Antimicrobial Stewardship Practices Research Articles

Antimicrobial stewardship programs: perceptions and practices among Jordanian healthcare practitioners

AbstractObjectiveAntimicrobial stewardship programs are of paramount importance in containing antibiotic resistance and combat the acquisition of multi-drug resistance strains. Healthcare practitioners, specifically physicians and clinical pharmacists are the direct clinical antibiotic prescribing authorities. Therefore, this study aimed to assess Jordanian practitioners' perceptions and practices towards antimicrobial stewardship programs.MethodsThis was a cross-sectional study, in which physicians and clinical pharmacists were approached to fill out a previously validated study instrument. A close-ended structured questionnaire comprising 34 questions covering aspects related to antimicrobial stewardship program perceptions, practices and participants' demographic data were used to collect pertinent information.Key findingsA total of 286 participants were enrolled in the study. There was an overall positive perception towards antimicrobial stewardship programs, while practices related to this element was still suboptimal. Additional comparison of the overall perception scores among different demographic characteristics showed that long years of practice, postgraduate studies and practice in academic sectors yielded higher perception scores (P = 0.0335, 0.0328 and 0.0007, respectively).ConclusionThere is an imminent need to enhance Jordanian practitioners' knowledge about antimicrobial stewardship programs. Clear recognition of integral antimicrobial stewardship programs' components must be coupled with highlight changes in current practices related to antimicrobials usage and prescription.

Practice of antimicrobial stewardship in a government hospital of India and its impact on extended point prevalence of antibiotic usage.

Background:Antimicrobial resistance (AMR) is a global concern requiring immediate attention. Among many proven measures of decreasing AMR, practice of antimicrobial stewardship is the lowest hanging which can be adapted with negligible financial implications.Methods:This is a case record based extended cross-sectional type of observational operation research study conducted at an institute of national importance established by Government of India. Point prevalence of antibiotic usage among the patients admitted in the hospital, on four different days in four different quarters of a year was done to study the impact of antimicrobial stewardship program (AMSP).Results:A cumulative 711 patients were exposed on antibiotics among 1396 study participants. There was a significant decrease in antibiotic consumption across the 1st and 4th quarter. The average antibiotic usage was 50.9% (61.75, 60%, 48.4%, and 39% respectively in the 1st to 4th quarter). Among the total number of patients, intravenous antibiotic usage was 47.9% (60.71%, 58.4%, 44.9%, and 34.2% respectively in 1st to 4th quarter). Among the newly admitted patients, the consumption of antibiotic usage decreased from 45.9% to 25.7%. Among the intravenous antibiotics, the top 10 consumed antibiotics were 3rd generation cephalosporin (39.8%), aminoglycoside (14.8%), amoxicillin/amoxy-clav (12.5%), piperacillin-tazobactum (8.5%), carbapenams (6.6%), cefuroxime (6.4%), quinolones (4.3%), vancomycin/linezolid (4.1%), colistin (0.8%), and others (0.8%).Conclusion:Government run hospitals can run low budget antimicrobial stewardship program with sustainable impact on antibiotic consumption. For a successful AMSP, it requires change in attitude, commitment, and administrative support rather than a huge financial support.

Knowledge, Attitude and Practices of Clinicians, Nurses and Pharmacists Regarding Antimicrobial Stewardship: A Five Centre Survey from India

Introduction: Increasing awareness and practice of Antimicrobial Stewardship (AMS) has gained immense importance in Indian hospitals for preventing the irrational use of antibiotics. India is one of the world’s largest consumers for antibiotics. Assessment of the local Knowledge, Attitude and Practices (KAP) of Antimicrobial Resistance (AMR) and AMS among Healthcare Providers (HCPs) will help in designing effective public health policies and engaging the community in campaigns against increasing microbial resistance. Aim: To understand the status of AMS programs and practices in five private sector multispecialty hospitals situated in the East, West, North and South zones of the country and to assess the KAP of HCPs regarding AMR and AMS. Materials and Methods: The cross-sectional survey was conducted to assess the implementation of AMS in five hospitals among clinicians, nurses and pharmacists across India using a predeveloped AMS checklist between June 2019 and October 2019. The analysis was done between July and August 2020. Responses were collected using a five-point Likert scale, with choices ranging from ‘strongly agree’ to ‘strongly disagree’.Descriptive analysis was done for the KAP survey to determine the percentages of participants under each response category. Results: Total 32 clinicians, 55 nurses and eight pharmacists responded to the KAP survey (100% response rate). The clinicians were aware that AMR is caused by irrational prescribing of antimicrobials (n=31, 96.87%) and improper diagnosis of infective conditions (n=27, 84.37%). However, knowledge of clinicians on infection control practices (n=6, 18.75% disagreed) in controlling AMR and practice of referring local epidemiology before prescribing antimicrobials (n=7, 21.87% did not follow routinely) could be improved. The knowledge and practice of nurses and pharmacists on antibiotic use were spread over a wide range. According to the nurses, AMR was mainly caused by using antimicrobials for non bacterial infections (n=30, 54.54%) and deviations from their standard duration (~63.64%-72.73%). As per pharmacists, the lack of restrictions on antimicrobial usage and widespread use or overuse of antibiotics were major contributors to AMR (n=3, 37.5% strongly agreed). Both nurses and pharmacists could benefit from reinforced training on antibiotic usage. Conclusion: Implementation of AMS was not adequate in private Indian hospitals. Although clinicians have good knowledge on antibiotic use, it was not equally reflected in their practice. The KAP data of nurses and pharmacists suggest that training and education on appropriate antibiotic usage should be emphasised. More efforts are required to improve AMS practices in hospitals.

130. Antimicrobial Stewardship Practices in Community Pharmacies Across the United States

BackgroundAntimicrobial stewardship (AMS) in the community is essential as majority of antibiotic prescribing occurs in the community. Pharmacists are recognized by the Center for Disease Control and Prevention (CDC) as co-leaders for leading implementation efforts to improve antibiotic use. The purpose of this study is to evaluate current AMS practices in community pharmacies across the United States (US) and identify challenges.MethodsA 15-item survey was created based on CDC’s Core Elements of Outpatient AMS to assess current policies and practices in place, as well as collect baseline demographics and pharmacists’ perceptions. A survey invite was posted on the Facebook group, Pharmacist Moms, in September 2019. Participation was voluntarily and anonymous.ResultsParticipants included 61 community pharmacists from 25 states across the US. 88.5% work in a chain pharmacy with 54.1% in staff positions and 37.7% in management. 37.7% have been practicing for > 10 years, 36.1% for 6–10 years and 26.2% 5 or less years. Minimal responses met CDC’s Core Elements of AMS: commitment (27.9%), action (24.6%), tracking and reporting (14.8%), and education and expertise (23% for pharmacists, 9.8% for patients).In regards to perception, 67.9% felt AMS is important in the community. 88.5% would participate in AMS if the opportunity were provided. 91.8% were unsure or had no plans to implement AMS within the next 2 years.Common challenges include the lack of time/staff (83.6%), pushback from prescribers (68.9%), lack of leadership (57.4%), lack of financial incentives (52.5%), pushback from patients (52.5%), lack of pharmacist knowledge/training (39.3%), lack of funding/financial support (29.5%), lack of legal requirement (21.3%), lack of information technology support (19.7%), and lack of pharmacist interest (11.5%).Current Trends of U.S. Community Pharmacies in Meeting CDC’s Core Elements of Outpatient Antimicrobial Stewardship Challenges in Implementing Antimicrobial Stewardship in Community Pharamacies ConclusionResults from this study reveal the lack of AMS practices in community pharmacies. Pharmacists have a critical role in AMS, but many challenges exist in the community setting inhibiting the full potential of pharmacists in AMS efforts. This study highlights the importance and need for addressing these issues as regulations and strategies for AMS in community settings develop.Disclosures All Authors: No reported disclosures

133. Creation of an Emergency Department (ED)-Specific Urine Antibiogram and Evaluation of Urinary Tract Infection (UTI) Prescribing Practices at a Tertiary Academic Medical Center

BackgroundInpatient settings have been the focus of most antimicrobial stewardship (AS) practices; however, the Joint Commission has now published requirements for accredited ambulatory healthcare organizations to implement AS. This analysis aimed to create a urine isolate antibiogram and to evaluate microbiological data and prescribing practices for UTI patients in the ED.MethodsThis retrospective cohort study included adults admitted to either of two EDs at University of Minnesota Medical Center and diagnosed with a UTI between 1/1/2018 and 12/31/2018. Patients were excluded if subsequently admitted to an inpatient unit or if they had a repeat culture growing the same organism as the index isolate. Diagnosis of cystitis versus pyelonephritis was based on ICD-10 coding. Data including urinalysis and culture results, susceptibilities, empiric antibiotic selection, and readmissions were collected.ResultsData from 350 isolates were collected for inclusion in the antibiogram. Patient characteristics corresponding to this isolate collection included 78.9% female, median age of 41 years, and 64.6% diagnosed with pyelonephritis. Escherichia coli was the most common organism (70%), followed by Klebsiella pneumoniae (5.4%) and Proteus mirabilis (4%). Combined susceptibilities of E. coli isolates from both EDs were: 49.4% ampicillin, 55.7% ampicillin/sulbactam, 69.8% sulfamethoxazole/trimethoprim, 83.7% ciprofloxacin (CIP), 85.7% cefazolin, 93.9% ceftriaxone, and 94.3% nitrofurantoin (NIT). The most common discharge antibiotics prescribed for cystitis patients were NIT (29.8%) and cephalexin (25%). Pyelonephritis patients were most frequently prescribed CIP (32.3%) and cefdinir (14.2%). Drug-bug mismatches occurred in 19.1% of patients (10.5% cystitis vs. 23.9% pyelonephritis). The rates of ED readmission within 96-hours and inpatient admission within 30 days, for any reason, were 4.3% and 9.1% respectively.ConclusionBased on the ED-specific urine antibiogram generated, NIT (cystitis) and CIP (pyelonephritis) could be considered first-line agents for empiric treatment of UTI at our institution. Drug-bug mismatches were more common in pyelonephritis patients. These data will be used to develop a treatment algorithm aimed at improving treatment of UTI in the ED.Disclosures Elizabeth B. Hirsch, PharmD, Merck (Grant/Research Support)Nabriva Therapeutics (Advisor or Review Panel member)

19. A Global Point Prevalence Survey of Antimicrobial Use in Neonatal Intensive Care Units

BackgroundAntimicrobials are one of the most commonly used medications in the NICU. We aimed to gather baseline global data on antimicrobial use to facilitate subsequent antimicrobial stewardship efforts.MethodsWe conducted a one-day global NICU point prevalence study on July 1, 2019 with a 30-day follow up. Data collection included patient demographics, antimicrobial therapy, site location, antimicrobial stewardship (AS) practices as well as the duration of antimicrobial therapy and in-hospital mortality were recorded.ResultsEighty-one NICUs from twenty-eight different countries identified 2,163 admitted patients of which 570 (26%) were prescribed at least one antimicrobial. Three NICUs did not have any patients on antimicrobial therapy, all had less than 20 patients admitted. Level 3 and Level 4 NICUs comprised 51% and 48% respectively. Delivery units comprised 74%, the rest were referral centers. AS programs were in place in 62% of the hospitals and 47% of the units had NICU specific initiatives. Patients were on average 32.5 weeks gestational age (+/-5.3 SD), with birth weight of 1976 grams (+/- 1022 SD), and were 32 days (+/-65 SD) postnatal age at the time of the study.Antibiotics were the most frequently used medication in 92% of patients with 931 antibiotics prescribed on the assessment day. Hospitals with any NICU AS initiative had significantly lower rates of antibiotic utilization compared to NICUs without AS (21% and 32%; p-value: < 0.01). Of those on antibiotic therapy, ampicillin, gentamicin and amikacin were prescribed to 41%, 34%, and 21% of patients respectively. When only definitive treatment was evaluated, vancomycin, amikacin, and meropenem were the highest prescribed antibacterial agents at 25%, 19%, and 19% respectively. At the initial assessment, study participants indicated either 3 or 7 days (37% and 26%) for planned duration. Actual treatment duration for empiric and definitive treatment, was 7 and 14 days (29% and 19%) When comparing patients who had an established treatment course at the time of the initial assessment, the final length of treatment for culture negative sepsis was 7 (IQR:5–10) and culture positive sepsis was 11 days (IQR:10–14; p-value: 0.07).ConclusionBenchmarking global antimicrobial use is crucial for improving NICU-AS practices.Disclosures Pavel Prusakov, PharmD, Merck (Research Grant or Support) Debra A. Goff, PharmD, Merck (Research Grant or Support)

898. Prevalence of Extended Spectrum Beta-Lactamase Producing Escherichia coli, Klebsiella Pneumoniae and Pseudomonas Aeruginosa from Hospital Acquired Surgical Site Infections in Ghana

BackgroundGlobally, ESBL-producing bacteria pose a great challenge for treating hospital acquired SSI. Currently, the prevalence of ESBL pathogens in Ghana hospitals is poorly understood. Determining the frequency ESBLs are encountered will, in turn, provide insight for antibiogram development and shape antimicrobial stewardship policies in Ghana.MethodsUsing U.S. CDC criteria for SSI, wound swabs or aspirates were collected from 112 participants who met study inclusion criteria. Specimens were plated on MacConkey and blood agar; then colonies were isolated and identified using MALDI-TOF. Antimicrobial susceptibility testing was performed using the Kirby-Bauer disk diffusion method and interpreted according to the 2018 Clinical and Laboratory Standards Institute (CLSI) guidelines. The combined disk method was used to screen for ESBLs among E.coli and K. pneumoniae isolates. Genes associated with ESBL production (SHV, TEM and CTX-M) were detected using PCR analysis.ResultsThirty-eight percent of the bacterial isolates recovered were E. coli, K. pneumonia accounted for 32%, and P. aeruginosa accounted for 16% of the total isolates; remaining isolates were gram positive pathogens not discussed here. ESBL production was detected in 50% of E. coli isolates and 73% of K. pneumoniae isolates. ESBL-producing isolates were susceptible to meropenem but resistant to cefuroxime, cefotaxime, tetracycline, trimethoprim-sulfamethoxazole, gentamicin, ciprofloxacin and chloramphenicol. P. aeruginosa isolates were only sensitive to meropenem, gentamicin, and ciprofloxacin. In our study, CTX-M was the most frequently detected gene producing the ESBL-phenotype: 33% of E. coli isolates and 73% of K. pneumoniae isolates possessed the CTX-M gene.ConclusionApproximately 70% of total bacterial isolates recovered from our SSI study were ESBL producers. The presence of these multi-drug resistant organisms raises clinical concerns due to the absence of routine antimicrobial resistance (AMR) testing and lack of suitable first-line antimicrobials for ESBL pathogens. Improved laboratory capacity to more readily detect MDROs is essential for effective clinical management of patients, antibiogram development and refining antimicrobial stewardship practices in Ghana hospitals.Disclosures All Authors: No reported disclosures

206. The Utility of Lactate as a Biomarker for Sepsis in Cancer Patients

BackgroundSerum lactate is included in the initial assessment of patients with sepsis. However, cancer patients develop lactic acidosis for a variety of reasons and are underrepresented in most studies. Therefore, elevated lactate levels may lead to overdiagnosis of sepsis and excessive antibiotic use. The purpose of this study is to evaluate the utility of lactate as a biomarker for sepsis in cancer patients. The primary endpoint is the rate of 24-hour lactate clearance between infectious and non-infectious causes of lactic acidosis in cancer patients. Secondary objectives explore the duration of antibiotic therapy (DOT), the impact of liver metastasis on serum lactate levels, and the role of procalcitonin in distinguishing between infectious and non-infectious causes of lactic acidosis.MethodsRetrospective chart review by Antimicrobial Stewardship teamFigure 1: Study design ResultsPreliminary data from a random subset of our sample (45/150) suggests there is no difference in mean serum lactate levels between infectious and non-infectious groups (4.6 vs 6.4). However, a substantial difference exists in the rate of 24h lactate clearance, although the difference was not statistically significant (58.3% vs 33%; p=0.13) (Fig2). There was a significant difference in antibiotic DOT (12.6 vs 3.3; p< 0.0001) presumably due to robust antimicrobial stewardship practices. Consistent with previous studies, there was a significant difference in procalcitonin levels between groups (27.2 vs 1.5, p=0.04).A sub-analysis of non-infectious patients with liver metastasis revealed a statistically significant difference in the rate of lactate clearance (21% vs 61.5%, p=0.03) (Fig3) suggesting that liver involvement impacts lactate clearance. Antibiotic DOT were also longer in non-infectious patients with liver metastasis (4.53 vs 1.38, p=0.02).Comparing end points between cancer patients with and witthout infection. Liver involvement affecting Lactate clearance in patients without infection. ConclusionCancer patients often manifest SIRS criteria at baseline which may lead to the overdiagnosis of infection and excessive antibiotic usage. Our observation is that lactate clearance as opposed to degree of lactic acidosis may be a more accurate indicator of infection in cancer patients especially those with liver involvement. This information may mitigate unnecessary antibiotic use in cancer patients with persistent lactic acidosis unrelated to infection.Disclosures All Authors: No reported disclosures

Diagnostic and antimicrobial stewardship with molecular respiratory testing across the SHEA Research Network.

This survey investigated diagnostic and antimicrobial stewardship practices related to molecular respiratory panel testing in adults with lower respiratory tract infections at acute care hospitals. Most respondents reported use of rapid respiratory panels, but related stewardship practices were uncommon and the real-world impact of respiratory panels were difficult to quantify.

Exploring perspectives on antimicrobial stewardship: a qualitative study of health managers in Kenya

BackgroundAntimicrobial resistance is a significant public health concern with the establishment of antimicrobial stewardship in hospitals being increasingly obligatory. Perspectives and insights of health managers on antimicrobial stewardship (AMS), complementary health services and building blocks are imperative towards implementation of robust AMS programs. This study aimed to understand perspectives of hospital managers on AMS and identify areas of management engagement while addressing potential blockades to change.MethodsA cross-sectional, qualitative, multicenter study was conducted in three hospitals in Kenya. Key-informant interviews on perspectives on AMS were administered to hospital managers. Qualitative data was captured using audio tapes and field notes, transcribed and managed using NVivo 12 software. An iterative process was used to develop the thematic framework and updated in two rounds of iteration analysis. Analysis charts for each emergent theme were developed and categorized across all participants.ResultsPerspectives on AMS are described in five thematic categories; Importance of antimicrobial stewardship and the role of medicines and therapeutics committee, availability of antimicrobial formulary and usage surveillance systems, laboratory competency and recommendations for infection prevention and management, educational resources and communications channels available, building blocks and low-lying fruits for Antimicrobial Stewardship Committees. The role of stewardship collaboration in diagnosis and antimicrobial prescription was alluded to with managers indicating a growing rise in occurrence of antimicrobial resistance. There lacked contextualized, hospital specific antimicrobial formulary and adequate laboratory competency. Staff training and communication channels were available in varying capacity across the three hospitals. Building blocks identified include medicines and therapeutics committee, education, and training platforms (Continuous Medical Education and Continuous Professional Development activities) and hospital leadership commitment.ConclusionsThe practice of antimicrobial stewardship is not implemented and well developed as demonstrated by lack of core AMS complementary health services. However, the health managers are aware of the fundamental importance of antimicrobial stewardship programs and the vast benefits of implementation and institutionalization of AMS to hospitals and their clients. The findings underpin the importance of understanding and incorporating perspectives of health managers on existing contextual mechanisms that can be leveraged on to establish robust AMS programs in the fight against antimicrobial resistance.

Addressing antimicrobial resistance in Nigerian hospitals: exploring physicians prescribing behavior, knowledge, and perception of antimicrobial resistance and stewardship programs

ABSTRACT Introduction We assessed the knowledge of, attitude toward antimicrobial resistance (AMR) and practice of antimicrobial stewardship (AMS) among physicians in Nigeria to provide future guidance to the Nigerian National Action Plan for AMR. Methods A descriptive cross-sectional questionnaire-based study explored the physicians’ self-reported practice of antibiotic prescribing, knowledge, attitude, and practice of AMR and components of ASPs. Results The majority (217; 67.2%) of respondents prescribed antibiotics daily in their clinical practice AMR was recognized as a global and local problem by 308 (95.4%) and 262 (81.1%) respondents, respectively. Only 91 (28.2%) of respondents have ever heard of antibiotic stewardship. The median AMR knowledge score was 40 (19–45)out of 45while that for ASP was 46.0(32–57) out of 60. There was significant statistical difference between the ASP median scores among the medical specialties category (P value <0.0001) More respondents had good knowledge of AMR than ASPs (82.7% versus 36.5%; p < 0.0001). Conclusion Respondents in this study were more knowledgeable about AMR than AMS and its core components.

Antimicrobial use data collection in animal agriculture.

Antimicrobial drug use can contribute to the emergence of antimicrobial drug-resistant organisms; therefore, judicious use of this important category of drugs is critical in both human and animal medicine to slow the development and spread of resistance. The US Food and Drug Administration (FDA) Center for Veterinary Medicine (CVM) is committed to advancing efforts to implement good antimicrobial stewardship practices in veterinary settings as part of our mission to protect human and animal health. In order to understand the drivers of resistance in veterinary settings and assess the impact of interventions designed to slow the development and spread of resistance, it is vital to have access to scientifically sound data on antimicrobial use and resistance. In 2016, FDA awarded funds in the form of cooperative agreements to support pilot projects for the collection of farm-level antimicrobial use data in animal agriculture. These funded data collection efforts are intended to provide needed information on antimicrobial use practices in various animal production settings and to inform the development of long-term strategies for collecting and reporting such data in a sustainable and nationally representative manner. Data were collected from records of participating dairy and feedlot cattle operations, swine companies, and broiler and turkey companies. Information from the first 2years of the pilot projects is presented in this special issue, along with discussions related to challenges of collecting and reporting antimicrobial use data.

Antimicrobial Stewardship Practice in the Ambulatory Setting From a National Cohort.

BackgroundThe majority of antimicrobial use occurs in the ambulatory setting. Antimicrobial stewardship programs (ASPs) are effective in improving appropriate prescribing and are now required by accreditation bodies.MethodsThis was a cross-sectional, multicenter survey describing the current state of ambulatory ASPs in a national cohort of Vizient member hospitals with ambulatory healthcare settings and serves as a benchmark for stewardship strategies related to program effectiveness.ResultsOne hundred twenty-nine survey responses from a variety of institution types across 44 states were received. Survey respondents reported a fully functioning ASP in 7% (9 of 129) of ambulatory practices compared with 88% (114 of 129) of inpatient institutions. Effectiveness in at least 1 antibiotic use-related outcome (ie, utilization, resistance, Clostridioides difficile infection, or cost) in the past 2 years was reported in 18% (18 of 100) of ambulatory and 84% (103 of 123) of inpatient ASPs. Characteristics of ambulatory ASPs demonstrating effectiveness were institution guidelines (89%, 16 of 18), rapid diagnostic testing for respiratory viruses or group A Streptococcus (89% 16 of 18), outpatient antibiograms (78% 14 of 18), and dedicated pharmacist support (72%, 13 of 18). Ambulatory ASP effectiveness was shown to increase as programs met more of the Centers for Disease Control and Prevention (CDC) Core Elements of Outpatient Antimicrobial Stewardship (P < .001).ConclusionsAntimicrobial stewardship programs are needed in the ambulatory setting, but they are not common. Currently, few ambulatory ASPs in this survey self-identify as fully functioning. The CDC Core Elements of antimicrobial stewardship should remain foundational for ASP development and expansion.

Motivational Application of Standardized Antimicrobial Administration Ratios Within a Healthcare System

Background: Hospitals in the United States have been encouraged to report antimicrobial use (AU) to the CDC NHSN since 2011. Through the NHSN Antimicrobial Use Option module, health systems may compare standardized antimicrobial administration ratios (SAARs) across specific facilities, patient care locations, time periods, and antimicrobial categories. To date, participation in the NHSN Antimicrobial Use Option remains voluntary and the value of reporting antimicrobial use and receiving monthly SAARs to multihospital healthcare systems has not been clearly demonstrated. In this cohort study. we examined potential applications of SAAR within a healthcare system comprising multiple local hospitals. Methods: Three hospitals within Prisma Health-Midlands (hospitals A, B, and C) became participants in the NHSN Antimicrobial Use Option in July 2017. SAAR reports were presented initially in October 2017 and regularly (every 3–4 months) thereafter during interprofessional antimicrobial stewardship system-wide meetings until end of study in June 2019. Through interfacility comparisons and by analyzing SAAR categories in specific patient-care locations, primary healthcare providers and pharmacists were advised to incorporate results into focused antimicrobial stewardship initiatives within their facility. Specific alerts were designed to promote early de-escalation of antipseudomonal β-lactams and vancomycin. The Student t test was used to compare mean SAAR in the preintervention period (July through October 2017) to the postintervention period (November 2017 through June 2019) for all antimicrobials and specific categories and locations within each hospital. Results: During the preintervention period, mean SAAR for all antimicrobials in hospitals A, B, and C were 0.69, 1.09, and 0.60, respectively. Notably, mean SAARs at hospitals A, B, and C in intensive care units (ICU) during the preintervention period were 0.67, 1.36, and 0.83 for broad-spectrum agents used for hospital-onset infections and 0.59, 1.27, and 0.68, respectively, for agents used for resistant gram-positive infections. After antimicrobial stewardship interventions, mean SAARs for all antimicrobials in hospital B decreased from 1.09 to 0.83 in the postintervention period (P &lt; .001). Mean SAARs decreased from 1.36 to 0.81 for broad-spectrum agents used for hospital-onset infections and from 1.27 to 0.72 for agents used for resistant gram-positive infections in ICU at hospital B (P = .03 and P = .01, respectively). No significant changes were noted in hospitals A and C. Conclusions: Reporting AU to the CDC NHSN and the assessment of SAARs across hospitals in a healthcare system had motivational effects on antimicrobial stewardship practices. Enhancement and customization of antimicrobial stewardship interventions was associated with significant and sustained reductions in SAARs for all antimicrobials and specific antimicrobial categories at those locations.Funding: NoneDisclosures: None

Antimicrobial Stewardship Programs and Antibiotic Usage and Resistance in Department of Veterans’ Affairs Medical Centers

Background: Implementation of antimicrobial stewardship programs (ASPs) in acute-care facilities may optimize antibiotic use and decrease antibiotic resistance. To explore the relationship between ASPs and clinical outcomes, we reviewed bivariate relationships between VA Medical Center (VAMC) complexity level and presence of an ASP, presence of an ASP and inpatient antibiotic use, and antibiotic use and antibiotic resistance or Clostridioides difficile infection (CDI). Methods: We conducted a cross-sectional study of national data using the following elements: a detailed survey of antimicrobial stewardship practices at VAMCs in 2012 which included facility complexity designations; data from the VA national Electronic Health Record (EHR) for inpatient antibiotic use (2009–2012 in days of therapy per 1,000 bed days of care); EHR laboratory data in 2013 for antibiotic resistance in E. coli isolates; and 2013 CDI rate data from the VA Inpatient Evaluation Center. These data were reviewed for assessment of the presence of ASPs and for antibiotic use and resistance. We assessed 4 groups of antibiotics for use and resistance: total antibiotics, fluoroquinolones, cephalosporins, and carbapenems. Categorical, t test, or nonparametric analyses were performed, as appropriate. Results: 120 VAMCs were evaluated; 71% had ASPs. Proportions of VAMCs with ASPs were not significantly different by facility complexity level. Differences were observed between presence or absence of ASP and some antibiotic use groups (Table). Presence or absence of an ASP was not statistically associated with a difference in E. coli resistance (any antibiotic group examined) or CDI rates. In addition, antibiotic use (any group) did not statistically associate with E. coli resistance rates, and this result remained unchanged when stratified by presence or absence of an ASP. Conclusions: Total antibiotic use and fluroquinolone use were lower among facilities with ASPs than without, a finding consistent with ASP implementation reducing the amount of antibiotics prescribed. Although we did not find an association between facilities with an ASP and antibiotic resistance or CDI rates in this preliminary review, it sets the stage for future multivariate analyses. Furthermore, given the years of antibiotic use needed for development of resistance, the limited years evaluated may not have been sufficient to determine an impact, highlighting the need for further research into understanding clinical outcomes.Funding: NoneDisclosures: None

Infection prevention and control and antimicrobial stewardship in European long-term care, 2016-2017

Abstract Background Europe's population is ageing. Long-term care facilities (LTCFs) for this vulnerable population are often relatively homelike with low staff-to-resident ratios. In 2016-2017, ECDC coordinated its third point prevalence survey (PPS) of healthcare-associated infections (HAIs) and antimicrobial use in European long-term care facilities (LTCFs). It included collection of data on structure and process indicators (SPIs) of infection prevention and control (IPC) and antimicrobial stewardship, to support countries' identification of national and local interventions in LTCFs. Methods In each country, national contacts recruited a convenience sample of LTCFs. National/LTCF PPS teams used a standard protocol that included case definition algorithms (adapted US CDC/SHEA definitions) applied to each resident with signs/symptoms of infection on the PPS day, and questions for LTCF staff on SPIs of IPC and antimicrobial stewardship activities. Denominators indicate the number of responses available for analysis. Results 3,052 LTCFs in 24 EU/EEA countries were recruited, with 102,301 residents included. The prevalence of HAIs (residents with ≥1 HAI) was 3.7%. Although 1,524/1,623 (94%) LTFS had a hand hygiene (HH) protocol, only 1,046/1,585 (66%) LTCFs had organised ≥1 HH training session for care professionals during the previous year. 1,185/1,561 (76%) LTCFs reported IPC training of nursing and paramedical staff. Only 340/1,639 (21%) of LTCFs reported training on appropriate prescribing and 493/1,623 (30%) LTCFs had provided feedback to GPs on antimicrobial consumption. On the PPS day, annual antimicrobial consumption data were available to only 530/1,623 (32%) LTCFs. Conclusions Even in LTCFs with the capacity to perform this PPS, IPC training was non-ubiquitous and antimicrobial stewardship activities, including training, were rarely reported. ECDC encourages EU/EEA countries to recruit LTCFs to participate in future PPSs, to allow them to benchmark HAI rates and practices. Key messages The prevalence of healthcare-associated infections in European long-term care facilities (LTCFs) highlights their requirement for infection prevention and control (IPC) and antimicrobial stewardship. This multi-national point prevalence survey (PPS) indicates that European countries can consider reinforcing IPC, antimicrobial stewardship practices and participation in PPSs in LTCFs.

Assessing Pharmacy Students' and Preceptors' Understanding of and Exposure to Antimicrobial Stewardship Practices on Introductory Pharmacy Practice Experiences.

Antimicrobial stewardship (AMS) is commonly employed, and may be required, in multiple healthcare settings, with pharmacists playing an integral role in developing and conducting AMS techniques. Despite its prevalence, AMS is minimally taught in pharmacy school curricula. In order to increase student and preceptor understanding and application of AMS techniques, the Medical College of Wisconsin School of Pharmacy required introductory pharmacy practice students to complete three checklists and reflections of AMS techniques observed at three different practice settings: inpatient, ambulatory, and community (retail) pharmacy. Student and preceptor understanding and application of AMS techniques were then assessed via voluntary survey. Survey response rates were 43% for pharmacy students, while preceptor response rates were 27%. Student understanding and application of AMS techniques increased after completion of the AMS checklist, with the largest magnitude of change seen with antibiotic selection recommendations and guideline and policy development. Preceptor understanding was minimally impacted by the activity; however, an increase in understanding was seen for allergy assessments, antibiotic time-outs, and vaccine assessments and recommendations. AMS is an important component of pharmacy practice today. Implementation of a checklist and reflection activity within experiential education increases perceived student understanding and application of relevant AMS techniques.

Why do hospital prescribers continue antibiotics when it is safe to stop? Results of a choice experiment survey

BackgroundDeciding whether to discontinue antibiotics at early review is a cornerstone of hospital antimicrobial stewardship practice worldwide. In England, this approach is described in government guidance (‘Start Smart then Focus’). However, < 10% of hospital antibiotic prescriptions are discontinued at review, despite evidence that 20–30% could be discontinued safely. We aimed to quantify the relative importance of factors influencing prescriber decision-making at review.MethodsWe conducted an online choice experiment, a survey method to elicit preferences. Acute/general hospital prescribers in England were asked if they would continue or discontinue antibiotic treatment in 15 hypothetical scenarios. Scenarios were described according to six attributes, including patients’ presenting symptoms and whether discontinuation would conflict with local prescribing guidelines. Respondents’ choices were analysed using conditional logistic regression.ResultsOne hundred respondents completed the survey. Respondents were more likely to continue antibiotics when discontinuation would ‘strongly conflict’ with local guidelines (average marginal effect (AME) on the probability of continuing + 0.194 (p < 0.001)), when presenting symptoms more clearly indicated antibiotics (AME of urinary tract infection symptoms + 0.173 (p < 0.001) versus unclear symptoms) and when patients had severe frailty/comorbidities (AME = + 0.101 (p < 0.001)). Respondents were less likely to continue antibiotics when under no external pressure to continue (AME = − 0.101 (p < 0.001)). Decisions were also influenced by the risks to patient health of continuing/discontinuing antibiotic treatment.ConclusionsGuidelines that conflict with antibiotic discontinuation (e.g. pre-specify fixed durations) may discourage safe discontinuation at review. In contrast, guidelines conditional on patient factors/treatment response could help hospital prescribers discontinue antibiotics if diagnostic information suggesting they are no longer needed is available.

Phenotypically distinguishing ESBL-producing pathogens using paper-based surface enhanced Raman sensors

Antimicrobial stewardship practices are critical in preventing the further erosion of treatment options for bacterial infections. Yet, at the same time, determination of an infection’s antimicrobial susceptibility requires multiple rounds of culture and expensive lab automation systems. In this work, we report the use of paper-based surface enhanced Raman spectroscopy (SERS) sensors and portable instrumentation to phenotypically discriminate multi-drug resistance with fewer culture steps than conventional clinical microbiology. Specifically, we demonstrate the identification of resistance to varying generations of β-lactam antibiotics by detecting the activity of particular β-lactamase enzymes in a multiplexed assay. The method utilizes molecular reporters that consist of β-lactams with SERS barcodes. Hydrolysis of the β-lactam by β-lactamase enzymes in the sample expels the barcode; the released sulfur-containing barcode is then detected via SERS. Using this approach, we demonstrate the differentiation of E. coli strains with (1) extended spectrum β-lactamase (ESBL), (2) narrow-spectrum β-lactamase, and (3) no resistance, using only a single measurement on a single sample. In addition, we experimentally validate an approach to expand the library of reporters through the simple chemical synthesis of new barcoded β-lactams. Importantly, the reported method determines the susceptibility based on phenotypic β-lactamase activity, which is aligned with current microbiology lab standards. This new method will enable the precise selection of effective β-lactam antibiotics (as opposed to defaulting to drugs of last resort) faster than current methods while using simple steps and low-cost portable instrumentation.

Machine learning for the prediction of antimicrobial stewardship intervention in hospitalized patients receiving broad-spectrum agents.

A significant proportion of inpatient antimicrobial prescriptions are inappropriate. Post-prescription review with feedback has been shown to be an effective means of reducing inappropriate antimicrobial use. However, implementation is resource intensive. Our aim was to evaluate the performance of traditional statistical models and machine-learning models designed to predict which patients receiving broad-spectrum antibiotics require a stewardship intervention. We performed a single-center retrospective cohort study of inpatients who received an antimicrobial tracked by the antimicrobial stewardship program. Data were extracted from the electronic medical record and were used to develop logistic regression and boosted-tree models to predict whether antibiotic therapy required stewardship intervention on any given day as compared to the criterion standard of note left by the antimicrobial stewardship team in the patient's chart. We measured the performance of these models using area under the receiver operating characteristic curves (AUROC), and we evaluated it using a hold-out validation cohort. Both the logistic regression and boosted-tree models demonstrated fair discriminatory power with AUROCs of 0.73 (95% confidence interval [CI], 0.69-0.77) and 0.75 (95% CI, 0.72-0.79), respectively (P = .07). Both models demonstrated good calibration. The number of patients that would need to be reviewed to identify 1 patient who required stewardship intervention was high for both models (41.7-45.5 for models tuned to a sensitivity of 85%). Complex models can be developed to predict which patients require a stewardship intervention. However, further work is required to develop models with adequate discriminatory power to be applicable to real-world antimicrobial stewardship practice.