Stewardship Team Research Articles

58. Evaluation of a Disease State Stewardship Intervention for Urinary Tract Infections at an Academic Medical Center

BackgroundUrinary tract infections (UTIs) are often misdiagnosed and mismanaged. Disease state stewardship initiatives targeting UTIs may have a significant impact on the overuse of antimicrobials (ABX). The purpose of our study is to evaluate the effectiveness of a UTI focused disease state stewardship intervention.MethodsThis retrospective study was conducted at a tertiary care academic medical center. Patients > 18 years of age with a collected urinalysis (UA) and receiving ABX for a UTI were included. Retrospective review of UTI management from 9–11/2017 was performed and used as the baseline. In the post-intervention period, 9–11/2018, the UTI management guideline had been published and service lines educated. A prospective audit and feedback (PAAF) initiative was started 6/2019, whereby the antimicrobial stewardship team performed daily reviews of patients on ABX for UTIs. Patients reviewed 9–11/2019 were included in the PAAF cohort. Exclusion criteria included: pregnancy, undergoing a urologic procedure, treatment of a concomitant infection, receiving therapy based on outside recommendations, or left AMA/expired during treatment. The primary outcome of this study was to evaluate overall guideline adherence.Results600 patients (200 in each group) were included, with 419 (69.8%) female and an overall median age of 61.4 years. Altered mental status (24.8%) and dysuria (21.5%) were the two main diagnostic testing indications. Treatment of asymptomatic presentations decreased between the three periods, 74.0% vs 48.5% vs 36.0%. Appropriate ordering of UA (33.5% vs 55.0% vs 68.5%, p< 0.001) and urine cultures (29.0% vs 57.1% vs 64.8%, p< 0.001) improved following guideline implementation and PAAF. Interventions by the stewardship team were made in 21% of patients during PAAF, namely therapy discontinuation (78.6%). Overall guideline adherence significantly improved over time, 13.0% vs 27.0% vs 36.5%, p< 0.001.ConclusionUTI disease state intervention was associated with a reduction in the treatment of asymptomatic presentations, increase in appropriate diagnostic ordering, and improvement in overall guideline adherence. PAAF can be a powerful stewardship strategy for promoting consistency in UTI treatment and decreasing unnecessary ABX use.Disclosures All Authors: No reported disclosures

54. Effectiveness of a Venous Catheter Stewardship Intervention Targeting Parenteral Antimicrobial Therapy at Hospital Discharge

BackgroundPeripherally inserted central catheters (PICCs) and midlines are often used in hospitalized patients who require outpatient parenteral antimicrobial therapy (OPAT) upon discharge. PICCs/midlines offer ease of insertion but still carry the risks of venous thrombosis, phlebitis, and catheter-associated infection. We report the results of a prospective audit and feedback (PAF) intervention targeting the placement of PICCs/midlines for OPAT at our institution.MethodsWe prospectively identified a cohort of patients identified by a real-time PICC/midline alert from 5/20/2019 through 5/29/2020 at two large academic medical centers. Alerts were generated by a third-party interface with the electronic health record and identified new line orders with an antimicrobial indication selected. Patients without infectious diseases (ID) consult underwent PAF by the antimicrobial stewardship team. Descriptive statistics were used to characterize patients, interventions, and outcomes.ResultsDuring the study period, 1267 PICC/midline alerts were identified. Most were excluded due to ID consult (85.4%). After exclusions, 113 alerts underwent full review. Median patient age was 64 years with female predominance (54.2%). Reviewable alerts most commonly originated from Pulmonary (36.5%) and Hospitalist (26.0%) services. The most frequent antimicrobial indications were pneumonia (37.5%) and bloodstream infection (28.1%), and the most frequently ordered antimicrobials were cefepime (27.1%) and piperacillin-tazobactam (17.7%). Median time from line order to insertion was 22 hours and from line insertion to discharge was 48 hours. Of 113 alerts reviewed by the stewardship team, 26 (23.0%) resulted in a recommendation to avoid line placement and 45 (39.8%) resulted in at least one specific stewardship recommendation (Table 1). Recommendations were fully or partially accepted in 58.3% of instances.TABLE 1. Interventions Resulting from Prospective Venous Catheter Stewardship ConclusionProspective audit of PICC/midline orders for OPAT identified a line-sparing opportunity in nearly 1 in 4 cases. Where line avoidance was not possible, other opportunities for antimicrobial optimization were common. This high-yield intervention should be considered for institutions that do not mandate infectious diseases consult for all OPAT discharges.Disclosures All Authors: No reported disclosures

668. Rapid Identification and Antimicrobial Susceptibility Testing of Gram-Negative Rod Bacteremia: Impact on Duration of Hospital Admission

BackgroundThere are many emerging diagnostic technologies that provide rapid identification (ID) and antimicrobial susceptibility testing (AST) of blood cultures after initial microbial growth is detected. The clinical utility of having these results sooner than standard of care (SOC) ID/AST testing is less clear; one potential advantage would be shorter hospital admissions for those patients with less severe infections whose discharge planning is delayed while waiting for ID/AST results.MethodsThe Accelerate Pheno™ rapid ID/AST system (AP) was implemented in the clinical microbiology lab at two hospitals within our academic hospital system to run in parallel with our SOC ID/AST diagnostics for all blood cultures with Gram-negative rod (GNR) bacterial growth on initial Gram stain. Results of both diagnostic assays were uploaded to the medical record when available; our antimicrobial stewardship (AS) team discussed the AP results with clinical care teams during working hours. Length of stay (LOS) data was compared between a cohort with GNR bacteremia before and after the implementation of AP testing with AS review.ResultsThere were 207 patients with GNR bacteremia admitted to the hospital during the first six months after implementation of AP testing with AS review (12/2019 – 05/2020). A historical cohort of 96 patients with GNR bacteremia (admitted 01/2018 – 08/2018) with SOC testing without AS review was used for comparison. Median LOS was 5.28 and 5.84 days for the AP and SOC cohorts, respectively; the distribution in the two groups differed significantly (Mann-Whitney U = 8728.5, p = 0.0446). There was also an increase in the percent of admissions shorter than 2 days between the AP and SOC cohorts (12.5% v. 5.2%, p = 0.024) [Figure1].Figure 1 ConclusionThe use of a rapid ID/AST diagnostic technology with AS review may lead to shorter hospitalizations in select patient populations.Disclosures Kimberle Chapin, MD, genmark (Scientific Research Study Investigator)

161. Assessing Antimicrobial Stewardship Engagement among Frontline Oncology Nurses and Chartering a Path Forward

BackgroundDeveloping robust, multidisciplinary antimicrobial stewardship programs to combat drug resistance is a priority of healthcare institutions, in accordance with Joint Commission standards and national legislature. However, the involvement of nurses in stewardship programs has trailed behind that of physicians and pharmacists, despite their unique position as frontline providers. In particular, oncology nursing staff can play a key role in extending stewardship to their high acuity patients, who frequently require antimicrobials. We sought to conduct a survey study of oncology nursing providers on their understanding, perceptions, and attitudes about antimicrobial stewardship.MethodsA voluntary and anonymous survey was emailed to oncology nursing staff on adult and pediatric oncology wards and clinics throughout our hospital system. We used an adapted 28-item Likert scale-based survey to assess understanding of antimicrobial stewardship attitudes and perceived barriers to greater involvement in stewardship programs. A survey reminder was emailed weekly for 8 weeks and completion was encouraged by nursing leadership in unit staff meetings.ResultsThe survey was emailed to 281 nurses, of whom 39% (n=109) responded. 54.1% of nurses believed that an antibiotic stewardship program was very important in their healthcare setting. However, 56% of respondents were unfamiliar with the meaning of antibiotic stewardship, and 83.5% were not aware of how to contact the antimicrobial stewardship team with questions. More than 75% felt that nurses could help with antibiotic use, though 76% indicated wanting to know more about which antibiotics treat different infections and 74% wanted to know more about appropriate durations of antibiotics.ConclusionOncology nurses have the potential to play a valuable role in antimicrobial stewardship. Barriers to nursing involvement include knowledge gaps on antibiotics and unfamiliarity with existing stewardship programs and their functions within hospital systems. Nursing education and orientation to available resources are key steps to involving nursing staff in antimicrobial stewardship programs, maximizing benefits for both patients and hospitals.Disclosures All Authors: No reported disclosures

223. Difference in Carbapenem Use by ASP Intervention in Japanese Healthcare Facilities

BackgroundAntimicrobial stewardship program (ASP) interventions have been reported to reduce unnecessary antimicrobial use (AMU). In this study, we investigated the difference in the use of carbapenems by ASP intervention in Japanese healthcare facilities.MethodsData on two components of AMU and ASP registered in Japan Surveillance for Infection Prevention and Healthcare Epidemiology (J-SIPHE) from January to December 2019, were used. Facilities with an infection control team in addition to an antimicrobial stewardship team responsible for the proper use of antimicrobial agents were included in the study. AMU data (such as DOT [Days of Therapy / 100 patient days]) are entered semi-automatically from medical fee statement (receipt) file at each facility. ASP intervention is divided into four categories 1) pre-authorization, 2) prospective audit and feedback (PAF), 3) PAF and required notification (RN), 4) RN. The Kruskal-Wallis test is performed to see overall difference and the Dunn test with the Bonferroni correction is done for each pair of categories.ResultsA total of 114 hospitals were included in the analysis. The median number of beds at participating facilities were 430 [IQR: 281–602], the median average hospital stay was 13.0 days [IQR: 11.4–15.2] and total number of inpatients per month was 10087 [6247–14536]. PAF and RN were the most common ASP interventions for carbapenems (62.5%), followed by RN (33.6%). The median DOT [IQR] of participating facilities were 2.1 [1.2–3.1] and 1) 0.7 [0.2–1.1], 2) 2.7 [2.1–3.4], 3) 2.1 [1.4–3.1] and 4) 2.0 [1.2–3.5] by ASP categories. There are significant differences between 1) and 2), 1) and 3), and 1) and 4) (p=0.014, p< 0.01 and p< 0.01, respectively) while the differences between 2) and 3), 2) and 4), and 3) and 4) are not significant (p=1.00).Table 1. Summary statistics of healthcare facilities by ASP Interventions Figure 1. DOT by ASP Interventions ConclusionOnly 3.5% of ASP interventions belong to 1) pre-authorization category and this might be due to the complexity of registration process. This category was found to have the lowest DOT among all ASP interventions in Japanese healthcare facilities. The variances of DOT were especially large in categories 3) and 4), and more detailed analyses would be necessary to evaluate their efficacies accurately.Disclosures All Authors: No reported disclosures

77. Out of Sight, Out of Mind: Impact of an Antimicrobial Stewardship Bundle on Fluoroquinolone Utilization

BackgroundFluoroquinolones are broad spectrum antimicrobials associated with a growing list of adverse effects, such as Clostridioides difficile infection, arrhythmias, central nervous system effects, tendon rupture and aortic aneurysm. Due to increasing concerns regarding adverse events and growing resistance, the antimicrobial stewardship team at Wesley Healthcare implemented a bundle aimed at reducing fluoroquinolone usage beginning in June 2017. The components of this bundle included suppression of fluoroquinolone susceptibility in Enterobacteriaceae isolates, removal of fluoroquinolones as first line options on order sets, and introduction of a respiratory specific antibiogram.MethodsThe objective was to evaluate the impact of the stewardship bundle on fluoroquinolone utilization. The primary outcome was ciprofloxacin and levofloxacin usage in days of therapy per 1000 inpatient days (DOT) collected at monthly intervals for 24 months before and after intervention. Overall antimicrobial usage in DOT served as a control variable. The secondary outcomes were E. coli and P. aeruginosa susceptibility to ciprofloxacin measured at the same time points as the primary outcome. An interrupted time-series analysis using segmented regression was performed for all variables.ResultsThe mean monthly levofloxacin usage was reduced from 14.1 (95% CI, 12.7 - 15.4) to 8.4 (95% CI, 7.6 - 9.3) DOT. The mean monthly ciprofloxacin usage was reduced from 26.9 (95% CI, 24.6 - 29.4) to 15.8 (95% CI, 14.0 - 17.5) DOT. The trend in levofloxacin usage was reduced (p=0.035), while a pre-existing downward trend in ciprofloxacin usage was unchanged (p=NS). Overall antimicrobial usage increased, likely due to increasing hematology/oncology populations during the study period. There were no differences in E. coli or P. aeruginosa susceptibilities observed.ConclusionThis antimicrobial stewardship bundle may be a useful intervention to reduce fluoroquinolone usage. The bundle may be of particular utility in reducing levofloxacin usage, as our results demonstrated a change in both its usage and trend in usage.Disclosures All Authors: No reported disclosures

234. Improving Antibiotic Prophylaxis Selection for Patients Undergoing Urology Procedures

BackgroundEvidence evaluating prescribing patterns in antibiotic (ABC) prophylaxis (PPX) for urology (UGY) procedures is limited. Although national guidelines give direction on the ABC PPX for specific procedures, ABC PPX should also be based on local ABC resistance patterns, individual host factors and procedure type factors. Our institution’s urine culture antibiogram illustrates increasing resistance to Cefazolin, a national guideline preferred ABC. The purpose of this study is to assess the impact of a quality improvement intervention on prescribing practices for ABC PPX in patients undergoing UGY procedures.MethodsThis is a retrospective study evaluating all patients receiving perioperative ABC PPX for UGY procedures from 01/01/2019 to 07/31/2019. The intervention (focusing on UGY provider education for ABC PPX based on local ABC resistance patterns, host factors and UGY procedure type) occurred on multiple in-person sessions during 04/2019. Emphasis occurred with replacing Cefazolin with Ceftriaxone, given local resistance patterns. We compared patient characteristics, appropriate ABC PPX use (deemed by local ABC Stewardship Team) and postoperative infections between the “pre” (01/01/2019 – 03/31/2019) and “post” (05/01/2019 – 07/31/2019) groups.ResultsThe “pre” group had 85 patients and the “post” group had 80 patients. 62% had a same day UGY procedure with the most common procedures designated as “clean-contaminated” (81.8%) and ASA physical status classification as “ASA II” (53.9%). After the intervention, appropriate ABC PPX choice improved (14.5% to 76%, P < 0.001) based on local ABC resistance patterns. No significant difference is noted in urine culture collection before procedure (36.4% to 43.7%, P = 0.3), ABC PPX choice based on prior patient-specific culture results including multi-drug resistant pathogens (75% to 82.3%, P = 0.6), use of ABC PPX post-procedure (40% to 35%, P = 0.5) and postoperative infections (7% to 11.2%, P = 0.4).ConclusionUtilization of education sessions as a quality improvement intervention resulted in significant improvement in ABC PPX choice for UGY procedures based on local ABC resistance patterns. Further interventions are necessary to optimize additional areas related to ABC PPX use for UGY procedures.Disclosures All Authors: No reported disclosures

383. Increased Need for Antimicrobial Stewardship during a COVID-19 Outbreak in New York City

BackgroundThe impact of COVID-19 on the health care system in New York City (NYC) cannot be overstated. The first documented cases of COVID-19 in Queens NYC occurred in early March of 2020. The total number of patients with proven or suspected COVID-19 at Elmhurst Hospital peaked in early April. A dramatic increase in the use of antimicrobials occurred in April, and correlated with the increased number of intubated COVID-19 patients at Elmhurst Hospital.MethodsAntimicrobial Stewardship Committee activities and meetings had been suspended for the months of March and April due to the increased clinical demands associated with the COVID-19 outbreak. In preparation for the May meeting, a retrospective analysis of antimicrobial use for March and April of 2020 was performed.ResultsThe analysis revealed a 30% increase in the use of antimicrobials. The average total days of antimicrobials per 1000 patient days (TDA/TPD) was 445 for January through March of 2020. In April, this number climbed to 580. TDA/TPD increased from 57 to 90 (58%) for vancomycin, 25 to 35 (40%) for meropenem, and 31 to 89 (187%) for cefepime. The number of intervention by the Antibiotic Stewardship team remained low during this time period.Total Days of Antimicrobials per 1000 Patient Days (TDA/TPD) ConclusionA dramatic increase in the use of antimicrobials correlated with an increase in the number of intubated patients at Elmhurst Hospital during a COVID-19 outbreak. It is likely that the frequent appearance of fever and leukocytosis in intubated patients with COVID-19 prompted an increase in empiric antimicrobial use. The 48 hour time outs and prospective review of antimicrobial use may be necessary to maintain stewardship efforts during the COVID-19 epidemic. Further review of antibiotic usage in critically ill COVID-19 patients is needed to help define stewardship practices as we go forward in this pandemic.Disclosures All Authors: No reported disclosures

229. Hospitalists Antimicrobial Scorecard Improves Antibiotic Prescribing at a Community Teaching Hospital

BackgroundMeasuring antimicrobial consumption data is a foundation of antimicrobial stewardship programs. There is data to support antimicrobial scorecard utilization to improve antibiotic use in the outpatient setting. There is a lack of data on the impact of an antimicrobial scorecard for hospitalists. Our objective was to improve antibiotic prescribing amongst the hospitalist service through the development of an antimicrobial scorecard.MethodsConducted in a 451-bed teaching hospital amongst 22 full time hospitalists. The antimicrobial scorecard for 2019 was distributed in two phases. In October 2019, baseline antibiotic prescribing data (January – September 2019) was distributed. In January 2020, a second scorecard was distributed (October – December 2019) to assess the impact of the scorecard. The scorecard distributed via e-mail to physicians included: Antibiotic days of therapy/1,000 patient care days (corrected for attending census), route of antibiotic prescribing (% intravenous (IV) vs % oral (PO)) and percentage of patients prescribed piperacillin-tazobactam (PT) for greater than 3 days. Hospitalists received their data in rank order amongst their peers. Along with the antimicrobial scorecard, recommendations from the antimicrobial stewardship team were included for hospitalists to improve their antibiotic prescribing for these initiatives. Hospitalists demographics (years of practice and gender) were collected. Descriptive statistics were utilized to analyze pre and post data.ResultsSixteen (16) out of 22 (73%) hospitalists improved their antibiotic prescribing from pre- to post-scorecard (χ 2(1)=3.68, p = 0.055). The median antibiotic days of therapy/1,000 patient care days decreased from 661 pre-scorecard to 618 post-scorecard (p = 0.043). The median PT use greater than 3 days also decreased significantly, from 18% pre-scorecard to 11% post-scorecard (p = 0.0025). There was no change in % of IV antibiotic prescribing and no correlation between years of experience or gender to antibiotic prescribing.ConclusionProviding antimicrobial scorecards to our hospitalist service resulted in a significant decrease in antibiotic days of therapy/1,000 patient care days and PT prescribing beyond 3 days.Disclosures All Authors: No reported disclosures

185. Pilot of a Face-to-Face Model of Stewardship (Handshake Stewardship) in a General Medicine Ward

BackgroundHandshake stewardship (HS) is an antibiotic stewardship strategy that includes a more in-person approach to prospective audit and feedback (PAF). It has emerged as an effective form of PAF, enhancing trust and collaboration between the antibiotic stewardship team (AST) and the prescribers. However, resources can be a barrier to implementation. We sought to describe our experience of a HS pilot implementation at our institution. Methods: Our HS model was implemented as a pilot among five attending-only hospital medicine teams at Temple University Hospital. All antimicrobials administered to patients on these teams were reviewed by the AST pharmacist on weekdays from 2/4/19 to 3/4/19. The AST physician and pharmacist then physically located each team to discuss recommendations and answered questions. Number and types of AST recommendations were recorded along with the outcome. As patients on all five teams were centralized in one patient care unit (PCU), antibiotic utilization of this PCU, measured as days of therapy per 1000 patient days (DOT/1000 PD) was collected from January to March 2019. An anonymous survey of hospitalists involved in this pilot was also performed to determine their perceptions toward the HS model. Results: During the pilot period, 108 recommendations were made on 63 unique patients. On average, 20 patients were on antimicrobials on a given day, and AST spent 2 hours per day reviewing data and interacting with the teams. The most common recommendation was a change in antibiotic regimen (39%), mostly for de-escalation of therapy, with an overall acceptance rate of 91%. Overall antibiotic usage was numerically lower in the pilot month (February; 622 DOT/1000 PD) compared to the two adjacent non-pilot months; January (824 DOT/1000 PD) and March (728 DOT/1000 PD). The difference was mostly explained by the decrease in anti-pseudomonal beta-lactam use. The HS model was widely accepted among the surveyed hospitalists, who preferred it over the current PAF model completed via telecommunication. Conclusion: The HS model appears to be effective and well accepted by our hospitalists. Strategies to expand this face-to-face approach may provide additional opportunities for antimicrobial optimization while increasing provider satisfaction.Disclosures All Authors: No reported disclosures

Surgeon-led 7-VINCut Antibiotic Stewardship Intervention Decreases Duration of Treatment and Carbapenem Use in a General Surgery Service.

Antibiotic stewardship programs optimize the use of antimicrobials to prevent the development of resistance and improve patient outcomes. In this prospective interventional study, a multidisciplinary team led by surgeons implemented a program aimed at shortening the duration of antibiotic treatment <7 days. The impact of the intervention on antibiotic consumption adjusted to bed-days and discharges, and the isolation of multiresistant bacteria (MRB) was also studied. Furthermore, the surgeons were surveyed regarding their beliefs and feelings about the program. Out of 1409 patients, 40.7% received antibiotic therapy. Treatment continued for over 7 days in 21.5% of cases, and, as can be expected, source control was achieved in only 48.8% of these cases. The recommendations were followed in 90.2% of cases, the most frequent being to withdraw the treatment (55.6%). During the first 16 months of the intervention, a sharp decrease in the percentage of extended treatments, with R2 = 0.111 was observed. The program was very well accepted by surgeons, and achieved a decrease in both the consumption of carbapenems and in the number of MRB isolations. Multidisciplinary stewardship teams led by surgeons seem to be well received and able to better manage antibiotic prescription in surgery.

Impact of a Systematic Pharmacist-Initiated Antibiotic Time-Out Intervention for Hospitalized Adults

Introduction: Antibiotic time-outs (ATO) are a recommended antimicrobial stewardship action, but data assessing their impact are lacking. This study investigated the impact of a systematic, pharmacist initiated ATO intervention. Methods: This pre-post study included inpatients on hospitalist and intensivist services receiving empiric antibiotics for ≥48 hours. The ATO was initiated by pharmacists after 48 hours of empiric therapy and the outcome was documented including antibiotic indication, plan, and duration. An electronic medical record (EMR) alert facilitated ATO completion and pharmacists and prescribers received education prior to implementation. The primary outcome was EMR documentation of an antibiotic plan by 72 hours. Secondary outcomes included antibiotic utilization and antibiotic therapy modifications by 2 hours. Results: 399 patients were included, 199 pre- and 200 post-intervention. The most common indications were pneumonia (32%), intra-abdominal infection (20%) and urinary tract infection (19%), with no between-group differences. EMR documentation of an antibiotic plan significantly improved in the post-intervention group (19% vs. 79%, p<0.0001) as did modifications to antibiotic therapy. The median duration of in-hospital antibiotic therapy was similar between groups (4.0 vs. 4.0 days, p = 0.2499). Approximately 45% of patients in each group received discharge antibiotics and median duration of discharge antibiotic therapy prescribed was reduced (7 vs. 5 days in the pre- and post-intervention groups, respectively; p = 0.0140). Discussion: Implementation of pharmacist initiated ATO was associated with improvements in supporting EMR documentation and antibiotic therapy modifications. These findings highlight an important role in which pharmacists can serve as part of a collaborative antibiotic stewardship team.

Intermittent Education and Audit and Feedback Reduce Inappropriate Prescribing of Oral Third-Generation Cephalosporins for Pediatric Upper Respiratory Tract Infections

In June 2017, leaders within a pediatric ambulatory care network in Houston approached the antimicrobial stewardship team at Texas Children's Hospital with concerns for high oral third-generation cephalosporin (oTGC) use in their clinics. An outpatient quality improvement (QI) team was formed. The specific aim was to reduce inappropriate oTGC prescribing at one clinic ("Clinic A") by 15% in one year. Following a benchmark analysis of oTGC use at Clinic A, Plan-Do-Study-Act (PDSA) cycles were designed and conducted over one year: one educational session, three individual audit and feedback sessions, and one group feedback session. The primary outcome was the percentage of oTGCs not aligning with American Academy of Pediatrics (AAP) guidelines for bacterial upper respiratory tract infections. Monthly oTGC prescribing at Clinic A was also compared to four control clinics. In June 2017, 72% (231/322) of oTGCs prescriptions at Clinic A did not align with AAP guidelines. The most common diagnosis was primary/nonrecurrent acute otitis media. Following interventions, the mean percentage inappropriate oTGCs decreased from 72% to 45% (absolute reduction 27%, p < 0.001), which was sustained the year following the last PDSA cycle (absolute reduction 26%, p < 0.001). Total monthly oTGC prescribing at Clinic A decreased over time, but not in four control clinics. Provider active participation in stewardship activities decreased over time. Intermittent education and audit and feedback were associated with reduced oTGC misuse at Clinic A but not at four control clinics. Improvements were maintained despite decreased participation in stewardship activities, suggesting that perceptions of ongoing antibiotic audits can help sustain prescribing improvements.

Impact of antibiotic consumption post-implementation of antimicrobial stewardship in Orthopaedic and Obstetrics & Gynaecology (O&G) Department

Background: Engagement of the surgical discipline into an active role in antimicrobial stewardship is a challenge. The usage of Ciprofloxacin and Cefoperazone/Sulbactam in the Orthopaedic and O&G, respectively, in Hospital Ampang was recorded to be the highest among Malaysian hospitals in 2017. Methods and materials: An antimicrobial stewardship team was established that consisted of leaders from the respective disciplines ie: Medical, Intensive Care Unit, Orthopaedics, Surgical, O&G. The objective of the team is to have ownership of antimicrobial issues regarding inappropriate usage of antibiotics or increase consumption in their own disciplines. The teams were given regular feedback regarding the antibiotic consumption and suggested personalised intervention for their departments by using the National Antibiotic Guideline 2014 as a guide. A dedicated pharmacist was also assigned to each department to carry out AMS activities. Results: There was a significant reduction in the Defined Daily Dose (DDD) of ciprofloxacin injection from 34.73 in 2017 to 0.92 in 2018 in the Orthopaedic Department (97.35% reduction). Marked decrement in cefoperazone/sulbactam usage in O&G was also seen, with DDD dropped from 6.67 in 2017 to 2.1 in 2018 (68.52% reduction). This achievement was resulted from changing the surgical prophylaxis antibiotic from cefoperazone/sulbactam to cefuroxime according to NAG. Conclusion: Engagement and ownership of AMS issues from the respective disciplines was the key step into making AMS implementation a priority and success in the Orthopaedic and O&G Department. This had led to a significant reduction in the usage of ciprofloxacin and cefoperazone/sulbactam in Hospital Ampang. Continued engagement is important to sustain this success.

The benefits and safety of oral sequential antibiotic therapy in non-complicated and complicated Staphylococcus aureus bacteremia

BackgroundTreatment optimization for serious infections, such as Staphylococcus aureus bacteremia (SAB), is a challenge for antimicrobial stewardship teams. Currently, SAB guidelines recommend a completely intravenous therapy (CIT). ObjectivesThe objective of the study was to analyze the usefulness and safety of oral sequential therapy (OST) in SAB. Patients and methodsWe conducted a retrospective, observational study in a tertiary teaching hospital in Spain. The inclusion criteria were complicated and non-complicated monomicrobial SAB and an adequate duration of therapy, with patients classified into OST or CIT. The primary endpoint was the 90-day recurrence of S. aureus infection. We also analyzed the mortality, the length of the hospital stay, and the duration of the intravenous antibiotic administration. ResultsOf a total of 201 patients with SAB, 125 (62%) underwent OST. The most commonly administered oral antibiotic was trimethoprim-sulfamethoxazole (66% of patients). Of those administered OST, 43% had complicated bacteremia (most with an osteoarticular source of infection), and 6% had an intravascular device. The 90-day recurrence rate was 4%, with no differences between the two groups. The duration of the therapy (22 [16–28] vs. 13 days [8–17] for CIT and OST, respectively; p < 0.001) and the hospital stay (36 [27–71] vs. 18 days [13–29] for CIT and OST, respectively; p < 0.001) were shorter for OST. MRSA was related with mortality (OR 4.4, 95% CI [1.67−11.37]; p = 0.003). ConclusionsOST for properly selected patients with SAB could be a safe therapeutic option and can reduce their use of CIT and their hospital stay.

Quality indicators for appropriate antimicrobial therapy in the emergency department: a pragmatic Delphi procedure

ObjectivesAntimicrobial stewardship (AMS) has established its importance for inpatient care. AMS is, however, also urgently needed in emergency departments (ED), where many antimicrobial prescriptions are initiated. It is currently unclear what metrics stewardship teams can use to measure and improve the appropriateness of antimicrobial prescription in the ED. In this study we develop quality indicators (QIs) for antimicrobial use in the ED. MethodsA RAND-modified Delphi procedure was used to develop a set of QIs applicable to adult patients who present at the ED with a potential infection. First, pragmatically using two recent papers of the international expert-group DRIVE-AB, potential ED-specific QIs for appropriate antimicrobial use were retrieved. Thereafter, an international multidisciplinary expert panel appraised these QIs during two questionnaire rounds with a meeting in between. ResultsThirty-three potential QIs were extracted from the DRIVE-AB papers. After appraisal by 13 experts, 22 QIs describing appropriate antimicrobial use in the ED were selected. These indicators provide recommendations within five domains: stewardship prerequisites (six QIs); diagnostics (one QI); empirical treatment (ten QIs); documentation of information (four QIs); and patient discharge (one QI). ConclusionsWe pragmatically developed a set of 22 QIs that can be used by stewardship teams to measure the appropriateness of antimicrobial prescription in the ED. There is probably room for additional QI development to cover all key aspects of AMS in the ED. Measuring QIs can be a first step for stewardship teams to, in collaboration with ED professionals, choose targets for improvement and optimize antimicrobial use.

Time and personnel requirements for antimicrobial stewardship in small hospitals in a rural area in Germany

BackgroundIn order to control their anti-infectives consumption, hospitals are required to provide multidisciplinary teams comprising among others an infectiologist, a microbiologist and a pharmacist. Small hospitals though often do not dispose of the defaulted personnel. This study illustrates a solution for an antimicrobial stewardship program (ASP) in small community hospitals in a rural area in Germany. MethodsFour hospitals of ca. 200 beds each, jointly hired an antimicrobial stewardship expert to start a common ASP. This expert did rounds on every ward once a week, mostly as chard reviews with the physician in charge. Outside the rounds, he could be consulted by mail. Working time and number of visited patients were documented. Anti-infectives consumption, incidence of Clostridioides difficile infections (CDI) and mortality rates were retrieved from routinely collected data. The intervention period (01/2018–12/2018) was compared to the preintervention period (01/2017–12/2017). Results3321 patients were visited in the intervention period. In average, 20 patients were seen per day and 20 min were needed per patient/ chard. About 65% of the expert’s working time was needed for rounds, 15% for driving between the hospitals. The anti-infectives consumption of the 4 hospitals in the preintervention period amounted to 50 defined daily doses per 100 occupied bed days. The total consumption was reduced by 10% and of quinolones by 36%. The incidence of hospital-acquired CDI receded from 0.14 to 0.07 cases per 100 patient days (−50%, p = 0.001). The overall in-hospital mortality did not change. ConclusionsA single expert was able to implement a successfull ASP in 4 hospitals. While multidisciplinary antimicrobial stewardship teams are ideal for tertiary care hospitals, small hospitals need a more practical solution. This survey shows that one expert can be sufficient for several small hospitals even with the distances in a rural setting.

Implementation of infectious diseases rapid molecular diagnostic tests and antimicrobial stewardship program involvement in acute-care hospitals.

A survey of acute-care hospitals found that rapid molecular diagnostic tests (RMDTs) have been widely adopted. Although many hospitals use their antimicrobial stewardship team and/or guidelines to help clinicians interpret results and optimize treatment, opportunities to more fully achieve the potential benefits of RMDTs remain.

Optimization of microbial diagnostics by introduction of ablood culture standard operating procedure in the emergency department

EinleitungZentrale Notaufnahmen stellen die Eintrittspforte für viele stationär aufzunehmende Patienten in einem Krankenhaus dar und sind häufig der Ausgangspunkt für die antiinfektive Diagnostik und Therapie von Notfallpatienten. In dieser retrospektiven Untersuchung soll der Frage nachgegangen werden, wie die Etablierung einer Standard Operating Procedure (SOP) „Blutkulturen“ und deren Schulung die mikrobielle Diagnostik in einer zentralen Notaufnahme verbessern kann.MethodikIn einer Vorher-und-nachher-Untersuchung wurde über einen jeweils 3‑monatigen Zeitraum (11/2017 bis 01/2018 und 11/2018 bis 01/2019) die Anzahl der abgenommenen Blutkulturen, die Rate an Blutkulturen/1000 Fälle, die Anzahl positiver Blutkulturen und die Häufigkeit typischer Hautkeime analysiert. Im Zeitraum zwischen den evaluierten Zeitabschnitten wurde eine SOP „Blutkulturen“ in Zusammenarbeit mit dem Antibiotic-Stewardship(ABS)-Teams und der zentrale Notaufnahme entwickelt, implementiert und geschult. Ein positives Votum der Ethikkommission der Heinrich-Heine-Universität (2019-392-RetroDEuA) lag vor.ErgebnisseDie pflegerischen und ärztlichen Mitarbeiter wurden zu 92 % bzw. 93 % geschult. Die Anzahl der abgenommenen Blutkulturen stieg von 1757 auf 2872 um 64 % ebenso wie die Anzahl der Blutkulturen/1000 Fälle von 287 auf 481 (68 %). Die Anzahl der positiven Blutkulturen reduzierte sich von 18,6 auf 13,7 % (p < 0,05). Typische Hautkeime fanden sich in 34,4 % und 26,4 % der Fälle (p < 0,05).InterpretationDie durch Schulungen begleitete Einführung einer SOP „Blutkulturen“ in der zentralen Notaufnahme kann einen relevanten Beitrag zur antimikrobiellen Diagnostik leisten und sowohl die Quantität als auch die Qualität erhöhen.

Antibiotic Stewardship for Nursing: Can E-learning Be a First Step?

Background: The CDC and The Joint Commission have called for an interdisciplinary approach to antibiotic stewardship implementation. The healthcare team should consist of infectious disease physicians, pharmacists, infectious disease pharmacists, infection preventionists, microbiologists, and nurses. The scant literature to date has looked at nurses’ attitudes and beliefs toward participating in antibiotic stewardship and have identified several factors that contribute to the lack of uptake by nurses: lack of education around stewardship, poor communication among healthcare providers, and hospital or unit culture, among others. Additionally, nurses’ lack of interest in what would be more work or not within their scope of work was put forth as an additional factor by infection preventionists and pharmacists as a barrier to implementation. Method: An investigator-developed online survey was used to assess the usefulness of 3 investigator-developed educational e-learning modules that encompassed the role of nurses in antibiotic stewardship, pharmacy and laboratory topics related to antimicrobial stewardship, as well as the nurses’ attitudes toward their participation in such activities. Results: Participants took the survey after review of the 3 e-learning modules. The results indicate that, contrary to what pharmacists and infection preventionists thought, 82% of nurses felt they should contribute to and be part of the antimicrobial stewardship team. Additionally, after completing the modules, 73% felt more empowered to participate in stewardship discussions with an additional 23% wanting more education. 100% felt that they learned information that they could utilize in their everyday work. Barriers to implementation of stewardship activities on their unit included lack of education (41%), hospital or unit culture (27%), with only 4% citing they did not feel it was their job or that they had anything to contribute to a discussion. Also, 24% felt that there were no obstacles to participation. Conclusions: Surprisingly, most nurses who took this educational series and survey felt that they should be part of the antibiotic stewardship team. As cited previously from the literature, education and culture need to be addressed to overcome the nurses’ barriers to stewardship involvement. E-learning can provide an easy first step to educating nurses when time permits and can provide a good springboard for discussion on the units and with physicians and pharmacists. For a copy of the modules, please contact the author.Funding: NoneDisclosures: None