bluuebunny/crossref_metadata_2025_split huggingface dataset:
Not as simple as it seems: Extensive facility and training gaps in nursing home bathing
Authors: Nguyen Kristine , Singh Raveena , Saavedra Raheeb , Billimek John , Tam Steven , Huang Susan 
Published: September 2023

Background: Existing training for resident bathing in nursing homes (NHs) is brief and limited, likely because bathing is assumed to be intuitive. However, residents have complex skin issues, devices, dressings, and limited ability for self-care. We sought to assess bathing quality and to identify barriers to proper bathing techniques. Methods: We conducted a prospective observational study of bathing in 8 NHs in Orange County, California, involving a convenience sample of observed bed baths and showers conducted for quality improvement. NH staff were told that observation was occurring, and no feedback was given during or after bathing. Survey elements included cleansing of 6 specific body sites and adherence to bathing procedures (11 for bed baths and 17 for showers). Surveys also included queries to staff to further assess knowledge and perceived barriers. Observed lapses were documented, along with observer-determined reasons for noncompliance (ie, training issue, time pressure, facility issue (insufficient water temperature), resident refusal/behavior). Frequency of noncompliance with each element was tabulated for bed-baths and showers separately. Reasons for failure were displayed graphically. Results: In total, 50 bed baths (NH range, 5–8) and 50 showers (NH range, 4–7) were observed across 8 NHs. Lapses in bathing quality and process were extremely common for both bed baths and showers (Fig.). Inadequate body cleansing occurred for all observed body sites (88%–100% failure for bed baths, 58%–100% failure for showers). Most body areas were either skipped or sprayed with water without soaping. Procedural failures were high for both bed baths and showers (insufficient lather: 100% for bed bath and 40% for shower) lack of firm massage for cleaning (94% for bed bath and 90% for shower), failure to change wipes or cloths when dirty (100% for bed bath and 96% for shower), failure to follow clean-to-dirty sequence (100% for bed bath and 96% shower). In addition, failing to wrap or unwrap devices (73%) and failing to towel dry (94%) were common after showering. Reasons for failure were largely based on training or facility shortcomings (eg, insufficient hot water, inflexible showerhead attachment). Also, 86% of residents complained of being cold. Timing constraints and resident combativeness or refusal were rare. Staff-to-staff bathing advice most commonly involved competing for the “better shower” and “bathing early to get hot water.” Conclusions: Knowing how to appropriately bathe NH residents is not intuitive, and current training is brief and insufficient for high-quality resident care. Unacceptably high failures in proper bathing techniques in NHs necessitate re-evaluation of formal training and standardized practices to better cleanse residents. Moreover, common failures in facility processes for ensuring adequate water temperature and showerhead mobility for bathing or showering should be addressed.Disclosures: None
Colonization with extended-spectrum cephalosporin-resistant Enterobacterales (ESCrE) in hospitalized patients in Botswana
Authors: Mannathoko Naledi Betsi , Mosepele Mosepele , Gross Robert , Smith Rachel , Styczynski Ashley , Cressman Leigh , Richard-Greenblatt Melissa , Glaser Laurel , Alby Kevin , Jaskowiak Anne , Sewawa Kgotlaetsile , Cowden Laura , Otukile Dimpho , Paganotti Giacomo , Mokomane Margaret , Bilker Warren , Lautenbach Ebbing 
Published: September 2023

Background: The epidemiology of extended-spectrum cephalosporin-resistant Enterobacterales (ESCrE) in hospitalized patients in low- and middle-income countries (LMICs) is poorly described. Although risk factors for ESCrE clinical infection have been studied, little is known of the epidemiology of ESCrE colonization. Identifying risk factors for ESCrE colonization, which can predispose to infection, is therefore critical to inform antibiotic resistance reduction strategies. Methods: This study was conducted in 3 hospitals located in 3 districts in Botswana. In each hospital, we conducted ongoing surveillance in sequential units hospitalwide. All participants had rectal swabs collected which were inoculated onto chromogenic media followed by confirmatory testing using MALDI-TOF MS and VITEK-2. Data were collected via interview and review of the inpatient medical record on demographics, comorbidities, antibiotic use, healthcare exposures, invasive procedures, travel, animal contact, and food consumption. Participants with ESCrE colonization (cases) were compared to noncolonized participants (controls) using bivariable and multivariable analyses to identify risk factors for ESCrE colonization. Results: Enrollment occurred from January 15, 2020, to September 4, 2020, and 469 participants were enrolled. The median age was 42 years (IQR, 31–58) and 320 (68.2%) were female. The median time from hospital admission to date of sampling was 5 days (IQR, 3–12). There were 179 cases and 290 controls (ie, 38.2% of participants were ESCrE colonized). Independent risk factors for ESCrE colonization were a greater number of days on antibiotic, recent healthcare exposure, and tending swine prior to hospitalization. (Table). Conclusions: ESCrE colonization among hospitalized patients was common and was associated with several exposures. Our results suggest prior healthcare exposure may be important in driving ESCrE. The strong link to recent antibiotic use highlights the potential role of antibiotic stewardship interventions for prevention. The association with tending swine suggests that animal husbandry practices may play a role in community exposures, resulting in colonization detected at the time of hospital admission. These findings will help to inform future studies assessing strategies to curb further emergence of hospital ESCrE in LMICs.Disclosures: None
Real-world clinical outcomes of cefiderocol therapy in the Veterans Health Administration, 2019–2022
Authors: Amenta Eva , Trautner Barbara , Ramsey David , Chou Andrew 
Published: September 2023

Background: Cefiderocol is a novel siderophore cephalosporin with broad-spectrum activity. In the CREDIBLE-CR phase 3 clinical trial examining treatment of carbapenem-resistant gram-negative infections, cefiderocol had similar clinical and microbiological efficacy compared to the best available therapy, but the mortality rate was unexpectedly higher in the cefiderocol group. We investigated the postapproval, real-world clinical outcomes of cefiderocol therapy. Methods: We conducted a prospective, observational study of patients who received cefiderocol for at least 2 days within the Veterans’ Health Administration (VHA) between the date of approval by the US Food and Drug Administration (FDA), November 14, 2019, and August 31, 2022. Types of infections were defined by NHSN criteria. Clinical failure was a composite outcome based on type of infection including survival (30- and 90-day mortality) and resolution of signs and symptoms of infection. Microbiologic failure was defined as culturing the same organism, as defined by the CDC NHSN, at least 7 days after the start of cefiderocol. Structured data were sourced from the VHA Corporate Data Warehouse, and each eligible episode underwent manual chart review. Results: During the study period, 8,763,652 patients across 132 VA medical centers received 1,142,940,842 prescriptions (not limited to antibiotics). Overall, 48 unique individuals had received cefiderocol, with 48 cefiderocol courses prescribed. Patients had a median age of 70.5 years (range, 61–75), and a median Charlson comorbidity score of 6 (range, 2–9). The most common infectious syndromes were lower respiratory tract infection in 23 (47.9%) of these 48 patients and urinary tract infection in 14 (29.2%) of these patients. The most common pathogens cultured were P. aeruginosa in 30 patients (62.5%), Enterobacterales in 17 patients (35.4%), and A. baumannii in 10 patients (20.8%). The clinical failure rate was 35.4% (17 of 48), and 15 (88.2%) of these 17 patients died within 3 days of clinical failure. The 30-day and 90-day microbiologic failure rates were 33.3% (16 of 48) and 45.8% (22 of 48), respectively. The 30-day and 90-day all-cause mortality rates were 27.1% (13 of 48) and 45.8% (22 of 48), respectively (Table 1). Conclusions: Our study cohort included older individuals with multiple comorbidities who were treated with cefiderocol mainly for lower respiratory tract and urinary tract infections, with Pseudomonas aeruginosa as the main causative pathogen. Clinical and microbiologic failure were seen in>30% of patients, and >40% of these patients died within 90 days. These data contribute to the growing body of literature on the real-world use of cefiderocol and provide outcome data on clinical failure, microbiologic failure, and mortality.Financial support: This study was supported by the Department of Veterans Affairs Clinical Science Research and Development (VA CSRD grant no. IK2 CX001981).Disclosures: None
Methicillin-resistant Staphylococcus aureus mupirocin resistance rates in a large healthcare system
Authors: Sampson Mindy , Fairman Robert , Palavecino Elizabeth , Bischoff Werner , Williamson Julie , Keste Shelley , Passaretti Catherine 
Published: September 2023

Methicillin-resistant Staphylococcus aureus (MRSA) is a common etiology of hospital-acquired infections (HAIs). One strategy to reduce HAIs due to MRSA involves a multistep decolonization process. This often involves nasal application of mupirocin 2% ointment. In our institution, when individuals meet criteria for decolonization, we recommend 5 days of treatment given twice daily. High levels of mupirocin resistance have been reported in some hospital systems, with >80% of tested isolates being resistant. To better understand our resistance levels, we selected 238 MRSA isolates from blood cultures to be tested for mupirocin resistance to correlate the presence of resistance and use of mupirocin for decolonization. We choose to assess MRSA blood isolates rather than nasal swabs given that we aim to prevent invasive MRSA infections, including blood stream infections, with decolonization. The blood cultures were collected from 11 acute-care facilities within our system from March 2021 through June 2022. High-level resistance was defined as an MIC >1,024 μg/mL according to Clinical and Laboratory Standards Institute guidelines. Of those, 7.14% showed high level resistance, and 76.47% occurred in those who were exposed to mupirocin and 23.53% occurred in those without mupirocin exposure (P = .0094). On average, those with high-level resistance had had more recent exposure to mupirocin compared to those without resistance, which was statistically significant. Also, those with high resistance, on average, received more doses of mupirocin, although this was not statistically significant. Conclusions: More recent and higher number of doses of mupirocin were associated with the development of resistance, which is consistent with what we know from pharmacodynamics of antibiotic resistance with other agents. These findings may be particularly important for those patients who have frequent hospitalizations and often require decolonization. Understanding baseline mupirocin resistance levels in an institution can assist with determining decolonization strategies.Disclosures: None
Fanny pack transmission of carbapenem-resistant Acinetobacter baumannii
Authors: DelleFave Amber , Mandarano Juliana , El-Daher Nayef 
Published: September 2023

Background: Carbapenem-resistant Acinetobacter baumannii (CRAB) is a gram-negative coccobacillus that has garnered notoriety as a formidable cause of nosocomial infection with significant mortality. This organism poses a significant threat due to its multitude of resistance mechanisms and ability to endure within the environment. In the summer of 2022, a 350-bed acute-care hospital identified an outbreak of CRAB among critically ill patients in the intensive care unit (ICU) and intensive nursing care unit (INCU). Here, we report actions taken to contain the outbreak and to identify a common environmental source. Methods: In total, 7 nosocomial CRAB infection cases were identified by the infection prevention team between July and September 2022. A multidisciplinary team reviewed the cases using relevant medical history and available microbial susceptibilities. Clinical culture sites include 1 PICC tip, 1 urine sample, 1 peritoneal fluid samples, 5 wounds, and 1 sputum sample. Of 7 infections, 6 met the criteria for hospital onset, with an average time to infection from admission of 61 days. We quickly initiated universal contact precautions in the ICU and INCU for 6 weeks, enhanced daily cleaning of high-touch surfaces, provided staff and visitor education, conducted adenosine triphosphate (ATP) testing, collected observations, and performed selective environmental culturing based on observations. Results: In total, 71 environmental specimens were collected for culture. All were negative with the exception of 1 isolate obtained from the fanny pack of a wound-care nurse that was positive for CRAB. Also, 4 available patient isolates and the environmental isolate were sent to New York State Department of Health Wadsworth Center (NYSDOH Wadsworth) for genome sequencing, and relation to the same cluster was confirmed. Of 7 isolates, 6 were confirmed to express the blaOXA-23 resistance mechanism (1 was not available for testing). Subsequently, chart review identified that a wound-care nurse had had contact with all 7 patients within 30 days of their infections. Conclusions: After initiation of the described action plan, no further transmission was identified in the ICU or INCU. Real-time observation and environmental culturing was critical in identifying the epidemiological link, and this finding speaks to the ability of this organism to persist on a surface for a substantial length of time. Fanny pack use for transport of patient-care supplies was identified as a high-risk practice due to the inability to be properly disinfected between rooms and limited laundering. Fanny packs are no longer permitted in clinical spaces at this facility.Disclosures: None
Healthcare-associated Stenotrophomonas maltophilia infections in the United States, 2018–2022
Authors: Keaton Amelia , Fike Lucy , Spicer Kevin , Kallen Alexander , Perkins Kiran 
Published: September 2023

Background:Stenotrophomonas maltophilia is an important cause of opportunistic healthcare-associated infections (HAIs) in critically ill patients and is difficult to treat due to intrinsic resistance to multiple antibiotic classes. During the COVID-19 pandemic, the CDC received anecdotal reports of increases in S. maltophilia respiratory infections. To further investigate these reports, we used a national electronic healthcare database to evaluate changes in S. maltophilia during the pandemic. Methods: Using the PINC-AI healthcare data (Premier Inc, Charlotte, NC) we identified all potential HAIs by calculating the total number of unique patients hospitalized during January 1, 2018, through December 31, 2021, who had any organism isolated on clinical culture obtained >3 days after admission. We calculated the proportion of patients with S. maltophilia detected in culture and stratified them by specimen source. To determine whether COVID-19 diagnosis influenced the proportion of patients diagnosed with S. maltophilia respiratory infections during the pandemic (January 1, 2020–December 31, 2021), we calculated the proportion of patients with S. maltophilia detected among those with any bacterial pathogen isolated from a respiratory culture >3 days after hospitalization. We stratified these results by presence or absence of concurrent COVID-19 diagnosis. Pearson χ2 test was used to test for differences where appropriate. Results: Among hospitalized patients with any organism isolated from a clinical culture, the proportion with S. maltophilia detected was higher in 2021 (n = 2,554 of 118,029, 2.2%) than in 2018 (n = 2,063 of 155,624, 1.3%) p 3 days after hospital admission from 2018 to 2021. Most patient isolates were from respiratory specimens. A concurrent diagnosis of COVID-19 did not appear to increase the likelihood of respiratory S. maltophilia detection. The increases in S. maltophilia during the pandemic might be explained by challenges inherent to caring for increased numbers of higher-acuity patients during this time, including staffing shortages and changes to infection prevention practices. Additional exploration of these data, as well as data from other sources and from additional years, may help to elucidate this issue more fully.Disclosures: None
Impact of respiratory syncytial virus in an open bay neonatal intensive care unit
Authors: Morris Minisha , Vasandani Annette , Estrada Yvonne , Merchant Malik , Garcia Annie , Duran John , Gallant Melissa , Benesh Adonica 
Published: September 2023

Background: Respiratory syncytial virus, RSV, is a respiratory virus that causes cold-like symptoms in adults. In infants and young children, RSV can cause severe illnesses such as bronchiolitis or pneumonia. We describe a successful response to a laboratory-confirmed RSV outbreak in a 21-bed open-pod neonatal intensive care unit (NICU) at a level 2 trauma hospital. Methods: After 2 of the 3 initial neonates were diagnosed with hospital-onset RSV, an outbreak investigation began on November 16, 2022. Following the results, testing was expanded to all neonates in the NICU. The clinical case was defined as a hospitalized neonate with laboratory confirmation of RSV by RSV antigen screen or polymerase chain reaction (PCR) detection on the Biofire respiratory panel. Outbreak resolution was determined by utilizing a viral test for the remaining positive neonates after the 2-week incubation period from the last identified positive neonate. Results: On day 1 of the investigation, 6 of 18 neonates were identified as positive for RSV. The initial 12 negative neonates received a prophylactic dose of palivizumab. Due to the increase in positive neonates, enhanced infection prevention and control measures were immediately implemented. These measures included the immediate closure of the NICU for new transfers, placing all positive neonates in a single-bay cohort in the NICU, implementing contact and droplet precautions, minimizing shared staff, increasing environmental cleaning, and using dedicated equipment. With awareness of the increased community occurrence of RSV, additional measures were taken to monitor adherence to infection prevention and control measures by staff and visitors entering the NICU, including daily symptom screening. Visitation was restricted to block scheduling to monitor the number of individuals in the NICU. Once we obtained the complete conversion of the initial neonate cohort, the additional focus shifted to maintaining the enhanced precautions until all neonate laboratory tests were negative. The NICU was successfully reopened once the remaining 3 positive neonates received no growth on their viral culture. Conclusions: The quick and effective response from a multidisciplinary team allowed a successful intervention to mitigate the identified outbreak. This investigation highlights the importance of enhanced infection prevention and control practices during increased community spread. Future efforts focus on educating staff and visitors on appropriate measures to decrease transmission risks.Disclosures: None
COVID-19 outbreak in an acute psychiatric unit—Unique challenges and creative solutions
Authors: Narasimhan Supriya , Oribello Sherilyn , Tang Laura , Stoll Tracey , Mony Vidya 
Published: September 2023

Background: We describe the management of a major COVID-19 outbreak in January 2022 during the SARS-CoV-2 omicron-variant winter surge involving the only inpatient psychiatric facility of Santa Clara County, California, which serves a population of 1.9 million. Methods: On January 14, 2022, infection prevention staff were notified of a symptomatic COVID-19 case in our locked inpatient psychiatric unit who had been admitted since October 2021. The index patient had no visitors or transfers outside the unit. The patients in this unit were noncompliant with masking and mingled with each other during meals. Initial testing identified 23 positive cases among 47 patients and 12 staff cases. Mitigating actions included closing the unit to new admissions, creating alternate care areas in the emergency psychiatric unit, and separating patients into “exposed but negative” and “infected” cohorts and housing them in “red,” and “yellow” zones, respectively. A “green” zone was created by clearance of positive cases. For the cohort exposed to COVID-19, masking was enforced by supervision, dining was scheduled in batches, and daily symptom screening and antigen testing were performed in addition to standard postexposure RT-PCR testing on day 4 and day 7. Mandatory N95 respirators and eye protection were implemented for staff on unit entry. Exposed staff followed employee health protocols for postexposure testing. Enhanced environmental control measures included terminal cleaning and UV-C disinfection of common areas and patient rooms and a thorough investigation of airflow. Discharged patients were contacted if they were residing in congregate facilities. Results: Of 47 patients, 39 (83%) tested positive for COVID-19. However, 8 patients remained negative; all 8 had received at least their primary vaccine series (Table 1). In total, 16 HCWs were SARS-CoV-2 positive in this outbreak. The outbreak officially ended 25 days after the first case. All SARS-CoV-2–positive patients had mild illness, not requiring treatment or hospitalization. We identified vaccine immune escape, staff presenteeism, patient noncompliance with masking, and comingling as major causes of transmission. We determined through contact tracing and temporality that the outbreak likely started from a positive staff member or visitor because most patients had been long-term residents. Conclusions: This outbreak was challenging due to the specialized behavioral needs of the involved patients. It was imperative to reopen this unit quickly and safely to provide psychiatric care to our county’s most vulnerable patients. Ongoing PPE education, repeated reinforcement, engagement in staff wellness to combat pandemic fatigue, and aggressive vaccination are all crucial to minimizing the impact of future outbreaks.Disclosures: None