Role In Antimicrobial Stewardship Programs Research Articles

From Protection to Prevention: Redefining Vaccines in the Context of Antimicrobial Resistance.

Antimicrobial resistance (AMR) poses a significant threat to global health, compromising the effectiveness of treatments and increasing medical risks. In this crisis, the importance of vaccines in reducing AMR is being increasingly acknowledged, although not thoroughly explored. This literature review asserts that vaccines can significantly lessen the occurrence of infections, thereby reducing the need for antibiotics and limiting the emergence of resistance. Vaccines play a crucial role in antimicrobial stewardship programs by preventing diseases that would otherwise necessitate the use of antibiotics. Expanding vaccine coverage supports responsible usage of antimicrobials and aligns with global health priorities to maintain effective medical interventions. This review emphasizes the need for equitable funding and policy support for vaccine initiatives comparable to new antibiotics and diagnostic techniques. Moreover, it calls for more detailed investigations into vaccines' economic and health benefits in managing AMR, highlighting their potential as cost-effective solutions to this urgent health challenge. Through a careful analysis of existing literature, this review highlights the fundamental role of vaccines in transforming the landscape of AMR, shifting the focus from a protective approach to a preventive health strategy.

The role of community pharmacists and their perception towards antimicrobial stewardship in Baghdad, Iraq

AbstractBackgroundThis study aimed to assess the role of community pharmacists and their perception toward antimicrobial stewardship, in addition to identifying factors influencing their perception and practices in community pharmacy.MethodsA cross‐sectional study was carried out among community pharmacists regarding antimicrobial stewardship. Convenience sampling was used to obtain the required sample from a community pharmacy in Baghdad. In total, 381 participants have completed the survey.ResultsThe majority of the participants (85.6%) strongly agreed/agreed that “antimicrobial stewardship programs reduce the problems of antibiotic resistance”; and 85.5% of them strongly agreed/agreed that community pharmacists required adequate training on antibiotics use. In addition, high percent of community pharmacists (88.4%) strongly agreed/agreed that pharmacists have a responsibility to take a prominent role in antimicrobial stewardship programs and infection‐control programs in the health system. The total score of perception was significantly influenced by older age groups, postgraduate degrees, and experience of 6–10 years (p < 0.001). This study also showed that 65.4% of pharmacists always/often advise patients to continue the full course of antimicrobials, and 64.9% of them reported always/often considering clinical and safety parameters before dispensing antibiotics. The role of pharmacists was significantly influenced by the younger age group, females, higher degree in pharmacy, experience of 3–5 years, and medical complex pharmacy (p < 0.001).ConclusionCommunity pharmacists have a good perception toward antimicrobial stewardship programs, but their role is still limited. More efforts are needed to design better strategies for antimicrobial stewardship in community pharmacy.

Brave New World of Artificial Intelligence: Its Use in Antimicrobial Stewardship-A Systematic Review.

Antimicrobial resistance (AMR) is a growing public health problem in the One Health dimension. Artificial intelligence (AI) is emerging in healthcare, since it is helpful to deal with large amounts of data and as a prediction tool. This systematic review explores the use of AI in antimicrobial stewardship programs (ASPs) and summarizes the predictive performance of machine learning (ML) algorithms, compared with clinical decisions, in inpatients and outpatients who need antimicrobial prescriptions. This review includes eighteen observational studies from PubMed, Scopus, and Web of Science. The exclusion criteria comprised studies conducted only in vitro, not addressing infectious diseases, or not referencing the use of AI models as predictors. Data such as study type, year of publication, number of patients, study objective, ML algorithms used, features, and predictors were extracted from the included publications. All studies concluded that ML algorithms were useful to assist antimicrobial stewardship teams in multiple tasks such as identifying inappropriate prescribing practices, choosing the appropriate antibiotic therapy, or predicting AMR. The most extracted performance metric was AUC, which ranged from 0.64 to 0.992. Despite the risks and ethical concerns that AI raises, it can play a positive and promising role in ASP.

Treatment and Management of Acinetobacter Pneumonia: Lessons Learned from Recent World Event.

Acinetobacter pneumonia is a significant healthcare-associated infection that poses a considerable challenge to clinicians due to its multidrug-resistant nature. Recent world events, such as the COVID-19 pandemic, have highlighted the need for effective treatment and management strategies for Acinetobacter pneumonia. In this review, we discuss lessons learned from recent world events, particularly the COVID-19 pandemic, in the context of the treatment and management of Acinetobacter pneumonia. We performed an extensive literature review to uncover studies and information pertinent to the topic. The COVID-19 pandemic underscored the importance of infection control measures in healthcare settings, including proper hand hygiene, isolation protocols, and personal protective equipment use, to prevent the spread of multidrug-resistant pathogens like Acinetobacter. Additionally, the pandemic highlighted the crucial role of antimicrobial stewardship programs in optimizing antibiotic use and curbing the emergence of resistance. Advances in diagnostic techniques, such as rapid molecular testing, have also proven valuable in identifying Acinetobacter infections promptly. Furthermore, due to the limited availability of antibiotics for treating infections caused A. baumannii, alternative strategies are needed like the use of antimicrobial peptides, bacteriophages and their enzymes, nanoparticles, photodynamic and chelate therapy. Recent world events, particularly the COVID-19 pandemic, have provided valuable insights into the treatment and management of Acinetobacter pneumonia. These lessons emphasize the significance of infection control, antimicrobial stewardship, and early diagnostics in combating this challenging infection.

An Observational Study on Prescription Pattern of Antibiotics Using WHO Indicators in Primary, Secondary, Tertiary Care–A Need for Antimicrobial Stewardship

Background: Antibiotics have revolutionized modern medicine, playing a pivotal role in treating infectious diseases and preventing life-threatening complications. However, antibiotic misuse and overuse have resulted in the emergence to antibiotic resistance, posing a hazard to global public health. As a result of the rising epidemic, it has become critical to investigate and correct antibiotic prescribing behaviors in primary and secondary care settings. This environment allows for an observational research that evaluates antibiotic prescribing trends using World Health Organization (WHO) indicators and emphasizes the critical need for Antimicrobial Stewardship Programs (ASPs). As assessment metrics, the WHO indicators such as the proportion of antibiotics prescribed by class, the percentage of antibiotics administered without a recognized diagnosis, and the percentage of antibiotics prescribed from the essential medications list were used. Aim: This observative study aimed to assess the prescription patterns of antibiotics in primary and secondary care settings using the World Health Organization (WHO) indicators and to highlight the pressing need for Antimicrobial Stewardship Programs (ASPs) to combat this critical issue. Methods: The study was conducted on total no of 351 patients were included and studied in which 176 patients from primary care setting and 185 patients from primary, secondary and tertiary care setting with their respective prescribed antibiotics for a period of 6 months at apollo hospitals, apex hospitals on those who had age above 20. All prescription records containing antibiotics within a defined time period of will be included in the sample. Results: The inferential statistics results showed that the A p-value of 6.4E-25 is an extremely small p-value in the context of a statistical test, such as a chi-square test. This value represents a highly significant result, which representing there is significant variance in the prescription of antibiotics. The analysis of inpatient antibiotic usage revealed that a substantial proportion of patients (89.3%) received antibiotic treatment during their hospital stay. However, when assessing the appropriateness of antibiotic prescriptions, it was found that only 74.1% of antibiotic-containing prescriptions met the criteria for proper use, suggesting a potential area for improvement in antibiotic prescribing practices within the inpatient and outpatient setting. Conclusion: This observative study sheds light on the suboptimal prescription patterns of antibiotics in primary and secondary care, emphasizing the critical role of Antimicrobial Stewardship Programs in addressing this issue. These programs are essential for preserving the effectiveness of antibiotics, safeguarding public health, and mitigating the looming threat of antibiotic resistance

929. A Nationwide Survey on the Role of Antimicrobial Stewardship Programs during the COVID-19 Pandemic: What is restricted and who decides?

Abstract Background During the COVID-19 pandemic, evolving literature and emerging therapies have led to significant controversies on what constitutes optimal therapy for hospitalized patients with COVID-19. In addition, multiple guidelines emerged exhibiting variable recommendations in key areas of therapeutic management. Thus, interpreting emerging data and deploying novel therapeutics during the pandemic has been challenging. Antimicrobial stewardship programs (ASP) have been proven to help promote evidence-based practices and are now common the United States (US). We seek to further understand the role of ASP during the COVID-19 pandemic. Methods A survey was developed and disseminated through Infectious Diseases Society of America (IDSA) IDea network, IDSA Antimicrobial Stewardship Centers for Excellence and the Society for Healthcare Epidemiology messaging boards. Data collected included city, hospital size, facility type, and existence of active ASP. COVID-19 therapeutic restrictions and type of provider who decides on treatment allocation was surveyed. Results A total of 92 surveys were completed, representing wide geographic reach within the United States (Figure 1). Hospital size by beds were 14% less than 200 (13), 18.5% 201-300 beds (17), 15.2% 301-400 beds (14), and 52.2% over 400 beds (48). Community hospitals accounted for 31.5% (29), county/public hospital 3.3% (3, 3.3%), University-affiliated Community-Based Teaching Hospitals 10.9% (10), University-based Teaching Hospital 45.7% (42), and 8.7% selected other. ASP were present in 97.2% of hospitals. COVID-19 therapeutic restrictions were common (Figure 2). Infectious diseases (ID) approval was required in 87.9% of facilities (Figure 3). Figure 1Geographic distribution of hospitals represented in the survey Figure 2. Restricted COVID-19 therapies by medication type (%) Figure 3 Specialties or providers that are able to order or approve restricted COVID-19 therapies (%) Conclusion COVID-19 therapeutics were commonly restricted during the COVID-19 pandemic. Approval by ID clinicians was required almost universally (87.9%). The role of other specialties was significantly lower, representing less than 45% of hospitals. ID clinicians have played a vital role in guiding therapy and supporting ASP during the COVID-19 pandemic. This survey highlights the value of ID clinicians to healthcare systems in allocating resources and promoting evidence-based practices through ASP. Disclosures All Authors: No reported disclosures.

Drug Utilization 90% Profile of Antibiotics Use during the Period of 2013 – 2017 at a Private Teaching Hospital in Yogyakarta

Evaluation of antibiotics use plays an important role in antimicrobial stewardship programs to support the rational use of antibiotics at all healthcare facilities. This study aimed to describe the profile of drug utilization 90% (DU90%) of antibiotics use for hospitalized patients at a private teaching hospital in Yogyakarta over period of 2013 – 2017. Aggregate data of all systemic antibiotics having an anatomic therapeutic chemical (ATC) code and used for hospitalized patients during 2013 – 2017 were included in this study. Quantity of antibiotics use was expressed in defined daily dose (DDD) and final quantity was expressed in DDD/100 bed days. DU90% profile was obtained by calculating the cumulative use of antibiotics from the highest to the lowest percentage. There were 44 antibiotic agents used each year over the period of 2013 – 2017. However, there were only 10 – 12 agents within the DU90% segment. Cephalosporins group was identified as the most used antibiotics consistently over the period and the top three antibiotics that were consistently prescribed were: ceftriaxone, levofloxacin, and cefixime. It can be concluded that only about a quarter of the total antibiotic agents used in hospitals are within the DU90% segment and those antibiotic agents are relatively consistent, especially for the top three of the highest used antibiotics.

Impact of pharmacist-led services on antimicrobial stewardship programs: a meta-analysis on clinical outcomes

Abstract Purpose This meta-analysis aims to find out the impact of pharmacists on clinical outcomes of antimicrobial stewardship (AMS). Method Articles were searched and analyzed based on quality assessed through the JSM quality assessment tool to filter articles with a low level of bias. Two thousand three hundred sixty articles were reviewed for initial screening and 28 articles were included for critical analysis. Statistical analysis used to risk ratio (RR) and standard mean differences calculated using Review manager 5.4. Confidence intervals (CI 95%) were calculated using the fixed-effect model. The I2 statistic assessed heterogeneity. A random-effect model performed in the case of statistical heterogeneity, subgroup and sensitivity analyses. The primary outcome is mortality and inappropriateness, whereas the secondary outcome is cost, readmission, length of stay, consumption and duration of therapy. Result A detailed review and analysis of 28 AMSs programs led by pharmacists showed low inappropriateness with pharmacist versus without pharmacist RR = 0.36 with 95% CI of (0.32 to 0.39) and mortality RR is 0.68 with 95% CI of 0.59 to 0.79. Secondary outcomes such as consumption, length of stay, duration of therapy and cost are standard mean difference of −1.61 with 95% CI (−1.72 to −1.50), −0.58 with 95% CI (−0.62 to −0.53), −0.95 with 95% CI (−1.01 to −0.89) and −0.99 with 95% CI (−1.12 to −0.86), respectively, whereas for 30 days readmission is RR = 0.81 with 95% CI (0.70 to 0.93). Conclusion AMS with pharmacist effectively reduces mortality, inappropriateness, cost, length of stay, duration of treatment, consumption of antimicrobials and the return rate to hospital. So it is suggested pharmacists should lead or play a vital role in antimicrobial stewardship programs to get better outcomes.

Antibiotics and adverse events: the role of antimicrobial stewardship programs in 'doing no harm'.

Antimicrobial resistance (AMR) is a global threat worldwide, with deaths associated with AMR infections projected to exceed 10 million per year by the year 2050. The overuse and misuse of antibiotics is the primary driver of this resistance, with up to 50% of antibiotics prescribed in the hospital setting being either unnecessary or inappropriate. Antimicrobial stewardship (AMS) programs (ASPs) can mitigate some of this resistance, with the benefits well recognized; however, if we are to truly advance the state of AMS, the principles and practices should align with patient safety. In a recent evaluation, among 1488 adult patients receiving systemic antibiotic therapy, 298 (20%) experienced at least one antibiotic-associated adverse drug event (ADE). Fifty-six (20%) nonclinically indicated antibiotic regimens were associated with an ADE. It is also well recognized that besides ADEs, the inappropriate use of antibiotics is associated the development of multidrug-resistant infections and Clostridium difficile infection. Currently, there is a significant gap in ASPs correlating initiatives with patient safety goals, including reductions in antibiotic-associated ADEs and multidrug-resistant infections. Therefore, in this article, we provide the rationale for why ASPs are best suited to lead a collaborative effort to prevent antibiotic-associated ADEs and multidrug-resistant infections.

Antimicrobial consumption in three pediatric and neonatal intensive care units in Saudi Arabia: 33-month surveillance study

BackgroundDespite their critical role in antimicrobial stewardship programs, data on antimicrobial consumption among the pediatric and neonatal population is limited internationally and lacking in Saudi Arabia. The current study was done as part of our antimicrobial stewardship activities.ObjectivesTo calculate overall and type-specific antimicrobial consumption.MethodsA prospective surveillance study was conducted at King Abdulaziz Medical City, Riyadh, Saudi Arabia, between October 2012 and June 2015 in two pediatric and one neonatal intensive care units (ICUs). Consumption data were collected manually on a daily basis by infection control practitioners. Data were presented as days of therapy (DOT) per 1000 patient-days and as frequency of daily consumption.ResultsDuring the 33 months of the study, a total of 30,110 DOTs were monitored during 4921 admissions contributing 62,606 patient-days. Cephalosporins represented 38.0% of monitored antimicrobials in pediatric ICUs followed by vancomycin (21.9%), carbapenems (14.0%), aminoglycosides (8.8%), and piperacillin/tazobactam (8.8%). Their consumption rates were 265.1, 152.6, 97.6, 61.4, and 61.4 DOTs per 1000 patient-days (respectively). Aminoglycosides represented 45.4% of monitored antimicrobials in neonatal ICU followed by cephalosporins (30.4%) vancomycin (13.6%), and carbapenems (8.3%). Their consumption rates were 147.5, 98.7, 44.3, and 27 DOTs per 1000 patient-days (respectively).ConclusionCephalosporins are frequently used in pediatric ICU while aminoglycosides are frequently used in neonatal ICU. The local consumption of cephalosporins and carbapenems in both ICUs is probably higher than international levels. Such data can help in establishing and monitoring the functions of antimicrobial stewardship activities aiming to ensure judicious consumption of antimicrobials.

Evaluation of Antibiotic Utilization in an Emergency Department After Implementation of an Antimicrobial Stewardship Pharmacist Culture Review Service.

Background: Antimicrobial stewardship programs (ASP) have been widely implemented in hospitals to improve antimicrobial use and prevent resistance. However, the role of ASP in the emergency department (ED) setting is not well defined. Objective: The objective of this study is to evaluate the impact of an ASP pharmacist culture review service in an ED. Methods: This was a retrospective, quasi-experimental study of all patients discharged from the ED with a positive culture. Patients discharged from the ED from February 1, 2015 to October 31, 2015 were managed by ED providers (pre-ASP), and those discharged from February 1, 2016 to October 31, 2016 were managed by a pharmacist-driven ASP (post-ASP implementation). The primary outcome was median time to change of antibiotic(s) in patients with inadequate antimicrobial therapy based on culture results. Secondary outcomes included time to culture evaluation, appropriateness of antimicrobials, and 30-day readmissions. Results: A total of 790 patients were included in the analysis (398 in pre-ASP group vs 392 in post-ASP implementation group). Median time to modification of inadequate antibiotic therapy decreased from 6.79 days in the pre-ASP group to 1.99 days in the post-ASP implementation group (P < .0001). Median time to culture review decreased in the post-ASP implementation group from 9.83 to 0.32 days (P < .0001). Appropriateness of culture-guided therapy increased in the post-ASP implementation group from 85.7 to 91.8% (P = .047). The rate of combined ED revisits and hospital readmissions was similar between groups (P = .367). Conclusion: ASP pharmacist evaluation of positive cultures in the ED was associated with a significant decrease in the time to appropriate therapy in patients discharged with inadequate therapy and higher rates of appropriate antimicrobial therapy.

1862. The Role of Infection Preventionists in Antimicrobial Stewardship Programs in Acute Care Hospitals

BackgroundHealthcare-associated infections due to multiply-resistant organisms cause significant morbidity and mortality in acute care settings. Antimicrobial stewardship programs (ASP) are one practice used to limit resistance and are especially crucial given the lack of new antimicrobials in development. The aim of this study was to describe the presence of ASP in a national sample of acute care hospitals and examine the engagement of Infection Preventionists (IPs) in antimicrobial stewardship activities.MethodsIn winter of 2018, we conducted an electronic survey of IPs working in acute care hospitals who are members of the Association of Professionals in Infection Control and Epidemiology (APIC). An initial invitation email was sent out directly by APIC and reminders were included in a weekly e-blast over a period of 6 weeks. Descriptive statistics were computed to describe the ASP in place, as well as IP engagement in these programs.ResultsOverall, 255 IPs participated in the survey. Of these, the majority (79%) reported the presence of an established ASP; another 13% reported that ASP activities are conducted without a formalized ASP. The presence of specific ASP policies and activities are presented in the Figure. The majority (88%) reported that an IP was a member of the core ASP team. Few IPs reported budgeted financial support and specific time commitment in the IP job description for ASP activities (14% and 9%, respectively). The majority of respondents agreed with the statement that ASP cannot be successful without a strong infection prevention and control (ICP) program (87%); however, only half agreed that the IP role in ASP is well defined (46%) and that IPs have adequate AS knowledge to participate in ASP activities (59%). The most frequently reported barriers for IP participation in ASP included: time (41%), no allocated FTE (23%), no defined IP role or responsibility (20%), and lack of knowledge (18%).ConclusionThis survey represents a current snapshot of the implementation of ASP policies in US acute care hospitals and identifies important barriers to IP engagement in ASP activities. Future work should focus how best to facilitate IP participation and engagement in ASP activities. Disclosures All authors: No reported disclosures.

Appropriate Antibiotic Selection and Use for Intensive Care Unit Patients, Part I: Rationale for Antibiotic Choices

The aim of this review is to help clinicians optimize treatment of infections and reduce adverse events. With that goal in mind, we discuss the basis for the selection of antibiotics for the surgical patient in the intensive care unit (ICU), the mechanism of antibiotic action, and resistance of pathogens to antibiotic therapy—factors that may affect antibiotic levels, the rationales for dosing, and the role of antimicrobial stewardship programs. The evaluation and management of infections in critically ill patients are uniquely different from those of the general patient population. Age, medical comorbidities, alterations in anatomy, changes in vascular supply, insertion of vascular conduits, and orthopedic hardware are some factors that increase the risk of infection and influence antibiotic choice in the surgical ICU patient. Key words: antibiotics, antibiotic resistance, antibiotic stewardship, intensive care unit

Impact of an emergency medicine pharmacist on empiric antibiotic prescribing for pneumonia and intra-abdominal infections

PurposeIt is critical to engage ED providers in antimicrobial stewardship programs (ASP). Emergency medicine pharmacists (EMPs) play an important role in ASP by working with providers to choose empiric antimicrobials. This study aimed to determine the impact of an EMP on appropriate empiric antibiotic prescribing for community-acquired pneumonia (CAP) and intra-abdominal infections (CA-IAI). MethodsA retrospective cohort study was conducted evaluating adult patients admitted with CAP or CA-IAI. The primary outcome of this study was to compare guideline-concordant empiric antibiotic prescribing when an EMP was present vs. absent. We also aimed to compare the impact of an EMP in an early-ASP vs. established-ASP. Results320 patients were included in the study (EMP n = 185, no-EMP n = 135). Overall empiric antibiotic prescribing was more likely to be guideline-concordant when an EMP was present (78% vs. 61%, p = 0.001); this was true for both the CAP (95% vs. 79%, p = 0.005) and CA-IAI subgroups (62% vs. 44%, p = 0.025). Total guideline-concordant prescribing significantly increased between the early-ASP and established-ASP (60% vs. 82.5%, p < 0.001) and was more likely when an EMP was present (early-ASP: 68.3% vs. 45.8%, p = 0.005; established-ASP: 90.5% vs. 73.7%, p = 0.005). Patients receiving guideline-concordant antibiotics in the ED continued appropriate therapy upon admission 82.5% of the time vs. 18.8% if the ED antibiotic was inappropriate (p < 0.001). ConclusionThe presence of an EMP significantly improved guideline-concordant empiric antibiotic prescribing for CAP and CA-IAI in both an early and established ASP. Inpatient orders were more likely to be guideline-concordant if appropriate therapy was ordered in the ED.

Role of Antimicrobial Stewardship Programs in Decreasing Hospital-Associated Clostridium difficile Infections

To provide a review of literature that discusses some of the most successful antimicrobial stewardship interventions reported across institutions worldwide in response to increased Clostridium difficile infection (CDI) rates. Although many different types of antimicrobial reduction practices have been proven effective, differences in resources across varying sizes of institutions may make some interventions more attainable than other. Regardless of available resources, an initial assessment of the correlation of positive laboratory tests to clinical disease is necessary to quantify the true burden of hospital-onset CDIs (HO-CDI). Infection prevention programs, in conjunction with antimicrobial reduction interventions, and the appropriate identification of patients to undergo laboratory testing, are key components of a HO-CDI reduction program. Clostridium difficile is an important cause of serious healthcare-associated infections (HAIs), causing adverse consequences for patients including, but not limited to, increased length of hospital stay, healthcare costs, and mortality. Since the early 2000s, there has been a notable increase in CDI. Antimicrobial stewardship programs (ASPs) have responded to this public health threat with a number of different strategies including antimicrobial use reduction, education, appropriate testing, and multiple other interventions. Along with providing a literature review on ASP interventions to address the CDI threat, we describe our experience in successfully reducing HO-CDI at Northwestern Memorial Hospital with the use of multiple interventions.

The Expanding Role of Antimicrobial Stewardship Programs in Hospitals in the United States: Lessons Learned from a Multisite Qualitative Study

Misuse of antibiotics can lead to the development of antibiotic resistance, which adversely affects morbidity, mortality, length of stay, and cost. To combat the threat of antimicrobial resistance, The Joint Commission and the Centers for Medicare & Medicaid Services have initiated or proposed requirements for hospitals to have antimicrobial stewardship programs (ASPs), but implementation remains challenging. A key-informant interview study was conducted to describe the characteristics and innovative strategies of leading ASPs. Semistructured interviews were conducted with 12 program leaders at four ASPs in the United States, chosen by purposive sampling on the basis of national reputation, scholarship, and geography. Questions focused on ASP implementation, program structure, strengths, weaknesses, lessons learned, and future directions. Content analysis was used to identify dominant themes. Three major themes were identified. The first was evolution of ASPs from a top-down structure to a more diffuse approach involving unit-based pharmacists, multidisciplinary staff, and shared responsibility for antimicrobial prescribing under the ASPs' leadership. The second theme was integration of information technology (IT) systems, which enabled real-time interventions to optimize antimicrobial therapy and patient management. The third was barriers to technology integration, including limited resources for data analysis and poor interoperability between software systems. The study provides valuable insights on program implementation at a sample of leading ASPs across the United States. These ASPs used expansion of personnel to amplify the ASP's impact and integrated IT resources into daily work flow to improve efficiency. These findings can be used to guide implementation at other hospitals and aid in future policy development.

Appropriate Antibiotic Selection and Use for Intensive Care Unit Patients, Part I: Rationale for Antibiotic Choices

The aim of this review is to help clinicians optimize treatment of infections and reduce adverse events. With that goal in mind, we discuss the basis for the selection of antibiotics for the surgical patient in the intensive care unit (ICU), the mechanism of antibiotic action, and resistance of pathogens to antibiotic therapy—factors that may affect antibiotic levels, the rationales for dosing, and the role of antimicrobial stewardship programs. The evaluation and management of infections in critically ill patients are uniquely different from those of the general patient population. Age, medical comorbidities, alterations in anatomy, changes in vascular supply, insertion of vascular conduits, and orthopedic hardware are some factors that increase the risk of infection and influence antibiotic choice in the surgical ICU patient. Key words: antibiotics, antibiotic resistance, antibiotic stewardship, intensive care unit

Impact of an Emergency Medicine Pharmacist on Appropriate Empiric Antibiotic Prescribing for Community-Acquired Pneumonia and Intra-Abdominal Infections

BackgroundAntibiotics are the second most common drug class prescribed in the Emergency Department (ED); therefore, it is critical to engage ED providers in antimicrobial stewardship programs (ASP). Emergency medicine pharmacists (EMP) play an important role in ASP by working with providers to choose the most appropriate antimicrobial agent, dose, and duration. This study aimed to determine the impact of an EMP on appropriate empiric antibiotic prescribing for community-acquired pneumonia (CAP) and community-acquired intra-abdominal infections (CA-IAI).MethodsA retrospective cohort study was conducted evaluating adult patients admitted with a diagnosis of CAP or CA-IAI. The primary outcome of this study was to compare guideline-concordant empiric antibiotic prescribing when an EMP was present vs. absent. We also aimed to compare the impact of an EMP in a new ASP (2014) vs. established ASP (2016). Secondary outcomes included in-hospital mortality and hospital-acquired Clostridium difficileinfection (CDI).Results320 patients were included in the study (EMP n = 185; no-EMP n = 135). Empiric antibiotic selection was more likely to be guideline-concordant when an EMP was present (78% vs. 61%, P = 0.001). Guideline-concordant empiric prescribing occurred more often when an EMP was present in the subgroup of CAP patients (95% vs. 79% P = 0.005) as well as in the subgroup of CA-IAI patients (62% vs. 44% P = 0.025). Overall guideline-concordant prescribing significantly increased between the new ASP and established ASP (60% vs. 82.5%, P < 0.001) and was more likely when an EMP was present (new ASP: 68.3% vs. 45.8%, P = 0.005; established ASP: 90.5% vs. 73.7%, P = 0.005). Patients receiving guideline-concordant antibiotics in the ED were continued on appropriate therapy on admission 82.5% of the time vs. 18.8% if the ED antibiotic was inappropriate (P < 0.001). The presence of an EMP did not impact hospital-acquired CDI (1.1% vs. 1.5%, P = 1.0) or in-hospital mortality (4.3% vs. 1.5%, P = 0.2).ConclusionThe presence of an EMP significantly improved guideline-concordant empiric antibiotic prescribing for CAP and CA-IAI. This impact was demonstrated in both a new and established ASP. Inpatient orders were more likely to be guideline-concordant if appropriate therapy was ordered in the ED.Disclosures All authors: No reported disclosures.

The Confounding Role of Antimicrobial Stewardship Programs in Understanding the Impact of Technology on Patient Care.

Numerous studies have demonstrated the benefit of the combination of antimicrobial stewardship program (ASP) intervention and rapid diagnostic testing (RDT). However, few studies have attempted to study the incremental benefit of ASP and RDT, making it difficult to understand the true benefits of each intervention. This issue is discussed in the context of an article by S. H. McVane and F. S. Nolte (J Clin Microbiol 54:2476-2484, 2016, http://dx.doi.org/doi:10.1128/JCM.00996-16), with suggestions about how the findings of this study can be applied to other areas of clinical microbiology.

Specialist trainees on rotation cannot replace dedicated consultant clinicians for antimicrobial stewardship of specialty disciplines

Our prospective-audit-and-feedback antimicrobial stewardship (AS) program for hematology and oncology inpatients was switched from one led by dedicated clinicians to a rotating team of infectious diseases trainees in order to provide learning opportunities and attempt a “de-escalation” of specialist input towards a more protocol-driven implementation. However, process indicators including the number of recommendations and recommendation acceptance rates fell significantly during the year, with accompanying increases in broad-spectrum antibiotic prescription. The trends were reversed only upon reverting to the original setup. Dedicated clinicians play a crucial role in AS programs involving immunocompromised patients. Structured training and adequate succession/contingency planning is critical for sustainability.