Antimicrobial Prescribing Data Research Articles

Antimicrobial prescribing in a secondary care setting during the COVID-19 pandemic.

Increased antimicrobial resistance patterns lead to limited options for antimicrobial agents, affecting patient health and increasing hospital costs. To investigate the antimicrobial prescribing patterns at two district hospitals in Northern Ireland before and during the COVID-19 pandemic. A mixed prospective-retrospective study was designed to compare pre- and during pandemic antimicrobial prescribing data in both hospitals using a Global Point Prevalence Survey. Of the 591 patients surveyed in both hospitals, 43.8% were treated with 402 antimicrobials. A total of 82.8% of antimicrobial prescriptions were for empirical treatment. No significant difference existed in numbers of patients treated or antimicrobials used before and during the pandemic. There was a slight decrease of 3.3% in the compliance rate with hospital antimicrobial guidelines during the pandemic when compared with the pre-pandemic year of 2019, when it was 69.5%. Treatment based on patients' biomarker data also slightly decreased from 83.5% pre-pandemic (2019) to 81.5% during the pandemic (2021). There was no overall significant impact of the pandemic on the antimicrobial prescribing patterns in either hospital when compared with the pre-pandemic findings. The antimicrobial stewardship programmes would appear to have played an important role in controlling antimicrobial consumption during the pandemic.

1755. Interactive Provider Dashboards for Comparison of Outpatient Antimicrobial Prescribing for Respiratory and Otic Conditions in Urgent and Quick Care Clinics

Abstract Background Due to antibiotic overutilization, development of antimicrobial stewardship (AMS) in the outpatient setting has become a necessary focus for AMS programs. The cornerstone of AMS is utilization of antimicrobial prescribing data to provide feedback to individual providers and compare providers to each other in order to promote improved prescribing practices. Respiratory infections, especially conditions that never require antimicrobials, are a common target for this feedback. We aimed to create interactive data visualization dashboards of end-users prescribing for these respiratory and otic conditions in order for AMS and urgent/quick care program staff to identify potential areas of intervention. Methods A multidisciplinary work group consisting of data analysts, infectious diseases physicians, urgent/quick care physicians, and infectious diseases pharmacists determined dashboard content, layout, and comparison charts. Graph types were tested to determine optimal visual output. Using the electronic medical record ICD10 and antimicrobial prescription data was extracted for the encounter with focus on ICD10 codes for respiratory and otic conditions which never require antimicrobials. Rates were calculated as number of antimicrobial prescriptions over total number of visits for these conditions. Results A multi-faceted dashboard was developed in Tableau® to view antimicrobial prescribing rates. Dashboard capabilities include the option to view individual provider prescribing rates compared to other de-identified providers, overall clinic prescribing rate, or individual rate compared to clinic rate. This allows for quick direct comparison of antimicrobial prescribing on the same graph by clinic to identify outliers (Figure 1) and allows visualization of trends in prescribing rates by clinics and providers over time (Figures 2,3). Never Antimicrobial Prescribing Rate Comparison Scatter plot comparing individual prescribers rate of prescribing for never antimicrobial events Clinic Antimicrobial Prescribing Rate Trend Clinic prescribing rate trend over time for never antimicrobial events Prescriber and Clinic Antimicrobial Prescribing Rate Trend Individual prescriber rate compared to clinic rate over time for never antimicrobial events Conclusion We developed an interactive outpatient AMS dashboard to visualize prescribing of antimicrobials for never respiratory and otic conditions. These dashboards can be used by providers along with AMS and clinic leadership to determine areas of intervention in the urgent/quick care setting. Disclosures Kelly M. Percival, PharmD, Gilead Sciences Inc: Advisor/Consultant Patrick M. Kinn, PharmD, MPH, Gilead Sciences: Advisor/Consultant Dilek Ince, MD, Evergreen: Member of data monitoring board|Gilead Sciences: Grant/Research Support|Leidos: Grant/Research Support|Moderna: Grant/Research Support.

Antimicrobial prescribing for children in China: data from point prevalence surveys in 18 tertiary centres in China in 2016–2017

ObjectivesThe reports on evaluating the classification of antibiotic agents prescribed for Chinese children by combining WHO’s and China’s administrative categories were rare. This study aimed to investigate the pattern of...

Patterns of antimicrobial prescribing, utilization, and cost of in patients attending a tertiary care hospital's general medicine ward

BACKGROUND: Antibiotic overuse is of great public health concern.Multiple studies performed globally have demonstrated a strong association between antibiotic use and antibiotic resistance (AMR), at both individual and community levels and they also shown that Antimicrobials are most commonly prescribed medications in acute care settings with 80% of its usedeemed inappropriate. OBJECTIVES: The primary aim of this study was to determine the possible impact of appropriate prescribing of antibiotics in General medicine ward of tertiary health centre on treatment outcomes and costs related to treatment. METHODOLOGY: This retrospective study looked at antimicrobial prescribing data in patients admitted to general medicine.Patients data was retrieved from Medical record section and the records of discharged patients were reviewed. The demographic data, disease related data and utilization of antibiotics were noted in specially designed proforma and analyzed. The documented data evaluated for use, safety outcomes and cost for the treatment associated with the use of antibiotics. RESULTS: Female patients 60.2 %(n=759)aremore hospitalized when compared to males, Average length of stay in hospital was 8 days. Majority of hospitalized patients had HTN & DM as primary comorbidities. The widely prescribed antibiotics among all classes as prophylaxis were third generationcephalosporins in parenteral form.

Patterns of antimicrobial prescribing, utilization, and cost of in patients attending a tertiary care hospital's general medicine ward

Background: Antibiotic overuse is of great public health concern.Multiple studies performed globally have demonstrated a strong association between antibiotic use and antibiotic resistance (AMR), at both individual and community levels and they also shown that Antimicrobials are most commonly prescribed medications in acute care settings with 80% of its usedeemed inappropriate. Objectives: The primary aim of this study was to determine the possible impact of appropriate prescribing of antibiotics in General medicine ward of tertiary health centre on treatment outcomes and costs related to treatment. Methodology: This retrospective study looked at antimicrobial prescribing data in patients admitted to general medicine.Patients data was retrieved from Medical record section and the records of discharged patients were reviewed. The demographic data, disease related data and utilization of antibiotics were noted in specially designed proforma and analyzed. The documented data evaluated for use, safety outcomes and cost for the treatment associated with the use of antibiotics. Results: Female patients 60.2 % (n=759)aremore hospitalized when compared to males, Average length of stay in hospital was 8 days. Majority of hospitalized patients had HTN & DM as primary comorbidities. The widely prescribed antibiotics among all classes as prophylaxis were third generationcephalosporins in parenteral form.

Patterns of multidrug resistant organism acquisition in an adult specialist burns service: a retrospective review

BackgroundMultidrug resistant organisms (MDROs) occur more commonly in burns patients than in other hospital patients and are an increasingly frequent cause of burn-related mortality. We examined the incidence, trends and risk factors for MDRO acquisition in a specialist burns service housed in an open general surgical ward, and general intensive care unit.MethodsWe performed a retrospective study of adult patients admitted with an acute burn injury to our specialist statewide tertiary burns service between July 2014 and October 2020. We linked patient demographics, injury, treatment, and outcome details from our prospective burns service registry to microbiology and antimicrobial prescribing data. The outcome of interest was first MDRO detection, stratified into the following groups of interest: methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococcus (VRE), two groups of Pseudomonas (carbapenem resistant, and piperacillin-tazobactam or cefepime resistant), carbapenem-resistant Acinetobacter species, Stenotrophomonas maltophilia, carbapenem-resistant Enterobacteriaceae (CRE), and extended-spectrum beta-lactamase producing Enterobacteriaceae (ESBL-PE). We used a Cox proportional hazards model to evaluate the association between antibiotic exposure and MDRO acquisition.ResultsThere were 2,036 acute admissions, of which 230 (11.3%) had at least one MDRO isolated from clinical specimens, most frequently wound swabs. While acquisition rates of individual MDRO groups varied over the study period, acquisition rate of any MDRO was reasonably stable over time. Carbapenem-resistant Pseudomonas was acquired at the highest rate over the study period (3.5/1000 patient days). The 12.8% (29/226) of MDROs isolated within 48 h were predominantly MRSA and Stenotrophomonas. Median (IQR) time from admission to MDRO detection was 10.9 (5.6–20.5) days, ranging from 9.8 (2.7–24.2) for MRSA to 23.6 (15.7–36.0) for carbapenem-resistant P. aeruginosa. Patients with MDROs were older, had more extensive burns, longer length of stay, and were more likely to have operative burn management. We were unable to detect a relationship between antibiotic exposure and emergence of MDROs.ConclusionsMDROs are a common and consistent presence in our burns unit. The pattern of acquisition suggests various causes, including introduction from the community and nosocomial spread. More regular surveillance of incidence and targeted interventions may decrease their prevalence, and limit the development of invasive infection.

1129. Outpatient Prescribing During the COVID-19 Pandemic

BackgroundThe Joint Commission requires ambulatory healthcare systems to collect, analyze and report antimicrobial prescribing data. Duke University Health System (DUHS) piloted a dashboard to capture outpatient prescribing for pediatric patients with URI. Implementation in 2020 allowed for an assessment of antibiotic prescribing during the pandemic.MethodsWe included patients 0 - < 19 years seen at DUHS for URI and pharyngitis from 1/1/2019 -2/21/2021. Patient characteristics included: age, sex, race, ethnicity, Pediatric Medical Complexity Algorithm (PMCA) score and insurance status (public versus private). Provider characteristics included: type (physician, NP, PA) and specialty (pediatrics, family medicine, internal medicine, other). We compared pre- and post-COVID ( March 1, 2020) prescribing and prescribing during telehealth versus in-person visits. A logistic regression model was used to identify factors independently associated with antibiotic prescribing.Results62,447 children were seen during the study period, 29% of whom received an antibiotic. Amoxicillin was the most commonly prescribed antibiotic (64.4%), followed by cefdinir (11%) amoxicillin-clavulanic acid (10%) and azithromycin (8%). Factors associated with antibiotic prescribing are shown in Table 1. White race, private insurance, visits with nurse practitioners and visits with non-pediatric providers were associated with high prescribing. Higher PMCA scores, indicating greater medical complexity, were associated with decreased likelihood of prescribing. Although the total number of outpatient visits plummeted during the COVID period, rates of prescribing only decreased mildly from 31% to 25% (Figure 1).Table 1. Factors Associated with Antibiotic Prescribing in Logistic Regression Model ConclusionOutpatient prescribing was associated with multiple patient and provider characteristics. Similar to other studies, white race, private insurance, and visits with non-physician, non-pediatric providers were associated with antibiotic prescription. Despite a large decrease in the number of outpatient visits during the pandemic, rates of prescribing for URI decreased minimally. A better understanding of factors associated with antibiotic prescribing during the pandemic may identify priority targets for outpatient stewardship as mitigation strategies are relaxed.Disclosures Michael J. Smith, MD, M.S.C.E, Merck (Grant/Research Support)Pfizer (Grant/Research Support)

Stewardship of Remdesivir Use in a Rural Community Hospital During the COVID-19 Pandemic

Background: Remdesivir was granted EUA followed by full FDA approval for treatment of hospitalized COVID-19 patients on October 22, 2020, based on the results from the ACTT1 trial. Remdesivir use was initially restricted to infectious disease (ID) physicians in our hospital with prescription needing formal ID consultation until complete approval. Due to increasing case counts in our hospital, a decision was made to allow intensivists and hospitalists the authorization to prescribe remdesivir in a phased manner. In this retrospective study, we assessed the impact of phased-in prescribing on remdesivir utilization and days of therapy of antimicrobials. Methods: Remdesivir prescribing was streamlined by real-time institutional guidelines developed by a COVID-19 treatment committee constituting ID and other clinicians. Eligibility for remdesivir included positive SARS-CoV-2 PCR test, severe disease defined as persistent hypoxia (&lt;94% oxygen saturation on room air), requiring supplemental oxygen and/or on mechanical ventilation (MV) for &lt;72 hours, and symptom onset of &lt;10 days. We retrospectively reviewed cohorts of 3 periods during which remdesivir was prescribed. In the first cohort A, between October 23, 2020, and November 12, 2020, remdesivir was restricted to ID physicians with formal ID consultation. Cohort B comprised inpatients between November 13, 2020, and December 6, 2020, when hospitalists and intensivists were allowed to prescribe remdesivir through an EMR order set after prior authorization by an ID physician via curbside or telephonic consultation. Cohort C, from December 7, 2020, to December 26, 2020, comprised inpatients with unrestricted prescribing of remdesivir by hospitalists and intensivists. We also evaluated antibiotic use. Results: In cohort A, SARS CoV-2 positivity was 20.3%; 64 inpatients tested positive and 35 patients (54.7%) who met the criteria were prescribed remdesivir after a formal consultation with an ID physician. In cohort B, requiring prior authorization by an ID physician, SARS-CoV-2 positivity rapidly increased to 34%; 193 patients tested positive and 97 patients (50.3%) received remdesivir. In cohort C, during unrestricted access, positivity further increased to 38%; 235 inpatients tested positive and 123 (52.5%) received remdesivir. Remdesivir use remained steady during the 3 phases of gradual de-escalation of restricted prescribing and safe handoff in the context of clear guidelines, as well as ongoing curbside education provided by ID physicians during the second phase. Cohort B demonstrated the best prescribing rates. Antimicrobial prescribing data were also collected during the 3 cohort phases (Figures 1–3). Conclusions: Remdesivir is an expensive antiviral with limited utility and maximum benefit in COVID-19 inpatients who are hypoxic but do not require mechanical ventilation. Stewardship of remdesivir with safe, gradual handoff to inpatient can be achieved without overuse.Funding: NoDisclosures: None

1352. Pediatric azithromycin prescriptions in a healthcare system from 2016-2018

BackgroundIn 2017, the Centers for Disease Control and Prevention (CDC) estimated that 30% of all antibiotics prescribed in outpatient clinics are unnecessary, with children receiving more antibiotics than any other age group. Among those antibiotics being prescribed, azithromycin is one of the most commonly prescribed antibiotics.MethodsWe reviewed antimicrobial prescribing data of children 0 to 19 years of age who visited West Virginia University (WVU) Health system which is the flagship institution for the state. We reviewed information of patients who were prescribed azithromycin by healthcare providers between January 2016 and December 2018. We included prescribing data from urgent care centers, outpatient clinics and emergency departments. The primary visit diagnosis associated with the visit was reviewed.ResultsDuring the study period there were 29,983 visits identified during which antibiotics were prescribed and azithromycin was prescribed in 40.6% of those visits. The majority of visits occurred between the months of October through February (54.4%), with December having the most visits. There were 11,934 unique patients identified and only 26.5% of these patients were marked as allergic to penicillin (PCN) or amoxicillin. The distribution of the age groups for azithromycin prescriptions is shown in figure 1. The age group of 11-19 years had the highest azithromycin prescription rate (38.7%) and the most common diagnosis for this group was pharyngitis. The distribution of the common diagnoses associated with azithromycin prescriptions can be seen in figure 2 and acute otitis media (AOM) was the most common diagnosis (23.6%).Figure 1- Age distribution of children who received azithromycin prescriptions during the study period Figure 2- Distribution of diagnoses associated with azithromycin prescriptions ConclusionAcute otitis media and pharyngitis accounted for almost half of the diagnoses associated with azithromycin prescriptions. Treatment guidelines for both conditions recommend PCN-based therapy as first-line treatment unless there is a history of PCN allergy. Only a quarter of the patients had allergy documented to PCN or amoxicillin and, therefore, azithromycin would be considered a suboptimal antimicrobial choice. These results provide us with a stewardship opportunity to nudge providers to select appropriate antimicrobial based on diagnosis and history of allergy.Disclosures All Authors: No reported disclosures

What antimicrobial stewardship strategies do NHS commissioning organizations implement in primary care in England?

To identify and explore strategies that English NHS commissioning organizations implemented to improve antimicrobial stewardship (AMS) within primary care. Questionnaire sent to the medicines management teams (MMTs) of all 209 clinical commissioning groups (CCGs) in England, in 2017. A total of 89% (187/209) of all English CCGs responded to the questionnaire; 74% of responding CCGs (123/167) had a prescribing incentive/engagement scheme, with MMTs representing 88% (90/102) considering incentive schemes successful or very successful for prioritizing AMS in primary care, especially when linked to prescribing NHS Quality Premium indicators. AMS audits were considered successful or very successful by 91% (126/138) of responding CCGs, as they identify reasons for inappropriate prescribing and opportunities for future improvement. All responding MMTs (169/169 CCGs) reported feeding back local/national antimicrobial prescribing data to the general practices they commission, 85% (142/168) to their CCG/Commissioning Support Unit (CSU) board and only 33% (56/169) to out-of-hours services. Benchmarking prescribing data was reported as a powerful tool to engage practices, facilitating an element of competition and peer pressure. National antimicrobial resistance improvement schemes, in particular the NHS England Quality Premium, have influenced CCG improvement priorities. Most CCGs now report successful improvement strategies including the use of both local and national antibiotic prescribing data to motivate improvements; these should be continued and extended to out-of-hours providers. As local audit data have helped to identify reasons for inappropriate prescribing and inform improvement planning, all organizations should adopt this strategy and include it in local quality improvement schemes, ensuring performance reporting to organizational board level.

Utilising data held within ePACT2 to monitor and influence antimicrobial prescribing within secondary care outpatient clinics

Background Assurance and intervention is needed around antimicrobial prescribing in secondary care outpatient settings, which has increased by 21% in 5-years. Use of NHS FP10 prescriptions impedes timely monitoring of prescribing. This project aimed to develop an efficient method for monitoring and reporting outpatient prescribing on FP10 forms. Methods A Microsoft Excel spreadsheet was developed to allow direct importing of antimicrobial prescribing data from ePACT2, which then automatically updates charts of prescribing activity using VLookup formulae and pivot charts. Reports were developed in Microsoft Word that directly pull updated charts from the spreadsheet described. Results The method allows rapid calculation and collation of DDDs and creates charts for assessing monthly antimicrobial prescribing trends. The reports highlight areas for review and action, which have driven engagement in antimicrobial stewardship across the organisation. Unexpectedly, these reports heightened nurses’ awareness of antimicrobial stewardship (AMS), who now seek reassurance on, and challenge, antimicrobial prescribing at the time of prescribing. The process takes less than 20-minutes on average (versus 3-hours previously), freeing up antimicrobial pharmacists’ time to interrogate prescribing trends and undertake clinical duties. This method also allows potentially inappropriate prescriptions to be identified and pulled from NHS BSA sooner, so that individual prescribers and teams can be targeted for intervention and reflection. Conclusion This method allows efficient reporting of antimicrobial prescribing, enables stewardship teams to focus interventions on prescribers and teams, and drives engagement in antimicrobial stewardship. This method could be adapted by other organisations to monitor and interrogate antimicrobial prescribing.

1958. Assessment of Guideline-Concordant Antimicrobial Prescribing in Urgent Care Centers

BackgroundIn the United States in 2014, 266 million outpatient antibiotic prescriptions were dispensed. The Center for Disease Control and Prevention estimates that 30% of outpatient antibiotic prescriptions are inappropriate. These inappropriate prescriptions contribute to increased resistance, adverse events, and healthcare costs.MethodsThis was a retrospective study of patients presenting to 22 urgent care centers within a large healthcare system between September 1, 2018 and February 28, 2019. Data were collected from a dashboard designed to track antimicrobial prescribing data by indication, location, and provider. ICD-9 and -10 codes associated with otitis media, pharyngitis, sinusitis, cystitis, and upper respiratory infections (URI) were included. Guideline-concordant antimicrobial prescribing was determined based on compliance with national guideline recommendations, after taking patient allergies into account. The URI category includes disease states in which antimicrobials are rarely appropriate (e.g., acute rhinitis, nasopharyngitis, and acute bronchitis).ResultsA total of 57,799 encounters were included in this analysis (19,242 pediatric and 38,557 adult) and 60% of patients received an antibiotic prescription. Overall antimicrobial guideline concordance was higher in pediatrics (84%) than adults (62%). Rates of guideline-concordant antimicrobial selection are shown in Table 1. The most common guideline-discordant prescriptions were tetracyclines (39%), amoxicillin/clavulanate (26%), and macrolides (17%) in adult patients with sinusitis, pharyngitis, or otitis media. In pediatric patients, the most common discordant prescriptions were macrolides (32%), third-generation cephalosporins (30%), and amoxicillin/clavulanate (19%). Unnecessary antimicrobial prescribing for URI occurred in 23% of pediatric patients and 36% of adult patients.ConclusionGuideline-discordant antimicrobial prescribing is common in urgent care centers, particularly in adult patients. In addition to encouraging utilization of order sets, emphasis on education and feedback may be important to improve and sustain guideline-concordant prescribing rates and reduce prescribing for URI. Disclosures All Authors: No reported Disclosures.

Antimicrobial stewardship: an evaluation of structure and process and their association with antimicrobial prescribing in NHS hospitals in England.

Rigorous antimicrobial stewardship programmes (ASPs) are an essential strategy against antimicrobial resistance. To evaluate and score ASPs in acute English NHS hospitals and determine association of ASP scores with antimicrobial prescribing. ASP structure and process were evaluated through an online survey in 148/152 acute hospitals in 2017. Scores were assigned to quality indicators based on resource- and labour-intensiveness, and their association with total and modified WHO-categorized 'Access', 'Watch' and 'Reserve' (AwaRe) prescribing was analysed. The survey response rate was 97% with 78% of trusts submitting antimicrobial prescribing data. Over 80% of ASPs contained stewardship teams, policies and access to outpatient parenteral antimicrobial therapy, whilst less than 50% scored well for leadership or funding. High process performance was observed for antimicrobial pre-authorization, prescribing review and feedback, restricted susceptibility reporting, antimicrobial consumption monitoring, adherence to guidelines and junior doctor training. Low process attainment included education of senior prescribers and lack of resistance surveillance data distribution. Between 2016 and 2017, there was no difference in total trust prescribing (P = 0.117) although carbapenem prescribing fell (incidence rate ratio = 0.93, 95% CI 0.88-0.98) in non-teaching hospitals; 'Watch' prescribing also increased for specialist hospitals (OR = 1.10, 95% CI 1.01-1.20), as did 'Reserve' category prescribing in teaching (OR = 1.58, 95% CI 1.23-3.02) and specialist hospitals (OR = 3.09, 95% CI 2.02-4.74). A high process score was associated with lower 'Reserve' prescribing (OR = 0.82, 95% CI 0.67-1.01). All responding trusts had established ASPs. The association of a scoring system with total and 'AWaRe' prescribing to assess effectiveness of ASPs merits further study.

Skin and soft tissue infections and current antimicrobial prescribing practices in Australian aged care residents.

To determine the burden of skin and soft tissue infections (SSTI), the nature of antimicrobial prescribing and factors contributing to inappropriate prescribing for SSTIs in Australian aged care facilities, SSTI and antimicrobial prescribing data were collected via a standardised national survey. The proportion of residents prescribed ⩾1 antimicrobial for presumed SSTI and the proportion whose infections met McGeer et al. surveillance definitions were determined. Antimicrobial choice was compared to national prescribing guidelines and prescription duration analysed using a negative binomial mixed-effects regression model. Of 12 319 surveyed residents, 452 (3.7%) were prescribed an antimicrobial for a SSTI and 29% of these residents had confirmed infection. Topical clotrimazole was most frequently prescribed, often for unspecified indications. Where an indication was documented, antimicrobial choice was generally aligned with recommendations. Duration of prescribing (in days) was associated with use of an agent for prophylaxis (rate ratio (RR) 1.63, 95% confidence interval (CI) 1.08-2.52), PRN orders (RR 2.10, 95% CI 1.42-3.11) and prescription of a topical agent (RR 1.47, 95% CI 1.08-2.02), while documentation of a review or stop date was associated with reduced duration of prescribing (RR 0.33, 95% CI 0.25-0.43). Antimicrobial prescribing for SSTI is frequent in aged care facilities in Australia. Methods to enhance appropriate prescribing, including clinician documentation, are required.

206. Respiratory Viral Testing Is Associated with Lower Frequency of Antibiotic Prescribing for Acute Upper Respiratory Infections at a Large Ambulatory Cancer Center

BackgroundInappropriate outpatient antibiotic prescribing for acute upper respiratory infections (URIs) is a high priority target for antimicrobial stewardship and has not been described for cancer patients. The goal of this study was to characterize patterns of and factors associated with antibiotic prescribing among ambulatory oncology patients with URIs.MethodsWe selected outpatients >18 years old seen at an ambulatory cancer center with ICD-10 diagnosis code consistent with URI from October 1, 2015 to September 30, 2016 for chart review. Patients without documented active URI symptoms or with lower tract infection at the first clinical encounter for the URI (day 0) were excluded. We obtained demographic, clinical, antimicrobial prescribing and viral testing data for days 0–14. We used generalized estimating equations to test for associations of baseline factors with a ≥1 antibiotic prescription for URI while accounting for correlation among patients seen by the same provider.ResultsOf the 341 charts reviewed, 251 (74%) patients, seen by 99 providers were eligible for analysis. A total of 162/251 (65%) had an underlying hematologic malignancy or disorder; of those, 51% had a prior hematopoietic cell transplant. Eighty-four (33%) received ≥1 antibiotic prescription for URI with 63% ordered on day 0. Azithromycin (47%) and fluoroquinolones (25%) were most often prescribed. One hundred thirteen (45%) patients had respiratory viral testing performed; 85 (75%) tested positive (Figure 1). Both antibiotic prescribing (P = 0.005) and viral testing (P < 0.001) varied by clinical service (Figure 2). Viral testing on day 0 was associated with lower risk of antibiotic prescribing while sputum production or chest congestion was associated with higher risk of antibiotic prescribing (Figure 3).ConclusionAntibiotics were prescribed in one in three oncology outpatients with URI, although viral etiologies were identified in most who were tested. Respiratory viral testing was associated with reduced antibiotic prescribing though collinearity between clinical service and viral testing limited our ability to separate these effects on antibiotic prescribing. It is important to further explore the role of viral testing in antibiotic prescribing for URI in outpatient oncology settings. Disclosures All authors: No reported disclosures.

Local implementation of AMS initiatives: a mixed-methods study

BackgroundThe NHS English Quality Premium recommends that inappropriate antibiotic prescribing is reduced; there are a range of national antimicrobial stewardship (AMS) initiatives to support this.AimThe aim of this study is to assess AMS activities in primary care across England. The findings will be used to inform how the RCGP, PHE and NHS can help optimise stewardship activities.MethodQualitative interviews: with AMS leads within Clinical Commissioning Groups’ (CCGs) and Commissioning Support Units’ (CSUs) medicines management teams. Questionnaire: informed by the qualitative data, sent to all 209 CCGs in England in 2017.ResultsIn total, 89% (187/209) of CCGs returned a questionnaire; 82% of AMS leads reported spending only 0.1 whole-time equivalent on AMS activities, as it was only one role within a wider remit, so dedicating time is challenging. 99% (167/169) of CCGs had delivered AMS education in the last 2 years: 140 face-to-face; 121 via e-learning. 99% (184/186) actively promoted the TARGET Antibiotics Toolkit; 94% (175/187) actively promoted TARGET patient leaflets: 92% The Treating Your Infection (TYI) leaflet. 90% (166/185) used the PHE managing common infections guidance: 81% (149/185) modify or localise; 41/185 (22%) signpost directly to it. Eighty-six CCGs reported using CCG audit tools and 82 CCGs reported using TARGET’s audit tools. 85% (142/168) fed back antimicrobial prescribing data to the CCG/CSU board; 100% (169/169) to general practices and 33% (56/169) to out-of-hours providers.ConclusionAlthough CCGs reported promoting these AMS activities, there was little evaluation of uptake by primary care practitioners. Future work should focus on measuring AMS uptake; having staff dedicated solely to AMS could facilitate this.

Antimicrobial prescribing in post-graduate training practices: a cross-sectional study of prescribing data in general practices in England

IntroductionSeventy-five percent of all antimicrobials are prescribed in primary care. There is a growing concern about inappropriate oral antimicrobial prescribing. Interventions to enhance antimicrobial stewardship are actively promoted through educational and other means. GP training practice status has been shown to influence patient care. This study seeks to study the influence of GP training practice status on antimicrobial prescribing.MethodsA cross-sectional analysis of practice antimicrobial prescribing data was conducted for the year 2015–2016 comparing training and non-training practices across England. Data for all practices and prescribing was obtained from NHS Digital. Univariate analyses were conducted on the two measures of antibiotic prescribing included in the study. Multivariable regression models were constructed to identify the predictors of antibiotic prescribing volumes and of broad spectrum antibiotic prescribing.ResultsGP training practice status was a significant predictor of overall antibiotic prescribing volume, B = −0.009 (95% confidence intervals, −0.012, −0.005), p < 0.001. GP training practices prescribed fewer antibiotics, representing a reduction of 6.2 centiles from the median. GP training practice status was also a significant predictor of broad spectrum antibiotic prescribing, B = −0.3 (95% confidence intervals, −0.04, −0.01), p = 0.001. GP training practices prescribed fewer broad spectrum antibiotics, representing a reduction from the median of 6.0 centiles.DiscussionTraining practices prescribe fewer antimicrobials overall and specifically fewer broad spectrum oral antimicrobials (quinolones and cephalosporins). There is a need for further research to understand the interplay between postgraduate GP training and reductions in antimicrobial prescribing.

A Novel Metric to Monitor the Influence of Antimicrobial Stewardship Activities.

The antimicrobial use (AU) option within the National Healthcare Safety Network summarizes antimicrobial prescribing data as a standardized antimicrobial administration ratio (SAAR). A hospital's antimicrobial stewardship program found that greater involvement of an infectious disease physician in prospective audit and feedback procedures was associated with reductions in SAAR values across multiple antimicrobial categories. Infect Control Hosp Epidemiol 2017;38:721-723.

Effects of control interventions on Clostridium difficile infection in England: an observational study

SummaryBackgroundThe control of Clostridium difficile infections is an international clinical challenge. The incidence of C difficile in England declined by roughly 80% after 2006, following the implementation of national control policies; we tested two hypotheses to investigate their role in this decline. First, if C difficile infection declines in England were driven by reductions in use of particular antibiotics, then incidence of C difficile infections caused by resistant isolates should decline faster than that caused by susceptible isolates across multiple genotypes. Second, if C difficile infection declines were driven by improvements in hospital infection control, then transmitted (secondary) cases should decline regardless of susceptibility.MethodsRegional (Oxfordshire and Leeds, UK) and national data for the incidence of C difficile infections and antimicrobial prescribing data (1998–2014) were combined with whole genome sequences from 4045 national and international C difficile isolates. Genotype (multilocus sequence type) and fluoroquinolone susceptibility were determined from whole genome sequences. The incidence of C difficile infections caused by fluoroquinolone-resistant and fluoroquinolone-susceptible isolates was estimated with negative-binomial regression, overall and per genotype. Selection and transmission were investigated with phylogenetic analyses.FindingsNational fluoroquinolone and cephalosporin prescribing correlated highly with incidence of C difficile infections (cross-correlations >0·88), by contrast with total antibiotic prescribing (cross-correlations <0·59). Regionally, C difficile decline was driven by elimination of fluoroquinolone-resistant isolates (approximately 67% of Oxfordshire infections in September, 2006, falling to approximately 3% in February, 2013; annual incidence rate ratio 0·52, 95% CI 0·48–0·56 vs fluoroquinolone-susceptible isolates: 1·02, 0·97–1·08). C difficile infections caused by fluoroquinolone-resistant isolates declined in four distinct genotypes (p<0·01). The regions of phylogenies containing fluoroquinolone-resistant isolates were short-branched and geographically structured, consistent with selection and rapid transmission. The importance of fluoroquinolone restriction over infection control was shown by significant declines in inferred secondary (transmitted) cases caused by fluoroquinolone-resistant isolates with or without hospital contact (p<0·0001) versus no change in either group of cases caused by fluoroquinolone-susceptible isolates (p>0·2).InterpretationRestricting fluoroquinolone prescribing appears to explain the decline in incidence of C difficile infections, above other measures, in Oxfordshire and Leeds, England. Antimicrobial stewardship should be a central component of C difficile infection control programmes.FundingUK Clinical Research Collaboration (Medical Research Council, Wellcome Trust, National Institute for Health Research); NIHR Oxford Biomedical Research Centre; NIHR Health Protection Research Unit on Healthcare Associated Infection and Antimicrobial Resistance (Oxford University in partnership with Public Health England [PHE]), and on Modelling Methodology (Imperial College, London in partnership with PHE); and the Health Innovation Challenge Fund.

Antimicrobial Resistance of Faecal Escherichia coli Isolates from Pig Farms with Different Durations of In-feed Antimicrobial Use.

Antimicrobial use and resistance in animal and food production are of concern to public health. The primary aims of this study were to determine the frequency of resistance to 12 antimicrobials in Escherichia coli isolates from 39 pig farms and to identify patterns of antimicrobial use on these farms. Further aims were to determine whether a categorization of farms based on the duration of in-feed antimicrobial use (long-term versus short-term) could predict the occurrence of resistance on these farms and to identify the usage of specific antimicrobial drugs associated with the occurrence of resistance. Escherichia coli were isolated from all production stages on these farms; susceptibility testing was carried out against a panel of antimicrobials. Antimicrobial prescribing data were collected, and farms were categorized as long term or short term based on these. Resistance frequencies and antimicrobial use were tabulated. Logistic regression models of resistance to each antimicrobial were constructed with stage of production, duration of antimicrobial use and the use of 5 antimicrobial classes included as explanatory variables in each model. The greatest frequencies of resistance were observed to tetracycline, trimethoprim/sulphamethoxazole and streptomycin with the highest levels of resistance observed in isolates from first-stage weaned pigs. Differences in the types of antimicrobial drugs used were noted between long-term and short-term use farms. Categorization of farms as long- or short-term use was sufficient to predict the likely occurrence of resistance to 3 antimicrobial classes and could provide an aid in the control of resistance in the food chain. Stage of production was a significant predictor variable in all models of resistance constructed and did not solely reflect antimicrobial use at each stage. Cross-selection and co-selection for resistance was evident in the models constructed, and the use of trimethoprim/sulphonamide drugs in particular was associated with the occurrence of resistance to other antimicrobials.