Antimicrobial Stewardship Program Recommendations Research Articles

Benefits of Accepting Infectious Diseases Pharmacist Recommendations: A 5-Year Outcome Study in a Multihospital System.

Background: Infectious diseases (ID) pharmacists are pivotal members of antimicrobial stewardship teams. Prospective audit and feedback is a strong recommendation by The Infectious Diseases Society of America Guidelines for Antimicrobial Stewardship Programs (ASP). Utilizing customized ASP intervention documentation tools known as "ivents" in Epic, we aimed to assess the impact of interventions by measuring outcomes that were accepted compared to those that were rejected in a multihospital health system over 5 years. Methods: A multicenter, retrospective cohort study was conducted to compare clinical outcomes among intensive care unit (ICU) and non-ICU patients with accepted and rejected ASP interventions over 5 years from October 2015 to December 2020. Outcomes measured included antibiotic days of therapy per 1000 patient days (DOT/1000 PD), antibiotic doses per 1000 patient days (doses/1000 PD), hospital length of stay (LOS), in-hospital mortality, hospital-acquired Clostridioides difficile infection (HA-CDI), community-onset C. difficile infection (CO-CDI) within 30 days, and hospital readmission within 30 days. Coarsened exact matching (CEM) was used as a non-parametric matching method to balance covariates between groups and to control for confounding. Results: ASP recommendations by ID pharmacists were well-received by providers in a multihospital system over 5 years as evidenced by an overall acceptance rate of 92%. Acceptance of ASP interventions was associated with substantial reductions in antibiotic utilization without adversely affecting mortality or hospital readmissions. While high-risk C. difficile antibiotic use increased significantly due to frequent de-escalation to ceftriaxone among non-ICU patients with accepted interventions, rates of HA-CDI and CO-CDI within 30 days did not worsen. Furthermore, hospital LOS was notably shorter by an average of 1 day for non-ICU patients with accepted interventions, which resulted in substantial cost avoidance of $7 631 400. Conclusion: Collaboration with ID pharmacists to optimize antimicrobial stewardship was associated with significant reductions in antibiotic utilization, costs, and hospital LOS without worsening patient outcomes.

1257. The Impact of Communication Type on Acceptance Rates of Antimicrobial Stewardship Interventions

Abstract Background While face-to-face communication (ie. “handshake stewardship” (HS)) has been shown to improve antimicrobial stewardship program (ASP) intervention acceptance rates, this strategy is resource intensive. Therefore, systems unable to conduct HS must identify the optimal mode of communication for ASP recommendations. This study evaluated the effects of communication type on ASP intervention acceptance. Methods An infectious disease physician and ASP pharmacist met Monday through Friday to assess appropriateness of select antimicrobials. ASP recommendations were delivered through direct communication via telephone conversations or passive communication via text-page. A text page consisted of a message limited to 240 characters sent directly to the primary team. We performed a retrospective review of all interventions and associated acceptance rates, antimicrobials and antimicrobial indications between January 1st, 2023 to March 31st, 2023. The primary outcome evaluated was ASP intervention acceptance rate. Results Recommendations were delivered through telephone conversations in 267/454 (58.8%) cases compared to 187/454 (41.2%) cases in which recommendations were provided via text-page. We found that direct communication delivered telephonically resulted in a significant increase in ASP intervention acceptance rate compared to passive communication via text page (82.8% vs 73.8%, respectively; p=0.02). This resulted in 884 and 552 days of antimicrobial therapy saved in the telephonic and text-page group, respectively (p=0.64). Significant differences in baseline characteristics included: antimicrobial indications of intraabdominal, respiratory, sepsis and febrile neutropenia; having a broad differential; and an intervention category of de-escalation. Conclusion Direct communication with clinicians (eg. telephonically) improves ASP intervention acceptance rates compared to passive communication styles (eg. text-page). Direct communication with the prescriber encourages shared decision making, increases visibility of ASP, and allows for education to modify prescribing behavior. The success of an ASP relies heavily on provider relationships, which direct communication can further promote. Disclosures All Authors: No reported disclosures

The effect of Telehealth Antimicrobial Stewardship Program (Tele-ASP) on antimicrobial use in a pediatric intensive care unit: Pre- and post-implementation single center study

BackgroundOveruse or misuse of antimicrobials is common in pediatric intensive care units (PICU) and may be associated with poor clinical outcomes. Although an antimicrobial stewardship program (ASP) has been found to improve this practice, the required expertise in infectious diseases may be limited in some centers. We aimed to evaluate the effect of telehealth ASP on the rate of PICU antimicrobial use in a center without a local Infectious Diseases consultation service. MethodsA retrospective cohort study was performed between October 1st, 2018, and October 31st, 2020, in Farwaniya Hospital PICU, a 20-bed unit. All pediatric patients who were admitted to PICU and received systemic antimicrobials during the study period were included and followed until hospital discharge. The ASP team provided weekly prospective audit and feedback on antimicrobial use starting October 8th, 2019. A pediatric infectious diseases specialist joined the ASP rounds remotely. Descriptive analyses and a pre-post intervention comparison of days of therapy (DOT) were used to assess the effectiveness of the ASP intervention. ResultsThere were 272 and 156 PICU admissions received systemic antimicrobial before and after the initiation of ASP, respectively. Bronchiolitis and pneumonia were the most common admission diagnoses, together compromising 60.7% and 61.2% of cases pre- and post-ASP. The requirement for respiratory support was higher post-ASP (76.5% vs. 91.5%, p < 0.001). Average monthly antimicrobial use decreased from 922 (95%CI 745–1000) to 485 DOT/1000 patient-days (95%CI 246–722, P < 0.05). A decline in DOT was observed across most antibiotic classes, except for ceftriaxone. No effect on the length of PICU stay, length of hospitalization, or mortality was observed. Most (89.7%) ASP recommendations were followed either fully or partially. ConclusionIn settings where Infectious Diseases consultation services are unavailable, PICU telehealth ASP can be effectively implemented and associated with significantly reducing antimicrobial use.

1655. Factors Associated with Acceptance of Telehealth-based Antimicrobial Stewardship Program Recommendations in a Community Hospital Health System

Abstract Background Telehealth-based antimicrobial stewardship programs (TeleASPs) have led to reduced broad-spectrum antimicrobial utilization. Data on factors associated with acceptance of stewardship recommendations are limited. Methods A TeleASP, facilitated by remote infectious disease physicians and local pharmacists, was implemented in 2 community hospitals from February 2018 through July 2020. Variables potentially affecting acceptance of TeleASP recommendations were tracked. Odds ratios of acceptance were determined utilizing multiple logistic regression. Results During the 30 month period, 4863 (91.2%) of the total 5333 recommendations were accepted. Hospitalist and Critical Care Medicine services had significantly higher odds of acceptance in univariable analysis, while General Surgery, Private Practice Primary Care Physician, Pulmonology, and Urology had lower odds of acceptance. Only Critical Care Medicine remained significant on multivariable analysis (OR 3.23, 95%CI 1.4–7.5). Other factors associated with a higher odds of acceptance in multivariable analysis were recommendations for antimicrobial dose/frequency adjustment (OR 2.63, 95%CI 1.6–4.3) and order for labs/tests (OR 3.30, 95%CI 2.1–5.2), while recommendations for antimicrobial de-escalation (OR 0.75, 95%CI 0.60–0.95) and antimicrobial discontinuation (OR 0.57, 95%CI 0.42–0.76) were associated with lower odds of acceptance. Female physicians were more likely to accept recommendations compared to males (93.1% vs 90.3% acceptance, OR 1.65; 95%CI 1.3–2.2). Compared to physicians with less than 3 years of experience, who had the highest acceptance rate (96.3%), physicians with 21 or more years of experience had the lowest (87.1%, OR 0.26; 95%CI 0.15–0.45). Conclusion TeleASP recommendations were accepted at a high rate. Acceptance rates were higher among female physicians, and recommendations to stop or de-escalate antimicrobials led to lower acceptance. Recommendations made to the most experienced physicians were the least accepted, which may be an important factor for stewardship programs to consider in education and intervention efforts. Disclosures Thomas L. Walsh, MD, Accelerate Diagnostics: Honoraria.

949. Impact of Antimicrobial Stewardship Pharmacist Participation in Pediatric Infectious Diseases Rounds on Prospective Audit and Feedback Recommendations

Abstract Background Prospective audit and feedback (PAF) is a core strategy of antimicrobial stewardship programs (ASPs). To improve communication of PAF recommendations to the inpatient pediatric infectious diseases (ID) consult service, the ASP pharmacists at our hospital were integrated into ID rounds. The purpose of this study was to assess the impact of ASP pharmacy participation in ID rounds on the rate of ASP recommendations. Methods Prior to implementation of the ASP pharmacist rounding service, the ASP pharmacist did not routinely attend rounds or communicate PAF recommendations directly to the ID consult service. Starting 1/3/22, the ASP pharmacists had daily (M-F) in-person discussions with the ID team regarding their patients’ antimicrobials. Audits performed between 1/4/21-12/30/21 and 1/3/22-4/29/22 on patients with an ID consult were included in the non-rounding cohort (NRC) and rounding cohort (RC), respectively. We compared PAF recommendation rates, characteristics, and acceptance rates between the two cohorts. Results There was an increase in PAF recommendation rate in the RC compared to NRC (188/485 [39%] vs 359/1234 [29%], p &amp;lt; 0.001). Antibiotics were the antimicrobial category mostly likely to have a recommendation and the rate of antibiotic PAF recommendations was higher in the RC compared to the NRC (132/341 [39%] vs. 271/934 [29%], p = 0.001) (Table 1). The most common recommendation types in both cohorts were to optimize the antimicrobial dose and antimicrobial discontinuation. Recommendations were more frequently communicated to the ID team in the RC compared to NRC (125/188 [66%] vs. 107/359 [30%], p &amp;lt; 0.001). The recommendation acceptance rate was similar between the two cohorts (159/188 [85%] RC vs. 290/359 [81%] NRC, p = 0.29). CNS: Central nervous system; IV: Intravenous; NRC: Non-rounding cohort; PAF: Prospective audit and feedback; PO: Per os, oral; RC: Rounding cohort; SSTI: Skin and soft tissue infection; UTI: Urinary tract infection. Conclusion Implementation of a pediatric ASP pharmacist rounding service increased the PAF recommendation rate and improved recommendation communication with the pediatric ID consult service. Participation in rounds may better inform ASP pharmacist PAF recommendations. Future studies describing the potential benefit to the ID team by having an ASP pharmacist present on rounds are warranted. ASPs should consider formal integration of ASP pharmacists as part of the ID consult service to further improve the quality of antimicrobial prescribing. Disclosures All Authors: No reported disclosures.

Factors Associated With Acceptance of Telehealth-Based Antimicrobial Stewardship Program Recommendations in a Community Hospital Health System.

BackgroundTelehealth-based antimicrobial stewardship programs (TeleASPs) have led to reduced broad-spectrum antimicrobial utilization. Data on factors associated with acceptance of stewardship recommendations are limited.MethodsA TeleASP, facilitated by remote infectious disease physicians and local pharmacists, was implemented in 2 community hospitals from February 2018 through July 2020. Variables potentially affecting acceptance of TeleASP recommendations were tracked. Odds ratios of acceptance were determined utilizing multiple logistic regression.ResultsDuring the 30-month period, 4863 (91.2%) of the total 5333 recommendations were accepted. Factors associated with a higher odds of acceptance in multivariable analysis were recommendations for antimicrobial dose/frequency adjustment (odds ratio [OR], 2.63; 95% CI, 1.6–4.3) and order for labs/tests (OR, 3.30; 95% CI, 2.1–5.2), while recommendations for antimicrobial de-escalation (OR, 0.75; 95% CI, 0.60–0.95) and antimicrobial discontinuation (OR, 0.57; 95% CI, 0.42–0.76) were associated with lower odds of acceptance. Female physicians were more likely to accept recommendations compared with males (93.1% vs 90.3% acceptance; OR, 1.65; 95% CI, 1.3–2.2). Compared with physicians with <3 years of experience, who had the highest acceptance rate (96.3%), physicians with ≥21 years of experience had the lowest (87.1%; OR, 0.26; 95% CI, 0.15–0.45).ConclusionsTeleASP recommendations were accepted at a high rate. Acceptance rates were higher among female physicians, and recommendations to stop or de-escalate antimicrobials led to lower acceptance. Recommendations made to the most experienced physicians were the least accepted, which may be an important factor for stewardship programs to consider in education and intervention efforts.

#23 Clinical Outcomes with Rapid Gram-Positive Blood Culture Identification in an Academic Pediatric Hospital

Abstract Background BACKGROUND Delays in initiating appropriate antibiotics increases mortality, length of stay, and overall admissions costs in patients with bloodstream infections. Adult studies using rapid diagnostic tests such as the GenMark’s e-Plex Blood Culture Identification (BCID) Panels coupled with Antimicrobial Stewardship Program (ASP) interventions have led to reductions in each of these metrics. Similar data assessing use in the pediatric population are generally lacking. The primary aim of this study was to assess the impact of the GenMark Blood Culture Identification Gram Positive panel (BCID-GP panel) on the time to optimal antimicrobial therapy (OAT) in pediatric patients with positive blood cultures growing gram-positive bacteria (GPB). Method METHOD A 2-year Quality Improvement study of admitted pediatric patients was carried out at UPMC Children’s Hospital of Pittsburgh (CHP) between June 25, 2019 and June 26, 2021. Pre-intervention data (6/25/19 – 6/25/20) was collected retrospectively from the CHP Electronic Medical Record (EMR). During the post-intervention time-period (6/26/20 - 6/26/21), BCID-GP panel was run daily from 6AM to 10 PM on blood cultures with Gram stains revealing GPB. Results were provided to the ASP who generated recommendations and communicated them to the patient’s primary team after reviewing the EMR using a pre-determined algorithm. Statistical analyses were performed using Wilcoxon rank sum test and Chi-squared tests. Results RESULTS 317 and 265 blood cultures with GPB were evaluated in the pre- and post-intervention groups, with median ages of 2.26 and 3.2 years in the 2 groups, respectively. Overall panel accuracy was 97% with gene accuracy of 100%. Percent compliance with ASP recommendations within 12 hours was 89%. The median time to OAT was 48 (range of 0-175), and 33.1 hours (range 0-165) in the pre- and post-intervention groups, respectively (p &amp;lt;0.001). The median time to OAT for patients with MSSA decreased from 65 to 30.5 hours (p &amp;lt;0.001), and 37 to 20 hours (p 0.048) for those with MRSA. Antibacterial therapy was avoided in 42.2% of patients in the post-intervention group when results were interpreted as contaminants, compared with 23.4% in the pre-intervention group with this assessment (p = 0.008). Length of stay and 30-day mortality was similar between groups, 6.1 days vs 6.9 days (p = 0.23) and 3.5% vs 3.4%, (p = 1.00) respectively. Conclusion CONCLUSION Use of BCID-GP panel significantly decreased the time to OAT and avoided initiation of antibiotics in incidences of contamination in our study population. This was also true for positive blood cultures due to MSSA and MRSA. However, significant differences in the length of stay or 30-day mortality were not identified between groups. We did find the overall accuracy, defined as the percentage of BCID panels detected targets confirmed by conventional laboratory culture and gene accuracy, defined as the percent of BCID panels with results detected confirmed by conventional laboratory susceptibility methods, of the panel mirrored with previously published data. We also found ASP recommendations based on the BCID-GP were followed 89% of the time within 12 hours of them being made.

Colistin Action Against Planktonic Pseudomonas aeruginosa

Pseudomonas aeruginosa is an opportunistic human pathogen that causes nosocomial, acute, and chronic infections in patients with conditions such as cystic fibrosis, severe burns, and cancer. P. aeruginosa is associated with increased patient morbidity, mortality, and healthcare costs and is known for its persistence of infections. P. aeruginosa is resistant to many antibiotics; however, most strains are susceptible to colistin. The World Health Organization has identified antimicrobial resistance as a major threat and Antimicrobial Stewardship Programs (ASP) have been initiated. ASP goals are to improve patient outcomes, optimize patient safety, reduce antimicrobial resistance, and control healthcare costs. Recommendations to reduce antimicrobial resistance include optimizing the use of antimicrobials and preventing the transmission of drug‐resistant organisms. Using antimicrobic agents wisely leads to optimization of their use. For these reasons, we sought to adopt a model system for testing minimum inhibitory concentration (MIC) and minimum bactericidal concentration (MBC) levels for standardized strains of P. aeruginosa (ATCC strains 10145, 27853, 1744, CRM‐9027, 9721) using standardized methods. This study sought to compare results of standardized analysis that used Mueller‐Hinton Broth (MHB), the recommended and standardized growth medium, or tryptic soy broth (TSB), the growth medium used in many labs with published MIC and MBC reports. Given the ASP recommendations of optimizing use of antimicrobial agents, it is important to know the impact of variations in and deviations from standardized MIC and MBC methodologies in reporting of research results relevant to antimicrobic agents. This comparison study tested the assumption that MIC and MBC results are the same regardless of whether MHB or TSB is used as the growth medium. Preliminary results suggest that MIC and MBC values obtained by using TSB or MHB may display some degree of variability.

Impact of the Acceptance of the Recommendations Made by a Meropenem Stewardship Program in a University Hospital: A Pilot Study.

Antimicrobial stewardship programs (ASP) promote appropriate antimicrobial use. We present a 4-year retrospective study that evaluated the clinical impact of the acceptance of the recommendations made by a meropenem-focused ASP. A total of 318 meropenem audits were performed. The ASP team (comprising infectious disease physicians, pharmacists and microbiologists) considered meropenem use in 96 audits (30.2%) to be inappropriate. The reasons to consider these uses inappropriate were the possibility of de-escalating to a narrower-spectrum antibiotic, in 66 (68.7%) audits, and unnecessary meropenem use, in 30 (31.3%) audits. The ASP team recommended de-escalation in 66 audits (68.7%) and discontinuation of meropenem in 30 audits (31.3%). ASP interventions were stratified according to whether or not recommendations were followed. The group in which recommendations were accepted and followed (i.e., accepted audit, AA) included 66 audits (68.7%) and the group in which recommendations were not followed (i.e., rejected audit, RA) included 30 (31.3%) audits. The comorbidity of the AA group (Charlson score) was higher than in the RA group (7.0 (5.0–9.0) vs. 6.0 (4.0–7.0), p = 0.02). Discontinuation of meropenem was recommended in 83.3% of audits in the AA group vs. 62.2% in the RA group (OR 3.05 (1.03–8.99), p = 0.04). Ertapenem de-escalation resulted in a 100% greater rate of follow-up compared with the non-carbapenem option (100% vs. 51.9%, OR 1.50 (1.21–1.860), p = 0.001). Significant differences were observed in the AA group when cultures were taken before antibiotic prescription—98.5% vs. 83.3% (p = 0.01, OR 13.0 (1.45–116.86))—or when screening cultures were taken—45.5% vs. 19.2% (p = 0.03, OR 3.5 (1.06–11.52)). There were no differences between the groups in terms of overall mortality and 30-day mortality, length of stay, Clostridiodes difficile infection, 30-day readmission or hospitalization costs. In conclusion, meropenem ASP recommendations contributed to a decrease in meropenem prescription without worsening clinical and economic outcomes.

1134. The Effect of Telehealth Antimicrobial Stewardship Program on Antimicrobial Use in a Pediatric Intensive Care Unit

BackgroundInappropriate antimicrobial use is common in pediatric intensive care units (PICU). We aimed to evaluate the effect of telehealth antimicrobial stewardship program (ASP) on the rate of PICU antimicrobial use in a center without a local infectious diseases consultation service. MethodsAretrospective cohort study was performed between October 1st, 2018 and October 31st, 2020 in Farwaniyah Hospital PICU, a 20-bed unit. All pediatric patients who were admitted to PICU and received systemic antimicrobials during the study period were included and followed until hospital discharge. Patients admitted to the PICU prior to the study period but still receiving intensive care during the study period were excluded. Weekly prospective audit and feedback on antimicrobial use was provided starting October 8th, 2019 (post-ASP period) by the ASP team. A pediatric infectious diseases specialist would join ASP rounds remotely. Descriptive analyses and a pre-post intervention comparison of days of therapy (DOT) were used to assess the effectiveness of the ASP interventionResultsThere were 272 and 152 PICU admissions before and after initiation of ASP, respectively. Bronchiolitis and pneumonia were the most common admission diagnoses, together compromising 60.7% and 61.2% pre- and post-ASP. Requirement for respiratory support was higher post-ASP (76.5% vs 91.5%, p< 0.001). Average monthly antimicrobial use decreased from 92.2 (95% CI 74.5 to 100) to 48.5 DOT/1,000 patient-days (95% CI 24.6 to 72.2, P < 0.05) (figure). A decline in DOT was observed across all antibiotic classes, except for ceftriaxone and clarithromycin. No effect on length of PICU stay, hospital length of stay, or mortality was observed. Most (89.7%) ASP recommendations were followed fully or partially changes in antimicrobial days of therapy (DOT)/1,000 patient-days over time. The dashed line represents the start of the antimicrobial stewardship program (ASP) ConclusionIn settings where infectious diseases services are not available, telehealth stewardship can be effectively implemented and associated with a significant reduction of antimicrobial use.Disclosures Jesse Papenburg, MD, AbbVie (Grant/Research Support, Other Financial or Material Support, Personal fees)Medimmune (Grant/Research Support)Sanofi Pasteur (Grant/Research Support)Seegene (Grant/Research Support, Other Financial or Material Support, Personal fees)

116. Impact of an Antimicrobial Stewardship Program in the First Year of Pandemic 2020 in a Large,Academic, Public Network Hospitals in Bogotá,Colombia

BackgroundAntimicrobial resistance is a major public health threat internationally but, particularly in Colombia. High and increasing rates of carbapenemases are challenging. Implementing antimicrobial stewardship programs (AMSs) in a large, academic, public network hospitals in Bogotá, Colombia.will help curb inappropriate antibiotic use. Adherence to AMS Program 2020. Subred Integrada de Servicios de Salud Sur Occidente E.S.E Bogotá, Colombia. Impact of an Antimicrobial Use Optimization Program in the First Year of Pandemic 2020 in a Large, Academic, Public Network Hospitals in Bogota ColombiaMethodsAMS was established in April 2020 consisting of an administrative champion, Infectious Diseases staff, nurse, General Physician, microbiologist, and pharmacists. Antimicrobial stewardship program interventions included postprescriptive audit and establishment of institutional guidelines. The AMS tracked appropriate drug selection including loading dose, maintenance dose, frequency, route, duration of therapy, de-escalation, and compliance with AMS recommendations. Defined daily dose (DDD) of drugs and health economics evaluations of antimicrobials (April-December 2020). Recommendations are placed in the electronic medical record as a progress note.ResultsFrom April to December 2020, 1013 patients were evaluated by means of a prospective methodology. Unnecessary 689 days of hospitalization and 4420 days of antibiotic therapy were avoided. Among the top antibiotics discontinued were piperacillin tazobactam for the months of July, August, November and December, while for September and October was meropenem. The intensive care unit was the most frequently intervened service (52%), followed by hospitalization (43%) and the emergency department (5%).Over the course of the year, there was significant adherence to the program, with 100% in July, followed by 93.3% in April, 87% in December, 86.6% in May and June, 83% in November, 80% in September, 73.3% in August and 57% in October. The AMS program was able to save &47.409US in antibiotics and &55.529US in hospitalization, and 11% decrease in nephrotoxicity events (14 renal failures were avoided), which also saved additionally & 23.503 US for a total of an estimated cost saving for the network public hospitals of & 126.441 US by 2020.ConclusionImplementation of a multidisciplinary antibiotic stewardship program in this academic, large, academic, public network hospitals in Bogotá, Colombia demonstrated feasibility and economic benefits even in a Covid19 pandemic situation.Disclosures All Authors: No reported disclosures

P0611 / #1112: ANTIMICROBIAL STEWARDSHIP AND PROCALCITONIN TESTING TO OPTIMIZE SEPSIS CARE IN CRITICALLY ILL PEDIATRIC PATIENTS

Aims & Objectives: We aim to prospectively evaluate an antimicrobial stewardship program (ASP) and Procalcitonin (PCT) testing on septic pediatric intensive care (PICU) patients. Methods: We performed a 30-week baseline collection (Phase 1), and a 30-week evaluation (Phase 2) of ASP and PCT in PICU patients with suspected or confirmed sepsis (inclusion criteria: temperature >38.0 or <36.0 and requiring IV antibiotic). The primary endpoint was in-hospital mortality; secondary endpoints included antimicrobial adequacy, ASP interventions and acceptance, LOS, re-admissions and economic indices, etc. Segmented logistic and linear regression analyses were performed for associations. Results: Each phase had 40 children, mean age of 3.9 (1.8) years; 56.3% male; PRISM III mean was 3.3 and 7.0 (CI:±2.66,p=0.0068) in each phase, respectively. From 104 antibiotic prescriptions, 91 (88%) were guideline-concordant; 103 ASP recommendations were made in 60 assessments, with 83% full acceptance rate; in 12% of patients antimicrobials were not indicated, in 6% narrower spectrum was suggested. PCT was measured at least once in 95% of patients: in 24% initial PCT values were <0.25 ng/mL (stopping rule) while in 71% were >1 ng/mL (continuation rule). Only 1 patient died (phase 1), mortality 1.2%. In phase 2 the mean ICU LOS was shorter (-6.58 days; 95% CI, -14.51, 1.36, p=0.10) and PICU readmissions decreased (12 vs. 4; p=0.048); costs were lower (-$5,830) and QALYs were higher (0.192 vs 0.188). Conclusions: ASP and PCT testing were effectively implemented, well accepted and helpful, albeit mortality did not differ. Implementation was cost effective with fewer re-admissions and resulted in higher quality-adjusted life years.

Implementation of a Rapid Phenotypic Susceptibility Platform for Gram-Negative Bloodstream Infections With Paired Antimicrobial Stewardship Intervention: Is the Juice Worth the Squeeze?

BackgroundImplementation of the Accelerate PhenoTM Gram-negative platform (RDT) paired with antimicrobial stewardship program (ASP) intervention projects to improve time to institutional-preferred antimicrobial therapy (IPT) for Gram-negative bacilli (GNB) bloodstream infections (BSIs). However, few data describe the impact of discrepant RDT results from standard of care (SOC) methods on antimicrobial prescribing.MethodsA single-center, pre-/post-intervention study of consecutive, nonduplicate blood cultures for adult inpatients with GNB BSI following combined RDT + ASP intervention was performed. The primary outcome was time to IPT. An a priori definition of IPT was utilized to limit bias and to allow for an assessment of the impact of discrepant RDT results with the SOC reference standard.ResultsFive hundred fourteen patients (PRE 264; POST 250) were included. Median time to antimicrobial susceptibility testing (AST) results decreased 29.4 hours (P < .001) post-intervention, and median time to IPT was reduced by 21.2 hours (P < .001). Utilization (days of therapy [DOTs]/1000 days present) of broad-spectrum agents decreased (PRE 655.2 vs POST 585.8; P = .043) and narrow-spectrum beta-lactams increased (69.1 vs 141.7; P < .001). Discrepant results occurred in 69/250 (28%) post-intervention episodes, resulting in incorrect ASP recommendations in 10/69 (14%). No differences in clinical outcomes were observed.ConclusionsWhile implementation of a phenotypic RDT + ASP can improve time to IPT, close coordination with Clinical Microbiology and continued ASP follow up are needed to optimize therapy. Although uncommon, the potential for erroneous ASP recommendations to de-escalate to inactive therapy following RDT results warrants further investigation.

167. Communication is Key: A Multifaceted Approach to Improving Essential ASP Metrics in Surgical Services

BackgroundDespite widespread antimicrobial resistance, suboptimal antimicrobial use is common, particularly among surgical services. Studies show that antimicrobial stewardship programs (ASPs) effectively improve antimicrobial use and decrease adverse events. However, evidence for optimal ASP intervention in surgical departments is lacking, and some surgical services perceive ASPs negatively. This study aimed to evaluate the effect of several collaborative ASP interventions and workflow changes on the non-acceptance rate (NAR) of ASP recommendations and antimicrobial use among surgical services.MethodsThis was a retrospective, pre-post study of services in the department of surgery at a 681-bed, academic medical center between 12/01/2018 and 5/31/2020. Throughout 10/2019 and 11/2019, the core ASP, which consists of two infectious diseases physicians and two infectious diseases pharmacists, performed several interventions with surgical services. These included meetings with the chairman, vice chairs, and division chiefs of the surgery department, a grand rounds presentation to surgical house staff, and monthly surgeon NAR reporting to the chairman. Also, per feedback from surgeons, the ASP began to communicate recommendations directly to attending surgeons instead of residents or via ASP notes in the medical record. Data for the pre-period was collected from 12/2018 to 9/2019; data for the post-period was collected from 12/2019 to 5/2020. Wilcoxson rank sum, chi-square, and Fisher’s exact tests were used to compare outcomes.ResultsThe ASP communicated 353 recommendations to surgical services in the pre-period, and 181 in the post-period. ASP offered most recommendations to trauma (n=244), cardiothoracic (n=60), and plastic surgery (n=54) during the study periods. NAR decreased post-intervention overall (43% vs 29%, p=0.0013) and in trauma surgery (63% vs 47%, p=0.03). Mean monthly days of therapy per 1000 patient days trended towards a decrease post-intervention (1105 vs 1044, p=0.26). Cost per 1000 patient days decreased post-intervention ($27,677.91 vs $19,766.31, p =0.0075).ConclusionA communicative and adaptive approach to ASP in surgical services improved NAR and antimicrobial costs and trended towards a reduction in antimicrobial use.Disclosures All Authors: No reported disclosures

90. Impact of Discrepant Rapid Diagnostic Test (RDT) Results on Antimicrobial Stewardship Program (ASP) Interventions in Patients with Bloodstream Infections (BSI) due to Gram-Negative Bacilli (GNB)

BackgroundImplementation of the Accelerate PhenoTM Gram-negative platform (AXDX) paired with ASP intervention projects to improve time to definitive institutional-preferred antimicrobial therapy (IPT). However, few data describe the impact of discrepant RDT results from standard of care (SOC) methods on antimicrobial prescribing. Here we evaluate the prescribing outcomes for discrepant results following the first year of AXDX + ASP implementation.MethodsConsecutive, non-duplicate blood cultures for adult inpatients with GNB BSI following combined RDT + ASP intervention were included (July 2018 – July 2019). AXDX results were emailed to the ASP in real time then released into the EMR upon ASP review and communication with the treating team. SOC identification (ID; Vitek® MS/Vitek® 2) and antimicrobial susceptibility testing (AST; Trek SensititreTM) followed RDT as the reference standard. IPT was defined as the narrowest susceptible beta-lactam, and a discrepancy was characterized when there was categorical disagreement between RDT and SOC methods. When IPT by AXDX was found to be non-susceptible on SOC, this was characterized as “false susceptible“. Conversely, “false resistance” was assessed when a narrower-spectrum agent was susceptible by SOC. Results were also deemed discrepant when the AXDX provided no/incorrect ID for on-panel organisms, no AST, or a polymicrobial specimen was missed.ResultsSixty-nine of 250 patients (28%) had a discrepancy in organism ID or AST: false resistance (9%), false susceptible (5%), no AST (5%), no ID (4%), incorrect ID (2%), and missed polymicrobial (2%). A prescribing impact occurred in 55% of cases (Table 1), where unnecessarily broad therapy was continued most often. Erroneous escalation (7%) and de-escalation to inactive therapy (7%) occurred less frequently. In-hospital mortality occurred in 4 cases, none of which followed an inappropriate transition to inactive therapy. ConclusionThough the AXDX platform provides rapid ID and AST results, close coordination with Clinical Microbiology and continued ASP follow up are needed to optimize therapy. Although uncommon, the potential for erroneous ASP recommendations to de-escalate to inactive therapy following AXDX results warrants further investigation.DisclosuresAmy J. Mathers, MD, D(ABMM), Accelerate Diagnostics (Consultant)

Implementation and Evaluation of Antimicrobial Stewardship Program in Medical ICU in Cairo University Specialized Pediatric Hospital

BACKGROUND: High antibiotics use in pediatric intensive care units (PICUs) results in antibiotic resistance, the unfavorable clinical outcome of patients, increase the length of hospital stay, and drug expenditure.&#x0D; AIM: This study aimed at setting clinical guidelines customized according to local diseases epidemiology and local cumulative antimicrobial susceptibility, implementing, and evaluating the Antimicrobial Stewardship Program (ASP) effect in; optimizing antibiotics use, decreasing antibiotics expenditure, decreasing the length of therapy and stay in hospitals, and improving patients’ clinical outcomes.&#x0D; METHODS: A prospective study was conducted at a PICU of the Specialized Pediatric Hospital, Cairo University. Facility-specific guidelines were set, and the ASP was implemented and evaluated through the following indicators; adherence of physicians to the guidelines, ASP recommendations and acceptance of them, the rate of mortality, length of stay, drug costs, antibiotics days of therapy, and length of therapy.&#x0D; RESULTS: The adherence to the ASP guidelines was positively correlated to the patient’s clinical outcome (p = 0.018). In post ASP period, the average length of stay and the length of therapy significantly decreased (p = 0.047, p = 0.001, respectively), the rate of adherence to the ASP guidelines was (91.9%), the days of therapy of ceftazidime, ceftriaxone, and amikacin decreased significantly (p = 0.041, p = 0.026, p = 0.004, respectively). The most common ASP recommendation was drug schedule/frequency change (26.1%) followed by drug discontinuation (17.8%) and the most common antibiotic required intervention was ampicillin-sulbactam (21.6%).&#x0D; CONCLUSION: The antimicrobial stewardship is very effective in optimizing antibiotics use and leads to favorable outcomes in terms of decreased length of therapy, hospital stay, and mortality rate of the patients.

Barriers to Adherence to Antimicrobial Stewardship Postprescription Review and Feedback For Broad-Spectrum Antimicrobial Agents: A Nested Case-Control Study.

BackgroundPostprescription review and feedback (PPRF) is one of the most common strategies in antimicrobial stewardship program (ASP) intervention. However, disagreements between the prescribers and ASP personnel can occur. The aim of the present study was to identify the factors associated with nonadherence to PPRF intervention.MethodsThe present retrospective nested case-control study was performed at a tertiary care center, which has been conducting a once-weekly PPRF for carbapenems and piperacillin/tazobactam since 2014. Nonadherence to ASP recommendations was defined as the failure of the primary care team to modify or stop antimicrobial therapy 72 hours after the issuance of PPRF recommendations. Factors associated with nonadherence to PPRF intervention were identified using multivariate logistic regression analysis.ResultsIn total, 2466 instances of PPRF in 1714 cases between April 2014 and September 2019 were found. The nonadherence rate was 5.9%, and 44 cases were found in which carbapenems or piperacillin/tazobactam continued to be used against PPRF recommendations. Factors associated with nonadherence to PPRF recommendations were a previous history of hospitalization within 90 days (adjusted odds ratio [aOR], 2.62; 95% confidence interval [CI], 1.18–5.81) and a rapidly fatal McCabe score at the time of PPRF intervention (aOR, 2.87; 95% CI, 1.18–6.98). A review of the narrative comments in the electronic medical records indicated that common reasons for nonadherence were “the patient was sick” (n = 12; 27.3%) and “the antimicrobial seemed to be clinically effective” (n = 9; 20.5%).ConclusionsNonadherence to PPRF recommendations was relatively uncommon at the study institution. However, patients with a severe disease condition frequently continued to receive broad-spectrum antimicrobials against PPRF recommendations. Understanding physicians’ cognitive process in nonadherence to ASP recommendations and ASP interventions targeting medical subspecialties caring for severely ill patients is needed to improve ASP.

2237. Early Discontinuation of Antibacterials Is Safe for Patients with Community-Acquired Pneumonia (CAP) Who Have a Positive Viral Test, Negative Tests for Bacteria, and Low Procalcitonin

BackgroundStudies using molecular testing methods have found monomicrobial infection with a virus as the etiology of CAP in adult patients admitted to the hospital in 6–30% of cases. The use of antibacterial agents in such patients is unnecessary, and can lead to untoward consequences. A test confirming a viral etiology may reduce the needless use of antibiotics, especially if the procalcitonin (PCT) level is low, suggesting that bacterial co-infection is unlikely. Our Antimicrobial Stewardship Program (ASP) routinely follows patients admitted with respiratory tract infections, and provides recommendations for appropriate therapy based on diagnostic test results as well as PCT levels. We present a retrospective evaluation of our experience.MethodsA retrospective review of ASP interventions on patients admitted to Summa Health System—Akron Campus was performed for the time frame of January 2018–March 2019. Patients were included if they had a positive viral PCR result (VERIGENE™, BioFire™), a PCT level <0.25 ng/mL (BioMérieux™, Abbott™), negative bacterial studies, and an accepted intervention to discontinue antimicrobial therapy made by the ASP.ResultsThe ASP assessed 131 patients with positive viral PCR studies and low PCT levels who had antimicrobials discontinued based on ASP recommendations; 68 with CAP and 63 without pneumonia (WPNA) as demonstrated on imaging. Most patients in the WPNA category had acute exacerbation of COPD. Common viruses identified were Influenza A or B, Rhinovirus and RSV. Mean duration of antibiotics was 2.6 days for CAP and 2.4 days for WPNA (Table 1). The 30-day readmission rate was similar for each group, and for CAP patients was similar for all-cause pneumonia patients at our institution (14% during similar time period). 30-day Mortality of CAP patients was low.ConclusionWhile national guidelines recommend a minimum of 5 days of antimicrobial therapy for CAP patients, we have observed that discontinuing antibiotics well before that is safe if a viral etiology is identified without evidence of bacterial co-infection (including low PCT) and results in less antibiotic usage. Reduction in unnecessary antibiotic use has the potential to improve the quality of care for adults with CAP. Disclosures All authors: No reported disclosures.

1043. Love Thy Steward – Who Does Not Love Antimicrobial Stewardship?

BackgroundThe impact of antimicrobial stewardship programs (ASPs) depends on physician perception of antimicrobial stewardship and institutional antibiotic prescribing culture. At Rush University Medical Center (RUMC), we conducted an antimicrobial stewardship study targeting inpatient levofloxacin (FQ) use and assessed rates of implementation of recommendations (IORs) by general medicine (GM), vs. surgical services (SS) (general surgery, urology, orthopedics and neurosurgery), vs. transplant surgery-immunocompromised host (T-ICH) teams when made by either infectious disease pharmacists (IDPharmD) or infectious disease fellows (IDMDF).MethodsBetween August 13, 2018 and January 15, 2019 at RUMC, IDPharmDs reviewed 251 inpatients on FQ, and made ASP recommendations on 36 (14%) that were communicated via telephone. No scripted discussion or note was utilized. From January 15, 2019 to April 19, 2019, an IDMDF reviewed 207 inpatients on FQ, and made ASP recommendations on 47 (22%). IDMDF’s recommendations were communicated via a scripted discussion describing the role of ASP, highlighting the importance of optimizing FQ use due to toxicity, low rates of RUMC’s FQ susceptibilities and to decrease rates of resistance. Telephone recommendations were made to the primary team house staff or attending followed by a templated electronic note left in the medical chart. Rates of IORs were assessed during each period and by each group.ResultsIn 20 out of 83 recommendations (24%), no antibiotic was indicated (Figure 1). GM teams had the highest overall (IDPharmD + IDMDF) IOR (76%), compared with 40% IOR for both SS and T-ICH groups. For all groups, the scripted IDMDF recommendations had higher IOR compared with the nonscripted IDPharmD recommendations (GM 89% vs. 61%; SS 50% vs. 29%; T-ICH 50% vs. 0%).ConclusionASP interventions using scripted discussions and notes by an IDMDF were more effective than nonscripted IDPharmD interventions across all service lines. Both interventions were less successful with SS or T-ICH compared with GM services. These findings demonstrate the need for further research to understand the importance of scripted vs. nonscripted communication methods by pharmacists and ID physicians, and to develop alternative communication models for nongeneral medicine service providers. Disclosures All authors: No reported disclosures.

Clinical impact of an antimicrobial stewardship program on high-risk pediatric patients

To evaluate the clinical impact of an antimicrobial stewardship program (ASP) on high-risk pediatric patients. Retrospective cohort study. Free-standing pediatric hospital. This study included patients who received an ASP review between March 3, 2008, and March 2, 2017, and were considered high-risk, including patients receiving care by the neonatal intensive care (NICU), hematology/oncology (H/O), or pediatric intensive care (PICU) medical teams. The ASP recommendations included stopping antibiotics; modifying antibiotic type, dose, or duration; or obtaining an infectious diseases consultation. The outcomes evaluated in all high-risk patients with ASP recommendations were (1) hospital-acquired Clostridium difficile infection, (2) mortality, and (3) 30-day readmission. Subanalyses were conducted to evaluate hospital length of stay (LOS) and tracheitis treatment failure. Multivariable generalized linear models were performed to examine the relationship between ASP recommendations and each outcome after adjusting for clinical service and indication for treatment. The ASP made 2,088 recommendations, and 50% of these recommendations were to stop antibiotics. Recommendation agreement occurred in 70% of these cases. Agreement with an ASP recommendation was not associated with higher odds of mortality or hospital readmission. Patients with a single ASP review and agreed upon recommendation had a shorter median LOS (10.2 days vs 13.2 days; P &lt; .05). The ASP recommendations were not associated with high rates of tracheitis treatment failure. ASP recommendations do not result in worse clinical outcomes among high-risk pediatric patients. Most ASP recommendations are to stop or to narrow antimicrobial therapy. Further work is needed to enhance stewardship efforts in high-risk pediatric patients.