Days Of Therapy Research Articles

944. Development & Implementation of a Biomarker-based Remotely-delivered Antimicrobial Stewardship (AMS) Strategy during the COVID-19 Pandemic

Abstract Background Increased antibiotic usage during the COVID-19 pandemic and resultant infection control measures derailed the existing antimicrobial stewardship program which involved in person post prescription review and feedback. We performed a time series analysis using Procalcitonin as a tool for a remotely delivered antimicrobial stewardship program by a clinical pharmacist. Methods This study was conducted in a tertiary care 3500 bedded teaching hospital in southern India. In the baseline phase, all COVID-19 in-patients receiving antibiotics > 48 hours were screened via the electronic records by a pharmacist and antimicrobial consumption indices like days of therapy (DOT) and length of therapy (LOT) were measured. In the intervention phase, if a patient was on antimicrobials, then a PCT was sent. An alert was sent to the treating team based on the procalcitonin levels and a screening of electronic records by a clinical pharmacist to either continue/ de-escalate or discontinue an antibiotic under supervision of an Infectious Diseases physician. Figure 1Guideline for continuing or stopping antibiotics based on procalcitonin levelsFigure 2Guideline for continuing or stopping antibiotics based on procalcitonin levelsStudy Flow Results About 481 patients were enrolled in the pre intervention phase of the study from July to October 2020 (peak of the pandemic) and 90 patients in the intervention phase December 2020 - March 2021 (decline of the pandemic. The baseline characteristics are shown in Figure3. The DOT/1000 patient days (PD) for all antibiotics was 9269 (DOT-6915) in the baseline and 2032 (DOT-886) in the intervention arm. The total length of therapy (LOT) for antimicrobial consumption significantly reduced from 3779 in the pre-intervention phase to 657 in the intervention phase (Figure 4). Out of the 90 recommendations given in the intervention phase, 82 (91.1%) were accepted by the treating team. For Azithromycin and Doxycycline, DOT significantly reduced from 3319 to 486 per 1000 PD and 602 to 158 per 1000 PD respectively. The DOT of the reserve antibiotics according to the WHO AWaRe classification like Polymyxins and Carbapenems decreased from 323 to 67 and 777 to 443 per 1000 PD days in the intervention phase. Figure 3Baseline Characteristics comparing Pre- intervention and Intervention Phase Figure 4 Comparison of LOT (Length of therapy) and DOT (Days of therapy) in the Pre-intervention and Intervention Phase Figure 5 Comparison of the DOT per 1000 PD in the Pre-Intervention and Intervention phase of frequently used antibiotics in Covid- 19 infection Conclusion This study demonstrated the utility of a novel biomarker driven antimicrobial stewardship strategy by clinical pharmacists during the COVID pandemic when access to patients was restricted to both infection control physicians and pharmacists. Disclosures Priscilla Rupali, MD, DTM&H, PFIZER: Grant/Research Support|PFIZER: Grant/Research Support.

927. Successful Implementation of an Inpatient Fluoroquinolone (FQ) Pre-Authorization (PA) Program at a Tertiary Care Academic Center and Associated Changes in Antibiotic Use, Antibiogram Susceptibility, and Provider Behavioral Changes

Abstract Background In 2017, our adult tertiary care academic hospital in the Midwest implemented an inpatient fluoroquinolone (FQ) prior authorization (PA) policy using the electronic health record (EHR) as a stewardship tool. We examined the changes in antibiotic use, the antibiogram, and antibiotic use at an affiliated hospital without PA but staffed by physicians from the PA site. Methods This quasi-experimental study used a pre-post implementation design to evaluate a PA policy at our University Hospital requiring approval of all inpatient FQ use from the antimicrobial stewardship physician or infectious disease consult teams. Time periods consisted of 2.5 year pre-implementation, 9-month wash-in (pilot on 2 wards), and 5-year post-implementation periods. Monthly antibiotic use in days of therapy per 1000 patient days (DOT/KPD) and antibiogram data, limited to first inpatient culture per patient per week from any anatomic site, were collected. Monthly FQ use from an affiliated hospital without the restriction policy staffed by physicians from the University Hospital was also collected. Changes in antibiotic use were examined using t-test, or Mann-Whitney Rank Sum, and antibiotic susceptibility rates were compared using z-test. Results Following implementation of PA, FQ use decreased by 76% (-53.2 DOT/KPD, p< 0.001) (Fig. 1). FQ use also declined from 26.4 DOT/KPD to 7.7 DOT/KPD (p< 0.001) at the affiliated hospital without PA but staffed by physicians from University Hospital. Changes in gram-negative agents use are shown in Table 1, with greatest increase noted for ceftriaxone (∼50%). The ciprofloxacin inpatient antibiogram improved significantly (Table 2); whereas, a slight decline in susceptibility was noted for ceftriaxone and cefepime. Figure 1.Fluoroquinolone use across study periods. Wash-in period included a pilot fluoroquinolone prior authorization in 2 wards. Abbreviations: Days of Therapy (DOT); patient days (PD) Table 1.Mean antibiotic days of therapy during each study period. Successive shortages for cefepime and piperacillin-tazobactam during the wash-in period, as indicated by NA. Table 2.Proportion of susceptible isolates pre- and post-implementation of Fluoroquinolone prior-authorization.Pip-tazo, piperacillin-tazobactam; %S, the percent susceptible for Pre- or Post-implementation periods; * indicates significant improvement and ¥ significant decline (p<0.05) pre vs post; R indicates intrinsic resistance. Conclusion FQ PA leads to significant and sustained decline in FQ use, indicating that suitable alternative choices exist for most hospitalized patients. Decreased FQ use was associated with increased use of cephalosporins, mainly ceftriaxone. As might be expected, changes in use were associated with subsequent changes in the antibiogram. This intervention was associated with a significant decline in FQ use at a site without the restriction policy and the EHR modifications, suggesting successful diffusion of educational and behavioral changes. Disclosures Lindsay Taylor, MD, Merck: Grant/Research Support Jessica S. Tischendorf, MD, MS, Merck: Grant/Research Support.

890. Bundled Antimicrobial Stewardship Intervention Reduces Inpatient Third Generation Cephalosporin Use without Restriction

Abstract Background The use of third generation cephalosporins (3GC) has been linked to collateral damage such as increased risk of infection with C. difficile, ESBL-producing organisms, VRE, and MRSA. Reduction in use of 3GC has been shown to reduce prevalence of these infections, particularly with C. difficile and ESBLs. An increase in 3GC use was observed at our facility in 2019 and 2020, likely due to targeted fluoroquinolone reduction initiatives in 2019 and COVID-19 surges in 2020. A multifaceted intervention targeting 3GC reduction without restriction was implemented starting in December 2020. Figure 1Monthly third generation cephalosporin use (Days of Therapy per 1000 patient days) from January 2019 to December 2021. Methods We conducted a retrospective quasi-experimental study evaluating the impact of a combination of interventions intended to reduce 3GC use. The intervention included modification of local clinical guidelines for urinary tract infection (UTI) and community acquired pneumonia (CAP), provider education, and daily review of active 3GC orders in 2021. Local guideline changes include preferred use of ampicillin/sulbactam and amoxicillin/clavulanate for CAP and cefazolin and cephalexin for UTI over 3GCs. Use of first generation cephalosporins for UTI was supported by local antibiogram susceptibilities for common UTI pathogens. Days of therapy (DOT) per 1000 patient days were collected monthly and yearly for ceftriaxone, ceftazidime, cefpodoxime, and cefdinir for pre-intervention (January 2019 to December 2019 and January to December 2020) and post-intervention (January 2021 to December 2021) periods. Results 3GC use significantly decreased from 89.52 DOT per 1000 patient days in 2020 to 53.06 in 2021, a 40.73% reduction. To account for increases in antibiotic use during COVID-19 surges in 2020 as a potential confounding variable, 2019 3GC use was also compared to 2021 use. A 31.40% decrease was seen, with 77.35 DOT per 1000 patient days in 2019. This effect was sustained through COVID-19 surges in January and August 2021 (Figure 1). Conclusion A combination of interventions without restriction of 3GC was successful in reducing inpatient use of this class of antibiotics, including through two COVID-19 surges in 2021. Further study is required to determine impact on clinical outcomes, such as C. difficile and antimicrobial resistance rates. Disclosures All Authors: No reported disclosures.

919. Let’s GO PO: Impact of Monthly Feedback on a Longitudinal Intravenous to Oral Antimicrobial Conversion Initiative

Abstract Background Timely conversion of antimicrobials from intravenous (IV) to oral (PO) route has been shown to decrease costs and length of stay (LOS) without compromising safety and efficacy of therapy. Use of oral antimicrobials may additionally prevent complications related to IV catheters, such as infection, emboli, and patient discomfort. An approved IV to PO policy allowed pharmacists to convert orders for fourteen included antimicrobials and eligible patients at time of order verification. Methods This single-center, retrospective, comparative study was conducted at AdventHealth Orlando, a 1,368-bed community teaching hospital in central Florida. In November 2020, six clinical pharmacist teams began receiving monthly feedback on IV to PO conversion rates in the form of a RePOrt Card, containing IV to PO conversion rates compared to other clinical teams, individual antimicrobial conversion rates, and comparison to prior team progress (Figure 1). RePOrt Cards were provided through October 2021. This study compared pre-intervention days of therapy (DOTs) of antimicrobials from November 2019-October 2020 to post-intervention DOTs from November 2020 to March 2022. The primary objective of this study was to assess the impact of monthly, team-based feedback on percentage of antimicrobials administered orally during a pharmacist-driven IV to PO stewardship initiative. Figure 1Example RePOrt Card Results Significantly more DOTs were administered orally in the post intervention group (62% vs 67%, p=0.0012). Positive change in oral conversion rates was observed for all agents except linezolid, minocycline, and voriconazole (Table 1). The largest increase in percentage of DOT administered orally was observed for azithromycin (20%), rifampin (14%), and metronidazole (10%). Estimated monthly and total cost differences are available in Table 2. Minocycline represents the largest opportunity missed; while oral conversion rates remained the same, an increase in overall drug use creates opportunity to continue to prioritize oral conversion due to high cost. Conclusion Monthly, team-based feedback positively impacted IV to PO conversion rates. Opportunities remain to optimize cost benefits in high-cost agents such as linezolid, minocycline, and voriconazole. Disclosures Amy L. Carr, PharmD, BCIDP, Shionogi: Advisory Board.

1656. Impact of Pharmacist Intervention on Antibiotic Prescribing at Hospital Discharge for Community-Acquired Pneumonia, Urinary Tract Infection, and Skin and Soft Tissue Infections

Abstract Background The high incidence of suboptimal antibiotic use at transitions of care represents a novel area for antimicrobial stewardship for community-acquired pneumonia (CAP), urinary tract infection (UTI), and skin and soft tissue infections (SSTIs). The objective of this study was to investigate the role of a pharmacist intervention at discharge to improve antibiotic use. Methods This was a single-center, retrospective, crossover analysis of patients admitted to general medicine units from 11/1/21 to 3/31/22 with a diagnosis of CAP, UTI, or SSTI. The study was divided into two phases separated by a one-month washout. Each two-month phase included two pre-specified units, an intervention and control. During phase 2, the intervention and control units were switched. Patients on antibiotics identified for discharge were reviewed and interventions were communicated by the pharmacist to the provider. Interventions were made based on predefined guidance for oral step-down therapy and total duration. The primary outcome, discharge antibiotic days of therapy (DOT), was compared between the intervention and control cohorts. Secondary outcomes included total DOT, hospital length of stay (LOS), 30-day readmission, and appropriateness of drug selection, dose, and duration. Results Records of 161 patients were included in this study, 85 in the intervention cohort (47 in phase 1, 38 in phase 2) and 76 in the control (41 in phase 1, 35 in phase 2). Overall discharge DOT was 3 (IQR 0–4.5) in the intervention cohort and 3 (IQR 0-5) in the control cohort (P = 0.8), and overall total DOT was 7 (IQR 5-9) and 7 (IQR 5-10) respectively (P = 0.27). Patients in the intervention group were more likely to have appropriate total duration (61.2% vs 44.7%, P = 0.001) and discharge duration of antibiotics (67.1% vs 53.9%, P = 0.013) for all three indications based on predefined guidance. Hospital LOS was 4 (IQR 3-5) vs 5 days (IQR 3-6.3) in the intervention and control cohorts (P = 0.001) respectively, and a lower 30-day readmission (14.1% vs. 23.7%, resp.). Conclusion Despite similar antibiotic DOTs, pharmacist intervention at discharge appeared to improve overall antibiotic total duration and discharge duration for CAP, UTI, and SSTI. Opportunities to improve discharge stewardship processes should be further explored. Disclosures Joseph L. Kuti, PharmD, Abbvie: Honoraria|bioMeriuex: Advisor/Consultant|bioMeriuex: Grant/Research Support|Contrafect: Grant/Research Support|Entasis: Grant/Research Support|Merck and Co: Grant/Research Support|Roche Diagnostics: Grant/Research Support|Shionogi: Advisor/Consultant|Shionogi: Grant/Research Support|Shionogi: Honoraria|Summit: Grant/Research Support David P. Nicolau, PharmD, Shionogi: Grant/Research Support.

1791. Leveraging EMR Alerts for Vancomycin Time Outs

Abstract Background Vancomycin represented the most used antibiotic at our academic medical center from 2014-2022. To enhance compliance with the “antibiotic time out” part of the CDC Core Elements for Stewardship, we designed an electronic medical record (EMR) best practice alert (BPA) to assist providers in identifying patients eligible for vancomycin discontinuation. Methods This is a single center, retrospective pre (06/01/14-2/24/20)/post (02/25/20-03/31/22) comparison of vancomycin utilization after the introduction of a locally validated automated vancomycin time-out. The BPA alerted on patients who had received vancomycin for 72h, had no microbiological evidence of methicillin resistant S. aureus, and had no infectious diseases consult. While other vancomycin reduction strategies had previously been implemented as part of the stewardship program, no other intervention debuted during the same time period. An interrupted time series analysis was performed to assess immediate and ongoing trend changes of institutional vancomycin use. Wilcoxon rank sum and chi2 analyses were also performed. Results There were 36,817 inpatient vancomycin orders placed. The BPA triggered during 1,881 (15.7%) orders in the post-BPA period, which was 49.6% of the 3,794 orders still active at 72h. After BPA introduction, there was an immediate decrease in vancomycin days of therapy (DOT)/1000 patient days (PD) ±SE (-8.5 ±3.6; P = 0.021) followed by a significant decrease in the monthly trend relative to the pre-intervention trend (-0.7 DOT/1000 PD ±0.2; P< 0.001). Median vancomycin DOT/1000 PD decreased from 145.9 (IQR 140.2-153.0) to 117.3 (IQR 107.7-122.6) in pre and post periods respectively (P< 0.001). Length of therapy (LOT) decreased, orders were more commonly discontinued by day 5, and orders were more likely to be discontinued prior to discharge. Separate analysis including only orders with >72h showed similar results (Table 1). Table 1Vancomycin length of therapy (LOT) pre and post-BPA Time Out.Figure 1Vancomycin days of therapy per 1000 patient days (DOT/1000PD) trends pre and post-BPA Time Out. Conclusion Introduction of an EMR automated vancomycin time out was an effective tool to decrease vancomycin utilization at an academic medical center. Disclosures All Authors: No reported disclosures.

1658. Using remote Infectious Disease physician expertise to support inpatient antibiotic stewardship activities at three VA medical centers an implementation-effectiveness trial

Abstract Background Remote Infectious Disease (ID) physicians can provide stewardship support through telehealth. Using the RE-AIM framework, we assessed the implementation of telehealth-supported prospective-audit-and-feedback (tele-PAF) across 3 rural Veterans Administration medical centers (VAMC). Methods All 3 invited sites agreed to participate and lacked ID support for stewardship at baseline. During 2021, an ID physician met virtually 3 times/week with the stewardship pharmacist champion at each participating VAMC to review patients on antibiotics in acute-care (mean daily census 3/site) and nursing-homes (NHs; mean census 71/site); real-time feedback on antibiotic use was given to clinicians. The primary outcome of effectiveness was monthly antibiotic days of therapy (DOT) per 1,000 days-present aggregated across all sites; the secondary outcome was days of antibiotic spectrum coverage (DASC) per 1,000 days-present. An interrupted time-series analysis was performed to asses these outcomes during the 1-year intervention period vs. the 2-year prior baseline. Semi-structured interviews with 20 clinicians and pharmacists were conducted to assess implementation. Results RE-AIM elements are summarized in Table 1. Tele-PAF reviewed 502 unique patients and made 681 recommendations to 23 clinicians; 77% of recommendations were accepted. The most common recommendations were to stop antibiotics (28%) and change duration (20%). After the start of tele-PAF, antibiotic DOT and DASC immediately decreased in acute-care (-20%, p=0.01; -22%, p< 0.01) and NHs (-28%, p=0.03; -37%, p< 0.01). Both metrics began to rise again in acute-care (DOT: +2.5%/month, p=0.02; DASC: +2.7%/month, p=0.02) but were stable in NHs (Figure 1). Clinicians generally appreciated feedback, found it compatible with their workflow and responded favorably to collaborative discussions. Barriers included difficulty establishing rapport with some providers. Conclusion The implementation of tele-PAF was associated with sustained reductions in antibiotic use across 3 NHs but not in the studied small acute-care units. Overall, clinicians perceived the intervention as acceptable and appropriate. Wider implementation of telehealth-supported stewardship activities may achieve reductions in antibiotic use. Disclosures Daniel J. Livorsi, MD, Merck & Co.: Grant/Research Support.

408. Benchmarking the Use of New β-lactams Utilizing a Novel Metric of Microbiological Burden

Abstract Background Several methods are used to account for various hospital characteristics when comparing antimicrobial use (AU) between heterogenous hospitals. Recently, a new antimicrobial stewardship metric that adjusts AU by microbiological burden (a-AU) of the bacteria was proposed (Figure 1). It accounts for the resistant phenotypes observed at a given institution, allowing for a more balanced comparison of AU across hospitals. This multicenter retrospective cohort study examined the use of new β-lactams for Gram-negative bacteria (GNB) with difficult-to-treat resistance (DTR) by both AU and adjusted (a-AU) metrics in the southeastern United States. Methods AU of new β-lactams was determined in 9 hospitals within the Southeastern Research Group Endeavor (SERGE-45) between 2015 to 2020. New β-lactams included ceftolozane/tazobactam, ceftazidime/avibactam, meropenem/vaborbactam, imipenem/cilastatin/relebactam, and cefiderocol. AU was adjusted for prevalence of GNB with DTR including Enterobacterales, Pseudomonas aeruginosa, and Acinetobacter species. DTR was defined as nonsusceptibility to all of the following: cefepime or ceftazidime, levofloxacin or ciprofloxacin, meropenem or imipenem, and piperacillin/tazobactam if tested. Hospitals were ranked by AU and a-AU from lowest to highest. Descriptive statistics were utilized. Results The cumulative mean AU and a-AU from 2015 to 2020 were 1.96 (range 0.10 to 6.44) and 2.3 (range 0.20 to 8.05) days of therapy (DOT)/1000 patient days, respectively (Figure 2). After adjusting for the prevalence of GNB with DTR, 6 hospitals moved by at least 1 position in ranking (2 hospitals moved up; 4 hospitals moved down) and 1 hospital moved by at least 2 positions in ranking. Conclusion Overall, the AU of new β-lactams increased after adjusting for the local microbiological burden suggests a potential higher use of antibiotics in relationship to the observed prevalence of GNB with DTR. More than half of the hospitals had a shift in ranking after microbiological adjustment reflecting a more balanced comparison of antibiotic use across heterogenous hospitals. Disclosures P. Brandon Bookstaver, PharmD, Spero Therapeutics: Advisor/Consultant Julie Ann Justo, PharmD, MS, FIDSA, BCPS-AQ ID, bioMerieux: Honoraria|bioMerieux: Honoraria|Entasis Therapeutics: Advisor/Consultant|Entasis Therapeutics: Advisor/Consultant|Gilead Sciences: Advisor/Consultant|Gilead Sciences: Advisor/Consultant|Merck & Co: Advisor/Consultant|Merck & Co: Advisor/Consultant|Shionogi: Advisor/Consultant|Shionogi Inc.: Advisor/Consultant|Spero Therapeutics: Honoraria|Spero Therapeutics: Honoraria|Vaxart: Stocks/Bonds Julie Ann Justo, PharmD, MS, FIDSA, BCPS-AQ ID, bioMerieux: Honoraria|bioMerieux: Honoraria|Entasis Therapeutics: Advisor/Consultant|Entasis Therapeutics: Advisor/Consultant|Gilead Sciences: Advisor/Consultant|Gilead Sciences: Advisor/Consultant|Merck & Co: Advisor/Consultant|Merck & Co: Advisor/Consultant|Shionogi: Advisor/Consultant|Shionogi Inc.: Advisor/Consultant|Spero Therapeutics: Honoraria|Spero Therapeutics: Honoraria|Vaxart: Stocks/Bonds Bruce M. Jones, Pharm.D., FIDSA, BCPS, AbbVie: Advisor/Consultant|AbbVie: Honoraria|La Jolla: Honoraria|Melinta: Advisor/Consultant|Paratek: Honoraria|Regeneron: Honoraria.

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

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

333. Clinical Impact of a Multiplex Rapid Diagnostic Panel in Critically Ill Patients

Abstract Background The BioFire FilmArray® Pneumonia Panel® (PP) is a rapid diagnostic test that detects select bacterial and viral respiratory pathogens and the presence of certain antimicrobial resistance genes within 75 min of testing. Starting Nov 2021 respiratory specimens from all adult ICU patients (pts) with quantitative cultures (cx) obtained by bronchoalveolar lavage (BAL) or tracheal aspirate (TA) were automatically tested with PP. The purpose of this study was to evaluate the clinical impact of the PP. Methods This single-center, retrospective cohort study compared patients prior to (PRE) (Jan - Mar 2021) and after (POST) (Jan - Mar 2022) implementation of the PP. Adult ICU pts with a quantitative cx obtained by BAL or TA during the study periods were reviewed in random order until 25 pts from each study month meeting study criteria were identified (75 pts in each cohort). Pts with another infection other than bacteremia with the same causative pathogen requiring antibiotics (ABX) in the previous 14 days through 5 days after specimen collection or pts who died within 5 days after specimen collection were excluded. ABX therapy for the 5 days after cx collection was evaluated. The primary outcome was time to first ABX change based on microbiologic test results. Secondary outcomes included ABX days of therapy (DOTs), time to adequate therapy, and potential vs actual ABX changes made based on the PP in POST cohort. Results PRE pts were a median of 54 yrs old and 56% female compared to 59 yrs and 32% female in POST cohort. Median time to first ABX change based on microbiologic data was 50.3 hrs PRE vs 21.2 hrs POST (p=0.0006). 56 (75%) of POST ABX regimens were eligible for change based on PP results; actual change occurred in 30 (54%) of these regimens (ABX de-escalation in 23 and escalation in 7). Median ABX DOTs were 8 PRE vs 6 POST (p = 0.07). For the pts with ABX changes made based on PP results, median time to first ABX change was 10 hrs. For pts who were initially on inadequate therapy, time to adequate therapy was 67 hrs PRE vs 37 hrs POST. Conclusion The PP was associated with decreased time to first ABX change and fewer ABX DOTs. The PP may have had a larger impact if a higher percentage of potential ABX changes were implemented. The PP may be a useful ABX stewardship tool. Disclosures All Authors: No reported disclosures.

1572. Impact of a Multicenter Fluoroquinolone Stewardship Collaboration on Prescribing Trends over Five Years

Abstract Background Fluoroquinolone (FQ) use is generally discouraged in uncomplicated infections when alternative therapies exist. Antimicrobial stewardship programs use diverse strategies to encourage appropriate prescribing of antibiotics, and FQ stewardship is often a priority due to the known toxicity risks. This study aimed to evaluate how the coordinated implementation of several stewardship strategies impacted FQ prescribing at eight community hospitals. Methods This retrospective, observational study includes data from January 2017 to January 2022. In 2018, the facility clinical pharmacy programs established formal clinical metrics to be tracked and reported on a regular basis. One such metric tracked FQ prescribing in urinary tract infections (UTI), and this metric has remained active since 2018. In early 2019, the health-system implemented a clinical decision support alert in the electronic health record, which requires acknowledgement of a risk/benefit assessment upon FQ order entry. In late 2019, some facilities began suppressing automated susceptibility results for FQ on cultures, due to technological limitations with new minimum inhibitory concentration breakpoints. Using a clinical surveillance system, a report was generated to assess the year-over-year changes in FQ days of therapy (DOT) per 1000 patient days at each facility. Results An 83% reduction in FQ use was observed over five years (737 DOT/1000 patient days vs. 125 DOT/1000 patient days), with facility-level reductions ranging from 62% to 96%. The smallest decrease in FQ use (18%) occurred from 2017–2018, before any system-wide FQ stewardship initiatives were adopted. A larger decrease in FQ use (33%) was seen from 2018–2019, after introducing the formal FQ UTI metric. The biggest decrease in FQ use (50%) occurred from 2019–2020, when the FQ alert and susceptibility suppression strategies were implemented alongside the existing UTI metric. An additional 39% decrease in FQ use was seen from 2020–2022, when no additional FQ interventions were implemented. Conclusion Substantial decreases in FQ prescribing were observed when multiple FQ stewardship strategies were utilized. The decreases were sustained over several years across multiple hospitals. Disclosures All Authors: No reported disclosures.

1806. The gap in the amount of monthly antimicrobial use according to the data source: Electronic Health Record Data vs. National Health Insurance Claim Data in Korea

Abstract Background Korea has single health insurance system and insurance claim information on almost all medical practices in Korean hospitals is collected and processed by the Health Insurance Review and Assessment Service (HIRA). Since information about prescription of almost all hospitals is available in National Health Insurance (NHI) claim data, recently established the Korea National Antimicrobial Use Analysis System (KONAS) has been using NHI claim data as data source. The purpose of this study is to validate the accuracy of NHI claim data. Methods Data on all antimicrobial agents prescribed in four tertiary-care hospitals in Korea between January 2019 and December 2019 were obtained using NHI claim data extracted by HIRA and data extracted by common data model based on electronic health record (EHR) in each hospital. Antibiotics and antifungal agents according to the Anatomical Therapeutic Chemical class J01 and J02 were included while antiviral, antitubercular, antiparasitic, and topical antimicrobial agents were excluded. Antimicrobial consumption was measured as days of therapy (DOT) and standardized to per 1,000 patient-days. The ratio of monthly antimicrobial consumption calculated using the NHI claim data compared to that calculated using the common data model was demonstrated (HIRA/EHR ratio). Results The monthly HIRA/EHR ratio of broad-spectrum antibiotics predominantly used for hospital-onset infections was 1.08-1.12 and that of broad-spectrum antibiotics predominantly used for community-acquired infections was 1.11-1.21. The monthly HIRA/EHR ratio of other antimicrobial classes are as follows: antibacterial agents predominantly used for resistant gram-positive infections 1.15-1.31, narrow-spectrum beta-lactam agents 1.00-1.05, antifungal agents predominantly used for invasive candidiasis 1.00-1.27, and antibacterial agents predominantly used for extensive antibiotic-resistant gram-negative bacteria 0.70-1.09. Conclusion The monthly antimicrobial consumption calculated using NHI claim data differs from that calculated using EHR data by up to 30%. It would be desirable to establish a system that can analyze and monitor antimicrobial consumption using EHR data in each hospital in Korea in the future. Disclosures Hyunki Woo, BS, Evidnet Inc.: Employee changhui Kim, BS, Evidnet Inc.: Employee.

1790. Dethroning Vancomycin: A Multifaceted Stewardship Approach to Reduce Vancomycin in an Academic Medical Center

Abstract Background Vancomycin is a broadly used antimicrobial, and from 2014-2022 represented the most used antibiotic at our academic medical center. Since 2015, the stewardship program has introduced several measures to optimize vancomycin use including pharmacy consultation, addition of MRSA nares PCR testing, embedding MRSA nares PCR order into vancomycin order panel, and introducing an electronic medical record (EMR) best practice alert to assist providers in identifying patients eligible for vancomycin discontinuation. The impact of each of these interventions are described. Methods This is a retrospective, single academic center, comparison of vancomycin utilization over time, following the introduction of various stewardship measures. Each intervention remained in place during subsequent periods. Wilcoxon rank sum was used for analysis. Period 1 (P1): 4/2015-12/2016 vancomycin pharmacy consultPeriod 2 (P2): 1/2017-6/2019 pharmacists authorized to order Nasal MRSA PCRPeriod 3 (P3): 7/2019-2/2020 embed nasal MRSA PCR into consult panelPeriod 4 (P4): 2/2020-3/2022 addition of automated EMR time-out Results Each period of vancomycin optimization was associated with a statistically significant decrease in vancomycin length of therapy (LOT) in days, when compared to the period before it (P1 vs P2, p< 0.0001; P2 vs P3, p< 0.0001; P3 vs P4, p< 0.0001). Overall institution vancomycin consumption, expressed as monthly days of therapy (DOT)/1000 patient days (PD) also decreased over time, starting with period 3 (P1 vs P2, p=0.4812; P2 vs P3, p=0.0003; P3 vs P4, p=0.0019) (Table 1). Table 1Vancomycin utilization trends over 4 periods of stewardship intervention. Conclusion Decreasing vancomycin at an academic medical center is challenging and takes a multifaceted approach with continued efforts over time to maintain a steady downward trend for utilization. These combined efforts have led to vancomycin no longer being the most commonly prescribed antibiotic at our institution. Disclosures All Authors: No reported disclosures.

276. Factors Predicting Bacterial Coinfection in Hospitalized COVID-19 Patients

Abstract Background Despite multiple studies indicating a low prevalence of bacterial coinfection in coronavirus disease 2019 (COVID-19) patients, the majority of hospitalized COVID-19 patients receive one or more antibiotics. Patients with coinfection usually have multiple risk factors and poor clinical outcomes. Methods A retrospective case control study was conducted comparing clinical characteristics and antimicrobial use in hospitalized adult COVID-19 patients with bacterial co-infections vs. randomly selected patients without co-infections (matched on month of admission). The study was conducted at three hospitals within the Montefiore Medical Center, Bronx, NY between March 1, 2020 and October 31, 2020. A multivariable logistic regression model was developed to assess the relationship of each predictor variable with coinfection status. Secondary outcomes included hospital mortality, antibiotic days of therapy (DOT), and C. difficile infection. Results A total of 150 patients with coinfection and 150 patients without co-infection were included in the analysis. Table 1 summarized baseline characteristics and risk factors. The multivariable logistic regression model indicated that presence of a central line (OR=5.4, 95% CI: 2.7-11.1), prior antibiotic exposure within 30 days (OR=5.3, 95% CI: 2.8-10.0), prior ICU admission (OR=3.6, 95% CI: 1.7-7.6), steroid use (OR=2.7, 95% CI: 1.4-4.9), and any comorbid condition (OR=2.7, 95% CI: 1.4-5.2) were significantly associated with the development of coinfection (table 2). Mortality was higher in patients with coinfection (56% vs. 11%, p < 0.0001) (table 3). Average antibiotic DOT was 10.5 in coinfected patients compared to 4 in non-coinfected patients, (p < 0.0001). Forty-one percent of coinfected patients had a multidrug resistant organism isolated. C. difficile rate was higher in coinfected patients (4% vs. 0%, p=0.03). Conclusion As the healthcare community contends with a 3rd year of COVID-19 pandemic, understanding risk factors most predictive of bacterial coinfection can guide empiric antimicrobial therapy and targeted stewardship interventions. Ideally, co-infection risk scores are developed which may be useful for future inpatient surges. Disclosures Yi Guo, PharmD, BCIDP, Merck: Grant/Research Support Kelsie Cowman, MPH, Merck: Grant/Research Support.

1571. Hospital COVID-19 Burden Impact on Inpatient Antibiotic Use Rates

Abstract Background COVID-19 shifted antibiotic stewardship program resources and changed antibiotic use (AU). Shifts in patient populations with COVID surges, including pauses to surgical procedures, and dynamic practice changes makes temporal associations difficult to interpret. Our analysis aimed to address the impact of COVID on AU after adjusting for other practice shifts. Methods We performed a longitudinal analysis of AU data from 30 Southeast US hospitals. Three pandemic phases (1: 3/20–6/20; 2: 7/20–10/20; 3: 11/20–2/21) were compared to baseline (1/2018–1/2020). AU (days of therapy (DOT)/1000 patient days (PD)) was collected for all antimicrobial agents and specific subgroups: broad spectrum (NHSN group for hospital-onset infections), CAP (ceftriaxone, azithromycin, levofloxacin, moxifloxacin, and doxycycline), and antifungal. Monthly COVID burden was defined as all PD attributed to a COVID admission. We fit negative binomial GEE models to AU including phase and interaction terms between COVID burden and phase to test the hypothesis that AU changes during the phases were related to COVID burden. Models included adjustment for Charlson comorbidity, surgical volume, time since 12/2017 and seasonality. Results Observed AU rates by subgroup varied over time; peaks were observed for different subgroups during distinct pandemic phases (Figure). Compared to baseline, we observed a significant increase in overall, broad spectrum, and CAP groups during phase 1 (Table). In phase 2, overall and CAP AU was significantly higher than baseline, but in phase 3, AU was similar to baseline. These phase changes were separate from effects of COVID burden, except in phase 1 where we observed significant effects on antifungal (increased) and CAP (decreased) AU (Table). Conclusion Changes in hospital AU observed during early phases of the COVID pandemic appeared unrelated to COVID burden and may have been due to indirect pandemic effects (e.g., case mix, healthcare resource shifts). By pandemic phase 3, these disruptive effects were not as apparent, potentially related to shifts in non-COVID patient populations or ASP resources, availability of COVID treatments, or increased learning, diagnostic certainty, and provider comfort with avoiding antibacterials in patients with suspected COVID over time. Disclosures Melissa D. Johnson, PharmD, Biomeme: Licensed Transcriptional Signature for Candidemia|Charles River Laboratories: Grant/Research Support|Entasis Therapeutics: Advisor/Consultant|Merck & Co. Inc: Advisor/Consultant|Merck & Co. Inc: Grant/Research Support|Pfizer, Inc.: Advisor/Consultant|Scynexis Inc.: Grant/Research Support|Theratechnologies: Advisor/Consultant Angelina Davis, PharmD, M.S., Merck & Co.: Honoraria Sonali D. Advani, MBBS, MPH, FIDSA, Locus Biosciences: Advisor/Consultant|Locus Biosciences: Honoraria|Sysmex America: Advisor/Consultant Ibukun Kalu, MD, Pfizer, Inc.: Institutional support for clinical trial Rebekah W. Moehring, MD, MPH, FIDSA, FSHEA, UpToDate, Inc.: Author Royalties.

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.

948. Impact of a Multi-pronged Approach to Antimicrobial Stewardship on the Vascular Ward at a Tertiary Hospital

Abstract Background Up to 50% of inpatient antibiotic use may be inappropriate, and guideline concordance for antibiotic prescribing in surgical wards tends to be lower than medical wards. As such, our study describes a multi-pronged approach to antimicrobial stewardship (AMS) targeting a vascular ward and its impact on improving antibiotic use. Methods This is a quality improvement study at a tertiary hospital in British Columbia, Canada. All patients admitted to the vascular surgery ward for any vascular related issues and who received piperacillin-tazobactam or a carbapenem were included. Patients were excluded if admitted to the ward for < 48 hours. The primary outcome is appropriateness of carbapenem and piperacillin-tazobactam use in concordance with local policies. Secondary outcome is consumption of these agents. The pre-intervention period was March 2020 to June 2020. The AMS team prospectively reviewed included patients to establish the baseline level of appropriate antibiotic use. The intervention period was from July 2020 to February 2021. Aside from presentations to surgeons, the main intervention was regular audit and feedback to a nurse practitioner who rounds with the surgeons. Mandatory ID consultation for carbapenems was the last resort if AMS recommendations were not accepted. Results During the pre-intervention period, 19 out of 25 prescriptions (76%), either carbapenem or piperacillin-tazobactam, had appropriate indications. In the intervention period, 121 prescriptions were reviewed and the appropriateness level increased to 87% (Figure 1). Eleven mandatory ID consultations were generated. The mean days of therapy (DOT) per 1000 patient-days for carbapenem decreased from 94.6 to 56.6 for pre- and intervention periods, respectively. For piperacillin-tazobactam, the mean DOT per 1000 patient-days decreased from 209.9 to 138.5 for pre- and intervention periods. The reduced usage of piperacillin-tazobactam remained sustainable post-intervention (Figure 2). Figure 1:Summary of patient characteristics and outcomes during intervention period (July 2020 to February 2021)Figure 2:Usage of piperacillin-tazobactam from June 2019 to June 2021 Conclusion A multi-pronged approach, consisting of education, prospective audit and feedback to the surgical team, and mandatory ID consult in selected cases, is effective in decreasing inappropriate broad-spectrum antibiotic use on the vascular ward at a tertiary centre. Disclosures All Authors: No reported disclosures.

172. Does Passive Reporting of Streptococcus spp Identified by Rapid Molecular Assay Change Antibacterial Prescribing Compared to Gram Stain (GS) Alone?

Abstract Background At University of Virginia Health, the detection of Streptococcus spp via rapid molecular assay from blood cultures (BCx) was not historically reported in the EMR until the isolate was further identified. However this was reconsidered following anecdotal observation of inappropriate vancomycin (VAN) prescribing with GS alone. The purpose of this study was to investigate the impact of implementing passive reporting of Streptococcus spp on antibacterial prescribing patterns with a focus on VAN. Methods This was a single-center, pre-post quasi-experimental study of adult inpatients with non-duplicate Streptococcus spp identified via rapid molecular assay (ePlex®; GenMark Diagnostics) from BCx before (pre-intervention, Jul 2020 – Sep 2021) and after (post-intervention, Oct 2021 - Apr 2022) implementing passive reporting of Streptococcus spp. The primary outcome was any antibacterial switch within 24 hours of GS. VAN days of therapy (DOT) within 7 days and rates of Streptococcus spp deemed contamination by the primary team were also assessed. Results A total of 83 patients were included (58 pre- and 25 post-intervention). Baseline characteristics were similar including immunocompromised status (45% vs 52%), febrile neutropenia (28% vs 28%), and admission to a medical service (90% vs 96%). An antibacterial switch occurred within 24 hours of GS in 59% and 64% of the pre- and post-intervention groups, respectively, and was most commonly the addition of VAN (66% [25/38] vs 40% [8/20]; p=0.09). Fewer post-intervention patients continued VAN beyond 24 hours (66% vs 48%; p=0.15), but this was not statistically significant. The median VAN DOT remained unchanged at 2 days. A non-significant decrease in Streptococcus spp deemed contaminants was noted in the post-intervention arm (28% vs 16%; p=0.16). Finally, a non-streptococcal organism was isolated from concomitant BCx in approximately one-third of patients in each arm. Conclusion Passively reporting Streptococcus spp identified by rapid molecular assay without paired stewardship intervention did not impact antibacterial prescribing. The identification of Streptococcus spp may be characterized by heterogeneous circumstances requiring nuanced real-time stewardship intervention. Disclosures All Authors: No reported disclosures.

1798. Impact and Sustainability of Antibiotic Prescribing Feedback with Peer Comparison to Hospitalists in a Community Hospital

Abstract Background Antibiotic prescribing feedback with peer comparison has been shown to reduce antibiotic prescription rates in the outpatient setting, but data regarding its impact in community hospitals are lacking. We previously developed novel denominator metrics to control for differences between physician practices such as patient volume or workload. Using these metrics, we provided regular antibiotic prescribing feedback with peer comparison to hospitalists in a community hospital over four years and evaluated its impact on targeted antibiotic prescribing. Methods Antibiotic days of therapy (DOT) for all antibacterials and targeted agents (aztreonam, antipseudomonal beta-lactams, vancomycin, and the fluoroquinolones (FQ)) were obtained from electronic medication administration records and linked to the ordering hospitalist. Physician-specific shifts worked data by month were calculated from local administrative datasets. De-identified data were presented in DOT/shifts worked, and trends in facility-wide and hospitalist-specific antibiotic prescribing were evaluated. Results A total of 37,938 antibiotic DOTs were prescribed by hospitalists from January 2018 to March 2022. De-identified feedback was shared in-person (4/2018, 4/2019, 3/2020, 11/2021) or virtually (9/2020) in small group sessions, and education, including local antibiogram data and recommended alternatives, was provided for targeted agents. Of the 31 hospitalists that received feedback, trends in FQ use for 7 hospitalists with longitudinal data are shown (Figure 1). In the month following feedback sessions, hospitalist antibiotic use data demonstrated substantial reductions in FQ prescribing, and similar trends were observed among all targeted agents. A single hospitalist’s prescribing trend for targeted agents is shown in Figure 2. Facility-wide, targeted agent use decreased 31% from 2017 to 2021 and was primarily driven by reductions in use by hospitalists. Conclusion Regular antibiotic prescribing feedback with peer comparison and education was associated with a reduction in targeted agent prescribing by hospitalists at a community hospital. Disclosures All Authors: No reported disclosures.

959. It Takes a Village: Reducing Empiric Vancomycin Use by Leveraging Primary Team Pharmacist Oversight of a 72-hour Approval Process

Abstract Background Vancomycin is often initiated empirically in hospitalized patients for broad spectrum gram-positive coverage, however in many cases it is initiated unnecessarily and/or continued empirically for longer durations than necessary. Strategies to facilitate timely discontinuation of vancomycin when unnecessary may reduce antibiotic toxicity (e.g. nephrotoxicity) and the development of bacterial resistance. In large hospital systems, it may not be feasible for stewardship programs to implement prior authorization requirements or prospective audit/feedback for all vancomycin orders. Novel strategies to enlist other clinicians to serve as stewards of antibiotic use are needed. Methods On February 1, 2020, we implemented a protocol requiring providers to obtain approval from the primary team pharmacist to continue empiric vancomycin regimens >72 hours. Primary team pharmacists were provided a list of appropriate indications for vancomycin continuation. After 72 hours, the pharmacist placed a note describing the approved indication or if ASP or ID consult was obtained. We evaluated the standardized antibiotic administration ratio (SAAR) for antibacterial agents for resistant gram-positive infections for FY2019 (pre-protocol) and FY2020 (post-protocol) to assess the impact of this intervention. Vancomycin utilization was also evaluated in days of therapy (DOT)/1000 patient days during both time periods. Results The SAAR for antibacterial agents for resistant gram-positive infections for FY2019 was 1.17 and FY2020 was 1.04 (95% CI (0.87, 0.91), p-value < 0.001). A significant reduction in SAAR was observed in patients admitted to the ICU and floor (Figure 1). Overall vancomycin utilization according to days of therapy/1000 patient days was reduced from 111.13 (FY2019) to 104.08 (FY2020). Conclusion Leveraging the oversight of primary team pharmacists proved to be an effective strategy to reduce empiric vancomycin durations of therapy. Following the implementation of a 72-hour approval protocol with primary team pharmacist oversight, we observed a significant reduction in the SAAR for antibacterials for resistant gram-positive infections with a corresponding reduction in vancomycin utilization. Disclosures All Authors: No reported disclosures.