Background: Diagnostic stewardship modifies the ordering, performing, and reporting of diagnostic tests to optimize clinical care and infection prevention while conserving healthcare resources. Timely and accurate diagnosis of respiratory virus infections can optimize the use of antibiotics, antivirals, ancillary tests, and inpatient beds. Influenza-like illnesses (ILIs) are frequently caused by viruses. However, before COVID-19, specific antiviral medication was commonly used only for the treatment of influenza virus infections. Methods: Eskenazi Health (EH) had 2 respiratory PCR assays: influenza/RSV ($58.18 per assay) and a 20-pathogen respiratory pathogens panel (RPP) ($129 per assay). An inpatient ILI algorithm was developed and implemented in the electronic health record (EHR) in October 2018 to guide the selection of the appropriate assay (Figure 1). Ambulatory testing defaulted to the influenza/RSV assay. Prescribers retained the ability to override recommendations. We performed a retrospective chart review of all orders for RPP and influenza/RSV assays before implementation of the ILI algorithm (October 1, 2017, to September 30, 2018) and after implementation (October 1, 2018, to September 30, 2019). The primary end point was the number of RPP assays ordered. The secondary end point was the appropriateness of RPP assays ordered (ie, met ≥1 criteria) and number of influenza/RSVs assays ordered with virus detected. Results: Before the implementation of the intervention, 1,882 orders were reviewed. After implementation 1,621 orders were reviewed. All influenza/RSV and RPP assays were included if they were ordered between October 1, 2017, and September 30, 2019, at EH. There were no exclusion criteria. After implementation, RPP assays decreased ~40% (Table 1), with associated cost savings of $35,368.68 (22.6% of total assay costs; $163,742.88 before implementation and $128,374.20 after implementation). Although some of this reduction could be attributed to the lower number of overall assays ordered, the 40% reduction in RPP assays exceeded the 14% decrease in overall orders, demonstrating improvement in utilization of RPP assays. A corresponding increase in influenza/RSV assay orders was not observed; both groups had similar total influenza/RSV orders. Both groups also had similar percentages of viruses detected with influenza/RSV and RPP (33% before vs 31% after). After implementation, 1,522 (94%) of 1,621 orders followed the recommendations of the ILI algorithm (Table 2). Several prescribers ordered influenza/RSV despite the patient meeting criteria for RPP assay; of these 26 assays, 4 (15%) resulted in virus detection. Of the 73 instances in which prescribers bypassed recommendations for the influenza/RSV assay and ordered an RPP assay, 14 (19%) of the assays resulted in virus detection; only 1 of 14 was a virus that would have been detected by the influenza/RSV. We were unable to identify any trends that would assist in developing additional order questions to capture these patients. Conclusions: Implementation of the ILI algorithm was associated with high adherence, improvement in the appropriateness of ordering, and significant cost savings.

Funding: No

Disclosures: None

Figure 1.

Table 1.

Table 2.

Background: Over the past decade, the CLSI has updated susceptibility break points for several antimicrobial agents. The purpose of this study was to evaluate the impact of these changes against gram-negative bacteria at our academic medical center. Methods: In this retrospective, IRB-approved study, we collected consecutive, nonduplicate clinical isolates of Enterobacter cloacae, Escherichia coli, Klebsiella aerogenes, K. oxytoca, K. pneumoniae, and Pseudomonas aeruginosa for the past decade (2010–2019) at our academic medical center and 3 adult ICUs. Susceptibility testing was performed using the BD Phoenix automated system. For these isolates, susceptibilities for 7 β-lactams (aztreonam, ceftriaxone, ceftazidime, cefepime, piperacillin/tazobactam, ertapenem, and meropenem) and 2 fluoroquinolones (levofloxacin, ciprofloxacin) were calculated based upon CLSI break points in 2010 and current CLSI break points in 2020. Any change >5% in susceptibility was deemed significant for this analysis. Results: In 17.5% of Enterobacteriales isolates tested, at least 1 antimicrobial demonstrated significant decline. Ertapenem was the most commonly affected antimicrobial (45% of the isolates) followed by ceftriaxone (35%) and cefepime (25%). Susceptibilities of aztreonam, ceftazidime, and meropenem were not affected for any of the Enterobacteriales. The most common organism demonstrating a significant impact on change in susceptibility among the Enterobacteriales was E. cloacae (41.7% of the time) followed by E. aerogenes (20.8%), K. oxytoca (12.5%), K. pneumoniae (8.3%) and E. coli (4.2%). Most of the impact was observed hospital-wide (33.3%), followed closely by the MICU (28.6%), the NSICU (23.8%) and the CVICU (14.3%). For P. aeruginosa, the impact of the antimicrobial break-point changes on susceptibility was more pronounced than the Enterobacteriales. Overall, 93.8% of the time there was a significant decline in antimicrobial susceptibility. Each antimicrobial (ciprofloxacin, levofloxacin, meropenem, and piperacillin/tazobactam) demonstrated a significant decline in susceptibility hospital-wide and in each ICU except for the susceptibility of meropenem in the NSICU. Conclusions: Changes in break points had a significant impact on the susceptibility of all antimicrobials for P. aeruginosa at our institution, both hospital-wide and in the adult ICUs. Although the impact was less for the Enterobacteriales, ertapenem, ceftriaxone, and cefepime demonstrated significant susceptibility changes, especially with E. cloacae. Understanding and evaluating the impact of the break-point changes may lead to changes in empiric therapy in other institutions.

Funding: No

Disclosures: None

Background: Tracheal aspirate bacterial cultures are routinely collected in mechanically ventilated children for the evaluation of ventilator-associated infections (VAIs). However, frequent bacterial colonization of endotracheal and tracheostomy tubes contribute to the marginal performance characteristics of the test for diagnosing VAI. Published literature characterizing drivers of culture collection and the predictive value of positive cultures are limited. Methods: This single-center, retrospective cohort study included children admitted to the pediatric intensive care unit who were receiving mechanical ventilation for at least 48 hours and had 1 or more semiquantitative tracheal aspirate cultures collected between September 1, 2019, and August 31, 2020. Indications for culture collection were determined through medical record review and included fever, hypothermia, tracheal secretion changes, radiographic pneumonia, increased oxygen requirement, and/or increased positive end-expiratory pressure (PEEP). A positive culture was defined as moderate or heavy growth of a noncommensal bacterial organism. A purulent Gram stain was defined as detection of moderate or many white blood cells. Diagnosis of VAI was based on treating-clinician documentation and was ascertained through medical record review. Logistic regression accounting for clustering by patient was performed to estimate the association between indications for culture collection and (1) culture positivity, (2) purulent Gram stain, and (3) diagnosis of VAI. Results: In total, 625 tracheal aspirate cultures were performed in 261 unique patients. Common indications for culture collection included isolated fever or hypothermia (n = 124, 20%), fever with an increase in oxygen requirement or PEEP (n = 71, 11%), isolated increase in oxygen requirement or PEEP (n = 67, 11%), or isolated secretion change (n = 54, 9%) (Figure 1). Overall, 230 cultures (37%) were positive and 218 (35%) Gram stains were purulent. There were no associations between culture indications and a positive culture. Presence of isolated fever was negatively associated with a purulent Gram stain (odds ratio [OR], 0.49; 95% CI, 0.30–0.81; P = .005); otherwise, there were no associations between indication and purulent Gram stain. Finally, in a multivariable model, odds of VAI diagnosis increased with both the number of indications for culture collection and purulent Gram stain, but not with positive culture (Figure 2). Conclusions: Number and type of clinical signs were not associated with tracheal aspirate culture positivity or purulence on Gram stain, but they were associated with a clinical diagnosis of VAI. These findings suggest that positive tracheal aspirate cultures may not aid clinicians in the diagnosis of VAI, and they highlight the opportunity for improved diagnostic stewardship.

Funding: No

Disclosures: None

Figure 1.

Figure 2.

Background: The use of the automated system for identification and susceptibility tests can improve antimicrobial stewardship. The reduction in the time of identification of the pathogen and the correct dose of antibiotic are factors that contribute significantly to institutional programs and patient outcomes. Objective: We identified and evaluated the susceptibility tests of microorganisms for common pathogens through antibiograms that accounted for the minimum inhibitory concentration (MIC), in a tertiary-care public hospital in Brazil. Methods: This retrospective, cross-sectional study was performed to identify microbiologic profiles after the implementation of a VITEK 2 system at a tertiary-care public hospital in Curitiba, Brazil. Based on data from the medical records, patients with positive cultures of clinical samples from August to December 2017 were included in this study. The analysis included culture results, susceptibility profiles, and MICs of 5 antibiotics: amikacin, cefepime, ciprofloxacin, meropenem and vancomycin. Results: In total, 545 antibiograms were evaluated using VITEK 2. The following microorganisms were isolated: 345 gram-negative bacilli (63.3%), 187 gram- positive cocci (34.3%), 9 unidentified microorganisms (1.7%), and 4 yeasts (0.7%). Among the analyzed antibiograms, amikacin was tested in 371 isolates (68.1%), with an MIC of 2 mg/L being the most prevalent value, with a frequency of 224 results (41.1%). Cefepime was tested in 319 isolates (58.5%), with an MIC of 1 mg/L being the most prevalent, with a frequency of 177 results (32.5%). Ciprofloxacin was tested in 470 isolates (86.2%), with an MIC of 0.25 mg/L being the most prevalent value, with frequency of 189 results (34.7%). Meropenem was tested in 318 isolates (58.3%), with an MIC of 0.25 mg/L being the most prevalent value, with a frequency of 223 results (40.9%). Vancomycin was tested in 157 isolates (28.8%), with an MIC of 1 mg/L being the most prevalent value, with frequency of 87 results (16%). Conclusions: When analyzing the most frequently isolated microorganisms and their predominant sensitivity profiles in our institution, amikacin proved to be a good therapeutic option, considering the epidemiological profile, as gram-negative bacilli showed greater sensitivity. Furthermore, VITEK 2 systems provided early access to appropriate antimicrobial therapy for patients, which is a known factor for reducing bacterial resistance.

Funding: No

Disclosures: None

Background: US healthcare facilities experienced significant personal protective equipment (PPE) shortages, including N95 masks, in the spring and summer of 2020. The Centers for Disease Control and Prevention issued guidance for extended use, reprocessing, and reuse of N95s. Eskenazi Health (EH) implemented a program to reprocess N95s and other PPE on-site using low-heat decontamination (LHD). EH considered large-scale and small-scale ultraviolet (UV), hydrogen peroxide vapor, and LHD for on-site reprocessing of N95s. All of these methods allowed up to 3 reprocessing cycles according to most literature available at the time. However, each method differed in feasibility and acceptability to staff. EH chose to implement LHD based on both considerations. Methods: Numerous small-group meetings were held in April 2020 to determine the feasibility and acceptability of N95 reprocessing methods. Staff wanted a method that was easy for the end user, had quick turnaround, and allowed them to retrieve their own N95s. They favored a method that could be used for all PPE. EH had deployed numerous small UV machines that individuals could use for N95s. The UV machines could not be scaled up easily. To scale up, a multidisciplinary team comprising infection prevention, biomedical engineering, and sterile processing representatives reviewed available methods and implemented LHD. Biomedical engineers determined that existing blanket warmers could be reprogrammed and repurposed for low-heat decontamination. Food warmers were also available but were not needed. Biomedical engineers reprogrammed the blanket warmers to 70°C and developed a wicking system using a towel and water tray to maintain humidity; decontamination took 30 minutes. Testing runs determined that both N95s and eye protection tolerated LHD without apparent damage. Infection prevention staff developed a workflow in which staff deposited all PPE in a paper bag; the PPE bag was centrally reprocessed, marked (Figure 1), and returned to designated locations (Figure 2) for staff to retrieve their original PPE. Sterile processing staff facilitated the reprocessing workflow, and elective surgeries were canceled during the COVID-19 surge. Results: From April 20, 2020, to July 19, 2020, 7,512 units were decontaminated with LHD. If each N95 was sterilized thrice (4 uses per N95), then LHD reduced the need to purchase 22,536 N95s. Restarting elective surgeries decreased staff and support from sterile processing; the space was needed for other purposes; and N95 availability increased. All of these factors led to the discontinuation of LHD. Conclusions: LHD enables reprocessing of N95s and other PPE using existing assets. LHD is advantageous because of scalability and the capacity to provide staff with their own reprocessed PPE.

Funding: No

Disclosures: None

Figure 1.

Figure 2.

Background: So far, there have been no studies on Candida auris in Qatar. We describe the clinical spectrum and outcome of C. auris infection in patients admitted to a general hospital in Qatar. Methods: We conducted this descriptive observational study in a general hospital in Qatar. We have included all patients with C. auris infection and colonization admitted to a general hospital from December 2018 to August 2019. Results: We identified 13 patients with confirmed C. auris infection or colonization, of whom 5 cases represented an actual C. auris infection, while the remaining 8 cases were considered colonization. The mean age of the patients with infection was 76.6 years (SD, ±8.4), while the mean age of the patients with colonization was 66.4 years (SD, ±24.7). Among the individuals clinically infected with C. auris, 2 had urinary tract infections, 1 had candidemia, 1 acquired a soft-tissue infection, and 1 had a lower respiratory tract infection. All strains of C. auris were susceptible to echinocandins, flucytosine, and posaconazole while resistant to fluconazole and amphotericin B. Of the patients with C. auris infection who received systemic antifungal therapy, 3 (60%) died during antifungal therapy. Conclusions: Our study showed that C. auris can cause a wide variety of invasive infections, including bloodstream infection, urinary tract infection, skin infection, and lower respiratory tract infections, especially in critically ill patients. In addition, our isolates showed resistance to the most common antifungal agents such as fluconazole and amphotericin B.

Funding: No

Disclosures: None

Background: Contaminated surfaces in healthcare settings contribute to the transmission of pathogens. Environmental cleaning and disinfection are important for preventing pathogen transmission and reducing healthcare-associated infections (HAIs). Hospital cleanliness plays a large role in patient perception of the healthcare setting and, consequently, of patient satisfaction. However, patient perceptions of environmental cleaning remain unclear. To engage patients as part of achieving patient-centered care, we undertook a qualitative study to examine patient perspectives on environmental cleaning and disinfection in healthcare settings. Methods: We conducted semistructured qualitative interviews with 14 hospitalized patients at a large midwestern Veterans’ Administration hospital. Interviews were audio recorded, professionally transcribed verbatim, summarized in a “key domains” template developed by the research team, then coded for emerging themes. Results: Patients reported feeling satisfied with hospital cleanliness and especially the daily cleaning they observed while hospitalized. Cleaning activities highlighted included mopping and disinfecting high-touch surfaces, bathrooms, and floors. Despite this overall positive response, some patients expressed worries of being “in the way” or burdensome if they were in their rooms while staff were cleaning. One interviewee stated, “It’s easier for them if there isn’t a patient in [the room] … it’s hard to do any endeavor when you’ve got a complete stranger watching you.” Patients also acknowledged the importance of careful cleaning, especially during the COVID-19 crisis; “It’s got to be something you take seriously, especially during this pandemic.” Some patients spoke of the relationship which can develop between environmental services staff during daily hospital room cleaning. Conclusions: Patient perceptions of environmental cleaning are important to understand and incorporate into clinical practice. Overall, patients felt that their environments were clean, and they expressed confidence in the staff’s work. Interviewees additionally spoke of their own self-efficacy, saying they try to clean up after themselves and would feel comfortable speaking up if something needed to be cleaned. However, some patients acknowledged feeling burdensome to the environmental services staff if patients were present in rooms while staff cleaned. Cleaning activities may become more patient-centric if they are better planned (eg, while patient is out of the room) or based on patient preferences on time of day.

Funding: No

Disclosures: None

Background: Environmental cleaning is important in the interruption of pathogen transmission and subsequent infection. Although recent initiatives have targeted cleaning of high-touch surfaces and incorporated audit-and-feedback monitoring of cleaning practices, practice variations exist and compliance is still reportedly low. Evaluation of human factors influencing variations in cleaning practices can be valuable in developing interventions, leading to standardized practices and improved compliance. We conducted a work system analysis using a human-factors engineering framework [the Systems Engineering Initiative for Patient Safety (SEIPS) model] to identify barriers and facilitators to current environmental cleaning practices within Veterans’ Affairs hospitals. Methods: We conducted semistructured interviews with key stakeholders (ie, environmental staff, nursing, and infection preventionists) at 3 VA facilities across acute-care and long-term care settings. Interviews were conducted among 18 healthcare workers, audio recorded, and transcribed verbatim. Transcripts were analyzed for thematic content within the SEIPS constructs (ie, person, environment, organization, tasks, and tools). Results: Within the SEIPS domain ‘person,’ we found that many environment service (EVS) staff were veterans and were highly motivated to serve fellow veterans, especially to prevent them from acquiring infections. However, the hiring of service members as EVS staff comes with significant hurdles that affect staffing. Within the domain of ‘environment’, EVS staff reported rooms that were either occupied by the patient or were multibed, were more difficult to clean. Conversely, they reported that it was easier to clean in settings where the patient was more likely to be out of bed (eg, long-term care residents). Patient flow and/or movement greatly influenced workload within the ‘organizational’ domain. Workload also changed by patient population and setting (eg, the longer the stay or more critical the patient), increased their workload. EVS staff felt that staffing consistency and experience improved cleaning practices. Within the ‘task’ domain, EVS staff were motivated for cleaning high-touch surfaces; however, knowledge of these surfaces varied. Finally, within the ‘tool’ domain, most EVS staff described having effective cleaning products; however, sometimes in limited supply. Most sites reported some form of monitoring of their cleaning process; however, there was variation in type and frequency. Conclusions: Human-factors analysis identified barriers to and facilitators of cleaning compliance. Incorporating environmental cleaning practices that address barriers and facilitators identified may facilitate standardized cleaning of environmental surfaces. Standardized procedures for cleaning multibed rooms and environmental surfaces surrounding occupied beds may improve cleaning compliance. Future research should evaluate standardized cleaning procedures or bundles that incorporate these best practices and steps to overcoming barriers and pilot feasibility.

Funding: No

Disclosures: None

Background: Hospital beds are now high-tech, reprocessable, medical devices. The surface of the mattress (cover) is manufactured using polyurethane-coated fabric to ensure moisture-vapor transmission to prevent pressure ulcers. In recent years, due to multidrug-resistant organisms, healthcare organizations have used increasingly harsh chemicals to clean these mattresses. None of these chemicals are approved for use on polyurethane-coated fabric. Previous research has shown that many mattresses in hospitals are damaged. The US Food and Drug Administration, Centers for Disease Control and Prevention, ECRI, and manufacturers recommend routine mattress inspection and replacement of mattresses with any visible signs of stains, wear, or damage. Damaged mattresses have been linked to fluid leakage, resulting in patient exposure and outbreaks of healthcare-acquired infections. Methods: Four hospitals of a midwestern hospital system had all of their mattresses inspected for damage and staining to the mattress. After external examination, each mattress was opened, and the mattress core was evaluated for damage. The cover of each mattress was examined using the naked eye and then using an LED light to demonstrate smaller holes. Each bed frame was examined for evidence of rust, and the amount of rust was recorded. If available, the age of the mattress was determined based on a label on the mattress. Results: In total, 727 beds and mattresses were inspected. Of these mattresses, 523 (72%) were damaged. Also, 340 (47%) required replacement of the mattress cover, and 183 (25%) required replacement of the entire mattress (cover and core). For the 209 damaged mattresses (40%) with the date of manufacture label, 156 (75%) were <4 years old. Damage to the mattress included 428 (59%) with holes in the cover: 113 (16%) were visible to the naked eye and 315 (43%) small holes only detected by using an LED light. Also 173 mattresses (24%) had stains on the exterior cover, 215 (30%) had stains on the interior of the top cover, and 192 (26%) had stains on the interior of the bottom cover. Bed-frame rust was identified on 175 (24%) beds, of which 65 (9%) had widespread rust. Conclusions: These findings confirm previous reports that damaged mattresses are common in hospitals and potentially place patients at risk. Most of these failed mattresses are <4 years old, which is much less than the expected life of a mattress and bed deck.

Funding: No

Disclosures: None

Background: Disinfection procedures are an essential aspect of preventing cross contamination, especially in situations where the risk of infection is higher, such as in operating rooms (ORs). Disinfection procedures in ORs at the end of each surgery session are not the same as final cleaning procedures. We assessed the difference in microbial contamination between different levels of disinfection, before T(0) and after T(1) the use of an ultraviolet C device (UVC-D). Methods: A cross-sectional study was conducted between December 2019 and August 2020 in a private clinic. Three sanitation levels (SL1–SL3) were compared for the reduction in colony-forming units (CFU) between T(0) and T(1): (1) no disinfection after surgery (SL1);, (2) after in-between cleaning (SL2), and (3) after terminal cleaning (SL3). UVC-D was used for 6 minutes, 3 minutes per bed side. Overall, 260 Petri dishes were used in 3 ORs, incubated at 36°C, and CFU were counted after 48 hours. Descriptive statistics, Wilcoxon test, and MANOVA for repeated measures were performed to verify the 95% statistical difference between T(0) and T(1), both on the whole sample and combined with the different SLs. Results: The unstratified analysis showed statistically significant differences (Wilcoxon test, p < 0.05) between T(0) and T(1), with means and standard deviations of 11.42 ± SD 41.19 CFU/PD and 5.91 ± SD 30.89, respectively. The Manova test for repeated measures, applied to 54 pairs of measurements, showed no significant difference between SLs in T(0)-T(1) CFU reduction. Overall, the mean percent reduction in CFU was 93.48% (CI95% = 86.97-99.99%). Conclusions: The results showed significant improvements in disinfection under any condition tested with UVC-D. Using the device immediately after surgery (SL1), before standard cleaning procedures, reduced CFUs by 97.3%. In some situations, UVC light was sufficient to reduce CFU to zero, even without chemical and mechanical cleaning. However, we do not recommend this approach; UVC light disinfection should be applied only after sanitization procedures because it does not remove dirt.

Funding: UltraViolet Device, Inc

Disclosures: None

Background: Hand hygiene is essential to preventing the spread of disease in hospitals. Renewed emphasis has been placed on hand hygiene during the COVID-19 pandemic. We investigated whether UNC Medical Center’s well-established Clean-In Clean-Out (CICO) program for hand hygiene observations was sustainable throughout a public health and healthcare crisis and whether the COVID-19 pandemic had an effect on hand hygiene compliance. Methods: UNC Medical Center utilizes a crowd-sourced hand-hygiene audit application, CICO, to track hand-hygiene observations, compliance, and feedback. This application encourages participation from all staff and promotes providing real-time feedback in the form of a compliment or reminder when performing hand hygiene observations. During this evaluation, hand hygiene data were queried from the CICO application on the number of observations performed, hand hygiene compliance percentage, and feedback compliance percentage from July 2019 to December 2020. Hand hygiene data were compared to patient volumes in different care settings and the number of hospitalized patients being treated for COVID-19. Results: Initial increases in hand hygiene observations, compliance, and feedback were detected in the months leading up to UNC Medical Center receiving its first SARS-CoV-2–positive patient. Observations were highest when patient volumes were low due to closed clinics and restrictions on elective surgeries (Figure 1). When patient volumes returned to pre–COVID-19 levels coupled with treating more COVID-19 patients, the number of observations and compliance rate metrics declined. Feedback compliance percentage remained relatively stable through the entire period (Figure 2). Conclusions: Despite the additional strain on healthcare staff during COVID-19, the CICO model was a sustainable method to track hand hygiene observations and compliance. Notably, however, engagement was highest when patient census was lower, demonstrating that operating at a high capacity is not beneficial for patient safety. Due to the success and sustainment of the CICO program, UNC Medical Center used this model to create a Mask-On Mask-Up campaign to engage staff to submit observations, track compliance, and encourage feedback to promote the appropriate use of masks during COVID-19.

Funding: No

Disclosures: None

Figure 1.

Figure 2.

Background: We sought to determine the minimum number of observations needed to determine hand hygiene (HH) compliance among healthcare workers. Methods: The study was conducted at a referral hospital. We retrospectively analyzed the result of HH monitoring from January to December 2018. HH compliance was calculated by dividing the number of observed HH actions by the total number of opportunities. Appropriate HH compliance rates were calculated based on the 6-step technique, modified from the World Health Organization (WHO) recommendation. The minimum number of required observations (n) was calculated by the following equation using overall mean value (r), absolute precision (d), and confidence interval (1-α) [The equation: n3 Zα/22×ρ×1-ρ/d2]. We considered ds of 5%, 10%, 20%, and 30%, with CIs of 99%, 95%, and 90%, respectively. Among the various cases, we focused on 10% for d and 95% for CI. Results: During the study period, 8,791 opportunities among 1,168 healthcare workers were monitored. The mean HH compliance and appropriate HH compliance rates were 80.3% and 59.7%, respectively (Table 1). The minimum number of observations required to determine HH compliance rates ranged from 2 (d, 30%; CI, 90%) to 624 (d, 5%; CI, 99%), and the minimum number of observations for optimal HH compliance ranged from 5 (d, 30%, CI, 90%) to 642 (d, 5%; CI, 99%) (Figure 1). At 10% absolute precision with 95% confidence, the minimum number of observations to determine HH and optimal HH compliance were 61 and 92, respectively. Conclusions: The minimum number of observations to determine HH compliance varies widely according to setting, but at least 5 were needed to determine optimal HH compliance.

Funding: No

Disclosures: None

Figure 1.

Table 1.

Background: Daily chlorhexidine gluconate (CHG) bathing in intensive care units (ICUs) is widely supported in the literature to decrease risk of central-line-associated infections (CLABSIs). However, adoption of this practice is inconsistent. The primary objective of this implementation science study was to assess the effect of a bathing intervention on compliance with the AHRQ CHG bathing protocol. Secondary objectives were to examine (1) moderating effects of unit characteristics, (2) the intervention effect on nursing staff’s knowledge and perceptions of CHG bathing, and (3) the intervention effect on CLABSI rates. Methods: A stepped-wedge cluster-randomized design was used to implement and evaluate the effectiveness of a CHG bathing intervention. At 2 large hospitals, 14 units were clustered into 4 sequences. Units included 9 adult ICUs, 3 pediatric ICUs, 1 pediatric bone marrow transplant unit, and 1 adult hematology-oncology unit. Sequences were enrolled into the active intervention phase over the course of 4 months. The intervention included 2 evidence-based implementation strategies: (1) educational outreach visits and (2) audit and feedback on CHG bathing compliance. Compliance with the CHG bathing processes and daily CHG bathing documentation were assessed. At 12 months after the last enrolled date, booster sessions were completed, and outcomes were assessed for sustainability. Results: In models of CHG bathing process compliance, the implementation strategy was significant (b = 6.97; P = .009), indicating that compliance was 6.97% higher after the intervention than before. There was a statistically significant improvement in nursing knowledge of CHG bathing (χ2 = 9.32, p = .002) and perception of the priority of CHG bathing (t = 2.56; P = .01). Daily CHG bathing documentation compliance and CLABSI rates did not significantly improve immediately following the intervention; however, a clinically significant decrease (27.4%) in CLABSI rate was observed. At 12 months after the intervention, improvements in CHG bathing documentation and process outcomes were sustained. There was no change in bathing process compliance after 12 months (b = −0.19; P = .87; intercept=96.96, p < .001), and compliance remained high at 96.96%. There was no change in documentation compliance after 12 months (b=3.89, p=.37, intercept=78.72, p < .001), and compliance remained high at 78.72%. After 12 months, CLABSI rates were statistically significantly reduced (b = −0.16; P = .009; intercept =1.97, p < .001). Conclusions: Using educational outreach visits and audit-and-feedback strategies can improve the adoption of evidence-based CHG bathing practices. CHG bathing—a simple, nurse-driven practice—can make a significant improvement in patient outcomes.

Funding: No

Disclosures: None

Background: Hospitals are required to have antibiotic stewardship programs (ASPs), but there are few models for implementing ASPs without the support of an infectious disease (ID) specialist, defined as an ID physician and/or ID pharmacist. In this study, we sought to understand ASP implementation at hospitals within the Veterans’ Health Administration (VHA) that lack on-site ID support. Methods: Using a mandatory 2016 VHA survey, we identified acute-care hospitals that lacked an on-site ID specialist. For each hospital, antibiotic use (2018–2019) was quantified as days of therapy (DOT) per 1,000 days present, based on NHSN methodology for tracking all antibacterial agents. From July 2019 through April 2020, we conducted semistructured interviews with personnel involved in or affected by ASP activities at 7 qualifying hospitals. All interview transcripts were analyzed using thematic content analysis. Results: Of the 7 acute-care hospitals, 6 (86%) had a long-term care unit; 3 (43%) had an intensive care unit; and 2 (29%) had full-time employment equivalents dedicated to stewardship. Sites averaged 1,075 (SD, ±654) and 148 (SD, ±96) admissions per year in acute-care and long-term care, respectively. At the site-level, mean antibiotic use was 486 DOT (SD, ±98) per 1,000 days-present in acute-care and 207 DOT (SD, ±74) per 1,000 days present in long-term care. We interviewed 42 personnel across the 7 sites. Although sites reported using similar interventions to promote antibiotic stewardship, the shape of these interventions varied. The following 4 common themes were identified: (1) The primary responsibility for ASPs fell on the pharmacist champions, who were typically assigned multiple other non-ASP responsibilities. (2) The pharmacist champions were more successful at gaining buy-in for stewardship initiatives when they had established rapport with clinicians, but at some sites, the use of contract physicians and frequent staff turnover were potential barriers. (3) Some sites felt that having access to an off-site ID specialist was important for overcoming institutional barriers to stewardship and improving the acceptance of their stewardship interventions. (4) In general, stewardship champions struggled to mobilize institutional resources, which made it difficult to advance their programmatic goals. Conclusions: In this study of 7 hospitals without local ID support, we found that ASPs are largely a pharmacy-driven process. Remote ID support, if available, was seen as helpful for implementing stewardship interventions. These findings may inform the future implementation of ASPs in settings lacking local ID expertise.

Funding: No

Disclosures: None

Background: Unlike passive didactic teaching, the introduction of innovative active-learning approaches to university nursing curricula aims to address the educational content in an interactive learning environment, improving in turn the learning process and problem-solving skills indispensable for future infection control professionals. One such strategy is the use of educational games, which can motivate students and enhance the degree of their engagement. We appraised the effectiveness of introducing an interactive game based on a popular television quiz show “Who Wants to be a Millionaire?” for educational attainment, exam performance, and course perception in nursing students. Methods: A whole generation of second-year undergraduate nursing students (126 female and 27 male participants; age range, 19–41 years) from a public university in Croatia (University Centre Varazdin, University North) were divided into 2 groups by cluster randomization; one group had received additional hours of game play after core training curriculum in a “Hygiene and Epidemiology” course, while the other had not. Game play was accomplished by employing ‘edutaining’ interactive multimedia approach, and covered primarily hand hygiene, cough etiquette, the use of personal protective equipment, sterilization and disinfection, and safe injection practices. Quantitative results of multiple-choice exams were used to evaluate any differences in the knowledge level of respective groups. A satisfaction opinion survey was used to gauge attitudes of students attending the course. Statistical significance was defined as P < .05 (2-tailed). Results: The mean baseline examination score was 28.30±5.79 points for the game group and 24.65±5.94 points for the control group, demonstrating improved knowledge retention when the interactive game was introduced into the curriculum. The statistically significant improvement in knowledge was observed in the domains of personal protective equipment and safe injection practices. There was no statistically significant difference in the overall scores between male and female students. Students who were subjected to game play expressed more agreement on a Likert scale regarding course enjoyment and innovativeness, albeit they did not differ from control group when assessing the educational merit of the course. Conclusions: Introducing interactive games to university courses that cover infection control may boost student enjoyment and enhance long-term retention of information, as confirmed by this study. Nonetheless, extra care should be taken when specific games that have not been assessed objectively are implemented. Further research in this field will elucidate how this increased knowledge retention in infection control principles translates to quotidian practice, for the benefit of students and (ultimately) patients.

Funding: No

Disclosures: None

Background: Infection prevention and control (IPC) is key (1) to keeping health workers and patients safe from contracting infections during care, (2) to enabling continuity of essential health services, and (3) to pandemic preparedness and response. Frontline health workers are at 3-fold increased risk for COVID-19 (Lancet 2020) and account for 6% of COVID-19 hospitalizations (CDC 2020). With the support of the US Agency for International Development Bureau of Humanitarian Assistance (USAID/BHA) and collaboration of the Haitian Ministry of Health (MSPP), MSH’s Rapid Support to COVID-19 Response in Haiti project (RSCR Haiti) developed an instrument to assess select public hospitals and identify IPC gaps that informed COVID-19 response and system strengthening measures for increasing patient and provider safety. Methods: The IPC tool contains 13 IPC domains and 80 questions, for a total of 600 points. It was developed based on the World Health Organization IPC Assessment Framework for Health Facilities (2018) and US Centers for Disease Control Facility Readiness Assessment for COVID-19 (2020). In total, 39 health facilities chosen by the MSPP across all 10 departments of Haiti were evaluated in October 2020. Data were analyzed in Microsoft Excel by category, site, and IPC capabilities then classified as inadequate, basic, intermediate or advanced. Results: IPC capabilities scored as inadequate in 18% and basic in 67% of hospitals (Graph 1). No institution was advanced. Among health facilities, IPC programs existed in only 18%; IPC guidelines or procedures were present in 38%; staff were trained regularly in 12%; and healthcare-associated infection surveillance was performed in 19%. Systems for COVID-19 triage existed in 56%; 39% had IPC commodity management systems; 45% provided COVID-19 training; 26% practiced monitoring of staff and patients for COVID-19; 36% had protocols for an influx of COVID-19 cases; and 72% practiced risk communication (Table 1). Conclusions: No health facility was sufficiently equipped to implement adequate COVID-19 IPC measures, and all needed strengthening, even in the highest-scoring IPC areas. Through RSCR Haiti, MSH and MSPP were able to identify and address priorities in hospitals: establishing hospital IPC programs; training staff; monitoring health workers and patients; and implementing guidance, triage, and commodity-management systems. This study demonstrates that it is possible to do a quick yet thorough assessment to rapidly identify IPC needs and opportunities, using the results to rapidly build response capacity. Haiti’s experience of integrating locally contextualized global IPC tools to inform systemic COVID-19 response measures can benefit other experts globally.

Funding: United States Agency for International Development Bureau of Humanitarian Assistance (USAID/BHA)

Disclosures: None

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Table 1.

Background: Carbapenem-resistant Enterobactericeae (CRE) has emerged as a global health threat with increasing incidence. It is a particular problem in India because control over antibiotics prescription is really poor; these agents can be easily bought over the counter and the antibiotic prescription threshold is low among Indian doctors. Also, even when administered, antibiotics are given in inappropriate dosages and durations. CRE infections are a healthcare challenge due to their difficulty to treat and high morbidity and mortality. Colonization requires infection prevention measures, and it should be prioritized. Methods: We sought to determine the prevalence rate of CRE colonization in the gastrointestinal tract in newly admitted ICU patients along with follow-up of any subsequent infection following colonization. A prospective observational study was carried out among ICU patients from January 2019 to August 2020 by collecting perirectal swabs from patients who gave consent. Clinical variables were identified, and the relationship between CRE colonization and subsequent systemic CRE infection was assessed. Processing was carried out by culturing on MacConkey agar plate with ertapenem disk and further identified using conventional microbiological techniques. The ertapenem MIC was determined using an Epsillometer (E) test. The modified carbapenem inactivation (mCIM) test and the EDTA carbapenem inactivation method (eCIM) were used to confirm carbapenem resistance using Clinical Laboratory Standards Institute 2020 guidelines (Figure 1). Results: Among 192 ICU patients, 37 (19.27%) were colonized with CRE (Table 1). Also, 13 (35.13%) CRE isolates showed metallo-β-lactamase resistance. Furthermore, 18 CRE isolates (48.64%) showed serine carbapenemase activity; 6 CRE isolates showed no carbapenemase activity. Klebsiella pneumoniae (n = 25 of 37, 67.56%) was the most common CRE isolated followed by Escherichia coli (n = 11 of 37, 29.72%) and 1 isolate of Enterobacter spp (n = 1 of 37, 0.02%). Of 37 patients, 33 (89.18%) developed CRE infection during their hospital stay. Pneumonia was the most common infection developed (36.36%), followed by surgical site infection (21.21%) and urinary tract infection (12.12%). Only 1 patient developed a bloodstream infection. However, 9 patients (27.27%) developed multiple-site infections. Of 37 CRE-colonized patients, 10 (27.02%) died during their hospital stay. Conclusions: Our study highlights the increased risk of CRE infection and mortality in patients with CRE colonization in ICU patients. Hence, CRE perirectal screening for detection of asymptomatic carriers should be conducted, and strict infection control measures, such as isolation and cohorting with barrier nursing of such patients, should be done to prevent further spread of CREs in hospital settings.

Funding: No

Disclosures: None

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Table 1.

Table 2.

Background: Medical tape is used routinely for a variety of tasks across healthcare settings. The literature contains numerous publications in which common practices around medical tapes have been suspected to lead to infection transmission. Healthcare providers can turn to individually packaged single-patient-use medical tape rolls to help reduce cross-contamination risk by limiting exposure to environmental contaminants, minimizing contact with hospital surfaces and equipment, and minimizing exposure to healthcare workers’ hands and other patients. Methods: We evaluated the effect of individually packaged tape on cross contamination using a controlled laboratory assay. Ceramic tiles were inoculated with microorganisms evenly spread across the surface and allowed to air dry. Using gloves, packaged and unpackaged tapes were rolled over their entire outside circumference onto the contaminated tiles to simulate cross contamination. Using new gloves, the packaged tapes were then removed from their package with minimum contact. All cross-contaminated tape rolls were placed in phosphate-buffered water and mixed in a vortexer for bacterial recovery procedures. Serial dilutions were plated on appropriate media for bacterial enumeration. The average log10 colony-forming unit (CFU) recovery was measured for comparison. We used 4 types of tapes in this study (3M Micropore S Surgical Tape, 3M Medipore H Soft Cloth Surgical Tape, 3M Durapore Surgical Tape, and 3M Transpore White Surgical Tape). We used 4 different microorganisms as inoculates: Staphylococcus aureus (methicillin-resistant), Enterococcus faecium (vancomycin-resistant), Klebsiella pneumoniae (carbapenem-resistant), and Clostridium difficile (spore). Each test (tape and bacteria combination) was done in 3 or 6 replicates; each bacterial enumeration was the average of duplicate plates. The detection limit for this method is 8 CFU per sample, which is equivalent to 0.9 log10. Results: The results for all tapes tested showed a statistically significant lower mean log10 recovery of each of the microorganisms tested for packaged versus unpackaged tape (Figure 1). The mean differences of log10 recoveries from a packaged and unpackaged tape ranged from 2.51 log10 (for S. aureus on Micropore S) to 4.64 log10 (for K. pneumoniae on Medipore H). This is equivalent to 99%–99.99% cross-contamination protection from the 4 organisms tested. Conclusions: Individual packaging of medical tape rolls protects them from external contaminants. Even if the packaging becomes contaminated, the tape retrieved from the package will be significantly less contaminated than it would have been from exposure to the same contaminants without packaging.

Funding: 3M Company

Disclosures: None

Figure 1.

Background: Patient colonization and shedding of vancomycin-resistant enterococci (VRE) is a major source of environmental contamination leading to VRE transmission in nursing homes. We hypothesize that we can inform mitigation strategies by identifying patient clinical and microbiota features associated with environmental contamination with VRE. Methods: During a 6-month period of active surveillance in 6 Michigan nursing homes, 245 patients (with 806 follow-up visits) were enrolled. Patient clinical data and swabs for VRE were collected from multiple body sites and high-touch environmental surfaces. In total, 316 perirectal swabs were collected from 137 patients for gut microbiota analysis and community status type (CST) assignment based on taxonomic composition. The associations between VRE colonization pattern, gut microbial CST, and patient factors were examined using multivariable generalized estimating equations, adjusting for patient-and facility-level clustering. We used VRE colonization patterns to group study visits: “uncolonized” (patient−/environment−); “environment-only” (patient−/environment+); “patient-only” (patient+/environment−); “both” (patient+/environment+). Results: Across all study visits, VRE colonization on patient hand and groin/perirectal area was positively correlated with VRE contamination of high-touch environmental surfaces, suggesting direct transfer of VRE between patient and environment via patient hands (Figure 1A). We next set out to identify patient factors associated with patient colonization and environmental contamination. At baseline, while patients in the “both” group had anticipated risk factors such as longer prior hospitalization and more frequent broad-spectrum antibiotic use, they were unexpectedly younger than “uncolonized” patients and had similar functional status. This last feature contrasted with the “patient-only” group, characterized by higher urinary catheter use and higher functional dependence, suggestive of lower functional dependence facilitating patient contamination of their environment. No clinical features distinguished “uncolonized” and “environment-only” patients (Table 1). Lastly, in multivariable analyses, we determined the contribution of patient functional status and gut microbiota features to environmental contamination. Low-diversity CST, characterized by reduced anaerobic taxa, was weakly associated with “patient-only” and significantly associated with “both.” Notably, high functional dependence was significantly associated with “environment-only” and “patient-only” but not “both,” indicating high-functioning patients with disrupted gut microbiota as drivers of environmental contamination (Figure 1B). Conclusions: Our findings suggest that antimicrobial exposure disrupts patient gut microbiota, a significant mediator of colonization dynamics between patients and their environment, and that high-functioning patients may be more likely to spread VRE between their body sites and high-touch environmental surfaces (Figure 2). These findings highlight both antibiotic stewardship and patient hand hygiene as important targets for interrupting transmission mediated by environmental contamination.

Funding: No

Disclosures: None

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Figure 2.

Background: Infections are common at end-of-life in older nursing-home residents. This often leads to the overuse of antibiotics and burdensome treatments. Improving infection management through palliative care at the end of life has been proposed as a key strategy to reducing inappropriate antibiotic use. Black nursing-home residents tend to reside in poorly performing nursing homes. We examined palliative care services in nursing homes with varying proportions of black residents. Methods: Cross-sectional, nationally representative nursing-home survey data (2017–2018) was combined with the Minimum Data Set 3.0 (nursing-home resident characteristics), the Certification and Survey Provider Enhanced Reporting data (nursing-home facility characteristics), and the Multidimensional Deprivation Index (county-level poverty estimates). The survey included 24 validated items on nursing-home palliative care services, as well as the nursing home’s infection control program and integration of infection management and palliative care (summative score, 0–100). We used nursing-home facility-level multivariate regression to estimate the relationship between proportion of black residents and palliative care scores, before and after controlling for county-level poverty estimates, facility characteristics, and resident characteristics. We categorized proportion of black residents using methods reported in the literature (25%). Results: The mean weighted palliative-care score in our sample of 869 nursing homes (weighted n = 15,020) was 47.7 (SE, 0.70). In unadjusted analyses, nursing homes with higher proportions of black residents provided significantly fewer palliative care services than nursing homes with no black residents, with the greatest differences (P = .027) observed between nursing homes with >25% black residents (mean palliative care score, 43.82; SE, 2.31) versus nursing homes with no black residents (mean palliative care score, 49.47; SE, 1.08). These disparities persisted after adjustment for urbanicity and county-level poverty rates (p < 0.01) but were attenuated after further adjustment for resident and facility level characteristics (p=0.138). Conclusions: Our findings demonstrate that wide variations in nursing-home palliative-care services exist with increased proportions of black residents, even after accounting for community characteristics. Further research is needed to identify and understand the specific community characteristics that play a role in the provision of palliative care services. Palliative care is a method to reduce inappropriate antimicrobial use at the end of life and should be expanded with a focus on nursing homes with higher proportions of black residents.

Funding: No

Disclosures: None

Table 1.