Active Antimicrobial Stewardship Research Articles

Outpatient and peri-operative antibiotic stewardship in solid organ transplantation.

The consequences of inappropriate antimicrobial use including resistance are increasingly recognized as a global public health threat and many steps have been taken over the last few decades to advance antimicrobial stewardship initiatives with most organ transplant centers currently part of institutions with active antimicrobial stewardship programs. A review of the literature was conducted and articles were categorized according to the topic and relevance in the judgment of the two authors. A summary review of the currently available literature was created with a focus on periprocedural and outpatient antimicrobial stewardship. Limitations in the data were significant and discussed in the review. The principles of antimicrobial stewardship remain important throughout all phases starting with periprocedural prophylactic antimicrobial selection all the way through to discharge and subsequent healthcare encounters. Despite the broad advances in stewardship initiatives and the rapidly progressing supportive data overall there continue to be significant opportunities for additional research within various special patient populations including recipients of solid organ transplantation (SOT). The recent white paper published in the American Journal of Transplantation called to action the transplant and stewardship communities to have an increased focus and awareness of the issues that antimicrobial overuse can present in the SOT patient population. This is an important step that will hopefully generate more data in this group of patients that arguably faces the greatest vulnerability to the consequences of increased antimicrobial resistance.

The interplay of infectious diseases consultation and antimicrobial stewardship in candidemia outcomes: A retrospective cohort study from 2016 to 2019.

To evaluate the need for mandatory infectious diseases consultation (IDC) for candidemia in the setting of antimicrobial stewardship guidance. Retrospective cohort study from January 2016 to December 2019. Academic quaternary-care referral center. All episodes of candidemia in adults (n = 92), excluding concurrent bacterial infection or death or hospice care within 48 hours. Primary outcome was all-cause 30-day mortality. Secondary outcomes included guideline-adherence and treatment choice. Guideline-adherence was assessed with the EQUAL Candida score. Of 186 episodes of candidemia, 92 episodes in 88 patients were included. Central venous catheters (CVCs) were present in 66 episodes (71.7%) and were the most common infection source (N = 38, 41.3%). The most frequently isolated species was Candida glabrata (40 of 94, 42.6%). IDC was performed in 84 (91.3%) of 92 candidemia episodes. Mortality rates were 20.8% (16 of 77) in the IDC group versus 25% (2 of 8) in the no-IDC group (P = .67). Other comparisons were numerically different but not significant: repeat blood culture (98.8% vs 87.5%; P = .17), echocardiography (70.2% vs 50%; P = .26), CVC removal (91.7% vs 83.3%; P = .45), and initial echinocandin treatment (67.9% vs 50%; P = .44). IDC resulted in more ophthalmology examinations (67.9% vs 12.5%; P = .0035). All patients received antifungal therapy. Antimicrobial stewardship recommendations were performed in 19 episodes (20.7%). The median EQUAL Candida score with CVC was higher with IDC (16 vs 11; P = .001) but not in episodes without CVC (12 vs 11.5; P = .81). In the setting of an active antimicrobial stewardship program and high consultation rates, mandatory IDC may not be warranted for candidemia.

Nurses' and Physicians' Responses to a New Active Antimicrobial Stewardship Program: A Two-Phase Study of Responses and Their Underlying Perceptions and Values.

Successful implementation of an antimicrobial stewardship program (ASP) depends on staff members' response to it. We introduced at the Hadassah Medical Center in Israel a significant change to our long-standing handshake ASP. As before, the new ASP involved a dialogue between the treating physician and the infectious disease physician over the appropriate antibiotic therapy. The main change was that the infectious disease physician's decision was now integrated into the patient's electronic medical record (EMR). Our purpose in this study was to uncover the concerns and expectations of physicians and nurses towards the new ASP, before and after its implementation, and link these with their basic perceptions of the ASP and their personal values. We used open-ended questions and Likert-type scales to study staff members' personal values, basic perceptions of the new system, and attitudes towards it, both before (N = 143), and one year after (N = 103) the system's implementation. Relationships of the system's perceptions and personal values with attitudes toward the system were tested using correlations and multiple regression analyses. Prior to its implementation, physicians and nurses had multiple concerns about the new ASP's demandingness and inefficiency and its threat to physicians' autonomy and expertise. They also had positive expectations for benefits to the hospital, the patients and society. A year later, following the system's implementation, concerns dissipated, whereas the perceived benefits remained. Moreover, staff members' attitudes tended to be more positive among those who value conformity. Introducing new ASPs is a challenging process. Our findings suggest that hospital staff's initial concerns about the new ASP were primarily about its ease of use and demandingness. These concerns, which diminished over time, were linked with perceived satisfaction with the system. Conformity values had an indirect effect in predicting satisfaction with the system, mediated by perceptions of the system as straightforward.

Association between duration of antipseudomonal beta-lactam therapy and Clostridioides difficile infections in monomicrobial Enterobacterales bloodstream infections at an academic medical center

To evaluate the effects early de-escalation of antipseudomonal β-lactam (APBL) on 90-day CDI risk in Enterobacterales bloodstream infections (BSIs). Retrospective cohort analysis. An academic medical center in South Carolina. We included patients aged >18 years with monomicrobial BSIs with Enterobacterales who received APBL between July 1, 2015, and June 30, 2020. Rates of CDI were compared between patients who received an APBL for >72 hours and <72 hours, followed by comparison between formulary APBLs utilized. In total, 447 patients were included; 292 and 155 patients received APBL for < 72 hours and > 72 hours, respectively. The incidences of CDI for <72 hours compared to >72 hours were 2.4% and 6.5%, respectively (unadjusted hazard ratio [HR], 2.70; 95% confidence interval [CI], 1.03-7.10; P = .04). This difference was not statistically significant in the adjusted model (HR, 2.66; 95% CI, 0.97-7.31; P = .06). Meropenem was associated with an increased risk of CDI when compared with all other formulary APBLs: 4 (26.7%) of 15 versus 13 (3.0%) of 432 (P < .001). Utilization of an APBL for >72 hours was associated with a statistically significant increase in the incidence of CDI in an unadjusted model and with a numerically higher CDI incidence in the adjusted model. Meropenem was the formulary APBL that carried the highest risk of CDI. The results of this study provide further evidence supporting active antimicrobial stewardship to reduce unnecessary broad-spectrum antibiotics in the effort to alleviate the burden that CDI imposes on the healthcare system.

Impact of multiplexed respiratory viral panels on infection control measures and antimicrobial stewardship: a review of the literature.

Multiplexed respiratory viral panels (MRVP) have recently been added to the diagnostic work-up of respiratory infections. This review provides a summary of the main literature of MRVP for patients with regard to 3 different topics. Can the results of MRVP reduce the inappropriate use of antibiotics, can they guide the use of appropriate antiviral therapy and do they have an added value with respect to infection control measures? Literature was searched for based on a defined search string using both the PubMed and Embase database. Twenty-five articles report on the impact of MRVP on antibiotic therapy. In all the articles where active antimicrobial stewardship was performed (e.g., education/advice on interpreting results of MRVP) (N = 9), a reduction in antibiotic therapy was shown (with exception of 2 studies). Three studies evaluating the effect of MRVP on antimicrobial use in a population that is not suspected of having bacterial pneumonia (e.g., absence of radiology suggestive for bacterial infection or low PCT) found a positive impact on antibiotic therapy. Eight studies with a short TAT (< 7 h) had a positive impact on use of antibiotic therapy. Eleven studies focused on the impact of MRVP on antiviral use. In contrast to antibiotic reduction, all studies systematically objectified improved antiviral use as a consequence of MRVP results. With regard to the impact of MRVP on infection control, eleven articles were withheld. All these studies led to a more accurate use of infection control measures by detecting unidentified pathogens or stopping isolation precautions in case of a negative MRVP result. MRVP don’t reduce antibiotic therapy in all populations. Reduction seems more likely if the following factors are present: active antimicrobial stewardship, low likelihood of a bacterial infection, and a short turnaround time to result. With respect to antiviral therapy, all studies have an impact but the targeted use of antivirals is so far not that evidence based for all viral respiratory pathogens. Regarding infection control measures, the potential impact of MRVP is high because of the need of additional isolation precautions for many respiratory viruses, although logistical problems can occur.

Pharmacy practice in hospital settings in GCC countries: Prescribing and transcribing

PurposeTo outline hospital pharmacy practices across the Gulf Cooperation Councils (GCC) countries’ hospitals. MethodsA modified survey questionnaire was prepared from the original 2019 American Society of Health-System Pharmacist (ASHP) survey questions. Survey details were discussed with some pharmacy directors for clarity and relevance. A list of hospitals were obtained from the Ministry of Health of each of the targeted GCC countries. A secure invitation link containing a survey questionnaire was sent to the participants directly. ResultsSixty four hospitals responded to this survey. The overall response rate was 52%. About 47% of the surveyed hospitals considered their drug formularies as closed, and strict. Additionally, only 44% of hospitals compare the effectiveness of products, when taking formulary decisions for drug inclusion. Forty-four percent of hospitals have computerized prescriber order entry (CPOE / EHR) system functionality for formulary system management. At about 39.1% hospitals, pharmacists have the responsibility for managing medication therapies, majority were engaged in providing anticoagulation therapies. About 61% of hospital pharmacies in GCC countries receive medication orders electronically, through CPOE/EHR. Majority (66%) of the hospitals in GCC countries have an active Antimicrobial Stewardship Program (ASP) while only 40% of pharmacists have a key role in providing clinical support. About 57.8% of hospital pharmacy directors reported that pharmacists do not provide ambulatory care clinical pharmacy servicesin their hospitals. ConclusionIn GCC countries’ hospitals, there are major areas for improvement to patient care of which pharmacists are uniquely qualified as the medication experts to have the most meaningful outcomes in all of the domains of safe medication use, medication therapy management, antimicrobial stewardship program and participation in outpatient clinics.

New Microbiological Techniques for the Diagnosis of Bacterial Infections and Sepsis in ICU Including Point of Care.

Purpose of ReviewThe aim of this article is to review current and emerging microbiological techniques that support the rapid diagnosis of bacterial infections in critically ill patients, including their performance, strengths and pitfalls, as well as available data evaluating their clinical impact.Recent FindingsBacterial infections and sepsis are responsible for significant morbidity and mortality in patients admitted to the intensive care unit and their management is further complicated by the increase in the global burden of antimicrobial resistance. In this setting, new diagnostic methods able to overcome the limits of traditional microbiology in terms of turn-around time and accuracy are highly warranted. We discuss the following broad themes: optimisation of existing culture-based methodologies, rapid antigen detection, nucleic acid detection (including multiplex PCR assays and microarrays), sepsis biomarkers, novel methods of pathogen detection (e.g. T2 magnetic resonance) and susceptibility testing (e.g. morphokinetic cellular analysis) and the application of direct metagenomics on clinical samples. The assessment of the host response through new “omics” technologies might also aid in early diagnosis of infections, as well as define non-infectious inflammatory states.SummaryDespite being a promising field, there is still scarce evidence about the real-life impact of these assays on patient management. A common finding of available studies is that the performance of rapid diagnostic strategies highly depends on whether they are integrated within active antimicrobial stewardship programs. Assessing the impact of these emerging diagnostic methods through patient-centred clinical outcomes is a complex challenge for which large and well-designed studies are awaited.

Impact of the COVID-19 Pandemic on Antimicrobial Consumption and Hospital-Acquired Candidemia and Multidrug-Resistant Bloodstream Infections.

During the COVID-19 pandemic, the implementation of antimicrobial stewardship strategies has been recommended. This study aimed to assess the impact of the COVID-19 pandemic in a tertiary care Spanish hospital with an active ongoing antimicrobial stewardship programme (ASP). For a 20-week period, we weekly assessed antimicrobial consumption, incidence density, and crude death rate per 1000 occupied bed days of candidemia and multidrug-resistant (MDR) bacterial bloodstream infections (BSI). We conducted a segmented regression analysis of time series. Antimicrobial consumption increased +3.5% per week (p = 0.016) for six weeks after the national lockdown, followed by a sustained weekly reduction of −6.4% (p = 0.001). The global trend for the whole period was stable. The frequency of empirical treatment of patients with COVID-19 was 33.7%. No change in the global trend of incidence of hospital-acquired candidemia and MDR bacterial BSI was observed (+0.5% weekly; p = 0.816), nor differences in 14 and 30-day crude death rates (p = 0.653 and p = 0.732, respectively). Our work provides quantitative data about the pandemic effect on antimicrobial consumption and clinical outcomes in a centre with an active ongoing institutional and education-based ASP. However, assessing the long-term impact of the COVID-19 pandemic on antimicrobial resistance is required.

Do rapid diagnostic methods improve antibiotic prescribing in paediatric bacteraemia?

Rapid blood culture pathogen identification facilitated by matrix-assisted laser desorption ionisation time-of-flight and GeneXpert has the potential to improve antibiotic prescribing. This study investigates the impact of these rapid diagnostics on the timeliness of effective and optimal antibiotic prescribing in paediatric patients with bacteraemia. A single centre retrospective cohort study was performed comparing paediatric bacteraemia cases pre- and post-rapid diagnostic implementation. Primary outcomes were the proportion of cases receiving, and median time to administration of effective and optimal antibiotics from blood culture collection. Secondary outcomes included hospital length of stay, intensive care unit admissions, and all-cause mortality. A total of 255 bacteraemia cases were subject to final data analysis, 129 in the control cohort (pre-implementation of rapid diagnostics) and 126 in the rapid diagnostics cohort. The median time to effective (2.3 vs. 1.8 h, P = 0.20) and optimal therapy (44.4 vs. 39.1 h, P = 0.66) did not differ significantly between the cohorts. There was also no significant difference found in the number of cases reaching effective (120 vs. 116, P = 0.77) and optimal therapy (66 vs. 62, P = 0.76), length of stay (7 vs. 9 days), all-cause mortality (1.6 vs. 1.6%) and number of intensive care unit admissions (20 vs. 15). The implementation of rapid diagnostics, when used in isolation, resulted in no improvement in antibiotic prescribing or patient clinical outcomes. To be effective, rapid diagnostics must be coupled with active real-time antimicrobial stewardship promotion, de-escalation or modification based on early laboratory results.

A Pathway for Community-Acquired Pneumonia With Rapid Conversion to Oral Therapy Improves Health Care Value.

BackgroundEvidence supports streamlined approaches for inpatients with community-acquired pneumonia (CAP) including early transition to oral antibiotics and shorter therapy. Uptake of these approaches is variable, and the best approaches to local implementation of infection-specific guidelines are unknown. Our objective was to evaluate the impact of a clinical decision support (CDS) tool linked with a clinical pathway on CAP care.MethodsThis is a retrospective, observational pre–post intervention study of inpatients with pneumonia admitted to a single academic medical center. Interventions were introduced in 3 sequential 6-month phases; Phase 1: education alone; Phase 2: education and a CDS-driven CAP pathway coupled with active antimicrobial stewardship and provider feedback; and Phase 3: education and a CDS-driven CAP pathway without active stewardship. The 12 months preceding the intervention were used as a baseline. Primary outcomes were length of intravenous antibiotic therapy and total length of antibiotic therapy. Clinical, process, and cost outcomes were also measured.ResultsThe study included 1021 visits. Phase 2 was associated with significantly lower length of intravenous and total antibiotic therapy, higher procalcitonin lab utilization, and a 20% cost reduction compared with baseline. Phase 3 was associated with significantly lower length of intravenous antibiotic therapy and higher procalcitonin lab utilization compared with baseline.ConclusionsA CDS-driven CAP pathway supplemented by active antimicrobial stewardship review led to the most robust improvements in antibiotic use and decreased costs with similar clinical outcomes.

Advances in rapid diagnostics for bloodstream infections

Septicemia from bloodstream infections (BSI) is the second largest cause of inpatient mortality and the single most expensive condition for US hospitals to manage. There has been an explosive development of commercial diagnostic systems to accelerate the identification and antimicrobial susceptibility testing (AST) of causative pathogens. Despite adoption of advanced technologies like matrix-assisted laser desorption imaging–time-of-flight mass spectrometry and multiplex polymerase chain reaction for rapid identification, clinical impact has been variable, in part due to the persistent need for conventional AST as well as prescriber understanding of these rapidly evolving platforms. Newer technologies are expanding on rapid detection of genotypic determinants of resistance, but only recently has rapid phenotypic AST been available. Yet, improved outcomes with rapid diagnostic platforms are still most evident in conjunction with active antimicrobial stewardship. This review will outline key advancements in rapid diagnostics for BSI and the role of antimicrobial stewardship in this new era.

Bacterial pneumonia coinfection and antimicrobial therapy duration in SARS-CoV-2 (COVID-19) infection.

BackgroundBacterial respiratory coinfection in the setting of SARS-CoV-2 infection remains poorly described. A description of coinfection and antimicrobial usage is needed to guide ongoing antimicrobial stewardship.ObjectivesTo assess the rate of empirical antimicrobial treatment in COVID-19 cases, assess the rate and methods of microbiological sampling, assess the rate of bacterial respiratory coinfections and evaluate the factors associated with antimicrobial therapy in this cohort.MethodsInpatients with positive SARS-CoV-2 PCR were recruited. Antibiotic prescription, choice and duration were recorded. Taking of microbiological samples (sputum culture, blood culture, urinary antigens) and culture positivity rate was also recorded. Linear regression was performed to determine factors associated with prolonged antimicrobial administration.ResultsA total of 117 patients were recruited; 84 (72%) were prescribed antimicrobial therapy for lower respiratory tract infections. Respiratory pathogens were identified in seven (6%) patients. The median duration of antimicrobial therapy was 7 days. C-reactive protein level, oxygen requirement and positive cultures were associated with prolonged duration of therapy. ConclusionsThe rate of bacterial coinfection in SARS-CoV-2 is low. Despite this, prolonged courses of antimicrobial therapy were prescribed in our cohort. We recommend active antimicrobial stewardship in COVID-19 cases to ensure appropriate antimicrobial prescribing.

141. Use of Rapid Diagnostic Testing in Gram-negative Bloodstream Infections with and without Antimicrobial Stewardship

BackgroundVerigene Blood Culture Gram-Negative (VBC-GN) is a rapid diagnostic test (RDT) that can detect key GNs and resistance within hours from Gram-stain. Numerous studies have shown that RDTs in BSIs improve clinical outcomes, particularly with active antimicrobial stewardship (AMS) intervention. Little is known regarding outcomes in GN BSI without vs. with AMS intervention.MethodsA retrospective three-part quasi-experimental study of adult patients with GN BSI from December 2014 to April 2018. VBC-GN was introduced September 2015 and AMS review was implemented October 2017. Antibiotics were appropriate if active in vitro against isolated GN. Optimal antibiotics were not overly broad, accounted for resistance, source of infection, and other infecting organisms. Comparisons were made using Chi-squared for nominal variables and Kaplan–Meier with log-rank for time to event analysis.ResultsIn total, 772 patients met inclusion. The most common source was urinary (30.1%) and E. coli was the most common GN (37.9%). Infectious Disease consults increased with each group (50.6% vs. 67.9% vs. 81.8%, P < 0.001). More patients pre-RDT (37.36%) and RDT+AMS (35.6%) compared with RDT only (24.6%) were critically ill, P = 0.001. Optimal therapy was achieved in more patients in RDT-only (79%) and RDT+AMS (86%) groups compared with pre-RDT (66%), P < 0.001. More patients in the pre-RDT group (44.7%) were appropriately de-escalated compared with RDT only (31.6%) and RDT + AMS (38.7%), P = 0.026. Appropriate escalation occurred most often in the RDT-only group (39.3%) vs. pre-RDT (15.2%) and RDT + AMS (14.2%), P = 0.019. Median post-BSI length of stay (8.2 vs. 7.1 vs. 8.5 days, P = 0.226) and inpatient mortality (10.8% vs. 14.3% vs. 11.4%, P = 0.493) were similar.ConclusionWith the implementation of VBC-GN RDT there was a significantly decreased time to optimal therapy, mainly based on necessary antibiotic escalation. Antibiotic de-escalation remained a challenge, even with active AMS review. Disclosures All authors: No reported disclosures.

2010. A Significant Reduction in Empiric Vancomycin Days of Therapy for Suspected MRSA Pneumonia in Adult Non-ICU Patients After Implementation of a Rapid MRSA Nasal PCR Test with Antimicrobial Stewardship Intervention

BackgroundMethicillin-resistant Staphylococcus aureus (MRSA), when implicated in respiratory tract infections, can be associated with significant morbidity and mortality. The prevalence of severe MRSA pneumonia may be as high as 10%; however, recent evidence suggests that MRSA is much less prevalent as a cause of community-acquired pneumonia (CAP) among community-dwelling patients and may be as low as 0.1%. Nonspecific features of pneumonia in non-ICU patients (viral co-infection, multi-lobar infiltrates) often lead clinicians to cautiously initiate empiric anti-MRSA therapy. Recommendations of when to safely de-escalate empiric treatment prior to known respiratory cultures are not established. To decrease anti-MRSA therapy in non-ICU pneumonia patients with a low probability of MRSA pneumonia, we employed a nasal screening paired with antimicrobial stewardship intervention.MethodsA retrospective, single-center, pre-post interventional study was conducted at Northwestern Memorial Hospital (NMH), in Chicago, IL, to assess the duration of empiric vancomycin for suspected MRSA pneumonia in non-ICU patients before (January 2019) and after (March 2019) the implementation of a rapid MRSA nasal PCR test. During the post-implementation period, an NMH Antimicrobial Stewardship (AS) member identified and assessed the daily (M-F) use of empiric vancomycin for pneumonia in non-ICU patients. When vancomycin use criteria were not met, the AS pharmacist requested the team order a BD MRSA Nasal PCR test (NPV: 97.2%) to classify patients as either possible MRSA pneumonia or unlikely MRSA pneumonia. Results of a negative MRSA Nasal PCR with an ongoing clinical disposition not suggestive of MRSA pneumonia prompted the AS pharmacist to recommend de-escalation of vancomycin.ResultsSee table.ConclusionThe use of a rapid MRSA nasal PCR test with active antimicrobial stewardship intervention significantly reduced the duration of empiric vancomycin in hospitalized non-ICU patients with suspected MRSA pneumonia. Disclosures All authors: No reported disclosures.

2137. Impact of Accelerate Pheno™ Rapid Blood Culture Detection System with Real-time Notification vs. Standard Antibiotic Stewardship on Clinical Outcomes in Bacteremic Patients

BackgroundAccelerate Pheno™ blood culture detection system (AXDX) provides identification (ID) and antimicrobial susceptibility testing (AST) within 8 hours of growth in blood culture. We previously reported length of stay (LOS), time to optimal therapy (TTOT), and antibiotic days of therapy (DOT) decrease following AXDX implementation alongside an active antimicrobial stewardship program (ASP). It is unclear whether real-time notification (RTN) of results further improves these variables.MethodsA single-center, quasi-experimental before/after study of adult bacteremic inpatients was performed after implementation of AXDX. A 2017 historical cohort was compared with two 2018 intervention cohorts. Intervention-1: AXDX performed 24/7 with results reviewed by providers or ASP as part of their normal workflow. Intervention 2: AXDX performed 24/7 with RTN to ASP 7 days per week 9a-5p and overnight results called to ASP at 9a. Interventions 1 and 2 were utilized on an alternating weekly basis during the study (February 2018–September 2018). Historical ID/AST were performed using VITEK® MS and VITEK®2. Exclusion criteria included polymicrobial or off-panel isolates, prior positive culture, and patients not admitted at the time of AST. Clinical outcomes were compared with Wilcoxon rank-sum and χ 2 analysis.Results540 (83%) of 650 positive cultures performed on AXDX had on-panel organisms. 308 (57%) of these cultures and 188 (77%) of 244 reviewed historical cultures met inclusion criteria. Baseline illness severity and identified pathogens were similar between cohorts. Clinical outcomes and antimicrobial DOT are reported in Tables 1 and 2.ConclusionFollowing our implementation of AXDX, clinical outcomes including LOS, TTOT, total DOT, BGN DOT, and frequency of achieving optimal therapy were significantly improved compared with a historical cohort. Addition of RTN for AXDX results in the setting of an already active ASP did not further improve these metrics. However, compared with historical arm, AXDX with RTN did significantly impact specific subsets of antibiotic use while AXDX alone did not. This may be due to earlier vancomycin de-escalation. These results support the benefit of integration of AXDX into healthcare systems with an active ASP even without the resources to include real-time notification. Disclosures All authors: No reported disclosures.

1799. Impact of Real-Time Electronic Notifications to Pharmacists of Rapid Diagnostic Blood Culture Results

BackgroundRapid diagnostic tests that utilize multiplex PCR technology provide faster time to pathogen identification, but maximizing the impact on outcomes is dependent upon who is available to respond to test results. In June 2017, pharmacists began receiving in-basket notifications of positive results from the institution’s FilmArray BCID assay. The objective of this study was to determine the impact on antibiotic utilization associated with this method of communicating results.MethodsThis was a retrospective, observational, before-and-after study at an academic medical center with an established stewardship program. Inclusion criteria: Adult patients age ≥18 admitted to an ICU or oncology unit with ≥1 positive blood culture containing a gram-positive organism identified by FilmArray BCID. Patients with polymicrobial infection, concomitant infection caused by a different organism, antibiotics started before admission, or death prior to organism identification were excluded. Data were collected during a 4-month period before (PRE) and a 4-month period after (POST) implementation of in-basket notifications. Stewardship metrics and other outcome measures were compared between the two groups. Pharmacists received no targeted stewardship training on how to respond to results.ResultsNinety-two patients met study criteria (49 PRE and 43 POST). Patients were age 62 ± 16, male (55%), and 77 (84%) were located in an ICU. Median Charlson Comorbidity Index was 4 and Pitt Bacteremia Score was 1. Sixty-seven patients were considered to have noncontaminant bloodstream infection. Median results for these patients are listed in the table. Patients with contaminants (n = 25) had 3.5 and 7 antibiotic-free days in the PRE and POST groups, respectively (P = 0.34).ConclusionIn-basket notifications did not significantly improve antibiotic utilization or clinical outcomes. Active interventions and antimicrobial stewardship initiatives are needed in combination with rapid diagnostic tests.PRE (n = 35)POST (n = 32) P-valueTime to active therapy (hours)0.853.20.33Time to optimal abx (hours)47.444.40.43Time to de-escalation (hours)48.446.80.24Defined daily doses10.410.40.81Days of therapy13110.70In-hospital mortality, n (%)9 (26)8 (25)0.98Length of stay from positive culture (days)9.67.90.94Disclosures All authors: No reported disclosures.

1758. Impact of Accelerate Pheno™ Rapid Blood Culture Detection System on Laboratory and Clinical Outcomes in Bacteremic Patients

BackgroundMolecular-based automated systems for the rapid diagnosis of bacterial infections have potential to improve patient care. The Accelerate Pheno™ blood culture detection system (ACCEL) is an FDA approved platform that allows for identification (ID) and antimicrobial susceptibility testing (AST) 8 hours following growth in routine culture.MethodsThis is a single-center retrospective chart review of bacteremic adult inpatients before and after implementation of ACCEL. Laboratory and clinical data were collected February–March 2018 (intervention) and compared with a January–April 2017 historical cohort (standard of care). Standard of care ID and AST were performed using VITEK® MS (MALDI-TOF MS) and VITEK®2, respectively. An active antimicrobial stewardship program was in place during both study periods. Patients with polymicrobial cultures, off-panel isolates, previous positive culture, or who were discharged prior to final AST report were excluded. Primary outcome was length of stay (LOS). Secondary outcomes were inpatient antibiotic duration of therapy (DOT) and time to optimal therapy (TTOT). Nonparametric unadjusted analyses were performed due to non-normal distributions. Statistics were performed using SAS 9.4.ResultsOf the 143 positive cultures performed on ACCEL during intervention, 118 (83%) were identified as on-panel organisms. Seventy-five (64%) of these 118 cultures and 79 (70%) of 113 reviewed standard of care cultures met inclusion criteria. Patient comorbidities (P = NS), MEWS severity score (P = 0.10), source of bacteremia (P = NS), and pathogen detected (P = 0.30) were similar between cohorts. Time from collection to ID (28.2 ± 12.7 hours vs. 53.8 ± 20.9 hours; P < 0.001) and AST (31.9 ± 11 hours vs. 71.8 ± 20 hours; P < 0.001) were shorter in the intervention arm.Clinical OutcomesStandard of Care (Mean ± SD) N = 79Intervention (Mean ± SD), N = 75 P-valueLOS (days)12.1 (11.9)9.1 (7.6)0.03TTOT (hours)73.5 (50.2)37.5 (32.7)<0.001Total antibiotic DOT (days)9.0 (7.5)7.0 (4.6)0.05Meropenem DOT (days)6.6 (3.7)3.7 (2.1)0.03ConclusionCompared with standard of care, ACCEL shortens laboratory turn-around-time and improves clinical outcomes. The use of this system has resulted in decreased mean antibiotic DOT, TTOT, and LOS. Further studies are needed to verify these findings.Disclosures All authors: No reported disclosures.

Disease-based antimicrobial stewardship: a review of active and passive approaches to patient management.

Although new antimicrobial stewardship programmes (ASPs) often begin by targeting the reduction of antimicrobial use, an increasing focus of ASPs is to improve the management of specific infectious diseases. Disease-based antimicrobial stewardship emphasizes improving patient outcomes by optimizing antimicrobial use and increasing compliance with performance measures. Directing efforts towards the comprehensive management of specific infections allows ASPs to promote the shift in healthcare towards improving quality, safety and patient outcome metrics for specific diseases. This review evaluates published active and passive disease-based antimicrobial stewardship interventions and their impact on antimicrobial use and associated patient outcomes for patients with pneumonia, acute bacterial skin and skin structure infections, bloodstream infections, urinary tract infections, asymptomatic bacteriuria, Clostridium difficile infection and intra-abdominal infections. Current literature suggests that disease-based antimicrobial stewardship effects on medical management and patient outcomes vary based on infectious disease syndrome, resource availability and intervention type.

Impact of antimicrobial stewardship and rapid microarray testing on patients with Gram-negative bacteremia.

A rapid microarray assay, Nanosphere Verigene® Gram-negative blood culture test (BC-GN), detects four Gram-negative species, four Gram-negative genera, and six resistance genes directly from positive blood culture samples, shortening the time from Gram stain to pathogen and resistance-gene identification. The purpose of this study was to determine the impact of the BC-GN paired with an antimicrobial stewardship intervention on antimicrobial and clinical outcomes. Patients with Gram-negative bacteremia were compared before (n=456) and after (n=421) BC-GN implementation. The primary objective was to compare time from Gram stain to antimicrobial switch pre- and post-implementation. Time from Gram stain to effective treatment, in-hospital mortality, and hospital length of stay were also compared. The number and type of antimicrobial switches were similar between groups. Median (IQR) time from Gram stain to antimicrobial switch was significantly decreased in the post group, 28.6 (8.6-56.9) h vs 44.1 (18.9-64.6) h, p=0.004. In patients on ineffective antimicrobial therapy at the time of result, median time to effective therapy was lower in the post group, 8.8 (5.5-18.4) h vs 24.5 (4.9-44.3) h, p=0.034. Median (IQR) hospital length of stay was also decreased in the post group, 7 (5-15) days vs 9 (4.5-21) days, p=0.001. The rate of in-hospital mortality was similar between groups, 11.6% (pre) vs 11.4% (post), p=0.87. Rapid microarray testing on blood cultures combined with active antimicrobial stewardship intervention was associated with decreased time to antimicrobial switch, time to effective therapy, and hospital length of stay.

A Retrospective Study of the Impact of Rapid Diagnostic Testing on Time to Pathogen Identification and Antibiotic Use for Children with Positive Blood Cultures.

IntroductionRapid identification of bloodstream pathogens provides crucial information that can improve the choice of antimicrobial therapy for children. Previous impact studies have primarily focused on adults. Our objective was to evaluate the impact of rapid testing in a children’s hospital on time to organism identification and antibiotic use in the setting of an established antimicrobial stewardship program.MethodsWe conducted a retrospective study over three consecutive time periods (spanning January 2013–August 2015) as our hospital sequentially introduced two rapid testing methods for positive blood cultures. An antimicrobial stewardship program was active throughout the study. In the baseline period, no rapid diagnostic methods were routinely utilized. In the second period (PNAFISH), a fluorescent in situ hybridization test was implemented for gram-positive organisms and in the third a rapid multiplex PCR (rmPCR) test was employed. For children with positive blood cultures, time to organism identification use and duration of select antimicrobial therapies were compared between periods.ResultsPositive blood cultures were analyzed. Median overall time to organism identification was 23, 11, and 0 h in the baseline, PNAFISH, and rmPCR periods, respectively (p < 0.001 for both PNAFISH and rmPCR vs. baseline). For gram-negative organisms, only rmPCR performed significantly faster than baseline (p < 0.001). The duration of vancomycin use for coagulase-negative staphylococci was shorter in both the PNAFISH and rmPCR periods (mean 31 h in the baseline period, 12 and 14 h in the PNAFISH and rmPCR periods, respectively). For MSSA bacteremia, use of vancomycin was significantly decreased only in the rmPCR period (32% of patients vs. 64 and 72% in the baseline and PNAFISH periods; mean duration of 9 h vs. 30 and 26 h). There was no difference in use or duration of broad-spectrum gram-negative therapy across the three time periods.ConclusionRapid diagnostic testing for children with positive blood cultures results in faster time to identification and can influence antibiotic prescribing in the setting of active antimicrobial stewardship particularly for gram-positive pathogens.FundingMerck.