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Background ID Carnival was established as a term project in the infectious disease (ID) elective for pharmacy students in their third professional year. In small groups and with frequent faculty feedback, students designed, developed, and created games based on an ID topic. At the end of the semester, students presented their development process and played each other’s games during ID Carnival. The goal of ID carnival was to engage and motivate students to reinforce the foundational knowledge taught in the course and challenge students to develop personally and professionally. The purpose of this study was to assess the impact of ID Carnival on achieving the Center for the Advancement of Pharmacy Education (CAPE) 2013 Educational Outcomes and evaluate students’ perception of ID Carnival. Methods From 2019 to 2022, student feedback was anonymously collected via an electronic survey. Students evaluated the impact of ID Carnival based on the 4 domains of the CAPE 2013 Educational Outcomes (Foundational Knowledge, Essentials for Practice and Care, Approach to Practice and Care, and Personal and Professional Development) on a Likert scale from strongly disagree (1) to strongly agree (5). Results 125 students responded. Majority strongly agreed or agreed that ID Carnival allowed them to build foundational knowledge (122/125, 98%), apply drug information skills (120/125, 96%), develop problem solving skills (121/125, 97%), improve effective communication skills (124/125, 99%), become self-aware in their ability to enhance personal and professional growth (120/125, 96%), hone their leadership skills (123/125, 98%), and creatively think of ways to accomplish professional goals (125/125, 100%). Additionally, students expressed that ID Carnival enhanced their desire to learn ID, provided a fun, engaging, and rewarding environment to learn, and felt motivated to participate in ID Carnival. Conclusion ID Carnival was positively received and provided an opportunity for students to expand beyond foundational knowledge and skills, and develop on the affective domain, including self-awareness, innovation, leadership, and professionalism. Opportunities like ID Carnival are important in the education of pharmacy students to prepare them to practice at the highest level of the profession. Disclosures All Authors: No reported disclosures.

Background In 2021, Clostridioides difficile infection (CDI) treatment guidelines were updated to recommend fidaxomicin over oral vancomycin as first-line therapy in initial and recurrent CDI episodes. Prior to this update, fidaxomicin use in management of CDI was limited, as cheaper alternatives were recommended as first-line therapy. The purpose of this study was to assess the guideline adaptation of fidaxomicin as first-line therapy in CDI management in institutions across the United States (US) and to identify barriers to its use. Methods An electronic survey was distributed to members of the American Society of Health-System Pharmacists in April 2022. Baseline demographics, current practices, and barriers to fidaxomicin use were collected. Results were analyzed using descriptive statistics. Fisher’s Exact Test was used to compare categorical variables. Results Based on 63 responses, majority of institutions (41/63, 65%) did not recommend use of fidaxomicin as first-line therapy for CDI. While most hospitals reported having institution specific CDI guidelines (48/63, 76%), over half of institutions with CDI guidelines still recommended oral vancomycin as first-line therapy (26/48, 54%). None of the institutions without CDI guidelines (0/15, 0%) recommended use of fidaxomicin as first-line therapy and majority of them (12/15, 80%) did not have fidaxomicin on formulary or restricted its use to ID services. Recommendation of fidaxomicin as first-line therapy was significantly higher in institutions with CDI guidelines versus those without (46% vs 0%, Fisher’s Exact 0.0006, p< 0.05). Approximately 92% (58/63) of respondents reported at least 1 barrier to using fidaxomicin, with 39.6% (25/63) reporting 2 or more barriers to use. Barriers identified were cost (55/63, 87.3%), lack of formulary inclusion (14/63, 22.2%), lack of provider familiarity (13/63, 20.6%) and inability of patients to afford upon discharge (7/63, 11.1%). Conclusion Majority of institutions do not currently recommend use of fidaxomicin as first-line therapy for CDI despite the recent guideline updates. Institutions with CDI treatment guidelines were more likely to recommend use fidaxomicin as first-line therapy. Cost and lack of formulary inclusion were cited as the most frequent barriers to fidaxomicin use. Disclosures All Authors: No reported disclosures.

Introduction: Pharmacists are uniquely qualified to promote Pre-Exposure Prophylaxis (PrEP) and Post Exposure Prophylaxis (PEP). The objective of this study was to measure pharmacy students’ awareness, knowledge, and comfort regarding PrEP and PEP in an urban setting. Methods: A 23-point questionnaire was distributed to pharmacy students between 2 May 2019 and 31 May 2019. Results: Eighty six pharmacy students responded to the survey. Most of them correctly identified FDA-approved regimens for PrEP and PEP. Most students thought that a pharmacist or intern counselling patients on PrEP or PEP was beneficial; however, a minority felt confident counselling patients on PrEP or PEP. Students who met criteria for composite knowledge were significantly more likely to report confidence in counselling. Conclusion: Pharmacy students have strong awareness, but limited knowledge and comfort regarding PrEP and PEP. Results from the survey will be used to assess the learning needs of pharmacy students and inform future curricular changes.

Introduction: The latest vancomycin therapeutic drug monitoring guidelines for serious MRSA infections have made a pivotal change in dosing, switching from targeting trough levels to AUC dosing. Because of these new recommendations, antimicrobial stewardship programs across the country are tasked with implementing AUC based dosing. Objectives: To assess plans for institutional adoption of vancomycin AUC dosing programs and perceptions of currently used programs in hospitals across the US. Methods: An electronic survey was distributed to members of the American College of Clinical Pharmacy IDprn Listserv and American Society of Health-System Pharmacists between May and June 2020 to assess current institutional vancomycin dosing. Institutional program use and multiple software user parameters were analyzed using descriptive statistics. Results: Two hundred two pharmacists responded to the survey with the majority practicing in institutions with 251-500 beds. Most respondents have yet to implement AUC dosing (142/202, 70.3%) with many of them planning to do so in the next year (81/142, 57.0%). Of those that already implemented AUC dosing programs, purchased Bayesian software (23/60, 38.3%) and homemade software (21/60, 35.0%) were the 2 methods most frequently utilized. Purchased Bayesian software users were more likely to recommend their software to other institutions and ranked user friendliness higher compared to non-purchased software. Conclusion: Most respondents have not made the switch to vancomycin AUC dosing, but there is a growing interest with many institutions looking to adopt a program within the next year.

Background Antimicrobial susceptibility testing (AST) is critical in identifying the optimal antimicrobial regimen for individual patients with serious gram-negative infections. Limitations to AST for newly developed antibiotics include the lack of commercially available AST methods, challenges of implementation due to regulations, and delays in obtaining results. The purpose of this study was to evaluate the access to AST for cefiderocol (FDC), imipenem-relebactam (IPR), meropenem-vaborbactam (MEV), and eravacycline (ERV) in hospitals across the U.S. Methods An electronic survey was distributed to the American College of Clinical Pharmacist Infectious Diseases Practice and Research Network in May 2021. Hospital baseline demographics and current practices were collected. Results Based on 50 responses, specimens were sent to in-house microbiology labs (37, 74%), core microbiology labs (8, 16%), and 3rd party reference microbiology labs (5, 10%). AST for FDC was performed by 13 (35%) in-house labs, 4 (50%) core labs, and 1 (20%) reference lab. AST for IPR was performed by 11 (30%) in-house labs, 2 (25%) core labs, and 1 (20%) reference lab. AST for MEV was performed by 25 (68%) in-house labs, 3 (37.5%) core labs, and 1 (20%) reference lab. AST for ERV was performed by 1 (20%) in-house lab, 1 (20%) core lab, and 0 reference labs. 15 (30%) respondents were not able to get AST for any of the novel agents at their respective microbiology labs. Turn-around-times (TATs) for FDC, IPR, MEV, and ERV were ≥72 hours for 33 (66%), 35 (70%), 21 (42%), and 35 (70%) hospitals, respectively. When compared with 3rd party reference labs, in-house labs with the ability to perform AST for these novel agents had significantly shorter TATs (p< 0.05). The average number of requests for AST for these novel agents was 20 times a year with an average of 113 minutes spent per patient on the coordination of AST. Conclusion Access to AST for these novel agents varied across hospitals in the U.S. Nearly 1/3 of the respondents were not able to obtain AST for these agents at all. Long TATs exist and a great deal of time is spent per patient for coordinating AST for these novel agents. There is a crucial need for a multidisciplinary, collaborative approach to resolve the challenges in obtaining AST for newly developed antibiotics to provide patient care. Disclosures All Authors: No reported disclosures

Objective To emphasize adverse outcomes associated with applying adult immunization protocols to the pediatric population. Case summary A 15-year-old female with no past medical history developed severe pain in her left arm and decreased range of motion 11 days after receiving an intramuscular injection of the human papillomavirus vaccine. Over the following month, she was treated with a short course of steroids for frozen shoulder and gabapentin for Parsonage-Turner syndrome. During the third visit to a specialist for severe pain and loss of left arm mobility, she was sent to the emergency department for further workup. An x-ray and magnetic resonance imaging of the left arm were suspicious for osteomyelitis. The diagnosis was confirmed by incision and drainage of the abscess and a bone biopsy. A 6-week course of antibiotic therapy was initiated after the biopsy results. The injury was attributed to overpenetration by the needle during the intramuscular injection she had received in the previous month. Practice implications As the number of states allowing pharmacists to vaccinate patients of all ages grows, pharmacists must be prepared to safely provide vaccinations to patients of varying sizes. Assessing body habitus while balancing the constant responsibilities of a community pharmacy will be a challenge. Introduction of a guidance document with specific needle lengths based on weight, age, and sex can address potential errors before they occur.

Objective: To provide insight into the practical implications of the use of ceftazidime/avibactam and meropenem/vaborbactam for the management of carbapenem-resistant Enterobacteriaceae (CRE) and to identify strategies for overcoming barriers to the use of these agents in clinical practice. Data sources: A literature search of PubMed was conducted using the following search terms: ceftazidime/avibactam, meropenem/vaborbactam, carbapenem-resistant Enterobacteriaceae, antimicrobial stewardship, and clinical laboratory standards institute. Abstracts from infectious diseases conferences, article bibliographies, and relevant drug monographs were also reviewed. Study selection/data extraction: Relevant English-language studies were considered. Data synthesis: Studies demonstrating the clinical utility of ceftazidime/avibactam and meropenem/vaborbactam over older agents for CRE were summarized. Laboratory challenges, including lack of widespread technology and delays in usable information, and formulary considerations were discussed. Insight was provided into overcoming these challenges and minimizing barriers using infectious diseases pharmacists, antimicrobial stewardship teams, and infection control teams. Relevance to patient care and clinical practice: This review informs clinicians of the potential difficulties of the use of ceftazidime/avibactam and meropenem/vaborbactam in clinical practice and provides tools to overcome these difficulties, thus allowing clinicians to stay at the forefront of CRE treatment. Conclusions: Clinicians treating patients with CRE infections need to be aware of challenges they may face when using ceftazidime/avibactam and meropenem/vaborbactam. Infectious disease (ID) pharmacists and antimicrobial stewardship teams play an important role in minimizing barriers and ensuring appropriate use of these antibiotics.

Background Antimicrobial stewardship (AMS) in the community is essential as majority of antibiotic prescribing occurs in the community. Pharmacists are recognized by the Center for Disease Control and Prevention (CDC) as co-leaders for leading implementation efforts to improve antibiotic use. The purpose of this study is to evaluate current AMS practices in community pharmacies across the United States (US) and identify challenges. Methods A 15-item survey was created based on CDC’s Core Elements of Outpatient AMS to assess current policies and practices in place, as well as collect baseline demographics and pharmacists’ perceptions. A survey invite was posted on the Facebook group, Pharmacist Moms, in September 2019. Participation was voluntarily and anonymous. Results Participants included 61 community pharmacists from 25 states across the US. 88.5% work in a chain pharmacy with 54.1% in staff positions and 37.7% in management. 37.7% have been practicing for > 10 years, 36.1% for 6–10 years and 26.2% 5 or less years. Minimal responses met CDC’s Core Elements of AMS: commitment (27.9%), action (24.6%), tracking and reporting (14.8%), and education and expertise (23% for pharmacists, 9.8% for patients). In regards to perception, 67.9% felt AMS is important in the community. 88.5% would participate in AMS if the opportunity were provided. 91.8% were unsure or had no plans to implement AMS within the next 2 years. Common challenges include the lack of time/staff (83.6%), pushback from prescribers (68.9%), lack of leadership (57.4%), lack of financial incentives (52.5%), pushback from patients (52.5%), lack of pharmacist knowledge/training (39.3%), lack of funding/financial support (29.5%), lack of legal requirement (21.3%), lack of information technology support (19.7%), and lack of pharmacist interest (11.5%). Current Trends of U.S. Community Pharmacies in Meeting CDC’s Core Elements of Outpatient Antimicrobial Stewardship Challenges in Implementing Antimicrobial Stewardship in Community Pharamacies Conclusion Results from this study reveal the lack of AMS practices in community pharmacies. Pharmacists have a critical role in AMS, but many challenges exist in the community setting inhibiting the full potential of pharmacists in AMS efforts. This study highlights the importance and need for addressing these issues as regulations and strategies for AMS in community settings develop. Disclosures All Authors: No reported disclosures

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Bezlotoxumab (Zinplava) to prevent the recurrence of Clostridium difficile infection

Purpose Guidelines recommend daptomycin combination therapy as an option for methicillin-resistant Staphylococcus aureus (MRSA) bacteremia after vancomycin failure. Recent data suggest that combining daptomycin with a β-lactam may have unique benefits; however, there are very limited clinical data regarding the use of ceftaroline with daptomycin. Methods All 26 cases from the 10 medical centers in which ceftaroline plus daptomycin was used for treatment of documented refractory staphylococcal bacteremia from March 2011 to November 2012 were included. In vitro (synergy studies, binding assays, cathelicidin LL-37 killing assays), and in vivo (virulence assays using a murine subcutaneous infection model) studies examining the effects of ceftaroline with daptomycin were also performed. Findings Daptomycin plus ceftaroline was used in 26 cases of staphylococcal bacteremia (20 MRSA, 2 vancomycin-intermediate S aureus , 2 methicillin-susceptible S aureus [MSSA], 2 methicillin-resistant S epidermidis ). Bacteremia persisted for a median of 10 days (range, 3–23 days) on previous antimicrobial therapy. After daptomycin plus ceftaroline was started, the median time to bacteremia clearance was 2 days (range, 1–6 days). In vitro studies showed ceftaroline synergy against MRSA and enhanced MRSA killing by cathelicidin LL-37 and neutrophils. Ceftaroline also induced daptomycin binding in MSSA and MRSA to a comparable degree as nafcillin. MRSA grown in subinhibitory concentrations of ceftaroline showed attenuated virulence in a murine subcutaneous infection model. Implications Ceftaroline plus daptomycin may be an option to hasten clearance of refractory staphylococcal bacteremia. Ceftaroline offers dual benefit via synergy with both daptomycin and sensitization to innate host defense peptide cathelicidin LL37, which could attenuate virulence of the pathogen.

Objectives Polymyxin B is an active agent against many MDR Gram-negative bacteria, but nephrotoxicity is a major hindrance to its widespread use. To guide its optimal use, we determined the risk factors for nephrotoxicity onset associated with polymyxin B. Methods In a multicentre, retrospective, cohort study, we evaluated adult patients with normal renal function who received ≥72 h of polymyxin B therapy. Pertinent information was retrieved from medical records; patients were followed for up to 30 days after therapy was started. The primary endpoint of this study was the onset of nephrotoxicity. A Cox proportional hazards model was used for analysis. Results A total of 192 patients (52.1% male, 67.7% Caucasian) were evaluated. The mean ± SD age, actual body weight (ABW) and daily dose by ABW were 68.3 ± 17.2 years, 71.5 ± 20.4 kg and 1.5 ± 0.5 mg/kg, respectively. The median duration of therapy was 9.5 days. The overall prevalence rate of nephrotoxicity was 45.8% and the median onset of nephrotoxicity was 9 days. Independent risk factors for the onset of nephrotoxicity included daily dose by ABW (HR = 1.73; P = 0.022), concurrent use of vancomycin (HR = 1.89; P = 0.005) and contrast media (HR = 1.79; P = 0.009). Nephrotoxicity was seen earlier in the high-risk group (P = 0.003). Conclusions Risk factors for nephrotoxicity onset associated with polymyxin B were identified. In conjunction with susceptibility and other pharmacokinetic/pharmacodynamic data, our results can be used to optimize treatment for MDR Gram-negative infections.

Despite concerns of nephrotoxicity, polymyxin antibiotics often remain the only susceptible agents for multidrug-resistant (MDR) Gram-negative bacteria. Colistin has been more commonly used clinically due to a perceived safety benefit. We compared the nephrotoxicity of colistin to polymyxin B. The in vitro cytotoxicity of colistin was compared to polymyxin B in two mammalian renal cell lines. To validate the clinical relevance of the findings, we evaluated adult patients with normal renal function who received a minimum of 72 h of polymyxin therapy in a multicenter study. The primary outcome was the prevalence of nephrotoxicity, as defined by the RIFLE (risk, injury, failure, loss, end-stage kidney disease) criteria. Colistin exhibited an in vitro cytotoxicity profile similar to polymyxin B. A total of 225 patients (121 receiving colistimethate, 104 receiving polymyxin B) were evaluated. Independent risk factors for colistimethate-associated nephrotoxicity included age (odds ratio [OR], 1.04; 95% confidence interval [CI], 1.00 to 1.07; P = 0.03), duration of therapy (OR 1.08; 95% CI, 1.02 to 1.15; P = 0.02), and daily dose by ideal body weight (OR 1.40; 95% CI, 1.05 to 1.88; P = 0.02). In contrast, cystic fibrosis was found to be a protective factor in patients who received colistimethate (OR, 0.03; 95% CI, 0.001 to 0.79; P = 0.04). In a matched analysis based on the risk factors identified ( n = 76), the prevalence of nephrotoxicity was higher with colistimethate than with polymyxin B (55.3% versus 21.1%; P = 0.004). Polymyxin B was not found to be more nephrotoxic than colistin and may be the preferred polymyxin for MDR infections. A prospective study comparing the two polymyxins directly is warranted.