Antimicrobial Stewardship Rounds Research Articles

Stewardship: it's going viral

Historically, antimicrobial stewardship (AMS) has considered the judicious use of antibiotics. AMS is widely adopted across Europe and the US; recently antifungal AMS is gaining momentum but antiviral AMS has been little described. Here we describe the introduction of AMS virology reviews at University Hospitals Birmingham (UHBFT); a novel concept and an opportunity to broaden the beneficial aspects of AMS to virology, termed anti-viral stewardship (AVS). In June 2022, a UK supply issue with aciclovir injection (ACV IV) was announced. In order to review and preserve parenteral ACV for those in greatest need, UHBFT pharmacist and virologists implemented a specialist review for patients prescribed more than 48 hours of treatment. This review initially lasted 10 weeks and data was collected on the advice offered, whether it was accepted, and time required completing the review. AVS rounds halved IV ACV consumption, compared to pre or post intervention levels, with more than half of patients advised to stop or switch to oral therapy. Diagnostics and sampling guidance was offered in one quarter of reviews, whilst the remaining interventions were more stewardship focused. In almost all cases stewardship advice was readily accepted by clinical teams. Due to positive feedback from clinicians and its effective management of supply, the anti-viral stewardship (AVS) programme was re-introduced in June 2023. Antiviral AMS rounds provide an opportunity to optimise sampling, diagnosis and improve patient management. Introduction of regular AVS at UHBFT are now well established and plan to be implemented in other hospitals.

936. Antimicrobial Stewardship Assessments in De-labeling Beta-lactam Allergies

Abstract Background Unnecessary use of broad-spectrum antibiotics due to false antibiotic allergy labels leads to an increase in drug resistant and health care associated infections. Therefore, allergy assessments to de-label patients not truly allergic is an important antimicrobial stewardship (AMS) tool. The purpose of this study was to assess the effectiveness of a pharmacy-led questionnaire and AMS rounds in improving the accuracy of beta-lactam allergy labels (BLA). Methods AMS piloted BLA de-labeling rounds three times a week from November 1, 2021 to April 1, 2022. Rounds consisted of an infectious disease physician and an AMS pharmacist that reviewed allergy questionnaires conducted by trained pharmacy personnel. The questionnaire was provided to patients 18 years or older with a documented BLA and an admission stay of two or more nights. Patients were excluded if unable to participate or did not have a representative available for interview. The primary outcomes evaluated were: (i) direct de-labelling (ii) future de-labeling upon patient consent (iii) allergy profile changes. The secondary outcomes were potential days of therapy (DOTs) saved for anti-MRSA agents (vancomycin, linezolid, clindamycin) and fluoroquinolones (ciprofloxacin, levofloxacin) and PEN-FAST scores for those with a penicillin-specific allergy. Results 93 of 96 patients interviewed (96.9%) had their allergy profile updated to include type, severity, or timing of reaction. 82 of 96 patients (85.4%) were classified as low-risk allergies in which 11 patients (13.4%) were successfully de-labeled and 18 patients (22.0%) were eligible for de-labeling upon patient consent. The remaining patients were eligible for further interrogation with an oral challenge (Figure 1). Potential DOTs saved were 131 and 67 days for anti-MRSA agents and fluoroquinolones, respectively. Average PEN-FAST scores for those de-labeled and eligible for oral challenge was 0.5 (SD 0.85) and 1.08 (SD 1.20), respectively. Conclusion AMS BLA assessments can decrease the prevalence of false BLA labels and prescribing of unnecessary broad-spectrum agents. PEN-FAST scores less than 2 suggests that allergy assessments help identify patients with low-risk penicillin allergies. Disclosures All Authors: No reported disclosures.

P34 Impact of medical microbiology lead antimicrobial stewardship rounds on antimicrobial consumption in a level 3 hospital

BackgroundNo onsite consultant medical microbiologist (CMM) was available in this centre from September 2018 to November 2019. During this time antimicrobial stewardship (AMS) rounds were carried out by the antimicrobial pharmacist (AMP) with feedback provided directly to clinical teams. Antimicrobial consumption rose from 88.81 DDD/bed-days used (DDD/BDU) in 2017 to 95.57 DDD/BDU in 2019. The aim of this study was to assess the impact of AMS service led by a CMM.MethodsA structured antimicrobial stewardship programme has been in place since 2013. The re-addition of an onsite CMM in November 2019 facilitated new AMS initiatives, including ward based, targeted antimicrobial rounds, team audits and education sessions led by the CMM. These rounds focused on the choice of antimicrobial agent and duration of therapy.ResultsOverall antimicrobial consumption decreased from 95.57 DDD/BDU in 2019 to 82.16 DDD/BDU (14% reduction) in 2020. The addition of team-based AMS rounds with a CMM and AMP alongside the clinical team enhanced the existing AMS programme and appeared to have the most benefit in reducing antimicrobial consumption. Increases in consumption were noted during weeks where there was poor attendance or cancellation of the AMS rounds.ConclusionsAMS is most effective with specialty leadership and a multidisciplinary approach. Continuous intervention is required in order to sustain improvements. AMS programmes have been shown to reduce the incidence of healthcare-associated infection and have a positive impact on antimicrobial resistance. AMS should be prioritized by healthcare institutions for increased investment.

Antimicrobial stewardship audit and feedback rounds: the impact of electronic systems and moving beyond the restricted antibiotic list

Current methods of antimicrobial usage surveillance have limited efficacy in changing practice due to delayed reporting to clinicians and the inability to stratify by medical specialty. This study was undertaken in a tertiary teaching hospital with a well established antimicrobial stewardship (AMS) programme and electronic medicines management (eMM) system in Sydney, Australia. To describe and analyse the implementation of a novel AMS audit and feedback method, in the context of an eMM system. The AMS team conducted the audit weekly, and the study design was a prospective, observational study. All acute, adult inpatients were included in this intervention. All active systemic antimicrobial prescriptions on the day of the rounds were included. The prevalence of patients on antimicrobial therapy was 37%. The median time taken per round was 44 min for eMM compared to 58 min for paper. All key performance indicators improved over the study period. Appropriateness compared to guidelines increased from 55% to 71%, and documentation of an indication increased from 75% to 98%. There were 1413 recommendations made, with the most common being to cease an antimicrobial agent. The recommendation uptake rate was 47% at 24 h post-round. AMS rounds are an effective tool for auditing and providing feedback on antimicrobial use and should include all antimicrobials rather than solely 'restricted' agents. These rounds had a high uptake rate, improvements in the appropriateness of antimicrobial use, and a planned duration or review date. A benefit of eMM was improvement in the documentation of indication for antimicrobial agents, and reduced time taken to audit.

Antimicrobial stewardship, therapeutic drug monitoring and infection management in the ICU: results from the international A- TEAMICU survey

BackgroundSevere infections and multidrug-resistant pathogens are common in critically ill patients. Antimicrobial stewardship (AMS) and therapeutic drug monitoring (TDM) are contemporary tools to optimize the use of antimicrobials. The A-TEAMICU survey was initiated to gain contemporary insights into dissemination and structure of AMS programs and TDM practices in intensive care units.MethodsThis study involved online survey of members of ESICM and six national professional intensive care societies.ResultsData of 812 respondents from mostly European high- and middle-income countries were available for analysis. 63% had AMS rounds available in their ICU, where 78% performed rounds weekly or more often. While 82% had local guidelines for treatment of infections, only 70% had cumulative antimicrobial susceptibility reports and 56% monitored the quantity of antimicrobials administered. A restriction of antimicrobials was reported by 62%. TDM of antimicrobial agents was used in 61% of ICUs, mostly glycopeptides (89%), aminoglycosides (77%), carbapenems (32%), penicillins (30%), azole antifungals (27%), cephalosporins (17%), and linezolid (16%). 76% of respondents used prolonged/continuous infusion of antimicrobials. The availability of an AMS had a significant association with the use of TDM.ConclusionsMany respondents of the survey have AMS in their ICUs. TDM of antimicrobials and optimized administration of antibiotics are broadly used among respondents. The availability of antimicrobial susceptibility reports and a surveillance of antimicrobial use should be actively sought by intensivists where unavailable. Results of this survey may inform further research and educational activities.

Impact of an antimicrobial stewardship intervention in neonatal intensive care: Recommendations and implementation.

To (i) determine the appropriateness of antimicrobial prescribing in the neonatal intensive care unit (NICU) and (ii) assess the impact of a collaborative antimicrobial stewardship (AMS) intervention on prescribing practices. The intervention was a weekly AMS audit-feedback joint ward round (6-month period) of Neonatology and Infectious Diseases clinicians in a tertiary neonatal intensive care unit in Melbourne, Australia. Antibiotic prescriptions were audited and recommendations delivered in real time. The proportion of recommendations implemented was used to assess acceptability of the intervention. During the study period, there were 23 AMS rounds, during which 249 patients were reviewed at 627 separate episodes. Of these, 233 (37%) episodes were for patients receiving antimicrobials. Of these, 147 (63%) received empirical antimicrobial treatment, 43 (18%) targeted antimicrobial treatment and 43 (18%) antimicrobial prophylaxis. There were 58 (25%) of 233 episodes of inappropriate antibiotic use, and 62 recommendations for improvement. Most common recommendations were to narrow (33/62, 53%) or stop (12/62, 19%) antimicrobials. The majority (45, 73%) of recommendations were accepted, resulting in significant improvement in the proportion of the 233 episodes that had completely appropriate antibiotic prescribing: 175 (75%) to 217 (93%) (relative risk 1.2, 95% confidence intervals 1.1-1.3, P < 0.001). A collaborative audit-feedback AMS intervention was effective in identifying inappropriate antimicrobial prescriptions and impacted positively on treatment plans. Ancillary benefits were improved communication between departments and the revision of antimicrobial prescribing guidelines.

Effects of coronavirus disease 2019 (COVID-19) pandemic on antimicrobial prevalence and prescribing in a tertiary hospital in Singapore

BackgroundThe deployment of antimicrobial stewardship (AMS) teams to deal with the COVID-19 pandemic can lead to a loss of developed frameworks, best practices and leadership resulting in adverse impact on antimicrobial prescribing and resistance. We aim to investigate effects of reduction in AMS resources during the COVID-19 pandemic on antimicrobial prescribing.MethodsOne of 5 full-time equivalent AMS pharmacists was deployed to support pandemic work and AMS rounds with infectious disease physicians were reduced from 5 to 2 times a week. A survey in acute inpatients was conducted using the Global Point Prevalence Survey methodology in July 2020 and compared with those in 2015 and 2017–2019.ResultsThe prevalence of antimicrobial prescribing (55% in 2015 to 49% in 2019 and 47% in 2020, p = 0.02) and antibacterials (54% in 2015 to 45% in 2019 and 42% in 2020, p < 0.01) have been reducing despite the pandemic. Antimicrobial prescribing in infectious disease wards with suspected or confirmed COVID-19 cases was 29% in 2020. Overall, antimicrobial prescribing quality indicators continued to improve (e.g. reasons in notes, 91% in 2015 to 94% in 2019 and 97% in 2020, p < 0.01) or remained stable (compliance to guideline, 71% in 2015 to 62% in 2019 and 73% in 2020, p = 0.08).ConclusionDuring the COVID-19 pandemic, there was no increase in antimicrobial prescribing and no significant differences in antimicrobial prescribing quality indicators.

Physician experiences implementing antimicrobial stewardship rounds in pediatric hospital medicine: An exploratory, qualitative study.

An antimicrobial stewardship intervention was implemented for pediatric medicine units using an in-person rounds-based approach to provide stewardship recommendations and education from an antimicrobial stewardship physician and antimicrobial stewardship pharmacist. In this exploratory qualitative study, purposeful sampling was used to recruit participants for individual interviews at a tertiary- and quaternary-care referral center. Pediatricians and residents who attended ≥1 stewardship round were included. A semistructured interview guide was created focusing on perceptions of antimicrobial stewardship, personal experiences at stewardship rounds, and perceived impacts on patient care. Using a constant comparative analysis approach, codes were developed and collapsed into themes. Overall, 8 pediatricians and 10 residents completed interviews. Qualitative analysis yielded 3 themes: insights into clinical reasoning, opportunity for growth and learning, and establishing and exploring professional relationships. The handshake-rounds approach encouraged participants to critically evaluate antimicrobial choices and to engage in discussion with the antimicrobial stewardship team. Participants felt validated at stewardship rounds and gained confidence prescribing antimicrobials. Face-to-face interaction reduced reluctance for some participants to consult infectious disease (ID) service; however, others worried that physicians may avoid ID consultation because of stewardship rounds. Participants found stewardship rounds to be an effective strategy for education and development of clinical reasoning skills for optimal antimicrobial prescribing-choosing wisely or choosing rightly. The effects of stewardship rounds on timing and frequency of ID consultation are interesting. Further research into important patient outcomes and consultation practices are needed locally, but our experiences may help others to reflect on the power of conversation and relationships in antimicrobial stewardship.

Antimicrobial stewardship in spinal cord injury: A multidisciplinary approach

Context: In a global environment of escalating antimicrobial resistance and limited new antibiotic development, there is a desire to optimize antibiotic use across all settings to preserve options for the future. Despite this, antibiotics continue to be prescribed inappropriately in many settings. Patients with a spinal cord injury (SCI) are particularly vulnerable to receiving multiple courses of antibiotics, yet there is limited data reviewing antimicrobial stewardship (AMS) programs in this patient population. Hypothesis: Adopting AMS rounds will reduce days of antibiotic treatment. Intervention: We implemented a systematic bedside AMS multidisciplinary team (MDT) ward round within the SCI Unit at our hospital, where a collaborative inter-speciality and inter-professional approach was undertaken to address antibiotic prescriptions. A retrospective audit of antibiotic prescriptions was performed one month prior and one month during the intervention. Outcome measures: An infectious disease consultant led a multidisciplinary, multispecialty ward rounding team, looking at antibiotic appropriateness and guideline compliance. The effectiveness of this intervention was assessed by retrospectively looking at antibiotic days of usage per patient day of occupancy. Results: Antibiotic consumption significantly decreased following the AMS intervention, from 69.8 to 24.3 days on treatment per 100 patient days (P < 0.001). Following implementation of the ward round the proportion of therapeutic guideline compliant prescriptions significantly rose from 18% in April to 56% in August (P < 0.001). Conclusions: Utilizing a collaborative inter-speciality and inter-professional AMS approach and providing face to face feedback about the appropriateness of antibiotic prescribing can help optimize antibiotic usage within a SCI unit.

Attitudes and Perceptions amongst Critical Care Physicians towards Handshake Antimicrobial Stewardship Rounds.

RationaleIn an era of antimicrobial resistance, antimicrobial stewardship programs are tasked with reducing inappropriate use of antimicrobials in community and hospital settings. Intensive care units are unique, high-stakes environments where high usage of broad-spectrum antimicrobials is often seen. Handshake stewardship has emerged as an effective mode of prospective audit and feedback to help optimize antimicrobial usage, emphasizing an in-person approach to providing feedback.ObjectivesSix months following the implementation of handshake stewardship rounds in our intensive care unit, we performed a cross-sectional survey of critical care physicians to assess their attitudes and perceptions towards handshake stewardship rounds and preferred mode of delivery of antimicrobial stewardship prospective audit and feedback strategies.MethodsA web-based survey was distributed to 22 critical care physicians working in our hospital and responses were collected over a two-week period.Measurements and Main ResultsMost critical care physicians believe that handshake stewardship rounds improve the quality of patient care (85.7%) and few believe that handshake stewardship rounds are an ineffective use of their time (14.3%). The majority of critical care physicians believe formal, scheduled rounds with face-to-face verbal interaction are very useful compared to providing written suggestions in the absence of face-to-face interaction (71.4% vs 0%).ConclusionsBased upon our survey results, handshake stewardship is valued amongst the majority of critical care physicians. Antimicrobial stewardship prospective audit and feedback strategies emphasizing face-to-face interaction are favored amongst critical care physicians.

2085. Bedside Nurses Improve Antimicrobial Stewardship and Infection Prevention Outcomes: Results of a 3.5-Year Study in Three Hospital Telemetry Units

BackgroundMinimal literature exists to demonstrate the quantitative impact of bedside nurses in antimicrobial stewardship (AMS). We initiated bedside nurse-driven AMS and infection prevention (AMS/IP) rounds on three inpatient telemetry units of a community regional medical center. Rounds were nurse-driven, involved an infectious diseases (ID) pharmacist and infection preventionist, and were designed to complement traditional ID pharmacist and ID physician AMS rounds. Rounds were focused on use of antibiotics, urinary catheters (UCs), and central venous catheters (CVCs). Recommendations from rounds were communicated by the bedside nurse either directly to providers or to the ID pharmacist and ID physician for intervention.MethodsThis was an observational, multiple-group, quasi-experimental study conducted over 3.5 years (July 2015 to December 2018) to characterize the impact of bedside nurse-driven AMS/IP rounds on antibiotic, urinary catheter and CVC use, hospital-onset C. difficile infection (CDI), catheter-associated urinary tract infections (CAUTI), and central line-associated bloodstream infections (CLABSI). Outcomes were assessed in two cohorts based on time of AMS/IP rounds implementation (Cohort 1 implemented on one telemetry unit in July 2016, Cohort 2 implemented in two telemetry units in January 2018).ResultsA total of 2,273 patient therapy reviews occurred (Cohort 1: 1,736; Cohort 2: 537). Of these reviews, 1,209 (53%) were antibiotics, 879 (39%) were urinary catheters, and 185 (8%) were CVCs. Pre- vs. post-intervention, significant reductions were observed in both cohorts for mean monthly antibiotic days of therapy per 1,000 patient-days (Cohort 1: 791 vs. 688, P < 0.001; Cohort 2: 615 vs. 492, P < 0.001), UC days per patient day (Cohort 1: 0.25 vs. 0.16, P < 0.001; Cohort 2: 0.19 vs. 0.14, P < 0.001), CVC days per patient day (Cohort 1: 0.15 vs. 0.11, = 0.002; Cohort 2: 0.09 vs. 0.07, p = 0.005), and CDI per 10,000 patient-days (Cohort 1: 17.8 vs. 7.1, p = 0.035; Cohort 2: 19.1 vs. 5.4, p = 0.003). Numerical reductions were observed in CAUTI and CLABSI per 10,000 patient-days.ConclusionBedside nurses can improve AMS and IP outcomes in a scalable fashion when supported by an interdisciplinary AMS/IP team and are complimentary to traditional AMS and IP practices. Disclosures All authors: No reported disclosures.

1119. Implementation of Pediatric Antimicrobial Stewardship Rounds in a Children’s Hospital

BackgroundAntimicrobial stewardship programs (ASP) are required in all acute care hospitals per The Joint Commission. ASP must adhere to the recommendations laid out by the Centers for Disease Control and Prevention, but how each ASP chooses to implement these recommendations is left to the individual program. In January 2018, we began formal antimicrobial stewardship (AMS) walking rounds, led by infectious diseases trained physician and pharmacist, in our 99-bed pediatric hospital.MethodsIn January 2018, we started twice-weekly AMS rounds on the pediatric hospitalist service. A custom-made “Antimicrobial Stewardship Patient List” was designed in our electronic medical record (EMR) to generate a list of all patients receiving antibiotics. The ASP team (comprised of an infectious diseases pharmacist and a pediatric infectious diseases physician) reviewed EMR charts to determine antibiotic prescribing appropriateness and design recommended interventions. Any recommendations and teaching points were then discussed with the hospitalist team in person. After piloting the hospitalist service, AMS rounds were extended to include the general surgery patients and finally the intensive care unit. Data on number of charts reviewed, proposed interventions, and acceptance rates were collected throughout the process. Descriptive statistics were used to assess the intervention data.ResultsIn the first year of the program, 427 patient charts were reviewed with 186 identified interventions. In total, 156 (84.3%) of the interventions were accepted and implemented by the primary team. The most common types of interventions were the duration of therapy (29%), antibiotic discontinuation (16.7%), intravenous to oral conversion (11.3%), de-escalation (10.2%), and infectious diseases consult (5.9%).ConclusionPediatric AMS rounds led to the successful implementation of the majority of recommended interventions. Future goals of the program include calculating days of therapy per 1000 patient-days to assess antibiotic consumption before and after AMS rounds and to expand into other services to further promote appropriate antibiotic use in hospitalized pediatric patients.Disclosures All authors: No reported disclosures.

Impact of Hospitalist-Led Interdisciplinary Antimicrobial Stewardship Interventions at an Academic Medical Center

Approximately 20%-50% of antimicrobial use in hospitals is inappropriate. Limited data exist on the effect of frontline provider engagement on antimicrobial stewardship outcomes. A three-arm pre-post quality improvement study was conducted on three adult internal medicine teaching services at an urban academic hospital. Data from September through December 2016 were compared to historic data from corresponding months in 2015. Intervention arms were (1) Educational bundle (Ed-only); (2) Educational bundle plus antimicrobial stewardship rounds twice weekly with an infectious disease-trained clinical pharmacist (Ed+IDPharmDx2); and (3) Educational bundle plus internal medicine-trained clinical pharmacist embedded into daily attending rounds (Ed+IMPharmDx5). Total antibiotic use decreased by 16.8% (p < 0.001), 6.8% (p = 0.08), and 33.0% (p < 0.001) on Ed-only, Ed+IDPharmDx2, and Ed+IMPharmDx5 teams, respectively. Broad-spectrum antibiotic use decreased by 26.2% (p < 0.001), 7.8% (p = 0.09), and 32.4% (p < 0.001) on the Ed-only, Ed+IDPharmDx2, and Ed+IMPharmDx5 teams, respectively. Duration of inpatient antibiotic therapy decreased from 4 to 3 days on the Ed+IMPharmDx5 team (p = 0.01). Length of stay for patients who received any antibiotic decreased from 9 to 7 days on the Ed-only team (p < 0.001) and from 9 to 6 days on the Ed+IMPharmDx5 team (p < 0.001). There was no significant change in 30-day readmission to the same facility, transfer to ICU, or in-hospital mortality for any team. Multidisciplinary, frontline provider-driven approaches to antimicrobial stewardship may contribute to reduced antibiotic use and length of hospital stay.

Neonatal Ventilator Associated Pneumonia: A Quality Improvement Initiative Focusing on Antimicrobial Stewardship.

Background and Aims: Neonatal ventilator associated pneumonia (VAP) is a common nosocomial infection and a frequent reason for empirical antibiotic therapy in NICUs. Nonetheless, there is no international consensus regarding diagnostic criteria and management. In a first step, we analyzed the used diagnostic criteria, risk factors and therapeutic management of neonatal VAP by a literature review. In a second step, we aimed to compare suspected vs. confirmed neonatal VAP episodes in our unit according to different published criteria and to analyze interrater-reliability of chest x-rays. Additionally, we aimed to evaluate the development of VAP incidence and antibiotic use after implementation of multifaceted quality improvement changes regarding antimicrobial stewardship and infection control (VAP-prevention-bundle, early-extubation policy, antimicrobial stewardship rounds).Methods: Neonates until 44 weeks of gestation with suspected VAP, hospitalized at our level-III NICU in Lucerne from September 2014 to December 2017 were enrolled. VAP episodes were analyzed according to 4 diagnostic frameworks. Agreement regarding chest x-ray interpretation done by 10 senior physicians was assessed. Annual incidence of suspected and confirmed neonatal VAP episodes and antibiotic days were calculated and compared for the years 2015, 2016, and 2017.Results: 17 studies were identified in our literature review. Overall, CDC-guidelines or similar criteria, requesting radiographic changes as main criteria, are mostly used. Comparison of suspected vs. confirmed neonatal VAP episodes showed a great variance (20.4 vs. 4.5/1,000 ventilator-days). The interrater-reliability of x-ray interpretation was poor (intra-class correlation 0.25). Implemented changes resulted in a gradual decline in annual VAP incidence and antibiotic days from 2015 compared with 2017 (28.8 vs. 7.4 suspected episodes/1,000 ventilator-days, 5.5 vs. 0 confirmed episodes/1,000 ventilator-days and 211 vs. 34.7 antibiotic days/1,000 ventilation-days, respectively).Conclusion: The incidence of suspected VAP and concomitant antibiotic use is much higher than for confirmed VAP, therefore inclusion of suspected episodes should be considered for accurate evaluation. There is a high diagnostic inconsistency and a low reliability of interpretation of chest x-rays regarding VAP. Implementation of combined antimicrobial stewardship and infection control measures may lead to an effective decrease in VAP incidence and antibiotic use.

Changes in antimicrobial prescribing behavior after the introduction of the antimicrobial stewardship program: A pre- and post-intervention survey.

The introduction of an antimicrobial stewardship (AMS) program is associated with a change in antimicrobial prescribing behavior. A proposed mechanism for this change is by impacting the prescribing etiquette described in qualitative studies. This study sought to detect a change in prescribing attitudes 12 months after the introduction of AMS and gauge utility of various AMS interventions. Surveys were distributed to doctors in two regional Australian hospitals on a convenience basis 6 months before, and 12 months after, the introduction of AMS. Agreement with 20 statements describing attitudes (cultural, behavioral and knowledge) towards antimicrobial prescribing was assessed on a 4-point Likert scale. Mean response scores were compared using the Wilcoxon Rank sum test. 155 responses were collected before the introduction of AMS, and 144 afterwards. After the introduction of AMS, an increase was observed in knowledge about available resources such as electronic decision support systems (EDSS) and therapeutic guidelines, with raised awareness about the support available through AMS rounds and the process to be followed when prescribing restricted antimicrobials. Additionally, doctors were less likely to rely on pharmacy to ascertain when an antimicrobial was restricted, depend on infectious diseases consultant advice and use past experience to guide antimicrobial prescribing. Responses to this survey indicate that positive changes to the antimicrobial prescribing etiquette may be achieved with the introduction of an AMS program. Use of EDSS and other resources such as evidence-based guidelines are perceived to be important to drive rational antimicrobial prescribing within AMS programs.

Challenges of Antibiotic Stewardship on the Internal Medicine Ward

BackgroundAudit and feedback programs are considered to be one of the most effective antimicrobial stewardship (ASP) strategies to improve antibiotic prescribing; however, resource requirements are a limiting factor.MethodsIn a controlled, quasi-experimental study we evaluated the impact of once weekly ASP rounds conducted with one Medicine teaching team, while two Medicine teams served as controls, at a tertiary care center from November 2014 until November 2015. We assessed process measures and changes in antibiotic utilization (reported as monthly defined daily doses per 1000 patient days from November 2013 to November 2015 using statistical process control charts).ResultsIn total, 249 patients (40% of 627 patients on the team) were on anti-infectives on the day of the rounds and had been discussed, of which 18% (48/249) were already followed by infectious diseases. A total of 79 interventions were made. Reduced duration of therapy comprised over half of the recommendations (39/76, 51%). Discontinuing antibiotics on the same day was the second most common intervention (20/76, 26%). All stewardship suggestions were accepted by the Medicine team. However, no significant changes in antibiotic utilization were observed with a similar reduction in both groups for piperacillin-tazobactam and meropenem while at the same time, an increased use of first and third-generation cephalosporins was observed.ConclusionWhile the process measures demonstrated a change in the treatment plan in 1 out of 3 patients reviewed, this did not translate into a significant change in antibiotic utilization as compared with the control groups. This may be related to the comparably small proportion of patients reviewed by ASP given that rounds occurred only once a week, and were cancelled 28 times within a one year period due to limited Medicine clinician availability. There also could have been cross-contamination between the two study arms with faculty and trainees who received the intervention while on the intervention team continuing their learned practice while on a control team. Process measures are an important means to measure the impact of ASPs, as antibiotic utilization is not a sensitive metric and may not reliably reflect improvement in antibiotic management at the individual patient level.Disclosures All authors: No reported disclosures.

An international cross-sectional survey of antimicrobial stewardship programmes in hospitals.

To report the extent and components of global efforts in antimicrobial stewardship (AMS) in hospitals. An Internet-based survey comprising 43 questions was disseminated worldwide in 2012. Responses were received from 660 hospitals in 67 countries: Africa, 44; Asia, 50; Europe, 361; North America, 72; Oceania, 30; and South and Central America, 103. National AMS standards existed in 52% of countries, 4% were planning them and 58% had an AMS programme. The main barriers to implementing AMS programmes were perceived to be a lack of funding or personnel, a lack of information technology and prescriber opposition. In hospitals with an existing AMS programme, AMS rounds existed in 64%; 81% restricted antimicrobials (carbapenems, 74.3%; quinolones, 64%; and cephalosporins, 58%); and 85% reported antimicrobial usage, with 55% linking data to resistance rates and 49% linking data to infection rates. Only 20% had electronic prescribing for all patients. A total of 89% of programmes educated their medical, nursing and pharmacy staff on AMS. Of the hospitals, 38% had formally reviewed their AMS programme: reductions were reported by 96% of hospitals for inappropriate prescribing, 86% for broad-spectrum antibiotic use, 80% for expenditure, 71% for healthcare-acquired infections, 65% for length of stay or mortality and 58% for bacterial resistance. The worldwide development and implementation of AMS programmes varies considerably. Our results should inform and encourage the further evaluation of this with a view to promoting a worldwide stewardship framework. The prospective measurement of well-defined outcomes of the impact of these programmes remains a significant challenge.

215Impact of Multidisciplinary Antimicrobial Stewardship Rounds on Prospective Audit with Intervention and Feedback Recommendations

215Impact of Multidisciplinary Antimicrobial Stewardship Rounds on Prospective Audit with Intervention and Feedback Recommendations