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Objective:To determine whether a clinician-directed acute respiratory tract infection (ARI) intervention was associated with improved antibiotic prescribing and patient outcomes across a large US healthcare system.Design:Multicenter retrospective quasi-experimental analysis of outpatient visits with a diagnosis of uncomplicated ARI over a 7-year period.Participants:Outpatients with ARI diagnoses: sinusitis, pharyngitis, bronchitis, and unspecified upper respiratory tract infection (URI-NOS). Outpatients with concurrent infection or select comorbid conditions were excluded.Intervention(s):Audit and feedback with peer comparison of antibiotic prescribing rates and academic detailing of clinicians with frequent ARI visits. Antimicrobial stewards and academic detailing personnel delivered the intervention; facility and clinician participation were voluntary.Measure(s):We calculated the probability to receive antibiotics for an ARI before and after implementation. Secondary outcomes included probability for a return clinic visits or infection-related hospitalization, before and after implementation. Intervention effects were assessed with logistic generalized estimating equation models. Facility participation was tracked, and results were stratified by quartile of facility intervention intensity.Results:We reviewed 1,003,509 and 323,023 uncomplicated ARI visits before and after the implementation of the intervention, respectively. The probability to receive antibiotics for ARI decreased after implementation (odds ratio [OR], 0.82; 95% confidence interval [CI], 0.78–0.86). Facilities with the highest quartile of intervention intensity demonstrated larger reductions in antibiotic prescribing (OR, 0.69; 95% CI, 0.59–0.80) compared to nonparticipating facilities (OR, 0.89; 95% CI, 0.73–1.09). Return visits (OR, 1.00; 95% CI, 0.94–1.07) and infection-related hospitalizations (OR, 1.21; 95% CI, 0.92–1.59) were not different before and after implementation within facilities that performed intensive implementation.Conclusions:Implementation of a nationwide ARI management intervention (ie, audit and feedback with academic detailing) was associated with improved ARI management in an intervention intensity–dependent manner. No impact on ARI-related clinical outcomes was observed.

Objective:To assess the feasibility of electronic data capture of postdischarge durations and evaluate total durations of antimicrobial exposure related to inpatient hospital stays.Design:Multicenter, retrospective cohort study.Setting:Two community hospitals and 1 academic medical center.Patients:Hospitalized patients who received ≥1 dose of a systemic antimicrobial agent.Methods:We collected and reviewed electronic data on inpatient and discharge antimicrobial prescribing from April to September 2016 in 3 pilot hospitals. Inpatient antimicrobial use was obtained from electronic medication administration records. Postdischarge antimicrobial use was calculated from electronic discharge prescriptions. We completed a manual validation to evaluate the ability of electronic prescriptions to capture intended postdischarge antibiotics. Inpatient, postdischarge, and total lengths of therapy (LOT) per admission were calculated to assess durations of antimicrobial therapy attributed to hospitalization.Results:A total of 45,693 inpatient admissions were evaluated. Antimicrobials were given during 23,447 admissions (51%), and electronic discharge prescriptions were captured in 7,442 admissions (16%). Manual validation revealed incomplete data capture in scenarios in which prescribers avoided the electronic system. The postdischarge LOT among admissions with discharge antimicrobials was median 8 days (range, 1–360) with peaks at 5, 7, 10, and 14 days. Postdischarge days accounted for 38% of antimicrobial exposure days.Conclusion:Discharge antimicrobial therapy accounted for a large portion of antimicrobial exposure related to inpatient hospital stays. Discharge prescription data can feasibly be captured through electronic prescribing records and may aid in designing stewardship interventions at transitions of care.

Background: Patients with a penicillin/aminopenicillin (PCN) allergy label are more likely to receive non–β-lactam antibiotics and to experience worse clinical outcomes. Given that nurses are often first to interact with patients, we pilot tested a nurse-driven quality improvement initiative to improve PCN allergy documentation and increase β-lactam use. Methods: We conducted a before-and-after study on a labor and delivery unit at The Johns Hopkins Hospital (JHH) from May 2018 to September 2019. Patients aged 18 years with a PCN allergy were included. The intervention included (1) the use of an algorithm developed by the antimicrobial stewardship team to assist nurses in obtaining accurate PCN allergy histories (Fig. 1), (2) identification of a nurse champion to facilitate implementation of the algorithm, and (3) in-person education by a stewardship physician regarding the importance and impact of adequate PCN allergy documentation on clinical outcomes. Readmissions were counted as separate encounters. The primary outcome was improved allergy documentation (either fewer blank documentations, nonspecified rash reactions, drug intolerance documentations (eg, isolated nausea), documentation of signs and symptoms of anaphylaxis not specified as such). The secondary outcome was β-lactam use. Categorical variables were compared using the 2 test and continuous variables were compared with the Student t test. Severe allergic reactions were defined as anaphylaxis, severe skin reactions (eg, Stevens-Johnson syndrome), and organ involvement (eg, hepatitis). Results: Overall, 382 patient admissions were included, 305 in the preintervention (May 2018 to May 2019) and 77 in the postintervention period (June 2019 to September 2019). Mean age and length-of-stay were 30 years and 4 days, respectively, for both periods. The proportion of admitted patients with a PCN allergy label was 8% and 7% for pre- and postintervention periods. Documentation findings in the pre- and postintervention periods respectively were as follows: blank documentation 11% and 12% (P = .89), documentation of specified rashes 0.6% and 1.3% (P = .56), documentation of drug intolerance 11% and 8% (P = .39), documentation of reactions that were indicative of anaphylaxis but not documented specifically as anaphylaxis 8% and 13% (P = .20). Among patients with a documented PCN allergy who received antibiotics, 83 of 177 (47%) and 27 of 43 (63%) received β-lactams (P = .01) in the pre- and postintervention periods, with cefazolin being the antibiotic most commonly used in both periods. Conclusions: Nursing education and an algorithm did not result in significant improvements in PCN allergy documentation in the 3 months after implementation. More data collection is planned to assess the impact of the intervention.Funding: NoneDisclosures: None

Background: Antimicrobial stewardship (AMS) is recommended in hospital, postacute, and outpatient settings. Transitions of care (TOC) are important in each of these settings; however, AMS efforts during TOC have been limited. Beginning in October 2018, we sequentially implemented a pharmacist-led multidisciplinary review of oral antimicrobial therapy prescribed at hospital discharge from general and specialty medicine wards across a health system. Pharmacists facilitated data input of discharge prescriptions following early identification and collaborative discussion of patients to be discharged on oral antimicrobials The purpose of this study was to evaluate the impact of AMS during TOC. Methods: This project was an IRB-approved stepped-wedge, quasi-experimental study in a 5-hospital health system that included hospitalized adults with skin, urinary, intra-abdominal, and respiratory tract infections who had been discharged from general and specialty wards with oral antimicrobials. Patients with complicated infections, neutropenia, or who were transferred from an outside hospital were excluded. The primary end point was optimization of antimicrobial therapy at time of hospital discharge, defined by correct selection, dose, and duration according to institutional guidance. Outcomes were compared before and after the intervention. Results: In total, 800 patients were included: 400 in the preintervention period and 400 in the postintervention period. Among this cohort, 252 (63%) received the intervention by a pharmacist per protocol during TOC. Patients had similar comorbid conditions before and after the intervention. Preintervention patients were more likely to be discharged from community hospitals. Before the intervention, 36% of discharge regimens were considered optimized, compared to 81.5% after the intervention (P < .001); this difference was largely driven by a reduction in patients receiving a duration of therapy beyond the clinical indication (44.5 vs 10%; P < .001). We observed similar clinical resolution, 30-day readmission, and adverse drug events (ADEs) between the pre- and postintervention periods. Postdischarge antimicrobial duration of therapy was reduced from 4 days (range, 3–5) to 3 days (range, 2–4) (P < .001) Severe ADEs occurred more frequently in the preintervention group (9 vs 3.3%; P = .001), which was driven by isolation of multidrug-resistant pathogens (7 vs 2.5%; P = .003) and Clostridioides difficile (1.8 vs 0.5%; P = .094). Patients who received optimal therapy at discharge were less likely to develop an ADE (aOR, 0.530; 95% CI, 0.363–0.773). Conclusions: Implementation of an AMS TOC protocol reduced antimicrobial days, optimized therapy selection, and reduced duration. This intervention was associated with improved safety without compromise of clinical effectiveness. To increase patient safety, AMS programs should target antimicrobial optimization during TOC.Funding: This work was completed under CDC contract number 200-2018-02928.Disclosures: None

Background: Antibiotic overuse contributes to antibiotic resistance and unnecessary adverse drug effects. Antibiotic stewardship interventions have primarily focused on acute-care settings. Most antibiotic use, however, occurs in outpatients with acute respiratory tract infections such as pharyngitis. The electronic health record (EHR) might provide an effective and efficient tool for outpatient antibiotic stewardship. We aimed to develop and validate an electronic algorithm to identify inappropriate antibiotic use for pediatric outpatients with pharyngitis. Methods: This study was conducted within the Children’s Hospital of Philadelphia (CHOP) Care Network, including 31 pediatric primary care practices and 3 urgent care centers with a shared EHR serving >250,000 children. We used International Classification of Diseases, Tenth Revision (ICD-10) codes to identify encounters for pharyngitis at any CHOP practice from March 15, 2017, to March 14, 2018, excluding those with concurrent infections (eg, otitis media, sinusitis), immunocompromising conditions, or other comorbidities that might influence the need for antibiotics. We randomly selected 450 features for detailed chart abstraction assessing patient demographics as well as practice and prescriber characteristics. Appropriateness of antibiotic use based on chart review served as the gold standard for evaluating the electronic algorithm. Criteria for appropriate use included streptococcal testing, use of penicillin or amoxicillin (absent β-lactam allergy), and a 10-day duration of therapy. Results: In 450 patients, the median age was 8.4 years (IQR, 5.5–9.0) and 54% were women. On chart review, 149 patients (33%) received an antibiotic, of whom 126 had a positive rapid strep result. Thus, based on chart review, 23 subjects (5%) diagnosed with pharyngitis received antibiotics inappropriately. Amoxicillin or penicillin was prescribed for 100 of the 126 children (79%) with a positive rapid strep test. Of the 126 children with a positive test, 114 (90%) received the correct antibiotic: amoxicillin, penicillin, or an appropriate alternative antibiotic due to b-lactam allergy. Duration of treatment was correct for all 126 children. Using the electronic algorithm, the proportion of inappropriate prescribing was 28 of 450 (6%). The test characteristics of the electronic algorithm (compared to gold standard chart review) for identification of inappropriate antibiotic prescribing were sensitivity (99%, 422 of 427); specificity (100%, 23 of 23); positive predictive value (82%, 23 of 28); and negative predictive value (100%, 422 of 422). Conclusions: For children with pharyngitis, an electronic algorithm for identification of inappropriate antibiotic prescribing is highly accurate. Future work should validate this approach in other settings and develop and evaluate the impact of an audit and feedback intervention based on this tool.Funding: NoneDisclosures: None

Background: Antimicrobial stewardship (AMS) interventions have predominantly involved inpatient antimicrobial therapy. However, for many hospitalized patients, most antibiotic use occurs after discharge, and unnecessarily prolonged courses of therapy are common. Patient transition from hospitalization to discharge represents an important opportunity for AMS intervention. We describe patterns of antibiotic use selection and duration of therapy (DOT) for common infections including discharge antibiotics. Methods: This retrospective cross-sectional analysis was derived from an IRB-approved, multihospital, quasi-experiment at a 5-hospital health system in southeastern Michigan. The study population included patients discharged from an inpatient general and specialty practice ward on oral antibiotics from November 2018 through April 2019. Patients were included with the following diagnoses: skin and soft-tissue infections (SSTIs), community-acquired pneumonia (CAP), hospital-acquired pneumonia (HAP), respiratory viral infections, acute exacerbation of chronic obstructive pulmonary disease (AECOPD), intra-abdominal infections (IAIs), and urinary tract infections (UTIs). Other diagnoses were excluded. Data were extracted from medical records including antibiotic indication, selection, and duration, as well as patient characteristics. Results: In total, 1,574 patients were screened and 800 patients were eligible for inclusion. The most common antibiotic indications were respiratory tract infections, with 487 (60.9%) patients. These included 165 AECOPD cases (20.6%) and 200 CAP cases (25%) with no multidrug resistant organism (MDRO) risk factors; 57 patients (7.1%) with MDRO risk factors; HAP in 7 patients (0.9%); and influenza in 58 patients (7.2%). Also, 205 (25.6%) patients were diagnosed with UTIs: 71 with cystitis (8.9%), 86 (10.8%) with complicated UTI (cUTI), and 48 (6%) with pyelonephritis. Furthermore, 125 patients (15.6%) were diagnosed with SSTI: 59 (7.4%) purulent and 66 (8.3%) nonpurulent. 31 (3.9%) patients had an IAI. The most commonly used antibiotics were cephalosporins in 536 patients (67%), azithromycin in 252 patients (31.5%), and fluroquinolones and tetracyclines in 231 patients (28.9%). Fluroquinolones were the most frequent antibiotic prescribed at discharge in 210 patients (26.3%). Figure 1 displays the average DOT relative to specific indications. The median duration of total antibiotic therapy exceeded institutional guideline recommendation for multiple conditions, including AECOPD (7 days vs recommended 5 days), CAP with COPD (8.3 vs 7 days ), CAP without COPD (7.7 vs 5 days), and pyelonephritis (11 vs 7–10 days). Also, 269 (33.6%) patients received unnecessary therapy; 218 (27.3%) of these were due to excess duration. Conclusions: Among a cross-section of hospitalized patients, the average DOT, including after discharge, exceeded the optimal therapy for many patients. Further understanding of patterns and influences of antibiotic prescribing is necessary to design effective AMS interventions for improvement.Funding: This work was completed under CDC contract number 200-2018-02928.Disclosures: None

Background: Community-acquired pneumonia (CAP), urinary tract infection (UTI), pharyngitis, acute otitis media (AOM), and skin and soft-tissue infection (SSTI) are among the most common outpatient conditions for which antibiotics are prescribed. The objective of this study was to describe the observed duration of outpatient antibiotic therapy compared with guideline recommendations for these common conditions in 2017 in the United States to identify antibiotic stewardship targets. Methods: We estimated therapy duration for oral and parenteral antibiotic prescriptions associated with CAP, AOM, pharyngitis, acute cystitis, pyelonephritis, SSTI, and sinusitis diagnoses from the IQVIA National Disease and Therapeutic Index 2017 dataset, a two-stage stratified cluster sample of office-based physician visits. We excluded azithromycin due to its unique pharmacokinetics, and we limited our study to prescriptions from emergency medicine, family practice, general practice, geriatrics, internal medicine, osteopathic medicine, and pediatrics physicians. We excluded observations with antibiotic prescriptions for multiple conditions. We used NDTI projection weights and complex sample methods to estimate antibiotic prescription numbers and durations by condition and age group. Results: Table 1 shows antibiotic prescriptions by condition and population. The median antibiotic therapy duration for all conditions except acute cystitis was 10 days. The median duration for acute cystitis was 7 days. Conclusions:Clinicians prescribed 10-day antibiotic courses for the most common outpatient conditions, regardless of guideline-recommended duration. Antibiotic stewardship efforts targeting excessive durations of antibiotic therapy for common outpatient conditions, particularly sinusitis in adults, CAP, SSTI, and acute cystitis, are needed.Funding: This work was supported by the Centers for Disease Control and Prevention. The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.Disclosures: Laura M. King is a contractor employed by Northrop Grumman Corporation to fulfill research needs at the Centers for Disease Control and Prevention as part of a contract covering many positions and tasks. All other authors declare no conflicts.

Background: Bedside nurses have been recognized as potential antibiotic stewards; however, data on effective ways that nurses can contribute to stewardship activities in acute-care hospitals are scarce. Methods: A nurse-driven urine culture intervention to improve urine culture ordering practices was implemented in a medicine and a neurocritical care unit (NCCU) at The Johns Hopkins Hospital. Bedside nurses implemented an algorithm (Fig. 1) developed by the antibiotic stewardship program (ASP) to review the appropriateness of urine culture and to guide discussions with ordering providers regarding unnecessary urine cultures. Nurses received in-person training by an ASP physician champion on how to use the algorithm and education on the definition and indications for evaluation for asymptomatic bacteriuria and urinary tract infections. The ASP physician periodically visited the units to address concerns and questions. In both units, a nurse champion was identified to serve as liaison between the ASP and bedside nurses, and physician support was obtained before the intervention. The pre- and postintervention periods for the medicine unit were September 2017–August 2018 and September 2018–August 2019, respectively. For the NCCU, these periods were September 2018–February 2019 and March 2019–September 2019, respectively. Trends in urine cultures per 100 patient days (PD) were examined with statistical process charts and compared before and after the intervention using a standard incident ratio (IRR) and Poisson regression. Results: In total, 327 urine cultures were collected in the medicine unit and 293 in the NCCU over the study period. Although the intervention led to a significant 34% reduction in the rate of urine cultures on the medicine unit (from 2.3 to 1.5 cultures/100 PD; IRR, 0.66; 95% CI, 0.50–0.87; P < .01), the number of urine cultures remained without a significant change in the NCCU (from 4.5 to 3.7 cultures/100 PD; IRR, 0.89; 95% CI, 0.65–1.22; P = .48) (Fig. 2). Conclusions: Algorithm-based, nurse-driven review of urine culture indications reduced urine cultures on a medicine unit but not in a neurosciences ICU. Success on the medicine unit may have been driven by highly engaged nurse and physician champions and by patients being able to respond questions about symptoms. The following factors might have impacted results on NCCU: presence of conflicting protocols (eg, panculturing patients every 48 hours per a hypothermia protocol), unit tradition (eg, obtaining cultures to assess treatment response), perception of greater risk benefit in NCCU patients, and unit dynamics (open unit with other primary services placing orders for patients). Unit and team dynamics can affect effective implementation of antimicrobial stewardship interventions by nurses.Funding: NoneDisclosures: None

Background: Unnecessary and prolonged antibiotic use is an important driver of antimicrobial resistance, increasing patient harm and resource utilization. Antimicrobials prescribed at hospital discharge represent an important opportunity to intervene and optimize therapy. Objective: We describe the implementation of a pharmacist-led multidisciplinary antimicrobial stewardship (AMS) intervention at transition of care (TOC) to improve antibiotic selection and duration. Methods: This intervention an IRB-approved multihospital, quasi-experimental, 3-phase stepped-wedge project in a 5-hospital health system. The setting included a large, urban, academic medical center in Detroit, Michigan, and 4 community hospitals in southeastern Michigan. AMS is provided by a pharmacist and infectious diseases physician at each site. For the AMS TOC intervention, pharmacists implemented 3 strategies: (1) early identification of patients to be discharged on oral antibiotics; (2) collaborative planning and communication regarding guideline-recommended antibiotic selection and duration; and (3) facilitation of discharge antibiotic prescription with appropriate stop date. Process improvements were modified to fit the academic and community hospital practice models. The process was implemented in general and specialty practice wards at each hospital site. Prior to implementation in October 2018, pharmacists were trained on tools to standardize identification, collaboration, and documentation. Pocket cards were used to augment education and electronic medical record (EMR) templates standardized documentation. Physicians and nurses on participating units were educated on the rationale and process. Following initiation, ongoing feedback was provided regularly to pharmacists to discuss challenges and to identify solutions. Process measures included the total number of patients receiving the intervention monthly, as indicated by pharmacist AMS TOC notes placed. Protocol adherence was evaluated in 25 randomly selected patients in each study phase each month. Adherence was defined as a pharmacist preparing discharge prescriptions and a placing note in the EMR. Results: Over the study period, 1,558 patient encounters received AMS TOC facilitation by a pharmacist. Monthly protocol adherence ranged from 29% to 87% (higher in academic institutions than community) (Fig. 1). Months of low protocol adherence were associated with times of reduced staffing and onboarding a large group of new employees or trainees. Additional barriers included discharges over weekends. The most common area needing clarification was how to count days of therapy to determine the appropriate stop date. A guide of how to count days of therapy was created to assist. Conclusions: Pharmacist-led antimicrobial stewardship at discharge is a feasible intervention in both academic and community settings. Identifying potential barriers and assessing strategies with multidisciplinary healthcare teams allows for optimal implementation and intervention rollout.Funding: This work was completed under CDC contract number 200-2018-02928.Disclosures: None

Background: Antibiotic resistance has increased at alarming rates, driven predominantly by antibiotic overuse. Although most antibiotic use occurs in outpatients, antimicrobial stewardship programs have primarily focused on inpatient settings. A major challenge for outpatient stewardship is the lack of accurate and accessible electronic data to target interventions. We sought to develop and validate an electronic algorithm to identify inappropriate antibiotic use for outpatients with acute bronchitis. Methods: This study was conducted within the University of Pennsylvania Health System (UPHS). We used ICD-10 diagnostic codes to identify encounters for acute bronchitis at any outpatient UPHS practice between March 15, 2017, and March 14, 2018. Exclusion criteria included underlying immunocompromising condition, other comorbidity influencing the need for antibiotics (eg, emphysema), or ICD-10 code at the same visit for a concurrent infection (eg, sinusitis). We randomly selected 300 (150 from academic practices and 150 from nonacademic practices) eligible subjects for detailed chart abstraction that assessed patient demographics and practice and prescriber characteristics. Appropriateness of antibiotic use based on chart review served as the gold standard for assessment of the electronic algorithm. Because antibiotic use is not indicated for this study population, appropriateness was assessed based upon whether an antibiotic was prescribed or not. Results: Of 300 subjects, median age was 61 years (interquartile range, 50–68), 62% were women, 74% were seen in internal medicine (vs family medicine) practices, and 75% were seen by a physician (vs an advanced practice provider). On chart review, 167 (56%) subjects received an antibiotic. Of these subjects, 1 had documented concern for pertussis and 4 had excluding conditions for which there were no ICD-10 codes. One received an antibiotic prescription for a planned dental procedure. Thus, based on chart review, 161 (54%) subjects received antibiotics inappropriately. Using the electronic algorithm based on diagnostic codes, underlying and concurrent conditions, and prescribing data, the number of subjects with inappropriate prescribing was 170 (56%) because 3 subjects had antibiotic prescribing not noted based on chart review. The test characteristics of the electronic algorithm (compared to gold standard chart review) for identification of inappropriate antibiotic prescribing were the following: sensitivity, 100% (161 of 161); specificity, 94% (130 of 139); positive predictive value, 95% (161 of 170); and negative predictive value, 100% (130 of 130). Conclusions: For outpatients with acute bronchitis, an electronic algorithm for identification of inappropriate antibiotic prescribing is highly accurate. This algorithm could be used to efficiently assess prescribing among practices and individual clinicians. The impact of interventions based on this algorithm should be tested in future studies.Funding: NoneDisclosures: None

Background: Assessing antimicrobial use (AU) appropriateness isa cornerstone of antimicrobial stewardship, largely accomplished through time-intensive manual chart review of specific agents or diagnoses. Efforts to evaluate appropriateness have focused on assessing the appropriateness of an entire treatment course. An electronic measure was developed to assess the appropriateness of each day of inpatient AU leveraging electronic health record data. Methods: We extracted contextual data, including risk factors for resistant organisms, allergies, constitutional signs and symptoms from diagnostic and procedural codes, and microbiological findings, from the electronic health records of patients in Veterans’ Health Administration inpatient wards reporting data to the National Healthcare Safety Network (NHSN) AU option from 2017–2018. Only the antibacterial categories shown in Figure 1 were included. Respiratory, urinary tract, skin and soft-tissue, and other infection categories were defined and applied to each hospital day. Algorithm rules were constructed to evaluate AU based on the clinical context (eg, in the ICU, during empiric therapy, drug–pathogen match, recommended drugs, and duration). Rules were drawn from available literature, were discussed with experts, and were then refined empirically. Generally, the rules allowed for use of first-line agents unless risk factors or contraindications were identified. AU was categorized as appropriate, inappropriate, or indeterminate for each day, then aggregated into an overall measure of facility-level AU appropriateness. A validation set of 20 charts were randomly selected for manual review. Results: Facility distribution of appropriateness, inappropriateness, and indeterminate AU by 4 of the adult, 2017 baseline NHSN Standardized Antimicrobial Administration Ratio (SAAR) categories are shown in Figure 1. The median facility-level inappropriateness across all SAAR categories was 37.2% (IQR, 29.4%–52.5%). The median facility-level indeterminate AU across all SAAR categories was 14.4% (IQR, 9.1%–21.2%). Chart review of 20 admissions showed agreement with algorithm appropriateness and inappropriateness in 95.4% of 240 antibacterial days.Conclusions: We developed a comprehensive, flexible electronic tool to evaluate AU appropriateness for combinations of setting, antibacterial agent, syndrome, or time frame of interest (eg, empiric, definitive, or excess duration). Application of our algorithm in 2 years of VA acute-care data suggest substantial interfacility variability; the highest rates of inappropriateness were for anti-MRSA therapy. Our preliminary chart review demonstrated agreement between electronic and manual review in >95% of antimicrobial days. This approach may be useful to identify potential stewardship targets, in the development of decision support systems, and in conjunction with other metrics to track AU over time.Funding: NoneDisclosures: None

Background: To provide a standardized, risk-adjusted method for summarizing antimicrobial use (AU), the Centers for Disease Control and Prevention developed the standardized antimicrobial administration ratio, an observed-to-predicted use ratio in which predicted use is estimated from a statistical model accounting for patient locations and hospital characteristics. The infection burden, which could drive AU, was not available for assessment. To inform AU risk adjustment, we evaluated the relationship between the burden of drug-resistant gram-positive infections and the use of anti-MRSA agents. Methods: We analyzed data from acute-care hospitals that reported ≥10 months of hospital-wide AU and microbiologic data to the National Healthcare Safety Network (NHSN) from January 2018 through June 2019. Hospital infection burden was estimated using the prevalence of deduplicated positive cultures per 1,000 admissions. Eligible cultures included blood and lower respiratory specimens that yielded oxacillin/cefoxitin–resistant Staphylococcus aureus (SA) and ampicillin-nonsusceptible enterococci, and cerebrospinal fluid that yielded SA. The anti-MRSA use rate is the total antimicrobial days of ceftaroline, dalbavancin, daptomycin, linezolid, oritavancin, quinupristin/dalfopristin, tedizolid, telavancin, and intravenous vancomycin per 1,000 days patients were present. AU rates were modeled using negative binomial regression assessing its association with infection burden and hospital characteristics. Results: Among 182 hospitals, the median (interquartile range, IQR) of anti-MRSA use rate was 86.3 (59.9–105.0), and the median (IQR) prevalence of drug-resistant gram-positive infections was 3.4 (2.1–4.8). Higher prevalence of drug-resistant gram-positive infections was associated with higher use of anti-MRSA agents after adjusting for facility type and percentage of beds in intensive care units (Table 1). Number of hospital beds, average length of stay, and medical school affiliation were nonsignificant. Conclusions: Prevalence of drug-resistant gram-positive infections was independently associated with the use of anti-MRSA agents. Infection burden should be used for risk adjustment in predicting the use of anti-MRSA agents. To make this possible, we recommend that hospitals reporting to NHSN’s AU Option also report microbiologic culture results.Funding: NoneDisclosures: None