Background: Prior research has implicated contaminated surfaces in the transmission of Clostridioides difficile within the hospital. To reduce the risk of transmission, enhanced environmental hygiene is performed in rooms of patients with known C.difficile infection (CDI). We wished to evaluate the residual impact of environmental surfaces on hospital-onset CDI (HO-CDI) by comparing HO-CDI rates before and after the opening of a new 504-bed hospital building, HUP Pavilion (PAV). We hypothesized that we would observe a reduction in HO-CDI after opening of PAV due to a reduced burden of C.difficile spores in the environment. Methods: We included NHSN reported HO-CDI rates for 28 months prior and 24 months after opening of PAV. Upon opening, patients were divided between the old building (HUP) and PAV. We included all patient units before and after opening. We created hierarchical models of HO-CDI rates using Stan Hamiltonian Monte Carlo (HMC) version 2.30.1, via the “cmdstanr” and “brms” packages with a GAM smooth function by month and intervention period with default, weakly-informative priors. Results: At baseline, there was an average of approximately 20,100 patient days per month, subsequently divided between HUP and PAV (mean 10,100 and 12,100 patient days per month). After opening of PAV, we observed a reduced HO-CDI rate (mean 0.21 vs 0.31 per 1000 patient days, P=0.01). When comparing the two specific buildings after opening of PAV, there was a greater reduction noticed in the old building (HUP) as compared to the new building (PAV) (0.12 vs 0.29 per 1000 patient days) (Figure 1). The predicted contrast in HO-CDI rate (Figure 2), shows no immediate change in HO-CDI after opening, however a sustained reduction estimated at 0.1 HO-CDI events per 1000 patient days for the duration of follow-up. Conclusions: We observed a reduction in HO-CDI rates after the opening of a new hospital building. The difference in HO-CDI rates between hospital buildings after the move is likely due to the concentration of high-risk patient cohorts within this building. Our findings suggests that there remains an opportunity to reduce HO-CDI through environmental hygiene. However, it is possible that other factors beyond surface environment contributed to an observed reduction in HO-CDI, including other concurrent infection control interventions that focused on smaller populations within the hospital. In future work we will investigate the durability of this observed effect with additional analyses including patient-level risk for HO-CDI.

Background: Feedback reports summarizing clinician performance are effective tools to improve antibiotic stewardship in the ambulatory setting, but few studies have evaluated their effectiveness for pediatric inpatients. We developed and implemented feedback reports reflecting electronically-derived measures of appropriate antibiotic choice and duration for community acquired pneumonia (CAP) and measured their impact on appropriate antibiotic use in children hospitalized for CAP. Methods: We performed a single center quasi-experimental study including children 6 months to 17 years hospitalized for CAP between 12/1/2021-11/30/2023. Children with chronic medical conditions, ICU stays >48 hours, and outside transfers were excluded. The intervention occurred in 11/2022 and included clinician education, a monthly group-level feedback report disseminated by email (Figure 1), and a monthly review of clinician performance during a virtual quality improvement meeting. Patient characteristics were compared using chi-square or Wilcoxon rank sum tests. Interrupted time series analysis (ITSA) was used to measure the immediate change in the proportion of CAP encounters receiving both the appropriate antibiotic choice and duration, as well as the change in slope from the preintervention to the postintervention periods. Choice and duration were analyzed separately using ITSA as a secondary analysis. Results: There were 817 CAP encounters, including 420 preintervention and 397 postintervention. Patients admitted in the postintervention period were older (median age 2 years vs 3 years, P=0.03), but otherwise there were no differences in race, ethnicity, sex, ICU admission, or complicated pneumonia. Preintervention, 52% of encounters received both the appropriate antibiotic choice and duration; 96% of encounters received the appropriate antibiotic choice and 54% received the appropriate duration. The ITSA demonstrated an immediate 16% increase in the proportion of patients receiving both appropriate antibiotic choice and duration (95% confidence interval, 1-31%; P = 0.047) and no significant further increase over time following the intervention (P = 0.84) (Figure 2). When antibiotic choice was analyzed separately by ITSA, there was no immediate change or change over time in the proportion of patients receiving the appropriate antibiotic choice. In the ITSA of duration alone, there was an immediate 17% increase in the proportion receiving the appropriate duration (95% confidence interval, 2-33%; P = 0.03) and no change over time. Conclusion: Feedback reports generated from electronically-derived metrics of antibiotic choice and duration, combined with ongoing clinician education, increased the proportion of children with CAP treated with the appropriate antibiotic duration. Electronic feedback reports are a scalable and impactful intervention to improve antibiotic use in children hospitalized with CAP.

We conducted a retrospective study to assess performance of provider-selected antibiotic indication (PSI) in identifying hospitalized adults with community-acquired pneumonia. PSI showed moderate sensitivity (64.4%) and high specificity (96.3%). PSI has potential utility for targeted real-time antibiotic stewardship interventions, though future research should investigate methods to improve sensitivity.

Background: The epidemiology of extended-spectrum cephalosporin-resistant Enterobacterales (ESCrE) in hospitalized patients in low- and middle-income countries (LMICs) is poorly described. Although risk factors for ESCrE clinical infection have been studied, little is known of the epidemiology of ESCrE colonization. Identifying risk factors for ESCrE colonization, which can predispose to infection, is therefore critical to inform antibiotic resistance reduction strategies. Methods: This study was conducted in 3 hospitals located in 3 districts in Botswana. In each hospital, we conducted ongoing surveillance in sequential units hospitalwide. All participants had rectal swabs collected which were inoculated onto chromogenic media followed by confirmatory testing using MALDI-TOF MS and VITEK-2. Data were collected via interview and review of the inpatient medical record on demographics, comorbidities, antibiotic use, healthcare exposures, invasive procedures, travel, animal contact, and food consumption. Participants with ESCrE colonization (cases) were compared to noncolonized participants (controls) using bivariable and multivariable analyses to identify risk factors for ESCrE colonization. Results: Enrollment occurred from January 15, 2020, to September 4, 2020, and 469 participants were enrolled. The median age was 42 years (IQR, 31–58) and 320 (68.2%) were female. The median time from hospital admission to date of sampling was 5 days (IQR, 3–12). There were 179 cases and 290 controls (ie, 38.2% of participants were ESCrE colonized). Independent risk factors for ESCrE colonization were a greater number of days on antibiotic, recent healthcare exposure, and tending swine prior to hospitalization. (Table). Conclusions: ESCrE colonization among hospitalized patients was common and was associated with several exposures. Our results suggest prior healthcare exposure may be important in driving ESCrE. The strong link to recent antibiotic use highlights the potential role of antibiotic stewardship interventions for prevention. The association with tending swine suggests that animal husbandry practices may play a role in community exposures, resulting in colonization detected at the time of hospital admission. These findings will help to inform future studies assessing strategies to curb further emergence of hospital ESCrE in LMICs.

Disclosures: None

Background: Community-acquired pneumonia (CAP) is a common indication for antibiotic use in hospitalized children and is a key target for pediatric antimicrobial stewardship programs (ASPs). Building upon prior work, we developed and refined an electronic algorithm to identify children hospitalized with CAP and to evaluate the appropriateness of initial antibiotic choice and duration. Methods: We performed a cross-sectional study including children 6 months to 17 years hospitalized for CAP between January 1, 2019, and October 31, 2022, at a tertiary-care children’s hospital. CAP was defined electronically as an International Classification of Disease, Tenth Revision (ICD-10) code for pneumonia, a chest radiograph or chest computed tomography scan (CT) performed within 48 hours of admission, and systemic antibiotics administered within the first 48 hours of hospitalization and continued for at least 2 days. We applied the following exclusion criteria: patients transferred from another healthcare setting, those who died within 48 hours of hospitalization, children with complex chronic conditions, and those with intensive care unit stays >48 hours. Criteria for appropriate antibiotic choice and duration were defined based on established guidelines. Two physicians performed independent medical record reviews of 80 randomly selected patients (10% sample) to evaluate the performance of the electronic algorithm in (1) identifying patients treated for clinician-diagnosed CAP and (2) classifying antibiotic choice and duration as appropriate. A third physician resolved discrepancies. The electronic algorithm was compared to this medical record review, which served as the reference standard. Results: Of 80 children identified by the electronic algorithm, 79 (99%) were diagnosed with CAP based on medical record review. Antibiotic use was classified as the appropriate choice in 75 (94%) of 80 cases, and appropriate duration in 16 (20%) of 80 cases. The sensitivity of the electronic algorithm for identifying appropriate initial antibiotic choice was 94%; specificity could not be calculated because no events of inappropriate antibiotic choice were identified based on chart review. The sensitivity and specificity for determining appropriate duration were 88% and 97%, respectively (Table 1).

Conclusions: The electronic algorithm accurately identified children hospitalized with CAP and demonstrated acceptable performance for identifying appropriate antibiotic choice and duration. Use of this electronic algorithm may improve the efficiency of stewardship activities and could facilitate alignment with updated accreditation standards. Future studies validating this algorithm at other centers are needed.

Disclosures: None

Background: Inappropriate antibiotic use for community-acquired pneumonia (CAP) is common. Although antibiotic stewardship activities require real-time, accurate identification of patients being treated for CAP, there are few reliable methods to identify such patients using the electronic health record (EHR). We conducted a retrospective study to assess the performance of provider-selected antibiotic indication in identifying patients being treated for CAP among a cohort of hospitalized adults. Methods: We randomly selected 440 patients from a cohort of patients who received at least 1 systemic antibiotic within 48 hours of admission between January 1, 2019, and December 31, 2021, at 3 acute-care hospitals. The reference standard for treatment of CAP was defined as intention to treat for pneumonia by inpatient provider(s) within 48 hours of admission, as assessed by chart review of provider notes. Treatment for pneumonia using any terminology except with “hospital-acquired pneumonia” (HAP) or “ventilator-associated pneumonia” (VAP) were counted. Provider-selected indication of CAP (in an antibiotic order) was compared against this reference standard; sensitivity, specificity, and positive and negative predictive values were calculated. Performance characteristics of International Classification of Disease, Tenth Revision (ICD-10) codes for pneumonia in identifying CAP patients were assessed against the same reference standard. A secondary analysis including terms HAP and VAP in the reference standard was performed. Results: Provider-selected antibiotic indication for CAP had a sensitivity of 64.4%, specificity of 96.3%, positive predictive value (PPV) of 73.1%, and negative predictive value (NPV) of 96.1%, giving comparable performance to ICD-10 codes (Table 1). Of those with 21 false-negative results, 13 (61.9%) had a healthcare-associated lower respiratory tract infection and 14 (66.7%) had sepsis indicated in at least 1 antibiotic order. Conclusions: Provider-selected antibiotic indication showed moderate sensitivity and high specificity for identifying CAP-treated cases. Importantly, use of this method can be deployed for real-time antibiotic stewardship interventions for CAP.

Disclosures: None

Background: Antibiotic overuse contributes to antibiotic resistance and unnecessary adverse drug effects. Antibiotic stewardship interventions have primarily focused on acute-care settings. Most antibiotic use, however, occurs in outpatients with acute respiratory tract infections such as pharyngitis. The electronic health record (EHR) might provide an effective and efficient tool for outpatient antibiotic stewardship. We aimed to develop and validate an electronic algorithm to identify inappropriate antibiotic use for pediatric outpatients with pharyngitis. Methods: This study was conducted within the Children’s Hospital of Philadelphia (CHOP) Care Network, including 31 pediatric primary care practices and 3 urgent care centers with a shared EHR serving >250,000 children. We used International Classification of Diseases, Tenth Revision (ICD-10) codes to identify encounters for pharyngitis at any CHOP practice from March 15, 2017, to March 14, 2018, excluding those with concurrent infections (eg, otitis media, sinusitis), immunocompromising conditions, or other comorbidities that might influence the need for antibiotics. We randomly selected 450 features for detailed chart abstraction assessing patient demographics as well as practice and prescriber characteristics. Appropriateness of antibiotic use based on chart review served as the gold standard for evaluating the electronic algorithm. Criteria for appropriate use included streptococcal testing, use of penicillin or amoxicillin (absent β-lactam allergy), and a 10-day duration of therapy. Results: In 450 patients, the median age was 8.4 years (IQR, 5.5–9.0) and 54% were women. On chart review, 149 patients (33%) received an antibiotic, of whom 126 had a positive rapid strep result. Thus, based on chart review, 23 subjects (5%) diagnosed with pharyngitis received antibiotics inappropriately. Amoxicillin or penicillin was prescribed for 100 of the 126 children (79%) with a positive rapid strep test. Of the 126 children with a positive test, 114 (90%) received the correct antibiotic: amoxicillin, penicillin, or an appropriate alternative antibiotic due to b-lactam allergy. Duration of treatment was correct for all 126 children. Using the electronic algorithm, the proportion of inappropriate prescribing was 28 of 450 (6%). The test characteristics of the electronic algorithm (compared to gold standard chart review) for identification of inappropriate antibiotic prescribing were sensitivity (99%, 422 of 427); specificity (100%, 23 of 23); positive predictive value (82%, 23 of 28); and negative predictive value (100%, 422 of 422). Conclusions: For children with pharyngitis, an electronic algorithm for identification of inappropriate antibiotic prescribing is highly accurate. Future work should validate this approach in other settings and develop and evaluate the impact of an audit and feedback intervention based on this tool.

Funding: None

Disclosures: None

Background: Automatic discontinuation of antimicrobial orders after a prespecified duration of therapy has been adopted as a strategy for reducing excess days of therapy (DOT) as part of antimicrobial stewardship efforts. Automatic stop orders have been shown to decrease antimicrobial DOT. However, inadvertent treatment interruptions may occur as a result, potentially contributing to adverse patient outcomes. To evaluate the effects of this practice, we examined the impact of the removal of an electronic 7-day ASO program on hospitalized patients. Methods: We performed a quasi-experimental study on inpatients in 3 acute-care academic hospitals. In the preintervention period (automatic stop orders present; January 1, 2016, to February 28, 2017), we had an electronic dashboard to identify and intervene on unintentionally missed doses. In the postintervention period (April 1, 2017, to March 31, 2018), the automatic stop orders were removed. We compared the primary outcome, DOT per 1,000 patient days (PD) per month, for patients in the automatic stop orders present and absent periods. The Wilcoxon rank-sum test was used to compare median monthly DOT/1,000 PD. Interrupted time series analysis (Prais-Winsten model) was used to compared trends in antibiotic DOT/1,000 PD and the immediate impact of the automatic stop order removal. Manual chart review on a subset of 300 patients, equally divided between the 2 periods, was performed to assess for unintentionally missed doses. Results: In the automatic stop order period, a monthly median of 644.5 antibiotic DOT/1,000 PD were administered, compared to 686.2 DOT/1,000 PD in the period without automatic stop orders (P < .001) (Fig. 1). Using interrupted time series analysis, there was a nonsignificant increase by 46.7 DOT/1,000 PD (95% CI, 40.8 to 134.3) in the month immediately following removal of automatic stop orders (P = .28) (Fig. 2). Even though the slope representing monthly change in DOT/1,000 PD increased in the period without automatic stop orders compared to the period with automatic stop orders, it was not statistically significant (P = .41). Manual chart abstraction revealed that in the period with automatic stop orders, 9 of 150 patients had 17 unintentionally missed days of therapy, whereas none (of 150 patients) in the period without automatic stop orders did. Conclusions: Following removal of the automatic stop orders, there was an overall increase in antibiotic use, although the change in monthly trend of antibiotic use was not significantly different. Even with a dashboard to identify missed doses, there was still a risk of unintentionally missed doses in the period with automatic stop orders. Therefore, this risk should be weighed against the modest difference in antibiotic utilization garnered from automatic stop orders.

Funding: None

Disclosures: None

Background: Antibiotic resistance has increased at alarming rates, driven predominantly by antibiotic overuse. Although most antibiotic use occurs in outpatients, antimicrobial stewardship programs have primarily focused on inpatient settings. A major challenge for outpatient stewardship is the lack of accurate and accessible electronic data to target interventions. We sought to develop and validate an electronic algorithm to identify inappropriate antibiotic use for outpatients with acute bronchitis. Methods: This study was conducted within the University of Pennsylvania Health System (UPHS). We used ICD-10 diagnostic codes to identify encounters for acute bronchitis at any outpatient UPHS practice between March 15, 2017, and March 14, 2018. Exclusion criteria included underlying immunocompromising condition, other comorbidity influencing the need for antibiotics (eg, emphysema), or ICD-10 code at the same visit for a concurrent infection (eg, sinusitis). We randomly selected 300 (150 from academic practices and 150 from nonacademic practices) eligible subjects for detailed chart abstraction that assessed patient demographics and practice and prescriber characteristics. Appropriateness of antibiotic use based on chart review served as the gold standard for assessment of the electronic algorithm. Because antibiotic use is not indicated for this study population, appropriateness was assessed based upon whether an antibiotic was prescribed or not. Results: Of 300 subjects, median age was 61 years (interquartile range, 50–68), 62% were women, 74% were seen in internal medicine (vs family medicine) practices, and 75% were seen by a physician (vs an advanced practice provider). On chart review, 167 (56%) subjects received an antibiotic. Of these subjects, 1 had documented concern for pertussis and 4 had excluding conditions for which there were no ICD-10 codes. One received an antibiotic prescription for a planned dental procedure. Thus, based on chart review, 161 (54%) subjects received antibiotics inappropriately. Using the electronic algorithm based on diagnostic codes, underlying and concurrent conditions, and prescribing data, the number of subjects with inappropriate prescribing was 170 (56%) because 3 subjects had antibiotic prescribing not noted based on chart review. The test characteristics of the electronic algorithm (compared to gold standard chart review) for identification of inappropriate antibiotic prescribing were the following: sensitivity, 100% (161 of 161); specificity, 94% (130 of 139); positive predictive value, 95% (161 of 170); and negative predictive value, 100% (130 of 130). Conclusions: For outpatients with acute bronchitis, an electronic algorithm for identification of inappropriate antibiotic prescribing is highly accurate. This algorithm could be used to efficiently assess prescribing among practices and individual clinicians. The impact of interventions based on this algorithm should be tested in future studies.

Funding: None

Disclosures: None