Search

Background The University of Washington Tele-Antimicrobial Stewardship Program (UW-TASP) provides antimicrobial stewardship education and training to rural and critical access hospitals (CAHs) in the United States through collaborative tele-mentoring. In 2021, UW-TASP implemented a pilot stewardship cohort to reduce antibiotic treatment of asymptomatic bacteriuria (ASB). We sought to quantify the overall prevalence of ASB and proportion treated in participating hospitals. Methods Patients undergoing urine testing were identified through local electronic medical records and microbiology data. CAHs adjudicated their own cases and reported demographics, symptoms of urinary tract infection, systemic inflammatory response symptoms (SIRS), location at the time of culture, laboratory results, and antibiotic treatment through a RedCap collection tool. The data form was created and analyzed by UW-TASP faculty. This study was waived by the University of Washington institutional review board. Results Nineteen CAHs in 5 states participated in this pilot. Eight submitted urine analysis and culture data for 417 patients. Seventy-seven percent of patients were female and the median age was 70. The emergency department was the most common culture collection location (274/417, 66%), followed by ambulatory care clinics (111/417, 27%), and nursing facilities (13/417, 3%). SIRS criteria and/or organ dysfunction were present in 149/417 patients (36%). Two hundred sixty patients (62%) had a positive culture with Escherichia coli being the most common implicated organism (167/260, 64%). ASB was identified in 69/260 patients (27%), and antibiotics were prescribed for 53/69 (77%) of those with ASB. Oral antibiotics were prescribed for 311 (75%) patients. Of those, 22% were prescribed a fluoroquinolone. Median treatment duration was 7 days (range, 1-14). Conclusion Although the prevalence of ASB was only 27% among 417 patients, treatment of ASB was high at 77%. High numbers of culture collections from the emergency department and ambulatory care settings identify these locations as future foci for stewardship interventions in CAHs. Low hanging fruit for intervention include reducing unnecessary fluoroquinolone use and reducing duration of antibiotic therapy. Disclosures Chloe Bryson-Cahn, MD, Alaska Airlines: Advisor/Consultant.

Background Critical access hospitals (CAHs) in the United States service nearly one fifth of the US population, predominantly in rural areas. CAHs are required to provide antimicrobial stewardship (AMS) services, however, access to infectious diseases and antimicrobial stewardship expertise is limited. We assessed the feasibility of implementing a tele-AMS intervention in CAHs. Methods We piloted a one-year, biphasic, intensive quality improvement collaborative of self-selected CAHs to address asymptomatic bacteriuria (ASB). In phase 1, we engaged multidisciplinary teams from participating hospitals, facilitated goal-setting, and implemented a monthly curriculum to train local stewards regarding appropriate diagnosis and management of urinary tract infections (UTIs). In phase 2, we focused on quality improvement education and data collection. We discussed stewardship strategies and addressed barriers identified on a one-on-one basis. Results Nineteen CAHs in five states across the Western region participated in this pilot. Nine of 19 attended all 8 monthly didactic sessions. The median number of one-on-one sessions attended per site was 3 (range, 1-4). Eighteen of 19 hospitals set a goal and documented it in a Plan-Do-Study-Act framework. Six CAHs set a goal related to staff and/or patient education, 10 CAHs focused on workflow and processes surrounding identification of UTI including reflex of urine analyses to urine culture, and 2 CAHs set goals to prospectively review cases of ASB treated with antibiotics and provide feedback to prescribers. Commonly encountered barriers included turnaround time for urine culture data, difficulty obtaining data from the electronic medical record, resistance to change among personnel, high staff turnover, limited time and availability to perform stewardship, and short duration of the collaborative. Conclusion We successfully launched a tele-stewardship training program to mentor CAH antimicrobial stewards to identify and manage ASB and use quality improvement tools. A standardized approach to address asymptomatic bacteriuria or other AMS goals are unlikely to be successful in CAHs without significant tailoring to fit specific site and process needs. Disclosures Chloe Bryson-Cahn, MD, Alaska Airlines: Advisor/Consultant.

Across 20 vaccine breakthrough cases detected at our institution, all 20 (100%) infections were due to variants of concern (VOCs) and had a median Ct of 20.2 (IQR, 17.1–23.3). When compared with 5174 contemporaneous samples sequenced in our laboratory, VOCs were significantly enriched among breakthrough infections (P < .05).

Background Following a meropenem shortage, we implemented a postprescription review with feedback (PPRF) in November 2015 with mandatory infectious disease (ID) consultation for all meropenem and imipenem courses > 72 hours. Providers were made aware of the policy via an electronic alert at the time of ordering. Methods A retrospective study was conducted at the University of Washington Medical Center (UWMC) and Harborview Medical Center (HMC) to evaluate the impact of the policy on antimicrobial consumption and clinical outcomes pre- and postintervention during a 6-year period. Antimicrobial use was tracked using days of therapy (DOT) per 1000 patient-days, and data were analyzed by an interrupted time series. Results There were 4066 and 2552 patients in the pre- and postintervention periods, respectively. Meropenem and imipenem use remained steady until the intervention, when a marked reduction in DOT/1000 patient-days occurred at both hospitals (UWMC: percentage change −72.1% (95% confidence interval [CI] −76.6, −66.9), P < .001; HMC: percentage change −43.6% (95% CI −59.9, −20.7), P = .001). Notably, although the intervention did not address antibiotic use until 72 hours after initiation, there was a significant decline in meropenem and imipenem initiation (“first starts”) in the postintervention period, with a 64.9% reduction (95% CI 58.7, 70.2; P < .001) at UWMC and 44.7% reduction (95% CI 28.1, 57.4; P < .001) at HMC. Conclusions PPRF and mandatory ID consultation for meropenem and imipenem use beyond 72 hours resulted in a significant and sustained reduction in the use of these antibiotics and notably impacted their up-front usage.

Two near-identical clinical Streptococcus pyogenes isolates of emm subtype emm43.4 with a pbp2x missense mutation (T553K) were detected. Minimum inhibitory concentrations (MICs) for ampicillin and amoxicillin were 8-fold higher, and the MIC for cefotaxime was 3-fold higher than for near-isogenic control isolates, consistent with a first step in developing β-lactam resistance.

Background Between 15–50% of patients seen in ambulatory settings are prescribed an antibiotic. At least one third of this usage is considered unnecessary. In 2019, our institution implemented the MITIGATE Toolkit, endorsed by the Centers for Disease Control and Prevention to reduce inappropriate antibiotic prescribing for viral respiratory infections in emergency and urgent care settings. In February 2020 we identified our first hospitalized patient with SARS-CoV(2). In March, efforts to limit person-to-person contact led to shelter in place orders and substantial reorganization of our healthcare system. During this time we continued to track rates of unnecessary antibiotic prescribing. Methods This was a single center observational study. Electronic medical record data were accessed to determine antibiotic prescribing and diagnosis codes. We provided monthly individual feedback to urgent care prescribers, (Sep 2019-Mar 2020), primary care, and ED providers (Jan 2020 – Mar 2020) notifying them of their specific rate of unnecessary antibiotic prescribing and labeling them as a top performer or not a top performer compared to their peers. The primary outcome was rate of inappropriate antibiotic prescribing. Results Pre toolkit intervention, 14,398 patient visits met MITIGATE inclusion criteria and 12% received an antibiotic unnecessarily in Jan-April 2019. Post-toolkit intervention, 12,328 patient visits met inclusion criteria and 7% received an antibiotic unnecessarily in Jan-April 2020. In April 2020, patient visits dropped to 10–50% of what they were in March 2020 and April 2019. During this time the unnecessary antibiotic prescribing rate doubled in urgent care to 7.8% from 3.6% the previous month and stayed stable in primary care and the ED at 3.2% and 11.8% respectively in April compared to 4.6% and 10.4% in the previous month. Conclusion Rates of inappropriate antibiotic prescribing were reduced nearly in half from 2019 to 2020 across 3 ambulatory care settings. The increase in prescribing in April seen in urgent care and after providers stopped receiving their monthly feedback is concerning. Many factors may have contributed to this increase, but it raises concerns for increased inappropriate antibacterial usage as a side effect of the SARS-CoV(2) pandemic. Disclosures All Authors: No reported disclosures

Concerns about severe acute respiratory syndrome coronavirus 2 exposure in health care settings may cause patients to delay care. Among 2992 patients testing negative on admission to an academic, 3-hospital system, 8 tested positive during hospitalization or within 14 days postdischarge. Following adjudication of each instance, health care–associated infection incidence ranged from 0.8 to 5.0 cases per 10 000 patient-days.

Background Inappropriate testing for Clostridioides difficile leads to overdiagnosis of C difficile infection (CDI). We determined the effect of a computerized clinical decision support (CCDS) order set on C difficile polymerase chain reaction (PCR) test utilization and clinical outcomes. Methods This study is an interrupted time series analysis comparing C difficile PCR test utilization, hospital-onset CDI (HO-CDI) rates, and clinical outcomes before and after implementation of a CCDS order set at 2 academic medical centers: University of Washington Medical Center (UWMC) and Harborview Medical Center (HMC). Results Compared with the 20-month preintervention period, during the 12-month postimplementation of the CCDS order set, there was an immediate and sustained reduction in C difficile PCR test utilization rates at both hospitals (HMC, −28.2% [95% confidence interval {CI}, −43.0% to −9.4%], P = .005; UWMC, −27.4%, [95% CI, −37.5% to −15.6%], P Conclusions Computerized clinical decision support tools can improve C difficile diagnostic test stewardship without causing harm. Additional studies are needed to identify key elements of CCDS tools to further optimize C difficile testing and assess their effect on adverse clinical outcomes.

Background Healthcare workers (HCWs) who serve on the front lines of the coronavirus disease 2019 (COVID-19) pandemic have been at increased risk for infection due to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in some settings. Healthcare-acquired infection has been reported in similar epidemics, but there are limited data on the prevalence of COVID-19 among HCWs and their associated clinical outcomes in the United States. Methods We established 2 high-throughput employee testing centers in Seattle, Washington, with drive-through and walk-through options for symptomatic employees in the University of Washington Medicine system and its affiliated organizations. Using data from these testing centers, we report the prevalence of SARS-CoV-2 infection among symptomatic employees and describe the clinical characteristics and outcomes among employees with COVID-19. Results Between 12 March 2020 and 23 April 2020, 3477 symptomatic employees were tested for COVID-19 at 2 employee testing centers; 185 (5.3%) employees tested positive for COVID-19. The prevalence of SARS-CoV-2 was similar when comparing frontline HCWs (5.2%) with nonfrontline staff (5.5%). Among 174 positive employees reached for follow-up at least 14 days after diagnosis, 6 reported COVID-related hospitalization; all recovered. Conclusions During the study period, we observed that the prevalence of positive SARS-CoV-2 tests among symptomatic HCWs was comparable to that of symptomatic nonfrontline staff. Reliable and rapid access to testing for employees is essential to preserve the health, safety, and availability of the healthcare workforce during this pandemic and to facilitate the rapid return of SARS-CoV-2–negative employees to work.

Background The Infectious Diseases Society of America (IDSA) has supported the development of the Core and Advanced Antimicrobial Stewardship (AS) Curricula for fellows to ensure the future ID workforce is effectively prepared to practice, participate in and lead AS efforts in health care institutions. The Core AS Curriculum is currently available; the Advanced AS Curriculum pilot will begin July, 2020. Methods IDSA formed the AS Curriculum Workgroup, comprised of leaders in AS and medical education from institutions across the country, to lead the AS Curricula development process. The workgroup conducted two surveys of ID Fellowship Program Directors, one in 2016 for the core curriculum and a second in 2018 for the advanced curriculum, to assess existing AS educational resources and determine needs for additional AS educational and evaluation resources. The workgroup used the evaluation data to inform the content, delivery methods, and assessment tools for the curricula. The Core AS Curriculum is designed to provide fellows foundational knowledge and skills in AS. The Advanced AS Curriculum is designed to provide fellows the knowledge and skills to become leaders in AS. The Core AS Curriculum was piloted by 56 ID Fellowship Programs in 2018 and then made broadly available via IDSA Academy in 2019. Pilot data will be used to improve future iterations of the curriculum. The Advanced AS Curriculum pilot will begin in 2020 and will be broadly available in 2021. Results The curricular packages contain a variety of training resources including eLearning modules, lectures slides, case-based questions, videos, reading materials, pocket cards, group-based learning, role play exercises and simulations. The modules can be taught by faculty to fellows or conducted as a self-directed learning experience. Program directors and fellows who participated in the Core AS Curriculum pilot reported that their fellowship program was significantly more effective in teaching multiple key stewardship content areas (Table). Table. Conclusion Evaluation data from programs who piloted the Core AS Curriculum indicate that this blended learning experience is an effective method for teaching AS and in providing educational and assessment tools for ID fellowship programs. The Advanced AS Curriculum will be similarly evaluated. Disclosures Julie Ann Justo, PharmD, MS, BCPS-AQ ID, bioMerieux (Speaker’s Bureau)TRC Healthcare (Speaker’s Bureau)

Background In an effort to support stewardship endeavors, the MITIGATE (a Multifaceted Intervention to Improve Prescribing for Acute Respiratory Infection for Adult and Children in Emergency Department and Urgent Care Settings) Toolkit was published in 2018, aiming to reduce unnecessary antibiotics for viral respiratory tract infections (RTIs). At the University of Washington, we have incorporated strategies from this toolkit at our urgent care clinics. This study aims to address solutions to some of the challenges we experienced. Challenges and Solutions Methods This was a retrospective observational study conducted at Valley Medical Center (Sept 2019-Mar 2020) and the University of Washington (Jan 2019-Feb 2020) urgent care clinics. Patients were identified through ICD-10 diagnosis codes included in the MITIGATE toolkit. The primary outcome was identifying challenges and solutions developed during this process. Results We encountered five challenges during our roll-out of MITIGATE. First, using both ICD-9 and ICD-10 codes can lead to inaccurate data collection. Second, technical support for coding a complex data set is essential and should be accounted for prior to beginning stewardship interventions of this scale. Third, unintentional incorrect diagnosis selection was common and may require reeducation of prescribers on proper selection. Fourth, focusing on singular issues rather than multiple outcomes is more feasible and can offer several opportunities for stewardship interventions. Lastly, changing prescribing behavior can cause unintended tension during implementation. Modifying benchmarks measured, allowing for bi-directional feedback, and identifying provider champions can help maintain open communication. Conclusion Resources such as the MITIGATE toolkit are helpful to implement standardized data driven stewardship interventions. We have experienced some challenges including a complex data build, errors with diagnostic coding, providing constructive feedback while maintaining positive stewardship relationships, and choosing feasible outcomes to measure. We present solutions to these challenges with the aim to provide guidance to those who are considering using this toolkit for outpatient stewardship interventions. Disclosures All Authors: No reported disclosures

Background In an effort to combat antimicrobial resistance and adverse drug events, The Joint Commission mandated expansion of antimicrobial stewardship programs into ambulatory healthcare settings Jan 2020. The most common diagnoses resulting in inappropriate antimicrobial prescribing are respiratory infections. This study aimed to assess the rate of antibiotic prescribing for viral respiratory tract infections within six urgent care clinics affiliated with University of Washington Medicine health system in Seattle, WA. Methods This was a retrospective observational study from Jan 2019-Feb 2020. We used the MITIGATE toolkit; a resource that meets CDC’s core elements for outpatient stewardship. Patients were identified based upon pre-specified ICD-10 codes for viral respiratory infections. The primary outcome was the rate of unnecessary antimicrobial prescriptions for acute viral respiratory infections. Secondary outcomes evaluated inappropriate prescribing practices based on antibiotic selection, diagnosis, and age. Results Of 7,313 patients (6078 adults and 1235 pediatric) included, 23% were inappropriately prescribed antibiotics. The most common antibiotics inappropriately prescribed were azithromycin (62%), amoxicillin (13%), and doxycycline (13%). Fluoroquinolone (FQ) utilization was low (2%). Bronchitis (61%) and nonsuppurative otitis media (NSOM) (24%) were the most common viral diagnoses for which antibiotics were prescribed. Overall, unnecessary prescribing was lower in pediatrics than adults at 13% and 25%, respectively (p< 0.001). Adults were more often prescribed antibiotics inappropriately for bronchitis and NSOM compared to pediatrics (p=0.0013). Conclusion Inappropriate prescribing practices across six urgent care clinics varied based upon age and diagnosis. Azithromycin is most often inappropriately prescribed but the low rate of FQ prescribing is encouraging. The lower rate of unnecessary prescribing in pediatrics is promising although there is room for improvement as 1 in 8 children were unnecessarily prescribed antibiotics. These findings support the need for antibiotic stewardship in the outpatient setting, targeting areas for azithromycin use and therapeutic management of bronchitis. Disclosures All Authors: No reported disclosures

Background Following a meropenem shortage, we implemented a post-prescription review with feedback (PPRF) in November 2015 with mandatory infectious disease (ID) consultation for all meropenem and imipenem courses > 72 hours. Providers were made aware of the policy via an electronic alert at the time of ordering. Methods A retrospective study was conducted at the University of Washington Medical Center (UWMC) and Harborview Medical Center (HMC) to evaluate the impact of the policy on antimicrobial consumption and clinical outcomes pre- and post-intervention during a 6-year period. Antimicrobial use was tracked using days of therapy (DOT) per 1,000 patient-days, and data were analyzed by an interrupted time series. Results There were 4,066 and 2,552 patients in the pre- and post-intervention periods, respectively. Meropenem and imipenem use remained steady until the intervention, when a marked reduction in DOT/1,000 patient-days occurred at both hospitals (UWMC: percentage change -72.1%, (95% CI -76.6, -66.9), P < 0.001; HMC: percentage change -43.6%, (95% CI -59.9, -20.7), P = 0.001). Notably, although the intervention did not address antibiotic use until 72 hours after initiation, there was a significant decline in meropenem and imipenem initiation (“first starts”) in the post-intervention period, with a 64.9% reduction (95% CI 58.7, 70.2; P < 0.001) at UWMC and 44.7% reduction (95% CI 28.1, 57.4; P < 0.001) at HMC. Meropenem and Imipenem DOT (January 2013 – November 2019) Conclusion Mandatory ID consultation and PPRF for meropenem and imipenem beyond 72 hours resulted in a significant and sustained reduction in the use of these antibiotics and notably impacted their up-front usage. Disclosures All Authors: No reported disclosures

Background Critical access hospitals (CAH), defined as those with 25 or fewer beds and/or located in rural settings, may have difficulty implementing core elements of antimicrobial stewardship (CES) due to limited human resources, expertise, and funding. A 2015 National Healthcare Safety Network (NHSN) hospital survey found only 26% of CAH reported implementing all 7 CES compared with 50% of larger hospitals across the United States. The University of Washington Tele-Antimicrobial Stewardship Program (UW TASP) was developed through partnership with the University of Washington for hospitals lacking stewardship resources. The state department of health (DOH) provided funding to allow CAH to participate. Methods In January 2017, CAH were recruited to join UW TASP and participate in weekly 60 minute audiovisual conference calls led by an interdisciplinary team of infectious diseases physicians, pharmacists and microbiologists. Each session included a 15-minute didactic on stewardship topics followed by a discussion of case studies presented by participating hospitals. UW TASP faculty visited CAH to foster a collegial relationship between teams. Using hospital-reported metrics from the NHSN hospital survey reported in year 2016–2018 for years 2015–2017, we compared CES implementation by CAH participating in UW TASP (TASP CAH) in 2017 (n = 17) to those not participating (non-TASP CAH) (n = 22). Results TASP CAH reported increased implementation of all 7 CES from 29% (2015) to 59% (2016) before joining TASP to 76% (2017) after joining TASP (Figure 1). Non-TASP CAH reported implementation increased from 32% (2015) to 45% (2016) to 59% (2017). By the end of 2017, TASP CAH also succeeded in implementing individual CES to a greater degree than did non-TASP CAH (Table 1). Conclusion TASP CAH reported more successful implementation of CES than did non-TASP CAH. Improved CES implementation in TASP CAH may in part be due to differences in baseline hospital characteristics; however, expertise and support provided by UW TASP likely contributed. The use of telehealth mentoring increased antimicrobial stewardship in this resource-limited setting. Disclosures All authors: No reported disclosures.

Background Between 15–50% of patients seen in ambulatory settings are prescribed an antibiotic. At least one-third of this usage is considered unnecessary. Multiple tools have emerged to evaluate antibiotic prescribing in ambulatory settings. The toolkits, MITIGATE and Choosing Wisely, have been funded by the Centers for Disease Control and Prevention and promoted by the American Board of Internal Medicine, respectively, but use different reporting criteria. Notably, the target rate of antibiotic prescribing in the MITIGATE framework is zero, whereas the target rate for Choosing Wisely is not zero because it includes diagnoses for which an antibiotic may be appropriate. We compared both to evaluate prescribing in primary care and specialty clinics, urgent care, and the emergency department. Methods This was a single-center observational study. Electronic medical record data were accessed to determine antibiotic prescribing and diagnosis codes. The primary outcome was rate of inappropriate antibiotic prescribing overall and in each of the individual settings. Results Between March 2018 and April 2019, 42,650 patient visits met MITIGATE inclusion criteria and 11% received an antibiotic unnecessarily. In the same time-period, 23,366 patient visits met Choosing Wisely inclusion criteria and 17% received an antibiotic unnecessarily. Within the MITIGATE framework, inappropriate prescribing was highest in the ED (17%), followed by primary care (12%), urgent care (10%), and specialty care (5%). Choosing Wisely, inappropriate prescribing was highest in primary care (23%), followed by urgent care (15%), and specialty care (8%). The ED was not included in the Choosing Wisely technical specifications. The top coded diagnosis in both frameworks was acute respiratory infection, unspecified. Conclusion Rates of inappropriate antibiotic prescribing varied widely depending upon the toolkit used. Inappropriate antibiotic prescribing in primary care by Choosing Wisely framework was double that of MITIGATE. Careful consideration of the differences and goals of using these toolkits is needed both on the local level for individual provider feedback and more broadly, when comparing prescribing rates between institutions. Disclosures All authors: No reported disclosures.