134. Impact of an Antibiotic Stewardship Treatment and Management Algorithm for Liver Abscesses

Background Antibiotic prescribing for pyogenic liver abscess(es) (PLA) is highly variable with literature primarily aimed at assessing surgical intervention with a scarcity of data for antibiotic selection and duration of therapy. Given the lack of data, there is no clear consensus for treatment options or length of treatment. Our Antimicrobial Support Network (ASN) in collaboration with the hepatopancreatobiliary (HPB) team created a treatment and management algorithm to guide duration of therapy and antibiotic selection. Methods A retrospective, quasi-experimental cohort study was performed at Carolinas Medical Center in hospitalized patients with PLA with an HPB and/or infectious diseases consult. The primary outcome was antipseudomonal beta-lactam days of therapy (DOT) per 1000 patient days (PD) in the pre-versus post-intervention group. Secondary outcomes included rates of treatment failure at 90 days, 90-day all-cause and abscess-related hospital readmission, C. difficile and multi-drug resistant organism (MDRO) colonization at 90 days from diagnosis, and hospital length of stay (LOS). Additional a priori subgroup analyses of duration of therapy, treatment failure, all-cause and abscess-related readmissions were also conducted based on surgical intervention. Results A total of 93 patients were included, 49 patients in the pre-intervention group and 44 patients in the post-intervention group. Baseline characteristics were similar between the groups. The majority of liver abscesses were unilocular and monomicrobial. Anti-pseudomonal beta-lactam DOT per 1000 PD decreased by 13.8% (507.4 versus 437.5 DOT/1000 PD). Treatment failure occurred in 30.6% of pre-intervention patients and 18.2% of post-intervention patients (p = 0.165). Patients in the post-intervention group were discharged a median of 2.4 days sooner than the pre-intervention period (12.2 days vs. 9.8 days, p = 0.159). No significant differences resulted in 90-day readmission rates or 90-day C. difficile or MDRO rates. Table 1. Primary Outcome for Patients with Pyogenic Liver Abscesses Treated Pre- and Post-Antibiotic Stewardship Algorithm Table 2. Secondary Outcomes for Patients with Pyogenic Liver Abscesses Treated Pre- and Post-Antibiotic Stewardship Algorithm Conclusion The implementation of a PLA treatment and management algorithm led to a decrease in anti-pseudomonal beta-lactams without impacting clinical outcomes and a trend towards decreased LOS. Disclosures All Authors: No reported disclosures

Improvement in time to oral anticancer agent follow-up.

235 Background: Use of oral anticancer agents (OAAs) for cancer treatment continues to grow and creates a need for oncology practices to adapt their ambulatory infusion model of care to one that supports patients taking anti-cancer treatment at home. Historically, our practice has had success with care managers supporting infusion treatment patients. A recently published randomized trial has shown considerable benefits of dedicated pharmacist follow-up for patients taking OAAs. As a result, our practice added a dedicated oncology pharmacist to provide education and follow-up for our OAA patients. Methods: This is a single-center, retrospective evaluation of time to first follow up for patients taking OAAs pre-intervention (11/1/20 - 2/28/21) versus post-intervention (3/1/21 - 4/30/21). The intervention consists of structured symptom and adherence monitoring by a dedicated oncology pharmacist as part of our care management team for all patients prescribed an OAA. In the pre-intervention group, OAA monitoring was divided between care team members without a dedicated OAA program. The population consists of 139 patients newly started on OAAs over the 6-month period. “On-time” follow up defined by our practice is follow up that is <10 days from the OAA start date. There were 20 patients (10 per group) excluded from data analysis due to being deceased before follow-up could be assessed (n= 3), transferring oncology care elsewhere (n= 5), or never starting the OAA (n= 12). Results: Pre-intervention, initial follow up occurred via pharmacist or nurse care manager visit (n=47), provider visit (n=29), or unplanned admission (n=3). Post-intervention, all but two initial follow up visits were performed by the designated oncology pharmacist, and there were no unplanned admissions prior to first follow up. The median time to first follow up visit was 8 days (range 2 to 31 days) in the pre-intervention group (n=79) and 7 days (range 3 to 15 days) in the post-intervention group (n=40). Follow up visits occurred within 10 days of OAA initiation for 67.1% of patients in the pre-intervention group and 95% of patients in the post-intervention group (p=<0.001). Follow up occurred within 14 days of initiation for 82.3% of pre-intervention patients and 97.5% of post-intervention patients (p=0.018). Conclusions: Post-intervention assessment showed improvement in the time to follow up for patients taking OAAs. Future analyses will include outcomes, such as interventions at the time of follow-up, length on therapy, and unplanned admissions.

Impact of an automatic palliative care consultation trigger on healthcare use in patients with relapsed/refractory acute myeloid leukemia.

224 Background: Patients with relapsed/refractory acute myeloid leukemia (AML) have poor outcomes and high levels of healthcare use at end of life. Palliative care remains underused in hematology and questions remain on how best to integrate palliative care for high-risk patients. We conducted a prospective cohort study evaluating palliative care consultation triggers for patients admitted to a tertiary academic center with advanced AML. Methods: Criteria were developed for all hospitalized patients with hematologic malignancy on the inpatient hematology floors and included: 1) persistent disease after ≥ 2 lines of therapy, 2) length of stay (LOS) > 7 days for symptom management, 3) ECOG performance status > 2, and 4) refractory GVHD ≥ 3 lines of therapy. Patients with relapsed/refractory AML were included if they met criteria 1. A nurse coordinator performed chart review of admitted patients 1-2 times/week from June to December 2020 on the inpatient hematology floor at Smilow Cancer Hospital and contacted the primary team when patients met eligibility. Patient characteristics and healthcare outcomes were compared with patients with AML meeting criteria 1 admitted pre-intervention (June to December 2019) using Fisher t-tests. Results: A total 110 admitted patients were eligible (64 pre-intervention and 46 post-intervention). Baseline patient and disease characteristics were similar, including mean age at admission (60.4 vs 60.9 years, p = 0.848), gender (64% vs 59% male, p = 0.691), prior transplant (56% vs 52%, p = 0.702), and AML risk stratification (67% vs 78% adverse risk, p = 0.283). In the post-intervention group, 61% of eligible patients were screened. Of the screened patients, 54% received a palliative care consult, 18% were declined by the primary team, 14% were marked as not eligible, and 14% did not have consult with reason unspecified. Overall, palliative care consults increased in the post-intervention group (22% vs 43%, p = 0.021). There was a significant increase in advance care planning and/or advanced directive documentation post-intervention (13% vs 28%, p = 0.049). There was no differences in pre- and post-intervention groups in LOS (12.13 vs 12.33 days, p = 0.941), 30-day readmissions (52% vs 39%, p = 0.557), critical/intermediate care escalation (22% vs 13%, p = 0.318) and non-palliative chemotherapy post-discharge (48% vs 39%, p = 0.246). Conclusions: A triggered palliative care referral intervention is feasible and doubled palliative care use in patients with relapsed/refractory AML, a group with high mortality and high healthcare utilization. Our intervention improved documentation of advance care planning. Although there were directional reductions in other healthcare use measures, the differences were not statistically significant, likely from the small sample sizes leading to the study being underpowered.

Impact of Educational Intervention on Rational Antibiotic Use In Pediatric Ward

Introduction: Antibiotics are a class of natural and synthetic compounds that inhibit the growth of or kill other microorganisms. Overuse of antibiotic is one of the most important factors for the development and spread of resistance in the hospital, as well as in the community. Present study was designed to describe antibiotic use in children and to assess the impact of an educational intervention on antibiotic prescription. Methods: The present study was conducted in pediatric ward of a tertiary care institute. The study population included two groups of children – each having 250 children. The first group consisted of 250 consecutive children admitted in one unit of the pediatric ward and they were analyzed for antibiotic use without any prior priming of the members of the unit regarding rationality of antibiotic use. This was followed by an intervention in the form of a 3hour workshop for all members of the unit. The second group included another 250 children consecutively admitted in the wards after this intervention. Results: In Pre intervention group 55 (44%) children received antibiotics in rational way, while in Post intervention group 90(60.40%) children received antibiotic in rational way. One hundred and thirty-six children (49.4%) received antibiotics for respiratory tract infections, this being the commonest disease for which antibiotics were received. As seen in the table, unindicated use of antibiotic was significantly reduced in Post intervention group (p = 0.03). Conclusion: The present study included 500 children. There were 285 (57%) males and 215 (43%) females. Amongst these 500 patients, 178 (35.6%) were below 1 year of age. This group had the highest number of patients. In the Pre intervention group, 55 (44%) children received antibiotics rationally, while in Post intervention group 90(60.40%) children received antibiotic rationally.

Reducing the use of empiric antibiotic therapy in COVID-19 on hospital admission

Background Empiric antibiotics for community acquired bacterial pneumonia (CABP) are often prescribed to patients with COVID-19, despite a low reported incidence of co-infections. Stewardship interventions targeted at facilitating appropriate antibiotic prescribing for CABP among COVID-19 patients are needed. We developed a guideline for antibiotic initiation and discontinuation for CABP in COVID-19 patients. The purpose of this study was to assess the impact of this intervention on the duration of empiric CABP antibiotic therapy among patients with COVID-19. Methods This was a single-center, retrospective, quasi-experimental study of adult patients admitted between 3/1/2020 to 4/25/2020 with COVID-19 pneumonia, who were initiated on empiric CABP antibiotics. Patients were excluded if they were initiated on antibiotics > 48 h following admission or if another source of infection was identified. The primary outcome was the duration of antibiotic therapy (DOT) prior to the guideline (March 1 to March27, 2020) and after guideline implementation (March 28 to April 25, 2020). We also evaluated the clinical outcomes (mortality, readmissions, length of stay) among those initiated on empiric CABP antibiotics. Results A total of 506 patients with COVID-19 were evaluated, 102 pre-intervention and 404 post-intervention. Prior to the intervention, 74.5% (n = 76) of patients with COVID-19 received empiric antibiotics compared to only 42% of patients post-intervention (n = 170), p < 0.001. The median DOT in the post-intervention group was 1.3 days shorter (p < 0.001) than the pre-intervention group, and antibiotics directed at atypical bacteria DOT was reduced by 2.8 days (p < 0.001). More patients in the post-intervention group were initiated on antibiotics based on criteria consistent with our guideline (68% versus 87%, p = 0.001). There were no differences between groups in terms of clinical outcomes. Conclusion Following the implementation of a guideline outlining recommendations for initiating and discontinuing antibiotics for CABP among COVID-19 inpatients, we observed a reduction in antibiotic prescribing and DOT. The guideline also resulted in a significant increase in the rate of guideline-congruent empiric antibiotic initiation.

Genetic counseling and testing rates among community cancer programs for patients with breast cancer following site-directed quality improvement.

10529 Background: National Comprehensive Cancer Network (NCCN) guidelines recommend testing for highly penetrant breast/ovarian cancer genes in several scenarios, including women with early-onset (≤ 45 years) or metastatic HER-2 negative breast cancer regardless of family history. A 2018 Association of Community Cancer Centers (ACCC) survey (N = 95) showed that > 80% of respondents reported ≤ 50% testing rate of patients with breast cancer who met guidelines. To improve rates of genetic counseling(GC)/testing, ACCC partnered with 15 community cancer programs to support site-directed quality improvement (QI) interventions. Methods: Pre- and post-intervention data from 9/15 partner programs for genetically at-risk women with early-onset or HER-2 negative metastatic breast cancer (MBC) were analyzed. Pre-intervention data were collected between 01/01/2017 and 06/30/2019 while post-intervention data were collected as early as 07/01/2019 and as late as 10/01/2020. QI project scope ranged from creation of testing eligibility education to implementation of a virtual GC clinic. De-identified data collected included: family history documentation; GC appointment; test results; and timing of results relative to surgical date. Results: The pre-intervention cohort included 2691 women and the post- cohort included 3104 women who were eligible for GC. Early-onset patients in the post-intervention group attended a GC appointment 83% (331/401) of the time and 74% (296/401) had genetic test results, with 92% (271/296) receiving results before surgery. Sixty-one percent (1387/2267) of women with HER-2 negative MBC in the post-intervention group received GC, compared to 36% (658/1845) in the pre-intervention group. There was an overall increase in the number of MBC patients with documented test results following GC in the post-intervention cohort (55% (1243/2267) versus 15% (273/1845); p < 0.0001). Rates of GC appointments improved overall, regardless of family history documentation. Rates among those with a documented high-risk family history improved from 57% (729/1284) to 85% (1485/1741) following QI interventions (p < 0.0001). There was also a significantly higher rate of GC provided in the post-intervention group among women with negative family histories (40% (462/1155) versus 23% (181/778); p < 0.0001). GC also increased from 6% (35/629) to 45% (94/208) of women in the post-intervention cohort with no documentation of family history (p < 0.0001). Conclusions: Genetic testing is underutilized in women with breast cancer. Significant improvement was achieved with QI initiatives specifically designed to target easily identified populations meeting guidelines for GC/testing. This project demonstrates the importance of attention to practice-directed strategies aimed at improving identification of risk as well as follow through to GC/testing.

A retrospective cohort study on a pharmaceutical consultation mode of multidisciplinary individualized medication recommendations

Aims: To develop a pharmaceutical consultation mode of multidisciplinary individualized medication recommendations, to improve the quantity and quality of clinical pharmacists’ consultations Methods: A retrospective study of 542 clinical pharmacists-led consultations was conducted. In the pre-intervention group, medication advice was given based on the purpose of the consultation. In the post-intervention group, a consultation mode of multidisciplinary individualized medication recommendation was implemented, in which clinical pharmacists with specialties of anticoagulation, gastroenterology and nutrition were asked to give individualized medication recommendations and a set of evaluation criteria for rational drug use was formulated. Outcomes, including the patterns and number of consultations, individualized medication recommendations, acceptance rate and effectiveness rate, were compared between the two periods. Results: A total of 651 cases were reviewed, and 542 cases of which meeting the predesigned inclusion and exclusion criteria were included, with 94 and 448 patients in the pre-intervention and post-intervention groups, respectively. The total number of consultations increased year by year, so did the number of general consultations, multidisciplinary difficult consultations, departments applying for general consultations, departments applying for multidisciplinary difficult consultations, anti-infection consultations and non-anti-infection consultations in details. The effectiveness rate of consultations in the post-intervention group was 81.7% vs 70.2% in the pre-intervention group (P < 0.05). No difference was shown between two groups in acceptance rate (96.9% vs 95.7%, p=0.578).

Instructional Moves that Increase Chances of Engaging All Students in Learning Mathematics

Despite the construct of challenge being recognized as an essential element of mathematics instruction, concerns have been raised about whether such approaches benefit students with diverse academic needs. In this article, we focus on the beliefs and instructional practices of teachers teaching students in the first three years of school (5 to 8 years of age). These teachers participated in professional learning focused on challenging mathematical tasks differentiated through their open-ended design and the use of enabling and extending prompts. The instructional practices are explained using the Theory of Didactical Situations. Questionnaire data from pre-intervention (n = 148) and post-intervention (n = 100) groups of teachers indicated that teachers in the post-intervention group held more negative beliefs than those in the pre-intervention group about the capability of instructional approaches involving a priori grouping of students by performance levels. Interviews with ten teachers from the post-intervention group revealed and characterized the ways teachers employed open-ended tasks with enabling and extending prompts to engage all learners. Findings reveal that teachers knowing their students as individual learners accompanied by knowledge of a range of teaching practices to differentiate instruction are central to engaging all learners.

The DOOR to Antibiotic Stewardship: Refining Assessments of Interventions With Desirability of Outcome Ranking

Background: Limited sample size and disparate outcome measures can hinder the ability of antimicrobial stewardship programs to assess the utility of their quality improvement interventions. Desirability of outcome ranking (DOOR) is a novel methodology that incorporates multiple outcomes into a single value to more comprehensively compare therapeutic strategies. The objective of this study was to apply DOOR to a single center antibiotic stewardship intervention. Methods: A pre- and post-interventional study was conducted evaluating the impact of prospective pharmacist review of rapid molecular diagnostic testing (RDT) of blood cultures on antibiotic optimization. Outcomes included the percentage of patients who were switched to appropriate therapy, the time to appropriate therapy, and the percentage of patients who had missed de-escalation opportunities. Results: A total of 19 and 29 patients were included in the final analysis. The percentage of patients reaching appropriate therapy was 84% (16/19) and 97% ([28/29], p = 0.16) in the pre-intervention and post-intervention groups respectively. Median time to appropriate therapy was 26 hours and 36 minutes (IQR 13:05-50:45) and 22:40 (IQR 3:42-48:23, p = 0.32), respectively. One missed de-escalation opportunity was identified in the post-intervention group (0% vs 3%, p = 1.00). DOOR analysis indicated that the probability of a better outcome for the post-intervention group than the pre-intervention group was 58% (95% CI 54-62). Conclusion: In this analysis, DOOR revealed a benefit that would not have been apparent with traditional outcomes assessments. Antimicrobial stewardship programs conducting quality improvement studies should consider incorporating DOOR into their methodology.

Impact of a Systematic Pharmacist-Initiated Antibiotic Time-Out Intervention for Hospitalized Adults

Introduction: Antibiotic time-outs (ATO) are a recommended antimicrobial stewardship action, but data assessing their impact are lacking. This study investigated the impact of a systematic, pharmacist initiated ATO intervention. Methods: This pre-post study included inpatients on hospitalist and intensivist services receiving empiric antibiotics for ≥48 hours. The ATO was initiated by pharmacists after 48 hours of empiric therapy and the outcome was documented including antibiotic indication, plan, and duration. An electronic medical record (EMR) alert facilitated ATO completion and pharmacists and prescribers received education prior to implementation. The primary outcome was EMR documentation of an antibiotic plan by 72 hours. Secondary outcomes included antibiotic utilization and antibiotic therapy modifications by 2 hours. Results: 399 patients were included, 199 pre- and 200 post-intervention. The most common indications were pneumonia (32%), intra-abdominal infection (20%) and urinary tract infection (19%), with no between-group differences. EMR documentation of an antibiotic plan significantly improved in the post-intervention group (19% vs. 79%, p<0.0001) as did modifications to antibiotic therapy. The median duration of in-hospital antibiotic therapy was similar between groups (4.0 vs. 4.0 days, p = 0.2499). Approximately 45% of patients in each group received discharge antibiotics and median duration of discharge antibiotic therapy prescribed was reduced (7 vs. 5 days in the pre- and post-intervention groups, respectively; p = 0.0140). Discussion: Implementation of pharmacist initiated ATO was associated with improvements in supporting EMR documentation and antibiotic therapy modifications. These findings highlight an important role in which pharmacists can serve as part of a collaborative antibiotic stewardship team.