period, no structured alerting or assessment was performed. Inclusion: ≥18 years old and trigger of an alert. Exclusions: pediatric service, cystic fibrosis, discharged or deceased prior to alert sensitivities, outside hospital (OSH) transfer growing identical organism upon admission, culture contamination or colonization. The primary outcome of time to effective therapy is determined from time of alert for MDRO to the order time of the effective antimicrobial agent. Secondary outcome measures include: length of stay, 30-day all-cause mortality, and 30-day readmission.

Results
152 alerts were included in the study (post, n = 75 and pre, n = 77). Outcomes were assessed in patients not on effective therapy at the time of alert (68.0% vs. 70.1%). Time to effective therapy was significantly improved in the intervention group (2.08hours vs. 3.72hours, P = 0.0010). Length of stay (18 days vs. 15.5 days, P = 0.1662) and 30-day all-cause mortality (17.6% vs. 18.5%, P = 0.9088) were not different between groups. However, 30-day readmission rates were significantly reduced with the intervention (21.4% vs. 43.2%, P = 0.0316).

Conclusion
Real-time stewardship team interventions for infections due to MDRO improve time to effective therapy and are associated with a decrease in hospital readmissions.

Disclosures
All authors: No reported disclosures.
1060. Impact of Laboratory Cessation of Extended-Spectrum β-Lactamase (ESBL) Reporting on Minimum Inhibitory Concentration (MIC) Distribution Trends and Associated Clinical Outcomes
Authors: Chiang Anthony , Beganovic Maya , Dela-Pena Jennifer , Gandhi Kelvin , Miller Jessica , LaChance Erik , Anderson Morgan , Wieczorkiewicz Sarah 
Published: October 2019

Abstract

Background
The Clinical and Laboratory Standards Institute (CLSI) lowered the minimum inhibitory concentration (MIC) breakpoints of various β-lactam antimicrobials eliminating the need for confirmatory testing of extended-spectrum β-lactamase (ESBL) organisms. Our institution adopted the new CLSI breakpoints in June 2015. This multi-site study assessed the impact of laboratory cessation of ESBL reporting on the MIC distribution of commonly used antimicrobials and clinical outcomes.

Methods
This retrospective study included adult inpatients with positive blood cultures for Escherichia coli, Klebsiella pneumoniae, K. oxytoca, or Proteus mirabilis from June 2012 to June 2018. Patients were included in the pre-implementation group if they had an ESBL-positive blood culture from June 2012 to May 2015 and in the post-implementation group if they had a ceftriaxone-resistant organism from June 2015 to June 2018. Patients who died or transitioned to hospice within 48 hours of blood culture identification or before final susceptibilities were excluded. The primary outcome was MIC distribution of ceftriaxone, ceftazidime, cefepime, piperacillin/tazobactam, fluoroquinolones, and carbapenems. Secondary outcomes were antimicrobial prescribing patterns, 30-day all-cause mortality, 30-day re-infection rate, and time to microbiological clearance.

Results
A total of 249 patients were included (n = 40, pre-implementation; n = 209, post-implementation). Pitt Bacteremia Scores were significantly higher in the pre-implementation group (3.59 ± 2.85 vs. 2.21 ± 2.06; P = 0.0004). The median MIC distribution for each antimicrobial stayed within one dilution throughout the study timeframe. Carbapenem use decreased in the post-implementation group [n = 35 (87%) vs. n = 131 (63%)]. No significant differences were noted for other secondary outcomes: 30-day all-cause mortality (15% vs. 10%; P = 0.40), 30-day re-infection rate (2.5% vs. 4.3%; P = 1), and time to microbiological clearance (2.28 ± 1.2 vs. 2.41 ± 1.76 days; P = 0.72).

Conclusion
Adoption of lowered CLSI breakpoints did not impact MIC distribution of select antimicrobials for Enterobacteriaceae; however, it has affected antimicrobial prescribing patterns.

Disclosures
All authors: No reported disclosures.
1061. Decreased Utilization of Piperacillin–Tazobactam for Escherichia coli and Klebsiella Bacteremia due to Selective Susceptibility Reporting
Authors: Zahlanie Yorgo , Hall Brenton , Wei Wenjing , Mang Norman , Ortwine Jessica , Anderson Shelby S , Morgan Kristi , Guzman Tamara , Prokesch Bonnie C 
Published: October 2019

Abstract

Background
Over 2 million people in the United States are diagnosed with antibiotic-resistant infections annually. The Infectious Diseases Society of America (IDSA) recommends cascade reporting of antibiotic susceptibility data by the clinical microbiology laboratory as an intervention to decrease resistance, though this is based on low-quality evidence.

Methods
We conducted a retrospective study to assess the effect of cascade susceptibility reporting on prescribing practices and patient outcomes. A cascaded testing algorithm was executed wherein susceptibility data for piperacillin–tazobactam (PT) was suppressed from the susceptibility report if an organism was susceptible to ceftriaxone. Patients with positive monomicrobial blood cultures with non-ESBL Escherichia coli (E. coli) or Klebsiella isolates in blood cultures and receiving empiric PT were included. Data were collected one year prior and one year after cascading protocol implementation, and included patient demographics, length of stay (LOS), duration of antibiotics, time to de-escalation, and adverse events including acute kidney injury (AKI) and Clostridioides difficile infection (CDI).

Results
212 patients (108 pre-intervention and 104 post-intervention) were included. 87% of patients were de-escalated from PT pre-intervention, while 90% were deescalated post-intervention. Mean time to deescalation decreased from 30 hours before to 17 hours after cascade implementation (P = 0.02) (Figure 1). Median LOS decreased from 15 to 10 days following the intervention (P = 0.12). While the rate of AKI increased from 14 to 19% post-intervention (P = 0.89), the rate of CDI (2 vs. 2 patients) was comparable among both cohorts (P = 0.97) (Figure 2).

Conclusion
While cascade susceptibility reporting is recommended by the IDSA as a tool for antimicrobial stewardship, this recommendation has weak support due to paucity of data. In this study, we found that selective susceptibility reporting has the potential to decrease the use of PT and to reduce LOS in patients with E. coli and Klebsiella bacteremia. Further research to better identify patient populations most impacted by a cascade algorithm and its overall effectiveness as a stewardship tool is needed.

Disclosures
All authors: No reported disclosures.
1063. A Healthcare Worker-Informed Approach to the Hospital-to-Home Transition on Oral Antibiotics
Authors: Sharara Sima L , Cosgrove Sara E , Cosgrove Sara E , Arbaje Alicia , Gurses Ayse P , Dzintars Kate , Keller Sara C 
Published: October 2019

Abstract

Background
Improved antibiotic decision-making during the hospital-to-home transition is an important but under-addressed target for antimicrobial stewardship. This study aims to provide a healthcare worker-informed approach to characterize prescriber antibiotic decision-making and patient medication management at discharge to identify barriers to and strategies for antibiotic stewardship during the hospital-to-home transition.

Methods
Semi-structured interviews were conducted at an academic medical center with relevant stakeholders including house staff (n = 10), nurses (n = 2), nurse practitioners (n = 5), inpatient pharmacists (n = 4), and discharge coordinators (n = 2). Interviews focused on challenges to antibiotic decision-making and patient medication management at discharge. Transcripts were independently coded and analyzed by two physicians using the constant comparative method.

Results
We identified four main barriers to antibiotic decision-making at hospital discharge: (1) uncertainty over antibiotic choice (due to lack of microbiology data), (2) pressure to discharge, (3) lack of control over antibiotic decision-making (attending-led decision with little room for input), and (4) lack of awareness of cost and insurance coverage. We also identified challenges to patient medication management specific to patient education: (1) role ambiguity around who provides education and (2) lack of education to patients around side effects. To improve antibiotic decision-making, prescribers relied heavily on institutional guidelines and interaction with experts in informing antibiotic choices, and used multidisciplinary approaches to verify antibiotic cost and availability. Five strategies to improve medication management were proposed: (1) assessing patient health literacy when providing instructions, (2) an in-hospital trial of the oral antibiotic to ensure tolerance, (3) ensuring the patient leaves the hospital with the antibiotic in hand, (4) care coordination after discharge, and (5) close follow-up with prescribers after discharge.

Conclusion
Our findings identify barriers to discharge antibiotic decision-making and medication management that allow for targeted interventions to improve antibiotic decision-making during the hospital-to-home transition.

Disclosures
Sara E. Cosgrove, MD, MS, Basilea: Consultant; Theravance: Consultant.
1069. Implementation and Results of a Health-System Antimicrobial Stewardship (AMS) Program
Authors: Boldt Dayla , Anthone Jennifer , Alexander Bryan , Ased Sumaya J , Carroll Cassara , Schmidt David , Destache Christopher J , Vivekanandan Renuga 
Published: October 2019

Abstract

Background
AMS expansion initiative was implemented in fiscal year 18 (FY18) across a 14-member health system (~1,000 average daily census combined) consisting of 8 community hospitals, 5 rural critical access hospitals and 1 academic medical center.

Methods
The expansion initiative included a 0.5 full-time equivalent (FTE) infectious diseases (ID) physician and 2.5 FTE ID-trained clinical pharmacists to support daily AMS activities. Clinical decision support software (Theradoc) had previously been implemented across the health system. Here we report our continuation results for the first 9 months of year 2 (FYTD19) of the expansion initiative.

Results
AMS personnel documented an average of 319.8 and 313.2 interventions per month in FY18 vs. FYTD19, respectively. Mean acceptance rate of AMS interventions by providers was 87.9% and 89.4% in FY18 vs. FYTD19. Provider groups with the highest acceptance rate were Hospital Medicine, Pulmonary/Critical Care and Infectious Disease. Highest interventions in FYTD19 included recommending other diagnostic testing (17%) followed by de-escalating/targeting therapy based on culture results and recommending alternative therapy (both at 11%). Most common ID disease states AMS intervened included bacteremias (29%), pneumonias (ventilator-associated or community-acquired) 13% each, and UTIs 13%. AMS interventions generated 168 ID consults in FYTD19. The financial impact of AMS across the health system was a cumulative saving in antimicrobial expenditures of $1.29 million and $1.27 million in FY18 and FYTD19, respectively.

Conclusion
The ability to review offsite electronic medical records daily for antimicrobial optimization with ID pharmacist and physician support, identify facility-specific needs and opportunities, and collect available data endpoints to determine program effectiveness has helped to ensure program success.

Disclosures
All authors: No reported disclosures.
1082. Hold the Phone: Antibiotic Prescribing Practices Associated with Nonvisit Encounters for Urinary Tract Infections (UTIs) in Urology Clinics
Authors: Akbar Nina , Dobson Erica L , Keefer Michael , Munsiff Sonal , Dumyati Ghinwa 
Published: October 2019

Abstract

Background
Surveillance data uncovers a high proportion of multidrug-resistant Gram-negative organisms found in the outpatient setting, often in patients with recurrent urinary tract infections (UTIs), underlying urologic abnormalities, and prior treatment for UTIs. We assessed prescribing practices at urology clinics to identify potential stewardship strategies for UTI management.

Methods
Antibiotic prescription encounters for adult patients from nine urology clinics were obtained from July to September 2018 using the EHR. We collected encounter types (visit or nonvisit), ordering medical provider types, antibiotic classes and patient demographics. A subset of 50 randomized, unique patient telephone encounters (TEs) was reviewed for documentation of a UTI diagnosis, symptoms, urinalysis and culture results, antibiotic prescriptions and duration.

Results
A total of 1,704 antibiotic orders were identified for 1,210 patients (48% female, median age 69 years, IQR 20). The majority (75%) of antibiotic encounters were from nonvisits: TEs (39%), orders only (25%), refills (9%), and patient email (2%). Major prescribers were advanced practice providers (APPs, 61%) followed by attending physicians (38%). Antibiotics prescribed were fluoroquinolones (FQs, 27%), nitrofurantoin (24%), first-generation cephalosporins (16%), and trimethoprim–sulfamethoxazole (15%). From the subset of 50 TEs, APPs wrote 76% of prescriptions and 32% of all orders were FQs. Thirty-nine patients had a clinical UTI diagnosis, yet 33% (13/39) did not have documentation of at least one urinary sign or symptom. For symptomatic patients, 15% (4/26) did not have a urine culture result within one week before or after the TE date. The distribution of antibiotics prescribed was similar to overall use and the median duration was 7 days.

Conclusion
Urology practices care for patients with the most complicated urinary tract pathology and appropriate antibiotic use in this population is a challenge. We found that urology providers often prescribe antibiotics to elderly patients without in-person visits, documentation of symptoms or microbiologic evidence of a UTI. Stewardship efforts should involve APPs, developing diagnostic and treatment guidelines for UTIs and improving documentation for antibiotic orders.

Disclosures
All authors: No reported disclosures.
1089. Implementation of a Febrile Neutropenia Management Algorithm on Antibiotic Use and Outcomes: An Interrupted Time Series Analysis
Authors: Trinh Trang D , Strnad Luke , Damon Lloyd E , Dzundza John H , Graff Larissa R , Griffith Laura M , Hilts-Horeczko Alexandra , Olin Rebecca L , Shenoy Samantha , DeVoe Catherine , Wang Lusha , Rodriguez-Monguio Rosa , Doernberg Sarah B 
Published: October 2019

Abstract

Background
Febrile neutropenia (FN) is a common complication of cancer therapy and often necessitates prolonged antibiotic treatment. Antibiotic de-escalation can be challenging given tenuous clinical status. Furthermore, a microbiological or clinical etiology is identified in a minority of FN patients. In 2016 we implemented several evidence-based strategies to guide antibiotic use in high-risk FN patients including specifying vancomycin use indications, minimizing carbapenem escalation in stable patients with ongoing fevers, and defining antibiotic durations regardless of neutrophil count. The study objective was to characterize and evaluate our experience implementing these strategies on antibiotic use and clinical outcomes.

Methods
Interrupted time series analysis of all admissions to the Malignant Hematology service at the University of California, San Francisco between June 2014 and December 2018. The primary outcome was monthly days of therapy (DOT) per 1,000 patient-days of broad-spectrum IV antibiotics (aztreonam, cefepime, piperacillin–tazobactam, meropenem, and vancomycin). Secondary outcomes included DOT/1,000 patient-days for each IV antibiotic, incidence rates of bloodstream infections (BSI) and C. difficile infections (CDI), and in-hospital all-cause mortality. A segmented regression analysis was conducted to evaluate the impact of the FN management algorithm implementation on antibiotic use and clinical outcomes. Summary statistics and time series scatter plots were used to visualize the trends and outliers.

Results
2319 unique patients with 6,788 encounters were included. The median (IQR) age was 59 (46–68) years and 60% were male. Regression results and time series plots are shown in Table 1 and Figures 1–3.

Conclusion
Implementation of an evidence-based FN management algorithm led to decreased vancomycin and meropenem use without a statistically significant impact on overall antibiotic use, CDI rates, or mortality.While BSI rates fluctuated in the 2 months post-implementation, rates returned to baseline thereafter. A multidisciplinary effort facilitated successful implementation of this stewardship project. This collaboration remains essential to addressing future antimicrobial management strategies in this population.

Disclosures
All authors: No reported disclosures.
1095. Prevalence and Characteristics of Self-Reported Antibiotic Allergies Across a Multi-Hospital Healthcare System
Authors: Perez Katherine K , Drake Ty C , Fuentes Amaris , Gentry Clare N 
Published: October 2019

Abstract

Background
Collaborations between medication safety and antimicrobial stewardship programs (ASP) have not been well described despite many overlapping best practice initiatives. In partnership with medication safety, the ASP at Houston Methodist (HM) reviews patient safety events submitted by hospital staff and identified a best practice opportunity in allergy reporting practices. Our objective was to benchmark self-reported antibiotic allergies among hospitalized patients and compare the prevalence and characteristics among hospital settings.

Methods
We evaluated the prevalence of self-reported antibiotic allergies in the electronic medical record for adult patients admitted to any HM entity including 1 flagship referral center (933-beds) and 6 community-based hospitals (1,379-beds) in January 2019. Antibiotics were grouped by class into penicillins, sulfas, cephalosporins, tetracyclines, macrolides, quinolones, and others. Point-prevalence rates were calculated using the total patient count as the denominator.

Results
There were 4,730 patients admitted to HM in January 2019 of which 85% (n = 4,029) self-reported 9,186 active drug allergies. There were 2,353 (49.7%) individuals who self-reported 3,665 antibiotic allergies, of which 987 (21%) reported an allergy to ≥2 antibiotic classes. The prevalence rate for a penicillin allergy was highest at 26.1% (n = 1,235), followed by allergy to sulfa 15.9% (n = 751) and quinolones 7.9% (n = 411). Antibiotic allergies were most prevalent in patients aged 70–79 (11%, n = 518) and 60–69 (10%, n = 495). Antibiotic allergies were higher among females (61.6%; n = 1,679/2,724) compared with males (40.7%; n = 662/1,305) (P = 0.002). There was no difference in prevalence rates between community-based hospitals and the flagship institution (P = 0.51).

Conclusion
We identified an antibiotic allergy point prevalence rate of 49.7% among hospitalized patients, including a 26.1% rate to penicillin, across our 7-hospital system. This analysis provides a road map to deploy system-wide efforts to improve antibiotic detailing in patients regardless of the hospital setting.

Disclosures
All authors: No reported disclosures.