The standardized antibiotic administration ratio (SAAR) enables comparison of antibiotic use (AU) within and between hospitals and identifies target locations and antimicrobials for stewardship interventions. Thousands of institutions have already been submitting AU to the National Healthcare Safety Network. We highlight the benefits and meaningful utilization of SAAR in conjunction with antimicrobial stewardship interventions to improve antimicrobial prescribing in the clinical setting.

Over 3 months, we provided monthly education to internal medicine residents and distributed resources regarding penicillin-allergy history taking. Allergy information in the electronic record was updated more often during the intervention compared to the period before the intervention (16.1% vs 10.9%; P = .02). Education and interdepartmental collaboration have the potential to affect provider behavior.

Background: Fungemia is associated with high rates of morbidity, mortality, and increase in length of hospital stay. Several studies have recognized increased rates of candidemia since the COVID-19 pandemic. Methods: Patients with candidemia during January through May 2020 were identified through Theradoc. Patient demographics, comorbidities, hospital management, and microbiology were extracted by medical chart review. Patients were divided into cohorts based on COVID-19 status. The Fisher exact and Satterthwaite tests were used for analyses of categorical and continuous variables, respectively. Results: Overall, 31 patients developed candidemia and 12 (38.7%) patients tested SARS-CoV-2 positive. Candida glabrata was the most prevalent causative organism in both groups. On average, COVID-19 patients developed fungemia 12.1 days from admission, compared to 17.8 days in the COVID-19 negative or untested cohort (P = .340). Additionally, COVID-19 patients with a fungemia coinfection were significantly more likely to expire; 10 COVID-19 patients (83.3%) died, compared to 7 (36.8%) in the COVID-19–negative or untested cohort (P = .025). The cohorts did not demonstrate statistically significant differences in terms of demographic, comorbidities, hospital management, or coinfections. Conclusions: The prevalence of fungemia in COVID-19 patients is significantly greater than historically reported figures. Known risk factors for candidemia, such as use of corticosteroid, use of central venous catheters, and prolonged ICU length of stay were higher in the SARS-CoV-2–positive cohort in this period, which likely contributed to increased fungemia rates, as these factors are also more pronounced in those with COVID-19. Patients who developed candidemia in the COVID-19 cohort had poorer outcomes than those who were SARS-CoV-2 negative or were untested. Further investigation should be conducted in larger studies.

Funding: No

Disclosures: None

Table 1.

Using point-prevalence methodology and the World Health Organization (WHO) Access, Watch, and Reserve Classification, we measured antibiotic use in 5 hospitals in Okinawa, Japan, on October 1, 2020. Overall, 29% of patients were prescribed an antibiotic on the survey date and the 3 most used antibiotics in the “Watch” category were cefazolin, ampicillin-sulbactam, and ampicillin.

We surveyed clinicians to evaluate the perceived usefulness of a mnemonic, STORY, to improve penicillin allergy evaluation. Survey responses indicated that the perceived usefulness of STORY was high, and support for nurses’ involvement in penicillin allergy assessment was high. Future research may evaluate the feasibility of STORY implementation in clinical care.

Background: Antibiotics targeted against Clostridioides difficile bacteria are necessary, but insufficient, to achieve a durable clinical response because they have no effect on C. difficile spores that germinate within a disrupted microbiome. ECOSPOR-III evaluated SER-109, an investigational, biologically derived microbiome therapeutic of purified Firmicute spores for treatment of rCDI. Herein, we present the interim analysis in the ITT population at 8 and 12 weeks. Methods: Adults ≥18 years with rCDI (≥3 episodes in 12 months) were screened at 75 US and CAN sites. CDI was defined as ≥3 unformed stools per day for <48 hours with a positive C. difficile assay. After completion of 10–21 days of vancomycin or fidaxomicin, adults with symptom resolution were randomized 1:1 to SER-109 (4 capsules × 3 days) or matching placebo and stratified by age (≥ or <65 years) and antibiotic received. Primary objectives were safety and efficacy at 8 weeks. Primary efficacy endpoint was rCDI (recurrent toxin+ diarrhea requiring treatment); secondary endpoints included efficacy at 12 weeks after dosing. Results: Overall, 287 participants were screened and 182 were randomized (59.9% female; mean age, 65.5 years). The most common reason for screen failure was a negative C. difficile toxin assay. A significantly lower proportion of SER-109 participants had rCDI after dosing compared to placebo at week 8 (11.1% vs 41.3%, respectively; relative risk [RR], 0.27; 95% confidence interval [CI], 0.15–0.51; p-value <0.001). Efficacy rates were significantly higher with SER-109 vs placebo in both stratified age groups (Figure 1). SER-109 was well-tolerated with a safety profile similar to placebo. The most common treatment-emergent adverse events (TEAEs) were gastrointestinal and were mainly mild to moderate. No serious TEAEs, infections, deaths, or drug discontinuations were deemed related to study drug. Conclusions: SER-109, an oral live microbiome therapeutic, achieved high rates of sustained clinical response with a favorable safety profile. By enriching for Firmicute spores, SER-109 achieves high efficacy while mitigating risk of transmitting infectious agents, beyond donor screening alone. SER-109 represents a major paradigm shift in the clinical management of patients with recurrent CDI. Clinicaltrials.gov Identifier NCT03183128. These data were previously presented as a late breaker at American College of Gastroenterology 2020.

Funding: Seres Therapeutics

Disclosures: None

Figure 1.

Background: Antibiotic overuse and the resulting patient outcomes span all hospitals. However, although antibiotic stewardship can improve antibiotic use, effective stewardship programs require expertise and an infrastructure that are not present in all hospitals. Rural hospitals have less access to resources, infectious disease expertise, and participation in academic research. Thus, we compared antibiotic overuse at discharge between rural and nonrural hospitals for patients diagnosed with community-associated pneumonia (CAP) or urinary tract infection (UTI)—the 2 most common hospital infections. Methods: To determine whether antibiotic overuse at discharge was higher among rural versus nonrural hospitals, we analyzed data from a 41-hospital prospective cohort of patients treated for CAP or UTI between July 1, 2017, and July 30, 2019, in Michigan. Antibiotic overuse was defined as treatment that was unnecessary (ie, patient did not have an infection), excessive (ie, duration >4 days for CAP), or included suboptimal fluoroquinolone use (ie, safer alternative available). Overuse was determined based on patient risk factors, symptoms, allergies, diagnostic results, and time to stability. Hospital rurality was defined using the Rural–Urban Continuum Codes (RUCC) score. We defined rural as a score ≥4 and very rural as a score of 7–9. We used t tests to compare the mean percentage of patients with antibiotic overuse at discharge between nonrural and rural (and very rural) hospitals. Results: Across 41 hospitals, we included 23,449 patients with CAP or UTI. There were 5 rural (and 3 very rural) hospitals with 2,039 (and 1,082) patients. Antibiotic overuse at discharge was present in 43.1% of patient cases in nonrural hospitals, 52.5% in rural hospitals (P = .04 vs nonrural) and 58.1% in very rural hospitals (P = .007 vs nonrural). Compared to nonrural hospitals, the mean percentage of cases with antibiotic overuse at discharge in rural hospitals was 9.4% higher (15.1% higher in very rural hospitals). Results were similar in a subgroup analysis of only patients with UTI (47.0% in rural vs 37.5% in nonrural, mean difference, 9.5%; P = .03) but were not statistically significant in patients with CAP (53.8% vs 48.0%, respectively; mean difference, 5.8%; P = 0.23). Conclusions: In this retrospective study, rural hospitals—especially very rural hospitals, had higher rates of antibiotic overuse at discharge than nonrural hospitals. Our findings suggest that antibiotic stewardship interventions tailored toward the unique differences in infrastructure, resources, and needs of rural hospitals are essential to community health.

Disclosures: None

We evaluated the impact of preliminary blood-culture antibiotic susceptibility testing on time to optimal antibiotic therapy in a cohort of 503 patients with monomicrobial bloodstream infections. The median time from blood-culture collection to optimal antibiotics was 17 hours earlier in the preliminary antibiotic susceptibility testing group.

Background: Clinical pharmacists are a critical part of antibiotic stewardship. Stewardship often relies on relationships and persuasion, which may be affected by gender bias. Thus, we aimed to assess the association of sex with the acceptance of antibiotic stewardship recommendations. Methods: Between May and October 2019, medicine pharmacists at single hospital reviewed patients on antibiotics and–when a discharge was anticipated–led an antibiotic discussion (or “timeout”) prior to discharge. To explore differences in antibiotic timeout effectiveness by gender, we assessed the association of pharmacist sex with suggestion and acceptance of antibiotic changes using logistic regression controlling for patient characteristics. We also assessed whether hospitalist sex was associated with or moderated the effect of pharmacist sex on acceptance of timeout recommendations. Results: Between May 1, 2019, and October 31, 2019, pharmacists conducted 295 timeouts (patient characteristics in Fig. 1). Overall, 54% of timeouts were conducted by 12 female pharmacists and the remaining 46% were conducted by 8 male pharmacists. Overall, 82 (29%) of 295 timeouts resulted in a pharmacist recommending an antibiotic change, and male pharmacists were more likely to recommend a change: 52 (38%) of 137 versus 30 (19%) 158 (P Conclusions: In this discharge antibiotic intervention, timeouts conducted by women were less likely to result in an antibiotic change than those conducted by men. The difference in effectiveness resulted both from female pharmacists being less likely to recommend a change and from hospitalists being less likely to accept recommendations from a female pharmacist. These findings suggest that gender bias may play a role acceptance of antibiotic stewardship recommendations, which could affect antibiotic use, pharmacist job satisfaction, and patient outcomes.

Funding: None

Disclosures: None

Objectives: Carbapenemase-producing carbapenem-resistant Enterobacteriaceae (CP-CRE) are nosocomial pathogens, and control of CP-CRE transmission is one of the most important infection control issues healthcare organizations face today. Increasing colonization acquisition and clinical infections of CP-CRE occurred in our institution in 2019. In this observational study, we monitored CP-CRE acquisition following implementation of multimodal control measures, and we describe the impact of this intervention on clinical infections. Methods: Increased hospital-acquired CP-CRE colonization and clinical infections were observed in early 2019. Increased CP-CRE surveillance was implemented to include CP-CRE contacts, patients with lengths of stay >7 days, patients with a recent history of hospitalization in other hospitals, and renal dialysis patients. The following interventions were also implemented: (1) isolation or placing CP-CRE patients in cohorts in a designated multidrug-resistant organism (MDRO) ward; (2) emphasis on hand hygiene and contact precautions; (3) mandatory use of gown and gloves for predefined ‘high-risk’ nursing activities, including diaper changing, toilet assistance, wound dressing, and handling urine or stool; (4) enhanced environmental and equipment cleaning; (5) regular audit and feedback regarding compliance; and (6) weekly feedback on ward-level CP-CRE acquisition. CP-CRE colonization cases and clinical infections were tracked by infection prevention and control nurses. Results: The hospital-acquired CP-CRE colonization rate was 4.39 per 10,000 patient days in 2019; it decreased slightly to 3.61 in 2020 and remained steady at 3.77 in 2021. The predominant CP-CRE genes were NDM, OXA-48–like, and KPC. There were 12 hospital-acquired CP-CRE infections in 2019, a rate of 0.37 per 10,000 patient days. This incidence decreased to 6 infections in 2020 and 3 infections in 2021, with corresponding infection rates of 0.19 and 0.09 per 10,000 patient days, respectively. Conclusions: Control of CP-CRE remains extremely challenging in hospitals with multibed open wards. A bundle approach to infection control showed a gradual reduction in CP-CRE cases, with a significant impact on the prevention of clinical infections.

Background: Sink drains can act as breeding grounds for multidrug-resistant (MDR) bacteria, leading to outbreaks. Drains provide a protected humid environment where nutrient-rich substances are available. Recent and growing installation of water and energy conservation devices have led to increased frequency of drain blockage due to biofilm accumulation. Ineffective drainage may lead to backflow and accumulation of water in the sink during use, increasing the risk of contaminated aerosols formation or direct contamination of surrounding material and equipment. Cleaning and disinfection procedures of sink drains need to be improved to prevent amplification and dispersion of MDR bacteria. The objective of this study was to investigate alternatives to reduce the biofilm and risk of contamination through aerosols. Methods: Sink drains from patient rooms were randomly selected in the neonatal intensive care unit of a 450-bed pediatric hospital. We tested 4 approaches: (1) new drain; (2) self-disinfecting heating-vibration drain; (3) chemical disinfection with 20 ppm chlorine for 30 minutes; and (4) thermal disinfection with > 90°C water for 30 minutes. A special device was used during disinfection to increase the disinfectant contact time with the biofilm. Treatments were conducted weekly, with prior sampling of drain water. Other drains were also sampled weekly, including a control drain with no intervention. Bacterial loads were evaluated using flow cytometry and heterotrophic plate counts. The drains were made of stainless steel, a heat-conductive material. Results: Preliminary results show that chlorine disinfection had a small impact (<1 log) on culturable bacteria at 48 hours after disinfection but not after a week or repeated weekly disinfection. Thermal disinfection using boiling water is promising, showing an important decrease of 4 log in culturable cells after 48 hours and a concentration still 100× lower 1 week after the disinfection. Repeated weekly thermal disinfection maintained lower culturable levels in the drain. No culturable cells were detected in water from the self-disinfecting drain 2 months after installation, whereas the new drain became fully colonized to concentrations similar to those of drains prior to interventions during the same period. Conclusions: Thermal disinfection of drains is a promising alternative to chlorine. This solution is interesting because it is nontoxic and easy to perform, requiring a small volume of hot water. The rapid recolonization of the new drain suggests that replacing contaminated drains is not a sustainable solution and would need to be paired with a thermal disinfection program to maintain low culturable cells.

Funding: No

Disclosures: None

In this study, we evaluated the impact of a microbiology nudge on de-escalation to first-generation cephalosporins in hospitalized patients with urinary tract infections secondary to Escherichia coli, Klebsiella pneumoniae, and Proteus mirabilis isolates with minimum inhibitory concentrations (MICs) ≤ 16 µg/mL. De-escalation to first generation-cephalosporins was uncommon at MICs = 4–16 µg/mL.

Background: Central-line–associated bloodstream infections (CLABSIs) significantly burden the US population and healthcare system. Reporting facilities in Tennessee consistently omit race and ethnicity data in the NHSN despite having the option to enter. Racial and ethnic disparities are well documented across many health outcomes, including patient safety. CLABSIs were compared among 3 racial groups to better understand the impact of race on CLABSI incidence in Tennessee. Methods: CLABSI data from NHSN were linked with records from the TN Hospital Discharge Data System (HDDS) for 2018–2021. A multivariable linear regression model was used to determine relative risk (RR) between racial groups for contracting a CLABSI after controlling for confounding variables including Charlson comorbidity index (CCI) and social vulnerability index (SVI) scores. Statistical significance was set at P < .05. Data linkage and statistical analyses were performed in SAS version 9.4 software. Results: In Tennessee between 2018 and 2021, 342 (17.2%) of the 1,980 CLABSI events had race documented, and no ethnicity variables exist in the NHSN. The data linkage process yielded a 72% match (1,426 CLABSIs). The remaining 28% were excluded from the analysis. Per 1,000 central-line days (CL days) for all races, white patients had the highest CLABSI rate (17.5), followed by Black patients (1.36), and Native American or Alaskan Native patients (0.68). Per 1,000 admissions by race, Black patients had a higher CLABSI rate (1.26) than Native American/Alaskan Native patients (0.85) and white patients (0.75). The risk of contracting a CLABSI was 79% higher in Black patients than in white patients (RR, 1.79; 95% CI, 1.55–2.07; P < .0001) when controlling for CCI, age group, and SVI. Conclusions: These results suggest that racial disparities between Black and white patients are present in Tennessee hospitals regarding CLABSIs. Although most CLABSI events were linked to HDDS patients, there were limitations in the ability to match all cases and calculate CL days by race. This study highlights the need for complete race and ethnicity data in the NHSN. Further studies should examine infection types at the regional and facility levels to target interventions for reducing HAI inequities in Tennessee.

Disclosures: None