Antimicrobial Stewardship Efforts Research Articles

Improvement in Diagnosis and Management of Nosocomial Pneumonias in a Cardiovascular Surgery Intensive Care Unit: A Multidisciplinary Approach

Abstract: Background: While criteria for the diagnosis of nosocomial pneumonias exist, objective definitions are a challenge and there is no gold standard for diagnosis. We analyzed the impact of the implementation of a logical, consensus-based diagnostic and treatment protocol for managing nosocomial pneumonias in the cardiovascular surgery intensive care unit (CVS-ICU). Methods: We conducted a quasi-experimental, interrupted time series analysis to evaluate the impact of a diagnostic and treatment protocol for nosocomial pneumonias in the CVS-ICU. Impacts were measured relative to patient outcomes, diagnostic processes, and antimicrobial stewardship improvement. Descriptive statistics were used to analyze results. Results: Overall, 35 pre-protocol and 39 post-protocol patients were included. Primary clinical variables suggesting pneumonia in pre- and post-protocol patients were new lung consolidation (50% vs. 71%), new leukocytosis (59% vs. 64%), and positive culture (32% vs. 55%). Appropriate diagnostic testing improved (23% vs. 54%, p = 0.008) after protocol implementation. The proportion of patients meeting the criteria for nosocomial pneumonia (77% vs. 87%) was not statistically significant, though more patients in the post-protocol group met probable diagnostic criteria (51% vs. 77%). Duration of therapy was not significantly different (6 days [IQR = 5.0, 10.0] vs. 7 days [IQR = 6.0, 9.0]). Conclusions: The implementation of a diagnostic and treatment protocol for management of nosocomial pneumonias in the CVS-ICU resulted in improved diagnostic accuracy, advanced antimicrobial and diagnostic stewardship efforts, and laboratory cost savings without an adverse impact on patient-centered outcomes.

Opportunities to Enhance Diagnostic Testing and Antimicrobial Stewardship: A Qualitative Multinational Survey of Healthcare Professionals.

Antimicrobial resistance (AMR) is a global public health challenge. Global efforts to decrease AMR through antimicrobial stewardship (AMS) initiatives include education and optimising the use of diagnostic technologies and antibiotics. Despite this, economic and societal challenges hinder AMS efforts. The objective of this study was to obtain insights from healthcare professionals (HCPs) on current challenges and identify opportunities for optimising diagnostic test utilisation and AMS efforts. Three hundred HCPs from six countries (representing varied gross national incomes per capita, healthcare system structure, and AMR rates) were surveyed between November 2022 through January 2023. A targeted literature review and expert interviews were conducted to inform survey development. Descriptive statistics were used to summarise survey responses. These findings suggest that the greatest challenges to diagnostic test utilisation were economic in nature; many HCPs reported that AMS initiatives were lacking investment (32.3%) and resourcing (40.3%). High resistance rates were considered the greatest barriers to appropriate antimicrobial use (52.0%). Most HCPs found local and national guidelines to be very useful (≥ 51.0%), but areas for improvement were noted. The importance of AMS initiatives was confirmed; diagnostic practices were acknowledged to have a positive impact on decreasing AMR (70.3%) and improving patient outcomes (81.0%). AMS initiatives, including diagnostic technology utilisation, are pivotal to decreasing AMR rates. Interpretation of these survey results suggests that while HCPs consider diagnostic practices to be important in AMS efforts, several barriers to successful implementation still exist including patient/institutional costs, turnaround time of test results, resourcing, AMR burden, and education. While some barriers differ by country, these survey results highlight areas of opportunities in all countries for improved use of diagnostic technologies and broader AMS efforts, as perceived by HCPs. Greater investment, resourcing, education, and updated guidelines offer opportunities to further strengthen global AMS efforts.

Estimating Clostridioides difficile infection-associated readmission rates: A systematic review and meta-analysis.

The economic burden of Clostridioides difficile infection (CDI) is considerable and mostly associated with a high frequency of hospitalizations. Numerous publications have demonstrated that CDI is associated with a higher risk of hospital readmission, but not always a specific rate or attributable to disease recurrence. In this systematic review, we describe the incidence of 30-day CDI-associated readmission rates and the effect of active interventions. Three search engines were utilized for the literature search, and a total of 9 studies were included in this review. Hospital readmission proportions from interventional and observational studies were analyzed through meta-analysis with random effects. Two thousand five hundred and twenty-one articles were identified. After screening full-text articles, 9 eligible articles published between 2002 and 2023 met the inclusion criteria. In total, 132,862 CDI patients were evaluated. Thirty-day CDI-associated readmissions were defined as either an ICD9/10 code indicating CDI admission with a prior admission within the past 30 days (n = 4) or a medical chart evaluation of signs and symptoms consistent with CDI (diarrhea) along with a positive diagnostic test (n = 5) with a prior hospitalization for CDI within the past 30 days. Meta-analysis of observational studies estimated 30-day CDI readmissions were 6% (95% CI, 5%-7%). Three studies evaluated the effect of active interventions to reduce CDI-associated 30-day readmission rates. Two of 3 interventions reduced the likelihood of CDI-associated 30-day readmissions. This systematic review identified a 6% rate of 30-day CDI-associated hospital readmission. Antimicrobial stewardship efforts and the use of specific therapeutics were shown to reduce these rates.

The use of new antibacterial drugs against infections caused by multidrug-resistant Gram-negative bacteria: an Italian real-world evidence study in a Lombardy hospital.

Infections caused by multidrug-resistant (MDR) bacteria are typically associated with high morbidity and mortality, especially in vulnerable individuals such as patients with prolonged hospitalizations, immunocompromised individuals, and the elderly. This study aimed to provide post-marketing surveillance results concerning the prevalence of antibiotic resistance against Gram-negative bacteria through the collaboration of a multidisciplinary team. Patients involved have been treated with new antibacterial drugs, in particular ceftazidime/avibactam (C/A), meropenem/vaborbactam (M/V), cefiderocol, and ceftolozane/tazobactam (C/T). The most resistant bacterial species were Klebsiella spp., Pseudomonas aeruginosa, and Acinetobacter baumannii. Italian Drug Agency (AIFA) monitoring records for inpatients have been collected and analyzed, assessing the characteristics of the patients involved. Adverse drug reactions (ADRs) and drugs involved have been reported using a descriptive analytical approach. All data have been collected retrospectively from patient's medical records and entered into an electronic case report form (CRF). Among the 104 treated patients, Klebsiella spp. accounted for 50.1% of infections, Pseudomonas aeruginosa for 32.7%, Acinetobacter baumannii for 3%, and other bacterial species for 1.92% configuring polymicrobial infections. Regarding treatment outcomes, healing was achieved in 61 (58.6%) patients, 23 (22.1%) patients died, 8 (7.7%) patients discontinued empirical therapy, and 3 (2.9%) patients were lost to follow-up. Despite the introduction of new antibacterial drugs active against Gram-negative bacteria is improving the clinical scenario, it is crucial that the use of new antibacterial drugs be implemented by appropriate antimicrobial stewardship, surveillance programs, and monitoring efforts to prevent further spread of resistance. This study showed that the new antibiotics have good efficacy against MDR bacteria and cause negligible side effects.

Determining a future policy focus to support antimicrobial stewardship in community pharmacy: A modified Delphi study

BackgroundOver the past decade, the pharmacy sector's policy, academic and professional spheres have increasingly drawn attention to the opportunities to better leverage the untapped potential of the community pharmacy sector in contributing to global efforts to reduce antimicrobial resistance (AMR). While efforts are in train, progress is slow. ObjectiveTo draw insights from global experts in the field to identify a broad range of potential future policy directions to support community pharmacists' involvement in antimicrobial stewardship (AMS). MethodsA modified Delphi technique, comprising two survey rounds to build consensus amongst global community pharmacy sector stakeholders and opinion leaders. In Round 1, participants rated their level of agreement with 28 statements across the three domains of policy design, implementation design, and monitoring and evaluation. Participants were also invited to contribute feedback in Round 1, which was reflected as new statements (n = 10) in Round 2. In Round 2, participants were asked to re-assess Round 1 statements in view of the group consensus and to rate the new statements. Results289 participants were invited to participate. 48/289 (17% response rate) completed Round 1, and 25/42 (60% response rate) completed Round 2. Consensus (defined as >70% agreement) was achieved for 79% (n = 30) of the statements across the three domains. ConclusionPharmacy sector experts agreed that acknowledging community pharmacists in AMS national action plans is an important component, signalling a recognition of the sector's contribution to whole-of-nation AMS efforts. Implementation components that achieved consensus reflect the profession's evolution to a professional service driven model, particularly in complementary AMS initiatives including infection prevention and control measures. Context-specific adjustments to support implementing these AMS measures will be required, in addition to striking the appropriate balance to support the pace of increased community pharmacists'involvement in AMS with building whole-of-profession buy-in.

A predictive algorithm for the analysis of AMR trends and healthcare decision support

Background Translating available AMR surveillance data to observe evolving patterns of microbial resistance to antimicrobial agents while identifying regions at high risk of resistant cases and serving as a decision-support tool is an aspect of AMR surveillance that is rarely explored nationwide and uncommon globally. Therefore, we developed a two-tier dashboard algorithm (PATHFINDER) that can analyse antimicrobial surveillance datasets, observe evolving global spatiotemporal patterns of AMR, and integrate local AMR gene resources to identify functional AMR determinant genes and antibiotic classes from the query organism genome. Methods The Python-based plotly library was used to develop the interactive variables of the Antimicrobial Testing Leadership Surveillance (ATLAS) dataset in an adjustable spatiotemporal environment. A lightweight database containing multiple known resistant genes from the ResFinder database was used as a prototype to identify unique AMR determinant genes from query nucleotide sequences. In R, a function was created to accept query genome sequences and generate Kmers of length 250 using the blaster package. The GPT-4 API plug-in was embedded with adequate prompt parsing for it as an interpretation LLM function. Results AMR trendline plots were designed for invasive infections and customised based on the class of antibiotics and infection types on the surveillance dashboard. The decision-support tool correctly predicted resistant genes with a sensitivity of 75% on pre-confirmed organisms. The observed specificity score (51.5%) was due to the need for more filtering and optimisation and not to PATHFINDER performance. When run against the reference gene dataset containing pre-identified AMR genes, the support tool generated a BLAST table with identified AMR gene determinants in a nucleotide sequence. Conclusions The PATHFINDER algorithm has the potential to revolutionise healthcare decision-making. It can inform targeted interventions, guide antimicrobial stewardship efforts at a national level, promote appropriate antibiotic use, and significantly reduce the risk of resistance development.

Nurses' attitudes, behaviours, and enablers of intravenous to oral switching (IVOS) of antibiotics: a mixed-methods survey of nursing staff in secondary care hospitals across the Midlands region of England

Intravenous (IV) antibiotic use in secondary care in England is widespread. Timely appropriate intravenous to oral switch (IVOS) has the potential to deliver significant clinical and operational benefits. To date, antimicrobial stewardship (AMS) efforts around IVOS have not focused on the nursing staff who administer antibiotics, which represents a significant gap in AMS programmes. To determine the involvement of bedside nurses in acute trusts in the Midlands region of England in IVOS in their organisations and describe their views regarding how to improve IVOS. An anonymous self-administered mixed-methods online survey was developed and distributed to nursing staff in acute trusts via antimicrobial stewardship networks between March and May 2023. Quantitative data was analysed to describe participant demographics and behaviours, whereas barriers and enablers to IVOS were explored through thematic content analysis of responses to open-ended questions. 545 nursing staff responded to the survey. The majority (65.3%) routinely suggested IVOS to clinicians, despite only 50.6% being aware of local IVOS policies. One third (34.7%) did not suggest IVOS, relying on doctors, believing their patients needed IV treatment, or lacked knowledge and skills to request IVOS. Content analysis of suggestions for improving the rate of IVOS proposed three major themes (People, Process, System) and identified that education and training, improved confidence and interprofessional relationships, and prompts were important drivers. Nursing staff suggest IVOS to other clinicians, but more education and resources are needed to enable and empower them in this role.

A survey of community pharmacists’ and healthcare advisors’ views and experiences on the provision of a Test and Treat Service for uncomplicated lower urinary tract infection in a retail pharmacy chain in Ireland

Abstract Introduction The use of Point of Care Testing (POCT) as an aid to guide antibiotic prescribing has been highlighted in Ireland’s second One Health National Action Plan on Antimicrobial Resistance 2021-2025 (iNAP2).[1] The role of community pharmacy is expanding with the introduction of antimicrobial stewardship (AMS) POCT strategies. Uncomplicated urinary tract infections (UTIs) are frequent and burdensome in the community. With antibiotic resistance on the rise amongst uropathogens, AMS efforts to reduce inappropriate antibiotic prescribing for urinary symptoms are paramount. Aim To evaluate community pharmacy staff views and experiences on the provision of a Cystitis Test-and-Treat Service for uncomplicated UTIs, while identifying opportunities for service improvement and expansion. Methods An electronic survey on Microsoft® Forms was distributed within a large retail pharmacy chain in Ireland during November 2021, with two reminders issued. Pharmacists and Healthcare advisors over the age of 18, working in 88 pharmacies that provided the Velieve Cystitis Test-and-Treat Service were eligible to participate. The survey was subdivided into participant demographics, local UTI information, views and experiences of participants on the Cystitis Test-and-Treat Service, the patient information leaflet and the training completed by pharmacy staff providing the service and included open-ended and closed-ended or Likert-scale questions. The survey was developed based on the literature and was revised following the contributions of pharmacy chain pharmacists and its Research Governance Committee who have a working knowledge of Service. Data were analysed using Microsoft® Excel and IBM® SPSS® statistics version 28.0. Qualitative data from the open-ended survey questions were analysed using thematic analysis. Results A total of 43 pharmacy staff (18 pharmacists and 25 healthcare advisors) participated in the study (overall participation rate of 10.2%). The majority of participants were female (83.7%) and most pharmacies were located in a town/suburb area (55.8%). The majority of participants (76.7%) estimated that service users with symptoms suggestive of UTI present to the pharmacy first, before visiting their GP. Participants believed that the Cystitis Test-and-Treat Service improved service user satisfaction in symptom management, reduced antimicrobial prescribing, alongside reduced general practitioner workload. High acceptability was attributed to the speed and convenience of the service, while time cost and time required explaining the service were identified as barriers. The associated smartphone application was identified as a service weakness. Participants recommended extended training on service user eligibility with perhaps training videos to improve overall confidence. While the low response rate and small sample size is a limitation of this study, the inclusion of participants from two differing pharmacy roles strengths the findings. Conclusion This study highlights that POCT are feasible AMS initiatives that enhance management of uncomplicated UTI and could be incorporated into community pharmacy practice. The perceived ‘poor public awareness of the service’ reported by the participants, suggests the need for increased promotion and advertising.

Assessment of antimicrobial prescribing patterns, guidelines compliance, and appropriateness of antimicrobial prescribing in surgical-practice units: point prevalence survey in Malaysian teaching hospitals.

Objectives: This study sought to investigate the quality of antimicrobial prescribing among adult surgical inpatients besides exploring the determinants of non-compliance and inappropriate prescribing to inform stewardship activities. Methods: A cross-sectional point prevalence study employing Hospital National Antimicrobial Prescribing Survey (Hospital NAPS) was conducted in April 2019 at two teaching hospitals in Malaysia. Results: Among 566 surgical inpatients, 44.2% were receiving at least one antimicrobial, for a total of 339 prescriptions. Antimicrobials belonging to the World Health Organization's Watch group were observed in 57.8% of cases. Both hospitals exhibited similar types of antimicrobial treatments prescribed and administration routes. A significant difference in antimicrobial choice was observed between hospitals (p < 0.001). Hospital with electronic prescribing demonstrated better documentation practice (p < 0.001). Guidelines compliance, 32.8% (p = 0.952) and appropriateness, 55.2% (p = 0.561) did not significantly differ. The major contributors of inappropriateness were incorrect duration, (15%) and unnecessary broad-spectrum coverage, (15.6%). Non-compliance and inappropriate prescribing were found to be 2 to 4 times significantly higher with antimicrobial prophylaxis prescription compared to empirical therapy. Conclusion: Antimicrobial stewardship efforts to improve appropriate surgical prescribing are essential. These initiatives should prioritize surgical prophylaxis prescribing, focusing on reducing unnecessarily prolonged use and broad-spectrum antimicrobials, raising awareness among prescribers and promoting proper documentation.

A Review on Colistin Resistance: An Antibiotic of Last Resort.

Antibiotic resistance has emerged as a significant global public health issue, driven by the rapid adaptation of microorganisms to commonly prescribed antibiotics. Colistin, previously regarded as a last-resort antibiotic for treating infections caused by Gram-negative bacteria, is increasingly becoming resistant due to chromosomal mutations and the acquisition of resistance genes carried by plasmids, particularly the mcr genes. The mobile colistin resistance gene (mcr-1) was first discovered in E. coli from China in 2016. Since that time, studies have reported different variants of mcr genes ranging from mcr-1 to mcr-10, mainly in Enterobacteriaceae from various parts of the world, which is a major concern for public health. The co-presence of colistin-resistant genes with other antibiotic resistance determinants further complicates treatment strategies and underscores the urgent need for enhanced surveillance and antimicrobial stewardship efforts. Therefore, understanding the mechanisms driving colistin resistance and monitoring its global prevalence are essential steps in addressing the growing threat of antimicrobial resistance and preserving the efficacy of existing antibiotics. This review underscores the critical role of colistin as a last-choice antibiotic, elucidates the mechanisms of colistin resistance and the dissemination of resistant genes, explores the global prevalence of mcr genes, and evaluates the current detection methods for colistin-resistant bacteria. The objective is to shed light on these key aspects with strategies for combating the growing threat of resistance to antibiotics.

Shorter and Longer Antibiotic Durations for Respiratory Infections: To Fight Antimicrobial Resistance-A Retrospective Cross-Sectional Study in a Secondary Care Setting in the UK.

As antimicrobial resistance (AMR) escalates globally, examining antibiotic treatment durations for respiratory infections becomes increasingly pertinent, especially in the context of the COVID-19 pandemic. In a UK secondary care setting, this retrospective study was carried out to assess the appropriateness of antibiotic treatment durations-shorter (≤5 days) versus longer (6-7 days and >8 days)-for respiratory tract infections (RTIs) in 640 adults across 2019 and 2020, in accordance with local antimicrobial guidelines. The analysis employed these guidelines and clinical evidence to examine the effectiveness and suitability of antibiotic prescribing practices. This study considered the 'Shorter Is Better' approach, noting an increased rate of patient discharges associated with shorter antibiotic regimens (≤5 days). It further demonstrates that shorter treatments are as effective as longer ones for conditions such as COPD exacerbation, COVID-19 pneumonia, and hospital-acquired pneumonia (HAP), except in cases of community-acquired pneumonia (CAP) and unspecified diagnoses. Nevertheless, this study raises concerns over an observed increase in mortality risk with shorter treatment durations. Although these mortality differences were not statistically significant and might have been influenced by the COVID-19 pandemic, the need for extended research with a larger sample size is highlighted to confirm these findings. This study also emphasises the critical need for accurate and specific diagnoses and considering risk assessments at admission, advocating for tailored, evidence-based antibiotic prescribing to ensure patient safety. It contributes to antimicrobial stewardship efforts by reinforcing the importance of adapting antibiotic use to current healthcare challenges and promoting a global commitment to fight antimicrobial resistance. This approach is crucial for enhancing patient outcomes and saving lives on a global scale.

Antimicrobial resistance of clinical bacterial isolates in China: current status and trends.

Antimicrobial resistance surveillance systems have been established in China. Two representative national surveillance networks are the China Antimicrobial Surveillance Network (CHINET) and China Antimicrobial Resistance Surveillance System (CARSS), both of which were established in 2005. For all clinical isolates collected in both of these surveillance networks, the ratio of Gram-negative bacilli to Gram-positive cocci was approximately 7:3 during the past 18 years. Generally, Gram-negative bacilli have a higher antimicrobial resistance profile in China. The prevalence of ESBLs in Escherichia coli is as high as approximately 50%. Acinetobacter baumannii-calcoaceticus complex (ABC) has a high antimicrobial resistance profile, with a carbapenem resistance rate of approximately 66%. However, the prevalence of carbapenem-resistant ABC has also shown a decreasing trend from 2018 to 2022. The prevalence of vancomycin-resistant Enterococcus was low, and the prevalence of MRSA and carbapenem-resistant Pseudomonas aeruginosa showed decreasing trends from 2005 to 2022. CHINET surveillance data demonstrated that the prevalence of carbapenem-resistant Klebsiella pneumoniae showed a remarkable increasing trend from 2.9% (imipenem resistance) in 2005 to 25.0% in 2018, and then slightly decreased to 22.6% in 2022. The decreasing trends may reflect the antimicrobial stewardship efforts in China: a professional consensus on the rational clinical use of carbapenems was issued by the National Health Commission of China and was well implemented nationally; after that, the clinical use of carbapenems decreased slightly in China.

Prioritizing Equity in Antimicrobial Stewardship Efforts (EASE): a framework for infectious diseases clinicians.

Health equity gaps persist across minoritized groups due to systems of oppression affecting health-related social needs such as access to transportation, education and literacy, or food and housing security. Consequently, disparities in the prevalence of multidrug-resistant infections, infectious disease outcomes, and inappropriate antimicrobial use have been reported across minoritized populations. The Joint Commission and Centers for Medicare and Medicaid Services (CMS) have formally acknowledged the importance of integrating health equity-focused initiatives into existing hospital quality improvement (QI) programs. Here, we review documented disparities in antimicrobial stewardship and offer a framework, derived from components of existing health equity and QI tools, to guide clinicians in prioritizing equity in antimicrobial stewardship efforts (EASE).

Cohort study of patients with advanced cancer: outcomes associated with duration of antibiotic therapy for non-ventilator hospital-acquired pneumonia.

In this single-center observational study of 118 older adults with advanced cancer who developed non-ventilator hospital-acquired pneumonia, prolonged antibiotic durations (8-14 and ≥15 vs ≤7 d) were not associated with reduced adjusted odds of 90-day all-cause readmission or death. These data may inform antimicrobial stewardship efforts in palliative care settings.

Early empiric antibiotic use in COVID-19 patients: results from the international VIRUS registry

ObjectivesCOVID-19 escalated inappropriate antibiotic use. We determined the distribution of pathogens causing community-acquired co-infections, the rate, and factors associated with early empiric antibiotic (EEAB) treatment among hospitalized COVID-19 patients. MethodsThe Society of Critical Care Medicine Discovery Viral Infection and Respiratory Illness Universal Study (VIRUS) COVID-19 Registry including 68,428 patients from 28 countries enrolled between January 2020 and October 2021 were screened. After exclusions, 7830 patients were included in the analysis. Azithromycin and/or other antibiotic treatment given within the first 3 days of hospitalization was investigated. Univariate and multivariate analyses were performed to determine factors associated with EEAB use. ResultsThe majority (6214, 79.4%) of patients received EEAB, with azithromycin combination being the most frequent (3146, 40.2%). As the pandemic advanced, the proportion of patients receiving EEAB regressed from 84.4% (786/931) in January-March 2020 to 65.2% (30/46) in April-June 2021 (P < 0.001). Beta-lactams, especially ceftriaxone was the most commonly used antibiotic. Staphylococcus aureus was the most commonly isolated pathogen. Multivariate analysis showed geographical location and pandemic timeline as the strongest independent predictors of EEAB use. ConclusionsEEAB administration decreased as pandemic advanced, which may be the result of intensified antimicrobial stewardship efforts. Our study provides worldwide goals for antimicrobial stewardship programs in the post-COVID-19 era.

Machine learning to identify risk factors associated with the development of ventilated hospital-acquired pneumonia and mortality: implications for antibiotic therapy selection.

Among patients with nosocomial bacterial pneumonia, those who decompensated to requiring mechanical ventilation (vHABP) faced the highest mortality followed by ventilator-associated pneumonia (VABP) and non-ventilated hospital-acquired pneumonia (nvHABP). The objectives of this study were to identify risk factors associated with the development and mortality of vHABP and to evaluate antibiotic management. A multicenter retrospective cohort study of adult inpatients with nosocomial pneumonia during 2014-2019 was performed. Groups were stratified by vHABP, nvHABP, and VABP and compared on demographics, clinical characteristics, treatment, and outcomes. Multivariable models were generated via machine learning to identify risk factors for progression to vHABP as well as pneumonia-associated mortality for each cohort. 457 patients (32% nvHABP, 37% vHABP, and 31% VABP) were evaluated. The vHABP and nvHABP groups were similar in age (median age 66.4 years) with 77% having multiple comorbidities but more vHABP patients had liver disease (18.2% vs. 7.7% p = 0.005), alcohol use disorder (27% vs. 7.1%, p < 0.0001), and were hospitalized within the past 30 days (30.4% vs. 19.5%, p = 0.02). An immediate need for ventilatory support occurred in 70% of vHABP patients on the day of diagnosis. Mortality was the highest in vHABP followed by VABP and nvHABP groups (44.6% vs. 36% vs. 14.3%, p < 0.0001). Nearly all (96%) vHABP patients had positive cultures, with Gram-negative pathogens accounting for 58.8% whereby 33.0% were resistant to extended-spectrum β-lactams (ESBLs), ceftriaxone (17.5%), fluoroquinolones (20.6%), and carbapenems (12.4%). Up to half of the vHABP patients with ESBL-Enterobacterales or P. aeruginosa did not receive an effective empiric regimen; over 50% increase in mortality rate was observed among patients whom effective therapy was initiated past the day of pneumonia diagnosis. Risk factors associated with vHABP development were alcohol use disorder, APACHE II score, vasopressor therapy prior to infection, and culture positive for ESBL-Enterobacterales whereas history of hospitalization in the past 30 days, active malignancy, isolation of ceftriaxone-resistant pathogens or Pseudomonas aeruginosa, and vasopressor therapy were risk factors for vHABP-associated mortality. Patients with vHABP experienced an acute and severe decompensation upon diagnosis. The risk factors identified in this study could provide actionable data for clinicians to identify those at risk for vHABP at the onset of pneumonia and to target antimicrobial stewardship efforts to improve treatment success.

2954. Coordinated Antimicrobial Stewardship Efforts to Produce Sustained Reductions in Outpatient Fluoroquinolone Consumption

Abstract Background Starting in 2020, antimicrobial stewardship efforts were coordinated to reduce outpatient consumption of FQs prescribed in 20 urgent care centers (UCCs) throughout a not-for-profit healthcare system. Coordinated efforts included clinician education on FQ treatment alternatives and direct prescriber audit and feedback in specific cases. Additionally, a shorter duration of a FQ regimen was introduced in automated pharmacy dispensing machines located throughout the UCCs. The study's objective was to assess if these coordinated efforts resulted in sustained reductions in FQ consumption several years after implementation. Automated Pharmacy Dispensing Machine Example of an automated pharmacy dispensing machine found in UCCs throughout the healthcare system. Each machine contains frequently prescribed outpatient regimens for antibiotics, analgesics, antihistamines, and more. In cases where a patient is prescribed a stocked regimen, the machine is able to safely and conveniently dispense the medication prior to the patient leaving the UCC. Literature has shown automated pharmacy dispensing machines can promote patient medication adherence. Methods The Cerner Discern Reporting Portal was used to generate FQ electronic prescription (eRx) data during 2019 (pre-intervention) and 2022 (post-intervention) to assess any potential sustained impact of the targeted interventions from 2020. The primary endpoint was a 10% reduction in total FQ eRx count, total FQ days of therapy (DOT), and median FQ DOT per monthly UCC patient volume compared to the pre-intervention period. UCC monthly patient volume was used to standardize days of therapy comparisons among the pre-intervention and post-intervention periods. Total calendar-year FQ DOT was assessed by summing up monthly values. The secondary endpoint was a median monthly FQ eRx count of less than 550 in the post-intervention period. Continuous data were analyzed using an unpaired t-test. Institutional Review Board approval was granted. Results Total UCC annual patient volume was 337,941 in 2019 and 285,865 in 2022. Total FQ eRx count decreased from 7,214 in 2019 to 3,883 in 2022 (46% reduction, p=&amp;lt; 0.0001). The total FQ DOT in the calendar year decreased from 58,761 days in the pre-intervention period to 29,578 days in the post-intervention period (50% reduction, p=&amp;lt; 0.0001). Median monthly DOT per UCC patient volume decreased from 176 days per UCC monthly volume in 2019 to 106 days per UCC monthly volume in 2022 (40% reduction, p=&amp;lt; 0.0001). The median monthly FQ eRx count in 2022 was 318 which was substantially below our target of 550 and the median count of 602 in 2019. Conclusion Coordinated antimicrobial stewardship efforts in urgent care centers to reduce outpatient FQ consumption had a sustained impact following intervention implementation. Disclosures Timothy P. Gauthier, PharmD, BCPS, BCIDP, American Pharmacist Association: Honoraria|Belmont University CME Office: Honoraria|Compact: Honoraria|European Society for Clinical Microbiology and Infectious Diseases: Honoraria|Ferring Pharma: Advisor/Consultant|Firstline Mobile Health: Advisor/Consultant|Florida Society of Health-System Pharmacists: Honoraria|Gilead Biosciences: Advisor/Consultant|GlaxoSmithKline Inc.: Advisor/Consultant|Learn Antibiotics and IDstewardship.com: Owner of all published content|Learn Antibiotics and IDstewardship.com: Owner|Learn Antibiotics and IDstewardship.com: Ownership Interest|Melinta Therapuetics: Advisor/Consultant|Pattern Bioscience: Advisor/Consultant|Pfizer, Inc.: Advisor/Consultant

2230. Consumption of Quinolones, Macrolides, and Beta-Lactam Antibiotics at a Tertiary Care Veterans Affairs Medical Center (VAMC) during COVID-19 Pre-pandemic and Pandemic periods: A 4-year Analysis and Implications for Antimicrobial Stewardship

Abstract Background During the coronavirus disease 2019 (COVID-19) pandemic, antimicrobial use increased tremendously. Evidence suggests that the pandemic has resulted in an increased rate of AMR due to inadvertent antibiotic use. This likely reflects difficulties in distinguishing COVID-19 from community-acquired pneumonia when patients first arrive at a hospital. Strengthening antimicrobial stewardship (AMS) efforts by formulating policies for the use of antibiotics is crucial to prevent emergence of AMR. Methods A retrospective analysis to assess changes in antibiotic use during the pandemic and pre-pandemic patterns was done. Results : In the inpatient setting, there was an overall decrease in antibiotic use (all units that follow are in DOT/1000 BDOC) from an average of 380 to 300, vancomycin from 90 to 62, cefazolin from 30 to 17, Linezolid from 5 to 2, Zosyn from 57 to 30 from pre-pandemic period (Jan 2019) to pandemic period (Dec 2022). Antimicrobials that showed an increase during the pandemic included ceftriaxone from 70 to 82, Cefepime from 5 to 8, Levofloxacin from 2 to 5, and fluconazole from 4 to 10 compared to pre-pandemic use. In the outpatient settings (units are in fills/1000 unique patients), levofloxacin use doubled from 3 to 6, cefuroxime use increased from 0.5 to 2 and Azithromycin use dropped from 80 to &amp;lt; 20, with concomitant increase in doxycycline use from 45 to 60. Outpatient antibiotic prescriptions were high for levofloxacin, doxycycline and cefuroxime and increases corresponded to peaks in cases of COVID-19. Conclusion Our analysis demonstrates that COVID-19 had shifted the antibiotic consumption curve towards treatment of pneumonia and invasive fungal infections (in seriously ill patients) which has key implications for AMS. Implementation of stringent AMS and mandatory Infectious disease consultation for all COVID 19 infections helped keep our antibiotic consumption well below the national average and curtail AMR. Disclosures All Authors: No reported disclosures

1695. Epidemiology of Positive Blood Cultures with Negative BioFire® Blood Culture Identification Panel Results at a Pediatric Center

Abstract Background The BioFire® Blood Culture Identification (BCID) Panel is a rapid multiplex PCR assay designed to identify common bloodstream infection (BSI) organisms from positive blood cultures (Figure 1). Although a positive BCID result can identify and often guide pathogen-directed treatment, a negative result may lead to uncertainty. Therefore, we aimed to describe the organisms isolated from cultures with negative BCID tests in pediatric patients. Figure 1 Targets on the BioFire Blood Culture Identification Panels 1 vs. 2 Methods In this retrospective study of children (≤ 21 years) in our health system, we extracted all BCID tests performed 01/01/2018 to 03/12/2023 from the electronic medical record (EMR). We excluded positive BCID tests and from the negative tests, excluded duplicates, those with no growth and isolated Gram-positive rod Gram stain. Demographic, clinical, and culture data were abstracted from the EMR. Host status was categorized as previously healthy (PH), chronic condition (CC), and immunocompromised (IC). Descriptive statistics were used to summarize the data. Results Of the 4049 BCID tests (3123 BCID1, 926 BCID2) performed, 387 resulted negative (327 BCID1 [10.4%], 61 BCID2 [6.6%]). After applying exclusion criteria, 351 negative BCID tests (296 BCID1, 55 BCID2) from 325 patients were included in the dataset. Among the 351 negative tests, 81 (23.1%) were in PH hosts, 151 (43.0%) in CC hosts, and 119 (33.9%) in IC hosts. The majority (n=208, 59.3%) of negative test results were from cultures drawn peripherally. Eighteen tests (5.1%) resulted in polymicrobial growth, and 156 (44.4%) were not treated as BSIs by the clinician (Table 1). After the BCID negative result, the median delay in organism identification using conventional methods was 28.9 hours. The 351 cultures from negative BCID tests yielded 372 organisms with the most common Micrococcus spp. (Figure 2). Table 1 Demographic and culture characteristics of patients with negative BioFire BCID test results: a comparison between BCID1 and BCID2 Figure 2 Top 3 organisms isolated from positive cultures with negative BioFire BCID tests, stratified by patient host status and reported Gram stain Conclusion In this large pediatric cohort, the BioFire® BCID1 was negative in 10.4% of tests, decreasing to 6.6% with BCID2. We provide clinicians with a useful resource of organisms isolated from cultures with negative BCID results based on underlying host status. With an identification delay of &amp;gt; 24 hours for the majority of BCID negative tests and many not ultimately treated as BSIs, the impact of negative BCID results on antimicrobial stewardship efforts remains an area of future study. Disclosures Pratik A. Patel, MD, Cardinal Health Inc: Advisor/Consultant

The Impact of Antimicrobial Stewardship in Treating Patients with Escherichia coli Bacteremia in a Small Single Center Community Hospital.

Purpose: There are many challenges that pharmacist led antimicrobial stewardship programs can encounter including lack of resources, costs, and inaccurate antimicrobial susceptibility testing (AST) results. The COVID-19 pandemic has led to increased resistance especially with gram negative infections. At a small single center community hospital, gram negative infections, particularly Escherichia coli infections, predominately occur. Therefore, this study aims to address gram negative bacteremia burden and its impact on antimicrobial stewardship efforts for combatting Escherichia coli and ESBL organisms with such barriers during the pandemic. Methods: In a retrospective cohort study, patients ≥ 18 years of age from a small community hospital were reviewed. Patients were excluded if their blood cultures were not positive for Escherichia coli and if antibiotics were not initiated during hospital stay. The primary endpoint was to determine the length of hospital stay. Critical secondary endpoints include antibiotic de-escalations, duration of antibiotics, time to definitive antibiotic therapy, serum procalcitonin levels, blood culture availabilities, MIC breakpoints, co-infection of COVID-19, and Clostridioides difficile occurrences. Results: Out of 74 patients with gram negative bacteremia, 41 patients specifically had Escherichia coli bacteremia. The primary endpoint results showed that patients with Escherichia coli bacteremia that stayed in the ICU had a length of stay of 13.6 days. Patients with Escherichia coli bacteremia in the Non-ICU setting has a length of stay of 7.3 days, and patients with ESBL bacteremia in the Non-ICU setting had a length of stay of 6.8 days. Conclusions: Despite the various challenges that antimicrobial stewardship programs (ASP) face in a single center small community hospital, the ASP at this small community hospital utilizes various policies and tools to increase appropriate antibiotic use and decrease hospital length of stay in patients with Escherichia coli bacteremia.