Antibiotic Stewardship Activities Research Articles

148. Antibiotic duration for lower respiratory tract infections with and without procalcitonin monitoring: a propensity score matched cohort across an integrated healthcare network

Abstract Background Clinical trials have shown that procalcitonin (PCT) testing is efficacious in reducing antibiotic duration, but it is not known whether the test is also effective in routine clinical practice. The goal of this study was to evaluate whether PCT use in patients with lower respiratory tract infections (LRTI) was associated with shorter antibiotic duration. Methods We performed a retrospective cohort study across Veterans Affairs acute care hospitals that were ordering PCT with some degree of frequency between January 2018 and December 2021 and included patients with LRTI (acute exacerbations of COPD and pneumonia) that lacked complicating factors (Figure 1). The primary outcome was length of antibiotic therapy. We used 1:1 nearest neighbor propensity score matching to estimate the difference in the primary outcome between PCT-tested and non-tested patients. Patients were fixed matched on hospital site and admission date, and propensity scores were calculated using a logistic regression model that included demographics, ward location, infection type, comorbidities, severity of illness, and antibiotic class. Figure 1. Flow diagram of patient selection based on inclusion and exclusion criteria Results Eighty-one (65%) VA hospitals had on-site PCT testing; all 81 sites had a pharmacist devoting at least some time to antibiotic stewardship activities. Of the 35,610 admissions that met inclusion criteria, 6,015 (17%) had ≥ 1 PCT test at least 48 hours into their antibiotic course (Table 1); in these patients, the median number of PCT tests checked was 2 (interquartile range, 1-3). Using propensity scores, 3,903 patients in the PCT group were matched to 3,903 patients in the no PCT group: the length of therapy was higher in the PCT group compared to the no PCT group with median of 8 days (IQR 6-11) compared to 7 days (IQR 5-10) and mean difference of 0.4 days (p< 0.01, Table 2). Conclusion In this retrospective propensity-matched cohort of patients with LRTI across 81 hospitals, we failed to demonstrate shorter antibiotic duration for patients who underwent PCT testing compared to those who did not. While our findings suggest that PCT use may not be effective for reducing antibiotic duration for LRTI under real-life circumstances, it is unclear if the PCT test was optimally implemented at these sites and whether other stewardship activities may have minimized the test's overall impact. Disclosures Daniel J. Livorsi, MD, Merck: Grant/Research Support

Trends in Inpatient Antibiotic Use Among Adults Hospitalized During the Coronavirus Disease 2019 Pandemic in Argentina, Brazil, and Chile, 2018-2021.

High rates of antibiotic use (AU) among inpatients with coronavirus disease 2019 (COVID-19) despite low rates of bacterial coinfection and secondary infection have been reported. We evaluated the impact of the COVID-19 pandemic on AU in healthcare facilities (HCFs) in South America. We conducted an ecologic evaluation of AU in inpatient adult acute care wards in 2 HCFs each in Argentina, Brazil, and Chile. The AU rates for intravenous antibiotics were calculated as the defined daily dose per 1000 patient-days, using pharmacy dispensing records and hospitalization data from March 2018-February 2020 (prepandemic) and March 2020-February 2021 (pandemic). Differences in median AU were compared between the prepandemic and pandemic periods, using the Wilcoxon rank sum test to determine significance. Interrupted time series analysis was used to analyze changes in AU during the COVID-19 pandemic. Compared with the prepandemic period, the median difference in AU rates for all antibiotics combined increased in 4 of 6 HCFs (percentage change, 6.7%-35.1%; P < .05). In the interrupted time series models, 5 of 6 HCFs had significant increases in use of all antibiotics combined immediately at the onset of the pandemic (immediate effect estimate range, 15.4-268), but only 1 of these 5 HCFs experienced a sustained increase over time (change in slope, +8.13; P < .01). The effect of the pandemic onset varied by antibiotic group and HCF. Substantial increases in AU were observed at the beginning of the COVID-19 pandemic, suggesting the need to maintain or strengthen antibiotic stewardship activities as part of pandemic or emergency HCF responses.

Description of antibiotic stewardship expertise and activities among US public health departments, 2022

Background: In 2021, the CDC awarded &gt;$100 million to 62 state, local, and territorial health departments (SLTHDs) to expand antibiotic stewardship expertise and implement antibiotic stewardship activities in different healthcare settings. Our objective was to describe SLTHD antibiotic stewardship personnel and activities to characterize the impact of the funding. Methods: SLTHDs submitted performance measures, including quantitative and qualitative responses, describing personnel supporting antibiotic stewardship activities, types of activities, and healthcare facilities and professionals engaged from January through June 2022. A quantitative analysis of performance measures and qualitative thematic analysis of select narrative responses are reported. Results: Most SLTHDs (58 of 62, 94%) submitted performance measures. Among them, 37 (64%) reported identifying an antibiotic stewardship leader or coleader; most were pharmacists (57%) or physicians (38%) with infectious diseases training (68%) (Table 1). Of the remaining STLHDs, 20 reported barriers to identifying a leader or coleader, including hiring process delays and programmatic barriers (Table 2). SLTHDs reported 254 antibiotic stewardship activities; most reported activities involving multiple activity types (44%). Education and communication (eg, providing stewardship expertise) was the most common single activity (30%), followed by antibiotic use tracking and reporting (13%), assessment of antibiotic stewardship implementation (8%), and action and implementation (eg, audit and feedback letters) (4%). The highest number of activities were implemented in multiple healthcare settings (35%), followed by acute care (21%), outpatient (18%), long-term care (17%), and other (9%) (Fig. 1). SLTHDs reported engaging 4,970 healthcare facilities and 15,194 healthcare professionals in antibiotic stewardship activities across healthcare settings, to date, as part of this funding opportunity (Fig. 2). Conclusions: Antibiotic stewardship funding to SLTHDs allowed for increases in capacity and expanded outreach to implement a variety of antibiotic stewardship activities across multiple healthcare settings. Sustaining STLHD antibiotic stewardship activities can help increase engagement and coordination with healthcare facilities, healthcare professionals, and other partners to optimize antibiotic prescribing and patient safety.Disclosure: None

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

A qualitative evaluation of frontline clinician perspectives toward antibiotic stewardship programs.

To examine the perspectives of caregivers that are not part of the antibiotic stewardship program (ASP) leadership team (eg, physicians, nurses, and clinical pharmacists), but who interact with ASPs in their role as frontline healthcare workers. Qualitative semistructured interviews. The study was conducted in 2 large national healthcare systems including 7 hospitals in the Veterans' Health Administration and 4 hospitals in Intermountain Healthcare. We interviewed 157 participants. The current analysis includes 123 nonsteward clinicians: 47 physicians, 26 pharmacists, 29 nurses, and 21 hospital leaders. Interviewers utilized a semistructured interview guide based on the Consolidated Framework for Implementation Research (CFIR), which was tailored to the participant's role in the hospital as it related to ASPs. Qualitative analysis was conducted using a codebook based on the CFIR. We identified 4 primary perspectives regarding ASPs. (1) Non-ASP pharmacists considered antibiotic stewardship activities to be a high priority despite the added burden to work duties: (2) Nurses acknowledged limited understanding of ASP activities or involvement with these programs; (3) Physicians criticized ASPs for their restrictions on clinical autonomy and questioned the ability of antibiotic stewards to make recommendations without the full clinical picture; And (4) hospital leaders expressed support for ASPs and recognized the unique challenges faced by non-ASP clinical staff. Further understanding these differing perspectives of ASP implementation will inform possible ways to improve ASP implementation across clinical roles.

Clostridioides difficile dynamic electronic order panel, an effective automated intervention to reduce inappropriate inpatient ordering.

Ordering Clostridioides difficile diagnostics without appropriate clinical indications can result in inappropriate antibiotic prescribing and misdiagnosis of hospital onset C. difficile infection. Manual processes such as provider review of order appropriateness may detract from other infection control or antibiotic stewardship activities. We developed an evidence-based clinical algorithm that defined appropriateness criteria for testing for C. difficile infection. We then implemented an electronic medical record-based order-entry tool that utilized discrete branches within the clinical algorithm including history of prior C. difficile test results, laxative or stool-softener administration, and documentation of unformed bowel movements. Testing guidance was then dynamically displayed with supporting patient data. We compared the rate of completed C. difficile tests after implementation of this intervention at 5 hospitals to a historic baseline in which a best-practice advisory was used. Using mixed-effects Poisson regression, we found that the intervention was associated with a reduction in the incidence rate of both C. difficile ordering (incidence rate ratio [IRR], 0.74; 95% confidence interval [CI], 0.63-0.88; P = .001) and C. difficile-positive tests (IRR, 0.83; 95% CI, 0.76-0.91; P < .001). On segmented regression analysis, we identified a sustained reduction in orders over time among academic hospitals and a new reduction in orders over time among community hospitals. An evidence-based dynamic order panel, integrated within the electronic medical record, was associated with a reduction in both C. difficile ordering and positive tests in comparison to a best practice advisory, although the impact varied between academic and community facilities.

Circumstances for treatment and control of invasive Enterobacterales infections in eight hospitals across sub-Saharan Africa: a cross-sectional study.

Background: Bloodstream infections caused by Enterobacterales show high frequency of antimicrobial resistance (AMR) in many Low- and Middle-Income Countries. We aimed to describe the variation in circumstances for management of such resistant infections in a group of African public-sector hospitals participating in a major research study. Methods: We gathered data from eight hospitals across sub-Saharan Africa to describe hospital services, infection prevention and antibiotic stewardship activities, using two WHO-generated tools. We collected monthly cross-sectional data on availability of antibiotics in the hospital pharmacies for bloodstream infections caused by Enterobacterales. We compared the availability of these antibiotics to actual patient-level use of antibiotics in confirmed Enterobacterales bloodstream infections (BSI). Results: Hospital circumstances for institutional management of resistant BSI varied markedly. This included self-evaluated infection prevention level (WHO-IPCAF score: median 428, range 155 to 687.5) and antibiotic stewardship activities (WHO stewardship toolkit questions: median 14.5, range 2 to 23). These results did not correlate with national income levels. Across all sites, ceftriaxone and ciprofloxacin were the most consistently available antibiotic agents, followed by amoxicillin, co-amoxiclav, gentamicin and co-trimoxazole. There was substantial variation in the availability of some antibiotics, especially carbapenems, amikacin and piperacillin-tazobactam with degree of access linked to national income level. Investigators described out-of-pocket payments for access to additional antibiotics at 7/8 sites. The in-pharmacy availability of antibiotics correlated well with actual use of antibiotics for treating BSI patients. Conclusions: There was wide variation between these African hospitals for a range of important circumstances relating to treatment and control of severe bacterial infections, though these did not all correspond to national income level. For most antibiotics, patient-level use reflected in-hospital drug availability, suggesting external antibiotics supply was infrequent. Antimicrobial resistant bacterial infections could plausibly show different clinical impacts across sub-Saharan Africa due to this contextual variation.

Systematic review of time lag between antibiotic use and rise of resistant pathogens among hospitalized adults in Europe.

Antimicrobial resistance (AMR) causes substantial health and economic burden to individuals, healthcare systems and societies globally. Understanding the temporal relationship between antibiotic consumption and antibiotic resistance in hospitalized patients can better inform antibiotic stewardship activities and the time frame for their evaluation. This systematic review examined the temporal relationship between antibiotic use and development of antibiotic resistance for 42 pre-defined antibiotic and pathogen combinations in hospitalized adults in Europe. Searches in MEDLINE, Embase, Cochrane Library and NIHR Centre for Reviews and Dissemination were undertaken from 2000 to August 2021. Pathogens of interest were Escherichia coli, Klebsiella pneumoniae, Streptococcus pneumoniae, Staphylococcus aureus, Enterococcus faecium, CoNS, Pseudomonas aeruginosa and Acinetobacter baumannii complex. Twenty-eight ecological studies and one individual-level study were included. Ecological studies were predominantly retrospective in design (19 studies) and of reasonable (20 studies) to high (8 studies) methodological quality. Of the eight pathogens of interest, no relevant data were identified for S. pneumoniae and CoNS. Across all pathogens, the time-lag data from the 28 ecological studies showed a similar pattern, with the majority of studies reporting lags ranging from 0 to 6 months. Development of antibiotic resistance for the investigated antibiotic/pathogen combinations tends to occur over 0 to 6 months following exposure within European hospitals. This information could inform planning of antibiotic stewardship activities in hospital settings.

943. Cross-Sectional Survey of Antibiotic Stewardship Activities Across Kansas Healthcare Settings including Hospitals, Ambulatory Centers and Long-Term Care Facilities

Abstract Background Kansas ranks as the second-worst state nationally for inpatient antibiotic stewardship core element implementation. Based on the Center for Disease Control and Prevention's 2020 National Healthcare Safety Network (NHSN) Annual Survey, Kansas hospitals reporting at 17% below the national average. We sought to investigate and characterize the stewardship activities healthcare facilities including hospitals, ambulatory centers, long-term care settings, among others, are engaging in, regardless of whether a formal stewardship program exists or not. Methods A survey was drafted based on the NHSN Annual Facility Survey for hospitals and long-term care settings. The survey was distributed to antibiotic stewardship experts and revised based on input. Surveys were distributed electronically from December 2021 through April 2022 via direct communication through Kansas Department of Health and Environment contacts, and partner organization dissemination. Results A total of 95 programs responded to the survey. Facilities from 55 of 106 counties responded. 52 of the 95 responses were from critical access hospitals. The facility representation is shown in Fig 1. 33% facilities reported not having a formal ASP. Thirty-five percent of those with formal ASP have had it for 2 years or less. 53% of respondents found it challenging to establish an ASP. About 58% of respondents felt their facility leadership was committed to improving antibiotic use. Accountability amongst all respondents was poor with only 55% reporting a physician/surgeon/dentist leader responsible for ASP activities. The most common activities implemented were clinical decision pathways and audit, and feedback (19% each), followed by guidelines (15%), dosing or duration optimization strategies (13%), with the least implemented being peer comparison (8%), prophylactic guidelines (5.5%) and pre-authorization (5.5%) as seen in figure 2. Figure 1- Number of responses per facility typeFigure 2:Actions reported (all healthcare facilities) Conclusion There have been ongoing endeavors to start ASPs, but these appear to have been hampered by the COVID-19 pandemic, lack of adequate support from facility leadership and lack of leadership representation in antibiotic stewardship. Further efforts are needed in developing and supporting antibiotic stewardship activities across facilities in Kansas. Disclosures All Authors: No reported disclosures.

1658. Using remote Infectious Disease physician expertise to support inpatient antibiotic stewardship activities at three VA medical centers an implementation-effectiveness trial

Abstract Background Remote Infectious Disease (ID) physicians can provide stewardship support through telehealth. Using the RE-AIM framework, we assessed the implementation of telehealth-supported prospective-audit-and-feedback (tele-PAF) across 3 rural Veterans Administration medical centers (VAMC). Methods All 3 invited sites agreed to participate and lacked ID support for stewardship at baseline. During 2021, an ID physician met virtually 3 times/week with the stewardship pharmacist champion at each participating VAMC to review patients on antibiotics in acute-care (mean daily census 3/site) and nursing-homes (NHs; mean census 71/site); real-time feedback on antibiotic use was given to clinicians. The primary outcome of effectiveness was monthly antibiotic days of therapy (DOT) per 1,000 days-present aggregated across all sites; the secondary outcome was days of antibiotic spectrum coverage (DASC) per 1,000 days-present. An interrupted time-series analysis was performed to asses these outcomes during the 1-year intervention period vs. the 2-year prior baseline. Semi-structured interviews with 20 clinicians and pharmacists were conducted to assess implementation. Results RE-AIM elements are summarized in Table 1. Tele-PAF reviewed 502 unique patients and made 681 recommendations to 23 clinicians; 77% of recommendations were accepted. The most common recommendations were to stop antibiotics (28%) and change duration (20%). After the start of tele-PAF, antibiotic DOT and DASC immediately decreased in acute-care (-20%, p=0.01; -22%, p&amp;lt; 0.01) and NHs (-28%, p=0.03; -37%, p&amp;lt; 0.01). Both metrics began to rise again in acute-care (DOT: +2.5%/month, p=0.02; DASC: +2.7%/month, p=0.02) but were stable in NHs (Figure 1). Clinicians generally appreciated feedback, found it compatible with their workflow and responded favorably to collaborative discussions. Barriers included difficulty establishing rapport with some providers. Conclusion The implementation of tele-PAF was associated with sustained reductions in antibiotic use across 3 NHs but not in the studied small acute-care units. Overall, clinicians perceived the intervention as acceptable and appropriate. Wider implementation of telehealth-supported stewardship activities may achieve reductions in antibiotic use. Disclosures Daniel J. Livorsi, MD, Merck &amp; Co.: Grant/Research Support.

An Implementation Roadmap for Establishing Remote Infectious Disease Specialist Support for Consultation and Antibiotic Stewardship in Resource-Limited Settings.

Infectious Disease (ID)-trained specialists, defined as ID pharmacists and ID physicians, improve hospital care by providing consultations to patients with complicated infections and by leading programs that monitor and improve antibiotic prescribing. However, many hospitals and nursing homes lack access to ID specialists. Telehealth is an effective tool to deliver ID specialist expertise to resource-limited settings. Telehealth services are most useful when they are adapted to meet the needs and resources of the local setting. In this step-by-step guide, we describe how a tailored telehealth program can be implemented to provide remote ID specialist support for direct patient consultation and to support local antibiotic stewardship activities. We outline 3 major phases of putting a telehealth program into effect: pre-implementation, implementation, and sustainment. To increase the likelihood of success, we recommend actively involving local leadership and other stakeholders in all aspects of developing, implementing, measuring, and refining programmatic activities.

Impact of the COVID-19 Outbreak on the Antibiotic Use Patterns among a Rural Community Population in Eastern China.

There are growing concerns that the coronavirus disease of 2019 (COVID-19) pandemic may change antibiotic use patterns and accelerate antibiotic resistance, but evidence from the community level is lacking. This study aims to estimate the impact of the COVID-19 outbreak on the antibiotic use patterns among a community population in Eastern China. A self-administered medicine diary was used to collect information on antibiotic use from July 2019 to June 2021 among a rural community in Eastern China. We analyzed the changes in antibiotic use patterns over five months from August to December 2019 and the corresponding months in 2020. The risk of antibiotic use and its changes were measured with the incidence rate (IR) and relative risk (RR). In total, 1111 participants were eligible for the final analysis (440 in 2019 and 671 in 2020). After the COVID-19 outbreak, antibiotic use increased by 137% (5.43 per 100 person months in the 2019 vs. 12.89 per 100 person months in the 2020), and after the adjustment of covariates, the adjusted RR was 1.72 (95% CI: 1.10~2.34). It was higher among those who were women (RR = 2.62), aged 35−59 years old (RR = 2.72), non-farmers (RR = 2.75), had less than six years of education (RR = 2.61), had an annual household income over CNY 100,000 (USD 14,940) (RR = 2.60), and had no history of chronic diseases (RR = 2.61) (all p < 0.05). The proportion of cephalosporins consumed increased from 54.29% in 2019 to 64.92% in 2020 (p = 0.011). Among those aged 35 years and older, the proportion of antibiotics obtained from medical facilities increased, while the proportion obtained from retail pharmacies, homes, and other sources decreased (all p < 0.05). The COVID-19 outbreak changed antibiotic use patterns in this study population (Eastern China) significantly. More efforts to monitor and enhance antibiotic stewardship activities at the community level are needed in future.

Antibiotic point prevalence survey at a tertiary healthcare hospital in India: Identifying strategies to improve the antibiotic stewardship program immediately after a COVID-19 wave

BackgroundThe COVID-19 pandemic has substantially affected the antibiotic stewardship activities in most hospitals of India.AimsWe conducted an antibiotic point-prevalence survey (PPS) immediately after the decline of a major COVID-19 wave at a dedicated COVID-19 hospital. By doing so we aimed to identify the antibiotic prescription patterns, identify factors influencing the choice of antibiotics, and identify/develop strategies to improve the antibiotic stewardship program in such setups.MethodsThe PPS was single-centred, cross-sectional, and retrospective in nature. Patients admitted in various wards and intensive care units (ICUs) between September 2021 to October 2021 were included in our PPS.ResultsOf the included 460 patients, 192 were prescribed antibiotics. Of these 192 patients, ICU-admitted patients had the highest number of antibiotics prescribed i.e. 2.09 ± 0.92. Only a minor fraction (7.92 %) of antibiotics prescriptions were on the basis of culture reports. Most of the antibiotics were prescribed empirically by the parenteral route. The most common group of antibiotics prescribed were third-generation cephalosporins. Carbapenems were the most common designated antibiotics prescribed. A large number of patients (22.40 %) were prescribed double anaerobic cover.ConclusionThe strategies that we identified to improve the antibiotic stewardship program at our institute included reviving the culture of sending culture reports to prescribe antibiotics, improving surgical prophylaxis guidelines, training resident doctors to categorize antibiotic prescriptions appropriately, closely monitoring prescriptions providing double anaerobic cover, and improving the electronic medical record system for improving prescription auditing.

Trends in the hospital-sector consumption of the WHO AWaRe Reserve group antibiotics in EU/EEA countries and the United Kingdom, 2010 to 2018.

BackgroundIn 2019, the World Health Organization published the 21st Model list of Essential Medicines and updated the Access, Watch Reserve (AWaRe) antibiotics classification to improve metrics and indicators for antibiotic stewardship activities. Reserve antibiotics are regarded as last-resort treatment options.AimWe investigated hospital-sector consumption quantities and trends of Reserve group antibiotics in European Union/European Economic Area countries and the United Kingdom (EU/EEA/UK).MethodsHospital-sector antimicrobial consumption data for 2010–2018 were obtained from the European Centre for Disease Prevention and Control. Antibacterials’ consumption for systemic use (Anatomical Therapeutic Chemical classification (ATC) group J01) were included in the analysis and expressed as defined daily doses (DDD) per 1,000 inhabitants per day. We defined reserve antibiotics as per AWaRe classification and applied linear regression to analyse trends in consumption of reserve antibiotics throughout the study period.ResultsEU/EEA/UK average hospital-sector reserve-antibiotic consumption increased from 0.017 to 0.050 DDD per 1,000 inhabitants per day over the study period (p = 0.002). This significant increase concerned 15 countries. In 2018, four antibiotics (tigecycline, colistin, linezolid and daptomycin) constituted 91% of the consumption. Both absolute and relative (% of total hospital sector) consumption of reserve antibiotics varied considerably (up to 42-fold) between countries (from 0.004 to 0.155 DDD per 1,000 inhabitants per day and from 0.2% to 9.3%, respectively).ConclusionAn increasing trend in reserve antibiotic consumption was found in Europe. The substantial variation between countries may reflect the burden of infection with multidrug-resistant bacteria. Our results could guide national actions or optimisation of reserve antibiotic use.

Antibiotic stewardship to reduce inappropriate antibiotic prescribing in integrated academic health-system urgent care clinics.

To develop and implement antibiotic stewardship activities in urgent care targeting non-antibiotic-appropriate acute respiratory tract infections (ARIs) that also reduces overall antibiotic prescribing and maintains patientsatisfaction. Patients and clinicians at the urgent care clinics of an integrated academic health system. The stewardship activities started in fiscal 2020 and included measure development, comparative feedback, and clinician and patient education. We measured antibiotic prescribing in fiscal years 2019, 2020, and 2021 for the stewardship targets, potential diagnosis-shifting visits, and overall. We also collected patient satisfaction data for ARI visits. From FY19 to FY21, 576,609 patients made 1,358,816 visits to 17 urgent care clinics, including 105,781 visits for which stewardship measures were applied and 149,691 visits for which diagnosis shifting measures were applied. The antibiotic prescribing rate decreased for stewardship-measure visits from 34% in FY19 to 12% in FY21 (absolute change, -22%; 95% confidence interval [CI], -23% to -22%). The antibiotic prescribing rate decreased for diagnosis-shifting visits from 63% to 35% (-28%; 95% CI, -28% to -27%), and the antibiotic prescribing rate decreased overall from 30% to 10% (-20%; 95% CI, -20% to -20%). The patient satisfaction rate increased from 83% in FY19 to 89% in FY20 and FY21. There was no significant association between antibiotic prescribing rates of individual clinicians and ARI visit patient satisfaction. Although it was affected by the COVID-19 pandemic, an ambulatory antimicrobial stewardship program that focused on improving non-antibiotic-appropriate ARI prescribing was associated with decreased prescribing for (1) the stewardship target, (2) a diagnosis shifting measure, and (3) overall antibiotic prescribing. Patient satisfaction at ARI visits increased over time and was not associated with clinicians' antibiotic prescribing rates.

Current Status and Prospect of Qualitative Assessment of Antibiotics Prescriptions.

Identifying inappropriately prescribed antibiotics for infectious diseases by monitoring the quality of antibiotics use is essential for effective implementation of antibiotic stewardship. Qualitative assessment of the use of antibiotics has been conducted in some countries, including Korea, since the 2000s. The qualitative assessment generally involves an assessment of each component of the antibiotics prescription process, based on specific criteria. However, there is no standardized assessment method or cycle, and infectious diseases or antibiotics included in the assessments vary from country-to-country. According to the results reported in the United States, Europe, Australia, and Korea so far, approximately 20 - 55% of all antibiotics prescriptions are inappropriate. In this review, we describe the current progress in the quality assessment of the use of antibiotics on a global scale. Further, we highlight the future directions to improve antibiotic stewardship activities and the quality assessment of the use of antibiotics in Korea.

88. Review of nursing home antibiotic stewardship citation deficiencies to identify opportunities to improve antibiotic stewardship implementation, 2018-2019

Abstract Background Centers for Medicare &amp; Medicaid Services (CMS) set standards for nursing homes (NH) and conduct inspections to assess adherence to regulatory requirements, including antibiotic stewardship implementation. NHs not meeting requirements are issued a citation. We reviewed text summaries for citations related to antibiotic stewardship to assess implementation in NHs. Methods We obtained publicly available antibiotic stewardship deficiency citations issued to NHs from 9/2018—7/2019 and NH characteristics data from CMS Nursing Home Compare. We used the χ2 test to compare characteristics of NHs with and without citations. We did a qualitative review of a randomly selected subset (318/635) of antibiotic stewardship citations and classified citations into one or more of four categories based on Centers for Disease Control and Prevention’s Core Elements of Antibiotic Stewardship: 1) Leadership &amp; Accountability, 2) Action, 3) Tracking &amp; Reporting, 4) Education (Fig 1). We developed subcategories based on our iterative review process to further describe the citations. Each citation was reviewed by two reviewers and yielded 95% agreement in categorization. Discordant citations were reviewed by a third reviewer, and core element categories with agreement by ≥2/3 reviewers were assigned, resulting in 99% agreement. Antibiotic Stewardship Citation Deficiency Category Common Themes and Examples from Citation Text from Qualitative Review of Antibiotic Stewardship Citation Deficiencies. Results There were 635 NH stewardship citation deficiencies across 44 states from 9/2018—7/2019. NHs with a citation were more likely to have &amp;lt; 100 beds (60% vs. 50%) and for-profit ownership (75% vs. 70%) (Table 1). Of the 318 reviewed citations, Action was cited in 67% of NHs; 115/213 had missing or incomplete criteria documented for antibiotic initiation. Tracking &amp; Reporting was cited in 40% of NHs; 117/126 had missing or incomplete antibiotic or infection tracking logs. Leadership &amp; Accountability was cited in 23% of NHs; 41/72 NHs had no stewardship policy available. Education was cited in 13% of NHs (Fig 2). Table 1. Characteristics of US Nursing Homes With and Without an Antibiotic Stewardship Citation Deficiency from 9/2018-7/2019. Figure 2. Types of Antibiotic Stewardship Citation Deficiencies in US Nursing Homes, 2018-2019, N=318. Conclusion The most common opportunities for improvement fell under appropriate assessment and documentation of criteria for antibiotic initiation at the resident and facility-level. Training NH staff to use available resources for antibiotic stewardship activities may improve implementation. Further evaluation to identify barriers to implementation is needed. Disclosures David Gifford, MD, MPH, American Healthcare Association (Employee)

Aminoglycoside or Polymyxin Monotherapy for Treating Complicated Urinary Tract Infections Caused by Extensively Drug-Resistant Pseudomonas aeruginosa: A Propensity Score-Adjusted and Matched Cohort Study.

IntroductionExtensively drug-resistant (XDR) Pseudomonas aeruginosa (PA) infections are difficult to treat. We aimed to compare aminoglycosides or polymyxin monotherapy versus other antibiotic regimens (carbapenems, aztreonam, ceftazidime, cefepime, ceftolozane-tazobactam, or ceftazidime-avibactam) in complicated urinary tract infections (cUTI) caused by XDR-PA.MethodsStudy performed at a tertiary-care hospital from 2010 to 2019. All consecutive adult patients with XDR-PA urine cultures and diagnosed with cUTI were retrospectively reviewed. XDR phenotype was defined according to Magiorakos et al. A propensity score was used as a covariate in multivariate analyses and for matching. Primary outcome was early clinical failure and at end of treatment (EOT). Main secondary outcomes were 30- and 90-day mortality, microbiological clearance, and antibiotic-related side effects.ResultsOf the 465 episodes screened, 101 were included, 48% were treated with aminoglycoside or colistin monotherapy. Most XDR-PA were susceptible to colistin (100%) and amikacin (43%). Patients treated with antibiotic regimens other than aminoglycosides or polymyxin monotherapy were more likely to have hematologic malignancy (p < 0.001), higher SOFA score (p = 0.048), and bacteremia (p = 0.003). In multivariate models adjusted by propensity score, aminoglycoside or colistin monotherapy was not associated with worse outcomes. After propensity score matching, 28 episodes in each treatment group were matched. Adjusted ORs (95% CI) for early clinical failure and at EOT with aminoglycosides or polymyxin monotherapy were 0.53 (0.18–1.58) and 1.29 (0.34–4.83), respectively. Aminoglycoside or colistin monotherapy was not associated with higher 30-day (HR 0.93, 95% CI 0.17–5.08) or 90-day mortality (HR 0.68, 95% CI 0.20–2.31), nor with absence of microbiological clearance (OR 0.72, 95% CI 0.33–1.58). No statistically significant differences were found in terms of nephrotoxicity. Clostridioides difficile infection was observed only in the “other antibiotic regimens” group (n = 6, 11.3%).ConclusionsAminoglycosides or polymyxin monotherapy showed good efficacy and safety profile in treating cUTI caused by XDR-PA. These results may be useful for antibiotic stewardship activities.Electronic Supplementary MaterialThe online version of this article (10.1007/s40121-021-00570-z) contains supplementary material, which is available to authorized users.

Community pharmacists' views on their current role and future opportunities for antibiotic stewardship: a French qualitative study.

BackgroundDifferent healthcare professionals should contribute to antibiotic stewardship (ABS) activities. Involvement of community pharmacists (CPs) has been little explored worldwide to date.ObjectivesTo explore French CPs’ views on ABS and antibiotic resistance, their role and current practices, and future opportunities for ABS.MethodsA qualitative study using semi-structured face-to-face individual interviews was performed from May to October 2019 among CPs from north-eastern France. Transcripts of the interviews were analysed using a thematic analysis.ResultsTwenty-seven interviews were conducted. Most participants had a clear understanding of antibiotic resistance and ABS. They considered themselves as ‘guardians of the appropriate use of drugs’ but often failed to fulfil this mission because of difficult relationships with physicians. Their current ABS practices are: (i) counselling patients about the antibiotic treatment; and (ii) reporting to the prescriber when they identify contraindications/drug interactions. Concerning their potential increased involvement in ABS, CPs felt they could perform more rapid diagnostic testing for sore throat; they were divided on the possibility for them to change the antibiotic prescription made by a physician and were mainly against the possibility of initiating an antibiotic prescription. The idea of systematically collecting unused antibiotics was perceived well by CPs, while unit dose delivery was not.ConclusionsFrench community pharmacists are willing to become more involved in ABS activities. Collaboration and trust between pharmacists and prescribers should however be improved.

Antibiotic stewardship program in Pakistan: a multicenter qualitative study exploring medical\xa0doctors\u2019 knowledge, perception and practices

BackgroundThe emerging threat of antibiotic resistance is growing exponentially and antibiotic stewardship programs are cornerstone to fight against this global threat. The study aimed to explore the knowledge, perspectives and practices of physicians regarding various aspects of antibiotic stewardship program including antibiotic stewardship activities, rational use of antibiotics, antibiotic resistance, prescribing practices and factors associated with these practices.MethodsIn this qualitative study, a total of 17 semi-structured, in-depth interviews with doctors of three tertiary care public sector hospitals in Bahawalpur and Rahim Yar Khan were conducted. The convenient sampling method was adopted to collect the data and the saturation point criterion was applied to determine the sample size. Thematic analysis approach was used to draw conclusions from the data.ResultsThe analysis of data yielded five themes, 12 subthemes and 26 categories. The themes included, (i) perception about antibiotic use and antibiotic stewardship, (ii) antibiotic prescription practices, (iii) antibiotic resistance, (iv) limited strategies adopted by hospital administration to ensure quality and safe distribution of antibiotics, (v) implementation of antibiotic stewardship program: barriers, suggestion and future benefits. Doctors had misconceptions about the rational use of antibiotics. The perception regarding antibiotic stewardship programs was poor. Moreover, very few activities related to ASP existed. The participants gave many suggestions for successful implementation of ASP in order to reduce the burden of antibiotic resistance, including development of guidelines for the use of antibiotics, strict legislation regarding use of antibiotics, active participation of healthcare professionals and awareness program among general public about the use of antibiotics.ConclusionThis study concluded that poor knowledge of doctors regarding ASP, non-existence of antibiogram of hospital and lack of rules for the safe use of antibiotics were the main driving factors associated with irrational antibiotic prescription practices and development of AR.