Fluoroquinolone Prescriptions Research Articles

Changing the culture of fluoroquinolone prescribing

Changing the culture of fluoroquinolone prescribing

Intervention with impact: Reduced isolation of methicillin-resistant Staphylococcus pseudintermedius from dogs following the introduction of antimicrobial prescribing legislation in Germany.

Legislation was introduced in Germany in 2018, requiring bacterial culture and antimicrobial susceptibility testing before the prescription of fluoroquinolones and third-generation cephalosporins to dogs. We hypothesised that, following this intervention, the number of clinical samples testing positive for methicillin-resistant Staphylococcus pseudintermedius (MRSP) would reduce. Reports of S. pseudintermedius isolated from canine clinical samples by three German veterinary diagnostic microbiology laboratories during the 38 months before the introduction of the legislation and the 46 months after were compared. Bacterial identification was performed by matrix-assisted laser desorption/ionisation time-of-flight mass spectrometry, and antimicrobial susceptibility testing followed recognised recommendationsbut with changes during the study period. Among a total of 120,571 S. pseudintermedius isolates, MRSP accounted for 7.1% overall. Following the legislative intervention, monthly submissions yielding S. pseudintermedius increased at all three laboratories. The MRSP percentage was lower in the period after the intervention in two of the three laboratories (p < 0.001); in the third laboratory, there was no change between periods, but a year-on-year reduction in MRSP percentages occurred after the intervention (p = 0.0004). Changing susceptibility testing methods limited the direct comparison of resistance patterns among laboratories. The reduction in MRSP in canine clinical samples following the introduction of this legislation suggests a positive impact of compulsory laboratory testing on reducing antimicrobial resistance.

Surveillance of Antimicrobial Prescriptions in Community Pharmacies Located in Tokyo, Japan.

An antimicrobial resistance (AMR) Action Plan was launched in 2016 to prevent the spread of antimicrobial-resistant bacteria in Japan. Additional support for the appropriate use of pediatric antimicrobial agents was initiated in 2018 to promote the appropriate use of antimicrobial agents in the community. To evaluate the effectiveness of the AMR Action Plan in the community, we investigated antimicrobial prescriptions in community pharmacies. Data on prescriptions for antimicrobial agents dispensed in 42 community pharmacies located in the Tama district, Tokyo, Japan, were collected between April 2013 and December 2019. In this study, we employed the DPY, which was calculated as defined daily doses (DDDs)/1000 prescriptions/year. The DPY is the number of antimicrobial agents used (potency) per 1000 antimicrobial prescriptions dispensed in pharmacies per year. The number of prescriptions for third-generation cephalosporins, fluoroquinolones, and macrolides decreased after the initiation of the AMR Action Plan; the DPYs of these antimicrobial agents decreased significantly by 31.4%, increased by 15.8%, and decreased by 23.6%, respectively (p < 0.05). The number of antimicrobial prescriptions for pediatric patients has been decreasing since 2018. Declines in the DPYs of third-generation cephalosporins, fluoroquinolones, and macrolides were higher in pediatric pharmacies than in other pharmacies. Our data suggest that the AMR Action Plan and additional support for the appropriate use of antimicrobial agents in children influenced the number of antimicrobial prescriptions in community pharmacies in Japan.

Carrier prevalence of Clostridioides difficile in emergency departments and the association of prior antibiotic consumption: a combined cross-sectional and nested case-control study.

Clostridioides difficile infection is an urgent public health threat, and the incidence has been increasing over the last decades. Knowledge of the prevalence of C. difficile in acutely admitted patients and risk factors for colonization with C. difficile assists emergency departments (EDs) in prioritizing preventive initiatives. This national study aimed to describe prevalence and risk factors for C. difficile carriers acutely admitted to EDs, focusing on the impact of earlier antibiotic prescription. We conducted a nationwide analytic cross-sectional study with prospective data collection combined with a nested case-control study with retrospective data collection. All adults visiting one of eight Danish EDs were interviewed and examined for C. difficile. Using a national register, we collected the antibiotic history within the 2 years prior to enrolment. The primary outcome was the prevalence of C. difficile colonization, and secondary outcomes were related to risk factors and prior antibiotic prescription. Multivariate analyses examined the association between earlier antibiotic prescription and C. difficile colonization. Of 5019 participants, 89 were colonized with C. difficile (prevalence of 1.8%). A significant and exposure-dependent association was found for penicillins [DDD/person-year(PY) > 20; OR 4.93 (95% CI 2.22-10.97)] and fluoroquinolones [DDD/PY > 20; OR 8.81 (95% CI 2.54-30.55)], but not macrolides. Timing of the prescription did not affect the association. One out of 55 patients visiting a Danish ED were colonized with C. difficile. Risk factors for colonization included high age, comorbidity and prior prescription of fluoroquinolones and penicillins.

Acute Respiratory Infection Incidence and Outpatient Antibiotic Prescription Patterns in People With or Without Human Immunodeficiency Virus Infection: A Virtual Cohort Study.

Inappropriate antibiotic use in acute respiratory infections (ARIs) is a major public health concern; however, data for people with human immunodeficiency virus (PWH) are limited. The HIV Virtual Cohort Study is a retrospective cohort of adult Department of Defense beneficiaries. Male PWH cases (n = 2413) were matched 1:2 to controls without HIV (n = 4826) by age, gender, race/ethnicity, and beneficiary status. Acute respiratory infection encounters between 2016 and 2020 and corresponding antibiotic prescriptions were characterized as always, sometimes, or never appropriate based on International Classification of Diseases, Tenth Revision coding. Incidence of ARI encounters and antibiotic appropriateness were compared between PWH and controls. Subgroup analyses were assessed by CD4 count and viral load suppression on antiretroviral therapy. Mean rates of ARI encounters were similar for PWH (1066 per 1000 person-years) and controls (1010 per 1000 person-years); however, the rate was double among PWH without viral load (VL) suppression (2018 per 1000 person-years). Antibiotics were prescribed in 26% of encounters among PWH compared to 34% for controls (P ≤ .01); antibiotic use was "never" appropriate in 38% of encounters with PWH and 36% in controls. Compared to controls, PWH received more sulfonamides (5.5% vs 2.7%; P = .001), and variation existed among HIV subgroups in the prescription of sulfonamides, fluoroquinolones, and β-lactams. Acute respiratory infection encounters were similar for PWH and those without HIV; however, PWH with lower CD4 counts and/or nonsuppressed VL had more frequent ARI visits. Inappropriate antibiotic use for ARIs was high in both populations, and focused interventions to improve antibiotic appropriateness for prescribers caring for PWH should be pursued.

The COVID-19 Pandemic Enhanced the Decade-Long Trend of the Decreasing Utilization of Antibiotics.

A decline in antibiotic (AB) prescriptions was reported during the coronavirus 2019 (COVID-19) pandemic. Therefore, we investigated AB utilization during the COVID-19 pandemic using data from a large database in Germany. AB prescriptions in the Disease Analyzer database (IQVIA) were analyzed for each year between 2011 and 2021. Descriptive statistics were used to assess developments in relation to age group, sex, and antibacterial substances. Infection incidence rates were also investigated. In total, 1,165,642 patients received antibiotic prescriptions during the entire study period (mean age: 51.8; SD: 18.4 years; 55.3% females). AB prescriptions started to decline in 2015 (505 patients per practice), and this development persisted until 2021 (2020: 300 patients per practice and 2021: 266 patients per practice). The sharpest drop was observed in 2020 and occurred in both women and men (27.4% and 30.1%). In the youngest age group (≤30), the decrease was -56%, while in the age group >70, it was -38%. The number of patients with prescriptions for fluoroquinolones dropped the most, falling from 117 in 2015 to 35 in 2021 (-70%), followed by macrolides (-56%) and tetracyclines (-56%). In 2021, 46% fewer patients were diagnosed with acute lower respiratory infections, 19% fewer with chronic lower respiratory diseases, and just 10% fewer with diseases of the urinary system. AB prescriptions decreased more in the first year (2020) of the COVID-19 pandemic than infectious diseases did. While the factor of older age influenced this trend negatively, it remained unaffected by the factor of sex and the selected antibacterial substance.

Descriptive management of suspected acute cystitis in adult patients by French general practitioners during remote consultation

ObjectivesThe main objective of this study was to analyze French general practitioners’ (GP) online prescriptions for suspected acute cystitis using a single nationwide teleconsultation platform. Patients and MethodsFirst, a descriptive study of management for suspected cystitis was conducted from the 1st of January to the 31st of December 2020. After which, following pedagogical intervention, a pre/post descriptive analysis of the antibiotics prescribed was carried out. ResultsSome 496,041 teleconsultations (TCs) were carried out in 2020 on the Qare platform. Among them, 15,089 TCs for cystitis with ICD-10 encoding (N30) were analyzed. Fosfomycin trometamol was the most prescribed antibiotic (n = 10297, 69%), while fluoroquinolones (n = 1568, 10.6%) were the second. Urine test strip was prescribed in 3157 (20%) and urine culture in 7033 (47%) of the TCs. July-August 2020 and July-August 2021 were compared and while a significant drop in fluoroquinolone prescriptions and a major increase in Fosfomycin trometamol were observed, there was no change in the prescriptions of urine culture. An average antibiotic conformity rate of 61.5% was observed before the intervention, and 68.8% afterwards. ConclusionsCystitis is a recurrent reason for remote consultation. The study demonstrated sizable over-prescription of urine culture, ultrasound, and fluoroquinolones. Intervention should be improved and strengthened to guarantee continuous training and awareness of GP's on appropriate cystitis prescriptions in telemedicine.

Impact of European Union Label Changes for Fluoroquinolone-Containing Medicinal Products for Systemic and Inhalation Use: Post-Referral Prescribing Trends.

Concerns of the persistence and severity of the adverse effects of fluoroquinolones, mainly involving the nervous system, muscles and joints, resulted in the 2018 referral procedure led by the European Medicines Agency (EMA). They advised to stop prescribing fluoroquinolones for infections of mild severity or of a presumed self-limiting course and for prevention of infections, plus to restrict prescriptions in cases of milder infections where other treatment options are available, and restrict in at-risk populations. We aimed to examine whether the impact of EMA regulatory interventions implemented throughout 2018-2019 had an impact on fluoroquinolone prescribing rates. A retrospective population-based cohort study was conducted using electronic health care records from six European countries between 2016 and 2021. We analysed monthly incident fluoroquinolone use rates overall and for each fluoroquinolone active substance through flexible modelling via segmented regression to detect time points of trend changes, in monthly percentage change (MPC). The incidence of fluoroquinolone use ranged from 0.7 to 8.0/1000 persons per month over all calendar years. While changes in fluoroquinolone prescriptions were observed over time across countries, these were inconsistent and did not seem to be temporally related to EMA interventions (e.g., Belgium: February/May 2018, MPC - 33.3%, 95% confidence interval [CI] - 35.9 to - 30.7; Germany: February/May 2019, MPC - 12.6%, 95% CI - 13.7 to - 11.6]; UK: January/April 2016, MPC - 4.9%, 95% CI - 6.2 to - 3.6). The regulatory action associated with the 2018 referral did not seem to have relevant effects on fluoroquinolone prescribing in primary care.

Expert consensus on monitoring antimicrobial stewardship in French nursing homes using assessed reimbursement database indicators.

Monitoring the appropriateness of antibiotic prescriptions with indicators based on reimbursement data is required to guide antibiotic stewardship (AMS) interventions in nursing homes (NHs). Quantity metrics (QMs) monitor the volume of prescriptions while proxy indicators (PIs) reflect the appropriateness of antibiotic use. Our objectives were: (i) to provide a relevant consensual set of indicators to be used in French NHs; and (ii) to assess the feasibility of their implementation at the national and local scale. Nine French professional organizations implicated in AMS in NHs were asked to nominate at least one member to create a national expert panel of 20 physicians. Twenty-one recently published QMs and 11 PIs were assessed by the expert panel. Indicators were evaluated using a RAND-modified Delphi procedure comprising two online surveys and a videoconference meeting. Indicators were kept in the final list if >70% of stakeholders validated their relevance for estimating the volume (QMs) and appropriateness (PIs) of prescriptions. Of the 21 QM indicators submitted to the panel, 14 were selected, describing the consumption of antibiotics overall (n = 3), broad-spectrum (n = 6) and second-line antibiotics (n = 2). The three remaining QMs evaluated the route of administration (n = 1) and urine culture prescriptions (n = 2). Ten PIs (six modified, two rejected, one new) were selected to assess the appropriateness of prescriptions for urinary tract infections (n = 2), seasonal variations in prescriptions (n = 2), repeated prescriptions of fluoroquinolones (n = 1), cephalosporins' route of administration (n = 1), duration of treatment (n = 1), rate of second-line antibiotics (n = 1), co-prescriptions with non-steroidal anti-inflammatory drugs (n = 1), and flu vaccine coverage (n = 1). The panel was in favour of using these indicators for regional and facility level AMS programmes (91%), feedback to NH prescribers (82%), benchmarking by health authorities (55%) and public reporting at the facility level (9%). This consensual list of indicators, covering a wide range of frequent clinical situations, may be used as part of the French national AMS strategy for monitoring antibiotic prescriptions in NHs at the national and local levels. Regional AMS networks might manage this selected list to guide personalized action plans with concrete objectives of reducing the quantity and improving the quality of antibiotic prescriptions.

Is Fluoroquinolone Exposure after Primary Tendon Repair Associated with Higher Rates of Reoperations? A Matched Cohort Study.

The association between tendon damage and fluoroquinolone (FQ) antibiotics has been well documented. However, there is limited data evaluating the impact of postoperative FQ use on outcomes of primary tendon repairs. The purpose of this study was to compare rates of reoperation for patients with FQ exposure after primary tendon repair versus controls. A retrospective cohort study was conducted using the PearlDiver database. All patients who underwent primary repair of distal biceps ruptures, Achilles tendon ruptures, and rotator cuff tears were identified. For each tendon, patients who were prescribed FQs within 90 days postoperatively were propensity score matched at a 1:3 ratio with controls without postoperative FQ prescriptions across age, sex, and several comorbidities. Rates of reoperation were compared at two years postoperatively with multivariable logistic regression. A total of 124,322 patients who underwent primary tendon procedures were identified, including 3,982 (3.2%) patients with FQ prescriptions within 90 days postoperatively: 448 with distal biceps repair, 2,538 with rotator cuff repair, and 996 with Achilles tendon repair. These cohorts were matched with 1,344, 7,614, and 2,988 controls, respectively. Patients with postoperative FQ prescriptions exhibited significantly higher rates of revision surgery after primary repair of distal biceps ruptures (3.6% vs.1.7%; OR 2.13; 95% CI, 1.09-4.04), rotator cuff tears (7.1% vs.4.1%; OR 1.77; 95% CI, 1.48-2.15), and Achilles tendon ruptures (3.8% vs.1.8%; OR 2.15; 95% CI, 1.40-3.27). Patients with FQ prescriptions within 90 days after primary tendon repair demonstrated significantly higher rates of reoperations for distal biceps, rotator cuff, and Achilles tendon repair at two years postoperatively. To achieve optimal outcomes and avoid complications in patients following primary tendon repair procedures, physicians should consider prescribing alternative non-FQ antibiotics and counsel patients on the risk of reoperation associated with postoperative FQ use.

Differences in concomitant medication prescribing before and after novel hormonal therapy (NHT) in men with prostate cancer: A population-based study.

138 Background: Prostate cancer (PCa) is the most common non-skin cancer affecting American men. Two common NHTs used to treat PCa are enzalutamide and abiraterone. Due to the different mechanisms of these two NHTs, we hypothesized that the concomitant medications prescribed might be related to therapy-related adverse effects. The purpose of this study was to examine whether changes in concomitant medications depended on the NHT prescribed. Methods: Medicare patients with a prescription of either enzalutamide or abiraterone in the Surveillance, Epidemiology, and End Results (SEER)–Medicare database diagnosed with prostate cancer from January 01, 2004 to December 31, 2015 were included. Medications were classified by Lexicomp’s pharmacologic category. Only oral prescriptions were included. McNemar’s test was used to compare the drug use prevalence of each category prior to and after initiation of NHT. Generalized logistic regression was used to evaluate whether changes in prescription drug class during the 6 months post-NHT initiation periods depended on the type of NHT. Results: Among the 1067 patients included, 354 were prescribed enzalutamide and 713 were prescribed abiraterone. We found statistically significant interactions between NHT (enzalutamide vs. abiraterone) and period (post vs. preinitiation NHT). Patients prescribed enzalutamide were more likely to discontinue prescriptions for steroids (p&lt;0.01) as expected. The odds of fluoroquinolones, non-steroidal anti-inflammatory drugs (NSAIDs), and loop diuretics prescriptions were similar pre-NHT initiation for both enzalutamide and abiraterone patients; however, patients treated with enzalutamide were significantly less likely than abiraterone patients to have post-NHT initiation prescriptions for fluoroquinolones (Odds ratio (OR) 0.69 p=0.01) or loop diuretics (OR: 0.57 p&lt;0.01). Conclusions: To our knowledge, this is the first population-based study to describe concurrent medication prescribing before and after NHT. Further studies are warranted to better understand the underlying reasons for the observed patterns.

Outpatient fluoroquinolone use in relation to European Medicines Agency's recommendation: An Estonian nationwide drug utilization study.

To determine possible changes in prescribing of fluoroquinolones in relation to the European Medicines Agency's (EMA) recommendation in October 2018. We conducted a nationwide time-series study on outpatient use of fluoroquinolones during January 2016-June 2021 in Estonia. Joinpoint regression was used to identify change points over time. Several subgroup analyses by prescriber specialty, indication group, risk factors for tendon injury, aortic aneurysm/dissection or heart valve regurgitation/incompetence and the prescribing of other antibiotics were performed. During the study period 236 989 prescriptions of fluoroquinolones were dispensed to 142 659 persons. The number of episodes per month declined from 3780 (2.9/1000 inhabitants) to 2570 (1.9/1000 inhabitants). We identified three change points with four different trend segments: from January 2016 to November 2018 monthly percent change (MPC) -0.4%, from November 2018 to June 2019 MPC -2.5%, from June 2019 to July 2020 MPC 1.7% and from July 2020 to June 2021 MPC -3.3%. Prescribing for indications which were removed or restricted by EMA's recommendation comprised a small proportion of all fluoroquinolone episodes -2.8% and 6.3%, respectively. The risk factors for tendon injury and for cardiac disorders (aortic aneurysm/dissection or heart valve regurgitation/incompetence) were present in 46.4% and 57.8% episodes of fluoroquinolone users, respectively. No changes in the trend of prescribing to users with risk factors was detected. The EMA's recommendation may have contributed to the greater decline in the use of fluoroquinolones. However, there is still a high proportion of users with predisposing factors for tendon injury and serious cardiac disorders.

1754. Implementation of a targeted antimicrobial stewardship clinical decision support system on outpatient fluoroquinolone prescribing

Abstract Background Fluoroquinolones are broad spectrum antibiotics with several Food and Drug Administration (FDA)-issued black box warnings. Due to these risks, the FDA recommends reserving fluoroquinolones for situations with no alternatives. Beginning in 2020, the Joint Commission required outpatient antimicrobial stewardship activities due to overprescribing and growing resistance to antimicrobials. The role of this study was to implement a clinical decision support system (CDSS) targeting inappropriate outpatient fluoroquinolone prescribing. Methods This was a single center, quasi-experimental study evaluating patients prescribed oral fluoroquinolones in an outpatient ambulatory care setting between December 1, 2020-February 28, 2021 and December 1, 2021-February 28, 2022. Patients included in this study were divided into Pre-CDSS and Post-CDSS groups if they received oral antibiotics for pre-determined indications (see table 2 for the list of indications). The primary outcome was overall reduction in outpatient fluoroquinolone prescribing. Secondary objectives were reduction in outpatient fluoroquinolone prescribing by indication, orders by provider type, appropriate fluoroquinolone dosing per renal function and incidence of an emergency department (ED) visit or hospitalization within 90 days consistent with a fluoroquinolone adverse drug reaction. Results A total of 2,447 (1,105 in Pre-CDSS vs. 1,342 in Post-CDSS) were included for analysis. Fluoroquinolone prescribing significantly decreased in Post-CDSS group compared to Pre-CDSS group (4.9% vs. 3.4%; p = 0.03). There was a significant reduction in fluoroquinolone prescribing in abscess (8.5% vs. 4.9%; p = 0.003), dental abscess (4.4% vs. 0%; p &amp;lt; 0.00001), sinusitis (2.4% vs. 0.2%; p &amp;lt; 0.00001) and soft skin tissue infections (5.3% vs. 0.8%; p &amp;lt; 0.00001). In the fluoroquinolone subgroups, prescribing per provider type and appropriate dosing per renal function were similar, and there were no adverse events leading to an ED visit or hospitalization within 90 days. Conclusion Implementation of a CDSS resulted in a reduction of overall and targeted indication inappropriate fluoroquinolone prescribing. Disclosures Teri Fanizza, Pharm.D., BCPS, BCIDP, Merck &amp; co inc: Stocks/Bonds|Pfizer Inc: Stocks/Bonds.

1749. Nursing Home Providers’ Empiric Antibiotic Choices for Residents with Urinary Tract Infections: A National Survey

Abstract Background Urinary tract infections (UTIs) are the most common indication for antibiotic prescriptions in nursing homes (NHs) and frequently result in fluoroquinolone (FQ) prescriptions. We performed a vignette-based survey of NH providers to better understand empiric UTI treatment decision-making. Methods Study participants were recruited nationally through professional organizations and snowball sampling from December 2021 to February 2022. Clinical vignettes depicting four UTI presentations in NH residents (1. simple cystitis, 2. pyelonephritis with cephalosporin allergy, 3. catheter-associated UTI and 4. cystitis with history of resistant organism) were developed and distributed via electronic survey. Respondents provided free-text antibiotic choice, which two physicians independently reviewed and implicitly determined if a preferred or not-preferred antibiotic was selected. A panel of three physicians adjudicated discrepancies between the primary reviewers. Analysis was performed in R. Results Of 86 respondents, 74% were physicians and 26% were advanced practitioners. Half of respondents (50%) had &amp;gt;10 years NH experience, 41% were geriatrics trained, and none were infectious disease trained. Figure 1 details antibiotic choices and preferred agents for each case. Overall, 70% of antibiotic choices were deemed preferred antibiotics, with the least number of preferred choices observed for case 3 depicting catheter-associated UTI (53%). FQs (43%) and nitrofurantoin (14%) were the most frequent non-preferred choices. Case 2 received the greatest proportion of FQ prescriptions (38%), but this was a preferred agent. In cases where FQs were not a preferred choice, they comprised 17% of antibiotic choices. There was no difference in FQ or preferred prescribing choices by role. Providers with &amp;gt;10 years NH experience, however, prescribed fewer FQs over the four cases than those with less NH experience (0.7 vs. 1.1, p=0.04). Antibiotic Choice and Preferred Agents per Case Antibiotic choices are ordered from highest to lowest cumulative frequency. Conclusion This sample of NH providers made mostly preferred empiric antibiotic choices, however, FQ use remained high, particularly in providers with less NH practice experience. Further exploration of decision-support tools for empiric antibiotic prescribing in this setting may improve antibiotic stewardship. Disclosures Robin L. Jump, MD, PhD, Merck: Grant/Research Support|Pfizer: Advisor/Consultant.

1787. County Level Association Between the Rate of Fluoroquinolone-Resistance Gram Negative Bacteria and Fluoroquinolone Utilization in Kansas

Abstract Background Kansas ranks as the 8th-worst state nationally for outpatient antibiotic prescribing, with a rate of 690 antibiotic prescriptions per 1000 population. The statewide rate of fluoroquinolone (FQ) is disproportionately higher than other antibiotic drug classes. Statewide antibiograms can be developed by health departments for antimicrobial stewardship monitoring. The purpose of this study was to investigate the correlation between the FQ resistance rate of gram-negative bacteria to FQ consumption. Methods A retrospective design utilizing 2018-2019 county level FQ-resistant Escherichia coli, Klebsiella pneumoniae and Pseudomonas aeruginosa was categorized by county level based on the Kansas statewide antibiogram. Outpatient FQ utilization data was obtained from IQVIA and categorized into county level FQ rate based on prescriptions dispensed per 1000 population. Linear regression was used to compare antibiotic resistance (AR) to FQ utilization by county. Results Sixty-six of 123 facilities contacted for antibiogram data responded with results. Of these, 47 were critical access hospitals, and the rest were acute care hospitals or clinics. A total of 31,573 E. coli isolates, 5,942 K. pneumoniae and 5,017 P. aeruginosa isolates were represented. All 106 counties had FQ prescription data. Of the 49 counties with AR reported, FQ rates ranged from 4.6 to 105.6/1000 population. There was no statistical significance associated between counties for FQ-resistant E. coli, K. pneumoniae or P. aeruginosa with FQ-utilization rates (p=0.184, 0.572, 0.352, respectively). Comparing urban and rural regions was also compared for each AR-FQ use combination. There was statistical significance for urban P. aeruginosa FQ-resistance and FQ utilization (p=0.025), but not for urban E. coli (p=0.120) or urban K. pneumoniae (p=0.331). Conclusion A strong correlation was demonstrated between FQ consumption and rates of FQ-resistant P. aeruginosa within urban counties. No significant correlations were found between FQ consumption rates and other organisms. This study demonstrates additional applications for state-level antibiogram data, particularly when paired with antibiotic use data. Disclosures All Authors: No reported disclosures.

149 Patterns of Fluoroquinolone Use in the Emergency Department 2009 - 2019

Fluoroquinolone antibiotics, with high concentration in the prostate and lung tissue, are excellent candidates for urinary and respiratory infections. However, since 2008, their usage might have been declining, potentially secondary to adverse effects, per warning by the US Food and Drug Administration. This study aims to examine the trend in fluoroquinolone prescribing in emergency departments (ED) from 2009-2019.

229 Clinical Decision Support for Antibiotic Stewardship in the Emergency Department

Antibiotic resistance is an important patient safety issue and is among the greatest public health threats today. A behaviorally enhanced quality improvement (QI) intervention reduced inappropriate prescribing for acute respiratory infections for emergency department (ED) encounters in our health system. There is a paucity of data on clinical decision support (CDS) implementation in the ED to compliment an antibiotic stewardship program. As part of our multifaceted QI intervention, a CDS was implemented to decrease inappropriate antibiotic prescribing of fluoroquinolones (FQ) and azithromycin in the ED.

Current Status of Outpatient Oral Antimicrobial Prescription and the Influence of Antimicrobial Stewardship for Inpatients: A Repeated Cross-Sectional Study at a Japanese Community Hospital.

This study aimed to clarify the details of outpatient oral antimicrobial use (AMU) at a Japanese community hospital and investigate the influence of the current inpatient-based antimicrobial stewardship (AS) on outpatients. A repeated cross-sectional study was conducted in Komaki City Hospital. Data on patients, physicians, and oral antibiotics were collected in October 2013, 2016, and 2019, and appropriateness of treatment and surgical antimicrobial prophylaxis (SAP) was evaluated. The percentage of patients receiving oral antibiotics increased significantly from 4.7% in 2013 (345/7338) to 5.9% in 2019 (365/6146), and the overall number of antimicrobial prescriptions per 1000 outpatients increased from 51.8 in 2013 to 68.0 in 2019. Prescriptions for third-generation cephalosporins per 1000 outpatients decreased (from 21.4 to 6.3), whereas the number of prescriptions for penicillin (from 3.8 to 15.3), fluoroquinolones (from 7.0 to 13.2), and co-trimoxazole (from 5.0 to 15.8) increased from 2013 to 2019. The appropriate AMU for overall infections significantly increased (from 68.4% in 2013 to 83.7% in 2019). The choice and duration of AMU significantly improved for SAP. However, even in 2019, only 29.3% of patients received antibiotics before surgery. The improved selection of antibiotics on outpatient prescription may be due to the influence of AS-which is focused on inpatients-while prescriptions for fluoroquinolones and prophylactics also increased. The challenges of antimicrobial administration after surgeries were also highlighted.

Systematic review of antibiotic stewardship interventions for urinary tract infection management in the ambulatory setting

Background: Urinary tract infections (UTIs) are common indications for antibiotics in ambulatory setting, and inappropriate use is prevalent. Fluoroquinolones account for 40% of antibiotics prescribed for uncomplicated UTIs, despite clinical guidance against their use as firstline agents. We conducted a systematic review to determine which antibiotic stewardship intervention(s) are effective in improving antibiotic prescribing for UTIs in the ambulatory setting. Methods: Following PRISMA guidelines, English-language literature from 1995 to September 21, 2021, was searched for articles about antimicrobial stewardship, UTI, and ambulatory setting from PubMed, Embase, and Central. Additional articles were identified from authors’ collections and references of pertinent articles. Studies were included if the authors implemented intervention targeting adults 18 years and older in outpatient setting (excluding emergency departments). Interventions were categorized into Guideline Development and Dissemination (GDD), Audit and Feedback, Clinical Decision Support System (CDSS), and Multimodal Interventions. Results: The literature search identified 1,899 papers; 14 papers were included in this review; and 4 additional papers were identified from other sources. The main interventions were GDD in 6 studies, audit and feedback in 3 studies, CDSS in 4 studies, and multimodal interventions in 5 stidues. These studies had heterogeneity of the practice settings and interventions. Moreover, 11 studies targeted primary care, 2 studies targeted urgent care, 1 study targeted both primary and urgent care, 2 studies were conducted in spinal cord injury clinics, and 2 studies were conducted in hospital-wide outpatient sites. Outcomes included (1) statistically significant increase in guideline-concordant antibiotic prescribing in 12 studies (range, 4.6%–246%); (2) statistically significant decrease in fluoroquinolone prescriptions (range, 9.1%–86.3%) in 7 of 9 studies focusing on fluoroquinolones; (3) significant decreases in drug resistance in urine pathogens in 2 studies that evaluated this. Provider education, in conjunction with passive CDSS tools, such as integrating order sets for UTI prescriptions with prefilled instructions into electronic medical records appeared most beneficial. Several studies have investigated negative impact and have found no increase in retreatment rates or worse outcomes. Conclusions: Our systematic literature review identified a limited number of studies with a variety of interventions that improved antibiotic use for UTIs in the ambulatory care setting. Provider education, in conjunction with CDSS tools, can be less time-consuming than audit and feedback and can target a large number of providers and practices. Future studies need to address sustainability over longer periods and should target specialty clinic populations because they have high burden of patients with multidrug-resistant UTI organisms.Funding: NoneDisclosures: None

Prescribing of common outpatient antibiotics for respiratory infections in adults amid the COVID-19 pandemic in Brazil

Background: Inappropriate antibiotic use for SARS-CoV-2 infection has the potential to increase the burden of antibiotic resistance. Brazil experienced spread of a new SARS-CoV-2 variant in the fourth quarter (Q4) of 2020, resulting in the highest case counts in Latin America, raising concerns of antibiotic overuse. To better understand antibiotic use during the COVID-19 pandemic, we evaluated prescribing changes in antibiotics commonly used for outpatient respiratory infections (amoxicillin-clavulanate, azithromycin, and levofloxacin or moxifloxacin [AALM]) among adults aged ≥20 years in Brazil in 2020 versus 2019. Methods: We analyzed the IQVIA MIDAS medical data set for AALM prescribing by age group (20–39, 40–59, 60–64, 65–74, ≥75 years), comparing Q4 2020 rates to those in Q4 2019. We estimated crude rate ratios and 95% CIs using prescription number as the numerator (assuming Poisson counts) and age-adjusted population as the denominator. We also determined the most common prescribing specialties for each antibiotic across both time points. Results: Compared to Q4 2019, Q4 2020 azithromycin prescribing increased among all ages, ranging from 90.7% (95% CI, 90.0%–91.4%) in those aged 20–39 years to 927.2% (95% CI, 912.9%–941.7%) in those aged 65–74 years (Fig. 1). Amoxicillin-clavulanate prescribing decreased for most ages, ranging from −78.4% (95% CI, −78.7% to −78.1%) in those aged 60–64 years to −25.8% (95% CI, −26.6% to −25.0%) in those aged 65–74 years. Prescribing of levofloxacin or moxifloxacin decreased for most ages, ranging from −39.1% (95% CI, −39.4% to −38.8%) in those aged 20–39 years to −16.9% (95% CI, −18.1% to −15.7%) in those aged 60–64 years. For those aged ≥75 years, prescribing of amoxicillin-clavulanate and levofloxacin or moxifloxacin increased by 13.2% (95% CI, 11.9%–14.5%) and 43.1% (95% CI, 41.7%–44.5%), respectively. In Q4 2019 and Q4 2020, the 2 most common prescribing specialties for azithromycin were general practice (48%–50% of prescriptions) and gynecology (19%–25%). Compared to Q4 2019, infectious disease specialists in Q4 2020 saw the largest decline in percentage of azithromycin prescriptions (10% to 1%) and surgeons saw the largest increase (0% to 7%). General practitioners were also the most common prescribers of the remaining antibiotics (43%–54%), followed by gynecology for levofloxacin or moxifloxacin (25%–29%) and otolaryngology for amoxicillin-clavulanate (14%–20%). Conclusions: Despite decreases in prescribing of amoxicillin-clavulanate and respiratory fluoroquinolones for most adults, azithromycin prescribing increased dramatically across all adults during the COVID-19 pandemic. Targeting inappropriate outpatient antibiotic use in Brazil, particularly azithromycin prescribing among general practitioners, gynecologists, and surgeons, may be high-yield targets for antibiotic stewardship.Funding: NoneDisclosures: None