bluuebunny/crossref_metadata_2025 huggingface dataset:
Quality Initiative to Reduce Catheter-Associated Urinary Tract Infections Using Cleansing Cloths With a Standardized Method
Authors: Droske Lauren , Patel Parul , Schora Donna , Patel Jignesh , Barza Ruby , Monsalud Cherie Faith , Fisher Adrienne , Lim Rachel , Shah Mona , Kufner Bridget , Zelencik Shane , Lavin Mary Alice , Singh Kamaljit
Published: November 2020

Background: Catheter-associated urinary tract infections (CAUTIs) account for >15% of hospital-acquired infections, resulting in increased length of stay and costs. Consequently, methods to improve indwelling urinary catheter (IUC) care and maintenance are warranted to reduce the risk of hospital-acquired CAUTIs. This study was a prospective quality improvement (QI) project to reduce CAUTIs using prepackaged cloths (ReadyCleanse by Medline Industries) and a simple, standardized cleaning process for care and maintenance of IUCs. Methods: This study is an ongoing QI project at NorthShore University HealthSystem, a 4-hospital system located north of Chicago, Illinois, with 750 beds and ∼64,000 annual admissions. The study consists of a 1.5-month staff training on proper product use (phase 1), followed by an intervention using the cloths for IUC care (phase 2). Each package contains 5 individual cloths corresponding to a simple, 5-step, cleansing protocol. IUC care and maintenance are performed twice daily on a routine basis and after each incontinent episode. Beginning July 2018, current practice (soap and wash cloth) was replaced with the ReadyCleanse cloths, and on August 1, 2018, data collection began. Adult patients admitted at all 4 NorthShore Hospitals with an IUC for >24 hours are enrolled in the study. From patient electronic health records, we collected patient demographics, reason for IUC insertion, days of catheter use, and development of CAUTI (according to the NHSN definition). During the intervention, observations of compliance and performance of catheter care were also performed. For the analysis described here, results for the first 14 months of the study were compared to CAUTI numbers from the 14-month period prior to the start of the study (February 2017–March 2018); the data presented represent ∼50% of the planned data collection. Results: As of September 30, 2019, 4,969 patients were prospectively enrolled in the study: 1,491 patients from hospital A, 1,451 from hospital B, 1,091 from hospital C, and 936 from hospital D. Patient demographics for the study cohort were 47% female, with a median age of 77 years and an average of 3.9 catheter days per patient. Systemwide, observational audits for compliance using the cloths averaged 95%. Upon completion of study month 14, 22 CAUTIs had been identified, compared to 26 CAUTIs for the comparison period, indicating a 15% reduction. Conclusion: Implementation of this simple, standardized alternative for IUC care is feasible on a large scale and may have potential for reducing CAUTI rates.

Funding: Medline Industries supported this study.

Disclosures: None
Tube Feeding: A Risk Factor for Clostridioides difficile Infection Among Long-Term Care Facility Residents Hospitalized at a Tertiary-Care Hospital in Detroit
Authors: Polistico Jordan , Awali Reda , Chopra Teena , Virdi Parminder kaur , Zaher Nathan , Baidoun Mohammad , Oring Justin , Gonzalez Elisa , Zhang Pingping , Heinrich Kirstin
Published: November 2020

Objective: We investigated the epidemiology of Clostridioides difficile infection (CDI) in long-term care facility (LTCF) patients admitted to a tertiary-care center in Detroit. Methods: A retrospective case-control study was conducted of LTCF residents who were hospitalized with CDI at the Detroit Medical Center between January 1, 2009, and December 31, 2016. Case patients (LTCF residents admitted with CDI) were compared to 2 sets of inpatient controls. The first set of controls included inpatients presenting from the same LTCFs without CDI (control A). Second set included inpatients admitted from non-LTCF (home, community, hospital) who acquired CDI > 48 hours after admission or those who acquired CDI within 48 hours of admission but were exposed to an acute-care hospital within 4 weeks prior to admission (control B). Cases were matched (1:3 ratio) to the 2 sets of controls (control A and control B) based on year of admission. Matched multivariable analyses using conditional logistic regression were performed to identify independent predictors of CDI. Results: In total, 85 cases were matched to 2 sets of controls. For the first multivariate logistic regression model performed on cases and control A (n1 = 255), significant risk factors identified included tube feeding (OR, 3.60; 95% CI, 1.43–9.02; P = .006) and albumin ≤2.5 g/dL (OR, 4.98; 95% CI, 2.02–12.31; P < .001). For the second multivariate logistic regression model performed on cases and control B (n2 = 255), significant risk factors identified included Charlson comorbidity index score (OR, 1.25; 95% CI, 1.12–1.40; P < .001), tube feeding (OR, 3.63; 95% CI, 1.81–7.25; P < .001), prior use of PPI (OR, 0.37; 95% CI, 0.20–0.68; P = .001), prior use of H2 blockers (OR, 0.34; 95% CI, 0.16–0.69; P = .003), and prior use of antibiotics (OR, 0.12; 95% CI, 0.06–0.24; P < .001). Cases were more likely to have complicated CDI (OR, 7.02; P < .001) and recurrent CDI (OR, 2.63; P =.02) when compared to control B. Conclusions: Patients who acquired CDI at LTCFs experienced more severe CDI and were at greater risk for recurrent CDI than patients with other healthcare-associated CDI. For the regression model performed on cases and control A as well as that performed on cases and control B, tube feeding was the only variable that consistently predicted CDI among LTCF patients.

Funding: This study was supported by Pfizer Inc (Collegeville, PA).

Disclosures: None
A Ten-Year Review of Carbapenemase Producing Enterobacterales (CPE) in London, United Kingdom
Authors: Patel Bharatkumar , Hopkins Katie , Meunier Daniele , Staves Peter , Hopkins Susan , Woodford Neil
Published: November 2020

Background: To determine the pattern of CPE observed in a single region in the United Kingdom. Methods: From 2009 to 2018, clinical laboratories in England were requested to send suspected CPE from all sites to the national reference laboratory for confirmation and investigation of carbapenem resistance mechanism(s). Isolates of Enterobacterales from London laboratories and confirmed to have 1 or more carbapenemase genes were included in the analysis. Result: Between 2009 and 2018, 5,133 isolates were confirmed to produce a carbapenemase; at least 1 CPE was identified in every London Laboratory and hospital. Confirmations increased from 28 isolates in 2009 to 1857 in 2018 and with a sharp rise after the introduction of the ‘PHE toolkit’ in 2013 (Fig. 1). Most CPE (2655, 51.7%) were from rectal screens (the 3 most frequently identified carbapenemase families were OXA-48–like in 1,263 isolates, NDM in 971 and IMP in 128), 631 (12.3%) were from urine samples, 180 (3.5%) from blood cultures, 103 (2.0%) from sputum specimens and the remainder (1564, 30.5%) were swabs, fluids and tissues from various body sites. Moreover, 51 CPE (1%) were identified from environmental swabs. Isolates were predominantly Klebsiella spp (2,525, 49%; 2,088 were K. pneumoniae), followed by Escherichia coli (1,434, 27.9%), Enterobacter spp (746, 14.5%; 605 were E. cloacae complex), and Citrobacter spp (349, 6.8%); 10 other species contributed smaller numbers. Within the carbapenemase families, OXA-48-like enzymes predominated overall (2303, 44.9%), followed by NDM (1822, 35.5%), IMP (313, 6.1%), VIM (207, 4.0%), NDM+OXA-48-like (205, 4.0%), and KPC (196, 3.8%). The first detection of a CPE with 2 distinct enzymes occurred in 2012 (OXA-48-like and NDM) and since then 235 co-detections have been identified; 233 related to OXA-48-like with another gene. Conclusion: The first CPE isolate in London was identified in 2003, a Klebsiella spp with a VIM enzyme. The number of isolates submitted to the national reference laboratory has continued to increase year on year. VIM and NDM carbapenemases predominated in the early years, because of their association with several outbreaks; these have now been overwhelmed by OXA-48-like detections and outbreaks. The increasing numbers of CPE with a combination of a metallo- and a non-metallo carbapenemase increases the therapeutic challenges to treat infected patients. Bacteremia caused by CPE remains rare, suggesting that infection prevention and control efforts are having some impact. However, as colonization prevalence increases, the number of clinical infections will rise in the future unless control measures to limit transmission and spread are improved.

Funding: None

Disclosures: None
Clinical Metrics for a Large Healthcare System’s Antimicrobial Management Program
Authors: Burgess Hayley , Kramer Joan , Hofammann Elizabeth , Cooper Mandelin
Published: November 2020

Background: Clinical metrics and outcomes for evaluation of antimicrobial management programs (AMP) are challenging and inconsistent throughout the United States. Here, we present the results of the development of clinical metrics to measure and trend AMP outcomes within 161 acute-care facilities affiliated with a large healthcare system. Methods: Key AMP metrics were implemented in 2018 using 2017 as baseline: use of fluoroquinolones in UTIs, dosing of vancomycin, de-escalation, and intravenous (IV)-to-oral conversion of targeted drugs. Fluoroquinolone (FQ) and UTI metric evaluated all inpatients who received at least 1 dose of a FQ based on barcoded medication administration (BCMA) data and urinary tract infections were based on cystitis ICD-10 coding. Vancomycin dosing metric evaluated inpatient vancomycin troughs within therapeutic range during the admission. De-escalation metric evaluated for patients on a broad-spectrum antibiotic with a positive culture and sensitivity to narrower antibiotics. The IV-to-oral ratio was used to monitor targeted medications. Nonantimicrobial medications appropriate for IV-to- oral conversion were included in the ratio. Goals were established for each metric using the 75th percentile and ranges for “at goal,” “close to goal,” and “not at goal” were established using green–yellow–red color coding. Metrics were monitored via a systemwide dashboard that included all affiliated facilities. Data were shared monthly to key stakeholders including physicians, pharmacists, and senior leadership. Results: From 2017 to the third quarter of 2019, the FQ and UTI metric decreased 55%. This reduction in the FQ usage in UTI metric correlated with a reduction of 26.7 days of therapy (DOT) per 1,000 days present for FQ and a 50% reduction in FQ DOT for all affiliated facilities. The vancomycin dosing metric improved 2.9% from 75.2% of patients to 78.1% of patients with at least 1 vancomycin trough within range during the admission, which represents ~2,000 more patients with dosing in the target range over baseline. The de-escalation metric improved by 7% overall from 2018 to the third quarter of 2019, which translates to ~1,600 more patients with therapy de-escalated. The IV-to-oral ratio metric improved 5.5%, which means that ~180,000 more oral dosages were administered. Conclusions: Implementing AMP program clinical metrics in a large health system positively influenced antimicrobial medication therapy management for patients. Monitoring of process metrics should be considered for all AMP programs to advance antibiotic stewardship.

Funding: None

Disclosures: None
Potential Impact of CDC’s Enhanced Barrier Precautions Recommendations on Veterans’ Affairs Long-Term Care Facilities
Authors: Evans Martin , Kralovic Stephen , Roselle Gary , Lipscomb Karen , Flarida Linda
Published: November 2020

Background: We previously showed that ~25% of Veterans’ Affairs (VA) long-term care facility (LTCF) residents had 1 or more indwelling medical devices. Of these devices, 36% were indwelling urinary catheters, 18% were percutaneous gastrostomy tubes, 12% were peripherally inserted central catheters, 8% were suprapubic urinary catheters, and 6% were peripheral intravenous catheters. Approximately 11% of those with an indwelling device developed an LTCF-acquired infection, compared to 3.5% of those without a device. Methicillin-resistant Staphylococcus aureus (MRSA) is a targeted multidrug-resistant organism (MDRO) in all VA LTCFs nationwide. All admissions to VA LTCFs are screened for MRSA carriage upon admission and, since 2013, those that screen positive (~21%) are placed in VA enhanced barrier precautions (EBPs). VA EBPs require that all healthcare workers entering a resident’s bedroom don gowns and gloves for specific activities likely to be associated with contamination of the worker’s hands and clothes. With proper hand hygiene and clean clothing, the colonized resident is encouraged to leave their bedroom and participate fully in all LTCF activities. In July 2019, the US Centers for Disease Control and Prevention (CDC) recommended the use of EBPs for all residents in LTCFs with a wound or device regardless of their colonization status if a resident is identified within the facility with novel or targeted MDROs including panresistant organisms, carbapenemase-producing gram-negative bacteria, and Candida auris. Methods: We assessed the potential impact of this recommendation on VA LTCFs by asking our 133 LTCFs to do a 1-day point-prevalence survey. Results: In total, 63 sites (47%) responded. On the survey day, there were 4,777 residents in the participating facilities, of whom 891 (18.7%) were under EBPs or contact precautions (CPs) for MRSA or other MDROs. Moreover, 963 (20.2%) residents (not already in EBP or CP) had a wound or an indwelling device such as central venous catheter, urinary catheter, feeding tube, tracheostomy or were on a ventilator (if >1 device, resident counted only once). If newly published CDC recommendations were implemented for novel or targeted MDRO precautions in VA LTCFs nationwide, 1,854 residents (38.8%) in VA LTCFs would be placed under EBPs or CPs. Conclusions: In VA LTCFs, adopting the CDC recommendation to place all patients with wounds or indwelling devices under EBPs regardless of colonization status would increase the percentage of residents on transmission-based precautions to ~40% (nearly doubling those in an isolation precaution status).

Funding: None

Disclosures: None
An Outbreak of New Delhi Metallo--Lactamase-5 (blaNDM-5)–Producing Escherichia coli in Companion Animals in the United States
Authors: Rankin Shelley C. , Cole Stephen D.
Published: November 2020

Background: The emergence of carbapenem-resistant Enterobacteriaceae (CRE) in companion animals will be a game changer for infection prevention and control strategies in veterinary and human healthcare facilities. CRE have emerged as an important cause of human healthcare-associated infections and are a major clinical and public health problem. Although reports of CRE from animals are still very rare, they have been documented in China, Europe, and the United States. Methods: In April 2019, a passive veterinary surveillance system identified the blaNDM-5 gene in an E. coli isolated from a dog in Philadelphia in July 2018. CRE are reportable to the Philadelphia Department of Public Health (PDPH), and in May 2019, the Matthew J. Ryan Veterinary Hospital at the University of Pennsylvania (MJRVH) reported a cluster of carbapenem-resistant E. coli (CR-E. coli) isolated from 14 animals to the PDHP. This cluster of 17 isolates, that all contained a blaNDM-5 gene, was the first report of a CR-E. coli outbreak at a US veterinary facility. The first isolate, E. coli 24213-18, was sequenced on the Pacific Biosciences (PacBio) Sequel Sequencer and has been uploaded to GenBank. Whole genome sequencing was performed on all 17 isolates using the Illumina MiSeq platform. Antimicrobial resistance genes were identified from the National Center for Biotechnology Information Pathogen Detection Isolates Browser using AMRFinder. Results: PacBio sequencing confirmed E. coli ST167 and identified a circular IncFII plasmid of 139,547 bp that contained the blaNDM-5 gene, along with many additional resistance genes. In June 2019, a retrospective review of hospital records was completed and showed that, from July 2018, 17 CR- E. coli were isolated from 14 animals. Conclusions: Control of CRE infections in human healthcare settings is challenging because the organisms colonize the gastrointestinal tract and can go undetected. The same issue is to be expected with companion animals. Healthcare-associated spread of CRE E. coli in a veterinary facility emphasizes the importance of rapidly identifying and characterizing carbapenem-resistant isolates from animals. Methods to control the spread of CRE in veterinary medical settings have not yet been studied, and related investigations will be critically important to limit the transmission of these pathogens in animal populations. The risk of transmission of CRE from animals to people is currently poorly understood. CRE will be a major challenge across all health fields as these organisms become more prevalent in the community. It is likely that a ‘One Health’ approach to surveillance, infection prevention, and antimicrobial stewardship will be required to limit the spread and potential global dominance of CRE.

Funding: None

Disclosures: None
Chlorhexidine MICs Remain Stable Among Antibiotic-Resistant Bacterial Isolates Collected from 2005 to 2019 at Three US Sites
Authors: Lutgring Joseph , Grass Julian , Lonsway David , Yoo Brian , Epson Erin , Crumpler Megan , Galliher Karen , Zahn Matthew , Evans Eric , Jacob Jesse , Page Alexander , Satola Sarah , Smith Gillian , Kainer Marion , Hayden Mary , Reddy Sujan , Elkins Christopher , Magill Shelley , Guh Alice
Published: November 2020

Background: Chlorhexidine bathing reduces bacterial skin colonization and prevents infections in specific patient populations. As chlorhexidine use becomes more widespread, concerns about bacterial tolerance to chlorhexidine have increased; however, testing for chlorhexidine minimum inhibitory concentrations (MICs) is challenging. We adapted a broth microdilution (BMD) method to determine whether chlorhexidine MICs changed over time among 4 important healthcare-associated pathogens. Methods: Antibiotic-resistant bacterial isolates (Staphylococcus aureus from 2005 to 2019 and Escherichia coli, Klebsiella pneumoniae, and Enterobacter cloacae complex from 2011 to 2019) were collected through Emerging Infections Program surveillance in 2 sites (Georgia and Tennessee) or through public health reporting in 1 site (Orange County, California). A convenience sample of isolates were collected from facilities with varying amounts of chlorhexidine use. We performed BMD testing using laboratory-developed panels with chlorhexidine digluconate concentrations ranging from 0.125 to 64 μg/mL. After successfully establishing reproducibility with quality control organisms, 3 laboratories performed MIC testing. For each organism, epidemiological cutoff values (ECVs) were established using ECOFFinder. Results: Among 538 isolates tested (129 S. aureus, 158 E. coli, 142 K. pneumoniae, and 109 E. cloacae complex), S. aureus, E. coli, K. pneumoniae, and E. cloacae complex ECVs were 8, 4, 64, and 64 µg/mL, respectively (Table 1). Moreover, 14 isolates had an MIC above the ECV (12 E. coli and 2 E. cloacae complex). The MIC50 of each species is reported over time (Table 2). Conclusions: Using an adapted BMD method, we found that chlorhexidine MICs did not increase over time among a limited sample of S. aureus, E. coli, K. pneumoniae, and E. cloacae complex isolates. Although these results are reassuring, continued surveillance for elevated chlorhexidine MICs in isolates from patients with well-characterized chlorhexidine exposure is needed as chlorhexidine use increases.

Funding: None

Disclosures: None
Effectiveness of Ultraviolet-C Room Disinfection on Preventing Healthcare-Associated Clostridioides difficile Infection
Authors: Goto Michihiko , Balkenende Erin , Clore Gosia , Nair Rajeshwari , Simbartl Loretta , Evans Martin , Safdar Nasia , Perencevich Eli
Published: November 2020

Background: Enhanced terminal room cleaning with ultraviolet C (UVC) disinfection has become more commonly used as a strategy to reduce the transmission of important nosocomial pathogens, including Clostridioides difficile, but the real-world effectiveness remains unclear. Objectives: We aimed to assess the association of UVC disinfection during terminal cleaning with the incidence of healthcare-associated C. difficile infection and positive test results for C. difficile within the nationwide Veterans Health Administration (VHA) System. Methods: Using a nationwide survey of VHA system acute-care hospitals, information on UV-C system utilization and date of implementation was obtained. Hospital-level incidence rates of clinically confirmed hospital-onset C. difficile infection (HO-CDI) and positive test results with recent healthcare exposures (both hospital-onset [HO-LabID] and community-onset healthcare-associated [CO-HA-LabID]) at acute-care units between January 2010 and December 2018 were obtained through routine surveillance with bed days of care (BDOC) as the denominator. We analyzed the association of UVC disinfection with incidence rates of HO-CDI, HO-Lab-ID, and CO-HA-LabID using a nonrandomized, stepped-wedge design, using negative binomial regression model with hospital-specific random intercept, the presence or absence of UVC disinfection use for each month, with baseline trend and seasonality as explanatory variables. Results: Among 143 VHA acute-care hospitals, 129 hospitals (90.2%) responded to the survey and were included in the analysis. UVC use was reported from 42 hospitals with various implementation start dates (range, June 2010 through June 2017). We identified 23,021 positive C. difficile test results (HO-Lab ID: 5,014) with 16,213 HO-CDI and 24,083,252 BDOC from the 129 hospitals during the study period. There were declining baseline trends nationwide (mean, −0.6% per month) for HO-CDI. The use of UV-C had no statistically significant association with incidence rates of HO-CDI (incidence rate ratio [IRR], 1.032; 95% CI, 0.963–1.106; P = .65) or incidence rates of healthcare-associated positive C. difficile test results (HO-Lab). Conclusions: In this large quasi-experimental analysis within the VHA System, the enhanced terminal room cleaning with UVC disinfection was not associated with the change in incidence rates of clinically confirmed hospital-onset CDI or positive test results with recent healthcare exposure. Further research is needed to understand reasons for lack of effectiveness, such as understanding barriers to utilization.

Funding: None

Disclosures: None
Effects of Susceptibility Result Suppression on National Healthcare Safety Network Antibiotic Resistance Option Data
Authors: Estes Matthew , Ouedraogo Youssoufou , Evans Christopher David , Muleta Daniel , Adre Cullen , Keaton Amelia , Kainer Marion
Published: November 2020

Background: The National Healthcare Safety Network’s (NHSN) Antibiotic Resistance (AR) Option offers hospitals a way to report antibiotic resistance data from their facility’s laboratory information system and create facility-specific antibiograms. Suppression of select antibiotic susceptibility results may be used by antibiotic stewardship teams to prevent unnecessary use of broad-spectrum therapies by not making those susceptibilities available to providers. To be of use, antibiograms should offer a complete picture of antibiotic resistance. We wanted to understand the impact of data suppression. Methods: A retrospective cross-sectional study was conducted including data from 2017 and 2018. The clinical susceptibility data for cefotaxime, ceftriaxone, ceftazidime, ertapenem, imipenem, and meropenem against carbapenem-resistant Enterobacteriaceae (CRE), Pseudomonas aeruginosa (CRPA), Acinetobacter baumannii (CRAB), and extended-spectrum β-lactamase–producing Enterobacteriaceae (ESBL) were collected from commercial antimicrobial susceptibility testing instruments (cASTI) in 3 Tennessee healthcare networks that also report to the NHSN AR Option. These data were linked to the NHSN data using 4 keys: date of birth, isolate collection date, pathogen, and specimen source. An isolate was defined as suppressed when susceptibility results were observed from the cASTI but not in NHSN. The proportions of suppressed results were calculated and stratified by genus, facility, and antibiotic. Results: Overall, 1,009 isolates were matched between the NHSN AR data and the laboratory test results. Of these, 4.1% were CRAB, 23.3% were CRPA, and 72.6% were Enterobacteriaceae. In total, 4,948 susceptibility results were available from cASTIs. Suppressed results in NHSN data were observed in 918 isolates (91.0%) and accounted for 2,797 results (56.6%). Of the 817 isolates tested against imipenem, 18.7% were found to be suppressed. Moreover, 100%, 57.9%, and 8.6% of imipenem tests against CRAB, CRPA, and Enterobacteriaceae, respectively, were suppressed. Of the suppressed results, 38.3%, 3.6%, and 58.1% were susceptible, intermediate, and resistant respectively. Of the 363 isolates tested against meropenem, 48.2% were found to be suppressed. In addition, 12.2%, 53.0%, and 52.2% of meropenem tests against CRAB, CRPA, and Enterobacteriaceae, respectively, were suppressed. Of the suppressed results, 47.4%, 11.4%, and 41.1% were susceptible, intermediate, and resistant, respectively. Conclusions: A large proportion of isolates had at least 1 analyzed antibiotic suppressed within the NHSN AR Option. It will be important to develop and implement strategies to ensure that nonsuppressed data are available to be reported to the NHSN AR module.

Funding: None

Disclosures: None
Escherichia coli Antibiotic Susceptibility Patterns for Infants Admitted to NICUs Across the United States from 2009 to 2017
Authors: Flannery Dustin , Akinboyo Ibukun , Mukhopadhyay Sagori , Tribble Alison , Song Lihai , Chen Feiyan , Gerber Jeffrey , Puopolo Karen
Published: November 2020

Background:Escherichia coli (E. coli) is a leading cause of infections among term and preterm newborn infants. Continued surveillance of neonatal E. coli antibiotic susceptibility patterns is important to optimize empiric antibiotic prescription for infants at risk for infection, in light of evolving reports of multidrug-resistant gram-negative bacteria in all settings. Our objective was to determine E. coli epidemiology and antibiotic susceptibility patterns among a large sample of infants admitted to neonatal intensive care units (NICUs) across the United States from 2009 to 2017. Methods: Retrospective observational study using the Premier Database, including infants born from 2009 to 2017 and admitted to academic or community NICUs contributing microbiology data during the study period. We analyzed antibiotic susceptibilities for E. coli isolated from blood, cerebrospinal fluid, and urine. We focused on clinically relevant and priority susceptibility categories: (1) ampicillin nonsusceptible; (2) aminoglycoside nonsusceptible; (3) carbapenem nonsusceptible; and (4) extended-spectrum β-lactamase (ESBL; phenotypic definition). We determined the proportion of infants with nonsusceptible organisms in each category by year and tested for changes over time. Lastly, we assessed susceptibility patterns by specimen source, birthweight, and timing of infection. Results: Of the 117,484 included infants, 733 (0.6%) had at least 1 E. coli episode, of which 721 (98.4%) had available susceptibility results, from 69 centers. Patient and center characteristics of infants with E. coli are shown in Table 1. Most organisms were tested against ampicillin (99.9%), gentamicin (99.6%), and ceftriaxone (91.5%). Figure 1 shows nonsusceptibility rates for the categories of interest. Overall, ampicillin nonsusceptibility ranged from 63.3% to 68.6% per year (mean, 66.8%±1.5%); aminoglycoside nonsusceptibility ranged from 10.7% to 23.2% (mean, 16.8%±4.5%); carbapenem nonsusceptibility was 0% for all years; and ESBL ranged from 1.2% to 11.3% (mean, 5.1%±3.4%). We detected no statistically significant trends for any of the categories of interest over time (all P > .05), and susceptibility trends were consistent when repeated by specimen source, birthweight, and timing of infection. Conclusions: We found stable, yet concerning, patterns of E. coli antibiotic nonsusceptibility among infants admitted to NICUs across the United States from 2009 to 2017. Rates of ampicillin nonsusceptibility and aminoglycoside nonsusceptibility were higher than previous reports. ESBL E. coli rates were low but present among neonatal patients. No carbapenem nonsusceptible E. coli was identified. These findings can inform empiric antibiotic prescription for infants admitted to NICUs across the United States.

Funding: None

Disclosures: None
Group Electronic Monitoring of Hand Hygiene on Inpatient Units: A Multicenter Cluster Randomized Quality Improvement Study
Authors: Leis Jerome , Powis Jeff , McGeer Allison , Ricciuto Daniel , Agnihotri Tanya , Coyle Natalie , Williams Victoria , Moore Christine , Salt Natasha , Wong Louis , McCreight Liz , Sivaramakrishna Sajeetha , Junaid Shara , Cao Xingshan , Muller Matthew
Published: November 2020

Background: The current approach to measuring hand hygiene (HH) relies on human auditors who capture <1% of HH opportunities and rapidly become recognized by staff, resulting in inflation in performance. Our goal was to assess the impact of group electronic monitoring coupled with unit-led quality improvement on HH performance and prevention of healthcare-associated transmission and infection. Methods: A stepped-wedge cluster randomized quality improvement study was undertaken across 5 acute-care hospitals in Ontario, Canada. Overall, 746 inpatient beds were electronically monitored across 26 inpatient medical and surgical units. Daily HH performance as measured by group electronic monitoring was reported to inpatient units who discussed results to guide unit-led improvement strategies. The primary outcome was monthly HH adherence (%) between baseline and intervention. Secondary outcomes included transmission of antibiotic resistant organisms such as methicillin resistant Staphylococcus aureus (MRSA) and other healthcare-associated infections. Results: After adjusting for the correlation within inpatient units, there was a significant overall improvement in HH adherence associated with the intervention (IRR, 1.73; 95% CI, 1.47–1.99; P < .0001). Monthly HH adherence relative to the intervention increased from 29% (1,395,450 of 4,544,144) to 37% (598,035 of 1,536,643) within 1 month, followed by consecutive incremental increases up to 53% (804,108 of 1,515,537) by 10 months (P < .0001). We identified a trend toward reduced healthcare-associated transmission of MRSA (0.74; 95% CI, 0.53–1.04; P = .08). Conclusions: The introduction of a system for group electronic monitoring led to rapid, significant, and sustained improvements in HH performance within a 2-year period.

Funding: None

Disclosures: None
Hospital Microbiologic Culture Results to Predict the Use of Anti–methicillin-Resistant Staphylococcus aureus (MRSA)
Authors: Wu Hsiu , Kratzer Tyler , Zhou Liang , Soe Minn , Edwards Jonathan , Neuhauser Melinda , Benin Andrea , Hicks Lauri , Srinivasan Arjun , Pollock Daniel
Published: November 2020

Background: To provide a standardized, risk-adjusted method for summarizing antimicrobial use (AU), the Centers for Disease Control and Prevention developed the standardized antimicrobial administration ratio, an observed-to-predicted use ratio in which predicted use is estimated from a statistical model accounting for patient locations and hospital characteristics. The infection burden, which could drive AU, was not available for assessment. To inform AU risk adjustment, we evaluated the relationship between the burden of drug-resistant gram-positive infections and the use of anti-MRSA agents. Methods: We analyzed data from acute-care hospitals that reported ≥10 months of hospital-wide AU and microbiologic data to the National Healthcare Safety Network (NHSN) from January 2018 through June 2019. Hospital infection burden was estimated using the prevalence of deduplicated positive cultures per 1,000 admissions. Eligible cultures included blood and lower respiratory specimens that yielded oxacillin/cefoxitin–resistant Staphylococcus aureus (SA) and ampicillin-nonsusceptible enterococci, and cerebrospinal fluid that yielded SA. The anti-MRSA use rate is the total antimicrobial days of ceftaroline, dalbavancin, daptomycin, linezolid, oritavancin, quinupristin/dalfopristin, tedizolid, telavancin, and intravenous vancomycin per 1,000 days patients were present. AU rates were modeled using negative binomial regression assessing its association with infection burden and hospital characteristics. Results: Among 182 hospitals, the median (interquartile range, IQR) of anti-MRSA use rate was 86.3 (59.9–105.0), and the median (IQR) prevalence of drug-resistant gram-positive infections was 3.4 (2.1–4.8). Higher prevalence of drug-resistant gram-positive infections was associated with higher use of anti-MRSA agents after adjusting for facility type and percentage of beds in intensive care units (Table 1). Number of hospital beds, average length of stay, and medical school affiliation were nonsignificant. Conclusions: Prevalence of drug-resistant gram-positive infections was independently associated with the use of anti-MRSA agents. Infection burden should be used for risk adjustment in predicting the use of anti-MRSA agents. To make this possible, we recommend that hospitals reporting to NHSN’s AU Option also report microbiologic culture results.

Funding: None

Disclosures: None
Reduction in Abdominal Hysterectomy Surgical Site Infection Rates After the Addition of Anaerobic Antimicrobial Prophylaxis
Authors: Jenn Kyle , Bowdler Noelle , Holley Stephanie , Kukla Mary , Abosi Oluchi , Dains Angie , Meacham Holly , Diekema Daniel , Edmond Michael , Salinas Jorge
Published: November 2020

Background: Antimicrobial prophylaxis is one of the strongest surgical site infection (SSI) prevention measures. Current guidelines recommend the use of cefazolin as antimicrobial prophylaxis for abdominal hysterectomy procedures. However, there is growing evidence that anaerobes play a role in abdominal hysterectomy SSIs. We assessed the impact of adding anaerobic coverage on abdominal hysterectomy SSI rates in our institution. Methods: The University of Iowa Hospitals & Clinics is an 811-bed academic medical center that serves as a referral center for Iowa and neighboring states. Each year, ~33,000 major surgical operations are performed here, and on average, 600 are abdominal hysterectomies. Historically, patients have received cefazolin only, but beginning November 2017, patients undergoing abdominal hysterectomy received cefazolin + metronidazole for antimicrobial prophylaxis. Order sets within the electronic medical record were modified, and education was provided to surgeons, anesthesiologists, and other ordering providers. Procedures and subsequent SSIs were monitored and reported using National Healthcare Safety Network (NHSN) definitions. Infection rates are calculated using all depths (superficial, deep and organ space) and by deep and organ space only, as this is how they are publicly reported. We used numerator (SSIs) and denominator (number of abdominal hysterectomy procedures) data from the NHSN from January 2015 through September 2019. We performed an interrupted time-series analysis to determine how the addition of metronidazole was associated with abdominal hysterectomy SSIs (all depths, and deep and organ space). Results: From January 2015 through October 2017, the hysterectomy SSI rates were 3.2% (all depths) and 1.5% (deep and organ space). After the adjustment was made to antimicrobial prophylaxis in November 2017, the rates decreased to 1.6% (all depths) and 0.6% (deep and organ space). Of the SSIs with pathogens identified, the proportion of anaerobes decreased from 59% to 25% among all depths and from 82% to 50% among deep and organ-space SSIs. The rate of SSI decline after the intervention was statistically significant (P = .01) for deep and organ-space infections but not for all depths (P = .73). Conclusions: The addition of anaerobic coverage with metronidazole was associated with a decrease in deep and organ-space abdominal hysterectomy SSI rates at our institution. Hospitals should assess the microbiology of abdominal hysterectomy SSIs and should consider adding metronidazole to their antimicrobial prophylaxis.

Funding: None

Disclosures: None
VA Antibiotic Stewardship Intervention to Improve Outpatient Antibiotic Use for ARIs: A Cost-Effectiveness Analysis
Authors: Yoo Minkyoung , Nelson Richard , Nevers McKenna , Madaras-Kelly Karl , Fleming-Dutra Katherine , Hersh Adam , Ying Jian , Haaland Benjamin , Samore Matthew
Published: November 2020

Background: The Core Elements of Outpatient Antibiotic Stewardship provide a framework to improve antibiotic use, but cost-effectiveness data on interventions to improve antibiotic use are limited. Beginning in September 2017, an antibiotic stewardship intervention was launched in within 10 outpatient Veterans Healthcare Administration clinics. The intervention was based on the Core Elements and used an academic detailing (AD) and an audit and feedback (AF) approach to encourage appropriate use of antibiotics. The objective of this analysis was to evaluate the cost-effectiveness of the intervention among patients with uncomplicated acute respiratory tract infections (ARI). Methods: We developed an economic simulation model from the VA’s perspective for patients presenting for an index outpatient clinic visit with an ARI (Fig. 1). Effectiveness was measured as quality-adjusted life-years (QALYs). Cost and utility parameters for antibiotic treatment, adverse drug reactions (ADRs), and healthcare utilization were obtained from the published literature. Probability parameters for antibiotic treatment, appropriateness of treatment, antibiotic ADRs, hospitalization, and return ARI visits were estimated using VA Corporate Data Warehouse data from a total of 22,137 patients in the 10 clinics during 2014–2019 before and after the intervention. Detailed cost data on the development of the AD and AF materials and electronically captured time and effort for the National AD Service activities by specific providers from a national ARI campaign were used as a proxy for the cost estimate of similar activities conducted in this intervention. We performed 1-way and probabilistic sensitivity analyses (PSAs) using 10,000 second-order Monte Carlo simulations on costs and utility values using their means and standard deviations. Results: The proportion of uncomplicated ARI visits with antibiotics prescribed (59% vs 40%) was lower and appropriate treatment was higher (24% vs 32%) after the intervention. The intervention was estimated to cost $110,846 (2018 USD) over a 2-year period. Compared to no intervention, the intervention had lower mean costs ($880 vs $517) and higher mean QALYs (0.837 vs 0.863) per patient because of reduced inappropriate treatment, ADRs, and subsequent healthcare utilization, including hospitalization. In threshold analyses, the antibiotic stewardship strategy was no longer dominant if intervention cost was >$64,415,000 or the number of patients cared for was <3,672. In the PSA, the antibiotic stewardship intervention was dominant in 100% of the 10,000 Monte Carlo iterations (Fig. 2). Conclusions: In every scenario, the VA outpatient AD and AF antibiotic stewardship intervention was a dominant strategy compared to no intervention.

Funding: None

Disclosures: None
Assessing the Efficacy and Unintended Consequences of Utilizing a Behavioral Approach to Reduce Inappropriate Clostridioides difficile Testing
Authors: Dbeibo Lana , Brinkman Allison , Beeler Cole , Kelley Kristen , Fadel William , Wang Yun , Snyderman William , Hatfield Nicole , Sadowski Josh , Kara Areeba
Published: November 2020

Background: Effective strategies to improve diagnostic stewardship around C. difficile infection (CDI) remain elusive. Electronic medical record-based solutions, such as ‘hard’ and ‘soft’ stops, have been associated with reductions in testing, but may not be sustainable due to alert fatigue. Additionally, data on the potential for undertesting, missed diagnoses, and the implications regarding patient harm or clusters of transmission are limited. In this study, we assessed the efficacy of a behavioral approach to diagnostic stewardship, while monitoring for unintended consequences. Methods: This quality improvement study was conducted January 2018–May 2019; baseline period: January–April 2018, implementation period: May–December 2018, sustainment period: January 2019–May 2019. First, we conducted an internal analysis and identified 3 barriers to appropriate testing: clinician’s perceived risk of CDI, inconsistent definition of diarrhea, and lack of involvement of nurses in diagnostic stewardship. A multidisciplinary team to address these barriers was then convened. The team utilized the Bristol stool scale to improve the reliability of diarrhea description, and created a guideline-concordant testing algorithm with clinicians and nurses. The primary outcome was the number of tests ordered. The secondary outcomes were the proportion of inappropriate tests and the proportion of delayed tests. Delayed tests were defined as CDI-compatible diarrhea based on the algorithm where the test was sent >24 hours after symptom onset. Results: During the baseline period, we detected no significant change in number of tests ordered month to month, with 194.2 tests ordered per month on average. During the postimplementation period, the number of tests ordered decreased by ~4.5 each month between January 2018 and May 2019 (P < .0001). The proportion of inappropriate tests steadily decreased from 54% to 30% across the 3 study periods, and the number of delayed testing changed from 11% to 1% then increased to 20% in the sustainment period. There were no cases of toxic megacolon associated with delayed testing. Conclusions: The decision to test for CDI is complex. Interventions that address this issue as a simple ‘right’ and ‘wrong’ fail to address the root cause of CDI overdiagnosis, and they have no embedded mechanism to detect unintended consequences. Our study demonstrates that by taking a behavioral approach and addressing clinicians’ safety concerns, we were able to sustain a significant reduction in testing. We could not determine the significance of the increase in delayed testing given the low numbers; however, further studies are needed to evaluate the safety of CDI reduction strategies through diagnostic stewardship only.

Funding: None

Disclosures: None
Characteristics Associated with Death in Patients with Carbapenem-Resistant Acinetobacter baumannii, United States, 2012–2017
Authors: Reses Hannah E. , Hatfield Kelly , Jacob Jesse , Bower Chris , Vaeth Elisabeth , Mounsey Jacquelyn , Muleta Daniel , Witwer Medora , Dumyati Ghinwa , Hancock Emily , Baggs James , Walters Maroya , Bulens Sandra
Published: November 2020

Background: Carbapenem-resistant Acinetobacter baumannii (CRAB) is an important cause of healthcare-associated infections with limited treatment options and high mortality. To describe risk factors for mortality, we evaluated characteristics associated with 30-day mortality in patients with CRAB identified through the Emerging Infections Program (EIP). Methods: From January 2012 through December 2017, 8 EIP sites (CO, GA, MD, MN, NM, NY, OR, TN) participated in active, laboratory-, and population-based surveillance for CRAB. An incident case was defined as patient’s first isolation in a 30-day period of A. baumannii complex from sterile sites or urine with resistance to ≥1 carbapenem (excluding ertapenem). Medical records were abstracted. Patients were matched to state vital records to assess mortality within 30 days of incident culture collection. We developed 2 multivariable logistic regression models (1 for sterile site cases and 1 for urine cases) to evaluate characteristics associated with 30-day mortality. Results: We identified 744 patients contributing 863 cases, of which 185 of 863 cases (21.4%) died within 30 days of culture, including 113 of 257 cases (44.0%) isolated from a sterile site and 72 of 606 cases (11.9%) isolated from urine. Among 628 hospitalized cases, death occurred in 159 cases (25.3%). Among hospitalized fatal cases, death occurred after hospital discharge in 27 of 57 urine cases (47.4%) and 21 of 102 cases from sterile sites (20.6%). Among sterile site cases, female sex, intensive care unit (ICU) stay after culture, location in a healthcare facility, including a long-term care facility (LTCF), 3 days before culture, and diagnosis of septic shock were associated with increased odds of death in the model (Fig. 1). In urine cases, age 40–54 or ≥75 years, ICU stay after culture, presence of an indwelling device other than a urinary catheter or central line (eg, endotracheal tube), location in a LTCF 3 days before culture, diagnosis of septic shock, and Charlson comorbidity score ≥3 were associated with increased odds of mortality (Fig. 2). Conclusion: Overall 30-day mortality was high among patients with CRAB, including patients with CRAB isolated from urine. A substantial fraction of mortality occurred after discharge, especially among patients with urine cases. Although there were some differences in characteristics associated with mortality in patients with CRAB isolated from sterile sites versus urine, LTCF exposure and severe illness were associated with mortality in both patient groups. CRAB was associated with major mortality in these patients with evidence of healthcare experience and complex illness. More work is needed to determine whether prevention of CRAB infections would improve outcomes.

Funding: None

Disclosures: None