Opportunities For Antimicrobial Stewardship Research Articles

Infections following chimeric antigen receptor T cell therapy: 2018–2022

AbstractBackgroundChimeric antigen receptor (CAR) T‐cell therapy is an emerging therapeutic modality for relapsed and refractory hematological malignancies. Infectious complications following CAR T‐cell therapy are not well defined.MethodsThis is a retrospective analysis of data on patients who received CAR T‐cell therapy between April 2018 and December 2022 at the Karmanos Cancer Center, Detroit. Patients’ data were collected up to their last known clinic or inpatient follow‐up visit. An infectious episode was defined as any microbiologically proven or clinically documented infection.ResultsSeventy‐six patients received therapy with FDA‐approved CAR T‐cell products. Thirty‐three patients (43.4%) had at least one infectious episode. There were 61 infectious episodes during a median follow‐up of 184 (96–340) days. Median duration for the onset of infection was 59 (22–209) days. Bacterial and viral infections occurred in 42.6% and 41% of the infectious episodes, respectively. COVID‐19 was the most common infectious complication (14.8%). Time‐to‐event analysis showed that most infections occurred within the first 100 days. Empirical antibiotic use during Cytokine Release Syndrome/Immune effector Cell‐Associated Neurotoxicity Syndrome (CRS/ICANS) in the absence of documented bacterial infection was reported in 85.7% of patients. Clostridioides difficile accounted for 11.5% of all infectious episodes. Five of six patients with C. difficile infection had CRS/ICANS and received antibiotics.ConclusionCOVID‐19 and C. difficile infection were the most common infections following CAR T‐cell therapy. Most infections occurred within the first 100 days. Empiric antibiotic use and C. difficile infection were common in patients with CRS/ICANS, in the absence of documented bacterial infection, thus providing an excellent opportunity for antimicrobial stewardship in this population. image

Understanding the impact of COVID-19 on antibiotic use in Canadian primary care: a matched-cohort study using EMR data

BackgroundInappropriate or overuse of antibiotic prescribing in primary care highlights an opportunity for antimicrobial stewardship (AMS) programs aimed at reducing unnecessary use of antimicrobials through education, policies and practice audits that optimize antibiotic prescribing. Evidence from the early part of the pandemic indicates a high rate of prescribing of antibiotics for patients with COVID-19. It is crucial to surveil antibiotic prescribing by primary care providers from the start of the pandemic and into its endemic stage to understand the effects of the pandemic and better target effective AMS programs.MethodsThis was a matched pair population-based cohort study that used electronic medical record (EMR) data from the Canadian Primary Care Sentinel Surveillance Network (CPCSSN). Participants included all patients that visited their primary care provider and met the inclusion criteria for COVID-19, respiratory tract infection (RTI), or non-respiratory or influenza-like-illness (negative). Four outcomes were evaluated (a) receipt of an antibiotic prescription; (b) receipt of a non-antibiotic prescription; (c) a subsequent primary care visit (for any reason); and (d) a subsequent primary care visit with a bacterial infection diagnosis. Conditional logistic regression was used to evaluate the association between COVID-19 and each of the four outcomes. Each model was adjusted for location (rural or urban), material and social deprivation, smoking status, alcohol use, obesity, pregnancy, HIV, cancer and number of chronic conditions.ResultsThe odds of a COVID-19 patient receiving an antibiotic within 30 days of their visit is much lower than for patients visiting for RTI or for a non-respiratory or influenza-like-illnesses (AOR = 0.08, 95% CI[0.07, 0.09] compared to RTI, and AOR = 0.43, 95% CI[0.38, 0.48] compared to negatives). It was found that a patient visit for COVID-19 was much less likely to have a subsequent visit for a bacterial infection at all time points.ConclusionsEncouragingly, COVID-19 patients were much less likely to receive an antibiotic prescription than patients with an RTI. However, this highlights an opportunity to leverage the education and attitude change brought about by the public health messaging during the COVID-19 pandemic (that antibiotics cannot treat a viral infection), to reduce the prescribing of antibiotics for other viral RTIs and improve antibiotic stewardship.

Retrospective observational study of antibiotic prescribing in an out-of-hours doctors service

Abstract Introduction Surveillance of antibiotic use is a key part of Ireland’s National Action Plan for Antimicrobial Resistance 2021-2025. A higher proportion of patients are reported to be prescribed antibiotics in out-of-hours (OOH) doctors services compared to daytime general practice.[1] Challenges with antibiotic prescribing in this setting include unfamiliarity between doctor and patient, lack of follow-up, access to medical history and diagnostics. Surveillance of antibiotic use in OOH services is important to develop tailored antimicrobial stewardship (AMS) interventions in this setting. In Ireland, a national Preferred Antibiotic Initiative encourages prescribers in community settings to avoid, where possible, a list of Red (less preferred) antibiotics, and choose from a Green (preferred) list, if an antibiotic is required. Aim To evaluate antibiotic prescribing patterns in OOH services in the Cork/Kerry region to inform future AMS interventions and to ascertain trends in prescribing of Red antibiotics. Methods A retrospective, observational study was conducted of all oral antibiotic prescriptions in OOH doctors’ consultations between 1st December 2019 and 31st December 2021 in the region. Data were gathered on age, gender, date and time of consultation, consultation method (in person, remote), antibiotic and its indication. Data were analysed using Microsoft Excel v2018 and SPSS v28. Results Overall, 17% (69,017 of 406,812) of the OOH doctors’ consultations resulted in an antibiotic prescription, with considerable variation over the study period just prior to and during the COVID-19 pandemic, ranging from 31% in December 2019 to less than 2% in April 2020 and 22% in December 2021. During the COVID-19 pandemic part of the study period (April 2020 to December 2021), 66% of antibiotics prescribed were from remote consultations, prior to which antibiotic prescribing from remote consultations was rare. Of the antibiotics prescribed, 21% were in children under 6 years old. Respiratory tract infections (RTIs) were the most common indication for antibiotics (60%). Amoxicillin was the most commonly prescribed antibiotic (40% of all prescriptions). Red (reserved) antibiotics accounted for 19% of all prescriptions, which is substantially lower than national figures reported for the study period (35-45%)[2] and the national target of less than 34% for 2021. Red antibiotics were more commonly prescribed during the overnight shifts and in older adults, and less commonly prescribed in remote consultations. Conclusion Low antibiotic prescribing levels during the early stages of the pandemic were not sustained. Antibiotic prescriptions from remote consultations were common. Red antibiotic prescribing proportion is lower than the national mean in this OOH service. Key opportunities for AMS are addressing the volume of antibiotic prescribing for RTIs, particularly in children, AMS in telemedicine and the higher proportion of Red antibiotics prescribed by the overnight shift doctors. This is the first study describing indications antibiotic prescriptions in the OOH setting in Ireland. A limitation of this study is clinical presentation was not available for all OOH consultations. This would have given opportunity to assess the proportion of infectious presentations resulting in an antibiotic prescription to identify further of areas for AMS intervention.

Knowledge, attitudes and perceptions of Latin American healthcare workers relating to antibiotic stewardship and antibiotic use: a cross-sectional multi-country study

BackgroundThe burden of antimicrobial resistance (AMR) in Latin America is high. Little is known about healthcare workers’ (HCWs) knowledge, attitudes, and perceptions of antimicrobial stewardship (AS), AMR, and antibiotic use (AU) in the region.MethodsHCWs from 42 hospitals from 5 Latin American countries were invited to take an electronic, voluntary, anonymous survey regarding knowledge, attitudes, and perceptions of AS, AMR, and AU between March–April 2023.FindingsOverall, 996 HCWs completed the survey (52% physicians, 32% nurses, 11% pharmacists, 3% microbiologists, and 2% “other”). More than 90% of respondents indicated optimizing AU was a priority at their healthcare facility (HCF), 69% stated the importance of AS was communicated at their HCF, and 23% were unfamiliar with the term “antibiotic stewardship”. Most (> 95%) respondents acknowledged that appropriate AU can reduce AMR; however, few thought AU (< 30%) or AMR (< 50%) were a problem in their HCF. Lack of access to antibiogram and to locally endorsed guidelines was reported by 51% and 34% of HCWs, respectively. Among prescribers, 53% did not consider non-physicians’ opinions to make antibiotic-related decisions, 22% reported not receiving education on how to select antibiotics based on culture results and 60% stated patients and families influence their antibiotic decisions.ConclusionsAlthough HCWs perceived improving AU as a priority, they did not perceive AU or AMR as a problem in their HCF. AS opportunities include improved access to guidelines, access to AMR/AU data, teamwork, and education on AS for HCWs and patients and families.

Performance of ePlex® blood culture identification panels in clinical isolates and characterization of antimicrobial stewardship opportunities

We assessed the performance of GenMark's ePlex® Blood Culture Identification (BCID) Panels for overall agreement of organism identification and resistance mechanism detection with standard microbiologic methods. This study included patients with a positive blood culture from May 2020 to January 2021. The primary outcomes were to assess concordance of ePlex® organism identification with standard identification methods and concordance of ePlex® genotypic resistance mechanism detection with standard phenotypic susceptibility testing. Secondary outcomes included panel specific performance and characterization of antimicrobial stewardship opportunities. The overall identification concordance rate in 1276 positive blood cultures was 98.1%. The overall concordance for the presence of resistance markers was 98.2% and concordance for the absence of resistance markers was 100%. A majority of ePlex® results (69.5%) represented opportunities for potential antimicrobial stewardship intervention. High concordance rates between the ePlex® BCID panels and standard identification and susceptibility methods enable utilization of results to guide rapid antimicrobial optimization.

Effect of automated identification of antimicrobial stewardship opportunities for suspected urinary tract infections

Abstract Objective: We aimed to determine whether automated identification of antibiotic targeting suspected urinary tract infection (UTI) shortened the time to antimicrobial stewardship (AS) intervention. Design: Retrospective before-and-after study. Setting: Tertiary and quaternary care academic medical center. Patients: Emergency department (ED) or admitted adult patients meeting best practice alert (BPA) criteria during pre- and post-BPA periods. Methods: We developed a BPA to alert AS pharmacists of potential ASB triggered by the following criteria: ED or admitted status, antibiotic order with genitourinary indication, and a preceding urinalysis with ≤ 10 WBC/hpf. We evaluated the median time from antibiotic order to AS intervention and overall percent of UTI-related interventions among patients in pre-BPA (01/2020–12/2020) and post-BPA (04/15/2021–04/30/2022) periods. Results: 774 antibiotic orders met inclusion criteria: 355 in the pre- and 419 in the post-BPA group. 43 (35 UTI-related) pre-BPA and 117 (94 UTI-related) post-BPA interventions were documented. The median time to intervention was 28 hours (IQR 18–65) in the pre-BPA group compared to 16 hours (IQR 2–34) in the post-BPA group (P &lt; 0.01). Despite absent pyuria, there were six cases with gram-negative bacteremia presumably from a urinary source. Conclusions: Automated identification of antibiotics targeting UTI without pyuria on urinalysis reduced the time to stewardship intervention and increased the rate of UTI-specific interventions. Clinical decision support aided in the efficiency of AS review and syndrome-targeted impact, but cases still required AS clinical review.

Trends in antibiotic prescribing in primary care out-of-hours doctors' services in Ireland.

Infections are a common reason for patient consultation in out-of-hours (OOH) doctors' services. Surveillance of antibiotic prescribing in OOH settings is important to develop tailored antimicrobial stewardship (AMS) interventions. To evaluate antibiotic prescribing patterns in OOH services in the Cork Kerry region, Ireland to inform future AMS interventions. A retrospective, observational cohort study was conducted of all oral antibiotic prescriptions in OOH doctors' consultations between 1 December 2019 and 31 December 2021 in the region. Data were gathered on age, gender, date and time of consultation, consultation method (in person, remote), antibiotic and its indication. Data were analysed using Microsoft Excel v.2018 and SPSS v.28. Overall, 17% (69 017 of 406 812) of the OOH doctors' consultations resulted in an antibiotic prescription during the study period. This varied from 31% of OOH consultations in December 2019 to less than 2% of OOH consultations in April 2020. Of the antibiotics prescribed, 21% were for children under 6 years old. Respiratory tract infections (RTIs) were the most common indication for antibiotics (59%). Amoxicillin was the most commonly prescribed antibiotic (40% of all prescriptions). Red (reserved) antibiotics accounted for 19% of all prescriptions. During the COVID-19 pandemic period of the study, 66% of 49 421 of antibiotic prescriptions were issued from remote consultations. Low antibiotic prescribing levels during the early stages of the pandemic were not sustained. Antibiotic prescriptions from remote consultations were common. A key opportunity for AMS is addressing the volume of antibiotic prescribing for RTIs, particularly in children.

1244. Antimicrobial Stewardship Knowledge, Attitudes, and Practices (KAP) Among Nurses

Abstract Background Nurses are underutilized members of the antimicrobial stewardship (AS) team. Understanding knowledge, attitudes, and practices (KAP) is essential to designing effective AS initiatives. While KAP surveys have been performed among a variety of provider types, less is known about KAP among nurses. We describe KAP pertaining to AS among nurses at a large, academic hospital. Methods An electronic, 24-question KAP survey was designed by the AS team with relevant nursing and infection prevention champions. Nine knowledge-based questions about antimicrobials focused on 4 domains: beta-lactams first in sepsis, intravenous to oral transition, urinary tract infections, and penicillin allergies. Voluntary responses were collected via Qualtrics from January 9, 2023-March 31, 2023. Surveys were distributed by email link, with reminders to enhance survey response. Incentives included a chance to win a meal voucher. Results 85 complete survey responses were received. The majority of respondents worked on dayshift (69%) in a staff nurse role (66%). Discrepancies were seen in perceptions of issues of stewardship nationally and locally. While nurses felt antimicrobial resistance and harm caused by antimicrobials are high nationally (92 and 69%, respectively), this was not as commonly felt to be true on a local level (35% and 26%). The majority (87%) agreed or strongly agreed that nurses’ responsibility includes promoting appropriate antimicrobial use. When assessing knowledge of AS domains, reported confidence in performance was discordant with actual performance and differed by domain (Figure 1). Respondents were largely unfamiliar with common AS reference resources (73-74%) and were more likely to consult an ID pharmacist (81%), ID physician (78%) or infection prevention team member (78%) with questions. Conclusion Nurses recognized AS as an important part of their professional responsibilities, but perceived AS opportunities to be a national rather than local need. Differing patterns in knowledge vs. confidence among topic domains provides key information to then design relevant, sustainable, nurse-driven antimicrobial stewardship initiatives. Disclosures Rebekah W. Moehring, MD, MPH, FIDSA, FSHEA, UpToDate, Inc.: Author Royalties

164. Performance of ePlex® Blood Culture Identification Panels in Clinical Isolates and Characterization of Antimicrobial Stewardship Opportunities

Abstract Background Rapid diagnostic testing allows pathogen identification within hours of a positive blood culture. GenMark’s ePlex® Blood Culture Identification (BCID) Panels detect bacteria, fungi, and antibiotic resistance genes. This study assessed concordance of ePlex® organism identification with standard microbiologic identification methods and concordance of ePlex® genotypic resistance mechanism detection and standard susceptibility testing. Secondary outcomes included panel specific performance and characterization of antimicrobial stewardship opportunities. Methods This retrospective, single center study included patients with a positive blood culture from May 2020 – January 2021. Polymicrobial cultures were excluded. Identification concordance was evaluated between ePlex® and MALDI-TOF, BD Phoenix™, and biochemical tests. Resistance mechanism/phenotypic susceptibility concordance was evaluated between ePlex® and BD PhoenixTM/ETEST®. MecA was assessed via oxacillin resistance, vanA via vancomycin resistance, CTX-M via ceftriaxone resistance, and KPC via carbapenem resistance. Opportunities for antimicrobial stewardship were also quantified. Results The overall identification concordance rate in 1276 positive blood cultures was 98.2%, with rates of 98.5%, 98.1%, and 93.3% for Gram-positive, Gram-negative, and fungal isolates, respectively. In 381 staphylococcal isolates, concordance rates were 98.3% and 100% for the presence and absence of mecA. Both the presence and absence of vanA were 100% concordant in 63 enterococcal isolates. CTX-M and KPC were evaluated in 189 Enterobacterales. Concordance rates were 96.8% for the presence of CTX-M and 60% for the presence of KPC, demonstrating that 40% of carbapenem resistance was due to non-enzymatic mechanisms. Ceftriaxone and carbapenem susceptibility correlated with the absence of CTX-M and KPC, respectively, in 100% of cultures. A majority of ePlex results (69.5%) represented opportunities for potential antimicrobial stewardship intervention. Conclusion High concordance rates between ePlex® and standard identification and susceptibility testing methods enable rapid antimicrobial optimization. Numerous opportunities for antimicrobial stewardship were identified based on ePlex® results. Disclosures All Authors: No reported disclosures

Asymptomatic bacteriuria in critical-access hospitals: Prevalence and patient characteristics driving treatment.

We evaluated the prevalence and treatment of asymptomatic bacteriuria (ASB) in 17 critical-access hospitals. Among 891 patients with urine cultures from September 2021 to June 2022, 170 (35%) had ASB. Also, 76% of patients with ASB received antibiotics for a median duration of 7 days, demonstrating opportunities for antimicrobial stewardship.

Impact of the COVID-19 pandemic on antimicrobial stewardship support for general practices in England: a qualitative interview study.

In England, Clinical Commissioning Group (CCG) (now replaced by Integrated Care Systems (ICS)) and Primary Care Network (PCN) professionals support primary care prescribers to optimise antimicrobial stewardship (AMS). To explore views and experiences of CCG/PCN staff in supporting AMS, and the impact of COVID-19 on this support. Qualitative interview study in primary care in England. Semi-structured interviews-with staff from CCG/PCNs responsible for AMS-at two time-points, via telephone interviews. These were audio-recorded, transcribed, and analysed thematically. Twenty-seven interviews were conducted with 14 participants (nine CCG, five PCN) in Dec 2020/Jan 2021 and Feb/Mar 2021.We found that AMS support was 1) deprioritised- to keep general practice operational and deliver COVID-19 vaccines; 2) disrupted-as social distancing made it harder to build relationships, conduct routine AMS activities, and challenge prescribing decisions; and 3) adapted-with opportunities identified for greater use of technology and from changed patient/public perceptions of viruses and self-care. We also found that resources to support AMS were valued if they were both novel, to counter AMS 'fatigue', and sufficiently familiar to fit with existing/future AMS. AMS needs to be reprioritised in general practice in the post-pandemic era and within the new ICS in England. This should include interventions/strategies that combine novel elements with already familiar strategies to refresh prescribers' motivation and opportunity for AMS. Behaviour change interventions should be aimed at improving the culture and processes for how PCN pharmacists voice concerns about AMS to prescribers in general practice and take advantage of the changed patient/public perceptions of viruses and self-care.

Inpatient pediatric antimicrobial use for respiratory infections during the RSV surge

Background: In the United States, pneumonia causes &gt;100,000 pediatric hospitalizations annually. On November 4, 2022, the CDC issued a Heath Advisory concerning an upcoming surge of respiratory illnesses including SARS-CoV-2, influenza, and respiratory syncytial virus (RSV). Differentiating between viral and bacterial causes is challenging and can lead to antimicrobial overuse. Currently, tools are being developed to distinguish between viral and bacterial pneumonia. The VALS-DANCE Pneumonia Etiology Predictor (PEP) provides clinical scoring criteria (Fig. 1) to determine probable cause of pneumonia with 93.1% sensitivity for bacterial pneumonia. Scores &gt;11 have a &gt;25% likelihood of having bacterial etiology. Given that antimicrobial exposure increases resistance rates, disrupts natural flora, and increases the risk of side effects, a core goal of researchers is to develop ways to promote stewardship and reduce inappropriate use. We assessed the patterns of use for antimicrobials in pediatric patients admitted with pneumonia at our institution. Methods: This retrospective review included pediatric cases admitted to an urban safety-net community hospital from July 22, 2022, to December 16, 2022. A daily list of all patients receiving antimicrobials was reviewed, and pediatric patients with diagnosis of a respiratory infection were included. Patients with additional indications for antimicrobial therapy, diagnosis of bronchitis, incomplete records, or without complete information were excluded from the scoring criteria. The primary objective was to assess the appropriateness of antimicrobial use for pneumonia, defined as use consistent with PEP scoring recommendations. Results: Of 53 patients reviewed, 37 met inclusion criteria. Of 37 patients, 22 (59.5%) met study criteria for appropriate therapy. The 15 patients (40.5%) who were inappropriate for treatment received an average of 4.67 ± 1.91 days of antibiotics. Of these 15 patients, 11 (73.3%) also had a positive viral test, further increasing the likelihood of a viral etiology. This subgroup had an average antibiotic exposure of 4.27 ± 1.79 days. Documented rationale for therapy included severity of illness (4 of 11), radiograph consolidation (4 of 11), and provider disagreement with radiograph interpretation (3 of 11). Conclusions: Pediatric respiratory infections represent a significant opportunity for antimicrobial stewardship. In this study, as many as 40% of pediatric patients may have received unnecessary antibiotic exposure. Use of the VALS-DANCE criteria may help clinicians identify patients with low likelihood of bacterial infection and reduce antimicrobial use. The national surge of viral infections serves to highlight the vital importance of appropriate diagnostic stewardship.Disclosure: None

Point prevalence audit surveys of respiratory tract infection consultations and antibiotic prescribing in primary care before and during the COVID-19 pandemic in Ireland.

Respiratory tract infections (RTIs) are the most common reason for prescribing antibiotics in general practice. The COVID-19 pandemic has impacted on antibiotic prescribing and delivery of primary care in Ireland. To assess the quality of antibiotic prescribing, the impact of the COVID-19 pandemic and identify opportunities for antimicrobial stewardship (AMS) in Ireland. Point prevalence audit surveys for RTI consultations were conducted as part of a European study at three time periods: January-February 2020, March-May 2020 and March-May 2021. Antibiotic prescribing was assessed and comparisons made between the three time periods. In total, 765 consultations were recorded, which were mainly face to face before the pandemic, but changed to predominantly remote consultations during the pandemic surveys in 2020 and 2021 (82% and 75%). Antibiotics were prescribed in 54% of RTI consultations before the pandemic. During pandemic surveys, this dropped to 23% in 2020 and 21% in 2021. There was a decrease in prescribing of Red (reserve) agents in 2021. Assessment against indication-specific quality indicators showed a high proportion of consultations for bronchitis and tonsillitis resulting in an antibiotic prescription (67% and 85%). Point-of-care testing (POCT) to aid diagnosis of RTIs were utilized in less than 1% of consultations. During the COVID-19 pandemic, there was a reduction in antibiotic prescribing. Opportunities identified to support AMS in primary care in Ireland are targeted initiatives to reduce antibiotic prescribing for bronchitis and tonsillitis and introducing POCT to support appropriate antibiotic prescribing.

Antimicrobial use and opportunities for antimicrobial stewardship in pediatric postacute and long-term care settings.

We performed a point-prevalence study of antimicrobial prescriptions in 9 pediatric postacute and long-term care (pPALTC) settings. Antimicrobials were prescribed for 5%-7% of residents including infectious (41%), noninfectious (24%), prophylaxis (24%), and unknown (11%) indications. Macrolides were often prescribed for noninfectious indications. Developing treatment guidelines are antimicrobial stewardship opportunities for pPALTC.

Missed Antimicrobial Stewardship Opportunities for Hospitalized Patients with Urinary Tract Infections Receiving Ceftriaxone.

Ceftriaxone is a commonly utilized antibiotic for the treatment of urinary tract infections (UTI) despite the limited literature supporting its use. Opportunities for antimicrobial stewardship (ASP), including IV-to-PO conversions and de-escalation of therapy, are often missed in the hospital setting. The study reported here describes the utilization of ceftriaxone in patients admitted to the hospital and treated for UTIs in a large health system, focusing on opportunities for IV-to-PO conversion of antibiotic therapy. This was a multi-center, retrospective, descriptive study conducted in a large health system. Patients admitted from January 2019 to July 2019 were included for analysis if they were 18 years or older at admission, diagnosed with acute cystitis, acute pyelonephritis, or unspecified UTI, and received two or more doses of ceftriaxone. The primary outcome was to evaluate the percentage of patients who were eligible for conversion from IV ceftriaxone to oral antibiotics while admitted to the hospital based on the defined criteria for automatic pharmacist conversion in the health system. Percentage of urine cultures with susceptibility to cefazolin, the duration of antibiotic therapy in the hospital, and an evaluation of oral antibiotics prescribed at discharge were also recorded. A total of 300 patients were included; 88% met the pre-specified criteria for IV-to-PO conversion, but only 12% were converted from IV-to-PO antibiotics during hospitalization. Approximately 65% of patients remained on IV ceftriaxone until discharge, at which time they were converted to a PO antibiotic, most commonly fluoroquinolones followed by third-generation cephalosporins. Patients admitted to the hospital and receiving treatment with ceftriaxone for UTI were infrequently converted to oral therapy prior to discharge despite meeting criteria for automatic pharmacist IV-to-PO conversion. Findings highlight opportunities to contribute to antimicrobial stewardship initiatives across the health system and the importance of tracking and reporting results to frontline providers.

Identifying Opportunities for Antimicrobial Stewardship in a Tertiary Intensive Care Unit: A Qualitative Study

Background: Antimicrobial stewardship (AMS) encompasses numerous interventions that seek to improve antimicrobial usage, as inappropriate use of antimicrobials may result in the promotion of antimicrobial resistance, patient harm, and increased costs. AMS is of particular interest in intensive care units (ICUs) where antimicrobial use is extensive. Few qualitative studies have sought to identify the perceived attitudes and beliefs of intensive care clinicians around AMS. Objectives: To understand ICU nursing and physician priorities and preferences around AMS and possible AMS interventions for implementation in the ICU. Methods: Using consecutive sampling, semi-structured one-to-one interviews were conducted with ICU nursing and physician staff at a tertiary hospital in BC, Canada. Results: Nine participants (seven nurses and two physicians) were interviewed, and themes were identified and categorized as: opportunities to improve AMS in the ICU, barriers to AMS in the ICU, and possible future AMS interventions for implementation in the ICU. Opportunities identified included: clinician activities (improved communication, de-escalation, ICU nurse assessment) and support (infectious disease and antibiotic experts, AMS presence). Barriers identified included: knowledge gaps (infectious disease and antibiotic knowledge, AMS awareness), AMS and ICU integration (nursing role in AMS, AMS efficacy in ICU), and environment (competing priorities, critical care context). Interventions identified included: organisational (EMR modifications, checklists, algorithms), learning (infectious disease and antimicrobial education, audit, and feedback), and nursing intervention (antibiotic review, prompting reassessment).

188. Opportunities for antimicrobial stewardship: Time to optimal therapy and vancomycin use in gram-positive and contaminated blood cultures before and after implementation of rapid blood culture diagnostic testing

Abstract Background Rapid molecular diagnostic tests improve time to organism identification and may expedite antimicrobial de-escalation. Through faster detection of contaminated samples, rapid blood culture identification (BCID) should also reduce unnecessary antibiotic use. BioFire FilmArray BCID was implemented in July 2019 at a community hospital. This study compared antimicrobial use for gram-positive blood cultures before and after BCID implementation to identify areas for further antimicrobial stewardship intervention. Methods This retrospective cohort study evaluated adult patients at a 450-bed community hospital with gram-positive blood culture results between February and June 2018 and 2019 (pre-and post-BCID). Patients were excluded for polymicrobial bacteremia, pregnancy, or expiration/hospice status before blood culture positivity. The primary outcome was time to optimal therapy (TTOT) for bacteremia, defined as time to antimicrobial de-escalation, discontinuation, or result for untreated contaminated cultures. Time to organism identification, receipt of optimal therapy, and vancomycin duration were also evaluated, in addition to subgroup analysis of contaminated cultures (identified by microbiology comment or physician note). Results Of the 232 patients, median age was 70 years and 54.3% were male. Coagulase-negative staphylococci was most commonly isolated (n=104, 45%) and contamination rate was 53.4%. Median TTOT improved from 53.3 vs 28 hours, p&amp;lt; 0.001 in pre- vs post-groups, respectively, and optimal therapy selection increased from 83% to 93%, p=0.028. Median time to organism identification was 60.2 vs 23.5 hours, p&amp;lt; 0.001. Median duration for vancomycin (35.1 vs 25.2 hours, p=0.231) and overall antimicrobial duration did not differ between groups. Among contaminated blood cultures, TTOT improved (54 vs 27.3 hours, p&amp;lt; 0.001) and vancomycin median duration decreased (27.5 vs 16.6 hours, p=0.253). Conclusion Rapid BCID significantly improved TTOT, resulting in improved rates of optimal therapy and an observed reduced vancomycin duration. High rates of contaminated blood cultures identified opportunities for coordination with antimicrobial stewardship to reduce contamination rates and improve antimicrobial use. Disclosures All Authors: No reported disclosures.

1782. Antimicrobial Stewardship Opportunities in Gram-Negative Bacteremia Treatment at a Community Teaching Hospital

Abstract Background Gram Negative Bacteremia (GNB) is frequently encountered among hospitalized patients. In contrast to traditional 14-day lengths of treatment (LOT), recent literature supports a shorter (7-day) LOT for uncomplicated GNB with adequate source control, and the effectiveness of oral antibiotics. The goal of the following is to outline current practices of GNB treatment and identify opportunities for antibiotic stewardship (AS). Methods This study retrospectively reviewed all cases of uncomplicated GNB at a 528-bed community teaching hospital in Rochester, NY from January 2021 through March 2022. Demographic, laboratory, microbiologic, antibiotic therapy data, results of follow-up blood cultures (FUBC), hospital length of stay and 30-day readmission were collected. Exclusions were complicated or polymicrobial bacteremia, deaths during treatment, or prolonged hospitalization due to other medical factors. Influences of Infectious diseases (ID) or AS consult on treatment and outcomes were compared to cases with no consult. Continuous variables were analyzed using unpaired t-tests; categorical variables were analyzed using Fischer’s exact test and Chi-square as appropriate. Results 133 cases met inclusion criteria. Demographic and laboratory data are in Table 1. The frequency of bacteria isolated and source of infection are in Figure 1 and Figure 2. ID was significantly more often consulted for central line infections (17% vs 3%, p=0.01), and significantly less frequently involved in urinary tract infections (39% vs 69%, p=0.009). While total LOT were similarly longer than current literature supports (11.7 vs 12.5 days, p=0.2644), cases without ID consultation received significantly more days of oral treatment (4.7 vs 7.1 days, p=0.0275). There were no significant differences between receipt and no receipt of AS recommendations. Conclusion GNB continued to receive longer LOTs than current literature recommends, with longer IV durations recommended by ID consultants compared to those without ID consult. Educational initiatives regarding the safety of shorter LOT for GNB, including the efficacy of oral antibiotics, are needed and should include ID specialists. Disclosures All Authors: No reported disclosures.

2184. Predictors of Pneumococcal Urinary Antigen Test Positivity in Patients with Community-acquired Pneumonia: A Meta-analysis and Systematic Review

Abstract Background The 2019 American Thoracic Society/Infectious Diseases Society of America (ATS/IDSA) guidelines argue against routine pneumococcal urinary antigen testing (pUAT), except in patients with severe community-acquired pneumonia (CAP). Recent studies, however, have suggested that these recommendations identify a low-risk population, resulting in missed opportunities for antimicrobial stewardship. The optimal patient population for pUAT thus remains unknown. Our objective was to summarize predictors of pUAT positivity among patients hospitalized with CAP as determined by previous observational studies. Methods We systematically searched MEDLINE, Embase, Web of Science, and Scopus for articles related to urinary antigen tests and community-acquired pneumonia. Studies published until August 26, 2021, were included if risk factors for pUAT positivity in adult patients with CAP were evaluated with multivariable analyses. No language filters or limits were applied in order to capture all potentially relevant material. Two investigators independently screened studies, extracted, and compiled data. Results Of the 1,144 studies that were screened, 9 met the inclusion criteria, representing 8,536 patients who underwent pUAT. The most frequent independent risk factors associated with a positive pUAT were intensive care unit (ICU) admission (OR 1.77, 95% CI 1.27 – 2.48, I2 = 21%) (Figure 1) and female sex (OR 1.53, 95% CI 1.19 – 1.97, I2 = 36%) (Figure 2). Laboratory parameters such as C-reactive protein (OR 0.26, 95% CI 0.02 – 4.49, I2 = 93%) and BUN (OR 1.36, 95% CI 0.84 – 2.19, I2 = 93%) were not significantly associated with pUAT positivity. Many variables were inconsistently reported and thus could not be combined for analysis, including age &amp;gt; 65, current smoking, history of emphysema, hyponatremia, certain markers of severity, and antibiotic history. Figure 1:Forest plot of the association between ICU admission and positive pneumococcal UAT. The vertical line corresponds to the no difference point between the two groups. Squares, the size of which indicates the proportion of information given by each study, correspond to ORs. Horizontal lines represent the 95% CIs. The diamond indicates the pooled odds ratios. df = degrees of freedom; IV = inverse variance Figure 2:Forest plot of the association between female sex and positive pneumococcal UAT. The vertical line corresponds to the no difference point between the two groups. Squares, the size of which indicates the proportion of information given by each study, correspond to ORs. Horizontal lines represent the 95% CIs. The diamond indicates the pooled odds ratios. df = degrees of freedom; IV = inverse variance Conclusion Consistent with current guidelines, ICU admission, an indication of severe CAP, appears to be an important predictor of pUAT positivity. Additionally, however, female sex was significantly associated with pUAT positivity. Recognition of these risk factors can assist in identifying patient populations most likely to benefit from pUAT and may be considered in future CAP guidelines. Disclosures Abhishek Deshpande, MD, PhD, Clorox: Grant/Research Support|Merck: Advisor/Consultant|Seres Therapeutics: Grant/Research Support.

2151. Time to Positivity in Blood Cultures at a Free-Standing Level IV NICU

Abstract Background In the Neonatal Intensive Care setting, subtle clinical deterioration of the infant combined with the lack of specificity in clinical signs to identify true infection often triggers an evaluation for sepsis. Blood cultures are obtained, and empiric antibiotics are initiated. Limiting the duration of antibiotic exposure has potential benefits in curtailing antimicrobial resistance and reducing unwanted adverse effects. We aimed to determine the time to positivity (TTP) of blood cultures in a level IV NICU over a 6-year period, with the goal to reassess our antimicrobial practice. Methods Data were extracted from the Children’s Hospital Colorado data warehouse for all neonates admitted to the NICU with a positive blood culture between Jan 2013 to Dec 2018. These patient’s charts were reviewed for both microbiologic and clinical data. TTP was calculated based on date and time culture was collected, compared to the date and time growth was first reported. Micro-organisms were categorized into absolute pathogens, potential pathogens, common contaminants, yeast and other less frequently identified organisms. Results A total of 309 positive blood cultures were identified from 268 neonates. The mean gestational age was 34.7 weeks with an average birthweight of 2353g. Overall TTP median and interquartile range (IQR) was 21.1 (14.4 ,25.4) hours. The median (IQR) TTP for gram-positive absolute pathogens and gram-negative absolute pathogens were 16.3 (13.0, 22.4) and 12.6 (11.3, 14.4) hours, respectively. Of the 309 positive culture results, 295 (95%) had been initiated with antibiotics; 110 (37%) were later deemed as contaminant, and treatment discontinued. Central line associated bacterial infection was documented in 35 cases (11%). Death within 4 weeks of culture positivity was recorded in 25 (9.5%) cases. Conclusion The majority of gram-positive and gram-negative pathogens were identified within 24h of blood culture collection. A substantial number of cases were later categorized as contaminants, highlighting the importance of correct sterile technique when obtaining cultures. These findings highlight opportunities for antimicrobial stewardship to limit antibiotic exposure in the NICU. The high mortality within 4 weeks of blood culture positivity warrants further study. Disclosures All Authors: No reported disclosures.