47. Transitioning to Batch Dosing of High-Cost Antimicrobials in the Inpatient Setting

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

Effects of the cefazolin shortage on the sales, cost, and appropriate use of other antimicrobials

Background Shortages of antimicrobials lead to treatment failures, increase medical costs, and accelerate the development of antimicrobial resistance. We evaluated the effects of the serious cefazolin shortage in 2019 in Japan on the sales, costs, and appropriate use of other antimicrobials. Methods We evaluated monthly defined daily doses/1000 inhabitants/day (DID) values of antimicrobial sales from January 2016 to December 2019 using wholesaler’s sales databases. Using 2016–2018 sales data, we generated a prediction model of DID in 2019 under the assumption that the cefazolin shortage did not occur. We then compared the predicted DID and actual DID. Cefazolin, government-recommended alternatives, and government-not-recommended broad-spectrum alternatives were assessed. Antimicrobial groups according to the AWaRe classification were also assessed to evaluate the effect on appropriate antimicrobial use. In addition, we evaluated changes in costs between 9 months before and after the cefazolin shortage. Results DID values of total antimicrobials increased sharply 1 month before the decrease in cefazolin. Actual DIDs were higher than predicted DIDs for ceftriaxone, flomoxef, clindamycin, cefotiam, piperacillin/tazobactam, and meropenem. Actual DID values were higher than the predicted DID values in the Watch group. The costs of antimicrobials between pre- and post- cefazolin shortage were unchanged. Conclusion The cefazolin shortage brought confusion to the antimicrobial market and led to a setback in the appropriate use of antimicrobials. Early recognition and structures for prompt reactions to antimicrobial shortages are needed. Moreover, development of a system to secure the supply of essential antimicrobials is required.

Effects of the cefazolin shortage on the sales, cost, and appropriate use of other antimicrobials

Background Shortages of antimicrobials lead to treatment failures, increase medical costs, and accelerate the development of antimicrobial resistance. We evaluated the effects of the serious cefazolin shortage in 2019 in Japan on the sales, costs, and appropriate use of other antimicrobials. Methods We evaluated monthly defined daily doses/1,000 inhabitants/day (DID) values of antimicrobial sales from January 2016 to December 2019 using wholesaler’s sales databases. Using 2016–2018 sales data, we generated a prediction model of DID in 2019 under the assumption that the cefazolin shortage did not occur. We then compared the predicted DID and actual DID. Cefazolin, government-recommended alternatives, and non-government-recommended broad-spectrum alternatives were assessed. Antimicrobial groups according to the AWaRe classification were also assessed to evaluate the effect on appropriate antimicrobial use. In addition, we evaluated changes in costs between 9 months before and after the cefazolin shortage. Results DID values of total antimicrobials increased sharply 1 month before the decrease in cefazolin. Actual DIDs were higher than predicted DIDs for ceftriaxone, flomoxef, clindamycin, cefotiam, piperacillin/tazobactam, and meropenem. Actual DID values were higher than the predicted DID values in the Watch group. The costs of antimicrobials between pre- and post- cefazolin shortage were unchanged. Conclusion The cefazolin shortage brought confusion to the antimicrobial market and led to a setback in the appropriate use of antimicrobials. Early recognition and structures for prompt reactions to antimicrobial shortages are needed. Moreover, development of a system to secure the supply of essential antimicrobials is required.

920. Use of the Web by State and Territorial Health Departments to Promote the Dissemination of State Antimicrobial Resistance Surveillance Data, United States

Background Antimicrobial resistant (AMR) bacteria pose a serious threat to public health. The national response to this threat includes calls for promoting judicious use of antibiotics in humans and animals and strengthening integrated One Health surveillance of AMR bacteria in humans, animals, and environment. However, the extent to which public health jurisdictions are disseminating surveillance findings to promote judicious use of antimicrobials is unclear. Methods We used a standardized web audit tool to manually review and document the presence of AMR-related information on the websites of all public health jurisdictions that participate in national notifiable disease surveillance in the United States. We also emailed a survey to representatives in the 54 jurisdictions that participate in the National Antimicrobial Resistance Monitoring System (NARMS) activities coordinated by the Centers for Disease Control and Prevention. The survey asked questions about AMR-related information on their public health department website. Results Of the 37 (68.5%) jurisdictions that responded to the email survey, 26 (70.3%) indicated that their websites have information on appropriate antibiotic use for health professionals, veterinarians and general public, compared to 89.3% from the web survey (Figure). Eleven (29.7%) indicated that they have data on antimicrobial susceptibility for pathogens, or antibiograms, on their websites, compared to 48.2% from the web survey. While 11 (29.7%) jurisdictions indicated that they have highlighted appropriate antimicrobial use on the homepage, the web survey found no reference on the homepage. Comparison of results from email and web survey on public health jurisdictions’ website, United States - 2020 Conclusion Public health jurisdictions have begun to use websites to increase awareness about the threat of antimicrobial resistance. However, the limited presence of information on appropriate antimicrobial use for the public, health professionals and veterinarians suggest the need for improvement. Gaps exist between the awareness of the epidemiologists and laboratorians and the information reported on public health jurisdictions’ websites. Websites can be expanded and better leveraged to increase visibility of AMR and appropriate antimicrobial prescribing across One Health domains. Disclosures All Authors: No reported disclosures

Old In Vitro Antimicrobial Breakpoints Are Misleading Stewardship Efforts, Delaying Adoption of Innovative Therapies, and Harming Patients

The current antimicrobial market and old (pre-2000) in vitro antimicrobial susceptibility test interpretative criteria (STIC) are not working properly. Malfunctioning susceptibility breakpoints and antimicrobial markets have serious implications for both patients (ie, from a safety and efficacy perspective) and antibiotic-focused pharmaceutical and biotechnology company economic viability. Poorly functioning STIC fail both patients and clinicians since they do not discriminate between likely effective and ineffective antimicrobial regimens. Poor economic viability fails patients and clinicians as it decreases the industry’s ability to develop antimicrobial agents that clinicians and patients urgently require now and in the future. Herein, we review how STIC for older antimicrobial agents were determined and how their correction can impact the perceived utility of old relative to new antimicrobial agents. Moreover, we describe the data and analysis needs to systematically reevaluate older STIC values. We call for professional infectious diseases societies, government agencies, and other consensus bodies interested in the appropriate use of antimicrobial agents to join an effort to systematically evaluate and, where warranted, correct STIC for all relevant antimicrobial agents. This effort will amplify the effects of other measures designed to increase appropriate antimicrobial use (ie, good antimicrobial stewardship), development, and regulation.

A trend in prevalence of antimicrobial use and appropriateness of antimicrobial therapy in an acute care hospital from 2018 to 2019: repeated prevalence surveys in Japan

Objectives The supply of cefazolin has been reduced dramatically since March 2019 in Japan. However, no studies have evaluated the effects of cefazolin shortage on the appropriateness of antimicrobial use. Therefore, we compared the appropriateness of inpatient antimicrobial drug use between the two surveys conducted in August 2018 and August 2019 in a Japanese hospital with no supply of cefazolin since the cefazolin shortage. Results In the 2019 survey, a total of 275 patients were included, and 256 patients were included in the 2018 survey. The prevalence of antimicrobial drug use did not change from 2018 to 2019 (28.5% versus 28.7%; p = 0.96). The proportion of cefazolin in all antimicrobial drugs used on the survey date significantly decreased from 2018 to 2019 (24.1% versus 0.0%; p < 0.001). The proportion of appropriate antimicrobial use in all antimicrobial therapies tended to be lower in 2019 than in 2018 (41.2% versus 60.6%; p = 0.06), and the proportion of unnecessary use of a broader spectrum of antimicrobial drugs significantly increased from 2018 to 2019 (4.7% versus 37.3%; p = 0.002). The shortage of cefazolin might lead to inappropriate use of other antimicrobial drugs.

Pattern of inappropriate antibiotic use among hospitalized patients in Pakistan: a longitudinal surveillance and implications

Background The inappropriate use of antibiotics in hospitals increases resistance, morbidity, and mortality. Little is currently known about appropriate antibiotic use among hospitals in Lahore, the capital city of Pakistan. Methods Longitudinal surveillance was conducted over a period of 2 months among hospitals in Lahore, Pakistan. Antibiotic treatment was considered inappropriate on the basis of a wrong dosage regimen, wrong indication, or both based on the British National Formulary. Results A total of 2022 antibiotics were given to 1185 patients. Out of the total prescribed, approximately two-thirds of the study population (70.3%) had at least one inappropriate antimicrobial. Overall, 27.2% of patients had respiratory tract infections, and out of these, 62.8% were considered as having inappropriate therapy. Cephalosporins were extensively prescribed among patients, and in many cases, this was inappropriate (67.2%). Penicillins were given to 283 patients, out of which 201 (71.0%) were prescribed for either the wrong indication or dosage or both. Significant variations were also observed regarding inappropriate prescribing for several antimicrobials including the carbapenems (70.9%), aminoglycosides (35.8%), fluoroquinolones (64.2%), macrolides (74.6%) and other antibacterials (73.1%). Conclusion Educational interventions, institutional guidelines, and antimicrobial stewardship programs need to be developed to enhance future appropriate antimicrobial use in hospitals in Pakistan. Policies by healthcare and Government officials are also needed to minimize inappropriate antibiotic use.

2041. Impact of an Infectious Disease Specialist-led Post-Prescription Carbapenem Intervention in a Large Japanese Tertiary Hospital: A Before–After Cohort Study

Background There are fewer board-certified infectious disease (ID) specialists in Japan (n = 1494) than in the United States (n = 8535); therefore, we have insufficient protected time for antimicrobial stewardship activities, and thus, there is a need for an innovative solution. Methods This study compared carbapenem consumption between a 24-month baseline period and a 12-month intervention period at the Iizuka Hospital with 1048 inpatient beds in Japan. During the intervention period, a board-certified ID specialist provided daily feedback to prescribers against prolonged carbapenem use (≥14 days) through conversations and medical records. Additionally, we reported through e-mail the weekly point prevalence surveillance data of the long-term carbapenem users for 7–13 and ≥14 days, which were aggregated by each department. Results We provided a total of 106 feedbacks regarding carbapenem use for ≥14 days during the intervention period. After the initiation of intervention, the trend of monthly carbapenem consumption changed (coefficient: −0.62; 95% CI: −1.15 to −0.087, P = 0.024), and its overall consumption has decreased (coefficient: −0.098; 95% CI: −0.16 to −0.039, P = 0.002, Figure 1) without a change in the in-hospital mortality (P = 0.53) as revealed by segmented regression analysis. Interestingly, the number of monthly carbapenem users, but not the duration of carbapenem use, significantly decreased (coefficient: −3.02; 95% CI: −4.63 to −1.42, P = 0.001, Figure 2). An annual estimated saving after the intervention was $82,266 with a cost reduction of 22%. Conclusion Our ID specialist-led daily intervention in carbapenem prescription and weekly feedback for long-term carbapenem use were effective in reducing this antibiotic’s consumption and consequently the number of carbapenem users. These feedbacks may be useful in changing the behavior of prescribers and promoting appropriate antimicrobial use even in resource-poor settings. Disclosures All authors: No reported disclosures.