Stop Dates Research Articles

Prescription Practices and Usage of Antimicrobials in a Tertiary Teaching Hospital in Rwanda: A Call for Antimicrobial Stewardship

Background: Antimicrobial resistance (AMR) is a global problem that results in high morbidity and mortality, particularly in low- and middle-income countries. Inappropriate use of antimicrobials is a major driver of AMR. This study aimed to evaluate the rate and quality of antimicrobial prescription and use at the University Teaching Hospital of Kigali (CHUK), a tertiary-referral teaching hospital. Methodology: A point prevalence survey (PPS) of antimicrobial prescription was conducted using the Global PPS tool, including a healthcare-acquired infection (HAI) module. Results: On the day of the PPS, 39.3% (145/369) of inpatients were prescribed at least one antimicrobial. Out of the 259 prescribed antimicrobials, 232 (89.6%) were antibacterials, of which 151 (65.1%) belonged to the watch group of the WHO AWaRe classification. The top three antibiotics prescribed were cefotaxime (87; 37.5%), parenteral metronidazole (31; 13.4%), and meropenem (23; 9.9%). Stop or review dates for the prescribed antimicrobials were documented in 27/259 prescriptions (10.4%). Surgical prophylaxis (SP) was prescribed for longer than one day in 83.3% of 61 patients. Samples for culture were sent for 27.1% (63/232) of all the patients prescribed antibiotics. Conclusion: This PPS demonstrates multiple indicators of the poor use of antimicrobials, including the high prevalence usage of watch antibiotics and prolonged surgical prophylaxis and other poor-quality indicators. Thus, there is an urgent need for intervention to improve antimicrobial stewardship.

Prescribing a Green Future: A Review of Antimicrobial Waste in Pediatric Hospitals and Practices to Promote Healthcare Sustainability.

Pediatric hospitals are uniquely positioned to be impacted by antimicrobial waste. To explore this issue, we reviewed the current literature to identify the reasons, costs, and potential solutions to waste. Identified reasons for waste included weight-based dosing, medication order changes due to changing patient status, loss or expiration of doses, and medication errors. The cost of waste included financial costs, promotion of antimicrobial resistance, and generation of greenhouse gases. Proposed interventions to reduce waste included an early switch from intravenous to oral administration, required stop dates, standardized dosing times, and optimization of the pharmacy batching process. However, additional studies are needed to assess the potential correlation between these proposed interventions and waste reduction. Antimicrobial stewardship programs have been identified as a group that can play a crucial role in partnering to implement these interventions to potentially reduce antimicrobial waste and promote better healthcare sustainability.

Potential drivers of differences in breeding phenology as a component of life history strategies among coexisting species

Abstract Breeding phenology can have strong demographic consequences. Yet, the reasons why coexisting animal species differ in breeding phenology have received little attention. We tested selection pressures that underlie life history variation, such as age‐specific mortality, diet, and body size to explain breeding phenology of 16 coexisting songbird species in arid shrubland in South Africa. The average start and end dates for the earliest and latest species differed by 1.5 months, with a gradient among remaining species. Nest predation risk generally increased through the season, although species differed in seasonal patterns. Species with lower annual adult mortality, greater seasonal increases in nest predation, and greater nest predation rates had earlier start and stop dates, thereby reducing demographic risks. Species with higher adult mortality had larger brood sizes that require more food and they bred later when food was more abundant. Evolved timing of breeding thereby reflected risk management and food availability related to longevity and brood size. These factors may place unrecognized constraints on within‐species responses to climate change. Given the importance of phenology for fitness, phenology should be integrated as a core life history trait in future theory, and evolutionary constraints need to be considered in responses to climate change. Read the free Plain Language Summary for this article on the Journal blog.

36 Real-world treatment patterns and clinical outcomes of metastatic renal cell carcinoma patients post immune-oncology (IO) and Vascular Endothelial Growth Factor (VEGF) receptor targeted therapies

Abstract Background The metastatic renal cell carcinoma (mRCC) treatment landscape has rapidly evolved with approval of newer IO agents and VEGF targeted tyrosine kinase inhibitors (TKIs). However, real-world treatment patterns and clinical outcomes data for mRCC in post IO and TKI setting is limited. The objective of this study is to describe real-world treatment patterns and clinical outcomes of mRCC patients with a prior receipt of IO and TKI therapies in community oncology settings. Methods This retrospective cohort study utilized data from The US Oncology Network (iKnowMed) electronic health record database. The study cohort included adult mRCC patients receiving subsequent line of therapy (LOT; index date) post IO and TKI in combination or sequence between January-18’ and March-23’. All patients were followed from the index date until June-23’ to examine treatment pattern and estimate overall survival (OS), real-world time on treatment (rwToT), and real-world time to next treatment (rwTTNT) by line of therapy (LOT) and individual index regimen (with sample size ≥10). LOT was assigned based on patient’s absolute order of treatment regimen using start and stop dates. OS was defined as the time between Index date and the date of death due to any cause. Descriptive analyses were used to describe patient characteristics and treatment pattern. Time-to-event outcomes (OS, rwToT, and rwTTNT) from index date were summarized using Kaplan-Meier method with a log-rank test by individual regimens. A multivariate analysis using Cox proportional hazards model was performed to assess the association of index regimens with clinical outcomes after controlling for patient characteristics. Results The study cohort included 820 patients. The median age was 66 (range: 58, 72) years, 72.6% were male and 77.1% were Caucasian. Moreover, 60.0% had an Eastern Co-operative Oncology Group (ECOG) performance status of 0-1 and 74.5% had intermediate/poor IMDC risk score. Overall, 253 (30.9%) received index treatment in LOT2, 509 (62.1%) in LOT3 and 58 (7.1%) in LOT4+. The most common treatments post IO and TKI settings were cabozantinib (35.6%), everolimus plus lenvatinib (9.5%), ipilimumab plus nivolumab (7.4%), and axitinib (7.2%). The median OS for LOT2, LOT3, and LOT4 was (18.0, 17.8, and 28.6 months, respectively). The median rwTOT for LOT2 was 2.5 months, LOT3 was 3.5 months, and LOT4 was 6.2 months. The median rwTTNT for LOT2, LOT3, and LOT4 was 6.4, 7.7, and 11.5 months, respectively. Statistically significant difference across individual regimens was observed for OS, rwToT, and rwTTNT (Table). Conclusions This study presents one of the most comprehensive analysis of treatment patterns and clinical outcomes among mRCC patients in the post IO and TKI settings. TKI-with or without IO-based treatments were the most preferred treatments and associated with improved survival. Overall, clinical outcomes in the post IO and VEGF/TKI setting are limited, and novel treatments are needed in this patient population.

Standardized order set for the management of infective endocarditis.

Infective endocarditis (IE) is a potentially life-threatening infection that affects the inner lining of the heart, particularly the heart valves. Patients with preexisting heart conditions, damaged heart valves, or a history of intravenous drug use are at a higher risk of acquiring IE. A rural acute care facility reported that 68.75% of patients who had a methicillin-resistant Staphylococcus aureus infection were diagnosed with IE. Review of medical records showed that 65% of patients with IE did not have antibiotic start/stop dates and 51% were discharged before the 6-week completion date. The quality-improvement project used a pretest and posttest design. An order set was created based on evidence-based guidelines to assist with the management of patients with IE. The order set included administering intravenous (IV) antibiotics for a minimum of 6 weeks for patients with IE and included a set of recommended weekly follow-up laboratory tests. An order set with the standard of care and reminders in the electronic health records (EHRs) were implemented for the management of IE, including antibiotic start and stop dates and weekly follow-up labs. After implementation, there was an improvement in the completion of IV antibiotics, documentation of start/stop dates for IV antibiotics, and completion of recommended laboratory tests. An order set with the standard of care and reminders in the EHR reduced variations in care and improved patient outcomes by ensuring that all providers were following the same evidence-based guidelines for the management of IE.

Check of APpropriaTeness of Antimicrobial therapy In Nursing homes (CAPTAIN):a point prevalence study in Belgium.

The overall prevalence of antimicrobial therapy (AMT) in nursing homes is well described. However, less is known about the appropriateness of AMT in nursing home residents. Therefore, the Check of APpropriaTeness of antimicrobial therapy in nursing homes (CAPTAIN) study aimed to assess both prevalence and appropriateness of AMT in Belgian nursing homes. In a prospective, observational, point prevalence study, researchers documented prevalence and identified potentially inappropriate prescriptions (PIPs) by evaluating accordance of AMT with national guidelines. The severity of inappropriateness was assessed by a modified Delphi expert panel. Eleven nursing homes, including 1178 residents, participated in this study. On the survey day, 8.0% of residents took systemic AMT, primarily for urinary tract infections (54.2%), respiratory tract infections (36.5%), and skin and skin-structure infections (6.3%). About half of these prescriptions were used in prophylaxis (52.1%). Registration of indication and stop date was missing in 58.3% and 56.3% of AMTs, respectively. In 89.6% of the systemic AMTs, at least one discordance with national guidelines was identified, resulting in a total of 171 PIPs, with 49 unique PIPs. Of all unique PIPs, 26.5% were assessed with a high severity score (≥4). According to the expert panel, most inappropriate practice was starting AMT for cough without other symptoms. Inappropriate timing of time-dependent AMTs was common, but assessed as 'moderately severe'. One-third of systemic AMT exceeded the recommended duration. AMT in nursing homes is often not prescribed according to national guidelines, highlighting the need for future interventions to promote the rational use of AMT in this setting.

Barriers and Facilitators to Optimal Antibiotic Prescribing on Discharge from the Hospital to Nursing Homes

Background: Up to half of antibiotics used in nursing homes (NHs) are initiated in acute care hospitals prior to nursing home admission. Optimizing antibiotic prescribing on hospital discharge presents an opportunity to improve NH antibiotic use. We aimed to identify barriers and facilitators to optimal antibiotic prescribing on discharge from the hospital to NHs. Methods: This was a qualitative thread of a convergent parallel mixed methods study to identify high-value targets to optimize antibiotic prescribing on discharge from the hospital to NHs. We conducted 32 qualitative interviews: 16 with prescribers (9), pharmacists (6), and a care manager (1) from 3 acute care hospitals and 16 with advanced practice providers (12) and registered nurses/nurse managers (4) from 7 NHs in Oregon and Wisconsin. Interview participants were asked to describe their typical practice for prescribing antibiotics on discharge to NHs or admitting patients with antibiotic prescriptions from hospitals, and about barriers and facilitators for optimal antibiotic prescribing during these transitions. Interviews were audio recorded, transcribed verbatim, and analyzed by 3 investigators using the qualitative descriptive analysis Results: Hospital healthcare workers described that there are different practice flows for oral and intravenous (IV) antibiotic prescribing. IV antibiotic orders are typically routed to the infectious diseases (ID) specialists and ID pharmacists to review and verify appropriateness. There were minimal established workflows to review and verify oral antibiotic orders. Pharmacists appeared integral to optimal antibiotic prescribin; however, the high frequency of oral prescriptions and short turnaround times from discharge orders to transportation limited pharmacists’ abilities to review these orders. With limited pharmacist involvement, the quality of oral antibiotic prescription relied on the prescribers’ knowledge, and there was no systematic oversight for inexperienced prescribers or specialists who may not be familiar with the adequacy of antibiotic use for NH residents. NH participants perceived that most antibiotics prescribed from hospitals were appropriate. Yet, some commented that they occasionally observe inadequate or unusual prescriptions from newer prescribers or specialists. NH participants most common concern related to antibiotic prescriptions was missing information including unclear or lack of antibiotic indications or stop dates. NH participants also stated that the frequent need to contact the hospital to obtain missing information is challenging and burdensome. Conclusions: Qualitative interviews identified several barriers and facilitators to optimal antibiotic prescribing on discharge to NHs. These results will be used to develop an intervention to improve antibiotic prescribing during these transitions.

Ascertaining accurate exposure to aspirin and other antithrombotic medications using structured electronic health record data

BackgroundAscertaining accurately the exposure to antithrombotic medications for both research and quality initiatives has been challenging due to a multitude of reasons: aspirin, the most commonly used antithrombotic, is available over the counter in the United States. Additionally, antithrombotic medications are frequently interrupted for bleeding and procedures. ObjectivesWe aimed to develop and validate an algorithm to capture accurately the longitudinal exposure to antithrombotic medications including aspirin using the electronic health record. MethodsWe used the Medical Inpatient Thrombosis and Hemostasis cohort, which consists of primary care patients at a university medical center followed for a median of 6.2 years. Exposure to antithrombotic medications was captured using the medication reconciliation data linked to each ambulatory encounter. We developed an algorithm that used the taking “yes” or “no” tab as well as start and stop dates to define the duration of exposure for each medication. Eighty charts were reviewed and compared with results of the algorithm for validation. We estimated the sensitivity, specificity, and positive and negative predictive values. ResultsThe algorithm was 97% (95% CI, 94%-100%) sensitive and 95% (95% CI, 90%-100%) specific in identifying exposure to any antithrombotic medication. This translated to a 93% (95% CI, 85%-100%) positive predictive value and 98% (95% CI, 96%-100%) negative predictive value. When looking at aspirin alone, the sensitivity and the positive predictive value were 95% (95% CI, 88%-100%) and 87% (95% CI, 71%-100%). ConclusionThis current algorithm provides a new and easily adaptable strategy to capture accurately exposure to aspirin and other antithrombotic medications.

Sodium phenylbutyrate-taurursodiol access, adherence and adverse event in patients with amyotrophic lateral sclerosis: Experience at one center in the United States.

Sodium phenylbutyrate-taurursodiol (PB-TURSO) was recently approved for treating amyotrophic lateral sclerosis (ALS). Third-party payors' coverage policies are evolving, and adverse events are just being fully assessed. The goals of this study were to evaluate patients' experiences in obtaining and continuing PB-TURSO and assess adverse events and medication adherence. Medical records of 109 ALS patients who were considered PB-TURSO candidates by the treating physician at a tertiary ALS clinic from October 2022 to May 2023 were reviewed. Data was recorded for demographics, clinical, and insurance information. A survey was e-mailed to patients asking about out-of-pocket expenses for PB-TURSO, financial assistance, medication start and (if applicable) stop dates, and reasons for discontinuation. Insurance information was available for 91 patients [57 males (62%); mean age 64.8 years (range 25.7-88)]. Of 79 who applied for insurance approval, 71 (90%) were approved; however, 19 required 1-3 appeals. Among 73 patients with available data about medication status, 54 started PB-TURSO and 19 did not, most commonly due to personal choice or out-of-pocket expenses. About 44% of patients (24/54) stopped taking PB-TURSO, primarily due to adverse events. Monthly out-of-pocket expenses varied from $0 to $3500 and 36 patients qualified for financial assistance. Administrative and nursing staff devoted 7.2 hours/week to the insurance authorization process. Most patients received insurance approval for PB-TURSO, but one-fourth required appeals. Some out-of-pocket costs were very high. Investment of staff time was substantial. These findings have implications for insurance coverage of, and adherence to, future ALS treatments.

P018 A review of the use of anakinra in hyperinflammatory conditions at a large central London teaching hospital

Abstract Background/Aims The interleukin-1 receptor antagonist, anakinra, is increasingly used to treat inflammatory disorders. We recognized a need to provide patients with accurate information regarding the trajectory of their treatment. In this service evaluation project, we collected data on patients prescribed anakinra at a London teaching hospital over a 4-year period. Methods Patients included were started on anakinra to manage an inflammatory disorder between April 2019 and Feb 2023. Patients were identified by searching a high-cost drugs system. Data on indication for the drug, start and stop date(s) of treatment and any adverse effects were then collected using electronic patient records. Results 74 patients met inclusion criteria, 43 females and 31 males. Median age 38.5 years. 56 patients were treated for haemophagocytic lymphohisticytosis (HLH), 5 for Juvenile Idiopathic Arthritis (JIA) and 13 for Adult Onset Still’s Disease (AOSD). Median time on anakinra was 140.5 days (IQR 563.5), 1487.5 days (IQR 861) and 673 days (IQR 1017) for HLH, JIA and AOSD respectively. Of those treated for HLH, drivers and median duration of anakinra treatment for each respective driver were: infection (seven patients, 31 days), rheumatological (six patients, 785 days), haematological (26 patients, 36.5 days), iatrogenic (1 patient, 89 days), primary HLH (2 patients, 89 days), underlying rheumatological condition with infective/drug trigger (3 patients, 345 days), unknown (11 patients, 191 days). 9/56 patients with HLH remained on treatment at data collection - 4 with an unknown driver, two with AOSD, one with underlying Sjogren’s and a drug trigger, one with a haematological driver and one with primary HLH. 12/56 patients with HLH had died. Of those who died, eight had a haematological malignancy driving their condition, three had an infective driver and one an unknown driver. Five patients in our study had HLH driven by AOSD. Of these, 2/5 successfully stopped anakinra during the study period. Five patients (8.9%) with HLH required multiple courses of treatment with anakinra; three had lymphoma associated HLH, one primary HLH and one idiopathic HLH. Three patients were unable to continue with therapy due to side effects: neutropenia(1), rash (1), problems self-injecting (1). Conclusion From this data set we can begin to formulate answers to many commonly encountered questions regarding anakinra therapy. The length of time someone can expect to receive treatment with anakinra is significantly impacted by the indication for prescribing. Those with a haematological malignancy driving their HLH receive anakinra for the shortest time of all groups, usually while awaiting definitive treatment for their cancer, or before transition to palliative management. Some patients with AOSD driven HLH can safely stop treatment. Some patients may require multiple courses of treatment with anakinra for disease relapse. Adverse effects requiring treatment cessation are low in all groups. Disclosure I. Munro: None. R. Allen: None. A. Jones: None. J. Manson: None.

A229 DRUG PERSISTENCE WITH THERAPY OF ADALIMUMAB BIOSIMILAR, IDACIO, IN INFLAMMATORY BOWEL DISEASES

Abstract Background For post marketed medicine, drug persistence could be used as an indication for effectiveness and safety in routine clinical care over time. Non-adherence and non-persistence to treatment are associated with disease flares and may lead to disease progression among patients with inflammatory bowel diseases (IBD) in real-life. Aims The aim of this analysis was to explore drug persistence with an adalimumab biosimilar, Idacio, in IBD patients using the data collected by Fresenius Kabi patient support program (KabiCare) in Canada. Methods Patients with IBD enrolled in KabiCare and received at least one dose of adalimumab biosimilar, Idacio, were followed up from February 2021 to September 2023 in Canada. Medication initiation date and stop date, disease types (Crohn’s disease [CD], and ulcerative colitis [UC]) and patient treatment (categorized by naïve to biologic,or switched from other biologics) were recorded in the database. The stop date was the date when KabiCare was informed that medication was discontinued. The patients continuing medication were censored at the maximal follow-up date of analysis, September 12, 2022. Log-rank tests were used for KM (Kaplan-Meier) plot comparison to examine if there were differences in medication adherence between CD and UC, and between naïve group vs. switch group by disease. Results The study sample consisted of 1049 patients: 830 (79.1%) had CD, and 338 (32.2%) were in naïve group. KabiCare followed patients with CD for a median time of 512 days (interquartile range: 285-673 days; maximum: 895 days), and followed patients with UC for a median time of 492 days (interquartile range: 183-672 days; maximum: 925 days). At 800 days after starting the medicine, the drug persistence probability was similar for patients with CD and UC (At day-800: 76.6% vs. 67.6%, p=0.07). Among patients with CD, the drug persistence probability was higher in the switch group compared to naïve group (At day-800: 78.9% vs. 71.7%, p=0.0028). Among patients with UC, the drug persistence probably was similar in the switch group compared to naïve group (At day-800: 78.4% vs. 62.3%, p=0.34). Conclusions The drug persistence of adalimumab biosimilar, Idacio, was over 76% in patients with CD and over 67% in patients with UC 800 day after therapy initiation. Compared to patients in the naïve group, patients in the switch group were more likely to stay on adalimumab therapy. Funding Agencies None

1853 Improving treatment for urinary tract infections for older adults in the Health and Ageing Unit

Abstract Introduction A suspected urinary tract infection (UTI) is the most common reason to prescribe antibiotics in a frail older patient. Therefore, correct recognition and documentation of UTIs, as well prescribing of antibiotics, is important for optimising patient care. Methods We reviewed UTI antibiotic prescribing practice across the Health and Ageing Unit (HAU) wards at Kings College Hospital over a two-month period. Weekly data we collected from all patients commenced on antibiotics for a suspected UTI highlighted key areas for improvement. We designed and delivered a multifaceted educational intervention to all healthcare professionals caring for older adults across the HAU. This consisted of teaching sessions, distribution of posters, and board round reminders. Results A further two months of data post-intervention showed improvements in several outcomes. Correct prescribing rose from 61% to 93%. The number of prescriptions with stop dates went up from 50% to 68%. The number of patients with urine samples processed in the laboratory rose from 64% to 93%. We also saw an improvement in the management of patients with catheter associated UTIs. Conclusions A multidisciplinary team intervention of teaching and visual cues improved the management of UTIs. This shows the power of multifaceted educational interventions for improving the care of older adults.

P23 Benchmarking voriconazole therapeutic drug monitoring in adults and paediatrics

Abstract Background Voriconazole is the first-line agent for invasive aspergillosis and microbiology approved fungal infections. Voriconazole acts as both a substrate/inhibitor of several hepatic cytochrome P450 enzymes and demonstrates non-linear kinetics due to metabolism saturation. Inter-individual variability of voriconazole pharmacokinetics is high.1 Therapeutic drug monitoring (TDM) of trough plasma levels can mitigate treatment failure/toxicity. A therapeutic index between 1 and 5.5 mg/L is aimed for.1 An online protocol directs IV/oral dosing in line with British National Formulary guidance. An audit was conducted to benchmark protocol compliance. Standards Total compliance to the following standards was investigated for all voriconazole prescriptions: (i) suitable indication; (ii) documented stop or review date; (iii) protocol prescribed loading and maintenance dose; (iv) dose adjustment for non-therapeutic voriconazole trough level; and (v) trough sampling between 4 and 7 days since initiation. Methods Retrospective voriconazole dispensing data (April 2020–April 2022) was used to identify treated adult and paediatric patients. Correlating electronic prescribing and medicines administration (ePMA) system data was examined in line with standards. Patients receiving voriconazole prophylaxis or under 7 days total treatment were excluded from data collection. Descriptive statistics were used to describe patient characteristics and compliance with standards. Results In total, 47 patients (31 adults and 16 children) were identified. The IQR of age was 48 years. Total compliance was obtained to standard (ii) only. Overall, 94% of patients’ prescriptions possessed an appropriate indication and 6% were clinically appropriate with unclear documented indications. A total of 66% received protocol directed loading and maintenance doses, 6% were prescribed appropriate loading doses, without maintenance doses, and 28% received an inappropriate loading/maintenance dose. Within 4 to 7 days since treatment initiation, 55% had therapeutic trough levels; 27% had supratherapeutic levels, but only 33% of doses were reduced, whereas when subtherapeutic trough levels were encountered in 18% of cases, 75% of doses were increased. Overall, 47% had plasma trough levels taken within the recommended period; 30% did not have a trough level ordered, whilst the remaining 23% had sampling taken before 4 days or after 7 days. Conclusions Person and system interventions are required to improve pre-/post-prescription standards. Prescriber education focusing on indication documentation and recent patient body weight for dosing is required. Whereas an ePMA prescribing package incorporating protocol guidance, consecutive loading and maintenance doses, plus trough sampling orders should be trialled. Protocol integrated instructions on dosing adjustment as done for other TDM drugs should be explored. Occasional nursing omissions of both 12-hourly loading doses on Day 1 of treatment should be addressed with practice educators. Reliance on an external laboratory and third party to communicate trough sample results was associated with delays. This should be investigated further as a cause of dose adjustment issues. ePMA availability of samples, direct laboratory communication with prescribers/pharmacists and investigations into cost-effectiveness of internal laboratory assays should be considered. Interventions should be agreed with stakeholders and reaudit occur. Earlier sampling and dosing practices better representing local the patient population could be investigated further as part of an antimicrobial stewardship improvement project.

2206. Using Day-Level Registry Data on Patients in OPAT to Assess Heterogeneous Patterns of Time-Varying Antimicrobial Exposure and Unplanned Stopping across Multiple Infection Diagnoses, 2015-2022

Abstract Background Patients receiving outpatient parenteral antimicrobial therapy (OPAT) are often medically complex and require carefully tailored treatments to address severe and often concomitant infections. Methods We conducted a cohort study of patients enrolled in the University of North Carolina Medical Center OPAT program between March 2015 and December 2022 (2358 OPAT courses among 2072 unique patients). Patients were followed from OPAT regimen initiation (day 0) until observed treatment stop date, based on a grace period of 5 days to confirm discontinuation. Using hierarchical and mutually exclusive categorization schema, we classified patients into 1 of 10 infection diagnosis groups (Figure 1A), and classified all observed antibiotic cocktails (64 distinct antimicrobial medications comprising 520 distinct cocktails) into 18 treatments (Figure 1B). For each patient, we assessed their planned OPAT duration to classify their observed discontinuation as “planned,” “unanticipated early stop,” or “unanticipated prolonged treatment.” Stratified by infection diagnosis and treatment classifications, we used stacked bar charts to describe treatment heterogeneity, and Aalen-Johansen-based cumulative incidence curves to estimate occurrence of each type of discontinuation amid competing events. Results The cohort was 59.7% male with median age 56 years (IQR 45-66); the most common infection diagnosis was osteomyelitis +/- diabetic foot infection (28.1%, Figure 1A). Medication exposures were heterogeneous within and across infection diagnoses (Figure 1A and 1B). Median planned OPAT duration was 36 days (middle 90% 15-44). Overall cumulative incidence of unanticipated early discontinuation was 11.9%; overall incidence of unanticipated prolonged treatment was 22.9% (Figure 2). Conclusion Day-level data on medication use in this registry provided evidence of heterogeneity in medication exposure and unplanned discontinuation from OPAT, within and across infection diagnoses. These data highlight the need for multi-layered ascertainment of medication exposure, microorganisms, and infection diagnosis in this medically complex patient population to inform surveillance for adverse effects and comparative effectiveness research for post-discharge antibiotic treatment. Disclosures Asher J. Schranz, MD, MPH, WoltersKluwer: Honoraria Alan C. Kinlaw, PhD, MSPH, Genentech: Grant/Research Support

A comprehensive point prevalence survey of the quality and quantity of antimicrobial use in Chinese general hospitals and clinical specialties

Antimicrobial resistance (AMR) is a serious, worldwide public health crisis. Surveillance of antimicrobial use forms part of an essential strategy to contain AMR. We aimed to conduct a national point prevalence survey (PPS) on antimicrobial use, and to compare this data with similar international surveillance programs to provide a reference for future AMR strategy development in China. Twenty general hospitals encompassing 10,881 beds and 10,209 inpatients around the country participated the survey using a standardized protocol, at 8am of someday from October 10th to November 31st, 2019. Of the patients, 37.00% (3777/10209) received antimicrobial agents, 31.30% (1630/5208) had surgical operations, and 76.63% (1249/1630) received prophylactic antibiotic. The prevalence of antimicrobial use in medical, surgical, and intensive care units (ICU) patients was 38.84% (1712/4408), 32.07% (1670/5208), and 66.61% (395/593), respectively. Of prescriptions, 5.79% (356/6151) were made in the absence of indication. The intensity of antimicrobial use was 61.25 DDDs/100 patient days, while the intensity of use in internal medicine, surgery, and ICU were 67.79, 45.81, 124.45 DDDs/100 patient days, respectively. Only 11.62% (715/6151) of prescriptions had a reason described in the patient record. Furthermore, 8.44% (210/2487), 14.19% (424/2989), and 12% (81/675) of the prescriptions in internal medicine, surgery, and ICU had a recorded indication, respectively. The review and stop date recorded for antimicrobial therapy was 43.73% (1976/4518). Of the patients, 38.07% (1438/3777) received combination therapy. The classes of antimicrobials prescribed were limited, and the proportion of prescriptions encompassed by the top 20 antimicrobial agents was 75.06% (4617/6151). The prevalence of antimicrobial use in China is close to that of Sweden, the UK, and Canada, but lower than that in India, and higher than that in Switzerland. The data described in this report indicate that the quality of antimicrobial prescriptions requires improvement in China. Further, hospitals should implement professional interventions to improve the rational use of antimicrobials.

Treatment Persistence of Apremilast Among Patients with Psoriatic Arthritis.

Persistence in drug therapy reflects treatment effectiveness and tolerability. We aim to estimate the persistence of apremilast prescribed to patients with psoriatic arthritis (PsA) and to identify characteristics associated with treatment discontinuation in a real-world setting. Patients with PsA treated with apremilast from January 2016 were identified from a large health database and followed until medication stop date (using 3-months grace period), death or the end of observation period (June 2021). Demographic data, Charlson comorbidity index and concomitant and previous use of conventional and biologic DMARDs were extracted. The reasons for drug discontinuation were manually retrieved from patient charts. Time to discontinuation was estimated using survival analysis using Kaplan-Meier functions. Overall, 568 PsA patients treated with apremilast were identified. The mean age was 55.3±14.0 years, of whom 332 (58.5%) were females, 38.4% were obese (BMI>30), 75.2% had a Charlson comorbidity index>1, 24.1% were on concomitant treatment with methotrexate and 72.4% were biologic naïve. The median persistent period was 6.1,95% CI (5.2-6.9) months in which only 16.9% remained persistent on apremilast. No difference was found with regard to age, sex, socioeconomic status, ethnicity and obesity between patients who were persistent compared to patients who discontinued apremilast. Concomitant treatment with methotrexate and prior history of biologic therapy did not affect drug persistency (log rank P=0.957 and 0.082, respectively). Causes for treatment discontinuation were due to lack of skin efficacy in 19.4%, lack of joint efficacy in 33.3%, combined skin and joint inefficacy at 2.3% and due to side effects in 24.1%. In this large observational retrospective cohort of patients treated with apremilast, a relatively low drug persistence was observed with 6-month and 1-year survival rates of 50.3% and 31.3%, respectively. Treatment discontinuation was mainly due to joint inefficacy, advocating for more studies for proper patient selection to assure treatment effectiveness and persistency.

An Assessment of Comparative Medication Durability in Inflammatory Bowel Disease Patients With and Without Co-morbid Psoriasis, Rheumatoid Arthritis, and/or Enteropathic Arthritis.

Patients with inflammatory bowel disease (IBD) are at increased risk for many co-morbid diseases. However, little is known about durability of IBD medications in patients with co-morbid diseases. Determine medication durability in IBD patients with and without psoriasis, rheumatoid arthritis, and/or enteropathic arthropathy. All patients with at least three ICD-9 or 10 diagnoses for IBD were included in the cohort. The risk factors of interest were a co-morbid diagnosis of psoriasis (IBD-Ps), rheumatoid arthritis (IBD-RA), and/or enteropathic arthritis (IBD-EA). Medication durability was defined as days of medication use, calculated using order start and stop dates from the electronic medical record. Significant differences were tested using the Wilcoxon rank sum test for continuous variables and Fisher's exact test or Pearson's Chi-squared test, as appropriate, for categorical variables. Boxplots were constructed for graphical interpretation of results. In the psoriasis group, there were 481 patients with 831 medication exposures [131 IBS-Ps (16%), 700 IBD only (84%)]. The median days of medication use were numerically higher in the IBD-Ps group for all therapies [anti-TNF: 1109 vs 861 (p = 0.17); anti-IL-12/23: 984 vs 834 (p = 0.33); JAKi: 682 vs 230 (p = 0.13)], anti-TNF/IM: 370 vs 202 (p = 0.57), except anti-integrin therapy [214 vs 470 (p = 0.08)]. When restricting to UC only, patients with co-morbid again Ps had a significantly shorter duration on anti-integrin therapy (84 vs 456days, p = 0.02). While not reaching statistical significance, there was a distinctly longer medication duration on JAKi therapy (910 vs 317, p = 0.10). When restricting to patients with CD only, no results reached statistical significance though there was a trend towards longer anti-TNF durability in CD-Ps (1340 vs 1000days, p = 0.098). There were no differences in medication durability in IBD-RA or IBD-EA patients. Larger studies investigating medication durability of JAKi and anti-integrin therapy in IBD patients with psoriasis would be beneficial given noteworthy trends towards increased and decreased durability, respectively.

Antibiotic use and quality indicators of antibiotic prescription in Bhutan: a point prevalence survey using the Australian National Antimicrobial Prescribing Survey tool.

The National Action Plan on Antimicrobial Resistance in Bhutan promotes the rational use of antibiotics. It is important to establish baseline data on the use of antibiotics and the quality indicators of antibiotic prescriptions to identify where improvement efforts may need to be focused. To describe the prevalence and patterns of antibiotic prescription and establish baseline data regarding quality indicators of antibiotic prescriptions in four major hospitals in Bhutan. This was a point prevalence survey of antibiotic use among inpatients in June 2022 conducted using the Australian National Antibiotic Prescribing Survey (NAPS). There were 314 patients (41.5%) receiving at least one antibiotic on the audit day. Among prescriptions reviewed, 278 (88.5%) had indications for use documented, 102 (32.5%) had a review or stop date documented and 120 (38.2%) had microbiology samples collected prior to antibiotics. Ceftriaxone (68; 21.7%), cefazolin (41; 13.1%) and metronidazole (32; 10.2%), were the common antibiotics prescribed. The most common indications for use were surgical prophylaxis (42; 13.4%), community-acquired pneumonia (39; 12.4%) and sepsis (26; 8.3%). There were 125 prescriptions (39.8%) that were compliant with national/therapeutic antibiotic guidelines and 169 (53.8%) where antibiotic prescriptions were appropriate. This study identified key areas for targeted interventions in antimicrobial stewardship programmes in Bhutan. The prevalence of antibiotic use, indications for use, and drug choices were similar to data from other countries. Documentation plans for durations of use, prolonged surgical prophylaxis and concordance of choices with guideline recommendations present opportunities for improvement.

Decision-making regarding antibiotic therapy duration: An observational study of multidisciplinary meetings in the intensive care unit

PurposeAntibiotic therapy is commonly prescribed longer than recommended in intensive care patients (ICU). We aimed to provide insight into the decision-making process on antibiotic therapy duration in the ICU. MethodsA qualitative study was conducted, involving direct observations of antibiotic decision-making during multidisciplinary meetings in four Dutch ICUs. The study used an observation guide, audio recordings, and detailed field notes to gather information about the discussions on antibiotic therapy duration. We described the participants' roles in the decision-making process and focused on arguments contributing to decision-making. ResultsWe observed 121 discussions on antibiotic therapy duration in sixty multidisciplinary meetings. 24.8% of discussions led to a decision to stop antibiotics immediately. In 37.2%, a prospective stop date was determined. Arguments for decisions were most often brought forward by intensivists (35.5%) and clinical microbiologists (22.3%). In 28.9% of discussions, multiple healthcare professionals participated equally in the decision. We identified 13 main argument categories. While intensivists mostly used arguments based on clinical status, clinical microbiologists used diagnostic results in the discussion. ConclusionsMultidisciplinary decision-making regarding the duration of antibiotic therapy is a complex but valuable process, involving different healthcare professionals, using a variety of argument-types to determine the duration of antibiotic therapy. To optimize the decision-making process, structured discussions, involvement of relevant specialties, and clear communication and documentation of the antibiotic plan are recommended.

796-P: Real-World Persistence with GLP-1 RA Treatment in Patients with Type 2 Diabetes Mellitus (T2DM) and Advanced Chronic Kidney Disease (CKD)

Guidelines (ADA 2023 and KDIGO 2020) recommend treatment with GLP-1RAs in advanced CKD and ESRD because of their cardiovascular benefits, low risk of hypoglycemia, and potential renal benefits. GLP-1RA are vastly under-prescribed in this population, mainly due to concerns related to tolerability. We compared persistence rate with GLP-1RA vs dipeptidyl peptidase 4 inhibitors (DPP-4i) in this population. We extracted EHR data from a university health system from patients with T2DM and GFR <30 treated with either GLP-1RA or DPP-4i (2012- 2022). All charts were manually reviewed to confirm treatment start & stop date and reason for discontinuation. At the time of treatment initiation, those treated with GLP-1RA (N=149) vs DPP-4i (N=87) were younger, more likely to be female (51% vs 44%) and had a higher BMI. Only 12.7% and 9.2% of patients discontinued treatment with GLP-1RA and DPP-4i, respectively, within 180 days of initiation. The average treatment duration was 1036 and 1109 days with 34.9% and 54% having discontinued treatment at the time of data extraction. The maximum tolerated dose of GLP-1RA were comparable to that expected in patients without CKD (Table). Persistence with GLP-1RA treatment in patients with T2DM and advanced CKD is similar to DPP-4i and the vast majority tolerated the highest approved dose of GLP-1RA, confirming their tolerability in this population. Disclosure F.Sidra: None. D.Xie: None. S.Agarwal: None. I.Lingvay: Advisory Panel; Novo Nordisk A/S, Lilly Diabetes, Boehringer-Ingelheim, Sanofi, Consultant; Carmot Therapeutics, Inc., Merck Sharp & Dohme Corp., Janssen Scientific Affairs, LLC, Pfizer Inc., Intercept, Intarcia, Valeritas, TargetRWE, Shionogi, Zealand Pharma, Structure, Bayer, Research Support; Novo Nordisk A/S, Boehringer-Ingelheim.