bluuebunny/crossref_metadata_2025 huggingface dataset:
Investigation of Pansusceptible Pseudomonas aeruginosa Meningitis Cases in Patients With External Ventricular Devices
Authors: Kim Yoojin , Cortes-Ramos Carmen , Nix Chad Douglas , Ogden Lauren , Hale Molly , Townes John
Published: November 2020

Background: During a 2-month period at an academic medical system, 4 cases of pansusceptible P. aeruginosa (PsA) meningitis were identified among neuroscience intensive care unit (NSICU) patients with an external ventricular device (EVD). Methods: We reviewed microbiology data for the previous 2 years to determine background PsA rates and to identify additional cases of PsA meningitis. A case was defined as the isolation of PsA from a CSF specimen. We convened a multidisciplinary group of stakeholders to review medical records of case patients and to conduct a series of observational rounds. Scalp swab specimens were collected from NSICU patients to detect possible skin colonization. Pulsed-field gel electrophoresis (PFGE) analyses were performed on PsA isolates from the 4 case patients and 5 patients with PsA isolates from other body sites. Results: There was no hospital-wide increase in PsA incidence, and no patient without an EVD had PsA cultured from CSF. Infections occurred, on average, 10 days (range, 6–15 days) after EVD insertion. Cases were geographically dispersed in the NSICU and did not share common staff. None of the PsA isolates were genetically related and all scalp cultures were negative. Observations included multiple opportunities for contact with water sources: sinks in proximity to the head of the bed, storage of supplies next to sinks, reuse of bath basins, and use of dilute peroxide to clean surgical wounds. Multiuse shampoos, conditioners and lotions, not approved for hospital use, were found on the unit. Furthermore, 3 of 4 patients received cefazolin >24 hours after 6 of their 7 neurosurgeries for an average of 4.7 days (range, 0.8–4 days). Care practices were changed to mitigate contact between EVD sites and environmental water sources, and extended cefazolin surgical prophylaxis was discontinued. EVD practices were revised, and clinical teams had their competency confirmed. No additional cases have been identified in the 16 months following these interventions. Conclusions: This cluster of EVD infections was likely caused by patient care practices that resulted in independent introductions of PsA from multiple nonsterile or contaminated water sources. Antibiotic selection of PsA by extended use of cefazolin perioperative prophylaxis may have also contributed. EVD care practices should be designed to limit contact between and EVD insertion sites and nonsterile water sources or potentially contaminated care supplies. To substantiate performance improvement efforts and ensure interinstitutional comparability, a practical, standardized EVD-associated infection surveillance definition is needed.

Funding: None

Disclosures: None
Knowledge of Adverse Events Following Immunization Reporting Tool and System Among Primary Healthcare Workers in Jigawa State
Authors: Umar Ahmad , Sufiyan Muawiyyah , Tukur Dahiru , Onoja-Alexander Mary , Amadu Lawal , Bashir Sulieman
Published: November 2020

Background: Adverse events following immunization (AEFI) surveillance largely depends on the ability of the healthcare worker (HCW) to timely detect and report cases using the correct reporting tools through an appropriate system. AEFI surveillance is carried out regularly during both routine immunization services and supplemental immunization activities in the state. Objective: We assessed knowledge of adverse events following immunization reporting tools and system among primary HCWs in Jigawa state, northwestern Nigeria. Method: A descriptive cross-sectional design was used for this study. A multistage sampling technique was used to select 290 HCWs that had spent at least 6 months in immunization units of primary healthcare centers of Jigawa state. Data were collected using pretested self-administered structured questionnaire with open and closed ended questions and were analyzed using IBM SPSS version 20 software. All statistical tests were 2-tailed with P < .05 as the statistical significance level. Results: Most of the primary HCWs (93.2%) had AEFI reporting forms in their health facilities, and 68.9% said that the AEFI reporting form could be obtained from a focal or contact person in the health facility. Up to 96.4% of the primary HCWs were aware of how to report AEFI. Also, ~76.6% of primary HCWs knew the correct AEFI reporting flow, but only 15.8% knew that only serious AEFIs are reported. Furthermore, ~78.8% and 19.4% of HCWs mentioned telephone and filling forms as some of the appropriate methods of AEFI notification, respectively. Conclusions: Most primary HCWs had reporting forms in their health facilities and were aware of how to report an AEFI. Most of the respondents knew the correct AEFI reporting flow. The state in collaboration with local government authorities should provide quality training on AEFI reporting and reporting system.

Funding: None

Disclosures: None
KPC-Producing Enterobacter cloacae Transfer Through Pipework Between Hospital Sink Waste Traps in a Laboratory Model System
Authors: Aranega Bou Paz , Ellaby Nicholas , Ellington Matthew , Moore Ginny
Published: November 2020

Background: Carbapenemase-producing Enterobacterales (CPE) have become an increasingly common cause of hospital-acquired infections while their reservoirs within the clinical setting remain poorly understood. Outbreaks have been linked to hospital sinks, which have been shown to harbor and, under certain conditions, disperse CPE to surrounding surfaces. Hospital and laboratory studies have proposed that Gram-negative organisms, including CPE, can migrate through plumbing biofilms, leading to widespread contamination of the drainage system. Methods: To assess the prevalence of CPE in hospital sinks, drain swabs and waste trap water samples were taken from 10 sinks in 10 hospitals. Hospitals were in different regions of England; 4 had reported recent cases of CPE infection. To investigate spread and dispersal of CPE, waste traps from a single hospital were installed in a laboratory model sink system. Built to simulate a clinical setting, the model incorporated 12 sinks, 6 of which were connected through a common waste pipe. All 12 taps were automatically flushed. Drainage was automatically controlled. Nutrients were provided daily to maintain the bacterial populations, which were regularly sampled to monitor their composition. At 3 weeks after installation, the waste traps were subjected to a drainage backflow event. Waste trap water populations continued to be monitored, and when transfer between sinks was suspected, isolates were characterized and compared using whole-genome sequencing. Results: Between January and June 2019, 200 samples were taken from 103 sinks. In total, 24 (23%) sinks (in 8 hospitals) harbored CRE; of which 10 (in 5 hospitals) harbored at least 1 CPE. Immediately after a backflow event in the laboratory model system, 2 KPC-producing E. cloacae were recovered from a waste trap in which CPE had not been previously detected. The isolates were identified as ST501 and ST31 and were genetically indistinguishable from those colonizing sinks elsewhere in the system. Following intersink transfer, KPC-producing E. cloacae ST501 successfully integrated into the microbiome of the recipient sink and was detected in the waste trap water at least 6 months after the backflow event. At 2 and 3 months after the backflow, other intersink transfers involving Escherichia coli and KPC-producing E. cloacae were also observed. Conclusions: Sink waste traps and drains are a reservoir for CPE in hospitals. Once established, CPE contamination might not be confined to a single sink and could spread through wastewater plumbing. Hospitals frequently report drainage problems, which could cause or facilitate CPE transfer between sinks and could lead to long-term establishment.

Funding: None

Disclosures: None
Laboratory Testing, Diagnostic Coding, and Treatment for Electronic Identification of Clostridioides difficile Infection
Authors: Stevens Vanessa , Benin Andrea , Dantes Raymund , Khader Karim , Nugent Sean , Lewis Julia , Adam Terrence , Zhang Rui , Fu Steven , Jones Makoto , Pollock Daniel , Waisbren Steven
Published: November 2020

Background: Accurate identification of Clostridioides difficile infections (CDIs) from electronic data sources is important for surveillance. We evaluated how frequently laboratory findings were supported by diagnostic coding and treatment data in the electronic health record. Methods: We analyzed a retrospective cohort of patients in the Veterans’ Affairs Health System from 2006 through 2016. A CDI event was defined as a positive laboratory test for C. difficile toxin or toxin genes in the inpatient, outpatient, or long-term care setting with no prior positive test in the preceding 14 days. Events were classified as incident (no CDI in the prior 56 days), or recurrent (CDI in the prior 56 days) and were evaluated for evidence of clinical diagnosis based on International Classification of Disease, Ninth Revision, Clinical Modification (ICD-9-CM) and ICD-10-CM codes and at least 1 dose of an anti-CDI agent (intravenous or oral metronidazole, fidaxomicin, or oral vancomycin). We further assessed the possibility of treatment without testing by quantifying positive laboratory tests and diagnostic codes among inpatients receiving an anti-CDI agent. A course of anti-CDI therapy was defined as continuous treatment with the same drug. Results: Among 119,063 incident and recurrent CDI events, 70,114 (58.9%) had a diagnosis code and 15,850 (13.3%) had no accompanying treatment. The proportion of patients with ICD codes was highest among patients treated with fidaxomicin (82.6% of 906) or oral vancomycin (74.3% of 30,777) and was lower among patients receiving metronidazole (63.3% of 103,231) and those without treatment (29.9% of 15,850). The proportion of events with ICD codes and treatment was similar between incident and recurrent episodes. During the study period, there were ~470,000 inpatient courses of metronidazole, fidaxomicin, and oral vancomycin. Table 1 shows the presence of ICD codes and positive laboratory tests by anti-CDI agents. Among 51,100 courses of oral vancomycin, 51% had an ICD code and 44% had a positive test for C. difficile within 7 days of treatment initiation. Among 1,013 courses of fidaxomicin, 79% had an ICD code and 56% had a positive laboratory test. Conclusions: In this large cohort, there was evidence of substantial CDI treatment without confirmatory C. difficile testing and, to a lesser extent, some positive tests without accompanying treatment or coding. A combination of data sources may be needed to more accurately identify CDI from electronic health records for surveillance purposes.

Funding: None

Disclosures: None
Lack of Evidence of Transmission of Bloodborne Viruses by Improperly Reprocessed Fiberoptic Endoscopes
Authors: Sellick John , Oda Gina , Schirmer Patricia , Lucero-Obusan Cynthia , Holodniy Mark
Published: November 2020

Background: A sterile processing service (SPS) technician was found to inadequately clean fiberoptic endoscope channels during reprocessing prior to high-level disinfection. Channels were only brushed once and 7 of 30 audited scopes had measurable bioburden. Consistent with VA policy, a retrospective investigation, along with public disclosure, was performed. Methods: A potentially exposed case (PEC) was defined as any patient who had flexible fiberoptic endoscopy between April 19, 2015, and June 23, 2017, when the identified SPS technician worked in the endoscope reprocessing station. Using the internal log of the automated high–level disinfection equipment (Medivators/Cantel, Minneapolis, MN), device serial numbers were matched to patients in endoscopy suite procedure logs. Additionally, the VA Corporate Data Warehouse (CDW) was queried for CPT and International Classification of Disease, Ninth Revision (ICD-9) and ICD-10 procedure codes to verify identified cases and to search for other PECs. All PECs were notified by telephone and mail, and serologic testing for human immunodeficiency virus (HIV-1), hepatitis C virus (HCV), and hepatitis B virus (HBV) was offered. Results were compared to prior bloodborne pathogen (BBP) testing results extracted from the CDW. Facility microbiology laboratory records of positive cultures/microscopy for enteric pathogens also were compared to the list of PECs; no active testing was performed. Results: Of the 565 PECs, 552 (98%) were successfully contacted. 8 declined testing or preferred non-VA testing, and 22 died before testing could be initiated. Repeat testing at 6 months was requested for PECs who had initial testing performed <6 months after exposure; 32 refused additional tests or did not respond to additional requests. In total, 522 PECs (92%) had testing performed for 1 or more BBPs: (1) 521 were anti–HIV negative with 1 previously known positive; (2) 481 were anti–HCV negative—43 were previously known positive and 1 PEC with an undetectable HCV viral load was newly identified; (3) 461 were negative for both HBV core or surface antibodies and surface antigen—32 were previously known positive and 17 were newly positive for one or both antibody tests with negative HBV surface antigen. Of 17 newly identified positive PECs, 16 had undetectable HBV DNA; 1 died prior to HBV DNA testing. Conclusions: There was no evidence of transmission of BBPs in this cohort of PECs who had procedures with potentially improperly cleaned fiberoptic endoscopes. Although not all patients completed all retrospective BBP testing, <10% were missing all or some tests. Local passive surveillance did not indicate enteric pathogen transmission. Additional education regarding and monitoring of reprocessing procedures have been instituted.

Funding: None

Disclosures: None
Leptospirosis Outbreak in a Hill Due to Water From an Unprotected Well, Keerakadu Village, Kollihills, Namakkal, Tamilnadu, India
Authors: Mohankumar Sree Kalpana , Govindarajan Ramesh Kumar , Chokkalingam Mohanasundari
Published: November 2020

Background: Annually, an estimated 1.03 million leptospirosis cases lead to 2.9 million disability adjusted life years. A cluster of fever cases was reported in Keerakadu village, Kollihills block in Namakkal district of Tamilnadu state, India, on April 28, 2017. We investigated to control the outbreak. Methods: We did a cross-sectional survey between April 29 and May 1. We defined a case of fever as any resident of Keerakadu village with fever for >2 days, with or without headache or myalgia, between April 15 and May 1, 2017. We conducted active surveillance. We reviewed medical records. We collected the line list from nearby health centers. We computed proportions to calculate the attack rate. We collected 11 serum samples and tested for dengue, scrub typhus, hepatitis A and leptospirosis by IgM ELISA method. We did a Widal slide agglutination test. We conducted an environmental survey to identify water sources. We performed a dengue larval survey. We collected 5 water samples: 1 from unprotected well, 1 from overhead tank and 3 from the houses of residents. We tested for fecal coliforms in the district public health laboratory. Results: The population of Keeradu village was 540. We identified 11 cases, for an attack rate of 2% (11 of 540). The hospitalization rate of cases was 81% (9 of 11). Median age was 45 years (range, 23–65). Of 11 samples, 3 were positive for leptospirosis; all were negative for dengue, scrub typhus, hepatitis A, and typhoid. The single water source for the whole village was an open, unprotected well. This well supplied water every day to the community, both for drinking purpose and domestic use. No breeding of dengue larva was observed. All the 5 water samples tested positive for fecal coliforms. Water was not chlorinated regularly. All patients were isolated and treated in the primary health center. Prophylactic antibiotics were given to the whole community. Conclusions: There was a leptospirosis outbreak in Keerakadu village, probably due to contaminated water from unprotected well. There were no cases after May 1, 2017. We recommended that the community chlorinate the water regularly and protect the well. We also recommend continued surveillance and a rodent survey.

Funding: None

Disclosures: None
Leveraging Electronic Health Record Clinical Decision Support to Identify Clostridium difficile Infection in Clinically Appropriate Patient Populations
Authors: Cook Amy , Fruehan Sharon , Goodling Pamela
Published: November 2020

Background: In 2017, the IDSA and the SHEA released updated Clostridium difficile practice guidelines. Implementing institutionally accepted criteria for identifying clinically appropriate patients for testing was endorsed. When utilizing NAAT as the sole laboratory testing methodology, testing clinically symptomatic patients is important to reduce inappropriate treatment of C. difficile colonization. C. difficile rates at a regional community health system were higher than expected, and patient case reviews identified inappropriate patient testing as an issue. Therefore, the infection prevention team sought to optimize and standardize protocols surrounding appropriate patient selection for C. difficile testing. Methods: Current recommendations were evaluated, and processes formulated to implement an innovative process to support our clinicians in identifying clinically appropriate patients to test for C. difficile infection. The electronic decision support is summarized as a bundled approach with 4 best practice alerts that incorporate algorithms that warn providers of potentially inappropriate testing scenarios. These alerts include the following criteria: (1) a laxative having been administered within 48 hours of attempted order, (2) a negative test resulted within 7 days, (3) a positive test resulted within 14 days, and (4) identification of patients at high risk for C. difficile infection (based on recent long-term care facility exposure, recent inpatient hospital visits, recent antimicrobial therapy). Outcomes of our acute-care hospitals were monitored by real-time evaluation of each hospital’s quarterly C. difficile LabID standardized infection ratio (SIR) as defined by the NHSN. For statistical analyses, the cumulative second and third quarters of 2018 (before the intervention) were compared to the cumulative second and third quarters of 2019 to account for seasonality of C. difficile infections. Results: Utilizing the NHSN statistical calculator to compare 2 SIRs, there was a statistically significant decrease (P = .0026) in the largest hospital’s C. difficile LabID SIR when comparing representative preintervention cumulative quarters to the postintervention cumulative quarters. Although the other hospitals did not see a statistically significant decrease in their C. difficile LabID SIR, a clinically significant decrease was appreciated for 2 of our hospitals. Conclusions: Electronic health record–based decision support helps clinicians identify clinically appropriate patients to test by NAAT alone for C. difficile infection. By limiting the number of patients tested without clinical signs or symptoms of infection and/or after receiving laxatives, hospitals more accurately capture their true C. difficile rates and maximize reimbursement based on this measure within the CMS Safety of Care Measure.

Funding: None

Disclosures: None
Leveraging the Electronic Medical Record to Identify Patients at Risk of Antibiotic Resistant Organisms
Authors: Rasmusson Jenna , Barth Jean , Mahler Sarah Bellows , Apenhorst Debra , Dalton Mary , Senst Laura , Siple Leah , Faller Rebecca , Sampathkumar Priya
Published: November 2020

Background: Carbapenemase-producing carbapenem-resistant Enterobacteriaceae (CP-CRE) pose a serious public health threat. The CDC guidelines for combating CP-CRE include a recommendation to screen selected high-risk patients. Objective: We describe a program to identify and screen patients at risk for CP-CRE. Setting: An academic, tertiary-care center with 1,297 licensed beds and 62,071 admissions per year. Methods: A report was created in the electronic medical record (EMR) to identify adult patients admitted in the previous 24 hours from countries and states with known CP-CRE transmission based on address and ZIP code. Patients with a known travel history outside the United States were also reviewed, but these data were inaccurate. Initially, a physician from Infection Prevention and Control (IPAC) placed orders for CP-CRE screening of these patients. Subsequently, a nursing protocol was developed to facilitate infection preventionists placing orders for CP-CRE screening earlier in the eligible patient’s hospital stay. An electronic communication is sent via the EMR alerting the patient care team to the order, the rationale for the order, and links to a tool kit with resources to help answer patient questions. A single perirectal swab is obtained by the nurse caring for the patient and is tested for Klebsiella pneumoniae carbapenemase (KPC), New Delhi metallo-β-lactamase (NDM), oxacillinase-48 (OXA-48), and Verona integron-encoded metallo-β-lactamase (VIM) by polymerase chain reaction (PCR). Results: From May 2018 to November 2019, 688 patients were screened for CP-CRE using the case-finding report and the nursing protocol. Overall, 9 patients with CP-CRE were identified: 1 KPC, 2 NDM, and 5 OXA-48, and 1 patient was identified to have both NDM and OXA-48. The yield of 1.3% from this screening is higher than that reported previously in the literature. Use of the nursing protocol has enabled IPAC to complete timely CP-CRE surveillance and prevent transmission to other patients. We are currently using a similar process to identify and screen persons at risk for the emerging infection Candida auris.Conclusions: The EMR can be leveraged for early identification and screening of patients with epidemiologically significant pathogens. Protocols within the EMR can be effectively replicated and modified to respond to emerging infections and changing surveillance guidelines.

Funding: None

Disclosures: Consulting fee-—Merck (Priya Sampathkumar)
Linezolid-Resistant Staphylococcus haemolyticus: Emergence of G2447U and C2534U Mutations at the Domain V of 23Sr RNA Gene
Authors: Kumari Sanjana , Rawre Jyoti , Trikha Anjan , Sireenivas Vishnubhatla , Sood Seema , Kapil Arti , Dhawan Benu
Published: November 2020

Background: Linezolid an oxazolidinone drug available in both parenteral and oral formulations has emerged as a novel alternative to vancomycin and other second-generation drugs for the treatment of infections from gram-positive cocci. Clinical isolates of linezolid-resistant staphylococci and enterococci were reported. Since then, linezolid-resistant strains have become an increasing problem worldwide. The most frequently reported mechanisms of linezolid resistance include the mutation in 23S ribosomal nucleic acid and presence of cfr gene. Methicillin-resistant coagulase-negative staphylococci (MR-CoNS) and vancomycin-resistant Enterococcus (VRE) have become a worrisome clinical problem. Objective: Therefore, we aimed to determine the distribution of linezolid-resistant strains in an inpatient setting of a tertiary-care hospital in India and to evaluate the resistance mechanisms among these isolates. In addition, the clonal diversity of the isolates was determined by pulsed-field gel electrophoresis (PFGE). Methods: The distribution, clonal diversity, and resistance mechanism of linezolid resistant-Staphylococcus haemolyticus (LRSH) strains were determined. The isolates were identified by MALDI-TOF. The mechanism of resistance was determined by sequence analysis of the domain V of 23SrRNA and screening for cfr gene. Clonal relatedness was defined by PFGE. Results: In total, 13 LRSH isolates were recovered from pus specimens. The 13 LRSH strains isolated had an linezolid MIC of 256 g/mL. Sequencing results revealed G2576T mutations in 7 (53.8%), G2447U in 4 (30.7%) and C2534U in 1 (7.6%) isolate of S. haemolyticus. One isolate of S. haemolyticus showed 2 simultaneous mutations (G2576T and G2447U) in the domain V region of 23Sr RNA gene. PFGE of the LR-SH isolates revealed the presence of 11 clones. Of the 11 clones, clones I and II had 2 isolates each. Isolates of clone I exhibited a band pattern identical with the previous isolates of LRSH isolated from the orthopedic unit. Similarly, isolates of clone II also shared the same band pattern with the previous LRSH isolates from the dermatology unit of our center. Conclusions: This study highlights the importance of continuous monitoring of vigilance of linezolid resistance in staphylococci. Rationalizing the use of linezolid and implementing methods to control the spread of hospital clones is of paramount importance to prevent further dissemination of these strains.

Funding: None

Disclosures: None
Missing the Point in Point Prevalence: Harnessing EMR Data to Identify Epi-Linked Patients in an Outbreak Investigation
Authors: Stancill Lisa , DiBiase Lauren , Sickbert-Bennett Emily
Published: November 2020

Background:
A critical step during outbreak investigations is actively screening for additional cases to assess ongoing transmission. In the healthcare setting, one widely used method is point-prevalence screening on the whole unit where a positive patient is housed. Although this point-prevalence approach captures the “place,” it can miss the “person” and “time” elements that define the population-at-risk. Methods: At University of North Carolina (UNC) Hospitals, we used business intelligence tools to build a query that harnesses the admission, discharge, and transfer (ADT) data from the electronic medical record (EMR). Using this data identifies every patient who overlapped in time and space with a positive patient. An additional query identifies currently admitted overlap patients and their current location. During an outbreak investigation, an analyst executes these queries in the mornings when surveillance screens are scheduled. The queries generate a list of patients to screen that are prioritized on the number of days they were in the same unit with the positive patient. This overlap methodology successfully captures the person, place, and time associated with possible disease transmission. We implemented the overlap method for the last 3 months following 1 year of point-prevalence approach screening during a novel disease outbreak at UNC Hospitals. Results: In total, 4,385 unique patients overlapped with previously identified infected or colonized patients, of which 781 (17.8%) from 40 departments were screened over 15 months. During a subsequent, currently ongoing, outbreak, we are utilizing the overlap method and in 6 weeks have already screened 161 of the 1,234 overlapping patients (13%). After 3 rounds of overlap screening, we have already been able to identify 1 additional positive patient. This patient was on the same unit as patient zero 4 months prior but was readmitted to a unit that would not have received a point-prevalence screen using the standard approach. Conclusions: Surveillance screening is a time-consuming, resource-intensive effort that requires collaboration between infection prevention, clinical staff, patients, and the laboratory. By harnessing EMR ADT data, we can better target the population at risk and more efficiently utilize resources during outbreak investigations. In addition, the overlap method fills a gap in the current CDC guidelines by focusing on patients who were on the same unit with any positive patient, including those who discharged and readmitted. Most importantly, we identified an additional positive patient that would not have been detected through a point-prevalence screen, helping us prevent further disease transmission.

Funding: None

Disclosures: None
Molecular Landscape of Carbapenemase-Producing Acinetobacter baumanii in the United States
Authors: Burrell Kellan , Huang Jennifer , Karlsson Maria , McAllister Gillian , Brown Allison
Published: November 2020

Background: Carbapenem-resistant Acinetobacter baumannii (CRAB) are an urgent public health threat because they cause healthcare-associated infections that are difficult to treat and can spread in healthcare environments. Acinetobacter spp may develop resistance to carbapenems through various mechanisms, including decreased permeability, overexpression of efflux pumps, and production of carbapenemases. Carbapenemases found in CRAB commonly belong to the group of carbapenem-hydrolyzing class D β-lactamases, which can be either intrinsic or acquired. The most clinically relevant class D enzymes are the OXA-23-like, OXA-24/40–like, and OXA-58–like because they are commonly plasmid mediated and thereby have the potential for rapid dissemination. We describe the molecular epidemiology of CRAB in the United States using a convenience sample of isolates collected from reference submissions, an isolate-based surveillance system, and the Antibiotic Resistance Laboratory Network (ARLN). Methods: Beginning in August 2017, 7 public health laboratories in the ARLN began testing CRAB isolates submitted by participating sentinel clinical laboratories across their region. Carbapenem-resistant isolates were identified by resistance to imipenem, meropenem, or doripenem. Testing included molecular detection of 4 targeted carbapenemase genes: blaKPC, blaNDM, blaVIM, and blaIMP. Participating labs reported testing results to CDC at least monthly. A separate collection of isolates from CDC reference and surveillance activities between 2013 and 2015 underwent whole-genome sequencing (WGS) to evaluate the presence of acquired carbapenemase genes, including class D OXA-variants. Results: From August 2017 through July 2019, the ARLN tested 2,368 CRAB isolates across 44 states. Only 12 (0.5%) of these harbored a bla- gene: blaKPC (n = 5), blaNDM (n = 5), blaIMP (n = 1), and blaVIM (n = 1). Of 95 reference and surveillance isolates sequenced, none harbored these targeted carbapenemases. However, 69 (73%) harbored at least 1 acquired class D OXA gene; OXA-23 was the most commonly acquired OXA variant (n = 46, 48.4%). Conclusions: Using a multipronged approach, our studies indicate that the presence of class D β-lactamases of the OXA type are common in CRAB among surveillance and reference samples that underwent WGS analysis. Other acquired carbapenemases appear to be rare. To prevent the spread of highly resistant CRAB, particularly those carrying the targeted, emerging carbapenemase genes, continued testing, and rapid infection control are necessary to improve patient safety and maintain situational awareness.

Funding: None

Disclosures: None
Multidrug-Resistant Organism Carriage in Wisconsin Children
Authors: Kates Ashley , Putman-Buehler Nathan , Watson Lauren , LeCaire Tamara , Malecki Kristen , Peppard Paul , Sethi Ajay , Wald Ellen , Mares Julie , Shirley Daniel , Suen Garret , Safdar Nasia
Published: November 2020

Background: Children attending daycare are at increased risk of carrying multidrug-resistant organisms (MDROs) compared to children not attending daycare. Carriage of MDROs greatly increases the risk of infection, not only in the child but also for others living in the household. Understanding the epidemiology of MDRO carriage in children is essential to devising effective containment strategies. Here, we present the findings from a cross-sectional study assessing MDRO carriage in daycare-attending and nonattending children in Wisconsin. Methods: We applied the following enrollment criteria: Children aged between 6 months and <6 years and not enrolled in kindergarten; children who did not have an MDRO infection in the previous 6 months and did not receive any antimicrobials in the previous month; and children who did not have a gluten allergy, asthma, eczema, allergic rhinitis, cystic fibrosis, or an immunodeficiency. Children were enrolled by a parent or guardian who filled out a questionnaire on MDRO risk factor history and diet. Samples were collected from the nares, axilla or groin (pooled swab), and stool. Nasal samples were cultured for H. influenzae, S. pneumoniae, M. catarrhalis, and methicillin-resistant S. aureus (MRSA). Skin samples were cultured for MRSA, and stool samples were cultured for MRSA, C. difficile, vancomycin-resistant enterococci (VRE), and extended-spectrum β-lactamase–producing Gram-negative bacilli (ie, ESBL GNR). Results: In total, 44 children were enrolled in this study. The average age was 2.6 years and 50% were girls. Furthermore, 30 (68.2%) were identified by their parents as white, 9 (20.5%) as black, and 5 (11.3%) as other or multiracial. Incidentally, 23 children (52.3%) were enrolled in daycare. Overall, 18 children were positive for at least 1 organism, 9 of which had daycare exposure, and 5 children (1 in daycare) were positive for >1 organism (11.4%). From stool samples, 6 children (13.6%, 2 in daycare) were C. difficile carriers, 3 were VRE carriers (6.8%, 1 in daycare), 8 carried an ESBL GNR (18.2%, 4 in daycare), and 3 carried MRSA (6.8%, 1 in daycare). One child was positive for H. influenzae (2.3%, not in daycare) and 2 were positive for S. pneumoniae (4.6%, 1 in daycare) from nares swabs. One child was positive for MRSA (2.3%, not in daycare) from a skin swab. We detected no significant differences between children with and without daycare exposure for any organism. Conclusions: Children in this population had higher than expected rates of ESBL GNRs and MRSA for a community population. Daycare exposure was not correlated with increased carriage in this small pilot study, though larger longitudinal studies are needed.

Funding: None

Disclosures: None
Multiscale Modeling of Patient Movement to Determine Effects of Surveillance on Healthcare-Associated Infections
Authors: Lin Gary , Tseng Katie , Martinez Diego , Klein Eili
Published: November 2020

Background: The transmission of pathogenic organisms in healthcare settings is a major cause of healthcare-associated infections (HAIs). In recent years, infections with carbapenem-resistant Enterobacteriaceae (CRE) have become a significant public health threat, in part because many patients are arriving at the hospital already colonized, and colonization is a major risk factor for infection. Reducing transmission requires understanding how patient movement drives the spread of CRE; however, analysis of this issue has mostly been modeled at a hospital-level without much consideration for the population dynamics that occur outside of the hospital setting and how patients move between healthcare settings. Patients move between hospitals, other healthcare settings, such as long-term care facilities (LTCFs), and the community, all of which pose different colonization risks. Thus, studying each environment in isolation fails to realistically address the consequences of large-scale policy interventions. One such intervention is a statewide electronic registry to track patients who are known to be colonized or have had a CRE infection. Understanding the potential for reducing CRE morbidity and mortality requires consideration of small- and large-scale effects on patients’ movement and transmission. Methods: We developed a multiscale, metapopulation model for hospitals, communities, and LTCFs in the state of Maryland. In our computational simulation, we included a regional- as well as a local-scale model that were informed by the patient-mix data from the Maryland Health Service Cost Review Commission. We examined the impact of implementing a registry compared to less coordinated scenarios. Results: The most effective policy was the implementation of an electronic registry which resulted in 9.6% median reduction in CRE HAIs in Maryland for simulated outcomes (Fig. 1). Other interventions included colonization screening at various or all hospitals and using a predictive algorithm to determine at-risk patients that need to be screened. These interventions only resulted in ~1%–3% reductions in HAIs. We also observed that coupling other interventions with an electronic registry does not aid in reducing more HAIs.

Funding: None

Disclosures: None

Boxplot of simulated outcomes of all scenarios compared to the baseline scenario. The scenarios include (1) complete screening with no electronic registry, (2) selective screening with no electronic registry, (3) predictive screening with no electronic registry, (4) baseline with an electronic registry, (5) complete screening with an electronic registry, (6) selective screening with an electronic registry, and (7) predictive screening with an electronic registry. Scenarios 5-7 include the same interventions as 1–3 coupled with an electronic registry.
National Frequencies of Administering or Prescribing Immunosuppressive Opioids in US Ambulatory Care Settings: 2006–2016
Authors: Romine James , Ellingson Katherine
Published: November 2020

Background: Several decades of animal and basic science research have demonstrated that certain opioids have immunosuppressive properties, but the clinical relevance of opioid-related immunosuppression remains unclear. Although experts have called for epidemiologic research to inform clinical practice, prioritization of that research depends partly on a determination of the number of people potentially affected. To date, population-level estimates of administering or prescribing immunosuppressive opioids (ISOs) have not been measured. Our objective was to estimate the overall frequency of ambulatory visits involving ISOs, and to estimate the frequency of these visits among immunocompromised patients. Methods: We used the CDC National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey–Emergency Departments (NHAMCS-ED) data sets (2006–2016) to compute average annual frequencies of patient visits involving ISOs. We accounted for survey sampling design and visit weights using SAS version 9.4 software. We adopted a definition of ISOs from the literature as ‘alone or in-combination’ formulas of codeine, morphine, and fentanyl. We approximated patients’ immunocompromised status by the administering or prescribing of anti-infective drugs, and by chronic conditions indicative of immunocompromised status. We stratified visits with mentions of ISOs by co-occurring clinical-use of anti-infective drugs, and by selected chronic conditions. Results: From 2006 to 2016, annual averages of 7.9% (N = 10,383,000; SE, 447,000) of all ED visits and 1.3% (N = 12,674,000; SE, 558,000) of all outpatient office visits involved the administering or prescribing of 1 or more ISO. Over the same period, coprescribing or administering of anti-infective drugs alongside ISOs occurred during 2.1% (N = 2,782,000; SE, 130,000) of all ED visits, and 0.4% (N = 3,525,000; SE, 219,000) of all outpatient office visits. ED visits by patients with selected chronic conditions who were administered or prescribed ISOs include cancer—499,000 (SE, 39,000), diabetes—1,369,000 (SE, 82,000), and HIV—45,000 (SE, 7,000). Outpatient office visits by patients with selected chronic conditions who were administered or prescribed ISOs include cancer—1,032,000 (SE, 92,000), diabetes—1,802,000 (SE, 142,000), and chronic renal failure—138,000 (SE, 22,000). Conclusions: More than 10 million ED visits and 12 million outpatient office visits involved the clinical use of ISOs on average, from 2006 to 2016. These averages include visits by immunocompromised patients who could potentially benefit from nonimmunosuppressive analgesic alternatives, when appropriate. Until further research is conducted on the clinical relevance of these opioids’ immunosuppressive properties, their use to treat immunocompromised patients may represent unrecognized patterns of inappropriate drug use.

Funding: None

Disclosures: None
NHSN Catheter-Associated Urinary Tract (CAUTI) Definition—Opportunity for Improvement
Authors: Muto Carlene , Rea Kathleen , Piedmont Christie
Published: November 2020

Background: Urinary tract infections (UTIs) are one of the most common hospital-acquired infections; ~70%–80% are attributable to an indwelling urethral catheter. Daily risk of bacteriuria acquisition varies from 3% to 7% with a catheter. CAUTIs are associated with increased mortality, cost, and inappropriate treatment of asymptomatic bacteriuria which promotes antimicrobial resistance and Clostridium difficile infection. NHSN CAUTI criteria is most commonly met when a patient has a positive urine culture and a fever. Although fever can be associated with many sources, it cannot be excluded from UTI determination even when attributable to another recognized source. Given the high prevalence of bacteriuria in catheterized patients and the many sources of fever, the NHSN definition lacks specificity. Objective: To better classify CAUTI using enhanced criteria to so that appropriate reduction efforts would be utilized. Methods: A retrospective review was conducted to evaluate NHSN-defined CAUTIs from July 2017 to December 2018. Patients with NHSN defined CAUTI were evaluated to determine elements present to meet criteria. Overcaptured (O-CAUTIs) were defined as follows: (1) O-CAUTI 1, a positive culture with fever attributable to an infectious source; (2) O-CAUTI 2, a positive culture with fever attributable noninfectious source; (3) O-CAUTI 3, repeated positive cultures outside the RI period; (4) O-CAUTI 4, a positive culture with symptoms attributable to another source and no fever. Classifications were discussed with the medical and clinical leadership to determine appropriate opportunities for improvement. Results: Overall, 49 NHSN CAUTIs were identified with 11 of 49 (22%) being true CAUTIs and 38 of 49 (78%) O-CAUTI. O-CAUTI 1 was most common, with 17 of 38 (45%). The most frequent attributable source of fever for O-CAUTI 1 (infectious source) was respiratory (7 of 17, 59%) followed by gastrointestinal (6 of 17, 35%). Also, 14 of 38 (37%) were O-CAUTI 2. Central fever was the most frequent source of fever for the noninfectious source (9 of 14, 64%) followed by drug fever (2 of 14, 14%). Of 38 patients, 3 (8%) had both an infectious and noninfectious reason for fever (CAUTI 1 and 2); 4 patients had no fever. Furthermore, 2 were O-CAUTI 3 (repeat culture positive) and 2 were O-CAUTI 4 (1 with hematuria and renal cell carcinoma and 1 with dysuria without leukocytosis). Conclusions: NHSN CAUTI definitions capture UTIs and other events. In FY2018, there were no true CAUTIs in 5 of 12 months (42%). Also, 50% of CDC CAUTIs were not UTI but could lead to inappropriate antibiotic use. Reviewing only CAUTI reduction work in O-CAUTIs prevents the assessment of other appropriate opportunities for improvement.

Funding: None

Disclosures: None
Naturally Emerging Cohorting Behavior of Healthcare Workers and Its Implications for Disease Spread
Authors: Kharkar Abhijeet , Hasan D M Hasibul , Polgreen Philip , Segre Alberto , Sewell Daniel , Pemmaraju Sriram
Published: November 2020

Background: Mobility patterns of healthcare workers (HCWs) (ie, the spatiotemporal distribution of patient rooms they visit) have a significant impact on the spread of healthcare acquired infections (HAIs). Objective: In this project, we used fine-grained data from a sensor deployment at the medical intensive care unit (MICU) in the University of Iowa Hospitals and Clinics (UIHC) to study the mobility patterns of HCWs and their impact on HAI spread. Methods: We analyzed 10 days of data from a 20-bed MICU sensor deployment. For parameters t1 and t2, each pair of rooms i and j is assigned a weight W(i, j) representing the number of times an HCW spends at least t1 seconds in room i followed by at least t1 seconds in room j, within t2 seconds of each other. W(i, j) is a measure of HCW traffic going from room i to room j; we study the correlation between W(i, j) and the distance between rooms i and j. Additionally, we perform 2 disease-spread simulations: (1) a base simulation, obtained by replaying observed HCW mobility traces and (2) a perturbed simulation, which is the same as the base simulation, except that we replace each HCW who visits a room by a random available HCW. Thus, the perturbed simulation removes correlations in the observed HCW mobility traces. Results: We computed W(i, j) for all room pairs i, j for parameters t1 = 30 seconds and t2 = 1,800 and 3,600 seconds. For nurses, there was a strong negative correlation of between pairwise room distance and the weights W(i, j) (−0.768 for t2 = 1,800; −0.711 for t2 = 3,600), The more distant 2 rooms were, the less they shared nurse traffic. This was not true for physicians (correlation = −0.027 for t2 = 1,800; −0.014 for t2 = 3,600). Figure 1 shows a weight versus distance scatter plot for nurses for t1 = 30 and t2 = 1,800. This spatial correlation has positive implications for disease spread; the base simulation, which preserves these spatial correlations, has between 12% and 55% fewer mean infected patients (>100 replicates) for different simulation parameters compared to the perturbed simulation. Conclusions: Our results, based on fine-grained data, show a “naturally emerging” cohorting behavior of nurses, where nurses are more likely to visit rooms close to each other within a 30–60 minute time window, than rooms further away. Through simulations, this behavior provides substantial protection against disease spread.

Funding: None

Disclosures: None
Opening Doors in the Operating Rooms: An Intervention and Outcome Study
Authors: Doshi Akash , Shadowen Rebecca
Published: November 2020

Background:
Surgical site infections (SSIs) are a major cause of morbidity and mortality with an estimated cost of $3–10 billion annually in the United States. Laminar air flow in the operating room (OR) is 1 factor in reducing SSIs. Opening the OR door results in interruption of laminar air flow. As a part of annual infection prevention evaluation of our facility, we observed cases in the OR in which we identified excessive unnecessary door openings during surgical cases. We report an intervention in door openings in the OR and the effect on infection rate after surgery. Methods: We conducted an observational analytical study using prospective audit and feedback. Door-opening counters were placed on 4 OR doors. Each day, they were reset and the number was logged for each case by the circulating nurse. A baseline number of door openings was established between April 18, 2019, and May 2, 2019. Subsequently, daily feedback sheets were provided to all persons involved in the previous day’s procedures detailing the rationale to limit unnecessary door openings and the number of door openings that had occurred during the case(s) in which they were specifically involved from May 3, 2019, to June 4, 2019. Analyses of postoperative infection rates compared with historical controls were conducted. Using Stata version 15 statistical software, independent sample t tests were performed to see the difference between control and intervention groups. A CI 95% was set for significance. Results: There were no differences between control and intervention groups with the number of procedures (71 vs 80), OR, duration of procedure, or type of case. Outliers due to vibration of doors triggering the counters were removed, and door stabilizations were performed throughout the study. After removing outliers, there were no differences in control groups and interventions groups (39 vs 43). An independent sample t test showed a significant difference in the mean number of door openings between the control and intervention groups: 32.13 versus 24.84 (P < .05 and P = .0072). There have been no postoperative infections in any of the cases in the study to date compared to an overall annual rate of 1.5% in 2018 at our facility. Conclusions: Prospective audit and feedback to OR staff can reduce the number of unnecessary door openings during operating procedures. The baseline number of door openings from this study was 25 per case. No postoperative infections occurred in the patients receiving surgery in this study.

Funding: None

Disclosures: None