Point Prevalence Survey of Antimicrobial Utilization in Ghana’s Premier Hospital: Implications for Antimicrobial Stewardship

The first comprehensive point prevalence survey at the Korle Bu Teaching Hospital (KBTH) was performed as part of the 2019 Global Point Prevalence Survey (Global-PPS) on antimicrobials. The aim was to establish a PPS baseline for the whole hospital and to identify required stewardship interventions. The PPS was conducted over three days in June 2019 using the GLOBAL-PPS standardized method for surveillance of antimicrobial utilization in hospitals to evaluate antimicrobial prescribing. In all, 988 patients were admitted to 69 wards. Overall antimicrobial prevalence was 53.3%. More community-acquired infections (CAI) were treated empirically compared to health-care associated infections (94.0% vs. 86.1% respectively, p = 0.002). Main indications for prescribing antimicrobials were pneumonia (18.4%), skin and soft tissue infections (11.4%) and sepsis (11.1%). Among antimicrobials, systemic antibiotics accounted for 83.5%, of which amoxicillin with beta-lactam inhibitor (17.5%), metronidazole (11.8%) and ceftriaxone (11.5%) dominated. Guideline compliance was 89.0%. Stop/review dates were completed in 33.4% and documented reason was recorded in 53.0% of all prescriptions. If the findings in this PPS can be addressed antimicrobial stewardship at the KBTH stands to improve significantly.

164. Restriction of Antimicrobials Dispensing without Prescription on a National Level: Impact on the Overall Antimicrobial Utilization in Community Pharmacies in Saudi Arabia

Background High rates of non-prescription dispending of antimicrobials has led to a significant increase in antimicrobial overuse and misuse in Saudi Arabia (SA). The objective of this study was to evaluate antimicrobial utilization following enforcement of a new prescription-only antimicrobial dispensing policy in the community pharmacy setting in SA. Methods Data were extracted from the IQVIA database between May 2017 and May 2019. Antimicrobial consumption rate based on the sales, defined daily dose in grams (DDD), DDD/1000 inhabitants’/day (DID), and antimicrobial claims for pre-policy (May 2017 to April 2018) and post-policy (June 2018 to May 2019) periods was assessed. Results Overall antimicrobial utilization slightly declined (~9-10%) in post-policy vs. pre-policy period (sales, 31,334 vs.34,492 thousand units; DDD, 183,134 vs. 202,936 thousand grams), with an increase in the number of claims (~16%) after policy implementation. There was a sudden drop in the consumption rate immediately after policy enforcement; however, the values increased subsequently, matching closely to the pre-policy values. Consumption patterns were similar in both periods. Penicillins were the most commonly used antimicrobial (sales, 14,700 - 11,648 thousand units; DDD, 71,038 - 91,227 thousand grams; DID, 2.88 - 3.78). For both the periods, the highest dip in utilization was observed in July (sales, 1,027 - 1,559 thousand units; DDD, 6,194 - 9,399 thousand grams), while the highest spike was in March/October (sales, 3,346 - 3,884 thousand units; DDD, 22,329 - 19,453 thousand grams). Conclusion Non-prescription antimicrobial utilization reduced minimally following policy implementation in the community pharmacy setting across SA. Measures to aid effective implementation of prescription-only regulations are necessary. Disclosures All Authors: No reported disclosures

592. Antimicrobial Utilization in Solid Organ Transplant Recipients 12-Months Post-Transplantation

Background Antimicrobials are widely used in solid organ transplant recipients (SOTr). Yet, antimicrobial utilization in the transplant (TP) population is not well characterized. National Healthcare Safety Network antimicrobial use (NHSN-AU) does not provide data specific to SOTr. This study sought to describe inpatient antibiotic use among SOTr up to 1-year post-TP. Methods A cross-sectional study was performed of all SOTr who received a TP between January 2015 to December 2016. Demographics, TP type, antibiotic use variables, hospital days, and Clostridioides difficile infection (CDI) are described. Inpatient antibiotic administration was measured for 365 days starting from date of TP surgery. Automated data generated for NHSN-AU reporting was utilized, and SOTr data was abstracted by cross-matching with the transplant database. Transplant-patient days was used as the denominator for metrics. Variables included duration of therapy (DOT), DOT/1000 patient days, antimicrobial free days (inpatient days no antimicrobials were administered), and NHSN-AU reporting targets of anti-methicillin resistant S. aureus (MRSA), broad spectrum, and high-risk CDI agents. Data was analyzed using descriptive statistics via Microsoft Excel®. Results A total of 530 SOTr were analyzed. Baseline characteristics are shown in Table 1. Median age was 61, male gender 64%, median Charlson Comorbidity Index was 5. Kidney TP (43%), liver TP (32%), lung (9%) and heart (8%) were most common TP types. Among these four TP types: Lung TP had the highest median DOT (13 days), DOT/1000 patient days (6.6) and ratio of DOT/total patient (1.9) (Table 2). Liver TP had the most antimicrobial free days (34%). Proportionally, anti-MRSA agents use was highest in thoracic TP (lung/heart), broad-spectrum agent use was common in all but kidney TPs, and high-risk CDI agents use was highest among kidney TP (Table 3). A total of 34 SOTr had CDI, 76% in kidney/liver TPs. Table 1. Antimicrobial usage and SOT - ID Week 2021 Table 2. Antimicrobial usage and SOT - ID Week 2021 Table 3. Antimicrobial usage and SOT - ID Week 2021 Conclusion Our study provides preliminary and important data of inpatient antibiotic utilization specifically in SOTr, generated using automated NHSN-AU data cross-matched to transplant database. These metrics can be utilized to promote antimicrobial stewardship efforts directed to specific TP types. Disclosures Rachel Kenney, PharmD, Medtronic, Inc. (Other Financial or Material Support, spouse is an employee and shareholder)

286. Infectious Complications and Antimicrobial Utilization in Hospitalized Patients with COVID-19

Background Hospitalized patients with COVID-19 have created increased demands on health care infrastructure and resources. Bacterial and fungal infections have been reported and have increased the need for antimicrobial utilization. We performed a retrospective chart review to characterize bacterial infections and antibiotic utilization during the COVID-19 surge at our tertiary care center. Methods All patients diagnosed with COVID-19 using SARS-CoV-2 PCR admitted to MedStar Georgetown University Hospital from 01Mar2020 through 31Aug2020 were included in the analysis. Data was collected on hospital-wide antimicrobial utilization [mean days of therapy per 1000-patient-days (DOT)] during the 6-month surge and was compared to antimicrobial utilization during a 6-month period that preceded the COVID-19 surge. Clinical and microbiological data and patient outcomes were also collected and analyzed. Results A total of 238 patients met eligibility criteria during the observation period, of which 25.6% (n = 61) developed a bacterial, fungal, or viral co-infection. Culture-positive bacterial complications were seen in 21.8% (n = 52) with 32.8% (n = 20) having a multidrug resistant organism (MDRO). There was a statistically significant difference between COVID-19 patients with co-infection and those without for intubation (p < 0.001), vasopressor use (p < 0.001), and renal replacement therapy (p = 0.001). COVID-19 patients with co-infections had a longer mean length of stay (21.9 days vs 13.5 days, p < 0.001) and greater mortality (32.8% vs 20.6%, p = 0.006) compared to those without a co-infection, respectively. Mean antimicrobial utilization for the entire hospital population was 790.6 DOT during the COVID surge compared to 928.7 DOT during a 6-month period preceding the COVID surge (p < 0.001). For all COVID-19 patients, antimicrobial utilization was 846.9 DOT; however, this increased to 1236.4 DOT for COVID-19 patients with co-infections. Table 1. Demographics Table 2. Antimicrobial Utilization in COVID-19 Patients Conclusion Although hospital-wide antimicrobial utilization had decreased during the COVID surge, COVID-19 patients with co-infections demonstrated a disproportionate use of antimicrobial agents as well as ICU resources. As MDRO infections were relatively common, antimicrobial stewardship should be prioritized in the COVID-19 population. Disclosures Lan Duong, Pharm.D., Astra Zeneca (Shareholder)Eli Lilly & Co. (Shareholder)Gilead Sciences, Inc. (Shareholder)Merck & Co. (Speaker’s Bureau)Moderna, Inc. (Shareholder)Novavax, Inc. (Shareholder)Sarepta Therapeutics (Shareholder)Thermo Fisher Scientific (Shareholder) Princy N. Kumar, MD, AMGEN (Other Financial or Material Support, Honoraria)Eli Lilly (Grant/Research Support)Gilead (Grant/Research Support, Shareholder, Other Financial or Material Support, Honoraria)GSK (Grant/Research Support, Shareholder, Other Financial or Material Support, Honoraria)Merck & Co., Inc. (Grant/Research Support, Shareholder, Other Financial or Material Support, Honoraria)

170. Antimicrobial Use Before and During COVID-19 – Data from 108 VA Facilities

Background Increased antibiotic prescribing rates during the early phases of the COVID-19 pandemic have been widely reported. We previously reported that while both antibiotic days of therapy (DOT) and total days present (DP) declined in the first 5 months of 2020 at Veterans Affairs (VA) acute care facilities nationwide relative to the comparable period in 2019, antibiotic DOT per 1000 DP increased by 11.3%, largely reversing declines in VA antimicrobial utilization from 2015 – 2019. We now evaluate whether these changes in antibiotic use persisted throughout the COVID-19 pandemic. Methods Data on antibacterial use, patient days present, and COVID-19 care for acute inpatient care units in 108 VA level 1 and 2 facilities were extracted through the VA Informatics and Computing Infrastructure; level 3 facilities which provide limited acute inpatient services were excluded. DOT per 1000 DP were calculated and stratified by CDC-defined antibiotic classes. Results From 1/2020 to 2/2021, care for 34,096 COVID-19 patients accounted for 13% of all acute inpatient days of care in the VA. Following the onset of COVID-19 pandemic, monthly total acute care antibiotic use increased from 533 DOT/1000 DP in 1/2020 to a peak of 583 DOT/1000 DP in 4/2020; during that month COVID-19 patients accounted for 13% of all DP (Figure). In subsequent months, total antibiotic use declined such that for the full year the change of antibiotic use from 2019 to 2020 (a decrease of 18 DOT/1000 DP) was similar to the rate of decline from 2015 to 2019 (mean decrease of 13 DOT/1000 DP; Table). The decreased DOT/1000 DP from 5/2020 to 2/2021 occurred even as the percentage of all DP due to COVID-19 peaked at 14 - 24% from 11/2020 to 2/2021. Conclusion Although rates of antibiotic use increased within the VA during the early phases of the COVID-19 pandemic, rates subsequently decreased to below previous baseline levels even as the proportion of COVID-19 DP spiked between 11/2020 and 02/2021. Although the degree to which the initial increase in antibiotic use is attributable to concerns of bacterial superinfection versus changes in case-mix (e.g., decreased elective admission) remains to be assessed, these data support the continued effectiveness of antimicrobial stewardship programs in the VA. Disclosures Matthew B. Goetz, MD, Nothing to disclose

47. Transitioning to Batch Dosing of High-Cost Antimicrobials in the Inpatient Setting

Background Antimicrobial stewardship (AMS) committees ensure appropriate antimicrobial utilization. One stewardship intervention is to evaluate the delivery model of high-cost antimicrobials to better utilize resources and mitigate expenses. We analyzed the total medication waste and costs of high-cost antimicrobials, specifically daptomycin, ertapenem, amphotericin, and micafungin, at our institution and propose innovative cost-savings changes at a systems level. Methods This retrospective study consisted of 263 patients. All patients were at least 18 years old who was admitted to our academic institution from January 2020 to April 2021 and received daptomycin, ertapenem, amphotericin, or micafungin. Demographics, daily medication dosage, total doses received, the date and time of the start of the medication, last administered dose, and discontinued order were recorded. Results The daptomycin cohort consisted of 143 patients with 46.2% females and average age of 56.3 years. In this group, 145.3 vials were wasted which equated to a loss of &22,630. The ertapenem group had 53 patients with 62.3% females and a mean age of 62.3 years. There were 24 vials wasted with a calculated loss of &1080. The amphotericin cohort had 32 patients with an average age of 52.2 years and 43.8% females. There were 189 vials wasted with a loss of &46,116. The micafungin group had 35 patients with 42.9% females and average age of 60.4 years. This group had 12 vials wasted with a loss of &2052. Conclusion Each antimicrobial has a specific formulation protocol. Daptomycin and ertapenem formulation occurs in the early morning. Amphotericin formulation occurs 2 hours prior to medication use. Micafungin formulation occurs at the time the order label prints. These medications were more often administered in the late morning to early afternoon timeframe. The order to discontinue the medications also occurred at the same interval. One reason could be due to decisions made on morning rounds from primary teams and specialty input. These orders would then be placed after rounds. A cost-saving method would be to batch and change the formulation time for all antimicrobials to later in the afternoon, which would not only prevent waste, but also allow the AMS team to effectively audit appropriate antimicrobial use. Disclosures All Authors: No reported disclosures

A Culture Change: Impact of a Pediatric Antimicrobial Stewardship Program Based on Guideline Implementation and Prospective Audit with Feedback

Reports analyzing the impact of pediatric antimicrobial stewardship programs (ASP) over long periods of time are lacking. We thus report our ASP experience in a pediatric tertiary referral center over a long-term period from 2011 to 2018. Our ASP was implemented in 2011. The program was based primarily on guideline development with key stakeholders, engaging and educating providers, followed by prospective audit with feedback (PAF). Monitored antibiotics included meropenem, piperacillin–tazobactam, and cefepime, followed by the addition of ceftriaxone, ceftazidime, cefotaxime, ciprofloxacin, levofloxacin, linezolid, and vancomycin at various time points. Specifically, the program did not implemented the core strategy of formulary restriction with prior authorization. Process- and outcome-related ASP measures were analyzed. We saw a 32% decrease in overall antibiotic utilization, a 51% decrease in the utilization of antibiotics undergoing PAF, and a 72% reduction in the use of broad-spectrum antibiotics such as meropenem. There was a concomitant increase in organism susceptibility and a reduction in yearly drug purchasing costs of over USD 560,000 from baseline without changes in sepsis-related mortality. Our study highlights that a pediatric ASP based primarily on the principles of guideline development and PAF can improve antibiotic utilization and institutional bacterial susceptibilities without a detrimental impact on patient outcomes by changing the culture of antimicrobial utilization within the institution.

A Retroprospective Study of an Antimicrobial Stewardship Program on Antimicrobial Utilization at a Tertiary Care Medical Center in Kolkata

The WHO has set Defined Daily Dose which represent the average daily dose of an antibiotic in a standard patient. The DDD mainly focuses on population-based parameters & assumes that patients as well as hospitals are homogenous entities. DOTs are very useful in order to classify antibiotic days based on patient-level exposure. DOTs merely mean the number of days that a patient is on an antibiotic, irrespective of dose. DOTs signifies that the underlying assumptions about antibiotic dosing was appropriate. Additionally, when patients receive more than one antibiotic, supplementary DOT may be counted. The 300-bed tertiary care medical center serves adults and paediatrics. An all-time Microbiology Consultant and a Clinical Pharmacology trainee used to go for round daily and used to collect data for ASP for the period of 3 months that is April to June,2021. In this study we have compared DOT of some important antibiotics for a specific period of time for both COVID and NON COVID patient. ASP-focused antibiotics were antibiotics routinely evaluated by the ASP team for appropriateness during therapy and the potential to optimize their appropriate use through policies, protocols, formulary restrictions, or clinician education. ASP-focused antibiotics included meropenem, linezolid, pip-taz, poly b, colistin, teicoplanin. In this study we have compared the DDD for 2 specific period of time for better understanding the consumption of those antibiotics. In conclusion, following the initiation of an ASP, significant decreases in utilization, increases in cost savings occurred. In our study we have reduced the consumption and DDD of linezolid which is clinically significant. When it comes to DOTs; We have reduced the DOTs of piptaz and teicoplanin for covid patient And Reduced the DOTs of meropenem and teicoplanin for noncovid patient which is clinically and statistically significant.

Antimicrobial utilization and stewardship in patients with uncomplicated urinary tract infections managed by pharmacists in the community: A sub-study of the RxOUTMAP trial

BACKGROUND: Urinary tract infections (UTIs) often lead to suboptimal antibacterial use. Pharmacists are accessible primary care professionals who have an important role to play in antimicrobial stewardship. Our objective was to evaluate the appropriateness of pharmacists’ antibacterial prescribing for patients with uncomplicated UTI. METHODS: We conducted a prospective registry trial with 39 community pharmacies in New Brunswick, Canada. Adult patients were enrolled if they presented to the pharmacy with either symptoms of UTI with no current antibacterial treatment (pharmacist-initial arm) or an antibacterial prescription for UTI from a physician (physician-initial arm). Pharmacists assessed patients; patients with complicating factors or red flags for systemic illness or pyelonephritis were excluded. Pharmacists prescribed antibacterial therapy or modified antibacterial therapy, provided education only, or referred to a physician, as appropriate. Antibacterial therapy prescribed was compared between study arms. RESULTS: Seven hundred fifty patients were enrolled (87% pharmacist-initial arm). The most commonly prescribed agents in the pharmacist-initial arm were nitrofurantoin (88%), sulfamethoxazole–trimethoprim (TMP–SMX) (8%), and fosfomycin (2%); in the physician-initial arm, nitrofurantoin (55%), TMP–SMX (26%), and fluoroquinolones (11%) were prescribed. Therapy was guideline concordant for 95.1% of patients in the pharmacist-initial arm and 35.1% of patients in the physician-initial arm ( p < 0.001). For guideline-discordant therapy from physicians, pharmacists prescribed to optimize therapy for 46% of patients. CONCLUSION: Treatment was highly guideline concordant when pharmacist initiated, with physicians prescribing longer treatment durations and more fluoroquinolones. This represents an important opportunity for antimicrobial stewardship interventions by pharmacists in the community.

Association of Physician Orders for Life-Sustaining Treatment (POLST) with Inpatient Antimicrobial Use at End of Life in Patients with Cancer

Background Antimicrobial utilization at end of life is common, but whether advance directives correlate with usage is unknown. We sought to determine whether Washington State Physician Orders for Life Sustaining Treatment (POLST) form completion or antimicrobial preferences documented therein correlate with subsequent inpatient antimicrobial prescribing at end of life. Methods A single-center, retrospective cohort study of adult patients at a cancer center who died between January 1, 2016 – June 30, 2019. We used negative binomial models adjusted for age, sex, and malignancy type to test the relationship between POLST form completion ≥ 30 days before death, antimicrobial preferences and antimicrobial days of therapy (DOT) per 1000 inpatient days in the last 30 days of life. Results Among 1295 eligible decedents with ≥1 inpatient day during the last 30 days of life, 318 (24.6%) completed a POLST form. Of 318, 120 (37.7%) were completed ≥ 30 days before death; 35/120 (29.2%) specified limited antimicrobials, 55/120 (45.8%) specified full antimicrobial use, and 30/120 (25%) omitted antimicrobial preference. 83% (1070/1295) received ≥1 inpatient antimicrobial. Median total and IV antimicrobial DOT/1000 inpatient-days was 1077 and 667. Patients specifying limited antimicrobials had significantly lower total antimicrobial DOT (adjusted incidence rate ratio [IRR] 0.68, 95% CI 0.49-0.95, p=0.02) and IV antimicrobial DOT (IRR 0.57, 95% CI 0.38-0.86, p=0.008) compared to those without a POLST. Conclusions Indicating a preference for limited antimicrobials on a POLST form ≥30 days before death may lead to less inpatient antimicrobial use in the last 30 days of life.