scholarly journals 19. A Global Point Prevalence Survey of Antimicrobial Use in Neonatal Intensive Care Units

2020 ◽  
Vol 7 (Supplement_1) ◽  
pp. S10-S10
Author(s):  
Pavel Prusakov ◽  
Debra A Goff ◽  
Phillip Wozniak ◽  
Pablo J Sanchez
Keyword(s):  
Antimicrobial Stewardship ◽  
Antimicrobial Therapy ◽  
Point Prevalence ◽  
Initial Assessment ◽  
Definitive Treatment ◽  
P Value ◽  
Antimicrobial Use ◽  
Site Location ◽  
Prevalence Survey ◽  
Research Grant

Abstract Background Antimicrobials are one of the most commonly used medications in the NICU. We aimed to gather baseline global data on antimicrobial use to facilitate subsequent antimicrobial stewardship efforts. Methods We conducted a one-day global NICU point prevalence study on July 1, 2019 with a 30-day follow up. Data collection included patient demographics, antimicrobial therapy, site location, antimicrobial stewardship (AS) practices as well as the duration of antimicrobial therapy and in-hospital mortality were recorded. Results Eighty-one NICUs from twenty-eight different countries identified 2,163 admitted patients of which 570 (26%) were prescribed at least one antimicrobial. Three NICUs did not have any patients on antimicrobial therapy, all had less than 20 patients admitted. Level 3 and Level 4 NICUs comprised 51% and 48% respectively. Delivery units comprised 74%, the rest were referral centers. AS programs were in place in 62% of the hospitals and 47% of the units had NICU specific initiatives. Patients were on average 32.5 weeks gestational age (+/-5.3 SD), with birth weight of 1976 grams (+/- 1022 SD), and were 32 days (+/-65 SD) postnatal age at the time of the study. Antibiotics were the most frequently used medication in 92% of patients with 931 antibiotics prescribed on the assessment day. Hospitals with any NICU AS initiative had significantly lower rates of antibiotic utilization compared to NICUs without AS (21% and 32%; p-value: < 0.01). Of those on antibiotic therapy, ampicillin, gentamicin and amikacin were prescribed to 41%, 34%, and 21% of patients respectively. When only definitive treatment was evaluated, vancomycin, amikacin, and meropenem were the highest prescribed antibacterial agents at 25%, 19%, and 19% respectively. At the initial assessment, study participants indicated either 3 or 7 days (37% and 26%) for planned duration. Actual treatment duration for empiric and definitive treatment, was 7 and 14 days (29% and 19%) When comparing patients who had an established treatment course at the time of the initial assessment, the final length of treatment for culture negative sepsis was 7 (IQR:5–10) and culture positive sepsis was 11 days (IQR:10–14; p-value: 0.07). Conclusion Benchmarking global antimicrobial use is crucial for improving NICU-AS practices. Disclosures Pavel Prusakov, PharmD, Merck (Research Grant or Support) Debra A. Goff, PharmD, Merck (Research Grant or Support)

Point Prevalence Survey of Antimicrobial Prescription Patterns in a Pediatric Tertiary-Care Unit in Thailand 2019

2021 ◽  
Vol 104 (9) ◽  
pp. 1476-1482
Keyword(s):  
Antimicrobial Stewardship ◽  
Point Prevalence ◽  
Audit And Feedback ◽  
Antimicrobial Use ◽  
Prospective Audit ◽  
Prevalence Survey ◽  
Prescription Patterns ◽  
Point Prevalence Survey ◽  
Stewardship Program ◽  
Prospective Audit And Feedback

Background: Surveillance data is an essential part of antimicrobial stewardship programs (ASP). Objective: To describe and compare prescription patterns of antibiotics after a 3-years implementation of an ASP using prospective audit and feedback. Materials and Methods: The authors conducted a point prevalence survey (PPS) of antibiotic prescriptions at a 200-bed pediatric unit at King Chulalongkorn Memorial Hospital. A standardized study protocol from the Global Antimicrobial Resistance, Prescribing, and the Efficacy in Neonates and Children (GARPEC) project was used. The authors reviewed medical charts of hospitalized children of less than 18 years of age, using a point prevalence method on the 15 of February, May, August, and November 2019. Endpoints measures included rate of antimicrobial prescriptions and type of antimicrobial use, stratified by neonatal and pediatric ward types. Rate of antimicrobial prescriptions will be compared with historical data form PPS in the same institute collected in 2016. Results: In 2019, the medical records of 269 neonates and 409 children hospitalized were reviewed. The proportion of children receiving antibiotics in neonatal units overall was 18.6% (95% CI 14.1 to 23.8), of which ampicillin or gentamicin (52.0%) was the most common regimen. Rate of antibiotic prescriptions in general pediatric wards was 46.5%, with third generation cephalosporins being the most used antibiotics. Prescription rate in the oncology ward was 52.9% with antipseudomonal agents or meropenem being the most prescribed antibiotics. Prescription rates in the pediatric intensive care unit (PICU) was 88.9%, with meropenem being the most used antibiotic. Compared to a previous PPS study in 2016, prevalence of antimicrobial use was higher in general pediatric wards at 46.5% versus 37.2% (p=0.02) and PICU at 88.9% versus 67.7% (p=0.007). Conclusion: The prevalence rates of antimicrobial use in pediatric wards increased despite implementation of a prospective audit and feedback antibiotic stewardship program. Other measures are needed to reduce the unnecessary prescriptions. Keywords: Antimicrobial; Antimicrobial stewardship program; Pediatric; Point prevalence survey

scholarly journals 2034. Standardized Point Prevalence Survey on Antibiotic Use to Inform Antimicrobial Stewardship Strategies in the Caribbean

2019 ◽  
Vol 6 (Supplement_2) ◽  
pp. S683-S684
Author(s):  
Jenny Hsieh ◽  
Hatim Sati ◽  
Pilar Ramon-Pardo ◽  
Nienke Bruinsma ◽  
Marcelo F. Galas ◽  
...  
Keyword(s):  
Antimicrobial Stewardship ◽  
Antibiotic Use ◽  
Point Prevalence ◽  
Prescribing Patterns ◽  
Antibiotic Prescribing ◽  
Antimicrobial Use ◽  
Feedback Systems ◽  
Prevalence Survey ◽  
Local Capacity ◽  
The Caribbean

Abstract Background Inappropriate use of antimicrobials is one of the core contributors to antimicrobial resistance. While hospitals create high selection pressures on bacteria due to the high quantity and broader spectrum of antibiotics used, information on antimicrobial use at the patient level in the Caribbean is sparse. In response, PAHO implemented a standardized WHO methodology to engage national leaderships, build local capacity, and facilitate the use of data to inform antimicrobial stewardship programs (ASP) in the Caribbean. Methods Point prevalence surveys (PPS) were performed in four acute care hospitals in Barbados, Guyana and Saint Lucia between June and July 2018. Medical records of all inpatients were reviewed to collect information on antibiotic use, indications and use of laboratory services (Figure 1). A hospital questionnaire was used to assess hospital infrastructure, policy and practices, and monitoring and feedback systems (Figure 2). Training on PPS methods and electronic data collection tool in REDCap™ were provided to build local capacity and identify potential ASP leaderships. A standardized data validation, analysis and reporting system was built in R to streamline the process. Results and recommendations were disseminated to national authorities and stakeholders to support hospital and national decision-making and training for healthcare providers (Figure 3). Results A total of 60 physicians, nurses, pharmacists, laboratory technicians, and infection control specialists were trained and participated in the PPS. The survey collected records of 816 patients in which 442 (54%) were females and 374 (46%) were males. In total, 356 (44%) patients received 551 antibiotics. Overall, 300 (75%) of 398 indications for antibiotic use were treatment and 72 (18%) were prophylaxis. A higher use of parenteral antibiotics (79%) was observed compared with oral antibiotics (21%). Antibiotic prescribing patterns differed across hospitals. The most commonly used antibiotics were metronidazole (12%) and amoxicillin/clavulanate (11%). Conclusion The PPS method provided a feasible and effective way to collect baseline data and identify target areas for interventions. Engaging national leaderships and building local capacity offered a sustainable way in optimizing antimicrobial use in resource-limited settings. Disclosures All authors: No reported disclosures.

scholarly journals Antimicrobial Use at Acute Care Hospitals in Nova Scotia: A Point Prevalence Survey

2018 ◽  
Vol 71 (4) ◽  
Author(s):  
Emily Black ◽  
Heather Neville ◽  
Mia Losier ◽  
Megan Harrison ◽  
Kim Abbass ◽  
...  
Keyword(s):  
Nova Scotia ◽  
Antimicrobial Agent ◽  
Acute Care ◽  
Antimicrobial Stewardship ◽  
Antimicrobial Agents ◽  
Treatment Guidelines ◽  
Point Prevalence ◽  
Antimicrobial Use ◽  
Prevalence Survey ◽  
Point Prevalence Survey

<p><strong>ABSTRACT</strong></p><p><strong>Background:</strong> Point prevalence surveys are used to monitor antimicrobial use and identify targets for improvement through antimicrobial stewardship activities. Few studies have evaluated antimicrobial use in Nova Scotia acute care institutions.</p><p><strong>Objectives: </strong>To determine the prevalence and characteristics of antimicrobial use in Nova Scotia hospitals.</p><p><strong>Methods:</strong> A point prevalence survey was conducted between June and November 2015 for patients admitted to hospitals with at least 30 acute care beds. On each survey day, charts were reviewed to identify patients receiving antimicrobial agents on that day. Data were gathered on the type of antimicrobial agent prescribed, route of administration, intended duration of use, and indication. Adherence to regional and local treatment guidelines was assessed. Results were summarized descriptively. Findings were compared using the Fisher exact test or the Cochran–Armitage trend test.</p><p><strong>Results:</strong> Twelve of the 13 eligible hospitals participated, and a total of 1499 patient charts were examined. The overall prevalence of antimicrobial use was 30.6% (458/1499). The prevalence of antimicrobial use differed<br />significantly according to area of specialty, with the highest prevalence occurring in intensive care wards (47.2%, 50/106) and surgical wards (43.4%, 179/412), as compared with medical wards (27.9%, 192/687) and “other” specialty wards (11.1%, 32/289) (p &lt; 0.001). Among the 520 indications for antimicrobial use, the most common was respiratory tract infection (81 or 15.6%). In total, 660 antimicrobial agents were prescribed to the 458 patients; a third of these patients (152 or 33.2%) received more than 1 antimicrobial agent. The class of antimicrobials most frequently prescribed was “other beta-lactam antimicrobials” (31.2%, 206/660). The majority of antimicrobials (62.0%, 409/660) were prescribed for administration via the parenteral route. Adherence to regional treatment guidelines was 29.9% (26 of 87 indications analyzed). Documentation of indication was lacking for 104 (20.0%) of the 520 indications, and documentation of the intended duration of antimicrobial use was lacking for 326 (62.7%) of the 520 indications.</p><p><strong>Conclusions:</strong> Antimicrobial agents were prescribed for about one-third of acute care patients in Nova Scotia. Specific targets for improvement in antimicrobial use include decreases in prescribing of broad-spectrum and parenteral antimicrobials, better adherence to guidelines, and improved documentation. In developing initiatives, antimicrobial stewardship programs in Nova Scotia should focus on identified targets for improvement.</p><p><strong>RÉSUMÉ</strong></p><p>Contexte: Les enquêtes de prévalence ponctuelle sont employées pour surveiller l’utilisation des antimicrobiens et cibler des points à améliorer grâce aux activités de gestion responsable des antimicrobiens. Peu d’études se sont penchées sur l’utilisation des antimicrobiens dans les établissements de soins de courte durée en Nouvelle-Écosse.</p><p><strong>Objectifs :</strong> Déterminer quelle est la prévalence de l’utilisation des anti -microbiens dans les hôpitaux de la Nouvelle-Écosse et offrir un portrait de cette utilisation.</p><p><strong>Méthodes :</strong> Une enquête de prévalence ponctuelle a été menée entre juin et novembre 2015 pour les patients admis aux hôpitaux dotés d’au moins 30 lits de soins de courte durée. À chaque jour d’enquête, des dossiers médicaux ont été examinés afin de repérer les patients ayant reçu des agents antimicrobiens cette journée-là. On a recueilli des données sur le type d’agent antimicrobien prescrit, la voie d’administration, la durée attendue d’utilisation et l’indication. Le respect des lignes directrices thérapeutiques régionales et locales a aussi été évalué. Les résultats ont été résumés de façon descriptive. Les comparaisons ont été vérifiées à l’aide du test exact de Fisher ou du test de tendance de Cochran-Armitage.</p><p><strong>Résultats :</strong> Douze des 13 hôpitaux admissibles ont été inclus et un total de 1 499 dossiers médicaux de patients ont été examinés. Le taux de prévalence globale d’utilisation d’antimicrobiens était de 30,6 % (458/1499).<br />La prévalence d’utilisation d’antimicrobiens variait significativement selon les unités de soins : en tête de liste, les unités de soins intensifs (47,2 %, 50/106) et les unités de chirurgie (43,4 %, 179/412) comparativement aux unités de médecine (27,9 %, 192/687) et aux « autres » unités de soins (11,1 %, 32/289) (p &lt; 0.001). Parmi les 520 indications pour l’utilisation des antimicrobiens, la plus fréquente était l’infection des voies respiratoires (81 ou 15,6 %). Au total, 660 agents antimicrobiens ont été prescrits aux 458 patients et le tiers de ces patients (152 ou 33,2 %) ont reçu plus d’un agent antimicrobien. La classe d’antimicrobien la plus souvent prescrite était les « autres bêtalactamines » (31,2 %, 206/660). La voie parentérale était prescrite pour l’administration de la majorité desantimicrobiens (62,0%, 409/660). Le respect des lignes directrices régionales de traitement était de 29,9 % (26 des 87 indications analysées). Parmi les 520 indications, 104 (20,0 %) n’étaient pas mentionnées au dossier et 326 (62,7 %) étaient dépourvues de mention de la durée du traitement antimicrobien au dossier.</p><p><strong>Conclusions :</strong> Des agents antimicrobiens ont été prescrits à environ un tiers des patients recevant des soins de courte durée en Nouvelle-Écosse. L’amélioration de l’utilisation des antimicrobiens devrait cibler précisément les réductions de la prescription d’antibiotiques à large spectre et du recours à la voie parentérale, un plus grand respect des lignes directrices et une meilleure consignation. Les programmes de gestion responsable des antimicrobiens en Nouvelle-Écosse devraient être axés sur des objectifs d’amélioration définis afin de mettre au point des stratégies.</p>

scholarly journals Establishing a baseline for a national paediatric antimicrobial stewardship programme

2019 ◽  
Vol 74 (10) ◽  
pp. 3104-3110
Author(s):  
C L Gibbons ◽  
W Malcolm ◽  
J Sneddon ◽  
C Doherty ◽  
S Cairns ◽  
...  
Keyword(s):  
Antimicrobial Stewardship ◽  
Antimicrobial Use ◽  
Local Policy ◽  
Prevalence Survey ◽  
Antimicrobial Prescribing ◽  
Common Diagnosis ◽  
Acute Hospitals ◽  
Healthcare Associated ◽  
Hospital Acquired ◽  
National Prevalence

Abstract Background The majority of antimicrobial stewardship programmes focus on prescribing in adult populations; however, there is a recognized need for targeted paediatric antimicrobial stewardship to improve the quality and safety of prescribing amongst this patient group. Objectives To describe the current epidemiology of antimicrobial prescribing in paediatric inpatient populations in Scotland to establish a baseline of evidence and identify priority areas for quality improvement to support a national paediatric antimicrobial stewardship programme. Methods A total of 559 paediatric inpatients were surveyed during the Scottish national point prevalence survey of healthcare-associated infections and antimicrobial prescribing, 2016. The prevalence of antimicrobial prescribing was calculated and characteristics of antimicrobial prescribing were described as proportions and compared between specialist hospitals and paediatric wards in acute hospitals. Results Prevalence of antimicrobial use in paediatric inpatients was 35.4% (95% CI = 31.6%–39.4%). Treatment of community- and hospital-acquired infections accounted for 47.1% and 20.7% of antimicrobial use, respectively, with clinical sepsis being the most common diagnosis and gentamicin the most frequently prescribed antimicrobial for the treatment of infection. The reason for prescribing was documented in the notes for 86.5% of all prescriptions and, of those assessed for compliance against local policy, 92.9% were considered compliant. Conclusions Data from national prevalence surveys are advantageous when developing antimicrobial stewardship programmes. Results have highlighted differences in the prescribing landscape between paediatric inpatient populations in specialist hospitals and acute hospitals, and have informed priorities for the national antimicrobial stewardship programme, which reinforces the need for a targeted paediatric antimicrobial stewardship programme.

scholarly journals Improving Antimicrobial Use by Implementing the CDC Antimicrobial Stewardship Core Elements Across a Diverse Healthcare System

2017 ◽  
Vol 4 (suppl_1) ◽  
pp. S62-S62
Author(s):  
Michael A Lane ◽  
Amanda Hays ◽  
Helen Newland ◽  
Jeanne Zack ◽  
Jason Newland
Keyword(s):  
Healthcare System ◽  
Antimicrobial Stewardship ◽  
Gap Analysis ◽  
Treatment Guidelines ◽  
Antimicrobial Use ◽  
Local Hospital ◽  
Core Elements ◽  
Regulatory Mandates ◽  
Multidisciplinary System ◽  
Research Grant

Abstract Background With increasing national focus on reducing inappropriate antimicrobial use, state and national regulatory mandates require hospitals to develop robust antimicrobial stewardship programs (ASP). Methods BJC HealthCare is a 13 hospital healthcare system serving the St. Louis, mid-Missouri, and Southern Illinois region and includes adult and pediatric academic medical centers, as well as community and critical access hospitals. In 2015, BJC system leaders engaged relevant clinical and executive stakeholders at each hospital to champion formation of a multidisciplinary system ASP Council. A comprehensive gap analysis was performed to assess current stewardship resources and activities. BJC system clinical leads facilitated the development of hospital specific leadership support statements, identification of hospital pharmacy and medical leaders, and all mandated educational components. To facilitate tracking, reporting and improvement activities, a robust antimicrobial use data dashboard was created. Each hospital has a dedicated ASP team that is supported by the system clinical leads. Hospital learnings are shared at monthly system ASP meetings allowing for broad dissemination. Results By leveraging system resources, all 13 BJC HealthCare hospitals met all Joint Commission requirements by January 2017. BJC’s model of ASP allows for the development of broad-based stewardship activities including development of education modules for patients and providers, and clinical decision support tools while allowing individual hospitals to implement activities based on local needs and resource availability. Local hospital teams have developed treatment guidelines, targeted antibiotic pharmacy review, “handshake” stewardship models, and allergy testing protocols. Central support of local hospital ASP has resulted in a 7.6% system decrease in tracked antimicrobial use, including a 16.5% reduction in quinolone usage. Additionally, the C. difficilestandardized infection ratio decreased from 1.08 to 0.622 since program initiation. Conclusion Despite significant differences in hospital resources, a system-supported ASP model focused on implementing the CDC core elements can result in significant reductions in antimicrobial use. Disclosures J. Newland, Merck: Grant Investigator, Research grant; Allergan: Grant Investigator, Research grant

scholarly journals P32 An audit to assess the suitability of patients at a tertiary/quaternary paediatric hospital to switch from intravenous (IV) to oral (PO) antimicrobial therapy

2020 ◽  
Vol 105 (9) ◽  
pp. e23.1-e23
Author(s):  
Orlagh McGarrity ◽  
Aliya Pabani
Keyword(s):  
High Risk ◽  
Antimicrobial Resistance ◽  
Blood Culture ◽  
Antimicrobial Stewardship ◽  
Antimicrobial Therapy ◽  
Blood Cultures ◽  
Antimicrobial Use ◽  
List Type ◽  
Paediatric Hospital ◽  
Oral Agents

Introduction, Aims and ObjectivesIn 2011 the Start Smart then Focus campaign was launched by Public Health England (PHE) to combat antimicrobial resistance.1 The ‘focus’ element refers to the antimicrobial review at 48–72 hours, when a decision and documentation regarding infection management should be made. [OM1] At this tertiary/quaternary paediatric hospital we treat, immunocompromised, high risk patients. In a recent audit it was identified that 80% of antimicrobial use is IV, this may be due to several factors including good central access, centrally prepared IV therapy and oral agents being challenging to administer to children. The aim of the audit was to assess if patient have a blood culture prior to starting therapy, have a senior review at 48–72 hours, and thirdly if our high proportion of intravenous antimicrobial use is justified.MethodElectronic prescribing data from JAC was collected retrospectively over an 8 day period. IV antimicrobials for which there is a suitable oral alternative, this was defined as >80% bioavailability, were included. Patients were excluded in the ICU, cancer and transplant setting, those with absorption issues and with a high risk infection, such as endocarditis or bacteraemia. Patient were assessed against a set criteria to determine if they were eligible to switch from IV to PO therapy; afebrile, stable blood pressure, heart rate <90/min, respiratory rate < 20/min for 24 hours. Reducing CRP, reducing white cell count, blood cultures negative or sensitive to an antibiotic that can be given orally.Results100% of patients (11) had a blood cultures taken within 72 hours of starting therapy55% of patients had a positive blood culture82% of patients had a senior review at 48–72 hours46% of patients were eligible to switch from IV to PO therapy at 72 hours33% of eligible patients were switched from IV to PO therapy at 72 hoursConclusion and RecommendationsThis audit had a low sample size due to the complexity of the inclusion and exclusion criteria, and the difficulty in reviewing patient parameters on many different hospital interfaces. It is known that each patient is reviewed at least 24 hourly on most wards and therefore there is a need for improved documentation of prescribing decisions. Implementation of an IV to oral switch guideline is recommended to support prescribing decisions and educate and reassure clinicians on the bioavailability and benefits of PO antimicrobial therapy where appropriate. Having recently changed electronic patient management systems strategies to explore include hard stops on IV antimicrobial therapies, however this will require much consideration. Education of pharmacist and nurses is required to raise awareness about antimicrobial resistance and the benefits of IV to PO switches, despite the ease of this therapy at out Trust. This will promote a culture in which all healthcare professionals are active antimicrobial guardians, leading to better patient outcomes, less service pressures, and long term financial benefit.ReferenceGOV.UK. 2019. Antimicrobial stewardship: Start smart - then focus. [ONLINE]Available at: https://www.gov.uk/government/publications/antimicrobial-stewardship-start-smart-then-focus [Accessed 3 July 2019]

scholarly journals 109. Impact of Accelerate PhenoTM System on Time to De-escalation of Antimicrobial Therapy

2020 ◽  
Vol 7 (Supplement_1) ◽  
pp. S69-S69
Author(s):  
Caroline Powers ◽  
Ryan P Moenster ◽  
Travis W Linneman
Keyword(s):  
Blood Culture ◽  
Hospital Stay ◽  
Antimicrobial Stewardship ◽  
Antimicrobial Therapy ◽  
Multivariate Regression ◽  
Univariate Analysis ◽  
Length Of Hospital Stay ◽  
P Value ◽  
Gram Positive ◽  
Quasi Experimental

Abstract Background The Accelerate PhenoTM system yields identification (ID) and antimicrobial susceptibility testing (AST) within 7 hours of growth in blood culture. The objective of this study was to determine its impact on time to de-escalation of antimicrobial therapy. Methods This retrospective quasi-experimental, observational cohort study included patients hospitalized at the St. Louis VA who received intravenous antibiotics for a positive blood culture. Patients with blood cultures positive for polymicrobial growth or fungi or those requiring antibiotics for other infections were excluded. The primary endpoint was time to de-escalation of antimicrobial therapy from before and after implementation of Accelerate PhenoTM (September 2017 to August 2018 and September 2018 to August 2019, respectively). Secondary outcomes included time to ID and AST, length of hospital stay, and days of antimicrobial therapy. The variables of gram-positive infections, use of Accelerate PhenoTM, and presence of infectious diseases consult and/or pharmacist antimicrobial stewardship note were included in a univariate analysis. Variables with a p-value&lt; 0.2 were included in a multivariate regression. Results 168 patients were included, with 92 patients in the pre-implementation and 76 in the post-implementation group. Overall, mean age was 67 years and 162 (96%) were men. Staphylococcus spp. and Escherichia coli were the most common causative organisms. Time to de-escalation did not differ significantly between the post-implementation and pre-implementation groups (65 vs. 61 hours, p=0.47). Time to organism ID was decreased by 16 hours using Accelerate PhenoTM (50 vs. 66 hours, p=0.016). However, no difference was found in time to AST or length of hospital stay. Days of antimicrobial therapy while hospitalized was also similar between groups (6.8 vs. 5.9 days, p=0.256). Only gram-positive infections and presence of antimicrobial stewardship notes were included in the multivariate regression. Neither were independently associated with de-escalation within 48 hours. Conclusion Accelerate PhenoTM system did not impact time to de-escalation of antimicrobial therapy. Disclosures All Authors: No reported disclosures

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