bluuebunny/crossref_metadata_2025 huggingface dataset:
Facemasks for Source Control: Testing Influenza Transfer to Bedside Tables
Authors: Biggio Adriane , Nagy-Agren Stephanie
Published: November 2021

Background: Research testing human study participants regarding the effectiveness of face masks in preventing influenza transfer or transmission is limited. In this pilot study, we investigated the following question: In influenza-positive veterans, what is the effect of face-mask wearing in comparison to not wearing a face mask on influenza transfer to bedside tables measured for 2 hours per condition over a 10-week period during the 2019–2020 influenza season Methods: Influenza-positive veterans with influenza symptom onset ≤ 120 hours admitted to the Salem Veterans Affairs Medical Center were recruited to participate in this study. Exclusion criteria included critical illness requiring an oxygen mask or intubation. The Precept® FluidGard® 160 Procedure Mask 15300, Precept Medical Products, Inc., Arden, NC was worn by all participants during the two-hour intervention period. Surface swabs were used to measure the presence of influenza on bedside tables. CDC/NIOSH tested for influenza A and B from surface samples and facemasks using real-time polymerase chain reaction (PCR) assay (TaqMan ThermoFisher Scientific). Demographic information was collected (Table 1). A study questionnaire collected qualitative data on tolerability and feasibility of wearing a facemask when hospitalized with influenza. Institutional Review Board approval was granted. Results: From January 2, 2020, to March 11, 2020, 8 participants completed the study. Mean age was 67 years, all were male. Of these 8 participants, 6 had influenza A and 2 had influenza B. Half were diabetic; all received oseltamivir. Relative room humidity ranged from 15.6% to 39.8%. Neither influenza A nor B was detected by qPCR on bedside tables for any of the 8 participants under either face-mask–wearing condition. All participants reported that wearing the face mask was easy or very easy; of these, 5 reported experiencing warmth from the mask. Also, 50% of participants selected 2 hours as the time they could tolerate wearing a mask; the other 25% specified they could wear the face mask for 3 hours or 5 hours or more, respectively. Conclusions: In this pilot study, we demonstrated that wearing face masks is a tolerable infection control practice for providing source control for inpatients with influenza and will guide future research. Because a major limitation was the small size of the study, associated with lack of viral capture, a larger study is planned. Using face masks for source control among inpatients with influenza and other respiratory virus infections should be considered a standard infection control practice.

Funding: No

Disclosures: None
The Impact of Narrowing Perioperative Antibiotic Prophylaxis for Left-Ventricular-Assist Device Implantation
Authors: Allen Lauren , Bartash Rachel , Cowman Kelsie , Guo Yi , Minamoto Grace , Patel Snehal , Vukelic Sasha , Nnani Daryl , Fauvel Daphenie
Published: November 2021

Background: Left-ventricular-assist device (LVAD)–related infections occur in 20%–40% of LVAD recipients and may result in up to 10% of LVAD-related deaths. Optimal surgical infection prophylaxis for LVAD implantation is not well defined. Our institution historically used a 4-drug surgical infection prophylaxis regimen of fluconazole, ciprofloxacin, rifampin, and vancomycin as recommended by the device manufacturer. In January 2020, a 2-drug surgical infection prophylaxis regimen of vancomycin and cefazolin was implemented to reduce broad-spectrum antibiotic use while preserving gram-positive coverage. The primary objective of this study was to compare LVAD-associated infection rates before and after changing surgical infection prophylaxis. Methods: A retrospective review of patients who underwent LVAD implantation between January 2018 and January 1, 2021, was performed. Definitions of LVAD-associated infections and non-LVAD infections were based on the International Society for Heart and Lung Transplantation guidelines. Infection rates at 2 weeks and 30 days after implantation and 30-day mortality were compared between the 4-drug surgical infection prophylaxis regimen (January 2018–December 2019) and the 2-drug regimen (January 2020–January 2021). Additional data collected included demographics, cause of cardiomyopathy, type of infection, and causative organism. Results: In total, 51 patients were in the 4-drug surgical infection prophylaxis group and 23 patients were in the 2-drug surgical infection prophylaxis group. Baseline characteristics between the groups were similar. The cause of cardiomyopathy in both groups was predominantly nonischemic (67% vs 70%, = .81), and most patients received a Heartmate III device (84% vs 100%, P = .06). There was no statistical difference between infection rates in the 4-drug and 2-drug prophylaxis groups at 2 weeks or 30 days (Table 1). The 30-day mortality rate was 4% in the 4-drug group versus 13% in the 2-drug group (P = .17). No deaths were due to infections. Gram-negative and fungal LVAD–associated infections were rare: 4% versus 4% (P = .99) for gram-negative infections and 2% versus 0% (P = .99) for fungal infections. The most commonly isolated organisms were Staphylococcus aureus and coagulase-negative Staphylococcus in both groups. Pneumonia was the most common infection in both groups (Figure 1). Conclusions: We did not observe a significant increase in infection or mortality with narrowing of perioperative antibiotics. However, these results should be interpreted cautiously given the small sample size. Larger studies are needed to confirm these findings.

Funding: No

Disclosures: None
A Cluster of Aspergillosis Associated with SARS-CoV-2
Authors: VerLee Kerrie , Codman Jim , Lampen Russell , Nguyen Chau , Peters Tunisia , Kruse Greg , VanderHorst Derek , Marcinek Doreen , Kane-Carbone Molly
Published: November 2021

Background: Coronavirus disease 2019 (COVID-19) has demonstrated a variety of presentations and clinical complications, among them coinfection of pneumonia with the mold Aspergillus spp. Patients at risk for invasive disease include transplant recipients and those with prolonged neutropenia, immune disorders, cystic fibrosis, and steroid use. There have been recent descriptions of coronavirus disease–associated pulmonary aspergillosis (CAPA). An outbreak investigation into a cluster of Aspergillus fumigatus infections in a health system intensive care unit uncovered a community-onset (CO) increase in CAPA. Methods: A multidisciplinary outbreak investigation was conducted evaluating sources of contamination, completion of construction projects, and changes in clinical processes. Retrospective chart review was done for the prior 18 months and incidence density rates for Aspergillus infections from June 2019 through December 2020 were calculated per 10,000 patient days, stratified by unit, specimen source, and coinfection with COVID-19. Data were linked with all positive and negative COVID-19 tests performed by the health system’s regional laboratory from March to December 2020. Healthcare-onset (HO) classification was based on infections identified ≥7 days after admission. Statistical analysis was calculated with significance at p < 0.05. Results: Over the last 18 months, 82 patients were identified positive with Aspergillus cultures; of which 10 (12%) met CAPA definitions. Aspergillus fumigatus was the most common species and accounted for 62% of samples, followed by Aspergillus niger (17%). Median rates of HO Aspergillosis were 0.45 cases per 10,000 patient days, whereas the median total rates of infection were 1.97 cases per 10,000 patient days. Rates of CAPA coincided with COVID-19 hospitalization rates. In the spring and fall, surges of COVID-19, the rate ratio of CAPA to COVID hospitalized infections per 10,000 patient days, ranged from 0.006 to 0.015. Once CAPA infections were adjusted for, rates of CO Aspergillus remained high, whereas HO cases suggested baseline acquisition. Conclusion: This study outlines rates of CO aspergillosis as well as CAPA rates coinciding with the healthcare system’s spring and fall surges of COVID-19 hospitalizations. Despite the determination that this was not a hospital-acquired cluster, the investigation revealed some areas for opportunity in construction processes along with maintaining coverage of all patient supplies to reduce the risk of contamination.

Funding: No

Disclosures: None
COVID-19 Vaccination of HCWs in the First Phase of a Large-Scale Mass Vaccination Program within a Healthcare System
Authors: Korwek Kimberly , Blanchard E. Jackie , Moody Julia , Lange Katherine , Sledge Ryan , Benedetti Maria , Sands Kenneth
Published: November 2021

Background: The approval of the first SARS-COV-2 vaccines for COVID-19 were accompanied by unprecedented efforts to provide vaccination to healthcare workers and first responders. More information about vaccine uptake in this group is needed to better refine and target educational messaging. Methods: HCA Healthcare used federal guidance and internal experience to create a systemwide mass vaccination strategy. A closed point-of-dispensing (POD) model was developed and implemented. The previously developed enterprise-wide emergency operations strategy was adapted and implemented, which allowed for rapid development of communications and operational processes. A tiering strategy based on recommendations from the National Academies was used in conjunction with human resources data to determine vaccine eligibility for the first phase of vaccination. A comprehensive data and reporting strategy was built to connect human resources and vaccine consent data for tracking vaccination rates across the system. Results: Vaccination of employed and affiliated colleagues began December 15, 2020, and was made available based on state-level release of tiers. Within the first 6 weeks, in total, 203,544 individuals were eligible for vaccine based on these criteria. Of these, 181,282 (89.1%) consented to and received vaccine, 19,788 (9.7%) declined, and 2,474 (1.2%) indicated that they had already been vaccinated. Of those eligible, the highest acceptance of vaccine was among the job codes of specialists and professionals (n = 7,914 total, 100% consent), providers (n = 23,335, 99.6%,), and physicians (n = 3,218, 98.4%). Vaccine was most likely to be declined among job codes of clerical and other administrative (n = 12,889 total, 80.1% consent), clinical specialists and professionals (n = 22,853, 81.0%,) and aides, orderlies and technicians (n = 17,803, 82.6%,). Registered nurses made up the largest eligible population (n = 56,793), and 89.5% of those eligible consented to receive vaccination. Average age among those who consented was slightly older (48.3 years) than those that declined (44.7 years), as was length of employment tenure (6.9 vs 5.0 years). Conclusion: A large-scale, closed POD, mass vaccination program was able to vaccinate nearly 200,000 healthcare workers for SARS-CoV-2 in 6 weeks. This program was implemented in acute-care sites across 20 different US states, and it was able to meet the various state-level requirements for management of processes, product, and required reporting. The development of a standardized strategy and custom, centralized monitoring and reporting facilitated insight into the characteristics of early vaccine adopters versus those who decline vaccination. These data can aid in the refining and targeting of educational materials and messaging about the SARS-CoV-2 vaccine.

Funding: No

Disclosures: None
Optimizing Urine Collection Represents an Important Stewardship Opportunity in Primary Care
Authors: Grigoryan Larissa , Matas Jennifer , Hansen Michael , Willis Samuel , Danek Lisa , Katta Anna , Muldrew Kenneth , Zare Mohammad , Hudson Forrest , Atmar Robert , Chou Andrew , Trautner Barbara
Published: November 2021

Background: Urine cultures are the most common microbiological tests in the outpatient setting and heavily influence treatment of suspected urinary tract infections (UTIs). Antibiotics for UTI are usually prescribed on an empiric basis in primary care before the urine culture results are available. However, culture results may be needed to confirm a UTI diagnosis and to verify that the correct antibiotic was prescribed. Although urine cultures are considered as the gold standard for diagnosis of UTI, cultures can easily become contaminated during collection. We determined the prevalence, predictors, and antibiotic use associated with contaminated urine cultures in 2 adult safety net primary care clinics. Methods: We conducted a retrospective chart review of visits with provider-suspected UTI in which a urine culture was ordered (November 2018–March 2020). Patient demographics, culture results, and prescription orders were captured for each visit. Culture results were defined as no culture growth, contaminated (ie, mixed flora, non-uropathogens, or ≥3 bacteria isolated on culture), low-count positive (growth between 100 and 100,000 CFU/mL), and high-count positive (>100,000 CFU/mL). A multivariable multinomial logistic regression model was used to identify factors associated with contaminated culture results. Results: There were 1,265 visits with urine cultures: 264 (20.9%) had no growth, 694 (54.9%) were contaminated, 159 (12.6%) were low counts, and 148 (11.7%) were high counts. Encounter-level factors are presented in Table 1. Female gender (adjusted odds ratio [aOR], 15.8; 95% confidence interval [CI], 10.21–23.46; P < .001), pregnancy (aOR, 13.98; 95% CI, 7.93–4.67; P < .001), and obesity (aOR, 1.9; 95% CI 1.31–2.77; P < .001) were independently associated with contaminated cultures. Of 264 patients whose urine cultures showed no growth, 36 (14%) were prescribed an antibiotic. Of 694 patients with contaminated cultures, 153 (22%) were prescribed an antibiotic (Figure 1). Conclusions: More than half of urine cultures were contaminated, and 1 in 5 patients were treated with antibiotics. Reduction of contamination should improve patient care by providing a more accurate record of the organism in the urine (if any) and its susceptibilities, which are relevant to managing future episodes of UTI in that patient. Optimizing urine collection represents a diagnostic stewardship opportunity in primary care.

Funding: This study was supported by the National Institute of Allergy and Infectious Diseases of the National Institutes of Health (grant no. UM1AI104681). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Disclosures: None
Selection and Duration of Therapy as a Target for Antimicrobial Stewardship during COVID-19: Levees for a Hundred-Year Flood
Authors: Mena Lora Alfredo , Burgos Rodrigo , Li Ella , Simpkins Nichelle , Herald Fischer , Marchionne John , Ali Mirza , Takhsh Eden , Spencer Sherrie , Krill Candice , Bleasdale Susan , Borgetti Scott
Published: November 2021

Background: The disease caused by SARS-CoV-2, COVID-19, has caused a pandemic leading to strained healthcare systems worldwide and an unprecedented public health crisis. The hallmark of severe COVID-19 is lower respiratory tract infection (LRTI) and hypoxia requiring hospitalization. A paucity of data on bacterial coinfection and a lack of therapeutic options for COVID-19 during the first surge of cases has increased pressure on antimicrobial use and has challenged antimicrobial stewardship programs (ASPs). We implemented a multimodal approach to antimicrobial stewardship in an urban safety-net community hospital targeting selection and duration of therapy. Methods: Retrospective review of cases during the first wave of COVID-19 in a 151-bed urban safety-net community hospital from March to June 2020. EMR order sets (Figure 1) and prospective audit and feedback by ASPs targeting empiric antimicrobial selection and duration were implemented as part of the COVID-19 response. Hospitalized patients with COVID-19 were reviewed retrospectively. Demographic information was collected. Data on antimicrobial use were tabulated, including selection and duration of antimicrobials (Figure 1). Results: In total, 302 patients were reviewed, of whom 221 (73%) received empiric antimicrobials. The most commonly used antimicrobials were ceftriaxone and azithromycin (Figure 2). Days of therapy per 1,000 patient days (DOT/1,000 PD) for ceftriaxone increased from 71 in the quarter prior to 113 during the study period. Average duration of therapy was 6 days. In the ICU, average duration was 8 days compared to 5 days in non-ICU settings. Average durations of parenteral therapy were 5.54 days in the ICU and 3.36 days in non-ICU settings. Procalcitonin was obtained in 37 cases (17%) and ranged from 0.09 to 12.57 ng/mL, with an average of 1.21 ng/mL. No cases had documented bacterial coinfection (Figure 1). Conclusions: Antimicrobials were commonly prescribed during the first wave of COVID-19 in a safety-net community hospital. Procalcitonin did not guide therapy nor did lack of documented coinfection change physician behavior. With limited resources, ASP successfully guided clinicians toward IDSA guideline recommendations for selection and duration, as evidenced by antimicrobial use. During this unprecedented surge of LRTIs, a multimodal approach to antimicrobial stewardship was used and guided toward early transition to oral agents and shorter durations.

Funding: No

Disclosures: None
Sociodemographic Factors, Cycle Threshold Values, and Clinical Outcomes of COVID-19
Authors: Rivera Frida , Gmehlin Cameron , Pezzin Liliana , Nattinger Ann B. , Hanson Ryan , Perez Adriana , Singh Siddhartha , Buchan Blake , Ledeboer Nathan , Munoz-Price L. Silvia
Published: November 2021

Background: The gold standard for diagnosis of COVID-19 has been SARS-CoV-2 detection by reverse-transcriptase-quantitative polymerase chain reaction (RT-qPCR), which provides a semiquantitative indicator of viral load (cycle threshold, Ct). Our research group previously described how African American race and poverty were associated with an increased likelihood of hospitalization due to COVID-19. We sought to characterize the relationship between Ct values and clinical outcomes while controlling for sociodemographic factors. Methods: We conducted a cross-sectional study of SARS-CoV-2–positive patients admitted to Froedtert Health between March 16 and June 1, 2020. Ct values were obtained by direct interrogation of either cobas SARS-CoV-2 or Cepheid Xpert Xpress platforms. Patient demographics, comorbidities, symptoms at admission, health insurance, and hospital course were collected using electronic medical records. A proxy for socioeconomic disadvantage, area-deprivation index (ADI), was assigned using ZIP codes. Multivariate models were performed to assess associations between Ct values and clinical outcomes while controlling for ADI, race, and type of insurance. Results: Overall, 302 patients were included. The mean age was 60.89 years (SD, 18.2); 161 (53%) were men, 177 (58%) were African Americans; and 156 (51%) had Medicaid or were uninsured. Of the 302 inpatients, 158 (52%) required admission to the ICU, 199 (65.9%) were discharged to home, 49 (16.2%) were discharged to a nursing home, and 54 (17.9%) died. Lower Ct values (higher viral load) were associated with Medicaid or lack of insurance (coefficient, −2.88, 95% confidence interval [CI], −4.96 to −0.79, P = .007) and age >60 years old (coefficient, −2.98, 95% CI −4.87 to −1.08, P = .002). Contrary to what was expected, higher CT values (lower viral load) were associated with higher ADI scores (coefficient, 2.62, 95% CI, 0.52–4.85; P = .017). However, when patients were stratified into low, medium, and high ADI, those with Medicaid or no insurance had the lowest mean Ct values (23.3, 25.9, and 27.6, respectively) compared to Medicare or other insurance (Figure 1). Body mass index (odds ratio [OR], 1.04; 95% CI, 1.02–1.07; P = .001) and male sex (OR, 2.15; 95% CI, 1.28–3.60; P = .004) were independently associated with ICU admission. Every increase of a CT point (OR, 0.90; 95% CI, 0.85–0.95; p <0.001) and age >60 years old (OR 2.62, 95% CI; 1.14-6.04; p=0.023) was associated with death. Conclusions: In this cross-sectional study of adults tested for COVID-19 in a large midwestern academic health system, lower Ct values were independently associated with poverty and age >60 years old.

Funding: No

Disclosures: None
Evaluating N95 Respirator Filtration, Seal, Qualitative and Quantitative Fit with Vaporous Hydrogen Peroxide Reprocessing
Authors: Yen Christina , Mehrotra Preeti , Pepe Dana , Wright Sharon , Gordon Patrick , Parameswaran Lalitha
Published: November 2021

Background: The COVID-19 pandemic has created personal protective equipment (PPE) shortages, particularly of N95 respirators. Institutions have used decontamination strategies including vaporous hydrogen peroxide (VHP) to augment respirator supplies. VHP can be used to decontaminate nonporous surfaces without compromising material integrity. However, little is known about its impact on N95 respirator efficacy. We assessed whether repeated VHP reprocessing altered 4 key respirator efficacy qualities: quantitative fit, qualitative fit, seal check, and filtration rate. Methods: We conducted a prospective cohort study from June 15 to August 31, 2020. In total, 7 participants were fitted to a 3M 1860 small or regular N95 respirator based on qualitative and quantitative fit testing. Respirators underwent 25 disinfection cycles with the Bioquell BQ-50 VHP generator. After each cycle, participants donned and doffed respirators and performed a seal check. Participants were given 2 attempts to pass their seal check. Every 10 cycles, qualitative fit testing was done using an aerosolized Bitrex solution. Quantitative fit testing was conducted using a PortaCount Pro 8038 Fit Tester to generate a fit factor score. Appropriate fit is defined as a fit factor score of 100 or greater. Quantitative testing was done at cycles 1, 3, 5, 7, 10, 15, 20, and 25. Filtration efficiencies of particles ≥0.3 µm in diameter were measured using the TSI Optical Particle Sizer 3330 at cycles 1, 5, 10, 15, 20, and 25. The Fisher exact test was used to assess qualitative fit and seal check. The Kruskal-Wallis test was used to analyze quantitative fit and filtration rate. Results: We observed no seal-check or quantitative-fit test failures during the study window. All participants passed qualitative fit testing. Although there was a significant degree of variability in fit factor scores across disinfection cycles (mean score 163.5, p <0.05), there was no significant difference between participants (p = 0.6) (Figure 1). There was no statistically significant change in mean filtration rate from cycle 10 to 25 (P = .05), and the filtration rate remained >95% by cycle 25 (Figure 2). Conclusions: VHP reprocessing did not diminish the efficacy of N95 respirators based on the 4 metrics we assessed: filtration rate, seal check, qualitative fit, and quantitative fit. Of significance, the filtration rate remained well above the 95% standard filtration for N95 respirators—even through 25 cycles of reprocessing. VHP reprocessing is a safe, viable strategy to disinfect N95 respirators and extend their use, particularly during supply shortages.

Funding: No

Disclosures: None
Discontinuation of Contact Precautions in Patients with Nosocomial MRSA and VRE Infections During the COVID-19 Pandemic
Authors: Hudson Marisa , Al Mohajer Mayar
Published: November 2021

Background: Gaps exist in the evidence supporting the benefits of contact precautions for the prevention of methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococci (VRE). The Centers for Disease Control and Prevention allow suspending contact precautions for MRSA and VRE in cases of gown shortages, as we have seen during the COVID-19 pandemic. We evaluated the impact of discontinuing isolation precautions in hospitalized patients with MRSA and VRE infection, due to gown shortage, on the rate of hospital-acquired (HA) MRSA and VRE infections. Methods: A retrospective chart review was performed on adult patients (n = 2,200) with established MRSA or VRE infection at 5 hospitals in CommonSpirit Health, Texas Division, from March 2019 to October 2020. Data including demographics, infection site, documented symptoms, and antibiotic use were stratified based on patient location (floor vs ICU). Rates of hospital-acquired MRSA and VRE infection before and after the discontinuation of isolation (implemented in March 2020) were compared. Incidence density rate was used to assess differences in the rate of MRSA and VRE infections between pre- and postintervention groups. Results: The rate of hospital-acquired (HA) MRSA infection per 10,000 patient days before the intervention (March 19–February 20) was 12.19, compared to 10.64 after the intervention (March 20–July 20) (P = .038). The rates of HA MRSA bacteremia were 1.13 and 0.93 for the pre- and postintervention groups, respectively (P = .074). The rates of HA VRE per 10,000 patient days were 3.53 and 4.44 for the pre- and postintervention groups, respectively (P = .274). The hand hygiene rates were 0.93 before the intervention and 0.97 after the intervention (P = .028). Conclusions: Discontinuing isolation from MRSA and VRE in the hospital setting did not lead to a statistically significant increase in hospital-acquired MRSA or VRE infections. In fact, rates of hospital-acquired MRSA decreased, likely secondary to improvements in hand hygiene during this period. These results support the implementation of policies for discontinuing contact isolation for hospitalized patients with documented MRSA or VRE infection, particularly during shortages of gowns.

Funding: No

Disclosures: None
Successful Control of Human Parainfluenza Type 3 Outbreak in a Level IV Neonatal Intensive Care Unit
Authors: Navalkele Bhagyashri , Fletcher Sheila , Martin Sanjosa , Galloway Regina , Palmer April
Published: November 2021

Human parainfluenza (HPIV) is a common cause for upper respiratory tract illnesses (URTI) and lower respiratory tract illnesses (LRTI) in infants and young children. Here, we describe successful control of an HPIV type 3 (HPIV3) outbreak in a neonatal intensive care unit (NICU). NICU babies with new-onset clinical signs or symptoms of RTI and positive HPIV-3 nasopharyngeal specimen by respiratory pathogen panel (RPP) test on hospital day 14 or later were diagnosed with hospital-onset (HO) HPIV-3 infection. After 3 NICU babies were diagnosed with HO HPIV-3, an outbreak investigation was initiated on May 3, 2019, and continued for 2 incubation periods since the last identified case. Enhanced infection prevention measures were immediately implemented. All positive cases were placed in a cohort in a single pod of the NICU and were placed on contact precautions with droplet isolation precautions. Dedicated staffing and equipment were assigned. Environmental cleaning and disinfection with hospital-approved disinfectant wipes was performed daily. Visitors were restricted in the NICU. All employees entering the NICU underwent daily symptom screening for respiratory tract illness. All NICU babies were screened daily for respiratory tract illness with prompt isolation and RPP testing on positive screen. To determine the source of the HPIV3 outbreak, all HPIV3-positive specimens from the NICU and available temporally associated community-onset (CO) controls collected from non-NICU units were sent to the Centers for Disease Control and Prevention (CDC) for whole-genome sequencing (WGS) analysis. The first and last cases of HPIV-3 were diagnosed on May 1 and May 5, 2019, respectively. In total, 7 HO HPIV3 cases were reported: 1 in newborn nursery (NBN) and 6 in NICU. The case from the NBN was determined to be unrelated to the outbreak and the source was linked to a sick visitor. Of the 6 NICU babies, 5 had an LRTI and 1 had a URTI. Average time from admission to diagnosis was 71 days (range, 24–112). None had severe illnesses requiring intubation, and all had full recovery. No CO HPIV3 cases were reported from the NICU during the investigation. A maximum likelihood phylogenetic tree of HPIV3 WGS (Figure 1) showed that sequences from the 6 HO cases clustered together separately from the 3 CO controls, suggesting a single source of transmission, and 3 CO cases were not related to the HO cases or source of the outbreak. Early diagnosis and isolation of respiratory tract viral infections is important to prevent an outbreak. Successful control of outbreak in NICU requires prompt implementation of infection prevention measures with focus on symptom screening, cohorting, and disinfection practices.

Funding: No

Disclosures: None
Association of Antibiotic Duration and Outcomes among NICU Infants with Invasive Staphylococcus aureus Infections
Authors: Bukhari Areej , Akinboyo Ibukunoluwa , Zimmerman Kanecia , Benjamin Danny , Tolia Veeral , Greenberg Rachel
Published: November 2021

Background:Staphylococcus aureus is the second-leading cause of late-onset sepsis among infants in US neonatal intensive care units (NICUs). Management of S. aureus bacteremia and meningitis in infants varies widely due to the lack of standardized guidelines. We examined the association between initial antibiotic duration and recurrent S. aureus infection or death among NICU infants with S. aureus bacteremia and/or meningitis. Methods: We conducted a retrospective cohort study of infants in Pediatrix Medical Group NICUs from 1997 to 2018 with first episode of S. aureus bacteremia and/or meningitis, identified as having at least 1 blood or cerebrospinal fluid (CSF) culture growing only S. aureus at any point during their NICU stay. Excluded infants were those not started on antistaphylococcal therapy within 2 days of positive culture, those with had endocarditis or osteomyelitis, or those who died or were discharged during or up to 1 day after antibiotic cessation. Antibiotic cessation was defined as last day of antibiotic given if followed by at least 3 days without antibiotics. Multivariable logistic regression was used to analyze the association between antibiotic duration categorized as <14 or ≥14 days) and recurrent SA infection (within 12 weeks of antibiotic cessation, prior to hospital discharge), or death (within 7 days of antibiotic cessation and at discharge). Results: Of 4,086 infants included, 3,991 (98%) had S. aureus bacteremia only and 95 (2%) had meningitis ± bacteremia. Of those with bacteremia only, 2,017 (50.5%), and 17 (18%) of those with meningitis received <14 days antibiotics (Figure 1). Longer antibiotic duration was associated with lower gestational age, methicillin-resistance, severe illness and bacteremia duration of ≥4 days (Table 1). There was a significant association between <14 days antibiotics and recurrent infection (p = 0.04) and 7-day mortality (p = 0.02) in the meningitis cohort. Infants with SA bacteremia who received ≥14 days antibiotics had reduced odds of recurrent SA infection (OR 0.24, 95% CI 0.18-0.32) and death (OR 0.33, 95% CI 0.25-0.44), adjusting for post-natal age, gestational age, sex, methicillin-resistance, severe illness and duration of bacteremia (Table 2). Conclusions: In the largest study thus far examining antibiotic duration among hospitalized infants with S. aureus bacteremia and/or meningitis, ≥14 days antibiotics was associated with decreased odds of recurrent infection or death. Further studies are needed to define the optimal treatment duration and identify clinical factors distinguishing infants able to safely receive a shorter antibiotic duration.

Funding: No

Disclosures: None
Antimicrobial Stewardship in Acute-Care Hospitals: A Report of the California Healthcare-Associated Infections Honor Roll
Authors: Kriengkauykiat Jane , Epson Erin , Garcia Erin , Komaiko Kiya
Published: November 2021

Background: Antimicrobial stewardship has been demonstrated to improve patient outcomes and reduce unwanted consequences, such as antimicrobial resistance and Clostridioides difficile infection. The California Department of Public Health (CDPH) Healthcare-Associated Infection (HAI) Program developed an honor roll to recognize facilities with the goal of promoting antimicrobial stewardship programs and encouraging collaboration and research. Methods: The first open enrollment period in California was from August 1 to September 1, 2020, and was only open to acute-care hospitals (ACHs). Enrollment occurs every 6 months. Applicants completed an application and provided supporting documentation for bronze, silver, or gold designations. The criteria for the bronze designation were at least 1 item from each of CDC’s 7 core elements for ACHs. The criteria for silver were bronze criteria plus 9 HAI program prioritized items (based on published literature) from the CDC Core Elements and demonstration of outcomes from an intervention. The criteria for gold designation were silver criteria plus community engagement (ie, local work or collaboration with healthcare partners). Applications were evaluated in 3 phases: (1) CDPH reviewed core elements and documentation, (2) CDPH and external blinded antimicrobial stewardship experts reviewed outcomes as scientific abstracts, and (3) CDPH reviewed each program for overall effectiveness in antimicrobial stewardship and final designation determination. Designations expire after 2 years. Results: In total, 119 applications were submitted (30% of all ACHs in California), of which 100 were complete and thus were included for review. Moverover, 33 facilities were from northern California and 67 were from southern California. Also, 85 facilities were part of a health system or network, 14 were freestanding, and 1 was a district facility. Facility types included 68 community hospitals, 17 long-term acute-care (LTAC) facilities, 17 academic or teaching hospitals, 4 critical-access hospitals, and 4 pediatric hospitals. There was an even distribution of hospital bed size: 35 facilities had <250 beds. The final designations included 19 gold, 35 silver and 43 bronze designations. There was 44% incongruency in applicants not receiving the designation for which they applied. Community hospitals were 63%–74% of all designations, and no LTACs received a gold designation. Moreover, 63% of hospitals with gold designations had >250 beds, and 47% of hospitals with bronze designations had <1 25 beds. Conclusions: The number of applicants was higher than expected because the open enrollment period occurred during the COVID-19 pandemic. This finding demonstrates the high importance placed on antimicrobial stewardship among ACHs. It also provides insight into how facilities are performing and collaborating and how CDPH can support facilities to improve their ASP.

Funding: No

Disclosures: None
Blood Culture Utilization at Six Southeastern US Hospitals
Authors: Warren Bobby , Moehring Rebekah , Yarrington Michael , Anderson Deverick , Polage Christopher
Published: November 2021

Group Name: Duke Center for Antimicrobial Stewardship and Infection Prevention

Background: Blood cultures are an essential diagnostic test, but over- and underutilization may cause harm. Methods: We analyzed blood culture utilization at 6 hospitals in the southeastern United States including 1 academic hospital (A) and 5 community hospitals (B–F) from May 2019 to April 2020. We measured blood culture utilization rate (BCUR) per 1,000 patient days and blood cultures per encounter. We counted blood cultures by laboratory accession number and measured utilization per 1,000 patient days and encounter. A likely contaminant was defined as 1 of 2 blood cultures collected in the same calendar day positive for a common skin commensal (CSC), as defined by the NHSN, and not identified from subsequent cultures. A likely pathogen was defined as a culture with a pathogen not on the CSC list or a CSC not meeting the contaminant definition. Hospital-level BCUR included samples for culture collected in the emergency department (ED) and inpatient areas divided by inpatient days. Results: The analysis included 117,897 blood cultures and 662,723 patient days with a median BCUR of 209.7 per hospital and median blood culture per encounter of 2 (Table 1). One community hospital (C) demonstrated a substantially higher BCUR than others. Cultures were frequently collected in the ED (54%; range, 36%–78%); most encounters with cultures in the ED were subsequently admitted to an inpatient unit (84%; range, 73%–89%). Higher BCURs were observed in intensive care and oncology units. The proportion of first blood cultures drawn after initiation of antibiotics was 6% (range, 3%–9%. Mondays had higher BCURs than other days of the week (Figure 1). The average BCUR by month was 176.1 (range, 164.3–181.4) with no seasonal patterns observed. Overall, 7.7% (range, 4.5%–9.1%) of blood cultures identified a likely pathogen and 2.1% (range, 1.3%–3.2%) identified a likely contaminant. The 3 hospitals with BCURs >200 also had contaminant rates >2% and >60% ED cultures. Conclusions: Blood culture utilization varied by hospital, unit, and day of the week. We observed higher rates of likely contaminants among hospitals with higher BCURs and ED culture rates. Comparisons may assist in identifying opportunities to optimize practice around blood-culture ordering and collection.

Funding: No

Disclosures: None
Outpatient Antibiotic Use for Common Infectious Diagnoses: Patterns in Telehealth During the Emergence of COVID-19
Authors: Wilson Brigid , Bej Taissa , Song Sunah , Briggs Janet M , Banks Richard , Jump Robin , Perez Federico , Akpoji Ukwen
Published: November 2021

Background: The influence of increased use of telehealth during the emergence of COVID-19 on antibiotic prescriptions in outpatient settings is unknown. The VA Northeast Ohio Healthcare System has 13 community-based outpatient clinics (CBOCs) that provide primary and preventive care. We assessed changes in antibiotic prescriptions that occurred as care shifted from in-person to telehealth visits. Methods: Using VHA administrative databases, we identified all primary care CBOC visits between January 1, 2019, and December 31, 2020, that included a diagnosis for an acute respiratory infection (ARI), a urinary tract infection (UTI), or a skin or soft-tissue infection (SSTI), excluding visits with >1 of these diagnoses or with additional infectious diagnoses (eg, pneumonia, influenza). We summarized the proportion of telehealth visits and the proportion of patients prescribed antibiotics at quarterly intervals. We specifically assessed outpatient visits from April to December 2019 compared to the same months in 2020 to account for seasonality while analyzing diagnosis and antibiotic trends in the emergence of the COVID-19 pandemic. Results: The patients receiving care in April–December 2019 compared to April–December 2020 were similar (Table 1). From April through December 2019, 90% of CBOC primary care visits with a diagnosis for ARI, UTI, or SSTI were in-person, and antibiotics were prescribed at 63%, 46%, and 65% of visits in either modality, respectively (Figure 1). From April through December 2020, only 33% of CBOC primary care visits for ARI, UTI, and SSTI were in person, and antibiotics were prescribed at 46%, 38%, and 47% of visits in either modality, respectively. Comparing April–December in 2019 and 2020, the number of CBOC visits for ARI fell by 76% (2,152 visits to 509 visits), with a more modest decline of 20% and 35% observed for UTI and SSTI visits. In-person visits for ARIs and SSTIs were more likely than telehealth visits to result in an antibiotic prescription (Figure 2). Conclusions: Among the CBOCs at our healthcare system, an increase in the proportion of telehealth visits and a reduction in ARI diagnoses occurred after the emergence of COVID-19. In this setting, we observed a reduction in the proportion of visits for ARIs, UTIs, and SSTIs that included an antibiotic prescription.

Funding: Merck

Disclosures: None
Minimal Mortality Among Veterans with Urine Cultures Positive for Group B Streptococcus
Authors: Mongilardi Nicole , Jump Robin , Perez Federico , Bej Taissa , Briggs Janet M , Banks Richard , Wilson Brigid , Song Sunah
Published: November 2021

Background: Group B Streptococcus (GBS) can cause life-threating invasive infections, yet GBS is also a normal component of the intestinal and genitourinary tract. Although it is regarded as a potential urinary pathogen, the morbidity and mortality associated with recovery of GBS from urine cultures of nonpregnant adults is not well understood. We evaluated characteristics and mortality among nonpregnant adults with urine cultures that grew GBS. Methods: Using administrative data from the Veterans’ Healthcare Administration (VHA), we conducted a retrospective cohort study of VA healthcare system users from January 1, 2008, through December 31, 2017, with monomicrobial urine cultures growing ≥100,000 colony-forming units of GBS. Urinary tract infection (UTI) cases were defined as urinalysis positive for leukocyte esterase and pyuria (≥10 white blood cells), an International Classification of Diseases (ICD) code for UTI, and an antibiotic prescription. Cases with colonization were defined as negative for leukocyte esterase and pyuria, no ICD code for UTI, and no antibiotic prescription. Cases not meeting either definition were deemed unclassifiable. We compared demographics, comorbidities, and all-cause mortality among these 3 groups. Results: Over the 10-year study period, 26,848 veterans had 30,740 urine cultures positive for GBS. Applying the definitions above, there were 2,807 cases of infection, 8,789 cases of colonization, and 15,252 cases that were unclassifiable. Patients with a GBS UTI were slightly older compared to those who were colonized, with a higher Charlson comorbidity index and greater burden of chronic renal disease (Table 1). Individuals with infection versus colonization had 30-day mortality rates of 1% and 0%, respectively, and 1-year mortality rates of 9% and 4%, respectively (Figure 1). Conclusions: The association of a greater burden of illness among veterans who met our definition of UTI compared to colonization might be more reflective of providers’ responses to patients with chronic medical conditions rather than a difference in GBS as a cause of UTI. Overall, the prospect of a urine culture that grows GBS does not appear to be associated with adverse long-term outcomes.

Funding: No

Disclosures: None
Assessing Baccalaureate Nursing Students’ Antibiotic Stewardship Knowledge Using Virtual Standardized Patient Simulations
Authors: Lou Manning Mary , Pogorzelska-Maziarz Monika , Jack David , Wheeler Lori
Published: November 2021

Background: According to the Centers for Disease Control and Prevention, the single most important factor leading to the development of antibiotic resistance (AMR) is the use of antibiotics. Studies indicate that up to 50% of hospitalized patients receive at least 1 antibiotic, half of which are inappropriate. The outpatient setting accounts for >60% of antibiotic use and over half of these prescriptions are inappropriate. Antibiotic stewardship programs improve appropriate antibiotic use, reduce AMR, decrease complications of antibiotic use, and improve patient outcomes. Building a nursing workforce with necessary AMR and antibiotic stewardship knowledge and skill is critical. Nursing graduates can translate knowledge into practice, promoting the judicious use of antibiotics to keep patients safe from antibiotic harm. Methods: Third-year baccalaureate nursing students enrolled in a fall 2020 health promotion course at an urban university affiliated with an academic medical center participated. Students received a 3-hour lecture on antibiotics, AMR and antibiotic stewardship nursing practices and actively engaged in antibiotic stewardship simulations using standardized patient (SP) encounters. The SP participants were specifically trained for these activities. Simulations included a 30-minute brief before and a 60-minute briefing after the activities. All activities occurred via video conferencing. Case scenarios, developed by the authors, focused on penicillin-allergy delabeling of an adolescent prior to elective surgery and appropriate use of antibiotics in managing pediatric urinary tract infections and acute otitis media (AOM). Before-and-after tests were used to assess the impact on AMR and antibiotic stewardship knowledge. Results: Over a period of 4 days, all enrolled students (n = 165) participated in 1 three-hour virtual simulation session. Using Zoom video conferencing with multiple breakout rooms, the activities were easily managed. During the simulations, students often struggled with reading an antibiogram and applying the concept of “watchful waiting” in AOM management. Significant differences were found in before-and-after test results, with significant improvement in students’ general and specific knowledge and awareness of antibiotics (P < .01). During the debriefing sessions, students reported increased awareness related to their role in advancing the judicious use of antibiotics. Conclusions: Initially, we planned to conduct in-person SP simulations. Due to the COVID-19 pandemic, faculty and students demonstrated remarkable flexibility and resilience as we successfully converted to a virtual format. Virtual lecture and SP simulations, followed by debriefing, was an effective approach to educate baccalaureate nursing students about AMR and their role in antibiotic stewardship. Areas for course content improvement were identified.

Funding: No

Disclosures: None
Evaluation of Penicillin Allergies and an Allergy Assessment Pilot in the Emergency Department
Authors: Norris Ashlyn , Northam Kalynn , Daniels Lindsay , Kwan Mildred , Burke Gary , Mavrogiorgos Nikolaos , Boerneke Renae
Published: November 2021

Penicillin (PCN) allergy is one of the most frequently reported medication allergies, with ~10% of the US population reporting a PCN allergy. However, studies have shown that only 1% of the US population have a true IgE-mediated reaction to PCN. Delabeling and appropriately updating patient allergy profiles could decrease the use of alternative broad-spectrum antibiotics, rates of infectious complications [C. difficile, methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococcus (VRE)], antibiotic resistance, and overall healthcare cost. The emergency department (ED) is an important setting in which to assess PCN allergies and to delabel patients when appropriate because there are >130 million ED visits in the United States each year. We sought to determine the percentage of PCN allergy–labeled patients who could be delabeled through a PCN allergy assessment interview in an ED. Key secondary outcomes included the percentage of interviewed patients who could not be delabeled based on history alone but would be eligible for an amoxicillin oral challenge or a PCN skin test (PST). A prospective PCN allergy assessment pilot was performed for patients aged >18 years presenting to the UNC Medical Center ED between December 1 and December 17, 2020, with a documented PCN allergy. A pharmacist conducted penicillin allergy assessments on a convenience sample of patients presenting to the ED between 8 a.m. and 3 p.m. on weekdays. Based on patients’ reported and documented histories, charts were updated with the most accurate information and allergies were delabeled if appropriate. In total, 95 patients were assessed; 62 (65.3%) were interviewed and 15 (24.2%) were delabeled. In addition, 26 patients (41.9%) were deemed eligible for an oral amoxicillin challenge, 19 (30.6%) qualified for a PST, and 2 (3.2%) patients did not qualify for further assessment due to having a an IgE-mediated reaction in the past 5 years. Of the 15 patients who were delabeled, 6 (40.0%) received antibiotics during their admission: 4 (73.3%) of those patients received a penicillin and 2 (36.7%) received a cephalosporin, all without adverse reactions. Patient assessments took ~20 minutes to complete, including chart review, patient interview, and postinterview chart updating. The results from this pilot study demonstrate the impact of performing PCN allergy assessments in ED. Interdisciplinary opportunities should be explored to develop processes that will improve the efficiency and sustainability of PCN allergy assessments within the ED to allow this important stewardship intervention to continue.

Funding: No

Disclosures: None