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1139. Multidisciplinary Initiative to Increase Guideline-Concordant Antibiotic Prescriptions at Discharge for Hospitalized Children with Uncomplicated Community-Acquired Pneumonia

Abstract Background Community-acquired pneumonia (CAP) is the most common diagnosis in hospitalized children. The Pediatric Infectious Diseases Society and the Infectious Diseases Society of America published evidenced-based clinical practice guidelines for the management of CAP in children 3 months of age or older in 2011. These guidelines are not consistently followed. Our objective was to evaluate if quality improvement (QI) methods could improve guideline-concordant antibiotic prescribing, specifically addressing the use of oral third-generation cephalosporins, at hospital discharge for children with uncomplicated CAP. Methods QI interventions, implemented at a single tertiary care children’s hospital in Washington, D.C., focused on key drivers targeting hospital medicine resident teams. Multiple plan-do-study-act (PDSA) cycles were performed. Initial interventions included educational sessions (in small group and lecture formats) aimed at pediatric resident physicians, as well as visual job aids (Figure 1) and guideline summaries posted in resident physician work areas. Interventions were implemented in series to allow for statistical analysis via run chart. Medical records of eligible patients were reviewed monthly after each intervention to determine the impact on appropriate discharge antibiotic prescribing. Results At baseline, the median percentage of children with a diagnosis of uncomplicated CAP discharged with guideline-concordant antibiotics was 50%. Median rates of guideline-concordant antibiotic prescribing improved to 87.5% after initial interventions (Figure 2). Conclusion A fellow-led multidisciplinary QI initiative was successful in decreasing rates of non-guideline-concordant antibiotic prescribing at discharge. These interventions can be tailored for use at other institutions and for other infectious processes with established treatment guidelines. To ensure sustained improvement in guideline-concordant prescribing, future planned interventions include additional educational sessions with residents, faculty, and pharmacists, EMR order set modification and physician benchmarking. These tactics are intended to address the anticipated challenge of resident/faculty turnover and automate antibiotic choice for uncomplicated CAP. Disclosures All authors: No reported disclosures.

Background. When considering antimicrobial stewardship (AMS) interventions, pediatrics is an important and often overlooked group. By 5 years of age, 97% of New Zealand (NZ) children have received antibiotics (median 8 antibiotic courses/ child). Prescribing is complex due to age and weight-based adjustments, unpalatable oral preparations and inappropriate allergy labeling. Our tertiary Children's Hospital has >250 web-based nationally utilized guidelines, 15% including antimicrobials. A point prevalence audit showed only 63% guideline adherence for inpatient antimicrobial prescriptions. We designed an accessible app to bring antibiotic prescribing and antibiotic allergy decision-making to prescribers at point of care.
Methods. Using local hospital and community guidelines, the national formulary and in consultation with subspecialist teams, 31 algorithms were developed. Each algorithm asked questions including diagnosis, age, antibiotic allergy history and known colonization with-resistant organisms.
Results. The smartphone app (Script) uses the algorithms to advise on appropriate antimicrobial, dose, route and duration of treatment. Advice regarding IV-oral switch parameters and oral antibiotic choice is provided. If allergy is suspected symptom-based decision-making enables the user to choose an alternative agent or encourages allergy de-labeling. Further AMS occurs in some algorithms when advice is given not to prescribe antimicrobials.
Conclusion. Script for Pediatrics launched in NZ in March 2019 with >1000 users in the first 6 weeks. The most frequently accessed guidelines are otitis media, pneumonia and meningitis.
Smartphone applications with local relevance and the ability to update in realtime may prove important tools, by providing easily accessible and intuitive advice to help support antimicrobial stewardship activities. This intervention has been rapidly adopted by pediatric hospital prescribers. The impact on prescribing in concordance with guidelines, timely intravenous to oral antibiotic switch and allergy de-labeling will be assessed.

Disclosures. All authors:
No reported disclosures. Background. Community-acquired pneumonia (CAP) is the most common diagnosis in hospitalized children. The Pediatric Infectious Diseases Society and the Infectious Diseases Society of America published evidenced-based clinical practice guidelines for the management of CAP in children 3 months of age or older in 2011. These guidelines are not consistently followed. Our objective was to evaluate if quality improvement (QI) methods could improve guideline-concordant antibiotic prescribing, specifically addressing the use of oral third-generation cephalosporins, at hospital discharge for children with uncomplicated CAP.

Multidisciplinary Initiative to Increase Guideline-Concordant Antibiotic Prescriptions at Discharge for Hospitalized Children with Uncomplicated Community-Acquired Pneumonia
Methods. QI interventions, implemented at a single tertiary care children's hospital in Washington, D.C., focused on key drivers targeting hospital medicine resident teams. Multiple plan-do-study-act (PDSA) cycles were performed. Initial interventions included educational sessions (in small group and lecture formats) aimed at pediatric resident physicians, as well as visual job aids (Figure 1) and guideline summaries posted in resident physician work areas. Interventions were implemented in series to allow for statistical analysis via run chart. Medical records of eligible patients were reviewed monthly after each intervention to determine the impact on appropriate discharge antibiotic prescribing.
Results. At baseline, the median percentage of children with a diagnosis of uncomplicated CAP discharged with guideline-concordant antibiotics was 50%. Median rates of guideline-concordant antibiotic prescribing improved to 87.5% after initial interventions (Figure 2).

Conclusion.
A fellow-led multidisciplinary QI initiative was successful in decreasing rates of non-guideline-concordant antibiotic prescribing at discharge. These interventions can be tailored for use at other institutions and for other infectious processes with established treatment guidelines. To ensure sustained improvement in guideline-concordant prescribing, future planned interventions include additional educational sessions with residents, faculty, and pharmacists, EMR order set modification and physician benchmarking. These tactics are intended to address the anticipated challenge of resident/faculty turnover and automate antibiotic choice for uncomplicated CAP. Background. Clinical practice surrounding neonatal sepsis varies significantly among physicians. In efforts to confront the challenge of inappropriate and overuse of antimicrobials in our Neonatal Intensive Care Unit (NICU), a multidisciplinary team developed a guideline for the evaluation and management of suspected and proven sepsis within the NICU in preterm infants. We evaluated the antimicrobial utilization before and after the implementation of our guideline, developed in July 2018.

Evaluation of Neonatal Sepsis Guidelines in a Neonatal
Methods. All infants <37 gestational weeks born in July and August of 2016, 2017, and 2018 were retrospectively reviewed and compared before and after implementation of the guideline. The primary outcome was the percentage of antibiotic-free days per admission. Secondary outcomes include percentage of directive treatment courses and percentage of antibiotic days for culture-negative sepsis. Chi-square and Mann-Whitney U tests were performed, as appropriate.
Results. A total of 75 and 37 patients were included for preliminary data analysis in the pre-and post-implementation periods, respectively. Chi-square and Mann-Whitney U tests were performed, as appropriate. The percentage of antibiotic-free days per admission per patient born in the pre-implementation period was lower (84.4% vs. 86.5%, P = 0.028). There is no statistical difference in the percentage of directive treatment between the two groups. The percentages of culture-negative antibiotic days were not statistically significant (69.2% vs. 80.5%, P = 0.296). The average birth weights were lower (1,719.7 grams vs. 1,420.7 grams, P = 0.02) and gestational ages were younger (31.4 weeks vs. 29 weeks, P = 0.001) in the post-implementation period.
Conclusion. Our preliminary data did not show a significant decline in the percentage of antibiotic-free days or culture-negative antibiotic days after the implementation of our guideline; however, this may be confounded by the differences noted in our patient populations and is based on preliminary data. Implementation of this guideline is feasible and may reduce the inappropriate use of antimicrobials. Further data collection is ongoing to fully assess the impact of this guideline.