bluuebunny/crossref_metadata_2025 huggingface dataset:
Containment Strategies for Carbapenem-Resistant Enterobacteriaceae in Low- and Middle-Income Countries
Authors: Osuka Hanako , Park Benjamin J. , Lessa Fernanda
Published: November 2020

Background: Carbapenem-resistant Enterobacteriaceae (CRE) represent one of the most critical emerging antimicrobial-resistance threats globally. Data from low-and middle-income countries (LMICs) are increasingly reported as a part of global efforts to improve surveillance, and they demonstrate a high and increasing burden of CRE. However, containment of CRE using all recommended infection prevention and control (IPC) strategies requires substantial resources, which may be limited in LMICs. We conducted a review of the literature to better understand how approaches to CRE containment in LMICs have varied. Methods: We conducted a literature search using electronic databases (Medline, Embace, Cochrane Library, and Global Health) with no limit to study design or publication year. Search terms consisted of 3 categories: CRE, IPC, and LMIC. Additional publications were also identified from the references of identified articles. Publications were screened for eligibility; non-English articles and studies on other gram-negative organisms were excluded from the analysis. Control measures in included studies were categorized as active surveillance, hand hygiene, contact precautions, isolation, education, environmental control, monitoring and feedback, and other. Results: In total, 2,667 publications were identified using the databases and an additional 24 were manually identified. After deduplicating and screening for eligibility, 27 publications were included in the analysis. Overall, 21 publications (78%) were outbreak reports and 3 (11%) were quasi-experimental studies in settings of high rates of CRE. Also, 23 (85%) described a successful reduction in CRE. Among those 23 publications, 22 publications described adequate descriptions of IPC measures implemented, and the median number of IPC measures was 4.5 (range, 1–8). Environmental control was the most commonly utilized intervention (n = 19, 86%), followed by hand hygiene (n = 14, 64%) and contact precautions (n = 14, 64%). Three publications did not show a reduction in CRE despite the combination of IPC measures (median, 4.5). Overall, 13 publications utilized some method of active surveillance, but complete details on methodology were often lacking. In addition, 4 studies (15%) used only horizontal measures (defined as hand hygiene, environmental control, and/or education) and successfully controlled the CRE outbreaks. Conclusions: Among published reports, successful approaches to CRE control have been reported from LMICs. Use of only horizontal approaches, which are often lower cost and simpler to implement than some vertical strategies, have demonstrated some success; however, additional experience with identifying and implementing cost-effective strategies is needed.

Funding: None

Disclosures: None
Determining Antibiotic Use in Long-Term Care Facilities Across Tennessee
Authors: Adre Cullen , Ouedraogo Youssoufou , Evans Christopher David , Keaton Amelia , Kainer Marion
Published: November 2020

Background: Antibiotic stewardship is an area of great concern in long-term care facilities nationwide. The CDC promotes 7 core elements of antimicrobial stewardship. Based on information obtained from the Infection Control Assessment and Response (ICAR) Program, the 2 core elements most infrequently achieved by LTCFs are tracking and reporting. Currently, minimal data are available on antibiotic use (AU) in LTCFs in Tennessee. To address both issues, the Tennessee Department of Health (TDH) developed a monthly antibiotic use (AU) point-prevalence (PP) survey to provide LTCFs with a free tool to both track and report their AU and to gather data on how LTCFs are using antibiotics. Methods: We used REDCap to create a questionnaire to collect information on selected antibiotics administered in Tennessee LTCFs. This self-administered survey was promoted through the TDH monthly antimicrobial stewardship and infection control (ASIC) call as well as at various conferences and speaking engagements across the state. Antimicrobial stewardship leads for each facility were targeted. Antibiotics were grouped into 4 classes according to their indications: C. difficile infections, urinary tract infections, skin and soft-tissue infections (SSTIs) and respiratory infections. We determined AU percentage by dividing the number of days of therapy for a drug by a facility’s average census. Individualized reports are provided to each participating facility on a quarterly basis. Results: Currently, 16 facilities have participated in the survey. Overall, 40.7% of antibiotics prescribed were in the common for SSTI category and 39.3% were common for respiratory infections. The top 33 most commonly prescribed antibiotics were amoxicillin (156 days of therapy [DOT]), nitrofurantoin (92 DOT), and levofloxacin (88 DOT). The average percentage of residents on antimicrobials on the day of survey was 12.3%; within this group, 57% of antibiotics were initiated in the LTCF, whereas 43% were present upon admission. Conclusions: Early results from the TDH AU PP survey revealed that drugs commonly used for SSTIs and respiratory infection were the most common antibiotic prescriptions and a potential area of focus for TDH’s antimicrobial stewardship efforts. None of the 3 most frequently prescribed antibiotics, however, fall under the SSTI indication, despite SSTI being the most commonly prescribed indication based on the survey’s evaluation metrics. This finding could be related to the larger number of antibiotics that fall under the SSTI indication. Preliminary data are being used to guide the direction of TDH’s future ASIC calls to better suit disease states, which have room for improvement.

Funding: None

Disclosures: None
Digital Education on Prudent Antibiotic Use—Evaluation of a Massive Open Online Course for General Practitioners in Germany
Authors: Salm Florian , Kramer Tobias , Remschmidt Cornelius , Gastmeier Petra , Schneider Sandra
Published: November 2020

Background: Antimicrobial resistance is a growing global health problem predominantly driven by overuse of antibiotics. In humans, most antibiotics are used outside the hospital. Overprescribing for acute respiratory infections (ARIs) is common despite clear guidelines. The need for further training of general practitioners is well known. Objective: To develop and evaluate a massive open online course (MOOC) on antibiotic therapy of common infectious diseases in general practice. Methods: A 4-week MOOC was developed on the basis of previous face-to-face trainings (platform, Hasso Plattner Institute for Digital Engineering) and was conducted 3 times between July 10, 2017, and May 31, 2019. The course was promoted through various general practitioner (GP) networks, local multipliers, and conferences and in the local trade press. In addition to epidemiological background information, the focus was on guideline-based diagnostics and treatment of ARI, side effects of antibiotics, correct drug selection, dosage and duration of indicated antibiotic therapy, as well as aspects of doctor–patient communication. Content included videos, self-tests, additional written material, and an optional exam. At the end of the course, participants were asked to complete a voluntary, anonymous online assessment questionnaire (LimeSurveyPro software). Usage data from the MOOC platform and data from the questionnaire were analyzed using IBM SPSS statistical software. Results: In total, 2,177 registered persons retrieved content (= learners). The proportion of learners dropped from 99.6% in week 1 to 40.7% in week 4. However, among those attending week 4, the average proportion of content used was still high (74.5%). Furthermore, 27.5% of learners completed the course, 23.8% took the exam, and 19.7% passed the exam. Moreover, 284 learners answered the assessment questionnaire (response rate, 13.0%); 62.3% were women, and the mean age was 45.9 years. Also, 225 participants (79.2%) stated that they were physicians; 122 of these worked as general practitioners (54.2% of physicians). Among the other physicians, 23% stated were in specialist training and 15.6% had a different specialist designation. The average overall rating of the course was 1.31 (1 = very good to 6 = not sufficient). General practitioners rated it slightly better than other physicians (1.23 vs 1.41). The clinical relevance was rated at 1.27 (GPs vs other physicians, 1.18 vs 1.35). For all scores, see Table 1. Conclusions: A massive open online course appears to be an appropriate format in which to deliver clinical relevant content concerning prudent antibiotic use in the outpatient setting. It is a good complement to existing face-to-face formats and helps to cover needs related to antibiotic training.

Funding: None

Disclosures: None
Does the Fist Bump Transfer Less Methicillin-Resistant Staphylococcus aureus Than a Handshake?
Authors: Herrera Natalia Pinto , Jones Lucas , Cadnum Jennifer , Donskey Curtis
Published: November 2020

Background: Contaminated hands are the most important source for transmission of pathogens in healthcare settings. It has been proposed that replacing the handshake with alternative greetings such as the fist bump might reduce the risk for pathogen transmission. Methods: In a cohort of 50 patients with methicillin-resistant Staphylococcus aureus (MRSA) colonization, we compared the frequency of transfer of MRSA by handshake versus fist bump versus cruise tap (ie, a modified fist bump involving knuckle-to-knuckle contact with a single finger). MRSA-colonized patients performed each greeting with research personnel wearing sterile gloves, and cultures were obtained to determine the number of colonies transferred. Transfer by handshake was also assessed after MRSA-colonized patients used alcohol-based hand sanitizer. Quantitative cultures were obtained to compare the burden of MRSA on the palm versus dorsum of the hands of the MRSA carriers. Results: As shown in Fig. 1, there was a significant reduction in the frequency of MRSA transfer for the cruise tap compared to the handshake, but not for the fist bump. Use of alcohol-based hand sanitizer by MRSA carriers also significantly reduced the risk for transfer of MRSA. There was no significant difference in the burden of MRSA on the dorsum versus the palm of the hands (mean +SE colonies recovered, 32.7+12.3 vs 27.3+12.7; P > .05). Conclusions: The fist-bump greeting did not transfer less MRSA than a handshake. However, transfer was significantly reduced by a cruise-tap greeting or by handshake after the use of hand sanitizer. Modified greetings and patient hand hygiene are potential strategies to reduce transmission of healthcare-associated pathogens.

Funding: None

Disclosures: None
Effective Utilization of Limited Isolation Rooms to Provide Safe Patient Care and Staff Safety in a Low- and Middle-Income Country
Authors: Roshanali Rozina
Published: November 2020

Background: My tertiary-care hospital is a 750-bed hospital with only 17 airborne infection isolation room (AIIR) and negative-pressure rooms to isolate patients who have been diagnosed or are suspected with prevalent diseases like tuberculosis, measles, and chickenpox. On the other hand, only 14 single-patient isolation rooms are available to isolate patients with multidrug-resistant organisms (MDROs) such as CRE (carbapenum-resistant Enterobacter) or colistin-resistant MDROs. Due to the limited number of isolation rooms, the average number of hours to isolate infected patients was ~20 hours, which ultimately directly placed healthcare workers (HCWs) at risk of exposure to infected patients. Methods: Plan-Do-Study-Act (PDSA) quality improvement methodology was utilized to decrease the average number of hours to isolate infected patients and to reduce the exposure of HCWs to communicable diseases. A detailed analysis were performed to identify root causes and their effects at multiple levels. A multidisciplinary team implemented several strategies: coordination with information and technology team to place isolation alerts in the charting system; screening flyers and questions at emergency department triage; close coordination with admission and bed management office; daily morning and evening rounds by infection preventionists in the emergency department; daily morning meeting with microbiology and bed management office to intervene immediately to isolate patients in a timely way; infection preventionist on-call system (24 hours per day, 7 days per week) to provide recommendations for patient placement and cohorting of infected patients wherever possible. Results: In 1 year, a significant reduction was achieved in the number of hours to isolate infected patients, from 20 hours to 4 hours. As a result, HCW exposures to communicable diseases also decreased from 6.7 to 1.5; HCW exposures to TB decreased from 6.0 to 1.9; exposures measles decreased from 4.75 to 1.5; and exposures chickenpox decreased from 7.3 to 1.0. Significant reductions in cost incurred by the organization for the employees who were exposed to these diseases for postexposure prophylaxis also decreased, from ~Rs. 290,000 (~US$3,000) to ~Rs. 59,520 (~US$600). Conclusions: This multidisciplinary approach achieved infection prevention improvements and enhanced patient and HCW safety in a limited-resource setting.

Funding: None

Disclosures: None
Effectiveness of Twenty Germicides Against Five Strains of C. difficile spores, With and Without Calf Serum, at Several Exposure Times
Authors: Rutala William , Gergen Maria , Gerding Dale , Weber David Jay
Published: November 2020

Background:Clostridioides difficile is a major cause of antibiotic-associated colitis and the most common healthcare-associated pathogen in the United States. Interrupting the known transmission mechanisms of C. difficile in hospitals requires appropriate hand hygiene, disinfection of potentially contaminated surfaces, and patient equipment. However, only limited data are available on the effectiveness of germicides against various strains of C. difficile, with and without fetal calf serum, and at multiple exposure times. For this reason, we undertook the following evaluation to determine the effectiveness of germicides. Methods: The effectiveness of the sporicidal activity of the germicides against 5 strains of C. difficile was evaluated using a quantitative carrier test, a standard of ASTM International developed by Sattar et al. In this protocol, metal carriers (1 cm diameter 0.7 mm thick) were inoculated with 10 L spore suspension, containing ~103 or 106 C. difficile spores, and we then exposed them to 50 L germicide for 1, 5, 10, or 20 minutes. The following C. difficile strains were used in these studies: ATCC strains 9689; J9; BI-9; 630; and CF-4. To determine whether C. difficile spore susceptibility was similar to other spores, we also tested Bacillus atrophaeus spores, ATCC strain 19659. Fetal calf serum (FCS) was used to simulate organic matter. Results: In general, high-level disinfectants (eg, OPA, glutaraldehyde), chemical sterilants (eg, peracetic acid), and high concentrations of chlorine (>5,000 ppm) were generally sporicidal (>3 log10 reduction) in 5–10 minutes (and sometimes 1 minute). This level of sporicidal activity was demonstrated for the various strains of C. difficile spores and B. atrophaeus spores (Table 1). There did not appear to be any significant differences in inactivation of C. difficile spores (BI-9 strain) in the presence or absence of FCS (Table 2). Discussion: The sporicidal activity of disinfectants is critical because such formulations are routinely used to eliminate the risk associated with noncritical and semicritical instruments and environmental surfaces. Our data suggest that immersion in most (but not all) high-level disinfectants for 10 minutes is likely to be successful in eradicating C. difficile spores (>4 log10 reduction) from semicritical equipment (eg, endoscopes). Additionally, high concentrations of chlorine and some high-level disinfectants will kill C. difficile spores in 1 or 2 minutes.

Funding: None

Disclosures: Drs. Rutala and Weber are consultants to PDI (Professional Disposable International)
Effectiveness of Standard Daptomycin Dose in Treatment of Methicillin-Resistant Staphylococcus aureus Bacteremia
Authors: Nair Rajeshwari , Richardson Kelly , Livorsi Daniel , Goto Michihiko , Perencevich Eli , Schweizer Marin
Published: November 2020

Background: Daptomycin is considered an effective alternative to vancomycin in patients with methicillin-resistant Staphylococcus aureus bloodstream infection (MRSA BSI). Objective: We investigated the real-world effectiveness of recommended daptomycin doses compared with vancomycin. Methods: This nationwide retrospective cohort study included patients from 124 Veterans’ Affairs hospitals who had a MRSA BSI and were initially treated with vancomycin during 2007–2014. Patients were categorized into 3 groups by daptomycin dose calculated using adjusted body weight: low (>6 mg/kg/day), standard (6–8 mg/kg/day), and high (≥8 mg/kg/day). International Classification of Diseases, Ninth Revision (ICD-9) diagnosis codes were used to identify other prior or concurrent infections and comorbidities. Multivariate cox regression was used to compare 30-day all-cause mortality as the primary outcome comparing patients on either low-dose, standard-dose, or high-dose daptomycin with vancomycin. Hazard ratio (HR) and 95% confidence intervals (CIs) were reported. Results: Of the 7,518 patients in the cohort, 683 (9.1%) were switched to daptomycin after initial treatment with vancomycin for their MRSA BSI episode. A low dose of daptyomycin was administered to 181 patients (26.5%), a standard dose was given to 377 patients (55.2%), and a high dose was administered to 125 patients (18.3%). Dose groups differed significantly in body mass index (BMI), presence of an osteomyelitis diagnosis, and diagnosis of diabetes. Thirty-day mortality was significantly lower in daptomycin patients than in those given vancomycin (11.3% vs 17.6%; P < .0001). Treatment with daptomycin was associated with improved 30-day survival compared with vancomycin (HR, 0.66; 95% CI, 0.53–0.84), after adjusting for age, BMI, diagnosis of endovascular infection, skin and soft-tissue infection and osteomyelitis, hospitalization in the prior year, immunosuppression, diagnosis of diabetes, and vancomycin minimum inhibitory concentration (MIC). Treatment with a standard dose of daptomycin was associated with lower mortality compared with vancomycin (HR, 0.63; 95% CI, 0.46–0.86). High and low daptomycin dose groups had a trend toward improved 30-day survival compared with vancomycin (Fig. 1). In 2 separate sensitivity analyses excluding vancomycin patients, there was no difference in 30-day mortality between a standard dose and a high dose (HR, 1.01; 95% CI, 0.51–1.97). However, we detected a trend toward poor survival with a low dose compared with a standard dose (HR, 1.21; 95% CI, 0.73–2.02). Conclusions: A standard dose of daptomycin was significantly associated with lower 30-day mortality compared with continued vancomycin treatment. Accurate dosage of daptomycin and avoidance of low-dose daptomycin should be a part of good antibiotic stewardship practice.

Funding: None

Disclosures: None
Effects of Irregularities in the Microstructure of Surgical Instruments on Microbial Adherence and Challenges for Processing
Authors: Evangelista Sintia , Oliveira Adriana
Published: November 2020

Background: A surgical instrument can have areas that pose different challenges to cleaning, hindering the removal of dirt. This can directly impact the effectiveness of its processing while potentially promoting cross contamination. Moreover, structural changes (ie, cracks or fissures) on the instrument surface, although rarely addressed, can act as reservoirs for microorganisms, contributing to organic matter retention, microbial growth, and biofilm formation. Our aim was to determine the effect of irregularities in the microstructure of surgical instruments on microbial adherence. Methods: We analyzed 18 fragments of 3 distinct areas of new crile forceps: the ratchet, shank, and jaw. Of these fragments, 15 were artificially contaminated by immersion in tryptic soy broth containing 10 6 CFU/mL of Escherichia coli (ATCC 25922), for 4, 6, 8, and 12 hours of incubation at 37C with agitation at 100 rpm. The other 3 fragments were used as controls. All fragments were subjected to scanning electron microscopy to evaluate the adhesion of the microorganism. Results: An irregular surface was found in 3 of 6 shank fragments (50%) (Fig. 1) and in all the jaw and ratchet fragments, grooves, and cracks. Initially, there was less adherence of E. coli to the smooth shank surface after contamination, but the concentration of the microorganism increased progressively over time in relation to that in the jaw or ratchet at the same time, and a higher concentration occurred in the cracks and grooves. Conclusions: Structural damage was observed in all fragments, especially in the ratchet and jaw areas, favoring microbial accumulation. Microorganisms housed in the cracks and grooves were better protected from removal by scrubbing with a brush (being unlikely to reach them), making these areas a microbial reservoir and source of contamination. Prolonged contact of the instrument with the contaminating microorganism allowed for greater adherence, even on the smooth areas. The results support the relevance of the early onset of cleaning, considering that even microscopic changes on the surface of the instrument may represent an additional challenge to its effective processing.

Funding: None

Disclosures: None
Efficacy of a Sink Tailpiece Heating Device to Decrease Microbial Colonization of Sink Drains
Authors: Park Stacy , Steinberg Limor , Carroll Joanne , Mathers Amy , Attai April
Published: November 2020

Background: Many institutions have reported transmission of multidrug-resistant organisms to patients from colonized sinks. Prior data have shown that bacterial colonization of the sink drain, which can occur via biofilm from a colonized p-trap or via seeding from above, results in dispersion of bacteria in the area of the sink when water from the faucet comes in contact with the drain. Heat disruption of biofilm formation between the p-trap and sink drain is a potential strategy in preventing colonization of sink drains. Methods: In an academic center hospital, 54 tail-piece heaters were installed in 3 intensive care units and 2 acute-care units in an associated regional hospital. Half of the installed devices were sham (no heat). The devices were programmed to heat the tail piece to 72C for 1 hour every fourth hour. Rooms were randomized to heating or sham devices on a 1:1 basis within each unit. Sink drains and p-traps were sampled biweekly. Samples were assessed for semiquantitative growth of gram-negative bacteria on MacConkey agar, looking especially for Pseudomonas aeruginosa and Stenotrophomonas maltophilia. Carbapenemase-producing Enterobacterales (CPE) was detected by broth enrichment followed by growth on Colorex KPC agar. Frontline personnel were blinded to device assignment. Results: Linear mixed modeling revealed reduced risk of detectable gram-negative bacteria (OR, 0.16; 95% CI, 0.037–0.536) and Enterobacterales (OR, 0.17; 95% CI, 0.368–0.668) in sink drains with a heating device (Fig. 1), but no difference in risk of detectable P. aeruginosa or S. maltophilia (Table 1). We detected a trend toward reduction in CPE that did not reach statistical significance, and there was no difference in risk for detection of any bacteria in the p-trap between heating and sham devices. Audits of devices demonstrated that few reached the target heating temperature of 72C (median, 65.9C; range, 50.1–73.7C). Conclusions: Disruption of biofilm between the p-trap and the sink drain is a promising strategy for the prevention of sink-drain colonization with clinically important bacteria. The presence of a heating device was associated with reduced risk of detectable gram-negative organisms, specifically Enterobacterales, in sink drains. The limitations of this study included low overall rates of positivity for certain pathogens, including CPE, and suboptimal, inconsistent performance across heating devices. Further work with a larger sample size and more consistent heating devices is warranted, as are data regarding patient outcomes as a result of such interventions.

Funding: None

Disclosures: None
Epidemiology of NDM-Producing Enterobacteriaceae in Michigan
Authors: Gill Gurmat , Sandhu Avnish , Polistico Jordan , Awali Reda , McNamara Sara , Chopra Teena
Published: November 2020

Background: Carbapenem-resistant Enterobacteriaceae (CRE) are classified as an urgent antibiotic-resistant threat by the CDC, and they are listed on the critical priority list by the World Health Organization due to the lack of antibiotic treatment options. New-Delhi metallo-β-lactamase (NDM) is an emerging mechanism of carbapenem resistance in the United States. We sought to understand the risk factors and clinical characteristics of patients with NDM CRE in Michigan to improve surveillance. Methods:A retrospective descriptive study was conducted in collaboration with the Michigan Department of Health and Human Services (MDHHS). CRE isolates submitted to MDHHS between April 2014 and July 2019 were tested for the presence of NDM using CDC PCR protocols. Additional information on case demographics, laboratory results, healthcare and antibiotic exposure history, and travel history were collected. Results: In total, 30 NDM cases were identified in Michigan during the study period. Of these 30 cases, 15 (50%) were men, and the median age was 73.5 years (range, 20–88 20). Also, 2 of these patients (6.6%) were immunocompromised; 2 patients (6.6%) had had extensive abdominal surgery, and 2 patients (6.6%) had recurrent hospitalization. Furthermore, 12 case isolates (40%) were collected in outpatient settings, whereas 16 (53%) were collected from inpatient settings. In addition, 13 (43%) patients were admitted from home and 4 (13%) presented from an extended-care facility. Urine was the most common site of isolation in 19 of 30 (63%) cases, followed by blood and tissue culture in 4 of 30 (13%) each. Escherichia coli was the most common organism (17 of 30, 57%), followed by Klebsiella pneumoniae (9 of 30, 30%). Also, 15 of 30 cases (50%) had a recent history of international travel, and of these, 9 of 15 (60%) reported travel to India. Among these 15 cases, 12 (80%) sought medical care in the countries they visited. Two cases (6.6%) had a documented history of multidrug-resistant organism colonization or infection. The mortality rate was 6.6% (2 of 30). The mean time from admission to implementation of contact precautions was 7.3 days (range, 0–20). Conclusions: Suspicion of NDM CRE strains should remain high in patients with a travel history from areas known as major reservoirs of NDM. Delay in implementing contact precautions, as noted in the present study, can lead to a greater risk of transmission. Early detection and subsequent isolation of NDM patients are essential strategies for preventing transmission within healthcare facilities. Future efforts include performing whole-genome sequencing of these isolates to assist in identifying potential epidemiological links among the affected patients.

Funding: None

Disclosures: None
European Union One Health Country Visits as Driver to Combat on Antimicrobial Resistance
Authors: Spruijt Pita , Bergervoet Paul , Westerhof Robbin , Langelaar Merel , Ploy Marie-Cécile
Published: November 2020

Background: In 2016, the European Union adopted unanimously Council Conclusions on the next steps to combat antimicrobial resistance under a One Health approach. To implement some of the provisions laid down in the Council Conclusions, a European Joint Action on Antimicrobial Resistance (AMR) and Healthcare-Associated Infections (HCAI) or EU-JAMRAI was set up, gathering 44 partners. Methods: As part of EU-JAMRAI, 13 participating European countries set up a country-to-country peer review system to evaluate each other’s national action plans (NAPs). This review system entailed a self-assessment, strengths–weaknesses–opportunities–threats (SWOT) analysis, and country visits. All steps were executed with representatives from both the human and the veterinary domains (One Health approach). Special attention was given to supervision and the way supervision can enhance the implementation of guidelines on AMR, both at the policy level and within healthcare institutions. Results: Despite differences in the stage of developing and implementing NAPs, all 13 countries are working on NAPs. In this process, country visits function as a moment to exchange best practices and to provide an outsider’s point of view. At the end of 2019, 13 country-to-country visits had taken place, resulting in tailor-made recommendations for each country. These recommendations were shared with the competent authority. An example is a country that used the recommendation to improve infection prevention as an immediate reason to get the topic on the agenda of the Ministry of Health. During the country visits, intersectoral participation was perceived as desirable, but in some cases it was challenging to arrange. For some highly relevant topics, it has been recognized that discussion should take place on a European level. Examples of such topics include supervision, infection prevention guidelines, funding, surveillance, and regular audits of antibiotic prescriptions for physicians including feedback loops. Conclusions: Peer review is a cooperative and friendly working method compared to common audits. The country visits function as an agenda setting tool to get or to keep AMR on the political agenda and presenting the most relevant topic(s) to address for each country.

Funding: None

Disclosures: None
Evaluating Healthcare Worker Movements and Patient Interactions Within ICU Rooms
Authors: Khader Karim , Leecaster Molly , Ray William , Haroldsen Candace , Keegan Lindsay , Samore Matthew , Rubin Michael
Published: November 2020

Background: Contamination of healthcare workers and patient environments likely play a role in the spread of antibiotic-resistant organisms. The mechanisms that contribute to the distribution of organisms within and between patient rooms are not well understood, but they may include movement patterns and patient interactions of healthcare workers. We used an innovative technology for tracking healthcare worker movement and patient interactions in ICUs. Methods: The Kinect system, a device developed by Microsoft, was used to detect the location of a person’s hands and head over time, each represented with 3-dimensional coordinates. The Kinects were deployed in 2 intensive care units (ICUs), at 2 different hospitals, and they collected data from 5 rooms in a high-acuity 20-bed cardiovascular ICU (unit 1) and 3 rooms in a 10-bed medical-surgical ICU (unit 2). The length of the Kinect deployment varied by room (range, 15–48 days). The Kinect data were processed to included date, time, and location of head and hands for all individuals. Based on the coordinates of the bed, we defined events indicating bed touch, distance 30 cm (1 foot) from the bed, and distance 1 m (3 feet) from the bed. The processed Kinect data were then used to generate heat maps showing density of person locations within a room and summarizing bed touches and time spent in different locations within the room. Results: The Kinect systems captured In total, 2,090 hours of room occupancy by at least 1 person within ~1 m of the bed (Table 1). Approximately half of the time spent within ~1 m from the bed was at the bedside (within ~30 cm). The estimated number of bed touches per hour when within ~1 m was 13–23. Patients spent more time on one side of the bed, which varied by room and facility (Fig. 1A, 1B). Additionally, we observed temporal variation in intensity measured by person time in the room (Fig. 1C, 1D). Conclusions: High occupancy tends to be on the far side (away from the door) of the patient bed where the computers are, and the bed touch rate is relatively high. These results can be used to help us understand the potential for room contamination, which can contribute to both transmission and infection, and they highlight critical times and locations in the room, with a potential for focused deep cleaning.

Funding: None

Disclosures: None
Evaluating Metagenomic Analysis for Pathogen Transmission in Healthcare Settings
Authors: Hewitt Curt , Weber Katharina , LeSassier Danielle , Kappell Anthony , Schulte Kathleen , Westfall Nicole , Albright Nicolette , Godbold Gene , Palsikar Veena , Acevedo Carlos , Ternus Krista
Published: November 2020

Background: The prevalence of healthcare-acquired infections (HAIs) and rising levels of antimicrobial resistance place a significant burden on modern healthcare systems. Cultures are typically used to track HAIs; however, culture methods provide limited information and are not applicable to all pathogens. Next-generation sequencing (NGS) can detect and characterize pathogens present within a sample, but few research studies have explored how NGS could be used to detect pathogen transmission events under HAI-relevant scenarios. The objective of this CDC-funded project was to evaluate and correlate sequencing approaches for pathogen transmission with standard culture-based analysis. Methods: We modeled pathogen transfer via hand contact using synthetic skin. These skin coupons were seeded with a community of commensal organisms to mimic the human skin microbiome. Pathogens were added at physiologically relevant high or low levels prior to skin-to-skin contact. The ESKAPE pathogens: E. faecium, S. aureus, K. pneumoniae, A. baumannii, P. aeruginosa, and Enterobacter spp plus C. difficile were employed because they are the most common antibiotic resistant HAIs. Pathogen transfer between skin coupons was measured following direct skin contact and fomite surface transmission. The effects of handwashing or fomite decontamination were also evaluated. Transferred pathogens were enumerated via culture to establish a robust data set against which DNA and RNA sequence analyses of the same samples could be compared. These data also provide a quantitative assessment of individual ESKAPE+C pathogen transfer rates in skin contact scenarios. Results: Metagenomic and metatranscriptomic analysis using custom analysis pipelines and reference databases successfully identified the commensal and pathogenic organisms present in each sample at the species level. This analysis also identified antibiotic resistance genes and plasmids. Metatranscriptomic analysis permitted not only gene identification but also confirmation of gene expression, a critical factor in the evaluation of antibiotic resistance. DNA analysis does not require cell viability, a key differentiator between sequencing and culturing reflected in simulated handwashing data. Sensitivity remains a key limitation of metagenomic analysis, as shown by the poor species identification and gene content characterization of pathogens present at low abundance within the simulated microbial community. Species level identification typically failed as ratios fell below 1:1,000 pathogen CFU:total community CFU. Conclusions: These findings demonstrate the strengths and weaknesses of NGS for molecular epidemiology. The data sets produced for this study are publicly available so they can be employed for future metagenomic benchmarking studies.

Funding: None

Disclosures: None
Extending the Use of Healthcare-Associated Infections and Antibiotic Use and Resistance Surveillance Data
Authors: Mirza Muzna , Wattenmaker Lauren , Clunis Odion , Vance Wendy , Moon Shunte , Pollock Daniel
Published: November 2020

Background:
The CDC National Healthcare Safety Network (NHSN) is the nation’s most widely used healthcare-associated infection (HAI) and antibiotic use and resistance (AUR) surveillance system. More than 22,000 healthcare facilities report data to the NHSN. The NHSN data are used by facilities, the CDC, health departments, the CMS, among other organizations and agencies. In 2017, the CDC updated the NHSN Agreement to Participate and Consent (Agreement), completed by facilities, broadening health department access to NHSN data and extending eligibility for data use agreements (DUAs) to local and territorial health departments. DUAs enable access to NHSN data reported by facilities in the health department’s jurisdiction and have been available to state health departments since 2011. The updated agreement also enables the CDC to provide NHSN data to health departments for targeted prevention projects outbreak investigations and responses. Methods: We reviewed the current NHSN DUA inventory to assess the extent to which health departments use the NHSN’s new data access provisions and used semistructured interviews with health department staff, conducted via emails, phone, and in person conversations, to identify and describe their NHSN data uses. Results: As of late 2019, the NHSN has DUAs with health departments in 17 states, 7 local health departments (including municipalities and counties), and 1 US territory. The NHSN also has received requests from 2 state health departments for data supporting HAI prevention projects. Health departments with DUAs described improved relationships with facilities in their jurisdictions because of new opportunities to offer NHSN data analysis assistance to facilities. One local health department analyzed their NHSN carbapenem-resistant Enterobacteriaceae (CRE) data to identify (1) facilities in its jurisdiction with comparatively high CRE infection burden and (2) geographic areas to target for a CRE isolate submission program. Outreach to facilities with high CRE burden led to enrollment of 15 clinical laboratories into a voluntary isolate submission program to analyze CRE isolates for additional characterization. Examples of health departments’ use of data for action include: notifying facilities with high standardized infection ratios (SIRs) and sharing Targeted Assessment for Prevention (TAP) reports. Conclusions: The NHSN’s role as a shared surveillance resource has expanded in multiple public health jurisdictions as a result of new data access provisions. Health departments are using NHSN data in their programmatic responses to HAI and AR challenges. New access to NHSN data is enabling public health jurisdictions to assess problems and opportunities, provide guidance for prevention projects, and support program evaluations.

Funding: None

Disclosures: None
From Little Things Big Things Grow: The Development of an Auditing Program to Assess the Quality of Antimicrobial Prescribing
Authors: James Rodney , Chen Caroline , Buising Kirsty , Thursky Karin , Ierano Courtney
Published: November 2020

Background: An important aspect of antimicrobial stewardship is the qualitative assessment of antimicrobial prescribing. Owing to lack of standardized tools and resources required to design, conduct and analyze qualitative audits, these assessments are rarely performed. Objective: We designed an audit tool that was appropriate for all Australian hospital types, suited to local user requirements and including an assessment of the appropriateness of antimicrobial prescribing. Methods: In 2011, a pilot survey was conducted in 32 Australian hospitals to assess the usability and generalizability of a qualitative audit tool. The tool was revised to reflect the respondents’ feedback. A second study was performed in 2012 in 85 hospitals. In 2013, following further feedback and refinement, an online auditing tool, the Hospital National Antimicrobial Prescribing Survey (NAPS), was developed. Early audits demonstrated that surgical prophylaxis had the highest rates of inappropriate prescribing. In 2016, the Surgical NAPS was developed to further investigate reasons for this, and the NAPS program was further expanded to audit antimicrobial prescribing practices in Australian aged-care homes (ie, the Aged Care NAPS). Results: Between January 1, 2013, and November 12, 2019, 523 Australian public and private hospitals (53.8%) utilized the Hospital NAPS; 215 (22.1%) have utilized the Surgical NAPS; and 774 of Australian aged-care homes (29.0%) have utilized the Aged Care NAPS. National reporting has identified key target areas for quality improvement initiatives at both local and national levels. The following initiatives have been outlined in 14 public reports: improved documentation; prolonged antimicrobial prophylaxis; compliance with prescribing guidelines; appropriateness of prescribing; access to evidence-based guidelines; and improved microbiology sampling. Conclusions: By utilizing the Plan-Do-Study-Act cycle for healthcare improvement and by involving end users in the design and evaluation, we have created a practical and relevant auditing program to assess both quantitative and qualitative aspects of antimicrobial prescribing in a wide range of settings. This voluntary program is now endorsed by the National Strategy for Antimicrobial Resistance Surveillance, partners with the Antimicrobial Use and Resistance in Australian Surveillance System, and is utilized by facilities to meet mandatory national accreditation standard requirements. With the success of the NAPS program in Australia, it has now been implemented in New Zealand, Canada, Malaysia, Fiji, and Bhutan, with plans for other countries to implement the program soon. Current research is being conducted to expand the program to include audits for family physicians, veterinarians, and remote indigenous communities, and for antifungal use.

Disclosures: None

Funding: None
Genomic analysis of Clostridioides difficile in two regions reveals a diversity of strains and limited transmission
Authors: Pecora Nicole , Holzbauer Stacy , Wang Xiong , Gu Yu , Hatwar Trupti , Dziejman Michelle , Myers Jason , D’Heilly Paige , Guh Alice , Qiu Xing , Gill Steven , Dumyati Ghinwa
Published: November 2020

Background: The epidemic NAP1/027 Clostridioides difficile strain (MLST1, ST1) that emerged in the mid-2000 is on the decline. The current distribution of C. difficile strain types and their transmission dynamics are poorly defined. We performed whole-genome sequencing (WGS) of C. difficile isolates in 2 regions to identify the predominant multilocus sequence types (MLSTs) in community- and healthcare-associated cases and potential transmission between cases using whole-genome single-nucleotide polymorphism (SNP) analysis. Methods: Isolates were collected through the CDC Emerging Infections Program population-based surveillance for C. difficile infections (CDI) for 3 months between 2016 and 2017 in 5 Minnesota counties and 1 New York county. Isolates were limited to incident cases (CDI in a county resident with no positive C. difficile test in the preceding 8 weeks). Cases were classified as healthcare associated (HA-CDI) or community associated (CA-CDI) based on healthcare exposures as previously described. WGS was performed on an Illumina Miseq. The CFSAN (FDA) pipeline was used to compute whole-genome SNPs, SPAdes was used for assembly, and MLST was assigned according to www.pubmlst.org. Results: Of 431 isolates, 269 originated from New York and 162 from Minnesota; 203 cases were classified as CA-CDI and 221 as HA-CDI. The proportion of CA-CDI cases was higher in Minnesota than in New York: 62% vs 38%. The predominant MLSTs across both sites were ST42 (9%), ST8 (8%), and ST2 (8%). MLSTs more frequently encountered in HA-CDI than CA-CDI included ST1 (note that this ST includes PCR Ribotype 027; 76% HA-CDI), ST53 (84% HA-CDI), and ST43 (80% HA-CDI). In contrast, ST110 (63% CA-CDI) and ST3 (67% CA-CDI) were more commonly isolated from CA-CDI cases. ST1 accounted for 7.6% of circulating strains and was more common in New York than Minnesota (10% vs 3%) and was concentrated among New York HA-CDI cases. Also, 412 isolates (1 per patient) were included in the final whole-genome SNP analysis. Of these, only 12 pairs were separated by 0–3 SNPs, indicating potential transmission, and most involved HA-CDI cases. ST1, ST17, and ST46 accounted for 8 of 12 pairs, with ST17 and ST46 potentially forming small clusters. Conclusions: This analysis provides a snapshot of the current genomic epidemiology of C. difficile across 2 geographically and epidemiologically distinct regions of the United States and supports other studies suggesting that the role of direct transmission in the spread of CDI may be limited.

Funding: None

Disclosures: None
Hospital Outbreak of Respiratory Syncytial Virus in Neonatal Intensive Care Unit: The Risk of Admitting External Patients
Authors: Mendes Elisa Teixeira , Souza s Bomediano , Paranhos Hadassa Louback , Santos Isabela Cristina Moreira
Published: November 2020

Background: Acute viral bronchiolitis caused by respiratory syncytial virus (RSV) may be a manifestation of high severity in neonatal-ICU (NICU) patients, with high risk of in-hospital cross transmission and outbreaks. During the epidemic seasonal period, intense viral circulation occurs in community; thus, transmission in the NICU is difficult to control. Objective: We describe an outbreak that occurred in a NICU in a public hospital in So Paulo state, Brazil. We also discuss the role of admitting external newborns with community-acquired virus in the incidence of these outbreaks in the NICU. Methods: In 2017 in Campinas, an RSV epidemic occurred during the seasonal period, resulting in a outbreak at the Campinas maternity hospital. A retrospective investigation was performed, and patients were analyzed for clinical and epidemiological characteristics and for risk factors for poor prognosis. We included neonates admitted in NICU with positive nasal lavage for RSV from April to July 2017. Statistical analysis were performed with 2 test for the categorical variables and the Student t test for the continuous variables comparing the newborn group from the community (external) with infected newborns in the hospital (internal). P < .05 was considered significant. Results: Of 44 neonates with RSV during this period, 32 were external and 12 were internal (Fig. 1). The mean gestational age of the external neonates was 38 weeks and 2 days, whereas the mean gestational age of the internal neonates was 29 weeks and 1 day (P < .001). The hospitalization time was higher in the internal group (P < .001). Table 1. One death associated with infection occurred in the internal group. Community neonates (external group) were mostly term-born, with no comorbidities, and they had a more favorable clinical course. In the literature, neonates infected with RSV at the hospital have several risk factors for poor prognosis, with a 13.5% mortality rate. Discussion: RSV outbreaks have great relevance in hospital settings, especially in the NICU, where there are a large number of vulnerable patients and a high risk of in-hospital cross transmission. Neonates infected with RSV at the hospital have several risk factors for poor prognosis, including high mortality. Therefore, it is important to discuss the exposure of this population to community-based infectious agents, mainly viral, and the risk of accepting patients from the community to be admitted to the NICU.

Funding: None

Disclosures: None