scholarly journals 1031. Effect of On-Site ID Specialist Led, Antimicrobial Stewardship Pharmacist Driven Program on Provider Acceptance, Antimicrobial Utilization and Clostridoides Infection Rates In a Community Hospital / Rural Regional Referral Center

2019 ◽  
Vol 6 (Supplement_2) ◽  
pp. S363-S363
Author(s):  
Daniel Brailita ◽  
Justin Lane
Keyword(s):  
Community Hospital ◽  
Antibiotic Use ◽  
Antimicrobial Use ◽  
Referral Center ◽  
Clostridioides Difficile ◽  
Antimicrobial Utilization ◽  
Core Elements ◽  
Implementation Guidelines ◽  
Hospital Acquired ◽  
Direct Feedback

Abstract Background Antibiotic Stewardship (ASP) standards for hospitals became effective January 1, 2017. Core Elements implementation guidelines have been challenging for rural hospitals usually lacking on-site expertise. Our 170-bed Community Hospital / rural referral center has dedicated resources for on-site ASP. Our team includes on-site Infectious Disease (ID) Specialist and dedicated ASP pharmacist. Over first 2 years, our model shows very high provider acceptance, improvement in antimicrobial use pattern and reduction in the number of Clostridioides difficile infections (CDI). Methods The ASP Pharmacist conducted a daily review of ASP targets. He met with on-site ID Physician 3 days weekly to discuss interventions and review complex cases. The ASP team - ID Medical Director, ASP Pharmacist, Microbiologist, Invention Preventionist and Hospitalist met monthly to discuss outcomes and facility-wide interventions. ASP audit included: positive cultures, patients on multiple or broad-spectrum antimicrobials, patients receiving dual nephrotoxic drugs, carbapenems, fluoroquinolones, candidates for IV to PO conversion The audit results were communicated in-person to attending physician and documented in electronic medical record. Results ASP team recommendations were accepted in 94% of cases ID consult was recommended in 4.69% and was accepted 100%. Top 20 IV antimicrobial use decreased by 10%. Fluoroquinolones (29%) and carbapenems (28%) showed highest decrease. Cephalosporins showed small increase. Hospital-acquired CDI rate decreased from 0.83 cases/ 1000 patient-days (PD) pre-ASP to 0.53 cases/ 1000 PD post-ASP. General CDI diagnosis decreased from 3.21 cases/1000 PD pre-ASAP to 2.23 cases/ 1000 PD post-ASP Conclusion An on-site, ID Specialist reviewed and dedicated ASP Pharmacist driven program at a rural referral center/ Community Hospital significantly improved antibiotic use and decreased Clostridium Difficile Infections in the first 2 years. Direct feedback of ASP review to providers resulted in an excellent acceptance rate. On-site ID and ASP Pharmacist collaboration is logistically difficult to achieve but expanding our model to rural referral centers should be considered. More research is needed to determine the cost-effectiveness of onsite, dual led programs. Disclosures All authors: No reported disclosures.

Sustained reductions in unnecessary antimicrobial administration and hospital Clostridioides difficile rates via stewardship in a nonacademic setting

2021 ◽  
pp. 1-3
Author(s):  
Neil Gaffin ◽  
Brad Spellberg
Keyword(s):  
Community Hospital ◽  
Community Setting ◽  
Antimicrobial Use ◽  
Antimicrobial Stewardship Program ◽  
Gram Negative ◽  
Clostridioides Difficile ◽  
Stewardship Program ◽  
Acquisition Costs ◽  
Hospital Acquired ◽  
Antimicrobial Administration

Abstract A large community hospital sought to reduce its burden of hospital-acquired Clostridioides difficile infection (CDI). We implemented an antimicrobial stewardship program (ASP), resulting in marked reductions in unnecessary antimicrobial use, CDI rates, antimicrobial acquisition costs, with preservation of gram-negative susceptibilities. ASP programs are effective in a community setting.

scholarly journals 39. Impact of Antimicrobial Stewardship Interventions in a Community Hospital setting: An Interrupted Times Analysis

2021 ◽  
Vol 8 (Supplement_1) ◽  
pp. S141-S142
Author(s):  
Jason Li ◽  
Ken Chan ◽  
Hina Parvez ◽  
Margaret Gorlin ◽  
Miriam A Smith
Keyword(s):  
Antimicrobial Stewardship ◽  
Community Hospital ◽  
Hospital Setting ◽  
Interrupted Time Series ◽  
Antibiotic Use ◽  
Antimicrobial Use ◽  
Intervention Period ◽  
Prospective Audit ◽  
Post Intervention ◽  
The Impact

Abstract Background Community hospitals have fewer resources for antimicrobial stewardship programs (ASP) compared to larger tertiary hospitals. At our 312-bed community hospital, Long Island Jewish Forest Hills/Northwell, a combination of modified preauthorization, prospective audit feedback, and ASP education was implemented starting in August 2019 (Monday through Friday 9 am to 5 pm). Methods This retrospective study evaluated the impact of ASP interventions on the rate of targeted antimicrobial use over a 7 month pre- vs 7 month post- intervention period (Aug 2018 to Feb 2019 vs Aug 2019 to Feb 2020). Targeted antimicrobials included piperacillin-tazobactam, vancomycin, daptomycin, and carbapenems. The primary outcome was the monthly mean for overall targeted antimicrobial use measured by the rate of antimicrobial days per 1000 days present. Secondary outcomes were the individual rates of antimicrobial days per 1000 days present for each of the targeted antimicrobials, and the hospital’s overall standardized antimicrobial administration ratio (SAAR). Data were analyzed as a segmented regression of interrupted time series. Results Pre-intervention, there was an increasing trend (positive slope, p< 0.05) in the monthly mean, hospital SAAR, vancomycin and piperacillin-tazobactam use. Post-intervention, there was a significant change in slope for these same metrics, indicating a decrease in the mean use. Immediate impact of ASP interventions, measured by the difference in antibiotic use between the end of each intervention period, was visually evident in all cases except carbapenems (Fig. 1 through 4). The immediate impact on the overall monthly mean represented a significant reduction in the rate of antimicrobial days per 1000 days present, -12.72 (CI -21.02 to -4.42, P < 0.0066). The pre- vs post- ASP gap for all measures was negative and consistent with fewer days of antibiotic use immediately following intervention. Conclusion A targeted, multifaceted ASP intervention utilizing modified preauthorization, prospective audit feedback, and education significantly reduced antibiotic use in a community hospital. Disclosures All Authors: No reported disclosures

scholarly journals 174. Impact of Cascade Reporting of Antimicrobial Susceptibility on Antimicrobial Consumption at a Veterans Affairs Medical Center

2020 ◽  
Vol 7 (Supplement_1) ◽  
pp. S94-S95
Author(s):  
Nicole C Vissichelli ◽  
Christine M Orndahl ◽  
Jane A Cecil ◽  
Emily Hill ◽  
Roy T Sabo ◽  
...  
Keyword(s):  
Antimicrobial Susceptibility ◽  
Medical Center ◽  
Tertiary Care ◽  
Antimicrobial Use ◽  
Clostridioides Difficile ◽  
Antimicrobial Utilization ◽  
Days Of Therapy ◽  
Consumption Rates ◽  
Quasi Experimental ◽  
Amoxicillin Clavulanate

Abstract Background Cascade reporting (CR) is a strategy of reporting antimicrobial susceptibility test results in which secondary agents are only reported if an organism is resistant to primary, narrow spectrum agents within a drug class. A multidisciplinary team developed CR algorithms for Gram-negative bacteria based on the local antibiogram and infectious diseases practice guidelines. Methods CR was implemented at a 399-bed tertiary care VAMC in March 2018. In a quasi-experimental study, antimicrobial use data across 8 inpatient units were extracted from the CDC’s NHSN AU module from April 2017 – March 2019 (12 months pre- and post-implementation of CR), reported as antimicrobial days of therapy (DOT) per 1000 days present (DP). T-tests and linear mixed models accounting for seasonal and random unit effects were used to compare antimicrobial use pre- and post-CR implementation. Figure 1A. Cascade reporting algorithm for antimicrobial susceptibility reporting for Enterobacteriaceae Figure 1B. Cascade reporting algorithm for antimicrobial susceptibility reporting for Pseudomonas aeruginosa Results Following CR implementation, mean monthly meropenem (p=0.005) and piperacillin/tazobactam (p=0.002) use decreased, while cefepime use increased (p< 0.001). The slope of ciprofloxacin use decreased by 2.16 DOTs/1,000 DP per month (SE=0.25, p< 0.001). The slope of cefpodoxime and moxifloxacin use decreased by 18% (p< 0.001), and 7% (p< 0.001), respectively. The slope of cephalexin use decreased by 0.55 DOTs/1,000 DP (SE=0.26, p< 0.001). The slope of ceftriaxone and cefepime use increased by 1.51 (SE=0.59, p=0.011) and 1.06 (SE=.32, p=0.002) DOTs/1000 DP per month, respectively. There were no significant changes in the slope of amoxicillin/clavulanate, levofloxacin, or meropenem consumption. Rates of Clostridioides difficile infection did not significantly change. Figure 2A. Average monthly use of oral antibiotics across all units in average days of therapy (DOTs) per 1000 days present. CR = Cascade reporting. *For Cefpodoxime and moxifloxacin medians were reported as data was not normally distributed. Figure 2B. Average monthly use of intravenous antibiotics across all units in average days of therapy (DOTs) per 1000 days present. CR = Cascade reporting. Table 1. Slope of Antimicrobial Utilization Pre and Post-Cascade Reporting Implementation. Conclusion After implementation of CR, the slope of ciprofloxacin use decreased and mean monthly meropenem use decreased. CR is a valuable tool that can be employed by ASPs to encourage optimal use of antibiotics. Disclosures All Authors: No reported disclosures

scholarly journals Does electronic stewardship work?

2017 ◽  
Vol 24 (5) ◽  
pp. 981-985 ◽  
Author(s):  
Barbara B Lambl ◽  
Nathan Kaufman ◽  
Janice Kurowski ◽  
W O’Neill ◽  
Frederick Buckley Jr ◽  
...  
Keyword(s):  
Decision Support ◽  
High Risk ◽  
Clostridium Difficile ◽  
Antimicrobial Stewardship ◽  
Community Hospital ◽  
Antibiotic Use ◽  
Drug Resistant ◽  
Community Hospitals ◽  
Hospital Acquired ◽  
Electronic Order

Abstract Faced with national requirements to promote antimicrobial stewardship and reduce drug-resistant infections, community hospitals are challenged to make the best use of existing resources. Eighteen months after building antibiotic decision support into our electronic order platform, high-risk antibiotic use decreased by 83% (P < .001) at our community hospital. Hospital-acquired Clostridium difficile infections declined 24% (P = .07).

scholarly journals 1985. Impact of Suppressing Ciprofloxacin Susceptibility Results on Antibiotic Utilization and Hospital-acquired Clostridioides difficile Infection

2019 ◽  
Vol 6 (Supplement_2) ◽  
pp. S664-S665
Author(s):  
Bryan P White ◽  
Daniel B Chastain ◽  
Karen Kinney ◽  
Katie Thompson ◽  
Jerry Kelley ◽  
...  
Keyword(s):  
Antibiotic Use ◽  
Interrupted Time Series Analysis ◽  
E Coli ◽  
Clostridioides Difficile ◽  
Antibiotic Utilization ◽  
Increased Risk ◽  
Days Of Therapy ◽  
Before And After ◽  
Hospital Acquired ◽  
The Impact

Abstract Background Fluoroquinolones (FQs) are broad-spectrum antibiotics associated with multiple adverse effects and an increased risk of Clostridioides difficile infections (CDI). Previous data suggest that suppression of FQ susceptibility results decreased FQ use. The purpose of this study was to examine the impact of suppressing ciprofloxacin susceptibility on antibiotic use, susceptibility, and CDI. Methods This was a single-center quasi-experimental study of the effect of the suppression of ciprofloxacin susceptibility on pan susceptible urine isolates for Klebsiella sp. and E. coli starting in March 2018 in the 11 months before and after the intervention. Monthly antibiotic utilization in days of therapy (DOT)/1,000 patient-days for levofloxacin, ciprofloxacin, ceftriaxone, trimethoprim/sulfamethoxazole (TMP/SMZ), fosfomycin, and nitrofurantoin, hospital-acquired CDI (HA-CDI) rates as defined by CDC, and Pseudomonas aeruginosa susceptibility was compared with interrupted time series analysis using Stata MP 12.1 before and after the intervention to compare the level, intercept, and rate, slope, of a trend line. Results There was no change in the level or rate of ciprofloxacin DOT (0.27, 95% CI: −0.94 to 1.48–3.49; 95% CI: −10.89 to 3.90) and levofloxacin DOT (−5.87, 95% CI: −17.79 to 6.06; −0.98, 95% CI −2.86 to 0.90) with the intervention, respectively. Level of P. aeruginosa susceptibility to ciprofloxacin level (8.13, 95% CI: 0.00 to 16.26) had a trend toward increasing and rate (1.65, 95% CI: 0.44 to 2.87) increased after the intervention. Ceftriaxone DOT level decreased after the intervention (P = 0.01), but the rate did not change. Cephalexin (P = 0.01) and nitrofurantoin (P = 0.01) DOT levels increased after the intervention without changes in rates. There was no change in the level or rate of HA-CDI, fosfomycin, or TMP/SMZ DOTs. Conclusion Suppressing ciprofloxacin susceptibility results on pan susceptible Klebsiella sp. and E. coli urine isolates was associated with increased P. aeruginosa susceptibility to ciprofloxacin and increased cephalexin and nitrofurantoin DOTs. No changes were seen in FQ use or HA-CDI rates. Disclosures All authors: No reported disclosures.

scholarly journals 178. Implementation of the Core Elements of Antibiotic Stewardship in Nursing Homes – National Healthcare Safety Network (NHSN), 2016–2018

2020 ◽  
Vol 7 (Supplement_1) ◽  
pp. S96-S96
Author(s):  
Katryna A Gouin ◽  
Sarah Kabbani; Angela Anttila ◽  
Josephine Mak ◽  
Elisabeth Mungai ◽  
Ti Tanissha McCray ◽  
...  
Keyword(s):  
Nursing Homes ◽  
Antibiotic Stewardship ◽  
Care Facility ◽  
Antibiotic Use ◽  
Infection Prevention And Control ◽  
Term Care ◽  
Long Term Care Facility ◽  
The Core ◽  
Use Of Resources ◽  
Core Elements

Abstract Background Since 2016, nursing homes (NHs) enrolled in the Centers for Disease Control and Prevention’s NHSN Long-term Care Facility (LTCF) Component have reported on their implementation of the core elements of antibiotic stewardship. In 2016, 42% of NHs reported implementing all seven core elements. Recent regulations require antibiotic stewardship programs in NHs. The objectives of this analysis were to track national progress in implementation of the core elements and evaluate how time dedicated to infection prevention and control (IPC) is associated with the implementation of the core elements. Methods We used the NHSN LTCF 2016–2018 Annual Surveys to assess NH characteristics and implementation of the core elements, defined as self-reported implementation of at least one corresponding stewardship activity. We reported absolute differences in percent implementation. We used log-binomial regression models to estimate the association between weekly IPC hours and the implementation of all seven core elements, while controlling for confounding by facility characteristics. Results We included 7,506 surveys from 2016–2018. In 2018, 71% of NHs reported implementation of all seven core elements, a 28% increase from 2016 (Fig. 1). The greatest increases in implementation from 2016–2018 were in Education (+19%), Reporting (+18%) and Drug Expertise (+15%) (Fig. 2). Ninety-eight percent of NHs had an individual responsible for antibiotic stewardship activities (Accountability), with 30% indicating that the role was fulfilled by an infection preventionist. Furthermore, 71% of NHs reported pharmacist involvement in improving antibiotic use, an increase of 27% since 2016. NHs that reported at least 20 hours of IPC activity per week were 14% more likely to implement all seven core elements, when controlling for facility ownership and affiliation, 95% CI: (1.07, 1.20). Conclusion NHs reported substantial progress in antibiotic stewardship implementation from 2016–2018. Improvements in accessing drug expertise, providing education and reporting antibiotic use may reflect increased stewardship awareness and use of resources among NH providers under new regulatory requirements. NHs with at least 20 hours dedicated to IPC per week may have greater capacity to implement all core elements. Disclosures All Authors: No reported disclosures

scholarly journals 2′FL and LNnT Exert Antipathogenic Effects against C. difficile ATCC 9689 In Vitro, Coinciding with Increased Levels of Bifidobacteriaceae and/or Secondary Bile Acids

Pathogens ◽  
2021 ◽  
Vol 10 (8) ◽  
pp. 927
Author(s):  
Louise Kristine Vigsnaes ◽  
Jonas Ghyselinck ◽  
Pieter Van den Van den Abbeele ◽  
Bruce McConnell ◽  
Frédéric Moens ◽  
...  
Keyword(s):  
Antimicrobial Effect ◽  
Secondary Bile Acid ◽  
Clostridioides Difficile ◽  
Life Threatening ◽  
Intermediate Time ◽  
Indigenous Microbiota ◽  
Hospital Acquired ◽  
Gut Microbial Community ◽  
Secondary Bile Acids

Clostridioides difficile (formerly Clostridium difficile) infection (CDI) is one of the most common hospital-acquired infections, which is often triggered by a dysbiosed indigenous gut microbiota (e.g., upon antibiotic therapy). Symptoms can be as severe as life-threatening colitis. The current study assessed the antipathogenic potential of human milk oligosaccharides (HMOs), i.e., 2′-O-fucosyllactose (2′FL), lacto-N-neotetraose (LNnT), and a combination thereof (MIX), against C. difficile ATCC 9689 using in vitro gut models that allowed the evaluation of both direct and, upon microbiota modulation, indirect effects. During a first 48 h fecal batch study, dysbiosis and CDI were induced by dilution of the fecal inoculum. For each of the three donors tested, C. difficile levels strongly decreased (with >4 log CFU/mL) upon treatment with 2′FL, LNnT and MIX versus untreated blanks, coinciding with increased acetate/Bifidobacteriaceae levels. Interindividual differences among donors at an intermediate time point suggested that the antimicrobial effect was microbiota-mediated rather than being a direct effect of the HMOs. During a subsequent 11 week study with the PathogutTM model (specific application of the Simulator of the Human Intestinal Microbial Ecosystem (SHIME®)), dysbiosis and CDI were induced by clindamycin (CLI) treatment. Vancomycin (VNC) treatment cured CDI, but the further dysbiosis of the indigenous microbiota likely contributed to CDI recurrence. Upon co-supplementation with VNC, both 2′FL and MIX boosted microbial activity (acetate and to lesser extent propionate/butyrate). Moreover, 2′FL avoided CDI recurrence, potentially because of increased secondary bile acid production. Overall, while not elucidating the exact antipathogenic mechanisms-of-action, the current study highlights the potential of HMOs to combat CDI recurrence, help the gut microbial community recover after antibiotic treatment, and hence counteract the adverse effects of antibiotic therapies.

scholarly journals Infection Preventionist Run Clostridioides difficile Testing Diagnostic Stewardship Protocol- Experience From a Rural Community Hospital

2020 ◽  
Vol 41 (S1) ◽  
pp. s484-s485
Author(s):  
Raghavendra Tirupathi ◽  
Ruth Freshman ◽  
Norma J Montoy ◽  
Melissa Gross
Keyword(s):  
Cost Savings ◽  
Antibiotic Use ◽  
First Year ◽  
Multiple Parameters ◽  
Clostridioides Difficile ◽  
Stewardship Program ◽  
Commercial Company ◽  
Surgical History ◽  
Test Ordering ◽  
Infection Preventionists

Background: Distinguishing active Clostridioides difficile infection (CDI) from asymptomatic colonization remains a challenging task in the era of PCR testing. Inappropriate testing leads to overtesting and overdiagnosis, inadvertent treatment, and isolation in addition to laboratory identified (LabID) events, leading to increased incidence to hospital-onset CDI (HO-CDI). The institution has a nurse-driven C. difficile test ordering protocol, and we noted a significant increase in the HO-CDI incidence in 2017 due to inappropriate testing, with rates as high as 0.94 per 1,000 patient days. Methods: In September 2017, a multidisciplinary team reviewed and initiated algorithm-based testing with mandatory audit and review by infection preventionists (IPs) under the guidance of an ID physician of all ordered tests. They reviewed the adequacy and legitimacy of order for multiple parameters, including minimum 3 loose stools in 24 hours, use of laxatives in last 24 hours, consistency of the sample, presence of at least 1 clinical parameters (ie, fever, abdominal pain, leukocytosis, sepsis, or septic shock), recent or concomitant antibiotic use, recent PCR testing in the last 14 days, and chart review for medical and/or surgical history. The IPs served as the gatekeepers to testing and rejected the samples that were deemed inappropriate. Ambiguous cases were discussed with the ID specialist. On the microscope lab side, all specimens sent were batched to be run twice a day at 8:30 a.m. and 2:30 p.m., and testing was performed only on the samples cleared by infection preventionists. Results: The number of PCR tests completed in the comparison quarter of 2016 was 220, which decreased to 157 tests in 2017 with a reduction of 28%. After a full year of implementation of the diagnostic stewardship protocol, the number of completed PCR tests decreased to 626 from 940 PCR tests in 2016, with an overall 34% decrease in testing. In the year following the implementation of diagnostic stewardship, HO-CDI decreased from 60 events in 2017 to 43 events in 2018, with a reduction of 28%. Subsequently, HO-CDI further decreased in 2019 from 43 to 28, with a reduction of 35%. Since the implementation of the project in 2017, HO-CDIs have decreased by 54% overall. The reduction in 314 C. difficile PCR tests in the first year led to a savings of $8,300 in laboratory testing supplies. The reduction of HO CDI by 17 led to cost avoidance of $293,420. Conclusions: Our experience shows that the IP-run diagnostic stewardship program was highly successful in streamlining testing, with cost savings on several fronts.Funding: NoneDisclosures: NoneDisclosures:Commercial Company : If I am presenting research funded by a commercial company, the information presented will be based on generally accepted scientific principals and methods, and will not promote the commercial interest of the funding company.DisagreeRaghavendra Tirupathi

scholarly journals 139. association of Physician Orders for Life-sustaining Treatment (POLST) with Antimicrobial Use at End of Life in Cancer Patients: An Antimicrobial Stewardship Opportunity

2020 ◽  
Vol 7 (Supplement_1) ◽  
pp. S199-S200
Author(s):  
Olivia Kates ◽  
Elizabeth M Krantz ◽  
Juhye Lee ◽  
John Klaassen ◽  
Jessica Morris ◽  
...  
Keyword(s):  
End Of Life ◽  
Cancer Patients ◽  
Symptom Management ◽  
Research Study ◽  
Antibiotic Use ◽  
Antimicrobial Use ◽  
Study Investigator ◽  
Days Of Therapy ◽  
Life Sustaining Treatment ◽  
Rate Ratios

Abstract Background IDSA/SHEA guidelines recommend that antimicrobial stewardship programs support providers in antibiotic decisions for end of life care. Washington State Physician Orders for Life-Sustaining Treatment (POLST) forms allow patients to indicate antimicrobial use preferences. We sought to characterize antimicrobial use in the last 30 days of life for cancer patients by presence of a POLST and antimicrobial use preferences. Methods We performed a single-center, retrospective cohort study of cancer patient deaths from January 1, 2016 - June 30, 3018. Patient demographics, clinical characteristics, POLST, and antimicrobial use within 30 days before death were extracted from electronic records. To test for an association between POLST completed at least 30 days before death and inpatient antimicrobial days of therapy (DOT) in the 30 days before death, we used negative binomial models adjusted for age, sex, race, and service line (hematologic versus solid malignancy); model estimates are presented as incidence rate ratios (IRR) with 95% confidence intervals (CI) Results Of 1796 patients, 406 (23%) had a POLST. 177/406 (44%) were completed less than 30 days before death, and 58/177 (32.8%) specified limited antibiotic use; 40/177 (23%) did not specify any antimicrobial use preference (Fig 1). Of 1295 patients with at least 1 inpatient day in the 30 days before death, 1070 (83%) received at least 1 inpatient antimicrobial with median DOT of 1077 per 1000 inpatient days (Tab 1). There was no difference in DOT among patients with and without a POLST > /= 30 days before death (IRR 0.92, CI 0.77, 1.10). Patients with a POLST specifying limited antibiotic use had significantly lower inpatient IV antimicrobial DOT compared to those without a POLST (IRR 0.64, CI 0.42–0.97) (Fig 2). Figure 1. Classification of Patients by Presence of POLST, Timing, and Antimicrobial Preference Content of POLST. Numbers shown represent the number of patients (percentage). Full antibiotic use refers to the selection “Use antibiotics for prolongation of life.” Limited antibiotic use refers to the selection “Do not use antibiotics except when needed for symptom management.” Table 1: Antimicrobial use for all patients and by advance directive group Figure 2. Forest plot of model estimates, represented as incidence rate ratios (IRR) with 95% confidence intervals (CI), for associations between POLST antimicrobial specifications completed at least 30 days before death and inpatient antibiotic days of therapy (DOT) in the 30 days before death. Estimates represent comparisons between each POLST category and no POLST completed at least 30 days before death. Dots represent the IRR and brackets extend to the lower and upper limit of the 95% CI. Blue estimates are for the inpatient antibiotic DOT outcome and red estimates are for the inpatient IV antibiotic DOT outcome. Conclusion POLST completion is rare > /= 30 days before death, with few POLSTs specifying antimicrobial use. Compared to those with no POLST in this time frame, patients who indicated that antibiotics should be used only for symptom management received significantly fewer inpatient IV antimicrobials. Early discussion of advance directives including POLST with specification of antimicrobial use preferences may promote more thoughtful use of antimicrobials near the end of life in a compassionate, patient-centered way. Disclosures Steven A. Pergam, MD, MPH, Chimerix, Inc (Scientific Research Study Investigator)Global Life Technologies, Inc. (Research Grant or Support)Merck & Co. (Scientific Research Study Investigator)Sanofi-Aventis (Other Financial or Material Support, Participate in clinical trial sponsored by NIAID (U01-AI132004); vaccines for this trial are provided by Sanofi-Aventis)

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