An Opt-out Approach to Antimicrobial Stewardship Utilizing Electronic Alert Recommendations at a Community Hospital

BACKGROUND: Prospective audit and feedback is a primary tool for antimicrobial stewardship, but inefficient communication and provider non-participation can limit the impact. To address these issues, a customizable electronic alert system was created to deliver antimicrobial stewardship recommendations to providers upon opening the electronic medical record. If no provider declined the recommendation after 24 hours, the recommendation was implemented by the antimicrobial stewardship program per protocol. This study describes the experience of an opt-out antimicrobial stewardship pilot at a community hospital. METHODS: This is a pragmatic, quasi-experimental, single center study describing the frequency of accepted recommendations delivered during a 12 week intervention period. Recommendation responses are categorized by intent of the recommendation, day of antibiotic therapy, prescribed antibiotics, responding provider specialty, and clinical reasoning. Secondary outcomes are target antimicrobial days of therapy (DOT) per 1000 patient days and healthcare facility-onset Clostridium difficileinfections (HO-CDI) per 10,000 patient days for the three months before, during, and three months after the intervention period. RESULTS: In total, 804 of 1170 (69%) antibiotic recommendations were accepted yielding an average of 10 accepted recommendations per day. Of those accepted, 113 (14%) recommendations were implemented by the antimicrobial stewardship program per protocol. Antibiotic recommendations to de-escalate therapy were accepted more often than recommendations to discontinue therapy, 376/524 (72%) and 414/631 (66%), respectively. Target antibiotic DOT per 1000 patient days decreased from 775.2 in three months prior to 631 during the pilot (P < 0.05). HO-CDI per 10,000 patient days decreased from 16.24 to 11.70 (P = 0.12). After cessation of the intervention, antibiotic DOT and HO-CDI rates increased, 681 and 15.55, respectively. CONCLUSION: The combination of opt-out antimicrobial stewardship with electronic delivery of recommendations demonstrated an efficient and effective approach to prospective audit and feedback. Future applications are broad including antimicrobial stewardship telepharmacy. DISCLOSURES: All authors: No reported disclosures.