Antimicrobial Stewardship Strategies Research Articles

Epidemiological and Genomic analysis of Vibrio parahaemolyticus isolated from imported travelers at the port of Shanghai, China (2017-2019)

BackgroundVibrio parahaemolyticus is the predominant etiological agent of seafood-associated foodborne illnesses on a global scale. It is essential to elucidate the mechanisms by which this pathogen disseminates. Given the existing research predominantly concentrates on localized outbreaks, there is a pressing necessity for a comprehensive investigation to capture strains of V. parahaemolyticus cross borders.ResultsThis study examined the frequency and genetic attributes of imported V. parahaemolyticus strains among travelers entering Shanghai Port, China, between 2017 and 2019.Through the collection of 21 strains from diverse countries and regions, Southeast Asia was pinpointed as a significant source for the emergence of V. parahaemolyticus. Phylogenetic analysis revealed clear delineation between strains originating from human and environmental sources, emphasizing that underlying genome data of foodborne pathogens is essential for environmental monitoring, food safety and early diagnosis of diseases. Furthermore, our study identified the presence of virulence genes (tdh and tlh) and approximately 120 antibiotic resistance-related genes in the majority of isolates, highlighting their crucial involvement in the pathogenesis of V. parahaemolyticus.ConclusionsThis research enhanced our comprehension of the worldwide transmission of V. parahaemolyticus and its antimicrobial resistance patterns. The findings have important implications for public health interventions and antimicrobial stewardship strategies, underscoring the necessity for epidemiological surveillance of pathogen at international travel hubs.

The role of community pharmacists and their perception towards antimicrobial stewardship in Baghdad, Iraq

AbstractBackgroundThis study aimed to assess the role of community pharmacists and their perception toward antimicrobial stewardship, in addition to identifying factors influencing their perception and practices in community pharmacy.MethodsA cross‐sectional study was carried out among community pharmacists regarding antimicrobial stewardship. Convenience sampling was used to obtain the required sample from a community pharmacy in Baghdad. In total, 381 participants have completed the survey.ResultsThe majority of the participants (85.6%) strongly agreed/agreed that “antimicrobial stewardship programs reduce the problems of antibiotic resistance”; and 85.5% of them strongly agreed/agreed that community pharmacists required adequate training on antibiotics use. In addition, high percent of community pharmacists (88.4%) strongly agreed/agreed that pharmacists have a responsibility to take a prominent role in antimicrobial stewardship programs and infection‐control programs in the health system. The total score of perception was significantly influenced by older age groups, postgraduate degrees, and experience of 6–10 years (p < 0.001). This study also showed that 65.4% of pharmacists always/often advise patients to continue the full course of antimicrobials, and 64.9% of them reported always/often considering clinical and safety parameters before dispensing antibiotics. The role of pharmacists was significantly influenced by the younger age group, females, higher degree in pharmacy, experience of 3–5 years, and medical complex pharmacy (p < 0.001).ConclusionCommunity pharmacists have a good perception toward antimicrobial stewardship programs, but their role is still limited. More efforts are needed to design better strategies for antimicrobial stewardship in community pharmacy.

Efficacy and safety of withholding antimicrobial therapy in children with cancer, fever, and neutropenia, with a demonstrated viral respiratory infection: a randomized clinical trial

ObjectivesTo validate the efficacy and safety of withholding antimicrobial therapy in a new cohort of children with cancer and febrile neutropenia (FN) having a demonstrated viral respiratory tract infection. MethodsProspective, multicenter, noninferiority, randomized study, approved by the ethical committee, in children presenting with FN at seven hospitals in Chile, evaluated at admission for diagnosis of bacterial and viral pathogens. Children who were positive for a respiratory virus, negative for a bacterial pathogen, and had a favourable evolution after 48–72 hours of antimicrobial therapy were randomized to either maintain or withhold antimicrobial therapy. The primary endpoint was the percentage of episodes with an uneventful resolution, whereas the secondary endpoints were days of fever or hospitalization, requirement of antimicrobial treatment, readministration, sepsis, paediatric intensive care unit admission, and death. ResultsA total of 301 of 939 children with FN episodes recruited between March 2021 and December 2023 had a respiratory virus as a unique identified microorganism, of which 139 had a favourable evolution at 48–72 hours and were randomized, 70 to maintain and 69 to withdraw antimicrobial therapy. The median days of antimicrobial therapy was 5 (IQR 3–6) versus 3 (IQR 3–6) days (p < 0.001), with similar frequency of uneventful resolution 66/70 (94%) and 66/69 (96%); relative risk, 1.01; (95% CI, 0.93–1.09), absolute risk difference 0.01; (95% CI, −0.05–0.08) and similar number of days of fever and days of hospitalization. No cases of sepsis, paediatric intensive care unit admission, or death were reported. DiscussionWe validated the strategy of withdrawal antimicrobial therapy in children with FN and viral respiratory tract infection based on clinical and microbiological/molecular diagnostic criteria. This will enable advances in antimicrobial stewardship strategies with a possible future impact on antimicrobial resistance.

Genome mining of Escherichia coli WG5D from drinking water source: unraveling antibiotic resistance genes, virulence factors, and pathogenicity

BackgroundEscherichia coli, a ubiquitous inhabitant of the gut microbiota, has been recognized as an indicator of fecal contamination and a potential reservoir for antibiotic resistance genes. Its prevalence in drinking water sources raises concerns about the potential dissemination of antibiotic resistance within aquatic ecosystems and the subsequent impact on public health. The ability of E. coli to acquire and transfer resistance genes, coupled with the constant exposure to low levels of antibiotics in the environment, underscores the need for comprehensive surveillance and rigorous antimicrobial stewardship strategies to safeguard the quality and safety of drinking water supplies, ultimately mitigating the escalation of antibiotic resistance and its implications for human well-being.MethodsWG5D strain, isolated from a drinking water distribution source in North-West Province, South Africa, underwent genomic analysis following isolation on nutrient agar, anaerobic cultivation, and DNA extraction. Paired-end Illumina sequencing with a Nextera XT Library Preparation kit was performed. The assembly, annotation, and subsequent genomic analyses, including phylogenetic analysis using TYGS, pairwise comparisons, and determination of genes related to antimicrobial resistance and virulence, were carried out following standard protocols and tools, ensuring comprehensive insights into the strain’s genomic features.ResultsThis study explores the notable characteristics of E. coli strain WG5D. This strain stands out because it possesses multiple antibiotic resistance genes, encompassing tetracycline, cephalosporin, vancomycin, and aminoglycoside resistances. Additionally, virulence-associated genes indicate potential heightened pathogenicity, complemented by the identification of mobile genetic elements that underscore its adaptability. The intriguing possibility of bacteriophage involvement and factors contributing to pathogenicity further enriches our understanding. We identified E. coli WG5D as a potential human pathogen associated with a drinking water source in South Africa. The analysis provided several antibiotic resistance-associated genes/mutations and mobile genetic elements. It further identified WG5D as a potential human pathogen. The occurrence of E. coli WG5D raised the awareness of the potential pathogens and the carrying of antibiotic resistance in drinking water.ConclusionsThe findings of this study have highlighted the advantages of the genomic approach in identifying the bacterial species and antibiotic resistance genes of E. coli and its potential as a human pathogen.

Carbapenem-resistant Enterobacterales among hospitalized patients in Cape Town, South Africa: clinical and microbiological epidemiology.

Carbapenem-resistant Enterobacterales (CRE) are a substantial problem in Cape Town. CRE epidemiology is largely unknown and mortality remains high. To describe and characterize the clinical and microbiological epidemiology of CRE within Cape Town hospitals to better inform therapy with regard to current and novel antibiotics, as well as improve antimicrobial stewardship (AMS), and infection prevention and control (IPC). This prospective, multicentre study performed between 1 November 2020 and 30 November 2022, across three public and three private hospitals included hospitalized participants with CRE from clinical cultures. Participant demographics, clinical information and microbiology results were collected and analysed. Ninety percent of participants were from public hospitals. The age distribution ranged from 7 days to 88 years. Notable risk factors for CRE infection included recent exposure to antibiotics, medical devices and surgery. The most prevalent species was Klebsiella pneumoniae. However, a higher proportion of Serratia marcescens compared with previous reports was identified. The detected carbapenemases were blaOXA-48-like (80%) and blaNDM (11%). With the exception of amikacin (63%), tigecycline (65%), colistin (95%) and ceftazidime/avibactam (87%), susceptibility to antibiotics was low. This study identified common risk factors for CRE infection and generated a description of carbapenemase enzymes, species distribution and antibiograms, enabling a better understanding of CRE epidemiology. This provides insights into transmission patterns and resistance determinants of CREs, beneficial to informing data-driven regional patient management, AMS and IPC strategies.

Improving antimicrobial treatment in terms of antimicrobial stewardship and health costs by an OPAT service.

Outpatient parenteral antimicrobial therapy (OPAT) is a standard for antimicrobial therapy internationally. With this prospective cohort study, we aimed to assess the impact of an OPAT service as part of antimicrobial stewardship (AMS) and evaluate the safety and efficiency of the program while illuminating the financial benefit for the hospital. Socio-demographic data, treatment regimen and outcomes were prospectively recorded for all patients assigned to the program of the OPAT unit of the University Hospital of Zurich between November 2018 and September 2022. In total, we recorded 303 OPAT assignments of which 260 resulted in effective OPAT episodes. The 260 OPAT episodes were further optimized toward the choice of antimicrobial agent (n = 18) and length of therapy (n = 6). Moreover, OPAT resulted in alteration of patient assessment and care led by AMS strategies in 247 of 260 episodes (95%). While the bed days saved per year increased consistently with time, a total of 3934 in-hospital treatment days were saved amounting to a cost saving of 9,835,000 CHF over 47months. Adverse events were recorded in 46 cases whilst only two of these have been the reason for readmission during OPAT treatment. Clinical cure was noted in 77% (199/260) and was negatively associated with Charlson Comorbidity Index (CCI; OR per 1 unit higher 0.85 (95% CI 0.78-0.93)). This study demonstrates the impact of an OPAT service in the framework of AMS as well as its benefits for the hospital whilst preserving safety and efficacy for the patient's parenteral antimicrobial treatment.

Enterobacterales carrying chromosomal AmpC β-lactamases in Europe (EuESCPM): Epidemiology and antimicrobial resistance burden from a cohort of 27 hospitals, 2020–2022

IntroductionThe ESCPM group (Enterobacter species including Klebsiella aerogenes - formerly Enterobacter aerogenes, Serratia species, Citrobacter freundii complex, Providencia species and Morganella morganii) has not yet been incorporated into systematic surveillance programs. MethodsWe conducted a multicentre retrospective observational study analysing all ESCPM strains isolated from blood cultures in 27 European hospitals over a 3-year period (2020–2022). Diagnostic approach, epidemiology, and antimicrobial susceptibility were investigated. ResultsOur study comprised 6,774 ESCPM isolates. MALDI-TOF coupled to mass spectrometry was the predominant technique for bacterial identification. Susceptibility to new β-lactam/β-lactamase inhibitor combinations and confirmation of AmpC overproduction were routinely tested in 33.3% and 29.6% of the centres, respectively. The most prevalent species were E. cloacae complex (44.8%) and S. marcescens (22.7%). Overall, third-generation cephalosporins (3GC), combined third- and fourth-generation cephalosporins (3GC + 4GC) and carbapenems resistance phenotypes were observed in 15.7%, 4.6%, and 9.5% of the isolates, respectively. AmpC overproduction was the most prevalent resistance mechanism detected (15.8%). Among carbapenemase-producers, carbapenemase type was provided in 44.4% of the isolates, VIM- (22.9%) and OXA-48-enzyme (16%) being the most frequently detected. E. cloacae complex, K. aerogenes and Providencia species exhibited the most notable cumulative antimicrobial resistance profiles, with the former displaying 3GC, combined 3GC + 4GC and carbapenems resistance phenotypes in 15.2%, 7.4%, and 12.8% of the isolates, respectively. K. aerogenes showed the highest rate of both 3GC resistant phenotype (29.8%) and AmpC overproduction (32.1%), while Providencia species those of both carbapenems resistance phenotype (42.7%) and carbapenemase production (29.4%). ESCPM isolates exhibiting both 3GC and combined 3GC + 4GC resistance phenotypes displayed high susceptibility to ceftazidime/avibactam (98.2% and 95.7%, respectively) and colistin (90.3% and 90.7%, respectively). Colistin emerged as the most active drug against ESCPM species (except those intrinsically resistant) displaying both carbapenems resistance phenotype (85.8%) and carbapenemase production (97.8%). ConclusionsThis study presented a current analysis of ESCPM species epidemiology in Europe, providing insights to inform current antibiotic treatments and guide strategies for antimicrobial stewardship and diagnostics.

An Assessment of the Current Level of Implementation of the Core Elements of Antimicrobial Stewardship Programs in Public Hospitals in Ghana

Introduction: Antimicrobial resistance (AMR) is becoming a threat to global public health. Antimicrobial stewardship (AMS) program (ASP) is one of the 5 strategic areas in the Ghana National Action Plan to fight this menace. Assessment of the core elements of ASP in a hospital setting has been identified as a pragmatic way of identifying the barriers and facilitators for its effective implementation. Method: The World Health Organization’s toolkit for assessment of the 7 core elements of ASP in hospitals in low and middle income countries was used for this situational analysis of public hospitals in 2 regions of Ghana. The core elements included leadership commitment, accountability and responsibility, pharmacy expertize, AMS actions and interventions, education and training, and periodic monitoring and surveillance. Data collected using a checklist were imported into STATA version 14 for descriptive and bivariate analyses. Results: 15 public hospitals were assessed with the toolkit. Most of them were primary health care facilities (n = 12, 80.0%), had bed capacities between 100 and 199 beds, less than 50 medical doctors (n = 12, 80.0%), less than 5 pharmacists (n = 10, 66.7%), and between 100 and 199 nurses. Performances in 4 out of the 7 core elements were most deficient and they included leadership commitment, pharmacy expertize, AMS actions (interventions) implemented, monitoring and surveillance of antibiotic use, and bacteria resistance rates. Pharmacist-led ASPs were also found to be associated with their formal training on AMS. Key barriers identified included lack of skilled human resources, lack of available time for AMS-related duties and poor laboratory infrastructure. Conclusion: There was sub-optimal performance for almost all the core elements of ASP in the public hospitals in Ghana hampered mostly by lack of skilled human and financial resources. Pharmacists must be empowered through formal training and certificate programs in infectious disease management and AMS principles and strategies to enhance their contribution toward ASPs in hospitals. The results from this study should encourage nationwide assessment of ASPs across hospital settings in Ghana to better evaluate the level of their implementation and address potential barriers to guide AMS policies and ASP strategy development toward the fight against AMR.

Confronting the Disruption of the Infectious Diseases Workforce by Artificial Intelligence: What This Means for Us and What We Can Do About It.

With the rapid advancement of artificial intelligence (AI), the field of infectious diseases (ID) faces both innovation and disruption. AI and its subfields including machine learning, deep learning, and large language models can support ID clinicians' decision making and streamline their workflow. AI models may help ensure earlier detection of disease, more personalized empiric treatment recommendations, and allocation of human resources to support higher-yield antimicrobial stewardship and infection prevention strategies. AI is unlikely to replace the role of ID experts, but could instead augment it. However, its limitations will need to be carefully addressed and mitigated to ensure safe and effective implementation. ID experts can be engaged in AI implementation by participating in training and education, identifying use cases for AI to help improve patient care, designing, validating and evaluating algorithms, and continuing to advocate for their vital role in patient care.

More Than One and Done: The Continued Challenge of Identifying Sustainable Outpatient Antimicrobial Stewardship Strategies.

More Than One and Done: The Continued Challenge of Identifying Sustainable Outpatient Antimicrobial Stewardship Strategies.

Implementing Community Antimicrobial Stewardship Model in Nigeria: Lessons Learned from AMS Outpatient Setting among Community Pharmacists/Patent and Proprietary Medicine

Antimicrobial resistance (AMR) is a growing global concern primarily driven by the overuse and inappropriate utilization of antimicrobials. In Nigeria, AMR is exacerbated by the routine sale of prescription-only medicines, including antimicrobials, without proper monitoring. The National Action Plan for Antimicrobial Resistance (2017-2022) highlighted widespread inappropriate antibiotic use, with significant proportions obtained without prescriptions. Antimicrobial stewardship (AMS) in outpatient settings is a novel concept in Nigeria. This interventional study sought to contribute to the reduction of inappropriate antibiotic dispensing and use in community/outpatient settings in Nigeria, focusing on enhancing the skills and capacity of improved rational antibiotic therapy among community pharmacists and Patent and Proprietary Medicine Vendors (PPMVs), with the sole aim of improving patient health outcomes. The CAMS interventional study involves education, quality improvement capacity building, patient empowerment, and a multifaceted AMS strategy. Results from the CFID’s CAMS model indicated a significant improvement in the rational dispensing and use of antimicrobials within the intervention group, emphasizing the effectiveness of CAMS. Notable variations in post-visit actions between the intervention and monitoring groups further support the positive impact of the intervention. Variation in attitudes towards sharing of antibiotic to friends and relatives was reduced among the intervention group, offering clear understanding into the potential impact of CFID AMS outpatient setting (CAMS) intervention. The study’s conclusion underscores the pivotal role of implementing AMS in outpatient and community settings such as the CAMS interventional model in improving antibiotic-related practices in both urban and rural communities in Nigeria, emphasizing its relevance and impact.

Positive effects of audit and feedback on antimicrobial use in hospitalized patients limited to audited patients.

Audit and feedback is an antimicrobial stewardship (AMS) strategy, with the potential to also optimize antimicrobial use in non-audited patients. This study aimed to determine whether audit and feedback reduce antimicrobial use in both audited and non-audited patients. Before-after trial with a 1-year intervention period and 2.5-year historical cohort. 750-bed community hospital in the Netherlands. All patients admitted to the urology wards during the 3.5-year study period were observed. Patients were classified as using antimicrobials if any antimicrobial was used for therapeutic reasons. Patients using antimicrobials prophylactically were excluded from measurements. The AMS team provided audit and feedback on antimicrobial use for patients using antimicrobials for 2 days. Retrospectively, antimicrobial use and length of stay (LOS) were compared with the historical cohort. Audits modified antimicrobial treatment in 52.8% of the cases. De-escalating, stopping, and switching from intravenous to oral treatment accounted for 72% of these modifications. Compared to patients from the cohort, who also used antimicrobials for 2 days, antimicrobial use decreased from 14.21 DDD/patient (95% CI, 13.08-15.34) to 11.45 DDD/patient (95% CI, 8.26-14.64; P = .047) for audited patients. Furthermore, mean LOS decreased from 7.42 days (95% CI, 6.79-8.06) to 6.13 days (95% CI, 5.38-6.89; P = .031). However, looking at all patients admitted to the urology wards, the percentage of patients using antimicrobials and total antimicrobial use remained unchanged. Audit and feedback reduce antimicrobial use and LOS, but only for audited patients. Positive effects are not automatically transferred to patients for whom no audits have been performed.

Five steps to high quality antimicrobial stewardship research

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

Pilot study to evaluate the need and implementation of a multifaceted nurse-led antimicrobial stewardship intervention in residential aged care.

To evaluate the need and feasibility of a nurse-led antimicrobial stewardship (AMS) programme in two Australian residential aged care homes (RACHs) to inform a stepped-wedged, cluster randomized controlled trial (SW-cRCT). A mixed-methods pilot study of a nurse-led AMS programme was performed in two RACHs in Victoria, Australia (July-December 2019). The AMS programme comprised education, infection assessment and management guidelines, and documentation to support appropriate antimicrobial use in urinary, lower respiratory and skin/soft tissue infections. The programme was implemented over three phases: (i) pre-implementation education and integration (1 month); (ii) implementation of the intervention (3 months); and (iii) post-intervention evaluation (1 month). Baseline RACH and resident data and weekly infection and antimicrobial usage were collected and analysed descriptively to evaluate the need for AMS strategies. Feedback on intervention resources and implementation barriers were identified from semi-structured interviews, an online staff questionnaire and researcher field notes. Six key barriers to implementation of the intervention were identified and used to refine the intervention: aged care staffing and capacity; access to education; resistance to practice change; role of staff in AMS; leadership and ownership of the intervention at the RACH and organization level; and family expectations. A total of 61 antimicrobials were prescribed for 40 residents over the 3 month intervention. Overall, 48% of antibiotics did not meet minimum criteria for appropriate initiation (respiratory: 73%; urinary: 54%; skin/soft tissue: 0%). Several barriers and opportunities to improve implementation of AMS in RACHs were identified. Findings were used to inform a revised intervention to be evaluated in a larger SW-cRCT.

The epidemiology of pediatric outpatient acute respiratory tract infections in the US: a multi-facility analysis of multiplex PCR testing from 2018 to 2023.

Post-pandemic, it is essential to understand the epidemiology of pediatric acute respiratory tract infections (ARTIs). Our multi-facility study elucidates the outpatient epidemiology of pediatric ARTI using highly multiplexed PCR testing, providing critical insights into the evolving landscape of the etiological agents with a particular focus on the years following the emergence of SARS-CoV-2. Utilizing data from two different multiplex PCR panels, our research provides a comprehensive analysis of respiratory pathogen positivity from 2018 to 2023. Our findings indicate that over half of the annual test results identified at least one pathogen, primarily of viral origin. Intriguingly, despite the surge in testing during the COVID-19 pandemic, pathogen detection rates remain similar to the pre-pandemic era. These data hold significant implications for directing antimicrobial stewardship strategies, curbing unnecessary antibiotic use in pediatric respiratory diseases, and the value of multiplex PCR testing in the outpatient setting among pediatrics.

1208. Impact of Selected Antimicrobial Stewardship and Infection Control Strategies in Carbapenem Resistance in a Third Level Public Hospital in Colombía.

Abstract Background Antimicrobial Stewardship (AMS) Programs and Infection prevention and control (IPC) strategies have been shown to effectively reduce antimicrobial resistance. The resources required for the implementation of these programs in low-resource settings could be limited. This study aimed to assess the impact of a few AMS and IPC strategies on carbapenem resistance in a third-level public hospital in Colombia. Methods A retrospective before-and-After study was completed. The baseline period consisted of 6 months (January 2021-Jun 2021) and the intervention period consisted of 18 months (July 2021-December 2022) The AMS intervention consisted of the implementation of prospective audits on prescriptions of meropenem, cefepime, and piperacillin-tazobactam, along with educational seminars. The IPC intervention consisted of screening for carbapenemase-producing-Enterobacterales (CPE) through rectal swabs for every patient transferred to the ICU and weekly for all patients in the ICU. A cohorting area with 24 beds was also established to isolate CPE colonized/infected patients Results During the intervention period, 886 prospective audits were made. We suspended 208, 111, and 55 prescriptions of Meropenem, piperacillin-tazobactam, and cefepime respectively. The length of therapy was shortened in 239, 290, and 99 prescriptions of Meropenem, piperacillin-tazobactam, and cefepime respectively. The antimicrobial consumption was lower in the intervention period for meropenem (24,8 DDD/100 patients-days Vs 74.3 DDD/100 patients-days baseline period). Figure 1 The prevalence of positive rectal swabs showed a downward trend during the intervention period. Figure 2. The prevalence of CPE also decreased and was 0,45 during the baseline period and 0,28 during the last semester of the intervention period. Figure 3 The carbapenem resistance K. pneumoniae laboratory-confirmed bloodstream infection rate also decreased during the intervention period, going from 15.4/10.000 patients-days to 1.17/10.000 patient-days. Figure 4 Conclusion The implementation of selected AMS and IPC strategies in a resource limited third level hospital reduced the prevalence of carbapenemase-producing Enterobacterales and the rate of Carbapenem-resistant K. pneumoniae bloodstream infections. Disclosures GERARDO A. MUÑETON, Infectious diseases and Internal Medicine Specialist, PFIZER: Advisor/Consultant

2209. Reducing Inappropriate Antibiotic Prescribing for the Treatment of Urinary Tract Infections (UTI) in Urgent Care Clinics

Abstract Background In 2020, The Joint Commission released new standards to promote expansion of antimicrobial stewardship into the ambulatory care setting. Urinary tract infections (UTIs) are one of the most common bacterial infections encountered in the outpatient setting and therefore an opportunistic area for intervention. The aim of our study was to evaluate current outpatient prescribing patterns for the treatment of UTIs and develop a methodology to improve antibiotic prescribing. Methods A single-center, retrospective study was conducted across 5 Jackson Health-University of Miami Urgent Care Clinics (UCC) in Miami, Florida. We utilized ICD-10 diagnosis codes to identify adults diagnosed with UTIs between January 1, 2021 and October 31, 2022. We identified the top five prescribers and audited 10% of their prescriptions. The data was analyzed and as our intervention, we shared results with UCC leadership and disseminated provider-specific report cards to highlight inappropriate prescribing practices. After this, we allowed 3 months for change to occur and set a goal of reducing the percentage of inappropriate UTI durations by 50%. Results For baseline data, 123 charts were reviewed. We identified 95 patients with cystitis (77.3%), 26 pyelonephritis (21.1%), and 2 asymptomatic bacteriuria (1.6%). Inappropriate prescribing ranged from 17.6% to 80.6% between the UCC prescribers (Figure 1). Various types of prescribing opportunities were identified, with the most common being prolonged length of therapy (Figure 2). For post-intervention, 114 charts were reviewed. We identified 90 patients with cystitis (78.9%), 22 pyelonephritis (19.3%), and 2 asymptomatic bacteriuria (1.8%). Inappropriate durations of UTI treatment were reduced by 25% (Figure 3), with the greatest improvement seen in nitrofurantoin prescribing (Figure 4). Figure 1 Figure 2 Figure 3 Conclusion Retrospective audit and feedback using provider-specific report cards was an effective antimicrobial stewardship strategy for the ambulatory care setting. Our intervention led to reduced durations of UTI treatment for nitrofurantoin but not necessarily with fluoroquinolones, trimethoprim/sulfamethoxazole, or beta-lactams. Next steps will include providing more education to further promote appropriate use of all classes of antibiotics. Figure 4 Disclosures Lilian M. Abbo, MD, MBA, Ferring: Advisor/Consultant|Pfizer: Advisor/Consultant|Regeneron: Grant/Research Support|Shionogi: Advisor/Consultant

1228. Evaluation of the Practice of Switching from Intravenous to Oral Antimicrobial Therapy at King Abdulaziz University Hospital

Abstract Background Conversion from intravenous (IV) antibiotics to an oral (PO) in eligible patients is an important antimicrobial stewardship strategy. Recently, King Abdul-Aziz University Hospital (KAUH) in updated its IV to PO conversion policy. This policy describes eligibility criteria for patients to be switched to oral therapy from IV and it suggests PO alternative to IV medications. The aim of this prospective observational study is to observe IV to PO conversion practices on selected antimicrobials in selected ward after updating and implementing this policy. Methods Adult patients admitted to the medical, surgical, and hematology/oncology wards who received either metronidazole, ciprofloxacin or clindamycin IV were evaluated for antibiotic need and for eligibility for IV to PO conversion according to the policy. Evaluation period spanned from November 2021 – December 2022. Results 194 patients were evaluated. Of them, 154 (80%) had a clear indication for the antibiotic of which 98 (63%) required IV administration for the following reasons: impaired oral route (59%), impaired gastrointestinal absorption (15.3%), acute treatment phase of the infection (15.3%), and other reasons such as surgical prophylaxis (3%) and severe sepsis/septic shock (2%). The remaining 56 (36.7%) met the policy’s eligibility criteria for IV to PO conversion. Conclusion We found that most patients received antibiotics appropriately in the appropriate route for an existing indication. However, there are plenty of opportunities for improvement in discontinuing unnecessary antibiotics and de-escalating from IV to PO. Ideally, this discussion should be had while rounding on the patient for collective decision making at the point of care. Disclosures Nour Baghdady, PharmD, BCPS, MPH, BCIDP, CSL Seqirus: Advisor/Consultant|CSL Seqirus: Stocks/Bonds

Antimicrobial stewardship strategy implementation and impact in acute care spinal cord injury and disorder units

Context Antimicrobial Stewardship Programs (ASPs) are crucial to optimizing antibiotic use. ASPs are implemented in the Veterans Health Administration (VAs), but they do not target the needs of populations at high risk for resistant infections, such as spinal cord injury and disorder (SCI/D). Objective The goal of this study was to assess key ASP leader and SCI/D clinicians’ perceived level of implementation and impact of 33 Antimicrobial Stewardship (AS) strategies. Method SCI/D clinicians and ASP leaders across 24 VA facilities with SCI/D units were surveyed. Participants rated their perceived level of impact (“high”, “mild”, “low”) and perceived level of implementation (“not”, “partially”, “fully”) for 33 AS strategies in SCI/D units in VAs. Strategies were grouped into core elements which they support. We conducted a Fisher’s exact test to assess differences between respondent perceptions based on role (SCI/D clinicians versus ASP leaders). Results AS strategy implementation varied across VA facilities. Of the AS strategies, pre-authorization was perceived to be highly impactful (78%) and fully implemented (82%). SCI/D clinicians and ASP leaders rated AS strategies differently such that SCI/D clinicians were less aware of implementation of AS strategies related to reporting requirements; further, SCI/D clinicians rated strategies which guide treatment duration and which limit C. difficile antibiotic exposure as more impactful than ASP leaders. Ratings for facility-wide and SCI/D unit ratings did not significantly differ for impact or implementation. Conclusion Implementation practices varied across VA facilities. Future work should implement highly impactful AS strategies according to facility and unit needs.

Use of Ceftriaxone and Benzylpenicillin in Outpatient Parenteral Antimicrobial Therapy: Spectrum vs Cost.

The application of antimicrobial stewardship (AMS) principles may entail increased cost to allow for narrower-spectrum therapy. Prescribing benzylpenicillin (BP) and ceftriaxone (CRO) for outpatient parenteral antimicrobial therapy (OPAT) demonstrates the complex challenge of this principle. The aim of this study is to analyze the use of BP and CRO in our OPAT program, including indications and relative cost. We analyzed all adult patients in our OPAT program who received intravenous BP or CRO over 1 year. We identified a "crossover group" of patients who could have received either agent. Economic comparison was based on acquisition cost of the therapy (drug, infuser, and preparation costs). Of 105 eligible patients, 54 (51%) and 51 (49%) received BP and CRO, respectively. Forty (38%) patients were suitable for either agent; of these, the majority (n = 31, 78%) were treated with BP. Economic analysis demonstrated that the average daily cost of BP therapy was $93.76/d (AUD) vs $1.23/d for CRO. Thus, across our OPAT programs, we had an additional average cost of $92.53/patient/d to use BP instead of CRO. Program-wide the annual additional cost of using BP and thus applying this AMS strategy was $68 386.12. BP is often selected over CRO by clinicians, where possible, as recommended by the Australian guidelines; however, BP is associated with higher daily acquisition costs. More broadly, a number of narrower-spectrum agents may involve significantly higher costs than comparators; as such, the $92.53/d to prevent CRO exposure can be considered when applying other antimicrobial-substitution AMS interventions in an acute health care setting.