bluuebunny/crossref_metadata_2025 huggingface dataset:
Implementing a Massive Personal Protective Equipment Education—A Multidisciplinary Team Approach
Authors: Al Mohajer Mayar , Fischer Megan , Rouse Melissa , Pipkins Takei , Byrne John
Published: November 2020

Background: Personal protective equipment (PPE) is defined by the Occupational Safety and Health Administration as specialized clothing or equipment worn by an employee for protection against infectious materials. They include gloves, gowns, masks, respirators, googles and face shields. The CDC has issued guidelines on appropriateness of when, what, and how to use PPE. Despite these guidelines, compliance with PPE remains challenging. Methods: We implemented a massive hospital-wide rapid education program on PPE donning and doffing of all employees and staff. This program included an online video, return demonstration and just-in-time training. To develop the program, we recorded PPE training video, reviewed PPE validation checklist, developed new isolation precaution signage with quick response (QR) code to video, developed a nutrition tray removal video and a equipment cleaning video, developed family and visitor guidelines for isolation precautions, and created an audit tool for PPE donning and doffing practices. The program required interdisciplinary collaboration including administration, infection prevention, nursing education, central supply, environmental services, facility maintenance, and security. Results: The first phase of the program was implemented through 30 separate 4-hour PPE skills fair offered over 48 hours. In total, 500 staff members were trained in the first 48 hours; 6 additional 3-hour sessions were provided on site in the following 3 month. Additionally, training was provided in off-site clinics, physician leadership meetings, new-hire orientation for nursing staff, and monthly resident and fellow training through graduate medical education. As needed, training was provided by infection prevention, nursing education, and floor nurses. In total, 5,237 staff members were trained within 3 months after implementation. Actual audit results (50 audits per week) showed improved and sustained compliance to >94%. Conclusions: A massive hospital-wide educational program including online video, return demonstration, and just-in-time training is a feasible and very effective method to improve compliance with PPE donning and doffing. A multidisciplinary team approach, administration support, and continuous education and audits are key factors in successful implementation.

Funding: None

Disclosures: None
Implications of Oxacillin-Resistant, mecA-Negative Staphylococcus aureus Detected in NICU MRSA Surveillance Cultures
Authors: Ikpeama Geoffrey , Squires Crystal , Wallace Meghan , Kieffer Patricia , Hayes Ericka , Ransom Eric , Burnham Carey-Ann , Reich Patrick
Published: November 2020

Background: Weekly surveillance to identify neonatal intensive care unit (NICU) infants with methicillin-resistant S. aureus (MRSA) nasal colonization was performed using Remel Spectra MRSA chromogenic media. An increased MRSA colonization rate from baseline was detected in 2019, prompting additional review of all positive MRSA NICU screening cultures from 2019. Methods: A subset of 23 positive cultures were interrogated in detail. Species-level identification was confirmed using matrix-assisted laser desorption/ionization-time of flight (MALDI-TOF) with a Bruker Biotyper. Penicillin-binding protein 2a (PBP2a) testing was performed using the Alere culture colony test, and cefoxitin and oxacillin susceptibility were assessed via Kirby-Bauer disk-diffusion methods (for the purpose of this analysis, oxacillin zone sizes 18 mm were considered susceptible). Molecular detection of mecA and mecC genes using PCR was performed. Results: All 23 isolates in the subset group were confirmed as S. aureus based on MALDI-TOF testing. Moreover, 8 isolates (35%) were confirmed as MRSA based on cefoxitin susceptibility, positive rapid PBP2a testing, and mecA PCR results. Overall, 15 isolates (65%) tested cefoxitin-susceptible and PBP2a negative with negative mecA and mecC gene testing. Of these, 1 (7%) tested oxacillin-susceptible based on disk-diffusion testing, consistent with methicillin-susceptible S. aureus (MSSA). The remaining 14 isolates (93%) tested oxacillin resistant based on oxacillin zone size. Conclusions: Our findings indicate the detection of mecA/mecC negative S. aureus isolates demonstrating oxacillin resistance and growth on Remel Spectra MRSA chromogenic media. These results have important implications for infection prevention surveillance efforts to detect MRSA and raise questions regarding optimal antibiotic therapy in patients with isolates displaying this phenotype.

Funding: None

Disclosures: None
Importance of the Respiratory Tract in Carbapenemase-Producing Enterobacteriaceae Spread
Authors: Martínez Olaia Pérez , Rodríguez Raquel García , Rodríguez Mª José Pereira , Camino Angela Varela
Published: November 2020

Background: Carbapenemase-producing Enterobacteriaceae (CPE) causes infections associated with high mortality rates among hospitalized patients. CPE transmission occurs frequently, and prevention of patient-to-patient transmission is a priority. However, transmission pathways are not yet completely understood. The colonization of the respiratory tract with a CPE may lead to a higher risk of contamination of the patient’s environment increasing the spread of CPE. Objective: We estimated the rate of CPE spread when respiratory tract infection or colonization is present. Methods: We studied CPE dissemination analyzing a cohort of patients admitted between January 2013 and December 2018 at the university hospital complex of A Corua, a tertiary-care hospital. All patients who were hospitalized in the same room as a patient colonized or infected with a CPE (index case) for at least 24 hours were screened for CPE carriage. The microbiological screening was performed with conventional culture or polymerase chain reaction (PCR) to identified possible CPE patient-to-patient transmission. The screening test included several samples: rectal swab, perineal swab, wound or drainage swab, and low respiratory tract sample. Results: Active screening for CPE carriage was performed in 84 contact patients. Men represent 57.1% of the sample, and the mean age was 78.5 years (men, 68.0 years and women, 80.8 years), with significant differences between sexes (12.9; 95% CI, 19.6 to 6.1). The major group of cases (86.9%) were hospitalized in medical wards. Transmission confirmed by PCR occurred in 13 (15.5%) of 84 contact patients, after a mean exposure to the index case of 13.3 days. No significant differences were detected in terms of mean exposure to index cases between those contact patients who result negative and those who result positive. The 35 index cases (41.7%) tested positive for CPE on the respiratory sample, and exposure to them led to 8 positive contact patients (61.5%). Conclusions: CPE transmission in a tertiary-care hospital occurred frequently. The spread rate is even higher when CPE is present at the respiratory level. Understanding the mode of spread is important for designing effective control measures and adding a respiratory sample to CPE screening could be a key consideration.

Funding: None

Disclosures: None
Improving Appropriate Testing for Clostridium difficile Infection: Update on Sustainability of a Quality Improvement Project
Authors: Bula-Rudas Fernando , Chatterjee Archana , Lopez Santiago
Published: November 2020

Background: Children aged <1 year are usually colonized with Clostridium difficile: colonization rates range between 30% and 70%. In children, other infectious causes of diarrhea are more common than C. difficile. Molecular testing for C. difficile yields very high sensitivity. Clinical judgement is required for testing children with suspected infectious diarrhea. Inappropriate C. difficile testing may lead to antibiotic overuse. Methods: Initially, for the years 2016–2018, we collected data for positive C. difficile nucleic acid amplification tests (NAATs) at Sanford Children’s Hospital. In 2017, a physician-driven protocol was implemented to replace the current nurse-driven protocol for testing. We implemented national guidelines for testing and treatment in pediatric patients. Microbiology lab was given autonomy to use Bristol stool criteria to process stool samples for C. difficile. Formed stools were rejected for testing for C. difficile. The result was suppressed in patients aged <1 year. We presented the available data at the SHEA spring conference in 2020. We collected new data until June of 2019 to measure the sustainability of the intervention. Results: In 2016, there were 78 C. difficile tests: 17 were positive and 11 were categorized as an HAI. From January 1 to June 30, 2017, there were 26 C. difficile tests: 8 were positive and 3 were categorized as an HAI. Furthermore, 16 C. difficile tests were obtained from July 7 to December 31, 2017: 4 were positive and 1 categorized as an HAI. In 2018, there were 18 tests and 2 were positive; 1 was categorized as an HAI. In 2019, there were 16 tests and 2 were positive; 1 of these was categorized as an HAI. Conclusions: Implementing 2 interventions (removal of a nurse-driven protocol and microbiology lab autonomy for rejecting formed stool samples) for improving C. difficile testing accomplished a reduction of >80% in the number of tests obtained. Overall, there was a sustained reduction in the number of positive tests and HAIs in the years 2018 and 2019. The 2 interventions have been sustainable over time.

Funding: None

Disclosures: None
Improving Confirmatory Testing for the Antimicrobial Resistance Surveillance Network in Ethiopia
Authors: Wadhwa Ashutosh , Parsons Michele , Beyene Degefu , Assefa Dawit , Alebachew Gebrie , Hazim Carmen , Westercamp Matthew , Kanter Theresa , Thomas Elizabeth , Dinku Surafel Fentaw , Hailu Kibra , Mohamed Aynalem , Mitiku Mequanit , Omondi Michael , Gallagher Kathleen , Berhanu Amare , Halpin Alison , Bollinger Susan
Published: November 2020

Background: In July 2017, the Ethiopian Public Health Institute (EPHI) launched an antimicrobial resistance (AMR) surveillance network at 4 sentinel laboratories. The National Clinical Bacteriology and Mycology Laboratory (NRL) at EPHI performs monthly confirmatory testing on a subset of isolates submitted by these sites. We assessed the existing confirmatory testing program to identify gaps and develop solutions, including a monitoring and evaluation (M&E) system. Methods: We assembled a technical working group (TWG) of key stakeholders. Laboratory site visits included workflow observation, process mapping, document review, and technologist interviews. Proposed solutions to observed gaps were drafted in formats consistent with their intended application. Feedback from the TWG was incorporated into final drafts. Available AMR network staff members were trained remotely, and they will train remaining staff. Results: Table 1 describes major gaps and solutions identified. Conclusions: Confirmatory testing provides a mechanism to evaluate laboratory testing proficiency, target improvements, and estimate surveillance data quality, yet standardized methods were lacking. Our efforts highlight key components of confirmatory testing programs and provide a model for use in laboratories with similar needs.

Funding: None

Disclosures: None
Inactivation of Candida auris and Candida albicans by Ultraviolet-C
Authors: Rutala William , Kanamori Hajime , Gergen Maria , Sickbert-Bennett Emily , Weber David Jay
Published: November 2020

Background:Candida auris is an emerging fungal pathogen that is often resistant to major classes of antifungal drugs. It is considered a serious global health threat because it has caused severe infections with frequent mortality in over a dozen countries. C. auris can survive on healthcare environmental surfaces for at least 7 days, and it causes outbreaks in healthcare facilities. C. auris has an environmental route of transmission. Thus, infection prevention strategies, such as surface disinfection and room decontamination technologies (eg, ultraviolet [UV-C] light), will be essential to controlling transmission. Unfortunately, data are limited regarding the activity of UV-C to inactivate this pathogen. In this study, a UV-C device was evaluated for its antimicrobial activity against C. auris and C. albicans. Methods: We tested the antifungal activity of a single UV-C device using the vegetative bacteria cycle, which delivers a reflected dose of 12,000 µW/cm2. This testing was performed using Formica sheets (7.6 × 7.6 cm; 3 × 3 inches). The carriers were inoculated with C. auris or C. albicans and placed horizontal on the surface or vertical (ie, perpendicular) to the vertical UV-C lamp and at a distance from 1. 2 m (~4 ft) to 2.4 m (~8 ft). Results: Direct UV-C, with or without FCS (log10 reduction 4.57 and 4.45, respectively), exhibited a higher log10 reduction than indirect UV-C for C. auris (log10 reduction 2.41 and 1.96, respectively), which was statistically significant (Fig. 1 and Table 1). For C. albicans, although direct UV-C had a higher log10 reduction (log10 reduction with and without FCS, 5.26 and 5.07, respectively) compared to indirect exposure (log10 reduction with and without FCS, 3.96 and 3.56, respectively), this difference was not statistically significant. The vertical UV had statistically higher log10 reductions than horizontal UV against C. auris and C. albicans with FCS and without FCS. For example, for C. auris with FCS the log10 reduction for vertical surfaces was 4.92 (95% CI 3.79, 6.04) and for horizontal surfaces the log10 reduction was 2.87 (95% CI, 2.36–3.38). Conclusions:C. auris can be inactivated on environmental surfaces by UV-C as long as factors that affect inactivation are optimized (eg, exposure time). These data and other published UV-C data should be used in developing cycle parameters that prevent contaminated surfaces from being a source of acquisition by staff or patients of this globally emerging pathogen.

Funding: None

Disclosures: None
India Antimicrobial Stewardship and Resistance (INTEREST): A Needs Assessment Survey
Authors: Shah Aditya , OHoro John , Shah Varun , Dutt Taru , Shah Sanjiv , Kashyap Rahul
Published: November 2020

Background: The emergence and spread of antimicrobial resistance is a major problem in India with significant knowledge on whether this is a systems–based, prescriber and patient characteristic based or diagnostic technologies–based issue. Methods: An electronic survey was sent to select distribution list of intensive care units (ICU) and hospital inpatient (medicine ward) providers from India. Survey questions included antimicrobial clinical practice data, access to electronic medical records, microbiological diagnostic techniques, and access to microbiology data. The survey focused on antimicrobial prescription trends and their association with diagnostic techniques. Results: There were 90 responses from 18 states in 65 ZIP codes. They had median of 187.5 beds (IQR, 40–470). Representative responders had a median age of 40 years (IQR, 31–53). Among the responders, 73 (81%) were men. Of the 90 responses, 48 providers (52%) practiced solely in ICUs (medical and surgical) and 40 providers (45%) practiced solely on the medical ward or floor, with the rest practicing in other units. In total, 31 centers (34%) reported full access to electronic medical records, and 53 centers (59%) had access to wi-fi or Internet. Interestingly, 27 centers (30%) needed to use personal provider phone data for Internet access. Only 26 centers (29%) had electronic microbiological data. Also, 63 respondents (70%) agreed to de-escalation behavior after receiving microbiological data. In addition, 55 respondents (61%) agreed that patients have easy access to outpatient antibiotics without an appropriate prescription, over the counter. Furthermore, 58 responders (64%) said that antibiotic resistance was a major problem at their center, and 61 responders (68%) were familiar with antimicrobial stewardship programs. Among the centers, 69 (77%) had no access to formal infectious disease programs at their center. Only 27 centers (30%) had a formal Clostridium difficile–associated infection reporting and control program. Only 28 centers (31%) had a formal occupational health program. Conclusions: In a large-scale, semistructured, online survey, most issues related to easy availability of antibiotics and lack of “electronization” of medical and microbiological records. It was reassuring that most providers expressed knowledge of the existing antimicrobial stewardship program.

Funding: None

Disclosures: None
Inequities and Barriers to Routine Immunization Coverage in Urban and Rural Areas of Sindh, Pakistan
Authors: Masood Tariq , Guriro Subhash , Mehraj Jaishri
Published: November 2020

Background: Child mortality has remained a major challenge in developing countries. Annually, many children <5 years of age die prematurely due to vaccine-preventable diseases. In South Asia, Pakistan has struggled to achieve global standards of vaccination. Objective: Therefore, we sought to determine barriers to vaccination coverage among children aged 12–23 months and inequities in rural and urban settings of the Sindh province of Pakistan. Methods: We conducted a cross-sectional study in the rural and urban settings of the Sindh province of Pakistan. A 30-cluster household survey was conducted following the WHO guidelines, and 300 children were recruited from each study setting: Lyari, Karachi (urban area) and Umerkot (rural area). Information on the pretested questionnaire was obtained from consenting parents of the children in the study area. The multivariable logistic regression model was used to identify the determinants of vaccination. Results: In total, 600 children from both urban and rural settings were included in the analysis. The mean age was 17.70 months (SD, 3.46), and 50.2% children in the study were boys. Overall, 62.8% children were vaccinated in both settings. Moreover, ~80.3% children were fully vaccinated in the urban part compared with 45.3% in the rural part. The dropout rates for BCG and measles 1 were 17% and 29% in urban and rural areas, respectively. The dropout rates for Penta 1 to Penta 3 were 7% in Lyari and 38% in Umerkot. The penta 1–measles 1 dropout rates were 15% in Lyari and 37% in Umerkot. In multivariable analysis, parental knowledge about vaccination (OR, 9.77; 95% CI, 1.76–54.28), access to a vaccination center (OR, 2.51; 95% CI, 1.19–5.26) and mother’s tetanus vaccination: 1 dose (aOR, 4.27; 95% CI, 1.84–9.93) and 2 doses (OR, 12.43; 95% CI, 7.71–20.04) were associated with vaccination. Conclusions: We identified inequities in vaccination status among the populations of rural and urban areas of Pakistan. Vaccination coverage was higher in an urban setting than in a rural setting of Sindh province. Parental knowledge about vaccination, access to a vaccination center, and mother’s tetanus vaccination status were the major factors of low vaccination coverage among these children.

Funding: None

Disclosures: None
Insertion Site Inflammation Is Associated with Central-Line–Associated Bloodstream Infection
Authors: Salinas Jorge , Clore Gosia , Kukla Mary , AlZunitan Mohammed , Abosi Oluchi , Puig-Asensio Mireia , Marra Alexandre , Diekema Daniel , Edmond Michael
Published: November 2020

Background: Central lines (CL) are widely used in the inpatient setting and central-line–associated bloodstream infection (CLABSI) is a serious complication of CL use. Because CL insertion site inflammation (ISI) may precede the onset of CLABSI, we aimed to define ISI, to determine whether ISI was associated with CLABSI, and to develop an automated surveillance system for ISI. Methods: We extracted electronic medical records (EMRs) of adult patients hospitalized at the University of Iowa Hospitals & Clinics during January 2015–December 2018. Nurses routinely document CL insertion-site characteristics in specifically designed flow sheets in the EMR. An ISI was counted every time ≥1 of the following signs were documented during CL assessments: edema, erythema, induration, tenderness, or drainage. A 1:2 case-control investigation was performed by matching nonmucosal barrier injury (non-MBI) CLABSI patients (cases) to patients without a CLABSI diagnosis (controls). We matched for age (±10 years), sex, date (±30 days), inpatient unit, central-line days, and central-line type (temporary vs permanent). The main exposure of interest was having an ISI on or before CLABSI onset. CLABSIs were determined using CDC NHSN definitions. We then created a metric: ISI days (defined as the number of days with ≥1 ISI documented) and plotted ISI incidence (ISI days per central-line days) to quantify the burden of ISIs and to determine whether ISI and non-MBI CLABSI incidences were collinear. An automated surveillance system for ISI was created using structured query language queries to the EMR data repository and Tableau software. Results: During 2015–2018, we detected 194 CLABSI cases that were matched to 338 controls. CLABSI patients had greater odds of having an ISI (OR, 2.3; 95% CI, 1.3–4.0). Over the study period, ISI incidence decreased from ~80 to ~50 ISI days per 1,000 CL days. Non-MBI CLABSI rates also decreased from ~1.5 to ~1.0 CLABSIs per 1,000 CL days. Conclusions: ISI incidence is associated with non-MBI CLABSI incidence. Because ISI incidence is higher than CLABSI incidence, surveillance for ISI could be a more sensitive indicator for monitoring the impact of CLABSI prevention practices. Automated surveillance for novel process metrics is a promising infection prevention tool.

Funding: None

Disclosures: None
Investigation and Containment of New Delhi Metallo-β-Lactamase (NDM)–Producing Carbapenem-Resistant Enterobacteriaceae (CRE) in a Hospital Intensive Care Unit
Authors: Sperling Karoline , Priddy Amy , Suntharam Nila , Karlen Adam
Published: November 2020

Background: With increasing medical tourism and international healthcare, emerging multidrug resistant organisms (MDROs) or “superbugs” are becoming more prevalent. These MDROs are unique because they are resistant to antibiotics and can carry special resistance mechanisms. In April 2019, our hospital was notified that a superbug, New Delhi Metallo-β-lactamase

(NDM)–producing carbapenem-resistant Enterobacteriaceae (CRE), was identified in a patient who had been transferred to another hospital after being at our hospital for 3 weeks. Our facility had a CRE admission screening protocol in place since 2013, but this patient did not meet the criteria to be screened on admission. Methods: The infection prevention (IP) team consulted with the Minnesota Department of Health (MDH) and gathered stakeholders to discuss containment strategies using the updated 2019 CDC Interim Guidance for Public Health Response to Contain Novel or Targeted Multidrug-resistant Organisms (MDROs) to determine whether transmission to other patients had occurred. NDM CRE was classified under tier 2 organisms, meaning those primarily associated with healthcare settings and not commonly identified in the region, and we used this framework to conduct an investigation. A point-prevalence study was done in an intensive care unit that consisted of rectal screening of 7 patients for both CRE and Candida auris, another emerging MDRO. These swabs were sent to the Antibiotic Resistance Laboratory Network (ARLN) Central Regional Lab at MDH for testing. An on-site infection control risk assessment was done by the MDH Infection Control Assessment and Response (ICAR) team. Results: All 7 patients were negative for both CRE and C. auris, and no further screening was done. During the investigation, it was discovered that the patient had had elective ambulatory surgery outside the United States in March 2019. The ICAR team assessment provided overall positive feedback to the nursing unit about isolation procedures, cleaning products, and hand hygiene product accessibility. Opportunities included set-up of soiled utility room and updating our process to the 2019 MDH recommendation to screen patients for CRE and C. auris on admission who have been hospitalized, had outpatient surgery, or hemodialysis outside the United States in the previous year. Conclusions: Point-prevalence study results showed no transmission of CRE and highlighted the importance of standard precautions. This event supports the MDH recommendation to screen for CRE any patients who have been hospitalized, had outpatient surgery, or had hemodialysis outside the United States in the previous year.

Funding: None

Disclosures: None
Investigation of a Prolonged Group A Streptococcus Outbreak Among Residents and Outpatients Receiving Wound Care at a Long-Term Care Facility (LTCF)
Authors: Cilwick Alana , Burdorf April , Bamberg Wendy , Czaja Christopher , Burakoff Alexis , Brousseau Geoffrey , Johnston Helen
Published: November 2020

Background: In February 2019, the Colorado Department of Public Health and Environment (CDPHE) identified a cluster of 3 invasive group A Streptococcus (GAS) infections in residents receiving wound care in a long-term care facility (LTCF). An investigation revealed a larger outbreak that extended to nonresidents receiving outpatient wound care at the LTCF. Methods: A case was defined as a positive culture for GAS emm type 82 from an individual with exposure to the LTCF between January and June 2019. Cases were categorized as clinical (symptoms of GAS disease or GAS isolated from a wound or sterile site) or carriage (no symptoms). Carriers were identified via samples collected from throat and skin lesions. Screening occurred in 2 rounds and included residents of affected units followed by screening of all wound-care staff and residents facility-wide. Available isolates were sent for emm type testing and whole-genome sequencing (WGS) at the CDC. CDPHE staff performed infection control observations. Results: We identified 14 cases: 8 clinical and 6 carriage (from 5 residents and 1 staff member). Two patients with invasive GAS died. Of 8 patients with clinical GAS, 6 resided in the facility on or 1 day prior to symptom onset; 2 were not residents but received outpatient therapy at the LTCF. All 8 patients with clinical GAS (100%) and 3 carriers had received wound care. The staff member with emm 82 carriage had provided wound care and occupational therapy to the affected residents and the 2 outpatients. Two additional cases were detected with onset dates following staff member decolonization. Moreover, 13 of the 14 emm 82 isolates were found to be identical by WGS. Infection control observations identified lapses in staff wound care and hand hygiene practices in the residential and outpatient settings of the facility. Conclusions: This investigation details a large GAS outbreak in an LTCF associated with asymptomatic carriage in residents and staff that included patients who had only received care in the outpatient portion of the facility. The outbreak was halted following decolonization of a staff member and improvements in infection control, including in the outpatient setting. Outpatient services, particularly wound care, provided by LTCFs should be considered when investigating LTCF-related GAS cases and outbreaks.

Funding: None

Disclosures: None
Is Hospital-Onset Bloodstream Infection (HOBSI) a Useful Measure to Evaluate Infection Prevention Progress?
Authors: Sturm Lisa , Service Network , Bufalino Angelo , Huang Ren-huai , Sharma Mamta , Erlinger Thomas , Fakih Mohamad
Published: November 2020

Background: Acute-care hospitals in the United States are required to submit 6 healthcare-associated infection (HAI) metrics to the CMS for reporting and performance purposes prior to payment. We examined the association between HAI rate trends and hospital-onset bloodstream infection (HO-BSI) rate trends across a large, multihospital health system. Methods: HO-BSI events were identified across 52 hospitals attributable to Staphylococcus aureus, Pseudomonas aeruginosa, Escherichia coli, Klebsiella pneumoniae, or Candida spp using the NHSN Lab ID event definition of ≥day 4 of admission. We compared the performance from January 2016 to March 2019 for HO-BSI and the 6 NHSN-defined HAIs: central-line–associated bloodstream infection (CLABSI), catheter-associated urinary tract infection (CAUTI), Clostridioides difficile, methicillin-resistant Staphylococcus aureus (MRSA) bacteremia, abdominal hysterectomy surgical site infections (SSIs), and colon SSI. We calculated 2 “infection composite scores” to account for the 6 HAIs based on all observed or predicted events (score 1) and an average of the 6 HAI standardized infection ratios (SIRs; score 2). We normalized both measures to 1 for a 12-months rolling baseline. We evaluated the HO-BSI rate change over time and compared it to the change in the infection score over the same period. We compared the change in the 12-month rolling rates of the 2 HAI scores and the HO-BSI rate. Results: During the 39-month period, 3,288 HO-BSI events occurred over 9,775,118 patient days. The source of HO-BSI events included S. aureus (33.5%), P. aeruginosa (10.2%), E. coli (19.7%), K. pneumoniae (13.8%), and Candida spp (22.8%). HO-BSI event rates decreased by 17.3% from 12-month rolling baseline to last 12 months (3.70 vs 3.06 per 10,000 patient days). Similarly, 7,648 HAI events were observed, with the source of events being Clostridioides difficile (57.0%), CAUTI (15.1%), CLABSI (12.8%), MRSA (7.0%), colon SSI (6.4%), and abdominal hysterectomy SSI (1.7%). The 2 HAI scores and the HO-BSI rate all showed a notable decrease from the 2016 baseline period (Fig. 1). The reductions in the HAI scores were both strongly correlated with the reduction in the HO-BSI rate, with the HAI score 1 having a stronger correlation (r = 0.949; P < .001) than was observed for HAI score 2 (r = 0.867; P < .001). Conclusions: Utilization of a HO-BSI measure may prove useful as a correlated but distinct marker of infection prevention improvement or trends. HO-BSI could be useful as an objective electronically obtainable measure to assist in the evaluation of performance within and across facilities.

Funding: None

Disclosures: None
Modeling Transmission of Human Metapneumovirus in a Long-Term Care Facility
Authors: Washington Erica , Terry Ashley , Hand Julie , Ramirez Alexa
Published: November 2020

Background: In September 2019, the Louisiana Department of Health (LDH) was notified of a possible outbreak of influenza in a nursing home. Upon investigation, the infectious agent was determined to be human metapneumovirus (HMPV). By the conclusion of the outbreak, 35 (31.3%) symptomatic cases were identified of which 15 were laboratory-confirmed HMPV. Public health coordination, infection control interventions, environmental cleaning audits, halting new admissions, and ceasing group activities are credited with stopping transmission. Considering the high attack rate, LDH epidemiologists examined scenarios wherein the aforementioned interventions were not utilized. The aim of this analysis is to describe transmission of HMPV in a 112-bed nursing home using mathematical models under conditions wherein interventions were not readily implemented. Methods: Two deterministic and 1 stochastic susceptible–preinfectious–infectious–recovered (SEIR) models are presented. Although recovered persons can be susceptible to HMPV following an infection experience, the potential for reinfection was not considered for this analysis. Fixed variables considered include a 5-day incubation period, basic reproduction number of 2, 14-day infectious period, and 112 susceptible patients. Three counterfactual modeling conditions are considered: delaying notification of an outbreak to public health epidemiologists (model 1), staff hand hygiene compliance of 50% (model 2), and continuing to accept new admissions (model 3). Average rate of recovery per day was and other metrics are used to demonstrate the number of susceptible individuals. Excel workbooks developed by Vynnycky and White (2010) were used for analysis. Results: In model 1, the average rate of onset of infectiousness per day = 0.20, and the average recovery rate per day = 0.07. With no notification to public health epidemiologists, all 112 patients would have been infected with HMPV after 94 days. The reproductive number was doubled to 4 in model 2 to posit poor healthcare worker hand hygiene of 50% compliance. Given this, the number of days until all patients are infected with HMPV decreases to 39 days. Finally, the stochastic scenario (model 3) demonstrates that the number of newly infected persons per day = 0.86, and the hazard rate for infectious individuals becoming immune = 0.07. Conclusions: Infection control interventions are extremely useful for containing viral respiratory diseases for which there is no vaccine or treatment. Mathematical models can communicate utility of public health interventions in the presence of outbreaks. These models demonstrate worst-case scenarios for infection spread.

Funding: None

Disclosures: None
Molecular Epidemiology of Bordetella pertussis Strains Isolated in Vietnam During 2015–2017
Authors: Nguyen Anh H. V. , Pham Hoan T. , Nghia Cao Huu
Published: November 2020

Background: Whooping cough is a serious respiratory illness in infants caused by Bordetella pertussis. In spite of the vaccination program, the incidence rates of whooping cough per 100,000 population in Vietnam increased from 0.33 in 2015 to 0.58 in 2017. If this represents a pertussis resurgence, contributors may include pathogen adaptation, the spread of specific variants, vaccine failure, and failure to effectively treat cases and contacts. There has been little research in Vietnam on B. pertussis strains. Therefore, we investigated the molecular epidemiology of circulating B. pertussis strains in Southern Vietnam by applying multilocus sequence typing (MLST) for 7 housekeeping genes and 4 antigenic determinant genes as components in the acellular vaccine including prn, ptxP, ptxS1, and fim3. Methods: DNA was extracted from 15 isolates collected from 263 case patients during 2015–2017 and was subject to MLST using primers and cycling conditions from the Bordetella pubMLST website (www.Pubmlst.org/Bordetella/). The products were analyzed using BioEdit version 7.2.5 software and then were aligned and compared to reference sequences of each genotype in the database. The evolutionary relationship among sequence types (STs) from housekeeping genes was performed as a minimum spanning tree via the goeBURST algorithm, whereas the correlation of different variants from 4 antigenic determinant genes was built up and clarified with phylogenetic trees based on the UPGMA method by MEGA 7 program. Results: The 15 isolates were all classified as ST2 (100%) by MLST of housekeeping genes, and they belonged to a common global clonal group (Fig. 1). Sequencing of antigenic determinant genes prn2 – ptxP3 – ptxS1-1 – fim3-1 determined that all were identical to each another and the reference sequences (Fig. 2). Conclusions:B. pertussis isolates circulating in Southern Vietnam appeared to be the same as the common global strain. Few isolates were available for testing; therefore, continued surveillance is important to confirm these findings and to monitor population changes over time.

Funding: None

Disclosures: None
Methicillin-Resistant Staphylococcus aureus (MRSA) Admission Screening in the Neonatal Intensive Care Unit (NICU): Algorithm for Hospital Transfers
Authors: Shah Mona , Singh Kamaljit , Edwardson Tina , Lavin Mary Alice
Published: November 2020

Background: Methicillin-resistant Staphylococcus aureus (MRSA) is a frequent source of infection in the neonatal intensive care unit (NICU). Due to the serious consequences associated with MRSA infections in neonates, much effort has been made to prevent and control epidemics in NICUs. Since 2006, our hospital has performed MRSA nasal surveillance screening of all newborns in the NICU in accordance with the recommendations of the Chicago-Area Neonatal MRSA Working Group. In 2017, a MRSA infection was identified in a newborn shortly after transfer from an outside hospital and who had an initial negative MRSA admission screen. As a result, we modified the admission screening process for all transfers from outside NICUs. Methods: The Evanston Hospital Infant Special Care Unit is a level 3 NICU in the northern suburbs of Chicago with 44 NICU beds and 450 admissions per year. Effective July 1, 2017, all NICU transfers have a nasal MRSA screen performed upon admission and after 48 hours. The transferred baby is placed on contact isolation until both screening results return negative. Nasal MRSA testing is performed using both PCR on the BD MAX MRSA Assay platform and is confirmed by culture using MRSA CHROMagar TM. Results: Between July 1, 2017, and October 31, 2019, 112 neonates were transferred from outside NICUs. Moreover, 105 (94%) had at least 1 MRSA screen completed and 99 (88%) had both MRSA screens completed. Of 99 with 2 screens, only 1 neonate had an initial positive nasal MRSA screen. Of the remaining 98 negative babies, none had a repeat positive nasal MRSA screen within 48 hours of admission. of 99 neonates with 2 serial admission MRSA screens, 82 (83%) were transferred within 48 hours of birth. In addition, 17 neonates were transferred >48 hours after birth, including the 1 MRSA-positive baby. Conclusions: In an attempt to identify all potential MRSA-positive neonates transferred to our NICU, we instituted a policy of 2 admission nares swabs. However, our data suggest that a single initial MRSA swab may be sufficient. If continued collection of a second screen is performed, it may be sufficient to screen babies who have been hospitalized for at least 48 hours prior to transfer, which eliminates 83% of admission testing and results in a cost savings.

Funding: None

Disclosures: None
Multi-Facility Reduction in Hospital-Acquired Infections (HAIs) Through Real-Time Feedback and Individual Accountability
Authors: Hermann Christopher , Watters Metta , Sharrer Rebecca , Ennis Randy
Published: November 2020

Background: Hospital-acquired infections (HAIs) are a leading cause of healthcare morbidity and cost for the health community. It is widely recognized that hand hygiene is the leading contributor infections, but hand hygiene still remains a major problem for nearly all healthcare systems. A longitudinal study was conducted over a 4-year period in a community-based health system. Methods: An electronic hand hygiene reminder system was installed in 2 different facilities including both critical care and noncritical units. This system collects data on individual healthcare provider hand hygiene and provides a real-time voice reminder in the event that a provider forgets to perform hand hygiene. The primary study was designed to investigate the impact of a real-time voice reminder to improve hand hygiene. A baseline period of hand hygiene was established prior to the interventions after installing the system without any access to data reporting or the voice reminder. Each of the hospitals had the voice reminder turned on and off 3 times. The baseline HAI rates were established by comparing in each facility for the 12 months prior to the implementation of the system. During the study period, there were no significant changes to other common infection control practices. Results: In both facilities, every time the voices were turned on, hand hygiene improved significantly and each clinical unit saw a >200% improvement in hand hygiene within 3 months of turning the voice reminder. HAIs fell by a statistically significant in all clinical areas by 51%. After a period of stabilization, the voice reminder was turned off hand hygiene compliance fell and HAI rates then increased. The voice reminder was then turned back on and off 2 more times. In every case, hand hygiene rates fell back to the baseline and HAIs returned to their baseline. When the voice reminder was then turned back on, HAIs dropped to 54%–81% of the baseline in each of the clinical units. The system also captured individual providers’ hand hygiene performance data and displayed it in a simple and engaging way, allowing managers easily understand who was struggling with hand hygiene. These data were then leveraged through a series of competitions to systematically drive hand hygiene performance improvement. These included traditional interventions to address an education issue in addition to interventions to identify workflow problems. Conclusions: Using this highly targeted approach, the leadership were able to efficiently drive sustained hand hygiene improvement and a further reduction in HAIs.

Funding: None

Disclosures: None
Multidisciplinary Response to Nosocomial Influenza
Authors: Donelan Susan , Singh Francina , Spitzer Eric , Sands Mark
Published: November 2020

Background: Nosocomial influenza infections can be caused by direct patient-to-patient transmission, as well as bidirectionally between patient and healthcare workers (HCWs). Lapses in infection control practices (droplet precautions), and HCWs who come to work despite influenza-like illness (ILI, ie, “presenteeism”) can potentiate transmission. Cocirculation of >1 strain of influenza may complicate efforts to track infections. We describe a multidisciplinary response that helped control a late winter nosocomial influenza outbreak at a time when both influenza A/H3 and A/H1(2009) were prevalent in the community. Methods: Infection control practitioners detected a potential cluster of influenza A/H3 cases on an adult general medicine unit during the middle of March. The patients were spread out in nonadjacent rooms in a 30-bed unit, which suggested a possible common shared source. Further investigation revealed other potential clusters. Hospital incident command (HIC) was deployed to assess and respond to the outbreak; the incident commander was the chief medical officer (CMO) and the hospital epidemiologist was the subject matter expert. Other HIC roles were manned by nursing leadership, hospital administration, employee health, and the clinical laboratory. The group met at least daily (teleconference on weekends) until the extent of the outbreak was known and no new cases were identified. Results: A multipronged approach was used to control the outbreak. HCWs who reported to work with ILI symptoms were referred to employee health, tested with a PCR-based influenza screening panel, and sent home. Inpatients with ILI symptoms were tested with a comprehensive respiratory virus panel that could distinguish influenza A/H1(2009) from A/H3. Inpatients who were newly positive for influenza were evaluated to determine whether they were epidemiologically linked to an existing cluster, represented a new case of nosocomial acquisition, or were presumed to be community-acquired. The outbreak involved separate clusters caused by A/H3 and A/H1(2009) that affected 40 patients on 9 clinical units. Conclusions: A key component of the response was implementation of a local “mask rule”: all physicians, nurses, other employees, students, and visitors were required to wear surgical masks on affected floors regardless of their vaccination status. In addition, the hospital IT team developed a dynamic spreadsheet that listed information about all nosocomial cases (location, date of onset, etc), as well as ILI call-ins for HCWs. A password-protected version was posted on the hospital intranet and facilitated cohorting of infected patients. Additionally, it allowed timely discontinuation of the local mask rule on specific units, once 2 incubation periods concluded without new cases.

Funding: None

Disclosures: None
National Trends of Prevalence of Fluroquinolone Resistance Among Healthcare-Associated Escherichia coli Infections
Authors: Soe Minn , Lastinger Lindsey , Dudeck Margaret , Edwards Jonathan
Published: November 2020

Background:Escherichia coli is the third most common pathogen responsible for healthcare-associated infections (HAIs), but it is increasingly resistant to multiple antibiotics. Antimicrobial susceptibility test (AST) results for fluoroquinolones (FQs) among E. coli implicated in select HAIs are reported to the NHSN surveillance system. Trend analyses in the prevalence of FQ resistance among healthcare-associated E. coli infections reported to NHSN have not been previously assessed. Objective: We investigated the national trends of prevalence of FQ resistance among E. coli HAIs in acute-care hospitals from 2009 through 2018. Method: We analyzed E. coli AST data from central-line–associated bloodstream infections (CLABSIs), catheter-associated urinary tract infections (CAUTIs), and surgical site infections (SSIs) reported to the NHSN between 2009 and 2018. Fluoroquinolone resistance is defined as the number of E. coli isolates that tested resistant or intermediate to at least 1 of 3 quinolones (ciprofloxacin, levofloxacin, and moxifloxacin), divided by number of pathogens tested for susceptibility, multiplied by 100. To evaluate the trends of fluoroquinolone resistance over time, we conducted an interrupted time-series analysis using a generalized linear mixed model with a logistic function. Substantial HAI definitional changes, most consequentially CAUTI in 2015 and a directional incidence change in 2018, were treated as interruptions to the outcome. Regression models adjusted for patient-level (ie, age, gender, HAI type) and facility-level characteristics (ie, facility type, teaching status, number of beds in intensive care units, and average length of stay) were obtained from the NHSN annual hospital surveys. Random-intercept and slope models were evaluated with covariance tests and were included to account for differential baseline fluoroquinolone resistance and trends among reporting facilities. Data were analyzed using SAS with statistical significance defined at alpha = 0.05. Results: During 2009–2018, the number of E. coli isolates with AST results for FQ reported to NHSN (Fig. 1) increased. After adjusting for covariates, fluoroquinolone resistance significantly increased from 2009 through 2015 at an average of 4.2% per year (Fig. 2, β1). There was no significant change in fluoroquinolone resistance from 2015 through 2017 (Fig. 2, β1+ β3). In 2018, there was 6.4% decline in fluoroquinolone resistance compared to 2017 (Fig. 2, β4) Conclusions: An increasing trend of fluoroquinolone resistance from 2009 through 2015 was observed, and fluoroquinolone resistance was stable during 2015–2017. Despite a relatively brief decline in fluoroquinolone resistance in 2018, the absolute change was small (~2%). Sustaining this decline warrants continued efforts in infection prevention and antimicrobial stewardship.

Funding: None

Disclosures: None