Background:Staphylococcus aureus bacteraemia confers significant morbidity and mortality. A multi-disciplinary team was created to optimize bacteraemia management. Methods:The intervention included integration of rapid diagnostic blood culture processing and a multi-disciplinary approach to real-time management of results. This was a retrospective, pre-post study to compare outcomes in the standard of care (SOC, n = 50) and intervention (n = 100) groups of patients with community-onset S. aureus bacteraemia. Patients were excluded for death before Gram stain result, leaving against medical advice, polymicrobial bacteraemia or withdrawal of life sustaining treatments during hospitalization. The primary outcome was 30-day all-cause mortality. Secondary outcomes were in-hospital, 6 month and 1 year mortality as well as S. aureus-related readmission and time to effective antibiotic therapy. Results:54% of the SOC group and 46% of the intervention group had methicillin-resistant S. aureus infections. The primary outcome, 30-day mortality, was 3% in the intervention group compared to 20% in the SOC group (P = 0.004). There was no difference in in-hospital mortality (P = 0.08) but lower mortality in the intervention group at 30 days (P = 0.003), 6 months (P = 0.005) and 1 year (P < 0.001). S. aureus-related readmission was significantly lower at 31 days-6 months after discharge in the intervention group. Median time to effective antibiotic therapy was 13 h versus 6.3 h in the SOC and intervention groups, respectively. Conclusions:The integration of real-time rapid diagnostic blood culture technology tied to immediate clinical actions was associated with improved time to effective therapy and mortality in patients with community-onset S. aureus bacteraemia.

IntroductionRapid diagnostic technology can improve patient outcomes, particularly when combined with Antimicrobial Stewardship Program (ASP) intervention. Bacteremic patients due to drug-resistant organisms are most likely to benefit from rapid diagnostic technologies as they are more likely to be prescribed inadequate empiric therapy. The purpose of this study was to analyze the impact of a pharmacy-driven Rapid Bacteremia Response Program (RBRP) on the process and clinical outcomes of patients with bacteremia due to an extended-spectrum beta-lactamase (ESBL)-producing organism.MethodsA retrospective, quasi-experimental study was conducted at a large healthcare system. The RBRP was implemented in 2017 to expedite antimicrobial therapy for bacteremia based on Gram stain and Verigene (R) system (Luminex Corp, Austin, TX, USA) results. Adults hospitalized with ESBL bacteremia were evaluated pre-intervention and post-intervention (utilizing the RBRP). The primary outcome was time to active therapy. Secondary outcomes included in-hospital and 30-day mortality, length of hospital and intensive care unit (ICU) stay, and factors associated with mortality.ResultsA total of 200 patients were included: 100 patients in the pre-intervention and 100 patients in the post-intervention group. The post-intervention group resulted in 6.4 h faster time to active therapy from blood culture collection (median 22.8 h pre-intervention vs. 16.4 h post-intervention, p = 0.001). No statistical difference was identified for the length of hospital or ICU stay and in-hospital or 30-day mortality between groups. Multivariable analysis identified age, male sex, quick Pitt bacteremia score, and hospital-acquired infection to be significantly associated with 30-day mortality.ConclusionThe pharmacy-driven RBRP resulted in decreased time to active therapy for patients with ESBL bacteremia.

Antimicrobial stewardship (AMS) is an important tool in the fight against antimicrobial resistance. However, many areas of the world suffer from lack of access to healthcare professionals with AMS training. The Kentucky Antimicrobial Stewardship Innovation Consortium (KASIC) was created to address such inequities in Kentucky, USA. Regional AMS centres of excellence such as KASIC are an effective strategy to improve AMS efforts. Global accreditation of regional AMS centres of excellence may potentiate AMS internationally.

Objective:To describe the screening practice of nasal methicillin-resistant Staphylococcus aureus (MRSA) polymerase chain reaction (PCR) among nine health organizations in Kentucky. Methods:The Kentucky Antimicrobial Stewardship Innovation Consortium (KASIC) invited its Advisory Board members to share their nasal MRSA PCR protocols and guidelines. The documents were examined to highlight institutional similarities and differences. Results:Nine health systems, including both community hospitals and academic medical centers, responded to the KASIC request. Most systems with nasal MRSA PCR testing capacity had established protocols or guidelines to support its appropriate use. All institutions recommended nasal MRSA PCR for pneumonia indications while three organizations also used it for non-pneumonia indications. None of these institutions permitted pharmacists to discontinue anti-MRSA antibiotics per protocol. Conclusions:This study provides the first statewide overview of nasal MRSA PCR screening practices, offering stewardship programs a framework to customize their own protocols and guidelines.

OBJECTIVE:To compare rates of Clostridioides difficile infection (CDI) recurrence following initial occurrence treated with tapered enteral vancomycin compared to standard vancomycin. DESIGN:Retrospective cohort study. SETTING:Community health system. PATIENTS:Adults ≥18 years of age hospitalized with positive C. difficile polymerase chain reaction or toxin enzyme immunoassay who were prescribed either standard 10-14 days of enteral vancomycin four times daily or a 12-week tapered vancomycin regimen. METHODS:Retrospective propensity score pair matched cohort study. Groups were matched based on age < or ≥ 65 years and receipt of non-C. difficile antibiotics during hospitalization or within 6 months post-discharge. Recurrence rates were analyzed via logistic regression conditioned on matched pairs and reported as conditional odds ratios. The primary outcome was recurrence rates compared between standard vancomycin versus tapered vancomycin for treatment of initial CDI. RESULTS:The CDI recurrence rate at 6 months was 5.3% (4/75) in the taper cohort versus 28% (21/75) in the standard vancomycin cohort. The median time to CDI recurrence was 115 days versus 20 days in the taper and standard vancomycin cohorts, respectively. When adjusted for matching, patients in the taper arm were less likely to experience CDI recurrence at 6 months when compared to standard vancomycin (cOR = 0.19, 95% CI 0.07-0.56, p < 0.002). CONCLUSIONS:Larger prospective trials are needed to elucidate the clinical utility of tapered oral vancomycin as a treatment option to achieve sustained clinical cure in first occurrences of CDI.

Purpose This report describes a comprehensive pharmacy-driven rapid bacteremia response program.Summary This novel program positioned the pharmacy department at a large, community health system to receive and respond to critical microbiologic diagnostic testing results, 24/7/365. The program empowered pharmacists to provide centralized, comprehensive care including assessing blood culture Gram stain results, adjusting antibiotic therapy per protocol, ordering repeat blood cultures, analyzing and interpreting rapid molecular diagnostic test results, placing orders for contact isolation, and communicating antibiotic recommendations to the treatment team. In the first year after program implementation, 2,282 blood culture Gram stains and 2,046 rapid diagnostic test results were called in to the pharmacy department. The program reduced the median time to effective therapy in patients who did not already have active antimicrobial orders from over 10 hours to less than 1 hour. Based on the Gram stain results, antibiotics were started per protocol in 34.2% of patients. Based on the rapid molecular diagnostic test results, adjustments were made to antibiotic regimens in 55.7% of cases after discussion with a provider. Of these adjustments, 39.9% were for escalation of antibiotics and 37.7% were for de-escalation of antibiotics.Conclusion By expanding the scope of pharmacy practice, barriers to optimizing clinical care were overcome.

Introduction Viruses are a frequent cause of community-acquired pneumonia (CAP). Even after a viral pathogen has been identified, clinicians still must consider the possibility of bacterial co-infection and determine if antibiotic therapy is needed. This question, whether bacterial co-infection is present, becomes critical when considering optimal therapeutic management for patients with viral CAP. Methods A review was conducted of the epidemiology of viral CAP, reported rates of bacterial co-infections, antibiotic prescribing, and diagnostic and clinical methods for assessing risk of bacterial co-infection. Results Reported co-infection rates are variable, but evidence suggests bacterial co-infections are not documented in the majority of cases of viral CAP. Conclusions Practical research is needed to determine when antibiotics can be withheld or discontinued in patients with viral CAP in order to prevent harm associated with unnecessary antibiotic use.

Antimicrobial resistance is a significant threat to modern healthcare and is driven by antimicrobial overuse. Hospital antimicrobial use in Kentucky exceeds national rates and long-term care facility antimicrobial stewardship implementation is low. Partnering with the Kentucky Department for Public Health, the Kentucky Antimicrobial Stewardship Innovation Consortium (KASIC) was created to facilitate antimicrobial stewardship across the Commonwealth of Kentucky. This manuscript describes KASIC objectives, defines the KASIC target audience, and describes KASIC methods

Abstract Background Clostridioides difficile infection (CDI) recurrence rates may be reduced with fidaxomicin, but financial barriers can limit access. Tapered and/or pulsed oral vancomycin is recommended in patients with recurrent CDI, however there is currently limited data for use in treating initial CDI. Methods Multicenter retrospective propensity-matched cohort study in patients ≥ 18 years old hospitalized with a first occurrence of CDI from 6/18/2018 – 12/21/2021 conducted at Norton Healthcare in Louisville, Kentucky. Standard of care (SOC) was receipt of oral vancomycin for 10-14 days compared to a standardized oral vancomycin taper (Figure 1). Subjects were matched based on age < or ≥ 65 and receipt of non-CDI antibiotics during index hospitalization or within 6 months post-discharge. Selected baseline characteristics and receipt of CDI and non-CDI antibiotics were collected. Non-CDI antibiotics were stratified by high, medium or low risk for CDI. The primary outcome was CDI recurrence within 6 months of hospital discharge. Secondary outcomes included time to recurrence, recurrence rates stratified by age group < or ≥ 65 years, CDI severity of illness per IDSA guidelines and all-cause mortality within 6 months of hospital discharge. Categorical variables were analyzed using Chi-squared and Fisher’s exact tests as appropriate. Standardized Oral Vancomycin Taper Results Recurrence rates at 6 months were 5.3% (4/75) in the taper arm and 28% (21/75) in the SOC arm (p=0.002). All-cause mortality was 20% (15/75) in the taper arm and 5.3% in the SOC arm (p=.026). Severe/fulminant CDI occurred in 49.3% of the taper arm and 58.7% of the SOC arm (p=0.53). Both groups received antibiotics at the same rate based on matching, and rates of antibiotics considered high risk for CDI were similar at 65% in the taper and SOC groups (65% vs. 61.3%, p=0.809). More patients in the taper arm were immunocompromised (25.3% vs 9.3%, p=0.029). Conclusion A significantly lower rate of CDI recurrence was observed at 6 months with tapered oral vancomycin coupled with higher all-cause mortality in patients being treated for first CDI. Additional information is needed to elucidate the clinical utility of this approach. Disclosures Ashley M. Wilde, PharmD, BCIDP, Pfizer: Grant/Research Support

Context Intravenous (IV) to oral (PO) transition of antimicrobial therapy is a common antimicrobial stewardship activity. Inpatient institutions seeking to create new IV to PO switch services or enhance existing services may benefit from a review of practices utilized at other institutions. Objective The objective of this review is to summarize IV to PO switch practices utilized by healthcare institutions with established antimicrobial stewardship programs across Kentucky. Methods The Kentucky Antimicrobial Stewardship Innovation Consortium (KASIC) invited pharmacists on the Advisory Board to share current IV to PO switch practices utilized at their institutions. The submitted documents were evaluated in a systematic approach and summarized. Results Nine of ten institutions represented by the Advisory Board submitted an IV to PO switch practice document for analysis. All institutions utilized pharmacist-driven protocols to allow automatic conversion from IV to PO for select antimicrobials based on specific patient criteria. All protocols included the following antimicrobials eligible for conversion: azithromycin, doxycycline, fluconazole, levofloxacin, linezolid, and metronidazole. Majority of protocols also had inclusion and exclusion criteria based on patient specific factors such as ability to use the enteral route, clinical stability, and infection type. There was variation in the level of restriction placed on conversion eligibility criteria among protocols. Conclusion IV to PO switch practices for antimicrobials vary across the state of Kentucky. Institutions should tailor protocols based on specific needs, clinical leadership support, and feasibility of implementation.

The southern United States, including the Commonwealth of Kentucky has higher rates of antimicrobial use relative to the rest of the country. Antimicrobial stewardship experts discuss the state of antimicrobial use and explore stewardship issues and opportunities based on their practice experiences.

Purpose To describe the Norton Healthcare electronic antimicrobial stewardship program (E-ASP), a novel prospective audit and feedback approach that leverages the electronic medical record to overcome efficiency barriers. Additionally, to describe an accompanying opt-out antimicrobial stewardship approach that addresses provider nonresponsiveness. Summary Prospective audit and feedback is recommended by antimicrobial stewardship guidelines; however, execution can be difficult due to labor requirements, delays in communication, and provider nonparticipation. The Norton E-ASP was developed to address these issues by reliably identifying target patients, documenting assessments, streamlining recommendation delivery, promoting handoff, and providing automated tracking of recommendation responses. Opt-out stewardship allows recommendations to be implemented if not rejected after 24 hours. Conclusion A 25% reduction in target antimicrobial use has been achieved and sustained with the program. Use of the Norton E-ASP, including opt-out antimicrobial stewardship, broadened the reach and furthered the impact of infectious diseases pharmacists. Successes of this program justified addition of 3 full-time infectious diseases pharmacist positions at a large community health system. This strategy may serve as a model for tele-antimicrobial stewardship or other pharmacy recommendations.

Hospitalized coronavirus disease 2019 (COVID-19) patients receiving antibiotics (n = 173) were retrospectively assigned to the early or late discontinuation groups. The length of therapy was shorter in the early discontinuation group (3 vs 7 days; P < .0001). Mortality rates (14.3% vs 20.7%; P = .316) and length of stay (7 vs 9 days; P = .063) were similar.

Objective: To describe inpatient fluoroquinolone use and susceptibility data over a 10-year period after the implementation of an antimicrobial stewardship program (ASP) led by an infectious diseases pharmacist starting in 2011. Design: Retrospective surveillance study. Setting: Large community health system. Methods: Fluoroquinolone use was quantified by days of therapy (DOT) per 1,000 patient days (PD) and reported quarterly. Use data are reported for inpatients from 2016 to 2020. Levofloxacin susceptibility is reported for Pseudomonas aeruginosa and Escherichia coli for inpatients from 2011 to 2020 at a 4 adult-hospital health system. Results: Inpatient fluoroquinolone use decreased by 74% over a 5-year period, with an average decrease of 3.45 DOT per 1,000 PD per quarter (P < .001). Over a 10-year period, inpatient levofloxacin susceptibility increased by 57% for P. aeruginosa and by 15% for E. coli. P. aeruginosa susceptibility to levofloxacin increased by an average of 2.73% per year (P < .001) and had a strong negative correlation with fluoroquinolone use, r = -0.99 (P = .002). E. coli susceptibility to levofloxacin increased by an average of 1.33% per year (P < .001) and had a strong negative correlation with fluoroquinolone use, r = -0.95 (P = .015). Conclusions: A substantial decrease in fluoroquinolone use and increase in P. aeruginosa and E. coli levofloxacin susceptibility was observed after implementation of an antimicrobial stewardship program. These results demonstrate the value of stewardship services and highlight the effectiveness of an infectious diseases pharmacist led antimicrobial stewardship program.

Abstract Background Retrospective studies demonstrate similar efficacy between oral (PO) and intravenous (IV) antibiotics at discharge for gram negative bacteremia (GNB), with reduced duration of hospitalization, hospital costs, and duration of therapy with PO. Understanding current physician discharge practices can help guide future antimicrobial stewardship initiatives. Methods A multicenter, retrospective cohort study was conducted on adult inpatients admitted between July 1, 2020 and June 30, 2021 with urinary source GNB. Patients with both blood and urine cultures positive for Escherichia coli, Klebsiella species, or Proteus mirabilis and a PO antibiotic available at discharge were included. The primary outcome was the percentage of patients discharged on PO antibiotics. Secondary outcomes included duration of hospitalization, total length of therapy, and 30-day readmission secondary to clinical failure or therapeutic complication in the IV and PO at discharge groups. Results Of the 157 included patients, 128 (82%) were discharged on PO antibiotics. Patients discharged on IV and PO had similar median quick Pitt bacteremia scores [1(IQR, 0 – 2) vs. 1 (IQR, 0 – 1), p=0.420]. Mean duration of hospitalization for patients discharged on IV vs. PO therapy was 5 (SD, 2.91) days vs. 4 (SD, 2.75) days, p=0.001, respectively. Mean total length of antibiotic therapy was 21.6 (SD, 13.80) days as compared to 13.5 (SD, 4.94) days, p=0.017, for the IV vs. PO arms, respectively. Thirty–day readmission rates were 11/29 (38%) and 23/128 (18%), p=0.035, in the IV and PO arms, respectively. Notably, 21/29 (72%) of the IV arm had an organism from blood culture that was susceptible to trimethoprim-sulfamethoxazole (TMP-SMX). Conclusion Most patients with urinary source GNB were discharged on PO antibiotics. Patients discharged on IV antibiotics were more likely to be readmitted within 30 days. Future efforts to decrease IV antibiotic use may focus on increasing TMP-SMX use at discharge. Disclosures Matthew Song, PharmD, BCIDP, Merck: Stocks/Bonds|ObsEva: Stocks/Bonds.

Introduction: Hospital-based antimicrobial stewardship efforts have traditionally focused on inpatient settings. Antibiotic prescribing at discharge is often an overlooked area of focus for antimicrobial stewardship programs. Discharge prescribing optimization is necessary to combat antibiotic overuse. Methods: This was an observational, retrospective cohort study at a four–adult community hospital system. Four hundred adult patients admitted with community-acquired pneumonia and discharged with antibiotics were included. The primary outcome was overall (inpatient and discharge) antibiotic length of therapy. The secondary outcome was percentage of patients discharged on a fluoroquinolone who had not received one in the hospital. Descriptive statistics were utilized. Results: The median total antibiotic length of therapy was 9.5 days (IQR 8, 11). The median inpatient and discharge antibiotic lengths of therapy were 4 days (IQR 3, 5) and 5 days (IQR 5, 7), respectively. Of the 108 patients prescribed a fluoroquinolone at discharge, 43% (46/108) had not previously received a fluoroquinolone while hospitalized. Conclusion: Both length of therapy and fluoroquinolone stewardship at discharge may represent possible antimicrobial stewardship targets in community-acquired pneumonia patients.

Background Adult vaccination programs are suboptimal. Methods Pneumococcal vaccination history, and healthcare contact were assessed in patients with invasive pneumococcal disease. Results Of the 229 cases, 14% were vaccinated. Observed mortality was 20.1%. Conclusions Numerous missed vaccination opportunities were identified.

Abstract Background Education on antimicrobial stewardship (AMS) is one of the several elements outlined by the Center for Disease Control for hospital antibiotic stewardship programs. However, the Infectious Diseases Society of America guideline on implementing antimicrobial stewardship notes that passive education should not be a sole method for training as the effects are often short lived. AMS education strategies beyond didactic lectures and written material distribution are needed. We sought to describe the implementation of an interactive, case-based AMS educational program targeting pharmacists across a multi-hospital community health system licensed for over 1,500 beds. Methods Each month, a custom patient case was drafted by an infectious diseases trained pharmacist to highlight a common AMS principle encountered in practice. These topics were broadly categorized into appropriate empiric antibiotic selection, treatment plan modification, and identification of non-infectious clinical syndromes. A specific question with multiple choice answers was drafted. The case was disseminated to all hospital pharmacists via email using Microsoft Outlook. Pharmacists were prompted to use the voting buttons to select the correct answer (Figure 1). After a week, results of the survey was shared with the entire pharmacist staff along with information on the primary teaching point and detailed explanations for why each answer was correct or incorrect. Example Voting Buttons for Case-Based Education Results A total of eleven AMS cases were disseminated to 88 hospital pharmacists involved with direct patient care. Average number of responses per case was 27 (31%), range 17-41 (19%-47%). Average number of correct responses for each case was 74%, range 26%-100%. The highest rates of correct responses came from cases focusing on empiric antibiotic selection (87%), followed by identification of non-infectious clinical syndromes (73%). The lowest rate of correct responses were found with treatment plan modification cases (65%). Conclusion This case-based AMS education program leveraged existing technology to provide engagement across a large and geographically diverse pharmacist staff, provide opportunity to apply stewardship concepts, and assess staff pharmacist knowledge on general AMS principles. Disclosures Matthew Song, PharmD, BCIDP, Merck: Stocks/Bonds|ObsEva: Stocks/Bonds.

In this study, we evaluated the impact of a microbiology nudge on de-escalation to first-generation cephalosporins in hospitalized patients with urinary tract infections secondary to Escherichia coli, Klebsiella pneumoniae, and Proteus mirabilis isolates with minimum inhibitory concentrations (MICs) ≤ 16 µg/mL. De-escalation to first generation-cephalosporins was uncommon at MICs = 4-16 µg/mL.

Rapid diagnostic technologies are revolutionizing the clinical microbiology laboratory. Next generation sequencing (NGS) is poised to be the next powerful tool in standard clinical laboratories building on the widespread adoption of multiplex polymerase chain reaction (PCR) panels and matrix-assisted laser desorption/ionization-time of flight (MALDITOF) technology.[1] NGS can provide a quantitative analysis of all non-human DNA or RNA in a sample without requiring growth on a traditional medium. This improves the diagnostic yield of infections that are difficult to culture due to biofilm production, such as prosthetic joint infections.[2] As these technologies become faster and cheaper, research efforts are urgently needed to guide clinicians to wider applications of NGS, including use in non-sterile sites, such as lower and upper respiratory tract samples. The diagnostic utility of NGS of respiratory samples has already been noted in cases of pneumonia caused by pathogens that are difficult to identify through conventional testing.[3, 4] However, the use of NGS as a diagnostic tool in community-acquired pneumonia (CAP) remains to be elucidated. The characterization of the respiratory microbiome in clinical practice may improve the diagnosis and therefore the treatment of CAP. However, without adequate research, using NGS in patients with suspected CAP may unnecessarily accelerate antimicrobial prescribing simply by providing the names of all commensal organisms present in a respiratory sample.