Antimicrobial Restriction Research Articles

Third-generation cephalosporins programmed restriction in the context of an outbreak of AmpC β-lactamase-producing gram-negative bacilli in critical units: a real-life experience

Programmed restriction (PR) of antimicrobials can selectively decrease the rate of infections by certain microorganisms. In this sense, AmpC β-lactamase-producing gram-negative bacilli (GNB-blaAmpC) are selected for the overuse of third generation cephalosporins (3GC). These bacteria also acquire genes and co-produce other β-lactamases, such as New Delhi ones (GNB-blaNDM). To decrease the isolation rate of GNB- blaAmpC and GNB- blaNDM in cultures from ICU patients after a PR of 3GC. Quasi-experimental study, before (P1= 12 months) and after (P2= 12 months) a PR of 3GC in an adults' hospital. The use of antibiotics was expressed as "percentage days of treatment (%DOT)" /100 beds occupied per day (100-BOD). The rates of GNB-blaAmpC and GNB-blaNDM were compared in blood cultures (BC), mini-bronchio alveolar lavages (mB) and urine cultures (UC) in the ICU. In P2, 3GC consumption was 2.5% DOT/100-COD. There was a decrease in GNB-blaAmpC from BC (RR 0.48 [0.2-0.9] p < 0.02) and mB (RR 0.52 [0.3-0.9] p < 0.02), as well as of GNB-blaNDM from BC (RR 8.1 [1.6-39.4] p < 0.00). PR of 3GC was linked to the reduction of GNB-blaAmpC and GNB-blaNDM in BC, as well as GNB-blaAmpC in mB from ICU patients.

Removal of antimicrobial prophylaxis and its effect on swine carriage of antimicrobial-resistant coliforms.

The use of antimicrobials in the food animal industry has caused an increased prevalence of antimicrobial-resistant bacteria and antimicrobial resistance genes, which can be transferred to the microbiota of humans through the food chain or the environment. To reduce the development and spread of antimicrobial resistance, restrictions on antimicrobial use in food animals have been implemented in different countries. We investigated the impact of an antimicrobial restriction intervention during two generations of pigs. Fecal samples were collected in five growth phases. The frequency of antimicrobial-resistant coliforms and antimicrobial-resistant bacteria or antimicrobial resistance genes was analyzed. No differences in the richness or abundance of antimicrobial-resistant coliforms or antimicrobial resistance genes were found when animals fed with or without prophylactic antimicrobials were compared. Withholding antimicrobial supplementation did not negatively affect weight gain in pigs. Withdrawal of prophylactic antimicrobial consumption during two generations of pigs was not enough to reduce the prevalence of antimicrobial resistance genes, as measured by richness and abundance markers. This study indicates that the fitness costs associated with bacterial carriage of some antimicrobial resistance genes are low.

The implementation and outcome of a 2-year prospective audit and feedback based antimicrobial stewardship program at a private tertiary care hospital

PurposeAntimicrobial resistance has emerged as a major public health problem in India. Hence effective antimicrobial stewardship programs (AMSP) are needed. We report the design, implementation and results of a prospective audit and feedback based AMSP at a private tertiary care hospital. MethodsDuring the study period – January 2018 to December 2019 – the prescription of restricted antimicrobials required the filling of a justification form which was reviewed by the antimicrobial stewardship committee (AMSC) at 48–72 ​h. Patients in whom the restricted antimicrobial was stopped earlier than 48 ​h were not applicable for review. The eligible prescriptions were judged as justified/unjustified by AMSC based on the patient's clinical and previous antimicrobial history, course, results of investigations/cultures, guidelines and communicated to the treating team. Compliance to the recommendations of the AMSC was measured. Days of therapy for each restricted antimicrobial/1000 patient days was calculated. Colistin resistance rates in pathogens causing central line associated blood stream infections (CLABSI) were compared with previous years. ResultsA total of 2397 restricted antimicrobials in 1366 patients were prescribed in the study period of which 1801 prescriptions were applicable for review (75%). Overall, 1.4% of admitted patients were prescribed restricted antimicrobials. The total days of therapy with restricted antimicrobials was 41/1000 patient days. The AMSC committee adjudged 12.5% of prescriptions as unjustified and recommendations for de-escalation were accepted in 89%. There was no significant difference in the study outcomes between 2018 and 2019. ConclusionThe prospective audit and feedback component of AMSP provided insight into the use of restricted antimicrobials at our hospital. This component should be considered by hospitals for inclusion in their AMSP program on an ongoing basis even if limited to a few drugs and in few areas of the hospital.

Antimicrobial stewardship, therapeutic drug monitoring and infection management in the ICU: results from the international A- TEAMICU survey

BackgroundSevere infections and multidrug-resistant pathogens are common in critically ill patients. Antimicrobial stewardship (AMS) and therapeutic drug monitoring (TDM) are contemporary tools to optimize the use of antimicrobials. The A-TEAMICU survey was initiated to gain contemporary insights into dissemination and structure of AMS programs and TDM practices in intensive care units.MethodsThis study involved online survey of members of ESICM and six national professional intensive care societies.ResultsData of 812 respondents from mostly European high- and middle-income countries were available for analysis. 63% had AMS rounds available in their ICU, where 78% performed rounds weekly or more often. While 82% had local guidelines for treatment of infections, only 70% had cumulative antimicrobial susceptibility reports and 56% monitored the quantity of antimicrobials administered. A restriction of antimicrobials was reported by 62%. TDM of antimicrobial agents was used in 61% of ICUs, mostly glycopeptides (89%), aminoglycosides (77%), carbapenems (32%), penicillins (30%), azole antifungals (27%), cephalosporins (17%), and linezolid (16%). 76% of respondents used prolonged/continuous infusion of antimicrobials. The availability of an AMS had a significant association with the use of TDM.ConclusionsMany respondents of the survey have AMS in their ICUs. TDM of antimicrobials and optimized administration of antibiotics are broadly used among respondents. The availability of antimicrobial susceptibility reports and a surveillance of antimicrobial use should be actively sought by intensivists where unavailable. Results of this survey may inform further research and educational activities.

ANTIMICROBIAL AGENT’S UTILIZATION AND COST PATTERN IN MEDICAL INTENSIVE CARE UNIT OF A TERTIARY CARE HOSPITAL

Objective: The objective of this study was to evaluate the utilization and cost pattern of AMAs (Antimicrobial Agents) in the Medical ICU of a tertiary care teaching hospital, and to determine the predictor of antimicrobial number per day. Methods: A prospective cross-sectional study was carried out and a total of 101 patients were studied. The drugs were classified into different groups according to the World Health Organization’s ATC (Anatomical Therapeutic Chemical) Classification System. Results: The mean [95% confidence interval (CI)] duration of ICU stay was 7.11 (5.70-8.52) days and the mortality rate in the ICU was 42.6%. The AMAs DDD (Defined Daily Dose) per 100 patient days and number of AMAs per prescription were 296.64 and 2.65, respectively. Piperacillin-tazobactam was the most commonly utilized AMAs followed by metronidazole, meropenem, fluconazole, and colistin. The mean number [95% CI] of AMAs, DDD, and cost (INR) per patient were 18.82 (14.05-23.59), 21.09 (15.36-26.81) and 25,827 (18,716-32,939) respectively. The AMAs constituted 88.53% of the total treatment cost. Meropenem was the most costly AMA (32.10% of the total AMAs cost) followed by imipenem-cilastatin (20.50%), colistin (14.65%), piperacillin-tazobactam (8.40%), and clindamycin (4.47%). The independent predictor for the antimicrobial number per day was acute physiology and chronic health evaluation II (APACHE-II) score at admission and nosocomial infections. Conclusion: The AMAs, DDD per 100 patient days, and number per prescription were higher. This leads to a higher cost of AMAs per patient and the AMAs cost out of the total cost as compared to previous studies. We suggest, there is a need to formulate and implement an antimicrobial restriction policy.

Antimicrobial defined daily dose in neonatal population

BackgroundAntimicrobial defined daily dose (DDD), a standardized metric to assess antimicrobial consumption in adult population, has limitations hampering its use in neonatal patients. This study proposes an alternative DDD design applicable for neonates. MethodsNeonates (<1 month-old) from 6 Spanish hospitals during a 12-months period were included. Weight and weeks gestational age of each neonate were the variables collected. DDD (g) for each antimicrobial was calculated by multiplying the obtained weight times the recommended dose (mg/kg) of the antimicrobial for the most common infectious indication selected by the Delphi method. ResultsA total of 4820 neonates were included. Mean age was 36.72 weeks of gestational age and Mean weight was 2.687kg. Standardized DDD (intravenous; oral route) for representative antimicrobials were: Amoxicillin (0.08; 0.08), amoxicillin-clavulanic acid (0.27; 0.08), ampicillin (0.27; x), cloxacillin (0.13; 0.13), penicillin G sodium (0.12), cefazolin (0.13), cefuroxime (0.27; x), cefotaxime (0.27), ceftazidime (0.27), ceftriaxone (0.13), cefepime (0.27) piperacillin-tazobactam (0.54), aztreonam (0.24), azithromycin (0.03; 0.03), clindamycin (0.04; 0.04), amikacin (0.04), gentamicin (0.01), metronidazole (0.04; 0.08), ciprofloxacin (0.04; 0.05), levofloxacin (x;x), fluconazole (0.02; 0.02), itraconazole (0.01; 0.01), fosfomycin (0.27). Restricted antimicrobials: meropenem (0.11), teicoplanin (0.02), vancomycin (0.08; 0.11), linezolid (0.08; 0.08), daptomycin (x), amphotericin B liposomal (0.01). ConclusionsA useful method for antimicrobial DDD measurement in neonatology has been designed to monitor antimicrobial consumption in hospital settings. It should be validated in further studies and thereby included in the design for neonatal antimicrobial stewardship programs in the future.

Analysis of the correctly filling in the request form for Antimicrobials in an Oncology Reference Hospital in the State of Pará

Objective: Analyze the filling in the antimicrobial request form of the Intensive Care Unit in an oncology reference hospital in the state of Pará. Methods: This was a quantitative and retrospective study by collecting data from the restricted use antimicrobials request form, developed in the Intensive Care Unit of Hospital Ophir Loyola. Forms analyzed were from August to December 2018 in the file of the Hospital Infection Control Committee. Data obtained were organized in a database in Microsoft Excel® software, for descriptive statistical application, and the results were categorized and presented in a box and tables. Results: Of the 469 forms analyzed, 125 belonged to the month of August (27%), 96 (20%) September, 79 (17%) October, 96 (20%) November (20%) and 73 (16%) December. Meropenem was the most prescribed medication in the first three months (16%, 21.90% and 20.30%), in November, vancomycin was the most dispensed (11.5%) and, in December, piperacillin-tazobactam (tazocin - 20.5%). Regarding non-conformities, there is no form with the item “pharmaceutical form”. There were missing information on indication of use, data on the isolated infectious agent and omission of information on “progress of the requested microbiological study”. The indication for use was comprised between empirical and specific therapy. Conclusion: Thus, it is necessary to adjust the antimicrobial request form, inserting complementary data for greater patient safety and better prescription, promoting their rational use.

Antimicrobial stewardship in the Western Cape: A situational analysis of existing facility-level initiatives.

Antimicrobial resistance (AMR) is a growing problem worldwide. With the current occurrence of pan-resistant bacterial infections and a paucity of novel antimicrobials in development, the world has entered a post-antibiotic era, in which previously treatable, common infections can become fatal. Antimicrobial stewardship (AMS), defined as 'co-ordinated interventions to ensure appropriate and rational use of antimicrobials', aims to decrease rates of AMR. To co-ordinate AMS in Western Cape Province. The National Department of Health (NDoH) has identified AMS as a key strategic objective, and the Western Cape has formed a provincial AMS committee. However, not much is known regarding current AMS activities in health facilities in the province. A self-administered, email questionnaire was sent to specific staff at all district, regional and tertiary hospitals in the 6 health districts of the Western Cape - 47 facilities in total, of which 35 (74.4%) responded. Respondents included pharmacists, managers, doctors, nurses, infection prevention and control practitioners, as well as quality assurance practitioners. The number of facilities implementing AMS were determined, as well as the composition of AMS committees and the nature and frequency of team activities. Barriers to facility-level AMS were explored. Support and outreach activities were assessed, as well as facilities' needs and expectations of the provincial AMS committee. Approximately half of all responding hospitals (n=19; 54.3%) had active AMS committees. Double the proportion of metropolitan (83.3%) than rural facilities (39.1%) had committees. Stewardship activities included antimicrobial prescription chart reviews and audits, AMS ward rounds, antimicrobial restriction policies and training. Most committees included a pharmacist and an infection prevention and control practitioner. More than a third of hospitals (36.1%) did not review their antimicrobial consumption data on a regular basis. Just over half of the hospitals (n=18; 51.4%) did not review AMR patterns. Despite the need for effective AMS, there is limited information on AMS in South Africa. Most assistance is required in rural areas and smaller hospitals with low numbers of staff and greater numbers of transient rotating junior staff. Information management support, multidisciplinary teamwork and clinical governance are required to enable regular and ongoing AMS in facilities. Rural and smaller facilities require greater support to establish effectively functioning AMS committees.

Quality Analysis of Antimicrobial Restriction Policy in Pediatrics

Background: Antimicrobial stewardship programs (ASPs) are coordinated programs developed in recent years to promote the appropriate use of antimicrobials and reduce microbial resistance. One important action for a successful ASP is the implementation of an antimicrobial policy restriction. Objective: The study analyzed the quality of target-antimicrobial requisitions after the introduction of an antimicrobial policy restriction for children. Methods: We conducted a retrospective study in a neonatal intensive care unit (NICU) and three pediatric intensive care units (PICUs). An ASP was implemented in October 2016, and 14 target antimicrobials were selected to be prescribed after pre-approval by a pediatric infectious disease specialist. All requisitions were analyzed according to indication, antimicrobial type, dose, duration, and collection of cultures before administration. There were no exclusion criteria for requisition analysis. Results: Between October 2016 and December 2017, 1,173 patients were admitted to the units with 120 requisitions of target antimicrobials. Sepsis (43/120; 35.8%) was the most common indication, followed by respiratory infections (23/120; 19.2%) and infections in two or more sites (11/120; 9.2%). The most common target antimicrobials requested were meropenem (68/120; 56.7%), amphotericin B lipid formulations (12/120; 10%), teicoplanin (11/120; 9.2%), and linezolid (11/120; 9.2%). In 98 (81.7%) cases, previous cultures before antimicrobial administration were collected. An infectious agent was detected in 52 of the 98 cultures (53.1%), and Gram-negative and Gram-positive bacteria represented 50% and 26.9% of all positive samples, respectively. Besides, 111 (92.5%) requisitions were approved. In five refused requisitions, a narrow-spectrum antimicrobial was prescribed after further discussion; four were refused due to lack of information, and in one case, the de-escalation of the antimicrobial was possible. No mistake regarding dosage and duration was detected. Conclusions: We found a high-quality rate of target antimicrobial requisition. Antimicrobial policy restriction could contribute to improving the quality of antimicrobial prescription, even in NICUs and PICUs.

Location, distribution, and quantification of myenteric plexus neurons of the jejunum of quails fed with different levels of commercial Macleaya cordata extract

ABSTRACT: Coturniculture has been promising, progressing from a subsistence to a technical activity due to its quick production, low breeding investment, and rapid economic return. After the restriction of antimicrobials as growth promoters, some studies aimed to evaluate alternative products that would make the farming of healthy birds viable without impacting their performance, with commercial Macleaya cordata extract being one of these substitutes. The functions of the gastrointestinal tract are coordinated mainly by the enteric nervous system, and the myenteric plexus is responsible for the reflex control of contractile activities of the external muscles. Thus, this study located and demonstrated the distribution of the myenteric plexus, quantifing the total population of myenteric neurons (Giemsa+) and the subpopulation of myenteric nitrergic neurons (NADPH-d+), and evaluated the effects of commercial Macleaya cordata extract on these populations of quail jejunum neurons. A total of 240 one-day-old female laying quails were distributed into four treatments, with four repetitions of 15 birds each. The test groups (T1, T2, and T3) were treated with commercial Macleaya cordata extract throughout the experimental period using the following doses: T1 - test group, basal diet added with 150 ppm of the extract in the feed; T2- test group, basal diet added with100 ppm of the extract in the feed; T3 - test group, basal diet added with 50 ppm of the extract in the feed; and T4 - control group, basal diet with no added extract. The study included histological analysis, Giemsa+, and NADPH-d+ myenteric neuron staining. The results showed that the myenteric plexus is located between longitudinal layer fibers and in the transition region between the longitudinal and circular layers of the muscular tunic, with the myenteric population organized into ganglia and isolated in the region of neuronal fiber bundles. The commercial Macleaya cordata extract showed no quantitative changes in the myenteric Giemsa+ population and myenteric NADPH-d+ subpopulation, however, the groups that consumed the extract showed greater NADPH-d+ neuron activity compared to the control group, implying that the food remained longer in the intestinal lumen, therefore, enabling greater nutrient use and resulting in increased productive performance.

Evaluation of a hybrid antimicrobial restriction process at a large academic medical center.

We conducted a retrospective review of a hybrid antimicrobial restriction process demonstrating adherence to appropriate use criteria in 72% of provisional-only orders, in 100% of provisional orders followed by ID orders, and in 97% of ID-initiated orders. Therapy interruptions occurred in 24% of provisional orders followed by ID orders.

Patient-provider relationship: Compliance with care

The Provider-Patient Relationship (PPR) is a clever thought of restorative human science in which patients deliberately approach a master and, along these lines, transform into a bit of an assertion in which they will all in all dwell with the pro's bearing. It has been suggested that an ideal PPR has six sections, explicitly purposeful choice, expert's ability, incredible correspondence, sympathy by the pros, congruity, and no hostile situation. Frankly, a poor PPR has been ended up being a critical obstacle for the two authorities and patients, and has at last impacted the idea of therapeutic administrations and limit of the patients to adjust to their malady. Inferable from poor PPR, patients don't exhibit consistence with master direction thoroughly; pick master - shopping by changing their expert again and again; remain tense; may pick quacks or other non-consistent kinds of treatment; basic addition in quick and circuitous remedial expenses. In perspective of irregular change in line of treatment as per the advice of different master and non-climax of the entire course of prescriptions, there is an indisputable augmentation for the ascent of antimicrobial restriction, which further heightens the restorative cost and strain, in conclusion may make real kinds of illness or complexities. From the experts' perspective, they may ask for unnecessary examinations or may give over-medicines, as a once-over to make sure everything seems ok. There is in like manner watched a stunning reduction in human touch or sensitivity; and a vital rising in sad contention among authorities. Keywords: Compliance, Patient satisfaction, Communication skills, Empathy, Trust, Patient comprehension, Motivation, Primary care.

Antimicrobial Stewardship (AMS) Program in Private Hospitals in the Philippines: Its Acceptability, Barriers, and Enablers

Background: Antimicrobials are drugs that are often misused and inappropriate antimicrobial prescribing often results in poor clinical outcome and drug resistance. Monitoring and regulation of antimicrobial use is currently being done by the Department of Health through the Antimicrobial Stewardship (AMS) Program. There is a need to determine the factors that affect successful implementation of an AMS program in private hospitals in the Philippines. This study was conducted to identify the enablers and potential barriers in implementing an AMS program in nine (9) private hospitals. Methodology: A concurrent mixed methods design was used to assess various stakeholders’ (physicians, administrators, other AMS members) perceptions of existing or proposed AMS programs, and to identify barriers and enablers in their implementation. Quantitative data were collected using self-administered survey questionnaire to assess clinician’s acceptance of AMS programs. Qualitative data were collected through semi-structured one-on-one interviews of clinicians and other AMS personnel and focus group discussions (FGD) of selected clinician groups. Data were gathered from October 2018 to October 2019. Results: 409 clinicians were surveyed, 52 were interviewed and 46 sat for 13 sessions of FGDs. Overall, the survey established that physicians were well aware of antimicrobial resistance problem. Majority of the clinicians indicated general agreement with the currently practiced antimicrobial protocols in their hospitals and with the AMS program. However, there were disagreements in perceptions with how antimicrobial restrictions impair prescribing practices and overuse of the same. These responses were strong points of discussion during the Key Informant Interviews (KII) and FGDs. All respondents were amenable with the institutionalization of an AMS program in their hospitals. The hospital leadership’s commitment was determined to be the key enabler of a successful AMS program’s implementation. Barriers identified for hospitals with existing AMS programs were: lack of dedicated staff, resistance and/or non-cooperation of physicians, lack of support from non-medical departments, and inadequate cooperation between hospital personnel. Barriers identified, regardless of the status of the AMS programs were: deficiency in knowledge with developing and implementing an AMS program, inadequate information dissemination, unavailability of an IT-based monitoring for antibiotic use, and the influence of pharmaceutical companies on stakeholders with regards to antimicrobial use. Conclusion: Similar enablers and barriers to a successful implementation of an AMS program were seen in the different hospitals. A hospital leadership’s commitment was determined to be the key enabler. The success or failure of any AMS program appears to depend on physician understanding, commitment and support for such a program. By involving the main players in an AMS program- the hospital administrators, clinicians and other key members, perceived barriers will be better identified and overcome, and enablers will help allow a successful implementation of an AMS program.

Paediatric antimicrobial stewardship programmes in the UK's regional children's hospitals

A survey was conducted in UK regional children's hospitals with paediatric intensive care and paediatric infectious disease (PID) departments to describe the characteristics of paediatric antimicrobial stewardship (PAS) programmes. A structured questionnaire was sent to PAS coordinators. 'Audit and feedback' was implemented in 13 out of 17 centres. Microbiology-led services were more likely to implement antimicrobial restriction (75% vs 33% in PID-led services), to focus on broad-spectrum antibiotics, and to review patients with positive blood cultures. PID-led services were more likely to identify patients from e-prescribing or drug charts and review all antimicrobials. A PAS network has been established.

Update on Streptococcus suis Research and Prevention in the Era of Antimicrobial Restriction: 4th International Workshop on S. suis.

Streptococcus suis is a swine pathogen and a zoonotic agent afflicting people in close contact with infected pigs or pork meat. Sporadic cases of human infections have been reported worldwide. In addition, S. suis outbreaks emerged in Asia, making this bacterium a primary health concern in this part of the globe. In pigs, S. suis disease results in decreased performance and increased mortality, which have a significant economic impact on swine production worldwide. Facing the new regulations in preventive use of antimicrobials in livestock and lack of effective vaccines, control of S. suis infections is worrisome. Increasing and sharing of knowledge on this pathogen is of utmost importance. As such, the pathogenesis and epidemiology of the infection, antimicrobial resistance, progress on diagnosis, prevention, and control were among the topics discussed during the 4th International Workshop on Streptococcus suis (held in Montreal, Canada, June 2019). This review gathers together recent findings on this important pathogen from lectures performed by lead researchers from several countries including Australia, Canada, France, Germany, Japan, Spain, Thailand, The Netherlands, UK, and USA. Finally, policies and recommendations for the manufacture, quality control, and use of inactivated autogenous vaccines are addressed to advance this important field in veterinary medicine.

Effect of a “handshake” stewardship program versus a formulary restriction policy on High-End antibiotic use, expenditure, antibiotic resistance, and patient outcome

This study reports the effect of implementing an antibiotic stewardship program (ASP) based on the “handshake” strategy for 2 years on multiple endpoints compared with that in a preceding period when an antimicrobial restriction policy was only applied in the absence of a complete program in a tertiary-care Lebanese hospital. The studied endpoints were broad-spectrum antibiotic consumption, antibiotic expenditure, nosocomial bacteremia incidence rate, and patient outcome.An interrupted time series analysis was undertaken to assess the changes in the trend (ΔT) and level (ΔL) of the aforementioned endpoints among adult inpatients before (October 2013 to September 2015) and after the introduction of the ASP (October 2016 to September 2018).After the implementation of the “handshake” ASP, marked changes were observed in the consumption of broad-spectrum antibiotics. The mean use density levels for imipenem and meropenem decreased by 13.72% (P = 0.017), coupled with a decreasing rate of prescription (ΔT = −24.83 defined daily dose [DDD]/1,000 patient days [PD]/month; P = 0.02). Tigecycline use significantly decreased in level by 69.19% (P < 0.0001) and in trend (ΔT = −25.63 DDD/1,000 PD/month; P < 0.0001). A reduction in the use of colistin was also documented but did not reach statistical significance (ΔL = −8.71%, P = 0.56; ΔT = −5.51 DDD/1,000 PD/month = −5.5; P = 0.67). Antibiotic costs decreased by 24.6% after ASP implementation (P < 0.0001), and there was a distinct change from an increasing rate to a decreasing rate of expenditure (ΔT = −12.19 US dollars/PD/month; P = 0.002). The incidence rate of nosocomial bacteremia caused by carbapenem-resistant gram-negative bacteria (CRGNB) decreased by 34.84% (P = 0.13) coupled with a decreasing trend (ΔT = −0.23 cases/1,000 PD/month, P = 0.08). Specifically, a noticeable reduction in the incidence rate of bacteremia due to carbapenem-resistant Acinetobacter baumannii was documented (ΔL = −54.34%, P = 0.01; ΔT = −0.24 cases/1000 PD/month, P = 0.01). Regarding patient outcome, all-cause mortality rates did not increase in level or in rate (ΔL = −3.55%, P = 0.59; ΔT = −0.29 deaths/1000 PD/month, P = 0.6). The length of stay and 7-day readmission rate remained stable between the two periods.In conclusion, the “handshake” ASP succeeded in controlling the prescription rates of antibiotics and in decreasing the nosocomial bacteremia rates caused by CRGNB without compromising patient outcome in our facility. It also had an economic effect in reducing antibiotic costs compared with the previous restriction policy on antimicrobial dispensing.

2030. Impact of an Antimicrobial Stewardship Program on Carbapenem Susceptibility in a National Hospital in Bhutan

BackgroundThe overuse of broad-spectrum antibiotics drives antimicrobial resistance (AMR), and the prevalence of highly-resistant Gram-negative infections is increasing across the world, especially in low- and middle-income countries (LMIC). Carbapenem resistance is of particular concern since these are often the last line agents. Antimicrobial restriction is an antimicrobial stewardship intervention (AMS) that aims to reduce the use of broad-spectrum antibiotics to preserve antimicrobial susceptibility.MethodsThis is retrospective, observational study of antibiotic consumption and prevalence of antibiotic resistance of bacterial isolates from inpatients at Jigme Dorji Wangchuck National Referral Hospital, a 350-bed multi-specialty hospital in Thimphu, Bhutan. Antibiotic consumption and antimicrobial susceptibility were monitored from January 2015 to December 2017 by the pharmacy department and the microbiology lab, respectively. Antibiotic consumption was measured using defined daily doses (DDD) and expressed as DDDs per 1,000 persons per day. The antibiotic susceptibility was determined using the Clinical Laboratory Standards Institute (CLSI) guideline. A hospital AMS program with multidisciplinary team and good hospital managerial/ leadership support were initiated in 2016 and interventions included antimicrobial restrictions, educations, guidelines for use, post prescription review, de-escalation, audit and feedback.ResultsFrom 2015 to 2016, the DDDs of carbapenems and piperacillin–tazobactam (PTZ) increased while ceftriaxone decreased (Figure 1). After the AMS program was implemented in 2016, the annual DDDs of carbapenems decreased while PTZ and ceftriaxone increased. Antimicrobial susceptibility of Klebsiella pneumoniae and Escheriachia coli blood isolates to carbapenems and ceftriaxone increased from 2016 to 2017: 50/61 (82%) vs. 45/49 (92%) and 24/91 (26%) vs. 31/92 (34%), respectively.ConclusionImplementing an AMS program that restricted the use of carbapenems resulted in a decrease in carbapenem use and increased antimicrobial susceptibility for carbapenems and ceftriaxone. AMS interventions can be successful to decrease carbapenem-resistance in LMIC.

1064. Antimicrobial Stewardship Program at a Large Academic Medical Center, Impact Over 12 Years

BackgroundThe University of Minnesota Medical Center (UMMC) is a tertiary care facility, which has had a comprehensive antimicrobial stewardship program (ASP) for 12 years.MethodsThe antimicrobial stewardship team is comprised of a full-time PharmD and ID staff physicians. Recommendations are placed in the electronic medical record as a progress note. Verbal recommendations may also be made.ResultsThere was a downward trend in Hospital-acquired (HA) C. difficile diarrhea from 2007 to 2014 from 1.2 to 0.5/1000 patient-days (pt day). Rates appear stable from 2014 to 2019 with adjustment for change to NHSN lab-based CDI surveillance (Figure 1). From 2009 to 2019 a decrease was seen in VRE hospital-acquired infections (HAI) from 0.53 to 0.21/1,000 patient-days and in MRSA HAIs from 0.2 to 0.14/1,000 patient-days. Newly acquired ESBL HAIs have remained relatively stable from 2009 to 2019 at 0.09 to 0.05/1,000 patient-days. CRE HAIs are low but stable rates at 0.02/1,000 patient-days (Figure 2). We track antimicrobial utilization for internal and national reporting (starting in July 2017). A SAAR for all Antibacterial agents (ICUs, wards, and oncology units) of 1.33 in 2018. Our top four agents average DOT; piperacillin/tazobactam (66.81), cefepime (34.40), oral levofloxacin (23.56) and intravenous meropenem (21.49). We demonstrate lower average DOT for our restricted antimicrobials (206.21) as compared with our nonrestricted antimicrobials (236.74) (Figure 3). Cost savings continued from year to year. After adjusting for inflation annually, our expected costs ($84.08) compared with actual costs ($40.12 ytd 2019), demonstrates effective cost management of antimicrobial agents. (Figure 4)ConclusionWe observed a decrease in HAIs VRE and C. difficile infections after 3 years of operation, and MRSA after 5 years. This downward trend has continued. ESBL HAIs remain relatively stable and CRE are stable at low rates but remain emerging HAIs of concern. We are now focusing efforts on limiting unneeded fluoroquinolone and carbapenem use. We continue to analyze our SAAR data and internal DOT data to identify areas of opportunity to improve antimicrobial use. The ASP outcomes have continued to cost justify ongoing efforts. The effects of the program and the Infection Prevention Department appear to be synergistic. Disclosures All authors: No reported disclosures.

Patient-Provider Relationship: Compliance with Care

The Provider-Patient Relationship (PPR) is a clever thought of restorative human science in which patients deliberately approach a master and, along these lines, transform into a bit of an assertion in which they will all in all dwell with the pro's bearing. It has been suggested that an ideal PPR has six sections, explicitly purposeful choice, expert's ability, incredible correspondence, sympathy by the pros, congruity, and no hostile situation. Frankly, a poor PPR has been ended up being a critical obstacle for the two authorities and patients, and has at last impacted the idea of therapeutic administrations and limit of the patients to adjust to their malady. Inferable from poor PPR, patients don't exhibit consistence with master direction thoroughly; pick master - shopping by changing their expert again and again; remain tense; may pick quacks or other non-consistent kinds of treatment; basic addition in quick and circuitous remedial expenses. In perspective of irregular change in line of treatment as per the advice of different master and non-climax of the entire course of prescriptions, there is an indisputable augmentation for the ascent of antimicrobial restriction, which further heightens the restorative cost and strain, in conclusion may make real kinds of illness or complexities. From the experts' perspective, they may ask for unnecessary examinations or may give over-medicines, as a once-over to make sure everything seems ok. There is in like manner watched a stunning reduction in human touch or sensitivity; and a vital rising in sad contention among authorities. Keywords: Compliance, Patient satisfaction, Communication skills, Empathy, Trust, Patient comprehension, Motivation, Primary care.

How to Save Half a Million Dollars: An Antimicrobial Stewardship Program in a Tertiary Care Center.

We started a quality improvement project (QIP) with the aim of implementing an antimicrobial stewardship program (AMSP) to optimize antimicrobial use. We implemented this QIP in our tertiary care center with baseline data from July 1, 2017, to December 31, 2017 (pre-AMSP period), and the project period between January 1, 2018, and June 30, 2018. It covered every inpatient with a positive microbiological culture and patients who were initiated on a pre-selected list of 16 restricted antimicrobials. Numerous plan-do-study-act (PDSA) cycles were conducted alongside daily AMSP rounds, consisting of prospective audit and feedback to all stakeholders. The outcome measures used were antibiotic consumption and costs, Clostridium difficile infection (CDI) rates, the average length of stay (LOS), and adverse drug reaction (ADR) reporting rates. We demonstrated a considerable reduction in the consumption of the selected antibiotics, as well as a direct translation to cost-saving. The AMSP directly contributed to collective savings of around half a million US dollars in hospital bills for patients. We also demonstrated reduced average LOS, CDI rates, and increased reporting of ADRs to antibiotics. The reduction in average LOS was also directly beneficial to patients with reduced time spent in the hospital. The reduction in CDI rates proves that there is a reduction in the development of AMR, and in the short term, fewer incidences of healthcare-associated infections. This, in addition to better surveillance of ADRs to antimicrobials, improved patient safety and quality of care.