Inappropriate Antibiotic Selection Research Articles

Compliance with National guidelines for antibiotic prophylaxis use in surgery: A case study in Thu Duc City Hospital, South of Vietnam

Objectives: To evaluate compliance with national guidelines for surgical antibiotic prophylaxis use (SAP) at a general hospital in southern Vietnam and explore the impact of patient and surgery demographics on compliance. Methods: A cross-sectional study using quantitative methods was used. A total of 270 medical records (MRs) of patients who underwent clean or clean-contaminated surgeries between January 1, 2021, and June 30, 2021, at Thu Duc City Hospital were selected by systematic random sampling. A range of data was collected, which included patient demographics, surgery type, and antibiotic selection, as well as appropriate timing, route of administration, and duration of prophylaxis for each surgical procedure. Evaluating compliance based on the national practice standards for SAP. Data were entered by Epidata 3.0 and analyzed by SPSS 22.0 software. Results: Of the 270 cases included in the study, the overall compliance rate of SAP use was only 17.0%. Inadequate timing of SAP administration (17.8%) was the major cause of non-compliance, follow by inappropriate antibiotic selection (77.0%). Furthermore, patient and surgery characteristics were found to play a significant role in compliance with guidelines, with gender, surgery type, wound infection condition, and pre-operative hospital stay all having notable correlations. Conclusion: In conclusion, the overall compliance rate of SAP use was lower than expected, and there was a significant difference among specific types of surgeries. There is a relationship between surgery type, wound infection classification, and length of pre-operative hospital stay with SAP use compliance (p < .01). To improve compliance with national guidelines for SAP use, appropriate timing, and antibiotic selection should be emphasized. Further efforts are still needed to improve the standards of antiseptic surgery in Vietnam. Keywords: Compliance, adherence, antibiotic prophylaxis, surgery, hospital.

Risk Factors and outcomes associated with inappropriate empiric broad-spectrum antibiotic use in hospitalized patients with community-acquired pneumonia

Background: Inappropriate broad-spectrum antibiotic use targeting methicillin-resistant Staphylococcus aureus (MRSA) and Pseudomonas aeruginosa can result in increased adverse events, antibiotic resistance, and Clostridioides difficile infection. In 2019, revised ATS/IDSA community-acquired pneumonia (CAP) guidelines removed healthcare-associated pneumonia (HCAP) as a clinical entity and modified patient factors warranting empiric broad-spectrum antibiotic (BSA) use. As a result, most patients hospitalized with CAP should receive empiric antibiotics targeting standard CAP pathogens. Based on revised guidelines, we evaluated predictors and outcomes associated with inappropriate BSA use among hospitalized patients with CAP. Methods: Between November 2019 and July 2022, trained abstractors collected data on non-ICU adult medical patients admitted with CAP at 67 Michigan hospitals who received either an inappropriate empiric BSA on hospital day 1 or 2 or a standard CAP regimen. Inappropriate empiric BSA use was defined as use of an anti-MRSA or anti-pseudomonal antibiotic in a patient eligible for standard CAP coverage per IDSA guidelines. Patients with immune compromise, moderate or severe chronic obstructive pulmonary disease (COPD), pulmonary complication, or guideline-concordant treatment with BSA were excluded. Data collected included comorbidities, antibiotic use and hospitalizations in the preceding 90 days, cultures in the preceding year, signs or symptoms of pneumonia, hospital characteristics, and 30-day postdischarge patient outcomes. Data were collected through chart review and patient phone calls. Predictors of inappropriate empiric BSA were evaluated using logistic general estimating equation (GEE) models, accounting for hospital-level clustering. We assessed the effect of inappropriate empiric BSA (vs standard CAP therapy) on 30-day patient outcomes using logistic GEE models controlling for predictors associated with the outcome and probability of treatment. Results: Of 8,286 included patients with CAP, 2,215 (26.7%) were empirically treated with inappropriate BSA. The median BSA treatment was 3 days (IQR, 2.5). After adjustments, factors associated with inappropriate empiric BSA treatment included hospitalization or treatment with high-risk antibiotics in preceding 90 days, transfer from a postacute care facility, hemodialysis, support with ≥3 L supplemental oxygen, severe sepsis, leukocytosis, and higher pneumonia severity index (Fig. 1). After adjustments, patients with inappropriate empiric BSA treatment had higher readmissions 30 days after discharge, more transfers to the intensive care unit, more antibiotic-associated adverse events, and longer hospitalizations (Fig. 2). Conclusions: Patients hospitalized with CAP often received inappropriate BSA as empiric coverage, and this inappropriate antibiotic selection was associated with worse patient outcomes. To improve patient outcomes, stewardship efforts should focus on reducing inappropriate BSA use in patients hospitalized for CAP with historic HCAP risk factors or severe CAP without other guideline-directed indications for BSA.Financial support. H.M.S. initiative is underwritten by Blue Cross and Blue Shield of Michigan.Disclosures: None

1743. Antimicrobial and Diagnostic Stewardship Targeting Urinary Tract Infections in the Emergency Department: A Pharmacist-driven Quality Improvement Project at a Tertiary Military Treatment Facility

Abstract Background With the increasing interest in ambulatory stewardship, we designed a quality improvement project to enhance guideline concordant antimicrobial and diagnostic stewardship practices targeting urinary tract infections (UTI) in the ED of a Military Treatment Facility. Between two data collection phases (P1, P2), we provided education on national guidelines, local protocols and antibiograms, modified order-sets, and implemented enhancements targeting urine collection. The primary outcome was a change in guideline-concordant practices between P1 and P2. Methods This prospective pharmacist-driven study had two 3-month data collection periods including ED encounters that resulted in a urinalysis (UA), urine culture (UCx) and antibiotics for UTI upon discharge. We collected data on participant demographics, clinical course and therapy details via chart review. Culture callback and corresponding interventions were made within 72 hours. Based on P1 results, we broadened our scope in P2 to include a diagnostic stewardship arm (Figure 1). This project was IRB approved under a non-research determination. Results There were no significant changes in guideline-concordant prescribing or diagnostic practices between P1 and P2 (Figure 2). Inappropriate antibiotic selection was primarily due to use of cephalosporins and FQs as first line agents (Table 1). The primary pharmacy intervention was discontinuation of therapy (P1 29.1%, P2 39.8%). One-third of patients receiving antibiotics were asymptomatic, a majority of which had a positive UA (P1 68.4%, P2 73.3%). There was a high rate of UCx contamination which improved in P3 but did not reach statistical significance (P1 25.6%, P2 17.2%, p=0.19). Across all P2 encounters, 51.4% of UCx were deemed inappropriate. Conclusion Significant guideline-discordant prescribing persisted despite interventions. An overreliance on UA findings results in treatment of asymptomatic bacteriuria. Education and order-set modification alone are insufficient for a lasting impact on prescribing practices especially where there is a high rate of provider turnover. An EMR with embedded clinical and alert-based decision support capabilities are likely to make a sustained impact in curbing inappropriate treatment of asymptomatic bacteriuria. Disclosures All Authors: No reported disclosures.

1229. Evaluation of Colorectal and Hip/Knee Arthroplasty Surgical Site Infections at Ocean University Medical Center

Abstract Background A surgical site infection (SSI) is defined as an infection that occurs up to 30 days after surgery without an implant (or within one year if an implant is placed). The infection also must appear to be related to surgery. In 2021, there were 19 SSIs reported at Ocean University Medical Center (OUMC). These SSIs were associated with colorectal and hip/knee arthroplasty cases. The primary objective of this study is to evaluate appropriate preoperative antibiotic administration based on the type of surgical procedure. Some secondary objectives include the number of preoperative antibiotics administered and the appropriate timing of preoperative antibiotic administration. Methods A retrospective observational evaluation was conducted on patients identified to have a SSIs from January 1, 2021, to December 31, 2021. Appropriate preoperative antibiotics were defined as the administration of guideline-recommended antibiotics for the given procedure. Appropriate timing of antibiotics was defined as antibiotics administered within guideline-recommended time frames prior to procedure start time. Descriptive statistics were used to analyze the results. Results Of the 19 infections, ten were associated with colorectal procedures, and nine were associated with hip/knee arthroplasty procedures. Patients received preoperative antibiotics in 89% of the surgeries (17 of 19). We found that 71% (12 of 17) of patients received appropriate antibiotics determined by the surgical procedure. Of the five inappropriate antibiotic selection instances, two lacked appropriate bacterial coverage, while the other three covered the suspected pathogens but were not guideline-recommended agents. The timing of preoperative antibiotics was found to be appropriate in 76% of all surgeries. When assessing the overall compliance with antibiotic selection and timing, 58% (11 of 19) of cases followed all guideline recommendations. Conclusion This study has identified areas of improvement regarding the antimicrobial selection and timing, documentation process of administration, and the use of order sets to combat inappropriate prescribing of surgical antimicrobial prophylaxis. Educational materials and in-services have been provided at OUMC. Disclosures All Authors: No reported disclosures.

Efficacy of VERIGENE® Blood Culture Assays in Accurately and Rapidly Detecting Gram-Negative and Gram-Positive Pathogens.

Rapid administration of appropriately indicated antibiotics is crucial in septic patients. Sepsis data supports that there is a higher risk of mortality for each hour delay from triage to antibiotic therapy, as well as for inappropriate antibiotic selection. There are a variety of rapid microbial detection systems, such as VERIGENE®, used in acute care facilities to rapidly detect bacteremia and identify resistance markers. Our study investigates the usefulness of VERIGENE® assays in accurately detecting Gram-positive and Gram-negative pathogens when compared to traditional blood culture analysis systems, such as VITEK®. 819 Gram-positive and 373 Gram-negative blood samples were collected and tested using both VERIGENE® and VITEK®. Statistical tests were two-tailed and observations were defined as statistically significant if P ≤ 0.05. VERIGENE® detected a pathogen in 816/819 (99.6%) samples of the Gram-positive blood cultures and 367/373 (98.3%) samples of the Gram-negatives compared to 805/819 (98.3%) and 367/373 (98.4%), respectively, using VITEK®. Gram-positive cultures had a sensitivity of 99.5% and a specificity of 27.3% (PPV 99.0%, NPV 42.9%, 98.7% accuracy) with VERIGENE analysis. Gramnegatives had a sensitivity of 99.2% and a specificity of 20.0% (PPV 98.9%, NPV 25.0%, 98.4% accuracy). Although statistically insignificant (P = 0.25), VERIGENE® was 1.3% more likely to identify Gram-positive bacteria when compared to conventional methods. Overall, we concluded that VERIGENE® assays are valuable in their ability to rapidly detect microorganisms and resistance markers, given their high sensitivities. This allows for select targeted therapy in patients with sepsis and can ultimately reduce mortality rates.

97. Pharmacist Driven Antimicrobial Stewardship Interventions on the Management of Urinary Tract Infections in the Emergency Department at a Tertiary Military Treatment Facility

BackgroundWith the Joint Commission standards targeting ambulatory settings serving as a catalyst, we designed a quality improvement (QI) project was designed to evaluate the existing management and prescribing patterns for urinary tract infections (UTI) in the Walter Reed National Military Medical Center (WRNMMC) Emergency Department (ED) in order to identify targets for ASP intervention. MethodsThis was a Pharmacist-driven, prospective, QI project conducted over a 3-month period. The clinical presentations and microbiological data of uncomplicated cystitis and pyelonephritis cases managed in the ED were reviewed. Within 24-72 hours of ED discharge, recommendations were relayed to both patients and ED staff. Diagnostic criteria and management concordant with established clinical guidelines were assessed. Inclusion criteria included age ≥ 18, admission status, urine culture and antibiotics for UTI or pyelonephritis.ResultsA daily urinalysis (UA) report identified 1781 ED encounters of which 117 cases met inclusion criteria. Nitrofurantoin was most prescribed empirically at 39.3% followed by a cephalosporin (23.1%) or a fluoroquinolone (19.7%), accounting for 32% of inappropriate empiric antibiotic selection. Cases were identified with inappropriate duration of therapy (22.2%), dosage (9.4%), and drug-bug mismatch (9.4%). Nearly 38% of cases required intervention to discontinue (32.5%) or initiate new antibiotics (3.4%). Diagnostic concordance was defined as having positive urinary symptoms, clinically significant UA and positive urine culture. This was only observed in 37.6% of all cases, of which only 43.2% were treated with a guideline concordant empiric regimen, dosage and duration of therapy. Although not included in the final analysis, it was noted 916 urine culture results were ordered where 70% were not associated with genitourinary complaints or sepsis.ConclusionDespite guidelines for UTI management, considerable practice discordance was found in the ED. Multiple Pharmacist targeted interventions were identified. Prioritized areas for ED provider education include first-line therapy, treatment duration, and diagnostic stewardship. This QI project has potential for optimizing prescribing practices in Military Health System ambulatory settings. Disclosures All Authors: No reported disclosures

WHO key access antibiotics prices, availability and affordability in private sector pharmacies in Pakistan

BackgroundPoor availability and unaffordability of key access antibiotics may increase antimicrobial resistance in the community by promoting inappropriate antibiotic selection and abridged therapy compliance.ObjectiveTo check the prices, availability, and affordability of the World Health Organization (WHO) key access antibiotics in private sector pharmacies of Lahore, Pakistan.MethodologyA survey of WHO key access antibiotics from WHO essential medicine list 2017 was conducted in private sector pharmacies of 4 different regions of Lahore employing adapted WHO/HAI methodology. The comparison of prices and availability between originator brands (OB) and lowest price generics (LPG) were conducted followed by the effect of medicine price differences on patient’s affordability. The data were analyzed using a preprogrammed WHO Microsoft excel workbook.ResultsThe mean availability of OB products was 45.20% and the availability of LPGs was 40.40%. The OBs of co-amoxiclav, clarithromycin and metronidazole and LPGs of azithromycin and ciprofloxacin were easily available (100%) in all private sector pharmacies. Whereas, antibiotics like chloramphenicol, cloxacillin, nitrofurantoin, spectinomycin, and cefazolin were totally unavailable in all the surveyed pharmacies. The OBs and LPGs with high MPRs were ceftriaxone (OB; 15.31, LPG; 6.38) and ciprofloxacin (OB; 12.42, LPG; 5.77). The median of brand premium obtained was 38.7%, which varied between the lowest brand premium of 3.97% for metronidazole and highest for ceftriaxone i.e. 140%. The cost of standard treatment was 0.5 day’s wage (median) if using OB and 0.4 day’s wage (median) for LPG, for a lowest paid unskilled government worker. Treatment with OB and LPG was unaffordable for ciprofloxacin (OB; 2.4, LPG; 1.1) & cefotaxime (OB; 12.7, LPG; 8.1).ConclusionThere is dire need to properly implement price control policies to better regulate fragile antibiotic supply system so that the availability of both OB and LPG of key access antibiotics should be increased. The prices could be reduced by improving purchasing efficiency, excluding taxes and regulating mark-ups. This could increase the affordability of patients to complete their antibiotic therapy with subsequent reduction in antimicrobial resistance.

Healthcare utilization associated with adherence to antibiotics for abdominal surgeries in Japan: cross-sectional analysis of administrative database.

Since patients receiving surgery may experience surgical site infections, therapeutic guidelines for reducing hospitalization time and cost include appropriate antibiotic use. However, the association between adherence to therapeutic guidelines and healthcare utilization is currently unclear. This study aimed to confirm the positive association between the adherence to guidelines of antibiotic therapy and a reduction in the length of stay and cost of hospitalization, especially considering the high infection rates in abdominal surgery. This cross-sectional study used administrative data (diagnosis procedure combination data) collected using the case-mix system implemented in acute-care hospitals in Japan. We assessed the length of hospital stay and cost of hospitalization for patients who received prophylactic antibiotic for abdominal surgeries consistent with therapeutic guidelines. The data of patients aged 15 years or older who received appendectomy, laparoscopic cholecystectomy or inguinal hernia repair were extracted. The appropriateness of antibiotic prophylaxis was evaluated in terms of the Japanese guidelines for antibiotic selection and treatment duration. To assess the mean difference in antibiotic costs and length of stay, we performed the propensity score matching by confounding factors. Furthermore, we assessed the progress in healthcare utilization of this therapy over a decade. Of the 302 233 patients who received single general surgery from April 2014 to March 2016, 198 885 were eligible for analysis after applying the exclusion criteria (143 975 in the adherence and 54 910 in the non-adherence group). Each group comprised 48 439 patients after propensity score matching. Inappropriate antibiotic selection and duration were observed in 9294 (9.8%) and 687 (0.7%) of inguinal hernia repairs, 6431 (25.3%) and 311 (1.2%) of appendectomies and 38 134 (48.5%) and 391 (0.5%) of laparoscopic cholecystectomy cases, respectively. After propensity score matching by operation type, average hospitalization length (6.5 [SD 3.8] and 7.3 [SD 4.8] days) and costs (536 000 [SD 167 000] JPY and 573 000 [SD 213 000] JPY) differed significantly between adherence and non-adherence groups. The results revealed that unnecessary healthcare utilization was associated with failure to adhere to therapeutic guidelines for prophylactic antibiotic therapy in elective general surgeries. We concluded that the progress of reduction in length of hospitalization over the decade was successful. Notably, adherence to treatment duration was better than that was 10 years ago. In this decade, administrators in hospitals have attempted to reduce the duration of hospitalization by developing various clinical pathways for surgical procedures and quality indicators. However, 15 877 patients (8.7%) were prescribed oral antibiotics the day after surgery. These observations should be evaluated further.

Systematic Review on the Impact of Guidelines Adherence on Antibiotic Prescription in Respiratory Infections.

Overuse and inappropriate antibiotic prescription for respiratory tract infections (RTI) are one of the major contributors to the current antibiotic resistance problem. Guidelines provide support to prescribers for proper decision-making. Our purpose is to review the impact of prescribers’ exposure to guidelines in antibiotic prescription for RTIs. A systematic review was performed searching in the scientific databases MEDLINE PubMed and EMBASE for studies which exposed prescribers to guidelines for RTI and compared antibiotic prescription rates/quality before and after the implementation, with thirty-four articles included in the review. The selected studies consisted on a simple intervention in the form of guideline implementation while others involved multifaceted interventions, and varied in population, designs, and settings. Prescription rate was shown to be reduced in the majority of the studies, along with an improvement in appropriateness, defined mainly by the prescription of narrow-spectrum rather than broad-spectrum antibiotics. Intending to ascertain if this implementation could decrease prescription costs, 7 articles accessed it, of which 6 showed the intended reduction. Overall interventions to improve guidelines adherence can be effective in reducing antibiotic prescriptions and inappropriate antibiotic selection for RTIs, supporting the importance of implementing guidelines in order to decrease the high levels of antibiotic prescriptions, and consequently reduce antimicrobial resistance.

Modeling inpatient and outpatient antibiotic stewardship interventions to reduce the burden of Clostridioides difficile infection in a regional healthcare network.

Antibiotic exposure can lead to unintended outcomes, including drug-drug interactions, adverse drug events, and healthcare-associated infections like Clostridioides difficile infection (CDI). Improving antibiotic use is critical to reduce an individual’s CDI risk. Antibiotic stewardship initiatives can reduce inappropriate antibiotic prescribing (e.g., unnecessary antibiotic prescribing, inappropriate antibiotic selection), impacting both hospital (healthcare)-onset (HO)-CDI and community-associated (CA)-CDI. Previous computational and mathematical modeling studies have demonstrated a reduction in CDI incidence associated with antibiotic stewardship initiatives in hospital settings. Although the impact of antibiotic stewardship initiatives in long-term care facilities (LTCFs), including nursing homes, and in outpatient settings have been documented, the effects of specific interventions on CDI incidence are not well understood. We examined the relative effectiveness of antibiotic stewardship interventions on CDI incidence using a geospatially explicit agent-based model of a regional healthcare network in North Carolina. We simulated reductions in unnecessary antibiotic prescribing and inappropriate antibiotic selection with intervention scenarios at individual and network healthcare facilities, including short-term acute care hospitals (STACHs), nursing homes, and outpatient locations. Modeled antibiotic prescription rates were calculated using patient-level data on antibiotic length of therapy for the 10 modeled network STACHs. By simulating a 30% reduction in antibiotics prescribed across all inpatient and outpatient locations, we found the greatest reductions on network CDI incidence among tested scenarios, namely a 17% decrease in HO-CDI incidence and 7% decrease in CA-CDI. Among intervention scenarios of reducing inappropriate antibiotic selection, we found a greater impact on network CDI incidence when modeling this reduction in nursing homes alone compared to the same intervention in STACHs alone. These results support the potential importance of LTCF and outpatient antibiotic stewardship efforts on network CDI burden and add to the evidence that a coordinated approach to antibiotic stewardship across multiple facilities, including inpatient and outpatient settings, within a regional healthcare network could be an effective strategy to reduce network CDI burden.

A Prospective Observational Study on Rational Use of Antibiotics for Paediatric Patients with Respiratory Tract Infections in a Tertiary Care Hospital

Background: Antibiotic drug overuse and inappropriate antibiotic drug selection are associated with increased drug resistance among respiratory pathogens (most notably, Streptococcus pneumoniae), possible progression to chronic disease, and increased treatment costs.[1] The selection of an antibiotic for prophylaxis should be based on known or likely target pathogens, for a short duration of time.
 Objective: To evaluate Rational use of antibiotics in Paediatric patients suffering from Respiratory tract infections.
 Method: It was Prospective, observational study conducted by random selection of patients. Based on diagnosis, the study population was categorized into 2 groups: Upper respiratory tract infections and Lower respiratory tract infections. The study population was interviewed after obtaining written informed consent for information like demographics, diagnosis, treatment and antibiotics prescribed.
 Results and Discussion: In our study population, it was observed that male patient (74%) were higher than female patients (26%). Total number of antibiotics prescribed during the study period is 83. Most commonly prescribed antibiotic was Augmentin (Amoxicillin +Clavulanic acid) of dose (450mg IV BD) which is the combination drug, i.e, more effective than individual antibiotic drugs.
 Conclusion: In the present study it is observed that 4-different classes of antibiotics-Pencillins,Cephalosporins,Macrolides and Aminoglycosides were prescribed and used for different Respiratory diseases.The percentage of average antibiotic utilization is highest in Lower Respiratory Tract Infection with (55.22%).Mostly used Antibiotic in males for both LRTI and URTI is Augmentin with the percentage of (52%) and (80%) respectively.Where as in females it is observed that in both LRTI and URTI mostly used Antibiotic is Augmentin with percentage of (38.8%) and( 80%) respectively.Overall Second mostly used antibiotic is Ceftriaxone.
 Keywords: pediatrics, lower and upper respiratory tract infections, antibiotics.

Antibiotic resistance in childhood urinary tract infections: A single-center experience.

Aim:Urinary tract infections are the most common genitourinary tract disease in children, and inappropriate antibiotic and/or dose selection increase the likelihood of resistance. The aim of this study was to determine the prevalence of urinary tract infection pathogens, patterns of resistance to antibiotics, and empirical treatment options.Material and Methods:Between January 2013 and December 2017, urine culture and antibiogram results of pediatric patients aged 0 days to 16 years were analyzed retrospectively. Antibiotic susceptibilities were determined using disc diffusion according to methods of the Clinical and Laboratory Standards Institute.Results:Of the 1326 children with culture growth, 1070 (80.6%) were female and 256 (19.3%) were male. The most common microorganism found was (1138, 85.8%) E. Coli, followed by Klebsiella spp. (71, 5.3%), Enterobacter spp. (44, 3.3%), and Proteus spp. (28, 2.1%). High frequency of resistance to ampicillin, ampicillin-sulbactam, amoxicillin-clavulanate, cefuroxime axetil, as TMP-SMX was detected in all microorganisms, whereas resistance to amikacin, meropenem, imipenem, ertapenem, fosfomycin, and nitrofurantoin was low.Conclusion:E. coli was the most common causative agent of urinary tract infections in childhood. High resistance to ampicillin, ampicillin-sulbactam, amoxicillin-clavulanate, cefuroxime axetil, and TMP-SMX was detected in all agents in our center.

PROSPECTIVE OBSERVATIONAL STUDY ON ANTIBIOTIC-PRESCRIBING PATTERN AND MEDICATION ERRORS IN SURGICAL PROPHYLAXIS IN A SPECIALTY HOSPITAL

Objective: The objective was to study the antibiotic-prescribing patterns, identify the medication errors and impact of surgical antimicrobial prophylaxis (SAP) in preventing surgical site infection (SSI), and to understand the prescribers’ adherence to surgical prophylaxis guidelines.
 Methods: The study was conducted for a period of 6 months in all surgical departments of a specialty hospital. Data were collected from inpatients records. Australian guideline for SAP was used to assess the appropriateness in prescribing pattern. The sample size was calculated using Raosoft sample size calculator.
 Results: A prospective observational study was carried out among 178 patients. Of which, 100 were male and 78 were female. Four hundred and thirty-three antimicrobials were prescribed as pre- and post-operative surgical prophylaxis, among that 87% prescribed by brand name and 13% by generic. Seventy-one percent received single antimicrobial agent preoperatively, of which 99.5% prescribed as parenteral and 0.5% as oral formulation. Most often prescribed antibiotic was cefoperazone (28%) of cephalosporin group. Only 5.6% of cases had compliance with SAP guidelines. In this study, 11 patients affected with SSI due to inappropriate antibiotic selection and non-adherence to prophylactic antibiotic guidelines.
 Conclusion: The present study revealed that there is a poor compliance to SAP guidelines in terms of inappropriateness in antibiotic drug selection, dose, duration, and omission of drugs. Inappropriateness and non-compliance are mainly due to unavailability of clinical pharmacist to assist the physicians in the selection and administration of correct choice of prophylactic drug and unavailability of proper national or local guidelines. Hence, there is dire need to make local SAP guidelines to improve SAP-prescribing pattern.

1185. Impact of Utilizing Drug Resistance in Pneumonia (DRIP) Score on Management of Pneumonia

BackgroundPneumonia is a leading cause of infection-related admissions and death. It is imperative that appropriate antibiotic therapy is selected. Traditional scoring systems for identifying at-risk persons for drug-resistant pathogens– i.e., Healthcare-associated pneumonia (HCAP), have been inaccurate and often lead to inappropriate antibiotic selection. A novel pneumonia scoring system –“Drug Resistance in Pneumonia (DRIP)” was implemented at the Detroit Medical Center (DMC) in January 2018. The objective of this study was to evaluate the effectiveness of the DRIP score in reducing the use of broad-spectrum antibiotics and the impact on key outcomes in patients treated for pneumonia.MethodsA retrospective chart review of 89 patients admitted to the DMC for treatment of pneumonia was conducted—45 patients prior to and 44 patients post-implementation of the DRIP score. Basic demographics, signs and symptoms, antibiotics data, pneumonia severity score (CURB – 65), Charlson co-morbidity score, and outcome measures were compared. DRIP scores and HCAP risk factors were calculated for all patients. The definitions of broad-spectrum antibiotics (BSA) were consistent with DMC guidelines for the treatment of pneumonia (antibiotics targeting nosocomial Gram-negative organisms and/or methicillin-resistant Staphylococcus aureus).ResultsDemographics are shown in Table 1. 18 (40%) of the pre-implementation cohort had risk factors for resistance (HCAP risk factors) compared with 14 (32%) in the post. Conversely, 15 (33%) of the pre-implementation cohort had risk factors for resistance (DRIP ≥4) compared with 8 (18%) in the post-implementation period (Table 2). A difference in BSA prescribing was seen in patients previously characterized as having a high risk of resistance (HCAP) but with DRIP score <4 [5/7 (72%) vs.1/7 (16%) (Table 2)]. BSA use was 24 (53%) in the pre-implementation cohort and 12 (27%) in post-implementation cohort, P = 0.03. Durations of antibiotics were 8.3 days vs. 9.8 days respectively, P = 0.04. Readmission with pneumonia at 30 days was 3 (7.5%) for both groups.ConclusionThe implementation of a novel DRIP scoring system resulted in improved prescribing patterns and a significant reduction of broad-spectrum antibiotics by 26% as compared with traditional HCAP score. Disclosures All authors: No reported disclosures.

Infection-mediated preterm birth: Bacterial origins and avenues for intervention.

Preterm birth (PTB) is globally the leading cause of death and disability in children under five years of age. Intra-amniotic infection is well recognised as a major cause of PTB. Importantly, it is the most common cause of extreme PTB (birth prior to 28weeks gestation), which is frequently associated with a wide range of serious neonatal morbidities. Recent developments in next generation sequencing technologies, combined with many years of culture-based microbiological data have allowed us to gain a deeper understanding of the pathogenesis of infection-mediated PTB. In particular, studies have revealed numerous potential routes to intra-amniotic infection beyond the classically described ascending vaginal route. Currently, antibiotic therapy is standard treatment for suspected or confirmed intra-amniotic infection, although its use in this context has had mixed success due to problems ranging from inappropriate antibiotic selection in relation to the target organism/s, to poor transplacental drug passage. In this review, we will draw together evidence from animal models and human studies to characterise pathways to intra-amniotic infection. We will then thoroughly outline current therapeutic protocols for cases of intra-amniotic infection and suggest potential new avenues for treatment.

Antimicrobial Stewardship: Analysis of Provider Management of Drug-Bug Mismatch in Multi-Drug Resistant Organisms in a Large Medical Group

BACKGROUND The Centers for Disease Control and Prevention (CDC) estimates that 50% of antibiotics used in the outpatient setting are ordered inappropriately. Inappropriate antibiotics can lead to adverse patient outcomes, including clostridium difficile infection and antibiotic-resistant organisms. The purpose of this study is to review inappropriate antibiotic selection, drug-bug mismatch, in a large medical group. METHODS In a large multi-specialty medical group, encompassing 450 sites of care, multi-drug resistant organisms (MDROs) were identified by the microbiology department. Culture results included all MDROs identified from June 1 to August 31, 2018. The infection prevention department, upon receipt of the MDRO surveillance data, reviewed the electronic health record (EHR) for potential drug-bug mismatch. Providers were given 24 hours to address the drug-bug mismatch before infection prevention intervention. RESULTS A total of 179 MRDO cases were reviewed. 47 of the cases (26%) had a drug-bug mismatch. In 41 out of the 47 cases (87%), the provider recognized the drug-bug mismatch before the 24 hour timeframe and changed to effective antimicrobial therapy. 6 out of the 47 cases (13%) required infection prevention intervention. Of the 47 drug-bug mismatches identified, 30 (64%) were Methicillin-resistant Staphylococcus aureus (MRSA) in various wound cultures. 17 (36%) were Escherichia coli or Klebsiella pneumoniae Extended Spectrum Beta-Lactamases (ESBL) producing organisms. CONCLUSIONS This review identifies that providers in a large medical group most often manage drug-bug mismatches appropriately. This model of infection prevention intervention identifies 6 patients (13%) that benefited from early identification of inappropriate antimicrobial selection. The Centers for Disease Control and Prevention (CDC) estimates that 50% of antibiotics used in the outpatient setting are ordered inappropriately. Inappropriate antibiotics can lead to adverse patient outcomes, including clostridium difficile infection and antibiotic-resistant organisms. The purpose of this study is to review inappropriate antibiotic selection, drug-bug mismatch, in a large medical group. In a large multi-specialty medical group, encompassing 450 sites of care, multi-drug resistant organisms (MDROs) were identified by the microbiology department. Culture results included all MDROs identified from June 1 to August 31, 2018. The infection prevention department, upon receipt of the MDRO surveillance data, reviewed the electronic health record (EHR) for potential drug-bug mismatch. Providers were given 24 hours to address the drug-bug mismatch before infection prevention intervention. A total of 179 MRDO cases were reviewed. 47 of the cases (26%) had a drug-bug mismatch. In 41 out of the 47 cases (87%), the provider recognized the drug-bug mismatch before the 24 hour timeframe and changed to effective antimicrobial therapy. 6 out of the 47 cases (13%) required infection prevention intervention. Of the 47 drug-bug mismatches identified, 30 (64%) were Methicillin-resistant Staphylococcus aureus (MRSA) in various wound cultures. 17 (36%) were Escherichia coli or Klebsiella pneumoniae Extended Spectrum Beta-Lactamases (ESBL) producing organisms. This review identifies that providers in a large medical group most often manage drug-bug mismatches appropriately. This model of infection prevention intervention identifies 6 patients (13%) that benefited from early identification of inappropriate antimicrobial selection.

Inappropriate use of antibiotics for childhood diarrhea case management \u2014 Kenya, 2009\u20132016

BackgroundAntibiotics are essential to treat for many childhood bacterial infections; however inappropriate antibiotic use contributes to antimicrobial resistance. For childhood diarrhea, empiric antibiotic use is recommended for dysentery (bloody diarrhea) for which first-line therapy is ciprofloxacin. We assessed inappropriate antibiotic prescription for childhood diarrhea in two primary healthcare facilities in Kenya.MethodsWe analyzed data from the Kenya Population Based Infectious Disease Surveillance system in Asembo (rural, malaria-endemic) and Kibera (urban slum, non-malaria-endemic). We examined records of children aged 2–59 months with diarrhea (≥3 loose stools in 24 h) presenting for care from August 21, 2009 to May 3, 2016, excluding visits with non-diarrheal indications for antibiotics. We examined the frequency of antibiotic over-prescription (antibiotic prescription for non-dysentery), under-prescription (no antibiotic prescription for dysentery), and inappropriate antibiotic selection (non-recommended antibiotic). We examined factors associated with over-prescription and under-prescription using multivariate logistic regression with generalized estimating equations.ResultsOf 2808 clinic visits with diarrhea in Asembo, 2685 (95.6%) were non-dysentery visits and antibiotic over-prescription occurred in 52.5%. Of 4697 clinic visits with diarrhea in Kibera, 4518 (96.2%) were non-dysentery and antibiotic over-prescription occurred in 20.0%. Antibiotic under-prescription was noted in 26.8 and 73.7% of dysentery cases in Asembo and Kibera, respectively. Ciprofloxacin was used for 11% of dysentery visits in Asembo and 0% in Kibera. Factors associated with over- and under-prescription varied by site. In Asembo a discharge diagnosis of gastroenteritis was associated with over-prescription (adjusted odds ratio [aOR]:8.23, 95% confidence interval [95%CI]: 3.68–18.4), while malaria diagnosis was negatively associated with antibiotic over-prescription (aOR 0.37, 95%CI: 0.25–0.54) but positively associated with antibiotic under-prescription (aOR: 1.82, 95%CI: 1.05–3.13). In Kibera, over-prescription was more common among visits with concurrent signs of respiratory infection (difficulty breathing; aOR: 3.97, 95%CI: 1.28–12.30, cough: aOR: 1.42, 95%CI: 1.06–1.90) and less common among children aged < 1 year (aOR: 0.82, 95%CI: 0.71–0.94).ConclusionsInappropriate antibiotic prescription was common in childhood diarrhea management and efforts are needed to promote rational antibiotic use. Interventions to improve antibiotic use for diarrhea should consider the influence of malaria diagnosis on clinical decision-making and address both over-prescription, under-prescription, and inappropriate antibiotic selection.

Urgent action on antimicrobial resistance

Urgent action on antimicrobial resistance

1065. Evaluation of a Staphylococcus aureus Bacteremia Treatment Checklist

Background Staphylococcus aureus bacteremia (SAB) is associated with high morbidity and mortality. Appropriate management involves repeat blood cultures, echocardiography, drug selection/route, and duration of therapy. Multiple studies have demonstrated improved outcomes in patients who are managed by infectious disease (ID) physicians compared with non-ID physicians; however, not all sites have access to an ID provider. To improve management of SAB, a checklist was developed and approved for use in a large healthcare system in August 2015.MethodsA retrospective review was conducted on 400 randomly selected patients with SAB, 200 pre- and 200 post-implementation of a four-part management checklist. The primary outcome was overall adherence to the checklist, which included: repeat blood cultures, echocardiography, correct antibiotic/route selection, and appropriate antibiotic duration. Secondary outcomes included adherence when an ID physician was not consulted, adherence to the four components individually, and appropriate imaging.ResultsAdherence to the four part bundle remained stable from 2015 to 2017, with overall adherence rates of 80% and 79%, respectively. From 2015 to 2017, patients without repeat blood cultures (7% vs. 2%, respectively) and inappropriate inpatient antibiotic selection (6% vs. 3%, respectively) improved. Outpatient prescribing (11% vs. 11%), lack of imaging (11% vs. 9%), and antibiotic duration (15% vs. 15%) were consistent from 2015 to 2017, respectively. In 2017, 13 patients were discharged on oral antibiotics and were deemed inappropriate per the study criteria, although 12 of these patients were on appropriate antibiotics while inpatient. Infectious diseases providers were consulted on 96% of cases in 2017, an increase from 90% in 2015.ConclusionAdherence to an evidence based treatment bundle remains consistent with a previous analysis, despite an increase in cases with an ID provider consulted. Repeating blood cultures and inpatient prescribing improved over the interval. Focus areas for improvement include imaging, outpatient prescribing, and duration of therapy.Disclosures All authors: No reported disclosures.

Management of parapneumonic effusion in pregnant women.

Pneumonia and parapneumonic effusion (PPE) are not more common in pregnant women compared to normal population. Pneumonia is considered the second most common infection in pregnant women. PPE is a serious complication of pneumonia and occurs especially in case of treatment delay or inappropriate antibiotic selection. The data on the management of PPE in pregnant women is limited to few case reports.