Developing a theory-based behavior change intervention to improve the prescription of surgical prophylaxis

Antimicrobial resistance (AMR) is increasingly pervasive due to multiple, complex prescribing and consuming behaviours. Accordingly, behaviour change is an important component of response to AMR. Little is known about the best approaches to change antibiotic use practices and behaviours. This project aims to develop a context-specific behaviour change strategy focusing on promoting appropriate prescription practices following the World Health Organization recommendations for surgical prophylaxis. In an orthopaedic surgery unit in Egypt. The project included a formative qualitative research study with 31 in-depth interviews with orthopaedic surgeons that was based on the Theoretical Domains Framework (TDF) and an intervention that was developed to following the Behaviour Change Wheel (BCW) in a knowledge co-production workshop with ten public health experts that ensured that the theory based intervention was a culturally acceptable, practical and implementable intervention. The prescription of surgical prophylaxis was influenced by eight TDF domains from which workshop participants selected five to be included in the behaviour change intervention including, knowledge, belief in consequences (mistrust towards infection prevention and control measures), environmental factors (lack of prescription guidelines), professional role and reinforcement (a lack of appropriate follow up actions influenced prescription of surgical prophylaxis). The appropriate set of behaviour change functions of BCW and related activities to improve the current practices included education, enablement, persuasion, environmental restructuring and restriction. The study showed that a theory based, and context specific intervention can be created by using the TDF and BCW together with knowledge-co creation to improve the prescription of surgical prophylaxis in and Egyptian orthopaedic unit. The intervention needs to piloted and scaled up.

107. Impact of Penicillin Allergy Assessment During Pre-Anesthesia Testing (PAT) on Beta-Lactam Surgical Prophylaxis in Bariatric Surgery Patients

Background Due to utilization of alternative antibiotics, documented penicillin (PCN) allergies are associated with an increased risk of surgical site infections, cost, and infections caused by resistant organisms. In October 2019, a community hospital implemented a beta-lactam (BL) allergy assessment service in a pre-anesthesia testing (PAT) clinic without access to allergy specialists or PCN skin testing (PST). In phase 1, the surgeon was contacted to change surgical prophylaxis for BL eligible patients based on the assessment. In phase 2, an automatic protocol was implemented to allow advanced practice providers (APPs) to switch from alternative antibiotics in BL eligible patients. The objective of this study was to assess the impact of the PCN assessment service and protocol on BL surgical prophylaxis. Methods This retrospective cohort study included bariatric surgery patients who visited PAT clinic with a documented BL allergy between Jun 2019-Sept 2019 (control), Nov 2019-Feb 2020 (phase 1), and Nov 2020-Feb 2021 (phase 2). Patients with procedures not requiring surgical prophylaxis were excluded. Patients were determined to be eligible for BL surgical prophylaxis if: intolerance or mild-moderate reaction to PCN, previously tolerated cephalosporin, intolerance to cephalosporin, or surgeon deemed it appropriate. The primary outcome was overall utilization of BL surgical prophylaxis. Results This study included 38 patients in the control group, 14 in the phase 1 group, and 17 in the phase 2 group. Overall utilization of BL surgical prophylaxis significantly increased with 16% in the control group, 43% in the phase 1 group, and 65% in the phase 2 group (p=0.001). In the BL eligible patient subgroup, BL surgical prophylaxis significantly increased with 35% (n=6/17) in the control group, 50% (n=6/12) in the phase 1 group, and 92% (n=11/12) in the phase 2 group (p= 0.001). There were no reported surgical site infections or adverse drug reactions. Conclusion Overall utilization of BL surgical prophylaxis significantly increased after implementation of a PCN allergy assessment service with an automatic protocol for patients determined as BL eligible. This service and protocol demonstrates successful optimization of surgical prophylaxis when allergy specialists or PST is not available. Disclosures All Authors: No reported disclosures

1125. Decreasing Concomitant Vancomycin and Piperacillin-Tazobactam Use in Children to Reduce Incidence of Acute Kidney Injury

Background Concomitant use of vancomycin (V) and piperacillin-tazobactam (PT) is associated with increased incidence of acute kidney injury (AKI). AKI develops 3 times faster on this combination compared to alternative vancomycin combinations. We sought to reduce AKI in our patients by reducing concomitant use of V/PT using a QI framework. Methods We implemented several PDSA cycles to reduce concomitant V/PT use at a 415-bed quaternary children’s hospital in Boston, MA. Interventions included substitution of PT with other agents in surgical prophylaxis guidelines and order sets starting in February 2020 and in the hospital-wide sepsis order set in March 2021. The Antimicrobial Stewardship Program reinforced these changes during daily audit-and-feedback reviews. In November 2020, we implemented an electronic alert that apprises clinicians of the AKI risk when V/PT are ordered and recommends an alternative regimen. We measured the monthly number of patients on combination V/PT, new exposures to nephrotoxic medications, AKI events, and the percentage of days with serum creatinine monitoring for patients on ≥2 nephrotoxic medications. Results From 02/01/20 to 05/31/21, the number of patients exposed to combination V/PT decreased from 23 to 6 per month (Figure 1). New nephrotoxic medication exposures declined from 17.1 to 7.7 per 1,000 patient days, and AKI events dropped from 2.8 to 0.6 per 1,000 patient days (Figures 2 and 3). The percentage of days with serum creatinine monitoring increased from 60% to 66%. Rate of New Exposures to Nephrotoxic Medications per 1000 Patient Days Conclusion Revising guidelines and electronic order sets and implementing an order alert led to marked decreases in exposures to V/PT and nephrotoxic medications overall and was associated with reduced AKI events. Use of electronic health record tools is an effective way to drive safer antimicrobial use. Disclosures Gabriella S. Lamb, MD, MPH, Nothing to disclose

Role of cefuroxime as antibiotic prophylaxis for general surgery: An expert opinion

Surgical site infections (SSIs) are serious postoperative complications reported globally, which lead to perioperative antibiotics use during routine practice in surgical procedures. Selection of appropriate antibiotic/s for prophylaxis is a vital step in the management and care of invasive surgical procedures. This expert opinion review was developed based on expert discussion and literature search on scientific databases with special emphasis on cefuroxime in surgical prophylaxis for general surgeries. Cephalosporins are globally considered to be the drugs of choice for surgical prophylaxis in general surgeries owing to good safety, bactericidal activity, penetration to critical tissues, and proven efficacy in clinical trials. Cefuroxime, a 2nd generation cephalosporin, is an effective, safe and low-cost antibiotic for surgical prophylaxis in general surgeries, in particular for patients who need sequential antibiotic therapy. Cefuroxime can be administered alone or in combination with other classes of antibiotics based on clinical characteristics of individual patients and surgeon’s discretion to reduce the risk of postoperative SSIs, abscess, septicemia, and microbial growth. Cefuroxime can be administered alone or in combination with other classes of antibiotics based on clinical characteristics of individual patients and surgeon’s discretion to reduce the risk of postoperative SSIs, abscess, septicemia, and microbial growth.

Real-World Data on the Effectiveness and Safety of wilate for the Treatment of von Willebrand Disease

Background The efficacy and safety of wilate (human von Willebrand factor/coagulation factor VIII) in patients with von Willebrand disease (VWD) has been demonstrated in clinical trials. Here, we present real-world data on the use of wilate for the routine care of patients with VWD. Objectives The objectives of this observational, prospective, phase 4 study were to evaluate the safety, tolerability, and effectiveness of wilate in on-demand treatment of bleeding episodes (BEs), long-term prophylaxis, and surgical prophylaxis among patients with any type of VWD. Methods Patients were enrolled at 31 study centers in 11 countries and followed for up to 2 years. Safety endpoints included adverse drug reactions (ADRs) and drug tolerability. Effectiveness was assessed using annualized bleeding rates (ABRs) during prophylaxis and predefined criteria for the treatment of BEs and surgical prophylaxis. Results A total of 111 patients (76 [68%] female) including 41 (37%) children were treated with wilate. Twenty-five patients received prophylaxis, 29 on-demand treatment, and 62 surgical prophylaxis. Tolerability was rated by patients as “excellent” for 96.2% of 6,497 infusions. No unexpected ADRs or thrombotic events were reported. Median ABR during prophylaxis was 1.9. Effectiveness was assessed as “excellent” or “good” by patients and investigators for 100% of BEs treated on-demand, 98% (patient rating) and 99% (investigator rating) of breakthrough BEs, and 99% of surgical procedures (investigator rating). Conclusion wilate was safe, well tolerated, and effective for the prevention and treatment of bleeding in pediatric and adult VWD patients in a real-world setting.

The impact of patient-reported penicillin or cephalosporin allergy on surgical site infections

Objective: To determine the impact of a documented penicillin or cephalosporin allergy on the development of surgical site infections (SSIs). Background: Appropriate preoperative antibiotic prophylaxis reduces SSI risk, but documented antibiotic allergies influence the choice of prophylactic agents. Few studies have examined the relationship between a reported antibiotic allergy and risk of SSI and to what extent this relationship is modified by the antibiotic class given for prophylaxis. Methods: We conducted a retrospective cohort study of adult patients undergoing coronary artery bypass, craniotomy, spinal fusion, laminectomy, hip arthroplasty and knee arthroplasty at 3 hospitals from July 1, 2013, to December 31, 2017. We built a multivariable logistic regression model to calculate the adjusted odds ratio (aOR) of developing an SSI among patients with and without patient-reported penicillin or cephalosporin allergies. We also examined effect measure modification (EMM) to determine whether surgical prophylaxis affected the association between reported allergy and SSI. Results: We analyzed 39,972 procedures; 1,689 (4.2%) with a documented patient penicillin or cephalosporin allergy, and 374 (0.9%) resulted in an SSI. Patients with a reported penicillin or cephalosporin allergy were more likely to develop an SSI compared to patients who did not report an allergy to penicillin or cephalosporins (adjusted odds ratio, 3.26; 95% confidence interval, 2.71–3.93). Surgical prophylaxis did not have significant EMM on this association. Conclusions: Patients who reported a penicillin or cephalosporin allergy had higher odds of developing an SSI than nonallergic patients. However, the increase in odds is not completely mediated by the type of surgical prophylaxis. Instead, a reported allergy may be a surrogate marker for a more complicated patient population.

Developing a theory-based behavior change intervention to improve the prescription of surgical prophylaxis

Background: Antimicrobial resistance (AMR) is increasingly pervasive due to multiple, complex prescribing and consuming behaviours. Accordingly, behaviour change is an important component of response to AMR. Little is known about the best approaches to change antibiotic use practices and behaviours. Aim: This project aims to develop a context-specific behaviour change strategy focusing on promoting appropriate prescription practices following the World Health Organization recommendations for surgical prophylaxis. in an orthopaedic surgery unit in Egypt. Methods: The project included a formative qualitative research study was based on the Theoretical Domains Framework (TDF) and an intervention that was developed to following the Behaviour Change Wheel (BCW) in a knowledge co-production workshop that ensured that the theory based intervention was a culturally acceptable, practical and implementable intervention. Results: The prescription of surgical prophylaxis was influenced by five TDF domains including, knowledge, belief in consequences (mistrust towards infection prevention and control measures), environmental factors (lack of prescription guidelines) , professional role and reinforcement (a lack of appropriate follow up actions influenced prescription of surgical prophylaxis). The appropriate set of behaviour change functions of BCW and related activities to improve the current practices included education, enablement, persuasion, environmental restructuring and restriction. Conclusions: The study showed that a theory based and context specific intervention can be created by using the TDF and BCW together with knowledge-co creation to improve the prescription of surgical prophylaxis in and Egyptian orthopaedic unit. The intervention need to piloted and scaled up.

Developing a theory-based behavior change intervention to improve the prescription of surgical prophylaxis in an Egyptian University Hospital.

Background: Antimicrobial resistance (AMR) is increasingly pervasive due to multiple, complex prescribing and consuming behaviours. Accordingly, behaviour change is an important component of response to AMR. Little is known about the best approaches to change antibiotic use practices and behaviours. This project aims to develop a context-specific behaviour change strategy focusing on promoting appropriate prescription practices following the World Health Organization recommendations for surgical prophylaxis in an orthopaedic surgery unit in Egypt.Methods: The project included a formative qualitative research study was based on the Theoretical Domains Framework (TDF) to explore the determinants for inappropriate prescription of surgical antibiotic prophylaxis at an orthopaedic unit. The intervention was developed to following the Behaviour Change Wheel (BCW) in a knowledge co-production workshop with infection prevention and control experts that ensured that the theory based intervention was a culturally acceptable, practical and implementable intervention. Results: The prescription of surgical prophylaxis was influenced by five TDF domains including, knowledge, belief in consequences (mistrust towards infection prevention and control measures), environmental factors (lack of prescription guidelines) , professional role and reinforcement (a lack of appropriate follow up actions influenced prescription of surgical prophylaxis). The appropriate set of behaviour change functions of BCW and related activities to improve the current practices included education, enablement, persuasion, environmental restructuring and restriction. Conclusions The study showed that a theory based and context specific intervention can be created by using the TDF and BCW together with knowledge-co creation to improve the prescription of surgical prophylaxis in and Egyptian orthopaedic unit. The intervention need to piloted and scaled up.