bluuebunny/crossref_metadata_2025 huggingface dataset:
Does Blood on “Dirty” Instruments Interfere With the Effectiveness of Sterilization Technologies?
Authors: Rutala William , Gergen Maria , Weber David Jay
Published: November 2020

Background: Surgical instruments that enter sterile tissue should be sterile because microbial contamination could result in disease transmission. Despite careful surgical instrument reprocessing, surgeons and other healthcare personnel (HCP) describe cases in which surgical instruments have been contaminated with organic material (eg, blood). Although most of these cases are observed before the instrument reaches the patient, in some cases the contaminated instrument contaminates the sterile field, or rarely, the patient. In this study, we evaluated the robustness of sterilization technologies when spores and bacteria mixed with blood were placed on dirty (uncleaned) instruments. Methods: Dirty surgical instruments were inoculated with 1.5105 to 4.1107 spores or vegetative bacteria (MRSA, VRE or Mycobacterium terrae) in the presence or absence of blood. The spores used were most resistant to the sterilization process tested (eg, Geobacillus stearothermophilus for steam and HPGP and Bacillus atrophaeus for ETO). Once the inoculum dried, the instruments were placed in a peel pouch and sterilized by steam sterilization, ethylene oxide (ETO), or hydrogen peroxide gas plasma (HPGP). These experiments are not representative of practice or manufacturer’s recommendations because cleaning must always precede sterilization. Results: Steam sterilization killed all the G. stearothermophilus spores and M. terrae when inoculated onto dirty instruments in the presence or absence of blood (Table 1). ETO failed to inactivate all test spores (B. atrophaeus) when inoculated onto dirty instruments (60% failure) and dirty instruments with blood (90% failure). ETO did kill the vegetative bacteria (MRSA, VRE) under the same 2 test conditions (ie, dirty instruments with and without blood). The failure rates for HPGP for G. stearothermophilus spores and MRSA were 60% and 40%, respectively, when mixed with blood on a dirty instrument. Conclusions:This investigation demonstrated that steam sterilization is the most robust sterilization process and is effective even when instruments were not cleaned and the test organisms (G. stearothermophilus spores and MRSA) were mixed with blood. The low-temperature sterilization technologies tested (ie, ETO, HPGP) failed to inactivate the test spores but ETO did kill the test bacteria (ie, MRSA, VRE). These findings should assist HCP to assess the risk of infection to patients when potentially contaminated surgical instruments enter the sterile field or are unintentionally used on patients during surgery. Our data also demonstrate the importance of thorough cleaning prior to sterilization.

Funding: None

Disclosures: Dr. Rutala was a consultant to ASP (Advanced Sterilization Products)
Effectiveness of an Alcohol-Based Nasal Antiseptic in Reducing MRSA Bacteremia in an Adult Intensive Care Population
Authors: Reeves Lauren , Barton Lisa , Nash Michelle , Williams Jennifer , Guimera Don , Simmons Bryan , Hysmith Nicholas , Morton Jackie
Published: November 2020

Background: Hospitalized patients are at an increased risk of invasive infection with Staphylococcus aureus when colonized with the bacteria on admission. Rates of methicillin-resistant Staphylococcus aureus (MRSA) bacteremia are directly correlated with overall patient acuity, placing patients in intensive care areas at greatest risk. Universal decolonization with nasal antibiotic ointments has been shown to reduce the incidence of invasive MRSA in critically ill patients; however, debate remains regarding the long-term efficacy of this strategy and the possibility of developing antimicrobial resistance. An alcohol-based nasal antimicrobial may be an effective alternative. This study evaluated the effectiveness of a twice daily alcohol-based product in reducing the rate of MRSA bacteremia in an academic tertiary-care adult intensive care setting. Methods: Our study was an observational design with retrospective and prospective cohorts each consisting of 61 critical care beds. The baseline incidence of MRSA bacteremia was determined from a 7-month period preceding the implementation of the nasal antimicrobial. At implementation, each admission received an electronic order for an alcohol-based nasal antiseptic that was applied twice daily during the intensive care stay. The primary outcome was the incidence of MRSA bacteremia in each group. MRSA bacteremia was defined by the CDC NHSN criteria after review by an infection prevention nurse. The 2 test was used to compare the rates between the 2 groups, and P < .005 was considered significant. Results: The study periods contained similar patient days, with 12,475 in the retrospective group and 12,733 in the prospective group. The rate of MRSA bacteremia in the retrospective cohort was 0.2404 compared to 0 in the prospective cohort. This rate change was statistically significant, with P < .0001. Conclusions: The alcohol-based nasal antiseptic was effective in reducing healthcare-onset MRSA bacteremia in this intensive care population. This approach may be a safe and effective alternative to nasal antibiotic ointment that avoids antibiotic resistance risks.

Funding: None

Disclosures: None
Effectiveness of Antimicrobial Filter Placement in ICU Taps to Prevent the Occurrence of HAIs by Pseudomonas aeruginosa (12-Months)
Authors: Chico-Sánchez Pablo , Canovas-Javega Sandra , Jimenez-Sepulveda Natali J. , Leutscher-Vasen Edith , Villanueva-Ruiz Cesar O. , Benito-Miralles Carmen M. , Hernandez-Maldonado Maria , Lameiras-Azevedo Ana S. , Sanchez-Paya Jose
Published: November 2020

Background:Pseudomonas aeruginosa, is the third etiologic agent of healthcare associated infections, and the most frequent pathogen in ventilator-associated pneumonia (VAP). In critical care units is associated with high mortality, long hospital stay, and high healthcare-associated costs. We evaluated the effectiveness of filter placement in the water taps in critical care units to prevent the occurrence of healthcare-associated infections (HAIa) by Pseudomonas aeruginosa. Methods: This experimental study was both cross-over and open-label in nature. We included patients admitted for >24 hours in critical care units over 24 months. The study was divided into 4 periods of 6 months each. We divided the study into 2 groups: patients in units with filters and patients in units without filters. We compared the incidence density of P. aeruginosa HAIs (number of cases divided by the number of person days) according the ECDC definition of case criteria between the groups. The 2 test was used, and the magnitude of the association was calculated as a rate ratio with a 95% confidence interval, adjusted using a Poisson regression model. Results: Overall, 1,132 patients were included in the study: 595 in units with water tap filters and 537 in units without water tap filters. HAI incidence among patients in units with water tap filters was 5.3 per 1,000 person days stay; without water tap filters, HAI incidence was 4.7 per 1,000 person days stay (HR, 0.94; 95% CI, 0.47–1.90). Conclusions: The preliminary results of this study indicate a a lower incidence of P. aeruginosa HAIs in units with filters placed in water taps than in units without filters.

Disclosures: None

Funding: None
Evaluation of a Disease State Stewardship Intervention for Urinary Tract Infections at an Academic Medical Center
Authors: Xhemali Xhilda , Forster Derek , Clemons Bryant , Cotner Sarah , VanHoose Jeremy , Burgess Donna , Burgess David , Myint Thein , Maskey Mitu Karki , Wallace Katie
Published: November 2020

Background: Urinary tract infections (UTIs) are often misdiagnosed and mismanaged. Disease state stewardship initiatives targeting UTIs through the development of institutional guidelines and real-time prospective audit and feedback (PAAF) on provider management may have a significant impact on the overuse of antimicrobials. Objective: Our study evaluated the effectiveness of a UTI focused disease state stewardship intervention by assessing institutional guideline adherence before and after implementation. Methods: This retrospective quasi-experimental study was conducted at a tertiary-care academic medical center. Patients >18 years of age receiving antimicrobials for a UTI were included. A previously performed retrospective review of UTI management from September-November 2017 was used as the baseline. The UTI management guideline was implemented in July 2018, and service lines were educated. A PAAF initiative began in June 2019, whereby the antimicrobial stewardship team performed daily reviews of patients receiving antimicrobials for UTIs. Data was collected on their management, and providers were contacted in real time with recommendations based on the institutional guideline. Patients reviewed June–October 2019 were included in the postimplementation analysis. Patients were excluded if they were pregnant, underwent a urological procedure with risk of mucosal bleeding, or were an outside hospital transfer already on UTI therapy. The primary outcome of this study was to evaluate guideline adherence before and after the implementation of PAAF for the management of UTIs. Results: In total, 198 patients in the preintervention group and 246 in the PAAF group were included. The emergency department was the primary ordering service of urinalyses (60.1% vs 66.1%; P = .2287) in both periods and altered mental status as the main indication for testing (35.2% vs 31.3%; P = .5465). Treatment of asymptomatic bacteriuria and pyuria decreased significantly between the 2 periods: 74.8% versus 36.2% (P = .0001). Appropriate ordering of urinalyses (33.8% vs 68.3%; P = .0001) and urine cultures (29.3% vs 61.0%; P = .0001) also improved in the PAAF group. Recommendations made during PAAF included therapy discontinuation (66.7%), antimicrobial therapy change (15.5%), or duration modification (15.5%), and 59.5% of first interventions were accepted. Overall guideline compliance significantly improved from 13.1% in the preintervention period to 26.1% in the PAAF period (P = .0011). Conclusions: A UTI disease state intervention was associated with significant reductions in the treatment of asymptomatic presentations as well as an improvement in overall guideline adherence. We believe that this approach represents a powerful stewardship strategy for decreasing unnecessary antimicrobial usage.

Funding: None

Disclosures: None
Evaluation of Initial Outcomes of an Antimicrobial Stewardship Program in a Nonprofit Hospital in Brazil
Authors: Junior Adelino Freire , Fagundes Fernando , Neto Mozar Castro , Barbosa Carine , Alves Thais
Published: November 2020

Background: One of the main global public health challenges is the fight against microbial resistance, according to the World Health Organization. Inadequate use of antimicrobials is considered one of the main factors related to the phenomenon and is quite common in the hospital environment. Managing the use of antimicrobials in hospitals has become a necessity and has shown positive results in many ways, such as maximizing the effects of pharmacotherapy, preventing the emergence of resistant microorganisms, and reducing healthcare costs. Methods: The prescriptions for patients admitted to a 380-bed nonprofit private hospital in Belo Horizonte, Brazil were monitored from January 1, 2019, to August 31, 2019, with a monthly average of 251 patients followed by the antimicrobial stewardship (AMS) team (1 infectious diseases doctor and 2 clinical pharmacists). Patients selected for follow-up and intervention were those submitted to intravenous, intramuscular, and/or oral antibiotic therapy with the following antimicrobial agents: piperacillin/tazobactam, carbapenem, polymyxin B, tigecycline, vancomycin, teicoplanin, daptomycin, third- and fourth-generation cephalosporins, quinolone, and aminoglycosides. Patients on prophylactic or antimicrobial treatment not mentioned above were excluded from surveillance. Interventions were dose adjustments, drug adjustment by culture results, intravenous to oral treatment switch, and discontinuation of therapy. Results: There were 318 interventions, and 64.82% of the interventions performed by the AMS team were accepted by prescribers. The interventions provided a total savings of BR$ 119,706 (~US$30,000) in direct antimicrobial spending. Correlating the interventions with the defined daily dose (DDD) measurement and comparing data from the same period in 2018, we detected a reductions in the consumption of several antimicrobials: ceftriaxone (25.6%), ciprofloxacin (45.7%), meropenem (34%), piperacillin/tazobactam (12.7%), teicoplanin (18.8%), vancomycin (20.6%), cefepime (23.9%) and polymyxin B (26%). We also detected reductions in days of therapy (DOT) for most of these drugs, such as polymyxin B, with an average reduction of 2 DOT. Conclusions: Reducing antimicrobial use is one of the key strategies for avoiding unnecessary exposure and selective pressure leading to the emergence of resistant microorganisms. The measured data point to a favorable trend in the rational use of antimicrobials in our institution with simple interventions. The results presented were used to reaffirm the importance of the AMS team in our institution. More data on length of stay, indirect costs, reduction of side effects, mortality, and occurrence of microbial resistance should be made.

Funding: None

Disclosures: None
Evaluation of Novel “No-Touch” Technologies for Decontamination of Toys in Pediatric Healthcare Settings
Authors: Haydar Hanan , Kumar Jessica , Cadnum Jennifer , Hoyen Claudia , Donskey Curtis
Published: November 2020

Background: Toys in playrooms are often shared among patients in pediatric healthcare settings; they can present a risk for transmission of bacterial and viral pathogens. Effective cleaning and disinfection of toys using disinfectant wipes is labor intensive and difficult due to irregular surfaces. Methods: We conducted a point-prevalence culture survey to determine the frequency of contamination of in-use toys and high-touch surfaces in playrooms in a pediatric healthcare facility with methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE), and Clostridioides difficile. Using a variety of toys inoculated with pathogens, we evaluated efficacy and ease-of-use of 3 novel “no-touch” technologies: (1) an electrostatic sprayer, (2) a small ultraviolet-C (UV-C) box (18.9 × 9.9 × 1.8 inches) for smaller toys, and (3) a high-level disinfection cabinet using ultrasonic submicron droplets of peracetic acid and hydrogen peroxide. Test pathogens included C. difficile, MRSA, and Candida auris. Results: Of 135 items cultured in playrooms, 6 (4.4%) were contaminated with MRSA, 1 (0.7%) was contaminated with VRE, and none were contaminated with C. difficile. Each of the technologies reduced all pathogens by >4 log10 CFU on all types of toys tested (plastic, soft rubber, and tablet). The electrostatic sprayer was considered the easiest to use by all users because large numbers of toys could be processed much more quickly (ie, spray for 20 seconds and allow to air dry) than with disinfectant wipes. The disinfection cabinet required 21 minutes for cycle completion, whereas the decontamination cycle for the UV box was only 30–90 seconds but with limited capacity to hold toys. Conclusions: Three “no-touch” technologies were effective for disinfection of toys contaminated with healthcare-associated pathogens. The electrostatic spray application of disinfectant was considered the easiest to use for rapid decontamination of toys.

Funding: None

Disclosures: None
Evaluation of Patient Risk Factors for Carbapenemase-Producing Organism Colonization
Authors: Stover Carolyn , Chan Allison , Vallabhaneni Snigdha , Brown Allison , Keaton Amelia , Shugart Alicia , Dotson Nychie , Arenas Sebastian , Kainer Marion , Walters Maroya
Published: November 2020

Background: Carbapenemase-producing organisms (CPOs) are a growing antibiotic resistance threat. Colonization screening can be used to identify asymptomatically colonized individuals for implementation of transmission-based precautions. Identifying high-risk patients and settings to prioritize screening recommendations can preserve facility resources. To inform screening recommendations, we analyzed CPO admission screens and screening conducted on point-prevalence surveys (PPSs) performed through the Antibiotic Resistance Laboratory Network’s Southeast Regional Laboratory (SE AR Lab Network). Methods: During 2017–2019, the SE AR Lab Network collected data via a REDCap survey for a subset of CPO screens on a limited set of easily determined patient risk factors. Rectal swabs were collected and tested with the Cepheid Carba-R. Specimens collected within 2 days of admission were classified as admission screening and the remainder were classified as PPS. Index cases were excluded from analyses. Odd ratios (ORs) and 95% confidence intervals were calculated, and a value of 0.1 was used for cells with a value of zero. Results: In total, 520 screens were conducted, which included 366 admission screens at 2 facilities and 154 screens from 27 PPSs at 8 facilities. CPOs were detected in 14 (2.7%) screens, including in 10 (2.7%) admission screens and in 4 (2.6%) contacts during PPSs; carbapenemases detected were Klebsiella pneumoniae carbapenemase (KPC) (n = 12), New Delhi Metallo-β-lactamase (NDM) (n = 1) and Verona Integron-Encoded Metallo-β-lactamase (VIM) (n = 1). One long-term acute care hospital (LTACH) performed universal admission screening, which accounted for 96% of admission screens and all 10 CPOs detected by admission screening. Mechanical ventilation (OR, 5.0; 95% CI, 1.4–18.0) and the presence of a tracheostomy (OR, 5.4; 95% CI, 1.5–19.4) were associated with a positive admission screen. Moreover, 8 facilities conducted PPSs: 4 acute care hospitals, 2 long-term acute care hospitals, and 2 nursing homes. CPO prevalence in long-term acute care hospitals was 4.8% (2 of 42), 2.4% (1 of 41) in acute care hospitals, and 1.5% (1 of 69) in nursing homes. Requiring assistance with bathing (OR, 4.8; 95% CI, 1.6–8.0) and stool incontinence (OR, 16.6; 95% CI, 13.4–19.8) were associated with a positive screen on PPSs. All 7 roommates of known cases tested negative for CPO colonization. Conclusions: Findings suggest that patients with certain easily assessed characteristics, such as mechanical ventilation, tracheostomy, or stool incontinence or who require bathing assistance, may be associated with CPO positivity during screening. Further data collection and analysis of such risk factors may provide insight for the development of more targeted admission and contact screening strategies.

Funding: None

Disclosures: None
Evolution and Associated Factors of Hand Hygiene Compliance in the Surgical Areas of a Tertiary-Care Hospital
Authors: Algado-Sellés Natividad , Gras-Valentí Paula , Mora-Muriel Juan Gabriel , Chico-Sánchez Pablo , Fuster-Pérez Marina , Canovas-Javega Sandra , Villanueva-Ruiz Cesar O. , Leutscher-Vasen Edith , Lameiras-Azevedo Ana S. , Hernandez-Maldonado Maria , Jimenez-Sepulveda Natali J. , Sanchez-Paya Jose
Published: November 2020

Background: Hand hygiene (HH) is the most important measure for preventing healthcare-associated infections. The objective is to gain insight into the evolution of the degree of compliance with recommendations (DCR) on HH and its associated factors in the surgical areas of a tertiary-care hospital. Methods: This observational, cross-sectional study, was repeated over time, with direct observation of the DCR on HH during the daily activity of healthcare workers in surgical areas: general surgery, urology, vascular surgery, traumatology, neurosurgery, thoracic surgery, heart surgery, pediatric surgery, otorhinolaryngology, gynecology and obstetrics, ophthalmology. Over 14 years (from 2005 to 2018), 15,946 HH opportunities were registered, together with different additional variables (age, sex, professional position, surgical area ). The 2 test was used to study the association and the crude, and adjusted odds ratios were used to quantify its magnitude. Results: The DCR on HH in surgical areas was 49.7% (95% CI, 48.9%–50.5%), and in the group of nonsurgical areas it was 53.4% (95% CI, 53.1%–54.1%). The area with the highest degree of compliance was urology (56.7%; 95% CI, 53.9%–59.6%), and the area with the lowest degree of compliance was traumatology (43.3%; 95% CI, 40.4%–46.2%). Some associated factors were the indications after an activity has been performed (58.6%; aOR, 2.7; 95% CI, 2.5–2.9) and the availability of pocket-size alcohol-based disinfectant (63.8%; aOR, 2.4; 95% CI, 2.2–2.5). Conclusions: The DCR on HH in surgical areas is lower than in other hospital areas, and there is still some margin for improvement. We have identified some modifiable factors that have an independent association with HH compliance in surgical areas. Focusing on them will increase compliance with HH with the ultimate goal of reducing healthcare-associated infections.

Funding: None

Disclosures: None
Factors Associated With Inappropriate Antibiotic Use in Hospitalized Patients
Authors: Cabral Stephanie , Adediran Timileyin , Harris Anthony , Tamma Pranita , Cosgrove Sara , Morgan Daniel , Dzintars Kathryn , Srinivasan Arjun , Avdic Edina , Pineles Lisa , Thom Kerri
Published: November 2020

Background: Inappropriate antibiotic prescription leads to increased Clostridiodes difficile infections, adverse effects including organ toxicity, and generation of antibiotic-resistant bacteria. Despite efforts to improve antibiotic use in acute-care settings, unnecessary and inappropriate prescription still occur in 30%–50% of patients. Objectives: We assessed factors associated with inappropriate antibiotic prescription at 2 time points: (1) initial, empiric therapy and (2) 3–5 days after therapy initiation. Methods: As part of a multicenter study investigating strategies to reduce antibiotic therapy after 3–5 days of use, antibiotic prescription data were collected from 11 adult and pediatric intensive care and general medical units at 6 hospitals in Maryland in 2014 and 2015. We performed a retrospective cohort study of all hospitalized patients who received any of 23 common antibiotics for at least 3 days. Each medical record was reviewed for demographics, admission and discharge dates, patient comorbidities, and antibiotic regimen by at least 1 infectious disease physician or pharmacist. Classification of antibiotic inappropriateness was based on each institution’s guidelines and standards. Bivariate analyses were performed using logistic regression for both initial therapy and therapy at days 3–5. Multivariable logistic regression was performed using covariates meeting the significance level of P < .05. Results: In total, 3,436 antibiotic courses were assessed at time of initial therapy, and 1541 regimens were continued and reviewed again at days 3–5 of therapy. For the initial therapy, 1,255 regimens (37%) were inappropriate; 45% of these were considered unnecessary and 41% were too broad in spectrum. In the multivariable regression, older age and antibiotic prescription during the summer were associated with the receipt of inappropriate antibiotics (Table 1). Having end-stage renal disease as a comorbid condition was protective against inappropriate use. At days 3–5 of therapy, 688 (45%) of the antibiotic courses were inappropriate. Reasons regimens were considered inappropriate included unnecessary antibiotic prescriptions (49%) and antibiotics being too broad (38%). Older age and receiving cefepime or piperacillin-tazobactam on day 3 of therapy were factors associated with inappropriate use (Table 2). Having undergone a transplant or a surgical procedure was protective of inappropriate antimicrobial use at days 3–5 of therapy. Conclusions: Older patients are more likely to receive inappropriate antibiotics at both initial regimen and 3–5 days later. Patients receiving cefepime or piperacillin-tazobactam are at greater risk of receiving inappropriate antibiotics at days 3–5 due to failure to de-escalate. Antibiotic stewardship strategies targeting these patient populations may limit inappropriate use.

Funding: None

Disclosures: None
Impact of Diagnosed and Undiagnosed Respiratory Pseudomonas on VAP and VAE During Long-Term Acute Care
Authors: Harrigan James , Lautenbach Ebbing , Reesey Emily , Wernovsky Magda , Tolomeo Pam , Morawski Zygmunt , Jacob Jerry , Grippi Michael , Kelly Brendan
Published: November 2020

Background: Clinically diagnosed ventilator-associated pneumonia (VAP) is common in the long-term acute-care hospital (LTACH) setting and may contribute to adverse ventilator-associated events (VAEs). Pseudomonas aeruginosa is a common causative organism of VAP. We evaluated the impact of respiratory P. aeruginosa colonization and bacterial community dominance, both diagnosed and undiagnosed, on subsequent P. aeruginosa VAP and VAE events during long-term acute care. Methods: We enrolled 83 patients on LTACH admission for ventilator weaning, performed longitudinal sampling of endotracheal aspirates followed by 16S rRNA gene sequencing (Illumina HiSeq), and bacterial community profiling (QIIME2). Statistical analysis was performed with R and Stan; mixed-effects models were fit to relate the abundance of respiratory Psa on admission to clinically diagnosed VAP and VAE events. Results: Of the 83 patients included, 12 were diagnosed with P. aeruginosa pneumonia during the 14 days prior to LTACH admission (known P. aeruginosa), and 22 additional patients received anti–P. aeruginosa antibiotics within 48 hours of admission (suspected P. aeruginosa); 49 patients had no known or suspected P. aeruginosa (unknown P. aeruginosa). Among the known P. aeruginosa group, all 12 patients had P. aeruginosa detectable by 16S sequencing, with elevated admission P. aeruginosa proportional abundance (median, 0.97; IQR, 0.33–1). Among the suspected P. aeruginosa group, all 22 patients had P. aeruginosa detectable by 16S sequencing, with a wide range of admission P. aeruginosa proportional abundance (median, 0.0088; IQR, 0.00012–0.31). Of the 49 patients in the unknown group, 47 also had detectable respiratory Psa, and many had high P. aeruginosa proportional abundance at admission (median, 0.014; IQR, 0.00025–0.52). Incident P. aeruginosa VAP was observed within 30 days in 4 of the known P. aeruginosa patients (33.3%), 5 of the suspected P. aeruginosa patients (22.7%), and 8 of the unknown P. aeruginosa patients (16.3%). VAE was observed within 30 days in 1 of the known P. aeruginosa patients (8.3%), 2 of the suspected P. aeruginosa patients (9.1%), and 1 of the unknown P. aeruginosa patients (2%). Admission P. aeruginosa abundance was positively associated with VAP and VAE risk in all groups, but the association only achieved statistical significance in the unknown group (type S error <0.002 for 30-day VAP and <0.011 for 30-day VAE). Conclusions: We identified a high prevalence of unrecognized respiratory P. aeruginosa colonization among patients admitted to LTACH for weaning from mechanical ventilation. The admission P. aeruginosa proportional abundance was strongly associated with increased risk of incident P. aeruginosa VAP among these patients.

Funding: None

Disclosures: None
Impact of Each Component of a Ventilator Bundle on Preventing Ventilator-Associated Pneumonia and Lower Respiratory Infection
Authors: Pinho Rafaela , Tanure Luciana , Pessoa Jussara , Santos Leonardo , Couto Braulio , Starling Carlos
Published: November 2020

Background: Ventilator-associated lower respiratory infections (LRIs) and pneumonia (VAP) are important healthcare-associated infections and are among the leading causes of death worldwide. Prevention of these infections are often based on care bundles. We investigated the incidence of VAP+LRI and the preventive efficacy of each component of our ventilator bundle. Methods: Our ventilator bundle includes 6 components that are daily checked by an infection control practitioner. These 6 evidence-based practices were implemented in 3 ICUs from a general tertiary-care private hospital in Belo Horizonte City (Brazil): (1) daily oral care with chlorhexidine; (2) elevate the head of the bed to between 30 and 45; (3) avoid scheduled ventilator circuit change; (4) monitor cuff pressure; (5) use subglottic secretion drainage; and (6) daily sedation interruption and daily assessment of readiness to extubate. VAP and ventilator-LRI definitions were obtained from the CDC NHSN. The impact of adherence rate to items in the ventilator bundle (%) on the incidence rate of VAP+LRI was assessed using linear regression and scatterplot analyses. Results: Between January 2018 and April 2019, 1,888 ventilator days were observed in the 3 ICUs, with 42 VAP and LRI events, an overall incidence rate of 22.2 cases per 1,000 ventilator days. After September 2018, the infection control service started a campaign to increase the ventilator bundle compliance (Fig. 1). Adherence rates to all 6 bundle components increased between January–August 2018 and September 2018–April 2019 from 25% to 55% for daily oral care, from 34% to 79% for elevating the head of the bed, 28% to 86% for avoiding scheduled ventilator circuit change, from 32% to 83% for cuff pressure monitoring, from 32% to 83% for subglottic secretion drainage, and from 33% to 85% for daily sedation interruption. PAV and LRI incidence decreased from 41 to 16 in ICU A, from 22 to 14 in ICU B and from 24 to 18 in ICU C. The impact of each bundle component was identified by linear regression, calculating the percentage of PAV+LRI incidence rate that is explained by bundle item adherence (r2) and correlation coefficient (r): daily sedation interruption (r2 = 48%; r = 0.69; P = .004) (Fig. 2), cuff pressure monitorization (r2 = 0.3721; r = 0.61; P = .016), subglottic secretion drainage (r2 = 36%; r = 0.60; P = .017), avoidance of scheduled ventilator circuit change (r2 = 34%; r = 0.58; P = .023), daily oral care (r2 = 25%; r = 0.50; P = .050), and elevate the head of the bed (r2 = 25%; r = 0.48; P = .067). Conclusions: The impact of each bundle component on preventing PAV+LRI was identified by the study. An educational intervention performed by the infection control service increased the adherence to the ventilator bundle, and the PAV and LRI incidence decreased.

Funding: None

Disclosures: None
Impact of Positive Vancomycin-Resistant Enterococcus (VRE) Screen Result on Appropriateness of Definitive Antibiotic Therapy
Authors: Reynolds Jenna , Chan Lynn , Trudeau Raelene , Seville Maria Teresa
Published: November 2020

Background: Vancomycin-resistant Enterococcus (VRE) screening has been utilized to identify colonized patients to prevent transmission. However, little is known about the utility of screening to guide antibiotic therapy. We assessed the appropriateness of definitive therapy in patients with a VRE screen and evaluate the predictive value of screening for the development of a VRE infection. Methods: In this retrospective study, we evaluated VRE screening of patients aged 18 years admitted between June 1, 2015, and May 31, 2018, to a 280-bed, academic, tertiary-care hospital. Rectal swabs were tested using Cepheid Xpert. Screening was performed routinely on admission for hematologic malignancy and liver transplantation patients. Only the first screen result was included for patients who had multiple VRE screens. The patient was classified as having a VRE infection if any Enterococcus isolates were vancomycin resistant. The primary outcome was appropriateness of antibiotic therapy in patients who had a VRE screen. Appropriateness of VRE-directed therapy was defined as therapy with linezolid or daptomycin for patients who had a positive VRE culture and an identifiable source of infection, or who had no clinical improvement on alternative therapy, or who had a documented β-lactam allergy. If appropriateness was unclear, 2 infectious diseases specialists determined appropriateness. Results: In total, 1,374 patients who had a rectal VRE screen met inclusion criteria. Of these, 1,053 (88%) had a negative screen. We detected no difference in the appropriateness of VRE-directed therapy between patients with a positive screen and those with a negative screen (59.3% vs 61.0%; P = .8657). The VRE screen had a sensitivity of 60% (95% CI, 43%–74%), specificity of 90% (95% CI, 88%–92%), positive predictive value of 18% (95% CI, 12%–25%), and negative predictive value of 98% (95% CI, 97%–99%) for VRE infection. Conclusions: Although VRE screening may have utility to detect colonization in high-risk patients, a positive VRE screen is of limited value in determining the need for VRE-directed therapy. Patients with a negative VRE screen have a low likelihood of developing a VRE infection, and a negative screen could be used to identify patients who may not require empiric coverage for VRE. Further research is needed to determine optimal utilization of VRE screening for prediction and treatment of VRE infections.

Funding: None

Disclosures: None
Implementation of a Nursing Algorithm for Penicillin Allergy Documentation in the Inpatient Setting
Authors: Fabre Valeria , Salinas Alejandra B. , Rosales Lauren , Srinivasan Arjun , Hicks Lauri , Neuhauser Melinda , Cosgrove Sara
Published: November 2020

Background: Patients with a penicillin/aminopenicillin (PCN) allergy label are more likely to receive non–β-lactam antibiotics and to experience worse clinical outcomes. Given that nurses are often first to interact with patients, we pilot tested a nurse-driven quality improvement initiative to improve PCN allergy documentation and increase β-lactam use. Methods: We conducted a before-and-after study on a labor and delivery unit at The Johns Hopkins Hospital (JHH) from May 2018 to September 2019. Patients aged 18 years with a PCN allergy were included. The intervention included (1) the use of an algorithm developed by the antimicrobial stewardship team to assist nurses in obtaining accurate PCN allergy histories (Fig. 1), (2) identification of a nurse champion to facilitate implementation of the algorithm, and (3) in-person education by a stewardship physician regarding the importance and impact of adequate PCN allergy documentation on clinical outcomes. Readmissions were counted as separate encounters. The primary outcome was improved allergy documentation (either fewer blank documentations, nonspecified rash reactions, drug intolerance documentations (eg, isolated nausea), documentation of signs and symptoms of anaphylaxis not specified as such). The secondary outcome was β-lactam use. Categorical variables were compared using the 2 test and continuous variables were compared with the Student t test. Severe allergic reactions were defined as anaphylaxis, severe skin reactions (eg, Stevens-Johnson syndrome), and organ involvement (eg, hepatitis). Results: Overall, 382 patient admissions were included, 305 in the preintervention (May 2018 to May 2019) and 77 in the postintervention period (June 2019 to September 2019). Mean age and length-of-stay were 30 years and 4 days, respectively, for both periods. The proportion of admitted patients with a PCN allergy label was 8% and 7% for pre- and postintervention periods. Documentation findings in the pre- and postintervention periods respectively were as follows: blank documentation 11% and 12% (P = .89), documentation of specified rashes 0.6% and 1.3% (P = .56), documentation of drug intolerance 11% and 8% (P = .39), documentation of reactions that were indicative of anaphylaxis but not documented specifically as anaphylaxis 8% and 13% (P = .20). Among patients with a documented PCN allergy who received antibiotics, 83 of 177 (47%) and 27 of 43 (63%) received β-lactams (P = .01) in the pre- and postintervention periods, with cefazolin being the antibiotic most commonly used in both periods. Conclusions: Nursing education and an algorithm did not result in significant improvements in PCN allergy documentation in the 3 months after implementation. More data collection is planned to assess the impact of the intervention.

Funding: None

Disclosures: None
Implementation of Antibiotic Time Outs Using Quality Improvement Methodology
Authors: Willis Zachary , Sten May-Britt , Daniels Lindsay , Juliano Jonathan , Swartwood Michael , Davis Ronald , Krzastek Donna , Mock Clare , Mavrogiorgos Nikolaos , Sickbert-Bennett Emily , Weber David Jay
Published: November 2020

Background: Antibiotic time outs (ABTOs), formal reassessments of all new antimicrobial regimens by the care team, can optimize antimicrobial regimens, reducing antimicrobial overuse and potentially improving outcomes. Implementation of ABTOs is a substantial challenge. We used quality improvement methods to implement robust, meaningful, team-driven ABTOs in general medicine ward services. Methods: We identified and engaged stakeholders to serve as champions for the quality improvement initiative. On October 1, 2018, 2 internal medicine teaching services (services A and B), began conducting ABTOs on all patients admitted to their services receiving systemic antimicrobials for at least 36 hours. Eligible patients were usually identified by the team pharmacist. ABTOs were completed within 72 hours of antibiotic initiation and were documented in the electronic medical record (EMR) by providers using a template. The process was modified as necessary in response to feedback from frontline clinicians using plan-do-study-act (PDSA) methods. We subsequently spread the project to 2 additional internal medicine services (services C and D); 2 family medicine teams (services E and F); and 1 general pediatric service (service G). The project is ongoing. We collected data for the following metrics: (1) proportion of ABTO-eligible patients with an ABTO; (2) proportion of ABTOs conducted within the recommended time frame; (3) documented plan changes as a result of ABTO (eg, change IV antibiotics to PO); (4) proportion of documented plan changes actually completed within 24 hours. Results: Within 12 weeks, services A and B were successfully completing time outs in >80% of their patients. This target was consistently reached by services C, D, E, F, and G almost immediately following launch on those services. As of June 29, 2019, >80% of eligible patients across all participating services have had a time out conducted for 16 consecutive weeks. ABTOs have resulted in a change in management in 35% of cases, including IV-to-PO change in 19% of cases and discontinuation in 5%. Overall, 77% of time outs occurred during the 36–72-hour window. Ultimately, 95% of documented plan changes were completed within 24 hours. Conclusions: ABTOs are effective but implementation is challenging. We achieved high compliance with ABTOs without using electronic reminders. Our results suggest that ABTOs were impactful in the non–critical-care general medicine setting. Next steps include (1) development of EMR-based tools to facilitate identifying eligible patients and ABTO documentation; (2) continued spread through our health care system; and (3) analysis of ABTO impact using ABTO-unexposed patients as a control group.

Funding: None

Disclosures: None
Improved Postoperative Outcomes By Utilizing A Comprehensive Perioperative Surgical Site Infection (SSI) Reduction Bundle
Authors: D’Souza Aarikha , Ivaska Joan
Published: November 2020

Background: Surgical site infections (SSIs) can be attributed to increased patient morbidity and mortality, prolonged hospital stays, and overall increased healthcare costs. The Surgical Care Improvement Project (SCIP) was implemented in 2002 but has made limited impact on SSI rates across our facilities, which has led to the creation of a bundled approach of current evidence-based strategies. Methods: In January 2019, a comprehensive SSI prevention bundle of strategies was implemented across a multihospital health system. The bundle was comprised of 8 interventions focusing on the preoperative, intraoperative, and postoperative continuum of care, and refining documentation in the electronic medical record. From January to September 2019 (preointervention period), data were collected from 7,163 adult inpatient and observation elective patients undergoing colon surgery (COLO), abdominal hysterectomy (HYST), hip arthroplasty (HPRO), knee arthroplasty (KPRO), and cardiac bypass graft (CBGB/CBGC). The preintervention period for SSI standardized infection ratios (SIRs) and retrospective review of process measures was set as January–December 2018 (postintervetnion period). Each process measure had outlined targets along with primary outcome measures of overall SSI SIRs and SIRs for each of the 5 reported procedure categories. SSIs were validated to meet CDC and NHSN surveillance case definitions. Secondary outcomes evaluated included length of stay (LOS), readmission rates, and mortality. Results: Overall SIR for all 5 monitored surgical categories decreased by 5% to 1.131 from January to September 2019, compared to SIR of 1.190 in 2018. Hip and knee arthroplasties demonstrated 40% and 38% reductions after the intervention, respectively. Completion of 7 or 8 interventions of the SSI bundle were correlated with lower readmission rates (P = .0488). When any portion of the bundle was used, this was correlated with shorter LOS (P < .0001). Adherence to standardized antimicrobial prophylaxis was associated with decreased mortality (P = .017), for all 5 surgical categories. Conclusions: With the implementation of a focused SSI reduction bundle, our institution has realized reductions in surgical readmissions, length of stay, and mortality. Additionally, SSI rates in certain procedure categories have shown marked improvement. The initial success of this bundle has garnered development of additional procedure focused supplemental strategies for the future year.

Funding: None

Disclosures: Aarikha D’Souza, Banner Health
In Vitro Activity of Cefiderocol Against Multidrug-Resistant Gram-Negative Clinical Isolates
Authors: Boyd Sandra , Anderson Karen
Published: November 2020

Background: New antimicrobials are being developed as a response to the global threat of multidrug-resistant and panresistant bacterial pathogens. Cefiderocol (FDC; Shionogi & Co) is a novel parenteral siderophore cephalosporin with activity against gram-negative rods. Here, we report on the in vitro activity of FDC against multidrug-resistant gram-negative isolates collected by the CDC, including isolates available through the CDC and FDA Antibiotic Resistance Isolate Bank (AR Isolate Bank). Methods: The challenge set of gram-negative isolates (n = 339), most of which were obtained from the AR isolate bank (n = 258), comprised 188 Enterobacteriaceae (ENT), 72 Pseudomonas aeruginosa (PSA), and 79 Acinetobacter baumannii (ACB). Minimum inhibitory concentrations (MICs) for FDC in iron-depleted cation-adjusted Mueller-Hinton broth were determined using frozen reference broth microdilution panels (IHMA, Schaumburg, IL) according to CLSI guidelines. Isolates displaying nonsusceptibility to FDC (MIC >4 µg/mL) underwent additional testing with β-lactamase inhibitors (FDC with 4 µg/mL avibactam, FDC with 100 µg/ml dipicolinic acid (DPA), and FDC with both 100 µg/mL dipicolinic acid (DPA) and 4 µg/mL avibactam). Results: Cefiderocol MICs ranged from ≤0.03 to >64 µg/mL, and 313 (92.3%) isolates displayed susceptibility to FDC (MIC ≤4 μg/mL). The proportions of susceptible ENT, PSA, and ACB were 93.1%, 94.4%, and 88.6%, respectively. Among isolates harboring Ambler class A, class B, or class D carbapenemases, the proportions of susceptible isolates were 96.5%, 79.5%, and 94.0%, respectively. Overall, 26 (7.7%) isolates were categorized as FDC nonsusceptible (MIC ≥ 8 µg/mL); 65% of these were NDM producers. We selected 23 isolates for testing with β-lactamase inhibitors. The combination FDC-avibactam reduced the MIC to susceptible for all isolates harboring an Ambler class A or D carbapenemase, except for 1 OXA-71–producing ACB and 1 KPC-producing Citrobacter farmeri. The combination FDC-DPA reduced the MIC to susceptible for 9 of 13 (69.2%) NDM-producing and 4 of 4 (100%) OXA-23–producing ACB. By combining FDC with both DPA and avibactam, the MIC was reduced to susceptible (91%) for all but 1 KPC-producing and 1 NDM-producing Enterobacteriaceae isolate. Conclusions: Cefiderocol (FDC) demonstrated potent activity against a diverse collection of multidrug-resistant, gram-negative isolates, including producers of Ambler class A, B, and D carbapenemases. Among the 26 FDC nonsusceptible isolates, 65% were NDM positive. Our data indicate that FDC combined with β-lactamase inhibitors may restore susceptibility in FDC nonsusceptible isolates. Additional studies are needed to understand the underlying mechanism(s) of FDC resistance and to further explore the use of β-lactamase inhibitors in combination with FDC.

Funding: None

Disclosures: None
Incidence and Risk Factors of Surgical Site Infection Following Pediatric Neurosurgery
Authors: Bergeron Corinne , Doyon-Plourde Pamela , Veronneau Chantal , Quach Caroline
Published: November 2020

Background: Neurosurgeries are at high risk of surgical site infections (SSI), a complication associated with increased morbidity, mortality, and cost. Our aim was to measure SSI incidence and risk factors following pediatric neurosurgery at CHU Sainte-Justine, the provincial center for pediatric craniofacial surgery in Québec, Canada. Methods: Retrospective cohort study of all patients with elective neurosurgery performed at CHUSJ between October 2014 and October 2018. Medical records were reviewed to compare demographics, clinical presentations, and outcomes of patients. SSIs occurring within 30 days of a procedure without implant and up to 90 days with implant, were identified. SSI incidence was measured in patient years, and risk factors were assessed using univariate logistic regressions. Results: In total, 379 patients were included with an overall SSI incidence of 3.96 patient years. We found a higher SSI incidence in 2014–2015 compared to 2016–2018 (1.82 vs 4.83 patient years). The median age was 3.90 years, and cases seemed younger than controls (1.45 vs 4.15 years). No difference between groups was found for sex, body mass index, prematurity, and length of hospitalization. The proportion of deep SSIs was greater than superficial SSIs (53.3% vs 46.7%). Cases were more likely to present with a more severe ASA score, previous history of neurosurgery, neurological conditions, and pulmonary conditions than controls: OR, 3.90 (95% CI, 1.36–11.49); OR, 2.59 (95% CI, 0.88–7.40); OR, 2.77 (95% CI, 0.98–8.41), and OR, 3.21 (95% CI, 0.86–9.94), respectively. Among patients with history of neurosurgery, a higher proportion of cases experienced a cerebrospinal fluid leak (28.6% vs 2.2%). Most patients (85.8%) received preoperative prophylactic antibiotic. Of those, 49.3% were considered appropriate based on antibiotic and timing of administration. When antibiotic dosage was also considered, the number of patients who received an appropriate antibiotic therapy decreased radically. Conclusions: Patients with comorbidities, especially neurological and pulmonary conditions, are at higher risk of SSI after neurosurgery. We are currently working on a detailed analysis to explain the increase in SSI incidence after 2016. Finally, prophylactic antibiotic therapy needs to be improved and its impact on SSI rates needs to be monitored.

Funding: None

Disclosures: None