bluuebunny/crossref_metadata_2025 huggingface dataset:
Optimizing COVID-19 Symptom Screening in the Pediatric Population
Authors: Zhou Geena , Singh Prachi , Perito Emily R. , Bardach Naomi , Penwill Nicole , Burrough William , Cheung Ann , Nguyen Margaret , Mittal Shalini , Cheng Grace , Spad Mia-Ashley
Published: November 2021

Background: Research analyzing COVID-19 symptom screening has primarily focused on adult patients. In efforts to safely reopen schools, symptom screeners are being widely utilized. However, pediatric-specific outpatient data on which symptom combinations best identify children with COVID-19 are lacking. Such data could refine school symptom screening by improving screener sensitivity and specificity. In this study, we assessed the frequency of symptoms and symptom combinations in children tested for SARS-CoV-2 in outpatient settings. We aim to contribute to the optimization of pediatric COVID-19 screening questionnaires, to ultimately minimize both COVID-19 transmission in schools and missed school days. Methods: We conducted a retrospective analysis of outpatient symptoms screens, SARS-CoV-2 test results, and demographics of children (≤18 years) tested for SARS-CoV-2 between March 30 and November 30, 2020, at 3 UCSF-affiliated COVID-19 outpatient screening clinics in northern California. Those with incomplete symptom screens, >7 days between symptom documentation and test, and invalid test results were excluded. Results: Of 473 children tested at 1 site, 21 children had positive SARs-CoV-2 results and 452 children had negative results (4.4% positivity rate). Moreover, 85.7% of SARS-CoV-2–positive children had a known exposure to COVID-19 (Table 1). Of SARS-CoV-2–positive children, 61.9% had >1 symptom. Also, 52.4% of SARS-CoV-2–positive children had at least 1 symptom (fever, cough, or loss of taste or smell) versus 62.8% of SARS-CoV-2–negative children (Table 2). Runny nose or nasal congestion was the most frequently reported symptom in the SARS-CoV-2–positive group (47.6%) as well as the SARS-CoV-2–negative group (58.6%). Also, 14.3% of SARS-CoV-2–positive children had eye redness or discharge versus 3.1% of SARS-CoV-2–negative children. Isolated runny nose presented in 10.8% of SARS-CoV-2–negative versus 9.5% of SARS-CoV-2–positive children. All children with isolated diarrhea (n = 5), isolated headache (n = 3), and isolated rash (n = 2) tested negative. Preliminary symptom data based on 176 children from a second site showed that 9.9% of symptomatic children had a positive test result. Conclusions: Runny nose or nasal congestion was the most frequently reported symptom in all children tested for SARS-CoV-2. However, isolated runny nose or nasal congestion identified 2 cases of COVID-19 in our cohort. Eye redness or discharge may be an important symptom to screen for COVID-19 in children. Further research with a larger number of positive cases is needed to make conclusions about improving efficiency and efficacy of symptom screeners for COVID-19 in children.

Funding: No

Disclosures: None
COVID-19 Outbreak in an Acute-Care Hospital: Lessons Learned
Authors: Narasimhan Supriya , Mony Vidya , Stoll Tracey , Oribello Sherilyn , Yvonne Karanas , Goel Dolly
Published: November 2021

Background: We describe the infection prevention investigation of a cluster of 15 healthcare workers (HCWs) and 7 patients in a single non–COVID-19 unit of an acute-care hospital in September 2020. Methods: The infection prevention team was notified of 13 SARS-CoV-2–positive, symptomatic HCWs in an acute-care non–COVID-19 unit in 1 week (August 30, 2020, to September 3, 2020). In the same week, 2 patients who had been on the unit were diagnosed with nosocomial COVID-19. An epidemiologic investigation identified the exposure period to be between August 19, 2020, and September 3, 2020. The following immediate containment measures were implemented: closing the unit to new admissions, restricting float staff, moving existing patients to private rooms, mandatory masking of patients, and mandatory respirator and eye protection on unit entry for all HCWs. Exposed unit staff were tested immediately and then every 4 days until September 18, 2020. Likewise, exposed patients, including those discharged, were notified and offered testing. Hospital-wide HCW surveillance testing was conducted. Enhanced environmental control measures were conducted, including terminal cleaning and ultraviolet C (UV-C) disinfection of common areas and patient rooms and a thorough investigation of airflow. Detailed staff interviews were performed to identify causes of transmission. Multiple town hall meetings were held for staff education and updates. Results: In total, 108 total patients were deemed exposed: 33 were inpatients and 75 had been discharged. Testing identified 5 additional patient cases among 57 patients who received testing; 51 chose to self-monitor for symptoms. Staff testing identified 2 additional cases. Thus, 15 HCWs and 7 patients were linked in this cluster. The containment measures successfully ended staff transmission as of September 5, 2020. The last patient case was detected on September 10, 2020. Secondary cases were noted in 6 HCW families. We identified staff presenteeism, complacency, and socialization in break rooms and outside work as major causes of transmission. Suboptimal compliance with universal eye protection and hand hygiene (67%) were contributing factors. We determined by contact tracing and temporality that the outbreak could have stemmed from nursing home patient(s) through floating HCWs to staff on the affected unit. Directionality of transmission was from staff to patients in this cluster. Conclusions: Many facets of pandemic fatigue were apparent in this outbreak, namely, inability of HCWs to adhere to changing PPE guidance, presenteeism pressures due to workforce needs, and socialization with peers due to a false sense of security conferred by biweekly surveillance testing. Ongoing PPE education, repeated reinforcement, as well as engagement in staff wellness are crucial to combatting pandemic fatigue, conserving our workforce, and preventing future outbreaks.

Funding: No

Disclosures: None
Impact of Female External Urinary Catheter on Indwelling Catheter Use and Catheter-Associated Urinary Tract Infection Rates
Authors: Monday Lea , Suleyman Geehan , Alangaden George , Schuldt Stephanie , Jackman Catherine , Halash Christine
Published: November 2021

Background: Catheter-associated urinary tract infections (CED: TIs) are one of the most prevalent healthcare-associated infections. They can lead to bacteremia and increased length of stay, healthcare costs, and mortality. Indwelling urinary catheter (IUC) prevention bundles, nurse-driven removal protocols, and the use of external catheters can help reduce CED: TIs. However, female external urinary catheters (FEUCs) have only recently become widely available. FEUCs were introduced at our institution in July 2017. The purpose of this study was to evaluate the impact of FEUC on IUC utilization ratio and overall CED: TI rate in an 844-bed teaching hospital in southeastern Michigan. Methods: We retrospectively evaluated the utilization ratio of FEUCs (female FEUC days per patient days ×1,000) and female IUCs (IUC days per patient days ×1,000), and labia hospital-acquired pressure injury (HAPI) rate due to FEUC from July 2017 through June 2019. We compared the overall (male and female) CED: TI rate per 1,000 IUC days in the preintervention period (January 2016 to June 2017) to the postintervention period (July 2017 to June 2019). Results: In total, 4,013 FEUCs were placed during the intervention period. The utilization ratio of FEUC increased by 59% and the utilization ratio of female IUC decreased by 13% over the course of the 2 years. Only 1 HAPI was reported during the observation period at a rate of 0.025% (1 of 4,013). The overall CED: TI rate decreased from 1.60 to 1.40 (P = .372). Conclusion: Introduction of a FEUC was associated with a decrease in the IUC utilization ratio in female patients with minimal adverse events; however, there was no significant difference in the overall CED: TI rate.

Funding: No

Disclosures: None
Comparison of Outcomes in Candidemia Between COVID-19 and Non–COVID-19 Patients
Authors: Beatriz Cruz Angela , LeRose Jennifer , Chopra Teena
Published: November 2021

Background: Fungemia is associated with high rates of morbidity, mortality, and increase in length of hospital stay. Several studies have recognized increased rates of candidemia since the COVID-19 pandemic. Methods: Patients with candidemia during January through May 2020 were identified through Theradoc. Patient demographics, comorbidities, hospital management, and microbiology were extracted by medical chart review. Patients were divided into cohorts based on COVID-19 status. The Fisher exact and Satterthwaite tests were used for analyses of categorical and continuous variables, respectively. Results: Overall, 31 patients developed candidemia and 12 (38.7%) patients tested SARS-CoV-2 positive. Candida glabrata was the most prevalent causative organism in both groups. On average, COVID-19 patients developed fungemia 12.1 days from admission, compared to 17.8 days in the COVID-19 negative or untested cohort (P = .340). Additionally, COVID-19 patients with a fungemia coinfection were significantly more likely to expire; 10 COVID-19 patients (83.3%) died, compared to 7 (36.8%) in the COVID-19–negative or untested cohort (P = .025). The cohorts did not demonstrate statistically significant differences in terms of demographic, comorbidities, hospital management, or coinfections. Conclusions: The prevalence of fungemia in COVID-19 patients is significantly greater than historically reported figures. Known risk factors for candidemia, such as use of corticosteroid, use of central venous catheters, and prolonged ICU length of stay were higher in the SARS-CoV-2–positive cohort in this period, which likely contributed to increased fungemia rates, as these factors are also more pronounced in those with COVID-19. Patients who developed candidemia in the COVID-19 cohort had poorer outcomes than those who were SARS-CoV-2 negative or were untested. Further investigation should be conducted in larger studies.

Funding: No

Disclosures: None
Using Low-Heat Decontamination to Allow N95 and PPE Reuse During the COVID-19 Pandemic
Authors: Kressel Amy , Swafford Katie , Shannon DJ , Cathey Rachel , Fryar Jamie R. , Royal Matthew E. , Noyes Ryan
Published: November 2021

Background: US healthcare facilities experienced significant personal protective equipment (PPE) shortages, including N95 masks, in the spring and summer of 2020. The Centers for Disease Control and Prevention issued guidance for extended use, reprocessing, and reuse of N95s. Eskenazi Health (EH) implemented a program to reprocess N95s and other PPE on-site using low-heat decontamination (LHD). EH considered large-scale and small-scale ultraviolet (UV), hydrogen peroxide vapor, and LHD for on-site reprocessing of N95s. All of these methods allowed up to 3 reprocessing cycles according to most literature available at the time. However, each method differed in feasibility and acceptability to staff. EH chose to implement LHD based on both considerations. Methods: Numerous small-group meetings were held in April 2020 to determine the feasibility and acceptability of N95 reprocessing methods. Staff wanted a method that was easy for the end user, had quick turnaround, and allowed them to retrieve their own N95s. They favored a method that could be used for all PPE. EH had deployed numerous small UV machines that individuals could use for N95s. The UV machines could not be scaled up easily. To scale up, a multidisciplinary team comprising infection prevention, biomedical engineering, and sterile processing representatives reviewed available methods and implemented LHD. Biomedical engineers determined that existing blanket warmers could be reprogrammed and repurposed for low-heat decontamination. Food warmers were also available but were not needed. Biomedical engineers reprogrammed the blanket warmers to 70°C and developed a wicking system using a towel and water tray to maintain humidity; decontamination took 30 minutes. Testing runs determined that both N95s and eye protection tolerated LHD without apparent damage. Infection prevention staff developed a workflow in which staff deposited all PPE in a paper bag; the PPE bag was centrally reprocessed, marked (Figure 1), and returned to designated locations (Figure 2) for staff to retrieve their original PPE. Sterile processing staff facilitated the reprocessing workflow, and elective surgeries were canceled during the COVID-19 surge. Results: From April 20, 2020, to July 19, 2020, 7,512 units were decontaminated with LHD. If each N95 was sterilized thrice (4 uses per N95), then LHD reduced the need to purchase 22,536 N95s. Restarting elective surgeries decreased staff and support from sterile processing; the space was needed for other purposes; and N95 availability increased. All of these factors led to the discontinuation of LHD. Conclusions: LHD enables reprocessing of N95s and other PPE using existing assets. LHD is advantageous because of scalability and the capacity to provide staff with their own reprocessed PPE.

Funding: No

Disclosures: None
Building on the Foundation of a Sustainable Hand Hygiene Program During the COVID-19 Pandemic
Authors: Stancill Lisa , Sickbert-Bennett Vavalle Emily , DiBiase Lauren
Published: November 2021

Background: Hand hygiene is essential to preventing the spread of disease in hospitals. Renewed emphasis has been placed on hand hygiene during the COVID-19 pandemic. We investigated whether UNC Medical Center’s well-established Clean-In Clean-Out (CICO) program for hand hygiene observations was sustainable throughout a public health and healthcare crisis and whether the COVID-19 pandemic had an effect on hand hygiene compliance. Methods: UNC Medical Center utilizes a crowd-sourced hand-hygiene audit application, CICO, to track hand-hygiene observations, compliance, and feedback. This application encourages participation from all staff and promotes providing real-time feedback in the form of a compliment or reminder when performing hand hygiene observations. During this evaluation, hand hygiene data were queried from the CICO application on the number of observations performed, hand hygiene compliance percentage, and feedback compliance percentage from July 2019 to December 2020. Hand hygiene data were compared to patient volumes in different care settings and the number of hospitalized patients being treated for COVID-19. Results: Initial increases in hand hygiene observations, compliance, and feedback were detected in the months leading up to UNC Medical Center receiving its first SARS-CoV-2–positive patient. Observations were highest when patient volumes were low due to closed clinics and restrictions on elective surgeries (Figure 1). When patient volumes returned to pre–COVID-19 levels coupled with treating more COVID-19 patients, the number of observations and compliance rate metrics declined. Feedback compliance percentage remained relatively stable through the entire period (Figure 2). Conclusions: Despite the additional strain on healthcare staff during COVID-19, the CICO model was a sustainable method to track hand hygiene observations and compliance. Notably, however, engagement was highest when patient census was lower, demonstrating that operating at a high capacity is not beneficial for patient safety. Due to the success and sustainment of the CICO program, UNC Medical Center used this model to create a Mask-On Mask-Up campaign to engage staff to submit observations, track compliance, and encourage feedback to promote the appropriate use of masks during COVID-19.

Funding: No

Disclosures: None
Results of a Stepped-Wedge Cluster-Randomized Implementation Science Trial to Improve Chlorhexidine Gluconate Bathing Compliance
Authors: Reynolds Staci , Keating Edward
Published: November 2021

Background: Daily chlorhexidine gluconate (CHG) bathing in intensive care units (ICUs) is widely supported in the literature to decrease risk of central-line-associated infections (CLABSIs). However, adoption of this practice is inconsistent. The primary objective of this implementation science study was to assess the effect of a bathing intervention on compliance with the AHRQ CHG bathing protocol. Secondary objectives were to examine (1) moderating effects of unit characteristics, (2) the intervention effect on nursing staff’s knowledge and perceptions of CHG bathing, and (3) the intervention effect on CLABSI rates. Methods: A stepped-wedge cluster-randomized design was used to implement and evaluate the effectiveness of a CHG bathing intervention. At 2 large hospitals, 14 units were clustered into 4 sequences. Units included 9 adult ICUs, 3 pediatric ICUs, 1 pediatric bone marrow transplant unit, and 1 adult hematology-oncology unit. Sequences were enrolled into the active intervention phase over the course of 4 months. The intervention included 2 evidence-based implementation strategies: (1) educational outreach visits and (2) audit and feedback on CHG bathing compliance. Compliance with the CHG bathing processes and daily CHG bathing documentation were assessed. At 12 months after the last enrolled date, booster sessions were completed, and outcomes were assessed for sustainability. Results: In models of CHG bathing process compliance, the implementation strategy was significant (b = 6.97; P = .009), indicating that compliance was 6.97% higher after the intervention than before. There was a statistically significant improvement in nursing knowledge of CHG bathing (χ2 = 9.32, p = .002) and perception of the priority of CHG bathing (t = 2.56; P = .01). Daily CHG bathing documentation compliance and CLABSI rates did not significantly improve immediately following the intervention; however, a clinically significant decrease (27.4%) in CLABSI rate was observed. At 12 months after the intervention, improvements in CHG bathing documentation and process outcomes were sustained. There was no change in bathing process compliance after 12 months (b = −0.19; P = .87; intercept=96.96, p < .001), and compliance remained high at 96.96%. There was no change in documentation compliance after 12 months (b=3.89, p=.37, intercept=78.72, p < .001), and compliance remained high at 78.72%. After 12 months, CLABSI rates were statistically significantly reduced (b = −0.16; P = .009; intercept =1.97, p < .001). Conclusions: Using educational outreach visits and audit-and-feedback strategies can improve the adoption of evidence-based CHG bathing practices. CHG bathing—a simple, nurse-driven practice—can make a significant improvement in patient outcomes.

Funding: No

Disclosures: None
An Observational Study on CRE Colonization and Subsequent Risk of Infection in Adult ICU Patients
Authors: Sharma Kirtika , Tak Vibhor , Nag Vijaya Lakshmi
Published: November 2021

Background: Carbapenem-resistant Enterobactericeae (CRE) has emerged as a global health threat with increasing incidence. It is a particular problem in India because control over antibiotics prescription is really poor; these agents can be easily bought over the counter and the antibiotic prescription threshold is low among Indian doctors. Also, even when administered, antibiotics are given in inappropriate dosages and durations. CRE infections are a healthcare challenge due to their difficulty to treat and high morbidity and mortality. Colonization requires infection prevention measures, and it should be prioritized. Methods: We sought to determine the prevalence rate of CRE colonization in the gastrointestinal tract in newly admitted ICU patients along with follow-up of any subsequent infection following colonization. A prospective observational study was carried out among ICU patients from January 2019 to August 2020 by collecting perirectal swabs from patients who gave consent. Clinical variables were identified, and the relationship between CRE colonization and subsequent systemic CRE infection was assessed. Processing was carried out by culturing on MacConkey agar plate with ertapenem disk and further identified using conventional microbiological techniques. The ertapenem MIC was determined using an Epsillometer (E) test. The modified carbapenem inactivation (mCIM) test and the EDTA carbapenem inactivation method (eCIM) were used to confirm carbapenem resistance using Clinical Laboratory Standards Institute 2020 guidelines (Figure 1). Results: Among 192 ICU patients, 37 (19.27%) were colonized with CRE (Table 1). Also, 13 (35.13%) CRE isolates showed metallo-β-lactamase resistance. Furthermore, 18 CRE isolates (48.64%) showed serine carbapenemase activity; 6 CRE isolates showed no carbapenemase activity. Klebsiella pneumoniae (n = 25 of 37, 67.56%) was the most common CRE isolated followed by Escherichia coli (n = 11 of 37, 29.72%) and 1 isolate of Enterobacter spp (n = 1 of 37, 0.02%). Of 37 patients, 33 (89.18%) developed CRE infection during their hospital stay. Pneumonia was the most common infection developed (36.36%), followed by surgical site infection (21.21%) and urinary tract infection (12.12%). Only 1 patient developed a bloodstream infection. However, 9 patients (27.27%) developed multiple-site infections. Of 37 CRE-colonized patients, 10 (27.02%) died during their hospital stay. Conclusions: Our study highlights the increased risk of CRE infection and mortality in patients with CRE colonization in ICU patients. Hence, CRE perirectal screening for detection of asymptomatic carriers should be conducted, and strict infection control measures, such as isolation and cohorting with barrier nursing of such patients, should be done to prevent further spread of CREs in hospital settings.

Funding: No

Disclosures: None
Racial Differences in Infection Management and Palliative Care at End-of-Life in Nursing Homes Nationwide
Authors: Estrada Leah , Dick Andrew , Stone Patricia , Harrison Jordan
Published: November 2021

Background: Infections are common at end-of-life in older nursing-home residents. This often leads to the overuse of antibiotics and burdensome treatments. Improving infection management through palliative care at the end of life has been proposed as a key strategy to reducing inappropriate antibiotic use. Black nursing-home residents tend to reside in poorly performing nursing homes. We examined palliative care services in nursing homes with varying proportions of black residents. Methods: Cross-sectional, nationally representative nursing-home survey data (2017–2018) was combined with the Minimum Data Set 3.0 (nursing-home resident characteristics), the Certification and Survey Provider Enhanced Reporting data (nursing-home facility characteristics), and the Multidimensional Deprivation Index (county-level poverty estimates). The survey included 24 validated items on nursing-home palliative care services, as well as the nursing home’s infection control program and integration of infection management and palliative care (summative score, 0–100). We used nursing-home facility-level multivariate regression to estimate the relationship between proportion of black residents and palliative care scores, before and after controlling for county-level poverty estimates, facility characteristics, and resident characteristics. We categorized proportion of black residents using methods reported in the literature (25%). Results: The mean weighted palliative-care score in our sample of 869 nursing homes (weighted n = 15,020) was 47.7 (SE, 0.70). In unadjusted analyses, nursing homes with higher proportions of black residents provided significantly fewer palliative care services than nursing homes with no black residents, with the greatest differences (P = .027) observed between nursing homes with >25% black residents (mean palliative care score, 43.82; SE, 2.31) versus nursing homes with no black residents (mean palliative care score, 49.47; SE, 1.08). These disparities persisted after adjustment for urbanicity and county-level poverty rates (p < 0.01) but were attenuated after further adjustment for resident and facility level characteristics (p=0.138). Conclusions: Our findings demonstrate that wide variations in nursing-home palliative-care services exist with increased proportions of black residents, even after accounting for community characteristics. Further research is needed to identify and understand the specific community characteristics that play a role in the provision of palliative care services. Palliative care is a method to reduce inappropriate antimicrobial use at the end of life and should be expanded with a focus on nursing homes with higher proportions of black residents.

Funding: No

Disclosures: None
Evaluation of Ceftolozane/Tazobactam, Ceftazidime/Avibactam and Meropenem/Vaborbactam Against Multidrug-Resistant (MDR) Pseudomonas
Authors: Shamsulddin Haider , Lin Jeffrey , Ribes Julie , Myint Thein
Published: November 2021

Background: Data on the patient outcomes for newer β-lactam–β-lactamase inhibitor (BLBI) drugs compared to carbapenem-containing combination antibiotics for multidrug-resistant (MDR)–Pseudomonas aeruginosa infections are limited. Methods: This retrospective, case–control observational study was based on chart review of the patients managed at the University of Kentucky. Results: In total, 143 patients with MDRO Pseudomonas aeruginosa infections were identified and divided into 2 groups: 1 group received newer BLBI combinations with or without aminoglycosides or polymyxins, for at least 72 hours, and the control group received carbapenem containing combination antibiotics or other antibiotics. Baseline characteristics and patient outcomes are shown in Table 1. Discussion: The newer BLBI combinations group consisted of 60.8% MDR Pseudomonas bacteremia, whereas the control group had 68.4% of MDR Pseudomonas respiratory cultures. Overall, the use of newer BLBI combinations such as ceftazidime/avibactam, ceftolozane/tazobactam, and meropenem/vaborbactam was associated with lower rates of acute kidney injury (AKI), shorter LOS, and lower mortality rates compared to the control group, and these differences were statistically significant. Because the 2 populations of patient differed significantly based on the site of infection (sepsis vs pneumonia), the data were reanalyzed to evaluate the impact of therapy on the occurrence of AKI, LOS, and mortality based on the site of infection. Only those patients with sepsis who received the newer combination drugs had significantly better rates of AKI, lower LOS, and had lower rates of mortality. The 2 treatment arms were not statistically different when comparing patients with pneumonia. Additionally, the use of these new combination therapies did not make a difference regarding readmission rates or duration of bacteremia for the patients included in the study.

Funding: No

Disclosures: None
Difference in Susceptibility Between Carbapenemase- and Non–Carbapenemase-Producing Carbapenem-Resistant Enterobacteriaceae
Authors: Clark Justin , Burgess David
Published: November 2021

Background: Carbapenem-resistant Enterobacteriaceae (CRE) remain among the most urgent infectious threats according to the CDC Threats Reports. Although focus has often been placed on carbapenemase-producing phenotypes, there is increasing interest in distinguishing the optimal treatment and outcomes of carbapenemase-producing (CP) and non–carbapenemase-producing (NCP) CRE. We compare antimicrobial susceptibility patterns between CP-CRE and NCP-CRE isolated from patients at our academic medical center. Methods: All CRE isolates of Enterobacter cloacae, Escherichia coli, Klebsiella aerogenes, K. oxytoca, and K. pneumoniae in adult inpatients from 2010 to 2019 were included in this study. Susceptibility testing was performed using the BD Phoenix Automated System (BD Diagnostics, Sparks, MD). CLSI susceptibility break points were utilized in the susceptibility analyses of all antimicrobials tested. To determine carbapenemase production, isolates resistant only to ertapenem were considered NCP-CRE, and those resistant to both ertapenem and meropenem were considered CP-CRE. Statistical comparisons of susceptibility profiles were performed using either the χ2 test or the Fisher exact test. All data preprocessing and statistical analyses were performed using Python software. Results: Over the decade, we identified 291 CRE isolates (216 isolates resistant only to ertapenem and 75 resistant to ertapenem and meropenem). The ertapenem-resistant–only phenotype comprises ~66% of the total CRE population and is largely composed of E. cloacae (67%). As expected, most β-lactam susceptibilities were negligibly low between the 2 groups; however, other clinically relevant antimicrobials (aminoglycosides, fluoroquinolones, and sulfamethoxazole/trimethoprim) exhibited starkly different susceptibility profiles (P value Conclusions: These findings suggest that the most predominant CRE phenotype at our institution is not carbapenemase production. Evaluation of outcomes between CP- and NCP-CRE should be pursued further. The large differences in the MIC distributions may lead to differing outcomes for the affected patients.

Funding: No

Disclosures: None
Extended-Spectrum Β-Lactamases in E. coli Isolates From Hospitalized Patients: A Single-Center Snapshot From Croatia
Authors: Mestrovic Tomislav , Bedenic Branka , Tomic-Paradzik Maja , Drenjancevic Domagoj
Published: November 2021

Background: A significant increasing trend in the prevalence of Escherichia coli strains that produce extended-spectrum β-lactamases (ESBLs) has been observed in recent years, both in the community setting and in the healthcare arena. We aimed to provide a snapshot of the current situation with E. coli β-lactamase–producing strains in a single general hospital by appraising their β-lactamase content and plasmid types, which will inform further clinical and research efforts. Methods: Our study population consisted of all hospitalized patients in different clinical units of the General Hospital in Slavonski Brod during a 1-year period: internal medicine, infectious disease, surgery, urology and ICU. Phenotypic tests for the detection of ESBLs and plasmid-mediated AmpC β-lactamases were initially pursued, followed by the molecular detection (polymerase chain reaction, PCR) of resistance genes using primers for blaTEM, blaCTX-M, and blaSHV. PCR-based replicon typing (PBRT) was conducted to type resistance plasmids carrying ESBL genes. Results: During the study period, 30 E. coli isolates with reduced susceptibility to third-generation cephalosporins (ie, ceftazidime, cefotaxime, and ceftriaxone) were detected in hospitalized patients. These isolates stemmed from blood culture (66.7%), wound swabs (13.3%), urine (13.3%), and drainage content (6.7%). Alongside complete resistance to β-lactam antimicrobial agents, they were also characterized by high resistance to gentamicin (93.3%) and ciprofloxacin (96.7%), whereas 23.3% of isolates were also resistant to ertapenem. Most isolates harbored both blaCTX-M and blaTEM genes concurrently (46.7%), while solitary blaTEM and blaCTX-M genes were found in 33.3% and 20% of these isolates, respectively. The presence of SHV β-lactamases was not found in any of the isolates. PBRT revealed a wide array of diverse plasmid groups, with most of the isolates harboring different combinations; however, 80% of isolates were characterized by plasmid incompatibility group B/O (IncB/O). Conclusions: We detected increased frequency of both TEM and CTX-M type β-lactamases in E. coli isolates from a single-hospital setting, with significant consequences for further treatment approaches. The high prevalence of broad- and extended-spectrum β-lactamase producers tends to prompt an increased carbapenem use (potentially resulting in increased resistance to carbapenems); thus, this type of analytical work should become a standard approach (where possible) in hospital centers in our country and worldwide.

Funding: No

Disclosures: None
Sustainable Neonatal CLABSI Surveillance: Consensus Toward New Criteria in the Netherlands
Authors: Heijting Ilja , Hopman Joost , Hogeveen Marije , de Boode Willem , Tostmann Alma , Antonius Tim
Published: November 2021

Group Name: Working Group on Neonatal Infectious Diseases of the Section of Neonatology of the Dutch Paediatric Society

Background: Central-line–associated bloodstream infections (CLABSIs) are a main focus of infection prevention and control initiatives in neonatal care. Standardized surveillance of neonatal CLABSI enables intra- and interfacility comparisons, which can contribute to quality improvement. To date, there is no national registration system for CLABSI in neonatal care in the Netherlands. Across neonatal intensive care units (NICUs), several different sets of CLABSI criteria and surveillance methods are used for local monitoring of CLABSI incidence rates. To achieve standardized CLABSI surveillance, we conducted a consensus procedure with regard to nationwide neonatal CLABSI surveillance criteria. Method: A modified Delphi consensus procedure for the development of nationwide neonatal CLABSI surveillance criteria was performed between January 2016 and January 2017 in the Netherlands. An expert panel was formed by members of the Working Group on Neonatal Infectious Diseases of the Section of Neonatology of the Dutch Paediatric Society. The consensus procedure consisted of 3 expert panel rounds. Figure 1 shows a detailed description of the consensus procedure. Result: The expert panel achieved consensus on Dutch neonatal CLABSI surveillance criteria, which are summarized in Figure 2. Neonatal CLABSI is defined as a bloodstream infection occurring >72 hours after birth, associated with an indwelling central venous or arterial line and laboratory confirmed by 1 or more blood cultures. In addition, the blood culture finding should not be related to an infection at another site and one of the following criteria can be applied: (1) a bacterial or fungal pathogen is identified from 1 or more blood cultures; (2) the patient has clinical symptoms of sepsis and (2A) a common commensal is identified in 2 separate blood cultures or (2B) a common commensal is identified by 1 blood culture and C-reactive protein (CRP) level is >10 mg/L in the first 36 hours following blood culture collection. Conclusion: The newly developed Dutch neonatal CLABSI surveillance criteria are concise, are specific to the neonatal population, and comply with a single blood-culture policy in actual neonatal clinical practice. International agreement upon neonatal CLABSI surveillance criteria is needed to identify best practices for infection prevention and control.

Funding: No

Disclosures: None
Hospital Onset Vancomycin-Resistant Enterococci Infections in a Northern California Tertiary-Care Center From 2019 to 2020
Authors: Rasmussen Stephanie , Waldman Sarah
Published: November 2021

Background: Understanding the epidemiology and risk factors for nosocomial infections with vancomycin-resistant enterococci (VRE) is necessary for the prevention and control of VRE infections in the hospital setting. We sought to determine the incidence of nosocomial infections of VRE and to ascertain predictors associated with nosocomial infection. Methods: In this retrospective cohort study, data were collected from patients with VRE infection from January 2019 to December 2020 at a tertiary-care center in northern California. VRE infections were designated as hospital onset (HO) if the specimen was collected >3 days after hospital admission or community onset (CO) if the specimen was collected ≤3 days after admission. Associations between HO infections with time, unit, and specimen were identified. Results: Over the 2-year period, 214 unique VRE infections were identified in hospitalized patients; 115 infections were CO and 99 were HO. HO-VRE were associated most frequently with stay in medical/telemetry units (68%), followed by oncology–transplant units (15%) and ICUs (12%). There were ~4.7 and ~3.6 HO-VRE infections per month in 2019 and 2020, respectively. No differences were identified between HO-VRE infections in 2 medical units regarding glycopeptide and cephalosporin use in those units. The sources of VRE infections were urinary 45%, bloodstream 15%, stool 10%, and other 30%. Of the 45 infections in urine, 51% were identified from catheters (Foley and straight) and 27% were identified from clean-catch urine. Interestingly, 71% of patients with VRE identified from urine did not report urinary tract infection (UTI) symptoms at the time of collection. Urine was most often collected for urinalysis and culture from patients with nonspecific symptoms such as fever, leukocytosis, hypotension, tachycardia, or altered mental status. All urine collected from patients who reported UTI symptoms grew >100,000 CFU/mL in culture, while only 75% of cultures from patients without symptoms grew >100,000 CFU/mL. The most common antibiogram was resistance to ampicillin, cefazolin, levofloxacin, minocycline, penicillin, tetracycline, and/or vancomycin (42% of cases) and susceptibility to both daptomycin and linezolid (60% of cases). Conclusions: HO-VRE infections were frequently identified with urinary sources and were often associated with catheter use. However, the frequent lack of concurrent UTI symptoms suggests VRE colonization rather than infection in many cases. Understanding the epidemiology and risk factors for HO-VRE infections is essential for developing infection prevention protocols to reduce the incidence of those infections.

Funding: No

Disclosures: None
Klebsiella pneumoniae Carbapenemase (KPC)–Producing K. pneumoniae Contamination of an In-Room Sink in a New Bed Tower
Authors: Warren Bobby , Smith Becky , Lewis Sarah , Anderson Deverick , Addison Bechtler
Published: November 2021

Group Name: Duke Center for Antimicrobial Stewardship and Infection Prevention

Background: Wastewater drains in hospital patient rooms have been identified as environmental reservoirs for multidrug-resistant organisms, and they have been linked to outbreaks of carbapenem-resistant Enterobacteriaceae (CRE). We studied the colonization of wastewater drains in a new hospital bed tower. Methods: A patient care unit in a new bed tower opened on July 18, 2020. In-room sinks were located in each hospital room opposite the patient head wall. Patients admitted to this unit underwent weekly rectal cultures to survey for carbapenemase-producing CRE. Additionally, infection preventionists performed routine surveillance of all clinical cultures for CRE. Cultures were performed from all patient room sinks in this unit monthly beginning September 14, 2020. Samples were obtained from the drain cover, handles, and top of bowl using sponges soaked in neutralizing buffer and processed using the stomacher technique. The tail-pipe was sampled using a flocked mini-tip swab soaked in neutralizing buffer; the P-trap water was sampled with sterile tubing attached to a 50-mL syringe. All samples were plated on HARDYCHROM-ESBL and KPC Colorex media and were incubated at 37°C for 24 hours. Results: The first identified CRE-positive patient was admitted to the new unit on December 4, 2020; urine culture obtained at the time of admission grew KPC–producing Klebsiella pneumoniae (KPC-KP). The sink in this patient’s room had been sampled 3 prior times (most recently on November 9, 2020) and was negative for CRE. On December 7, 2020, KPC-KP was found on the drain cover (6,750 colony-forming units, CFU) and in the sink’s P-trap (1,840 CFU) of the index patient’s room during routine sink surveillance. Additional samples from other room surfaces were taken on December 9, 2020, and KPC-KP was recovered from the computer keyboard (452 CFU) and patient bedrails (880 CFU). The patient was discharged from this room December 13, 2020, and the room underwent enhanced terminal room cleaning including UV-C light. On the next routine sink sampling on January 4, 2021, KPC-KP was recovered again in the index room sink P-trap (9,800 CFU) but at no additional sites. MLST was performed, and all isolates were ST-258. Conclusions: In a new bed tower with no prior evidence of CRE-positive patients, the first identified case of a CRE (KPC-KP) in a patient resulted in widespread environmental contamination of the room after only 3 days of hospitalization and contamination of the in-room sink drain that persisted after 1 month. Given the ease with which CRE colonizes wastewater drains, new strategies are needed to mitigate drain colonization and to prevent CRE transmission to subsequent patients.

Funding: No

Disclosures: None
Risk of Methicillin-Resistant Staphylococcus aureus (MRSA) and Vancomycin-Resistant Enterococcus (VRE) Acquisition in Ambulances: A Retrospective Propensity Score-Matched Cohort Analysis
Authors: Schaps Diego , Anderson Deverick , Godfrey Andrew
Published: November 2021

Background: Infection following ambulance transport, or medical-transport–associated infection (MTAI), is understudied. Although medical-transport vehicles are routinely contaminated with methicillin-resistant Staphylococcus aureus (MRSA) and/or vancomycin-resistant Enterococcus (VRE), an association between vehicle exposure and disease development has not been identified. We estimated the relative risk (RR) of developing MRSA or VRE colonization or infection within 30 days of ambulance exposure. Methods: We performed a retrospective cohort study of patients with a principal diagnosis of chest pain presenting to our emergency department (ED) from January 1, 2016, through December 31, 2019. To control for confounding by healthcare exposure, patients were included if they presented from and were discharged to nonhealthcare locations without being admitted to the hospital. Encounters were stratified by whether the patient arrived at the ED via ambulance or private vehicle. Propensity scores were calculated using multivariable logistic regression with ambulance exposure as the dependent variable. Age, smoking status, history of myocardial infarction, congestive heart failure, peripheral vascular disease, cerebrovascular disease, dementia, diabetes mellitus, and chronic kidney disease were included as covariates because their standard differences were >0.10. Propensity score matching was performed in a 2:1 ratio, but not all exposed patients received 2 matching unexposed patients due to a low sample size. A multivariable logistic regression was performed on the matched cohort to estimate the RR of newly diagnosed MRSA or VRE infection or colonization within 30 days following ambulance exposure. Results: In total, 321,229 patients had ED encounters during the study period. After applying inclusion criteria and propensity score-matching there were 11,324 patients: 3,903 in the ambulance group and 7,421 in the unexposed group. Moreover, 12 patients (0.11%) had the outcome of interest, including 9 (0.08%) with MRSA and 3 (0.03%) with VRE. The 30-day prevalences of MRSA and VRE were larger in the ambulance group than in the unexposed group: 8 (0.20%) and 4 (0.05%), respectively (P = .02). Patients who presented to the ED via ambulance were almost 4 times more likely to have MRSA or VRE within 30 days of their encounter (RR, 3.72; 95% CI, 1.09–12.71; P = .04). The RRs for MRSA and VRE alone were 3.33 (95% CI, 0.79–13.94; P = .10) and 4.14 (95% CI, 0.37–46; P = .25), respectively. Conclusions: To our knowledge, our cohort study is the first to demonstrate an association between ambulance exposure and the development of disease. These results represent the first step in evaluating MTAI burden to eventually develop targeted interventions with the purpose of reducing it.

Funding: No

Disclosures: None
Respiratory Syncytial Virus: An Underrecognized Healthcare-Associated Infection
Authors: Gettler Erin , Talbot Thomas , Talbot H. Keipp , Ndi Danielle , Mitchel Edward , Markus Tiffanie , Harris Bryan , Schaffner William
Published: November 2021

Background: Despite significant morbidity and mortality, estimates of the burden of healthcare-associated viral respiratory infections (HA-VRI) for noninfluenza infections are limited. Of the studies assessing the burden of respiratory syncytial virus (RSV), cases are typically classified as healthcare associated if a positive test result occurred after the first 3 days following admission, which may miss healthcare exposures prior to admission. Utilizing an expanded definition of healthcare-associated RSV, we assessed the estimates of disease prevalence. Methods: This study included laboratory-confirmed cases of RSV in adult and pediatric patients admitted to acute-care hospitals in a catchment area of 8 counties in Tennessee identified between October 1, 2016, and April 30, 2019. Surveillance information was abstracted from hospital and state laboratory databases, hospital infection control databases, reportable condition databases, and electronic health records as a part of the Influenza Hospitalization Surveillance Network by the Emerging Infections Program. Cases were defined as healthcare-associated RSV if laboratory confirmation of infection occurred (1) on or after hospital day 4 (ie, “traditional definition”) or (2) between hospital day 0 and 3 in patients transferred from a chronic care facility or with a recent discharge from another acute-care facility in the 7 days preceding the current index admission (ie, “enhanced definition”). The proportion of laboratory-confirmed RSV designated as HA-VRI using both the traditional definition as well as with the added enhanced definition were compared. Results: We identified 900 cases of RSV in hospitalized patients over the study period. Using the traditional definition for HA-VRI, only 41 (4.6%) were deemed healthcare associated. Adding the cases identified using the enhanced definition, an additional 12 cases (1.3%) were noted in patients transferred from a chronic care facility for the current acute-care admission and 17 cases (1.9%) were noted in patients with a prior acute-care admission in the preceding 7 days. Using our expanded definition, the total proportion of healthcare-associated RSV in this cohort was 69 (7.7%) of 900 compared to 13.1% of cases for influenza (Figure 1). Although the burden of HA-VRI due to RSV was less than that of influenza, when stratified by age, the rate increased to 11.7% for those aged 50–64 years and to 10.1% for those aged ≥65 years (Figure 2). Conclusions: RSV infections are often not included in estimates of HA-VRI, but the proportion of cases that are healthcare associated are substantial. Typical surveillance methods likely underestimate the burden of disease related to RSV, especially for those aged ≥50 years.

Funding: No

Disclosures: None