Patient Demographics, Clinical Characteristics, and Medication Adherence to Treatment Among Patients on Oral Tyrosine Kinase Inhibitors in a Retail Pharmacy Setting

INTRODUCTION Previous studies have demonstrated the importance of adherence to oral tyrosine kinase inhibitors in improving outcomes, including achieving a complete cytogenic response. Patients with chronic myeloid leukemia (CML) that had a suboptimal response were more likely to be non-adherent. Early identification and intervention based on predictors of non-adherence may lead to improved outcomes for patients in the non-trial setting. This research aimed to determine the rate of adherence and persistence to oral tyrosine kinase inhibitors (TKI) and to assess associated effect of patient characteristics using real world data from a retail pharmacy setting. METHODS This retrospective analysis of administrative pharmacy claims data included a random sample of 5000 patients who filled at least one TKI medication (bosutinib, dasatinib, imatinib, nilotinib) from national retail pharmacy chain in the study period of May 1, 2018 to April 30, 2021. Data elements included prescription fill attributes, patient-level demographics, medication adherence by therapeutic class (TKI, antidiabetics, antihypertensives and antihyperlipidemics), as well as patient health conditions and diagnoses. Patient adherence barrier data were also analyzed for a subset of patients who received select clinical interventions. This research was reviewed and approved by Advarra IRB as exempt (Pro00044844). Medication adherence was measured using the proportion of days covered (PDC) metric. For each therapeutic class, PDC was measured from first fill date for that class from May 01 2018 to April 30 2021, followed for maximum of 365 days, and calculated as the ratio of the number of days of medication available and the measurement period. A cut-off to indicate suboptimum adherence of <85% was used for TKI and <80% for other classes. Length of therapy was measured as number of days a patient had underline medication coverage from the index date to the start date of medication gap that was>45 days. PDC and length of therapy and their influential factors were assessed using generalized linear models. Persistency rates were calculated descriptively and using Kaplan-Meier analyses. Associations among PDCs in TKI and common chronic medications were assessed using multivariate correlation statistics. All statistics were conducted using SAS 9.4. RESULTS The random sample of patients had a mean age of 61.7 years (median=65.6, IQR= =51, 75) and 49.9% were male. TKI use in our sample was predominantly imatinib (2,857, 57.1%) and dasatinib (1,428, 28.6%) with fewer patients on nilotinib (556, 11.1%) or bosutinib (159, 3.2%). Among those patients with adherence barrier data, the average number of barriers was 1.7. Among TKI users, 38.3% also had hypertension, 13.6% had diabetes and 15.6% had hyperlipidemia. Percent of TKI users who had common chronic conditions and who were taking corresponding therapies were 38.2%, 33.9%, and 33.3% for hypertension, hyperlipidemia, and diabetes, correspondingly. Mean TKI PDC was 0.797 (95% CL 0.789 to 0.804) with a median of 0.889. Over half of patients (55% patients) had a PDC>=.85. Mean TKI length of therapy was 18.3 months with a median of 15 months with differences by therapy. Correlation of TKI PDC to three common chronic therapy PDC were all low: 0.095 for antidiabetics; 0.032 for antihypertensives; 0.083 for antilipidemics) and not statistically significant. Age was a significant predicator of PDC, with every 10-year increase in age associated with a 2% increase in PDC. When a patient had previously stated adherence barriers, PDC was estimated to decrease by 1.7% for each barrier faced by the patient. Only a small portion (33%-38%) of TKI patients, who had a diagnosis for a common chronic condition, had a claim for the corresponding therapeutic class. CONCLUSIONS Adherence to TKI was influenced by non-modifiable risk such as age and modifiable risks such as the number of adherence barriers. Many patients on TKI who also had a common chronic condition were not taking medications for their chronic condition, noting a discordance in care. Ongoing capture of barrier data beyond specialty medications will help predict patient adherence behavior and identify targeted interventions. Disclosures No relevant conflicts of interest to declare.

327. Assessment of Bacterial Co-infection Rates and Antibiotic Exposure in COVID-19 Patients

Background COVID-19 pandemic data suggest risk for bacterial co-infection upon hospital presentation remain extremely low. Despite low co-infection rates, antibiotics are prescribed for most patients. Current data are limited regarding institutional-specific change in antibiotic use over the course of the pandemic. Given the low rates of co-infections, Saint Luke’s Health System’s COVID-19 Treatment Taskforce developed a COVID-19 evaluation and treatment order set which included procalcitonin (PCT) . As co-infection literature emerged, active education was provided, and order sets were modified to provide passive education regarding co-infection rates. We aimed to assess antibiotic practice changes as data and strategies to influence use evolved during the pandemic. Methods This was a multi-center, single health-system retrospective cohort study. Ten community hospitals and 1 academic medical center were included in analysis. Inclusion criteria were age ≥18 years, admitted during April or September 2020 and had a positive COVID-19 result on admission. Patients were excluded if they were readmitted for COVID-19 related issues. Both primary and secondary outcomes were analyzed from the first 7 days after admission. The primary outcome was rate of respiratory bacterial co-infections. This was determined through sputum and blood cultures, urinary antigens including Streptococcus pneumoniae and Legionella, and PCT. Secondary outcomes included rate of antibiotic use, antibiotic days of therapy (DOT), length of therapy, and antibiotic use trends. Baseline Characteristics Results A total of 294 patients were included with 69 patients in April 2020 and 225 in September 2020. Primary and secondary results are shown in Table 2. Rate of culture-confirmed bacterial co-infection when examining April 2020 was 4.38% and 4.44 % in September 2020. Antibiotic uses, antibiotic DOT, and length of therapy were all significantly lower in September 2020 compared to April 2020. Conclusion Our results show bacterial co-infections were extremely low in our health system. Despite positive trends in antibiotic use, prescribing remained high. More targeted interventions to decrease antibiotic exposure in COVID-19 patients are needed. Disclosures All Authors: No reported disclosures

128. Development of an Analytics Dashboard to Monitor Antimicrobial Selection and Duration for Pneumonia

Background Analytical and visual tools can be used to monitor progress for a variety of ASP key performance indicators, but few data describe the process of building disease-state specific tools to retrospectively monitor antimicrobial choice and duration. We describe process and methods for development of a pneumonia dashboard. Methods In late 2019, the Carolina ASP began construction of a dashboard to monitor antimicrobial selection and duration in patients admitted with a diagnosis code (ICD-10) consistent with pneumonia. Data extracted from the medical record after discharge included: admission date and time, admission and discharge ICD-10s, inpatient orders and administrations for agents included in the NHSN Antimicrobial Use (AU) option, and antimicrobials ordered at discharge with associated ICD-10. Extracted data fields were validated using a one-month sample. Displays were constructed to trend selection during the first 48 hours of admission, inpatient days of therapy, and total length of therapy (sum of inpatient + outpatient days) for patients who received a discharge prescription for an antimicrobial included in the AU option that was associated with an ICD-10 consistent with pneumonia. Trends observed between Jan 2020 and Mar 2021 are reported. Results 341 admissions were trended. Within the first two days of admission, monthly proportions of patients receiving an antimicrobial by category were: anti-MRSA therapies (vancomycin, linezolid), 0.20 to 0.75; broad spectrum beta-lactams (e.g., cefepime, pip/tazo), 0.40 to 0.81; CAP therapies (e.g., ceftriaxone, levofloxacin), 0.48 to 1.00 (Figure). Median inpatient duration of therapy was 5 days (IQR 3-8; range 1 to 68). Total length of therapy was median 6 days (IQR 4-10; range 1 to 68). Figure. Proportions of Patients Prescribed Antimicrobial Categories of Interest During the First 48 Hours of Admissions for Pneumonia. Legend: Anti-MRSA = vancomycin or linezolid; HAP abx = cefepime, piperacillin/tazobactam, ceftazidime, meropenem; CAP = ceftriaxone, azithromycin, ampicillin/sulbactam, amoxicillin/clavulanate, cefdinir, levofloxacin. Conclusion Automated reports and visual tools can provide actionable insights for ASP practice. From this dashboard, we identified variable but high rates of anti-MRSA and broad-spectrum beta-lactam use within the first 48 hours of admission. The median inpatient and total length of therapy of 5 and 6 days, respectively, were similar to guideline-recommended durations. The up-front cost for building analytical tools can be substantial, but can be viewed as an investment if the metrics and methods are carefully selected. Disclosures All Authors: No reported disclosures

597. The Impact of COVID-19 on Outpatient Intravenous Antimicrobial Therapy (OPAT) in Physician Office Infusion Centers (POICs)

Background The coronavirus disease 2019 (COVID-19) pandemic dramatically affected the provision of healthcare in the U.S. with sharp declines in routine and elective healthcare services. Outpatient clinic visits declined nearly 60% in the early pandemic. We investigated how COVID-19 impacted the provision of OPAT at various Infectious Disease (ID) POICs nationwide. Methods Patient (pt) records were evaluated from Jan 2019 – July 2019 and compared to Jan 2020 – July 2020. Data collected included new OPAT pts, demographics, infection type, location prior to OPAT and therapy characteristics. Statistical analysis was performed using Chi-square test with p< 0.05 considered statistically significant. Results Fourteen POICs reported data with a total of 2410 new OPAT pts in 2019 and 1807 in 2020, representing a decrease of 25%. Table 1 shows the comparison of OPAT characteristics between 2019 and 2020. Mean age and gender were similar, but there was a significantly higher percentage of pts ≥65 years treated in 2020 (43% vs. 36%, p< 0.001). Infection type and location prior to OPAT were consistent between 2019 and 2020. Primary antimicrobial use was comparable with the exception of cefepime, which showed a greater use in 2020 (14% vs. 11%, p=0.006). OPAT management differed significantly from 2019 to 2020 with fewer pts completing therapy as prescribed in 2020 (85.9% vs. 88.3%, p=0.021), driven largely by more early discontinuations and switches to oral therapy. Other reasons for those not completing therapy were also significant and due primarily to transfer of care to other settings, most commonly the home (1.9% vs. 2.9%, p=0.029). Overall length of therapy was comparable. Table 1. Comparison of OPAT in 2019 (Pre-COVID) and 2020 (Post-COVID) Conclusion OPAT provided through ID POICs experienced a substantial decrease in pts treated during the first half of 2020 compared to 2019. This was expected with the decline in healthcare services, especially elective procedures. Most pt and treatment characteristics were comparable between years, but interestingly, more elderly received OPAT during the pandemic and fewer completed therapy as planned. Further analysis of these differences can help determine effects of the pandemic on overall health outcomes in the OPAT population. Disclosures Lucinda J. Van Anglen, PharmD, Merck & Co. (Research Grant or Support)

Antibiotic “Timeout” on Electronic Prescribing - Impact of Antibiotic Hardstop on Antimicrobial Stewardship Initiatives

Background: Antimicrobial resistance (AMR) remains a major public health threat and the exploration of interventions which may reduce inappropriate antimicrobial use are of particular interest. An Antibiotic Timeout (ATO) was included within the electronic medicine (eMeds) system introduced to the Central Coast Local Health District (CCLHD) in 2018. The function allows prescribers to set a predetermined time at which antibiotic orders would cease. By default, the function set prescribed length to 5 days with a view to encourage prescribers to review existing antimicrobial orders and reduce inappropriate use.Methods: Records of adult inpatients prescribed broad spectrum antimicrobials with a registered indication of community acquired pneumonia (CAP) or an infective exacerbation of chronic obstructive pulmonary disease (IECOPD) between the 1st of March 2017 and 31st May 2017 for the pre eMeds cohort and 1st March 2019 and 31st May 2019 for the post eMeds cohort were randomly selected from our local health network’s Guidance MS® system. Baseline demographics, antimicrobial prescribing records and documented adverse events related to the antibiotic timeout function were collated/analysed. The days of therapy (DOT) and length of therapy (LOT) for each encounter were calculated manually and results analysed using a two-tailed t-test or Mann-Whitney U test.Results: Of patients eligible to have the ATO function activated during their admission, 34% (n=34) had the function deployed at least once. Following the introduction of eMeds mean DOT for the pooled indications cohort was reduced by 3.02 days (CI 95% 0.41 – 5.63, p<0.05) and mean LOT by 1.97 days (CI 95% 0.39 – 3.55, p<0.05). The timeout function resulted in 2 cases of delayed or unintentionally ceased therapies. Conclusions: Following the introduction of electronic prescribing and ATO, a significant reduction was observed in the DOT and LOT for antimicrobial use for inpatients with CAP and IECOPD without a significant increase in adverse events. Further research is required to determine the extent to which the antibiotic timeout functionality directly contributed to this effect and if the effect is present across a broader range of indications.

Use of monitoring indicators in hospital management of antimicrobials

Background According to the literature, 25% to 50% of antimicrobials prescribed in hospitals are unnecessary or inappropriate, directly impacting antimicrobial resistance. Thus, the present study aimed to evaluate the use of antimicrobials in a university hospital in Northeast Brazil, using days of therapy (DOT) and length of therapy (LOT) indicators in accordance with the latest national and international recommendations for monitoring the use of antimicrobials. Methods This is an observational, prospective analytical study conducted in a teaching hospital, with 94 active beds, distributed between the intensive care unit (ICU), the surgical clinic (SUR), the medical clinic (MED), the pneumology/infectology department (PNE/INF) and pediatrics (PED). The duration of the study was from the beginning of January to the end of December 2018. Results During the study period, a total of 11,634 patient-days were followed up and 50.4% of the patients were found to have received some antimicrobial, with a significant reduction in use of 1% per month throughout the year. Patients were receiving antimicrobial therapy for 376 days in every 1000 days of hospitalization (LOT = 376/1000pd). Overall, the 1st-generation cephalosporins and fluoroquinolones were the most used in respect of the number of prescriptions and the duration of therapy. The calculated global DOT/LOT ratio showed that each patient received an average of 1.5 antimicrobials during the hospital stay. The incidence of antimicrobial resistance, globally, for both methicillin-resistant Staphylococcus aureus (methicillin R), Carbapenem-resistant Klebsiella pneumoniae, Pseudomonas aeruginosa and Acinetobacter baumannii (Carbapenem R), was 1 per 1000 patient-days. Conclusions The results obtained from the analyses revealed that half of the patients admitted to the hospital who took part in the study were exposed to the use of antimicrobials at some point during their stay. Although moderate, it is noteworthy that there was a decline in the use of antimicrobials throughout the year. The indicators used in this study were found to be very effective for gathering data on the use of antimicrobials, and assessing the results of the initiatives taken as part of the Stewardship program.

Antimicrobial Stewardship in Patients with Confirmed COVID-19

173 hospitalized COVID-19 patients receiving antibiotics were retrospectively assigned to the early or late discontinuation groups. Length of therapy was shorter in the early discontinuation group (3 vs 7 days, p<0.0001). Mortality (14.3% vs 20.7%, p=0.316) and length of stay (7 vs. 9 days, p=0.063) were similar.

The maximum dose and duration in the therapy single use methotrexate to achieve remission by rheumatoid arthritis patients through disease activity score 28 (DAS28)

Objectives One of the treatments for rheumatoid arthritis (RA) was methotrexate which a disease modifying antirheumatic drug therapy. The use of methotrexate required the right dose and length of therapy to achieve remission. The effectivity of methotrexate could be accounted by disease activity score 28 (DAS28) as a tool has been used clinically with a combination number of tender joints, swollen joints, erythrocyte sedimentation rate, and global clinical assessment by the patient. The aim of this study was to determine the effective dose and length of therapy methotrexate was measured by DAS28 score. Methods This research was a cross-sectional study and data was collected from patient medical records in Saiful Anwar Hospital, Malang, from February to July 2018. The research has been given ethical clearance. The inclusion criteria for the 88 subjects were men and women, over 20 years of age, usage of only methotrexate for at least three months, an erythrocyte sedimentation rate score, uncomplicated inflammatory bowel disease, cancer, and systemic lupus erythematosus. All data obtained was entered in formula DAS28. The Statistic analysis used both Pearson and Spearman’s rank correlation. Results Only 16 patients achieved remission. There were not significant correlation in statistical analysis between DAS score and cumulative dose (r=−0.091; p=0.400), average dose (r=0.043; p = 0.692), maximum dose (r=0.074; p=0.492), and length of therapy (r=−0.075; p = 0.489). The initial dose of therapy methotrexate was different and the length of therapy was adjusted to the patient’s health condition. Conclusions The maximum dose and length of therapy methotrexate was required to achieve remission in RA.

RANCANG BANGUN ALAT TERAPI ELEKTRIK UNTUK MEMBANTU PENYEMBUHAN CEDERA DI POLI FISIOTERAPI RSUD Dr SOEDOMO TRENGGALEK

An injury is a disorder that occurs in the body which results in the appearance of redness, pain, swelling and the inability to function properly in the limbs. Handling of minor to severe injuries is carried out with medical treatment such as surgery or traditional medicine, but this treatment has not provided any assurance of healing, as for the alternative treatment, namely heat therapy. Heat therapy is able to open blood vessels wider and can provide a supply of oxygen and nutrients to reduce pain in injured sufferers. From this research, it can be produced a design of an electric therapy device that can produce heat equipped with a heat setting and a therapy time controller. The design of an electric therapy device to help heal physiotherapy dipole injuries at Dr. SOEDOMO Trenggalek Hospital has several advantages, namely that it can generate heat according to temperature settings, can adjust the length of therapy process time according to time settings and can also provide a display of temperature and time on the LCD display. The results of research on this electric therapy device are able to work according to predetermined working principles.

Effects of a Paediatric Antimicrobial Stewardship Program on Antimicrobial Use and Quality of Prescriptions in Patients with Appendix-Related Intraabdominal Infections

The effectiveness of antimicrobial stewardship programs (ASP) in reducing antimicrobial use (AU) in children has been proved. Many interventions have been described suitable for different institution sizes, priorities, and patients, with surgical wards being one of the areas that may benefit the most. We aimed to describe the results on AU and length of stay (LOS) in a pre-post study during the three years before (2014–2016) and the three years after (2017–2019) implementation of an ASP based on postprescription review with feedback in children and adolescents admitted for appendix-related intraabdominal infections (AR-IAI) in a European Referral Paediatric University Hospital. In the postintervention period, the quality of prescriptions (QP) was also evaluated. Overall, 2021 AR-IAIs admissions were included. Global AU, measured both as days of therapy/100 patient days (DOT/100PD) and length of therapy (LOT), and global LOS remained unchanged in the postintervention period. Phlegmonous appendicitis LOS (p = 0.003) and LOT (p < 0.001) significantly decreased, but not those of other AR-IAI diagnoses. The use of piperacillin–tazobactam decreased by 96% (p = 0.044), with no rebound in the use of other Gram-negative broad-spectrum antimicrobials. A quasisignificant (p = 0.052) increase in QP was observed upon ASP implementation. Readmission and case fatality rates remained stable. ASP interventions were safe, and they reduced LOS and LOT of phlegmonous appendicitis and the use of selected broad-spectrum antimicrobials, while increasing QP in children with AR-IAI.