bluuebunny/crossref_metadata_2025 huggingface dataset:
Whole-Genome Sequencing for Investigation of Possible Hospital Transmission of Tuberculosis
Authors: Rasmusson Jenna , Sampathkumar Priya , Wengenack Nancy
Published: November 2020

Background: Whole-genome sequencing (WGS) is increasingly used in epidemiological investigations of infectious diseases. We describe the use of WGS to identify drug-resistance variants of tuberculosis (TB) and to determine potential transmission between patients at an academic medical center. Methods: Chart review and interviews of patients and healthcare workers along with WGS of M. tuberculosis isolates from the patients. Clinical information: In June 2019, patient A, a 20-year-old college student born in the United States was admitted with massive hemoptysis. The patient was identified as having active, cavitary TB that was acid-fast smear positive, and the mycobacterial culture grew M. tuberculosis. Patient B, a 40-year-old foreign-born patient with advanced lung cancer was acid-fast smear negative, but mycobacterial cultures were positive for M. tuberculosis. The 2 patients had overlapping stays in the medical intensive care unit. There was concern that patient B had acquired TB during her stay in the hospital from patient A, who was highly infectious. WGS showed that the mycobacterial isolates from the 2 patients were unrelated. Patient A was a student at a college campus where the state health department had previously issued a health advisory concerning active pulmonary TB in a student; and 7 additional TB cases were subsequently identified through contact investigation. Patient A denied any contact with other persons who were part of the outbreak and had not been included in the contact investigations of any of the cases. Of the 8 outbreak cases, 6 had been seen at our institution and had isolates available for testing. WGS showed that these 6 isolates matched patient A, establishing that she was part of the college outbreak. Conclusions: WGS was useful in establishing the source of M. tuberculosis infection in a patient who did not have known exposure to TB and in demonstrating that transmission of TB did not occur in the hospital.

Funding: None

Disclosures: None
Risk Estimate of Duodenoscope-Associated Infections in The Netherlands
Authors: Vos M. , Kwakman Judith , Bruno Marco
Published: November 2020

Background: The likelihood of endoscopy-associated infections (EAIs) is often referenced from a paper published in 1993 by Kimmery et al1 in which a risk of 1 exogenous infection for every 1.8 million endoscopies (0.00006%) is proclaimed. Even though Ofstead et al2 pointed out in 2013 that this was at least an underestimation by 6-fold because of erroneous assumptions and mathematical errors, the original calculation is still often referred to. In the past decade, multiple outbreaks of multidrug-resistant microorganisms (MDROs) related to contaminated duodenoscopes have been reported worldwide. This leads to the assumption that the former risk calculation is indeed incorrect. Objective: We calculated the duodenoscope-associated infection (DAI) risk for the Dutch ERCP practice. Methods: We searched and consolidated all Dutch patients reported in the literature to have suffered from a clinical infection linked to a contaminated duodenoscope between 2008 and 2018. From a national database, the number of ERCPs performed per year in The Netherlands were retrieved. Actual numbers were available from 2012 to 2018. Numbers from 2008 to 2011 were estimated and assumed to be equal to 2012. Results: In 2008–2018, 3 MDRO outbreaks in Dutch hospitals were reported in the literature, with 21 patients suffering from a clinical infection based on a microorganism proven to be transmitted by a duodenoscope. In that period, ∼203,500 ERCP procedures were performed. Hence, for every 9,690 procedures, 1 patient developed a clinically relevant infection (DAI risk, 0.010%). Conclusions: The risk of developing a DAI is at least 30–180 times higher than the risks that were previously reported for all types of endoscopy-associated infections. Importantly, the current calculated risk of 0.010% constitutes a bare minimum risk of DAI because endoscope-related infections are underreported. Apart from DAI risk, a patient is also at risk of becoming colonized with a microorganism through contaminated endoscopes but without developing symptoms of clinical infection. These data call for consorted action of medical practitioners, industry, and government agencies to minimize and ultimately eliminate the risk of exogenous endoscope-associated infections and contamination. As a first step, the FDA recently recommended that healthcare facilities and manufacturers begin transitioning to duodenoscopes with disposable components.3

Funding: None

Disclosures: None
“The Six Moments:” A Novel Educational Tool to Promote Infection Prevention Practices in Patients Injecting Drugs
Authors: Linsenmeyer Katherine , Hyde Justeen , Branch-Elliman Westyn
Published: November 2020

Background: The opioid epidemic has led to a dramatic increase in the rate of invasive bacterial infections, including a 4-fold increase in sepsis and a 12-fold increase in endocarditis. The increase has been demonstrated in both veteran and nonveteran populations (Fig. 1). Thus, an urgent need exists to develop novel tools to educate patients and providers regarding (1) at-risk moments among intravenous drug users and (2) methods for preventing transmission of bacterial and viral infections associated with injection drug use. Methods: We conducted a survey among medical trainees and staff and collected information about knowledge and attitudes about harm-reduction services. To address gaps in knowledge, we developed an educational tool for promoting better infection prevention practices among patients who inject drugs by adapting the WHO Five Moments of Hand Hygiene. Results: In total, 43 medical trainees and staff responded to the survey. All respondents regarded infections as a serious risk among patients who inject drugs, although there was variation in perception about which types of pathogens were the most likely to be acquired through this pathway (ie, bacterial vs viral). Among survey respondents, 15 of 39 (38%) reported that they have counseled patients who inject drugs about infection prevention, whereas 24 (58%) reported that they had never provided counseling. The reason for the lack of counseling was primarily a lack of knowledge and a lack of resources (10 of 24, 42%). One-quarter (6 of 24, 25%) reported that they did perceive infection prevention counseling to be part of their role. To solve this knowledge and resource gap, we developed an educational tool designed to promote understanding of the risk of bacterial, viral, and fungal infections and how to prevent them (Fig. 2, A and B). The “Six Moments” model highlights important high-risk moments and activities, such as skin cleaning, use of clean needles, and avoiding oral contamination of needles, as well as the corresponding pathogens that can be transmitted at each stage. Infection prevention strategies are them applied to demonstrate how these infections can be averted. The tool focuses on simple infection prevention interventions that can be taught to patients and providers not trained in infection control to limit transmission of infections associated with IV drug use and addresses the knowledge gap identified through the provider survey. Conclusions: This novel tool can be part of a comprehensive educational program that translates infection prevention principles and applies them to reduce infectious morbidity and mortality related to injection drug use.

Funding: None

Disclosures: None
A Continuously Active Antimicrobial Surface Coating Reduces Bioburden in a Healthcare Setting
Authors: Beck Valerie
Published: November 2020

Background: It is well known that contaminated surfaces contribute to the transmission of pathogens in healthcare settings, necessitating the need for antimicrobial strategies beyond routine cleaning with momentary disinfectants. A recent publication demonstrated that application of a novel, continuously active antimicrobial surface coating in ICUs resulted in the reduction of healthcare-associated infections. Objective: We determined the general microbial bioburden and incidence of relevant pathogens present in patient rooms at 2 metropolitan hospitals before and after application of a continuously active antimicrobial surface coating. Methods: A continuously active antimicrobial surface coating was applied to patient rooms in intensive care units (ICUs) twice over an 18-month period and in non-ICUs twice over a 6-month study period. The environmental bioburden was assessed 8–16 weeks after each treatment. A 100-cm2 area was swabbed from frequently touched areas in patient rooms: patient chair arm rest, bed rail, TV remote, and backsplash behind the sink. The total aerobic bacteria count was determined for each location by enumeration on tryptic soy agar (TSA); the geometric mean was used to compare bioburden before and after treatment. Each sample was also plated on selective agar for carbapenem-resistant Enterobacteriaceae (CRE), vancomycin-resistant enterococci (VRE), methicillin-resistant Staphylococcus aureus (MRSA), and Clostridioides difficile to determine whether pathogens were present. Pathogen incidence was calculated as the percentage of total sites positive for at least 1 of the 4 target organisms. Results: Before application of the antimicrobial coating, total aerobic bacteria counts in ICUs were >1,500 CFU/100 cm2, and at least 30% of the sites were positive for a target pathogen (ie, CRE, VRE, MRSA or C. difficile). In non-ICUs, the bioburden before treatment was at least 500 CFU/100 cm2, with >50% of sites being contaminated with a pathogen. After successive applications of the surface coating, total aerobic bacteria were reduced by >80% in the ICUs and >40% in the non-ICUs. Similarly, the incidence of pathogen-positive sites was reduced by at least 50% in both ICUs and non-ICUs. Conclusions: The use of a continuously active antimicrobial surface coating provides a significant (P < .01) and sustained reduction in aerobic bacteria while also reducing the occurrence of epidemiologically important pathogens on frequently touched surfaces in patient rooms. These findings support the use of novel antimicrobial technologies as an additional layer of protection against the transmission of potentially harmful bacteria from contaminated surfaces to patients.

Funding: Allied BioScience provided Funding: for this study.

Disclosures: Valerie Beck reports salary from Allied BioScience.
Frequency of Testing for Clostridioides difficile in Long-Term Care Facilities in Louisville, Kentucky
Authors: Angulo Frederick , Pena Senen , Carrico Ruth , Stephen Furmanek , Joann Zamparo , Gonzalez Elisa , Gray Sharon , Ford Kimbal , Ferreira Catia , Ramirez Julio
Published: November 2020

Background:Clostridioides difficile infection (CDI), caused by toxigenic C. difficile and predominately manifested by moderate-to-severe diarrhea, is an important cause of morbidity and mortality in long-term care facilities (LTCFs). However, for CDI to be diagnosed in an LTCF resident, an LTCF resident with diarrhea must have a stool specimen collected for CDI diagnostic testing. The objective of this study was to define the frequency of stool specimen collection and testing for CDI in adult LTCF residents with diarrhea in Louisville, Kentucky. Methods: A cross-sectional study was conducted in 14 (31%) of the 45 LTCFs in Louisville (adults aged ≥18 years; population, 599,276) to identify LTCF residents with diarrhea and to observe the frequency of stool specimen collection for CDI diagnosis. For 14 consecutive days in February 2019, each LTCF was visited to identify new onset diarrhea (≥3 loose stools in 24 hours) by interviews of nursing staff. For residents with diarrhea, staff reviewed electronic medical records to determine whether a stool specimen was collected for CDI diagnosis and interviewed nurses about potential noninfectious causes of diarrhea. Results: The 14 participating LTCFs have 1,208 beds (median, 86 beds and 43 occupied beds per participating LTCF). Among 743 LTCF residents (with 10,402 patient days of surveillance), new-onset diarrhea was identified in 63 residents (21% male; median age 75 years); 0.6 diarrhea cases per 100 patient days (diarrhea attack rate, 0.6% per day). Nurses indicated that 16 (25%) of the 63 residents with diarrhea had a potential noninfectious cause of diarrhea (11 laxatives, 3 feeding tube, 1 colostomy, and 1 gastric surgery). Stool specimens were collected for CDI testing from 20 of 63 of residents (32%) with diarrhea; none with potential noninfectious cause of diarrhea and from 20 of 47 other residents (42%) with diarrhea. Of 20 stool specimens tested, 9 (47%) yielded toxigenic C. difficile (8.6 CDI cases per 10,000 patient days). During this survey, none of the 63 LTCF residents with diarrhea were transferred to a hospital or other healthcare facility. Conclusions: Diarrhea was common among LTCF residents, and toxigenic C. difficile was frequently identified in stool specimens collected from LTCF residents with diarrhea. The majority of non–laxative-receiving LTCF residents with diarrhea did not have a stool specimen collected for CDI diagnosis. The low frequency of CDI diagnostic testing of LTCF residents with diarrhea indicates that CDI may be underdiagnosed in these LTCFs and suggests that the CDI disease burden may be larger than currently appreciated.

Funding: Pfizer Vaccines provided support for this study.

Disclosures: Frederick Angulo, Kimbal D. Ford, Joann Zamparo, Elisa Gonzalez, Sharon Gray, David Swerdlow, and Catia Ferreira all report salary from Pfizer.
Large-Scale Analysis of Hand Hygiene Frequency Across Healthcare Facilities Varying in Key Hospital Characteristics
Authors: Albright Jessica , White Bruce , Carlson Pete , Littau Cheryl
Published: November 2020

Background:
Hand hygiene by healthcare personnel is a critical infection prevention intervention. Direct observation, the most widely utilized method to observe hand hygiene practices, often provides an incomplete picture due to small sample size and altered behavior in the presence of observers. A growing number of healthcare facilities are employing electronic hand hygiene monitoring systems to capture overall compliance rates. These electronic systems can provide a wealth of data on hand hygiene practices within and across healthcare facilities. Objective: We used high-accuracy electronic monitoring data to perform a detailed analysis of hand hygiene practices across numerous facilities that varied in key hospital characteristics. Methods: In total, 11 tertiary-care facilities were equipped with an electronic hand hygiene monitoring system. Hospitals varied in size, region, area classification (urban vs rural), acuity level, and teaching status. The electronic monitoring system was composed of uniquely assigned employee badges and electronically monitored dispensers. Every recorded dispensing event was time stamped and associated with a specific healthcare worker, the location of the dispenser, and the specific product being dispensed (ie, alcohol-based hand rub [ABHR] or hand soap). The total number of dispensing events for each product type and the total number of hours worked were calculated for each healthcare worker and were used to determine hand hygiene frequency. Hospital attributes, such as size and area classification, were obtained from publicly available sources including but not limited to facility-owned websites and CMS data. Results: More than 15.7 million hand hygiene events, performed by nearly 11,000 healthcare workers, were captured by the electronic monitoring system and were included in the analysis. Overall, median hand hygiene frequency was 4.1 events per hour and ranged from 2.0 events per hour to 5.6 events per hour, depending on the facility. ABHR use (median, 3.6 events per hour) was more frequent than handwashing (median, 0.4 events per hour). Hospitals included in the analysis ranged from small (<20 beds) rural facilities to large (>600 beds) academic hospitals and provided a variety of services from general medical-surgical treatment to intensive care. Interfacility differences in observed hand hygiene frequency were analyzed. Conclusions: The current analysis reinforces and builds upon previous work that examined a smaller subset of 5 hospitals located in a single geographic region. Combined, these datasets represent >20 million hand hygiene events among ∼15,000 healthcare workers from 16 unique healthcare facilities. This analysis provides detailed information about hand hygiene practices across a diverse set of healthcare facilities.

Funding: Ecolab, Inc, provided support for this study.

Disclosures: Jessica Carol Albright and Cheryl A Littau report salary from Ecolab.
A Portable, Easily Deployed Approach to Measure Healthcare Professional Contact Networks in Long-Term Care Settings
Authors: Herman Ted , Francis Shelby , Dube William , Krupp Treyton , Fridkin Scott , Samore Matthew , Segre Alberto , Polgreen Philip
Published: November 2020

Background:
The movement of healthcare professionals (HCPs) induces an indirect contact network: touching a patient or the environment in one area, then again elsewhere, can spread healthcare-associated pathogens from 1 patient to another. Thus, understanding HCP movement is vital to calibrating mathematical models of healthcare-associated infections. Because long-term care facilities (LTCFs) are an important locus of transmission and have been understudied relative to hospitals, we developed a system for measuring contact patterns specifically within an LTCF. Methods: To measure HCP movement patterns, we used badges (credit-card–sized, programmable, battery-powered devices with wireless proximity sensors) worn by HCPs and placed in 30 locations for 3 days. Each badge broadcasts a brief message every 8 seconds. When received by other badges within range, the recipients recorded the time, source badge identifier, and signal strength. By fusing the data collected by all badges with a facility map, we estimated when and for how long each HCP was in any of the locations where instruments had been installed. Results: Combining the messages captured by all of our devices, we calculated the dwell time for each job type (eg, nurses, nursing assistants, physical therapists) in different locations (eg, resident rooms, dining areas, nurses stations, hallways, etc). Although dwell times over all job and area types averaged ∼100 seconds, the standard deviation was large (115 seconds), with a mean of maximums by job type of ∼450 seconds. For example, nursing assistants spent substantially more time in resident rooms and transitioned across rooms at a much higher rate. Overall, each distribution exhibits a power-law–like characteristic. By aggregating the data from devices with location data extracted from the floor plan, we were able to produce an explicit trace for each individual (identified only by job type) for each day and to compute cross-table transition probabilities by area for each job type. Conclusions: We developed a portable system for measuring contact patterns in long-term care settings. Our results confirm that frequent interactions between HCPs and LTC residents occur, but they are not uniform across job types or resident locations. The data produced by our system can be used to better calibrate mathematical models of pathogen spread in LTCs. Moreover, our system can be easily and quickly deployed to any healthcare settings to similarly inform outbreak investigations.

Funding: None

Disclosures: Scott Fridkin reports that his spouse receives a consulting fee from the vaccine industry.
Are Patients Preferentially Receiving Oral Vancomycin for Clostridioides difficile Infection in 2018? A Population Perspective
Authors: Goodenough Dana , Mackey Carolyn , Woodworth Michael , Adelman Max , Fridkin Scott
Published: November 2020

Background: Historically, metronidazole was first-line therapy for Clostridioides difficile infection (CDI). In February 2018, the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA) updated clinical practice guidelines for CDI. The new guidelines recommend oral vancomycin or fidaxomicin for treatment of initial episode of CDI in adults. We examined the changes in treatment of CDI during 2018 across all types of healthcare settings in metropolitan Atlanta. Methods: Cases were identified through the Georgia Emerging Infections program (funded by the Centers for Disease Control and Prevention), which conducts active population-based surveillance in an 8-county area including Atlanta, Georgia (population, 4,126,399). An incident case was a resident of the catchment area with a positive C. difficile toxin test and no additional positive test in the previous 8 weeks. Recurrent CDI was defined as >1 incident CDI episode in 1 year. Clinical and treatment data were abstracted on a random 33% sample of adult (>17 years) cases. Definitive treatment categories were defined as the single antibiotic agent, metronidazole or vancomycin, used to complete a course. We examined the effect of time of infection, location of treatment, and number of CDI episodes on the use of metronidazole only. Results: We analyzed treatment information for 831 adult sampled cases. Overall, cases were treated at 29 hospitals (568 cases), 4 nursing homes (6 cases), and 101 outpatient providers (257 cases). The mean age was 60 (IQR, 34–86), and 111 (13.4%) had recurrent infection. Moreover, ∼28% of first-incident CDI episodes, 8% of second episodes, and 6% of third episodes were treated with metronidazole only. Compared to facility-based providers, outpatient providers were more likely to treat initial CDI episodes with metronidazole only (44% vs 21%; relative risk [RR], 2.1; 95% CI, 1.7–2.7). Treatment changed over time from 56% metronidazole only in January to 10% in December (Fig. 1). First-incident cases in the first quarter of 2018 were more likely to be treated with metronidazole only compared to those in the fourth quarter (RR, 2.76; 95% CI, 1.91–3.97). Conclusions: Preferential use of vancomycin for initial CDI episodes increased throughout 2018 but remained <100%. CDI episodes treated in the outpatient setting and nonrecurrent episodes were more likely to be treated with metronidazole only. Additional studies on persistent barriers to prescribing oral vancomycin, such as cost, are warranted.

Funding: None

Disclosures: Scott Fridkin reports that his spouse receives a consulting fee from the vaccine industry.
Effect of Meropenem Restriction on Time Between Order and Administration in a Medical Intensive Care Unit
Authors: Le Aline , Kang Le , Noda Andrew , Godbout Emily , Markley John Daniel , Lee Kimberly , Pakyz Amy , Kim Jihye , Doll Michelle Elizabeth , Bearman Gonzalo , Stevens Michael
Published: November 2020

Background:
In this study, we assessed whether meropenem restriction led to delays in administration for patients in a medical intensive care unit (MICU) at a large tertiary-care urban teaching hospital. Methods: The antimicrobial stewardship program (ASP) at Virginia Commonwealth University Health System (VCUHS) requires approval for restricted antimicrobial orders placed between 8 a.m. and 9 p.m. Between 8 a.m. and 5 p.m. (daytime), authorized approvers include ASP and infectious diseases (ID) physicians. From 5 p.m. to 9 p.m. (evening) orders are approved by ID fellows. Orders were entered as Stat, Now, and Routine. Between 9 p.m. and 8 a.m. (night), patients receive doses without approval. Meropenem restriction began in mid-January 2018. Pre- and postmeropenem restriction periods were defined as February–December 2017 and February–December 2018. Meropenem use data were compared for adult patients in the MICU. A multivariable Cox regression model was implemented to compare (1) time from order entry to approval; (2) time from order approval to patient administration; (3) total time from order entry to patient administration, adjusting for order priority, approver (ASP, ID consult, ID fellow, pharmacy); and (4) time of day of order placement (day, eve, night). The analyses were performed using SAS version 9.4 software (SAS Institute, Cary, NC). Result: Time from order approval to patient administration was significantly decreased in the postrestriction period (HR, 1.840; P < .001) (Table 1). Stat orders were faster compared to routine orders for order entry to approval (HR, 1.735; P < .001), approval to administration (HR, 2.610; P < .001), and total time from order entry to administration (HR, 2.812; P < .001). No significant differences were found in time to approval by approving service. Time from order entry to approval was faster for nighttime orders than for daytime orders (HR, 1.399; P = .037). Conclusions: Our data indicate that the time from order entry to administration decreased following meropenem restriction in our MICU. More research is needed to identify the reason for this finding, but we postulate that this is due to an effect on drug administration prioritization within nursing workflow. These data will inform our local meropenem restriction efforts.

Funding: None

Disclosures: Michelle Doll reports a research grant from Molnlycke Healthcare.
Effectiveness of Methicillin-Resistant Staphylococcus aureus (MRSA) Nasal Screening for Reduction of Vancomycin Use for Pneumonia
Authors: Snellgrove Shannon , Brown Matthew , Edwards Seth , Leal Sixto , Bryan Allen , Pappas Peter , Lee Rachael
Published: November 2020

Background: Methicillin-resistant Staphylococcus aureus (MRSA) nasal colonization has been a well-established risk for developing MRSA pneumonia. In previous studies, the MRSA nasal screening test has shown an excellent negative predictive value (NPV) for MRSA pneumonia in patients without exclusion criteria such as mechanical ventilation, hemodynamic instability, cavitary lesions, and underlying pulmonary disease. MRSA nasal screening can be used as a stewardship tool to de-escalate broad antibiotic coverage, such as vancomycin. Objective: The purpose of this study was to determine whether implementation of a MRSA nasal screening questionnaire improves de-escalation of vancomycin for patients with pneumonia. Methods: A retrospective review was performed on 250 patients from October 2018 to January 2019 who received MRSA nasal screening due to their prescriber choosing only “respiratory” on the vancomycin dosing consult form. Data obtained included demographics and clinical outcomes. Statistical analyses were performed, and P < .05 was considered significant. Results: Of the 250 patients screened, only 19 patients (8%) were positive for MRSA. Moreover, 40% of patients met exclusion criteria. In 149 patients without exclusion criteria, the MRSA nasal swab had a 98% NPV. Although not statistically significant, vancomycin days of therapy (DOT) based on MRSA nasal swab result was 1 day shorter in those with negative swabs (3.49 days negative vs 4.58 days positive; P = .22). Vancomycin DOT was significantly reduced in pneumonia patients without exclusion criteria (3.17 days “no” vs 4.17 days “yes”; P = .037). Conclusions: The implementation of an electronic MRSA nasal screening questionnaire resulted in reduced vancomycin DOT in pneumonia patients at UAB Hospital. The MRSA nasal swab is an effective screening tool for antibiotic de-escalation based on its 98% NPV for MRSA pneumonia if utilized in the correct patient population.

Funding: None

Disclosures: Rachael Anne Lee reports a speaker honoraria from Prime Education, LLC.
Improvement of Adequacy of Empirical Antimicrobial Therapy in Escherichia coli Bacteremia of Urinary Source in Catalonia (VINCat-PROA)
Authors: Horcajada Juan P. , Hernández Sergi , Padullés Ariadna , Gimenez Montserrat , Lucía Boix-Palop , Ferrer Ricard , Melendo Susana , Badia Josep Maria , Oliva Glòria , Calbo Esther , Grau Santiago
Published: November 2020

Background: The antibiotic use optimization program (PROA) in Catalonia (Spain) is part of the surveillance program for nosocomial infections in hospitals in Catalonia (VINCat). Despite the existence of guidelines for the treatment of urinary tract infections in hospitals, adherence to them is not guaranteed. Objective: Our objective was to evaluate the adequacy of empirical antimicrobial therapy to local guidelines in bacteremia caused by Escherichia coli of urinary source within the PROA-VINCat program during a 3-year period. The impact of a voluntary survey asking for evaluating local results and implementing correction measures was also analyzed. Methods: Multicentric prospective observational study including all episodes of E. coli bacteremia of urinary source between May 2017 and September 2019, in adult hospitalized patients in 45 Catalan hospitals. Adequacy of the empirical therapy to local guidelines was one of the prospectively recorded items. A survey evaluating local results of 2017–2018 and asking for possible correcting measures was sent to the participating centers at the end of 2018. Percentages of adequacy of empirical antimicrobial therapy in 2017, 2018, and 2019 were compared by means of χ2 test. Results: Overall, 3,804 episodes of bacteremia were recorded: 845 in 2017, 1,861 in 2018 and 1,098 until September 30, 2019. Globally, adequacy of empirical therapy to guidelines increased from 73.7% in 2017 to 78.2% in 2019 (P = .06). Interestingly, in the 24 hospitals that responded to the voluntary survey, the adequacy of empirical therapy increased significantly from 72.9% in 2017 to 79.9% in 2019 (P = .009). In hospitals that did not respond, adequacy remained the same over the years (76.7% in 2017, 75.1% in 2019; P = .90). Correction measures applied were: meeting with the antimicrobial stewardship team to evaluate the results (100%), review of local resistance rates (62%), review of local guidelines (58.3%), improving guidelines dissemination (75%), sessions for improving guidelines adherence (58%), and analysis of adherence to guidelines after education (65%). Conclusions: In the empirical treatment of E. coli bacteremia of urinary source, adequacy to local antimicrobial therapy guidelines improved from 2017 to 2019, but only in hospitals answering a voluntary survey regarding correcting measures for improving adequacy. Adherence to antimicrobial stewardship proposals improves indicators at local and regional level.

Funding: None

Disclosures: Juan Pablo Horcajada reports consulting fees from MSD, Pfizer, and Menarini and speaker honoraria from MSD, Pfizer, and Zambon.
Infection Control, Antimicrobial Consumption, and Hospital-Acquired Clostridioides difficile Infection in Acute-Care Hospitals in Catalonia
Authors: Calbo Esther , Castellà Laia , Hornero Ana , Larrosa Nieves , Sopena Nieves , Grau Santiago , Hernández Sergi , Gimenez Montserrat , Melendo Susana , Boix-Palop Lucía , Horcajada Juan P.
Published: November 2020

Background: Hospital-acquired Clostridioides difficile infection (HA-CDI) is a major infection control challenge. Using whole-genome sequencing, <40% of HA-CDI cases have been estimated to have been acquired from other inpatient cases. Huge regional variations have been described depending on the prevalence of epidemic ribotypes. We hypothesized that, according to the geographical area, variations in HA-CDI rates between hospitals could be attributable either to differences in infection control policies or to antimicrobial consumption. Objectives: To assess the association of HA-MRSA rates (a surrogate marker of infection control policies) and antimicrobial consumption with HA-CDI incidence from 2011 to 2018 in hospitals reporting at the VINCat-program (Infection Control and Antimicrobial Stewardship Catalan Program). Methods: Data on 45 hospitals in Catalonia (with 70.5% of all adult acute-care hospital beds) reporting antimicrobial consumption, HA-MRSA, and HA-CDI new cases to the VINCat-program since 2011 to 2018 were analyzed. To report antimicrobial consumption, the Anatomical Therapeutic Chemical Classification (ATC) defined daily dose (DDD) index 2018 was used. Participating hospitals were classified into 3 groups according to size: group 1 (>500 beds), 9 hospitals; group 2 (500–200 beds), 15 hospitals; and group 3 (<200 beds), 21 hospitals. The number of hospitalization days recorded at the participating hospitals increased from 2,828,101 in 2011 to 3,201,680 in 2018. To analyze the association between HA-MRSA rate, antimicrobial consumption and the rate of CDI-HA, a Poisson regression model was used. HA-CDI annually new cases have been defined as a dependent variable, the stays as an offset of the model and the HA-MRSA rates and antimicrobial consumption (measured in DDD) as independent factors. The exponents of model coefficients are equal to incidence rate ratios (IRR). Results: The regression model showed an association of with antimicrobial consumption with HA-CDI (IRR,1.05; 95% CI, 1.03–1.07; P < .001) and a lack of association with HA-MRSA (IRR, 0.83; 95% CI, 0.46–1.48; P = .52). Conclusions: The HA-CDI incidence rate grew annually by 5% for an increase of 1 DDD in annual antibiotic consumption. No association HA-MRSA rates was detected, suggesting that antimicrobial stewardship programs are urgently needed to improve the control of HA-CDI in Catalonia, a geographical area with a low prevalence of epidemic ribotypes.

Funding: None

Disclosures: Juan Pablo Horcajada reports consulting fees from MSD, Pfizer, and Menarini and speaker honoraria from MSD, Pfizer, and Zambon.
Patient Involvement in Infection Prevention and Control (IPC) Practice: Knowledge and Perception Study
Authors: Fofanah Bobson Derrick , Conteh Christiana
Published: November 2020

Background: Patient involvement is increasingly recognized as critical component for improved care, and patients has been identified of as having a potentially important role for better health outcome as a result of their involvement in their care plan. A usual saying that infection prevention and control is “everyone’s business” is frequently understood to include not only healthcare workers but also patients and their relatives, all of whom are seen as stakeholders with a part to play in ensuring a better patient outcome. There is limited evidence about knowledge and perception about involving patient and/or relatives in IPC implementation in a post–Ebola-outbreak country. Objectives: We aimed to ascertain the knowledge and perception of patient involvement in infection prevention and control (IPC) practice. Methods: We used a qualitative approach comprising interviews with patients and/or relatives and health workers sampled from 5 hospitals. Participants (n = 60) included 25 nurses, 25 patients and/or relatives, 5 IPC focal persons, and 5 hospital administrators. Interviews used a structured questionnaire to explore staff views on patient involvement. A separate questionnaire was used to survey patient perspectives and knowledge about basic hospital IPC practices. Results: Of 60 interviews, 64% of nurses supported involving patient in hospital IPC practice, saying that the patient can serve as a reminder during the time of care, whereas 36% disagreed with involving the patient because of fear of having confrontations with the patient. Also, 92% of patients and/or relatives agreed to their involvement because they viewed it as their right; only 8% did not accept involvement because they thought it was a burden and not their responsibility. All 5 IPC focal persons (100%) supported patient involvement; they thought it would enhance overall IPC compliance and keep healthcare workers reminded of IPC practice, most especially hand hygiene. Also, 100% of hospital administrators supported involving patients because they felt that patient should be involved in their care plan. Conclusions: From this study, it is evident that patient involvement is key in optimizing IPC compliance in hospitals. The study findings indicate that most patients have knowledge of the importance of hand washing since the Ebola outbreak; however, they lack knowledge on other practices such as waste disposal, cough etiquette, etc. There is need for IPC orientation on admission and continuous patient education.

Funding: None

Disclosures: None

If I am discussing specific healthcare products or services, I will use generic names to extent possible. If I need to use trade names, I will use trade names from several companies when available, and not just trade names from any single company.

Disagree

Christiana Kallon
Prevalence of Carbapenem-Resistant Enterobacteriaceae (CRE) at a Tertiary-Care Center in the United States
Authors: Heipel Diane , Major Yvette , Viola-Luqa Carli , Doll Michelle Elizabeth , Stevens Michael , Cooper Kaila , Godbout Emily , Bearman Gonzalo
Published: November 2020

Background: Quantification of the magnitude of CRE both within a facility and regionally poses a challenge to healthcare institutions. Periodic point-prevalence surveys are recommended by the CDC CRE tool kit as a facility-level prevention strategy. A 2016 point-prevalence survey of 2 high-risk units at a tertiary-care center in the United States for CRE colonization found that all patients surveyed were negative for CRE. The infection prevention (IP) team repeated the study in 2019 to reassess the prevalence of CRE in the healthcare facility. Methods: A point-prevalence survey was performed in November 2019 on the same 2 high-risk units surveyed in 2016. A perirectal flocked swab was collected from all patients unless a patient refused and/or a contraindication to rectal swab was present. Swabs were inoculated onto HardyChrom TM CRE agar for incubation in ambient air at 35°C for 24 hours. Organism identification was performed using MALDI-TOF mass spectrometry on a MBT Smart by Bruker. Results: None of the patients on either high-risk unit was known to be colonized or infected with CRE at the time of the point-prevalence survey. Of 41 perirectal swabs collected, 4 (9.8%) were positive for CRE. None (0 of 20) were surgical ICU patients and 4 of 21 (19%) were medical ICU patients. All positive swabs revealed different organisms identified as follows: Escherichia coli, Enterobacter cloacae, Enterobacter kobai, and Enterobacter aerogenes. All 4 positive patients had had recent contact with multiple acute-care hospitals. Also, 2 had been transferred for liver transplant evaluation. None of these patients had received a carbapenem during their admission to the facility. Conclusion: CRE are increasingly identified in healthcare centers in the United States. Centers previously classified as low prevalence will need to maintain preventive strategies to limit transmission risks as colonized patients arrive in the facility for care. Adoption of a robust horizontal infection prevention program may be an effective strategy to avoid the spread of CRE.

Funding: None

Disclosures: Michelle Doll reports a research grant from Molnlycke Healthcare.
Using Whole-Genome Sequencing to Improve Surveillance Measures: Case Study of Methicillin-Resistant Staphylococcus aureus (MRSA) in a Florida Hospital
Authors: Lamers Susanna , Nolan David , McCarter Yvette Simone , Neilsen Chad , Rose Rebecca , Rodriguez Christopher , Cross Stephanie
Published: November 2020

Background: The CDC considers methicillin-resistant Staphylococcus aureus (MRSA) one of the most important hospital-acquired infections (HAIs) in the United States. However, infection control departments (ICDs) often rely on subjective data to determine whether multiple MRSA cases are a true outbreak and whether the hospital is responsible (community- vs hospital-acquired). Objective: Our objective was to determine whether whole-genome sequencing (WGS) of MRSA provided new insights into on transmission dynamics at large, inner-city hospital in Jacksonville, Florida. Methods: Over a 4-month period, MRSA samples were obtained from 44 infected patients at 3 campuses within a single hospital system. Limited nonpatient identifying information was obtained, including date of collection, campus, unit, reason for admission, and days post admission (DPA) of MRSA diagnosis. Whole-genome sequences were generated using the Illumina platform. Raw reads were processed, and genetic distances were calculated and used to identify genetically linked bacterial infections using FoxSeq version 1.0 software. Results: Based on their length of stay, 10 patients were reported by the ICD as obtaining an HAI. Three distinct “episodes” were evident in which >5 MRSA cases were observed within a 3–5-day period. Genomic analysis identified 5 clusters of linked infections: 4 clusters contained 2 patients and another contained 3. Of these clusters, only 1 contained multiple cases that were reported as HAIs; however, because these case were separated by 2 weeks, it is unlikely that they came from a source in the hospital. The results suggest that HAIs were overreported and that most MRSA present in the hospital likely came from community sources. Conclusions: WGS provided clear evidence that temporally clustered MRSA cases do not imply an outbreak is occurring. Furthermore, ongoing detection of the same community-acquired infections over several months is indicative of a shared source outside of the hospital, which could be uncovered through examination of clinical records. Considering the implications of HAIs, best approaches to combat them should include identifying their sources. As molecular surveillance approaches to infection control are rapidly becoming easier and less expensive, the methods can be used to bring objective clarity to the ICD.

Funding: None

Disclosures: Susanna L. Lamers reports salary from BioInfoExperts and contract research for the NIH, the University of California - San Francisco, and UMASS Medical School.
Variation in Measures of Antimicrobial Use Across Four Nursing Homes, Atlanta, Georgia, 2019
Authors: Dube William , Saiyed Sahebi , Comer Patricia , Hanichen Michael , Klinczar Christie , Price Crystal , Fridkin Scott
Published: November 2020

Background: Although antibiotic stewardship programs (ASP) are now required in nursing homes, assimilating and responding to data to improve prescribing in nursing homes is novel. Four Atlanta-based skilled nursing facilities (SNFs) began collaborating (EASIL: Emory Antibiotic Stewardship in Long-Term Care) to share standardized prescribing data to allow interfacility comparisons and action. Methods: After SNF ASPs were evaluated and trained, standardized prescribing logs were submitted (January 2019 to June 2019) including the following data: start date, treatment site, prescriber attribution of order (ie, SNF order vs hospital order) and monthly resident days. SNF-specific point estimates of usage rates were calculated as pooled means for all antibiotic starts, SNF-order starts, and days of therapy (DOT), by treatment site per 1,000 resident days. Duration of urinary tract infection (UTI) therapy was assessed by calculating percentage of SNF-UTI starts over recommended duration defined by the local treatment guideline. Rate ratios (RRs) of use were calculated to compare SNF-specific rates to the largest SNF. The 95% CIs were calculated using normal approximation. Results: Monthly starts ranged from 124 to 177, with a pooled mean of 7.8 antibiotic starts (any type), 4.5 SNF-order starts, and 1.2 SNF-UTI starts per 1,000 resident days. Approximately half of all starts were SNF starts (range, 43%–53%), and less than half of DOT were attributed to SNF starts (range, 35%–45%). Overall, SNF-order treatment sites were most often UTIs (29%), lower respiratory infections (17%), and skin and soft-tissue infections (17%). SNF-order UTI starts per 1,000 patient days varied at 1 SNF (SNF B RR, 1.57; 95% CI, 1.04–2.36). SNF-order UTI DOT per 1,000 patient days was more variable, with SNFs B and C having significantly higher rates (B RR, 1.49, 1.24, and 1.82; C RR, 5.42; 95% CI, 4.65–6.34) than SNF A (Fig. 1). The percentage of SNF-order UTI starts that were over recommended duration ranged from 8% (nitrofurantoin, SNF A) to 100% (fluoroquinolones, SNF C) (Fig. 1). Conclusions: Although UTIs are the single most common reason to prescribe antibiotics after arriving in a SNF, they account for a small fraction of overall starts and an even smaller fraction of DOT. We identified outlier prescribing by different SNFs using 3 metrics, suggesting that distinct corrective actions are necessary to target distinct prescribing challenges (starts, duration, and transitions of care).

Funding: None

Disclosures: Scott Fridkin reports that his spouse receives consulting fees from the vaccine industry.
Variations in Concurrent Central-Line Use Among Central-Line–Associated Bloodstream Infection (CLABSI) Patients by National Healthcare Safety Network (NHSN) Location Type
Authors: Dube William , Jacob Jesse , Robichaux Chad , Steinberg James , Fridkin Scott
Published: November 2020

Background: Current NHSN denominator reporting for central-line–associated bloodstream infection (CLABSI) counts each patient day with n central lines as 1 central-line day. The NHSN does not directly adjust for potential increased risk of CLABSI from concurrent central lines, but the current NHSN standardized infection ratio (SIR) methods may account for differences in concurrence by adjusting for location type. Objective: We examined differences in central-line concurrence by NHSN location type among CLABSI patients. Methods: In a retrospective cohort of adults with CLABSI at 4 hospitals from 2012 to 2017, we linked central-line data to encounter and CLABSI data. Central lines were considered concurrent if they overlapped for >1 day. We calculated proportion of patients with concurrence at both NHSN location and SIR group levels; risk ratios for concurrence between NHSN location types within each SIR group (ie,, locations defined by SIR models as equal “risk”) were determined. Results: In total, 930 CLABIs were identified from 19 NHSN-defined locations that map to 7 SIR groups. Most CLABSIs occurred in locations mapped to either of 2 SIR groups: wards (227, 16% concurrence) and ICUs (294, 33% concurrence). The ward group had 3 NHSN locations (median, 78 CLABSIs) with concurrence range 8% (medical-surgical ward) to 20% (surgical ward). The ICU group had 6 NHSN locations (median, 47.5 CLABSIs) and concurrence ranged from 20% (neurosurgical ICU) to 39% (medical ICU). Despite the noted variations, no risk ratio was statistically different within each SIR group (Table 1). Conclusions: In patients with CLABSIs, the frequency of concurrence varied up to 2-fold between location types within the current NHSN SIR groups, though not statistically significantly. Assessing whether this difference in magnitude persists in all patients with central lines is an important next step in refining risk adjustment methods to account for concurrent central-line use.

Funding: None

Disclosures: Scott Fridkin reports that his spouse receives consulting fees from the vaccine industry.