bluuebunny/crossref_metadata_2025 huggingface dataset:
Trends in Staphylococcus aureus Bloodstream Infections in Nursing Homes in Monroe County, New York
Authors: Tracy Marissa , Felsen Christina B. , Gellert Anita , Dumyati Ghinwa
Published: November 2020

Background: Methicillin-resistant Staphylococcus aureus (MRSA) bloodstream infections (BSIs) are common in hospitals and nursing homes. Infection prevention efforts reduced MRSA BSI in hospitals but the trend in nursing homes is not well described. In addition, the contribution of methicillin sensitive S. aureus (MSSA) to the total burden of invasive S. aureus (iSA) in nursing homes remains unknown. Methods: As part of the CDC Emerging Infections Program, we conduct population-based surveillance for iSA infections in Monroe County, New York. Case patients were county residents with S. aureus isolated from a sterile site. Our analysis was limited to data from 2009–2018 for MRSA and 2015–2018 for MSSA and to cases classified as hospital-onset (HO, positive culture ≥3 calendar days after admission) or nursing home-onset (NHO, positive culture in nursing homes or within 3 days of hospital admission from a nursing home). Risk factors for iSA BSI in nursing homes were compared using the χ2 and Student t tests in SAS version 9.4 software. Results: During 2009–2014, 664 MRSA cases occurred and 427 (64%) were BSIs. Of these, 228 (53%) were NHO and 199 (47%) were HO. The BSI incidence per 100,000 population of NHO cases declined from 7.9 in 2009 to 2.8 in 2014, mirroring the decline in HO incidence from 8.7 in 2009 to 3.1 in 2014 (Fig. 1). During 2015–2018, 203 MRSA cases (163 BSIs, 80%) and 235 MSSA cases (163 BSIs, 69%) occurred. Of the 163 MRSA BSIs, 94 (58%) were NHO and 69 (42%) were HO, whereas of the 235 MSSA BSIs, only 56 (34%) were NHO and 107 (66%) were HO. MRSA BSI incidence per 100,000 population in both settings plateaued during 2015–2018 (Fig. 1) and MSSA NHO BSI incidence was lower than HO (1.9 NHO vs 3.6 HO). The total iSA BSI incidence was similar in both settings (5.9 vs 5.0 per 100,000 population in HO and NHO, respectively). NHO MSSA and MRSA cases have similar risk factors for BSI; 45 (30%) had decubitus ulcers, 34 (23%) were on chronic dialysis, 41 (27%) had a CVC in place within 2 days of BSI onset, and 63% had prior healthcare exposures. Most of these developed within 4 weeks of hospital discharge (Fig. 2). Conclusions: The incidence of MRSA BSI in nursing homes has declined since 2009 but plateaued starting in 2015. Compared to MRSA, MSSA caused fewer BSIs in nursing homes; however, iSA risk factors, including previous healthcare exposure, were similar. Continued study is needed to identify interventions effective against all iSA infections in nursing homes.

Funding: None

Disclosures: None
Tuberculosis Exposure and Conversion Rates Can Guide Deimplementation of Annual Tuberculosis Screening
Authors: Meacham Holly , Kobayashi Takaaki , Alsuhaibani Mohammed , Holley Stephanie , Edmond Michael , Diekema Daniel , Dains Angie , Abosi Oluchi , Kukla Mary , Jenn Kyle , Salinas Jorge
Published: November 2020

Background: The CDC recently updated recommendations on tuberculosis (TB) screening in healthcare facilities, suggesting the discontinuation of annual TB screening. However, hospitals may opt to continue based on their local TB epidemiology. We assessed TB infection control parameters in our facility to guide the implementation of the new CDC recommendations. Methods:We retrieved data for patients with an International Classification of Disease, Tenth Revision (ICD-10) code for TB treated at the University of Iowa Hospitals and Clinics during 2016–2019. We supplemented our search with microbiology data: culture or PCR for Mycobacterium tuberculosis. Based on manual chart review, we adjudicated each patient as active TB, latent TB, previously treated TB, unclear history, or no TB. We further labeled active TB cases based on their risk of transmission (pulmonary or extrapulmonary cases that underwent an aerosol generating procedure). We then calculated the number of exposure events associated with those patients and tuberculin skin test (TST) conversion rates among the exposed. Results: During 2016–2019, we identified 197 patients based on ICD-10 codes. In total, 10 additional patients were detected by microbiology data review. Of these 207 patients, 48 (23.2%) had active TB: lung, n = 24 (50%); lymph node, n = 9 (19%); bone or spine, n = 5 (10%); eye, n = 3 (6%); disseminated, n = 2 (4%); pleura, n = 2 (4%); skin abscess, n = 2 (4%); and meningitis, n = 1 (2%). Of the 24 pulmonary patients, 6 (25%) had either a positive smear or a cavity on imaging. In total, 159 patients were excluded: no TB, n = 22 (14%); latent TB, n = 27 (17%); old or treated TB, n = 93 (58%); and unclear history, n = 9 (6%). Of the 48 cases with active TB, 31 (65%) were deemed potentially infectious. Also, 10 cases (32%) led to the exposure of 204 healthcare workers (HCWs). Baseline and postexposure TST were available for 179 HCWs (88%); 72 (35%) followed up in the employee health clinic within the 8–12 weeks after exposure. Of 161 HCWs with a negative TST at baseline, no conversions occurred. Of 18 HCWs with positive TST at baseline, no HCW developed symptoms during the observation period. Conclusions: Nearly one-third of infectious TB cases led to HCW exposures in a low-incidence setting. However, no TST conversions or active TB infections were seen. Exposure and conversion rates are useful indicators of TB infection control in healthcare facilities and may help guide implementation of the new CDC TB control recommendations.

Funding: None

Disclosures: None
Using a Human Factors Framework to Assess Clinician Perceptions of and Barriers to High Reliability in Hand Hygiene
Authors: Vaughan Ana Maria , Sandora Thomas J.
Published: November 2020

Background: Hand hygiene is essential to prevent healthcare-associated infections, but adherence among clinicians remains low. Objective: We used a human factors framework to understand clinician perceptions of and barriers to achieving high reliability in hand hygiene. Methods: The Systems Engineering Initiative for Patient Safety 2.0 model was used to develop a 24-item electronic survey. Perceived barriers to hand hygiene were classified into several domains: technology and tools, person, organization, tasks, environment, and care processes. After pilot testing, the survey was distributed to a stratified random sample of attending physicians, nurse practitioners, and physician assistants in medical specialties and surgery-anesthesia at a quaternary-care pediatric hospital. Frequencies, percentages, and descriptive statistics were used to summarize responses. Results: Of 200 clinicians, 61 (31%) responded to the survey: 74% were attending physicians, 18% were nurse practitioners, and 7% were physician assistants. Moreover, 51% of respondents represented medical specialties, and 49% came from surgical disciplines or anesthesia. Respondents had served a median 12 years (IQR, 5–19 years) in their current role. Overall, 70% perceived hand hygiene to be “essential” among patient safety issues at the institution, and 84% agreed that leadership openly promotes hand hygiene. Additionally, 97% believed personal hand hygiene efforts were effective in preventing healthcare-associated infections. The availability of alcohol-based hand rub and being a good example for colleagues were perceived as “very effective” in permanently improving hand hygiene reliability by most respondents (87% and 67%, respectively). Furthermore, 77% of clinicians reported alcohol-based hand rub dispensers to be “sometimes” or “often” empty; 52% cited distractions in the workplace as hindrances to hand hygiene; and 21% reported that peers do not openly promote hand hygiene. One-quarter of the respondents indicated that the layout of patient care areas was not conducive to performing hand hygiene. Staffing shortages and the pace and demands of work precluded hand hygiene for 15% and 11% of respondents, respectively. Conclusions: Most clinicians view hand hygiene as essential to patient safety, but aspects of organizational culture, environment, tasks, and tools were identified as barriers to high performance reliability. These data can inform efforts to use human factors engineering principles to optimize systems and organizations to more effectively promote hand hygiene.

Funding: None

Disclosures: None
Using Basic Principles of an Outbreak Investigation to Investigate Fractured Central Venous Catheter Hubs
Authors: Honeycutt Michele , Wisdom Christy , Barron Sharon , Capouya Jared
Published: November 2020

Background: Central venous catheters (CVCs) are used to provide necessary vascular access. Mechanical issues with the catheters, such as fractures, result in a break in the sterility of the line, increasing the patient’s risk for infection or other adverse events. During a 5-month period in 2018, 15 CVCs (involving 13 patients) were noted to have cracked hubs. Methods: An outbreak should be suspected when a number of adverse events occur above the expected rate. We used a standardized process, Association for Professionals in Infection Control and Epidemiology (APIC) Basic Principles of an Outbreak Investigation, to conduct the epidemiological investigation of the outbreak.Results: All 15 CVCs required replacement, and 1 case of bacteremia was recorded. We suspect that the underlying cause was related to changes in the manufacturing process of hubs along with the product used to prepare the hubs prior to access (Table 1). Conclusions: Following an outbreak investigation process to investigate a noninfectious related outbreak can ensure that a thorough and comprehensive investigation is being completed. Early recognition of an outbreak is essential to recognition of the outbreak and the implementation of mitigation strategies. Inconsistent reporting of adverse events related to mechanical issues with the catheters may have contributed to a delay in recognition.

Funding: None

Disclosures: None
Application of a Continuously Active Antimicrobial Surface Coating in Two Professional Sports Training Facilities
Authors: Grossman Gavriel , Beck Valerie , Watson Dan , Toklu Ece , El-Sayed Maha
Published: November 2020

Background: The role of surface contamination in infections is of interest in healthcare as well as other industries, especially where infections incur high cost. One such industry is professional sports, where infections pose significant risks to players and the organizations that employ them. Sports training facilities experience highly variable occupancy rates due to differing seasonal activities, presenting a measurement challenge because the relationship between occupancy and surface contamination is not well described. In a recent publication, a continuously active antimicrobial (CAA) surface coating demonstrated a reduction in bacterial bioburden in ICUs alongside a reduction in healthcare-associated infections (HAIs). Objective: We investigated the impact of a CAA surface coating on bioburden in 2 professional sports training facilities, despite changes in occupancy. Methods: A CAA surface coating was applied using an electrostatic sprayer to all surfaces in both facilities during a period of high-occupancy at facility A and during low occupancy at facility B. Surface cultures were taken using 3M Sponge-Sticks from lockers, gym equipment, and physiotherapy surfaces before treatment, 4–13 weeks after treatment at facility A and 4–23 weeks after treatment at facility B. Total aerobic bacteria counts were obtained by plating on tryptic soy agar, and geometric means of aerobic plate counts (APCs) were used to compare bioburden before and after treatment at both facilities and for an out-of-efficacy period at facility B (17–23 weeks). Occupancy rates were monitored as person days per week (pd/w) over the course of the study. Results: APC counts at facility A decreased 61% (585 CFU/100 cm2 to 226 CFU/100 cm2) from baseline to posttreatment, and occupancy remained constant (165 pd/w to 171 pd/w). At facility B, there was no significant change in APC (76 CFU/100 cm2 to 80 CFU/100 cm2), although occupancy increased >13,000% during the treatment period (3 pd/w to 386 pd/w). During the out-of-efficacy period at facility B, total bacteria increased 170% (217 CFU/100 cm2) compared to the treatment period, and the occupancy remained relatively constant (344 pd/w). Conclusions: Levels of bioburden were significantly influenced by the application of the CAA surface coating, especially considering the variation in occupancy in both facilities before, during, and after the efficacy period. Facility A saw a significant reduction in bioburden during the treatment period (P < .0001), and a significant increase was observed at facility B during the out-of-efficacy period (P < .0001) despite constant occupancy rates, demonstrating the ability of the surface coating to reduce bioburden levels despite large changes in occupancy.

Funding: Allied BioScience, Inc, provided Funding: for this study.

Disclosures: Gavri Grossman, Valerie Beck, and Daniel S Watson report salary from Allied BioScience.
One Health: Farmworker Perceptions of Antibiotic Resistance and Personal Protective Practices on Wisconsin Dairy Farms
Authors: Konkel Ali , Kates Ashley , Knobloch Mary Jo , Safdar Nasia , Byrs Nicole , Steinberger Andrew , Young Amanda , Shutske John , Ruegg Pamela , Sethi Ajay , Goldberg Tony , de Campos Juliana Leite , Suen Garret
Published: November 2020

Background:
Antimicrobials are used on dairy farms for preventing disease and treating common infections such as mastitis. Objective: We aimed to understand farmworker practices that potentially contribute to transmission of antimicrobial resistance bacteria and their genes (ARG) among animals and farm workers, and to identify human behavioral interventions to reduce risk. Methods: Focus groups with farm workers were held at 8 dairy farms across Wisconsin selected to represent a range of antibiotic use in cattle. We explored the nature of potentially high-risk practices and farm-worker knowledge and experiences with antibiotic use and resistance. Farm workers were asked to describe common tasks, including hand hygiene and eating practices, and the policies guiding these practices. Focus groups were conducted in English and Spanish guided by the Systems Engineering in Patient Safety (SEIPS) framework, adapted for an agricultural context. Discussions were recorded, transcribed, and translated. A content analysis was conducted to identify themes. Dedoose version 8.0.35 software was used to organize the data. Results: In total, 10 focus groups were conducted on 8 farms. Knowledge of when to use antibiotics for human health varied; upset stomach, headache, and flu symptoms were suggested as appropriate uses. Few workers had personal experience with antibiotic resistance at home or on the farm. Some displayed knowledge of the role of antibiotic stewardship in preventing the spread of ARG (“I guess all dairy farmers have a responsibility not to overdo it”). Others associated the risk of spread with the consumption of raw milk or meat from cows receiving antibiotics. Knowledge of personal protective equipment was stronger among workers who commonly reported glove use. Some perceived glove use to be mandatory, and others chose to wear gloves in the perceived absence of written rules. Some workers reported changing gloves numerous times throughout the day, and others did so less frequently or “only when they rip.” In general, hand hygiene practices are guided by individual knowledge of established rules, beliefs about risk, and personal discretion. Conclusions: Knowledge about mechanisms of spread of ARGs varies among workers on Wisconsin dairy farms and reflects a combination of farm-level rules, experience, individual knowledge, and beliefs. Applying knowledge from the healthcare setting to reduce ARG spread into agriculture is crucial to the tenets of One Health. Programs to reduce ARG spread on dairy farms should focus on proper hand hygiene and PPE use at the level of knowledge, beliefs, and practices.

Funding: Funding: was provided by the USDA-NIFA Food Safety Challenge (grant no. 2017-68003-26500).

Disclosures: None
Access to Alcohol-Based Hand Rub Is Associated With Improved Hand Hygiene in an Ebola-Threatened District of Western Uganda
Authors: Lamorde Mohammed , Lozier Matthew , Kesande Maureen , Akers Patricia , Tumuhairwe Olive , Watsisi Martin , Omuut Winifred , Person Margaret , Murphy Jen , Quick Rob , Berendes David
Published: November 2020

Background: Ebola virus disease (EVD) is highly transmissible and has a high mortality rate. During outbreaks, EVD can spread across international borders. Inadequate hand hygiene places healthcare workers (HCWs) at increased risk for healthcare-associated infections, including EVD. In high-income countries, alcohol-based hand rub (ABHR) can improve hand hygiene compliance among HCWs in healthcare facilities (HCF). We evaluated local production and district-wide distribution of a WHO-recommended ABHR formulation and associations between ABHR availability in HCF and HCW hand hygiene compliance. Methods: The evaluation included 30 HCF in Kabarole District, located in Western Uganda near the border with the Democratic Republic of the Congo, where an EVD outbreak has been ongoing since August 2018. We recorded baseline hand hygiene practices before and after patient contact among 46 healthcare workers across 20 HCFs in August 2018. Subsequently, in late 2018, WHO/UNICEF distributed commercially produced ABHR to all 30 HCFs in Kabarole as part of Ebola preparedness efforts. In February 2019, our crossover evaluation distributed 20 L locally produced ABHR to each of 15 HCFs. From June 24–July 5, 2019, we performed follow-up observations of hand hygiene practices among 68 HCWs across all 30 HCFs. We defined hand hygiene as handwashing with soap or using ABHR. We conducted focus groups with healthcare workers at baseline and follow-up. Results: We observed hand hygiene compliance before and after 203 and 308 patient contacts at baseline and follow-up, respectively. From baseline to follow-up, hand hygiene compliance before patient contact increased for ABHR use (0% to 17%) and handwashing with soap (0% to 5%), for a total increase from 0% to 22% (P < .0001). Similarly, hand hygiene after patient contact increased from baseline to follow-up for ABHR use (from 3% to 55%), and handwashing with soap decreased (from 12% to 7%), yielding a net increase in hand hygiene compliance after patient contact from 15% to 62% (P < .0001). Focus groups found that HCWs prefer ABHR to handwashing because it is faster and more convenient. Conclusions: In an HCF in Kabarole District, the introduction of ABHR appeared to improve hand hygiene compliance. However, the confirmation of 3 EVD cases in Uganda 120 km from Kabarole District 2 weeks before our follow-up hand hygiene observations may have influenced healthcare worker behavior and hand hygiene compliance. Local production and district-wide distribution of ABHR is feasible and may contribute to improved hand hygiene compliance among healthcare workers.

Funding: None

Disclosures: Mohammed Lamorde, Contracted Research - Janssen Pharmaceutica, ViiV, Mylan
Changes in Nursing Team Composition and Risk of Device Associated Infection in Intensive Care Units
Authors: Shah Hirsh , Knowlson Shelley A , Roberson Audrey , Godbout Emily , Stevens Michael , Bearman Gonzalo , Doll Michelle Elizabeth
Published: November 2020

Background: The relationship between nursing staffing and healthcare-associated infections (HAIs) has been explored previously, with conflicting results. Intensive care units increasingly struggle to maintain trained staff. In May 2019, clinical coordinator (CC) roles changed to include 50% of time in direct patient care rather than supportive roles. In this study, we used shift records to explore the impact of staffing on HAI risk. Methods: Daily staffing records from December 2018 August 2019 for the medical-respiratory unit (MRICU) and the cardiac surgery unit (CSICU) were reviewed. Both units staff a fixed 2:1 patient:nurse ratio (1:1 for specific cardiac surgeries). Staff deficiency was defined as assignments filled by nurses pulled from other units/supplemental/or CC roles. Staff support comprised nursing assistants and unit secretaries. Census, admissions, and complexity score for number of devices were used to estimate care acuity. In CSICU, additional points were added for continuous renal replacement therapy, extracorporeal membrane oxygenation, ventricular assist devices, transplant, operative cases. NHSN definitions were used for central-line–associated bloodstream infections (CLABSIs) and catheter-associated urinary tract infections (CAUTIs). The Spearman correlation coefficient was used to determine relationship between staffing, acuity, and risk window for HAI (days 1–10 preinfection). Linear regression was used to determine whether staffing deficiencies and/or support associate with the risk window prior to HAI. The final model included census and complexity score as control variables. The statistical analysis was performed using SAS version 9.4 software (Cary, NC). Results: Overall, 8 HAIs occurred in the study period: medical-respiratory intensive care unit (MRICU: 3 CAUTIs and 1 CLABSI) and cardiac surgery intensive care unit (CSICU: 1 CAUTI and 3 CLABSIs). Staffing and census fluctuated daily (Table 1). Total number of nurses correlated with complexity scores (r = 0.35; P < .0001) and daily census (r = 0.31; P < .0001) in the CSICU, and the census (r = 0.12; P = .04) in the MRICU. Nursing deficiencies correlated with days 1–10 before infection (r = 0.20; P = .0013) in the CSICU. In the regression model for the CSICU, nursing deficiencies increased in the time prior to HAI (P = .004), and support staff decreased in the time prior to HAI (P = .034) while controlling for census and complexity. These relationships were not significant in the MRICU. Conclusion: The lack of core nurses to support the staffing structure in CSICU correlated with periods prior to CLABSI or CAUTI in this small, unit-based study. Failure to recruit and retain highly skilled core staff may produce HAI risks, particularly for CLABSI in specialized units.

Funding: None

Disclosures: Michelle Doll, Research Grant from Molnlycke Healthcare
From Outbreak to Compliance and Beyond: UAB Medicine’s Successful Implementation of a Water Safety Program
Authors: Salah Shatha , Lee Rachael A. , Camins Bernard , Sidari Frank
Published: November 2020

Background:
Pre-emptive management of the water supply can reduce hospital-onset legionellosis associated with building water systems. In 2014, an outbreak of Legionella pneumonia occurred in a 1,150-bed academic medical center (with ∼0.557 km2 or ∼6 million ft2 of space) among hematology-oncology patients. A comprehensive water safety and management program was implemented after the outbreak was controlled. We describe our experience implementing this prevention program. Methods: After the Legionella outbreak was controlled, an air and water safety committee (AWSC) was established and cochaired by the healthcare epidemiologist and the chief facilities officer. The AWSC established protocols for proactive environmental testing and the development of the an infection control risk assessment (ICRA) dedicated to water safety known as the water system construction and renovation risk assessment (WSCRRA).The water system management plan (WSMP) was developed (prior to the publication of ASHRAE 188) to direct the risk assessments and mitigation of any risks throughout the campus. Results: The WSMP identifies critical control measures, points, and limits that need to be maintained to control and monitor Legionella growth in the water systems. A control point is any step in a process at which biological, chemical, or physical factors can be controlled. The UAB Medicine WSMP includes 7 control points that are monitored on a daily basis. Examples of these control steps include monitoring of the hot water temperatures at the water heaters and distal outlets, managing the levels of mono-chloramines and chlorines in the water system, and managing water system components. To validate the efficacy of the WSMP, >610 water samples are collected from 19 hospital buildings over a year to be tested for Legionella. The results of water testing have shown significant decrease in distal site positivity due to managing and controlling these control points. This WSMP also evaluated the efficacy of 2 different methods for disinfecting water systems on campus as a corrective measure to Legionella growth. These methods are hyperchlorination and temporary copper silver ionization; based on the culture results of the water samples collected post disinfection, WSMP data show that the copper silver ionization method was more effective than hyperchlorination in controlling Legionella growth and decreasing the distal site positivity. Conclusions: The WSMP has provided ongoing management of building water systems and proactive actions around construction and renovation projects that involve water systems to prevent healthcare-acquired legionellosis. We strongly recommend other healthcare facilities to implement a similar program to avoid outbreaks.

Funding: None

Disclosures: Rachael Anne Lee reports speaker honoraria from Prime Education, LLC.
Point of Care Stations: A Novel Way to Improve Stethoscope Hygiene
Authors: Gibbens Kimberly , Hota Susy , Seidelin Peter , Rebelo Carly , Ross Kathleen , Vaisman Alon
Published: November 2020

Background: Stethoscopes are known to be highly contaminated by a multitude of bacteria and therefore carry the potential to transmit pathogens within hospitals. North American infection prevention groups recommend low-level disinfection of stethoscopes for bioburden reduction between patients; however, adherence remains low in inpatient settings. Given that the lack of access to disinfection materials is the most commonly reported barrier to stethoscope hygiene, we studied an intervention using a point-of-care approach to increase stethoscope hygiene compliance among healthcare workers in critical care units. Methods: This quality improvement study was conducted in 2 critical-care units of a quaternary-care, academic, health sciences center in Toronto, Canada. We designed novel stethoscope hygiene stations consisting of a wall-mounted board with alcohol wipes, hooks for drying, and hand sanitizer dispensers to combine stethoscope and hand hygiene. Observations of stethoscope disinfection events per opportunity were collected by trained human auditors before and after the multimodal intervention, which consisted of the installation of 14 stations at the entrances of single-patient ICU rooms, accompanied by educational lectures and infographic dissemination. Anonymous feedback forms were used to gather information on healthcare workers’ stethoscope hygiene knowledge and behavior before and after the intervention. Results: In total, 124 observations were collected using convenience sampling between February and July 2019. Overall stethoscope hygiene compliance increased significantly from a baseline of 38% to 62% (P = .0316) (Fig. 1). Physician adherence to stethoscope disinfection increased by 22%. During the study period, hand hygiene compliance remained unchanged at 75%. Also, 74 healthcare providers completed feedback forms; they revealed an increase in awareness of stethoscope hygiene policies and/or recommendations (9% to 41%) and self reports of stethoscope hygiene compliance (28% to 44%). Conclusions: The implementation of stethoscope hygiene stations, coupled with an educational initiative, lead to a significant increase in overall stethoscope hygiene compliance among healthcare workers. Future quality improvement initiatives can adapt this strategy to promote disinfection and reduce pathogen burden of other personal and multiuse medical equipment.

Funding: None

Disclosures: Susy Hota reports contract research for Finch Therapeutics.
Repeated Prevalence Surveys and Admission Screening for Candida auris at One Long-Term Acute-Care Hospital, Chicago, 2016–2019
Authors: Pacilli Massimo , Walblay Kelly , Adil Hira , Xydis Shannon , Kerins Janna , Valley Ann , Black Stephanie
Published: November 2020

Background: Since the initial identification of Candida auris in 2016 in Chicago, ongoing spread has been documented in the Chicago area, primarily among older adults with complex medical issues admitted to high-acuity long-term care facilities, including long-term acute-care hospitals (LTACHs). As of October 2019, 790 cases have been reported in Illinois. Knowing C. auris colonization status on admission is important for prompt implementation of infection control precautions. We describe periodic facility point-prevalence surveys (PPSs) and admission screening at LTACH A. Methods: Beginning September 2016, we conducted repeated PPSs for C. auris colonization at LTACH A. After a baseline PPS, we initiated admission screening in May 2019 for patients without prior evidence of C. auris colonization or infection. C. auris screening specimens consisted of composite bilateral axillary/inguinal swabs tested at public health laboratories. We compared a limited set of patient characteristics based on admission screening results. Results: From September 2016 through October 2019, 277 unique patients were screened at LTACH A during 10 PPSs. Overall, 36 patients (13%) were identified to be colonized. The median facility C. auris prevalence increased from 2.8% in 2016 to 37% in 2019 (Fig. 1). During May–September 2019, among 174 unique patients admitted, 151 (87%) were screened for C. auris colonization on admission, of whom 18 (12%) were found to be colonized. Overall, 14 patients were known to have C. auris colonization on admission and were not rescreened, and 9 patients were discharged before screening specimens could be collected. A significantly higher proportion of patients testing positive for C. auris on admission had a central venous catheter or a peripherally inserted central catheter or were already on contact precautions (Table 1). The PPS conducted on October 1, 2019, revealed 5 new C. auris colonized patients who had screened negative on admission. Conclusions: Repeated PPSs at LTACH A indicated control of C. auris transmission in 2016–2017, followed by increasing prevalence beginning in May 2018, likely from patients admitted with unrecognized C. auris colonization and subsequent facility spread. Admission screening allowed for early detection of C. auris colonization. However, identification during subsequent PPS of additional colonized patients indicates that facility transmission is ongoing. Both admission screening and periodic PPSs are needed for timely detection of colonized patients. Given the high C. auris prevalence in LTACHs and challenges in identifying readily apparent differences between C. auris positive and negative patients on admission, we recommend that all patients being admitted to an LTACH in endemic areas should be screened for C. auris.

Funding: None

Disclosures: None
Performance of Mumps PCR and Serologic Testing During a University-Associated Mumps Outbreak in Charleston, SC
Authors: Stoltz Kristen , Puri Shruti , Curry Scott
Published: November 2020

Background: Sensitive diagnostic testing is critical in responses to mumps outbreaks. PCR testing of buccal swabs is the most sensitive diagnostic test, but IgM serology remains standard in much of the United States. We provided testing guidance stressing use of mumps PCR to ambulatory clinics and emergency departments in addition to the standard serologic testing for acute mumps beginning in 2018. We compared the performance of PCR and IgM serology to assess cases of parotitis presenting during a community outbreak of mumps in fall 2019 associated with a university in Charleston, SC. Methods: All patients tested for mumps who presented to our facility (ER and ambulatory clinics) with mumps PCR and/or mumps IgM ordered between September 2019 and January 2020 were included. Mumps PCRs were sent to a commercial reference laboratory (ARUP). Confirmed cases were defined as having a positive mumps PCR and/or IgM with parotitis. Clinical characteristics of mumps patients including age, duration of symptoms, MMR history, and association with the university were obtained by chart review. Results: Mumps was confirmed in 15 of 44 tested patients (34%), with 15 of 15 mumps patients (100%) having positive PCR and 1 of 15 patients (7%) and 1 of 15 patients (7%) having positive and equivocal mumps IgM serologies, respectively. Only 1 patient who did not meet our mumps case definition (no CT imaging evidence of parotitis, no fevers, chronic sinus symptoms) had a positive PCR and had recent receipt of a third MMR dose in response to the ongoing outbreak. Median age for mumps patients was 22 years (range, 15–48) with 8 of 15 cases (53%) detected among university students and an additional 2 cases having close connections to the university associated with the outbreak. Only 1 of 15 mumps patients (6.7%) was febrile at presentation (median temperature, 37.2°C) and mumps cases presented for testing ≤3 days for 7 of 15 cases (47%) (range, 0–13 days from symptom onset). No cases were diagnosed by IgM only, and 10 of 15 mumps cases had some recollection of remote MMR immunization, whereas 6 of 15 (40%) had 2 documented MMR doses at <5 years of age. Conclusion: Serologic IgM testing for diagnosis of mumps appears insensitive for detection of cases in outbreaks within highly immunized adult patients. Although our recommended shift to PCR likely enhanced case finding during this outbreak, the potential for false-positive PCRs due to vaccine strain shedding following third-dose MMR immunization may also be considered a threat to the specificity of the test during outbreak situations.

Funding: None

Disclosures: None
Surgical Antibiotic Prophylaxis in Hysterectomy: Is Cefazolin Still the Best?
Authors: Valentyne Alyssa , Osman Fauzia , Al-Niaimi Ahmed , Pop-Vicas Aurora
Published: November 2020

Background: Prior studies suggest that cefazolin, widely used for antibiotic prophylaxis in hysterectomy, might not prevent surgical site infections (SSIs) as well as antibiotics with a broader antianaerobic antimicrobial spectrum. We compared the effectiveness of cefazolin versus antibiotic regimens with a broader antimicrobial spectrum in a ≥500-bed regional referral center. Methods: Study design: retrospective cohort. Population and setting: patients ≥18 years old who underwent hysterectomy between 1998 and 2018 at the University of Wisconsin Hospital. Analysis: propensity score matching with a caliper of 0.2 to select controls for cefazolin treatment, matching on: age, body mass index (BMI), diabetes, length of stay, duration of surgery, and preoperative renal function. We conducted a crude SSI incidence analysis and adjusted for additional covariates (malignancy, intraoperative temperature, and preoperative glucose level) using a Cox proportional hazards model. All analyses were conducted using STATA SE v15 software. Results: We had 4,087 hysterectomy patients, with 123 SSIs (3%). Among these SSIs, 46%, 11%, and 42% were superficial, deep, and organ-space, respectively. Malignancies were present in 83% of SSI patients, with 30% being ovarian cancer. Risk factors for SSI in the unmatched sample multivariable analysis (MV) were length of stay (aHR, 1.1; 95% CI, 1.05–1.1; P < .001), duration of surgery (aHR, 1.2; 95% CI, 1.1–1.32; P < .001), and BMI (aHR, 1.04; 95% CI, 1.02–1.06; P < .001). After propensity matching, 2,282 hysterectomies remained. In the crude incidence analysis, cefazolin (IR, 6.0) had a protective SSI effect compared to cefoxitin (IR, 7.1), ciprofloxacin/metronidazole (IR, 27.2), clindamycin/gentamicin (IR, 14.1), any antianaerobic regimen (IR, 8.0), and regimens not guideline recommended (IR, 11.7). In our MV analyses of cefazolin versus comparator antibiotic regimens, we found that hypothermia was consistently associated with a higher SSI risk (P ≤ .03). Receipt of a β-lactam antibiotic regimen was associated with a significantly lower SSI risk (aHR, 0.31; 95% CI, 0.11–0.89, P = .03), but cefazolin’s protective SSI effect was no longer statistically significant. Conclusions: We found that cefazolin had a lower SSI risk compared to other antibiotic regimens, including those with better antianaerobic spectrum, in our tertiary-care hospital’s 11-year high-risk cohort. Our analysis suggests that maintaining intraoperative normothermia and administering β-lactam antibiotic prophylaxis are important modifiable risk factors for SSI prevention.

Funding: None

Disclosures: None
Observed Time Burden With Isolation Precautions at Three University-Affiliated Hospitals in Korea
Authors: Kang JaHyun , Karlsson Omar , Yeon Bock-hui , Han Si-Hyeon , Kim Jae Yeun
Published: November 2020

Background: Isolation precautions (IPs; ie, patient isolation with transmission-based precautions) are essential in hospital infection control interventions to prevent the transmission of healthcare-associated infections. Because IPs require healthcare personnel (HCP) to use personal protective equipment (PPE; eg, gown, gloves, and mask) to enter patient isolation rooms and perform hand hygiene (HH) frequently, IPs are often regarded as cumbersome tasks and may lead to fewer HCP visits. This observation study examined the time burden of IPs (ie, PPE use and HH) from time spent on HCP tasks, including patient treatment and care, in patient isolation rooms. Methods: With institutional review board approval, participating hospitals were recruited. At each hospital, assigned infection control nurses observed HCP tasks at patient isolation rooms of interest and recorded each task’s duration, using a stopwatch or timer and an observation form. For each observation block (ie, a duty period at 1 observation unit, regardless of the number of observed isolation rooms), unit-related information was collected, including the numbers of hospitalized patients, admission patients, discharge patients, isolation patients, and nurses. For each block, IP proportions were calculated by total time spent on IP divided by the total time spent on all tasks. Descriptive statistics, t test, ANOVA, and regression analyses were conducted using STATA version 16.0 software. Results: Three university-affiliated hospitals (838 average hospital beds, range 811–855) participated from April 2 to May 18, 2019 (for 7–9 days). In total, 2,901 tasks were monitored and the total time spent was 164,973 seconds; most tasks were done by nurses (89.2%) and females (86.8%). Although the most time-intensive task was procedures (eg, intravenous infusion) followed by medication, PPE use was the most frequent task followed by HH (Table 1). Regarding IP proportions, an overall average of 23.6% of total task time was spent on IPs (16.1% for PPE use and 7.5% for HH) in patient isolation rooms (Table 2). Notably, tasks in the tuberculosis isolation room of hospital B showed a greater HH proportion (13.7%) than PPE proportion (13.5%) because HCP usually use N95 masks only. Wards, compared to intensive care units (ICUs), showed higher PPE proportions (19.2%), potentially due to PPE stock in the nurse station and less PPE education compared to ICUs. Conclusions: Our study results demonstrated the substantial amount of time spent on IP compliance among all task durations in patient isolation rooms. To improve IP compliance, this time burden needs to be considered with greater system support, such as more nursing staff.

Funding: This research was supported by the Basic Science Research Program through the National Research Foundation of Korea (NRF) funded by the Ministry of Education (Grant no. 2017R1D1A1B03036377).

Disclosures: None
A Descriptive Analysis of Infection Present at Time of Surgery (PATOS) in NHSN Surgical Site Infection (SSI) Data, 2015–2018
Authors: Konnor Rebecca , Russo Victoria , Dudeck Margaret A. , Allen-Bridson Katherine
Published: November 2020

Background: In 2015, the CDC NHSN introduced infection present at time of surgery (PATOS) as a required data element for reporting surgical site infections (SSIs). PATOS is the documented observation that infection was visualized during the operative procedure and at the same tissue level of subsequent SSI. PATOS SSIs are excluded from CDC calculations of SSI summary measures, the standardized infection ratios (SIRs), including the SSI SIRs used by CMS public reporting and payment programs. The characteristics of PATOS SSIs have not been assessed since its introduction, prompting interest in the review of these SSIs. This study describes PATOS SSI surveillance for 2015–2018, with specific focus on infections following colon surgery (COLO), the NHSN operative procedure category with highest reported incidence of PATOS. Methods: We analyzed all procedures and SSIs reported to the NHSN. Using measures of frequency, we quantified the proportion of SSI and PATOS SSI attributed to all procedures and to COLO specifically. The mid-p method was used for proportion comparison. Procedure and SSI data were described by year and characteristics. Results: Between 2015 and 2018, 12,046,033 procedures and 188,770 SSIs (2%) were reported. Of these SSIs, 22,096 (12%) were PATOS SSIs (Fig. 1). COLO accounted for 11% of all procedures reported, for a total of 1,328,852 procedures with 72,891 (5%) resulting in SSI. COLO accounted for 64% of PATOS SSIs. The proportion of SSIs reported as PATOS SSIs resulting from COLO increased from 18% in 2015 to 22% by 2018 (Fig. 2). The proportion of COLO PATOS SSIs was statistically different from the proportion of PATOS SSIs for all other procedures each year (P < .0001). Organ-space (OS) SSIs accounted for 76% of COLO PATOS SSIs (10,558 of 13,911), and most of these SSIs were SSI intra-abdominal infections (IABs) (91%). The proportion of COLO PATOS SSI superficial incisional primary (SIP) was statistically different from non-COLO PATOS SSI SIP (P = .0105) (Fig. 2). Of COLOs linked to PATOS SSIs, 53% were assigned dirty or infected wound classification. Conclusions: The increase in PATOS SSIs linked to COLO procedures underscores the importance of monitoring PATOS SSIs at the facility level. Focused validation of PATOS data is needed to identify reasons for this increase, which may include misapplication or misunderstanding of PATOS determinations. Validation may highlight the potential need for prevention strategies or interventions related to PATOS.

Funding: None

Disclosures: None
Admission Screening for Candida auris Among High-Risk Patient Populations
Authors: Spalding Christine D. , Adrian Zelazny , Kenosky Christina M. , Shallom Shamira J. , Syedmoussavi Seyedmojtaba , Segre Julia A. , Palmore Tara
Published: November 2020

Background:Candida auris is a highly transmissible healthcare-associated pathogen that can cause severe infection as well as long-lasting colonization. C. auris is often resistant to the antifungals that are commonly used to treat Candida infections, which may lead to clinical failure. Therefore, healthcare facilities must identify the organism quickly and implement strict precautions to prevent its spread. In 2019, the NIH Clinical Center instituted C. auris admission screening among its high-risk patient populations. Methods: Patients admitted to the NIH Clinical Center, a 200-bed research hospital, were identified on admission as having been hospitalized outside the United States in the prior 6 months. Admission screening began in August 2019. In September 2019, due to evolving regional epidemiology, we expanded surveillance criteria to include patients housed in any healthcare facility in the District of Columbia, Maryland, and Virginia metro area in the previous 6 months. Screening was performed as routine clinical care, and therefore did not require written informed consent. Swabs were obtained from nares, axilla and groin, with subsequent addition of mouth and toe web (BD ESwabs). Patients were placed on empiric contact isolation for at least 48 hours and concurrently screened for carbapenemase-producing organisms. Swabs were cultured on CHROMagar Candida and in Sabouraud dextrose broth with 10% NaCL and 50 mg/L chloramphenicol and gentamicin, and incubated for 14 days at 30°C and 40°C, respectively. Positive broth tubes were subcultured onto CHROMagar Candida. C. auris was identified by MALDI-TOF MS and ITS sequence analysis. Susceptibility testing was performed using Sensititre YeastOne Colorimetric assay. Whole-genome sequencing was used to identify clonal designations and genetic relatedness of isolates. Results: Since August 2019, 1 to 2 patients per week have been screened for C. auris. As of November 2019, 1 of 15 patients screened on admission grew C. auris from a groin swab. The patient, who had been hospitalized abroad, was found to be cocolonized with blaNDM-1+ E. coli and K. pneumoniae. Subsequent screening of other patients on the same ward identified no evidence of spread. Admission surveillance is ongoing. Conclusions: Healthcare-associated outbreaks can originate from C. auris–colonized patients. Admission surveillance of high-risk patients is intended to prevent transmission from undetected reservoirs. Our sampling of multiple sites, though laborious, may add to the data on C. auris colonization. Future plans include incorporating molecular testing and streamlining geographic criteria. C. auris admission screening has already identified one colonized patient, and will continue as a new and important patient safety measure at our hospital.

Funding: None

Disclosures: None
Admission Screening for Clostridium difficile Infection (CDI) in Bone Marrow Transplant Populations
Authors: Tarabay Jessica , Ayers Marie , Soni Tanushree , Langston Amelia , Bracewell Emily , Bell Christina , Crain Maria , Hutcherson Don , Smiley Mitzy
Published: November 2020

Background:Clostridium difficile infection (CDI) is the most common healthcare-associated infection (HAI) and is often associated with increased medical costs and longer lengths of hospital stay. Previous studies have highlighted that hematopoietic stem cell transplant (HSCT) recipients are at an increased risk for CDI of up to 33% from other hospitalized patients. Studies have also supported the prevalence of asymptomatic colonization with C. difficile among HSCT patients. Asymptomatic colonization with C. difficile is a significant risk factor for transmission of infection to other patients developing hospital onset (HO-CDI). Therefore, targeted infection prevention efforts, such as early identification of patients with community-onset (CO-CDI) and patients with asymptomatic colonization with CDI in HSCT patients, may be effective in reducing the occurrence of HO-CDI. We discuss the CDI admission screening protocol in Emory University Hospital’s (EUH) bone marrow transplant (BMT) unit. Methods: As part of an infection prevention initiative, a CDI screening protocol was implemented in December 2018 for all patients that admitted to the EUH inpatient BMT unit. Upon admission, patients were screened for CO-CDI symptoms, specifically loose or unformed stools. A C. difficile toxin assay PCR would be collected within the first 3 calendar days of admission for all patients screened. Patients with symptoms were placed on isolation precautions pending results of the C. difficile toxin assay. If a patient had a positive C. difficile toxin assay result, isolation precautions would be maintained for the duration of hospitalization regardless of symptoms. Patients who are were unable to produce a stool specimen on the first 3 days of admission were excluded from the screening protocol. Patients with positive C. difficile toxin assay PCRs were classified as CO-CDI and were treated. Results: Since implementation of the CDI screening protocol, 109 CDI events were identified from January 2019 to October 2019. Moreover, 79% of positive C. difficile toxin assays were collected within the first 3 calendar days of admission. HO-CDI has decreased from 78% in 2018 to 21% during the designated time frame. Conclusions: CDI screening upon admission of BMT populations has shown a decrease among HO-CDI by early identification of CO-CDI and CO asymptomatic colonization with C. difficile. This early identification has allowed rapid implementation of infection preventions precautions, thus reducing risk of unit-based transmission.

Funding: None

Disclosures: None