Part Of Antimicrobial Stewardship Program Research Articles

Survey on infectious disease telephone hotlines in primary care: General practitioners’ satisfaction and compliance with advice

ObjectivesInfectious disease (ID) advice is a major part of antimicrobial stewardship programs. The objective of this study was to assess general practitioners’ (GPs)’ opinions and compliance with advice given by ID hotlines. Patients and methodsThis multicenter survey was based on the 7-day assessment of initial advice requested by GPs to a hotline set up by volunteer hospital ID teams to record advice for 3 years. The primary endpoint was the GPs’ satisfaction with the advice given by ID specialists. ResultsTen ID teams participated in the study and recorded 4138 requests for advice, of which 1325 requests included a proposal for antibiotic therapy and justified a follow-up call at seven days. Only 398 follow-up calls (30%) were carried out because many GPs were not reachable.GPs were very satisfied with ID hotlines: 58% considered them indispensable and 38% very useful. The recommendations provided by ID specialists were followed by GPs in more than 80% of cases. The two main motivations for GPs to call the hotline were to get quick advice (86%) and to receive help in managing a patient (76%). ConclusionsThe ID telephone consultations and advice systems for GPs are highly appreciated and are effective in terms of following the recommendations.

Infectious disease hotlines to provide advice to general practitioners: a prospective study

BackgroundTelephone hotlines in infectious diseases (ID) are part of antimicrobial stewardship programs designed to provide support and expertise in ID and to control antibiotic resistance. The aim of the study was to characterize the activity of the ID hotlines and estimate their usefulness for general practitioners (GPs).MethodsThis was a multicenter prospective observational study in different French regions. ID teams involved in antimicrobial stewardship with a hotline for GPs were asked to record their advice from April 2019 to June 2022. In these regions, all GPs were informed of the ID hotline’s operating procedures. The main outcome was usage rate of the hotlines by GPs.ResultsTen volunteer ID teams collected 4138 requests for advice from 2171 GPs. The proportion of GPs using the hotline varied pronouncedly by region, from 54% in the Isere department, to less than 1% in departments with the lowest usage. These differences were associated with the number of physicians in ID teams and with the age of the hotline. These results highlighted the value of working time as a means of ensuring the permanence of expertise. The main reasons for calling were: a diagnostic question (44%); choice of antibiotic (31%). The ID specialist provided advice on antibiotic therapy (43%) or a proposal for specialized consultation or hospitalization (11%).ConclusionsID hotlines could help to strengthen cooperation between primary care and hospital medicine. However, the deployment and perpetuation of this activity require reflection concerning its institutional and financial support.

2144. Duration of perioperative antibiotic prophylaxis in ventriculoperitoneal shunt surgery in children

Abstract Background Placement of ventriculoperitoneal (VP) shunt is an important treatment for pediatric hydrocephalus. Although prolonged perioperative antibiotic prophylaxis has theoretically no benefit in reducing device-associated infections, duration of antibiotic prophylaxis for VP shunt placement in pediatrics is not well established. As a part of antimicrobial stewardship program (ASP), our ASP team recommended to stop perioperative antibiotic prophylaxis for sterile medical placement within 48 hours following surgery in April 2017. Our aim of this study was to evaluate rate of VP shunt-associated infections following shunt placement between children received < 48 hours and ≧ 48 hours of perioperative antibiotic prophylaxis. Methods Children aged 15 years old or younger who underwent VP shunt insertion between April 2014 and November 2021 were enrolled at Tokyo Metropolitan Children's Medical Center. Children with co-existing infection at time of surgery were excluded. Rates of VP shunt-associated infections following 1 month and 6 months of post-surgical periods were compared between children who received < 48 hours and ≧ 48 hours of perioperative antibiotic prophylaxis. Results A total of 110 children were identified. Among them, 11 cases with VP shunt-associated meningitis and 15 cases with other infections were excluded. Girl ratio was 44%. Median age was 4.5 months old (IQR 8-40). Numbers of children with cefazolin and vancomycin-contained regimen were 83 (98.8%) and 1 (1.2%), respectively. Numbers of children who received perioperative antibiotic prophylaxis for < 48 hours and ≧ 48 hours were 43 (51.2%) and 41 (48.8%), respectively. Incidence of VP shunt-associated infections for 1 month of post-surgical period in < 48 hours and ≧ 48 hours antibiotic prophylaxis groups were 4.65% (2/43) and 12.2% (5/41), respectively. (P=0.211) Incidence of VP shunt-associated infections for 6 months of post-surgical period in < 48 hours and ≧ 48 hours antibiotic prophylaxis groups were 11.6% (5/43) and 12.2% (5/41), respectively. (P=0.936). Conclusion Shorter duration of < 48 hours of perioperative antibiotic prophylaxis did not increase rates of VP shunt-associated infections among children in short and long terms. Disclosures All Authors: No reported disclosures.

Management of Beta-Lactam Antibiotics Allergy: A Real-Life Study.

Beta-lactam allergy is a common problem in everyday medical practice and is recognized as a major public health issue. Carrying this label frequently leads to the avoidance of all beta-lactam antibiotics, favoring the use of other less preferred classes of antibiotics, that are more expensive and associated with more side effects and increased antimicrobial resistance. Therefore, delabeling a beta-lactam allergy is part of antimicrobial stewardship programs. Herein, we retrospectively examined the clinical records of 576 patients who were referred to our center for a label of allergy to beta-lactam antibiotics and were systematically investigated following a standardized algorithm. Our main aim was to evaluate the frequency of confirmed immediate- and delayed-type allergy to commonly prescribed subclasses of beta-lactam antibiotics (penicillin and cephalosporin), as well as the negative predictive value (NPV) and the sensitivity of skin tests. Our secondary aims were to examine the safety of beta-lactam skin testing and drug challenge. We identified that 260 patients reported a history of immediate reactions, 131 of delayed reactions, and 114 of unknown timing or mechanism of reactions. Following assessment and testing, 86 (18.3%) patients had a confirmed allergy to any beta-lactam antibiotics; 63 (13.4%) with an immediate- and 23 (4.9%) with a delayed-type reaction. Most frequently identified confirmed allergy was to penicillins (65 patients), followed by cephalosporins (21 patients). When immediate-type reactions were examined, NPV of skin tests were 96.3% and 100% for penicillins and cephalosporins, respectively. When delayed reactions were considered, NPV were 91.9 and 87.5% for penicillins and cephalosporins, respectively. Evaluation of the safety of skin tests according to the standardized procedure showed that systemic allergic reactions occurred in only 0.7% of skin tests and in 3.1% of drug challenges. Overall, our data indicate that only 18.3% of patients with a beta-lactam allergy label have a confirmed allergy and non-allergic patients can be safely delabeled through allergic workup based on skin tests and drug challenge. This approach supports the policy of saving second-line antibiotics through a standardized allergy workup.

Point Prevalence Survey of Antimicrobial Prescription Patterns in a Pediatric Tertiary-Care Unit in Thailand 2019

Background: Surveillance data is an essential part of antimicrobial stewardship programs (ASP). Objective: To describe and compare prescription patterns of antibiotics after a 3-years implementation of an ASP using prospective audit and feedback. Materials and Methods: The authors conducted a point prevalence survey (PPS) of antibiotic prescriptions at a 200-bed pediatric unit at King Chulalongkorn Memorial Hospital. A standardized study protocol from the Global Antimicrobial Resistance, Prescribing, and the Efficacy in Neonates and Children (GARPEC) project was used. The authors reviewed medical charts of hospitalized children of less than 18 years of age, using a point prevalence method on the 15 of February, May, August, and November 2019. Endpoints measures included rate of antimicrobial prescriptions and type of antimicrobial use, stratified by neonatal and pediatric ward types. Rate of antimicrobial prescriptions will be compared with historical data form PPS in the same institute collected in 2016. Results: In 2019, the medical records of 269 neonates and 409 children hospitalized were reviewed. The proportion of children receiving antibiotics in neonatal units overall was 18.6% (95% CI 14.1 to 23.8), of which ampicillin or gentamicin (52.0%) was the most common regimen. Rate of antibiotic prescriptions in general pediatric wards was 46.5%, with third generation cephalosporins being the most used antibiotics. Prescription rate in the oncology ward was 52.9% with antipseudomonal agents or meropenem being the most prescribed antibiotics. Prescription rates in the pediatric intensive care unit (PICU) was 88.9%, with meropenem being the most used antibiotic. Compared to a previous PPS study in 2016, prevalence of antimicrobial use was higher in general pediatric wards at 46.5% versus 37.2% (p=0.02) and PICU at 88.9% versus 67.7% (p=0.007). Conclusion: The prevalence rates of antimicrobial use in pediatric wards increased despite implementation of a prospective audit and feedback antibiotic stewardship program. Other measures are needed to reduce the unnecessary prescriptions. Keywords: Antimicrobial; Antimicrobial stewardship program; Pediatric; Point prevalence survey

#86: A Quality Improvement Study Using Blended Learning as Part of Antimicrobial Stewardship Program (ASP) to Improve Ampicillin Sulbactam Prescription in Pediatric Hospital in Bogotá, Colombia

Abstract Background Antimicrobial agents are the second most common prescribed drugs in hospital settings. Antibiotic resistance is a major public health problem. Some studies have found that 20–50% of antibiotics prescriptions are inadequate or not necessary. Ampicillin-sulbactam is the second most common prescribed antibiotic in inpatients children in our hospital. We designed a quality improvement study to improve ampicillin–sulbactam prescription in a third-level children hospital in Bogotá, Colombia. Methods A before and after study was designed. We obtained days of treatment (DOT) for ampicillin–sulbactam in last 3 years (2017, 2018, and 2019). In October of 2019, we included ampicillin–sulbactam as a targeted antibiotic in our ASP. We focus the efforts in 2 principals’ strategies: Educative strategy and audit and feedback strategy. Educative strategy included a blended learning intervention and audit and feedback strategy included surveillance of prescriptions in real time to evaluate local guidelines adherence with feedback to prescribers. We designed a form to collect and analyze data with Epi Info®. Results In 2 months of surveillance, we reviewed and analyzed 67 prescriptions. Median age of patients was 2 years (0.75–7.5 years). The main diagnosis was pulmonary infection in 70.1% (multilobar pneumonia 13 patients, lobar pneumonia 8 patients and bacterial co-infected bronchiolitis in 5 patients). Three prescriptions were based in etiologic isolation while 64 was an empiric formulation. Only 24 prescriptions (35%) were considered adequate according to local guidelines. The principal’s reasons of inadequate prescription were the possibility to use a narrow-spectrum antibiotic (58.1%) and error about inadequate infectious disease diagnosis (39.5%). In 43 of inadequate prescriptions, ASP changed the antibiotic in 24 patients, stopped all antimicrobial therapy in 14, and changed to oral rout in other 4. In the patient’s follow-up, all have an adequate clinical course, and only 3 required to restart antimicrobial therapy. There were no deaths related to infectious diseases. In the educational strategy we trained 34 staff members (32.9%) with lectures and 72 staff members (69.2%) using virtual strategy. We use a pre- and post-test evaluations, with a score improvement in 33% after the educational strategy. Finally, we compared DOT of ampicillin-sulbactam for the last 3 years and we found a reduction of 65% in prescription between October 2017 and October 2019 (Figure 1). Conclusion This is the first quality improvement study with an ASP targeting a narrow-spectrum antibiotic in children. Many ASP focused their efforts only in broad-spectrum antibiotics, but few studies have been published in narrow-spectrum antibiotics. The implementation of an ASP to improve prescription of ampicillin–sulbactam had a dramatic impact in reduction of prescriptions in our settings. The educational strategy using blended learning strategy is especially valuable in hospital education because virtual learning has a great flexibility and if facilitated by the high availability of mobile devices.

98. Clinical and Pharmacoeconomic Impact of Rapid Diagnostic Pneumonia Panel in Critically Ill Patients Admitted with Nosocomial Pneumonia

BackgroundRapid identification of causative organisms and tailored antibiotic therapy is essential to improving patient outcomes in critically ill patients with nosocomial pneumonia (NP). The BioFire ® FilmArray ® Pneumonia Panel (BFPP) can identify and semi-quantify the causative organisms via PCR. However, there is limited evidence of its implementation and utility within antimicrobial stewardship program (ASP) in managing NP.MethodsThis was an IRB-approved retrospective pre- and post-interventional study at an acute care hospital. Critically ill patients were included in the intervention group (IG) with a confirmed diagnosis of NP and had BFPP performed. Patients in IG were matched on a 2:1 ratio to a comparator group (CG) who did not receive BFPP. The primary endpoint was clinical cure (CC), defined as: 1) resolution of symptoms and/or leukocytosis; or 2) radiographic improvement; or 3) expression of CC noted by infectious disease physician. Secondary endpoints include time to escalation, de-escalation, or discontinuation of antibiotics, and inpatient mortality (IM). In addition, a pharmaco-economic analysis of the utilization of this panel was conducted.ResultsThere were 52 patients evaluated, of which 26 were included in IG and 13 were matched to be included in CG. Demographics were similar between the two groups. No difference in CC was observed between IG and CG (38.5% vs 38.5%, p = 1). However, when evaluating ASP interventions, more patients in IG had de-escalation (53.8% vs 15.4%, p = 0.01) and discontinuation (50% vs 7.7%, p = 0.003) performed compared to CG. No difference was seen in escalation of therapy (34.6% vs 30.8%, NS) and IM (26.9% vs 46.2%, p = 0.27). Time to ASP intervention was quicker by 24 hours in IG vs CG (24 vs 48 hours, p = 0.01). No difference was seen in total cost of therapy between the two groups ($289,500 vs $243,705, p = 0.6). However, cost savings of $31,000 was seen in total cost of ICU care in IG vs CG ($144,000 vs $175,000, p = 0.032).Figure 1: ASP Intervention ConclusionThere was no observed impact of BFPP on CC and IM in critically ill patients. However, utilization of BFPP led to faster time to ASP interventions and higher rates of de-escalation and discontinuation of antibiotics. When utilized as part of ASP, BFPP can serve to be a cost-effective option for critically ill patients.Disclosures All Authors: No reported disclosures

The protocol of empirical antimicrobial therapy of the inpatient hospital of the National Medical and Surgical Center n. a. N. I. Pirogov (fourth edition, 2018)

The protocol of empirical antimicrobial therapy (AMT) in the National Medical & Surgical Center n. a. N. I. Pirogov is a part of antimicrobial stewardship program, implemented in 2013. The protocol is based on local antimicrobial resistance data, takes into account features of the hospital and contains the decision-making process for risk stratification of antibiotic-resistant microorganisms, for start, choice, removal of AMT and its results assessment, as well as differentiated algorithms of empirical antibiotic therapy for respiratory tract infections, skin and soft tissues infections, urinary tract infections, bloodstream infections, intra-abdominal infections, periprosthetic joint infection, central nervous system infection, infections in neutropenic patients, treatment regimens for antibiotic-associated colitis. The protocol is updated annually, the fourth edition of the protocol is presented.

Cost minimization analysis on IV to oral conversion of antimicrobial agent by the clinical pharmacist intervention

Antimicrobial agents are used to treat the infectious diseases which and has become a routine milieu. Prescribing intravenous (IV) antimicrobial agents are needed for abruptly subduing the infectious stage and will leads to decrease the infectious severity of the patient. The cost minimization Analysis involved monitoring the IV to oral conversions carried out in General Medicine department as a part of Antimicrobial stewardship Programme (ASP) for initial 3 months followed by feedbacks, guideline preparation and CME programs as intervention. This was followed up by a post-intervention audit to assess the effectiveness of the interventions performed. An aggregate of 102 subjects were enrolled in the study and quantitative use of the parenteral AMA was found to be significantly reduced in the post-interventional phase in comparison to the pre-interventional phase (p=0.028) and the conversion per patient rate is also increased (p=0.0001). Similar reductions were also achieved by the intervention in the duration required for oral conversions, average difference is 2days (p=0.000). 19.5% reduction in the usage of cost of antibiotics is achieved with a 0.010076DDD/100 Bed days difference to the control population. The study was successful in increasing the conversion rate which clearly implicated the acceptance of guideline. The recommendations of the clinical pharmacist were successful in reducing both the length of stay and duration of parenteral therapy, there in reducing the consumption and cost of antimicrobial therapy. The cost minimizations were found by IV to oral conversion of antibiotics without any change in the treatment outcome.

Good Nursing Is Good Antibiotic Stewardship.

: Resistance to antibiotics has increased dramatically in the United States, with serious associated medical, social, and economic consequences. The most promising approach to this national crisis is a new understanding of the need for the careful and responsible use of antibiotics, both for the benefit of society and for the optimal care of each patient. This multidisciplinary approach, called antimicrobial stewardship, has typically involved specialists but not necessarily nurses, who perform numerous antibiotic-related activities daily and should be an integral part of antimicrobial stewardship programs. In this article, we use patient examples to review several stewardship activities and illustrate how nurses are essential to the appropriate use of antibiotics.