Background: The estimated economic cost of Clostridioides difficile infection (CDI) is $5.4 billion annually, primarily attributed to acute-care costs. We previously reported data from ECOSPOR III that SER-109, an investigational oral microbiome therapeutic, was superior to placebo in reducing recurrent CDI (rCDI) in adults at 8 weeks after treatment, with a 68% relative risk reduction. Adults with rCDI have more hospitalizations and emergency room (ER) visits (defined herein as healthcare resource utilization, HRU) compared to those without recurrence. Thus, we evaluated incidence of HRU. Methods: Adults with rCDI (≥3 episodes in 12 months) were screened at 56 US and Canadian sites and were randomized 1:1 to SER-109 (4 capsules × 3 days) or placebo following resolution of CDI with standard-of-care CDI antibiotics. The primary end point was rCDI at 8 weeks. Exploratory end points included cumulative incidence of hospitalizations through 24 weeks after treatment. Here, we report cumulative incidence of all-cause HRU through 8 weeks after treatment. Results: In total, 281 patients were screened and 182 were randomized (59.9% female; mean age 65.5 years; 98.9% outpatient). Overall, 31 patients (17%) had 38 hospitalizations or ER visits through week 8 (11 events in 10 SER-109 patients and 27 events in 21 placebo patients) (Table 1). The cumulative incidence of HRU was lower in SER-109–treated patients compared to placebo at both weeks 4 and 8 with most events (65.8%) recorded within 4 weeks after treatment. The adjusted HRU incidence rate (by person time, age, sex, and antibiotic use) was also lower in SER-109–treated patients compared to placebo at weeks 4 and 8 (0.256 [95% CI, 0.096–0.683] versus 0.417 [95% CI, 0.199–0.873], respectively). Conclusions: SER-109–treated patients had less HRU compared to placebo patients through 8 weeks after treatment in this mostly outpatient population. These data suggest a potential benefit of SER-109 in reducing HRU, thus lowering the healthcare burden of rCDI.

Funding: Seres Therapeutics

Disclosures: None

Background: Central-line–associated bloodstream infections (CLABSIs) arise from bacteria migrating from the skin along the catheter, by direct inoculation, or from pathogens that form biofilms on the interior surface of the catheter. However, given the oxygen-poor environments that obligate anaerobes require, these organisms are unlikely to survive long enough on the skin or on the catheter after direct inoculation to be the true cause of a CLABSI. Although some anaerobic CLABSIs may meet the definition for a mucosal-barrier-injury, laboratory-confirmed, bloodstream infection (MBI-LCBI), some may be not. We sought to determine the proportion of CLABSIs attributed to obligate anaerobic bacteria, and we sought to determine the pathophysiologic source of these infections. Methods: We performed a retrospective analysis of prospectively collected CLABSI data at 54 hospitals (academic and community) in the southeastern United States from January 2015 to December 2020. We performed chart reviews on a convenient sample for which medical records were available. We calculated the proportion of CLABSIs due to obligate anaerobes, and we have described a subset of anaerobic CLABSI cases. Results: We identified 60 anaerobic CLABSIs of 2,430 CLABSIs (2.5%). Of the 60 anaerobic CLABSIs, 7 were polymicrobial with nonanaerobic bacteria. The most common species we identified were Bacteroides, Clostridium, and Lactobacillus (Table 1). The proportion of anaerobic CLABSIs per year varied from 1.2% to 3.7% (Fig. 1). Of 60 anaerobic CLABSIs, 29 (48%) occurred in the only quaternary-care academic medical center in the database. In contrast, an average of 0.6 (SD, 0.6) anaerobic CLABSIs occurred in the 53 community hospitals over the 6-year study period. Of these 29 anaerobic CLABSIs, 23 (79%) were clinically consistent with secondary bloodstream infections (BSIs) due to gastrointestinal or genitourinary source, but they lacked appropriate documentation to meet NHSN criteria for secondary BSI or MBI-LCBI based on case reviews by infection prevention physicians. The other 6 anaerobic CLABSIs did not have a clear clinical etiology and did not meet MBI-LCBI criteria. In addition, 27 (93%) of 29 anaerobic CLABSIs occurred in patients who were either solid-organ transplant recipients, were stem-cell transplant recipients, or were receiving chemotherapy. Lastly, 27 (93%) of 29 anaerobic CLABSIs were treated with antibiotics. Conclusions: Anaerobic CLABSIs are uncommon events, but CLABSI may disproportionately affect large, academic hospitals caring for a high proportion of medically complex patients. Additional criteria could be added to the MBI-LCBI to better classify anaerobic BSI.

Funding: None

Disclosures: None

Background: Contact tracing alone is often inadequate to determine the source of healthcare personnel (HCP) COVID-19 when SARS-CoV-2 is widespread in the community. We combined whole-genome sequencing (WGS) with traditional epidemiologic analysis to investigate the frequency with which patients or other HCP with symptomatic COVID-19 acted as the source of HCP infection at a large tertiary-care center early in the pandemic. Methods: Cohort samples were selected from patients and HCP with PCR-positive SARS-CoV-2 infection from a period with complete retention of samples (March 14, 2021–April 10, 2020) at Rush University Medical Center, a 664-bed hospital in Chicago, Illinois. During this period, testing was limited to symptomatic patients and HCP. Recommended respiratory equipment for HCP evolved under guidance, including a 19-day period when medical face masks were recommended for COVID-19 care except for aerosol-generating procedures. Viral RNA was extracted and sequenced (NovaSeq, Illumina) from remnant nasopharyngeal swab samples in M4RT viral transport medium. Genomes with >90% coverage underwent cluster detection using a 2 single-nucleotide variant genetic distance cutoff. Genomic clusters were independently evaluated for valid epidemiologic links by 2 infectious diseases physicians (with a third adjudicator) using metadata extracted from the electronic medical record and according to predetermined criteria (Table 1). Results: In total, 1,031 SARS-CoV-2 sequences were analyzed, identifying 49 genomic clusters with HCP (median, 8; range, 2–43 members per cluster; total, 268 patients and 115 HCP) (Fig. 1). Also, 20,190 flowsheet activities were documented for cohort HCP and patient interactions, including 686 instances in which a cohort HCP contributed to a cohort patient’s chart. Most HCP infections were considered not healthcare associated (88 of 115, 76.5%). We did not identify any strong linkages for patient-to-HCP transmission. Moreover, 13 HCP cases (11.3%) were attributed to patient source (weak linkage). Also, 14 HCP cases (12.2%) were attributed to HCP source (11 strong and 3 weak linkages). Weak linkages were due to lack of epidemiologic data for HCP location, particularly nonclinical staff (eg, an environmental service worker who lacked location documentation to rule out patient-specific contact). Agreement for epidemiologic linkage between the 2 evaluators was high (κ, 0.91). Conclusions: Using genomic and epidemiologic data, we found that most HCP COVID-19 infections were not healthcare associated. We found weak evidence to support symptomatic patient-to-HCP transmission of SARS-CoV-2 and stronger evidence for HCP-to-HCP transmission. Large genomic clusters without plausible epidemiologic links were identified, reflecting the limited utility of genomic surveillance alone to characterize chains of transmission of SARS-CoV-2 during extensive community spread.

Funding: None

Disclosures: None

Background: Povidone-iodine and chlorhexidine gluconate are commonly used antiseptics that have broad antiviral properties, including against SARS-CoV-2. Nasal and oral antisepsis is a possible option to reduce viral transmission; however, effectiveness data are limited. The acceptability of this method for adjunct infection control is also unknown. We are conducting a clinical randomized controlled trial (NCT04478019) to evaluate the effectiveness and feasibility of nasal and oral antisepsis to prevent COVID-19. Methods: Healthcare and other essential workers with in-person job duties were recruited into a 10-week clinical trial. Participation did not require in-person activities: all communication was web- or telephone-based, supplies were shipped directly to the participant, and participants self-collected specimens. Participants completed a 3-week intervention and 3-week control phases and were randomized to the timing of these phases (Fig. 1). During the 3-week intervention phase, participants applied povidone-iodine nasal swabs 2 times per day and chlorhexidine gluconate oral rinse 4 times per day following the manufacturers’ instructions for use. Participants continued all usual infection control measures (eg, face masks, eye protection, gowns, hand hygiene) as required by their workplace. To measure effectiveness against viral transmission, participants collected midturbinate nasal swabs 3 times per week to measure SARS-CoV-2 viral load. Participants also self-reported COVID-19 tests they received and why (eg, symptoms or exposure). To assess acceptability, participants completed pre- and post-surveys about their perceived and actual experience with the interventions. Participants also self-reported adverse effects due to the intervention. Results: As of December 3, 2021, 221 participants (148 healthcare workers and 73 non–healthcare essential workers) had enrolled. Moreover, 20 adverse effects have been reported, including skin irritation, epistaxis, and mouth discoloration; 9 participants withdrew due to side effects. Laboratory analyses are ongoing to measure effectiveness in reducing SARS-CoV-2 viral load. We performed an interim analysis of intervention acceptability. Survey responses were given on a Likert scale of 1 (not at all) to 5 (extremely). Although 36% of respondents (n = 74) reported on the postsurvey that the intervention was less acceptable than they had expected on the presurvey, the overall acceptability measure was still relatively high (3.76) (Fig. 2). In addition, 76% of respondents reported that they would use the intervention in the future (n = 56). Conclusions: Participant recruitment is ongoing, and data continue to be collected to analyze effectiveness and feasibility. Preliminary data suggest that participants find the nasal and oral antisepsis intervention to be an acceptable option to complement standard infection control methods to prevent COVID-19.

Funding: Professional Disposables International, Healthcare Division (PDIHC)

Disclosures: None

Background: SARS-CoV-2 infection of healthcare workers (HCWs) occasionally occurs via acquisition from their colleagues. Data regarding the infection rates of HCWs with close contact and non–close contacts of HCWs are limited. In addition, the protective effect of COVID-19 vaccination against transmission between HCWs is unknown. We evaluated the infection rates of HCWs with close contact and non–close contact of infected HCWs and the effect of COVID-19 vaccination on transmission among HCWs in a tertiary-care hospital in South Korea. Methods: This study was performed in a tertiary-care hospital in Korea. We analyzed the COVID-19 cases and contacts among HCWs from January to December 2021. We reviewed the vaccination status of confirmed and exposed HCWs, the type of vaccination, and the infection rate according to the contact. We performed subgroup analyses in individuals who had been diagnosed since July 2021 when the δ (delta) variant became the dominant strain in South Korea. Transmission was defined based on their spatiotemporal epidemiologic association. Results: During the study period, 173 HCWs had COVID-19, and 2,693 HCWs were exposed to them. Among them, 18 (1.52%) of 1,186 close contacts and 13 (0.86%) of 1,507 non–close contacts had a positive SARS-CoV-2 test (P = .11). When the index cases had been fully vaccinated, the infection rate of close contacts was 0.85% (7 of 820), whereas the infection rate of close contacts was 3.01% (11 of 366) when the index had not been fully vaccinated (P = .005). However, the infection rate of non–close contacts was not different according to the vaccination status of index (0.83% vs 0.89%; P = .90). During the period of δ (delta) variant being dominant, the infection rate of close contacts was significantly lower when the index case had been fully vaccinated index than in cases with a non–fully vaccinated index case (0.85% vs 5.88%; P < .001). Conclusions: Transmission to colleagues was significantly lower from vaccinated HCWs than from nonvaccinated HCWs, and this finding was more significant in the era of the δ (delta) variant. Our findings support the importance of vaccination in HCWs.

Funding: None

Disclosures: None

Background: During this pandemic, the public has struggled to navigate the abundance of COVID-19 vaccine misinformation, and it is unclear how this misinformation has affected medical providers and their recommendations for patients. We sought to understand differences in COVID-19 vaccine knowledge, beliefs, and attitudes among Oregon healthcare provider types and regions of practice (rural, suburban, urban). Methods: A 36-question survey was constructed using Qualtrics with consultation from a survey methodologist. The survey was reviewed and approved by OHSU IRB and distributed via listserv or social media posting to provider societies in Oregon, including nurse practitioners (NPs), naturopathic doctors (NDs), physician assistants (PAs), doctors of medicine (MDs), doctors of osteopathic medicine (DOs), or practioners with a bachelor of medicine–bachelor of surgery (MBBS), and via the Oregon Health Authority (OHA) immunization practice listserv. The survey accepted responses from July 9 to August 12, 2021. Participants were volunteers and responses were anonymous. Results: We collected 101 responses. Among them, 87 participants completed 100% of survey questions. Survey respondents were predominantly White females aged 41–50 years with an MD, DO, or MBBS. The overall COVID-19 vaccination rate of respondents was 94.6%. The vaccination rate was highest among the 4 NDs and 7 PAs at 100%, followed by 78 MDs, DOs, and MBBSs at 96.2%, and 12 NPs at 75%. Of NP respondents, 67% practiced rurally; 25.6% of MDs, DOs, and MBBSs practiced rurally; and 25% of NDs and 28.6% of PAs practiced rurally. In total, 22% of NPs did not feel comfortable recommending the COVID-19 vaccine to patients, compared to 1% of MDs, DOs, and MBBSs and 0% of NDs or PAs. All provider types had high rates of disagreement with the statement that the COVID-19 pandemic had increased their trust in vaccine safety: 44% of NPs; 29% of PAs; 25% of NDs; and 7% of MDs, DOs, and MBBSs. Among 19 rural providers, 19% indicated mistrust in public health to ensure that vaccines are safe versus 3% in suburban areas and 0% in urban areas. Conclusions: COVID-19 vaccine hesitancy is prevalent among healthcare providers and may be higher in NPs and those practicing rurally. Unfortunately, the response rate of NPs was low. Future research should focus on these providers to better understand their knowledge, beliefs, and attitudes about COVID-19 vaccines. These results can also inform future targeted vaccine education to healthcare providers during public health crises.

Funding: None

Disclosures: None

Background: SARS-CoV-2, the virus causing COVID-19 infection, can significantly contaminate environmental surfaces and can remain viable on surfaces for up to 9 days. Although respiratory route remains the most significant mode of transmission, fomites and environmental sources of infection remain a concern for healthcare personnel who are working in dedicated COVID-19 units. We investigated the extent of detectable SARS-CoV-2 contamination in the environment of COVID-19 patients at a single VA hospital, with the intent of identifying potential high-touch surfaces at risk for viral contamination, which could be used to inform the development of simple COVID-19 prevention strategies. Methods: We conducted a cohort study at 1 VA hospital in a unit housing adult veterans admitted with COVID-19 between October and December 2020. In total, 11 swab specimens were collected for PCR analysis (SARS-CoV-2 env gene) from environmental surfaces inside and just outside the rooms of COVID-19 patients one time. Retrospective chart reviews were conducted to provide the SARS-CoV-2 epidemiologic context for environmental detection. Results: In total, 297 swabs were collected from the unit and environmental areas surrounding 27 hospitalized patients: average age, 72.5 years (range, 34–94); 100% male; 92% non-Hispanic white; average comorbidities, 1.8 (SD, 1.1). Of 297 swabs, 80 (27%) were positive for SARS-CoV-2 and 19 (70%) of 27 patients had at least 1 positive site. The most contaminated site was the floor just outside the patient room (78% positive samples), followed by the patient’s bedrail (37%) and chair handle (37%) (Fig. 1). Traditionally high-touch surfaces, such as the door handle (outside patient room) and the light switch, did not have high positivity rates (<15%). Interestingly, both the personal protective equipment (PPE) cart outside patient’s room (33%) and the double doors leading out of the unit (19%) were positive, which are surfaces often touched with bare hands after handwashing. Analyses of clinical data are underway to examine whether specific care needs, based on activities of daily living disability, comorbidities, and clinical presentation of COVID-19, predict SARS-CoV-2 environmental contamination. Conclusions: The presence of environmental contamination by SARS-CoV-2 highlights the importance of transmission via direct or indirect contact. Studies targeting high-risk populations are needed to better understand the transmission of SARS-CoV-2 between infected patients and their environment. Our findings also suggest that handwashing and attention to using disinfecting wipes may mitigate the risk of transmission of virus from surfaces that one might consider safe to touch.

Funding: None

Disclosures: None

Background: Aerosol-generating procedures (AGPs) performed on COVID-19–positive patients raise concerns about the dissemination of SARS-CoV-2 via aerosols and droplets. Infectious aerosols and droplets generated by SARS-CoV-2–positive patient AGPs or through direct COVID-19 patient coughing or exhalation could potentially contaminate surfaces, leading to the indirect spread of SARS-CoV-2 via fomites within the emergency department (ED). We sampled surfaces of ED patient rooms occupied by known SARS-CoV-2–positive patients or patients under investigation for COVID-19 and undergoing an AGP to determine the frequency of room contamination with SARS-CoV-2 RNA. Methods: Swabs were collected from 5 room surfaces in the ED following AGPs performed on patients under investigation for COVID-19 or positive for SARS-CoV-2. High- and low-touch surfaces 6 feet (2 m) from the patient (door handle and return vent, respectively) and reusable medical equipment were swabbed. Swabs were tested for SARS-CoV-2 RNA by RT-qPCR; positive samples were cultured in Vero E6 cells. Patient COVID-19 results were confirmed through the electronic medical record. Results: In total, 203 rooms were sampled: 43 SARS-CoV-2–positive patients with an AGP, 44 SARS-CoV-2–positive patients who did not have an AGP, and 116 SARS-CoV-2–negative patients with an AGP, for a total of 1,015 swabs. Overall, SARS-CoV-2 RNA was detected on 36 (3.5%) surfaces from 29 rooms (14.3%) (Table 1). RNA contamination was detected more frequently in rooms occupied by SARS-CoV-2–positive patients who did not have an AGP than rooms occupied by COVID-19 patients (30% vs 14%). SARS-CoV-2 RNA was also detected in rooms occupied by SARS-CoV-2–negative patients undergoing an AGP (9%). SARS-CoV-2 RNA was most frequently detected on air vents (n = 15), bedrails (n = 10), equipment and vital signs monitors (n = 4 each), and door handles (n = 3). One bedrail was positive by culture and confirmed by an RT-qPCR cycle threshold reduction from >40 to 13. Conclusions: We detected SARS-CoV-2 RNA contamination on room surfaces in the ED, regardless of patient AGP or COVID-19 status; however, RNA contamination of room surfaces was most common in rooms occupied by SARS-CoV-2–positive patients who did not have an AGP, which may be attributable to stage of disease and viral shedding. SARS-CoV-2 RNA contamination was also present in rooms where APGs were performed on SARS-CoV-2–negative patients, suggesting carryover from previous patients. SARS-CoV-2 RNA was found most often on room air-return vents, further emphasizing the importance of aerosols in the spread of SARS-CoV-2.

Funding: None

Disclosures: None

Background: An increase in candidemia has been observed throughout the world since the start of the COVID-19 pandemic. Patients with COVID-19 may have different risk factors, clinical presentations, and outcomes compared to patients without COVID-19. Methods: We conducted a retrospective chart review of all inpatients with candidemia at a large, academic medical center from April 30, 2019, to February 19, 2021. The first case of COVID-19 was detected at our institution March 2020 and patients were sorted into pre– versus post–COVID-19 pandemic groups. Data regarding clinical characteristics, risk factors, and outcomes were collected. The rate of candidemia per 10,000 patient days was calculated from January 2013 through February 2021. Results: In total, 202 patients were identified with candidemia: 92 cases were identified before the pandemic and 110 cases were identified after the pandemic began. Moreover, 33 (16.3%) patients were diagnosed with COVID-19 during the admission and 169 (83.7%) did not have COVID-19. Patients with COVID-19 were significantly more likely to be older (median, 64.5 vs 54.8 years; P = .0006) and to have a higher body mass index (32.8 vs 29.1; P = .03) than patients without COVID-19. Patients with COVID-19 were less likely have some of the traditional risk factors (eg, abdominal surgery, total parenteral nutrition, history of injecting drugs) for candidemia compared to patients without COVID-19. Patients with COVID-19 were significantly more likely to require ICU care (97.0% vs 67.5%; P < .001) and to require mechanical ventilation (90.9% vs 53.9%; P < .001), and they had higher mortality at 30 days (66.7% vs 31.4%; P < .001). A multivariate logistic regression model showed that COVID-19 (OR, 2.53; 95% CI, 1.09–5.90) and higher age (OR 1.45, 95% CI, 1.11–1.91) were significant predictors of 30 day mortality. Using a Poisson regression model, the incidence rate ratio for candidemia per month after the start of the COVID-19 pandemic was 2.09 (95% CI, 1.85–2.36; P < .0001) compared to the years prior. Conclusions: Rates of candidemia significantly increased after the start of the COVID-19 pandemic. Patients with candidemia in the post–COVID-19 era tend to have nontraditional risk factors, to be more critically ill, and to have increased mortality compared to patients in the pre–COVID-19 era. COVID-19 and higher age were independent predictors of mortality. More studies are needed to further define risk factors for candidemia in patients with COVID-19.

Funding: None

Disclosures: None

Background: Candida auris is an emerging multidrug-resistant yeast that is transmitted in healthcare facilities and is associated with substantial morbidity and mortality. Environmental contamination is suspected to play an important role in transmission but additional information is needed to inform environmental cleaning recommendations to prevent spread. Methods: We conducted a multiregional (Chicago, IL; Irvine, CA) prospective study of environmental contamination associated with C. auris colonization of patients and residents of 4 long-term care facilities and 1 acute-care hospital. Participants were identified by screening or clinical cultures. Samples were collected from participants’ body sites (eg, nares, axillae, inguinal creases, palms and fingertips, and perianal skin) and their environment before room cleaning. Daily room cleaning and disinfection by facility environmental service workers was followed by targeted cleaning of high-touch surfaces by research staff using hydrogen peroxide wipes (see EPA-approved product for C. auris, List P). Samples were collected immediately after cleaning from high-touch surfaces and repeated at 4-hour intervals up to 12 hours. A pilot phase (n = 12 patients) was conducted to identify the value of testing specific high-touch surfaces to assess environmental contamination. High-yield surfaces were included in the full evaluation phase (n = 20 patients) (Fig. 1). Samples were submitted for semiquantitative culture of C. auris and other multidrug-resistant organisms (MDROs) including methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococcus (VRE), extended-spectrum β-lactamase–producing Enterobacterales (ESBLs), and carbapenem-resistant Enterobacterales (CRE). Times to room surface contamination with C. auris and other MDROs after effective cleaning were analyzed. Results: Candida auris colonization was most frequently detected in the nares (72%) and palms and fingertips (72%). Cocolonization of body sites with other MDROs was common (Fig. 2). Surfaces located close to the patient were commonly recontaminated with C. auris by 4 hours after cleaning, including the overbed table (24%), bed handrail (24%), and TV remote or call button (19%). Environmental cocontamination was more common with resistant gram-positive organisms (MRSA and, VRE) than resistant gram-negative organisms (Fig. 3). C. auris was rarely detected on surfaces located outside a patient’s room (1 of 120 swabs; <1%). Conclusions: Environmental surfaces near C. auris–colonized patients were rapidly recontaminated after cleaning and disinfection. Cocolonization of skin and environment with other MDROs was common, with resistant gram-positive organisms predominating over gram-negative organisms on environmental surfaces. Limitations include lack of organism sequencing or typing to confirm environmental contamination was from the room resident. Rapid recontamination of environmental surfaces after manual cleaning and disinfection suggests that alternate mitigation strategies should be evaluated.

Funding: None

Disclosures: None

Background: Bloodstream infections (BSIs) due to carbapenem-resistant Acinetobacter baumannii (CRAB) are difficult to treat and are associated with high mortality, particularly in neonates. Healthcare-associated CRAB infections have been linked to environmental reservoirs and are associated with seasonal clustering. CRAB outbreaks are being reported more frequently in sub-Saharan Africa, but published reports from this region that incorporate comprehensive surveillance data and environmental investigations are rare. Methods: We reviewed microbiology surveillance records at a 530-bed, public, tertiary-care hospital in Botswana from January 1 to December 13, 2021, and we collected data regarding age, specimen type, and onset date for all cultures from unique patients growing Acinetobacter spp. An automated blood-culture system was used for organism detection, manual biochemical tests were used for identification, and disc and agar diffusion methods were used for antimicrobial sensitivity testing. During this time, we conducted 4 point-prevalence environmental sampling surveys at this hospital’s 36-bed neonatal unit from January through June 2021 in addition to 3 neonatal CRAB cluster investigations. Environmental samples from surfaces, hands of caregivers and healthcare workers, and equipment were collected using flocked swabs. Extended-spectrum β-lactamase–producing organisms from environmental samples were identified using selective and differential chromogenic media (CHROMagarTM ESBL). Results: Overall, 48 Acinetobacter infections were identified, including 28 BSIs (among 3,699 blood cultures processed, approximately one-third of which were from neonates). More than half of cases were perinatal, which included 16 neonatal BSIs (median age, 4 days; case fatality rate, 56%), and 1 fatal case of postpartum sepsis in a 37-year-old mother. Among isolates tested, 35 (92%) of 38 demonstrated carbapenem resistance. Treatment information was not available for all neonatal patients, but delays in appropriate antimicrobial therapy were cited in all fatal cases. Most neonatal CRAB cases clustered in time and space (Fig. 1). For example, 15 (71%) of 21 neonatal cases occurred in the same unit and same week as another case. In the neonatal unit, CRAB clusters were associated with increased Acinetobacter recovery during environmental point-prevalence surveys (Fig. 1). Acinetobacter contamination was identified on feeding equipment (breast pumps, feeding tubes), respiratory equipment (suction machines or catheters, ventilator humidifiers), and hands of caregivers and healthcare workers. Conclusions: We report hyperendemic rates of CRAB infections with evidence of spatotemporal clustering, especially among neonates. Higher CRAB incidence coincided with increased Acinetobacter recovery during environmental sampling. We identified plausible transmission vehicles (respiratory or feeding devices, hands) in the neonatal care environment highlighting the value of environmental sampling to support CRAB investigations and reinforcing the importance of comprehensive and consistent disinfection practices, especially in resource-limited settings where equipment is shared or reused.

Funding: None

Disclosures: None

Background: Monitoring uptake of infection prevention and control (IPC) interventions is critical for the targeted and rational use of limited resources. A national facility readiness assessment conducted in August 2020 provided key information for targeted interventions to strengthen priority IPC areas. We assessed the level of COVID-19 preparedness in the facilities, identified priority COVID-19 IPC gaps, and generated a baseline report to further guide IPC investments at all levels. Methods: The Kenya Ministry of Health in collaboration with the CDC and International Training and Education Center for Health adapted a WHO Facility Readiness Assessment tool to include COVID-19–specific areas. In August 2020, data were collected using tablets through an Android-based electronic platform and were analyzed using descriptive statistics. Assessments were conducted in public, private, and faith-based health facilities nationally after 4 months of preparedness and investment in the healthcare system. Results: We assessed 684 facilities of the targeted 844 (81%). Overall facility readiness in Kenya was rated above average (61%), and the performance score significantly increased with the Kenya Essential Package for Health level, with level 5 and 6 facilities scoring an average of 83% and 79% respectively. Of the assessed facilities, 82% had an appointed IPC coordinator. Only 14% of the facilities had all the required guidelines, policies, and the appropriate COVID-19 case definitions. 67% of the facilities had updated supply inventories for past week. Only 50% of the facilities had adequate supplies of N95 masks. The assessment revealed that 52% of healthcare facilities had trained their healthcare workforce; morticians were the least trained (only 17% of facilities). Moreover, 41% of the facilities had clear work plans for monitoring healthcare workers exposures to COVID-19, but only 33% of the facilities had policies on the management of infected healthcare workers. Conclusions: The findings provided critical information for stakeholders at all levels to be used for policy decisions, to prioritize key intervention areas in leadership and governance of facility IPC programs, for guideline development, and for capacity building and targeted investment in IPC to improve COVID-19 facility preparedness.

Funding: None

Disclosures: None

Background: Transmission of methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococcus (VRE) is of special concern among frail patients in nursing homes. To understand environmental contamination patterns in this setting, we screened a suitable section of a nursing home over time and assessed MRSA and VRE prevalence in patients and their rooms. We were especially interested in assessing whether MRSA and VRE strains persist in rooms during changes of occupancy after patient discharge. Methods: We conducted a prospective cohort study of MRSA and VRE colonization and contamination among successive patients in a cluster of 9 single-occupancy rooms. Using flocked swabs, 5 high-touch surfaces were screened 3 times a week for 34 weeks. Patients were also screened (ie, nares, groin, and hands), if they agreed to participate. Whole-genome sequencing was performed on 67 nonredundant MRSA and VRE strains. Single-nucleotide polymorphism heatmaps and similarity trees were generated to evaluate strain diversity and persistence the facility. Results: Overall, 146 distinct occupancy events were captured during the study (16.5 average per room; range, 11–22), with 387 study visits and 4,670 total swabs collected. All rooms were contaminated with VRE, and 8 of 9 were contaminated with MRSA at least once during the study period. New contamination of a room with MRSA or VRE was observed in 43 (23%) of 185 opportunities, with potential persistence during occupancy changes in 25 (32.9%) of 76 opportunities. Sequencing of 67 nonredundant isolates identified at least 6 enterococcal clades and 10 MRSA clades (6 USA100 and 4 USA300), indicating a high degree of diversity and probably multiple introductions in the facility during the study time. In 3 separate cases, whole-genome sequencing confirmed persistence of a specific MRSA strain during a change of room occupancy, including 1 case of a MRSA strain persisting in a clean room before admission of the next patient. For VRE, 2 cases of persistence during room occupancy changes were confirmed, along with 6 cases of possible persistence (contamination across noncontiguous room occupancy events). Conclusions: Active surveillance screening and a recurring evaluation of terminal cleaning procedures should be considered due to high levels of circulation and persistence of MRSA and VRE in the nursing home setting.

Funding: None

Disclosures: None

Background: Multidrug-resistant organisms (MDROs) are a global threat. To track and contain the spread, the Tennessee Department of Health (TDH) performs targeted surveillance of carbapenemase-producing and pan-nonsusceptible organisms. When these MDROs are identified, TDH conducts a containment response and collects epidemiological data, which includes risk factors such as indwelling devices and previous hospitalizations. The impact of the COVID-19 pandemic on these MDROs is not well understood. Therefore, we have described the characteristics of cases positive for both COVID-19 and select MDROs. Methods: MDRO investigation data from January 1, 2020–September 30, 2021 were matched with all COVID-19 case data from the TDH statewide surveillance system, National Electronic Disease Surveillance System Base System. MDRO-positive date was defined as the specimen collection date; COVID-19 case date was first defined as the date of symptom onset and if missing, then diagnosis date, and investigation creation date, respectively. Descriptive statistics and Fisher exact tests were calculated using SAS version 9.4 software. Results: Among 336 MDRO cases, 50 had a reported SARS-CoV-2–positive result. MDRO types were Enterobacterales (CRE) (n = 31), Acinetobacter spp (CRA) (n = 18), and Pseudomonas aeruginosa (n = 1). Of these 50 cases, 20 were MDRO-positive before and 30 days after the COVID-19 case date, respectively. Of the 18 CRA cases, 16 (89%), were positive after the COVID-19 case date, compared to 13 (42%) among 31 CRE cases (P < .01). Also, 35 patients (70%) had a record of hospitalization, and 22 (63%) had their MDRO specimen collected after the COVID-19 case date (P = .37). Of these 22 patients, 4 had their MDRO specimen collected during their COVID-19 hospitalization, with an average duration from admission to MDRO collection date of 17 days (range, 4–36). Among the 50 coinfected cases, 8 died, 7 (88%) of whom were MDRO-positive after their COVID-19 case date. Data on indwelling devices at time of MDRO positivity were completed for 17 cases; 14 had an indwelling device and, among these, 13 (93%) were MDRO-positive after their COVID-19 case date. Conclusions: MDRO cases with specimen collections after COVID-19 comprised the majority of hospitalized patients, patients who died, and patients with indwelling devices compared to those with MDROs collected before their COVID-19 case date. These results show a stark difference with CRA as the most common MDRO among post–COVID-19 cases. Our data were limited by reporting gaps. We recognize that patients can remain colonized with MDROs for lengthy durations, which could have result in undetected MDRO cases prior to the COVID-19 case date. More data and analyses are needed to make targeted public health recommendations. However, these findings highlight the burden of MDROs among COVID-19 cases. including adverse health outcomes.

Funding: None

Disclosures: None

Background: Efficient monitoring of devices to ensure timely removal is an ongoing challenge. There is a need for data visualization products that can aggregate disparate data streams to support device reviews, increase consistency across changes in caregiver teams, and synergize with people and operational processes within and across regional acute-care facilities. Methods: A data display application was developed to provide data from nearly any source in a consistent visual representation that could be used in real time. The infection prevention (IP) overlay combined data related to urinary catheters, central vascular catheters, and femoral vascular catheters from the electronic health record system. Clinical and data experts collaborated to develop data definitions, inclusion criteria, and report components. The application display indicated the current catheter or device status of each patient facility-wide, organized by service unit (Fig. 1). Additional patient information could be accessed from within the application, and a comment feature allowed caregivers to communicate directly through the tool (Fig. 2). Results: Pilot implementation began February 2021, and the NATE IP application was live for all users (unit and facility leaders, providers, infection preventionists, etc) as of July 2021. The tool is currently available for use at 171 acute-care hospitals within the HCA healthcare system, and it accommodated 3 different electronic medical record systems. Usage peaked in August 2021, with an average of 1,700 views per day. Daily utilization maximum ranges from 1,100 to 1,500 views per day, with an average of ~1,300 views per day. The tool is used during daily patient safety rounds, including weekends and holidays. User feedback was overwhelmingly positive, with users reporting an increase in communication, streamlined documentation, improved tracking of reasons to retain, and increased accountability for daily updates. During the proof-of-concept implementation, zero bugs were identified and several feature enhancements were implemented, including addition of port status and device-day reporting counts. Planned enhancements include mupirocin and chlorhexidine bathing use, isolation precaution use, and blood cultures ordered >3 days after admission. Conclusions: The NATE IP tool brings together data related devices into a single view for use by direct caregivers and all levels of leadership. Development of this or similar tools to consolidate various data streams into a central tool facilitates improved communication and consistency between caregiver teams. It also drives operational efficiencies and improves safety. Expansion to incorporate notifications related to potential issue will expand the proactive utility of this tool.

Funding: None

Disclosures: None

Background: Traditional infection prevention (IP) methods for outbreak detection often rely on geotemporal clustering confined to single locations. We recently developed the Enhanced Detection System for Healthcare-Associated Transmission (EDS-HAT), which combines whole-genome sequencing (WGS) surveillance and machine learning of the electronic health record (EHR). Our retrospective research findings show potential transmissions averted and cost savings using EDS-HAT in real time. Here, we describe the process and initial findings from EDS-HAT real-time implementation. Methods: Real-time whole-genome sequencing surveillance began on November 1, 2021. Patient cultures positive for select bacterial pathogens who were hospitalized for ≥3 days or had a recent healthcare exposure in the prior 30-days were collected. Isolates were deemed genetically related if ≤15 single-nucleotide polymorphisms (SNPs) were identified for all organisms except Clostridioides difficile (≤2 SNPs). Clusters were manually investigated by both research and IP teams, and interventions were performed by the IP team. Data on collection, analysis, notification, and intervention dates were gathered. Results: As of January 11, 2022, 413 isolates had undergone whole-genome sequencing. Among them, 18 unique patient isolates were genetically related to ≥1 other isolate, comprising 7 clusters (range, 2–6 patients). Notable findings include a Pseudomonas aeruginosa cluster possibly related to a shared bronchoscope, a pseudo-outbreak of Serratia marcescens related to autopsy blood culture practice, and a cluster of vancomycin-resistant Enterococcus faecium on a shared transplant unit. Only 1 cluster of 2 isolates of Klebsiella pneumoniae had no known possible transmission routes. The median turnaround time from patient’s culture date to IP notification was 19 days (range, 13–28), with noted delays over the winter holiday. Concusions: Real-time WGS can identify small clusters including potentially interruptible transmission routes. Rapid turnaround time, coordination between clinical and genomic laboratories, and a robust IP team are key factors in implementing a WGS surveillance program. Real-time WGS surveillance has the potential to reduce costs for hospitals, improve patient safety, and save lives.

Funding: None

Disclosures: None

Background: Inequities are seen in many health-related outcomes, and systemic and structural factors result in inequitable care based on social determinants of health (SDOH). However, whether disparities exist specifically in healthcare-associated infections (HAIs) based on these factors has not been well described. Furthermore, there are no national standards on whether information related to equity and SDOH should be included in HAI surveillance and how such information could be used. Methods: We surveyed US members of the SHEA Research Network (SRN), a consortium of healthcare facilities with leaders interested in healthcare epidemiology and infection prevention, via an online REDCap survey from October to December 2021. Results: Of the 68 eligible US SRN facilities, 28 (41%) responded. Among them, 27 institutions provide direct patient care and were analyzed. Of these 27 facilities, 8 (30%) collected data regarding variables related to equity including language for care, race or ethnicity, insurance status, and other. Of these faclilities, 38% are collecting but not otherwise using this information; other facilities use this information for a variety of reporting and intervention purposes (Fig. 2). Only 3 facilities (11%) analyzed whether disparities exist in any HAI rates. The most common barrier to collecting SDOH information is that facilities have not considered doing this work (Fig. 3). Of the 15 facilities not yet undertaking such work, 10 (67%) were interested in doing so. Specific recommendations about how to operationalize such collection are needed (Table 1). Conclusions: Most institutions in this sample are not collecting data that would allow for assessment of disparities in the rates of HAIs; however, there is interest in doing so. A minority of early adopter facilities are assessing whether disparities exist and are designing interventions. National guidance can play a key role in standardizing the collection of this information and translating early findings to identify and subsequently improve disparities within HAIs.

Funding: None

Disclosures: None

Background: The δ (delta) variant has spread rapidly worldwide and has become the predominant strain of SARS-CoV-2. We analyzed an outbreak caused by a vaccine breakthrough infection in a hospital with an active infection control program where 91.9% of healthcare workers were vaccinated. Methods: We investigated a SARS-CoV-2 outbreak between September 9 and October 2, 2021, in a referral teaching hospital in Korea. We retrospectively collected data on demographics, vaccination history, transmission, and clinical features of confirmed COVID-19 in patients, healthcare workers, and caregivers. Results: During the outbreak, 94 individuals tested positive for SARS-CoV-2 using reverse transcription-polymerase chain reaction (rtPCR) testing. Testing identified infections in 61 health care workers, 18 patients, and 15 caregivers, and 70 (74.5%) of 94 cases were vaccine breakthrough infections. We detected 3 superspreading events: in the hospital staff cafeteria and offices (n = 47 cases, 50%), the 8th floor of the main building (n = 22 cases, 23.4%), and the 7th floor in the maternal and child healthcare center (n = 12 cases, 12.8%). These superspreading events accounted for 81 (86.2%) of 94 transmissions (Fig. 1, 2). The median interval between completion of vaccination and COVID-19 infection was 117 days (range, 18–187). There was no significant difference in the mean Ct value of the RdRp/ORF1ab gene between fully vaccinated individuals (mean 20.87, SD±6.28) and unvaccinated individuals (mean 19.94, SD±5.37, P = .52) at the time of diagnosis. Among healthcare workers and caregivers, only 1 required oxygen supplementation. In contrast, among 18 patients, there were 4 fatal cases (22.2%), 3 of whom were unvaccinated (Table 1). Conclusions: Superspreading infection among fully vaccinated individuals occurred in an acute-care hospital while the δ (delta) variant was dominant. Given the potential for severe complications, as this outbreak demonstrated, preventive measures including adequate ventilation should be emphasized to minimize transmission in hospitals.

Funding: None

Disclosures: None

Background: In late September 2021, a cluster of patients with nosocomial COVID-19 was identified on a liver transplant unit at University of Nebraska Medical Center. Methods: The outbreak investigation included contact tracing via patient chart and employee health record reviews and serial prevalence testing for SARS-CoV-2 among potentially exposed patients and healthcare workers (HCWs). Routine admission and preprocedural screening for SARS-CoV-2 was performed, and involved patients had negative admission screening results with positive SARS-CoV-2 tests >5 days from admission. Mitigation strategies involved reinforcement of patient care and visitation procedures. Whole-genome sequencing of positive SARS-CoV-2 specimens was conducted. Results: The potential outbreak cluster included 6 patients in the same quadrant of the liver transplant unit, 1 visitor, and 11 healthcare workers (Fig. 1). Moreover, 4 patients had severe liver disease, including 2 with liver transplants. All HCWs and half of the patients had received 2 doses of mRNA vaccine, albeit >5 months from their second vaccination. Whole-genome sequencing confirmed patients 1–6 and HCWs 1–3 had related transmission of COVID-19. However, infections in HCWs 4–6, who worked in a transplant-related office setting without patient contact, were due to 2 separate introductions of SARS-CoV-2 unrelated to the hospital outbreak. Sequencing could not be performed on HCWs 7–11 due to low viral concentration in the original specimens or unavailable specimen. The SARS-CoV-2 δ (delta) variant (B.1.617.2) was identified in all sequenced samples. HCWs 8–10 were asymptomatic and had had contact with each other and had been involved with an intubation without proper PPE for SARS-CoV-2 on patient 6. HCW 8 had had contact with all 6 patients and HCW 9 had had contact with 5 patients. A clear index case could not be identified; however, we suspect that the index case was either visitor 1, who tested positive during patient 2’s admission, or an asymptomatic healthcare worker (HCWs 8–10). Conclusions: We identified a nosocomial outbreak of the SARS-CoV-2 δ (delta) variant in a solid-organ transplant unit including patients, a visitor, and vaccinated healthcare workers with multiple introductions of the virus. Further transmission was not detected after enhanced infection control measures were introduced, including universal masking and eye protection, closing patient doors, and enforcement of visitor masking policy. We describe the difficulties tracing SARS-CoV-2 transmission in the hospital setting, even with advanced sequencing techniques. This outbreak highlights the importance of booster vaccination and strict infection control practices, especially in the setting of the δ (delta) variant.

Funding: None

Disclosures: None

Background: Carbapenem-resistant Acinetobacter baumannii (CRAB) is primarily associated with hospital-acquired infections and is an urgent public health threat due to its ability to contaminate the environment and cause severe disease. In 2019, Illinois began pilot surveillance for CRAB requiring select laboratories to submit specimens for molecular characterization. On July 17, 2020, the Chicago Department of Public Health (CDPH) was notified of an increase in CRAB infections in a 20-bed ICU at an acute-care hospital in Chicago (hospital A) during the initial COVID-19 surge. We summarize the outbreak investigation findings and infection control recommendations. Methods: Clinical cultures were collected from patients in hospital A, and CRAB-positive isolates were sent to the Wisconsin State Laboratory of Hygiene for mechanism of resistance and antibiotic susceptibility testing. On-site assessments and remote follow-ups were conducted by CDPH infection preventionists to evaluate infection control practices including environmental cleaning, hand hygiene compliance, and use of personal protective equipment (PPE). The Illinois Department of Public Health and CDPH summarized the testing results, facilitated a containment response, and provided recommendations for infection control. Results: From March 18, 2020, to September 30, 2021, 56 patients with CRAB infections were identified from hospital A, and 33 (59%) of these cases were pan-nonsusceptible. Most specimen sources were sputum (n = 30, 54%), followed by blood (n = 13, 23%), urine (n = 6, 11%) and other (n = 7, 13%). Among isolates with mechanism testing (n = 54), 45 (83%) were positive for OXA-24/40 and 9 (17%) were positive for OXA-23. Of the CRAB-positive patients, 28 (50%) were previously positive for SARS-CoV-2. To date, 25 of these patients (45%) have been discharged and 31 (55%) have died. Two onsite visits and 7 remote-assistance sessions were conducted as part of the investigation. In response to increased COVID-19 hospitalizations, hospital A moved to crisis-capacity PPE use and encountered staffing shortages, which led to compromised infection control measures. Cleaning agents (Quat disinfectant cleaner) were also found to be ineffective against CRAB and required long contact times. Conclusions: In response to the CRAB outbreak at hospital A, CDPH recommended that the hospital stop crisis-capacity protocols for PPE, conduct admission screening and point-prevalence testing for CRAB, implement a hand hygiene campaign, and use an EPA-registered List K product for environmental cleaning. These recommendations were implemented in May 2021, and no CRAB cases have been reported since July 2021. To reduce CRAB transmission during the pandemic, facility leadership must commit resources to educate staff on effective infection control practices including conventional use of PPE, appropriate cleaning agents, and improved hand hygiene.

Funding: None

Disclosures: None