Days Of Antimicrobial Therapy Research Articles

Significance of early diagnosis and surgical management in treating Mycobacterium immunogenum-related pyogenic extensor tenosynovitis: a case report

BackgroundNon-tuberculous mycobacteria (NTM) are environmental organisms that are increasingly contributing to human infections. Mycobacterium immunogenum, a variant of NTM discovered in 2001, is a rapidly growing mycobacterium that exhibits multidrug resistance. Reports of infections caused by this organism, particularly tenosynovitis in the musculoskeletal system, are limited.Case presentationA 71-year-old female with vesicular pemphigus, undergoing immunosuppressive therapy, presented with a progressively enlarging tumour on the dorsum of her right hand, along with erythematous papules that extended across her right forearm. The specimens of skin tissues and blood cultures revealed the presence of M. immunogenum. Magnetic resonance imaging evaluation led to the diagnosis of pyogenic extensor tenosynovitis. A multidrug regimen, comprising amikacin and clarithromycin, was initiated, followed by synovectomy. The patient underwent a course of 180 days of antimicrobial therapy and demonstrated no signs of disease recurrence one year after treatment completion.ConclusionEarly diagnosis and surgical intervention are crucial to prevent the adverse prognostic implications of pyogenic extensor tenosynovitis caused by M. immunogenum. Effective management requires precise microbial identification and susceptibility testing, necessitating collaborative engagement with microbiological laboratories.

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.

Evaluating the utility of procalcitonin and a clinical decision support tool to determine duration of antimicrobial therapy for respiratory tract infections.

In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. Procalcitonin (PCT) levels may play a role in decreasing the duration of antimicrobial therapy in institutions that have long durations of therapy for management of community-acquired pneumonia. We assessed the impact of the combination of pharmacist stewardship interventions assisted by a clinical decision support (CDS) tool and PCT assessment on the antimicrobial days of therapy (DOT) prescribed for respiratory tract infections (RTIs). We conducted a quasi-experimental study in which patients in the preintervention group were admitted between April and June 2021 and patients in the intervention group were admitted between April and June 2022. In the intervention phase, a CDS tool was utilized to alert clinical pharmacists when patients met specific criteria. This alert was programmed to activate for individual patients when a reported PCT level was less than 0.25ng/mL and on antimicrobials prescribed for an RTI as indicated by providers in the electronic health record. Stewardship interventions were made by pharmacists via prospective audit and feedback. The primary endpoint was inpatient antimicrobial DOT for RTIs. There were 90 patients in the preintervention group and 104 patients in the intervention group. Although baseline characteristics were not well matched between the groups, favoring the preintervention group, the median DOT was lower in the intervention group at 3 days (interquartile range [IQR], 2-4 days), compared to 4 days (IQR, 2.8-5 days) in the preintervention group (P = 0.001). The results of our study demonstrate the utility of pharmacist interventions coupled with CDS and PCT in reducing antimicrobial DOT prescribed for RTIs. Antimicrobial stewardship programs may benefit from implementing a PCT bundle.

1257. The Impact of Communication Type on Acceptance Rates of Antimicrobial Stewardship Interventions

Abstract Background While face-to-face communication (ie. “handshake stewardship” (HS)) has been shown to improve antimicrobial stewardship program (ASP) intervention acceptance rates, this strategy is resource intensive. Therefore, systems unable to conduct HS must identify the optimal mode of communication for ASP recommendations. This study evaluated the effects of communication type on ASP intervention acceptance. Methods An infectious disease physician and ASP pharmacist met Monday through Friday to assess appropriateness of select antimicrobials. ASP recommendations were delivered through direct communication via telephone conversations or passive communication via text-page. A text page consisted of a message limited to 240 characters sent directly to the primary team. We performed a retrospective review of all interventions and associated acceptance rates, antimicrobials and antimicrobial indications between January 1st, 2023 to March 31st, 2023. The primary outcome evaluated was ASP intervention acceptance rate. Results Recommendations were delivered through telephone conversations in 267/454 (58.8%) cases compared to 187/454 (41.2%) cases in which recommendations were provided via text-page. We found that direct communication delivered telephonically resulted in a significant increase in ASP intervention acceptance rate compared to passive communication via text page (82.8% vs 73.8%, respectively; p=0.02). This resulted in 884 and 552 days of antimicrobial therapy saved in the telephonic and text-page group, respectively (p=0.64). Significant differences in baseline characteristics included: antimicrobial indications of intraabdominal, respiratory, sepsis and febrile neutropenia; having a broad differential; and an intervention category of de-escalation. Conclusion Direct communication with clinicians (eg. telephonically) improves ASP intervention acceptance rates compared to passive communication styles (eg. text-page). Direct communication with the prescriber encourages shared decision making, increases visibility of ASP, and allows for education to modify prescribing behavior. The success of an ASP relies heavily on provider relationships, which direct communication can further promote. Disclosures All Authors: No reported disclosures

The Impact of an Antimicrobial Stewardship Clinical Pharmacy Specialist on Antimicrobial Days of Therapy through Education Driven Policies, Procedures, and Interventions.

The primary goal of antimicrobial stewardship is to improve patient outcomes and minimize the consequences of antibiotic use. Prospective audit and feedback cannot always be performed by an antimicrobial stewardship program member which is where policies, procedures and education can aid interventions. The purpose of this study was to evaluate the impact on antimicrobial days of therapy due to a dedicated clinical pharmacy specialist primarily responsible for developing policies and procedures and providing education. A pre-intervention and post-intervention retrospective analysis of antimicrobial days of therapy from September 2019-May 2020 and July 2020-March 2021 was performed. Inclusion criteria consisted of adults receiving IV vancomycin, azithromycin, meropenem, ciprofloxacin, and/or levofloxacin. Excluded criteria consisted of documented interventions that were not related to implemented policies and procedures or performed education and patients receiving antimicrobial surgical prophylaxis. The primary outcome was antimicrobial days of therapy. An average of 3.47 ± 2.46 days (pre-intervention, n = 203) and 3.21 ± 2.52 days (post-intervention, n = 203) were observed for the primary outcome (p < 0.04182). Pharmacists performed 75 interventions pre-intervention and 102 interventions post-intervention (p = 0.0092). The implementation of a dedicated antimicrobial stewardship clinical pharmacy specialist responsible for developing policies, procedures, and education successfully reduced antimicrobial days of therapy and documented interventions.

Effects of antimicrobial therapy duration and class on risk of antimicrobial-resistant Gram-negative bacillus bloodstream infection in patients with AML.

Antimicrobial-resistant Gram-negative bacilli (ARGNB) bloodstream infection (BSI) has been associated with prior antibiotic exposure among hematologic malignancy patients. The relationships between days of therapy (DOT), antimicrobial class, and ARGNB BSI risk are poorly understood. This is a single-center, case-control study of acute myeloid leukemia (AML) patients including 115 cases with ARGNB BSI and 230 matched controls with non-ARGNB BSI between January 1, 2007 and December 31, 2018. Fixed- and mixed-effects logistic regression was used to examine relationships between antibiotic DOT and risk of ARGNB BSI. Admission to an intensive care unit (ICU) within 7 days, 30-day mortality, and Pitt Bacteremia Score (PBS) were secondary outcomes. Prior isolation of a antimicrobial-resistant organism (ARO) (OR 4.45 95% CI 1.46, 13.54), surgery within 90 days (OR 3.71, 95% CI 1.57, 8.73), aminoglycoside DOT (OR 1.14, 95% CI 1.05, 1.23), cefepime DOT (OR 1.09, 95% CI 1.05, 1.13), and carbapenem DOT (OR 1.10, 95% CI 1.05, 1.16) were associated with increased odds of ARGNB BSI. Days since last antibiotic administration (OR 0.98, 95% CI 0.97, 0.99) and inpatient days within 90 days (OR 0.95, 95% CI 0.93, 0.98) showed reduced odds of ARGNB BSI. Total antimicrobial DOT regardless of class was not associated with ARGNB BSI. ARGNB BSI was associated with increased 30-day mortality (OR 2.86, 95% CI 1.57, 5.22) CONCLUSIONS: Among AML patients with GNB BSI, greater DOT of aminoglycosides, cefepime, and carbapenems in the 90 days prior to BSI were associated with increased odds of ARGNB BSI.

Impact of multiplex polymerase chain reaction syndromic panel on antibiotic use among hospitalized children with respiratory tract illness during COVID-19 pandemic.

Precise detection of respiratory pathogens by molecular method potentially may shorten the time to diagnose and reduce unnecessary antibiotic use. Medical records of hospitalized children from January 2020 to June 2021 with acute respiratory illness who received a FilmArray RP for respiratory pathogens were reviewed and compared with data from diagnosis-matched patients without receiving the test. In total, 283 patients and 150 diagnosis-matched controls were included. Single pathogen was detected in 84.3% (193/229) of the patients. The most common pathogen was human rhinovirus/enterovirus (31.6%, 84/266), followed by respiratory syncytial virus (18.8%, 50/266) and adenovirus (15%, 40/266). Although antimicrobial days of therapy (DOT) was significantly longer in FilmArray group than the control [7.1±4.9 days vs 5.7±2.7 days, P=0.002], the former showed a higher intensive care unit (ICU) admission rate (3.9% vs 0%; P=0.010). All ICU admissions were in FilmArray RP-positive group. There was no difference in antimicrobial DOT between FilmArray RP-positive and the negative groups, in all admissions, even after excluding ICU admissions. Antimicrobial DOT was shorter in the positive than negative group in patients with lower respiratory tract infections without admission to ICU [median (IQR): 6 (4-9) days vs 9 (4-12) days, P=0.047]. Shorter antimicrobial DOTs were identified in children with lower respiratory tract infection admitted to general pediatric ward and with an identifiable respiratory pathogen, indicating a role of the multiplex PCR in reducing antimicrobial use for children with respiratory tract infection.

Reduction of antimicrobial treatment time in intensive care units in Fortaleza, Brazil

Objective: To evaluate the application of the Antimicrobial (ATM) treatment time reduction strategy in Intensive Care Units (ICU) in an Antimicrobial Stewardship Program (ASP). Method: This is a descriptive and cross-sectional study, carried out in two ICU of a university hospital in Fortaleza, Brazil, from January/2017 to January/2019. Adult patients were included, accompanied by a pharmacist, and using ATM, in which the treatment time reduction strategy was applied. The evaluation of the strategy was made through the difference between the predicted time established at the beginning of the treatment and the effective days of use of each ATM. Results: Of the 100 patients included, 51.0 % were male and 64.0 % were elderly. The respiratory system was the most frequently affected by the infections (37.4 %) and the most prevalent classes of ATM were carbapenems (23.0 %) and glycopeptides (20.1 %). There was a decrease from 831 unnecessary days of antimicrobial therapy and from an average of 13.7 to 8.9 days of treatment. The greatest reductions in days were observed for meropenem, with 202 days reduced. The study also allowed the identification of associations between the reduction &gt; 8 days of treatment and the variables length of stay &gt; 22 days and patients in exclusive palliative care, and associations between hospital discharge and reductions of up to 7 days of therapy. Conclusions: The data obtained suggest that the presence of an ASP influences the practices of ATM use and its treatment time and emphasize the role of pharmaceutical professionals in these programs.

Teams in transition: Increasing role of advanced practice providers in inpatient antimicrobial use

Background: Antimicrobial stewardship strategies must be tailored to effectively engage prescribers with distinct training, experiences, and career paths. Advanced practice providers (APPs) have taken on increasing roles as primary team members in acute-care hospitals, but the impact of this practice shift on antimicrobial prescribing is unknown. We describe longitudinal trends in antimicrobial days of therapy (DOT) by attributed provider type in 3 hospitals. Methods: We performed a retrospective time-series analysis of antimicrobial use for the 7-year period of July 2015–June 2022 to investigate the changes by provider type at 3 hospitals: a major university hospital and 2 community hospitals. DOT, antibacterial, and antifungal agent groups were defined using National Healthcare Safety Network methods. We included anti-influenza and antiherpesvirus agents in the antiviral group. We defined protected agents as those targeted by hospital antimicrobial stewardship program policy (eg, requiring preauthorization). Provider type was defined by electronic health record user profiles in 3 categories: physician, trainees (residents, fellows and medical students), and APPs (nurse practitioners, physician assistants, and nurse anesthetists). We evaluated DOT per 1,000 days present over time by agent group to assess quarterly rate trends. Then, we calculated the percentage of total DOT by provider group. We used multinomial logistic regression to measure changes in percentage DOT across the clinician groups over time using physicians as the referent. Results: Across hospitals and provider groups, we observed an overall decrease in use rates for antibacterial and protected agents (17% each) and increased use rates for antiviral agents (38%) and antifungal agents (4%) (Table 1). Baseline distribution of DOT by provider group and change in distribution over time varied by hospital and agent group (Fig. and Table 2). The largest increases in percentage DOT attributed to APPs compared with physicians occurred in the university hospital with the following average increases per quarter: 1.5% for antibacterials, 3.9% for antivirals, 3.3% for antifungals, and 3.8% for protected agents (Table 3). Community hospitals had higher initial percentage DOT attributed to physicians, but both hospitals experienced increased percentage DOT attributed to APPs. Percentage DOT attributed to trainees varied significantly across agent groups and hospitals. Conclusions: Hospitals had differing baseline patterns of DOT attributed to provider groups, but all experienced increases in DOT attributed to APPs. APPs have increasing involvement in antimicrobial use decisions and should be engaged in future antimicrobial stewardship initiatives.Disclosures: None

Effect of Pharmacist-Initiated Interventions on Duration of Antibiotic Therapy for Acute Exacerbation of Chronic Obstructive Pulmonary Disease and Community-Acquired Pneumonia.

Current guidelines for the treatment of acute exacerbation of chronic obstructive pulmonary disease (AECOPD) and community-acquired pneumonia (CAP) recommend 5 days of antimicrobial therapy. Despite these recommendations, the duration of therapy exceeds 5 days for up to 70% of patients, with most superfluous prescribing occurring upon discharge from hospital. Shortening the duration of antibiotic therapy could decrease adverse events, resistance, and costs. To determine whether a pharmacist-initiated modification to the duration of antibiotic therapy prescribed for the treatment of AECOPD or CAP reduced the duration of antibiotic prescriptions. In this prospective, single-centre study of adult inpatients receiving antibiotics for the treatment of AECOPD or CAP between October 2020 and March 2021, pharmacists assigned a 5-day duration to antimicrobials prescribed for these indications. For patients discharged before completion of therapy, the antibiotic start date and intended duration were included on the discharge prescription. Study patients were matched 1:1 with historical controls to compare the total duration of antibiotic therapy with and without the intervention. A total of 100 patients (66 with CAP and 34 with AECOPD) met the inclusion criteria and had their antibiotic treatment duration modified to 5 days. Mean total duration of antibiotic therapy was 5.31 days in the intervention group and 7.11 days in the control group (p < 0.001). Outpatient antibiotic prescribing was 0.86 days in the intervention group and 3.2 days in the control group (p < 0.001). In both groups, the rates of readmission at 30 and 90 days were 19% and 31%, respectively. Pharmacist-initiated modification of antimicrobial therapy resulted in shortening of the duration of therapy by almost 2 days. Including information about treatment duration on the discharge prescription reduced outpatient prescribing without affecting readmission rates.

Pediatric Antimicrobial Usage in a Secondary Care Hospital in Ras Al Khaimah, United Arab Emirates

Objectives To assess the pattern of antimicrobial use among pediatric inpatients in a secondary care hospital in the United Arab Emirates. Materials and Methods The prospective study was conducted based on the electronic records of 600 patients, collected over a period of 11 months, from September 2020 to July 2021. The primary patient population was the pediatric patients receiving antimicrobials admitted to Saqr Hospital, Ras Al Khaimah (RAK), United Arab Emirates (UAE). The data gathered includes general patient information, lab investigations, diagnoses, chronic medical conditions, and antimicrobials used. The number of defined daily doses (DDDs) administered per patient was calculated for each antimicrobial prescribed as per the WHO anatomical therapeutic chemical classification. Results Out of 1400 patients admitted to the pediatric unit during the 11-month study period, 600 (42.8%) received antimicrobials. The mean duration of hospital stay was 3.44 days, and each patient received a mean of 1.41 antimicrobials per prescription. The mean days of antimicrobial therapy were 6.9 days. The majority of the patients were aged 0–5 years (61.1%), and 58% of the total sample was male. Amongst a total of 41 different antimicrobials prescribed, the beta-lactam co-amoxiclav (J01CR02) was the most frequently (19.3%) used one, followed by cefuroxime (J01DC02) (16.3%), amoxicillin (J01CA04) (15.0%), and azithromycin (J01FA10) (5.99%). These were administered mainly via the parenteral route, and the most common indication was respiratory disease. Conclusion Our study concludes that most of the prescribed antimicrobials for pediatric patients are within the WHO access and watch group. Co-amoxiclav, cefuroxime, and amoxicillin are the most frequently used antimicrobials. The main indication for use was respiratory illness.

Antimicrobial stewardship during COVID-19: An analysis of culture negative patients receiving extended antimicrobial agents

Background: COVID-19 is associated with symptoms, clinical findings, and laboratory abnormalities that raise concern for secondary infections. Excess antimicrobial use despite low rates of secondary infections has been reported and presents a continuing challenge for antimicrobial stewardship programs (ASPs), particularly during COVID-19 surges. The objective of this study was to analyze the appropriateness of antimicrobial use in patients with extended antimicrobial therapy during 2 distinct COVID-19 hospital surges. Methods: We conducted an observational, retrospective, cohort study of COVID-19 patients admitted to our 548-bed community teaching hospital between November and December 2021 (ie, the SARS-CoV-2 delta-variant predominant phase) and January–February 2022 (ie, the SARS-CoV-2 omicron-variant predominant phase) and who received antibiotics for &gt;4 days without positive cultures. Demographic and clinical data were obtained from the institutional data warehouse. Infectious diseases–trained researchers evaluated the appropriateness of antimicrobials based on diagnostic and clinical reporting and institutional antimicrobial stewardship guidelines. Patients were considered to have probable secondary bacterial infection if they had 2 of the following symptoms: fever, unexplained leukocytosis, worsening secretions, or hypoxia and/or imaging. The outcomes of interest included confirmed infections and excess antimicrobial days. Categorical and continuous variables were analyzed using χ2 tests, Fisher exact tests, and Mann-Whitney U tests, respectively. Statistical significance was defined as P ≤ .05. Results: In total, 87 patients were included in the study. Moreover, 56 patients were identified in the SARS-CoV-2 delta-variant predominant phase and 31 patients were identified in the SARS-CoV-2 omicron-variant predominant phase. The groups were similar, with higher vaccination rates in the SARS-CoV-2 omicron-variant predominant group (37.5% vs 64.5%; P = .016). Patients in the SARS-CoV-2 omicron-variant predominant group required less mechanical ventilation (39.3% vs 16.1%; P = .025). There were no significant differences in infectious diseases consultation, immunomodulator or remdesivir use, antimicrobials classes prescribed, or antimicrobial days of therapy or duration between cohorts. There were no significant differences in length of stay, 30-day mortality, or 30-day readmissions. Infections were confirmed in 78.6% in the delta-variant group versus 83.9% in the omicron-variant group (P = .55). Pneumonias accounted for 60.7% in the delta-variant group and 40.9%, in the omicron-variant group. Excess antibiotic use occurred in 14.3% of patients in the delta-variant group and in 3.1% of patients in the omicron-variant group (P = .149). There was no significant difference in the duration of inappropriate antimicrobial use between groups in patients without infections: 5 days in the delta-variant group versus 5 days in the omicron-variant group (P = .24). Conclusions: Results demonstrated that most antimicrobial use was appropriate in a challenging patient population lacking positive cultures to guide therapy. Inappropriate antimicrobial utilization occurred demonstrating continued opportunities for our institutional ASP.Disclosures: None

A Needs Assessment for Infectious Diseases Consultation in Community Hospitals.

Infectious diseases (ID) consultations have been demonstrated to improve patient outcomes in the treatment of severe infections. However, ID consultation is often unavailable to patients that live in rural communities. Little is known regarding the treatment of infections in rural hospitals with no coverage from an ID specialist. We characterized the outcomes of patients cared for in hospitals without coverage from an ID physician. Patients aged 18years or older admitted to eight community hospitals without access to ID consultation during a 6.5-month period were assessed. All patients had received at least three days of continuous antimicrobial therapy. The primary outcome was the need for transfer to a tertiary facility for ID services. The secondary outcome was the characterization of antimicrobials received. Antimicrobial courses were evaluated independently by two board-certified ID physicians. 3706 encounters were evaluated. Transfers for ID consultation occurred in 0.01% of patients. The ID physician would have made modifications in 68.5% of patients. Areas for improvement included treatment of chronic obstructive pulmonary disease exacerbations, broad-spectrum treatment of skin and soft tissue infection, long courses of azithromycin, and management of Staphylococcus aureus bacteremia, including choice and length of therapy, as well as obtaining echocardiography. Patients evaluated received 22,807days of antimicrobial therapy. Patients hospitalized in community hospitals are rarely transferred for ID consultation. Our work demonstrates a need for ID consultation in community hospitals, identifying opportunities to enhance patient care by modifying antimicrobial regimens to improve antimicrobial stewardship and avoid inappropriate antimicrobials. Efforts to expand the ID workforce to include coverage at rural hospitals will likely improve antibiotic utilization.

Tracking antimicrobial stewardship activities beyond days of therapy (DOT): Comparison of days of antibiotic spectrum coverage (DASC) and DOT at a single center.

Even though antimicrobial days of therapy did not significantly decrease during a period of robust stewardship activities at our center, we detected a significant downward trend in antimicrobial spectrum, as measured by days of antibiotic spectrum coverage (DASC). The DASC metric may help more broadly monitor the effect of stewardship activities.

Beta-lactam comprehensive allergy management program in a community medical center.

The Beta-lactam Comprehensive Allergy Management Program (CAMP) was implemented to facilitate complete beta-lactam allergy history documentation in the electronic medical record (EMR) and increase beta-lactam utilization. The study objective was to assess the rate of complete allergy histories and days of antimicrobial therapy (DOT) before versus after CAMP implementation. Quasi-experimental study with interrupted time-series analysis. Non-teaching, urban, and community medical center within a multi-hospital health system. Adult inpatients with a beta-lactam allergy receiving antimicrobial therapy. The multidisciplinary CAMP team screened, interviewed, and collected allergy history details of adult inpatients with a beta-lactam allergy receiving antimicrobial therapy starting January 4, 2021. Patients were stratified as high, moderate, or low risk of IgE-mediated allergy and referred to an allergist for skin testing or drug challenge. The EMR was updated with interview details and drug challenge or skin test results. The primary endpoint was rate of complete allergy history documentation before (12/1/18-4/1/19) compared to after (1/4/21-5/1/21) program implementation. The secondary endpoint was days of inpatient beta-lactam therapy. Implementation logistics, de-labeling rate, and antimicrobial therapy changes were evaluated. The program evaluated 392 individuals, with 184 and 208 patients comprising the pre- and post-intervention groups, respectively. The post-intervention period was associated with an increase of 19.8% in complete allergy histories (0.359 PPc; R 2 0.26; p = 0.002) and 9.34 beta-lactam DOT per 1,000-days-present (1.106 PPc; R 2 0.194; p = 0.009). Implementation of a comprehensive beta-lactam allergy management program was associated with higher rates of complete beta-lactam allergy history and beta-lactam use.

916. Increased efficiency and impact of implementing ILUM insight within an antimicrobial stewardship program (ASP) at an academic medical center

Abstract Background An ASP is mandated for all hospitals and requires extensive resources with multidisciplinary collaboration. We measured the impact of implementing real-time decision support software (ILUM Insight) within our ASP. Methods Our ASP has relied on prior authorization since 2002 and focused audit and feedback since 2015. In August 2021 we implemented to bring actionable data to front-line stewards. ILUM provides real-time notifications, organizes communications, and tracks patient-and provider-level data. We hypothesized that ILUM would increase the efficiency of ASP workflow and result in decreased antimicrobial utilization. We compared data 6 months before (8/20 – 1/21) and after (8/21 – 1/22) implementation. There were no significant staffing changes during either period. Results Existing notifications within ILUM were tailored to local practices, including alerts with intervention for positive blood cultures, antibiotic de-escalation, and bug-drug mismatches. New notifications were built for restricted antimicrobials, antibiotic timeouts, and MRSA screening. ASP pharmacists and physicians received training in July and November, respectively. A breakdown of all notifications received during the post-implementation period is provided in Fig 1. With increased ILUM usage, the number of interventions made by our ASP increased while missed opportunities decreased (Fig 2.). During the same time period, ASP communications rose from 205 to 1200 per month. Comparing pre- and post-implementation periods, antimicrobial days of therapy (DOT) per 1,000 patient days (PD) decreased by 14.5% from a median of 969 to 846 per month (Fig 3;P=0.002). Antimicrobial expenditures were decreased by a median 21% per month during the post-intervention period compared to baseline. Among patients prescribed antimicrobials during an index admission, 30-day re-admissions decreased from 330 to 262 and re-admissions associated with re-ordering of antimicrobials decreased from 235 to 182 (Fig 4). Conclusion Custom-designed, task-specific software improves the efficiency of daily ASP workflow and significantly decreased antimicrobial utilization without the need for additional ASP team members. Disclosures Ryan K. Shields, PharmD, MS, Infectious Disease Connect: Advisor/Consultant|Merck: Advisor/Consultant|Merck: Grant/Research Support|Roche: Grant/Research Support J Ryan Bariola, MD, Infectious Disease Connect: Salary support|Merck: Grant/Research Support Caley Yakemowicz, n/a, Infectious Disease Connect: Employee Courtney Simonick, n/a, Infectious Disease Connect: Stocks/Bonds Riaan Erwee, na, Infectious Disease Connect: Employee Erin K. McCreary, PharmD, Infectious Disease Connect: Advisor/Consultant Rima Abdel-Massih, MD, Infectious Disease Connect: Co founder and Chief Medical Officer|Infectious Disease Connect: Ownership Interest.

Analysis of the Clinical Impact of the BioFire FilmArray Meningitis Encephalitis Panel on Antimicrobial Use and Duration of Therapy at an Academic Medical Center.

The purpose of this study was to assess the clinical impact of the BioFire FilmArray Meningitis/Encephalitis (ME) panel on antimicrobial use and clinical outcomes. This retrospective, quasi-experiment evaluated adult and pediatric patients with suspected ME, evidenced by cerebrospinal fluid (CSF) culture. Hospital-acquired meningitis patients and patients who received antimicrobials &gt;48 h prior to lumbar puncture were excluded. The primary endpoint was days of antimicrobial therapy pre- and post-implementation of the ME panel. Secondary endpoints included total length of stay, 30-day readmission, and individual days of antimicrobial therapy. Two hundred and sixty-four total adult and pediatric patients were included. Antimicrobial days of therapy had a median of 3 days (IQR 0-5) in the pre vs. post group with a median of 2 days (2-5) (p = 0.099). Days of therapy for acyclovir were significantly decreased in the post group (median 2 days [IQR 1-3] vs. 3 days [IQR 2.5-4.5], p = 0.0002). There were no significant differences in the secondary endpoints. Overall, implementation of the ME panel impacted the duration of antimicrobials, particularly acyclovir; however, opportunities for further education regarding antimicrobial de-escalation and utilization of the panel were identified. Antimicrobial stewardship program intervention is critical to maximize benefit of this rapid diagnostic test.

Novel care pathway to optimise antimicrobial prescribing for uncomplicated community-acquired pneumonia: study protocol for a prospective before–after cohort study in the emergency department of a tertiary care Canadian children’s hospital

IntroductionEvidence-based recommendations for paediatric community-acquired pneumonia (CAP) diagnosis and management are needed. Uncomplicated CAP is often caused by respiratory viruses, especially in younger children; these episodes self-resolve without antibiotic treatment....

A RARE CAUSE OF COMMUNITY-ACQUIRED BACTERIAL PNEUMONIA IN A PATIENT WITH POORLY CONTROLLED DIABETES

SESSION TITLE: Rare Pulmonary and Cardiac InfectionsSESSION TYPE: Rapid Fire Case ReportsPRESENTED ON: 10/18/2022 01:35 pm - 02:35 pmINTRODUCTION: Salmonellosis is an infectious disease caused by Nontyphoidal Salmonella (NTS). Rarely the infection extends from the gastrointestinal tract to blood to cause localized and extra-intestinal manifestations, of which community-acquired bacterial pneumonia is a rare presentation [1]. Here we describe a case of NTS pneumonia in an uncontrolled diabetic patient.CASE PRESENTATION: A 35-year-old female with uncontrolled type 1 diabetes mellitus and multiple readmits for diabetic ketoacidosis (DKA) presented with nausea, abdominal pain, shortness of breath and confusion to the emergency department. At admission, her blood glucose was 980 mg/dL and pH 6.98. Recent hemoglobin A1C was 11.9%.She was admitted to the medical intensive care unit (MICU) and started on DKA protocol. Shortly after arrival to the MICU, she was intubated for respiratory failure and airway protection. Initial ventilator settings revealed an inspired fraction of oxygen of 55% and a positive end-expiratory pressure of 8 cms of H2O. Initially, the patient was treated for DKA and respiratory failure, and no antibiotics were administered. The next day patient developed septic shock with elevated inflammatory markers necessitating vasopressor support. Computed tomography of her chest, abdomen, and pelvis with contrast revealed multifocal pneumonia (Figure1) with no pulmonary embolism and enterocolitis. The patient was initiated on broad-spectrum antibiotics, and blood cultures, quantitative tracheal lavage cultures, and stool panel were obtained, which returned positive for Salmonella within 24 hours. After initiating antibiotics and correcting the patient's DKA, she rapidly improved and was extubated two days later. She completed 12 days of antimicrobial therapy with levofloxacin and was discharged home.DISCUSSION: NTS causes self-limited acute gastroenteritis called salmonellosis from consumption of contaminated food and water, and in 8% of patients, it results in bacteremia [2]. Among bacteremic patients, exceedingly very few develop community-acquired bacterial pneumonia with very high mortality of 25% -60% [2]. Susceptible patients include patients with diabetes mellitus, chronic liver or renal disease, sickle cell disease, malignancy, stem cell transplant, human immunodeficiency virus infection, corticosteroid, or biologic therapy [2]. Diabetes predisposes to infection by reducing gastric acidity and decreasing gastric motility [3]. NTS pneumonia should be considered in differential in the immunocompromised and those presenting with NTS bacteremia [2]. In this case, NTS was identified as Salmonella enterica subspecies houtenae. This case re-enforces evaluation for the underlying cause of DKA in patients, regardless of non-compliance and recurrent admissions history.CONCLUSIONS: NTS pneumonia should be suspected in salmonellosis with bacteremia, and the cause of DKA needs always to be investigated.Reference #1: Bastin, ML Thompson, et al. "An unusual case of Salmonella Enteritidis causing pneumonia, septic shock and multiple organ failure in an immunocompetent patient.” IDCases 6 (2016): 85-89.Reference #2: Pegues, David A., Miller Samuel I. Mandell, Douglas, and Bennett's Principles and Practice of Infectious Diseases, Salmonella Species (9th ed.), Elsevier, Philadelphia (2020).223 p: 2725-2736.e3Reference #3: Knight JC, Knight M, Smith MJ. Two cases of pulmonary complications associated with a recently recognised Salmonella enteritidis phage type, 21b, affecting immunocompetent adults. Eur J Clin Microbiol Infect Dis.2000;19(9):725-726. doi:10.1007/s100960000351DISCLOSURES: No relevant relationships by Ethan KarleNo relevant relationships by SACHIN PATILNo relevant relationships by Shelby SchuhNo relevant relationships by ahmad ziadeh SESSION TITLE: Rare Pulmonary and Cardiac Infections SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/18/2022 01:35 pm - 02:35 pm INTRODUCTION: Salmonellosis is an infectious disease caused by Nontyphoidal Salmonella (NTS). Rarely the infection extends from the gastrointestinal tract to blood to cause localized and extra-intestinal manifestations, of which community-acquired bacterial pneumonia is a rare presentation [1]. Here we describe a case of NTS pneumonia in an uncontrolled diabetic patient. CASE PRESENTATION: A 35-year-old female with uncontrolled type 1 diabetes mellitus and multiple readmits for diabetic ketoacidosis (DKA) presented with nausea, abdominal pain, shortness of breath and confusion to the emergency department. At admission, her blood glucose was 980 mg/dL and pH 6.98. Recent hemoglobin A1C was 11.9%.She was admitted to the medical intensive care unit (MICU) and started on DKA protocol. Shortly after arrival to the MICU, she was intubated for respiratory failure and airway protection. Initial ventilator settings revealed an inspired fraction of oxygen of 55% and a positive end-expiratory pressure of 8 cms of H2O. Initially, the patient was treated for DKA and respiratory failure, and no antibiotics were administered. The next day patient developed septic shock with elevated inflammatory markers necessitating vasopressor support. Computed tomography of her chest, abdomen, and pelvis with contrast revealed multifocal pneumonia (Figure1) with no pulmonary embolism and enterocolitis. The patient was initiated on broad-spectrum antibiotics, and blood cultures, quantitative tracheal lavage cultures, and stool panel were obtained, which returned positive for Salmonella within 24 hours. After initiating antibiotics and correcting the patient's DKA, she rapidly improved and was extubated two days later. She completed 12 days of antimicrobial therapy with levofloxacin and was discharged home. DISCUSSION: NTS causes self-limited acute gastroenteritis called salmonellosis from consumption of contaminated food and water, and in 8% of patients, it results in bacteremia [2]. Among bacteremic patients, exceedingly very few develop community-acquired bacterial pneumonia with very high mortality of 25% -60% [2]. Susceptible patients include patients with diabetes mellitus, chronic liver or renal disease, sickle cell disease, malignancy, stem cell transplant, human immunodeficiency virus infection, corticosteroid, or biologic therapy [2]. Diabetes predisposes to infection by reducing gastric acidity and decreasing gastric motility [3]. NTS pneumonia should be considered in differential in the immunocompromised and those presenting with NTS bacteremia [2]. In this case, NTS was identified as Salmonella enterica subspecies houtenae. This case re-enforces evaluation for the underlying cause of DKA in patients, regardless of non-compliance and recurrent admissions history. CONCLUSIONS: NTS pneumonia should be suspected in salmonellosis with bacteremia, and the cause of DKA needs always to be investigated. Reference #1: Bastin, ML Thompson, et al. "An unusual case of Salmonella Enteritidis causing pneumonia, septic shock and multiple organ failure in an immunocompetent patient.” IDCases 6 (2016): 85-89. Reference #2: Pegues, David A., Miller Samuel I. Mandell, Douglas, and Bennett's Principles and Practice of Infectious Diseases, Salmonella Species (9th ed.), Elsevier, Philadelphia (2020).223 p: 2725-2736.e3 Reference #3: Knight JC, Knight M, Smith MJ. Two cases of pulmonary complications associated with a recently recognised Salmonella enteritidis phage type, 21b, affecting immunocompetent adults. Eur J Clin Microbiol Infect Dis.2000;19(9):725-726. doi:10.1007/s100960000351 DISCLOSURES: No relevant relationships by Ethan Karle No relevant relationships by SACHIN PATIL No relevant relationships by Shelby Schuh No relevant relationships by ahmad ziadeh

Impact of a Medication Reconciliation Pharmacist Program on Appropriateness of Community-Acquired Pneumonia Treatment Durations at Hospital Discharge.

Antimicrobial stewardship programs have made large efforts to minimize the inappropriate use of antibiotics. Implementation of these programs can be challenging, since many institutions have limited resources. Utilizing resources that already exist may be beneficial, including medication reconciliation pharmacist (MRP) programs. This study aims to evaluate the impact of a MRP program on appropriateness of community-acquired pneumonia (CAP) treatment durations at hospital discharge. This study was a retrospective, observational, single-center study comparing the total days of antibiotic therapy for CAP in the preintervention period (9/2020-11/2020) versus the post-intervention period (9/2021-11/2021). Implementation of a new clinical intervention occurred between the 2 periods and included education to MRPs on appropriate CAP treatment durations and on documentation of recommendations. Data was collected utilizing a chart review of the electronic medical record of patients diagnosed with CAP using ICD-10 codes. The primary objective of this study was to compare the total days of antibiotic therapy in the pre-intervention period versus the postintervention period. One-hundred fifty-five patients were included in the primary analysis. When observing total days of antibiotic therapy, there was no change from the pre-intervention period at 8 days compared to the postintervention period (P = .109). When analyzing antibiotic days of therapy at discharge, there was a decrease from 4.55 days in the preintervention period compared to 3.8 days in the post-intervention period (P = .109). The incidence of those with appropriate treatment durations, defined as 5 to 7 days of antibiotic therapy, was higher in the post-intervention period (26.5% in the pre-intervention group vs 37.9% in the post-intervention group, P = .460). There was a non-statistically significant decrease in median days of antimicrobial therapy for CAP at hospital discharge after implementation of a new clinical intervention targeting antibiotic days of therapy. Though median total antibiotic days of therapy were similar between both time periods, patients had an overall increase in incidence of appropriate duration of therapy, defined as 5 to 7 days, after intervention. Further studies are necessary to show how MRPs have a positive impact on improving outpatient antibiotic prescribing at hospital discharge.