Suboptimal Use Of Antibiotics Research Articles

Antibiotic allergy de-labeling in the intensive care unit: The prospective ADE-ICU study

PurposeCritically ill patients in the intensive care unit (ICU) are frequently prescribed antibiotics, with many reporting an antibiotic allergy label, predominantly to penicillin. Mislabeling contributes to suboptimal antibiotic use, increasing multidrug-resistant organisms and Clostridium difficile infections, and increased hospital length of stay. This prospective study implemented an antibiotic allergy assessment and testing program in the ICU, independently of clinical immunology/allergy services. Materials and methodsTrained ICU staff prospectively identified and risk assessed eligible patients as having a non-immune mediated drug reaction, or a low, intermediate or high risk antibiotic allergy. Non-immune mediated reactions were directly de-labeled. Low-risk allergies underwent direct drug provocation testing, while intermediate-risk allergies included skin testing followed by drug provocation testing. High-risk allergies were confirmed without testing. ResultsOf 71 eligible patients, 62 underwent assessment. Antibiotic allergy de-labeling occurred in 48 of 51 patients (94 %) with a non-immune, low or intermediate risk allergy. High risk allergies were confirmed in 11 patients (18 %). The study resulted in increased penicillin use and decreased broad-spectrum antibiotic use. No adverse events occurred from testing. ConclusionsThis study shows the feasibility of ICU led antibiotic allergy assessment and testing, highlighting a potential model for implementation in settings lacking immunology/allergy services.

Knowledge and attitude factors influencing primary care clinicians' diagnosis, treatment and management of urinary tract infections in women: A qualitative ‘think’ aloud study in England

AbstractObjectivesThe present study aimed to identify factors related to knowledge and attitudes that influence primary care clinicians' decision‐making when diagnosing, treating, and managing suspected urinary tract infections (UTIs) in women. Understanding the factors that influence clinicians' decision‐making is important for maximising health outcomes in women and reducing suboptimal use of antibiotics and antimicrobial resistance.DesignA qualitative think‐aloud study design was employed.MethodsSemi‐structured qualitative interviews were conducted with primary care clinicians in England over Microsoft Teams. Interviews were transcribed and coded in two ways. First, clinicians' responses for each scenario were coded as either following (optimal), not following evidence‐based national guideline or incorrectly citing certain diagnosis, treatment, and management procedures (suboptimal). Second, the knowledge and attitude factors that influenced decision‐making were coded according to an empirically informed umbrella framework. Clinicians external to the study team reviewed the findings to promote their trustworthiness and utility.ResultsTen clinicians (six female) took part. Clinicians prescribing decisions were mostly influenced by knowledge rather than attitude factors. Despite clinicians expressing high awareness of relevant evidence‐based guidelines (a knowledge factor) and high confidence (an attitude factor), more than half of their decisions (60%) were suboptimal in some way thereby impacting women's health. Most clinicians relied on their experiential knowledge rather than using evidence‐based guidelines. Our results suggest that knowledge could impede adherence, for example, where local guidelines conflict with national guidelines of when to perform a urine dipstick test.ConclusionsSuboptimal prescribing decisions could result from a combination of different knowledge and attitude factors leading to negative outcomes in women's health such as inappropriate treatment of asymptomatic bacteriuria in women over 65 years old. To optimise antibiotic prescribing in women, policy‐level interventions could increase concordance across local and national guidelines, or more tailored individual‐level interventions could help clinicians recognise where their experiential knowledge causes deviations from evidence‐based guidelines when diagnosing, treating and managing UTIs.

Antibiotic Prescribing in Outpatient Settings: Rural Patients Are More Likely to Receive Fluoroquinolones and Longer Antibiotic Courses.

Suboptimal antibiotic prescribing may be more common in patients living in rural versus urban areas due to various factors such as decreased access to care and diagnostic testing equipment. Prior work demonstrated a rural health disparity of overprescribing antibiotics and longer durations of antibiotic therapy in the United States; however, large-scale evaluations are limited. We evaluated the association of rural residence with suboptimal outpatient antibiotic use in the national Veterans Affairs (VA) system. Outpatient antibiotic dispensing was assessed for the veterans diagnosed with an upper respiratory tract infection (URI), pneumonia (PNA), urinary tract infection (UTI), or skin and soft tissue infection (SSTI) in 2010-2020. Rural-urban status was determined using rural-urban commuting area codes. Suboptimal antibiotic use was defined as (1) outpatient fluoroquinolone dispensing and (2) longer antibiotic courses (>ten days). Geographic variation in suboptimal antibiotic use was mapped. Time trends in suboptimal antibiotic use were assessed with Joinpoint regression. While controlling for confounding, the association of rurality and suboptimal antibiotic use was assessed with generalized linear mixed models with a binary distribution and logit link, accounting for clustering by region and year. Of the 1,405,642 veterans diagnosed with a URI, PNA, UTI, or SSTI and dispensed an outpatient antibiotic, 22.8% were rural-residing. In 2010-2020, in the rural- and urban-residing veterans, the proportion of dispensed fluoroquinolones declined by 9.9% and 10.6% per year, respectively. The rural-residing veterans were more likely to be prescribed fluoroquinolones (19.0% vs. 17.5%; adjusted odds ratio (aOR), 1.03; 95% confidence interval (CI), 1.02-1.04) and longer antibiotic courses (53.8% vs. 48.5%; aOR, 1.19, 95% CI, 1.18-1.20) than the urban-residing veterans. Among a large national cohort of veterans diagnosed with URIs, PNA, UTIs, and SSTIs, fluoroquinolone use and longer antibiotic courses were disproportionally more common among rural- as compared to urban-residing veterans. Outpatient antibiotic prescribing must be improved, particularly for rural-residing patients. There are many possible solutions, of which antibiotic stewardship interventions are but one.

1766. Application of Defined Daily Dose to Antibiotic Prescribing in Massachusetts Jails

Abstract Background Minoritized populations experience increased risk of antimicrobial resistant infections in the community and are subjected to further risk of infections because of mass incarceration. At highest risk for infections are criminal-legal involved older adults, who experience increased social vulnerability and are often high users of medical care. Antimicrobial stewardship is recommended by the IDSA to reduce unnecessary or suboptimal antibiotic use but is rarely implemented in carceral settings. The defined daily dose (DDD) per 1000 patient days is a frequently used metric of calculating antibiotic prescriptions that can be used to benchmark and track impact of interventions. The goal of this research was to apply the DDD metric as related to 1000 jail inhabitants to 2021 antibiotics prescribing in Massachusetts jails. Methods After receiving approval from the Massachusetts Sheriffs Association, we requested de-identified antibiotics prescription records from the State Office of Pharmaceutical Services for 2021. We followed the World Health Organization guidance for DDD calculation. We grouped antibiotics into 7 categories. We estimated the yearly number of people incarcerated by monthly capacity and the average length of incarceration. Results We found heterogeneity in antibiotic use patterns at the jails (Figure 1). Certain jails (e.g., Jail 1) were high users of antibiotics, while other jails (e.g., Jail 6) were low users. We also found significant heterogeneity in the classes of antibiotics used across the jails. Certain jails appear to prefer cephalosporins (e.g., Jail 1) while others (e.g., Jail 8) frequently use fluoroquinolones. Conclusion Applying the DDD metric is feasible in the novel setting of jails and may be utilized to benchmark antibiotic usage. This proof of concept can inform future antimicrobial stewardship interventions in carceral settings. Disclosures Tara Bylsma, MD, Takeda Pharmaceuticals: My husband was employed by Takeda June-Aug 2021 as a summer MBA intern Shira Doron, MD, Sunovion: Advisor/Consultant.

1656. Impact of Pharmacist Intervention on Antibiotic Prescribing at Hospital Discharge for Community-Acquired Pneumonia, Urinary Tract Infection, and Skin and Soft Tissue Infections

Abstract Background The high incidence of suboptimal antibiotic use at transitions of care represents a novel area for antimicrobial stewardship for community-acquired pneumonia (CAP), urinary tract infection (UTI), and skin and soft tissue infections (SSTIs). The objective of this study was to investigate the role of a pharmacist intervention at discharge to improve antibiotic use. Methods This was a single-center, retrospective, crossover analysis of patients admitted to general medicine units from 11/1/21 to 3/31/22 with a diagnosis of CAP, UTI, or SSTI. The study was divided into two phases separated by a one-month washout. Each two-month phase included two pre-specified units, an intervention and control. During phase 2, the intervention and control units were switched. Patients on antibiotics identified for discharge were reviewed and interventions were communicated by the pharmacist to the provider. Interventions were made based on predefined guidance for oral step-down therapy and total duration. The primary outcome, discharge antibiotic days of therapy (DOT), was compared between the intervention and control cohorts. Secondary outcomes included total DOT, hospital length of stay (LOS), 30-day readmission, and appropriateness of drug selection, dose, and duration. Results Records of 161 patients were included in this study, 85 in the intervention cohort (47 in phase 1, 38 in phase 2) and 76 in the control (41 in phase 1, 35 in phase 2). Overall discharge DOT was 3 (IQR 0–4.5) in the intervention cohort and 3 (IQR 0-5) in the control cohort (P = 0.8), and overall total DOT was 7 (IQR 5-9) and 7 (IQR 5-10) respectively (P = 0.27). Patients in the intervention group were more likely to have appropriate total duration (61.2% vs 44.7%, P = 0.001) and discharge duration of antibiotics (67.1% vs 53.9%, P = 0.013) for all three indications based on predefined guidance. Hospital LOS was 4 (IQR 3-5) vs 5 days (IQR 3-6.3) in the intervention and control cohorts (P = 0.001) respectively, and a lower 30-day readmission (14.1% vs. 23.7%, resp.). Conclusion Despite similar antibiotic DOTs, pharmacist intervention at discharge appeared to improve overall antibiotic total duration and discharge duration for CAP, UTI, and SSTI. Opportunities to improve discharge stewardship processes should be further explored. Disclosures Joseph L. Kuti, PharmD, Abbvie: Honoraria|bioMeriuex: Advisor/Consultant|bioMeriuex: Grant/Research Support|Contrafect: Grant/Research Support|Entasis: Grant/Research Support|Merck and Co: Grant/Research Support|Roche Diagnostics: Grant/Research Support|Shionogi: Advisor/Consultant|Shionogi: Grant/Research Support|Shionogi: Honoraria|Summit: Grant/Research Support David P. Nicolau, PharmD, Shionogi: Grant/Research Support.

Optimizing antibiotic use in Indonesia: A systematic review and evidence synthesis to inform opportunities for intervention.

A major driver of antimicrobial resistance (AMR) and poor clinical outcomesis suboptimal antibiotic use, although data are lacking in low-resource settings. We reviewed studies on systemic antibiotic use (WHO ATC/DDD category J01) for human health in Indonesia, and synthesized available evidence to identify opportunities for intervention. We systematically searched five international and national databases for eligible peer-reviewed articles, in English and Indonesian, published between 1 January 2000 and 1 June 2021 including: (1) antibiotic consumption; (2) prescribing appropriateness; (3) antimicrobial stewardship (AMS); (4) consumers' and providers' perceptions. Two independent reviewers included studies and extracted data. Study-level data were summarized using random-effects model meta-analysis for consumption and prescribing appropriateness, effect direction analysis for antimicrobial stewardship (AMS) interventions, and qualitative synthesis for perception surveys. (PROSPERO: CRD42019134641). Of 9323 search hits, we included 100 reports on antibiotic consumption (20), prescribing appropriateness (49), AMS interventions (13), and/or perception (25) (8 categorized in >1 domain). The pooled estimate of overall antibiotic consumption was 134.8 DDD per 100 bed-days (95%CI 82.5-187.0) for inpatients and 121.1 DDD per 1000 inhabitants per day (10.4-231.8) for outpatients. Ceftriaxone, levofloxacin, and ampicillin were the most consumed antibiotics in inpatients, and amoxicillin, ciprofloxacin, and cefadroxil in outpatients. Pooled estimates for overall appropriate prescribing (according to Gyssens method) were 33.5% (18.1-53.4) in hospitals and 49.4% (23.7-75.4) in primary care. Pooled estimates for appropriate prescribing (according to reference guidelines) were, in hospitals, 99.7% (97.4-100) for indication, 84.9% (38.5-98.0) for drug choice, and 6.1% (0.2-63.2) for overall appropriateness, and, in primary care, 98.9% (60.9-100) for indication, 82.6% (50.5-95.7) for drug choice and 10.5% (0.8-62.6) for overall appropriateness. Studies to date evaluating bundled AMS interventions, although sparse and heterogeneous, suggested favourable effects on antibiotic consumption, prescribing appropriateness, guideline compliance, and patient outcomes. Key themes identified in perception surveys were lack of community antibiotic knowledge, and common non-prescription antibiotic self-medication. Context-specific intervention strategies are urgently needed to improve appropriate antibiotic use in Indonesian hospitals and communities, with critical evidence gaps concerning the private and informal healthcare sectors. Wellcome Africa Asia Programme Vietnam.

Patterns and Determinants of Antibiotic Use Behaviors among Rural Community Residents in Eastern China.

Inappropriate antibiotic use may lead to antibiotic resistance, which has become a serious global crisis. Addressing suboptimal antibiotic use in the general population can play a significant role in the fight against antimicrobial resistance. This study aims to describe antibiotic use and sources of acquisition, and to identify factors influencing antibiotic access among rural community residents in Eastern China. A cross-sectional survey was conducted from July to August 2020, and 1494 participants from two villages in Eastern China were enrolled. Information was obtained using face-to-face interviews with a structured electronic questionnaire. Chi-squared and multinominal logistic regression analysis were used to explore possible determinants. In total, 1379 participants were eligible for the analysis. In the past 12 months, nearly half the respondents had taken any antibiotic (48.4%), and this proportion varied across marital status and age group. Two thirds of them (59.9%) obtained antibiotics from medical facilities with a prescription when they last took antibiotics, while 17.7% and 22.4% chose retail pharmacies and other sources, respectively. Multinominal analysis found that a higher proportion obtained antibiotics outside medical facilities among those aged 15 to 44 years, unmarried, non-white collar workers, with more years of education, lower annual household income per capita and lower levels of antibiotic knowledge. The antibiotic use behavior of rural community residents in Eastern China remains suboptimal. Antibiotic use and access behaviors need to be further addressed. Effective antibiotic stewardship in non-medical facility sources and training programs targeted for rural Chinese is warranted in future.

International virtual confidential reviews of infection-related maternal deaths and near-miss in 11 low- and middle-income countries – case report series and suggested actions

BackgroundObstetric infections are the third most common cause of maternal mortality, with the largest burden in low and middle-income countries (LMICs). We analyzed causes of infection-related maternal deaths and near-miss identified contributing factors and generated suggested actions for quality of care improvement.MethodAn international, virtual confidential enquiry was conducted for maternal deaths and near-miss cases that occurred in 15 health facilities in 11 LMICs reporting at least one death within the GLOSS study. Facility medical records and local review committee documents containing information on maternal characteristics, timing and chain of events, case management, outcomes, and facility characteristics were summarized into a case report for each woman and reviewed by an international external review committee. Modifiable factors were identified and suggested actions were organized using the three delays framework.ResultsThirteen infection-related maternal deaths and 19 near-miss cases were reviewed in 20 virtual meetings by an international external review committee. Of 151 modifiable factors identified during the review, delays in receiving care contributed to 71/85 modifiable factors in maternal deaths and 55/66 modifiable factors in near-miss cases. Delays in reaching a GLOSS facility contributed to 5/85 and 1/66 modifiable factors for maternal deaths and near-miss cases, respectively. Two modifiable factors in maternal deaths were related to delays in the decision to seek care compared to three modifiable factors in near-miss cases. Suboptimal use of antibiotics, missing microbiological culture and other laboratory results, incorrect working diagnosis, and infrequent monitoring during admission were the main contributors to care delays among both maternal deaths and near-miss cases. Local facility audits were conducted for 2/13 maternal deaths and 0/19 near-miss cases. Based on the review findings, the external review committee recommended actions to improve the prevention and management of maternal infections.ConclusionPrompt recognition and treatment of the infection remain critical addressable gaps in the provision of high-quality care to prevent and manage infection-related severe maternal outcomes in LMICs. Poor uptake of maternal death and near-miss reviews suggests missed learning opportunities by facility teams. Virtual platforms offer a feasible solution to improve routine adoption of confidential maternal death and near-miss reviews locally.

1414. Real-World Study of Healthcare Resource Use and Costs Associated with Inappropriate and Suboptimal Antibiotic Use Among Females with Uncomplicated Urinary Tract Infection in the United States

BackgroundUrinary tract infections (UTIs) are the most common outpatient infection requiring medical care in the US; but, despite Infectious Diseases Society of America 2011 guidelines for treating uncomplicated UTI (uUTI), variation in prescribing practices still exists. Few studies have used real-world data (RWD) to evaluate uUTI-associated healthcare resource use (HRU) and costs. We examined HRU and direct costs associated with appropriate and optimal (AP&OP) and inappropriate or suboptimal (IA/SO) antibiotic (AB) prescribing in females with uUTI using US RWD.MethodsThis retrospective cohort study used RWD from IBM MarketScan (commercial/Medicare claims) to examine uUTI-related HRU and costs (inpatient, emergency room, outpatient, pharmacy) per index uUTI episode and during 1-year follow-up among females (age ≥ 12 years) diagnosed with uUTI from July 1, 2013–December 31, 2017 (index date). Patients had an oral AB prescription ± 5 days of the index date, and continuous health plan enrollment ≥ 6 months pre/1 year post-index date; those with complicated UTI were excluded. Patients were stratified by AB prescription as follows: AP&OP = guideline-compliant and correct duration; IA/SO = guideline non-compliant/incorrect duration or re-prescription/switch within 28 days.ResultsThe study included 557,669 patients. In the commercial population (n=517,664, mean age 37.7 years), fewer patients were prescribed AP&OP (11.8%) than IA/SO (88.2%) ABs, a trend also seen in the Medicare population (n=40,005, mean age 74.5 years). In both populations, adjusted average numbers of uUTI-related ambulatory visits and pharmacy claims were lower for the AP&OP cohort than the IA/SO cohort during index episode and 1-year followup (p < 0.0001, Table 1). In the commercial population, total adjusted uUTI-related costs were &194 (AP&OP) versus &274 (IA/SO; p < 0.0001); in the Medicare population, total adjusted uUTI-related costs were &253 (AP&OP) versus &355 (IA/SO; p < 0.0001) (Table 2).Table 1. uUTI-related HRU for commercial and Medicare populations calculated using the GLM model Table 2. uUTI-related costs for commercial and Medicare populations calculated using the GLM model ConclusionOverall uUTI-related HRU and costs in the US were low during index episodes and follow-up. However, females with uUTI prescribed IA/SO ABs were more likely to incur higher HRU and costs than those prescribed AP&OP ABs, suggesting an unmet need for training to optimize uUTI prescribing per US guidelines.Disclosures Madison T. Preib, MPH, STATinMED Research (Employee, Former employee of STATinMED Research, which received funding from GlaxoSmithKline plc. to conduct this study) Fanny S. Mitrani-Gold, MPH, GlaxoSmithKline plc. (Employee, Shareholder) Xiaoxi Sun, MA, STATinMED Research (Employee, Employee of STATinMED Research, which received funding from GlaxoSmithKline plc. to conduct this study) Christopher Adams, MPH, STATinMED Research (Employee, Employee of STATinMED Research, which received funding from GlaxoSmithKline plc. to conduct this study) Ashish V. Joshi, PhD, GlaxoSmithKline plc. (Employee, Shareholder)

Poor clinical outcomes associated with suboptimal antibiotic treatment among older long-term care facility residents with urinary tract infection: a retrospective cohort study

BackgroundAntibiotic use is associated with several antibiotic-related harms in vulnerable, older long-term care (LTC) residents. Suboptimal antibiotic use may also be associated with harms but has not yet been investigated. The aim of this work was to compare rates of poor clinical outcomes among LTC residents with UTI receiving suboptimal versus optimal antibiotic treatment.MethodsWe conducted a retrospective cohort study among residents with an incident urinary tract infection (UTI) treated in Veterans Affairs LTC units (2013–2018). Potentially suboptimal antibiotic treatment was defined as use of a suboptimal initial antibiotic drug choice, dose frequency, and/or excessive treatment duration. The primary outcome was time to a composite measure of poor clinical outcome, defined as UTI recurrence, acute care hospitalization/emergency department visit, adverse drug event, Clostridioides difficile infection (CDI), or death within 30 days of antibiotic discontinuation. Shared frailty Cox proportional hazard regression models were used to compare the time-to-event between suboptimal and optimal treatment.ResultsAmong 19,701 LTC residents with an incident UTI, 64.6% received potentially suboptimal antibiotic treatment and 35.4% experienced a poor clinical outcome. In adjusted analyses, potentially suboptimal antibiotic treatment was associated with a small increased hazard of poor clinical outcome (aHR 1.06, 95% CI 1.01–1.11) as compared with optimal treatment, driven by an increased hazard of CDI (aHR 1.94, 95% CI 1.54–2.44).ConclusionIn this national cohort study, suboptimal antibiotic treatment was associated with a 6% increased risk of the composite measure of poor clinical outcomes, in particular, a 94% increased risk of CDI. Beyond the decision to use antibiotics, clinicians should also consider the potential harms of suboptimal treatment choices with regards to drug type, dose frequency, and duration used.

Irrational use of antibiotics in Iran from the perspective of complex adaptive systems: redefining the challenge

BackgroundIrrational use of antibiotics is proving to be a major concern to the health systems globally. This results in antibiotics resistance and increases health care costs. In Iran, despite many years of research, appreciable efforts, and policymaking to avoid irrational use of antibiotics, yet indicators show suboptimal use of antibiotics, pointing to an urgent need for adopting alternative approaches to further understand the problem and to offer new solutions. Applying the Complex Adaptive Systems (CAS) theory, to explore and research health systems and their challenges has become popular. Therefore, this study aimed to better understand the complexity of the irrational use of antibiotics in Iran and to propose potential solutions.MethodThis research utilized a CAS observatory tool to qualitatively collect and analyse data. Twenty interviews and two Focus Group discussions were conducted. The data was enriched with policy document reviews to fully understand the system. MAXQDA software was used to organize and analyze the data.ResultWe could identify several diverse and heterogeneous, yet highly interdependent agents operating at different levels in the antibiotics use system in Iran. The network structure and its adaptive emergent behavior, information flow, governing rules, feedback and values of the system, and the way they interact were identified. The findings described antibiotics use as emergent behavior that is formed by an interplay of many factors and agents over time. According to this study, insufficient and ineffective interaction and information flow regarding antibiotics between agents are among key causes of irrational antibiotics use in Iran. Results showed that effective rules to minimize irrational use of antibiotics are missing or can be easily disobeyed. The gaps and weaknesses of the system which need redesigning or modification were recognized as well.ConclusionThe study suggests re-engineering the system by implementing several system-level changes including establishing strong, timely, and effective interactions between identified stakeholders, which facilitate information flow and provision of on-time feedback, and create win-win rules in a participatory manner with stakeholders and the distributed control system.

Adherence to antimicrobial prophylaxis guidelines in cardiac implantable electronic device procedures in two Australian teaching hospitals.

Objective This study investigated antibiotic prophylaxis (AP) guideline adherence and the cardiac implantable electronic device (CIED) infection rate in two major Australian public teaching hospitals. Methods In a retrospective observational study, the medical records of patients who underwent CIED procedures between January and December 2017 were reviewed (Hospital A, n = 400 procedures; Hospital B, n = 198 procedures). Adherence to AP guidelines was assessed regarding drug, dose, timing, route and frequency. Infection was identified using follow-up documentation. Results AP was administered in 582 of 598 procedures (97.3%). Full guideline adherence was observed in 33.9% of procedures (203/598) and differed significantly between Hospitals A and B (47.3% vs 7.1%, respectively; P < 0.001). Common reasons for non-adherence were the timing of administration (42.3% vs 60.6% non-adherent in Hospitals A and B, respectively; P < 0.001) and repeat dosing (19.3% vs 78.8% non-adherent in Hospitals A and B, respectively; P < 0.001). Twenty infections were identified over 626.6 patient-years of follow-up (mean (±s.d.) follow-up 1.0 ± 0.3 years). The infection rate was 3.19 per 100 patient-years (P = 0.99 between hospitals). Two devices were removed due to infection; no patients died from CIED infection. Conclusions Although the rate of serious CIED infection was low, there was evidence of highly variable and suboptimal antibiotic use, and potential overuse of AP. What is known about the topic? Previous Australian studies have revealed high rates of inappropriate surgical AP. CIED infections are potentially life threatening, but can be avoided through effective use of AP. However, prolonged durations of AP in this setting may also result in complications, including Clostridioides difficile infection. What does this paper add? This study, the first to our knowledge to focus specifically on adherence to Australian guidelines for AP in CIED procedures, highlighted several common issues between AP in this setting and surgical and procedural AP more broadly. 'Early' and 'late' dose administration and extended post-procedural AP were common. Only 34% of prescriptions fully adhered to the guidelines; practices varied significantly between the two hospitals. What are the implications for practitioners? There is a clear need for institution-specific antimicrobial stewardship strategies to optimise AP in CIED procedures, aligned with the Antimicrobial Stewardship Clinical Care Standard. Patients are being placed at potentially avoidable risk of both complications of extended durations of AP and CIED infection, although the rate of serious CIED infection was low. A standardised approach to surveillance of CIED infections and prospective multisite audits of AP in CIED procedures using a validated tool, such as the Surgical National Antimicrobial Prescribing Survey, are recommended to better inform evidence-based practice. Potential strategies to optimise guideline adherence include prescribing support in patients with immediate penicillin hypersensitivity or methicillin-resistant Staphylococcus aureus colonisation, optimising the in-patient location of drug administration to promote timely dosing, limiting inappropriate post-procedural prophylaxis and routine S. aureus screening and decolonisation.

123. Treatment Patterns and Prevalence of Inappropriate and Suboptimal Antibiotic Use Among Females with Uncomplicated Urinary Tract Infection in the US

BackgroundUrinary tract infections (UTIs) are the most common bacterial infection requiring medical care. Despite Infectious Diseases Society of America (IDSA) 2011 guidelines on antimicrobial agent selection and duration of therapy for uncomplicated UTI (uUTI), prescribing practices vary. Few studies have used real-world data (RWD) to evaluate inappropriate and suboptimal antibiotic use among patients treated for uUTI. We examined the prevalence of potentially inappropriate and suboptimal use of antibiotics among females with uUTI.MethodsThis retrospective cohort study examined the first-line use of antibiotics in females (age ≥ 12 years) with diagnosed uUTI in the US, identified using RWD from IBM MarketScan (commercial and Medicare claims) Jan 1, 2013–Dec 31, 2017. Index date was the date of uUTI diagnosis. Patients were included based on criteria in Table 1 and assigned to one of two groups: appropriate and optimal; or inappropriate or suboptimal antibiotic use. As uUTI is often treated empirically, appropriate use was defined based on IDSA 2011 guidelines on drug class, dose and therapy duration; antibiotic use was considered suboptimal if there was evidence of treatment failure (Table 2).Table 1. Key inclusion and exclusion criteria ResultsIn total, 557,669 patients with uUTI were included in the study; see Table 3 for baseline characteristics. Overall, 88.7% had inappropriate or suboptimal antibiotic use (Table 4). Of these, 86.1% had inappropriate use only, 2.1% had suboptimal use only, and 11.9% had both. Inappropriate drug class assignment was observed in 53.4% of patients with inappropriate use, 83.7% of whom were administered fluoroquinolones (a second-line agent) as first-line therapy. Among patients with inappropriate therapy duration: most given trimethoprim/sulfamethoxazole received 5- (27.2%), 7- (42.1%) or 10- (27.8%) days’ supply rather than the recommended 3 days; the majority given nitrofurantoin were provided a 7- (80.5%) or 10- (13.4%) day supply rather than the recommended 5 days; and 46.2% given fosfomycin received 3-days’ supply instead of the recommended 1 day.Table 3. Baseline characteristics Table 4. Patient disposition ConclusionIn the treatment of uUTI, the prevalence of inappropriate and/or suboptimal antibiotic use is very high which may have subsequent implications for patient health outcomes.DisclosuresYuexi Wang, M.Econ, GlaxoSmithKline plc. (Other Financial or Material Support, Funding)STATinMED Research (Employee) Fanny S. Mitrani-Gold, MPH, GlaxoSmithKline plc. (Employee, Shareholder) Lin Xie, MS, MA, GlaxoSmithKline plc. (Other Financial or Material Support, Funding)STATinMED Research (Employee) Mamta Jaiswal, PhD, GlaxoSmithKline plc. (Other Financial or Material Support, Funding)STATinMED Research (Employee) Xiaoxi Sun, MA, GlaxoSmithKline plc. (Other Financial or Material Support, Funding)STATinMED Research (Employee) Ashish V. Joshi, PhD, GlaxoSmithKline plc. (Employee, Shareholder)

EDITORIAL COMMENT

Standard urine cultures typically result in 48 hours or longer, and in practice this often leads to empiric antibiotic treatment of presumed infections, including the suboptimal use of antibiotics. In one study, 23% of emergency room patients with positive urine cultures received inappropriate empiric antibiotic treatment requiring later intervention following discharge. 1 Lingenfelter E Drapkin Z Fritz K et al. ED pharmacist monitoring of provider antibiotic selection aids appropriate treatment for outpatient UTI. Am J Emerg Med. 2016; 34: 1600 Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar In the current era of rampant antibiotic resistance, rapid diagnosis of infections and associated antibiotic resistance are desperately needed to expedite targeted treatment, and minimize overuse and inappropriate use of antibiotics. Culture-independent assays, such as the one described in the accompanying paper, may result in as few as 6 hours. The current study is a timely investigation comparing standard urinary cultures and a multiplex PCR-based assay in detecting bacteria in patients with UTI symptoms. The authors conclude that the multiplex PCR assay was noninferior to standard cultures in detection of bacteria in symptomatic patients. This study is a step forward in the implementation of culture-independent assays in the diagnosis and treatment of UTI.

Evaluating Penicillin Allergies Without Skin Testing.

An unconfirmed penicillin allergy is known to confer significant risk to patients. Only a small minority of patients labeled with penicillin allergy will be confirmed to be hypersensitive with the current reference standard test, an oral amoxicillin therapeutic dose challenge. Skin testing has been recommended prior to oral challenges to reduce the risk of severe acute challenge reactions. The rate of severe acute anaphylactic reactions with oral amoxicillin is currently extremely low. Unfortunately, penicillin skin testing, as commonly performed, has a high rate of false positive results. Encouraging skin testing in all individuals with an unconfirmed penicillin allergy, prior to a confirmatory oral challenge, would be technically difficult, make testing all individuals with an unconfirmed penicillin allergy very unlikely, and ultimately increase the risk to patients because of suboptimal antibiotic use. Most patients, who are appropriate candidates for a direct oral amoxicillin challenge, to confirm current penicillin tolerance, can be safely identified by their clinical histories. Higher risk individuals, those with a history of anaphylaxis or other acute onset potentially IgE-mediated reaction such as hives within 6h of the first dose of the last course of a penicillin, may benefit from properly performed puncture and intradermal skin testing, using commercially available penicilloyl-polylysine, prior to an oral challenge, if skin test negative. Direct oral amoxicillin challenges in low-risk individuals are well accepted by patients and a safe and effective part of penicillin allergy delabeling.

Antibiotic Prophylaxis in Cardiac Implantable Electronic Device Procedures: A Tale of Two Western Australian Hospitals

Australian guidelines recommend antibiotic prophylaxis (AP) for CIED procedures, however the level of adherence to these guidelines is currently unknown. This study aimed to investigate guideline adherence and the CIED infection rate in the two largest Western Australian public teaching hospitals. In a retrospective, observational study, medical records of patients who underwent CIED procedures at the two hospitals from January to December 2017 were reviewed. Adherence to the AP guidelines was assessed with respect to drug, dose, timing, route and frequency. CIED infection was identified using patient follow-up documentation. AP was administered in 589 (98.5%) of 598 procedures reviewed (Hospital A: n = 400, B: n = 198). Full guideline adherence was observed in 33.9% of procedures and differed significantly between the hospitals (A: 47.3% vs. B: 7.1%, p < 0.001). The most common reasons for non-adherence were timing of administration (A: 42.3% vs. B: 60.6% non-adherent, p < 0.001) and repeat dosing (A: 19.3% vs. B: 78.8% non-adherent, p < 0.001). Twenty infections were identified over 626.6 patient-years (PY) of follow-up (mean [SD] follow-up: 1.0 [0.3] years). The infection rate was 3.19 per 100 PY (p = 0.99 between the two hospitals). Two devices were removed; no patients died from CIED infection. There were no statistically significant associations between infection and any patient, procedure or AP-related factors. Infection occurred in 2.0% of AP guideline adherent and 4.1% of non-adherent cases (p = 0.27). Although the rate of serious infection was low, there was evidence of suboptimal antibiotic use, and notably potential overuse of AP in CIED procedures. Practices varied significantly between hospitals.

How do hospital respiratory clinicians perceive antimicrobial stewardship (AMS)? A qualitative study highlighting barriers to AMS in respiratory medicine

Suboptimal antibiotic use in respiratory infections is widespread in hospital medicine and primary care. Antimicrobial stewardship (AMS) teams within hospitals, commonly led by infectious diseases physicians, are frequently charged with optimizing the use of respiratory antibiotics, but there is limited information on what drives antibiotic use in this area of clinical medicine, or on how AMS is perceived. To explore the perceptions of hospital respiratory clinicians on AMS in respiratory medicine. In-depth interviews were conducted with 28 clinicians (13 doctors and 15 nurses) from two hospitals in Australia. Data were analysed thematically using the framework approach. Four key barriers to the integration of AMS processes within respiratory medicine, from the participants' perspectives, were identified: CONCLUSIONS: AMS processes are introduced in hospitals with established social structures and knowledge bases. This study found that AMS in respiratory medicine challenges and conflicts with many of these dynamics. If the influence of these dynamics is not considered, AMS processes may not be effective in containing antibiotic use in hospital respiratory medicine.

The intersection of antimicrobial stewardship and microbiology: educating the next generation of health care professionals.

With the alarming rise of antibiotic resistance, clinical professionals are called upon to manage antibiotic therapies using the most relevant and recent clinical and laboratory data. To this end, antimicrobial stewardship (AMS) programs aim to reduce unnecessary or suboptimal use of antibiotics while maximizing outcomes for the patient. For AMS programs to succeed, the active participation of clinical professionals at all levels of patient care is required. Although programs exist to train established clinicians in AMS, there is a paucity of literature on how and when to integrate AMS concepts and skills in pre-clinical and clinical coursework. Here, we discuss the crucial microbiology concepts and proficiencies that are necessary for building and supporting an AMS program. We provide recommendations for key points to include in clinical curricula in order to develop the necessary microbiology interpretation skills to participate in AMS. The influence of AMS programs on local organism susceptibility patterns is emphasized. The importance of antibiograms, rapid diagnostic testing and the practical interpretations of microbiology laboratory reporting are discussed in regard to prioritization in clinical curricula. We also review the current literature on instructional strategies for introducing AMS into clinical programs, and propose concepts that should be included in didactic coursework in order to provide a foundation for AMS education.

Using a simple point-prevalence survey to define appropriate antibiotic prescribing in hospitalised children across the UK

BackgroundThe National Health Service England, Commissioning for Quality and Innovation for Antimicrobial Resistance (CQUIN AMR) aims to reduce the total antibiotic consumption and the use of certain broad-spectrum antibiotics in...

PIN81 - Seasonal Variations of Outpatient Antibiotic use in Austria

Large seasonal variations concerning the prescription of antibiotics for systemic use (ATC group J01) in the outpatient sector may be a sign of overuse regarding virus infections. The aim of this study is to analyse those seasonal variations in Austria. The data comprise all filled prescriptions at the expense of the 19 statutory health insurance funds in Austria, covering more than 97% of the national population. Observation period lasts from 2013 to 2015, on a quarterly basis. The main measure of antibiotic use is the number of persons to whom at least one antibiotic drug has been prescribed. Additionally, analyses were conducted regarding patient age as well as antibiotic subgroups. The highest number of patients was observed in the first quarter of every year, followed by the fourth and the second quarter. Thus, 10.0% of the population received an antibiotic in 2013/Q3, while in 2013/Q1 the share amounted to 15.3% - this represents a fluctuation of 53%. In 2014 and 2015 the respective fluctuations were 34% and 63%. Variations were especially high among the youngest cohorts (age 0 to 9 years) – with up to 99%. Looking at the number of prescribed medication packages of the subgroups, fluctuations were highest for macrolides, lincosamides and streptogramins (J01F), with 58% more packages being prescribed in winter 2014/15 (2014/Q4, 2015/Q1) than in the previous summer (2014/Q2, 2014/Q3). The respective increase for cephalosporins (J01DB/DC/DD/DE) was 34%, and for penicillins (J01C) 32%. Compared to other European countries, Austria has a relatively low overall antibiotic use. Nonetheless, the seasonal variations are high. This might be an indicator for suboptimal use of antibiotics. As this is a growing public health concern, the use of antibiotics in the Austrian health system should be considered carefully by doctors as well as patients.