Background: Recurrence rates and risk factors of Clostridium difficile infection (CDI) are well established in adults, though little is known about the rate of recurrent CDI (rCDI) within the pediatric population. The purpose of this study was to identify rates and risk factors of rCDI in pediatric at-risk groups to guide the optimization of targeted prevention efforts against disease recurrence. Methods: We report on the ongoing retrospective cohort study of pediatric patients at the CHU Sainte-Justine with a laboratory confirmed diagnosis of CDI between April 1, 2012, and March 31, 2017. Incidence rates of rCDI were obtained per 100 cases. Frequencies of rCDI were compared using the Fisher exact test. Univariate and multivariate logistic regression were used to identify risk factors for rCDI. Two-tailed P < .05 was considered significant. All statistical calculations were performed using R version 3.5.2 software. Results: Of 80 patients analyzed with CDI, 16 had rCDI, for a rCDI rate in this population of 20%. Most recurrences were observed in secondarily immunosuppressed patients including, but not limited to, oncology patients undergoing chemotherapy and/or radiotherapy (30.4%) and patients with inflammatory bowel disease (IBD, 29.2%). Patients that were administered vancomycin orally (PO) had recurrent infection less often than patients that administered metronidazole PO or IV (8.3% vs 23.4%, respectively). This trend was observed in all at-risk patient groups. Patients with secondary immunodeficiency had 7.4 times increased odds of recurrence compared to nonimmunodeficient patients (adjusted OR, 7.43,; 95% CI, 1.84–50.4; P = .0126). Conclusions: Initial vancomycin PO therapy seems to be associated with a lower risk of recurrence. Pediatric patients with IBD and with secondary immunodeficiency are at increased risk of rCDI. Given that these populations have an increased underlying risk of diarrhea, it would be worthwhile to determine whether toxin is actually produced (EIA testing) and to prioritize prevention efforts.

Funding: None

Disclosures: None

Background: Central-line–associated bloodstream infections (CLABSIs) are an important cause of healthcare-associated morbidity and mortality in the United States. CLABSI surveillance in the CDC NHSN began in 2005 and has been propelled by state CLABSI reporting requirements, first introduced in 2005, and subsequently by the CMS requirements for intensive care units (ICUs) in 2011 and select ward locations in 2015. Although trend analyses were previously reported, no recent assessment of the NHSN CLABSI incidence rate changes has been performed. In this analysis, we evaluated trends in CLABSI rates in nonneonatal ICUs and all wards reported from acute-care hospitals. Methods: CLABSI rates, including blood stream infections attributed to mucosal barrier injury reported to the NHSN from 2009 to 2018, were analyzed. To evaluate trends in CLABSI incidence and to account for the potential impact of definitional changes in catheter-associated urinary tract infections (CAUTIs) that indirectly impacted CLABSI rates, as well as the CMS mandate for select wards, we conducted an interrupted time-series analysis using negative binomial random-effects modeling with an interruption in 2015. ICUs and ward locations were analyzed separately. Models were adjusted for patient care location type and hospital-level characteristics: hospital type, medical affiliation, teaching status, bed size, number of ICU beds, and average length of inpatient stay. Random intercept and slope models were used to account for differential baseline incidence and trends among reporting hospitals. Results: The overall crude incidence of CLABSI per 1,000 central-line days decreased from 1.6 infections in 2009 to 0.9 infections in 2018, except for an increase in 2015. Similar trends were observed by location type. Among the ICUs, adjusted CLABSI incidence decreased by 10% annually in 2009–2014, increased nearly 29% in 2015, and thereafter decreased at an average of 6.8% per year. Among the wards, adjusted CLABSI incidence decreased at an average of 7.9% annually, except for a 29.3% increase in 2015. Conclusions: Substantial progress has been made in reducing CLABSIs in both ICUs and wards over the last 10 years. Indirect effects of CAUTI definitional changes may explain the immediate increase in ICUs, whereas the CMS mandate may explain the similar increase in wards in 2015. Despite this increase, these findings suggest that policies and practices aimed at prevention of CLABSI have likely been effective on a national level.

Funding: None

Disclosures: None

Background: Resin-containing blood culture bottles (RBB) are used to increase the isolation of microorganisms by binding antimicrobials in sampled blood. Since RBB implementation in April 2018, our infection preventionists noted an increase in positive blood cultures on routine surveillance. Objective: To describe the change in bacterial isolation post-RBB implementation. Methods: All positive blood culture sets drawn in adult inpatient units or the emergency room between October 2017 and September 2018 and their associated organisms were obtained from the hospital laboratory database. Then, regardless of central-line placement or “present on admission” designation, the 2019 NHSN surveillance definitions for laboratory-confirmed bloodstream infection (LCBI-1 and LCBI-2) were applied to categorize all positive cultures as “common commensals” (CCs) or pathogens. A univariate analysis was performed using the Mantel-Haenszel χ2 test (OpenEpi version 3.01). Results: Although the number of monthly blood cultures drawn remained effectively stable before and after implementation (pre-RBB median, 3,512.5; post-RBB median, 3,626), the rate ratio of positive cultures increased by 1.36 times: pre-RBB median, 127 sets per month and post-RBB median, 172.5 sets per month (χ2 = 5.785; P = .008). The rate ratio of pathogen-containing cultures increased by 1.40 times (pre-RBB median, 98 sets per month and post-RBB median, 137.5 sets per month; χ² = 5.615; P = .009) with only a 1.24 increase in CCs (pre-RBB median, 29 and post-RBB median, 36; χ² = 0.553; P = .229) (Fig. 1). Conclusions: After RBB implementation, the monthly incidence rate of pathogen-containing sets increased. Additionally, the increase in these sets as well as of overall positive blood cultures was statistically significant. Current literature on RBBs does not suggest preferential increased isolation of pathogens. Further study is needed to determine whether our findings are related to blood-culturing practices or the RBBs themselves.

Funding: None

Disclosures: None

Background: A multicenter audit-and-feedback intervention was conducted to improve management of acute respiratory infections (ARIs) including group A streptococcal (GAS) pharyngitis within 6 VA medical Centers (VAMCs). A relative reduction (24.8%) in azithromycin prescribing after the intervention was observed. Within these facilities during 2015–2018, 2,266 cases of GAS occurred, and susceptibility to erythromycin ranged from 55% to 70%. We evaluated whether prescribing a macrolide for GAS pharyngitis was associated with an increase in outpatient return visits. Methods: A cohort of ambulatory adults treated for GAS pharyngitis (years 2014–2019) at 6 VAMCs was created. Demographic, diagnostic, treatment, and revisit data were extracted from the Corporate Data Warehouse. GAS pharyngitis was defined by an acute pharyngitis diagnostic code combined with a GAS-positive rapid strep test or throat culture ≤3 days of index date. Antibiotic prescriptions were included if filled ≤3 days of index date and were classified as first line (penicillin/amoxicillin), second line (cephalexin/clindamycin), macrolides (azithromycin, clarithromycin, erythromycin), or other (remaining antibiotics). A return visit was defined as a new visit to primary care, urgent care, or the emergency department with a diagnostic code for an ARI ≤30 days from the index visit. Logistic regression was used to adjust for nonantibiotic covariates and to compare treatments. Results are reported as odds ratio (OR ± 95% CI; P value). Results: Of 12,666 patients with a diagnostic code for acute pharyngitis, 2,923 (23.1%) had GAS testing performed. Of those, 582 (19.9%) were GAS-positive and 460 (15.7%) received antibiotics. The mean age was 39.0 years (±SD, 11.7) and 73.7% were male. Antibiotics included penicillins for 363 patients (78.9%), cephalosporins for 21 (4.6%), clindamycin for 32 (7.0%), macrolides for 47 (10.2%), and other for 17 (3.9%). Penicillin allergy was documented in 48 patients (10.5%), and these patients received cephalosporins (18.8%), clindamycin (35.4%), macrolides (41.7%), and other antibiotics (4.2%). Return visits occurred in 47 cases (10.4%). Limited chart review indicated that 6 of 10 macrolide recipients (60.0%) with return visits had recurrence or unresolved symptoms. After adjustment for calendar month and facility, odds of a return visit for treatment with a macrolide relative to penicillins was 2.79 (OR, 1.19; 95% CI, ±6.56; P = .02). The audit-feedback intervention was not associated with ARI-related return visits (OR, 0.53; 95% CI, 0.26–1.06; P = .07). Conclusions: Return visit rates were higher for GAS pharyngitis patients treated with a macrolide than for those treated with penicillins. Macrolides were the most commonly prescribed non-penicillin therapy irrespective of penicillin allergy. Further work is necessary to determine the reason for the increase in return visits.

Funding: None

Disclosures: None

Background: In 2005, our healthcare system began universal admission screening for nasal colonization with MRSA and decolonization of MRSA positive patients with mupirocin. In 2010–2012, we studied the impact of nasal MRSA decolonization and concluded that it does not add benefit when contact precautions are used; plus, it resulted in increased rates of mupirocin resistance up to 9.4% in 2012. In September 2012 routine decolonization of hospitalized patients was discontinued. In the 2 years following discontinuation of mupirocin use for decolonization of MRSA carriers, the rate of mupirocin resistance gradually declined. We undertook a contemporary review of mupirocin resistance rates to ensure that the rates were stable. Methods: NorthShore University HealthSystem, Illinois, consists of 4 hospitals in the northern suburbs of Chicago, with 750 beds and 60,000 annual admissions. Admission nasal swab samples were collected from at-risk hospitalized patients based on a risk-adjusted algorithm. Nasal swabs were tested using the BD MAX MRSA assay. Positive samples were cultured onto BD BBL CHROMagar MRSA to recover the organism and were tested for the mupA gene, which confers high-level mupirocin resistance using an in-house PCR test. Data for mupirocin orders were provided by the pharmacy. Results: Mupirocin resistance rates and prescription orders are shown in Figs. 1 and 2. Conclusions: Mupirocin resistance rates plateaued between 2012 and 2014 and then increased from 9.1% in 2015 to 18.1% in 2019, despite discontinuation of routine decolonization of hospitalized patients. The reason for the increase is unclear; inpatient mupirocin orders were stable from 2015 to 2017.

Funding: None

Disclosures: None

Background: The CDC NHSN launched the Antimicrobial Use Option in 2011. The Antimicrobial Use Option allows users to implement risk-adjusted antimicrobial use benchmarking within- and between- facilities using the standardized antimicrobial administration ratio (SAAR) and to evaluate use over time. The SAAR can be used for public health surveillance and to guide an organization’s stewardship or quality improvement efforts. Methods: Antimicrobial Use Option enrollment grew through partner engagement, targeted education, and development of data benchmarking. We analyze enrollment over time and discuss key drivers of participation. Results: Initial 2011 Antimicrobial Use Option enrollment efforts awarded grant Funding: to 4 health departments. These health departments partnered with hospitals, which encouraged vendors to build infrastructure for electronic antimicrobial use reporting. CDC supported vendors through outreach and education. In 2012, with CDC support, Veterans’ Affairs (VA) Informatics, Decision-Enhancement, and Analytic Sciences Center and partners began implementation of Antimicrobial Use Option reporting and validation of submitted data. These early efforts led to enrollment of 64 facilities by 2014 (Fig. 1). As awareness of the antimicrobial use option grew, we focused on facility engagement and development of benchmark metrics. A second round of grant Funding: in 2015 supported submission to the Antimicrobial Use Option from additional facilities by Funding: a vendor, a healthcare system, and an antimicrobial stewardship network. In 2015, CMS recognized the Antimicrobial Use Option as a choice for public health registry reporting under Meaningful Use Stage 3, resulting in an increase in participating hospitals. Antimicrobial Use Option enrollment increased in 2015 (n = 120), coinciding with national prioritization of antimicrobial stewardship. In 2016, the SAAR, was released in NHSN. We leveraged the SAAR to encourage participation from additional facilities and began quarterly calls to encourage continued participation from existing users. In 2016, the Department of Defense began submitting data to the Antimicrobial Use Option, resulting in 207 facilities enrolled in 2016, which grew to 616 in 2017. As of November 2019, 12 vendors self-report submission capabilities and 1,470 facilities, of ~6,800 active NHSN participants, are enrolled in the Antimicrobial Use Option. Two states have passed requirements regulating Antimicrobial Use Option reporting with Tennessee’s requirement going into effect in 2021. Conclusions: The Antimicrobial Use Option offers evidence that collaboration with partners, and leveraging of benchmarking metrics available to a national surveillance system can lead to increased voluntary participation in surveillance of high-priority public health data. Moving forward, we will continue expanding analytic capabilities and partner engagement.

Funding: None

Disclosures: None

Background: The emergence and spread of antimicrobial resistance is a major problem in India with significant knowledge on whether this is a systems–based, prescriber and patient characteristic based or diagnostic technologies–based issue. Methods: An electronic survey was sent to select distribution list of intensive care units (ICU) and hospital inpatient (medicine ward) providers from India. Survey questions included antimicrobial clinical practice data, access to electronic medical records, microbiological diagnostic techniques, and access to microbiology data. The survey focused on antimicrobial prescription trends and their association with diagnostic techniques. Results: There were 90 responses from 18 states in 65 ZIP codes. They had median of 187.5 beds (IQR, 40–470). Representative responders had a median age of 40 years (IQR, 31–53). Among the responders, 73 (81%) were men. Of the 90 responses, 48 providers (52%) practiced solely in ICUs (medical and surgical) and 40 providers (45%) practiced solely on the medical ward or floor, with the rest practicing in other units. In total, 31 centers (34%) reported full access to electronic medical records, and 53 centers (59%) had access to wi-fi or Internet. Interestingly, 27 centers (30%) needed to use personal provider phone data for Internet access. Only 26 centers (29%) had electronic microbiological data. Also, 63 respondents (70%) agreed to de-escalation behavior after receiving microbiological data. In addition, 55 respondents (61%) agreed that patients have easy access to outpatient antibiotics without an appropriate prescription, over the counter. Furthermore, 58 responders (64%) said that antibiotic resistance was a major problem at their center, and 61 responders (68%) were familiar with antimicrobial stewardship programs. Among the centers, 69 (77%) had no access to formal infectious disease programs at their center. Only 27 centers (30%) had a formal Clostridium difficile–associated infection reporting and control program. Only 28 centers (31%) had a formal occupational health program. Conclusions: In a large-scale, semistructured, online survey, most issues related to easy availability of antibiotics and lack of “electronization” of medical and microbiological records. It was reassuring that most providers expressed knowledge of the existing antimicrobial stewardship program.

Funding: None

Disclosures: None

Background: Child mortality has remained a major challenge in developing countries. Annually, many children <5 years of age die prematurely due to vaccine-preventable diseases. In South Asia, Pakistan has struggled to achieve global standards of vaccination. Objective: Therefore, we sought to determine barriers to vaccination coverage among children aged 12–23 months and inequities in rural and urban settings of the Sindh province of Pakistan. Methods: We conducted a cross-sectional study in the rural and urban settings of the Sindh province of Pakistan. A 30-cluster household survey was conducted following the WHO guidelines, and 300 children were recruited from each study setting: Lyari, Karachi (urban area) and Umerkot (rural area). Information on the pretested questionnaire was obtained from consenting parents of the children in the study area. The multivariable logistic regression model was used to identify the determinants of vaccination. Results: In total, 600 children from both urban and rural settings were included in the analysis. The mean age was 17.70 months (SD, 3.46), and 50.2% children in the study were boys. Overall, 62.8% children were vaccinated in both settings. Moreover, ~80.3% children were fully vaccinated in the urban part compared with 45.3% in the rural part. The dropout rates for BCG and measles 1 were 17% and 29% in urban and rural areas, respectively. The dropout rates for Penta 1 to Penta 3 were 7% in Lyari and 38% in Umerkot. The penta 1–measles 1 dropout rates were 15% in Lyari and 37% in Umerkot. In multivariable analysis, parental knowledge about vaccination (OR, 9.77; 95% CI, 1.76–54.28), access to a vaccination center (OR, 2.51; 95% CI, 1.19–5.26) and mother’s tetanus vaccination: 1 dose (aOR, 4.27; 95% CI, 1.84–9.93) and 2 doses (OR, 12.43; 95% CI, 7.71–20.04) were associated with vaccination. Conclusions: We identified inequities in vaccination status among the populations of rural and urban areas of Pakistan. Vaccination coverage was higher in an urban setting than in a rural setting of Sindh province. Parental knowledge about vaccination, access to a vaccination center, and mother’s tetanus vaccination status were the major factors of low vaccination coverage among these children.

Funding: None

Disclosures: None

Background: In 2018, the Ministry of Health (MOH) in Saudi Arabia launched the Infection Control Excellence Center (ICEC) program among healthcare governmental institutions to create an exceptionally high concentration of expertise and resources within the infection prevention and control discipline to afford the best patient outcomes possible. King Saud Medical City (KSMC), one of the main healthcare institutions in Riyadh, was selected to be among the 10 facilities participating in ICEC 2019 competition. It is expected to qualify the facility to lead the Kingdom infection prevention and control as well as sharing expertise at regional and international levels. Methods: The infection control team at KSMCA used a business model canvas to present the project vision, resources, partners, values, and revenue streams (Fig. 1). All project stakeholders were engaged, including core infection control team, various hospital departments as internal partners, along with the MOH team as external partners. The ICEC program was presented at the KSMC executive council to earn leadership support. The following assessment areas were included in the presentation: (1) quality assurance and patient care through sustain basic infection control standards and improve key performance indicators (KPIs); (2) enhance the development and structure of the infection control team; (3) pursue innovative ideas in infection control practices. Overall, 17 projects arranged into 4 programs have been proposed (Fig. 2). Results: The institution successfully passed the eligibility criteria assessment in the first quarter of 2019. Infection control KPIs have been corporatized with KSMC strategic KPIs that support infection control improvement initiatives. The infection control team continues to grow in function and capacity. Also, 4 additional were awarded CIC certification in 2019 to reach total of 11 CICs, which represent 30% of the team (including 1 recertification). A dashboard designed by the project management office facilitates follow-up with the proposed projects in progress. Completion levels ranging between 30% and 100% have been achieved among these projects. A final evaluation was conducted in December 2019, including a field visit by the MOH ICEC team as well as a written MCQs exams and interviews with the core infection control team. Communication among the stakeholders and leadership involvement were considered among the assessment criteria. Conclusions: The ICEC supports and motivates investment in human capital and encourages innovative, cost-effective solutions in infection control field in Saudi Arabia. It is also aligned with Saudi Arabia healthcare transformation and the 2030 vision through integrated programs in healthcare facilities.

Funding: None

Disclosures: None

Background: As of July 1, 2019, ~18% of all cases in the Ebola virus disease (EVD) outbreak in the Democratic Republic of Congo (DRC) were healthcare-associated (ie, nosocomial) infections (HAIs) and healthcare worker (HCW) infections. Although progress has been achieved, gaps remained in infection prevention and control (IPC), specifically, a need to reinforce standardized, evidence-based IPC practices to effectively address HAIs. The Ministry of Health (MOH), in collaboration with partners, developed an IPC tool kit consisting of >70 documents (ie, terms of reference, standard operating procedures, training modules, etc) to improve HCW IPC knowledge and practices at healthcare facilities among staff. The tool kit incorporated international IPC standards, DRC-specific experiences, and best practices. Thus, it serves as a technical and operational package, covering general guidance (standard precautions) and EVD specific issues. Methods: A decentralized rollout approach was used to disseminate the tool kit content at the various health-system levels over several months. Initially, national-level training of trainers was held, followed by subnational-level training of IPC supervisors and key IPC implementers, and lastly, training of healthcare facility (HCF) IPC focal persons. The 5-day training adhered to the MOH standard of 60% theory and 40% practice. Participants completed evaluations before and after training; changes in knowledge between the pre- and posttraining tests were analyzed and the results of the statistical tests were reported (P < .05 was considered statistically significant). Results: In total, 294 IPC supervisors were trained across 7 subnational commissions. Data were analyzed for 138 participants. Participants were 60.9% IPC supervisors, 8% WASH supervisors, and 31% others. MOH representation was 52.9% The average results before the test were 66% (19.8 of 30), the average posttest results were 72% (21.6 of 30)—a significant improvement. The worst-performing pretest IPC domain was IPC approach, and facility closure was the worst performing for posttest. As of November 11, 15.7% of all cases were HAIs. Conclusions: The IPC training program initiated during an outbreak can increase knowledge and potentially improve practices and confidence. An association with the downward HAI trend is yet to be validated. The MOH anticipates that this tool kit will be the go-to resource for future Ebola outbreaks and that it will be incorporated into the preservice medical curriculum to ensure a resilient heath system.

Funding: None

Disclosures: None

Background: Infection prevention and control (IPC) is a national priority in all healthcare settings, and IPC staffing characteristics have been linked to patient safety outcomes. However, there is a lack of knowledge about IPC in home healthcare (HHC), the fastest growing healthcare sector. Our aim was to better understand the current state of IPC in HHC, as well as the HHC staff involved with IPC policy implementation. Methods: A national survey was conducted between October 2018 and November 2019. The participants included (1) agencies recruited from a national HHC conference and (2) a national random sample of 1,501 agencies stratified by census region, ownership status, and rural or urban location. Survey items included staff influenza vaccination policies, antibiotic stewardship, infection surveillance, and IPC staffing. Descriptive statistics were computed, and differences by ownership were calculated using 2 and Student t tests. Results: Of the 535 HHC agencies that responded to the survey (response rate, 33%), 64% were for-profit agencies. Overall, 30.8% of the agencies (17.9% for-profit, 57.6% nonprofit; P < .01) required staff influenza vaccination. Most nonprofit agencies (84.1%) and about half of the for-profit agencies (48.1%) offered free influenza vaccinations to staff (P < .01). During the past influenza season, 62.6% of agencies (81.5% nonprofit vs 51.6% for-profit; P < .01) had 75% of their employees vaccinated for influenza, and 9.3% (2% nonprofit vs 13.5% for-profit; P < .01) reported that they did not track this data. Only 17.9% of HHC agencies used antibiotic prescribing guidelines, and 33.3% reported that they reviewed cases to assess the appropriateness of antibiotic administration and/or indication. Most HHC agencies (86%) reported collecting and reviewing infection data to identify trends, which was often done quarterly or more frequently. Almost every responding agency reported that the staff member in charge of IPC had other responsibilities including administrative, education/training, or quality improvement, and 33.5% of those personnel had received no specific IPC training. Also, ~6% of agencies (12.5% of government-owned agencies) reported that they currently did not have a staff member in charge of IPC. Conclusions: This is the first national study of IPC in HHC, which can be used as a benchmark for quality improvement initiatives in the home care environment. Compared to other healthcare settings, HHC agencies have substantial challenges related to IPC. Most HHC agencies do not have a staff member exclusively dedicated to IPC, and staff training is inadequate. Furthermore, a significant number of agencies have no staff influenza vaccination or antibiotic stewardship policies in place. The situation is worse at for-profit agencies, which dominate the current US HHC industry.

Funding: None

Disclosures: None

Background: Measles can cause miscarriages and preterm birth in nonimmune pregnant women. During the 2018–2019 measles outbreak in New York, a woman with measles delivered an extremely low birth weight preterm infant at our Women and Children’s Hospital. We describe our measles preparedness strategies and infection prevention and control (IPC) management relevant to congenital measles. Methods: Because of the measles outbreak, in Q4 2018, IPC verified measles immunity in all obstetric and pediatric staff, per state regulations, and recommended determining the measles immune status of all pregnant women. To prevent measles exposure, visitor restrictions for the neonatal intensive care unit (NICU) were implemented (May 2019); only 3 visitors were permitted for each infant, including parents. All visitors had to provide written documentation of immunity to measles, regardless of epidemiologic risk factors or receive an MMR vaccine prior to visiting. New York state and New York City health departments performed measles diagnostic testing for maternal and infant specimens. Results: Our hospital was informed of the imminent transfer of a woman in preterm labor with suspected measles. To avoid any exposure, the mother was masked in the ambulance bay and taken by commandeered elevator to the obstetrical operating room suite, which was cleared of other patients. She delivered by C-section and was transferred to an airborne infection isolation (AII) room. The 25-week-gestation infant was transported by isolette to the NICU and was placed on AII. Testing confirmed measles in the mother (measles PCR- and IgM-positive) and congenital measles in the infant (Table 1). The mother was allowed to visit the NICU when her respiratory symptoms and rash resolved, as confirmed by her provider, ~10 days after discharge. The infant never developed a rash, pneumonia, or neurologic findings. AII was discontinued on day of life 61 in consultation with the health departments. The infant was discharged at ~36 weeks gestation. No secondary cases of measles occurred among patients, visitors, or staff. Conclusions: We safely cared for an extremely preterm infant with congenital measles. Laboratory testing suggested prolonged presence of measles virus, but it is unknown how long an infant in the NICU should remain on AII. The current Council of State and Territorial Epidemiologists case definition for measles requires the presence of rash. This case provides support to revise this case definition if laboratory findings are consistent with congenital measles.

Funding: None

Disclosures: None

Background: The Infectious Diseases Society of America released updated community-acquired pneumonia (CAP) guidelines in October 2019. One of the recommendations, with a low quality of supporting evidence, is the standard administration of antibiotics in adult patients with influenza and radiographic evidence of pneumonia. Procalcitonin (PCT) is not endorsed as a strategy to withhold antibiotic therapy, but it could be used to de-escalate appropriate patients after 48–72 hours. Radiographic findings are not indicative of the etiology of pneumonia. Prescribing antibiotics for all influenza-positive patients with an infiltrate has significant implications for stewardship. Therefore, we reviewed hospitalized, influenza-positive patients at our institution during the 2018–2019 season, and we sought to assess the impact of an abnormal chest x-ray (CXR) and PCT on antibiotic prescribing and outcomes. Methods: We conducted a retrospective chart review of all influenza-positive admissions at 2 urban, community-based, teaching hospitals. Demographic data, vaccination status, PCT levels, CXR findings, and treatment regimens were reviewed. The primary outcome was the difference in receipt of antibiotics between patients with a negative (<0.25 ng/mL) and positive PCT. Secondary outcomes included the impact of CXR result on antibiotic prescribing, duration, 30-day readmission, and 90-day mortality. Results: We reviewed the medical records of 117 patients; 43 (36.7%) received antibiotics. The vaccination rate was 36.7%. Also, 11% of patients required intensive care unit (ICU) admission and 84% received antibiotics. Moreover, 109 patients had a CXR: 61 (55.9%) were negative, 29 (26.6%) indeterminate, and 19 (17.4%) positive per radiologist interpretation. Patients with a positive PCT (OR, 12.7; 95% CI, 3.43–60.98; P < .0007) and an abnormal CXR (OR, 7.4; 95% CI, 2.9–20.1; P = .000003) were more likely to receive antibiotics. There was no significant difference in 30-day readmission (11.6% vs 13.5%; OR, 0.89; 95% CI, 0.21–3.08; P = 1) and 90-day mortality (11.6% vs 5.4%; OR, 2.37; 95% CI, 0.48–12.75; P = .28) between those that received antibiotics and those that did not, respectively. Furthermore, 30 patients (62.5%) with an abnormal CXR received antibiotics and 21 (43.7%) had negative PCT. There was no difference in 30-day readmission or 90-day mortality between those that did and did not receive antibiotics. Conclusions: Utilization of PCT allowed selective prescribing of antibiotics without impacting readmission or mortality. Antibiotics should be initiated for critically ill patients and based on clinical judgement, rather than for all influenza-positive patients with CXR abnormalities.

Funding: None

Disclosures: None

Background: Central lines (CL) are widely used in the inpatient setting and central-line–associated bloodstream infection (CLABSI) is a serious complication of CL use. Because CL insertion site inflammation (ISI) may precede the onset of CLABSI, we aimed to define ISI, to determine whether ISI was associated with CLABSI, and to develop an automated surveillance system for ISI. Methods: We extracted electronic medical records (EMRs) of adult patients hospitalized at the University of Iowa Hospitals & Clinics during January 2015–December 2018. Nurses routinely document CL insertion-site characteristics in specifically designed flow sheets in the EMR. An ISI was counted every time ≥1 of the following signs were documented during CL assessments: edema, erythema, induration, tenderness, or drainage. A 1:2 case-control investigation was performed by matching nonmucosal barrier injury (non-MBI) CLABSI patients (cases) to patients without a CLABSI diagnosis (controls). We matched for age (±10 years), sex, date (±30 days), inpatient unit, central-line days, and central-line type (temporary vs permanent). The main exposure of interest was having an ISI on or before CLABSI onset. CLABSIs were determined using CDC NHSN definitions. We then created a metric: ISI days (defined as the number of days with ≥1 ISI documented) and plotted ISI incidence (ISI days per central-line days) to quantify the burden of ISIs and to determine whether ISI and non-MBI CLABSI incidences were collinear. An automated surveillance system for ISI was created using structured query language queries to the EMR data repository and Tableau software. Results: During 2015–2018, we detected 194 CLABSI cases that were matched to 338 controls. CLABSI patients had greater odds of having an ISI (OR, 2.3; 95% CI, 1.3–4.0). Over the study period, ISI incidence decreased from ~80 to ~50 ISI days per 1,000 CL days. Non-MBI CLABSI rates also decreased from ~1.5 to ~1.0 CLABSIs per 1,000 CL days. Conclusions: ISI incidence is associated with non-MBI CLABSI incidence. Because ISI incidence is higher than CLABSI incidence, surveillance for ISI could be a more sensitive indicator for monitoring the impact of CLABSI prevention practices. Automated surveillance for novel process metrics is a promising infection prevention tool.

Funding: None

Disclosures: None

Background: Development of an interrater reliability (IRR) process for healthcare-associated infection surveillance is a valuable learning tool for infection preventionists (IPs) and increases accuracy and consistency in applying National Healthcare Safety Network (NHSN) definitions (1-3). Case studies from numerous resources were distributed to infection preventionists of varying experience levels (4-6). Item analysis, including item difficulty index and item discrimination index, was applied to individual test questions to determine the validity of the case scenarios at measuring individual mastery of the NHSN surveillance definitions (7-8). Methods: Beginning in 2016, a mandatory internal IRR program was developed and distributed to infection preventionists (IPs) of varying experience level. Each year through 2019, a test containing 30–34 case studies was developed with multiple-choice questions. Case studies were analyzed using 2 statistical methods to determine item difficulty and validity of written scenarios. P values for each test question were calculated using the item difficulty index formula, with harder questions resulting in values closer to 0.0. Point biserial correlation was applied to each question to determine highly discriminating questions, measured in a range from −1.0 and 1.0. Results: Between 2016 and 2019, 124 questions were developed and 145 respondents participated in the mandatory IRR program. The overall test difficulty was 0.70 (range, 0.64–0.74). Moreover, 17 questions (14%) were determined to have high “excellent” discrimination, 41 questions (33%) were determined to have “good” discrimination, 57 questions (46%) were determined to have “poor” discrimination, and 9 questions (7%) were found to have negative discrimination values. Conclusions: IRR testing identifies educational opportunities for IPs responsible for the correct application of NHSN surveillance definitions. Valid test scenarios are foundational components of IRR tests. Case scenarios that are determined to have a high discrimination index should be used to develop future test questions to better assess mastery of application of surveillance definitions to clinical cases.

Funding: None

Disclosures: None

Background: Carbapenem-resistant Acinetobacter baumannii (CRAB), a multidrug-resistant gram-negative bacterium, can cause difficult-to-treat infections with mortality in approximately half of CRAB cases. CRAB can spread among healthcare facilities after transfer of an infected or colonized patient. Strategies to limit CRAB spread include adherence to contact precautions, environmental cleaning with bleach, and screening to identify colonized patients. During July–September 2018, the Connecticut Department of Public Health (DPH) worked with an acute-care hospital (hospital A) to contain an outbreak of OXA-23–producing CRAB (OXA-23 is an enzyme that confers resistance to carbapenems). During November 2018–March 2019, statewide CRAB surveillance identified additional cases of related OXA-23–producing CRAB at other healthcare facilities. DPH, Connecticut State Public Health Laboratory (SPHL), and the Antibiotic Resistance Laboratory Network (ARLN) investigated to prevent additional cases. Methods: Since January 2017, CRAB isolates have been routinely sent to SPHL and ARLN for carbapenemase gene detection and whole-genome sequencing (WGS) to determine isolate relatedness. During November 2018–March 2019, DPH collected patient healthcare history for patients with CRAB isolates to identify outbreaks and provide assistance in infection control and prevention to healthcare facilities reporting CRAB cases. Beginning May 2019, DPH and ARLN offered facilities screening to identify patients colonized with OXA-23–producing CRAB. Results: Of 10 OXA-23–producing CRAB isolates reported to DPH during November 2018–March 2019, 3 were closely related to the 9 isolates from hospital A’s outbreak by WGS (single-nucleotide polymorphism difference range, 1–16). One isolate was from a patient who had been admitted to hospital A during July 2018. All 3 patients with CRAB isolates shared a history of residence at long-term–care facility A (LTCF A). Two patients received a CRAB infection diagnosis upon admission to hospital B after transfer from LTCF A. Both LTCF A and hospital B performed environmental cleaning with bleach and placed CRAB-identified patients on contact precautions. LTCF A declined screening patients for CRAB, whereas hospitals B and C, which receive frequent transfers from LTCF A, screened all patients on admission from LTCF A. During May–September 2019, among 6 patients screened, 1 was colonized with OXA-23–producing CRAB and was placed on contact precautions. Conclusions: Transfer of patients who are infected or colonized with CRAB among hospitals and LTCFs can facilitate the regional spread of CRAB. Strategies for containing the spread of carbapenemase-producing organisms include adherence to contact precautions, colonization screening, interfacility communication, and collaboration with public health.

Funding: None

Disclosures: None

Background: Methicillin-resistant Staphylococcus aureus (MRSA) is a growing clinical problem in rehabilitation hospitals, where patients stay for extended periods for intensive rehabilitation therapy. In addition to cutaneous sites, the nares could be a source for nosocomial MRSA transmission. Decolonization of nasal and cutaneous reservoirs could reduce MRSA acquisition. We evaluated the effectiveness of topical intranasal octenidine gel, coupled with universal chlorhexidine baths, in reducing MRSA acquisition in an extended-care facility. Methods: We conducted a quasi-experimental before-and-after study from January 2013 to June 2019. All patients admitted to a 100-bed rehabilitation hospital specialized in stroke and trauma care in Singapore were screened for MRSA colonization on admission. Patients screened negative for MRSA were subsequently screened at discharge for MRSA acquisition. Screening swabs were obtained from the nares, axillae, and groin and were cultured on selective chromogenic agar. Patients who tested positive for MRSA from clinical samples collected >3 days after admission were also considered to have hospital-acquired MRSA. Universal chlorhexidine baths were implemented throughout the study period. Intranasal application of octenidine gel for MRSA colonizers for use for 5 days from admission was added to the hospital’s protocol beginning in September 2017. An interrupted time series with segmented regression analysis was performed to evaluate the trends in MRSA acquisition before the intervention (January 2013–July 2017) and after the intervention (September 2017–June 2019) with intranasal octenidine. August 2017 was excluded from the analysis because the intervention commenced midmonth. Results: In total, 77 observational months (55 before the intervention and 22 after the intervention) were included. The mean monthly MRSA acquisition rates were 7.0 per 1,000 patient days before the intervention and 4.4 per 1,000 patient days after the intervention (P < .001), with a mean number of patient days of 2,516.3 per month before the intervention and 2,427.2 per month after the intervention (P = .0172). The mean monthly number of MRSA-colonized patients on admission to the hospital decreased from 24.8 before the intervention to 18.7 after the intervention (P < .001). Mean monthly hand hygiene compliance rate increased significantly from 65.7% before the intervention to 87.4% after the intervention (P < .001). After adjusting for the number of MRSA-colonized patients on admission and hand hygiene compliance rates, a constant trend was observed from January 2013 to July 2017 (adjusted mean coefficient, 0.012; 95% CI, −0.037 to 0.06), with an immediate drop in September 2017 (adjusted mean coefficient, −2.145; 95% CI, −0.248 to −0.002; P = .033), followed by a significant reduction in MRSA acquisition after the intervention from September 2017 through June 2019 (adjusted mean coefficient, −0.125; 95% CI, -4.109 to -0.181; P = .047). Conclusions: Topical intranasal octenidine, coupled with universal chlorhexidine baths, can reduce MRSA acquisition in extended-care facilities. Further studies should be conducted to validate the findings in other healthcare settings.

Funding: None

Disclosures: None

Background: With increasing medical tourism and international healthcare, emerging multidrug resistant organisms (MDROs) or “superbugs” are becoming more prevalent. These MDROs are unique because they are resistant to antibiotics and can carry special resistance mechanisms. In April 2019, our hospital was notified that a superbug, New Delhi Metallo-β-lactamase

(NDM)–producing carbapenem-resistant Enterobacteriaceae (CRE), was identified in a patient who had been transferred to another hospital after being at our hospital for 3 weeks. Our facility had a CRE admission screening protocol in place since 2013, but this patient did not meet the criteria to be screened on admission. Methods: The infection prevention (IP) team consulted with the Minnesota Department of Health (MDH) and gathered stakeholders to discuss containment strategies using the updated 2019 CDC Interim Guidance for Public Health Response to Contain Novel or Targeted Multidrug-resistant Organisms (MDROs) to determine whether transmission to other patients had occurred. NDM CRE was classified under tier 2 organisms, meaning those primarily associated with healthcare settings and not commonly identified in the region, and we used this framework to conduct an investigation. A point-prevalence study was done in an intensive care unit that consisted of rectal screening of 7 patients for both CRE and Candida auris, another emerging MDRO. These swabs were sent to the Antibiotic Resistance Laboratory Network (ARLN) Central Regional Lab at MDH for testing. An on-site infection control risk assessment was done by the MDH Infection Control Assessment and Response (ICAR) team. Results: All 7 patients were negative for both CRE and C. auris, and no further screening was done. During the investigation, it was discovered that the patient had had elective ambulatory surgery outside the United States in March 2019. The ICAR team assessment provided overall positive feedback to the nursing unit about isolation procedures, cleaning products, and hand hygiene product accessibility. Opportunities included set-up of soiled utility room and updating our process to the 2019 MDH recommendation to screen patients for CRE and C. auris on admission who have been hospitalized, had outpatient surgery, or hemodialysis outside the United States in the previous year. Conclusions: Point-prevalence study results showed no transmission of CRE and highlighted the importance of standard precautions. This event supports the MDH recommendation to screen for CRE any patients who have been hospitalized, had outpatient surgery, or had hemodialysis outside the United States in the previous year.

Funding: None

Disclosures: None

Background: In February 2019, the Colorado Department of Public Health and Environment (CDPHE) identified a cluster of 3 invasive group A Streptococcus (GAS) infections in residents receiving wound care in a long-term care facility (LTCF). An investigation revealed a larger outbreak that extended to nonresidents receiving outpatient wound care at the LTCF. Methods: A case was defined as a positive culture for GAS emm type 82 from an individual with exposure to the LTCF between January and June 2019. Cases were categorized as clinical (symptoms of GAS disease or GAS isolated from a wound or sterile site) or carriage (no symptoms). Carriers were identified via samples collected from throat and skin lesions. Screening occurred in 2 rounds and included residents of affected units followed by screening of all wound-care staff and residents facility-wide. Available isolates were sent for emm type testing and whole-genome sequencing (WGS) at the CDC. CDPHE staff performed infection control observations. Results: We identified 14 cases: 8 clinical and 6 carriage (from 5 residents and 1 staff member). Two patients with invasive GAS died. Of 8 patients with clinical GAS, 6 resided in the facility on or 1 day prior to symptom onset; 2 were not residents but received outpatient therapy at the LTCF. All 8 patients with clinical GAS (100%) and 3 carriers had received wound care. The staff member with emm 82 carriage had provided wound care and occupational therapy to the affected residents and the 2 outpatients. Two additional cases were detected with onset dates following staff member decolonization. Moreover, 13 of the 14 emm 82 isolates were found to be identical by WGS. Infection control observations identified lapses in staff wound care and hand hygiene practices in the residential and outpatient settings of the facility. Conclusions: This investigation details a large GAS outbreak in an LTCF associated with asymptomatic carriage in residents and staff that included patients who had only received care in the outpatient portion of the facility. The outbreak was halted following decolonization of a staff member and improvements in infection control, including in the outpatient setting. Outpatient services, particularly wound care, provided by LTCFs should be considered when investigating LTCF-related GAS cases and outbreaks.

Funding: None

Disclosures: None

Background: During a 2-month period at an academic medical system, 4 cases of pansusceptible P. aeruginosa (PsA) meningitis were identified among neuroscience intensive care unit (NSICU) patients with an external ventricular device (EVD). Methods: We reviewed microbiology data for the previous 2 years to determine background PsA rates and to identify additional cases of PsA meningitis. A case was defined as the isolation of PsA from a CSF specimen. We convened a multidisciplinary group of stakeholders to review medical records of case patients and to conduct a series of observational rounds. Scalp swab specimens were collected from NSICU patients to detect possible skin colonization. Pulsed-field gel electrophoresis (PFGE) analyses were performed on PsA isolates from the 4 case patients and 5 patients with PsA isolates from other body sites. Results: There was no hospital-wide increase in PsA incidence, and no patient without an EVD had PsA cultured from CSF. Infections occurred, on average, 10 days (range, 6–15 days) after EVD insertion. Cases were geographically dispersed in the NSICU and did not share common staff. None of the PsA isolates were genetically related and all scalp cultures were negative. Observations included multiple opportunities for contact with water sources: sinks in proximity to the head of the bed, storage of supplies next to sinks, reuse of bath basins, and use of dilute peroxide to clean surgical wounds. Multiuse shampoos, conditioners and lotions, not approved for hospital use, were found on the unit. Furthermore, 3 of 4 patients received cefazolin >24 hours after 6 of their 7 neurosurgeries for an average of 4.7 days (range, 0.8–4 days). Care practices were changed to mitigate contact between EVD sites and environmental water sources, and extended cefazolin surgical prophylaxis was discontinued. EVD practices were revised, and clinical teams had their competency confirmed. No additional cases have been identified in the 16 months following these interventions. Conclusions: This cluster of EVD infections was likely caused by patient care practices that resulted in independent introductions of PsA from multiple nonsterile or contaminated water sources. Antibiotic selection of PsA by extended use of cefazolin perioperative prophylaxis may have also contributed. EVD care practices should be designed to limit contact between and EVD insertion sites and nonsterile water sources or potentially contaminated care supplies. To substantiate performance improvement efforts and ensure interinstitutional comparability, a practical, standardized EVD-associated infection surveillance definition is needed.

Funding: None

Disclosures: None