bluuebunny/crossref_metadata_2025 huggingface dataset:
Low function and frequent readmission in nursing home patients with persistent resistant gram-negative bacterial colonization
Authors: Mills John , Mantey Julia , Cassone Marco , Kaye Keith , Mody Lona
Published: May 2022

Background: Persistent colonization with resistant gram-negative bacteria (R-GNB) increases risk of clinical infection and intra-facility transmission among nursing home (NH) patients. Limited data exist on the roles of age and function on duration of R-GNB colonization. Methods: Secondary data analysis was performed from a cohort study of patients admitted to 6 Michigan NHs between November 2013 and May 2018. Swabs obtained upon enrollment, day 14, day 30, then monthly until NH discharge from 6 anatomical sites were cultured for GNB. R-GNB were defined as resistant to ciprofloxacin, ceftazidime, or imipenem. Positive R-GNB culture from a single visit followed by negative cultures for the same organism from ≥2 subsequent visits were defined as transient R-GNB colonization. All other patients with positive R-GNB cultures from multiple visits were considered persistently colonized. Demographic data, antibiotic use, device use, and physical self-maintenance scales (PSMSs) were obtained upon enrollment. Characteristics were compared between patients with transient versus persistent R-GNB and uncolonized patients using multinomial logistic regression. Results: We recruited 896 patients (median age, 75 years; 41% male; 46% nonwhite) and followed them for 2,437 total visits. Of 896 patients, 407 (45.4%) were colonized with ≥1 R-GNB during their stay. Of 171 patients with ≥ 2 follow-up visits after R-GNB detection, 94 (55%) remained persistently colonized with the same R-GNB (Table 1). Escherichia coli (30%) and Proteus mirabilis (22%) were the most frequently identified R-GNB. The most common anatomical colonization sites were perirectal (368 [24.3%] of 1,147) groin (340 [14.3%] of 2,046), and hands (115 [4.8%] of 2283). Compared to uncolonized patients, patients with persistent (1.09; 95% CI, 1.00–1.19, P = .048) and transient R-GNB colonization (1.13; 95% CI, 1.04–1.23; P = .003) had lower PSMS (Tables 2 and 3). Compared to uncolonized and transiently colonized patients, patients with persistent R-GNB colonization had prolonged lengths of NH stay (1.01; 95% CI, 1.00–1.01; P = .003). Conclusions: R-GNB colonization in vulnerable NH patients is common (407 [45.5%] of 896 and often persistent (94 [55%] of 171 patients with sufficient follow-up to assess persistence). Patients with persistent R-GNB had lower functional status, longer LOS, and higher readmission rates than those without. R-GNB decolonization should be investigated as a strategy to potentially improve outcomes among NH patients.

Funding: None

Disclosures: None
Targeted Staphylococcus aureus decolonization in acute inpatient and intensive care settings of an academic medical center
Authors: DiTullio David , Takats Courtney , Hochman Sarah
Published: May 2022

Background:Staphylococcus aureus is a common cause of healthcare associated infections and is associated with high mortality. S. aureus colonization of skin and mucosa contributes to its pathogenesis. Universal S. aureus decolonization reduces methicillin-resistant S. aureus (MRSA) and other bloodstream infections among ICU patients. However, universal decolonization in acute-care settings has not shown a similar benefit. We describe a targeted decolonization protocol implemented at a large academic hospital across acute-care and intensive care settings. We assessed the impact of decolonization on S. aureus–related infections. Methods: Adults admitted in 2018–2019 to the medicine, oncology, transplant, and ICU services were screened for S. aureus colonization using nasal swabs for MRSA/MSSA by culture. Those with S. aureus detected underwent decolonization with 5 days of chlorhexidine 2% baths and mupirocin intranasal ointment. Decolonization was considered complete if given for 5 days. The primary outcome was S. aureus invasive infection from hospital day 3 until discharge, defined by positive clinical cultures from sterile sites. Secondary outcomes included 30-day readmission and 30-day mortality. The control population was patients with negative MRSA/MSSA nasal screening in the same hospital units. Results: In total, 4,465 (23%) of 19,065 screening tests were positive for MSSA (75%) or MRSA (25%). The median age was 69 years (IQR, 56–80), and the median length of stay (LOS) was 6 days (IQR, 4–10). Among patients with LOS ≥3 days, 541 (16%) completed decolonization and 2,161 (64%) received no decolonization. The rate of complete decolonization increased to 35% among those with LOS ≥ 7 days. In total, 802 screened patients developed invasive S. aureus infections. Of 4,437 colonized patients, 536 (12%) had invasive infections, compared with 265 (2.1%) invasive infections in 12,917 noncolonized patients. Among patients with S. aureus colonization, 24% of decolonized patients developed invasive infection and 13% of patients who were not decolonized developed invasive infection. Rates of 30-day readmission and mortality were 28% and 10%, respectively, among fully decolonized patients, versus 20% and 6.6% among those receiving no decolonization. Conclusions: These data provide an assessment of the efficacy of a targeted screening and decolonization program. Although decolonization did not reduce rates of invasive infection or secondary outcomes, further analysis is needed. Patients with longer lengths of stay are more likely to receive full decolonization but are also at higher risk of invasive infection, which may contribute to our unexpected results.

Funding: None

Disclosures: None
Stethoscope hygiene, workflow, and patient safety: The crux of healthcare-associated infections
Authors: Peacock William , Kipper Stuart , Neath Sean-Xavier
Published: May 2022

Objective: We evaluated the impressions and perceived workflow consequences following installation of a touch-free aseptic stethoscope barrier dispenser in the clinical environment. Methods: Beginning in 2020, we conducted a volunteer survey of aseptic stethoscope diaphragm barrier (AseptiScope, San Diego, CA) users in multiple departments at 7 US healthcare facilities. A 10-question survey was presented on an iPad near the aseptic barrier dispenser, which was usually located in the patient exam room, to be available immediately after the practitioner completed their examination, which included the use of the stethoscope barrier. This evaluation was considered a quality improvement project and was exempt from institutional review board approval. For this analysis, only 1 survey per practitioner was included. Results: Overall, 147 surveys were obtained from 7 institutions geographically distributed across the United States, immediately after placement of the DiskCover system in the patient care environment. Responses were generally positive and included ease of use (95.2% rated easy or very easy), comparison to a disposable stethoscope (97.9% as similar to, improved over, or significant improvement), workflow changes (53.7% improvement, 97.3% no impact, or improved), and perceived effect on patient safety (90.3% felt that patient safety was improved or significantly improved). Conclusions: The use of a touch-free aseptic stethoscope barrier system was reported to be easy to use, superior to a disposable stethoscope, and an improvement to practitioner workflow and perceived patient safety.

Funding: AseptiScope, Inc.

Disclosures: None
Risk factors for candidemia: A case–control study
Authors: Erayil Serin Edwin , Tessier Katelyn , Kline Susan
Published: May 2022

Background:Candida bloodstream infections (candidemia) have significant mortality and morbidity rates, as well as healthcare cost implications. Emerging multidrug-resistant Candida spp such as Candida auris, as well as increasing resistance among non–albicans species, which are becoming more prevalent, also raise concern. Understanding the epidemiology of this infection could enhance prevention and management efforts. We studied risk factors for candidemia. Methods: This matched case–control study was conducted at a university hospital from December 2019 through May 2021. Cases of candidemia were identified using positive blood-culture results. Controls were matched 5:1 to cases by age, sex, and month and year of admission. Risk factors of interest included total parenteral nutrition (TPN), central venous access (CVA), neutropenia, Clostridium difficile, pancreatic disease, Candida in urine culture, cancer, invasive procedures, H2 blockers, chemotherapy, antibiotic use, immunosuppression, and antifungal use. Bivariate conditional logistic regression models were used to study the association of individual factors with candidemia. Multivariable conditional logistic regression models were performed using factors with a P Results: Overall, 101 patients with candidemia and 505 matched controls were included. In the bivariate analysis, associations were detected between candidemia and TPN, CVA, pancreatic disease, invasive procedures, H2 blocker use, antibiotic use, and antifungal use (all Ps Conclusions: Associations of candidemia with recent antifungal use and pancreatic disease were relatively novel findings. Neutropenia was not an independent risk factor for candidemia in this study. Future directions include further evaluations of previous antifungal use in patients with candidemia to identify opportunities for possible intervention and antifungal stewardship.

Funding: None

Disclosures: None
Learnings from a Cutibacterium acnes pseudo-outbreak in pediatric neurosurgical patients
Authors: Huang Felicia Scaggs , Ankrum Andrea , Hospital Cincinnati , Teoh Zheyi , Courter Joshua , Francesco  , Mangano  , Bierbrauer Karin , Josh
Published: May 2022

Background:Cutibacterium acnes is normal skin flora as well as a common culture contaminant. It can cause infections in the setting of sterile implants, although clinical presentations can be subtle. Differentiating true infection from sample contamination is challenging and has implications for patient care. We describe an investigation of a cluster of 7 hospitalized pediatric patients with C. acnes isolated from anaerobic cultures of cerebrospinal fluid (CSF) over 3 weeks at a quaternary-care children’s hospital. Methods: An outbreak response was coordinated between the infection prevention and control (IPC), microbiology, and neurosurgery teams. We defined a case as a hospitalized patient with C. acnes isolated from a CSF culture beginning in November 2020. We reviewed charts of all cases and CSF culture collection on all case units, transport to and processing at the microbiology laboratory, and the IPC team measured adherence for all processes. Results: There were 8 positive cultures in 7 cases from November 10 to 27, 2020. The median case age was 2 months (range, 0–119). Cases occurred on 4 different units. All positive patients had at least 1 implanted neurosurgical device used for CSF drainage. There were no clear commonalities in surgeon responsible for device placement, hardware type placed, or staff collecting CSF samples. A standard protocol for CSF collection was followed for all cases. Overall, 3 patients cleared cultures without intervention, 2 received oral antibiotics, and 2 underwent surgical removal of their device. Specimen processing was unchanged, although due to supply issues, an alternative anaerobic culture media (Anaerobic Systems, Morgan Hills, CA) was used for 6 weeks, during which all cases were identified. Compared to routine media, the alternative is known to enhance organism detection. The company reported no concerns for media contamination or C. acnes outbreaks. Once routine media became available, CSF culture positivity for C. acnes returned to baseline (late November or early December) (Fig. 1). Conclusions: We identified a likely pseudo-outbreak related to temporary use of a more sensitive culture media. No direct patient harm was identified, although many had increased risk of harm by surgical intervention or prolonged length of stay. Technological advances may enhance organism identification but challenge existing paradigms of care. More studies are needed to better delineate the intersection of diagnostic advancements with patient care standards.

Funding: None

Disclosures: None
Evaluation of an oral care bundle for reduction of nonventilator hospital-acquired pneumonia in a community hospital
Authors: Coury Elias , Dietz Shannon
Published: May 2022

Objectives: We sought to determine the relationship between an oral-care bundle that includes use of new oral care devices, education of best practices for performing oral care, and daily audits to measure compliance with oral care best practices and the reduction of nonventilator hospital-acquired pneumonia (NV-HAP) and NV-HAP–associated sepsis and mortality outcomes. Methods: Havasu Regional Medical Center (HRMC) is a 171-bed acute-care community hospital in Lake Havasu City, Arizona. The hospital inpatient units measured in this quasi-experimental study were the medical surgical telemetry ortho unit (MTSO), the intermediate care unit (IMC), and the ICU.

There were 30,838 hospital patient days in 2021. NV-HAP were captured as patients coded as an NV-HAP and being discharged in 2021. Sepsis was captured as sepsis being documented with the source being identified as a NV-HAP with a discharge date in 2021. Mortality was captured by coding of an NV-HAP and mortality with a time of death documented in 2021. Results: From January 1, 2021, to June 4, 2021, during the baseline period before the oral-care bundle was implemented, HRMC had 12,415 patient days and experienced a NV-HAP rate of 1.2 per 1,000 patient days and a sepsis rate of 0.56 per 1,000 patient days with the source documented as NV-HAP, and mortality rate of 0.32 per 1,000 patient days with a code of NV-HAP. HRMC used June 5, 2021, as their implementation period of the bundle, which included a new oral-care device, multilevel education to staff on best practices for oral care, and daily audits to measure compliance with oral-care best practices. During the postimplementation period, HRMC had 18,413 patient days, a NV-HAP rate of 0.54 per 1,000 patient days, a sepsis rate of 0.33 per 1,000 patient days with source documented as NV-HAP, and a mortality rate of 0.16 per 1,000 patient days with a code for NV-HAP. Conclusions: From June 5, 2021, to December 31, 2021, after the implementation of the oral-care bundle, the NV-HAP rate decreased by 58%, the sepsis rate with source documented as NV-HAP decreased by 41%, and the morality rate documented as NV-HAP decreased by 50%. Hospital infection control programs should consider implementation of a robust oral-care bundle that includes best-practices education and auditing to monitor staff compliance as a potential strategy to reduce NV-HAP.

Funding: None

Disclosures: None
Respiratory Virus infections in symptomatic and asymptomatic children: Results of one year of hospital admission screening
Authors: Most Zachary , Sebert Michael , Perl Trish
Published: May 2022

Background: Respiratory viral infections are very common among children. Transmission-based precautions are frequently used with patients who test positive for a respiratory virus in pediatric hospitals to prevent transmission of infections, regardless of whether the patient has symptoms of a respiratory infection or not (asymptomatic). However, few data are available on the prevalence of respiratory viral infections in symptomatic and asymptomatic children who are admitted to a pediatric hospital. The study was conducted in 3 hospitals that combine for a 601-bed pediatric healthcare system in northern Texas. Methods: From July 7, 2020, to the present, all patients admitted to the hospital had a nasopharyngeal swab collected and tested with a multiplex PCR panel including SARS-CoV-2 and 8 other common respiratory viruses. Over a 1-year period from October 1, 2020, to September 30, 2021, the prevalences of infection with each of the 9 respiratory viruses were calculated and stratified by respiratory infection symptom status (determined by the ordering provider in an electronic order set) and age group. Results: During this 1-year period, 28,421 PCR panels were collected on patients admitted to the hospital. The median age was 5 years (IQR, 1–12 years), and 15,105 patients were male (53.2%). Overall, 12,792 panels were positive for at least 1 virus (45.0%). Among 26,688 panels on individuals with known symptom status, 26.3% of asymptomatic patients and 69.4% of symptomatic patients tested positive for at least 1 virus. The most common virus was rhinovirus or enterovirus (17.7% asymptomatic positive and 40.2% symptomatic positive) (Fig. 1). Asymptomatic rhinovirus or enterovirus prevalence varied by age group and was greatest in children aged 1–4 years (31.7%) and those aged 5–9 years (23.1%). It was lowest in adolescents aged 15–21 years (7.1%) (Fig. 2). Over time, the prevalence of asymptomatic infections fluctuated with local outbreaks. For SARS-CoV-2, in the resolution phase of an outbreak the prevalence of asymptomatic infections tended to overlap or surpass symptomatic infections. Conclusions: Asymptomatic respiratory viral infections, and in particular rhinovirus or enterovirus infections, were common among pediatric patients admitted to the hospital during the COVID-19 pandemic and were most common among children aged 1–9 years. However, symptomatic patients were still more likely to test positive for a respiratory virus compared to asymptomatic patients. Prolonged shedding of SARS-CoV-2 may explain why asymptomatic prevalence surpasses symptomatic prevalence in the resolution phase after outbreaks.

Funding: None

Disclosures: None
Susceptibility results discrepancy analysis between NHSN Antibiotic Resistance (AR) Option and laboratory instrument data
Authors: Ouedraogo Youssoufou , Evans Christopher , Muleta Daniel , Wilson Christopher
Published: May 2022

Background: The NHSN Antibiotic Resistance (AR) Option can serve as a useful tool for tracking antibiotic-resistant infections and can aid in the development of inpatient antibiograms. We recently described the frequency of antibiotic suppression in NHSN AR Option data. In this analysis, we describe the effects of suppression on practical uses of the NHSN AR Option, specifically selected agent antibiogram development, and detection of reportable conditions. Methods: Antibiotic susceptibility data were collected from the NHSN AR Option and commercial automated antimicrobial susceptibility testing instruments (cASTI) from 3 hospital networks. Data were obtained from January 1, 2017, to December 31, 2018. The clinical susceptibility data for third-generation cephalosporins and carbapenems against carbapenem-resistant Enterobacterales (CRE), Pseudomonas aeruginosa, and Acinetobacter baumannii were included. Susceptibility results were defined as suppressed when susceptibility results were observed from the laboratory instrument but not from NHSN data. For the overall percentage susceptibility estimation, isolates with <30 susceptibility results were excluded. Percentage susceptibility of NHSN results were compared to their counterparts from cASTI. Results: Of the 852 matched isolates in the primary analysis, 804 had at least 1 suppressed result. Of the 804 isolates, 16.9% were P. aeruginosa, 67.3% by E. coli, and 11.1% by Klebsiella spp. The following pathogen–drug combinations had no difference observed in the percentage susceptible between the 2 systems: ceftazidime tested against P. aeruginosa, ceftriaxone tested against Klebsiella spp, ertapenem tested against Klebsiella spp, imipenem tested against E. coli and P. aeruginosa, and meropenem tested against P. aeruginosa. Significant differences were observed for the following drugs tested against E. coli: ceftazidime (11.1%), cefotaxime (8.6%), and ceftriaxone (8.3%). In the NHSN AR Option, the following isolates showed suppressed results related to their phenotypic case definition: 17 (3%) CRE isolates, 7 (28%) carbapenem-resistant Acinetobacter baumannii (CRAB) isolates, 511 (93.2%) extended spectrum β-lactamase (ESBL) isolates, and 94 (66.7%) carbapenem-resistant Pseudomonas aeruginosa (CRPA) isolates. Conclusions: For select isolates, notably E. coli, we observed a large difference in the percentage of susceptible isolates reported into the NHSN AR Option compared to the cASTI data. This difference significantly limits the ability of the AR Option to create valid antibiograms for select pathogen–drug combinations. Moreover, significant numbers of CRAB, ESBL, and CRPA isolates would not be identified from NHSN AR Option because of suppression. This finding warrants the need for antimicrobial stewardship teams to regularly assess the impact of selective reporting in identifying pathogens of public health importance.

Funding: None

Disclosures: None
Factors associated with antimicrobial drug prescription among inpatient dogs and cats at an academic veterinary hospital
Authors: Price Emma , Fellman Claire , Wayne Annie , Kwong Manlik , Beaulac Kirthana , Doron Shira
Published: May 2022

Background: Widespread antimicrobial use in dogs and cats drives antimicrobial resistance in both animals and humans. Knowledge of the factors associated with antimicrobial use is limited in veterinary medicine. We examined factors associated with antimicrobial drug prescription among inpatient dogs and cats at an academic veterinary hospital. Methods: A veterinary-adapted observational medical outcomes partnership common data model was utilized to extract demographic, clinical, and prescription data from the electronic medical record system in this descriptive observational study. Using generalized estimating equations, we assessed the association between demographic and clinical factors and systemic antimicrobial drug prescription among inpatient dogs and cats at a small-animal teaching hospital between 2018 and 2020. Results: Across 11,685 dogs with 14,328 admissions (mean age, 7.4 years; 47% females), the following factors were associated with increased odds of any antimicrobial drug prescription: female, longer admission, a history of chemotherapy within 30 days of hospital admission, surgery upon admission or within the last 30 days, urinary catheterization, ICU admission, and oxygen support. In 3,371 cats with 4,088 admissions (mean age, 8.6 years; 39% females), the following factors were associated with increased odds of any antimicrobial drug prescription: female, longer admission, increased age (>8 years), admission into the ICU, surgery upon admission, and feline that did not require oxygen support or urinary catheterization. Conclusions: This study identifies multiple patient and clinical factors associated with increased risk of antimicrobial drug use in inpatient dogs and cats that can inform veterinary antimicrobial stewardship efforts and may be useful for antimicrobial use benchmarking on an institutional or multi-institutional scale.

Funding: None

Disclosures: None
Private practice dentists improve antibiotic use after dental antibiotic stewardship from infectious diseases experts
Authors: Goff Debra , Mangino Julie , Trolli Elizabeth , Goff Douglas
Published: May 2022

Background: Dentists prescribe ~25.7 million antibiotic prescriptions annually. Private practice dentists (PPDs) represent 80% of US dentists who need to implement dental antimicrobial stewardship. We conducted a prospective cohort study of PPDs comparing appropriateness of antibiotic use before and after dental AS education. Methods: PPDs were invited to participate in this study. In phase 1 (pre-education), we collected 3 months (June–August 2019) of retrospective antibiotic use data (indication, dose, duration, penicillin allergy history) and number of dental procedures. We also conducted a preliminary survey to assess baseline antimicrobial stewardship knowledge. In phase 2 (education), PPDs attended 4 televideo education sessions (March–May 2021) taught by an infectious disease– antimicrobial stewardship (ID-AS) pharmacist and physician. In phase 3 (posteducation), we prospectively collected 3 months (June–August 2021) of antibiotic use data (as in phase 1), using an online database with ongoing feedback. In phase 4, we conducted antibiotic use audit and feedback to PPDs after the survey, and we solicited recommendations to reach more PPDs. The Student t test was used for statistical analyses. Results: Study participants comprised 15 PPDs: 2 oral maxillofacial surgeons, 6 periodontists, 4 endodontists, and 3 general dentists. Among them, 10 had been in practice >20 years. The presurvey revealed that 14 were unfamiliar with dental antimicrobial stewardship. All prescribed clindamycin (25% for nonpenicillin allergy), and standard antibiotic duration ranged from 5 to 14 days based on dental school training. In phase 3, despite more procedures, overall antibiotic use and duration decreased, and the use of clindamycin, quinolones, and prophylaxis for joint implant patients, also decreased. Appropriate use improved from 22% to 95%. Postsurvey responses on perceived value of antimicrobial stewardship education were 100% positive, with recommendations to make antimicrobial stewardship a required annual continuing education, similar to opioid continuing education. Study participants invited the ID-AS experts to teach an additional 150 PPDs to date via established PPD study clubs to expand dental antimicrobial stewardship across the United States. Conclusions: After learning dental antimicrobial stewardship guidance from ID-AS experts, PPDs rapidly optimized antibiotic prescribing behavior. PPDs identified their established study clubs as a forum to quickly expand dental antimicrobial stewardship training by ID-AS experts throughout the United States.

Funding: MERCK

Disclosures: None
Metrics in outpatient stewardship: Is more always better?
Authors: Medvedeva Natalia , Ha David , Onguti Sharon , Rosen Emily , Mui Emily , Pearce Sean , Schneider Alex , Chang Amy , Hersh Adam , Stenehjem Eddie , Holubar Marisa
Published: May 2022

Background: Emerging evidence supports the use of billing data to identify stewardship targets in primary care. Standardizing an approach to antibiotic prescribing rate (APR) calculations could facilitate external benchmarking. Methods: Using methodology and an ICD-10 dictionary validated in urgent care clinics,1 we created an expanded ICD-10 dictionary to incorporate additional ICD-10 codes from primary care associated with antibiotic prescriptions (Fig. 1). We then compared antibiotic prescribing rates using the urgent care and expanded dictionaries. We included all primary care visits from 2019 to 2020 and extracted ICD-10 codes and antibiotic order data. Using the urgent care and expanded ICD-10 dictionary, we classified each encounter by prescribing tier based on whether antibiotics are almost always (tier 1), sometimes (tier 2), or almost never (tier 3) indicated. For encounters with ICD-10s in multiple tiers, we chose the lowest tier. For multiple ICD-10 codes within the same tier, we chose the first extracted ICD-10 code. We calculated antibiotic prescribing rates as the proportion of encounters associated with ≥ 1 antibacterial prescription. This quality improvement project was deemed non–human subjects research by the Stanford Panel on Human Subjects in Medical Research. Results: The urgent care dictionary has 1,400 ICD-10 codes. We added 1,439 ICD-10 codes derived from primary care encounters to create the expanded ICD-10 dictionary (8.5% tier 1, 9.1% tier 2, and 82.4% tier 3) (Fig. 1). We identified 177,531 encounters; 74% had ≥ 2 associated ICD-10 codes (Fig. 2). In total, 147,085 encounters (82.9%) were classified into a tier using the urgent care dictionary. An additional 22,039 encounters were classified with the expanded dictionary (Table 1). Most added encounters were tier 3 with low 0.7% APR (Tables 1 and 3). In total, 41,473 (28.2%) encounters were classified differently depending on the ICD-10 dictionary used, most commonly changing from tier 3 to tier 2 without an increase in overall tier 2 antibiotic prescribing rate (Tables 2 and 3). Overall antibiotic prescribing rates were similar when using either the urgent care or expanded ICD-10 dictionary (Table 2). Conclusions: The expanded ICD-10 dictionary allowed for classification of more encounters in primary care; however, it did not meaningfully change antibiotic prescribing rates. Antibiotic prescribing rates were likely diluted by classifying more encounters without identifying an associated increase in antibiotic prescribing. A more sophisticated classification system may help to accommodate the diversity and volume of ICD-10 codes used in primary care.

1. Stenehjem E, et al. Clin Infect Dis 2020;70:1781–1787.

Funding: None

Disclosures: None
Rates of intravenous antibiotic starts among outpatient hemodialysis patients using NHSN dialysis event reporting, 2016–2020
Authors: Wilson William , Kabbani Sarah , Novosad Shannon , Fike Lucy , Gouin Katryna , Bell Jeneita , Bagchi Suparna , Edwards Jonathan , Apata Ibironke , Cali Susan
Published: May 2022

Background: Nearly one-third of patients on hemodialysis receive intravenous (IV) antibiotics annually, but national data characterizing antibiotic use in this population are limited. Using NHSN surveillance data for outpatient dialysis facilities, we estimated temporal changes in the rate of IV antibiotic starts (IVAS) among hemodialysis patients as well as the proportion of IVAS that were not supported by a reported clinical indication. Methods: IVAS events were obtained from the NHSN Dialysis Event module between 2016 and 2020, excluding patients who were out of network, receiving peritoneal or home dialysis, or with unspecified vascular access. IVAS unsupported by documentation were defined as new IVAS without a collected or positive blood culture, pus, redness or swelling event, or an associated clinical symptom. Pooled mean rates of total and unsupported IVAS were estimated per 100 patient months yearly and stratified by vascular access type. Differences in IVAS rates by year were estimated with negative binomial regression. Results: Between 2016 and 2020, 7,278 facilities reported 648,410 IVAS events; 161,317 (25%) were unsupported by documentation (Table 1). In 2016, 3,340 (54%) facilities with ≥1 IVAS event reported an IVAS unsupported by documentation, which increased to 4,994 (73%) in 2020. Total IVAS rates decreased by an average of 8.2% annually (95% CI, 7.1%–9.3%; P < .001). The average annual percentage decrease did not differ significantly by vascular access site. The total IVAS rate was lowest in 2020 (2.17 per 100 patient months; 95% CI, 2.18–2.17). IVAS rates in 2020 were greatest for patients with catheter access (4.79 per 100 patient months; 95% CI, 4.75–4.83), followed by graft (1.71 per 100 patient months; 95% CI, 1.68–1.73), and lowest for patients with fistulas (1.30 per 100 patient months; 95% CI, 1.29–1.31). The overall pooled mean rate of unsupported IVAS was 0.64 per 100 patient months (95% CI, 0.63–0.64), which did not significantly change by year (Fig. 1). Conclusions: Total IVAS rates among outpatient hemodialysis patients have decreased since 2016, and rates among catheter patients remain highest compared to patients with fistulas or grafts. However, unsupported IVAS rates did not change, and the proportion of facilities reporting an unsupported IVAS increased annually. Targeted efforts to engage facilities with unsupported IVAS may help improve accurate reporting and prescribing practices.

Funding: None

Disclosures: None
Healthcare resource utilization in a phase 3 trial of SER-109 in patients with recurrent Clostridioides difficile infection
Authors: Cohen Stuart , Louie Thomas , Berenson Charles , Amin Alpesh , Lombardi David , Pham Sissi , Huang Shirley , Wang Elaine , Hasson Brooke , McGovern Barbara , Von Moltke Lisa
Published: May 2022

Background: The estimated economic cost of Clostridioides difficile infection (CDI) is $5.4 billion annually, primarily attributed to acute-care costs. We previously reported data from ECOSPOR III that SER-109, an investigational oral microbiome therapeutic, was superior to placebo in reducing recurrent CDI (rCDI) in adults at 8 weeks after treatment, with a 68% relative risk reduction. Adults with rCDI have more hospitalizations and emergency room (ER) visits (defined herein as healthcare resource utilization, HRU) compared to those without recurrence. Thus, we evaluated incidence of HRU. Methods: Adults with rCDI (≥3 episodes in 12 months) were screened at 56 US and Canadian sites and were randomized 1:1 to SER-109 (4 capsules × 3 days) or placebo following resolution of CDI with standard-of-care CDI antibiotics. The primary end point was rCDI at 8 weeks. Exploratory end points included cumulative incidence of hospitalizations through 24 weeks after treatment. Here, we report cumulative incidence of all-cause HRU through 8 weeks after treatment. Results: In total, 281 patients were screened and 182 were randomized (59.9% female; mean age 65.5 years; 98.9% outpatient). Overall, 31 patients (17%) had 38 hospitalizations or ER visits through week 8 (11 events in 10 SER-109 patients and 27 events in 21 placebo patients) (Table 1). The cumulative incidence of HRU was lower in SER-109–treated patients compared to placebo at both weeks 4 and 8 with most events (65.8%) recorded within 4 weeks after treatment. The adjusted HRU incidence rate (by person time, age, sex, and antibiotic use) was also lower in SER-109–treated patients compared to placebo at weeks 4 and 8 (0.256 [95% CI, 0.096–0.683] versus 0.417 [95% CI, 0.199–0.873], respectively). Conclusions: SER-109–treated patients had less HRU compared to placebo patients through 8 weeks after treatment in this mostly outpatient population. These data suggest a potential benefit of SER-109 in reducing HRU, thus lowering the healthcare burden of rCDI.

Funding: Seres Therapeutics

Disclosures: None
Readiness assessment: Implications for COVID-19 infection prevention and control (IPC) preparedness in health facilities
Authors: Wesangula Evelyn , Kamau Veronica , Kiberenge Felister , Tanui Emmanuel , Githii Susan , Ndegwa Linus , Owiso George , Kamau Irungu , Njuhigu Jennifer
Published: May 2022

Background: Monitoring uptake of infection prevention and control (IPC) interventions is critical for the targeted and rational use of limited resources. A national facility readiness assessment conducted in August 2020 provided key information for targeted interventions to strengthen priority IPC areas. We assessed the level of COVID-19 preparedness in the facilities, identified priority COVID-19 IPC gaps, and generated a baseline report to further guide IPC investments at all levels. Methods: The Kenya Ministry of Health in collaboration with the CDC and International Training and Education Center for Health adapted a WHO Facility Readiness Assessment tool to include COVID-19–specific areas. In August 2020, data were collected using tablets through an Android-based electronic platform and were analyzed using descriptive statistics. Assessments were conducted in public, private, and faith-based health facilities nationally after 4 months of preparedness and investment in the healthcare system. Results: We assessed 684 facilities of the targeted 844 (81%). Overall facility readiness in Kenya was rated above average (61%), and the performance score significantly increased with the Kenya Essential Package for Health level, with level 5 and 6 facilities scoring an average of 83% and 79% respectively. Of the assessed facilities, 82% had an appointed IPC coordinator. Only 14% of the facilities had all the required guidelines, policies, and the appropriate COVID-19 case definitions. 67% of the facilities had updated supply inventories for past week. Only 50% of the facilities had adequate supplies of N95 masks. The assessment revealed that 52% of healthcare facilities had trained their healthcare workforce; morticians were the least trained (only 17% of facilities). Moreover, 41% of the facilities had clear work plans for monitoring healthcare workers exposures to COVID-19, but only 33% of the facilities had policies on the management of infected healthcare workers. Conclusions: The findings provided critical information for stakeholders at all levels to be used for policy decisions, to prioritize key intervention areas in leadership and governance of facility IPC programs, for guideline development, and for capacity building and targeted investment in IPC to improve COVID-19 facility preparedness.

Funding: None

Disclosures: None
Nosocomial outbreak of δ (delta) variant SARS-CoV-2 on a liver transplant unit: A complex epidemiologic and genomic investigation
Authors: Ryder Jonathan , Van Schooneveld Trevor , Abdalhamid Baha , Wood Macy , Starlin Richard , Gillett Gayle , Balfour Teresa , Pflueger Libby , Rupp Mark
Published: May 2022

Background: In late September 2021, a cluster of patients with nosocomial COVID-19 was identified on a liver transplant unit at University of Nebraska Medical Center. Methods: The outbreak investigation included contact tracing via patient chart and employee health record reviews and serial prevalence testing for SARS-CoV-2 among potentially exposed patients and healthcare workers (HCWs). Routine admission and preprocedural screening for SARS-CoV-2 was performed, and involved patients had negative admission screening results with positive SARS-CoV-2 tests >5 days from admission. Mitigation strategies involved reinforcement of patient care and visitation procedures. Whole-genome sequencing of positive SARS-CoV-2 specimens was conducted. Results: The potential outbreak cluster included 6 patients in the same quadrant of the liver transplant unit, 1 visitor, and 11 healthcare workers (Fig. 1). Moreover, 4 patients had severe liver disease, including 2 with liver transplants. All HCWs and half of the patients had received 2 doses of mRNA vaccine, albeit >5 months from their second vaccination. Whole-genome sequencing confirmed patients 1–6 and HCWs 1–3 had related transmission of COVID-19. However, infections in HCWs 4–6, who worked in a transplant-related office setting without patient contact, were due to 2 separate introductions of SARS-CoV-2 unrelated to the hospital outbreak. Sequencing could not be performed on HCWs 7–11 due to low viral concentration in the original specimens or unavailable specimen. The SARS-CoV-2 δ (delta) variant (B.1.617.2) was identified in all sequenced samples. HCWs 8–10 were asymptomatic and had had contact with each other and had been involved with an intubation without proper PPE for SARS-CoV-2 on patient 6. HCW 8 had had contact with all 6 patients and HCW 9 had had contact with 5 patients. A clear index case could not be identified; however, we suspect that the index case was either visitor 1, who tested positive during patient 2’s admission, or an asymptomatic healthcare worker (HCWs 8–10). Conclusions: We identified a nosocomial outbreak of the SARS-CoV-2 δ (delta) variant in a solid-organ transplant unit including patients, a visitor, and vaccinated healthcare workers with multiple introductions of the virus. Further transmission was not detected after enhanced infection control measures were introduced, including universal masking and eye protection, closing patient doors, and enforcement of visitor masking policy. We describe the difficulties tracing SARS-CoV-2 transmission in the hospital setting, even with advanced sequencing techniques. This outbreak highlights the importance of booster vaccination and strict infection control practices, especially in the setting of the δ (delta) variant.

Funding: None

Disclosures: None
Comparison of traditional instruction versus nontraditional learning to improve trainee knowledge of urine culture practices in catheterized patients
Authors: Gao Catherine A. , Datta Rupak , Dunne Dana , Dembry Louise-Marie , Martinello Richard A. , Juthani-Mehta Manisha , Advani Sonali D.
Published: May 2022

We surveyed trainees about their urine culture practices and assessed the impact of an educational intervention delivered electronically and in person. Trainee scores improved across all levels of training and across all questions on the postintervention survey, but there was no difference in scores by mode of education (P = .91).
Impact of different COVID-19 encounter definitions on antibiotic prescribing rates in urgent care
Authors: Onguti Sharon , Ha David , Mui Emily , Chang Amy , Stenehjem Eddie , Hersh Adam , Holubar Marisa
Published: May 2022

Background: Billing data have been used in the outpatient setting to identify targets for antimicrobial stewardship. However, COVID-19 ICD-10 codes are new, and the validity of using COVID-19 ICD-10 codes to accurately identify COVID-19 encounters is unknown. We investigated COVID-19 ICD-10 utilization in our urgent care clinics during the pandemic and the impact of using different COVID-19 encounter definitions on antibiotic prescribing rates (APRs). Methods: We included all telemedicine and office visits at 2 academic urgent-care clinics from January 2020 to September 2021. We extracted ICD-10 encounter codes and testing data from the electronic medical record. We compared encounters for which COVID-19 ICD-10 codes were present with encounters for which SARS-CoV-2 nucleic acid amplification testing (NAAT) was performed within 5 days of and up to 2 days after the encounter (Fig. 1). We calculated the sensitivity of the use of COVID-19 ICD-10 codes against a positive NAAT. We calculated the APR as the proportion of encounters in which an antibacterial drug was prescribed. This quality improvement project was deemed non–human-subjects research by the Stanford Panel on Human Subjects in Medical Research.

Funding: None

Disclosures: None
Coinfections in hospitalized COVID-19 patients are associated with high mortality: need for improved diagnostic tools
Authors: Kothadia Sonya , Wilson Brigid , Perez Federico , Bonomo Robert
Published: May 2022

Background: Hospitalized patients with COVID-19 often receive antimicrobial therapies due to concerns for bacterial and fungal coinfections. We analyzed patients admitted with COVID-19 to our VA facility to understand antimicrobial use, frequency of coinfections, and outcomes in our population. Methods: This retrospective study included veterans who were 18 years or older and hospitalized with COVID-19 from March 10, 2020, to March 9, 2021 at the Louis Stokes VA Medical Center in Cleveland, Ohio. We identified antimicrobials administered and coinfections with bacterial or fungal pathogens. Patients were deemed to have coinfection if there was supporting microbiological data and a consistent clinical course upon review of clinical records. Urinary tract infections were excluded because of difficulty determining infection. Odds ratios (ORs) and 95% confidence intervals (CIs) for 30-day mortality were derived using multivariate logistic regression models that included age, Charlson comorbidity index (CCI), corticosteroid use, and time of infection. Results: In our cohort of 312 patients, the median age was 70 years and 97% of the patients were male. The mean CCI was 3.7 (SD, 3.0), and 111 patients (35.6%) had a score ≥5. Oxygen was administered to 250 patients (80.1%), and 20 (6.4%) required mechanical ventilation. Antimicrobials were administered to 164 patients (52.6%) (Fig. 1). Of 20 patients (6.4%) with coinfection, 11 (3.5%) had a bloodstream infection (BSI) and 9 (2.9%) had bacterial pneumonia (Fig. 2). The overall 30-day mortality rate was 12.5% (39 of 312). Among patients with coinfection, the 30-day mortality rate was 45% (9 of 20). Diagnoses of BSI (OR, 6.35; 95% CI, 1.41–26.30) and bacterial pneumonia (OR, 9.34; 95% CI, 2.01–46.34) were associated with increased mortality. Of the data available, 12 (63%) of 19 patients with coinfection had elevated procalcitonin levels (ie, >0.50). At the time of COVID-19 diagnosis, the median absolute lymphocyte count in patients who died was 0.7 K/mm3 (95% CI, 0.6–1.12) in comparison to 1 K/mm3 (95% CI, 0.7–1.4) in patients who survived at 30 days. Conclusions: Our analysis of hospitalized COVID-19 patients with advanced age and underlying comorbid conditions demonstrated that coinfections were infrequent but that they were independently associated with increased mortality. This finding highlights the need for better tools to diagnose the presence or absence of bacterial and fungal coinfection in COVID-19 patients. Our findings also emphasize the need for judicious use of antimicrobials while discerning which patients are at risk of critical illness and mortality.

Funding: None

Disclosures: None
Work system factors affecting COVID-19 PPE use: A human factors approach to analysis of video recordings of emergency department clinical work
Authors: Nosakhare Esosa , Perry Shawna , Peterson Susan , Catalfumo Frankie , Osei Kelly , Osei Kelly , Osei Kelly , Williams Kelly , Bradley Maia , Sultan Marium , Daodu Oluseyi , Prabhu Nivedha , Gurses Ayse
Published: May 2022

Background: The effectiveness of PPE in preventing self-contamination of healthcare workers (HCWs) and transmission of pathogens (airborne and contact) in the emergency department (ED) is highly dependent on consistent, appropriate use of and other interactions (eg, storing, cleaning, etc) with the PPE. Pre–COVID-19 studies focused primarily on individual HCW contributions to incorrect or suboptimal PPE use. We conducted an analysis of ED video recordings using a human-factors engineering framework (ie, The Systems Engineering Initiative for Patient Safety, SEIPS), to identify work-system–level contributions to inappropriate PPE usage by HCWs while they provide care in their actual clinical care environment. Methods: In total, 47 video sessions (each ~15 minute) were recorded between June 2020 and May 2021 using a GoPro camera in an 8-bed pod area, designated for persons under investigation (PUI) and confirmed COVID-19–positive patients, in an ED of a large, tertiary-care, academic medical center. These recordings captured a ‘landscape view’: 2 video cameras were set up to capture the entire ED pod area and HCWs as they provided care. A team with hemorrhagic fever expertise, infection prevention and control expertise, and ED expertise reviewed each video together and extracted data using a semistructured form. Results: Guided by the 5 components of the SEIPS work system model, (ie, task, physical environment, person, organization, tools and technology), multiple work system failure points influencing HCWs appropriate use of PPE were identified. For example, under the task component, HCWs were observed not doffing and donning in recommended sequence. Also, inconsistencies with COVID-19 status signage on a patient’s door and ambiguous labelling of work areas designated as clean (donning) and dirty (doffing) sites acted as a barrier to appropriate PPE use under the physical environment section. Conclusions: Human factors–based analysis of video recordings of actual ED work identified a variety of work system factors that impede appropriate or correct use of PPE by HCWs. Future efforts to improve appropriate PPE use should focus on eliminating or mitigating the effects of these work system factors.

Funding: US CDC

Disclosures: The authors gratefully acknowledge the CDC for funding this work. This material is based upon work supported by the Naval Sea Systems Command (under contract No. N00024-13-D-6400, Task Order NH076). Any opinions, findings and conclusions or recommendations expressed in this material are those of the author(s) and do not necessarily reflect the views of the Naval Sea Systems Command (NAVSEA) or the US CDC.