bluuebunny/crossref_metadata_2025 huggingface dataset:
Trends in Hospital Onset Clostridioides difficile Infection Incidence, National Healthcare Safety Network, 2010–2018
Authors: Mu Yi , Dudeck Margaret , Jones Karen , Li Qunna , Soe Minn , Nkwata Allan , Edwards Jonathan
Published: November 2020

Background:Clostridioides difficile infection (CDI) is one of the most common laboratory-identified (LabID) healthcare-associated events reported to the National Healthcare Safety Network (NHSN). CDI prevention remains a national priority, and efforts to reduce infection burden and improve antibiotic stewardship continue to expand across the healthcare spectrum. Beginning in 2013, the Centers for Medicare and Medicaid Services (CMS) required acute-care hospitals participating in CMS’ Inpatient Quality Reporting program to report CDI LabID data to NHSN and, in 2015, extended this reporting requirement to emergency departments (ED) and 24-hour observation units. To assess national progress, we evaluated changes in hospital onset CDI (HO-CDI) incidence during 2010–2018. Methods: Cases of HO-CDI were reported to NHSN by hospitals using the NHSN’s LabID criteria. Generalized linear mixed-effects modeling was used to assess trends of HO-CDI by treating the hospital as a random intercept to account for the correlation of the repeated responses over time. The data were summarized at the quarterly level, the main effect was time, and the covariates of interest were the following: CDI test type, inpatient community-onset (CO) infection rate, hospital type, average length of stay, medical school affiliation, number of beds, number of ICU beds, number of infection control professionals, presence of an ED or observation unit , and an indicator for 2015 to account for CDI protocol changes that required hospitals to conduct surveillance in both inpatient and ED or observation unit setting. Results: During 2010–2013, the number of hospitals reporting CDI increased and then stabilized after 2013 (Table 1). Crude HO-CDI rates decreased over time, except for an increase in 2015 and steeper reduction thereafter. (Table 2). During 2010–2014, the adjusted quarterly rate of change was −0.45% (95% CI, −0.57% to −0.33%; P < .0001). The rate of reduction was smaller in 2010–2014 compared to those of 2015–2018 (−2.82%; 95% CI, −3.10% to −2.54%; P < .0001). Compared to 2014, the adjusted rate in 2015 increased by 79.14% (95% CI, 72.42%–86.11%; P < .0001). Conclusions: The number of hospitals reporting CDI LabID data grew substantially in 2013 as a result of the CMS requirement for reporting. Adjusted HO-CDI rates decreased over time, with a rate hike in the year of 2015 and a rapid decrease thereafter. The increase in 2015 may be explained by changes in the NHSN CDI surveillance protocol and better test type classification in later years. Overall decreases in HO-CDI rates may be influenced by prevention strategies.

Funding: None

Disclosures: None
Whole-Genome Sequencing Reveals a Novel Subclade of Pansusceptible Candida auris in Ontario, Canada
Authors: Hota Susy , Gade Lalitha , Forsberg Kaitlin , Susky Erica , Poutanen Susan , Katz Kevin , Leis Jerome , Nadarajah Jeya , Amirov Chingiz , Nankoosingh Vydia , Williams Victoria , Salt Natasha , Litvintseva Anastasia , Kus Julianne
Published: November 2020

Background:Candida auris is an emerging pathogen that has recently disseminated globally and caused challenging outbreaks in healthcare facilities (HCFs), in part because it is commonly multidrug-resistant. Candida auris remains rare in Canada, with ~20 known cases to date. We describe the emergence of a novel subclade of C. auris in Ontario, Canada, using whole-genome sequencing (WGS). Methods: In Ontario, many HCFs submit yeast isolates from sterile sites requiring species-level characterization and antifungal susceptibility testing (AFST) to the provincial reference laboratory. Yeasts were identified using a combination of standard methods (morphology, API 20C, MALDI-ToF MS) including ITS2 sequencing. Sensititre YO9 panels were used for AFST. Genomic analysis of C. auris was performed using an Illumina HiSeq platform with at least 50× coverage; variants were called against the reference genome by using the previously published North Arizona SNP pipeline (NASP). Phylogenetic trees were produced by maximum parsimony method (MEGA7.0). Results: Between 2014 and 2018, yeast isolates from 5 different patients from 4 HCFs in the same region of Ontario were confirmed to be C. auris by ITS2 PCR and sequence analysis (Table 1). Based on interim CDC criteria for antifungal drug break points, all isolates were pansusceptible to common antifungals. WGS analysis demonstrated that the C. auris isolates were part of the South American clade (IV) and formed an isolated subclade that is well supported by bootstrap analysis, indicating clonal relationships among these isolates (Fig. 1). Conclusions: Although C. auris isolates are usually drug resistant, all 5 initial Ontario isolates were pansusceptible. WGS determined that these isolates clustered within clade IV and were clonal. This cluster of C. auris appears to represent a new subclade of the South American clade that has been transmitted among patients within a region of Ontario. C. auris may have been present in Ontario for some time, escaping earlier detection due to lack of screening programs in HCFs, historical challenges with microbiologic detection of C. auris, and the antifungal susceptibility of the circulating isolates. Investigations are underway to determine clinical features and epidemiologic relatedness among patients in this cluster.

Funding: None

Disclosures: Susy Hota, Contracted Research - Finch Therapeutics
Incidence Trends of Central-Line–Associated Bloodstream Infections in Neonatal Intensive Care Units, NHSN, 2009–2018
Authors: Nkwata Allan , Soe Minn , Li Qunna , Godfrey-Johnson Dominque , Edwards Jonathan , Dudeck Margaret A.
Published: November 2020

Background: Central-line–associated bloodstream infections (CLABSIs) are a major source of healthcare-associated infections (HAIs) in neonatal intensive care unit (NICU) patients, and they are associated with increased morbidity, mortality, and costs. CLABSI surveillance has been a critical component for hospitals participating in the Center for Disease Control and Prevention’s National Healthcare Safety Network (NHSN) for many years. CLABSI reporting grew substantially as a result of state reporting mandates first introduced in 2005 and federal reporting requirements for all intensive care units that began in 2011. However, no recent assessment of NHSN CLABSI incidence rate changes have been performed. The objective of this analysis was to estimate the overall trends in annual CLABSI incidence rates in NICUs from 2009 to 2018. Methods: We analyzed NHSN CLABSI data reported from NICUs during 2009–2018. CLABSIs further classified as mucosal barrier injury were included in this analysis. To evaluate the trends of CLABSI incidence (per 1,000 central-line days), and to account for the potential impact of definition changes introduced in 2015, we conducted an interrupted time-series analysis using mixed-effects negative binomial regression modeling. Birth weight category, patient care location type and hospital-level characteristics such as hospital type, medical affiliation, teaching status, bed size, and average length of inpatient stay) were assessed as potential covariates in regression analysis. Random intercept and slope models were evaluated with covariance tests and used to account for differential baseline incidence and trends among reporting NICUs. Results: The number of NICUs reporting to NHSN increased significantly following the federal mandate and has remained slightly >1,000 NICUs since 2013. The crude incidence of CLABSI dropped from 2.24 in 2009 to 0.98 infections per 1,000 central-line days in 2018, except for an increase in 2015 (Table 1). The CLABSI incidence, adjusted for birth weight category, decreased by an average of 11.6% per year from 2009 to 2018 except for a 35.8% increase in 2015 (Table 2). Conclusion: These findings suggest that hospitals have made significant strides in reducing the occurrence of CLABSIs in NICUs over the last 10 years. The increase in 2015 could be explained in part by the implementation and application of new definitional changes. Continued practices and policies that target, assess and prevent CLABSI in this setting may have been effective and remain vital to sustaining this decline nationally in subsequent years.

Funding: None

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

Background: In 2017, a new antimicrobial stewardship standard was established by the Joint Commission that requires long-term care facilities (LTCFs) to have an antimicrobial stewardship program (ASP) based on current scientific literature. The Tennessee Department of Health (TDH) team sought to ascertain the current state of ASPs across Tennessee and to assist programs with implementation strategies. Utilizing a Centers for Medicaid and Medicare Services’ Civil Monetary Penalties grant, the TDH purchased copies of the National Quality Partners Playbook for Antibiotic Stewardship in Post-Acute and Long-Term Care to provide to LTCFs as incentive to complete a survey that would evaluate their current adoption of core elements. Methods: A self-administered questionnaire on ASP practices was developed and distributed to LCTFs. This survey expanded upon questions from the NHSN 2018 LTCF annual survey. These questions pertained to actionable items facilities are taking to achieve core elements. Achievement of the CDC’s 7 core elements of ASPs was determined based upon a combination of 1 or more responses to the survey questions. The percentage of LTCFs achieving each ASP core element at the regional and statewide level was determined. We also calculated the percentage of LTCFs that achieved all 7 elements versus 5 or more core elements. The analyses and visualizations were performed using SAS 9.4 and Tableau software. Results: Currently, 88 of 316 licensed LTCF facilities in Tennessee have participated in the survey. All regions were represented by EMS region. Based on the results of our survey, 100% of participating facilities have achieved at least 5 core elements, and 78% of participating facilities have achieved all 7 core elements. The core element with the lowest achievement was Accountability at 89%, and reporting and action had the highest achievement (100%). Conclusions: Early results suggest that LTCFs across Tennessee have active ASPs with strong core element achievement. However, we received responses from only 27% of licensed LTCFs. Minimal data are available regarding the current state of LTCF ASPs in Tennessee, and data will continue to be collected and analyzed. Participation may be limited to those already actively engaged in public health efforts, including antimicrobial stewardship. LTCFs that have participated in the initial evaluation will be surveyed at 6 months and 12 months after receipt of playbooks to evaluate their ASP progression and NQP Playbook utilization.

Funding: None

Disclosures: None
ASPChat: Participation and Reach of a Real-Time Twitter Chat on Antimicrobial Stewardship
Authors: Langford Bradley , Gauthier Timothy
Published: November 2020

Background: Healthcare professionals with roles in infectious disease and antimicrobial stewardship have a growing presence on social media. Twitter has evolved to become a popular venue for healthcare professional communication, with the potential to support improved quality of patient care. To harness this growth and provide an opportunity for learning and networking, we developed a monthly Twitter chat on a variety of antimicrobial stewardship topics. Our objective was to evaluate the reach of this online initiative. Methods: In November 2016, to coincide with World Antibiotic Awareness Week, we held the first ASP chat (#ASPChat). Twitter chats continue monthly for 1 hour each month. Topics range from rapid diagnostic testing to duration of antibiotic therapy, and 6 questions are posed for each event. Questions about common strategies, clinical pearls, helpful resources, and literature are commonly integrated into the discussion. The event is open to all Twitter users regardless of discipline or location of practice. Participants use the ASPChat hash tag to follow along with the conversation. To evaluate the monthly Twitter chats, analytics were obtained from Symplur Healthcare Hashtags including impressions, the number of potential views for each Tweet, number of Tweets, and number of participants. Results: To date, 33 ASPChat events have been held, with a total of 20,478,000 impressions. The average number of Tweets per month was 346 and the average number of participants was 86 (Fig. 1). Participants have included pharmacists, physicians, infection control practitioners, and nonclinicians. Countries represented have included the United States, Canada, the United Kingdom, Australia, New Zealand, and South Africa. The average monthly impressions stands at 620,559 and has increased each year from between 23% and 86%. Conclusions: A monthly Twitter Chat is a feasible and sustainable approach to connecting antimicrobial stewards across a wide geographical range. The broad reach of the ASPChat events presents an opportunity to influence and unite a diverse group of professionals aiming to improve antibiotic use. Further evaluation is recommended to understand the professional and clinical impact of this important communication tool.

Funding: None

Disclosures: None
A Quality Improvement Project to Reduce Unnecessary Use of Multilumen PICCs
Authors: Kleinman-Sween Jennifer , Lowrie Angela , Kirmse Jane , Sampathkumar Priya
Published: November 2020

Background: Peripherally inserted central catheters (PICCs) are an increasingly common vascular access device. At our institution, >4,000 devices are placed per year by a trained team of vascular access nurses. Although PICCs are generally safe and effective, they do carry the risk of infection and thrombosis, and this risk increases exponentially with increasing number of lumens. As part of a multidisciplinary quality improvement effort to address rising CLABSI rates, we designed interventions to improve PICC utilization. Methods: The project team used 6-σ methodology, specifically following the DMAIC (define, measure, analyze, implement, control) framework to guide analysis and interventions. Process mapping, semistructured interviews with key stakeholders, electronic surveys, and audits were performed to identify gaps and inform interventions. The interventions consisted of 3 components: changes to the electronic ordering system, education (presentations to ordering providers and an online toolkit), and clinical decision support in the form of a team of vascular-access subject-matter experts who provided guidance on line selection. Results: In total, 4,655 PICCs and 434 midlines were inserted in the 12 months before the intervention, and 7,457 PICCs and 929 midlines were placed in the 24 months after the intervention. Following the implementation of the intervention, proportions of triple-lumen catheter utilization decreased from 31.9% to 22.3% (P < .0001). Concurrently, the proportion of single-lumen catheters has increased from 28.5% to 41.9% (P < .0001). Overall PICC utilization decreased in the postintervention period from an average of 387.9 PICCs placed per month to 310.7. The proportion of midline catheters increased from 8.5% of total lines inserted to 11.4% in the postintervention period (P < .001). Conclusions: Our intervention reduced overall PICC use and triple-lumen PICC use and increased relative utilization of single-lumen PICCs and midline catheters. Optimization of electronic orders, in conjunction with targeted education and decision support, can have a sustained impact on provider ordering behaviors and can shift the culture of utilization, even in a large academic medical center with frequent turnover of trainees.

Funding: None

Disclosures: Consulting fee- Merck (Priya Sampathkumar)
Adverse Events Associated With Midline Vascular Catheters
Authors: Hankins Richard , Lambert Nicholas , Rupp Mark , Micheels Terry , Lyden Elizabeth , Evans Luana , Cawcutt Kelly
Published: November 2020

Background: Central-line–associated bloodstream infections (CLABSIs) result in increased patient morbidity. Guidelines recommend against peripheral venous catheters when access is required for longer than 6 days, often leading to central venous catheter (CVC) placement. To improve vascular access device choice and reduce the potential risk of CLABSI, we implemented a quality improvement initiative comprised of a vascular access algorithm and introduction of a midline vascular access device (MVAD). We report complications associated with MVAD use including deep vein thrombosis (DVT), thrombophlebitis, and BSI. Methods: A prospective quality improvement assessment from October 2017 through March 2018. All MVADs were monitored for DVT, thrombophlebitis, and BSI. Insertion time and removal of MVAD were tracked, as well as presence of other vascular access devices. Results: From October 2017 through March 2018, 858 MVADs were inserted in 726 different patients, yielding 3,588 MVD days. In total, 6 primary BSIs occurred in patients with MVADs. In patients with only a MVAD, the rate was 0.72 BSI per 1,000 MVAD days, whereas patients with an MVAD as well as a CVC had a rate of 1.98 per 1,000 MVAD days. The overall CLABSI rate at the institution during this period of time was 1.24 per 1,000 CVC days. Also, 29 cases of thrombophlebitis occurred, for a rate of 3.84 per 1,000 catheter days in patients with only an MVAD compared to 4.63 per 1,000 catheter days in patients with an MVAD and a CVC. Also, 25 DVTs occurred during this time, resulting in a rate of 2.88 per 1,000 catheter days in patients with only an MVAD and 4.63 per 1,000 catheter days in patients with multiple vascular-access devices. A significant correlation was noted between MVAD indwell time and BSI (P = .0021) and thrombophlebitis (P = .0041). The median indwell time for patients experiencing BSI was 16.17 days ± 8.04 days, whereas the median indwell time for patients experiencing thrombophlebitis was 9.24 days ± 7.99 days. Conclusions: The implementation of a vascular-access algorithm including MVAD may effectively reduce CVC insertions and BSIs. The rate of BSI in MVAD was below that of CLABSI during the assessment period. Known complications associated with MVAD include DVTs and thrombophlebitis, which correlates with the duration of catheterization, and these risks appear to be further compounded in patients requiring multiple devices for vascular access. Further research into comparing the risk of vascular access of MVAD with CVC is warranted.

Funding: None

Disclosures: None
Analyzing Healthcare Workers’ Perspectives on Healthcare-Associated Infections and Infection Control Practices Using Video Reflexive Ethnography (VRE)
Authors: Paul Esther , Alzaydani Ibrahim , Hakami Ahmed , Chandramoorthy Harish C.
Published: November 2020

Background: This study explores the perspectives of healthcare workers on the healthcare-associated infection (HAI) and infection control measures in a tertiary-care unit, through a self-administered questionnaire, semi-structured interviews, and reflexive sessions based on video-recorded sterile procedures performed in respondents’ work contexts. Video reflexive ethnography (VRE) is a method that provides feedback to medical practitioners through reflection analysis, whereby practitioners identify problems and find solutions. Methods: Quantitative questionnaire data were used to assess the knowledge of HAI among 50 healthcare workers and their attitude toward practice of infection control measures. Semistructured interviews based on an interview guide were used to collect qualitative data from 25 doctors and nurses. The interviews were audio recorded and transcribed verbatim immediately. Also, routine sterile procedures in the wards and intensive care unit were video recorded, and the footage was discussed by the infection control team and the personnel involved in the videos. This discussion was video recorded and transcribed. Both interview data and reflexive discussion of video-graph were analyzed using a thematic analysis. The quantitative data were analyzed using the Kruskal–Wallis test. Results: The quantitative data revealed no difference in the knowledge, attitude, and practice scores used to evaluate the infection control practices among the healthcare workers. We identified 4 themes from the qualitative data: (1) knowledge of HAI and infection control, (2) infection control measures in practice, (3) the shortfall in infection control measures and HAI, and (4) required implementation. Although the qualitative data indicated that the participants had excellent compliance with hand hygiene and personal protective equipment (PPE) use, the VRE and reflective sessions indicated otherwise. Some astounding lapses were revealed, like failure to engage in boundary maintenance between sterile and nonsterile areas, failure to observe proper hand hygiene measures, and use of traditional hijab face covers (used in an unsterile environment as well) instead of surgical masks. These findings demonstrate the advantage of combining VRE with qualitative and quantitative methodology to deduct the lapses in the practice of infection control among healthcare workers. Conclusions: Introduction of training programs focused on HAI and infection control measures in the educational system will help better inform medical and nursing students. Live video demonstrations of appropriate infection control practices during sterile procedures would be highly beneficial to educate the healthcare workers on correct infection control practices. Lapses in the use of PPE can be a possible reason for the outbreak of MERS-CoV, an endemic disease, in this part of Saudi Arabia.

Disclosures: None

Funding: None
CDIFFerently: A Bundled Approach to Clostridium difficile Reduction
Authors: Deming Sarah
Published: November 2020

Background: Since 2015 the rate of healthcare facility-onset Clostridium difficile infections (HO CDI) at Faxton-St Luke’s Healthcare (FSLH) has remained higher than both New York state and federal benchmarks, despite the use of traditional prevention efforts. Methods: We used the define-measure-analyze-improve-control (DMAIC) process improvement model to better understand the reasons that our rates remained high and to develop a comprehensive reduction strategy.

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Define: High HO CDI rates. NHSN SIR consistently above 1.0

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Measure

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Diagnostic stewardship. Are patients being tested appropriately?

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Antibiotic stewardship: Do prescribing practices follow best-practice recommendations?

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Environmental cleanliness: Are staff following standard and transmission based precautions? How effective are current cleaning practices? What is being done to limit contamination of the environment of care?

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Perform a gap analysis of CDI prevention strategies at FSLH vs current best practice recommendations, emerging strategies in scientific literature and successful approaches at other health-care facilities.

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Analyze

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Staff do not have a clear understanding of symptoms and risk factors of CDI and often initiate testing inappropriately.

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Overuse of broad spectrum antimicrobial agents. No antibiotic time outs. Limited Pharmacy staff available for auditing and feedback regarding prescribing practices.

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UV disinfection system under-utilized. Shared patient care equipment not cleaned between uses. Delay in implementation of contact precautions. Lack of opportunities for patient hand hygiene.

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Improve

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Algorithms for screening and testing built into Electronic Medical Record Orders for testing coupled with orders for contact precautions

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Align antimicrobial prescribing with best practice

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Audit and reward compliance with UV light utilization, environmental cleaning Reduce shared patient care equipment, replace with disposable items

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Provide products for patient hand hygiene

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Implement marketing campaign to tie elements together

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Control

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Audit compliance with testing and isolation policies

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Laboratory rejection of formed stools

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Audit cleaning processes with adenosine triphosphate (ATP) monitor

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Track ultraviolet light usage

Funding: None

Disclosures: None
Effect of Removing Contact Precautions for Multidrug-Resistant Organisms on Hospital Infections in a Pediatric Health System
Authors: Linam Matthew , Hoskins Dorian , Jaggi Preeti , Gonzalez Mark , Watson Renee , Shane Andi
Published: November 2020

Background: Discontinuation of contact precautions for methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococci (VRE) have failed to show an increase in associated transmission or infections in adult healthcare settings. Pediatric experience is limited. Objective: We evaluated the impact of discontinuing contact precautions for MRSA, VRE, and extended-spectrum β-lactamase–producing gram-negative bacilli (ESBLs) on device-associated healthcare-associated infections (HAIs). Methods: In October 2018, contact precautions were discontinued for children with MRSA, VRE, and ESBLs in a large, tertiary-care pediatric healthcare system comprising 2 hospitals and 620 beds. Coincident interventions that potentially reduced HAIs included blood culture diagnostic stewardship (June 2018), a hand hygiene education initiative (July 2018), a handshake antibiotic stewardship program (December 2018) and multidisciplinary infection prevention rounding in the intensive care units (November 2018). Compliance with hand hygiene and HAI prevention bundles were monitored. Device-associated HAIs were identified using standard definitions. Annotated run charts were used to track the impact of interventions on changes in device-associated HAIs over time. Results: Average hand hygiene compliance was 91%. Compliance with HAI prevention bundles was 81% for ventilator-associated pneumonias, 90% for catheter-associated urinary tract infections, and 97% for central-line–associated bloodstream infections. Overall, device-associated HAIs decreased from 6.04 per 10,000 patient days to 3.25 per 10,000 patient days after October 2018 (Fig. 1). Prior to October 2018, MRSA, VRE and ESBLs accounted for 10% of device-associated HAIs. This rate decreased to 5% after October 2018. The decrease in HAIs was likely related to interventions such as infection prevention rounds and handshake stewardship. Conclusions: Discontinuation of contact precautions for children with MRSA, VRE, and ESBLs were not associated with increased device-associated HAIs, and such discontinuation is likely safe in the setting of robust infection prevention and antibiotic stewardship programs.

Funding: None

Disclosures: None
Evaluation of Antibiotic Prophylaxis and Postsurgery Antibiotics for Urological Surgeries at an Academic Medical Center
Authors: Drwiega Emily , Rab Saira , Kandiah Sheetal , Kriengkauykiat Jane , Wong Jordan
Published: November 2020

Objective: The purpose of this study was to evaluate antibiotic use in patients undergoing urological procedures. Methodology: This single-center, IRB-approved, retrospective, observational study was conducted at Grady Health System. Patients were included if they underwent their first inpatient urologic procedure between April 1, 2016, and April 1, 2018. Patients were excluded if they were <18 years old, pregnant, or a prisoner. The primary outcome was percentage of overall adherence to our institutional guidelines for surgical prophylaxis as a composite of antibiotic selection, dose, preoperative timing, and postoperative duration. Secondary outcomes include individual components of the composite outcome, nephrotoxicity, Clostridium difficile infection, and discharge antibiotic prescriptions. Descriptive statistics were used. Results: Of the 100 patients evaluated, 11% achieved adherence with the primary outcome. Of the 89 patients who did not achieve composite outcome, only 8 selected the appropriate perioperative antibiotic. Overall, 30% were dosed appropriately, 47% were administered at the appropriate time with respect to time of incision, and 46% received perioperative antibiotics for no more than 24 hours. Also, 19 patients did not receive perioperative antibiotics. Overall, 14 different perioperative antibiotic regimens were utilized, despite institutional guidelines recommending 1 of 3 options. All 9 patients who developed nephrotoxicity received noncompliant perioperative prophylaxis. No patient developed Clostridium difficile infection within 30 days of surgery. Moreover, 58 patients were discharged with a prescription for at least 1 antibiotic. Conclusions: Most perioperative antibiotic prophylaxes for genitourinary surgeries are not compliant with institution guideline recommendations. Despite having institutional guidelines, there was a large variety in the antibiotic regimens that patients received. All of the patients identified as having an evaluated antibiotic-related adverse effect did not receive appropriate perioperative antibiotic prophylaxis. More than half of the patients received a prescription at discharge for at least 1 antibiotic.

Funding: None

Disclosures: None
Financial and Labor Benefits of the Individual TB Risk Assessment Model for Annual TB Screening
Authors: Sims Kristin , Stienecker Roger
Published: November 2020

Background:
Since 1991, US tuberculosis (TB) rates have declined, including among health care personnel (HCP). Non–US born persons accounted for approximately two-thirds of cases. Serial TB testing has limitations in populations at low risk; it is expensive and labor intensive. Method: We moved a large hospital system from facility-level risk stratification to an individual risk model to guide TB screening based on Tuberculosis Screening, Testing, and Treatment of US Health Care Personnel: Recommendations from the National Tuberculosis Controllers Association and CDC, 2019. This process included individual TB risk assessment, symptom evaluation, TB testing for M. tuberculosis infection (by either IGRA or TST) for HCP without documented evidence of prior LTBI or TB disease, with an additional workup for TB disease for HCP with positive test results or symptoms compatible with TB disease. In addition, employees with specific job codes deemed high risk were required to undergo TB screening. Result: In 2018, this hospital system of ~10,000 employees screened 7,556 HCP for TB at a cost of $348,625. In 2019, the cost of the T Spot test increased from $45 to $100 and the cost of screening 5,754 HCP through October 31, 2019, was $543,057. In 2020, it is anticipated that 755 HCP will be screened, saving the hospital an estimated minimum of $467,557. The labor burden associated with employee health personnel will fall from ~629.66 hours to 62.91 hours. The labor burden associated with pulling HCPs from the bedside to be screened will be reduced from 629.66 hours to 62.91 hours as well. Conclusion: Adoption of the individual risk assessment model for TB screening based on Tuberculosis Screening, Testing, and Treatment of US Health Care Personnel: Recommendations from the National Tuberculosis Controllers Association and CDC, 2019 will greatly reduce financial and labor burdens in healthcare settings when implemented.

Funding: None

Disclosures: None
First Candida auris Outbreak Experience in a Tertiary-Care General Hospital in Qatar, 2019
Authors: Visan Feah , Ansari Naser Al , Wali Walid Al , Zakaria Almunzer , Hasanat Omar Al , Castro Jenalyn , Hudaib Ghada , Ummer Ubaid , Ajmi Jameela Al , Asuncion Mildred , Shaukat Adila , Hamed Manal
Published: November 2020

Background:Candida auris is an invasive, multidrug-resistant pathogen that can cause outbreaks in hospitals. The mode of transmission is through contaminated hospital items such as fomites and staff interventions. The outbreak of Candida auris affecting 13 patients at the medical intensive care unit (MICU) and medical inpatient unit, either in the form of infection or colonization, is the first documented C. auris outbreak in the Qatar. Methods: The first case was identified in November 2018 in a patient colonized in the respiratory tract. Candida auris biweekly tests were conducted. The second to fourth cases were confirmed in the MICU admitted in the same room (room 2). The fifth case was identified incidentally and was not part of the screening in another ward (6 North Medical Inpatient Unit), and 4 weeks later, Candida auris was isolated from the urine and throat of a patient on this ward. The realization that case 5 was an index case changed the direction of the outbreak investigation, and expanded screening was started among the medical inpatients. When the IPC team identified cases 6–11 and 13, all had possible epidemiological links with case 5. Results: Our root-cause analysis suggests that the index case came from another general hospital. However, because no screening protocol has been established for Candida auris, interventions have not been in place to effectively prevent and control this organism. A strong collaborative outbreak team worked to end this outbreak using the following evidence-based IPC interventions: (1) patient screening and decolonization; (2) environmental screening; (3) enhanced environmental disinfection using peracetic acid wipes, 1% chlorine, and hydrogen peroxide vapor disinfection; (4) prophylactic contact precautions; (5) enhanced hand hygiene with bare below elbows protocol; and (6) a no white gown policy. Conclusions: The outbreak of Candida auris was declared to have nbeen terminated on August 22, 2019. Despite the long period involved in this outbreak, we succeeded in ending it through the concerted efforts of a multidisciplinary team utilizing the latest scientific evidence.

Funding: None

Disclosures: None
Friend or Foe: Perceptions of Infectious Disease Specialists as Stewards and Social Determinants of Antimicrobial Prescribing
Authors: Constantinescu Cora , Furr Caitlyn Cook , Vayalumkal Joseph , Conly John , Gilfoyle Elaine , Kassam Aliya
Published: November 2020

Background: Inappropriate prescribing behavior can be associated with higher rates of antibiotic resistance, calling for detailed studies on how physicians make prescribing decisions. We conducted a mixed-methods study to investigate physician antibiotic prescribing behavior in a 141-bed pediatric hospital. Methods: We applied a mixed-methods research design. The quantitative phase was conducted over a 6-month period to identify cases of inappropriate prescribing. The qualitative phase comprised 22 qualitative interviews with clinical teaching units (CTU) and pediatric intensive care unit (PICU) team members (physicians and pharmacists). Two coders analyzed the data deductively using the theoretical domain framework (TDF), as well as the social determinants of antimicrobial prescribing (SDAP). Results: In 52.9% of the 36 identified cases in the CTU and 31.4% of the 37 cases in the PICU, an infectious diseases (ID) consultation occurred. Compliance rates with ID recommendations were 79% and 91% in the CTU and PICU, respectively. The CTU and PICU expressed appreciation for ID involvement when ID supported their de-escalation choices in complex cases and in cases in which less commonly known antibiotics were used. However, the ID service involvement was perceived as detrimental to antimicrobial prescribing decisions for CTU and PICU across 3 of the 4 SDAP domains (Fig. 1, qualitative research quotes). Relationship between clinicians: CTU physicians and pharmacists perceived ID involvement as negatively impacting the relationship of the team. Antimicrobial decisions were automatically defaulted to ID, whereas pharmacy involvement was disregarded and the decisions were delayed. Risk, fear, and emotion: These were experienced across all respondents’ groups that identified ID specialists’ egos and personalities as contrary to open collaborative discussion on antimicrobial decisions. (Mis)perception of the problem: ID physicians were identified as more conservative in their antimicrobial choices, leading to prolonged duration of treatment, broader choices, and longer hospitalizations. The CTU and pharmacy respondents felt that ID recommendations were inconsistent among physicians and deviated from guidelines with little justification. Conclusions: Although CTU and PICU teams tend to comply with ID prescribing recommendations and ID involvement with complicated cases, pharmacists, CTU physicians, and PICU physicians perceived ID consultations to negatively affect collaborative efforts for stewardship. These findings offer novel insights into how an ID service can improve its role to positively affect appropriate prescribing. CTU and PICU respondents called for a supportive and trusting relationship with the ID service as a major driver for behavioral change and enhanced stewardship.

Funding: None

Disclosures: None
Highly Local Clostridioides difficile Infection (CDI) Pressure as Risk Factors for CDI
Authors: Riaz Talal , Khan Nabeel , Polgreen Philip , Segre Alberto , Sewell Daniel , Pemmaraju Sriram
Published: November 2020

Background.
Colonization pressure at the unit level is known to be a risk factor for Clostridioides difficile infections in hospitals. Because C. difficile colonization is not routinely detected in clinical practice, only patients identified as having C. difficile infection (CDI) are included in these pressure calculations. We used data from the University of Iowa Hospitals and Clinics (UIHC) to determine whether highly local CDI pressure, due to patients in nearby rooms, is more strongly correlated with CDI than unit-level CDI pressure. Methods: We designed a base logistic regression model using variables known to be risk factors for CDI: age, antibiotic/gastric acid suppressor use, low albumin, prior hospitalization, comorbidities. To the base model, we add 2 measures, mean colonization pressure (MCP) and sum colonization pressure (SCP) of CDI at the unit level to obtain new models. To the base model, we also added CDI colonization pressure by considering CDI cases at different distance thresholds from the focal patient. Distances between patient rooms were extracted from hospital floor plans. Results: Adding unit-level CDI colonization pressures to the base model improved performance. However, adding CDI colonization pressures due to roommates and due to patients at different distances improved the model much more (Table 1). The top (resp. bottom) row shows in-sample (resp. out-of-sample) C-statistics for the base model, the base model with unit-level MCP, the base model with roommate MCP, and the base model with MCP from patients are different distances added as separate features. C-statistics for the base model and the base model with unit CDI pressure (SCP and MCP) are compared in Fig. 1 with C-statistics from the base model with CDI pressure from patients at distances D = 0, 1, 2, 3, 4, 5, 10, 15, 20 hops (1 hop = 5–6 meters). Conclusions: Our results support the hypothesis that unit CDI colonization pressure is a risk factor for CDI. However, by incorporating spatially granular notions of distances between patients in our analysis, we were able to demonstrate that the true source of CDI pressure at the UIHC is almost exclusively attributable to roommates and patients in adjacent rooms.

Funding: None

Disclosures: None
Impact of Leadership Walk-Arounds and Feedback from Senior Management to Reduce CLABSI Rates
Authors: Warrier Anup , Bernadit Soumya
Published: November 2020

Background:
Aster Medcity is a 400-bed tertiary-care hospital in India. Over the years, the CLABSI rates have been within the INICC benchmarks but much above the CDC benchmarks. Is it possible to achieve the CDC/NHSN benchmarks without using engineered vascular access devices? How can we implement the available evidence in using feedback as an effective way to improve practices? Methods: In this prospective interventional trial, we compared the CLABSI rates at baseline over the previous 6 months (January 2019 to June 2019) with the CLABSI rates over the following 3 months (July –September 2019) with introduction of a new feedback structure. This feedback was delivered in the following ways. (1) Leadership walk-arounds consisted of the CEO, CNO, and CMS visiting each unit that reported a CLABSI as soon as it was reported (instead of the month end when cumulative reports become available) to discuss what went wrong and what could be corrected with the local unit teams. (2) The CEO had a 1-to-1 discussion with the nursing leadership regarding the monthly CLABSI rates with clear goal setting for the nursing teams. (3) Daily feedback on the practices as reviewed in the observational audits by the infection control team (ie, infection control nurses) was provided to the ICU teams through the ICO and CMS to the individual practitioners (both nurses and doctors). Results: Metrics were collected for both the process measures as well as outcome measures. The CLABSI outcome measure dropped from a mean of 4 per 1,000 CVC days before the intervention to a mean of 1 per 1,000 CVC days after the intervention, both calculated for a 6-month period. The compliance to hand hygiene as per the WHO 5 Moments improved from a mean of 79% to 86%, and the compliance to safe injection practices improved from 76% to 95%. Noncompliant HCWs observed via the daily feedback system dropped from 16–20 HCWs per week at the start of the intervention to 5–6 HCWs per week by the end of 6 months. The environmental cleaning scores (using glow-gel scores with the CDC environmental cleaning tool) remained at an average of 85%. Conclusions: Feedback is the backbone of most of the interventions of quality and infection control teams of healthcare organizations. Increased frequency and feedback from senior management can overcome inertia in improving practices on the ground level. This method could be more cost-effective at reducing CLABSIs than engineered devices.

Funding: None

Disclosures: None
Implementation of Two-Step Clostridioides difficile Testing Algorithm and Management of Possible Carriers
Authors: Markley J. Daniel , Tassone Daniel , Christian Melanie , Vaughan Leroy , Stevens Michael P. , Hitchcock Matthew M. , Hill Emily
Published: November 2020

Background: Updated IDSA-SHEA guidelines recommend different diagnostic approaches to C. difficile depending on whether There are pre-agreed institutional criteria for patient stool submission. If stool submission criteria are in place, nucleic acid amplification testing (NAAT) alone may be used. If not, a multistep algorithm is suggested, incorporating various combinations of toxin enzyme immunoassay (EIA), glutamate dehydrogenase (GDH), and NAAT, with discordant results adjudicated by NAAT. At our institution, we developed a multistep algorithm leading with NAAT with reflex to EIA for toxin testing if NAAT is positive. This algorithm resulted in a significant proportion of patients with discordant results (NAAT positive and toxin EIA negative) that some experts have categorized as possible carriers or C. difficile colonized. In this study, we describe the impact of a multistep algorithm on hospital-onset, community-onset, and healthcare-facility–associated C. difficile infection (HO-CDI, CO-CDI, and HFA-CDI, respectively) rates and the management of possible carriers. Methods: The study setting was a 399-bed, tertiary-care VA Medical Center in Richmond, Virginia. A retrospective chart review was conducted. The multistep C. difficile testing algorithm was implemented June 4, 2019 (Fig. 1). C. difficile testing results and possible carriers were reviewed for the 5 months before and 4 months after implementation (January 2019 to September 2019). Results: In total, 587 NAATs were performed in the inpatient and outpatient setting (mean, 58.7 per month). Overall, 123 NAATs (21%) were positive: 59 in the preintervention period and 63 in the postintervention period. In the postintervention period, 23 positive NAATs (26%) had a positive toxin EIA. Based on LabID events, the mean rate of HO+CO+HCFA CDI cases per 10,000 bed days of care (BDOC) decreased significantly from 9.49 in the preintervention period to 1.15 in the postintervention period (P = .019) (Fig. 2). Also, 9 of the possible carriers (22%) were treated for CDI based on high clinical suspicion, and 6 of the possible carriers (14%) had a previous history of CDI. Of these, 5 (83%) were treated for CDI. In addition, 1 patient (2%) converted from possible carrier to positive toxin EIA within 14 days. The infectious diseases team was consulted for 11 possible carriers (27%). Conclusions: Implementation of a 2-step C difficile algorithm leading with NAAT was associated with a lower rate of HO+CO+HCFA CDI per 10,000 BDOC. A considerable proportion (22%) of possible carriers were treated for CDI but did not count as LabID events. Only 2% of the possible carriers in our study converted to a positive toxin EIA.

Funding: None

Disclosures: None
Improving Patient Knowledge and Understanding of Their Antimicrobial Therapy: An Antimicrobial Stewardship Intervention
Authors: Yeoh Kim , George Catherine , Buising Kirsty
Published: November 2020

Background: The Australian Antimicrobial Stewardship Clinical Care Standard states that patients should receive information about their antimicrobial therapy, including their indication, how and when to take them, their duration, and potential side effects. The level of information provided to hospital inpatients about their prescribed antimicrobial therapy is not well understood. Our objective was to evaluate whether adult inpatients received specific information about their antimicrobials in accordance with antimicrobial stewardship clinical care standards, to identify any gaps that needed to be addressed. Methods: Patients receiving 1 or more antimicrobials for >72 hours who were admitted on an acute or subacute ward were recruited. A survey tool was designed and conducted to establish the current status of information provision to patients. The information gathered was used to develop and deliver activities and resources to facilitate better communication about antimicrobial therapy. Results: In total, 54 patients were surveyed. Most patients (83%) were informed that they were taking antimicrobials, and of these, 96% said they knew the indication, 18% were informed of potential side effects, and 36% knew the duration. Only 22% were informed of the review plan, and only 27% knew whether antimicrobials would be continued on discharge. Written information was given to 11% of patients. Over half of these patients (56%) either wanted more information or had concerns about their antimicrobials. Patients reported difficulty in obtaining information with some receiving information via “word-of-mouth from other patients.” Moreover, 58% of patients received antimicrobial information from doctors, 13% from nurses, and 12% from pharmacists. However, most patients stated that they expected information from all 3 professional groups. In response to these survey findings, a focus group of antimicrobial stewardship experts was convened to discuss methods of improving delivery of information to patients regarding their antimicrobial therapy. We undertook nursing education to empower nurses to discuss information about antimicrobials with their patients, and we developed consumer information sheets. Conclusions: More needs to be done to inform patients about the antimicrobials used in their treatments to empower them to participate in their treatment. This factor will be the focus of future antimicrobial stewardship interventions.

Funding: None

Disclosures: None