Antimicrobial stewardship is a systematic approach for promoting and monitoring responsible antimicrobial use globally. We conducted a prospective point prevalence survey of antimicrobial utilization among hospitalized adult patients during September 2021. The survey instrument was adapted from the WHO methodology for point prevalence surveys, and it was conducted at The Indus Hospital and Health Network, Karachi. Among the 300 admitted patients, 55% were males and the mean age was 44 (±18) years. At least 67% of the patients received one antimicrobial agent and the most common indication was surgical prophylaxis (40%). The most frequently used were antibacterial agents (97%) among all antimicrobials. Amoxicillin/Clavulanic acid and Ceftriaxone were the most frequently used antibacterial agents, i.e., 14% each. At least 56% of the antibacterial agents were amenable to antimicrobial stewardship when reviewed by infectious disease (ID) experts. Reasons for stewardship were: antibacterial not indicated (n = 39, 17.0%), unjustified prolonged duration of antibacterial (n = 32, 13.9%), extended surgical prophylaxis (n = 60, 26.2%), non-compliance to surgical prophylaxis guidelines (n = 30, 13.1%), and antibacterial not needed on discharge (n = 27, 11.7%). Median days of therapy (DOT) per agent was 3 days (IQR 2–4), while median DOT per patient was 2 days (IQR 1–4). These data have described the pattern of antimicrobial utilization in our institute. We found a higher prevalence of antimicrobial use overall as compared to the global figures, but similar to other low- and middle-income countries. Two important areas identified were the use of antimicrobials on discharge and extended surgical prophylaxis. As a result of these data, our institutional guidelines were updated, and surgical teams were educated. A post-intervention survey will help us to further determine the impact. We strongly recommend PPS at all major tertiary care hospitals in Pakistan for estimating antimicrobial utilization and identifying areas for stewardship interventions.

Hematopoietic stem cell transplant recipients are at increased risk of infection and immune dysregulation due to reception of cytotoxic chemotherapy; development of graft versus host disease, which necessitates treatment with immunosuppressive medications; and placement of invasive catheters. The prevention and management of infections in these vulnerable hosts is of utmost importance and a key "safety net" in stem cell transplantation. In this review, we provide updates on the prevention and management of CMV infection; invasive fungal infections; bacterial infections; Clostridium difficile infection; and EBV, HHV-6, adenovirus and BK infections. We discuss novel drugs, such as letermovir, isavuconazole, meropenem-vaborbactam and bezlotoxumab; weigh the pros and cons of using fluoroquinolone prophylaxis during neutropenia after stem cell transplantation; and provide updates on important viral infections after hematopoietic stem cell transplant (HSCT). Optimizing the prevention and management of infectious diseases by using the best available evidence will contribute to better outcomes for stem cell transplant recipients, and provide the best possible "safety net" for these immunocompromised hosts.

BackgroundThe impact of antimicrobial stewardship programs (ASPs) depends on physician perception of antimicrobial stewardship and institutional antibiotic prescribing culture. At Rush University Medical Center (RUMC), we conducted an antimicrobial stewardship study targeting inpatient levofloxacin (FQ) use and assessed rates of implementation of recommendations (IORs) by general medicine (GM), vs. surgical services (SS) (general surgery, urology, orthopedics and neurosurgery), vs. transplant surgery-immunocompromised host (T-ICH) teams when made by either infectious disease pharmacists (IDPharmD) or infectious disease fellows (IDMDF).MethodsBetween August 13, 2018 and January 15, 2019 at RUMC, IDPharmDs reviewed 251 inpatients on FQ, and made ASP recommendations on 36 (14%) that were communicated via telephone. No scripted discussion or note was utilized. From January 15, 2019 to April 19, 2019, an IDMDF reviewed 207 inpatients on FQ, and made ASP recommendations on 47 (22%). IDMDF’s recommendations were communicated via a scripted discussion describing the role of ASP, highlighting the importance of optimizing FQ use due to toxicity, low rates of RUMC’s FQ susceptibilities and to decrease rates of resistance. Telephone recommendations were made to the primary team house staff or attending followed by a templated electronic note left in the medical chart. Rates of IORs were assessed during each period and by each group.ResultsIn 20 out of 83 recommendations (24%), no antibiotic was indicated (Figure 1). GM teams had the highest overall (IDPharmD + IDMDF) IOR (76%), compared with 40% IOR for both SS and T-ICH groups. For all groups, the scripted IDMDF recommendations had higher IOR compared with the nonscripted IDPharmD recommendations (GM 89% vs. 61%; SS 50% vs. 29%; T-ICH 50% vs. 0%).ConclusionASP interventions using scripted discussions and notes by an IDMDF were more effective than nonscripted IDPharmD interventions across all service lines. Both interventions were less successful with SS or T-ICH compared with GM services. These findings demonstrate the need for further research to understand the importance of scripted vs. nonscripted communication methods by pharmacists and ID physicians, and to develop alternative communication models for nongeneral medicine service providers. Disclosures All authors: No reported disclosures.

BackgroundIn January 2019, the Clinical and Laboratory Standards Institute (CLSI) lowered breakpoints of fluoroquinolones (FQ) for Enterobacteriaceae (EB)and Pseudomonas aeruginosa (PsAr). Automated commercial antimicrobial susceptibility testing (cAST) can only report levofloxacin MIC ≤1 μg/mL according to 2018 breakpoints. Updated panels will not be available until FDA approval. Laboratories and antimicrobial stewardship programs (ASP) must decide how to implement the adoption of new FQ breakpoints.MethodsAll microbiologic isolates of EB or PsAr were collected March 11, 2019–March 22, 2019. Manual E-tests and cAST by Microscan were performed for levofloxacin. Susceptible or non-susceptible (NS) isolates to levofloxacin were identified using 2018 and 2019 CLSI breakpoints [Table1]. Data were analyzed by Microsoft Excel and SPSS.Results159 isolates were analyzed. Isolates were predominantly from urine (78%) and females (68%). E.coli was the most frequently identified organism (40%) [Figure 1]. Application of new breakpoints changed 7% of EB (P = 0.083) and 16% of PsAr (P = 0.238) from susceptible to NS. [Figure 2] PsAr had higher rates of FQ NS compared with EB with new breakpoints (37% vs. 22%, P = 0.132, not shown). Non-urine and inpatient isolates had decreased susceptibility of ≥10% (P = 0.168 and 0.117). Lack of other resistance mechanism (ESBL, CRE, MDRO) was associated with a change in susceptibility (P = 0.036). Diagnosis of active cancer or immunosuppression (IS) was strongly associated with FQ NS by new breakpoints (P = 0.019, not shown). Patients with cancer or IS had the largest decrease in susceptibility (18%, P = 0.069) with application of new breakpoints. [Table 2].ConclusionUpdated CLSI FQ breakpoints resulted in trends of increased resistance. PsAr, non-urine and inpatient isolates were disproportionately affected. Implementation of manual MIC determination from select clinical isolates may be useful until approval of updated cAST. Diagnosis of cancer or IS was associated with FQ NS by new breakpoints. Restriction of FQ for empiric use may be considered, particularly in patients with cancer or IS. Larger studies are needed to determine the long-term effects of adjusted FQ breakpoints, but are anticipated to have significant impacts on ASP. Disclosures All authors: No reported disclosures.

Primary Epstein-Barr virus (EBV) infection may rarely present with cholestatic hepatitis or hemolytic anemia. We share a case of EBV-associated infectious mononucleosis presenting with a unique triad of findings comprising cholestatic hepatitis with marked hyperbilirubinemia, warm autoimmune hemolytic anemia, and pancytopenia. Early diagnostic challenges included negative Monospot heterophile testing. Additional testing revealed EBV serologies consistent with acute primary infection, EBV viremia and bone marrow biopsy showing EBV-encoded RNA-positive cells. A tapered prednisone course was administered for warm autoimmune hemolytic anemia. Improvement in symptoms and laboratory findings occurred over 3 weeks.