bluuebunny/crossref_metadata_2025_split huggingface dataset:
1210. Prospective review of provider discontinuation of inappropriate intravenous (IV) vancomycin at a community teaching hospital in Chicago
Authors: Oderinde Jennifer , Chiang Anthony , Juska Alicia , ADEYEMI O L U W A D A M I L O L A A 
Published: November 2023

Abstract

Background
Vancomycin is often started empirically for its reliability with gram-positive pathogens, particularly Methicillin Resistant Staph aureus (MRSA). Consequently, it is often over-prescribed. Antimicrobial stewardship programs (ASP) have used time-outs to ensure therapies are tailored to the patient with proper indication and coverage.

Methods
Between November 2022 and February 2023 provider discontinuation of IV vancomycin was prospectively reviewed when it was no longer needed at a 298 licensed bed community teaching hospital in Chicago. Results of culture sensitivities including MRSA nares screen, blood, and wound cultures were used to analyze appropriateness. Appropriateness was defined as having a positive MRSA culture, positive MRSA nares for treatment of PNA only, gram positive infections with a true and severe beta-lactam allergy, gram positive infections with beta-lactam resistant pathogens (i.e. ampicillin resistant Enterococcus), purulent cellulitis without culture data, and pending or negative cultures for deep-seated infections (i.e. CNS, Cardiovascular, BJI) with ID consult.

Results
153 patients met criteria for discontinuation of IV vancomycin and 107 of those were able to be discontinued. Inappropriate regimens were continued in 46 patients for various indications including pneumonia, skin and soft tissue infections, intra-abdominal infections, urinary tract infections, and endocarditis without infectious disease (ID) consult.
Of the 107 patient encounters, pharmacists intervened and discontinued 62 (57.9%), ID discontinued 16 (14.9%) and the primary medical team discontinued 29 (27.1%).

Conclusion
30% (46/153) of patients studied continued an inappropriate vancomycin regimen. There is room for improvement in regards to proper education surrounding antimicrobial stewardship. An antimicrobial time-out can help further decrease inappropriate vancomycin use.

Disclosures
All Authors: No reported disclosures
1216. ASP Initiated Blood Culture Service Is Highly Accepted, Reduced Antibiotic Durations Associated with Good Safety Outcomes
Authors: Foo Geraldine Tingting , Chen Hui Hiong , Wu Jia En , Chew Ka Lip , Santoso Erna G , Somani Jyoti 
Published: November 2023

Abstract

Background
NUH is a 1200 bed academic medical center with quaternary medical services ; the ASP program was initiated in 2014. A 2020 review found 18.5% of bacteremic patients were on inappropriate antibiotics (ABX) or wrong duration, and the overall majority of bacteremias were gram-negative (E .coli and Klebsiella). Since out ASP program has been promoting shorter durations in general, we hypothesized that a blood culture service where recommendations for de-escalation and appropriate duration were given early would help shorten ABX durations in patients with uncomplicated bacteremias. On March 15, 2021, we initiated an ASP led blood culture (BC) service (SVC) which reviewed case notes of patients Monday to Friday as soon as blood culture (BC) susceptibilities were available. We report on the types of interventions (INV), acceptance rate, and the impact and outcomes of our BC SVX between patients in whom the INV was accepted versus rejected.

Methods
Prospective data on BC SVC interventions, acceptance rate, and patient status at five days were collected. Antibiotic duration (IV and oral), Length of Stay (LOS) and 30-day mortality as well as Charlson Comorbidity Index (CCI) were determined from electronic medical records for all ASP BCSVX interventions between March 15, 2021- December 31, 2022. Statistical analysis was performed in excel and STATA.

Results
790 INVs were made on 625 patients and 693 courses of ABX with an 83.9 % overall acceptance rate. De-escalate ABX and treatment duration were the most common INVs (Table 1). 92.5% of patients had improved or no change in Day 5 status when ASP INV was accepted compared to 84.3% when rejected (p=0.003). Mean days of ABX per course was 5.9 versus 7.3 (p= 0.008) in the accepted versus rejected groups. CCI and LOS were similar, while 30-day mortality almost reached significance in the accepted INV group (Table 2).

Conclusion
ASP led BC SVC was well accepted, saved 2.14 days of ABX per intervention, and was very safe.

Disclosures
All Authors: No reported disclosures
1222. Impact of Microbiology Reporting Changes in Treatment of AmpC Bloodstream Infections
Authors: Wesolowski Alec , Miller Jessica , Argotsinger Jill , Gavaghan Victoria , Dela-Pena Jennifer 
Published: November 2023

Abstract

Background
Recent literature suggests that AmpC production may be overcalled in Enterobacterales, leading to unnecessary broad-spectrum antimicrobial utilization. The Infectious Diseases Society of America (IDSA) has since reassessed classification of high and low risk organisms with inducible AmpC expression. With this updated guidance, our health system approved changes to our microbiology reporting of AmpC producers in an effort to guide prescribing of appropriate antibiotics. The primary objective of this project was to compare antibiotic prescribing patterns for high and low risk AmpC producers in patients with bloodstream infections (BSI) based on the addition of appended comments to antimicrobial susceptibility results.

Methods
This multicenter, retrospective, cohort study included patients with BSI from October 2022 to March 2023who received at least 48 hours of antimicrobial therapy for the following high and low risk AmpC producers: Citrobacter spp., Enterobacter spp., Klebsiella aerogenes, Serratia spp., Morganella spp., Providencia spp. The primary endpoint was the number of patients placed on optimal therapy based on adherence to the appended microbiology comment and IDSA guidance. Secondary endpoints included time to effective treatment, time to optimal treatment, duration of therapy, 30 day mortality, microbiological failure, microbiological relapse, 30 day readmission, length of stay, and hospital acquired Clostridioides difficile infection.

Results
A total of 191 positive blood cultures were identified with 93 patients (pre-appended comment = 57; post-appended comment = 36) meeting inclusion criteria. Patients were more likely to receive optimal therapy post-appended comment based on IDSA guidance for BSI (38.6% vs 72.2%, OR 4.14; 1.68-10.21). When stratified by high risk and low risk organism, the number of patients on optimal therapy increased in the post-appended comment group but was not statistically significant (high risk: 70.3% vs 88%, OR 3.08; 0.72-13.32; low risk: 10% vs 36.3%, 5.14; 0.92-28.50). No difference in secondary outcomes were detected.

Conclusion
Implementation of an appended microbiology note has the potential to have a positive impact on antimicrobial prescribing patterns in treatment of AmpC bloodstream infections.

Disclosures
All Authors: No reported disclosures
1224. Outcomes of Empirical Vancomycin De-escalation Based on Methicillin-Resistant Staphylococcus aureus Nares
Authors: Xu Jiachen , Chan Arthur , Wattengel Bethany A , Mergenhagen Kari A 
Published: November 2023

Abstract

Background
Vancomycin is a first-line therapy for methicillin-resistant Staphylococcus aureus (MRSA) infections. Studies found that vancomycin is associated with a higher incidence of nephrotoxicity, even within therapeutic range. MRSA nares screening allows for rapid identification of MRSA carriers. It has been proposed that MRSA nares screening may improve patient care by avoiding vancomycin. Clinical data showing the impact of de-escalation based on MRSA nares is sparse. The objective of this study is to examine the incidence of nephrotoxicity, length of stay and clinical outcomes in those who were empirically deescalated vs. those who were not.

Methods
This was a retrospective cohort study conducted across Veterans Affairs (VA) medical centers nationwide from 1 January 2018 to 1 August 2022. In addition to baseline patient characteristics, MRSA nares results on admission and vancomycin usage were obtained. Patients were stratified based on the timing of vancomycin de-escalation. Primary outcome was development of acute kidney injury, defined as a 50% increase in serum creatinine or increases in SCr by 0.3 mg/dL. Secondary outcomes included hospital length of stay and clinical course of empirical de-escalation. Odds ratios were generated from a multivariate logistic regression of significant factors.

Results
This cohort yielded 49,340 cases across the nation. Vancomycin was de-escalated after 1 dose in 7196 cases (14.58%) after MRSA nares results being documented in the electronic health record. AKI rates were lower with the early de-escalation (377/7196[5.24%] vs 3185/42144 [7.56%], P&lt; 0.0001). In multivariate analysis, incidence of nephrotoxicity was reduced by 30% (OR = 0.686; CI 0.612-0.767). Additionally, the mean hospital length of stay was reduced (8.5 vs 12 days).

Conclusion
De-escalation of vancomycin based on MRSA nares screening result can reduce the risk of nephrotoxicity and decrease hospital length of stay.

Disclosures
All Authors: No reported disclosures
1231. Development of state public health goals for antimicrobial stewardship using local data
Authors: Biehle Lauren , Schaefer Rachel , Czaja Christopher A 
Published: November 2023

Abstract

Background
Antimicrobial stewardship (AS) is critical to effectively treat infections and combat antibiotic resistance. Our Healthcare-Associated Infections/Antimicrobial Resistance (HAI/AR) program used state-level data to set public health priorities for AS across diverse acute care (ACH) and critical access (CAH) hospital settings.
Infographic describing antimicrobial stewardship goals and priority actions for Colorado hospitals

Methods
Hospitals reported antibiotic use (AU) data and implementation of priority core elements of AS to the National Healthcare Safety Network (NHSN). The Colorado Department of Public Health and Environment (CDPHE) accessed the data according to a data use agreement with NHSN. We used these data and antibiotic resistance surveillance data to inform state public health goals for AS.

Results
AU data were available for 47/53 ACH (88%) and 18/31 (58%) CAH. Three antibiotics (ABS) of highest use were ceftriaxone (18% of all ABS reported), vancomycin (14%), and piperacillin-tazobactam (10%). Data from the NHSN Patient Safety Survey indicated prospective audit and feedback (PAF) occurred in 79% of ACH and 47% of CAH. Monitoring discharge duration of therapy was reported in 27% of ACH and 37% of CAH. We developed three goals: Goal One is to decrease broad-spectrum ABS used for community-acquired infections (BSCA) by 5% in five years by encouraging hospitals to achieve 75% adherence to facility-specific treatment guidelines by 2025. Goal Two is to reduce the use of ABS active against methicillin-resistant Staphylococcus aureus (MRSA) by 5% in five years by encouraging facilities to evaluate their empiric anti-MRSA ABS and provide PAF. Goal Three is to increase NHSN AU/AR reporting to 100%/75% of ACH and 75%/50% of CAH with support through virtual AU/AR office hours and financial grants. Finally, we identified an increase in carbapenemases as an urgent threat and will encourage facilities to review use of broad-spectrum ABS and provide PAF, while monitoring rates of carbapenemases. These initiatives will be promoted through AS collaborations and feedback reports, with progress monitored through the AU Targeted Assessment for Stewardship reports.

Conclusion
These novel state-wide AS initiatives are tailored by local data and best practices to support a common vision for action for hospital AS providers.

Disclosures
All Authors: No reported disclosures
1233. Leveraging Informatics to Evaluate and Sustain Improvements in Peri-Operative Antimicrobial Prophylaxis Achieved Under the Surgical Care Improvement Project (SCIP)
Authors: Branch-Elliman Westyn , Golenbock Samuel , Hederstedt Kierstin , Pendergast Jacquelyn , Shin Marlena , Engle Ryann , Elwy A Rani , Colborn Katie , Hawn Mary , Mull Hillary J 
Published: November 2023

Abstract

Background
The Surgical Care Improvement Project (SCIP) was a national quality improvement program designed to improve peri-operative outcomes. The SCIP Program included several guideline-based antimicrobial stewardship measures, including discontinuation of antibiotics within 48 hours of skin closure for cardiac surgeries (INF-3). INF-3 was retired at the end of 2015; since this time, no systematic tools have been developed to support ongoing quality assessments.

Methods
We developed a retrospective, national cohort of cardiac surgeries in the national VA healthcare system during the period from 2010-2015 and merged these data with data from the VA External Peer Review Program, which included manually-assessed SCIP metrics, including INF-3. We electronically re-created the SCIP program by mapping exclusion criteria and developing code to assess the duration of post-operative antimicrobial use (Table 1). Among the manually-adjudicated cohort, we then iteratively refined the electronic tool until pre-specified criterion validity were achieved. After development, INF-3 compliance as assessed manually and by the objective informatics tool were compared.

Results
During the study period, 11,361 cardiac surgeries representing 26 VA facilities met inclusion criteria. The overall estimated compliance rate was 97.7% in the EPRP-reviewed cases (N=11,361) and 95.9% as-assessed by the informatics tool (N=9,561 cases); facility quality rankings using both methods were similar but not exactly the same (Figure 1). Facility-level compliance trends were similar using both measurement methodologies and the correlation between the two measures was high (r=0.69); however, the informatics tool consistently estimated compliance to be approximately 1.9% lower than manually reviewed cases (Figure 2). As estimated by the manual review program, 16 facilities (61.5%) achieved &gt;97% compliance rates versus 9 facilities (34.6%) as estimated by the informatics tool.
Figure 2. Facility-Level Compliance with INF-3 as Measured by Manual Review versus via Objective Electronic Tool

Conclusion
We developed a comprehensive, objective informatics tool for assessing ongoing compliance with SCIP INF-3. The tool can be applied in future investigations to assess the sustainability of practice changes achieved under the SCIP program and to identify areas for future improvement.

Disclosures
Westyn Branch-Elliman, MD, MMsc, DLA Piper, LLC/Medtronic: Advisor/Consultant|DLA Piper, LLC/Medtronic: Expert Testimony|Gilead Sciences: Grant/Research Support
1240. Perceptions of Antimicrobial Stewardship and Antibiotic Use by Healthcare Workers in Latin America
Authors: Fabre Valeria , Cosgrove Sara E , Lessa Fernanda C , Patel Twisha S , Patel Payal K , Quirós Rodolfo E 
Published: November 2023

Abstract

Background
The burden of antimicrobial resistance (AMR) in Latin America is high. Little is known about healthcare workers’ (HCWs) perceptions of antimicrobial stewardship (AS) and antibiotic use (AU) in the region.

Methods
HCWs from 42 hospitals in Panama, Guatemala, Colombia, Ecuador, and Argentina were invited to participate in an electronic, voluntary, anonymous survey regarding perceptions of AS and AU from March-April 2023. All participants were asked 21 questions; prescribers were asked additional questions about antibiotic prescribing. Answers with 5-point Likert scale were categorized into two groups, strongly agree/agree and neutral/disagree/strongly disagree.

Results
Of 475 HCWs that completed the survey, 52% were physicians (29% in training), 28% nurses, 13% pharmacists, 3% microbiologists, and 3% “other.” Median years of experience was 12 (interquartile range 6, 20). Although 93% indicated optimizing AU was a priority at their healthcare facility (HCF), only 69% said the importance of AS was communicated at their HCF. Nurses and those in “other” roles were more likely to report lack of familiarity with the term AS than physicians (32% and 27% respectively vs. 21%, P&lt; 0.01).
Most (99%) respondents acknowledged that appropriate AU can reduce AMR and that inappropriate AU could harm patients. However, fewer thought antibiotics were overused (30%) or AMR was a problem (52%) in their HCF. Thirty-eight percent of HCWs did not have access to guidelines and 24% did not value recommendations by the AS team (Figure 1). Of prescribers, 99% reported to modify antibiotics based on culture results, 55% do not consult non-physician staff (e.g., pharmacists, nurses) to make antibiotic decisions, 20% do not use local guidelines or do not receive training on how to interpret culture results to make antibiotic decisions (Figure 2). Prescribers felt pressure from colleagues (38%) and patients or their families (63%) to make antibiotic decisions.

Conclusion
Although most HCWs perceived improving AU as a priority, they did not perceive AU or AMR to be a problem in their HCF. Opportunities to optimize AU include improved access and adherence to guidelines, access to AMR data, teamwork, and education on AS for HCW.

Disclosures
Sara E. Cosgrove, MD, MS, Debiopharm: Advisor/Consultant|Duke Clinical Research Institute: Advisor/Consultant Payal K. Patel, MD MPH, qiagen: Honoraria
1246. Impact of Leveraging Clinical Decision Support Tools to Implement a Tiered Antimicrobial Stewardship Workflow at a Rural Academic Medical Center
Authors: Howard Catessa A , Freeman Lauren , Mehta Meera , Grimm Derek , Guilfoose John A 
Published: November 2023

Abstract

Background
The Infectious Diseases Society of America and The Joint Commission recommend Antimicrobial Stewardship Programs (ASPs) incorporate preauthorization and/or prospective audit and feedback (PAF) as mechanisms for stewardship interventions. However, each institution must customize their ASP workflow. The ASP at West Virginia University Hospitals (WVUH), a rural, comprehensive academic medical center, was recently revamped by leveraging clinical decision support (CDS) tools via a tiered workflow in efforts to prioritize stewardship interventions for preauthorization and PAF.

Methods
In March 2021 ASP pharmacists created a tiered workflow incorporating CDS tools from Theradoc® and Epic®. Review of patients identified on CDS alerts (Table 1), preauthorization, and PAF were conducted Monday through Friday 8:00 am to 5:00 pm by ASP pharmacist(s). Tiered workflow effectiveness was measured by internal and external benchmarking: antimicrobial days of therapy (DOT)/1000 days present, antimicrobial spend, and Standardized Antimicrobial Administration Ratio (SAAR). Interventions were documented within the electronic medical record and tracked via a Quality Assurance and Performance Improvement (QAPI) format. Post implementation data from March 2021 to March 2023 was analyzed and compared to baseline 2019 data.
CRE: Carbapenem-resistant Enterobacterales; ESBL: Extended Spectrum Beta-Lactamase; HIV: Human Immunodeficiency Virus

Results
The following outcomes were observed within the post implementation timeframe. Monthly average DOT/1000 days present decreased ≥ 20% for the following antimicrobials: vancomycin (27%), ceftaroline (53%), cefepime (20%), ertapenem (59%), aztreonam (68%), tigecycline (23%), fosfomycin (80%), micafungin (27%), ceftazidime-avibactam (40%). Monthly average total antimicrobial SAAR decreased by 11% from 1.216 to 1.074. Additionally, monthly average antimicrobial spend/patient day decreased by 36% from $26.47 to $16.95. QAPI data demonstrated a 74% intervention acceptance rate including correction of 344 drug-bug matches.

Conclusion
Implementation of a tiered ASP workflow effectively identified patients for interventions, decreased antimicrobial utilization, and demonstrated antimicrobial cost containment. Acceptance of stewardship interventions was favorable. This tiered approach may serve as a model for other ASPs.

Disclosures
All Authors: No reported disclosures
1271. Antimicrobial Appropriateness after Ambulatory Antimicrobial Stewardship Program for Uncomplicated Cystitis
Authors: Thongwitokomarn Harit , Yasri Saowaluck , Chaiwarith Romanee 
Published: November 2023

Abstract

Background
Urinary tract infection (UTI) is a common bacterial infection found in outpatient departments. Previous studies showed the rising trend of fluoroquinolone use for urinary tract infections treatment coinciding with the increase of fluoroquinolone-resistance uropathogens. The major cause of this problem is inappropriate antimicrobial use. Therefore, we implemented antimicrobial stewardship programs to improve antimicrobial appropriateness and treatment outcome in ambulatory uncomplicated cystitis patients at Maharaj Nakorn Chiang Mai Hospital.

Methods
We conducted a retrospective pre-post intervention study design among ambulatory uncomplicated cystitis patients aged ≥ 18 years in Maharaj Nakorn Chiang Mai Hospital compared the pre-intervention group (1 March 2021 – 31 August 2021) and post-intervention group (1 October 2021 – 31 March 2022).

Results
There were 49 patients included in the study; 29 were in the pre-intervention group and 20 were in the post-intervention group. Antimicrobial appropriateness increased significantly (0% vs 55%, P&lt; 0.001) after antimicrobial stewardship programs’ implementation attributed to significant improvement in appropriate antimicrobial choice (6.9% vs 95%, P&lt; 0.001), dose (0% vs 89.5%, P= 0.029) and duration (6.9% vs 95%, P&lt; 0.001). The antimicrobials were indicated in post-intervention group more than pre-intervention group but did not reach statistically significance (44.8% vs 65%, P=0.164). There was a significant improvement in concordant antimicrobial therapy after the antimicrobial stewardship programs’ implementation (25% vs 92.3%, P= 0.001), although there was no difference in treatment failure between groups (12.5% vs 7.1%, P= 1.000).

Conclusion
Antimicrobial appropriateness and concordant antimicrobial therapy increased significantly after antimicrobialstewardship programs’ implementation. However, there was no difference in treatment failure between groups.

Disclosures
All Authors: No reported disclosures