Background: Intravenous vancomycin is commonly used as initial empiric coverage for pneumonia but is often unnecessary. MRSA nasal surveillance cultures (MRSA nasal swab) have been highlighted in recent literature and the 2019 IDSA Pneumonia Treatment Guidelines as a tool to avoid unnecessary MRSA coverage in pneumonia. A negative MRSA nasal swab can be utilized by clinicians to de-escalate anti-MRSA therapies for pneumonia. The purpose of this study is to determine if implementing stewardship pharmacist driven MRSA nasal surveillance increases use of the test and reduces the inappropriate use of vancomycin for MRSA coverage in patients with pneumonia. Method: This study was a retrospective chart review and was approved by the Trinity Health of New England Institutional Review Board. For this initiative, a stewardship pharmacist evaluated all patients receiving vancomycin for anti-MRSA therapy at Saint Francis Hospital and Medical Center in Hartford, CT. If the patient’s indication was pneumonia and a MRSA nasal swab had not been ordered, the pharmacist contacted the patient’s provider and requested an order for it. Upon receipt of a negative MRSA nasal swab result, the pharmacist recommended discontinuation of vancomycin to the provider if appropriate. Outcomes from the first four weeks of the pharmacist-driven initiative (April 10, 2023 to May 5, 2023) were compared to the four weeks prior to the initiative (March 13, 2023 to April 7, 2023) as a control group. The primary outcome of this study was percentage of patients who received a MRSA nasal swab. Secondary outcomes included percentage of patients who had vancomycin appropriately de-escalated based on MRSA nasal swab results and mean length of vancomycin therapy. Result: 116 patients met inclusion criteria: 61 in the control group and 55 in the intervention group. Percentage of swabs ordered increased from 36.1% (22/61) without pharmacist intervention to 80.0% (44/55) with pharmacist intervention (p < 0 .0001). There were also increased rates of vancomycin de-escalation in patients with pharmacist intervention, with 58.2% (32/55) of patients in the intervention group having vancomycin discontinued following a negative MRSA swab compared to 19.7% (12/61) in the control group (p < 0 .0001). Conclusion: The results suggest implementing a pharmacist driven MRSA nasal surveillance program into practice could increase the number of MRSA nasal swabs ordered and in turn promote more timely de-escalation of vancomycin in patients with pneumonia. The results from this study can be used to support the wide-spread use of pharmacist driven MRSA nasal surveillance protocols at other institutions.

Background: Non-prescription antibiotic use is defined as taking antibiotics without medical guidance, which includes using leftover antibiotics, obtaining antibiotics from friends or relatives, or purchasing antibiotics without a prescription. This study aimed to (1) determine the symptoms prompting individuals to use non-prescription antibiotics, identify their sources of acquisition, and document the types of antibiotics utilized, (2) identify any associated side effects, and (3) gain insights into antibiotic storage practices, including whether antibiotics were used beyond their expiration date. Methods: A cross-sectional quantitative survey was conducted from January 2020-June 2021 in waiting rooms of six safety-net primary care clinics and two private emergency departments in Houston, Texas. Participants were read survey questions in English or Spanish by a bilingual research coordinator, and their responses to five questions about antibiotic use were recorded. Descriptive analysis was performed. Results: Among the 564 patients surveyed, the median age was 51 (range 19-92). The majority identified as female (72%), Hispanic/Latinx (47%), Black/African American (33%), held a college education (44%), and received public health insurance, such as Medicaid or County Financial Assistance (56%). Of all patients surveyed, 44% (246) reported taking an antibiotic without a prescription and answered questions about associated symptoms. Of all symptoms/illnesses associated with non-prescription use, the most common were sore throat (18%), dental symptoms (16%), and cold/flu (13%). The most common sources for non-prescribed antibiotics were leftover antibiotics (50%), from friends or relatives (31%), and purchased abroad (13%), although 3% had purchased non-prescription antibiotics from a local store or market (Figure 1). The most common antibiotics used were amoxicillin (38%) and penicillin (7%). The reported side effects were stomach pain/upset (24%), nausea and vomiting (19%), allergic reaction (e.g., rash) (14%), and diarrhea (14%). Among 246 participants reporting antibiotic use, 63% reported that the antibiotic they took had been previously prescribed for the same symptom/illness, and 93% had acquired antibiotics in a container, of which 90% reported that the container had an expiration date. Conclusions: Our survey reveals that 63% of individuals who use non-prescription antibiotics were motivated by having received prescribed antibiotics for similar symptoms previously. Leftover antibiotics were the source for half of all non-prescription use. These observations suggest that outpatient antibiotic stewardship campaigns have a window of opportunity at the time of the initial prescription of antibiotics, to focus on providing the shortest course possible, and to deliver antibiotic safe use information at that time. Acknowledgments: Financial Support AHRQ R01HS026901

Disclosure: Barbara Trautner: Stock: Abbvie--sold in December 2023; Abbott Laboratories--sold in December 2023; -Bristol Myers Squibb--sold in December 2023; Pfizer--sold in December 2023; Consultant--Phiogen—consultant. Contracted research through NIAID for STRIVE trial, currently testing Shionogi product; Contracted research--Peptilogics; Contracted research—Genentech

Background: National guidelines recommend penicillins (PCN) as first-line treatment for many common pediatric infections in the outpatient setting. Although less than 1% of the United States population has a true, IgE-mediated PCN-allergy, approximately 10% of patients are labeled with a PCN-allergy. Accurate adverse drug reaction (ADR) documentation plays an important role in this over-labeling. We have previously shown that nurses feel assessment and documentation of PCN-allergies are critical to their role. However, additional evidence purports nurse hesitancy to interrogate allergy accuracy or reclassify parent’s response to side effect. Our objective was to explore frontline clinicians’ confidence in assessing, documenting, and responding to PCN-allergy labels. Methods: To expose barriers and prioritize improvement ideas for a multidisciplinary quality improvement (QI) project aimed to improve PCN-allergy labeling in our pediatric urgent care clinics, we deployed this investigator-developed survey to prescribers and nurses. It’s comprised of 14-questions scored on a 5-point Likert scale (4 demographic, 4 PCN/safety, 3 allergy types, 4 allergy documentations, 3 treatment options), and 1 optional free-text. We used descriptive statistics to compare survey responses between prescribers and nurses and evaluated free text comments for themes. Results: Eighty-seven clinicians across 3 sites participated, with a response rate of 35%, with variation by sites (25.3% to 41.4%). Forty-one percent of (n=36) responders have been in practice >15 years and 40.2% (n=35) have worked at our hospital > 15 years (Table 1). Overall, perceived knowledge of PCN-allergies and safety was favorable (Table 2). Prescribers reported higher confidence with: 1) perceiving many patients who believe they are allergic to PCN can safety take PCN (prescribers median=5 [IQR: 4, 5] vs. nurses median=4 [4,4], p = 0.003); and 2) perceiving that time pressures influenced their ability to reconcile allergies and side effects (prescribers median=4 [4, 5] vs. nurses median=3 [2, 4], p = 0.001). Both prescribers and nurses reported lower confidence in continuing to administer or prescribe an antibiotic in the setting of a reported ADR. Thirteen respondents (15%) provided comments with specific requests for additional family education and practice guidance, including the referral process to subspecialty clinics for PCN-allergy testing. Conclusions: Our survey results identified barriers to accurate PCN-allergy labels, including knowledge on documentation, time pressures, hesitancy to challenge parent report, and uncertainty on referral process for PCN-allergy testing. This survey will inform future drivers for our QI. Opportunities include electronic medical record refinement, improving referrals to PCN-allergy de-labeling clinics, and the development of scripted education to guide family discussions.

Disclosure: Rana El Feghaly: Merck- grant funding. Amanda Nedved: Contracted Research – Merck

Background: In rural areas, antimicrobial stewardship programs often have limited access to infectious disease (ID) expertise. Videoconference Antimicrobial Stewardship Teams (VASTs) pair rural Veterans Affairs (VA) medical centers with an ID expert to discuss treatment of patients with concerns for infection. In a pilot study, VASTs were effective at improving antimicrobial use. Here, we evaluated 12-month operating costs for staffing for 3 VASTs. Methods: We used the following data to describe 12 months of clinical encounters for 3 VASTs operating from January 2022 – March 2023: the number of VAST sessions completed and clinical encounters; Current Procedural Terminology (CPT) codes associated with clinical encounters; session attendees (by role) and the time spent (percent effort) on VAST-related activities. The annual operating cost was based on the annual salaries and percent effort of VAST attendees. We used these characteristics combined with private-sector and Medicare reimbursements to evaluate the cost of implementation and number of clinical encounters needed to offset those costs (breakeven) for each site. Results: Three VASTs recorded 229 clinical encounters during 117 sessions (Table 1). Based on CPT codes, the approximate revenue per patient was $516.46. Site A, the only site to break even, had the most sessions and clinical encounters as well as the lowest operating costs. For Site B, a slight increase in the clinical encounters, which might be achieved by 3 additional VAST sessions, would help achieve breakeven. For Site C, increasing the number of clinical encounters to 3-4 per session would have helped their VAST break even without requiring a decrease in operating costs. Conclusions: The frequency of VAST sessions, volume of clinical encounters, and low operating costs all contributed the VAST at Site A achieving a financial break-even point within 12 months. Consideration of the potential number of clinical encounters and sessions will help other VASTs achieve financial sustainment, independent of cost-savings related to potential decreases in expenditures for antibiotics and antibiotic-related adverse events. These results also provide insight into possible adoption and diffusion of VAST-like programs in the Medicare hospital setting.

Background: Aztreonam (AZT) is frequently used for the treatment of Enterobacterales-related infections, particularly for patients with penicillin allergy. We aimed to analyze the impact over time of changes in AZT Days of therapy (DOTs) on AZT susceptibility from some Enterobacterales after a multifaceted intervention to improve antibiotic management at a University Hospital in Florida. Methods: The study took place at a 560-lbed academic hospital in Miami, FL. A multifaceted intervention was implemented in this hospital to improve antibiotic management of patients with reported allergies to penicillin. The intervention included use of algorithm-based guidance, education, and feedback to providers. The analysis period spans from 2018 (pre-intervention) through 2022 (post intervention); 2019 was considered the wash-out period (Figure 1). Quarterly data for AZT-DOT and percentage of resistance to AZT for Enterobacterales were collected as part of the normal operations of the antimicrobial stewardship program (ASP) using the infection control module integrated in the electronic medical record (Epic Bugsy). DOT and Enterobacterales antibiotic resistance to AZT was analyzed using linear regression in SPSS. Results: We identified a decrease in DOT AZT and percentage of AZT resistance from E. coli during the study period (Table 1). This intervention led to AZT DOT’s decrease from a quarterly average of 24 DOTs in 2018 levels to a sustained quarterly average of 4.3 DOTs for 2020 to Q2 2023 (decrease 80%) Antibiotic resistance to E. coli AZT changed from a 26.6% to 21.5% (19% decrease) (Table1). Simple linear regression identified a decrease in percentage of E. coli resistance to AZT associated with a decrease on AZT DOT (P-value 0.003), there was no association for other Enterobacterales. For each unit of decrease in AZT DOT there was 0.3% decrease in percentage of E. coli resistance to AZT (Table 2.) Conclusions: A decrease in AZT DOT during the observation period was associated with a decrease in E. coli resistance to AZT. Interventions aimed to decrease inappropriate antibiotic use are pivotal part of the fight against antimicrobial resistance; in our study we report a decrease in E. coli resistance to aztreonam related to decrease in the use of this antibiotic using education, guidance, and feedback to providers.

Background: Up to half of antibiotics used in nursing homes (NHs) are initiated in acute care hospitals prior to nursing home admission. Optimizing antibiotic prescribing on hospital discharge presents an opportunity to improve NH antibiotic use. We aimed to identify barriers and facilitators to optimal antibiotic prescribing on discharge from the hospital to NHs. Methods: This was a qualitative thread of a convergent parallel mixed methods study to identify high-value targets to optimize antibiotic prescribing on discharge from the hospital to NHs. We conducted 32 qualitative interviews: 16 with prescribers (9), pharmacists (6), and a care manager (1) from 3 acute care hospitals and 16 with advanced practice providers (12) and registered nurses/nurse managers (4) from 7 NHs in Oregon and Wisconsin. Interview participants were asked to describe their typical practice for prescribing antibiotics on discharge to NHs or admitting patients with antibiotic prescriptions from hospitals, and about barriers and facilitators for optimal antibiotic prescribing during these transitions. Interviews were audio recorded, transcribed verbatim, and analyzed by 3 investigators using the qualitative descriptive analysis Results: Hospital healthcare workers described that there are different practice flows for oral and intravenous (IV) antibiotic prescribing. IV antibiotic orders are typically routed to the infectious diseases (ID) specialists and ID pharmacists to review and verify appropriateness. There were minimal established workflows to review and verify oral antibiotic orders. Pharmacists appeared integral to optimal antibiotic prescribin; however, the high frequency of oral prescriptions and short turnaround times from discharge orders to transportation limited pharmacists’ abilities to review these orders. With limited pharmacist involvement, the quality of oral antibiotic prescription relied on the prescribers’ knowledge, and there was no systematic oversight for inexperienced prescribers or specialists who may not be familiar with the adequacy of antibiotic use for NH residents. NH participants perceived that most antibiotics prescribed from hospitals were appropriate. Yet, some commented that they occasionally observe inadequate or unusual prescriptions from newer prescribers or specialists. NH participants most common concern related to antibiotic prescriptions was missing information including unclear or lack of antibiotic indications or stop dates. NH participants also stated that the frequent need to contact the hospital to obtain missing information is challenging and burdensome. Conclusions: Qualitative interviews identified several barriers and facilitators to optimal antibiotic prescribing on discharge to NHs. These results will be used to develop an intervention to improve antibiotic prescribing during these transitions.

Background: Coagulase-negative staphylococci (CoNS) are often considered contaminants when isolated from blood cultures. While criteria exist to distinguish true bacteremia from contamination (Table 1), clinical judgement is often necessary. Clinical microbiology laboratories have traditionally identified CoNS to the species level only if present in multiple cultures. There have been concerns that blood cultures positive for rare or less familiar CoNS species might be misinterpreted as true bacteremia. Tufts Medical Center (TMC) clinical microbiology laboratory started reporting all CoNS to the species level in January 2023. We studied the impact of species-level identification of CoNS on clinically relevant outcomes following this change. Methods: The study evaluated inpatients at TMC aged ≥ 18 years with CoNS isolated from blood cultures between July 2022 and June 2023. The primary outcome was the difference in anti-staphylococcal antibiotic utilization between the pre- and post-intervention groups. Secondary outcomes included differences in true bacteremia diagnosis, length of hospital stay, and mortality between the two groups. We also compared the performance of Souvenir’s criteria with clinical judgement at distinguishing contamination from true bacteremia. A total of 100 patients were included in the pre- and post-intervention groups to detect an estimated effect size of 15% with a power of 81%. Results: Most patients were male, White, and English speaking (Table 2). No differences were found between the two groups in terms of infectious disease consultation frequency, blood culture collection department, or the presence of central venous catheters (Table 2). Staphylococcus epidermidis was the predominant CoNS in the post-intervention group. Blood cultures were repeated before and after starting antibiotics in 24% and 74% (pre-intervention) and 18% and 84% (post-intervention) of cases, respectively. Anti-staphylococcus antibiotic use was the same in both groups (82%). The median antibiotic therapy duration was 4.5 days pre- vs 3 days post-intervention (p =0.39). There were no differences in hospital length of stay or mortality between the two groups (Table 3). The clinical diagnosis of true bacteremia was established in 28% of cases in the pre- vs 25% in the post-intervention group (p= 0.63). Compared to clinical judgement, Souvenir’s true bacteremia criteria demonstrated a sensitivity of 80.3%, negative PV of 91.9%, and positive PV of 55.2%. Conclusions: Species-level identification of CoNS positive blood cultures did not impact antibiotic utilization, diagnosis of true bacteremia, length of hospital stay, or mortality. Further studies with larger cohorts and prospective designs are needed to validate these findings and assess the long-term implications in patients.

Introduction: The organizational readiness for change assessment survey (ORCA) is a tool to assess a site’s readiness for implementation and identify barriers to change. As the “Kicking CAUTI” antibiotic stewardship intervention rolled out on a national scale, we administered ORCA surveys to participating sites to capture baseline actionable information about differences among sites, to inform implementation. Methods: ORCA surveys were distributed by email to prescribing providers, nurses, pharmacists, infection preventionists, and quality managers at 40 participating VA Hospitals. VA hospital sites who submitted three or more surveys and their complexity level (measured as Level 1 (highest)-3) were included in the analysis. The highest complexity level facilities are those with the largest patient volume/risk, teaching and research, along with the largest number of physician specialists and contain at least five ICUs. Mean Likert scores were calculated for each of the 7 ORCA subscales on a scale of 1-5 (5 highest), and the mean of the 7 subscales was the overall ORCA score for a site. Non-parametric testing was performed comparing overall ORCA and each subscale based on complexity. Results: Among the participating sites, 30/40 (75%) completed at least three surveys, with a total of 202 surveys included for analysis, with 82% of surveys coming from higher complexity centers (Level 1). The highest ranked ORCA domain was the evidence subscale (measures perceived strength of evidence), mean 4.2, (SD 0.7). The lowest ranked ORCA domain across sites was resources (available to facilitate implementation), mean 3.3 (SD 0.9). Higher complexity centers had a significantly higher overall ORCA score than lower complexity centers (Level 1 or 2 vs. Level 3, p= 0.02). This difference was driven by the subscales evidence (p < 0 .01), leadership (p =0.05), measurement (p= 0.06), and resources (p=0.07) all being higher in the higher complexity facilities (Figure 1). Two of the categories (leadership and measurement) pertain to an organization’s leaders ability to create an environment for change to occur as well as promoting team building. Conclusions: The lowest scoring ORCA domain across all sites was the respondents’ perception of resources (staff, training) available for achieving change. Perceived resources were also lower in lower complexity sites, implying that medical centers of lower complexity may have higher barriers when implementing an antimicrobial stewardship intervention. This finding highlights the benefit of a national stewardship campaign that provides support to lower complexity medical centers that may not otherwise receive targeted training and support for their efforts.

Disclosure: Barbara Trautner: Stock: Abbvie--sold in December 2023; Abbott Laboratories--sold in December 2023; -Bristol Myers Squibb--sold in December 2023; Pfizer--sold in December 2023; Consultant--Phiogen--consultant. Contracted research through NIAID for STRIVE trial, currently testing Shionogi product; Contracted research--Peptilogics; Contracted research—Genentech

Background: Feedback reports summarizing clinician performance are effective tools to improve antibiotic stewardship in the ambulatory setting, but few studies have evaluated their effectiveness for pediatric inpatients. We developed and implemented feedback reports reflecting electronically-derived measures of appropriate antibiotic choice and duration for community acquired pneumonia (CAP) and measured their impact on appropriate antibiotic use in children hospitalized for CAP. Methods: We performed a single center quasi-experimental study including children 6 months to 17 years hospitalized for CAP between 12/1/2021-11/30/2023. Children with chronic medical conditions, ICU stays >48 hours, and outside transfers were excluded. The intervention occurred in 11/2022 and included clinician education, a monthly group-level feedback report disseminated by email (Figure 1), and a monthly review of clinician performance during a virtual quality improvement meeting. Patient characteristics were compared using chi-square or Wilcoxon rank sum tests. Interrupted time series analysis (ITSA) was used to measure the immediate change in the proportion of CAP encounters receiving both the appropriate antibiotic choice and duration, as well as the change in slope from the preintervention to the postintervention periods. Choice and duration were analyzed separately using ITSA as a secondary analysis. Results: There were 817 CAP encounters, including 420 preintervention and 397 postintervention. Patients admitted in the postintervention period were older (median age 2 years vs 3 years, P=0.03), but otherwise there were no differences in race, ethnicity, sex, ICU admission, or complicated pneumonia. Preintervention, 52% of encounters received both the appropriate antibiotic choice and duration; 96% of encounters received the appropriate antibiotic choice and 54% received the appropriate duration. The ITSA demonstrated an immediate 16% increase in the proportion of patients receiving both appropriate antibiotic choice and duration (95% confidence interval, 1-31%; P = 0.047) and no significant further increase over time following the intervention (P = 0.84) (Figure 2). When antibiotic choice was analyzed separately by ITSA, there was no immediate change or change over time in the proportion of patients receiving the appropriate antibiotic choice. In the ITSA of duration alone, there was an immediate 17% increase in the proportion receiving the appropriate duration (95% confidence interval, 2-33%; P = 0.03) and no change over time. Conclusion: Feedback reports generated from electronically-derived metrics of antibiotic choice and duration, combined with ongoing clinician education, increased the proportion of children with CAP treated with the appropriate antibiotic duration. Electronic feedback reports are a scalable and impactful intervention to improve antibiotic use in children hospitalized with CAP.

Background: The use of antibiotics and the occurrence of antimicrobial resistance in Bangladesh are very high. Inappropriate use of antibiotics among hospitalized children has contributed to a high rise in antimicrobial resistance in Bangladesh. Data on the rational use of antibiotics in Bangladeshi hospitals are limited. This study documented current antimicrobial usage among children under five in selected tertiary hospitals in Bangladesh. Methods: From August to September 2022, we conducted a point prevalence survey in four tertiary hospitals in Bangladesh. We used the World Health Organization’s Point Prevalence Survey (PPS) methods and guidelines to conduct the study. Study participants were hospitalized under the age of five years children, and we collected information from the pediatric and neonatal wards of each hospital. Antibiotic-suggesting shapes were analyzed according to WHO AWaRe metrics and Anatomical Therapeutic Chemical (ATC) Classification. Results: The assessment included 189 children under the age of five, with the majority (78.8%, 149/189) being under one year children. Approximately three-fourths (75.1%) of children had peripheral vascular catheters following admission. Overall, 86.2% (163/189) of children were given antibiotics after being admitted to the hospital, with infants receiving the most (81.0%, 132/163). The majority of antibiotics were administered by parents (84.7%). Antibiotics from the Watch Group were most commonly prescribed (73.0%, 119/163), followed by a combination of the Watch and Access Groups (23.3%) to treat the children. Ceftriaxone (63.8%), Meropenem (16.0%), and Ceftazidime/Amikacin (8.0%) were the most regularly prescribed antibiotics. Young children (< 1 year) were more likely to get antibiotics (AOR: 3.54, p-value: 0.003) than the other children under the age of five. Conclusion: The data showed that most children received empirical antibiotics during hospitalization, and overuse of broad-spectrum Watch group antibiotics was common practice in hospital settings. Developing and implementing antibiotic use guidelines is critical to limit the inappropriate use of antibiotics for young children

Background: Healthcare accounts for 8.5% of total US greenhouse gas emissions (GHGE), with US healthcare the main contributor. Yet little effort has been made to measure healthcare related GHGE. Specifically, GHGE related to unnecessary antibiotic prescriptions is unclear, and to our knowledge, no one has used estimates of GHGE of unnecessary antibiotics as an antibiotic stewardship tool. We aimed to measure GHGE from solid waste associated with unnecessary antibiotic prescriptions for respiratory conditions. Methods: We calculated emissions for an outpatient prescription including the plastic bottle, paper leaflet, and paper bag (photos) based on the weight of each item multiplied by US Environmental Protection Agency (EPA) GHGE factors. Emission factors depend on waste type and treatment method which we assumed to be landfilled. To estimate unnecessary antibiotic prescriptions for respiratory infections, visits from nine University of Utah Health Urgent Care Centers from 2019-2022 were electronically identified and included if they had an ICD-10-CM code for a respiratory diagnosis where antibiotics are not indicated. Waste emissions of the paper and plastic in an individual prescription were then multiplied by the number of unnecessary respiratory antibiotic prescriptions for designated time periods to arrive at total landfilled waste emissions. We used similar methods applied to published 2014 data from CDC to estimate national waste emissions due to unnecessary antibiotic prescriptions for respiratory infections. Finally, we used the EPA’s GHG Equivalencies Calculator to convert emissions into tangible GHGE for providers and patients. Results: A prescription has 32g of paper and 15g of plastic waste. Among 124,461 urgent care visits (Table 1) in 2019-2022, 18,531 (14.9%) received an antibiotic. This equates to 593 kg of paper waste and 278 kg of plastic waste leading to a total landfilled waste emissions of 0.479 MT CO2e/ton. Using the EPA GHG Equivalencies Calculator, this equates to driving an average gasoline-powered car 1,228 miles. There were 14,482,976 unnecessary antibiotic prescriptions (Table 2) in the US for respiratory infections in 2014. Our estimates suggest these prescriptions led to 375.109 CO2e/ton of GHGE, the same as driving 961,610 miles by an average gasoline-powered vehicle. Conclusion: Unnecessary antibiotic prescriptions are associated with substantial GHGE. This estimate demands further evaluation across diagnoses and care delivery sites, and most importantly action. Additionally, the large GHG contribution of unnecessary antibiotics should be used as a stewardship tool to highlight low-value care that is likely contributing to global climate change.

Background: Antimicrobial susceptibility testing (AST) is critical for detecting antimicrobial resistance (AR) and guiding antimicrobial treatment. The Clinical and Laboratory Standards Institute (CLSI) regularly publishes and revises breakpoints to guide the interpretation of AST results. In 2010–2019, CLSI has lowered many breakpoints for Enterobacterales and Pseudomonas aeruginosa. Timely implementation of updated breakpoints can vary across hospital laboratories, leading to shifts in the interpretation of AST results. This issue is a potential threat to the estimation of national prevalence estimates for AR and limits the comparability of AR data across hospitals. Hospitals submit AST data with clinical laboratory interpretations to the AR Option of CDC’s National Healthcare Safety Network (NHSN). NHSN tracks whether a hospital adopted the revised CLSI breakpoints for six organism-antimicrobial combinations involving AR phenotypes commonly associated with healthcare associated infections through hospital self-reporting status into a structured survey — 2022 NHSN Annual Hospital Survey (Table). For this analysis, we describe the uptake of revised CLSI breakpoints and compare cumulative antibiograms among hospitals that used various breakpoints. Methods: We included hospitals that completed the 2022 NHSN annual survey and submitted data to the NHSN AR Option for at least 9 months in 2022 by November 1, 2023. The percentage of hospitals that implemented CLSI breakpoints, published during 2010–2019, were determined for combinations of antibiotic class, organism, and CLSI revision year (Table). We calculated percent resistance (%R) as the number of isolates meeting AR phenotype definitions divided by the total number of Isolates tested for the following phenotypes: carbapenem-resistant Enterobacterales (CRE) which included E. coli, Klebsiella, and Enterobacter species; extended-spectrum cephalosporin-resistant Enterobacterales (ESC); carbapenem-non-susceptible P. aeruginosa; fluoroquinolone-resistant P. aeruginosa; and fluoroquinolone-resistant Enterobacterales. Results: Among the 741 hospitals included, 75%–93% implemented any of the six revised CLSI breakpoints (Table). The %R was higher among isolates from hospitals that adopted revised breakpoints compared to those that did not (p < 0 .0001). The largest difference was observed for carbapenem-non-susceptible P. aeruginosa (14.91% vs 10.11%). Conclusions: The uptake of revised CLSI breakpoints varied across hospitals, organism-antimicrobial combinations, and CLSI versions. This analysis indicates that the prevalence of AR for corresponding phenotypes could be underestimated if data from hospitals using higher, outdated breakpoints are included. It is important for NHSN to continue tracking breakpoints used in individual hospitals and encourage hospitals to report complete data on the original AST results, such as MIC, to optimize the accuracy of national AR surveillance.

Background: False-positive blood cultures compromise care; extended stays, Clostridioides difficile risk increases and renal woes tagged to antibiotic alms contribute to the doubling of patient in-hospital mortality that is observed relative to true negative diagnostic results. False-positive affiliated central line-associated bloodstream infection reports can further obfuscate the quality of care provided. Between personnel performance pressures, laboratory resource losses and the risk for financial penalty under Value-Based Purchasing and Hospital-Acquired Condition Reduction Programs (Centers for Medicare & Medicaid Services), it becomes difficult to brush aside the burden of a non-zero blood culture contamination rate. Following unsuccessful and unsustainable endeavors that included educational exercise and waste tube employment, initial-specimen diversion devices designed to shift performance burdens from technicians to technology were co-opted in an effort to secure reliable blood culture contamination rate reductions. Methods: A 3.6% blood culture contamination rate was observed systemwide prior to intervention, which began in 2020. Among seventeen facilities that share a data system, twelve co-opted initial-specimen diversion device technology as the evidence-based anchor to a trifurcate intervention strategy that included value analysis and cultural curation. Results: The 2023 systemwide blood culture contamination rate was 1.95%; down from 2.8% in 2022 and 3.2% in 2021. The average cost per false-positive event was $2,111, with intervention amounting to systemwide savings of $4.1 million in 2023 as approximately 1,920 patients avoided false-positive incidents. Critical to year-over-year systemwide uptick in adoption of interventive technology was consistent and near real-time communication to caretakers regarding outcomes. Conclusion: The sustained success of the multifactorial solution showcased herein stems from the coupling of an evidence-based action with an ongoing assessment of value and communication channels carefully constructed to celebrate and perpetuate value observed. Layered uncertainties often cloud the crux of a multifactorial solution to a complex conundrum; for many decades the literature-supported solution to high blood culture contamination rates was to educate every person involved in every possible way. Only recently, following recommended practice revisions endorsed by the Clinical and Laboratory Standards Institute and Centers for Disease Control and Prevention, did it become apparent nationwide that education alone was insufficient; some contaminant pathways persist without meticulously mechanical closure. Antimicrobial stewardship requires the respectful removal of adaptable pressures from microorganisms, but the inverse is equally important; by setting an ambitious systemwide blood culture contamination rate target of 1% or less, it is hoped that all facilities involved herein respond to this pressure with optimism, introspection and innovation.

Background: While Outpatient Parenteral Antibiotic Therapy (OPAT) offers patient convenience and reduced healthcare costs, its increasing utilization has brought various complications to light, including antibiotics-related and line-related OPAT complications. In a large prospective study, 18% of the patients experienced adverse drug events. Another study showed 8.45% of patients had vascular complications. Our study aims to identify clinical predictors associated with OPAT complications. Identifying predictors for suboptimal OPAT outcomes provides an opportunity to intervene, thereby minimizing the risk of OPAT-related complications. Method: We conducted a retrospective cohort study at Tufts Medical Center of all adult patients aged ≥18 years discharged on OPAT from April 2022 to October 2022. Demographic, treatment, outcome, and complications data were extracted through chart review. The primary outcome was the proportion and predictors of OPAT complications. The secondary outcomes were OPAT completion rate, 30-day ED visit, and 30-day readmission rates related to OPAT complications. We used univariable and multivariable analyses using logistic regression models for the predictors of OPAT complications. Variables with p5 (OR, 0.281, 95% CI 0.101–0.784), but they were more likely to have received two antibiotics (OR, 2.265; 95% CI 1.155-4.442). However, no significant independent predictor OPAT complications was identified in multivariable regression analysis (Figure 2). OPAT completion rates were lower in patients with complications (59.1% versus 75.4%). The 30-day ED visit and 30-day readmission rates were significantly higher in the complication group (31.8% vs. 0 and 34.1% vs. 2.1%, respectively). Conclusion: Our study highlights the significant difference in treatment completion rates and higher incidence of ED visits and readmissions rates among those with OPAT complications. Although specific independent predictor was not identified, the association with multiple antibiotic therapies and telemedicine follow-ups suggests areas for further investigation.

Introduction: Vancomycin-associated acute kidney injury (V-AKI) is a common adverse reaction; however, there is currently no method to systematically monitor its incidence. We previously developed and internally validated an electronic algorithm to identify cases of V-AKI using structured electronic health record data at the Johns Hopkins Hospital, which demonstrated excellent agreement with chart review (percent agreement 92.5%; weighted kappa coefficient 0.95), as well as excellent sensitivity (89.7%) and specificity (98.2%) in detecting at least possible V-AKI events. The objective of this study was to evaluate the generalizability of the V-AKI electronic algorithm. Methods: We identified a retrospective cohort of adult and pediatric patients who received ≥1 dose of intravenous vancomycin while admitted to University of Virginia (UVA) Medical Center from 1/2021-1/2023. An increase in creatinine (Cr) of ≥0.3 mg/dL within 48 hours or ≥50% increase in baseline Cr within 7 days, occurring after the first dose and up to 72 hours after the last dose of IV vancomycin, was considered a potential V-AKI event. The electronic algorithm was executed at UVA with only limited contextualization of hospital specific variables (e.g., procedure names). Patients were categorized as excluded/not meeting criteria, or as having an unlikely, possible or probable V-AKI event using a causality framework. A random subset of the cohort underwent chart review by a blinded reviewer for external validation. Percent agreement and a weighted kappa coefficient were calculated. The sensitivity and specificity in identifying at least possible V-AKI events was determined. Results: The electronic algorithm was validated using 200 cases and demonstrated 60.0% percent agreement with chart review (Figure). The weighted kappa coefficient was 0.75. The algorithm was 83.8% sensitive and 71.4% specific in detecting at least possible V-AKI events. Among the 80 discrepant cases, there was only a 1-category difference in 62.5% of cases. The most common reasons for discrepant assessments, which were partly due to inconsistencies in chart review, included disagreement regarding timing of AKI onset (18.6%) and whether renal function returned to baseline (16.3%). Conclusions: An electronic algorithm to identify V-AKI events was successfully implemented at another institution. Although agreement with chart review was only fair, sensitivity in detecting at least possible V-AKI events remained excellent. The electronic algorithm may be useful for systematically and reproducibly identifying V-AKI events across institutions in a scalable manner to inform stewardship interventions. However, further refinement of the algorithm and improvement in consistency of chart review assessments is needed.

Disclosure: Lindsay Donohue: Advisor – Abbvie

Background: The Clinical & Laboratory Standards Institute (CLSI) recommends use of annual antibiograms to help guide empiric antibiotic therapy. Because CLSI periodically updates minimum inhibitory concentration (MIC) breakpoints, we assessed the impact of these updates on longitudinal trends in antibiotic susceptibility rates for Escherichia coli and Klebsiella pneumoniae at a single academic medical center in Atlanta, GA. Methods: Susceptibilities for cefepime, ceftazidime, and levofloxacin in E. coli and K. pneumoniae were extracted from hospital antibiograms from 1988 to 2022. Starting in 1995, intensive care units (ICUs) and wards had separate annual antibiograms, which we combined using weighted averages to create annual overall hospital antibiograms. After summarizing the frequency of isolates tested and susceptibilities using medians and interquartile ranges (IQR), we conducted an interrupted time series analysis using linear segmented regression models, to evaluate the level changes and trends in susceptibility, before and after CLSI MIC breakpoints were updated for ceftazidime (2010 and 2017), cefepime (2014 and 2017), and levofloxacin (2013). Results: Among 21,214 E. coli, there was a median of 291 [IQR: 104, 555] isolates tested annually. Similarly, among 8,686 K. pneumoniae isolates, the median was 125 per year (IQR: 76, 178). Prior to the MIC breakpoint changes, baseline susceptibility trends of both organisms to all 3 antibiotics significantly declined at a rate between 0.2% to 2.4% per year (Table 1). For cefepime (Figure 1), susceptibility decreased annually during 1988 – 2013 for both E. coli (-0.5%) and K. pneumoniae (-1.2%). There were no significant level changes but there were trend changes after 2018, for E. coli (+2.1%) and K. pneumoniae (– 5.5%). For ceftazidime (Figure 2), significant level changes occurred after 2010 for both organisms (E. coli: -5.7%; K. pneumoniae: -5.2%). For levofloxacin (Figure 3), the breakpoint update in 2013 lead to significant level change in susceptibility (E. coli: +8.4%; K. pneumoniae: +11.4%). Conclusion: Overall, we observed a consistent decrease in antibiotic susceptibility in E. coli and K. pneumoniae over three decades, with immediate increases in the level change of susceptibility when MIC breakpoints were changed, followed by a decreasing trend. These findings highlight the importance of longitudinal surveillance and MIC breakpoint changes to inform antimicrobial stewardship strategies.

Background: The standardized antimicrobial administration ratio (SAAR) is a metric utilized to measure antimicrobial use within and between hospitals by comparing observed to predicted antimicrobial days of therapy. However, it remains unknown whether narrow-spectrum beta-lactam (NSBL) use adds to overall antimicrobial utilization or substitutes broad-spectrum agents. This muti-hospital cohort study examined the impact of NSBL use on overall antimicrobial utilization and the correlation between the use of NSBL and various broad-spectrum antimicrobial categories in South Carolina (SC) hospitals. Methods: SAARs were collected from all hospitals in SC that reported antimicrobial use (AU) data to the National Healthcare Safety Network (NHSN) between 2017 and 2021. SAARs collected included: overall SAAR, broad-spectrum agents predominantly used for hospital-onset infections (BSHO), broad-spectrum agents predominantly used for community-acquired infections (BSCA), NSBL, and antibacterial agents posing the highest risk for Clostridioides difficile infection (CDI). Category SAARs were combined to include data in both the adult intensive care unit (ICU) and adult wards using the formula: [(total observed antimicrobial days ICU + total observed antimicrobial days ward) / (total predicted antimicrobial days ICU + total predicted antimicrobial days wards)]. Pearson correlation coefficient (r) was used to examine the correlation between various SAARs categories. Results: A total of 38 hospitals in South Carolina reported AU to NHSN at least during one calendar year during the study period. The use of NSBL agents was negatively correlated with the use of BSHO (r = -0.596, p < 0.001), BSCA (r = -0.543, p < 0.001), and high-risk CDI antibiotics (r = -0.601, p < 0.001). Moreover, the use of NSBL agents did not correlate with the overall SAAR (r = 0.008, p = 0.93), whereas the use of BSHO (r = 0.587, p < 0.001), BSCA (r = 0.494, p < 0.001), and high-risk CDI agents (r = 0.464; p < 0.001) positively correlated with the overall SAAR. Conclusion: In South Carolina hospitals, the use of NSBLs does not contribute to additional antibiotic use overall as it seems to replace broad-spectrum antimicrobials in various categories. By de-escalating from broad-spectrum agents to NSBL agents, one can improve antimicrobial use without negatively impacting the overall SAAR. This observation encourages implementation of antimicrobial stewardship interventions that increase utilization of NSBLs, when appropriate, such as de-escalation of antimicrobial therapy among others without concerns for increasing the SAAR for overall antibiotic use.

Background: Antibiotic prescribing for children is highest in rural areas. Tele-stewardship allows for implementation of antimicrobial stewardship (AS) via telecommunication with providers. This study addresses need for better AS in rural areas by implementing and evaluating bundled outpatient AS interventions using tele-stewardship in rural pediatric primary care (PC) clinics and emergency departments (EDs) affiliated with Vanderbilt University Medical Center. Methods: The bundle includes (1) patient/guardian educational materials, (2) antibiotic use commitment posters (3) provider education through quarterly teaching pearls and app-based microlearning modules (QuizTime), and (4) quarterly audit/feedback with peer comparison on guideline-concordant antibiotic use via tele-meeting and email. Participants are pediatric prescribers (physician, physician assistant, nurse practitioner). We compared antibiotic prescription data for children < 1 8 years collected during the baseline period (Jan–Dec 2022) to the intervention period (Jan-Sept 2023). Two academic PC clinics and one ED where interventions were not implemented were included as “controls”. The primary outcome is percent of encounters that result in an antibiotic prescription. Secondary outcomes include (1) percent of encounters with guideline-concordant antibiotic choice for otitis media (AOM), streptococcal pharyngitis (GAS), sinusitis, and community-acquired pneumonia (CAP); (2) percent of encounters with 5-day antibiotic duration for AOM, sinusitis, and CAP; and (3) percent of encounters with rapid GAS testing. ED sinusitis data not analyzed due to small N. Significance was determined by calculating 95% confidence intervals for the difference of proportions. Results: There were 139,474 PC encounters (91,706 baseline and 47,768 intervention) and 94,205 ED encounters (54,138 baseline and 40,067 intervention) among 20 PC prescribers and 38 ED prescribers from January 2022-September 2023. Compared to baseline, the antibiotic prescription rate decreased 1.1% in intervention PCs but increased 0.9% in control PCs (Figure 1). Compared to baseline, the antibiotic prescription rate decreased by 0.4% in the intervention EDs but increased 3.1% in the control ED (Figure 1). Secondary outcomes showed significantly increased proportions of guideline concordant ED AOM prescriptions, 5-day PC AOM prescriptions (Figure 2), guideline concordant ED streptococcal pharyngitis prescriptions (Figure 3), and guideline concordant PC sinusitis prescriptions (Figure 4). There was a decrease in GAS tests in intervention PCs and EDs (Figure 6). Conclusions: Interim analysis shows bundled implementation strategies using tele-AS led to significantly decreased overall antibiotic use in rural PC clinics compared to control sites. The study is ongoing and will continue to evaluate outcomes over a longer intervention period to reduce seasonal bias.

Disclosure: Sophie Katz: Research Grant - Pfizer; Research Grant - Dolly Parton Pediatric Infectious Diseases Research Fund; Consultant - Optum

Background: The University of Washington (UW) Center for Stewardship in Medicine (CSiM) supports a tele-antimicrobial stewardship (AMS) program (TASP) using the ECHO approach (Extension for Community Healthcare Outcomes) in small, rural, and Critical Access Hospitals (primarily in the western U.S.) with education, mentoring, organizational capacity building, and a community of peers. To evaluate the continuing education (CE) component of UW-TASP ECHO, CSiM surveyed individuals receiving CE credits as part of the program. This survey was designed to track individuals’ satisfaction with the program and to assess the impact of UW-TASP ECHO on AMS in participating facilities. Methods: The CE participants’ survey was completed annually by individuals participating in UW TASP ECHO using online survey software. The survey included closed-ended and open-ended questions. Responses to open-ended questions were entered into Atlas.ti qualitative analysis software and coded iteratively according to themes that emerged. When a new code emerged partway through the coding process, earlier surveys were re-coded for the new code. Final codes were grouped into themes and sub-themes and quotes from each theme identified were summarized and attached to the theme and reported. Results: Data from three administrations of this survey were available: 2018-2019 (n=66); 2020-2021 (n=27); and 2021-2022 (n=30). These surveys were completed by a total of 95 individuals from 53 hospitals. Seven of these individuals completed a survey in each year, 14 completed a survey in two years, and 74 completed only one survey. Themes identified were COVID-19 support (including procedures and policies, being kept up-to-date, research summaries, and peer support), the antibiotic pocket guide developed by UW, strength in community, staff education, role of CSiM in developing/strengthening the AMS program at the facility, change in use of antibiotics, UW imprimatur, learning/growing as a healthcare provider, and importance for small, rural hospitals (see examples in Table 1). Conclusions: This qualitative analysis provides evidence from surveys of individuals participating in CE that UW TASP ECHO has had a meaningful impact in such domains as building a strong community among small, rural and critical access hospitals, educating staff, changing antibiotic use and providing peer support, among others.

Background: Combating antibiotic resistance, exacerbated by widespread unnecessary outpatient antibiotic prescriptions, necessitates innovative stewardship solutions. Audit and feedback reports are effective but often resource heavy. We introduced a free, open-source system, Outpatient Automated Stewardship Information System (OASIS©), for automating the creation and distribution of recurring audit and feedback reports to clinicians to improve antibiotic prescribing. Methods: We used mixed methods to evaluate implementation of OASIS© across 11 clinics at Denver Health and Hospital Authority (DHHA) and Children’s Hospital Colorado (CHCO) from July 2022 to August 2023. Both sites host their own Epic® electronic healthcare and enterprise data warehouse systems. R statistical software was utilized to retrieve and process the data needed to create individual[HCM1] clinician audit and feedback reports with peer comparison. Reports were provided for 1) antibiotics prescribed for respiratory diagnoses, 2) antibiotics prescribed for respiratory diagnoses where antibiotics are never indicated, 3) first-line antibiotic prescribing for acute otitis media (AOM), and 4) five-day duration of antibiotics for children two years and older with AOM. Feedback reports for each metric were emailed to clinicians for three consecutive months. The primary outcome was adaptations needed to implement OASIS©. Secondary outcomes included fidelity (measured by email readership), time to set up and maintain the program, and barriers and facilitators to implementation (assessed by four qualitative interviews with OASIS© stakeholders). Results: The most significant adaptations made pertained to the automation of OASIS© reports for organizations not using R for data retrieval and reporting, setting up OASIS© specific email addresses, and validating clinician fidelity via read receipts. Fidelity was higher at DHHA (91-100%) compared to CHCO (10-30%). When interviewed, data analysts expressed that time for initial setup ranged from 1-6 hours. After reporting was automated, the estimated monthly time to send reports was 10 minutes. Views on setup complexity were split, but all recognized the readability of the reports and OASIS©’s value for improving prescribing behaviors. The greatest barriers to implementation included obtaining analytic resources for initial setup and the need to download additional R packages. No interviewee had prior experience creating audit and feedback reports. Conclusions: Implementing OASIS© requires addressing system diversity and knowledge gaps in outpatient informatics and antibiotic stewardship. Despite these challenges, the tool proved efficient and beneficial for monitoring and reporting antimicrobial prescribing. This free tool could likely be effectively disseminated to other health systems given the limited time and resources required for adaptations, setup, and monitoring. [HCM1]I