bluuebunny/crossref_metadata_2025 huggingface dataset:
Efficacy of UV-C Disinfection in Hyperbaric Chambers
Authors: Warren Bobby , Masker Jason , Brown Gregory , Gamez Isabella , Smith Becky , Anderson Deverick John , Turner Nicholas
Published: November 2020

Background: UV-C light reduces contamination of high-touch clinical surfaces. Few studies have tested the relative efficacy of UV-C devices in real-world clinical environments. Methods: We assessed the efficacy of the Tru-D (SmartUVC) and Moonbeam-3 UV-C (Diversey) devices at eradicating important clinical pathogens in 2 hyperbaric chambers at a tertiary-care hospital. Formica sheets were inoculated with 106–107 CFU of MRSA (USA300) or 104–105 CFU of C. difficile (NAP1). Sheets were placed in 6 predetermined locations throughout the chambers. Two Moonbeam-3 UV-C devices were positioned in the center of each chamber and were run for 3-minute (per manufacturer’s instructions) and 5-minute cycles. One Tru-D was positioned in the center of the chamber and was run on the vegetative cycle for MRSA and the spore cycle for C. difficile. UV-C dosage was measured for both machines. Quantitative cultures were collected using Rodac plates with DE neutralizing agar and were incubated at 37C for 48 hours. C. difficile was likewise plated onto sheep’s blood agar. Results: We ran each combination of chamber, microbe, and UV-C device in triplicate for In total, 108 samples per species.

For MRSA, the Tru-D vegetative cycle, the 5-minute Moonbeam cycle, and the 3-minute Moonbeam cycle resulted in average CFU log10 reductions of 7.02 (95% CI, 7.02–7.02), 6.99 (95% CI, 6.95–7.02), and 6.58 (95% CI, 6.37–6.79), respectively (Fig. 1). The Tru-D vegetative and 5-minute Moonbeam cycles were similarly effective (P > .99), and both were more effective than the 3-minute Moonbeam cycle (P < .001 and P < .001, respectively). MRSA samples receiving direct UV-C exposure had significantly greater log10 reductions (6.95; 95% CI, 6.89–7.01) than did indirect exposure (6.67; 95% CI, 6.46–6.87; P < .05) (Fig. 2). For C. difficile, the Tru-D sporicidal, the 5-, and 3-minute Moonbeam cycles resulted in average CFU log10 reductions of 1.78 (95% CI, 1.43–2.12), 0.57 (95% CI, 0.33–0.81) and 0.64 (95% CI, 0.42–0.86), respectively (Fig. 1). Tru-D was significantly more effective than either the 3- or 5-minute Moonbeam cycles (P < .00). C. difficile samples receiving direct UV-C exposure had higher dosage and significantly greater log10 reductions (1.34; 95% CI, 1.10–1.58) than did indirect exposure (0.58; 95% CI, 0.31–0.86; P < .01) (Fig. 2). Conclusions: Use of the Tru-D vegetative cycle and the Moonbeam 3- and 5-minute cycles resulted in similar reductions in MRSA; both resulted in significantly greater reductions than the manufacturer’s recommended 3-minute Moonbeam cycle. Therefore, healthcare facilities should carefully evaluate manufacturer-recommended run times in their specific clinical setting. For C. difficile, the Tru-D sporicidal cycle was significantly more effective than either of the Moonbeam cycles, likely due to higher irradiation levels. As such, direct UV-C exposure resulted in greater average reductions than indirect exposure.

Funding: None

Disclosures: None
Enhanced Environmental Cleaning to Reduce Rates of Clostridioides difficile Infection on Oncology Units
Authors: Ziegler Matthew , Pegues David , Gaynes Steven , Desphy-Carter Ariel , Omorogbe Jacqueline , Gilmar Cheryl , Tolomeo Pam , Lautenbach Ebbing , Han Jennifer
Published: November 2020

Background:Clostridioides difficile infection (CDI) is a major contributor to morbidity and mortality in patients with hematologic malignancy. Due to both immunosuppression and frequent antibiotic exposures, up to one-third of inpatients receiving chemotherapy or stem-cell transplant develop CDI. Transmission of C. difficile in healthcare facilities occurs due to environmental surface contamination and hand carriage by healthcare workers from colonized and infected patients. We investigated the effectiveness of enhanced room cleaning in collaboration with environmental services (EVS) staff to prevent CDI transmission and infection.

Methods: From April 1, 2018, to September 30, 2018, a multimodal enhanced cleaning intervention was implemented on 2 oncology units at the Hospital of the University of Pennsylvania. This intervention included real-time feedback to EVS staff following ATP bioluminescence monitoring. Additionally, all rooms on the intervention units underwent UV disinfection after terminal cleaning. We performed a system-level cohort study, comparing rates of CDI on the 2 study units to historic and 2 concurrent control units. Historic and concurrent control units received UV disinfection only for rooms with prior occupants with MRSA or CDI. All units during the intervention period received education on the importance of environmental cleaning for infection prevention. Mixed-effects Poisson regression was used to adjust for system-level confounders. Results: A median of 1.34 CDI cases per 1,000 patient days (IQR, 1.20–3.62) occurred during the 12-month baseline period. There was a trend toward a reduced rate of CDI across all units during the intervention period (median, 1.19; IQR, 0.00–2.47; P = .13) compared with all units during the historical period. Using mixed-effects Poisson regression, accounting for the random effects of study units, the intervention was associated with an incidence rate ratio for C. difficile of 0.72 compared to control units (95% CI, 0.53–0.97; P = .03). Average room turnaround time (TAT) increased across all units during the study period, from 78 minutes (IQR 74–81) to 92 minutes (IQR, 85–96; P < .001). Within the intervention period, TAT was higher on intervention units (median, 94 minutes; IQR, 92–98) compared to concurrent control units (median, 85; IQR, 80–92; P = .005). Conclusions: Enhanced environmental cleaning, including UV disinfection of all patient rooms and ATP bioluminescent monitoring with real-time feedback, was associated with a reduction in the incidence of CDI.

Funding: None

Disclosures: None
Epidemiologic Characteristics of ESBL-Producing ST131 E. coli Identified Through the Emerging Infections Program, 2017
Authors: Duffy Nadezhda , Campbell Davina , Reses Hannah E. , Basiliere Elizabeth , Bower Chris , Dumyati Ghinwa , Kainer Marion , Muleta Daniel , Byrd-Warner Benji , Stanton Richard , Daniels Jonathan , Halpin Alison , Lutgring Joseph , See Isaac
Published: November 2020

Background: Extended-spectrum β-lactamase–producing (ESBL) Escherichia coli infection incidence is increasing in the United States. This increase may be due to the rapid expansion of ST131, which is now the predominant ESBL strain globally, often multidrug resistant, and has been shown to establish longer-term human colonization than other E. coli strains. We assessed potential risk factors that distinguish ST131 from other ESBL E. coli. Methods: From October 1 through December 31, 2017, 5 CDC Emerging Infections Program (EIP) sites pilot tested active, laboratory-based surveillance in selected counties in Colorado, Georgia, New Mexico, New York, and Tennessee. An E. coli case was defined as the first isolation from a normally sterile body site or urine in a surveillance area resident in a 30-day period resistant to 1 extended-spectrum cephalosporin antibiotic and susceptible or intermediate to all carbapenem antibiotics tested. Epidemiologic data were collected from case patients’ medical records. A convenience sample of 117 E. coli isolates from case patients was collected. All isolates underwent whole-genome sequencing to determine sequence type and the presence of ESBL genes. We compared ST131 E. coli epidemiology to other ESBL E. coli. Results: Among 117 E. coli isolates, 97 (83%) were ESBL producers. Of the 97 ESBL E. coli, 52 (54%) were ST131 (range, for 4 EIP sites submitting >10 isolates: 25%–88%; P < .001). Other common STs were ST38 (12%) and ST10 (5%). ST131 infections were more likely to be healthcare-associated than non-ST131 (56% vs 36%; P = .05) (Table 1). Among specific prior healthcare exposures, only residence in long-term care facilities (LTCFs) in the year before culture was more common among ST131 case patients (29% vs 11%; P = .03). Notably, 85% of ESBL E. coli collected from LTCF residents were ST131. ST131 E. coli were more common among patients with underlying medical conditions (81% vs 60%; P = .02). No statistically significant difference by sex, race, age, culture source, location of culture collection, and frequency of antibiotic use in the prior 30 days was observed. Conclusions:The prevalence of ST131 E. coli varies regionally. The association between ST131 and LTCFs suggests that these may be particularly important settings for ST131 acquisition. Improving infection control measures that limit ESBL transmission in these settings and preventing dissemination in facilities receiving patients from LTCFs may be necessary to contain ST131 spread.

Funding: None

Disclosures: None
Establishment of a Sink Gallery to Investigate Growth of Carbapenemase-Producing Klebsiella pneumoniae and Biofilms in P-Traps
Authors: Ganim Christine , Mazher Mustafa , Breaker Erin
Published: November 2020

Background: Hand-hygiene sink drains in healthcare facilities may provide an environment for the survival and dissemination of various multidrug-resistant organisms (MDROs), including carbapenemase-producing Klebsiella pneumoniae (CPKP). We developed a sink model system to establish and test native drinking water biofilms containing CPKP in the p-traps of hand-hygiene sink drains. Methods: A handwashing sink gallery was designed to consist of 6-wall mounted stainless-steel sink basins connected to the same municipal water line. Each sink’s plumbing included a chrome-plated brass p-trap. Healthcare facility conditions were simulated to include handwashing events with the addition of hand-soap and municipal water 4 per day, and nutritional shake (simulating liquid waste) 1 per day. Resultant biofilms in the p-traps of each sink were harvested after 28 days for community analysis. Microbial community analyses were performed on selected biofilm samples using 16S rRNA sequencing of the V4 hypervariable region of genomic DNA. Another experiment evaluated 28-day p-trap biofilm inoculated with CPKP CAV1016 (10 mL 7.010E 7 CFU/mL) and was assessed over 14 days. Heterotrophic plate counts (HPCs) were determined on R2A medium (7 days of incubation at 25C). CPKP was quantified on mEndo selective medium (48 hours of incubation at 36C). Results: Biofilms developed in all p-traps, but biofilm HPC (5.78 mean log CFU/cm2, range 4.35–7.16) and community diversity (15–20 genera per p-trap) varied with sink position. Community analysis showed similarities in bacterial community composition and diversity between sinks 1 and 2, and between sinks 3, 5 and 6, but with differences between the 2 groups. The most abundant family in sinks 3, 5, and 6 was Erythrobacteriaceae (76%, 78%, and 55% of the total reads, respectively), whereas sinks 1 and 2 were dominated by Sphingomonadaceae (63% and 36%) and Methylobacteriaceae (19% and 55%). Also, 16S sequencing revealed the presence of potential opportunistic pathogens in the biofilms, including reads attributed to Pseudomonas and Acinetobacter. CPKP CAV1016 inoculated into 28-day p-trap biofilms colonized and persisted in all 6 sinks for 12 days after inoculation. Conclusions: Despite all 6 sinks sharing an incoming water line, soap, and carbon and energy source, there was a significant variation in the bacterial community composition observed between the sinks. CPKP can colonize and persist in the p-trap biofilms; however, additional work is needed to achieve a reproducible model system. Once this is achieved, the sink gallery will be used to investigate interventions to mitigate colonization or persistence of CPKP in p-trap biofilms.

Funding: None

Disclosures: None
Geographic Evaluation of Georgia Vaccination Disparity Among Laboratory-Confirmed Influenza Cases in a Children’s Hospital
Authors: Hoskins Dorian , Kaplan Cynthia , Pruitt Andrea , McCarter Andrea
Published: November 2020

Background: Vaccination coverage among children aged ≤18 years in Georgia remains one of the lowest in the nation with 39.3% coverage. During the 2018–2019 influenza season, the CDC reported 142 pediatric deaths, 3 of which occurred in Georgia. In a time of increasing complexity of immunization schedules, increase severity with a high level of flu-related deaths and hospitalization, it is important to understand localized factors that contribute to decrease influenza immunization and increased flu-related hospital visits among children. Methods: Data include electronic medical record chart review of 5,827 laboratory confirmed Children’s Healthcare of Atlanta visitor cases from October 1, 2016, to September 24, 2019. System-wide county level data included 3 pediatric hospitals, 5 primary care facilities, 8 urgent care facilities, and 2 outpatient clinics. Characteristics associated with disparities in vaccine were explored using univariate and multiple regressions analysis. Of those children with a primary care physician (PCP), 30% had flu vaccinations, whereas only 16.5% of those without a PCP had been vaccinated (P ≤ .00001). There was a positive relationship between increased county influenza rate and percentage of children in county who were preschoolers <5 years old (r = 0.93; P ≤ .05). Moreover, 78% of children who received the flu vaccine ≤ 2 weeks prior to a confirmed flu diagnosis got the flu during peak flu periods (r = 0.29; P ≤ .05). Predictors of increased flu rate per 1,000 children were associated with flu vaccines given ≤2 weeks before a lab confirmed flu diagnosis (P ≤ .02). Children in counties that had a higher rate of flu during the peak period also had an overall higher rate of flu (P ≤ .005). The higher the percentage of children who got flu during peak flu period, the lower the vaccination rate for the county (P ≤ .001). The percentage of children ≤18 years old with no health insurance was associated with lower vaccination rates in the county (P ≤ .004). There appears to be a positive relationship between receiving flu vaccine 2 weeks prior to lab-confirmed flu diagnosis and onset of illness during the peak flu periods. Missed opportunities to obtain a flu vaccine by a PCP were associated with increased flu-related hospital visits and lower vaccination rates. Results may support predischarge hospital vaccinations and the promotion of flu vaccination education. Pediatric research is needed to facilitate localized PCP vaccination or predischarge hospital vaccinations prior to peak flu periods when hospital-related flu visits increase.

Funding: None

Disclosures: None
Getting to the Heart of the Matter: Epidemiology of Surgical Site Infections Following Open Heart Surgery in Children
Authors: Magyar Matthew , Shephard Allyson , Bedard Pat , Tang Ken , Maharajh Gyaandeo , Thampi Nisha
Published: November 2020

Background: Surgical site infections (SSIs) following open heart surgery involving cardiopulmonary bypass (CPB) among pediatric patients are healthcare-associated infections associated with significant morbidity and mortality. At a pediatric acute-care facility, an increase in SSI incidence prompted an epidemiologic review. We describe the incidence of cardiac SSIs at our hospital; we identified risk factors and areas of practice variation to inform improvement initiatives. Methods: SSI cases following CPB at our hospital have been identified through routine surveillance using NHSN definitions since January 2016. An increase in cases was noted in mid-2018, prompting a common cause analysis with stakeholders across the preoperative, intraoperative, and postoperative care continuum. Areas of practice variability were identified, and an epidemiologic review was performed to determine risk factors among cases compared to noncases between January 2016 and August 2018. The rate of SSIs and 95% confidence intervals were estimated, and univariate logistic regressions were fitted to estimate unadjusted odds ratios (ORs) for the association between each of the predetermined preoperative, intraoperative, and postoperative factors and developing an SSI. Results: Overall, 139 patients underwent surgery involving CPB between January 1, 2016, and August 31, 2018. Preoperative bathing was infrequently documented (9% among cases vs 5% among noncases; P = .56). Operating room observations identified frequent door openings and equipment crowding. Moreover, 11 patients (7.9%) developed a cardiac SSI, with 6 (14.3%) occurring in the first 8 months of 2018 (P = .067). There were no predominant pathogens; 3 of 11 cases were associated with methicillin-susceptible Staphylococcus aureus. Also, 9 cases were classified as deep incisional or organ-space SSI. Each hour increase in total CPB duration was associated with a 63% increase in odds of developing an SSI (OR, 1.626; 95% CI, 1.041–2.539). Each additional day of intubation (OR, 2.400; 95% CI, 1.203–4.788) and peritoneal dialysis (OR, 1.767; 95% CI, 1.070–2.919) during the first 3 days postoperatively were also associated with increased SSI risk. Postoperative documentation of wound assessment occurred in 60% of patients, with no difference between cases and noncases (55% vs 67%; P = .42). Conclusions: Using a mixed-methods approach, preoperative bathing, increased operating room traffic, and postoperative care around wounds and invasive devices were identified as areas of improvement toward safer surgical care. Although no unique organism or process explained the increased rate, determining risk factors and areas of practice variability through stakeholder engagement provided insight into opportunities to prevent SSIs.

Funding: None

Disclosures: None
Hand Hygiene Compliance in a University Hospital in West Bank, Palestine: An Observational Study 2017–2019
Authors: Belkebir Souad , Jeetawi Rawan , Kanaan Alaa
Published: November 2020

Background: Worldwide, medical staff adherence to hand hygiene (HH), the most cost-effective measure to decrease healthcare-associated infections (HAIs), is ~40%–60%. The infection control program (ICP) at An-Najah National University Hospital (NNUH), a tertiary-care referral teaching hospital located in Nablus, in northern Palestine, monitors HH compliance by direct observations using the WHO observation checklist. In this descriptive study, we investigated the prevalence of HH across the institution during 2017–2019. Methods: The WHO multimodal strategy to enhance HH in healthcare settings was implemented at NNUH, a tertiary-care referral hospital, in 2017. HH compliance has been measured during routine patient care by direct observation by ICP team and anonymously by other trained observers. Results are reported on monthly basis to the administration and medical team (nurses and doctors), and corrective plans to increase the compliance are discussed. Training is reinforced with ultraviolet light and fluorescent alcohol-based hand rub. Yearly, staff are engaged in HH Day activities (Figs. 1 and 2). Leadership support is constant by securing the annual budget for the HH program and the enforcement of HH policy across the setting. Results: NNUH, using the WHO Hand Hygiene Self-Assessment Framework, is currently in the advanced level (395 of 500) compared to 2017 (intermediate level, 292 of 500). Overall, HCW HH compliance increased from 44% (range, 31%–57%) in 2017 to 53% (range, 30%–72%) in 2018 and to 61% (range, 55%–66%) through October 2019. During the 3-year study period, Nursing compliance increased from 36% to 59% and to 64%, respectively, whereas the compliance for doctors increased from 42% to 56% and 58%, respectively. Regarding the missed opportunities, before patient was the most frequent cause for missed opportunity with a rate of 60% (Fig. 3). This missed opportunity was mainly related to the misuse of gloves (mainly among nurses), which requires an ad hoc intervention. Conclusions: Implementation of the WHO HH strategy is feasible and effective in low-income countries and leads to significant improvements in compliance. Periodic training, personnel engagement, and leadership are key factors of HH improvement in our setting.

Funding: None

Disclosures: None
Healthcare-Associated Pneumonia in a Mexican Tertiary Care Center Micro to Systemic Analysis: A 2017–2019 Case Series Study
Authors: Salcido Miguel Ángel García , González Roxana Trejo , González Lucio Antonio Hernández
Published: November 2020

Objectives: The aim of this study was to identify the biological, microbiological, and healthcare factors related to the occurrence of nosocomial pneumonia in our confirmed cases during 2017–2019. Methods: We conducted a case series study. For the selection of the cases we used the CDC criteria for hospital-acquired pneumonia, we collected cases from the data set for healthcare-associated infections from a tertiary-care hospital in Mexico City. For the quantitative analysis, we used Stata v14 software, and we obtained frequencies, proportions, accumulated incidence rate, lethality rate, central tendency, and dispersion metrics. This study was a secondary data set analysis; we obtained signed authorization for the use of the data from the Epidemiological Surveillance Unit. Results: During our analysis period (January 2017 to June 2019), we identified 107 cases that fulfilled the CDC criteria: 47 cases (43.93%) from 2017, 38 cases (35.51%) from 2018, and 20.56% from 2019. The month that reported the highest frequency was February, with 17 cases (15.89%). The median age was 63 years (range, 0–97 years; IQR, 36). The most affected age group was 65 years (48.60%), and the most affected 5-year age group was 75–79 years (13.08%). Moreover, 60 cases (56.07%) were men and 47 (43.93%) were women. Regarding the reason for discharge, 71% were discharged due to improvement, 27% died, and 2% were transferred to another healthcare facility. Also, 17 patients (15.89%) required readmission due to respiratory illness within 72 hours of previous discharge. The most common diagnosis was a solid malignant neoplasm (20.19%), followed by heart or vascular malformation or anomaly (12.50%). The mean inpatient hospital stay was 39.95 days (46.40; median, 27 days, range, 2–317 days; IQR 35 days). The median time elapsed until detection was 14 days. The hospitalization area with the most cases was the intensive care unit, with 24 cases (22.43%); the service with most cases was oncology with 21 cases (20.56%). The most isolated pathogen was Pseudomonas aeruginosa (14%). Moreover, 59% were gram-negative, 36% were gram-positive, 19.67% were viruses, and 14.75% were fungi. Our accumulated-incidence-rate was 0.58 cases per 1,000 patient days and our case-fatality-rate was 25.23%. Furthermore, 41% of cases required invasive mechanical ventilation, 52.34% required noninvasive mechanical ventilation, 5% cases had an endo-pleural tube, 9.35% had a nasogastric tube, and 41.12% had a central venous catheter. The most-prescribed antimicrobial was meropenem (33.33%), and meropenem-resistance was 61.54%. Conclusions: Infection prevention efforts should target oncological patients, critical-care units, and the elderly. We must reinforce our antimicrobial policy due to our overprescription of carbapenems. Early detection is needed to reduce mortality.

Funding: None

Disclosures: None
Hepatitis C Virus Transmission at a Long-Term Care Facility (LTCF) Providing Hemodialysis Services—Georgia, United States, 2019
Authors: Wagner JoAnna , Gandhi Ami , Johnson Bill , Gualandi Nicole , Bixler Danae , Hayden Tonya , Ho Po-Yi , Ramachandran Sumathi , Patel Priti , Negley Jeanne
Published: November 2020

Background: Hepatitis C virus (HCV) transmission at outpatient hemodialysis clinics is well documented, but little is known about HCV transmission risks in long-term care facilities (LTCFs) providing hemodialysis services. LTCFs can provide onsite hemodialysis for residents by contracting with a licensed hemodialysis clinic to either provide its staff to the LTCF or to train LTCF staff as caregivers. In August 2019, the Georgia Department of Public Health (DPH) was notified about an HCV seroconversion in patient A at a LTCF providing onsite hemodialysis. Methods: Three residents (including patient A) were receiving hemodialysis at the LTCF in August 2019; patients B and C had chronic HCV infection upon admission. Records were reviewed for medical history, behavioral risk factors, and healthcare exposures. We conducted onsite infection control assessments and interviewed staff. Serum specimens were collected for all 3 patients in August 2019 and HCV tested for genetic similarity using Global Hepatitis Outbreak Surveillance Technology (GHOST). Results: The facility reported initiating onsite hemodialysis in November 2018; facility staff were trained by a dialysis provider. Patient A, admitted in September 2018, was anti-HCV negative in June 2019 and both anti-HCV and HCV RNA positive in July 2019. Patient B was admitted in December 2018, discharged for 1 month in May 2019, and then readmitted. Patients A and B reported previous injection drug use, and they were not observed by staff to use during their stay and had limited mobility. Patient A was wheelchair confined and B was bed confined. Patient C was admitted in May 2019. HCV samples from patients A and B both had HCV genotype 1b and demonstrated 100% genetic relatedness, indicating that patient B was the likely source. Patient C had HCV genotype 1a. Hemodialysis was provided to residents simultaneously in a converted resident room with 4 hemodialysis stations, and the LTCF operated 2 shifts, 3 times per week. We observed multiple infection control gaps, such as preparation of IV medications and inadequate disinfection in the shared dialysis treatment area. Recommendations addressing gaps were issued, and a follow-up site visit was conducted to validate implementation. With the exception of May 2019, patients A and B received hemodialysis on the same shift and days from December 2018 to September 2019. Conclusions: Phylogenetic and epidemiological results indicate HCV transmission likely occurred during hemodialysis services provided by the LTCF. As the provision of dialysis expands to nontraditional settings such as LTCFs, it is essential that proper infection control procedures and oversight are in place.

Funding: None

Disclosures: None
Hospital Infections by Stenotrophomonas maltophilia: Results in Five Years of Multicentric Study
Authors: Tanure Luciana , Pinho Rafaela , Oliveira Mayra de , Ribeiro Daniela , Ferreira Jose A. , Couto Braulio , Starling Carlos
Published: November 2020

Background:Stenotrophomonas maltophilia is an emerging pathogen responsible for high morbidity and mortality rates. Hospital infections caused by this bacteria, especially in intensive care centers, are concerning for the health system, given that the microorganism is multidrug resistant to most antimicrobials available. Objective: Therefore, the present study is built from an analysis of the variables related to nosocomial infections caused by S. maltophilia in hospitals in Brazil, to display points of major concern. Methods: We used the data collected by the Infection Prevention and Control Service to clarify the incidence rate of Stenotrophomonas maltophilia in Brazilian hospitals as well as the gross lethality of these infections and the profiles of infected patients. We collected and analyzed epidemiological data from 10 hospitals in Brazil for the period July 2014 to June 2019 according to the CDC NHSN protocol. Results: In 5 years, 93 Stenotrophomonas maltophilia infections were diagnosed in the hospitals analyzed. Overall, 61 occurred in men (66%) and 32 occurred in women (34%). Furthermore, 47 cases (51%) occurred in adult ICUs; 19 cases (20%) followed zascular surgery; 9 (10%) cases occurred in the neonatal ICU; 7 (8%) cases were from the medical clinic; and 11 (12%) were from other clinics. The incidence rate was 1.2 cases for 10,000 hospitalizations, ranging from 0.0 to 2.8 (Fig. 1). Patients’ ages ranged from 0 to 90 years, with a mean of 55 years (SD, 26 years) and a median of 64 years. Time between admission and diagnosis of infection was 1 to 102 days, with a mean of 24 days (SD, 21 days) and a median of 17 days. The gross lethality for S. maltophilia infection was 43 of 93 (46%) (95% CI, 35.8%–56.9%). The frequencies of specific infections were as follows (Fig. 2): pneumonia, 26 (28%); tracheobronchitism, 22 (24%); primary bloodstream infection, 18 (19%); skin and soft-tissue infection, 13 (14%); local infection, 7 (8%); vascular access infection, 3 (3%); urinary tract infection, 2 (2%); gastrointestinal infection, 1 (1%); and eye, nose, throat, and mouth infections, 1 (1%). Conclusions:Stenotrophomonas maltophilia infection is a rare and highly lethal event that usually occurs after 2 weeks of hospitalization. The most affected region is the respiratory tract, with a higher incidence in patients aged >60 years or in the ICU. Early and accurate investigations of multiresistant microorganisms in a hospital setting are needed to reduce patient morbidity and mortality.

Funding: None

Disclosures: None
Impact of Expansion of Vascular Access Team on Central-line–Associated Bloodstream Infections
Authors: Holder Carolyn , Overton Elizabeth , Kalaf Sarah , Wong Doris , Holdsworh Jill , Yun Mylinh , Schreck Debra , Haun Philip , Omess Sarah , Whitson Margaret , Ott Deborah , Mitchell Rae , Steinberg James
Published: November 2020

Background: Through participation in a system-wide healthcare-associated infection-reduction task force, we leveraged our ability to standardize best practices across hospitals in a university-owned healthcare system to reduce central-line–associated bloodstream infection (CLABSI) rates. Methods: Our multidisciplinary team had representation from all hospitals in our healthcare system. The team benchmarked practices in place and compared CLABSI standardized infection ratios (SIRs). One hospital had a robust vascular access team (VAT) and consistently low CLABSI SIRs; expanding and standardizing VAT across the hospitals in the system became the primary goal of the team. We developed a business case to justify VAT expansion that considered savings from decreasing CLABSIs and benefits to interventional radiology revenue by decreasing PICC insertion and comparing costs for added full-time equivalents (FTEs). CLABSI rates before and after VAT team expansion at 2 large hospitals were compared to the hospital with existing robust VAT. Other process improvement activities were implemented across all hospitals. The expanded VAT assumed responsibility for central-line maintenance, promoted removal of unneeded lines, expanded education efforts, and enhanced capacity for insertions. Results: The VAT expansion from 5.4 FTEs to 15.9 FTEs at 2 large hospitals (1,100 total beds) began in April 2017 and was phased over ~6 months. CLABSI SIRs for the 15 months preceding expansion were compared to the SIRs for the 15-month period after expansion for the 2 hospitals with expanded VAT (hospitals A and B) and for hospital C with preexisting robust VAT (Table 1). We observed a 33% decrease in PICC insertions in interventional radiology department in hospitals A and B. Overall return on investment (ROI) estimates using lower and upper cost per CLABSI ranged from a loss of $156,000 to a net gain of $623,000. Conclusions: A significant decrease in CLABSI rates temporally related to expansion of VAT occurred in 2 hospitals, whereas the hospital with existing robust VAT demonstrated a modest decrease in CLABSI rates. We were able to demonstrate a favorable ROI from the VAT expansion without an impact on HAC penalties. Using the model of standardizing best practices across a system and creative ROIs may help justify the addition of scarce resources.

Funding: None

Disclosures: None
Implementing Admission Screening for Candida auris
Authors: Rasmusson Jenna , Wengenack Nancy , Sampathkumar Priya
Published: November 2020

Background:Candida auris is a globally emerging, multidrug-resistant fungal pathogen that causes serious, difficult-to-treat infections in hospitalized patients. C. auris cases in the United States have been linked to receipt of healthcare overseas. Outbreaks have also occurred in New York City, New Jersey, Chicago, and most recently in California. We provide care to patients from all 50 states and 138 countries; therefore, we are at risk for encountering C. auris in our facility. Setting: An academic, tertiary-care center with 1,297 licensed beds and >62,000 admissions each year. Methods: Infection prevention and control (IPAC) initiated a C. auris screening program in August 2019 in partnership with the State Health Department. A case-finding tool was created to identify adult patients admitted in the previous 24 hours from countries and areas of the United States (Chicago, New Jersey, and New York metropolitan areas) with known C. auris transmission based on the zip code of their primary address. IPAC sends an electronic communication via the electronic medical record (EMR) alerting the patient care team that the patient meets criteria for screening along with information on C. auris and links to a tool kit with additional resources to help answer questions. After obtaining verbal consent, the patient’s primary nurse collects a composite axilla–groin skin swab using a nylon-flocked swab (BD ESwab collection and transport system; Becton Dickinson, Sparks, MD). The sample is sent to the State Health Department laboratory for testing by polymerase chain reaction (PCR). Results are communicated back to IPAC and then scanned into the patient’s EMR. Results: From August 2019 to November 2019, 157 patients were identified for C. auris screening using the case-finding tool. Testing was performed on 95 patients; all tests were negative. The primary reasons for testing not to be performed on eligible patients were inability to obtain verbal consent and patient dismissal before sample could be obtained. The need for a special swab that is not routinely stocked on patient care units has been a limitation to timely specimen collection. Conclusions: The EMR can be leveraged for early identification and screening of patients at risk of C. auris colonization. Case finding tools can be effectively replicated and modified to respond to emerging infections and changing surveillance guidelines.

Funding: None

Disclosures: None
Incidence of Mucosal Barrier Injury Bloodstream Infections Reported to the National Healthcare Safety Network
Authors: Patel Prachi , Dudeck Margaret A. , Magill Shelley , Chea Nora , Thompson Nicola , Godfrey-Johnson Dominque
Published: November 2020

Background: The NHSN collects data on mucosal barrier injury, laboratory-confirmed, bloodstream infections (MBI-LCBIs) as part of bloodstream infection (BSI) surveillance. Specialty care areas (SCAs), which include oncology patient care locations, tend to report the most MBI-LCBI events compared to other location types. During the update of the NSHN aggregate data and risk models in 2015, MBI-LCBI events were excluded from central-line–associated BSI (CLABSI) model calculations; separate models were generated for MBI-LCBIs, resulting in MBI-specific standardized infection ratios (SIRs). This is the first analysis to describe risk-adjusted incidence of MBI-LCBIs at the national level. Methods: Data were analyzed for MBI-LCBIs attributed to oncology locations conducting BSI surveillance from January 2015 through December 2018. We generated annual national MBI-LCBI SIRs using risk models developed from 2015 data and compared the annual SIRs to the baseline (2015) using a mid-P exact test. To account for the impact of an expansion in the MBI-LCBI organism list in 2017 from 489 organisms (32 genera) to 1,003 organisms (89 genera), we removed the MBI-LCBI events that met the newly added MBI organisms and generated additional MBI SIRs for 2017 and 2018. Results: The annual SIRs remained above 1 since 2015, indicating a greater number of MBI-LCBIs identified than were predicted based on the 2015 national data (Fig. 1). Each year’s SIR was significantly different than the national baseline, and the highest SIR was observed in 2017 (SIR, 1.377). In 2017, 12% of MBI events were attributed to an organism that was added to the MBI organism list, and in 2018 it was 10%. After removal of MBIs attributed to the expanded organisms, the 2017 and 2018 SIRs remained higher than those of previous years (1.241 and 1.232, respectively). Conclusions: The distinction of MBI-LCBIs from all other CLABSIs provides an opportunity to assess the burden of this infection type within specific patient populations. Since 2015, the increase of these events in the oncology population highlights the need for greater attention on prevention strategies pertinent to MBI-LCBI in this vulnerable population.

Funding: None

Disclosures: None
Investigation of the First Case of New Delhi Metallo-β-Lactamase-1–Producing Pseudomonas aeruginosa in Texas
Authors: Sopirala Madhuri , Badejogbin Aderonke , Christie-Smith Angela , Psenicka Andrew , Reid Sherry , Hartless Kathleen , Fiveash Jeanette
Published: November 2020

Background: New Delhi metallo-β-lactamases impart resistance to carbapenems. Enterobacteriaceae carrying New Delhi metallo-β-lactamases have been reported before. However, only 7 cases of blaNDM-carrying Pseudomonas aeruginosa has been reported from 4 states in the United States as of January 1, 2018, according to the CDC. We describe an epidemiologic investigation of the first reported case of blaNDM-carrying Pseudomonas aeruginosa in Texas and the measures that controlled the spread of the organisms carrying this gene at a 30-bed spinal cord injury unit (SCI) and the acute-care hospital within the Veterans’ Affairs North Texas Health Care System. Methods: After identification of blaNDM-1–carrying P. aeruginosa from a urine culture in an SCI patient who received medical treatment in Thailand prior to transfer, we performed a rectal screen for the presence of blaNDM in the index patient’s hospital roommates. Based on the results, we expanded the investigation to other patient care units that had provided care to the patient. We initiated universal contact isolation precautions, 1:1 nursing care, restricted movement, phased point-prevalence testing, and intense environmental cleaning until the threat of blaNDM was mitigated. Whole-genome sequencing (WGS) was performed on clinical isolates from the index patient and the roommates by the CDC. Results: Of the 2 roommates of the index, 1 patient had a urine culture positive for blaNDM-5-carrying Escherichia coli. The second roommate has subsequently grown blaNDM-1-carrying P. aeruginosa from a clinical culture. A third patient who was in the same unit as the index patient but not in the same room in an acute-care unit tested positive for blaNDM in a rectal screen. Of the 54 patients who were hospitalized in the same unit as the index patient, 26 refused to get the test and 28 tested negative. In addition, point-prevalence rectal screening was conducted in the SCI in 3 phases that were 3 to 4 weeks apart. All of these screening tests were negative. WGS revealed that the index patient and roommate 2 had blaNDM-1–carrying P. aeruginosa, whereas the roommate 1 had blaNDM-5–carrying E. coli. No further spread occurred. Conclusions: Our aggressive efforts quickly mitigated further spread of blaNDM. Our epidemiologic investigation indicates that an intergenus transfer of blaNDM from P. aeruginosa to E. coli likely took place. In addition, it appears there was an evolution of NDM-1 to NDM-5, which differs from the former by 2 amino acid substitutions at positions 88 (Val→Leu) and 154 (Met→Leu). This type of evolution has been shown by prior studies to confer increased antibiotic resistance in certain resource limited settings.

Funding: None

Disclosures: None
Liberal and Restrictive Blood Transfusion Strategies in Orthopedic Surgery: Risk Factors for Surgical Site Infection
Authors: Pereira Hoberdan , Perucci Marcelo , de Lima Lucas , Bodour Daniel , Vieira Laura , Teixeira Rafael , Couto Braulio , Andrade Antônio
Published: November 2020

Background: The identification of risk factors for infections in surgical patients with lower-limb fractures and blood transfusions has increased in recent years. Surgical site infections (SSIs) increase hospitalization, care costs, and patient suffering. Correction surgery for lower-limb fractures and blood transfusion is quite common between surgical procedures. The aim of this study was to describe the relationship between blood transfusion and SSI in patients undergoing orthopedic surgery on lower limbs. Methods: We conducted a prospective cohort study to identify risk factors for SSI in blood transfused patients undergoing fracture repair in lower-limb surgeries between February 2017 and May 2019 in 2 reference tertiary-care hospitals in Belo Horizonte, a city of 3 million people in Brazil. Data regarding patient characteristics, surgical procedures, blood transfusions, and surgical infections were collected. Patient characterization was performed by calculating the absolute and relative frequencies of categorical variables and calculating mean, median, minimum, maximum, standard deviation, and coefficient of variation for quantitative variables. The incidence of surgical site infection, the risk of postoperative hospital death, and the total length of hospital stay were calculated by point estimates and 95% confidence intervals identified by statistical tests of bilateral hypotheses, considering the level of significance of 5%. A multivariate analysis (logistic regression) was performed to identify SSI risk factors. Results: Patients who had an indication for blood transfusion (n = 38) but who did not receive blood (n = 4) had significantly lower hemoglobin, comparing discharge with admission, than the group who received blood. Intraoperative transfusion was a risk factor for SSI (OR, 4.7) (Fig. 1). Among the 205 patients with no indication for transfusion, 98 received blood even without the indication: there was no difference in hemoglobin outcome when discharge and admission were compared, and the 98 patients were exposed to unnecessary risk. Regarding restrictive versus liberal transfusion strategies, there were differences in the variables, age (P = .000), duration of surgery (P = .003), number of comorbidities (P = .000), body mass index (BMI) (P = .027), previous hemoglobin (P = .000), and high hemoglobin (P = .000), considering the transfusion practice employed (Fig. 2). Conclusions: The indications for and definition of protocols and careful evaluation of blood transfusion are critical to avoid infectious complications in orthopedic patients with lower-limb fractures.

Funding: None

Disclosures: None
Moving Beyond Contact Precautions: Implementation of a Staphylococcus aureus Screening and Decolonization Program
Authors: Hochman Sarah , Stachel Anna , Phillips Michael , Sterling Stephanie , Lighter Jennifer , Aguero-Rosenfeld Maria , King-Morrieson Tamara
Published: November 2020

Background:Staphylococcus aureus–colonized hospitalized patients are at risk for invasive infection and can transmit S. aureus to other patients in the absence of symptoms. Infection isolation precautions do not reduce the risk of infection in colonized patients and are untenable in health systems with high rates of S. aureus colonization. Objective: We implemented an inpatient S. aureus screening and targeted decolonization program across hospital campuses to reduce transmission and invasive infection. We screen and decolonize for methicillin-susceptible S. aureus (MSSA) and methicillin-resistant S. aureus (MRSA) because MSSA makes up more than half of all S. aureus isolated from clinical cultures in our health system. Methods: All medicine, pediatrics, and transplant patients receive S. aureus nares culture at admission and upon change in level of care for medicine, and at admission and weekly for pediatrics and transplant patients. All S. aureus–colonized patients receive decolonization with nasal mupirocin ointment and chlorhexidine baths. Two implementation frameworks guide our processes for S. aureus screening and decolonization: the Consolidated Framework for Implementation Research, to evaluate factors affecting implementation at different levels of the health system, and the Dynamic Sustainability Framework, to account for iterative changes as the hospital setting and patient population change over time. Implementation interventions focus on education of patients and bedside nurses who perform S. aureus screening and decolonization; utilization of the electronic health record to identify patients for screening and/or decolonization and avoid human error; and introduction of a clinical nurse specialist to oversee the program and to provide iterative feedback. Results: At baseline, 21% of patients had S. aureus colonization, 20% of which was MRSA, and the MRSA bloodstream infection rate was 0.06 per 1,000 patient days. After program implementation, there was no change in S. aureus colonization and the MRSA bloodstream infection rate fell to 0.04 per 1,000 patient days. Screening compliance improved from 39% (N = 1,805) of eligible patients in the 6-month period before the introduction of the clinical nurse specialist to 52% (N = 2,024) after the introduction of the clinical nurse specialist. In the same periods, decolonization increased from 18.6% to 41% of eligible patients. Conclusions: We used 2 implementation frameworks to design our S. aureus screening and decolonization program and to make iterative changes to the program as it evolved to include new patient populations and different hospital settings. This resulted in a large-scale, sustainable, health system program for S. aureus control that avoids reliance on infection isolation precautions.

Funding: None

Disclosures: None