44. Cost Effectiveness and Clinical Outcomes of Long Acting Lipoglycopeptides Used in Transitions of Care for Deep-Seated Infections

Abstract Background Dalbavancin and oritavancin are long-acting lipoglycopeptides (LaLGPs) FDA-approved for one-time only dosing for skin and skin structure infections. The use of these agents in serious, deep-seated infections requiring protracted antibiotic courses is of increasing interest. The purpose of this study is to evaluate the economic and clinical utility of LaLGPs in patients requiring protracted antibiotic courses who are not ideal candidates for oral transition or outpatient parenteral antibiotic therapy (OPAT). Methods This is a retrospective, observational, matched cohort study of adult patients who received a LaLGP. Patients who received a LaLGP were matched 1:1 to those who received standard of care (SOC) therapy by age (+/- 10 years), infection type, microorganism, and socioeconomic factor (e.g. persons who inject drugs, homelessness). Cost effectiveness was evaluated as total healthcare-related costs between groups. Clinical failure was a composite endpoint of mortality, recurrence, or need for extended antibiotics beyond planned course within 90 days of initial infection. Secondary outcomes included hospital length of stay and proportion of patients who left against medical advice (AMA). Results A total of 46 patients were included (23 per group). The most frequent indication was endovascular infection and the most common organism methicillin-resistant Staphylococcus aureus. The average length of stay was 22.9 days vs. 31.9 days in the LaLGP and SOC cohorts, respectively (p=0.153). The average total healthcare-related cost of care was USD &295,589 in the LaLGP cohort compared to &326,089 in the SOC cohort (p=0.282). LaLGPs were associated with a mean savings of &30,500 - &55,831 per patient (cumulative cost savings of &701,510). There was no difference in clinical failure between the two cohorts (22% vs. 30%; p=0.491). Nearly 26% of patients in the SOC cohort left AMA compared to 0% in the LaLGP cohort (p=0.022). Conclusion Receipt of LaLGPs may be a beneficial treatment option for patients with socioeconomic factors and deep-seated infections who are not candidates for oral transition or OPAT. Disclosures Julie Ann Justo, PharmD, MS, BCPS-AQ ID, bioMerieux (Speaker’s Bureau)Merck & Co. (Advisor or Review Panel member)Therapeutic Research Center (Speaker’s Bureau)Vaxart (Shareholder) P. Brandon Bookstaver, Pharm D, ALK Abello, Inc. (Grant/Research Support, Advisor or Review Panel member)Biomerieux (Speaker’s Bureau)Kedrion Biopharma (Grant/Research Support, Advisor or Review Panel member)

received contributed antiseptic and cleaning products)Molnlycke (Other Financial or Material Support, Conducted studies in which participating hospitals and nursing homes received contributed antiseptic and cleaning products)Stryker (Sage) (Other Financial or Material Support, Conducted studies in which participating hospitals and nursing homes received contributed antiseptic and cleaning products)Xttrium (Other Financial or Material Support, Conducted studies in which participating hospitals and nursing homes received contributed antiseptic and cleaning products)

Impact of a Five-Year Intervention of an Antimicrobial Stewardship Program on the Optimal Antibiotic Prophylaxis Selection in Surgery in a Hospital without Restrictions on Antibiotics Prescription in Costa Rica
José P. Díaz-Madriz, PharmD 1 ; Esteban Zavaleta-Monestel, PharmD 1 ; Jorge A. Villalobos-Madriz, PharmD 2 ; Alison V. Meléndez-Alfaro, n/a 2 ; Priscilla Castrillo-Portillo, n/a 2 ; Ana F. Vásquez-Mendoza, n/a 1 ; Gabriel Muñoz-Gutierrez, MD ID 1 ; Sebastián Arguedas-Chacón, n/a 3 ; 1 Hospital Clínica Bíblica, San José, San Jose, Costa Rica 2 Universidad de Ciencias Médicas (UCIMED), San José, San Jose, Costa Rica 3 Universidad de Costa Rica, San José, San Jose, Costa Rica Session: P-04. Antimicrobial Stewardship: Outcomes Assessment (clinical and economic) Background. In a private hospital without restrictions on antibiotic prescription, the success of an Antimicrobial Stewardship Program (ASP) depends mainly on prospective feedback and education. Previously, the ASP of this hospital (PROA-HCB) managed to achieve a positive impact on the antibiotic prophylaxis in cesarean delivery. The purpose of this study is to characterize the impact after implementing the PROA-HCB on the optimal prophylaxis selection of all the procedures included in the clinical guideline for surgical antibiotic prophylaxis in adult patients.

Methods.
A retrospective observational study that compares the selection, duration, antibiotic consumption, bacterial resistance profiles and patient's safety outcomes regarding antibiotic use for all surgical prophylaxis prescription over six months for the periods before (pre-ASP) and after a five-year intervention of PROA-HCB (post-ASP).
Results. After a five-year intervention, the percentage of optimal selection of antibiotic prophylaxis in Surgery was 21.0% (N=1598) in the pre-ASP period and 80.0% (N=841) in the post-ASP period (59% absolute improvement, p < 0.001). Percentage of optimal duration was 69,1% (N=1598) in the pre-ASP period and 78.0% (N=841) in the post-ASP period (8.9% absolute improvement, p < 0.001). Mean ceftriaxone utilization was 217.7 defined daily doses (DDD) per 1,000 patient days DDD for the pre-ASP period and 139.8 DDD per 1,000 patient days for the ASP period (35.8% decrease; p = 0.019). Mean cefazolin utilization was 14.9 DDD per 1,000 patient days for the pre-ASP period and 153.3 DDD per 1,000 patient days for the ASP period (928.6% increase; p = 0.021). Regarding percentage of bacterial resistance, there was detected an improvement in some isolates like Escherichia coli with a decrease of ESBL detection (11% decrease; p = 0.007). In addition, no serious adverse reactions or an increase in surgical site infections were detected after the intervention.
Conclusion. The implementation of an ASP in the surgical ward showed an overall positive impact on selection and duration of antibiotic prophylaxis. Furthermore, this intervention could have had a positive impact on antimicrobial resistance and at the same time had no negative effects on the patients. Background. Dalbavancin and oritavancin are long-acting lipoglycopeptides (LaLGPs) FDA-approved for one-time only dosing for skin and skin structure infections. The use of these agents in serious, deep-seated infections requiring protracted antibiotic courses is of increasing interest. The purpose of this study is to evaluate the economic and clinical utility of LaLGPs in patients requiring protracted antibiotic courses who are not ideal candidates for oral transition or outpatient parenteral antibiotic therapy (OPAT).
Methods. This is a retrospective, observational, matched cohort study of adult patients who received a LaLGP. Patients who received a LaLGP were matched 1:1 to those who received standard of care (SOC) therapy by age (+/-10 years), infection type, microorganism, and socioeconomic factor (e.g. persons who inject drugs, homelessness). Cost effectiveness was evaluated as total healthcare-related costs between groups. Clinical failure was a composite endpoint of mortality, recurrence, or need for extended antibiotics beyond planned course within 90 days of initial infection. Secondary outcomes included hospital length of stay and proportion of patients who left against medical advice (AMA).
Results. A total of 46 patients were included (23 per group). The most frequent indication was endovascular infection and the most common organism methicillin-resistant Staphylococcus aureus. The average length of stay was 22.9 days vs. 31.9 days in S144 • OFID 2021:8 (Suppl 1) • Abstracts the LaLGP and SOC cohorts, respectively (p=0.153). The average total healthcare-related cost of care was USD $295,589 in the LaLGP cohort compared to $326,089 in the SOC cohort (p=0.282). LaLGPs were associated with a mean savings of $30,500 -$55,831 per patient (cumulative cost savings of $701,510). There was no difference in clinical failure between the two cohorts (22% vs. 30%; p=0.491). Nearly 26% of patients in the SOC cohort left AMA compared to 0% in the LaLGP cohort (p=0.022).
Conclusion. Receipt of LaLGPs may be a beneficial treatment option for patients with socioeconomic factors and deep-seated infections who are not candidates for oral transition or OPAT.
Disclosures Background. According to the WHO, carbapenems and fluoroquinolones (FQ) should be key targets for stewardship programs.
Methods. A multifaceted antimicrobial stewardship program (ASP) was implemented in July 2018 at a 160-bed tertiary care center serving the tristate area of Iowa, South Dakota and Nebraska. Carbapenem and FQ use during pre-ASP intervention period (P1: 12/01/2016-6/30/2018) was compared with ASP-intervention period (P2: 07/01/2018-1/31/2020). ASP interventions included: stewardship educational pearls in monthly physician newsletters; educational posters in provider areas; suppression of carbapenem results on microbiology susceptibility reports; provider counseling for appropriate ordering; creating carbapenem alternative alert in order-entry software; removing FQ and carbapenems from order-sets where appropriate; default antibiotic stop dates changed to 7 days in EMR (Epic); adverse effects warning fired as an alert when ordering FQ. Pharmacist interventions: procalcitonin protocol allowing pharmacists to reorder follow-up procalcitonin and make recommendations to discontinue therapy where appropriate.
Results. FQ use declined significantly from a mean of 133 days of therapy (DOT) per 1000 days to 46 DOT per 1000 patient days during P2 (p< 0.0001). Carbapenem use declined significantly from a mean of 65 DOT per 1000 patient days during P1 to 9 DOT per 1000 patient days in P2 (p< 0.001). All hospital units showed a significant decrease in use, with intensive care units (ICUs) noting 56% reduction (p< 0.00001) during P2 compared to P1. During P2, 55% of orders for carbapenems and FQ during P2 were found to be appropriate compared to 39% in P1 (p< 0.0001). Sensitivity profile for Pseudomonas aeruginosa improved from 86% carbapenem sensitivity during P1 to 89% in P2 and no Carbapenem-Resistant Enterobacteriaceae isolates were identified during the study period; FQ sensitivity remained stable at 81%. Cost savings of $757 per 1000 patient days were recognized in P2 as a result of reduced use.
Conclusion. With ASP and pharmacist interventions, a significant decline in total utilization of carbapenem and FQ, considerable cost savings and an increase in proportion of appropriate use were observed.
Disclosures. Background. Behavioral interventions have been shown to improve antimicrobial selection. Such practices are low cost and effective means of stewardship promotion. One area of overtreatment that contributes to unnecessary antifungal use is in hospitalized patients with candiduria. We implemented a templated microbiology comment to guide prescribing of antifungals for hospitalized patients with candiduria.
Methods. This was a quasi-experimental, multi-center, single health system study. When Candida is isolated, the following comment appears in the microbiology result section along with the urine culture result: "In the absence of symptoms, Candida is generally considered normal flora. No therapy indicated unless high risk (pregnant, neonate or neutropenic) or undergoing urologic procedure. If Foley catheter present, remove or replace when able. " We compared a pre-implementation cohort (June 2018-Janurary 2019) to a post-implementation cohort (June 2019-Janurary 2020). Patients were included in the study if they were inpatients, 18 years and older, with candiduria. The primary outcome was the rate of antifungal administration within 72 hours after culture results became available. Secondary outcomes include duration of therapy and rate of antifungal given within 73-240 hours after culture result.
Results. The study included a total of 297 patients between the two groups (156 pre-implementation, 141 post-implementation). The primary outcome was found to be significantly lower in the post-implementation group (48.1% vs 34.0%, p=0.014). A multivariate adjustment for baseline characteristics that were significantly different between groups revealed that post-implementation group maintained its effect (OR 0.49 (0.29,0.82), p=0.0067). For secondary outcomes, no difference was found in patients requiring antifungal administration within 73-240 hours after microbiology results were available (1.3% vs 3.5%, p=0.199). There was no difference in mean antifungal duration (4 vs 3 days, p=0.449).

Conclusion.
Adding a templated comment to urine cultures was associated with a significant reduction in the number of antifungals prescribed in patients with candiduria. This strategy is an effective low-cost, passive education technique to improve antimicrobial stewardship.
Disclosures. Background. Antimicrobial stewardship (AMS) committees ensure appropriate antimicrobial utilization. One stewardship intervention is to evaluate the delivery model of high-cost antimicrobials to better utilize resources and mitigate expenses. We analyzed the total medication waste and costs of high-cost antimicrobials, specifically daptomycin, ertapenem, amphotericin, and micafungin, at our institution and propose innovative cost-savings changes at a systems level.
Methods. This retrospective study consisted of 263 patients. All patients were at least 18 years old who was admitted to our academic institution from January 2020 to April 2021 and received daptomycin, ertapenem, amphotericin, or micafungin. Demographics, daily medication dosage, total doses received, the date and time of the start of the medication, last administered dose, and discontinued order were recorded.
Results. The daptomycin cohort consisted of 143 patients with 46.2% females and average age of 56.3 years. In this group, 145.3 vials were wasted which equated to a loss of $22,630. The ertapenem group had 53 patients with 62.3% females and a mean age of 62.3 years. There were 24 vials wasted with a calculated loss of $1080. The amphotericin cohort had 32 patients with an average age of 52.2 years and 43.8% females. There were 189 vials wasted with a loss of $46,116. The micafungin group had 35 patients with 42.9% females and average age of 60.4 years. This group had 12 vials wasted with a loss of $2052.
Conclusion. Each antimicrobial has a specific formulation protocol. Daptomycin and ertapenem formulation occurs in the early morning. Amphotericin formulation occurs 2 hours prior to medication use. Micafungin formulation occurs at the time the order label prints. These medications were more often administered in the late morning to early afternoon timeframe. The order to discontinue the medications also occurred at the same interval. One reason could be due to decisions made on morning rounds from primary teams and specialty input. These orders would then be placed after rounds. A cost-saving method would be to batch and change the formulation time for all antimicrobials to later in the afternoon, which would not only prevent waste, but also allow the AMS team to effectively audit appropriate antimicrobial use.
Disclosures. All Authors: No reported disclosures