195. Intravenous to Oral Antibiotics Versus Intravenous Antibiotics: A Step-Up or a Step-Down for Extended Spectrum Beta-Lactamase Producing Urinary Tract Infections?

Background The treatment of extended-spectrum beta-lactamase (ESBL)-producing urinary tract infections (UTI) may include either intravenous (IV) or oral (PO) antibiotics, according to the Infectious Diseases Society of America guidelines for resistant gram negative infections. The purpose of this study is to evaluate if PO step-down antibiotics, the switch group, compared to continued IV therapy in these UTIs affects clinical outcomes. Methods This multicenter retrospective cohort study was conducted in hospitalized patients with an ESBL-producing UTI between July 2016 and March 2020. The control group received a complete antibiotic course with a carbapenem. The switch group was transitioned to an oral agent within five days from initiation of a carbapenem. The primary endpoint was a composite all-cause clinical failure, which was defined as readmission or hospital mortality within 30 days of hospital discharge or a change in antibiotic during hospital admission. The secondary endpoints included individual components of the primary outcome, readmission indication, inpatient length of stay, direct antibiotic costs, and adverse events. Results The study included 153 patients: 95 and 58 patients in the control and switch groups, respectively. Demographics between the two groups were similar (Table 1). The mean ± SD duration of therapy was 8.7 ± 3.1 and 7.1 ± 3.3 days, respectively. Four oral agents were used for step-down therapy (Figure 1). The primary outcome occurred in 28% in both groups (27 vs 16 patients, p=0.91). The individual components of the primary outcome and readmission indication were also similar: readmission (93% vs 94%, p=0.95), readmission due to a recurrent UTI (33% vs 25%, p=0.73), hospital mortality (7% vs 6%, p=1.0), and change in antibiotic (0% vs 2%, p=0.38). The median (IQR) length of stay and direct antibiotic cost in the control and switch groups were 8 (6) vs 5 (2) days (p< 0.01) and &278 (&244) vs &180 (&104) (p< 0.01), respectively. Adverse events were similar in both groups except for diarrhea (15% vs 2%, p=0.01). Table 1. Baseline Demographics. SD: standard deviation, ICU: intensive care unit, qSOFA: quick Sequential Organ Failure Assessment, ESBL: extended spectrum beta-lactamase, UTI: urinary tract infection Figure 1. Oral Antibiotics. QD: once daily, BID: twice daily, Q2D: every 2 days, Q3D: every 3 days, DS tab: double strength tablet Conclusion There was no difference in clinical failure, readmission rate, mortality rate, or change in antibiotic between the control and switch groups; however, the switch group was associated with reduced hospital length of stay and direct antibiotic cost. Disclosures All Authors: No reported disclosures

Trends of Antibiotic Use and Expenditure After an Intensified Antimicrobial Stewardship Policy at a 2,200-Bed Teaching Hospital in China

Objective: This study aimed to evaluate the effects of intensified Chinese special rectification activity on clinical antibiotic use (CSRA) policy on a tertiary-care teaching hospital.Methods: A 48-month longitudinal dataset involving inpatients, outpatients, and emergency patients were collected. Study period included pre-intervention stage (adopting soft measures like systemic training) and post-intervention stage (applying antibiotic control system to intensify CSRA policy). Antibiotic use was evaluated by antibiotic use rate (AUR) or antibiotic use density (AUD). Economic indicator was evaluated by antibiotic cost in prescription or antibiotic expenditure in hospitalization. Data was analyzed by interrupted time series (ITS) analysis.Results: The medical quality indicators remained stable or improved during the study period. AUR of inpatients (AURI) declined 0.553% per month (P = 0.025) before the intervention and declined 0.354% per month (P = 0.471) after the intensified CSRA policy was implemented. AUD, expressed as defined daily doses per 100 patients per day (DDDs/100PD), decreased by 1.102 DDDs/100PD per month (P = 0.021) before and decreased by 0.597 DDDs/100PD per month (P = 0.323) thereafter. The ratio of antibiotic expenditure to medication expenditure (AE/ME) decreased by 0.510% per month (P = 0.000) before and fell by 0.096% (P = 0.000) per month thereafter. AE per patient decreased by 25.309 yuan per month (P = 0.002) before and decreased by 7.987 yuan per month (P = 0.053) thereafter. AUR of outpatient (AURO) decreased by 0.065% per month before (P = 0.550) and decreased by 0.066% per month (P = 0.994) thereafter. The ratio of antibiotic cost to prescription cost in outpatient (ACO/PCO) decreased by 0.182% per month (P = 0.506) before and decreased by 0.216% per month (P = 0.906) thereafter. AUR of emergency patient (AURE) decreased by 0.400% per month (P = 0.044) before and decreased by 0.092% per month (P = 0.164) thereafter. The ratio of antibiotic cost to prescription cost in emergency patient (ACE/PCE) decreased by 0.616% per month (P < 0.001) before and decreased by 0.151% per month (P < 0.001) thereafter.Conclusions: Implementation of CSRA policy was associated with declining antibiotic use and antibiotic expenditure in inpatients, outpatients, and emergency patients. However, it is also important to note that the declining trend of antibiotic consumption slowed due to the limited capacity for decline in the later stages of CSRA intervention.

Anatomy of a successful stewardship intervention: Improving perioperative prescribing in penicillin-allergic patients

Objective: To evaluate whether a series of quality improvement interventions to promote safe perioperative use of cephalosporins in penicillin-allergic patients improved use of first-line antibiotics and decreased costs. Design: Before-and-after trial following several educational interventions. Setting: Academic medical center. Patients: This study included patients undergoing a surgical procedure involving receipt of a perioperative antibiotic other than a penicillin or carbapenem between January 1, 2017, and August 31, 2019. Patients with and without a penicillin allergy label in their electronic medical record were compared with respect to the percentage who received a cephalosporin and average antibiotic cost per patient. Methods: A multidisciplinary team from infectious diseases, allergy, anesthesiology, surgery, and pharmacy surveyed anesthesiology providers about their use of perioperative cephalosporins in penicillin-allergic patients. Using findings from that survey, the team designed a decision-support algorithm for safe utilization and provided 2 educational forums to introduce this algorithm, emphasizing the safety of cefazolin or cefuroxime in penicillin-allergic patients without history of a severe delayed hypersensitivity reaction. Results: The percentage of penicillin-allergic patients receiving a perioperative cephalosporin improved from ∼34% to >80% following algorithm implementation and the associated educational interventions. This increase in cephalosporin use was associated with a ∼50% reduction in antibiotic cost per penicillin-allergic patient. No significant adverse reactions were reported. Conclusions: An educational antibiotic stewardship intervention produced a significant change in clinician behavior. A simple intervention can have a significant impact, although further study is needed regarding whether this response is sustained and whether an educational intervention is similarly effective in other healthcare systems.

Cross-Sectional Study of Outpatient Drug Indicators, Prescribing Trends and Economic Data of Chinese Jingzhou Area With WHO/INRUD Methodology

Background: In order to get the baseline data of Chinese hospital overall medical reformation and investigate the drug indicators, prescribing trends and economic data, we investigated the data before administrative interventions with the historical control method. Method: According to the WHO/INRUD criteria and cross-sectional studies, the retrospective method and equal sample interval of systematic sampling were used. We sampled from daily ordinary prescriptions, computed the drug indicators, prescribing trends and economic data and compared the mean of twelve days. Result: We sampled 1171 from 38246 adult ordinary prescriptions, the sampling percent was 3.06%, percentage of drugs prescribed by generic name 100.00%, In 2012-2014, the percentage of antibiotic cost in the daily drug cost decreased from17.44% to 8.01%, percentage of prescriptions with an antibiotic prescribed decreased from 12.64% to 9.64%, percentage of encounters with an injection prescribed decreased from 15.21% to 12.77%, the percentage of antibiotic cost in the daily drug cost decreased from 17.44% to 8.01%.Conclusion: By comparing the related data, most indicators were in decreasing trend and becoming more rational, administrative interventions had greatly most prescribing indicators, our hospital overall medical reformation was steadily advanced.

PSXIV-35 Evaluation of a direct fed microbial in newly received, high-risk beef calves and the subsequent impact on performance and health

Crossbred beef calves [n = 240, body weight (BW) = 257 ± 3.5 kg] were obtained on 3 dates (block, 8 pens/block) and were assigned randomly to 1 of 2 treatments: 1) CON = top-dress supplement (0.11 kg/d) with no direct-fed microbial, 2) BOV = top dress supplement (0.11 kg/d) that provided 113.5 mg/d of a direct-fed microbial (BOVAMINE DEFEND®, 2 g/d, Lactobacillus animalis, Propionibacterium freudenreichii, 1 × 109 CFU2/g). Study objective was to determine the effect of BOV on growth performance and health when included in the diet. From d 0 to 14, ADG was improved (P = 0.05) for BOV compared to CON as ADG were 0.89 and 0.74 kg, respectively. Overall ADG over the 43-d receiving period was not different (P = 0.65); numerically there was a 0.03 kg improvement in BOV (0.90) compared to CON (0.87 kg). The percentage of calves treated for clinical BRD with the first treatment antibiotic (florfenicol) was not affected (P = 0.40); however, was numerically reduced by 6.8% for BOV (61.2% morbidity) compared to CON (68.0% morbidity). There was a trend for the percentage of calves treated with a second antibiotic (enrofloxacin) to be reduced (P = 0.17) for calves supplemented with BOV (9.1%) compared to CON (15.2%). There was also a trend for the mean total number of antibiotics used to be reduced (P = 0.16) in BOV compared to CON. Overall antibiotic cost, was not affected (P = 0.23) by BOV supplementation; however, numerically there was a $3.27 reduction in antibiotic cost for BOV compared to CON. The supplementation of BOV in high-risk calves may improve growth performance and health, reduce clinical BRD in calves after first treatment and could potentially reduce the use of antibiotics in calves at a high risk for BRD during the receiving period.

1991. Implementation of Rapid Turnaround PCR Bacterial/Viral Panel Testing in Community-acquired Pneumonia Decreases LOS, Antibiotic Cost, Antibiotic Charges, and Antibiotic Use

Background Community-acquired pneumonia (CAP) is a significant infection contributing to hospitalization, morbidity, mortality, intensive care, antibiotic use, and healthcare costs. Antibiotic stewardship aims to improve appropriate antibiotic use which addresses these same issues. Accurate, confirmed diagnosis upon presentation of CAP patients using Respiratory Bacteria/Viral (RBVP) Polymerase Chain Reaction (PCR) panels can significantly impact outcomes in the CAP patient population. Methods In this cross-sectional study, commercially available RBVP PCR panels were used. Comparison of CAP patient populations was done before PCR use (2014–2015 control group) and after implementation (2016–2017 intervention group) using a provider choice intervention following education and order availability. Providers were educated via multiple means with lectures, individual meetings, online brief presentation, and group discussions. A nursing computer-based learning module was also developed and required to be completed. Independent sample t-test and binary logistic regression were used to analyze data. Results Out of total 2,523 observations in the study, 1,994 (79.03%) were in the control group and 529 (20.96%) were in the intervention group. An independent sample t-test showed significant differences in the mean of length of stay (LOS) (P = 0.04, 95% CI: 8.67–9.36), total antibiotic cost (TAC) (P = 0.000, 95% CI: 486.61–550.45), antibiotic charges (ACH) (P = 0.048, 95% CI: 1,815.79–2,009.75), and antibiotic defined daily doses (DDD) (P = 0.039, 95% CI: 6.84–7.42). Binary logistic regression results revealed statistical significance in LOS (P = 0.01, 95% CI: 0.9251–0.9902) and TAC (P = 0.000, 95% CI: 0.9989–0.9994). Actual savings per patient were LOS 0.88 days, TAC $202.73, ACH $240.23, and DDD 0.77. Conclusion The use of RBVP PCR panel testing in CAP patients decreases antibiotic use, LOS, and cost of care. This correlated with antibiotic de-escalation providing a significant contribution to antibiotic stewardship. PCR panel testing with rapid turnaround is widely available and cost effective. Disclosures All authors: No reported disclosures.

The Impact of Penicillin Skin Testing on Aztreonam Stewardship and Cost Savings in Immunocompromised Cancer Patients

Objective Reported penicillin allergies result in alternative antimicrobial use and are associated with worse outcomes and increased costs. Penicillin skin testing (PST) has recently been shown to be safe and effective in immunocompromised cancer patients, yet its impact on antimicrobial costs and aztreonam utilization has not been evaluated in this population. Method From September 2017 to January 2018, we screened all admitted patients receiving aztreonam. Those with a self-reported history of possible immunoglobulin E (IgE)-mediated reaction to penicillin were eligible for PST with oral challenge. Results A total of 129 patients were screened, and 49 patients were included and underwent testing. Sixteen patients (33%) had hematologic malignancies and 33 patients (67%) had solid tumors. After PST with oral challenge, 46 patients (94%) tested negative, 1 patient tested positive on oral challenge, and 2 patients had indeterminate results. The median time from admission to testing was 2 days (interquartile range, 1–4). After testing negative, 33 patients (72%) were switched to beta-lactam therapy, which resulted in a total of 390 days of beta-lactam therapy. For identical therapy durations, the direct total antibiotic cost was $15 138.89 for beta-lactams versus $78 331.50 for aztreonam, resulting in $63 192.61 in projected savings. A significant reduction in median days of aztreonam therapy per 1000 patient days (10.0 vs 8.0; P = .005) was found during the intervention period. Conclusions Use of PST in immunocompromised cancer patients receiving aztreonam resulted in improved aztreonam stewardship and significant cost savings. Our study demonstrates that PST with oral challenge should be considered in all cancer patients with reported penicillin allergies.

Cost and Risk Analysis of Lifelong Penicillin Allergy

Patients labeled as being penicillin-allergic require the use of alternative antibiotics. The objective of this study was to estimate the lifetime antibiotic costs of patients labeled as being penicillin allergic prior to age 10 compared with those who were not penicillin allergic and to compare antibiotic utilization between these 2 groups with regard to risks of adverse effects. Using the low end of the antibiotic cost range, penicillin-allergic patients had a mean lifetime antibiotic cost of $8171 per patient, compared with $6278 for non–penicillin-allergic patients, a difference of $1893. Penicillin-allergic patients utilized more moderate-spectrum antibiotics, more fluoroquinolones, and had a higher estimated Clostridium difficile risk.