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Background Congenital syphilis incidence has more than tripled in recent years, in parallel with the resurgence of syphilis among reproductive-aged women. An understanding of risk factors associated with maternal syphilis infection can guide prevention of congenital syphilis through prenatal diagnosis and treatment. We aimed to describe factors associated with maternal syphilis and congenital syphilis at a public medical center in Chicago, Illinois. Methods Maternal syphilis diagnoses were identified using a database for local health department reporting. Medical records were reviewed for infant congenital syphilis diagnoses, sociodemographic information, medical history, and other behavioral factors. Maternal characteristics associated with congenital syphilis were assessed using logistic regression. Results Of 106 maternal syphilis diagnoses between 2014 and 2018, 76 (72%) had a known pregnancy outcome; of these, 8 (11%) delivered an infant with congenital syphilis. Women with psychiatric illness and noninjection substance use each had a >5-fold increased odds of having an infant with congenital syphilis. Cases with congenital syphilis were more likely to have late or scant prenatal care and initiated treatment nearly 3 months later in pregnancy. None were human immunodeficiency virus positive or reported incarceration, intravenous substance use, sex work, or having sex with men who have sex with men. Conclusions Maternal psychiatric illness and substance use may have complicated prenatal care and delayed syphilis treatment, describing a population in need of public health intervention. Women experiencing such barriers to care may benefit from closer follow-up after a prenatal syphilis diagnosis to prevent congenital transmission. [ABSTRACT FROM AUTHOR]

Background Outbreaks of coronavirus disease 2019 (COVID-19) have been reported in nursing homes and assisted living facilities; however, the extent of asymptomatic and presymptomatic severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in this high-risk population remains unclear. Methods We conducted an investigation of the first known outbreak of SARS-CoV-2 at a skilled nursing facility (SNF) in Illinois on 15 March 2020 and followed residents for 30 days. We tested 126/127 residents for SARS-CoV-2 via reverse-transcription polymerase chain reaction and performed symptom assessments. We calculated the point prevalence of SARS-CoV-2 and assessed symptom onset over 30-day follow-up to determine: (1) the proportion of cases who were symptomatic, presymptomatic, and asymptomatic and (2) incidence of symptoms among those who tested negative. We used the Kaplan-Meier method to determine the 30-day probability of death for cases. Results Of 126 residents tested, 33 had confirmed SARS-CoV-2 on 15 March. Nineteen (58%) had symptoms at the time of testing, 1 (3%) developed symptoms over follow-up, and 13 (39%) remained asymptomatic. Thirty-five residents who tested negative on 15 March developed symptoms over follow-up; of these, 3 were re-tested and 2 were positive. The 30-day probability of death among cases was 29%. Conclusions SNFs are particularly vulnerable to SARS-CoV-2, and residents are at risk of severe outcomes. Attention must be paid to preventing outbreaks in these and other congregate care settings. Widespread testing and infection control are key to help prevent COVID-19 morbidity and mortality in these high-risk populations. [ABSTRACT FROM AUTHOR]

Background Vancomycin is the most commonly administered antibiotic in hospitalized patients, but optimal exposure targets remain controversial. To clarify the therapeutic exposure range, this study evaluated the association between vancomycin exposure and outcomes in patients with methicillin-resistant Staphylococcus aureus (MRSA) bacteremia. Methods This was a prospective, multicenter (n = 14), observational study of 265 hospitalized adults with MRSA bacteremia treated with vancomycin. The primary outcome was treatment failure (TF), defined as 30-day mortality or persistent bacteremia ≥7 days. Secondary outcomes included acute kidney injury (AKI). The study was powered to compare TF between patients who achieved or did not achieve day 2 area under the curve to minimum inhibitory concentration (AUC/MIC) thresholds previously found to be associated with lower incidences of TF. The thresholds, analyzed separately as co-primary endpoints, were AUC/MIC by broth microdilution ≥650 and AUC/MIC by Etest ≥320. Results Treatment failure and AKI occurred in 18% and 26% of patients, respectively. Achievement of the prespecified day 2 AUC/MIC thresholds was not associated with less TF. Alternative day 2 AUC/MIC thresholds associated with lower TF risks were not identified. A relationship between the day 2 AUC and AKI was observed. Patients with day 2 AUC ≤515 experienced the best global outcomes (no TF and no AKI). Conclusions Higher vancomycin exposures did not confer a lower TF risk but were associated with more AKI. The findings suggest that vancomycin dosing should be guided by the AUC and day 2 AUCs should be ≤515. As few patients had day 2 AUCs <400, further study is needed to define the lower bound of the therapeutic range. [ABSTRACT FROM AUTHOR]

Background Respiratory viruses on fomites can be transferred to sites susceptible to infection via contact by hands or other fomites. Methods Care for hospitalized patients with viral respiratory infections was observed in the patient room for 3-hour periods at an acute care academic medical center for over a 2 year period. One trained observer recorded the healthcare activities performed, contacts with fomites, and self-contacts made by healthcare workers (HCWs), while another observer recorded fomite contacts of patients during the encounter using predefined checklists. Results The surface contacted by HCWs during the majority of visits was the patient (90%). Environmental surfaces contacted by HCWs frequently during healthcare activities included the tray table (48%), bed surface (41%), bed rail (41%), computer station (37%), and intravenous pole (32%). HCWs touched their own torso and mask in 32% and 29% of the visits, respectively. HCWs' self-contacts differed significantly among HCW job roles, with providers and respiratory therapists contacting themselves significantly more times than nurses and nurse technicians (P <.05). When HCWs performed only 1 care activity, there were significant differences in the number of patient contacts and self-contacts that HCWs made during performance of multiple care activities (P <.05). Conclusions HCWs regularly contact environmental surfaces, patients, and themselves while providing care to patients with infectious diseases, varying among care activities and HCW job roles. These contacts may facilitate the transmission of infection to HCWs and susceptible patients. [ABSTRACT FROM AUTHOR]

Antimicrobial stewardship programs (ASPs) are recommended by the Centers for Disease Control and Prevention and World Health Organization and mandated by the Joint Commission to curb antimicrobial resistance. However, <50% of institutions have optimal ASPs in place. Building on its experience of antimicrobial stewardship (AMS) advocacy, the Infectious Diseases Society of America (IDSA) developed the AMS Centers of Excellence (CoE) program, which will serve as a conduit to share best practices and highlight the standards for other hospitals to achieve in order to advance the field of AMS. A designation of CoE signifies that these institutions deliver high-quality care consistently, serve as the "gold" standard for executing novel AMS principles, and demonstrate commitment to their ASP. Here, we describe the process and purpose of designating institutions as AMS CoEs, provide awareness to clinicians on opportunities available through IDSA with this CoE designation, and discuss the evolution of the program. [ABSTRACT FROM AUTHOR]

Background Intervention by infectious diseases (ID) physicians improves outcomes for inpatients in Medicare, but patients with other insurance types could fare differently. We assessed whether ID involvement leads to better outcomes among privately insured patients under age 65 years hospitalized with common infections. Methods We performed a retrospective analysis of administrative claims data from community hospital and postdischarge ambulatory care. Patients were privately insured individuals less than 65 years old with an acute-care stay in 2014 for selected infections, classed as having early (by day 3) or late (after day 3) ID intervention, or none. Key outcomes were mortality, cost, length of the index stay, readmission rate, mortality, and total cost of care over the first 30 days after discharge. Results Patients managed with early ID involvement had shorter length of stay, lower spending, and lower mortality in the index stay than those patients managed without ID involvement. Relative to late, early ID involvement was associated with shorter length of stay and lower cost. Individuals with early ID intervention during hospitalization had fewer readmissions and lower healthcare payments after discharge. Relative to late, those with early ID intervention experienced lower readmission, lower spending, and lower mortality. Conclusions Among privately insured patients less than 65 years old, treated in a hospital, early intervention with an ID physician was associated with lower mortality rate and shorter length of stay. Patients who received early ID intervention during their hospital stay were less likely to be readmitted after discharge and had lower total healthcare spending. [ABSTRACT FROM AUTHOR]

The article focuses on the Joint Commission (TJC) has added an ambulatory stewardship program (ASP) standard to begin in January of 2020. It mentions that inappropriate antimicrobial use is the most important modifiable factor in tackling the coronavirus crisis. It also mentions that dentists often prescribed unnecessary antibiotic prophylaxis (AP) to patients with conditions such as rheumatic heart disease, coronary artery bypass graft, and mitral valve prolapse.

Background. Anti-infective shortages are a pervasive problem in the United States. The objective of this study was to identify any associations between changes in prescribing of antibiotics that have a high risk for CDI during a piperacillin/tazobactam (PIP/TAZO) shortage and hospital-onset Clostridium difficile infection (HO-CDI) risk in 88 US medical centers. Methods. We analyzed electronically captured microbiology and antibiotic use data from a network of US hospitals from July 2014 through June 2016. The primary outcome was HO-CDI rate and the secondary outcome was changes in antibiotic usage. We fit a Poisson model to estimate the risk of HO-CDI associated with PIP/TAZO shortage that were associated with increased high-risk antibiotic use while controlling for hospital characteristics. Results. A total of 88 hospitals experienced PIP/TAZO shortage and 72 of them experienced a shift toward increased use of high-risk antibiotics during the shortage period. The adjusted relative risk (RR) of HO-CDI for hospitals experiencing a PIP/TAZO shortage was 1.03 (95% confidence interval [CI], .85-1.26; P = .73). The adjusted RR of HO-CDI for hospitals that both experienced a shortage and also showed a shift toward increased use of high-risk antibiotics was 1.30 (95% CI, 1.03-1.64; P < .05). Conclusions. Hospitals that experienced a PIP/TAZO shortage and responded to that shortage by shifting antibiotic usage toward antibiotics traditionally known to place patients at greater risk for CDI experienced greater HO-CDI rates; this highlights an important adverse effect of the PIP/TAZO shortage and the importance of antibiotic stewardship when mitigating drug shortages. [ABSTRACT FROM AUTHOR]

The empirical combination of vancomycin and an antistaphylococcal penicillin or first-generation cephalosporin may improve clinical outcomes with Staphylococcus aureus bacteremia.The high prevalence of methicillin resistance among Staphylococcus aureus bacteremias leads to common use of vancomycin as empirical therapy. However, investigators have reported poor outcomes with vancomycin treatment for methicillin-susceptible Staphylococcus aureus bacteremia. We review the evidence supporting empirical combination of both vancomycin and a β-lactam agent for Staphylococcus aureus bacteremia. Vancomycin therapy for methicillin-susceptible Staphylococcus aureus bacteremia is associated with 2–3 times the risk of morbidity and mortality compared to an antistaphylococcal penicillin (oxacillin and nafcillin) or first-generation cephalosporin (cefazolin). De-escalation of empirical vancomycin to definitive β-lactam therapy still appears inferior to initial β-lactam therapy. Although there is no clinical trial supporting combination therapy, a scientific rationale for benefit exists and should be weighed against the risks (adverse events, antibiotic resistance, and cost) of additional pharmacotherapy. The empirical combination of vancomycin and a β-lactam (either nafcillin, oxacillin, or cefazolin) for staphylococcal bacteremia may improve infection-related clinical outcomes. [ABSTRACT FROM PUBLISHER]

Background Candidemia is a major cause of morbidity and mortality in hospitalized patients. The global epidemiology of invasive Candidiasis is changing, with distribution of species and resistance varying in different geographic and healthcare settings. There is a paucity of data on candidemia in the Dominican Republic (DR). Understanding epidemiologic risk factors and resistance rates may improve early diagnosis and empiric antifungal selection. Methods We performed a retrospective review of patients with positive Candida blood cultures from January 2017 to December 2018. Data were extracted from medical records. Clinical and demographic information, including co-morbidities, antifungal sensitivities, and outcomes were collected. Results A total of 52 cases were identified, 34 in 2017 and 18 in 2018. Ages ranged from <1 to 89 years and was distributed in various groups (Figure 1). The most common comorbidities included DM (38%), nephropathy (37%), cerebrovascular accident (25%), and malignancy (19%). Device use and prior antimicrobial exposure were the most common risk factors (Table 1). There was no antifungal resistance to amphotericin, voriconazole, or echinocandins. No fluconazole resistance was found in 2017, compared with 11% resistance in 2018 in C. albicans , C. glabrata, and C. tropicalis species. Mortality was 64% in 2017 and 61% in 2018. Conclusion Candidemia with non-albicans Candida species was common (87%). Susceptibilities and species varied by year but did not affect mortality. Resistance to fluconazole is rising but remains low and other antifungals retain susceptibility. Indwelling catheters, mechanical ventilation and antibiotic exposure were common risk factors in our cohort. Mortality for candidemia was high. Rapid diagnostic testing and early empiric therapy with echinocandins for patients at risk may curb mortality. Disclosures All authors: No reported disclosures. [ABSTRACT FROM AUTHOR]

Background The use of anti-Pseudomonal β-lactam (APBL) agents has significantly increased in the past decade, carrying higher costs and contributing to antimicrobial pressure. Antimicrobial stewardship (ASP) can promote evidence-based antimicrobial selection and mitigate excess APBL use. We implemented a comprehensive ASP with syndrome-based prospective audit and feedback (PAF) at an urban community hospital. The goal of this study is to assess the impact of syndrome-based PAF on APBL use, C. difficile rates and cost. Methods ASP with all CDC core elements was implemented at a 151-bed community hospital in October 2017. Syndrome-based guidelines and PAF was established and overseen via direct communication with an ID physician. Days of therapy (DOT), cost and C. difficile rates were assessed 12 months before and after ASP. DOT for APBL and non-APBL utilization was tabulated by unit and paired t-test performed. Results Most cases reviewed by PAF (51%) were represented in our syndrome-based treatment guidelines (Figure 1). Soft tissue (33%) and intra-abdominal (24%) infections were the most common syndromes. Change to guideline was the most common PAF intervention (62%) followed by de-escalation (30%). At 12 months, total DOT/1,000 increased (392.5 vs. 404) while the proportion of parenteral antimicrobials used decreased (71% vs. 65%). Antibiotic expenditures decreased by 23%, with a reduction in APBL of 20% and non-APBL of 10% (Table 1). Statistically significant reductions APBL use in non-ICU settings (P = 0.0139) and statistically significant increases in non-APBL in ICU settings occurred (P = 0.0001) (Figure 2 and 3). C difficile rates decreased from 21% (3.27 vs. 2.56). Conclusion Syndrome-based PAF was successfully implemented. A reduction in APBL use was seen in non-ICU settings, where evidence-based de-escalation may be more feasible. APBL use remained high in the ICU but was guideline consistent. A rise in non-APBL use also occurred. Certain critical illness syndromes warrant APBLs, but PAF may promote culture-directed and syndrome-specific treatments. ASP increased guideline-based therapy and contributed to decreased broad-spectrum antimicrobial use, antimicrobial expenditures and C difficile rates. Syndrome based PAF can be successfully implemented in community settings. Disclosures All authors: No reported disclosures. [ABSTRACT FROM AUTHOR]

Doernberg and colleagues describe the role and resourcing of the infectious disease (ID) physician for an effective hospital-based antibiotic stewardship program (ASP). There are similar resource requirements for the ID physician leader in an effective infection prevention (IP) program. This ID physician partnership is supported by professional organizations and predates the imperative of ID physician leadership in ASP. There are regulatory requirements for established IP programs, but they do not specify leadership structure to the same degree as ASP regulations. The Centers for Medicare and Medicaid and The Joint Commission have specified the inclusion of an ID-trained physician leader in ASP, and this has led to the development of curriculum to train more ASP physicians. More robust advocacy may ensure a similar regulatory mandate supporting the participation of ID-trained physicians in IP programs. This may encourage the development of a curriculum to meet the workforce. [ABSTRACT FROM AUTHOR]

The author discusses the study regarding the control of carbapenem-resistant Enterobacteriaceae. She mentions the study characteristics which involve multiple interventions, outcomes, unity and facility types, the quality of the study in terms of measuring the level of change of infection or colonization incidence by bacteria, and the limitations of evidence-based guidance infection prevention and control as shown in the study.

Background Antimicrobial resistance (AMR) is a rising global health challenge. Antimicrobial use (AU) is a key factor in the development of AMR, but knowledge gaps remain on AU and dispensation in low- and middle-income countries (LMICs). AU can be purchased without prescriptions in many LMICs and are available in pharmacies and non-pharmacy stores. We seek to describe the availability, training and AU recommendations in pharmacies and non-pharmacy stores in the Dominican Republic (DR). Methods We conducted a survey of pharmacies and non-pharmacy stores that dispense antimicrobials from March to April 2019 in randomly selected locations throughout metropolitan Santo Domingo. Data on the availability of antimicrobials and training on AU was obtained. Antimicrobial of choice for common symptoms such as dysuria, throat pain, diarrhea, fever, and cough were queried, and data tabulated. Availability of antimicrobials by phone and online delivery was assessed. Results A total of 35 stores were surveyed. Ten pharmacies and 15 nonpharmacy stores agreed to participate. Ten refused and were excluded. Fifty AU recommendations were given in pharmacies and 16 in non-pharmacy stores. The most common type of antimicrobial recommended were aminopenicillins (Figure 1). Staff received prior training on antimicrobials in 70% of pharmacies and 0% of non-pharmacy stores. Antimicrobial recommendations by symptom in pharmacies and non-pharmacy stores are seen in Figure 2 and 3. Antimicrobials are available for phone delivery in 100% of pharmacies and 90% of non-pharmacy stores. No antimicrobials were available via online delivery apps. Conclusion Antimicrobials are widely available in the DR without prescriptions and can be purchased in person or via phone delivery. Aminopenicillins are commonly prescribed and may contribute to high rates of ESBL in the DR. Pharmacy staff gave more specific symptom-based recommendations than non-pharmacy staff and commonly had prior training on antibiotic use. In LMICs with easy access to antimicrobials, frontline staff in pharmacies and non-pharmacy stores are gatekeepers for AU and may benefit from further education and training. Further studies on attitudes and perceptions related to antimicrobial use in the community are needed. Disclosures All authors: No reported disclosures. [ABSTRACT FROM AUTHOR]

Background Lower respiratory tract infections (LRTIs) are one of the most common infectious disease-related emergency department (ED) visits in the United States. The ID Society of America and the Agency for Healthcare Research and Quality support the use of procalcitonin (PCT) for antimicrobial stewardship (ASP) in LRTI. Though not widely available, awareness and access to PCT is rising. At our facility, PCT became available in February 2018. The aim of our study is to assess the impact of PCT at an urban community hospital and identify possible targets for ASP interventions. Methods Retrospective review of cases from February to August 2018. Cases from the ED were selected for review. Appropriateness of testing was assessed, defined as guideline-based use for cessation of antibiotics in uncomplicated LRTIs without critical illness or immunosuppression. Demographic variables and clinical characteristics, such as, diagnosis, antimicrobial use and PCT levels were obtained. Results PCT was ordered 268 times hospital-wide, of which 160 (60%) were in the ED. Ages ranged from 0–90, with an average of 47. Most cases were male (51%). Appropriate testing for LRTI occurred in 33 (29%) cases. Antimicrobials were used in 75% of cases with low (< 0.5) PCT levels (Figure 1). Length of stay (LOS) was higher in groups that received antimicrobials (Figure 2). Testing was not appropriate in 127 cases (71%), with upper respiratory (21%), soft-tissue (17%), genitourinary (15%) and abdominal (13%) infections as the most common reasons for testing. Other diagnosis included alcohol withdrawal, seizures and altered mental status. Cumulative cost of PCT testing was $24000, of which $19050 was not consistent with guidelines. Conclusion Clinicians routinely ordered PCT in the ED. Antimicrobials were used for LRTIs despite low PCT levels. This may have contributed to higher LOS and excess antimicrobial use. Unwarranted PCT testing had a cost of $19050. As PCT becomes widely available in hospitals across the United States, education and decision support by ASP to clinicians may be needed to enhance guideline-appropriate evidence-based use of PCT. Targeted ASP interventions in the ED may have cost savings by reducing excess testing, length of stay and improving antimicrobial use. Disclosures All authors: No reported disclosures. [ABSTRACT FROM AUTHOR]

Background Adherence to the CMS sepsis core measure (SEP-1) has been a challenge for facilities nationwide. Checklists, electronic medical record (EMR) alerts and order sets have been shown to improve compliance. We implemented a comprehensive SEP-1 guideline with order sets, checklists and EMR alerts at an urban community hospital. Subsequently, a SEP-1 improvement team with an infectious disease physician and a nurse led a prospective audit and feedback (PAF) program to help improve adherence and reduce errors. We seek to understand the impact of PAF on SEP-1 compliance. Methods Quasi-experimental pre- and post-intervention study of SEP-1 compliance at a 151-bed urban community hospital from January 2015 to December 2018. PAF intervention was started on July 2017. Cases were reviewed, SEP-1 failures identified, and feedback given to nurses and clinicians involved within 48 hours of admission. Gaps in adherence are identified, education given, and corrective actions taken. SEP-1 adherence before and after PAF implementation was reviewed. Results A total of 307 cases met the SEP-1 inclusion criteria. PAF was successfully implemented. There were 169 SEP-1 cases before and 138 after implementation of PAF. The success rate increased from 44% to 52% with PAF (Figure 1). The most common reasons for failure were initial and repeat lactic acid on both groups (Figure 2). Conclusion Prospective audit and feedback for SEP-1 improved compliance rates at our facility. Prospective audit can help identify core measure failures early and provide immediate feedback to clinicians, nurses and laboratory personnel. Immediate feedback by the SEP-1 improvement team may help increase SEP-1 awareness, strengthen existing protocols and promote a culture of safety. SEP-1 is a complex core measure that may transition to pay-for-performance. An ID physician-led SEP-1 improvement team with PAF may be an area for future value-based care opportunities for ID physicians. Disclosures All authors: No reported disclosures. [ABSTRACT FROM AUTHOR]

Background Bloodstream infections (BSI) with gram-negative bacilli (GNB) are a major cause of morbidity and mortality worldwide. Sepsis due to BSI can carry a mortality rate as high as 40%, with higher mortality in developing nations. Early and appropriate empiric therapeutic selection plays an important role in survival. The rising incidence of antimicrobial resistance (AMR) limits empiric treatment options. Local susceptibility patterns can vary per region, institution or setting. Understanding local AMR may help guide empiric treatment choices. We seek to describe resistance rates for GNB BSI in the Dominican Republic (DR). Methods This is a retrospective review of antimicrobial susceptibility patterns from bloodstream infections in a tertiary hospital in the DR. Susceptibility data from all adult inpatient blood cultures were collected from January 1 to December 31, 2017. Results A total of 124 blood cultures were reported. The most common organisms were Escherichia coli (43%) and Klebsiella pneumoniae (23%). Fluoroquinolone resistance was present in 70% of E. coli. Phenotypic susceptibility patterns consistent with extended-spectrum β-lactamase (ESBL) producing GNB were present in 46% of isolates. Carbapenem resistance was found in 4 samples and was most common in P. aeruginosa. Susceptibility profile is described on Table 1. Conclusion AMR was high in GNB BSIs in the DR. High rates of ESBL render common cephalosporins sub-optimal for empiric treatment. PTZ retains in vitro susceptibilities despite cefepime resistance but clinical efficacy is controversial. CTX-M ESBLs may cause these resistance pattern in vitro. Further studies are needed to determine genetic mechanisms of resistance. Establishing antimicrobial stewardship programs with rapid diagnostic testing that identify mechanisms of resistance may promote judicious use of carbapenems and reduce further the risk of further development of AMR. Disclosures All authors: No reported disclosures. [ABSTRACT FROM AUTHOR]

Objective Candida auris is a globally emerging pathogen associated with significant mortality. This pathogen frequently is misidentified by traditional biochemical methods and is resistant to commonly used antifungals. The echinocandins currently are recommended as the first-line treatment for C. auris infections. The objective of this work is to demonstrate the challenges associated with C. auris in the real-world setting. Methods A 54-year-old male presented to our institution for concerns of sepsis on multiple occasions over a 5-month period. Eleven urine cultures were positive over this timeframe for yeast (9 unidentified Candida isolates and 2 C. lusitaniae isolates). On day 27, the patient developed echinocandin-susceptible candidemia, which was initially identified as C. haemulonii but later accurately identified as C. auris at an outside mycology reference laboratory. Approximately 10 weeks later, the patient had a recurrence of candidemia, this time caused by an echinocandin-resistant C. auris strain. Results Genomic DNA sequencing performed at the outside mycology reference laboratory identified a single serine to proline base pair change at position 639 (S639P) in the hotspot 1 region of the FKS1 gene of the echinocandin-resistant strain. Conclusions Our experiences highlight 4 major concerns associated with C. auris: misidentification, persistent colonization, infection recurrence despite the receipt of appropriate initial therapy, and development of resistance. [ABSTRACT FROM AUTHOR]

Background Most antibiotic use in the United States occurs in the outpatient setting, and 10% of these prescriptions are generated by dentists. The development of comprehensive antibiotic stewardship programs (ASPs) in the dental setting is nascent, and therefore we describe the implementation of a dental ASP. Methods A collaborative team of dentist, pharmacist, and physician leaders conducted a baseline needs assessment and literature evaluation to identify opportunities to improve antibiotic prescribing by dentists within Illinois' largest oral health care provider for Medicaid recipients. A multimodal intervention was implemented that included patient and provider education, clinical guideline development, and an assessment of the antibiotic prescribing rate per urgent care visit before and after the educational interventions. Results We identified multiple needs, including standardization of antibiotic prescribing practices for patients with acute oral infections in the urgent care clinics. A 72.9% decrease in antibiotic prescribing was observed in urgent care visits after implementation of our multimodal intervention (preintervention urgent care prescribing rate, 8.5% [24/283]; postintervention, 2.3% [8/352]; P <.001). Conclusions We report the successful implementation of a dental ASP that is concordant with the Centers for Disease Control and Prevention Core Elements of Antibiotic Stewardship in the Outpatient Setting. Our approach may be adapted to other dental practices to improve antibiotic prescribing. [ABSTRACT FROM AUTHOR]