121. Evaluation of Multifaceted Antimicrobial Stewardship in Optimizing Antimicrobial Usage in Intraabdominal Infection at a Community Hospital

Abstract Background Treatment of intraabdominal infections (IAI) commonly involves broad spectrum antimicrobials based on the severity and etiology of infections as well as the underlying medical conditions. However, the overuse of broad-spectrum agents has driven selection for Gram-negative and -positive resistance, as well as collateral consequences such as Clostridioides difficile colitis. We sought to evaluate the utilization of a pharmacy-driven multifaceted antimicrobial stewardship (AMS) intervention to optimize empiric antimicrobial therapy by risk stratification among IAI patients and reduce the number of antibiotic treatment days. Methods This is a single-center case observation study in hospitalized adult IAI patients on antimicrobial therapy from Dec 2019-Feb 2020 compared to patients from Dec 2020-Feb 2021 after initiation of AMS with daily prospective audit and feedback. The composite primary outcome is reduction of antibiotic treatment days and de-escalation from broad spectrum antibiotics (fluoroquinolones, piperacillin/tazobactam, and carbapenems) to cephalosporins. Results We identified 40 patients each in the baseline (pre-AMS group) and post-AMS group via electronic medical record. Baseline characteristics were well-matched between groups. The majority of patients were diagnosed with community-acquired IAIs such as appendicitis, diverticulitis, and cholecystitis. Fluoroquinolone use as empiric therapy was significantly lower in the post-AMS group vs. pre-AMS group (2.5% vs. 25%, p< 0.001), while non-Pseudomonas cephalosporin use was increased (25% post-AMS vs. 0% pre-AMS, p< 0.001). Oral fluoroquinolone use at discharge was significantly decreased in the post-AMS group (p< 0.001). Antibiotic treatment days remained unchanged. There was no statistical difference between the two groups in 30-day mortality, 30-day readmission, relapse, and C. difficile colitis. Conclusion A multifaceted antimicrobial therapy intervention successfully reduced the use of fluoroquinolones in patients with community-acquired IAI during hospitalization and discharge. No differences in mortality, readmission, or relapse rates were observed. Disclosures All Authors: No reported disclosures

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172. Evaluation of Multifaceted Antimicrobial Stewardship Interventions on The Treatment of Asymptomatic Bacteriuria

Open Forum Infectious Diseases ◽

10.1093/ofid/ofaa439.216 ◽

2020 ◽

Vol 7 (Supplement_1) ◽

pp. S93-S94

Author(s):

Tho H Pham ◽

Angela Huang ◽

Vanthida Huang ◽

Scott T Hall

Keyword(s):

Clostridium Difficile ◽

Length Of Stay ◽

Antibiotic Treatment ◽

Clostridium Difficile Infection ◽

Antimicrobial Stewardship ◽

Antimicrobial Therapy ◽

Asymptomatic Bacteriuria ◽

Audit And Feedback ◽

Hospital Length Of Stay ◽

Positive Urine

Abstract Background Treatment of asymptomatic bacteriuria (ASB) and asymptomatic candiduria (ASC) is a leading cause of inappropriate use of antimicrobial therapy in many healthcare facility, and has been associated with undesirable outcomes such as Clostridium difficile infection, longer length of stay, long-term antibiotic resistance, and delayed time back to baseline activity. This evaluation was designed to utilize a pharmacy-driven multifaceted antimicrobial stewardship intervention to reduce the number of antibiotic treatment days in patients with ASB/ASC Methods This retrospective single-center study included hospitalized adult patients with a positive urinalysis and/or a positive urine culture with or without antimicrobial therapy from January-March 2019, compared to patients from January-March 2020 after initiation of a multifaceted antimicrobial stewardship intervention, including daily prospective audit and feedback. The primary outcome was the number of antibiotic treatment days in patients with ASB/ASC before and after implementation of the targeted antimicrobial stewardship interventions Results 189 patients were identified upon retrospective chart review in the pre-group and 110 patients were included in the post-group. Baseline characteristics were well-matched between groups, except that the pre-group had a higher percentage of patients coming from nursing facilities while the post-group had a significantly higher percentage of patients with positive urine cultures. Antibiotic treatment days were significantly lower in the post- versus pre-group 0 (IQR 0–3) vs. 3 (IQR 1–7), p< 0.001. Incidence of ASB/ASC treatment was also significantly lower in the post- versus pre-group 45.5 vs 72.5%, p< 0.001. There was no statistical difference between the two groups in 30-day mortality, 30-day hospital readmission, and hospital length of stay. There was one case of Clostridium difficile infection among patients being inappropriately managed with antibiotics in each groups Conclusion A multifaceted antimicrobial stewardship interventions successfully reduced antimicrobial treatment days in patients with ASB/ASC, as well as overall incidence of inappropriate treatment of ASB/ASC without increasing mortality or readmission rate Disclosures All Authors: No reported disclosures

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Combined influence of practice guidelines and prospective audit and feedback stewardship on antimicrobial treatment of community-acquired pneumonia and empyema in children: 2012 to 2016

Paediatrics & Child Health ◽

10.1093/pch/pxaa066 ◽

2020 ◽

Author(s):

Nicole M A Le Saux ◽

Jennifer Bowes ◽

Isabelle Viel-Thériault ◽

Nisha Thampi ◽

Julie Blackburn ◽

...

Keyword(s):

Broad Spectrum ◽

Empiric Therapy ◽

Community Acquired Pneumonia ◽

Antimicrobial Treatment ◽

Audit And Feedback ◽

Third Generation ◽

Prospective Audit ◽

Stewardship Program ◽

Prospective Audit And Feedback ◽

Third Generation Cephalosporins

Abstract Background Aminopenicillins are recommended empiric therapy for community-acquired pneumonia (CAP). The aim of the study was to assess treatment over a 5-year period after CAP guideline publication and introduction of an antimicrobial stewardship program (ASP). Methods Using ICD-10 discharge codes for pneumonia, children less than 18 years admitted to the Children’s Hospital of Eastern Ontario January 1, 2012 and December 31, 2016 were identified. Children ≥ 2 months with consolidation were included. One day of therapy (DOT) was one or more doses of an antimicrobial given for 1 day. Results Of 1,707 patients identified, 713 met inclusion criteria. Eighteen (2.5%) had bacteria identified by culture and 79 of 265 (29.8%) had Mycoplasma pneumoniae detected. Mean DOT/1,000 patient days of aminopenicillins/penicillin (AAP) increased by 18.1% per year (95% confidence interval [CI] −0.2, 39.9%) and decreased by 37.6% per year (95% CI −56.1, −11.3%) for second- and third-generation cephalosporins in the post-ASP period. The duration of discharge antimicrobials decreased. Of 74 (10.4%) patients who had pleural fluid drained, 35 (47.3%) received more than 5 days of AAP and ≤ 5 days of second-/third-generation cephalosporins with no difference in median length of stay nor mean duration of antimicrobials. Conclusions Implementation of CAP management guidelines followed by prospective audit and feedback stewardship was associated with a sustained decrease in the use of broad-spectrum antibiotics in childhood CAP. Use of AAP should also be strongly considered in patients with effusions (even if no pathogen is identified), as clinical outcome appears similar to patients treated with broad-spectrum antimicrobials.

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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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Targeted Outpatient Fluoroquinolone Intervention utilizing an Integrated Electronic Health Record in the Bureau of Prisons

Infection Control and Hospital Epidemiology ◽

10.1017/ice.2020.1048 ◽

2020 ◽

Vol 41 (S1) ◽

pp. s402-s402

Author(s):

Deborah Long ◽

Alisha Edmunds ◽

Tyler Campbell ◽

Michael Long

Keyword(s):

Electronic Health Record ◽

Antimicrobial Stewardship ◽

Singular System ◽

Audit And Feedback ◽

Health Record ◽

Prospective Audit ◽

Short Period ◽

Electronic Health ◽

Prospective Audit And Feedback ◽

Bureau Of Prisons

Background: Fluoroquinolones are the perfect target for antimicrobial stewardship programs (ASPs) due to their broad-spectrum nature, poor safety profile, and frequent misuse. In April 2019, the Bureau of Prisons (BOP) created a national antimicrobial stewardship clinical pharmacist consultant program. One of the program’s main initiatives was to screen active fluoroquinolone prescriptions for appropriateness and work with providers to tailor therapy as needed. Since July 2019, pharmacist consultants have utilized a singular system-wide electronic health record (EHR) to conduct fluoroquinolone prospective audit and feedback targeting all BOP sites across the country. The objective was to assess the national impact of prospective audit and feedback on outpatient fluoroquinolone prescriptions utilizing pharmacist consultants and an integrated EHR. Method: Reviews were conducted in a federal correctional setting including 122 BOP sites with an average daily population of 167,308 inmates. The ASP consisted of 7 pharmacists, each assigned a region across the country. Consultant pharmacists were in charge of conducting daily fluoroquinolone reviews within 72 hours of the prescription being written, utilizing a singular system-wide EHR to gain remote access to newly prescribed prescriptions along with all other pertinent information (ie, clinical notes, patient profiles, laboratory, and radiology). Interventions were sent via e-mail. Total fluoroquinolone prescriptions per 1,000 inmates during the preintervention period (July 1, 2018, to September 30, 2018) were compared to the postintervention period (July 1, 2019, to September 30, 2019), after the development of the clinical consultant program. Data were also collected during the 3-month postintervention period to include total fluoroquinolone prescriptions reviewed, total recommendations sent, percentage of recommendations accepted, and intervention types. Results: In total, 833 fluoroquinolone prescriptions of 1, 264 total prescriptions written (66%)were reviewed over the 3-month postintervention period. In total,192 interventions were recommended (23%). Of the interventions recommended, 65 (34%) were accepted. The most common intervention was to stop therapy (41%), followed by changing antibiotic (37%), and shorten therapy duration (8%). Total outpatient fluoroquinolone prescriptions decreased by 1.5 prescriptions per 1,000 patients after the intervention. Conclusions: Pharmacist-driven prospective audit and feedback on a national scale utilizing a singular system-wide EHR resulted in an overall decrease in outpatient fluoroquinolone prescriptions over short period of time.Funding: NoneDisclosures: None

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Assessing the impact of antibiotic stewardship program elements on antibiotic use across acute-care hospitals: an observational study

Infection Control and Hospital Epidemiology ◽

10.1017/ice.2018.121 ◽

2018 ◽

Vol 39 (8) ◽

pp. 941-946 ◽

Cited By ~ 2

Author(s):

Bradley J. Langford ◽

Julie Hui-Chih Wu ◽

Kevin A. Brown ◽

Xuesong Wang ◽

Valerie Leung ◽

...

Keyword(s):

Observational Study ◽

Acute Care ◽

Antimicrobial Stewardship ◽

Acute Care Hospitals ◽

Antibiotic Use ◽

Audit And Feedback ◽

Prospective Audit ◽

Defined Daily Doses ◽

Prospective Audit And Feedback ◽

The Impact

AbstractObjectivesAntibiotic use varies widely between hospitals, but the influence of antimicrobial stewardship programs (ASPs) on this variability is not known. We aimed to determine the key structural and strategic aspects of ASPs associated with differences in risk-adjusted antibiotic utilization across facilities.DesignObservational study of acute-care hospitals in Ontario, CanadaMethodsA survey was sent to hospitals asking about both structural (8 elements) and strategic (32 elements) components of their ASP. Antibiotic use from hospital purchasing data was acquired for January 1 to December 31, 2014. Crude and adjusted defined daily doses per 1,000 patient days, accounting for hospital and aggregate patient characteristics, were calculated across facilities. Rate ratios (RR) of defined daily doses per 1,000 patient days were compared for hospitals with and without each antimicrobial stewardship element of interest.ResultsOf 127 eligible hospitals, 73 (57%) participated in the study. There was a 7-fold range in antibiotic use across these facilities (min, 253 defined daily doses per 1,000 patient days; max, 1,872 defined daily doses per 1,000 patient days). The presence of designated funding or resources for the ASP (RRadjusted, 0·87; 95% CI, 0·75–0·99), prospective audit and feedback (RRadjusted, 0·80; 95% CI, 0·67–0·96), and intravenous-to-oral conversion policies (RRadjusted, 0·79; 95% CI, 0·64–0·99) were associated with lower risk-adjusted antibiotic use.ConclusionsWide variability in antibiotic use across hospitals may be partially explained by both structural and strategic ASP elements. The presence of funding and resources, prospective audit and feedback, and intravenous-to-oral conversion should be considered priority elements of a robust ASP.

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Taking on Clostridioides difficile

Preventing Hospital Infections ◽

10.1093/med/9780197509159.003.0010 ◽

2021 ◽

pp. 141-157

Author(s):

Jennifer Meddings ◽

Vineet Chopra ◽

Sanjay Saint

Keyword(s):

Urinary Tract Infection ◽

Urinary Tract ◽

Clostridium Difficile ◽

Tract Infection ◽

Infectious Diseases ◽

Antimicrobial Stewardship ◽

Broad Spectrum ◽

Infection Prevention ◽

Hospital Staff ◽

Clostridioides Difficile

The adaptive approach used in the previous chapters to prevent catheter-associated urinary tract infection (CAUTI) is applied to an initiative to prevent Clostridioides difficile (formerly Clostridium difficile) infection. These two initiatives differ regarding their scope, the members of their teams, and the elements of their bundles. For preventing C. difficile, for example, the most important bundle item is antimicrobial stewardship since the use of broad-spectrum antibiotics vastly increases a person’s risk of becoming infected. Infectious diseases physicians or clinical pharmacists are to examine the circumstances of antimicrobial prescriptions they have filled to see whether they meet infection prevention standards; if not, the prescribing physician will receive prompt feedback. Differences aside, the basic elements of the CAUTI framework apply, from the C-suite’s decision to go ahead with the initiative to the tactics used to sell the C. difficile bundle to the hospital staff.

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228. Impact of Early Alert to Antimicrobial Stewardship Interventions with the Prospective Audit and Feedback Strategy

Open Forum Infectious Diseases ◽

10.1093/ofid/ofy210.239 ◽

2018 ◽

Vol 5 (suppl_1) ◽

pp. S98-S98

Author(s):

Sarah Si Lin Tang ◽

Lun Yi Tan ◽

Daphne Yah Chieh Yii ◽

Andrea L Kwa ◽

Piotr Chlebicki

Keyword(s):

Antimicrobial Stewardship ◽

Audit And Feedback ◽

Prospective Audit ◽

Feedback Strategy ◽

Prospective Audit And Feedback ◽

Early Alert

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Clinical impact of a pharmacist-led antimicrobial stewardship initiative evaluating patients with Clostridioides difficile colitis

Journal of Investigative Medicine ◽

10.1136/jim-2019-001173 ◽

2020 ◽

Vol 68 (4) ◽

pp. 888-892 ◽

Cited By ~ 1

Author(s):

Paige A Bishop ◽

Carmen Isache ◽

Yvette S McCarter ◽

Carmen Smotherman ◽

Shiva Gautam ◽

...

Keyword(s):

Clinical Outcomes ◽

Antimicrobial Stewardship ◽

Treatment Guidelines ◽

Clinical Success ◽

Audit And Feedback ◽

Healthcare Associated Infection ◽

Clostridioides Difficile ◽

Stewardship Program ◽

The Usa ◽

The Impact

Clostridioides difficile is the most common cause of healthcare-associated infection and gastroenteritis-associated death in the USA. Adherence to guideline recommendations for treatment of severe C. difficile infection (CDI) is associated with improved clinical success and reduced mortality. The purpose of this study was to determine whether implementation of a pharmacist-led antimicrobial stewardship program (ASP) CDI initiative improved adherence to CDI treatment guidelines and clinical outcomes. This was a single-center, retrospective, quasi-experimental study evaluating patients with CDI before and after implementation of an ASP initiative involving prospective audit and feedback in which guideline-driven treatment recommendations were communicated to treatment teams and documented in the electronic health record via pharmacy progress notes for all patients diagnosed with CDI. The primary endpoint was the proportion of patients treated with guideline adherent definitive regimens within 72 hours of CDI diagnosis. Secondary objectives were to evaluate the impact on clinical outcomes, including length of stay (LOS), infection-related LOS, 30-day readmission rates, and all-cause, in-hospital mortality. A total of 233 patients were evaluated. The proportion of patients on guideline adherent definitive CDI treatment regimen within 72 hours of diagnosis was significantly higher in the post-interventional group (pre: 42% vs post: 58%, p=0.02). No differences were observed in clinical outcomes or proportions of patients receiving laxatives, promotility agents, or proton pump inhibitors within 72 hours of diagnosis. Our findings demonstrate that a pharmacist-led stewardship initiative improved adherence to evidence-based practice guidelines for CDI treatment.

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