1137. Effect of an Antibiotic Stewardship Program on Antibiotic Choice, Dosing, and Duration in Pediatric Urgent Care

Abstract Background Many studies have focused on decreasing inappropriate antibiotic prescriptions. In August 2018, our institution implemented an outpatient antibiotic stewardship program (ASP). We describe the impact of an outpatient ASP on the antibiotic choice, dose, and duration for common pediatric infections in a pediatric urgent care (PUC) setting. Methods We reviewed all encounters at 4 freestanding PUC centers within our organization of patients >60 days and < 18 years with a discharge diagnosis of acute otitis media (AOM), group A streptococcal (GAS) pharyngitis, community acquired pneumonia (CAP), urinary tract infection (UTI), cellulitis, abscess, and animal bite who received systemic antibiotics between July 2017 and December 2020. We excluded patients who were transferred, admitted, or had a concomitant diagnosis that required systemic antibiotics. We used established national guidelines to determine appropriateness of antibiotic choice, dose, and duration for each diagnosis (Table 1). Our outpatient ASP efforts included the development of an antibiotic handbook, data sharing, education, quality improvement projects, and commitment letters. Pearson’s chi-square test was used to compare appropriate prescribing (choice, dose, and duration) between pre-implementation (July 2017 – July 2018) and post-implementation (August 2018 -forward). Monthly run charts evaluated improvement over time. Results We included 35,915 encounters. Appropriate antibiotic agent improved in AOM (75.8% to 77.2%; p=0.03), UTI (74.9% to 89.5%; p< 0.001), cellulitis (70.5% to 75.1%; p=0.02) and abscess (53.6% to 67.7%; p< 0.001) following implementation of our ASP (Figure 1). Excluding GAS pharyngitis, all diagnoses had improvement in appropriate duration (p< 0.001) (Figure 2). Appropriate dosing improved for AOM (75.7% to 81.6%; p< 0.001), UTI (34.9% to 42.9%; p=0.01) animal bites (37.1% to 45.6%; p=0.048), and cellulitis (28.0% to 42.3%; p< 0.001) (Figure 3). Figure 1. Appropriate Agent Run chart of percentage of encounters with antibiotic choice consistent with national guideline recommendations by discharge diagnosis. The vertical line indicates the start of outpatient antibiotic stewardship efforts in August 2018. Figure 2. Appropriate Duration Run chart of percentage of encounters with antibiotic duration consistent with national guideline recommendations. The vertical line indicates the start of outpatient antibiotic stewardship efforts in August 2018. Figure 3. Appropriate Dose Run chart of percentage of encounters with antibiotic dose consistent with national guideline recommendations. The vertical line indicates the start of outpatient antibiotic stewardship efforts in August 2018. Conclusion Our outpatient ASP improved prescribing patterns for agent, duration, and dose for many common pediatric infections in the PUC setting. Future work will focus on identifying opportunities to improve prescribing practices when antibiotics are indicated. Disclosures Brian R. Lee, PhD, MPH , Merck (Grant/Research Support)Pfizer (Grant/Research Support)

Primary Y axis indicates the proportion of patients with at least one antibiotic prescription during rounds. Secondary Y axis indicates antibiotic consumption by days of therapy metrics.
Antibiotic prescription costs and NICU mortality rates during study period A. Annual antibiotic prescription costs; B. NICU mortality rate Conclusion. Weekly antibiotic rounds led to a significant decrease in antibiotic utilization in our NICU. This strategy is relatively simple and low-cost, saves hospital resources and has a large impact on antibiotic use. Hence, its implementation is encouraged as part of successful antimicrobial stewardship programs.
Disclosures. Background. Many studies have focused on decreasing inappropriate antibiotic prescriptions. In August 2018, our institution implemented an outpatient antibiotic stewardship program (ASP). We describe the impact of an outpatient ASP on the antibiotic choice, dose, and duration for common pediatric infections in a pediatric urgent care (PUC) setting.
Methods. We reviewed all encounters at 4 freestanding PUC centers within our organization of patients >60 days and < 18 years with a discharge diagnosis of acute otitis media (AOM), group A streptococcal (GAS) pharyngitis, community acquired pneumonia (CAP), urinary tract infection (UTI), cellulitis, abscess, and animal bite who received systemic antibiotics between July 2017 and December 2020. We excluded patients who were transferred, admitted, or had a concomitant diagnosis that required systemic antibiotics. We used established national guidelines to determine appropriateness of antibiotic choice, dose, and duration for each diagnosis (Table 1). Our outpatient ASP efforts included the development of an antibiotic handbook, data sharing, education, quality improvement projects, and commitment letters. Pearson's chi-square test was used to compare appropriate prescribing (choice, dose, and duration) between pre-implementation (July 2017 -July 2018) and post-implementation (August 2018 -forward). Monthly run charts evaluated improvement over time.
Disclosures Background. Empirical antibiotic regimens frequently include treatment for methicillin-resistant Staphylococcus aureus (MRSA). Studies in adults with pneumonia support the use of a negative MRSA nares screening (MNS) to help de-escalate antibiotic therapy. Comparable pediatric data in the literature is scarce. We aimed to evaluate the use of MNS for antibiotic de-escalation in hospitalized children (< 18 years) at a tertiary children's hospital.
Methods. A retrospective chart review was conducted of pediatric inpatients (January 01, 2015 to December 31, 2020) with a presumed infectious diagnosis who had a PCR-based MNS test and a clinical culture (i.e. site of infection or blood) performed as part of their diagnostic work up. Those who were screened >5 days since admission or > 48 hours since start of MRSA-active antimicrobials, and those who had antibiotic treatment withdrawn after 48 hours because of negative cultures were excluded.
Results. A total of 101 children were included with a median age (range) of 2 years (0-17) and about half (n=57, 56.4%) were male. Top three diagnosis groups were skin and soft tissue infections (n=33, 32.7%), toxin-mediated syndromes (n=21, 20.8%), and osteoarticular infections (n=13, 12.9%). Pneumonia accounted for only six (5.9%) patients. The prevalence of nasal MRSA colonization was 6.9% (n=7). The sensitivity of the MNS test to predict a MRSA infection was 42.9% with a specificity of 95.7%. The positive predictive value (PPV) and negative predictive values (NPV) were 42.9% and 95.7%, respectively. In about half (55/95, 57.9%) of patients initiated on anti-MRSA therapy, these agents were discontinued during the admission. A quarter (n=14, 25.5%) were de-escalated based on the negative MNS test alone, and another third (n=21, 38.2%) after negative MNS test and negative culture results became available.
Conclusion. Pediatric providers at this institution have started to use the MNS to help limit anti-MRSA therapy. We noted a high NPV which suggests that MNS may be useful for timely de-escalation of anti-MRSA therapy and thereby a useful antimicrobial stewardship tool for hospitalized children. Prospective studies to evaluate the utility of MNS for the various infectious syndromes are warranted.
Disclosures. All Authors: No reported disclosures Background. Tracheal aspirate (TA) bacterial cultures are often collected in mechanically ventilated children to evaluate for ventilator-associated infections (VAI), including tracheitis and pneumonia. However, frequent bacterial colonization of tracheal tubes results in poor specificity of positive TA cultures for distinguishing bacterial infection from colonization, which contributes to antibiotic overuse for VAI. We performed a quality improvement project to reduce collection of TA cultures through implementation of a consensus guideline to standardize culture ordering, and measured its impact on antibiotic use in a tertiary PICU.

Reducing Collection of Tracheal Aspirate Bacterial Cultures: A Diagnostic Test Stewardship Intervention
Methods. A multidisciplinary team including PICU, pulmonary, and ID clinicians developed the consensus guideline in November 2019-February 2020. The first Plan-Do-Study-Act (PDSA) cycle occurred in August 2020 and included provider education, providing a link to the guideline in the TA culture order, and signs and screensavers highlighting key guideline recommendations. The second PDSA cycle occurred in October-December 2020 and included weekly emails to on service PICU clinicians. Statistical process control charts were used to measure the number of TA cultures collected/100 ventilator days and broad-spectrum antibiotic DOT/100 ventilator days. The number of patients treated for VAI/100 ventilator days and guideline compliance were also measured.
Results. The baseline rate of TA culture collection was 4.58/100 ventilator days. A centerline shift to 3.33 cultures/100 ventilator days occurred in March 2020. Following PDSA 1 and 2 in October 2020, a second downward centerline shift to 2.22 cultures/100 ventilator days occurred (Figure 1). Broad-spectrum antibiotic days of therapy/100 ventilator days decreased in November 2019 coincident with the start of the project, but no further reductions occurred after PDSA 1 and 2 ( Figure 2). The number of patients treated for VAI decreased from a baseline of 1.24/100 ventilator days to 0.66/100 ventilator days. Finally, the proportion of TA cultures ordered that