Antimicrobial Stewardship Committee Research Articles

Building an antimicrobial stewardship model for a public-sector hospital: a pre-implementation study.

Introduction. Antimicrobial resistance (AMR) is recognized as an important global health risk, associated with increased mortality, morbidity and healthcare costs. Antimicrobial stewardship (AMS) involves a coherent set of processes that promote the rational use of antimicrobials.Gap statement. An AMS programme should be adapted and developed according to the available resources of a facility. This requires an analysis of the core AMS elements that are already in place and the resources available.Aim. This study aimed to assess the readiness of a tertiary healthcare facility and staff towards implementing an antimicrobial stewardship programme (ASP).Methodology. This study focused on two aspects during an AMS pre-implementation phase. A situational or strengths, weaknesses, opportunities, and threats analysis was conducted based on (1) a questionnaire on attitudes and perceptions of pharmacists, clinicians and nurses towards AMR and AMS and (2) a situational analysis on the readiness of the facility.Results. The questionnaire, which was available for completion between September 2021 and December 2021, was sent to a total of 3100 healthcare professionals (HCPs). Thirty-two (1.0 %) HCPs comprising 2 pharmacists, 16 clinicians and 14 nurses completed the questionnaire. Of the total participants, 31 (96.9 %) viewed AMR as a problem in South African hospitals and 29 (90.6 %) perceived AMR as a problem at their facility. The majority (n = 29, 90.6 %) of the participants were familiar with the term AMS, and 26 (81.3 %) participants agreed to willingly participate in any initiatives involving antimicrobial use at the facility. The situational analysis depicted existing strengths in terms of AMS structures such as the formation of an AMS committee and information and technology systems at the HCP's disposal. Weaknesses included the limited number of AMS activities being carried out and poor participation from HCPs within the AMS team.Conclusion. A pre-implementation phase in the building of an ASP can greatly assist in finding gaps for improvement, which can then be addressed in the implementation phase. Furthermore, the pre-implementation phase provides a baseline to measure improvements once the implementation phase has been instituted.

P16 Centre of excellence on antimicrobial stewardship in Central Uganda

Abstract Background Supported by a Commonwealth Partnership for Antimicrobial Stewardship (CwPAMS 2) grant, our partnership team comprising members from Makerere University, Nottingham Trent University, Buckinghamshire Healthcare NHS Trust and Entebbe Regional Referral Hospital (ERRH) seeks to scale up and enhance sustainability on antimicrobial stewardship (AMS) in Central Uganda. Building on the achievements of our previous CwPAMS projects, this current initiative aims at strengthening, human, animal and environmental health practitioners’ capacity on AMS in health facilities and the community, as well as promoting increased use of microbiology and prescribing data to inform clinical decisions. Objectives To establish a centre of excellence on antimicrobial stewardship in Central Uganda using a One Health approach with a focus on capacity building, mentorship of lower-level facilities, and knowledge transfer. Methods This project uses a One Health approach involving professionals from the domains of human, animal and environmental health. ERRH, the project hub, is currently mentoring lower health facilities (spokes) in AMS. AMS champions have been identified in each of these health facilities who are leading ongoing activities. The project has also employed CwPAMS AMS assessment tools during scoping visits to assess the baseline conditions at seven lower-level health facilities (one regional referral hospital, two district hospitals, three health centre IIIs and two health centre IIs). AMS workshops have so far been held in two districts (Nakaseke and Butambala) including two general hospitals. Results The project held inception meetings that brought together different stakeholders in AMS. Scoping visits and AMS assessments have been successfully completed across seven health facilities, highlighting different AMS practices, challenges and intervention strategies. Furthermore, mentorship has so far resulted in establishment of AMS committees, identification of AMS champions, and adoption of the prescribing companion app at five of the seven mentored lower-level health facilities. AMS workshops held in the two districts resulted in increased knowledge on antimicrobial practices among the participants. The post assessments from the workshops showed that 73.4% of the participants had learnt the key importance of surveillance in AMS, 89.6% of the participants recognized the role of public awareness in promoting AMS, and 79.8% understood the value of infection prevention and control in promoting AMS in comparison with 51.7% at the pre-assessment (Figure 1). In addition, the online Community of Practice on AMS we established for health professionals in Uganda has seen a notable increase in membership, growing from 420 to over 600 members. Conclusions By engaging directly with front-line health practitioners using a hub and spoke mentorship model, the early stages of this project have provided more information on the prevailing AMS challenges in Uganda, particularly knowledge and training gaps, while revealing promising opportunities such as the existing health care structures and supportive policies. AMS capabilities of health practitioners have been improved by participation in the project, but further work is needed to limit the development of AMR in Uganda.

Overuse of Antibiotics: Who is to Blame? A Qualitative Study.

The irrational use of antibiotics seriously threatens global health. Clinicians undoubtedly play an essential role in consuming antibiotics in hospitals and communities, and their attitudes may help the health system's optimal treatment of antibiotics. In this study, we reported clinicians' experiences with antibiotics used in Isfahan, Iran. In a qualitative study conducted from October 2020 to March 2021, the experiences of 13 clinicians with different clinical specialties were collected through one-to-one interviews. Participants were selected through purposive sampling until data saturation; data collection was conducted through semi-structured interviews. Conventional content analysis was used to analyze the transcribed interviews. The main category was recognized and subcategorized and coded by three researchers. Eight women and five men with a mean work experience of 12.54 ± 10.047 years participated in the study. All of them worried about the overuse of antibiotics and antibiotic resistance. Clinicians believe that the antimicrobial stewardship committee is not active in our country. Laboratory challenges, healthcare providers, the poor performance of the health system, and marketing and business were the main categories of the study. Subcategrories of main categories included inefficiency in the function of laboratories, harmful profit, challenges in medical education, ups and downs of disease treatment, the unacceptable performance of hospitals, failure to upgrade the health system, threats and opportunities, and jobbery. The participants of this study believed that excessive use of antibiotics is a serious challenge in our country. Physicians were concerned about antibiotic resistance and believed that the pattern of antibiotic resistance was not routinely reported. Therefore, in our region, we should make more efforts to collect data in this field and provide this information to physicians. Also, this study confirmed many obstacles to implementing the antimicrobial stewardship program, and the infrastructure needs strengthening. There is also a need for cultural changes and the views of physicians.

HIV Type-1 Genotyping in the Context of the COVID-19 Pandemic: A Critical Tool for Identifying Antiretroviral Drug Resistance and Optimizing Treatment Strategies

Abstract Introduction/Objective The COVID-19 pandemic strained the healthcare system and the WHO recently reported increased rates of antibiotic resistance. Meanwhile, antiretroviral resistance can also lead to treatment failure and disease progression, especially in HIV patients. Here, we investigated the rates of HIV drug resistance (HIVDR) in our HIV population between pre and post-COVID-19 eras. Methods/Case Report The post-COVID-19 era began on 03/11/2020. Patients positive for HIV-1 between 01/2019- 08/2021 were included (total: 94 patients, 46 pre-COVID-19; 48 post-COVID-19). Patients’ charts were reviewed for demographics, laboratory results (including HIV-1 sequencing/genotyping (e.g., Genosure)), clinical presentation and management. Student t-test and Fisher exact test were calculated. Results (if a Case Study enter NA) Most patients were male (70%) and had a mean age of 49 years. 70% of patients had sufficient viral loads in samples reflexed to HIV genotyping. Post-COVID-19 patients harbored lower viral loads (1.8x105 vs. 3.4x105 copies/mL, p=0.05), CD4 counts (174 vs. 196 cells/mcL, p=0.7), CD8 counts (555 vs. 800 cells/mcL, p=0.04), and higher CD4/CD8 ratio (0.312 vs. 0.266, p=0.57). Overall, 20% of patients had HIVDR. Following COVID-19 pandemic, there was a 9% increase in HIVDR, predominantly seen in non-nucleotide reverse transcriptase inhibitors (NNRTI), although insignificant. Specifically, high resistance was documented for drugs Efavirenz (16%), Nevirapine (16%), and Rilpivirine (13%). We observed an increased prevalence of G190A, K101, K103, and E138 mutations conferring resistance to NNRTIs. Changes to therapy were observed in 47.8% (42/88) of total cases, with an increase of 12.5% in patients from post-COVID-19 era. Additionally, changes to therapy were observed more in patients with infectious diseases consultation (16% increase). Conclusion Increasing HIVDR was seen in our patient population post-COVID-19. Continued surveillance is critical to managing HIVDR and improving patient outcomes. The clinical utility of sequencing tests can outweigh the cost if results are appropriately acted upon which may involve the participation of other clinical teams and the antimicrobial stewardship committee.

2197. Impact of an INtake FOrm for Restricted Medications to (INFORM) better antibiotic use within a long-term acute care hospital system

Abstract Background Long-term Acute Care Hospitals (LTACHs) are uniquely positioned to treat patients with a high severity of illness for a long period of time. Despite this, there are substantial barriers to providing antimicrobial stewardship in this setting including limited resources and lack of patient data from transferring facilities. Methods This multi-center retrospective, quasi-experimental study evaluated the use of broad-spectrum antibiotics (BSAbx) over 3 timeframes in 43 LTACHs and rehabs within the Post Acute Medical System. Despite implementation of a restriction policy in June 2018, use remained high for ceftolozane/tazobactam (C/T), ceftazidime/avibactam (CZA), and meropenem/vaborbactam (MEV). In July 2020, the system antimicrobial stewardship committee created an INtake FOrm for Restricted Medications (INFORM) that required submission of pertinent clinical information for each patient receiving one of the target antibiotics as well as systematic review by an ID pharmacist. An electronic version of the INFORM was implemented in April 2022. Study timeframes included baseline (BL: July 2019-June 2020), phase 1 (P1: July 2020-March 2022), and phase 2 (P2: April 2022-March 2023). The primary objective was to determine if there was a difference in the combined use of C/T, CZA, and MEV measured as cost/acute patient day (APD) across the three timeframes. Secondary analyses included post-hoc analyses between these groups, and an evaluation of C/T, CZA, MEV with the addition of imipenem/cilastatin/relebactam (I/C/R). Results There was a significant reduction in antimicrobial use across intervention periods (mean cost/APD BL=2.5, P1=1.3, P2=0.8, p=0.045 using ANOVA, Figure 1). Sub-hoc analyses showed a significant difference for BL:P1 (p=0.02) and BL:P2 (p< 0.01), but not for P1:P2 (p=0.6). Even when adding I/C/R to control for any shifts in utilization to this agent after it was approved by the FDA, there was a statistically significant reduction across the intervention periods (p< 0.01 using ANOVA, Figure 2). Figure 2: Cost/Acute Patient Day for C/T, CZA, MEV vs. I/C/R over time C/T = ceftolozane/tazobactam, CZA = ceftazidime/avibactam, MEV = meropenem/vaborbactam, I/C/R = imipenem/cilastatin/relebactam Conclusion Completion of both the paper and electronic INFORM reduced C/T, CZA, and MEV use from baseline, showing that the systematic collection and review of patient data by an ID pharmacist reduced use of these BSAbx in a system of LTACHs and rehabs. Disclosures All Authors: No reported disclosures

Optimizing prophylactic antibiotic use among surgery patients in Ethiopian hospitals

BackgroundSince 2018, the Ethiopian Ministry of Health (MOH) has been working to institutionalize antimicrobial stewardship (AMS) programs across the country. The US Agency for International Development Medicines, Technologies, and Pharmaceutical Services Program supported Ethiopia’s multipronged One Health approach to combat AMR. The objective of this paper was to evaluate the effect of a quality improvement intervention to optimize the use of antimicrobials for surgical prophylaxis. MethodsBasic AMS interventions were introduced in five hospitals from January to May 2023. The AMS committees and multidisciplinary teams working at the surgical wards were trained and provided on-site support to implement surgical antibiotic prophylaxis (SAP) interventions. A before-after comparison was made for 206 medical records at baseline and 213 during the intervention phase. Qualitative data were gathered through discussions during experience-sharing workshops to supplement the quantitative results. ResultThere were improvements in the presurgery dose of the prophylactic antibiotic and its timing: the doses within the recommended range increased from 11.2 % to 61.0 % (p < 0.001) and the optimal timing increased from 68 % to 82.6 % (p < 0.001). The hospitals also demonstrated some nonsignificant improvement in the duration of prophylactic antibiotic use (from 35 % to 44.6 % [p = 0.106]), with change in practice hampered by practitioners' resistance to early discontinuation for fear of infection due to perceived weaknesses in infection prevention and control practices. Nonavailability of the recommended antibiotic of choice for surgical prophylaxis was another major challenge in addressing all the elements of SAP. The intervention demonstrated a significant antibiotic-related average cost saving, 51.8 Ethiopian birr (∼1 US dollar) per patient (p = 0.028). ConclusionShort-term investments with basic AMS interventions can help to improve SAP use in surgical wards. However, comprehensive success requires complementing AMS interventions with concurrent attention to proper supply chain and infection prevention and control.

Drug Utilization Evaluation and Impact of Pharmacist Interventions on Optimization of Piperacillin/Tazobactam Use: A Retrospective Analysis and Prospective Audit.

(1) Background: Piperacillin/tazobactam is a broad-spectrum antimicrobial encompassing most Gram-positive and Gram-negative aerobic and anaerobic bacteria. The inappropriate use of such broad-spectrum antibiotics is an important contributor to the rising rates of antimicrobial drug resistance worldwide. Drug utilization evaluation studies and pharmacists' interventions are vital to assess, develop, and promote the rational use of antibiotics. This drug utilization study aimed to evaluate the current utilization practice of piperacillin/tazobactam in a hospital setting and assess the impact of pharmacist intervention in improving its appropriate use. (2) Methodology: In this study, we used a retrospective cohort and a prospective cohort, a cross-sectional, observational method. It included a retrospective (Cycle A/pre-intervention-CycA) phase followed by an educational interventional phase conducted by the pharmacists. During the 2 months of educational intervention, pharmacists used several methods, including workshops, lectures, oral presentations, and the development and reinforcement of clinical pathways to promote the judicious use of piperacillin/tazobactam. This was followed by a prospective (Cycle B/post-intervention-CycB) phase to improve piperacillin/tazobactam usage appropriateness. The appropriateness criteria for this drug utilization evaluation were established based on antimicrobial guidelines, the published literature, the institutional antibiogram, consultation from the antimicrobial stewardship committee, and the product monograph (Tazocin). The appropriateness of CycA and CycB patients was compared using the measurable elements, including indication and dose based on renal function, timely order for cultures, de-escalation, and use of extended infusion protocol. (3) Results: The study population comprised 100 patients in both CycA and CycB. The mean age of the patients was 66.28 ± 16.15 and 67.35 ± 17.98, and the ratios of men to women were found to be 49:51 and 61:39 in CycA and CycB, respectively. It was observed that inappropriate usage was high in CycA patients, and the appropriateness was improved in CycB patients. A total of 31% of inappropriate empirical broad-spectrum use was found in CycA, and it was reduced to 12% in CycB patients. The transition of appropriateness was observed in all measurable criteria, which includes the optimized dose according to the renal function (CycA = 49% to CycB = 94%), timely bacterial culture orders (CycA = 47% to CycB = 74%), prompt de-escalation (CycA = 31% to CycB = 53%), and adherence to extended infusion institutional guidelines (CycA = 34% to CycB = 86%). (4) Conclusions: The study highlighted important aspects of inappropriate piperacillin/tazobactam use. This can be considerably improved by proper education and timely interventions based on the pharmacists' vigilant approach. The study results emphasized the need for surveillance of piperacillin/tazobactam usage by conducting similar drug utilization evaluations and practice to improve quality and safety in healthcare organizations globally.

Utilizing Clinical Decision Support in the Treatment of Urinary Tract Infection across a Large Pediatric Primary Care Network.

Cystitis and pyelonephritis are common bacterial infections in infants and children, and initial treatment is usually empirical. Antimicrobial stewardship advocates using narrow-spectrum antibiotics with consideration for local resistance patterns. Narrow-spectrum antibiotic use is critical in addressing the global issue of bacterial antimicrobial resistance, associated with approximately 5 million annual deaths. The antimicrobial stewardship committee developed a guideline for diagnosing and managing urinary tract infections and distributed it to all primary care providers. A standardized order set provided clinical decision support regarding appropriate first-line antibiotic therapy. A chief complaint of dysuria prompted the use of the order set. Prescription rates for the most common antimicrobials were tracked on a control chart. From March 2018 through March 2020, there were 4,506 antibiotic prescriptions for urinary tract infections. Utilization of the recommended first-line therapy, cephalexin, increased from 27.5% to 74.8%. Over the same period, trimethoprim-sulfamethoxazole, no longer recommended due to high local resistance, decreased from 31.8% to 8.1%. Providers have maintained these prescribing patterns since the conclusion of the project. Using clinical decision support as a standardized order set can sustainably improve the use of first-line antimicrobials for treating pediatric urinary tract infections.

Implementation of MRSA Nasal Swabs as an Antimicrobial Stewardship Intervention to Decrease Anti-MRSA Therapy in COVID-19 Infection.

In the early stages of treating patients with SARS-CoV-2, limited information was available to guide antimicrobial stewardship interventions. The COVID-19 Task Force and Antimicrobial Stewardship Committee, at a 988-bed academic medical center, implemented the use of methicillin-resistant Staphylococcus aureus (MRSA) nasal swab polymerase chain reaction (PCR) testing to assist with the de-escalation of anti-MRSA therapy in patients with suspected superimposed bacterial pneumonia in COVID-19. A retrospective study was conducted to evaluate the impact of MRSA nasal swab PCR testing on the rate of anti-MRSA therapy between 13 April 2020 and 26 July 2020. A total of 122 patients were included in the analysis. Of the patients included in the final analysis, 58 (47.5%) had anti-MRSA therapy discontinued and 41 (33.6%) avoided anti-MRSA therapy completely due to a negative swab result. With the implementation of MRSA nasal swab PCR testing in COVID-19 patients, anti-MRSA therapy was reduced in 81% of patients in this study. In patients who continued with anti-MRSA therapy, nasal swabs were either positive for MRSA or an alternative indication for anti-MRSA therapy was noted. Only three patients in the cohort had MRSA identified in a sputum culture, all of whom had anti-MRSA therapy continued. MRSA nasal swab PCR testing may serve as an effective antimicrobial stewardship tool in COVID-19 pneumonia.

P023 Evaluation of Beta-D-glucan assay as a tool for antifungal stewardship at a hospital in Mumbai, India

Poster session 1, September 21, 2022, 12:30 PM - 1:30 PMObjectivesClinical evidence suggests that the Beta-D glucan (BDG) test is useful as a tool for antifungal stewardship by helping in discontinuing empiric antifungal therapy. This study was hence initiated with the following objectives: (1) to calculate the percentage of echinocandin prescriptions in patients with a subsequent negative BDG test and the compliance to recommendations for stopping echinocandins for the above prescriptions, (2) to study outcomes in patients where echinocandins were stopped, and (3) to study the total cost savings.MethodsThe study was conducted for a 1-year period from January 2021 to December 2021 in a tertiary care hospital in Mumbai. The antimicrobial stewardship committee recommends sending a serum sample for BDG along with paired blood culture for all patients before starting empirical antifungal therapy. The choice of empiric antifungal therapy at our hospital is echinocandins (caspofungin, micafungin, and anidulafungin). The BDG test was performed using Fungitell® assay (Associates of Cape Cod, Massachusetts) that quantitatively measures 1, 3-β-D-glucan levels which is run twice a week on Wednesday and Saturday. The cut-offs for a negative, indeterminate and positive result are 60 pg/ml, 60-79 pg/ml, and >80 pg/ml respectively. The result of the BDG test and blood culture was promptly informed to the consultant in charge and recommendations were made to discontinue the echinocandin if both tests were negative. The compliance with these recommendations was monitored. The patients in whom the echinocandin was stopped were monitored during their hospital stay or on day 28 after stopping the echinocandin whichever was earlier. The total cost savings [in Indian Rupees (INR) and converted into US Dollars (USD)] were calculated based on an average of 10 days extra therapy with echinocandins.ResultsA total of 337 echinocandins were prescribed in 294 patients and reviewed during the study period; anidulafungin (170, 50%) was the most commonly prescribed echinocandin followed by caspofungin (131, 39%), and micafungin (36, 11%). The BDG result as well as blood fungal cultures were negative for 53 prescriptions in 49 patients (15.7%). The compliance to recommendations for stopping echinocandin in these prescriptions was 100% (53/53). None of these 49 patients had a sterile culture positive for Candida during the follow-up period. A total of 17 patients died, 1 was discharged against medical advice, 19 were discharged and 12 were still in hospital at the end of the follow-up period. No deaths could be attributed to invasive fungal infections at 28-day follow-up. Total cost savings were 6794 440 INR, corresponding to 89 000 USD during the study year.ConclusionBDG test-based stewardship strategy helped in reducing the use of echinocandins with cost savings and no increased risk of invasive fungal infections related to adverse outcomes in patients where echinocandins were discontinued. The universal compliance to recommendations to deescalate could be achieved by constant dialogue between the departments of Clinical Microbiology and Clinical Medicine.

Comparing Patterns in Antimicrobial Use During Global Point Prevalence Study at a Single Tertiary Hospital in Ghana: Implications for Antimicrobial Stewardship Programme

BackgroundThe Global Point Prevalence Study (PPS) provides a platform for institutions to register and add clinical information on antimicrobial usage and determine variables related to proper antimicrobial stewardship.ObjectiveTo assess the trends in antimicrobial usage and quality indicators in antimicrobial prescriptions at our hospital.MethodWe retrospectively compared data collected at Komfo Anokye Teaching Hospital (KATH) during the Global PPS in 2015 and 2019. Both surveys took place on a day in September of the respective year. Medical records of all in-patients on admission at 0800 hours on a specific day were reviewed for antimicrobial use in the survey. Data on antibiotic use, including indications for use and the presence of quality indicators, were recorded.ResultsThe total number of patients on admission in 2015 and 2019 were 386 and 630, respectively. The proportion of patients on at least one antimicrobial was 64% (247/386) and 58.4% (368/630) in 2015 and 2019, respectively. Pneumonia was the most common medical condition for which antimicrobial was prescribed for 2015, 30(16.9%) and 2019, 44(23.0%), respectively. There was a decrease in Hospital-acquired infections from 2015, 6.2% (24/386) to 4.8% (30/630) in 2019. The use of biomarkers increased from 4.9% (12/247) to 7.6% (28/368).ConclusionOver 50% of hospitalised patients were on antimicrobials for both years. The inauguration of the antimicrobial stewardship committee at KATH will improve these quality indicators.

Antimicrobial Stewardship in Public-Sector Hospitals in KwaZulu-Natal, South Africa.

Antimicrobial resistance (AMR) is a serious global public-health threat. Evidence suggests that antimicrobial stewardship (AMS) is a valuable tool to facilitate rational antibiotic use within healthcare facilities. A cross-sectional situational analysis using a questionnaire was conducted to determine the current status of antimicrobial stewardship (AMS) activities in all public-sector hospitals in KwaZulu-Natal (KZN). The survey had a 79% (57, N = 72) response rate. A total of 75% of hospitals had an antimicrobial stewardship committee (AMSC), 47% (20, N = 43) had a formal written statement of support from leadership, and 7% (3, N = 43) had budgeted financial support. Only 37% (16, N = 43) had on-site or off-site support from a clinical microbiologist, and 5% (2, N = 43) had an on-site infectious disease (ID) physician. Microbiologist input on pathogen surveillance data (aOR: 5.12; 95% CI: 4.08–22.02; p-value = 0.001) and microbiological investigations prior to the commencement of antibiotics (aOR: 5.12; 95% CI: 1.08–42.01; p-value = 0.041) were significantly associated with having either on- or off-site microbiology support. Respondents that had a representative from microbiology on the AMSC were significantly associated with having and interrogating facility-specific antibiograms (P = 0.051 and P = 0.036, respectively). Those facilities that had access to a microbiologist were significantly associated with producing an antibiogram (aOR: 4.80; 95% CI: 1.25–18.42; p-value = 0.022). Facilities with an ID physician were significantly associated with having a current antibiogram distributed to prescribers within the facility (P = 0.010) and significantly associated with sending prescribers personalized communication regarding improving prescribing (P = 0.044). Common challenges reported by the facilities included suboptimal hospital management support; a lack of clinicians, pharmacists, nurses, microbiologists, and dedicated time; the lack of a multidisciplinary approach; low clinician buy-in; inadequate training; a lack of printed antibiotic guidelines; and financial restrictions for microbiological investigations. The survey identified the need for financial, IT, and management support. Microbiology and infectious disease physicians were recognized as scarce human resources.

Improving antimicrobial use through antimicrobial stewardship in a lower-middle income setting: a mixed-methods study in a network of acute-care hospitals in Viet Nam

ObjectivesThis study aimed to analyse the current state of antimicrobial stewardship (AMS) in hospitals in Viet Nam, a lower-middle income country (LMIC), to identify factors determining success in AMS implementation and associated challenges to inform planning and design of future programmes. MethodsWe conducted a mixed-methods study in seven acute-care hospitals in the antimicrobial resistance (AMR) surveillance network in Viet Nam. Data collection included 7 focus group discussions, 40 in-depth interviews and a self-administered quantitative survey of staff on AMR and AMS programmes. We summarised qualitative data by reporting the most common themes according to the core AMS elements, and analysed quantitative data using proportions and a linear mixed-effects model. ResultsThe findings reveal a complex picture of factors and actors involved in AMS implementation from the national level to the departmental and individual level within each hospital. The level of implementation varied, starting from the formation of an AMS committee, with or without active delivery of specific interventions. Development of treatment guidelines, pre-authorisation of antimicrobial drug classes, and post-prescription audit and feedback to doctors in selected clinical departments were the main interventions reported. A higher level of leadership support and commitment to AMS led to a higher level of engagement with AMS activities from the AMS team and effective collaboration between departments involved. ConclusionEstablishing country-specific guidelines on AMS staffing and adapting standards for AMS education and training from international resources are needed to support capacity building to implement AMS programmes effectively in LMICs such as Viet Nam.

Antibiotic resistance in aerobic bacterial isolates from infected diabetic foot ulcers in North Eastern Tanzania: an urgent call to establish a hospital antimicrobial stewardship committee

Background: Diabetic foot ulcers (DFU) is among major health problems which impact the socio economic burden globally. We aimed at assessing the susceptibility pattern of antimicrobials in DFU infections among patients admitted in the surgical department at Kilimanjaro Christian Medical Centre (KCMC).Methods: This descriptive cross-sectional study was conducted from September 2018 through March 2019. Pus swabs were collected on the first day of admission by deep wound swabbing after irrigation with normal saline solution. Kirby-Bauer method was done according to the Clinical and Laboratory Standard Institute (CLSI) guidelines.Results: Sixty diabetic ulcer patients had 62 bacterial isolates. Majority of the isolates were gram negative 49/62 (79.03%). The most common isolate was Escherichia coli 15/62 (24.19%) followed by Pseudomonas aeruginosa 14/62 (22.58%), Proteus mirabilis 8/62 (12.9%) and Staphylococcus aureus 5/62 (8.06%). Klebsiella pneumoniae, coagulase negative Staphylococcus, Proteus vulgaris, and Streptococcus pyogenes each contributed 4/62 (6.25%) isolates. Of the 49/62 (79.3%) gram negative isolates, 8/49 (16.33%) were mono resistant, 30/49 (61.22%) were multiresistant, and 11/49 (22.45%) were susceptible. Of the multi-resistant isolates, E. coli 12/15 (80.00%), and P. aeruginosa 7/14 (50.00%) were predominant. A total of 39/62 (62.90%) isolates in patients contributed to poorer outcomes including loss of body part. Patients with ulcers infected by P. aeruginosa 11/39 (28.21%) had the highest number of surgical removal of body parts followed by E. coli 8/39 (20.51%). Gram negative bacteria were highly susceptible to amikacin 91.18%, meropenem 93.33% and imipenem 95.24%. Isolates susceptibility to ceftriaxone was 32%.Conclusions: Amikacin, meropenem and imipenem can be safely used as broad-spectrum antimicrobials in DFU. The standard of care remains culture and sensitivity of isolated microorganisms in combating diabetic foot ulcers infections.

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.

Diagnostic Stewardship in Lower Respiratory Tract Infections Using Procalcitonin

Background: A team of infectious diseases physicians, infectious diseases pharmacists, clinical laboratorians, and researchers collaborated to assess the management of lower respiratory tract infections (LRTIs). In 1 sample from our institution, 96.1% of pneumonia cases were prescribed antibiotics, compared to 85.0% in a comparison group. A collaborative effort led to the development of a protocol for procalcitonin (PCT)-guided antibiotic prescribing that was approved by several hospital committees, including the Antimicrobial Stewardship Committee and the Healthcare Pharmacy &amp; Therapeutics Committee in December 2020. The aim of this analysis was to develop baseline information on PCT ordering and antibiotic prescribing patterns in LRTIs. Methods: We evaluated all adult inpatients (March–September 2019 and 2020) with a primary diagnosis of LRTI who received at least 1 antibiotic. Two cohorts were established to observe any potential differences in the 2 most recent years prior to adoption of the PCT protocol. Data (eg, demographics, specific diagnosis, length of stay, antimicrobial therapy and duration, PCT labs, etc) were obtained from the UK Center for Clinical and Translational Science, and the study was approved by the local IRB. The primary outcome of interest was antibiotic duration; secondary outcomes of interest were PCT orders, discharge antibiotic prescription, and inpatient length of stay. Results: In total, 432 patients (277 in 2019 and 155 in 2020) were included in this analysis. The average patient age was 61.2 years (SD, ±13.7); 47.7% were female; and 86.1% were white. Most patients were primarily diagnosed with pneumonia (58.8%), followed by COPD with complication (40.5%). In-hospital mortality was 3.5%. The minority of patients had any orders for PCT (29.2%); among them, most had only 1 PCT level measured (84.1%). The median length of hospital stay was 4 days (IQR, 2–6), and the median duration of antibiotic therapy was 4 days (IQR, 3–6). Conclusions: The utilization of PCT in LRTIs occurs in the minority of patient cases at our institution and mostly as a single measurement. The development and implementation of a PCT-guided therapy could help optimize antibiotic usage in patients with LRTIs.Funding: NoDisclosures: None

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.

53. Effect of rapid identification of bloodstream isolates on antibiotic management using a pharmacist-based treatment algorithm

BackgroundThe use of rapid molecular diagnostic testing to identify microorganisms and resistance markers has great potential to optimize medical care and assist with antimicrobial stewardship. We implemented the Verigene bloodstream infection testing panel along with a pharmacy notification system to clinicians and assessed efficacy of the system.MethodsIn November 2019, we implemented the Verigene gram positive and negative panels for patients with positive blood cultures. Our antimicrobial stewardship committee developed a recommended treatment algorithm for pharmacists to use when notified of Verigene results. The first positive bottle per patient and per admission was tested. Subsequent positive bottles were not tested on the Verigene unless a different morphology was noted on the gram stain. A gram stain was performed on all positive cultures and this result was called to the patient’s nurse (if inpatient) and the covering physician was notified of the result. After the Verigene result was available, an assigned pharmacist was notified of these results (organism identification and resistance markers if identified). Pharmacists notified covering physicians of the test results and the recommended antibiotic management. Pharmacists documented the frequency that the test result changed the antibiotic management, including escalation, de-escalation or no change in therapy. The data from the first six months was summarized.ResultsFrom 11/19/19-5/18/20, a total of 575 test results were called into the pharmacist (average 3.2/day). Among these, 165 (28.7%) were considered likely contaminants, 106 had no change in therapy and 59 had antibiotic de-escalation. Among the remaining 410 patients, 156 had de-escalation, 53 had escalation, 30 were not on any antibiotics and appropriate antibiotics were started. Overall, antibiotic management changed in 298/575 (51.8%) of isolates run by Verigene in our institution including 215 (37.4%) de-escalations. The most frequent antibiotics that were stopped included vancomycin (142) and cefepime (53).ConclusionOur pharmacist-based algorithm for notification and treatment recommendation based on Verigene results was highly successful in optimizing antibiotic management and improving antimicrobial stewardship in our institution.Disclosures All Authors: No reported disclosures

42. A Pharmacist-Led Intervention to Decrease Anaerobic Coverage for Hospitalized Patients with Community-Acquired Pneumonia

BackgroundCommunity-acquired pneumonia (CAP) is frequently mis-categorized as aspiration pneumonia, prompting the addition of anaerobic coverage to the antibiotic regimen. In our institution, this usually takes the form of adding metronidazole to ceftriaxone. The 2019 American Thoracic Society and Infectious Diseases Society of America CAP guidelines recommend anaerobic coverage only for hospitalized patients with a suspected lung abscess or empyema. The objective of this study was to determine if a pharmacist-led workflow could increase adherence to the 2019 CAP guideline recommendations by limiting anaerobic coverage to those rare occasions.MethodsThe hospital antimicrobial stewardship committee approved a pharmacist workflow and guidance document which outlines criteria to evaluate appropriateness of anaerobic coverage for hospitalized patients with CAP and no other indications for antibiotics. If anaerobic coverage is not indicated, the pharmacist submits a standardized message to the treating provider via the electronic medical record, recommending discontinuation of metronidazole. This workflow was implemented on October 3, 2019. Metronidazole days of therapy (DOT) per 1000 patient days in quarters 1 through 4 of 2019 and quarter 1 of 2020 were collected as well as percent acceptance of documented pharmacist interventions from October 3, 2019 until March 31, 2020.ResultsBetween October 3, 2019 and March 31, 2020, a total of 221 interventions were made by pharmacists to discontinue metronidazole in hospitalized CAP patients where anaerobic coverage was not indicated. Out of those 221 interventions, 164 (74%) were accepted by providers and only 57 (26%) were rejected.The DOT per 1000 patient days of metronidazole was assessed for the three quarters prior to our intervention and the two quarters after the intervention. Compared to the three quarters prior, metronidazole DOT per 1000 patient days decreased by 26.6% for the two quarters following implementation of the pharmacist-led intervention (Figure 1).Figure 1: Metronidazole DOT per 1000 patient days from January 1, 2019 through March 31, 2020. Vertical line indicates when pharmacist workflow was implemented. ConclusionA pharmacist antimicrobial stewardship intervention at our institution increased adherence to CAP guidelines and decreased unnecessary antibiotic exposure in hospitalized CAP patients when anaerobic coverage was not indicated.Disclosures All Authors: No reported disclosures

Exploring perspectives on antimicrobial stewardship: a qualitative study of health managers in Kenya

BackgroundAntimicrobial resistance is a significant public health concern with the establishment of antimicrobial stewardship in hospitals being increasingly obligatory. Perspectives and insights of health managers on antimicrobial stewardship (AMS), complementary health services and building blocks are imperative towards implementation of robust AMS programs. This study aimed to understand perspectives of hospital managers on AMS and identify areas of management engagement while addressing potential blockades to change.MethodsA cross-sectional, qualitative, multicenter study was conducted in three hospitals in Kenya. Key-informant interviews on perspectives on AMS were administered to hospital managers. Qualitative data was captured using audio tapes and field notes, transcribed and managed using NVivo 12 software. An iterative process was used to develop the thematic framework and updated in two rounds of iteration analysis. Analysis charts for each emergent theme were developed and categorized across all participants.ResultsPerspectives on AMS are described in five thematic categories; Importance of antimicrobial stewardship and the role of medicines and therapeutics committee, availability of antimicrobial formulary and usage surveillance systems, laboratory competency and recommendations for infection prevention and management, educational resources and communications channels available, building blocks and low-lying fruits for Antimicrobial Stewardship Committees. The role of stewardship collaboration in diagnosis and antimicrobial prescription was alluded to with managers indicating a growing rise in occurrence of antimicrobial resistance. There lacked contextualized, hospital specific antimicrobial formulary and adequate laboratory competency. Staff training and communication channels were available in varying capacity across the three hospitals. Building blocks identified include medicines and therapeutics committee, education, and training platforms (Continuous Medical Education and Continuous Professional Development activities) and hospital leadership commitment.ConclusionsThe practice of antimicrobial stewardship is not implemented and well developed as demonstrated by lack of core AMS complementary health services. However, the health managers are aware of the fundamental importance of antimicrobial stewardship programs and the vast benefits of implementation and institutionalization of AMS to hospitals and their clients. The findings underpin the importance of understanding and incorporating perspectives of health managers on existing contextual mechanisms that can be leveraged on to establish robust AMS programs in the fight against antimicrobial resistance.