bluuebunny/crossref_metadata_2025 huggingface dataset:
58. Evaluation of a Disease State Stewardship Intervention for Urinary Tract Infections at an Academic Medical Center
Authors: Xhemali Xhilda , Forster Derek W , Clemons Bryant , Cotner Sarah , VanHoose Jeremy , Burgess Donna R , Burgess David , Myint Thein , Maskey Mitu , Wallace Katie
Published: January 2021

Background

Urinary tract infections (UTIs) are often misdiagnosed and mismanaged. Disease state stewardship initiatives targeting UTIs may have a significant impact on the overuse of antimicrobials (ABX). The purpose of our study is to evaluate the effectiveness of a UTI focused disease state stewardship intervention.

Methods

This retrospective study was conducted at a tertiary care academic medical center. Patients > 18 years of age with a collected urinalysis (UA) and receiving ABX for a UTI were included. Retrospective review of UTI management from 9–11/2017 was performed and used as the baseline. In the post-intervention period, 9–11/2018, the UTI management guideline had been published and service lines educated. A prospective audit and feedback (PAAF) initiative was started 6/2019, whereby the antimicrobial stewardship team performed daily reviews of patients on ABX for UTIs. Patients reviewed 9–11/2019 were included in the PAAF cohort. Exclusion criteria included: pregnancy, undergoing a urologic procedure, treatment of a concomitant infection, receiving therapy based on outside recommendations, or left AMA/expired during treatment. The primary outcome of this study was to evaluate overall guideline adherence.

Results

600 patients (200 in each group) were included, with 419 (69.8%) female and an overall median age of 61.4 years. Altered mental status (24.8%) and dysuria (21.5%) were the two main diagnostic testing indications. Treatment of asymptomatic presentations decreased between the three periods, 74.0% vs 48.5% vs 36.0%. Appropriate ordering of UA (33.5% vs 55.0% vs 68.5%, p< 0.001) and urine cultures (29.0% vs 57.1% vs 64.8%, p< 0.001) improved following guideline implementation and PAAF. Interventions by the stewardship team were made in 21% of patients during PAAF, namely therapy discontinuation (78.6%). Overall guideline adherence significantly improved over time, 13.0% vs 27.0% vs 36.5%, p< 0.001.

Conclusion

UTI disease state intervention was associated with a reduction in the treatment of asymptomatic presentations, increase in appropriate diagnostic ordering, and improvement in overall guideline adherence. PAAF can be a powerful stewardship strategy for promoting consistency in UTI treatment and decreasing unnecessary ABX use.

Disclosures

All Authors: No reported disclosures
842. Impact of Active Treatment of Carbapenem-Resistant Acinetobacter baumannii Infections in US Hospitals Between 2014 and 2019
Authors: Pogue Jason M , Zhou Yun , Kanakamedala Hemanth , Cai Bin
Published: January 2021

Background

Treatment choices for carbapenem-resistant (CR) Acinetobacter baumannii infections are limited. We analyzed the impact of active treatment on outcomes in patients infected with CR vs carbapenem-susceptible (CS) A. baumannii.

Methods

Adult patients hospitalized between January 1, 2014 and June 30, 2019 with A. baumannii infections recorded in the Premier Database were retrospectively evaluated. Outcomes including mortality, discharge status (home vs other), and readmission rates were calculated as a function of receipt of active antibiotic treatment, infection site, and CR status. Antibiotic therapy was considered active if given after the index culture and displaying in vitro susceptibility.

Results

Among 3,500 patients with A. baumannii (CR n=1,608; CS n=1,892), 2,057 patients (58.8%) received active treatment, with a much lower proportion of CR A. baumannii patients receiving active treatment than CS patients (606 [37.7%] vs 1,451 [76.7%]). Patients without active treatment had similar rates of in-hospital mortality (14.3% vs 12.9%, P=0.25) but were less likely to be discharged to home (26.3% vs 37.0%, P< 0.001) than those that received active treatment. No association between receipt of active treatment and overall mortality or discharged status was demonstrated for CR isolates (Table 1). However, among the subset of patients with CR bloodstream infections, mortality was higher in those without active treatment compared to those with active treatment (55.1% vs 25.9%, P=0.009). Overall readmission rates due to A. baumannii were considerably higher for those who did not receive active treatment vs those who did (16.0% vs 7.5%, P< 0.001) and the same was seen by differing infection sites; primarily driven by CR patients with bloodstream, respiratory, or urine infections (Table 2).

Table 1. Mortality and discharge status by active treatment and carbapenem susceptibility

Table 2. Readmission due to A. baumannii by active treatment and CR status among patients discharged alive

Conclusion

Active antibiotic therapy was associated with improved outcomes in patients with A. baumannii infections, although perhaps not to the extent expected. Further investigation into the impact of active therapy on outcomes is warranted.

Disclosures

Jason M Pogue, PharmD, BCPS, BCIDP, Shionogi Inc. (Advisor or Review Panel member) Yun Zhou, MS, Shionogi Inc. (Independent Contractor) Hemanth Kanakamedala, BS, Shionogi Inc. (Independent Contractor) Bin Cai, MD, PhD, Shionogi Inc. (Employee)
843. Increased Carbapenemase Testing Following Implementation of VA Guidelines for Carbapenem-Resistant Enterobacteriaceae (CRE)
Authors: Fitzpatrick Margaret A , Suda Katie J , Ramanathan Swetha , Wilson Geneva M , Jones Makoto M , Perencevich Eli N , Rubin Michael , Klutts James S , Pfeiffer Christopher D , Evans Martin , Evans Charlesnika T
Published: January 2021

Background

Carbapenem-resistant Enterobacteriaceae (CRE) are a substantial burden, with recent data showing no change in hospital CRE between 2012-2017. All carbapenemases produced by CRE have been identified in the U.S., however trends in testing and detection over time have not been well described.

Trends in carbapenemase testing in the VA, 2013-2018

Methods

A retrospective cohort study of Veterans hospitalized between 2013-2018 with CRE cultures defined by either 2015 or 2017 VA guidelines. In general, this was Escherichia coli, Klebsiella pneumoniae/oxytoca, or Enterobacter spp. non-susceptible to imipenem, meropenem, and/or doripenem, and to 3rd generation cephalosporins for 2015 definition. Testing for Klebsiella pneumoniae carbapenemase (KPC), New Dehli metallo-β-lactamase (NDM), Verona integron-encoded metallo-β-lactamase (VIM), Imipenemase (IMP), and Oxacillinase-48-like (OXA-48) was summarized with descriptive statistics. Facility characteristics assessed included region, complexity, and rurality.

Results

Out of 5,778 CRE cultures, 1,900 (32.9%) were tested for carbapenemases and 1,612 (84.8%) of these had carbapenemases detected. Among CP-CRE cultures, 1,042 (64.6%) had testing for ≥1 genetic mechanism; all tests included KPC. Testing for NDM (n=585, 56.1%), VIM (n=102, 9.8%), IMP (n=102, 9.8%), and OXA-48 (n=507, 48.7%) was less frequent. KPC was detected in 915/1,042 cultures (87.8%), while NDM (n=7/585, 1.2%) was rarely detected. There were no cases of VIM, IMP, or OXA-48. Carbapenemase testing increased significantly over the study period; KPC, NDM, and OXA-48 were the predominant mechanisms tested (Figure 1). The South (38.6%) and Northeast (37.2%) had the highest proportion of CRE with carbapenemase testing. High complexity (vs low) and urban (vs rural) facilities were significantly associated with carbapenemase testing (p< 0.001).

Conclusion

Following publication of initial CRE guidelines in 2015, carbapenemase testing and detection increased in the VA, although tests for non-KPC carbapenemases were less frequent. Surveillance of non-KPC carbapenemases is important due to global dissemination and enhanced antibiotic resistance. Efforts should support carbapenemase testing in low complexity, rural facilities in the Midwest and West.

Disclosures

All Authors: No reported disclosures
846. Trends in Acinetobacter baumanii Antibiotic Resistance Rates
Authors: Caffrey Aisling , O’Neill Emily T , Appaneal Haley J , Lopes Vrishali , LaPlante Kerry
Published: January 2021

Background

Carbapenem-resistant Acinetobacter baumannii is described as an urgent threat by the Centers for Disease Control and Prevention and several older studies have indicated increasing resistance in Acinetobacter. We sought to describe these trends in the national Veterans Affairs (VA) Healthcare System.

Methods

We assessed A. baumannii positive clinical cultures collected from VA patients (> 18 years) from 2010 to 2018. We categorized cultures based on location at the time of collection: VA medical center (VAMC), community living center (CLC), or outpatient (Outpt). Multidrug resistance (MDR) and extensive drug resistance (XDR) were defined as resistance to > 1 drug in > 3 or all of the following categories, respectively: extended-spectrum cephalosporins (es-CS), fluoroquinolones (FQ), aminoglycosides (AMG), carbapenems (CARB), piperacillin/tazobactam (PIP/TAZ), and ampicillin/sulbactam (AMP/SUL). Joinpoint Software was used for regression analyses of trends over time and to estimate annual average percent changes (AAPC) with 95% confidence intervals.

Results

We identified 19,376 A. baumannii positive cultures over the study period (53% VAMCs, 4% CLCs, 43% Outpts), which represented 0.5% of all positive cultures in the VA. In VAMCs, the number of A. baumannii cultures decreased significantly by 12.5% per year. Of all positive cultures in VAMCs, the proportion that were A. baumannii decreased significantly by 5.4% per year. Similar trends were observed in CLCs, while Outpt cultures remained stable. Over the 9-year study period, resistance decreased significantly, with MDR decreasing by 10.2% per year and XDR decreasing by 9.4%. Carbapenem resistance decreased significantly by 4.9% per year in VAMCs (2010, 39%; 2018 28%) and 11.3% in Outpts (2010, 12%; 2018, 6%). Similar annual significant decreases were observed with AMG (9.4%), es-CS (1.4%), and FQ (7.4%) in VAMCs; es-CS (2.7%) and FQ (5.6%) in CLCs; and AMG (9.5%) and FQ (8.2%) in Outpts.

Conclusion

In the national VA Healthcare System, the prevalence of A. baumannii is decreasing, as is the resistance previously observed with this organism. MDR A. baumannii still made up one-third of cultures in VAMCs and CLCs in 2018, and thus remains a treatment challenge.

Disclosures

Aisling Caffrey, PhD, Merck (Research Grant or Support)Pfizer (Research Grant or Support)Shionogi (Research Grant or Support) Haley J. Appaneal, Pharm.D, Shionogi, Inc. (Research Grant or Support) Kerry LaPlante, PharmD, Merck (Advisor or Review Panel member, Research Grant or Support)Ocean Spray Cranberries, Inc. (Research Grant or Support)Pfizer Pharmaceuticals (Research Grant or Support)Shionogi, Inc. (Research Grant or Support)
847. Trends in Stenotrophomonas maltophilia Antibiotic Resistance Rates
Authors: Caffrey Aisling , O’Neill Emily T , Appaneal Haley J , Lopes Vrishali , LaPlante Kerry
Published: January 2021

Background

Studies from the 1990’s and 2000’s identified increasing rates of Stenotrophomonas maltophilia, particularly among respiratory isolates and in intensive care populations. Additionally, resistance in S. maltophilia was found to be worsening. We aimed to quantify recent trends in prevalence and resistance of S. maltophilia in the national Veterans Affairs (VA) Healthcare system.

Methods

We identified positive S. maltophilia clinical cultures among VA adult patients from 2010 to 2018, collected in either VA medical centers (VAMCs), community living centers (CLCs), or the outpatient (Outpt) setting. Multidrug resistance (MDR) was defined as resistance to sulfamethoxazole/trimethoprim (SMX/TMP) and minocycline or levofloxacin. Time trends were assessed with regression analyses to estimate annual average percent changes (AAPC) with 95% confidence intervals using Joinpoint Software.

Results

Over the 9-year study period, we identified 18,285 S. maltophilia cultures (57% VAMCs, 3% CLCs, 40% Outpt). S. maltophilia cultures made up 0.4% of all positive cultures in the VA. In VAMCs and CLCs, the number of S. maltophilia cultures decreased 5.1% and 8.5% per year, respectively. Alternatively, of all positive cultures in VAMCs, the proportion that were S. maltophilia increased significantly by 2.6% per year.

SMX/TMP resistance decreased significantly by 8.5% (2010, 15%; 2018, 6%) per year in VAMCs, and decreased non-significantly by 8.7% (2010, 13%, 2018, 6%) per year in CLCs and 6.0% (2010, 12%; 2018, 7%) in the outpatient setting. No other significant changes in resistance were observed over the study period. MDR increased non-significantly by 1.2% per year.

Conclusion

While previous studies found increasing rates of S. maltophilia, the number of positive S. maltophilia cultures decreased in the national VA Healthcare System between 2010 and 2018. However, S. maltophilia is making up a greater proportion of positive culture over time. During the study period, resistance to SMX/TMP decreased and now more closely reflects previously reported resistance rates worldwide (0-10%).

Disclosures

Aisling Caffrey, PhD, Merck (Research Grant or Support)Pfizer (Research Grant or Support)Shionogi (Research Grant or Support) Haley J. Appaneal, Pharm.D, Shionogi, Inc. (Research Grant or Support) Kerry LaPlante, PharmD, Merck (Advisor or Review Panel member, Research Grant or Support)Ocean Spray Cranberries, Inc. (Research Grant or Support)Pfizer Pharmaceuticals (Research Grant or Support)Shionogi, Inc. (Research Grant or Support)
852. Genomic Clusters of Methicillin-Resistant Staphylococcus aureus (MRSA) Causing Bloodstream Infections (BSIs) in Hospitalized Adults, 2018-19
Authors: Read Timothy D , Jacko Natasia F , Petit Robert A , Pegues David A , David Michael Z
Published: January 2021

Background

MRSA BSIs have 15-50% mortality and are commonly diagnosed in US hospitals. However, the frequency of hospital transmission of MRSA causing BSI is unknown.

Methods

We performed Illumina shotgun whole genome sequencing (WGS) of 106 sequential MRSA isolates from different adults with a BSI at two Philadelphia academic hospitals in a single health system in July 2018-June 2019. We abstracted clinical data from the electronic medical record. Genomic data were analyzed preliminarily using the Staphopia Analysis Pipeline.

Results

Among 106 subjects, 51.9% were male, 47.2% were white, 46.2% were black, 23.6% were < 40 years of age, and mean age was 53.1 years (s.d. 17 years). One isolate had WGS data that were inadequate for analysis. Of 105 genomes, 52 were clonal cluster (CC) 8, 22 were sequence type (ST) 5, and 16 were ST105; the remaining 15 strains belonged to 8 other CCs. Of CC8 strains, 44 were USA300 and 6 were USA500. There were 6 clusters (i.e., < 35 SNP differences in the core genome) among the 105 isolates. Four clusters were CC5 and two were CC8 strains. One cluster of CC5 strains involved 3 subjects, and 5 clusters involved 2 subjects. One cluster of ST8/USA300 strains were separated by only 1 SNP (Fig a). This and two other clustered pairs were from subjects who had overlapping hospital stays. Two of these paired subjects had an overlap in the same unit while the third pair was in the hospital together on a number of occasions (total of 40 days overlap) but never simultaneously in the same unit. The other three clustered pairs did not have temporally overlapping hospital stays, suggesting transmission via a hospital reservoir. One of these three pairs had hospitalizations overlapping in time, one at each study hospital, before each of them had infections with the related MRSA strains. There was not a clear-cut clustering of SNP distances among the isolate genomes into transmission and non-transmission groups, with some pairs of patient isolates separated by 40-80 SNPs (Fig. b).

Figure 1.

Conclusion

We were able to discern from WGS data alone that some MRSA BSIs in 2 hospitals were likely due to strains transmitted between patients. Universal WGS of BSI strains may detect MRSA outbreaks in real time, even in the absence of overlapping hospitalizations, and is an emerging strategy to detect healthcare transmission of MRSA.

Disclosures

Michael Z. David, MD PhD, GSK (Consultant)
853. Hospital-acquired Infections by Vancomycin-Resistant Enterococcus (VRE): Results in 3 Years of Multicenter Study
Authors: Tanure Luciana Coelho , Pinho Rafaela Tonholli , Alves Érico Macedo Pacheco , Pires Bárbara Caldeira , Lopes Joice Ribeiro , Ribeiro Daniela Teixeira , de Souza Flávio Henrique Batista , Couto Braulio Roberto Gonçalves Marinho , Starling Carlos Ernesto Ferreira
Published: January 2021

Background

Vancomycin-Resistant Enterococcus (VRE) is considered one of the main pathogens of hospital-acquired infections (HAI), responsible for high morbidity and mortality rates. HAI caused by this bacteria, especially in intensive care units (ICU), are concerning for the health system, given that the microorganism is multi resistant to most antimicrobials available, especially vancomycin. Therefore, the present study is built from and analyzes the data of VRE, collected by the Infection Prevetion and Control Service of hospitals in Brazil, to clarify: the incidence rate, the gross lethality of these infections and what are the profiles of infected patients.

Methods

Collection and analysis of epidemiological data, according to the National Healthcare Safety Network (NHSN) protocol of the Centers for Disease Control and Prevention (CDC), in 10 hospitals in Brazil, between Jan/2017 - Dec/2019.

Results

In three years, 118 VRE infections were diagnosed in the hospitals analyzed: 51 from ICU (43%), 24 from Vascular Acess (20%), 18 from General Clinic (15%), 10 from General Surgery (8%) and 15 from Others (13%). Patients ages ranged from 0 to 93 years, with a mean of 62 years (standard deviation of 20 years) and a median of 66 years. Time between admission and diagnosis of infection was 1 to 1001 days, with a mean of 68 days (standard deviation of 25 days) and a median of 59 days. The gross lethality for VRE infections was 47/118 (40%). The infection sites were: Bloodstream Infections – BSI = 34 (29%); Urinary Tract Infections – UTI = 28 (24%); Surgical Site Infections – SSI = 27 (23%); Skin and Soft Tissue Infections – SST = 14 (12%); Bone and Joint Infections – BJ = 5 (4%); Cardiovascular System Infections – CVS = 5 (4%); Lower Respiratory System Infections, other than pneumonia – LRI = 2 (2%); Pneumonia – PNEU = 2 (2%) and Gastrointestinal System Infections – GI = 1 (1%).

Percentage of VRE infections by hospital units

Percentage of VRE infections by infection sites

Infection sites of VRE infections by hospital

Conclusion

VRE infection is a highly lethal event that usually occurs after two months of hospitalization. The main site of infection is the BSI, with a higher incidence in patients over 62 years or the ones in ICU. Early and accurate investigations of multiresistant microorganisms in a hospital setting are necessary to reduce patient morbidity and mortality.

Disclosures

All Authors: No reported disclosures
855. Significance of Invasive Infections due to Methicillin Sensitive Staphylococcus aureus in the neonatal population
Authors: Riollano Mariawy , Altman Deena , kowalsky shanna , Pan Stephanie
Published: January 2021

Background

Staphylococcus aureus is a well-known cause of hospital acquired infections. Methicillin resistant staphylococcus aureus (MRSA) colonization is a recognized risk factor for invasive infections. The neonatal population in the intensive care unit (NICU) is particularly vulnerable to these types of infections, resulting in high mortality and morbidity. However, only scant data is available to establish the risk for invasive disease in patients with Methicillin sensitive staphylococcus aureus (MSSA). As a result, surveillance and prevention strategies are only address for MRSA colonization. Here, we describe the clinical characteristics of S. aureus colonized patients identified in late 2018 during transmission events in a single center NICU. As a result of the targeted surveillance investigation for MRSA infection control measures, S. aureus colonization was stratified, and we were able to compare the differences in invasive disease between MRSA and MSSA.

Methods

This is a retrospective chart review of the 47 colonized patients identified during October 2018- January 2019 SA transmission events in single center NICU. Risk factors, clinical characteristics, and the hospital course of these cases, including the proportion of invasive illness were reviewed.

Results

We found that most clinical characteristic, risk factors, and hospital course were the same between MRSA and MSSA colonized infants (p values > 0.05). Additionally, there was no difference in the proportion of invasive infection between MRSA and MSSA colonized patients (p value > 0.05). The type of invasive infections identified were SSTI, bacteremia, and osteomyelitis.

Conclusion

The proportion of invasive infection was the same in MSSA and MRSA colonized patients. This data provides us with supportive material for future recommendations of infection control measures for MSSA colonized patients.

Disclosures

All Authors: No reported disclosures
856. Assessment of Hand Hygiene amongst Health Care Professionals at Jimma University Medical Center
Authors: Berman Leigh R , Kavalier Meredith , Deressa Beshea G , Yilma Daniel , Tesfaw Getnet , Shirley Daniel
Published: January 2021

Background

Lack of hand hygiene (HH) amongst healthcare workers (HCWs) contributes to healthcare associated infections and the spread of multidrug-resistant organisms. We assessed HCW HH knowledge, attitudes, and compliance using WHO tools and applied the Systems Engineering Initiative for Patient Safety (SEIPS) model in interviews to help guide and increase sustainability of HH interventions.

Methods

We conducted a cross-sectional study at Jimma University Medical Center (JUMC) in Jimma, Ethiopia. We assessed HCW’s HH knowledge and attitudes using questionnaires adapted from WHO resources via systematic sampling. Observations of HH practices at WHO’s 5 Moments of HH were conducted by non-identified, trained observers via systematic sampling. 22 semi-structured interviews were conducted via convenience sampling with HCWs using an interview guide based on the SEIPS model.

Results

We observed 1,386 HH moments and found a compliance rate of 9.38%, with compliance highest after contact with patient surroundings (27.92%) compared to the other four HH moments (1.77 - 9.57%). Of 251 survey participants, 13.6% had prior HH training and 69.9% reported routine HH compliance. The average knowledge score was 61.4%, with no significant difference between participants that identified as trained vs untrained (p=0.41). 68% of interview participants stated they were unaware of JUMC’s Infection Prevention and Control (IPC) team and are more likely to perform HH if a patient appears infectious. Interview participants cited multiple barriers to HH (table 1).

Table 1

Conclusion

Baseline HH compliance and knowledge were low despite perceived compliance and regardless of prior HH training. Relatively higher compliance after patient contact may be due to perceptions of patient infectiousness. Utilizing the SEIPS model as an adjunct to WHO HH guidelines has provided actionable items upon which the JUMC IPC team can focus to improve HH practices: providing a sustainable supply of alcohol hand rub, ongoing HH education targeting knowledge deficits, and enhanced IPC presence and HH monitoring.

Disclosures

Meredith Kavalier, MD, University of Wisconsin-Madison Global Health Institute (Grant/Research Support)
857. Contact Precautions as a Barrier to Hand Hygiene: PDSA to Improve Compliance with Gloved Hand Hygiene
Authors: Bailey Pamela , Armstrong-Novak Jo Dee , Cooper Kaila , Stevens Michael , Bearman Gonzalo , Doll Michelle
Published: January 2021

Background

Full compliance with personal protective equipment (PPE) is challenging, with multiple barriers noted: adherence to appropriate PPE, lack of knowledge of appropriate PPE, added time to workflow, and appropriate donning/doffing techniques of PPE to avoid self-contamination. Recent studies note that nurses tend to batch care to achieve more while in the room. A hand hygiene technology system alerted MRICU nurses to difficulties performing WHO’s Five Moments of hand hygiene (HH) when in contact precaution PPE.

Methods

We implemented the ‘Plan-Do-Study-Act’ (PDSA) framework to address the MRICU team concerns. Six nurses were directly observed while providing bedside care to understand nursing workflow and barriers to HH while in contact precautions.

Results

All 6 nurses performed hand hygiene prior to entering the room and at the time of exiting the room. Once donning contact precautions, they had variable but low compliance with any additional HH opportunities. The average missed opportunities per encounter was 5.2 (range: 2-11). Moments that would require hand washing or sanitizer if nurse were not gloved were not met with changing gloves. An average of 9.8 tasks were achieved in each room (range: 3-18). On average, each visit was 16 (range: 4-30 minutes) minutes long.

Conclusion

There is significant opportunity for improved HH while in PPE. Nurses may be more aware of the “Five moments” when not wearing gloves in contact precaution rooms, but lose the trigger once the gloves are on in the contact precaution rooms. An education campaign to improve hand sanitizer usage with gloves is the next step in this PDSA. More prominent placement of glove boxes in the rooms will also serve as a trigger to remind nurses to change gloves after certain tasks. Limitations of this PDSA cycle include Hawthorne effect of the nurses knowing they were observed and potentially changing their workflow. We also only observed morning workflow; nurses on different shifts may have different workflow.

Disclosures

All Authors: No reported disclosures
858. Inter-rater Reliability of Hand Hygiene Observers with an Electronic Monitoring System
Authors: Bailey Pamela , Armstrong-Novak Jo Dee , Cooper Kaila , Stevens Michael , Bearman Gonzalo , Doll Michelle
Published: January 2021

Background

Hand hygiene (HH) is the bedrock of infection prevention. Knowing the limitations of hand hygiene observers, Virginia Commonwealth University Health System invested in technology to remotely monitor health care workers’s (HCW) HH. Each hand sanitizer and soap dispenser in the patient care areas has a sensor, as well as each patient’s bed and each HCW. As the HCW moves around the environment, the sensors detect whether or not HH was performed for each opportunity.

Methods

While monitoring HH via observations, we compared the manual observations and the technologic hand hygiene observations.

Results

Of 31 witnessed and manually recorded HH observations, 30 were noted in the electronic system (96.7% correspondence). There was only one witnessed opportunity that the technology failed to capture, when the staff member was performing hand hygiene while standing in the doorway talking to the nurse inside the room. There were multiple missed opportunities for HH while in patient rooms, as defined by the WHO’s Five Moments.

Conclusion

There was excellent correspondence between the manual observations and the HH technology in this study. There is significant limitation in what an observer can do, while the HH technology will average around 35,000 ‘observations’ on a daily basis and is capable of capturing more of the 5 moments of HH. We have previously noted interference in the wireless technology in the healthcare environment. However, failure of providers to perform HH when indicated overshadow the failures of technology to capture HH that is performed. Better understanding of the indications for HH in accordance with the WHO 5 Moments may improve provider trust in the technology.

Disclosures

All Authors: No reported disclosures
60. Evaluation of Outcomes Associated with Intermittent Versus Extended Infusion of Piperacillin/tazobactam in Acutely Ill Veterans
Authors: Encarnacion Marianne Angeli , Ma Ariel , Johns Scott T
Published: January 2021

Background

Antibiotic dosing optimization is a key principle of antimicrobial stewardship. This study evaluated the impact of an extended infusion piperacillin/tazobactam dosing protocol on clinical outcomes in acutely ill veterans treated for infections at VA San Diego.

Methods

This retrospective cohort study looked at veterans admitted to the medical-surgical unit who were treated with piperacillin/tazobactam for at least 48 hours. The control group included patients who received treatment between 12/14/2017 to 7/22/2018, and the “protocol” or after protocol implementation group included patients who received treatment between 7/23/2018 to 2/28/2019. Excluded from the study were veterans with microbiological cultures showing intermediate sensitivity or resistance to piperacillin/tazobactam, those who experienced interruption in therapy, or those who required dialysis. Primary clinical outcomes included in-hospital mortality rate, 30-day mortality rate, hospital length of stay (LOS), and 30-day readmission rates. Rates of adverse effects such as elevated liver enzymes, thrombocytopenia, acute kidney impairment (AKI), and Clostridium difficile infection were also collected. χ 2, Fisher’s exact, and Mann-Whitney U tests were used for statistical analysis.

Results

260 veterans were included in the final analysis: 96% male, mean age 65 years, mean BMI 29, 84 met SIRS criteria for sepsis, and 55% received at least 48 hours of concomitant vancomycin. Groups had similar outcomes for median LOS, in-hospital mortality, and 30-day mortality. The incidence of AKI was significantly lower in the protocol group (39.2% vs. 56.9%, p=0.004), in veterans on concomitant vancomycin (42.3% vs. 63.2%, p=0.011), and in veterans with obesity (36.4% vs. 70.8%, p=0.001). Rates of liver enzyme elevation, thrombocytopenia, and C. difficile infection were lower in the protocol group though these were not significant.

Conclusion

There was a significantly lower rate of AKI with EI dosing which supports enhanced patient safety. This may be the preferred method of administration for obese patients and/or those receiving vancomycin concurrently. This is the first study to demonstrate that EI piperacillin/tazobactam dosing significantly reduces rates of AKI in patients on concomitant vancomycin.

Disclosures

All Authors: No reported disclosures
861. Evolution of Antifungal Use Over Fifteen Years in a Burn Intensive Care Unit
Authors: Kiley John L , Barsoumian Alice , Giancola Stephanie , Pruskowski Kaitlin , Rizzo Julie , Blyth Dana M
Published: January 2021

Background

Systemic antifungals (AF) and surgery are the cornerstone of therapy for burn-related fungal infections. Multiple AFs were introduced in the last decade with broader spectrum and improved safety profiles, but use in burn patients has yet to be thoroughly described. Here we evaluate 15 years of AF prescribing patterns in a burn intensive care unit (BICU).

Methods

We included all US Army Institute of Surgical Research BICU patients who received > 1 dose of AF from 2004-18. First we sought to describe overall AF prescribing. Clinical features, mortality and AF use (including in combination) from 2004-8 (T1), 2009-2013 (T2), 2014-18 (T3) were compared.

Results

Between 2004-18, 361 patients with a median total body surface area (TBSA) of 45% (IQR: 25-60) received AF. Median duration of hospital stay prior to and duration of initial AF (AF1) were 13.5 (IQR: 7-22) and 4 days (IQR: 2-9), respectively. Patients prescribed AF had a median of 2 (IQR 1-3) different AFs. AF1 was most commonly fluconazole [FLC; n=141 (39%)], amphotericin [AMB; n=62 (17%)] and voriconazole [VRC; n=55 (15%)]. Of those who survived, (N=233) AF1 was AMB, 40 (17.2%); FLC, 102 (43.8%); itraconazole, 1 (0.4%); VRC, 35 (15%); posaconazole (POS), 6 (2.6%); isavuconazole (ISA), 4 (1.7%); caspofungin (CAS), 7 (3%); micafungin (MFG), 28 (12%), VRC/AMB, 8 (3.4%); FLC/AMB, 0; FLC/CSP, 1 (0.4%); and VCR/MFG 1 (0.4%). AF1 use differed across T1, T2, and T3 (Table). Notably, there was shift towards use of POS, ISA, and MFG. The use of AF1 combination therapy differed across T1, T2, and T3 (p = 0.002). 200 patients had a second AF (AF2) prescribed at a median of 4.15 days (IQR 1.1-12.5) after AF1 for a median duration of 5.3 days (IQR 2-9.7). AF2 were most commonly VRC (n=54, 27%), AMB (n =46, 23%) and FLC (n=44, 22%). There were no differences in AF2 over time.

Table. Clinical characteristics and antifungal use by five year increments

Conclusion

AF use evolved to include echinocandins and broader spectrum triazoles and decreased use of AMB as part of AF1. However, AF2 remained most commonly VRC, AMB, and FLC.

Disclosures

All Authors: No reported disclosures
862. Impact of Caregiver Health on Pediatric Healthcare-Associated Viral Respiratory Infections (HAVRIs): A Retrospective Study
Authors: Paquette Maude , Shephard Allyson , Bedard Pat , Thampi Nisha , Thampi Nisha
Published: January 2021

Background

The burden of healthcare-associated viral respiratory infections (HAVRIs) in children is significant, with increased healthcare costs and risk of poor outcomes. However, while healthcare workers are the main target of infection prevention measures, little is known about the impact of sick contacts during hospitalization on the incidence of HAVRIs. The objective of our study was to determine the proportion of pediatric HAVRIs following contact with an ill caregiver or visitor. Secondary objectives were to describe the characteristics of affected patients as well as the complications associated with the HAVRI episodes.

Methods

This is a retrospective chart review that took place in a pediatric tertiary care center with both multiple and single-bed rooms. All cases of HAVRIs that occurred between December 2017 and July 2019 in patients aged less than 18 years old were included in the study. HAVRIs were defined as a laboratory confirmed respiratory viral illness occurring after 72 hours of admission.

Results

Forty-four HAVRIs were included in the analysis. The majority (n=32, 72.7%) were among patients aged less than 24 months. Only 2 patients had no comorbidities and almost half (n=21, 47.7%) had multiple complex medical conditions. Rhinovirus was the most frequently isolated virus (n=20, 45.5%). Nine patients (20.5%) had a documented contact with a sick caregiver (n=8, 88.9%) or sick visitor (n=2, 22.2%) in the 7 days prior to the onset of new respiratory symptoms and subsequent HAVRI diagnosis. In the 72 hours prior to HAVRI onset, 18 patients (40.9%) were in a single-bed room and 6 patients (13.6%) were already under droplet/contact precautions. Twelve patients (27.3%) had new or increased O2 requirements and 4 (9.1%) were transferred to the intensive care unit. There were no associated deaths.

Conclusion

Our study suggests that having a contact with a sick caregiver or visitor is a potential risk factor for acquiring a HAVRI. This reinforces the relevance of a strict visitor-screening policy and of educating caregivers on the importance of appropriate hand hygiene when caring for their child. Of note, more than one third of HAVRI cases occurred in patients already in a single-bed room, with or without additional precautions, suggesting that those measures are not entirely protective.

Disclosures

All Authors: No reported disclosures
61. Evaluation of the Impact of a Micafungin Time-Out Protocol for Hospitalized Patients
Authors: Williams Kelsey N , Elshaboury Ramy H , Letourneau Alyssa R , Adamsick Meagan L , Gandhi Ronak G , Paras Molly L , Bidell Monique R
Published: January 2021

Background

Echinocandin overuse is associated with increased prevalence of non-albicans Candida spp, resistance, and high costs. Prospective review of micafungin prescribing by an Antimicrobial Stewardship Pharmacist (ASP) has shown reduced rates of inappropriate therapy. The aim of this study was to describe ASP’s interventions following introduction of a micafungin time out (MTO) protocol.

Methods

The approved MTO protocol was implemented in November 2019. Active micafungin orders for hospitalized patients were reviewed Monday through Friday at initiation and on day five. The MTO algorithm assessed micafungin use based on patient risk factors for Candida infection and de-escalation was guided by clinical status, culture data, and susceptibility testing. Micafungin use and ASP’s interventions were reviewed post-implementation between 12/01/2019 and 02/29/2020. Micafungin use was also characterized between 12/01/2018 and 02/28/2019 to serve as a control.

Results

A random sample of 50 patients who received micafungin for ≥ 48 hours during the pre- and post- protocol periods were included. 39 (78%) and 38 (76%) patients in the pre- and post-MTO cohort had indications for micafungin initiation according to algorithm. In the post-MTO group, 9 (75%) of the 12 micafungin initiations outside of algorithm approval were intervened on successfully by the ASP, increasing appropriate antifungal therapy to 47 (94%) patients. On day five, 18 (50%) and 25 (65.8%) (p=0.17) micafungin orders were according to algorithm in the pre- and post-MTO groups, respectively. Culture data on day five revealed 18 (50%) in the pre-MTO and 13 (34.2%) in the post-MTO group were eligible for de-escalation. An ASP-initiated MTO on day five identified 23 opportunities for antifungal therapy optimization in the post-MTO group. Interventions included de-escalation (13; 61.9%), discontinuation (6; 28.6%), and dose optimization (4; 19%). Of the 23 ASP interventions on day 5, 10 (43.4%) led to micafungin discontinuation or de-escalation, increasing the overall antifungal appropriateness to 35 (92.1%) patients.

Conclusion

An ASP-initiated MTO can facilitate appropriate and timely optimization of antifungal therapy. The most frequent interventions were de-escalation from micafungin or therapy discontinuation.

Disclosures

All Authors: No reported disclosures
871. Assessment of the Wide-resistant Pseudomonas aeruginosa Outbreak at a University Hospital in Brazil: Have We Lost This War?!
Authors: Reis Henry Pablo Lopes Campos e , Rodrigues Ana Beatriz Ferreira , Silva Julio César Castro , de Lima Lia Pinheiro , Quinaher Talita Lima , de Freitas Thaynara Carvalho , Pereira Carla Mônica Porto , de Araujo Breno Queiroz , de Sousa Paulo Cesar Pereira , Pontes Licia Borges , Rodrigues Jorge Luiz Nobre
Published: January 2021

Background

Resistance profile analysis in Pseudomonas aeruginosa isolates is extremely important to prevent its transmission and to detect outbreaks. Broadly resistant strains (BR) have a high mortality rate in invasive infections. By analyzing the clinical and microbiological characteristics of these infections, one can define more effective actions in a nosocomial outbreak setting in a university hospital in Brazil.

Methods

From January to September 2019, 13 patients from the oncohematology services and intensive care unit (ICU) followed by the stewardship program of a public university hospital in Brazil had Pseudomonas aeruginosa (PsA) BR infection. Resistant multidrug (MDR) was defined as resistant to three or more antimicrobial classes. Extensively resistant (XDR) was sensitive to a maximum of two antimicrobial classes. Resistant pandrug (PDR) has been defined as resistant to all antimicrobial classes. Bacterial samples were identified by the automated VITEK®2 system (BioMérieux). The resistance pattern was defined based on the CLSI-M100 2019 criteria. Colistin sensitivity was assessed by the colistin drop test (Pasteran et al., 2018). The modified carbapenemic inactivation method (mCIM) was performed by disk diffusion.

Results

The 13 strains of PsA were isolated from 84.6% (11/13) blood cultures and 15.4% (2/13) tracheal aspirates, being 76.9% (10/13) from the oncohematology unit and 23.1% (3/13) of the ICU. The resistance profile was 23.1% (3/13) strains PsA MDR, 61.5% (8/13) PsA XDR and 15.4% (2/13) strains resistant to all classes (PsA PDR). 69.2% (9/13) of the strains were mCIM positive, in which the therapeutic option was ceftazidime/avibactam in combination with polymyxin. Regarding the sites of infection and use of devices, 53.8% (7/13) of the patients developed the infection after the use of central venous catheter and/or mechanical ventilation. The mortality rate was 76.9% (10/13).

Conclusion

The investigation of the outbreak of Pseudomonas aeruginosa highlights the importance of infectious surveillance of this pathogen with this resistance profile, to better understand the causalities, minimize its damage and reduce potential recurrence of new outbreaks.

Disclosures

All Authors: No reported disclosures
873. Clusters of Postpartum Group A Streptococcus (GAS) Infections on a Labor and Delivery (L&D) Unit June-October 2019
Authors: Haden Michael , Liscynesky Christina , Colburn Nora , Smyer Justin , Gonsenhauser Iahn , Malcolm Kimberly , Isley Michelle M , Hardgrow Michele , Pancholi Preeti , Thomas Keelie E , Cygnor Anita , Tabor Heather , Berger Brynn , Aluko Oluseun , Koch Elizabeth , Tucker Naomi E , Brandt Eric , Cibulskas Katie , Florek Kelsey , Mohr Marika C , Day Shandra R
Published: January 2021

Background

GAS can cause severe postpartum infections and may be transmitted from colonized healthcare workers (HCWs).

Methods

Two cases of GAS bacteremia following vaginal delivery were identified on the L&D unit June-July 2019 (Cluster 1), prompting a carrier-disseminator investigation. Two additional cases were identified September-October 2019 (Cluster 2), followed by an additional 3 cases late October 2019, all of whom delivered on the same night (Cluster 3).

All patients and HCWs were evaluated for GAS risk factors and screened for colonization via throat, vaginal and perirectal cultures. During Clusters 1 and 2, only HCWs with patient contact were screened, but this was expanded to the entire unit in October after Cluster 3 was identified. All GAS colonized HCWs were provided chemoprophylaxis and rescreened 7-10 days after treatment to ensure eradication. GAS isolates from patients and HCWs were analyzed by whole genome sequencing (WGS).

Results

During Cluster 1 a total of 43 HCWs were screened and HCWA was colonized at all three sites. In Cluster 2, nine HCWs were screened; HCWA was negative at that time but HCWB was colonized in the throat only. Patient 3 was confirmed to be community acquired by pulsed-field gel electrophoresis, patient 4 was closely related by WGS. A new policy was instituted that required all HCWs present at delivery to wear gowns, gloves, masks, eye protection, and to undergo infection prevention education and practice review. Following Cluster 3, all HCWs on the unit were screened (681 total). HCWA was again positive at all 3 sites and two additional HCWs were found to be colonized with the outbreak strain on throat swab only. Isolates from patients 1, 2, 4, 5, 6, 7 and the 4 HCWs were identified as subtype emm 28 and all closely related by WGS (figure 1). A household contact of HCWA was colonized with the outbreak strain as well.

Figure 1

Conclusion

A carrier-disseminator investigation identified clusters of nosocomial postpartum GAS infections involving 6 patients, 4 HCWs and a HCW household contact that were highly related based on WGS. The outbreak strain of GAS was likely spread amongst HCWs via ping pong transmission on the unit. Transmission to patients was halted with implementation of strict infection prevention measures and mass screening and chemoprophylaxis of all colonized HCWs.

Disclosures

All Authors: No reported disclosures
880. Artificial Neural Networks to Predict Surgical Site Infection in Aorta Artery Aneurysm Correction
Authors: de Souza Flávio Henrique Batista , Couto Braulio Roberto Gonçalves Marinho , da Conceição Felipe Leandro Andrade , da Silva Gabriel Henrique Silvestre , Dias Igor Gonçalves , Rigueira Rafael Vieira Magno , Pimenta Gustavo Maciel , Martins Maurilio B , Mendes Júlio César O , Januário Guilherme Brangioni , Oliveira Rayane Thamires , de Vasconcelos Laura Ferraz , de Araújo Laís L , Rodrigues Ana Clara Resende , Silva Camila Morais Oliveira E , De Souza Eduarda Viana , Melo Júlia Faria , Assunção De Sá Maria Cláudia , Silva Walquíria Magalhães , Araujo Allana Luiza Padilha , Magalhães Bianca Braga , Caetano Caio Vieira , Guerra Carine Marina Dias , Braga Giovanna Lima
Published: January 2021

Background

A survey was conducted in three hospitals, between July 2016 and June 2018, about surgical site infection (SSI) in patients undergoing surgeries to correct aortic artery aneurysms in the city of Belo Horizonte, with more than 3,000,000 of inhabitants. The general objective is to statistically evaluate such incidences and enable an analysis of the predictive power of SSI, through MLP (Multilayer Perceptron) pattern recognition algorithms.

Methods

Through the Hospital Infection Control Committees (CCIH) of the hospitals involved in the research, data collection on SSI was carried out. Such data is used in the analysis during your routine SSI surveillance procedures. Thus, three procedures were performed: a treatment of the database collected for use of intact samples; a statistical analysis on the profile of the collected hospitals and; an assessment of the predictive power of five types of MLPs (Backpropagation Standard, Momentum, Resilient Propagation, Weight Decay and Quick Propagation) for SSI prediction. The MLPs were tested with 3, 5, 7 and 10 neurons in the hidden layer and with a division of the database for the resampling process (65% or 75% for testing, 35% or 25% for validation). They were compared by measuring the AUC (Area Under the Curve - ranging from 0 to 1) for each of the configurations.

Results

From 600 records, 575 were complete for analysis. It was found that: the average age is 68 years (from 24 to 98 years); the average hospital stay is 9 days (with a maximum of 127 days), the death rate reached 6.43% and the SSI rate 2.78%. A maximum prediction power of 0.75 was found.

Conclusion

There was a loss of 4% of the database samples due to the presence of noise. It was possible to evaluate the profile of the three hospitals. The predictive process presented configurations with results that reached 0.75, which promises the use of the structure for the monitoring of automated SSI for patients undergoing surgery to correct aortic artery aneurysms. To optimize data collection, enable other hospitals to use the prediction tool and minimize noise from the database, two mobile application were developed: one for monitoring the patient in the hospital and another for monitoring after hospital discharge. The SSI prediction analysis tool is available at www.nois.org.br.

Disclosures

All Authors: No reported disclosures