bluuebunny/crossref_metadata_2025 huggingface dataset:
2896. Reduction in Liver-related Mortality Among HCV Infected Persons Is Driven by Attainment of SVR Independent of the Regimen Used: Results from the ERCHIVES Cohort
Authors: Butt Adeel A , Yan Peng , Aslam Samia , Lo Re III Vincent , Shaikh Obaid
Published: October 2019

Background

Beneficial effect of hepatitis C virus (HCV) treatment with directly acting antiviral agents (DAAs) upon overall mortality is well-established. However, the effect of treatment upon liver-related mortality is not well documented.

Methods

We used ERCHIVES database to identify all chronic HCV-infected persons between January 1, 2002 and December 31, 2016. We excluded those with HIV or HBV coinfection or hepatocellular carcinoma. HCV treatment status was defined as prescription of pegylated interferon (PEG)/ribavirin (RBV) for >24 weeks, PEG/RBV plus boceprevir or telaprevir, or a newer DAA regimen for >8 weeks. Propensity score-matched untreated controls were identified for each treated person. We linked HCV+ cases to the National Death Index (NDI) data updated to the end of 2016. Cause of death was retrieved from the underlying cause listed on the death certificate by using ICD‐10 codes. The listed primary cause was assigned as the cause of death. Each cause of death was categorized as “Liver related” or “Not liver related” by two physician members of the study team. Liver-related causes included viral hepatitis-related causes, complications of liver disease, and hepatocellular carcinoma, but excluded any cause where alcohol or any other known liver disease other than viral hepatitis was specified. Discordant results were adjudicated by a third physician member.

Results

Among 34,412 treated and 21,287 untreated controls, there were 13,098 deaths, of which 2,474 (18.9%) were liver related. Overall liver-related mortality rate per 100 person-years of follow-up was 0.64 in the treated and 1.24 in the untreated group (P). Among the treated group, the liver-related mortality rate per 100 person-years was 0.14 for those who achieved SVR and 1.26 among those who did not achieve SVR. When stratified by treatment regimen, those treated with PG/RBV had a mortality rate of 0.73 vs. 0.24 for those treated with a DAA regimen. However, further stratification by attainment of SVR revealed that the difference between regimens was almost entirely driven by the difference in SVR rates (see table).

Conclusion

HCV-infected persons who receive treatment have a substantial reduction in liver-related mortality. This reduction is largely driven by attainment of SVR and is independent of the regimen use when stratified by SVR attainment.

Disclosures

All Authors: No reported Disclosures.
2897. Collocated Buprenorphine Is Associated with Improved HCV Visit Adherence in People Who Inject Drugs (PWID): Data From the ANCHOR Study
Authors: Rosenthal Elana S , Silk Rachel , Mathur Poonam , Eyasu Rahwa , Nussdorf Laura , Hill Kristi , D’Amore Aaron , Brokus Christopher , Bijole Phyllis , Jones Miriam , Kier Randy , Sternberg David , Masur Henry , Kottilil Shyam , Kattakuzhy Sarah
Published: October 2019

Background

Engaging PWID in HCV treatment and monitoring for reinfection is critical to eliminate HCV and improve health in people who use drugs. However, PWID are often marginalized and can be difficult to engage and retain in care. The collocation of HCV treatment with buprenorphine to treat opioid use disorder (OUD) may improve visit adherence in this population.

Methods

ANCHOR is a single-center study evaluating treatment of HCV in PWID with chronic HCV, OUD, and IDU. Participants receive sofosbuvir/velpatasvir x12 weeks and are offered collocated buprenorphine. HCV visits occur at weeks 4, 12, 24, 48, 72 and 96.

Results

At screening, the 100 enrolled patients were predominantly male (76%), black (93%), middle-aged (median 57years), injected opioids daily or more (58%), and were not on OAT (67%). Fifty-five (55%) patients were initiated on collocated buprenorphine at some point after day 0.

Being on collocated buprenorphine at the time of HCV visit was associated with increased likelihood of visit attendance at weeks 12 (P = 0.002), 24 (P = 0.01), 48 (P = 0.02), 72 (P = 0.003), and 96 (P = 0.04). For patients who attended study visits, being on collocated buprenorphine was associated with a shorter time between planned visit and actual visit at weeks 12 (P = 0.03), 24 (P = 0.04), and 48 (P = 0.04). When looking at patients not on collocated buprenorphine, being on noncollocated opioid agonist therapy vs. not being on OUD treatment did not impact visit adherence.

Conclusion

Evidence-based treatment of HCV and OUD are critical to improving health in PWID. The collocation of HCV treatment with office-based buprenorphine may improve adherence to visits and visit timing, especially in long-term follow-up. Infectious disease providers should offer collocated buprenorphine as a tool to improve long-term outcomes and engagement in this high-risk population.

Disclosures

All Authors: No reported Disclosures.
2898. Achieving Hepatitis C SVR12 of 95% in Mono-Infected Patients with Severe Comorbidities Using Volunteer Staff and Minimal Clinic Visits and Phlebotomy
Authors: van der Horst Charles M , Greenberg Gary , Kirchgessner Erin , Vaughn Amanda , Alfano-Sobsey Edie , Riggleman Amy , Soufan Ayat , Horner Mandy , Nadabar Asha , Castillo Diana , Campbell Elizabeth , Lynn Ledford Sue
Published: October 2019

Background

HCV is the most common chronic bloodborne infection in the United States with an estimated 3.5 million infected. With direct-acting antivirals, cure can be achieved in 8 to 12 weeks. To achieve WHO elimination targets by 2030 (>90% reduction in incidence) requires increased detection, access to care, and simpler treatment protocols that patients, challenged by substance use and mental health disorders, can readily complete.

Methods

In 2016, Wake County, NC began HCV testing at 32 sites finding prevalence >10% at 5 shelters and drug treatment centers. An adapted simplified HCV treatment protocol, used in the high prevalence settings of Ukraine and Burma, was implemented at the Open Door Clinic – a free clinic for uninsured persons living in poverty in Wake County. After initially using genotype-specific therapy, we switched to pan-genotypic sofosbuvir/velapatisvir (SOF/VEL) for 12 weeks. Clinic visits were limited to pre-treatment and 12 weeks after treatment completion. Patients were contacted weekly via text to check on their health and adherence.

Results

Thirty HCV mono-infected patients have initiated treatment including 9 women. 21 were infected by IDU, 5 by transfusion, 3 by sex with an infected partner, and 5 have unknown risk. In genotype (GT) testing 22 have GT1, 3 GT 2, and 4 GT3. Major comorbidities include 24 with current or recent IDU, alcohol dependency, psychotic depression or schizophrenia, or missing all medical appointments other than the HCV. Twenty-seven of 30 have completed their prescribed course of HCV therapy and 20 have achieved an SVR at 12 weeks. The 1 patient who failed was admitted to the hospital 4 times in the first 6 weeks of treatment and did not take his medication consistently. An additional 2 remain on treatment and 6 are awaiting results of testing done at 12 weeks post-therapy completion. One patient died within 2 weeks of initiating therapy due to a perforated duodenal ulcer.

Conclusion

Using targeted on-site HCV testing, we identified high prevalence sites. Implementing a simplified HCV treatment program reduces patient and clinic burden and resulted in 95% achieving SVR12 despite severe comorbidities. Expansion of this program to other clinics in Wake County is underway.

Disclosures

All Authors: No reported Disclosures.
1136. Antifungal Prescribing Patterns among Hospitalized Children in the United States: Are There Opportunities for Antifungal Stewardship?
Authors: Eguiguren Lourdes , Bio Laura , Lee Brian R , Newland Jason , Hersh Adam , Gerber Jeffrey , Kronman Matthew , Lee Grace , Schwenk Hayden
Published: October 2019

Background

Antifungal stewardship may help reduce the toxicity, cost, and emergence of resistance related to inappropriate antifungal use. A better understanding of antifungal prescribing patterns, particularly in high-risk, high-utilization populations, is needed to guide appropriate stewardship interventions. We analyzed antifungal prescribing characteristics, including the indications for use and differences between oncology/bone marrow transplant (Onc/BMT) and non-Onc/BMT patients, using a multi-center national cohort of hospitalized children.

Methods

We analyzed antifungal prescribing data from 32 hospitals that participated in the SHARPS Antibiotic Resistance, Prescribing, and Efficacy among Children (SHARPEC) study, a point prevalence survey conducted quarterly between June 2016 and December 2017. We included inpatients <18 years of age with an active order for a systemic antifungal agent and evaluated the patient and antifungal characteristics. In the Onc/BMT group, we classified antifungal prescribing by indication and compared the proportion of antifungal prescriptions in each category based on antifungal class, route of administration, and use of combination therapy.

Results

Six percent (2,095/34,927) of patients received a total of 2,207 antifungal prescriptions. Fifty-eight percent (1,291/2,207) of antifungal prescriptions were for Onc/BMT patients. Among patients prescribed an antifungal, those with an Onc/BMT diagnosis were older, received broader-spectrum agents, and were more likely to receive combination therapy (Table 1). The majority of antifungal use in the Onc/BMT group was for prophylaxis, with significant variation in the rate and choice of prophylactic antifungal prescribing across hospitals (Figure 1). Combination antifungal use was common among Onc/BMT patients receiving targeted therapy (Table 2).

Conclusion

The majority of antifungal use among hospitalized children is for patients with an Onc/BMT diagnosis and the patterns of antifungal utilization in this population appear to differ significantly from non-Onc/BMT patients. Based on the variation observed in this nationwide cohort, potential stewardship targets include the rate and type of antifungal prophylaxis and the use of combination therapy in Onc/BMT patients.

Disclosures

All authors: No reported disclosures.
1139. Multidisciplinary Initiative to Increase Guideline-Concordant Antibiotic Prescriptions at Discharge for Hospitalized Children with Uncomplicated Community-Acquired Pneumonia
Authors: Yonts Alexandra B , Bozzella Michael Jason , Magyar Matthew , O’Neill Laura , Harik Nada
Published: October 2019

Background

Community-acquired pneumonia (CAP) is the most common diagnosis in hospitalized children. The Pediatric Infectious Diseases Society and the Infectious Diseases Society of America published evidenced-based clinical practice guidelines for the management of CAP in children 3 months of age or older in 2011. These guidelines are not consistently followed. Our objective was to evaluate if quality improvement (QI) methods could improve guideline-concordant antibiotic prescribing, specifically addressing the use of oral third-generation cephalosporins, at hospital discharge for children with uncomplicated CAP.

Methods

QI interventions, implemented at a single tertiary care children’s hospital in Washington, D.C., focused on key drivers targeting hospital medicine resident teams. Multiple plan-do-study-act (PDSA) cycles were performed. Initial interventions included educational sessions (in small group and lecture formats) aimed at pediatric resident physicians, as well as visual job aids (Figure 1) and guideline summaries posted in resident physician work areas. Interventions were implemented in series to allow for statistical analysis via run chart. Medical records of eligible patients were reviewed monthly after each intervention to determine the impact on appropriate discharge antibiotic prescribing.

Results

At baseline, the median percentage of children with a diagnosis of uncomplicated CAP discharged with guideline-concordant antibiotics was 50%. Median rates of guideline-concordant antibiotic prescribing improved to 87.5% after initial interventions (Figure 2).

Conclusion

A fellow-led multidisciplinary QI initiative was successful in decreasing rates of non-guideline-concordant antibiotic prescribing at discharge. These interventions can be tailored for use at other institutions and for other infectious processes with established treatment guidelines. To ensure sustained improvement in guideline-concordant prescribing, future planned interventions include additional educational sessions with residents, faculty, and pharmacists, EMR order set modification and physician benchmarking. These tactics are intended to address the anticipated challenge of resident/faculty turnover and automate antibiotic choice for uncomplicated CAP.

Disclosures

All authors: No reported disclosures.
1154. Impact of Educational Feedback on Reducing Hospital-Onset Catheter-Associated Urinary tract Infections at an Academic Medical Center
Authors: Navalkele Bhagyashri D , Truhett Nora , Ward Miranda , Fletcher Sheila
Published: October 2019

Background

High regulatory burden on hospital-onset (HO) infections has increased performance pressure on infection prevention programs. Despite the availability of comprehensive prevention guidelines, a major challenge has been communication with frontline staff to integrate appropriate prevention measures into practice. The objective of our study was to evaluate the impact of educational intervention on HO CAUTI rates and urinary catheter days.

Methods

At the University of Mississippi Medical Center, Infection prevention (IP) reports unit-based monthly HO infections via email to respective unit managers and ordering physician providers. Starting May 2018, IP assessed compliance to CAUTI prevention strategies per SHEA/IDSA practice recommendations (2014). HO CAUTI cases with noncompliance were labeled as “preventable” infections and educational justification was provided in the email report. No other interventions were introduced during the study period. CAUTI data were collected using ongoing surveillance per NHSN and used to calculate rates per 1,000 catheter days. One-way analysis of variance (ANOVA) was used to compare pre- and post-intervention data.

Results

Prior to intervention (July 2017–March 2018), HO CAUTI rate was 1.43 per 1,000 catheter days. In the post-intervention period (July 2018–March 2019), HO CAUTI rate decreased to 0.62 per 1,000 catheter days. Comparison of pre- and post-intervention rates showed a statistically significant reduction in HO CAUTIs (P = 0.04). The total number of catheter days reduced, but the difference was not statistically significant (8,604 vs. 7,583; P = 0.06). Of the 14 HO CAUTIs in post-intervention period, 64% (8/14) were reported preventable. The preventable causes included inappropriate urine culturing practice in asymptomatic patients (5) or as part of pan-culture without urinalysis (2), and lack of daily catheter assessment for necessity (1).

Conclusion

At our institute, regular educational feedback by IP to frontline staff resulted in a reduction of HO CAUTIs. Feedback measure improved accountability, awareness and engagement of frontline staff in practicing appropriate CAUTI prevention strategies.

Disclosures

All authors: No reported disclosures.
1157. GET IT OUT! Nurses and Clinical Quality Improvement Specialists Drive Initiative to Reduce Standardized Utilization Ratios for Indwelling Urinary Catheters in Hospitalized Patients
Authors: Martinez Aldo , Parilla Deborah , Green Melissa , Murphy Anne , Suarez-Ponce Sylvia , Rasmussen Teresa , Thomas Karen , Patel Shruti B , Smith Kevin R , Gomez Belkys T , Parada Jorge P
Published: October 2019

Background

Urinary tract infections (UTIs) account for 34% of all healthcare-associated infections (HAI). Urinary catheters (UC) are placed in 15–25% of hospitalized patients and >75% of HAI UTIs are UC-related. Bacteria introduced via UC can colonize the bladder within 3 days. So, the greatest risk factor for acquiring a catheter-associated urinary tract infection (CAUTI) is prolonged use of indwelling UC. Nursing (RN) staff noted inconsistency with appropriate use of UC and commonly UC remained in place well after their original indication had expired.

Methods

As part of a multi-faceted approach for quality improvement and patient safety, we rolled out an Agency for Healthcare Research and Quality (AHRQ)-based initiative to reduce UC days/Standardized Utilization Ratio (SUR). Daily critical reviews of the indication for UC were conducted by two groups. First, frontline night shift RN staff identified patients who no longer had a valid justification for continued UC. They handed-off the information to day-shift RNs, who recommend removal of UC during daily rounds with the physician teams. A second review was performed by Clinical Quality Improvement Specialists (CQIS) based on defined criteria from our nursing decatheterization protocol. Their discontinue UC recommendations were also sent to the care teams. The critical reviews of UC for CAUTI reduction started with 4 ICUs in August 2018, with additional ICUs added in December, January and March. Monthly UC SURs were tracked

Results

Figure 1 shows the number of UCs recommended for removal by RNs vs. CQIS (bars), as well as the percent discordance between RNs and CQIS (line). CQIS identified many more removable UCs than the RNs (888 vs. 256). 211 UC were removed after RN recommendations, and an additional 386 UCs were removed as a result of the CQIS audits. Figure 2 shows the marked corresponding decline in our SUR over this intervention.

Conclusion

As more units participated in the initiative, we saw increasing numbers of “discontinue UC” recommendations. Over time there was also a moderate decrease in the discordance between RN and CQIS recommendations for UC removal. CQIS routinely identified many more UCs to be removed compared with RNs, and more than doubled the number of discontinued UC. Notably, the UC SUR markedly improved, decreasing from 0.98 to 0.78.

Disclosures

All authors: No reported disclosures.
1176. Antibiotic Prophylaxis Strategies Prior to Left Ventricular Assist Device Implantation: A Survey of Practice
Authors: Mourad Ahmad , Bishawi Muath , Arif Sana , Miller Rachel , Miller Rachel , Maskarinec Stacey
Published: October 2019

Background

Short duration, single-agent antimicrobial prophylaxis with anti-staphylococcal activity is recommended at the time of left ventricular assist device (LVAD) placement to prevent infection-related complications. Despite consensus guidelines, there continues to be wide variability in antimicrobial regimens among implantation centers. The aim of this study was to characterize current peri-operative antimicrobial prophylactic strategies at different LVAD implantation centers.

Methods

A survey study was conducted from September 26, 2017 to October 25, 2017. Surveys were distributed electronically to both LVAD coordinators and infectious diseases specialists at 75 US medical centers identified as having an LVAD program. Data collection included information about antimicrobial selection, duration, MRSA screening and decolonization procedures.

Results

We received 29 survey responses. The majority of surveys were completed by infectious diseases physicians [72.4% (21/29)]. Most responding centers reported LVAD programs established for >10 years [20/29 (69%)]. Cardiac transplantation was performed in 28/29 (96%) centers. Of centers reporting a defined antimicrobial prophylaxis regimen for nonpenicillin allergic patients [97% (28/29)], 17.9% (5/28) reported a four-drug regimen, 35.7% (10/28) reported a three-drug regimen, and 46.4% (13/28) reported a two-drug regimen, while no centers reported a single-drug regimen. Empiric fluconazole was common [50% (14/28)] and 96.4% (27/28) of regimens included Vancomycin. Duration of antimicrobial prophylaxis (24 h-5 d), MRSA screening, decolonization procedures, and alterations due to drug allergies varied significantly across participating centers.

Conclusion

Our survey results indicate a wide variation in the peri-operative antimicrobial prophylaxis regimens among participating LVAD centers. These results highlight the need for further studies evaluating the utility, toxicity, and stewardship implications of multi-drug regimens and whether specific clinical factors that prolong antimicrobial duration impact post-operative LVAD-related infection rates.

Disclosures

Rachel Miller, MD, Synexis: Research Grant.
1187. Estimation of Individual Healthcare Workers’ Relative Hand Hygiene Compliance Using an Anonymous Electronic Monitoring System
Authors: Tremblay Maxime-Antoine , Abou Sader Mona , Longtin Yves
Published: October 2019

Background

The current hand hygiene (HH) auditing and feedback strategy include anonymized data collection using direct observation and feedback of aggregated data. We aimed to evaluate whether an anonymous (without wearable device) HH electronic monitoring system (EMS) could detect patterns associated with individual healthcare workers (HCWs) and estimate their relative HH performance.

Methods

Observational study of HH compliance via an EMS in 10 rooms in a tertiary care hospital. The EMS measures HH product dispenser activation (an indicator of HH events) as well as entries and exits from patient rooms (a surrogate of HH opportunities). HH rates were obtained by dividing the number of HH events by the number of opportunities. HH rates were aggregated at room-shift level (i.e., an 8-hour period for a single room). For each room-shift, the HH rate was converted to a Z score, which was then associated with the individual HCW assigned to that room-shift. The relative HH performance of individual HCWs was estimated by comparing the mean Z scores of each HCW with the rest of the group by the Student T-test, with a level of significance set at P < 0.001 after adjustment by Bonferroni’s correction. To investigate whether any association could be due to chance, we looked into the potential association between average Z scores and calendar days, as a counterexample.

Results

Over a 100-day period, there were 45 775 HH events and 136 821 opportunities (global compliance, 33%). Schedules were available for 2980 room-shifts. Fifty-four individual HCWs took part in at least one room-shift (average per HCW, 52 room-shifts; range 1–140). Eight HCWs (15%) had a mean Z score significantly above the group average (Figure 1, green boxes; mean Z score 0.71; range, 0.52 to 0.86; P < 0.001), whereas 9 HCWs (17%) had a significantly inferior Z score (Figure 1, red boxes; mean Z score -0.47, range -0.58 to -0.31, P < 0.001). In contrast, there was no significant difference in Z scores between calendar days (Figure 2; p >0.001).

Conclusion

Cross-linking a high-volume HH database with HCW schedules identified a significant association between individual HCWs and HH compliance in the rooms to which they were assigned. If confirmed in further studies, anonymous EMS could be used to provide HCWs with personalized relative HH compliance feedback.

Disclosures

All authors: No reported disclosures.
1195. Hand Hygiene Compliance of Patients’ Family Members in India: Importance of Educating the Unofficial “Fourth Category” of Healthcare Personnel
Authors: Biswal Manisha , Angrup Archana , Rajpoot Surria , Kaur Rupinder , Kaur Kulbeer , Kaur Harinder , Kaur Harpreet
Published: October 2019

Background

In India,due to manpower constraints, patients’ family members are often actively involved in healthcare activities of their near and dear ones. They have significant contact with the patient at all the 5 moments for hand hygiene (HH) as listed by WHO. At our tertiary care hospital in north India, we have been monitoring HH compliance (HHC) for nearly a decade. In this study, we analyzed the impact of decade long awareness campaigns to improve HH compliance in our patients’ attendants.

Methods

Trained infection control nurses directly observed the compliance to hand hygiene at each of the five moments for patients’ attendants over different areas of the hospital over a period of 5 years (January 2014–December 2018). Compliance was calculated as percentage of events over total opportunities and compared.

Results

7290 opportunities were observed with an overall compliance of 46.3%. The overall HHC in patient attendants has increased from 35.5% in 2014 to 48.2% in 2018 (P < 0.0001). Compliance at WHO moment 1, 2, 3, 4 and 5 was 51.2%, 47.8%, 67.8%, 48.9% and 24.4% respectively. Among family members, mothers of newborn babies had a much higher HHC (77%) than others (44.7%) (P < 0.0001). Also, the compliance was higher in medical vs. surgical wards and pediatric wards vs. adult wards (P < 0.0001 in both).

Conclusion

This is the first study about family members’ HHC in a hospital setting in a low and middle-income country. Once trained, family members exhibit fairly good hand hygiene compliance while involved in healthcare activities of their patients. Mothers of newborn babies exhibit exemplary hand hygiene compliance while caring for their babies in our hospital. It is worthwhile empowering and educating patient attendants about the importance and process of hand hygiene as it is likely to result in immense benefit for patients.

Disclosures

All authors: No reported disclosures.
1198. Developing Infection Prevention and Control (IPC) Educational Videos to Improve Knowledge of Respiratory Virus Transmission and Etiquette
Authors: Gianchetti Lauren , Sharova Anna , Hanley Samantha E , Feemster Kristen , Odeniyi Folasade
Published: October 2019

Background

Most pediatric healthcare encounters for influenza-like-illness (ILI) take place in ambulatory settings where there may be multiple opportunities for transmission of respiratory viruses, yet adherence to recommended respiratory etiquette behaviors is inconsistent. We developed brief family education videos and evaluated their impact on knowledge about respiratory virus transmission and IPC practices and intention to use respiratory etiquette behaviors.

Methods

We developed 3 animated, 2–3 minute videos for waiting room display. Content included respiratory virus transmission and the use of hand hygiene, masks, and tissues in a Cover Your Cough Station (CYCS). A convenience sample of caregivers (N = 116) recruited from waiting rooms of two primary care clinics in a large pediatric care network completed a questionnaire measuring perceptions of respiratory virus transmission risk in clinics and knowledge about IPC strategies before and after viewing the videos. Clinical staff (N = 8) from participating clinics revaluated content and clarity of each video using an adapted version of The Patient Education Materials Assessment Tool (PEMAT).

Results

After viewing all videos, a significantly higher proportion of respondents knew where to find a CYCS (59%, 93%, P < 0.0001), accurately named CYCS items (30%, 72%, P < 0.0001), identified why cough etiquette is important (65% vs. 83%, P = 0.0003) and would use CYCS during office visits (61% vs. 89%, P = 0.0001). Baseline knowledge about appropriate hand hygiene and cough etiquette practices was high with no significant change post-video. Most caregivers reported that our videos were easy to understand (90%, 79%, and 82% for videos 1–3, respectively) and that the videos made them want to use a CYCS (95%, 91%, 85% for videos 1–3.). All clinical staff agreed that the videos were appropriate for parents and children and also align with the practices’ IPC policies and other healthcare messages received by clinical staff

Conclusion

Targeted educational videos may be an effective method for increasing awareness of respiratory etiquette resources in pediatric clinics to encourage the use of IPC strategies and prevent the spread of respiratory viruses.

Disclosures

All authors: No reported disclosures.
1200. Parent Perspectives on Infection Prevention and Control in the NICU
Authors: Science Michelle , Khan Sarah , Arnold Callum , Sanchez Pablo J , Lee Kyong-soon , Bacchini Fabiana , Hawes Judith , Mertz Dominik , el Helou Salhab , Kaufman David
Published: October 2019

Background

Infants admitted to the neonatal intensive care unit (NICU) are at high risk for healthcare-associated infections (HAIs) due to their immature immune systems and need for invasive devices. Parents have frequent contact with their infants and present an opportunity for prevention practices. The objective of this study was to evaluate parental opinions related to infection prevention and control (IPAC) in the NICU.

Methods

An online survey was sent to a network of 2,000 parents from the Canadian Premature Babies Foundation. The survey included questions about patient-centered outcomes, IPAC practices experienced during their infants’ NICU admission, and specifically, opinions regarding nonsterile glove use by both healthcare workers (HCWs) and parents.

Results

A total of 72 parents responded to the survey. The majority were parents of infants born at less than 37 weeks (94%) and had been admitted to an NICU after 2010 (89%). When asked about preventing infections in the NICU, 82% of parents indicated they had been given information on how the NICU prevents infection and 96% had been told how they can prevent infection in their infant (Table 1). The most common information was related to hand hygiene (96%) and what to do if they were unwell (89%). Opportunities for improvement included being bare below the elbow, nail care, and feeding human milk. With respect to IPAC outcomes of interest, 96% agreed that it was important to study interventions to reduce bloodstream infections (BSIs). Other outcomes of interest (Table 2) included necrotizing enterocolitis (72%), antibiotic-resistant organism acquisition (69%), and length of stay (67%). With respect to glove use, 89% of parents felt that it was acceptable for HCWs to wear gloves when caring for their infant. Only 37% of parents indicated that they would want to wear gloves if HCWs were wearing gloves, but 47% would consider wearing gloves if there was evidence that it reduced infection in their infant.

Conclusion

Reducing infections, specifically BSIs, in infants admitted to the NICU is an outcome of interest for parents. Nonsterile gloving by HCWs is considered an acceptable strategy by parents to reduce infections. Missed opportunities exist for the education of parents in the NICU on IPAC practices.

Disclosures

All authors: No reported disclosures.
1224. Factors Associated with Aerosolization of Gammaproteobacteria from Intensive Care Unit (ICU) Sinks in a Randomized Trial of Copper Alloy vs. Standard Chrome Sink Drains
Authors: Volling Cheryl , Anceva-Sami Sofia , Boyd David , Coleman Brenda , Downing Mark , Hota Susy , Jamal Alainna , Johnstone Jennie , Katz Kevin , Leis Jerome , Li Angel , Mahesh Vinaya , McLeod Chris , Muller Matthew P , Mulvey Michael , Nayani Sarah , Paterson Aimee , Pejkovska Mare , Ricciuto Daniel , Sultana Asfia , Vikulova Tamara , Zhong Zoe , McGeer Allison
Published: October 2019

Background

Hospital wastewater environments are recognized as reservoirs for multi-drug-resistant bacteria, and sink drains in ICUs have been implicated in numerous outbreaks. The mechanism of pathogen transmission to patients, and the best approach to risk mitigation remains unclear. We tested a new copper alloy sink drain for its effect on detection of gammaproteobacteria in sink drains and adjacent aerosols.

Methods

We randomized 90 sinks in 76 ICU rooms/bedspaces in 7 ICUs to new standard chrome or copper alloy drains. We sampled sinks on 4 occasions over 4 months. Drain tailpieces were sampled using cotton swabs of 140 cm2 of the interior surface, inserted into 1mL of Dey-Engley neutralizing broth, and cultured semi-quantitatively for gammaproteobacteria on Mac3CV. 850L samples of air adjacent to sinks were obtained by impaction onto Mac3CV. Faucet swabs were also cultured. Multivariable analysis adjusting for factors associated with growth in air and drains used conditional logistic regression, GEE with an exchangeable correlation matrix, a robust estimate of variance, negative binomial distribution and log link function.

Results

Gammaproteobacteria were detected in 247/424 (58%) tailpiece swabs, 137/456 (30%) air samples, and 31/456 (7%) faucet swabs. In multivariable analysis, growth was less likely from air adjacent to sinks with copper vs. chrome drains [IRR 0.50 (95% CI 0.35, 0.73), P < 0.0001], with reduced effect size observed when drain growth was included in the model [IRR 0.64 (95% CI 0.43, 0.94)], P = 0.025]. Growth in air was more likely when drain growth was 1–899 cfu/cm2 [IRR 2.38 (95% CI 1.46, 3.88), P = 0.001] or ≥900 cfu/cm2 [IRR 3.55 (95% CI 1.87, 6.86), P < 0.001] vs. no growth. Tailpiece swab growth was more likely if rooms were occupied compared with empty [IRR 1.85 (95% CI 1.25, 2.76), P = 0.002], and less likely from copper drains compared with swabs from chrome drains [IRR 0.51 (95% CI 0.47, 0.75), P ≤ 0.001].

Conclusion

Sinks with new copper drains are less likely to have detectable gammaproteobacteria in adjacent air when compared with standard chrome drains, and results suggest this is mediated through reduced bacterial growth in the drains. Ongoing study is needed to determine whether this influences patient risk for hospital-acquired infection.

Disclosures

All authors: No reported disclosures.
1227. Replacement and Rerouting of Pipes to Remediate Intractable Contamination of Potable Water Fixtures in a Pair of ICU Rooms
Authors: Carroll David M , Michelin Angela V , Craig Melanie J , Johnson Johnathan J , Yoo Jonathan N , Evans Michele R , Henderson David K , Lau Anna F , Palmore Tara N , Palmore Tara N
Published: October 2019

Background

“Green” construction approaches may place hospitals at risk for long-term contamination of potable water, presenting hazards for immunosuppressed patients. Remediation may be needed to manage these unanticipated consequences. An indolent, 11-year cluster of Sphingomonas koreensis infections at the NIH Clinical Center was traced to potable water. During the investigation, 4 sinks in 2 ICU rooms were found to have intractable contamination. Despite replacement of sink fixtures, faucet swabs and water continued to grow S. koreensis, and mean free chlorine residual (FCR) from the sinks was 0.27 mg/L (goal > 0.5). We undertook a major project to replace and reroute sections of pipes leading to the sinks (Figures 1 and 2).

Methods

Hot and cold water pipes were removed from the sinks to the supply pipes and replaced. Pipes were rerouted so that hot and cold water supplying the sinks returned in a loop to the domestic hot water heater to eliminate 10-meter drop-down sections of dead-leg pipe. Automatic faucets were replaced with manual faucets. Faucet biofilm was swabbed and cultured monthly for S. koreensis. Environmental samples were cultured on sheep blood agar for 5 days. Yellow colonies were subcultured and identified by MALDI-TOF MS (Bruker).

Results

Demolition of the wall behind the sinks revealed hot and cold water piping containing stagnant water. Water pooled in cold water pipe had heavy growth of S. koreensis; water from the hot water pipe could not be collected. Hot and cold water FCR for the sinks after piping changes averaged 0.74 and 1.07 mg/L, respectively, compared with 0.27 mg/L simultaneously from automated faucets in unmodified ICU rooms. Faucet cultures were negative for S. koreensis after replumbing, and have remained negative for >6 months.

Conclusion

New hospital construction strategies appear to increase potable water contamination risks; novel remediation approaches are needed. Replacing contaminated water pipes and rerouting pipes to minimize stagnation eradicated longstanding contamination of 2 ICU sinks. Although the experiment was conducted on a small scale, it demonstrates that plumbing flaws that jeopardize patient safety can be corrected through multidisciplinary collaboration and creative plumbing strategies.

Disclosures

All authors: No reported disclosures.
1230. Estimating Effective Point-of-Use Biocide Levels for Legionella Control in Building Water Systems Using a Large, Real-World Dataset
Authors: Decker Brooke K , Goto Michihiko , Gamage Shantini D , Kralovic Stephen
Published: October 2019

Background

Legionnaires’ disease is a potentially life-threatening illness often associated with Legionella growth in water sources. Oxidizing biocides, such as chlorine (CL), monochloramine (MC) and chlorine dioxide (CD), can reduce Legionella contamination. However, limited guidance exists regarding optimal target biocide levels in building water systems to prevent Legionella growth. We examined Legionella and biocide data collected by Department of Veterans Affairs medical facilities nationally to estimate effective biocide levels.

Methods

Water samples collected at point of use for routine surveillance purposes between 2015 and 2017 were used for this analysis. Samples were limited to those with reported biocide being CL, MC or CD. Samples with biocide levels above safe drinking water maximums and from nonpotable water sources were excluded. Samples were stratified by hot and cold water and univariate logistic generalized additive models were used to assess nonlinear associations of probability of Legionella positivity and biocide level.

Results

The dataset included 144,458 samples (cold: 72,674; hot: 71,784) from 789 buildings at 168 hospitals, with 99,419 samples with reported biocide as CL, 40,922 as MC, and 4,117 as CD. For CL, cold water analysis showed a minimum probability of positivity at approximately 0.5 parts per million (ppm), but with a second minimum at 2 ppm. Hot water showed an inflection point around 0.6 ppm, but the likelihood of positivity continued to decrease until plateauing beyond 2 ppm (Figure 1). Cold water with MC showed a minimum probability of positivity at 0.3 ppm followed by a second minimum at 1.7 ppm with plateau beyond that concentration. Hot water showed a similar graph with initial minimum at 0.25 ppm and a second minimum at 1.6 ppm (Figure 2). CD graphs for both hot and cold showed a decrease at 0.2 ppm (Figure 3).

Conclusion

The variability in the dynamics of Legionella inhibition by different biocides as seen in our analysis indicates minimum biocide targets for the different agents. For CL and MC, biocide levels >2 ppm at point of use in building water systems may not provide added benefit for suppression of Legionella.

Disclosures

All authors: No reported disclosures.
1237. Review of Implant Surgical Site Infections and Staphylococcus aureus Screening Compliance for 2018 at a Large Healthcare System
Authors: Strollo Stephanie L , Passaretti Catherine
Published: October 2019

Background

Surgical site infections (SSIs) following hip arthroplasty (THA), knee arthroplasty (TKA) and spinal fusions result in substantial morbidity, mortality and increased cost. Guidelines recommend preoperative Staphylococcus aureus (SA) screening and decolonization; however, there are numerous logistical challenges with implementing this process. We reviewed compliance with SA screening and decolonization practices and relation to THA, TKA, and fusion SSI performance

Methods

Preoperative SA screening programs and associated data were reviewed for THA, TKA and fusion procedures between September and December 2018 across 9 hospitals in a large healthcare system. Compliance with preoperative SA screening was counted if SA nares culture or polymerase chain reaction (PCR) was completed at any point in the 28 days prior to surgery. This SA screening compliance snapshot was compared with year end 2018 SSI rates per 100 procedures and National Health Safety Network (NHSN) all SSI Standardized Infection Ratio (SIR). All 2018 SSIs were reviewed to determine whether infection was due to SA and for compliance with preoperative SA surveillance.

Results

Overall preoperative SA screening compliance for September through December 2018 was 49% (32%, 54% and 62% for fusions, THA and TKA respectively). Sixty-nine implant-related SSIs were identified in 2018. 33% were due to SA. 2018 all SSI rate per 100 procedures was 0.78 (1.437 with SIR of 1.05, 0.783 with SIR of 0.67, and 0.315 with SIR 0.45 for fusions, THA and TKA respectively). Only 36% (25/69) of all SSI and 30% (7/23) of SA SSIs had preoperative SA screening completed. (Table 1). While overall preoperative SA screening compliance was poor, day of surgery SA screening with immediate decolonization using nasal iodine was 75% compared with 58% and 44% for those screened at preoperative medical visit or by surgeon order.

Conclusion

One-third of our implant surgeries were complicated by SSIs due to SA. Overall compliance with preoperative SA screening was poor however SSI rates trended down with higher preoperative SA screening compliance. Better operationalization of preoperative SA screening programs or further data on impact of day of surgery screening and immediate decolonization are needed.

Disclosures

All authors: No reported disclosures.
1244. Evaluation of Intraoperative Topical Vancomycin and the Incidence of Acute Kidney Injury
Authors: Blackman Alison L , Ali Sabeen , Gao Xin , Mesumbe Rosina , Cheng Carly , Seung Hyunuk , Banoub Mary , Claeys Kimberly C , Heil Emily
Published: October 2019

Background

The use of intraoperative topical vancomycin (VAN) is a strategy aimed to prevent surgical site infections (SSI). Although there is evidence to support its efficacy in SSI prevention following orthopedic spine surgeries, data describing its safety, specifically acute kidney injury (AKI) risk, is limited. The purpose of this study was to determine the AKI incidence associated with intraoperative topical VAN.

Methods

This is a retrospective cohort study reviewing patient encounters where intraoperative topical VAN was administered from February 2018 to July 2018. All adult patients ( ≥18 years) that received topical VAN in the form of powder, beads, rods, paste, cement spacers, or unspecified topical routes were included. Patient encounters were excluded for AKI or renal replacement therapy (RRT) at baseline, ≤ 2 serum creatinine values drawn after surgery, and/or if irrigation was the only topical formulation given. The primary outcome was the percentage of patients who developed AKI after intraoperative topical VAN administration. AKI was defined as an increase in serum creatinine (SCr) ≥50% from baseline, an increase in SCr >0.5 from baseline, or0 if RRT was initiated after topical VAN was given. Secondary outcomes included analysis of AKI risk factors and SSI incidence. AKI risk factors were analyzed using a multivariable logistic regression model.

Results

A total of 589 patient encounters met study criteria. VAN powder was the most common formulation (40.9%), followed by unspecified topical routes (30.7%) and beads (9.9%%). Nonspinal orthopedic surgeries were the most common procedure performed 46.7%. The incidence of AKI was 8.7%. In a multivariable logistic regression model, AKI was associated with concomitant systemic VAN (OR 3.39, [3.39–6.22]) and total topical VAN dose. Each doubling of the topical dose was associated with increased odds of developing AKI (OR = 1.42, [1.08–1.86]). The incidence of SSI was 5.3%.

Conclusion

AKI rates associated with intraoperative topical VAN are comparable to that of systemic VAN. Total topical vancomycin dose and concomitant systemic VAN was associated with an increased AKI risk. Additional analysis is warranted to compare these patients to a similar population that did not receive topical VAN.

Disclosures

All authors: No reported disclosures.
1263. Anti-Retroviral (ART) Success in an Active Duty Military Cohort from 2002 to 2016, A Model for Ending the HIV Epidemic in the United States
Authors: Schofield Christina , Colombo Rhonda , Won Seunghyun , Okulicz Jason , Ganesan Anuradha , Blaylock Jason M , Maves Ryan , Lalani Tahaniyat , Gleeson Todd , Murray Clinton , Agan Brian
Published: October 2019

Background

Since 1985, all active duty (AD) U.S. military service members have undergone periodic mandatory HIV screening. Subsequent care in the Military Health System (MHS) allows evaluation of clinical outcomes in a setting of open access to healthcare and medications. We describe ART outcomes in HIV-positive AD military utilizing data collected over 15 years in our prospective, multi-center HIV Natural History Study (NHS).

Methods

We included AD NHS participants diagnosed with HIV from 2002–2016 with ≥1 year of follow-up. Demographics, clinical diagnoses and laboratory data collected at study visits were compared for those on vs. never on ART by HIV diagnosis era at 5-year intervals. Among participants who initiated ART with ≥1 year of follow-up after ART initiation (AI), we assessed rates of virologic suppression (VS) and virologic failure (VF).

Results

From 2002 to 2016, 1,599 NHS participants were diagnosed with HIV infection; 1,482 had ≥1 year of follow-up. 1,337 (90.2%) received ART; ART recipients were more likely male (OR 2.5 [95% CI 1.2–5.3]), Caucasian (1.6 [1.1–2.3]), older (1.5 per 10 years [1.1–2.0]), diagnosed from 2012–2016 (14.6 [6.6–31.9]), and have lower CD4 counts (0.8 per 100 cells [0.7–0.8]) and higher VL at diagnosis (2.1 [1.8–2.5]). The median time from diagnosis to AI was 0.3 years [0.1–1.3], decreasing by era (P <0.0001). Of those ever on ART, 1,212 (90.7%) had ≥1 year of follow-up on ART; of whom, 1,196 (98.7%) achieved ≥1 measure with VS, 91% on their first regimen and 69% within 6 months. Participants not achieving VS were younger at diagnosis (0.87 per year [0.78–0.98]) and at AI (0.89 per year [0.81–0.98]), were diagnosed in 2002–2011 (9.11 [1.20–69.22]), and had lower CD4 counts at AI (0.50 per 100 cells [0.33–0.75]). 92 (7.7%) had subsequent VF after initial VS. VF was more likely in participants diagnosed in 2002–2006 (3.0 [2.0–4.7]). 281 (23.2%) had an AIDS-defining diagnosis (CD4<200 cells/uL in 88%), which decreased by era (P <0.05). There were 6 deaths in the cohort, all prior to 2012.

Conclusion

Universal HIV testing and open access to care has resulted in excellent outcomes for AD HIV-positive military members. The MHS model reinforces the benefits of the Department of Health and Human Services’ recommendations for universal testing, linkage to care and ART.

Disclosures

All authors: No reported disclosures.