Antimicrobial Stewardship Resources Research Articles

Frequency and mortality rate following antimicrobial-resistant bloodstream infections in tertiary-care hospitals compared with secondary-care hospitals.

There are few studies comparing proportion, frequency, mortality and mortality rate following antimicrobial-resistant (AMR) infections between tertiary-care hospitals (TCHs) and secondary-care hospitals (SCHs) in low and middle-income countries (LMICs) to inform intervention strategies. The aim of this study is to demonstrate the utility of an offline tool to generate AMR reports and data for a secondary data analysis. We conducted a secondary-data analysis on a retrospective, multicentre data of hospitalised patients in Thailand. Routinely collected microbiology and hospital admission data of 2012 to 2015, from 15 TCHs and 34 SCHs were analysed using the AMASS v2.0 (www.amass.website). We then compared the burden of AMR bloodstream infections (BSI) between those TCHs and SCHs. Of 19,665 patients with AMR BSI caused by pathogens under evaluation, 10,858 (55.2%) and 8,807 (44.8%) were classified as community-origin and hospital-origin BSI, respectively. The burden of AMR BSI was considerably different between TCHs and SCHs, particularly of hospital-origin AMR BSI. The frequencies of hospital-origin AMR BSI per 100,000 patient-days at risk in TCHs were about twice that in SCHs for most pathogens under evaluation (for carbapenem-resistant Acinetobacter baumannii [CRAB]: 18.6 vs. 7.0, incidence rate ratio 2.77; 95%CI 1.72-4.43, p<0.001; for carbapenem-resistant Pseudomonas aeruginosa [CRPA]: 3.8 vs. 2.0, p = 0.0073; third-generation cephalosporin resistant Escherichia coli [3GCREC]: 12.1 vs. 7.0, p<0.001; third-generation cephalosporin resistant Klebsiella pneumoniae [3GCRKP]: 12.2 vs. 5.4, p<0.001; carbapenem-resistant K. pneumoniae [CRKP]: 1.6 vs. 0.7, p = 0.045; and methicillin-resistant Staphylococcus aureus [MRSA]: 5.1 vs. 2.5, p = 0.0091). All-cause in-hospital mortality (%) following hospital-origin AMR BSI was not significantly different between TCHs and SCHs (all p>0.20). Due to the higher frequencies, all-cause in-hospital mortality rates following hospital-origin AMR BSI per 100,000 patient-days at risk were considerably higher in TCHs for most pathogens (for CRAB: 10.2 vs. 3.6,mortality rate ratio 2.77; 95%CI 1.71 to 4.48, p<0.001; CRPA: 1.6 vs. 0.8; p = 0.020; 3GCREC: 4.0 vs. 2.4, p = 0.009; 3GCRKP, 4.0 vs. 1.8, p<0.001; CRKP: 0.8 vs. 0.3, p = 0.042; and MRSA: 2.3 vs. 1.1, p = 0.023). In conclusion, the burden of AMR infections in some LMICs might differ by hospital type and size. In those countries, activities and resources for antimicrobial stewardship and infection control programs might need to be tailored based on hospital setting. The frequency and in-hospital mortality rate of hospital-origin AMR BSI are important indicators and should be routinely measured to monitor the burden of AMR in every hospital with microbiology laboratories in LMICs.

1250. Association Between Antimicrobial Stewardship Resources and Practices Reported by California Hospitals in the National Healthcare Safety Network Annual Survey and California Department of Public Health Antimicrobial Stewardship Program Honor Roll Designation

Abstract Background California hospitals report information on antimicrobial stewardship (AS) Core Elements, resources, and practices through the National Healthcare Safety Network Annual Survey. The California Department of Public Health has an AS Program (ASP) Honor Roll to recognize and promote hospital AS. We explored associations between AS-related responses in the Annual Survey with Honor Roll designation, which ranks increasingly comprehensive ASP as Bronze, Silver, or Gold. Methods We linked 2020–2021 Annual Survey data to Honor Roll designations for acute care and critical access hospitals by year. We included 59 AS-related survey questions based on completeness and consistency between survey years. We compared survey responses by designations with chi-square and Fisher’s exact tests. We used a multivariable proportional odds regression model to evaluate the association of survey responses with the likelihood of ordinal designations. We used a stepwise approach and compared goodness-of-fit statistics at each iteration of model variable selection. Results Of 179 Honor Roll hospital designations with linked survey data, 21% were Gold, 41% Silver, and 38% Bronze in 2020, and 21% were Gold, 53% Silver, and 26% Bronze in 2021. The final ordinal model included 29 survey covariates related to leadership oversight, ASP lead, AS practices, and education. Hospitals significantly associated with higher designation included those that: performed prospective audit and feedback (PAF) of vancomycin (OR:4.09, 95%CI 1.27-13.83) and azoles (OR:3.37, 95%CI 1.07-11.31); and required prior authorization of newer beta-lactam/-lactamase inhibitors (OR:3.31, 95%CI 1.18-9.49) and echinocandins (OR:2.78, 95%CI 1.02-7.77), holding constant all other variables. Odds for higher designations were reduced if facilities performed PAF of echinocandins (OR:0.17, 95%CI 0.05-0.53). Conclusion Higher Honor Roll designation is a marker for a more effective ASP; thus, AS practices, especially prospective audit and feedback, in conjunction with resources related to ASP lead(s) and leadership oversight, should be prioritized by ASPs. Further exploration of practices, such as prior authorization of select antimicrobials, would be warranted as there were varying associations with designations. Disclosures All Authors: No reported disclosures

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.

896. Cost-Avoidance Associated with Active Stewardship of Remdesivir

Abstract Background The COVID pandemic shifted antimicrobial stewardship resources at community hospitals. One reason for this shift was new COVID treatments, the first of which was remdesivir, which received initial emergency use authorization (EUA) for the treatment of COVID-19 in May 2020. The UNC Health Southeastern (UNC SEH) pharmacy director stewarded remdesivir by reviewing patients to ensure they met emergency use authorization (EUA) and guideline-based appropriateness criteria. The infectious diseases physician resolved any disputes regarding patient candidacy for remdesivir. The goal of remdesivir stewardship was to optimize care; however, the shift in workflow presented an unrecognized opportunity for stewards to reduce remdesivir costs. Methods The percentage of COVID patient admissions receiving remdesivir at UNC SEH for calendar years 2020 and 2021 was benchmarked against 32 community hospitals in the Duke Antimicrobial Stewardship Outreach Network (DASON) (Figure 1). UNC SEH purchasing data were used to calculate remdesivir expenditures for 2020 and 2021. Next, the anticipated cost if the hospital had prescribed remdesivir to the same percentage of admissions as the DASON mean was calculated. The difference was calculated to determine the cost avoidance achieved by having below average use of remdesivir (Table 1). Results At UNC SEH, 28.1% of COVID admissions received remdesivir in 2020 and annual remdesivir expenditures were $693,680. In 2021, 47.45% of COVID-19 admissions received remdesivir and drug expenditures were $1,248,000. The DASON mean % of COVID admissions receiving remdesivir in 2020 was 44.08% and 60.07% in 2021. A total cost avoidance of $726,407 was calculated based on the hospital’s below-benchmark use of remdesivir (Table 1). Conclusion UNC SEH achieved significant cost-savings in 2020 and 2021 due to active remdesivir stewardship. The team created a patient-centered model that focused on using drugs for the right patients and the organization realized cost-savings while ensuring that patients received therapy in accordance with remdesivir EUAs and published guidelines. Disclosures All Authors: No reported disclosures.

98. Outcomes of Clinical Decision Support for Outpatient Management of Clostridioides difficile Infection

BackgroundOur antimicrobial stewardship program identified high rates of suboptimal metronidazole prescribing for Clostridioides difficile infection (CDI) within ambulatory clinics. An outpatient best practice advisory (BPA) was implemented to notify prescribers “Vancomycin or fidaxomicin are preferred over metronidazole for C.difficile infection” when metronidazole was prescribed to a patient with CDI. MethodsWe conducted an IRB approved quasi-experiment before and after implementation of the BPA on June 3, 2020. Inclusion: Adult patients diagnosed with and treated for a first episode of symptomatic CDI at an ambulatory clinic between 11/1/2019 and 11/30/2020. Exclusion: fulminant CDI. Primary endpoint: guideline-concordant CDI therapy, defined as oral vancomycin or fidaxomicin. Oral metronidazole was considered guideline-concordant if prescribed due to cost barrier. Secondary endpoints: reasons for alternative CDI therapy, patient outcomes, prescriber response to the BPA. Descriptive and bivariate analyses were completed.Results189 patients were included in the study, 92 before and 97 after the BPA. Median age: 59 years, 31% male, 75% Caucasian, 30% with CDI-related comorbidities, 35% with healthcare exposure, 65% with antibiotic exposure, 44% with gastric acid suppression therapy within 90 days of CDI diagnosis. The BPA was accepted 23 out of 26 times and optimized the therapy of 16 patients in six months. Guideline-concordant therapy increased after implementation of the BPA (72% vs. 91%, p=0.001) (Figure 1). Vancomycin prescribing increased and metronidazole prescribing decreased after the BPA (Figure 2). Reasons for alternative CDI therapy included medication cost, lack of insurance coverage, and non-CDI infection. There was no difference in clinical response or unplanned encounter within 14 days after treatment initiation. Fewer patients after the BPA had CDI recurrence within 14-56 days of the initial episode (27% vs. 7%, p< 0.001). Figure 1. Guideline-concordant CDI therapy Figure 2. Specific CDI therapy ConclusionClinical decision support increased prescribing of guideline-concordant CDI therapy in the outpatient setting. A targeted BPA is an effective stewardship intervention and may be especially useful in settings with limited antimicrobial stewardship resources.Disclosures Susan L. Davis, PharmD, Nothing to disclose Rachel Kenney, PharmD, Medtronic, Inc. (Other Financial or Material Support, spouse is an employee and shareholder)

Change in Antimicrobial Use During COVID-19 Pandemic in South Carolina Hospitals: A Multicenter Observational Cohort Study

ObjectivesThis retrospective cohort study examined the impact of the pandemic on antimicrobial use (AU) in South Carolina hospitals. MethodsAntimicrobial use in days of therapy (DOT) per 1000 days-present was evaluated in 17 hospitals in South Carolina. Matched-pairs mean difference was used to compare AU during the pandemic (March–June 2020) with that during the same months in 2019 in hospitals that did and did not admit patients with COVID-19. ResultsThere was a 6.6% increase in overall AU in the seven hospitals that admitted patients with COVID-19 (from 530.9 to 565.8; mean difference (MD) 34.9 DOT/1000 days-present; 95% CI 4.3, 65.6; P = 0.03). There was no significant change in overall AU in the remaining 10 hospitals that did not admit patients with COVID-19 (MD 6.0 DOT/1000 days-present; 95% CI –55.5, 67.6; P = 0.83). Most of the increase in AU in the seven hospitals that admitted patients with COVID-19 was observed in broad-spectrum antimicrobial agents. A 16.4% increase was observed in agents predominantly used for hospital-onset infections (from 122.3 to 142.5; MD 20.1 DOT/1000 days-present; 95% CI 11.1, 29.1; P = 0.002). There was also a 9.9% increase in the use of anti-methicillin-resistant Staphylococcus aureus (MRSA) agents (from 66.7 to 73.3; MD 6.6 DOT/1000 days-present; 95% CI 2.3, 10.8; P = 0.01). ConclusionThe COVID-19 pandemic appears to drive overall and broad-spectrum antimicrobial use in South Carolina hospitals admitting patients with COVID-19. Additional antimicrobial stewardship resources are needed to curtail excessive antimicrobial use in hospitals to prevent subsequent increases in antimicrobial resistance and Clostridioides difficile infection rates, given the continuing nature of the pandemic.

Outcomes of clinical decision support for outpatient management of Clostridioides difficile infection.

To determine the impact of clinical decision support on guideline-concordant Clostridioides difficile infection (CDI) treatment. Quasi-experimental study in >50 ambulatory clinics. Primary, specialty, and urgent-care clinics. Adult patients were eligible for inclusion if they were diagnosed with and treated for a first episode of symptomatic CDI at an ambulatory clinic between November 1, 2019, and November 30, 2020. An outpatient best practice advisory (BPA) was implemented to notify prescribers that "vancomycin or fidaxomicin are preferred over metronidazole for C.difficile infection" when metronidazole was prescribed to a patient with CDI. In total, 189 patients were included in the study: 92 before the BPA and 97 after the BPA. Their median age was 59 years; 31% were male; 75% were white; 30% had CDI-related comorbidities; 35% had healthcare exposure; 65% had antibiotic exposure; 44% had gastric acid suppression therapy within 90 days of CDI diagnosis. The BPA was accepted 23 of 26 times and was used to optimize the therapy of 16 patients in 6 months. Guideline-concordant therapy increased after implementation of the BPA (72% vs 91%; P = .001). Vancomycin prescribing increased and metronidazole prescribing decreased after the BPA. There was no difference in clinical response or unplanned encounter within 14 days after treatment initiation. Fewer patients after the BPA had CDI recurrence within 14-56 days of the initial episode (27% vs 7%; P < .001). Clinical decision support increased prescribing of guideline-concordant CDI therapy in the outpatient setting. A targeted BPA is an effective stewardship intervention and may be especially useful in settings with limited antimicrobial stewardship resources.

Description of a pharmacist-driven safety algorithm in Staphylococcus aureus bacteremia: Compliance, interventions, and good saves.

To evaluate the impact of a pharmacist-driven Staphylococcus aureus bacteremia (SAB) safety bundle supported by leadership and to compare compliance before and after implementation. Retrospective cohort study with descriptive and before-and-after analyses. Tertiary-care academic medical center. All patients with documented SAB, regardless of the source of infection, were included. Patients transitioned to palliative care were excluded from before-and-after analysis. A pharmacist-driven safety bundle including documented clearance of bacteremia, echocardiography, removal of central venous catheters, and targeted intravenous therapy of at least 2 weeks duration was implemented in November 2015 and was supported by leadership with stepwise escalation for nonresponse. A descriptive analysis of all patients with SAB during the study period included pharmacy interventions, acceptance rates, and escalation rates. A pre-post implementation analysis of 100 sequential patients compared bundle compliance and descriptive parameters. Overall, 391 interventions were made in the 20-month period following implementation, including 20 "good saves" avoiding potentially major adverse events. No statistically significant differences in complete bundle compliance were detected between the periods (74% vs 84%; P = .08). However, we detected a significant increase in echocardiography after the bundle was implemented (83% vs 94%; P = .02) and fewer patients received suboptimal definitive therapy after the bundle was implemented (10% vs 3%; P = .045). This pharmacist-driven SAB safety bundle with leadership support showed improvement in process measures, which may have prevented major adverse events, even with available infectious diseases (ID) consultation. It provides a critical safety net for institutions without mandatory ID consultation or with limited antimicrobial stewardship resources.

Collation of resources within a regional antimicrobial pharmacy group

Background: Previous regional antimicrobial meetings identified duplication of antimicrobial stewardship work in Acute trusts. In 2018, collation of guidelines for hospital acquired pneumonia, community acquired pneumonia and urinary tract infections led to creation of exemplar guidelines. All documents were emailed, which was inefficient due to volume, with no central repository that could be accessed across sites. Given the regional shortage of microbiologists, easy access to job descriptions and business cases was considered essential to improvement of pharmacy staff resources regionally. Aim: To create an open access regional hub for antimicrobial resources within Yorkshire and the Humber using the Specialist Pharmacy Service (SPS) website. Methods: The Yorkshire and Humber Antimicrobial Pharmacy Group’s objective is to continuously improve antimicrobial stewardship and infection management through networking, sharing best practice, learning, peer support and joint working/initiatives. Starting in March 2019, resources were submitted to the SPS website. Results: A total of nine job descriptions were uploaded, along with members of the group, educational links such as the #todipornottodip campaign, terms of reference, annual workplan, meeting agendas and a brief summary of the group’s objectives and regional geography. Conclusion: The SPS website has facilitated a more efficient sharing of regional antimicrobial stewardship resources. Further work is warranted for sharing education resources, and business cases that don’t contain commercial information. As the site is open access, a decision was made to continue emailing meeting minutes.

An Antimicrobial Stewardship Intervention Improves Adherence to Standard of Care for Staphylococcus aureus Bloodstream Infection.

Staphylococcus aureus bloodstream infections (SABSI) are a major cause of morbidity and mortality in the United States, and proper management is important to effect cure and prevent metastatic foci of infection. We aimed to utilize our antimicrobial stewardship program (ASP) to improve practices at a large academic hospital system. Our ASP implemented a SABSI educational campaign directed at the hospital medicine, cardiology, and infectious diseases divisions. A stewardship intervention was then begun for all patients with SABSI recommending infectious diseases consultation, transesophageal echocardiography (TEE), source control, and preliminary antibiotic changes. A retrospective review was performed for all SABSI cases 2 years before and after implementation of the SABSI intervention. Two hundred forty-three cases before intervention and 259 after intervention were included. An increase in obtaining follow-up negative blood cultures (79.8% vs. 89.6%), infectious diseases consultation (52.7% vs. 86.5%), TEE (25.5% vs. 54.8%), beta-lactam switch for methicillin-susceptible S. aureus (55.2% vs. 74.4%), and source control (41.2% vs. 57.9%) was demonstrated. We demonstrated similar durations of bacteremia, length of stay, relapse, mortality, and rates of infective endocarditis. Adherence to standard of care for patients with SABSI can be dramatically improved through provider education, leveraging antimicrobial stewardship resources, and infectious diseases consultation.

2538. Directed Educational Intervention and Resident Physician Outpatient Antimicrobial Prescribing

BackgroundAntimicrobial stewardship is the coordinated approach to optimal use of antimicrobials. Directed stewardship may benefit resident physicians and improve outpatient antimicrobial prescribing.MethodsInternal medicine residents as of July 1, 2017 (n = 37) with continuity clinic at the Minneapolis Veterans Affairs Health Care System were eligible. Antimicrobial prescriptions and number of patient visits per month were extracted from the Computerized Patient Record System. Antimicrobial rate was calculated for 9 baseline months (July 1, 2017–March 31, 2018) and 12 intervention months (April 1, 2018–March 31, 2019). Residents were divided into high and low prescribing groups based on baseline antimicrobial rate. The low prescribing group received one email with links to antimicrobial stewardship resources. The high prescribing group received the same email and one in person meeting with an infectious disease fellow to discuss antimicrobial prescribing.ResultsPrescription and visit data were available for 37 residents. The low and high prescribing interventions were administered to 17/17 (100%) and 12/20 (60%) participants, respectively. Remaining high prescribing participants (8, 40%) graduated and did not complete the intervention. During the intervention period, there were a total of 171 prescriptions and 4,018 visits, for an average antimicrobial rate of 43 prescriptions/1,000 visits compared with baseline rate of 51 (P = 0.09). Antimicrobial rate per month is shown in Figure 1.ConclusionAn educational intervention did not significantly change antimicrobial prescribing rates in a VA resident clinic. Antimicrobial prescribing rates were much lower than expected, suggesting that weekly continuity clinic may not be an optimal setting for learning how to manage outpatient antimicrobials. Our study was small and conducted at a single site without evaluation of antimicrobial appropriateness. Further studies should explore the optimal setting for residents to gain outpatient antimicrobial prescribing experience. Disclosures All authors: No reported disclosures.

Facility type and surgical specialty are associated with suboptimal surgical antimicrobial prophylaxis practice patterns: a multi-center, retrospective cohort study

BackgroundGuidelines recommend discontinuation of antimicrobial prophylaxis within 24 h after incision closure in uninfected patients. However, how facility and surgical specialty factors affect the implementation of these evidence-based surgical prophylaxis guidelines in outpatient surgery is unknown. Thus, we sought to measure how facility complexity, including ambulatory surgical center (ASC) status and availability of ancillary services, impact adherence to guidelines for timely discontinuation of antimicrobial prophylaxis after outpatient surgery. A secondary aim was to measure the association between surgical specialty and guideline compliance.MethodsA multi-center, national Veterans Health Administration retrospective cohort from 10/1/2015–9/30/2017 including any Veteran undergoing an outpatient surgical procedure in any of five specialties (general surgery, urology, ophthalmology, ENT, orthopedics) was created. The primary outcome was the association between facility complexity and proportion of surgeries not compliant with discontinuation of antimicrobials within 24 h of incision closure. Data were analyzed using logistic regression with adjustments for patient and procedural factors.ResultsAmong 153,097 outpatient surgeries, 7712 (5.0%) received antimicrobial prophylaxis lasting > 24 h after surgery; rates ranged from 0.4% (eye surgeries) to 13.7% (genitourinary surgeries). Cystoscopies and cystoureteroscopy with lithotripsy procedures had the highest rates (16 and 20%), while hernia repair, cataract surgeries, and laparoscopic cholecystectomies had the lowest (0.2–0.3%). In an adjusted logistic regression model, lower complexity ASC and hospital outpatient departments had higher odds of prolonged antimicrobial prophylaxis compared to complex hospitals (OR ASC, 1.3, 95% CI: 1.2–1.5). Patient factors associated with higher odds of noncompliance with antimicrobial discontinuation included younger age, female sex, and white race. Genitourinary and ear/nose/throat surgeries were associated with the highest odds of prolonged antimicrobial prophylaxis.ConclusionsFacility complexity appears to play a role in adherence to surgical infection prevention guidelines. Lower complexity facilities with limited infection prevention and antimicrobial stewardship resources may be important targets for quality improvement. Such interventions may be especially useful for genitourinary and ear/nose/throat surgical subspecialties. Increasing pharmacy, antimicrobial stewardship and/or infection prevention resources to promote more evidence-based care may support surgical providers in lower complexity ambulatory surgery centers and hospital outpatient departments in their efforts to improve this facet of patient safety.

257. A Whole of Country Analysis of Antimicrobial Stewardship Resources, Activities, and Barriers for Children in Hospitals in Australia

BackgroundWe aimed to assess antimicrobial stewardship (AMS) resources and activities for children in hospitals throughout Australia, to identify gaps in services.MethodsEvery public hospital in Australia with paediatric beds was identified via the Australian Institute of Health and Welfare. The director of pharmacy or most senior paediatrician was asked to complete an online evaluation in 2017 regarding their AMS resources and activities. For analysis, tertiary (7) and major metropolitan hospitals (50) were combined (metropolitan) and compared with hospitals in regional (42) and rural towns (7) combined (rural).ResultsWe identified 106 hospitals and received 106 (100%) responses. Paediatric bed numbers ranged from 3 to 360. In metropolitan hospitals, 17 (35%) had a paediatric AMS team or representation, compared with 5 (9%) for rural (P = 0.001) There was an AMS pharmacist in 42 (86%) metropolitan hospitals compared with 37 (65%) rural (P = 0.1) although the majority of these were not paediatric. Fifty-one (48%) hospitals had locally adapted empirical antibiotic prescribing guidelines (metropolitan 28 (57%) vs. rural 23 (40%)(P = 0.06)), although fewer had specialty-specific guidelines (figure). One hundred two (96%) hospitals had restrictions on broad-spectrum antimicrobials, but formal approval systems were fewer: metropolitan 44 (90%) vs. rural 35 (66%) (P = 0.004)). Auditing methods differed but were mostly ad hoc, with results fed back in an untargeted way with only 22 (34%) providing direct physician feedback. There was a paucity of AMS education: only 25 (24%) provided education for senior medical staff, and 24 (23%) had no education for any staff (metropolitan 8 (17%) vs. rural 16 (29%)(P = 0.1)). The commonest perceived barriers to successful AMS for all hospitals were lack of dedicated infectious diseases and microbiology services (64 (60%)), lack of dedicated pharmacy resources (62 (59%)), and a lack of education for clinicians in antibiotic use (53 (50%)).ConclusionAustralian hospitals have implemented some AMS activities for children, but most lack resources—this was much more evident in regional/rural than metropolitan hospitals. Barriers to successful AMS include a lack of infectious diseases and pharmacy resources and education, which need to be addressed in workforce planning. Disclosures All authors: No reported disclosures.

1801. Impact of Matrix-Assisted Laser Desorption/Ionization Time-of-Flight Mass Spectrometry (MALDI-TOF MS) on Clinical Outcomes in Patients with Gram Positive Blood Cultures in a Diverse, Multicenter Healthcare System With a Central Laboratory

BackgroundRapid diagnostic testing in combination with real-time antimicrobial stewardship intervention can reduce time to de-escalation of empiric antibiotics and discontinuation of unnecessary therapy. This study aims to evaluate the clinical impact of Matrix-Assisted Laser Desorption/Ionization Time-of-Flight Mass Spectrometry (MALDI-TOF MS) for Gram-positive organism identification for blood cultures across a healthcare system comprised of pediatric, adult academic, and adult community hospitals utilizing a central microbiology laboratory with unique antimicrobial stewardship resources at each site.MethodsThis multicenter retrospective study compared patients with a positive blood culture for a Gram-positive organism identified via MALDI-TOF MS to a historical cohort identified using conventional methods. Primary outcome was time to optimal therapy (TTOT). Secondary outcomes included time to effective therapy, duration of therapy, time to microbiologic clearance, hospital length of stay (LOS), ICU LOS, recurrence, readmission, in-hospital mortality, and all-cause mortality.ResultsThis study included 129 cultures (12% pediatric patients) in the conventional period and 129 cultures (19% pediatric patients) in the MALDI-TOF MS group. Of the total 258 blood cultures included, 147 (57%) represented true bloodstream infection and 111 (43%) were deemed to be contaminants. Despite a median reduction in time to organism identification (60.0 vs. 45.4 hours, P < 0.001), there was no difference in the primary outcome of overall median TTOT between the two groups (70.7 hours vs. 65.9 hours, P = 0.407). There were no significant differences for any secondary outcomes. Overall TTOT was longer as distance from the central laboratory increased (47.3 hours at central site vs. 76.9 hours at distance >30 miles). Among contaminants, median TTOT was reduced from 72.5 hours with conventional methods to 59.8 hours with MALDI-TOF MS (P = 0.015). Conclusion. Implementation of MALDI-TOF MS for organism identification may not reduce time to optimal therapy in patients with true Gram-positive bacteremia. However, it can result in a significant reduction in time to discontinuation of unnecessary therapy for patients with contaminated cultures. Figure 1. Differences in outcomes for conventional methods vs. MALDI-TOF MS Disclosures All authors: No reported disclosures.

1867. A Regional Collaboration to Share Antimicrobial Stewardship Resources in Three Geographically Related Veterans Affairs Medical Centers

BackgroundAntibiotic Stewardship (AS) programs are tasked with monitoring the use of antimicrobial agents across a variety of clinical settings. Most medical centers work independently, developing their own programs and using various clinical surveillance systems (CSSs) to identify intervention opportunities and monitor metrics. Geographically related medical centers may share patients and similar environments, and could benefit from working collaboratively to share knowledge and resources.MethodsThe AS programs were assessed at three Veterans Affairs Medical Centers (VAMCs) in three neighboring states (DC, MD, and WV) over 2016 and 2017. The AS programs cover 350 acute care beds and 422 long-term care (LTC)/rehab beds. Each AS team has one infectious disease physician and one pharmacist. A SharePoint site was developed; meetings and teleconferences were held regularly. By way of a shared contract, a CSS (Theradoc, DSS Inc.) was installed at all three VAMCs between November 2015 and March 2016. Within TheraDoc, each AS program designed alerts and interventions specific to its own medical center and collaborated to develop a group of 22 interventions that were shared by all sites. There was no attempt to alter individually determined AS practices of each VAMC.ResultsThe table demonstrates the combined AS team interventions and aggregate cost-saving generated by the shared CSS. The number of interventions and the hours spent in CSS varied between centers; the top five most heavily conducted interventions differed between sites. Over time, new interventions developed at one VAMC were adopted at one or more of the other VAMCs at the discretion of the respective AS teams. Within a short period of time the cost savings generated exceeded the CSS start-up investment.CY 2016CY 2017CombinedAS interventions2,94610,01612,962Time spent AS PharmDs (hours)4722,0322,503Time spent AS MD (hours)199308508Cost savings$532,520$1,790,906$2,323,426ConclusionWorking collaboratively allowed each VAMC to leverage shared resources. Each AS program was able to adapt to its VAMC’s specific needs, while also demonstrating significant aggregate cost savings as a result of coordinated and defined AS activities.Disclosures M. Zuzick, Document Storage Systems: Employee, Salary. J. Chang, Document Storage Systems: Employee, Salary.

262. Pediatric Antibiotic Use in the Duke Antimicrobial Stewardship Outreach Network

BackgroundThe Duke Antimicrobial Stewardship Outreach Network (DASON) was established in 2013 to provide antimicrobial stewardship resources to community hospitals in the Southeast. Pediatric patients in community hospitals may benefit from antimicrobial stewardship program (ASP) activities.MethodsAntibacterial use (AU) was reviewed using the DASON Antimicrobial Stewardship Assessment Portal, which includes filters for National Healthcare Safety Network (NHSN) unit types. We performed a retrospective review of AU in pediatric units from January 1 to December 31, 2017. AU was summarized by days of therapy (DOT) and percent of total DOT for specific unit types and agents. AU rates were reported by DOT/1,000 patient-days.ResultsA total of 41 pediatric units were included from the 28 hospital DASON cohort: 11 Neonatal Critical Care or Step Down Nurseries, eight Pediatric Medical/Surgical Wards, and 22 Well Baby Units. There were no pediatric (non-neonatal) critical care or oncology units. A total of 21,731 antibiotic DOT were attributable to pediatric units, accounting for 1.6% of all AU in the cohort. These include 5,585 (26%) DOT in Neonatal Critical Care (level II/III) Units, 4,898 (23%) in Pediatric Medical/Surgical Units, 3,910 (18%) in Well Baby Units, 3,307 (15%) in Neonatal Critical Care (level III) Units, 3,217 (15%) in Step Down Neonatal Nurseries (level II), and 814 (4%) in Pediatric Medical Wards. Ampicillin (7,229 DOT, 33%), gentamicin (6,320 DOT, 29%), ceftriaxone (1,750 DOT, 8%), and vancomycin (1,462, 7%) were the most common antibiotics administered.AU rates were 219 DOT/1,000 patient-days in children when compared with 979 in adults. Unit-specific rates ranged from 65 (Well Baby Units) to 1,081 DOT/1,000 patient-days (Pediatric Medical/Surgical Units). Rates in level II and III nurseries ranged from 302 to 697 DOT/1,000 patient-days.ConclusionPediatric patients accounted for a small proportion of AU in community hospitals. AU rates on pediatric medical/surgical units were comparable with adult units. Although rates were lower in neonatal units, these units accounted for 75% of pediatric AU. Antibiotic exposure in the neonatal period has been associated with short- and long-term outcomes, including necrotizing enterocolitis, obesity, and atopy. This population would benefit from a dedicated focus from community hospital ASPs.Disclosures All authors: No reported disclosures.

Antimicrobial use in European acute care hospitals: results from the second point prevalence survey (PPS) of healthcare-associated infections and antimicrobial use, 2016 to 2017.

Antimicrobial agents used to treat infections are life-saving. Overuse may result in more frequent adverse effects and emergence of multidrug-resistant microorganisms. In 2016–17, we performed the second point-prevalence survey (PPS) of healthcare-associated infections (HAIs) and antimicrobial use in European acute care hospitals. We included 1,209 hospitals and 310,755 patients in 28 of 31 European Union/European Economic Area (EU/EEA) countries. The weighted prevalence of antimicrobial use in the EU/EEA was 30.5% (95% CI: 29.2–31.9%). The most common indication for prescribing antimicrobials was treatment of a community-acquired infection, followed by treatment of HAI and surgical prophylaxis. Over half (54.2%) of antimicrobials for surgical prophylaxis were prescribed for more than 1 day. The most common infections treated by antimicrobials were respiratory tract infections and the most commonly prescribed antimicrobial agents were penicillins with beta-lactamase inhibitors. There was wide variation of patients on antimicrobials, in the selection of antimicrobial agents and in antimicrobial stewardship resources and activities across the participating countries. The results of the PPS provide detailed information on antimicrobial use in European acute care hospitals, enable comparisons between countries and hospitals, and highlight key areas for national and European action that will support efforts towards prudent use of antimicrobials.

Antimicrobial stewardship in pediatric post-acute care facilities

Providers in pediatric post-acute care facilities were surveyed about knowledge of and resources for antimicrobial stewardship. All agreed that antibiotics were overused in such pediatric facilities, but 60% had not implemented stewardship strategies. Lack of treatment guidelines (47%) was identified as the most common barrier to antimicrobial stewardship.

Expanding Antimicrobial Stewardship to Urgent Care Centers Through a Pharmacist-Led Culture Follow-up Program.

IntroductionUrgent care centers represent a high-volume outpatient setting where antibiotics are prescribed frequently but resources for antimicrobial stewardship may be scarce. In 2015, our pharmacist-led Emergency Department (ED) culture follow-up program was expanded to include two urgent care (UC) sites within the same health system. The UC program is conducted by ED and infectious diseases clinical pharmacists as well as PGY1 pharmacy residents using a collaborative practice agreement (CPA). The purpose of this study was to describe the pharmacist-led UC culture follow-up program and its impact on pharmacist workload.MethodsThis retrospective, descriptive study included all patients discharged to home from UC with a positive culture from any site resulting between 1 January and 31 December 2016. Data collected included the culture type, presence of intervention, and proportion of interventions made under the CPA. Additionally, pharmacist workload was reported as the number of call attempts made, new prescriptions written, and median time to complete follow-up per patient. Data were reported using descriptive statistics.ResultsA total of 1461 positive cultures were reviewed for antibiotic appropriateness as part of the UC culture follow-up program, with 320 (22%) requiring follow-up intervention. Culture types most commonly requiring intervention were urine cultures (25%) and sexually transmitted diseases (25%). A median of 15 min was spent per intervention, with a median of one call (range 1–6 calls) needed to reach each patient. Less than half of patients required a new antimicrobial prescription at follow-up.ConclusionA pharmacist-led culture follow-up program conducted using a CPA was able to be expanded to UC sites within the same health system using existing clinical pharmacy staff along with PGY1 pharmacy residents. Service expansion resulted in minimal increase in pharmacist workload. Adding UC culture follow-up services to an existing ED program can allow health systems to expand antimicrobial stewardship initiatives to satellite locations.

Antimicrobial Stewardship Curriculum and Training among Health Professional Schools and Residency Training Programs in California

BackgroundImproving antimicrobial use is the single most important action to slow development and spread of antimicrobial resistance. Antimicrobial prescribing habits are likely developed early in education or clinical training, but information about curricula is lacking.MethodsIn November 2016, the California Department of Public Health Healthcare-Associated Infections Program distributed a 19-item survey to 65 health professional schools (dentistry, medicine, nurse practitioner, pharmacy, physician assistant) and 287 residency and fellowship training programs (dentistry, emergency medicine, family medicine, internal medicine, pediatrics, pharmacy, infectious disease). The survey assessed knowledge, attitudes, and practices related to antimicrobial stewardship (AS) and antimicrobial resistance (AR) as well as antimicrobial stewardship curriculum and training activities.ResultsWe received data from 23 health professional schools and 78 residency training programs for response rates of 35% and 27%, respectively. Among 101 respondents, 89 (88%) agreed or strongly agreed that “AR is a major issue at my hospital” and 56 (55%) were satisfied with their current AS curriculum. Ninety-four (93%) respondents were interested in learning about successful strategies for implementing AS curricula or training from other schools or programs. Respondents incorporated a median of 7 of 8 specific AS principles and practices into their curricula and training [range, 0–8] (Figure 1) and used a median of 4 of 9 different teaching methods [range, 0–9] (Figure 2). The most cited barriers to incorporating AS curriculum and training were limited training infrastructure or resources (n = 58, 63%) and competing training priorities (n = 50, 54%). The least cited barrier was lack of interest or concern about AR and AS (n = 10, 11%) (Figure 3).ConclusionHealth professional schools and residency training programs recognize that antimicrobial resistance is a major public health issue and acknowledge the need to strengthen antimicrobial stewardship curricula. Public health agencies can facilitate sharing antimicrobial stewardship resources and materials as a strategy to enhance curricula in health professional schools and training programs.Disclosures All authors: No reported disclosures.