bluuebunny/crossref_metadata_2025_split huggingface dataset:
122. Optimization of Antibiotic Time-Outs Within a Health System
Authors: Long Ashley , Revolinski Sara , Daniels Anne R 
Published: December 2021

Abstract

Background
The Infectious Diseases Society of America estimates that up to 50% of antibiotic use in hospitals is inappropriate. In order to assist with reducing inappropriate antibiotic use, the Centers for Disease Control and Prevention has recommended systemic evaluation of ongoing antibiotic therapy need, such as antibiotic time-outs (ATOs), be implemented. This has further been supported by the Joint Commission in their antimicrobial stewardship medication management standard. Our system implemented a prescriber-led ATO process in 2018, but documented completion of the ATO remained low. Due to this, pharmacists were integrated into the ATO process with the goal of increasing completion rates.

Methods
This pre-post interventional study analyzed the impact of an antibiotic time out process implemented for patients receiving piperacillin/tazobactam (P/T) or cefepime (CEF) for a minimum of 48 hours. The pre-group (Jan-April 2018) had ATOs completed by the primary medical team, while pharmacists completed the ATO in the post group (Jan-April 2020). For each group, a computerized alert prompted completion of the ATO in the electronic health record (EHR). The alert included systematic questions to assess the need for continued P/T and CEF use. The primary outcome was percentage of ATO documentation completed. Secondary outcomes included inappropriate continuation of P/T and CEF and de-escalation within 24 hours after ATO completion.

Results
A total of 248 and 234 patients in the pre- and post-groups were included, respectively. Significantly more ATOs were documented in the post-group compared to the pre-group (65.5% vs 48.5%, p&lt; 0.001). Similarly, inappropriate continuation of P/T and CEF after the ATO process was significantly lower in the post-group compared to the pre-group (11.6% vs 64.0%, p&lt; 0.001). While not statistically significant, there was a trend toward increased de-escalation in the post-group within 24 hours of ATO completion (58.9% vs 47.9%, p=0.105).

Conclusion
A pharmacist-led ATO process reduced inappropriate use of P/T and CEF compared to a prescriber-led process. Incorporating pharmacists into an ATO process may optimize antimicrobial stewardship outcomes.

Disclosures
All Authors: No reported disclosures
123. Formal Pediatric Antimicrobial Stewardship Program at a Children’s Hospital Within a Larger Academic Medical Center Decreases Antimicrobial Prescribing
Authors: Feustel Paul , Botti Mark , Andrews Shannon 
Published: December 2021

Abstract

Background
Antimicrobial stewardship is a coordinated approach to antimicrobial overprescribing, an avoidable contributor to adverse events in children. Implementation of a formal pediatric antimicrobial stewardship program (pASP) in a children’s hospital within a hospital poses unique challenges due to staffing, funding, and institutional priorities. We hypothesized that a formalized pASP would decrease antimicrobial prescribing in a children’s hospital within a large academic medical center.

Methods
We extracted pharmacy administration data for all patients receiving systemic antimicrobials in a tertiary care, academic children’s hospital in Upstate NY from 3/1/2020-5/31/2021. We grouped patients into floor (including patients with surgical, hematologic, and oncologic processes), pediatric intensive care unit (PICU), and neonatal intensive care unit (NICU). We calculated antimicrobial days of therapy per 1000 patient days (DOT/1000PD) for 6 months before, 3 months during, and 6 months after institution of pASP. The formalized pASP involved physician and pharmacy leadership of prospective audit and feedback. We developed run charts and used two-way analysis of variance (ANOVA) with an effect of location, an effect of the intervention, and an interaction effect. Significant effects were then tested using Tukey’s test for multiple comparisons.

Results
Run charts are displayed in figures 1-3. Overall, the pediatric floor(DOT/1000PD=1181) had significantly higher prescribing than the PICU(847), which was significantly higher than the NICU(327) (p&lt; 0.001, ANOVA). Antimicrobial prescribing after pASP dropped by 80 DOT/1000PD (98%CI: 23 to 137) (p=0.008; Tukey’s test) after including the effect of location. The interaction effect was not significant (p=0.77; ANOVA) suggesting that the intervention did not have a significantly different effect in the three locations.
Variation in Antimicrobial Prescribing on the Pediatric Floors

Variation in Antimicrobial Prescribing in the Pediatric Intensive Care Unit

Variation in Antimicrobial Prescribing in the Neonatal Intensive Care Unit

Conclusion
Antimicrobial prescribing decreased following implementation of a formalized pASP in a children’s hospital within a large academic medical center. Despite unique challenges with implementation in this environment, antimicrobial stewardship remains effective. Variation between floor, PICU, and NICU antimicrobial prescribing was also notable.

Disclosures
All Authors: No reported disclosures
124. Implementation of IV Push Antibiotics for Outpatients During a National Fluid Shortage Following Hurricane Maria
Authors: Yagnik Kruti J , Saad Hala , Bird Cylaina , Brown Steven , Alvarez Kristin , Mang Norman , Cerise Frederick , Bhavan Kavita 
Published: December 2021

Abstract

Background
Prior to the introduction of intravenous (IV) drip infusion, most IV drugs were delivered in a single bolus. However, with the advent of new agents, IV drip infusions became the standard for all medication delivery. In September 2017, Hurricane Maria made landfall in Puerto Rico and took a devastating toll. As Puerto Rico is the largest supplier of IV fluid bags, this lead to a worldwide fluid bag shortage. The outpatient antimicrobial therapy program (OPAT) was significantly impacted by the fluid shortage and this required effective stewardship at the Parkland Health and Hospital System in order to serve a largely uninsured and under-insured patient population.

Methods
Parkland pharmacists evaluated all self-administered antimicrobials for viability of administration as an IV single bolus push (IV-push) instead of a mini-bag infusion (IV-drip infusion). These medications were transitioned to IV-push for patient care. Data was gathered on patient demographics, 30-day readmission rates, mortality, discharge teaching satisfaction, patient satisfaction, and cost evaluation.

Results
113 treatment courses were self-administered using the IV-push method and were compared to 102 self-administered courses using the IV drip infusion method, over the same time course. Individuals using IV-push had a statistically significant decrease in hospital length of stay as compared to those using IV-drip infusion. The 30-day readmission rate, emergency department visits, and mortality were similar between groups. Patient satisfaction was greater with IV-push (96% preferring). The shift to IV-push via the S-OPAT program saved 504 liters of normal saline, which along with a reduction in supplies and drug costs, resulted in an additional savings of &43,652 over a 6-month period.

Conclusion
The abrupt IV fluid shortage following a natural disaster challenged clinicians to think differently about standard practices. This led to implementation of a high value care model that is sustainable without affecting safety, efficacy, or efficiency. Given the cost savings, increased patient satisfaction, and equal clinical outcomes, the IV push model is not only a viable alternative initiated during a crisis; it is preferable in many standard situations.

Disclosures
All Authors: No reported disclosures
126. Outpatient Antimicrobial Stewardship Utilizing a Decentralized Model
Authors: Powers Harry , McMullan Stephen , Anderson Therese , Boeff Deborah , Bonner William , Epps Kevin L , Harris Dana , LaCouture Jacqueline , Leak Michelle A , Leybeg Angelica , Riffe Izabela , Schnusenberg Lynda , Mendez Julio C 
Published: December 2021

Abstract

Background
The majority of human antimicrobial utilization occurs in the outpatient setting. Despite being mainly viral in etiology, upper respiratory tract infections (URIs) were the most common indication for outpatient antimicrobial prescriptions at our institution.

Methods
Through our electronic health record (EHR), we were able to determine our rate of antibiotic prescriptions for inappropriate URI diagnosis at our primary care practice sites. We selected staff volunteers from each our primary care practice sites to serve as stewardship champions. They were given training in stewardship best practices, and an URI stewardship toolkit which included viral URI prescription pad, EHR order panel, and patient education signage. They were tasked with providing education and feedback to their practice sites. We meet with them on a monthly basis to disseminate prescribing data and education. They also provided feedback from practice sites to the stewardship committee.

Results
Our decentralized model was put in place in November 2020. In the 6 months prior to the intervention, the average prescribing rate was 29.1%. In the 6 months after the intervention, the average prescribing rate decreased by 15% to 24.8%. During the intervention phase, there was an increase in number of non-COVID URIs diagnosed at our primary care sites.
Temporal Trend in Inappropriate Antibiotics Prescribing Rates for Viral URIs Pre- and Post- Intervention

Inappropriate antibiotic prescribing rate for viral upper respiratory tract infections from May 2020 until May 2021. Intervention started in December 2021 (arrow). Pre-intervention average was 29.1%. Post-intervention age was 24.8% which is a 15% decline in prescribing rate.
Viral Upper Respiratory Infections Visits

The total number of visits for presumed viral upper respiratory infections to primary care sites from May 2020 until May 2021. The majority of COVID-19 precautions in the area expired at the end of March 2021.

Conclusion
We have been able to lower our inappropriate prescriptions for URIs utilizing a decentralized model of stewardship champions. This result was especially notable as the intervention phase corresponded with the end of COVID-19 precautions and an increase in non-COVID URIs diagnosed. The advantage of this approach includes an advocate embedded at each practice site who is familiar with the opportunities and challenges of the site, and a two-way flow of information from practice sites to the stewardship committee. This model provided additional benefit during the COVID-19 pandemic as the ability of centralized staff to travel to off campus clinic sites was curtailed.

Disclosures
All Authors: No reported disclosures
128. Development of an Analytics Dashboard to Monitor Antimicrobial Selection and Duration for Pneumonia
Authors: Marx Ashley , Browder Sydney E , Liu Jason C , Swartwood Michael J , Mavrogiorgos Nikolaos 
Published: December 2021

Abstract

Background
Analytical and visual tools can be used to monitor progress for a variety of ASP key performance indicators, but few data describe the process of building disease-state specific tools to retrospectively monitor antimicrobial choice and duration. We describe process and methods for development of a pneumonia dashboard.

Methods
In late 2019, the Carolina ASP began construction of a dashboard to monitor antimicrobial selection and duration in patients admitted with a diagnosis code (ICD-10) consistent with pneumonia. Data extracted from the medical record after discharge included: admission date and time, admission and discharge ICD-10s, inpatient orders and administrations for agents included in the NHSN Antimicrobial Use (AU) option, and antimicrobials ordered at discharge with associated ICD-10. Extracted data fields were validated using a one-month sample. Displays were constructed to trend selection during the first 48 hours of admission, inpatient days of therapy, and total length of therapy (sum of inpatient + outpatient days) for patients who received a discharge prescription for an antimicrobial included in the AU option that was associated with an ICD-10 consistent with pneumonia. Trends observed between Jan 2020 and Mar 2021 are reported.

Results
341 admissions were trended. Within the first two days of admission, monthly proportions of patients receiving an antimicrobial by category were: anti-MRSA therapies (vancomycin, linezolid), 0.20 to 0.75; broad spectrum beta-lactams (e.g., cefepime, pip/tazo), 0.40 to 0.81; CAP therapies (e.g., ceftriaxone, levofloxacin), 0.48 to 1.00 (Figure). Median inpatient duration of therapy was 5 days (IQR 3-8; range 1 to 68). Total length of therapy was median 6 days (IQR 4-10; range 1 to 68).

Figure. Proportions of Patients Prescribed Antimicrobial Categories of Interest During the First 48 Hours of Admissions for Pneumonia. Legend: Anti-MRSA = vancomycin or linezolid; HAP abx = cefepime, piperacillin/tazobactam, ceftazidime, meropenem; CAP = ceftriaxone, azithromycin, ampicillin/sulbactam, amoxicillin/clavulanate, cefdinir, levofloxacin.

Conclusion
Automated reports and visual tools can provide actionable insights for ASP practice. From this dashboard, we identified variable but high rates of anti-MRSA and broad-spectrum beta-lactam use within the first 48 hours of admission. The median inpatient and total length of therapy of 5 and 6 days, respectively, were similar to guideline-recommended durations. The up-front cost for building analytical tools can be substantial, but can be viewed as an investment if the metrics and methods are carefully selected.

Disclosures
All Authors: No reported disclosures
129. Safety and Cost-effectiveness Analysis Outpatient Continuous Parenteral Antibiotics via a Disposable Elastomeric Pump at Two County Hospitals in Houston, Texas
Authors: Rao Aishwarya , Karimaghaei Sam , Chijioke Juliet , Constance Kristin , Finch Natalie , Masayuki Nigo 
Published: December 2021

Abstract

Background
Outpatient parenteral antibiotic therapy (OPAT) is a therapeutic option for patients who require longer intravenous (IV) antimicrobial courses, yet do not need to remain hospitalized. HarrisHealth system OPAT programs implement a disposable elastomeric continuous infusion pump (eCIP) for IV antibiotics. Here we report the clinic-demographic features, outcomes of a cohort of patients receiving OPAT via eCIP (OPAT-eCIP), as well as the cost-effectiveness of OPAT in comparison to standard inpatient care.

Methods
We retrospectively obtained the clinic-demographic characteristics and outcomes of 91 patients discharged from HarrisHealth-affiliated hospitals from December 2018 to February 2021 who underwent OPAT-eCIP. We then compared the total costs associated with home OPAT-eCIP care with that of an equivalent of inpatient IV antimicrobial treatment based on previous studies.

Results
We identified 481 total OPAT patients; 91 (18.9%) received intravenous antibiotics via eCIP, with two initiating therapy outpatient. In total, 1925 days of IV antimicrobial therapy were administered outpatient by OPAT-eCIP, with a median treatment course of 12 days. Eighty-three (92.2%) patients completed their antimicrobial course, with 85 (93.4%) cured of respective infections (Table 1). Antimicrobial-associated adverse events and PICC line associated complications were 6.6% and 14.3% respectively. 30-day hospital readmission rates were under 10% with 21 patients (23.1%, 28 total visits) presenting to the emergency room over the course of IV therapy. Estimated costs of OPAT-eCIP care over the study period ranged from &417,000-&576,750 with costs of equivalent inpatient care estimated at &2,945,250 to &3,927,000; estimated overall cost savings of OPAT-eCIP were &2,368,500 to &3,509,900 (Table 2).
Table 1. Characteristics and Outcomes of Patients Receiving Continuous IV Antibiotics via Disposable Elastomeric Pump

Table 2. Cost Analysis Comparison of OPAT-eCIP therapy versus inpatient antimicrobial therapy in patients from December 2018 from February 2021

Conclusion
OPAT-eCIP therapy in a cohort of patients was highly effective and well-tolerated. While ED visit frequency indicates the necessity of close patient monitoring, low 30-day hospital readmission rates were encouraging. Along with the above, the significant cost savings demonstrated when compared with standard inpatient antimicrobial therapy suggest that OPAT-eCIP should be increasingly utilized as an effective therapeutic option.

Disclosures
All Authors: No reported disclosures
130. Effects of COVID-19 on a Complex Behavioral Intervention to Improve the Diagnosis and Management of UTI in Nursing Homes
Authors: Ford James H , Jolles Sally , Heller Dee , Selle Katie , Uribe-Cano Daniela , Nordman-Oliveira Susan , Irvine Jessica , Coughlin DaRae , Crnich Christopher J 
Published: December 2021

Abstract

Background
Half of all urinary tract infections (UTI) are probably unnecessary. We conducted a cluster-randomized trial in which a toolkit to enhance the diagnosis and treatment of UTIs was introduced in study NHs via usual implementation versus an enhanced implementation approach based on external facilitation and peer comparison reporting.

Methods
Thirty Wisconsin NHs were randomized to each treatment arm in a 1.5:1 ratio. NHs used an online portal to report urine culture and antibiotic treatment data over a 6-month pre-intervention period (Jan-June 2019), a pre-COVID 8-month post intervention period (July 2019-Feb 2020) and an 8-month post-COVID intervention period (Mar-Oct 2020). Study outcomes included urine culture (UC), antibiotic start (AS), and antibiotic days of therapy (DOT) rates per 1,000 resident days. A generalized estimating equation model for panel data was used to assess differences in study outcomes between treatment arms before and after onset of the COVID-19 pandemic. STATA 16.1 was used for all analyses.

Results
A total of 802 UCs (457 pre-COVID, 345 post-COVID), 724 AS (401 pre-COVID, 323 post-COVID), and 6,454 DOT (3553 pre-COVID and 2901 post-COVID) were reported over the 16-month intervention period. No significant differences in the study outcomes were observed during the pre-COVID intervention period, however, UC rates in NHs assigned to the usual care arm of the study increased while those in the enhanced arm declined following onset of COVID-19 (Figure 1). AS and DOT rates followed a similar pattern although the differences between the study arms were not statistically significant.
Figure 1. Post Implementation Periods

Conclusion
Our findings suggest that NHs assigned to usual implementation regressed in their diagnosis and treatment of UTIs during the COVID-19 pandemic while those receiving external facilitation and peer comparison reports were more resilient to the effects of COVID-19.

Disclosures
All Authors: No reported disclosures
131. A Pharmacist Led Antimicrobial Stewardship Pilot at Discharge Improves Outpatient Antibiotic Utilization
Authors: Hiryak Kayla , Kludjian Geena , Gallagher Jason C , Gallagher Jason C , Cavaretta Marissa 
Published: December 2021

Abstract

Background
The impact of antimicrobial stewardship programs has been well observed in institutional settings; however, patients complete over one-third of their antibiotic course after discharge. This creates a gap in stewardship efforts at transitions of care. We studied whether pharmacist review of antibiotic prescriptions at discharge would improve outpatient antibiotic prescribing.

Methods
This was a pilot project of patients in medicine wards of an academic medical center who were discharged on oral antibiotics between February and May 2021. Patients who were pregnant, &lt;18 YO, had COVID-19, or leaving against medical advice were excluded from evaluation. For the pilot, a verification queue was created in the electronic health record (EHR) system where orders for discharge antibiotics were reviewed by investigator pharmacists before prescriptions were electronically sent to outpatient pharmacies. During the pilot, prescriptions were reviewed Monday-Friday afternoons from 12pm-4pm. Data was collected on incidence, type, and acceptance rate of pharmacist interventions, and a cost savings analysis was conducted with values calculated by the EHR system.

Results
There were 149 patients included with oral antibiotic prescriptions reviewed during the time frame. Of those patients, 48 (32.2%) had at least one prescription that was intervened on by a pharmacist. A total of 55 interventions were made with an acceptance rate of 76%. The median time for pharmacist review was 10 minutes (IQR 5-15). Patients who received infectious diseases (ID) consultation during admission required less intervention than patients without expert consultation but did not reach significance (8/35 and 47/114 respectively, p=0.07). The total cost savings associated with all interventions was &20,743.00.
Table 1. Interventions

Conclusion
Direct pharmacist review and intervention at discharge improved the prescribing of oral antibiotics within our institution during this pilot. Considering that this was conducted part-time in a subset of hospitalized patients during a limited time period, significant cost savings are possible with greater implementation.

Disclosures
Jason C. Gallagher, PharmD, FIDP, FCCP, FIDSA, BCPS, Astellas (Consultant, Speaker’s Bureau)Merck (Consultant, Grant/Research Support, Speaker’s Bureau)Qpex (Consultant)scPharmaceuticals (Consultant)Shionogi (Consultant) Jason C. Gallagher, PharmD, FIDP, FCCP, FIDSA, BCPS, Astellas (Individual(s) Involved: Self): Speakers’ bureau; Merck (Individual(s) Involved: Self): Consultant, Grant/Research Support; Nabriva: Consultant; Qpex (Individual(s) Involved: Self): Consultant; Shionogi (Individual(s) Involved: Self): Consultant Marissa Cavaretta, PharmD, Merck (Grant/Research Support)