bluuebunny/crossref_metadata_2025 huggingface dataset:
1954. In vivo Efficacy of Delayed Therapy with the Novel Inositol Acyltransferase Inhibitor Fosmanogepix (APX001) in a Murine Model of Candida auris Invasive Candidiasis
Authors: Wiederhold Nathan P , Najvar Laura K , Shaw Karen J , Jaramillo Rosie , Patterson Hoja P , Olivo Marcos , Catano Gabriel , Patterson Thomas F
Published: October 2019

Background

Candida auris is an emerging pathogen associated with antifungal resistance and high mortality. The novel antifungal manogepix (APX001A) prevents glycosylphosphatidylinositol-anchored protein maturation through inhibition of the inositol acyltransferase Gwt1 enzyme, and has demonstrated in vitro and in vivo activity against numerous pathogenic fungi, including C. auris. We evaluated the efficacy of the prodrug fosmanogepix (APX001) following delayed initiation of therapy in a murine model of C. auris invasive candidiasis.

Methods

Neutropenic outbred mice (10 per cohort) were inoculated intravenously with C. auris (minimum inhibitory concentrations [MICs]: manogepix 0.03 mg/mL, fluconazole >64 mg/mL, caspofungin 0.25 mg/mL).Treatment with placebo, fosmanogepix (104 or 130 mg/kg by intraperitoneal injection [IP] three times daily, or 260 mg/kg IP twice daily), fluconazole (20 mg/kg/day orally), or caspofungin (10 mg/kg/day IP) began 1 day later and continued for 7 days. Mice were followed post therapy until day 21 to assess survival. Kidneys and brains were collected on day 8, on the days that mice succumbed to infection, or on day 21. Fungal burden was assessed by colony-forming units (CFU).

Results

Survival was significantly improved at each dose level of fosmanogepix (median >21 days; 90–100%) and high dose caspofungin (>21 days; 90%) compared with placebo (5 days; 10%; P < 0.0001). On day 8 post-inoculation, kidney and brain fungal burdens were significantly reduced in mice treated with fosmanogepix 260 mg/kg BID compared with placebo and in kidneys of mice treated with caspofungin (Table 1). In the survival arm, fungal burden in kidneys and brains was significantly lower at each dose level of fosmanogepix and with high dose caspofungin compared with placebo. In contrast, no improvements in survival or reductions in fungal burden were observed with fluconazole.

Conclusion

Fosmanogepix demonstrated potent in vivo activity against invasive candidiasis caused by C. auris even with delayed initiation of treatment. Improvements in both survival and reductions in fungal burden within the kidneys and brains were observed. These data demonstrate the potential utility of fosmanogepix against C. auris infections.

Disclosures

All Authors: No reported Disclosures.
2851. Impact of Antimicrobial-Resistant Gram-Negative Bloodstream Infections on Outcomes Among Pediatric Hospitalizations in the United States, 2009–2016
Authors: Spaulding Alicen B , Watson David , Dreyfus Jill , Heaton Phillip , Kharbanda Anupam
Published: October 2019

Background

Antimicrobial-resistant (AMR) Gram-negative bloodstream infections (GNBSIs) are more challenging to treat and may be associated with higher rates of morbidity and mortality. However, no recent studies have assessed the impact of pediatric AMR GNBSIs on outcomes. This study’s objective was to analyze the impact of AMR GNBSIs on mortality, length of stay (LOS), and costs among pediatric hospital admissions in the United States.

Methods

We conducted a retrospective cohort study of patients ages < 19 from the Premier Healthcare Database (2009–2016) limited to hospitals reporting ≥4 years of blood culture data and to encounters with susceptibility testing among the five most common laboratory-confirmed GNBSIs. AMR was defined per pathogen according to Centers for Disease Control and Prevention criteria. Outcomes mortality, LOS, and total patient encounter costs were compared between AMR and susceptible GNBSIs using Bayesian hierarchical regression modeling, which allowed us to analyze outcomes at the pathogen-level and to incorporate adjustment for confounding factors in order to produce risk-adjusted average differences or risk ratios (RR), and corresponding 95% credible intervals (CrI).

Results

Among 1,279 GNBSI encounters with susceptibility testing from 104 hospitals, 153 (12%) were AMR, but varied by pathogen. AMR GNBSI occurred more often among non-neonates (62% vs. 51%); non-neonates more often had hospital-acquired infections (27% vs. 13%) or were transferred from a healthcare facility (16% vs. 10%) vs. susceptible GNBSIs. The adjusted RR for mortality was 1.31 (95% CrI 0.62, 3.07) and adjusted average differences for LOS were 6.8 days (95% CrI: −0.3, 16.3) and for cost $23800 (95% CrI $400, $53900) comparing AMR to susceptible GNBSIs.

Conclusion

This study analyzed the impact of AMR GNBSIs, which were rare, on pediatric patient outcomes using laboratory-confirmed GNBSIs with susceptibility results and advanced statistical methods, finding the greatest impact of pediatric AMR on costs. Knowing the impact of AMR GNBSIs can help improve management of these serious infections, increase clinician and patient awareness of the issue, and further strengthen evidence for justifying pediatric antimicrobial stewardship.

Disclosures

All Authors: No reported Disclosures.
2857. A Statistical Model to Predict Invasive Fungal Disease in Pediatric Cancer and Hematopoietic Stem Cell Transplantation Patients
Authors: Alali Muayad , Kumar Madan
Published: October 2019

Background

Invasive fungal diseases (IFDs) are devastating opportunistic infections that result in significant morbidity and death in pediatric cancer and hematopoietic stem cell transplantation (SCT) patients. Identification of risk factors for IFD will help clinical decisions relevant to the diagnosis and management of IFD in a timely manner. Despite this, data evaluating prediction risk tools for IFD in pediatric cancer are limited.

Methods

We conducted a retrospective review of pediatric oncology patients with a diagnosis of febrile neutropenia (FN) at UChicago Comer Children’s Hospital from July 2009 to December 2016. We analyzed 13 clinical, laboratory, and treatment-related risk factors for IFD including (age, gender, underlying diagnosis, SCT status, graft vs. host disease, chemotherapy in the last 2 weeks, temperature, height, fever duration, presence of hypotension, absolute neutrophil count, duration of neutropenia, absolute monocyte count, and the absolute lymphocyte count (ALC)). IFD was stratified as possible, probable, and proven according to the latest EORTC/MSG criteria (2008). Multivariable logistic regression risk prediction models were developed with separate analyses for all suspected IFD cases and only proven and probable cases.

Results

A total of 667 FN episodes (FNEs) were identified in 265 patients. IFD was diagnosed in 62 episodes (9.2%) of which 13 (1.9%) were proven, 27 (4%) probable, and 22 (3.3%) possible. Five variables obtained were signiﬁcantly more common in IFD. Patients presenting with hypotension and fever >5 days were highly associated with IFD (P < 0.001). SCT receipts (P < 0.01), neutropenia longer than 10 days (P = 0.02), and ALC <300 mm3 at time of presentation (P = 0.03) were additional risk factors. The final model performs very well compared with other published models with a receiver operating characteristic–area under the curve (ROC-AUC) of 86.5 for all IFD cases and ROC-AUC of 84.5 for proven, probable IFD cases.

Conclusion

Our findings showed important clinical markers for the development of IFD in pediatric oncology patients. A predictive regression model including identified significant factors has been created. Risk stratification with prospective external validation using this model can be used to refine the clinical approach.

Disclosures

All Authors: No reported Disclosures.
2888. STAT4 Mutation in Three Generations with Disseminated Coccidioidomycosis (DCM) also Exhibits Increased Susceptibility to Coccidioidal Infection in Transfected Mice
Authors: Powell Daniel A , Shubitz Lisa F , Hsu Amy , Davis Joie , Holland Steven M , Berghout Joanne , Lussier Yves A , Frelinger Jeffrey A , Galgiani John N
Published: October 2019

Background

Reported coccidioidomycosis has increased with case rates of 198/100,000 in Arizona (2012). In California alone, 2000–2011 hospitalizations were $2.2B. Dissemination occurs in 8% of reports with significant morbidity and occasional deaths. DCM was found in 3 generations: grandmother (skin), mother (skin), and son (bone). Whole exome sequencing identified a heterozygous (het) STAT4 mutation (p.E626G) in all three. This mutation alters the phosphotyrosine binding pocket and is predicted to impair STAT4 function, interfering with (i) receptor binding and phosphorylation, (ii) nuclear localization, and/or (iii) transcription. Expression profiling of antigen-stimulated peripheral blood mononuclear cells from one patient showed dampening of known STAT4 targets compared with controls.

Methods

STAT4 p.E626G was generated and confirmed in C57BL/6NJ (WT) mice using CRISPR-Cas9. With continued breeding, neither homozygous (hom) nor het mice had gross abnormalities. There were normal spleen and lung lymphoid cell numbers. Thymus and bone marrow had normal development of lymphoid subsets. We performed intranasal infection with reduced virulence C. posadasii strain 1038 or with F. tularensis live vaccine- strain (LVS). Naïve or Δcps1-vaccinated mice were tested for resistance to C. posadasii strain Silveira.

Results

At day 21 post Cp 1038 infection, hom, het, and WT mice had similar lung fungal burdens (~104.7 cfu). All p.E626G mice died between days 31 and 39 with lung burden significantly higher (~9 × 106 cfu) than WT sacrificed on day 44 (7 × 105 cfu, P = 0.015). After LVS infection, p.E626G mice had increased lung bacterial cfu and all had dissemination to the spleen compared with WT lung bacterial burden and no splenic dissemination. Immunized het and WT mice all had significantly reduced lung cfu 14 days following C. posadasii infection compared with unvaccinated WT mice.

Conclusion

The STAT4 p.E626G mutated mouse recapitulated patients’ increased susceptibility to coccidioidal infection. The decreased fungal burdens seen in Δcps1-vaccinated mice suggest that vaccination may be effective in those persons genetically susceptible to DCM. Given the increasing frequency and economic burdens of coccidioidomycosis, pursuit of vaccination strategies should continue.

Disclosures

All Authors: No reported Disclosures.
1145. Reducing Antibiotic Use In Children With Respiratory Syncitial Virus-related Bronchiolitis: Implementation of TeamSTEPPS® 2.0 to Improve Pharmacy-Physician Communication in a Community Hospital Antibiotic Stewardship Program
Authors: Dutta Ankhi , Moffett Brady , Mobeen Samrah , Singh Amrita
Published: October 2019

Background

Overuse of antibiotics in Respiratory Syncytial virus (RSV) bronchiolitis in children has been reported between 29–80%. Our antibiotic stewardship program (ASP) utilized a validated communication tool using TeamSTEPPS ® 2.0 principles to improve pharmacy-physician communication and improve audit-feedback technique (AFT).

Methods

We trained pharmacists and physicians in TeamSTEPPS ® 2.0 using simulation-based training. The key component of the training was: closed-loop communication and using a scripted pharmacy communication tool. The scripted pharmacy communication tool was modified from the “DESC” script used in TeamSTEPPS ® 2.0, which includes (1) Describing the situation, (2) Expressing concern, (3) providing Solutions, (4) stating Consequences and coming to an agreement. We incorporated this to improve the audit-feedback technique. We aimed to: (1) Reduce overall percentage of antibiotic (abx) use in RSV bronchiolitis by 25%, (2) reduce use of ceftriaxone, (3) reduce average antibiotic days of therapy (DOT).

Results

Our baseline data from 2017–18 RSV season showed a 42% (48/113) use of abx, of which 10% were deemed inappropriate. When compared with the 2018–2019 season, no differences were noted in patient demographics. The median length of stay between the two time periods was similar (2.9 days, IQR 1.9–4.8 days vs. 3.1 days, IQR 2.1–5.1 days, P = 0.17). More patients were admitted to the pediatric intensive care unit (PICU) in the 2018–2019 period: 35/96 (36.4%) as compared with 17/113 (15%) in the previous season. Although similar proportions of patients received abx (42% vs. 41%) in the two groups (Figure 1), average abx DOT, significantly decreased in the 2018–2019 period as compared with 2017–2018 (Figure 2). There was also a decrease in the use of ceftriaxone during the 2018–2019 (Figure 3). All physicians and pharmacists were satisfied with the communication technique and thought that it improved their interaction and understanding of the ASP process.

Conclusion

Though we did not reduce the overall abx use in RSV bronchiolitis, we did reduce the average abx DOT and use of ceftriaxone in our institution. The use of a validated communication tool to improve prospective AFT was crucial to the success of the ASP program.

Disclosures

All authors: No reported disclosures.
1146. Antibiotic Use in Infants Predicts Asthma Rate in Children 1–4 years at Fine Geographic Scale
Authors: Mamun Abdullah A , Sbihi Hind , Turvey Stuart , Dai Darlene , Rose Caren , Rasali Drona , Marra Fawziah , Patrick David M
Published: October 2019

Background

Early-life exposure to antibiotics is associated with childhood asthma. We previously reported that a dramatic drop in infant antibiotic use is correlated with a decline in asthma incidence in children in British Columbia (BC). This study aims to see whether antibiotic exposure predicts asthma at a fine geographic scale after adjustment for known covariates.

Methods

We used prescribing data from BC PharmaNet, a population-based database capturing all outpatient prescribing for BC population (n = 4.7 million). Prescribing rates for infants <1 year were calculated as prescriptions per 1000 population per year using age and sex-specified denominator estimates. Age-adjusted aggregate asthma incidence data for children 1–4 years were obtained from the BC Ministry of Health Chronic Disease Registry. The disease identification uses a standard case definition making using of diagnostic codes (ICD9-493 and ICD10-J45) in BC’s universal hospital and physician billing databases and relevant asthma-specific drug data from BC PharmaNet. We modeled the association between antibiotic prescribing rate and asthma incidence in 91 Local Health Areas using multivariable Poisson regression employing a generalized linear mixed-effects model adjusting for covariates.

Results

Between 2000 and 2014, the annual asthma incidence (ages 1–4 years) fell 26% from 27.3 (95% CI: 26.5–28.0) to 20.2 (95% CI: 19.5–20.8) per 1000 population. For children aged 1–4 years in 2000, the average proportion of infants exposed to one or more courses of antibiotics fell from 66.9 to 32.1% over the same interval. Antibiotic was a significant predictor of asthma rate (IRR=1.24 per 10% absolute increase in antibiotic prescribing; 95% CI: 1.19–1.27). Other covariates that remained significant in the model included male sex (IRR=1.56; 95% CI: 1.53–1.58), and atmospheric particulate matter PM 2.5 (IRR=1.08 per interquartile increase; 95% CI: 1.06–1.10).

Conclusion

Our findings suggest that antibiotic exposure in the first year of life increases the risk of being diagnosed with asthma later in childhood. This is congruent with similar findings at the individual level in a prospective cohort of Canadian children that also points to a pathway through altered gut microbiota.

Disclosures

All authors: No reported disclosures.
1149. Reducing Piperacillin/Tazobactam Use in Children with Acute Perforated Appendicitis
Authors: Seddik Talal B , Bio Laura , Bassett Hannah , Contopoulos-Ioannidis Despina , Qureshi Lubna , Schwenk Hayden
Published: October 2019

Background

Children with perforated appendicitis have more frequent complications compared with nonperforated appendicitis. Existing data suggest broad-spectrum antibiotics are not superior to narrow-spectrum antibiotics for this condition. In an effort to safely decrease broad-spectrum antibiotic use at our hospital, we evaluated the impact of an antimicrobial stewardship program (ASP) intervention on the use of piperacillin/tazobactam (PT) and clinical outcomes in children with perforated appendicitis.

Methods

Single-center, retrospective cohort study of children ≤ 18 years with perforated appendicitis who underwent primary appendectomy. Children with primary nonoperative management or interval appendectomy were excluded. Prior to the intervention, children at our hospital routinely received PT for perforated appendicitis. An electronic health record (EHR)-integrated guideline that recommended ceftriaxone and metronidazole for perforated appendicitis was released on July 1, 2017 (Figure 1). We compared PT utilization, measured in days of therapy (DOT) per 1,000 patient-days, and clinical outcomes before and after the intervention.

Results

A total of 74 children with perforated appendicitis were identified: 23 during the pre-intervention period (June 1, 2016 to June 30, 2017) and 51 post-intervention (July 1, 2017 to September 30, 2018). Thirty-three patients (45%) were female and the median age was 8 years (IQR: 5–11.75 years). Post-intervention rate of guideline compliance was 84%. PT use decreased from 556 DOT per 1000 patient-days to 131 DOT per 1000 patient-days; incidence rate ratio of 0.24 (95% CI: 0.16–0.35), post-intervention vs. pre-intervention. There was no statistically significant difference in duration of intravenous antibiotics, total antibiotic duration, postoperative length of stay (LOS), total LOS, ED visits/readmission, or surgical site infection (SSI) between pre- and post-intervention periods (Table 1).

Conclusion

An EHR-integrated ASP intervention targeting children with perforated appendicitis resulted in decreased broad-spectrum antibiotic use with no statistically significant difference in clinical outcomes. Larger, multicenter trials are needed to confirm our findings.

Disclosures

All authors: No reported disclosures.
1151. A Comparison of Periurethral Cleaning Between Normal Saline and Savlon Solutions Before Indwelling Urinary Catheterization in Reducing Catheter-Associated Bacteriuria: A Randomized Controlled Study
Authors: Khahakaew Sarin , Suwanpimolkul Gompol , Wongkeskij Thanittha , Punakabutra Napawan , Suankratay Chusana
Published: October 2019

Background

Catheter-associated urinary tract infection (CAUTI) is one of the most common nosocomial infections. To date, there have been no randomized controlled studies to recommend the most appropriate antiseptic solution for periurethral cleaning before indwelling urinary catheterization. This study was aimed to compare normal saline solution (NSS) and Savlon solution for periurethral cleaning before indwelling urinary catheterization in reducing catheter-associated bacteriuria.

Methods

A randomized controlled, noninferiority, cross-over study to determine the incidence of significant bacteriuria (SB) on day 5 after Foley catheterization, using 2 different solutions for periurethral cleaning (NSS and Savlon solutions), was carried out in all adult patients admitted in the 2 medical intensive care units (ICUs), 1 surgical ICU, 2 neurosurgical ICUs, 4 medical wards, 4 surgical wards and 1 emergency room (ER) of King Chulalongkorn Memorial Hospital, Thailand, from June 2018 to March 2019. The acceptable prespecified noninferiority margin was set to be 10%. Each solution was used alternately every 3 months in each unit. Urine culture was collected on day 1, 3, and 5 of Foley catheter.

Results

During the study period, there were 207 and 160 patients in the NSS and Savlon groups, respectively. 202 (55%) patients had received Foley catheterization in the emergency room. There were no significant differences in the indication, the current illness, and preexisting condition between the 2 groups. The overall incidence of SB on day 3 and 5 after catheterization was 4% and 8.2%. The incidence of CAUTI was 3.43/1,000 catheter-day. The median duration of catheterization was 5 (IQR 3, 7) days. On day 5 after catheterization, noninferiority was demonstrated for the incidence of SB with an adjusted difference of 4 (95% CI of the difference: −2.1% to 8.9%, P = 0.05). Regarding the incidence of CAUTI, there was no significant difference between the 2 groups.

Conclusion

To the best of our knowledge, our study was the first randomized controlled study to compare the 2 solutions for periurethral cleaning before indwelling urinary catheterization in different departments. This study demonstrates the noninferiority of NSS to Savlon solution in reducing the incidence of SB.

Disclosures

All authors: No reported disclosures.
1158. Discontinuation of Urine Cultures by Infection Preventionists in Hospitalized Patients with Indwelling Urinary Catheters: Is It Safe?
Authors: Faith Monsalud Cherie , Lim Rachel , Zelencik Shane , Singh Kamaljit
Published: October 2019

Background

A majority of healthcare-associated urinary tract infections (UTIs) are caused by the use of urinary catheters (CAUTI). Finding of bacteriuria is common in catheterized patients and often leads to unnecessary antibiotic treatment, increased length of stay and additional healthcare costs. We implemented an innovative intervention to improve urine culture (UCx) orders and prevent overdiagnosis of CAUTIs.

Methods

Orders for UCx in adult patients with short-term urinary catheters at NorthShore University HealthSystem, IL were reviewed daily for appropriateness based on the Infectious Diseases Society of America Guidelines. Appropriate urine testing was defined as: (1) presence of fever ( >38°C) within past 48 hours, (2) new urinary complaints: flank or suprapubic pain/tenderness or dysuria, frequency, urgency or incontinence within 48 hours after catheter removal, and (3) no other reasonable explanation for fever. If UCx was deemed inappropriate, ordering provider was contacted to cancel the order. Chart review was performed at least 30-days post-discharge to determine whether patients developed recurrent UTI, sepsis, were readmitted or expired.

Results

Between 1 January to 31 March 2019, 65 UCx were submitted. Sixty-four patients (98%) did not meet criteria for testing. Most common reasons for not meeting criteria were absence of fever (60%) and no localizing UTI signs or symptoms (57%). 35 (54%) UCx were canceled after discussion with ordering providers. 21/35 patients (60%) were treated with antibiotics. All 35 patients were discharged, with a majority going to a skilled nursing facility (34%) or home (31%). 4/35 (11%) had a subsequent positive UCx. Two patients developed symptomatic UTI (sUTI) during the index admission. Two patients developed sUTI within 30-days post-discharge; one patient was transitioned to hospice after completion of therapy. All 4 patients were treated for sUTI.

Conclusion

We were able to safely discontinue UCx in 89% of patients. A majority of patients were already started on empiric treatment and development of subsequent sUTI was infrequent (11% of patients). Our findings suggest that discontinuation of inappropriately ordered UCx is safe with low risk for sepsis or mortality.

Disclosures

All authors: No reported disclosures.
1161. Frequency of Urine Cultures, their Positivity, and CAUTI: Analysis of a Large Health System
Authors: Fakih Mohamad G , Sturm Lisa K , Saake Karl , Daragjati Florian , Sebastian Danielle , Bufalino Angelo
Published: October 2019

Background

Hospitalized patients with bacteriuria are often identified based on positive urine cultures during the workup of urinary tract infection (UTI). However, the frequency of obtaining urine cultures varies between hospitals and may affect the detection of asymptomatic bacteriuria and symptomatic UTI.

Methods

We evaluated the frequency of urine cultures, their positivity and any association to CAUTI in the inpatient setting (excluding emergency department) of 53 hospitals during 2017 and 2018. Total inpatient urine cultures, positive urine cultures and positive urine cultures identified >2 days post-admission were normalized to patient-days. In addition, the rates of positive urine cultures >2 days post-admission were compared per institution to the corresponding CAUTI SIR. We compared small (75,000 patient-days per year).

Results

A total of 238,451 urine cultures were obtained in 53 hospitals over a period of 2 years with bacteriuria detected in 97,138 (40.74%). Hospitals varied in how often urine cultures were obtained, the % of positive urine cultures, and positive urine cultures per 10,000 patient-days (table). Medium size hospitals had significantly higher number of cultures per 10,000 compared with large hospitals (mean difference= 191; P = 0.006), while % positives were significantly lower (mean difference= -8.4; P = 0.02). There was no significant association between the rate of positive urine cultures >2 days after admission and CAUTI SIR (figure).

Conclusion

Our findings underscore the importance of addressing appropriate urine culturing as part of the infection workup in the hospital setting. A lower detection of bacteriuria after 2 days of admission did not necessarily result in a reduction of CAUTI, reflecting the importance of working on a better identification of patients likely to have a urinary tract infection.

Disclosures

All authors: No reported disclosures.
1171. Impact of Catheter Management on the Clinical Outcome in Adult Cancer Patients with Gram-Negative Bacteremia
Authors: Fares Johny , Khalil Melissa , Hajjar Chaftari Anne-Marie , Jiang Ying , Hachem Ray Y , Raad Issam I
Published: October 2019

Background

Over the last 2 decades, Gram-negative organisms have been on the rise as an etiology of bloodstream infections (BSI) in cancer patients. Management of the central venous catheter (CVC) in the setting of Gram-negative BSI remains challenging. The aim of our study was to evaluate cancer patients with different types of Gram-negative BSI, in the presence of an indwelling CVC, and assess the impact of line management on the outcome of the BSI.

Methods

We identified all the patients older than 14 years with CVC who had a documented BSI with a Gram-negative organism at M.D Anderson Cancer Center, from May 2017 until May 2018. Patients were divided into three groups. Group 1 (G1) included patients with central-line associated bloodstream infection and no mucosal barrier injury (non-MBI CLABSI) and/or those who met the catheter-related bloodstream infection (CRBSI) criteria; Group 2 (G2) consisted of patients who had a CLABSI with a mucosal barrier injury that did not meet the CRBSI definition; and Group 3 (G3) consisted of patients who had a non-line-related BSI. We assessed catheter management (CVC removed/exchanged or retained) at 2 days after the onset of bacteremia. We then determined the effect of line management on clinical and microbiologic outcomes through various measures.

Results

A total of 300 patients were included with 100 patients in each group. The univariate analyses showed that in G1, CVC removal within 2 days of bacteremia was significantly associated with higher rate of microbiologic eradiation of the bacteremia compared with delayed CVC removal (3 to 5 days) or CVC retention (98% vs. 72% vs. 78% respectively, P = 0.002; P < 0.001), and lower overall mortality rate at 3 months follow-up (3% vs. 22% vs. 17% respectively, P = 0.02; P = 0.01). By multivariate analysis, this association persisted (P = 0.018 and P = 0.016, respectively). CVC removal within 2 days of bacteremia did not affect the outcome of BSI in G2 and G3.

Conclusion

CVC removal within 48 hours of the onset of Gram-negative bacteremia significantly improved the infectious outcome and the overall mortality in adult cancer patients with definite CRBSI and CLABSI without MBI.

Disclosures

All authors: No reported disclosures.
1190. Hygiene of the Hands 90/90: A Program of Continuous Improvement for the Compliance of the Hygiene of the Hands
Authors: Trejo Roxana , Koretzky Solange G
Published: October 2019

Background

Healthcare-associated infections (HAIs) are associated with high rates of morbidity and mortality, which translates into an increase in the days of hospitalization and costs of care. The research of hand hygiene in health workers demonstrate that this action decreases the spread of pathogens; however, the compliance of hand hygiene remains low among health workers. Hand hygiene is a cheap method to prevent infections. It has been estimated that the total cost of hand hygiene promotion represents <1% of the costs associated with the HAIs. Our goal is to strengthen the culture of hand hygiene (In and Out) in all health professionals in a period of 90 days, achieving a 90% compliance.

Methods

The ABC Medical Center is a high specialty hospital, on average it has 465 beds. The program led by the Epidemiology Unit was formed by a multidisciplinary team with the patriation of leaders of different areas (Epidemiology, Nursing, Physicians, Human resources, Quality and Teaching). We used the “WHO Guidelines on Hand Hygiene in Health Care” consisting of: (1) system change, (2) training for employees, (3) evaluation and feedback, (4) a reminder at the workplace, (5) institutional security climate, (6) monitoring of the compliance to hand hygiene: The monitoring of the evaluation personnel was carried out in two stages, when entering and leaving the patient’s room.

Results

A total of 9,732 observations were made, of which 55.32% went to the nursing staff, 22.80% to doctors and 21.87% to the hospital staff. The compliance of the hand hygiene at the beginning of the program was 70%, by the and the 91% was reached. Sustainability has been maintained through continuous campaigns of the importance of hand hygiene reaching a 98% adherence to hands hygiene in 2018. The behavior of HAIs is notorious since at the beginning of the program there was a rate of 0.95 and by 2018, with the increase in compliance to hand hygiene, it decreased to 0.56.

Conclusion

The 90/90 Hand Hygiene program is a pioneer in its modality for the implementation of the program in a short period of time and excellence in its scope. It is confirmed that leadership is essential and strategic to ensure quality and safety in patient care. Through the incentive to the staff a clear sense of participation and belonging to the institution is achieved

Disclosures

All authors: No reported disclosures.
1191. Hand Hygiene Education: Why Is It so Critical to Tissue Banking?
Authors: Imrit-Thomas Kavita D , Watson Jasmine , Owens Alexandria
Published: October 2019

Background

In the United States, the most commonly transplanted tissues are bones, tendons, skin, heart valves, vessels and corneas. Over two million tissue grafts are distributed each year.Efforts to advance tissue transplant safety are less defined compared with organ transplant, and continuously being improved and regulated by national agencies. Environmental contamination, postmortem translocation of microorganisms, cross-contamination, and tissue processing are critical components which can be prevented with hand hygiene education thus preventing the transmission of infectious diseases. Microorganisms from technicians’ skin can potentially result in infection and nontransplantable tissue. This is particularly true of regenerative tissue, such as Vivigen, that undergo no sterilization process.

Methods

A review was done of all 2018 ViviGen culture with these organisms: Bacillus, Cornebacterium, Diptheroids, Propionibacterium, Staphylococcus Coagulase negative, and Streptococcus viridians defined as Category 1.

Results

In 2018, 384 out of 1418 ViviGen donors were discarded due to positive cultures. Of the 384, 190 were due the presence of a Cat. 1 microorganism in post-processing cultures, for a discard rate of 17.6%. In these donors, preprocessing cultures were initially negative, thus indicating contamination was due to technician contamination. In the first quarter of 2019, and since implementation of Hand Hygiene education, we have already start to see a decline in acquisition of Cat 1 organism for a total reduction of 6% from Q1 of 2018 compared with 2019.

Conclusion

Tissue banking is a complex process of many steps to assure quality and safety of the tissue. Contamination is critical even when the microorganisms are considered low-virulent skin flora (i.e., Cat 1). This is especially important if these Cat 1 organisms are found in Post-processing cultures of grafts not terminally irradiated or sterilized. Implementation of proper hand hygiene education and aseptic techniques among tissue recovery and processing staff can significantly reduce the bioburden. Furthermore, a reduction in bioburden equates to higher likelihood in honoring the gift of donation in this selfless act of the donor and their loved one while also decreasing the financial loss due to culture results.

Disclosures

All authors: No reported disclosures.
1192. A Visual Family Empowerment Tool Is Associated with Increased Healthcare Worker Hand Hygiene in a Pediatric Intensive Care Unit in Vietnam
Authors: Campbell Jeffrey I , Thanh Thuy Pham , Trang Le , Thi Thu Huong Dang , Chandonnet Celeste , Thi Hoa Truong , Duong Hao , Duc Duat Nguyen , Thi Huyen Le , Thi Ha Tran , Thi Kim Oanh Nguyen , Thi Minh Than Ho , Kien Ngai Le , Pollack Todd , Sandora Thomas
Published: October 2019

Background

Hand hygiene (HH) is the most effective way to prevent healthcare-associated infections. The World Health Organization (WHO) recommends empowering patients and families to remind healthcare workers (HCWs) to perform HH. The effectiveness of patient and family empowerment tools in Southeast Asia is unknown.

Methods

We performed a prospective intervention study in an intensive care unit of a pediatric referral hospital in Vietnam. Using family and HCW input, we created a visual tool for families to use to remind HCWs to perform HH. For 2 weeks pre-intervention, we collected baseline data on HH performance, method (hand rub or soap and water), adequacy, HCW type (e.g., physician, nurse), and WHO 5 moments of HH using direct, unobtrusive observation. During a subsequent 3-week intervention period, consenting families were provided the visual tool and educated on its use to prompt HCW HH. Prospective collection of outcome data continued during the intervention period. The primary outcome was change in HCW HH between baseline and intervention periods. Multivariable logistic regression models were used to identify independent predictors of HH.

Results

A total of 2,014 pre-intervention and 2,498 intervention period HH opportunities were observed. During the intervention period, 73 families received visual reminder tools and education. Overall HCW HH was 46% pre-intervention, which increased to 73% in the intervention period (P < 0.001). Lowest HH adherence in both periods occurred after HCW contact with patient surroundings (WHO Moment 5; 16% pre-intervention and 24% intervention). In multivariable analyses, the odds of HCW HH during the intervention period were significantly higher than pre-intervention (OR 2.94 [95% CI 2.54 – 3.41], P < 0.001) after adjusting for observation room, HCW type, time of observation (weekday business hours vs. evening/weekend), and HH moment. Among completed HH opportunities, HH adequacy was >90% in both periods.

Conclusion

Introduction of a visual empowerment tool was associated with significant improvement in HH adherence among HCWs in a Vietnamese pediatric intensive care unit. More research is needed to explore acceptability and barriers to the use of such tools in other low- and middle-income settings.

Disclosures

All authors: No reported disclosures.
1199. Provider Perspectives on Nonsterile Glove Use in the NICU
Authors: Khan Sarah , Science Michelle , Arnold Callum , Hawes Judith , Lee Kyong-soon , el Helou Salhab , Sanchez Pablo J , Mertz Dominik , Kaufman David
Published: October 2019

Background

Late-onset infection is a serious cause of mortality and long-term morbidity in NICU patients. Healthcare worker hands are the most common vehicle for transmission of pathogenic organisms to neonates. Studies have suggested a reduction in infections in neonatal and pediatric patients cared for with universal nonsterile glove use.

Methods

We developed an online survey (https://fhspeds.mcmaster.ca/pedsCapOne/surveys/?s=9RDX7EHT79) for clinicians to understand the current glove use and hand hygiene practices in NICUs in North America. The survey was sent to neonatologists and Pediatric Infectious Disease Specialists via the AAP Neonatal-Perinatal Section listserv, SHEA and the Canadian Neonatal Network.

Results

Of 336 responses; the majority were from physicians at level 3 to 4 NICUs (97%), and from the United States (96.1%). Beyond sterile procedures, sterile gloves were used for central line dressing changes (88.4%), contact with central nervous system shunts (61.0%), and direct contact with central lines (57.4%). Nonsterile gloves were used most commonly for universal precautions and diaper changes (Table 1). Almost half of participants also used nonsterile gloves for all patients and 37.5% for extremely low birth weight (<1000 g) infants. While most sites (76.8%) stated that nonsterile gloves were not required for parents, 15.8% requested gloves also for parents. 58% of respondents felt there was not enough evidence for a practice change at this time and 53.3% felt further study was needed to assess the effect of nonsterile gloves and infection (Figures 2 and 3). Almost a third of respondents (n = 109) would be interested in participating in a randomized study to assess glove-based care. Major concerns with this approach included a possible reduction in hand hygiene compliance, environmental waste, and glove contamination (Figure 4).

Conclusion

There is variability in gloving practices across NICUs in North America, with equipoise and interest in a potential randomized study to further explore the hypothesis that nonsterile gloves prevent late-onset infections in neonates.

Disclosures

All authors: No reported disclosures.
1214. Microbiological and Clinical Effectiveness of Pulsed-Xenon Ultraviolet Disinfection of the Patient Room in the ICU
Authors: Morikane Keita , Suzuki Shoko , Yoshioka Jun , Yakuwa Jun , Nakane Masaki
Published: October 2019

Background

Contact precautions do not necessarily control transmission of MDROs as other route of transmission such as patient environment may be significant. No-touch environmental disinfection has been highlighted in the past several years to control transmission of MDROs. The effectiveness of portable Pulsed Xenon Ultraviolet (PX-UV) device has been examined and demonstrated in US healthcare settings. However, its effectiveness outside the US healthcare setting is seldom reported.

Methods

This study was conducted in the intensive care unit (ICU) of Yamagata University Hospital, a 637-bed tertiary referral hospital. The ICU has six rooms and beds. In the baseline period (August 2016 to January 2018), all rooms were manually cleaned after every patient transfer/discharge. In the intervention period (February 2018 to February 2019), PX-UV disinfection was added after the manual cleaning. In both periods, all patients were screened for MRSA and two drug-resistant Acinetobacter baumannii (2DRA) to detect acquisition of those pathogens in the ICU. For microbiological evaluation, surfaces were selected for sampling by contact plates before/after manual cleaning and after PX-UV. After overnight incubation, colonies on the plates were counted.

Results

The incidence of newly acquired MRSA declined over time (1.40 per 1,000 patient-days in the baseline period to 0.95 in the intervention period, relative risk (RR): 0.68, 95% confidence interval (CI): 0.12–3.70). The incidence of newly acquired 2DRA further declined (4.91 to 1.90, RR: 0.39, 95% CI: 0.13–1.18). Notably, no new acquisition of 2DRA was observed since August 2018 for more than 7 months, not only in the ICU but also throughout the hospital. The total count of colonies in the sampling of 140 sites after 17 patient discharges were 3,540 (before manual cleaning), 669 (after manual cleaning, before PX-UV) and 261 (after PX-UV). The percent reduction of microbiological burden by manual cleaning was 81%, but a further 61% reduction was achieved by PX-UV.

Conclusion

PX-UV is effective in further reducing the microbial burden even after through manual cleaning, which presumably led to termination of transmission of 2DRA in our hospital. The effectiveness of PX-UV in controlling MDROs in the non-US healthcare settings is suggested.

Disclosures

All authors: No reported disclosures.
1223. Endoscopic Retrograde Cholangiopancreatography (ERCP)-Associated Carbapenem-resistant Enterobacteriaceae (CRE) Before and After Implementation of Ethylene Oxide (ETO) Sterilization of Duodenoscopes
Authors: Bonisa Kathleen , Neelakanta Anupama , Layell Jessica , Mclain Jessica , Lana Haecherl , Betts Wendy , Kester Shelley , Passaretti Catherine
Published: October 2019

Background

Reusable duodenoscopes utilized for Endoscopic Retrograde Cholangiopancreatography (ERCP) procedures are challenging to clean thoroughly. Outbreaks of carbapenem-resistant Enterobacteriaceae (CRE) have been associated with the use of duodenoscopes even when no clear breaches in manufacturer-recommended manual cleaning and high-level disinfection have been found. We evaluate the impact of implementation of ethylene oxide (ETO) sterilization on rates of ERCP-associated CRE.

Methods

The charts of all patients who developed CRE colonization or infection between 2012 and 2018 in a large tertiary care teaching hospital were reviewed to determine whether the patient had an ERCP in the 90 days prior to the CRE culture date. Rates of CRE acquisition per 100 ERCPs performed were calculated and compared pre (ERCP performed January 2012 through February 2015) and post-implementation (ERCP performed March 2015 thru December 2018) of routine ETO sterilization of duodenoscope following high-level disinfection (HLD) with an automatic endoscope reprocessor (AER) rather than HLD alone.

Results

Between 2012 and 2018, 44 patients had first clinical culture with CRE within 90 days of ERCP (36% blood, 34% wound/surgical, 25% urinary and 7% respiratory sources). ETO sterilization of duodenoscopes following manufacturer recommended HLD was implemented March 2015. Rates of first CRE clinical culture within 90 days of ERCP decreased from 0.80 with HLD alone to 0.25 per 100 ERCP procedures with HLD plus ETO (unadjusted IRR 0.31 ETO vs. HLD alone, 95% CI 0.16–0.57, p-value < 0.001). This decrease occurred despite implementation of updated CLSI carbapenem breakpoints in July 2016. Figure 1 shows post ERCP CRE clinical culture trends over time

Conclusion

Implementation of ETO sterilization for duodenoscopes following HLD reduced our rates of post ERCP CRE in clinical cultures within 90 days of the procedure.

Disclosures

All authors: No reported disclosures.
1225. How Frequently Should Sink Drains Be Disinfected?
Authors: Ramos-Castaneda Jorge A , Faron Matthew L , Hyke Joshua , Buchan Blake W , Nanchal Rahul , Pintar Paula , Beth Graham Mary , Huerta Susan M , Bell-Key Dominique , Silvia Munoz-Price L
Published: October 2019

Background

New evidence shows the relevance of sink drains in the horizontal transmission of multidrug-resistant organisms. We recently demonstrated that a peroxide-based disinfectant (product B) was better than bleach at disinfecting sink drains; however, we did not determine the duration of this effect. In this study, we evaluate the duration of bacterial reduction in sink drains treated with product B and compared it to an enhanced hydrogen peroxide agent (product A).

Methods

Testing was performed in a 26-bed medical intensive care unit at a 566-bed tertiary care hospital in Milwaukee, WI. Two disinfectants were compared: product A (hydrogen peroxide, octanoic acid, and peroxyacetic acid; Virasept, Ecolab) and product B (hydrogen peroxide-based disinfectant; Peroxide Multi Surface Cleaner and Disinfectant, Ecolab). Sinks were randomly assigned to product A, product B, and control (no disinfection). On day 0, baseline cultures were obtained and disinfectant agents were applied. On post-intervention days 1, 3, 5, and, 7, samples from each drain were collected using E-swabs (Copan, Italy). Quantitation of Gram-negative burden was determined by serial dilution in saline plated to MacConkey agar and dilutions that contained 20–200 colonies were used for bacterial colony-forming units (CFU).

Multivariate multiple linear regression and analysis of variance were used to compare mean Ln(1+CFU) between groups using R v3.5.0. Environmental sampling, cultures, and statistical analyses were performed blinded to the disinfected used.

Results

All three groups had similar CFU counts at baseline (P > 0.05). On day 1, a statistically significant reduction in bacterial CFUs was observed in the group treated with product A compared with sinks treated with product B (P = 0.04) or the control group (P < 0.01). The same differences were observed on day 3 post-intervention. There were no significant reductions on days 5 and 7.

Conclusion

Product A was the most effective product at disinfecting sink drains but its effect disappeared at 5 days post-disinfection. These results suggest that treating sink drains every 5 days with a hydrogen peroxide mixture would be ideal for healthcare facilities dealing with sink drain contamination.

Disclosures

All authors: No reported disclosures.
1234. Mental Models of Surgical Site Infection Prevention Among Surgical Technicians and Nurses
Authors: Pop-Vicas Aurora E , Young Amanda , Knobloch Mary-Jo , Safdar Nasia
Published: October 2019

Background

Surgical site infections (SSI) are common and costly. Institutions have implemented complex prevention bundles to reduce SSI, but adherence remains challenging. Understanding clinicians’ mental models related to SSI prevention can help develop strategies to improve adherence.

Methods

We conducted focus groups with surgical clinicians at a tertiary care center. We used constructs from behavior change theories to analyze responses and identify relevant themes for SSI prevention.

Results

We had 19 participants (10 nurses, 9 surgical technicians) in 4 focus groups. We found the following SSI prevention challenges: (1) emphasis on rapid patient turnover, which impairs ability to complete all required infection control tasks; (2) OR crowding and traffic, with increased risk to sterile technique breaks; (3) poor compliance with OR attire, including wearing scrubs outside of the hospital; (4) inadequate OR cleaning between cases; (5) lack of emphasis on post-discharge wound care instructions. The following beliefs were commonly expressed: (1) belief that some SSI are inevitable, due to increased complexity and duration of surgical procedures in a referral center; (2) perceived lack of knowledge and training on OR sterile technique among medical and nursing students; (3) perceived incorrect techniques for applying skin preps among surgical residents, and, occasionally, attendings; (4) fear and hesitancy to bring up OR irregularities if individual involved is perceived as having a “difficult personality,” irrespective of social hierarchy; (5) feeling overwhelmed by too many requirements for SSI prevention, which frequently change; (6) belief that some policies originate from outside influences and are not relevant to frontline clinicians; (7) frustration to receiving SSI performance feedback that is not individualized and lacks actionable items; (8) feeling “blamed” for having SSI without knowing “how to fix it”; (9) belief that training rigor and dedication to patient care have decreased over time, and are lax among younger generations. Representative quotes categorized according to behavior change constructs are shown in Table 1.

Conclusion

Addressing clinicians’ perceptions of SSI prevention may help improve adherence to the process and reduce SSI incidence.

Disclosures

All authors: No reported disclosures.