Background: Widespread antimicrobial use in dogs and cats drives antimicrobial resistance in both animals and humans. Knowledge of the factors associated with antimicrobial use is limited in veterinary medicine. We examined factors associated with antimicrobial drug prescription among inpatient dogs and cats at an academic veterinary hospital. Methods: A veterinary-adapted observational medical outcomes partnership common data model was utilized to extract demographic, clinical, and prescription data from the electronic medical record system in this descriptive observational study. Using generalized estimating equations, we assessed the association between demographic and clinical factors and systemic antimicrobial drug prescription among inpatient dogs and cats at a small-animal teaching hospital between 2018 and 2020. Results: Across 11,685 dogs with 14,328 admissions (mean age, 7.4 years; 47% females), the following factors were associated with increased odds of any antimicrobial drug prescription: female, longer admission, a history of chemotherapy within 30 days of hospital admission, surgery upon admission or within the last 30 days, urinary catheterization, ICU admission, and oxygen support. In 3,371 cats with 4,088 admissions (mean age, 8.6 years; 39% females), the following factors were associated with increased odds of any antimicrobial drug prescription: female, longer admission, increased age (>8 years), admission into the ICU, surgery upon admission, and feline that did not require oxygen support or urinary catheterization. Conclusions: This study identifies multiple patient and clinical factors associated with increased risk of antimicrobial drug use in inpatient dogs and cats that can inform veterinary antimicrobial stewardship efforts and may be useful for antimicrobial use benchmarking on an institutional or multi-institutional scale.

Funding: None

Disclosures: None

In this large, retrospective cohort study, we used administrative data to evaluate nonpregnant adults with group B Streptococcus (GBS) bacteriuria. We found greater all-cause mortality in those with urinary tract infections compared to asymptomatic bacteriuria. Differences in patients’ baseline characteristics and the 1-year mortality rate raise the possibility that provider practices contribute to differences observed.

Background: Patients with recurrent urinary tract infections (rUTI) experience frequent exposure to antimicrobial regimens, leaving them at higher risk for developing antibiotic resistance. Little information on the prevalence of antibiotic resistance among patients with rUTI has been published. Although the IDSA recommends using a prior culture to guide empiric treatment, studies have not examined the predictive ability of a prior culture among patients meeting rUTI criteria. We constructed an antibiogram and evaluated test metrics, including sensitivity, specificity, and positive predictive value (PPV) and negative predictive values (NPV) of a prior culture (any organism), on predicting resistance (PPV) or susceptibility (NPV) of a future culture among patients with uncomplicated rUTI in an outpatient setting. Methods: We retrospectively extracted electronic health record data from outpatients aged ≥18 years who had an ICD-10 code for cystitis listed twice in 6 months or thrice in 12 months between November 1, 2016, and December 31, 2018. Patients sought care at either urology or primary care practices within an academic medical center in Houston, Texas. Patients with functional or structural abnormalities of the genitourinary tract, signs or symptoms of pyelonephritis, or pregnancy were excluded. Antibiogram data were reported for uropathogens with ≥30 isolates, and intermediate results were considered resistant. Test metrics and Bayes’ PPV and NPV were calculated using standard formulas. Results: We included 597 visits from 232 unique patients. Most were White (63%) and female (92%), and the cohort had a median age of 58 (IQR, 41–68). Among 310 rUTI episodes with a urine culture, 189 (61%) had at least 1 uropathogen isolated, and Escherichia coli (n = 130, 66%) was most common among all 196 uropathogens. E. coli isolates had >20% resistance to 10 of 18 antibiotics (Fig. 1). E. coli resistance to ciprofloxacin was 27.9%, resistance to nitrofurantoin was 5.5%, and resistance to trimethoprim-sulfamethoxazole was 38.0%. The PPVs for predicting resistance were highest for ceftriaxone (0.86; 95% CI, 0.60–0.96), ciprofloxacin (0.84; 95% CI, 0.63–0.94), and levofloxacin (0.84; 95% CI, 0.63–0.94). NPVs of resistance were highest for gentamicin (0.97; 95% CI, 0.83–1.00), ceftriaxone (0.94; 95% CI, 0.86–0.98), and cefepime (0.94; 95% CI, 0.84–0.98), whereas NPVs for cefuroxime, ciprofloxacin, levofloxacin, and nitrofurantoin were all >0.83. Conclusions: We detected considerable antibiotic resistance among patients with rUTI to commonly prescribed antibiotics. Prior urine culture susceptibility demonstrated moderate-to-high PPVs for predicting future resistance to ceftriaxone and fluoroquinolones as well as high NPVs for several cephalosporins and fluoroquinolones, which could inform empiric prescribing choices.

Funding: This investigator-initiated research study was funded by Rebiotix, a Ferring Company.

Disclosures: None

The Accelerate Pheno platform provides rapid identification and susceptibility data. We demonstrate successful incorporation of 24-hour pharmacist review of Accelerate Pheno results that reduced the number of patients going >3 hours from result without an order for active antimicrobial therapy from 29 (2.8%) of 1,043 to 9 (0.85%) of 1,053 (P < .001).

Background: Clinical pharmacists are a critical part of antibiotic stewardship. Stewardship often relies on relationships and persuasion, which may be affected by gender bias. Thus, we aimed to assess the association of sex with the acceptance of antibiotic stewardship recommendations. Methods: Between May and October 2019, medicine pharmacists at single hospital reviewed patients on antibiotics and–when a discharge was anticipated–led an antibiotic discussion (or “timeout”) prior to discharge. To explore differences in antibiotic timeout effectiveness by gender, we assessed the association of pharmacist sex with suggestion and acceptance of antibiotic changes using logistic regression controlling for patient characteristics. We also assessed whether hospitalist sex was associated with or moderated the effect of pharmacist sex on acceptance of timeout recommendations. Results: Between May 1, 2019, and October 31, 2019, pharmacists conducted 295 timeouts (patient characteristics in Fig. 1). Overall, 54% of timeouts were conducted by 12 female pharmacists and the remaining 46% were conducted by 8 male pharmacists. Overall, 82 (29%) of 295 timeouts resulted in a pharmacist recommending an antibiotic change, and male pharmacists were more likely to recommend a change: 52 (38%) of 137 versus 30 (19%) 158 (P Conclusions: In this discharge antibiotic intervention, timeouts conducted by women were less likely to result in an antibiotic change than those conducted by men. The difference in effectiveness resulted both from female pharmacists being less likely to recommend a change and from hospitalists being less likely to accept recommendations from a female pharmacist. These findings suggest that gender bias may play a role acceptance of antibiotic stewardship recommendations, which could affect antibiotic use, pharmacist job satisfaction, and patient outcomes.

Funding: None

Disclosures: None

A multimodal antimicrobial stewardship intervention was associated with a decrease in antibiotic prescribing for targeted non–coronavirus disease 2019 (COVID-19) upper respiratory infections from 27.6% in 2019 to 7.6% in 2021. We describe our approach to prioritizing departments for 3 levels of interventions in the setting of limited stewardship personnel.

Structural racism and systemic health inequities have an overwhelming and deadly impact on racially and ethnically minoritized groups. Antimicrobial resistance (AMR) is widely considered a global public health threat, and concerns that minoritized groups are disproportionately affected are increasing. With the emergence and spread of AMR, novel therapies and prevention strategies are imperative. Coronavirus disease-19 (COVID-19) has highlighted stark imbalances in the hospitalization and death rates of minoritized individuals compared to their White counterparts, irrespective of the availability of targeted preventive therapies (ie, vaccinations). Thus, dialogue regarding the utility of vaccines used prophylactically to decrease the number of infectious diseases cases and the historical lack of vaccine equity and uptake across minoritized groups is needed. All of these factors work in concert to increase the burden of AMR and ultimately health disparities within minoritized communities. Herein, we provide historical context pertaining to the impact of structural racism on healthcare inequities in the United States, we explore racial and ethnic disparities in AMR, and we discuss the intersection of racism, AMR, and vaccine equity. Lastly, we offer recommendations to mitigate the described inequities.

Background: Taking antibiotics outside the guidance of a clinician (nonprescription use) is a potential safety issue and runs counter to antibiotic stewardship efforts. We identified the symptoms and illnesses and situations that may predispose patients to take antibiotics, and we compared these findings between patients attending public primary care clinics and private emergency departments. Methods: A cross-sectional survey was conducted between January 2020 and March 2021 in 6 primary care clinics and 2 emergency departments in the United States. We queried patients about 5 symptoms and illnesses (Fig. 1) and 14 situations (Fig. 2) to investigate whether these would lead the patients to take antibiotics without a prescription. We used the χ2 test to compare the symptoms and illnesses and situations between the respondents from public and private healthcare systems. We set the P value for significance at <.025. Results: In total, the survey had 564 respondents (median age, 49.7 years; range, 19–92), and 72% were female. Most respondents identified as either Hispanic or Latina/Latino (46.6%) or African American or Black (33%), followed by White (15.8%), and other (4.6%). Most respondents had visited public clinics (72%). The most common insurance status for our respondents included Medicaid or county financial assistance program (56.6%), followed by private insurance or Medicare (36.7%) and self-pay (6.7%). In public primary care clinics, only 23% had private insurance or Medicare compared to 72.9% in private emergency departments. Of those surveyed, 69% agreed that antibiotics would improve the recovery from sinus infections, followed by bronchitis (64%), sore throat (64%), cold/flu (61.4%), and diarrhea (31.5%). The proportions of respondents who believed that antibiotics would improve the recovery from diarrhea (36.2% vs 19.4%; P = .004) and sore throat (59.9% vs 48.4%; P < .001) were significantly higher among public versus private outpatient respondents. We did not find significant differences for cold/flu, sinus infection, or bronchitis between these 2 healthcare systems (Fig. 1). In 11 of the 14 situations, patients in public clinics were more likely to report a likelihood of using nonprescription antibiotics than the patients visiting the private emergency rooms (Fig. 2). Conclusions: Future stewardship interventions should be aware of the symptoms and illnesses and situations that may influence outpatients to take nonprescription antibiotics. Addressing modifiable factors (eg, leftover antibiotics, antibiotics given by friends or family, and antibiotics available without a prescription in stores or markets) may also curtail these unsafe practices and reduce antibiotic resistance.

Funding: None

Disclosures: None

Background: Antibiotic resistance is pervasive in the Veterans’ Affairs (VA) healthcare system, with rates of fluoroquinolone and trimethoprim–sulfamethoxazole (TMP/SMX) resistance approaching 30% in E. coli urinary isolates. The efficacy of antimicrobial treatment is critically dependent on the susceptibility of the infecting pathogen; however, prescription decisions are often made empirically in practice. We analyzed susceptibility profiles of enteric gram-negative rods (Enterobacterales) from clinical urine cultures collected from ambulatory patients receiving care in VA clinics and emergency departments. Our goals were (1) to develop a predictive model to support choice of empiric antibiotics pending results of susceptibility testing and (2) to examine the relationship between past antibiotic exposures and susceptibility profiles to enhance understanding of antibiotic selective pressure. Methods: We obtained 265,076 positive cultures from 157,422 unique patients from 2015 to 2020. We trained random forest multinomial classifiers to estimate the risk of a positive urine culture isolate being resistant to the multinomial outcome: fluoroquinolone, TMP–SMX, cephalosporin, or any combination of these 3 agents. Data sources evaluated for model generation included demographics, comorbidities, trend and seasonal terms, treatment history for multiple antimicrobial treatments summarized using number of prescriptions in weekly intervals, and sample history summarized by number of resistant and susceptible cultures in weekly intervals. Using 5-fold cross validation, we assess the performance of the clinical prediction using the area under the receiver operating characteristic curve (AUC) for each multinomial outcome. In addition to prediction, we modeled the direct effect of treatment on resistance using multinomial group lasso (MGL). This method allows variable selection in variable groupings, such as all variables related to the fluoroquinolone treatment history, which allowed us to assess the effect of a patient’s complete course of treatment on resistance. Results: In cross-validation analysis, our random forest model was best at predicting outcomes with fluoroquinolone resistant phenotypes compared to non–fluoroquinolone-resistant phenotypes (Table 1). From MGL, we found that having a prescription for fluoroquinolone treatment 4–8 weeks prior to a urinalysis was positively associated with fluoroquinolone resistance and negatively associated with fluoroquinolone susceptible phenotypes (Fig. 1). Conclusions: Our results show that a patient’s sample and treatment history are highly predictive of a future resistance. Fluoroquinolone treatment is especially associated with increased risk of fluoroquinolone single- and multidrug resistances. A history of either fluoroquinolone or trimethoprim-sulfamethoxazole (TMP-SMX) treatment is a stronger indicator of a future resistant phenotype than cephalosporin or penicillin.

Funding: None

Disclosures: None

Background: Dentists prescribe ~25.7 million antibiotic prescriptions annually. Private practice dentists (PPDs) represent 80% of US dentists who need to implement dental antimicrobial stewardship. We conducted a prospective cohort study of PPDs comparing appropriateness of antibiotic use before and after dental AS education. Methods: PPDs were invited to participate in this study. In phase 1 (pre-education), we collected 3 months (June–August 2019) of retrospective antibiotic use data (indication, dose, duration, penicillin allergy history) and number of dental procedures. We also conducted a preliminary survey to assess baseline antimicrobial stewardship knowledge. In phase 2 (education), PPDs attended 4 televideo education sessions (March–May 2021) taught by an infectious disease– antimicrobial stewardship (ID-AS) pharmacist and physician. In phase 3 (posteducation), we prospectively collected 3 months (June–August 2021) of antibiotic use data (as in phase 1), using an online database with ongoing feedback. In phase 4, we conducted antibiotic use audit and feedback to PPDs after the survey, and we solicited recommendations to reach more PPDs. The Student t test was used for statistical analyses. Results: Study participants comprised 15 PPDs: 2 oral maxillofacial surgeons, 6 periodontists, 4 endodontists, and 3 general dentists. Among them, 10 had been in practice >20 years. The presurvey revealed that 14 were unfamiliar with dental antimicrobial stewardship. All prescribed clindamycin (25% for nonpenicillin allergy), and standard antibiotic duration ranged from 5 to 14 days based on dental school training. In phase 3, despite more procedures, overall antibiotic use and duration decreased, and the use of clindamycin, quinolones, and prophylaxis for joint implant patients, also decreased. Appropriate use improved from 22% to 95%. Postsurvey responses on perceived value of antimicrobial stewardship education were 100% positive, with recommendations to make antimicrobial stewardship a required annual continuing education, similar to opioid continuing education. Study participants invited the ID-AS experts to teach an additional 150 PPDs to date via established PPD study clubs to expand dental antimicrobial stewardship across the United States. Conclusions: After learning dental antimicrobial stewardship guidance from ID-AS experts, PPDs rapidly optimized antibiotic prescribing behavior. PPDs identified their established study clubs as a forum to quickly expand dental antimicrobial stewardship training by ID-AS experts throughout the United States.

Funding: MERCK

Disclosures: None

Background: Emerging evidence supports the use of billing data to identify stewardship targets in primary care. Standardizing an approach to antibiotic prescribing rate (APR) calculations could facilitate external benchmarking. Methods: Using methodology and an ICD-10 dictionary validated in urgent care clinics,1 we created an expanded ICD-10 dictionary to incorporate additional ICD-10 codes from primary care associated with antibiotic prescriptions (Fig. 1). We then compared antibiotic prescribing rates using the urgent care and expanded dictionaries. We included all primary care visits from 2019 to 2020 and extracted ICD-10 codes and antibiotic order data. Using the urgent care and expanded ICD-10 dictionary, we classified each encounter by prescribing tier based on whether antibiotics are almost always (tier 1), sometimes (tier 2), or almost never (tier 3) indicated. For encounters with ICD-10s in multiple tiers, we chose the lowest tier. For multiple ICD-10 codes within the same tier, we chose the first extracted ICD-10 code. We calculated antibiotic prescribing rates as the proportion of encounters associated with ≥ 1 antibacterial prescription. This quality improvement project was deemed non–human subjects research by the Stanford Panel on Human Subjects in Medical Research. Results: The urgent care dictionary has 1,400 ICD-10 codes. We added 1,439 ICD-10 codes derived from primary care encounters to create the expanded ICD-10 dictionary (8.5% tier 1, 9.1% tier 2, and 82.4% tier 3) (Fig. 1). We identified 177,531 encounters; 74% had ≥ 2 associated ICD-10 codes (Fig. 2). In total, 147,085 encounters (82.9%) were classified into a tier using the urgent care dictionary. An additional 22,039 encounters were classified with the expanded dictionary (Table 1). Most added encounters were tier 3 with low 0.7% APR (Tables 1 and 3). In total, 41,473 (28.2%) encounters were classified differently depending on the ICD-10 dictionary used, most commonly changing from tier 3 to tier 2 without an increase in overall tier 2 antibiotic prescribing rate (Tables 2 and 3). Overall antibiotic prescribing rates were similar when using either the urgent care or expanded ICD-10 dictionary (Table 2). Conclusions: The expanded ICD-10 dictionary allowed for classification of more encounters in primary care; however, it did not meaningfully change antibiotic prescribing rates. Antibiotic prescribing rates were likely diluted by classifying more encounters without identifying an associated increase in antibiotic prescribing. A more sophisticated classification system may help to accommodate the diversity and volume of ICD-10 codes used in primary care.

1. Stenehjem E, et al. Clin Infect Dis 2020;70:1781–1787.

Funding: None

Disclosures: None

Background: Prostate cancer is the leading cancer diagnosis and the second leading cause of cancer deaths in men. Definitive diagnosis is made by prostate biopsy. This procedure poses a risk of infection and, rarely, sepsis. Studies have found the incidence of symptomatic urinary tract infection (UTI) after biopsy to be 2%–3%, and the rate of infection-related hospitalization (IRH) to be 0.6%–4.1%. An initial review at our facility found the IRH rate to be 3.7%. The primary purpose of this study was to determine the incidence of IRH following prostate biopsy in patients at the Memphis VA Medical Center (VAMC) after initial review and education. Methods: All transrectal prostate biopsies performed at the Memphis VAMC from October 2017 through May 2021 were analyzed. Patients were excluded if they had a spinal cord injury or concomitant procedure. The primary outcome was IRH occurring within 30 days of the procedure. Variables collected included risk factors, antibiotic choice and duration, and details of postprocedural infections. Analyses were performed on a per-procedure basis. Results: Overall, 601 procedures were identified; 13 were excluded, for a total of 588 transrectal prostate biopsies on 533 patients. All patients were given antibiotics. Oral antibiotics alone were provided for 306 procedures (52%) for an average duration of 3 days. A combination of both oral and intramuscular antibiotics were provided for 282 (48%) procedures. The most common oral antibiotics used were cefuroxime (538, 91.4%), ciprofloxacin (17, 2.9%), amoxicillin–clavulanate (16, 2.7%), and sulfamethoxazole–trimethoprim (12, 2%). Intramuscular antibiotics included ceftriaxone (263, 93.3%) and gentamicin (19, 6.7%). An infectious complication occurred in 29 patients (4.9%): 26 (3.4%) were urogenital and 5 (0.8%) required hospitalization. Of the procedures complicated by a postprocedure infection, 22 (75.9%) received an oral antibiotic alone, 21 (95.4%) of which were cefuroxime, and 7 (24.1%) received both an intramuscular and an oral agent. Conclusions: In our initial review, the most common antibiotics used were fluroquinolones, with an average duration of 3 days periprocedure and an IRH rate of 3.7%. These findings were used to reinforce practices compliant with American Urological Association (AUA) guidelines. This follow-up review reveals that the first-line choice changed from fluroquinolones to cephalosporins, with average duration remaining at 3 days. Although the overall infection rate was 4.9%, the IRH rate decreased from 3.7% to 0.8%.

Funding: None

Disclosures: None

Background: Nearly one-third of patients on hemodialysis receive intravenous (IV) antibiotics annually, but national data characterizing antibiotic use in this population are limited. Using NHSN surveillance data for outpatient dialysis facilities, we estimated temporal changes in the rate of IV antibiotic starts (IVAS) among hemodialysis patients as well as the proportion of IVAS that were not supported by a reported clinical indication. Methods: IVAS events were obtained from the NHSN Dialysis Event module between 2016 and 2020, excluding patients who were out of network, receiving peritoneal or home dialysis, or with unspecified vascular access. IVAS unsupported by documentation were defined as new IVAS without a collected or positive blood culture, pus, redness or swelling event, or an associated clinical symptom. Pooled mean rates of total and unsupported IVAS were estimated per 100 patient months yearly and stratified by vascular access type. Differences in IVAS rates by year were estimated with negative binomial regression. Results: Between 2016 and 2020, 7,278 facilities reported 648,410 IVAS events; 161,317 (25%) were unsupported by documentation (Table 1). In 2016, 3,340 (54%) facilities with ≥1 IVAS event reported an IVAS unsupported by documentation, which increased to 4,994 (73%) in 2020. Total IVAS rates decreased by an average of 8.2% annually (95% CI, 7.1%–9.3%; P < .001). The average annual percentage decrease did not differ significantly by vascular access site. The total IVAS rate was lowest in 2020 (2.17 per 100 patient months; 95% CI, 2.18–2.17). IVAS rates in 2020 were greatest for patients with catheter access (4.79 per 100 patient months; 95% CI, 4.75–4.83), followed by graft (1.71 per 100 patient months; 95% CI, 1.68–1.73), and lowest for patients with fistulas (1.30 per 100 patient months; 95% CI, 1.29–1.31). The overall pooled mean rate of unsupported IVAS was 0.64 per 100 patient months (95% CI, 0.63–0.64), which did not significantly change by year (Fig. 1). Conclusions: Total IVAS rates among outpatient hemodialysis patients have decreased since 2016, and rates among catheter patients remain highest compared to patients with fistulas or grafts. However, unsupported IVAS rates did not change, and the proportion of facilities reporting an unsupported IVAS increased annually. Targeted efforts to engage facilities with unsupported IVAS may help improve accurate reporting and prescribing practices.

Funding: None

Disclosures: None

Outpatient antibiotic use increases during winter months, but information on temporal changes in inpatient antibiotic use in US hospitals is limited. The use of certain inpatient antibiotics, including extended-spectrum cephalosporins, macrolides, and tetracyclines, was strongly associated with influenza activity during the 2015–2019 viral respiratory seasons.

Background:Clostridioides difficile infection (CDI) is a major source of morbidity and mortality. Even after recovery, recurrent CDI (rCDI) occurs frequently, and concomitant antibiotic use for treatment of a concurrent non–C. difficile infection is a major risk factor. Treatment with fidaxomicin versus vancomycin is associated with similar rate of cure and lower recurrence risk. However, the comparative efficacy of these 2 agents remains unclear in those receiving concomitant antibiotics. Methods: We conducted a randomized, controlled, open-label trial at the University of Michigan and St. Joseph Mercy hospitals in Ann Arbor, Michigan. Patients provided written informed consent at enrollment. We included all hospitalized patients aged ≥18 years with a positive test for toxigenic C. difficile, >3 unformed stools per 24 hours, and ≥1 qualifying concomitant antibiotic with a planned treatment of an infection for ≥5 days after enrollment. We excluded patients with complicated CDI, allergy to vancomycin–fidaxomicin, planned adjunctive CDI treatments, CDI treatment for >24 hours prior to enrollment, concomitant laxative use, current or planned colostomy or ileostomy, and/or planned long-term (>12 weeks) concomitant antibiotic use. Clinical cure was defined as resolution of diarrhea for 2 consecutive days maintained until the end of therapy and for 2 days afterward. rCDI was defined as recurrent diarrhea with positive testing within 30 days of initial treatment. Patients were randomized (stratified by ICU status) to fidaxomicin 200 mg twice daily or vancomycin 125 mg orally 4 times daily for 10 days. If concomitant antibiotic treatment continued >10 days, the study drug continued until the concomitant antibiotic ended. Bivariable statistics included t tests and χ2 tests. Results: After screening 5,101 patients for eligibility (May 2017–May 2021), 144 were included and randomized (Fig. 1). Study characteristics and outcomes are noted in Table 1. Baseline characteristics were similar between groups. Most patients were aged <65 years, were on a proton-pump inhibitor (PPI), and were not in the ICU. The mean duration of concomitant antibiotic was 18.4 days. In the intention-to-treat population, clinical cure (73% vs 62.9%; P =.195), and rCDI (3.3% vs 4.0%; P >.99) were similar for fidaxomicin and vancomycin, respectively. Conclusions: In this study of patients with CDI receiving a concomitant antibiotic, a numerically higher proportion were cured with fidaxomicin versus vancomycin, but this result did not reach statistical significance. Overall recurrence was lower than anticipated in both arms compared to previous studies in which duration of CDI treatment was not extended during concomitant antibiotic treatment. Future studies are needed to ascertain whether clinical cure is higher with fidaxomicin than vancomycin during concomitant antibiotic exposure, and whether extending the duration of CDI treatment reduces recurrence.

Funding: Merck & Co.

Disclosures: None

We compared experiences with The Multifaceted Intervention to Improve Prescribing for Acute Respiratory Infection for Adult and Children in Emergency Department and Urgent Care Settings versus Choosing Wisely to evaluate inappropriate antimicrobial prescribing in ambulatory care. Both identified the same clinics, diagnoses, and antibiotics for high-yield antibiotic stewardship interventions.