Antimicrobial Stewardship Recommendations Research Articles

P-1736. Examining the Impact of Eliminating a Transitions of Care Pharmacist Program on Antimicrobial Use

Abstract Background Antimicrobial stewardship interventions during transitions of care (TOC) have increased guideline concordant prescribing at hospital discharge. A TOC pharmacy program targeting discharging patients at the high risk for mortality was established at our community teaching hospital in 2016. A previous program analysis reported 14.4% of all pharmacist interventions made involved antimicrobials. The TOC pharmacy program was eliminated in 2022. The purpose of this study was to assess the impact of program elimination on appropriate and optimal antimicrobial prescribing. Methods This retrospective, single center, pre-post cohort study investigated the impact of the elimination of the TOC program on appropriate and optimal antimicrobial prescribing. Adult inpatients with the highest risk of 30-day mortality receiving an antimicrobial at discharge between September - November 2021 (TOC pharmacist program cohort) and September - November 2022 (post-TOC cohort) were included. Appropriate antimicrobial use was defined as prescribing of indication-based effective and safe therapy. Optimal prescribing was defined as adherence to institutional guideline-based antimicrobial stewardship recommendations. Results Six-hundred twenty-six patients were included with 313 patients in each cohort. Baseline characteristics between cohorts were generally similar with significant differences in the number of patients treated for community-acquired pneumonia (20.4% vs. 28.4%; P = 0.026) and bacteremias (11.5% vs. 5.1%; P = 0.004). There were no differences in appropriate (90.4% vs. 90.1%; P = 0.893), or optimal prescribing (80.8% vs. 78%; P = 0.374) between cohorts. There were no differences in incidence of non-optimal antimicrobial dosing (6.4% vs. 5.8%; P = 0.738), or non-optimal antimicrobial selection (1.3% vs. 2.9%; P = 0.161); however, the incidence of non-optimal duration decreased in the post-TOC cohort (22% vs. 15%; P = 0.024). Conclusion The elimination of the TOC pharmacy program did not impact appropriate or optimal antimicrobial prescribing. Relatively high appropriate and optimal prescribing were noted in both cohorts and additional ongoing stewardship interventions may have confounded results. Disclosures All Authors: No reported disclosures

P-1132. Patient Pre-Selection Improves Efficiency and Acceptability of Antimicrobial Audit-and-Feedback Rounds in a Neonatal Intensive Care Unit

Abstract Background Audit-and-Feedback Rounds (AFR) are an effective way of evaluating the appropriateness of antimicrobials in inpatient settings, but they are time- and resource-intensive. In our 52-bed tertiary care neonatal intensive care unit (NICU), AFR methodology was modified in that pharmacists would pre-select patients to be discussed, in order to focus on value-added discussions. This observational study describes the impact of this intervention on key AFR metrics.Figure 1.Percentage of NICU patients on systemic antimicrobials who were discussed at audit-and-feedback rounds, pre- and post-intervention. Methods Since October 2019, the NICU team and an Infectious Diseases (ID) physician met weekly to review all patients on systemic antimicrobials at the time of AFR. The ID physician assessed the appropriateness of antimicrobials and made recommendations to the team. Pharmacists prospectively collected data on the duration of AFR, reasons for inappropriate prescriptions, recommendations made, and adherence to recommendations 24 hours later. To improve efficiency, from September 2021 on, it was agreed that pharmacists would select out some patients from the discussion list as they were considered by default to be on appropriate therapy: those followed by the ID service; neonates on empiric ampicillin and an aminoglycoside for early-onset sepsis; and those on prophylactic antimicrobials if already reviewed once before.Figure 2.Percentage of antimicrobial stewardship recommendations accepted by NICU team, assessed 24 hours post-rounds. Results In the pre-intervention period (Oct 2019 - Oct 2020), 92% (n = 226) of patients on systemic antimicrobials were reviewed, and AFR lasted 27 minutes on average. Antimicrobial use was considered appropriate for 88% of patients and 75% (n=55) of recommendations were accepted by the NICU team. In the initial post-intervention period (Oct 2021- Oct 2022), 30 % (n = 101) of patients on antimicrobials were discussed at AFR (Figure 1), and usage was considered appropriate in 80% (n = 123). Between Oct 2022 and Oct 2023, mean duration of AFR had decreased to 13 minutes, and adherence to recommendations increased to 92% (n=36). Conclusion Patient pre-selection for AFR was associated with shorter rounds and increased uptake of recommendations by clinical teams. This method could be used to conduct AFR in other busy inpatient settings. Disclosures All Authors: No reported disclosures

P-2220. Real-World Utilization of a Multiplex Pneumonia PCR Panel on Antimicrobial Stewardship and Antibiotic Use

Abstract Background In October 2022 the Queen of the Valley Medical Center (QVMC) microbiology department implemented the Biofire® Pneumonia Pathogen Panel polymerase chain reaction (PCR) for identification of viral and bacterial pathogens along with resistance genes. This may aid in improved identification of pneumonia pathogens with a quicker turnaround time. In contrast, respiratory cultures take multiple days to return with both the organism and antibiotic susceptibility, which delays the time to achieving targeted therapy. Methods This was a retrospective cohort study from October 2022 to April 2023. Patients were included if they were admitted to QVMC and had a positive pneumonia PCR. Patients were excluded if they were receiving antibiotics for an indication other than pneumonia, if they did not receive antibiotics, or if they were discharged, transferred or died prior to the PCR result. The primary outcome was if the patient achieved targeted therapy. Secondary outcomes included time to targeted therapy, actions performed based on the results, and correlation between respiratory culture results and PCR. Results Fifty-nine patients were included for analysis. Most patients had a diagnosis of CAP (n = 43, 72%), vs. HAP (n = 8, 14%), and VAP (n = 8, 14%). Targeted therapy was achieved in 41 patients (70%). Seven (12%) of these patients had empiric therapy which was also targeted therapy. The mean time from PCR collection to the start of targeted therapy was 23.11 hours. For patients who had respiratory cultures collected, the mean time to final identification with susceptibilities was 40.6 hours. Therefore, targeted therapy was achieved at least 17 hours sooner than if de-escalation or escalation was solely dependent upon respiratory culture results. There were 47 antimicrobial stewardship recommendations documented, and 31 (66%) were accepted by providers. Forty-four patients (75%) also had respiratory cultures collected, and only 19 (43%) had organism growth. Conclusion Utilizing multiplex PCR technology for patients with pneumonia can be useful for antimicrobial stewardship programs by providing higher rates of pathogen identification and resistance data compared to respiratory culture alone. This allows for improved time to targeted therapy. Disclosures All Authors: No reported disclosures

CLinician and patient characteristics effect on Antimicrobial Stewardship Interventions (CLASI) study.

To determine whether the gender of clinicians making antimicrobial stewardship recommendations has an impact on intervention acceptance rate. A retrospective, multivariable analysis of antimicrobial stewardship prospective audit and feedback outcomes. A multisite healthcare system including Mayo Clinic Rochester (MN), Mayo Clinic Arizona, Mayo Clinic Florida and 17 health-system hospital sites, where prospective audit and feedback is performed and documented within an electronic tool embedded in the medical record. The study included 143 Mayo Clinic clinicians (84 cisfemales and 59 cismales). Outcomes were analyzed from July 1, 2017, to June 30, 2022, for intervention rates, communication methods, and intervention acceptance by clinician gender, profession, patient age, and intensive care unit (ICU) status of patient. Of 81,927 rules, 71,729 rules met study inclusion. There were 18,175 (25%) rules associated with an intervention. Most of the rules were reviewed by pharmacists (86.2%) and stewardship staff (85.5%). Of 10,363 interventions with an outcome documented, 8,829 (85.2%) were accepted and 1,534 (14.8%) were rejected. Female clinicians had 6,782 (86.5%) of 7,843 interventions accepted, and male clinicians had 2,047 (81.2%) of 2,520 interventions accepted (P = .19). Female patients had more interventions than male patients (female vs male: 25.9% vs 24.9%; OR, 1.04; 95% CI, 1.02-1.08; P = .001). Patients in the ICU had a significantly lower intervention acceptance rate (ICU vs non-ICU: 78.2% vs 86.7%; OR, 0.56; 95% CI, 0.45-0.7; P < .001). Female and male clinicians were equally effective at prospective audit and feedback in a multisite antimicrobial stewardship program. Patients in the ICU were less likely to have stewardship interventions accepted.

O02 Improving antimicrobial use in HSE older persons residential care facilities

Abstract Background Antimicrobial use in Irish older persons residential care facilities (OP RCFs) is higher than in other European countries. In 2020/21, for the first time, an antimicrobial pharmacist (AMP) was appointed to each community healthcare organization (CHO) to monitor, develop and promote antimicrobial stewardship in community settings. Objectives To establish baseline antibiotic use, develop antimicrobial stewardship tools for OP RCFs, promote best practice in relation to antimicrobial stewardship (AMS) and monitor trends in antimicrobial use in HSE (state-run) OP RCFs. Methods A baseline point prevalence survey (PPS) of antimicrobial use was conducted across all HSE OP RCFs between October 2020 and August 2021. Following the survey, key national recommendations and AMS resources were developed in collaboration with the national Antimicrobial Resistance and Infection Control Programme. Feedback was provided to participating facilities by CHO AMPs with antimicrobial stewardship support and education for nursing and medical staff. In September 2021, monthly monitoring of antibiotic use was established in HSE OP RCFs in collaboration with local managers, to capture the proportion of antibiotics used for prophylaxis or treatment each month. Results A baseline PPS of antimicrobial use in 2020/21 showed that 11.9% (528/4446) of residents were on a systemic antibiotic, with 6.3% on antibiotic prophylaxis. Urinary tract infection accounted for 51% of antibiotic prescriptions. Following the baseline PPS, CHO AMPs developed an AMS toolkit for OP RCFs, engaged with nursing and medical staff to communicate PPS results, AMS resources and support implementation of AMS recommendations. Subsequently, monthly self-reporting of antimicrobial use in HSE OP RCFs was commenced in September 2021 and showed a sustained decrease in antimicrobial use with 7.9% residents on an antibiotic in Quarter 2 2022, with 2.7% on antibiotic prophylaxis. Conclusions Newly appointed CHO AMPs have successfully promoted AMS across HSE OP RCFs. Following audit, feedback, education, development and promotion of antimicrobial stewardship resources, there was a sustained decrease in the proportion of residents on antibiotics used for treatment and prophylaxis of infection.

930. Weakening the waves: Impact of a syndrome-based antimicrobial stewardship intervention during COVID-19

Abstract Background Lower respiratory tract infections (LRTIs) from SARS-CoV-2 are difficult to distinguish from other viral or bacterial etiologies. This has led to increased antimicrobial use (AU) during the pandemic and concerns for concomitant rise in antimicrobial resistance (AMR). It is crucial for antimicrobial stewardship (ASP) to develop strategies to mitigate excess AU and curve AMR. We leveraged a syndrome-based ASP intervention targeting LRTIs and the use of anti-Pseudomonal beta lactams (APBL) during the COVID-19 pandemic. Methods We incorporated COVID-19 elements into a syndrome-based prospective audit and feedback (PAF) at an urban community hospital. Elements included EMR order sets (Figure 1) that discouraged routine AU for COVID-19 and PAF targeting LRTIs and COVID-19 therapies. Empiric selection discouraging APBL was incorporated during the first COVID-19 wave. Order sets and PAF were then modified to reflect novel COVID-19 therapeutics and AU was strongly discouraged in subsequent waves. Data on AU and AMR from 2018-2022 was reviewed. Figure 1.Electronic medical records COVID-19 antimicrobial order set Results Average quarterly AU increased during the first pandemic year by 8.7%, from 359.5 to 391 days of therapy per 1000 patient days (DOT/1000), with peaks 22.5% above the pre-pandemic average during COVID-19 surges. AU increased each COVID-19 surge, with smaller peaks each subsequent wave. DOT/1000 declined 29% from the first wave to the Omicron wave. AU decreased the second year to 318, an 18.6% decrease from the first pandemic year. Ceftriaxone use increased during surges, reflecting our LRTI guidelines (Figure 2). Peaks declined each subsequent wave, from a peak of 239 in the first wave to 75 during Omicron, a 68% decrease. The average monthly DOT/1000 for APBL decreased from 73.51 to 63.21 (Figure 3). Incidence rate of ESBL and CRE initially rose and then declined (Figure 4). Figure 2.Antimicrobial use (DOT/1000) before and during the COVID-19 pandemicFigure 4.Antipseudomonal beta lactam use before and during the COVID-19 pandemic Figure 5. Incidence of multidrug resistance organisms before and during the COVID-19 pandemic Conclusion ASP successfully incorporated COVID-19 elements and steered AU during the pandemic. Though total AU increased, APBL use declined and AU peaks decreased with each COVID-19 wave, reflecting adherence with ASP recommendations. AMR increased during the first year and subsequently declined. ASP can play a vital role guiding AU during respiratory pandemics. Disclosures All Authors: No reported disclosures.

195. Reducing Time to Optimal Antimicrobial Therapy (OAT) for Bloodstream Infections (BSI) due to Gram Positive Cocci (GPC) in Chains Using Rapid Diagnostics Paired with Antimicrobial Stewardship (ASP) Efforts

Abstract Background Rapid microbiology diagnostic results paired with immediate ASP intervention have been shown to decrease time to OAT and improve patient outcomes. For Gram positive (GP) BSI, studies have primarily focused on Staphylococci. However, the value of using rapid diagnostics for GPC in chains is not well studied. With the use of BioFire® FilmArray® Blood Culture Identification 2 (BCID2) to identify GPC in chains, we aimed to compare the time to OAT between pre- and post- implementation. Methods In May 2021, our institution implemented the use of BCID2 for GPC in chains, which detects 5 types of GPC in chains to the species level and the van A/B gene. Positive results were communicated in real time 24/7 to ASP who provided recommendations on OAT to the treatment team. A retrospective chart review compared the pre-implementation cohort (Jan - Sept 2019) to the post-implementation cohort (May 2021 - Jan 2022). The following patients were excluded from analysis: &amp;lt; 18 years of age, presence of polymicrobial infection or Streptococci with unidentified species by BCID2, discharged or deceased before rapid diagnostic result, on comfort measures or left against medical advice within 72 hours of result. The primary study endpoint was time to OAT which was defined as time from positive Gram stain to OAT. Secondary outcomes included percentage of ASP recommendations accepted, length of stay (LOS), and 30-day mortality. Results A total of 199 patients met inclusion criteria, 117 pre-cohort vs. 82 post-cohort. Baseline demographics were similar in both groups with the exception of the post-cohort having a numerically higher Charlson Comorbidity Index (Table 1). The most common sources of the bacteremias were intra-abdominal, skin and soft tissue, and endovascular (Table 2). The primary endpoint, average time to OAT, was 35 hours in the pre-cohort and 18 hours in the post-cohort with a difference of 16.8 hours (95% CI 9.8 – 23.8; p &amp;lt; 0.0001) (Table 3). ASP recommendations were accepted 91% of the time. The median LOS was 9 days (IQR 6 - 21) in the pre-cohort vs. 13 days (IQR 7-32) in the post-cohort (p = 0.07). The 30-day mortality rate was numerically lower in the pre-cohort (6.1% vs. 10.3%; p = 0.79). Conclusion For BSI due to GPC in chains, rapid diagnostics via BCID2 paired with 24/7 ASP led to markedly decreased time to OAT. Disclosures David Peaper, MD, Tangen Biosciences: Stocks/Bonds.

948. Impact of a Multi-pronged Approach to Antimicrobial Stewardship on the Vascular Ward at a Tertiary Hospital

Abstract Background Up to 50% of inpatient antibiotic use may be inappropriate, and guideline concordance for antibiotic prescribing in surgical wards tends to be lower than medical wards. As such, our study describes a multi-pronged approach to antimicrobial stewardship (AMS) targeting a vascular ward and its impact on improving antibiotic use. Methods This is a quality improvement study at a tertiary hospital in British Columbia, Canada. All patients admitted to the vascular surgery ward for any vascular related issues and who received piperacillin-tazobactam or a carbapenem were included. Patients were excluded if admitted to the ward for &amp;lt; 48 hours. The primary outcome is appropriateness of carbapenem and piperacillin-tazobactam use in concordance with local policies. Secondary outcome is consumption of these agents. The pre-intervention period was March 2020 to June 2020. The AMS team prospectively reviewed included patients to establish the baseline level of appropriate antibiotic use. The intervention period was from July 2020 to February 2021. Aside from presentations to surgeons, the main intervention was regular audit and feedback to a nurse practitioner who rounds with the surgeons. Mandatory ID consultation for carbapenems was the last resort if AMS recommendations were not accepted. Results During the pre-intervention period, 19 out of 25 prescriptions (76%), either carbapenem or piperacillin-tazobactam, had appropriate indications. In the intervention period, 121 prescriptions were reviewed and the appropriateness level increased to 87% (Figure 1). Eleven mandatory ID consultations were generated. The mean days of therapy (DOT) per 1000 patient-days for carbapenem decreased from 94.6 to 56.6 for pre- and intervention periods, respectively. For piperacillin-tazobactam, the mean DOT per 1000 patient-days decreased from 209.9 to 138.5 for pre- and intervention periods. The reduced usage of piperacillin-tazobactam remained sustainable post-intervention (Figure 2). Figure 1:Summary of patient characteristics and outcomes during intervention period (July 2020 to February 2021)Figure 2:Usage of piperacillin-tazobactam from June 2019 to June 2021 Conclusion A multi-pronged approach, consisting of education, prospective audit and feedback to the surgical team, and mandatory ID consult in selected cases, is effective in decreasing inappropriate broad-spectrum antibiotic use on the vascular ward at a tertiary centre. Disclosures All Authors: No reported disclosures.

912. Impact of Rapid Identification and Stewardship Intervention on Coagulase-negative Staphylococcus Bloodstream Infection (BSI)

Abstract Background Coagulase-negative staphylococci (CoNS) are commonly isolated from blood cultures (BCx). Most do not require treatment (tx), yet antibiotics are frequently initiated. Workup of CoNS BSI consumes significant resources. We aimed to demonstrate the safety and efficacy of an early algorithm-based rapid diagnostic testing (RDT) plus antimicrobial stewardship (ASP) intervention. Methods BCx with CoNS were captured in 3 time periods to represent pre-RDT, RDT-only, and RDT+ASP. GenMark ePlex RDT was implemented for all Gram-positive BCx, identifying S. epidermidis and other non-aureus/lugdunensis Staphylococcal species. Results were called to ASP in both RDT-only and RDT+ASP periods. In the latter, a prospective algorithm was implemented to standardize ASP recommendations (Fig 1) for cases classified as simple, uncomplicated, and complicated BSI. The primary outcome was receipt of &amp;lt; 24h of antibiotic tx. Safety outcomes included rates of recurrent BSI and hospital readmission. Results 184 patients were included (Fig 2). The median age was 62, 54% were male, and the median Charlson comorbidity index was 5. 41% had a central venous catheter at time of BSI. Overall, 67%, 19%, and 12% of cases were classified as simple, uncomplicated, or complicated BSI, respectively (Fig 3). BSI class and patient demographics did not vary between periods. During pre- and post-RDT periods, median days of antibiotic tx did not vary significantly for patients with simple BSI (1.1 vs 1.2). In contrast, median days of tx were reduced to 0 (P=0.005) for simple BSI in the RDT+ASP period. Overall, 54% of patients with CoNS BSI received &amp;lt; 24h of tx in RDT+ASP time period compared to 34% (P=0.009) in the combined pre-RDT and RDT-only periods. Tx was entirely avoided in 28% of CoNS BSI cases in the RDT+ASP period compared to 16.5% of cases in other periods (P=0.07). 7 cases classified as simple were reclassified as uncomplicated or complicated after further work up. Rates of recurrent BSI and 30-day readmission were comparable across time periods. Conclusion Our algorithm-based ASP + RDT intervention reduced antibiotic tx for CoNS BSI, an effect not realized with RDT alone. These data attest to the safety and efficacy of early ASP intervention for patients with CoNS BSI identified by RDTs at the time of positive BCx. Disclosures J Ryan Bariola, MD, Infectious Disease Connect: Salary support|Merck: Grant/Research Support Tina Khadem, PharmD, Infectious Disease Connect: Salary support|Merck: Grant/Research Support Brian Potoski, PharmD, BCPS-AQ ID, Merck Group: Grant/Research Support Ryan K. Shields, PharmD, MS, Infectious Disease Connect: Advisor/Consultant|Merck: Advisor/Consultant|Merck: Grant/Research Support|Roche: Grant/Research Support.

The interplay of infectious diseases consultation and antimicrobial stewardship in candidemia outcomes: A retrospective cohort study from 2016 to 2019.

To evaluate the need for mandatory infectious diseases consultation (IDC) for candidemia in the setting of antimicrobial stewardship guidance. Retrospective cohort study from January 2016 to December 2019. Academic quaternary-care referral center. All episodes of candidemia in adults (n = 92), excluding concurrent bacterial infection or death or hospice care within 48 hours. Primary outcome was all-cause 30-day mortality. Secondary outcomes included guideline-adherence and treatment choice. Guideline-adherence was assessed with the EQUAL Candida score. Of 186 episodes of candidemia, 92 episodes in 88 patients were included. Central venous catheters (CVCs) were present in 66 episodes (71.7%) and were the most common infection source (N = 38, 41.3%). The most frequently isolated species was Candida glabrata (40 of 94, 42.6%). IDC was performed in 84 (91.3%) of 92 candidemia episodes. Mortality rates were 20.8% (16 of 77) in the IDC group versus 25% (2 of 8) in the no-IDC group (P = .67). Other comparisons were numerically different but not significant: repeat blood culture (98.8% vs 87.5%; P = .17), echocardiography (70.2% vs 50%; P = .26), CVC removal (91.7% vs 83.3%; P = .45), and initial echinocandin treatment (67.9% vs 50%; P = .44). IDC resulted in more ophthalmology examinations (67.9% vs 12.5%; P = .0035). All patients received antifungal therapy. Antimicrobial stewardship recommendations were performed in 19 episodes (20.7%). The median EQUAL Candida score with CVC was higher with IDC (16 vs 11; P = .001) but not in episodes without CVC (12 vs 11.5; P = .81). In the setting of an active antimicrobial stewardship program and high consultation rates, mandatory IDC may not be warranted for candidemia.

Epidemiology of extended-spectrum beta-lactamase producing Enterobacteriaceae in Qatar: A 3-year hospital-based study.

The incidence of ESBL infections is exponentially increasing with variable prevalence among geographical areas and treatment settings. Identifying local prevalence rate and patient-related factors will help in earlier recognition and initiation of appropriate antibiotics treatment of patients with ESBL infections. Retrospective analysis of all positive cultures for ESBL producing Enterobacteriaceae collected in Al-Khor hospital from January 2010 to December 2012. ESBL bacterial isolates reported as cephalosporin-resistant or ESBL using the automated VITEK Gram-Negative Susceptibility System with cards GNS 206 and 121 were screened for ESBL detection using the disk diffusion method in keeping with the Clinical and Laboratory Standards Institute. Both descriptive and analytic statistics were applied when appropriate, and univariate analysis was used to identify significant factors. Most of the ESBL-producing bacterial isolates were E. coli, which were also resistant to other classes of antimicrobials. Meropenem, amikacin and nitrofurantoin retained good coverage to most isolates. Klebsiella pneumonia infection was most likely associated with diabetes mellitus (p = 0.004), hospital-acquired infection (p = 0.046) and with more severe infection (p = 0.006). ESBL associated hospital-acquired infections were more likely to occur in older patients, those with comorbidities and with invasive device use. ESBL-associated urinary tract infections were most commonly community-acquired while ESBL associated respiratory tract infections were acquired from hospitals (p = < 0.001). Factors associated with mortality include treatment in the ICU (OR 104.8 [9.82-1116.96] p < 0.001), sepsis/septic shock (OR 20.80 (5.68-76.12) p < 0.001), hospital-acquired infections (OR 8.80 [1.88-41.16] p = 0.006) and bacteremia (OR 8.80 [1.63-47.5] p = 0.013). Multiple risk factors were associated with ESBL infections both in the community and hospital setting. Prediction tools are needed to improve the protocol of appropriate empiric antibiotic selection while preserving antimicrobial stewardship recommendations.

Infections in G6PD-Deficient Hospitalized Patients-Prevalence, Risk Factors, and Related Mortality.

G6PD deficiency is a genetic disease that weakens the immune system and renders affected individuals susceptible to infections. In the Sultanate of Oman resides a high number of recorded G6PD cases due to widespread consanguineous marriage, which may reach 25% of the population. We studied the infection patterns and risk factors for mortality to provide antimicrobial stewardship recommendations for these patients. After obtaining ethical approval, a registry of recorded cases was consulted retrospectively to include G6PD-deficient adult patients admitted to Suhar hospital over 5 years with microbiologically confirmed infections. Patient demographics, health-related information, infection causes, treatment, and clinical outcomes were studied. Data were analyzed to describe infection patterns and risk factors. Several variables, including underlying comorbidities and hospitalization details, such as length of stay, admission to critical care unit, blood transfusion, or exposure to an invasive procedure, were statistically associated with the acquisition of multidrug-resistant and hospital-acquired infections. Meanwhile, these infections were associated with a high mortality rate (28%), significantly associated with the patient’s health status and earlier exposure to antimicrobial treatment due to previous bacterial infection. The high prevalence of G6PD deficiency among the Omani population should alert practitioners to take early action when dealing with such cases during infection that requires hospitalization. Strict infection control measures, Gram-negative empiric coverage, hospital discharge as early as possible, and potent targeted antimicrobial therapy in this patient population can ameliorate the treatment outcomes and should be emphasized by the antimicrobial stewardship team.

Errors in Antimicrobial Prescription and Administration in Very Low Birth Weight Neonates at a Tertiary South African Hospital.

BackgroundAntimicrobial prescription and administration-related errors occur frequently in very low birth weight (VLBW; <1,500 g) neonates treated for bloodstream infections (BSI).MethodsAntimicrobial prescriptions for the treatment of laboratory-confirmed BSI were retrospectively analyzed for VLBW neonates at Tygerberg Hospital, Cape Town, South Africa (1 July 2018 - 31 December 2019), describing antimicrobial type, indication, duration of therapy and BSI outcomes. The prevalence of, and risk factors for prescription (dose, interval) and administration errors (hang-time, delayed/missed doses) were determined.ResultsOne hundred and sixty-one BSI episodes [16 (9.9%)] early-onset, 145 [90.1%] healthcare-associated) affected 141 neonates (55% male, 25% born to mothers living with HIV, 46% <1,000 g birth weight) with 525 antimicrobial prescription episodes [median 3.0 (IQR 2–4) prescriptions/BSI episode]. The median duration of therapy for primary BSI, BSI-associated with meningitis and BSI-associated with surgical infections was 9, 22, and 28 days, respectively. The prevalence of dose and dosing interval errors was 15.6% (77/495) and 16.4% (81/495), respectively with prescription errors occurring most commonly for piperacillin-tazobactam and vancomycin given empirically. Administration errors were less frequent [3.8% (219/5,770) doses missed; 1.4% (78/5,770) delayed], however 64% had a hang-time (time from sepsis diagnosis to 1st dose of antimicrobial) exceeding 60 min. On multivariable analysis, postnatal age >7 days was associated with prescription errors (p = 0.028). The majority of neonates with BSI required escalation of respiratory support (52%) and 26% required intensive care admission. Despite fair concordance between empiric antimicrobial/s prescription and pathogen susceptibility (74.5%), BSI-attributable mortality in this cohort was 30.4%.ConclusionVLBW neonates with BSI's were critically ill and had high mortality rates. Hang-time to first antimicrobial administration was delayed in two-thirds of BSI episodes and prescription errors affected almost 1 in 6 prescriptions. Targets for intervention should include reducing hang-time, use of standardized antimicrobial dosing guidelines and implementation of antimicrobial stewardship recommendations.

Coaching ward pharmacists in antimicrobial stewardship: A pilot study

BackgroundWard pharmacists are well-positioned to enhance the activities of hospital antimicrobial stewardship (AMS) programs by reviewing the appropriateness of antimicrobials and making recommendations to prescribers. However, recent studies have identified gaps in ward pharmacists' AMS practice, knowledge, skills, and confidence which suggests education and training programs are needed. Objective(s)To describe, for the first time, an interactive educational activity – coaching in AMS – targeted at ward pharmacists and explore their perceptions of coaching as a mode of delivering education to improve AMS knowledge, skills, confidence, and practice. A secondary objective was to describe the type, frequency, and acceptance of AMS recommendations made by coached pharmacists. MethodsThis was a descriptive pilot study with a qualitative evaluation of pharmacists' perceptions and experiences of coaching. AMS coaching was delivered over 2 months in 2019 to pharmacists providing clinical pharmacy services to general medical and surgical wards. A focus group was conducted one month after the coaching period to elicit pharmacists' perceptions of coaching as a mode of delivering AMS education and how it impacted their AMS knowledge, skills, confidence, and practice. AMS recommendations made by coached pharmacists were prospectively recorded, and the prescriber acceptance rate was determined. ResultsWard pharmacists reported positive experiences with AMS coaching and believed it helped them identify a range of recommendations to improve antimicrobial prescribing and increased their confidence to communicate recommendations to prescribers. Workload issues were identified as the main barrier to implementation. Suggestions were provided to improve coaching implementation feasibility. During coaching, 162 AMS recommendations were identified for a range of antimicrobials, and 69% (113/162) were accepted and implemented. ConclusionsWard pharmacists believed coaching improved their AMS knowledge, skills, confidence, and practice, including their confidence to discuss recommendations with prescribers. These results can assist with the design and evaluation of future hospital-based AMS educational initiatives.

Mapping the Implementation of a Clinical Pharmacist-Driven Antimicrobial Stewardship Programme at a Tertiary Care Centre in South India.

In many parts of the world, including in India, pharmacist roles in antimicrobial stewardship (AMS) programmes remain unexplored. We describe the evolution and effect of the role of adding clinical pharmacists to a multidisciplinary AMS at a tertiary care teaching hospital in Kerala, India. Through effective leadership, multidisciplinary AMS (February 2016) and antitubercular therapy (ATT) stewardship programmes (June 2017) were established. Clinical pharmacists were introduced as core members of the programmes, responsible for the operational delivery of key stewardship interventions. Pharmacy-led audit and feedback monitored the appropriateness of antimicrobial prescriptions and compliance to AMS/ATT recommendations. Between February 2016 and January 2017, 56% (742/1326) of antimicrobial prescriptions were appropriate, and 54% (318/584) of recommendations showed compliance. By the third year of the AMS, appropriateness increased to 80% (1752/2190), and compliance to the AMS recommendations to 70% (227/325). The appropriateness of ATT prescriptions increased from a baseline of 61% (95/157) in the first year, to 72% (62/86, June 2018–February 2019). The compliance to ATT recommendations increased from 42% (25/60) to 58% (14/24). Such a model can be effective in implementing sustainable change in low- and middle-income countries (LMICs) such as India, where the shortage of infectious disease physicians is a major impediment to the implementation and sustainability of AMS programmes.

Changes in antimicrobial utilization during the coronavirus disease 2019 (COVID-19) pandemic after implementation of a multispecialty clinical guidance team.

Evaluate changes in antimicrobial use during COVID-19 and after implementation of a multispecialty COVID-19 clinical guidance team compared to pre-COVID-19 antimicrobial use. Retrospective observational study. Tertiary-care academic medical center. Internal medicine and medical intensive care unit (MICU) provider teams and hospitalized COVID-19 patients. Difference-in-differences analyses of antibiotic days of therapy per 1,000 patient days present (DOT) for internal medicine and MICU teams treating COVID-19 patients versus teams that did not were performed for 3 periods: before COVID-19, initial COVID-19 period, and after implementation of a multispecialty COVID-19 clinical guidance team which included daily, patient-specific antimicrobial stewardship recommendations. Patient characteristics associated with antibiotic DOT were evaluated using multivariable Poisson regression. In the initial COVID-19 period, compared to the pre-COVID-19 period, internal medicine and MICU teams increased weekly antimicrobial use by 145.3 DOT (95% CI, 35.1-255.5) and 204.0 DOT (95% CI, -16.9 to 424.8), respectively, compared to non-COVID-19 teams. In the intervention period, internal medicine and MICU COVID-19 teams both had significant weekly decreases of 362.3 DOT (95% CI, -443.3 to -281.2) and 226.3 DOT (95% CI, -381.2 to -71.3). Of 131 patients hospitalized with COVID-19, 86 (65.6%) received antibiotics; no specific patient factors were significantly associated with an expected change in antibiotic days. Antimicrobial use initially increased for COVID-19 patient care teams compared to pre-COVID-19 levels but significantly decreased after implementation of a multispecialty clinical guidance team, which may be an effective strategy to reduce unnecessary antimicrobial use.

Point-Prevalence Surveys of Antibiotic Use at Three Large Public Hospitals in Kenya

Background: Antibiotics are the most prescribed medicines worldwide, accounting for 20%–30% of total drug expenditures in most settings. Antimicrobial stewardship activities can provide guidance for the most appropriate antibiotic use. Objective: In an effort to generate baseline data to guide antimicrobial stewardship recommendations, we conducted point-prevalence surveys at 3 hospitals in Kenya. Methods: Sites included referral hospitals located in Nairobi (2,000 beds), Eldoret (900 beds) and Mombasa (700 beds). [Results are presented in this order.] Hospital administrators, heads of infection prevention and control units, and laboratory department heads were interviewed about ongoing antimicrobial stewardship activities, existing infection prevention and control programs, and microbiology diagnostic capacities. Patient-level data were collected by a clinical or medical officer and a pharmacist. A subset of randomly selected, consenting hospital patients was enrolled, and data were abstracted from their medical records, treatment sheets, and nursing notes using a modified WHO point-prevalence survey form. Results: Overall, 1,071 consenting patients were surveyed from the 3 hospitals (n = 579, n = 263, and n = 229, respectively) of whom &gt;60% were aged &gt;18 years and 53% were female. Overall, 489 of 1,071 of patients (46%) received ≥1 antibiotic, of whom 254 of 489 (52%) received 1 antibiotic, 201 of 489 (41%) received 2 antibiotics, 31 of 489 (6%) received 3 antibiotics, and 3 of 489 (1%) received 4 antibiotics. Antibiotic use was higher among those aged &lt;5 years: 150 of 244 (62%) compared with older individuals (337 of 822, 41%). Amoxicillin/clavulanate was the most commonly used antibiotic (66 of 387, 17%) at the largest hospital (in Nairobi) whereas ceftriaxone was the most common at the other 2 facilities: 57 of 184 (31%) in Eldoret and 55 of 190 (29%) in Mombasa. Metronidazole was the next most commonly prescribed antibiotic (15%–19%). Meropenem was the only carbapenem reported: 22 of 387 patients (6%) in Nairobi, 2 of 190 patients (1%) in Eldoret, and 8 of 184 patients (4%) in Mombasa. Stop dates or review dates were not indicated for 106 of 390 patients (27%) in Nairobi, 75 of 190 patients (40%) in Eldoret, and 113 of 184 patients (72%) in Mombasa receiving antibiotics. Of 761 antibiotic prescriptions, 45% had a least 1 missed dose. Culture and antibiotic susceptibility tests were limited to 50 of 246 patients (20%) in Nairobi, 17 of 124 patients (14%) in Eldoret, and 23 of 119 patients (19%) in Mombasa who received antibiotics. The largest hospital had an administratively recognized antimicrobial stewardship committee. Conclusions: The prevalence of antibiotic use found by our study was 46%, generally lower than the rates reported in 3 similar studies from other African countries, which ranged from 56% to 65%. However, these survey findings indicate that ample opportunities exist for improving antimicrobial stewardship efforts in Kenya considering the high usage of empiric therapy and low microbiologic diagnostic utilization.Funding: NoneDisclosures: None

Feasibility of a Tertiary Hospital Antimicrobial Stewardship Ward Round Using an Electronic Prescribing System—A Pilot Study

Abstract Objectives The aim was to conduct a pilot study to determine staff resource requirements for an antimicrobial stewardship (AMS) ward round informed by electronic prescriptions, and the number of restricted antimicrobial prescriptions that would prompt a ward round recommendation. Methods Prescription data on 26 restricted antimicrobial agents (which have specific prescribing criteria defined by the national drug funding agency) were extracted from the electronic prescribing and administration system (MedChart). A language query was used for specific antimicrobial names on Mondays, Wednesdays, and Fridays over 4 weeks. Prescriptions that had ceased or had an appropriate indication documented were excluded. The remaining prescriptions were evaluated in the ward round upon clinical record review with theoretical AMS recommendations made and time requirements recorded. The ward rounds were performed by two clinical staff, a doctor and pharmacist. Results In 12 days, 622 prescriptions were extracted. Of these, 66 were evaluated in ward rounds, with 67% (44/66) being for ciprofloxacin or piperacillin-tazobactam. Theoretical AMS recommendations were made in 61% (40/66) of cases, 45% (18/40) being to use a narrower spectrum agent, 30% (12/40) to consult the Infectious Diseases Service, and 23% (9/40) to stop antimicrobial therapy. Data extraction took an analyst approximately 15 minutes, screening by a doctor approximately 20 minutes, and ward rounds approximately 41 minutes per day. Conclusion Our approach required, in total, approximately 100 clinical staff minutes per day to screen approximately 50 prescriptions and identify and evaluate approximately four prescriptions and showed clinical value. Resource planning should also consider Infectious Diseases and/or Microbiology (physician and service) involvement, and audit capability.

Reinforcement of an infection control bundle targeting prevention practices for Clostridioides difficile in Veterans Health Administration nursing homes

Clostridioides difficile infection (CDI) causes significant morbidity in nursing home residents. Our aim was to describe adherence to a bundled CDI prevention initiative, which had previously been deployed nationwide in Veterans Health Administration (VA) long-term care facilities (LTCFs), and to improve compliance with reinforcement. A multicenter pre- and post-reinforcement of the VA bundle consisting of environmental management, hand hygiene, and contact precautions was conducted in 6 VA LTCFs. A campaign to reinforce VA bundle components, as well as to promote select antimicrobial stewardship recommendations and contact precautions for 30 days, was employed. Hand hygiene, antimicrobial usage, and environmental contamination, before and after bundle reinforcement, were assessed. All LTCFs reported following the guidelines for cleaning and contact precautions until diarrhea resolution pre-reinforcement. Environmental specimens rarely yielded C difficile pre- or post-reinforcement. Proper hand hygiene across all facilities did not change with reinforcement (pre 52.51%, post 52.18%), nor did antimicrobial use (pre 87-197 vs. post 84-245 antibiotic days per 1,000 resident-days). LTCFs found it challenging to maintain prolonged contact precautions. Variation in infection prevention and antimicrobial prescribing practices across LTCFs were identified and lessons learned. Introducing bundled interventions in LTCFs is challenging, given the available resources, and may be more successful with fewer components and more intensive execution with feedback.

2095. Antimicrobial Stewardship (ASP) in Rural and Critical Access Hospitals (CAHs) Using TeleStewardship® Services

BackgroundMDstewardship® is a physician-owned company that uses TeleStewardship® services, which consist of telephone and HIPPA-compliant teleconferencing and texting, to provide rural and critical access hospital (CAH) ASP services, ensuring facilities remain compliant with Joint Commission ASP requirements. MDstewardship® also provides monthly webinars to all participating hospital personnel for continuing education. Webinars are live, interactive, and contain topics based on IDSA guidelines. MDstewardship® personnel discuss antibiotics with the hospital staff using a HIPPA-compliant secure audio-video feed, phone conference, or secure-text. CAH pharmacists discuss the antibiotics currently being given in their institution and MDstewardship® personnel provide further ASP recommendations. ASP recommendations are provided by MDstewardship® clinically-trained infectious disease pharmacists and infectious disease physicians, and are communicated to on-site pharmacists or directly with providers.MethodsMDstewardship® is active with many rural CAHs in Nebraska, and over 20 hospitals nationally. Here we report our ASP results for 10 CAHs in Nebraska from August 2018 to April 2019. A total of 401 ASP recommendations were given over that time.ResultsThe top three most common infectious diseases diagnoses involving recommendations were UTI (16.7%), pneumonia (15.2%), and bacteremia (13.7%). Most common ASP interventions included alternative therapy (15.7%), additional therapy (13.7%), oral step-down therapy (12.7%), and further laboratory monitoring (12.5%). Additional daily antimicrobial stewardship assistance includes: development of hospital protocols, order-sets, antibiograms and guideline adherence. Total acceptance of ASP recommendations averages > 90%. Reimbursement is based on a contract over 12 months.ConclusionThe use of TeleStewardship® services allow CAHs to have 24/7 infectious disease specialist and clinically trained antimicrobial stewardship pharmacist support with a high number of interventions and a high acceptance of recommendations. The goal of this program is to give the right antibiotic, right dose, for the right duration, for each patient.Disclosures All authors: No reported disclosures.