bluuebunny/crossref_metadata_2025 huggingface dataset:
Healthcare personnel at non–acute-care facilities are at risk of COVID-19 from workplace and community exposures
Authors: Mansoor Armaghan-e-Rehman , O’Neil Caroline , McDonald David , Fraser Victoria , Babcock Hilary , Kwon Jennie
Published: September 2023

Background: Healthcare personnel (HCP) working in non–acute-care facilities are at high risk of COVID-19. We sought to determine SARS-CoV-2 seroprevalence, and analyzed behaviors and activities related to COVID-19 acquisition in this cohort. Methods: Between May and June 2021, HCP were enrolled at a skilled nursing facility and a memory care facility in St. Louis, Missouri. Data regarding demographics, prior SARS-CoV-2 testing, symptoms consistent with COVID-19 in the previous 6 months, COVID-19 vaccination, personal protective equipment (PPE) use, and COVID-19 exposures were collected via survey. Blood specimens were obtained to determine SARS-CoV-2 nucleocapsid IgG antibody seroprevalence (Abbott Laboratories). Study protocol was approved by the Washington University Institutional Review Board. Results: The survey was completed by 74 HCP. 82% of participants were female, and 31% reported >10 years of healthcare experience. The overall SARS-CoV-2 seropositivity rate was 8.9% (5 HCP). Of the surveyed HCP, 50% reported symptoms concerning for COVID-19 in the prior 6 months. Headache (38%), fatigue (35%) and fever (27%) were the most common self-reported symptoms. Among symptomatic HCP, only 35% sought medical care for these symptoms. All HCP reported having taken at least 1 COVID-19 test prior to study enrollment. Of note, 18.9% (14 HCP) had a self-reported prior positive SARS-CoV-2 PCR test, of whom 9 HCP were seronegative. All seronegative HCP with a self-reported history of COVID-19 reported infection >3 months before study participation. Completion of a primary COVID-19 vaccination series was reported by 86% of HCP. Known exposure to COVID-19 at work was reported by 28% of HCP. When asked about PPE at the time of workplace exposure, N95 mask use was reported by 81%, gloves by 57%, gowns by 33%, face shields by 29% and surgical masks by 14%. Known specific exposure to COVID-19 outside work was reported by 31% of HCP. Conclusions: One year after the initial COVID-19 pandemic impacted the St. Louis region, HCP at non–acute-care facilities had a SARS-CoV-2 seroprevalence of 8.9%. Similar frequency of exposures were reported from both the workplace and community, with high rates of PPE use at the workplace. HCP in such settings remain at high risk of COVID-19 exposure from workplace and community exposures. Ongoing efforts are needed to maintain PPE use to prevent SARS-CoV-2 transmission within non–acute-care facilities, and continue access to timely COVID-19 screening for HCP.

Disclosure: None
Reducing the rate of guideline-discordant therapy for inpatients with community-acquired pneumonia
Authors: Hannan Kellie Arensman , Frykman Paul , Mathiowetz Eric , Sathre Jill , Yang Nou Cheng , Jensen Kelsey
Published: September 2023

Background: Despite guidelines recommending shorter durations of therapy and empiric coverage of Pseudomonas aeruginosa and methicillin-resistant Staphylococcus aureus (MRSA) only for patients with certain risk factors, optimizing therapy for community-acquired pneumonia (CAP) remains a challenge for antimicrobial stewardship (AMS) teams. We investigated the impact of a multimodal AMS initiative on the rate of guideline-discordant empiric antibiotic selection and total duration of therapy for CAP. Methods: A quality improvement initiative was implemented at 9 community hospitals in 2022 to optimize CAP therapy. Education was provided to pharmacists and providers. Alerts were implemented within the electronic medical record to prompt the AMS team to review fluoroquinolones, antipseudomonal β-lactams, and anti-MRSA agents ordered for CAP. Clinical pharmacists reviewed antibiotic orders for CAP at hospital discharge and encouraged providers to prescribe a total antibiotic duration of 5–7 days. For the preintervention period (July– September 2021) and the postintervention period (July to September 2022), a random sample of 320 patients with an antibiotic order for CAP were evaluated retrospectively via chart review. Patients treated for an indication other than CAP were excluded. The primary outcome was the proportion of patients with a total duration of therapy >7 days. Secondary outcomes included average duration of therapy, rate of guideline-discordant empiric therapy, and type of guideline discordance. Results: In total, 317 patients were included. The proportion of patients with a total duration of therapy >7 days decreased from 29% to 14% (P < .01). Average duration of therapy and guideline-discordant empiric therapy also decreased significantly (Table 1). Conclusions: This multifaceted AMS initiative was associated with decreased guideline-discordant empiric therapy and decreased total duration of therapy for CAP.

Disclosures: None
Prevalence of and risk factors for bacteremic UTIs in hospitalized adults without definitive signs or symptoms of UTI
Authors: Advani Sonali , Ratz David , Horowitz Jennifer , Petty Lindsay , Schmader Kenneth , Czilok Tawny , Malani Anurag , Gandhi Tejal , Flanders Scott , Vaughn Valerie
Published: September 2023

Background: IDSA guidelines recommend withholding treatment in patients with asymptomatic bacteriuria in the absence of systemic signs of infection. However, some patients with bacteriuria may not be able to express symptoms either due to presence of indwelling catheter, underlying complicated urologic anatomy, dementia, or altered mental status (AMS). Clinicians frequently treat bacteriuria in this population with antimicrobial therapy due to concern for sepsis. To determine treatment need, we aimed to review prevalence and risk factors for bacteremic urinary tract infection (UTI) in a cohort of hospitalized inpatients without definitive signs and symptoms of a UTI. Methods: This retrospective cohort study of inpatients with a positive urine culture who presented without definitive signs or symptoms of a UTI was conducted between July 1, 2017, and June 30, 2022, in 68 academic and community hospitals (Michigan Hospital Medicine Safety Consortium). Signs and symptoms were obtained from medical record review 3 days before and after urine-culture collection. Bacteremic UTI was defined as any positive blood culture growing at least 1 organism matching the urine culture. Risk factors for bacteremic UTI were assessed using multivariable logistic regression models with results expressed as odds ratios (ORs) for dichotomous variables and relative risks (RRs) for continuous variables. Results: Of 11,793 patients meeting study criteria, 73.6% were female with a median age of 78.2 years. Overall, 41.8% had AMS, 33.8% had dementia, 15.6% had an indwelling urinary catheter, and 54.6% had complicated urologic history (eg, urologic surgery). Of these, 166 patients (1.4%) developed bacteremic UTI. On adjusted analysis, male sex, hypotension, heart rate >90, urinary retention, fatigue, log of serum leukocytosis [1 log increase in serum WBC = 2.718 × serum white blood cell count (WBC)], and pyuria with >25 WBC per high-powered field (WBC/hpf) on urinalysis were associated with bacteremic UTI (Table). Older age, presence of an indwelling catheter, complicated urologic history, functional decline, AMS, dementia, and change in urine were not associated with higher odds for bacteremic UTI (Table). Of patients with AMS and no definitive signs or symptoms of a UTI, only 89 (1.8%) of 4,932 developed a bacteremic UTI. Conclusions: Bacteremic UTI is relatively rare in hospitalized inpatients presenting with bacteriuria without symptoms of UTI. Predictors of bacteremic UTI included male sex, hypotension, tachycardia, urinary retention, fatigue, serum leukocytosis, and higher levels of pyuria (>25 WBC/hpf) on urinalysis. Our findings provide stewards a framework to risk stratify inpatients of older age who present with positive urine cultures but without (or are unable to express) signs or symptoms of UTI.

Disclosures: None
Electronic health record–based identification of inpatients receiving antibiotic treatment for community-acquired pneumonia
Authors: Yang David , Cressman Leigh , Hamilton Keith , Dutcher Lauren
Published: September 2023

Background: Inappropriate antibiotic use for community-acquired pneumonia (CAP) is common. Although antibiotic stewardship activities require real-time, accurate identification of patients being treated for CAP, there are few reliable methods to identify such patients using the electronic health record (EHR). We conducted a retrospective study to assess the performance of provider-selected antibiotic indication in identifying patients being treated for CAP among a cohort of hospitalized adults. Methods: We randomly selected 440 patients from a cohort of patients who received at least 1 systemic antibiotic within 48 hours of admission between January 1, 2019, and December 31, 2021, at 3 acute-care hospitals. The reference standard for treatment of CAP was defined as intention to treat for pneumonia by inpatient provider(s) within 48 hours of admission, as assessed by chart review of provider notes. Treatment for pneumonia using any terminology except with “hospital-acquired pneumonia” (HAP) or “ventilator-associated pneumonia” (VAP) were counted. Provider-selected indication of CAP (in an antibiotic order) was compared against this reference standard; sensitivity, specificity, and positive and negative predictive values were calculated. Performance characteristics of International Classification of Disease, Tenth Revision (ICD-10) codes for pneumonia in identifying CAP patients were assessed against the same reference standard. A secondary analysis including terms HAP and VAP in the reference standard was performed. Results: Provider-selected antibiotic indication for CAP had a sensitivity of 64.4%, specificity of 96.3%, positive predictive value (PPV) of 73.1%, and negative predictive value (NPV) of 96.1%, giving comparable performance to ICD-10 codes (Table 1). Of those with 21 false-negative results, 13 (61.9%) had a healthcare-associated lower respiratory tract infection and 14 (66.7%) had sepsis indicated in at least 1 antibiotic order. Conclusions: Provider-selected antibiotic indication showed moderate sensitivity and high specificity for identifying CAP-treated cases. Importantly, use of this method can be deployed for real-time antibiotic stewardship interventions for CAP.

Disclosures: None
Fluconazole resistance in non-albicans Candida species in the United States, 2012-2021
Authors: Jenkins Emily , Lyman Meghan , Jackson Brendan , Lockhart Shawn , Wolford Hannah , Reddy Sujan , Baggs James
Published: September 2023

Background:Candida spp can cause a variety of infections known as candidiasis, ranging from severe invasive infections to superficial mucosal infections of the mouth and vagina. Fluconazole, a triazole antifungal, is commonly prescribed to treat candidiasis but increasing fluconazole resistance is a growing concern for several Candida spp. Although C. albicans has historically been the most common cause of candidiasis, other species are increasingly common and antifungal resistance is more prevalent in these non-albicans species, including C. glabrata, C. parapsilosis, and C. tropicalis, which were the focus of this analysis. Methods: We used the PINC AI healthcare data (PHD) database to examine fluconazole resistance for inpatient isolates between 2012 and 2021 from 187 US acute-care hospitals with at least 1 Candida spp culture with a fluconazole susceptibility result over the entire period. We calculated annual percentage fluconazole resistance for C. glabrata, C. tropicalis, and C. parapsilosis isolates using the clinical laboratory interpretation for resistance. Results: We identified 4,264 C. glabrata, 2,482 C. parapsilosis, and 2,283 C. tropicalis isolates between 2012 and 2021 with susceptibility results. The percentage of C. glabrata isolates resistant to fluconazole doubled between 2020 and 2021 (14.6% vs 29.3%) (Fig. 1a). The percentage of C. parapsilosis isolates resistant to fluconazole steadily increased since 2017 (Fig. 1b), with an 82% increase in 2021 compared with 2020 (3.8% in 2020 vs 6.9% in 2021). Fluconazole resistance among C. tropicalis isolates varied over the years, with a 0.3% decrease in 2021 from 2020 (Fig. 1c). Of hospitals reporting at least 1 result each year 2020–2021, 44% observed an increase in the proportion of C. glabrata isolates resistant to fluconazole in 2021 compared to 2020. Conclusions: Our analysis highlights a concerning increase in fluconazole resistance among C. glabrata and C. parapsilosis isolates in 2021 compared with previous years. Further investigation of the observed increases in fluconazole resistance among these Candida spp could provide further insight on potential drivers of resistance or limitations in reported results from large databases. More analyses are needed to understand rates, sites of Candida infections, and risk factors (eg, antifungal exposure) associated with resistance.

Disclosures: None
Validation of antibiotic stewardship metrics for genitourinary infection management in Veterans Affairs outpatient settings
Authors: Braunfeld Jordan , Samore Matthew , Crook Jacob , Nevers McKenna , Echevarria Kelly , Brintz Ben , Goetz Matthew , Madaras-Kelly Karl
Published: September 2023

Background: Diagnosis and management of suspected urinary tract infection (UTI) in outpatient settings has been shown to be suboptimal. We previously developed a set of stewardship metrics for UTIs based on electronic health record (EHR) data (Antimicrobial Stewardship & Healthcare Epidemiology 2022;2 suppl 1:S5–S6. doi:10.1017/ash.2022). A tier-based approach was used to more fully capture antibiotic use associated with genitourinary (GU) symptoms and diagnoses. Herein we report a preliminary analysis of validity and reliability of these metrics based on chart abstraction. Methods: The study cohort consisted of patients who visited Veterans Affairs emergency departments or primary care clinics between 2015 and 2022 and who had a GU diagnosis based on International Classification of Disease, Tenth Revision (ICD-10) codes, divided into 3 categories: tier 1 (antibiotics always indicated), tier 2 (antibiotics sometimes indicated), and tier 3 (antibiotics not indicated). Visits related to urological procedures, nontarget settings, or concomitant non-GU infections were excluded. Cases were randomly sampled for manual review from within 8 strata based on tier, use of antibiotics, and visit type. An infectious disease physician and pharmacist abstracted charts using a standardized data-collection instrument. Clinical judgments regarding diagnosis and treatment were recorded on a Likert scale without knowledge of how the patient was managed. The intraclass correlation coefficient (ICC) was used to estimate interrater reliability. Results: To date, 148 cases have been reviewed (50 by both reviewers). Mean (SD) age was 67.5 (15.3) years and 12.2% were female. In a majority of tier 1 and 2 visits in which antibiotics were given, the reviewers found evidence for GU infection (69.7%) and favored prescribing of antibiotics (60.6%) (Table). In contrast, most patients in the tier 3 category who received antibiotics were judged to have noninfectious conditions (eg, benign prostatic hypertrophy) and to not require antibiotics. In the subset of records examined by both reviewers, the interrater reliability of judgments of whether antibiotics were warranted was good (ICC = .704). Conclusions: This preliminary validation provides support for a tier-based approach for stewardship metrics for GU conditions that relies upon electronic data to identify patients for whom antibiotics are generally not indicated.

Disclosures: None
Effects of a hard stop for C. difficile testing: Provider uptake and patient outcomes
Authors: Doughman Danielle , Weber David , Mavrogiorgos Nikolaos , Summerlin-Long Shelley , Swartwood Michael , Commanday Alexander , Stancill Lisa , Kane Nicholas , Vavalle Emily Sickbert-Bennett
Published: September 2023

Background:Clostridioides difficile infection (CDI) is a serious healthcare-associated infection responsible for >12,000 US deaths annually. Overtesting can lead to antibiotic overuse and potential patient harm when patients are colonized with C. difficile, but not infected, yet treated. National guidelines recommend when testing is appropriate; occasionally, guideline-noncompliant testing (GNCT) may be warranted. A multidisciplinary group at UNC Medical Center (UNCMC) including the antimicrobial stewardship program (ASP) used a best-practice alert in 2020 to improve diagnostic stewardship, to no effect. Evidence supports use of hard stops for this purpose, though less is known about provider acceptance. Methods: Beginning in May 2022, UNCMC implemented a hard stop in its electronic medical record system (EMR) for C. difficile GNCT orders, with exceptions to be approved by an ASP attending physician. Requests were retrospectively reviewed May–November 2022 to monitor for adverse patient outcomes and provider hard-stop compliance. The team exported data from the EMR (Epic Systems) and generated descriptive statistics in Microsoft Excel. Results: There were 85 GNCT orders during the study period. Most tests (62%) were reviewed by the ASP, and 38% sought non-ASP or no approval. Of the tests reviewed by the ASP, 33 (62%) were approved and 20 (38%) were not. Among tests not approved by the ASP, no patients subsequently received CDI-directed antibiotics, and 1 patient (5%) warranted same-admission CDI testing (negative). Of tests that circumvented ASP review, 18 (56%) ordering providers received a follow-up email from an associate chief medical officer to determine the rationale. No single response type dominated: 3 (17%) were unaware of the ASP review requirement, 2 (11%) indicated their patient’s uncharted refusal of laxatives, 2 (11%) indicated another patient-specific reason. Provider avoidance of the ASP approval mechanism decreased 38%, from 53% of noncompliant tests in month 1 to 33% of tests in month 6. Total tests orders dropped 15.5% from 1,129 during the same period in 2021 to 954 during the study period (95% CI, 13.4%–17.7%). Compliance with the guideline component requiring at least a 48-hour laxative-free interval prior to CDI testing increased from 85% (95% CI, 83%–87%) to 95% (95% CI, 93%–96%). CDI incidence rates decreased from 0.52 per 1,000 patient days (95% CI, 0.41–0.65) to 0.41 (95% CI, 0.32–0.53), though the change was neither significant at P = .05 nor attributable to any 1 intervention. Conclusions: Over time and with feedback to providers circumventing the exception process, providers accepted and used the hard stop, improving diagnostic stewardship and avoiding unneeded treatment.

Disclosures: None
Identifying risk factors for pediatric central-line–associated bloodstream infections
Authors: Conrad Paula , Murphy Julie , Audain Pascale , Connors Michelle , Hopkinson Christopher , Yuen Jenny Chan , Ormsby Jennifer
Published: September 2023

Background: Pediatric patients often require central venous catheters (CVCs) for a variety of clinical indications, including medication administration, parenteral nutrition, and venous blood sampling. Patients with CVCs are at risk for central-line–associated bloodstream infections (CLABSI). These hospital-acquired infections are often preventable and may lead to increased morbidity and mortality. Clinicians at a 477-bed, freestanding pediatric academic hospital completed a quality improvement project to identify factors that place pediatric patients at increased risk for CLABSI and to outline strategies aimed at CLABSI reduction for our highest-risk patients. Methods: Project leaders completed a literature review to evaluate current research on the topic and then assembled a project team. The team completed a retrospective analysis and categorization of CLABSI cases and reviewed internal CLABSI root-cause analysis data. The group then completed a case–control analysis to identify risk factors in patients with CVCs who developed CLABSIs, compared to patients with CVCs who did not develop CLABSI. Following this analysis, the team created a CLABSI risk-factor tool for use by bedside nurses. This tool described patients with CLABSI risk factors and outlined best practices for CLABSI prevention. Results: Based upon literature review, root-cause analysis data, and retrospective CLABSI case review over the period from 2017 to 2021, an initial list of 9 potential CLABSI risk factors was compiled. A case–control analysis was performed comparing 97 CLABSI cases with 103 matched controls. Univariate, multivariate, and additional covariate analyses were employed to identify 3 factors placing pediatric patients at increased risk for CLABSI. These included (1) multiple enteral devices (ie, 2 or more devices, including gastrostomy tube, jejunostomy tube, gastrostomy or jejunostomy tube, ostomy, and peritoneal drain); (2) multiple CVC entries (ie, CVC used for medications and venous sampling); and (3) long-term CVC plus parenteral nutrition (CVC in place for >21 days and receiving parenteral nutrition and/or intralipids). Conclusions: Pediatric patients with central venous access are vulnerable to CLABSI, and certain patients may be at increased risk. Frontline clinicians may be able to identify these patients and adopt best practices to prevent infection. A tool for use by bedside nurses can be a useful adjunct to existing CLABSI prevention practices.

Disclosures: None
Inpatient remdesivir versus nirmatrelvir-ritonavir in the progression of COVID-19
Authors: Patel Dimple , Mccoy Christopher , Donohoe Kendall , Lee Matthew , Gold Howard , Chapin Ryan
Published: September 2023

Background: Nirmatrelvir-ritonavir received emergency use authorization (EUA) for the prevention of progression of COVID-19 in December 2021. Most data supporting this authorization are limited to the outpatient setting in unvaccinated patients, and high-quality head-to-head comparisons to other antivirals such as remdesivir are lacking. Patients at high risk of disease progression, such as advanced age, smokers, and those with cardiovascular disease, diabetes, obesity, or cancer continue to be admitted to acute-care settings for various indications, and some are incidentally found to have mild COVID-19. The objective of this project was to compare rates of progression of mild-to-moderate COVID-19 for inpatients treated with remdesivir versus nirmatrelvir-ritonavir. Methods: This study was a single-center, retrospective cohort study that included patients aged ≥18 years with PCR-confirmed SARS-CoV-2 infection who were initiated on nirmatrelvir-ritonavir within 5 days or remdesivir within 7 days of symptom onset between June 2022 and August 2022. The primary outcome was the worsening of symptoms via the WHO ordinal clinical severity scale for COVID-19. Secondary outcomes included escalation of care or readmission due to COVID-19, discharge prior to treatment completion, and any adverse drug reactions (ADRs). Within our institutional guidelines, prior approval is needed for COVID-19 treatment through collaboration between the primary team and antimicrobial stewards. Nirmatrelvir-ritonavir is the preferred agent for both in- and outpatients unless the patient had drug interactions or lack of enteral access, in which case remdesivir was considered. Results: In total, 58 patients were screened and 50 patients were included, 25 patients in each arm. Most were non-Hispanic, white males with at least 1 comorbidity. Compared to the remdesivir arm, the nirmatrelvir-ritonavir arm had more patients with at least a primary COVID-19 vaccine (44% vs 34%). Also, 88% of patients in each arm had a baseline ordinal score of 4, and 12% had a score of 5. Ordinal score changes between the start and end of therapy were similar between groups, and neither had an increase in oxygen requirements (Fig. 1). No readmissions were due to COVID-19, and both medications were well tolerated. Refer to Fig. 2 for secondary outcomes. Conclusions: Nirmatrelvir-ritonavir and remdesivir showed similar safety and efficacy in the treatment of hospitalized patients with mild-to-moderate COVID-19. Current evidence-based guidelines and treatment costs favor nirmatrelvir-ritonavir for patients who can receive this drug.

Disclosures: None
Decolonization of hospital patients may aid efforts to reduce transmission of carbapenem-resistant Enterobacterales
Authors: Singh Brajendra K. , Paul Prabasaj , Gowler Camden D. , Reddy Sujan C. , Slayton Rachel B.
Published: September 2023

Background: Multimodal approaches are often used to prevent transmission of antimicrobial-resistant pathogens among patients in healthcare settings; understanding the effect of individual interventions is challenging. We designed a model to compare the effectiveness of hand hygiene (HH) with or without decolonization in reducing patient colonization with carbapenem-resistant Enterobacterales (CRE). Methods: We developed an agent-based model to represent transmission of CRE in an acute-care hospital comprising 3 general wards and 2 ICUs, each with 20 single-occupancy rooms, located in a community of 85,000 people. The model accounted for the movement of healthcare personnel (HCP), including their visits to patients. CRE dynamics were modeled using a susceptible–infectious–susceptible framework with transmission occurring via HCP–patient contacts. The mean time to clearance of CRE colonization without intervention was 387 days (Zimmerman et al, 2013). Our baseline included a facility-level HH compliance of 30%, with an assumed efficacy of 50%. Contact precautions were employed for patients with CRE-positive cultures with assumed adherence and efficacy of 80% and 50%, respectively. Intervention scenarios included decolonization of culture-positive CRE patients, with a mean time to decolonization of 3 days. We considered 2 hypothetical intervention scenarios: (A) decolonization of patients with the baseline HH compliance and (B) decolonization with a slightly improved HH compliance of 35%. The hospital-level CRE incidence rate was used to compare the results from these intervention scenarios. Results: CRE incidence rates were lower in intervention scenarios than the baseline scenario (Fig. 1). The baseline mean incidence rate was 29.1 per 10,000 patient days. For decolonization with the baseline HH, the mean incidence rate decreased to 14.5 per 10,000 patient days, which is a 50.2% decrease relative to the baseline incidence (Table 1). The decolonization scenario with a slightly improved HH compliance of 35% produced a relative reduction of 71.9% relative to the baseline incidence. Conclusions: Our analysis shows that decolonization, combined with modest improvement in HH compliance, could lead to large decreases in pathogen transmission. In turn, this model implies that efforts to identify and improve decolonization strategies for better patient safety in health care may be needed and are worth exploring.

Disclosures: None
Developing a statewide infection prevention program assessment service for dialysis settings using a six-sigma framework
Authors: Ludington Chelsea , Brum Renee
Published: September 2023

Background: Due to the need for recurrent and direct access to the bloodstream, patients who require hemodialysis are at higher risk of developing healthcare-associated infections. Failure to assess gaps in systems and processes impedes the implementation of quality and performance improvement initiatives. In Michigan, there is no consultative service offered to dialysis units to assist with infection prevention practices, and no statewide dialysis data are being utilized. The Michigan Department of Health and Human Services developed a consultative, nonregulatory service dedicated to providing a comprehensive assessment of dialysis-based infection prevention programs. Methods: A multidisciplinary team created an infection prevention dialysis evaluation program using the six-sigma define–measure–analyze–design–verify model. These elements included content within the dialysis-specific Infection Control Assessment and Response (ICAR) Tool from the CDC with supporting program assessment items. From August 2021 through August 2022, the team completed 17 inpatient dialysis assessments within our cohort’s 17 hospitals. Data were analyzed using descriptive statistical analysis, and the final analysis included 1,086 observations from the developed assessment tool. Observations were grouped into 7 infection prevention categories: appropriate use of single and multiuse devices and supplies, aseptic technique, bloodborne pathogen prevention, cleaning and disinfection, hand hygiene, personal protection equipment (PPE) use, and storage of devices and supplies. Detailed summary reports were provided to the participating facilities after each site visit that included identified gaps, recommendations for improvement, and evidence-based resources. Results: Deficiencies were grouped into 7 major infection prevention categories among the 17 assessments, including cleaning and disinfection (n = 17, 100%), hand hygiene (n = 9, 53%), PPE use (n = 9, 53%), appropriate use of single and multiuse devices and supplies (n = 6, 35%), bloodborne pathogen prevention measures (n = 6, 35%), aseptic technique (n = 5, 29%), and storage of devices and supplies (n = 4, 24%). Conclusions: Our program’s prototype has been successful at detecting gaps in dialysis-based IP programs. By conducting data analyses of assessment findings, we have been able to assist the organization in establishing priorities for quality and performance improvement. Based on the results, comprehensive and robust systems to assess infection prevention programs, including those in dialysis settings, are necessary to enhance infection prevention operations across the continuum of care.

Disclosures: None
Some like it hot: Variable impact of a tailpiece heating device on different gram-negative bacteria
Authors: Park Stacy , Kotay Shireen , Barry Katie , Carroll Joanne , Attai April , Guilford William , Mathers Amy
Published: September 2023

Background: Transmission of multidrug-resistant bacteria to patients from colonized hospital sink drains has prompted attempts to interrupt transmission through a variety of interventions directed at the wastewater environment. We previously found that use of a heating device designed to disrupt biofilm formation between the P trap and the sink drain, which is the major point of dispersal of bacteria to the patient-care environment, was associated with reduced risk of detectable gram-negative organisms on hospital sink drains. However, there was no observed effect on some important pathogens, including Pseudomonas aeruginosa and Stenotrophomonas maltophilia. We hypothesized that heating to a higher temperature would provide additional efficacy in preventing drain colonization. Methods: As part of a previous randomized study, 54 tailpiece heaters were installed in 3 intensive care units in an academic hospital and 2 acute-care units in an associated regional hospital; half of these devices were shams (ie, no heat). The devices were programmed to heat for 1 hour every fourth hour. Prior to this study, a device update increased the heating temperature (during the previous study the median heated temperature was 65.9°C). Sink drains and P traps were sampled monthly. Samples were assessed for semiquantitative growth of gram-negative bacteria on MacConkey agar, looking especially for P. aeruginosa and S. maltophilia. Frontline personnel were blinded to device assignment. Results: The mean heated temperature reached was 74.4°C. Based on proportional odds logistic regression (wherein the odds ratio reflects the likelihood of a given sample falling in a lower microbiologic burden level versus the levels above it), the heating device was associated with increased likelihood of lower microbiologic burden at the drain level for general growth on MacConkey agar (OR, 2.47; 95% CI, 1.11–5.51) and for growth of S. maltophilia (OR, 5.39; 95% CI, 2.20–13.18). The device did not have an effect on burden of Enterobacterales (OR, 1.38; 95% CI, 0.58–3.24). For P. aeruginosa, there was a trend toward decreased likelihood of lower microbiologic burden (OR, 0.41; 95% CI, 0.18–1.07) that did not reach statistical significance at the drain level, and the heating device was associated with decreased likelihood of lower microbiologic burden of P. aeruginosa at the P-trap level (OR, 0.20; 95% CI, 0.10–0.39). Conclusions: Heat disruption of biofilm between the P trap and sink may be a promising strategy for prevention of hospital sink drain colonization; however, the impact is variable across different bacterial species. Further understanding of the dynamics of the microbiome within wastewater is needed.

Disclosures: None
Healthcare worker perceptions about infection prevention and control processes and practices in Latin America
Authors: Fabre Valeria , Beccar-Varela Pilar , Herzig Carolyn , Reyes-Morales Guadalupe , Rock Clare , Quiros Rodolfo
Published: September 2023

Background: The burden of hospital-associated infections (HAIs) and antimicrobial resistance (AMR) in Latin America is high. Improving engagement by healthcare workers (HCWs) in infection prevention and control (IPC) may lead to better patient outcomes; however, little is known about HCW perceptions of IPC in the region. We sought to understand HCW perceptions of IPC processes and practices. Methods: During August–September 2022, HCWs from 30 hospitals with IPC programs in 4 Latin American countries (Panama, Guatemala, Ecuador, and Argentina) were invited to participate in an electronic, voluntary, anonymous survey about their perceptions of IPC at their hospitals. Physicians, nurses, and environmental care (EVC) personnel were prioritized for recruitment. All respondents were asked 18 questions; IPC team members were asked 5 additional questions about specific activities implemented by IPC programs, how data are used, and how IPC could be improved. Answers with 5-point Likert scale responses were categorized into 2 groups (eg, strongly agree or agree vs neutral, disagree, or strongly disagree) for analysis. Results: Of 1,252 HCWs who completed the survey, 181 (14%) were IPC team members, 1,095 (87%) had direct patient contact, and 1,156 (92%) worked >20 hours per week. Figure 1 shows participant characteristics. Most participants (56%) rated their IPC program as very good, 38% rated it as good, and 6% rated it as bad. Physicians were less likely to give a favorable rating. Compliance with prevention bundles and hand hygiene (HH) by colleagues was rated as poor by 28% and 22% of HCWs, respectively; however, only 11% and 5% indicated that their own compliance was poor, respectively. Also, 25% of participants reported not receiving or only occasionally receiving HH compliance data. Similarly, 41% of participants reported not receiving HAI data on a regular basis, and 19% of IPC nurses reported not receiving data despite being responsible for conducting surveillance. Furthermore, 41% of respondents indicated not receiving or only occasionally receiving IPC training or education relevant to their role. When asked about the safety climate, 16% of participants reported not feeling appreciated. In addition, 22% of IPC nurses and 37% of individuals in the “other” category (eg, health technicians and therapists) were more likely to report this. When IPC team members were asked how frequently specific activities were conducted (Fig. 2), several opportunities for improvement were identified, including improving HCW access to HH data and development of strategic plans. Conclusions: Improving HCW access to training on IPC and to data on HAI burden and compliance with HH and prevention bundles should be emphasized in Latin American hospitals.

Disclosures: None
Oregon Project Firstline: A needs assessment of healthcare personnel infection prevention knowledge and training preferences
Authors: Ida Nicholas , Guzman-Cottrill Judith , Tammer Roza , Pierce Rebecca , Tran Dat
Published: September 2023

Background: Infection prevention and control (IPC) competency is critical for healthcare personnel (HCP) and patient safety. In collaboration with the CDC new national IPC training collaborative called Project Firstline, the Oregon Health Authority’s (OHA) Healthcare Associated Infection (HAI) Program established a state-level program in 2021. The goal of Oregon Project Firstline is to provide relevant, accessible, and engaging IPC training materials for our state’s HCP. We assessed the IPC learning needs of Oregon’s healthcare workforce, and to understand the preferred methods and formats of training across the various HCP roles. Methods: OHA’s HAI program recruited HCP by distributing electronic surveys through multiple healthcare, regulatory, and public health partners’ email listservs and HCP-targeted newsletters. Survey responses were recorded from September 23 to December 10, 2021. The HAI program assessed respondents’ IPC knowledge, online and in-person job training preferences, frequently used training devices, and trusted sources for IPC information. An individual’s understanding of an IPC topic was categorized based on their self-assessed confidence in their knowledge and ability to teach the topic to others. In total, 6,382 surveyed responses were analyzed. Results: The average understanding among HCP was lowest in IPC topics relating to triage and isolation of contagious patients and fit testing of respiratory protection devices. For these topics, 3,208 HCP (66.21%) and 3,657 HCP (75.48%) HCP, respectively, did not understand the topic well enough to teach others (Fig. 1). The highest number of HCP (n = 2,512, 39.36%) requested additional training in methods on how to educate others about IPC topics (ie, “train the trainer”). Surveyed respondents most frequently used personal computers for job trainings in both work and at-home settings (n = 4,603, 72.12%) and 3,437 HCP (53.85%) were open to either in-person or remote formats for job education. The CDC and OHA were the most frequented and trusted IPC sources among surveyed HCP: 4,124 HCP (64.62%) and 3,584 HCP (56.16%), respectively. Conclusions: IPC is a critical topic in HCP training across all healthcare facility types and employee roles. Effective educational planning includes understanding the learners’ knowledge needs and preferred methods of learning. Our learning needs assessment identified important IPC knowledge gaps and will help ensure that our training courses will be offered in effective educational formats for Oregon’s diverse HCP. Future training will include appropriate triage of potentially infectious patients, respiratory fit testing, and general IPC “train the trainer” sessions. Additionally, we will offer both in-person and remote options.

Disclosures: None
How COVID-19 spread varied by resident length of stay and resident–staff transmission pathways over time in US nursing homes
Authors: Healy Jessica , Paul Prabasaj , Singh Brajendra , Stone Nimalie , Slifka Kara Jacobs , Slayton Rachel
Published: September 2023

Background: Pathogen transmission among staff and residents in nursing homes can vary depending on their interactions and by the amount of time a resident receives care in the facility. Understanding the relative differences in transmission rates between and among staff and residents can identify the pathways that contributed most to the spread of SARS-CoV-2 in US nursing homes. Further exploring relative differences by categorizing facilities by residents’ lengths of stay can identify priority categories for intervention. Methods: Using US National Healthcare Safety Network (NHSN) surveillance data on resident and staff cases, vaccination, and resident deaths during June 2020–June 2022, we estimated SARS-CoV-2 transmission among and between residents and staff. We used a Bayesian inversion of a susceptible–exposed–infected–removed–virus–death (SEIRVD) compartmental model to produce the estimates. The facilities were divided into those with median length of stay (LOS) among the residents of 10 weeks. Additional inputs included the incidence and vaccination levels of the county where each facility was located. For the compartmental model, all data were averaged to form a representative facility for each category. Transmission was estimated separately for 3 periods: (1) June 2020–March 2021 as before the SARS-CoV-2 delta variant, (2) April 2021—October 2021 during SARS-CoV-2 delta variant dominance, and (3) November 2021—June 2022 during the prevalence of the SARS-CoV-2 omicron variant. Results: Regardless of facility category, transmission was highest from staff to residents or resident to resident (Fig.). These estimates of transmission were highest during the pre–SARS-CoV-2 delta variant phase. Transmission in that phase was highest in the facilities with LOS >10 weeks from staff to residents at 0.88 per week (95% credible interval [CrI], 0.06–1.85), in the facilities with LOS 6–10 weeks from staff to residents at 0.68 per week (95% CrI, 0.03–1.78), and in the facilities with LOS <6 weeks between residents at 0.47 per week (95% CrI, 0.02–0.95). Conclusions: Staff-to-resident or resident-to-resident transmission were the dominant pathways of spread of SARS-CoV-2 across the periods or the facility categories. Facilities with LOS 6 weeks or longer had higher median transmission estimates across the periods and transmission routes compared to facilities with LOS less than 6 weeks, implying that when prioritization of intervention resources is needed, facilities caring for populations with longer stays could be prioritized.

Disclosures: None
Transmission of multidrug-resistant organisms by VA CLC residents: A multisite prospective study
Authors: Mody Lona , Gibson Kristen , Cassone Marco , Saint Sanjay , Krein Sarah , Mantey Julia , Janevic Mary , Nguyen Alexandria , Bej Taissa , Hicks Oteshia , Min Lillian , Galecki Andrzej , Greene M Todd , Chigurupat Laxmi , Jump Robin
Published: September 2023

Background: Veterans Health Administration (VHA) community living centers (CLCs) provide postacute and long-term care. CLC veterans visit myriad locations outside their rooms (eg, rehabilitation, dialysis). Pathogen transmission during out-of-room visits is unknown. Methods: We recruited newly admitted veterans at 3 CLCs. After obtaining informed consent, we cultured nares, groin, hands, and 7 surfaces in the patient rooms. We accompanied veterans to up to 5 out-of-room visits and cultured patients’ hands and surfaces they touched. We tested for multidrug-resistant organisms (MDROs) including methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococcus (VRE), and quinolone, carbapenem, and/or ceftazidime-resistant gram-negative bacteria (R-GNB). We defined transmission as a positive culture following an initial negative culture during the same visit. Results: We enrolled 137 veterans (median follow-up, 29 days; mean, 5.9 visits); 97% were postacute patients. We conducted 539 patient-room sampling visits (mean, 3.9 per veteran; 5,490 swabs) and accompanied 97 veterans to 266 out-of-room sampling visits (mean, 2.7 per veteran; 2,360 swabs). Of 137 patients, 47 (35%) were colonized with an MDRO at enrollment and 74 (58%) of 128 patients were colonized on any follow-up patient-room visits. Of 133 patients, 55 (41%) acquired a new MDRO, most often VRE (31 of 97, 32%). In patient rooms, toilet seats [114 (21%) of 538], curtains [101 (19%) of 530] and bedrails [98 (18%) of 539] were most frequently contaminated. Among 266 out-of-room visits, 17% had surfaces contaminated with MDROs, most commonly involving dialysis [4 (31%) of 13], radiology [2 (25%) of 8], and rehabilitation therapy [29 (18%) of 159] (Fig. 1).Transmission of MDROs during out-of-room visits was common and occurred in 18% of visits with 8% (9 MRSA and 12 VRE) acquiring a new MDRO on their hands and 12% (9 MRSA and 23 VRE) of MDRO transmission occurring from hands to a surface that the patient touched (Fig. 1). In 18 (58%) of 31 cases, the organism transmitted to a surface was on patient hands at the start of the visit. Transmission was most common during visits to dialysis (3 to patients and 2 to surfaces), radiology (1 to a patient and 2 to surfaces), and rehabilitation therapy (13 to patients and 21 to surfaces) (Fig. 2). Conclusions: New MDRO acquisition during VHA CLC stay was common, and nearly one-fifth of out-of-room visits resulted in MDRO transmission. Our analyses suggest that veterans’ hands may shed MDROs (MRSA and VRE) to surfaces. Interventions to reduce MDRO transmission during visits for rehabilitation, dialysis, and other therapies are needed.

Disclosures: None
Assessment of changes in the national surveillance data for adult and pediatric VAE during the COVID-19 pandemic in hospitals
Authors: Pattabiraman Vaishnavi , Watkins Jennifer , Abner Sheila , Lastinger Lindsey
Published: September 2023

Background: Among US acute-care hospitals (ACHs) reporting to the NHSN, significant increases in the incidence of Ventilator-Associated Events (VAEs) were observed during the COVID-19 pandemic years in comparison with 2019. We assessed changes in the national event-level VAE data, including the incidence of specific event-types: Ventilator-Associated Condition (VAC), Infection-related Ventilator-Associated Complication (IVAC) and Possible Ventilator-Associated Pneumonia (PVAP). We also examined changes in associated pathogens, and we evaluated incidence density rates (IDRs) of pediatric VAE (PedVAE) before and during the pandemic years. Methods: We analyzed data on VAE and PedVAE reported to NHSN between 2019 through the second quarter of 2022 (2022Q2) in ACHs. Annual proportions of VAC, IVAC, or PVAP were calculated; changes versus 2019 were assessed. The 10 most common PVAP pathogens reported annually were examined, and the percentages and ranks for each were calculated. Among pediatric and neonatal locations, PedVAE IDR were calculated as the number of events per 1,000 ventilator days and were compared between the pre-pandemic and pandemic years. All comparisons were conducted using a mid-P exact test, and P<0.05 was considered statistically significant. Results: Between 1,266 - 1,357 ACHs reported VAE data each year. A total of 24,836 (2019), 37,592 (2020), and 50,362 (2021) VAEs were reported. The proportion of VAC events in 2020 (64.1%) was significantly higher than in 2019 (62.9%), while the 2020 and 2021 PVAP proportions (8.7% and 9.2%, respectively) were significantly lower than in 2019 (10.0%). The majority of VAEs were reported from the same location types annually. The top 3 PVAP pathogens reported for each year remained unchanged: Staphylococcus aureus, Pseudomonas aeruginosa, Klebsiella. However, the proportion identified as Haemophilus influenzae decreased significantly each year from 2019-2021, with the rank dropping from #5 in 2019 (6.6%) to #10 in 2021 (2.3%). Between 199 – 257 ACHs conducted PedVAE surveillance. PedVAE IDR were significantly lower in 2020 (0.8), 2021 (1.1), and the first half of 2022 (0.8) when compared to 2019 (1.3). Conclusions: This study provides a national view of specific VAEs before and during the COVID-19 pandemic. Some changes in the associated pathogens, and the proportions of VAC and PVAP, were observed. This study is the first to produce national benchmarks for PedVAE IDR. Additional ACHs conducting PedVAE surveillance in NHSN would improve the representativeness of our results.

Disclosures: None