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Clostridioides difficile infection guidelines were published in final format on April 1, 2018. Among 4962 and 3545 C. difficile infection cases in children the year before and after publication, oral metronidazole use decreased from 63.0% to 44.3% (P < 0.001) and oral vancomycin use increased from 27.3% to 47.7% (P < 0.001). Quarterly metronidazole utilization decreased postguidelines among 117 institutions, incidence rate ratios 0.86 (95% confidence intervals: 0.78-0.96).

Background Gram-negative organisms (GNOs) have increasing resistance rates to levofloxacin at Virginia Commonwealth University Health System (VCUHS), where levofloxacin is the most common agent added to provide double coverage of gram-negative infections. The goal of this study was to determine the adequacy of empiric gram-negative coverage for septic patients at our institution. Methods A retrospective review of patients admitted to VCUHS, from January 1, 2014, to December 31, 2014, with a diagnosis of sepsis, severe sepsis, or septic shock and documented infection, was performed to determine the adequacy of various empiric antibiotic combinations. Results Of 219 patients who met the inclusion criteria, 56% of patients received monotherapy and 21% of patients received combination therapy (2 antibiotics) covering GNOs. GNOs (84%) were susceptible to piperacillin-tazobactam. When used in combination with cefepime and meropenem, levofloxacin did not increase coverage. However, levofloxacin provided an 8% increase in coverage and gentamicin provided an additional 13% increase in coverage, respectively, when used in combination with piperacillin-tazobactam. Conclusions Among septic patients at VCUHS, gentamicin provided increased gram-negative coverage when compared with levofloxacin. Although susceptibility to piperacillin-tazobactam alone was relatively low, the combination of piperacillin-tazobactam and gentamicin provided nearly equivalent coverage to meropenem and gentamicin.

Background Identification of factors associated with antifungal utilization in neonatal, pediatric, and adult patient groups is needed to guide antifungal stewardship initiatives in academic medical centers. Methods For this hospital-level analysis, we analyzed antifungal use in hospitals across the United States of America, excluding centers only providing care for hematology/oncology patients. Analysis of variance was used to compare antifungal use between patient groups. Three multivariable linear regression models were used to determine independent factors associated with antifungal use in the neonatal, pediatric, and adult patient groups. Results For the neonatal, pediatric, and adult patient groups, 54, 44, and 60 hospitals were included, respectively. Total antifungal use was significantly lower in the neonatal patient group (14 days of therapy (DOT)/1000 patient days (PDs) versus 76 in pediatrics and 74 in adults, p

The recently described proportion of carbapenem consumption metric was used to assess the effectiveness of formulary restriction for carbapenems for 2 units housing predominantly immunocompromised patients at a large academic medical center. Interrupted time series analysis revealed a significant decrease in meropenem use for hematology-oncology and bone marrow transplant units after restriction.

The impact of formulary restriction and preauthorization (FRPA) on prescribing trends was examined over a 5-year period at an academic medical center. Ordinary least squares regression was used to identify hospital units demonstrating statistically significant trends in prescription of restricted agents. Significant decreases in restricted drug use were seen on 2 of 7 medicine units subject to FRPA, whereas a significant increase was seen in 1 of 4 surgical units subject to FRPA.

Patients with cancer are vulnerable to Clostridium difficile infection (CDI); hospitals with larger oncology populations may have worse CDI performance. Among 71 academic hospitals studied, there were significant differences in oncology patient-days per 1,000 admissions across CDI standardized infection ratio categories of better, no different, and worse; worse hospitals had the greatest number of patient-days. Oncology patients' most commonly used high-risk CDI medications were quinolones, third- and fourth-generation cephalosporins, and proton pump inhibitors.

Mobile medical apps are commonly used by health care professionals and could be used by antimicrobial stewardship programs to enhance adherence to local recommendations. We conducted a survey of health care workers to inform the design of an antimicrobial stewardship smartphone app.

Background The Centers for Medicare and Medicaid Services (CMS) implemented a core measure sepsis (SEP-1) bundle in 2015. One element was initiation of broad-spectrum antibiotics within 3 hours of diagnosis. The policy has the potential to increase antibiotic use and Clostridioides difficile infection (CDI). We evaluated the impact of SEP-1 implementation on broad-spectrum antibiotic use and CDI occurrence rates. Methods Monthly adult antibiotic data for 4 antibiotic categories (surgical prophylaxis, broad-spectrum for community-acquired infections, broad-spectrum for hospital-onset/multidrug-resistant [MDR] organisms, and anti–methicillin-resistant Staphylococcus aureus [MRSA]) from 111 hospitals participating in the Clinical Data Base Resource Manager were evaluated in periods before (October 2014–September 2015) and after (October 2015–June 2017) policy implementation. Interrupted time series analyses, using negative binomial regression, evaluated changes in antibiotic category use and CDI rates. Results At the hospital level, there was an immediate increase in the level of broad-spectrum agents for hospital-onset/MDR organisms (+2.3%, P = .0375) as well as a long-term increase in trend (+0.4% per month, P = .0273). There was also an immediate increase in level of overall antibiotic use (+1.4%, P = .0293). CDI rates unexpectedly decreased at the time of SEP-1 implementation. When analyses were limited to patients with sepsis, there was a significant level increase in use of all antibiotic categories at the time of SEP-1 implementation. Conclusions SEP-1 implementation was associated with immediate and long-term increases in broad-spectrum hospital-onset/MDR organism antibiotics. Antimicrobial stewardship programs should evaluate sepsis treatment for opportunities to de-escalate broad therapy as indicated.

We used multivariable analyses to assess whether meeting core elements was associated with antibiotic utilization. Compliance with 7 elements versus not doing so was associated with higher use of broad-spectrum agents for community-acquired infections [days of therapy per 1,000 patient days: 155 (39) vs 133 (29), P = .02] and anti-methicillin-resistant S. aureus agents [days of therapy per 1,000 patient days: 145 (37) vs 124 (30), P = .03].

Background Antimicrobial stewardship metrics that provide actionable guidance are needed to support efforts to improve hospital use of antibiotics. Antibiotics such as vancomycin and piperacillin/tazobactam are common empiric agents used frequently when the infectious process remains unknown. Thus short, incomplete courses of therapy are used more frequently for such agents. We aimed to evaluate the variability in short courses of vancomycin and piperacillin/tazobactam use across U.S. hospitals. Methods We performed a cross-sectional study among U.S. hospitals that contributed inpatient pharmacy data to the Vizient clinical database in 2016. We identified vancomycin and piperacillin-tazobactam courses initiated within the 48 hours of admission, measured as days of therapy received. We calculated the percent of patients that received 1, 2, 3, 4 or >4 days of therapy at each facility to describe short course empiric therapy use. To describe the variability across facilities, we then assessed the median, interquartile range (IQR), and total range of that percentage. Results We identified 145 hospitals representing approximately 3.7 million patient encounters for inclusion in this study. Within 48 hours of admission, 13.9% of encounters received vancomycin, 7.7% piperacillin/tazobactam, and 4.6% received both. The figure demonstrates the variability in the frequency of short course antibiotic use across hospitals; boxes indicate the IQR with the transecting line representing the median and whiskers representing the full range. The proportion of patients that received one day of therapy varied most across hospitals, with vancomycin ranging from 0–100%. In contrast, the frequency of patients that received greater than four days of therapy varied considerably less across hospitals; 0–33% for vancomycin. Conclusion The variability in use of short course empiric therapies suggests that use for non-infectious processes or infections not appropriately treated by these agents varies greatly across facilities. Measuring short course use for common empiric agents may serve as an important antimicrobial stewardship metric. Such a metric could inform antimicrobial stewardship efforts to reduce unnecessary initiation of empiric antimicrobial therapy. Disclosures All Authors: No reported disclosures

Background Although effectiveness of fecal microbiota transplantation (FMT) has been adequately documented, the patient experience of undergoing FMT has not. Methods We carried out a qualitative interview study using semistructured questions relating to aspects of health pre-FMT, during FMT, and post-FMT periods with 17 participants. Inductive coding was used to identify core themes during the periods. Results Pre-FMT themes included physical (continuous diarrhea and weight loss), mental (depression, wanting to die, and fear), quality of life (unable to perform normal activities), social support, and financial (medication costs) factors. Provider resistance/limited awareness were barriers to FMT. Participants reached a tipping point, experiencing feelings of hopelessness, which led them to pursue FMT. During FMT, participants commented on lack of a so-called ick factor. During the posttreatment period, participants experienced symptom relief, but had residual fears. Patient activation was present during all phases, including information seeking and empowerment. Conclusions During the pre-FMT period, participants experienced extreme discomfort and encountered FMT barriers. Undergoing FMT was reported as easy but residual fear remained. There were displays of patient activation at all FMT time periods, including the seeking of FMT. Participants could have benefited from having undergone FMT sooner, demonstrating a need for improvement in provider education and health system barriers regarding FMT.

Background: In this study, we assessed whether meropenem restriction led to delays in administration for patients in a medical intensive care unit (MICU) at a large tertiary-care urban teaching hospital. Methods: The antimicrobial stewardship program (ASP) at Virginia Commonwealth University Health System (VCUHS) requires approval for restricted antimicrobial orders placed between 8 a.m. and 9 p.m. Between 8 a.m. and 5 p.m. (daytime), authorized approvers include ASP and infectious diseases (ID) physicians. From 5 p.m. to 9 p.m. (evening) orders are approved by ID fellows. Orders were entered as Stat, Now, and Routine. Between 9 p.m. and 8 a.m. (night), patients receive doses without approval. Meropenem restriction began in mid-January 2018. Pre- and postmeropenem restriction periods were defined as February–December 2017 and February–December 2018. Meropenem use data were compared for adult patients in the MICU. A multivariable Cox regression model was implemented to compare (1) time from order entry to approval; (2) time from order approval to patient administration; (3) total time from order entry to patient administration, adjusting for order priority, approver (ASP, ID consult, ID fellow, pharmacy); and (4) time of day of order placement (day, eve, night). The analyses were performed using SAS version 9.4 software (SAS Institute, Cary, NC). Result: Time from order approval to patient administration was significantly decreased in the postrestriction period (HR, 1.840; P < .001) (Table 1). Stat orders were faster compared to routine orders for order entry to approval (HR, 1.735; P < .001), approval to administration (HR, 2.610; P < .001), and total time from order entry to administration (HR, 2.812; P < .001). No significant differences were found in time to approval by approving service. Time from order entry to approval was faster for nighttime orders than for daytime orders (HR, 1.399; P = .037). Conclusions: Our data indicate that the time from order entry to administration decreased following meropenem restriction in our MICU. More research is needed to identify the reason for this finding, but we postulate that this is due to an effect on drug administration prioritization within nursing workflow. These data will inform our local meropenem restriction efforts.Funding: NoneDisclosures: Michelle Doll reports a research grant from Molnlycke Healthcare.

Background Antibiotic therapy for inpatients with suspected infections is typically empirically initiated and therapy narrowed or altered when additional diagnostic evidence becomes available. For patients whose therapy is initiated on a weekend, differences in hospital staffing may impact the timing of therapy changes. We aimed to compare the duration of therapy of vancomycin and piperacillin-tazobactam between those who had therapy initiated on a weekday versus a weekend day. Methods We performed a cross-sectional study among U.S. hospitals that contributed pharmacy data for inpatients to the Vizient clinical database in 2016. We identified vancomycin and piperacillin-tazobactam courses initiated within the first 48 hours of admission; courses were categorized as weekend initiation (Friday, Saturday, Sunday) versus weekday initiation. The median days of therapy were compared between weekend and weekday initiation using the Wilcoxon rank-sum test. Results Among the 145 hospitals representing approximately 3.7 million patient encounters there were 401,101 encounters with vancomycin and 221,751 with piperacillin/tazobactam initiated within the first 48 hours of admission. Of these courses, 33% of vancomycin and 40% of piperacillin/tazobactam were initiated on a weekend day. The median (IQR) days of therapy for vancomycin initiated on a weekend was 2 days (1–4 days) compared to 2 days (1–3 days) when initiated on a weekday (p< .01). The median (IQR) days of therapy for piperacillin/tazobactam was 3 days (2–5 days) for courses initiated on either a weekend or weekday (p< .01). Conclusion We observed a statistically significant difference in the days of therapy received by patient encounters with vancomycin or piperacillin/tazobactam initiated on weekdays versus weekends. However, because of the large sample size in this study, we had power to identify small differences as statistically significant. Still, for vancomycin the 75th percentile received at least one additional day of therapy when initiated on a weekend versus a weekday. Further exploration is needed to identify if weekend initiation is associated with extended durations of therapy in specific sub-populations of patients. Disclosures All Authors: No reported disclosures

We aim to systematically review the literature on the effectiveness of pediatric antimicrobial stewardship programs (ASPs) and antimicrobial stewardship (AS) strategies in the United States (US) inpatient setting. Furthermore, we review current gaps and challenges for unique pediatric populations and those in ambulatory settings. Misuse and overuse of antimicrobials have been identified as key factors for antimicrobial resistance (AR). Multiple professional organizations support the implementation of hospital-based ASPs to decrease antimicrobial consumption, improve patient outcomes, and reduce healthcare costs. There is limited data on the effectiveness of inpatient pediatric ASPs and AS strategies in unique populations. Furthermore, there is a paucity of evidence on ASPs in ambulatory settings. This review contributes to the growing body of evidence that supports the use of pediatric ASPs to optimize antimicrobial therapy in the inpatient setting as well as in unique patient populations and ambulatory settings. Active stewardship is critical and antimicrobial consumption is a key outcome metric for programs.

A metric was developed to identify hospital proportion of carbapenem consumption (PoCC) among antipseudomonal antibiotics. The PoCC varied significantly among academic medical centers by Census Bureau geographic division after adjusting for patient mix. This metric may be useful in identifying disproportionate carbapenem use and potential carbapenem overuse.Infect Control Hosp Epidemiol 2018;39:229–232

Objectives To determine whether an antimicrobial stewardship ‘intensity’ score predicts hospital antimicrobial usage. Methods An antimicrobial stewardship score for 44 academic medical centres was developed that comprised two main categories: resources (antimicrobial stewardship programme personnel and automated surveillance software) and strategies (preauthorization, audit with intervention and feedback, education, guidelines and clinical pathways, parenteral to oral therapy programmes, de-escalation of therapy, antimicrobial order forms and dose optimization). Multiple regression analyses were used to assess whether the composite score and also the categories were associated with either total or antimicrobial stewardship programme-target antimicrobial use as measured in days of therapy. Results The mean antimicrobial stewardship programme score was 55 (SD 21); the total composite score was not significantly associated with total or target antimicrobial use [estimate –0.49 (95% CI –2.30 to 0.89)], while the category strategies was significantly and negatively associated with target antimicrobial use [–5.91 (95% CI –9.51 to –2.31)]. Conclusions The strategy component of a score developed to measure the intensity of antimicrobial stewardship was associated with the amount of antimicrobials used. Thus, the number and types of strategies employed by antimicrobial stewardship programmes may be of particular importance in programme effectiveness.

Vancomycin-resistant Enterococci (VRE) infections are problematic due to limited availability of anti-VRE agents and their potential for adverse effects and drug interactions. This review focuses on the role of daptomycin in treating VRE infections by summarizing key points of relevant clinical studies. Higher doses of daptomycin (≥ 6 mg/kg), as compared to standard doses, were found to be safe in terms of creatinine phosphokinase elevation and associated with successful infection outcomes and microbiological clearance. High doses are especially important in treatment of infections involving elevated daptomycin minimum inhibitory concentration (MIC) values (3–4 μg/mL). Daptomycin, especially in higher doses, has been shown to be an effective and safe VRE agent for a variety of serious infection types, such as catheter-associated bloodstream and intra-abdominal infections, and for different populations including oncology. Infections involving higher daptomycin MIC values were associated with previous daptomycin use and prosthetic devices.

This report examines the effectiveness of antimicrobial restriction at 1 tertiary care health care system by analyzing the consumption of restricted versus nonrestricted gram-positive agents over time for medical versus surgical units. Significant reductions in restricted antibiotic use were detected in 57% of medical units versus none of the surgical units. There were no significant reductions in nonrestricted antibiotic use. We think looking at antibiotic consumption by service line provides opportunities for targeted antibiotic restriction program refinement.

Background Gram-negative bacterial infections are associated with high mortality in immunocompromised hosts, and the presence of drug resistance further increases mortality. Antibiotic consumption is a key outcome measure for Antimicrobial Stewardship Programs. Proper utilization of antibiotics can help limit the development of antimicrobial resistance. Resistance in Gram-negative organisms such as Pseudomonas, Enterobacter, and Acinetobacter is a major issue given the paucity of new drugs in the antibiotic pipeline for these organisms. A novel relative carbapenem consumption metric (the Proportion of Carbapenem Consumption, or PoCC) was recently described in US academic medical centers. The PoCC is calculated as follows: PoCC = [(meropenem Days of therapy(DOT)/1,000 patient-days (PDs))/(meropenem DOT/1,000 PDs + cefepime DOT/1,000 PDs + piperacillin–tazobactam DOT/1,000 PDs)]. The regional mean PoCC for the South Atlantic region has previously been approximated at 17%. Methods We examined the PoCC for the Bone Marrow Transplant (BMT) and dedicated Hematology/Oncology (H/O) inpatient wards at an academic medical center from August 2012 to June 2017. Results Table 1: Average Use of Antibiotics Expressed in DOT/1,000 PDs. Ward Piperacillin– Tazobactam Cefepime Meropenem Total PoCC Hematology/oncology 105.1 134.4 76.6 316.1 0.24 Bone marrow transplant 34.3 201.0 127.4 362.7 0.35 National meansa 76.2 60.2 30.7 b 0.18 aAs described by Markley et al. Infect Control Hosp Epidemiol 2018;39:229–232. bData unavailable. Conclusion This is the first description of the PoCC metric for dedicated Hematology/Oncology and Bone Marrow Transplant wards. When compared with national and regional mean PoCC scores for academic medical centers, the PoCC for these units was higher. More research is needed to determine the optimal PoCC scores for these types of units. The PoCC can contextualize relative carbapenem use and may be a useful antibiotic consumption metric. However, it does not provide data on absolute consumption. Further studies are needed to determine the best use of the PoCC metric by Antimicrobial Stewardship Programs for Hematology/Oncology and Bone Marrow Transplant wards. Disclosures All authors: No reported disclosures.

Background Antibiotic use metrics are utilized by antimicrobial stewardship programs to benchmark performance against peer institutions and inform stewardship efforts. Benchmarking requires risk adjustment for patient- and facility-level factors so that remaining differences are attributable only to prescribing practices. Antibiotics for the treatment of methicillin-resistant Staphylococcus aureus (MRSA) are one of the most frequently used drug classes. Our objective was to identify predictors of anti-MRSA antibiotic use in a nationwide network of hospitals. Methods We used data from inpatient encounters at facilities participating in the Vizient data repository between January 1, 2016 and December 31, 2016. The outcome, anti-MRSA antibiotic use, was calculated as days of therapy per patient-days present for each encounter. We constructed a multivariable negative binomial regression model and assessed the following predictors for inclusion: age, sex, race, ethnicity, diagnosis related groups (DRGs), ICU days, admit month, facility bed size, facility teaching status, and region. A clinical framework was used to categorize DRGs based on risk of anti-MRSA antibiotic use. A backwards stepwise approach was used to identify the final model. We evaluated predictor effect size and significance, and assessed model fit using a deviance-based pseudo-R2. Results One hundred forty-five facilities representing 3,608,711 encounters met inclusion criteria. All predictors considered in our model were significant. Predictors with the greatest magnitude of association included DRG categories and patient age. The DRG categories with the strongest associations were DRGs for infections likely due to Staphylococcus aureus (RR = 1.66, P < 0.0001) or for diagnoses likely to receive long-term MRSA coverage (RR = 1.49, P < 0.0001). The age group with the strongest association was age 2–10 years (RR = 1.64; P < 0.001). The deviance-based pseudo-R2 of the final model was 0.19, indicating good model fit. Conclusion DRGs and patient-level characteristics can be utilized to account for variability in anti-MRSA antibiotic use beyond what is explained through facility-level characteristics. Incorporation of the significant predictors identified in this study may aid in more meaningful interhospital comparisons of anti-MRSA antibiotic use in both adults and pediatrics. Disclosures J. C. McGregor, Merck: Grant Investigator, Research grant.

Objectives The main objective of this study was to determine patient- and hospital-level medication risk factors associated with Clostridium difficile infection (CDI) occurrence among patients clustered within hospitals using a multilevel model. Methods Patients with healthcare-associated (HA)-CDI were identified from among 64 academic medical centres in 2009. A frequency match was conducted; for each case, up to two controls were selected, matched on similar pre-infection length of stay and clinical service line. Patient- and hospital-level medication use, including antibacterial and gastric acid-suppressant agents, was assessed using a two-level logistic regression model. Results A total of 5967 CDI cases and 8167 controls were included in the analysis. The odds of acquiring HA-CDI increased with the following medications [OR (95% CI)]: anti-methicillin-resistant Staphylococcus aureus agents [1.38 (1.22-1.56)]; third- or fourth-generation cephalosporins [1.75 (1.62-1.89)]; carbapenems [1.60 (1.44-1.79)]; β-lactam/β-lactamase inhibitor combinations [1.49 (1.36-1.64)]; vancomycin [1.73 (1.57-1.89)]; and proton pump inhibitors [1.43 (1.30-1.57)]. The odds of acquiring HA-CDI decreased with the following medications: clindamycin [0.74 (0.63-0.87)]; and macrolides [0.88 (0.77-0.99)]. Controlling for patient-level covariates, no hospital-level medication covariates that we analysed had statistically significant effects on HA-CDI. The odds of acquiring HA-CDI increased with the hospital proportion of patients aged ≥ 65 years [1.01 (1.00-1.02)]. Conclusions We found several medications that were associated with the risk of patients developing HA-CDI, including β-lactam/β-lactamase inhibitor combinations, third- or fourth-generation cephalosporins, carbapenems, vancomycin, proton pump inhibitors and anti-methicillin-resistant S. aureus agents. There were no medication effects significant at the hospital level.

The performance of a hospital- and community-onset Clostridium difficile infection definition using administrative data with a present-on-admission indicator was compared with definitions using clinical surveillance. For hospital-onset C. difficile infection, there was moderate sensitivity (68%) and high specificity (93%); for community-onset, sensitivity and specificity were high (both 85%).Infect Control Hosp Epidemiol 2015;36(7):838–840

The measurement of antibacterial consumption is important for tracking use over time, for assessing correlations between use and antibacterial resistance, and for serving as an outcome measure for antimicrobial stewardship programs. Accurate and consistent measures of use are important for meaningful inter- and intrainstitutional comparisons. The defined daily dose (DDD) and days of therapy methods are commonly used measures in the adult population; however, there is no one ideal measure of consumption that covers the breadth and depth of antibacterial prescribing. The use of the DDD and the prescribed daily dose methods, with further stratification of use by weight and age groups, aids in the evaluation of antimicrobial use in pediatric patients. Increasing availability of computerized pharmacy data should enhance the collection and analysis of data from hospitals.

Objective.To evaluate the impact of state laws on reporting of healthcare-associated infections on central line-associated bloodstream infection (CLABSI) rates.Design.Retrospective, cross-sectional study.Methods.Hospital-level administrative and Hospital Compare data were collected on University HealthSystem Consortium hospitals. An ordered probit regression model assessed the association between state legislation and CLABSI standardized infection ratio (SIR). The main independent variable was a state legislation variable concerning 3 legal requirements (data submission, reporting of data to the public, inclusion of facility identifiers in public reports) and was coded for hospitals accordingly located in a state that did not have CLABSI reporting, located in a state that had CLABSI reporting legislation and met 3 legal requirements, or located in a state that had CLABSI reporting but did not meet the 3 legal requirements. A secondary analysis ascertained whether the mean state SIR values differed among the 3 legislation groups.Results.There were 159 hospitals included; 92 were located in states that had CLABSI reporting and met 3 requirements, 33 were located in states that had reporting but did not meet the 3 requirements, and 34 were in states that had no legislation. There was no effect of state legislation group on CLABSI SIR. There were no significant differences in the mean state CLABSI SIRs among the legislation groups.Conclusions.In this sample of academic medical centers, there was no evidence of an effect of state HAI laws on CLABSI occurrence. The impact of state legislation may be lessened by other CLABSI prevention initiatives.

OBJECTIVENational hospital performance measures for C. difficile infection (CD) are available; comparing antibacterial use among performance levels can aid in identifying effective antimicrobial stewardship strategies to reduce CDI rates.DESIGNHospital-level, cross-sectional analysis.METHODSHospital characteristics (ie, demographics, medications, patient mix) were obtained for 77 hospitals for 2013. Hospitals were assigned 1 of 3 levels of a CDI standardized infection ratio (SIR): ‘Worse than,’ ‘Better than,’ or ‘No different than’ a national benchmark. Analyses compared medication use (total and broad-spectrum antibacterials) for 3 metrics: days of therapy per 1,000 patient days; length of therapy; and proportion of patients receiving a medication across SIR levels. A multivariate, ordered-probit regression identified characteristics associated with SIR categories.RESULTSRegarding total average antimicrobial use per patient, there was a significant difference detected in mean length of therapy: ‘No different’ hospitals having the longest (4.93 days) versus ‘Worse’ (4.78 days) and ‘Better’ (4.43 days) (PPPPCONCLUSIONSThese findings have potential implications regarding the need to fully account for hospital patient mix when carrying out inter-hospital comparisons of CDI rates.Infect Control Hosp Epidemiol 2016;37:909–915

Hospitals are categorized as better, no different, or worse at a national level based on their Clostridium difficile infection performance. Institutional antimicrobial stewardship programs seek to decrease the occurrence of C difficile by implementing strategies to address antibiotic usage; however, optimal structure and strategies for accomplishing this remain largely unknown. We found that a higher proportion of hospitals with either a worse or no different rank used a postprescription audit and feedback strategy than hospitals with a better rank.

Background The antibiotic timeout (ATO) is a stewardship tool that protocolizes review of objective clinical data after a predefined period of time and encourages antimicrobial regimen re-assessment. Methods Vizient member hospitals were utilized to recruit a variety of acute healthcare institutions, including institutions with and without an ATO process. Participating institutions submitted de-identified patient-level antibiotic therapy courses from a single day within a 5-week window to create a snapshot of overall antibiotic utilization. Therapy courses were evaluated on metrics including the prevalence of anti-pseudomonal agents, agents active against methicillin-resistant Staphylococcus aureus (MRSA), and oral (vs. intravenous) antibiotics. The outcome measures included: percent changes in prevalence of courses with antipseudomonal and anti-MRSA agents after day 3, and percent change in antibiotics ordered for oral administration after day 3. These outcome measures were compared between ATO institutions and non-ATO institutions. Results A total of 6,184 antibiotic therapy courses were collected from 61 participating institutions (17 ATO institutions; 44 non-ATO institutions). Of 71 institutions that completed enrollment survey, 10 did not complete submission of therapy course data. Antibiotic courses prescribed for prophylaxis (n = 975) and courses that extended beyond 7 days (n = 1,192) were excluded from analysis, resulting in an analysis group that included 4,017 therapy courses (1,396 from ATO institutions vs. 2,621 from non-ATO institutions). The prevalence of patients receiving anti-pseudomonal agents increased after day 3 by 3.03% (P = 0.28) at ATO institutions and decreased 0.45% (P = 0.84) at non-ATO institutions. The prevalence of patients receiving anti-MRSA agents decreased after day 3 by 2.16% (P = 0.41) at ATO institutions and decreased 5.05% (P = 0.005) at non-ATO institutions. Oral antibiotic use increased after day 3 by 3.09% (P = 0.08) at ATO institutions while use at non-ATO institutions increased 7.99% (P = 0.0001). Conclusion Antibiotic therapy course data collected across multiple sites provided no evidence for improved antimicrobial utilization among institutions that have implemented an antibiotic timeout compared with institutions without a timeout. Disclosures All authors: No reported disclosures.

Background Antimicrobial Stewardship Programs (ASPs) promote the optimal use of antimicrobial agents with the goal of preserving the effectiveness of existing drugs. One core ASP strategy is formulary restriction and preauthorization (PA). We evaluated restricted antimicrobial use at an academic medical center in Virginia; our program has a comprehensive restriction program that applies to adults only. Methods Data from August 2012 to June 2017 were evaluated at the hospital unit level by month in days of therapy (DOT) per 1,000 patient-days. Ordinary least squares regression was used to compare the time trend of restricted use with that of nonrestricted agents within the same unit. Results Across the study period significant decreases in restricted antibiotic use were detected for medical and pediatric units with no significant increases in use. However, significant increases were identified for surgical units. Table 1: Results of Time Trend Analysis by Unit for Restricted Drugs. Restricted Type Unit Time Trend P Medical Oncology 0.64 0.0924 Acute Care Medicine 0.39 0.4058 Cardiac ICU −0.37 0.1057 Medical ICU −2.06 0.0002 Bone Marrow Transplant 0.52 0.5002 Digestive Health −0.14 0.3004 Progressive Care −0.93 0.0002 Pediatric General Pediatrics −0.36 0.1363 Neonatal ICU −0.29 0.0007 Pediatric ICU −0.12 0.7849 Progressive Care −0.29 0.0993 Surgical Acute Care Surgery −0.30 0.1574 Burn ICU 0.84 0.0021 Cardiac Surgery ICU −0.50 0.2766 Surgical Trauma ICU −0.52 0.1019 Table 2: Significant Increases/ Decreases in Restricted Antimicrobials by Unit Type Restricted Unit Type Increase Decrease Medical 0/7 (0%) 2/7 (29%) Pediatric 0/4 (0%) 1/4 (25%) Surgical 1/4 (25%) 0/4 (0%) Conclusion These data suggest that the PA strategy for medical wards was effective across the time period whereas the PA strategy for surgical wards was suboptimal. However, it is unclear why pediatric wards (that were not subject to PA activities) also saw reductions in use; more research into this is needed. These data will help us to refine our PA strategy by targeting use on surgical wards. We believe that this type of analysis may be useful for other ASPs utilizing the PA strategy. Disclosures All authors: No reported disclosures.

Background Antibiotic utilization for geographically diverse areas can be difficult to obtain. The purpose of this study was to characterize patterns of US antibiotic use over a defined period to provide comparative data for benchmarking and to assist with identifying antibiotic stewardship opportunities. Methods Data were obtained as part of a larger study evaluating antibiotic time out practices. Participating institutions submitted de-identified patient-level antibiotic use data from a single day (between October 16, 2017 and November 17, 2017). Indication, expected duration, and antibiotic stop dates were documented. Antibiotics were classified by American Hospital Formulary Service (AHFS) therapeutic category and evaluated to identify duplicate anti-anaerobic, anti-MRSA, and AHFS classes. Hospital teaching status and US Census region were recorded. Results A total of 6,184 courses of therapy (8,996 individual antibiotics) were evaluated from 61 hospitals. Sixty-four percent of therapy courses submitted were from academic medical centers. Distribution by census region was Midwest (44.7%), Northeast (15.11%), South (23.2%), and West (16.9%). Over half (53.7%) of therapy was empiric and 33.4% was directed. Sixty-six percent of courses did not include a stop date within the electronic medical record. Twelve drugs comprised 80% of total antibiotic use. Percentage of antipseudomonal use was similar across regions, but anti-MRSA therapy was higher in the South and Midwest. Duplicate β-lactam therapy and duplicate anti-anaerobe therapy were identified in 1.5% of total courses (each). Duplicate anti-MRSA therapy occurred in 0.29% of therapy courses. Three percent of patients developed a Clostridium difficile infection during their hospitalization. Conclusion Vancomycin and piperacillin–tazobactam were the most common antibiotics used which is consistent with other analyses, but anti-anaerobic use as a percentage of overall use was higher than expected. Duplicate anti-anaerobe and β-lactam therapy is less frequent, but still represents an opportunity for stewardship. Antipseudomonal and anti-MRSA agents represent two key categories for stewardship given the high percentage of use. The addition of a stop date to the antibiotic order presents an opportunity to improve overall utilization. Disclosures All authors: No reported disclosures.

Objective.The International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) code for Clostridium difficile infection (CDI) is used for surveillance of CDI. However, the ICD-9-CM code alone cannot separate nosocomial cases from cases acquired outside the institution. The purpose of this study was to determine whether combining the ICD-9-CM code with medication treatment data for CDI in hospitalized patients could enable us to distinguish between patients with nosocomial CDI and patients who were admitted with CDI. The primary objective was to compare the sensitivity, specificity, and predictive value of using the combination of ICD-9-CM code for CDI and CDI treatment records to identify cases of nosocomial CDI with the sensitivity, specificity, and predictive value of using the ICD-9-CM code alone.Design.Validation sample cross-sectional study.Setting.Academic health center.Methods.Administrative claims data from July 1, 2004, to June 30, 2005, were queried to identify adults discharged with an ICD-9-CM code for CDI and to find documentation of CDI therapy with oral vancomycin or metronidazole. Laboratory and medical records were queried to identify symptomatic CDI toxin-positive adult patients with nosocomial CDI and were compared with records of patients whose cases were predicted to be nosocomial by means of ICD-9-CM code and CDI therapy data.Results.Of 23,920 adult patients discharged from the hospital, 62 had nosocomial CDI according to symptoms and toxin assay. The sensitivity of the ICD-9-CM code alone for identifying nosocomial CDI was 96.8%, the specificity was 99.6%, the positive predictive value was 40.8%, and the negative predictive value was 100%. When CDI drug therapy was included with the ICD-9-CM code, the sensitivity ranged from 58.1% to 85.5%, specificity was virtually unchanged, and the range in positive predictive value was 37.9%–80.0%.Conclusion.Combining the ICD-9-CM code for CDI with drug therapy information increased the positive predictive value for nosocomial CDI but decreased the sensitivity.

Many hospital antimicrobial stewardship programs restrict the availability of selected drugs by requiring prior approval. Carbapenems may be among the restricted drugs, but it is unclear if hospitals that restrict availability actually use fewer carbapenems than hospitals that do not restrict use. Nor is it clear if restriction is related to resistance. We evaluated the relationship between carbapenem restriction and the volume of carbapenem use and both the incidence rate and proportion of carbapenem-resistant Pseudomonas aeruginosa isolates from 2002 through 2006 in a retrospective, longitudinal, multicenter analysis among a consortium of academic health centers. Carbapenem use was measured from billing records as days of therapy per 1,000 patient days. Hospital antibiograms were used to determine both the incidence rate and proportion of carbapenem-resistant P. aeruginosa isolates. A survey inquired about restriction policies for antibiotics, including carbapenems. General linear mixed models were used to examine study outcomes. Among 22 hospitals with sufficient data for analysis, overall carbapenem use increased significantly over the 5 years of study ( P < 0.0001), although overall carbapenem resistance in P. aeruginosa did not change. Hospitals that restricted carbapenems ( n = 8; 36%) used significantly fewer carbapenems ( P = 0.04) and reported lower incidence rates of carbapenem-resistant P. aeruginosa ( P = 0.01) for all study years. Fluoroquinolone use was a potential confounder of these relationships, but hospitals that restricted carbapenems actually used fewer fluoroquinolones than those that did not. Restriction of carbapenems is associated with both lower use and lower incidence rates of carbapenem resistance in P. aeruginosa .

Sir, Fluoroquinolone-resistant Pseudomonas aeruginosa is associated with a negative impact on patient outcome,1 and treatment of these organisms can be challenging. Increases in fluoroquinolone-resistant P. aeruginosa have been reported across hospitals and these were related to fluoroquinolone use.2–4 These studies were conducted in periods during which fluoroquinolone use was increasing; more recent data show that their use appears to be stabilizing or decreasing.5 The purpose of this study was to examine recent trends in fluoroquinolone-resistant P. aeruginosa and to determine relationships to fluoroquinolone use in US hospitals. This multi-year cross-sectional study used data from academic medical centres that participated in the University HealthSystem Consortium (UHC). Specifically, UHC member hospitals that subscribed to the Clinical Resource Manager (CRM) database provided drug usage and demographic data. Systemic fluoroquinolones (ciprofloxacin, gatifloxacin, moxifloxacin and levofloxacin) administered to adult patients (age ≥18 years) discharged from 1 January 2002 to 31 December 2009 from 20 hospitals were recorded as days of therapy (DOT) per 1000 patient days (PD). Resistance data (the proportion of ciprofloxacin-resistant isolates) were obtained from the antibiograms that hospitals provided. General linear mixed models were used to assess the significance of changes in antibiotic use and resistance. To assess the relationship between use of individual fluoroquinolones and fluoroquinolone-resistant P. aeruginosa, we used population-averaged longitudinal models, generalized estimating equation (GEE) models, to adjust for correlation among hospitals across time. Quasi-likelihood under the independence model criterion (QIC; an extension of Akaike's information criterion to the GEE method) was used to determine the best distribution and link functions, as well as the working correlation structure. Based on comparison of QIC values, a binomial distribution, logit link and an exchangeable working correlation structure were chosen for this model. We also controlled for the use of other Gram-negative antibacterials (carbapenems, third- and fourth-generation cephalosporins, β-lactam/β-lactamase inhibitor combinations and aminoglycosides). A P value

Background The Centers for Disease Control and Prevention National Healthcare Safety Network (NHSN) provides hospitals a mechanism to report antibiotic use (AU) data to benchmark against peer institutions and direct antibiotic stewardship efforts. Differences in patient populations need to be adjusted for to ensure unbiased comparisons across hospitals. Our objective was to identify predictors of total AU across a nationwide network of hospitals. Methods Data from 126 academic hospitals were extracted from the Vizient Clinical Data Base Resource Manager for adult inpatients (age ≥ 18 years) in 2015. AU was expressed as total antibiotic days of therapy/patient-days. We constructed a negative binomial regression model to explore potential predictors of AU including age, race, sex, case mix index, hospital bed size, length of stay, geographic region, transfer cases, service line, and illness severity. A backwards stepwise approach based on likelihood ratio test was used to identify significant (P < 0.05) predictors and construct the final, parsimonious model. We calculated dispersion-based R2 to assess the percent variability explained by the full and final models. Results A total of 3,076,394 total admissions, representing 17,544,763 patient days, were included. Factors identified as significant predictors in the final model are shown in the Table. The percent variance explained by the full and final models was 90.3% and 89.6%, respectively. Table: Independent predictors of total facility antibiotic use per patient days Relative Risk 95% Confidence Interval Case Mix Index 1.36 1.16, 1.60 Region West Ref – Midwest 1.05 0.92, 1.20 Northeast 0.92 0.81, 1.04 South 1.07 0.94, 1.23 Transfer cases 0.31 0.15, 0.63 Surgery service line 0.45 0.25, 0.81 Major illness severity 3.24 1.04, 10.09 Conclusion The current NHSN AU risk adjustment metric, the standardized antimicrobial administration ratio (SAAR), has been developed separately for different antibiotic groupings and adjusts for a limited set of facility characteristics. Further work is needed to assess if the independent predictors identified in this model can improve upon the performance of existing SAAR metrics and aid in directing stewardship strategies. Disclosures All authors: No reported disclosures.

Background Facilities enrolled in the National Healthcare Safety Network (NHSN) provide annual information on their antibiotic stewardship programs (ASPs) via a mandatory survey. The survey contains 12 questions that explore uptake of CDC’s Core Elements for Hospital ASPs. Respondents (typically Infection Preventionists) are advised to seek input from pharmacist and physician ASP champions, but the professional completing the survey and the extent of input provided by ASP program personnel are unknown. A separate survey provided an opportunity to assess ASP responses reported to NHSN. Methods Individuals from 446 academic and community hospitals participating in the Vizient list-serve were surveyed in March 2016. The Vizient survey included the 12 ASP questions in the 2015 NHSN survey. Vizient responses were compared with NHSN survey responses to assess differences in reported uptake of core elements based on the professional completing the survey. Results 189 of the 211 hospitals completing the Vizient survey were successfully matched to NHSN hospitals. The majority of respondents were pharmacists; 83% were either Directors of Pharmacy or clinical pharmacists of which 48% and 61% reported assisting with the NHSN survey, respectively. Reported implementation of all 7 elements in this subset of 189 hospitals was 58.2% in the Vizient survey compared with 54.5% in NHSN. Results differed by respondent position and core element surveyed. Clinical pharmacists in the Vizient survey reported higher rates of core element adherence than Directors of Pharmacy (Figure 1). The position of survey respondents varied by hospital size. Of hospitals with less than 250 beds, 87.5% of surveys were completed by Directors of Pharmacy, whereas 77.1% of surveys were completed by clinical pharmacists in hospitals with ≥250 beds. Conclusion Overall similarities between NHSN and Vizient survey results indicate that ASP questions based on CDC’s Core Elements are interpreted in similar ways and answered consistently when analyzed overall. However, individual core element responses may differ based on position of respondent, ASP familiarity, ASP infrastructure, and/or hospital bed size. CDC is exploring improved wording of the survey questions to help further improve consistency in responses. Disclosures All authors: No reported disclosures.

Background Many hospitals have implemented antimicrobial stewardship programs (ASPs) and have included in their programs strategies such as prior authorization and audit and feedback. However there are few data concerning the facilitators and barriers that ASPs face when implementing their strategies. We conducted a qualitative study to discern factors that lead to successful uptake of ASP strategies. Methods Semistructured telephone interviews were conducted from June-July 2013 with 15 ASP member pharmacists and 6 physicians representing 21 unique academic medical centers. Results Successful implementation of ASP strategies was found to be related to communication style, types of relationships formed between the ASP and non-ASP personnel, and conflict management. Success was also influenced by the availability of resources in the form of adequate personnel, health information technology personnel and infrastructure, and the ability to generate and analyze ASP-specific data. Types of effective strategies commonly cited included audit and feedback; prior authorization, especially with an educative component; and use of real-time alert technology and guidelines. Conclusions Several factors may influence ASP success in the implementation of their strategies. ASP members may use these findings to improve upon the success of their programs.

Clostridium difficile infection (CDI) is a potentially serious disease for which the epidemiology has recently changed, because of an emerging drug-resistant strain of the pathogen. Metronidazole and oral vancomycin are the primary treatment agents.2 Metronidazole has been historically favored as the first-line agent, partly to reduce the selection pressure for vancomycin-resistant enterococci (VRE), although metronidazole can also select for VRE. Vancomycin was traditionally reserved for metronidazole treatment failure or life-threatening disease. In a study conducted before emergence of the epidemic strain, vancomycin was reported to be superior for the initial treatment of severe CDI and for treatment of CDI that does not respond to metronidazole. Expert opinion calling for the use of vancomycin as first-line therapy, especially for severe CDI emergence of the epidemic strain, and reports of decreased metronidazole efficacy may have impacted CDI treatment practices. The purpose of this study was to characterize trends in CDI treatment in US hospitals.

Trends in pediatric antibacterial use were examined in 20 academic health centers during the period 2002-2007. There was a significant increase in the use of linezolid (P < .001) and of macrolides (P = .001) and a significant decrease in the use of aminoglycosides (P < .001) and of first-generation cephalosporins (P < .001).

• Data were obtained from 89 University HealthSystem Consortium hospitals for adult patients (age≥ 18) for 2011 using the Clinical Resource Manager Database. • Antibacterials were measured in Days of Therapy per 100 admissions. • Risk factors considered were case mix index (CMI), bed size (expressed as < or ≥ the median), the % of intensive care unit days, average length of stay (LOS), a marker for market competition (the Herfindahl Index: HHI), region (Northeast, South, Midwest, West), 4 clinical service lines ( surgery, medicine, transplant, and other; expressed as < or ≥ the median number of admissions per CSL). • Three forward stepwise regression models were conducted to identify factors associated with total antibacterial, total antipseudomonal, and anti-methicillin resistant S. aureus (MRSA) drug use. Methods