Inappropriate Antibiotic Prescribing Research Articles

Appropriateness of antibiotic prescribing for patients with sepsis in rural hospital emergency departments.

This was a multicentre retrospective cohort study of adult patients (≥18 years) presenting with a process associated International Classification of Diseases code (ICD-AM-10) pertaining to sepsis between January 2017 and July 2020 to rural Emergency Departments. Our primary outcome was antibiotic appropriateness as defined by the Australian Therapeutic Guidelines (for antibiotic selection relative to infecting source) and the National Antimicrobial Prescribing Survey tool. Our secondary outcome was in-hospital mortality. Relevant clinical and non-clinical, physiological and laboratory data were collected retrospectively. Multivariate logistic regression was used to estimate the odds of both inappropriate antibiotic prescribing and in-hospital mortality based on clinical and non-clinical factors. A total of 378 patients were included who primarily presented with sepsis of unknown origin (36.8%), a genitourinary (22.22%) or respiratory (18.78%) source. Antibiotics were appropriately prescribed in 59% of patients. A positive Quick Sequential Organ Failure Assessment score (qSOFA) (odds ratio [OR] = 0.49; 95% confidence interval [CI], 0.29-0.83), a respiratory infection source (OR = 0.5; 95% CI, 0.29-0.86) and documented allergy (OR = 0.42; 95% CI, 0.25-0.72) were associated with a lower risk of appropriate prescribing in multivariate analysis. Forty-one percent of patients received antibiotics within 1 h of presentation. Inappropriate antibiotic prescribing was not associated with in-hospital mortality. The rates of appropriate antibiotic prescribing in rural Emergency Departments for patients presenting with sepsis is low, but comparable to other referral metropolitan centres.

Hospital prescribing patterns of antibiotics in Zambia using the WHO prescribing indicators post-COVID-19 pandemic: findings and implications.

Antimicrobial resistance (AMR) is a global public health problem that is fuelled by the inappropriate prescribing of antibiotics, especially those from the 'watch' and 'reserve' antibiotic lists. The irrational prescribing of antibiotics is particularly prevalent in developing countries, including Zambia. Consequently, there is a need to better understand prescribing patterns across sectors in Zambia as a basis for future interventions. This study evaluated the prescribing patterns of antibiotics using the WHO prescribing indicators alongside the 'access, watch and reserve' (AWaRe) classification system post-COVID pandemic at a faith-based hospital in Zambia. A cross-sectional study was conducted from August 2023 to October 2023 involving the review of medical records at St. Francis' Mission Hospital in Zambia. A WHO-validated tool was used to evaluate antibiotic prescribing patterns alongside the AWaRe classification tool. Out of 800 medical records reviewed, 2003 medicines were prescribed. Each patient received an average of 2.5 medicines per prescription. Antibiotics were prescribed in 72.3% of encounters, of which 28.4% were injectable. The most frequently prescribed antibiotics were amoxicillin (23.4%-access), metronidazole (17.1%-access), ciprofloxacin (8%-watch) and ceftriaxone (7.4%-watch), with 77.1% overall from the 'access' list. Encouragingly, 96.5% of the medicines were prescribed by their generic names and 98% were from the Zambia Essential Medicines List. There were high rates of antibiotic prescribing, including injectable antibiotics, which needs addressing going forward. It is crucial to implement targeted measures, including antimicrobial stewardship programmes, to improve future antibiotic prescribing in Zambia and reduce the risk of AMR.

Evaluating the role of primary care pharmacy technicians in antimicrobial stewardship (AMS) and acne management using TARGET resources.

Inappropriate antibiotic prescribing is accelerating antimicrobial resistance (AMR) (Antibiotic resistant infections and associated deaths increase https://www.gov.uk/government/news/antibiotic-resistant-infections-and-associated-deaths-increase). Pharmacy professionals (pharmacists and pharmacy technicians) promote good antibiotic prescribing practice. The traditional role of pharmacy technicians in supporting pharmacists and patients has expanded alongside the clinical expansion of pharmacist roles. (Boughen M, Fenn T. Practice, skill mix and education: the evolving role of pharmacy technicians in Great Britain. Pharmacy (Basel) 2020; 8(2): 50. doi:10.3390/pharmacy8020050) This paper focuses on the opinion of pharmacy technicians and their role in the review of acne management and the evaluation of the UKHSA TARGET acne 'How to…' review resources. To explore the impact of the TARGET resources on the capability, opportunity and motivation of pharmacy technicians in general practice in managing patients with acne.To evaluate the usefulness of the acne 'How to…' review resources. A primarily quantitative study using an electronic survey asking UK-based pharmacy technicians to rate their agreement on a five-point Likert scale with 21 predefined statements, themed on the COM-B model and usefulness of the TARGET resources for acne. The survey found that capability and opportunity in managing acne in the group familiar with TARGET resources was higher than the group not familiar with TARGET resources. Scores for motivation in both groups were high; pharmacy technicians have the motivation to undertake infection management roles, whether or not they are familiar with the TARGET toolkit.The acne 'How to…' review resources were overall rated as useful in supporting the review of patients with acne. The TARGET materials are effective resources that helps to upskill pharmacy technicians in the area of AMS, increasing capability and opportunity in the management of acne.

Scoping review of risk-scoring tools for early prediction of bloodstream infections caused by carbapenem-resistant Enterobacterales: do we really have a reliable risk-scoring tool?

Bloodstream infections (BSIs) caused by carbapenem-resistant Enterobacterales (CRE) are a global health concern. Rapid identification of CRE may improve patient outcomes and reduce inappropriate antibiotic prescription. The use of risk-scoring tools (RSTs) can be valuable for optimizing the decision-making process for empirical antibiotic therapy of suspected CRE bacteraemia. These tools can also be used to triage use of expensive rapid diagnostic methods. We systematically reviewed the relevant literature in PubMed/MEDLINE, CINAHL, Cochrane, Web of Science, Embase and Scopus up to 1 November 2022 to identify RSTs that predict CRE BSIs. The literature review and analysis of the articles were performed by two researchers; any inconsistencies were resolved through discussion. We identified 9 RSTs developed for early prediction of CRE BSIs and only logistic regression was used for most studies. These RSTs were quite different from each other in terms of their performance and the variables they included. They also had notable limitations and very few of them were externally validated. RSTs for early prediction of CRE BSIs have limitations and lack of external validity outside the local setting in which they were developed. Future studies to identify optimal RSTs in high and low CRE-endemic settings are warranted. Approaches based on rapid diagnostics and RSTs should be compared with a treatment approach using both methods in a randomized controlled trial.

Türkiye'deki Diş Hekimlerinin Antibiyotik ve Profilaksi Bilgilerinin Değerlendirilmesi

Introduction: Inappropriately prescribed antibiotics accelerate the formation of antibiotic-resistant bacteria. This circumstance creates a problematic situation in terms of public health. This study aims to measure dentists' antibiotic/prophylaxis knowledge and awareness of antibiotic resistance in Turkey based on two case scenarios.
 Materials Methods: Dentists in Turkey are invited by open invitation posts on various social media applications for our twelve-question online survey. The scoring was shaped based on answers to measure antibiotic/prophylaxis knowledge. The collected data were statistically analyzed by SPSS Statistics 22.
 Results: 321 participants answered all questions included in the study. The statistical analyses showed a significant difference in the evaluations according to gender, title, graduation time, and workplace.
 Conclusion: Inappropriate antibiotic prescription by dentists is common in Turkey. Dentists should receive more undergraduate lessons, and taking reminder antibiotic courses at regular intervals after graduation can contribute to keeping their knowledge up to date.

Interpretation using PRISMA 2020 methodology of antibiotic use in dentistry

The objective of this study is to interpret the use of antibiotics in dentistry using the PRISMA 2020 methodology. An integrative bibliographic review was conducted using PubMed, covering publications from 2019 to 2024. The search focused on identifying practices and patterns of antibiotic prescription in dentistry. Ten relevant studies were included, evidencing the prevalence of inappropriate antibiotic prescriptions and the impact of bacterial resistance. Findings highlight that antibiotic prophylaxis in dental procedures is often unjustified, contributing to antimicrobial resistance development. Additionally, a shift towards more rational prescribing guidelines was observed in some contexts. Recommendations include improving the education and continuous training of dental health professionals and establishing stricter policies for the regulation of antibiotic prescriptions and sales

Factors associated with inappropriateness of antibiotic prescriptions for acutely ill children presenting to ambulatory care in high-income countries: a systematic review and meta-analysis.

Acutely ill children are at risk of unwarranted antibiotic prescribing. Data on the appropriateness of antibiotic prescriptions provide insights into potential tailored interventions to promote antibiotic stewardship. To examine factors associated with the inappropriateness of antibiotic prescriptions for acutely ill children presenting to ambulatory care in high-income countries. On 8 September 2022, we systematically searched articles published since 2002 in MEDLINE, Embase, CENTRAL, Web of Science, and grey literature databases. We included studies with acutely ill children presenting to ambulatory care settings in high-income countries reporting on the appropriateness of antibiotic prescriptions. The quality of the studies was evaluated using the Appraisal tool for Cross-Sectional Studies and the Newcastle-Ottawa Scale. Pooled ORs were calculated using random-effects models. Meta-regression, sensitivity and subgroup analysis were also performed. We included 40 articles reporting on 30 different factors and their association with inappropriate antibiotic prescribing. 'Appropriateness' covered a wide range of definitions. The following factors were associated with increased inappropriate antibiotic prescribing: acute otitis media diagnosis [pooled OR (95% CI): 2.02 (0.54-7.48)], GP [pooled OR (95% CI) 1.38 (1.00-1.89)] and rural setting [pooled OR (95% CI) 1.47 (1.08-2.02)]. Older patient age and a respiratory tract infection diagnosis have a tendency to be positively associated with inappropriate antibiotic prescribing, but pooling of studies was not possible. Prioritizing acute otitis media, GPs, rural areas, older children and respiratory tract infections within antimicrobial stewardship programmes plays a vital role in promoting responsible antibiotic prescribing. The implementation of a standardized definition of appropriateness is essential to evaluate such programmes.

The Global Impact on Health of Dental Infections and Antibiotic Resistance:A mini Reveiw

Dental abscesses are a common infectious process that medical professionals are aware of. The aggressiveness of the bacteria, host resistance mechanisms, and local anatomy all influence how the infection turns out. A dental abscess that spreads can have serious implications that result in a high rate of morbidity and death. Acute dental abscesses are composed of a variety of microorganisms, including facultative anaerobes like _Streptococcus anginosus_ group and _viridans_ group _streptococci_, as well as stringent anaerobes such anaerobic _cocci_, _Prevotella_, and _Fusobacterium_ species. Antibiotics are commonly prescribed to treat dental infections. The benefits of antibiotics are that they can help resolve symptoms quickly, reduce pain, and prevent systemic infections. However, antibiotics can also have negative impacts on health, such as promoting antibiotic resistance. Antibiotic resistance refers to the phenomenon where bacteria evolve to become immune to antibiotics, making them harder to treat. Bacteria can develop resistance through mutations or by acquiring resistance genes from other bacteria. The overuse and misuse of antibiotics are one of the primary causes of antibiotic resistance. Inappropriate prescribing of antibiotics for illnesses such as the common cold and flu has led to the development of antibiotic resistance. In addition, patients who do not finish a full course of antibiotics can also contribute to the evolution of resistant bacteria. This has resulted in health risks that are not just confined to treating dental infections, but also pose a significant threat to global health. MATERIALS AND METHODS: This review is based on a thorough analysis of freely accessible literature from reputable sources such as Google, Google Scholar, and PubMed. The terms used in this review include dental, oral, maxillofacial infection, resistance pattern, epidemiology, common microorganisms, nutrition components, biofilm formation, morbidity, mortality, and increased healthcare costs. Overall, this review highlights the significant impact of dental infections and resistance on global health, including increased morbidity and mortality rates and rising healthcare costs. By understanding the epidemiology and resistance patterns of common microorganisms, as well as the role of nutrition and biofilm formation in infection prevention, we can work towards developing effective strategies for managing and preventing dental infections. In CONCLUSION, the epidemiology of dental infections is an important area of study that helps us understand the prevalence, incidence, and risk factors associated with these infections. By understanding these factors, we can develop effective prevention and treatment strategies to improve oral health and overall well-being.

Primary Care Antibiotic Prescribing and Infection-Related Hospitalisation.

Inappropriate prescribing of antibiotics has been widely recognised as a leading cause of antimicrobial resistance, which in turn has become one of the most significant threats to global health. Given that most antibiotic prescriptions are issued in primary care settings, investigating the associations between primary care prescribing of antibiotics and subsequent infection-related hospitalisations affords a valuable opportunity to understand the long-term health implications of primary care antibiotic intervention. A narrative review of the scientific literature studying associations between primary care antibiotic prescribing and subsequent infection-related hospitalisation was conducted. The Web of Science database was used to retrieve 252 potentially relevant studies, with 23 of these studies included in this review (stratified by patient age and infection type). The majority of studies (n = 18) were published in the United Kingdom, while the remainder were conducted in Germany, Spain, Denmark, New Zealand, and the United States. While some of the reviewed studies demonstrated that appropriate and timely antibiotic prescribing in primary care could help reduce the need for hospitalisation, excessive antibiotic prescribing can lead to antimicrobial resistance, subsequently increasing the risk of infection-related hospitalisation. Few studies reported no association between primary care antibiotic prescriptions and subsequent infection-related hospitalisation. Overall, the disparate results in the extant literature attest to the conflicting factors influencing the decision-making regarding antibiotic prescribing and highlight the necessity of adopting a more patient-focussed perspective in stewardship programmes and the need for increased use of rapid diagnostic testing in primary care.

Five Rights of Antibiotic Safety: Antimicrobial Stewardship at One NHS Foundation Trust in England Before and During the COVID-19 Pandemic

Abstract Introduction The study highlights the urgency of combating rising multi-drug-resistant infections, projecting 10 million deaths annually by 2050. With over 1.2 million deaths in 2019, Antimicrobial Resistance (AMR) has become a significant public health issue. Antimicrobial Stewardship (AMS) promotes judicious antibiotic use1. 'The Five Rights of Antibiotic Safety' ensure appropriate usage. It encompasses the right patient, drug, dose, time, and duration2. The COVID-19 pandemic, causing around 6 million deaths by 2023, has intensified AMR challenges. The Royal Pharmaceutical Society's AMS policy advocates for maximising the use of pharmacists' expertise to promote prudent antibiotic use, strengthen stewardship, and reduce AMR3. Aim This study aimed to evaluate AMS and adherence to the 'Five Rights of Antibiotic Safety' in antibiotic prescribing at an NHS Foundation Trust during 2019 and 2020 amidst the COVID-19 pandemic. Methods This research study was conducted using a cross-sectional retrospective design and undertook an in-depth analysis of 640 patient records in 2019 and 2020. The study included adult patients aged 25 and above, immunocompromised and pregnant individuals, and those prescribed antibiotics for respiratory tract infections or pneumonia during 2019 and 2020. A validated data extraction tool facilitated data collection. This study was registered under ISRCTN number 14825813, receiving ethical approval from the University of Hertfordshire Ethics and Health Research Authority (HRA) (REC Reference number 22/EM/0161). The Citizens Senate reviewed the study protocol, ensuring public and patient involvement. Results The study evaluated inappropriate antibiotic prescribing, identifying a rise in inappropriate antibiotic prescribing with no indication from 16% in 2019 to 20% in 2020. Inappropriate routes of administration also increased from 33% to 36%. While inappropriate drug choice remained steady around 63-64%, inappropriate dosing rose from 13% to 18%. Interestingly, inappropriate duration reduced slightly from 70% to 66%. The study assessed AMS champions, pharmacists' participation increased from 19% to 21%, and doctors decreased from 19% to 12%. However, combined collaboration jumped from 58% to 71%. Discussion/Conclusion This study highlights the surge in incorrect antibiotic prescribing during the 2020 COVID-19 pandemic, stressing the necessity of the 'Five Rights of Antibiotic Safety.' Strict guideline adherence and increased professional education are pivotal. Progress in reducing improper duration was seen, indicating the significance of refining prescribing practices. This research highlights the critical role of pharmacists and doctors as AMS champions. It demonstrates that their collaborative efforts during the pandemic positively impacted patient outcomes, thus reaffirming the Royal Pharmaceutical Society's AMS policy on the importance of a multidisciplinary team in ensuring appropriate antibiotic use. This study reveals a worrying increase in incorrect antibiotic use during 2020, calling for stricter compliance with the five safety rules and enhancing professional education. Reduced inappropriate duration of use suggests improvements in prescribing practices. The critical role of pharmacists and doctors in AMS, with heightened collaboration yielding prudent antibiotic use and better patient outcomes. Despite these insights, limitations like potential reporting bias, not exploring the causes of inappropriate prescribing in-depth, and a limited focus on doctors and pharmacists in AMS need future research.

Antibiotic prescription patterns in patients with suspected urinary tract infections in Ecuador.

Urinary tract infections (UTI) are among the most common cause to prescribe antibiotics in primary care. Diagnosis is based on the presence of clinical symptoms in combination with the results of laboratory tests. Antibiotic therapy is the primary approach to the treatment of UTIs; however, some studies indicate that therapeutics in UTIs may be suboptimal, potentially leading to therapeutic failure and increased bacterial resistance. This study aimed to analyze the antibiotic prescription patterns in adult patients with suspected UTIs and to evaluate the appropriateness of the antibiotic prescription. This is a cross-sectional study of patients treated in outpatient centers and in a second-level hospital of the Ministry of Public Health (MOPH) in a city in Ecuador during 2019. The International Classification of Disease Tenth Revision (ICD-10) was used for the selection of the acute UTI cases. The patients included in this study were those treated by family, emergency, and internal medicine physicians. We included a total of 507 patients in the analysis and 502 were prescribed antibiotics at first contact, constituting an immediate antibiotic prescription rate of 99.01%. Appropriate criteria for antibiotic prescription were met in 284 patients, representing an appropriate prescription rate of 56.02%. Less than 10% of patients with UTI had a urine culture. The most frequently prescribed antibiotics were alternative antibiotics (also known as second-line antibiotics), such as ciprofloxacin (50.39%) and cephalexin (23.55%). Factors associated with inappropriate antibiotic prescribing for UTIs were physician age over forty years, OR: 2.87 (95% CI, 1.65-5.12) p<0.0001, medical care by a general practitioner, OR: 1.89 (95% CI, 1.20-2.99) p = 0.006, not using point-of-care testing, OR: 1.96 (95% CI, 1.23-3.15) p = 0.005, and care at the first level of health, OR: 15.72 (95% CI, 8.57-30.88) p<0.0001. The results of our study indicate an appropriate prescription rate of 56.02%. Recommended antibiotics such as nitrofurantoin and fosfomycin for UTIs are underutilized. The odds for inappropriate antibiotic prescription were 15.72 times higher at the first level of care compared to the second. Effective strategies are needed to improve the diagnosis and treatment of UTIs.

Antimicrobial Resistance in Papua New Guinea: A Narrative Scoping Review.

Antimicrobial-resistant bacterial infections are a known threat to the public health of low-income countries and are undercharacterized in Papua New Guinea. A scoping literature review of scientific peer-reviewed publications on antimicrobial resistance in Papua New Guinea was conducted, and their results were summarized. Many of the available data on resistant bacteria in Papua New Guinea have come from Port Moresby and Goroka and have been focused on Staphylococcus aureus, as well as important pediatric pathogens such as Streptococcus pneumoniae and Haemophilus influenzae. Progressive resistance to the commonly used antibiotics penicillin and chloramphenicol among most clinically important bacterial pathogens has prompted healthcare workers to adopt expensive broad-spectrum antibiotics. There is already evidence of resistance to newly adopted antibiotics among several Gram-negative organisms. Drivers of antimicrobial resistance in Papua New Guinea include a high burden of infectious diseases, inappropriate antibiotic prescription practices, poor regulation of antibiotics, incomplete adherence, substandard drug quality, and overcrowding of healthcare facilities. There is a lack of information on antimicrobial resistance among priority pathogens and from several important regions of Papua New Guinea.

2260. Differences in the Prevalence of Inappropriate Antibiotic Prescribing by Payer Type

Abstract Background Understanding the relationship between inappropriate prescribing and patient insurance type could inform the targeting of antibiotic stewardship initiatives. However, few national data on this topic exist. Methods We analyzed the National Ambulatory Medical Care Survey, a nationally representative survey of office-based physician visits. We included all years from 2016 to 2019 except 2017, a year during which the survey was not fielded. We identified visits resulting in an oral antibiotic prescription among children and non-elderly adults who were privately insured, publicly insured, or uninsured. The exposure was safety-net status (publicly insured/uninsured versus privately insured). The outcome was inappropriate antibiotic prescribing, defined as an antibiotic prescription in a visit for which none of the diagnosis codes justified antibiotic use (following the approach of Chua et al, BMJ 2019). We assessed the association between safety-net status and inappropriate antibiotic prescribing using linear regression, controlling for patient characteristics, calendar quarter, and specialty. Models accounted for the complex design of the survey and employed designed-based variance estimators. Results Of 413,830,032 weighted visits for children, 16.9% resulted in an antibiotic prescription. Among these visits, the unadjusted prevalence of inappropriate antibiotic prescriptions was 29.1% overall, 23.4% for safety-net patients, and 32.4% for privately insured patients (adjusted difference, safety-net minus private: -11.9%, 95% CI: -20.6%, -3.2%). Of 1,240,610,825 weighted visits for non-elderly adults, 11.0% resulted in an antibiotic prescription. Among these visits, the unadjusted prevalence of inappropriate antibiotic prescriptions was 50.1% overall, 60.7% for safety-net patients, and 47.9% for privately insured patients (adjusted difference, safety-net minus private: 11.3%, 95% CI: 2.4%, 20.3%). Conclusion Safety-net status was associated with a lower rate of inappropriate antibiotic prescribing among children but a higher rate among non-elderly adults. Antibiotic stewardship initiatives targeting clinicians who care for privately insured children and adults with safety-net insurance may be warranted. Disclosures Jeffrey A. Linder, MD, MPH, FACP, Amgen, Biogen, Eli Lily: Stocks/Bonds

2256. Racial and Socioeconomic Disparities Evident in Inappropriate Antibiotic Prescribing in the Emergency Department

Abstract Background Inappropriate antibiotic prescribing for acute respiratory infections is a common source of low-value care in the emergency department. Racial disparities have been noted in episodes of low-value care, particularly in children, but the intersection between race and socioeconomics in inappropriate prescribing has received less attention. Decisions to prescribe antibiotics outside of guideline recommendations may result from underlying bias. We evaluated inappropriate prescribing by race and socioeconomic status in five emergency departments of a large hospital system. Methods We conducted an observational analysis of antibiotic prescribing in adult and pediatric EDs at five hospitals between October 2015 and March 2023. We calculated the rate of inappropriate prescribing for ED encounters that had an ICD-10 for an acute respiratory tract infection (ARTI) that did not require antibiotics and that had no secondary ICD-10 code on the record for which antibiotics may be indicated. Multivariable regression analysis controlling for comorbidities and patient-level factors was used to estimate the odds ratio of prescribing. Results A total of 147,402 ED encounters were included, of which ∼50% identified as Black, 23% as White, and 15% as Hispanic. Inappropriate prescribing rates were 8.5% overall, 13.6% for White patients, 7% for Black patients and 6% for Hispanic patients. After adjusting for patient-level factors, including socioeconomic status,White patients had 1.39 (95% CI, 1.32-1.47) higher odds of receiving an inappropriate prescription compared to Black patients. Patients residing in areas of greater socioeconomic deprivation, regardless of race, had 0.70 (95% CI, 0.66-0.75) lower odds of receiving a prescription. Inappropriate Prescribing Rate by Year and Race The overall rate of inappropriate prescribing did fall over the years, both overall (black line) and by race, but differences in prescribing by race persisted. Odds ratios of a patient being prescribed an inappropriate antibiotic Conclusion Our results suggest that after controlling for patient-level factors, White patients and patients from wealthier areas are more likely to receive inappropriate antibiotic treatment. While likely multifactorial in origin, it is possible that these disparities are driven by clinicians’ implicit biases that lead to overtreatment of White and wealthier patients. Further qualitative and quantitive approaches are needed to elucidate mechanisms and solutions to these disparities in care. Disclosures Oluwakemi Badaki-Makun, MD, PhD, Beckman Coulter: Grant/Research Support Sara E. Cosgrove, MD, MS, Debiopharm: Advisor/Consultant|Duke Clinical Research Institute: Advisor/Consultant Jeremiah S. Hinson, MD, PhD, Beckman Coulter: Advisor/Consultant|Beckman Coulter: Grant/Research Support|Beckman Coulter: TriageGO

1190. Nudging Away from Alert Fatigue: A Novel Method for Tracking the Impact of Integrated Clinical Decision Support on Meropenem Order Rates

Abstract Background The electronic health record (EHR) has streamlined quality of care and hospital prescribing; however, interruptive alerts and hard restrictions on antibiotic ordering can disrupt clinical workflow, often without significant benefit. This study aimed to determine the impact of permissive restriction on meropenem orders with embedded clinical decision support and prescriber attestation. Methods A quality improvement intervention implemented at Maine Medical Center (MMC, a 700-bed academic medical center) was evaluated through a multisite, quasiexperimental study within MaineHealth Hospitals. The intervention consisted of a provider-facing summary of guideline-directed indications for empiric and culture-directed uses of meropenem attached alongside the EHR order, and a required attestation button. To track meropenem order rates for adult patients prior to (Oct – Dec 2022) and after (Jan – Mar 2023) the intervention, the EHR was configured to fire a “silent” Best Practice Advisory behind-the-scenes when a provider opened the meropenem order. Rates of ordering were also monitored at other sites in MaineHealth, where the intervention was not implemented. The primary endpoint was the rate of “back-out” events, defined as a prescriber beginning a meropenem order but not signing it, and the secondary endpoint was the meropenem administration rate within 24 hours of opening an order. Results A meropenem order was initiated in 824 unique encounters during the study period; following the intervention at MMC, the back-out rate for orders increased from 20.3% (n =291) to 32.7% (n= 147, p = .01), while there was no significant difference during the same period at institutions where the intervention was not implemented (Table 1). The rate of patients who received meropenem within 24 hours following an order being opened decreased from 90.0% pre-intervention to 74.8% post-intervention (p &amp;lt; 0.01). Conclusion This study suggests that simple, non-resource intensive antimicrobial stewardship ‘nudges’ can simultaneously be implemented and monitored through creative EHR design, leading to a reduction in overall completion of meropenem orders and a decrease in inappropriate antibiotic prescribing. Similar interventions can be implemented in all fields of healthcare stewardship. Disclosures All Authors: No reported disclosures

2210. Reducing Inappropriate Antibiotic Prescribing for Acute Uncomplicated Bronchitis

Abstract Background Antimicrobial stewardship (AS) programs aim to slow the growing threat of antimicrobial resistance. The majority of antibiotic prescribing occurs in outpatient settings. This study examines the effect of an AS intervention bundle on the proportion of inappropriate antibiotic prescriptions given to adult patients with bronchitis in outpatient settings of a large healthcare system. Methods The Institutional Review Board approved this retrospective study of antibiotic prescription rates for adults (≥18 years old) diagnosed with bronchitis (identified using ICD-10 codes J20.9 or J20.8) during 2020 and 2021 in outpatient settings. An AS intervention bundle involving training and auditing of physicians’ antibiotic prescribing habits was enacted in January of 2021. A total of 8,176 encounters were reviewed for appropriateness of antibiotic prescriptions. Instances where no antibiotics were prescribed or antibiotics were prescribed for a comorbid condition were considered appropriate. Percentages of inappropriate antibiotic prescribing pre- and post-intervention were then compared via Chi-square analysis using SAS Enterprise Guide version 7.15 software. Results The proportion of inappropriate antibiotic prescribing for bronchitis decreased significantly from 44.9% pre-intervention to 32.5% post-intervention (p&amp;lt; 0.0001). Comparison of inappropriate prescribing rates by month showed significant decreases between the pre- and post-intervention periods in March (48.1% to 31.8%, p=0.0002), October (44.4% to 30.3%, p&amp;lt; 0.0001), and November (42.2% to 27.0%, p&amp;lt; 0.0001). Conclusion AS activities can decrease inappropriate antibiotic prescribing for bronchitis in outpatient settings. Further analyses on site-specific, seasonal and demographic differences on the effect of our AS intervention bundle may further enlighten on how programs can decrease unnecessary antibiotic use for respiratory tract infections. Disclosures All Authors: No reported disclosures

2264. Shorter Duration of Visit Associated with Inappropriate Antibiotic Prescribing for Respiratory Tract Infections in a National Sample of Ambulatory Visits, 2009 - 2016

Abstract Background Due to the reported decrease in the duration of primary care visits, it is important to assess provider adherence to guidelines when treating respiratory infections that are unlikely to necessitate antimicrobial treatment. This study aimed to investigate the relationship between the duration of visit and unnecessary antibiotic prescribing while considering patient and provider factors, including age, sex, race, and diagnosis. Methods This retrospective, cross-sectional study used outpatient, office-based data from the National Ambulatory Medical Care Survey from 2009 to 2016. All patients with a primary diagnosis of bronchitis, viral respiratory tract infection, influenza, and viral pneumonia were included for analysis. Patients with diagnoses that almost always require an antibiotic were excluded. Diagnoses were identified using ICD-9 or ICD-10 codes. Inappropriate antibiotic use was identified using multum codes and defined as at least one prescribed oral antibiotic during the visit. Provider status was defined as physician only or other provider. Multivariate logistic regression was used to determine predictors of inappropriate antibiotic prescribing. Data weights were applied to all analyses to generate national estimates. Results A total of 226,250,589 patient visits were included in the analysis, of which 83,404,484 (36.9%) resulted in an inappropriately prescribed antibiotic. Patients prescribed antibiotics were older (median age 42 vs. 13 years) and more often White (82.4% vs. 79.6%). After adjustment for covariates, time spent with provider less than 15 minutes (aOR 1.866, 95% CI 1.862-1.869), patient age 18-64 years (aOR 2.408, 95% CI 2.406-2.410), other provider types only (aOR 1.790, 95% CI 1.785-1.794), and viral pneumonia diagnosis (aOR 68.432, 95% CI 66.691-69.936) were most strongly associated with inappropriate antibiotic prescribing. Conclusion This study found that patients who spent less time with providers, had viral pneumonia, and were aged 18-64 years old were more likely to receive inappropriate treatment. Further investigation is necessary to determine reasons for inappropriate antimicrobial prescribing among outpatients. Disclosures Kelly Reveles, PharmD, PhD, Ferring Pharmaceuticals: Advisor/Consultant|Ferring Pharmaceuticals: Honoraria

2209. Reducing Inappropriate Antibiotic Prescribing for the Treatment of Urinary Tract Infections (UTI) in Urgent Care Clinics

Abstract Background In 2020, The Joint Commission released new standards to promote expansion of antimicrobial stewardship into the ambulatory care setting. Urinary tract infections (UTIs) are one of the most common bacterial infections encountered in the outpatient setting and therefore an opportunistic area for intervention. The aim of our study was to evaluate current outpatient prescribing patterns for the treatment of UTIs and develop a methodology to improve antibiotic prescribing. Methods A single-center, retrospective study was conducted across 5 Jackson Health-University of Miami Urgent Care Clinics (UCC) in Miami, Florida. We utilized ICD-10 diagnosis codes to identify adults diagnosed with UTIs between January 1, 2021 and October 31, 2022. We identified the top five prescribers and audited 10% of their prescriptions. The data was analyzed and as our intervention, we shared results with UCC leadership and disseminated provider-specific report cards to highlight inappropriate prescribing practices. After this, we allowed 3 months for change to occur and set a goal of reducing the percentage of inappropriate UTI durations by 50%. Results For baseline data, 123 charts were reviewed. We identified 95 patients with cystitis (77.3%), 26 pyelonephritis (21.1%), and 2 asymptomatic bacteriuria (1.6%). Inappropriate prescribing ranged from 17.6% to 80.6% between the UCC prescribers (Figure 1). Various types of prescribing opportunities were identified, with the most common being prolonged length of therapy (Figure 2). For post-intervention, 114 charts were reviewed. We identified 90 patients with cystitis (78.9%), 22 pyelonephritis (19.3%), and 2 asymptomatic bacteriuria (1.8%). Inappropriate durations of UTI treatment were reduced by 25% (Figure 3), with the greatest improvement seen in nitrofurantoin prescribing (Figure 4). Figure 1 Figure 2 Figure 3 Conclusion Retrospective audit and feedback using provider-specific report cards was an effective antimicrobial stewardship strategy for the ambulatory care setting. Our intervention led to reduced durations of UTI treatment for nitrofurantoin but not necessarily with fluoroquinolones, trimethoprim/sulfamethoxazole, or beta-lactams. Next steps will include providing more education to further promote appropriate use of all classes of antibiotics. Figure 4 Disclosures Lilian M. Abbo, MD, MBA, Ferring: Advisor/Consultant|Pfizer: Advisor/Consultant|Regeneron: Grant/Research Support|Shionogi: Advisor/Consultant

2242. Leveraging the McGeer criteria to Determine the Frequency of Potentially Inappropriate Antibiotic Prescribing for Urinary and Respiratory Tract Infections Prior to and During the COVID-19 pandemic at a Skilled Nursing Facility

Abstract Background Considerable reductions in antimicrobial stewardship efforts have been attributed to the COVID-19 pandemic, especially among low-resourced healthcare facilities, such as long-term care settings. Our study objectives were to (1) assess the appropriateness of antibiotic prescriptions for urinary (UTI) and respiratory tract infections (RTI) using standardized infection definitions, known as the McGeer criteria, and (2) to determine whether the prescribing practices differed prior to and during the COVID-19 pandemic. Methods We employed a HIPPA-compliant REDCap data collection tool to abstract Electronic Medical Record data from an Arizona-based, Skilled Nursing Facility between March 2019 and January 2022. Clinical and microbiologic infection characteristics were abstracted to determine whether indications for antibiotic prescriptions met the McGeer criteria for UTI and RTI. The frequency and proportion of antibiotic prescriptions for suspected infections that did not meet McGeer criteria were compared for the time period prior to and during the COVID-19 pandemic. Results 388 total antibiotic events prescribed for UTI and RTI infections between March 2019 – January 2022 were analyzed (Figure 1). 61% (n=14) and 78% (n=154) of UTI prescriptions did not meet McGeer criteria prior to and during the COVID-19 pandemic, respectively. 70% (n=14) of RTI antibiotic prescriptions prior to the pandemic and 60% (n=89) of antibiotic events during the pandemic were not in accordance with McGeer criteria (Table 1) (Figure 2). Flow diagram to demonstrate Electronic Medical Record abstraction analysis inclusion criteria Note: a suspected infection was defined as a laboratory order (e.g., urine analysis, chest x-ray), or an antibiotic prescription Frequency and percent of UTI and RTI antibiotic prescriptions that did not meet McGeer criteria, prior to and during the COVID-19 pandemic Note: suspected infections from March 01, 2019 - January 25, 2020 are considered “pre-pandemic,” and January 26, 2020 – January 23, 2022 are considered “during pandemic” *The McGeer criteria differentiate infection definitions based on the presence or absence of an indwelling catheter Antibiotic prescription accordance with McGeer criteria from March 2019 – January 2022 Conclusion Despite consorted efforts to improve antimicrobial stewardship infrastructure, the majority of antibiotic prescribing for UTIs and RTIs prior to the pandemic did not meet McGeer criteria. This trend also persisted during the pandemic, indicating a need for increased stewardship practices that can operate concurrently with future public health threats. Disclosures All Authors: No reported disclosures

Reducing prescribing of antibiotics for acute respiratory infections using a frontline nurse-led EHR-Integrated clinical decision support tool: protocol for a stepped wedge randomized control trial

BackgroundOverprescribing of antibiotics for acute respiratory infections (ARIs) remains a major issue in outpatient settings. Use of clinical prediction rules (CPRs) can reduce inappropriate antibiotic prescribing but they remain underutilized by physicians and advanced practice providers. A registered nurse (RN)-led model of an electronic health record-integrated CPR (iCPR) for low-acuity ARIs may be an effective alternative to address the barriers to a physician-driven model.MethodsFollowing qualitative usability testing, we will conduct a stepped-wedge practice-level cluster randomized controlled trial (RCT) examining the effect of iCPR-guided RN care for low acuity patients with ARI. The primary hypothesis to be tested is: Implementation of RN-led iCPR tools will reduce antibiotic prescribing across diverse primary care settings. Specifically, this study aims to: (1) determine the impact of iCPRs on rapid strep test and chest x-ray ordering and antibiotic prescribing rates when used by RNs; (2) examine resource use patterns and cost-effectiveness of RN visits across diverse clinical settings; (3) determine the impact of iCPR-guided care on patient satisfaction; and (4) ascertain the effect of the intervention on RN and physician burnout.DiscussionThis study represents an innovative approach to using an iCPR model led by RNs and specifically designed to address inappropriate antibiotic prescribing. This study has the potential to provide guidance on the effectiveness of delegating care of low-acuity patients with ARIs to RNs to increase use of iCPRs and reduce antibiotic overprescribing for ARIs in outpatient settings.Trial registrationClinicalTrials.gov Identifier: NCT04255303, Registered February 5 2020, https://clinicaltrials.gov/ct2/show/NCT04255303.