854. The Impact of the CMS SEP-1 Core Measure on Antimicrobial Utilization: a Multicenter Interrupted Time-Series (ITS) Analysis

Abstract Background Hospitals began reporting the SEP-1 Core Measure to CMS in October 1, 2015, to promote the use of best practices for patients with sepsis. The impact of SEP-1 on overall antimicrobial utilization (AU), a potential unintended consequence, is unclear. Methods We performed an ITS analysis to evaluate changes in antimicrobial utilization after SEP-1 implementation. AU was measured as days of therapy (DOT)/1,000 days present (dp) for all adult inpatients who spent more than 24 hours in 18 hospitals in the southeastern United States. The 12-month period from October 1, 2014 to September 30, 2015 was defined as the “pre” period. After a 1-month wash-in, the 12-month period from November 1, 2015 to October 31, 2016 was defined as the “post” period. AU was aggregated by hospital by month for inpatient units. Total AU and NHSN AU categories were analyzed separately. ITS was modeled using a segmented regression analysis through a GEE model with negative binomial distribution and log link. Results A total of 362,460 patients had 688,583 DOT pre-SEP1 (mean 1.9 DOT/admission), and 291,884 patients had 530,382 DOT post-SEP1 (mean 1.8 DOT/admission). The diagnosis of sepsis (3.1%) and median length of stay (3, IQR 2–4) were unchanged after SEP-1. Utilization of combined vancomycin and piperacillin–tazobactam (P-T) increased 17% at SEP-1 implementation but this increase was not statistically significant (Table). Overall AU, anti-MRSA agents, and anti-pseudomonal agents were unchanged after SEP-1 (figure, table). Conclusion Implementation of the CMS SEP-1 measure did not lead to higher rates of AU in our cohort of hospitals, although this study did not assess adherence to SEP-1. Further research is needed to improve the use of antimicrobial therapy in hospitalized patients with suspected sepsis. Disclosures All authors: No reported disclosures.

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Impact of the Centers for Medicare and Medicaid Services Sepsis Core Measure on Antibiotic Use

Clinical Infectious Diseases ◽

10.1093/cid/ciaa456 ◽

2020 ◽

Cited By ~ 1

Author(s):

Amy L Pakyz ◽

Christine M Orndahl ◽

Alicia Johns ◽

David W Harless ◽

Daniel J Morgan ◽

...

Keyword(s):

Broad Spectrum ◽

Negative Binomial ◽

Negative Binomial Regression ◽

Interrupted Time Series ◽

Antibiotic Use ◽

Multidrug Resistant ◽

Clostridioides Difficile ◽

Core Measure ◽

The Impact

Abstract Background The Centers for Medicare and Medicaid Services (CMS) implemented a core measure sepsis (SEP-1) bundle in 2015. One element was initiation of broad-spectrum antibiotics within 3 hours of diagnosis. The policy has the potential to increase antibiotic use and Clostridioides difficile infection (CDI). We evaluated the impact of SEP-1 implementation on broad-spectrum antibiotic use and CDI occurrence rates. Methods Monthly adult antibiotic data for 4 antibiotic categories (surgical prophylaxis, broad-spectrum for community-acquired infections, broad-spectrum for hospital-onset/multidrug-resistant [MDR] organisms, and anti–methicillin-resistant Staphylococcus aureus [MRSA]) from 111 hospitals participating in the Clinical Data Base Resource Manager were evaluated in periods before (October 2014–September 2015) and after (October 2015–June 2017) policy implementation. Interrupted time series analyses, using negative binomial regression, evaluated changes in antibiotic category use and CDI rates. Results At the hospital level, there was an immediate increase in the level of broad-spectrum agents for hospital-onset/MDR organisms (+2.3%, P = .0375) as well as a long-term increase in trend (+0.4% per month, P = .0273). There was also an immediate increase in level of overall antibiotic use (+1.4%, P = .0293). CDI rates unexpectedly decreased at the time of SEP-1 implementation. When analyses were limited to patients with sepsis, there was a significant level increase in use of all antibiotic categories at the time of SEP-1 implementation. Conclusions SEP-1 implementation was associated with immediate and long-term increases in broad-spectrum hospital-onset/MDR organism antibiotics. Antimicrobial stewardship programs should evaluate sepsis treatment for opportunities to de-escalate broad therapy as indicated.

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Impact of Removal of Automatic 7-Day Stop Orders for Inpatient Antimicrobials

Infection Control and Hospital Epidemiology ◽

10.1017/ice.2020.831 ◽

2020 ◽

Vol 41 (S1) ◽

pp. s264-s265

Author(s):

Afia Adu-Gyamfi ◽

Keith Hamilton ◽

Leigh Cressman ◽

Ebbing Lautenbach ◽

Lauren Dutcher

Keyword(s):

Time Series ◽

Time Series Analysis ◽

Interrupted Time Series ◽

Antibiotic Use ◽

Interrupted Time Series Analysis ◽

Series Analysis ◽

Treatment Interruptions ◽

Days Of Therapy ◽

Quasi Experimental ◽

The Impact

Background: Automatic discontinuation of antimicrobial orders after a prespecified duration of therapy has been adopted as a strategy for reducing excess days of therapy (DOT) as part of antimicrobial stewardship efforts. Automatic stop orders have been shown to decrease antimicrobial DOT. However, inadvertent treatment interruptions may occur as a result, potentially contributing to adverse patient outcomes. To evaluate the effects of this practice, we examined the impact of the removal of an electronic 7-day ASO program on hospitalized patients. Methods: We performed a quasi-experimental study on inpatients in 3 acute-care academic hospitals. In the preintervention period (automatic stop orders present; January 1, 2016, to February 28, 2017), we had an electronic dashboard to identify and intervene on unintentionally missed doses. In the postintervention period (April 1, 2017, to March 31, 2018), the automatic stop orders were removed. We compared the primary outcome, DOT per 1,000 patient days (PD) per month, for patients in the automatic stop orders present and absent periods. The Wilcoxon rank-sum test was used to compare median monthly DOT/1,000 PD. Interrupted time series analysis (Prais-Winsten model) was used to compared trends in antibiotic DOT/1,000 PD and the immediate impact of the automatic stop order removal. Manual chart review on a subset of 300 patients, equally divided between the 2 periods, was performed to assess for unintentionally missed doses. Results: In the automatic stop order period, a monthly median of 644.5 antibiotic DOT/1,000 PD were administered, compared to 686.2 DOT/1,000 PD in the period without automatic stop orders (P < .001) (Fig. 1). Using interrupted time series analysis, there was a nonsignificant increase by 46.7 DOT/1,000 PD (95% CI, 40.8 to 134.3) in the month immediately following removal of automatic stop orders (P = .28) (Fig. 2). Even though the slope representing monthly change in DOT/1,000 PD increased in the period without automatic stop orders compared to the period with automatic stop orders, it was not statistically significant (P = .41). Manual chart abstraction revealed that in the period with automatic stop orders, 9 of 150 patients had 17 unintentionally missed days of therapy, whereas none (of 150 patients) in the period without automatic stop orders did. Conclusions: Following removal of the automatic stop orders, there was an overall increase in antibiotic use, although the change in monthly trend of antibiotic use was not significantly different. Even with a dashboard to identify missed doses, there was still a risk of unintentionally missed doses in the period with automatic stop orders. Therefore, this risk should be weighed against the modest difference in antibiotic utilization garnered from automatic stop orders.Funding: NoneDisclosures: None

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1878. Title: Impact of Antibiotic Stewardship Rounds in the Intensive Care Setting: A Prospective Cluster-Randomized Crossover Study

Open Forum Infectious Diseases ◽

10.1093/ofid/ofz359.108 ◽

2019 ◽

Vol 6 (Supplement_2) ◽

pp. S48-S49

Author(s):

Jessica Seidelman ◽

Nicholas A Turner ◽

Rebekah Wrenn ◽

Christina Sarubbi ◽

Deverick J Anderson ◽

...

Keyword(s):

Intensive Care ◽

Usual Care ◽

Primary Outcome ◽

Negative Binomial ◽

University Hospital ◽

Stewardship Program ◽

Days Of Therapy ◽

Intervention Impact ◽

Cluster Randomized ◽

The Impact

Abstract Background The impact of formalized, interdisciplinary antimicrobial stewardship program (ASP) rounds in the intensive care unit (ICU) setting has not been well described. Methods We performed a two-arm, cluster-randomized, crossover quality improvement study over 8 months to compare the impact of weekly ICU rounds with an ASP team vs. usual care. The primary outcome was antibiotic use (AU) in days of therapy (DOT) per 1,000 days present during and following ICU exposure. Our cohort consisted of ICU patients in 5 ICUs in Duke University Hospital. The unit of randomization was rounding team, which corresponded to half of the ICU beds in each unit. Each team was randomized to the intervention for 4 months followed by usual care for 4 months (or vice versa). The intervention involved multidisciplinary review of eligible patients to discuss antibiotic optimization. Patients not on antibiotics, followed by infectious diseases, post-transplant, on ECMO, or with a ventricular assist device were excluded from review. Intervention impact was assessed with multivariable negative binomial regression rate ratios (RR). AU was assessed over time before and after the study period to assess global and unit-level trends. Results We had 4,683 ICU-exposed patients. Intervention effect was not significant for the primary outcome (table). The intervention order was not significant in the model. Eligible patients were lower in the cardiothoracic ICU (CTICU) compared with other units (table); the intervention led to a significant decrease in AU when the CTICU was removed (RR = 0.93 [0.89–0.98], P = 0.0025). Intervention impact was differential among ICUs, with the greatest effect in surgical and least in CTICU (table). nit-level AU decreased in all ICUs, driven by 4 of the 5 ICUs (table, figure). Conclusion The effect of ASP rounds on AU was mixed for different types of ICUs. The direct effect on AU (intervention vs. control) was small because the analysis addressed the whole ICU population and thus was subject to biases from exposures after an ICU stay, ineligible patients, and lack of blinding. However, we observed an overall decline in AU during the study period, which we believe represents indirect effects of increased ASP activity and awareness. Additional ASP resources to round more than weekly may result in greater effect. Disclosures All Authors: No reported Disclosures.

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Hospitalization for ischemic stroke was affected more in independent cases than in dependent cases during the COVID-19 pandemic: An interrupted time series analysis

PLoS ONE ◽

10.1371/journal.pone.0261587 ◽

2021 ◽

Vol 16 (12) ◽

pp. e0261587

Author(s):

Hiroyuki Nagano ◽

Jung-ho Shin ◽

Tetsuji Morishita ◽

Daisuke Takada ◽

Susumu Kunisawa ◽

...

Keyword(s):

Time Series ◽

Ischemic Stroke ◽

Hospital Admissions ◽

Health Care Systems ◽

Interrupted Time Series ◽

Interrupted Time Series Analysis ◽

State Of Emergency ◽

Its Analysis ◽

Care Systems ◽

The Impact

Background The pandemic of the coronavirus disease 2019 (COVID-19) has affected health care systems globally. The aim of our study is to assess the impact of the COVID-19 pandemic on the number of hospital admissions for ischemic stroke by severity in Japan. Methods We analysed administrative (Diagnosis Procedure Combination—DPC) data for cases of inpatients aged 18 years and older who were diagnosed with ischemic stroke and admitted during the period April 1 2018 to June 27 2020. Levels of change of the weekly number of inpatient cases with ischemic stroke diagnosis after the declaration of state of emergency were assessed using interrupted time-series (ITS) analysis. The numbers of patients with various characteristics and treatment approaches were compared. We also performed an ITS analysis for each group (“independent” or “dependent”) divided based on components of activities of daily living (ADL) and level of consciousness at hospital admission. Results A total of 170,294 cases in 567 hospitals were included. The ITS analysis showed a significant decrease in the weekly number of ischemic stroke cases hospitalized (estimated decrease: −156 cases; 95% confidence interval (CI): −209 to −104), which corresponds to −10.4% (95% CI: −13.6 to −7.1). The proportion of decline in the independent group (−21.3%; 95% CI: −26.0 to −16.2) was larger than that in the dependent group (−8.6%; 95% CI: −11.7 to −5.4). Conclusions Our results show a marked reduction in hospital admissions due to ischemic stroke after the declaration of the state of emergency for the COVID-19 pandemic. The independent cases were affected more in proportion than dependent cases.

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Impact of a hospital-wide computerised approach to optimise the quality of antimicrobial prescriptions in patients with severe obesity: a quasi-experimental study

BMC Infectious Diseases ◽

10.1186/s12879-021-06682-8 ◽

2021 ◽

Vol 21 (1) ◽

Author(s):

Stéphanie Sirard ◽

Vincent Nault ◽

Marie-France Langlois ◽

Julie Perron ◽

Louis Valiquette

Keyword(s):

Surveillance System ◽

Severe Obesity ◽

Interrupted Time Series ◽

Antimicrobial Consumption ◽

Class Iii ◽

Days Of Therapy ◽

Class Iii Obesity ◽

Quasi Experimental ◽

The Impact ◽

Antimicrobial Prescription

Abstract Background Rates of adherence to available recommendations for dose adjustments in patients with severe obesity are generally low. Hence, antimicrobials are often underdosed in these patients. Antimicrobial stewardship programmes can improve the use of antimicrobials in hospitalised patients. The aim of the study was to analyse the impact of an antimicrobial stewardship programme based on a computerised clinical decision support system for optimal dosing and antimicrobial use in inpatients with severe obesity. Methods This quasi-experimental retrospective study using interrupted time series was conducted in an academic centre in Canada from August 2008 to June 2018. The Antimicrobial Prescription Surveillance System was implemented in August 2010 (intervention 1) and specific rules targeting patients with class III obesity (body mass index ≥ 40 kg/m2) were added in June 2014 (intervention 2). Data were collected from all hospitalised adults receiving antimicrobials which required dose adjustment for severe obesity and were stratified by body mass index. Segmented regression analysis of interrupted time series was used to evaluate the impact of the Antimicrobial Prescription Surveillance System on the proportion of inappropriate days of therapy according to posology and on antimicrobial consumption. Results Overall, 65 205 antimicrobial prescriptions (68% non-obese, 25% class I-II obesity, and 7% class III obesity) were analysed. In patients with class III obesity, the intervention was associated with a decrease in the proportion of inappropriate days of therapy (trend after the first intervention, −0.8% per 2-month period [95% CI −1.1 to −0.5], p < 0.001; intercept, 11.3% [95% CI 8.2 to 14.5], p < 0.001), which led to a reduction of 35% over an eight-year period (from pre-intervention level of 19.1%). Intervention 1 resulted in a downward trend in antimicrobial consumption, followed by an increasing trend after intervention 2. In these patients, the most frequent interventions made by pharmacists targeted posology (46%). Conclusions Antimicrobial Prescription Surveillance System had a positive impact on dosing optimisation and antimicrobial consumption in patients with class III obesity. Improving antimicrobial prescriptions in these patients is important because suboptimal dosing could be associated with unfavourable outcomes.

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1141. Implementation of a Pediatric Handshake Antimicrobial Stewardship Program to Improve Antimicrobial Utilization

Open Forum Infectious Diseases ◽

10.1093/ofid/ofz360.1005 ◽

2019 ◽

Vol 6 (Supplement_2) ◽

pp. S406-S406

Author(s):

Amanda P Hughes ◽

Maya Beganovic ◽

Ronda Oram ◽

Sarah Wieczorkiewicz ◽

Anthony Chiang

Keyword(s):

Antimicrobial Stewardship ◽

Audit And Feedback ◽

Prescribing Practices ◽

Stewardship Program ◽

Antimicrobial Utilization ◽

Days Of Therapy ◽

Significant Difference ◽

Acceptance Rates ◽

Prospective Audit And Feedback ◽

The Impact

Abstract Background Antimicrobial stewardship (AMS) programs emerged in response to rising rates of resistance and adverse effects associated with inappropriate antimicrobial utilization. Optimal metrics and strategies (e.g., preauthorization, prospective audit and feedback) for AMS remain to be elucidated. This study evaluated the impact of a multidisciplinary, rounding-based AMS strategy (i.e., Handshake Stewardship) on antimicrobial utilization and prescribing practices at a pediatric hospital. Methods This was a single-center, retrospective quality improvement study at a community, teaching children’s hospital. All pediatric and neonatal inpatients with active antimicrobial orders between July 2018 and March 2019 were included in the study, and endpoints were compared with data from July 2017- March 2018. Antimicrobial courses were prospectively audited by a multidisciplinary AMS team, and feedback was provided to the primary teams during Handshake Stewardship rounds. The primary endpoint was a number of interventions made and the corresponding acceptance rates. The secondary endpoint was days of therapy (DOT) per 1000 patient-days. Descriptive statistics were performed on all continuous and categorical data as appropriate. Results Of 2238 antimicrobial courses reviewed, 710 (32%) required intervention, and 86% of the interventions made were accepted. The top 3 indications evaluated were respiratory (n = 522, 23%), sepsis/bacteremia (n = 351, 16%), and surgical prophylaxis (n = 266, 12%). Of the respiratory courses reviewed, there were 228 opportunities for antimicrobial optimization. The most common interventions were: bug-drug optimization (n = 208, 29%), discontinuation of anti-infective (n = 136, 19%), and dose optimization (n = 120, 17%). No significant difference was observed for overall, ceftriaxone, meropenem, and vancomycin DOT pre- and post-implementation of Handshake Stewardship. However, a statistically significant reduction in DOTs was observed for piperacillin–tazobactam (15.2 vs. 7.4, P = 0.004) and a nonsignificant reduction in meropenem (9.5 vs. 6.2). Conclusion Rounding-based, Handshake AMS was associated with overall high intervention acceptance rates and a reduction in commonly utilized broad-spectrum antimicrobials. Disclosures All authors: No reported disclosures.

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1071. Implementation and Impact of an Antimicrobial Tier Structure Along with Prospective Audit and Feedback at a Large Health System: Collaborations for Care Transformation

Open Forum Infectious Diseases ◽

10.1093/ofid/ofz360.935 ◽

2019 ◽

Vol 6 (Supplement_2) ◽

pp. S379-S380

Author(s):

Sarah Brooks Minor ◽

Kelly D Rafferty ◽

Julia Rutkowski ◽

Steven Allison ◽

Victor Herrera

Keyword(s):

Cost Savings ◽

Audit And Feedback ◽

Prospective Audit ◽

Antibiotic Overuse ◽

Antimicrobial Utilization ◽

Days Of Therapy ◽

Tier System ◽

Implementation Period ◽

Hospital Acquired ◽

The Impact

Abstract Background Antibiotic overuse continues to be a challenge in the acute care setting. At AdventHealth Orlando (AHO), pharmacy-led prospective audit with feedback (PAAF) has been the primary stewardship tool. Despite PAAF and criteria for use, overall utilization of high-cost, broad-spectrum agents continues to increase. Recently, the Antimicrobial Stewardship Awareness Program (ASAP) employed transformation medical directors (TMDs) and, along with the pharmacy team, developed a novel concept using an antimicrobial tier structure, in addition to historical PAAF. The purpose was to assess the impact of the tier structure, along with PAAF performed by the pharmacists and TMDs, compared with PAAF alone. Methods This retrospective pre (March–August 2018)- and post (October 2018–March 2019) implementation study was conducted at AHO. The ASAP team developed a hospital-wide policy listing antimicrobials based on a tier system (Figure 1), with higher priority agents falling in tiers 3 (T3) and 4 (T4). Education was completed in September 2018 and the process was implemented in October 2018. Criteria for use was evaluated at the point of order entry, followed by PAAF by the pharmacist and TMD. The primary outcome was impact on T3 and T4 antimicrobial utilization, measured in days of therapy (DOT) per 1,000 days present (DP). Secondary outcomes included T3 and T4 antimicrobial cost/adjusted patient-days and rates of hospital-acquired C. difficile infections (CDI). Results During the post-implementation period, the average DOT per 1,000 DP for T3 and T4 agents decreased by 21.3% (89 vs. 70, P = 0.001) compared with the pre-implementation period (Figure 2). Average T3 and T4 antimicrobial costs decreased by 26% during the post-implementation period ($9.83 vs. $7.27, P < 0.001). Additionally, rates of hospital-acquired CDI decreased by 14% (P = 0.41) during the post-implementation period. Conclusion The tier concept, along with PAAF collaborations between the pharmacists and TMD, allowed for a greater impact on antimicrobial utilization, compared with pharmacist-led PAAF alone. In addition to significant decrease in antimicrobial utilization, substantial cost-savings were demonstrated. A nonsignificant declining trend in the incidence of hospital-acquired CDI was also noted during the post-implementation period. Disclosures All authors: No reported disclosures.

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1344. Impact of Pharmacist-Physician Team on Antimicrobial Utilization at a Pediatric Hospital

Open Forum Infectious Diseases ◽

10.1093/ofid/ofaa439.1526 ◽

2020 ◽

Vol 7 (Supplement_1) ◽

pp. S683-S683

Author(s):

Julia Sapozhnikov ◽

Marisol Fernandez

Keyword(s):

Pediatric Hospital ◽

Antimicrobial Utilization ◽

Time Period ◽

Days Of Therapy ◽

Significant Difference ◽

Central Texas ◽

Successful Approach ◽

Time Periods ◽

The Impact ◽

Physician Team

Abstract Background “Handshake stewardship” is now considered a leading practice in antimicrobial stewardship (AMS) by The Joint Commission. This study aims to evaluate the impact of a pharmacist-led and physician-pharmacist led handshake stewardship method on antimicrobial utilization at a pediatric hospital. Methods This was a single-center, retrospective quality improvement study at a teaching children’s hospital in central Texas. We retrospectively measured hospital-wide antimicrobial utilization from June 2015 to May 2020. We compared the time periods with an ID pharmacist participating in handshake stewardship ([A] July 2012 to April 2015,[B] May 2015 to May 2018 and [D] August 2019 to May 2020) and without an ID pharmacist ([C] June 2018 to July 2019). We also compared time periods with only an ID pharmacist led ASP [A] compared to a physician-pharmacist led ASP [B].The primary endpoint was days of therapy per 1,000 patient days (DOT/1000 PD). Table 1. Overall Antimicrobial Utilization During Changes in ASP Structure Results Antimicrobial utilization during pharmacist-led ASP [A] was significantly higher than during the pharmacist-physician led ASP time period [B] (95% CI, 68.8-76.8; P=0.001). No significant difference was observed for mean hospital-wide antimicrobial, meropenem, piperacillin-tazobactam, or cefepime DOT/1000 PD from period [B] to [C]. However, the increase in mean DOT/1000 PD during these time periods was statistically significant for ceftriaxone (95% CI, 6.3-23.9; P=0.001) and vancomycin (95% CI, 1.2-18.1; P=0.03). For time period [C] to [D], there was a statistically significant reduction in mean DOT/1000 PD seen in overall antimicrobial use (95% CI, 156.9-313.6; P< 0.0001). Statistically significant decreases in DOT/1000 patient days were also seen for cefepime (95% CI, 11.4-36.4; P< 0.0007), ceftriaxone (95% CI, 5.0-24.8; P=0.005), and vancomycin (95% CI, 6.1-23.1; P=0.002). No difference was seen for piperacillin-tazobactam or meropenem DOT from [C] to [D]. Figure 1. Hospital-Wide Monthly Days of Therapy per 1000 Patient Days Conclusion Active engagement with frontline providers via handshake stewardship offers a more successful approach to decreasing antimicrobial utilization. A greater reduction in overall antimicrobial utilization was seen when the ASP was led by a pharmacist-physician team compared to when it was pharmacist-led without a physician champion. Disclosures All Authors: No reported disclosures

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82. Post-Prescription Review with Threat of Infectious Disease Consultation and Sustained Reduction in Meropenem Use Over Four Years

Open Forum Infectious Diseases ◽

10.1093/ofid/ofaa439.127 ◽

2020 ◽

Vol 7 (Supplement_1) ◽

pp. S58-S58

Author(s):

Nandita S Mani ◽

Kristine F Lan ◽

Rupali Jain ◽

H Nina Kim ◽

John B Lynch ◽

...

Keyword(s):

Infectious Disease ◽

Medical Center ◽

Interrupted Time Series ◽

Antibiotic Use ◽

Percentage Change ◽

Post Intervention ◽

Sustained Reduction ◽

Days Of Therapy ◽

The University ◽

The Impact

Abstract Background Following a meropenem shortage, we implemented a post-prescription review with feedback (PPRF) in November 2015 with mandatory infectious disease (ID) consultation for all meropenem and imipenem courses > 72 hours. Providers were made aware of the policy via an electronic alert at the time of ordering. Methods A retrospective study was conducted at the University of Washington Medical Center (UWMC) and Harborview Medical Center (HMC) to evaluate the impact of the policy on antimicrobial consumption and clinical outcomes pre- and post-intervention during a 6-year period. Antimicrobial use was tracked using days of therapy (DOT) per 1,000 patient-days, and data were analyzed by an interrupted time series. Results There were 4,066 and 2,552 patients in the pre- and post-intervention periods, respectively. Meropenem and imipenem use remained steady until the intervention, when a marked reduction in DOT/1,000 patient-days occurred at both hospitals (UWMC: percentage change -72.1%, (95% CI -76.6, -66.9), P < 0.001; HMC: percentage change -43.6%, (95% CI -59.9, -20.7), P = 0.001). Notably, although the intervention did not address antibiotic use until 72 hours after initiation, there was a significant decline in meropenem and imipenem initiation (“first starts”) in the post-intervention period, with a 64.9% reduction (95% CI 58.7, 70.2; P < 0.001) at UWMC and 44.7% reduction (95% CI 28.1, 57.4; P < 0.001) at HMC. Meropenem and Imipenem DOT (January 2013 – November 2019) Conclusion Mandatory ID consultation and PPRF for meropenem and imipenem beyond 72 hours resulted in a significant and sustained reduction in the use of these antibiotics and notably impacted their up-front usage. Disclosures All Authors: No reported disclosures

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1986. Impact of Two-Step Testing on the Diagnosis and Management of Clostridium difficile in a Multi-Hospital Healthcare System

Open Forum Infectious Diseases ◽

10.1093/ofid/ofz360.1666 ◽

2019 ◽

Vol 6 (Supplement_2) ◽

pp. S665-S666

Author(s):

Angelina Davis ◽

Todd Parker ◽

Julia Coluccio ◽

Kimberly Mann ◽

Elizabeth Dodds Ashley ◽

...

Keyword(s):

Health System ◽

Community Health ◽

Negative Binomial ◽

Cohort Analysis ◽

Antibiotic Use ◽

Baseline Period ◽

Post Intervention ◽

Care Community ◽

Days Of Therapy ◽

The Impact

Abstract Background Distinguishing active C. difficile infection (CDI) from asymptomatic colonization remains a significant challenge. A multi-step testing algorithm can improve the diagnostic accuracy of CDI and associated antibacterial prescribing. This study evaluated the impact of two-step testing on CDI rates and management in a multi-hospital community health system. Methods Two-step C. difficile testing (PCR for initial screening followed by EIA for toxin detection) was implemented in 6 acute care community hospitals in April 2018. EIA testing was automatically performed on all stool samples with a positive C. difficile PCR result. Prior to implementation, PCR alone was used to identify CDI. Messaging attached to the PCR laboratory report alerted prescribers of discrepant results (PCR +/EIA -). Anti-C. difficile therapy was at the discretion of the prescriber. We performed a retrospective cohort analysis over a 2-year period to evaluate the effect of two-step testing on system-wide hospital-onset CDI (HO-CDI) per 10,000 patient-days (PD) and anti-CDI antimicrobial use (AU) in days of therapy (DOT) per 1,000 PD. Segmented negative binomial regression with hospital clustering was used to estimate predicted HO-CDI rate for the baseline period between April 1, 2017 through March 31, 2018 and the post-intervention between May 1, 2018 through March 31, 2019. The implementation date at all sites in April 2018 was unknown; therefore, this month was removed from the analysis. Anti-CDI agents included fidaxomicin, metronidazole, and oral vancomycin, but may have included non-CDI indications for metronidazole. Results A total of 115 HO-CDI cases were identified; 91 (79%) before and 24 (21%) after. Prior to implementation of two-step testing, CDI rates declined at 4% per month (P = NS). The rate immediately dropped by 36% (P = 0.004) after two-step testing was implemented, but the trend did not significantly change (P = 0.52, Figure 1). Community-onset CDI rates also decreased during this time period. Combined facility-wide anti-CDI agent use was 824.87 before and 838.21 DOT/1,000 PD after and did not significantly change. Conclusion Use of a two-step approach for CDI testing reduced HO-CDI rates, but did not have a significant impact on anti-CDI antibiotic use in a multi-hospital community health system. Disclosures All authors: No reported disclosures.

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