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

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

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

Open Forum Infectious Diseases ◽

10.1093/ofid/ofaa439.267 ◽

2020 ◽

Vol 7 (Supplement_1) ◽

pp. S112-S113

Author(s):

Mio Endo ◽

Shinya Tsuzuki ◽

Yusuke Asai ◽

Taichi Tajima ◽

Nobuaki Matsunaga ◽

...

Keyword(s):

Antimicrobial Stewardship ◽

Antimicrobial Agents ◽

Median Number ◽

Audit And Feedback ◽

Average Hospital ◽

Healthcare Facilities ◽

Stewardship Program ◽

Days Of Therapy ◽

The Difference ◽

Prospective Audit And Feedback

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

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78. Impact of Methicillin-Resistant Staphylococcus aureus (MRSA) Nares Screen on Vancomycin Utilization for Respiratory Tract Infections

Open Forum Infectious Diseases ◽

10.1093/ofid/ofab466.280 ◽

2021 ◽

Vol 8 (Supplement_1) ◽

pp. S156-S156

Author(s):

Ashita Debnath ◽

Esther King ◽

Dimple Patel ◽

Pamela Giordano

Keyword(s):

Respiratory Tract ◽

Respiratory Tract Infections ◽

Retrospective Chart Review ◽

Audit And Feedback ◽

Teaching Hospitals ◽

Absolute Increase ◽

Days Of Therapy ◽

The Difference ◽

Prospective Audit And Feedback ◽

Tract Infections

Abstract Background S. aureus, including MRSA, is a common colonizer of the nares. Recent data have shown that a negative MRSA nares screen by PCR has a negative predictive value of 98%. This implies that the absence of colonization can significantly reduce empiric vancomycin utilization. This study aimed to determine the utilization of MRSA nares screening on patients receiving vancomycin for respiratory tract infections (RTI) following the addition of the screen to the institutional RTI management guidelines. Methods This was a retrospective chart review of adult inpatients presenting to two community-teaching hospitals who were prescribed vancomycin for the treatment of RTIs. Patients were divided into pre-guideline (Jan-Feb 2019), post-guideline 1 (Jan-Feb 2020), and post-guideline 2 (Jan-Feb 2021) groups. The primary endpoint was the difference in percent of vancomycin orders discontinued within 24 hours of a negative screen. Secondary endpoints included the percent of screens ordered, re-initiation of vancomycin within seven days for RTI, and total vancomycin days of therapy (DOT) per 1000 patient days (PD). Results Of 493 vancomycin orders screened, 100 orders in each arm were analyzed. There was an absolute increase of 20.6% in vancomycin orders discontinued within 24 hours of a negative screen between the pre-guideline and post-guideline 2 groups (59.1% vs. 79.7%, p = 0.0177). When compared to the pre-guideline group, utilization of the screen increased by 15% in the post-guideline 1 group (48% vs. 63%, p = 0.0328) and 26% in the post-guideline 2 group (48% vs. 74%, p = 0.000164). There was no difference in re-initiation of vancomycin. A statistically significant reduction in total vancomycin DOT/1000PD from the pre-guideline to the post-guideline 1 and 2 groups (66 to 63 to 60, respectively) was also observed. Conclusion The addition of the MRSA nares screen to the institutional RTI guidelines increased utilization of the test and demonstrated a reduction in vancomycin utilization. With an increase in education, prospective audit and feedback, and prescriber comfort with the use of the MRSA nares screen in the post-guideline 2 group, there was significant improvement in MRSA nares screen utilization, vancomycin discontinuation after a negative screen, and vancomycin utilization. Disclosures All Authors: No reported disclosures

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Acceptability and effectiveness of antimicrobial stewardship implementation strategies on fluoroquinolone prescribing

Infection Control and Hospital Epidemiology ◽

10.1017/ice.2021.10 ◽

2021 ◽

pp. 1-8

Author(s):

Katie J. Suda ◽

Gosia S. Clore ◽

Charlesnika T. Evans ◽

Heather Schacht Reisinger ◽

Ibuola Kale ◽

...

Keyword(s):

Antimicrobial Stewardship ◽

Clinical Pathways ◽

Statistical Significance ◽

Implementation Strategies ◽

Antibiotic Use ◽

Audit And Feedback ◽

Prior Approval ◽

Days Of Therapy ◽

Prospective Audit And Feedback ◽

Advanced Generation

Abstract Objective: To assess the effectiveness and acceptability of antimicrobial stewardship-focused implementation strategies on inpatient fluoroquinolones. Methods: Stewardship champions at 15 hospitals were surveyed regarding the use and acceptability of strategies to improve fluoroquinolone prescribing. Antibiotic days of therapy (DOT) per 1,000 days present (DP) for sites with and without prospective audit and feedback (PAF) and/or prior approval were compared. Results: Among all of the sites, 60% had PAF or prior approval implemented for fluoroquinolones. Compared to sites using neither strategy (64.2 ± 34.4 DOT/DP), fluoroquinolone prescribing rates were lower for sites that employed PAF and/or prior approval (35.5 ± 9.8; P = .03) and decreased from 2017 to 2018 (P < .001). This decrease occurred without an increase in advanced-generation cephalosporins. Total antibiotic rates were 13% lower for sites with PAF and/or prior approval, but this difference did not reach statistical significance (P = .20). Sites reporting that PAF and/or prior approval were “completely” accepted had lower fluoroquinolone rates than sites where it was “moderately” accepted (34.2 ± 5.7 vs 48.7 ± 4.5; P < .01). Sites reported that clinical pathways and/or local guidelines (93%), prior approval (93%), and order forms (80%) “would” or “may” be effective in improving fluoroquinolone use. Although most sites (73%) indicated that requiring infectious disease consults would or may be effective in improving fluoroquinolones, 87% perceived implementation to be difficult. Conclusions: PAF and prior approval implementation strategies focused on fluoroquinolones were associated with significantly lower fluoroquinolone prescribing rates and nonsignificant decreases in total antibiotic use, suggesting limited evidence for class substitution. The association of acceptability of strategies with lower rates highlights the importance of culture. These results may indicate increased acceptability of implementation strategies and/or sensitivity to FDA warnings.

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157. A Multidisciplinary Approach to Carbapenem Stewardship at a Large Community Hospital in Brooklyn, New York

Open Forum Infectious Diseases ◽

10.1093/ofid/ofaa439.202 ◽

2020 ◽

Vol 7 (Supplement_1) ◽

pp. S88-S88

Author(s):

Samuel Simon ◽

Rosanna Li ◽

Yu Shia Lin ◽

Suri Mayer ◽

Edward Chapnick ◽

...

Keyword(s):

New York ◽

Pseudomonas Aeruginosa ◽

Klebsiella Pneumoniae ◽

Infectious Diseases ◽

Antimicrobial Stewardship ◽

Audit And Feedback ◽

Chi Square ◽

Carbapenem Resistant ◽

Days Of Therapy ◽

Prospective Audit And Feedback

Abstract Background Carbapenem-resistant gram-negative organisms are a continuously mounting threat, underscoring the need for effective antimicrobial stewardship interventions to improve the use of carbapenems. We sought to implement several multidisciplinary antimicrobial stewardship interventions beginning in January 2019 in an effort to reduce unnecessary meropenem use and the incidence of carbapenem-resistant gram-negatives. Methods Prospective audit and feedback was utilized daily in combination with weekly stewardship rounds between an Infectious Diseases pharmacist and physician in the Intensive Care Units. A second Infectious Diseases physician attended weekly interdisciplinary rounds on meropenem high-use units. Meropenem Days of Therapy (DOT) per 1,000 patient days and the incidence of meropenem resistant Pseudomonas aeruginosa and Klebsiella pneumoniae were compared by the chi-square test of proportions. Results Between 2018 and 2019 the institution’s meropenem DOT per 1,000 patient days decreased 33%, from 57 to 38 days per 1,000 patient days (difference, 19 days per 1,000 patient days; p< 0.001). In the hospital antibiogram, the meropenem susceptibility of Pseudomonas aeruginosa over the same time period increased from 71% to 77% of isolates (difference, 6%; p = 0.009). A non-significant decrease in the susceptibility of meropenem to Klebsiella pneumoniae was also observed from 92 to 90% (difference, 2%: p = 0.1658). Conclusion These data support the need for antimicrobial stewardship efforts targeting broad-spectrum antimicrobials such as meropenem. In the setting of a sustained decrease in meropenem use over 12 months, we observed a significant improvement in the percent susceptibility rate of Pseudomonas aeruginosa to meropenem for the first time in five years. Disclosures All Authors: No reported disclosures

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A multifaceted stewardship intervention helps curb steroid overprescribing in hospitalized patients with acute exacerbations of COPD

American Journal of Health-System Pharmacy ◽

10.1093/ajhp/zxab468 ◽

2021 ◽

Author(s):

Jennifer L Cole ◽

Sarah E Smith

Keyword(s):

Length Of Stay ◽

Intervention Strategy ◽

Audit And Feedback ◽

Face To Face ◽

Duration Of Therapy ◽

Significant Difference ◽

Acute Exacerbations ◽

Before And After ◽

Quasi Experimental ◽

Prospective Audit And Feedback

Abstract Disclaimer In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. Purpose Corticosteroid overprescribing is well documented in real-world practice. There is currently no evidence to guide best practices for steroid stewardship. The aim of this study was to assess the effects of a 3-part stewardship intervention strategy on inpatient steroid prescribing in patients with acute exacerbations of COPD (AECOPD). Summary Investigators implemented a 3-part stewardship initiative consisting of (1) an anonymous survey for providers on steroid prescribing in a simplified case of AECOPD, (2) face-to-face education and review of survey results, and (3) prospective audit and feedback from a clinical pharmacist. This was a quasi-experimental before-and-after study evaluating hospitalized adults diagnosed with AECOPD in two 12-month study periods before (April 2019-March 2020) and after (May 2020-April 2021) implementation. The primary outcome was mean inpatient steroid dosing. Secondary outcomes were duration of therapy, length of stay (LOS), 30-day readmissions, 30-day mortality, and incidence of hyperglycemia. Per power analysis, there were 27 patients per cohort. The interventions resulted in a significant reduction in prednisone equivalents during hospitalization: 118 mg vs 53 mg (P = 0.0003). This decrease was similar in ICU (160 mg vs 61 mg, P = 0.008) and non-ICU (102 mg vs 49 mg, P = 0.004) locations. There was no significant difference in duration of therapy (8 days vs 7 days, P = 0.44), length of stay (3.3 days vs 3.9 days, P = 0.21), 30-day mortality (4% vs 7%, P = 0.55), 30-day readmissions (15% vs 7%, P = 0.39), or rate of hyperglycemia (48% vs 44%, P = 0.78). Conclusion A multifaceted stewardship intervention significantly reduced steroid dosing in hospitalized AECOPD patients. This reduction was not associated with known deleterious effects.

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1059. Impact of a Syndrome-Based Antimicrobial Stewardship Intervention on Anti-Pseudomonal β-Lactam Use, C. difficile Rates and Cost in an Urban Community Hospital

Open Forum Infectious Diseases ◽

10.1093/ofid/ofz360.923 ◽

2019 ◽

Vol 6 (Supplement_2) ◽

pp. S374-S375

Author(s):

Alfredo J Mena Lora ◽

Martin Cortez ◽

Ella Li ◽

Lawrence Sanchez ◽

Rochelle Bello ◽

...

Keyword(s):

Antimicrobial Stewardship ◽

Community Hospital ◽

Treatment Guidelines ◽

Urban Community ◽

Audit And Feedback ◽

Evidence Based ◽

Days Of Therapy ◽

Before And After ◽

Prospective Audit And Feedback ◽

The Impact

Abstract Background The use of anti-Pseudomonal β-lactam (APBL) agents has significantly increased in the past decade, carrying higher costs and contributing to antimicrobial pressure. Antimicrobial stewardship (ASP) can promote evidence-based antimicrobial selection and mitigate excess APBL use. We implemented a comprehensive ASP with syndrome-based prospective audit and feedback (PAF) at an urban community hospital. The goal of this study is to assess the impact of syndrome-based PAF on APBL use, C. difficile rates and cost. Methods ASP with all CDC core elements was implemented at a 151-bed community hospital in October 2017. Syndrome-based guidelines and PAF was established and overseen via direct communication with an ID physician. Days of therapy (DOT), cost and C. difficile rates were assessed 12 months before and after ASP. DOT for APBL and non-APBL utilization was tabulated by unit and paired t-test performed. Results Most cases reviewed by PAF (51%) were represented in our syndrome-based treatment guidelines (Figure 1). Soft tissue (33%) and intra-abdominal (24%) infections were the most common syndromes. Change to guideline was the most common PAF intervention (62%) followed by de-escalation (30%). At 12 months, total DOT/1,000 increased (392.5 vs. 404) while the proportion of parenteral antimicrobials used decreased (71% vs. 65%). Antibiotic expenditures decreased by 23%, with a reduction in APBL of 20% and non-APBL of 10% (Table 1). Statistically significant reductions APBL use in non-ICU settings (P = 0.0139) and statistically significant increases in non-APBL in ICU settings occurred (P = 0.0001) (Figure 2 and 3). C difficile rates decreased from 21% (3.27 vs. 2.56). Conclusion Syndrome-based PAF was successfully implemented. A reduction in APBL use was seen in non-ICU settings, where evidence-based de-escalation may be more feasible. APBL use remained high in the ICU but was guideline consistent. A rise in non-APBL use also occurred. Certain critical illness syndromes warrant APBLs, but PAF may promote culture-directed and syndrome-specific treatments. ASP increased guideline-based therapy and contributed to decreased broad-spectrum antimicrobial use, antimicrobial expenditures and C difficile rates. Syndrome based PAF can be successfully implemented in community settings. Disclosures All authors: No reported disclosures.

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Antibiotic stewardship in the intensive care unit: Challenges and opportunities

Infection Control and Hospital Epidemiology ◽

10.1017/ice.2019.74 ◽

2019 ◽

Vol 40 (6) ◽

pp. 693-698 ◽

Cited By ~ 1

Author(s):

Kathleen Chiotos ◽

Pranita D. Tamma ◽

Jeffrey S. Gerber

Keyword(s):

Intensive Care Unit ◽

Intensive Care ◽

Antibiotic Stewardship ◽

Audit And Feedback ◽

Molecular Diagnostic ◽

Future Research ◽

Antibiotic Overuse ◽

Challenges And Opportunities ◽

Prospective Audit And Feedback ◽

The Impact

AbstractInfections due to antibiotic-resistant organisms are increasing in prevalence and represent a major public health threat. Antibiotic overuse is a major driver of this epidemic, and antibiotic stewardship an important means of limiting antibiotic resistance. The intensive care unit (ICU) setting presents an intersection of opportunities and challenges for effective antibiotic stewardship, but limited data inform optimal stewardship interventions in this setting. In this review, we present unique considerations for stewardship interventions the ICU setting and summarize available data evaluating the impact of prospective audit and feedback, diagnostic test stewardship, rapid molecular diagnostic tests, and procalcitonin-guided algorithms for antibiotic discontinuation. The existing knowledge gaps ripe for future research are emphasized.

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Long-term efficacy of comprehensive multidisciplinary antibiotic stewardship programs centered on weekly prospective audit and feedback

Infection ◽

10.1007/s15010-017-1099-8 ◽

2017 ◽

Vol 46 (2) ◽

pp. 215-224 ◽

Cited By ~ 14

Author(s):

Takeshi Kimura ◽

Atsushi Uda ◽

Tomoyuki Sakaue ◽

Kazuhiko Yamashita ◽

Tatsuya Nishioka ◽

...

Keyword(s):

Antibiotic Stewardship ◽

Audit And Feedback ◽

Prospective Audit ◽

Term Efficacy ◽

Prospective Audit And Feedback

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Evaluating the Need for Antibiotic Stewardship Prospective Audit and Feedback on Weekends

Infection Control and Hospital Epidemiology ◽

10.1017/ice.2017.174 ◽

2017 ◽

Vol 38 (10) ◽

pp. 1262-1263

Author(s):

Tracelyn Freeman ◽

Greg Eschenauer ◽

Twisha Patel ◽

Tejal Gandhi ◽

Lindsay Petty ◽

...

Keyword(s):

Antibiotic Stewardship ◽

Audit And Feedback ◽

Prospective Audit ◽

Prospective Audit And Feedback

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105. Fluoroquinolone Stewardship at a Community Health-System: A Decade in Review

Open Forum Infectious Diseases ◽

10.1093/ofid/ofab466.307 ◽

2021 ◽

Vol 8 (Supplement_1) ◽

pp. S167-S167

Author(s):

Matthew Song ◽

Ashley Wilde ◽

Sarah E Moore ◽

Brian C Bohn ◽

...

Keyword(s):

Antimicrobial Stewardship ◽

Audit And Feedback ◽

Antimicrobial Stewardship Program ◽

Provider Education ◽

E Coli ◽

Stewardship Program ◽

Days Of Therapy ◽

Adult Inpatient ◽

Prospective Audit And Feedback ◽

Adult Hospital

Abstract Background Fluoroquinolone stewardship is a common target for antimicrobial stewardship programs seeking to maintain or improve fluoroquinolone susceptibility rates. Additional benefits include reducing C. difficile infection rates, drug toxicities, and resistance to other antimicrobials as fluoroquinolones can co-select for resistance. The Norton Healthcare antimicrobial stewardship program was founded in 2011 and provides services at 4 adult hospitals with ~1600 beds. Main fluoroquinolone stewardship activities have included provider education, prospective audit and feedback, and guideline and order-set development. The purpose of this study was to describe the resistance and usage rates of fluoroquinolones over time. Methods This was a descriptive study examining individual adult hospital antibiograms from 2010 to 2020. Levofloxacin susceptibility rates to E. coli and P. aeruginosa were collated from annual antibiograms between 2010 and 2020 for outpatients and each adult hospital. Adult hospital resistance rates were aggregated and weighted accordingly to number of isolates per hospital per year. Additionally, levofloxacin and ciprofloxacin inpatient days of therapy (DOT) was collected since 2016 when DOT was first readily retrievable and was normalized per 1000 patient days to compare between different time points. Results Outpatient levofloxacin likelihood of activity against P. aeruginosa improved from 81% to 91%. Outpatient levofloxacin likelihood of activity against E. coli remained stable between 84 – 86% (Figure 1). Adult inpatient fluoroquinolone usage decreased by approximately 75% from 83.5 to 21.37 DOT/1000 patient days since 2016 (Figure 2). Adult inpatient levofloxacin likelihood of activity against P. aeruginosa improved from 53% to 83%. Adult inpatient levofloxacin likelihood of activity against E. coli improved from 65% to 75% (Figure 3). Conclusion The Norton Healthcare antimicrobial stewardship program has been effective in reducing unnecessary fluoroquinolone usage and improving inpatient fluoroquinolone susceptibility rates. Future studies should examine opportunities to translate successes to the outpatient phase of care. Disclosures Ashley Wilde, PharmD, BCPS-AQ ID, Nothing to disclose Paul S. Schulz, MD, Gilead (Consultant, Speaker’s Bureau)Merck (Consultant, Speaker’s Bureau)

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