The updated vancomycin guideline for treatment of serious methicillin-resistant Staphylococcus aureus infections prompted institutions to convert from trough to area-under-the-curve monitoring. The physician perception of the transition, coupled with that of pharmacists, was measured by pre- and postimplementation surveys. Both groups believed safety would be increased without efficacy changes.

Background: Hand hygiene (HH) remains arguably the most effective way to prevent healthcare-associated infections (HAIs) and ultimately improve the prospect of patient safety. Studies have shown that as many as 50%–70% of infections are transmitted through hands due to poor HH practices. HH with use of alcohol-based hand rub (ABHR) is preferred over handwashing with soap and water because of its wide microbial efficacy, time efficiency, and improved skin tolerance. It is also well known that ABHR can be used as an effective prevention measure during disease outbreaks. Before and during the COVID-19 pandemic, health facilities in Sierra Leone have been challenged with HH infrastructural problems such as lack of sinks with constant running water. Before Sierra Leone recorded its first case of COVID-19 in March 2020, the consumption of ABHR in the health facilities was estimated to be 24,000 L per year, which doubled during the COVID-19 pandemic. The demand for commercially available ABHR increased, leading to acute shortages. The estimated cost of the locally produced ABHR ~$2–3 per 500 mL, although it may cost up to $10 for 500 mL when buying imported ABHR products from the local market. Methods: All ingredients were procured locally, and ABHR production was based on WHO formula 1. The production was set for 12 months to cover the estimated annual consumption of ABHR, with periodic monitoring to ensure effective distribution and availability at the point of care. Analysis of assessment results in 12 hospitals from the pre-COVID-19 era (2019) to the COVID-19 era (2021) was performed based on the WHO IPC Assessment Framework (IPCAF) indicator. Results: With an average monthly production of 3,482 L, a total of 41,780 L ABHR was produced and packaged in branded 500-mL containers for distribution to healthcare facilities. This quantity exceeded the estimated demand for ABHR during the COVID-19 pandemic. The data show a considerable increase (from 25% to 44%) in the number of available and functioning HH stations with mainly locally produced ABHR. Results from the monitoring of 575 peripheral health units (PHUs) in 2021 also showed that >67% of PHUs had HH facilities in all clinical areas and that the locally produced ABHR was used in 79% of these HH stations. Conclusions: Locally produced ABHR has shown to be a cost-effective and evidence-based intervention to optimize HH at the point of care. Therefore, localities are encouraged to undertake this realistic and sustainable approach to address issues of acute shortage of ABHR, especially during a global pandemic.

Funding: None

Disclosures: None

Background: Drawing blood cultures in the emergency room (ER) is essential for detecting bloodstream infections (BSIs). Although a practice of drawing blood culture usually indicates a presence of severe infection requiring hospitalization, some patients may nonetheless be safely discharged from the ER. Previous studies demonstrated that patients with a positive blood culture after ER discharge had favorable clinical outcomes. Moreover, given the increasing incidence of febrile illnesses, especially in the era of COVID-19, the shortage of inpatient hospital beds may lend further justification to this practice. We investigated the prevalence, outcomes, and factors associated with patient discharge from the ER after blood collection. Method: The present, nested, case–control study comparing patients initially discharged from the ER with those directly admitted to the study institution was conducted at a 790-bed tertiary-care medical center in Tokyo, Japan. The ratio of the respective patients was 1:3. Factors associated with ER discharge after a blood-culture collection were identified using multivariate logistic regression analysis. Results: From January 2014 through December 2020, 153,432 patients visited the ER. Blood cultures were obtained for 19,010 patients; 2,575 (13.5%) of these had a true BSI, and of the latter, 142 (5.5%) were initially discharged from the ER. During 2020, the proportion of patients with ER discharge increased 1.7 times over previous years. There was no significant difference in 28-day mortality between the groups (2.1% vs 4.5%; P = .31). On multivariate logistic regression analysis, factors significantly associated with the decision to discharge after blood culture collection were the absence of hypotension (aOR], 14,92; 95% CI, 3.38–65.93), lack of altered mental status (aOR, 8.44; 95% CI, 3.28–21.71) at ER presentation, unknown diagnosis at ER discharge (aOR, 3.75; 95% CI, 1.97–7.16), high level C-reactive protein (aOR, 0.91; 95% CI, 0.87–0.94), and a diagnosis of intra-abdominal or hepatobiliary infection (aOR, 0.11; 95% CI, 0.04–0.29). Conclusions: ER discharge after drawing blood for a culture was more frequently seen in the current COVID-19 era and was deemed acceptable under certain circumstances, such as patients with no systemic illnesses or specific diagnosis who may be managed safely without compromising clinical outcomes.

Funding: None

Disclosures: None

Background: The Veterans’ Affairs (VA) healthcare system has had established telehealth programs for several years. Even so, the COVID-19 pandemic led to an expansion of and changes in these services. Little is known about the influence of the increased use of telehealth due to the COVID-19 pandemic on antibiotic prescriptions in outpatient settings. Here, we report on changes in visit modality and antibiotic prescribing at primary care clinics at a large VA medical center after the emergence of the COVID-19 pandemic. Methods: Using VA administrative databases, we identified primary care visits from March 2018 to November 2019 (before the COVID-19 pandemic) and March 2020 to November 2021 (during the COVID-19 pandemic), which permitted us to account for seasonality while analyzing visit modality and antibiotic trends. For primary care visits during the pre–COVID-19 and COVID-19 periods, we have described the type of visit (in-person or telehealth), diagnostic codes for any infection, and antibiotic prescriptions. Results: The patient population was primarily men (89%) with a mean age of 62.9 years (SD, ±15.3) at first visit. The most common medical conditions were diabetes mellitus (26%) and chronic lung disease (17%). Comparing visits during the pre–COVID-19 and the COVID-19 periods, the proportions of telehealth visits were 20% (17,708 of 88,565) and 74% (69,891 of 94,937), respectively (Fig. 1). The proportions of visits with an antibiotic prescription were 1.4% (1,212 of 88,565) and 0.8% (798 of 94,396), respectively. When considered by the type of visit, the rates of antibiotics prescribed were consistent during the pre–COVID-19 and COVID-19 periods, with a lower rate for telehealth visits (Fig. 2). In both periods, >50% of antibiotic prescriptions occurred during visits without an associated infectious disease diagnosis. Conclusions: Compared to the pre–COVID-19 period, primary care providers at a large VA medical center prescribed fewer antibiotics during the COVID-19 period, and they saw most of their patients via telehealth. These results suggest that some aspects of telehealth may support clinical practices consistent with antibiotic stewardship. The prescription of an antibiotic without an associated diagnostic code also suggests opportunities to improve implementation of antibiotic stewardship principles in primary care settings.

Funding: This work was supported by the Merck Investigator Studies Program (grant no. MISP 59266 to F.P. and R.J.) and by funds and facilities provided by the Cleveland Geriatric Research.

Disclosures: None

Background: The Ohio State University Wexner Medical Center identified a cluster of coronavirus disease 2019 (COVID-19) cases on an inpatient geriatric stroke care unit involving both patients and staff. The period of suspected severe acute respiratory coronavirus virus 2 (SARS-CoV-2) transmission and exposure on the unit was December 20, 2020, to January 1, 2021, with some patients and staff developing symptoms and testing positive within the 14 days thereafter. Methods: An epidemiologic investigation was conducted via chart review, staff interviews, and contact tracing to identify potential patient and staff linkages. All staff who worked on the unit were offered testing regardless of the presence of symptoms as well as all patients admitted during the outbreak period. Results: In total, 6 patients likely acquired COVID-19 in the hospital (HCA). An additional 6 patients admitted to the unit during the outbreak period subsequently tested positive but had other possible exposures outside the hospital (Fig. 1). One patient failed to undergo COVID-19 testing on admission but tested positive early in the cluster and is suspected to have contributed to patient to employee transmission. Moreover, 32 employees who worked on the unit in some capacity during this period tested positive, many of whom became symptomatic during their shifts. In addition, 18 employees elected for asymptomatic testing with 3 testing positive; these were included in the total. Some staff also identified potential community exposures. Additionally, staff reported an employee who was working while symptomatic with inconsistent mask use (index employee) early in the outbreak period. The index employee likely contributed to employee transmission but had no direct patient contact. Our epidemiologic investigation ultimately identified 12 employees felt to be linked to transmission based on significant, direct patient care provided to the patients within the outbreak period (Fig. 1). In addition, 3 employees had an exposure outside the hospital indicating likely community transmission. Conclusions: Transmission was felt to be multidirectional and included employee-to-employee, employee-to-patient, and patient-to-employee transmission in the setting of widespread community transmission. Interventions to stop transmission included widespread staff testing, staff auditing regarding temperature and symptom monitoring, and re-education on infection prevention practices. Particular focus was placed on appropriate PPE use including masking and eye protection, hand hygiene, and cleaning and disinfection practices throughout the unit. SARS-CoV-2 admission testing and limited visitation remain important strategies to minimize transmission in the hospital.

Figure 1.

Funding: No

Disclosures: None

A policy mandating the completion of an online learning module for healthcare workers intending to decline influenza immunization was associated with a nearly 25% relative increase in immunization and significant reduction in healthcare-associated influenza. In the absence of mandatory vaccination, this model may help to augment severe acute respiratory coronavirus virus 2 (SARS-CoV-2) vaccine efforts.

In total, 20 severe acute respiratory coronavirus virus 2 (SARS-CoV-2) clusters were analyzed in a tertiary-care hospital from the beginning of the pandemic until July 2021. After the second pandemic wave, the number of clusters decreased with increasing vaccination rates and community infections increased again. These findings should motivate healthcare workers to participate in SARS-CoV-2 vaccination campaigns.

Background: Taking antibiotics outside the guidance of a clinician (nonprescription use) is a potential safety issue and runs counter to antibiotic stewardship efforts. We identified the symptoms and illnesses and situations that may predispose patients to take antibiotics, and we compared these findings between patients attending public primary care clinics and private emergency departments. Methods: A cross-sectional survey was conducted between January 2020 and March 2021 in 6 primary care clinics and 2 emergency departments in the United States. We queried patients about 5 symptoms and illnesses (Fig. 1) and 14 situations (Fig. 2) to investigate whether these would lead the patients to take antibiotics without a prescription. We used the χ2 test to compare the symptoms and illnesses and situations between the respondents from public and private healthcare systems. We set the P value for significance at <.025. Results: In total, the survey had 564 respondents (median age, 49.7 years; range, 19–92), and 72% were female. Most respondents identified as either Hispanic or Latina/Latino (46.6%) or African American or Black (33%), followed by White (15.8%), and other (4.6%). Most respondents had visited public clinics (72%). The most common insurance status for our respondents included Medicaid or county financial assistance program (56.6%), followed by private insurance or Medicare (36.7%) and self-pay (6.7%). In public primary care clinics, only 23% had private insurance or Medicare compared to 72.9% in private emergency departments. Of those surveyed, 69% agreed that antibiotics would improve the recovery from sinus infections, followed by bronchitis (64%), sore throat (64%), cold/flu (61.4%), and diarrhea (31.5%). The proportions of respondents who believed that antibiotics would improve the recovery from diarrhea (36.2% vs 19.4%; P = .004) and sore throat (59.9% vs 48.4%; P < .001) were significantly higher among public versus private outpatient respondents. We did not find significant differences for cold/flu, sinus infection, or bronchitis between these 2 healthcare systems (Fig. 1). In 11 of the 14 situations, patients in public clinics were more likely to report a likelihood of using nonprescription antibiotics than the patients visiting the private emergency rooms (Fig. 2). Conclusions: Future stewardship interventions should be aware of the symptoms and illnesses and situations that may influence outpatients to take nonprescription antibiotics. Addressing modifiable factors (eg, leftover antibiotics, antibiotics given by friends or family, and antibiotics available without a prescription in stores or markets) may also curtail these unsafe practices and reduce antibiotic resistance.

Funding: None

Disclosures: None

Misdiagnosis of bacterial pneumonia increases risk of exposure to inappropriate antibiotics and adverse events. We developed a diagnosis calculator (https://calculator.testingwisely.com) to inform clinical diagnosis of community-acquired bacterial pneumonia using objective indicators, including incidence of disease, risk factors, and sensitivity and specificity of diagnostic tests, that were identified through literature review.

Objectives: Sharp injuries are frequent occurrences in healthcare settings. According to the World Health Organization, >2 million occupational exposures to sharp injuries occur among 35 million healthcare workers (HCWs) annually. We report the 5-year incidence and trends of sharp injuries in an acute-care hospital. We compared the rates of injury, the distribution of injuries, and the type of exposure of HCWs during the prepandemic and pandemic eras. Methods: We conducted a retrospective analysis of a 5-year surveillance on self-reported sharp injuries in Changi General Hospital, a 1,000-bed acute-care hospital. The occupational groups, the type of sharps, and the incident activity involved were reviewed. The bloodborne pathogen statuses of the identified source patients were studied. Results: In total, 441 sharp injuries were reported from 2017 to 2021. Among the occupational groups, doctors reported the highest number of sharp injuries (N = 272, 61.7%), followed by nurses (N = 129, 29.3%) and other allied health professionals (N = 29, 6.4%). An increasing proportion of doctors reported sharp injuries from 2017 to 2019 (prepandemic era) and the proportion declined from 2020 to 2021 (pandemic era); 52 doctors (58.4%) reported sharp injuries in 2017, 61 (61.1%) in 2018, 72 (67.9%) in 2019, 47 (61%) in 2020, and 40 (57.1%) in 2021. Most sharp injuries were caused by solid sharps (212 of 441, 48.1%) and hollow-bore needles (205 of 441, 46.5%). Source patients were identified in 407 sharp injuries. From the known sources, 51 were seropositive: 20 for hepatitis B (HBV), 27 for hepatitis C (HCV), and 4 for human immunodeficiency virus (HIV). No seroconversion occurred. Overall, 198 sharp injuries (44.9%) were sustained during surgical procedures, 83 (18.8%) occurred during blood taking, and 44 (9.9%) occurred during injection administration. Also, 37.5% of sharp injuries among doctors occurred during surgical procedures, and 69.6% of sharp injuries in OT occurred among junior surgical doctors. Conclusions: The overall incidence of sharp injuries has decreased during the pandemic. Fewer elective surgical procedures were performed during the pandemic period. OT suturing training workshops and awareness programs on strategies for preventing sharps injuries in the operating theatre, targeted at surgical residents during the past 2 years, could have contributed to the decrease in the incidence of sharp injuries in our hospital. Sharp injuries pose a significant exposure to blood and body fluids and should be subject to continued epidemiological surveillance.

Objectives: Surgical-site infections (SSIs) cause significant increases in mortality, morbidity, and prolonged hospitalization after cesarean deliveries. We assessed the effectiveness of the implementation of an SSI bundle in reducing postoperative infections in cesarean deliveries in a tertiary-care teaching hospital in Malaysia. Method: We conducted a quality-improvement study on all women who underwent labor and scheduled cesarean sections at the University Malaya Medical Center (UMMC) between May and December 2020. The preintervention period was May–June 2020 and the postintervention period was September–December 2020. Patients were followed for 90 days after their operation. Before the intervention, SSI rates and compliance with prevention practices were documented. A multidisciplinary team was formed, and education regarding the elements of the SSI prevention bundle was conducted before they were implemented. The care bundle focused on monitoring compliance with preoperative bathing, contact time for skin preparation, hair management, and antibiotics prophylaxis given within 60 minutes prior to incision, as well as patient education. Result: With the implementation of the SSI bundle, we observed a significant reduction in the SSI rate by 50%, from 7 per 100 procedures to 2 per 100 procedures. Compared with the preintervention period, overall compliance with bundle elements improved greatly for preoperative bathing (0 vs 95.7%) and contact time for skin preparation (0 vs 98.8%). In the postintervention period, the method of hair removal was documented, compared to no documentation during the preintervention period. The administration of prophylactic antibiotics within 60 minutes prior incision decreased from 99% to 92.3%. Conclusion: Implementation of an SSI prevention bundle successfully reduced the rate of SSI after cesarean section. The SSI prevention bundle together with improvements by multidisciplinary teams and a good patient-safety culture helped reduce SSI rates. Patient education on pre- and postoperative infection prevention also played an important role in reducing this infection rate.

We assessed breakpoint changes of 13,101 Enterobacterales and Pseudomonas aeruginosa isolates from the past decade. All β-lactams and fluoroquinolones demonstrated decreased susceptibilities following breakpoint changes. Enterobacter cloacae experienced the largest average decrease in susceptibility amongst the Enterobacterales at 5.3% and P. aeruginosa experienced an average decrease in susceptibility of 9.3%.