Background: Antimicrobial resistance is a growing global health problem predominantly driven by overuse of antibiotics. In humans, most antibiotics are used outside the hospital. Overprescribing for acute respiratory infections (ARIs) is common despite clear guidelines. The need for further training of general practitioners is well known. Objective: To develop and evaluate a massive open online course (MOOC) on antibiotic therapy of common infectious diseases in general practice. Methods: A 4-week MOOC was developed on the basis of previous face-to-face trainings (platform, Hasso Plattner Institute for Digital Engineering) and was conducted 3 times between July 10, 2017, and May 31, 2019. The course was promoted through various general practitioner (GP) networks, local multipliers, and conferences and in the local trade press. In addition to epidemiological background information, the focus was on guideline-based diagnostics and treatment of ARI, side effects of antibiotics, correct drug selection, dosage and duration of indicated antibiotic therapy, as well as aspects of doctor–patient communication. Content included videos, self-tests, additional written material, and an optional exam. At the end of the course, participants were asked to complete a voluntary, anonymous online assessment questionnaire (LimeSurveyPro software). Usage data from the MOOC platform and data from the questionnaire were analyzed using IBM SPSS statistical software. Results: In total, 2,177 registered persons retrieved content (= learners). The proportion of learners dropped from 99.6% in week 1 to 40.7% in week 4. However, among those attending week 4, the average proportion of content used was still high (74.5%). Furthermore, 27.5% of learners completed the course, 23.8% took the exam, and 19.7% passed the exam. Moreover, 284 learners answered the assessment questionnaire (response rate, 13.0%); 62.3% were women, and the mean age was 45.9 years. Also, 225 participants (79.2%) stated that they were physicians; 122 of these worked as general practitioners (54.2% of physicians). Among the other physicians, 23% stated were in specialist training and 15.6% had a different specialist designation. The average overall rating of the course was 1.31 (1 = very good to 6 = not sufficient). General practitioners rated it slightly better than other physicians (1.23 vs 1.41). The clinical relevance was rated at 1.27 (GPs vs other physicians, 1.18 vs 1.35). For all scores, see Table 1. Conclusions: A massive open online course appears to be an appropriate format in which to deliver clinical relevant content concerning prudent antibiotic use in the outpatient setting. It is a good complement to existing face-to-face formats and helps to cover needs related to antibiotic training.

Funding: None

Disclosures: None

Background: Patients with methicillin-resistant Staphylococcus aureus (MRSA) colonization often shed MRSA, resulting in contamination of surfaces in their room. It is not known whether MRSA-colonized patients also frequently contaminate surfaces during medical appointments and other activities outside their room. Methods: We conducted an observational cohort study of MRSA-colonized long-term care facility (LTCF) residents to determine the frequency and mechanisms of contamination of surfaces outside patient rooms. Nares, skin, and clothing of patients in contact precautions for MRSA were cultured for MRSA, and high-touch surfaces in the residents’ room were contaminated with the live virus bacteriophage MS2 and cauliflower mosaic virus DNA. The participants were observed during activities and medical appointments outside their rooms for 3 days, and sites that were contacted were sampled for recovery of MRSA, bacteriophage MS2, and cauliflower mosaic virus DNA. Results: As shown in Fig. 1, bacteriophage MS2 and cauliflower mosaic virus DNA was transferred to 1 or more surfaces outside the resident’s room by 5 of the 7 participants, and MRSA was recovered from surfaces touched by 6 (86%) participants. MRSA was recovered during 16 of 35 episodes (46%) where sampling was performed, and recovery was similar for medical appointments (eg, hemodialysis, physical therapy) and nonmedical activities (eg, using the dining room or activity center). Moreover, MRSA, MS2, and the viral DNA marker were recovered both from sites contacted only by participants’ hands and from sites contacted only by clothing. Bacteriophage MS2 and the viral DNA marker were also recovered from portable equipment and from the nursing station. Conclusions: MRSA-colonized LTCF residents frequently disseminated MRSA and viral surrogate markers to surfaces outside their rooms through contact with contaminated hands and clothing. Efforts to reduce contamination of hands and clothing might reduce the risk for pathogen transmission.

Funding: None

Disclosures: None

Background: Surgical instruments that enter sterile tissue should be sterile because microbial contamination could result in disease transmission. Despite careful surgical instrument reprocessing, surgeons and other healthcare personnel (HCP) describe cases in which surgical instruments have been contaminated with organic material (eg, blood). Although most of these cases are observed before the instrument reaches the patient, in some cases the contaminated instrument contaminates the sterile field, or rarely, the patient. In this study, we evaluated the robustness of sterilization technologies when spores and bacteria mixed with blood were placed on dirty (uncleaned) instruments. Methods: Dirty surgical instruments were inoculated with 1.5105 to 4.1107 spores or vegetative bacteria (MRSA, VRE or Mycobacterium terrae) in the presence or absence of blood. The spores used were most resistant to the sterilization process tested (eg, Geobacillus stearothermophilus for steam and HPGP and Bacillus atrophaeus for ETO). Once the inoculum dried, the instruments were placed in a peel pouch and sterilized by steam sterilization, ethylene oxide (ETO), or hydrogen peroxide gas plasma (HPGP). These experiments are not representative of practice or manufacturer’s recommendations because cleaning must always precede sterilization. Results: Steam sterilization killed all the G. stearothermophilus spores and M. terrae when inoculated onto dirty instruments in the presence or absence of blood (Table 1). ETO failed to inactivate all test spores (B. atrophaeus) when inoculated onto dirty instruments (60% failure) and dirty instruments with blood (90% failure). ETO did kill the vegetative bacteria (MRSA, VRE) under the same 2 test conditions (ie, dirty instruments with and without blood). The failure rates for HPGP for G. stearothermophilus spores and MRSA were 60% and 40%, respectively, when mixed with blood on a dirty instrument. Conclusions:This investigation demonstrated that steam sterilization is the most robust sterilization process and is effective even when instruments were not cleaned and the test organisms (G. stearothermophilus spores and MRSA) were mixed with blood. The low-temperature sterilization technologies tested (ie, ETO, HPGP) failed to inactivate the test spores but ETO did kill the test bacteria (ie, MRSA, VRE). These findings should assist HCP to assess the risk of infection to patients when potentially contaminated surgical instruments enter the sterile field or are unintentionally used on patients during surgery. Our data also demonstrate the importance of thorough cleaning prior to sterilization.

Funding: None

Disclosures: Dr. Rutala was a consultant to ASP (Advanced Sterilization Products)

Background: Proper care and maintenance of central lines is essential to prevent central-line–associated bloodstream infections (CLABSI). Our facility implemented a hospital-wide central-line maintenance bundle based on CLABSI prevention guidelines. The objective of this study was to determine whether maintenance bundle adherence was influenced by nursing shift or the day of week. Methods: A central-line maintenance bundle was implemented in April 2018 at a 1,266-bed academic medical center. The maintenance bundle components included alcohol-impregnated disinfection caps on all ports and infusion tubing, infusion tubing dated, dressings, not damp or soiled, no oozing at insertion site greater than the size of a quarter, dressings occlusive with all edges intact, transparent dressing change recorded within 7 days, and no gauze dressings in place for >48 hours. To monitor bundle compliance, 4 non–unit-based nurse observers were trained to audit central lines. Observations were collected between August 2018 and October 2019. Observations were performed during all shifts and 7 days per week. Just-in-time feedback was provided for noncompliant central lines. Nursing shifts were defined as day (7:00 a.m. to 3:00 p.m.), evening (3:00 p.m. to 11:00 p.m.), and night (11:00 p.m. to 7:00 a.m.). Central-line bundle compliance between shifts were compared using multinomial logistic regression. Bundle compliance between week day and weekend were compared using Mantel-Haenszel 2 analysis. Results: Of the 25,902 observations collected, 11,135 (42.9%) were day-shift observations, 11,559 (44.6%) occurred on evening shift, and 3,208 (12.4%) occurred on the night shift. Overall, 22,114 (85.9%) observations occurred on a week day versus 3,788 (14.6%) on a Saturday or Sunday (median observations per day of the week, 2,570; range, 1,680–6,800). In total, 4,599 CLs (17.8%) were noncompliant with >1 bundle component. The most common reasons for noncompliance were dressing not dated (n = 1,577; 44.0%) and dressings not occlusive with all edges intact (n = 1340; 37.4%). The noncompliant rates for central-line observations by shift were 12.8% (1,430 of 1,1,135) on day shift, 20.4% (2,361 of 11,559) on evening shift, and 25.2% (808 of 3,208) on night shift. Compared to day shift, evening shift (OR, 1.74; 95% CI, 1.62–1.87; P < .001) and night shift (OR, 2.29; 95% CI, 2.07–2.52; P < .001) were more likely to have a noncompliant central lines. Compared to a weekday, observations on weekend days were more likely to find a noncompliant central line: 914 of 3,788 (24.4%) weekend days versus 3,685 of 22,114 (16.7%) week days (P < .001). Conclusions: Noncompliance with central-line maintenance bundle was more likely on evening and night shifts and during the weekends.

Funding: None

Disclosures: None

Background: Contaminated hands are the most important source for transmission of pathogens in healthcare settings. It has been proposed that replacing the handshake with alternative greetings such as the fist bump might reduce the risk for pathogen transmission. Methods: In a cohort of 50 patients with methicillin-resistant Staphylococcus aureus (MRSA) colonization, we compared the frequency of transfer of MRSA by handshake versus fist bump versus cruise tap (ie, a modified fist bump involving knuckle-to-knuckle contact with a single finger). MRSA-colonized patients performed each greeting with research personnel wearing sterile gloves, and cultures were obtained to determine the number of colonies transferred. Transfer by handshake was also assessed after MRSA-colonized patients used alcohol-based hand sanitizer. Quantitative cultures were obtained to compare the burden of MRSA on the palm versus dorsum of the hands of the MRSA carriers. Results: As shown in Fig. 1, there was a significant reduction in the frequency of MRSA transfer for the cruise tap compared to the handshake, but not for the fist bump. Use of alcohol-based hand sanitizer by MRSA carriers also significantly reduced the risk for transfer of MRSA. There was no significant difference in the burden of MRSA on the dorsum versus the palm of the hands (mean +SE colonies recovered, 32.7+12.3 vs 27.3+12.7; P > .05). Conclusions: The fist-bump greeting did not transfer less MRSA than a handshake. However, transfer was significantly reduced by a cruise-tap greeting or by handshake after the use of hand sanitizer. Modified greetings and patient hand hygiene are potential strategies to reduce transmission of healthcare-associated pathogens.

Funding: None

Disclosures: None

Background: Each year, the FDA receives more than a million reports of suspected device-associated deaths, serious injuries, and malfunctions. Medical device reports (MDRs) are submitted to the FDA by mandatory reporters (manufacturers, importers, and device user facilities) and voluntary reporters such as healthcare professionals, patients, and consumers. The FDA uses MDRs to monitor device performance, including monitoring reports of infection or device contamination to detect potential device-related safety issues and to share this information in public communications. In this analysis, the FDA presents MDRs for duodenoscopes, which are a type of flexible endoscope that have been associated with infections in patients. Methods: For this analysis, we searched the MDR database for duodenoscope reports submitted between January 2015 and July 1, 2019. MDRs were classified into clinical risk categories based on the MDR’s text narratives as patient infection (indicated the presence of infection in patients potentially transmitted by the device), patient exposure (indicated a contaminated device has been used in a patient, but the MDR lacks clear mention of patient infection), or device contamination (indicated that the device was contaminated, but no mention of device use in patients or patient infection). Results: Overall, 1,115 duodenoscope reports related to a patient infection, patient exposure, or device contamination for devices marketed inside and outside the United States were received from January 2015 to mid-2019. Among them, 79 MDRs were received for deaths in patient infection, patient exposure, or device contamination reports. The number of reported infections decreased from 247 MDRs in 2015 to 55 MDRs in the first half of 2019. Furthermore, the number of reported deaths decreased from 25 MDRs in 2015 to 2 MDRs reported in the first half of 2019. Conclusions: The MDR data indicate a decrease in the number of reported infections. The decrease in infections suggests that efforts to reduce the risk of infection from duodenoscopes have yielded improvements; however, additional improvements are necessary to further decrease the risk of infection.

Funding: None

Disclosures: None

Background: We describe and evaluate our outbreak of carbapenem-resistant K. pneumoniae transmitted by contaminated duodenoscopes during endoscopic retrograde cholangiopancreatography (ERCP) procedures. Methods: An outbreak investigation was performed when Klebsiella pneumoniae carbapenemase-producing K. pneumoniae (KPC-KP) were identified from bile specimens of 4 patients. The investigation included medical record review, practice audits, and surveillance cultures of duodenoscopes and environmental sites. If available, clinical specimens were obtained from patients who had undergone ERCP in the previous 3 months. Carbapenem-resistant Enterobacteriaceae (CRE) screening cultures were performed to identify additional patients until no CRE cases were detected during 2 consecutive weeks. Pulsed-field gel electrophoresis (PFGE) of KPC-KP isolates was implemented. Results: In total, 12 cases were identified with exposure to duodenoscope from February 2019 through April 2019, including 6 cases with infections and 6 asymptomatic carriers. Case-control analysis showed that 2 specific duodenoscopes would be associated with the KPC-KP outbreak. Duodenoscope reprocessing procedures did not deviate from manufacturer recommendations for reprocessing. After ethylene oxide (EO) gas sterilization, the outbreak was terminated. Conclusions: Meticulous cleaning protocol and enhanced surveillance are necessary to prevent outbreaks of CRE. Notably, enhanced cleaning measures, such as sterilization for duodenoscopes, would be required after procedures with KPC-KP carriers.

Funding: None

Disclosures: None

Background: Community-acquired pneumonia (CAP), urinary tract infection (UTI), pharyngitis, acute otitis media (AOM), and skin and soft-tissue infection (SSTI) are among the most common outpatient conditions for which antibiotics are prescribed. The objective of this study was to describe the observed duration of outpatient antibiotic therapy compared with guideline recommendations for these common conditions in 2017 in the United States to identify antibiotic stewardship targets. Methods: We estimated therapy duration for oral and parenteral antibiotic prescriptions associated with CAP, AOM, pharyngitis, acute cystitis, pyelonephritis, SSTI, and sinusitis diagnoses from the IQVIA National Disease and Therapeutic Index 2017 dataset, a two-stage stratified cluster sample of office-based physician visits. We excluded azithromycin due to its unique pharmacokinetics, and we limited our study to prescriptions from emergency medicine, family practice, general practice, geriatrics, internal medicine, osteopathic medicine, and pediatrics physicians. We excluded observations with antibiotic prescriptions for multiple conditions. We used NDTI projection weights and complex sample methods to estimate antibiotic prescription numbers and durations by condition and age group. Results: Table 1 shows antibiotic prescriptions by condition and population. The median antibiotic therapy duration for all conditions except acute cystitis was 10 days. The median duration for acute cystitis was 7 days. Conclusions:Clinicians prescribed 10-day antibiotic courses for the most common outpatient conditions, regardless of guideline-recommended duration. Antibiotic stewardship efforts targeting excessive durations of antibiotic therapy for common outpatient conditions, particularly sinusitis in adults, CAP, SSTI, and acute cystitis, are needed.

Funding: This work was supported by the Centers for Disease Control and Prevention. The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

Disclosures: Laura M. King is a contractor employed by Northrop Grumman Corporation to fulfill research needs at the Centers for Disease Control and Prevention as part of a contract covering many positions and tasks. All other authors declare no conflicts.

Background: Children with contagious illness are frequently cared for in the pediatric emergency department. Incomplete infection prevention knowledge and incorrect practices create opportunities for transmission of pathogens. We implemented an educational intervention to improve clinician infection prevention knowledge and behavior. Methods: Clinicians providing care in an academic tertiary-care affiliated, pediatric ED were invited to participate in a 3-month educational intervention focusing on basic infection prevention principles such as hand hygiene and symptom-based isolation. Qstream, an educational platform that employs spaced-learning and game theory, was used to develop and electronically distribute 7 scenario-based questions. Questions were distributed 1 question per day 3 times per week. Questions were repeated until they were answered correctly twice. Round 1 of questions began in March 2019. After a ~4-week hiatus, the process was repeated in May 2019 (round 2). The Kirkpatrick model was used to measure the effectiveness of the educational intervention. Outcomes included clinician assessment of acceptability of the intervention, change in correct responses to knowledge-based questions over time, hand hygiene performance of clinicians and the number of infectious exposures in the emergency department. Results: Overall, 61 (73%) clinicians participated, of whom >90% liked the format, found it easy to use, and thought it required an appropriate amount of time. During round 1, average proficiency increased from 36% to 64%. During round 2, average proficiency increased from 62% to 78%. Starting in May 2019, physician hand hygiene gradually increased from a baseline of 78% to 100%. In the 10 months before and after March 2019, there were 2 exposure events involving 10 healthcare personnel versus 3 exposure events involving 4 healthcare personnel. Conclusions: Novel education strategies that utilize adult learning principles are user-friendly effective strategies that improve infection prevention knowledge and practice.

Funding: None

Disclosures: None

Background: Catheter-associated urinary tract infections (CAUTIs) are a common hospital-acquired infection (HAI) resulting in excess morbidity, mortality, and cost. Urine management can be a challenging issue, particularly in women, due to limited options for control of urinary incontinence. Issues with urinary leakage and worry for subsequent skin break down often leads to indwelling catheter insertion. In the spring of 2018, our facility implemented a female external urine collection device (EUCD) in efforts to decrease catheter days and to limit CAUTIs. Methods: Retrospective, 32-month (January 2017–August 2019), quasi-experimental, before-and-after study. Catheter use and CAUTI were defined according to CDC NHSN criteria. Poisson regression was used to model the rate of CAUTI (per 1,000 patient days [PD] and per 1,000 catheter days [CD]) comparing the 14 months prior to EUCD introduction with the 14 months after introduction and allowing a 3-month introduction period. Results: The CAUTI rate did not change significantly. The overall CAUTI rate per 1,000 PD decreased slightly from 0.24 to 0.20 (P = 0.44; model risk, 0.86; 95% CI, 0.58–1.26) whereas the rate per 1,000 CD increased slightly 1.5 to 1.6 (P = 0.76; model risk, 1.06; 95% CI, 0.73-–1.56). The CAUTI rate for men increased from 0.09 to 0.11 per 1,000 PD (P = 0.42; model risk, 1.29) and from 0.99 to 1.55 per 1,000 CD (P = 0.17; model risk, 1.56). For women, the rate of CAUTI decreased from 0.15 to 0.09 per 1,000 PD (P = 0.10; model risk, 0.61) and from 2.12 to 1.65 per 1,000 CD (P = 0.38; model risk, 0.38). A significant decrease in catheter days (CD per 1,000 PD; P < .0001) was observed for all hospitalized patients (from 158.56 to 128.3; model risk, 0.81), for men (from 87.06 to 72.15; model risk, 0.83), and for women (from 71.49 to 56.15; model risk, 0.79). Of 2,347 adverse events, 5 (0.2%) involved perineal skin breakdown and redness. Three events were related to malposition of the ECUD or inappropriate level of suction and 1 event was related to latex allergy and EUCD use. Conclusions: The introduction of a EUCD for women was associated with a significant decrease in indwelling catheter usage. A trend toward a decrease in CAUTI per 1,000 PD for women was observed (P = .10). Additional studies on whether the EUCD is associated with changes in UTI rates (both CAUTIs and noncatheter UTIs) as well as cost implications of EUCD are warranted.

Funding: None

Disclosures: None

Background: Discontinuation of contact precautions for methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococci (VRE) have failed to show an increase in associated transmission or infections in adult healthcare settings. Pediatric experience is limited. Objective: We evaluated the impact of discontinuing contact precautions for MRSA, VRE, and extended-spectrum β-lactamase–producing gram-negative bacilli (ESBLs) on device-associated healthcare-associated infections (HAIs). Methods: In October 2018, contact precautions were discontinued for children with MRSA, VRE, and ESBLs in a large, tertiary-care pediatric healthcare system comprising 2 hospitals and 620 beds. Coincident interventions that potentially reduced HAIs included blood culture diagnostic stewardship (June 2018), a hand hygiene education initiative (July 2018), a handshake antibiotic stewardship program (December 2018) and multidisciplinary infection prevention rounding in the intensive care units (November 2018). Compliance with hand hygiene and HAI prevention bundles were monitored. Device-associated HAIs were identified using standard definitions. Annotated run charts were used to track the impact of interventions on changes in device-associated HAIs over time. Results: Average hand hygiene compliance was 91%. Compliance with HAI prevention bundles was 81% for ventilator-associated pneumonias, 90% for catheter-associated urinary tract infections, and 97% for central-line–associated bloodstream infections. Overall, device-associated HAIs decreased from 6.04 per 10,000 patient days to 3.25 per 10,000 patient days after October 2018 (Fig. 1). Prior to October 2018, MRSA, VRE and ESBLs accounted for 10% of device-associated HAIs. This rate decreased to 5% after October 2018. The decrease in HAIs was likely related to interventions such as infection prevention rounds and handshake stewardship. Conclusions: Discontinuation of contact precautions for children with MRSA, VRE, and ESBLs were not associated with increased device-associated HAIs, and such discontinuation is likely safe in the setting of robust infection prevention and antibiotic stewardship programs.

Funding: None

Disclosures: None

Background: Carbapenem-resistant GNB infections are a serious public health problem worldwide, particularly due to the high mortality associated with them and the low number of therapeutic options. One approach to this challenge is the development of antimicrobial stewardship programs. Objective: We evaluated the impact of a carbapenem restriction program on reducing of bacterial resistance in an intensive care unit (ICU). Methods: A retrospective study conducted in 2 phases in the 80-bed ICU of an acute-care public hospital in Minas Gerais, Brazil. The preintervention phase lasted 16 months (January 2018–April 2019) and the second phase (carbapenem restriction), after the intervention, lasted 4 months (May–August 2019). The intervention was defined as carbapenem-sparing and the use of meropenem was authorized in 3 situations: (1) treatment of serious infections documented by extended-spectrum β-lactamase–producing Enterobacteriacea (ESBL); (2) therapeutic failure with the use of another antimicrobial; and (3) infectious disease recommendation. Data were obtained through consultation of electronic medical records and microbiological results, as standardized by the CLSI, for patients with a >48-hour stay in the ICU and who met the criteria for healthcare-associated infection (HAI) according to the CDC NHSN definition. Results: Before the intervention, on average, 50 cultures were obtained with positive results for multidrug-resistant GNB–MER-GNB (SD, 12.2) and in the intervention phase, this number was 31 cultures (SD, 12.8; P = .010). Average carbapenem consumption decreased significantly with corresponding increase in cefepime consumption in the same period (Fig. 1). The ATB (DDD per 1,000 patient days) before the intervention for carbapenems was 110.6 (SD, 97.1) and for cefepime was 8.2 (SD, 5.9). In the intervention phase, the ATB for carbapenems was 44.7 (SD, 38.5; P = .015) and for cefepime it was 32.0 (SD, 20.3; P < .001). In terms of multidrug resistance rate, before the intervention, 95 of 149 of Acinetobacter (64%) were resistant and during the intervention, 13 of 30 Acinetobacter (43%) were resistant (P = .043). Other GNB (Klebsiella, Proteus, Escherichia coli, and Pseudomonas) reduced the resistance rate, but without statistical significance. We observed a reduction in the HAI rate per MDR-GNB (Fig. 2): before the intervention, it was 22.7 (SD, 5.5) and during the intervention phase it was 16.5 (SD, 7.7; P = .07), although this change did not reach statistical significance. Nevertheless, the ICU Klebsiella infection rate did significantly decrease; it was 5.5 (SD, 1.9) before the intervention and 2.4 (SD, 1.8) after the intervention (P = .009). Conclusions: Short-term carbapenem restriction may be an effective strategy to reduce the incidence of carbapenem-resistant GNB infections in the ICU. The scarce arsenal available for the treatment of MDR-GNB and the high mortality rate justify the growing need for stewardship programs in Brazilian ICUs.

Funding: None

Disclosures: None

Background: Healthcare-associated Clostridioides difficile infection (CDI) rates have been decreasing in Department of Veterans’ Affairs (VA) acute-care medical facilities since the CDI Prevention Initiative began in 2012. Assessment of rates, however, is complicated by changing surveillance definitions and diagnostics. Over the past 2 years, the VA has adopted the less stringent surveillance definitions of the NHSN for hospital-onset healthcare-facility–associated (HO-HCFA) CDI (onset on or after day 4 of hospitalization) than was originally used (>48 hours after admission). New diagnostic testing methods have been developed, but variabilities in the reliability of testing methods for the diagnosis of CDI in patients have been detected, thus not yielding a gold standard test. As a result, some facilities use nucleic acid amplification testing (NAAT) for CDI diagnosis and reporting whereas others use a 2-step process of NAAT followed by a toxin enzyme immunoassay (EIA) test, with the latter determining positivity for reporting (as allowed by the NHSN). We reviewed CDI rates at facilities performing one-step and two-step testing to determine whether the testing protocol may be influencing CDI rate reporting. Methods: Data on HO-HCFA CDI rates entered monthly in fiscal year (FY) 2018 (October 2017 through September 2018) and FY2019 (October 2018 through September 2019) by each acute-care facility into the VA Inpatient Evaluation Center (IPEC) database were analyzed. HO-HCFA CDI rates in facilities that used NAAT in FY2018 and switched to in the 2-step NAAT plus EIA in FY2019 were compared to rates in facilities used NAAT alone for both FY2018 and FY2019. Statistical regression analysis was performed. Results: From FY 2018 through FY2019, 70 facilities performed NAAT for the entire 2-year period. Overall, 7 facilities performed NAAT for FY 2018 and then switched to NAAT + EIA in FY2019. We detected no significant decrease in HO-HCFA CDI rates in FY 2018 when both groups were using NAAT (P = 0.21) (Fig. 1). However, in FY2019, there was a significant decrease in HO-HCFA CDI rates for those facilities that performed the 2-step testing versus those facilities that continued to use strictly NAAT alone (P < .0001). Conclusions: HO-HCFA CDI rates decreased for those VA acute-care facilities that switched to 2-step testing, and this finding highlights implications for assessing rates over time. Given the variable reliability of the toxin test, individual patient consideration for therapeutic decisions is reasonable.

Funding: None

Disclosures: None

Background: A cluster of sternal surgical site infections caused by Pseudomonas aeruginosa led to sampling of shower heads in patient rooms. Multiple subtypes of Pseudomonas aeruginosa were found and were genetically diverse from the patient isolates. Visible biofilm was found in showerheads in the cardiothoracic ward. Ways of minimizing formation and persistence of biofilm in the shower heads were sought. Methods: A low-dose chlorination dosing system was introduced in September 2018 to the circulating warm-water system supplying the building block where the cardiac surgery ward is situated. Of the 145 showers in that block, 70 shower heads were sampled and the shower heads were replaced. Of these, 35 were sampled at 3 months and 35 were tested at 6 months (biofilm prevention group). Of the remaining 70 shower heads, 35 were tested at 3 months and 35 at 6 months (biofilm removal group). Heterotrophic colony count (HCC) in CFU/mL was chosen as the outcome measure. Analysis was conducted in accordance with AS 4276.3.2 (2003). The microbial growth data followed a log-normal distribution due to the exponential growth of bacteria. The natural log of the data was therefore calculated, and results from each period were compared using analysis of variance (ANOVA). Free chlorine residual levels were controlled using a combination of feed-forward and oxidation reduction potential (ORP) feedback control, and levels were retested and adjusted during the review period using N,N-diethyl-p-phenylenediamine (DPD) chemistry. Results: Mean and median levels of log HCC data are shown in Fig. 1. We detected a statistically significant difference in HCC between the 6-month-old untreated shower heads (group B) and treated shower heads (Group D) (P < .001). Hypochlorite was generally dosed at a concentration of 0.5 mg/L free chlorine for the first 3 months, and 1.5 mg/L for the second 3 months. Approximately 65% of the chlorine was lost as it travelled around the system. Discussion: Waterborne pathogens, especially multiresistant Gram-negative bacilli, have been increasingly recognized as hospital-acquired pathogens. Many instances of the transmission of these pathogens have been reported, from premise plumbing to patients, and have been confirmed using molecular typing techniques. Conclusions: A low-dose chlorination system of the circulating warm-water supply seemed effective in preventing biofilm formation and reducing existing biofilm in shower heads using HCCs as a measure of biofilm. This information adds to the potential armamentarium for controlling the spread of these waterborne pathogens.

Funding: None

Disclosures: None

Background: My tertiary-care hospital is a 750-bed hospital with only 17 airborne infection isolation room (AIIR) and negative-pressure rooms to isolate patients who have been diagnosed or are suspected with prevalent diseases like tuberculosis, measles, and chickenpox. On the other hand, only 14 single-patient isolation rooms are available to isolate patients with multidrug-resistant organisms (MDROs) such as CRE (carbapenum-resistant Enterobacter) or colistin-resistant MDROs. Due to the limited number of isolation rooms, the average number of hours to isolate infected patients was ~20 hours, which ultimately directly placed healthcare workers (HCWs) at risk of exposure to infected patients. Methods: Plan-Do-Study-Act (PDSA) quality improvement methodology was utilized to decrease the average number of hours to isolate infected patients and to reduce the exposure of HCWs to communicable diseases. A detailed analysis were performed to identify root causes and their effects at multiple levels. A multidisciplinary team implemented several strategies: coordination with information and technology team to place isolation alerts in the charting system; screening flyers and questions at emergency department triage; close coordination with admission and bed management office; daily morning and evening rounds by infection preventionists in the emergency department; daily morning meeting with microbiology and bed management office to intervene immediately to isolate patients in a timely way; infection preventionist on-call system (24 hours per day, 7 days per week) to provide recommendations for patient placement and cohorting of infected patients wherever possible. Results: In 1 year, a significant reduction was achieved in the number of hours to isolate infected patients, from 20 hours to 4 hours. As a result, HCW exposures to communicable diseases also decreased from 6.7 to 1.5; HCW exposures to TB decreased from 6.0 to 1.9; exposures measles decreased from 4.75 to 1.5; and exposures chickenpox decreased from 7.3 to 1.0. Significant reductions in cost incurred by the organization for the employees who were exposed to these diseases for postexposure prophylaxis also decreased, from ~Rs. 290,000 (~US$3,000) to ~Rs. 59,520 (~US$600). Conclusions: This multidisciplinary approach achieved infection prevention improvements and enhanced patient and HCW safety in a limited-resource setting.

Funding: None

Disclosures: None

Background:Clostridioides difficile is a major cause of antibiotic-associated colitis and the most common healthcare-associated pathogen in the United States. Interrupting the known transmission mechanisms of C. difficile in hospitals requires appropriate hand hygiene, disinfection of potentially contaminated surfaces, and patient equipment. However, only limited data are available on the effectiveness of germicides against various strains of C. difficile, with and without fetal calf serum, and at multiple exposure times. For this reason, we undertook the following evaluation to determine the effectiveness of germicides. Methods: The effectiveness of the sporicidal activity of the germicides against 5 strains of C. difficile was evaluated using a quantitative carrier test, a standard of ASTM International developed by Sattar et al. In this protocol, metal carriers (1 cm diameter 0.7 mm thick) were inoculated with 10 L spore suspension, containing ~103 or 106 C. difficile spores, and we then exposed them to 50 L germicide for 1, 5, 10, or 20 minutes. The following C. difficile strains were used in these studies: ATCC strains 9689; J9; BI-9; 630; and CF-4. To determine whether C. difficile spore susceptibility was similar to other spores, we also tested Bacillus atrophaeus spores, ATCC strain 19659. Fetal calf serum (FCS) was used to simulate organic matter. Results: In general, high-level disinfectants (eg, OPA, glutaraldehyde), chemical sterilants (eg, peracetic acid), and high concentrations of chlorine (>5,000 ppm) were generally sporicidal (>3 log10 reduction) in 5–10 minutes (and sometimes 1 minute). This level of sporicidal activity was demonstrated for the various strains of C. difficile spores and B. atrophaeus spores (Table 1). There did not appear to be any significant differences in inactivation of C. difficile spores (BI-9 strain) in the presence or absence of FCS (Table 2). Discussion: The sporicidal activity of disinfectants is critical because such formulations are routinely used to eliminate the risk associated with noncritical and semicritical instruments and environmental surfaces. Our data suggest that immersion in most (but not all) high-level disinfectants for 10 minutes is likely to be successful in eradicating C. difficile spores (>4 log10 reduction) from semicritical equipment (eg, endoscopes). Additionally, high concentrations of chlorine and some high-level disinfectants will kill C. difficile spores in 1 or 2 minutes.

Funding: None

Disclosures: Drs. Rutala and Weber are consultants to PDI (Professional Disposable International)

Background: Hospitalized patients are at an increased risk of invasive infection with Staphylococcus aureus when colonized with the bacteria on admission. Rates of methicillin-resistant Staphylococcus aureus (MRSA) bacteremia are directly correlated with overall patient acuity, placing patients in intensive care areas at greatest risk. Universal decolonization with nasal antibiotic ointments has been shown to reduce the incidence of invasive MRSA in critically ill patients; however, debate remains regarding the long-term efficacy of this strategy and the possibility of developing antimicrobial resistance. An alcohol-based nasal antimicrobial may be an effective alternative. This study evaluated the effectiveness of a twice daily alcohol-based product in reducing the rate of MRSA bacteremia in an academic tertiary-care adult intensive care setting. Methods: Our study was an observational design with retrospective and prospective cohorts each consisting of 61 critical care beds. The baseline incidence of MRSA bacteremia was determined from a 7-month period preceding the implementation of the nasal antimicrobial. At implementation, each admission received an electronic order for an alcohol-based nasal antiseptic that was applied twice daily during the intensive care stay. The primary outcome was the incidence of MRSA bacteremia in each group. MRSA bacteremia was defined by the CDC NHSN criteria after review by an infection prevention nurse. The 2 test was used to compare the rates between the 2 groups, and P < .005 was considered significant. Results: The study periods contained similar patient days, with 12,475 in the retrospective group and 12,733 in the prospective group. The rate of MRSA bacteremia in the retrospective cohort was 0.2404 compared to 0 in the prospective cohort. This rate change was statistically significant, with P < .0001. Conclusions: The alcohol-based nasal antiseptic was effective in reducing healthcare-onset MRSA bacteremia in this intensive care population. This approach may be a safe and effective alternative to nasal antibiotic ointment that avoids antibiotic resistance risks.

Funding: None

Disclosures: None

Background:Pseudomonas aeruginosa, is the third etiologic agent of healthcare associated infections, and the most frequent pathogen in ventilator-associated pneumonia (VAP). In critical care units is associated with high mortality, long hospital stay, and high healthcare-associated costs. We evaluated the effectiveness of filter placement in the water taps in critical care units to prevent the occurrence of healthcare-associated infections (HAIa) by Pseudomonas aeruginosa. Methods: This experimental study was both cross-over and open-label in nature. We included patients admitted for >24 hours in critical care units over 24 months. The study was divided into 4 periods of 6 months each. We divided the study into 2 groups: patients in units with filters and patients in units without filters. We compared the incidence density of P. aeruginosa HAIs (number of cases divided by the number of person days) according the ECDC definition of case criteria between the groups. The 2 test was used, and the magnitude of the association was calculated as a rate ratio with a 95% confidence interval, adjusted using a Poisson regression model. Results: Overall, 1,132 patients were included in the study: 595 in units with water tap filters and 537 in units without water tap filters. HAI incidence among patients in units with water tap filters was 5.3 per 1,000 person days stay; without water tap filters, HAI incidence was 4.7 per 1,000 person days stay (HR, 0.94; 95% CI, 0.47–1.90). Conclusions: The preliminary results of this study indicate a a lower incidence of P. aeruginosa HAIs in units with filters placed in water taps than in units without filters.

Disclosures: None

Funding: None

Background: Daptomycin is considered an effective alternative to vancomycin in patients with methicillin-resistant Staphylococcus aureus bloodstream infection (MRSA BSI). Objective: We investigated the real-world effectiveness of recommended daptomycin doses compared with vancomycin. Methods: This nationwide retrospective cohort study included patients from 124 Veterans’ Affairs hospitals who had a MRSA BSI and were initially treated with vancomycin during 2007–2014. Patients were categorized into 3 groups by daptomycin dose calculated using adjusted body weight: low (>6 mg/kg/day), standard (6–8 mg/kg/day), and high (≥8 mg/kg/day). International Classification of Diseases, Ninth Revision (ICD-9) diagnosis codes were used to identify other prior or concurrent infections and comorbidities. Multivariate cox regression was used to compare 30-day all-cause mortality as the primary outcome comparing patients on either low-dose, standard-dose, or high-dose daptomycin with vancomycin. Hazard ratio (HR) and 95% confidence intervals (CIs) were reported. Results: Of the 7,518 patients in the cohort, 683 (9.1%) were switched to daptomycin after initial treatment with vancomycin for their MRSA BSI episode. A low dose of daptyomycin was administered to 181 patients (26.5%), a standard dose was given to 377 patients (55.2%), and a high dose was administered to 125 patients (18.3%). Dose groups differed significantly in body mass index (BMI), presence of an osteomyelitis diagnosis, and diagnosis of diabetes. Thirty-day mortality was significantly lower in daptomycin patients than in those given vancomycin (11.3% vs 17.6%; P < .0001). Treatment with daptomycin was associated with improved 30-day survival compared with vancomycin (HR, 0.66; 95% CI, 0.53–0.84), after adjusting for age, BMI, diagnosis of endovascular infection, skin and soft-tissue infection and osteomyelitis, hospitalization in the prior year, immunosuppression, diagnosis of diabetes, and vancomycin minimum inhibitory concentration (MIC). Treatment with a standard dose of daptomycin was associated with lower mortality compared with vancomycin (HR, 0.63; 95% CI, 0.46–0.86). High and low daptomycin dose groups had a trend toward improved 30-day survival compared with vancomycin (Fig. 1). In 2 separate sensitivity analyses excluding vancomycin patients, there was no difference in 30-day mortality between a standard dose and a high dose (HR, 1.01; 95% CI, 0.51–1.97). However, we detected a trend toward poor survival with a low dose compared with a standard dose (HR, 1.21; 95% CI, 0.73–2.02). Conclusions: A standard dose of daptomycin was significantly associated with lower 30-day mortality compared with continued vancomycin treatment. Accurate dosage of daptomycin and avoidance of low-dose daptomycin should be a part of good antibiotic stewardship practice.

Funding: None

Disclosures: None

Background: A surgical instrument can have areas that pose different challenges to cleaning, hindering the removal of dirt. This can directly impact the effectiveness of its processing while potentially promoting cross contamination. Moreover, structural changes (ie, cracks or fissures) on the instrument surface, although rarely addressed, can act as reservoirs for microorganisms, contributing to organic matter retention, microbial growth, and biofilm formation. Our aim was to determine the effect of irregularities in the microstructure of surgical instruments on microbial adherence. Methods: We analyzed 18 fragments of 3 distinct areas of new crile forceps: the ratchet, shank, and jaw. Of these fragments, 15 were artificially contaminated by immersion in tryptic soy broth containing 10 6 CFU/mL of Escherichia coli (ATCC 25922), for 4, 6, 8, and 12 hours of incubation at 37C with agitation at 100 rpm. The other 3 fragments were used as controls. All fragments were subjected to scanning electron microscopy to evaluate the adhesion of the microorganism. Results: An irregular surface was found in 3 of 6 shank fragments (50%) (Fig. 1) and in all the jaw and ratchet fragments, grooves, and cracks. Initially, there was less adherence of E. coli to the smooth shank surface after contamination, but the concentration of the microorganism increased progressively over time in relation to that in the jaw or ratchet at the same time, and a higher concentration occurred in the cracks and grooves. Conclusions: Structural damage was observed in all fragments, especially in the ratchet and jaw areas, favoring microbial accumulation. Microorganisms housed in the cracks and grooves were better protected from removal by scrubbing with a brush (being unlikely to reach them), making these areas a microbial reservoir and source of contamination. Prolonged contact of the instrument with the contaminating microorganism allowed for greater adherence, even on the smooth areas. The results support the relevance of the early onset of cleaning, considering that even microscopic changes on the surface of the instrument may represent an additional challenge to its effective processing.

Funding: None

Disclosures: None