158. Impact of Fluoroquinolone Cascade Reporting of Urine Samples on Antibiotic Prescribing Rates in a Network of Urgent Care Clinics

Abstract Background Cascade reporting is a type of selective reporting in which susceptibility results of certain antibiotics (either with broader spectrum or cost) are only reported if an organism is resistant to other prespecified agents. This strategy has been successfully deployed in inpatient settings but its impact in outpatient settings is less well characterized. Therefore, we aimed to evaluate the impact of cascade reporting of the antimicrobial susceptibility of fluoroquinolones on prescribing rates of select antibiotics in a network of urban Urgent Care clinics. Methods On July 2019, the susceptibility reporting policies for urine cultures growing Enterobacterales were changed to routinely reporting a limited antibiotic panel including first and second generation cephalosporins, nitrofurantoin and trimethoprim-sulfamethoxazole (TMP-SMX), and fluroquinolone (FQ) reporting was changed to a release only in case of resistance to all agents in the limited panel. Third and fourth generation cephalosporins and carbapenems were reported only in case of resistance to all narrower spectrum agents and FQs. We then compared monthly antibiotic use in prescriptions per 1000 patient-encounters for the pre-intervention (June 2018-June 2019) and post-intervention (August 2019-December 2020) periods using an interrupted times series analysis. Results Immediately following the change to cascade reporting, FQ prescribing decreased by 38% (incidence rate ratio [IRR] 1.38; 95% confidence interval [CI] 0.50-0.77 p< 0.0001) and no change in trend was subsequently seen (IRR 1.01, 95% CI 0.98-1.04; p=0.59) (Figure 1).Cephalexin prescribing did not immediately change following the intervention (IRR 1.20, 95% CI 1.00-1.33; p=0.05) but subsequently showed a trend towards increase use (IRR 1.04, 95% CI 1.02-1.06; p< 0.0001) (Figure 1). No immediate or trend changes in the prescribing rates of TMP-SMX or nitrofurantoin were identified (Figure 1). Conclusion In a network of Urgent Care clinics, cascade reporting of FQ susceptibility in urine cultures growing Enterobacterales resulted in a sustained decrease in FQ prescribing without major shifts towards prescribing of other agents. Cascade reporting should be considered as a feasible antimicrobial stewardship strategy in this outpatient setting. Disclosures All Authors: No reported disclosures


Conclusion.
A standardized eTP process appears to be a safe way to evaluate out of pocket cost without prolonging length of stay. Future work will focus on inequity in access to first line ABX.
Disclosures. Susan L. Davis, PharmD, Nothing to disclose Rachel Kenney, PharmD, Medtronic, Inc. (Other Financial or Material Support, spouse is an employee and shareholder) Background. Cascade reporting is a type of selective reporting in which susceptibility results of certain antibiotics (either with broader spectrum or cost) are only reported if an organism is resistant to other prespecified agents. This strategy has been successfully deployed in inpatient settings but its impact in outpatient settings is less well characterized. Therefore, we aimed to evaluate the impact of cascade reporting of the antimicrobial susceptibility of fluoroquinolones on prescribing rates of select antibiotics in a network of urban Urgent Care clinics.

Impact of Fluoroquinolone Cascade Reporting of Urine Samples on Antibiotic Prescribing Rates in a Network of Urgent Care Clinics
Methods. On July 2019, the susceptibility reporting policies for urine cultures growing Enterobacterales were changed to routinely reporting a limited antibiotic panel including first and second generation cephalosporins, nitrofurantoin and trimethoprim-sulfamethoxazole (TMP-SMX), and fluroquinolone (FQ) reporting was changed to a release only in case of resistance to all agents in the limited panel. Third and fourth generation cephalosporins and carbapenems were reported only in case of resistance to all narrower spectrum agents and FQs. We then compared monthly antibiotic use in prescriptions per 1000 patient-encounters for the pre-intervention (June 2018-June 2019) and post-intervention (August 2019-December 2020) periods using an interrupted times series analysis.

Conclusion.
In a network of Urgent Care clinics, cascade reporting of FQ susceptibility in urine cultures growing Enterobacterales resulted in a sustained decrease in FQ prescribing without major shifts towards prescribing of other agents. Cascade reporting should be considered as a feasible antimicrobial stewardship strategy in this outpatient setting.
Disclosures. All Authors: No reported disclosures Background. Asynchronous virtual patient care is growing in popularity; however, the effectiveness of virtually delivering guideline-concordant care in conjunction with antibiotic stewardship initiatives remains uncertain. We developed a bundled stewardship intervention aimed at improving antibiotic use in E-visits for upper respiratory tract infections (URTIs).

Improving Antibiotic Use for Sinusitis and Upper Respiratory Tract Infections: A Virtual Visit Antibiotic Stewardship Initiative
Methods. In this pre-post study, adult patients who completed an E-visit for "cough," "flu," or "sinus symptoms" at Michigan Medicine between 1/1/2018 and 9/30/2020 were included. Patient demographics, diagnoses, and antibiotic details were collected. The multi-faceted intervention occurred over 6 months ( Figure 1).
We performed segmented linear regression to estimate the effect of the intervention on the level and trend of appropriate antibiotic use for URTI diagnosis (defined as no antibiotic prescribed) and sinusitis (defined as guideline-concordant antibiotic selection and duration). Regression lines were fit to data before (March 2019) and after (May 2019) the physician championing period.

Results.
Among 5151 E-visits, the mean age was 46 years old, and most patients were female (71.3%, N=3674). 3405/5151 E-visits were for URTI. Inappropriate antibiotic use for URTI was stable in trend prior to the audit and feedback intervention (Figure 2), followed by a 12% (P-value = 0.01) decrease in inappropriate antibiotic use post-intervention. The trend in inappropriate antibiotic use continued to decrease after the intervention by 1.1%/month (P-value = 0.02) (Figure 2a).
Solid line represents time of the webinar, dashed line represents time of modified questionnaire roll out and electronic medical record "nudges", and shaded area is time of physician champion intervention. Guideline-concordant antibiotic prescribing for sinusitis included amoxicillin/clavulanate or doxycycline prescribed for a duration of 5-7 days Conclusion. A multifaceted stewardship bundle for E-visits improved guideline-concordant antibiotic use for URTIs. Changes implemented in the EMR are most beneficial after a period of audit and feedback. This approach can aid stewardship efforts in the ambulatory care setting particularly with regards to telemedicine. Background. Antibiotic overuse in urgent cares is common. Despite institutional guidance that recommends ≤ 5 days of therapy for most infections, a prior review found prescribed durations were often longer. This study evaluates the impact of an intervention on guideline-concordant durations of therapy.
Methods. This quasi-experimental study involved two urgent care centers (UC1 and UC2) in an integrated health care system. Prescriptions were included from January 2017 to May 2021 for patients ≥ 18 years of age for one of the following infections identified by ICD10 code: acute bacterial sinusitis, acute otitis media, cellulitis or skin abscess, COPD exacerbation, lower urinary tract infection, or pneumonia. The intervention was implemented in both urgent cares in January 2020 and included sharing baseline duration of therapy data with site directors and staff, providing in-person education on recommended durations of therapy, engaging peer champions, and posting educational flyers. An institutional smart phone application (app) with treatment recommendations for common infections was in place for the entirety of the study. The primary outcome was the proportion of antibiotic durations that were guideline-concordant during the app only and intervention periods in aggregate and by interrupted time-series analysis.
Results. On average, 1583 and 3850 antibiotic prescriptions were prescribed per year in UC1 and UC2, respectively. There was a significant increase in the proportion