Appropriateness Of Antimicrobial Therapy Research Articles

P-1811. Impact of Hemo-Alert Program on Appropriate Antimicrobial Therapy in Hospitalized Patients with Bacteremia: Results from a Quasi-experimental Study

Abstract Background Hemo-Alert program is an antimicrobial stewardship strategy, designed to shorten the time to appropriate antimicrobial therapy in bacteremic patients. Methods Eligible subjects were all hospitalized patients with at least one positive hemoculture. The standard of care included a prompt notification of positive hemoculture via a phone call. However, the final identification and susceptibility results need to be individually retrieved. The Hemo-alert program included a prompt notification of final identification and susceptibility results via a direct SMS to physician and by placing results on patient’s medical chart. Appropriateness of antimicrobial therapy was determined by two independent infectious disease specialists. Antimicrobial therapy for colonization, too-broad or too-narrow regimen were considered inappropriate. Results There were 150 subjects in the pre-implementation group and 150 subjects in the post-implementation group. Approximately half of both groups (pre vs. post; p-value) were male (50.7% vs. 48.7%; p=0.73) with a comparable mean age (66.14±17.13 vs. 68.57±14.41; p=0.18). The three leading causative pathogens were Escherichia coli (24.0% vs. 26.7%; p=0.60), followed by Klebsiella pneumoniae (14.0% vs. 16.7%; p=0.52), and Staphylococcus aureus (9.3% vs. 10.7%; p=0.70). The proportion of appropriate antimicrobial therapy within the first 72 hours was significantly higher in the post-implementation group (22.7% vs. 34.0%; p=0.03). Good clinical response was significantly higher in the post-implementation group (74.0% vs. 85.3%; p=0.02). Furthermore, the 28-day mortality was comparable between the two groups (24.0% vs. 18.0%; p=0.20). Conclusion Our study confirmed the positive impact of the Hemo-Alert program on the appropriateness of antimicrobial therapy and treatment response among bacteremic patients. Disclosures All Authors: No reported disclosures

Check of APpropriaTeness of Antimicrobial therapy In Nursing homes (CAPTAIN):a point prevalence study in Belgium.

The overall prevalence of antimicrobial therapy (AMT) in nursing homes is well described. However, less is known about the appropriateness of AMT in nursing home residents. Therefore, the Check of APpropriaTeness of antimicrobial therapy in nursing homes (CAPTAIN) study aimed to assess both prevalence and appropriateness of AMT in Belgian nursing homes. In a prospective, observational, point prevalence study, researchers documented prevalence and identified potentially inappropriate prescriptions (PIPs) by evaluating accordance of AMT with national guidelines. The severity of inappropriateness was assessed by a modified Delphi expert panel. Eleven nursing homes, including 1178 residents, participated in this study. On the survey day, 8.0% of residents took systemic AMT, primarily for urinary tract infections (54.2%), respiratory tract infections (36.5%), and skin and skin-structure infections (6.3%). About half of these prescriptions were used in prophylaxis (52.1%). Registration of indication and stop date was missing in 58.3% and 56.3% of AMTs, respectively. In 89.6% of the systemic AMTs, at least one discordance with national guidelines was identified, resulting in a total of 171 PIPs, with 49 unique PIPs. Of all unique PIPs, 26.5% were assessed with a high severity score (≥4). According to the expert panel, most inappropriate practice was starting AMT for cough without other symptoms. Inappropriate timing of time-dependent AMTs was common, but assessed as 'moderately severe'. One-third of systemic AMT exceeded the recommended duration. AMT in nursing homes is often not prescribed according to national guidelines, highlighting the need for future interventions to promote the rational use of AMT in this setting.

The Impact of Reporting the Same-Day Identification and Antibiotic Susceptibility Test Results on the Treatment of Bloodstream Infections.

The rise of antibiotic-resistant organisms necessitates the implementation of rapid identification (ID) and antibiotic susceptibility testing (AST) methods for patient management. We aimed to analyze how rapid ID and AST reporting influenced clinicians' treatment decisions. Bacteria were identified directly from positive blood cultures (BC) using serum separator tubes and MALDI-TOF MS. EUCAST rapid antibiotic susceptibility testing (RAST) method was performed for AST. The impact of rapid ID and AST reports on clinician treatment decisions was evaluated through clinical documentation. The appropriateness of antimicrobial therapy and interventions was assessed according to institutional antimicrobial prescribing guidelines, AST results, and clinical data. A total of 128 BC bottles from 86 patients underwent processing. The rapid ID method was successful in 105 (82.1%) bottles obtained from 76 patients. The rapid ID results were reviewed by the Infectious Diseases Team on the same day for 55 (72.4%) of the 76 patients. Following the evaluation, new treatments or interventions were recommended for 28 (36.8%) patients. RAST results were available for 24 patients. The susceptibility profile of seven patients was assessed by the Infectious Diseases Team on the same day. Antimicrobial treatment was escalated in four cases, and de-escalation was made in two based on RAST results. If all rapid results had been assessed, adjustments could have been made for eight (10.5%) and eleven (14.5%) more patients, according to ID and RAST results, respectively. Implementation of rapid ID and AST may contribute to patient management. Although rapid reporting was made, some results were not evaluated by the clinician on the same day, indicating that communication between the clinician and the laboratory needs to be strengthened.

Impact of Irrational Use of Antibiotics Among Patients in the Intensive Care Unit on Clinical Outcomes in Sudan.

Intensive Care Unit (ICU) is a specialized ward where critically ill patients are admitted to provide intensive health care Inappropriate antimicrobial therapy (AMT) and high mortality rates were documented in the ICU. The influence of irrational use of empiric antibiotics on clinical outcomes in ICU patients is not well studied in Sudan. This study aims to determine the rational use of antibiotics and its impact on clinical outcomes among ICU patients. Using data collection form, a retrospective longitudinal study was conducted among ICU patients at Omdurman Military Hospital, Khartoum State. Patients admitted from January 2019 to December 2019 were included in the study. Patients who stayed in ICU < 48 hr were excluded. Appropriateness of AMT is assessed using culture sensitivity test (CST) and the American Society of Infectious Diseases (IDSA) guideline. Among 102 patients, 54.9% male, one-third of patients developed nosocomial infections, 80.4% received empiric therapy with broad-spectrum antibiotics. The CST is done in 19%, and 43% patients are prescribed inappropriate AMT. Inappropriate AMT is associated with recurrent infections 38.4% (p=0.028) and high mortality 33.8% (p=0.014). Overall mortality rate 63.7% ICU patients. Elevated mortality in nosocomial 57.8%, decreased with inappropriate AMT in 21.6% patients. Significantly higher mortality rates 90.7% among uncontrolled infections (p<0.001), 80.6% nosocomial infections (p=0.001), and 76.7% renal compromised (p=0.002). Empirical AMT reduces the frequency of nosocomial infections, which has an impact on mortality. Inappropriate AMT is significantly associated with uncontrolled infections and lower mortality. Implementing a restrictive infectious control system and effective stewardship programs in hospital ICU wards is recommended.

Covenant between pharmacists and clinicians on the appropriateness of antimicrobial therapy.

Covenant between pharmacists and clinicians on the appropriateness of antimicrobial therapy.

928. The Cost-effectiveness of the Pediatric Antimicrobial Stewardship Program in a Non-Freestanding Children’s Hospital

Abstract Background Improper utilization of antimicrobials has impacted clinical outcomes in patient care and economical costs. Pediatric antimicrobial stewardship (Ped ASP) lowers healthcare costs by promoting efficient and judicious use of antimicrobials which improves patient outcomes and amends resource utilization. The objective of this study is to evaluate the cost-effectiveness of a Ped ASP in a non-freestanding children’s hospital within an adult-centered tertiary hospital. Methods We conducted a cost-effective analysis of our Ped ASP within a 685-bed, adult-centered medical center. Impacted by the COVID pandemic, the pediatric services reduced from 21 to 14 beds with 10 general pediatrics (PED) and 4 pediatric intensive care (PICU) beds. Our Ped ASP activities include thrice-weekly chart reviews followed by handshake rounds and quarterly reviews of documented interventions. The preset values of antimicrobial-specific interventions in the Electronic Medical Record system were utilized. An average cost savings of $732 (range: $2.5 - $2,640) per patient as determined by previous studies was used to calculate the annual cost savings. Results During years 2020 to 2021, antibiotic days of therapy per 1000 patient days (DOT) decreased from 290.4 to 100.2 in PED but increased from 433 to 569.1 in PICU. The ratio of broad to narrow-spectrum antibiotics decreased from 0.46 to 0.20 in PED and 0.69 to 0.63 in PICU. In 2020, 286 reviews were completed of 155 patients which projected an average cost savings of $113,460 (range: $387.5 - $409,200). In 2021, 256 reviews of 116 patients projected an average cost savings of $84,912 (range $290 - $306,240). An estimated overall annual cost-savings was $99,186. The total number of ASP-specific interventions in 2020 and 2021 were 172 and 146 with projected pharmacy intervention values of $26,354 and $19,170 respectively. Conclusion Our Ped ASP effectively reduces the usage of broad-spectrum antibiotics in both PED and PICU demonstrating cost savings. Implementing antibiotic time-out reports on specific broad-spectrum antibiotics based on local susceptibility data may further enhance the safety and appropriateness of antimicrobial therapy. Disclosures All Authors: No reported disclosures.

Antimicrobial therapy, resistance, and appropriateness in healthcare-associated and community-associated infections; a point prevalence survey

BackgroundData examining differences in antimicrobial therapy and its appropriateness between healthcare-associated infections (HAIs) and community-associated infections (CAIs) are limited. The objective was to compare antimicrobial therapy, resistance, and appropriateness between CAIs and HAIs. MethodsOne-day point prevalence survey targeting admitted patients with active infections was conducted in six tertiary care hospitals. Antimicrobial appropriateness was decided based on hospital antimicrobial guidelines, clinical assessment, culture results, and other relevant investigations. ResultsOut of 1666 patient records reviewed, 240 (14.4%) infection events were identified. Prevalence of infections treated with antimicrobials were 6.5% for HAIs and 7.1% for CAIs. The most commonly prescribed antimicrobials were carbapenems (19.6%), cephalosporins (14.8%), and vancomycin (13.2%), with some differences between HAIs and CAIs. The overall contribution of MDR pathogens to both HAIs and CAIs was similar (34.0% versus 34.3%, p = 0.969). ESBL was significantly associated with CAIs while other gram-negative MDR pathogens significantly associated with HAIs. Overall appropriateness of antimicrobial therapy was similar in HAI and CAI events (64.2% versus 64.7%, p = 0.934). However, it was highest in aminoglycosides (78.6%) and lowest in vancomycin (40.8%). It was lowest in bloodstream infections than other infections (48.5% versus 61% to 78%, p = 0.044). ConclusionAlthough the overall burden of MDR pathogens and appropriateness of antimicrobial therapy were similar in HAI and CAI events, there were some differences related to the type of MDR, type of antimicrobials, and type of infection. The current finding can guide training and educational activities of local antimicrobial stewardship initiatives aiming to improve antimicrobial therapy in hospital setting.

Early antimicrobial stewardship team intervention on appropriateness of antimicrobial therapy in suspected sepsis: a randomized controlled trial.

ObjectivesThere has been concern that the imperative to administer rapid antimicrobials in septic patients may result in inappropriate antimicrobial use. We aimed to determine the impact of early antimicrobial stewardship (AMS) team intervention in patients with Medical Emergency Team (MET) calls for suspected sepsis.MethodsWe performed a randomized controlled trial of non-ICU inpatients who had a MET call for suspected sepsis. Patients were randomized to standard care (management of antimicrobial therapy by the treating team) or early targeted intervention (AMS review 48 h post-MET call). The primary outcome was appropriateness of antimicrobial therapy 72 h post-MET call, as determined by a panel of blinded infectious diseases physicians.ResultsIn total, 90 patients were enrolled; 45 were randomly allocated to the intervention group, and 45 to the control group. More patients in the AMS intervention group were receiving appropriate antimicrobials 72 h following the MET call (67% versus 44%, P = 0.03). In the intervention group, 27 recommendations were made by the AMS team; 74% of recommendations were accepted, including 30% of cases where antimicrobials were discontinued or de-escalated. There were non-significant differences in total duration of antimicrobial therapy (8.7 versus 10.7 days, P = 0.39), sepsis-related ICU-admission rates (13% versus 18%, P = 0.56) and sepsis-related in-hospital mortality (7% versus 9%, P = 0.71) between intervention and control groups, respectively.ConclusionsAMS team intervention resulted in significant improvement in appropriateness of antimicrobial therapy following MET calls due to suspected sepsis. Targeted AMS review should be implemented to support early antimicrobial de-escalation and optimization in patients with suspected sepsis.

Facial Soft Tissue Injuries in Pediatric Patients.

Soft tissue injuries of the head and neck are a common reason for medical evaluation and treatment in pediatric populations with some unique and important considerations when compared with adults. The incidence and type of injuries continue to evolve with the adoption of new safety measures, technology advancements, and education of the general population. The goal of this article is to provide the reader with a thorough understanding of the evaluation and management of pediatric soft tissue trauma including the initial workup, physical examination, appropriateness of antimicrobial therapy, and setting for surgical repair. Additionally, the pediatric anesthetic considerations for evaluation and repair in regard to local anesthesia, sedation, and general anesthesia are described in detail. There is a focus on dog bites, perinatal injuries, and child abuse as these entities are distinctive to a pediatric population and have particular management recommendations. Lastly, application of the reconstructive ladder as it applies to children is supported with specific case examples and figures. Although there are many parallels to the management of soft tissue injury in adults, we will highlight the special situations that occur in pediatric populations, which are imperative for the facial plastic and reconstructive surgeon to understand.

Antimicrobial Therapy for Pneumonia or Fluid Overload?

Patients with evidence of fluid overload or heart failure (HF) without clinical symptoms of pneumonia are often treated with antimicrobial therapy for pneumonia. We conducted a retrospective study to evaluate the use of antimicrobial therapy in critically ill patients with fluid overload or heart failure diagnosed as pneumonia.A retrospective chart review of patients on antimicrobial therapy treated for pneumonia in the intensive care unit was conducted. The study's primary outcome was the number of cases with no evidence of pneumonia, including fluid overload or heart failure, managed with antimicrobial therapy for pneumonia. Patients on antimicrobial therapy for other infections were excluded. Appropriateness of antimicrobial therapy was based on radiographic evidence, clinical data, and presentation. Patient group categories were A (pneumonia) and B (no evidence of pneumonia, fluid overload, and heart failure). Based on the subdivision of patients in Group B, where there was no evidence of pneumonia, we further classified it into two subgroups: heart failure (HF)/fluid overload (Group B1) and no evidence of HF or fluid overload (Group B2). Patients with evidence of pneumonia (Group A) were compared to the group with fluid overload and heart failure (Group B1). A p-value of < 0.05% was considered significant for detecting statistical difference.Post-screening, data on 56 patients were collected for the study and analyzed. Mean body temperature and white blood cell count were 37.6 + 0.6 oC, and 17.4 + 6.88 x103 µL, respectively. Based on radiographic evidence, clinical data, and presentation, 29 (52%) were classified under Group A, while 27 (48%) were classified under Group B. Median brain natriuretic peptide (BNP) for Group A vs. Group B was 514 (IQR: 1077) vs. 758 (2212) pg/mL p=0.14. The median duration of inpatient antimicrobial therapy was 7 (interquartile range [IQR]: 6) vs. 6 (IQR: 4) days, p=0.52, while the median duration of the total (inpatient and discharge prescription) antimicrobial therapy was 11 (IQR: 6) vs. 11 (IQR: 5), p=0.21. Patients with evidence of pneumonia (Group A) were compared to the group with fluid overload and heart failure (Group B1). The median BNP for the two groups was 514 (IQR: 1077) vs. 1040 (2094) pg/mL, p=0.04. Patients with documented echocardiographic evidence of ejection fraction < 55% were 4 vs. 14 for Groups A and B1, respectively. Additionally, the median BNP for Group A vs. Group B2 was 514 (IQR: 1077) vs. 189 (418) pg/mL, p=0.02.These findings demonstrate a 48% inappropriate use of antimicrobial therapy in patients with congestive heart failure (CHF), or fluid congestion misdiagnosed as pneumonia. There was a significant difference in the median BNP observed in patients with pneumonia compared to those with fluid overload and heart failure treated as pneumonia. More cases of patients with elevated BNP and reduced left ventricular ejection fraction (LVEF) were observed in patients with fluid overload or CHF treated as pneumonia than those diagnosed with pneumonia alone. Appropriate interpretation of radiographic evidence, laboratory data, and critical clinical assessment for the use of empiric antimicrobial therapy in this population is warranted.

176. Impact of pharmacist electronic communication on the appropriateness of antimicrobial therapy at renewal time

BackgroundInappropriate antibiotic use increases the risk of antimicrobial resistance and adverse events. Our institution adopts all elements recommended by the CDC to improve antimicrobial stewardship (AMS). Compliance with such elements requires education, coaching and decision support tools. The objective of the study intervention is to engage prescribers to critically evaluate and improve antibiotic utilization through renewal communication in the electronic medical record (EMR).MethodsThis is a single center study with a retrospective phase and prospective phase. During the intervention period from October 1st, 2019 to January 1st, 2020 the pharmacist monitored targeted antibiotics and initiated an AMS EMR note. Prescribers were then requested to evaluate the appropriateness of therapy utilizing pre-defined criteria developed in agreement with the infectious disease (ID) service at 48 hours, in-line with the EMR time-out alert. Adults receiving vancomycin (VAN), piperacillin/tazobactam (TAZ), cefepime (CEF) or meropenem (MPN) for at least 48 hours were included. The historical group included patients on the targeted antibiotics between July 1st, 2019 and September 30th, 2019. The primary outcome was median days of therapy (DOT). Secondary outcomes were median DOT per antibiotic, percentage of ID consults and percentage of antibiotic optimization. Statistical analyses were conducted using T-test and chi-square test for continuous and categorical variables respectively.ResultsA total of 81 and 72 patients were included in the intervention and historical groups respectively. No statistical difference in the primary outcome of median DOT was observed (4.5 vs 4, p=0.5). However, Non-significant numerical reductions in DOT were observed for VAN (3 vs 3.5, p=0.5), CEF (3 vs 4, p=0.6) and TAZ (3 vs 4, p=0.3), but not for MPN (6 vs 5, p=0.6). The intervention resulted in more ID consults when prescribing targeted antibiotics (59.3% vs 41.6%, p=0.03). In the intervention group, antibiotic treatment was optimized in 87.7% of patient, in which 39.6% were treatment de-escalation and discontinuation.ConclusionPharmacist clinical guidance through the electronic medical record can provide a powerful educational tool to promote adherence to antimicrobials best practiceDisclosures All Authors: No reported disclosures

Long-term positive effect of an educational antimicrobial stewardship program implemented in an Internal Medicine Department: a prospective analysis and a point prevalence survey on long-term effect

The study aims to evaluate antimicrobial consumption and appropriateness one year after the implementation of an antimicrobial stewardship (AMS) program in an Internal Medicine Department in Milan. AMS program structured in two phases: “AMS phase”, 5 months AMS-program based on an “audit-and-feedback model”; the “follow-up phase”, 5 months long point prevalence survey conducted one year later. Outcomes of the study: antimicrobial consumption and appropriateness of antimicrobial therapy. Secondary outcomes: in-hospital mortality and length of stay (LOS). During the “AMS phase”, we obtained a mean decrease of −11.4% of total antibiotic consumption as compared to the previous year (67.9 defined daily dose (DDD)/100 bed-days (bd) vs. 79.4 DDD/100bd, p = 0.07). Antibiotic consumption remained stable during “follow-up phase” (66.3 DDD/100bd, p = 0.9). Rate of appropriateness during the project increased from 48% to 85% (p < 0.01). No difference in in-hospital mortality and in LOS were observed. The study documents a positive long-term effect of AMS program on consumption and appropriate use of antibiotics.

Evaluating the appropriateness of carbapenem and piperacillin-tazobactam prescribing in a tertiary care hospital in Saudi Arabia

BackgroundAntimicrobial resistance (AMR) is presently considered an emergent major global public health concern and excessive and/or inappropriate use of broad-spectrum antimicrobials contribute to the development of AMR. ObjectiveTo evaluate the appropriateness of carbapenems and piperacillin-tazobactam use in a tertiary care hospital. MethodsA retrospective, observational, cross-sectional, drug-utilization study was conducted. The study included all adult hospitalized patients who had received at least one dose of the antimicrobials during their admission for the period between 1 January 2016 and 31 December 2017. The appropriateness of antimicrobial therapy was evaluated according to the Infectious Diseases Society of America (IDSA) guidelines with the consideration of the institutional antibiogram. ResultsOverall, 2731 patients received 5005 courses with one of the antimicrobials, for a total of 5045.9 defined daily doses (DDD) of imipenem-cilastatin, 6492.3 of meropenem and 15,595 of piperacillin-tazobactam (4.93, 6.34 and 15.24 DDD/100 bed days, respectively). The mean age of the patients who received either antimicrobial was 55.5 ± 20.3 years, with a 14-day average length of hospital stay. About half (52%) of the prescriptions were written for patients treated in the medical ward. Pneumonia (26.6%) and sepsis (24.9%) were the most common indication for the initiation of antimicrobial therapy. Of the assessed prescriptions, only 2787 (56.5%) were prescribed appropriately, with 2142 (43.5%) deemed inappropriate. The three most common reasons for inappropriate prescription were: the spectrum of activity was too broad (44.6%), followed by antimicrobial use without culture request (32.4%), and failure of suitable antimicrobial de-escalation (19.9%). ConclusionsThe study indicates that the overall rate of inappropriateness was high, emphasizing the need to develop initiatives to effectively improve broad-spectrum antimicrobial prescribing.

The Clinical Impact of Rapid Molecular Microbiological Diagnostics for Pathogen and Resistance Gene Identification in Patients With Sepsis: A Systematic Review.

Fast microbiological diagnostics (MDx) are needed to ensure early targeted antimicrobial treatment in sepsis. This systematic review focuses on the impact on antimicrobial management and patient outcomes of MDx for pathogen and resistance gene identification compared with blood cultures. PubMed was searched for clinical studies using either whole blood directly or after short-term incubation. Twenty-five articles were retrieved describing the outcomes of 8 different MDx. Three interventional studies showed a significant increase in appropriateness of antimicrobial therapy and a nonsignificant change in time to appropriate therapy. Impact on mortality was conflicting. Length of stay was significantly lower in 2 studies. A significant decrease in antimicrobial cost was demonstrated in 6 studies. The limitations of this systematic review include the low number and observed heterogeneity of clinical studies. In conclusion, potential benefits of MDx regarding antimicrobial management and some patient outcomes were reported. More rigorous intervention studies are needed focusing on the direct benefits for patients.

Impact of Infectious Diseases Consultation on the Treatment of Staphylococcus aureus Bacteremia

Background This study assessed the impact of infectious diseases consultation (IDC) on 30-day readmission rates in patients with Staphylococcus aureus bacteremia (SAB). Furthermore, this study also evaluated the effect of IDC on adherence to guideline-directed therapy. Methods This retrospective cohort study enrolled 149 adult patients with SAB. Cohort 1 included 28 patients without IDC. Cohort 2 included 121 patients with IDC. Primary end point was all-cause 30-day readmission rates. Secondary outcomes included adherence to guideline-directed therapy and hospital length of stay (LOS). Guideline-directed therapy included repeat blood cultures until blood sterility, assessment for an echocardiogram, and appropriateness of antimicrobial therapy (including antibiotic, dose, and duration). Results Readmission rates were 46.4% (13/28) without IDC and 19% (23/121) with IDC (P = 0.006). Guideline-directed therapy occurred in 21.4% (6/28) without IDC versus 96.7% (117/121) with IDC (P = 0.0001). The average LOS was shorter without IDC than with IDC (5.6 vs 7.8 days, respectively; P = 0.01). The most common reasons for lack of guideline adherence in the control group were lack of echocardiogram (72.4%) and lack of repeat blood cultures (51.7%). Multivariate analysis demonstrated that only lack of IDC significantly affected readmission rates (odds ratio, 3.51; 95% confidence interval, 1.48–8.52; P = 0.0048). Conclusions Consultation with infectious diseases reduces 30-day readmission rates in patients with SAB and increases adherence to guideline-directed therapy; however, LOS was increased. Infectious diseases consultation should be considered for all patients with SAB.

Appropriate antibiotic prescribing among final-year medical students in Europe

Little is known about undergraduate education on antibiotic prescribing in Europe and even less about the antibiotic prescribing skills of nearly-graduated medical students. This study aimed to evaluate the antibiotic prescribing skills of final-year medical students across Europe and the education they received during medical training. In a cross-sectional study, final-year medical students from 17 medical schools in 15 European countries were asked to prescribe for two written case reports of infectious diseases (acute bronchitis and community-acquired pneumonia). The appropriateness of antimicrobial therapy was determined using a scoring form based on local guidelines. Teachers from each medical school were asked to complete a standardised questionnaire about the teaching and assessment of undergraduate education on antibiotic use. In total, 856 final-year medical students (95.6%) completed the assessment and 16 teachers (94.1%) completed the questionnaire. Overall, 52.7% (range 26-83%) of the 1.683 therapies prescribed were considered appropriate. The mean number of contact hours for undergraduate education on antimicrobials was 25.6 (range 2-90). Differences in education styles were found to have a significant impact on students' performance, with a problem-based learning style being associated with more appropriate antimicrobial prescribing than a traditional learning style (46.0% vs. 22.9%; P < 0.01). Although there are differences between medical schools, final-year medical students in Europe lack prescribing skills for two common infectious diseases, possibly because of inadequate undergraduate education on antibiotic use and general prescribing. To improve students' skills, interactive teaching methods such as prescribing for simulated and real patients should be used.

Association between appropriate empiric antimicrobial therapy and mortality from bloodstream infections in the intensive care unit.

Empirical antimicrobial treatment for patients presenting with bloodstream infections is considered to affect patients' outcome. We conducted a single-center, retrospective study of critically-ill patients hospitalized in the intensive care unit, to examine whether the appropriateness of antimicrobial therapy is associated with mortality from bloodstream infections. The primary study endpoints were the mortality and survival time up to 60 days after the sampling of the blood cultures. We enrolled 62 patients with bloodstream infection, of whom 46 received appropriate and 16 received inappropriate, empirical, antimicrobial therapy. The 60-day mortality of appropriately treated (35%) was significantly lower than that of inappropriately treated (88%) patients (p=.0003), with an adjusted odds ratio of dying=0.043 (95% confidence interval 0.0047-0.23; p=.0011). Survival time differed significantly between the two groups (p=.0004), with an adjusted hazard ratio=0.34 (95% confidence interval 0.16-0.70; p=.0043). Appropriate antimicrobial therapy administered to critically-ill patients presenting with bloodstream infections was associated with a lower 60-day mortality than inappropriate therapy.

Impact of interventions by an antimicrobial stewardship program team on appropriate antimicrobial therapy in patients with bacteremic urinary tract infection.

Inappropriate antimicrobial therapy often leads to poor outcomes. This study aimed to evaluate the impact of an antimicrobial stewardship program (ASP) team on appropriate therapy, in patients with bacteremic urinary tract infection (UTI). We retrospectively reviewed the interventions by the ASP team in 807 patients with bacteremic UTI. Interventions were divided into 3 groups: group A (conventional report), group B (conventional report and written alert on the chart), and group C (conventional report and oral recommendation with/without written alert). The appropriateness of antimicrobial therapy was assessed at 2 time points, based on blood culture results. The ASP team estimated that 166 and 576 patients received inappropriate antimicrobial therapy based on the results of Gram staining, and final report, respectively. Appropriate therapy after intervention was administered to 53.2% of group A, 63.5% of group B, and 89.3% of group C patients, respectively. Mortality was significantly lower in patients of de-escalation than in those with no antimicrobial changes, without prolonged hospital stay. This study provides one plausible benchmark for appropriate antimicrobial therapy by ASP, while observer bias and survivor treatment selection bias exist, and further studies including evaluation for severity are needed.

Validation of an Antimicrobial Stewardship Driven Verigene® Blood-Culture Gram-Negative Treatment Algorithm to Improve Appropriateness of Antibiotics

BackgroundGram-negative bacteremia (GNB) is associated with significant morbidity and mortality, emphasizing the need for timely, effective antimicrobial therapy. In comparison to conventional diagnostic methods, Verigene® Blood-Culture Gram-Negative (VBC-GN) is a microarray rapid diagnostic test that identifies eight target GN organisms and six genetic resistance determinants. This study examined the potential clinical impact of VBC-GN coupled with a proposed antimicrobial stewardship (AMS)-derived treatment algorithm to guide timely, appropriate antimicrobial therapy in GNB.MethodsRetrospective, single-center, study of adult patients (≥ 18 years) with GNB at University of Maryland Medical Center (UMMC) from September 2015 – May 2016. Patient clinical characteristics, co-morbidities, and antimicrobials administered were collected. Appropriateness of antimicrobial therapy was by in vitro susceptibility. Appropriateness of actual empiric antimicrobials received as standard care were compared with theoretical antimicrobials as guided by the UMMC AMS treatment algorithm. Two investigators (KCC and ELH) independently evaluated appropriateness of empiric and algorithm antimicrobial recommendations.Results188 patients (median age 57.0 (IQR 46.5 – 65.0) years) with GNB were included and 143 (76.1%) were positive for target GN organisms. Eight (4.3%) cases were GN polymicrobial, 8 (4.3%) were CTX-M positive. E. coli was the most common target GN organism (30.3%), and genitourinary was the most common source (29.3%). There was a good level of agreement between reviewers regarding appropriateness of empiric therapy (Kappa = 0.735) and algorithm recommendations (Kappa = 0.855). Overall, the proposed algorithm would have resulted in 88.4% of cases receiving appropriate antimicrobial therapy vs 78.1% actual empiric antimicrobials (P = 0.014). The AMS treatment algorithm would have resulted in 14.4% appropriate de-escalation, 4.8% inappropriate de-escalation, 5.3% appropriate escalation, and 16.0% unnecessary escalation.ConclusionProposed antibiotics by AMS-derived treatment algorithm applied in conjunction with rapid diagnostic testing would result in a significantly higher proportion of patients receiving appropriate antimicrobial therapy vs. standard care.Disclosures J. K. Johnson, Nanosphere: Grant Investigator, Grant recipient

Risk of Mortality of Catheter-Related Bloodstream Infections Caused by Acinetobacter Species

Bloodstream infections (BSIs) caused by Acinetobacter species have been extensively reported, however, which majorly focused on respiratory tract infections. The risk of mortality and the effect of early catheter removal on survival in catheter-related BSIs (CRBSIs) caused by Acinetobacter spp. remain unclear. This study aims to investigate that. This is a retrospective multicentric study conducted in Taiwan from 2012 to 2014. Patients with at least 1 positive blood culture and catheter culture for the same Acinetobacter spp., showing symptoms and signs of CRBSIs, were included (n = 119). Risk factors for 30-day mortality were analyzed using a logistic regression model. The characteristics of patients with early catheter removal (within 48 hours after CRBSIs) were compared to those without removal matching for age, sex, and disease severity. There were no differences in 30-day mortality with regard to causative Acinetobacter spp., catheter type, site, and appropriateness of antimicrobial therapy. Patients with higher Acute Physiologic and Chronic Health Evaluation (APACHE) II scores (odds ratio [OR]: 1.12; 95% confidence interval [CI]: 1.02-1.23; P = .014), shock (OR: 6.43; 95% CI: 1.28-32.33; P = .024), and longer hospitalization before CRBSIs (OR: 1.04; 95% CI: 1.00-1.08; P = .027) had a significantly higher 30-day mortality rate. Early removal of catheters after CRBSIs was not associated with better survival benefits. Higher disease severity (APACHE II score), shock, and longer hospitalization before bacteremia were independently associated with a higher 30-day mortality in CRBSIs caused by Acinetobacter spp. In previous published guidelines, infected catheters were suggested to be removed in CRBSIs caused by gram-negative bacilli. Even though early removal of catheters did not associate with a better survival outcome in current results, it should be judiciously evaluated according to the clinical conditions and risks individually. For better elucidation of these issues, further well-controlled prospective study may be warranted.