900. Evaluation of automated blood culture results and subsequent pharmacist intervention on time to targeted therapy in patients with bacteremia

Background

Bloodstream infections (BSIs) are associated with a high mortality rate and timely administration of empiric broad-spectrum antibiotics is critical. However, prolonged exposure increases the risk of colonization and subsequent infection with resistant bacteria. The use of rapid diagnostics and prospective audit and feedback allows for decreased time to targeted therapy and development of resistance.

Methods

This quasi-experimental study aimed to evaluate changes in time to targeted antibiotic therapy before and after implementation of a real-time pharmacist notification for bacteremic patients. The pre- and post- intervention periods were 9/1/19–12/31/19 and 9/1/21– 12/31/21, respectively. Bacteremic patients that were identified via automated Bruker’s MBT Sepsityper IVD kit reports and admitted for ≥48 hours were included in the study. Patients were excluded if they had ≥ 1 BSI or polymicrobial BSI during hospitalization, treatment of a concurrent infection, or transitioned to hospice. The primary outcome was change in time to targeted antibiotic therapy. Secondary outcomes included change in broad-spectrum antibiotic days of therapy, total duration therapy, hospital length of stay, and in-hospital all-cause mortality.

Results

A total of 132 charts were reviewed, 83 of which were included, with 47 in the pre- and 36 in the post-intervention group. The most common isolates in the study across both groups was E. coli (36.1%), Klebsiella spp. (15.7%), MSSA (15.7%) and MRSA (8.4%). A trend towards decreased time to targeted therapy was seen in the post-intervention group (5.4 hours vs 33.0 hours; p = 0.150). Median duration of anti-MRSA therapy was reduced from 49.4 hours in the pre-intervention group to 27.92 hours in the post-intervention group (p=0.035). There was no significant difference in total duration of therapy, days of anti-pseudomonal therapy, length of stay, or in-hospital all-cause mortality. Of the 22 pharmacist interventions, 18 (81.8%) were accepted. The most common pharmacist intervention was therapy de-escalation (72.7%).

Conclusion

Automated rapid blood culture diagnostic results used in conjunction with real-time notifications to pharmacists, further decreased time to targeted therapy and significantly reduced duration of anti-MRSA therapy.

Disclosures

All Authors: No reported disclosures.

Impact of Order-Set Modifications and Provider Education Following Guideline Updates on Broad-Spectrum Antibiotic Use in Patients Admitted With Community Acquired Pneumonia

Purpose: Following updates to the Infectious Diseases Society of America (IDSA) practice guidelines for the Diagnosis and Treatment of Adults with Community-acquired Pneumonia in 2019, Hartford HealthCare implemented changes to the community acquired pneumonia (CAP) order-set in August 2020 to reflect criteria for the prescribing of broad-spectrum antimicrobial therapy. The objective of the study was to evaluate changes in broad-spectrum antibiotic days of therapy (DOT) following these order-set updates with accompanying provider education. Methods: This was a multi-center, quasi-experimental, retrospective study of patients with a diagnosis of CAP from September 1, 2019 to October 31, 2019 (pre-intervention) and September 1, 2020 to October 31, 2020 (post-intervention). Patients were identified using ICD-10 codes (A48.1, J10.00-J18.9) indicating lower respiratory tract infection. Data collected included demographics, labs and vitals, radiographic, microbiological, and antibiotic data. The primary outcome was change in broad-spectrum antibiotic DOT, specifically anti-pseudomonal β-lactams and anti-MRSA antibiotics. Secondary outcomes included guideline-concordance of initial antibiotics, utilization of an order-set to prescribe antibiotics, and length of stay (LOS). Results: A total of 331 and 352 patients were included in the pre- and post-intervention cohorts, respectively. There were no differences in order-set usage (10% vs 11.3%, P = .642) between the pre- and post-intervention cohort, respectively. The overall duration of broad-spectrum therapy was a median of 2 days (IQR 0-8 days) in the pre-intervention period and 0 days (IQR 0-4 days) in the post-intervention period (P < .001). Patients in whom the order-set was used in the post-intervention period were more likely to have guideline-concordant regimens ([36/40] 90% vs [190/312] 60.9%; P = .003). Hospital LOS was shorter in the post-intervention cohort (4.8 days [2.9-7.2 days] vs 5.3 days [IQR 3.5-8.5 days], P = .002). Conclusion: Implementation of an updated CAP order-set with accompanying provider education was associated with reduced use of broad-spectrum antibiotics. Opportunities to improve compliance and thus further increase guideline-concordant therapy require investigation.

58. Impact of Order-set Modifications and Provider Education on Broad-Spectrum Antibiotic Use in Patients Admitted with Community Acquired Pneumonia

Background

Following updates to IDSA guidelines in 2019, Hartford HealthCare implemented changes to the community acquired pneumonia (CAP) order-set in August 2020 to reflect criteria for prescribing of broad-spectrum antimicrobial therapy. The objective of the study was to evaluate changes in broad-spectrum antibiotic days of therapy (DOT) following these order-set updates with accompanying provider education.

Methods

This was a multi-center, quasi-experimental, retrospective study of patients with CAP from 9/1/19 to 10/31/19 (pre-intervention) and 9/1/20 to 10/31/20 (post-intervention). Patients were identified using ICD-10 codes indicating lower respiratory tract infection and excluded if had a positive SARS-COV-2 PCR during admission. Data collected included demographics, labs and vitals, radiographic, microbiological, and antibiotic data. The primary outcome was change in broad-spectrum antibiotic DOT, specifically anti-pseudomonal β-lactams and anti-MRSA antibiotics. Secondary outcomes included guideline-concordance of initial antibiotics, utilization of an order-set to prescribe antibiotics, and length of stay (LOS).

Results

A total of 331 and 352 patients were included in the pre- and post-intervention groups, respectively. The overall duration of broad-spectrum therapy was a median of 2 days (IQR 0-8 days) in the pre-intervention period and 0 days (IQR 0-4 days) in the post-intervention period (p< 0.001). Patients in whom the order-set was used in the post-intervention period were more likely to have guideline-concordant regimens ([36/40] 90% vs. [190/312] 60.9%; p = 0.003). There were no differences in order set usage (10% vs. 11.3%, p = 0.642) between the pre- and post-intervention groups, respectively. Hospital LOS was lower in the post-intervention cohort (4.8 days [2.9-7.2 days] vs. 5.3 days [IQR 3.5-8.5 days], p = .002).

Conclusion

Despite low utilization of the order-set, education surrounding order-set changes appeared to improve antibiotic prescribing and hospital LOS in our population. Further opportunities to improve order-set use and thus further increase guideline-concordant therapy are still available.

Disclosures

Joseph L. Kuti, PharmD, Allergan (Speaker’s Bureau)BioMérieux (Consultant, Research Grant or Support, Speaker’s Bureau)Contrafect (Scientific Research Study Investigator)GSK (Consultant)Merck (Research Grant or Support)Paratek (Speaker’s Bureau)Roche Diagnostics (Research Grant or Support)Shionogi (Research Grant or Support)Summit (Scientific Research Study Investigator) David P. Nicolau, PharmD, Abbvie, Cepheid, Merck, Paratek, Pfizer, Wockhardt, Shionogi, Tetraphase (Other Financial or Material Support, I have been a consultant, speakers bureau member, or have received research funding from the above listed companies.)

112. Impact of Respiratory Viral PCR Panels (RVP) and Serum Procalcitonin (PCT) on Antibiotic Days of Therapy (DOT) in Patients Admitted with Lower Respiratory Tract Infections (LRTI)

Background

IDSA advocates for the use of RVP and PCT to reduce inappropriate antibiotic use. These assays were implemented in our health system without formal antimicrobial stewardship intervention. Herein, we evaluated assay utilization and impact on antibiotic DOT in patients admitted with LRTI.

Methods

Records of patients admitted to our health system in January 2019 with a diagnosis of LRTI (ICD 10 codes: J13-22, J44, or J85) were reviewed. Patients < 18 years old, receiving active treatment at time of admission for a concurrent infection, or had a RVP or initial PCT ordered > 48 hours from admission were excluded. Patients were cohorted based on at least one test ordered (VPPC) vs neither (CTRL). The primary endpoint was total antibiotic DOT, including inpatient and outpatient. Secondary endpoints were hospital length of stay (LOS), 30 day readmission (30DR), and all cause mortality (ACM). Multivariate linear regression was used to determine variables associated with DOT.

Results

Of 294 patients included, 15 (5.1%), 84 (28.6%), and 43 (14.6%) had RVP alone, PCT alone, or both ordered, respectively, resulting in 142 (48.3%) patients in the VPPC group. Providers modified therapy based on PCT and RVP results in 39.4% (50/127) and 33.3% (7/21) of patients, respectively. Median (IQR) DOT was similar between VPPC and CTRL groups (7 [5–9] vs 7 [3–8] days; p=0.159), respectively. Inpatient DOT (4 [2–5] vs 3 [2–4] days; p=0.001) and LOS (99.5 vs 81.7 hours; p=0.001) were longer in the VPPC group. VPPC patients were more likely to receive anti-pseudomonal B-lactams (anti-PSA) (26.8 vs 16.4%; p=0.044) and anti-MRSA antibiotics (45.1 vs 34.9%; p=0.096). No difference in 30DR (13.4 vs 15.1%; p=0.793) or ACM (2.1 vs 3.3%; p=0.794) was observed. Variables significantly associated with increased DOT were non-ICU admission, positive chest X-ray, LOS, younger age, and receipt of anti-MRSA or anti-PSA antibiotics.

Conclusion

Over one month, RVP or PCT was ordered in nearly half of admitted LRTI patients in our health system, but modification of therapy based on results was infrequent. The unrestricted use of these tests without stewardship intervention did not impact overall antibiotic DOT, LOS, 30DR, or ACM. These data emphasize the need for additional intervention to enhance the clinical utility of these tests.

Disclosures

Joseph L. Kuti, PharmD, Allergan (Speaker’s Bureau)bioMérieux (Research Grant or Support, Other Financial or Material Support, Speaker Honorarium)Melinta (Research Grant or Support)Merck & Co., Inc. (Research Grant or Support)Paratek (Speaker’s Bureau)Summit (Other Financial or Material Support, Research funding (clinical trials))

Plazomicin: an intravenous aminoglycoside antibacterial for the treatment of complicated urinary tract infections

INTRODUCTION

Antimicrobial resistance continues to be a major public health concern due to the emergence and spread of multi-drug resistant (MDR) organisms, including extended spectrum ß-lactamase (ESBL) and carbapenemase producing Enterobacterales. Plazomicin is a novel aminoglycoside that demonstrates activity against MDR gram-negatives, including those producing ESBLs and most carbapenemases, and retains activity against aminoglycoside modifying enzymes as a result of structural modifications. The information discussed is meant to assist in identifying plazomicin's place in therapy and to expand the clinician's armamentarium.

AREAS COVERED

Herein, we review the pharmacology, microbiology, clinical efficacy, and safety of plazomicin. To gather relevant information, a literature search was performed using PubMed, Ovid, and Google Scholar electronic databases. Search terms used include plazomicin, ACHN-490, extended spectrum ß-lactamase, ESBL, CRE, aminoglycoside modifying enzymes, and AME. Additional information was obtained from FDA review documents and research abstracts presented at international conferences.

EXPERT OPINION

Plazomicin is a promising carbapenem or β-lactam/β-lactamase inhibitor-sparing alternative for the treatment of complicated urinary tract infections caused by MDR Enterobacterales. Although robust data for bloodstream infections and bacterial pneumonias are lacking, plazomicin may be considered in individual clinical scenarios if combination therapy is warranted provided supportive microbiological data and therapeutic drug monitoring are available.