Background: Healthcare accounts for 8.5% of total US greenhouse gas emissions (GHGE), with US healthcare the main contributor. Yet little effort has been made to measure healthcare related GHGE. Specifically, GHGE related to unnecessary antibiotic prescriptions is unclear, and to our knowledge, no one has used estimates of GHGE of unnecessary antibiotics as an antibiotic stewardship tool. We aimed to measure GHGE from solid waste associated with unnecessary antibiotic prescriptions for respiratory conditions. Methods: We calculated emissions for an outpatient prescription including the plastic bottle, paper leaflet, and paper bag (photos) based on the weight of each item multiplied by US Environmental Protection Agency (EPA) GHGE factors. Emission factors depend on waste type and treatment method which we assumed to be landfilled. To estimate unnecessary antibiotic prescriptions for respiratory infections, visits from nine University of Utah Health Urgent Care Centers from 2019-2022 were electronically identified and included if they had an ICD-10-CM code for a respiratory diagnosis where antibiotics are not indicated. Waste emissions of the paper and plastic in an individual prescription were then multiplied by the number of unnecessary respiratory antibiotic prescriptions for designated time periods to arrive at total landfilled waste emissions. We used similar methods applied to published 2014 data from CDC to estimate national waste emissions due to unnecessary antibiotic prescriptions for respiratory infections. Finally, we used the EPA’s GHG Equivalencies Calculator to convert emissions into tangible GHGE for providers and patients. Results: A prescription has 32g of paper and 15g of plastic waste. Among 124,461 urgent care visits (Table 1) in 2019-2022, 18,531 (14.9%) received an antibiotic. This equates to 593 kg of paper waste and 278 kg of plastic waste leading to a total landfilled waste emissions of 0.479 MT CO2e/ton. Using the EPA GHG Equivalencies Calculator, this equates to driving an average gasoline-powered car 1,228 miles. There were 14,482,976 unnecessary antibiotic prescriptions (Table 2) in the US for respiratory infections in 2014. Our estimates suggest these prescriptions led to 375.109 CO2e/ton of GHGE, the same as driving 961,610 miles by an average gasoline-powered vehicle. Conclusion: Unnecessary antibiotic prescriptions are associated with substantial GHGE. This estimate demands further evaluation across diagnoses and care delivery sites, and most importantly action. Additionally, the large GHG contribution of unnecessary antibiotics should be used as a stewardship tool to highlight low-value care that is likely contributing to global climate change.

The prospective before-after quality improvement study was to assess bundle effectiveness to reduce urinary catheter days and prevent associated complications. All patients with preexisting or new urinary catheters in a regional hospital in Switzerland were included. We showed a reduction of catheter days, incorrect urinary catheter indications, and most strikingly formally correct indications.

Background: Antimicrobial susceptibility testing (AST) is critical for detecting antimicrobial resistance (AR) and guiding antimicrobial treatment. The Clinical and Laboratory Standards Institute (CLSI) regularly publishes and revises breakpoints to guide the interpretation of AST results. In 2010–2019, CLSI has lowered many breakpoints for Enterobacterales and Pseudomonas aeruginosa. Timely implementation of updated breakpoints can vary across hospital laboratories, leading to shifts in the interpretation of AST results. This issue is a potential threat to the estimation of national prevalence estimates for AR and limits the comparability of AR data across hospitals. Hospitals submit AST data with clinical laboratory interpretations to the AR Option of CDC’s National Healthcare Safety Network (NHSN). NHSN tracks whether a hospital adopted the revised CLSI breakpoints for six organism-antimicrobial combinations involving AR phenotypes commonly associated with healthcare associated infections through hospital self-reporting status into a structured survey — 2022 NHSN Annual Hospital Survey (Table). For this analysis, we describe the uptake of revised CLSI breakpoints and compare cumulative antibiograms among hospitals that used various breakpoints. Methods: We included hospitals that completed the 2022 NHSN annual survey and submitted data to the NHSN AR Option for at least 9 months in 2022 by November 1, 2023. The percentage of hospitals that implemented CLSI breakpoints, published during 2010–2019, were determined for combinations of antibiotic class, organism, and CLSI revision year (Table). We calculated percent resistance (%R) as the number of isolates meeting AR phenotype definitions divided by the total number of Isolates tested for the following phenotypes: carbapenem-resistant Enterobacterales (CRE) which included E. coli, Klebsiella, and Enterobacter species; extended-spectrum cephalosporin-resistant Enterobacterales (ESC); carbapenem-non-susceptible P. aeruginosa; fluoroquinolone-resistant P. aeruginosa; and fluoroquinolone-resistant Enterobacterales. Results: Among the 741 hospitals included, 75%–93% implemented any of the six revised CLSI breakpoints (Table). The %R was higher among isolates from hospitals that adopted revised breakpoints compared to those that did not (p < 0 .0001). The largest difference was observed for carbapenem-non-susceptible P. aeruginosa (14.91% vs 10.11%). Conclusions: The uptake of revised CLSI breakpoints varied across hospitals, organism-antimicrobial combinations, and CLSI versions. This analysis indicates that the prevalence of AR for corresponding phenotypes could be underestimated if data from hospitals using higher, outdated breakpoints are included. It is important for NHSN to continue tracking breakpoints used in individual hospitals and encourage hospitals to report complete data on the original AST results, such as MIC, to optimize the accuracy of national AR surveillance.

Background: False-positive blood cultures compromise care; extended stays, Clostridioides difficile risk increases and renal woes tagged to antibiotic alms contribute to the doubling of patient in-hospital mortality that is observed relative to true negative diagnostic results. False-positive affiliated central line-associated bloodstream infection reports can further obfuscate the quality of care provided. Between personnel performance pressures, laboratory resource losses and the risk for financial penalty under Value-Based Purchasing and Hospital-Acquired Condition Reduction Programs (Centers for Medicare & Medicaid Services), it becomes difficult to brush aside the burden of a non-zero blood culture contamination rate. Following unsuccessful and unsustainable endeavors that included educational exercise and waste tube employment, initial-specimen diversion devices designed to shift performance burdens from technicians to technology were co-opted in an effort to secure reliable blood culture contamination rate reductions. Methods: A 3.6% blood culture contamination rate was observed systemwide prior to intervention, which began in 2020. Among seventeen facilities that share a data system, twelve co-opted initial-specimen diversion device technology as the evidence-based anchor to a trifurcate intervention strategy that included value analysis and cultural curation. Results: The 2023 systemwide blood culture contamination rate was 1.95%; down from 2.8% in 2022 and 3.2% in 2021. The average cost per false-positive event was $2,111, with intervention amounting to systemwide savings of $4.1 million in 2023 as approximately 1,920 patients avoided false-positive incidents. Critical to year-over-year systemwide uptick in adoption of interventive technology was consistent and near real-time communication to caretakers regarding outcomes. Conclusion: The sustained success of the multifactorial solution showcased herein stems from the coupling of an evidence-based action with an ongoing assessment of value and communication channels carefully constructed to celebrate and perpetuate value observed. Layered uncertainties often cloud the crux of a multifactorial solution to a complex conundrum; for many decades the literature-supported solution to high blood culture contamination rates was to educate every person involved in every possible way. Only recently, following recommended practice revisions endorsed by the Clinical and Laboratory Standards Institute and Centers for Disease Control and Prevention, did it become apparent nationwide that education alone was insufficient; some contaminant pathways persist without meticulously mechanical closure. Antimicrobial stewardship requires the respectful removal of adaptable pressures from microorganisms, but the inverse is equally important; by setting an ambitious systemwide blood culture contamination rate target of 1% or less, it is hoped that all facilities involved herein respond to this pressure with optimism, introspection and innovation.

The use of face masks has been widely promoted and at times mandated to prevent coronavirus disease 2019 (COVID-19). The 2023 publication of an updated Cochrane review on mask effectiveness for respiratory viruses as well as the unfolding epidemiology of COVID-19 underscore the need for an unbiased assessment of the current scientific evidence. It appears that the widespread promotion, adoption, and mandating of masking for COVID-19 were based not primarily on the strength of evidence for effectiveness but more on the imperative of decision-makers to act in the face of a novel public health emergency, with seemingly few good alternatives. Randomized clinical trials of masking for prevention of COVID-19 and other respiratory viruses have so far shown no evidence of benefit (with the possible exception of continuous use of N95 respirators by hospital workers). Observational studies provide lower-quality evidence and do not convincingly demonstrate benefit from masking or mask mandates. Unless robust new evidence emerges showing the effectiveness of masks in reducing infection or transmission risks in either trials or real-world conditions, mandates are not warranted for future epidemics of respiratory viral infections.

Health equity gaps persist across minoritized groups due to systems of oppression affecting health-related social needs such as access to transportation, education and literacy, or food and housing security. Consequently, disparities in the prevalence of multidrug-resistant infections, infectious disease outcomes, and inappropriate antimicrobial use have been reported across minoritized populations. The Joint Commission and Centers for Medicare and Medicaid Services (CMS) have formally acknowledged the importance of integrating health equity-focused initiatives into existing hospital quality improvement (QI) programs. Here, we review documented disparities in antimicrobial stewardship and offer a framework, derived from components of existing health equity and QI tools, to guide clinicians in prioritizing equity in antimicrobial stewardship efforts (EASE).

Background: While Outpatient Parenteral Antibiotic Therapy (OPAT) offers patient convenience and reduced healthcare costs, its increasing utilization has brought various complications to light, including antibiotics-related and line-related OPAT complications. In a large prospective study, 18% of the patients experienced adverse drug events. Another study showed 8.45% of patients had vascular complications. Our study aims to identify clinical predictors associated with OPAT complications. Identifying predictors for suboptimal OPAT outcomes provides an opportunity to intervene, thereby minimizing the risk of OPAT-related complications. Method: We conducted a retrospective cohort study at Tufts Medical Center of all adult patients aged ≥18 years discharged on OPAT from April 2022 to October 2022. Demographic, treatment, outcome, and complications data were extracted through chart review. The primary outcome was the proportion and predictors of OPAT complications. The secondary outcomes were OPAT completion rate, 30-day ED visit, and 30-day readmission rates related to OPAT complications. We used univariable and multivariable analyses using logistic regression models for the predictors of OPAT complications. Variables with p5 (OR, 0.281, 95% CI 0.101–0.784), but they were more likely to have received two antibiotics (OR, 2.265; 95% CI 1.155-4.442). However, no significant independent predictor OPAT complications was identified in multivariable regression analysis (Figure 2). OPAT completion rates were lower in patients with complications (59.1% versus 75.4%). The 30-day ED visit and 30-day readmission rates were significantly higher in the complication group (31.8% vs. 0 and 34.1% vs. 2.1%, respectively). Conclusion: Our study highlights the significant difference in treatment completion rates and higher incidence of ED visits and readmissions rates among those with OPAT complications. Although specific independent predictor was not identified, the association with multiple antibiotic therapies and telemedicine follow-ups suggests areas for further investigation.

Introduction: Vancomycin-associated acute kidney injury (V-AKI) is a common adverse reaction; however, there is currently no method to systematically monitor its incidence. We previously developed and internally validated an electronic algorithm to identify cases of V-AKI using structured electronic health record data at the Johns Hopkins Hospital, which demonstrated excellent agreement with chart review (percent agreement 92.5%; weighted kappa coefficient 0.95), as well as excellent sensitivity (89.7%) and specificity (98.2%) in detecting at least possible V-AKI events. The objective of this study was to evaluate the generalizability of the V-AKI electronic algorithm. Methods: We identified a retrospective cohort of adult and pediatric patients who received ≥1 dose of intravenous vancomycin while admitted to University of Virginia (UVA) Medical Center from 1/2021-1/2023. An increase in creatinine (Cr) of ≥0.3 mg/dL within 48 hours or ≥50% increase in baseline Cr within 7 days, occurring after the first dose and up to 72 hours after the last dose of IV vancomycin, was considered a potential V-AKI event. The electronic algorithm was executed at UVA with only limited contextualization of hospital specific variables (e.g., procedure names). Patients were categorized as excluded/not meeting criteria, or as having an unlikely, possible or probable V-AKI event using a causality framework. A random subset of the cohort underwent chart review by a blinded reviewer for external validation. Percent agreement and a weighted kappa coefficient were calculated. The sensitivity and specificity in identifying at least possible V-AKI events was determined. Results: The electronic algorithm was validated using 200 cases and demonstrated 60.0% percent agreement with chart review (Figure). The weighted kappa coefficient was 0.75. The algorithm was 83.8% sensitive and 71.4% specific in detecting at least possible V-AKI events. Among the 80 discrepant cases, there was only a 1-category difference in 62.5% of cases. The most common reasons for discrepant assessments, which were partly due to inconsistencies in chart review, included disagreement regarding timing of AKI onset (18.6%) and whether renal function returned to baseline (16.3%). Conclusions: An electronic algorithm to identify V-AKI events was successfully implemented at another institution. Although agreement with chart review was only fair, sensitivity in detecting at least possible V-AKI events remained excellent. The electronic algorithm may be useful for systematically and reproducibly identifying V-AKI events across institutions in a scalable manner to inform stewardship interventions. However, further refinement of the algorithm and improvement in consistency of chart review assessments is needed.

Disclosure: Lindsay Donohue: Advisor – Abbvie

Decreasing the time to contact precautions (CP) is critical to carbapenem-resistant Enterobacterales (CRE) prevention. Identifying factors associated with delayed CP can decrease the spread from patients with CRE. In this study, a shorter length of stay was associated with being placed in CP within 3 days.

Background: The Clinical & Laboratory Standards Institute (CLSI) recommends use of annual antibiograms to help guide empiric antibiotic therapy. Because CLSI periodically updates minimum inhibitory concentration (MIC) breakpoints, we assessed the impact of these updates on longitudinal trends in antibiotic susceptibility rates for Escherichia coli and Klebsiella pneumoniae at a single academic medical center in Atlanta, GA. Methods: Susceptibilities for cefepime, ceftazidime, and levofloxacin in E. coli and K. pneumoniae were extracted from hospital antibiograms from 1988 to 2022. Starting in 1995, intensive care units (ICUs) and wards had separate annual antibiograms, which we combined using weighted averages to create annual overall hospital antibiograms. After summarizing the frequency of isolates tested and susceptibilities using medians and interquartile ranges (IQR), we conducted an interrupted time series analysis using linear segmented regression models, to evaluate the level changes and trends in susceptibility, before and after CLSI MIC breakpoints were updated for ceftazidime (2010 and 2017), cefepime (2014 and 2017), and levofloxacin (2013). Results: Among 21,214 E. coli, there was a median of 291 [IQR: 104, 555] isolates tested annually. Similarly, among 8,686 K. pneumoniae isolates, the median was 125 per year (IQR: 76, 178). Prior to the MIC breakpoint changes, baseline susceptibility trends of both organisms to all 3 antibiotics significantly declined at a rate between 0.2% to 2.4% per year (Table 1). For cefepime (Figure 1), susceptibility decreased annually during 1988 – 2013 for both E. coli (-0.5%) and K. pneumoniae (-1.2%). There were no significant level changes but there were trend changes after 2018, for E. coli (+2.1%) and K. pneumoniae (– 5.5%). For ceftazidime (Figure 2), significant level changes occurred after 2010 for both organisms (E. coli: -5.7%; K. pneumoniae: -5.2%). For levofloxacin (Figure 3), the breakpoint update in 2013 lead to significant level change in susceptibility (E. coli: +8.4%; K. pneumoniae: +11.4%). Conclusion: Overall, we observed a consistent decrease in antibiotic susceptibility in E. coli and K. pneumoniae over three decades, with immediate increases in the level change of susceptibility when MIC breakpoints were changed, followed by a decreasing trend. These findings highlight the importance of longitudinal surveillance and MIC breakpoint changes to inform antimicrobial stewardship strategies.

Background: The standardized antimicrobial administration ratio (SAAR) is a metric utilized to measure antimicrobial use within and between hospitals by comparing observed to predicted antimicrobial days of therapy. However, it remains unknown whether narrow-spectrum beta-lactam (NSBL) use adds to overall antimicrobial utilization or substitutes broad-spectrum agents. This muti-hospital cohort study examined the impact of NSBL use on overall antimicrobial utilization and the correlation between the use of NSBL and various broad-spectrum antimicrobial categories in South Carolina (SC) hospitals. Methods: SAARs were collected from all hospitals in SC that reported antimicrobial use (AU) data to the National Healthcare Safety Network (NHSN) between 2017 and 2021. SAARs collected included: overall SAAR, broad-spectrum agents predominantly used for hospital-onset infections (BSHO), broad-spectrum agents predominantly used for community-acquired infections (BSCA), NSBL, and antibacterial agents posing the highest risk for Clostridioides difficile infection (CDI). Category SAARs were combined to include data in both the adult intensive care unit (ICU) and adult wards using the formula: [(total observed antimicrobial days ICU + total observed antimicrobial days ward) / (total predicted antimicrobial days ICU + total predicted antimicrobial days wards)]. Pearson correlation coefficient (r) was used to examine the correlation between various SAARs categories. Results: A total of 38 hospitals in South Carolina reported AU to NHSN at least during one calendar year during the study period. The use of NSBL agents was negatively correlated with the use of BSHO (r = -0.596, p < 0.001), BSCA (r = -0.543, p < 0.001), and high-risk CDI antibiotics (r = -0.601, p < 0.001). Moreover, the use of NSBL agents did not correlate with the overall SAAR (r = 0.008, p = 0.93), whereas the use of BSHO (r = 0.587, p < 0.001), BSCA (r = 0.494, p < 0.001), and high-risk CDI agents (r = 0.464; p < 0.001) positively correlated with the overall SAAR. Conclusion: In South Carolina hospitals, the use of NSBLs does not contribute to additional antibiotic use overall as it seems to replace broad-spectrum antimicrobials in various categories. By de-escalating from broad-spectrum agents to NSBL agents, one can improve antimicrobial use without negatively impacting the overall SAAR. This observation encourages implementation of antimicrobial stewardship interventions that increase utilization of NSBLs, when appropriate, such as de-escalation of antimicrobial therapy among others without concerns for increasing the SAAR for overall antibiotic use.

Urine polymerase chain reaction is a laboratory test promoted to healthcare professionals working in long-term care facilities as a rapid diagnostic platform for urinary tract infection. Little is known about the place of this testing and its potential impact on antimicrobial stewardship programs. In this commentary, we review the currently available literature and provide recommendations for long-term care stewardship programs to consider.

Background: Antibiotic prescribing for children is highest in rural areas. Tele-stewardship allows for implementation of antimicrobial stewardship (AS) via telecommunication with providers. This study addresses need for better AS in rural areas by implementing and evaluating bundled outpatient AS interventions using tele-stewardship in rural pediatric primary care (PC) clinics and emergency departments (EDs) affiliated with Vanderbilt University Medical Center. Methods: The bundle includes (1) patient/guardian educational materials, (2) antibiotic use commitment posters (3) provider education through quarterly teaching pearls and app-based microlearning modules (QuizTime), and (4) quarterly audit/feedback with peer comparison on guideline-concordant antibiotic use via tele-meeting and email. Participants are pediatric prescribers (physician, physician assistant, nurse practitioner). We compared antibiotic prescription data for children < 1 8 years collected during the baseline period (Jan–Dec 2022) to the intervention period (Jan-Sept 2023). Two academic PC clinics and one ED where interventions were not implemented were included as “controls”. The primary outcome is percent of encounters that result in an antibiotic prescription. Secondary outcomes include (1) percent of encounters with guideline-concordant antibiotic choice for otitis media (AOM), streptococcal pharyngitis (GAS), sinusitis, and community-acquired pneumonia (CAP); (2) percent of encounters with 5-day antibiotic duration for AOM, sinusitis, and CAP; and (3) percent of encounters with rapid GAS testing. ED sinusitis data not analyzed due to small N. Significance was determined by calculating 95% confidence intervals for the difference of proportions. Results: There were 139,474 PC encounters (91,706 baseline and 47,768 intervention) and 94,205 ED encounters (54,138 baseline and 40,067 intervention) among 20 PC prescribers and 38 ED prescribers from January 2022-September 2023. Compared to baseline, the antibiotic prescription rate decreased 1.1% in intervention PCs but increased 0.9% in control PCs (Figure 1). Compared to baseline, the antibiotic prescription rate decreased by 0.4% in the intervention EDs but increased 3.1% in the control ED (Figure 1). Secondary outcomes showed significantly increased proportions of guideline concordant ED AOM prescriptions, 5-day PC AOM prescriptions (Figure 2), guideline concordant ED streptococcal pharyngitis prescriptions (Figure 3), and guideline concordant PC sinusitis prescriptions (Figure 4). There was a decrease in GAS tests in intervention PCs and EDs (Figure 6). Conclusions: Interim analysis shows bundled implementation strategies using tele-AS led to significantly decreased overall antibiotic use in rural PC clinics compared to control sites. The study is ongoing and will continue to evaluate outcomes over a longer intervention period to reduce seasonal bias.

Disclosure: Sophie Katz: Research Grant - Pfizer; Research Grant - Dolly Parton Pediatric Infectious Diseases Research Fund; Consultant - Optum

Background: The University of Washington (UW) Center for Stewardship in Medicine (CSiM) supports a tele-antimicrobial stewardship (AMS) program (TASP) using the ECHO approach (Extension for Community Healthcare Outcomes) in small, rural, and Critical Access Hospitals (primarily in the western U.S.) with education, mentoring, organizational capacity building, and a community of peers. To evaluate the continuing education (CE) component of UW-TASP ECHO, CSiM surveyed individuals receiving CE credits as part of the program. This survey was designed to track individuals’ satisfaction with the program and to assess the impact of UW-TASP ECHO on AMS in participating facilities. Methods: The CE participants’ survey was completed annually by individuals participating in UW TASP ECHO using online survey software. The survey included closed-ended and open-ended questions. Responses to open-ended questions were entered into Atlas.ti qualitative analysis software and coded iteratively according to themes that emerged. When a new code emerged partway through the coding process, earlier surveys were re-coded for the new code. Final codes were grouped into themes and sub-themes and quotes from each theme identified were summarized and attached to the theme and reported. Results: Data from three administrations of this survey were available: 2018-2019 (n=66); 2020-2021 (n=27); and 2021-2022 (n=30). These surveys were completed by a total of 95 individuals from 53 hospitals. Seven of these individuals completed a survey in each year, 14 completed a survey in two years, and 74 completed only one survey. Themes identified were COVID-19 support (including procedures and policies, being kept up-to-date, research summaries, and peer support), the antibiotic pocket guide developed by UW, strength in community, staff education, role of CSiM in developing/strengthening the AMS program at the facility, change in use of antibiotics, UW imprimatur, learning/growing as a healthcare provider, and importance for small, rural hospitals (see examples in Table 1). Conclusions: This qualitative analysis provides evidence from surveys of individuals participating in CE that UW TASP ECHO has had a meaningful impact in such domains as building a strong community among small, rural and critical access hospitals, educating staff, changing antibiotic use and providing peer support, among others.

In this national analysis of US emergency department visits with antibiotic prescribing during 2016–2021, 27.6% of visits resulted in inappropriate antibiotic prescribing: 14.9% had diagnosis codes plausibly antibiotic-related (eg, acute bronchitis), suggesting actual inappropriate prescribing, and 12.6% had diagnosis codes not plausibly antibiotic-related (eg, hypertension), suggesting poor coding quality.

Background: Combating antibiotic resistance, exacerbated by widespread unnecessary outpatient antibiotic prescriptions, necessitates innovative stewardship solutions. Audit and feedback reports are effective but often resource heavy. We introduced a free, open-source system, Outpatient Automated Stewardship Information System (OASIS©), for automating the creation and distribution of recurring audit and feedback reports to clinicians to improve antibiotic prescribing. Methods: We used mixed methods to evaluate implementation of OASIS© across 11 clinics at Denver Health and Hospital Authority (DHHA) and Children’s Hospital Colorado (CHCO) from July 2022 to August 2023. Both sites host their own Epic® electronic healthcare and enterprise data warehouse systems. R statistical software was utilized to retrieve and process the data needed to create individual[HCM1] clinician audit and feedback reports with peer comparison. Reports were provided for 1) antibiotics prescribed for respiratory diagnoses, 2) antibiotics prescribed for respiratory diagnoses where antibiotics are never indicated, 3) first-line antibiotic prescribing for acute otitis media (AOM), and 4) five-day duration of antibiotics for children two years and older with AOM. Feedback reports for each metric were emailed to clinicians for three consecutive months. The primary outcome was adaptations needed to implement OASIS©. Secondary outcomes included fidelity (measured by email readership), time to set up and maintain the program, and barriers and facilitators to implementation (assessed by four qualitative interviews with OASIS© stakeholders). Results: The most significant adaptations made pertained to the automation of OASIS© reports for organizations not using R for data retrieval and reporting, setting up OASIS© specific email addresses, and validating clinician fidelity via read receipts. Fidelity was higher at DHHA (91-100%) compared to CHCO (10-30%). When interviewed, data analysts expressed that time for initial setup ranged from 1-6 hours. After reporting was automated, the estimated monthly time to send reports was 10 minutes. Views on setup complexity were split, but all recognized the readability of the reports and OASIS©’s value for improving prescribing behaviors. The greatest barriers to implementation included obtaining analytic resources for initial setup and the need to download additional R packages. No interviewee had prior experience creating audit and feedback reports. Conclusions: Implementing OASIS© requires addressing system diversity and knowledge gaps in outpatient informatics and antibiotic stewardship. Despite these challenges, the tool proved efficient and beneficial for monitoring and reporting antimicrobial prescribing. This free tool could likely be effectively disseminated to other health systems given the limited time and resources required for adaptations, setup, and monitoring. [HCM1]I