Objectives: Antimicrobial stewardship programs (ASPs) often employ multipronged strategies, including Computerized Decision Support Systems (CDSSs), to promote appropriate prescribing.Physicians are key determinants of program effectiveness, yet little is known about their attitudes towards these interventions. We aimed to explore hospital physicians' perceptions of and attitudes toward ASPs and CDSSs using a focus group discussion (FGD) approach.Methods: We recruited physicians from one large tertiary teaching hospital where an ASP and CDSS were available, by purposive sampling and snowballing. Study participants were junior physicians (house officers and medical officers), and senior physicians (consultants who supervise the junior physicians and lead the clinical teams). FGDs for junior and senior physicians were conducted separately using the same question guide. FGDs were audio-recorded and transcripts independently and systematically coded with subsequent adjudication. Major themes on facilitators and barriers to acceptance of ASPs were extracted. FGDs and coding occurred concurrently. Data analysis and interpretation were consistent with a grounded theory approach.Results: Twenty-nine junior and eight senior physicians participated in six and two FGDs, respectively. Theme saturation was achieved. Two themes reflected facilitators for ASP acceptance: (1) helpfulness of ASP strategies; and (2) ASP team members' proactive contact, both of which guided physician antibiotic prescribing. Four themes identified barriers: (1) the primary team's clinical judgment is of utmost importance; (2) the consultant makes the final decision;(3) lack of awareness of ASP strategies/CDSS; and (4) perceived complexity of the CDSS.Conclusion: Communication, education, and medical hierarchy influence ASP acceptance by physicians. Future research is needed to identify best approaches to enhance collaboration between physicians and their ASP teams to enhance ASP/CDSS acceptance. K E Y W O R D Santimicrobial stewardship, anti-bacterial agents/therapeutic use*, attitude of health personnel*, decision support systems, clinical*, focus groups, Singapore
Background In early months of COVID-19 pandemic, SGH recorded a year-on-year increase in antibiotic (ABx) use for community acquired acute respiratory infection (CA ARI) from Feb-Apr 2019 (48.7 defined daily doses (DDD)/100 bed-days) to 2020 (50.8 DDD/100 bed-days). To address concerns of misuse, the antibiotic stewardship unit (ASU) expanded prospective audit feedback (PAF) to CA ARI patients admitted to ARI wards, with low procalcitonin (PCT). PAF was conducted on day 2-3 of ABx, on weekdays. Doctors received feedback to stop/modify when ABx was deemed inappropriate. Here, we describe the impact of ASU’s adaptive approach to curb rising ABx use in patients admitted for ARI during COVID-19 pandemic. Methods A Pre- & Post-intervention study was conducted. All patients started on ABx (ceftriaxone/co-amoxiclav/piptazo/carbapenems/levofloxacin) for CA ARI & PCT < 0.5µg/L were analysed. Those who died ≤48h of admission; admitted to intensive care; required ABx escalation; >1 infective sites; complex lung infection were excluded. Primary objective was to compare the proportion of ABx stopped ≤4 days (time to final infection diagnosis) Pre (22/3-18/4/20) & Post (21/4-13/7/20). Results 184 (Pre) & 528 (Post) ABx courses were analysed. ASU audited 51 (Pre) & 380 (Post) courses with the rest discontinued/discharged before review. Patients were largely similar in both periods; a third had low likelihood of bacterial infection (C reactive protein < 30mg/L). In Post, 73 feedback was given to stop ABx (often because symptoms suggested viral/fluid overload) & 18 to switch to oral ABx. 82 (90%) feedback was accepted. No ABx was restarted ≤48h or deaths ≤30 days due to ARI. 1 patient had C. difficile diarrhoea a day after ABx cessation as per ASU feedback. Proportion of all ABx stopped ≤4 days was higher in Post than Pre [27/184 (15%) vs 152/528 (29%), p< 0.01]. Median duration of therapy of IV ABx was reduced (6.5 vs 3 days, p< 0.01), with corresponding shorter median length of stay (10.5 vs 6 days, p< 0.01). Conclusion PAF directly and indirectly reduced ABx duration in patients treated for CA ARI as prescribers become more conscious about stopping ABx when investigations show low likelihood of bacterial infection. ASU must remain agile during pandemics to detect emerging problems and adapt processes to counter early. Disclosures All Authors: No reported disclosures
BackgroundAntimicrobial stewardship programs (ASPs) often employ multi-pronged strategies, including Computerized Decision Support Systems (CDSSs), to promote appropriate hospital antibiotic prescribing. Physicians are key determinants of the program’s effectiveness; yet little is known about their attitudes towards these interventions. We aimed to examine hospital physicians’ attitudes toward ASPs and their delivery via computerized systems, and their potential influence on physician antibiotic prescribing habits.MethodsThe focus group study was conducted in a large acute tertiary care teaching hospital in Singapore. We recruited physicians by purposive sampling and snowballing. Focus group discussions (FGDs) for junior and senior physicians were conducted separately. They were audio-recorded and transcripts were independently coded with subsequent adjudication. Major themes on facilitators and barriers to the adoption of ASPs were extracted. FGDs and coding occurred concurrently, consistent with the grounded theory approach.ResultsTwenty-nine junior physicians and eight senior physicians participated in six and two FGDs respectively. Theme saturation was achieved. Two motivators for adoption of ASPs were: (1) helpfulness of ASP initiatives/strategies; and (2) ASP team members’ proactive contact, both of which guide antibiotic prescription. Four barriers were identified: (1) the primary team’s clinical judgment is deemed of utmost importance; (2) the attending physician makes the final decision; (3) lack of awareness of ASP initiatives/strategies; and (4) complexity of the CDSS.ConclusionThemes extracted from the FGDs revealed that communication and education has a major influence on the adoption of ASP. The authors proposed a set of solutions for enhanced uptake of ASP initiatives through inter-professional collaboration. Future work is needed to identify the best and most effective methods to enhance collaboration between the physicians and the ASP team to improve antibiotic prescribing habits.Disclosures All authors: No reported disclosures.
BackgroundProspective audit-feedback is the primary strategy adopted by our hospital antibiotic stewardship program (ASP). It is labor-intensive and successful uptake relies on the visibility of the written intervention note. A rapid notification system (RNS), whereby the physical note is replaced by an electronic document followed by immediate prescriber alert through text messaging, was recently implemented. We seek to quantify the impact of this initiative on patient outcomes and ASP resource utilization.MethodsInterventions to discontinue, de-escalate, or switch from intravenous to oral antibiotics in the pre-implementation (P1: January 2016–February 2017) and post-implementation (P2: March 2017–February 2018) periods were identified from the ASP database. Same-day intervention acceptance rate (IAR), duration of antibiotic therapy (DOT), and hospital length of stay (LOS), measured from day of intervention to discharge, were compared. Manpower time saved from having to perform a next-day intervention follow-up (15 minutes/intervention) was calculated.ResultsA total of 1,904 (11.4%) and 1,311 (12.4%) interventions of 16,723 and 10,545 antibiotic audits were made during P1 and P2, respectively. There were no significant differences in antibiotic or intervention types between both periods–piperacillin–tazobactam (85.4%) was most common, followed by meropenem (11.4%); intervention to discontinue antibiotic (68.4%) was most frequent. Implementation of RNS led to a pronounced 2.5-fold increase in same-day IAR (19.3% vs. 47%, P < 0.01). Potential savings in ASP manpower was estimated at 75 hours/year. Overall improvement in IAR at 48-hours was also observed (79.2% vs. 82.5%, P = 0.02). Patients with ASP interventions accepted on the same day had significantly shorter DOT (4.4 vs. 5.4 days, P < 0.01) but not LOS (13.4 vs. 11.6 days, P = 0.08). Thirty-day-day infection-related mortality rates were similar across the two periods (3.3% vs. 3.3%).ConclusionAn early alert to ASP interventions can strengthen the impact of ASP in reducing unnecessary antibiotic use without compromise in patient safety. ASPs, particularly those serving large and busy hospitals, should consider having an RNS in place to improve program efficiency and visibility.Disclosures All authors: No reported disclosures.
Background International guidelines recommend up to 24 hours of perioperative antibiotic prophylaxis (AP) in joint replacement procedures. However, some observational studies support AP beyond 24 hours for the prevention of surgical site infections (SSI) and prosthetic joint infections (PJI), and this practice is also observed in our institution. This study aims to evaluate the incidence of SSI and PJI in patients receiving short- vs extended-course AP after unilateral primary total knee arthroplasty (TKA) at our center. Methods This was a retrospective cohort study of patients who underwent elective unilateral primary TKA from October to December 2019 at Singapore General Hospital. Patients were excluded if they received antibiotics for reasons other than post-operative AP or underwent other procedures in addition to unilateral primary TKA. Data was collected from electronic medical records and patients who received a short-course of AP (≤24 hours) were compared with patients who received an extended-course of AP. Primary outcomes were 30-day SSI and 30-day PJI rates. Secondary outcome was the impact of duration of AP on length of stay. Statistical analysis was performed using SPSS software version 20. Results There were 394 patients included in the study. 247 received short-course and 147 received extended-course AP. There were no differences in demographics (Table 1). Amongst those who received extended-course AP, median duration was 7 (IQR 4, 8) days, during which 119 (81.0%) patients switched from intravenous to oral route of antibiotics. Between the short- and extended-course arms, there were no differences observed in 30-day SSI (6.9% vs 6.1%, p=0.769) or PJI rates (0.4% vs 0.7%, p=0.999). However, extended-course AP was associated with a longer median length of stay (4 [IQR 3, 6] vs 5 [IQR 4, 7] days, p=0.001). In a subgroup analysis of 106 diabetic patients, there were no differences in 30-day SSI rates (12.3% vs 9.8%, p=0.763) and 30-day PJI rates (0% vs 2.4%, p=0.387) between both groups. Conclusion In this single center study, short-course AP in elective TKA was safe and effective. Extending AP did not reduce SSI or PJI rates, even in diabetic patients. In addition, extending AP was associated with increased length of stay, which translates to higher healthcare costs. Disclosures All Authors: No reported disclosures
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