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1779. Defining Antimicrobial Use and Resistance in a Teaching Hospital in the Dominican Republic: Key First Steps for Development of Antimicrobial Stewardship in a Resource Limited Setting

Abstract Background Antimicrobial resistance is a rising threat in developing nations. Establishing antimicrobial stewardship programs (ASP) in resource-limited settings may help curb the rise of antimicrobial resistance. Understanding local resistance patterns and antimicrobial usage may help define appropriate empiric treatment regimens and gaps for ASP development. There is a paucity of data on antimicrobial usage and local susceptibilities in the Dominican Republic (DR). As part of our antimicrobial stewardship initiative, we seek to define antimicrobial resistance and antimicrobial usage at Hospital General Plaza de la Salud (HGPS), a 200 bed teaching hospital in the DR. Methods This is a retrospective review of local susceptibility patterns and antimicrobial use. Antimicrobial susceptibility data for Gram-negative organisms was collected from 2014 to 2017. Antimicrobial use was collected from all inpatient units from January 1, 2017 to December 31, 2017. Defined daily doses (DDD) of antimicrobials used per 1,000 patient-days (DDD/1,000) was tabulated. Results The most common Gram-negative organisms were Klebsiella pneumoniae and Escherichia coli. Extended-spectrum β-lactamase (ESBL) producing E. coli and K. pneumoniae were common (Figure 1). The average rates of ESBL E. coli and K. pneumoniae were 55% and 64%. The total average DDD/1,000 was 83. The average DDD/1,000 per drug is graphed in Figure 2.Figure 1. Percentage of ESBL producing EC and KP.Figure 2. Average DDD per beds/day per antimicrobial. Conclusion Ceftriaxone and cefazolin were the most commonly prescribed antimicrobials. Rates of ESBL-producing EC and KP are high at HGPS, with average rates above 50%. This differs greatly from reported prevalence in the United States. Thus, local treatment guidelines need to be established and may differ from Infectious Diseases Society of America guidelines. Further studies are needed to identify the clinical characteristics and risk factors of patients with ESBL in the DR. This will help local ASP programs identify and advise carbapenem use for patients at risk. Our experience at HGPS suggests that assessing local antimicrobial susceptibilities and usage is a key initial step for understanding local needs toward ASP development in resource limited settings. Disclosures All authors: No reported disclosures.

Background. ASPs optimize antibiotic use, achieve best outcomes, minimize adverse effects, reduce costs, and limit pressures contributing to the emergence AMR. SHEA, IDSA, and PIDS recommend mandatory implementation of ASP throughout healthcare institutions. The objective was to describe antimicrobial stewardship-related lessons learnt in light of interventions made during the first year of implementation of an ASP at the Princess Margaret Hospital in Nassau, Bahamas.
Methods. Prospective audit of antimicrobial use with feedback and intervention was the strategy employed by antimicrobial stewardship between November 2016 and September 2017. The clinical pharmacist monitored patients on adult medical, surgical wards, and critical care unit for the use of carbapenems, vancomycin, antipseudomonal cephalosporins, piperacillin-tazobactam, fluoroquinolones, intravenous fluconazole, amphotericin B, and acyclovir. Antimicrobial stewardship rounds were done by the ID physicians and clinical pharmacist in order to make recommendations to the clinical team. These included de-escalation, escalation of antimicrobial therapy, infectious diseases consultation recommendations, and pharmacokinetic dosing. Acceptability of prospective and feedback recommendations, time to intervention, and patients socio-demographics were also obtained.
Conclusion. An ASP is a feasible strategy to reduce emerging antimicrobial resistance in The Bahamas. Implementing an ASP in The Bahamas is practical and may result in significant de-escalation of antimicrobial therapy. The way forward is to formalize ASP into a sustainable, structured program within the institution.
Disclosures. All authors: No reported disclosures. Background. Surveillance and characterization of bacterial isolates are the preliminary approaches to optimize the use of antibiotics and guide both clinical and institutional decisions surrounding the perspicacious use of antibiotics. We sought to describe the local prevalence of bacterial resistance to direct our stewardship interventions.

Exploring Bacterial
Methods. ResearchApproval was obtained from Ministry of Health, Sultanate of Oman. We surveyed all bacterial isolates collected by microbiology laboratory of Sohar Hospital (450-bed tertiary care facility serving patients of northern Oman) between January 1, 2016 to December 31, 2017. Acquired data included; patient demographics, requesting ward, relevant dates (admission, discharge, sample request and collection, result release), specimen type, isolate identification, and sensitivity. Samples from the same patient collected within less than a week with identical phenotype were excluded.
Conclusion. Vancomycin resistance is limited, cefazolin, and other β-lactams are appropriate empirical agents for a wide range of cases, adequate vancomycin dosing and monitoring should be emphasized to hinder resistance development. Increasing number of carbapenem-resistant cases are being encountered, necessitating consideration of early detection and treatment, appropriate alternative agents and combinations, in addition to a multi-disciplinary approach to treat these recalcitrant infections.
Disclosures. All authors: No reported disclosures.

Conclusion.
Ceftriaxone and cefazolin were the most commonly prescribed antimicrobials. Rates of ESBL-producing EC and KP are high at HGPS, with average rates above 50%. This differs greatly from reported prevalence in the United States. Thus, local treatment guidelines need to be established and may differ from Infectious Diseases Society of America guidelines. Further studies are needed to identify the clinical characteristics and risk factors of patients with ESBL in the DR. This will help local ASP programs identify and advise carbapenem use for patients at risk. Our experience at HGPS suggests that assessing local antimicrobial susceptibilities and usage is a key initial step for understanding local needs toward ASP development in resource limited settings.
Disclosures. All authors: No reported disclosures. Methods. This is an analysis of antimicrobial consumption in intensive care unit (ICU) of a public hospital in São Paulo, Brazil, before and after the implementation of the antibiotic stewardship program. In the pre-intervention period-January 2014 to December 2015-the rational use of antimicrobials was based only on postprescription authorization by the infectious diseases doctor. Since January 2016 was established an antibiotic stewardship program based on authorization of antimicrobial use, implementation of an empirical antibiotic protocol according to institutional microbiological profile, measurement of adherence to the protocol and feedback to the leadership, pharmaceutical intervention, educational measures for medical staff and leadership engagement to the program. We compared consumption in DDD per 1,000 patient-days (1,000/pd) and mean cost with antimicrobials in the ICU in US dollars.

Results of a Successful Implementation of a Antimicrobial Stewardship Program in a Public Hospital in São Paulo, Brazil
Results. The overall antimicrobial consumption reduced from 1,032 DDD/1,000 pd in the preintervention period to 785 DDD/1,000 pd postintervention. Analysis stratified by individual antibiotic was done for the five most commonly used antibiotics. A reduction of 51% consumption for meropenem, 41% for colistin, and 41% for vancomycin was observed. Antibiotic costs were reduced from a monthly median of US$71,176.49 to US$43,772.75 between the two periods. No difference in mortality or mean Apache was observed over the period.
Conclusion. The implementation of the antimicrobial stewardship program can lead to a safe reduction in antibiotic use in the ICU, with significant reduction of costs that can be reapplied in the patient care. Further analyzes are needed to assess the impact on clinical patient outcomes.
Disclosures. All authors: No reported disclosures.