Antimicrobial Restriction Research Articles

Impact of penicillin allergy records on antimicrobial prescribing in hospitalised patients

The overdiagnosis of penicillin allergy and misclassification of non-truly allergic reactions is a growing public health problem, associated with the overuse of broad-spectrum and restricted antimicrobials. We aimed to evaluate the impact of penicillin allergy status on antimicrobial prescribing. A retrospective study of inpatients with a documented penicillin allergy receiving antimicrobials was conducted from 1 April to 1 July 2021. Antimicrobial prescribing and clinical characteristics were compared between patients with an active penicillin allergy label and those whose label was removed following antimicrobial stewardship team review. Antimicrobials were classified in two categories: i) 'Access' (recommended), ii) 'Watch and Reserve' (restricted) according to WHO AWaRe classification, a tool to guide appropriate antibiotic use. 437 patients with a documented penicillin allergy receiving antimicrobials were included. 353 patients with an active penicillin allergy label, more frequently received antimicrobials from the 'Watch and Reserve list' (283;80% vs 30;37%; p<0.001). In contrast, 84 patients who were de-labelled received more often antimicrobials from the 'Access list' (53;63% vs 64;18%; p<0.001). Penicillin allergy reviews and de-labelling strategies may reduce the use of restricted antimicrobials under the 'Watch and Reserve list'. This practice should be encouraged and reinforced in all hospitals.

Limitations of Reporting Requirements under California's Livestock Antimicrobial Restriction Law.

Antimicrobial use in livestock production is considered a key contributor to growing antimicrobial resistance in bacteria. In 2015, California became the first state to enact restrictions on routine antimicrobial use in livestock production via Senate Bill 27 (SB27). SB27 further required the California Department of Food and Agriculture (CDFA) to collect and disseminate data on antimicrobial use in livestock production. The goal of this report is to assess whether CDFA's data release allows us to evaluate how antimicrobial use changed after the implementation of SB27. We combine the CDFA data with feed drug concentration ranges from the Code of Federal Regulation to evaluate the spread of plausible antimicrobial use trends. We also estimate antimicrobial consumption rates using data from the National Agricultural Statistical Service (NASS) and compare these to changes in medicated feed production reported by the CDFA. We show that CDFA's reported data are insufficient to reliably estimate whether antimicrobial usage has increased or decreased, most notably because no information is provided about the mass of antimicrobials approved for use or medicated feed drug concentrations. After incorporating additional external data on feed drug concentrations, one can at best provide uninformative bounds on the effect of SB27. We find some evidence that antimicrobial use has decreased by incorporating data on national sales of antimicrobials for food-producing animals, but the weakness of this inference underlines the need for improved data collection and dissemination, especially as other states seek to implement similar policies. We provide recommendations on how to improve reporting and data collection under SB27. https://doi.org/10.1289/EHP13702.

Assessing the impact of discontinuation of formulary prior authorization on antibiotic prescribing

Abstract Objective: To compare prescribing patterns of restricted antimicrobials before and after the removal of prior authorization and to develop a prospective audit and feedback program to mitigate the potential inappropriate prescribing of these antimicrobials. Methods: An interrupted time-series analysis assessing the trends in antibiotic use was conducted between May 2020 and February 2023 in large urban hospitals, where all ASP activities were discontinued in May 2022 and a pilot prospective audit and feedback (PAF) program was initiated in January 2023. Results: The collective change in restricted antibiotic utilization after the removal of prior authorization was trending towards increased utilization but was not statistically significant. With the PAF program, 9.8% of patients were identified by the antimicrobial stewardship pharmacists as requiring intervention. Within these patients, 19 different recommendations were made, with the most common being to narrow the therapeutic spectrum (47.4%). Stewardship interventions suggestions were accepted (full and partial) 69.2% of the time. Conclusions: Although there were some small statistically significant changes detected for a few antibiotics, there were no situations where those changes remained significant after appropriate controls were added to the analyses. As such, the intervention may not have had any statistically significant impact on DDDs of the studied antibiotics.

Antimicrobial Sales Comparison before and after the Implementation of Nationwide Restriction Policy in Saudi Arabia.

Antimicrobial dispensing without a prescription has been identified as a significant contributor to the burgeoning crisis of antimicrobial resistance. To combat this, the Saudi Ministry of Health introduced a stringent antimicrobial restriction policy in mid-2018, mandating prescriptions for all antimicrobial drug dispensations at pharmacies. Therefore, this study aimed to assess the immediate impact of this policy on retail antimicrobial sales. To do so, we analyzed annual sales data from 2017 to 2019 sourced from the IQVIA-MIDAS® database, which included a range of antimicrobials, such as antibiotics, antifungals, and other related agents. The analysis revealed a notable reduction in overall antimicrobial sales by 23.2%, decreasing from 818.9 million SAR in 2017 to 648.4 million SAR in 2019. While the Wilcoxon signed-rank test indicated a statistically significant median reduction in total antimicrobial sales post-policy implementation (p = 0.0397), it is important to acknowledge that the long-term effects and adherence to the policy require further investigation. Notably, sales of amoxicillin dropped by 70% in 2019 compared to 2017, contributing largely to the decline. Conversely, a continuous increase in sales of some antimicrobial drugs following the restriction policy was observed, led by amoxicillin/clavulanic acid. Our data support the implementation of antimicrobial restriction measures as an effective means of controlling excessive antimicrobial sales and dispensing without prescriptions.

The experience of an antimicrobial stewardship program and antibiotic consumption and resistance trends during the COVID-19 pandemic at a tertiary care center in Beirut

BackgroundAntimicrobial Resistance, a global concern, worsened with the COVID-19 pandemic that caused a surge of critically ill patients, increased antimicrobial consumption, and the spread of infections with multidrug-resistant organisms (MDROs). Antimicrobial Stewardship Programs (ASP) aim to optimize antimicrobial utilization to fight resistance. We aim to describe the ASP experience and to study antimicrobial consumption and MDRO rates among COVID-19 patients at a tertiary care center in Beirut. MethodsWe compiled the ASP interventions, defined as ASP team recommendations, from January 2019 until December 2021. Data on antimicrobial consumption, expressed as a defined daily dose (DDD) per 100 patient days, was collected per quarter for all antimicrobials and restricted antimicrobials per ASP guidance. Our primary objective was to report on the ASP experience, and the secondary objective was to reflect on the rates of MDROs among hospitalized COVID-19 patients with respiratory or bloodstream bacterial co-infections between March 2020 and September 2021. Results9922 ASP interventions were documented during this study period, with a noticeable correlation between COVID-19 surges in Lebanon and the number of ASP interventions. Acceptance rates for these recommendations improved over time, with a noticeable decrease in the proportion of interventions related to de-escalation and discontinuation of broad-spectrum antimicrobials. We noted an increase in all antimicrobial consumption after the onset of the pandemic, peaking in Q4 2020 (142.8 DDD of anti-infectives/100 patient days) and Q1 2021 (79.1 DDD of restricted anti-infectives/100 patient days). As expected, MDROs, particularly ESKAPE organisms (Enterococcus faecium, Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa, and Carbapenem-resistant Enterobacteriaceae) accounted for 24% of isolates obtained from this cohort. ConclusionThis study highlights the experience of the ASP as we adapted to the COVID-19 pandemic. The ASP team maintained its operations and continued to monitor antibiotic consumption and provide recommendations to limit antibiotic misuse in an effort to mitigate the impact of the pandemic on antimicrobial resistance.

1249. Stealth Stewardship: Compliance with Antimicrobial Restriction Processes at an Academic Medical Center

Abstract Background The 2023 Joint Commission Elements of Performance (EPs) for Antibiotic Stewardship (ASP) document includes a new requirement to implement preauthorization for antimicrobial use in hospitals. At VCUHS, a preauthorization process for restricted antimicrobials has existed since 2000. Prescribers must obtain formal approval for dose and duration of antimicrobials from an ASP or Infectious Diseases (ID) team member to allow inpatient pharmacy to dispense the drug. We employed a stealth stewardship strategy to assess compliance to the antimicrobial preauthorization process and identified opportunities for improvement. Methods Pharmacy orders for adult hospitalized patients who received at least one dose of select restricted antimicrobials between August 1, 2022 and October 31, 2022 were reviewed for a documented formal approval in the electronic medical record (EMR). Orders were excluded if not subject to antimicrobial restriction; placed at VCUHS satellite campuses or during de-restricted overnight hours. Stealth use of antimicrobials was defined as the use of a restricted agent without a formal ASP or ID approval. Results A total of 179 restricted antimicrobial orders were reviewed during the study period. Of those, 43 (24%) lacked documented approval in the EMR. Of these orders, 20/43 (46.5%) were for patients seen by the ID service, 16/43 (37.2%) were restricted agents continued beyond the initial approval duration, 5/43 (11.6%) were prophylactic antifungal agents approved during prior admissions, and 2/43 (4.7%) were home antimicrobial agents (Fig 1). Conclusion With a stealth stewardship review of restricted antimicrobials, we identified gaps in our stewardship process. Surprisingly, 46% of undocumented restricted antimicrobial use was under the guidance of the ID service. High staff turnover rates, frequent pharmacy and prescriber hand-offs, and lack of persistent education on the restriction process are probable drivers of noncompliance. These breaches in our approval process highlight opportunities for heightened education and feedback. We encourage other institutions to consider similar strategies to evaluate their established processes and ensure compliance with the current Joint Commission requirements. Disclosures All Authors: No reported disclosures

Evaluation of Restricted Antimicrobial Utilization in a Tertiary Care Hospital

The World Health Organization has declared that antimicrobial resistance is one of the top ten public health threats faced by humanity. In addition to death and disability, prolonged illness results in longer hospital stays, more expensive medicines and financial challenges for those impacted. The emergence of antimicrobial resistance was mainly attributed to the inappropriate prescribing and overuse of antimicrobials including self-medication. The main objective of our study was to study the prescribing patterns of restricted antimicrobials among in-patients in a tertiary care hospital. A prospective observational study was conducted among 108 in-patients and the rationality of prescriptions with restricted antimicrobials was analyzed. There were 174 antimicrobials prescribed in 108 patients, out of 174 antimicrobials prescribed 140 drugs were restricted antimicrobials and 34 drugs were non-restricted antimicrobials. Among restricted antimicrobials prescribed 53(49.07%) were Penicillin and Beta-lactamase inhibitors, 40(37.03%) were Carbapenems, 30 (21.42%) were third-generation Cephalosporins, 7(6.48%) were Oxazolidinones,7(6.48%) were glycopeptide antibiotic and 2(1.85%) Vancomycin. Out of 108 patients, 16(14.81%) patients were prescribed antimicrobials for prophylactic use, 63(58.33%) patients were prescribed with antimicrobials based on empirical therapy and 29(26.85%) patients were prescribed antimicrobials based on culture and sensitivity reports. The study concluded that the restricted antimicrobials were mostly prescribed based on empirical therapy (58.33%) in the study population which shows the need to control the use of restricted antimicrobials.

Antimicrobial stewardship and clinical pharmacist interventions in an Indian tertiary care hospital

AbstractObjectiveComprehensive antimicrobial stewardship programs (ASPs) are needed in Indian healthcare settings due to high rates of communicable diseases and excessive antibiotic use. However, the implementation of both ASPs and clinical pharmacists (CPs) into the system is still in its nascent stages in India. Therefore, our study aims to evaluate the type and acceptance rates of CP interventions in the implementation of ASPs and its impact on antimicrobial utilization.MethodsA single‐center quasi‐experimental study was conducted at Jehangir Hospital, India, wherein prescribed antimicrobials were subjected to evaluation by CPs using the prospective audit and feedback approach. The antimicrobials were reviewed for loading dose, dosages as per creatinine clearance (CrCl), weight, suitability with site of infection, drug interactions, de‐escalations, and therapeutic duplications. Impact on antimicrobial utilization in pre‐intervention (April 2021 to March 2022) and intervention (April 2022 to March 2023) periods were compared using daily defined dose (DDD) per 1000 in‐patient days, following World Health Organization (WHO) guidelines.ResultsDuring the intervention period, 485 out of 609 proposed interventions (79.6%) were implemented. Of these, 417 (85.9%) pertained to intravenous (IV) antimicrobials, while the remaining 68 (14.1%) involved oral formulations. Notably, interventions proposing antibiotic de‐escalations showed higher acceptance rates on Days 3, 5, 7, and 10 compared with other days (p = 0.027). Dosing based on CrCl yielded the highest acceptance rate (50/56, 89.2%). Significant reductions were observed in the DDDs of polymyxins by 58% (3.48–1.29), carbapenems by 7% (57.09–52.85), and glycopeptides by 10% (47.44–42.73). The reduction in these three classes combined was statistically significant (p = 0.04, 95% confidence interval [CI] = 0.3–7.0).ConclusionThis study highlights the vital role of CP interventions within the healthcare team in optimizing antimicrobial pharmacotherapy. The noteworthy reduction in DDDs of restricted antimicrobials provides compelling evidence of the impact CPs can have on antimicrobial consumption and the fight against antimicrobial resistance.

Effectiveness of antimicrobial interventions directed at tackling antimicrobial resistance in animal production: A systematic review and meta-analysis.

In the last decades, a more prudent and rational use of antimicrobials has been progressively directed towards animal production to reduce antimicrobial selective pressure and antimicrobial resistance (AMR) in microorganisms and safeguard the antimicrobial efficacy of treatments in human medicine. This systematic review evaluated the effectiveness of interventions that have been applied to reduce or improve veterinary antimicrobial usage and aimed at decreasing resistant bacteria in chicken broiler and pig production contexts. Original articles were identified by searching PubMed™, Scopus™, The Cochrane Library™, and Web of Science™, and grey literature by searching DANS EASY™, WorldCat™ and RCAAP™. Inclusion criteria included: chicken broiler or pig populations (predestined for meat production), interventions intended to reduce/improve antimicrobial use, comparator with standard or no use of antimicrobials, outcomes related to prevalence of resistant bacteria, farm level studies, original data, and analytical observational studies. Data was extracted from eligible studies and meta-analysis using random or fixed effects models was conducted for combinations including type of intervention, bacterial species, production type and animal populations. Models were selected according to heterogeneity between studies. The effectiveness of interventions was assessed using pooled odds ratio of resistance to antimicrobial substances/classes by bacteria for associations between animal populations with and without intervention. A total of 46 studies were eligible for review. For chicken broilers, most interventions were identified as antimicrobial restrictions on all non-therapeutic use (46%), complete restriction (27%), and prohibition on antimicrobials used for growth promotion (23%). As for pig populations, restrictions were mainly observed on all non-therapeutic use (37%), complete restriction (37%) and group treatments (22%). For meta-analysis, 21 studies were pooled after assessment of existing combinations. These combinations demonstrated a protective effect for most antimicrobial classes in Escherichia coli, Campylobacter and Enterococcus isolates from samples of chicken broilers as well in Escherichia coli and Campylobacter spp. from samples of pigs, compared to animals raised under conventional production or without intervention. Increased odds of resistance were only observed for cephalosporins in E. coli and broilers raised without antimicrobials, and to fluoroquinolones and quinolones in Campylobacter and pigs raised without antimicrobials, compared to conventional production. Our study indicates that organic production, antimicrobial-free farms, and group treatment restrictions are recommended for AMR reduction, providing information that may support decision-making to tackle AMR and better reporting to improve comparability of results between studies.

A 5-Year Retrospective Analysis of Antibiotic Utilisation Pattern by AWaRe Classification in Qatar

Background: To analyse the trend and pattern of antibiotic consumption rates over a period of five years in a secondary care hospital in Qatar. Consumption of antibiotics is a crucial factor in the evaluation of antibiotic usage.&#x0D; Methods: To measure and compare a five-year antibiotic consumption trend in inpatient department wards using Defined Daily Dose (DDD) per 100 bed days (DDD/100-BD). Antibiotics dispensed between January 2018 and December 2022 were evaluated. Data collection was done using Microsoft Excel. The analysis was done using the World Health Organization (WHO) AWaRe classification of antibiotics.&#x0D; Results: The analysis showed that antibiotic consumption significantly increased from 2018 (4.11 DBD) to 2020 (15.55 DBD) and then sustained thereafter. Widely used antibiotic belongs to the third generation cephalosporins which is under Watch class of antibiotics. Ceftriaxone, cefuroxime, and amoxicillin clavulanate were the most consumed antibiotics in the hospital throughout the study period at 53.92 DBD, 32.22 DBD and 21.65 DBD respectively.&#x0D; Conclusion: Establish benchmarking at the facility level. We observed the use of ceftriaxone is more as surgical prophylaxis, which is a Watch group of antibiotics, however there is zero use of restricted antimicrobials. Increase in parenteral fluroquinolone especially levofloxacin needs monitoring, which is not included in WHO essential list of medication. There is a scope to measure the appropriateness of antibiotics, as well as the duration of therapy. The goal of WHO Target ≥60% of total antibiotic consumption being Access group antibiotics can be used as an index to analyse the comparative use Watch and Access group of antibiotics.

Blood culture findings as tools for clinical management and patient safety

Introduction: Healthcare-associated Infections (HAI) have a significant impact on public health, and the use of indicators is a common practice for assessing and improving healthcare services. Aim: This study aimed to describe the utilization of blood culture results to develop indicators for hospital management and evaluate antimicrobial resistance. Outlining: This cross-sectional study was conducted at a teaching hospital. Blood cultures were performed during two periods: pre-implementation of antimicrobial sales restrictions in Brazil (05/2010-10/2010 - first period) and post-implementation (02/2011-07/2011 - second period). Computerized system reports were used to develop indicators, including infection incidence rates and antimicrobial resistance. Results: A higher infection rate (1.97/100 person-days) and a lower resistance rate (0.62/100 person-days) were observed in the second period, with the microorganism Staphylococcus sp. being more frequently identified in both periods. Implications: This study demonstrates the use of indicators to evaluate governmental actions related to HAIs, which can contribute to patient safety and healthcare management.

Scavenger receptor B2, a type III membrane pattern recognition receptor, senses LPS and activates the IMD pathway in crustaceans

The immune deficiency (IMD) pathway is critical for elevating host immunity in both insects and crustaceans. The IMD pathway activation in insects is mediated by peptidoglycan recognition proteins, which do not exist in crustaceans, suggesting a previously unidentified mechanism involved in crustacean IMD pathway activation. In this study, we identified a Marsupenaeus japonicus B class type III scavenger receptor, SRB2, as a receptor for activation of the IMD pathway. SRB2 is up-regulated upon bacterial challenge, while its depletion exacerbates bacterial proliferation and shrimp mortality via abolishing the expression of antimicrobial peptides. The extracellular domain of SRB2 recognizes bacterial lipopolysaccharide (LPS), while its C-terminal intracellular region containing a cryptic RHIM-like motif interacts with IMD, and activates the pathway by promoting nuclear translocation of RELISH. Overexpressing shrimp SRB2 in Drosophila melanogaster S2 cells potentiates LPS-induced IMD pathway activation and diptericin expression. These results unveil a previously unrecognized SRB2-IMD axis responsible for antimicrobial peptide induction and restriction of bacterial infection in crustaceans and provide evidence of biological diversity of IMD signaling in animals. A better understanding of the innate immunity of crustaceans will permit the optimization of prevention and treatment strategies against the arising shrimp diseases.

Pneumonia panel results and antibiotic prescribing in COVID-19 patients in 2020 versus 2022

Background: Antibiotics are frequently prescribed in patients with COVID-19 infections to treat secondary bacterial pneumonia. The pneumonia panel (PNP) is a molecular diagnostic tool that rapidly detects 33 bacterial and viral targets. The utility of this panel in COVID-19 patients and how it may direct antibiotic use is unknown. We sought to understand the utilization of PNP in patients with COVID-19 pneumonia over time by comparing clinical parameters, microbiologic results, and antibiotic use between May–December 2020 and January–July 2022. Methods: We implemented the PNP in May 2020 with antimicrobial stewardship guidance, provider education, and order restriction to critical care and infectious disease clinicians. From February–July 2021 prescribers received regular structured antimicrobial stewardship feedback regarding PNP results; from August 2021 to January 2022, no antimicrobial stewardship feedback was provided; from February to July 2022, intermittent feedback was provided. We compared PNP and culture results from sputum or bronchoalveolar lavage samples and antibiotic use and modification within 24 hours of PNP result from patients with confirmed COVID-19 pneumonia between May–December 2020 and January–July 2022. Clinical data and antibiotic use were abstracted through chart review. We excluded patients who died within 72 hours of PNP, those who had concurrent nonpulmonary infections, and those whose COVID-19 test was &gt;30 days prior. Results: We included 114 patients in 2020 and 71 patients in 2022. The overall median age was 61 years, 71% were male, and 66% were mechanically ventilated without statistical differences between the cohorts, including their comorbidities. Acute or worsening hypoxia remained the predominant indication for PNP (77% in 2020 vs 75% in 2022, NS). The median number of days between admission and PNP was 4 (IQR, 1–8) in 2020 versus 3 (IQR, 1–7), and the difference was not significant. PNP and culture results in Table 1 show that Staphylococcus aureus and Hemophilus influenzae were the pathogens most commonly identified. Table 2 describes empiric prescribing and modifications for commonly prescribed antibiotics. Prescribers used empiric cefepime and ceftriaxone more in 2020 and vancomycin more in the 2022 group; however, these were not statistically significant. Cefepime de-escalation was more common in 2022 (53% vs 28%; P = .03). Antibiotic modifications within 24 hours of PNP remained similar in 2020 vs 2022. Although vancomycin cessation was more common in 2020 (78%) versus 2022 (57%), the difference was not statistically significant. Conclusions: With ASP guidance, PNP may be a useful tool to stop or target antibiotics for secondary bacterial pneumonia in COVID-19 pneumonia. Early vancomycin cessation (prior to culture results) may be an enduring consequence of PNP implementation.Disclosures: None

Accuracy of antibacterial indication documentation in an electronic medicines management system.

Electronic medicines management (EMM) systems are relatively new in the Australian healthcare system. This tertiary hospital network implemented an EMM in 2018, with mandatory documentation of antimicrobial indication when prescribing. Free-text (unrestricted) and pre-defined dropdown (restricted) indications are utilized according to antimicrobial restriction. To determine accuracy of antibacterial indication documentation on the medication administration record (MAR) when prescribing and to evaluate factors influencing accuracy of documentation. A random sample of 400 inpatient admissions of ≥24 h, between March and September 2019, with the first antibacterial prescription per encounter reviewed retrospectively. Demographic and prescription details were extracted. Indication accuracy was assessed by comparing MAR documentation with the medical notes (gold standard). Statistical analysis compared factors associated with accuracy of indication using chi-squared and Fisher's exact tests. Antibacterials were prescribed in 9708 admissions. Of the 400 patients included (60% male; median age 60 years, IQR 40-73), 225 prescriptions were unrestricted and 175 were restricted. Patients were managed by emergency (118), surgical (178) and medical (104) teams. Overall accuracy of antibacterial indication documentation on the MAR was 86%. A higher accuracy rate was found for the unrestricted proportion compared with the restricted proportion (94.2% versus 75.2%; P < 0.0001). Surgical teams had higher accuracy compared with medical and emergency teams (94.4% versus 78.8% versus 79.7%; P < 0.0001). Antibacterial indication documentation on the MAR when prescribing demonstrated a high rate of accuracy. Multiple factors influenced this accuracy, which requires further study to determine the impact on accuracy, with a view to improve future EMM builds.

Drug use evaluation and rational prescription audit of restricted antibiotics in tertiary care corporate hospital: An interventional study

: Antimicrobial agent are the biggest contribution to 20th century, which are used to prevent and cure of the infections. Over use of antimicrobials has facilitated the development of resistance. Drug utilization research help in identification of clinical use of drugs in populations and its impact on healthcare system.: The aim of the study is to identify the overuse/misuse of the antibiotic usage in our intensive care unit. which helps in rationalising the antibiotic prescription and to avoid emergence of drug resistance and to improve better patient’s outcome. An observational audit has been conducted in inpatient admitted in our set up and has been prescribed with restricted antimicrobials. The audit has been done for 3 months. The Audit report for 218 patients have been prescribed with Restricted antimicrobials either one or more than one. The audit report shows that Meropenem and Colistin was prescribed more often 81 and 73 respectively. Geriatric Patients have been prrscribed more with Antimicrobials than other age groups. 193 patients were on single Restricted antimicrobial therapy, 24 patients were on dual restricted antimicrobial therapy and one patient was on more than 2 Restricted antimicrobial therapy. Out of 218 Prescription having Restricted Antibiotics, 39 prescription were found irrational. A wide spectrum of clinical diagnoses and a variety of drugs were utilized from various antibiotic classes. Results showed that Carbapenems(Meropenem) antibiotics were extensively used in ICU. Among Colistin and Vancomycin was most commonly prescribed. Policy for rational usage of restricted antimicrobial agents in ICU should be implemented and education needs to be provided.

Antimicrobial stewardship and drug formulary restrictions during COVID-19: what is restricted and who decides?

COVID-19 therapies were challenging to deploy due to evolving literature and conflicting guidelines. Antimicrobial stewardship can help optimize drug use. We conducted a survey to understand the role of stewardship and formulary restrictions during the pandemic. Restrictions for COVID-19 therapies were common and approval by infectious disease physicians often required.

Remdesivir use and antimicrobial stewardship restrictions during the coronavirus disease 2019 (COVID-19) pandemic in the United States: A cross-sectional survey.

Deploying therapeutics for coronavirus disease 2019 (COVID-19) has proved challenging due to evolving evidence, supply shortages, and conflicting guideline recommendations. We conducted a survey on remdesivir use and the role of stewardship. Use differs significantly from guidelines. Hospitals with remdesivir restrictions were more guideline concordant. Formulary restrictions can be important for pandemic response.

897. Criteria Restricting Inappropriate Meropenem Empiricism (CRIME): A Quasi-Experimental Carbapenem Restriction Pilot at a Large Academic Medical Center

Abstract Background Carbapenems’ broad spectrum of activity may make these agents appealing for empiric use; however, their use is associated with development of Clostridioides difficile infection (CDI) and multi-drug resistance. Selective use of carbapenems is vital in maintaining their effectiveness. Our study aimed to examine the impact of meropenem restriction criteria on utilization and patient outcomes. Methods This single-center, quasi-experimental study was conducted at an academic medical center where an initial medication use analysis found frequent inappropriate meropenem utilization. The antimicrobial stewardship team developed restriction criteria and implemented a pilot in February 2022. Investigators aimed to determine how restriction criteria affected meropenem utilization across 8 weeks in the pre-implementation period compared to the post-implementation period. The primary outcome was to compare the inappropriateness of meropenem utilization. Secondary outcomes included comparison of days of therapy per 1000 patient-days (DOT/1000 PD), hospital length of stay (LOS), frequency of CDI, and acquisition cost. Results Across the 8 week timeframes, reductions in inappropriate meropenem use (64.5% vs 12.8%; p&amp;lt; 0.001), duration of therapy (5.8 [3.2-7.3] vs. 2.4 [1.0-5.5] days, p&amp;lt; 0.0001), and utilization (30.5 vs. 8.3 DOT/1000 PD, p=0.04) in the pre- and post-implementation periods, respectively, were observed. Total number of meropenem orders decreased by 65% (p&amp;lt; 0.001). Implementation of restriction criteria also resulted in decreased median hospital LOS between periods (11.9 [7.8-20.4] vs. 9.2 [5.4-15.2] days, p=0.05). There was no difference in frequency of CDI (2 vs. 0, p=0.99). Projected annual cost savings was approximately $57,300. Conclusion Implementation of antimicrobial stewardship-initiated restriction criteria can reduce inappropriate utilization of meropenem, overall number of orders, and total duration of therapy. Disclosures Kerry O. Cleveland, MD, AbbVie: Honoraria|Cumberland: Honoraria|Merck: Honoraria|Pfizer: Honoraria.

1107. A Survey on Remdesivir Use and Antimicrobial Stewardship Restrictions Throughout the COVID-19 Pandemic

Abstract Background Remdesivir (RDV) was the first agent with proven clinical benefit against COVID-19, shortening the time to recovery in a randomized placebo-controlled trial (RCT). Based on this trial, the Food and Drug Administration approved RDV via emergency use authorization. Despite its wide use, RDV remains controversial. Early use of RDV in patients requiring low flow nasal canula has robust evidence. However, benefit in mechanical ventilation (MV), high-flow nasal canula (HFNC) and non-invasive positive pressure ventilation (NIPPV) is conflicting. Multiple studies, most notably the SOLIDARITY and DisCoVeRy trial, have conflicting results on who benefits from RDV. Deploying novel therapeutics in this changing landscape is challenging. We seek to understand RDV practices and the role of antimicrobial stewardship (ASP) in hospitals across the US. Methods A survey was developed and disseminated through Infectious Diseases Society of America (IDSA) IDea network, IDSA Antimicrobial Stewardship Centers for Excellence and the Society for Healthcare Epidemiology messaging boards. Data collected included city, presence of RDV therapeutic restrictions, and RDV use by degree of oxygen needs for each COVID-19 wave. Results A total of 78 responses were collected, representing wide geographic reach in the US (Figure 1). RDV was restricted in 53% of facilities. Hospitals without restrictions commonly used RDV for patients on MV, NIPPV and HFNC, with more use on HFNC than on NC during the first winter, Delta and Omicron waves (Figure 2). Use on MV declined with each surge. Hospitals with RDV restrictions had more use of RDV on NC than all other ordinal scales (Figure 3). Use in MV, NIPPV and HFNC compared to NC declined in the restricted group with each COVID-19 surge. Figure 1.Geographic distribution of hospitals represented in the survey Figure 2. Remdesivir use by oxygen requirements in hospitals without remdesivir therapeutic restrictions. Figure 3 Remdesivir use by oxygen requirements in hospitals without remdesivir therapeutic restrictions. Conclusion A wide gap between evidence-based guidelines and actual practice exists. This gap was wider in hospitals without COVID-19 therapeutic restrictions in place for RDV. In the unrestricted group, RDV was commonly used for MV, HFNC and NIPPV, where robust RCT evidence of benefit is lacking. Though this practice occurred in both groups, the restricted RDV group prioritized RDV use in NC and did so at higher percentages each subsequent COVID-19 surge. ASP restrictions can have an important role in guiding COVID-19 therapy. Disclosures All Authors: No reported disclosures.

916. Increased efficiency and impact of implementing ILUM insight within an antimicrobial stewardship program (ASP) at an academic medical center

Abstract Background An ASP is mandated for all hospitals and requires extensive resources with multidisciplinary collaboration. We measured the impact of implementing real-time decision support software (ILUM Insight) within our ASP. Methods Our ASP has relied on prior authorization since 2002 and focused audit and feedback since 2015. In August 2021 we implemented to bring actionable data to front-line stewards. ILUM provides real-time notifications, organizes communications, and tracks patient-and provider-level data. We hypothesized that ILUM would increase the efficiency of ASP workflow and result in decreased antimicrobial utilization. We compared data 6 months before (8/20 – 1/21) and after (8/21 – 1/22) implementation. There were no significant staffing changes during either period. Results Existing notifications within ILUM were tailored to local practices, including alerts with intervention for positive blood cultures, antibiotic de-escalation, and bug-drug mismatches. New notifications were built for restricted antimicrobials, antibiotic timeouts, and MRSA screening. ASP pharmacists and physicians received training in July and November, respectively. A breakdown of all notifications received during the post-implementation period is provided in Fig 1. With increased ILUM usage, the number of interventions made by our ASP increased while missed opportunities decreased (Fig 2.). During the same time period, ASP communications rose from 205 to 1200 per month. Comparing pre- and post-implementation periods, antimicrobial days of therapy (DOT) per 1,000 patient days (PD) decreased by 14.5% from a median of 969 to 846 per month (Fig 3;P=0.002). Antimicrobial expenditures were decreased by a median 21% per month during the post-intervention period compared to baseline. Among patients prescribed antimicrobials during an index admission, 30-day re-admissions decreased from 330 to 262 and re-admissions associated with re-ordering of antimicrobials decreased from 235 to 182 (Fig 4). Conclusion Custom-designed, task-specific software improves the efficiency of daily ASP workflow and significantly decreased antimicrobial utilization without the need for additional ASP team members. Disclosures Ryan K. Shields, PharmD, MS, Infectious Disease Connect: Advisor/Consultant|Merck: Advisor/Consultant|Merck: Grant/Research Support|Roche: Grant/Research Support J Ryan Bariola, MD, Infectious Disease Connect: Salary support|Merck: Grant/Research Support Caley Yakemowicz, n/a, Infectious Disease Connect: Employee Courtney Simonick, n/a, Infectious Disease Connect: Stocks/Bonds Riaan Erwee, na, Infectious Disease Connect: Employee Erin K. McCreary, PharmD, Infectious Disease Connect: Advisor/Consultant Rima Abdel-Massih, MD, Infectious Disease Connect: Co founder and Chief Medical Officer|Infectious Disease Connect: Ownership Interest.