Background: The burden of hospital-associated infections (HAIs) and antimicrobial resistance (AMR) in Latin America is high. Improving engagement by healthcare workers (HCWs) in infection prevention and control (IPC) may lead to better patient outcomes; however, little is known about HCW perceptions of IPC in the region. We sought to understand HCW perceptions of IPC processes and practices. Methods: During August–September 2022, HCWs from 30 hospitals with IPC programs in 4 Latin American countries (Panama, Guatemala, Ecuador, and Argentina) were invited to participate in an electronic, voluntary, anonymous survey about their perceptions of IPC at their hospitals. Physicians, nurses, and environmental care (EVC) personnel were prioritized for recruitment. All respondents were asked 18 questions; IPC team members were asked 5 additional questions about specific activities implemented by IPC programs, how data are used, and how IPC could be improved. Answers with 5-point Likert scale responses were categorized into 2 groups (eg, strongly agree or agree vs neutral, disagree, or strongly disagree) for analysis. Results: Of 1,252 HCWs who completed the survey, 181 (14%) were IPC team members, 1,095 (87%) had direct patient contact, and 1,156 (92%) worked >20 hours per week. Figure 1 shows participant characteristics. Most participants (56%) rated their IPC program as very good, 38% rated it as good, and 6% rated it as bad. Physicians were less likely to give a favorable rating. Compliance with prevention bundles and hand hygiene (HH) by colleagues was rated as poor by 28% and 22% of HCWs, respectively; however, only 11% and 5% indicated that their own compliance was poor, respectively. Also, 25% of participants reported not receiving or only occasionally receiving HH compliance data. Similarly, 41% of participants reported not receiving HAI data on a regular basis, and 19% of IPC nurses reported not receiving data despite being responsible for conducting surveillance. Furthermore, 41% of respondents indicated not receiving or only occasionally receiving IPC training or education relevant to their role. When asked about the safety climate, 16% of participants reported not feeling appreciated. In addition, 22% of IPC nurses and 37% of individuals in the “other” category (eg, health technicians and therapists) were more likely to report this. When IPC team members were asked how frequently specific activities were conducted (Fig. 2), several opportunities for improvement were identified, including improving HCW access to HH data and development of strategic plans. Conclusions: Improving HCW access to training on IPC and to data on HAI burden and compliance with HH and prevention bundles should be emphasized in Latin American hospitals.

Disclosures: None

The pace and trajectory of global and local environmental changes are jeopardizing our health in numerous ways, among them exacerbating the risk of disease emergence and spread in both the community and the healthcare setting via healthcare-associated infections (HAIs). Factors such as climate change, widespread land alteration, and biodiversity loss underlie changing human–animal–environment interactions that drive disease vectors, pathogen spillover, and cross-species transmission of zoonoses. Climate change–associated extreme weather events also threaten critical healthcare infrastructure, infection prevention and control (IPC) efforts, and treatment continuity, adding to stress to strained systems and creating new areas of vulnerability. These dynamics increase the likelihood of developing antimicrobial resistance (AMR), vulnerability to HAIs, and high-consequence hospital-based disease transmission. Using a One Health approach to both human and animal health systems, we can become climate smart by re-examining impacts on and relationships with the environment. We can then work collaboratively to reduce and respond to the growing threat and burden of infectious diseases.

This study assessed outcomes prior to and after electronic medical record-based clinical decision support implementation combined with prospective audit in patients with COVID-19. This multimodal stewardship intervention was associated with a decrease in antibiotic exposure for patients with COVID-19 (44.4% vs 61.8%, p = 0.002) within the first 7 days of hospitalization.

Background: Antimicrobial resistance is a worldwide problem leading to increasing deaths due to intractable infections, especially in postoperative patients who have extended stays in ICUs due to other surgical complications. Carbapenem and colistin resistance has been increasing here; hence, it was decided to monitor and control antibiotic use. In the neurosurgery unit of a quaternary-care hospital in South India, surgical prophylaxis was chosen as less problematic area in which to implement antibiotic stewardship. Objective: To study the difference in the antibiogram pattern of isolates from neurosurgery postoperative patients, before and after the introduction of a surgical antimicrobial prophylaxis policy from the UK National Health Service (NHS). Methods: After the implementation of a new surgical prophylaxis protocol taken from the UK NHS guidelines, we studied its impact by analyzing the antibiogram before implementation (period 1 from January 1, 2020, to December 31, 2020) and after implementation (period 2 from April 1, 2021, to September 30, 2021). This period corresponded to the same number of isolates as the earlier period. Antibiogram criteria: All clinically relevant infections due to the ESKAPE pathogens were included in the antibiogram. The antibiotics analyzed included β-lactams, cephalosporins, β-lactam- lactamase combinations, carbapenems, aminoglycosides, colistin and tigecycline for gram-negative bacilli and penicillin, oxacillin, aminoglycosides, vancomycin, and linezolid for gram-positive cocci. For analysis, the difference was deemed significant according to the criteria stated in CLSI document M39-A4 (4th edition, January 2014). Results: In period 1, 170 isolates were tested, and in period 2, 162 isolates were tested. Among the isolates, Enterococcus spp and Enterobacter spp were too few in number for a comparison. For the gram-negative bacilli, E. coli, Klebsiella pneumoniae, and Acinetobacter baumannii, the differences were significant for the β-lactam–lactamase combinations, carbapenems, and amikacin, with higher susceptibility in period 2. For Staphylococcus aureus, oxacillin, erythromycin, and clindamycin showed a significant increase in susceptibility in period 2. Relevant tables and a graph will be included in the presentation with detailed discussion. Conclusions: Controlled surgical prophylaxis strictly implemented can lead to a significant change in the antibiotic susceptibility pattern among isolates causing healthcare-associated infections among postoperative patients in intensive care units.

The 2021 focused update to the Infections Diseases Society of America/Society for Healthcare Epidemiology of America (IDSA/SHEA) guidelines for management of Clostridioides difficile infection (CDI) prioritizes the use of fidaxomicin over vancomycin for the treatment of initial and recurrent CDI. These recommendations have significant clinical and financial ramifications for hospitals and patients with CDI. Antimicrobial stewardship programs must balance the needs, goals, and barriers faced by patients and health systems when determining the best treatment strategy for CDI. In this commentary, we provide antimicrobial stewardship programs with a decision-making framework that acknowledges the fundamental principles of ethics to provide equitable patient care.

The optimal management of bacteriuria/pyuria of clinically undetermined significance (BPCUS) is unknown. Among 220 emergency department patients prescribed antibiotics for BPCUS, we found frequent readmissions, which were mitigated by outpatient follow-up visits. Observation and follow-up for an unknown diagnosis should be emphasized over antibiotics due to high likelihood of readmissions.

Although pharmacists are key members of the healthcare team, they are currently ineligible to independently prescribe the oral coronavirus disease 2019 (COVID-19) antivirals. We report the roles pharmacists have undertaken during the COVID-19 pandemic and provide evidence for the support of independent oral COVID-19 antiviral prescribing.

Group Name: Bright STAR Authorship Group

Background: Blood cultures are fundamental in the diagnosis and treatment of sepsis. Culture practices vary widely, and overuse can lead to false-positive results and unnecessary antibiotics. Our objective was to describe the implementation of a multisite quality improvement collaborative to reduce unnecessary blood cultures in pediatric intensive care unit (PICU) patients, and its 18-month impact on blood culture rates and safety metrics. Methods: In 2018, 14 PICUs joined the Blood Culture Improvement Guidelines and Diagnostic Stewardship for Antibiotic Reduction in Critically Ill Children (Bright STAR) Collaborative, designed to understand and improve blood culture practices in critically ill children. Guided by a centralized multidisciplinary study team, sites first reviewed existing evidence for safe reduction of unnecessary blood cultures and assessed local practices and barriers to change. Subsequently, local champions developed and implemented clinical decision-support tools informed by local patient needs to guide new blood-culture practices. The coordinating study team facilitated regular evaluations and discussions of project progress through monthly phone calls, site visits if requested by sites or the study team, and collaborative-wide teleconferences. The study team collected monthly blood culture rates and monitored for possible delays in obtaining blood cultures using a standardized review process as a safety balancing metric. We compared 24 months of baseline data to 18 months of postimplementation using a Poisson regression model accounting for the site-specific patient days and correlation of culture use within a site over time. Results: Across the 14 sites, before implementation, 41,768 blood cultures were collected over 259,701 PICU patient days. The mean preimplementation site-specific blood culture rate was 15.7 cultures per 100 patient days (rate range, 9.6–48.2 cultures per 100 patient days). After implementation, 22,397 blood cultures were collected over 208,171 PICU patient days. The mean postimplementation rate was 10.4 cultures per 100 patient days (rate range, 4.7–28.3 cultures per 100 patient days), which was 33.6% lower than the preimplementation (relative rate 0.66; 95% CI, 0.65–0.68 p <0.01). In 18 months post-implementation, sites reviewed 793 positive blood cultures, and identified only one suspected delay in culture collection possibly attributable to the site’s blood culture reduction program. Conclusions: Multidisciplinary quality improvement teams safely facilitated a 33.6% average reduction in blood culture use in critically ill children at 14 hospitals. Future collaborative work will determine the impact of blood culture diagnostic stewardship on antibiotic use and other important patient safety outcomes.

Funding: No

Disclosures: None

Figure 1.

Racially and ethnically minoritized (REM) patients are disproportionately impacted by infectious diseases. In our study, REM patients were more likely to receive care for urinary tract infections in the emergency department or urgent care, were younger, and were more likely to have higher social vulnerability.

A multicenter diagnostic study was conducted to investigate the implementation of an Antimicrobial Stewardship Program in Brazilian Pediatric Intensive Care Units. The analysis unveiled the main implementation impediments of the Antimicrobial Stewardship Program such as the lack of professionals and resources available to the program.

Background: The epidemiology of Clostridioides difficile infection (CDI) is complex, and the COVID-19 pandemic has had extreme impacts on known risk factors such as comorbidity burden and antibiotic prescribing. However, whether these changes have affected the incidence of hospital-associated CDI (HA-CDI) remains unknown. We compared incidence and trends of HA-CDI before and after the pandemic onset, and we assessed the impact of changes in key CDI-related risk factors. Methods: We conducted an interrupted time-series study (March 2018–March 2021) of adult inpatients hospitalized 4 or more days with no known CDI on admission at a 576-bed academic medical center. Our primary outcome was monthly HA-CDI per 10,000 patient days. We performed segmented linear regression to compare the preinterruption trend in HA-CDI rate to the postinterruption slope and level change. We established a series of 30-day intervals before and after the interruption timepoint of March 23, 2020, which corresponds with the Oregon stay-at-home executive order. The data included 24 preinterruption time points and 12 postinterruption time points. We also assessed changes in slope and trend for known HA-CDI risk factors. Results: We included 34,592 inpatient encounters in our prepandemic period and 10,932 encounters in our postinterruption period. The mean prepandemic HA-CDI rate was 4.07 cases per 10,000 patient days. After the pandemic onset, the rate was 3.6 per 10,000 patient days. However, the observed differences in rate (both in terms of slope and level) were not statistically significant (P = .90 for level; P = .60 for slope change). We observed a significant decrease in admissions per 30 days (1,441 vs 911; level-change P < .0001) and a slight increase in the mean number of Elixhauser comorbidities (1.96 vs 2.07; level-change P = .05). We also observed significant increases in both frequency and intensity of antibiotic use, with an increase average days of therapy per encounter (5.8 vs 7.2; level-change P = .01; slope-change P < .0001) and in antibiotic spectrum index (ASI) points per antibiotic day (4.4 vs 4.9; P < .0001). We observed a consistent downward trend for case days of CDI colonization pressure per hospital day (preinterruption slope P < .0001), which remained consistent after the pandemic onset (P = 0.5 for postinterruption slope change) (Fig. 1). Conclusions: Despite significant increases in high-intensity antibiotic use and comorbidity burden, we did not observe significant differences in HA-CDI after the pandemic onset. This may be due to the significant decrease in colonization pressure in the postpandemic period. Further research is required to fully understand the impact of the pandemic-related changes on

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: The Veterans’ Affairs (VA) healthcare system has had established telehealth programs for several years. Even so, the COVID-19 pandemic led to an expansion of and changes in these services. Little is known about the influence of the increased use of telehealth due to the COVID-19 pandemic on antibiotic prescriptions in outpatient settings. Here, we report on changes in visit modality and antibiotic prescribing at primary care clinics at a large VA medical center after the emergence of the COVID-19 pandemic. Methods: Using VA administrative databases, we identified primary care visits from March 2018 to November 2019 (before the COVID-19 pandemic) and March 2020 to November 2021 (during the COVID-19 pandemic), which permitted us to account for seasonality while analyzing visit modality and antibiotic trends. For primary care visits during the pre–COVID-19 and COVID-19 periods, we have described the type of visit (in-person or telehealth), diagnostic codes for any infection, and antibiotic prescriptions. Results: The patient population was primarily men (89%) with a mean age of 62.9 years (SD, ±15.3) at first visit. The most common medical conditions were diabetes mellitus (26%) and chronic lung disease (17%). Comparing visits during the pre–COVID-19 and the COVID-19 periods, the proportions of telehealth visits were 20% (17,708 of 88,565) and 74% (69,891 of 94,937), respectively (Fig. 1). The proportions of visits with an antibiotic prescription were 1.4% (1,212 of 88,565) and 0.8% (798 of 94,396), respectively. When considered by the type of visit, the rates of antibiotics prescribed were consistent during the pre–COVID-19 and COVID-19 periods, with a lower rate for telehealth visits (Fig. 2). In both periods, >50% of antibiotic prescriptions occurred during visits without an associated infectious disease diagnosis. Conclusions: Compared to the pre–COVID-19 period, primary care providers at a large VA medical center prescribed fewer antibiotics during the COVID-19 period, and they saw most of their patients via telehealth. These results suggest that some aspects of telehealth may support clinical practices consistent with antibiotic stewardship. The prescription of an antibiotic without an associated diagnostic code also suggests opportunities to improve implementation of antibiotic stewardship principles in primary care settings.

Funding: This work was supported by the Merck Investigator Studies Program (grant no. MISP 59266 to F.P. and R.J.) and by funds and facilities provided by the Cleveland Geriatric Research.

Disclosures: None