bluuebunny/crossref_metadata_2025 huggingface dataset:
Antibiotic Use at the End-of-Life in Patients with Advanced Dementia: A Systematic Literature Review
Authors: Marra Alexandre , Puig-Asensio Mireia , Perencevich Eli
Published: November 2020

Background: Improving the use of antibiotics across the care continuum will be necessary as we strive to protect our patients from antimicrobial resistance. One potential target for antimicrobial stewardship is during end-of-life care of patients with advanced dementia. We aimed to perform a systematic literature review measuring the burden of antibiotic use during end-of-life care in patients with dementia. Methods: We searched PubMed, CINAHL, and Embase through July 2019 for studies with the following inclusion criteria in the initial analysis: (1) end-of-life patients (ie, dementia, cancer, organ failure, frailty or multi-morbidity); (2) antibiotic use in the end-of-life care; with the final analysis restricted to (3) patients with advanced dementia. Only randomized controlled trials (RCTs) and cohort studies were included. Results: Of the 93 full-text articles, 17 studies (18.3%) met the selection criteria for further analysis. Most of the included studies were retrospective (n = 8) or prospective (n = 8) cohort studies. These studies in combination included 2,501 patients with advanced dementia. Also, 5 studies (698 patients, [27.9%]) were restricted to patients with Alzheimer’s disease. In 5 studies in which data were available, fewer than one-quarter of patients (19.9%, 498) with advanced dementia were referred to palliative care. In 12 studies >50% of patients received antibiotics during the end-of-life period. Also, 15 studies did not report the duration of antimicrobial therapy. Only 2 studies reported the antimicrobial consumption in days of therapy per 1,000 resident days. Only 6 studies studied whether the use of antibiotics was associated with beneficial outcomes (survival or comfort), and none of them evaluated potential adverse effects associated with antibiotic use. Conclusions: There are significant gaps in the literature surrounding antimicrobial use at the end of life in patients with advanced dementia. Future studies are needed to evaluate the benefits and harms of using antibiotics for patients during end-of-life care in this patient population.

Acknowledgement. We thank Jennifer Deberg from Hardin Library for the Health Sciences, University of Iowa Libraries on the search methods.

Disclosures: None

Funding: None
Assessing Policies Versus Practices Utilizing the CDC Infection Control Assessment and Response Tool
Authors: Lloyd-Krejci Buffy , Ellingson Katherine , Coury Elias
Published: November 2020

Background: The Infection Control Assessment and Response (ICAR) tool was developed by the CDC following the 2014 Ebola outbreak. Over a 3-year period, the CDC dispensed Funding: to all public health divisions in all 50 states to implement and promote the ICAR. The ICAR was developed as a self-assessment tool to evaluate policies, competencies, and practices across healthcare settings. The primary aim of the tool and associated Funding: was to guide quality improvement activities by addressing the identified gaps in infection prevention (IP). Independent of state funding, we sought to use the ICAR to evaluate whether there were differences in reported policies from observed practices related to hand hygiene (HH) and personal protective equipment (PPE) use in long-term care facilities (LTCFs), ambulatory surgical centers (ASCs), and outpatient pain clinics (OPCs). Methods: From November 2018 to August 2019, we conducted in-person ICAR assessments in 7 LTCFs in 3 states (Arizona, Utah, and Idaho), 2 ASCs in 2 states (Arizona, Indiana), and 5 OPCs in 1 state (Arizona). All on-site assessments were conducted with the ICAR tool by a board-certified infection preventionist. The paper form was converted to a mobile compatible digital audit tool utilizing Microsoft Forms on the Microsoft 365 platform. Once a survey was completed, it was sent to an Excel database and analyzed utilizing SPSS software. Results: All facilities (14 of 14, 100%) had a designated person responsible for coordinating and/or directing the IP program. Moreover, 4 of 7 LTCFs (57%), 2 of 2 ASCs (100%), and 5 of 5 OPCs (100%) reported having written IP policies that met evidence-based guidelines, regulations, or standards (eg, CDC/HICPAC). None of the 7 LTCFs (0%), 2 of 2 ASCs (100%), and none of the 5 OPCs (0%) reported active surveillance to monitor and document adherence to proper PPE selection and use. During direct observation of hand hygiene opportunities, compliance was 23% for LTCFs (7 of 31 opportunities), 37% for ASCs (7 of 19 opportunities), and (11 of 28 opportunities) 39% in OPCs. Conclusions: Our results indicate that the ICAR tool remains a useful resource for distinguishing between the reporting of IP polices from the actual implementation of evidence-based practices. Although all facilities had a designated role for IP and most had written evidence-based IP polices, this did not translate to the observation of recommended HH and PPE practices. By utilizing this tool, healthcare facilities can support their evidence-based IP polices and further promote patient safety by identifying and mitigating gaps in practices.

Funding: None

Disclosures: None
Bacterial Colonization of Waiting Rooms in a Newly Constructed Children’s Outpatient Clinic: Construction Through 6 Months After Opening In Waiting Rooms
Authors: Spratt Henry , Levine David , Woods Charles , Ledbetter Joel , Price Gary
Published: November 2020

Background: Healthcare-associated infections (HAIs) represent an ongoing problem for all clinics. Children’s clinics have waiting rooms that include toys and activities to entertain children, possibly representing reservoirs for HAIs. This study focuses on a newly constructed children’s outpatient clinic associated with a teaching hospital. We studied waiting room bacterial colonization of floors and play devices from the last phase of construction through 6 months of clinical use. Methods: Waiting room areas on the first 2 floors of the facility were studied due to high patient volume in those areas. In total, 16 locations were sampled: 11 on floors and 5 on play items. Using sterile double-transport swabs, all locations were sampled on 5 separate occasions over 2 months during the last phase of construction and 13 times over 6 months after the clinic was opened. After collection swabs were placed on ice, transported to a microbiology lab, and used to inoculate Hardy Diagnostics Cdiff Banana Broth (for Clostridium difficile - Cdiff), CHROM MRSA agar (for methicillin resistant Staphylococcus aureus - MRSA), Pseudomonas isolation agar (for Pseudomonas spp and P. aeruginosa), and tryptic soy agar to detect Bacillus spp. Media were incubated for 48 hours at 37°C and were scored for bacterial presence based on observation of colonies or change in the medium. Results: During the construction phase, waiting-room-floor bacterial colonies were dominated by Bacillus spp, and first-floor waiting rooms had nearly 7 times more colonies than those on the second floor (P < .05). A similar pattern was observed for C. difficile and MRSA. No Pseudomonas spp were observed during construction. Once patients were present, Bacillus spp contamination dropped for the first floor, but increased for the second floor. All other bacterial types (C. difficile, MRSA, Pseudomonas spp, and P. aeruginosa) increased on the second floor after the clinic opened (eg, from 23% to 42% for C. difficile and from 7% to 46% for MRSA; P < .05). The play devices showed small increases in bacterial load after clinic opening, most notably Pseudomonas spp. Conclusions: This study provides evidence that a shift from bacterial species associated with soil (eg, Bacillus spp) toward species commonly associated with humans occurred in waiting rooms after construction in this children’s outpatient clinic. Increases for MRSA, Pseudomonas spp, and P. aeruginosa were linked to patient presence. These data suggest that patients, their families, and clinic staff transport bacteria into clinic waiting rooms. This outpatient clinic environmental contamination may increase potential for HAIs and may represent a target for intervention.

Funding: None

Disclosures: None
Bronchoscope-Related Outbreaks and Pseudo-Outbreaks: CDC Consultations—United States, 2014–2019
Authors: Bardossy Ana , Novosad Shannon , Perkins Kiran , Moulton-Meissner Heather Adele , Arduino Matthew , Benowitz Isaac
Published: November 2020

Background: Exposure to medical devices can be a risk factor for the development of healthcare-associated infections; bronchoscopes are a leading cause of device-associated outbreaks. We describe bronchoscope-related outbreaks and pseudo-outbreaks reported to the Centers for Disease Control and Prevention’s Division of Healthcare Quality Promotion (DHQP), and we summarize investigation steps and control measures. Methods: We identified bronchoscope-related consultations with state and local health departments between July 1, 2014, and September 30, 2019, in the DHQP database. We abstracted data on patient symptoms, clinical culture results, investigation findings, and subsequent infection prevention and control interventions. Results: We identified 15 consultations involving 150 patients (range, 3–31 patients per consultation). Each consultation involved at least 1 cluster of the same organism. Organisms associated with bronchoscope-associated clusters were nontuberculous mycobacteria (n = 7), Candida spp (n = 3), Exophiala spp (n = 2), Pseudomonas aeruginosa (n = 2), Enterobacter spp (n = 2), and Raoultella planticola, Stenotrophomonas maltophilia, Achromobacter spp, Mycobacterium tuberculosis, and Aspergillus spp (1 each; 2 consultations involved multiple pathogens). Procedures from which these patient specimens were collected included bronchoalveolar lavage, bronchial wash, bronchial brushing, sputum swab, and lymph node biopsy. For the 7 outbreaks in which clinical data were available, 5 did not have patients with clinical infections related to the pathogen recovered. Two consultations involved pseudo-outbreaks: one involved contamination of specimen collection tubes and the other involved contamination of cultures within the laboratory. Potential underlying pathogen sources included contaminated bronchoscopes (inadequate reprocessing or device damage) (n = 10, 67%), use of nonsterile ice, water, or saline during the procedure (n = 4, 27%), contaminated specimen collection tubes (n = 1, 7%), contaminated bronchoscope suite (n = 1, 7%), and clinical laboratory contamination (n = 1, 7%). The most common interventions included improvement of reprocessing procedures (n = 5), removal of possibly damaged bronchoscopes (n = 4), and eliminating nonsterile ice and water exposures in bronchoscopy (n = 3). Conclusions: Water-related organisms were the most commonly identified pathogens in bronchoscope-related consultations, highlighting the important role that exposure to contaminated water during bronchoscopy and bronchoscope reprocessing might play in bronchoscopy-associated outbreaks and pseudo-outbreaks. During bronchoscope-related outbreaks identifying a common pathogen could indicate problems in bronchoscope handling or reprocessing, device damage, or exposure to nonsterile water.

Funding: None

Disclosures: None
Carbapenemase Gene Profiles in Carbapenem-Resistant Enterobacteriaceae—United States, January 2018–August 2019
Authors: Huang Jennifer , Pettinger Amanda , Bantle Katie , Bhatnagar Amelia , Gilbert Sarah , Malik Sarah
Published: November 2020

Background: Carbapenem-resistant Enterobacteriaceae (CRE) cause significant morbidity and mortality each year in the United States. Treatment options for these infections are often limited, in part due to carbapenemases, which are mobile β-lactam-hydrolyzing enzymes that confer multidrug resistance in CRE. As part of the CDC’s Containment Strategy for Emerging Resistance, public health laboratories (PHLs) in the CDC Antibiotic Resistance Laboratory Network (AR Lab Network) have worked to characterize clinical isolates of CRE for rapid identification of carbapenemase genes. These data are then used by public health and healthcare partners to promote patient safety by decreasing the spread of resistance. We summarize carbapenemase gene profiles in CRE, by genus and geography, using data collected through the AR Lab Network from January 2018 through August 2019. Methods: CRE isolates were submitted to 55 PHLs, including those of all 50 states, 4 large cities, and Puerto Rico, in accordance with each jurisdiction’s reporting laws. PHLs performed phenotypic and molecular testing on isolates to detect targeted, emerging carbapenemase genes and reported results to submitters. Carbapenemase-positive (CP) isolates were defined as PCR positive for ≥1 carbapenemase gene tested: blaKPC, blaNDM, blaVIM, blaIMP, blaOXA-48–LIKE. PHLs submitted results to CDC monthly. Genera other than Enterobacter, Klebsiella, and Escherichia coli are categorized as other genera in this analysis. Data were compiled and analyzed using SAS v 9.4 software. Results: From January 2018 to August 2019, the AR Lab Network tested 25,705 CRE isolates; 8,864 of 25,705 CRE (34%) were CP. Klebsiella spp represented the largest proportion of CP-CRE at 68% (n = 6,063), followed by E. coli (12%, n = 1,052), Enterobacter spp (11%, n = 981), and other genera (9%, n = 768). Figure 1a shows the composition of CP-CRE carbapenemase genes by genus. The most common carbapenemase and genus profiles were blaKPC in Klebsiella (74%; 5,562 of 7,561 blaKPC-positive) blaNDM in E. coli (43%; 372 of 868 blaNDM-positive) blaVIM in Enterobacter spp (35%; 25 of 72 blaVIM-positive), and blaIMP among other genera (90%; 92 of 102 blaIMP-positive). Common CP-CRE genes and genera also varied by geography (Fig. 1b). Conclusions: The AR Lab Network has greatly enhanced our nation’s ability to detect and characterize CP-CRE. Our data provide a snapshot of the organisms and regions where mobile carbapenemase genes are most often detected in CRE. Geographic variation in CP gene profiles provides actionable data to inform local priorities for detection and infection control and provide clinicians with situational awareness of the genes and organisms that are circulating in their region.

Funding: None

Disclosures: In this presentation, the authors discuss the drug combination aztreonam-avibactam and acknowledge that this drug combination is not currently FDA-approved.
Catheter-Associated Symptomatic Urinary Tract Infections in Nursing Homes—National Healthcare Safety Network, 2013–2018
Authors: Mungai Elisabeth , Edwards Jonathan , Eure Taniece , Anttila Angela , Rowe Theresa , Stone Nimalie , Bell Jeneita
Published: November 2020

Background: Catheter-associated symptomatic urinary tract infections (CA-SUTIs) are a common adverse healthcare event in nursing homes and have been the focus of multiple prevention strategies.1 In 2012, the CDC launched the NHSN Long-Term Care Facility (LTCF) Component, which nursing homes, the CDC, and prevention collaborators can use to monitor nursing home CA-SUTI incidence and prevention progress.2 The objective of this analysis was to compare CA-SUTI rates and reporting patterns of nursing homes between 2013–2015 and 2016–2018. Methods: We analyzed CA-SUTI data from nursing homes reporting to the NHSN during 2013–2018. Consistent reporters submitted ≥6 months of complete data in any calendar year during the period. To potentially confirm patterns in CA-SUTI rates, we defined “consecutive” reporters, as nursing homes that submitted data for ≥6 months each year during 2013–2018. CA-SUTI incidence rates were calculated as the number of CA-SUTI events divided by the number of catheter days multiplied by 1,000. Likelihood ratio tests using negative binomial regression were used to compare CA-SUTI rates from 2016–2018 and 2013–2015 among both consistent and consecutive reporters. Results: During 2013–2018, the number of nursing homes submitting at least 1 month of CA-SUTI data to NHSN increased from 60 to 120 (Fig. 1). Among these nursing homes, 194 (88%) were consistent reporters. The pooled CA-SUTI rate of 1.77 per 1,000 catheter days in 2016–2018 was significantly lower than the pooled CA-SUTI rate of 2.45 per 1,000 catheter days in 2013–2015 among consistent reporters by ~24% (Table 1). Also, 50 consecutive reporters submitted CA-SUTI data during 2013–2018. Among these consecutive reporters, the pooled CA-SUTI rate of 2.11 per 1,000 catheter days in 2016–2018 was significantly lower than the rate of 2.53 per 1,000 catheter days in 2013–2015 by ~21% (Table 1). Conclusions: This analysis suggests that nursing homes using NHSN for CA-SUTI surveillance have made progress in prevention efforts. During 2013–2018, evidence showed that CA-SUTI incidence rates declined among consistent reporters between the 2 reporting periods. This decrease was verified among consecutive reporters. Additional study is needed to determine which factors account for varying reporting patterns and differential CA-SUTI incidence.

Funding: None

Disclosures: None
CAUTIs in Patients With Thoracic Epidurals
Authors: Seidelman Jessica , Lewis Sarah , Smith Becky
Published: November 2020

Background: The Surgical Care Improvement Project 9 (SCIP 9) mandates the removal of urinary catheters within 48 hours following surgery to reduce the risk of catheter-associated urinary tract infections (CAUTIs). Although patients with thoracic epidurals are not exempt from SCIP 9, these patients may be inherently different from other surgical patients. Early removal of Foley catheters may cause urinary retention and recatheterization, which in turn can lead to CAUTI or urethral trauma. Our hospital’s current policy is to allow Foley catheters to remain in place until the thoracic epidural is removed. The goal of our study was to identify and compare the rate of CAUTI in patients with thoracic epidural catheters to the rate of CAUTI in patients without thoracic epidural catheters Methods: We performed a retrospective cohort study of patients with and without thoracic epidurals who had Foley catheters during hospitalization from July 1, 2017, to May 31, 2019. We used descriptive statistics to compare CAUTI rates based on unit between the 2 groups of patients. Results: We identified 1,834 unique patients with thoracic epidurals and urinary catheters during the study period. We found 4 CAUTIs of 9,896 catheter days (0.4 CAUTIs per 1,000 catheter days) in patients with epidural catheters and 43 CAUTIs of 36,809 catheter days (1.17 CAUTI per 1,000 catheter days) in patients without thoracic epidurals for a rate ratio of 0.346 (95% CI, 0.1242– 0.9639; P < .03). We conducted a sensitivity analysis on a subset of patients admitted under the cardiothoracic service and compared the patients with Foley catheters with and without thoracic epidurals. In this subset, we found 1 CAUTI in 5,890 catheter days (0.17 CAUTI per 1,000 catheter days) in patients with thoracic epidurals and 4 CAUTIs in 9,429 catheter days (0.42 CAUTIs per 1,000 catheter days) in patients without thoracic epidurals), for a rate of 0.4002 (95% CI, 0.0447–3.5808; P < .39). In this subgroup, 7.0% of patients with thoracic epidurals required a second Foley catheter compared to 16.9% of patients without thoracic epidurals who required a second Foley catheter (P < .01). Conclusions: Although patients with thoracic epidurals maintain Foley catheters beyond 48 hours, the CAUTI rate in these patients is lower than in patients without thoracic epidurals. Therefore, removing Foley catheters within 48 hours of surgery in patients with thoracic epidurals may not reduce the risk of CAUTI and, in fact, could be harmful. Further evaluation of confounding variables is warranted.

Funding: None

Disclosures: None
Challenges in Identification of Candida auris in Hospital Laboratories: Comparison Between HIC and LMIC
Authors: Sengupta Sharmila , Marimuthu Kalisvar , Stewardson Andrew , Harbarth Stephan , Durante Amanda , Singh Sanjeev
Published: November 2020

Background:Candida auris is an emerging nosocomial fungal pathogen causing invasive illness and outbreaks worldwide. A major issue regarding C. auris is that it can be misidentified unless appropriate technology is used. We conducted a survey of available methods for identification of C. auris in 21 hospital laboratories in India regarding their protocols for prevention of C. auris infection. Methods: The survey was an adaptation of a similar survey conducted for the Connecticut Laboratory Response Network in 2017. We mailed the survey to 30 microbiologists and ID physicians, and 21 of them from 12 states responded. All respondents were from private acute-care and teaching hospitals. The responses were analyzed and compared to the Connecticut study. Results: Of 21 hospitals, 19 (90.5%) can identify C. auris in house. Also, 18 (85.7%) have identified C. auris in the past 18 months. Species level identification was done only for blood cultures in all hospitals. Only 5 (26%) laboratories speciated Candida spp isolated from other sites such as respiratory and urinary specimens. Automated systems were used like Vitek 2 in 16 (84.2%), Phoenix BD in 2(10.5%) and Microscan in 1(5.26%) laboratory. MALDI-TOF MS and PCR for identification were used in 2 laboratories. Antifungal susceptibility testing is done in-house in 19 (90.5%) laboratories. Only 10 (52.6%) responding hospitals from India had infection prevention protocols for C. auris, and 9 (47.4%) of them isolated patients. The major challenges for infection prevention with C. auris are absence of screening in high-risk patients (66.7%), misidentification by automated systems (84.2%), and inability to speciate from nonsterile sites underestimates the prevalence (100%). Conclusions: There is an urgent need to enhance the capacity of hospital laboratories to detect C. auris early, and to implement infection prevention measures. In both studies early detection is the key and as suggested by the US authors, challenges can be overcome through collaboration between hospitals and referral laboratories when resources are limited. This optimizes laboratory capacity and prevents global spread through colonized patients. The limitation of this study is that data from public hospitals are unknown and larger studies are needed.

Funding: None

Disclosures: None
Changes in the Prevalence of Methicillin Resistance Among Healthcare-Associated Staphylococcus aureus Infections, 2009–2018
Authors: Weiner-Lastinger Lindsey M. , Soe Minn M. , Edwards Jonathan R. , Dudeck Margaret A.
Published: November 2020

Background:Staphylococcus aureus has long been an important cause of healthcare-associated infections (HAIs) and remains the second most common HAI pathogen in the United States. Often resistant to several antibiotics, S. aureus infections are difficult to treat and can leave patients at risk for serious complications such as pneumonia and sepsis. HAI pathogens and their antimicrobial susceptibility testing (AST) results have been reported to NHSN since its inception in 2005. Previous NHSN surveillance reports have presented national annual benchmarks for antimicrobial resistance phenotypes, such as methicillin-resistant S. aureus (MRSA). Whether there have been any significant changes over time in the prevalence of methicillin resistance among S. aureus infections reported to NHSN has not been previously assessed. Methods:S. aureus AST data from central-line–associated bloodstream infections, catheter-associated urinary tract infections, and inpatient surgical site infections reported from acute-care hospitals between 2009 and 2018 were analyzed. S. aureus was defined as MRSA if it was reported as resistant to oxacillin, cefoxitin, or methicillin. A national percentage resistant (%R) was calculated for each year as the number of resistant pathogens divided by the number of pathogens tested for susceptibility multiplied by 100. A generalized linear mixed model with logistic function was created to evaluate annual changes in the percentage resistant. Several patient-level and hospital-level characteristics were assessed as potential covariates. To account for differential baseline %R values between individual hospitals, specification of random intercept and slope were used during model creation. Differences in the trend of %R between HAI types were assessed using interaction terms. Data were analyzed using SAS v 9.3 software, and P < .05 was considered significant. Results: Overall, 3,317 hospitals reported at least 1 S. aureus pathogen tested for susceptibility between 2009 and 2018. The national unadjusted %R decreased from 49.2% (2009) to 41.2% (2018), with similar decreases seen in each HAI type (Table 1). After adjusting for significant covariates, a statistically significant annual 3% decrease in the prevalence of resistance was observed (Fig. 1). Significant differences between HAI types did not exist. Conclusions: The percentage of healthcare-associated S. aureus resistant to oxacillin, cefoxitin, or methicillin has declined consistently over the past 10 years. Continued efforts in infection prevention and antimicrobial stewardship are vital to sustaining this decline.

Funding: None

Disclosures: None
Changing the Culture of Ordering Urine Cultures
Authors: Adams Jane , File Thomas , England Matthew , Reynolds Nancy , Wells Patricia , Politis Paula
Published: November 2020

Background: Inappropriate ordering of urine cultures and the resulting unnecessary use of antibiotics can lead to complications of antimicrobial therapy including resistance, adverse effects (eg, disruption of microbiome and C. difficile infection), and increased healthcare costs, as well as the erroneous determination of CAUTI in patients with Foley catheters. A retrospective analysis of patients with CAUTI revealed frequent ordering of urine cultures for conditions and symptoms not supported by current IDSA guidelines. As a result, we created an action plan to reverse the trend of inappropriate urine culture ordering. Methods: Our urine culture reduction campaign was developed with input from the infectious disease service, antibiotic stewardship team (AST), infection prevention, pharmacy, and the microbiology service. The following educational efforts were included: (1) distribution of outpatient pocket cards with communication to providers about appropriate ordering of urine cultures; (2) creation of an evidence-based order set for urinalysis and urine cultures distributed electronically as emails and screensavers on computer stations and in person via didactic sessions with physicians and nursing staff; (3) a practice pointer for staff nurses that included recommended changes to urine culture ordering and encouraged open dialogue with physicians regarding the appropriateness of urine cultures; (4) didactic and personal communications to counter long-standing myths, such as “Urine cultures always for change in mental status”; (5) a peer-review process to evaluate and justify deviations from the testing algorithm.

Results: The first and second months after the introduction of the campaign, the microbiology laboratory reported 23% and 37% reductions in urine cultures ordered, respectively. During the same period, a 48% reduction in CAUTIs was reported for the entire health system. Conclusions: Reducing the number of inappropriate urine cultures is achievable with intense communication utilizing a multifaceted approach. With continued educational activities, we expect to sustain and even improve our successful reduction of inappropriate urine culture orders, ultimately improving patient outcomes.

Funding: None

Disclosures: None
Clinical Team Distribution and Antibiotic Use Patterns at a Tertiary-Care Academic Medical Center
Authors: Choudhury Rebecca , Beaulieu Ronald , Talbot Thomas , Nelson George
Published: November 2020

Background: As more US hospitals report antibiotic utilization to the CDC, standardized antimicrobial administration ratios (SAARs) derived from patient care unit-based antibiotic utilization data will increasingly be used to guide local antibiotic stewardship interventions. Location-based antibiotic utilization surveillance data are often utilized given the relative ease of ascertainment. However, aggregating antibiotic use data on a unit basis may have variable effects depending on the number of clinical teams providing care. In this study, we examined antibiotic utilization from units at a tertiary-care hospital to illustrate the potential challenges of using unit-based antibiotic utilization to change individual prescribing. Methods: We used inpatient pharmacy antibiotic use administration records at an adult tertiary-care academic medical center over a 6-month period from January 2019 through June 2019 to describe the geographic footprints and AU of medical, surgical, and critical care teams. All teams accounting for at least 1 patient day present on each unit during the study period were included in the analysis, as were all teams prescribing at least 1 antibiotic day of therapy (DOT). Results: The study population consisted of 24 units: 6 ICUs (25%) and 18 non-ICUs (75%). Over the study period, the average numbers of teams caring for patients in ICU and non-ICU wards were 10.2 (range, 3.2–16.9) and 13.7 (range, 10.4–18.9), respectively. Units were divided into 3 categories by the number of teams, accounting for ≥70% of total patient days present (Fig. 1): “homogenous” (≤3), “pauciteam” (4–7 teams), and “heterogeneous” (>7 teams). In total, 12 (50%) units were “pauciteam”; 7 (29%) were “homogeneous”; and 5 (21%) were “heterogeneous.” Units could also be classified as “homogenous,” “pauciteam,” or “heterogeneous” based on team-level antibiotic utilization or DOT for specific antibiotics. Different patterns emerged based on antibiotic restriction status. Classifying units based on vancomycin DOT (unrestricted) exhibited fewer “heterogeneous” units, whereas using meropenem DOT (restricted) revealed no “heterogeneous” units. Furthermore, the average number of units where individual clinical teams prescribed an antibiotic varied widely (range, 1.4–12.3 units per team). Conclusions: Unit-based antibiotic utilization data may encounter limitations in affecting prescriber behavior, particularly on units where a large number of clinical teams contribute to antibiotic utilization. Additionally, some services prescribing antibiotics across many hospital units may be minimally influenced by unit-level data. Team-based antibiotic utilization may allow for a more targeted metric to drive individual team prescribing.

Funding: None

Disclosures: None
Colonization and Genetic Diversity of MRSA Among ICU Patients and Healthcare Workers From a Hospital of Northeastern India
Authors: Phukan Chimanjita , Saikia Kandarpa Kumar , Phukan Chimanjita , Dutta Ridip , Sarma Dhruba Jyoti , Ahmed Giasuddin
Published: November 2020

Background: The prevalence of methicillin-resistant Staphylococcus aureus (MRSA) is diverse in different geographic regions, and transmission of MRSA in hospital settings occurs either through the patients or asymptomatic healthcare workers who MRSA colonized in the nares and thus act as a potential reservoir of infection for susceptible patients. Methods:S. aureus isolates were collected from ICU patients and healthcare workers at Gauhati Medical College and Hospital, Assam, India, from May 2010 to April 2015. Premoistened swab samples were obtained from the ICU patients from 4 different sites (ie, nares, axilla, groin, and perianal region) within 48 hours of admission. For healthcare workers (HCWs) a nasal swab was obtained. The isolates were identified by phenotypic and genotypic methods using CLSI guidelines and PCR (fem B, MecA, and PVL). The antibiograms were obtained using a Vitek 2 system. Results: For 84 patients admitted to the ICU, swab samples were obtained from various sites, and S. aureus was observed in 34 samples (40.5%). Among the isolates, 13 (38%) were MRSA and 21 (62%) were methicillin-susceptible Staphylococcus aureus (MSSA). Among the HCWs from the ICU, growth of S. aureus was obtained in 10 of 30 samples (33.34%), of which 3 (30%) were MRSA and 7 (70%) were MSSA. S. aureus isolates were genotypically identified as fem B among colonized patients (40.5%) and HCWs (33.34%). MRSA (mecA positive) was detected in 3% of colonized patients and 30% of HCWs. Among the ICU patients, 78.56% were PVL-positive S. aureus: 21.42% were PVL-positive MRSA and 57.14% were PVL-positive MSSA. Multilocus sequence typing of the 7 housekeeping genes against 2 S. aureus isolates showed the presence of ST1428, which had not been reported in India, whereas the other sequence was entirely novel. The MDR rates were 68% and 75% among ICU patients and HCWs, respectively, and all the strains were mupirocin sensitive. The S. aureus isolates were significantly proportional among HCWs compared to the colonized group (P = .031). Conclusions: The study results show a high prevalence of PVL-positive MSSA and MRSA among ICU patients. This finding indicates its transmission among hospitalized patients through the HCWs, for which constant monitoring of the pathogen, particularly its phenotypic and genotypic variations and antimicrobial resistance pattern, is needed to develop effective strategies for infection prevention.

Funding: None

Disclosures: None
Comparative Evaluation of the Microbicidal Activity of Low-Temperature Sterilization Technologies to Steam Sterilization
Authors: Rutala William , Gergen Maria , Sickbert-Bennett Emily , Weber David Jay
Published: November 2020

Background: Most medical and surgical devices used in healthcare facilities are made of materials that are sterilized by heat (ie, heat stable), primarily steam sterilization. Low-temperature sterilization methods developed for heat and moisture sensitive devices include ethylene oxide gas (ETO), hydrogen peroxide gas plasma (HPGP), vaporized hydrogen peroxide (VHP), and hydrogen peroxide plus ozone. This study is the first to evaluate the microbicidal activity of the FDA-cleared VHP sterilizer and other methods (Table 1) in the presence of salt and serum (10% FCS). Methods: Brushed stainless steel discs (test carriers) were inoculated with test microbes (Table 1) and subjected to 4 sterilization methods: steam, ETO, VHP and HPGP. Results: Steam sterilization killed all 5 vegetative and 3 spore-forming test organisms in the presence of salt and serum (Table 1). Similarly, the ETO and the HPGP sterilizers inactivated the test organisms with a failure rate of 1.9% for each (ie, 6 of 310 for ETO and 5 of 270 for HPGP). Although steam had no failures compared to both ETO and HPGP, which demonstrated some failures for vegetative bacteria, there was no significant difference comparing the failure rate of steam to either ETO (P > .05) or HPGP (P > .05). However, the VHP system tested failed to inactivate all the test organisms in 76.3% of the tests (206 of 270; P < .00001) (Table 1). Conclusions: This investigation demonstrated that steam sterilization was the most effective method, followed by ETO and HPGP and, lastly, VHP.

Funding: None

Disclosures: Dr. Rutala was a consultant to ASP (Advanced Sterilization Products)
Contamination of CSF Culture: Serious Risk to Patient Safety
Authors: Garg Rahul
Published: November 2020

Background: Acute bacterial meningitis is a medical emergency, and early initiation of appropriate therapy is important to improving outcomes. Culture-based methods are still the standards for the detection of microorganisms in cerebrospinal fluid (CSF). Automated blood culture systems yield better results in cultures sterile body fluids, including CSF. However, the high sensitivity of this technology does not negate the danger of contamination compromising the final outcome. Thus, we tried to study the culture yield in suspected meningitis to determine the rate of contamination. Methods: We conducted a retrospective cohort study of CSF samples collected for culture over 1 year from January 2018 to December 2018 from patients who presented with signs and symptoms indicative of meningitis. The bacterial etiologies and rates of contamination were extracted from laboratory records. Descriptive statistics from Microsoft Excel software were used to analyze patient data. Limited statistical analysis (ie, the Fisher exact test) was performed using SPSS for Windows version 18 software. Results: In total, 1,053 CSF samples were received for aerobic culture, of which the most frequent were conventional cultures (685 of 1053, 65%), whereas BacT/ALERT cultures were requested for 368 of 1,053 cases (35%). Of 685 conventional CSF cultures, pathogens were isolated in 28 of 685 (4.1%), most commonly Acinetobacter baumannii complex (10 of 28, 35.7%). Contaminants were identified in 0.58% samples (4 of 685). In the 368 BacT/ALERT cultures, pathogens were detected in 15 (4.1%), most commonly Streptococcus spp (5 of 15, 33.3%). The contamination rate was 51.1% (188 of 368 cases). The overall rate of contamination was 18.2% (192 of 1,053 cases). The most CSF cultures were received from patients in neurosurgery (350 of 1,053, 33.2%) followed by medicine wards (270 of 1,053, 25.6%). Aerobic spore bacilli was by far the most common contaminant (109 of 1,053, 10.35%).

Conclusions: We believe efforts to decrease contamination are among the most cost-effective, but targeted clinical re-evaluation for all patients with positive CSF cultures remains vital. Due to the high sensitivity of the automated culture system, it is a imperative to maintain strict aseptic conditions while collecting CSF samples. Failure to do so may lead to overgrowth of contaminants masking the growth of the true pathogens in culture.

Disclosures: None

Funding: None
Current Status of Antimicrobial Stewardship Programs in São Paulo Hospitals
Authors: Sato Silvia , Madalosso Geraldine , Assis Denise , Perdigão-Neto Lauro , Levin Anna , Oliveira Maura
Published: November 2020

Background: Antimicrobial stewardship programs (ASPs) consist of coordinated interventions designed to improve and measure appropriate antimicrobial use. Understanding the current structure of ASPs hospitals will support interventions for improvement or implementation of these programs. Objective: We aimed to describe the current status of ASP in hospitals in the state of São Paulo, Brazil. Methods: We conducted a cross-sectional survey regarding ASP of hospitals in São Paulo state, Brazil, from March to July 2018. Through interviews by telephone or e-mail, we asked participants which components of IDSA/SHEA and CDC guidelines had been implemented. Results: The response rate was 30% (28 of 93 hospitals) and 26 of the hospitals (85%) reported having a formal ASP. Policies, practices, and strategies of surveyed ASP are detailed in Table 1. The most frequently implemented strategies were (1) antimicrobial surgical prophylaxis guideline (100%), (2) empiric sepsis guideline (93%), and (3) presence of ASP team member during bedside rounds (96%). The least commonly implemented strategies included prior authorization for all antimicrobials (11%), pharmacokinetic monitoring and adjustment program for patients on IV aminoglycosides (3%). Regarding metrics of the ASP, the most common indicator was the rates of antimicrobial resistance (77%). Overall, 18 hospitals (19%) used defined daily dose and only 29% used days of therapy. Moreover, 61% of hospitals reported their results to hospital the administration and 39% of hospitals reported their results to the prescribers. Conclusions: Most hospitals have a formal ASP, but there are opportunities for improvement. Future efforts should prioritize tracking and reporting ASP metrics.

Funding: None

Disclosures: None
Duodenoscope Medical Device Reports Associated with Patient Infection, Patient Exposure, or Device Contamination
Authors: Connell Jian , Haugen Shanil , Ferriter Ann
Published: November 2020

Background: Each year, the FDA receives more than a million reports of suspected device-associated deaths, serious injuries, and malfunctions. Medical device reports (MDRs) are submitted to the FDA by mandatory reporters (manufacturers, importers, and device user facilities) and voluntary reporters such as healthcare professionals, patients, and consumers. The FDA uses MDRs to monitor device performance, including monitoring reports of infection or device contamination to detect potential device-related safety issues and to share this information in public communications. In this analysis, the FDA presents MDRs for duodenoscopes, which are a type of flexible endoscope that have been associated with infections in patients. Methods: For this analysis, we searched the MDR database for duodenoscope reports submitted between January 2015 and July 1, 2019. MDRs were classified into clinical risk categories based on the MDR’s text narratives as patient infection (indicated the presence of infection in patients potentially transmitted by the device), patient exposure (indicated a contaminated device has been used in a patient, but the MDR lacks clear mention of patient infection), or device contamination (indicated that the device was contaminated, but no mention of device use in patients or patient infection). Results: Overall, 1,115 duodenoscope reports related to a patient infection, patient exposure, or device contamination for devices marketed inside and outside the United States were received from January 2015 to mid-2019. Among them, 79 MDRs were received for deaths in patient infection, patient exposure, or device contamination reports. The number of reported infections decreased from 247 MDRs in 2015 to 55 MDRs in the first half of 2019. Furthermore, the number of reported deaths decreased from 25 MDRs in 2015 to 2 MDRs reported in the first half of 2019. Conclusions: The MDR data indicate a decrease in the number of reported infections. The decrease in infections suggests that efforts to reduce the risk of infection from duodenoscopes have yielded improvements; however, additional improvements are necessary to further decrease the risk of infection.

Funding: None

Disclosures: None
Effect of Testing Methods on Incidence of Clostridioides difficle Infection Rates in Veterans’ Affairs Medical Centers
Authors: McCauley Brian , Simbartl Loretta , Evans Martin , Gamage Shantini , Roselle Gary
Published: November 2020

Background: Healthcare-associated Clostridioides difficile infection (CDI) rates have been decreasing in Department of Veterans’ Affairs (VA) acute-care medical facilities since the CDI Prevention Initiative began in 2012. Assessment of rates, however, is complicated by changing surveillance definitions and diagnostics. Over the past 2 years, the VA has adopted the less stringent surveillance definitions of the NHSN for hospital-onset healthcare-facility–associated (HO-HCFA) CDI (onset on or after day 4 of hospitalization) than was originally used (>48 hours after admission). New diagnostic testing methods have been developed, but variabilities in the reliability of testing methods for the diagnosis of CDI in patients have been detected, thus not yielding a gold standard test. As a result, some facilities use nucleic acid amplification testing (NAAT) for CDI diagnosis and reporting whereas others use a 2-step process of NAAT followed by a toxin enzyme immunoassay (EIA) test, with the latter determining positivity for reporting (as allowed by the NHSN). We reviewed CDI rates at facilities performing one-step and two-step testing to determine whether the testing protocol may be influencing CDI rate reporting. Methods: Data on HO-HCFA CDI rates entered monthly in fiscal year (FY) 2018 (October 2017 through September 2018) and FY2019 (October 2018 through September 2019) by each acute-care facility into the VA Inpatient Evaluation Center (IPEC) database were analyzed. HO-HCFA CDI rates in facilities that used NAAT in FY2018 and switched to in the 2-step NAAT plus EIA in FY2019 were compared to rates in facilities used NAAT alone for both FY2018 and FY2019. Statistical regression analysis was performed. Results: From FY 2018 through FY2019, 70 facilities performed NAAT for the entire 2-year period. Overall, 7 facilities performed NAAT for FY 2018 and then switched to NAAT + EIA in FY2019. We detected no significant decrease in HO-HCFA CDI rates in FY 2018 when both groups were using NAAT (P = 0.21) (Fig. 1). However, in FY2019, there was a significant decrease in HO-HCFA CDI rates for those facilities that performed the 2-step testing versus those facilities that continued to use strictly NAAT alone (P < .0001). Conclusions: HO-HCFA CDI rates decreased for those VA acute-care facilities that switched to 2-step testing, and this finding highlights implications for assessing rates over time. Given the variable reliability of the toxin test, individual patient consideration for therapeutic decisions is reasonable.

Funding: None

Disclosures: None
Effect of Water Chlorination on Development and Persistence of Biofilm in Shower Heads
Authors: Marshall Caroline , Denton Sven , Christie Ian , Orr Liz
Published: November 2020

Background: A cluster of sternal surgical site infections caused by Pseudomonas aeruginosa led to sampling of shower heads in patient rooms. Multiple subtypes of Pseudomonas aeruginosa were found and were genetically diverse from the patient isolates. Visible biofilm was found in showerheads in the cardiothoracic ward. Ways of minimizing formation and persistence of biofilm in the shower heads were sought. Methods: A low-dose chlorination dosing system was introduced in September 2018 to the circulating warm-water system supplying the building block where the cardiac surgery ward is situated. Of the 145 showers in that block, 70 shower heads were sampled and the shower heads were replaced. Of these, 35 were sampled at 3 months and 35 were tested at 6 months (biofilm prevention group). Of the remaining 70 shower heads, 35 were tested at 3 months and 35 at 6 months (biofilm removal group). Heterotrophic colony count (HCC) in CFU/mL was chosen as the outcome measure. Analysis was conducted in accordance with AS 4276.3.2 (2003). The microbial growth data followed a log-normal distribution due to the exponential growth of bacteria. The natural log of the data was therefore calculated, and results from each period were compared using analysis of variance (ANOVA). Free chlorine residual levels were controlled using a combination of feed-forward and oxidation reduction potential (ORP) feedback control, and levels were retested and adjusted during the review period using N,N-diethyl-p-phenylenediamine (DPD) chemistry. Results: Mean and median levels of log HCC data are shown in Fig. 1. We detected a statistically significant difference in HCC between the 6-month-old untreated shower heads (group B) and treated shower heads (Group D) (P < .001). Hypochlorite was generally dosed at a concentration of 0.5 mg/L free chlorine for the first 3 months, and 1.5 mg/L for the second 3 months. Approximately 65% of the chlorine was lost as it travelled around the system. Discussion: Waterborne pathogens, especially multiresistant Gram-negative bacilli, have been increasingly recognized as hospital-acquired pathogens. Many instances of the transmission of these pathogens have been reported, from premise plumbing to patients, and have been confirmed using molecular typing techniques. Conclusions: A low-dose chlorination system of the circulating warm-water supply seemed effective in preventing biofilm formation and reducing existing biofilm in shower heads using HCCs as a measure of biofilm. This information adds to the potential armamentarium for controlling the spread of these waterborne pathogens.

Funding: None

Disclosures: None