Clinician perspectives on how situational context and augmented intelligence design features impact perceived usefulness of sepsis prediction scores embedded within a simulated electronic health record

OBJECTIVE

Obtain clinicians' perspectives on early warning scores (EWS) use within context of clinical cases.

MATERIAL AND METHODS

We developed cases mimicking sepsis situations. De-identified data, synthesized physician notes, and EWS representing deterioration risk were displayed in a simulated EHR for analysis. Twelve clinicians participated in semi-structured interviews to ascertain perspectives across four domains: (1) Familiarity with and understanding of artificial intelligence (AI), prediction models and risk scores; (2) Clinical reasoning processes; (3) Impression and response to EWS; and (4) Interface design. Transcripts were coded and analyzed using content and thematic analysis.

RESULTS

Analysis revealed clinicians have experience but limited AI and prediction/risk modeling understanding. Case assessments were primarily based on clinical data. EWS went unmentioned during initial case analysis; although when prompted to comment on it, they discussed it in subsequent cases. Clinicians were unsure how to interpret or apply the EWS, and desired evidence on its derivation and validation. Design recommendations centered around EWS display in multi-patient lists for triage, and EWS trends within the patient record. Themes included a "Trust but Verify" approach to AI and early warning information, dichotomy that EWS is helpful for triage yet has disproportional signal-to-high noise ratio, and action driven by clinical judgment, not the EWS.

CONCLUSIONS

Clinicians were unsure of how to apply EWS, acted on clinical data, desired score composition and validation information, and felt EWS was most useful when embedded in multi-patient views. Systems providing interactive visualization may facilitate EWS transparency and increase confidence in AI-generated information.

Information displays for automated surveillance algorithms of in-hospital patient deterioration: a scoping review

OBJECTIVE

Surveillance algorithms that predict patient decompensation are increasingly integrated with clinical workflows to help identify patients at risk of in-hospital deterioration. This scoping review aimed to identify the design features of the information displays, the types of algorithm that drive the display, and the effect of these displays on process and patient outcomes.

MATERIALS AND METHODS

The scoping review followed Arksey and O'Malley's framework. Five databases were searched with dates between January 1, 2009 and January 26, 2022. Inclusion criteria were: participants-clinicians in inpatient settings; concepts-intervention as deterioration information displays that leveraged automated AI algorithms; comparison as usual care or alternative displays; outcomes as clinical, workflow process, and usability outcomes; and context as simulated or real-world in-hospital settings in any country. Screening, full-text review, and data extraction were reviewed independently by 2 researchers in each step. Display categories were identified inductively through consensus.

RESULTS

Of 14 575 articles, 64 were included in the review, describing 61 unique displays. Forty-one displays were designed for specific deteriorations (eg, sepsis), 24 provided simple alerts (ie, text-based prompts without relevant patient data), 48 leveraged well-accepted score-based algorithms, and 47 included nurses as the target users. Only 1 out of the 10 randomized controlled trials reported a significant effect on the primary outcome.

CONCLUSIONS

Despite significant advancements in surveillance algorithms, most information displays continue to leverage well-understood, well-accepted score-based algorithms. Users' trust, algorithmic transparency, and workflow integration are significant hurdles to adopting new algorithms into effective decision support tools.

A qualitative evaluation of frontline clinician perspectives toward antibiotic stewardship programs

OBJECTIVE

To examine the perspectives of caregivers that are not part of the antibiotic stewardship program (ASP) leadership team (eg, physicians, nurses, and clinical pharmacists), but who interact with ASPs in their role as frontline healthcare workers.

DESIGN

Qualitative semistructured interviews.

SETTING

The study was conducted in 2 large national healthcare systems including 7 hospitals in the Veterans' Health Administration and 4 hospitals in Intermountain Healthcare.

PARTICIPANTS

We interviewed 157 participants. The current analysis includes 123 nonsteward clinicians: 47 physicians, 26 pharmacists, 29 nurses, and 21 hospital leaders.

METHODS

Interviewers utilized a semistructured interview guide based on the Consolidated Framework for Implementation Research (CFIR), which was tailored to the participant's role in the hospital as it related to ASPs. Qualitative analysis was conducted using a codebook based on the CFIR.

RESULTS

We identified 4 primary perspectives regarding ASPs. (1) Non-ASP pharmacists considered antibiotic stewardship activities to be a high priority despite the added burden to work duties: (2) Nurses acknowledged limited understanding of ASP activities or involvement with these programs; (3) Physicians criticized ASPs for their restrictions on clinical autonomy and questioned the ability of antibiotic stewards to make recommendations without the full clinical picture; And (4) hospital leaders expressed support for ASPs and recognized the unique challenges faced by non-ASP clinical staff.

CONCLUSION

Further understanding these differing perspectives of ASP implementation will inform possible ways to improve ASP implementation across clinical roles.

145. Comparing Antibiotic Use Across Inpatient Facilities with Different Antibiotic Stewardship Typologies using Machine Learning and Joint Modeling Approach

Background

Hospital antibiotic stewardship programs (ASP) aim to promote the appropriate use of antimicrobials (including antibiotics) and play a critical role in controlling antibiotic costs and antibiotic-resistant bacterial infection risk, and improving patient outcomes. However, unlike other health care quality improvement intervention programs, the ASP implementation strategies vary among healthcare facilities, and little is known about whether different types of ASP implementation will lead to the shifting of antibiotic drug use from one class to another.

Methods

We proposed an analytical framework using unsupervised machine learning and joint model approach to 1) develop a typology of ASP strategies in facilities from the Veterans Health Administration, America’s largest integrated health care system; and 2) simultaneously evaluate the impacts of different ASP types on the annual antibiotic use rates across multiple drug classes. The unsupervised machine learning method was used to leverage the structural components in the surveys conducted by the Veteran Affair (VA) Healthcare Analysis and Information group and the Consolidated Framework for Implementation Research experts from Boston University, and reveal the underlying ASP patterns in the VA facilities in 2016.

Results

We identified 4 groups in the VA facilities in terms of enthusiasm and implementation level of antibiotic control in our ASP typology. We found the facilities with high implementation level and high enthusiasm in ASP and those with high implementation level but low enthusiasm had statistically significant 30% (p-value=0.002) and 22% (p-value=0.031) lower antibiotic use rates in broad-spectrum agents used for community infections, respectively than those with low implementation level and low enthusiasm. However, the facilities with high implementation and high enthusiasm also marginally increased antibiotic use rates in beta-lactam antibiotics (p-value=0.096).

Conclusion

The developed analytical framework in the study provided an approach to the granular assessment of the impact of the healthcare intervention programs and might be informative for future health service policy development.

Disclosures

Matthew B. Goetz, MD, Nothing to disclose

Social dynamics of a population-level dashboard for antimicrobial stewardship: A qualitative analysis

OBJECTIVE

To evaluate antimicrobial stewards' experiences of using a dashboard display integrating local and national antibiotic use data implemented in the U.S. Department of Veterans Affairs (VA). This paper reports early formative evaluation.

DESIGN

Qualitative interviewing.

SETTING

Eight VA hospitals participated with established antimicrobial stewardship (AS) programs participated in the pilot.

PARTICIPANTS

Six infectious disease physicians and eight clinical pharmacists agreed to be interviewed (n = 14).

METHODS

A 3-part qualitative interview script was used involving a description of local stewardship activities, a Critical Incident description of dashboard use, and general questions regarding attitudes towards the tool. An inductive open coding approach was used for analysis.

RESULTS

We found 4 themes showing the complexities of using stewardship tools: (1) Data validity is socially negotiated; (2) Performance feedback motivates and persuades social goals when situated in an empirical distribution; (3) Shared problem awareness is aided by authoritative data; and (4) The AS dashboard encourages connections with local quality improvement culture.

CONCLUSIONS

Social dimensions of AS tool use emerged as distinct from, and equally important as decision support provided by the dashboard. Successful stewardship tools should be designed to support both the social and cognitive needs of users.

Simulated Adoption of 2019 Community-Acquired Pneumonia Guidelines Across 114 Veterans Affairs Medical Centers: Estimated Impact on Culturing and Antibiotic Selection in Hospitalized Patients

BACKGROUND

The 2019 American Thoracic Society/Infectious Diseases Society of America guidelines for community-acquired pneumonia (CAP) revised recommendations for culturing and empiric broad-spectrum antibiotics. We simulated guideline adoption in Veterans Affairs (VA) inpatients.

METHODS

For all VA acute hospitalizations for CAP from 2006-2016 nationwide, we compared observed with guideline-expected proportions of hospitalizations with initial blood and respiratory cultures obtained, empiric antibiotic therapy with activity against methicillin-resistant Staphylococcus aureus (anti-MRSA) or Pseudomonas aeruginosa (antipseudomonal), empiric "overcoverage" (receipt of anti-MRSA/antipseudomonal therapy without eventual detection of MRSA/P. aeruginosa on culture), and empiric "undercoverage" (lack of anti-MRSA/antipseudomonal therapy with eventual detection on culture).

RESULTS

Of 115 036 CAP hospitalizations over 11 years, 17 877 (16%) were admitted to an intensive care unit (ICU). Guideline adoption would slightly increase respiratory culture (30% to 36%) and decrease blood culture proportions (93% to 36%) in hospital wards and increase both respiratory (40% to 100%) and blood (95% to 100%) cultures in ICUs. Adoption would decrease empiric selection of anti-MRSA (ward: 27% to 1%; ICU: 61% to 8%) and antipseudomonal (ward: 25% to 1%; ICU: 54% to 9%) therapies. This would correspond to greatly decreased MRSA overcoverage (ward: 27% to 1%; ICU: 56% to 8%), slightly increased MRSA undercoverage (ward: 0.6% to 1.3%; ICU: 0.5% to 3.3%), with similar findings for P. aeruginosa. For all comparisons, P < .001.

CONCLUSIONS

Adoption of the 2019 CAP guidelines in this population would substantially change culturing and empiric antibiotic selection practices, with a decrease in overcoverage and slight increase in undercoverage for MRSA and P. aeruginosa.

Decreases in Antimicrobial Use Associated With Multihospital Implementation of Electronic Antimicrobial Stewardship Tools

BACKGROUND

Antimicrobial stewards may benefit from comparative data to inform interventions that promote optimal inpatient antimicrobial use.

METHODS

Antimicrobial stewards from 8 geographically dispersed Veterans Affairs (VA) inpatient facilities participated in the development of antimicrobial use visualization tools that allowed for comparison to facilities of similar complexity. The visualization tools consisted of an interactive web-based antimicrobial dashboard and, later, a standardized antimicrobial usage report updated at user-selected intervals. Stewards participated in monthly learning collaboratives. The percent change in average monthly antimicrobial use (all antimicrobial agents, anti-methicillin-resistant Staphylococcus aureus [anti-MRSA] agents, and antipseudomonal agents) was analyzed using a pre-post (January 2014-January 2016 vs July 2016-January 2018) design with segmented regression and external comparison with uninvolved control facilities (n = 118).

RESULTS

Intervention sites demonstrated a 2.1% decrease (95% confidence interval [CI], -5.7% to 1.6%) in total antimicrobial use pre-post intervention vs a 2.5% increase (95% CI, 0.8% to 4.1%) in nonintervention sites (absolute difference, 4.6%; P = .025). Anti-MRSA antimicrobial use decreased 11.3% (95% CI, -16.0% to -6.3%) at intervention sites vs a 6.6% decrease (95% CI, -9.1% to -3.9%) at nonintervention sites (absolute difference, 4.7%; P = .092). Antipseudomonal antimicrobial use decreased 3.4% (95% CI, -8.2% to 1.7%) at intervention sites vs a 3.6% increase (95% CI, 0.8% to 6.5%) at nonintervention sites (absolute difference, 7.0%; P = .018).

CONCLUSIONS

Comparative data visualization tool use by stewards at 8 VA facilities was associated with significant reductions in overall antimicrobial and antipseudomonal use relative to uninvolved facilities.

Weight gain associated with insulin detemir vs insulin glargine in clinical practice: A retrospective longitudinal cohort study

PURPOSE

In comparative randomized studies, use of insulin detemir has been consistently demonstrated to be associated with less weight gain than the industry standard, insulin glargine. However, the magnitude of the relative reduction in weight gain with use of insulin determir vs insulin glargine in regulatory studies (reported values ranged from 0.77 kg to 3.6 kg) may not be generalizable to patients in real-world practice conditions. A study was conducted to substantiate detemir's purported weight-sparing advantage over insulin glargine in newly treated patients with type 2 diabetes mellitus under the conditions found in a clinical practice setting.

METHODS

A retrospective longitudinal cohort study design was applied in reviewing electronic medical records to identify insulin-naive, overweight patients with type 2 diabetes who received insulin detemir or insulin glargine therapy continued for up to 1 year. Patient weights at baseline and at each subsequent clinic visit after treatment initiation were identified. The primary outcome was the maximum weight increase from baseline after exposure to insulin detemir or glargine. The difference-in-differences (DiD) mean total body weight change was tested by analysis of covariance (ANCOVA).

RESULTS

One hundred nine patient records (56 of patients who received insulin glargine and 53 of patients who received insulin detemir) met study criteria and underwent full abstraction. The covariate-adjusted estimated mean change in body weight associated with use of insulin detemir vs insulin glargine was -1.5 kg (95% CI, -2.89 to -0.12 kg; P = 0.04).

CONCLUSION

The mean weight gain associated with detemir use was significantly less than the mean weight change observed with glargine use. The magnitude of weight change was consistent with that demonstrated in randomized controlled trials. These results further substantiate detemir's purported comparative weight-sparing properties under conditions found in a real-world practice setting.

152. Applying A Difference-in-Difference Analysis to Assess Effect of Antimicrobial Stewardship Strategies on Changes in Antimicrobial Use

Background

About 30–50% of inpatient antimicrobial therapy is sub-optimal. Health care facilities have utilized various antimicrobial stewardship (AS) strategies to optimize appropriate antimicrobial use, improve health outcomes, and promote patient safety. However, little evidence exists to assess relationships between AS strategies and antimicrobial use. This study examined the impact of changes in AS strategies on antimicrobial use over time.

Methods

This study used data from the Veterans Affairs (VA) Healthcare Analysis & Informatics Group (HAIG) AS survey, administered at 130 VA facilities in 2012 and 2015, and antimicrobial utilization from VA Corporate Data Warehouse. Four AS strategies were examined: having an AS team, feedback mechanism on antimicrobial use, infectious diseases (ID) attending physicians, and clinical pharmacist on wards. Change in AS strategies were computed by taking the difference in the presence of a given strategy in a facility between 2012–2015. The outcome was the difference between antimicrobial use per 1000 patient days in 2012–2013 and 2015–2016. Employing multiple regression analysis, changes in antimicrobial use was estimated as a function of changes in AS strategies, controlling for ID human resources in and organizational complexity.

Results

Of the 4 strategies, only change in availability of AS teams had an impact on antimicrobial use. Compared to facilities with no AS teams at both time points, antibiotic use decreased by 63.9 uses per 1000 patient days in facilities that did not have a AS team in 2012 but implemented one in 2015 (p=0.0183). Facilities that had an AS team at both time points decreased use by 62.2 per 1000 patient days (p=0.0324).

Conclusion

The findings showed that AS teams reduced inpatient antibiotic use over time. While changes in having feedback on antimicrobial use and clinical pharmacist on wards showed reduced antimicrobial use between 2012–2015, the differences were not statistically significant. These strategies may already be a part of a comprehensive AS program and employed by AS teams. In further development of stewardship programs within healthcare organizations, the association between AS teams and antibiotic use should inform program design and implementation.

Disclosures

All Authors: No reported disclosures

Impact of Implementation of the Core Elements of Outpatient Antibiotic Stewardship Within Veterans Health Administration Emergency Departments and Primary Care Clinics on Antibiotic Prescribing and Patient Outcomes

BACKGROUND

The Core Elements of Outpatient Antibiotic Stewardship provide a framework to improve antibiotic use. We report the impact of core elements implementation within Veterans Health Administration sites.

METHODS

In this quasiexperimental controlled study, effects of an intervention targeting antibiotic prescription for uncomplicated acute respiratory tract infections (ARIs) were assessed. Outcomes included per-visit antibiotic prescribing, treatment appropriateness, ARI revisits, hospitalization, and ARI diagnostic changes over a 3-year pre-implementation period and 1-year post-implementation period. Logistic regression adjusted for covariates (odds ratio [OR], 95% confidence interval [CI]) and a difference-in-differences analysis compared outcomes between intervention and control sites.

RESULTS

From 2014-2019, there were 16 712 and 51 275 patient visits within 10 intervention and 40 control sites, respectively. Antibiotic prescribing rates pre- and post-implementation within intervention sites were 59.7% and 41.5%, compared to 73.5% and 67.2% within control sites, respectively (difference-in-differences, P < .001). Intervention site pre- and post-implementation OR to receive appropriate therapy increased (OR, 1.67; 95% CI, 1.31-2.14), which remained unchanged within control sites (OR,1.04; 95% CI, .91-1.19). ARI-related return visits post-implementation (-1.3% vs -2.0%; difference-in-differences P = .76) were not different, but all-cause hospitalization was lower within intervention sites (-0.5% vs -0.2%; difference-in-differences P = .02). The OR to diagnose non-specific ARI compared with non-ARI diagnoses increased post-implementation forintervention (OR, 1.27; 95% CI, 1.21 -1.34) but not control (OR, 0.97; 95% CI, .94-1.01) sites.

CONCLUSIONS

Implementation of the core elements was associated with reduced antibiotic prescribing for RIs and a reduction in hospitalizations. Diagnostic coding changes were observed.

Contribution of Penicillin Allergy Labels to Second-Line Broad-Spectrum Antibiotic Prescribing for Pediatric Respiratory Tract Infections

Introduction

Antibiotic allergies are overdiagnosed. This may lead to unnecessary use of second-line broader-spectrum agents in place of narrower-spectrum guideline-recommended first-line therapies especially for uncomplicated respiratory tract infections. The extent to which this occurs for children with respiratory tract infections is unknown.

Methods

We included outpatient encounters for patients < 18 years with acute respiratory tract infections (sinusitis, bronchitis, bronchiolitis, upper respiratory tract infection, pharyngitis, otitis media). Patients were classified as penicillin allergic based on the presence of an allergy label in the electronic medical record. First-line guideline-recommended antibiotics included penicillin, amoxicillin or amoxicillin-clavulanate; all others were considered second line. The percentage of patients treated with first-line versus second-line antibiotics was compared between those with and without penicillin allergy. Additionally, we calculated the contribution of penicillin allergy to overall use of second-line antibiotics.

Results

Among 17,578 eligible encounters for respiratory tract infections, 1332 (8%) included patients with a penicillin allergy label. Overall, second-line antibiotics were prescribed in 15% of encounters. Second-line antibiotics were prescribed in 91% of encounters for penicillin-allergic patients, compared with 8% of encounters for non-allergic patients (P < 0.001). Patients with penicillin allergy labels accounted for 47% of all second-line antibiotic prescriptions.

Conclusion

In a large population of pediatric outpatient encounters for acute respiratory tract infections, patients labeled with a penicillin allergy accounted for nearly half of second-line antibiotics, which are often broader spectrum. Efforts to de-label children with penicillin allergies have the potential to reduce broader-spectrum antibiotic use.

Perspectives of Physician and Pharmacist Stewards on Successful Antibiotic Stewardship Program Implementation: A Qualitative Study

Background

Antibiotic stewardship programs (ASPs) are required at every hospital regardless of size. We conducted a qualitative study across different hospital settings to examine perspectives of physician and pharmacist stewards about the dynamics within their team and contextual factors that facilitate the success of their programs.

Methods

Semistructured interviews were conducted in March-November 2018 with 46 ASP stewards, 30 pharmacists, and 16 physicians, from 39 hospitals within 2 large hospital systems.

Results

We identified 5 major themes: antibiotic stewards were enthusiastic about their role, committed to the goals of stewardship for their patients and as a public-health imperative, and energized by successful interventions; responsibilities of pharmacist and physician stewards are markedly different, and pharmacy stewards performed the majority of the day-to-day stewardship work; collaborative teamwork is important to improving care, the pharmacists and physicians supported each other, and pharmacists believed that having a strong physician leader was essential; provider engagement strategies are a critical component of stewardship, and recommendations must be communicated in a collegial manner that did not judge the provider competence, preferably through face-to-face interactions; and hospital leadership support for ASP goals and for protected time for ASP activities is critical for success.

Conclusions

The physician-pharmacist team is essential for ASPs; most have pharmacists leading and performing day-to-day activities with physician support. Collaborative, persuasive approaches for ASP interventions were the norm. Stewards were careful not to criticize or judge inappropriate antibiotic prescribing. Further research should examine whether this persuasive approach undercuts provider appreciation of stewardship as a public health mandate.

2074. A Successful Acute Respiratory Tract Infection Campaign to Improve Antibiotic Prescribing in Outpatient Clinics and an Emergency Department

Background

Acute Respiratory tract infections (ARI) are infections involving the upper respiratory tract. Most ARIs are viral in nature and self-limited in which most of the times antibiotic treatment is unnecessary. A recent VA medication utilization evaluation conducted in 28 medical centers identified high rates of unnecessary antibiotic prescribing for ARI. Based on these analyses the VA National Academic Detailing Service (VANADS) created the ARI campaign, providing materials for VA systems to employ as the seek to improve ARI management. Our project consists of implementation of the ARI Campaign in a South Florida Veteran Affairs HealthCare System (Miami VAHS).

Methods

We utilized VANADS resources for our campaign. Activities included assessing ARI prescribing patterns, garnering stakeholder support, identifying pharmacist and physician champions, providing targeted academic detailing, handing out provider ARI guidance documents (in paper and electronically), disseminating provider-specific feedback with peer comparison, order-set development with advertisement, promoting appropriate coding, and reporting to the Miami VAHS antimicrobial stewardship program (ASP) subcommittee. Campaign activities were initiated in October 2017. The ARI Campaign was selected as the priority item for FY-2019, from our annual ASP risk assessment with a goal of reducing antibiotic prescribing for ARI diagnosis to below 40%. We present the data up to March 2019.

Results

Baseline data from October 2015 through September 2017 revealed an antibiotic was prescribed to 1,651 of 2,843 (58%) encounters in which an ARI diagnosis was made in our system. In the months following ARI Campaign initiation, a decline in antibiotic prescribing for ARI diagnosis was found. In the most recent quarter (January–March 2019), the prescribing rate was 39%. Figure 1 shows system-wide vs. Florida region prescribing rates. Table 1 provides data by major site and for the top 10 priority providers we identified.

Conclusion

Implementation of a multifaceted ARI Campaign at a single-center resulted in a substantial reduction in antibiotic prescriptions. Future work is warranted investigating which activities are most impactful for reducing unnecessary antibiotic prescribing for ARI.

Disclosures

All authors: No reported disclosures.

2090. Are Changes in Antimicrobial Use Associated with a Decline in Hospital Pathogen Rates in Veterans Affairs Medical Centers?

Background

The relationship between antimicrobial use and resistance is complex, making it difficult to understand and predict the impact of antimicrobial policies. Here, we examine trends of antimicrobial pressure and pathogen rates using novel metrics.

Methods

Data were extracted from 2007 through 2016. GEE-negative binomial regression modeled incident (within a year) hospital-onset (HO) pathogen rates, defined as the number of unique positive isolates between hospital day 3 and discharge, offset by patient-days at risk (eliminating the first 2 hospital days from the denominator, etc.). As predictors, we used pathogen-specific AM pressure metrics, summing the selection pressure of each AM regimen, given to a patient in a day, for and against the pathogen by each facility and year (e.g., if a regimen was 70% active by antibiogram then 0.7 was counted as selection against and 0.3 for the pathogen; different regimens would contribute differentially). We also adjusted by facility complexity index and pathogen admission prevalence.

Results

All HO-pathogen rates declined significantly after adjustment (raw rates in Figure 1), except Bacteroides. Admission prevalence trends were variable (Table 1 and Figure 2). Figure 3 demonstrates the trend of the log ratio of AM pressure for and against pathogens. Significant negative associations with AM pressure against 5 pathogens and for 1 were observed (Table 1).

Conclusion

There was a broad decrease in adjusted hospital pathogen rates. The negative association with selection pressure against pathogens suggests that (a) AM resistance among pathogens is decreasing, (b) it causes a decrease in infection rates, or (c) both. While residual confounding and endogeneity still exist, our findings highlight the possibility that new metrics might better predict AM effects, including potential protective effects of some patterns of AM use. It is also notable that the measured associations were not large enough nor AM pressure trends consistent enough to explain the decreases in HO-pathogen rates. This suggests that other factors not measured in this analysis, including infection prevention, likely played a large role in observed trends. Interpretation of these results should be nuanced; we are not advocating broad-spectrum AM use.

Disclosures

All authors: No reported disclosures.

1058. Decreases in Antibiotic Use Associated with the Implementation of Electronic Antibiotic Visualization Tools for Stewards at Eight Veterans Affairs (VA) Healthcare Facilities

Background

To identify areas for improved antibiotic use, we developed and pilot-tested visualization tools to quantify antibiotic use at 8 VA facilities. These tools allow a facility to review its patterns of total use, and use by antibiotic class, compared with patterns of use at VA facilities with similar (or user-selected) complexity levels.

Methods

Antibiotic stewards from 8 VA facilities participated in iterative report development and implementation, with the final product consisting of two components: an interactive web-based antibiotic dashboard and a standardized antibiotic usage report updated at user-selected intervals. Stewards also participated in monthly learning collaboratives. The percent change in average monthly antimicrobial use (all antibiotics; anti-methicillin-resistant S. aureus agents (anti-MRSA); and broad-spectrum agents predominantly used for hospital-onset/multi-drug-resistant organisms (anti-MDRO)) was analyzed using a pre-post (January 2014–January 2016 vs. July 2016–January 2018) with un-involved controls (all other inpatient VA facilities, n = 132) design modeled using Generalized Estimation Equations segmented regression.

Results

Intervention sites had a 2.1% decrease (95% CI = [−5.7%,1.6%]) in all antibiotic use pre-post-intervention, vs. a 2.5% increase (95% CI = [0.8%, 4.1%]) in nonintervention sites (P = 0.025 for difference). Anti-MRSA antibiotic use decreased 11.3% (95% CI = [−16.0%,−6.3%]) at intervention sites vs. a 6.6% decrease (95% CI=[−9.1%, −3.9%]) at nonintervention sites (P = 0.092 for difference). Anti-MDRO antibiotic use decreased 3.4% (95% CI = [−8.2%,1.7%]) at intervention sites vs. a 3.6% increase (95% CI = [0.8%,6.5%]) at nonintervention sites (P = 0.018 for difference) (Figure 1). Examples of graphs include overall antibacterial use (Figure 2), and usage of broad-spectrum Gram-negative therapy (Figure 3) in intensive care units.

Conclusion

The use of data visualization tools use and participation in monthly learning collaboratives by antimicrobial stewards in a pilot implementation project at eight VA facilities was associated with decreases in antimicrobial use relative to uninvolved sites.

Disclosures

All authors: No reported disclosures.

2071. A Survey of Antibiotic Prescribing Practices Among Adult Primary Care Physicians in Idaho

Background

Prescribing an antibiotic is a complex process involving an interplay of prescriber’s knowledge, diagnostic acumen and patient factors. Understanding the prescriber rationale is key to provide feedback which might improve appropriateness of antibiotic prescribing. Currently, there are limited data on prescribing and test ordering practices among primary care physicians.

Methods

We surveyed primary care physicians taking care of adults (age 18 years and above). Physicians were contacted through the Idaho State Medical Board by a one-time email containing the survey link. The survey consisted of 25 questions under 2 major themes of diagnostic and antimicrobial stewardship (AS). It assessed physicians’ practice setting, ordering of diagnostic tests and antibiotics for common infections, delivery of patient education regarding antibiotics, availability of antibiogram and antimicrobial stewardship services, and assessment of penicillin allergy. Two infectious diseases physicians independently reviewed the results for appropriateness of testing and antibiotic prescribing per IDSA guidelines.

Results

Of 929 physicians surveyed, 157 (17%) responded. Of the respondents, 95 (61%) were male, the mean age was 50 years, and 72% worked in outpatient settings and were family medicine specialists. Only 55% of physicians reported having an AS program at their healthcare facility. Test-of-cure for C. difficile infection (24%) and UTI (13%) and use of superficial culture data to guide the treatment of osteomyelitis (27%) were the most common reasons for inappropriate testing. Longer than recommended duration, antibiotic combinations with overlap of spectrum, and guideline-discordant indications for prescribing antibiotics were the main reasons for inappropriate antibiotic use. The main factors influencing the decision to prescribe an antibiotic were diagnostic uncertainty (42%), being unsure of patient follow-up (23%) and cost of testing (21%).

Conclusion

The survey results highlight the need for prescriber education for decreasing inappropriate test ordering and antibiotic prescribing. Additional studies involving a review of patient records, lab and prescription data are needed to confirm these practices.

Disclosures

All authors: No reported disclosures.

1470. Linezolid for Treatment of Urinary Tract Infections Caused by Vancomycin-resistant Enterococci

Background

Urinary tract infections (UTI) caused by vancomycin-resistant enterococcus (VRE) are difficult to manage due to lack of effective oral treatment options. Linezolid is an antibiotic with activity against VRE that is available orally, but only 30% of each dose is excreted in the urine. Data on the efficacy of linezolid in the treatment of UTI is limited. The purpose of this analysis was to assess the comparative efficacy of linezolid to other VRE-active antibiotics in the treatment of UTI.

Methods

A national retrospective cohort of inpatient veterans with a positive urine culture for VRE during years 2013 through 2018 was developed. Patient demographics, vital signs, urinary symptoms, antibiotics prescribed, and 14-day post-treatment outcomes were collected. Patients without UTI symptoms, urine cultures with < 105 CFU/mL (<103 CFU/mL for catheterized patients), or patients not treated with VRE-active antibiotics were excluded. Odds ratios were used to compare linezolid and non-linezolid antibiotics for 14-day VRE bacteriuria, UTI retreatment, and death endpoints.

Results

Of 3,846 urine cultures identified with VRE, 624 (16%) patients were eligible for evaluation of UTI symptoms. Of these, 92/624 (15%) met study criteria. The primary reason for exclusion was asymptomatic bacteriuria [339/532 (64%)]. Linezolid was prescribed in 54/92 (59%) of cases. Comparators included penicillin’s [12/92 (13%)], nitrofurantoin [11/92 (12%)], daptomycin [7/92 (8%)], tetracycline’s [6/92 (7%)], and others [2/92 (2%)]. Between linezolid and comparator groups, mean (+S.D.) patient age [70 (12) vs. 68 (13) years, P = 0.45] and Charlson Comorbidity Index [8.9 (3.1) vs. 8.3 (3.5), P = 0.39] were similar. Negative outcomes were uncommon: 7% VRE bacteriuria, 8% UTI re-treatment, 4% death. No difference in [(OR) +95% CI] between linezolid and comparators was observed: positive VRE bacteriuria [0.3 (0.1, 1.9), P = 0.20], UTI retreatment [1.8 (0.3, 10.0), P = 0.49], death [1.4 (0.1, 16.1), P = 0.79].

Conclusion

Most patients with a VRE positive urine culture who received antibiotics did not meet diagnostic criteria for UTI, and negative outcomes were uncommon. Linezolid and comparator regimens with VRE activity were effective for treating mild VRE UTI.

Disclosures

All authors: No reported disclosures.

1020. Variations in inpatient and outpatient antibiotic use – opportunities for improvement and facility-level feedback

Background

Participation in the Antibiotic Use (AU) option of the National Health Safety Network (NHSN), provides medical facilities with the Standardized Antibiotic Administration Ratio (SAAR), a normalized ratio of facility antibiotic use. However, the range of antibiotic use by similar facilities is not provided and thus the opportunity to “nudge” behavior by comparing use with “best facilities” is lost. We developed reports of variations of antibiotic use that allow comparisons of local antibiotic use with that of 107 other VA facilities.

Methods

Data for 2018 were extracted from the VA Corporate Data Warehouse. Antibiotic use in CY2018 on acute inpatient care units was assessed as days of therapy (using CDC-defined drug classes) per 1000 days-present. In addition, we assessed the proportion of patients with pneumonia, urinary tract infections or skin-soft-tissue infections (collectively, PUS) who received anti-MRSA therapy or ß-lactam therapy directed against multi-drug-resistant and hospital GNR (anti-MDRGNR) during hospital days 0–2 (CHOICE, a timeframe representing empiric therapy).

Results

Rates of total antibiotic use by VA facility varied over two-fold from 460 to 965 days of therapy (DOT)/1000 days-present (DP); anti-MRSA and anti-MDRGNR varied over four-fold, from 44 to 184 and, 55 to 262, respectively. Fluoroquinolone variation was even higher, ranging over 8-fold, from 17 to 145 DOT/1000 DP (Figure 1). Substantial variations were also observed in the frequency of administration of anti-MRSA and anti-MDRGNR therapy for PUS during CHOICE (14 to 49% and 15 to 65%, respectively; Figure 2).

Conclusion

The large variations in the use of total antibiotic therapy, anti-MRSA, anti-MDRGNR and fluoroquinolone therapies are greater than can be readily explained by known variations in antibiotic resistance or differences in case-mix within the VA. Efforts are underway in the VA to strengthen antimicrobial stewardship programs. In other work, we have shown improvements in antimicrobial use among sites that have access to reports that provide the data described herein and that participate in group collaboratives. Our group is now making these data available to all VA facilities.

Disclosures

All authors: No reported disclosures.

Diagnosis and Antibiotic Management of Otitis Media and Otitis Externa in United States Veterans

Background

Acute otitis media (AOM) and otitis media with effusion (OME) occur primarily in children, whereas acute otitis externa (AOE) occurs with similar frequency in children and adults. Data on the incidence and management of otitis in adults are limited. This study characterizes the incidence, antibiotic management, and outcomes for adults with otitis diagnoses.

Methods

A retrospective cohort of ambulatory adult veterans who presented with acute respiratory tract infection (ARI) diagnoses at 6 VA Medical Centers during 2014-2018 was created. Then, a subcohort of patients with acute otitis diagnoses was developed. Patient visits were categorized with administrative diagnostic codes for ARI (eg, sinusitis, pharyngitis) and otitis (OME, AOM, and AOE). Incidence rates for each diagnosis were calculated. Proportions of otitis visits with antibiotic prescribing, complications, and specialty referral were summarized.

Results

Of 46 634 ARI visits, 3898 (8%) included an otitis diagnosis: OME (22%), AOM (44%), AOE (31%), and multiple otitis diagnoses (3%). Incidence rates were otitis media 4.0 (95% confidence interval [CI], 3.9-4.2) and AOE 2.0 (95% CI, 1.9-2.1) diagnoses per 1000 patient-years. By comparison, the incidence rates for pharyngitis (8.4; 95% CI, 8.2-8.6) and sinusitis (15.2; 95% CI, 14.9-15.5) were higher. Systemic antibiotics were prescribed in 75%, 63%, and 21% of AOM, OME, and AOE visits, respectively. Complications for otitis visits were low irrespective of antibiotic treatment.

Conclusions

Administrative data indicated that otitis media diagnoses in adults were half as common as acute pharyngitis, and the majority received antibiotic treatment, which may be inappropriate. Prospective studies verifying diagnostic accuracy and antibiotic appropriateness are warranted.

208. Trends in Antibiotic Prescribing for Acute Respiratory Tract Infections and Implementation of a Provider-Directed Intervention Within the Veterans Affairs Healthcare System (VA)

Background

Methods

Results

Conclusion

Disclosures

1825. Electronic Measure of Unnecessary Antimicrobial Use in US Veterans Affairs Medical Centers

Background

Antimicrobial inappropriateness is highly contextual and dynamic, depending not only on the patient’s disease condition but also the information available at the time. To estimate the extent to which antimicrobials could theoretically be decreased with antimicrobial stewardship, we sought to capture unnecessary inpatient antimicrobial use in context over time as manifested in the electronic health record in Veterans Affairs (VA).

Methods

We extracted antimicrobial use, administrative, admission, and laboratory data from all acute care VA medical centers between 2010 and 2016. Information present during Choice (hospital day [HD] 1–3), Change (HD 4–5), Completion (HD 6–7), and Post-completion (thereafter) was used to determine context. All antimicrobial use without any documented infection was considered unnecessary (admission, discharge, or otherwise). Choice Anti-MRSA agents were considered unnecessary in cellulitis without history of or current positive culture for MRSA. Choice HOMDR agents were unnecessary in cellulitis without history of positive culture for ceftriaxone-resistant Gram-negative rods. Also unnecessary were broad-spectrum antimicrobials (anti-methicillin-resistant Staphylococcus aureus [MRSA] and hospital-onset multidrug-resistant [HOMDR] organisms antimicrobials as defined by the National Healthcare Safety Network) administered without evidence of multidrug-resistant organisms existed during Change and Completion time frames.

Results

Figure 1 demonstrates the distribution of facility proportions of unnecessary antimicrobials of different classes over time. Table 1 illustrates the percentage of unnecessary antimicrobials administered during choice, change, completion, and post-completion time-frames.

Conclusion

By this measure, unnecessary anti-MRSA and HOMDR use has been decreasing in VA over time. The bulk of unnecessary use is empiric but there is a substantial proportion that is used for longer stays, during which time more information was likely present. More research is necessary to determine how well these simple rules correlate with clinical determinations of appropriateness. Also ICD-10-CM was implemented in October 2015, which may have introduced an ascertainment bias.

Disclosures

V. Stevens, Pfizer, Inc.: Grant Investigator, Research grant.

1875. How Many Different Antimicrobial Regimens Are There and Which Are Emerging and Declining?

Background

Antimicrobial regimens evolve with changing recommendations and emerging practice patterns. We sought to explore the diversity of these patterns and to identify which inpatient regimens may be emerging in US Veterans Affairs medical centers (VAMC).

Methods

We extracted antimicrobial use and admission data from all acute care VA medical centers between 2005 and 2016. A regimen was defined as all unique antimicrobials and their routes given in a day to a single patient. We applied smoothing to account for intended discontinuation and intermittent dosing due to clearance. We described the distribution of regimens among VAMCs using the Gini index (a Gini index of 0 would mean all regimens were equally frequent and 1 would mean that one regimen dominated all others). We calculated the rank percentile of all regimens. We also used the absolute change in rank percentile between years 2005 and 2016 of the regimen used to describe emerging and declining regimens.

Results

There were 55,767 distinct regimens. Table 1 describes the Gini index and its decomposition among VAMCs. Overlap accounts for most of the inequality present because regimens are shared between VAMCs. Approximately 20% of the inequality present can be accounted for by variation between VAMCs. Table 2 describes the top 10 rising and the top 10 declining regimens.

Conclusion

While there was a large number of distinct regimens, there was a relative handful of antimicrobial regimens dominated—most of which were commonly present among VAMCs (as manifest by the Gini “overlap” percent). Most regimens in the top 10 were broad-spectrum IV agents, with PO levofloxacin and doxycycline being notable standouts. IV vancomycin, which was the single most common regimen in 2005, decreased markedly. Linezolid and mixed PO metronidazole agents appear to be on the decline.

Disclosures

V. Stevens, Pfizer, Inc.: Grant Investigator, Research grant.

213. Multi-centered Evaluation of an Acute Respiratory Tract Infection Audit-Feedback Intervention: Impact on Antibiotic Prescribing Rates and Patient Outcomes

Background

Audit-feedback of antibiotic prescribing rates for acute respiratory infections (ARIs) is a promising approach to reduce antibiotic use; however, the generalizability and sustainability are unknown. We describe an audit-feedback intervention and outcomes across multiple seasons in different clinic settings.

Methods

Two VA Medical Centers distributed audit-feedback reports targeting providers with frequent ARI visits in emergency department (ED) and primary care (PC) during 2015–2016 and 2016–2017. An academic detailing visit delivered by local peers accompanied the initial audit-feedback report. The intervention was expanded to ED and PC clinics (n = 10) in three other VA facilities in 2017–2018. Outcomes included rates of antibiotics prescribed, recurrent visits for ARIs within 30 days, and adverse events. We assessed intervention sustainability in initiating VAs, and intervention generalizability in expansion VAs. Mixed-effect logistic regression models were used to assess intervention effect on antibiotic prescribing and outcomes.

Results

Antibiotic prescribing for uncomplicated ARI visits (n = 7,814) declined from 53.8% to 27.9% post intervention. The intervention was associated with a reduction in odds of prescribing antibiotics in initiating facilities (odds ratio [OR] 0.6 (95% CI 0.3, 0.9), which declined further with an annual OR 0.8 [95% CI 0.7, 1.1] per year. Preliminary 6-month postintervention results were available from pilot clinics (n = 3) within two of the expansion VAs, which indicated similar effectiveness (OR 0.5 [0.4, 0.7]). Recurrent visits for ARIs (8.2% vs. 8.6%, P = 0.14) and adverse events (2.3% vs. 2.1%, P = 0.90) were not different pre-/post-intervention. Receipt of an antibiotic was not associated with recurrent visits for ARI (8.6% vs. 8.0%, P = 0.45) or adverse events (1.9% vs. 1.7%, P = 0.11).

Conclusion

An audit-feedback intervention sustained a reduction in antibiotic prescribing for ARIs over 3 years, and resulted in similar reductions in antibiotic use in varied ED and PC settings without affecting ARI-related return visit rates.

Disclosures

All authors: No reported disclosures.

732. Description of Diagnoses and Antibiotic Management of Otitis Media and Otitis Externa in Adults

Background

Otitis diagnoses include acute otitis media (AOM), otitis media with effusion (OME), and acute otitis externa (AOE). AOM and OME occur primarily in children, whereas AOE occurs with similar frequency in children and adults. Treatment with amoxicillin or close observation without antibiotics is recommended for pediatric AOM, and oral antibiotics are not routinely recommended to treat OME or uncomplicated AOE. Data on otitis diagnoses in adults is limited. This study’s purpose is to characterize the incidence and antibiotic management of otitis diagnoses in adults. Methods. A retrospective cohort of ambulatory veterans who presented at one of six VA Medical Centers during years 2014–2016 with an ICD-9 or -10 code for AOM, OME, and AOE diagnoses was developed. Data extracted included demographics, vital signs, diagnoses, and antibiotic prescriptions. Incident density rates for adult AOM, OME, and AOE were calculated and compared with rates for acute rhinosinusitis. Antibiotic prescribing rates were calculated. Results. Of 4,759 otitis visits identified, the most frequent diagnoses included AOM (38%), OME (25%), and AOE (34%). A single otitis diagnosis was coded in 95.6% of visits and 13.0% had co-diagnosis of another acute respiratory infection (ARI). The incidence density (±95% confidence interval) was 5.4 (5.2, 5.7), 3.6 (3.5, 3.9), and 4.9 (4.7, 5.2) cases per 1,000 patient-years for AOM, OME, and AOE, respectively. For comparison, the incidence density of rhinosinusitis was 16.6 (16.2, 17.0) cases per 1,000 patient-years. Oral antibiotics were prescribed in 48% of visits: AOM (50%), OME (49%), and AOE (47%). Topical antibiotics were prescribed in 32% of AOE visits. The most common oral and otic antibiotics prescribed were amoxicillin/clavulanate (36%), amoxicillin (28%), azithromycin (11%), and hydrocortisone/neomycin/polymyxin (65%), respectively. Conclusion. Otitis diagnoses in adults were common independent of ARI co-diagnoses, but less frequent than rhinosinusitis. Almost half of the patients received an oral antibiotic including those with AOE and OME, indicating a possible focus for antibiotic stewardship programs. Studies to evaluate diagnostic accuracy and treatment of otitis diagnoses in adults are needed.

Disclosures

All authors: No reported disclosures.

170. Characterization of Appropriate Antibiotic Prescribing for Pediatric Respiratory Tract Infections: Setting the Stage for Stewardship

Background

Inappropriate antibiotic use includes prescribing for antibiotic inappropriate diagnoses and use of broad-spectrum instead of narrow-spectrum therapies and contributes to adverse events and antibiotic resistance. To guide the design and implementation of antibiotic stewardship interventions in a network of pediatric clinics, we sought to characterize appropriate antibiotic prescribing for children diagnosed with uncomplicated respiratory infections.

Methods

Retrospective cohort study of visits by children to one of 31 primary care or six urgent care clinics in a university healthcare system between January 1, 2016 and December 31, 2017. Two outcomes were used to characterize antibiotic prescribing: (1) percentage of antibiotic inappropriate diagnoses (bronchitis, bronchiolitis, upper respiratory infection) that were prescribed an antibiotic; (2) percentage of visits with a diagnosis for acute otitis media (AOM), sinusitis, or pharyngitis prescribed first-line recommended antibiotics (amoxicillin or penicillin). Children with a documented penicillin allergy or antibiotic prescriptions in the previous 30 days were excluded. Chi-square tests were used to compare prescribing between settings.

Results

Among 117,279 total visits examined, 16,760 (14%) were for antibiotic inappropriate diagnoses, 5,912 (5%) for AOM, 844 (1%) for sinusitis and 4,912 (4%) for pharyngitis. Only 3% (95% CI: 2.9–3.4) of antibiotic inappropriate diagnoses were prescribed antibiotics. The percent of visits for AOM, sinusitis, and pharyngitis prescribed first-line antibiotics ranged from 27% (95% CI: 21–33) for sinusitis in urgent care to 91% (95% CI: 90–92) for pharyngitis in urgent care (figure). Differences in appropriate prescribing by setting were observed for AOM (P < 0.01) and sinusitis (P < 0.01).

Conclusion

In this network of pediatric practices, we found minimal evidence of unnecessary antibiotic use for respiratory infections but substantial underuse of first-line therapy for sinusitis, especially in urgent care settings. Stewardship interventions designed to reinforce existing practices for antibiotic-inappropriate conditions and promote greater use of appropriate first-line therapies are planned for this setting.

Disclosures

All authors: No reported disclosures.

255. Evaluation of Antibiotic Prescribing at University-Affiliated Dental Clinics

Background

Methods

Results

Conclusion

Disclosures

Specifying an implementation framework for Veterans Affairs antimicrobial stewardship programmes: using a factor analysis approach

Objectives

Inappropriate antibiotic use poses a serious threat to patient safety. Antimicrobial stewardship programmes (ASPs) may optimize antimicrobial use and improve patient outcomes, but their implementation remains an organizational challenge. Using the Promoting Action on Research Implementation in Health Services (PARiHS) framework, this study aimed to identify organizational factors that may facilitate ASP design, development and implementation.

Methods

Among 130 Veterans Affairs facilities that offered acute care, we classified organizational variables supporting antimicrobial stewardship activities into three PARiHS domains: evidence to encompass sources of knowledge; contexts to translate evidence into practice; and facilitation to enhance the implementation process. We conducted a series of exploratory factor analyses to identify conceptually linked factor scales. Cronbach's alphas were calculated. Variables with large uniqueness values were left as single factors.

Results

We identified 32 factors, including six constructs derived from factor analyses under the three PARiHS domains. In the evidence domain, four factors described guidelines and clinical pathways. The context domain was broken into three main categories: (i) receptive context (15 factors describing resources, affiliations/networks, formalized policies/practices, decision-making, receptiveness to change); (ii) team functioning (1 factor); and (iii) evaluation/feedback (5 factors). Within facilitation, two factors described facilitator roles and tasks and five captured skills and training.

Conclusions

We mapped survey data onto PARiHS domains to identify factors that may be adapted to facilitate ASP uptake. Our model encompasses mostly mutable factors whose relationships with performance outcomes may be explored to optimize antimicrobial use. Our framework also provides an analytical model for determining whether leveraging existing organizational processes can potentially optimize ASP performance.

Broad-Spectrum Antibiotic Use at Choice, Change, and Completion Throughout VA: Patterns of Initiation and De-escalation

Background

Antimicrobial stewardship programs seek to reduce initiation of unwarranted therapy, promote de-escalation and prevent excessive duration. The CDC Antibiotic Use option provides ward-level reports of antibiotic use and risk-adjusted Standardized Antibiotic Administration Ratios for pre-specified antibiotics groups that allow for inter-facility comparison, but do not provide the indication for use or temporal patterns that allow de-escalation assessments.

Methods

We characterized antibiotic use on days 0–2 (Choice), 3-4 (Change) and 5-6 (Completion) of therapy (CCC) for pneumonia (LRTI), skin-soft-tissue infections (SSTI) and urinary tract infection (UTI). We then explored the relationship between total MRSA or multi-drug-resistant GNR (MDRO) antibiotic use and use over CCC intervals for LRTI and SSTI for patients in acute non-ICU settings in 33 high-complexity VA facilities. Data were from 2016 and extracted from the VA Corporate Data Warehouse.

Results

The mean rates of anti-MRSA and anti-MDRO therapy were 108 and 123 Days of Therapy (DOT)/1000 days present, respectively. The table shows the fraction (mean, range) of patients with SSTI or LRTI receiving anti-MRSA or anti-MDRO therapy at the CCC intervals and the change in use (i.e., de-escalation) over the treatment course.

Conclusion

Syndrome-specific CCC metrics show substantial variations in the rates of de-escalation of antimicrobial use over treatment courses. Insights provided by these metrics will allow facilities to identify specific areas for improvement by targeting syndrome-specific initial choices of therapy or antibiotic de-escalation.

Disclosures

All authors: No reported disclosures.

Significance of Prior Culture History for Predicting Urinary Tract Infection Caused by Multi-drug Resistant Enterobacteriaceae

Background

Extended-spectrum β-lactamase (ESBL) -producing E. coli, Klebsiella spp., and Proteus spp. (EKP), that cause urinary tract infections (UTI) are resistant to first-line therapies (e.g., ceftriaxone). Prediction of UTI caused by ESBL-producing organisms is important for selection of empirical therapy. The objective was to develop a prediction model to identify UTI caused by ceftriaxone (CRO)-resistant EKP and compare the model to other commonly cited predictive models (Tumbarello M et al. AAC Jul 2011; Johnson SW et al. ICHE Apr 2013).

Methods

A single-center, matched, case–control of Veterans Affairs (VA) outpatients with a positive (≥10^4 CFU/mL) urine culture was conducted. Patients were excluded if they had no UTI diagnosis or documented symptoms, age <18, transfer from another hospital, or a significant urine culture result. Cases were defined as any patient with a CRO-resistant EKP; controls were matched 4:1 to cases based on incident density (≤ 30 days) by random selection. Logistic regression and receiver operator curves were used to develop and assess models.

Results

One hundred subjects were included in the analysis. Demographics were similar except for age [Case 73.5 years (13.7); Control 64.5 years (15.2); P = 0.02] and history of CRO-resistant EKP in last 6 months (Case 40%; Control 0%; P < 0.01). Predictor variables in the final model (Likelihood Ratio 44.2, P < 0.01) included history of CRO-resistant EKP in last 6 months (131.5, 12.2–18308.0), cephalosporin use in past 60 days (12.7, 1.9–94.5), residence in a skilled nursing or assisted living facility (8.0, 1.6–40.5), and hospitalization in last 6 months (OR 3.0, 95% CI 0.7–12.5). In the VA population, the other models predicted significantly although less accurately (Figure 1).

Conclusion

Prior cephalosporin use, hospitalization, and residence were important predictors of UTI caused by CRO-resistant EKP; however, prior history of CRO-resistant EKP was the most important predictor. A Model that included prior culture results predicted CRO-resistant UTIs better than other commonly cited models that do not contain prior ESBL history. Prior culture data should be considered when selecting empirical antibiotics for UTI. Validation in a larger cohort is warranted.

Disclosures

All authors: No reported disclosures.

Causal Conditions Supporting Antibiotic Stewardship Information Dashboards

Background

Antibiotic stewardship is key to minimizing antibiotic resistance. To assist antibiotic stewards in dissecting population-level antibiotic use patterns, our study group developed a dashboard that displays consolidated patterns, supports data exploration, and compares facility-level antibiotic use to others. We report fuzzy set qualitative comparative analyses (QCA) of interviews designed to elicit user experiences to uncover different combinations of causal conditions supporting dashboard use.

Methods

Dashboards were iteratively designed based upon longitudinal feedback from stewards. Views include antibiotic use stratified by diagnoses and duration of therapy. Eight VAMCs, each with 0.5 to 2.0 FTE stewards, used the dashboard. One to 2 stewards from each site were interviewed using a structured script that focused on: 1) structure (i.e., program FTE) and functions of the local stewardship program; 2) critical incident or usage story; and 3) perceived knowledge and efficacy.

Results

Qualitative codes were developed from the interviews and were scaled in a fuzzy logic framework (i.e., between 0 and 1) to reflect the degree to which the qualitative theme was present in the stewardship program at participating clinical sites. The scaling was assigned using prior knowledge external to the data. The most parsimonious QCA solution identified just the absence of program structure (program FTE) a sufficient causal configuration to the frequency of dashboard use (coverage = 0.612, consistency = 0.813). Intermediate solutions added stewardship activities, dashboard self-efficacy, and trust in the data (coverage = 0.502, consistency = 0.952) as sufficient conditions. The coverage for both solutions exceeded 0.75, which was the lower bound of acceptability.

Conclusion

The dashboard may be successfully integrated into institutions based on the complicated interplay between program structure (e.g., # FTE) and dashboard self-efficacy, experience with data-activities, and trust of population data. Incorporating user-centered design of dashboards supports the development of fully functional teams and has the potential for important population health impact.

Disclosures

All authors: No reported disclosures.

Association of Inpatient Antimicrobial Utilization Measures with Antimicrobial Stewardship Activities and Facility Characteristics of Veterans Affairs Medical Centers

BACKGROUND

Antimicrobial stewardship programs (ASPs) have been advocated to improve antimicrobial utilization, but program implementation is variable. Antimicrobial stewardship programs (ASPs) have been advocated to improve antimicrobial utilization, but program implementation is variable.

OBJECTIVE

To determine associations between ASPs and facility characteristics, and inpatient antimicrobial utilization measures in the Veterans Affairs (VA) system in 2012.

DESIGN

In 2012, VA administered a survey on antimicrobial stewardship practices to designated ASP contacts at VA acute care hospitals. From the survey, we identified 34 variables across 3 domains (evidence, organizational context, and facilitation) that were assessed using multivariable least absolute shrinkage and selection operator regression against 4 antimicrobial utilization measures from 2012: aggregate acute care antimicrobial use, antimicrobial use in patients with non-infectious primary discharge diagnoses, missed opportunities to convert from parenteral to oral antimicrobial therapy, and double anaerobic coverage.

SETTING

All 130 VA facilities with acute care services.

RESULTS

Variables associated with at least 3 favorable changes in antimicrobial utilization included presence of postgraduate physician/pharmacy training programs, number of antimicrobial-specific order sets, frequency of systematic de-escalation review, presence of pharmacists and/or infectious diseases (ID) attendings on acute care ward teams, and formal ID training of the lead ASP pharmacist. Variables associated with 2 unfavorable measures included bed size, the level of engagement with VA Antimicrobial Stewardship Task Force online resources, and utilization of antimicrobial stop orders.

CONCLUSIONS

Formalization of ASP processes and presence of pharmacy and ID expertise are associated with favorable utilization. Systematic de-escalation review and order set establishment may be high-yield interventions. Journal of Hospital Medicine 2017;12:301-309.

Outcomes Associated With Antimicrobial De-escalation of Treatment for Pneumonia Within the Veterans Healthcare Administration

De-escalation, an antimicrobial stewardship concept, involves narrowing broad-spectrum empiric antimicrobial therapy based on clinical data. Current health outcomes evidence is lacking to support de-escalation. Studying Veterans Healthcare Administration pneumonia patients, de-escalation was associated with improved length of stay without affecting 30-day readmission or 30-day Clostridium difficile infection rates.

Antimicrobial de-escalation of treatment for healthcare-associated pneumonia within the Veterans Healthcare Administration

OBJECTIVES

The objective of this study was to measure quantitatively antimicrobial de-escalation utilizing electronic medication administration data based on the spectrum of activity for antimicrobial therapy (i.e. spectrum score) to identify variables associated with de-escalation in a nationwide healthcare system.

METHODS

A retrospective cohort study of patients hospitalized for healthcare-associated pneumonia was conducted in Veterans Affairs Medical Centers (n = 119). Patients hospitalized for healthcare-associated pneumonia on acute-care wards between 5 and 14 days who received antimicrobials for ≥ 3 days during calendar years 2008-11 were evaluated. The spectrum score method was applied at the patient level to measure de-escalation on day 4 of hospitalization. De-escalation was expressed in aggregate and facility-level proportions. Logistic regression was used to assess variables associated with de-escalation. ORs with 95% CIs were reported.

RESULTS

Among 9319 patients, the de-escalation proportion was 28.3% (95% CI 27.4-29.2), which varied 6-fold across facilities [median (IQR) facility-level de-escalation proportion 29.1% (95% CI 21.7-35.6)]. Variables associated with de-escalation included initial broad-spectrum therapy (OR 1.5, 95% CI 1.4-1.5 for each 10% increase in spectrum), collection of respiratory tract cultures (OR 1.1, 95% CI 1.0-1.2) and care in higher complexity facilities (OR 1.3, 95% CI 1.1-1.6). Respiratory tract cultures were collected from 35.3% (95% CI 32.7-37.7) of patients.

CONCLUSIONS

De-escalation of antimicrobial therapy was limited and varied substantially across facilities. De-escalation was associated with respiratory tract culture collection and treatment in a high complexity-level facility.

Trends in Antibiotic Use and Nosocomial Pathogens in Hospitalized Veterans With Pneumonia at 128 Medical Centers, 2006-2010

BACKGROUND

In 2005, pneumonia practice guidelines recommended broad-spectrum antibiotics for patients with risk factors for nosocomial pathogens. The impact of these recommendations on the ability of providers to match treatment with nosocomial pathogens is unknown.

METHODS

Among hospitalizations with a principal diagnosis of pneumonia at 128 Department of Veterans Affairs medical centers from 2006 through 2010, we measured annual trends in antibiotic selection; initial blood or respiratory cultures positive for methicillin-resistant Staphylococcus aureus (MRSA), Pseudomonas aeruginosa, and Acinetobacter species; and alignment between antibiotic coverage and culture results for MRSA and P. aeruginosa, calculating sensitivity, specificity, and diagnostic odds ratio using a 2 × 2 contingency table.

RESULTS

In 95 511 hospitalizations for pneumonia, initial use of vancomycin increased from 16% in 2006 to 31% in 2010, and piperacillin-tazobactam increased from 16% to 27%, and there was a decrease in both ceftriaxone (from 39% to 33%) and azithromycin (change from 39% to 36%) (P < .001 for all). The proportion of hospitalizations with cultures positive for MRSA decreased (from 2.5% to 2.0%; P < .001); no change was seen for P. aeruginosa (1.9% to 2.0%; P = .14) or Acinetobacter spp. (0.2% to 0.2%; P = .17). For both MRSA and P. aeruginosa, sensitivity increased (from 46% to 65% and 54% to 63%, respectively; P < .001) and specificity decreased (from 85% to 69% and 76% to 68%; P < .001), with no significant changes in diagnostic odds ratio (decreases from 4.6 to 4.1 [P = .57] and 3.7 to 3.2 [P = .95], respectively).

CONCLUSIONS

Between 2006 and 2010, we found a substantial increase in the use of broad-spectrum antibiotics for pneumonia despite no increase in nosocomial pathogens. The ability of providers to accurately match antibiotic coverage to nosocomial pathogens remains low.

Description and validation of a spectrum score method to measure antimicrobial de-escalation in healthcare associated pneumonia from electronic medical records data

BACKGROUND

Comparison of antimicrobial de-escalation rates between healthcare settings is problematic. To objectively and electronically measure de-escalation a method based upon the spectrum of antimicrobial regimens administered (i.e., spectrum score) was developed.

METHODS

A Delphi process was used to develop applicable concepts. Spectrum scores were created for 27 antimicrobials based upon susceptibility for 19 organisms. National VA susceptibility data was used to estimate microbial spectrum. Susceptibility estimates were converted to ordinal scores, and values for organisms with multi-drug resistance potential were weighted more heavily. Organism scores were summed to create antibiotic-specific spectrum scores and extended mathematically to score multi-antimicrobial regimens. Vignettes were created from antimicrobial regimens administered to 300 patients hospitalized with pneumonia. Daily spectrum scores were calculated for each case. Hospitalization day 4 scores were subtracted from day 2 scores (i.e., spectrum score ∆). A positive spectrum score ∆ defined de-escalation. Experts ranked each pneumonia case on a 7-point Likert scale (Likert >4 indicated de-escalation). Spectrum score ∆s were compared to expert review. Findings were used to identify score deficiencies. Next, 40 pairs of cases were modified to include antimicrobial administration routes. Each pair contained almost similar regimens; however, one contained oral (PO) the other only intravenous (IV) antimicrobials on day 4 of therapy. Experts reviewed cases as described. Spectrum score ∆ credits to account for PO conversion were derived from the mean paired differences in Likert Score. De-escalation status was evaluated in 100 vignettes containing antimicrobial route by different experts and compared to the modified method.

RESULTS

Initial sensitivity and specificity of the spectrum score ∆ to detect expert classified de-escalation events was 86.3 and 96.0%, respectively. In paired cases, the mean (± SD) Likert score was 5.0 (1.5) and 4.6 (1.5) for PO and IV (P = 0.002), respectively. To improve de-escalation event detection, two credits were added to spectrum score ∆s based upon the percentage of antimicrobials administered PO on day 4. The final method, exhibited sensitivity and specificity to detect expert classified de-escalation events of 96.2 and 93.6%, respectively.

CONCLUSIONS

The final spectrum score method exhibited excellent agreement with expert judgments of de-escalation events in pneumonia.

Initiation and termination of antibiotic regimens in Veterans Affairs hospitals

OBJECTIVES

To assess rates of starting or stopping antibiotics across different hospitals.

METHODS

We used barcode medication administration data to measure antibiotic use on acute-care wards in 128 Veterans Affairs medical centres (VAMCs) in 2010. A treatment day (TD) was defined as the administration of any antibiotic on a given day. A treatment period (TP) was defined as an interval of inpatient antimicrobial therapy with gaps of ≤1 day in TDs. The rate of starting antibiotics was calculated for inpatients who had not yet started antibiotics, as the number of start events divided by the 'person-time at risk'. The rate of stopping antibiotics was calculated analogously for inpatients that were on antibiotics. Once individuals had stopped antibiotics they were removed from further analysis. Per-day start and stop rates were also calculated for each day of hospitalization.

RESULTS

The hospital mean rate of starting the first TP was 18.1 start events/100 days at risk (range 8.4-25.6/100 days at risk). The mean hospital stopping rate was 21.1 stop events/100 days at risk (range 13.3-29.5/100 days at risk). The ratio of a facility's starting and stopping rates was highly correlated with overall antibiotic use in TDs/1000 patient-days (rs=0.92, P<0.001), while starting and stopping rates individually were only moderately correlated (rs=0.39, P<0.001).

CONCLUSIONS

VAMCs with similar antibiotic use showed marked differences in their starting and stopping rates of antibiotics. It may be useful to target empirical therapy when starting rates are high and definitive therapy when stopping rates are low.

Does universal active MRSA surveillance influence anti-MRSA antibiotic use? A retrospective analysis of the treatment of patients admitted with suspicion of infection at Veterans Affairs Medical Centers between 2005 and 2010

OBJECTIVES

After the implementation of an active surveillance programme for MRSA in US Veterans Affairs (VA) Medical Centers, there was an increase in vancomycin use. We investigated whether positive MRSA admission surveillance tests were associated with MRSA-positive clinical admission cultures and whether the availability of surveillance tests influenced prescribers' ability to match initial anti-MRSA antibiotic use with anticipated MRSA results from clinical admission cultures.

METHODS

Analyses were based on barcode medication administration data, microbiology data and laboratory data from 129 hospitals between January 2005 and September 2010. Hospitalized patient admissions were included if clinical cultures were obtained and antibiotics started within 2 days of admission. Mixed-effects logistic regression was used to examine associations between positive MRSA admission cultures and (i) admission MRSA surveillance test results and (ii) initial anti-MRSA therapy.

RESULTS

Among 569,815 included admissions, positive MRSA surveillance tests were strong predictors of MRSA-positive admission cultures (OR 8.5; 95% CI 8.2-8.8). The negative predictive value of MRSA surveillance tests was 97.6% (95% CI 97.5%-97.6%). The diagnostic OR between initial anti-MRSA antibiotics and MRSA-positive admission cultures was 3.2 (95% CI 3.1-3.4) for patients without surveillance tests and was not significantly different for admissions with surveillance tests.

CONCLUSIONS

The availability of nasal MRSA surveillance tests in VA hospitals did not seem to improve the ability of prescribers to predict the necessity of initial anti-MRSA treatment despite the high negative predictive value of MRSA surveillance tests. Prospective trials are needed to establish the safety and effectiveness of using MRSA surveillance tests to guide antibiotic therapy.