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Objective To implement a collaborative statewide antibiotic stewardship initiative in both the ambulatory and inpatient settings. Methods Five participating Delaware health systems each convened internal team(s) to translate the vision set forth by the eBrightHealth LLC Choosing Wisely Work Group into clinical action through process improvement efforts at their institutions. The teams focused on implementing antibiotic time-outs, and on improving antibiotic prescribing for upper respiratory infections in ambulatory settings. The learning network utilized an "all teach, all learn" methodology via monthly conference calls and quarterly face-to-face meetings. Results All inpatient teams implemented antibiotic time-outs for at least 1 unit. Other interventions included commitment posters; submitting antibiotic utilization data nationally; provider/patient surveys; local stewardship champions; and provider prescribing data feedback. Barriers to implementation included competing priorities, lack of reliable utilization data, and suboptimal provider engagement. Overall antibiotic utilization decreased by 9%, compared to the pre-intervention period. Conclusions This initiative has demonstrated the value of multidisciplinary teams, from varying healthcare systems, coming together to work on a single project. While each team's interventions and specific goals differed slightly, all teams implemented new initiatives to promote appropriate use of antibiotics. Policy Implications Antibiotic stewardship is a national priority. Acute care hospitals are required to have antibiotic stewardship programs; similar programs are proposed for ambulatory settings.

Background In June of 2016 at ChristianaCare a urinalysis with reflex to culture (UARC) order set was made available, which allows for urine cultures to be performed automatically if pre-defined criteria for a positive urinalysis are met. The objective of this study was to evaluate the utility of the UARC as it relates to identifying a symptomatic urinary tract infection (UTI), as well as to describe the impact of UARC on antibiotic utilization. Methods A retrospective cohort study was performed including patients aged 18 to 89 ordered a UARC. Patients were excluded if they were currently pregnant, had an absolute neutrophil count of < 100 cells/mm3, were undergoing a urological procedure, or receiving antibiotics for another indication. The primary outcome of this study was to determine the utility of the UARC in identifying a symptomatic UTI, as determined by the Youden index. Secondary outcomes evaluated included mean days antibiotics and length of stay, adherence to duration of treatment guidelines, 30 day post discharge readmissions, 30 day post discharge mortality, and new Clostridioides difficile infection within 30 days. Results A total of 123 patients were included in this study. A Youden index of 7.2% was calculated for the primary outcome. Patients with a positive UARC and UTI symptoms received an average of 7.54 days of antibiotics. Asymptomatic patients with a positive UARC received significantly more antibiotics than those with a negative UARC (3.05 vs 0 days, respectively,p=0.02). Adherence to duration of treatment guidelines was found to be 77.8%, 66.7%, and 50% for uncomplicated cystitis, complicated cystitis and pyelonephritis respectively. No difference was observed between groups for length of stay, 30 day post discharge readmissions, and 30 day post discharge mortality. No cases of new C. difficile infection were identified. Conclusion This study demonstrates that the UARC does not have utility as a diagnostic test for predicting a symptomatic UTI. The presence of a positive UARC in the absence of symptoms attributable to a UTI resulted in inappropriate prescribing of antibiotics. Further evaluation of how a UARC is ordered, perhaps requiring prescribers to document urinary symptoms, in addition to caregiver education is warranted Disclosures All Authors: No reported disclosures

Background Altered mental status (AMS) is the most common diagnosis among those 65 and older who present to the emergency department (ED). Urinary tract infections (UTIs) account for 15.5% of hospitalizations in this population. The purpose of this study was to determine the incidence of initiation of antibiotics in the ED in patients 65 years and older with mental status changes and asymptomatic bacteriuria or negative urine cultures. Methods A retrospective chart review was performed to evaluate patients aged 65 and older from January 2017 through June 2018 who presented to the ED from home with AMS, a urinalysis that reflexed to culture, and were admitted to an internal medicine unit. The primary outcome was defined as the percentage of patients with AMS who received antibiotics in the ED with asymptomatic bacteriuria or negative urine cultures. Secondary outcomes included adherence to the CCHS UTI antibiotic guideline, incidence of early discontinuation of antibiotics, culture sensitivity to ordered antibiotic, and disposition after discharge. Results A total of 91 patients were included in this study. Seventy-five patients had asymptomatic bacteriuria and antibiotics were started in the ED in 63 (84%) of these patients. Fourteen patients had no growth on culture and seven of these patients (50%) had antibiotics initiated in the ED. Of those who received antibiotics (n = 82), there was 81.7% adherence to the Christiana Care UTI antibiotic selection guideline. Sensitivities were available for 41 isolates and 65.9% were sensitive to the initial antibiotic administered. Antibiotics were discontinued early in 29/82 (35.4%) of patients. Thirty-one patients (33.7%) were discharged to a skilled nursing facility. Conclusion These results indicate that the majority of patients aged 65 and older who presented to the emergency department with altered mental status and no other UTI symptoms such as dysuria, urinary frequency, or urgency were treated with antibiotics. When antibiotics are initiated the majority of providers are adhering to organizational guidelines for antibiotic selection and duration. The results will be shared with Emergency Department and Internal Medicine leadership to foster practice change. Disclosures All authors: No reported disclosures.

Background The Christiana Care Antimicrobial Stewardship Program developed a pilot initiative for tracking and monitoring antibiotic utilization across the health system. This initiative aligns with the Joint Commission’s elements of performance, which calls for tracking and reporting of antibiotic prescribing, as well as the Centers for Medicare and Medicaid Services recommendations for documentation of antibiotic indication, dose, and duration with each order. A customized indication list in the order entry field was created for cefepime, ceftriaxone, levofloxacin, and ciprofloxacin orders. Methods A retrospective chart review of antibiotic indications was completed. A maximum of 50 orders per each antibiotic from December 31, 2017 to January 6, 2018 were randomly selected to be evaluated. The primary endpoint of our study was the percent of cases in which the indication was selected according to the true indication per chart review. Secondary endpoints included the percent of cases in which “other indication” was selected where an available indication was appropriate, percent of cases in which the appropriate dose and frequency were prescribed, and percent of cases in which the duration of therapy was appropriate for urinary tract infections (UTIs). Results A total of 540 orders were profiled between December 31, 2017 and January 6, 2018, of which 182 were reviewed. In regards to the accuracy of selected indication, 94% of cefepime, 88% of ceftriaxone, 78% of ciprofloxacin, and 89% of levofloxacin orders were considered appropriate. Dosing was most appropriate among ciprofloxacin orders (100%), followed by ceftriaxone (96%), cefepime (94%), and levofloxacin (74%). Frequency was most appropriate among ceftriaxone orders (98%), followed by ciprofloxacin (87%), levofloxacin (78%), and cefepime (74%). Duration of therapy was appropriate in greater than 90% of UTI orders. Conclusion The pilot initiative for tracking and monitoring of antibiotic indications has allowed for enhanced transparency between providers regarding antimicrobial use. Further evaluation may provide greater understanding of antibiotic utilization and aid in identifying opportunities for improvements. Disclosures All authors: No reported disclosures.

Background Complicated urinary tract infections (cUTI) including pyelonephritis may result in bacteremia, increasing the rate of morbidity and mortality. The Infectious Diseases Society of America recommends a fluoroquinolone as empiric therapy or trimethoprim/sulfamethoxazole as definitive therapy for acute pyelonephritis (AP). Oral β-lactams (BL) are considered sub-optimal based on historical efficacy data with aminopenicillins and variable bioavailability. Increasing resistance and toxicity with preferred agents, justifies further evaluation of oral BL for E. coli bacteremia secondary to urinary source. Methods This was a single-center, retrospective cohort study of patients with E. coli bacteremia secondary to AP or cUTI who received oral step-down therapy with a BL or non-BL. The primary outcome was the rate of clinical success defined by microbiological cure, clinical cure, and infection-related readmission. Secondary outcomes were time to oral step-down, total days of therapy, length of hospital stay, incidence of therapy escalation, 30-day readmissions, and antibiotic-associated adverse events. Results A total of 46 patients were included, with 23 patients in each group. The difference in clinical success between the BL and non-BL groups was not statistically significant (91.3% vs. 100%, P = 0.489). The most frequent oral step-down agents prescribed were cephalexin and ciprofloxacin. The median time to oral step-down was significantly lower in the non-BL group (4.39 vs. 3.41 days, P = 0.038), and the median duration of therapy in each group was 15 days. No patients required therapy escalation after oral step-down or had infection-related readmission within 30 days of discharge. Conclusion The observed clinical success rate of 91.3% remains consistent with previous studies evaluating oral BL as step-down therapy for Enterobacteriaceae bloodstream infections. The results of this study support the safety and efficacy of oral BL as step-down therapy for E. coli bacteremia due to cUTI, although larger studies may be beneficial. Disclosures All authors: No reported disclosures.

Background The purpose of this study was to implement a pharmacy-initiated β-lactam allergy assessment and to determine its impact on antibiotic prescribing patterns. Avoiding the use of β-lactams due to a documented allergy may lead to inferior treatment outcomes, particularly for indications where β-lactams are preferred. Methods This performance improvement study was conducted at a large community-based academic healthcare system in Delaware. A β-lactam allergy algorithm was developed to guide allergy assessments and categorize patients as low risk for possible reaction, possible type 1 reaction or insufficient information. Pharmacy residents and clinical pharmacists were educated on how to conduct the assessments, which were then performed on inpatients with a β-lactam allergy that were prescribed a non-β-lactam antibiotic from December 2018 through March 2019. The primary outcome of this study was the percentage of patients ordered a β-lactam antibiotic pre- and post-implementation of the assessment. Secondary outcomes included: allergy assessment classifications, number of patients with an allergy discrepancy, percentage of patients switched to a β-lactam antibiotic, development of a reaction, and the number of allergy consultations ordered. The primary endpoint was analyzed using a Chi-square test. Results The percentage of patients prescribed a β-lactam pre- and post-implementation was 59% and 63%, respectively (P = 0.055). A total of101 patients had an allergy assessment performed. Assessments resulted in 45% of patients categorized as low risk, 45% as possible type 1 reaction and 10% as insufficient information. In summary, 33% of patients were changed to a β-lactam following completion of an assessment and zero patients experienced a reaction. Additionally, 69% of patients had an allergy discrepancy in their electronic medical record, and four patients received an allergy consultation. Conclusion The use of clinical pharmacy services to perform β-lactam allergy assessments was successful, as the majority of patients with a low-risk allergy classification were changed to a β-lactam antibiotic. The next steps for this project include engagement of infectious diseases and allergy specialists to further optimize clinical practice. Disclosures All authors: No reported disclosures.