Stewardship Strategies Research Articles

Perspectives on Antibiotic Stewardship Programs among Health Care Providers at Two University Hospitals in Egypt

The perspectives of healthcare professionals on antibiotic stewardship programs (ASPs) should be explored. Any antibiotic stewardship strategy must be individualized based on patient needs, prescription habits, and local resources. The current study aimed to explore the perspectives of healthcare providers on antibiotics stewardship and their awareness of these perspectives. Furthermore, potential barriers to the application of ASPs should be identified and addressed. This exploratory cross-sectional study utilized a qualitative method to evaluate critical care physicians, pediatricians, and clinical pharmacists (n = 43). The mean age of the physicians was 32 ± 1.5 years. Among them, approximately two-thirds (66%) were women. A thematic content analysis was performed to examine the responses of the participants and to prioritize the recommendations for and barriers to the implementation of ASPs from the perspective of healthcare providers. According to the interviewees, the primary obstacles include lack of time in implementation and monitoring and lack of awareness of the need for ASPs. All respondents recommended the implementation of supervised and continuous trainings. In conclusion, the abovementioned barriers must be adequately addressed to facilitate the implementation of ASPs.

CDC puts new focus on antimicrobial stewardship

Arjun Srinivasan Now that about 95% of US hospitals have implemented antimicrobial stewardship programs that meet core elements from the Centers for Disease Control and Prevention (CDC), it’s time to shift resources to the most effective stewardship strategies, says CDC medical epidemiologist Arjun Srinivasan. “Not all stewardship approaches are created equal,” said Srinivasan, the featured speaker at the December 5 educational session “CDC Update on Antimicrobial Stewardship 2022” at the Midyear Clinical Meeting & Exhibition in Las Vegas, NV. Srinivasan said CDC is promoting specific practices that should be prioritized for implementation. “We have been working with the stewardship community, with lots of experts, to try and identify what should we be pointing people to if they’re ready to take their next step with their stewardship program,” he said. The stewardship priorities are described at www.cdc.gov/antibiotic-use/core-elements/hospital/priorities.html. One of the agency’s top priority approaches is to formalize antimicrobial stewardship responsibilities for hospital staff.

The socio-economic challenges of managing pathogen evolution in agriculture.

Genetic resistance forms the foundation of infectious disease management in crops. However, rapid pathogen evolution is causing the breakdown of resistance and threatening disease control. Recent research efforts have identified strategies for resistance gene deployment that aim to disrupt pathogen adaptation and prevent breakdown. To date, there has been limited practical uptake of such strategies. In this paper, we focus on the socio-economic challenges associated with translating applied evolutionary research into scientifically informed management strategies to control pathogen adaptation. We develop a conceptual framework for the economic valuation of resistance and demonstrate that in addition to various direct benefits, resistance delivers considerable indirect and non-market value to farmers and society. Incentives for stakeholders to engage in stewardship strategies are complicated by the uncertain timeframes associated with evolutionary processes, difficulties in assigning ownership rights to genetic resources and lack of governance. These interacting biological, socio-economic and institutional complexities suggest that resistance breakdown should be viewed as a wicked problem, with often conflicting imperatives among stakeholders and no simple cause or solution. Promoting the uptake of scientific research outcomes that address complex issues in sustainable crop disease management will require a mix of education, incentives, legislation and social change. This article is part of the theme issue 'Infectious disease ecology and evolution in a changing world'.

Antifungal Resistance of Clinical Candida albicans Isolates in Iran: A Systematic Review and Meta-Analysis.

The present systematic review aimed to investigate the drug susceptibility patterns of Iranian clinical Candida albicans isolates to antifungal drugs (azoles, polyenes, and echinocandins). Six electronic databases including "PubMed," "Scopus," "Web of Science," "IranDoc", "SID", and "Magiran" were searched from May 2000 to June 2021. The susceptibility of 6322 C. albicans strains from 19967 patients against 14 antifungal drugs was evaluated according to CLSI method. The pooled prevalence of antifungal resistance ranged from 0% to 26%. The lowest resistance levels among azoles were observed in luliconazole with a frequency of 0% and voriconazole of 3.94%. Due to the emergence of multi-drug resistant C. albicans, rational drug prescription based on the anti-fungal stewardship strategy and therapeutic drug monitoring is warranted.

Theorizing CSA’s impact on nonprofit stewardship: New challenges for ethical corporate partnerships and issue engagement

Corporate social advocacy (CSA) scholarship has helped public relations scholars and practitioners better understand business engagement in multiple contentious issue contexts (e.g., Dodd & Supa, 2014; Rim et al., 2020; Waymer & Logan, 2021). Nonprofit organizations, while often having similarly public platforms, significant resources, and the will to engage in polarizing issues outside of their core purpose or purview, have, to date, not been a part of this theoretical framework. This paper serves to theoretically link nonprofit organizations to polarizing issue discourse—while maintaining their distinct facets and relational/stakeholder needs—by developing Polarizing Issue Stewardship. This new construct shifts the perspective of nonprofit stewardship strategies, originally developed by Kelly (1998) to a contentious issue context. The new construct provides insights for both theory and praxis of nonprofit communication.

Improving diagnostic antimicrobial stewardship in respiratory tract infections: a protocol for a scoping review investigating point-of-care testing programmes in community pharmacy

IntroductionDiagnostic uncertainty regarding the cause of respiratory tract infections (RTIs) multiplies the problem of unnecessary use of antibiotics and antimicrobial resistance in primary care. Point-of-care testing (POCT) programmes have been...

O03 Rapid Infection Diagnostics in Cirrhosis (RIDiC): a novel molecular-based approach to address the ever increasing challenge of antimicrobial resistant infections in decompensated cirrhosis and acute-on-chronic liver failure

Abstract Background Global prevalence of MDR infections in cirrhotic patients has risen to 34% and associates with worsening clinical trajectory and mortality (Fernandez J et al. 2019). A major unmet need in addressing the challenge of antimicrobial resistance (AMR) in cirrhosis is rapid pathogen diagnosis and antimicrobial resistance (AMR) (Patel VC et al. 2019). These can facilitate selection of more effective antibiotic therapy, reducing selection for MDR organisms. The Curetis Unyvero™ platform (CUp) employs multiplex PCR technology for pathogen and AMR gene detection from multiple bodily tissues and fluids requiring minimal pre- processing. The investigator-initiated pilot study aimed to assess the utility of this platform for hospitalized cirrhotic patients. Methods Ascitic fluid, bronchoalveolar lavage (BAL) and blood culture samples were obtained from hospitalized cirrhotic patients with acute decompensation (AD) or acute-on-chronic liver failure (ACLF), in whom there was clinical suspicion of infection. Samples were tested using the IAI (intra-abdominal infection) panel, HPN (hospital pneumonia) panel and BCU (blood culture) panel based on sample type available. Results were not shared with clinicians for decision-making. Data were compared with standard microbiology diagnostics. Results 31 samples from 21 patients were tested: ascites (25), BAL (4), blood culture (2). Time to positive culture result of all samples was reduced with CUp compared with standard microbiology (4.59 versus 73.5 h). CUp showed 100% specificity (12/12) and detected the same organism in 100% of cases (10/12). In 6 samples, CUp identified pathogens which were consistent with clinical evidence of spontaneous bacterial peritonitis and previous positive isolates which standard microbiological diagnostics failed to identify. AMR genes identified by the CUp correlated with AMR patterns reported by standard diagnostics in 100% (5/5) of cases. In 2 patients, broad-spectrum antibiotic therapy continued although the CUp supported infection resolution. Four patients in whom CUp screening was negative continued to receive antibiotics whilst awaiting negative standard cultures that arrived 72 h later. CUp did not identify an Aspergillus species in one BAL sample as this is not part of the BAL panel. Conclusions These preliminary data suggest CUp results are compatible with standard laboratory diagnostics. The CUp may be utilized for earlier infection diagnosis and improve the targeting and de-escalation of antimicrobial therapy in AD and ACLF. These are crucial components in enhancing antibiotic stewardship strategies and to reduce MDR infections (Figure 1). Further work is however required to evaluate cost implications, validation and impact on clinical outcomes and mortality in cirrhosis.

Prevalence of Carbapenem Non-susceptible Gram-Negative Bacteria at Tertiary Care Hospitals in Saudi Arabia.

Background Antibiotics significantly increased life expectancy and decreased mortality rates due to infections. However, this trend is starting to fade with the rise of multidrug-resistant organisms (MDR); these strains are becoming a global burden on healthcare and the economy. The dramatic increase and spread of carbapenem-resistant gram-negative bacteria (CRGNB) has become a serious global public health concern. In this retrospective cross-sectional study, we aimed to estimate the rates of gram-negative bacteremia in five tertiary care hospitals in different geographical locations in Saudi Arabia for five years. Methods A retrospective cross-sectional study was conducted in five tertiary care hospitals in Saudi Arabia among patients with bacteremia due to CRGNB. Electronic medical records were used to retrieve data regarding patient demographics and antimicrobial susceptibility testing (AST) over five years between January 2016 and December 2020. Patients with positive blood cultures for carbapenem-resistant Escherichia (E.) coli, Klebsiella (K.) pneumonia, Pseudomonas (P.) aeruginosa, andAcinetobacter (A.) baumannii comprise the final study population. Results This retrospective multicentric study was conducted between 2016 and 2020 in five tertiary care hospitals across five cities in Saudi Arabia. E. coli (n=2190, 38.03%), K. pneumoniae (n=2154, 37.41%), P. aeruginosa (n = 918, 15.94%), and A. baumannii (n=496, 8.61%) constitutethe 5758 gram-negative bacteria isolates. E. coli was the most frequently identified species in Riyadh, AlAhsa, Dammam, and Madinah (40%, 46.50%, 61.67%, and 43.66%, respectively), with a p-value of (p<0.001), except in Jeddah, where K. pneumoniae was the most prevalent (42%). The mean age of patients across Riyadh, AlAhsa, Dammam, and Madinah was 62.2 years (± 4.24). In contrast to Jeddah, where the majority of isolates (702; 41.8%)belonged to the adult age group. Most isolates were from male patients (3045; 52.9%), compared to 2713 (47.1%) from female patients. K. pneumoniae 1226 (40.3%) was the most prevalent isolate among male patients while E. coli(1135; 41.8%) was the most prevalent isolate among female patients. Conclusion Our study showed that the prevalence of carbapenem non-susceptible Gram-negative bacteria is relatively high, which therefore makes them very challenging to treat. The results show an urgent need for improved antibiotic stewardship strategies, including better surveillance and more effective infection control measures to reduce this issue. Further research into the molecular epidemiology and risk factors associated with these infections is necessary to guide public health policymakers in developing interventions to help control the spread of carbapenem-resistant Gram-negative bacteria.

Development and Implementation of a Mobile Application for Choosing Empirical Antimicrobial Therapy for Bacteremia, Pneumonia, Urinary Tract Infection, and Skin and Soft Tissue Infection among Hospitalized Patients.

Clinical practice guidelines (CPGs) and computerized clinical decision support programs are effective antimicrobial stewardship strategies. The DigitalAMS™, a mobile-based application for choosing empirical antimicrobial therapy under the hospital's CPGs, was implemented at Siriraj Hospital and evaluated. From January to June 2018, a cross-sectional study was conducted among 401 hospitalized adults who received ≥1 dose of antimicrobials and had ≥1 documented site-specific infection. The antimicrobial regimen prescribed by the ward physician (WARD regimen), recommended by the DigitalAMS™ (APP regimen), and recommended by two independent infectious disease (ID) physicians before (Emp-ID regimen) and after (Def-ID regimen) the final microbiological results became available were compared in a pairwise fashion. The percent agreement of antimicrobial prescribing between the APP and Emp-ID regimens was 85.7% in the bacteremia group, 59.1% in the pneumonia group, 78.6% in the UTI group, and 85.2% in the SSTI group. The percent agreement between the APP and Emp-ID regimens was significantly higher than that between the WARD and Emp-ID regimens in three site-specific infection groups: the bacteremia group (85.7% vs. 47.9%, p &lt; 0.001), the UTI group (78.6% vs. 37.8%, p &lt; 0.001), and the SSTI group (85.2% vs. 40.2%, p &lt; 0.001). Furthermore, the percent agreement between the APP and Def-ID regimens was similar to that between the Emp-ID and Def-ID regimens in all sites of infection. In conclusions, the implementation of DigitalAMS™ seems useful but needs some revisions. The dissemination of this ready-to-use application with customized clinical practice guidelines to other hospital settings may be beneficial.

Implementation of A Year-Long Antimicrobial Stewardship Program in A 227-Bed Community Hospital in Southern Italy.

Healthcare-Acquired Infections (HAIs) are serious healthcare complications affecting hospital stay, in-hospital mortality, and costs. Root cause analysis has identified the inappropriate use of antibiotics as the main causative factor in the expansion of multi-drug-resistant organisms (MDRO) in our hospital. An Antimicrobial Stewardship (AMS) program was implemented to optimize antibiotic use, limit the development of resistance, improve therapeutic efficacy and clinical outcomes, and reduce costs. The stewardship strategies were: antimicrobial oversight on "critical" antibiotics; the development of hospital guidelines on antibiotic selection with the production of a consensus document; the implementation of clinical and management control algorithms with visual impact and Business Intelligence methods; training and updating; and the monitoring of outcome measures and process indicators. Clinical outcomes: length of stay reduced by 0.23 days, hospital readmission/first month rates decreased by 19%, and mortality for infections reduced by 8.8%. Microbiological Outcomes: Clostridium Difficile colitis incidence reduced by 9.1%.Economic Outcomes: Reduction in antimicrobial costs by 35% on average fee/discharged patient. The systematic application of the AMS program in a small hospital led to multiple improvements in clinical, microbiological, and economic outcome measures. The analysis of the core indicators for our hospital AMS program showed a significant adherence to the model and hospital recommendations.

'Prospective audit with intervention and feedback' as a core antimicrobial stewardship strategy in the paediatrics department of a Nigerian tertiary hospital.

Inappropriate use of antibiotics for childhood illnesses, especially for non-bacterial infections, contributes to the development of antimicrobial resistance (AMR). Globally, implementation of antimicrobial stewardship programme (ASP) in all healthcare institutions is a strategic intervention to improve the appropriate use of antibiotics, reduce antimicrobial consumption and tackle AMR. The aim of this study was to evaluate the effect of prospective audit with intervention and feedback as an antimicrobial stewardship strategy on antimicrobial use, evaluate prescribers' response to recommendations and determine the rate of AMR in the Paediatrics Department of the Lagos University Teaching Hospital, Nigeria. This was an implementation study of the paediatrics Antimicrobial Stewardship Programme (ASP) over a period of 6 months. It was initiated with a point prevalence survey (PPS) to describe the antimicrobial prescribing patterns and followed by prospective audit with interventions and feedback using an antimicrobial checklist and the existing antimicrobial guidelines in the Paediatrics Department. The antibiotic prescribing prevalence was high (79.9%) at baseline PPS with 139 patients on admission, of which 111 (79.9%) were treated with 202 antibiotic therapies. Over the 6 months of study, 582 patients on 1146 antimicrobial therapies were audited. Compliance with departmental guidelines was 58.1% of the total 1146 prescriptions audited (n = 666), making the antimicrobial prescription inappropriate in 41.9% (n = 480) of therapies. The most recommended intervention for inappropriateness was 'change antibiotics' 48.8% (n = 234), followed by 'stop antibiotics' 26% (n = 125), 'reduce the number of antibiotics' 19.6% (n = 194) and 'de-escalate' 2.4% (n = 11). Agreement with ASP interventions occurred in 193 (40.2%) cases, and the least agreed intervention was 'stop antibiotics' (n = 40, 32%). However, there was a steady increase in compliance rates with ASP interventions over the 6 months of period study, which was statically significant (χ2: 30.005; P = 0.001). ASP prospective audit with intervention and feedback was of significant benefit in improving compliance with antimicrobial guidelines, thereby improving antimicrobial therapy in the Paediatrics Department of LUTH, Nigeria.

Is penicillin allergy de-labelling about to find its place in UK antimicrobial stewardship strategy?

Is penicillin allergy de-labelling about to find its place in UK antimicrobial stewardship strategy?

Barriers to Optimal Surgical Antimicrobial Prophylaxis for Methicillin-Resistant Staphylococcus aureus-Colonized Patients at an Australian Tertiary Teaching Hospital

Background: Surgical antimicrobial prophylaxis (SAP) is a leading indication for antibiotic use in Australian hospitals with established high rates of inappropriate prescribing. Optimal administration of SAP for patients at high risk of methicillin-resistant Staphylococcus aureus (MRSA) infections presents additional complexities. A greater understanding of barriers to optimal SAP in this cohort is required to inform targeted antimicrobial stewardship strategies, optimize SAP, and reduce the rate of surgical site infections (SSIs). Methods: A multiple-choice questionnaire appraising knowledge and barriers to optimal SAP was electronically distributed to key stakeholders. Data from the questionnaire were collated and analyzed using Survey Monkey® (Momentive Inc., San Mateo, CA) data analysis tools. Results: Eighty-three persons provided full or partial responses to the questionnaire. There were 19% of respondents who considered MRSA colonization status of patients to be only "somewhat important" when selecting appropriate SAP. Additionally, 62% of responses did not correctly identify the appropriate SAP regimen for patients who are colonized with MRSA. Several barriers to optimal SAP were identified including poor understanding of SAP guidelines, lack of timely identification of patients confirmed to be colonized with MRSA, inaccurate documentation of antibiotic and surgical start times, and limitations of the current operating room management software program. Conclusions: The high level of engagement from most key stakeholders demonstrates accountability and an overall desire to improve SAP. Barriers identified in this audit should be considered by facilities wishing to optimize compliance with SAP guidelines and consequently reduce SSIs, in particular for patients who are at high risk of MRSA infections.

Selective reporting of antibiotic susceptibility testing results for urine cultures: feasibility and acceptability by general practitioners and laboratory professionals in France.

Selective reporting of antibiotic susceptibility testing (AST) is a recommended antibiotic stewardship strategy, aiming at reducing inappropriate antibiotic prescriptions. Our objectives were to evaluate (i) the feasibility of the implementation of selective reporting of AST for urine cultures for laboratory professionals; and (ii) its acceptability by prescribers and laboratory professionals, to explore facilitators and barriers to its potential implementation on a national scale. As part of the 'ANTIBIO-ciblés' interventional study (north-eastern France, August 2018-December 2019), we prospectively collected quantitative data on all resources dedicated by the laboratories of the intervention group to implement selective reporting of AST for Escherichia coli-positive urine cultures, and on the numbers and reasons of complete reporting of AST the prescribers requested to the laboratories. We also collected qualitative data using semi-structured interviews and focus groups of GPs and laboratory professionals. The implementation of selective reporting of AST required around 80 h and cost 23 000 euros. All interviewed professionals were favourable toward the principle of this tool. Most of them found it clear, simple and useful to improve the appropriateness of antibiotic prescriptions and reduce antibiotic resistance. Its major constraint was the necessity for GPs to call the laboratory to obtain the complete reporting of AST, but the number of requests was actually low (1.2% of all selective reporting of AST). Selective reporting of AST resulted in reasonable human and financial costs, and was well accepted by both GPs and laboratory professionals.

The communicative power of nonprofit actions and values: A pilot study of dialogic stewardship

The following study seeks to expand and advance stewardship theory in public relations by incorporating tenets of dialogic and contingency theories to propose dialogic stewardship. Given fundraising trends and a theoretical shift in public relations to reconsider relational outcomes beyond organizational performance, the study re-centers stewardship on donor preferences and highlights the need to co-create stewardship strategies with donors to nonprofit organizations. After defining dialogic stewardship and how it helps to address “negative spaces” in donor-nonprofit relationships, the study puts forth a measurement model incorporating donor perspectives by using quantitative scale development processes. Analysis suggests dialogic stewardship consists of five dimensions: Reporting on Responsibility, Strategic Recognition, Organizational Values, Financial Management, and Engagement. The conclusion explains how these dimensions build public relations theory by deliberately bringing stewardship and dialogue together.

Antibiotic prophylaxis prior to transrectal prostate biopsy in Croatia: A national survey.

Transrectal ultrasound guided prostate biopsy (TRUSPB) is the standard of care for diagnosis of prostate cancer. Increased antibiotic resistance has led to the suspension of indication for fluoroquinolones use in prostate biopsy prophylaxis. Several classes of antibiotics have been recommended for routine use. Unequivocal consensus regarding antibiotic prophylaxis has not been made to date. The objective of the study was to assess the diversity of antimicrobial prophylaxis among Croatian urologists. An online questionnaire was designed using Google Forms® and distributed to 19 urology public hospital's departments. Answers regarding infection risk assessment, type and duration of antimicrobial prophylaxis were accumulated. Descriptive statistical analysis was preformed using Statistica 10.0® analytics software. Twelve urology departments answered the questionnaire, representing 63% of urology departments in Croatia. Six different antibiotic protocols have been reported. Fluoroquinolones were the most commonly prescribed class of antibiotics (84%). Antibiotic prophylaxis started 1 day before the procedure (92%). Average duration of antibiotic prophylaxis was 5 days (75%). In case of increased risk of urinary tract infection, 42% of departments changed the type, and 8% changed the duration of antibiotic prophylaxis. Neither department performed a rectal swab prior to prostate biopsy. Various antimicrobial prophylaxis protocols are currently being used among Croatian urology departments. Lack of uniform guidelines contributes to protocol diverseness that inevitably leads to further increase in antibiotic resistance. New high quality studies are needed to reverse this trend and to facilitate the establishment of a uniform antimicrobial stewardship strategy.

1572. Impact of a Multicenter Fluoroquinolone Stewardship Collaboration on Prescribing Trends over Five Years

Abstract Background Fluoroquinolone (FQ) use is generally discouraged in uncomplicated infections when alternative therapies exist. Antimicrobial stewardship programs use diverse strategies to encourage appropriate prescribing of antibiotics, and FQ stewardship is often a priority due to the known toxicity risks. This study aimed to evaluate how the coordinated implementation of several stewardship strategies impacted FQ prescribing at eight community hospitals. Methods This retrospective, observational study includes data from January 2017 to January 2022. In 2018, the facility clinical pharmacy programs established formal clinical metrics to be tracked and reported on a regular basis. One such metric tracked FQ prescribing in urinary tract infections (UTI), and this metric has remained active since 2018. In early 2019, the health-system implemented a clinical decision support alert in the electronic health record, which requires acknowledgement of a risk/benefit assessment upon FQ order entry. In late 2019, some facilities began suppressing automated susceptibility results for FQ on cultures, due to technological limitations with new minimum inhibitory concentration breakpoints. Using a clinical surveillance system, a report was generated to assess the year-over-year changes in FQ days of therapy (DOT) per 1000 patient days at each facility. Results An 83% reduction in FQ use was observed over five years (737 DOT/1000 patient days vs. 125 DOT/1000 patient days), with facility-level reductions ranging from 62% to 96%. The smallest decrease in FQ use (18%) occurred from 2017–2018, before any system-wide FQ stewardship initiatives were adopted. A larger decrease in FQ use (33%) was seen from 2018–2019, after introducing the formal FQ UTI metric. The biggest decrease in FQ use (50%) occurred from 2019–2020, when the FQ alert and susceptibility suppression strategies were implemented alongside the existing UTI metric. An additional 39% decrease in FQ use was seen from 2020–2022, when no additional FQ interventions were implemented. Conclusion Substantial decreases in FQ prescribing were observed when multiple FQ stewardship strategies were utilized. The decreases were sustained over several years across multiple hospitals. Disclosures All Authors: No reported disclosures.

944. Development &amp; Implementation of a Biomarker-based Remotely-delivered Antimicrobial Stewardship (AMS) Strategy during the COVID-19 Pandemic

Abstract Background Increased antibiotic usage during the COVID-19 pandemic and resultant infection control measures derailed the existing antimicrobial stewardship program which involved in person post prescription review and feedback. We performed a time series analysis using Procalcitonin as a tool for a remotely delivered antimicrobial stewardship program by a clinical pharmacist. Methods This study was conducted in a tertiary care 3500 bedded teaching hospital in southern India. In the baseline phase, all COVID-19 in-patients receiving antibiotics &amp;gt; 48 hours were screened via the electronic records by a pharmacist and antimicrobial consumption indices like days of therapy (DOT) and length of therapy (LOT) were measured. In the intervention phase, if a patient was on antimicrobials, then a PCT was sent. An alert was sent to the treating team based on the procalcitonin levels and a screening of electronic records by a clinical pharmacist to either continue/ de-escalate or discontinue an antibiotic under supervision of an Infectious Diseases physician. Figure 1Guideline for continuing or stopping antibiotics based on procalcitonin levelsFigure 2Guideline for continuing or stopping antibiotics based on procalcitonin levelsStudy Flow Results About 481 patients were enrolled in the pre intervention phase of the study from July to October 2020 (peak of the pandemic) and 90 patients in the intervention phase December 2020 - March 2021 (decline of the pandemic. The baseline characteristics are shown in Figure3. The DOT/1000 patient days (PD) for all antibiotics was 9269 (DOT-6915) in the baseline and 2032 (DOT-886) in the intervention arm. The total length of therapy (LOT) for antimicrobial consumption significantly reduced from 3779 in the pre-intervention phase to 657 in the intervention phase (Figure 4). Out of the 90 recommendations given in the intervention phase, 82 (91.1%) were accepted by the treating team. For Azithromycin and Doxycycline, DOT significantly reduced from 3319 to 486 per 1000 PD and 602 to 158 per 1000 PD respectively. The DOT of the reserve antibiotics according to the WHO AWaRe classification like Polymyxins and Carbapenems decreased from 323 to 67 and 777 to 443 per 1000 PD days in the intervention phase. Figure 3Baseline Characteristics comparing Pre- intervention and Intervention Phase Figure 4 Comparison of LOT (Length of therapy) and DOT (Days of therapy) in the Pre-intervention and Intervention Phase Figure 5 Comparison of the DOT per 1000 PD in the Pre-Intervention and Intervention phase of frequently used antibiotics in Covid- 19 infection Conclusion This study demonstrated the utility of a novel biomarker driven antimicrobial stewardship strategy by clinical pharmacists during the COVID pandemic when access to patients was restricted to both infection control physicians and pharmacists. Disclosures Priscilla Rupali, MD, DTM&amp;H, PFIZER: Grant/Research Support|PFIZER: Grant/Research Support.

2219. Syphilis Diagnosis and Treatment Practices in the Ambulatory Setting of a Large Vertically Integrated Healthcare Organization: An Opportunity for Infectious Diseases Physician Engagement

Abstract Background Sexually transmitted infections (STIs) continue to increase in the United States. Syphilis management may challenge busy outpatient clinicians and diagnostic delays have been described. To better understand syphilis treatment practices and identify targets for improvement in our organization, we characterized outpatient encounters associated with a positive syphilis test. Methods Intermountain Healthcare (IH) is an integrated healthcare system with 23 emergency departments (ED), 34 urgent care (UC), and &amp;gt;100 primary care (PC) clinics. Protocols favor treponemal testing as the initial screening test. All positive treponemal tests associated with a positive non-treponemal test in the ambulatory setting were routed to an electronic inbox within the electronic health record (EHR) and reviewed by a team of Infectious Disease (ID) clinicians from May 1st 2021 – January 31st, 2022. Positive results originating from ID or HIV-trained primary care clinicians were excluded. Each encounter was assessed for staging and treatment plans based on CDC guidelines as well as HIV pre-exposure prophylaxis (PrEP) and HIV treatment eligibility. Results 119 encounters were reviewed. Patients 30-44 years old were most likely to have a positive test (50, 42.0%). PC (63, 52.9%) and UC (24, 20.2%) accounted for the most positive tests. 102 (85.7%) positive tests were from white patients, consistent with racial demographics of Utah. Only 40 (33.6%) encounters could be clinically staged after chart review by an ID clinician. Of these, 17 (42.5%) were determined to be staged and treated inappropriately by the treating provider. 54 (45.4%) encounters could not be staged and required further testing or more clinical history to determine the significance of positive test. 18 (15.1%) patients could possibly have benefitted from PrEP evaluation and one new HIV diagnosis was referred to ID clinic. Conclusion Our exploratory analysis revealed many syphilis cases unable to be staged on chart review and opportunities to improve care. Strategies such as prospective audit and feedback or eConsults may be insufficient and clinical evaluation may be necessary to stage syphilis infection. Syphilis care improvements in our system may be a future target for ID physician engagement and novel stewardship strategies. Disclosures All Authors: No reported disclosures.

2224. Aminopenicillins versus Non-aminopenicillins for Treatment of Enterococcal Cystitis

Abstract Background Aminopenicillins achieve urinary concentrations that overcome aminopenicillin resistance in Enterococcus spp. lower urinary tract infections (UTI). With this rationale, our clinical microbiology laboratory discontinued routine identification on Enterococcus urine isolates in 2012 and report “aminopenicillins are predictably reliable for uncomplicated enterococcal UTI”. The study objective was to compare outcomes of patients treated with aminopenicillins (AP) versus non-aminopenicillins (NAP) for enterococcal cystitis. Methods IRB approved, retrospective cohort of adults hospitalized with symptomatic enterococcal cystitis from 2013-2021. Exclusion: definitive E. faecalis, enterococcal UTI in past year, review of systems unavailable/altered mental status, urinary instrumentation except for stent/catheter, systemic infection, fever, genitourinary trauma, renal transplant. Primary endpoint: clinical and microbiologic success at 14 days, defined as resolution of symptoms without new symptoms and no repeat culture growth of index organism. Logistic regression evaluated characteristics associated with 14-day failure. Sample size of 178 calculated for non-inferiority using α=0.025, β=0.8, 15% non-inferiority margin. Results 178 subjects included, 89 AP, 89 NAP . VRE identified: 73 (82%) AP and 76 (85%) NAP (P=0.50). Amoxicillin (36/89, 40%) and ampicillin (36/89, 40%) used most in AP. Linezolid (41, 46%) and fosfomycin (30, 34%) most common agents in NAP. 14-day clinical composite endpoint was no different between AP and NAP groups, respectively (74 [83%] vs. 73 [82%], P=0.84). No variables independently predicted failure (Table 1). Non-inferiority analysis for AP vs. NAP for 14-day composite: mean difference 1.1% (-0.14 to 0.127, 97.5% CI; P=0.42). Definite E. faecium subgroup: 14-day clinical composite success for was no different between AP and NAP groups, respectively (27/34 [79%] vs. 53/66 [80%], P=0.916). Conclusion AP were non-inferior to NAP, supporting their use as first-line therapy for cystitis due to enterococci, including E. faecium. This stewardship strategy has implications to preserve VRE active therapies (e.g. linezolid) for serious infections. Disclosures All Authors: No reported disclosures.