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1857. Implementing Antibiotic Stewardship in Urgent Care Centers

Authors:

Abstract

Background Antibiotic stewardship (AS) has historically focused on inpatient facilities and primary care clinics; many antibiotics (ABx) are prescribed in urgent care clinics (UCCs). However, few centers have described implementing AS in such settings. We sought to reduce total ABx use in our UCCs as well as specifically decrease azithromycin use. Methods We conducted this study in four UCCs owned by a large community-based academic healthcare system in northern Delaware. The UCCs average >65,000 visits annually and include 38 providers (physicians, physician assistants and nurse practitioners). A new electronic health record was implemented in October 2016; ABx utilization data are not available prior to this time. Beginning in January 2017, all providers received in-person education on guideline-recommended management of common infectious diseases, including bronchitis, sinusitis, and pharyngitis. The lead physician performed chart audits and provided group and individual education and feedback via email and telephone. Individual ABx utilization rates were not provided, but documentation of rationale for ABx need was emphasized. Patient education included ABx links on the check-in website, posters in waiting and examination rooms, and patient education materials embedded within each discharge packet, with an emphasis on providing evidence-based care rather than “denying ABx.” We calculated number of total ABx prescriptions (Rx) and of azithromycin Rx per 100 visits per month, and calculated rate ratios comparing January 2017 (pre-intervention) to January 2018 (post). Results During the 16-month intervention period, total ABx use declined from 67 Rx per 100 visits to 44/100 visits (rate ratio, 0.55, 95% CI 0.37–0.80) and azithromycin use declined from 13 Rx/100 visits to 5/100 visits (RR 0.32, 95% CI 0.10–0.88). Seasonal variability was apparent (figure). Conclusion A multifaceted educational approach positively impacted provider behaviors and patient expectations, and did not rely upon providing ABx utilization data (either clinic- or individual-level). Ensuring leadership support of providers if patients expressed dissatisfaction and standardized messaging and tools were critical for managing patient expectations. Disclosures All authors: No reported disclosures.
S530 • OFID 2018:5 (Suppl 1) • Poster Abstracts
Disclosures. R. V. Nathan, Merck & Co.: Scientic Advisor and Speaker’s
Bureau, Consulting fee and Speaker honorarium. e Medicines Company: Speaker’s
Bureau, Speaker honorarium. Allergan: Speaker’s Bureau, Speaker honorarium. R.
L.Hengel, Merck & Co.: Scientic Advisor, Consulting fee. K. A. Couch, Allergan:
Speaker’s Bureau, Speaker honorarium. Merck: Speaker’s Bureau, Speaker honorarium.
Melinta: Speaker’s Bureau, Speaker honorarium. L. J.Van Anglen, Merck & Co.: Grant
Investigator, Research grant.
1855. Antimicrobial Stewardship (AMS) and the Outpatient Parenteral
Antimicrobial erapy (OPAT) Setting
N. DeborahFriedman, MD; Medicine and Infectious Diseases, Barwon health,
Geelong, Australia and National Centre for Antimicrobial Stewardship
Session: 221. Antimicrobial Stewardship: Outpatient Settings
Saturday, October 6, 2018: 12:30 PM
Background. Antimicrobial resistance is a major threat to human health. In the
OPAT setting broad-spectrum once daily antimicrobials may be chosen in preference
to other agents requiring multiple daily doses for reasons of convenience. e role and
eectiveness of antimicrobial stewardship (AMS) in the Australian hospital-in-the-
home (OPAT) setting have not previously been studied.
Methods. e National Antimicrobial Prescribing Survey (NAPS) was developed
in 2011 to provide an audit of antimicrobial prescribing in Australian hospitals and is
conducted by e Australian National Centre for Antimicrobial Stewardship (NCAS).
e Hospital NAPS was modied for the OPAT setting, trialed in 2016 in ve health
services and rolled out to all Australian OPAT services as a pilot in2017.
Results. Twenty-three OPAT services throughout Australia participated in the
OPAT NAPS pilot. In total, 1,154 prescriptions for 722 patients (63% male) were
included. Patients ranged in age from 1month to 101years; median age was 58years.
e most common indications for parenteral antimicrobials were; cellulitis (30%),
osteomyelitis (8%), pneumonia (7%), abscess (6%), Cystic Fibrosis exacerbation (5%),
endocarditis (4%), septic arthritis (4%), prosthetic joint infection (4%), and exacerbation
of bronchiectasis (2%). Piperacillin–tazobactam or ceriaxone were prescribed in 20% of
cases. e majority of prescriptions for antimicrobials to treat community-acquired pneu-
monia and exacerbations of chronic obstructive airways disease were not compliant with
guidelines.e median duration of parenteral therapy for cellulitis was 4days; however,
duration ranged overall from 1 to 44days for this indication. Prescriptions were compli-
ant with guidelines in 43% of cases, and appropriateness of antimicrobial prescribing was
assessed as optimal in 74%, adequate in 13%, suboptimal in 8.5% and inadequate in 3%.
Antimicrobial therapy duration was incorrect in 9% ofcases.
Conclusion. Opportunities exist for improving AMS interventions in the OPAT
setting, specically in regards to the use of broad-spectrum antimicrobials and in the
treatment of respiratory tract infection. Importantly, not all OPAT services have the
same access toAMS.
Disclosures. All authors: No reported disclosures.
1856. Comparison of Antibiotic Susceptibility in Hospitals vs. Hospital-Based
Emergency Departments
MandelinCooper, PharmD, BCPS; JoanKramer, PharmD, BCPS;
ElizabethHofammann, PharmD, BCPP and HayleyBurgess, PharmD, BCPP; Clinical
Services Group, HCA Healthcare, Nashville, Tennessee
Session: 221. Antimicrobial Stewardship: Outpatient Settings
Saturday, October 6, 2018: 12:30 PM
Background. Antibiotic susceptibility varies by hospital location (inpatient vs.
emergency department (ED)) and by geographic location. Despite these dierences,
hospitals oen have one antibiogram to determine empiric guidelines. e purpose of
this study was to evaluate a large health systems bacterial sensitivity for key organisms
in the inpatient vs. the ED setting to determine whether ED-specic antibiograms are
necessary based on region.
Methods. Ahealth-system, consisting of primarily large general community hos-
pitals across 20 US states, evaluated 156 of their hospitals and hospital-based EDs.
ese hospitals and hospital-based EDs were divided into regions based on geographic
area for assessment. Inpatient and ED susceptibilities were then compared and classi-
ed based on susceptibility dierences (Minimal 0–4, Moderate 5–10, Considerable
> 10). One year of susceptibility data for E.coli, P.aeruginosa and S.pneumoniae was
evaluated for antibiotic sensitivity.
Results. A total of 171,556 nonduplicative isolates were evaluated including
139,562 E. coli urine isolates (inpatient 41,612, ED 97,950), 28,685 P.aeruginosa (in-
patient 19,983, ED 8,702) and 3,309 S.pneumoniae (inpatient 1,565, ED 1,474). e
ED was expected to have less resistance than inpatients as ED patients primarily come
from a community setting. For E.coli urinary isolates, minimal dierences were found
for sulfamethoxazole/trimethoprim, and moderate dierences were seen in cefazolin
and ceriaxone for the California/Nevada and Texas San Antonio regions. Moderate or
considerable dierences were seen in nearly all regions for ciprooxacin. Considerable
dierences in S.pneuomoniae susceptibilities were seen between the inpatient and ED
for azithromycin and penicillin G, while one region also had a considerable dierence
for levooxacin. P.aeruginosa had one region with a considerable dierence, with the
Colorado + Central Kansas regions showing less resistance inpatient than theED.
Conclusion. Dierences in inpatient vs. ED bacterial sensitives warrant jus-
tication for-specic regions to monitor and develop inpatient and ED-specic
antibiograms.
Disclosures. All authors: No reported disclosures.
1857. Implementing Antibiotic Stewardship in Urgent Care Centers
Harold P.Kramer, MD1; JillianDougherty, PharmD, BCPS1; MichaelWiniarz, BS,
MS1; Christian M.Coletti, MD, MHCDS1; Edward F.Ewen, MD1 and MarciDrees,
MD, MS1,2; 1Christiana Care Health System, Newark, Delaware, 2Sidney Kimmel
Medical College, omas Jeerson University, Philadelphia, Pennsylvania
Session: 221. Antimicrobial Stewardship: Outpatient Settings
Saturday, October 6, 2018: 12:30 PM
Background. Antibiotic stewardship (AS) has historically focused on inpatient facil-
ities and primary care clinics; many antibiotics (ABx) are prescribed in urgent care clinics
(UCCs). However, few centers have described implementing AS in such settings. We sought
to reduce total ABx use in our UCCs as well as specically decrease azithromycinuse.
Methods. We conducted this study in four UCCs owned by a large communi-
ty-based academic healthcare system in northern Delaware. e UCCs average >65,000
visits annually and include 38 providers (physicians, physician assistants and nurse
practitioners). Anew electronic health record was implemented in October 2016; ABx
utilization data are not available prior to this time. Beginning in January 2017, all provid-
ers received in-person education on guideline-recommended management of common
infectious diseases, including bronchitis, sinusitis, and pharyngitis. e lead physician
performed chart audits and provided group and individual education and feedback via
email and telephone. Individual ABx utilization rates were not provided, but documen-
tation of rationale for ABx need was emphasized. Patient education included ABx links
on the check-in website, posters in waiting and examination rooms, and patient educa-
tion materials embedded within each discharge packet, with an emphasis on providing
evidence-based care rather than “denying ABx.” We calculated number of total ABx
prescriptions (Rx) and of azithromycin Rx per 100 visits per month, and calculated rate
ratios comparing January 2017 (pre-intervention) to January 2018 (post).
Results. During the 16-month intervention period, total ABx use declined from
67 Rx per 100 visits to 44/100 visits (rate ratio, 0.55, 95% CI 0.37–0.80) and azithro-
mycin use declined from 13 Rx/100 visits to 5/100 visits (RR 0.32, 95% CI 0.10–0.88).
Seasonal variability was apparent (gure).
Conclusion. A multifaceted educational approach positively impacted provider
behaviors and patient expectations, and did not rely upon providing ABx utilization
data (either clinic- or individual-level). Ensuring leadership support of providers if
patients expressed dissatisfaction and standardized messaging and tools were critical
for managing patient expectations.
Disclosures. All authors: No reported disclosures.
1858. Use and Perceptions of an Institution-Specic Antibiotic Prescribing “App”
among Emergency Department and Urgent Care Clinicians
Timothy C.Jenkins, MD1; NancyAsdigian, PhD2; HeatherYo u ng , MD3;
KatiShihadeh, PharmD4; JereySanko, MD5; BryanKnepper, MPH, MS, CIC6 and
Jason Haukoos, MD7; 1Denver Health, Denver, Colorado, 2Colorado School of Public
Health, Aurora, Colorado, 3Infectious Diseases, Denver Health Medical Center,
Denver, Colorado, 4Acute Care Pharmacy, Denver Health Medical Center, Denver,
Colorado, 5Emergency Medicine, Denver Health Medical Center, Denver, Colorado,
6Patient Safety and Quality, Denver Health Medical Center, Denver, Colorado,
7Emergency Medicine, Denver Health, Denver, Colorado
Session: 221. Antimicrobial Stewardship: Outpatient Settings
Saturday, October 6, 2018: 12:30 PM
Background. We developed an application (app), accessible by mobile device or
computer, to provide institution-specic antibiotic prescribing recommendations for
common infections. e app was disseminated to emergency department (ED) and
urgent care clinicians in August 2014. e purpose of this study was to assess current
use of the app and its perceived impact on prescribing.
Methods. We developed and administered an online survey. e survey instru-
ment was pre-tested by a survey methodologist, two emergency medicine physicians,
an infectious diseases (ID) physician, and an ID pharmacist and subsequently pilot-
tested in a group of 70 providers. e nal survey was administered to all clinicians
in the Denver Health ED and two urgent care centers, including physicians, advanced
practice providers, and Emergency Medicine residents. Respondents were eligible if
they had worked at least one ED or urgent care shi within 90days and either person-
ally prescribe antibiotics or oversee other clinicians who prescribe antibiotics.
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MD 7 ; 1 Denver Health
  • Bryan Knepper
  • Jason Haukoos
Bryan Knepper, MPH, MS, CIC 6 and Jason Haukoos, MD 7 ; 1 Denver Health, Denver, Colorado, 2 Colorado School of Public Health, Aurora, Colorado, 3 Infectious Diseases, Denver Health Medical Center, Denver, Colorado, 4 Acute Care Pharmacy, Denver Health Medical Center, Denver, Colorado, 5 Emergency Medicine, Denver Health Medical Center, Denver, Colorado, 6