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Lee Health Antimicrobial Stewardship Program 2023 Annual Report and 2024 Future Directions

Table of Contents Introduction ....................................................................................................................................1 Executive Summary .................................................................................................................. 4 System Antimicrobial Stewardship Committee Operations ...................................5 Community Antimicrobial Stewardship Committee Operations..........................7 Antimicrobial Utilization...........................................................................................................8 Antimicrobial Cost ....................................................................................................................16 Pharmacist-Driven Collaborative Antimicrobial Optimization.............................18 Antimicrobial Resistance Tracking and Microbiology Collaboration...............20 Antimicrobial Formulary Management..........................................................................22 Antimicrobial Stewardship Initiatives .............................................................................25 Lee Health Specialty Pharmacy.........................................................................................32 DNV Regulatory Compliance..............................................................................................34 Education and Training..........................................................................................................44 2024 Objectives........................................................................................................................47 Lee Health Antimicrobial Stewardship Program 2023 Annual Report and 2024 Future Directions

Introduction Purpose, Goals, and Structure of the Lee Health Antimicrobial Stewardship Program The collaborative operations of the program are conducted through the System Antimicrobial Stewardship Committee and the Community Antimicrobial Stewardship Committee, which are co-chaired by the stewardship pharmacists as well as physician champions specific to each setting. The program staff and committees also collaborate and coordinate efforts with the Antimicrobial Stewardship Team at Golisano Children’s Hospital (pictured left). These committees report to Infection Control Committee (ICC), and Pharmacy and Therapeutics (P&T), and other committees as applicable to individual initiatives. Left to right: Top Row: Leigh Sweet, Manuel Escobar, Gerard Jacinto, Katie Guglielmo; Bottom Row: Joy Uzoma, Kymberly Buzzeo, Liz Chandler, Mary Beth Saunders Left to right: Kymberly Buzzeo, Leigh Sweet Antimicrobial stewardship is defined by the Infectious Diseases Society of America (IDSA), the Society for Healthcare Epidemiology of America (SHEA) and the Pediatric Infectious Diseases Society (PIDS) as “coordinated interventions designed to improve and measure the appropriate use of [antibiotic] agents by promoting the selection of the optimal [antibiotic] drug regimen including dosing, duration of therapy, and route of administration.” The Lee Health Antimicrobial Stewardship Program abides by its Mission: Creating excellence in infectious diseases care by optimizing antimicrobial therapy at every opportunity. The Vision of the program is to promote the safe and appropriate use of antimicrobials, improve patient outcomes, reduce microbial resistance and mitigate the spread of infections. The objectives of the program align with the Mission, Vision, and Strategic Pillars of Lee Health. This report serves to summarize the 2023 operations of the stewardship program, as well as outline the program objectives for the 2024 calendar year. The stewardship team is very proud of the successes of the past year and excited for future initiatives to optimize antimicrobial-related patient care within Lee Health. 2023 Annual Report and 2024 Future Directions | 1

Lee Health Antimicrobial Stewardship Committee (ASC) Quality Organization Chart Version 1; 10/2023 BOARD OF DIRECTORS EQSC Medical Executive Committee Infection Control Committee (ICC) P + T Committee System ASC (SASC) Co-Chairs: Elena Gatskevich, MD Elisabeth Chandler, PharmD, BCIDP Pediatric AMS Team Co-Leader: Leigh Sweet, MD, MPH, MEd Microbiology Committee Fran Cioffi, MT (ASCP) Lab Supervisor CCH Leah Cernick, BS, MLS (ASCP) CM Lab Supervisor GCMC Community ASC (CASC) Co-chairs: Karen Calkins, MD Joy Uzoma, PharmD, BCIDP GCHSWFL ID Pharmacist Kymberly Buzzeo, PharmD, MBA, BCPPS CCH ID Pharmacist Catherine Guglielmo, PharmD, BCPS LMH ID Pharmacist Manuel Escobar, PharmD, BCIDP GCMC ID Pharmacist Elisabeth Chandler, PharmD, BCIDP HPMC ID Pharmacist Joy Uzoma, PharmD, BCIDP System Medical Director IP/AMS Mary Beth Saunders, DO, MPH Medical Director AMS GCHSWFL Leigh Sweet, MD, MPH, MEd EQSC Executive Quality and Safety Council P + T Pharmacy and Therapeutics IP Infection Prevention AMS Antimicrobial Stewardship ASC Antimicrobial Stewardship Committee GCHSWFL Golisano Childrens Hospital of Southwest Florida CCH Cape Coral Hospital LMH Lee Memorial Hospital GCMC Gulf Coast Medical Center HPMC HealthPark Medical Center 2 | Lee Health - Antimicrobial Stewardship Program

Program Leadership Mary Beth Saunders, DO, MPH System Medical Director Epidemiology/Infection Prevention Antimicrobial Stewardship Stephanie Stovall, MD, FAAP Medical Director of Quality and Safety, Antimicrobial Stewardship Program Co-Leader Golisano Children’s Hospital of Southwest Florida – Lee Health Leigh Sweet, MD, MPH, MEd Pediatric Infectious Diseases Physician, Antimicrobial Stewardship Co-Leader Golisano Children’s Hospital of Southwest Florida – Lee Health Liz Chandler, PharmD, BCIDP Pharmacy Clinical SpecialistInfectious Diseases Co-Chair, System Antimicrobial Stewardship Committee PGY2 ID Residency Program Director Gulf Coast Medical Center Manuel Escobar, PharmD, BCIDP Pharmacy Clinical SpecialistInfectious Diseases Lee Memorial Hospital Kymberly Buzzeo, PharmD, MBA, BCPPS Pediatric Pharmacy Clinical Specialist – Infectious Diseases, General Pediatrics Golisano Children’s Hospital of Southwest Florida – Lee Health Joy Uzoma, PharmD, BCIDP Pharmacy Clinical SpecialistInfectious Diseases Co-Chair, Community Antimicrobial Stewardship Committee Health Park Medical Center Catherine Guglielmo, PharmD, BCPS, CPh Pharmacy Clinical SpecialistInfectious Diseases, Internal Medicine Cape Coral Hospital Gerard Jacinto, PharmD PGY-2 Infectious Diseases Pharmacy Resident

Executive Summary Calendar Year 2023 Program Activity Highlights Stewardship Initiatives and 2023 Actions System Antimicrobial Stewardship Committee • Conducted 6 meetings and reviewed 31 business items Community Antimicrobial Stewardship Committee • Re-initiated committee meetings and updated charter and goals • Conducted 5 meetings and reviewed 13 business items Pharmacist Driven Collaboration • 31,456 documented pharmacist antimicrobial stewardship interventions • 468 pharmacist-conducted patient allergy history interviews Pediatric Antimicrobial Stewardship Team • 9 completed initiatives Microbiology Collaboration • AMS Team participation at monthly micro meetings • Creation and publication of system antibiograms • 9 collaborative projects Major Initiatives • Antibiotic Timeout BPA implementation • Validation phase of National Healthcare Safety Network (NHSN) Antimicrobial Use and Resistance (AUR) module Antimicrobial Cost • 8% decrease in drug costs between 2022 and 2023 ($407,576) Antimicrobial Formulary • 11 formulary related updates US Antibiotic Awareness Week (USAAW) 2023 • Interdisciplinary educational initiative on smart antibiotic use was conducted, including trivia, prizes, and social media posts Projects • 29 completed projects including order set revisions, treatment pathway creation/ updates, and other optimizations DNV MM8 and IC2/IC3 Antimicrobial Stewardship Standard Compliance • Successful DNV survey with no NCs noted with standards • AMS Team participation in DNV Advanced Certification in Infection Prevention Survey Education and Professional Involvement • 8 editions of “The Dose” newsletter published covering Infectious Diseases topics (ACPE/CME) • 2 ACPE/CME credited live presentations • Pharmacist annual competency update and training (ACPE) • Invited speaker at Florida Society of Health System Pharmacists Annual Meeting (ACPE) • 3 national meeting poster presentations • 4 online ContagionLive publications • Total of 18 weeks of pharmacy student APPE rotations, and 64 weeks of pharmacy resident rotations between ID preceptors 4 | Lee Health - Antimicrobial Stewardship Program

System Antimicrobial Stewardship Committee Operations The System Antimicrobial Stewardship Committee conducted 6 meetings during 2023 (April, June, July, September, October, and December). In addition to new business items, the meeting structure includes report-outs from key collaborative stakeholders, including pediatric antimicrobial stewardship, community antimicrobial stewardship, and microbiology. A drug shortage report is provided at each meeting. Meeting minutes are reviewed as P&T committee’s consent agenda; applicable new business items requiring full P&T review and approval are presented in full at that committee. The following bar graph is a summary of the 2023 business items. Detailed reports on the System Antimicrobial Stewardship Committee 2023 Business Item Summary Formulary Reviews Ordersets/Policies/ Protocols Medication Use Evaluation/Research Antimicrobial Use/ Resistance Reporting Other Business Items 0 1 2 3 4 5 6 7 8 9 10 business items and initiatives (See Page 25) of the committee will be provided in subsequent sections. The System Antimicrobial Stewardship Committee is an interdisciplinary committee consisting of infectious disease providers, pharmacists, microbiologists, and infection preventionists. Members include: Physician Co-Chair: Elena Gatskevich Pharmacist Co-Chair: Liz Chandler Core Membership: John Armitstead, Johanna Brown, Robert Castro, Leah Cernick, Jehan Chowdhury, Fran Cioffi, Manuel Escobar, Regina Evans, Catherine Guglielmo, Brian Horner, Tiara Hypolite, Cindy Knoke, Homar Martinez, Keri Mason, Sharon Occhino, Kristin Quarterman, Sivakumar Raman, Mary Beth Saunders, Pranav Shah, Rajendra Sharma, Stephanie Stovall, Leigh Sweet, Joy Uzoma, Stephanie Walton, Chris Scott (ad hoc), and the current Infectious Diseases PGY2 Pharmacy Resident Pictured: Liz Chandler and Elena Gatskevich 2023 Annual Report and 2024 Future Directions | 5

Community Antimicrobial Stewardship Committee 2023 Business Items Summary Formulary Reviews Smart sets/ Ordersets/Policies Antimicrobial Use/ Reporting/Tracking Other Business Items 0 1 2 3 4 5 6 Community Antimicrobial Stewardship Committee The Community Antimicrobial Stewardship Committee was originally chartered in February 2019 as part of a joint effort between Lee Convenient Care (LCC) physician leadership and the antimicrobial stewardship pharmacists. This group arose to address the growing need for expansion of antimicrobial stewardship efforts to settings outside of acute care. In July 2023, committee meetings were re-initiated, following recruitment of a pharmacist dedicated to community antimicrobial stewardship services. Five meetings were conducted in 2023 (July, August, September, November, and December). Meeting structure consists of review of new business items coupled with follow-up of standing/routine business items. Report outs from this meeting are provided to the Systems Antimicrobial Stewardship Committee. Meeting minutes are provided to P&T Committee for inclusion in that committee’s consent agenda. Applicable new business items, requiring full review and approval by P&T, are presented to that committee. Please see summary (at right) of 2023 business items. For detailed report of community antimicrobial stewardship committee business items and initiatives (See Page 25). The Community Antimicrobial Stewardship Committee is an interdisciplinary committee consisting of infectious disease providers, pharmacists, microbiologists, and an informatics physician. Members include: Physician Co-Chair: Karen Calkins Pharmacist Co-Chair: Joy Uzoma Core Membership: John Armitstead, Kymberly Buzzeo, Liz Chandler, Fran Cioffi, Cindy Drapal, Manuel Escobar, Kristine Fay, Morris Gieselman, Catherine Guglielmo, Yanela Lozano, Leah Lynch, Mary Beth Saunders, Kelly Snell, Amanda Wouk and the current PGY2 Infectious Diseases Pharmacy Resident Pictured: Joy Uzoma 2023 Annual Report and 2024 Future Directions | 7

Antimicrobial Utilization The following represent antimicrobials of interest that are tracked by antimicrobial stewardship for utilization trends within our patient population. Of note, a major initiative for the AMS program has been the implementation of reporting Antibiotic Use and Resistance Data to the National Healthcare Safety Network. Reporting is expected to commence in 2024, which will significantly enhance the ability to track, monitor, and report antibiotic use data. Narrative Summary: ■ Avycaz (ceftazidime-avibactam) use continued to decline in 2023, while the use of Zerbaxa (ceftolozanetazobactam) has increased. Zerbaxa remains as the preferred treatment of choice against multi-drug resistant Pseudomonas. Vabomere (meropenem-vaborbactam) maintains a cost advantage over Avycaz at Lee Health, making its use desirable as the first-line agent for Carbapenem-resistant Enterobacterales (CRE), in the setting of similar clinical efficacy. Use of Vabomere has increased slightly throughout 2023. ■ Overall, use of vancomycin and linezolid have remained steady over the past year, while the use of daptomycin has increased. While linezolid use has remained steady over the past year, linezolid restriction criteria was evaluated via a medication use evaluation and only the IV formulation will be restricted when its intended use is > 24 hours beginning in 2024 as a cost savings initiative. ■ Meropenem and ertapenem use has demonstrated an uptrend in 2023, while cefepime and piperacillin/ tazobactam use have remained steady overall • The antimicrobial stewardship program targets carbapenem specific interventions through day-to-day prospective audit and feedback and order set modifications. • The antimicrobial stewardship program implemented a 48-72 hour antibiotic timeout alert for clinicians to review a patient’s antimicrobial regimen when active for this timeframe. • Best practice advisories for aspiration pneumonia are planned to be implemented in 2024 to reduce use of piperacillin/ tazobactam ■ Decreasing usage of fluoroquinolone antibiotics (ciprofloxacin and levofloxacin) has been a consistent goal for the antimicrobial stewardship team due to the numerous adverse effects and C. difficile infection risk. Levofloxacin use has seen sustained downward trends in usage over the past few years. Ciprofloxacin use remains steady in the past year. 8 | Lee Health - Antimicrobial Stewardship Program

Anti-MRSA Antimicrobials Jul-23 — Aug-22 — Aug-23 — Sep-22 — Sep-23 — Oct-23 — Jan-22 — Jan-23 — Oct-22 — Feb-22 — Feb-23 — Nov-23 — Nov-22 — Mar-22 — Mar-23 — Dec-23 — Dec-22 — Apr-22 — Apr-23 — May-22 — May-23 — Jun-22 — Jun-23 — Jul-22 — Vancomycin Adjusted Antimicrobial Days (per 1,000 days present) 80 60 40 20 0 CCH HPMC Golisano GCMC LMH Jul-23 — Aug-22 — Aug-23 — Sep-22 — Sep-23 — Oct-23 — Jan-22 — Jan-23 — Oct-22 — Feb-22 — Feb-23 — Nov-23 — Nov-22 — Mar-22 — Mar-23 — Dec-23 — Dec-22 — Apr-22 — Apr-23 — May-22 — May-23 — Jun-22 — Jun-23 — Jul-22 — Daptomycin Adjusted Antimicrobial Days (per 1,000 days present) 100 50 0 CCH HPMC Golisano GCMC LMH Jul-23 — Aug-22 — Aug-23 — Sep-22 — Sep-23 — Oct-23 — Jan-22 — Jan-23 — Oct-22 — Feb-22 — Feb-23 — Nov-23 — Nov-22 — Mar-22 — Mar-23 — Dec-23 — Dec-22 — Apr-22 — Apr-23 — May-22 — May-23 — Jun-22 — Jun-23 — Jul-22 — Linezolid Adjusted Antimicrobial Days (per 1,000 days present) 100 80 60 40 20 0 CCH HPMC Golisano GCMC LMH 2023 Annual Report and 2024 Future Directions | 9

Jul-23 — Aug-22 — Aug-23 — Sep-22 — Sep-23 — Oct-23 — Jan-22 — Jan-23 — Oct-22 — Feb-22 — Feb-23 — Nov-23 — Nov-22 — Mar-22 — Mar-23 — Dec-23 — Dec-22 — Apr-22 — Apr-23 — May-22 — May-23 — Jun-22 — Jun-23 — Jul-22 — Ceftaroline Adjusted Antimicrobial Days (per 1,000 days present) 5 4 3 2 1 0 CCH HPMC Golisano GCMC LMH Jul-23 — Aug-22 — Aug-23 — Sep-22 — Sep-23 — Oct-23 — Jan-22 — Jan-23 — Oct-22 — Feb-22 — Feb-23 — Nov-23 — Nov-22 — Mar-22 — Mar-23 — Dec-23 — Dec-22 — Apr-22 — Apr-23 — May-22 — May-23 — Jun-22 — Jun-23 — Jul-22 — Ceftolozane/Tazobactam Adjusted Antimicrobial Days (per 1,000 days present) 10 8 6 4 2 0 CCH HPMC Golisano GCMC LMH High-Cost Beta-lactams 10 | Lee Health - Antimicrobial Stewardship Program

Jul-23 — Aug-22 — Aug-23 — Sep-22 — Sep-23 — Oct-23 — Jan-22 — Jan-23 — Oct-22 — Feb-22 — Feb-23 — Nov-23 — Nov-22 — Mar-22 — Mar-23 — Dec-23 — Dec-22 — Apr-22 — Apr-23 — May-22 — May-23 — Jun-22 — Jun-23 — Jul-22 — Ceftazidime/Avibactam Adjusted Antimicrobial Days (per 1,000 days present) 6 5 4 3 2 1 0 CCH HPMC Golisano GCMC LMH Jul-23 — Aug-22 — Aug-23 — Sep-22 — Sep-23 — Oct-23 — Jan-22 — Jan-23 — Oct-22 — Feb-22 — Feb-23 — Nov-23 — Nov-22 — Mar-22 — Mar-23 — Dec-23 — Dec-22 — Apr-22 — Apr-23 — May-22 — May-23 — Jun-22 — Jun-23 — Jul-22 — Meropenem/Vaborbactam Adjusted Antimicrobial Days (per 1,000 days present) 5 4 3 2 1 0 CCH HPMC Golisano GCMC LMH 2023 Annual Report and 2024 Future Directions | 11

Jul-23 — Aug-22 — Aug-23 — Sep-22 — Sep-23 — Oct-23 — Jan-22 — Jan-23 — Oct-22 — Feb-22 — Feb-23 — Nov-23 — Nov-22 — Mar-22 — Mar-23 — Dec-23 — Dec-22 — Apr-22 — Apr-23 — May-22 — May-23 — Jun-22 — Jun-23 — Jul-22 — Piperacillin/Tazobactam Adjusted Antimicrobial Days (per 1,000 days present) 200 150 100 50 0 CCH HPMC Golisano GCMC LMH Jul-23 — Aug-22 — Aug-23 — Sep-22 — Sep-23 — Oct-23 — Jan-22 — Jan-23 — Oct-22 — Feb-22 — Feb-23 — Nov-23 — Nov-22 — Mar-22 — Mar-23 — Dec-23 — Dec-22 — Apr-22 — Apr-23 — May-22 — May-23 — Jun-22 — Jun-23 — Jul-22 — Cefepime Adjusted Antimicrobial Days (per 1,000 days present) 100 80 60 40 20 0 CCH HPMC Golisano GCMC LMH Jul-23 — Aug-22 — Aug-23 — Sep-22 — Sep-23 — Oct-23 — Jan-22 — Jan-23 — Oct-22 — Feb-22 — Feb-23 — Nov-23 — Nov-22 — Mar-22 — Mar-23 — Dec-23 — Dec-22 — Apr-22 — Apr-23 — May-22 — May-23 — Jun-22 — Jun-23 — Jul-22 — Meropenem Adjusted Antimicrobial Days (per 1,000 days present) 60 40 20 0 CCH HPMC Golisano GCMC LMH Anti-Pseudomonal Beta-Lactams 12 | Lee Health - Antimicrobial Stewardship Program

2023 Annual Report and 2024 Future Directions | 13

Jul-23 — Aug-22 — Aug-23 — Sep-22 — Sep-23 — Oct-23 — Jan-22 — Jan-23 — Oct-22 — Feb-22 — Feb-23 — Nov-23 — Nov-22 — Mar-22 — Mar-23 — Dec-23 — Dec-22 — Apr-22 — Apr-23 — May-22 — May-23 — Jun-22 — Jun-23 — Jul-22 — Ertapenem Adjusted Antimicrobial Days (per 1,000 days present) 25 20 15 10 5 0 CCH HPMC Golisano GCMC LMH Jul-23 — Aug-22 — Aug-23 — Sep-22 — Sep-23 — Oct-23 — Jan-22 — Jan-23 — Oct-22 — Feb-22 — Feb-23 — Nov-23 — Nov-22 — Mar-22 — Mar-23 — Dec-23 — Dec-22 — Apr-22 — Apr-23 — May-22 — May-23 — Jun-22 — Jun-23 — Jul-22 — Ciprofloxacin Adjusted Antimicrobial Days (per 1,000 days present) 30 25 20 15 10 5 0 CCH HPMC Golisano GCMC LMH Jul-23 — Aug-22 — Aug-23 — Sep-22 — Sep-23 — Oct-23 — Jan-22 — Jan-23 — Oct-22 — Feb-22 — Feb-23 — Nov-23 — Nov-22 — Mar-22 — Mar-23 — Dec-23 — Dec-22 — Apr-22 — Apr-23 — May-22 — May-23 — Jun-22 — Jun-23 — Jul-22 — Levofloxacin Adjusted Antimicrobial Days (per 1,000 days present) 25 20 15 10 5 0 CCH HPMC Golisano GCMC LMH Other Gram Negative Antimicrobials Anti-Pseudomonal Beta-Lactams 14 | Lee Health - Antimicrobial Stewardship Program

Jul-23 — Aug-22 — Aug-23 — Sep-22 — Sep-23 — Oct-23 — Jan-22 — Jan-23 — Oct-22 — Feb-22 — Feb-23 — Nov-23 — Nov-22 — Mar-22 — Mar-23 — Dec-23 — Dec-22 — Apr-22 — Apr-23 — May-22 — May-23 — Jun-22 — Jun-23 — Jul-22 — Ceftriaxone Adjusted Antimicrobial Days (per 1,000 days present)100 80 60 40 20 0 CCH HPMC Golisano GCMC LMH Jul-23 — Aug-22 — Aug-23 — Sep-22 — Sep-23 — Oct-23 — Jan-22 — Jan-23 — Oct-22 — Feb-22 — Feb-23 — Nov-23 — Nov-22 — Mar-22 — Mar-23 — Dec-23 — Dec-22 — Apr-22 — Apr-23 — May-22 — May-23 — Jun-22 — Jun-23 — Jul-22 — Aztreonam Adjusted Antimicrobial Days (per 1,000 days present) 12 10 8 6 4 2 0 CCH HPMC Golisano GCMC LMH 2023 Annual Report and 2024 Future Directions | 15

Antimicrobial Cost The antimicrobial stewardship program tracks antimicrobial expenditures year-over-year for trends. Many factors play into expenditures, including introduction of generic products and drug shortages. Drug shortages may lead to higher costs as purchasing is often shifted to higher priced items and alternatives. It should be noted that antimicrobial expenditures are not considered a primary guideline-based metric or outcome of acute care antimicrobial stewardship programs. The comparative data represent CY 2022 and CY 2023 (excluding remdesivir*). The overall difference in drug costs between 2022 and 2023 was $407,576 (decrease of 8%). Reported cost information includes WAC and GPO pricing per campus as applicable. Pricing with 340B was excluded in this analysis. *Due to the COVID-19 pandemic, remdesivir cost was substantial to the health system in CY 2023 as well as previous years. For the purposes of normalizing cost information year over year, remdesivir expenditure is in the blue circle on page 17. Total System Antimicrobial Drug Cost per Calendar Year Location 2022 ($) 2023 ($) Cape Coral Hospital $927,024 $932,550 Golisano Children’s Hospital $363,315 $340,493 Gulf Coast Medical Center $1,849,997 $1,617,761 HealthPark Medical Center $801,259 $681,947 Lee Memorial Hospital $1,257,351 $1,218,623 Total $5,198,949 $4,791,373 Initiative Description Estimated Cost Savings/ Cost Avoidance Echinocandin Formulary Review Based on echinocandin formulary review, anidulafungin was replaced by micafungin as preferred formulary echinocandin Projected yearly cost savings $68,000 Remdesivir Stewardship Lee Health Remdesivir criteria for use was updated to reflect updated national clinical guidelines. Pharmacist-led daily review of active remdesivir orders was performed to ensure adherence to criteria for use. Along with a reduction in overall COVID-19 cases, these initiatives led to a cost decrease compared to previous years ~$3,000,000 (decrease in spend from CY2022) Ceftazidime/Avibactam Best Practice Alert and Education Initiative to promote use of ceftolozane/tazobactam as preferred treatment for MDRO pseudomonas resistant to meropenem. Best Practice Alert added to EPIC upon ordering of Ceftazidime/ Avibactam along with education to providers and pharmacists. ~$50,000 (decrease in spend from CY 2022) Intravenous Clindamycin Best Practice Alert Clindamycin was on shortage for part of 2023. Best practice alert was added to EPIC containing alternative recommendations to IV clindamycin ~$25,000 (decrease in spend from CY2022) Antimicrobial Cost-Savings Initiatives – Implementation CY2023 16 | Lee Health - Antimicrobial Stewardship Program

Top 10 Drug Expenditures The following data encompass Q1-Q4 of calendar year 2023 for all acute care facilities. Drug Generic Name Total Spend ($) Ceftolozane/Tazobactam* $ 569,313 Minocycline $ 299,658 Daptomycin* $ 271,521 Ceftaroline* $ 239,218 Ceftazidime/Avibactam* $ 236,273 Anidulafungin $ 208,854 Meropenem/Vaborbactam* $ 197,989 Piperacillin/Tazobactam $ 175,308 Vancomycin $ 162,178 Aztreonam $ 138,743 *Indicated restricted antimicrobial Pediatric Antimicrobial Cost • Within the Pediatric Antimicrobial Stewardship Program, we focus on utilization of the top 10 antibiotics rather than cost, due to the lower volume of patients compared to adult facilities and overall lower antimicrobial use. High cost antimicrobials, which make up the majority of the top 10 expenditures are often low utilizers, used on a case-by-case basis with infectious diseases physician oversight, and are monitored daily. • Due to the overall small size of our hospital and the nature of antibiotic use in pediatrics, solely analyzing cost data is often misleading and small purchases of costly antimicrobials can swing the cost tables dramatically. Cost data from purchasing information can be even further misleading as most often not all of the drug purchased is used at that time. • For completeness, a list of the top 10 antimicrobials by purchasing expenditures is listed below. Drug Generic Name Total Spend ($) Pentamidine $ 23,354 Cefepime $ 17,079 Foscarnet* $ 11,513 Penicillin G $ 10,032 Valganciclovir $ 9,603 Micafungin* $ 8,345 Linezolid* $ 6,870 Ampicillin/Sulbactam $ 6,838 Ampicillin $ 6,705 Ceftriaxone $ 6,285 *Indicated restricted antimicrobial Top 10 Antimicrobials by drug spend for 2023 (purchasing data): REMDESIVIR Remdesivir total spend for January 2023- December 2023 was $2,636,421. This is compared to ~$5,700,000 total spend in 2022. The system-wide remdesivir spend was more than 50% decreased from 2022 to 2023. 2023 Annual Report and 2024 Future Directions | 17

Pharmacist-Driven Collaborative Antimicrobial Optimization CY2023 Antimicrobial Stewardship iVents by Campus 10000 ______________________________________ 9000 ______________________________________ 8000 ______________________________________ 7000 ______________________________________ 6000 ______________________________________ 5000 ______________________________________ 4000 ______________________________________ 3000 ______________________________________ 2000 ______________________________________ 1000 ______________________________________ 0 ______________________________________ CCH HPMC LMH GCMC Golisano 7649 7738 4257 9434 1510 Clinical Pharmacist Antimicrobial Stewardship Actions Lee Health’s clinical pharmacists play a critical role in one of the stewardship program’s key actions: prospective audit and feedback of antimicrobial therapy. Pharmacists review opportunities for antimicrobial interventions daily and document their antimicrobial stewardship actions via iVent, a pharmacist communication tool within Epic. Types of interventions that may be documented include: Allergy Assessment, Bug-Drug Mismatch, Deescalation, Dosing Optimization, DrugLab mismatch, Duration of Therapy, Escalation of Therapy, ID Diagnostics, and IV to PO. Antimicrobial stewardship iVent volume may vary between campuses based on census, workflow, and campus-specific procedures surrounding antimicrobial stewardship practices. Lee Health System Pharmacist Antimicrobial Stewardship Interventions CY2023 N= 31,456 23% - De-escalation 16% - Duration of Therapy 8% - IV to PO 10% - Dosing Optimization 9% - Bug-Drug Mismatch 6% - Escalation of Therapy 4% - ID Diagnostics 1% - Allergy Assessment 8% - Therapeutic Recommendation 15% - Other Interdisciplinary Antimicrobial Stewardship Rounding Interdisciplinary collaboration as part of antimicrobial stewardship is a key action to improve antimicrobial use. In 2019, the program implemented weekly antimicrobial stewardship rounding with the Medical Director of IP/ Epidemiology and the adult Infectious Diseases Clinical Pharmacists; a practice that is presently ongoing. Pharmacy trainees, including pharmacy students and PGY1/PGY2 pharmacy residents, also participate in this rounding. Interdisciplinary input within these rounds facilitates antimicrobial stewardship interventions in patients of higher complexity. Recommendations for optimization of antimicrobial therapy are provided to treating clinicians subsequent to these rounds. 18 | Lee Health - Antimicrobial Stewardship Program

Pharmacist Driven Penicillin Allergy Assessments Pharmacists play an important role in optimizing antimicrobial therapy. Patients labeled with penicillin allergies often receive non-preferred antibiotics (e.g. fluoroquinolones, clindamycin, vancomycin) which leads to increased broad-spectrum antibiotic use, higher rates of Clostridioides difficile infections (CDI), and higher rates of multidrug- resistant infections. A pharmacist-led penicillin allergy assessment initiative was implemented, including a standardized interview note template in the EHR and education to pharmacists. A total of 468 patient interviews were conducted in CY2023 (chart right). CCH - 154 HPMC - 149 GCMC - 111 LMH - 29 Golisano - 20 CY2023 Pharmacist Penicillin Allergy Histories Antimicrobial Stewardship De-escalation Interventions. Antimicrobial de-escalation allows for the provision of effective empiric therapy, while minimizing unnecessary use that can promote resistance or adverse effects. For FY2024, the AMS team has set a quality metric goal to maintain an average of 500 antimicrobial de-escalation pharmacist interventions per month system wide. 600 ____________________________________________________ 500 ____________________________________________________ 400 ____________________________________________________ 300 ____________________________________________________ 200 ____________________________________________________ 100 ____________________________________________________ 0 ____________________________________________________ Oct-23 Nov-23 Dec-23 GCMC LMH CCH HPMC Golisano FY24 AMS De-Escalation iVents # of Interventions 2023 Annual Report and 2024 Future Directions | 19

Antimicrobial Resistance Tracking and Microbiology Collaboration The ASP closely collaborates with microbiology in a host of different capacities. Clinical microbiology plays a key role in furthering antimicrobial stewardship initiatives including selective reporting of antimicrobials, identification and monitoring of multidrug-resistant isolates, rapid diagnostic testing, implementation of new testing platforms, and Lee Health-specific antibiogram development. The ASP actively participates in monthly microbiology meetings as ongoing collaboration. 2023 COLLABORATIVE EFFORTS: ■ Development of 2022 hospital-specific antibiograms and Pseudomonas aeruginosa combination antibiograms ■ Gram-negative Vitek susceptibility card review and selection ■ Antifungal reporting updates ■ Aminoglycoside breakpoint updates ■ Candida auris system susceptibility data summary ■ CLSI M100 2023 review of breakpoint updates ■ Vibrio species reporting updates ■ Biofire BCID reporting updates ■ AmpC organism reporting updates Antimicrobial Resistance Tracking The stewardship program closely monitors important trends in antimicrobial resistance that may dictate empiric antimicrobial therapy choices for Lee Health patients. Examples of these include local Pseudomonas aeruginosa susceptibilities, as well as extendedspectrum betalactamase (ESBL)-producing Enterobacterales (formerly called Enterobacteriaceae). This information is used to support antibiotic selection in treatment pathways and order sets. 20 | Lee Health - Antimicrobial Stewardship Program

% of ESBL+ E. coli 2022 — 2023 — 2015 — 2016 — 2017 — 2018 — 2019 — 2020 — 2021 — 20 15 10 5 0 CCH Golisano GCMC HPMC LMH % of P. aeruginosa Susceptible to Cefepime (All) 2022 — 2023 — 2015 — 2016 — 2017 — 2018 — 2019 — 2020 — 2021 — 100 90 80 70 60 50 CCH Golisano GCMC HPMC LMH % of P. aeruginosa Susceptible to Meropenem (All) 2022 — 2023 — 2015 — 2016 — 2017 — 2018 — 2019 — 2020 — 2021 — 100 90 80 70 60 50 CCH Golisano GCMC HPMC LMH % of P. aeruginosa Susceptible to Pip-Tazo (All) 2022 — 2023 — 2016 — 2017 — 2018 — 2019 — 2020 — 2021 — 100 90 80 70 60 50 CCH Golisano GCMC HPMC LMH % of S. aureus that are MRSA 2022 — 2023 — 2017 — 2018 — 2019 — 2020 — 2021 — 100 80 60 40 20 0 CCH Golisano GCMC HPMC LMH % of ESBL+ K. pneumoniae 2022 — 2023 — 2015 — 2016 — 2017 — 2018 — 2019 — 2020 — 2021 — 20 15 10 5 0 CCH Golisano GCMC HPMC LMH ESBL increase likely multifactorial; reflective of removing ED discharged patients as well as overall system increase in gram-negative resistance 2023 Annual Report and 2024 Future Directions | 21

Formulary Management Antimicrobial Formulary Review Overview The Systems Antimicrobial Stewardship Committee and Community Antimicrobial Stewardship Committee functions as subsets of the Pharmacy and Therapeutics (P&T) committee. Formulary review of antimicrobials within Lee Health occurs according to the following process: Pharmacy Clinical Practice Council vets final recommendation for P&T committee Antimicrobial Stewardship Provides Recommendation to Pharmacy Clinical Practice Council Antimicrobial Stewardship Subcommittee Review with input from Formulary Advisory Committee (as applicable) P&T Review and Decision 22 | Lee Health - Antimicrobial Stewardship Program

FORMULARY ITEMS REVIEWED IN 2023 Echinocandin Formulary Review: August 2023 P&T ■ Review of safety and efficacy data for micafungin and anidulafungin. Comparable rates of clinical response and 1-month mortality observed between anidulafungin and micafungin. No statistically significant difference in treatment-emergent hepatotoxicity observed between agents. ■ Add micafungin to inpatient adult formulary • NO change to pediatric formulary ■ Remove anidulafungin from inpatient adult formulary Respiratory Syncytial Virus (RSV) Vaccines Formulary Review: September 2023 P&T ■ The Food and Drug Administration approved two vaccines (Abrysvo and Arexvy) for the prevention of RSV in eligible patients. Additionally, the Advisory Committee on Immunization Practices (ACIP) issued recommendations regarding use of RSV vaccine, prompting formulary review of these vaccines at Lee Health. ■ Add Abrysvo to ambulatory formulary • Restrict to outpatient use • Recommend use in patients age ≥ 60 years of age using shared clinical decision-making • Approved for use in pregnant individuals ■ Do not add Arexvy to ambulatory formulary Remdesivir, Nirmatrelvir/ritonavir, and Molnupiravir Formulary Review: September 2023 P&T ■ Review of updates needed to resources, documents, and Epic orders for these therapeutics, considering emerging clinical information along with new legislation, (Protection of Discrimination Based Upon Healthcare Choices Law) that warrants provider consent for therapeutics being utilized for the treatment of COVID-19. ■ Implement recommended changes to Epic order entry, COVID-19 website resources, and prescribing information: • Remdesivir: Update website resources, EPIC order entry questions, references for renal dysfunction • Nirmatrelvir/ritonavir: Update EPIC order entry questions/reference links/consent forms, Update COVID website • Molnupiravir: Add to formulary as emergency use authorization (EUA), update EPIC orders, update COVID website Tocilizumab and Baricitinib Formulary Review: October 2023 P&T ■Tocilizumab/Baricitinib recently received FDA approval for COVID treatment. ■ Keep tocilizumab and baricitinib restricted to critical care/ pulmonology and infectious diseases ■ Update inclusion and exclusion criteria ■ Remove EUA paperwork from EPIC and Virtual Lee ■ Add informed consent check box 2023 Annual Report and 2024 Future Directions | 23

Lactobacillus Formulary Review: November 2023 P&T ■ Probiotics are an ongoing area of clinical controversy, with conflicting data regarding risks and benefits. The patients at highest risk for adverse effects are: critically ill/ICU patients, critically ill pediatric patients (especially neonates), immunocompromised individuals and patients with central lines. ■ Remove probiotics (Lactobacillus (Floranex)) from formulary ■ Update therapeutic interchange document to remove substitution to (Lactobacillus (Floranex)) Fecal Microbiota Spores, Live-brpk - Formulary Update (Informational): November 2023 P&T ■ Vowst (Fecal Microbiota Spores, Live-brpk) is indicated for prevention of recurrent Clostridioides difficile infection (CDI) in adults following successful antibacterial treatment for recurrent CDI ■ Vowst is not available for inpatients as it is an outpatient specialty pharmacy product which requires prior authorization and ambulatory/ outpatient prescription drug coverage Nirsevimab-alip Formulary Review: November 2023 P&T – Pediatrics ■ The Food and Drug Administration approved monoclonal antibody product (nirsevimabalip) for prevention of RSV in eligible pediatric patients. ACIP issued recommendations for use of this product, prompting formulary review. ■ Inpatient: Limit nirsevimab indications due to limited availability and short supply secondary to increased demand: • Infants GA 29-32 weeks with CLD AND < 12 months of age • Infants > 29 weeks GA AND < 12 months of age at start of RSV season AND (1 of the following): • CHD-hemodynamically significant acyanotic heart disease receiving medication to control CHF AND will require cardiac surgical procedure • Moderate to severe pulmonary hypertension • Congenital abnormalities of airway or neuromuscular disease • Patient is not a candidate if maternal RSV vaccine was administered at least 14 days prior to birth ■ Outpatient: For all infants < 8 months of age entering their first RSV season can obtain nirsevimab from PCP d/t allocation considerations ■ Infants < 29 weeks will still require palivizumab • Due to limited data in patients < 29 weeks 24 | Lee Health - Antimicrobial Stewardship Program

Antimicrobial Stewardship Initiatives 2023 Annual Report and 2024 Future Directions | 25

Antibiotic Timeout Project • Collaborative initiative to implement a new best practice alert in accordance with the CDC core elements of Antimicrobial Stewardship recommendations • 48-72 hour timeout to providers to prompt deescalation of broad spectrum antimicrobials • Went live in July 2023 Study Partnerships: Lee Health/Wayne State University • 4 Recarbrio (imipenem/cilastatin/relebactam) patients submitted for inclusion NHSN Antimicrobial Use and Resistance Module • Validation completed for both AU and AR data • Anticipate active reporting to NHSN in 2024 Infection prevention collaboration • Infectious Disease Pharmacist Summer Series (6 newsletters published) • ICC Quarterly AMS Review/USP 797 • DNV Advanced IP Certification Evidence of Compliance Document Microbiology Collaboration • Creation and publication of 2022 antibiograms and Pseudomonas combination antibiogram • Vitek gram negative panel update • Antifungal reporting update • Aminoglycoside breakpoint update • CLSI M100 breakpoint review- Acinetobacter and meropenem • Candida auris susceptibilities update • Vibrio reporting update • Tuberculosis reporting update • BCID resistance reporting updates • Initiation of AmpC organism reporting Antimicrobial Optimization Collaborative Projects Order sets, Treatment Pathways, EHR updates • Azithromycin order panel creation • ID consult requirement for Staphylococcus aureus bacteremia • Voriconazole TDM: added to competency and kinetics list • Ceftazidime/avibactam (Avycaz) BPA creation • Candida auris tip sheet creation • AMS iVent update: Therapeutic Recommendations iVent subtype • COVID therapeutics update: antivirals (remdesivir, nirmatrelvir/ritonavir and molnupiravir) and immunomodulators (tocilizumab and baricitinib) • Trauma open fracture antibiotic policy update • ED Pneumonia order set review • IV clindamycin shortage BPA creation • IM penicillin shortage BPA creation • Surgical prophylaxis order set review – clindamycin alternatives • Antimicrobial dosing for renal dysfunction update • C-section antibiotic prophylaxis review • Post exposure prophylaxis policy update • Posaconazole TDM levels update and addition to IVMAG • Intraabdominal infection treatment pathway update • Desensitization order set update • COVID Vaccine Consent Form update • AMS Dashboard optimization • Nystatin shortage interchange • OB Order Set update • Nystatin and clotrimazole duration of therapy addition • Daptomycin dose rounding update • Resistant gram negative treatment pathway creation 26 | Lee Health - Antimicrobial Stewardship Program

• Rabies PEP update • Pharmacokinetics protocol update and order set review Formulary initiatives • Beyfortus (nirsevimab-alip) • Evusheld (tixagevimab/cilgavimab) removal • Lindane (gamma-hexachlorocyclohexane) removal • Rotateq RV5 (Rotavirus) vaccine addition • Quinolone eye drop therapeutic interchange • Vowst (fecal microbiota) • Pneumococcal vaccine formulary update • Recarbrio (imipenem/cilastatin/relebactam) • Echinochandin formulary update • Probiotic/Lactobacillus removal • RSV vaccine formulary review Community Antimicrobial Stewardship Initiatives • Re-initiation of committee meetings in July 2023 • Updates to charter and membership • Gap analysis of existing program • Wound care antibiotic provider discussion • Respiratory tract infection and Urgent Care initiative • Smart set updates/revision • Urgent care provider meeting • Dissemination of education materials • RSV vaccines formulary review • RSV monoclonal antibodies formulary review • Community outreach event • Vowst formulary review and collaboration with specialty pharmacy • Rabies PEP protocol approval • HIV Evaluation Guide creation • Initiation of quarterly tracking of respiratory tract infections for urgent care • Agency for Healthcare Research and Quality antimicrobial stewardship initiative in ambulatory telemedicine • Committee end-of-year survey • Hepatitis B vaccine health maintenance record update • Outpatient surgical prophylaxis handout Pediatric Antimicrobial Stewardship Initiatives • Late onset sepsis order set creation • Orbital cellulitis clinical pathway creation • Pneumococcal vaccine update • Monthly education series(educational handouts/ links): • Penicillin allergies • Duration of therapy for common pediatric infectious diseases • Treatment of Enterococcus spp • Publication of duration of therapy guidelines • Congenital syphilis order panel and clinical pathway creation • Review of historic antibiotic usage and adjustment of monthly targets reported to facility scorecard • Publication of skin and soft tissue infection management guidance • Publication of emergency department blood culture pathway 2023 Annual Report and 2024 Future Directions | 27

Assessment of Community-Acquired Aspiration Pneumonia Antibiotic Treatment in the Intensive Care Unit Objectives/Findings Action/Outcome Objective: To assess antibiotic therapy prescribing patterns for the treatment of community-acquired aspiration pneumonia in critically ill patients Primary outcome: evaluation of evidence-based antibiotic therapy for aspiration pneumonia based on diagnosis, patient risk factors, and treatment duration as defined by the 2019 IDSA/ATS CAP guidelines Secondary outcomes: percentage of patients that met criteria for community-acquired aspiration pneumonia diagnosis, duration of antibiotic therapy, and the percentage of patients without risk factors that received antibiotic therapy with coverage for anaerobes, MRSA, Pseudomonas aeruginosa, or ESBL-producing organisms Results: • 77 patients (77.2%) met diagnostic criteria (both clinical and radiographic) for community-acquired aspiration pneumonia. • 7 patients (6.9%) had empiric antibiotic therapy that aligned with patient-specific risk factors for anaerobes or resistant organisms (MRSA, Pseudomonas aeruginosa, or ESBL). • Patient-specific risk factors for bacterial organisms – Anaerobes: 0 patients; MRSA: 12 patients (11.9%); Pseudomonas aeruginosa: 13 patients (12.9%); ESBL: 0 patients • Spectrum of empiric antibiotic coverage: Anaerobes: 85.1%; MRSA: 39.7%; Pseudomonas aeruginosa: 67.3%; ESBL: 2% • Most utilized empiric antibiotics: Piperacillin-tazobactam (52.5%), linezolid (34.7%), ampicillin-sulbactam (26.7%) • The mean duration of antibiotic therapy was 5.8 days, with 44 patients (43.6%) receiving antibiotics for a total duration of 5 to 7 days. • Overall, evidence-based empiric antibiotic therapy was demonstrated for 1 patient in this evaluation. However, this was primarily driven by the high utilization of antibiotics with anaerobic and Pseudomonal coverage in our patient population. Approximately 85% of patients received anerobic coverage in the absence of risk factors. Similarly, 34% and 81% of patients received empiric antibiotics with MRSA and Pseudomonas coverage, respectively, without patient-specific risk factors present for empiric coverage for these organisms. Presentation to Lee Health Critical Care Quality Conference Presentation to Antimicrobial Stewardship Committee A Best Practice Alert (BPA) will be developed for when piperacillintazobactam is ordered for a selected indication of aspiration pneumonia within 24 hours of the patient’s hospital admission. This BPA will recommend utilization of ceftriaxone or ampicillin-sulbactam in the absence of Pseudomonal risk factors. Medication Use Evaluations (MUEs) Completed in 2023 28 | Lee Health - Antimicrobial Stewardship Program

Evaluation of Linezolid Restriction Criteria in a Community Health System Objectives/Findings Action/Outcome Objective: To assess the current use and adherence to restriction criteria of linezolid within a community health system Primary outcome was the percentage of patients meeting linezolid use criteria, in which 92% of all patients receiving linezolid either had an approved consult or met risks for nephrotoxicity when being treated for either pneumonia or skin and soft tissue infections. Secondary outcomes included total duration of therapy (2.4 [1.08 – 4.00] days), percentage of patients with linezolid ordered for empiric use (90.4%), and rate of de-escalation to a narrower therapy (75.7%). Due to high rates of use criteria compliance, short duration of therapy, and reduced cost of linezolid, the use of oral linezolid was removed from the facility restricted antimicrobial list. At this time only IV linezolid when used > 24 hours is restricted to infectious diseases, pulmonary, and trauma. Patients unable to swallow or are strict NPO may be initiated on IV linezolid without consult. Antimicrobial-Related Comparative Research The following IRB-approved retrospective analyses were completed in 2023. Impact of Intravenous Antibiotics for Suspected Pulmonary Infections in Patients with Acute Decompensated Heart Failure at a Community Hospital Katherine Schojan, PharmD • Elisabeth Chandler, PharmD, BCIDP Kristin Quarterman, PharmD, BCPS • Rakhi Patel, PharmD, BCPS, BCACP Stela McCarty, DO Objectives/Findings Action/Outcome Objective: To assess if patients admitted for acute decompensated heart failure who received IV antibiotics for suspected pulmonary infections versus those who did not has an impact on hospital length of stay and other clinical outcomes • Received IV antibiotics: received at least 48 hours of IV antibiotics during hospital encounter Primary Outcome: Hospital length of stay (days) Results: Patients in the IV antibiotic (IVAB) arm had a longer hospital length of stay (5 days vs 4 days; P<0.01) and received more total sodium (10.24 g vs 0 g; P<0.01) and total volume from IV antibiotics and fluids (1,825 mL vs 0 mL; P<0.01). No significant differences were found in the unmatched or matched cohorts concerning other secondary outcomes, with both groups having an average readmission rate of 24-31%, an average mortality rate of 6-18%, and an average of 180-200 mg of loop diuretic administered. Among the patients in the IVAB group, the most common antibiotics received were ceftriaxone and azithromycin and the median duration of IV antibiotic therapy was 4 days in both the unmatched and matched cohorts. Based on the results of this study our recommendations are to 1) avoid the use of IV antibiotics if there is a diagnosis of acute decompensated heart failure and low suspicion of infection, 2) de-escalate empiric antibiotics early when infectious cause is ruled out, and 3) encourage early transition from IV antibiotics to oral antibiotic agents in cases where antibiotic therapy is indicated. Data was presented at the Antimicrobial Stewardship Committee and recommendations were accepted. Education was provided to healthcare providers and pharmacists regarding the impact of IV antibiotics in patients with acute decompensated heart failure. An antibiotic timeout alert was implemented in July 2023 to prompt de-escalations of broad-spectrum IV antibiotics. 2023 Annual Report and 2024 Future Directions | 29

Evaluation of Treatment Options for Stenotrophomonas maltophilia Infection Within a Community Health System: A Retrospective Cohort Study Khawla Farah, PharmD, • Elisabeth Chandler, PharmD, BCIDP Manuel Escobar, PharmD, BCIDP • Kelly Groover, PharmD, BCPS, BCCCP Robert Castro, MD Objectives/Findings Action/Outcome Objective: To compare clinical outcomes in patients being treated for S. maltophilia with TMP/SMX, MIN (minocycline) or FQ (levofloxacin/ ciprofloxacin) Primary outcome: Incidence of clinical failure (TMP/SMX vs MIN vs FQ) defined as meeting any of the following: recurrence of infection, need for change in antibiotic therapy due to suspected treatment failure, 30 day in-hospital mortality in patients with S. maltophilia infections Clinical failure did not differ between the three groups in the unmatched cohort (33% vs 38% vs 37%; p = 0.92) and matched cohort (41% vs 27% vs 27%; p = 0.53). No difference was observed in key secondary outcomes including change in antibiotic therapy secondary to treatment failure (11% vs 9% vs 14%; p = 0.69) and 30-day in-hospital mortality (22% vs 18% vs 20%; p = 0.44). Conclusion: Among patients with S. maltophilia infections, the incidence of clinical failure was similar in patients receiving TMP/SMX, MIN or FQ. The findings from this study indicate that MIN and FQ are viable alternative treatment options especially in patients with intolerances to TMP/SMX. The results of this study were presented to Antimicrobial Stewardship Committee in July 2023. Our recommendations are 1) to utilize first line treatment options for the treatment of S. maltophilia such as TMP/SMX or MIN, 2) use combination therapy when appropriate (i.e moderate – severe infections) and 3) Optimize dosing based on current recommendations for the treatment of S. maltophilia infections (i.e TMP/SMX: 8 – 12 mg/ kg/day, MIN: 200 mg twice daily). Education was provided to healthcare providers and pharmacists regarding the recommended treatment and dosing recommendations for S.maltophilia infections. 30 | Lee Health - Antimicrobial Stewardship Program

Comparison of Neonatal Blood Culture Time to Positivity in Pathogens versus Contaminants Min Jee Kim, PharmD • Megan Patch, MS, PharmD, BCPS, BCIDP, BCPPS Analia Perdomo, PharmD • Bradley Murnyack, PharmD, BCPS • Noelia Aviles-Otero MD Leigh R. Sweet, MD, MPH, MEd Objectives/Findings Action/Outcome Objective: To assess the time to positivity of true pathogens versus contaminants to aid in antibiotic stewardship efforts within neonatal sepsis Primary outcome: Time to positivity (hours) of neonatal blood cultures designated as true pathogens compared to contaminants Time to positivity of blood cultures was significantly higher in the true pathogen arm compared to the contaminant group (21 vs 34.9 hours; p<0.001). By 48 hours, there were significantly more blood cultures containing pathogens that resulted positive compared to the contaminant group (100% vs. 83.3%; p<0.001). Median length of stay in the true pathogen group was significantly shorter compared to the contaminant group (75 days, IQR [34 – 121] vs. 34 days, IQR [14.8 – 86.3]; p=0.009). Conclusion: All true pathogens in this study resulted positive on blood cultures within 48 hours. Limiting empiric antibiotic duration to a 36 to 48-hour rule-out period for contaminants resulting in neonatal blood cultures can decrease unnecessary prolonged antibiotic use in neonates. Although there is a 36 to 48- hour rule-out period for empiric antibiotics for neonatal sepsis patients at Lee Health, there are contaminants that can result in neonatal blood cultures outside that time frame leading to prolonged antibiotic use. The results of this study will be presented to the NICU Stewardship Committee to discuss potential next steps. The following IRB-approved retrospective analyses will be concluding with results in Spring 2024. Evaluating the Impact of Electronic Provider-Selected Indications on Antifungal and Antiviral Prescribing: A Pre-Post Intervention Study Description/Objectives Description/Objective: At this community health system, only antibiotics required provider-selected indications upon order entry. After March 2023, expansion of provider-selected indications were required upon antifungal and antiviral order entry. The purpose of this research project was to evaluate the utility of the antifungal and antiviral provider-selected indications pre- and post-implementation. The primary outcome was the percentage of patients receiving guideline concordant therapy. Significant secondary outcomes included average duration of therapy stratified by disease state, percentage of patients with an infectious diseases consult, and percentage of patients receiving guideline concordant agent, dose, and duration of therapy. Statistical analysis is currently in progress at this time. 2023 Annual Report and 2024 Future Directions | 31

Lee Health Specialty Pharmacy Lee Health Specialty Pharmacy Lee Health Specialty Pharmacy (LHSP), with contracted services by CPS (formerly Trellis Rx) and operating from Lee Health Coconut Point, provides tailored solutions to address the complexities associated with specialty medications throughout Lee Health. Services are extended to more than 90 outpatient clinics within Lee Physician Group (LPG), including infectious disease service line. Among the medications most frequently managed by LHSP are antiretroviral therapy for Human Immunodeficiency Virus (HIV) and direct-acting antivirals for Hepatitis C Virus (HCV). In 2023 alone, LHSP serviced over 1000 specialty medications for HIV and HCV. Our specialty pharmacy team is strategically positioned to break down barriers and support patients and providers in initiating treatment promptly while ensuring adherence throughout the prescribed duration. Through regular communication and proactive interventions, LHSP maintains a remarkable track record, with 98.6% of HIV patients achieving an undetectable viral load which far surpasses the national benchmark of 65% (Table 1). Likewise, patients undergoing HCV treatment at Lee Health demonstrate higher therapy completion rates and SVR12 return rates, indicative of successful virological cure, compared to national averages (Table 2). HIV Viral Load Benchmark Centers for Disease Control and Prevention. Monitoring selected national HIV prevention and care objectives by using HIV surveillance data—United States and 6 dependent areas, 2020. HIV Surveillance Supplemental Report. 2022;27(3). https://www.cdc.gov/hiv/library/reports/hiv-surveillance.html. Updated August 26, 2022. Accessed December 6, 2022. 100 ______________________________________ 80 ______________________________________ 60 ______________________________________ 40 ______________________________________ 20 ______________________________________ 0 ______________________________________ Lee Health Benchmark Table 1. Undetectable HIV Viral Load 98.6% 65% Undetectable Rate 32 | Lee Health - Antimicrobial Stewardship Program

Lee Health Specialty Pharmacy collaborates closely with LPG Infectious Disease (ID) leadership to facilitate access to several novel, innovative therapies. ■ In 2023, LHSP notably introduced Cabenuva (cabotegravir/rilpivirine) and Vowst (fecal microbiota spores, live-brpk) to the treatment landscape. Cabenuva is a groundbreaking, longacting complete regimen for the treatment of HIV administered once monthly. Transitioning patients from daily oral regimens to this monthly treatment aims to enhance adherence and sustain virological suppression. ■ Vowst is the first orally-administered fecal microbiota product designed to prevent recurrent Clostridioides difficile (C. diff) infections. Given the challenges associated with C. diff infections, Vowst provides a valuable option for providers and patients to reduce recurrence rates post-antibiotic treatment. ■ Patient access to both Cabenuva and Vowst require insurance approval, financial assistance, and significant patient education due to complexity of treatment timing, dosing, and monitoring. The ongoing collaboration between LPG ID and LHSP underscores our commitment to advancing patient care through interdisciplinary medication management. Lee Health Specialty Pharmacy remains dedicated to optimizing patient outcomes by delivering innovative solutions and personalized support every step of the way. Therapy Completion Rate Benchmark Bolduc C, McCall K, Stickney K, Gelinas A, Levesque E. Applicability of a new specialty pharmacy-reported measure describing completion of therapy for hepatitis C. J Manag Care Spec Pharm. 2021;27(2):263-267. doi: 10.18553/ jmcp.2021.27.2.263. SVR12 Benchmark Ferrante ND, Newcomb CW, Forde KA, et al. The Hepatitis C Care Cascade During the Direct-Acting Antiviral Era in a United States Commercially Insured Population. Open Forum Infect Dis. 2022;9(9). doi: 10.1093/ofid/ofac445. 100 ______________________________________ 80 ______________________________________ 60 ______________________________________ 40 ______________________________________ 20 ______________________________________ 0 ______________________________________ Lee Health Benchmark Table 2. HCV Therapy Completion and SVR12 Return Rate 96% 87.5% 87% 63% Therapy Completion SVR12 Return Rate SVR12: Sustained Virological Response at 12-weeks post treatment 2023 Annual Report and 2024 Future Directions | 33

Regulatory Compliance 34 | Lee Health - Antimicrobial Stewardship Program

MM.8 / IC.2 SR.1 The organization shall demonstrate that an individual (or individuals), who is qualified through education, training, or experience in infectious diseases and/or antibiotic stewardship, is appointed by the governing body as the leader(s) of the antibiotic stewardship program EVIDENCE OF COMPLIANCE: • System Antimicrobial Stewardship Committee Charter • Antimicrobial Stewardship Committee (ASC) Quality Organization Chart • Antimicrobial Stewardship Physician Leader Appointment (meeting minutes) DNV MM.8 and IC.2, IC.3 Standards Evidence of Compliance “The organization shall have a program in place to enhance antimicrobial stewardship, an activity that includes appropriate selection, dosing, route, and duration of antimicrobial therapy. There shall be pharmacy involvement in the program that includes monitoring, prescribing and resistance patterns education and reporting to the antibiotic stewardship program as well as the QMS. See IC.2, IC.3 and QM.7 SR.4h(2)” 2023 Annual Report and 2024 Future Directions | 35

MM.8 / IC.2 SR.2/ QM.7 SR.4h(2) The organization-wide stewardship program: • SR.2a: Demonstrate coordination among all components of the organization responsible for antibiotic use and resistance, including, but not limited to: – The IPCP, QAPI, medical staff, laboratory services, and pharmacy services • SR.2b: Document the evidence-based use of antibiotics in all departments and services of the organization • SR. 2c: Documents any improvements, including sustained improvements, in proper antibiotic use EVIDENCE OF COMPLIANCE: • Lee Health Pharmacy Organization Chart • Antimicrobial Stewardship Committee (ASC) Quality Organization Chart • Pharmacy and Therapeutics Committee • Infection Control Committee • Clinical Collaboration Council • Microbiology Meeting • Policy S11 00 422 - Infection Control Committee and Epidemiology Infection Prevention Department Authority Statement • Antimicrobial Stewardship Program Annual Report – antimicrobial use monitoring summary • Real-time daily monitoring of restricted antibiotics • Medication use evaluation (descriptive): – Prophylactic antimicrobials for neutropenic AML patients – Sepsis order set antimicrobial utilization – Urinary tract infection antimicrobial utilization – Pediatric incidence of thrush after inhaled steroids – Oral beta-lactam utilization in Gram negative bacteremia – Neurosurgical antimicrobial prophylaxis utilization – Aminoglycoside dosing in pediatric cystic fibrosis – Community-acquired pneumonia antimicrobial utilization – Ertapenem in surgical prophylaxis – Ceftaroline utilization – Pediatric IV to oral conversion in intraabdominal infections – Prophylactic antibiotics in open fractures – Pediatric gentamicin levels post-maternal gentamicin administration – Evaluation of linezolid restriction criteria • Comparative Research – Evaluation of antifungal and antiviral provider-selected indications – Antibiotics for pulmonary infections in decompensated heart failure – Utilization of antibiotics for Stenotrophomonas infections – UTI and SSTI Stewardship Intervention Bundle in Emergency Department Discharges – Evaluation of Vanco AUC vs Trough based monitoring – Real world evaluation of T2Candida in patients with candidemia – Daily vs twice daily extended interval aminoglycosides in CF exacerbation – Outcomes of low vs high bioavailability oral antibiotics for bacteremia – Adjunctive use of tigecycline in patients with severe C. diff infections – Implementation of Vancomycin AUC monitoring – Comparison between candidemia identified by blood culture vs T2Candida – Utility of MRSA PCR for antibiotic deescalation 36 | Lee Health - Antimicrobial Stewardship Program

MM.8 / IC.2 SR.3 The antibiotic stewardship program adheres to nationally recognized guidelines, as well as best practices, for improving antibiotic use; and, • The antibiotic stewardship program reflects the scope and complexity of the organization services provided. EVIDENCE OF COMPLIANCE: • Lee Health Policy M03 03 024 – Antimicrobial Stewardship Program – Acute Care • Lee Health Restricted Adult Antimicrobials • Lee Health Restricted Pediatric Antimicrobials • PH7 01 002 Pharmacokinetic Monitoring Service • PH7 01 003 Medication Therapy Dosing and Optimization Protocol • PH7 01 004 Medication Therapy Monitoring Pharmacist/Physician Collaboration • PH7 01 005 Intravenous to Oral Protocol • PH4 01 005 Dosing and Dose Rounding Order Documentation • M03 03 048 Automatic Stop Orders • Antimicrobial dosing for renal dysfunction chart • Lee Health Policy SN02 00 019 - Antibiotic Stewardship (Skilled Nursing) • Pediatric Antimicrobial Maximum Dosing Guide • Infectious diseases-related order sets – Sepsis – Community-acquired pneumonia, hospitalacquired pneumonia, and ventilator associated pneumonia – Amphotericin B – Telavancin – Daptomycin + CPK – UTI SmartSet – SSTI SmartSet • Extended Infusion B-lactam Protocol • Antimicrobial formulary reviews • Infectious Diseases Treatment Guidance and Pathways – Urinary Tract Infection – Pneumonia – Clostridioides Difficile-associated Diarrhea – Intra-Abdominal Infection – Skin and Soft Tissue Infection – STI and Gynecologic Infections – Surgical Prophylaxis Antimicrobial Redosing – T2Candida Guidance – Micro Inbasket Guidance – Common Antimicrobial Stewardship Interventions • Project Approvals – Combination antibiogram 2022 Pseudomonas – Aminoglycoside breakpoint updates and education – Emergency Department pneumonia order set review – Candida auris susceptibility report and education – Daptomycin dose rounding • Policy PA3 01 015– Pre-Op Prophylactic IV Antibiotic • Policy SN03 01 176 – Drug Regimen Review (Skilled Nursing) • Policy S11 00 422 – Infection Prevention Committee and Epidemiology/Infection Prevention Department Authority Statement • Vaccination policies – Policy S11 01 430 – Influenza Immunization and Prevention – Policy S18 00 148 – Influenza Vaccine Screening, Ordering, and Administration – Pediatric Inpatients – Policy M03 03 425 – Influenza Vaccine Administration Adult Inpatients – Policy SN03 00 380 – Pneumococcal/ Influenza Vaccine Administration (Skilled Nursing) • Infection Prevention Order Sets, Patient Education and Forms 2023 Annual Report and 2024 Future Directions | 37

MM.8 / IC.3 SR.1/ QM.7 SR.4h(2) The governing body shall ensure all of the following • Systems are in place and operational for the tracking of all infection surveillance, prevention, and control, and antibiotic use activities, in order to demonstrate the implementation, success, and sustainability of such activities • All HAIs and other infectious diseases identified by the IPCP as well as antibiotic use issues identified by the antibiotic stewardship program are addressed in collaboration with organization QAPI leadership EVIDENCE OF COMPLIANCE: • Lee Health 2023 Infection Control Plan • Infection Control Committee • Clinical Consensus Workgroups and Clinical Collaboration Council • Lee Health Policy S11 00 887 – TransmissionBased Isolation Precautions • Lee Health Microbiology Policy 2 M 002 S– Multi-Drug-Resistant Organisms • Lee Health Policy SN02 00 137 – Management of Transmission-Based Isolation Precautions and MDRO (Skilled Nursing) • Lee Health Policy 5 M 031 S – Manual for Laboratory Services: Notification of Microbiology Results • Lee Health Policy 5 A 022 S – Manual for Laboratory Services: Notification of Reportable Diseases/Conditions • Lee Health Policy 5 M 182 S – Manual for Laboratory Services: Burkholderia mallei and pseudomallei, Sentinel Laboratory Guidelines • Lee Health Policy 5 M 007 S – Manual for Laboratory Services: Bacillus anthrasis and Bacillus cerus biovar anthracis, Sentinel Laboratory Guidelines • Lee Health Policy 5 M 223 S – Manual for Laboratory Services: Blood Culture Identification 2 (BCID2) Panel • CCH Microbiology Procedure Manual Review- 2022 (Biennial review) • GCMC Microbiology Procedure Manual Review- 2020 (Biennial review) • Lee Health Policy 6 A 003 S – Manual for Laboratory Services: Procedure Manuals • Infection Prevention EPIC dashboard • Antimicrobial Stewardship EPIC dashboard • Hospital-specific Antibiograms – Cape Coral Hospital – Golisano Children’s Hospital of SW Florida – GulfCoast Medical Center – HealthPark Medical Center – Lee Memorial Hospital – Pseudomonas aeruginosa Combination Antibiogram 38 | Lee Health - Antimicrobial Stewardship Program

MM.8/ IC.3 SR.2 The infection preventionist(s)/infection control professional(s) is responsible for: • The development and implementation of organization-wide infection surveillance, prevention, and control policies and procedures that adhere to nationally recognized guidelines • All documentation, written, or electronic, of the IPCP and its surveillance, prevention, and control activities • Communication and collaboration with the organization’s QAPI program on infection prevention and control issues • Competency-based training and education of hospital personnel and staff, including medical staff, and, as applicable, personnel providing contracted services, on the practical applications of infection prevention and control guidelines, policies, and procedures • The prevention and control of HAIs, including auditing of adherence to infection prevention and control policies and procedures by organization personnel • Communication and collaboration with the antibiotic stewardship program EVIDENCE OF COMPLIANCE: • Lee Health Microbiology Policy 2 M 002 S – Multi-Drug-Resistant Organisms • Lee Health Policy 5 M 085 S – Manual for Laboratory Services : Antimicrobial Reporting • Lee Health Policy S11 00 887 – TransmissionBased Isolation Precautions • Lee Health Policy SN02 00 137 – Management of Transmission-Based Isolation Precautions and MDRO (Skilled Nursing) • Lee Health 2023 Infection Control Plan • Infection Control Committee • Clinical Consensus Workgroups and Clinical Collaboration Council • Lee Health Pharmacy Organization Chart • Pharmacy and Therapeutics Committee • Infection Control Committee • Clinical Collaboration Council • Microbiology Meeting • Policy S11 00 422 - Infection Control Committee and Epidemiology Infection Prevention Department Authority Statement • Educational initiatives – Pharmacist continuing education (CE) programs – Physician CME programs – The Dose of Infectious Diseases newsletter – Pharmacist infectious diseases annual competency – Antibiotic Awareness Week 2023 Annual Report and 2024 Future Directions | 39

Lee Health Antimicrobial Stewardship Program IDSA/SHEA Antimicrobial Stewardship Guidelines Compliance Assessment IDSA/SHEA Guidelines for Implementing an Antimicrobial Stewardship Program Recommendation Lee Health Evidence of Compliance Interventions Implement Preauthorization and/or Prospective Audit and Feedback • Antimicrobial Stewardship Program (ASP) team members and clinical pharmacists perform prospective audit and feedback, documented in Antimicrobial Stewardship iVents • Required provider-selection of placement of ID consult or selection of authorized provider upon restricted antibiotic order entry • Restricted antibiotic list Didactic Education to Complement Stewardship Activities • The Dose of Infectious Diseases newsletter • Pharmacist Continuing Education (CE) Programs • Physician CME Programs • Annual US Antibiotic Awareness Week participation • Pharmacist Infectious Diseases/Microbiology annual competency • System-wide mandatory education (3 R’s education) • Physician, nursing, and CNA competency education • Nursing and CNA antimicrobial stewardship competencies Develop and Implement Facility-Specific Clinical Practice Guidelines for Common Infectious Diseases Syndromes • Treatment pathways (key pathways listed below- full list accessible online here) o Urinary Tract Infection o Pneumonia o Intra-abdominal Infection o Adult Acute Bacterial Skin and Soft Tissue Infection Pathway o Sexually-transmitted Infection o Clostridioides Difficile Infection Treatment Adult Pathway o Surgical Prophylaxis Antibiotic Redosing recommendations o Resistant gram-negative pathogens Implement Interventions to Improve Antibiotic Use and Clinical Outcomes that Target Patients with Specific Infectious Diseases Syndromes • Treatment pathways (above) • Physician Order Sets o Sepsis o Community-acquired Pneumonia o Febrile Neutropenia Implement Interventions Designed to Reduce the Use of Antibiotics Associated with a High Risk of C. Difficile Infection • Prospective audit and feedback • Clostridioides Difficile Infection Treatment Adult Pathway • Best Practice Advisory for physicians to review antibiotics active for 48 – 72 hours 40 | Lee Health - Antimicrobial Stewardship Program

IDSA/SHEA Guidelines for Implementing an Antimicrobial Stewardship Program Recommendation Lee Health Evidence of Compliance Use of Strategies to Encourage Prescriber-Led Review of Appropriateness of Antibiotics Recommendations • Requirement of prescriber-specified end dates (hard stop) on antimicrobial orders in HER o Lee Health M03 03 048 – Automatic Stop Orders • Best Practice Advisory for physicians to review antibiotics active for 48 – 72 hours Incorporation of Computerized Clinical Decision Support at the Time of Prescribing • EPIC order sets o Community Acquired Pneumonia Admission Orders o Sepsis Non-ICU Admission Orders o Sepsis ICU Admission Orders o Febrile Neutropenia Admission Orders Optimization Implement PK Monitoring Adjustment Programs for Aminoglycosides and Vancomycin • PH7 01 002 Pharmacokinetic Monitoring Service Advocate for Alternative Dosing Strategies Based on PK/Pharmacodynamic Principles to Improve Outcomes and Decrease Costs for Broad-Spectrum BetaLactams and Vancomycin • Extended interval dosing of beta-lactam agents: Protocol • PH7 01 003 Renal Dosing and Antimicrobial Optimization Protocol • Antimicrobial dosing for renal dysfunction chart • Implemented area under the curve (AUC)-based PK monitoring for vancomycin according to 2020 IDSA Vancomycin Therapeutic Drug Monitoring Guidelines • Gram Negative Treatment Pathway • Restricted antibiotic list • Polymyxin and Colistin Dosing Tip Sheet Implement Programs to Increase Both Appropriate Use of Oral Antibiotics for Initial Therapy and the Timely Transition of IV to Oral Antibiotics • PH7 01 005 Intravenous to Oral Protocol o Tracking and feedback of IV to PO antimicrobial conversion • Linezolid 24 hour IV to PO linked order In Patients with Reported History of Beta-Lactam Allergy, Promote Allergy Assessments and Penicillin Skin Testing When Appropriate • Penicillin Allergy Assessment Note • Pharmacist review of previous antibiotic administrations Implement Interventions to Reduce Antibiotic Therapy to the Shortest Effective Duration • Lee Health M03 03 048 – Automatic Stop Orders • Treatment pathways • Prospective review and feedback for antimicrobial orders • 48 – 72 hour antibiotic timeout alert • Common Antimicrobial Stewardship Interventions and Recommendations Tip Sheet 2023 Annual Report and 2024 Future Directions | 41

IDSA/SHEA Guidelines for Implementing an Antimicrobial Stewardship Program Recommendation Lee Health Evidence of Compliance Microbiology & Laboratory Diagnostics Work with the Microbiology Laboratory to Develop Stratified Antibiograms • Annual antibiograms for 5 Lee Health hospitals, stratified by hospital-wide and ICU • Biennial combination anti-Pseudomonal antibiogram Work with Microbiology Laboratory to Perform Selective or Cascade Reporting of Antibiotic Susceptibility Test Results • Lee Health Policy 5 M 085 S – Manual for Laboratory Services: Antimicrobial Reporting Advocate for the Use of Rapid Viral Testing for Respiratory Pathogens ton Reduce the Use of Inappropriate Antibiotics • Rapid diagnostics and molecular diagnostics for respiratory viruses available in-house o Respiratory viral panel o 4-Plex testing for Influenza A & B, Covid, and RSV Advocate for Rapid Diagnostic Testing on Blood Specimens to Optimize Antibiotic Therapy and Improve Clinical Outcomes • Microbiology lab in-house rapid diagnostics for blood cultures: o BCID2 o T2 Candida panel o Bruker MALDI Advocate Procalcitonin Testing as an Intervention to Decrease Antibiotic Use for Adults in the ICU • Procalcitonin testing available in-house Incorporate Non-culture Based Fungal Markers to Optimize Antifungal Use in Patients with Hematologic Malignancy • Fungitell and Galactomannan assays available • T2 Candida Assay available o T2 Candida Guidance Document Measurement Monitor Antibiotic Use as Days of Therapy in Preference to Defined Daily Dose • Antimicrobial use is reported as Days of Therapy per 1000 Patient Days Present Measures that Consider the Size and Goals of Syndrome Specific-Intervention Should be Used • Antimicrobial Stewardship Program Annual Report • Example of Lee Health drug- and syndrome-specific research and MUE: https://intranet.leehealth.org/group/pharmacy/ pharmacy-research-and-mue-projects Special Populations Develop Facility-Specific Guidelines for Management of F&N in HematologyOncology Patients to Reduce Unnecessary Antibiotic Use and Improve Outcomes • Febrile Neutropenia Admission Orders • PH7 01 003 Renal Dosing and Antimicrobial Optimization Protocol • Oncology antimicrobial prophylaxis protocol 42 | Lee Health - Antimicrobial Stewardship Program

IDSA/SHEA Guidelines for Implementing an Antimicrobial Stewardship Program Recommendation Lee Health Evidence of Compliance Implementation of ASP Interventions to Improve Appropriate Prescribing of Antifungal Treatment in Immunocompromised Patients • Orders for antifungal therapy are prospectively reviewed by clinical pharmacists • PH7 01 003 Renal Dosing and Antimicrobial Optimization Protocol • Fungitell and Galactomannan assays • T2 Candida assay Implementation of Antibiotic Stewardship Interventions in the NICU • Prospective review of antibiotic orders in the NICU by an ASP team member or clinical pharmacist • Routine update of NICU order sets containing antibiotics o NICU Admission Orders o NICU Ampicillin/Gentamicin Orders Implementation of Interventions to Reduce Antibiotic Therapy in Terminally Ill Patients • Prospective audit and feedback • End of life order set 2023 Annual Report and 2024 Future Directions | 43

Education and Professional Involvement The Dose of Infectious Diseases and The Dose of Pediatrics Newsletter The stewardship program provides education to our system’s clinicians via the Dose of Infectious Diseases newsletter, which is published on an approximately quarterly basis and is facilitated by the Lee Health Pharmacy Residency Program. The pediatric pharmacy residency program also produces an educational newsletter and often encompasses topics related to infectious diseases, edited by our antimicrobial stewardship pharmacist and infectious diseases physicians. This newsletter covers antimicrobial pharmacotherapy topics of interest to the Lee Health system and patient population and is evidence-based in its writing. The primary audience of the newsletter is physicians, pharmacists, and advanced clinicians. Volume 8 (2022-2023) of the Dose of Infectious Diseases covered the following topics: • Pathogen versus Contaminant in Blood Cultures • Stenotrophomonas maltophilia Infections • Treatment of Pseudomonas Infections • Reported Penicillin Allergies and How to Manage Them • Treatment of Aspiration Pneumonia Volume 6 (2022-2023) of the Dose covered the following ID-related topics: • Invasive Candida Infections in Neonates • Treatment of Neonatal Ventriculitis • Primary Amebic Meningoencephalitis Caused by Naegleria fowleri ACPE/CME Presentations The Lee Health Pharmacy Residency Program also facilitates continuing education presentations that typically focus on evidence-based overviews or updates in the management of disease states in a variety of clinical practice areas. Each pharmacy resident provides 1-2 ACPE-accredited presentations to pharmacy staff members annually. Some of these presentations are additionally offered as CME credits for providers. The following ID-related topics were presented in 2023: • Cefepime-Induced Neurotoxicity (ACPE and CME) • Overview of Guideline Directed Treatment Against Malaria (ACPE) 44 | Lee Health - Antimicrobial Stewardship Program

Pharmacist Education: Infectious Diseases Competency The 2023 Infectious Diseases/Microbiology competency for pharmacists centered around principles for being an antimicrobial steward. This competency aimed to guide pharmacists in identifying their role in making antimicrobial stewardship recommendations, appraising new literature on antimicrobial stewardship best practices, and formulating care plans for patients. Pharmacy PGY1/PGY2 Resident and Student Learning The stewardship program is heavily invested in the training of Lee Health’s pharmacy residents and 4th-year APPE students from Florida’s colleges of pharmacy. Trainees make up an integral part of the stewardship team and are crucial to the day-to-day work of antimicrobial stewardship at Lee Health. Learner summary for 2023: • PGY1 resident rotations: 9 • PGY2 resident rotations: 7 • Pharmacy APPE student rotations: 3 In 2023, the adult ID pharmacists combined precepted a total of 18 weeks of pharmacy student APPE rotations, and 64 weeks of pharmacy resident rotations. Our pharmacy trainees assist with prospective audit and feedback of antimicrobial utilization, as well as administrative antimicrobial stewardship projects as applicable (treatment pathways, formulary reviews, order sets, policies, etc.) Our PGY2 pharmacy residents have the opportunity to round with the ID consult service physicians to deepen their knowledge of complex disease state management, as well as provide drug therapy information and expertise to support the practice of Lee Health’s ID clinicians. National Poster Presentations ■ Chandler E, Cubillos A, Ducas S, Reyes I, Stedcke J, Saunders M. Implementation of a Nursing and Certified Nursing Assistant Antimicrobial Stewardship Competency-Based Educational Model at a Community Health System. Poster Presentation at ID Week, October 2023. Boston, MA. ■ Castell J, Jacinto G, Chandler E, Uzoma J, Whitley E. Evaluation of Linezolid Restriction Criteria in a Community Health System. Poster Presentation at ASHP Midyear. December 2023, Anaheim, CA. ■ Johnson K, Stanciauskas C, Vincent M. Assessment of Community-Acquired Aspiration Pneumonia Antibiotic Treatment in the Intensive Care Unit. Poster Presentation at ASHP Midyear. December 2023, Anaheim, CA. 2023 Annual Report and 2024 Future Directions | 45

Contagion Live Publications ■ Joy Uzoma June 2023: https://www.contagionlive.com/view/challenging-the-status-quo-oral-transitional-therapy-forinfective-endocarditis ■ Gerard Jacinto August 2023: https://www.contagionlive.com/view/using-cefazolin-in-patients-withb-lactam-allergies-forsurgical-prophylaxis- ■ Liz Chandler September 2023: https://www.contagionlive.com/view/in-the-aftermath-post-hurricane-infections ■ Cheryl Wood November 2023: https://www.contagionlive.com/view/new-fecal-microbiota-options-for-prevention-ofrecurrent-clostridioides-difficile Professional Presentations ■ FSHP Annual Meeting: Infectious Disease After Natural Disasters: Florida Hurricane Edition (ACPE) Liz Chandler US Antibiotic Awareness Week (USAAW) 2023 According to the CDC, “USAAW is an annual observance that raises awareness of the threat of antibiotic resistance and the importance of appropriate antibiotic use.” The antimicrobial stewardship program conducted an interdisciplinary health system wide initiative during this important week in November. The theme for 2023 was gram-negative resistance. Each day during USAAW, an Antimicrobial Trivia Question of the Day was emailed out to pharmacy, infection prevention, and infectious diseases providers and a Steward of the Day was awarded based on email submissions with antimicrobial stewardship interventions. Prizes were awarded to winners at the conclusion of USAAW. Pictured: Pharmacy Students and Residents participating in a group topic discussion 46 | Lee Health - Antimicrobial Stewardship Program

2024 Goals and Objectives The antimicrobial stewardship team is excited to pursue the following initiatives in 2024 to further the goals of the program. NHSN AUR IMPLEMENTATION • Implementation of NHSN AUR reporting • Utilize benchmarked metrics to assess Lee Health antimicrobial use ANTIMICROBIAL UTILIZATION AND OPTIMIZATION • Collaborate in development of antimicrobial recommendations for new Hospital at Home initiative • Monitor key quality metric for Antimicrobial Stewardship De-escalation pharmacy documented interventions • Initiation of dalbavancin process to facilitate transitions of care and positively impact length of stay • Implementation of interventions to stop unnecessary antibiotics in patients with C. difficile infection • S. aureus recommended ID consult for invasive infections and bacteremia • Go live of integrated vancomycin AUC calculator within the EHR • Surgical prophylaxis antibiotic optimizations • Change in linezolid restriction criteria based on MUE results • Aspiration community acquired pneumonia best practice advisory to reduce use of anaerobic coverage • Optimization of antifungal and antiviral providerselected indications • MUE/comparative research project regarding outcomes of antibiotic time out for target antimicrobials • Review current AMS list rules and optimize to enhance pharmacist workflow • Review of microbiology inbasket alerts to pharmacists to decrease alert fatigue MICROBIOLOGY COLLABORATIVE INITIATIVES • 2024 CLSI Breakpoint Review and Updates • Annual System antibiograms, including new antibiogram development for MDROs, Candida species, ED urine cultures, and outpatients • Gram negative resistance optimizations (carbapenemase testing, ampC organism reporting, implementation of new gram negative susceptibility cards) • Updates to Urinalysis with reflex to culture criteria to reduce the treatment of asymptomatic bacteriuria EDUCATION • ID Annual Competency for pharmacists • Educational Handouts to medical staff – pediatrics • Antibiogram Education for medical staff • ACPE/CME Presentations led by pharmacy residents • Attend and present AMS updates at hospitalist group meetings by campuses as needed • Medical staff newsletter education as needed • Update senior executives regarding yearly AMS initiatives and results • Ambulatory provider education/meetings as needed • PCS updates for nursing as needed 2023 Annual Report and 2024 Future Directions | 47

COMMUNITY ANTIMICROBIAL STEWARDSHIP PROGRAM • Ongoing monitoring and tracking of antimicrobial prescribing for acute respiratory tract infections in urgent care • SSTI smart set review and optimization • Creation and expansion of AMS initiatives for the ED • GI pathway review and update • Enrollment and participation in AHRQ safety program in ambulatory telemedicine • Creation of AMS initiatives focused on outpatient management of UTIs • Creation of outpatient ED antibiograms • Community outreach event – paired with antibiotic awareness week ORDER SET/POLICY/TREATMENT PATHWAY UPDATES • Desensitization order set updates • Antibiotic lock policy go live • Pneumonia pathway update • Skin and Soft Tissue pathway update • Urinary Tract Infection pathway update • Neutropenic prophylaxis guidance update • Surgical prophylaxis redosing update • COPD order set update PUBLICATIONS, RESEARCH, AND PROFESSIONAL DEVELOPMENT • Poster presentations at national meetings (MAD-ID) • IV Antibiotics in Acute Decompensated Heart Failure patients (accepted- pending publication) • Brucella endocarditis case report • Post-Hurricane Vibrio experience publication • Collaborative studies with Wayne State – Vabomere and Recarbrio PEDIATRIC ANTIMICROBIAL STEWARDSHIP • Update pre-op antibiotic recommendations to include neonatal specific procedures • Strep pharyngitis oral order panel • Modify dosing strategies for febrile neonate admission orders • Antibiotic lock panel in Epic • Renal dosing guidance 48 | Lee Health - Antimicrobial Stewardship Program