Ambulatory Antibiotic Prescribing Research Articles

P-1645. Appropriateness of Ambulatory Antibiotic Prescriptions Given Outside of Formal Patient-Clinician Encounters

Abstract Background There are limited published data on the frequency and appropriateness of outpatient antibiotic prescriptions ordered outside of formal patient-clinician encounters. Methods A random sample of oral antibiotics prescribed to adult patients from 4 primary care practices were manually reviewed for appropriateness. The need for any antibiotic, as well as the appropriateness of agent selection and duration, were compared between visit-based (formal in-person, video, or telephone encounters) and non-visit-based encounters. Results Of the 859 prescriptions reviewed, 543 (63.2%) were generated from visit-based encounters (48.2%, 13.2% and 1.9% were from in-person, video, and telephone visits, respectively) and 316 (36.8%) were non-visit-based. Overall, 29.7% of prescriptions were written despite no antibiotic indication (Table). Antibiotics were indicated in 382/543 (70.3%) of visit-based encounters, vs 165/316 (52.2%) of non-visit-based encounters (P< 0.0001). When an antibiotic was indicated, agent selection was more frequently appropriate in visit-based encounters (88.7% vs 81.8%, P=0.006), with no difference in appropriate duration (81.9% vs 89.7%, P=0.49). When duration was inappropriate, it was too long in 94.5% of cases. Among visit-based prescribing, antibiotic prescriptions were indicated more frequently from in-person encounters as compared to virtual (combined video and telephone) encounters (73.4% vs 60.5%, P=0.008). Compared to visit-based antibiotic prescriptions, significantly fewer non-visit-based antibiotic prescriptions were associated with any diagnosis code (543/543 (100%) vs 189/316 (59.8%), P< 0.0001). Azithromycin and fluoroquinolones were more likely to be inappropriately chosen agents compared to other antibiotics (46.7% vs 12.4%, P< 0.0001, and 45.5% vs 12.4%, P< 0.0001, respectively). Conclusion Compared to antibiotic prescriptions from formal patient-clinician encounters, antibiotic prescriptions generated from non-visit-based encounters were significantly less indicated, with less appropriate agent selection, and were frequently not associated with a diagnosis code. Outpatient stewardship efforts should target non-visit-based encounters. Disclosures Dustin R. Carr, PharmD, BCPS, BCIDP, Merck: Advisor/Consultant Derek N. Bremmer, PharmD, BCIDP, Thermo Fischer Scientific: Expert Testimony

P-1637. Four-year Experience on Ambulatory Antibiotic Prescribing for Viral Respiratory Infections

Abstract Background In 2019, our institution implemented the MITIGATE (a Multifaceted Intervention to Improve Prescribing for Acute Respiratory Infection for Adult and Children in Emergency Department and Urgent Care Settings) Toolkit, a multimodal antimicrobial stewardship strategy using education, data, and feedback to reduce unnecessary antibiotic prescribing for viral respiratory infections (RTIs) in ambulatory care settings. Methods This was a single center observational study. Prescribers in emergency department (ED), primary care (PC), and urgent care (UC) were notified of their individual unnecessary antibiotic prescribing from 9/2019 - 3/2022 via email. We reduced rate of feedback from notifying all prescribers, to half after the first year, and none after 2 years and observed the impact on antibiotic prescribing. Prescribers were labeled as a top performer or not a top performer compared to their peers. Unnecessary antibiotic prescribing for RTI was evaluated 4 years after the intervention began. Results In 2019 Pre-toolkit intervention, 14,247 patient visits had a qualifying viral RTI. 17.9%, 9.8%, and 6.4% received an antibiotic unnecessarily in the ED, PC, and UC, respectively. After 2-years of direct feedback, antibiotics were prescribed in 13.4%, 4.3% , and 4.7% , in the ED, PC, and UC (N = 48,192) (p< 0.001). In 2023, after feedback stopped, unnecessary prescribing remained lower in ED (14.4%, p< 0.001) and PC (5.8%, p< 0.001), but not UC (7.2%, p=0.015), N =53,496. Conclusion Rates of unnecessary antibiotic prescribing for viral RTI dropped most significantly following two years of varying degrees of direct feedback. Although prescribing rates in the ED and PC remain lower after 4 years compared to pre-intervention, current data demonstrate an uptrend. Although labor-intensive, this supports that feedback with peer comparison is an instrumental intervention. Strategies to ensure successful intervention maintenance should be considered when implementing outpatient stewardship. Disclosures All Authors: No reported disclosures

P-1142. Evaluating Ambulatory Antibiotic Prescribing for Respiratory Infections at a Pediatric Institution

Abstract Background Over 85% of antibiotic prescribing occurs in outpatient settings such as emergency departments (ED), urgent care centers (UCC), and primary care clinics (PCC); almost half of antibiotics are prescribed for respiratory infections (RI). Given the rise of telehealth visits (TH) in both UCC and PCC settings in the past several years, this study examines the effect of location sites on antibiotic prescribing for RI at our institution. Methods Single-center, retrospective cohort study in Portland, Oregon, USA. Patients < = 20 years of age seen in the ED, UCC, and PC settings between 1/1/2019-12/31/2024, were included. Electronic data included age, race, ethnicity, location and encounter type, payor status, visit ICD-10 codes, and antibiotic prescription details. Multivariate logistical regression determined the effect of patient factors on antimicrobial prescribing. Results A total of 157,499 ambulatory encounters were included of which 24,236 were respiratory ICD10 code-related visits. Respiratory visit rates were not significantly different between non-Hispanic White and Hispanic/non-White children or by age group. RI were categorized as viral (57.7%), possible bacterial (37.6%), or co-infection (4.7%); antibiotics were prescribed 5.3%, 60.4%, and 62.8% of visits respectively. The rate of antibiotic prescribing for viral and possible bacterial RI was not different between non-Hispanic White and Hispanic/non-White children or between payor status. For viral RI, PCC and UCC settings were more likely to prescribe antibiotics compared to the ED (OR 1.4 and OR 2.36, respectively). Furthermore, PCC and UCC were less likely to prescribe narrow-spectrum antibiotics for possible bacterial RI compared to the ED (OR 0.84 and OR 0.79, respectively), including TH PCC and TH UCC visits (OR 0.29 and OR 0.56, respectively). Conclusion Pediatric patients with RI can receive ambulatory care through multiple settings. PCC TH (although a small percentage of all RI visits) shows the highest use of antibiotics for viral RI and the least narrow spectrum antibiotic prescribing for presumed bacterial RI. Efforts to reduce antibiotic use in viral RI should focus on non-ED settings, including TH. Strategies to encourage use of narrow-spectrum activity agents for RI should be shared with all departments. Disclosures All Authors: No reported disclosures

Appropriateness of ambulatory antibiotic prescribing in South Carolina, 2012-2017.

This population-based cohort study examines the appropriateness of antibiotic prescribing in South Carolina via aggregated pharmacy claims data matched with diagnosis codes from medical claims. Inappropriate antibiotic prescribing decreased from 30.2% in 2012 to 22.6% in 2017 (P < 0.001) and was more common in adults >40 years old.

Ambulatory antibiotic prescription rates for acute respiratory infection rebound two years after the start of the COVID-19 pandemic.

During the COVID-19 pandemic, acute respiratory infection (ARI) antibiotic prescribing in ambulatory care markedly decreased. It is unclear if antibiotic prescription rates will remain lowered. We used trend analyses of antibiotics prescribed during and after the first wave of COVID-19 to determine whether ARI antibiotic prescribing rates in ambulatory care have remained suppressed compared to pre-COVID-19 levels. Retrospective data was used from patients with ARI or UTI diagnosis code(s) for their encounter from 298 primary care and 66 urgent care practices within four academic health systems in New York, Wisconsin, and Utah between January 2017 and June 2022. The primary measures included antibiotic prescriptions per 100 non-COVID ARI encounters, encounter volume, prescribing trends, and change from expected trend. At baseline, during and after the first wave, the overall ARI antibiotic prescribing rates were 54.7, 38.5, and 54.7 prescriptions per 100 encounters, respectively. ARI antibiotic prescription rates saw a statistically significant decline after COVID-19 onset (step change -15.2, 95% CI: -19.6 to -4.8). During the first wave, encounter volume decreased 29.4% and, after the first wave, remained decreased by 188%. After the first wave, ARI antibiotic prescription rates were no longer significantly suppressed from baseline (step change 0.01, 95% CI: -6.3 to 6.2). There was no significant difference between UTI antibiotic prescription rates at baseline versus the end of the observation period. The decline in ARI antibiotic prescribing observed after the onset of COVID-19 was temporary, not mirrored in UTI antibiotic prescribing, and does not represent a long-term change in clinician prescribing behaviors. During a period of heightened awareness of a viral cause of ARI, a substantial and clinically meaningful decrease in clinician antibiotic prescribing was observed. Future efforts in antibiotic stewardship may benefit from continued study of factors leading to this reduction and rebound in prescribing rates.

Prevalence and appropriateness of in-person versus not-in-person ambulatory antibiotic prescribing in an integrated academic health system: A cohort study.

Ambulatory antibiotic stewardship generally aims to address the appropriateness of antibiotics prescribed at in-person visits. The prevalence and appropriateness of antibiotics prescribed outside of in-person visits is poorly studied. Retrospective cohort study of all ambulatory antibiotic prescribing in an integrated health delivery system in the United States. Antibiotic prescribers and patients receiving oral antibiotic prescriptions between January 2016 and December 2019. Proportion of antibiotics prescribed with in-person visits or not-in-person encounters (e.g., telephone, refills). Proportion of prescriptions in in 5 mutually exclusive appropriateness groups: 1) chronic antibiotic use; 2) antibiotic-appropriate; 3) potentially antibiotic-appropriate; 4) non-antibiotic-appropriate; and 5) not associated with a diagnosis. Over the 4-year study period, there were 714,057 antibiotic prescriptions ordered for 348,739 unique patients by 2,391 clinicians in 467 clinics. Patients had a mean age of 41 years old, were 61% female, and 78% White. Clinicians were 58% women; 78% physicians; and were 42% primary care, 39% medical specialists, and 12% surgical specialists. Overall, 81% of antibiotics were prescribed with in-person visits and 19% without in-person visits. The most common not-in-person encounter types were telephone (10%), orders only (5%), and refill encounters (3%). Of all antibiotic prescriptions, 16% were for chronic use, 15% were antibiotic-appropriate, 39% were potentially antibiotic-appropriate, 22% were non-antibiotic-appropriate, and 8% were not associated with a diagnosis. Antibiotics prescribed in not-in-person encounters were more likely to be chronic (20% versus 15%); less likely to be associated with appropriate or potentially appropriate diagnoses (30% versus 59%) or non-antibiotic-appropriate diagnoses (8% versus 25%); and more likely to be associated with no diagnosis (42% versus <1%). Ambulatory stewardship interventions that focus only on in-person visits may miss a large proportion of antibiotic prescribing, inappropriate prescribing, and antibiotics prescribed in the absence of any diagnosis.

Ambulatory antibiotic prescribing for children in a practice research network

Background: Most antibiotic use occurs in ambulatory settings. Antibiotic prescribing for children living in the United States in medically underserved areas or in populations is not well understood.Objective: To characterize antibiotic prescribing for children in a practice-based research network (PBRN).Design and Methods: In this retrospective cohort study, we characterized oral antibiotic prescribing in a large PBRN. Patients aged 0–17 years with at least 1 in-person visit between January 1, 2014, and December 31, 2018, at 1 of 25 primary-care clinics located within the WWAMI (Washington, Wyoming, Alaska, Montana, and Idaho) region of the Practice and Research Network (WPRN) were included. Data were extracted from DataQUEST, a centralized data repository from included primary-care clinics. Encounters for wellness visits or those lacking a diagnosis code and patients with complex chronic conditions were excluded. Diagnoses were categorized using International Classification of Disease, Ninth Revision (ICD-9) and ICD-10 codes. Oral antibiotics prescribed within 3 days of an encounter were associated with that encounter. Demographic data included age, sex, race, and ethnicity. Antibiotic appropriateness was determined using a previously published 3-tiered classification system using diagnosis codes as always, sometimes, or never appropriate. Patient-level data (ZIP codes) were used to designate medically underserved areas (MUAs) and medically underserved populations (MUPs). Antibiotic prescribing was then analyzed within these groups. Results: In total, 37,314 patients across 206,845 encounters were included, of which 34,601 encounters (17%) resulted in antibiotic prescription (Table 1). Of those, appropriateness data were available for 34,286 (99%). Of the antibiotics prescribed, 14% were always appropriate, 57% were sometimes appropriate, and 27% were never appropriate (1% missing). In total, 64% and 35% of encounters occurred with patients from an MUA and MUP, respectively. Conclusions: Targets to improve oral antibiotic prescribing for children in a large PBRN include antibiotic prescribing for diagnoses that never require an antibiotic. Larger comparative studies may focus on the role (if any) that MUA/MUP has on antibiotic prescribing.Disclosures: None

Snapshots of ID Week 2022

Snapshots of ID Week 2022

875. Guess Who’s Back: The Return of Seasonal Respiratory Viruses in the State of Wisconsin and Associated Changes in Antibiotic Prescribing for Respiratory Complaints

Abstract Background Return of infections caused by common respiratory viruses (RV) may be expected with the relaxation and/or removal of infection prevention measures instituted during the COVID-19 pandemic. Therefore, we examined respiratory virus detection (RVD) rates in Wisconsin during the COVID-19 period, and whether ambulatory antibiotic prescribing for respiratory complaints has increased with return of typical RVs. Methods The Wisconsin State Laboratory of Hygiene’s Viral Surveillance program collects RVD data from &amp;gt;130 laboratories across the state for influenza (FLU), respiratory syncytial virus (RSV), seasonal coronaviruses (sCOR), parainfluenza virus (PARA), enteroviruses/rhinoviruses (E/R), and human metapneumovirus (hMPV). Data were collected from 1/1/2015 to 4/30/2022. Antibiotic prescribing for ambulatory care patients presenting with respiratory complaints was collected from our EHR, which utilizes a required order form for all ambulatory antibiotic prescriptions. Statistical analysis was performed using Mann-Whitney Rank Sum and Spearman’s rank correlation. Results In the first year after COVID-19 onset, E/R and sCOR were detected at low levels while other RVs were essentially nil. After 4/2021, when infection prevention measures (i.e. mask mandates) were significantly relaxed or removed, RVDs increased for all viruses. At present, RVDs have returned to typical rates (except of FLU, Fig. 1) and seasonality variation (except of RSV, Fig. 1). Antibiotic prescribing for respiratory complaints has increased 57% in this period (3.5 to 5.5 prescriptions/1000 encounters, Fig. 2) and continues to trend up with RV activity. Prescribing rates are strongly correlated with RVD rates, but most strongly correlated with non-FLU, non-RSV RVD rates (Spearman correlation 0.71). The dashed vertical line represents relaxation/discontinuation of public infection prevention measures (e.g. masking). The dashed vertical line represents relaxation/discontinuation of public infection prevention measures (e.g. masking). * Parainfluenza virus, human metapneumovirus, enterovirus/rhinovirus, or seasonal coronavirus. Conclusion In general, RVs have returned to pre-pandemic rates with seasonality. Interestingly, this return was associated with the relaxation/removal of infection prevention measures in the second year post-COVID-19 onset, and does not appear to be impacted by ongoing COVID-19 waves. Antibiotic prescribing in ambulatory care continues to be highly associated with RV activity, indicating this should remain a high priority of ambulatory stewardship education and intervention. Disclosures All Authors: No reported disclosures.

Look-Back and Look-Forward Durations and the Apparent Appropriateness of Ambulatory Antibiotic Prescribing.

Ambulatory antibiotic stewards, researchers, and performance measurement programs choose different durations to associate diagnoses with antibiotic prescriptions. We assessed how the apparent appropriateness of antibiotic prescribing changes when using different look-back and look-forward periods. Examining durations of 0 days (same-day), -3 days, -7 days, -30 days, ±3 days, ±7 days, and ±30 days, we classified all ambulatory antibiotic prescriptions in the electronic health record of an integrated health care system from 2016 to 2019 (714,057 prescriptions to 348,739 patients by 2391 clinicians) as chronic, appropriate, potentially appropriate, inappropriate, or not associated with any diagnosis. Overall, 16% percent of all prescriptions were classified as chronic infection related. Using only same-day diagnoses, appropriate, potentially appropriate, inappropriate, and not-associated antibiotics, accounted for 14%, 36%, 22%, and 11% of prescriptions, respectively. As the duration of association increased, the proportion of appropriate antibiotics stayed the same (range, 14% to 18%), potentially appropriate antibiotics increased (e.g., 43% for -30 days), inappropriate stayed the same (range, 22% to 24%), and not-associated antibiotics decreased (e.g., 2% for -30 days). Using the longest look-back-and-forward duration (±30 days), appropriate, potentially appropriate, inappropriate, and not-associated antibiotics, accounted for 18%, 44%, 20%, and 2% of prescriptions, respectively. Ambulatory programs and studies focused on appropriate or inappropriate antibiotic prescribing can reasonably use a short duration of association between an antibiotic prescription and diagnosis codes. Programs and studies focused on potentially appropriate antibiotic prescribing might consider examining longer durations.

Improvements in appropriate ambulatory antibiotic prescribing using a bundled antibiotic stewardship intervention in general pediatrics practices.

To improve appropriate antibiotic prescribing for children in Tennessee. We performed a before-and-after intervention study with 3 comparison periods: period 1 (P1, baseline) May 2018-September 2019; period 2 (P2, intervention before the COVID-19 pandemic) November 11, 2019-March 20, 2020; and period 3 (P3, intervention during the coronavirus disease 2019 [COVID-19] pandemic) March 21, 2020-November 10, 2020. We additionally surveyed participating providers to assess acceptance of the intervention. Community general pediatrics practices. In total, 81 general pediatricians, family medicine physicians, and nurse practitioners in 5 general pediatrics practices participated in this study. Each practice identified a practice and operations champion for the project. Practices chose 2-4 implementation strategies previously shown to be effective at reducing outpatient antibiotic use to implement in their practice throughout the study intervention period. Study personnel also held quarterly meetings with all providers to review deidentified peer comparison feedback both across practices enrolled in the study and at the provider level within each practice. We detected improvements in guideline-concordant antibiotic use in the pre-COVID-19 intervention period, and they were sustained in the study period during the pandemic (P3): otitis media (P1 72.14% vs P2 81.42% vs P3 86.11%), group A streptococcal pharyngitis (P1 66.13% vs P2 81.56% vs P3 80.44%), pneumonia (P1 70.6% vs P2 76.2% vs P3 100%), sinusitis (P1 76.2% vs P2 83.78% vs P3 82.86%), skin and soft-tissue infections (P1 97.18% vs P2 100% vs P3 100%). Bundled implementation strategies led to significant increases in guideline-concordant antibiotic prescribing for all diagnoses. Survey results demonstrate that the bundled implementation strategies were well-accepted by providers.

Using Belgian pharmacy dispensing data to assess antibiotic use for children in ambulatory care

BackgroundThe desired effect of antibiotics is compromised by the rapid escalation of antimicrobial resistance. Children are particularly at high-risk for unnecessary antibiotic prescribing, which is owing to clinicians’ diagnostic uncertainty combined with parents’ concerns and expectations. Recent Belgian data on ambulatory antibiotic prescribing practices for children are currently lacking. Therefore, we aim to analyse different aspects of antibiotic prescriptions for children in ambulatory care.MethodsPharmacy dispensing data on antibiotics for systematic use referring from 2010 to 2019 were retrieved from Farmanet, a database of pharmaceutical dispensations in community pharmacies. Population data were obtained from the Belgian statistical office (Statbel). Descriptive statistics were performed in Microsoft Excel. The Mann-Kendall test for trend analysis and the seasplot function for seasonality testing were conducted in R.ResultsThe past decade, paediatric antibiotic use and expenditures have relatively decreased in Belgian ambulatory care with 35.5% and 44.3%, respectively. The highest volumes of antibiotics for children are prescribed by GPs working in Walloon region and rural areas, to younger children, and during winter. The most prescribed class of antibiotics for children are the penicillins and the biggest relative reduction in number of packages is seen for the sulfonamides and trimethoprim and quinolone antibacterials.ConclusionsPaediatric antibiotic use has decreased in Belgian ambulatory care. Further initiatives are needed to promote prudent antibiotic prescribing in ambulatory care.

162. The Impact of the COVID-19 Pandemic on Antibiotic Prescribing in Pediatric Primary Care

BackgroundWith the onset of the coronavirus disease 2019 (COVID-19) pandemic, pediatric primary care delivery changed rapidly. Prior studies have demonstrated a reduction in ambulatory encounters and antibiotic prescriptions with the pandemic onset; however, the durability of these reductions in pediatric primary care in the United States has not been assessed. MethodsWe conducted a retrospective cohort study to assess the impact of the COVID-19 pandemic and associated public health measures (e.g. social distancing, masking, school closures, and increased availability of telemedicine) on antibiotic prescribing and encounter volume in 27 pediatric primary care practices, and the duration of these changes. Patients under age 19 with an encounter from January 1, 2018 through December 31, 2020 were included. The primary outcome was monthly antibiotic prescriptions per 1000 patients, in the overall population and a subset of encounters with infectious diagnoses, including respiratory tract infections (RTIs). Interrupted time series (ITS) analysis was performed.ResultsThere were 60,562 total antibiotic prescriptions from April to December in 2019 and 14,605 antibiotic prescriptions during the same months in 2020, a 76% reduction. The reduction in RTI encounter prescriptions accounted for 91.5% of the overall reduction in prescriptions from 2019 to 2020. Using ITS analysis, there was an immediate decrease from 31.6 to 7.4 prescriptions/1000 patients (predicted means) in April 2020 (-24.2 prescriptions/1000 patients; 95% CI: -31.9, -16.4) (Figures 1 and 2). This was followed by a stable rate of antibiotic prescriptions that remained flat through December 2020. For RTI encounters, a similar pattern was seen, with a decrease by 21.8 prescriptions/1000 patients; 95% CI: -29.5, -14.2) (Figures 1 and 2). Encounter volume also decreased immediately, and while overall encounter volume began returning to a pre-pandemic baseline volume toward the end of the study period, RTI encounter volume remained persistently lower through December 2020 (Figure 3).Figure 1. Antibiotic prescriptions per 1000 patients prescribed by month from January 2018 to December 2020, overall and for disease-specific subgroups RTI = respiratory tract infection; UTI = urinary tract infection; SSTI = skin and soft tissue infection. Months are numbered sequentially, starting with January (number 1). Dashed line indicates first full month of the pandemic, April 2020.Interrupted time series analysis for antibiotic prescriptions per 1000 patients by month from January 2018 to December 2020 for (A) all antibiotics as well as antibiotics prescribed at encounters with (B) respiratory tract infections (RTIs), (C) urinary tract infections (UTIs), and (D) skin and soft tissue infections (SSTIs) Intervention starts in April 2020 (dashed line). Months are numbered sequentially, starting with January (number 1). Dashed line indicates first full month of the pandemic, April 2020.Antibiotic prescriptions per 1000 billed encounters by month from January 2018 to December 2020 for (A) all encounters, as well as antibiotics prescribed at encounters with (B) respiratory tract infections (RTIs), (C) urinary tract infections (UTIs), and (D) skin and soft tissue infections (SSTIs) Months are numbered sequentially, starting with January (number 1).ConclusionDramatic reductions in antibiotic prescribing in pediatric primary care during the COVID-19 pandemic were sustained through 2020, primarily driven by reductions in RTI encounters.Disclosures All Authors: No reported disclosures

The commitment of dentists to prescribe antibiotics in modern conditions

The aim of this research was to study different patterns of antibacterial drugs prescribing in dentistry practice in Central Asian region. The online survey of 108 dentists was conducted. The online questionnaire included 18 questions. Almost half of respondents (42,1%) frequently prescribed antibiotics. The most preferred antibiotics were from the group of penicillin (46.6% of cases). The following groups of antibiotics also were prescribed by dentists: fluoroquinolones (42.6%), nitroimidazoles (30.7%), cephalosporins 3 generations (18.8%) and lincozamines (16.8%). The duration of therapy in was 5-7 days in 62.3%, the rest of patients took antibiotics 3-5 days. The 67.7% of respondents prescribed monotherapy. The most common combination of antibiotic drugs were ciprofloxacin and metronidazole (26%). The indications for ambulatory antibiotic prescription were tooth extraction (48.1%) and apical periodontitis (38.7%). Most of the respondents (61.3%) answered that they are familiar with the principles of rational antibiotic therapy. The 84% of respondents prescribe an antibiotic with an average therapeutic dose. The replacement of antibiotic because of inefficiency was provided in 84.5%. In the absence of an allergic history 48.1% of dentists prescribe ciprofloxacin. Thus, in the course of the study, it was found that the majority (64%) of antibiotic appointment were irrational in outpatient dental practice. The most common observation was prescribing antibiotics and their combinations without direct indications. This trend is a cause for concern and requires additional measures aimed at increasing awareness of dentists about antibiotic treatment as well as standardization of prescription.

Non-Visit-Based and Non-Infection-Related Antibiotic Use in the US: A Cohort Study of Privately Insured Patients During 2016-2018.

BackgroundAmbulatory antibiotic prescriptions without a clinic visit or without documentation of infection could represent overuse and contribute to adverse outcomes. We aim to describe US ambulatory antibiotic prescribing, including those without an associated visit or infection diagnosis.MethodsWe conducted an observational cohort study using data of all patients receiving antibacterial, antibiotic prescriptions from 04/01/2016 to 06/30/2018 in a large US private health insurance plan. We identified outpatient antibiotic prescriptions as (1) associated with a clinician visit and an infection-related diagnosis; (2) associated with a clinician visit but no infection-related diagnosis; or (3) not associated with an in-person clinician visit in the 7 days before the prescription (non-visit-based). We then assessed whether non-visit-based antibiotic prescriptions (NVBAPs) differed from visit-based antibiotics by patient, clinician, or antibiotic characteristics using multivariable models.ResultsThe cohort included 8.6M enrollees who filled 22.3M antibiotic prescriptions. NVBAP accounted for 31% (6.9M) of fills, and non-infection-related prescribing accounted for 22% (4.9M). NVBAP rates were lower for children than for adults (0–17 years old, 16%; 18–64 years old, 33%; >65 years old, 34%). Among most commonly prescribed antibiotic classes, NVBAP was highest for penicillins (36%) and lowest for cephalosporins (25%) and macrolides (25%). Specialist physicians had the highest rate of NVBAP (38%), followed by internists (28%), family medicine (20%), and pediatricians (10%). In multivariable models, NVBAP was associated with increasing age, and NVBAP was less likely for patients in the South, those with more baseline clinical visits, or those with chronic lung disease.ConclusionsOver half of ambulatory antibiotic use was either non-visit-based or non-infection-related. Particularly given health care changes due to the coronavirus disease 2019 pandemic, efforts to improve antibiotic prescribing must account for non-visit-based and non-infection-related prescribing.

Association of Changes in Seasonal Respiratory Virus Activity and Ambulatory Antibiotic Prescriptions With the COVID-19 Pandemic

Association of Changes in Seasonal Respiratory Virus Activity and Ambulatory Antibiotic Prescriptions With the COVID-19 Pandemic

Preparing for the New Joint Commission Requirements: a Model for Tracking Outcomes of an Ambulatory Antibiotic Stewardship Program in Primary Care

Since 2007, inpatient antibiotic stewardship programs have been required for all Joint Commission-accredited hospitals in the USA. Given the frequency of ambulatory antibiotic prescribing, in June 2019, the Joint Commission released new standards for antibiotic stewardship programs in ambulatory healthcare. This report identified five elements of performance (EPs): (1) Identify an antimicrobial stewardship leader, (2) establish an annual antimicrobial stewardship goal, (3) implement evidence-based practice guidelines related to the antimicrobial stewardship goal, (4) provide clinical staff with educational resources related to the antimicrobial stewardship goal, and (5) collect, analyze, and report data related to the antimicrobial stewardship goal. We provide eight practical tips for implementing the EPs for antimicrobial stewardship: (1) Identify a collaborative leadership team, (2) partner with informatics, (3) identify national prescribing patterns, (4) perform a needs assessment based on local prescribing patterns, (5) review guidelines for diagnosis and treatment of the selected condition, (6) identify systems-level interventions to help support providers in making appropriate treatment decisions, (7) prioritize individual EPs for your institution, and (8) re-assess local data to identify areas of strength and deficiency in local practice.

243. Temporal Trends in Appropriateness of Ambulatory Antibiotic Prescribing in South Carolina

BackgroundPrevious studies have reported high levels of inappropriate ambulatory antibiotic prescribing in the United States. This population-based cohort study examines temporal trends in appropriateness of ambulatory antibiotic prescribing in South Carolina.MethodsAggregated pharmacy claims data for oral antibiotic prescriptions among South Carolina residents < 65 years old were matched with primary diagnosis codes from medical claims within 14 days of the pharmacy claim from 2012–2017. Appropriateness of antibiotics was defined as maybe indicated or not indicated based on diagnosis codes. Chi-square tests were used to examine overall temporal trend in appropriateness and the trends across age group and gender.ResultsDuring the 6-year period, 3,133,379 prescriptions were identified. Overall, 25.6% of antibiotic prescriptions filled were not indicated. This decreased from 27.9% in 2012 to 22.7% in 2017 (p < 0.001). The most common not indicated conditions were viral upper respiratory infections (39.1%), bronchitis (26.7%), and serous otitis (10.9%). The most common maybe indicated conditions were bacterial otitis (27.5%), acute bacterial tonsillitis (24.8%), and sinusitis (23.6%). While females filled more antibiotic prescriptions, they were less likely than males to have a not indicated condition (24.7% vs. 27.1%, p < 0.001). Prescribing for not indicated conditions was more likely in adults aged 40–64 (33.7%) than those aged 18–39 (23.5%) and < 18 (24.2%).ConclusionThe observed decline in inappropriate ambulatory antibiotic prescribing from 2012 to 2017 in South Carolina represents welcomed news. Further improvements in ambulatory antibiotic stewardship efforts are needed particularly in men ≥ 40 years old with acute respiratory infections.DisclosuresJulie Ann Justo, PharmD, MS, BCPS-AQ ID, bioMerieux (Speaker’s Bureau)TRC Healthcare (Speaker’s Bureau)

220. Comparing Antibiotic Prescription Practices, and Provider’s Perceptions of Such Rates, Among Urgent Care and Non-Urgent Care Clinicians at One of the Nation’s Largest Federally Qualified Health Centers

BackgroundInappropriate antibiotic prescribing practices, and the resulting development of antibiotic resistance, contribute to a growing health emergency worldwide. In reviewing data from 2010–2011, it was estimated that over 30% of ambulatory antibiotic prescriptions in the United States are non-essential.1 Altamed, one of the nation’s largest federally qualified health centers, operates 21 clinics across Southern California and serves the primary care needs of a high-volume, socioeconomically disadvantaged, predominantly Hispanic population.Citation 1MethodsWe conducted an evaluation on the inappropriate antibiotic prescribing rate for Upper Respiratory Infections (URI) among all providers at Altamed (n=400). We limited our scope of encounters to cases of uncomplicated, acute bronchitis (URI) that occurred between January and December 2018. ICD 10 codes identified URIs, with exclusion criteria limiting confounding variables, charting errors, and dual diagnoses. Additionally, provider perceptions and mechanism for their antibiotic prescription practices were assessed with a de-identified 17 question, Likert-scale assessment (n=90).ResultsOf the encounters for URI seen by urgent care providers, 11.09% had inappropriate antibiotic prescriptions written. This is significantly different from encounters by non-urgent care providers, where 9.13% were deemed inappropriate (p=0.016). Despite this, providers were not uniform in believing their own antibiotic prescription rates to be as successful, with many estimating that their rate of CDC guideline concordance to fall below 90%. However, in their survey responses, providers as a whole report following healthy prescribing practices, identifying needs in their communities to recognize when it was inappropriate to prescribe an antibiotic, though they requested increased access to and education on antibiograms. Graph 1 Table 1 Graph 2 ConclusionOur study limitations included uneven or incomplete charting, the narrow time frame of the study, and the limited survey response rate of Altamed providers. Nevertheless, we are able to ascertain that inappropriate prescribing practices continue to be a challenge in the outpatient setting and are of greater concern among urgent care providers.Disclosures All Authors: No reported disclosures

1466. Antibiotic utilization reports may reduce prescribing practices for Upper Respiratory Infections

BackgroundMore than 90% of Upper respiratory tract infections (URI) have a viral etiology; nonetheless, these represent the most common reason for ambulatory antibiotic prescription. This translates in higher risk of antibiotic-related adverse events and promotion of antimicrobial resistance.MethodsA prospective single-center intervention surveying and providing individual, face-to-face comparative reports of antibiotic utilization, for any of the 4 diagnostic entities that constitute upper respiratory tract infection (common cold, pharyngitis, acute rhinosinusitis and acute bronchitis), was performed in our Emergency Department.Example of monthly provider reports used which included general and individualized goals. ResultsA total of 12 health care providers were followed for 12 months. Education, prescribing reports and individual goals were provided. The pre-intervention prescription rate from September to December 2018 averaged 74.75% (SD 20.59, 95% CI 61.6-87.8), with a post-intervention rate of 55.5% from September to December of 2019 (SD 19.20, 95% CI 43.3-67.7) that was statistically significant (p=0.0036). A higher use of antibiotic was observed in physicians when compared to non-physician providers in both pre and post intervention stages (reduction of 16.6% vs 23% after intervention respectively), with no statistical difference between the two groups (CI 95% of -38.82 to 2.395, p=0.0773). A proposed target of 50% or less was observed in 5 of 12 providers (41.6%), and 2 out of 12 (16.7%) had increase in their antibiotic utilization rate.Comparative use of antimicrobials in the pre (September-December 2018) and post (September-December 2019) - intervention periods. Average individual antimicrobial use rate before and after intervention. ConclusionRoutine face-to-face utilization reports may constitute an effective approach in reducing antibiotic prescription practices in the Emergency Department, and potentially, in other outpatient healthcare settings.Disclosures All Authors: No reported disclosures