2044. An Assessment and Feedback Model Bringing Antimicrobial Stewardship Program Expertise to Long-Term Care Facilities

Abstract Background Long-term care facilities (LTCF) often struggle with implementation of antimicrobial stewardship programs (ASP) that meet all CDC core elements (CE). The CDC recommends partnership with infectious diseases (ID)/ASP experts to guide ASP implementation. The Nebraska Antimicrobial Stewardship Assessment and Promotion Program (ASAP) is an initiative funded by NE DHHS via a CDC grant to assist healthcare facilities with ASP implementation. Methods ASAP performed on-site baseline evaluation of ASP in 5 LTCF (42–293 beds) in the spring of 2017 using a 64-item questionnaire based on CDC CE. After interviewing ASP members, ASAP provided prioritized facility-specific recommendations for ASP implementation. LTCF were periodically contacted in the next 12 months to provide implementation support and evaluate progress. The number of CE met, recommendations implemented, antibiotic starts (AS) and days of therapy (DOT)/1000 resident-days (RD), and incidence of facility-onset Clostridioides difficile infections (FO-CDI) were compared 6 to 12 months before and after on-site visits. Paired t-test and Wilcoxon signed rank test were used for statistical analyses. Results Multidisciplinary ASP existed in all 5 facilities at baseline with medical directors (n = 2) or directors of nursing (n = 3) designated as team leads. Median CE implemented increased from 3 at baseline to 6 at the end of follow-up (P = 0.06). No LTCF had all 7 CE at baseline. By the end of one year, 2 facilities implemented all 7 CE with the remaining implementing 6 CE. LTCF not meeting all CE were only deficient in reporting ASP metrics to providers and staff. Among the 38 recommendations provided by ASAP, 82% were partially or fully implemented. Mean AS/1000 RD reduced by 19% from 10.1 at baseline to 8.2 post-intervention (P = 0.37) and DOT/1000 RD decreased by 21% from 91.7 to 72.5 (P = 0.20). The average incidence of FO-CDI decreased by 75% from 0.53 to 0.13 cases/10,000 RD (P = 0.25). Conclusion Assessment of LTCF ASP along with feedback for improvement by ID/ASP experts resulted in more programs meeting all 7 CE. Favorable reductions in antimicrobial use and CDI rates were also observed. Moving forward, the availability of these services should be expanded to all LTCFs struggling with ASP implementation. Disclosures All authors: No reported disclosures.

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Impact of an Antibiotic Stewardship Program in Long-term Care Facilities: A Nursing Home Network Experience

Open Forum Infectious Diseases ◽

10.1093/ofid/ofx162.150 ◽

2017 ◽

Vol 4 (suppl_1) ◽

pp. S63-S63

Author(s):

Fabian Andres Romero ◽

Evette Mathews ◽

Ara Flores ◽

Susan Seo

Keyword(s):

Nursing Home ◽

Antibiotic Stewardship ◽

Long Term Care ◽

Post Intervention ◽

Term Care ◽

Stewardship Program ◽

Days Of Therapy ◽

Care Facilities ◽

The Impact

Abstract Background Antibiotic stewardship program (ASP) implementation is paramount across the healthcare spectrum. Nursing homes represent a challenge due to limited resources, complexity of medical conditions, and less controlled environments. National statistics on ASP for long-term care facilities (LTCF) are sparse. Methods A pilot ASP was launched in August 2016 at a 270-bed nursing home with a 50-bed chronic ventilator-dependent unit. The program entailed a bundle of interventions including leadership engagement, a tracking and reporting system for intravenous antibiotics, education for caregivers, Infectious Disease (ID) consultant availability, and implementation of nursing protocols. Data were collected from pharmacy and medical records between January 2016 and March 2017, establishing pre-intervention and post-intervention periods. Collected data included days of therapy (DOT), antibiotic costs, resident-days, hospital transfers, and Clostridium difficile infection (CDI) rates. Variables were adjusted to 1,000 resident-days (RD) and findings between periods were compared by Mann–Whitney U test. Results A total of 47,423 resident-days and 1,959 DOT were analyzed for this study. Antibiotic use decreased from 54.5 DOT/1000 RD pre-intervention to 27.6 DOT/1000 RD post-intervention (P = 0.017). Antibiotic costs were reduced from a monthly median of US $17,113 to US $7,073 but was not statistically significant (P = 0.39). Analysis stratified by individual antibiotic was done for the five most commonly used antibiotics and found statistically significant reduction in vancomycin use (14.4 vs. 6.5; P = 0.023). Reduction was also found for cefepime/ceftazidime (6.9 vs. 1.3; P = 0.07), ertapenem (6.8 vs. 3.6; P = 0.45), and piperacillin/tazobactam (1.8 vs. 0.6; P = 0.38). Meropenem use increased (1.3 vs. 3.2; P = 0.042). Hospital transfers slightly trended up (6.73 vs. 7.77; P = 0.065), and there was no change in CDI (1.1 s 0.94; P = 0.32). Conclusion A bundle of standardized interventions tailored for LTCF can achieve successful reduction of antibiotic utilization and costs. Subsequent studies are needed to further determine the impact on clinical outcomes such as transfers to hospitals and CDI in these settings. Disclosures All authors: No reported disclosures.

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Impact of Training Consultant Pharmacists on Antimicrobial Stewardship Programs in Long-Term Care Facilities

Infection Control and Hospital Epidemiology ◽

10.1017/ice.2020.1116 ◽

2020 ◽

Vol 41 (S1) ◽

pp. s446-s448

Author(s):

Muhammad Salman Ashraf ◽

Philip Chung ◽

Alex Neukirch ◽

Scott Bergman ◽

R. Jennifer Cavalieri ◽

...

Keyword(s):

Antimicrobial Stewardship ◽

Repeated Measures ◽

Long Term Care ◽

Antibiotic Use ◽

Rank Test ◽

Term Care ◽

Days Of Therapy ◽

Care Facilities ◽

Core Elements

Background: The CDC recommends that consultant pharmacists support antimicrobial stewardship programs (ASPs) in long-term care facilities (LTCFs). We studied CDC-recommended ASP core elements implementation and antibiotic use in LTCFs before and after training consultant pharmacists. Methods: Between August 2017 and October 2017, consultant pharmacists from a regional long-term care pharmacy attended 5 didactic sessions preparing them to assist LTCFs in implementation of CDC-recommended ASP core elements. Training also included creating a process for evaluating appropriateness of all systemic antibiotics and providing prescriber feedback during their monthly mandatory drug-regimen reviews. Once monthly “meet-the-expert” sessions were held with consultant pharmacists throughout the project (November 2017 to December 2018). LTCF enrollment began in November 2017 and >90% of facilities joined by January 2018. After enrollment, consultant pharmacists initiated ASP interventions including antibiotic reviews and feedback using standard templates. They also held regular meetings with infection preventionists to discuss Core Elements implementation and provided various ASP resources to LTCFs (eg, antibiotic policy template, guidance documents and standard assessment and communication tools). Data collection included ASP Core Elements, antibiotic starts, days of therapy (DOT), and resident days (RD). The McNemar test, the Wilcoxon signed-rank test, generalized estimating equation model, and the classic repeated measures approach were used to compare the presence of all 7 core elements and antibiotic use during the baseline (2017) and intervention (2018) year.Results: In total, 9 trained consultant pharmacists assisted 32 LTCFs with ASP implementation. When evaluating 27 LTCFs that provided complete data, a significant increase in presence of all 7 Core Elements after the intervention was noted compared to baseline (67% vs 0; median Core Elements, 7 vs 2; range, 6–7 vs 1–6; P < .001). Median monthly antibiotic starts per 1,000 RD and DOT per 1,000 RD decreased in 2018 compared to 2017: 8.93 versus 9.91 (P < .01) and 106.47 versus 141.59 (P < .001), respectively. However, variations in antibiotic use were detected among facilities (Table 1). When comparing trends, antibiotic starts and DOT were already trending downward during 2017 (Fig. 1A and 1B). On average, antibiotic starts decreased by 0.27 per 1,000 RD (P < .001) and DOT by 1.92 per 1,000 RD (P < .001) each month during 2017. Although antibiotic starts remained mostly stable in 2018, DOT continued to decline further (average monthly decline, 2.60 per 1,000 RD; P < .001). When analyzing aggregated mean, antibiotic use across all sites per month by year, DOT were consistently lower throughout 2018 and antibiotic starts were lower for the first 9 months (Fig. 1C and 1D). Conclusions: Consultant pharmacists can play an important role in strengthening ASPs and in decreasing antibiotic use in LTCFs. Educational programs should be developed nationally to train long-term care consultant pharmacists in ASP implementation.Funding: Merck & Co., Inc, provided funding for this study.Disclosures: Muhammad Salman Ashraf and Scott Bergman report receipt of a research grant from Merck.

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2055. Action: A Year in the Lives of Consultant Pharmacists Working on Antimicrobial Stewardship in Long-Term Care Facilities

Open Forum Infectious Diseases ◽

10.1093/ofid/ofz360.1735 ◽

2019 ◽

Vol 6 (Supplement_2) ◽

pp. S692-S693

Author(s):

Philip Chung ◽

Alex Neukirch ◽

Rebecca J Ortmeier ◽

Scott Bergman ◽

Mark E Rupp ◽

...

Keyword(s):

Antimicrobial Stewardship ◽

First Generation ◽

Long Term Care ◽

Diagnostic Testing ◽

Drug Regimen ◽

Term Care ◽

Clostridioides Difficile ◽

Care Facilities ◽

Tract Infections

Abstract Background The CDC recommends consultant pharmacists (CP) support antimicrobial stewardship (AS) activities in long-term care facilities (LTCF) by reviewing antimicrobial appropriateness. We initiated a project training CP from a regional long-term care pharmacy to support AS implementation in LTCF. Methods CP were trained to evaluate the appropriateness of all systemic antimicrobial therapy (AT) and provide prescriber feedback during their monthly drug regimen review (DRR). An electronic database was developed to facilitate data reporting. Antimicrobial use (AU) and adverse events (AE) from 32 LTCF were analyzed for 2018 using descriptive statistics. Results A total of 5327 courses of AT with a median duration of 7 days (IQR 5–10) were reviewed. The majority of AT was started in the LTCF (55%) but was also initiated in hospitals (24%), clinics (11%) and emergency departments (2%). Of 2926 AT started in LTCF, 36% were based on nurse evaluation (NE) while 33% began after prescriber evaluation (PE). Fluoroquinolones (FQ) and first-generation cephalosporins were the most commonly prescribed agents (Table 1). Treatment or prophylaxis of urinary tract infections accounted for 40% of AU (Figure 1). Diagnostic testing was associated with 37% of AT courses. Urine cultures were the most frequent test performed (81%). Overall, 41% of AT was determined to be inappropriate resulting in > 800 feedback letters sent to prescribers. Unnecessary antibiotic starts (based on revised Mc Geer or Loeb’s criteria) were identified as the most common reason (Figure 2). AT appropriateness varied depending on the setting in which it was initiated. A majority (87%) of AT initiated in hospitals was found to be appropriate with 56% and 46% appropriate for ED and clinic starts. Appropriateness of LTCF initiated AT was 49% (59% after PE and 42% after NE). AE were associated with 3% of AT with allergic reactions and Clostridioides difficile infections occurring with 0.4% and 0.7% of AT, respectively. AE were most frequently associated with folate antagonists (5%) and FQ (3%). Conclusion This study demonstrates many AU improvement opportunities exist in LTCF and CP can play an important role in identifying them if trained in AS principles. CP should review all AU for appropriateness and provide data to inform AS efforts in LTCF. Disclosures All authors: No reported disclosures.

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Determining Antibiotic Use in Long-Term Care Facilities Across Tennessee

Infection Control and Hospital Epidemiology ◽

10.1017/ice.2020.723 ◽

2020 ◽

Vol 41 (S1) ◽

pp. s185-s186

Author(s):

Cullen Adre ◽

Youssoufou Ouedraogo ◽

Christopher David Evans ◽

Amelia Keaton ◽

Marion Kainer

Keyword(s):

Infection Control ◽

Antimicrobial Stewardship ◽

Long Term Care ◽

Respiratory Infections ◽

Antibiotic Use ◽

Term Care ◽

Days Of Therapy ◽

Care Facilities ◽

Core Elements

Background: Antibiotic stewardship is an area of great concern in long-term care facilities nationwide. The CDC promotes 7 core elements of antimicrobial stewardship. Based on information obtained from the Infection Control Assessment and Response (ICAR) Program, the 2 core elements most infrequently achieved by LTCFs are tracking and reporting. Currently, minimal data are available on antibiotic use (AU) in LTCFs in Tennessee. To address both issues, the Tennessee Department of Health (TDH) developed a monthly antibiotic use (AU) point-prevalence (PP) survey to provide LTCFs with a free tool to both track and report their AU and to gather data on how LTCFs are using antibiotics. Methods: We used REDCap to create a questionnaire to collect information on selected antibiotics administered in Tennessee LTCFs. This self-administered survey was promoted through the TDH monthly antimicrobial stewardship and infection control (ASIC) call as well as at various conferences and speaking engagements across the state. Antimicrobial stewardship leads for each facility were targeted. Antibiotics were grouped into 4 classes according to their indications: C. difficile infections, urinary tract infections, skin and soft-tissue infections (SSTIs) and respiratory infections. We determined AU percentage by dividing the number of days of therapy for a drug by a facility’s average census. Individualized reports are provided to each participating facility on a quarterly basis. Results: Currently, 16 facilities have participated in the survey. Overall, 40.7% of antibiotics prescribed were in the common for SSTI category and 39.3% were common for respiratory infections. The top 33 most commonly prescribed antibiotics were amoxicillin (156 days of therapy [DOT]), nitrofurantoin (92 DOT), and levofloxacin (88 DOT). The average percentage of residents on antimicrobials on the day of survey was 12.3%; within this group, 57% of antibiotics were initiated in the LTCF, whereas 43% were present upon admission. Conclusions: Early results from the TDH AU PP survey revealed that drugs commonly used for SSTIs and respiratory infection were the most common antibiotic prescriptions and a potential area of focus for TDH’s antimicrobial stewardship efforts. None of the 3 most frequently prescribed antibiotics, however, fall under the SSTI indication, despite SSTI being the most commonly prescribed indication based on the survey’s evaluation metrics. This finding could be related to the larger number of antibiotics that fall under the SSTI indication. Preliminary data are being used to guide the direction of TDH’s future ASIC calls to better suit disease states, which have room for improvement.Funding: NoneDisclosures: None

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1148. Antimicrobial Stewardship Program at a Long-term Care Hospital for Severely Handicapped Children and Adults

Open Forum Infectious Diseases ◽

10.1093/ofid/ofz360.1012 ◽

2019 ◽

Vol 6 (Supplement_2) ◽

pp. S409-S410

Author(s):

Sho Ishii ◽

Kazuhiro Uda ◽

Yasuko Kudo ◽

Koji Fukano ◽

Masako Igari ◽

...

Keyword(s):

Infectious Diseases ◽

Antimicrobial Stewardship ◽

Long Term Care ◽

Antimicrobial Use ◽

Antimicrobial Stewardship Program ◽

Post Intervention ◽

Term Care ◽

Level Change ◽

Stewardship Program

Abstract Background Although antimicrobial stewardship program (ASP) is also recommended for a long-term care facility (LTCF), research on ASP in LTCFs is still limited. Our study was conducted at an LTCF offering chronic medical care for pediatric and adult patients with extensive medical needs since childhood. Our aim of this study was to evaluate the impacts of ASP in an LTCF. Methods A quasi-experimental study was conducted at Tokyo Metropolitan Fuchu Ryoiku Medical Center (250 beds) in Japan. The pre- and post-intervention periods were from April 2013 to March 2017 and April 2017 to March 2019, respectively. Periodic educational interventions were conducted throughout study period. ASP in post-intervention period consisted of mandatory consultation with infectious diseases service at an outside children’s hospital for prescription of restricted drugs. Fluoroquinolones, cefepimes, carbapenems and vancomycin were listed as restricted drugs. Intravenous and oral antimicrobial use was calculated by day of therapy (DOT) per 1,000 patient-days. Interrupted time series analysis was used for level and trend change for pre- and post-intervention periods. Results Oral agents comprised 89% of the total antimicrobial use. Oral antimicrobials were decreased by 39% in post-intervention with significant level change (P < 0.01) and without trend change (P = 0.61) (Figure 1). Among oral antimicrobials, macrolides, fluoroquinolones and third-generation cephalosporins were decreased by 72% in post-intervention with significant level change (P < 0.01) and without trend change (P = 0.42) (Figure 2). Intravenous antimicrobials were decreased by 40% without level change (P = 0.15) and trend change (P = 0.65) (Figure 3). Conclusion Combining education and mandatory consultation with infectious diseases service for restricted drug enhanced in decreasing total oral antimicrobials at an LTCF. Disclosures All authors: No reported disclosures.

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Determining Core Element Achievement in Long-Term Care Facilities Across Tennessee

Infection Control and Hospital Epidemiology ◽

10.1017/ice.2020.584 ◽

2020 ◽

Vol 41 (S1) ◽

pp. s89-s89

Author(s):

Cullen Adre ◽

Youssoufou Ouedraogo ◽

Christopher David Evans ◽

Amelia Keaton ◽

Marion Kainer

Keyword(s):

Antimicrobial Stewardship ◽

Long Term Care ◽

Core Element ◽

Term Care ◽

Current State ◽

Stewardship Program ◽

National Quality ◽

Care Facilities ◽

Core Elements

Background: In 2017, a new antimicrobial stewardship standard was established by the Joint Commission that requires long-term care facilities (LTCFs) to have an antimicrobial stewardship program (ASP) based on current scientific literature. The Tennessee Department of Health (TDH) team sought to ascertain the current state of ASPs across Tennessee and to assist programs with implementation strategies. Utilizing a Centers for Medicaid and Medicare Services’ Civil Monetary Penalties grant, the TDH purchased copies of the National Quality Partners Playbook for Antibiotic Stewardship in Post-Acute and Long-Term Care to provide to LTCFs as incentive to complete a survey that would evaluate their current adoption of core elements. Methods: A self-administered questionnaire on ASP practices was developed and distributed to LCTFs. This survey expanded upon questions from the NHSN 2018 LTCF annual survey. These questions pertained to actionable items facilities are taking to achieve core elements. Achievement of the CDC’s 7 core elements of ASPs was determined based upon a combination of 1 or more responses to the survey questions. The percentage of LTCFs achieving each ASP core element at the regional and statewide level was determined. We also calculated the percentage of LTCFs that achieved all 7 elements versus 5 or more core elements. The analyses and visualizations were performed using SAS 9.4 and Tableau software. Results: Currently, 88 of 316 licensed LTCF facilities in Tennessee have participated in the survey. All regions were represented by EMS region. Based on the results of our survey, 100% of participating facilities have achieved at least 5 core elements, and 78% of participating facilities have achieved all 7 core elements. The core element with the lowest achievement was Accountability at 89%, and reporting and action had the highest achievement (100%). Conclusions: Early results suggest that LTCFs across Tennessee have active ASPs with strong core element achievement. However, we received responses from only 27% of licensed LTCFs. Minimal data are available regarding the current state of LTCF ASPs in Tennessee, and data will continue to be collected and analyzed. Participation may be limited to those already actively engaged in public health efforts, including antimicrobial stewardship. LTCFs that have participated in the initial evaluation will be surveyed at 6 months and 12 months after receipt of playbooks to evaluate their ASP progression and NQP Playbook utilization.Funding: NoneDisclosures: None

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The Impact of Enhanced Antimicrobial Stewardship Support on Antibiotic Starts in Long-Term Care Facilities

Infection Control and Hospital Epidemiology ◽

10.1017/ice.2020.1212 ◽

2020 ◽

Vol 41 (S1) ◽

pp. s527-s527

Author(s):

Gabriela Andujar-Vazquez ◽

Kirthana Beaulac ◽

Shira Doron ◽

David R Snydman

Keyword(s):

Public Health ◽

Pilot Study ◽

Infection Control ◽

Antimicrobial Stewardship ◽

Long Term Care ◽

Medical Center ◽

Term Care ◽

Care Facilities ◽

The Impact

Background: The Tufts Medical Center Antimicrobial Stewardship (ASP) Team has partnered with the Massachusetts Department of Public Health (MDPH) to provide broad-based educational programs (BBEP) to long-term care facilities (LTCFs) in an effort to improve ASP and infection control practices. LTCFs have consistently expressed interest in individualized and hands-on involvement by ASP experts, yet they lack resources. The goal of this study was to determine whether “enhanced” individualized guidance provided by an ASP expert would lead to antibiotic start decreases in LTCFs participating in our pilot study. Methods: A pilot study was conducted to test the feasibility and efficacy of providing enhanced ASP and infection control practices to LTCFs. In total, 10 facilities already participating in MDPH BBEP and submitting monthly antibiotic start data were enrolled, were stratified by bed size and presence of dementia unit, and were randomized 1:1 to the “enhanced” group (defined as reviewing protocols and antibiotic start cases, providing lectures and feedback to staff and answering questions) versus the “nonenhanced” group. Antibiotic start data were validated and collected prospectively from January 2018 to July 2019, and the interventions began in April 2019. Due to staff turnover and lack of engagement, intervention was not possible in 2 of the 5 LTCFs randomized to the enhanced group, which were therefore analyzed as a nonenhanced group. An incidence rate ratios (IRRs) with 95% CIs were calculated comparing the antibiotic start rate per 1,000 resident days between periods in the pilot groups. Results: The average bed sizes for enhanced groups versus nonenhanced groups were 121 (±71.0) versus 108 (±32.8); the average resident days per facility per month were 3,415.7 (±2,131.2) versus 2,911.4 (±964.3). Comparatively, 3 facilities in the enhanced group had dementia unit versus 4 in the nonenhanced group. In the per protocol analysis, the antibiotic start rate in the enhanced group before versus after the intervention was 11.35 versus 9.41 starts per 1,000 resident days (IRR, 0.829; 95% CI, 0.794–0.865). The antibiotic start rate in the nonenhanced group before versus after the intervention was 7.90 versus 8.23 antibiotic starts per 1,000 resident days (IRR, 1.048; 95% CI, 1.007–1.089). Physician hours required for ASP for the enhanced group totaled 8.9 (±2.2) per facility per month. Conclusions: Although the number of hours required for intervention by an expert was not onerous, maintaining engagement proved difficult and in 2 facilities could not be achieved. A statistically significant 20% decrease in the antibiotic start rate was achieved in the enhanced group after interventions, potentially reflecting the benefit of enhanced ASP support by an expert.Funding: This study was funded by the Leadership in Epidemiology, Antimicrobial Stewardship, and Public Health (LEAP) fellowship training grant award from the CDC.Disclosures: None

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Antimicrobial Stewardship in Long-Term Care Facilities: Focus on Suspected Urinary Tract Infection

Urologic Nursing ◽

10.7257/1053-816x.2021.41.1.21 ◽

2021 ◽

Vol 41 (1) ◽

pp. 21

Author(s):

Margery Shane

Keyword(s):

Urinary Tract Infection ◽

Urinary Tract ◽

Tract Infection ◽

Antimicrobial Stewardship ◽

Long Term Care ◽

Term Care ◽

Care Facilities

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Changes in antibiotic use following implementation of a telehealth stewardship pilot program

Infection Control and Hospital Epidemiology ◽

10.1017/ice.2019.128 ◽

2019 ◽

Vol 40 (7) ◽

pp. 810-814 ◽

Cited By ~ 2

Author(s):

Brigid M. Wilson ◽

Richard E. Banks ◽

Christopher J. Crnich ◽

Emma Ide ◽

Roberto A. Viau ◽

...

Keyword(s):

Antibiotic Stewardship ◽

Long Term Care ◽

Antibiotic Use ◽

Veterans Affairs ◽

Term Care ◽

Medical Centers ◽

Stewardship Program ◽

Days Of Therapy ◽

Veterans Affairs Medical Centers

AbstractStarting in 2016, we initiated a pilot tele-antibiotic stewardship program at 2 rural Veterans Affairs medical centers (VAMCs). Antibiotic days of therapy decreased significantly (P < .05) in the acute and long-term care units at both intervention sites, suggesting that tele-stewardship can effectively support antibiotic stewardship practices in rural VAMCs.

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