AbstractBackgroundAntimicrobial Stewardship Programs Research Articles

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

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

Antibiotic use in pediatric acute care hospitals: an analysis of antibiotic consumption data from Germany, 2013-2020.

Antimicrobial stewardship (AMS) programs are effective tools for improving antibiotic prescription quality. Their implementation requires the regular surveillance of antibiotic consumption at the patient and institutional level. Our study captured and analyzed antibiotic consumption density (ACD) for hospitalized pediatric patients. We collected antibacterial drug consumption data for 2020 from hospital pharmacies at 113 pediatric departments of acute care hospitals in Germany. ACD was calculated as defined daily dose (DDD, WHO/ATC Index 2019) per 100 patient days (pd). In addition, we analyzed the trends in antibiotic use during 2013-2020. In 2020, median ACD across all participating hospitals was 26.7 DDD/100 pd, (range: 10.1-79.2 DDD/100 pd). It was higher at university vs. non-university hospitals (38.6 vs. 25.2 DDD/100 pd, p < 0.0001). The highest use densities were seen on oncology wards and intensive care units at university hospitals (67.3 vs. 38.4 DDD/100 pd). During 2013-2020, overall ACD declined (-10%) and cephalosporin prescriptions also decreased (-36%). In 2020, cephalosporins nevertheless remained the most commonly dispensed class of antibiotics. Interhospital variability in cephalosporin/penicillin ratio was substantial. Antibiotics belonging to WHO AWaRe "Watch" and "Reserve" categories, including broad-spectrum penicillins (+ 31%), linezolid (+ 121%), and glycopeptides (+ 43%), increased over time. Significant heterogeneity in ACD and prescription of different antibiotic classes as well as high prescription rates for cephalosporins and an increased use of reserve antibiotics indicate improvable antibiotic prescribing quality. AMS programs should urgently prioritize these issues to reduce antimicrobial resistance.

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 &amp; Co., Inc: Advisor/Consultant|Merck &amp; Co., Inc: Grant/Research Support|Merck &amp; Co., Inc: Honoraria|Pfizer: Advisor/Consultant|Pfizer: Honoraria.

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 &amp;gt; 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.

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

1289. The Challenge of Treating Community-Associated Enterobacterales Infections in a Middle-Income Country: Data from SMART 2018-2019

BackgroundAntimicrobial stewardship programs have been used widely in hospital settings due to the rise of resistant bacteria, antibiotic toxicities, and costs. Nevertheless, few efforts are done to prevent the rising antimicrobial resistance in community settings. The aim of our study was to evaluate the antimicrobial resistance from Enterobacterales community- and hospital-acquired infections in Southern Brazil.MethodsA total of 272 Enterobacterales isolates (i.e., Escherichia coli, Klebsiella spp., Citrobacter spp., Enterobacter spp., Serratia spp., Proteus spp., and Providencia) were collected from 2018 and 2019. Broth microdilution method was used to determine minimum inhibitory concentrations for ceftriaxone, cefepime, levofloxacin, amikacin and ertapenem. Molecular evaluation of beta-lactamases (ESBLs, AmpC, and KPC) was also performed.ResultsNinety-three, and a hundred and seventy-nine isolates were from community- and hospital-acquired infections, respectively. Similar MIC distribution was found between community and hospital settings (Table 1). Levofloxacin MIC of 8mg/L occurred in 38.7% (n=36) and 30.7% (n=55) of isolates from community- and hospital-acquired infections, respectively (Figure 1). Ceftriaxone MIC of 16mg/L occurred in 39.7%(n=37) and 39.1% (n=70) of isolates from community- and hospital-acquired infections, respectively (Figure 1). At last, cefepime MIC of 32mg/L occurred in 22% (n=21) and 25% (n=46) of isolates from community- and hospital-acquired infections, respectively. The following beta-lactamases were found in isolates from community-acquired group, ACT-MIR, CTX-M, SHV and TEM; while beta-lactamases from the hospital-acquired group were ACT-MIR, CMY II, KPC-2, CTX-M, SHV and TEM. Table 1. Enterobacterales ceftriaxone, cefepime, levofloxacin, amikacin and ertapenem minimum inhibitory concentrations (mg/L) distribution from community- and hospital-settings. Figure 1. Enterobacterales ceftriaxone and levofloxacin minimum inhibitory concentrations (mg/L) distribution from community- and hospital-settings.ConclusionSimilar antimicrobials resistances were found in Enterobacterales from community- and hospital-acquired infections. New anti-infective agents are needed urgently to treat pathogens from the community-acquired infections and hospitals that have resistance to the first line regimen. Additionally, community antimicrobial stewardship programs are required.Disclosures All Authors: No reported disclosures

104. Improving Efficiency of Antimicrobial Stewardship Reviews Using Artificial Intelligence Modelling

BackgroundAntimicrobial stewardship programs (ASP) in hospitals improve antibiotic prescribing, slow antimicrobial resistance, reduce hospitalisation duration, mortality and readmission rates, and save costs. However, the strategy of prospective audit and feedback is laborious. In Singapore General Hospital (SGH), 10 reviews are required to identify 2 inappropriate cases. Limited manpower constraints ASP audits to only about 30% of antibiotics prescribed. This proof-of-concept study explored the feasibility of developing a predictive model to prioritise inappropriate antibiotic prescriptions for ASP review. MethodsASP-audited adult pneumonia patients from January 2016 to December 2018 in SGH were included. Patient data e.g., demographics, allergies, past medical history, and relevant laboratory investigations at each antibiotic use episode were extracted from electronic medical records and re-assembled through linking for analysis. Ground truth for model training was based on ASP-defined appropriateness for each encounter. The dataset was split into 80% and 20% for training and testing respectively. Three modelling techniques, XGBoost, decision tree and logistic regression, were assessed for their relative performance in terms of precision, sensitivity and specificity. ResultsThere were 12471 unique patient encounters. Training was done on 10459 encounters and 39 data elements were included. When tested on 2012 encounters, the logistic regression model performed the best (86.7% sensitivity, 71.4% specificity). The model correctly classified 1377 out of 1388 (99.2%) encounters as “appropriate” (do not require ASP intervention). 624 antibiotic use encounters were classified as “inappropriate”, of which only 72 were truly inappropriate (positive predictive value for ASP intervention, PPV 11.5%). The low PPV was likely due to inadequate representation of “inappropriate” cases in the training dataset (4.1%). Applying this model would prioritise the number of immediate ASP reviews needed to identify cases for intervention by two-thirds, from 2012 to 624 (Figure 1). Figure 1. Illustration of AI benefits in ASP ConclusionASPs can leverage on machine learning capabilities to improve audit efficiency. This can increase ASP’s productivity and staff’s job satisfaction as they are freed up to perform other work. Disclosures All Authors: No reported disclosures

137. Impact of Antimicrobial Stewardship Interventions on Post-Elective Caesarean Antibiotic Prophylaxis and Surgical Site Infections

BackgroundAntimicrobial stewardship programs (ASP) aim to improve appropriate antimicrobial use. Post-operative antibiotics are generally not necessary, especially those without surgical site infections risk factors (e.g. obesity). Few studies have described the impact of ASP interventions on patient outcomes especially in unique populations such as obstetrics. This study aims to evaluate the impact of ASP interventions on post-elective caesarean (eLSCS) oral antibiotic prophylaxis use and patient outcomes including SSI rates.MethodsThis pre-post quasi-experimental study was conducted over 9 months (2 months pre- and 7 months post-intervention) in all women admitted for eLSCS in our institution. Interventions included eLSCS surgical prophylaxis guideline dissemination, where a single antibiotic dose within 60 minutes before skin incision was recommended. Post-eLSCS oral antibiotics was actively discouraged in those without SSI risk factors. This was followed by ASP intervention notes (phase 1) for 3 months, and an additional phone call to the ward team for the next 7 months (phase 2). Phase 3 (next 6 months) constituted speaking to the operating consultant. The primary outcome was post-operative oral antibiotics prescription rates. Secondary outcomes included rates of 30-day post-operative SSI.ResultsA total of 1751 women was reviewed. Appropriateness of pre-operative antibiotic prophylaxis was 98% in our institution. There were 244 women pre-intervention, 274 in post-intervention phase 1, 658 in phase 2 and 575 in phase 3. Pre-intervention post-eLSCS antibiotic prescribing rates was 82% (200), which reduced significantly post-intervention to 54% (148) in phase 1, 50% (331) in phase 2 and 39% (226) in phase 3 (p< 0.001). There was no significant difference in patients who developed post-operative SSI pre-post intervention (0.8%, 2 of 242 vs. 1.9%, 28 of 1479, p=0.420) and among who received post-operative oral antibiotics compared to those without (1.9%, 17 of 905 vs. 1.5%, 13 of 846, p=0.582).ConclusionASP interventions can reduce post-eLSCS antibiotic prophylaxis rates without adversely impacting patient safety.Disclosures All Authors: No reported disclosures

Impact of an electronic alert on prescription patterns of meropenem, voriconazole and caspofungin

BackgroundAntimicrobial stewardship programs promote the appropriate use of antimicrobial substances through the implementation of evidence-based, active and passive interventions. We analyzed the effect of a computer-assisted intervention on antimicrobial use in a tertiary care hospital.MethodsBetween 2011 and 2016 we introduced an electronic alert for patients being prescribed meropenem, voriconazole and caspofungin. At prescription and at day 3 of treatment, physicians were informed about the risk related to these antimicrobial substances by an electronic alert in the medical records. Physicians were invited to revoke or confirm the prescription and to contact the infectious disease (ID) team. Using interrupted time series regression, the days of therapy (DOTs) and the number of prescriptions before and after the intervention were compared.ResultsWe counted 64,281 DOTs for 5549 prescriptions during 4100 hospital stays. Overall, the DOTs decreased continuously over time. An additional benefit of the alert could not be observed. Similarly, the number of prescriptions decreased over time, without significant effect of the intervention. When considering the three drugs separately, the alert impacted the duration (change in slope of DOTs/1000 bed days; P = 0.0017) as well as the number of prescriptions (change in slope of prescriptions/1000 bed days; P < 0.001) of voriconazole only.ConclusionsThe introduction of the alert lowered prescriptions of voriconazole only. Thus, self-stewardship alone seems to have a limited impact on electronic prescriptions of anti-infective substances. Additional measures such as face-to-face prompting with ID physicians or audit and feedback are indispensable to optimize antimicrobial use.

Exploring the practice, confidence and educational needs of hospital pharmacists in reviewing antimicrobial prescribing: a cross-sectional, nationwide survey

BackgroundAntimicrobial stewardship (AMS) programs are usually limited in resources and scope. Therefore, wider engagement of hospital pharmacists in reviewing antimicrobial orders is necessary to ensure appropriate prescribing. We assessed hospital pharmacists’ self-reported practice and confidence in reviewing antimicrobial prescribing, and their knowledge in making AMS interventions.MethodsWe conducted an Australia-wide, cross-sectional survey in October 2017. A link to the online survey was emailed to hospital pharmacists via the Society of Hospital Pharmacists of Australia. Factors associated with higher knowledge scores were explored using linear regression models.ResultsThere were 439 respondents, of whom 272 (61.7%) were from metropolitan public hospitals. Pharmacists were more likely to assess the appropriateness of intravenous, broad-spectrum or restricted antibiotics than narrow-spectrum, oral antibiotics within 24–72 h of prescription; p < 0.001. Fifty percent or fewer respondents were confident in identifying AMS interventions related to dose optimization based on infection-specific factors, bug-drug mismatch, and inappropriate lack of spectra of antimicrobial activity. The median knowledge score (correct answers to knowledge questions) was 6 out of 9 (interquartile range, 5–7); key gaps were noted in antimicrobials’ anaerobic spectrum, beta-lactam allergy assessment and dosing in immunocompromised patients. Clinical practice in inpatient areas, registration for 3–5 years and receipt of recent AMS education were associated with higher knowledge scores. More interactive modes of education delivery were preferred over didactic modes; p ≤ 0.01.ConclusionGaps in practice, confidence and knowledge among hospital pharmacists were identified that could inform the design of educational strategies to help improve antimicrobial prescribing in Australian hospitals.

76. Optimizing Clinical Outcomes in Geriatric Patients through a Multidisciplinary Hospital Antimicrobial Stewardship Program

BackgroundAntimicrobial Stewardship Programs (ASP) aim to ensure the appropriate use of antibiotics. There is limited literature evaluating ASP outcomes in hospitalized geriatric patients who are at higher risk for developing Clostridium difficile infection (CDI) or other adverse outcomes. The primary objective of this study was to determine if ASP efforts in this age group decreases the rate of 30-day hospital readmissions due to reinfection or development of CDI, hospital length of stay (LOS) and mortality.MethodsA retrospective chart review was performed to compare the rates of 30-day hospital readmissions because of reinfection or development of CDI in patients 65 years and older who received ASP interventions between January and June 2017. A control group of patients 65 years and older who received antibiotics between January and June 2015 (pre-ASP) was analyzed for comparison. We also assessed their mortality rate and LOS. Patients were included if they received antibiotics for pneumonia (PNA), urinary tract infection (UTI), acute bacterial skin and skin structure infection (ABSSSI) and complicated intra-abdominal infection (cIAI). The ASP team consisted of an infectious diseases physician and a clinical pharmacist who met daily to review patients on broad spectrum antibiotics. ASP interventions consisted of de-escalation of empiric or definitive therapy, change in duration of therapy or discontinuation of therapy.ResultsOverall, 834 patients (540 control; 294 intervention) were included. The 30-day hospital readmission rate for all infection types decreased during the intervention period (19.6% vs 4.8%, P=0.0001). Both the development of CDI during hospital stay and 30-day readmission due to CDI during the intervention period decreased (2.6% vs 0.34%, P=0.019). There was no statistically significant decrease in 30-day hospital readmissions in the PNA (58.5% vs. 35.7%, P=0.11), UTI (18.9% vs. 35.7%, P=0.15), ABSSSI (12.3% vs. 21.4%, P=0.34) or cIAI (10.4% vs 7.1%, P=0.14) arms. There was no statically significant change in LOS (7.50 days vs 7.26 days, P=0.48) or mortality (9.6% vs 6.5%, P=0.12).ConclusionMultidisciplinary ASP efforts significantly reduced 30-day hospital readmission rates and development of CDI in hospitalized patients 65 years and older.Disclosures All Authors: No reported disclosures

204. Post-Liver Transplant Antimicrobial Use after the Expansion of a Pharmacist-Lead Antimicrobial Stewardship Program

BackgroundAntimicrobial stewardship programs (ASPs) allow for infectious diseases (ID)-trained practitioners to focus on timely and appropriate antimicrobial use. In December 2016, the ASP at Indiana University (IU) Health expanded from one ID pharmacist to three. The purpose of this study was to assess the impact of an expanding ASP on broad-spectrum antimicrobial use within post-liver transplant patients.MethodsThis was a retrospective, cross-sectional study. Data were collected from patients aged at least 18 years old that received a liver transplant either before or after the ASP expansion. Patients were excluded if they survived less than 72 hours after transplant, if they received a multivisceral transplant, or if there was an active infection prior to transplantation. The hypothesis of this study was that an expanded ASP leads to a reduction in days of therapy (DOT) per 1000 patient-days for a composite of broad-spectrum antimicrobial agents within this patient population.ResultsA total of 268 patients were included in this study. Of the patients that received at least one dose of the studied antimicrobial agents, the median (IQR) DOT per 1000 patient-days in the pre- and post-ASP expansion cohort was 174.4 (117.6 – 333.3) and 142.9 (62.5 – 257.5), respectively. This was statistically significant (difference 48.6, 95% CI 7.5 – 83.3). Specifically, the post-ASP expansion cohort used less meropenem (difference 197.8, 95% CI 66.3 – 451.6) and vancomycin (difference 57.6, 95% CI 2.2 – 132.2). The post-ASP expansion cohort also consulted ID for more patients (2 vs. 12 consults in the pre- and post-expansion group, respectively; p=0.011). Patient and graft survival one year after transplantation were similar between the two cohorts (p=0.540 and p=0.255, respectively).ConclusionAn expanded ASP contributed to a reduction in broad-spectrum antimicrobial use in post-liver transplant patients without negatively impacting patient and graft survival one year post-transplantation. These data provide further evidence of ASP benefits within immunocompromised populations.Disclosures All Authors: No reported disclosures

158. A multi-site, prospective study of antimicrobial prescribing practices in three low- or middle-income country hospitals

BackgroundAntimicrobial stewardship programs (ASPs) are being developed internationally to mitigate the misuse of antimicrobials. An understanding of current practices and prescribing patterns is necessary to determine targets to develop context-specific ASPs in low- and middle-income country (LMIC) hospitals.MethodsWe conducted a prospective study of patients admitted to the adult medical wards at three LMIC tertiary care centers in 2018- 2019: a 1,800-bed public hospital in Galle, Sri Lanka; a 991-bed public hospital in Eldoret, Kenya; and a 630-bed private hospital in Moshi, Tanzania. Information regarding antimicrobial therapy received during hospitalization, indications for antimicrobial therapy, and duration of antimicrobial use were extracted from the medical record.ResultsIn total, 3150 patients were enrolled: 1297 in Sri Lanka, 750 in Kenya, and 1103 in Tanzania. Antimicrobial use prevalence varied between the three sites, with 56.0% of patients receiving antimicrobials during hospitalization in Sri Lanka, 56.5% in Kenya, and 35.4% in Tanzania. Third-generation cephalosporins were used most frequently in Kenya (70.0%) and Tanzania (73.1%), whereas amoxicillin/ clavulanic acid was used most frequently in Sri Lanka (48.4%). Lower respiratory tract infection was the most common indication for antimicrobial use in all three locations: 37.4% in Sri Lanka, 27.8% in Kenya, and 49.2% in Tanzania. No clear indication for antimicrobial use was documented among 11.6% patients receiving antimicrobials in Sri Lanka, 32.8% in Kenya, and 10.5% in Tanzania. In Tanzania, 8.6% of the patients had documentation of input from the microbiology or infectious diseases teams compared to less than 1% in either Sri Lanka or Kenya. Pertinent culture data related to the primary indication for antimicrobials was present in 16.1% (Sri Lanka), 6.1% (Kenya), and 7.4% (Tanzania).ConclusionUnclear documentation for antimicrobial use was common in all three sites and most patients on antimicrobial therapy did not have pertinent culture data. Improving documentation and the capacity of the local microbiology laboratories could be initial targets for ASPs in these LMIC hospitals.Disclosures All Authors: No reported disclosures

1335. Accuracy of Outpatient Antibiotic Prescriptions for Urinary Tract Infection in Pediatric Ambulatory Care

BackgroundAntimicrobial stewardship programs have typically focused on inpatient care, but antibiotics are frequently prescribed at pediatric ambulatory care centers. Ensuring accurate pediatric antibiotic dosing is important to optimize outcomes while minimizing adverse drug effects. Outpatient pharmacists often lack the resources to recommend optimal antibiotic dosing for pediatric infections. The primary objective was to evaluate the accuracy of antibiotic dose, frequency and formulation prescribed. The secondary objective was to describe the most commonly prescribed treatment durations.MethodsA retrospective review of electronic medical records was conducted at two suburban pediatric practices. Patients diagnosed with uncomplicated UTI over a two year period were identified using ICD-10 codes N39, R30 and R35. Patients 2 months-18 years were included if prescribed an oral antibiotic for the treatment of UTI. Data collected included baseline demographics, antibiotic, dose (mg and mg/kg), frequency, formulation, and duration. Antibiotic dose, frequency and formulation were considered accurate if they were consistent with clinical guidelines and tertiary dosing references, allowing for 10% rounding in weight-based doses.ResultsA total of 472 outpatient prescriptions met inclusion criteria. Overall, 24% of dosing regimens were found to be inaccurate. Patients were most commonly prescribed doses that were too low (54/118, 45%) or too high (41/118, 35%). Less frequently, doses exceeded the maximum total dose (9/118, 8%), were given at the wrong frequency (8/118, 7%), or the wrong dosage form was selected (6/118, 5%). Of the commonly prescribed antibiotics, dosing errors were most likely to occur with ciprofloxacin (24/27, 89%) and amoxicillin (33/64; 55%). The majority of patients completed a 10 day course of antibiotics (381, 80%), followed by 7 days (66, 13.9%). Durations of 3 days (20, 4.2%), 5 days (7, 1.5%) and 14 days (2, 0.4%) occurred less frequently.ConclusionErrors in antibiotic dosing occurred with nearly one in four prescriptions written for outpatient UTI from pediatric primary care centers. Durations were most commonly 10 days. Education and resources should be provided to outpatient pediatric providers to optimize antibiotic dosing.Disclosures All Authors: No reported disclosures

69. Impact of antimicrobial stewardship interventions on post-elective caesarean antibiotic prophylaxis and surgical site infections

BackgroundAntimicrobial stewardship programs (ASP) aim to improve appropriate antimicrobial use. This study aims to evaluate the impact of ASP interventions on post-elective caesarean (eLSCS) oral antibiotic prophylaxis use. In a subgroup of those without surgical site infection (SSI) risk factors, 30-day SSI rates was compared in those who received post-eLSCS oral antibiotics vs. those without.MethodsThis pre-post quasi-experimental study was conducted over 9 months (2 months pre- and 7 months post-intervention) in all women admitted for eLSCS in our institution. Interventions included eLSCS surgical prophylaxis guideline dissemination, where a single antibiotic dose within 60 minutes before skin incision was recommended. Post-eLSCS oral antibiotics was discouraged in those without SSI risk factors (e.g. obesity). This was followed by ASP intervention notes (phase 1) for 3 months, and an additional phone call to the ward team for the next 4 months (phase 2).ResultsA total of 894 women were reviewed. There were 244 women in the pre-intervention phase, 274 in post-intervention phase 1 and 376 in phase 2. Pre-intervention post-eLSCS antibiotic prescribing rates was 82% (200), compared to 54% (148) in phase 1 and 49% (180) in phase 2 (p< 0.001). There were 560 women without SSI risk factors. Of these, only 4 of 301 (1.3%) who received oral antibiotics, and 3 of 259 (1.2%) without oral antibiotics developed post-op SSI (p=1.000).ConclusionASP can reduce post-eLSCS antibiotic prophylaxis. In those without SSI risk factors, use of post-eLSCS oral antibiotics did not impact SSI rates.Disclosures All Authors: No reported disclosures

230. Impact of 10-day versus 5-day Duration Default on Length of Antibiotic Outpatient Prescriptions from the Emergency Department

BackgroundAntimicrobial stewardship programs (ASP) traditionally focus on inpatient care; however there is a growing effort to optimize antibiotic prescribing at transitions of care. Longer than necessary discharge prescriptions increase risk of antimicrobial resistance, C. difficile infection and adverse events. In order to minimize unnecessary antibiotic exposure, the health system updated the electronic medical record (EMR) outpatient antibiotic prescription default from 10 days to 5 days. The objective of this study was to assess the impact of a 10-day versus 5-day EMR antibiotic outpatient prescriptions default on length of therapy for patients discharged from the Emergency Department (ED).MethodsThis is a retrospective, single-system cohort study evaluating ED discharge prescriptions before and after transition from a default duration of 10 days to 5 days. Discharge prescriptions were collected and screened from December 2019 through January 2020 in the control group and March 2020 through April 2020 in the intervention group. Outpatient prescriptions were included for primary diagnoses of urinary tract infection (UTI), community-acquired pneumonia (CAP), skin and soft tissue infections (SSTI), diverticulitis, or dental infections. The primary outcome was the incidence of prescriptions written for a < 5 day duration.ResultsThe study included 3060 of 9651 (32%) prescriptions in the control group and 1610 of 4938 (33%) prescriptions in the intervention group. The mean age was 38 years old with 61% female. The most common primary diagnoses were SSTI (n=1633, 35%) and UTI (n=1633, 32%). The mean duration for discharge prescriptions was similar between groups (8.44 vs. 8.30 days). The incidence of outpatient antibiotic prescriptions for < 5 days was not significantly different between groups (10.72% vs 10.56%, p=0.996). There was an improvement in duration of therapy, with more prescriptions < 5 days for SSTI (2.96% vs. 7.64%, p=0.860) and dental infections (3.30% vs. 10.86%, p=0.808).ConclusionImplementation of a shorter default duration for antibiotic outpatient prescriptions from the ED did not significantly increase the incidence of prescriptions written for < 5 days. There was an improvement in duration for SSTI and dental infections after implementation.Disclosures All Authors: No reported disclosures