Antibiotic Orders Research Articles

P-1643. Simply Scripting Success: Impact of Epic Preference List Changes on Antibiotic Prescribing in the Outpatient Setting

Abstract Background Preference lists in electronic health records are commonly used to streamline ordering processes, including antibiotic orders. In July 2023, we revised our institution's primary care preference list to align with institutional guidelines for the management of skin and soft tissue infections (SSTI) and pneumonia (Figure 1). Here we evaluate the impact of this intervention on antibiotic prescribing practices. Methods We included all adult telemedicine and office visits associated with antibiotic orders from 2/2023 to 2/2024 at 8 academic primary clinics. We used International Classification of Diseases, 10th revision (ICD10) data to identify encounters for SSTIs and pneumonia (Table 1 ). We defined “pre-intervention” as 2/1 – 7/31/2023 and “post-intervention” as 8/1/2023– 2/28/2024. We extracted encounter date, location, order source, antibiotic selection, and duration. We defined guideline adherence as 1st line antibiotic selection and 5-day duration (Figure 1). There were no education or dissemination efforts to providers. This was deemed a non-human subjects research quality improvement project. Results We included 349 total (165 pre, 184 post) encounters for SSTI (263) and pneumonia (86). 102 (29%) were telemedicine (50 pre, 52 post). Of the 349 encounters, 73 % of antibiotic orders were from the preference list (136 pre; 117 post). Guideline concordant antibiotic selection improved in the post-intervention group for pneumonia (8% pre, 44% post) and SSTIs (47% pre, 58% post), but only for orders sourced from the preference list (Table 2, Graphs 1-2). There was also improvement in guideline concordant 5-day durations with preference list orders post-intervention for pneumonia (55% pre, 78% post) and SSTI (20% pre, 50% post) (Table 2, Graphs 1-2). Antibiotic orders not using the preference list for these syndromes showed no improvement during this time. Conclusion We found that a simple revision of the primary care order preference list led to improved guideline concordant antibiotic prescribing for SSTI and pneumonia. For common syndromes in which antibiotic selection is typically made empirically in clinic, like SSTIs and pneumonia, pre-selected durations and highlighted first-line selections for antibiotic orders can improve adherence to guideline recommendations. Disclosures All Authors: No reported disclosures

P-1653. Current Prescribing Practices and Guideline Concordance for the Treatment of Community-Acquired Bacterial Pneumonia (CABP) across Outpatient and Urgent Care Visits

Abstract Background Resources and support for antibiotic stewardship programs (ASP) have focused on hospitalized patients and there is minimal prescribing data and interventions among outpatients. We aimed to assess the treatment of CABP in adults in order to develop interventions to improve antibiotic utilization. Methods This retrospective study (2022-2022) included patients within a large healthcare system presenting to outpatient clinics (n=120) and affiliated Urgent Care Centers (n=24) across Connecticut. Patient encounters were identified via CABP ICD-10 codes and IDSA relevant patient comorbidities (chronic heart, lung, liver, or renal disease; diabetes; alcoholism; malignancy; asplenia) were extracted from patient problem lists. Primary outcome was to describe the proportion of patients receiving concordant therapy (antibiotic choice and prescription of monotherapy or combination therapy depending on presence of comorbidity) per IDSA guideline and local antibiogram. Results Patient characteristics are listed in Table 1. Overall guideline concordance rate was 36.6% (1,468/4,011 antibiotic orders). Among orders in patients with comorbidities (n=2,212), a large proportion received discordant therapy (n=1,417; 64.1%) via monotherapy particularly doxycycline (DOX) or azithromycin (AZM). Among appropriate combination therapy orders (n=370) in patients with comorbidities, the most common pairings were amoxicillin-clavulanate plus AZM (160/370; 43.2%) followed by amoxicillin-clavulanate plus DOX (86/370; 23.2%). 10.5% (232/2,212) received a guideline concordant respiratory fluoroquinolone monotherapy. Among antibiotic orders in patients with no comorbidity (n=1,799), 1,126 (62.6%), orders were discordant largely due to inappropriate monotherapies (742/1,126; 65.9%) in particular AZM monotherapy (352/1,126; 31.3%) despite local pneumococcal resistance rates >25%. Conclusion Guideline concordance was low, primarily due to lack of combination therapy in patients with comorbidities, as well as use of AZM monotherapy despite high resistance rates. Overall, these data will be instrumental in our current efforts to initiate an outpatient ASP and deploy interventions to improve care across the continuum of care. Disclosures Tomefa E. Asempa, PharmD, FDA/CDER: Grant/Research Support|Paratek: Grant/Research Support|Shionogi: Grant/Research Support|Spero: Grant/Research Support|VenatoRx: Grant/Research Support David P. Nicolau, PharmD, CARB-X: Grant/Research Support|Innoviva: Grant/Research Support|Innoviva: Honoraria|Merck: Advisor/Consultant|Merck: Grant/Research Support|Merck: Honoraria|Pfizer: Advisor/Consultant|Pfizer: Grant/Research Support|Pfizer: Honoraria|Shionogi: Advisor/Consultant|Shionogi: Grant/Research Support|Shionogi: Honoraria|Venatorx: Grant/Research Support

P-1680. Retrospective Review of Adherence to Institutional Pneumonia Antimicrobial Guidelines at Hospital Admission

Abstract Background Literature supports the importance for institutions to have antimicrobial guidance accessible for providers in order to improve patient outcomes and antimicrobial stewardship (AMS). However, guideline adherence when prescribing for community acquired infections tends to be poor and includes more broad-spectrum antibiotics than required. We performed a review to assess adherence to our institutional pneumonia guidelines. Methods A retrospective chart review was conducted on all adult patients admitted to a Medicine or Hospitalist team at WVU Hospitals with an admission diagnosis of community acquired pneumonia (CAP)/pneumonia between January – June 2023. Demographic and clinical characteristics were collected as well as outcomes of interest: empiric antimicrobials and adherence to our institutional pneumonia guidelines. Data was collected and analyzed via WVU REDCap. Results We identified 154 patients with admission diagnosis of CAP to internal medicine services; however, 37 were excluded, as they were transfers from the ICU or outside facilities. Demographics showed 49.4% of the patients were female and median age was 69 years. 30% received antibiotics in preceding 90 days, with 77% of these for prior pneumonia. Identified comorbidities included: COPD (51.5%), Type II Diabetes (31.7%), CHF (43.6%), active malignancy (23.8%) and immunosuppressed (35.6%) (Figure 1). The median Patient Severity Index score was 91 (26-277). Adherence to institutional guidelines was 59% and of those non-adherent, 81% were over treated (Figure 2). Frequency of appropriate antibiotic use included: 24.8% ampicillin/sulbactam, 52.1% doxycycline, 33.3% ceftriaxone, and 12.8% azithromycin. Most common inappropriate antibiotic use included cefepime 28.2% and vancomycin 23.9%. Conclusion At 59% adherence to our pneumonia guidelines, this data shows there is a need for education and increased accessibility to institutional guidelines. Our QI intervention will include educational sessions on AMS guidelines and our CAP order panel, how to access the guidelines (via AMS app or webpage) and placement of guideline links within antibiotic orders. This study will also serve as a basis for assessing empiric treatment of other common infections and adherence to institutional AMS guidelines. Disclosures All Authors: No reported disclosures

P-1727. Impact of Four-Day Automatic-Stop Orders on the Duration of Antibiotic Treatment

Abstract Background Implementation of automatic antibiotic stop orders is an antimicrobial stewardship intervention that encourages timely antibiotic order re-evaluation for potential discontinuation, spectrum de-escalation, transition to oral therapy, or spectrum escalation if warranted based on emerging diagnostic results. This pre-post study was designed to evaluate the impact of a four-day automatic-stop order on antibacterial orders for patients admitted at a single community hospital site. Methods A single-center, retrospective pre-post study was conducted to compare outcomes following the re-introduction of a four-day automatic-stop order on antibacterial orders. The primary outcomes were hospital length of stay and median duration of antibiotic therapy. Secondary outcomes included hospital readmission within 30 days and the occurrence of C. difficile infections within 30 days. Data was compared between 2 non-consecutive weeks in the pre-implementation of the automatic-stop order policy with data from 2 non-consecutive weeks in the post-implementation of the automatic-stop order policy to ensure prescriber variability and prescribing practices. Patients admitted for fewer than 4 days, or who had orders with indications for meningitis, bacteremia, prosthetic material infection, bone and joint infections, endocarditis, C. difficile treatment, prophylaxis, or documented uncontrolled source were excluded to align with exclusions in the policy. Results The study included 362 patients in total, 167 in the pre-implementation group and 195 in the post-implementation group. The median hospital length of stay was 8.2 days in the pre-implementation group and 7.1 days in the post-implementation group (p=0.536). The median total treatment duration of antibiotic therapy was 6.2 days in the pre-implementation group and 5 days in the post-implementation group (p=0.02). Incidence of c. difficile was 3% in the pre-implementation group, compared to 1% in the post-implementation group (p=0.256). Conclusion An antimicrobial automatic stop policy of four days was associated with decreased antimicrobial days of therapy per patient, without differences in hospital length of stay. There were no safety concerns identified with this intervention. Disclosures All Authors: No reported disclosures

P-1124. Implementation and Evaluation of a Pediatric Tele-Antimicrobial Stewardship Program in an Integrated Healthcare System

Abstract Background Intermountain Health (IH) has had a successful adult telehealth antimicrobial stewardship program (ASP) since 2016, and Primary Children’s Hospital has also had a longstanding ASP. With 298 pediatric beds throughout the other 23 hospitals within IH, there was an opportunity to expand to these patients that were not previously reviewed. The purpose of this study is to describe the implementation and outcomes of a pediatric tele-antimicrobial stewardship program (PT-ASP) in these hospitals throughout an integrated healthcare system.Figure 1:U chart of antimicrobial days of therapy per patient day Methods This is a quasi-experimental, pre- post- analysis of a prospective audit and feedback PT-ASP across 23 medical centers throughout Intermountain Health in Utah. The pre-intervention group included patients < 18 years of age who had antibiotics at any of these 23 hospitals between January 1, 2018, and December 31, 2019. The post-intervention group included patients < 18 years of age who had antibiotics ordered between January 1, 2021, and December 31, 2022. Post-intervention patients were reviewed by a pediatric ASP pharmacist for a descriptive analysis of the daily census and interventions made. The primary outcome was antibiotic days of therapy/patient day (DOT) pre- and post-intervention. The secondary outcomes were to describe the types of interventions and the acceptance rates.Figure 2:U chart of IV antimicrobial days of therapy per patient day Results During the first two years of the PT-ASP implementation, 14,999 hospital census days with active antibiotic orders were reviewed. Compared to the pre-intervention period, there was a 21% decrease in total antimicrobial DOT per patient day and a 24% decrease in IV antimicrobial DOT per patient day during the intervention period. The census had a majority of NICU patients (51%). A total of 1,970 interventions were made on 1,287 unique patients, with 13% of the charts reviewed leading to an intervention. The acceptance rate of these interventions was 62%. The two most common types of interventions made were to change the antibiotic regimen and to discontinue antibiotics.Table 1:Pediatric tele-antimicrobial stewardship program intervention acceptance rates by type of intervention Conclusion The PT-ASP made over 1,900 interventions leading to a decrease in both total antimicrobial DOT and IV antimicrobial DOT per patient day throughout 23 hospitals in an integrated health system. A PT-ASP is a strategy to steward pediatric beds outside of a stand-alone children’s hospital. Disclosures All Authors: No reported disclosures

P-1594. Predictive models to improve antibiotic decision-making in the Emergency Department for Extended-Spectrum β-Lactamase-producing Enterobacterales infections

Abstract Background Extended-Spectrum β-Lactamase-producing Enterobacterales (ESBL-E) infections are associated with high morbidity and mortality, often due to delayed initiation of carbapenem therapy. Carbapenems must be used judiciously to prevent emergence of resistant organisms. We developed a machine learning algorithm (MLA) to identify patients at increased risk for ESBL-E infections in the emergency department (ED).Figure 1:Receiver Operating Characteristic (ROC) curve for predicting Extended-Spectrum β-Lactamase-producing Enterobacterales (ESBL-E) Receiver Operating Characteristic (ROC) curve for predicting Extended-Spectrum β-Lactamase-producing Enterobacterales (ESBL-E) infections in Emergency Department Patients using a gradient boosting machine learning model. The area under the curve (AUC) is 0.8, indicating good discrimination between patients with and without ESBL-E. Higher True Positive Rate (TPR) at a low False Positive Rate (FPR) signifies better model performance. Methods Adults (≥18) who visited an ED in the Johns Hopkins Health System between 1/2019 and 4/2024 and received Gram-negative therapies appropriate for sepsis or had documented ESBL-E infections were included. Timestamped ED vital signs, healthcare utilization, healthcare worker (HCW)-mediated patient connections, medication history, comorbidities and laboratory results populated prior to first antibiotic order were used as predictors; our primary outcome was ESBL-E infection defined by positive culture. The probability of ESBL-E infection was estimated using a gradient boosting machine learning algorithm (MLA). Because of the time-dependent nature of increasing ESBL-E infections, the MLA was derived using data from encounters prior to 7/1/2023 and evaluated in the remaining encounters using area under the operating characteristics curve (AUC) analysis.Table 1:Patient Cohort Demographics Results In total there were 129,773 patient encounters included, of which 4289 (3.3%) had a positive ESBL-E sample collected during their ED encounter. Out-of-sample predictive accuracy was high (AUC 0.80; Figure). Prior HCW-mediated connections to ESBL-positive patients and prior exposure (≤6 months) to carbapenems, cephalosporins and proton pump inhibitors were the strongest predictors of ESBL-E infection. Abnormal vital signs, increased age, and prior exposure to any antibiotic (prior 6 months) were also important factors in prediction accuracy. Conclusion An MLA using data readily available from the EHR at the time of antibiotic ordering provided good discrimination between ED patients with and without ESBL-E infection. Further refinement and implementation of MLA-driven decision-support in the EDs could drive more targeted use of broad-spectrum antibiotics and improved patient outcomes. Disclosures Jeremiah S. Hinson, MD, PhD, Beckman Coulter: Advisor/Consultant|Beckman Coulter: Grant/Research Support|Beckman Coulter: Stocks/Bonds (Private Company)

P-1651. Utilizing Electronic Medical Record (EMR) Based Tools to Shorten Duration of Therapy for Community Acquired Pneumonia in the Ambulatory Setting

Abstract Background Community acquired pneumonia (CAP) is a commonly encountered diagnosis is the pediatric outpatient setting. Short durations of antimicrobial therapy of 5-7 days are considered adequate for uncomplicated CAP. We wanted to utilize Electronic medical record (EMR) based tools to standardize treatment durations for CAP. Akron children’s hospital is a large pediatric health care provider in Northeast Ohio and offers pediatric care through more than 30 pediatric offices in the community. This extensive network of primary care offices affords unique opportunities to use the EMR based tools for care standardization. Counts of antibiotic orders based on duration. Methods The antimicrobial stewardship committee developed a guideline for diagnosing and managing community acquired pneumonia and distributed it to all primary care providers. A standardized smart set provided clinical decision support regarding choice of antibiotics and duration of therapy. A visit diagnosis of Community acquired pneumonia prompted the use of the smart set. Smart set usage and duration of therapy (7 days or less vs 8 days or more) were monitored. Baseline data for one year prior and 3 years post-introduction were tracked to measure impact and monitor sustainability of change. Percentage of antibiotic orders based on duration. Results The smart set went live in January 2020. Data review from January 2019 to December 2023 showed the percentage of orders with antibiotic prescriptions of 8 days or more decreased from 97% to 34% while 7 days or less increased from 3% to 66% (Figures 1,2). This change is associated with a high utilization of the pneumonia smart set of > 70 percent (Figure 3). Even though the project is in its maintenance phase the gains have sustained over time. Smart set usage for antibiotic orders Conclusion Utilizing EMR based tools can help shorten antibiotic duration for community acquired pneumonia in a sustainable fashion. This approach holds promise as it can be easily utilized to standardize care for other common outpatient conditions. Expectedly the strategy would be most applicable to health care networks with a wide outreach. It also requires intensive education of providers at the outset, but this can be accomplished by using interested primary care providers to partner with antimicrobial stewardship teams. Disclosures All Authors: No reported disclosures

P-848. Proactive Pharmacy-led Transition of Care Protocol to Increase Appropriate Oral Antibiotic Use in Uncomplicated Gram-Negative Bacteremia

Abstract Background Limited data are available to describe a pharmacist-driven Gram-negative bacteremia (GNB) protocol on treatment optimization and outcomes. The primary outcome was a composite of the percentage of patients on a pharmacist-driven antibiotic protocol. Secondary outcomes evaluated 30-day all-cause mortality and infection-related readmission. Methods This was a single-center, quasi-experimental study conducted in a 451-bed community teaching hospital. The pre- and post-intervention cohorts included patients from 8/1/22-9/30/23 and 10/1/23-4/31/24, respectively. Patients aged >18 years with GNB were included. Patients who are immunocompromised, had a non-functional gastrointestinal tract, were enrolled in hospice, expired during hospitalization, pregnant, left against medical advice, had a polymicrobial infection, bacteria resistant to all PO agents, inadequate source control, or those with infectious disease consultations were excluded. For the intervention, a pharmacist-driven GNB protocol was developed to include the definition of uncomplicated GNB, clinical improvement criteria, ranked order of preferred PO antibiotics with appropriate dosing and duration of therapy. These recommendations were communicated to providers by pharmacists. The Chi-square test and student t-test were used for nominal and continuous data, respectively. A p-value of < 0.05 was considered statistically significant. Results There were 61 and 41 patients in the pre- and post-intervention cohorts, respectively. Demographics were similar. The primary outcome was achieved in 59% and 81% of patients, respectively (p=0.02). Urinary source was most common, including 75% in the pre and 85% in the post-intervention group (p=0.22). Trimethoprim-sulfamethoxazole use increased from 6% to 29% (p=0.002). No difference in 30-day all-cause (p=0.51) and infection related readmission (p=0.82) was identified. Conclusion Implementation of a proactive pharmacy-led GNB protocol increased the use of appropriate PO transition regimens in uncomplicated GNB. Disclosures All Authors: No reported disclosures

P-1674. Comparative study of advance practice providers and physician prescribing practices for complicated intra-abdominal infections in patients hospitalized at a safety-net community hospital

Abstract Background The expansion of advanced practice providers (APPs) in the inpatient setting warrants understanding of their antimicrobial prescribing practices in these settings to help adapt antimicrobial stewardship (ASP) strategies. Variability in APP training programs further complicates the landscape. This study aims to investigate disparities in antibiotic prescription practices for complicated intra-abdominal infections (cIAI) between APPs and physicians. Figure 1 clAl severity and empiric antimicrobial selection by physicians and APPs Methods A retrospective review of antibiotic orders was conducted at a 151-bed community hospital. ASP prospective audit and feedback (PAF) data from July 2022 to June 2023 was reviewed, including initial antibiotic selection, duration, and guideline concordance for APPs and physicians. Guideline adherence, antimicrobial effectiveness, and days of therapy (DOT) per 1000 patient days was compared between APPs and physicians. FIgure 2 Empiric antimicrobial selection by physicians and APPs Results A total of 175 initial empiric PAF entries for cIAI were reviewed, of which 145 were from physicians and 30 from APPs. Guideline non-adherence was 10% (14) for physicians and 20% (6) for APPs. Additionally, 3% (5) of physician and 7% (2) of APP prescriptions were ineffective. Critical illness was higher for physician cases (Figure 1). Physicians prescribed more antipseudomonal beta-lactam (APBLs) than APPs (52% vs 30%). APPs prescribed more quinolones (FQ) than physicians (33% vs 26%). Of the patients treated with FQs by APPs, 37% had allergies to beta-lactams, compared to 22% of patients treated by physicians. Total DOT/1000 during the study period was 145. DOT/1000 was 44 for physicians, of which 11% were anti-pseudomonal beta lactams (APBLs) and 34% non-APBLs. DOT/1000 was 21 for APPs, of which 19% were anti-pseudomonal beta lactams (APBLs) and 27% non-APBLs (Figure 2). Conclusion Empiric antimicrobial selection for cIAI differed between APPs and physicians, with APP showing higher quinolone use, a non-preferred agent, and almost double the level of non-adherence to guidelines. These findings underscore the need for tailored ASP education and interventions that address the unique practices and educational backgrounds of APPs, aiming to standardizing and optimizing antimicrobial use. APPs may require specific education for cIAI and ASP guidance. Disclosures All Authors: No reported disclosures

P-1642. The Devil's in the details: Developing metrics for discharge antibiotic stewardship

Abstract Background International Classification of Diseases, Tenth Revision codes (ICD-10s) are commonly used to identify antibiotic indications but may not reflect clinician intent. We investigated concordance of different antibiotic indication sources in the electronic health record (EHR) with clinician intent upon discharge.Figure 1:Indication choices for inpatient antibiotic orders Methods In this quality improvement project, we included prescriptions for patients discharged on oral antibacterials from January 2022-March 2023, including patients with > 1 admission. We excluded those with >90 days duration and those for dapsone or rifaximin. We randomly selected 100 prescriptions and performed manual chart review to obtain the discharge summary antibiotic indications which we categorized into syndromes (Table 1.) We compared discharge indication with other EHR indication sources: last inpatient antibiotic order indication (is required, Figure 1), ICD-10s from separate fields ( “principle”, “encounter”, “billing”) and “composite ICD-10” which included all ICD-10s from any field. We compared each indication source with the associated discharge indication (considered most accurate) and report concordance.Table 1:Syndrome Categories and associated ICD-10 codes Results We included 3,088 prescriptions and excluded 364. Of the 100 encounters reviewed, 62% patients were discharged from medicine services and 46% had a trainee involved in discharge. These encounters were associated with 184 unique ICD-10s and 132 (72%) representing non-infectious diagnoses; the most common infectious diagnosis was skin and soft tissue infections (12 (7%)) (Table 2.) Overall, 37% (30/100) of prescriptions had ICD-10s that were categorized only as non-infectious. Clinicians most commonly intended discharge antibiotics for genitourinary indications (32/108, 30%) (Table 2). Last inpatient antibiotic order indication matched clinician intent in 91% of cases, while composite ICD-10 matched clinician intent in 47% of cases. Any single ICD-10 field (principle, billing, encounter) matched clinician intent in only 1/3 of cases (Table 3.)Table 2:ICD-10 codes and Clinician Intent by Syndrome Data from 100 chart reviews. A total of 184 unique ICD-10 were collected from 100 prescriptions. 8 discharge summaries included two indications. Conclusion Compared to ICD-10s, last inpatient antibiotic order indication more accurately matched clinician intent for antibacterial discharge prescriptions. This may be a useful and simple way to facilitate discharge prescription stewardship.Table 3:Agreement of different indication sources from EHR with ICD-10 code “Composite ICD-10” includes all ICD-10s from “principle”, “encounter”, “billing” fields. And was considered to match clinical intent if any ICD-10 category was concordant with clinical intent. Disclosures All Authors: No reported disclosures

P-1713. Impact of an Evidence-Based Order Panel on Antimicrobial Prescribing in Ambulatory Patients with Complicated and Uncomplicated Cystitis

Abstract Background Optimizing antimicrobial prescribing for urinary tract infections (UTI) represents an area of opportunity for ambulatory antimicrobial stewardship programs. A pre-populated, ambulatory antibiotic order panel for UTI was implemented in the Mayo Clinic Enterprise on 5/16/2022. The order panel provides antimicrobial regimens which align with both institutional and national treatment guidelines based on patient comorbidities, complicating factors, and beta-lactam allergy status. We aimed to assess the impact of panel use on antibiotic prescribing for complicated and uncomplicated cystitis in the ambulatory setting. Methods This retrospective review included ambulatory encounters from the Mayo Clinic Enterprise in 2022 and 2023. Eligible encounters were randomly selected and included those with a primary ICD-10 code of cystitis performed by primary care or urgent care clinicians. Encounters were excluded if patients had symptoms indicative of pyelonephritis, underwent urinary instrumentation within 30 days, or had a urinary pathogen isolated within 90 days. The primary outcome was concordance with institutional guidelines. Secondary outcomes included repeat healthcare contact and therapy duration. Outcomes were analyzed with Pearson's chi-squared and Wilcoxon rank sum tests (α level = 0.05). Results 793 encounters (397 panel vs. 396 non-panel) were included. Prescribing was guideline concordant in 79.3% and 64.9% (p< 0.001) of panel and non-panel encounters, respectively. Inappropriate duration was the most common reason for non-concordance in the panel use cohort. There was no difference between groups for repeat healthcare contact incidence. Antimicrobials prescribed differed between panel and no-panel groups (Table 1), with higher use of sulfamethoxazole/trimethoprim and lower use of cefdinir in the panel cohort. Numerically shorter durations were seen in the panel group, with more 3- and 5-day regimens than the no-panel group. Conclusion Use of a pre-populated antimicrobial order panel for outpatient cystitis encounters resulted in greater adherence to institutional guideline recommendations, particularly in terms of antimicrobial selection, without adversely impacting repeat healthcare contact. Disclosures Paschalis Vergidis, MD, MSc, AbbVie: Advisor/Consultant|Ansun Biopharma: Grant/Research Support|Cidara Therapeutics: Grant/Research Support|F2G: Grant/Research Support|Scynexis: Advisor/Consultant|Scynexis: Grant/Research Support

Impact of order set implementation on appropriate treatment of community-acquired pneumonia (CAP).

This study aimed to evaluate appropriate antimicrobial prescribing after implementing a pneumonia order set within a community teaching hospital. Retrospective chart review study. 450-bed community teaching hospital. Patients who are 18 years of age or older admitted for treatment of community-acquired pneumonia (CAP) between October 1, 2021, and August 1, 2023. This retrospective cohort study aimed to evaluate a composite endpoint of appropriate empiric antimicrobial selection, dosing, and duration in accordance with the national guidelines after the implementation of a CAP order set. Secondary outcomes included comparing hospital length of stay (LOS), readmission rates, mortality rates, and Clostridium difficile infection rates. A total of 236 patients were included (118 patients per group). Significantly more patients in the post-implementation group received guideline-concordant therapy for CAP (5.9% vs 35.6%, P < .001). Results were heavily influenced by improvements in appropriate durations of therapy (pre: 6.8% vs post: 39.9%, P < .001). There were no significant differences observed for LOS, 30-day readmission rates, C. difficile infections within 30 days, or mortality rates between groups. The order set was utilized in 66.1% of patients included in the post-implementation group. Implementing an order set significantly improved inpatient antibiotic prescribing for CAP with no difference in clinical or safety outcomes. Antibiotic order sets will be a useful tool for antimicrobial stewardship program expansion into other common community-acquired infections.

Default Antibiotic Order Durations for Skin and Soft Tissue Infections in Outpatient Pediatrics: A Cluster Randomized Trial.

Antibiotic durations for uncomplicated skin/soft tissue infections (SSTI) often exceed the guideline-recommended 5-7 days. We assessed the effectiveness of a default duration order panel in the Electronic Health Record (EHR) to reduce long prescriptions. Cluster randomized trial of a SSTI order panel with default antibiotic durations (implemented 12/2021), compared to a control panel (no decision support) in 14 pediatric primary care clinics. We assessed long prescription rates from 23 months before to 12 months after order panel implementation (1/2020-12/2022). Antibiotic duration was considered long if >5 days for cellulitis or drained abscess, or >7 days for undrained abscess, impetigo, or other SSTI. We included 1123 and 511 encounters in intervention and control clinics, respectively. In a piecewise generalized linear model, long prescription rate decreased from 63.8% to 54.6% (absolute difference, -9.2%) in the intervention group and from 70.0% to 54.9% (absolute difference, -15.1%) in the control group. The relative change in trajectories from pre-panel to post-panel periods did not differ significantly between intervention and control groups (P = .488). Although used in only 29.4% of eligible encounters, intervention panel use had lower odds of long prescription compared to all other prescriptions (OR 0.18). We did not detect an overall impact of an order panel with default durations in reducing long antibiotic prescriptions for SSTIs. When ordered from the intervention panel, prescriptions were usually guideline-concordant. Effective strategies to make choosing a default duration more automatic are necessary to further reduce long prescriptions.

Enhancing antibiotic prescribing practices at the main military training hospital of Tunis: A study of pharmaceutical interventions

Bacterial infections have historically posed significant challenges until the discovery of antibiotics, which revolutionized infectious disease treatment. However, bacterial adaptation mechanisms over time have led to increased antimicrobial resistance, necessitating judicious antibiotic use. This study aims to comprehensively analyze pharmaceutical interventions related to antibiotic prescriptions governed by antibiotic order forms to identify and rectify medication errors, optimizing antibiotic prescribing practices. Approval for this research was obtained from the institutional review board of the Main Military Training Hospital of Tunis, Tunisia. A retrospective study was conducted at the main military training hospital of Tunis over 4 months. Pharmaceutical validation of antibiotic prescriptions through antibiotic order forms was conducted by a pharmacy resident. Pharmaceutical interventions were initiated upon detection of errors, and patient records were accessed through institutional software. Out of 1100 prescription forms analyzed, 41 pharmaceutical interventions were conducted for 7 antibiotics. Twenty-four percent of all interventions were related to antibiotic order forms, with the intensive care unit accounting for the highest number of errors. Under-dosage and prescription errors were common. Our pharmaceutical interventions related to antibiotic order forms are crucial for optimizing antibiotic therapy. Feedback mechanisms to healthcare teams are essential for enhancing prescription quality and patient care outcomes. Ongoing surveillance and improvement efforts are necessary to address medication errors and enhance antimicrobial stewardship.

Barriers and Facilitators to Optimal Antibiotic Prescribing on Discharge from the Hospital to Nursing Homes

Background: Up to half of antibiotics used in nursing homes (NHs) are initiated in acute care hospitals prior to nursing home admission. Optimizing antibiotic prescribing on hospital discharge presents an opportunity to improve NH antibiotic use. We aimed to identify barriers and facilitators to optimal antibiotic prescribing on discharge from the hospital to NHs. Methods: This was a qualitative thread of a convergent parallel mixed methods study to identify high-value targets to optimize antibiotic prescribing on discharge from the hospital to NHs. We conducted 32 qualitative interviews: 16 with prescribers (9), pharmacists (6), and a care manager (1) from 3 acute care hospitals and 16 with advanced practice providers (12) and registered nurses/nurse managers (4) from 7 NHs in Oregon and Wisconsin. Interview participants were asked to describe their typical practice for prescribing antibiotics on discharge to NHs or admitting patients with antibiotic prescriptions from hospitals, and about barriers and facilitators for optimal antibiotic prescribing during these transitions. Interviews were audio recorded, transcribed verbatim, and analyzed by 3 investigators using the qualitative descriptive analysis Results: Hospital healthcare workers described that there are different practice flows for oral and intravenous (IV) antibiotic prescribing. IV antibiotic orders are typically routed to the infectious diseases (ID) specialists and ID pharmacists to review and verify appropriateness. There were minimal established workflows to review and verify oral antibiotic orders. Pharmacists appeared integral to optimal antibiotic prescribin; however, the high frequency of oral prescriptions and short turnaround times from discharge orders to transportation limited pharmacists’ abilities to review these orders. With limited pharmacist involvement, the quality of oral antibiotic prescription relied on the prescribers’ knowledge, and there was no systematic oversight for inexperienced prescribers or specialists who may not be familiar with the adequacy of antibiotic use for NH residents. NH participants perceived that most antibiotics prescribed from hospitals were appropriate. Yet, some commented that they occasionally observe inadequate or unusual prescriptions from newer prescribers or specialists. NH participants most common concern related to antibiotic prescriptions was missing information including unclear or lack of antibiotic indications or stop dates. NH participants also stated that the frequent need to contact the hospital to obtain missing information is challenging and burdensome. Conclusions: Qualitative interviews identified several barriers and facilitators to optimal antibiotic prescribing on discharge to NHs. These results will be used to develop an intervention to improve antibiotic prescribing during these transitions.

Preferences for Management of Pediatric Pneumonia: A Clinician Survey of Artificially Generated Patient Cases.

It is unknown which factors are associated with chest radiograph (CXR) and antibiotic use for suspected community-acquired pneumonia (CAP) in children. We evaluated factors associated with CXR and antibiotic preferences among clinicians for children with suspected CAP using case scenarios generated through artificial intelligence (AI). We performed a survey of general pediatric, pediatric emergency medicine, and emergency medicine attending physicians employed by a private physician contractor. Respondents were given 5 unique, AI-generated case scenarios. We used generalized estimating equations to identify factors associated with CXR and antibiotic use. We evaluated the cluster-weighted correlation between clinician suspicion and clinical prediction model risk estimates for CAP using 2 predictive models. A total of 172 respondents provided responses to 839 scenarios. Factors associated with CXR acquisition (OR, [95% CI]) included presence of crackles (4.17 [2.19, 7.95]), prior pneumonia (2.38 [1.32, 4.20]), chest pain (1.90 [1.18, 3.05]) and fever (1.82 [1.32, 2.52]). The decision to use antibiotics before knowledge of CXR results included past hospitalization for pneumonia (4.24 [1.88, 9.57]), focal decreased breath sounds (3.86 [1.98, 7.52]), and crackles (3.45 [2.15, 5.53]). After revealing CXR results to clinicians, these results were the sole predictor associated with antibiotic decision-making. Suspicion for CAP correlated with one of 2 prediction models for CAP (Spearman's rho = 0.25). Factors associated with a greater suspicion of pneumonia included prior pneumonia, duration of illness, worsening course of illness, shortness of breath, vomiting, decreased oral intake or urinary output, respiratory distress, head nodding, focal decreased breath sounds, focal rhonchi, fever, and crackles, and lower pulse oximetry. Ordering preferences for CXRs demonstrated similarities and differences with evidence-based risk models for CAP. Clinicians relied heavily on CXR findings to guide antibiotic ordering. These findings can be used within decision support systems to promote evidence-based management practices for pediatric CAP.

Factors affecting early antibiotic delivery in open tibial shaft fractures

IntroductionThe incidence of infection in open tibial shaft injuries varies with the severity of the injury with rates ranging from roughly 2% for Gustilo-Anderson type I to nearly 43% for type IIIB fractures. As with all fractures, timely antibiotics administration in the emergency department (ED) is an essential component of fracture management and infection prevention. This study identifies factors associated with the expedient administration of antibiotics for open tibial shaft fractures. MethodsThis retrospective study identified patients treated for open tibial shaft fractures at an academic level 1 trauma center between 2015 and 2021. Open fractures were identified by reviewing patient charts. We used chart reviews to gather demographics, fracture characteristics, postoperative outcomes, trauma activation, and time to antibiotic order, delivery, and operating room. Univariate analysis was used to compare patients who received antibiotics within 1 h of ED presentation to those who did not. Multivariate analysis was performed to investigate factors associated with faster delivery of antibiotics. ResultsAmong 70 ED patients with open tibial shaft fractures, 39 (56%) received early administration of antibiotics. Arrival at the ED via emergency medical service (EMS) as opposed to walking in (98% vs. 74%, p = 0.01) and trauma activation (90% vs. 52%, p < 0.001) were significantly more common in the early administration group than the late group. The early group had shorter intervals between antibiotic order and delivery (0.02 h vs. 0.35 h, p = 0.007). Multivariate analysis suggested that trauma activation, EMS arrival, and arrival during non-overnight shifts were independent predictors of a shorter time to antibiotic administration (odds ratios 11.9, 30.7, and 5.4, p = 0.001, 0.016, and 0.013, respectively). DiscussionEarlier antibiotic delivery is associated with non-overnight arrival at the ED, arrival via EMS, and a coordinated trauma activation. Our findings indicate that in cases where administering antibiotics is critical to achieving positive outcomes, it is advisable to initiate a coordinated trauma response. Furthermore, hospital personnel should be attentive to the need for rapid administration of antibiotics to patients with open fractures who arrive via walk-in or during late-night hours.

Impact of mandatory indications for outpatient antibiotic orders on accurate tracking of antibiotic indications.

We sought to evaluate whether implementing mandatory indications for outpatient electronic antibiotic orders or using encounter International Classification of Diseases, Tenth Revision (ICD10) codes more accurately reflected clinicians' charted diagnosis in encounter notes. Secondarily, we examined the appropriateness of antibiotic prescriptions. Cross-sectional study. Mandatory indications were added to all outpatient electronic antibiotic orders on May 18, 2022. A randomly selected convenience sample of 1300 outpatient encounters with antibiotics from walk-in clinics was reviewed. Adjusted logistic regression was used to compare the congruence between encounter ICD10 code and charted diagnosis for encounters from July 15 to September 15, 2021 (pre-implementation period) to the congruence between encounter ICD10 code, charted diagnosis, and mandatory indication for encounters from July 15 to September 15, 2022 (post-implementation period). Antibiotic appropriateness based on charted diagnosis was also evaluated. Among 1300 outpatient encounters, congruence between charted diagnosis and ICD10 code significantly increased in the post-implementation period (87.7% (565/644)) versus pre-implementation (83.3% (540/648), adjusted odds ratio (aOR) 1.52; 95% CI 1.03-2.25). Congruence between charted diagnosis and mandatory indication during post-implementation was 95.2% (613/644) and >5 times more likely to be congruent than charted diagnosis and ICD10 code during pre-implementation (aOR 5.45; 95% CI 3.26-9.11). Antibiotic prescribing based on charted diagnosis was twice as likely to be appropriate in the post-implementation period (aOR1.99; 95% CI 1.32-2.98). Mandatory indications within antibiotic orders show better congruence with charted diagnosis than ICD10 codes and may increase antibiotic appropriateness and congruence between ICD10 code and charted diagnosis.

A Quality Improvement Project to Increase Compliance With a Facility Protocol on Surgical Antimicrobial Prophylaxis.

Surgical site infections (SSIs) contribute to negative outcomes for patients and health care organizations. Compliancewith clinical practice guidelines likely can help prevent SSIs. An interdisciplinary team at a regional referral center in Michigan sought to reduce SSIs by improving compliance with the facility's preoperative antibiotic selection, dosing, timing, and redosing protocol. The interventions for the quality improvement project included adding the preprocedural antibiotics and doses to the master OR schedule; holding an education session for all preoperative nurses, intraoperative nurses, and anesthesia professionals; and posting a reference guide in the preoperative and intraoperative areas. Compliance with the facility's protocol for antibiotic selection, dosing, and timing significantly improved. However, SSI rates and compliance with redosing recommendations did not change significantly. The team decided to add the antibiotic order information to the master OR schedule permanently. The team plans to consider providing education sessions on administering preprocedural antibiotics outside the OR.

A five-year quasi-experimental study to evaluate the impact of empiric antibiotic order sets on antibiotic use metrics among hospitalized adult patients.

Evaluation of adult antibiotic order sets (AOSs) on antibiotic stewardship metrics has been limited. The primary outcome was to evaluate the standardized antimicrobial administration ratio (SAAR). Secondary outcomes included antibiotic days of therapy (DOT) per 1,000 patient days (PD); selected antibiotic use; AOS utilization; Clostridioides difficile infection (CDI) cases; and clinicians' perceptions of the AOS via a survey following the final study phase. This 5-year, single-center, quasi-experimental study comprised 5 phases from 2017 to 2022 over 10-month periods between August 1 and May 31. The study was conducted in a 752-bed tertiary care, academic medical center. Our institution implemented AOSs in the electronic medical record (EMR) for common infections among hospitalized adults. For the primary outcome, a statistically significant decreases in SAAR were detected from phase 1 to phase 5 (1.0 vs 0.90; P < .001). A statistically significant decreases were detected in DOT per 1,000 PD (4,884 vs 3,939; P = .001), fluoroquinolone orders (407 vs 175; P < .001), carbapenem orders (147 vs 106; P = .024), and clindamycin orders (113 vs 73; P = .01). No statistically significant change in mean vancomycin orders was detected (991 vs 902; P = .221). A statistically significant decrease in CDI cases was also detected (7.8, vs 2.4; P = .002) but may have been attributable to changes in CDI case diagnosis. Clinicians indicated that the AOSs were easy to use overall and that they helped them select the appropriate antibiotics. Implementing AOS into the EMR was associated with a statistically significant reduction in SAAR, antibiotic DOT per 1,000 PD, selected antibiotic orders, and CDI cases.