51. Sustained Impact of an Antimicrobial Stewardship (AS) Initiative Targeting Asymptomatic Bacteriuria and Pyuria in the Emergency Department (ED)

Abstract Background The sustainability of unique AS initiatives are largely unstudied. A multi-faceted initiative to reduce inappropriate treatment of asymptomatic pyuria (ASP) and asymptomatic bacteriuria (ASB) in the ED was implemented at our institution in 2016. A pre-post intervention analysis demonstrated reduction in the inappropriate treatment (tx) of ASP/ASB from 100% to 32% (p< 0.001) following the intervention. The purpose of this present study was to determine the sustained impact of the initiative and determine if re-education provided in Oct 2020 could further reduce inappropriate tx. Methods This was a retrospective, interrupted time series study conducted at an 885 bed academic medical center. Patients (pts) discharged from the ED in Nov 2019 – Feb 2020 (group 1) and Nov 2020 – Feb 2021 (group 2) were retrospectively screened in chronologic order until 50 pts in each group met study criteria. Similar to the 2016 study, pts were included if they were ≥ 18 years old and had a positive urine culture or pyuria. Pts were excluded if they had symptoms of a urinary tract infection (UTI), another infection requiring antibiotics (ABX), indwelling catheter, ureteral stent, or nephrostomy tube, or if pregnant or immunocompromised. The primary outcome was the proportion of pts prescribed ABX within 72 hrs of ED discharge. The secondary outcome was the number of pts returning to the ED with symptomatic UTI within 30 days of discharge. Group 1 was compared to the 2016 study’s post group to determine the sustained impact of the initial initiative; group 2 was compared to group 1 to determine the impact of re-education, which involved a presentation to ED providers and a posted algorithm and fact sheet. Results Results from all time periods are summarized in Table 1. Improvement in inappropriate tx was still noted 3 years after the intervention (28% vs 32%; p = NS). Re-education did not further improve inappropriate prescribing, with 28% of group 2 pts still receiving tx. Table 1. Conclusion The decrease in inappropriate use of ABX for ASP/ASB was still noted 3 years after implementation of a multi-faceted AS initiative. Re-education did not result in further improvement. Disclosures James Johnson, PharmD, FLGT (Shareholder) Vera Luther, MD, Nothing to disclose


Conclusion.
The Kicking CAUTI intervention was successful at reducing urine cultures and associated antibiotic use, with minimal time from the local team members. The research coordinators' time was primarily spent on collection of research data, which will not be necessary outside of a research project. Our model of centralized facilitation makes economic sense for widespread scale-up and dissemination of antibiotic stewardship interventions in integrated healthcare systems.
Disclosures. Barbara Trautner, MD, PhD, Genentech (Consultant, Scientific Research Study Investigator) Background. Gram-negative bacteremia is associated with significant morbidity and mortality. Development of an algorithm for antimicrobial selection, using institution-specific antibiogram data and rapid diagnostics (RDT), achieves timely and appropriate antimicrobial therapy. The objective of this study is to assess the impact of a pharmacy-driven antimicrobial stewardship initiative in conjunction with ePlex® BCID on time to optimal antimicrobial therapy for patients with gram-negative bloodstream infections.

Impact of a Rapid Genotypic Platform for Gram-negative Bloodstream Infections, Paired with an Antimicrobial Stewardship Intervention, on Time to Optimal Antimicrobial Therapy
Methods. This retrospective, observational, single-center study included adult patients with a documented gram-negative bloodstream infection in whom the ePlex® BCID was employed. A pharmacist-driven antimicrobial stewardship intervention was initiated on December 1, 2020; pre-intervention (December 2019 -March 2020) was compared to the post-intervention (December 2020 -February 2020) period. The following organisms were included: Citrobacter spp., Escherichia coli, Klebsiella aerogenes/pneumoniae/oxytoca, Proteus spp, Enterobacter spp., Pseudomonas aeruginosa, and Acinetobacter baumannii. Polymicrobial bloodstream infections or those who had an ePlex® panel performed prior to admission were excluded. The following clinical outcomes were assessed: time to optimal antimicrobial therapy, length of stay (LOS), and inpatient-30-day mortality.
Results. One hundred and sixty-three met criteria for inclusion; 98 patients in the pre-intervention group and 65 patients in the post-intervention group. The mean Pitt Bacteremia Score was 1 in both groups (p=0.741). The most common organism identified by ePlex® BCID was E. coli (65.3% vs 70.8%; p=0.676). Eight E. Coli isolates were CTX-M positive; no other gene targets were detected. The most common suspected source of bacteremia was genitourinary (72.5% vs 72.3%; p=1.0). Time to optimal therapy was reduced by 29 hours [37 (31 -55) vs. 8 (4 -28); p=0.048). Length of stay and mortality was similar between groups.
Conclusion. Implementation of a rapid blood culture identification panel along with an antimicrobial stewardship intervention significantly reduced time to optimal therapy. Further studies are warranted to confirm these results.
Disclosures. Background. Our hospital had a widespread use of colistin and tigecycline, and very high resistance of Acinetobacter Spp. to colistin. The hospital did not have any infectious disease (ID) pharmacist and had only one ID consultant physician. The objective of this study was to evaluate the impact of our intervention on the utilization of colistin and tigecycline and resistance of Acinetobacter Spp.
Methods. This was a before an observational before-and-after study at a tertiary medical center. An ID pharmacist trained in antibiotic stewardship program (ASP) was invited by a tertiary hospital to help create an ASP. The hospital also hired four ID assistant consultants to help the primary ID consultant and pharmacists. The ASP started by restriction of colistin and tigecycline. The study outcomes were antibiotic consumption and resistance of Acinetobacter spp.
Results. Colistin utilization decreased by 60%, and the resistance of Acinetobacter spp. to colistin significantly decreased from 31% to 3% in a year. In addition, tigecycline utilization decreased by 46%. On the other hand, there were no significant changes in carbapenem utilization and resistance, which could be explained by switching from colistin and tigecycline to carbapenems.
Conclusion. Adding an ID pharmacist and ID assistant consultants to the ASP team, and the strict restriction of colistin use was associated with significant reduction in colistin use and Acinetobacter resistance. Background. The sustainability of unique AS initiatives are largely unstudied. A multi-faceted initiative to reduce inappropriate treatment of asymptomatic pyuria (ASP) and asymptomatic bacteriuria (ASB) in the ED was implemented at our institution in 2016. A pre-post intervention analysis demonstrated reduction in the inappropriate treatment (tx) of ASP/ASB from 100% to 32% (p< 0.001) following the intervention. The purpose of this present study was to determine the sustained impact of the initiative and determine if re-education provided in Oct 2020 could further reduce inappropriate tx.
Methods. This was a retrospective, interrupted time series study conducted at an 885 bed academic medical center. Patients (pts) discharged from the ED in Nov 2019 -Feb 2020 (group 1) and Nov 2020 -Feb 2021 (group 2) were retrospectively screened in chronologic order until 50 pts in each group met study criteria. Similar to the 2016 study, pts were included if they were ≥ 18 years old and had a positive urine culture or pyuria. Pts were excluded if they had symptoms of a urinary tract infection (UTI), another infection requiring antibiotics (ABX), indwelling catheter, ureteral stent, or nephrostomy tube, or if pregnant or immunocompromised. The primary outcome was the proportion of pts prescribed ABX within 72 hrs of ED discharge. The secondary outcome was the number of pts returning to the ED with symptomatic UTI within 30 days of discharge. Group 1 was compared to the 2016 study's post group to determine the sustained impact of the initial initiative; group 2 was compared to group 1 to determine the impact of re-education, which involved a presentation to ED providers and a posted algorithm and fact sheet.
Results. Results from all time periods are summarized in Table 1. Improvement in inappropriate tx was still noted 3 years after the intervention (28% vs 32%; p = NS). Re-education did not further improve inappropriate prescribing, with 28% of group 2 pts still receiving tx. Table 1.

Conclusion.
The decrease in inappropriate use of ABX for ASP/ASB was still noted 3 years after implementation of a multi-faceted AS initiative. Re-education did not result in further improvement.

Direct Communication Improves Response Time to Acceptance of Antimicrobial Stewardship Interventions
Background. Hospital antimicrobial stewardship program (ASP) reviews broad-spectrum antibiotics and recommends interventions to optimise antimicrobial use. However, about 30% of interventions are not accepted. This project aims to improve the response rate and time for acceptance of ASP interventions by direct communication with providers (via call or text messaging) once an intervention was made.
Methods. Pre-direct communication (PC) phase lasted from 1 st Jan -31 st Dec 2017. A typed intervention was placed into the patient's medical records for the team to review. Thereafter, a direct communication (DC) phase ran from 1 st Jan 2018 -31 st Jan 2019. Teams were immediately notified of any ASP interventions made via a call or text message, in addition to the document placed in the medical records. Specialty, acceptance rates, type of intervention and time to acceptance was recorded. Overall acceptance was counted if team followed the ASP recommendations within 48 hours.
Results. A total of 621 interventions were made over the 25-month period (PC n=334, DC n=287). We found that direct communications did not improve the overall acceptance rates (PC 66% vs. DC 65%, p=0.791), but significantly improved same day acceptance rates (PC 15% [49/334] vs. DC 33% [96/287], p< 0.001). This trend for higher same-day acceptance was also noted regardless of specialty. It increased from 15% to 45% (p< 0.001) for medicine & 15% to 25% (p=0.025) for surgery. Furthermore, overall acceptance for medical discipline was significantly higher in the DC phase (68% to 80%, p=0.024); no significant difference noted for the surgical disciplines. Same-day acceptance also improved when we compared the most common types of interventions (culture based de-escalation, discontinue antibiotic, narrow empirical coverage). In addition, DC helped narrow empiric antibiotic choices, with improvements in both same-day and overall acceptance of interventions (increased from 8% to 43%, p< 0.001 and 57% to 78%, p=0.12, respectively).
Conclusion. Direct communication with clinicians boosted same-day acceptance for ASP interventions. In addition, it increased overall acceptance for medical disciplines, and to narrow empiric antibiotic use. Future efforts will focus on in-person strategy with surgical teams for fruitful results.
Disclosures. Background. Antimicrobial stewardship integral to patient care. Institutions with stewardship decrease antibiotic use, cost, and antibiotic-associated infections. However, few efforts have been formally made to address discharge antimicrobial prescribing, even though many patients started on antibiotic therapy in the hospital are prescribed oral antibiotics to complete their regimens.
Methods. This was an IRB approved, quasi-experimental, pre-post study. Patients were included if they were >18 years and were discharged from the hospital with an oral antibiotic prescription. Patients discharged against medical advice, prescribed indefinite prophylactic antimicrobial therapy for legitimate reasons, or discharged to a skilled nursing facility were excluded. The retrospective group evaluated a random sample of patients discharged in 2/2020. The prospective group included patients discharged between 1/2021 -6/2021. In the prospective group, a clinical pharmacist assessed the indication for antibiotics and pended discharge antibiotic prescriptions for physician review. Antibiotic choice and duration of therapy were based on local and national guidelines.