Antibiotic Orders Research Articles

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.

Sepsis Prediction at Emergency Department Triage Using Natural Language Processing: Retrospective Cohort Study.

Despite its high lethality, sepsis can be difficult to detect on initial presentation to the emergency department (ED). Machine learning-based tools may provide avenues for earlier detection and lifesaving intervention. The study aimed to predict sepsis at the time of ED triage using natural language processing of nursing triage notes and available clinical data. We constructed a retrospective cohort of all 1,234,434 consecutive ED encounters in 2015-2021 from 4 separate clinically heterogeneous academically affiliated EDs. After exclusion criteria were applied, the final cohort included 1,059,386 adult ED encounters. The primary outcome criteria for sepsis were presumed severe infection and acute organ dysfunction. After vectorization and dimensional reduction of triage notes and clinical data available at triage, a decision tree-based ensemble (time-of-triage) model was trained to predict sepsis using the training subset (n=950,921). A separate (comprehensive) model was trained using these data and laboratory data, as it became available at 1-hour intervals, after triage. Model performances were evaluated using the test (n=108,465) subset. Sepsis occurred in 35,318 encounters (incidence 3.45%). For sepsis prediction at the time of patient triage, using the primary definition, the area under the receiver operating characteristic curve (AUC) and macro F1-score for sepsis were 0.94 and 0.61, respectively. Sensitivity, specificity, and false positive rate were 0.87, 0.85, and 0.15, respectively. The time-of-triage model accurately predicted sepsis in 76% (1635/2150) of sepsis cases where sepsis screening was not initiated at triage and 97.5% (1630/1671) of cases where sepsis screening was initiated at triage. Positive and negative predictive values were 0.18 and 0.99, respectively. For sepsis prediction using laboratory data available each hour after ED arrival, the AUC peaked to 0.97 at 12 hours. Similar results were obtained when stratifying by hospital and when Centers for Disease Control and Prevention hospital toolkit for adult sepsis surveillance criteria were used to define sepsis. Among septic cases, sepsis was predicted in 36.1% (1375/3814), 49.9% (1902/3814), and 68.3% (2604/3814) of encounters, respectively, at 3, 2, and 1 hours prior to the first intravenous antibiotic order or where antibiotics where not ordered within the first 12 hours. Sepsis can accurately be predicted at ED presentation using nursing triage notes and clinical information available at the time of triage. This indicates that machine learning can facilitate timely and reliable alerting for intervention. Free-text data can improve the performance of predictive modeling at the time of triage and throughout the ED course.

Effect of automated identification of antimicrobial stewardship opportunities for suspected urinary tract infections

Abstract Objective: We aimed to determine whether automated identification of antibiotic targeting suspected urinary tract infection (UTI) shortened the time to antimicrobial stewardship (AS) intervention. Design: Retrospective before-and-after study. Setting: Tertiary and quaternary care academic medical center. Patients: Emergency department (ED) or admitted adult patients meeting best practice alert (BPA) criteria during pre- and post-BPA periods. Methods: We developed a BPA to alert AS pharmacists of potential ASB triggered by the following criteria: ED or admitted status, antibiotic order with genitourinary indication, and a preceding urinalysis with ≤ 10 WBC/hpf. We evaluated the median time from antibiotic order to AS intervention and overall percent of UTI-related interventions among patients in pre-BPA (01/2020–12/2020) and post-BPA (04/15/2021–04/30/2022) periods. Results: 774 antibiotic orders met inclusion criteria: 355 in the pre- and 419 in the post-BPA group. 43 (35 UTI-related) pre-BPA and 117 (94 UTI-related) post-BPA interventions were documented. The median time to intervention was 28 hours (IQR 18–65) in the pre-BPA group compared to 16 hours (IQR 2–34) in the post-BPA group (P &lt; 0.01). Despite absent pyuria, there were six cases with gram-negative bacteremia presumably from a urinary source. Conclusions: Automated identification of antibiotics targeting UTI without pyuria on urinalysis reduced the time to stewardship intervention and increased the rate of UTI-specific interventions. Clinical decision support aided in the efficiency of AS review and syndrome-targeted impact, but cases still required AS clinical review.

Application of center for disease control and prevention standardized antimicrobial administration ratio to an Indian hospital.

Rigorous antibiotic stewardship is advised by international societies to combat rising antibiotic resistance. A major component of these programs is the metric used for antibiotic consumption measurement. A method for standardized antimicrobial administration ratio (SAAR) is suggested by the Centre for Disease Control & Prevention-National Healthcare Safety Network (NHSN). We applied the SAAR method to calculate antibiotic consumption in a tertiary care hospital in India. We also validated a limited sampling approach to calculate SAAR. The prospective study was conducted in three medical intensive care units over a period of 12 months. Monthly antibiotic consumption was measured by the hospital electronic records. Limited sampling was performed by weekly bedside review of the antibiotic orders. Formulae for SAAR calculation were derived from the NHSN guide. SAAR obtained by electronic records and limited sampling were compared to validate this approach. SAAR was calculated as >1 for an Indian hospital (1.49 by electronic records and 1.43 by limited sampling approach). The difference between the two ratios was not statistically significant (P = .47). SAAR in our setting is 1.49, which is slightly higher than the NHSN benchmark. Antibiotic usage (AU) risk adjustment based on data from the NHSN might not be adequate for calculating SAAR for Indian hospitals. There is a need to perform AU risk factor analysis for Indian settings for better defining SAAR in Indian context. The limited sampling approach can be adapted for calculation of SAAR in settings with limited resources.

1190. Nudging Away from Alert Fatigue: A Novel Method for Tracking the Impact of Integrated Clinical Decision Support on Meropenem Order Rates

Abstract Background The electronic health record (EHR) has streamlined quality of care and hospital prescribing; however, interruptive alerts and hard restrictions on antibiotic ordering can disrupt clinical workflow, often without significant benefit. This study aimed to determine the impact of permissive restriction on meropenem orders with embedded clinical decision support and prescriber attestation. Methods A quality improvement intervention implemented at Maine Medical Center (MMC, a 700-bed academic medical center) was evaluated through a multisite, quasiexperimental study within MaineHealth Hospitals. The intervention consisted of a provider-facing summary of guideline-directed indications for empiric and culture-directed uses of meropenem attached alongside the EHR order, and a required attestation button. To track meropenem order rates for adult patients prior to (Oct – Dec 2022) and after (Jan – Mar 2023) the intervention, the EHR was configured to fire a “silent” Best Practice Advisory behind-the-scenes when a provider opened the meropenem order. Rates of ordering were also monitored at other sites in MaineHealth, where the intervention was not implemented. The primary endpoint was the rate of “back-out” events, defined as a prescriber beginning a meropenem order but not signing it, and the secondary endpoint was the meropenem administration rate within 24 hours of opening an order. Results A meropenem order was initiated in 824 unique encounters during the study period; following the intervention at MMC, the back-out rate for orders increased from 20.3% (n =291) to 32.7% (n= 147, p = .01), while there was no significant difference during the same period at institutions where the intervention was not implemented (Table 1). The rate of patients who received meropenem within 24 hours following an order being opened decreased from 90.0% pre-intervention to 74.8% post-intervention (p &amp;lt; 0.01). Conclusion This study suggests that simple, non-resource intensive antimicrobial stewardship ‘nudges’ can simultaneously be implemented and monitored through creative EHR design, leading to a reduction in overall completion of meropenem orders and a decrease in inappropriate antibiotic prescribing. Similar interventions can be implemented in all fields of healthcare stewardship. Disclosures All Authors: No reported disclosures

1669. Impact of Required Durations of Therapy for Antibiotic Orders at the Time of Order Entry

Abstract Background At this large academic children’s hospital, providers were required to select a stop date at the time of antibiotic order entry beginning in May 2022. There currently is limited to no published data surrounding the implementation of this practice and its effect on antimicrobial stewardship. This study aims to determine if requiring stop dates on antibiotic orders impacted antibiotic utilization. Methods This was a retrospective, pre- post-interventional study of antibiotic usage at a large academic children’s hospital. The pre-invention period was June – November 2020 and 2021. The post-intervention period was June – November 2022. Normalized days of therapy were based on the National Healthcare Safety Network (NHSN) definition. The following indications were selected: empiric for suspected infection, respiratory tract infection (RTI), intraabdominal/gastrointestinal infection, and skin and soft tissue infection. The secondary objective was to subdivide days of therapy, by drug according to the NHSN classifications. Statistical analysis with the Mann-Whitney U test was completed. Results The pre-invention group consisted of 3004 patients and the post-intervention group consisted of 1803 patients. There were no major differences between groups, Table 1. The implementation of stop dates decreased total days of therapy per 1000 days present (DOT) from 251 to 235 (p&amp;lt; 0.001) for the entire sample population as well as DOT for empiric indications (153 DOT vs. 124 DOT, p&amp;lt; 0.001), Table 2. For RTI, there was an increase from 42 DOT to 49 DOT (p=0.011). Further analysis revealed an increase in patients with RTI indications and a decrease in duration of therapy from 6 days to 4 days. There was an overall decrease in use of hospital-onset antibiotics (81 DOT vs. 66 DOT, p&amp;lt; 0.001) as well as vancomycin (33 DOT vs. 28 DOT, p &amp;lt; 0.001), Table 3. Conclusion After implementation of stop dates, DOT was significantly lower overall and for empiric indication. Decreased usage in hospital onset antibiotics and vancomycin was also seen. The increase in DOT for RTI can be attributed to the increased prevalence in the post-intervention group. Requiring stop dates at the time of antibiotic order entry was associated with lower antibiotic utilization and is a useful tool for stewardship programs. Disclosures Sophie E. Katz, MD MPH, Dolly Parton Pediatric Infectious Diseases Research Funds: Grant/Research Support|Optum: Advisor/Consultant|Pfizer: Grant/Research Support Ritu Banerjee, MD, Ph.D, bioMerieux: Grant/Research Support|bioMerieux: company is providing partial support for an ongoing trial unrelated to submitted abstract

2952. Impacts of an evidence-based, pre-populated order panel on antimicrobial prescribing trends in ambulatory patients with community-acquired pneumonia

Abstract Background Optimizing antimicrobial regimens for outpatients with community-acquired pneumonia (CAP) represents an area of opportunity for ambulatory antimicrobial stewardship programs. A pre-populated, antibiotic order panel for outpatient respiratory syndromes was implemented in the Mayo Clinic Enterprise on 1/4/2021. For CAP, it provides national guideline adherent regimens (i.e., selection, dosing, and durations) by patient comorbidity and beta-lactam allergy status. We aimed to assess impacts of panel use on antibiotic prescribing in outpatients with CAP. Methods This retrospective review included Mayo Clinic outpatient encounters from Minnesota in 2021 and 2022. Eligible encounters used a CAP-related primary ICD-10 code, conveyed intention to treat CAP in encounter notes, and were performed by primary care, emergency department, or urgent care clinicians who managed ≥1 CAP patient with the panel and ≥1 without the panel during the study period. Encounters were excluded if patients were already receiving antibiotics at the time of encounter. The primary outcome was adherence (drug and duration) to guideline recommendations. Secondary outcomes included utilization rate by agent and therapy duration. Outcomes were analyzed with Kruskal-Wallis rank sum and Pearson’s chi-squared tests (α level = 0.05). Results 352 encounters (134 panel vs. 218 non-panel) were included. Prescribing was guideline adherent in 61.9% and 29.4% (p&amp;lt; 0.01) of panel and non-panel encounters, respectively. The most common reason for guideline non-adherence during panel use was inappropriate drug selection (n = 45/51, 88.2%). This was predominantly driven by use of the incorrect section of the treatment panel based on patient comorbidity status (n = 30/45, 66.7%). Individual antibiotic utilization rates differed between panel and non-panel cohorts (Table 1), with higher rates of amoxicillin and amoxicillin/clavulanate use and lower rates of azithromycin and doxycycline use in the panel cohort. Durations &amp;gt;5 days were more common in the non-panel as compared to the panel cohort (34.4% vs. 7.5%, p &amp;lt; 0.01). Conclusion Use of a pre-populated antimicrobial order panel in outpatients with CAP resulted in greater adherence to national guideline recommendations. Disclosures Paschalis Vergidis, MD, MSc, AbbVie: Advisor/Consultant|Ansun: Grant/Research Support|Cidara: Grant/Research Support|Scynexis: Grant/Research Support

Implementing services for pediatric cystic fibrosis treatment in a community hospital.

Our community hospital was recently charged with providing care for pediatric people with cystic fibrosis (PwCF). Pediatric PwCF generally need a higher level of care than is required by other pediatric patients cared for at our institution. This project aimed to prepare the pharmacy department to care for this specialized population safely and efficiently. The implementation process was divided into 3 phases to accomplish the larger purpose. These phases were as follows: (1) creating order sets and protocols; (2) providing staff and clinical pharmacists with training and resources; and (3) creating and managing clinical decision support. The central aspect of preparing inpatient pharmacy staff to care for PwCF was the development of antibiotic dosing protocols and order sets comprised of intravenous and oral antibiotics as well as aminoglycoside and vancomycin pharmacokinetic guides. A pharmacokinetic calculator was created to assist with aminoglycoside dosing and monitoring. During phase 2, pharmacist education modules were created to provide guidance on cystic fibrosis and medications commonly used to treat it. As the newly designed protocols were enacted, education was provided on how to use them. Phase 3 occurred concurrently, as clinical decision support was vital to completing phases 1 and 2. The phased approach was imperative to the project's success and kept individual components on track. All parts were completed in just over one year.

Impact of Board Certified Psychiatric Pharmacists on improving urinary tract infection antibiotic appropriateness at an acute psychiatric hospital.

Urinary tract infections (UTIs) are one of the most common indications for antibiotic use; patients with psychiatric disorders have a greater risk for UTI compared with patients without these disorders. However, there is little guidance on how best to manage antibiotic therapy in psychiatric hospitals. This study assessed the impact of a Board Certified Psychiatric Pharmacist (BCPP)-driven guideline on managing UTI treatment in an acute psychiatric hospital. The guideline was developed by the psychiatric pharmacy team and distributed to internists, psychiatrists, and pharmacists. Preintervention data were assessed for patients admitted between November 30, 2019, and February 23, 2020; postintervention data were assessed from February 25, 2020, to April 24, 2020. All patients ages 13 years and older who were admitted and had orders for an antibiotic to treat a UTI were included in this study. Appropriate UTI management was defined as an appropriate agent, dose, route, and frequency per the treatment guideline. Additionally, the following criteria were to be ordered and assessed to be deemed appropriate: urinalysis, urine culture, complete blood count, basic or complete metabolic panel, temperature, and subjective symptoms. Before intervention, 19.0% of antibiotic orders were appropriate; after intervention, 46.7% of antibiotic orders were appropriate (P = .048). The implementation of a BCPP-driven treatment algorithm was associated with a significant increase in appropriate antibiotic regimens for the treatment of UTIs in patients admitted to a psychiatric hospital.

Decreasing Antibiotic Use in a Community Neonatal Intensive Care Unit: A Quality Improvement Initiative.

In view of the excessive use of antibiotics in our neonatal intensive care unit (NICU), we launched a 5-year multidisciplinary quality improvement (QI) initiative in our NICU in 2018. We had set our aim of decreasing the antibiotic use rate (AUR) from 22 to 17%. The QI initiative was conducted in our 53-bed level 3B NICU. We used the core elements of antibiotic stewardship and focused on improving gaps in knowledge by using updated standards of care and a multidisciplinary approach. Outcome measures included overall AUR in NICU. Statistical control chart (P chart) was used to plot the AUR data quarterly. The AUR demonstrated a decline at the onset, and at the end of the initiative the AUR demonstrated a sustained decline to 13.18%, a 40% decrease from the baseline AUR of 22%. The changes that were implemented included development of evidence-based guidelines for babies less than and greater than 35 weeks, daily antibiotic stewardship rounds, sepsis risk calculator, antibiotic stop orders (48-hour stop, 36-hour soft stop, and 36-hour hard stop), and periodic reviews. Our multidisciplinary approach using all the core elements of an antibiotic stewardship program significantly decreased AUR in our NICU. · Excessive use of antibiotics may cause harm to the infant's health.. · Indiscriminate use of antibiotics can lead to antibiotic resistance.. · Stewardship programs can significantly decrease AUR in NICUs..

A Process Improvement Project to Increase Compliance With Cephalosporin-based Surgical Antimicrobial Prophylaxis in Children With Non-severe Penicillin Allergies

Background/purposeCephalosporins are considered safe and first-line prophylaxis in children with non-severe penicillin allergies. However, use of second-line agents is common and is primarily driven by poor allergic response documentation and misunderstanding of cross-reactivity risk. The goal of this project was to improve compliance with cephalosporin prophylaxis through improved documentation and targeted educational efforts. MethodsA multidisciplinary working group including representatives from allergy, surgery, infectious disease, and pharmacy developed staged interventions to facilitate compliance with cephalosporin prophylaxis. These included: (1) caregiver outreach to clarify incomplete allergy documentation, (2) a decision-support algorithm for prophylaxis use in penicillin-allergic patients, (3) standardized educational resources for surgical faculty and rotating trainees, (4) email reminders with prophylaxis recommendations sent out prior to scheduled cases, and (5) EMR-based decision support during antibiotic ordering. Rates of complete allergy documentation and cephalosporin utilization were compared for general surgery procedures between a 12-month pre-intervention and 14-month post-intervention period. Results578 patients with penicillin allergies recorded in the EMR were included (301 pre-intervention and 277 post-intervention), 54.0% of which received prophylaxis. Compared to the pre-intervention period, complete documentation of allergic reactions increased from 57.1% to 84.2% (p < 0.001) following implementation of all interventions. Appropriate prophylaxis utilization increased from 34.5% to 88.5% following implementation of all interventions (p < 0.001), and evidence of a stepwise increase in appropriate utilization was evident with each intervention stage. Persistent compliance failures during the post-implementation period were most commonly associated with urgent and emergent add-on cases. No adverse events or allergic responses were reported before or after project implementation. ConclusionsCompliance with cephalosporin prophylaxis significantly improved following a multidisciplinary effort targeting education, allergy documentation, and clinical support at the point of care. Ongoing efforts include postoperative audits within 24 h for noncompliant cases in order to identify barriers and improve compliance for urgent and emergent add-on cases. Level of EvidenceIII. Type of StudyProspective.

Electronic health record–based identification of inpatients receiving antibiotic treatment for community-acquired pneumonia

Background: Inappropriate antibiotic use for community-acquired pneumonia (CAP) is common. Although antibiotic stewardship activities require real-time, accurate identification of patients being treated for CAP, there are few reliable methods to identify such patients using the electronic health record (EHR). We conducted a retrospective study to assess the performance of provider-selected antibiotic indication in identifying patients being treated for CAP among a cohort of hospitalized adults. Methods: We randomly selected 440 patients from a cohort of patients who received at least 1 systemic antibiotic within 48 hours of admission between January 1, 2019, and December 31, 2021, at 3 acute-care hospitals. The reference standard for treatment of CAP was defined as intention to treat for pneumonia by inpatient provider(s) within 48 hours of admission, as assessed by chart review of provider notes. Treatment for pneumonia using any terminology except with “hospital-acquired pneumonia” (HAP) or “ventilator-associated pneumonia” (VAP) were counted. Provider-selected indication of CAP (in an antibiotic order) was compared against this reference standard; sensitivity, specificity, and positive and negative predictive values were calculated. Performance characteristics of International Classification of Disease, Tenth Revision (ICD-10) codes for pneumonia in identifying CAP patients were assessed against the same reference standard. A secondary analysis including terms HAP and VAP in the reference standard was performed. Results: Provider-selected antibiotic indication for CAP had a sensitivity of 64.4%, specificity of 96.3%, positive predictive value (PPV) of 73.1%, and negative predictive value (NPV) of 96.1%, giving comparable performance to ICD-10 codes (Table 1). Of those with 21 false-negative results, 13 (61.9%) had a healthcare-associated lower respiratory tract infection and 14 (66.7%) had sepsis indicated in at least 1 antibiotic order. Conclusions: Provider-selected antibiotic indication showed moderate sensitivity and high specificity for identifying CAP-treated cases. Importantly, use of this method can be deployed for real-time antibiotic stewardship interventions for CAP.Disclosures: None

Implementing a health-system–wide antibiotic stewardship program in ambulatory surgery centers

Background: In 2016, the CDC released the Core Elements of Outpatient Antibiotic Stewardship, which extended the requirements previously released for hospital facilities and nursing homes to the outpatient setting. Several regulatory agencies focused on outpatient antimicrobial use. However, The Joint Commission and the Ambulatory Surgery Center (ASC) Leapfrog Group excluded ambulatory surgery centers from their medication management standards and questions. Due to the public health and patient safety benefits of implementing an antimicrobial stewardship program (ASP) and increasing regulatory interest in the matter, the Hospital Corporation of America (HCA) Ambulatory Surgery Division formally launched a nationwide ASP for its ambulatory surgery centers in March 2021. Methods: HCA is a large healthcare system with 146 ASCs in 16 states in 2021. The structure of the ASCs are local surgery centers with a medical director, a nurse responsible for infection prevention, and a pharmacist at a regional level. The types of surgeries vary based on location and ASC site. In 2019, a multidisciplinary team formed the corporate planning committee. The program was modeled after the CDC Core Elements and The Joint Commission’s requirements for an ASP. Each ASC was asked to build a local ASP team, led by a local physician and a regionally based pharmacist. In addition, a stewardship goal was established to update all preoperative antibiotic surgical-site infection prophylaxis order sets. The corporate committee provided educational resources, including evidence-based guidelines for appropriate antibiotic selection for surgical-site infections. They collected antibiotic cost per case as a baseline metric to track and analyze. Pediatric, ophthalmic, and gastrointestinal endoscopic procedures were excluded from the program. Results: From January 1, 2020, through December 31, 2021, including only centers that were operational during this period and excluding single specialty endoscopy centers, antibiotic cost per case decreased annually from $2.38 to $1.84 (t = 4.157; P &lt; .005), and the postoperative infection rate also declined from 0.370 to 0.304 (t = 2.079; P = .040). Conclusions: Our findings suggest that implementing a health-system–wide outpatient antibiotic stewardship program in the ambulatory surgery center setting is feasible and may contribute to decreased antibiotic cost per case and improved postoperative surgical site infection rates.Disclosures: None

Reducing the rate of guideline-discordant therapy for inpatients with community-acquired pneumonia

Background: Despite guidelines recommending shorter durations of therapy and empiric coverage of Pseudomonas aeruginosa and methicillin-resistant Staphylococcus aureus (MRSA) only for patients with certain risk factors, optimizing therapy for community-acquired pneumonia (CAP) remains a challenge for antimicrobial stewardship (AMS) teams. We investigated the impact of a multimodal AMS initiative on the rate of guideline-discordant empiric antibiotic selection and total duration of therapy for CAP. Methods: A quality improvement initiative was implemented at 9 community hospitals in 2022 to optimize CAP therapy. Education was provided to pharmacists and providers. Alerts were implemented within the electronic medical record to prompt the AMS team to review fluoroquinolones, antipseudomonal β-lactams, and anti-MRSA agents ordered for CAP. Clinical pharmacists reviewed antibiotic orders for CAP at hospital discharge and encouraged providers to prescribe a total antibiotic duration of 5–7 days. For the preintervention period (July– September 2021) and the postintervention period (July to September 2022), a random sample of 320 patients with an antibiotic order for CAP were evaluated retrospectively via chart review. Patients treated for an indication other than CAP were excluded. The primary outcome was the proportion of patients with a total duration of therapy &gt;7 days. Secondary outcomes included average duration of therapy, rate of guideline-discordant empiric therapy, and type of guideline discordance. Results: In total, 317 patients were included. The proportion of patients with a total duration of therapy &gt;7 days decreased from 29% to 14% (P &lt; .01). Average duration of therapy and guideline-discordant empiric therapy also decreased significantly (Table 1). Conclusions: This multifaceted AMS initiative was associated with decreased guideline-discordant empiric therapy and decreased total duration of therapy for CAP.Disclosures: None