Outcomes and antibiotic use in patients with coronavirus disease 2019 (COVID-19) admitted to an intensive care unit

Antibiotic overuse is high in patients hospitalized with coronavirus disease 2019 (COVID-19) despite a low documented prevalence of bacterial infections in many studies. In this study evaluating 65 COVID-19 patients in the intensive care unit, empiric broad-spectrum antibiotics were often overutilized with an inertia to de-escalate despite negative culture results.

Rational Prescription Pattern of Antibiotics: A Quantitative Analysis Based on Khwaja Yunus Ali Medical College and Hospital (KYAMCH), Sirajganj, Bangladesh

Antibiotics, alternatively known as antibacterial drugs, prevent or reduce the development of germs. A decade has been added to the life expectancy of human beings since the discovery of antibiotics. Antibiotic overuse can result in resistance to a wide spectrum of diseases and bacteria. Antibiotic utility is being jeopardized by the rise of resistance. There aren't enough innovative agents to deal with the problem of resistant strains. The current study targeted to highlight the current status of antibiotic use.The study was designed as a prescription-based survey where the medicines in prescriptions were checked containing antibiotics, whether the drugs were prescribed rationally or not. The study was conducted from February to July 2018 at Khwaja Yunus Ali Medical College and Hospital, Bangladesh. Patient’s data were collected through review of patient medical records and prepared questionnaires. 100 people were interviewed, and their prescriptions were captured as photos and then checked for rationality.The antibiotics are prescribed in the group of 10 to 30 years, 31 to 50 years and more than 50 years of age.The survey demonstrated that 46% of patients know about antibiotics partially, about 74% of patients fulfill their entire course of medication and the rest of the patients stop taking medication after feeling better. Only 21% of patients knew about antibiotic resistance, whereas 37% of patients only heard about antibiotic resistance. According to the age group from low to high, 92.9%, 91.67%, 86.36% prescriptions were rational; 2.4%, 2.78%, 4.55% prescriptions were contraindicated and 4.7%, 5.56%, 9.1% prescriptions where medicines interacted with other non-antibiotic drugs, respectively. The overall rational prescription is 91%, whereas 3% of prescriptions are contraindicated and 6% of prescriptions showed interaction between antibiotics and other drugs (non-antibiotics).The study concluded that lack of knowledge and awareness of patients and inaccurate prescription data by physicians are two key factors that contribute to irrational antibiotic usage.

Racial/ethnic disparities in antibiotic use and healthcare utilization, United States, 2016/2018: a cross-sectional study

ABSTRACTAntibiotic prescribing rates vary by patient race/ethnicity, with whites more likely to receive antibiotics and broader-spectrum antibiotics. However, the drivers of this disparity, and to what extent it represents antibiotic overuse or underprescribing of appropriate antibiotic treatment, remains unclear. Here, we investigate how antibiotic prescribing appropriateness varies by race/ethnicity and to what extent disparities in antibiotic use can be explained by differing rates of healthcare utilization. In data from two nationally representative healthcare utilization surveys, we found that racial/ethnic disparities in numbers of healthcare visits, not prescribers’ behavior, better explained disparities in antibiotic prescribing rates. We also found that the proportion of antibiotic prescriptions that were appropriate, potentially appropriate, or inappropriate did not vary significantly by race/ethnicity. These results suggest that whites’ higher antibiotic use is due primarily to increased healthcare utilization and that whites’ higher antibiotic use represents a mix of greater appropriate and inappropriate use. Thus, antibiotic stewardship goals should be informed by research into differing rates of antibiotic-treatable disease and healthcare seeking and access across different populations, to ensure that efforts to reduce inappropriate antibiotic overuse do not also reduce appropriate use in underserved populations.

Diagnosis of Multidrug-Resistant Pathogens of Pneumonia

Hospital-acquired pneumonia and ventilator-associated pneumonia that are caused by multidrug resistant (MDR) pathogens represent a common and severe problem with increased mortality. Accurate diagnosis is essential to initiate appropriate antimicrobial therapy promptly while simultaneously avoiding antibiotic overuse and subsequent antibiotic resistance. Here, we discuss the main conventional phenotypic diagnostic tests and the advanced molecular tests that are currently available to diagnose the primary MDR pathogens and the resistance genes causing pneumonia.

Quantifying the Gap between Expected and Actual Rates of Antibiotic Prescribing in British Columbia, Canada

Despite decades of stewardship efforts to combat antimicrobial resistance and quantify changes in use, the quality of antibiotic use in British Columbia (BC) remains unknown. As the overuse and misuse of antibiotics drives antibiotic resistance, it is imperative to expand surveillance efforts to examine the quality of antibiotic prescriptions. In late 2019, Canadian expected rates of antibiotic prescribing were developed for common infections. These rates were utilized to quantify the gap between the observed rates of prescribing and Canadian expected rates for antibiotic use for the province of BC. The prescribing data were extracted and matched to physician billing systems using anonymized patient identifiers from January 1, 2000 to December 31, 2018. Outpatient prescribing was further subdivided into community and emergency department settings and stratified by the following age groups: <2 years, 2–18 years, and ≥19 years. The proportions of physician visits that received antibiotic prescription were compared against the Canadian expected rates to quantify the unnecessary use for 18 common indications. Respiratory tract infections (RTI), including acute bronchitis, acute sinusitis, and acute pharyngitis, reported significant levels of overprescribing. Across all ages and health care settings, prescribing for RTI indications occurred at rates 2–8 times higher than the expected rates recommended by a group of expert Canadian physicians. Understanding the magnitude of unnecessary prescribing is a first step in delineating the provincial prescribing quality. The quantification of antibiotic overuse offers concrete targets for provincial stewardship efforts to reduce unnecessary prescribing by an average of 30% across both outpatient and emergency care settings.

91. Knowledge, Attitudes, and Practice of Antibiotic Prescribing among Nurse Practitioners

Background Antibiotic overuse (AO) in ambulatory care is an important public health problem. Nurse practitioners (NPs) account for a growing proportion of outpatient antibiotic prescriptions: 14.6% in 2016. Our objective was to assess NPs’ attitudes about antibiotic prescribing practices and knowledge and use of antibiotic prescribing guidelines (APG) in their practice. Methods We distributed a survey via email to NPs listed as licensed by the North Carolina Board of Nursing. Surveys were distributed three times; duplicate responses were not permitted. Respondents who reported not prescribing antibiotics in the outpatient setting were ineligible. Three randomly selected respondents received gift cards. Questions assessed degree type, practice type, years in practice, and attitudes about antibiotic prescribing practices antibiotic stewardship. Respondents answered four questions assessing knowledge of APG. Analyses were descriptive; scores on knowledge questions were compared using T-tests. Results Survey requests were sent to 10,094 listed NPs; there were 846 completed responses (8.4%), of which 672 respondents (79.4%) reported prescribing antibiotics in outpatient care. Of those, 595 (88.5%) treat adult patients. Most respondents agreed that AO is a problem in their state (84.5%); 41.3% agreed that it was a problem in their practice. Patient/family satisfaction was the most frequently reported driver of AO (90.1%). Most respondents agreed that national APG are appropriate (95.4%) and that quality improvement (QI) is warranted (93.4%). Respondents reported following APG always (18.5%) or more than half the time (61.0%). Respondents answered a mean of 1.89 out of 4 knowledge questions correctly, with higher scores among those reporting following APG more than half the time (1.97 vs 1.58, p&lt; 0.0001). Overall attitudes about antibiotic prescribing, antibiotic prescribing guidelines, and acceptance of Quality Improvement. N=595. Respondents’ reported drivers of antibiotic overuse. Respondents were permitted to select more than one driver. Content question performance by self-reported guideline compliance; scores represent the number correct out of four questions. Conclusion Respondents agree that AO is a problem but place responsibility externally. Confidence in APG was high; most respondents endorsed following APG most of the time. Performance on knowledge questions suggests a need for education. Most respondents would welcome QI focused on AO, including education and personalized feedback. Similar work is needed in other regions and among other prescriber groups. The results will inform outpatient antibiotic stewardship. Disclosures Elizabeth Walters, DNP, CPNP-PC, RN, Merck (Consultant, Other Financial or Material Support, I am a trainer for the Nexplanon product.) Ravi Jhaveri, MD, AstraZeneca (Consultant)Dynavax (Consultant)Elsevier (Other Financial or Material Support, Editorial Stipend as Co-editor in Chief, Clinical Therapeutics)Seqirus (Consultant)

1131. You’re Never Too Old for a Time-Out: Implementing Antibiotic Time-Outs on Pediatric Inpatient Teams

Background Antibiotic overuse leads to antimicrobial resistance, adverse events, and excess costs. Antibiotic time-outs (ABTOs) offer a structured approach to reevaluate antimicrobial regimens, but implementing and maintaining ABTOs can be challenging. In this project, we built on previous ABTO implementation in adult inpatient units to incorporate ABTOs in pediatrics using quality improvement (QI) methods. Methods We identified champions, including attending physicians, residents, nurses, team coordinators, and pharmacists. Following pilot testing, ABTOs began in November 2019 and January 2020 for two general pediatric teams, and in June 2020 in the pediatric ICU (PICU). Patients were eligible for an ABTO if they had been on antibiotics for 36-72 hours. ABTOs were documented in the electronic medical record (EMR) with a structured note template. These notes along with patient antimicrobial regimens were extracted and analyzed using an automated EMR query. Metrics included: (1) Proportion of ABTO-eligible patients with an ABTO; (2) Proportion of ABTOs conducted within goal time frame; (3) Documented plan changes in ABTO (e.g. change IV antibiotics to PO); and (4) Proportion of documented changes completed within 24 hours Results To date, there have been 342 pediatric ABTOs over 145 team weeks on the general pediatrics teams and 50 weeks in the PICU, representing 96.9% of eligible patients. 77.8% of ABTOs were completed within the recommended time frame. A majority of ABTOs (67%) resulted in no change to antibiotic regimen, and 18% of patients had already had de-escalation. In 10.5% of patients, the ABTO led to a de-escalation (antibiotics discontinued in 2%, converted from IV to PO in 8.5%). 86.8% of planned changes occurred within 24 hours of ABTO. Figure 1. Compliance with antibiotic time-outs over time, by week. The green line represents the goal of 80%, and the orange line represents median performance. Figure 2. Planned changes to antimicrobial regimen documented in antibiotic time-out. Table 1. Antibiotic time-out performance on participating pediatric services. Conclusion This project demonstrates that ABTOs can be implemented across a variety of teams and showed successful spread of an adult-based QI project to pediatrics. ABTOs led to clear de-escalation in 10.5% of cases, with other changes made in 5% of cases. Future directions include continued spread to inpatient teams, development of EMR-based ABTO alerts, comparison of overall antibiotic use and adverse events before and after ABTO implementation, and characterization of antimicrobial optimization prior to ABTO. Disclosures All Authors: No reported disclosures

160. Evaluation of an Intervention to Promote Guideline-Concordant Durations of Antibiotic Therapy in Two Urgent Care Centers

Background Antibiotic overuse in urgent cares is common. Despite institutional guidance that recommends ≤ 5 days of therapy for most infections, a prior review found prescribed durations were often longer. This study evaluates the impact of an intervention on guideline-concordant durations of therapy. Methods This quasi-experimental study involved two urgent care centers (UC1 and UC2) in an integrated health care system. Prescriptions were included from January 2017 to May 2021 for patients ≥ 18 years of age for one of the following infections identified by ICD10 code: acute bacterial sinusitis, acute otitis media, cellulitis or skin abscess, COPD exacerbation, lower urinary tract infection, or pneumonia. The intervention was implemented in both urgent cares in January 2020 and included sharing baseline duration of therapy data with site directors and staff, providing in-person education on recommended durations of therapy, engaging peer champions, and posting educational flyers. An institutional smart phone application (app) with treatment recommendations for common infections was in place for the entirety of the study. The primary outcome was the proportion of antibiotic durations that were guideline-concordant during the app only and intervention periods in aggregate and by interrupted time-series analysis. Results On average, 1583 and 3850 antibiotic prescriptions were prescribed per year in UC1 and UC2, respectively. There was a significant increase in the proportion of guideline-concordant antibiotic prescriptions at the two sites by an absolute value of 20% (p&lt; 0.0001) (Table). By interrupted time-series, the change in slope after the intervention was not statistically significant for UC1 (p= 0.11), UC2 (p= 0.73), or combined (p= 0.61); however, there was a significant increase in prescriptions for ≤ 5 days immediately after the intervention in UC1 (p= &lt; 0.001) (Figure). Conclusion This intervention to promote institutional guideline-concordant durations of therapy resulted in a significant increase in the proportion of antibiotic prescriptions for ≤ 5 days. Preventing prolonged durations of therapy is a potentially effective strategy to reduce antibiotic overuse in urgent cares. Disclosures All Authors: No reported disclosures

Antibiotic Overuse for COVID-19: Are We Adding Insult to Injury?

In this study, we described the proportion of COVID-19 patients started on antibiotics empirically and the work-ups performed to diagnose bacterial superinfection. We used a retrospective cohort study design involving medical records of symptomatic, hospitalized COVID-19 patients who were admitted to these centers. A total of 481 patients were included, with a median age of 41.0 years (interquartile range, 28-58.5 years). A total of 72.1% (N = 347) of COVID-19 patients received antibiotics, either before or during admission. This is troublesome because none of the patients’ bacterial culture or inflammatory markers, such as the erythrocyte sedimentation rate or C-reactive protein, were evaluated, and only 73 (15.2%) underwent radiological investigations. Therefore, national COVID-19 guidelines should emphasize the rational use of antibiotics for the treatment of COVID-19, a primarily viral disease. Integrating antimicrobial stewardship into the COVID-19 response and expanding microbiological capacities in low-income countries are indispensable. Otherwise, we risk one pandemic aggravating another.