Background: In August 2021, Saint Luke’s Health System (SLHS) transitioned Clostridioides difficile (C. diff.) testing from polymerase chain reaction (PCR)-only to two-step enzyme immunoassay (EIA) reflex following PCR+ for suspected C. diff. infection. Uncertainty in patient management may arise when PCR and EIA testing differ. Previous studies suggested that disease severity varies when a patient’s results demonstrate PCR+ and EIA- due to possible colonization. Clinicians may not treat if diarrhea self-resolves, patients remain stable, or alternate causes of diarrhea exist. We compared clinical outcomes of patients who received treatment to those who did not. Methods: This was a retrospective cross-sectional study from August 2021-August 2023 in a multi-site, integrated health system, comparing 181 inpatients with PCR+/EIA- C. diff. test results stratified by no treatment (0-48 hours of C. diff. targeted treatment), partial treatment (2-9 days), or full treatment (10+ days). The primary outcome was length of stay. Secondary outcomes were readmission rates, need for colectomy, intensive care unit (ICU) admission, and diarrhea resolution on day of discharge. Results: Of the 181 patients, 144 received full treatment, 17 had partial, and 20 had no treatment. Baseline characteristics were similar between groups. No significant difference was found for length of stay or any secondary outcomes (Table 1). Table 2 provides a subgroup of patients who received no treatment vs those receiving partial or full treatment. Conclusion: In this study, treatment exposure did not affect clinical outcomes for patients with PCR+/EIA- results, though sample sizes may limit generalizability. Further research is warranted regarding the clinical approach to PCR+/EIA-

Abstract Background Antimicrobial resistance poses a significant threat in treating bacterial infections. One such concern is the treatment of AmpC beta-lactamase producing Enterobacterales. In October 2019, Saint Luke’s Health System incorporated an automated microbiology comment advising the avoidance of third generation cephalosporins in patients with cultures positive for two bacteria which most frequently express AmpC resistance: Enterobacter cloacae and Klebsiella aerogenes. We assessed the comments effect on treatment decisions and microbiologic outcomes. Methods This is a retrospective, pre-post, cohort study in a single health system. Patients were included if they were inpatients 18 years of age or older and had urine or blood cultures positive for E. cloacae or K. aerogenes. Patients were excluded if cultures were determined to be colonizing pathogens. Pre- (May to December 2018) and post-comment (May to December 2020) cohorts were compared to assess the influence of the comment on therapy selection and subsequent development of resistance. The primary endpoint was escalation to targeted antimicrobial therapy within the first 24 hours after culture speciation. Secondary outcomes included escalation within 72 hours of culture speciation, time to escalation, length of hospital stay, and subsequent development of multi-drug resistant organism one year following admission. Results Escalation of targeted antimicrobial therapy within 24 hours of culture speciation occurred in 20 patients in the pre-implementation group and 46 patients in the post-implementation group (p< 0.001). Escalation within 72 hours occurred in 34 patients in the pre-implementation group and 57 patients in the post-implementation group (p=0.004). Median time to change in antimicrobial therapy was 23 hours in the pre-implementation group and 7 hours in the post-implementation group (p< 0.001). There was no difference between groups in development of MDR (5 vs. 5.7%, p=0.6). Conclusion Implementation of templated microbiology comments increased the rate of escalation to targeted antimicrobial therapy in hospitalized patients with blood or urine cultures positive for E. cloacae or K. aerogenes. Templated comments are an effective, minimally invasive strategy to promote antimicrobial stewardship. Disclosures All Authors: No reported disclosures

Background: The FIRST Trial is a 5-year study funded by the Agency for Healthcare Research and Quality. Our investigation is situated within a more extensive study to restrict fluoroquinolone antibiotics by requiring providers to obtain authorization from an infectious disease physician before prescribing fluoroquinolones. Our research team is performing a systematic evaluation to identify organizational characteristics and influencers of the fluoroquinolone preprescription authorization implementation process to understand variables that may facilitate or hinder implementation success. Methods: To address this critical gap, we present a qualitative analysis from our ongoing, multisite research project aimed at systematically assessing the adoption of an antimicrobial stewardship intervention in the form of an EHR-integrated best-practice alert (BPA) at each site to identify work system factors that impact uptake and variability in the implementation of the BPA at each location. The evaluation provides a detailed explanation of activities through the implementation process (eg, before implementation, during implementation, and after implementation) to assess how an organization effectively negotiates the phases and transitions, ultimately influencing the impact of the intervention. We have used a contextual determinant framework (CFIR) that has enabled us to perform a systematic and comprehensive exploration and identification of potential explanatory themes or variables to shed light on the complex social phenomenon of implementation. Results: Participants who will be a part of our poster presentation will learn about implementing a BPA, the potential barriers to implementation, and strategies for overcoming these barriers. Stakeholders within our study include site coordinators, medical doctors, nurses, pharmacists, and clinical informaticists. Our analysis synthesizes their experiences implementing and sustaining this evidence-based antimicrobial stewardship intervention. It includes (1) a detailed description of the process of change, (2) work-system factors (eg, inner setting and outer setting) that they believe influenced the success of the intervention, (3) barriers and facilitators (eg, CFIR constructs) within the implementation process; and (4) description of how these could have influenced the outcomes of interest (eg, implementation and intervention effectiveness). Conclusions: Our research is expected to advance patient safety research and initiatives by providing a more robust approach to performing systematic intervention evaluations. By outlining stakeholders’ experiences within our study, implementation leaders within healthcare systems will utilize our findings to aid them in their design and implementation process when designing and implementing similar types of healthcare interventions. Disclosures: None

This study assessed outcomes prior to and after electronic medical record-based clinical decision support implementation combined with prospective audit in patients with COVID-19. This multimodal stewardship intervention was associated with a decrease in antibiotic exposure for patients with COVID-19 (44.4% vs 61.8%, p = 0.002) within the first 7 days of hospitalization.

Abstract Background Clostridioides difficile can colonize or cause symptomatic disease from mild diarrhea to severe colonic inflammation requiring surgical intervention. Multiple C. difficile diagnostics are available and national guidelines recommend standalone or combination testing methods. Testing has mostly shifted to polymerase chain reaction (PCR)-based, which has shown up to a 50% increase in reporting of C. difficile infection (CDI). A two-step testing method has also been used to discern colonization versus active infection. The National Healthcare Safety Network has proposed changes to CDI reporting to include results and treatment, emphasizing the importance of diagnostic and antimicrobial stewardship. Methods In 2021 Saint Luke’s Health System moved from C. difficile PCR standalone to two-step testing with PCR and enzyme immunoassay (EIA) toxin test. If PCR is positive, an EIA is run. Both results are reported including interpretation guidance. A retrospective cohort study was conducted to evaluate if two-step testing impacts antibiotic prescribing rates for C. difficile. The pre-implementation group included PCR-only and post- implementation was split into PCR +/ EIA - and PCR +/ EIA + groups. Results Treatment rates for C. difficile did not significantly change after implementation of two-step testing (100% pre- vs 92% PCR +/ EIA - and 97% PCR +/ EIA +, p = 0.093). For PCR +/ EIA - results, treatment initiation more often occurred prior to results being available compared to the post-implementation PCR +/ EIA + group and pre-implementation group (30.3% PCR +/ EIA - vs 19.6% PCR +/ EIA + and 7.8% pre-implementation, (p = 0.028)). C. difficile antibiotic prescribing rates at discharge were no different between groups as the highest rates of treatment continuation were seen in the PCR +/ EIA - group (79.4% PCR +/ EIA - 72.5% pre-implementation vs 71.7% PCR+/ EIA +, p = 0.706). Conclusion Despite PCR +/ EIA - results, clinicians tended to treat patients irrespective of PCR-only or two-step results. The impact of two-step C. difficile testing on treatment rates was limited and prescribing rates did not significantly change. The findings of this study warrant investigation into alternative solutions to promote aligned diagnostic and antimicrobial stewardship. Disclosures All Authors: No reported disclosures

Abstract Objective: To evaluate the effect of templated microbiology reporting comments on antifungal utilization in patients with candiduria. Design: In this retrospective, quasi-experimental study, we evaluated a preimplementation cohort (June 2018–January 2019) compared with a postimplementation cohort (June 2019–January 2020). Setting: A multisite health system including 1 academic hospital and 4 community hospitals. Patients: Patients were aged ≥18 years, were hospitalized, and had candiduria documented at least once during their admission. The study included 156 patients in the preimplementation period and 141 patients in the postimplementation period. Methods: In June 2019, Saint Luke’s Health System implemented the use of templated comments for urine cultures with Candida spp growth. When Candida is isolated, the following comment appears in the microbiology result section: “In the absence of symptoms, Candida is generally considered normal flora. No therapy indicated unless high risk (pregnant, neonate, or neutropenic) or undergoing urologic procedure. If Foley catheter present, remove or replace when able.” The primary outcome was rate of antifungal prescribing. Results: Antifungal administration within 72 hours of a culture identifying a Candida spp occurred in 75 patients in the preimplementation group and 48 patients in the postimplementation group (48.1% vs 34.0%; P = .02). We did not detect a difference between groups in antifungal administration between 73 and 240 hours (1.3% vs 3.5%; P = .26), nor did we detect a difference in median antifungal duration (4 vs 3 days; P = .43). Conclusion: Using a templated comment with urine cultures reduced antifungal prescription rates in hospitalized patients with candiduria. This strategy is a low-resource technique to improve antimicrobial stewardship.

Abstract Background Infectious diarrhea is a common cause of emergency department (ED) visits and hospital admissions. Polymerase chain reaction (PCR) testing allows for quick and expansive pathogen identification and facilitates earlier targeted treatment. We implemented a multiplex gastrointestinal (GI) PCR panel in 2014. In collaboration with the Antimicrobial and Diagnostic Advisement Program (ADAP), post-launch optimization strategies have changed test use. We evaluate the impact of diagnostic stewardship initiatives. Methods GI PCR testing was initially unrestricted for ED or inpatients within 72 hours of admission. After fielding many questions regarding interpretation, the ADAP developed a guidance document in June 2019 regarding treatment considerations for all potential organisms detected. In January 2020, organism-specific treatment considerations were embedded in the test results real-time treatment guidance (figure 1). A pre-post quality improvement assessment of the changes was performed. In August 2021, individual GI PCR panel orders were replaced with an order set containing a decision tree to provide passive guidance evaluating acute vs chronic diarrhea, assessing recent antibiotic use (to consider C. difficile testing), no testing scenarios, and avoiding repeat testing (figure 2). Figure 1Example of templated comments for Norovirus embedded within GI PCR panel results. Figure 2 GI PCR panel order set Results GI PCR panel use peaked in 2019 with 3,142 tests processed. The guidance document was less helpful, requiring an external site link. Embedding organism-specific GI PCR guidance significantly improved appropriate antibiotic prescribing (77.9 vs 89.1%, p=0.001). A precipitous drop off in GI PCR test orders occurred after the COVID-19 pandemic began (1,774 in 2020), partly attributed to supply chain issues. When comparing intra-pandemic years (2020 vs 2021), implementation of a smart order set was associated with a 51.3% reduction in orders (1,774 vs 864) and $131,000 in savings despite significant patient volume increases in 2021. Low use rates have persisted into the first quarter of 2022 (n=229). Conclusion Diagnostic stewardship changes should be proactive and contextually relevant at the time of result interpretation. Antimicrobial stewardship programs are uniquely positioned to lead optimization initiatives and drive clinical and cost-effective solutions. Disclosures All Authors: No reported disclosures.

Antibiotic use is often the target of interventions in health care organizations that aim to decrease healthcare-associated infections (HAI) such as Clostridioides difficile (CDI); this is particularly important for fluoroquinolones (FQ), which are frequently used in critical care settings. In this study, using a multiple case study research approach, we conduct an in-depth analysis of an intervention aimed at limiting ICU prescriber access to FQ in two ICUs of two hospitals. The data collection and analysis were guided by a human factors engineering approach based on the SEIPS (Systems Engineering Initiative for Patient Safety) model and evidence-based implementation principles. Our results show some differences in the implementation of the FQ intervention between the two ICUs, such as level and method of FQ restriction, and training and communication with physicians and pharmacists. In both ICUs, several organizational learning mechanisms helped to quickly identify problems with the intervention and ensure that changes were made in a just-in-time manner (e.g. just-in-time training, removal of FQ in order set for pneumonia). Despite their organizational differences, both sites developed strategies to successfully implement the FQ intervention.

Background. Respiratory tract infections are often viral and but are frequently treated with antibiotics, providing a significant opportunity for antibiotic de-escalation in patients. We sought to determine whether an automated electronic medical record best practice alert (BPA) based on procalcitonin and respiratory polymerase chain reaction (PCR) results could help reduce inappropriate antibiotic use in patients with likely viral respiratory illness. Methods. This multisite, pre-post, quasi-experimental study included patients 18 years and older with a procalcitonin level <0.25 ng/mL and a virus identified on respiratory PCR within 48 hours of each other, and 1 or more systemic antibiotics ordered. In the study group, a BPA alerted providers of the diagnostic results suggesting viral infection and prompted them to reassess the need for antibiotics. The primary outcome measured was total antibiotic-days of therapy. Results. The BPA reduced inpatient antibiotic-days of therapy by a mean of 2.2 days compared with patients who met criteria but did not have the alert fire (8.0 vs 5.8 days, respectively, P < .001). The BPA also reduced the percentage of patients prescribed antibiotics on discharge (20% vs 47.8%, P < .001), whereas there was no difference in need for antibiotic escalation after initial discontinuation (7.6% vs 4.3%, P = .198). Conclusions. The automated antimicrobial stewardship BPA effectively reduced antibiotic use and discharge prescribing rates when diagnostics suggested viral respiratory tract infection, without a higher rate for reinitiation of antibiotics after discontinuation.

BackgroundReported beta-lactam (BL) antibiotic allergies lead to the avoidance of BL antibiotics. Despite that less than 10% of patients reporting have a true allergy, the documentation often leads to an increased use of alternative antibiotics. These nonpreferred antibiotics (NPA) have a significant impact on cost, clinical outcomes, and antimicrobial resistance. ObjectiveThe primary objective of this study was to assess the impact of a pharmacy-driven assessment on the prescribing frequency of penicillin or cephalosporin antibiotics in patients with a reported BL allergy. MethodsThis retrospective cohort analysis evaluated the effect of a best practice alert (BPA) and subsequent allergy assessment on BL use in patients with reported allergies at an integrated health system. The BPA notified pharmacy staff that a patient with a documented BL allergy was receiving a NPA. Pharmacy staff assessed previous BL tolerance and clarified reaction, severity, and timing of the documented allergy. Patients were identified for analysis if they had a documented BL allergy within the electronic medical record and received at least one antibiotic during the study period. ResultsA total of 418 patients were included in this analysis (180 preimplementation, 238 postimplementation). In the pharmacy-driven assessment group, BL antibiotic use increased by 12.9% (P = .008) in patients with a previously documented BL allergy with the largest use increase in 3rd/4th generation cephalosporins (P = .045). Days of therapy for NPAs decreased in the postimplementation group, including aztreonam (P = .006) and vancomycin (P = .009). ConclusionsOur data suggests that a pharmacy-driven allergy assessment using a BPA can increase appropriate use of BL antibiotics for hospitalized patients.

Objective. This study aimed to determine if integrating antimicrobial stewardship program (ASP) personnel with rapid diagnostic testing resulted in improved outcomes for patients with positive blood cultures. Method. Beginning in 2016, Saint Luke's Health System (SLHS) implemented a new process where all positive blood cultures were communicated to ASP personnel or SLHS pharmacy staff. Pharmacists then became responsible for interpreting results, assessing patient specific information, and subsequently relaying culture and treatment information to providers. This was a multisite, pre-post, quasi-experimental study (Pre: August to December 2014; Post: August to December 2016). Patients 18 years of age and older with a positive blood culture during admission were included (2014, n = 218; 2016, n = 286). Coprimary outcomes of time to optimal and appropriate therapy were determined from time of culture positivity via gram stain. Secondary outcomes focused on clinical, process, and fiscal endpoints. A pre-post intervention physician survey was conducted to assess the impact on antimicrobial decision making and perceived effect on patient outcomes. Results. There was no difference in time to appropriate therapy groups (P = .079). Time to optimal therapy was 9.2 hours shorter in 2016 (P = .004). Provider surveys indicated the process improved communication among clinicians and facilitated a shared decision-making process with a perceived improvement in patient care. Conclusions. An ASP-led blood culture communication process for patients with positive blood cultures was shown to improve time to optimal therapy, support physicians in their decision making on critical lab data, and improve the care for hospitalized patients.

Antimicrobial resistance is recognized as a global health crisis.1 In the United States alone, more than 2 million patients contract antibiotic-resistant infections that result in 23,000 deaths annually.2 One factor contributing to antimicrobial resistance is antimicrobial misuse or overuse. Most recent estimates suggest that 30–50% of antibiotic use in hospitalized patients is inappropriate.3 Typically, assessment of clinical antimicrobial appropriateness focuses on humans; however, misuse in food-producing animals is common.4 Combined, these forms of antimicrobial overuse have fueled the current ecological state of resistance. The concerning antimicrobial resistance trend has forced hospitals and health systems to work toward combating the issue. Responsibility for implementing a systematic approach to ensuring appropriate antimicrobial therapy is commonly assigned to an antimicrobial stewardship program (ASP). Many hospitals have developed ASPs informally; however, due to evolving regulatory interest, many hospitals and health systems are in the process of formalizing their ASP. In 2007, the Infectious Diseases Society of America (IDSA) and the Society for Healthcare Epidemiology of America (SHEA) published joint guidelines that provided recommendations for essential components and practices of an ASP.5 Those guidelines were updated in 2016 to reflect current ASP concepts and goals.6 The Centers for Disease Control and Prevention (CDC) provides a checklist of core elements required for effective ASPs.7,8 Recently, the Joint Commission published standards for antimicrobial stewardship.9 The Centers for Medicare and Medicaid Services (CMS) is developing similar standards as requirements for participation.10 Hospitals need to formalilze ASPs to meet these requirements; therefore, standardized and validated metrics to determine if these programs are effective are needed. Unfortunately, there is no standard metric for evaluating an ASP. This article reviews recent advances in antimicrobial stewardship metrics in the inpatient setting.

Background: Fecal Microbiota Transplantation (FMT) is a highly effective therapy for recurrent C. difficile infection (CDI), with ~15% one-year recurrence rate.Small studies with different patient populations have identified risk factors associated with FMT failure.We, therefore, performed a systematic review and meta-analysis to evaluate the predictors of FMT failure.Methods: A systematic search of Medline, Embase, and Web of Science was performed from January 2013 up to November 2017.All studies that assessed risk factors associated with FMT failure in a multivariate model were eligible for inclusion.Data on clinical characteristics and risk factors associated with FMT failure were collected.Study quality was assessed using the Newcastle-Ottawa scale.Meta-analyses were performed using random effects models and pooled odds ratios for risk factors reported in $ 2 studies were calculated.Results: Overall, 8 studies, including 1981 patients with recurrent/severe CDI who underwent FMT, were identified.FMT failure occurred in 322 patients (16.2%) with follow up ranging from 2 to 34.9 months.A total of 17 different risk factors were studied, of which 9 were identified in $ 2 studies.Meta-analysis showed that use of non-CDI antibiotics (Odds ratio [OR] 4.58, 95% confidence interval [CI] 1.8-11.4),presence of Inflammatory bowel disease (OR 4.88, 95% CI 2.1-10.9),poor quality of bowel preparation (OR 4.7, 95% CI 1.9-11.5),CDI related hospitalization before FMT (OR 1.42, 95% CI 1.1-1.7)and inpatient FMT (OR 4.7, 95% CI 2.3-9.8)were associated with statistically significant increased risk of failure after FMT.Increasing age, female gender, severe CDI and immunocompromised status were not associated with increased risk for FMT failure.Conclusions: Several risk factors (both modifiable and non-modifiable) are associated with FMT failure.Minimal use of antibiotics in the post-FMT period and good bowel preparation at the time of FMT are associated with lower risk of failure after FMT.Additionally, patients with nonmodifiable risk factors should be counselled to be particularly alert about recurrent symptoms after FMT.

Although antimicrobials are commonly used in children, it is important to remember that they can have a profound impact on this unique patient population. Inadvertent consequences of antiinfective use in children include antimicrobial resistance, infection caused by Clostridium difficile, increased risk of obesity, and adverse drug events. In addition, compared with adults, children have different dosing requirements, antimicrobial formulation needs, pharmacokinetics, and antimicrobial susceptibility profiles. Therefore, pediatric-specific antimicrobial stewardship efforts are needed to promote appropriate use of antimicrobials in children. The primary purposes of this review article are to provide a rationale behind pediatric-focused antimicrobial stewardship and to describe currently available evidence regarding the initiatives of pediatric antimicrobial stewardship programs (ASPs). A literature search of the Medline database was performed (from inception through March 2015). The studies included in this review focus on antimicrobial stewardship interventions in inpatient pediatric settings. Ten inpatient studies involving pediatric-focused antimicrobial stewardship interventions were identified from the published literature. Four studies used the core strategy of prospective audit with feedback; two used prior approval. The remaining four used supplemental antimicrobial stewardship strategies (guidelines, clinical pathways, and computerized decision support tools). In general, the interventions resulted in decreased antimicrobial use, reduced antimicrobial costs, and fewer prescribing errors. Children have unique medical needs related to antimicrobials and deserve focused ASP efforts. The literature regarding pediatric antimicrobial stewardship interventions is limited, but published interventions may serve as paradigms for developing pediatric ASPs as demonstrated by the general success of these interventions.