Antimicrobial Stewardship Initiatives Research Articles

Antimicrobial resistance determinants in the oropharyngeal microbiome of 'men having sex with men' attending an sexually transmitted infection clinic.

'Men having sex with men' (MSM) represent a key population with a significant prevalence of pharyngeal Neisseria gonorrhoeae (NG) infections and a high rate of antimicrobial resistance genes in the pharyngeal microbiome. As NG can acquire antibiotic resistance genes from other commensal oropharyngeal bacteria, monitoring the prevalence of these resistance determinants is critical to curtail the spread of NG-resistant strains. Here, we assessed the distribution of five resistance genes (pen (A), mtr (R), gyr (A), par (C), msr (D)) in the oropharynx of 164 MSM, attending an Outpatient clinic for STI screening. The most frequently detected resistance gene was msr (D) (88.4%), followed by gyr (A) (67.1%). The distribution of resistance genes was not influenced by pharyngeal gonorrhea nor by the HIV status, whereas a younger age was associated with mtr (R) presence (p = .008). Subjects using mouthwash exhibited significantly lower levels of mtr (R) (p = .0005). Smoking habit was associated with a higher prevalence of par (C) (p = .02). A noteworthy association was observed between the presence of msr (D) gene and the use of antibiotics (p = .014). Our findings reveal an enrichment of antimicrobial resistance genes in the oropharynx of MSM. These insights could aid in the development of screening programs and antimicrobial stewardship initiatives targeting populations at heightened risk of pharyngeal gonorrhea.

Current state of education, training and practices in antimicrobial stewardship among pharmacy students: A cross-sectional survey from Kerala, India

PurposePharmacists are recognised in guidelines from across the globe as key stakeholders in antimicrobial stewardship (AMS) initiatives. The current study aims to assess the current practices and level of training and education in relation to AMS among pharmacy students from Kerala, India. MethodsA cross-sectional web-based survey was developed and disseminated among doctor of pharmacy 5th year students and interns from selected pharmacy colleges across Kerala through key informants. Descriptive statistics were used to analyse the responses. ResultsThe response rate was 34.8% (157/450). Whilst the majority of respondents (89.8%, 141/157) recalled being taught about antimicrobial resistance (AMR) as part of the pharmacy curricula, 84.7% (133/157) believed they didn’t have sufficient knowledge about AMR. Most of the respondents (64.9%, 102/157) had not received any AMS training. Clinical posting in AMS was the preferred mode of training suggested by most respondents. Respondents who audited antimicrobials as part of their clinical postings (77.9%, 88/113) reported their main responsibility was review of patient records for assessing the appropriateness of antimicrobials (68.2%, 60/88). Inappropriate selection of antimicrobials was the most common error identified by respondents (38.1%, 43/113) and the key method of communicating their recommendation was informing the prescriber in person (46%, 52/113). ConclusionWhilst pharmacy students are reviewing antimicrobial prescriptions as part of their clinical postings, their education and training in AMR and AMS remain low. The inclusion of practical clinical training for pharmacy students as part of their curricula can be a cost-effective way to promote AMS initiatives.

Implementing a community-based antimicrobial stewardship intervention in Malaysia

Background In Malaysia, the unregulated use of antibiotics and lack of awareness about antimicrobial resistance (AMR) among pharmacists pose significant challenges. Implementing community-based Antimicrobial Stewardship (AMS) initiatives is crucial to address the rising AMR. Methods We developed a bespoke AMS intervention, aligned with the World Health Organization’s AMS modules, as a 2-day online educational seminar for community pharmacists. The effectiveness of the workshop was evaluated using pre- and post-seminar questionnaires, focusing on AMS knowledge and attitudes towards antimicrobial usage. Results Among 528 participants, 489 completed both questionnaires. Pre-seminar, only 59% correctly understood the concept of antibiotic resistance reversibility, which improved to 85.9% post-seminar ( p = .002). The average AMS knowledge score increased from 5/10 to 8/10 post-intervention ( p < .05). A significant improvement was also noted in pharmacists’ ability to select appropriate antibiotic therapies, particularly for urinary tract infections, with an increase from 78% to 90% correct responses. Conclusion The AMS seminar was well-received and significantly improved the AMS knowledge of community pharmacists. The results underline the need for more AMS-focused interventions in this demographic in Malaysia, contributing to the development of formalized AMS programs. Such initiatives are expected to enhance antibiotic use awareness, encourage optimal antibiotic practices, and positively shift professional conduct in community settings.

A five-year retrospective antibiogram review in the paediatric burns unit at a tertiary South African Hospital

BackgroundThere is a global concern regarding increasing colonization and/or infection of paediatric burns patients with multi-drug-resistant organisms, especially in Africa. Surveillance of antimicrobial resistant patterns enables clinicians to opt for the most appropriate empiric antimicrobial agent according to the unit’s susceptibility profile. ObjectiveThis study sought to compile unit-specific antibiograms comparing the organism prevalence and their antimicrobial resistance trends in the paediatric burns unit, Chris Hani Baragwanath Academic Hospital (CHBAH) from January 2015 to December 2019. MethodsA retrospective, laboratory-based review was conducted of bacterial and fungal isolates including antimicrobial susceptibility testing (AST) data from blood cultures and tissue samples. Enterobacterales, non-fermenters, gram-positive organisms, and yeasts were analysed as a percentage of total positive blood cultures comparing 2015–2017 to 2018–2019 data. Analysis of antimicrobial resistance trends was performed for extended-spectrum beta-lactamases (ESBLs), carbapenem-resistant Enterobacterales (CRE), extensively-drug-resistant (XDR) Acinetobacter baumannii, and meticillin-resistant Staphylococcus aureus (MRSA) for the years 2015, 2017, and 2019. ResultsA total of 1243 blood culture isolates were studied with A.baumannii (208/1243;17 %), coagulase negative staphylococci (141/1243; 11 %) and Candida auris (53/1243; 4 %) representing the predominant gram-negative bacteria, gram-positive bacteria, and yeast, respectively. A significant decrease in ESBLs (p = 0.00) was noted with a rise in CREs (p = 0.00) during the study period. Majority of the A. baumannii were XDR (≥77 %) despite an appreciable decrease. A notable decrease in MRSA (p = 0.00) isolates was observed. pseudomonas aeruginosa (72/275; 26 %) was the leading organism recovered from a total of 275 tissue isolates. ConclusionThe results of this study encourage review of the current antimicrobial choices in the unit for empiric antibacterial cover. Due to the low numbers of yeasts, we cannot comment on the institution of early antifungal strategies. We support reinforced infection prevention and control practices as well as antimicrobial stewardship initiatives.

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.

β-Lactam Resistant Phenotypes Reported by VITEK®2 Advanced Expert SystemTM (AES) Compared to Whole Genome Sequencing in Enterobacterales from North and Latin America

The VITEK®2 AES β-lactam phenotypes of 488 Enterobacterales from North and Latin America generated by the VITEK®2 were compared to the resistance genotypes provided by whole genome sequencing (WGS). The AES provided phenotypic reports for 447 (91.6%) isolates, including isolates harbouring carbapenemases (195; 43.6%), ESBLs (103; 23.0%) and transferable AmpCs (tAmpC; 28; 6.3%) genes, as well as wildtype isolates (WT; 121; 27.1%). Overall, the AES report was accurate for 433/447 (96.9%) isolates. The AES accurately reported carbapenemase, ESBL, and tAmpC phenotypes for 93.7%, 93.7%, and 98.4% of isolates, respectively, and sensitivity/specificity rates were 96.4%/91.7%, 98.1%/92.4%, 82.1%/99.5%, and 100%/98.8%. 14 isolates carrying carbapenemase (7 total; 3 KPC, 2 MBL, 2 OXA-48–like), ESBL (2), and tAmpC-encoding genes (5) were not correctly identified by AES. The AES phenotypic report detected resistance mechanisms among Enterobacterales rapidly and could significantly aid future antimicrobial stewardship initiatives and patient care.

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.

Antimicrobial Resistance: Stewardship and One Health in the Eastern Mediterranean Region.

Antimicrobial resistance (AMR) is a major threat in the Eastern Mediterranean region (EMR) due to factors such as the high prevalence of infectious diseases, weak health systems, and the misuse of antimicrobials. This paper aims to discuss how interdisciplinary action and collaboration, specifically through antimicrobial stewardship (AMS) and the One Health approach, can effectively address AMR in the EMR. The review focuses on successful AMS initiatives and the adoption of the One Health approach in countries within the EMR, including the Gulf Cooperation Countries (GCC), Egypt, Iran, Jordan, and Pakistan. The goal is to highlight the potential for progress in combating AMR and identify challenges and opportunities for strengthening interdisciplinary collaboration. The results showcase successful AMS programs and One Health initiatives in various EMR countries, demonstrating their potential to address AMR challenges. The paper also discusses the challenges faced by these nations, such as limited resources, fragmented health systems, and knowledge gaps. Additionally, opportunities for enhancing interdisciplinary action through regional cooperation, international partnerships, and research and innovation are outlined. In conclusion, this paper emphasizes the importance of a comprehensive and collaborative response to combat AMR in the EMR. It advocates for the One Health approach as a crucial framework to guide these efforts, promoting coordinated action, improved surveillance, responsible antimicrobial use, and enhanced interdisciplinary collaboration to effectively mitigate the threat of AMR.

Use of Antibiotics in Tertiary Care Hospitals of Meteropolitan City Islamabad

Background: The global threat of antimicrobial resistance (AMR) necessitates a deeper understanding of antibiotic use patterns within healthcare settings. Previous studies have indicated variable prevalence rates of antibiotic use across different regions, underscoring the need for localized data to inform antimicrobial stewardship initiatives. Objective: This study aimed to determine the prevalence and patterns of antibiotic use in two tertiary care hospitals in Islamabad, Pakistan, to identify opportunities for improving antibiotic prescribing practices and inform the development of targeted antimicrobial stewardship programs. Methods: A descriptive cross-sectional study was conducted through a point prevalence survey in two tertiary care hospitals over three months, from January to March 2022. Data on antibiotic use were collected from patient files, employing a two-stage random sampling method for both hospital and ward selection. The survey assessed the prevalence of antibiotic use, categorized according to the WHO Aware classification (Access, Watch, Reserve, Not Recommended), and analyzed the indications, dosages, routes of administration, and compliance with prescribing guidelines. Statistical analysis was performed using SPSS version 25. Results: The prevalence of antibiotic use among the surveyed population (n=255) was 78%, with a higher prevalence observed in neonatal (100%) and pediatric (100%) departments compared to the adult department (74.66%). Ceftriaxone (27.06%), meropenem (10.98%), and moxifloxacin (9.41%) were the most frequently used antibiotics. The majority of antibiotics prescribed belonged to the 'Watch' group (70%), with 17.6% in the 'Access' group, and 11.6% in the 'Reserve' group. Prophylactic use accounted for 62.9% of all antibiotics prescribed. The study also noted a lack of compliance with prescribing guidelines and a scarcity of culture sensitivity testing. Conclusion: The study reveals a high prevalence of antibiotic use in tertiary care hospitals in Islamabad, with a significant reliance on 'Watch' and 'Reserve' group antibiotics. These findings highlight the critical need for the implementation of antimicrobial stewardship programs and national action plans to promote rational antibiotic use and combat AMR. Background: Antimicrobial resistance is one of the biggest global healthcare concerns as per the World Health Organization. It has impacted high, mid, and low-income countries with mid and low-income countries taking higher tools. Lack of data on the pattern of antibiotic use will lead to difficulty in the implementation of antimicrobial stewardship programs at the facility level. The purpose of this study is to determine the point prevalence of antibiotic use among hospitals in Islamabad and to determine the pattern of the WHO-aware group antibiotics in paediatrics. Methodology: The point prevalence survey methodology was used to collect random sample of 255 in two tertiary care hospitals in Islamabad in three months. All the inpatients admitted on the day of PPS were included in the survey. Data was collected through questionnaires from patients' files and analysed in SPSS Results: Total of two tertiary care hospitals with 375 beds were assessed in this study. Out of these, 255 patients 78.03% patients were receiving at least one antibiotic. Out of 255 antibiotics were used in which 32.1% were prescribed for medical prophylaxis, while 29.8% of the antibiotics prescribed were for surgical prophylaxis. Ceftriaxone and Maropenm accounted for 27% & 10.98% of total antibiotic prescribed respectively. The result also indicates high use of watch group antibiotics in children under 5 years of age. The majority of antibiotics were used as Empirical therapy. There was no specific institutional guideline for the use of antibiotics, while in 95% of cases there was no reason notes available for the use of antibiotics. Conclusion: We concluded that use of antibiotics in the two hospitals is very high. It has been also seen that there was no proper guideline for the use of antibiotics in hospitals with poor quality documentation. It is an immediate need for the implementation of a national action plan on the antimicrobials resistance and the development of an antibiotics stewardship program at each facility level to protect the resistance to the antibiotic.

Creation of a CF-specific antibiotic spectrum index (ASI) as an antimicrobial stewardship initiative

Antibiotics are frequently utilized for cystic fibrosis (CF)-related pulmonary exacerbation treatment. The antibiotic spectrum index (ASI) is an antimicrobial stewardship tool developed to compare the relative breadth of individual antibiotics. This study aimed to create two expanded CF-specific ASI scoring indices for use in antimicrobial stewardship research and clinical care. The first scoring index expanded the original ASI to include bacterial microorganisms common to CF airway infections (CF-ASI). The second scoring system only included scores for bacterial microorganisms classically identified in CF airway infections (CF-sASI). Sixty-two antibiotics were evaluated and included in the updated ASIs. When multiple antibiotics are prescribed, we proposed using an additive ASI approach whereby the sum of the individual prescribed antibiotic scores represents the total ASI score. The application of CF-focused ASIs into CF research and stewardship programs can help to optimize antibiotic benefits, minimize harms and allow for increased sustainability of antibiotic use in CF.

Trends in Antibiotic Use in a Large Children's Hospital in London (United Kingdom): 5 Years of Point Prevalence Surveys.

Background: Antibiotics are commonly prescribed in paediatrics. As their excessive use contributes to adverse drug events, increased healthcare costs, and antimicrobial resistance, antimicrobial stewardship initiatives are essential to optimising medical care. These single-centre point prevalence surveys aimed to provide insights into antibiotic prescribing trends and identify targets for paediatric AMS activities. Methods: 14 point prevalence surveys were conducted from March 2016-April 2021, collecting data on antibiotic prescriptions, indication, adherence to guidelines, and route of administration. The UK adapted the World Health Organisation's AWaRe classification-guided antibiotic categorization. Results: 32.5% of all inpatients were on at least one antimicrobial; this remained stable during all surveys (range: 20-44%, p = 0.448). Of all prescriptions, 67.2% had an end- or review-date, and the majority was for agents in the Watch category (46.8-70.5%). Amoxicillin and clavulanate were the most frequently prescribed antibiotics (20.8%), followed by gentamicin (15.3%). Approximately 28.8% of all prescriptions were for prophylactic indications, while 7.6% of the prescriptions were not adherent to the hospital guidelines. Conclusions: This study highlights the importance of ongoing monitoring and robust AMS initiatives to ensure prudent antibiotic prescribing in paediatric healthcare. It underscores the need for tailored guidelines, educational efforts, and targeted interventions to enhance the quality of antibiotic usage, ultimately benefiting both individual patients and public health.

Antimicrobial Stewardship and Improved Antibiotic Utilization in the Pediatric Cardiac Intensive Care Unit.

We developed a multidisciplinary antimicrobial stewardship team to optimize antimicrobial use within the Pediatric Cardiac Intensive Care Unit. A quality improvement initiative was conducted to decrease unnecessary broad-spectrum antibiotic use by 20%, with sustained change over 12 months. We conducted this quality improvement initiative within a quaternary care center. PDSA cycles focused on antibiotic overuse, provider education, and practice standardization. The primary outcome measure was days of therapy (DOT)/1000 patient days. Process measures included electronic medical record order-set use. Balancing measures focused on alternative antibiotic use, overall mortality, and sepsis-related mortality. Data were analyzed using statistical process control charts. A significant and sustained decrease in DOT was observed for vancomycin and meropenem. Vancomycin use decreased from a baseline of 198 DOT to 137 DOT, a 31% reduction. Meropenem use decreased from 103 DOT to 34 DOT, a 67% reduction. These changes were sustained over 24 months. The collective use of gram-negative antibiotics, including meropenem, cefepime, and piperacillin-tazobactam, decreased from a baseline of 323 DOT to 239 DOT, a reduction of 26%. There was no reciprocal increase in cefepime or piperacillin-tazobactam use. Key interventions involved electronic medical record changes, including automatic stop times and empiric antibiotic standardization. All-cause mortality remained unchanged. The initiation of a dedicated antimicrobial stewardship initiative resulted in a sustained reduction in meropenem and vancomycin usage. Interventions did not lead to increased utilization of alternative broad-spectrum antimicrobials or increased mortality. Future interventions will target additional broad-spectrum antimicrobials.

Five steps to high quality antimicrobial stewardship research.

The escalating threat of antimicrobial resistance (AMR) necessitates impactful, reproducible, and scalable antimicrobial stewardship strategies. This review addresses the critical need to enhance the quality of antimicrobial stewardship intervention research. We propose five considerations for authors planning and evaluating antimicrobial stewardship initiatives. Antimicrobial stewards should consider the following mnemonic ABCDE: (A) plan Ahead using implementation science; (B) Be clear and thoroughly describe the intervention by using the TidIER checklist; (C) Use a Checklist to comprehensively report study components; (D) Select a study Design carefully; and (E) Assess Effectiveness and implementation by selecting meaningful outcomes. Incorporating these recommendations will help strengthen the evidence base of antimicrobial stewardship literature and support optimal implementation of strategies to mitigate AMR.

Effect of directive laboratory comments on prescribing response to positive throat swab cultures.

In patients without ethnicity risk factors for acute rheumatic fever (ARF), our local guidelines recommend limiting antibiotic use following a positive throat swab culture (TSC). If symptoms are severe, a 5-7 day course is recommended. Despite this, most local patients with a positive TSC for group A Streptococcus (GAS) or Streptococcus dysgalactiae subsp. equisimilis (SDSE) were being prescribed 10 days of antibiotics. In response, we added comments to positive TSC reports recommending shorter treatment durations in those without ARF risk factors. No other antimicrobial stewardship initiatives were implemented. To assess the effect of these comments on antibiotic course duration after positive TSC. All community TSC results from 1 October 2021 to 31 March 2023 (1 year pre- to 6 months post-change) were matched to antibiotic dispensing data. Patients who had been empirically dispensed an antibiotic prior to the culture report were excluded. The outcome of interest was the antibiotic duration dispensed in the 5 day period after the TSC report. Following introduction of the comments, median course duration reduced from 10 (IQR 5-10) to 7 days (IQR 0-10; P < 0.01) and from 7 (IQR 0-10) to 0 days (IQR 0-5; P < 0.01) following GAS- and SDSE-positive TSC, respectively, in those without ARF risk factors. The percentage of people receiving 10 days of antibiotics decreased from 63.0% to 37.0% (P < 0.01) and 41.2% to 14.6% (P < 0.01) for GAS and SDSE, respectively. The introduction of comments providing direct prescribing advice to requestors appears to have been highly effective at improving guideline-compliant prescribing following positive TSC report.

Awareness of infection care terms among outpatients and carers in a public health facility: a cross-sectional survey

Background As victims of antimicrobial resistance (AMR) and healthcare recipients, patients and their carers can be engaged in infection prevention and control (IPC) and antimicrobial stewardship (AMS) initiatives to manage AMR. To effectively participate in these initiatives, patients and carers need to understand general terms used in infection care. We explored awareness of commonly used infection-related terms among patients and carers in the surgical out-patient of a tertiary academic hospital. Methods Self-administered paper survey distributed among out-patients from August to September 2022. Categorical variables were analysed using Chi squared test. Significance was set as p-value of &lt; 0.05. Content analysis identified terms commonly used by patients when talking about infections. Results Overall, 896 out of 1,269 respondents (response rate 70.6%), with a 1:3 male to female ratio were included. Most respondents were patients (75%), with a minimum of high school education (91.2%) and a surgical history (60.3%). Surgical wound infection was the most familiar term to participants. While many respondents had not heard of Methicillin-resistant Staphylococcus aureus (MRSA) (92.3%, n=754) or antimicrobial resistance (92.8%, n=755), significantly more were aware of the descriptions provided for these terms (13.7% and 33.0%, respectively; p&lt;0.001). Participants considered antibiotic resistance to be a condition in which the body rejects, resists, or does not respond to antibiotics. Conclusions Findings show dissonance between patients’ awareness of and healthcare workers’ use of infection-care terms, highlighting the need for relatable and accessible terms in infection-care engagement initiatives. More than half of respondents acknowledged that patient engagement responsibility is everyone’s, underscoring the need for contextually fit and relevant communication strategies to advance patient engagement and infection awareness.

Descriptive evaluation of patients receiving one-time intravenous vancomycin doses at a large academic medical center emergency department

BackgroundIntravenous (IV) vancomycin is commonly used to treat a variety of infections caused by methicillin-resistant Staphylococcus aureus (MRSA). The practice of administering a single dose of IV vancomycin prior to emergency department (ED) discharge may be clinically ineffective and foster antimicrobial resistance. Furthermore, this practice introduces an unnecessary infection risk along with preventable adverse effects while potentially increasing ED length of stay (LOS). There is a paucity of literature identifying patient characteristics and objective findings in this patient population, which may foster future antimicrobial stewardship initiatives in the ED. MethodsThis was a single-center, retrospective, descriptive analysis of adult patients seen in the ED between January 2020 and January 2023 who received a single dose of IV vancomycin and were subsequently discharged from the ED without hospital admission. Information was collected on patient demographics and select comorbidities, vancomycin indication and dosing, ED LOS, initial vitals and labs, concomitant antibiotics administered, culture results, 30-day return ED visits and admissions, and antibiotics prescribed at ED discharge. ResultsA total of 295 patients met inclusion criteria. A total of 32.1% of patients met SIRS criteria. The most commonly selected order indication for IV vancomycin was “skin and skin structure infection” (41%). A total of 86.1% of patients received concomitant antibiotics in the ED and only 54.6% of patients were prescribed oral antibiotics at ED discharge. A total of 80% of patients had at least one culture obtained during the ED visit. In those who had at least one culture obtained, 78.4% of patients had negative cultures and 4.2% of patients had MRSA positive cultures, with MRSA skin cultures being the most common (3.1%). Return ED visits and admissions within 30 days were not statistically significantly different between patients who did and did not receive oral antibiotics at ED discharge. ConclusionsDespite a lack of clinical efficacy reported in prior literature and the potential risks, administration of a one-time dose of IV vancomycin prior to ED discharge is commonly encountered in clinical practice. There are opportunities for enhanced antimicrobial stewardship related to IV vancomycin use in the ED. Areas of future focus include the utilization of oral antimicrobials when clinically appropriate, particularly for skin and soft tissue infections, and clarification of antibiotic allergies.

1200. Evaluation of Pharmacist-Driven Azithromycin Dose Optimization Protocol for Respiratory Tract Infections as an Antimicrobial Stewardship Initiative

Abstract Background Azithromycin is a macrolide antibiotic commonly used empirically to treat atypical pathogens in CAP and acute COPD exacerbations. Due to its longer half-life and high tissues concentrations, a total treatment dose of 1.5 g (given over either 3 or 5 days) provides therapeutic exposure lasting approximately 10 days. Multiple randomized studies demonstrated similar treatment efficacy between 3 days and 5 days of azithromycin. Due to the increased rates of macrolide-resistant Streptococcus pneumoniae strains, shorter courses of azithromycin may decrease the emergence of more bacterial resistance, improve patient compliance, and decrease antibiotic-associated adverse events. Methods A retrospective cohort study conducted from March 2022 to March 2023 at Texas Health Harris Methodist Hospital Fort Worth. Pharmacists automatically adjusted azithromycin orders to a duration of 3 days and a dose of 500 mg for CAP and acute COPD exacerbations. Patients were excluded if treatment indications were for prophylaxis, mycobacterial disease, or Legionnaires disease. The primary outcome was azithromycin duration of therapy (DOT) after protocol implementation and secondary outcomes included 30-day all-cause in-hospital mortality and 30-day hospital readmission. Results 507 patients were included in the final analysis with 267 patients in the pre- and 240 patients in the post-group. After protocol implementation, a statistically significant reduction in mean azithromycin DOT was observed in the post- compared to the pre-group (3 days vs 5 days), p &amp;lt; .0001. No increase in 30-day all-cause in-hospital mortality (2.1% vs. 7.1%, p = .008) or 30-day hospital re-admission rates (5.4% vs. 15.3%, p = .001) were observed in the post- compared to the pre-group. Conclusion Based on the results of this study, implementation of a pharmacist-driven azithromycin dose optimization protocol is an effective antimicrobial stewardship initiative that can decrease unnecessary azithromycin DOT. The 3-day duration of high dose azithromycin was not associated with increased rates of mortality or hospital re-admissions compared to longer durations. Disclosures All Authors: No reported disclosures

2267. Evaluation of Antibiotic Prescribing Trends from a Dental Clinic After Implementation of a Dental Antimicrobial Stewardship Initiative

Abstract Background Inappropriate antibiotic prescribing by dentists is as high as 80% and in the U.S., dentists rank third for writing the most antibiotic prescriptions. At NewYork-Presbyterian Brooklyn Methodist (NYP-BMH), the Antimicrobial Stewardship Program (ASP) and Division of Dental Medicine collaborated to create a clinical practice guideline regarding antibiotic use in dentistry that was implemented in May 2021 and is reinforced with annual education to dental prescribers. The purpose of this study is to compare outpatient antibiotic prescribing trends pre- and post-guideline implementation. Methods Patients presenting to NYP-BMH dental clinic for an emergent indication and prescribed an antibiotic from January-April of 2019-2021 (pre) and January-April of 2022 (post) were included. The primary outcome was appropriateness of antibiotic therapy. Secondary outcomes included a comparison of antibiotic selection, dosing and duration of therapy. A subgroup analysis of patients with reported penicillin allergies was conducted to compare alternative agents prescribed. Results A total of 119 patients in the pre and 100 patients in the post-guideline period were included. The primary outcome of appropriate antibiotic prescriptions significantly improved after guideline implementation (pre 45% vs post 64%, p&amp;lt; 0.01). The majority of antibiotic indications were treatment-related and the most common dental diagnosis was caries. The most common antibiotic prescribed in the study was amoxicillin. Compared to pre-guideline, there was significant decreased utilization of penicillin VK (pre 3.4% vs post 0%, p=0.05) and amoxicillin-clavulanate post-guideline (pre 16% vs post 8%, p=0.02). A wide variety of dosing regimens were utilized with more guideline-concordant regimens utilized post-guideline (pre 59% vs post 72%, p=0.04). On average, shorter durations of therapy were prescribed post-guideline (pre 6.8 days vs post 5.7 days, p&amp;lt; 0.02). Penicillin-allergic patients were prescribed less clindamycin after guideline implementation. Conclusion ASP initiatives and collaboration with outpatient dental clinics can improve appropriate antibiotic prescribing. As ASPs look to expand into ambulatory care settings, dental clinics should be prioritized. Disclosures All Authors: No reported disclosures

1244. Antimicrobial Stewardship Knowledge, Attitudes, and Practices (KAP) Among Nurses

Abstract Background Nurses are underutilized members of the antimicrobial stewardship (AS) team. Understanding knowledge, attitudes, and practices (KAP) is essential to designing effective AS initiatives. While KAP surveys have been performed among a variety of provider types, less is known about KAP among nurses. We describe KAP pertaining to AS among nurses at a large, academic hospital. Methods An electronic, 24-question KAP survey was designed by the AS team with relevant nursing and infection prevention champions. Nine knowledge-based questions about antimicrobials focused on 4 domains: beta-lactams first in sepsis, intravenous to oral transition, urinary tract infections, and penicillin allergies. Voluntary responses were collected via Qualtrics from January 9, 2023-March 31, 2023. Surveys were distributed by email link, with reminders to enhance survey response. Incentives included a chance to win a meal voucher. Results 85 complete survey responses were received. The majority of respondents worked on dayshift (69%) in a staff nurse role (66%). Discrepancies were seen in perceptions of issues of stewardship nationally and locally. While nurses felt antimicrobial resistance and harm caused by antimicrobials are high nationally (92 and 69%, respectively), this was not as commonly felt to be true on a local level (35% and 26%). The majority (87%) agreed or strongly agreed that nurses’ responsibility includes promoting appropriate antimicrobial use. When assessing knowledge of AS domains, reported confidence in performance was discordant with actual performance and differed by domain (Figure 1). Respondents were largely unfamiliar with common AS reference resources (73-74%) and were more likely to consult an ID pharmacist (81%), ID physician (78%) or infection prevention team member (78%) with questions. Conclusion Nurses recognized AS as an important part of their professional responsibilities, but perceived AS opportunities to be a national rather than local need. Differing patterns in knowledge vs. confidence among topic domains provides key information to then design relevant, sustainable, nurse-driven antimicrobial stewardship initiatives. Disclosures Rebekah W. Moehring, MD, MPH, FIDSA, FSHEA, UpToDate, Inc.: Author Royalties

A multinational survey of companion animal veterinary clinicians: How can antimicrobial stewardship guidelines be optimised for the target stakeholder?

Antimicrobial stewardship initiatives are widely regarded as a cornerstone for ameliorating the global health impact of antimicrobial resistance. Within companion animal health, such efforts have largely focused on development and dissemination of antimicrobial stewardship guidelines (ASGs). However, there have been few attempts to understand veterinarian attitudes towards and knowledge of ASGs or to determine how awareness regarding ASGs might best be increased. An online survey regarding ASGs was formulated for veterinarians who treat companion animals. The survey was distributed across 46 European and associated countries between 12 January and 30 June, 2022. In total, 2271 surveys were completed, with 64.9% of respondents (n = 1474) reporting awareness and usage of at least one ASG. Respondents from countries with greater awareness of ASGs tended to report more appropriate use of antimicrobials (Spearman's rank coefficient = 0.6084, P ≤ 0.001), with respondents from countries with country-specific ASGs tending to score highest across both awareness and appropriate use domains. Respondents prioritised guidance around antimicrobial choice (82.0%, n = 1863), duration of treatment (66.0%, n = 1499), and dosage (51.9%, n = 1179) for inclusion in future ASGs, with 78.0% (n = 1776) of respondents preferring ASGs to be integrated into their patient management system. Awareness of ASGs and their use in companion animal veterinary practice appears to be greater than previously reported, with respondents tending to report antimicrobial prescription decision making broadly in line with current clinical recommendations. However, further initiatives aimed at maximising accessibility to ASGs both within countries and individual veterinary practices are recommended.