bluuebunny/crossref_metadata_2025 huggingface dataset:
Blood Culturing Practices at an Academic Medical Center
Authors: Sampathkumar Priya , Rodino Kyle , Ung Stacy (Tram)
Published: November 2020

Background: Blood cultures are part of the evaluation of hospital patients with fever. Patients with central lines in place, frequently have blood samples for culture drawn through lines. We sought to assess blood culturing practices at our institution. Methods: Retrospective review of BCs performed in hospitalized patients over a 12-month period (August 2018–July 2019) at an academic, tertiary-care center with 1,297 licensed beds and >62,000 admissions a year. A specialized phlebotomy team is involved in all peripherally drawn blood samples; however, the patient’s nurse obtains a blood sample through a central line. Results: Overall, 35,121 blood cultures were performed for an incidence rate of 106 BC per 1,000 patient days or 566 blood cultures per 1,000 admissions. Most blood samples (67%) were collected via peripheral venipuncture. We detected significant variation in culturing rates and the proportion of blood samples obtained through central lines among collecting units (Table 1). Overall, the blood culture contamination rate was 1.6%. Blood samples obtained through a central line had a higher contamination rate (2.2%) compared to samples obtained through peripheral venipuncture (1.3%; P < .0001). Blood culture rates were highest in intensive care units (ICUs) compared with other types of patient care units (Table 1). The blood culture positivity rate was significantly lower in ICUs (8.8%) compared with hematology-oncology (10%; HR, 0.88; CI, 0.80–0.96; P = .006), general medicine (10%; HR, 0.88; CI, 0.80–0.97; P = .013), and pediatrics (12%; HR, 0.74; CI, 0.59–0.92; P = .008). The ICUs had the lowest rate of BC contamination at 1.3%. Conclusions: Blood samples obtained through central lines for culture are more likely to be contaminated than peripherally drawn blood samples. Despite a relatively high rate of line-drawn blood samples for culture, ICUs had the lowest BC contamination rate, possibly reflecting high familiarity of ICU nurses with line draws. Blood samples collected through lines were most frequently performed in pediatrics and hematology-oncology, and these units had correspondingly higher rates of contamination. This information will be used to inform institutional guidelines on blood culturing and to identify ways to minimize blood culture contamination, which often results in additional testing and/or unnecessary antimicrobial use.

Funding: None

Disclosures: Consulting fee- Merck (Priya Sampathkumar)
Bloodstream Infections Caused by S. aureus: Daptomycin Nonsusceptibility and Clinical Aspects
Authors: Nouer Simone , Fernandes Débora S. , Les Rennan , Ferreira Adriana Lucia Pires , Santos Kátia Regina Netto dos
Published: November 2020

Background:Staphylococcus aureus is one of the leading pathogens isolated from bloodstream infections (BSIs), and vancomycin has been the main choice to treat MRSA (methicillin-resistant S. aureus) infections. Vancomycin-intermediate S. aureus (VISA) and heteroresistant-VISA (hVISA) have been described, limiting this antibiotic use. We evaluated aspects associated with the resistance and its clonality of the S. aureus isolated from BSIs, and we determined their association with clinical aspects of patients attended at Rio de Janeiro between 2016 and 2018. The detection of MRSA and trimethoprim-sulfamethoxazole resistant isolates was performed using the disk diffusion test, while the minimum inhibitory concentrations (MICs) were evaluated for 5 antimicrobials using the broth microdilution method. The MICs for ceftaroline and vancomycin of the MRSA isolates were determined using the E test. The presence of hVISA isolates was evaluated for isolates with vancomycin MICs of 1 and 2 μg/mL by screening on BHI agar added with vancomycin. The population profile was divided by the area under the curve (ie, PAP/AUC test). SCC mec was evaluated by PCR and the clonal profile by PFGE method. Among 123 S. aureus isolates from BSI, 31% were MRSA. MIC50 and MIC90 were daptomycin 2 and 2 μg/mL; linezolid, 1 and 1 μg/mL; oxacillin 1 and 256 μg mL; teicoplanin, 0.5 and 0.5 μg/mL and vancomycin 1 and 1 μg/ml. MIC values for ceftaroline and vancomycin were 0.75 and 2 μg/mL. The frequency of isolates not susceptible to daptomycin was 75%. The clonal lineages and SCCmec types found were USA100/ST5-II (50%), USA800/ST5-IV (22%), USA300/ST8-IV (15.8%), USA1100/ST30-IV (5.3%), BEC/ST239-III (5.3%), and 1 isolate carrying SCCmecV/ST1. We found 1 VISA isolate, and the PAP/AUC analysis detected 3 hVISA isolates that were associated with the USA100 and USA300 lineages. Overall, 85% of patients had a vascular catheter. More advanced age was associated with MRSA infection as was higher mortality. Patients with end-stage renal disease were more affected by MSSA infection. Daptomycin nonsusceptibility and VISA and hVISA phenotypes associated with prevalent clonal lineages were described. In addition, MRSA infections presented higher mortality, which emphasizes the importance of epidemiological studies.

Funding: None

Disclosures: None
Boots and Bugs: The Beginning of an Intervention for Firefighters
Authors: McGuire-Wolfe Christine
Published: November 2020

Background: Multiple studies have demonstrated that pathogens are present in both apparatus and stations within the fire service. Pasco County Fire Rescue’s (PCFR’s) 500+ firefighters routinely wear boots to trauma scenes and into patient’s residences and then into the dormitory and living areas of the fire stations. Pasco County Fire Rescue (PCFR) recently participated in a larger effort to identify the bacteria, yeast, and mold that firefighters, emergency medical technicians, and paramedics are exposed to on apparatuses and the station living environment during a typical shift. During these efforts to swab multiple touch points within apparatus (ambulances and engines) and common areas of the stations, firefighters’ boots were identified as a significant source of bacterial contamination. Methods: Swabs of 191 surfaces in 23 vehicles and 5 fire stations were collected, including 3 swabs from the bottom of firefighter boots. Results: Firefighter boots had the highest bacterial CFUs of all locations swabbed, with >900,000 and 378,000 CFUs per boot. Disinfection with a quaternary ammonium product sprayed through an electrostatic sprayer system effectively reduced the bacterial contamination on boots. Conclusions: PCFR recognizes firefighter boots as a critical vector of contamination between the environment encountered on emergency medical calls and the fire station environment and, as a result, has started a preliminary education campaign for agency firefighters regarding the need for regular boot disinfection. These efforts include regular submissions to the biweekly employee newsletter, as well as reminders on interoffice mailing envelopes (see example below) in hopes of increasing informal, self-directed boot cleaning and disinfection efforts. The next steps include verifying the effectiveness of specific disinfectant cleaners on boots; addressing logistical and practical barriers to routine cleaning and disinfection of boots; and developing, implementing, and evaluating a protocol for regular boot cleaning and disinfection.

Funding: None

Disclosures: None
Burden and Trends of Hospital-Associated Community-Onset (HACO) Infections From Antibiotic Resistant and Nonresistant Bacteria
Authors: Olubajo Babatunde , Reddy Sujan , Wolford Hannah , Hatfield Kelly , Jernigan John , Baggs James
Published: November 2020

Background: Studies on the effectiveness of hospital-based interventions often measure hospital-onset infections as the outcome of interest. However, hospital-associated infections may manifest after patient discharge (classified as hospital-associated community-onset, HACO), and the epidemiology may vary by antibiotic resistance (AR) profile. We examined the epidemiology and trends of HACO infections of AR and non–antibiotic-resistant (non-AR) bacteria. Methods: We included clinical community-onset (CO) cultures (obtained sooner than or on day 3 of hospitalization) yielding the bacterial species of interest among hospitalized patients in 260 hospitals in the Premier Healthcare Database from 2012 to 2017. HACO infections were defined as CO cultures in a patient who had a previous hospitalization in the same hospital within 30 days. We examined methicillin resistance among Staphylococcus aureus (MRSA), vancomycin resistance among Enterococcus spp (VRE), carbapenem resistance among Enterobacteriaceae (E. coli, Klebsiella spp, and Enterobacter spp) (CRE), extended-spectrum cephalosporin resistance suggestive of extended-spectrum β-lactamase (ESBL) production in Enterobacteriaceae, carbapenem resistance among Acinetobacter spp (CRAsp), and carbapenem resistance among Pseudomonas aeruginosa (CRPA). We described the proportion of CO infections that were HACO, the proportion of HACO infections from sterile sites, overall HACO rates, and annual trends for sensitive and resistant phenotypes. Generalized estimating equation regression models that accounted for hospital-level clustering were used to estimate annual trends controlling for hospital characteristics and month of discharge. Results: The rate of HACO infections by pathogen ranged from 0.78 to 38.76 per 10,000 hospitalizations; 7%–34% were sterile site infections (Table 1). For each bacterial pathogen, a significantly higher proportion of AR CO infections had a previous hospitalization compared to non-AR CO infections (all χ2, P < .05). The annual trends for AR and non-AR HACO infections between 2012 and 2017 were significantly decreasing for most pathogens, except ESBL HACO infections. Conclusions: Even when using a definition limited to readmission to the same hospital, HACO infections occur commonly with differing rates by pathogen and antibiotic resistance profile. Although these rates are decreasing for most of the pathogens studied, improving surveillance and identifying prevention strategies for these infections are necessary to further reduce the burden of hospital-associated infections.

Funding: None

Disclosures: None
Candida auris and Carbapenemase-Producing Organism Prevalence in an Extended Stay Pediatric Hospital, Chicago, Illinois, 2019
Authors: Walblay Kelly , McPherson Tristan , Roop Elissa , Soglin David , Valley Ann , Logan Latania , Vallabhaneni Snigdha , Black Stephanie , Pacilli Massimo
Published: November 2020

Background:Candida auris and carbapenemase-producing organisms (CPO) are multidrug-resistant organisms that can colonize people for prolonged periods and can cause invasive infections and spread in healthcare settings, particularly in high-acuity long-term care facilities. Point-prevalence surveys (PPSs) conducted in long-term acute-care hospitals in the Chicago region identified median prevalence of colonization to be 31% for C. auris and 24% for CPO. Prevalence of C. auris colonization has not been described in pediatric populations in the United States, and limited data exist on CPO colonization in children outside intensive care units. The Chicago Department of Public Health (CDPH) conducted a PPS to assess C. auris and CPO colonization in a pediatric hospital serving high-acuity patients with extended lengths of stay (LOS). Methods: CDPH conducted a PPS in August 2019 in a pediatric hospital with extended LOS to screen for C. auris and CPO colonization. Medical devices (ie, gastrostomy tubes, tracheostomies, mechanical ventilators, and central venous catheters [CVC]) and LOS were documented. Screening specimens consisted of composite bilateral axillae and groin swabs for C. auris and rectal swabs for CPO testing. The Wisconsin State Laboratory of Hygiene tested all specimens. Real-time polymerase chain reaction (PCR) assays were used to detect C. auris DNA and carbapenemase genes: blaKPC, blaNDM, blaVIM, blaOXA-48, and blaIMP (Xpert Carba-R Assay, Cepheid, Sunnyvale, CA). All axillae and groin swabs were processed by PCR and culture to identify C. auris. For CPO, culture was only performed on PCR-positive specimens. Results: Of the 29 patients hospitalized, 26 (90%) had gastrostomy tubes, 24 (83%) had tracheostomies, 20 (69%) required mechanical ventilation, and 3 (10%) had CVCs. Also, 25 (86%) were screened for C. auris and CPO; 4 (14%) lacked parental consent and were not swabbed. Two rectal specimens were unsatisfactory, producing invalid CPO test results. Median LOS was 35 days (range, 1–300 days). No patients were positive for C. auris. From CPO screening, blaOXA-48 was detected in 1 patient sample, yielding a CPO prevalence of 3.4% (1 of 29). No organism was recovered from the blaOXA-48 positive specimen. Conclusions: This is the first documented screening of C. auris colonization in a pediatric hospital with extended LOS. Despite a high prevalence of C. auris and CPOs in adult healthcare settings of similar acuity in the region, C. auris was not identified and CPOs were rare at this pediatric facility. Additional evaluations in pediatric hospitals should be conducted to further understand C. auris and CPO prevalence in this population.

Funding: None

Disclosures: None
Candidemia: Predisposing Factors, Antifungal Susceptibility, Clinical Outcome and Connotations for Management
Authors: Ahmed Abeera , Daud Nargis , Zaman Lahore Gohar , Ikram Aamer , Khadim Muhammed Tahir
Published: November 2020

Objective: We conducted this study to investigate the epidemiology of candidemia in our setting and to quantify the risk factors associated with disease, overall outcome, and mortality associated with candidemia. Methods: In this prospective observational study, we conducted lab-based surveillance with clinical correlation of all cases of candidemia within our ICUs during the period (2016–2018). Clinical assessment was done on day 5 and day 30, and comorbidities, clinical features, and outcome were observed within 30 days after the diagnosis. The diagnosis was made on the basis of positive blood culture for Candida spp and a compatible clinical picture. The demographic characteristics, sequential organ failure assessment (SOFA) scores, comorbidities, use of invasive devices, antibiotics administered were observed, and antifungal susceptibility testing was performed according to CLSI guidelines. Type and duration of antifungal administered and outcomes were noted. Results: In total, 48 episodes of candidemia, with 29 (60%) males and 19 (40%) females, were identified during the study period. C. albicans was the most common specie responsible for candidemia, causing 17 of the cases (~35%), whereas rest of the cases were caused by non–albicans spp, which included C. auris, accounting for 9 (19%) C. parapsilosis and C. tropicalis 7 (15%) each, C. glabrata and C. famata 2 (6%), and C. krusei was isolated in only 2 cases (4%). Among modifiable risk factors, CVC insertion and antibiotic exposure were the leading factors, seen in 100% of patient. Candida colonization was observed in 26 patients (28%), of whom 2 (4%) had multifocal Candida colonization. Among evaluable patients, 17 (35%) died within 30 days of the onset of candidemia. C. tropicalis was associated with the highest mortality rate, 27% (n = 4) in this cohort. Regarding the crude mortality in the different units, patients in medical ICU had the highest mortality rate (54%). In vitro activity of 3 systemically active antifungal agents was tested against 48 isolates of Candida spp. Based on CLSI break points, the susceptibility to voriconazole was 98%; only 1 isolate was resistant to voriconazole. Among candidemia-positive cases, 28 patients (58%) had taken the antifungals for >14 days, whereas 18 (37.5%) were treated for <14 days and 2 (4%) died before the initiation of therapy. Conclusions: In our study, C. albicans was the most common specie responsible for candidemia, but non–albicans spp are also emerging, with higher in vitro resistance to antifungals.

Funding: None

Disclosures: None
Carbapenemase Production and Mortality Risk Among Carbapenem-Resistant Enterobacteriaceae Cases in Tennessee, United States
Authors: Octaria Rany , Chan Allison , Kainer Marion
Published: November 2020

Background: Carbapenem-resistant Enterobacteriaceae (CRE) are an urgent public health threat associated with poor patient outcomes. CRE that produce carbapenemase (CP-CRE) are of particular concern because the mechanism-conferring genes in plasmids can be transferred to other bacteria. CRE are reportable in Tennessee (TN); isolate submission is required for CP production and resistance mechanism testing. We aimed to compare patient characteristics and outcomes between CP-CRE and non–CP-CRE patients to guide potential public health interventions. Methods: A retrospective cohort study to compare 30-day mortality, and clinical characteristics of CP-CRE to non–CP-CRE patients was conducted. Laboratory data were gathered from CRE isolates of Tennessee residents from July 1, 2015, to June 30, 2018. The most recent Council of State and Territorial Epidemiologists CRE and CP-CRE case definition was used to confirm and classify cases. Healthcare exposures within 1 year prior to onset, demographic characteristics, and clinical characteristics were obtained by linking surveillance data with the inpatient and outpatient Tennessee hospital discharge data. Cases were also matched with Tennessee vital statistics data to determine all-cause 30-day mortality from the event date. We evaluated risk ratios of 30-day mortality with a multivariable regression model. Results: Among 1,034 CRE cases that had at least 1 isolate submitted to public health, 445 (43.0%) were CP-CRE and 589 (57.0%) were non–CP-CRE. Among CP-CRE isolates, the blaKPC gene was found in 434 (98.9%). CP-CRE cases were more likely to have isolates from normally sterile sites, to have an organism with elevated resistance to meropenem (minimum inhibitory concentration, >16 µg/mL), to have prior admission to a long-term acute-care hospital, and to live in a nursing home (all P < .001). Also, 77 CP-CRE cases (17.3%) and 56 non–CP-CRE cases (9.6%) died within 30 days of infection onset. The risk of 30-day mortality was 57% higher for CP-CRE (adjusted risk ratio, 1.57; 95% CI:, 1.10–2.23) compared to non–CP-CRE patients after adjusting for comorbidities, nursing home residence, and prior healthcare exposures. Conclusions: CP-CRE cases had poorer outcomes than non–CP-CRE cases. This may be related in part to a higher proportion of sterile site infections among CP-CRE cases; our study was underpowered to analyze this subpopulation of sterile site cases. We plan to continue monitoring and performing analyses as mortality and hospital discharge data from more recent years become available and as more cases accumulate.

Funding: None

Disclosures: None
Care Bundles for Preventing Device Related Infections: Just Focus on These 6 Things
Authors: Zirges Christine , Rusbarsky Stephen
Published: November 2020

Background: Centralizing healthcare associated infection (HAI) data for 21 hospitals across several states facilitates a big picture assessment of monthly enterprise performance along with evaluation of practice, policy, and products. Variation in prevention practices has made it difficult to identify areas of focus and created confusion when attempting to standardize prevention tactics for central-line and urinary catheter care. Lack of consistent practice audits have made it difficult to evaluate actual practice. For these reasons, we performed a gap analysis to understand the current state. Methods: Gap assessment tools were developed to assess infection prevention practices for central lines and indwelling urinary catheters. Survey questions were developed with a comment option to collect qualitative data. The 2014 Compendium of Strategies to Prevent Healthcare-Associated Infection in Acute-care Hospitals was utilized as the reference point. This document facilitates the translation of essential information into clinical practice, thus providing the rationale and level of evidence needed for discussion groups. Completion occurred with various key stakeholders within each hospital. One survey per hospital was compiled. Results: All hospitals completed the survey with key themes emerging and supported by observational data. Findings included variation with education, chlorhexidine bathing, types of dressings, and compliance with alcohol port protectors. Gaps identified with urinary catheter care included confusion surrounding catheter care, breaches in seals, and optimizing alternatives to catheterization. Rather than segment solutions for identified gaps, care bundles were developed to provide focus, to facilitate evidence-based practice, and to create standard work-around clinical audits that consisted of going to the patient rather than the electronic health record. Care bundles provided the 6 items to focus on and for which to create policy and standardize products. Conclusions: Care-bundle implementation initially created resistance from clinicians and many questions regarding actual practice. The design of the tool was deliberate in that audit language, the metric, and the “why” were included and served as a medium to discuss the evidence and immediate feedback for practice. Pareto charts were posted on unit performance boards. It became evident that compliance with prevention tactics was not consistent. Although number of infections or outcome data did not appreciably decrease, standardized utilization ratio was reduced by 11% for each device after 3 quarters. Process measures from bundle audits continue to improve, as do observational data, and these are part of focused discussions at quality forums. A culture change has occurred as process measures and evidence-based practice has become a priority.

Funding: None

Disclosures: None
Catheter-Associated Urinary Tract Infection Reduction in the Solutions for Patient Safety Pediatric Safety Engagement Network
Authors: Foster Charles , Ackerman Kathy , Hupertz Vera , Mustin Laurie , Sanders Joann , Patricia Sisson , Wenthe Rachel
Published: November 2020

Background: Catheter-associated urinary tract infections (CAUTIs) are a leading cause of healthcare-associated infection. Catheter insertion and maintenance bundles have been developed to prevent CAUTIs, but they have not been extensively validated for use in pediatric populations. We report the CAUTI prevention efforts of a large network of children’s hospitals. Methods: Children’s hospitals joined the Solution for Patient Safety (SPS) safety engagement network from 2011 through 2017 and elected to participate in CAUTI prevention efforts, with 26 hospitals submitting data initially and 128 participating by the end. CAUTI prevention recommendations were first released in May 2012, and insertion and maintenance bundles were released in May 2014 (Table 1). Hospitals reported on CAUTIs, patient days, urinary catheter line days (CLD), and they tracked reliability to each bundle. For the network, control charts were used to plot CAUTI rates, urinary catheter utilization, and reliability to each bundle component. Results: Following the introduction of the pediatric CAUTI insertion and maintenance bundles, CAUTI rates across the network decreased 61.6%, from 2.55 to 0.98 infections per 1,000 CLD (Fig. 1). Centerline shifts occurred both before and after the 2015 CDC CAUTI definition change, which may also have contributed to a centerline shift. Urinary catheter utilization rates did not decline during the intervention period. Network reliability to the insertion and maintenance bundles increased to 95.4% and 86.9%, respectively. Conclusions: Insertion and maintenance bundles aimed at preventing CAUTIs were introduced across a large network of children’s hospitals. Across the network, the rate of urinary tract infections among hospitalized children with indwelling urinary catheters decreased 61.6%.

Funding: None

Disclosures: None
CDC Consultations for Outbreaks and Infection Control Breaches Occurring in Dental Settings, 2010–2019
Authors: Perkins Kiran , Brown Ieisha , Espinoza Lorena , Perz Joseph , Neuburger Michele
Published: November 2020

Background: Documented transmission of infectious agents involving dental care is uncommon. However, increasing attention to dental infection control, along with several recent outbreaks, have identified infection control gaps in dental settings. We describe CDC consultations involving outbreaks or infection control lapses occurring in dental settings to identify areas for prevention efforts. Methods: We reviewed internal CDC records from January 1, 2010, through October 1, 2019, to identify consultations involving investigations of potential or confirmed disease transmission and infection control lapses in dental settings. We determined yearly number of consultations, number of patients infected, how disease transmission or infection control breaches were identified, suspected mode of transmission, type of infection control breaches identified, and whether at-risk patients were notified. Results: We identified 41 consultations, among 27 states, involving investigation of possible disease transmission or infection control lapses in dental facilities. The number of consultations increased from 11 to 30 between the first half (2010–2014) and the second half (2015–2019) of the period and involved at least 113 infections confirmed or suspected to be associated with dental procedures. Most investigations (n = 29, 71%) began with identification of infection control breaches absent known patient infections; 8 (20%) investigations were initiated after identification of a single patient infection raised concerns for possible transmission associated with dental care (eg, single case of acute hepatitis B infection absent other risk factors). Moreover, 4 investigations involved >1 patient infection; 3 were outbreaks confirmed to be due to poor infection control practices. The most common infection control breaches were lapses in dental instrument reprocessing (n = 28, 78%), for example, failure to sterilize dental handpieces or failure to use biologic indicators. Of the 23 consultations where patient notification activities were discussed, 17 (74%) resulted in notification; >20,000 patients received information about their potential exposure, usually accompanied by advice on seeking screening tests. Conclusions: Dental-related consultations have increased in recent years, and they highlight the need for improved infection control training of dental healthcare personnel, especially related to dental instrument reprocessing. The CDC Division of Oral Health and the Organization for Safety, Asepsis, and Prevention offers tools, training, and other resources to help dental facilities improve infection control practices. Not all investigations resulted in notifying at-risk patients, but notification should be strongly considered, especially when serious breaches are identified, to promote transparency and help identify disease transmission that could otherwise go undetected.

Funding: None

Disclosures: None
Changes in the Characteristics of Hospitals Participating in the National Healthcare Safety Network (NHSN), 2008–2018
Authors: Amor Agasha , Dudeck Margaret A.
Published: November 2020

Background: The NHSN is the nation’s most widely used healthcare-associated infection surveillance system. Nearly all acute-care hospitals reporting to the NHSN do so in fulfillment of state mandates and/or as required for participation in the CMS Quality Reporting program, since 2011. All NHSN-participating acute-care hospitals (ACHs) reporting in the Patient Safety Component are required to complete an annual survey and to self-report on the hospital’s general characteristics, including hospital size and type, and patient volume. Due to the compulsory nature of the survey, the NHSN receives nearly a 100% completion rate each year. Furthermore, hospital-level characteristics are often used by the CDC to develop risk-adjusted summary measures and national benchmarks. This study is the first to evaluate ACH characteristics over an 11-year period. Methods: All ACHs that completed an annual survey during 2008–2018 were included. The data were divided into subsets to evaluate consistent reporters, defined as facilities that were enrolled in 2008 and completed surveys through 2018. Medical teaching status is defined as a facility that trains either medical students, nursing students, residents and fellows. Medical teaching status is grouped into 3 categories: (1) undergraduate facility that trains medical school students, (2) graduate facility that trains residents or fellows, and (3) major facility that trains both medical and residents or fellows. We used univariate analyses to assess characteristics of acute-care hospitals (ACHs). Results: Overall, the number of ACHs enrolled in the NHSN increased by 119%, from 1,772 in 2008 to 3,883 in 2018. More general acute-care hospitals (89%) were enrolled than all other facility types, with women’s and children’s hospitals were the least frequently enrolled (0.34%). Hospitals with any level of medical teaching status, increased from 38.5% in 2008 to 60% in 2018 (Fig. 1). We observed a modest reduction in the median hospital bed size of 20 beds. When reviewing hospital bed size by category, ACHs with 51–200 beds made up the largest proportion of hospitals and the number of hospitals within this bed size category has remained above 1,500 since 2010. Conclusions: Among all ACHs, the proportion of hospitals affiliated with a medical school increased over the 10-year period. Although hospitals with a major teaching status had been steadily increasing, there were more hospitals using this designation after 2013. Despite the increase in the number of hospitals reporting to NHSN, since 2011, the proportion of hospitals within each bed size category has seen minimal change.

Funding: None

Disclosures: None
Characteristics of Long-Term Care Hospital Ventilator-Associated Events, National Healthcare Safety Network, 2016–2018
Authors: Grigg Cheri , Nkwata Allan , Gross Cindy , Millson Tara , Powell Krista , Magill Shelley
Published: November 2020

Background: Ventilator-associated event (VAE) reporting to the CDC NHSN began in 2013. VAE reporting from long-term care hospitals (LTCHs) to the NHSN was required from January 2016 through September 2018 as part of the CMS LTCH Quality Reporting Program (QRP). We describe the incidence and characteristics of LTCH VAEs during the required reporting period. Methods: We analyzed VAE data reported to the NHSN from January 2016 through December 2018, from the LTCH ward and critical care locations participating in surveillance according to the NHSN protocol. We have described characteristics of VAE, and we determined the distribution of VAE types: ventilator-associated conditions (VAC), infection-related ventilator-associated complications (IVAC), and possible ventilator-associated pneumonia (PVAP). Furthermore, we calculated pooled mean VAE rates per 1,000 ventilator days, and we determined the rate distributions for locations with ≥20 units reporting >50 ventilator days per year. Results: Overall, 493 LTCHs reported 22,359 location months of VAE data from ward and critical care locations. In total, 5,290 VAEs were reported, of which 3,871 (73%) were VAC, 961 (18%) were IVAC, and 458 (9%) were PVAP. Also, 42% (2,241) of VAEs occurred in female patients, and 1,305 (25%) occurred in patients who died during their hospitalization. The median time from LTCH admission to VAE onset was 18 days (IQR, 9–37), and from initiation of mechanical ventilation to VAE onset was 22 days (IQR, 10–43). Pathogens were identified from 454 PVAPs, with Pseudomonas aeruginosa (43% of PVAPs) and Staphylococcus aureus (26%) being the most common organisms. Annual pooled mean incidence rates in critical care locations ranged from 2.11 to 2.62 VAEs per 1,000 ventilator days, whereas rates in ward locations ranged from 1.36 to 1.67 VAEs per 1,000 ventilator days (Table 1). Conclusions: During a period of required reporting, pooled mean LTCH VAE rates remained low. Most VAEs in LTCHs were reported as VACs. Additional work is needed to understand the clinical events associated with LTCH VAE, including whether most VAEs truly represent non–infection-related events or reflect limited evaluation to identify infection-related complications. This distinction might influence the identification of appropriate interventions to reduce LTCH VAE rates.

Funding: None

Disclosures: None
Characteristics of Pediatric Ventilator-Associated Events Reported to the National Healthcare Safety Network, 2019
Authors: Grigg Cheri , Nkwata Allan , Gross Cindy , Magill Shelley
Published: November 2020

Background: Mechanical ventilation is a life-saving measure for patients with respiratory failure; however, these patients are at high risk for complications and poor outcomes. Surveillance for ventilator-associated events (VAEs) via the CDC NHSN began in 2013 in adult patient care locations in hospitals. Pediatric ventilator-associated event (PedVAE) surveillance began in January 2019. The PedVAE definition is based on increases in mean airway pressure (MAP) or fraction of inspired oxygen (FiO2). We summarized the first 9 months of PedVAE data reported to the NHSN. Methods: Neonatal and pediatric locations of US acute-care hospitals, long-term acute-care hospitals, and inpatient rehabilitation facilities were eligible to participate in PedVAE surveillance as of January 1, 2019. When submitting PedVAEs to the NHSN, facilities may also optionally report information about antimicrobials, pathogens, and clinical events associated with PedVAEs. We analyzed PedVAE data from January through September 2019 submitted by facilities participating in surveillance according to the NHSN protocol. We calculated pooled mean incidence rates (no. events per 1,000 ventilator days) for neonatal and pediatric intensive care units (NICUs and PICUs), and we describe characteristics of PedVAEs. Results: Overall, 205 PedVAEs were reported: 111 events from 147 NICUs in 140 facilities and 94 events from 117 PICUs in 85 facilities. The pooled mean incidence was 1.61 events per 1,000 ventilator days in level 2 and 3 NICUs, 1.09 events per 1,000 ventilator days in level III NICUs, and 1.25 events per 1,000 ventilator days in PICUs. Of 205 PedVAEs, 133 (65%) met only the MAP criterion, 65 (32%) met only the FiO2 criterion, and 7 (3%) met both. Optional data on antimicrobials, pathogens, and clinical events were reported for 74 of 205 PedVAEs (36%). Among these 74 events, antimicrobial administration was common (50 of 74, 68%). By contrast, a minority had a pathogen reported (21 of 74, 28%). Of 74 PedVAEs, 60 were associated with a clinical event (80%), although only 15 (20%) were reported to be associated with a clinical infection. Of 74 PedVAEs, 4 (5%) were associated with mechanical ventilation weaning. Conclusions: PedVAE incidence rates are low in NICUs and PICUs. Most PedVAEs appear to be associated with clinical events. Although a minority of PedVAEs were associated with infections or pathogens, antimicrobial administration was reported for >60%. Further evaluation of the clinical correlates of PedVAEs can inform development of effective prevention and antimicrobial stewardship in mechanically ventilated children.

Funding: None

Disclosures: Cheri Grigg, Centers for Disease Control and Prevention
Chlorhexidine Gluconate Application as A Strategy to Reduce Cardiac Implantable Electronic Device Surgical Site Infection
Authors: Ponnaluri-Wears Sreelatha , Nomides Nicole , Brown Ricci , Stoneman Emily
Published: November 2020

Background: The electrophysiology laboratory within the cardiac procedures unit (CPU) at Michigan Medicine specializes in implanting, exchanging, and extracting cardiac implantable electronic devices (CIED). During routine surveillance of surgical site infections (SSI), an increase in CIED infections (specifically endocarditis) was noted starting in 2016. The predominant organisms involved with infection were skin organisms such as Staphylococcus aureus and coagulase-negative Staphylococcus. Methods: Cases of SSI following CIED implantation were identified using positive microbiology results collected within 90 days of a procedure. Cases were classified using the NHSN SSI definitions. Upon identifying an increase in infections, a work group of key stakeholders was formed to determine root causes. Factors discussed included standardized surgical skin preparation techniques, patient education regarding bathing before and after procedures, types of surgical drapes in use, traffic in and out of procedure rooms during cases, environmental cleanliness of the procedure area, and adherence to the institutional surgical attire policy. In addition to the workgroup, several cases were observed by the IP team. Results: The investigation revealed several areas for improvement. As a first step, a practice of using 2% chlorhexidine gluconate (CHG)–impregnated bathing clothes on patients prior to surgery was implemented for the chest, neck, axilla, and arm. No other changes were implemented during this time period. In the year following implementation, there were zero cases of endocarditis and only 2 superficial SSIs (Figs. 1 and 2). Conclusions: Employing application of CHG to reduce the microbial burden on the skin significantly aided in preventing infections related to CIEDs.

Funding: None

Disclosures: None
Clostridioides difficile Testing Stewardship for Laxative Use Is Effective and Safe When Combined With Expert Clinical Input
Authors: Torriani Francesca , El-Kareh Frank Myers Robert , Kang Minji , Taplitz Randy , Abeles Shira
Published: November 2020

Background: In January 2019, our large academic medical center implemented hard stops for ordering Clostridiodes difficile nucleic acid amplification testing (NAAT), and required a discussion with an infectious diseases physician if the order was placed in a clinical scenario not consistent with the 2017 IDSA/SHEA C. difficile infection (CDI) testing guidelines. Recently, some groups have expressed concerns that requiring the discontinuation of laxatives may delay the diagnosis of CDI and result in serious adverse outcomes. Methods:C. difficile testing stewardship interventions were performed at 2 hospitals within the same university health system to reduce inappropriate testing. In January 2019, a best practice advisory (BPA) was implemented to alert providers ordering C. difficile NAAT if patients had received laxatives within 24 hours, requiring a discussion with the ID physician to override the hard stop. We reviewed clinical outcomes of patients who had a BPA alert due to laxative use within the past 24 hours April 23 to October 23, 2019. Results: During the study period, there were 235 patients with a BPA because of laxative use within the past 24 hours. Moreover, 55 (23.4%) continued to experience diarrhea after the discontinuation of laxatives and were retested for CDI within 7 days. Only 8 tests returned positive, suggesting that, at most, 3.4% of cases had delayed diagnoses because of the hard stop. This finding is supported by the increase in the percentage of tests positive from 11.6% observed overall to 14.6% (8 of 55) after this intervention. There were no severe CDI cases (ICU admission, colectomy, or death) among patients who had delayed testing due to laxative use. Conclusions: In the setting of laxative use, C. difficile testing stewardship interventions with C. difficile NAAT using a hard-stop BPA are effective in reducing unnecessary testing and safe if they are used in combination with a real-time expert input of the risk of clinical disease.

Funding: None

Disclosures: None
Cluster of Infections Associated With Contaminated Stem-Cell Products
Authors: OYong Kelsey
Published: November 2020

Background: The unapproved and unregulated use of umbilical stem-cell products has been identified as a possible source of adverse events and infection. In 2018, a national outbreak of multiple bacterial infections was associated with use of umbilical stem cells products. From December 2018 through March 2019, the Los Angeles County Department of Public Health (LACDPH) identified 4 cases of bacterial infection in patients that had received therapies using umbilical stem-cell products. Although 2 cases were associated with the national outbreak of a single company’s product, 2 additional cases of Enterobacter cloacae were instead associated with a second stem-cell distributer. Methods: In December 2018, LACDPH staff received notification from a hospital infectious disease physician of 2 cases of E. cloacae infection in patients of a freestanding ambulatory surgery center following allogenic umbilical cord stem-cell injections on the same day in August 2018. LACDPH reviewed the medical records of these patients and conducted an on-site visit to the ambulatory surgery center, which included observation of infection prevention practices, interview of staff, and review of logs. The 2 isolates from each patient were sent to the CDC laboratory for relatedness testing. Results: The 2 case patients received products via intra-articular injection from different lot and donor numbers for lumbar spine pain. In addition to the stem-cell product, both patients also received antibiotics and pain medications during their procedures, though from different vials. Both patients were seen by the same surgeon, anesthesiologist, and nurse during their procedures. No additional cases occurred. The case patients were hospitalized for 12 and 27 days, respectively. Whole-genome sequencing indicated that the isolates from the 2 patients were related. No major gaps in infection prevention practices were identified at the surgery center. Conclusion: This report describes a cluster of 2 E. cloacae infections in patients who had received unapproved-use stem-cell products via spinal injection. Given molecular laboratory results and infection prevention observations, we hypothesize that the stem-cell products used on these 2 cases were likely contaminated before distribution. This cluster demonstrates that contamination of stem-cell products extends beyond the single outbreak previously described and points to the systematic inability to ensure the safety of unapproved use of umbilical stem- cell products.

Funding: None

Disclosures: None
Colonization and Infection With MRSA and CRKP and Its Result in an Increased Mortality Rate Within the Intensive Care and High-Dependency Units in Barbados
Authors: Gustave Keisha
Published: November 2020

Background: Methicillin-resistant Staphylococcus aureus(MRSA) and carbapenem-resistant Klebsiella pneumoniae (CRKP) are a growing public health concern in Barbados. Intensive care and critically ill patients are at a higher risk for MRSA and CRKP colonization and infection. MRSA and CRKP colonization and infection are associated with a high mortality and morbidly rate in the intensive care units (ICUs) and high-dependency units (HDUs). There is no concrete evidence in the literature regarding MRSA and CRKP colonization and infection in Barbados or the Caribbean. Objectives: We investigated the prevalence of MRSA and CRKP colonization and infection in the patients of the ICU and HDU units at the Queen Elizabeth Hospital from 2013 to 2017. Methods: We conducted a retrospective cohort analysis of patients admitted to the MICU, SICU, and HDU from January 2013 through December 2017. Data were collected as part of the surveillance program instituted by the IPC department. Admissions and weekly swabs for rectal, nasal, groin, and axilla were performed to screen for colonization with MRSA and CRKP. Follow-up was performed for positive cultures from sterile isolates, indicating infection. Positive MRSA and CRKP colonization or infection were identified, and patient notes were collected. Our exclusion criteria included patients with a of stay of <48 hours and patients with MRSA or CRKP before admission. Results: Of 3,641 of persons admitted 2,801 cases fit the study criteria. Overall, 161 (5.3%) were colonized or infected with MRSA alone, 215 (7.67%) were colonized or infected with CRKP alone, and 15 (0.53%) were colonized or infected with both MRSA and CRKP. In addition, 10 (66.6%) of patients colonized or infected with MRSA and CRKP died. Average length of stay of patients who died was 50 days. Conclusions: The results of this study demonstrate that MRSA and CRKP cocolonization and coinfection is associated with high mortality in patients within the ICU and HDU units. Patients admitted to the ICU and HDU with an average length of stay of 50 days are at a higher risk for cocolonization and coinfection with MRSA and CRKP. Stronger IPC measures must be implemented to reduce the spread and occurrence of MRSA and CRKP.

Funding: None

Disclosures: None
Comparison of Respiratory Microbiome Disruption Indices to Predict VAP and VAE risk at LTACH Admission
Authors: Clarke Erik , Chiotos Kathleen None , Harrigan James , Lautenbach Ebbing , Reesey Emily , Wernovsky Magda , Tolomeo Pam , Morawski Zygmunt , Jacob Jerry , Grippi Michael , Kelly Brendan
Published: November 2020

Background: Healthcare exposure results in significant microbiome disruption, particularly in the setting of critical illness, which may contribute to risk for healthcare-associated infections (HAIs). Patients admitted to long-term acute-care hospitals (LTACHs) have extensive prior healthcare exposure and critical illness; significant microbiome disruption has been previously documented among LTACH patients. We compared the predictive value of 3 respiratory tract microbiome disruption indices—bacterial community diversity, dominance, and absolute abundance—as they relate to risk for ventilator-associated pneumonia (VAP) and adverse ventilator-associated events (VAE), which commonly complicate LTACH care. Methods: We enrolled 83 subjects on admission to an academic LTACH for ventilator weaning and performed longitudinal sampling of endotracheal aspirates, followed by 16S rRNA gene sequencing (Illumina HiSeq), bacterial community profiling (QIIME2) for diversity, and 16S rRNA quantitative PCR (qPCR) for total bacterial abundance. Statistical analyses were performed with R and Stan software. Mixed-effects models were fit to relate the admission MDIs to subsequent clinically diagnosed VAP and VAE. Results: Of the 83 patients, 19 had been diagnosed with pneumonia during the 14 days prior to LTACH admission (ie, “recent past VAP”); 23 additional patients were receiving antibiotics consistent with empiric VAP therapy within 48 hours of admission (ie, “empiric VAP therapy”); and 41 patients had no evidence of VAP at admission (ie, “no suspected VAP”). We detected no statistically significant differences in admission Shannon diversity, maximum amplicon sequence variant (ASV)–level proportional abundance, or 16S qPCR across the variables of interest. In isolation, all 3 admission microbiome disruption indices showed poor predictive performance, though Shannon diversity performed better than maximum ASV abundance. Predictive models that combined (1) bacterial diversity or abundance with (2) recent prior VAP diagnosis and (3) concurrent antibiotic exposure best predicted 14-day VAP (type S error < 0.05) and 30-day VAP (type S error < 0.003). In this cohort, VAE risk was paradoxically associated with higher admission Shannon diversity and lower admission maximum ASV abundance. Conclusions: In isolation, respiratory tract microbiome disruption indices obtained at LTACH admission showed poor predictive performance for subsequent VAP and VAE. But diversity and abundance models incorporating recent VAP history and admission antibiotic exposure performed well predicting 14-day and 30-day VAP.

Disclosures: None

Funding: None