bluuebunny/crossref_metadata_2025 huggingface dataset:
Targeting Zero-Preventing Surgical Site Infections by Reducing Immediate-Use Steam Sterilization (IUSS)
Authors: Holdsworh Jill , Juno Zach , Rider Patty , McClendon Taviana , Key Billy
Published: November 2020

Objective: To reduce the number of immediate-use steam sterilization (IUSS) cycles performed to below 2% to increase patient safety and decrease surgical site infections (SSIs). Methods: The facility decide to make a “hard stop” date at which IUSS cycles were no longer going to be allowed without operating room (OR) and Sterile Processing Department (SPD) leadership approval, based on standardized indications for IUSS cycles. Before the start date, extensive education was given to surgeons, OR clinical teams, and SPD team members to ensure understanding of the process and risk of infection due to IUSS. The facility also recognized that workflow was a large part of why instruments were being sent through IUSS cycles, due to a backup of sets in the department and because some items could not be processed before the next day. Many items were purchased to increase workflow capabilities: such as a new washer, sonic, adding a pass-through window, a low-temperature sterilizer, Also, 3 sterilizers were replaced with newer, more efficient models. The facility also purchased a large number of instruments to create new and additional trays to accommodate the surgical volume. The SPD also underwent LEAN Kaizen events on both the clean and dirty sides to improve workflow and efficiency to prevent further IUSS. Project Results: The facility saw immediately results in reduction of IUSS cycles being performed and were the department was able to drop below the goal of 2% after the first month of using the new process. The rate has continued to be <2% for >5 months. Communication and partnership between the OR, infection prevention staff, and SPD were beneficial and will continue to move the facility forward in a shared decision-making model as improvement continues in the future.

Funding: None

Disclosures: None
Temporal Changes in Central-Line–Associated Bloodstream Infection Time Between Events, 2017–2018 Versus 2015–2016
Authors: Edwards Jonathan , Allen-Bridson Katherine , Pollock Daniel
Published: November 2020

Background: The CDC NHSN surveillance coverage includes central-line–associated bloodstream infections (CLABSIs) in acute-care hospital intensive care units (ICUs) and select patient-care wards across all 50 states. This surveillance enables the use of CLABSI data to measure time between events (TBE) as a potential metric to complement traditional incidence measures such as the standardized infection ratio and prevention progress. Methods: The TBEs were calculated using 37,705 CLABSI events reported to the NHSN during 2015–2018 from medical, medical-surgical, and surgical ICUs as well as patient-care wards. The CLABSI TBE data were combined into 2 separate pairs of consecutive years of data for comparison, namely, 2015–2016 (period 1) and 2017–2018 (period 2). To reduce the length bias, CLABSI TBEs were truncated for period 2 at the maximum for period 1; thereby, 1,292 CLABSI events were excluded. The medians of the CLABSI TBE distributions were compared over the 2 periods for each patient care location. Quantile regression models stratified by location were used to account for factors independently associated with CLABSI TBE, such as hospital bed size and average length of stay, and were used to measure the adjusted shift in median CLABSI TBE. Results: The unadjusted median CLABSI TBE shifted significantly from period 1 to period 2 for the patient care locations studied. The shift ranged from 20 to 75.5 days, all with 95% CIs ranging from 10.2 to 32.8, respectively, and P < .0001 (Fig. 1). Accounting for independent associations of CLABSI TBE with hospital bed size and average length of stay, the adjusted shift in median CLABSI TBE remained significant for each patient care location that was reduced by ∼15% (Table 1). Conclusions: Differences in the unadjusted median CLABSI TBE between period 1 and period 2 for all patient care locations demonstrate the feasibility of using TBE for setting benchmarks and tracking prevention progress. Furthermore, after adjusting for hospital bed size and average length of stay, a significant shift in the median CLABSI TBE persisted among all patient care locations, indicating that differences in patient populations alone likely do not account for differences in TBE. These findings regarding CLABSI TBEs warrant further exploration of potential shifts at additional quantiles, which would provide additional evidence that TBE is a metric that can be used for setting benchmarks and can serve as a signal of CLABSI prevention progress.

Funding: None

Disclosures: None
The Utility of Interaction Design as a Novel Tool to Improve Hand Hygiene Frequency on a Pediatric Hematology-Oncology Ward
Authors: Blaak Johanna , DiMaio Rachel , Kupis Julia , Sweetzir Ross , Betuzzi Conny , Dowler Corey , McIntytre Krista , Kaufman Jaime , Hallihan Greg , Conly John , Vayalumkal Joseph
Published: November 2020

Johanna Blaak, W21C, University of Calgary; Rachel DiMaio, University of Calgary; Julia Kupis, University of Calgary; Ross Sweetzir, Cisco Systems; Conny Betuzzi, Alberta Children’s Hospital, Alberta Health Services; Corey Dowler, Alberta Children’s Hospital, Alberta Health Services; Krista McIntytre, Alberta Children’s Hospital, Alberta Health Services; Jaime Kaufman, University of Calgary; Greg Hallihan, University of Calgary; John Conly, Foothills Medical Centre; Joseph Vayalumkal, Alberta Childrens Hospital

Background: Interaction design offers a novel interventional strategy to enhance hand-hygiene compliance (HHC) and reduce hospital-acquired infections (HAIs) in the pediatric setting. A quality improvement initiative in collaboration with the University of Calgary and Alberta Health Services led to the implementation of a pilot project with sensor-embedded alcohol -based hand rub (ABHR) dispensers at a hematology-oncology and hematopoietic stem cell transplant unit at Alberta Children’s Hospital (ACH). Methods: Internet of things (IoT) sensors were installed in ABHR dispensers (n = 3) on the unit. Usage data were transmitted to a local server using an MQTT messaging protocol for 16 weeks. Real-time data visualization was presented on a central display next to the nursing station with 11 unique pediatric themes including dinosaurs, transportation, and Canadian animals. Data were collected with and without visualization, and frequency of use (FoU) was determined for both periods. Qualitative interviews with unit stakeholders (n = 13) were held to determine perceptions of the intervention. Results: During the first 8 weeks of the study period, the mean daily use without visualization was 47 times (SD, 14.5) versus 99 times (SD, 23.9) with visualization. When accounting for novelty, by removing the first week of data, the mean daily use was 92 (SD 19.6). The percentage increase from period 1 to period 2 was 96.6%, accounting for novelty. Qualitative interviews with stakeholders (n = 13) on the unit indicated that the intervention increased their personal awareness of hand hygiene (75%) and acted as a constant reminder to perform hand hygiene for everyone on the unit including nonclinical staff, patients, and family members (92%). Conclusions: These limited data suggest that interaction design may improve HH frequency and show promise as a tool for increased HH awareness and education. Interaction design provides a unique, innovative, and acceptable hand hygiene improvement strategy for staff, patients, and families in the pediatric inpatient setting.

Funding: None

Disclosures: None
Timing and Route of Contamination of Patient Rooms With Healthcare-Associated Pathogens
Authors: Redmond Sarah , Cadnum Jennifer , Pearlmutter Basya , Herrera Natalia Pinto , Donskey Curtis
Published: November 2020

Background: Transmission of healthcare-associated pathogens such as Clostridioides difficile and methicillin-resistant Staphylococcus aureus (MRSA) is a persistent problem in healthcare facilities despite current control measures. A better understanding of the routes of pathogen transmission is needed to develop effective control measures. Methods: We conducted an observational cohort study in an acute-care hospital to identify the timing and route of transfer of pathogens to rooms of newly admitted patients with negative MRSA nares results and no known carriage of other healthcare-associated pathogens. Rooms were thoroughly cleaned and disinfected prior to patient admission. Interactions of patients with personnel and portable equipment were observed, and serial cultures for pathogens were collected from the skin of patients and from surfaces, including those observed to come in contact with personnel and equipment. For MRSA, spa typing was used to determine relatedness of patient and environmental isolates. Results: For the 17 patients enrolled, 1 or more environmental cultures became positive for MRSA in rooms of 10 patients (59%), for C. difficile in rooms of 2 patients (12%) and for vancomycin-resistant enterococci (VRE) in rooms of 2 patients (12%). The patients interacted with an average of 2.4 personnel and 0.6 portable devices per hour of observation. As shown in Figure 1, MRSA contamination of the floor occurred rapidly as personnel entered the room. In a subset of patients, MRSA was subsequently recovered from patients’ socks and bedding and ultimately from the high-touch surfaces in the room (tray table, call button, bedrail). For several patients, MRSA isolates recovered from the floor had the same spa type as isolates subsequently recovered from other sites (eg, socks, bedding, and/or high touch surfaces). The direct transfer of healthcare-associated pathogens from personnel or equipment to high-touch surfaces was not detected. Conclusions: Healthcare-associated pathogens rapidly accumulate on the floor of patient rooms and can be transferred to the socks and bedding of patients and to high-touch surfaces. Healthcare facility floors may be an underappreciated source of pathogen dissemination not addressed by current infection control measures.

Funding: None

Disclosures: None
Trends and Clinico-Epidemiological Features of Human Rabies Cases in Bangladesh, 2006–2018
Authors: Ghosh Sumon , Rana Md. Sohel , Chowdhury Sukanta
Published: November 2020

Background: Vaccinating dogs against rabies is an effective means of reducing human rabies. Methods: We analyzed 1,327 clinically diagnosed human rabies deaths and mass dog vaccination (MDV) data during 2006–2018 to quantify the impacts of MDV on human rabies incidence in Bangladesh and a subset of rabies death data (n = 422) for clinico-epidemiological analysis. Results: We found a positive and increasing trend of dog population vaccination (P = .01 and τ = 0.71) and a negative and declining trend (P < .001 and τ = −0.88) of human rabies cases (correlation coefficient, −0.82). Among 422 human rabies death cases, most victims (78%) sought treatment from traditional healers, and 12% received postexposure prophylaxis (PEP). The mean incubation period of rabies cases with exposure sites on the head and neck (35 days) was shorter than the upper limb (mean, 64 days; P = .02) and lower limb (mean, 89 days; P < .01). MDV is effective for reducing human rabies cases in Bangladesh. Conclusions: Creating awareness among the animal bite victims to stop relying on traditional healers rather seeking PEP, addressing the role of traditional healers through an awareness education program in respect to the treatment of dog bites, ensuring availability of PEP, and continuing to scale up MDV can help prevent human rabies deaths.

Funding: None

Disclosures: None
Unintended Consequences of MRSA Infection: Empiric Non-MRSA Antibiotic Use and Resultant Clostridioides difficile Infection
Authors: Weiland Anastasiia S. , Lu Julia Y. , Chen Caleb S. , Tjoa Thomas , Singh Raveena D. , McKinnell James A. , Center UCLA Medical , Miller Loren , Huang Susan
Published: November 2020

Background: Methicillin-resistant Staphylococcus aureus (MRSA) is responsible for the largest number of invasive infections due to a multidrug-resistant pathogen. Approximately 10% of hospitalized carriers will experience invasive MRSA disease in the year following discharge incurring antibiotic therapy beyond focused treatment of MRSA. Objective: We aimed to quantify the extent of non-MRSA empiric antibiotics incurred by MRSA infections and further assess the risk of Clostridioides difficile Infection (CDI) as a result of treatment of MRSA infection. Methods: The CLEAR Trial was a postdischarge randomized controlled trial of 2,121 MRSA carriers comparing MRSA education alone to education plus repeated decolonization that demonstrated a 30% reduction in MRSA infection and a 17% reduction in all-cause infection attributable to decolonization in the year following hospital discharge (Huang SS, NEJM 2019). We included all hospitalization outcomes due to MRSA infection in the CLEAR Trial with detailed medication administration records to quantify unintended consequences of MRSA infection related to empiric non-MRSA antibiotic use and resultant CDI. Full-text medical records were reviewed with a standardized abstraction form to collect inpatient administered antibiotics and hospital-associated CDI. Results: In total,154 hospitalizations due to MRSA infection with a mean length-of-stay of 10.6 days were identified. During 25 hospitalizations (16.2%), patients received only anti-MRSA antibiotics. During the remaining 129 (83.8%) hospitalizations, patients received a mean of 1.6 distinct non-MRSA antibiotics totaling a mean of 6.6 days of therapy (DOT). Empiric non-MRSA therapy was given for 3.2 DOT before MRSA culture results became available and was continued for an additional 3.4 DOT afterward. Among all 849 non-MRSA DOT, the most common were due to piperacillin-tazobactam (293 DOT, 34.5%), levofloxacin (105 DOT, 12.4%), and metronidazole (93 DOT, 11.0%). Across all 154 hospitalizations, a mean of 5.5 non-MRSA DOT was calculated per MRSA hospitalization, with 6 CDI cases (3.9%) as a direct sequelae of empiric non-MRSA antibiotics provided for MRSA infection. Conclusions: Hospitalization for MRSA infection results in extensive non-MRSA empiric antibiotic therapy both before and after MRSA culture results are known. This antibiotic use is associated with a 3.9% risk of CDI that exceeds the national risk of acquiring CDI (3.2 per 1,000 admissions) by 12-fold during any hospital stay (Barrett ML, AHRQ 2018). The CLEAR Trial findings that postdischarge decolonization reduces MRSA infection and hospitalization by 30% suggests that decolonization may also reduce non-MRSA antibiotic use and CDI in this population.

Funding: None

Disclosures: None
Use of Health Information Exchange Improved the Identification of Healthcare-Associated Group A Streptococcus Infections
Authors: Cilwick Alana , Burakoff Alexis , Bamberg Wendy , Brousseau Geoffrey , Alden Nisha , Johnston Helen
Published: November 2020

Background: Healthcare-associated group A Streptococcus (GAS) infections can cause severe morbidity and death. Invasive GAS is a reportable condition in the 5-county metropolitan area of Denver, Colorado. Prior to August 2018, methodology to identify long-term care facility (LTCF) residency among reported GAS cases was accomplished by reviewing addresses reported electronically, and identification of postsurgical cases and outbreaks relied on reporting by healthcare facilities. We evaluated whether the use of a health information exchange (HIE) to identify healthcare exposures improved our ability to detect and rapidly respond to these events. Methods: In August 2018, we implemented a review of health records available in the HIE accessible by the Colorado Department of Public Health and Environment for all incoming reports of GAS for selected healthcare exposures: LTCF residency, surgery, delivery, wound care, and other relevant exposures. We defined an LTCF-related case as GAS in a current or recent resident (ie, in the 14 days prior to the positive culture) of an LTCF. Postpartum and postsurgical cases were defined as GAS isolated from a sterile site or wound during the inpatient stay or within 7 days of discharge following a delivery or surgical procedure. Outbreaks in each of these settings were defined as 2 or more cases within a 3-month period. We compared the number of cases and outbreaks identified in each category during a 1-year period before and after implementation of the use of the HIE in the case ascertainment process. Results: During August 2017 through July 2018, prior to implementation of the HIE process, we detected 45 LTCF cases and conducted outbreak investigations in 9 facilities. Moreover, 1 postsurgical case and 1 postpartum outbreak were reported by healthcare facilities; none were detected via surveillance. During August 2018 through July 2019, after the implementation of HIE process, we identified 70 LTCF cases and conducted outbreak investigations in 13 LTCFs. We detected 5 postsurgical cases and 3 postpartum cases, which resulted in 2 outbreak investigations. Conclusions: Enhanced GAS surveillance through use of a HIE resulted in detection of more healthcare-associated GAS infections and outbreaks. Timely identification of healthcare-associated GAS infections can allow for prompt response to outbreaks and promotion of proper infection control practices to prevent further cases. Jurisdictions in which GAS is a reportable condition should consider the use of HIEs as part of routine surveillance to identify GAS outbreaks in high-risk settings. HIEs should be made available to public health agencies for case ascertainment and outbreak identification.

Funding: None

Disclosures: None
10 Years of Pulsed-Xenon Ultraviolet Disinfection
Authors: Stibich Mark , Simmons Sarah , Passey Deborah
Published: November 2020

Background: Ultraviolet light (UV) disinfection using low-pressure mercury lamps has been around since the 1940s. The advent of pulsed-xenon UV for hospital use in 2010 has provided a nontoxic and novel technology for hospital disinfection with the first data presented at the 2010 SHEA Decennial. The purpose of this systematic review and meta-analysis is to examine the current body of evidence for pulsed xenon UV disinfection. Methods: The literature search criteria included the following: research conducted in domestic and international settings using pulsed-xenon for surface disinfection, published between 2000 and 2019, and reporting on environmental effectiveness or hospital-acquired reductions (HAIs). We searched PubMed, Google Scholar, and Web of Science. The meta-analysis included 24 studies: 12 HAI outcome studies and 12 environmental effectiveness studies. Meta-analyses were conducted by calculating the percentage reductions for environmental effectiveness, and for the HAI outcome studies, we used a random-effects model to pool the relative risk of HAI. The outcome studies used 272 and 299 months of data for the experimental and control groups, respectively. Results: There was an overall benefit of using pulsed-xenon UV. The overall relative risk of infection decreased compared to the control arm (RR, 0.64; 95% CI, 0.54–0.76). The percentage reductions in environmental studies were as follows: Clostridioides difficile (94.8%), methicillin-resistant Staphylococcus aureus (91.5%), vancomycin-resistant Enterococcus (99.2%), and aerobic bacteria (94.2%). Conclusions: Overall, pulsed-xenon UV was effective for reducing environmental contamination and had the ability to significantly reduce HAIs.

Funding: Xenex, Inc., funded this study.

Disclosures: Mark Stibich receives a salary from Xenex and is a shareholder of Xenex. Deborah Passey receives a salary from Xenex Disinfection Services.
Antimicrobial Bacteria and Viruses Detected Through Systematic Sampling in the Childcare Environment
Authors: Chedid Khalil , Hayashi Michael , DeJonge Peter , Yancey Olivia , Siebert Elliane , Getz Amy , Eisenberg Joseph , Hashikawa Andrew , Martin Emily
Published: November 2020

Background: Approximately two-thirds of children aged <5 years receive out-of-home child care. Childcare attendees have an increased risk of infections compared to children not in childcare settings, possibly due to their close contact in a shared environment. As multidrug-resistant organisms (MDROs) increasingly move from healthcare-associated to community settings, childcare can provide a venue for further transmission of these pathogens. Our objective was to evaluate the bioburden of pathogens present on fomites in childcare centers and how surface contamination changes over time. Methods: The study was conducted in the single-room play area of an Ypsilanti, Michigan, childcare center caring for children aged 3–5 years. Polyester swabs were used to collect surface samples from 16 locations in the room, including (1) laminate, wood and plastic tabletops and furniture; (2) a stainless steel sink and adjacent plastic trash bin; and (3) wood, metal and plastic toys. A water sample was also collected at a 17th site. Samples were collected twice weekly for 5 of 6 weeks, followed by 1 additional collection (September–October 2019). Tryptic soy agar was used for standard plate counts and selective media were used to identify methicillin-resistant Staphylococcus aureus (MRSA), Vvancomycin-resistant Enterococcus (VRE), and extended-spectrum β-lactamase (ESBL)–producing Enterobacteriaceae. Single-plex RT-PCR was used to detect norovirus and adenovirus. Results: Among 175 samples collected on 11 days, MRSA and ESBL-producing Enterobacteriaceae were detected from 10.3% (18 of 175) and 8.0% (14 of 175), respectively, of environmental specimens. No specimens were positive for VRE or norovirus. Adenovirus was detected in 20 of 175 specimens (11.4%). Median bioburden by site ranged from 85 CFU/mL to 2,510 CFU/mL. The highest median bioburden was observed at the sink (2,510 CFU/mL), followed by the plastic building block table (1,620 CFU/mL), the small wood blocks (1,565 CFU/mL) and water from a water play area and an adjacent tabletop (1,260 and 1,100 CFU/mL respectively). The highest single day bioburden was 273,000 CFU/mL at the sink. Conclusion: The presence of MDROs on childcare center fomites raised concern for exposure to these pathogens among vulnerable populations. More study is needed to determine the degree to which these contaminated fomites drive transmission between children. We found the highest bioburdens on sites where children played or washed with water, identifying potential targets for more frequent cleaning.

Funding: None

Disclosures: Emily T. Martin reports a consulting from Pfizer.
Carbapenem-Resistant Enterobacteriaceae Resistant Only to Ertapenem: An Epidemiologically Distinct Cohort, Atlanta, 2016–2018
Authors: Bower Chris , Adelman Max , Howard-Anderson Jessica , Ansari Uzma , Lutgring Joseph , Tiga Gebre , Jacob Jesse
Published: November 2020

Background: Carbapenem-resistant Enterobacteriaceae (CRE), particularly carbapenemase-producing (CP) CRE, pose a major public health threat. In 2016, the phenotypic definition of CRE expanded to include ertapenem resistance to improve sensitivity for detecting CP-CRE. We compared characteristics of CRE resistant to ertapenem only (CRE-EO) to CRE resistant to ≥1 other carbapenem (CRE-O). Methods: The Georgia Emerging Infections Program performs active, population-based CRE surveillance in metropolitan Atlanta. CRE cases were defined as any Escherichia coli, Klebsiella pneumoniae, K. oxytoca, K. variicola, Enterobacter cloacae complex, or Enterobacter aerogenes resistant to ≥1 carbapenem by the clinical laboratory and isolated from urine or a sterile site between 2016 and 2018. Data were extracted from retrospective chart review and 90-day mortality from Georgia vital statistics for 2016–2017. Polymerase chain reaction (PCR) for carbapenemase genes was performed on a convenience sample of isolates by the CDC or Georgia Public Health Laboratory. We compared characteristics of CRE-EO cases to CRE-O cases using χ2 tests or t tests. Results: Among 927 CRE isolates, 553 (60%) were CRE-EO. CRE-EO were less frequently isolated from blood (5% vs 12%; P < .01) and less commonly K. pneumoniae (21% vs 58%; P < .01) than CRE-O. CRE-EO cases were more often women (65% vs 50%; P < .01), had a lower Charlson comorbidity index (mean ± SD, 2.4±2.3 vs 3.0±2.6; P < .01), and were less commonly at a long-term care facility (24% vs 31%) or hospital (15% vs 21%; P < .01) in the 4 days prior to the CRE culture. CRE-EO were more susceptible to all antibiotics tested at the clinical laboratory (P < .01) except for tigecycline (P = 1.0) (Table 1). Of the 300 (32%) isolates tested for carbapenemase genes, 98 (33%) were positive (7% CRE-EO vs 62% CRE-O; P < .01). Of the CP isolates, we identified blaKPC in 93 cases (95%), blaNDM in 3 cases (3%), blaOXA-48-like in 2 cases (2%). CRE-EO cases had lower 90-day mortality (13% vs 21%; P < .01). Conclusions: CRE-EO are epidemiologically distinct from CRE-O and are less likely to harbor carbapenemase genes. CRE-EO may require less intensive infection prevention interventions and have more therapeutic options.

Funding: None

Disclosures: None
Universal Masking to Prevent Nosocomial Respiratory Viral Infections in Malignant Hematology Inpatient Units
Authors: Arulsundaram Vishnuka , Houston Kelsey , Vicencio Elisa , Rebelo Carly , Vaisman Alon , Hota Susy
Published: November 2020

Background: Patients with hematologic malignancies are at increased risk for respiratory virus infections (RVIs) and may experience prolonged asymptomatic viral shedding contributing to transmission. In response to 2 extensive RVI outbreaks in our adult cancer center, a universal masking policy was implemented whereby inpatients on malignant hematology units and their visitors were required to wear procedure masks whenever they were walking outside their rooms. Visitors were required to mask when inside patient rooms. Staff were not included in the policy. Here, we describe the impact of universal masking on the incidence of nosocomial RVI in malignant hematology patients. Methods: In this before-and-after study, we examined the effects of universal masking in malignant hematology units of a 170-bed adult cancer hospital in Toronto, Canada, between January 1, 2015, and September 30, 2019. Nosocomial RVI incidence, RVI outbreak descriptions, and hand hygiene compliance rates were collected from hospital infection control databases. Mask utilization was extracted from hospital purchasing records. Staff influenza vaccination rates were obtained from occupational health records. RVI incidence rates before and after the intervention were compared using Wilcoxon rank-sum test. Results: The preimplementation phase ran from January 1, 2015, to February 28, 2017, and the postimplementation phase spanned March 1, 2017, to September 30, 2019. Monthly mask utilization on malignant hematology units increased by 105% after implementing the universal masking policy. Nosocomial RVI incidence decreased significantly after implementing the universal masking policy, and the number of cases involved in RVI outbreaks also decreased (Table 1). There was a 14% increase in nasopharyngeal swab orders after implementation. Staff influenza vaccination rates, hand hygiene compliance and infection control policies remained stable throughout the study. Conclusions: A reduction in the incidence of nosocomial RVI and number of RVI cases in outbreaks was observed after implementing the universal masking policy. Although we were unable to directly measure compliance with the intervention, increased mask utilization after the intervention implied adherence to the policy. Our experience suggests that universal masking in malignant hematology inpatients may be an effective RVI prevention strategy. Further rigorous study is warranted.

Funding: None

Disclosures: Susy Hota reports contract research for Finch Therapeutics.
Use of Next-Generation Sequencing to Rule Out Cluster of Pseudomonas aeruginosa in a Cardiac Critical Care Unit
Authors: Neilsen Chad , Rose Rebecca , Nolan David , McCarter Yvette Simone , Rollini Fabiana , Lamers Susanna , Sands Michael Lee , Hoadley Thuyvi
Published: November 2020

Background: In spring of 2019, 2 positive sputum cases of Pseudomonas aeruginosa in the cardiac critical care unit (CCU) were reported to the UFHJ infection prevention (IP) department. The initial 2 cases, detected within 3 days of each other, were followed shortly by a third case. Epidemiological evidence was initially consistent with a hospital-acquired infection (HAI): 2 of the 3 patients roomed next to each other, and all 3 patients were ventilated, 2 of whom shared the same respiratory therapist. However, no other changes in routine or equipment were noted. The samples were cultured and processed using Illumina NGS technology, generating 1–2 million short (ie, 250-bp) reads across the P. aeruginosa genome. As an additional positive control, 8 P. aeruginosa NGS data sets, previously shown to be from a single outbreak in a UK facility, were included. Reads were mapped back to a reference sequence, and single-nucleotide polymorphisms (SNPs) between each sample and the reference were extracted. Genetic distances (ie, the number of unshared SNPs) between all UFHJ and UK samples were calculated. Genetic linkage was determined using hierarchical clustering, based on a commonly used threshold of 40 SNPs. All UFHJ patient samples were separated by >18,000 SNPs, indicating genetically distinct samples from separate sources. In contrast, UK samples were separated from each other by <16 SNPs, consistent with genetic linkage and a single outbreak. Furthermore, the UFHJ samples were separated from the UK samples by >17,000 SNPs, indicating a lack of geographical distinction of the UFHJ samples (Fig. 1). These results demonstrated that while the initial epidemiological evidence pointed towards a single HAI, the high-precision and relatively inexpensive (<US$1500) NGS analysis conclusively demonstrated that all 3 CCU P. aeruginosa cases derived from separate origins. The hospital avoided costly and invasive infection prevention interventions in an attempt to track down a single nonexistent source on the CCU, and no further cases were found. This finding supports the conclusion reached from the NGS that this represented a pseudo-outbreak. Furthermore, these genomes serve as an ongoing record of P. aeruginosa infection, providing even higher resolution for future cases. Our study supports the use of NGS technology to develop rational and data-driven strategies. Furthermore, the ability of NGS to discriminate between single-source and multiple-source outbreaks can prevent inaccurate classification and reporting of HAIs, avoiding unnecessary costs and damage to hospital reputations.

Funding: None

Disclosures: Susanna L. Lamers reports salary from BioInfoExperts and contract research for the NIH, the University of California - San Francisco, and UMASS Medical School.
Utilizing Behavioral Science to Improve Antibiotic Prescribing in Rural Urgent Care Settings
Authors: Cummings Patricia , Alajajian Rita , May Larissa , Grant Russel , Greer Hailey , Dezfuli Massoud
Published: November 2020

Background: The rate of inappropriate antibiotic prescribing for acute respiratory tract infections (ARTIs) is 45% among urgent care centers across the United States. To contribute to the US National Action Plan for Combating Antibiotic-Resistant Bacteria, which aims to decrease rates of inappropriate prescribing, we implemented 2 behavioral nudges using the evidence-based MITIGATE tool kit from urgent-care settings, at 3 high-volume, rural, urgent-care centers. Methods: An interrupted time series (ITS) analysis was conducted comparing a preintervention phase during the 2017–2018 influenza season (October through March) to the intervention phase during the 2018–2019 influenza season. We compared the rate of inappropriate or non–guideline-concordant antibiotic prescribing for ARTIs across 3 urgent-care locations. The 2 intervention behavioral nudges were (1) staff and patient education and (2) peer comparison. Provider education included presentations at staff meetings and grand rounds, and patient education print materials were distributed to the 3 locations coupled with news media and social media. We utilized the CDC “Be Antibiotics Aware” campaign materials, with our hospital’s logo added, and posted them in patient rooms and waiting areas. For the peer comparison behavioral intervention, providers were sent individual feedback e-mails with their prescribing data during the intervention period and a blinded ranking e-mail in which they were ranked in comparison to their peers. In the blinded ranking email, providers were placed into categories of “low prescribers,” those with a ≤23% inappropriate antibiotic prescribing rate based on the US National Action Plan for Combating Antibiotic-Resistance Bacteria 2020 goal, or “high prescribers,” those with a rate greater than the national average (45%) of inappropriate antibiotic prescribing for ARTI. Results: Our results show that fewer inappropriate antibiotic prescriptions were written during the intervention period (58.8%) than during the preintervention period (73.0%), resulting in a 14.5% absolute decrease in rates of inappropriate prescribing among urgent-care locations over a 6-month period (Fig. 1). The largest percentage decline in rates was seen in the month of April (−35.8%) when compared to April of the previous year. The ITS analysis revealed that the rate of inappropriate prescribing was statistically significantly different during the preintervention period compared to the intervention period (95% CI, −4.59 to −0.59; P = .0142). Conclusions: Using interventions outlined in the MITIGATE tool kit, we were able to reduce inappropriate antibiotic prescribing for ARTI in 3 rural, urgent-care locations.

Funding: None

Disclosures: Larissa May repo, Speaking honoraria-Cepheid Research grants-Roche Consultant-BioRad Advisory Board-Qvella Consultant-Nabriva
When Legionnaires’ Disease Isn’t: Case Presentation and Implications of the Council of State and Territorial Epidemiologists (CSTE) Changes to Case Definitions
Authors: Stout Janet E. , Malani Anurag
Published: November 2020

Background: Most cases of Legionnaires’ disease are diagnosed by the urinary antigen test (UAT). Single cases of suspected healthcare-acquired Legionnaires’ disease are often investigated by local and state health departments. Such investigations can result in disruptive and expensive interventions. We report a case of a urine-antigen–positive patient whose clinical presentation was inconsistent with Legionnaires’ disease. Within the same year, an employee at this hospital was diagnosed with presumed community-acquired Legionnaires’ disease; however, the case was considered by the health department to be healthcare acquired. The occurrence of 2 cases, as determined by the health department, fulfilled the definition for an outbreak investigation and triggered water restrictions and extensive testing of the environment and patients for Legionella. The cases and the implications of these actions are reviewed in the context of new information about false-positive urinary-antigen tests and changes to the outbreak case definitions for Legionnaires’ disease by the Council of State and Territorial Epidemiologists (CTSE). This includes “probable” cases that have no positive diagnostic tests.

Funding: None

Disclosures: Janet E. Stout reports salary from the Special Pathogens Laboratory and is an owner.
Patients Discharged From Hospitals Without a Clostridioides difficile Infection Increase the Risk of CDI in Family Members
Authors: Miller Aaron , Segre Alberto , Sewell Daniel , Pemmaraju Sriram , Polgreen Philip
Published: November 2020

Background:Clostridioides difficile infections (CDIs) present and are transmitted in both community and healthcare settings. Patients who become colonized or infected during hospitalization may be discharged into the community. Asymptomatic spread and/or community-based transmission have also been posited as alternative sources for healthcare-onset CDI cases. The objective of our study was to determine whether individuals are at greater risk for developing a CDI if they have a family member that spent time hospitalized in the prior 90 days, even if the hospitalized family member had no prior diagnosis of CDI. Methods: We conducted a retrospective cohort study using the Truven Marketscan database from 2001 through 2017; both commercial claims and Medicare supplemental data were included. We categorized enrollees by age, sex, month, year, exposure to a family member with CDI, hospitalization, or high- or low-risk antibiotic use in the prior 90 days. We then subdivided these groups based on the total amount of time that other family members spent hospitalized in the prior 90 days: ≤4 days, 5–10, 11–20, 21–30, 41–50 or >50 days. Within each subgroup, we computed the incidence of CDI. We then used a stratified regression model (log-linear quasi-Poisson) to estimate the incidence of CDI in each enrollment bin. Finally, we repeated our analysis using all CDI cases, CDI cases with no prior CDI in the family, and cases without prior hospitalization. Results: Over the 17-year study period, >5.1 billion enrollment months were represented in our dataset. We identified 224,818 cases of CDI, 223,744 cases without prior CDI in a family member and 164,650 CDI cases where the case patient had no prior hospitalization. Table 1 depicts the estimated risk (incident rate ratios) associated with the amount of time that other family members spent hospitalized in the prior 90 days. There is a very clear dose–response curve, and the relative risk for CDI increase as the amount of time other family members spent hospitalized increased. Other risk factors included prior hospitalization, low- and high-risk antibiotics, age, female sex and exposure to a family member with CDI. Conclusions: Having a family member who has been hospitalized in the prior 90 days significantly increases the risk for CDI, even if the family member did not have CDI. The total amount of time other family members spent in the hospital is positively associated with the level of risk.

Funding: CDC Modeling Infectious Diseases (MInD) in Healthcare Network

Disclosures: None
Bloodstream Infections with Typical Probiotic Organisms
Authors: Gore Sara , Tucker Kendall
Published: November 2020

Background: Probiotics are protective against Clostridioides difficile infection and antibiotic-associated diarrhea, and they may decrease risk of infections following complex abdominal surgeries. Infectious risks associated with probiotic use are not well described in the literature. We describe probiotic use among patients with bloodstream infections (BSIs) due to organisms typically found in probiotics. Methods: Patients with positive blood cultures with Lactobacillus spp, Saccharomyces spp, and Bifidobacterium spp at our large academic hospital from October 2016 through October 2019 were identified using Theradoc, a clinical surveillance tool. Clinical data and orders for probiotics, including probiotic capsules, probiotic yogurt, and kefir, were extracted from the electronic medical record. Cases were considered distinct if the cultures were collected 7 or more days apart. True infections were defined as positive cultures which were treated with antimicrobials and had provider documentation outlining clinical relevance of culture data. Results: Among 26 distinct episodes of BSI, 16 (62%) were considered true infections. The remaining 10 cases were interpreted as contaminants or of unclear significance. Of the 16 cases representing true infection in 14 patients, 6 (38%) had received probiotics in the hospital in the preceding month. Among these patients, 5 had Lactobacillus bacteremia and had received Lactobacillus capsules, probiotic yogurt, and/or kefir. One patient had Saccharomyces fungemia following receipt of probiotic yogurt and kefir. All 6 patients with BSI possibly related to probiotic use had an antecedent gastrointestinal procedure or surgery within a month of the BSI, and 2 had intra-abdominal abscesses from which the same organism was cultured. Of the 16 true BSIs, 9 occurred in immunocompromised hosts, but antecedent probiotic use was confirmed in only 1 of these cases. Two episodes caused by different organisms occurred within the same month; all other episodes were >60 days apart. Conclusions: In our retrospective review of BSIs with organisms typically found in probiotics over a 3-year period at a large academic hospital, more than one-third of those with clinically relevant BSIs had antecedent probiotic use within the hospital. All patients with infections possibly related to probiotic use had recent gastrointestinal procedures or surgery, raising concern for probiotic use following interventions that increase the risk for gastrointestinal tract leakage or translocation. Further research is necessary to assess the risk of bloodstream infection in postoperative patients treated with probiotics.

Funding: None

Disclosures: None
Bright STAR Collaborative Consensus Guidelines for Blood Culture Use in Critically Ill Children
Authors: Woods-Hill Charlotte , Koontz Danielle , Voskertchian Annie , Miller Marlene , Fackler James , Shea Judy , Milstone Aaron Michael
Published: November 2020

Background: Blood cultures are essential diagnostic tools used to identify bloodstream infections and to guide antimicrobial therapy. However, collecting cultures without clear indications or that do not inform management can lead to false-positive results and unnecessary use of antibiotics. Blood culture practices vary significantly in critically ill children. Our objective was to create a consensus guideline focusing on when to safely avoid blood cultures in pediatric intensive care unit (PICU) patients. Methods: A panel of multidisciplinary experts, many participating in the Blood Culture Improvement Guidelines and Diagnostic Stewardship for Antibiotic Reduction in Critically Ill Children (Bright STAR) Collaborative, engaged in a 2-part modified Delphi process. Round 1 consisted of a preparatory literature summary and an electronic survey sent to subject matter experts (SMEs). In the survey, SMEs rated a series of recommendations about when to avoid blood cultures on a 5-point Likert scale, 1 being the lowest score and 5 being the highest score. Consensus was achieved for each recommendation if 75% of respondents chose a score of 4 or 5, and these were included in the final guideline. Any recommendations that did not meet these a priori criteria for consensus were set aside for discussion during the in-person expert panel review (round 2). An outside expert in consensus methodology facilitated round 2. After a review of the survey results and comments from round 1 and group discussion, the SMEs voted on these recommendations in real time. Voting was blinded. Participants included Bright STAR site leads, national content experts, and representatives from relevant national societies. Results: We received 29 completed surveys from 34 invited participants for an 85% response rate. Of the 27 round 1 recommendations, 18 met predetermined criteria for consensus. Round 2 included 26 in-person voting participants who (1) discussed and modified the 9 recommendations that had not met round 1 consensus, and (2) modified for clarity or condensed from multiple into single recommendations the 18 recommendations that had met the round 1 consensus. The final document contains 19 recommendations that provide guidance on how to safely improve blood culture use in PICU patients (Table 1). Also, 8 recommendations discussed did not reach consensus for inclusion. Conclusions: Using a modified Delphi process, we created consensus recommendations on when to avoid blood cultures and prevent overuse in critically ill children. These guidelines are a critical step in disseminating diagnostic stewardship and reducing unnecessary testing on a wider scale.

Funding: Agency for Healthcare Research and Quality, R18 HS025642-01, 9/2017 – 9/2020 (Aaron Milstone, PI)

Disclosures: None
Reductions in Positive Clostridioides difficile Events Reportable to NHSN With Adoption of Reflex EIA Testing in 13 Atlanta Hospitals
Authors: Goodenough Dana , Sefton Samantha , Smith Elizabeth , Kraft Colleen , Varkey Jay , Fridkin Scott
Published: November 2020

Background: US hospitals are required to report C. difficile infections (CDIs) to the NHSN as a performance measure tied to payment penalties for poor scores. Currently, only the charted CDI test results performed last in reflex testing scenarios are reported to the NHSN (CDI events). We describe the reduction in NHSN CDI events from the addition of a reflex toxin enzyme immunoassay (EIA) after a positive nucleic acid amplification test (NAAT) in teaching and nonteaching hospitals, and we estimate the impact on standardized infection ratios (SIR). Methods: Reporting of all CDI test results, by test method, occurred during April 2018–July 2019 to the Georgia Emerging Infections program (funded by the Centers for Disease Control and Prevention), which conducts active population-based surveillance in an 8-county Atlanta area (population, 4 million). Among facilities starting reflex EIA testing, results were aggregated by test method during months of reflex testing to calculate facility-specific reduction in NHSN CDI events (% reduction; 1-[no. EIA+/no. NAAT+]). Differences in percent reduction between facilities by characteristic were compared using the Kruskal-Wallis test. We simulated expected changes in the SIR for a range of reductions, assuming equal effect on both community-onset (CO) and hospital-onset (HO) tests. Each facility’s historical NHSN CDI events prior to reflex testing were used to estimate changes to facility-specific SIRs by reducing values by the corresponding facility’s percent reduction. Results: Overall, 13 acute-care hospitals (bed size, 52–633; ICU bed size, 6–105) started reflex testing during the study period (mean, 7 months, 15,800 admissions, 66,400 patient days), resulting in 550 +NAAT tests reflexing to 180 +EIA tests (pooled mean 58% reduction). Percent reduction varied (mean, 67%; range, 42%–81%) but did not differ between larger (≥217 beds) and smaller hospitals (61 vs 50% reduction; P > .05) or by outsourced versus inhouse testing (65% vs 54% reduction; P > .05). Simulations identified a threshold reduction at which point effect on HO counteract the effects on CO events enough to reduce the SIR; thresholds for nonteaching and teaching were 26% and 32% reduction, respectively (Fig. 1). The estimated reductions in facility-specific SIRs using measured percent reductions on historic NHSN CDI events closely paralleled the simulation, and the mean estimated change in SIR was −46% (range, −12% to −71%) (Fig. 1). Conclusions: Although the magnitude of the effect varied, all 13 facilities experienced dramatic reductions in CDI events reportable to NHSN due to reflex testing; applying these reductions to historical NHSN data illustrates anticipated reductions in their facility-specific SIRs due to this testing change.

Funding: None

Disclosures: Scott Fridkin, consulting fee, vaccine industry (various) (spouse)