bluuebunny/crossref_metadata_2025 huggingface dataset:
Teams in transition: Increasing role of advanced practice providers in inpatient antimicrobial use
Authors: Perez Reinaldo , Yarrington Michael , Deri Connor , Smith Michael , Hayes Jillian , Wrenn Rebekah , Moehring Rebekah
Published: September 2023

Background: Antimicrobial stewardship strategies must be tailored to effectively engage prescribers with distinct training, experiences, and career paths. Advanced practice providers (APPs) have taken on increasing roles as primary team members in acute-care hospitals, but the impact of this practice shift on antimicrobial prescribing is unknown. We describe longitudinal trends in antimicrobial days of therapy (DOT) by attributed provider type in 3 hospitals. Methods: We performed a retrospective time-series analysis of antimicrobial use for the 7-year period of July 2015–June 2022 to investigate the changes by provider type at 3 hospitals: a major university hospital and 2 community hospitals. DOT, antibacterial, and antifungal agent groups were defined using National Healthcare Safety Network methods. We included anti-influenza and antiherpesvirus agents in the antiviral group. We defined protected agents as those targeted by hospital antimicrobial stewardship program policy (eg, requiring preauthorization). Provider type was defined by electronic health record user profiles in 3 categories: physician, trainees (residents, fellows and medical students), and APPs (nurse practitioners, physician assistants, and nurse anesthetists). We evaluated DOT per 1,000 days present over time by agent group to assess quarterly rate trends. Then, we calculated the percentage of total DOT by provider group. We used multinomial logistic regression to measure changes in percentage DOT across the clinician groups over time using physicians as the referent. Results: Across hospitals and provider groups, we observed an overall decrease in use rates for antibacterial and protected agents (17% each) and increased use rates for antiviral agents (38%) and antifungal agents (4%) (Table 1). Baseline distribution of DOT by provider group and change in distribution over time varied by hospital and agent group (Fig. and Table 2). The largest increases in percentage DOT attributed to APPs compared with physicians occurred in the university hospital with the following average increases per quarter: 1.5% for antibacterials, 3.9% for antivirals, 3.3% for antifungals, and 3.8% for protected agents (Table 3). Community hospitals had higher initial percentage DOT attributed to physicians, but both hospitals experienced increased percentage DOT attributed to APPs. Percentage DOT attributed to trainees varied significantly across agent groups and hospitals. Conclusions: Hospitals had differing baseline patterns of DOT attributed to provider groups, but all experienced increases in DOT attributed to APPs. APPs have increasing involvement in antimicrobial use decisions and should be engaged in future antimicrobial stewardship initiatives.

Disclosures: None
Handshake stewardship on adult acute-care surgical services
Authors: Neuner Elizabeth , Hsueh Kevin , Durkin Michael , Sayood Sena
Published: September 2023

Background: Handshake stewardship is a variation of prospective audit and feedback that entails the individual review of patient charts by a physician–pharmacist collaborative team followed by in-person feedback to primary teams to communicate recommendations regarding optimal antibiotic use. Handshake stewardship has been shown to have durable effects in reducing antimicrobial use in children’s hospitals, but data regarding this intervention in adult hospitals are scarce. In particular, no data are available regarding the impact of this type of stewardship intervention on adult surgical units. We examined the effect of a handshake stewardship intervention at a large academic medical center on adult trauma and acute- and critical-care surgery (ACCS) units. Methods: The antimicrobial stewardship program (ASP) at Barnes-Jewish Hospital launched a handshake stewardship intervention targeting surgical floor teams in January 2022. These teams included the ACCS teams and a number of other surgical services. The intervention consisted of once weekly reviews and in-person rounds with the surgical floor teams along with the establishment of a 7 day per week “hotline” in which the surgical teams could contact an ID physician or pharmacist with questions regarding antibiotic use. Patients with formal ID consultations were not reviewed. Recommendations were tracked including the type, the antibiotic targeted, and recommendation acceptance or rejection. Descriptive statistics were performed to analyze these results. At the end of 12 months, antibiotic use in the floors covered by the ACCS teams were pulled from the NHSN AU module to perform an interrupted time-series analysis 12 months before and after the intervention. Results: Overall, 3,127 charts were reviewed during the intervention period and 637 recommendations were made to all the surgical teams. Opportunities for antibiotic use optimization were identified in ~20% of antibiotic orders. The overall recommendation acceptance rate was 71%. In the ACCS units, 272 interventions were recommended, with an acceptance rate of 67%. The most frequent recommendations were for antibiotic discontinuation (37%), antibiotic de-escalation (17%), shortening duration (12%), and broadening coverage (12%). Antibiotic usage trends (Fig. 1) on the ACCS floors, which were showing a nonsignificant increasing trend (P = .70) before and after the intervention, now show a nonsignificant decreasing trend (P = .20). Conclusions: There are numerous opportunities for antibiotic optimization on adult surgical floors. Although handshake stewardship is a labor-intensive intervention, preliminary findings after 1 year show that, on ACCS units, there may be a trend toward a sustained impact.

Disclosures: None
Variations in implementation of antimicrobial stewardship via telehealth at select Veterans Affairs medical centers
Authors: Wilson Geneva , Vivo Amanda , Livorsi Daniel , Sabzwari Rabeeya , Crnich Christopher , Jump Robin , Evans Charlesnika
Published: September 2023

Background: Antimicrobial stewardship programs (ASPs) seek to reduce the prevalence of antimicrobial-resistant and healthcare-associated infections. There are limited infectious disease (ID) physicians and pharmacists to support these ASPs, particularly in rural areas. The Veterans Health Administration has a robust telehealth program in place. Our previous work has demonstrated the feasibility of using telehealth modalities to support ASPs at rural Veterans Affairs medical centers (VAMCs) by pairing them with an ID expert from a larger, geographically distant, VAMC. This program, dubbed the Videoconference Antimicrobial Stewardship Team (VAST), emphasizes discussion of patients undergoing treatment for an active infection and additional relevant clinical topics with a multidisciplinary team at the rural VA. VAST implementation is ongoing at VAMCs. To understand and compare the qualitative differences in implementation, we used process maps to describe the VAST at 3 VAMC dyads. Methods: Team members from each dyad participated in interviews at 3, 6, and 9 months after beginning their VAST sessions. Questions addressed several aspects of VAST implementation and included identifying cases and topics to discuss; advance preparation for meetings; the frequency and general structure of VAST meetings; and documentation including workload capture. The research team used the responses to develop process maps to permit visual display and comparison of VAST implementation. Results: The first dyad began in January 2022 and the third in March 2022. The sessions had 3 phases: preparation, team meeting, and documentation of experts’ recommendations. Tasks were shared between VAST champions at the rural VAMC and the ID experts (Fig. 1). The preparation phase showed the most variation among the 3 dyads. In general, champions at the rural VA identified cases and topics for discussion that were sent to the ID expert for review. The approaches used to find cases and the type of preparatory work by the ID expert differed. Team meetings differed in both frequency and participation by professionals from the rural site. Documentation of expert recommendations processes appeared similar among the dyads. Discussion: Each of the 3 dyads implemented VAST differently. These results suggest that the overall structure of the VAST is readily adaptable and that each site tailored VAST to suit the clinical needs, workflow, and culture of their partner facility. Future work will seek to determine which aspects in the preparation, team meeting, or documentation phases are associated with successful ASPs, including assessment of quantitative and qualitative outcomes.

Disclosures: None
Heterogeneous OPAT regimens within and across infection diagnoses: Day-level medication use patterns among 2072 OPAT patients
Authors: Ponder Madison , Boerneke Renae , Schranz Asher , Swartwood Michael , Farel Claire , Kinlaw Alan
Published: September 2023

Background: Patients receiving outpatient parenteral antimicrobial therapy (OPAT) are often medically complex and require carefully tailored treatments to address severe and often concomitant infections. Our objective was to illustrate the heterogeneity in antimicrobials used for patients in OPAT, within and across infection diagnosis groups. Methods: We abstracted electronic health record data regarding day-level treatment into a registry of 2,358 OPAT courses (n = 2,072 unique patients) treated in the University of North Carolina Medical Center OPAT program during 2015–2022 (total, 11,861 person weeks; average, 7 OPAT weeks per patient). We classified infection diagnoses into 10 hierarchical or mutually exclusive categories (eg, bacteremia only, diabetic foot infection (DFI) only, osteomyelitis only) (Fig., vertical axes). Accounting for 64 antimicrobial medications and 520 cocktails administered for at least 1 patient day in our OPAT registry, we also defined 18 hierarchical or mutually exclusive classifications of treatment (eg, “daptomycin alone” or “daptomycin and any other antibiotic(s)” (Fig. key). We conducted 2 stratified analyses to describe the heterogeneity across infection diagnoses with respect (1) to medications used at OPAT initiation (patient as unit of analysis) and (2) to medications used throughout OPAT (person time as unit of analysis, allowing for differential OPAT course to other treatment classifications during follow-up). We present stacked bar charts to visualize the intersection between infection diagnosis and treatment group. Results: Among patients in this OPAT registry, 34.6% had osteomyelitis and/or DFI, 4.8% had bacteremia, and 44.6% had multiple infections (Fig. 1). The most common medications in initial OPAT regimens were vancomycin (30.8% of OPAT patients), ceftriaxone (15.0%), and daptomycin (10.9%). We observed overall similarity between the distribution of treatment groups at initiation compared to cumulative person-time during the OPAT course (Figs. 1 and 2). However, we observed heterogeneity in medications by infection diagnosis (Figs. 1 and 2); for example, vancomycin was used in 39% of osteomyelitis cases but only 14% for endocarditis (Fig. 2). For several infection groups (eg, osteomyelitis, DFI, multiple infections, “other” single infections), no treatment classification exceeded 20% use (Figs. 1 and 2). Conclusions: Day-level data on medication use in this monitored registry of patients provided evidence of heterogeneity in the types of medications used throughout treatment in OPAT, which varies within and across infection diagnoses. These data highlight the need for multilayered ascertainment of medication exposure in this medically complex patient population to inform surveillance for adverse effects and guide comparative effectiveness research for postdischarge antibiotic treatment.

Disclosures: None
Estimating racial differences in risk for CLABSI in a large urban healthcare system
Authors: Licitra Giancarlo , Fridkin Scott , Wiley Zanthia , Gottlieb Lindsey , Dube William , Kumar Vishnu Ravi , Patzer Rachel , Asrani Radhika Prakash
Published: September 2023

Background: Socioeconomic barriers or divergent implementation of prevention measures may impact risk of healthcare-associated infections by racial groups. We utilized a previously studied cohort of patients to quantify disparities in central-line–associated bloodstream infection (CLABSI) risk by race accounting for inherent differences in risk related to device utilization. Methods: In a retrospective cohort of adult patients at 4 hospitals (range, 110–733 beds) from 2012 to 2017, we linked central-line data to patient encounter data: race, age, comorbidities, total parenteral nutrition (TPN), chemotherapy, CLABSI. Analysis was limited to patients with >2 central-line days and <3 concurrent central lines. Patient exposures were calculated for each central-line episode (defined by insertion and removal dates); analysis of central-line episode-specific risk of CLABSI among Black versus White patients adjusted for clinical factors, duration of central-line episode, and central-line risk category (ie, low: single port, dialysis or PICC; medium: single temporary or nontunneled; or high: any concurrent central-lines) in Cox proportional hazards regression of time to CLABSI. Results: In total, 526 CLABSIs occurred a median of 14 days after insertion among 57,642 central-line episodes in 32,925 patients. CLABSIs occurred in similar frequency across racial groups: 217 (1.7%) among Black patients, 256 (1.6%) among White patients, and 11 (1.6%) among Hispanic patients (also 42 among unknown or other race). Duration of central-line episode was similar between racial groups (median, 5 days). Black patients were less likely to have medium-risk central lines (34%) compared to white patients (RR, 0.82; 95% CI, 0.79–0.84), but they had a similar frequency of high-risk central lines (21%; RR, 1.0; 95% CI, 1.0–1.1). Compared with low-risk central lines, risk of CLABSI was increased among medium-risk central lines (RR, 1.3; 95% CI, 1.0–1.7) and high-risk central lines (RR, 2.2; 95% CI, 1.8–2.7). CLABSIs were more likely in TPN central lines (RR, 2.3; 95% CI, 1.9–2.7) than others, but they were not more likely among Black patients than White patients (RR, 0.9; 95% CI, 0.1–1.1). In survival analysis, there were 24,700 central-line episodes among Black patients compared to 26,648 episodes among White patients; adjusting for central-line risk and TPN, the risk of CLABSI was similar during the first 21 days of central-line use (adjusted hazard ratio, 1.08; 95% CI, 0.88–01.32) (Fig. 1). Conclusions: After accounting for central-line configuration, Black patients did not have a higher risk of CLABSI within 21 central-line days. Further evaluation is warranted to assess racial disparities in risks of other healthcare-associated infections and to determine whether a lack of CLABSI-specific racial disparities can be replicated in other regions and healthcare systems.

Disclosures: None
Utilizing data to foster equity in infection prevention outreach among skilled nursing facilities in Michigan
Authors: White Christine , David Michael , Juarez Ruben
Published: September 2023

Background: Since October 2020, the Infection Prevention Resource and Assessment Team (IPRAT) has provided infection prevention guidance and support to congregate-care settings throughout Michigan. Specifically, outreach to skilled nursing facilities (SNFs) in response to reported positive COVID-19 resident and staff cases. Case rates provide limited data and do not factor in additional variables, such as staffing shortages, geographical location, or access to supplies, which can increase the vulnerability of staff and residents to outbreaks. To facilitate equitable outreach, a risk assessment was developed using variables related to infection prevention and poor COVID-19 outcomes utilizing local, state, and federal data reporting websites. Methods: A retrospective data review of IPRAT’s electronic data repository was performed, and 2 distinct periods were identified between November 6, 2020, and December 5, 2022. Outreach method 1 involved only using case counts from November 6, 2020, to September 24, 2021. Outreach method 2 (new risk-assessment–based outreach) involved additional data points from April 12, 2021, to December 5, 2022. Data included 17 self-reported items from the NHSN, 3 characteristics regarding facilities’ COVID-19 units, and 7 community-level variables derived from county vaccine rates, social vulnerability index (SVI), and COVID-19 community transmission level. The scoring of each data point ranged from 0–10, and outreach was prioritized to facilities with the highest overall scores. Successful referrals (resulting in a site visit) were compared to the SVI and healthcare emergency regional maps to determine whether the new outreach method reached more facilities in vulnerable communities. Results: Of 358 outreach attempts, IPRAT had a higher success rate with method 2 (6.9%) compared to method 1 (5.3%) and improved outreach in rural Michigan regions 7 and 8 (15% vs 3%). Site visits in counties with a high SVI rating with method 2 were 14.5% versus 10.6% using method 1. COVID-19 prevention referral success rates were higher (4.4% vs 3.1%) using method 2. Conclusions: The risk-assessment–based outreach method showed improvement in overall referral success rates among facilities in rural and higher-SVI counties. These communities tend to experience higher health disparities and poorer health outcomes. Incorporating the more nuanced data variables correlated with at-risk congregate-care settings receiving timelier outreach. The limitations of the study include sample size, period of data collected (2 years), and the complexity of objectively measuring equity.

Disclosures: None
Identifying opportunities for diagnostic stewardship in UTI testing in pediatrics
Authors: Acker Karen , Alfonzo Michael , Gray Tess , Dempsey Taylor , Saiman Lisa , Westblade Lars , Racine-Brzostek Sabrina , Gerber Nicole
Published: September 2023

Background: Reflexive urine culturing, a strategy wherein urine cultures are only performed on samples with pyuria, is increasingly being used to reduce unnecessary urine cultures, healthcare costs, and inappropriate antibiotics. To support implementation of a reflexive urine-culture order for pediatric patients aged <18 years, we assessed the proportion of urine cultures that would be avoided with reflexive urine culturing, and we calculated the sensitivity and negative predictive value (NPV) of the ≥10 white blood cells (WBC) per high-powered field (HPF) threshold for diagnosing urinary tract infections (UTI) in patients aged <18 years who presented to the pediatric emergency department (ED). Methods: A retrospective review of patients <18 years with a urine culture performed from January to May 2022 in an urban, tertiary-care, pediatric ED was performed. A positive urine culture was defined as ≥50,000 CFU/mL for catheterized specimens and ≥100,000 CFU/mL for clean-catch or unspecified specimens. Pyuria was defined as ≥10 WBC/HPF. ‘True UTI’ was defined as a positive urine culture with a consistent clinical presentation (eg, fever or dysuria). Sensitivity, specificity, and NPV were calculated using the pyuria threshold of ≥10WBC/HPF compared to the gold standard of a ‘true UTI.’ Results: During the study period, 658 patients aged <18 years had urine cultures sent, of which 46 (7%) were positive. In all, 407 urine cultures (61.9%) were obtained by clean catch, 233 (35.4%) were obtained by urethral catheterization, 2 (0.3%) were obtained by Foley catheter, and 16 (2.4%) were unspecified. Among the 46 positive cultures, 32 (69.6%) had ≥10 WBC/HPF, and 55 (9.0%) of 612 negative cultures had ≥10 WBC/HPF. Of the 14 patients with positive urine cultures without pyuria, 8 had a contaminated sample or asymptomatic bacteriuria, 3 had urologic abnormalities, and 3 were infants aged <3 months. Of the 14 patients, 3 (21.4%) had a consistent clinical presentation for UTI and were treated with antibiotics: 2 were infants aged <3 months and 1 had urologic abnormalities. Using the ≥10 WBC/HPF threshold compared to ‘true UTI,’ sensitivity was 91.4%, specificity was 91.5%, positive predictive value was 36%, and NPV was 99.5%. Sensitivity and NPV increased to 100% when infants aged <3 months and urologic patients with positive urine culture were excluded. We estimated a cost saving of ~$200,000 had reflexive testing been in place. Conclusions: A reflexive urine culture for specimens with ≥10 WBC/HPF would have reduced the number of urine cultures substantially because 571 (86.8%) of 658 urine cultures would not have been performed. To prevent missed diagnoses of UTI, infants aged <3 months and children with urologic abnormalities should be excluded from this diagnostic stewardship intervention.

Disclosures: None
Measuring hand hygiene opportunities per hour across two neonatal intensive care units
Authors: Lee Eugene , Al-Muthree Souad , Reason Paige , Donohue Meghan , Dunn Michael , Statchuk Meghan , Khan Sarah , Gupta-Bhatnagar Shikha , El-Helou Salhab , Leis Jerome , Mertz Dominik
Published: September 2023

Background: To estimate hand hygiene compliance using electronic hand hygiene monitoring, the number of hand hygiene opportunities (HHOs) per period must be known in a given setting. Data on the number of HHOs in a neonatal ICU (NICU) are limited. We measured HHOs per hour and identified factors that may influence the number of HHOs per hour to calibrate compliance estimates for electronic hand hygiene monitoring. Methods: The study was conducted in 2 large NICUs in Ontario, Canada (72 and 42 beds, respectively). We centrally trained observers to identify HHOs using the Ontario-based “Four Moments of Hand Hygiene,” which is similar to combining moments 4 and 5 of the WHO “Five Moments of Hand Hygiene.” To apply the moments of hand hygiene to the NICU setting, the following modifications were made: moment 1 was entering the incubator or contact with anything within the ‘baby space’ directly around the incubator, and moment 4 was when hands exited the incubator and, as such, the ‘baby space.’ Using a standardized tool, the investigators conducted direct observation of HHOs during randomized observation periods from July 1, 2022, to January 9, 2023. In addition to HHOs, data on covariables potentially associated with the frequency of HHOs were collected: time and day of the week, acuity, additional precautions, corrected gestational age, and private versus multibed room or open pod. Results: We audited HHOs for 146 hours including 26 at site A and 120 at site B. Overall, 804 HHOs (69.2%) occurred during weekdays and 739 (63.6%) occurred during day shifts from 7:00 a.m. to7:00 p.m. The most frequent moments of hand hygiene were moment 1 (47.8%, before contact) and moment 4 (36.8%, after contact). The average numbers of HHOs were 7.8 per hour overall, 7.6 per hour on weekdays, 7.7 per hour on weekends, 8.8 per hour on day shifts, and 6.8 per hour on night shifts. The breakdown of HHOs by profession was 92.8% nurses, 0.6% physicians, 4.5% allied health, and 2.1% for others. Discussion: The rate of HHOs in NICU varied over a 24-hour period and was similar between 2 different NICUs. Evenings and weekends had considerably fewer average HHOs, and peaks were observed following nursing shift changes. The rate of HHOs may be influenced by other factors including unit design, patient acuity, and use of transmission-based precautions. Further analysis using a Poisson regression model will help to explore these factors and to calibrate electronic monitoring for this population.

Disclosures: None
Exploring the relationship between the reduction of floor microbial burden and the impact on healthcare-associated infections
Authors: Crews-Stowe Caitlin , Lambert Elizabeth , Berthelot Lori , Baumgarten Katherine
Published: September 2023

Background: Healthcare floors are a vehicle and/or source for potential pathogens that cause healthcare associated infections, and hospital floors are often heavily contaminated with pathogens such as Clostridioides difficile and methicillin-resistant Staphylococcus aureus. However, definitive research linking reductions in floor burden to reductions in HAIs has not yet been established. We sought to evaluate emerging technology for continuous disinfection and its potential impact on HAIs. This study was designed to explore the potential relationship between the reduction of microbial burden of floors and healthcare associated infections. Methods: A prospective study was conducted in a 22-bed medical-surgical intensive care unit in a 180-bed suburban hospital near New Orleans, Louisiana, from November 2021 to June 2022. Using sterile, premoistened sponges, samples were collected from the floors of 10 areas throughout the unit including 2 nurses’ stations, the physician charting area, and 7 patient rooms. The advanced photocatalytic oxidation (aPCO) equipment was then installed in the HVAC ductwork throughout the ICU and activated. Environmental surface sampling of the same floor surfaces was then repeated every 4 weeks for the first 5 months of the study. HAIs were also tracked throughout the entire study period. The facility’s normal cleaning floor protocols using a neutralizing floor cleaner were unchanged and followed during the study. Changes in surface burden were calculated using a repeated-methods ANOVA with post hoc analyses as appropriate. Rates of healthcare associated infections were compared using χ2 analyses. Results: Overall, there was a 99.6% statistically significant decrease in floor environmental surface burden from the baseline to the final postactivation test (Fig. 1). The average colony forming unit count (CFU) decreased from 318,850 CFU per 100 cm2 to just 2,988 CFU per 100 cm2. The unit also saw a statistically significant decrease in publicly reported healthcare associated infections (HO-MRSA, CLABSI, HO-CDI) during the study period compared to the same period a year prior and in the 6 months immediately prior to the beginning of the study (Fig. 2). Conclusions: Advanced photocatalytic oxidation technology resulted in a reduction of microbial burden on the floors of a high-traffic intensive care unit. Statistically significant decreases in healthcare-associated infections was also seen. This study highlights a novel aPCO technology and its efficacy at reducing microbial burden and healthcare-associated infections despite no change in practice.

Disclosures: None
“Acute urinary antibiotics”—A simple metric to identify outpatient antibiotic stewardship opportunities in renal transplant
Authors: Zimmet Alex , Ha David , Mui Emily , Smith Mary , Alegria William , Holubar Marisa
Published: September 2023

Background:International Classification of Diseases, Tenth Edition (ICD-10) data help track outpatient antibiotic prescribing but lack validation in immunocompromised populations or subspecialty clinics for this purpose. Asymptomatic bacteriuria (ASB) and urinary tract infection (UTI) are important stewardship targets in renal transplant (RT) patients, but they may require alternative metrics to best monitor prescribing patterns. We describe ICD-10 utilization for RT clinic encounters in which antibiotics were prescribed. We developed a metric classifying “acute urinary antibiotics” (AUA) to track antibiotic use for ASB and UTI, and we validated systematic identification of AUA to enable practical implementation. Methods: We examined RT clinic visit and telemedicine encounters from 2018 to 2021 conducted 1 month after transplant. This project was deemed non–human-subjects research by the Stanford Panel on Human Subjects in Medical Research. Results: The analytic cohort included 420 antibacterial prescriptions from 408 encounters (Fig. 1). Of 238 patients, 136 (57%) were male and 112 (47%) were Hispanic or Latino. The most common primary ICD-10 code was Z94.0 (kidney transplant status) (N = 302 of 408 encounters, 75%); 26 encounters (6%) were coded for UTI (eg, N39.0, urinary tract infection, site not specified); and 214 encounters (53%) had multiple ICD-10 codes. The R82.71 code (bacteriuria) was never used. However, 215 prescriptions (51%) were classified as AUA (Fig. 2). The validation cohort included 130 prescriptions; 59 (45%) were classified as AUA and 51 (39%) had documented intent to treat ASB or UTI (positive percent agreement, 83%; negative percent agreement, 97%) (Table 1). For patients >1 month after transplant, the positive percent agreement was 95% and the negative percent agreement was 98%. Of 51 patients receiving AUA, 32 (63%) were asymptomatic despite frequently having a code for UTI (Fig. 3). Conclusions: ICD-10 coding may not be helpful in monitoring antibiotic prescribing in RT patients. The AUA metric offers a practical alternative to track antibiotic prescribing for urinary syndromes and reliably correlates with physician intent. Monitoring AUA prescribing rates could help identify opportunities to optimize antibiotic use in this complex outpatient setting.

Disclosures: None
Central-line team effort: Recognizing problematic central-line insertion sites in nursing homes
Authors: Nguyen Kristine , Singh Raveena D. , Gohil Shruti , Saavedra Raheeb , Billimek John , Tam Steven , Huang Susan
Published: September 2023

Background: Recognizing problematic central-line insertion sites is an important activity for CNAs, LVNs, and RNs in nursing homes (NHs). Although CNAs are not responsible for assessing central lines, they are often the first line of defense for noticing and relaying problems with a line because of the greater amount of time they spend with residents. We sought to assess how well CNAs, LVNs, and RNs could identify problematic insertion sites in NHs. Methods: We conducted a prospective observational study of central-line care in 8 NHs in Orange County, California. A convenience sample of central lines with a range of problematic elements was selected for quality improvement purposes. Research staff used standardized observation forms to evaluate presence of redness, cloudy drainage, and dressing integrity and change date. NH CNAs, LVNs, and RNs were asked to directly observe devices and to comment on problems or concerns. Participants were also asked open-ended questions about elements for a “picture-perfect line” and standard frequency of line checks and dressing changes. Failures to recognize existing problematic elements were tabulated for CNAs and LVNs or RNs separately. Results: In total, 50 CNAs (nursing home range, 3–6) and 50 LVNs and RNs (NH range, 4–6) directly observed lines with 131 problematic elements, including redness (N = 36), cloudy drainage (N = 30), peeling dressings (N = 29), and inappropriately dated dressing (N = 36). Failure to identify problematic elements involved redness [CNAs (50%) and LVNs or RNs (53%)], cloudy drainage [CNAs (40%) and LVNs or RNs (39%)], peeling dressings [CNAs (100%) and LVNs or RNs (87%)], and inappropriately dated dressing [CNAs (71%) and LVNs or RNs (68%)]. For both CNAs and LVNs and RNs, recognition of redness and cloudy drainage improved with severity. Failure to recognize minimal erythema [CNAs (83%) and LVNs or RNs (58%)] was higher than substantial erythema [CNAs (54%) and LVNs or RNs (50%)]. Similarly, failure to recognize minimal cloudy drainage [(CNAs (67%) and LVNs or RNs (50%)] was higher than substantial cloudy drainage [CNAs (42%) and LVNs or RNs (36%)]. Overall, identification of problematic elements did not vary by whether the staff member was assigned to care for that resident. Descriptions of “picture-perfect lines” were uniformly poor, with respondents not knowing what elements to mention. Conclusions: Failure to recognize redness, cloudy drainage, peeling dressings, and lapses in dressing change dates was common for CNAs and LVNs and RNs in nursing homes. This lack of recognition could prevent proper response to early and late signs of localized infection at central-line sites. Dedicated training regarding key elements of a “picture-perfect line” is needed, including changing the threshold for concern for both small and large amounts of redness and pus.

Disclosures: None
Correlating symptoms to infectivity among vaccinated healthcare workers with COVID-19
Authors: Almulhim Abdulaziz , Romo Francine Touzard , Mermel Leonard , Mathers Amy , Eby Joshua
Published: September 2023

Background: Directing COVID-19 diagnostic testing to healthcare workers (HCWs) who are likely to be infected has potential to reduce staffing shortages and decrease opportunity for in-hospital transmission; however, HCWs with COVID-19 may exhibit a range of symptoms. We assessed the burden of symptoms in relation to cycle threshold (Ct) values as a surrogate for viral shedding in vaccinated healthcare workers. Methods: We retrospectively reviewed employee health records of COVID-19–vaccinated employees who tested positive for SARS-CoV-2 between December 2020 and January 2022 at 2 academic hospital systems. We reviewed demographic data, reasons for testing including symptoms, exposure history, medical history, vaccination dates, Ct values, and genotypes when available. We compared mean Ct values between symptomatic and minimally symptomatic cases using independent sample t tests. Patients were defined as minimally symptomatic if they had no symptoms or a single symptom that is not cough, fever, or anosmia at the time of testing. Patients were defined as more symptomatic if they reported >1 symptom or cough, fever, or anosmia. Results: In total, 298 HCWs tested positive for COVID-19. Most positive cases were female (73%), white (78%), and had patient-facing roles (77%). Genotypic testing (n = 109) revealed that most genotypes belonged to the SARS-CoV-2 delta variant (AY lineages, B1.617.2). More cases were minimally symptomatic (62%) than were more symptomatic (38%). None required hospitalization during the study period. Mean Ct values (n = 141) showed no significant difference between more symptomatic and minimally symptomatic cases (19.8 vs 20.6; P = .40) (Fig. 1). Also, there was no significant difference in mean Ct value, comparing those with vaccination 90 days prior to positive (20.52 vs 19.88; P = .537). Conclusions: Our study shows no significant difference in cycle threshold values between minimally symptomatic and more symptomatic infections in vaccinated HCWs. In addition, HCWs exhibit high viral load even when infected within 90 days after vaccination. When considering whether to attend work, HCWs should be aware that mild symptoms and recent vaccination do not necessarily reflect low transmissibility and that they should follow CDC guidance regarding when to return to work.

Disclosures: None
Incidence, risk factors, and outcomes of hospital-acquired infections with common respiratory viruses
Authors: Petrie Joshua , Moore Riley , Lauring Adam , Kaye Keith
Published: September 2023

Background: We estimated the incidence of hospital-acquired respiratory virus infections (HARVIs) by viral species, and we identified risk factors for and outcomes of HARVIs. Methods: We identified a cohort of all inpatient admissions of ≥24 hours duration to University of Michigan hospitals during 3 study years (2017–2018, 2018–2019, and 2019–2020). HARVIs were defined as initial respiratory virus detection (adenovirus, coronaviruses, human metapneumovirus, influenza A and B, parainfluenza viruses, respiratory syncytial virus, or rhinovirus-enterovirus) in a clinical test ordered after the 95th percentile of the virus-specific incubation period. Incidence was calculated as the number of HARVIs per 10,000 patient admission days. Patient demographic and clinical characteristics were assessed as risk factors for HARVI in Cox proportional hazards models of the competing outcomes of HARVIs and hospital discharge. The association between time-varying HARVI status and the competing outcomes of discharge and in-hospital death was estimated in covariate-adjusted Cox-proportional hazards models. All analyses were performed separately for adult patients (aged ≥18 years) and pediatric patients (aged <18 years). Results: The overall incidences of HARVI were 8.5 and 3.0 per 10,000 admission days for pediatric and adult patients, respectively. Rhinovirus was the most common HARVI in both pediatric and adult patients, with incidences of 5.1 and 1.1 infections per 10,000 admission days, respectively. With the exception of influenza A, the incidence of HARVI was higher in pediatric patients than adult patients for all viral species. For adults, congestive heart failure, renal disease, and cancer all increased HARVI risk independent of their associations with extended hospital stays. Risk of HARVI was also elevated for patients admitted September through June relative to July admissions. For pediatric patients, chronic cardiovascular and respiratory conditions, cancer, medical-device dependence, and December admission increased risk of HARVI. Age, sex, and race were not associated with risk of HARVI for children or adults. Inpatient lengths of stay were longer for adults with HARVI compared to those without (range of virus-specific hazard ratios, 0.48– 0.77). However, estimated effects were not statistically significant for human metapneuomovirus, parainfluenza, or adenovirus. Only influenza A was associated with an increased risk of in-hospital death within 30 days of infection for adults. No HARVIs were associated with increased length of stay or risk of death for pediatric patients. Conclusions: The incidence of HARVI varied by viral species and was higher among pediatric patients. HARVIs increased the length of hospital stays for adults but not for pediatric patients.

Disclosures: None
Assessment of carbapenem-resistant Acinetobacter baumannii–colonized patients: Which specimens produce the highest yield?
Authors: Morrell Casey , McClanahan Kristina , Daniel Lauren , Burks James , Charles Argentina , Marin Ashley , Negley Jeanne , Roderick Melanie , Stover Carolyn
Published: September 2023

Background: Carbapenem-resistant Acinetobacter (CRA) bacteria are an urgent public health threat. Accurate and timely testing of CRA is important for proper infection control practices to minimize spread. In 2017, the CDC estimated 8,500 CRA cases among hospitalized patients, 700 deaths, and $281 million in attributable healthcare costs. Treatment options are extremely limited for carbapenem-resistant Acinetobacter baumannii (CRAB) infections, making CRAB a unique concern. Colonization screening is a valuable tool for containment but requires sampling of 4 body sites. Identifying a reliable specimen collection site for CRAB is important to inform public health recommendations as screening can cost healthcare facilities valuable time and resources. Methods: Results of all screening specimens of patients with at least 1 site positive for CRAB on a unique collection date were extracted from the Southeast Regional data of Antimicrobial Resistance Lab Network (SEARLN) data. Non-CRAB screening and screenings that did not yield at least 1 positive result on a single collection date were excluded. We also limited our data to include only the following screening sites, which have been validated by the Tennessee Department of Health’s State Public Health Laboratory: axilla and groin, rectal, sputum, and wound. For each specimen source, we calculated the percentage of positive specimen among CRAB-colonized patients. Data were extracted and analyzed using SAS version 9.4 software. Results: The SEARLN data contained 594 CRAB screening specimens collected over 4 years, 2018 through 2021, and 486 of those specimens yielded CRAB. For CRAB-colonized patients screened in this study, wound specimens had the highest positivity rate at 93.4% (95% CI, 89.9%–96.9%) of samples culturing CRAB. Sputum followed at 87.7%, then axilla and groin at 77.6% and rectal at 59.7%. Conclusions: Wound specimens produced the highest proportion of positive cultures among CRAB-positive patients, making them the sample type with the highest prevalence in our study. For healthcare facilities with limited time and resources seeking to optimize their CRAB screening process, wound specimens may be the most reliable single site for detecting CRAB colonization in patients with an open wound. When a wound is not present, sputum may be a good alternative single-source collection site. More research should be conducted before CRAB screening recommendations are updated.

Disclosures: None
Validation of automated surveillance of healthcare-associated infections using electronic screening algorithms
Authors: Lee Hyunju , Ryu Seunghee , Yang Hyejin , Lee Jeongyoung , Park Soyeon , Kim Eun Ok , Jung Jiwon , Kima Sung-Han
Published: September 2023

Background: Surveillance of healthcare-associated infection (HAI) is the basis of infection prevention programs. However, manual review of medical records is a labor-intensive and time-consuming process. We evaluated the diagnostic performance of automated surveillance of HAI using electronic screening algorithms. Methods: Between April and June 2022, we conducted surveillance of HAI manually and automatically using electronic screening algorithm on 75 units (general medical and surgical wards and ICUs) in a 2,700-bed, tertiary-care hospital in South Korea. Algorithms for surveillance of HAI were developed accordance with NHSN surveillance definitions (Fig. 1). Catheter-associated urinary tract infections (CAUTIs) were automatically detected when eligible pathogen and fever (>38°C) were matched within infection window period. Other specific types of infection were automatically classified based on laboratory results that met NHSN criteria. After the algorithm showed possible cases that met laboratory-confirmed bloodstream infection (LCBI) criteria, we excluded secondary BSIs using the automatic surveillance algorithm. We analyzed sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) for the automated surveillance system compared to manual surveillance. Results: An algorithm for detecting CAUTI showed 98.7% sensitivity (78 of 79), 100.0% specificity (2,443 of 2,443), 100.0% PPV (78 of 78), and 100.0% NPV (2,443 of 2,444). For CLABSI, the algorithm had 97.3% sensitivity (214 of 220), 98.3% specificity (5,759 of 5,861), 67.7% PPV (214 of 316), and 99.9% NPV (5,759 of 5,765). In total, 102 cases of possible CLABSI were identified by the algorithm, and 76 (74.5%) were eventually diagnosed as secondary BSIs. Also, by chart review, 20 BSIs (19.6%) were present on arrival in ER (ER-POA). In 4 cases (3.9%), an original pathogen reoccurred in a repeated infection timeframe (RIT), and 2 cases (2%) were mucosal barrier injury-LCBI (MBI-LCBI). When we additionally performed manual surveillance for intra-abdominal infection secondary BSI, ER-POA, and assigning pathogen to original BSI in RIT, PPV increased to 87.7% (214 of 244). Conclusions: Algorithm for automated surveillance of CAUTI had good performance; however, automated surveillance of CLABSI was suboptimal. More elaborate screening algorithm for diagnosis CLABSI is needed, and further studies are needed to determine whether an automated surveillance system can reduce workload for surveillance of HAI.

Disclosures: None
Risk factors for the transmission of Clostridioides difficile or methicillin-resistant Staphylococcus aureus in acute care
Authors: Wang Xuetao , Garrod Matthew , Duncombe Tamara , Lee Eunsun , Ng Katy Short Joyce
Published: September 2023

Background: Some hospitals continue to struggle with nosocomial transmission of Clostridioides difficile infection (CDI) and methicillin-resistant Staphylococcus aureus (MRSA) despite years of infection control efforts. We investigated the relationship between unit infrastructural–organizational risk factors and nosocomial transmission of CDI and MRSA. Methods: This retrospective observational study included 100 eligible acute-care inpatient units from 12 hospitals in British Columbia, Canada, from April 1, 2020, to September 16, 2021. The outcome variables included whether a unit was on the CDI or MRSA vulnerable unit list (ie, defined as having ≥5 CDI cases or ≥6 MRSA cases being attributed to the unit in the last 6 fiscal periods), the average CDI/MRSA rate, as well as the average CDI/MRSA standardized infection ratio (SIR). Independent variables included, but were not limited to, infection control factors (eg hand hygiene rate), infrastructural factors (eg, unit age, total beds on unit), and organizational factors (eg, hallway bed utilization, nursing overtime). Multivariable regression was performed to identify statistically significant risk factors using SAS, R Studio, and Stata software. Results: For CDI, older units were associated with higher odds of being on the CDI vulnerable unit list (aOR, 1.086; 95% CI, 1.024–1.175), higher CDI rate (adjusted relative risk [aRR], 0.012; 95% CI, 0.004–0.020), and higher CDI SIR (aRR, 0.011; 95% CI, 0.003–0.020). Larger unit size was associated with higher odds of being on the CDI vulnerable unit list (aOR, 1.210; 95% CI, 1.095–1.400) and higher CDI SIR (aRR, 0.013; 95% CI, 0.001–0.026). For MRSA, an increase in hand hygiene rate was associated with lower odds of being on the MRSA vulnerable unit list (aOR, 0.71; 95% CI, 0.53–0.897), lower MRSA rate (aRR, −0.035; 95% CI, −0.063 to −0.008), and lower MRSA SIR (aRR, −0.039; 95% CI, −0.069 to −0.008). Higher MRSA bioburden was associated with higher odds of being on the MRSA vulnerable unit list (aOR, >999; 95% CI, >999 to >999), higher MRSA rate (aRR, 9.008; 95% CI, 5.586–12.429), and higher MRSA SIR (aRR, 4.964; 95% CI, 1.971–7.958). Additionally, higher MRSA rates were associated increased utilization of hallway beds (aRR, 0.680; 95% CI, 0.094–1.267), increased nursing overtime rate (aRR, 5.018; 95% CI, 1.210–8.826), and not having a clean supply room with the door consistently closed (aRR, −0.283; 95% CI, −0.536 to −0.03). Conclusions: Several infrastructural and organizational factors were associated with nosocomial transmissions of CDI and MRSA. Further research is needed to investigate the mechanisms by which these factors are associated.

Disclosures: None