bluuebunny/crossref_metadata_2025 huggingface dataset:
Identifying Opportunities to Improve Accuracy of NHSN Reporting: Lessons Learned From State Health Department Validations.
Authors: Bagchi Suparna , Norrick Bonnie , Lewis Nigel
Published: November 2020

Background: State Health Departments (SHDs) have systematically studied the validity of healthcare-associated infection (HAI) surveillance data submitted by healthcare facilities in their jurisdictions to the Centers for Disease Control and Prevention’s (CDC’s) National Healthcare Safety Network (NHSN) for central-line–associated bloodstream infections (CLABSIs), catheter-associated urinary tract infections (CAUTIs), surgical site infections following colon and abdominal hysterectomy procedures (SSI COLO and HYST), methicillin-resistant Staphylococcus aureus and Clostridioides difficile laboratory identified (MRSA and CDI LabID respectively) events. These studies are a key source of information about data quality and completeness serving as an impetus and a guide for improving the caliber of NHSN’s HAI data. Methods: We contacted SHD HAI coordinators in all states for an inventory of HAI validation studies. We used data from these studies to calculate pooled mean sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) for HAI case determinations. HAI case reporting “error rates” were computed as the proportion of mismatches (underreport and overreport) among the medical records reviewed by SHDs and reasons for misclassification were categorized. Results: SHD validation studies varied by HAI type (range, 4 studies for MRSA LabID and 23 for CLABSI). Pooled mean sensitivity of HAI reporting ranged from 73.1% (COLO SSI) to 92.7% (CDI LabID). Pooled mean specificity and PPV exceeded 90% for all HAIs. LabID event validations demonstrated the lowest NPV (58.8% for MRSA and 55.1% for CDI). Error rates of HAI reporting to NHSN ranged from 2.5% (HYST SSI) to 13.6% (MRSA LabID). Common errors identified during CLABSI and CAUTI validations were incorrect application of general NHSN and CLABSI- and CAUTI-specific definitions. Incorrect secondary BSI attribution was the most frequently identified reason by CLABSI SHD validations (64.7%). Of all operative procedure-associated misclassifications, inconsistent surveillance practices (66.6%), incorrect NHSN operative procedure category assignment (55.5%), and misapplication of general organ-space and/or site-specific infection criteria (44.4%) were identified as the most common shortcomings. Among MRSA and CDI LabID validations, missed case finding due to failure to review candidate events and gaps in understanding the 14-day reporting rule of LabID protocol were identified as predominant reasons for inaccurate reporting. Conclusions: SHD HAI data validations identified specific targets for additional surveillance training, especially CLABSI determinations and application of the protocol rules for MDRO/CDI LabID case determinations. Further work is also needed to assure that data sources in addition to wound cultures are used for SSI determinations and that postdischarge SSI surveillance is more vigorous and comprehensive.

Funding: None

Disclosures: None
Validation of a Surgical Site Infection Detection Algorithm for Use in Cardiac and Orthopedic Surgery Research
Authors: Suzuki Hiroyuki , Balkenende Erin , Perencevich Eli , Clore Gosia , Richardson Kelly , Nair Rajeshwari , Goto Michihiko , Branch-Elliman Westyn , Gupta Kalpana , Sherlock Stacey Hockett , Schweizer Marin
Published: November 2020

Background: Studies of interventions to decrease rates of surgical site infections (SSIs) must include thousands of patients to be statistically powered to demonstrate a significant reduction. Therefore, it is important to develop methodology to extract data available in the electronic medical record (EMR) to accurately measure SSI rates. Prior studies have created tools that optimize sensitivity to prioritize chart review for infection control purposes. However, for research studies, positive predictive value (PPV) with reasonable sensitivity is preferred to limit the impact of false-positive results on the assessment of intervention effectiveness. Using information from the prior tools, we aimed to determine whether an algorithm using data available in the Veterans Affairs (VA) EMR could accurately and efficiently identify deep incisional or organ-space SSIs found in the VA Surgical Quality Improvement Program (VASQIP) data set for cardiac and orthopedic surgery patients. Methods: We conducted a retrospective cohort study of patients who underwent cardiac surgery or total joint arthroplasty (TJA) at 11 VA hospitals between January 1, 2007, and April 30, 2017. We used EMR data that were recorded in the 30 days after surgery on inflammatory markers; microbiology; antibiotics prescribed after surgery; International Classification of Diseases (ICD) and current procedural terminology (CPT) codes for reoperation for an infection related purpose; and ICD codes for mediastinitis, prosthetic joint infection, and other SSIs. These metrics were used in an algorithm to determine whether a patient had a deep or organ-space SSI. Sensitivity, specificity, PPV and negative predictive values (NPV) were calculated for accuracy of the algorithm through comparison with 30-day SSI outcomes collected by nurse chart review in the VASQIP data set. Results: Among the 11 VA hospitals, there were 18,224 cardiac surgeries and 16,592 TJA during the study period. Of these, 20,043 were evaluated by VASQIP nurses and were included in our final cohort. Of the 8,803 cardiac surgeries included, manual review identified 44 (0.50%) mediastinitis cases. Of the 11,240 TJAs, manual review identified 71 (0.63%) deep or organ-space SSIs. Our algorithm identified 32 of the mediastinitis cases (73%) and 58 of the deep or organ-space SSI cases (82%). Sensitivity, specificity, PPV, and NPV are shown in Table 1. Of the patients that our algorithm identified as having a deep or organ-space SSI, only 21% (PPV) actually had an SSI after cardiac surgery or TJA. Conclusions: Use of the algorithm can identify most complex SSIs (73%–82%), but other data are necessary to separate false-positive from true-positive cases and to improve the efficiency of case detection to support research questions.

Funding: None

Disclosures: None
A Machine-Learning Approach For Predicting Antibiotic Resistance in Pseudomonas aeruginosa
Authors: Magleby Reed , Simon Matthew , Calfee David , Zachariah Philip , Cohen Bevin , Cazer Casey , Wang Fei , Larson Elaine
Published: November 2020

Background:Pseudomonas aeruginosa is an important nosocomial pathogen associated with intrinsic and acquired resistance mechanisms to major classes of antibiotics. To better understand clinical risk factors for drug-resistant P. aeruginosa infection, decision-tree models for the prediction of fluoroquinolone and carbapenem-resistant P. aeruginosa were constructed and compared to multivariable logistic regression models using performance characteristics. Methods: In total, 5,636 patients admitted to 4 hospitals within a New York City healthcare system from 2010 to 2016 with blood, respiratory, wound, or urine cultures growing PA were included in the analysis. Presence or absence of drug-resistance was defined using the first culture of any source positive for P. aeruginosa during each hospitalization. To train and validate the prediction models, cases were randomly split (60 of 40) into training and validation datasets. Clinical decision-tree models for both fluoroquinolone and carbapenem resistance were built from the training dataset using 21 clinical variables of interest, and multivariable logistic regression models were built using the 16 clinical variables associated with resistance in bivariate analyses. Decision-tree models were optimized using K-fold cross validation, and performance characteristics between the 4 models were compared. Results: From 2010 through 2016, prevalence of fluoroquinolone and carbapenem resistance was 32% and 18%, respectively. For fluoroquinolone resistance, the logistic regression algorithm attained a positive predictive value (PPV) of 0.57 and a negative predictive value (NPV) of 0.73 (sensitivity, 0.27; specificity, 0.90) and the decision-tree algorithm attained a PPV of 0.65 and an NPV of 0.72 (sensitivity 0.21, specificity 0.95). For carbapenem resistance, the logistic regression algorithm attained a PPV of 0.53 and a NPV of 0.85 (sensitivity 0.20, specificity 0.96) and the decision-tree algorithm attained a PPV of 0.59 and an NPV of 0.84 (sensitivity 0.22, specificity 0.96). The decision-tree partitioning algorithm identified prior fluoroquinolone resistance, SNF stay, sex, and length-of-stay as variables of greatest importance for fluoroquinolone resistance compared to prior carbapenem resistance, age, and length-of-stay for carbapenem resistance. The highest-performing decision tree for fluoroquinolone resistance is illustrated in Fig. 1. Conclusions: Supervised machine-learning techniques may facilitate prediction of P. aeruginosa resistance and risk factors driving resistance patterns in hospitalized patients. Such techniques may be applied to readily available clinical information from hospital electronic health records to aid with clinical decision making.

Funding: None

Disclosures: None
A Simple Cleaning Intervention to Prevent Transmission of Carbapenemase-Producing Enterobacterales from Hospital Sinks
Authors: Kwong Jason , Leroi Marcel , Bannam Trudi , Edmonds Deidre , Grabsch Elizabeth , Narayanasamy Shanti , Greenough John , Lane Courtney , Easton Marion , Howden Benjamin , Johnson Paul , Grayson M.
Published: November 2020

Background: A prolonged outbreak of carbapenemase-producing Serratia marcescens (CPSM) was identified in our quaternary healthcare center over a 2-year period from 2015 through 2017. A reservoir of IMP-4–producing S. marcescens in sink drains of clinical hand basins (CHB) was implicated in propagating transmission, supported by evidence from whole-genome sequencing (WGS). We assessed the impact of manual bioburden reduction intervention on further transmission of CPSM. Methods: Environmental sampling of frequently touched wet and dry areas around CPSM clinical cases was undertaken to identify potential reservoirs and transmission pathways. After identifying CHB as a source of CPSM, a widespread annual CHB cleaning intervention involving manual scrubbing of sink drains and the proximal pipes was implemented. Pre- and postintervention point prevalence surveys (PPS) of CHB drains performed to assess for CPSM colonization. Surveillance for subsequent transmission was conducted through weekly screening of patients and annual screening of CHB in transmission areas, and 6-monthly whole-hospital PPS of patients. All CPSM isolates were assessed by WGS. Results: In total, 6 patients were newly identified with CPSM from 2015 to 2017 (4.3 transmission events per 100,000 surveillance bed days [SBD]; 95% CI, 1.6–9.4). All clinical CPSM isolates were linked to CHB isolates by WGS. The CHB cleaning intervention resulted in a reduction in CHB colonization with CPSM in transmission areas from 72% colonization to 28% (ARR, 0.44; 95% CI, 0.25–0.63). A single further clinical case of CPSM linked to the CHB isolates was detected over 2 years of surveillance from 2017 to 2019 following the implementation of the annual CHB cleaning program (0.7 transmissions per 100,000 SBD; 95% CI, 0.0–3.9). No transmissions were linked to undertaking the cleaning intervention. Conclusions: A simple intervention targeted at reducing the biological burden of CPSM in CHB drains at regular intervals was effective in preventing transmission of carbapenemase-producing Enterobacterales from the hospital environment to patients over a prolonged period of intensive surveillance. These findings highlight the importance of detailed cleaning for controlling the spread of multidrug-resistant organisms from healthcare environments.

Funding: None

Disclosures: Jason Kwong, Austin Health
Association Between Federal Value-Based Incentive Program Implementation and Hospital-Onset C. difficile Infection Rates
Authors: Alrawashdeh Mohammad , Rhee Chanu , Hsu Heather , Lee Grace
Published: November 2020

Background: The Hospital-Acquired Conditions Reduction Program (HACRP) and Hospital Value-Based Purchasing (HVBP) are federal value-based incentive programs that financially reward or penalize hospitals based on quality metrics. Hospital-onset C. difficile infection (HO-CDI) rates reported to the CDC NHSN became a target quality metric for both HACRP and HVBP in October 2016, but the impact of these programs on HO-CDI rates is unknown. Methods: We used an interrupted time-series design to examine the association between HACRP/HVBP implementation in October 2016 and quarterly rates of HO-CDI per 10,000 patient days among incentive-eligible acute-care hospitals conducting facility-wide HO-CDI NHSN surveillance between January 2013 and March 2019. Generalized estimating equations were used to fit negative binomial regression models to assess for immediate program impact (ie, level change) and changes in the slope of HO-CDI rates, controlling for each hospital’s predominant method for CDI testing (nucleic acid amplification including PCR (NAAT), enzyme immunoassay for toxin (EIA), or other testing method including cell cytotoxicity neutralization assay and toxigenic culture). Results: Of the 265 study hospitals studied, most were medium-sized (100–399 beds, 55%), not-for-profit (77%), teaching hospitals (70%), and were located in a metropolitan area (87%). Compared to EIA, rates of HO-CDI were higher when detected by NAAT (incidence rate ratio [IRR], 1.55; 95% CI, 1.41–1.70) or other testing methods (IRR, 1.47; 95% CI, 1.26–1.71). Controlling for CDI testing methods, HACRP/HVBP implementation was associated with an immediate 6% decline in HO-CDI rates (IRR, 0.94; 95% CI, 0.89–0.99) and a 4% decline in slope per year-quarter thereafter (IRR, 0.96; 95% CI, 0.95–0.97) (Fig. 1). Conclusions: HACRP/HVBP implementation was associated with both immediate and gradual improvements in HO-CDI rates, independent of CDI testing methods of differing sensitivity. Future research may evaluate the precise mechanisms underlying this improvement and if this impact is sustained in the long term.

Funding: None

Disclosures: None
Comparison of Matched Patient Data for SSIs following Total Hip and Total Knee Arthoplasty: IPC Versus NSQIP Surveillance
Authors: Ellison Jennifer , Chakravorty David , Conly John , Kim Joseph , Litvinchuk Stacey , Pokhrel Arun , Shen Ye , Smith Christopher , Bush Kathryn
Published: November 2020

Background: In Alberta, Canada, surgical site infections (SSIs) following total hip and knee replacements (THRs and TKRs) are reported using the infection prevention and control (IPC) surveillance system, which surveys all THRs and TKRs using the NHSN definitions; and the National Surgical Quality Improvement Program (NSQIP), which uses different definitions and sampling strategies. Deterministic matching of patient data from these sources was used to examine the overlap and discrepancies in SSI reporting. Methods: A retrospective multisite cohort study of IPC and NSQIP superficial, deep, and organ-space THR/TKR SSI data collected 30 days postoperatively from September 1, 2015, to March 31, 2018 was undertaken. To identify patients with procedures captured by both IPC and NSQIP, data were cleaned, duplicates removed, and patients matched 1:1 using year of birth, procedure facility, type, side, date, and time. Positive and negative agreement were assessed, and the Cohen κ values were calculated. The definitions and data capture methods used by both IPC and NSQIP were also compared. Results: There were 7,549 IPC and 2,037 NSQIP patients, respectively, with 1,798 matched patients: IPC (23.8%) and NSQIP (88.3%). Moreover, 17 SSIs were identified by both IPC and NSQIP, including 9 superficial and 8 complex by IPC and 6 superficial and 11 complex by NSQIP. Also, 7 SSIs were identified only by IPC, of which 5 were superficial, and 36 SSIs were identified only by NSQIP, of which 28 were superficial (positive agreement, 0.44; negative agreement, 0.99; κ = .43). Excluding superficial SSIs, 7 SSIs were identified by both IPC and NSQIP; 3 were identified only by IPC; and 12 were identified only by NSQIP (positive agreement, 0.48; negative agreement, 1.00; κ = 0.48). Conclusions: THR/TKR SSI rates reported by IPC and NSQIP were not comparable in this matched dataset. NSQIP identifies more superficial SSIs. Variations in data capture methods and definitions accounted for most of the discordance. Both surveillance systems are critically involved with improving patient outcomes following surgery. However, stakeholders need to be aware of these variations, and education should be provided to facilitate an understanding of the differences and their interpretation. Future work should explore other surgical procedures and larger data sets.

Funding: None

Disclosures: None
Developing a Clinically Informed Compartmental Mathematical Model of Pediatric Norovirus Transmission—A Feasibility Study
Authors: O’Callaghan Kevin , Privette Grayson , Handy Lori , Sammons Julia , Levy Michael
Published: November 2020

Background: Norovirus causes a significant disease burden of 20 million cases per year in the United States. Hospitals and long-term care facilities constitute the most commonly reported settings for noroviral outbreaks and clusters and thus represent a critically important site for prevention. Our institutional surveillance and response system identified 10–14 clusters or outbreaks of gastrointestinal viral disease per year, predominantly affecting staff. We sought to develop a compartmental mathematical model to examine the potential efficacy of various infection control practices in the management of noroviral clusters. Methods: We developed a set of parallel compartments representing both patient and staff categories (nursing, nurse assistants, etc) involved in a prototypical outbreak, using a 38-bed mixed medium- and high-acuity medical unit as the model basis. A susceptible–exposed–infected–recovered/immune (SEIR) model structure was used (Fig. 1). We conducted interviews with infection preventionists and nursing management to parameterize the model with data on (1) staff-to-patient ratios, (2) staff-patient contact time, (3) staff-staff contact time, (4) spatial distribution of patient assignments, and (5) baseline and intraoutbreak infection prevention practices. With these data, we proceeded to develop submodels, building on the primary model, that examined the effects of additional parallel compartmentalization of granular groups of staff, including resident physicians, environmental services, and clinical nursing assistants. Model parameters for these subanalyses were informed by interviews with clinical experts and review of internal data. Results and Conclusions: An SEIR model was developed that allowed for examination of a modeled outbreak of norovirus and comparison with a known prior outbreak on the same modeled unit for fidelity. Submodeling was performed with more staffing detail, allowing for the addition of further parallel SEIR tracks that delineated more granular staffing patterns. Staff interviews proved critical in the parameterization of these submodels, allowing for a more faithful representation of real-world dynamics. This work, through modification of model parameterization, can be used to assess the efficacy of hypothetical infection control interventions (eg, earlier unit closure, longer staff furlough) in altering transmission dynamics during an outbreak.

Funding: None

Disclosures: None
Healthcare-Associated Infection Decisions of Antibiotic-Resistant Organisms: A Data Quality Review
Authors: Ellison Jennifer , Bush Kathryn , Chow Blanda , Hearn Kaitlin , Howatt Andrea , Leal Jenine , Shen Ye , Yuan Christopher
Published: November 2020

Background: Infection Prevention and Control (IPC) for Alberta Health Services and Covenant Health in the province of Alberta, Canada conducts surveillance for methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococcus (VRE) on all individuals admitted to acute-care and acute tertiary-care rehabilitation care facilities. Objective: The objective of this study was to determine the consistency and accuracy of infection decisions for MRSA and VRE. Methods: Surveillance cases of antibiotic-resistant organisms (AROs) collected using the provincial data entry surveillance platform between April 1, 2015, and March 31, 2017, across the province were reabstracted by infection control professionals and physicians using the NHSN infection definitions and compared to the original case severity decisions. Interrater agreement (Cohen’s ) and validity (sensitivity, specificity and predictive values) were calculated to compare the original and reabstracted infection decisions. Results: Collectively, 97% (87 of 90) of the IPC program staff and physicians who were initially invited re-abstracted 264 MRSA cases and 103 VRE cases within the review period. Provincially, 20% of the ARO cases reviewed (74 of 367) differed from the original infection decision. Among these 74 cases, 46 cases (34 MRSA and 12 VRE cases) changed from infection (original decision) to colonization (reabstracted decision) and 28 cases (21 MRSA and 7 VRE cases) changed from colonization to infection. The Cohen values for MRSA and VRE were 0.55 and 0.56, respectively, suggesting a moderate level of agreement for decisions made among IPC program staff. The sensitivity of the infection decision was higher with MRSA (86.5%) than for VRE (74.1%), meaning that there were more MRSA cases than VRE cases classified as infection in the original decision that remained infection following the review. Conclusions: Observed discordances on infection decisions were identified and may be attributed (1) to variations in the interpretation of the NHSN definitions, (2) to additional information that may have been available in the re-abstracted review compared to the original review, or (3) a difference in the information that was accessed to perform the original review compared to the reabstraction. This data-quality review provided an opportunity for IPC staff and physicians to become more familiar with infection definitions and such reviews will continue to be a regular process used to assess data quality within the IPC department.

Funding: None

Disclosures: None
Hepatitis A Virus Survival on Drug Paraphernalia
Authors: Medrzycki Magdalena , Purdy Michael A.
Published: November 2020

Background: The ongoing hepatitis A outbreak in the United States has concerned public health authorities since March 2017. The outbreak has already spread throughout 30 states and includes primarily homeless individuals and persons who use drugs, including persons who inject drugs (PWIDs). Contaminated drug injection paraphernalia and sharing of these items are suspected to be one of multiple causes of hepatitis A virus (HAV) transmission in those populations. Methods: We used a standard plaque assay to investigate HAV infectivity. Liquid suspensions of HAV were tested to examine the effects of time and temperature on viral infectivity. We also examined HAV survival on commonly used drug paraphernalia, such as needles, syringes, cookers, tourniquets, and cotton balls/filters frequently shared among PWIDs. We investigated the effect of low pH on HAV survival using citric acid, which is frequently used by PWIDs during dose preparation. We also compared the plaque assay results with those concurrently obtained by RT-PCR to establish whether viral HAV RNA levels could be used as surrogates for plaque assay results. Results: We found that HAV suspended in PBS at room temperature was able to infect FRhk4 cells for >17 weeks. HAV remained viable in syringes and needles (ie, semidry conditions) for up to 10 weeks depending on the size of the needles and the syringe dead volume. HAV survival in dry conditions on cooker, tourniquet, and cotton balls/filter surfaces did not exceed 4 weeks. HAV retained its infectivity for >10 weeks at pH as low as 2. PCR results suggest that RNA is amplified from both infectious and noninfectious HAV. Conclusions: Our findings show that HAV can survive and remain infective in the PWID setting for 4–10 weeks depending on the type of paraphernalia examined. These findings suggest that sharing drug paraphernalia by the homeless and PWIDs can potentially facilitate the transmission of HAV within these populations. Moreover, our results confirm that the plaque assay is currently the only reliable method to determine the infectivity of HAV in vitro.

Funding: None

Disclosures: None
Impact of Critical Care Consultation Requests for Avoidable Central Venous Catheters on Medical-Surgical Units
Authors: Tirumandas Madhuri , Madaline Theresa , Weston Gregory David , Jain Ruchika , Figueredo Jamie
Published: November 2020

Background: Although central-line–associated bloodstream infections (CLABSI) in US hospitals have improved in the last decade, ~30,100 CLABSIs occur annually.1,2 Central venous catheters (CVC) carry a high risk of infections and should be limited to appropriate clinical indications.6,7 Montefiore Medical Center, a large, urban, academic medical center in the Bronx, serves a high-risk population with multiple comobidities.8–11 Despite this, the critical care medicine (CCM) team is often consulted to place a CVC when a peripheral intravenous line (PIV) cannot be obtained by nurses or primary providers. We evaluated the volume of CCM consultation requests for avoidable CVCs and related CLABSIs. Methods: Retrospective chart review was performed for patients with CCM consultation requests for CVC placement between July and October 2019. The indication for CVC, type of catheter inserted or recommended, and NHSN data were used to identify CLABSIs. CVCs were considered avoidable if a PIV was used for the stated indication and duration of therapy, with no anatomical contraindications to PIV in nonemergencies, according to the Michigan Appropriateness Guide for Intravenous Catheters (MAGIC).6Results: Of 229 total CCM consults, 4 (18%) requests were for CVC placement; 21 consultations (9%) were requested for avoidable CVCs. Of 40 CVC requests, 18 (45%) resulted in CVC placement by the CCM team, 4 (10%) were deferred for nonurgent PICC by interventional radiology, and 18 (45%) were deferred in favor of PIV or no IV. Indications for CVC insertion included emergent chemotherapy (n = 8, 44%) and dialysis (n = 3, 16%), vasopressors (n = 3, 16%), antibiotics (n = 2, 11%) and blood transfusion (n = 2, 11%). Of 18 CVCs, 9 (50%) were potentially avoidable: 2 short-term antibiotics and rest for nonemergent indications; 2 blood transfusions, 1 dialysis, 2 chemotherapy and 2 vasopressors. Between July and October 2019, 6 CLABSIs occurred in CVCs placed by the CCM team; in 3 of 6 CLABSI events (50%), the CVC was avoidable. Conclusions: More than half of consultation requests to the CCM team for CVCs are avoidable, and they disproportionately contribute to CLABSI events. Alternatives for intravenous access could potentially avoid 9% of CCM consultations and 50% of CLABSIs in CCM-inserted CVCs on medical-surgical wards.

Funding: None

Disclosures: None
Impact of Removal of Automatic 7-Day Stop Orders for Inpatient Antimicrobials
Authors: Adu-Gyamfi Afia , Hamilton Keith , Cressman Leigh , Lautenbach Ebbing , Dutcher Lauren
Published: November 2020

Background: Automatic discontinuation of antimicrobial orders after a prespecified duration of therapy has been adopted as a strategy for reducing excess days of therapy (DOT) as part of antimicrobial stewardship efforts. Automatic stop orders have been shown to decrease antimicrobial DOT. However, inadvertent treatment interruptions may occur as a result, potentially contributing to adverse patient outcomes. To evaluate the effects of this practice, we examined the impact of the removal of an electronic 7-day ASO program on hospitalized patients. Methods: We performed a quasi-experimental study on inpatients in 3 acute-care academic hospitals. In the preintervention period (automatic stop orders present; January 1, 2016, to February 28, 2017), we had an electronic dashboard to identify and intervene on unintentionally missed doses. In the postintervention period (April 1, 2017, to March 31, 2018), the automatic stop orders were removed. We compared the primary outcome, DOT per 1,000 patient days (PD) per month, for patients in the automatic stop orders present and absent periods. The Wilcoxon rank-sum test was used to compare median monthly DOT/1,000 PD. Interrupted time series analysis (Prais-Winsten model) was used to compared trends in antibiotic DOT/1,000 PD and the immediate impact of the automatic stop order removal. Manual chart review on a subset of 300 patients, equally divided between the 2 periods, was performed to assess for unintentionally missed doses. Results: In the automatic stop order period, a monthly median of 644.5 antibiotic DOT/1,000 PD were administered, compared to 686.2 DOT/1,000 PD in the period without automatic stop orders (P < .001) (Fig. 1). Using interrupted time series analysis, there was a nonsignificant increase by 46.7 DOT/1,000 PD (95% CI, 40.8 to 134.3) in the month immediately following removal of automatic stop orders (P = .28) (Fig. 2). Even though the slope representing monthly change in DOT/1,000 PD increased in the period without automatic stop orders compared to the period with automatic stop orders, it was not statistically significant (P = .41). Manual chart abstraction revealed that in the period with automatic stop orders, 9 of 150 patients had 17 unintentionally missed days of therapy, whereas none (of 150 patients) in the period without automatic stop orders did. Conclusions: Following removal of the automatic stop orders, there was an overall increase in antibiotic use, although the change in monthly trend of antibiotic use was not significantly different. Even with a dashboard to identify missed doses, there was still a risk of unintentionally missed doses in the period with automatic stop orders. Therefore, this risk should be weighed against the modest difference in antibiotic utilization garnered from automatic stop orders.

Funding: None

Disclosures: None
Measuring the Cost of Overtesting and Overdiagnosis of Clostridioides difficile Infection
Authors: Madden Gregory , Smith David , Sifri Costi
Published: November 2020

Background:C. difficile is the leading healthcare-associated pathogen. The C. difficile real-time polymerase chain reaction (PCR) stool test, used by >70% of hospitals, is highly sensitive but cannot differentiate colonization from infection. Inappropriate C. difficile testing may result in overdiagnosis and unnecessary treatment. Healthcare costs attributed to C. difficile are substantial, but the economic burden associated with C. difficile false positives in colonized patients is poorly understood. C. difficile PCR cycle threshold (CT) is as an inverse proxy for organism burden; high CT (≥30.9) has a high (>98%) negative predictive value compared to the reference gold standard, thus is a marker of colonization. Conversely, a low CT (≤28.0) suggests high organism burden and high specificity for true infection. Methods: A propensity score matching model for cost per hospitalization was developed to determine the costs of a hospital stay associated with C. difficile and to isolate the financial impacts of both true C. difficile infection and false positives. Relevant predictors of C. difficile positivity used in the model were age, Charlson comorbidity index, white blood cell count, and creatinine. We used CT data to identify and compare 3 inpatient groups: (1) true CDI, (2) C. difficile colonization, and (3) C. difficile negative. Results: A diagnosis of C. difficile adds significantly (>$3,000) to unadjusted hospital cost compared to a negative result. Propensity-adjusted analyses demonstrated that C. difficile colonization was associated with significantly increased (median, $5,000) hospital cost whereas any positive or true diagnoses of C. difficile were not associated with increased cost. Colonized patients also had significantly higher lengths of stay (1 day) and cost per length of stay ($218 per day). Conclusions:This is the first C. difficile cost analysis to utilize PCR CT data to differentiate colonization. Surprisingly, patients with a high CT had disproportionately higher hospital costs compared to matched C. difficile–negative patients, which was not seen among patients with a low CT or with any positive result. We hypothesize that this unexpected finding may be due to misdiagnosis and mistreatment of diarrhea not caused by C. difficile or unadjusted factors associated with high cost and non–C. difficile diarrhea. In addition, the discrepantly high cost attributed to C. difficile diagnosis cited in the literature ($3,000–11,000 per hospitalized case) could be explained by the common use of administrative data to identify C. difficile cases and controls as opposed to our study, which directly linked cost data to C. difficile–positive and –negative test results.

Funding: None

Disclosures: None
Modified Veterans Health Administration Clostridioides difficile Infection (CDI) Prevention Bundle: Progress Over 8 Years Decreasing CDI Laboratory-Identified (LabID) Events at a Large Veterans Affairs Medical Center
Authors: Byers Patricia , Hunter Andrew , Young Edward J. , Almeida Sherri-Lynne , Stonecypher Karen , Chou Andrew
Published: November 2020

Background: In March 2012, the Veterans’ Health Administration (VHA) published the Guideline for the Prevention of Clostridium difficile infection (CDI) in VHA Inpatient Acute-Care Facilities, with a goal of 30% reduction of cases within 2 years. In March 2011, this facility, along with 31 others, served as a pilot site to develop the guidelines. Methods: The CDI prevention bundle was implemented to prevent new onset CDI cases in the facility with 4 core measures: (1) environmental cleaning (EMS), (2) hand hygiene, (3) contact precautions, and (4) cultural transformation. Education was provided to EMS staff, nursing, and care providers on the CDI case definition, criteria for testing, empiric isolation for patients with diarrhea, hand hygiene, and PPE to control spread. In 2014, antimicrobial stewardship was added, and within 5 years an algorithm for isolation and testing was published. Cases were reviewed weekly using TheraDoc software and were reported monthly to the national VHA Inpatient Evaluation Center (IPEC). Isolation was communicated using a ward roster/isolation list in TheraDoc for all unit champions to consult daily. CDI cases were classified using NHSN definitions for a laboratory-identified (LabID) event, recurrent cases, and community-onset cases. Real-time case review and weekly multidisciplinary case discussions identified opportunities for improved compliance with the core measures. Results: Over an 8-year period, CDI healthcare-onset LabID events decreased by 73%. The cases decreased from 149 to 40 over the 8-year period. The infection rate decreased 70% from 16.19 per 10,000 bed days of care in FY2011 (October 2010) to 4.88 in FY2019. The incidence of community onset infections increased from 75 in FY2011 to a high of 146 in FY2018 for a rate of 8.15 to 18.17. In FY2019, there was a decrease in both LabID events and community-onset cases to lows of 40 and 102, respectively. Inappropriate testing decreased by 84% from 50 in FY2011 to 8 in FY2019. Conclusions: A multidisciplinary team approach that included support from leadership and clinical providers as well as front line staff involvement, daily rounding, and case review by infection preventionists has reduced all CDI cases over an 8-year period using the modified VHA CDI bundle. TheraDoc enabled case review, correct isolation, changes to cleaning practices, and more appropriate lab testing. The antimicrobial stewardship program that includes clinical pharmacists working daily with providers was a strong driver for change.

Funding: None

Disclosures: None
Novel Method to Detect Cardiac Device Infections by Integrating Electronic Medical Record Text with Structured Data in the Veterans Affairs Health System
Authors: Mull Hillary , Stolzmann Kelly , Shin Marlena , Kalver Emily , Schweizer Marin , Branch-Elliman Westyn
Published: November 2020

Background: Cardiovascular implantable electronic device (CIED) infections are highly morbid, yet infection control resources dedicated to preventing them are limited. Infection surveillance in outpatient care is also challenging because there are no infection reporting mandates, and monitoring patients after discharge is difficult. Objective: Thus, we sought to develop a replicable electronic infection detection methodology that integrates text mining with structured data to expand surveillance to outpatient settings. Methods: Our methodology was developed to detect 90-day CIED infections. We tested an algorithm to accurately flag only cases with a true CIED-related infection using diagnostic and therapeutic data derived from the Veterans Affairs (VA) electronic medical record (EMR), including administrative data fields (visit and hospital stay dates, diagnoses, procedure codes), structured data fields (laboratory microbiology orders and results, pharmacy orders and dispensed name, quantity and fill dates, vital signs), and text files (clinical notes organized by date and type containing unstructured text). We evenly divided a national dataset of CIED procedures from 2016–2017 to create development and validation samples. We iteratively tested various infection flag types to estimate a model predicting a high likelihood of a true infection, defined using chart review, to test criterion validity. We then applied the model to the validation data and reviewed cases with high and low likelihood of infection to assess performance. Results: The algorithm development sample included 9,606 CIED procedures in 67 VA hospitals. Iterative testing over 381 chart reviewed cases with 47 infections produced a final model with a C-statistic of 0.95 (Table 1). We applied the model to the 9,606 CIED procedures in our validation sample and found 100 infections of the 245 cases identified by the model to have a high likelihood of infection We identified no infections among cases the model as having low likelihood. The final model included congestive heart failure and coagulopathy as comorbidities, surgical site infection diagnosis, a blood or cardiac microbiology order, and keyword hits for infection diagnosis and history of infection from clinical notes. Conclusions: Evolution of infection prevention programs to include ambulatory and procedural areas is crucial as healthcare delivery is increasingly provided outside traditional settings. Our method of algorithm development and validation for outpatient healthcare-associated infections using EMR-derived data, including text-note searching, has broad application beyond CIED infections. Furthermore, as integrated healthcare systems employ EMRs in more outpatient settings, this approach to infection surveillance could be replicated in non-VA care.

Funding: None

Disclosures: None
Parental Knowledge, Attitudes, and Practices Regarding Antibiotic Use: A Cross-Sectional Study in Bangladesh
Authors: Harun Golam Dostogir , Haider Romel , Haque Imdadul , Chowdhury Alauddin , Islam Saiful
Published: November 2020

Background: Antibiotics play a vital role in reducing the morbidity and mortality associated with common infectious among children aged <5 years. Objective: We assessed the parental knowledge, attitudes, and practices regarding antibiotic use among a low-income urban population in Bangladesh. Methods: A cross-sectional study was conducted among the parents of 516 low-income urban children aged <5 years in Bangladesh from February 2018 to April 2019. A semi-structured questionnaire was developed and administrated to explore parental knowledge, attitudes, and practice regarding antibiotic use. A logistic regression analysis and Spearman rank-order correlation was used to compare and evaluate possible associations regarding parental KAP on antibiotic use. Results: The mean age of the participants was 26.65 years (SD, 6.38) and average monthly income was US$195.00. Most respondents (437 of 516) were women. One-third of the participants had no formal education, and 64% had only 5 years of education. We categorized the knowledge, attitudes, and practice regarding antibiotic use into 3 categories: poor, moderate, and good. More than half (52%) of these parents had poor knowledge of antibiotic use, and 32% had moderate knowledge of antibiotic use. Overall, 55% of parental attitudes were moderate and 70% of antibiotic practices were moderate. However, only 16% respondents had good knowledge, 14% had good attitudes, and 14% had good practices regarding antibiotic use for their children. The study revealed that 41% of parents thought that their child could be treated with antibiotics without advice from a qualified doctor, and 71% of parents thought that a child with flu-like symptoms got better faster if antibiotics were used. Also, 54% thought that the antibiotics could be stopped as soon as the symptoms disappeared. In this study, only 40% of parents completed the full dose of antibiotics. Monthly family income (P = .005), father’s profession (P = .003), and parents’ education were significantly associated with antibiotic use to treat the child. Conclusions: Most participants’ knowledge, attitude, and practices regarding rational antibiotic usage was very poor. Awareness campaigns and implementation of education on how to purchase, use, and sell antibiotics is crucial to optimum the use of antibiotics in Bangladesh.

Funding: None

Disclosures: None
Pilot Survey for National Point Prevalence Study of Healthcare-Associated Infections in Acute-Care Hospitals in South Korea
Authors: Lee Ji Young
Published: November 2020

Background: The Korean National Healthcare-Associated Infections Surveillance System (KONIS) was established to conduct nationwide surveillance of device-associated healthcare-associated infections (HAIs) and surgical site infections annually in 2006. However, no surveillance on overall HAIs has been conducted. Objective: We conducted a point-prevalence survey of total HAIs to estimate the incidence rate of HAIs in acute-care hospitals in South Korea. Methods: We defined HAIs according to KONIS and NHSN criteria. In total, 29 acute-care hospitals including 9 tertiary-care hospitals (TCHs) and 20 secondary-care hospitals (SCHs) were recruited as representing the population of every metropolitan city and province in South Korea. Patients who stayed at the hospitals on August 1, 2018, were randomly selected: 100 for SCHs and 200 for TCHs. Their medical records were retrospectively reviewed for HAIs according to the NHSN criteria by the infection control nurses (ICNs) from each hospital. A web-based data collection and analysis program was developed, and participating ICNs were educated in a 1-day training course with pre- and postevaluations. They received continuous feedback of input data and questions through the web-based system during the study. To generate estimates of the incidence rate of HAIs, we converted prevalence to incidence using the formula of Rhame and Sudderth. Results: Of 4,296 patients, 133 had ≥1 HAI (3.1%). In total, 141 HAIs were identified: gastrointestinal infections (n = 30, 21.3%), bloodstream infections (n = 30, 21.3%), pneumonia (n = 29, 20.6%), urinary tract infection (n =26, 18.4%). Among the gastrointestinal infections, C. difficile infections were the most common (17.7%). Device-associated infections accounted for 34.8% of all HAIs. The overall incidence of HAIs in TCHs was 4.39%, which was a higher incidence than SCHs (3.76%). Intensive care units had 12.6% of HAIs, whereas general wards had 3.4%. HAI incidences were 5.7%, 2.8%, and 2.3%, respectively, for each of the medical wards, surgical wards, and pediatric wards. The 3 most common pathogens were Escherichia coli, Acinetobacter baumannii, and Enterococcus faecium. Conclusions: The prevalence of HAI in Korea is lower than in most Western countries. The HAI burden of Clostridium difficile infection is surprisingly high, which calls for prompt control at the national level. To obtain national-level data on HAI burdens, ongoing surveillance is needed.

Funding: None

Disclosures: None
Procalcitonin Use in a Large Community Healthcare System
Authors: Cooper Mandelin , Burgess Hayley , Cuthbert Jeffrey , Septimus Edward Joel , Signorelli Heather
Published: November 2020

Background:
Appropriate testing of blood procalcitonin (PCT) can potentially inform antibiotic de-escalation in patients with severe infections. When used along with observed clinical improvements, PCT testing can support antimicrobial stewardship. However, this testing must be used optimally to ensure that it is actionable, cost-effective, and provides patient benefit. Although this test is widely used, little is known about the appropriateness of this testing in select populations. Methods: In this retrospective review, we evaluated PCT monitoring patterns and appropriateness of use and relationship to antibiotic days of therapy in a system of community hospitals. We evaluated the use of PCT testing in patients with known confounders, namely pregnancy, chronic kidney disease, or neutropenia, which we classified as “inappropriate use” because these conditions can affect the interpretation of PCT results. We also evaluated the relationship between PCT testing and antibiotic days of therapy for patients with sepsis, pneumonia, or lower respiratory tract infections. Results: In a 1-year period, ∼206,302 PCT tests were performed at 146 facilities, an average of ∼1,413 per facility per year. Approximately 27.7% of these tests were given to patients who were pregnant or had a confounding comorbidity such as chronic kidney disease or neutropenia. Of these “inappropriate” tests, >90% were given to patients with chronic kidney disease. Older patients (aged 60–80 years, n = 93,021) were more likely to receive a PCT test while also having a confounding comorbidities; 24% of older patients with a PCT test also had chronic kidney disease. Of all patients with a PCT test and chronic kidney disease, ∼76% were also diagnosed with either sepsis, pneumonia, or lower respiratory tract infections. Conclusions: Confounding conditions can affect PCT levels independently of infection. Additionally, some clinicians use PCT tests as probes for other physiological maladies. This analysis demonstrated that there is opportunity for education about the appropriate use of this test, how to interpret results in the presence of confounding conditions, and how to transform PCT test results into actions that facilitate antimicrobial stewardship and better patient care.

Funding: None

Disclosures: None