The microbiology of cardiac implantable electronic device (CIED) infections in Calgary, Alberta was described, identifying 50 infections from 2013 to 2019. The majority were Staphylococcus aureus (40.0%). There is significant economic burden, mostly related to inpatient costs, associated with CIED infections. However, there were no significant differences in costs stratified by organism.

Broad-spectrum antimicrobials are commonly used without indication and contribute to antimicrobial resistance (AMR). We implemented a syndrome-based stewardship intervention in a community hospital that targeted common infectious syndromes and antipseudomonal beta-lactam (APBL) use. Our intervention successfully reduced AMR, C. difficile rates, use of APBLs, and cost.

Background: Previously, our hospital manually built a static antibiogram from a surveillance system (VigiLanz) culture report. In 2019, a collaboration between the antimicrobial stewardship team (AST) and the infection control (IC) team set out to leverage data automation to create a dynamic antibiogram. The goal for the antibiogram was the ability to easily distribute and update for hospital staff, with the added ability to perform advanced tracking and surveillance of organism and drug susceptibilities for AST and IC. By having a readily available, accurate, and Clinical and Laboratory Standards Institute (CLSI)–compliant antibiogram, clinicians have the best available data on which to base their empiric antibiotic decisions. Methods: First, assessment of required access to hospital databases and selection of a visualization software (MS Power BI) was performed. Connecting SQL database feeds to Power BI enabled creation of a data model using DAX and M code to comply with the CLSI, generating the first isolate per patient per year. Once a visual antibiogram was created, it was validated against compiled antibiograms using data from the microbiology laboratory middleware (bioMerieux, Observa Integrated Data Management Software). This validation process uncovered some discrepancies between the 2 reference reports due to cascade reporting of susceptibilities. The Observa-derived data were used as the source of truth. The antibiogram prototype was presented to AST/IC members, microbiology laboratory leadership, and other stakeholders to assess functionality. Results: Following feedback and revisions by stakeholders, the new antibiogram was published on a hospital-wide digital platform (Fig. 1). Clinicians may view the antibiogram at any time on desktops from a firewall (or password)–protected intranet. The antibiogram view defaults to the current calendar year and users may interact with the antibiogram rows and columns without disrupting the integrity of the background databases or codes. Each year, simple refreshing of the Power BI antibiogram and changing of the calendar year allows us to easily and accurately update the antibiogram on the hospital-wide digital platform. Conclusions: This interdisciplinary collaboration resulted in a new dynamic, CLSI-compliant antibiogram with improved usability, increased visibility, and straightforward updating. In the future, a mobile version of the antibiogram may further enhance accessibility, bring more useful information to providers, and optimize AST/IC guidelines and education.

Disclosures: None

Clostridioides difficile infection (CDI) is one of the leading causes of hospital–onset infections. Clinically distinguishing true CDI versus colonization with C. difficile is challenging and often requires reliable and rapid molecular testing methods. At our academic center, we implemented a 2-step testing algorithm to help identify true CDI cases. The University of Mississippi Medical Center is a 700+ bed academic facility located in Jackson, Mississippi. Hospital-onset (HO) CDI was defined based on NHSN Laboratory Identified (LabID) event as the last positive C. difficile test result performed on a specimen using a multistep testing algorithm collected >3 calendar days after admission to the facility. HO-CDI data were collected from all inpatient units except the NICU and newborn nursery. HO-CDI outcomes were assessed based on standardized infection ratio (SIR) data. In May 2020, we implemented a 2-step testing algorithm (Figure 1). All patients with diarrhea underwent C. difficile PCR testing. Those with positive C. difficile PCR test were reflexed to undergo enzyme immunoassay (EIA) glutamate dehydrogenase antigen (Ag) testing and toxin A and B testing. The final results were reported as colonization (C. difficile PCR+/EIA Ag+/Toxin A/B−) or true CDI case (C. difficile PCR+/EIA +/Toxin A/B +) or negative (C. difficile PCR−). All patients with colonization or true infection were placed under contact isolation precautions until diarrhea resolution for 48 hours. During the preintervention period (October 2019–April 2020), 25 HO-CDI cases were reported compared to 8 cases in the postintervention period (June 2020–December 2020). A reduction in CDI SIR occurred in the postintervention period (Q3 2020–Q4 2020, SIR 0.265) compared to preintervention period (Q4 2019–Q1 2020, SIR 0.338) (Figure 2). We successfully reduced our NHSN HO-CDI SIR below the national average after implementing a 2-step testing algorithm for CDI. The 2-step testing algorithm was useful for antimicrobial stewardship to guide appropriate CDI treatment for true cases and for infection prevention to continue isolation of infected and colonized cases to reduce the spread of C. difficile spores.

Funding: No

Disclosures: None

Figure 1.

Figure 2.

Background: Prescribing errors related to the COVID-19 oral antiviral agent nirmatrelvir-ritonavir have been reported and are primarily due to improper renal dosing and significant drug–drug interactions. These patient safety issues are particularly concerning in the long-term care facility (LTCF) population. The Nebraska Antimicrobial Stewardship Assessment and Promotion Program (ASAP) is a unique collaborative partnership involving the University of Nebraska Medical Center, Nebraska Medicine, and the Nebraska Department of Health and Human Services (DHHS). ASAP is funded through the Nebraska DHHS healthcare-associated infections and antimicrobial resistance (HAI/AR) program and was established in 2016, with a primary focus of promoting safe and effective antimicrobial use in Nebraska. In 2022, ASAP developed a statewide pharmacist-led service to assist LTCFs in evaluating prescriptions for COVID-19 oral therapeutics. We studied the impact of ASAP pharmacist intervention on COVID-19 oral antiviral prescriptions. Methods: ASAP created a centralized LTCF treatment request process for oral antivirals. A REDCap survey hosted on a dedicated program webpage was used to collect requests for treatment submitted by any LTCF in Nebraska, including assisted living facilities. An ASAP pharmacist reviewed each survey submission for renal and hepatic function, drug–drug interactions, date of symptom onset, and ability to take oral medications. After pharmacist approval, delivery of the appropriate COVID-19 therapeutic to the LTCF was coordinated with the dispensing pharmacy. The pharmacists recorded the specific interventions for each treatment in the program database. Descriptive analyses were used to study the program impact. Results: In total, 630 courses of oral COVID-19 antivirals were administered to Nebraska LTCF residents through the ASAP program in 2022. The median patient age was 84 years, and 59% were female. Most dispensed courses (n = 410, 65%) needed pharmaceutical interventions upon review for 506 individual interventions. The most frequent intervention was to hold or adjust doses of concomitant medications in 205 patients (33%), followed by antiviral dose adjustment for renal function in 117 patients (19%), and selecting an alternative COVID-19 therapy due to drug–drug interactions in 108 patients (17%). COVID-19 therapeutic agents were changed upon ASAP intervention to be in compliance with the National Institute of Health COVID-19 treatment guidelines in 37 patients (6%). Conclusions: Pharmacist review of oral antiviral prescriptions for COVID-19 through a public health–supported initiative identified and prevented potential patient safety issues in LTCF residents. Future studies should analyze the impact of similar interventions on patient outcomes.

Disclosures: None

In a large healthcare worker cohort, we quantified the association between behaviors and risk of coronavirus disease 2019 (COVID-19) during different pandemic phases, adjusting for prior infection and vaccination. Individual characteristics, including personal concerns, were associated with these behaviors. Public health messaging should target high-risk populations and behaviors as the pandemic evolves.

Background: We evaluated the impact of a comprehensive SARS-CoV-2 (COVID-19) infection prevention (IP) bundle on rates of non–COVID-19 healthcare-acquired respiratory viral infection (HA-RVI). Methods: We performed a retrospective analysis of prospectively collected respiratory viral data using an infection prevention database from April 2017 to January 2021. We defined HA-RVI as identification of a respiratory virus via nasal or nasopharyngeal swabs collected on or after hospital day 7 for COVID-19 and non–COVID-19 RVI. We compared incident rate ratios (IRRs) of HA-RVI for each of the 3 years (April 2017 to March 2020) prior to and 10 months (April 2020 to January 2021) following full implementation of a comprehensive COVID-19 IP bundle at Duke University Health System. The COVID-19 IP bundle consists of the following elements: universal masking; eye protection; employee, patient, and visitor symptom screening; contact tracing; admission and preprocedure testing; visitor restrictions; discouraging presenteeism; population density control and/or physical distancing; and ongoing attention to basic horizontal IP strategies including hand hygiene, PPE compliance, and environmental cleaning. Results: During the study period, we identified 715 HA-RVIs over 1,899,700 inpatient days, for an overall incidence rate of 0.38 HA-RVI per 1,000 inpatient days. The HA-RVI IRR was significantly higher during each of the 3 years prior to implementing the COVID-19 IP bundle (Table 1). The incidence rate of HA-RVI decreased by 60% after bundle implementation. COVID-19 became the dominant HA-RVI, and no cases of HA-influenza occurred in the postimplementation period (Figure 1). Conclusions: Implementation of a comprehensive COVID-19 IP bundle likely contributed to a reduction in HA-RVI for hospitalized patients in our healthcare system. Augmenting traditional IP interventions in place during the annual respiratory virus season may be a future strategy to reduce rates of HA-RVI for inpatients.

Table 1.

Figure 1.

We surveyed trainees about their urine culture practices and assessed the impact of an educational intervention delivered electronically and in person. Trainee scores improved across all levels of training and across all questions on the postintervention survey, but there was no difference in scores by mode of education (P = .91).

Background: In Ghana, treatment of surgical site infections (SSIs) is often empirical and not based on targeted therapy (ie, knowledge of the organisms infecting surgical sites or their susceptibility profiles). This empirical approach most often leads to inappropriate prescription, which is a major driver of antimicrobial resistance. Using phenotypic and molecular tools, we investigated S. aureus, E. coli, K. pneumoniae, and P. aeruginosa recovered from patients with SSIs. Methods: Identification of bacteria species recovered from wound swabs and aspirates was performed using matrix-assisted laser desorption/ionization time-of-flight mass spectroscopy (MALDI-TOF MS). Antimicrobial susceptibility testing (AST) was done using the Kirby-Bauer disk diffusion method. Results were interpreted according to the CLSI 2018 guidelines. Extended-spectrum β-lactamase (ESBL) positivity was detected among the gram-negative isolates using the double disk-diffusion method and PCR amplification of ESBL genes (blaSHV, blaTEM, and blaCTX-M). Staphylococcus aureus isolates resistant to cefoxitin were further tested for the presence of mecA using PCR. Results: In total, 312 patients were enrolled in this prospective study. The 243 bacteria species identified comprised Escherichia coli (34%; 107 of 312), Klebsiella pneumoniae (20%; 62 of 312), Pseudomonas aeruginosa (16%; 49 of 312), and S. aureus (8%; 25 of 312). S. aureus isolates were susceptible to clindamycin, erythromycin, gentamicin, linezolid, rifampicin, and norfloxacin, but 10 S. aureus isolates were resistant to cefoxitin and were positive for the mecA gene (MRSA). Among the 169 isolates in the Enterobactericae category (E. coli and K. pneumoniae), 143 (85%) were resistant to tetracycline; 141 (83%) were resistant to trimethoprim–sulfamethoxazole; 118 (70%) were resistant to cefotaxime; 111 (66%) were resistant to cefuroxime; 98 (58%) were resistant to ciprofloxacin; 86 (51%) were resistant to gentamicin; and 81 (48%) were resistant to chloramphenicol. However, 161 (95%) were sensitive to amikacin and 159 (94%) were sensitive to meropenem. Among the 49 P. aeruginosa isolates, 45 (92%) showed sensitivity to amikacin, 43 (88%) showed sensitivity to meropenem, 35 (71%) showed sensitivity to gentamicin, and 35 (71%) showed sensitivity to ciprofloxacin. ESBL was detected in 59 (55%) of 107 E. coli isolates, and 48 (77%) of 62 K. pneumoniae isolates. blaCTX-M was the dominant ESBL gene in E. coli isolates (34 of 59, 58%). For K. pneumoniae isolates, blaCTX-M genes were detected in 45 (94%) of 48 isolates and blaSHV genes were detected in 44 (92%) of 48 isolates. Among the 49 P. aeruginosa isolates, 3 harbored the blaTEM gene. Conclusions: The findings of high proportions of ESBL-producing bacteria species in Ghana is a grave public health concern. Data generated in this study will inform treatment decisions and policies and appropriate antibiogram development and will support antimicrobial stewardship programs at the respective healthcare facilities in Ghana.

Funding: None

Disclosures: None

Background: Nursing home (NH) residents and staff were at high risk for COVID-19 early in the pandemic; several studies estimated seroprevalence of infection in NH staff to be 3-fold higher among CNAs and nurses compared to other staff. Risk mitigation added in Fall 2020 included systematic testing of residents and staff (and furlough if positive) to reduce transmission risk. We estimated risks for SARS-CoV-2 infection among NH staff during the first winter surge before widespread vaccination. Methods: Between February and May 2021, voluntary serologic testing was performed on NH staff who were seronegative for SARS-CoV-2 in late Fall 2020 (during a previous serology study at 14 Georgia NHs). An exposure assessment at the second time point covered prior 3 months of job activities, community exposures, and self-reported COVID-19 vaccination, including very recent vaccination (≤4 weeks). Risk factors for seroconversion were estimated by job type using multivariable logistic regression, accounting for interval community-incidence and interval change in resident infections per bed. Results: Among 203 eligible staff, 72 (35.5%) had evidence of interval seroconversion (Fig. 1). Among 80 unvaccinated staff, interval infection was significantly higher among CNAs and nurses (aOR, 4.9; 95% CI, 1.4–20.7) than other staff, after adjusting for race and interval community incidence and facility infections. This risk persisted but was attenuated when utilizing the full study cohort including those with very recent vaccination (aOR, 1.8; 95% CI, 0.9–3.7). Conclusions: Midway through the first year of the pandemic, NH staff with close or common resident contact continued to be at increased risk for infection despite enhanced infection prevention efforts. Mitigation strategies, prior to vaccination, did not eliminate occupational risk for infection. Vaccine utilization is critical to eliminate occupational risk among frontline healthcare providers.

Funding: None

Disclosures: None

Group Name: The Emory COVID-19 Quality and Clinical Research Collaborative

Background: Patients hospitalized with COVID-19 are at risk of secondary infections—10%–33% develop bacterial pneumonia and 2%–6% develop bloodstream infection (BSI). We conducted a retrospective cohort study to identify the prevalence, microbiology, and outcomes of secondary pneumonias and BSIs in patients hospitalized with COVID-19. Methods: Patients aged ≥18 years with a positive SARS-CoV-2 real-time polymerase chain reaction assay admitted to 4 academic hospitals in Atlanta, Georgia, between February 15 and May 16, 2020, were included. We extracted electronic medical record data through June 16, 2020. Microbiology tests were performed according to standard protocols. Possible ventilator-associated pneumonia (PVAP) was defined according to Centers for Disease Control and Prevention (CDC) criteria. We assessed in-hospital mortality, comparing patients with and without infections using the χ2 test. SAS University Edition software was used for data analyses. Results: In total, 774 patients were included (median age, 62 years; 49.7% female; 66.6% black). In total, 335 patients (43.3%) required intensive care unit (ICU) admission, 238 (30.7%) required mechanical ventilation, and 120 (15.5%) died. Among 238 intubated patients, 65 (27.3%) had a positive respiratory culture, including 15 with multiple potential pathogens, for a total of 84 potential pathogens. The most common organisms were Staphylococcus aureus (29 of 84; 34.5%), Pseudomonas aeruginosa (16 of 84; 19.0%), and Klebsiella spp (14 of 84; 16.7%). Mortality did not differ between intubated patients with and without a positive respiratory culture (41.5% vs 35.3%; P = .37). Also, 5 patients (2.1%) had a CDC-defined PVAP (1.7 PVAPs per 1,000 ventilator days); none of them died. Among 536 (69.3%) nonintubated patients, 2 (0.4%) had a positive Legionella urine antigen and 1 had a positive respiratory culture (for S. aureus). Of 774 patients, 36 (4.7%) had BSI, including 5 with polymicrobial BSI (42 isolates total). Most BSIs (24 of 36; 66.7%) had ICU onset. The most common organisms were S. aureus (7 of 42; 16.7%), Candida spp (7 of 42; 16.7%), and coagulase-negative staphylococci (5 of 42; 11.9%); 12 (28.6%) were gram-negative. The most common source was central-line–associated BSI (17 of 36; 47.2%), followed by skin (6 of 36; 16.7%), lungs (5 of 36; 13.9%), and urine (4 of 36; 11.1%). Mortality was 50% in patients with BSI versus 13.8% without (p < 0.0001). Conclusions: In a large cohort of patients hospitalized with COVID-19, secondary infections were rare: 2% bacterial pneumonia and 5% BSI. The risk factors for these infections (intubation and central lines, respectively) and causative pathogens reflect healthcare delivery and not a COVID-19–specific effect. Clinicians should adhere to standard best practices for preventing and empirically treating secondary infections in patients hospitalized with COVID-19.

Funding: No

Disclosures: None

Over a 4-year period, the antimicrobial stewardship team reviewed all positive (PCR+/Tox+) and indeterminate (PCR+/Tox−) cases with the most responsible physician for classification of patients as infection or colonization. Among 501 indeterminate samples, 213 (43%) were considered to be clinical infection, suggesting the need for ongoing clinical assessment of indeterminates.

We developed and validated a set of fully automated surveillance algorithms for healthcare-onset CDI using electronic health records. In a validation data set of 750 manually annotated admissions, the algorithm based on International Classification of Disease, Tenth Revision (ICD-10) code A04.7 had insufficient sensitivity. Algorithms based on microbiological test results with or without addition of symptoms performed well.

We conducted a retrospective review of a hybrid antimicrobial restriction process demonstrating adherence to appropriate use criteria in 72% of provisional-only orders, in 100% of provisional orders followed by ID orders, and in 97% of ID-initiated orders. Therapy interruptions occurred in 24% of provisional orders followed by ID orders.

Background: In the last 2 years of the COVID-19 pandemic, Singapore has been forced to explore alternative sites to quarantine persons or manage infected cases during surge periods in a national effort not to overwhelm the public healthcare facilities. External quarantine facilities were created at the EXPO and further extended to D’Resort and other hotels in May 2020. Infection prevention (IP) practices were implemented at these external facilities, where training non–healthcare staff to quickly learn and understand these required practices has been challenging. A team of staff from different clinical disciplines was formed to manage the COVID-19 patients at these facilities. The Infection Prevention and Epidemiology (IPE) department was invited to train all staff, including the clinical team, management agency, and security staff, regarding IP measures. We have described the system and approach used in the rapid training of all staff in IP measures where the goal is zero transmission while providing care to COVID-19 patients. Methods: Training materials were developed to facilitate rapid learning by all staff; medical jargon was avoided. Curriculum included precautions to be taken while performing terminal cleaning of patient rooms, serving meals, disinfecting phones and thermometers, as well as donning and doffing personal protective equipment (PPE). “Green” and “red” zones were created to assist staff in remembering appropriate PPE to be used. PPE training was provided using slides and video. Posters were created as a guide for staff at donning and doffing stations. Additionally, the IPE training team utilized an online data collection tool to capture staff completion on IP training and PPE competency for record keeping. We used a ‘soft’ approach because staff members were fearful of the unknown when caring for COVID-19 patients. Daily audits were conducted with immediate concurrent feedback to engage the relevant stakeholders. Infection prevention liaison officers (IPLOs) were appointed to assist in the daily audits. An electronic audit tool was used to facilitate audit and quick analysis. Conclusions: The experience gained in the last 2 years has been useful and may provide a template if new external sites are needed in the future because of the potential surge associated with the ο (omicron) variant.

Funding: None

Disclosures: None