AbstractBackgroundAntimicrobial Stewardship Research Articles

1208. Impact of Selected Antimicrobial Stewardship and Infection Control Strategies in Carbapenem Resistance in a Third Level Public Hospital in Colombía.

Abstract Background Antimicrobial Stewardship (AMS) Programs and Infection prevention and control (IPC) strategies have been shown to effectively reduce antimicrobial resistance. The resources required for the implementation of these programs in low-resource settings could be limited. This study aimed to assess the impact of a few AMS and IPC strategies on carbapenem resistance in a third-level public hospital in Colombia. Methods A retrospective before-and-After study was completed. The baseline period consisted of 6 months (January 2021-Jun 2021) and the intervention period consisted of 18 months (July 2021-December 2022) The AMS intervention consisted of the implementation of prospective audits on prescriptions of meropenem, cefepime, and piperacillin-tazobactam, along with educational seminars. The IPC intervention consisted of screening for carbapenemase-producing-Enterobacterales (CPE) through rectal swabs for every patient transferred to the ICU and weekly for all patients in the ICU. A cohorting area with 24 beds was also established to isolate CPE colonized/infected patients Results During the intervention period, 886 prospective audits were made. We suspended 208, 111, and 55 prescriptions of Meropenem, piperacillin-tazobactam, and cefepime respectively. The length of therapy was shortened in 239, 290, and 99 prescriptions of Meropenem, piperacillin-tazobactam, and cefepime respectively. The antimicrobial consumption was lower in the intervention period for meropenem (24,8 DDD/100 patients-days Vs 74.3 DDD/100 patients-days baseline period). Figure 1 The prevalence of positive rectal swabs showed a downward trend during the intervention period. Figure 2. The prevalence of CPE also decreased and was 0,45 during the baseline period and 0,28 during the last semester of the intervention period. Figure 3 The carbapenem resistance K. pneumoniae laboratory-confirmed bloodstream infection rate also decreased during the intervention period, going from 15.4/10.000 patients-days to 1.17/10.000 patient-days. Figure 4 Conclusion The implementation of selected AMS and IPC strategies in a resource limited third level hospital reduced the prevalence of carbapenemase-producing Enterobacterales and the rate of Carbapenem-resistant K. pneumoniae bloodstream infections. Disclosures GERARDO A. MUÑETON, Infectious diseases and Internal Medicine Specialist, PFIZER: Advisor/Consultant

1235. A Retrospective Review of Antimicrobial Stewardship Audit and Feedback: Assessing Acceptance of Stewardship Recommendations During the COVID-19 Pandemic

Abstract Background Antimicrobial stewardship is an underutilized strategy to mitigate the impact of antimicrobial resistance. It is well documented that many Antimicrobial Stewardship Programs (ASPs) were tasked with assisting healthcare teams in navigating the COVID-19 pandemic, leaving less time/fewer resources for day-to-day ASP activities. The aim of this study was to evaluate the acceptance of stewardship recommendations during a season when the ASP had less time to perform regular educational activities and handshake stewardship. Methods A retrospective study of patients receiving antimicrobial therapy at Saint Francis Hospital during 12/30/2020-10/01/2022, for which audit and feedback by the ASP was conducted. A well-established ASP existed prior to the pandemic. Independent variables included the reason for intervention, type of infection by organ system, and type of intervention. Interventions included recommendations to stop antibiotics, de-escalation, duration of therapy, ID consultation, or change the route of administration. The primary outcome was the audit and feedback acceptance rate, and the secondary outcome was whether the intervention resulted in infectious disease consultation. Results 297 patients underwent audit and feedback. Interventions most accepted by providers included changing the route of administration (100%) and consulting ID formally (92%). Adjusting the duration of therapy was the least accepted intervention at 78%. Regardless of intervention, 33% of providers requested a formal ID consult. The number of interventions varied sporadically, coinciding with periods of decreased availability by the ASP team and during peak waves of the COVID-19 pandemic. Conclusion Our ASP team, despite decreased resources while battling an ongoing pandemic, were still able to perform audit and feedback to providers with a good acceptance rate of recommendations, consistent with current literature. Having not only an existing but robust ASP prior to the pandemic, allowed continued success with ASP intervention acceptance rates, despite less dedicated time for typical ASP activities during the pandemic. Fostering good relationships between providers and ASP teams, as well as continued support and funding from hospital leadership, are vital to ongoing success. Disclosures All Authors: No reported disclosures

1263. The Experience of an Antimicrobial Stewardship Program at a Tertiary Referral Hospital in a Low/Middle Income Country

Abstract Background Antimicrobial Stewardship Programs (ASP) play a crucial role in optimizing antimicrobial utilization and limiting the use of broad-spectrum antibiotics, to reduce antimicrobial resistance. During the COVID-19 pandemic, there was a noticeable increase in antimicrobial consumption globally. The ASP at the American University of Beirut Medical Center (AUBMC) began formal operations in January 2019. In this study, our aim is to evaluate the activities of the ASP -since implementation and during the pandemic- at our institution, a tertiary referral hospital in Beirut. Methods The ASP team performed handshake stewardship rounds and daily reviews of antimicrobial use. It provided educational activities in a multi-disciplinary approach in addition to implementing a carbapenem sparing strategy and ongoing monitoring of antibiotic consumption. This study is a retrospective review of those activities. We compiled the ASP recommendations from January 2019 until December 2021. Data collected included the number of ASP recommendations and their sub-categories in addition to acceptance rates. Results We recorded a total of 9922 recommendations during this three-year period. Recommendations aiming at reducing antimicrobial consumption were the most common (42%), and included: duration of therapy, de-escalation, and duplicate coverage (Figure 1). Rates of acceptance of these recommendations were 88%, 92% and 95% in 2019, 2020 and 2021 respectively. The number of recommendations increased during the pandemic and coincided with COVID-19 surges in Lebanon (figure 2). There was also an increase in the acceptance rate of recommendations to reduce antibiotic consumption (Figure 3) over this period.Figure 1.Distribution of ASP Interventions per sub-CategoryFigure 2.Number of ASP Recommendations pre- and During COVID-19Figure 3.ASP recommendations to Reduce Antibiotic Consumption and Acceptance Rate Conclusion Despite the challenges imposed by the pandemic and the involvement of the ASP in the COVID-19 response, the team maintained its efforts and involvement to mitigate antibiotic misuse. The results are encouraging and attest to the important role of ASP in driving culture change regarding the judicious use of antimicrobials even during a pandemic. Disclosures Souha S Kanj, MD, Gilead: Advisor/Consultant|Menarini: Advisor/Consultant|MSD: Advisor/Consultant|Pfizer: Advisor/Consultant

1236. Implementation and Impact of a Pharmacist-driven Outpatient Antimicrobial Stewardship Program in a Costa Rican Private Hospital

Abstract Background Antimicrobial stewardship programs (AMS) have been shown to be beneficial in both inpatient (IP) and outpatient (OP) settings. The CDC set the core elements for OP AMS initiation. In Latin America, progress has been made about AMS, but mainly in the IP. This hospital has an IP AMS that lacks activities dedicated to OP prescriptions. After conducting a baseline characterization of the OP antibiotics (ABs) prescriptions received in the hospital pharmacies, it was identified that ABs were prescribed mostly for urinary tract infections (UTIs). Methods A retrospective observational analysis of the implementation of an OP AMS (Apr.-June 2022) and the impact of this program on the prescribing patterns for the management of OP UTIs. The level of adherence to CDC's core elements was assessed before and after the implementation. The impact in OP UTIs was estimated by comparing prescribing patterns according to the hospital clinical guideline in the emergency ward (ER) preAMS (July 2021-Mar. 2022) and postAMS (July 2022-Dec. 2022). Results Compliance with CDC only met 28.6% of the core elements in the preAMS period, a percentage that improved to 85.7% after the implementation (Fig.1). For the impact on UTIs, 269 patient cases were analyzed (53.2% preAMS and 46.8% postAMS). The optimal selection of ABs in the preAMS period was 53.8% (n=77) and 95.2% (n=120) in the postAMS with an improvement of 41.4% (p< 0.001). Ciprofloxacin optimal selection had a 31.3% (p=0.028) increase, while levofloxacin exhibited a 60.0% (p=0,027) increment. Additionally, in the postAMS, the overall use of nitrofurantoin increased 3.6 times and the use of TMP-SMX and fluoroquinolones was reduced by 92.9% and 48.3%, respectively (Table 1). By diagnosis, there was a 56.0% (p< 0.001) improvement in the optimal treatment of uncomplicated cystitis and 9.6% (p=0.05) for complicated cystitis (Table 1). The ER physicians were evaluated according to compliance with the clinical guidelines for UTIs. The mean score in the preAMS period was 46.2% and 90.0% in the postAMS (Fig.2).Figure 1.Compliance and activities related to the CDC Core Elements of outpatient AMS.Table 1.Comparison of optimal therapy selection in the emergency ward pre-AMS intervention and post-AMS by antibiotic prescription and UTI classification.Figure 2.Distribution of scores of ER physicians according to adherence to clinical guidelines for UTI by period. Conclusion The implementation of an OP-AMS according to CDC standards led to an improvement in complying with the OP UTI clinical guidelines. This suggests that this strategy could be applied to optimize the use of ABs in other infections in this population and region. Disclosures José P. Díaz-Madriz, PharmD, Eli Lilly: Stocks/Bonds|MSD: Advisor/Consultant|Pfizer: Advisor/Consultant

P20 Addition of a pharmacy technician to the ward team improves antimicrobial stewardship and patient care and safety

Abstract Background Antimicrobial stewardship (AS) is essential in reducing the risk of antimicrobial resistance (AMR).1,2 Prospective feedback of AS issues and adopting a multidisciplinary approach are beneficial to patient care and safety.3 Within the multidisciplinary team, antimicrobial pharmacy technician (AMPT) roles are evolving and offer an excellent opportunity to support everyday AS.4 Documenting antibiotic stop dates and allergy status on the prescribing chart and restricting broad spectrum antimicrobials to ‘protected’ status can improve AS by ensuring patients receive the correct antibiotic for the appropriate duration.5 In addition, management of common antibiotic drug interactions with cation products such as oral iron and enteral feeds is important in preventing treatment failure and AMR.6 Objectives This study set out to determine if introduction of an AMPT to the multidisciplinary team can improve AS, patient care and safety and reduce AMR risk. Methods A quality improvement approach was used to introduce an AMPT ward service to the Royal Alexandra Hospital (RAH) over a period of 6 months. The service was developed, standardized, piloted and agreed. The AMPT visited medical, surgical and older people service wards daily and screened prescribing charts for the following: (i) documented allergy status, (ii) documented antibiotic stop/review dates, (iii) completion of ‘protected’ antimicrobial order forms, and (iv) management of antibiotic cation interactions. AS issues identified were shared prospectively with the ward team and data displayed on run charts to measure improvement. Results Following introduction of the AMPT service documentation of allergy status and oral antibiotic stop dates improved from baseline in all wards. IV antibiotic stop/review documentation increased in all downstream medical and surgical wards with the greatest improvement achieved in the respiratory ward, increasing from a 0% baseline to a median of 37% after service introduction. Awareness and management of antibiotic cation interactions increased from a 41% baseline to a median of 86% and total antibiotic doses compromised by this interaction reduced from 66% at baseline to 21% post change. Completion of ‘protected’ antimicrobial forms improved from a baseline median of 53% to a median of 85% after service introduction. Conclusions Introduction of an AMPT service resulted in improved documentation of allergy status, oral and IV antibiotic stop/review dates, recognition and management of antibiotic cation interactions and compliance with the local ‘protected’ antimicrobial policy. These results demonstrate that introduction of an AMPT to the ward team can improve AS, patient care and safety and reduce the risk of AMR.

P21 Promoting antimicrobial stewardship and sustainability utilizing a ‘Go Green’ IV to oral switch (IVOST) policy and electronic prescribing prompts in antimicrobials with high oral bioavailability

Abstract Background Antimicrobial stewardship (AS) is crucial in reducing antimicrobial resistance (AMR) and the sustainability impact of inappropriate antimicrobial use.1 Promotion of the oral route and IV to oral switch (IVOST) are key AS initiatives providing benefits for patients, staff and the environment including reduced risk of line infections and AMR, reduced workload and costs, reduced plastic waste and improved sustainability.2 A recent quality improvement (QI) initiative to promote oral metronidazole (bioavailability > 90%) in eligible surgical patients at the Royal Alexandra Hospital (RAH) resulted in a change in prescribing behaviour and a 45% median reduction in IV metronidazole use.3 Objectives To scale and spread promotion of the oral route in antimicrobials with high oral bioavailability with the aim of reducing collective IV use by 20% by February 2023 at RAH. Methods A QI approach was used to promote the oral route where appropriate in the following agents: metronidazole, levofloxacin, fluconazole, ciprofloxacin, co-trimoxazole, clindamycin, linezolid and rifampicin. Techniques included the following: ‘Go Green IVOST’ posters in key ward areas highlighting benefits of the oral route; targeted pharmacist and pharmacy technician prospective audit and feedback using the electronic prescribing system; presentations to ward and pharmacy teams; staff champions and electronic IVOST prompts displayed when prescribing and administering the targeted agents IV. To measure improvement, oral and IV usage data were measured at baseline and for 24 months post change. Data were displayed on run charts to determine if the QI target was achieved. Results There was a 44% median reduction in IV defined daily doses (DDDs) in the targeted antimicrobials, surpassing the 20% target (Figure 1). There was a median 10% shift in the proportion of these agents given IV as a percentage of total (IV plus oral) use (Figure 2) The greatest reduction (60%) was in IV metronidazole where usage declined from a monthly baseline of 667 to 267 DDDs. This equates to a median reduction of 1200 IV metronidazole administrations and nearly 600 hours nursing time saved per month. IV fluconazole and IV levofloxacin usage declined from baseline by a median of 35% and 24%, respectively. Conclusions A QI approach to promote appropriate use of the oral route in antimicrobials with high oral bioavailability resulted in a change in prescribing behaviour and a sustained reduction in IV prescribing of these agents. This is important in terms of improved AS, patient care and safety, healthcare cost and efficiency and environmental sustainability.

1756. Prescriber Adherence to System-Wide Urinary Tract Infection Guidelines in Ambulatory Care Clinics

Abstract Background Antimicrobial stewardship (AMS) practices are well established in acute care, only recently expanding into ambulatory care settings. It has been estimated that 80-90% of antibiotic use occurs in the ambulatory setting with up to 52% of that use being unnecessary. Urinary tract infections (UTIs) are commonly treated in ambulatory settings, and drug selection and duration of therapy vary among different practices. Our study evaluated the impact of a system-wide guideline and prescriber education, two recommended AMS strategies, on antibiotic utilization for UTIs in the ambulatory setting. Methods This retrospective study evaluated female adult patients prescribed an antibiotic for acute uncomplicated cystitis by a primary care provider at a clinic within our organization between January and March 2021. System-wide UTI treatment guidelines were implemented in November 2020, with live education delivered to primary care prescribers in December 2020. The primary objective of this study was to assess prescriber adherence to system-wide guidelines. The secondary objective was to evaluate utilization of antibiotic regimens for treatment of acute uncomplicated cystitis. Results A total of 100 patients were evaluated. Guideline adherence was met in 49% of patients. The primary reason for guideline non-adherence was duration of therapy, which was inappropriate (too long) in 42% of patients. Nitrofurantoin, the first-line antibiotic recommendation on the system-wide guideline, was the antibiotic prescribed most frequently (48%), but was the antibiotic of choice in 90% of patients. Sulfamethoxazole/trimethoprim was prescribed in 35% of patients and was most often prescribed correctly with respect to appropriate dose and duration of therapy (60%), followed by nitrofurantoin (54%). Recurrent cystitis within 30 days occurred in 11% of patients. Conclusion Implementation of a system-wide guideline and prescriber education for treatment of UTIs in the ambulatory setting identified areas for future optimization of antibiotic use, namely first line antibiotic selection and duration of therapy. This data will be shared with our prescribers to continue to encourage guideline-adherent antibiotic use. Disclosures All Authors: No reported disclosures.

963. Perceived Antimicrobial Stewardship Roles of Pharmacists and Residents in US Intensive Care Units

Abstract Background Antimicrobial stewardship programs (ASPs) were developed as a way of addressing antibiotic resistance by promoting the judicious use of antibiotics. Pharmacist and resident perspectives of their own roles within antimicrobial stewardship are relatively unknown. An ethnographic study of intensive care units (ICU) was conducted to understand the perceptions and attitudes surrounding pharmacist and resident roles relative to stewardship. Methods A research assistant with medical anthropology training performed semi-structured interviews with intensive care pharmacy specialists and residents at a medical center in Cleveland, Ohio, USA between June 2021 and August 2021. Data analysis centered on the understandings of ASPs and antibiotic prescribing present in multidisciplinary groups where certain members are not primary antibiotic decision-makers. The data were analyzed using thematic coding aided by NVivo qualitative analysis software. Results Intensive care pharmacy specialists (N=5) and residents (N=6) were interviewed, accruing > 518 minutes of semi-structured interview data. Pharmacy specialists described their contributing role as serving stewardship goals such as “decreasing mortality” and believed that they should have input in antibiotic decision making. Residents also emphasized the importance of consulting pharmacists before antibiotic decisions were made. Both groups felt limited in their ability to contribute to final antibiotic decisions. Pharmacists regularly referred to their input as a “recommendation” and described their actions as “suggestions”. Residents expressed that physicians were better suited to make decisions due to the residents’ limited experience, acknowledging that they “don’t know everything.” Table 1.Key Themes and Perceived Roles in Intensive Care Conclusion This study found that ICU pharmacists and residents have an awareness of stewardship that might aid in antimicrobial prescribing. Both groups expressed an appreciation for stewardship goals despite being bounded by hierarchies of medical practice. Providing these groups with greater autonomy over prescribing practices might improve ASP effectiveness. Future studies may focus on analysis on the social dynamics of hospital spaces and the corresponding impact on decision-making and expert practices. Disclosures All Authors: No reported disclosures.

955. Improving Pharmacist Access to Training in Antimicrobial Stewardship in Latin American Countries: Partnership between the Pharmaceutical Forum of the Americas (PFA) and the Society of Infectious Diseases Pharmacists (SIDP)

Abstract Background Antimicrobial stewardship programs (AMS) in Latin America have varying degrees of development. One significant barrier is the lack of clinical pharmacists with specialized training in infectious diseases, as there are no residency programs or certifications available to train pharmacists in AMS in Latin America. To overcome this limitation and based on the roadmap for antimicrobial resistance action from the International Pharmaceutical Federation (FIP), the PFA established a partnership with SIDP to support specialized training and mentoring in AMS for pharmacists working in Latin America. Herein, we describe characteristics of this innovative program and its initial participants. Methods Pharmacist members of associations belonging to the PFA (9 Latin American countries) were invited to apply for the SIDP AMS Certificate Program (SIDP-CP) with additional mentoring. Selection was based on current employment status, support from hospital leadership, and an intermediate level of English. A 14-item survey was disseminated to the participants of this program and responses were collected in March 2022, at the beginning of their SIDP-CP. The survey collected information on demographics, characteristics of the AMS at their hospital, experience with AMS to-date, and support requirements to finish the SIDP-CP. Results The description of the SIDP-CP can be found in Figure 1. Surveys were completed by 11/12 (91.7%) program participants: 6 (54.5%) from Costa Rica, 4 (36.4%) from Colombia, and 1 (9.1%) from Argentina. Seven (63.6%) pharmacists work in hospitals with a formally approved AMS, with 6 providing basic and 1 reporting intermediate AMS services. None of the pharmacists have positions dedicated exclusively to AMS, and the majority of those surveyed work ≤ 25% of their time on AMS-related activities. In addition to completing the SIDP-CP, participants indicated high interest in attending periodic virtual meetings to increase their knowledge of how to implement, strengthen, or begin research in AMS. Conclusion Incorporating antimicrobial stewardship in all healthcare institutions worldwide is vital in the fight to slow antimicrobial resistance. Partnerships like this one between PFA and SIDP can inform future planning for expansion of AMS training. Disclosures José Pablo Díaz-Madriz, PharmD, MSc, Eli Lilly: Stocks/Bonds|Pfizer: Advisor/Consultant Melissa D. Johnson, PharmD, MHS, AAHIVP, Charles River Laboratories: Grant/Research Support|Entasis: Honoraria|Merck: Grant/Research Support|Pfizer: Honoraria|Scynexis: Grant/Research Support|Theratechnologies: Honoraria|UpToDate: Honoraria Scott J. Bergman, PharmD, BCIDP, FCCP, FIDSA, Merck & Co., Inc: Advisor/Consultant|Merck & Co., Inc: Grant/Research Support|Merck & Co., Inc: Honoraria|Pfizer: Advisor/Consultant|Pfizer: Honoraria.

P03 Improving antimicrobial stewardship and sustainability by promoting oral metronidazole in eligible surgical patients at the Royal Alexandra Hospital

BackgroundAntimicrobial stewardship (AS) is essential to minimize the emergence and spread of antimicrobial resistance.1 Timely IV to oral antibiotic switch and promotion of the oral route are key AS initiatives in the acute hospital setting.1 Metronidazole is commonly prescribed IV in the surgical management of intra-abdominal sepsis; however, metronidazole has excellent oral bioavailability of 95%–100%. In addition to improved AS, the oral route provides advantages to patients, staff and the environment including reduced patient risk of line infections/complications; reduced staff workload and healthcare costs; improved patient comfort/mobility; earlier discharge; and improved sustainability.ObjectivesTo measure baseline proportion of surgical patients meeting the criteria for oral receiving oral metronidazole; introduce tests of change to promote use of oral metronidazole where appropriate; and measure changes in prescribing behaviour to determine if improvement has been achieved, with the aim of increasing the proportion of oral metronidazole prescribed to eligible Royal Alexandra Hospital (RAH) surgical patients to 50% by February 2022.MethodsBaseline metronidazole prescribing data were collected over 6 weeks in surgical wards at the RAH. Exclusions for oral metronidazole included compromised gut absorption, oral route unreliable or worsening clinical condition/sepsis. A quality improvement approach was used to engage and raise awareness of the multidisciplinary surgical team to the benefits of prescribing oral metronidazole where appropriate. A range of methods were used including prospective audit and feedback; departmental presentations to surgical and pharmacy teams; eye-catching posters in key areas; staff champions; staff recognition awards; WhatsApp© group messages; and West of Scotland Surgical Association presentation. To measure improvement the proportion of oral and IV metronidazole prescribed was measured weekly and oral and IV metronidazole usage data in RAH surgical wards was measured monthly. A questionnaire was used to assess the impact of the project on nursing staff.ResultsBaseline data (n = 90) highlighted that only 13.5% of patients meeting the criteria for oral metronidazole were prescribed oral in RAH surgical wards. Post-change: oral metronidazole prescribing increased from a baseline median of 7% to 51%; IV metronidazole usage data decreased by 45%; there were 320 fewer IV metronidazole administrations per month; and nursing staff reported benefits including reduced workload, improved patient comfort and reduced plastic waste.ConclusionsA quality improvement approach to engage and raise staff awareness of the benefits of oral metronidazole resulted in a change in prescribing behaviour and increased the proportion of oral metronidazole prescribed to eligible surgical patients to 50% by February 2022.

Implementation of an antimicrobial stewardship programme in three regional hospitals in the south-east of Liberia: lessons learned.

BackgroundAntimicrobial stewardship (AMS) programmes can improve the use of antimicrobial agents. However, there is limited experience in the implementation of such programmes in low- and middle-income countries (LMICs).ObjectivesTo assess the effect of AMS measures in south-east Liberia on the quality of antimicrobial use in three regional hospitals.MethodsA bundle of three measures (local treatment guideline, training and regular AMS ward rounds) was implemented and quality indicators of antimicrobial use (i.e. correct compounds, dosage and duration) were assessed in a case series before and after AMS ward rounds. Primary endpoints were (i) adherence to the local treatment guideline; (ii) completeness of the microbiological diagnostics (according to the treatment guideline); and (iii) clinical outcome. The secondary endpoint was reduction in ceftriaxone use.ResultsThe majority of patients had skin and soft tissue infections (n = 108) followed by surgical site infections (n = 72), pneumonia (n = 64), urinary tract infection (n = 48) and meningitis (n = 18). After the AMS ward rounds, adherence to the local guideline improved for the selection of antimicrobial agents (from 34.5% to 61.0%, P < 0.0005), dosage (from 15.2% to 36.5%, P < 0.0005) and duration (from 13.2% to 31.0%, P < 0.0005). In total, 79.7% of patients (247/310) had samples sent for microbiological analysis. Overall, 92.3% of patients improved on Day 3 (286/310). The proportion of patients receiving ceftriaxone was significantly reduced after the AMS ward rounds from 51.3% to 14.2% (P < 0.0005).ConclusionsAMS measures can improve the quality of antimicrobial use in LMICs. However, long-term engagement is necessary to make AMS programmes in LMICs sustainable.

The impact of digital interventions on antimicrobial stewardship in hospitals: a qualitative synthesis of systematic reviews.

BackgroundAntimicrobial stewardship (AMS) programmes in hospitals support optimal antimicrobial use by utilizing strategies such as restriction policies and education. Several systematic reviews on digital interventions supporting AMS have been conducted but they have focused on specific interventions and outcomes.ObjectivesTo provide a systematic overview and synthesis of evidence on the effectiveness of digital interventions to improve antimicrobial prescribing and monitoring in hospitals.MethodsMultiple databases were searched from 2010 onwards. Review papers were eligible if they included studies that examined the effectiveness of AMS digital interventions in an inpatient hospital setting. Papers were excluded if they were not systematic reviews, were limited to a paediatric setting, or were not in English.ResultsEight systematic reviews were included for data extraction. A large number of digital interventions were evaluated, with a strong focus on clinical decision support. Due to the heterogeneity of the interventions and outcome measures, a meta-analysis could not be performed. The majority of reviews reported that digital interventions reduced antimicrobial use and improved antimicrobial appropriateness. The impact of digital interventions on clinical outcomes was inconsistent.ConclusionsDigital interventions reduce antimicrobial use and improve antimicrobial appropriateness in hospitals, but no firm conclusions can be drawn about the degree to which different types of digital interventions achieve these outcomes. Evaluation of sociotechnical aspects of digital intervention implementation is limited, despite the critical role that user acceptance, uptake and feasibility play in ensuring improvements in AMS are achieved with digital health.

Antimicrobial stewardship in companion animal practice: an implementation trial in 135 general practice veterinary clinics.

BackgroundAntimicrobial stewardship programmes (ASPs) have been widely implemented in medical practice to improve antimicrobial prescribing and reduce selection for multidrug-resistant pathogens.ObjectivesTo implement different antimicrobial stewardship intervention packages in 135 veterinary practices and assess their impact on antimicrobial prescribing.MethodsIn October 2018, general veterinary clinics were assigned to one of three levels of ASP, education only (CON), intermediate (AMS1) or intensive (AMS2). De-identified prescribing data (1 October 2016 to 31 October 2020), sourced from VetCompass Australia, were analysed and a Poisson regression model fitted to identify the effect of the interventions on the incidence rates of antimicrobial prescribing.ResultsThe overall incidence rate (IR) of antimicrobial prescribing for dogs and cats prior to the intervention was 3.7/100 consultations, which declined by 36% (2.4/100) in the implementation period, and by 50% (1.9/100) during the post-implementation period. Compared with CON, in AMS2 there was a 4% and 6% reduction in the overall IR of antimicrobial prescribing, and a 24% and 24% reduction in IR of high importance antimicrobial prescribing, attributable to the intervention in the implementation and post-implementation periods, respectively. A greater mean difference in the IR of antimicrobial prescribing was seen in high-prescribing clinics.ConclusionsThese AMS interventions had a positive impact in a large group of general veterinary practices, resulting in a decline in overall antimicrobial use and a shift towards use of antimicrobials rated as low importance, with the greatest impact in high-prescribing clinics.

P04 An evaluation of antimicrobial stewardship education in the School of Pharmacy of an Irish university—a mixed methods study

BackgroundAntimicrobial stewardship (AMS) is essential to control the emergence of antimicrobial resistance (AMR) which has become an international health priority. Education of undergraduate students on AMS and AMR is a strategic objective in the WHO Global Action Plan on AMR and Ireland's National Action Plan.1,2 Research on AMS/AMR education has focused primarily on medical students with less emphasis on those from other healthcare profession including pharmacy students.ObjectivesTo investigate AMS and AMR education in the Pharmacy undergraduate programme in the School of Pharmacy of an Irish University.MethodsA mixed methods study was conducted. Ten semi-structured interviews were conducted in October 2019 with academic staff to capture their views on AMS education. Participants included staff members from different disciplines, those identified as involved in teaching elements of infectious disease, antibiotics, AMS and related topics, and those involved in curriculum design and approval within the School of Pharmacy. Interview transcripts were analysed by thematic analysis. An electronic survey of 17 questions was emailed to all second to fifth year UCC Pharmacy students in October 2019 to gather students’ views and experiences of AMS education. The survey contained four sections which addressed demographics, AMS, resources and education using open-ended, closed-ended or Likert-scale questions. Ethical approval was obtained.ResultsSix key themes were identified from the ten interviews: (i) curriculum priorities and capacity; (ii) housing of the subject, fragmentation and cohesion; (iii) integration; (iv) communication; (v) teaching methods; and (vi) assessment methods. 113 students participated in the survey (32.3% response rate). 96% agree that a strong knowledge of antimicrobials for their future careers is important, and over 89% of students desire more education on AMR and AMS. Only 43% of students found their AMS education provided sufficient preparation for practice. Students felt most prepared to recognize clinical signs of infection and least prepared for IV to oral switching, interpreting biological marker and de-escalation of antimicrobials. Over 50% of students never used or were not familiar with the national primary care antimicrobial guidelines: www.antibioticprescribing.ie.ConclusionsPharmacy students and staff agree that AMS and AMR are important and need enhanced educational focus. Students feel there are gaps in their AMS education and expressed a desire for more education in this area. Improved communication and identification of curriculum priorities by staff could help to establish a more cohesive and comprehensive educational approach to this area.

513. Use of Antimicrobial Stewardship Program in Operationalizing Monoclonal Antibody Therapy in SARS-CoV-2 Infection

BackgroundAntimicrobial stewardship programs (ASP) have been essential during the coronavirus disease 2019 (COVID-19) pandemic response. Use of monoclonal antibodies for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection has proven difficult to operationalize, despite being available through emergency use authorization (EUA). Utilizing existing ASP and multidisciplinary approach to lead the effort, we aim to describe our experience in operationalizing monoclonal antibody therapy.MethodsRetrospective study of SARS-CoV-2 infected adults receiving monoclonal antibody therapy under EUA (December 2020-April 2021). An algorithm developed by the ASP provided education and an interactive online tool allowing referring physicians and patients to assess eligibility prior to hospital arrival. Patients were screened and approved by existing ASP which included; Infectious Disease (ID) physicians, pharmacist, and ID Nurse. A multidisciplinary approach with ER staff and development of pharmacy workflow with order set were utilized as eligible patients received infusion in dedicated ER location. Data such as demographics, co-morbid condition, infusion related complications, hospitalization, and death were reviewed and collected regularly by the ASP team with frequent monitoring and regulatory reporting. Primary patient outcome was preventing hospitalization.Results107 patients received monoclonal antibody therapy. 47% patients were male, 50% White, and 79% non-Hispanic. 87% received monotherapy (bamlanivimab) and 13% received dual therapy (bamlanivimab/etesevimab). 17 patients required hospitalization post infusion. 1 death occurred. COVID-19 related hospitalization within 30-days was avoided in 84% of treated patients. No adverse event directly related to infusion were seen.ConclusionUse of monoclonal antibody therapy under EUA for patients for SARS-CoV-2 infection led to decrease in hospitalization in this cohort. An existing ASP using an algorithmic approval process, frequent monitoring, and multidisciplinary approach successfully operationalized the use of monoclonal antibody therapy. ASP’s provide benefit and versatility beyond monitoring of antimicrobials alone and should continue to receive support by hospital leadership.Disclosures All Authors: No reported disclosures

158. National Cross-Sectional Study of Factors Influencing the Decision of Prescribing Penicillin as First Choice among Dentists in Japan

BackgroundAntimicrobial stewardship programs are needed to improve antimicrobial use among not only physicians but also dentists. This study aimed to investigate the factors influencing the decision of prescribing penicillin as first choice among dentists at clinics in Japan. MethodsWe conducted a nationwide cross-sectional study of dental clinics in Japan between July and September 2020. Data on the following were collected using questionnaires: basic information, types of antimicrobials stocked, first-choice antimicrobials, and knowledge and practice of antimicrobial resistance and infectious endocarditis. Using logistic regression, odds ratios (ORs) and 95% confidence intervals (CIs) were estimated to assess the factors influencing penicillin prescription.ResultsAmong the 1700 participating dental clinics, 342 dental clinics responded. The median age of the study cohort was 57 (49–65) years, and there were 298 (87.1%) men. The first choice of antimicrobials was third-generation cephalosporin (169 [49.4%]), followed by penicillin (103 [30.1%]) and macrolide (19 [5.6%]). In multivariate analysis, clinics with stocked penicillin (OR = 27.30 [95% CI: 12.04–63.00]) and with more than two dentists (OR = 0.48 [95% CI: 0.24–0.92]) were associated with penicillin use as first choice. ConclusionThis is the first study investigating the factors influencing the decision of prescribing penicillin as first choice among dentists in Japan. Further studies evaluating the relationships between penicillin use as first choice and stocked penicillin in the clinic and the number of working dentists are needed.Disclosures All Authors: No reported disclosures

103. Expansion of an Antimicrobial Stewardship Program Through Implementation of a Discharge Verification Queue

BackgroundAntimicrobial stewardship programs (ASPs) have traditionally focused interventions on inpatient care to improve antibiotic prescribing. Support of effective interventions for ASPs targeting antibiotic prescriptions at hospital discharge is emerging. Our objective was to expand stewardship services into the outpatient setting through implementation of a process by the antimicrobial stewardship team (AST) to verify antimicrobials prescribed at discharge.MethodsThis quality improvement initiative incorporated a discharge order verification queue managed by AST pharmacists to review electronically prescribed antimicrobials Monday through Friday, from 8:00 am to 4:00 pm. The queue was piloted Sep 2020 and expanded hospital-wide Feb 2021. Patients < 18 years old and those with observation or emergency department status were excluded. The AST pharmacist reviewed discharge prescriptions for appropriateness, intervened directly with prescribers, and either rejected or verified prescriptions prior to transmission to outpatient pharmacies. Complicated cases were reviewed with the AST physician to evaluate intervention appropriateness. Interventions were categorized as either dose adjustment, duration, escalation or de-escalation, discontinuation, or safety monitoring.ResultsA total of 602 prescriptions were reviewed between Sep 2020 and Apr 2021. An AST pharmacist intervened on 28% (171/602) of prescriptions. The most common intervention types were duration (41%, 70/171), discontinuation (18%, 31/171), and dose adjustment (17%, 30/171). The most common indications in which the duration was shortened was community acquired pneumonia (26%, 18/70), skin and soft tissue infection (21%, 15/70), and urinary tract infection (17%, 12/70). The most common antibiotics recommended for discontinuation were cephalexin (32%, 10/31) and trimethoprim-sulfamethoxazole (10%, 3/31). The overall intervention acceptance rate was 78%.ConclusionAn AST pharmacist review of antimicrobial prescriptions at discharge improved appropriate prescribing. The discharge queue serves as an effective stewardship strategy for inpatient ASPs to expand into the outpatient setting.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

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&amp;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

132. Standardized Antimicrobial Administration Ratios to Guide Antimicrobial Stewardship in the Neonatal Intensive Care Unit: a Single Center Experience

BackgroundAntimicrobial stewardship (AMS) is particularly challenging in the neonatal population. Both under- and overuse can negatively impact outcomes. There are limited reports of strategies to improve AMS in the neonatal population. Standardized Antimicrobial Administration Ratios (SAARs) are novel metrics of antimicrobial use, recently introduced for neonatal populations by the National Healthcare Safety Network (NHSN). We describe our experience using SAARs to guide AMS in the neonatal intensive care unit (NICU).MethodsThis was a retrospective study conducted from January 2020 to April 2021. A team consisting of AMS and NICU department staff identified and implemented AMS strategies. Based on a review of NICU SAAR data, a goal was set to reduce third generation cephalosporin use by encouraging aminoglycoside use when appropriate. The pre-implementation period was January 2020 to May 2020 and the post-implementation period was July 2020 to April 2021. Antibiotic use was measured as SAARs and compared between study periods. The primary outcome was the neonatal SAAR for third generation cephalosporins. Secondary outcomes included SAARs for aminoglycosides and all neonatal antibacterial agents. SAARs were compared using the NHSN Statistics Calculator.ResultsFor third generation cephalosporins, there were 385 observed antimicrobial days (OAD) and 115 expected antimicrobial days (EAD) in the pre-implementation period compared to 597 OAD and 228 EAD in the post implementation period. This resulted in a SAAR of 3.34 and 2.62, respectively; a reduction of 22% (p < 0.001). For aminoglycosides, there were 713 OAD and 584 EAD compared to 1617 OAD and 1155 EAD. This resulted in a SAAR of 1.22 and 1.4; an increase of 15% (p = 0.002). For all neonatal antibacterial agents, there were 2716 OAD and 1739 EAD compared to 5321 OAD and 3438 EAD. This resulted in a SAAR of 1.56 and 1.55; indicating no change in use (p = 0.70). See Table 1 for results.Table 1. Antibiotic Use ConclusionWhile this initiative resulted in decreased use of third generation cephalosporins, this was not associated with a decrease in antibiotic use overall. Use of SAARs in the NICU may be helpful in both identifying opportunities to improve antibiotic use and monitoring antibiotic use over time.Disclosures Steven Smoke, PharmD, Karius (Advisor or Review Panel member) Shionogi (Scientific Research Study Investigator, Advisor or Review Panel member)

47. Transitioning to Batch Dosing of High-Cost Antimicrobials in the Inpatient Setting

BackgroundAntimicrobial stewardship (AMS) committees ensure appropriate antimicrobial utilization. One stewardship intervention is to evaluate the delivery model of high-cost antimicrobials to better utilize resources and mitigate expenses. We analyzed the total medication waste and costs of high-cost antimicrobials, specifically daptomycin, ertapenem, amphotericin, and micafungin, at our institution and propose innovative cost-savings changes at a systems level.MethodsThis retrospective study consisted of 263 patients. All patients were at least 18 years old who was admitted to our academic institution from January 2020 to April 2021 and received daptomycin, ertapenem, amphotericin, or micafungin. Demographics, daily medication dosage, total doses received, the date and time of the start of the medication, last administered dose, and discontinued order were recorded.ResultsThe daptomycin cohort consisted of 143 patients with 46.2% females and average age of 56.3 years. In this group, 145.3 vials were wasted which equated to a loss of &22,630. The ertapenem group had 53 patients with 62.3% females and a mean age of 62.3 years. There were 24 vials wasted with a calculated loss of &1080. The amphotericin cohort had 32 patients with an average age of 52.2 years and 43.8% females. There were 189 vials wasted with a loss of &46,116. The micafungin group had 35 patients with 42.9% females and average age of 60.4 years. This group had 12 vials wasted with a loss of &2052.ConclusionEach antimicrobial has a specific formulation protocol. Daptomycin and ertapenem formulation occurs in the early morning. Amphotericin formulation occurs 2 hours prior to medication use. Micafungin formulation occurs at the time the order label prints. These medications were more often administered in the late morning to early afternoon timeframe. The order to discontinue the medications also occurred at the same interval. One reason could be due to decisions made on morning rounds from primary teams and specialty input. These orders would then be placed after rounds. A cost-saving method would be to batch and change the formulation time for all antimicrobials to later in the afternoon, which would not only prevent waste, but also allow the AMS team to effectively audit appropriate antimicrobial use.Disclosures All Authors: No reported disclosures