Background: The epidemiology of Clostridioides difficile infection (CDI) is complex, and the COVID-19 pandemic has had extreme impacts on known risk factors such as comorbidity burden and antibiotic prescribing. However, whether these changes have affected the incidence of hospital-associated CDI (HA-CDI) remains unknown. We compared incidence and trends of HA-CDI before and after the pandemic onset, and we assessed the impact of changes in key CDI-related risk factors. Methods: We conducted an interrupted time-series study (March 2018–March 2021) of adult inpatients hospitalized 4 or more days with no known CDI on admission at a 576-bed academic medical center. Our primary outcome was monthly HA-CDI per 10,000 patient days. We performed segmented linear regression to compare the preinterruption trend in HA-CDI rate to the postinterruption slope and level change. We established a series of 30-day intervals before and after the interruption timepoint of March 23, 2020, which corresponds with the Oregon stay-at-home executive order. The data included 24 preinterruption time points and 12 postinterruption time points. We also assessed changes in slope and trend for known HA-CDI risk factors. Results: We included 34,592 inpatient encounters in our prepandemic period and 10,932 encounters in our postinterruption period. The mean prepandemic HA-CDI rate was 4.07 cases per 10,000 patient days. After the pandemic onset, the rate was 3.6 per 10,000 patient days. However, the observed differences in rate (both in terms of slope and level) were not statistically significant (P = .90 for level; P = .60 for slope change). We observed a significant decrease in admissions per 30 days (1,441 vs 911; level-change P < .0001) and a slight increase in the mean number of Elixhauser comorbidities (1.96 vs 2.07; level-change P = .05). We also observed significant increases in both frequency and intensity of antibiotic use, with an increase average days of therapy per encounter (5.8 vs 7.2; level-change P = .01; slope-change P < .0001) and in antibiotic spectrum index (ASI) points per antibiotic day (4.4 vs 4.9; P < .0001). We observed a consistent downward trend for case days of CDI colonization pressure per hospital day (preinterruption slope P < .0001), which remained consistent after the pandemic onset (P = 0.5 for postinterruption slope change) (Fig. 1). Conclusions: Despite significant increases in high-intensity antibiotic use and comorbidity burden, we did not observe significant differences in HA-CDI after the pandemic onset. This may be due to the significant decrease in colonization pressure in the postpandemic period. Further research is required to fully understand the impact of the pandemic-related changes on

Disclosures: None

Background: Pathogen transmission among staff and residents in nursing homes can vary depending on their interactions and by the amount of time a resident receives care in the facility. Understanding the relative differences in transmission rates between and among staff and residents can identify the pathways that contributed most to the spread of SARS-CoV-2 in US nursing homes. Further exploring relative differences by categorizing facilities by residents’ lengths of stay can identify priority categories for intervention. Methods: Using US National Healthcare Safety Network (NHSN) surveillance data on resident and staff cases, vaccination, and resident deaths during June 2020–June 2022, we estimated SARS-CoV-2 transmission among and between residents and staff. We used a Bayesian inversion of a susceptible–exposed–infected–removed–virus–death (SEIRVD) compartmental model to produce the estimates. The facilities were divided into those with median length of stay (LOS) among the residents of 10 weeks. Additional inputs included the incidence and vaccination levels of the county where each facility was located. For the compartmental model, all data were averaged to form a representative facility for each category. Transmission was estimated separately for 3 periods: (1) June 2020–March 2021 as before the SARS-CoV-2 delta variant, (2) April 2021—October 2021 during SARS-CoV-2 delta variant dominance, and (3) November 2021—June 2022 during the prevalence of the SARS-CoV-2 omicron variant. Results: Regardless of facility category, transmission was highest from staff to residents or resident to resident (Fig.). These estimates of transmission were highest during the pre–SARS-CoV-2 delta variant phase. Transmission in that phase was highest in the facilities with LOS >10 weeks from staff to residents at 0.88 per week (95% credible interval [CrI], 0.06–1.85), in the facilities with LOS 6–10 weeks from staff to residents at 0.68 per week (95% CrI, 0.03–1.78), and in the facilities with LOS <6 weeks between residents at 0.47 per week (95% CrI, 0.02–0.95). Conclusions: Staff-to-resident or resident-to-resident transmission were the dominant pathways of spread of SARS-CoV-2 across the periods or the facility categories. Facilities with LOS 6 weeks or longer had higher median transmission estimates across the periods and transmission routes compared to facilities with LOS less than 6 weeks, implying that when prioritization of intervention resources is needed, facilities caring for populations with longer stays could be prioritized.

Disclosures: None

Background: Data regarding the effects of the SARS-COV-2 (COVID-19) pandemic on healthcare-associated infections (HAIs) in Canadian acute-care hospitals are limited. We examined the impact of the COVID-19 pandemic on HAIs and antimicrobial resistant organisms in hospitals participating in the Canadian Nosocomial Infection Surveillance Program. Methods: We analyzed 13,406 HAIs including adult mixed intensive care unit (ICU) central-line–associated bloodstream infections (CLABSIs), and healthcare-associated (HA) Clostridioides difficile infection (CDI), methicillin-resistant Staphylococcus aureus (MRSA) bloodstream infections (BSI), vancomycin-resistant Enterococcus (VRE) BSI, and carbapenemase-producing Enterobacterales (CPE) infections collected using standardized case definitions and questionnaires from 29–64 hospitals participating in the Canadian Nosocomial Infection Surveillance Program (CNISP) from January 2018 to December 2021. We used a generalized linear mixed model with quasi-Poisson distribution to assess step and slope changes in monthly HAI rates between the pre–COVID-19 pandemic period (January 1, 2018–February 29, 2020; 26 time points) and the COVID-19 pandemic period (March 1, 2020–December 31, 2021; 22 time points). Results were reported as incidence rate ratios (IRRs) with 95% confidence intervals (CIs) and adjusted for seasonality, hospital clustering, and hospital characteristics of interest. Results: In the CNISP network, 7,352 (55%) HAIs were reported in the prepandemic period and 6,054 (45%) in the pandemic period. Median age was significantly younger during the pandemic period compared to the prepandemic period among patients with HA-CDI, HA-MRSA BSI, and adult mixed ICU CLABSIs, and more than half of cases among all reported HAIs were male (range, 52%–65%). The 30-day all-cause in-hospital mortality rate did not significantly change between the prepandemic and pandemic periods for all reported HAIs and was highest among HA-VRE BSIs (34%). Modeling results indicated that the COVID-19 pandemic was associated with an immediate increase in HA-CDI and adult mixed ICU CLABSI rates whereas HA-MRSA BSI, HA-CPE and HA-VRE BSI rates immediately decreased. However, pandemic status did not have a statistically significant lasting impact on monthly rate trends for all reported HAIs after adjusting for seasonality, clustering, and hospital covariates (Fig. 1 and 2). Adjusted IRRs for all HAIs ranged from 1.00 to 1.01 (95% CI, 0.94–0.99 to 1.01–1.05).

Conclusions: Although the COVID-19 pandemic placed a significant burden on the Canadian healthcare system, the immediate impact on monthly rates of HAIs in Canadian acute-care hospitals was not sustained over time. Understanding the epidemiological effects of the COVID-19 pandemic in the context of changing patient populations, and clinical and infection control practices, are essential to inform the continued management and prevention of HAIs in Canadian acute-care settings.

Disclosures: None

Background: Many hospitals test all patients for SARS-CoV-2 upon admission to prevent silent transmission to other patients and healthcare workers. The utility of universal admission testing has been questioned, however, due to resource constraints, care delays, and sparse data on its impact on nosocomial infections. England and Scotland stopped requiring universal admission testing on August 31, 2022, and September 28, 2022, respectively. We assessed associations between these changes and hospital-onset SARS-CoV-2 infection rates. Methods: We used public data from National Health Service England and Public Health Scotland on hospital-onset SARS-CoV-2 infections, defined as cases diagnosed >7 days after admission, between July 1, 2021, and December 16, 2022. Because hospital-onset infections are driven by SARS-CoV-2 community incidence rates, we calculated the weekly ratio between hospital-onset versus community-onset SARS-CoV-2 admissions (diagnosed ≤7 days from admission) and assessed for temporal changes associated with stopping universal admission testing using interrupted time-series analysis. The study was divided into 3 periods: sARS-CoV-2 delta-variant dominance with admission testing, SARS-CoV-2 omicron-variant dominance with admission testing (starting December 14, 2021), and SARS-CoV-2 omicron-variant dominance without admission testing. Results: During the study period, there were 518,379 COVID-19 admissions in England, including 398,264 community-onset and 120,115 hospital-onset cases, and 46,517 COVID-19 admissions in Scotland, including 34,183 community-onset and 12,334 hospital-onset cases. The mean weekly ratio of new hospital-onset SARS-CoV-2 infections versus community-onset admissions in England rose from 0.12 during the SARS-CoV-2 delta-variant surge to 0.33 during the SARS-CoV-2 omicron-variant surge to 0.48 after universal admission testing ended (Fig.). There was a significant immediate level change both after the SARS-CoV-2 delta-to-omicron variant transition (92% relative increase; 95% CI, 58%–127%) and after admission testing ended (32% relative increase; 95% CI, 14%–50%). Likewise, the mean weekly ratios rose from 0.11 to 0.43 to 0.89 during their analogous periods in Scotland, with significant level changes both after SARS-CoV-2 delta-to-omicron variant transition (113% relative increase; 95% CI, 54%–172%) and after admission testing ended (72% relative increase; 95% CI, 43%–100%). No significant trend changes were observed. Conclusions: Stopping asymptomatic screening of hospitalized patients in 2 national health systems was associated with significant increases in hospital-onset SARS-CoV-2 infections. Nosocomial SARS-CoV-2 remains a common and potentially morbid complication, with reported mortality rates for nosocomial infections by SARS-CoV-2 omicron variant ranging from 5% to 13%. Preventing infections in vulnerable populations remains an important safety goal. Hospitals should exercise caution when considering reductions in SARS-CoV-2 admission screening.

Disclosures: None

Background: Clinical antibiotic susceptibility testing (AST) interpretations based on minimum inhibitory concentrations (MIC) breakpoints are important for both clinical decision making and some reportable condition criteria. Standardization of MIC breakpoints across clinical laboratories is lacking; AST instruments are often validated for outdated Clinical and Laboratory Standards Institute (CLSI) MIC breakpoint guidelines. In this study, we analyzed the agreement between the reported clinical laboratory AST interpretations and the guideline CLSI interpretation. Methods: Clinical laboratory AST data collected from the Multisite Gram-Negative Surveillance Initiative (MuGSI) carbapenem-resistant Enterobacterales (CRE) surveillance program in Tennessee between 2019 and 2021 were utilized. MIC values from the clinical instrument were used to calculate CLSI standard interpretations following the 2019–2021 CLSI M100 guidelines. Agreement between the clinical laboratory and CLSI interpretations of the reported MIC values were measured using a weighted Cohen κ calculated in SAS version 9.4 software. Total matches were isolates with identical CLSI and clinical laboratory interpretations. Results: In total, 14 antibiotics were assessed. Of those, 9 antibiotics had at least moderate agreement (κ > 0.41) between interpretations. Agreement between the clinical laboratory and the CLSI interpretations were near perfect (κ > 0.81) for 3 antibiotics. Agreement between the clinical laboratory and the CLSI interpretations were poor for cefazolin (0.06) and ertapenem (0.14). Cefotaxime (−0.07) was the only antibiotic that suggested no agreement. Conclusions: Of the antibiotics included in the analysis, 36% had less than moderate agreement between clinical laboratory and CLSI AST interpretations. Given the increases in antimicrobial resistance globally and the emphasis placed on antibiotic stewardship, standardization across clinical AST panels should be prioritized. Inconsistencies have the potential to contribute to inappropriate antibiotic use in addition to under- or overidentification of reportable conditions, including CRE.

Disclosures: None

Background: Serratia marcescens is a leading cause of hospital-acquired infections. There has been increasing recognition of hospital wastewater as a reservoir for carbapenemase-producing Enterobacterales (CPE), including S. marcescens. Because CPE can proliferate in biofilms in sink drains and traps, controlling nosocomial spread is challenging. The ideal approach to eliminate transmission from wastewater to patients remains unknown. Methods: Patients were included if they were admitted to 1 of 2 intensive care units (ICUs) for >12 hours between December 1, 2010, and January 31, 2016. During this period at the University of Virginia Hospital, there was ongoing patient acquisition of multiple species producing Klebsiella pneumoniae carbapenemase (KPC) as well as consistent perirectal KPC surveillance. In January 2014, to eliminate CPE-colonized sinks, the sink drains and traps in one of the ICUs (ie, the “intervention unit”) were exchanged followed by varied chemical mitigations to prevent recolonization. In another ICU, the same chemical mitigations were performed but without plumbing replacement (ie, the “control unit”). Acquisition of KPC-producing S. marcescens was defined as colonization or infection >12 hours after admission to either unit. To control for increases in patient-to-patient transmission, acquisition of methicillin-resistant Staphylococcus aureus (MRSA) was evaluated in the intervention unit during the same period and was defined as new colonization or infection with MRSA >12 hours after unit admission but within 21 days of last unit exposure. Results: For the postintervention period, risk of S. marcescens acquisition was increased (RR, 2.85; 95% CI, 1.24–6.58; P = .01) in the intervention unit compared to the control unit. In the intervention unit, the risk of S. marcescens acquisition increased in the postintervention period compared to the preintervention period (RR, 6.26; 95% CI, 2.59–15.1; P < .0001). There was no change in MRSA acquisition in the intervention unit representing consistent patient-to-patient infection prevention (RR, 0.95; 95% CI, 0.61–1.48; P = .81). S. marcescens isolates were noted to be highly clonal. Conclusions: Exposure to the intervention unit following plumbing replacement was associated with increased relative risk of acquisition of KPC-producing S. marcescens. This increased risk was not observed in the control unit, which had only chemical plumbing interventions. There was no concomitant increase in patient-to-patient MRSA transmission. The disturbance of the wastewater environment through the plumbing replacement intervention may have led to the unintended consequence of more KPC-producing S. marcescens acquisition.

Disclosures: None

Background: Using patient data from the electronic health record (EHR) and computer logic, an “electronic phenotype” can be created to identify patients with community-acquired pneumonia (CAP) in real time to assist with syndrome-specific antimicrobial stewardship efforts.1 We adapted and validated the performance of an inpatient CAP electronic phenotype for antimicrobial stewardship interventions. Methods: An automated scoring system was created within the EHR (Epic Systems) to identify hospitalized patients with CAP based on the variables and logic listed in Fig. 1B. We adapted a score used by the Michigan Hospital Medicine Safety Consortium (HMS) to identify patients with CAP, with additions made to improve sensitivity (Fig. 1).1 The score can be displayed in a column within the EHR patient list (Fig. 2). We validated the electronic phenotype via chart review of all hospitalized patients on systemic antimicrobials admitted to a medicine team consecutively between November 8 and 18, 2021. Patients who were readmitted within the validation time frame were excluded. We assessed the performance of the electronic phenotype by comparing the score to manual chart review, where “CAP diagnosis” was defined as (1) mention of “pneumonia” or “CAP” as part of the differential diagnosis in the admission documentation, (2) antimicrobials were started within 48 hours of admission, and (3) radiographic findings were suggestive of pneumonia. After initial evaluation, the scoring system was adjusted, and performance was re-evaluated during prospective audit and feedback performed on EHR CAP–positive patients over 13 days between July 2022 and December 2022. Results: We included 191 patients in our initial validation cohort. The CAP score had high sensitivity (95.83%), specificity (92.2%), and negative predictive value (99.35%), though lower positive predictive value (63.89%) was noted (Table 2). The rules were further refined to include bloodstream infection only with Haemophilus influenza or Streptococcus pneumoniae in rule 2B, and azithromycin was removed from “CAP antibiotics.” After these changes, repeated evaluation of 88 patients with positive CAP EHR score was performed, and only 20 (23%) were considered false-positive results. Conclusions: Electronic phenotypes can be used to create automated tools to identify patients with CAP with reasonable performance. Data from this tool can be used to guide more focused antimicrobial stewardship interventions and clinical decision support in the future. Reference: Vaughn VM, et al. A statewide collaborative quality initiative to improve antibiotic duration and outcomes in patients hospitalized with uncomplicated community-acquired pneumonia. Clin Infect Dis 2022;75:460–467.

Disclosures: None

Background: Carbapenem-resistant Acinetobacter baumannii (CRAB) has emerged as a major cause of bloodstream infection among hospitalized patients in low- and middle-income countries (LMICs). CRAB infections can be difficult to treat and are devastating in neonates (~30% mortality). CRAB outbreaks are hypothesized to arise from reservoirs in the hospital environment, but outbreak investigations in LMICs seldom incorporate whole-genome sequencing (WGS). Methods: WGS (Illumina NextSeq) was performed at the National Institute for Communicable Diseases (South Africa) on 43 preserved A. baumannii isolates from a 530-bed referral hospital in Gaborone, Botswana, from March 2021–August 2022. This included 23 blood-culture isolates from 21 unique patients (aged 2 days–69 years) and 20 environmental isolates collected at the 36-bed neonatal unit in April–June 2021. Infections were considered healthcare-associated if the culture was obtained >72 hours after hospital arrival (or sooner in inborn infants). Blood cultures were incubated using an automated system (BACT/ALERT, BioMérieux) and were identified using manual methods. Environmental isolates were identified using selective or differential chromogenic media (CHROMagarTM). Taxonomic assignment, multilocus sequence typing (MLST), antimicrobial resistance gene identification, and phylogenetic analyses were performed using publicly accessible analysis pipelines. Single-nucleotide polymorphism (SNP) matrices were used to assess clonal lineage. Results: All 23 blood isolates and 5 (25%) of 20 environmental isolates were confirmed as A. baumannii; thus, 28 A. baumannii isolates were included in the phylogenetic analysis. MLST revealed that 22 (79%) of 28 isolates were sequence type 1 (ST1), including all 19 healthcare-associated blood isolates and 3 (60%) of 5 environmental isolates. Genes encoding for carbapenemases (blaNDM-1, blaOXA-23) and biocide resistance (qacE) were present in all 22 ST1 isolates; colistin resistance genes were not identified. Phylogenetic analysis of the ST1 clade demonstrated spatial clustering by hospital unit. Related isolates spanned wide ranges in time (>1 year), suggesting ongoing transmission from environmental sources (Fig. 1). An exclusively neonatal clade (0–2 SNPs) containing all 8 neonatal blood isolates was closely associated with 3 environmental isolates from the neonatal unit: a sink drain, bed rail, and a healthcare worker’s hand. Conclusions: WGS analysis of clinical and environmental A. baumannii revealed the presence of unit-specific CRAB clones, with evidence of ongoing transmission likely driven by persistent environmental reservoirs. This research highlights the potential of WGS to detect hospital outbreaks and reaffirms the importance of environmental sampling to identify and remediate reservoirs (eg, sinks) and vehicles (eg, hands and equipment) within the healthcare environment.

Disclosures: None

Background: Veterans Health Administration (VHA) community living centers (CLCs) provide postacute and long-term care. CLC veterans visit myriad locations outside their rooms (eg, rehabilitation, dialysis). Pathogen transmission during out-of-room visits is unknown. Methods: We recruited newly admitted veterans at 3 CLCs. After obtaining informed consent, we cultured nares, groin, hands, and 7 surfaces in the patient rooms. We accompanied veterans to up to 5 out-of-room visits and cultured patients’ hands and surfaces they touched. We tested for multidrug-resistant organisms (MDROs) including methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococcus (VRE), and quinolone, carbapenem, and/or ceftazidime-resistant gram-negative bacteria (R-GNB). We defined transmission as a positive culture following an initial negative culture during the same visit. Results: We enrolled 137 veterans (median follow-up, 29 days; mean, 5.9 visits); 97% were postacute patients. We conducted 539 patient-room sampling visits (mean, 3.9 per veteran; 5,490 swabs) and accompanied 97 veterans to 266 out-of-room sampling visits (mean, 2.7 per veteran; 2,360 swabs). Of 137 patients, 47 (35%) were colonized with an MDRO at enrollment and 74 (58%) of 128 patients were colonized on any follow-up patient-room visits. Of 133 patients, 55 (41%) acquired a new MDRO, most often VRE (31 of 97, 32%). In patient rooms, toilet seats [114 (21%) of 538], curtains [101 (19%) of 530] and bedrails [98 (18%) of 539] were most frequently contaminated. Among 266 out-of-room visits, 17% had surfaces contaminated with MDROs, most commonly involving dialysis [4 (31%) of 13], radiology [2 (25%) of 8], and rehabilitation therapy [29 (18%) of 159] (Fig. 1).Transmission of MDROs during out-of-room visits was common and occurred in 18% of visits with 8% (9 MRSA and 12 VRE) acquiring a new MDRO on their hands and 12% (9 MRSA and 23 VRE) of MDRO transmission occurring from hands to a surface that the patient touched (Fig. 1). In 18 (58%) of 31 cases, the organism transmitted to a surface was on patient hands at the start of the visit. Transmission was most common during visits to dialysis (3 to patients and 2 to surfaces), radiology (1 to a patient and 2 to surfaces), and rehabilitation therapy (13 to patients and 21 to surfaces) (Fig. 2). Conclusions: New MDRO acquisition during VHA CLC stay was common, and nearly one-fifth of out-of-room visits resulted in MDRO transmission. Our analyses suggest that veterans’ hands may shed MDROs (MRSA and VRE) to surfaces. Interventions to reduce MDRO transmission during visits for rehabilitation, dialysis, and other therapies are needed.

Disclosures: None

Background: COVID-19 has presented hospitals with unique challenges. An SHEA Research Network survey showed that 40% reported “limited” or worse levels of personal protective equipment (PPE) and that 13% were self-producing PPE to address those deficits, including 3D-printed items. However, we do not know how efficiently, if at all, 3D-printed materials can be disinfected. Additionally, 2 filaments, PLACTIVE and PUREMENT, claim to be antimicrobial; they use copper nanocomposites and silver ions to reduce bacterial populations. We assessed how PLACTIVE and PUREMENT may be contaminated and how well they reduce contamination, and how readily polylactic acid (PLA), a standard 3D-printed material, may be disinfected. Methods: We grew methicillin-resistant and -susceptible Staphylococcus aureus, Escherichia coli, and Klebsiella pneumoniae on 3D-printed disks and conducted bacterial survival assays to determine whether bacteria grow on PLA, PLACTIVE, and PUREMENT. We performed a time series (with 3- and 24-hour dry times) followed by serial dilutions to attain colony-forming unit (CFU) averages for each strain per disk. To determine whether 3D-printed material can be cleaned, we used 70% EtOH on PLA only. We conducted the same time series followed by a disinfectant time series (with dry times 30 seconds, 2.5, minutes, 5 minutes, and 10 minutes). Again, serial dilutions were performed to attain the PLA CFU averages with disinfectant. The CFU averages from the control group (PLA) and testing group (PLACTIVE and PUREMENT) were compared to see how well the antimicrobial material decreased bacterial load. We also compared the CFU averages of PLA with and without disinfectant to see how well 70% EtOH decreased bacterial load. Results: 3D-printed material is readily contaminated with bacteria common in hospitals and can sustain that contamination. Antimicrobial materials, PLACTIVE and PUREMENT, had lower levels of bacterial contamination when compared to PLA. However, disinfected disks had lower overall CFU averages than those that were not, but the level of disinfection was variable and bacterial populations recovered hours after disinfection application. Conclusions: Proper disinfection and using appropriate 3D-printed materials are essential to limiting bacterial contamination. 3D printers and their products can be invaluable for hospitals, especially when supplies are low and healthcare worker safety is paramount. Environmental services should be made aware of the presence of antimicrobial 3D-printed materials, and patients should be discouraged from printing their own items for use in hospital environments.

Disclosures: None

Background: Statistically significant decreases in methicillin-resistant Staphylococcus aureus (MRSA) healthcare-associated infections (HAIs) occurred in Veterans Health Administration (VA) facilities from 2007 to 2019 using active surveillance for facility admissions and contact precautions for patients colonized (CPC) or infected (CPI) with MRSA, but the value of these interventions is controversial. Objective: To determine the impact of active surveillance, CPC, and CPI on prevention MRSA HAIs, we conducted a prospective cohort study between July 2020 and June 2022 in all 123 acute-care VA medical facilities. In April 2020, all facilities were given the option to suspend any combination of active surveillance, CPC, or CPI to free up laboratory resources for COVID-19 testing and conserve personal protective equipment. We measured MRSA HAIs (cases per 1,000 patient days) in intensive care units (ICUs) and non-ICUs by the infection control policy. Results: During the analysis period, there were 917,591 admissions, 5,225,174 patient days, and 568 MRSA HAIs. Only 20% of facilities continued all 3 MRSA infection control measures in July 2020, but this rate increased to 57% by June 2022. The MRSA HAI rate for all infection sites in non-ICUs was 0.07 (95% CI, 0.05–0.08) for facilities practicing active surveillance plus CPC plus CPI compared to 0.12 (95% CI, 0.08–0.19; P = .01) for those not practicing any of these strategies, and in ICUs the MRSA HAI rates were 0.20 (95% CI, 0.15–0.26) and 0.65 (95% CI, 0.41–0.98; P < .001) for the respective policies. Similar differences were seen when the analyses were restricted to MRSA bloodstream HAIs. Accounting for monthly COVID-19 admissions to facilities over the analysis period using a negative binomial regression model did not change the relationships between facility policy and MRSA HAI rates in the ICUs or non-ICUs. There was no statistically significant difference in monthly facility urinary catheter-associated infection rates, a nonequivalent dependent variable, in the categories during the analysis period in either ICUs or non-ICUs. Conclusions: In Veterans Affairs medical centers, there were fewer MRSA HAIs when facilities practiced active surveillance and contact precautions for colonized or infected patients during the COVID-19 pandemic. The effect was greater in ICUs than non-ICUs.

Disclosures: None

Background: Candida auris, an emerging and potentially multidrug-resistant fungus, was first identified in Maricopa County, Arizona, in 2020. On April 21, 2022, an acute-care hospital reported C. auris in a bronchoalveolar lavage (BAL) specimen, followed by a second case reported on April 26 identified via retrospective laboratory review and species identification in yeast isolated from a clinical specimen. The Maricopa County Department of Public Health (MCDPH) investigated, and we describe the largest ongoing C. auris outbreak containment response in Maricopa County. Methods: The MCDPH conducted clinical case and contact investigations in accordance with CDC novel organism containment strategy guidelines. In Maricopa County healthcare facilities (HCFs) with suspected transmission, virtual Infection Control Assessment Responses (ICARs) were administered to identify initial infection prevention and control (IPC) gaps; subsequent regular virtual visits were also provided. HCFs with confirmed transmission completed point-prevalence surveys (PPSs) every 2 weeks until transmission halted as evidenced by 2 sequential negative PPSs. Outreach education to affected HCFs was provided to increase awareness about the public health significance of C. auris and the importance of implementation and sustained adherence to standardized IPC protocols. Results: In total, 97 HCFs received IPC outreach education, of which 22 HCFs (23%) had suspected transmission and received a virtual ICAR. Contact investigation identified 1,990 contacts, of whom 1,028 (52%) were discharged to the community, 863 (43%) were admitted to other HCFs, and 99 (5%) died. Of the 863 transferred contacts, 10 (1.2%) declined colonization screening, 853 (98.8%) were screened, and 46 (5%) tested positive for C. auris. Through sequential PPSs, 101 (5%) of 1,914 screened patients tested positive for C. auris. By December 31, 16 clinical and 147 colonized cases were epidemiologically linked to the outbreak. Their median age was 60 years (IQR, 20), and 3 pediatric cases (median age, 17 years) were identified with no pediatric unit admissions. Also, 7colonized cases (5%) developed noninvasive infection and 3 (2%) developed candidemia. Conclusions: The MCDPH’s established partnerships with HCFs were key to this ongoing C. auris outbreak response spanning 22 facilities over 8 months. Challenges included delays in specimen collection and laboratory processing, operational burden of repeated PPS, and ensuring appropriate precautions for readmitted close contacts at subsequent HCFs. The MCDPH assisted facilities in balancing public health surveillance with facility capacity to execute guidance, including repeated PPS. Consistent adherence to stringent IPC practices, interfacility communication, and proactive C. auris education of healthcare workers are paramount to halting transmission.

Disclosures: None

Background: Candida auris is a frequently drug-resistant yeast that can cause invasive disease and is easily transmitted in healthcare settings. Pediatric cases are rare in the United States, with <10 reported before 2022. In August 2021, the first C. auris case in Las Vegas was identified in an adult. By May 2022, 117 cases were identified across 16 healthcare facilities, including 3 pediatric cases at an acute-care hospital (ACH) with adult cases, representing the first pediatric cluster in the United States. The CDC and Nevada Division of Public and Behavioral Health (NVDPBH) sought to describe these cases and risk factors for C. auris acquisition. Methods: We defined a case as a patient’s first positive C. auris specimen. We reviewed medical records and infection prevention and control (IPC) practices. Environmental sampling was conducted on high-touch surfaces throughout affected adult and pediatric units. Isolate relatedness was assessed using whole-genome sequencing (WGS). Results: All 3 pediatric patients were born at the facility and had congenital heart defects. All were aged <6 months when they developed C. auris bloodstream infections; 2 developed C. auris endocarditis. One patient died. Patients overlapped in the pediatric cardiac intensive care unit; 2 did not leave between birth and C. auris infection. Mobile medical equipment was shared between adult and pediatric patients; lapses in cleaning and disinfection of shared mobile medical equipment and environmental surfaces were observed, presenting opportunities for transmission. Overall, 32 environmental samples were collected, and C. auris was isolated from 2 specimens from an adult unit without current cases. One was a composite sample from an adult patient’s bed handles, railings, tray table and call buttons, and the second was from an adult lift-assistance device. WGS of specimens from adult and pediatric cases and environmental isolates were in the same genetic cluster, with 2–10 single-nucleotide polymorphisms (SNPs) different, supporting within-hospital transmission. The pediatric cases varied by 0–3 SNPs; at least 2 were highly related. Conclusions: C. auris was likely introduced to the pediatric population from adults via inadequately cleaned and disinfected mobile medical equipment. We made recommendations to ensure adequate cleaning and disinfection and implement monitoring and audits. No pediatric cases have been identified since. This investigation demonstrates transmission can occur between unrelated units and populations and that robust infection prevention and control practices throughout the facility are critical for reducing C. auris environmental burden and limiting transmission, including to previously unaffected vulnerable populations, like children.

Disclosures: None

Background: Measles is a highly transmissible respiratory virus that presents with nonspecific prodromal symptoms followed by a characteristic cephalocaudal rash. In the prodromal phase, children with measles can be challenging to differentiate from children with other circulating respiratory viral infections. A measles outbreak in Central Ohio starting in October 2022 coincided with a national surge in children with viral respiratory infections which presented unique challenges in preventing healthcare transmission in the pediatric ambulatory setting. Methods: Following initial identification of presumed community transmission of measles in Central Ohio in November 2022, a multidisciplinary measles response team was convened at Nationwide Children’s Hospital (NCH) to prevent secondary healthcare transmission via rapid-cycle quality improvement. Prevention efforts were focused broadly across NCH ambulatory locations in Central Ohio, including the main campus and offsite emergency departments, regional urgent cares, and primary care network. Preliminary risk factors were identified via chart review of initial cases, which included vaccine status, ZIP code of residence, and known daycare or household exposure. These risk factors were used to guide an intervention bundle comprising enhanced screening at registration and triage, creation of electronic medical record alerts to identify at-risk patients, increased clinician education, and expanded community messaging. As the outbreak evolved, risk factors were updated, and interventions were adjusted to adapt response. Outcome metrics included total patient exposures as well as the relative exposure score. The exposure score was an internal metric derived using the vaccine status of exposed patients and ventilation at the site of exposure to assess likelihood of secondary cases occurring from an exposure. Results: In total, 65 patients with measles were seen at NCH facilities between October 29 and December 8, 2022. The outbreak response was divided into 4 periods: (1) cases identified retrospectively prior to first diagnosis (October 29–November 7, 2022), (2) initial case discovery (November 8–14, 2022), (3) implementation of prevention bundle (November 15–28, 2022), and (4) updates to the response (November 29–December 8, 2022). Ambulatory healthcare exposures and incidence of secondary cases decreased over the outbreak periods in response to implementation of the prevention bundle (Fig. and Table). Conclusions: An outbreak of measles occurring simultaneously with peak respiratory viral season presented challenges in early identification of suspected cases and mitigation of healthcare exposure. Transmission was effectively prevented following rapid deployment of a prevention bundle adjusted in real-time through rapid-cycle quality improvement. Ongoing longitudinal vaccination efforts are needed to sufficiently mitigate transmission risk in communities with under-vaccinated populations.

Disclosures: None

Background: Healthcare activities that include instrumentation or manipulation of mucosal tissue or normally sterile sites, such as the eye and its associated structures, place patients at risk of infectious and other complications. We reviewed queries to the CDC Prevention and Response Branch that were focused on ophthalmologic procedures and settings to examine opportunities to improve infection prevention and control (IPC) practices in these settings. Methods: We reviewed internal CDC consultation records received from January 1, 2016, through December 31, 2021, to identify those involving ophthalmologic procedures or settings. Consultations were reviewed to determine setting type, number of patients affected, organisms identified, nature of infection control breaches, and whether medical products were implicated. Descriptive statistics were calculated. Results: We identified 24 consultations among 19 states and US territories. Of these, 21 (87.5%) involved outpatient settings, of which 9 (43%) were ambulatory surgery centers. Consultations included the following non–mutually exclusive categories. There were 18 adverse postsurgical events (75%), such as mycobacterial infection after laser surgery and toxic anterior segment syndrome following cataract surgery (n = 5). There were 11 infections following ophthalmologic clinical care (46%), such as epidemic keratoconjunctivitis due to adenovirus 8. There were 8 suspected medication-related events (33%) including contamination of ophthalmic medication when manufactured or compounded offsite. There were 8 medical-device reprocessing concerns (33%) including inappropriate high-level disinfection. There were 8 instances of improper environmental cleaning and disinfection (33%), for example, during an adenovirus outbreak. There were 3 cases of potential mishandling of medications onsite (12.5%), such as multiuse eye drops. Also, 3 events (12.5%) were associated with potentially contaminated donor tissue, such as corneas for transplantation. When a consultation included identification of a pathogen (n = 11), organisms included bacteria (n = 7, 64%), viruses (n = 2, 18%), and fungi (n = 3, 27%). In total, 202 patients had confirmed ophthalmologic infections or adverse events. Conclusions: Based on our review of recent outbreaks, healthcare personnel in ophthalmologic settings may have deficits in training related to instrument reprocessing and environmental cleaning specific to ophthalmic equipment and settings that can result in harm to patients. These settings could benefit from targeted training to improve IPC practices specific to ophthalmologic examinations and procedures. This review was limited to analysis of investigations that were voluntarily reported to the CDC. A formal surveillance system for adverse outcomes in this setting could clarify the nature and frequency of IPC issues of greatest concern.

Disclosures: None

Background: The CDC’s new Public Health Strategies to Prevent the Spread of Novel and Targeted Multidrug-Resistant Organisms (MDROs) were informed by mathematical models that assessed the impact of implementing preventive strategies directed at a subset of healthcare facilities characterized as influential or highly connected based on their predicted role in the regional spread of MDROs. We developed an interactive tool to communicate mathematical modeling results and visualize the regional patient transfer network for public health departments and healthcare facilities to assist in planning and implementing prevention strategies. Methods: An interactive RShiny application is currently hosted in the CDC network and is accessible to external partners through the Secure Access Management Services (SAMS). Patient transfer volumes (direct and indirect, that is, with up to 30 days in the community between admissions) were estimated from the CMS fee-for-service claims data from 2019. The spread of a carbapenem-resistant Enterobacterales (CRE)–like MDROs within a US state was simulated using a deterministic model with susceptible and infectious compartments in the community and healthcare facilities interconnected through patient transfers. Individuals determined to be infectious through admission screening, point-prevalence surveys (PPSs), or notified from interfacility communication were assigned lower transmissibility if enhanced infection prevention and control practices were in place at a facility. Results: The application consists of 4 interactive tabs. Users can visualize the statewide patient-sharing network for any US state and select territories in the first tab (Fig. 1). A feature allows users to highlight a facility of interest and display downstream or upstream facilities that received or sent transfers from the facility of interest, respectively. A second tab lists influential facilities to aid in prioritizing screening and prevention activities. A third tab lists all facilities in the state in descending order of their dispersal rate (ie, the rate at which patients are shared downstream to other facilities), which can help identify highly connected facilities. In the fourth tab, an interactive graph displays the predicted reduction of MDRO prevalence given a range of intervention scenarios (Fig. 2). Conclusions: Our RShiny application, which can be accessed by public health partners, can assist healthcare facilities and public health departments in planning and tailoring MDRO prevention activity bundles.

Disclosures: None

Background: Antimicrobial resistance (AMR) presents a global health threat. Training laboratory technicians to accurately identify and report AMR is critical in low- and middle-income countries (LMICs) to control the spread of AMR. Ethiopia and Kenya implemented a telementoring program, ECHO AMR, via the Project ECHO learning platform to improve laboratory technician capacity to isolate, identify, and report AMR organisms; to perform antimicrobial susceptibility testing (AST); and to develop a community of learning. Between January 2018 and January 2022, biweekly 1-hour sessions were held for 8 and 22 laboratories averaging 19 or 43 participants per session in Ethiopia and Kenya, respectively. Each session included a lecture, a laboratory challenge case presentation, and discussion. An evaluation was conducted to assess perceived strengths and weaknesses of the program and its usefulness in improving bacteriology capacity. Methods: In July–August 2022, semistructured key informant interviews of purposively and randomly selected laboratorians were conducted to understand participant perspectives of ECHO AMR, including session structure and content, changes in laboratory performance, and the virtual learning platform. Eligible participants attended at least one-third of available sessions in Ethiopia (8 of 26 sessions) or Kenya (5 of 16 sessions) during 2021. Key informant interviews were transcribed and systematically reviewed to identify key themes. Results: In total, 22 laboratory technicians participated in the key informant interviews: 12 in Ethiopia and 10 in Kenya. Participants reported that the ECHO AMR session structure was well organized but recommended increasing session duration to allow more time for discussion. Technical content was presented at an appropriate level and was highly rated. However, participants suggested including more subject-matter experts to provide the lectures. All participants reported positive change in laboratory practice, including implementation of international standards for AST, better quality control, improved confidence and critical thinking, and increased AMR awareness and reporting. Participants learned well in the virtual environment, with the platform providing wide-ranging geographic interactions to share skills and knowledge among sites without travel. However, there were connectivity issues, competing work priorities during sessions, and a lack of dedicated space for team participation. Conclusions: Laboratory technicians reported that virtual laboratory training was well-received, efficient, and impactful. Participants benefited both individually and collectively, as a laboratory. Suggested improvements included increasing session duration, connectivity support, and including more subject-matter experts to broaden technical content. Further assessment is needed to evaluate the ECHO AMR’s impact on laboratory practices through observation and laboratory data. Virtual programs, requiring less time and resources than traditional in-country trainings, can be optimized and used to share and increase bacteriology knowledge in LMICs.

Disclosures: None

Background: Considering the threat of antimicrobial resistance (AMR), Ethiopia implemented strategies to combat AMR, including partnering with the American Society for Microbiology (ASM) to conduct an AMR training program using the Project ECHO learning platform. ECHO AMR was used to virtually connect subject-matter experts with participating sentinel laboratories in remote locations to provide ongoing education, telementoring, and foster peer-to-peer learning and problem-solving in microbiology. In phase 1, the ASM had primary leadership in conducting sessions and project administration. In phase 2, roles and responsibilities transitioned from the ASM to the Ethiopian Public Health Laboratory (EPHI) with support from ECHO India. Here we describe the transition process and lessons learned. Methods: From December 2020–2021, biweekly 1-hour sessions were conducted for 8 sentinel laboratories. Each virtual session included a lecture led by a subject-matter expert, a case presentation by a participating laboratory, open discussion, and feedback via an end-of-session online survey. Following a transition plan, initial ASM-EPHI transition activities included formal administrative and logistical training, including participation in a 3-day Project ECHO-immersion program provided by ECHO India. Selected administrative and technical roles and responsibilities, including further developing their own SMEs, were transitioned from ASM to EPHI every 4 sessions. ASM conducted postsession reviews with EPHI and ECHO India to discuss successes and suggested improvements. Results: Leadership of ECHO AMR was fully transitioned to EPHI over 12 months. End-of-session surveys and postsession reviews indicated the transition process was successful, with EPHI staff leading the lectures, session coordination, and facilitation, and positive feedback from session participants. Challenges included variable sentinel site participation due to competing priorities such as COVID-19 testing and poor internet connectivity during the rainy season. Lessons learned included the need to use a gradual transition strategy with close monitoring, training facilitators to maintain implementation fidelity (level of reproducibility to conduct ECHO AMR as in phase 1) and improve participation, and assessing individual learning, using pretests and posttests. Recommendations included that ASM should remain as an external technical advisor to ensure program technical depth and session facilitators be trained to improve participation in the discussions. Implementation fidelity compared to phase 1 was considered moderate, with the gap primarily due to the need for dedicated release time from laboratory duties to ensure session leadership, coordination, and facilitation. Conclusions: Leadership and laboratory workforce capacity-building responsibility for AMR training was successfully transitioned from ASM to EPHI, promoting self-sufficiency in training and with far-reaching benefits in the global fight against AMR.

Disclosures: None

Background: Among US acute-care hospitals (ACHs) reporting to the NHSN, significant increases in the incidence of Ventilator-Associated Events (VAEs) were observed during the COVID-19 pandemic years in comparison with 2019. We assessed changes in the national event-level VAE data, including the incidence of specific event-types: Ventilator-Associated Condition (VAC), Infection-related Ventilator-Associated Complication (IVAC) and Possible Ventilator-Associated Pneumonia (PVAP). We also examined changes in associated pathogens, and we evaluated incidence density rates (IDRs) of pediatric VAE (PedVAE) before and during the pandemic years. Methods: We analyzed data on VAE and PedVAE reported to NHSN between 2019 through the second quarter of 2022 (2022Q2) in ACHs. Annual proportions of VAC, IVAC, or PVAP were calculated; changes versus 2019 were assessed. The 10 most common PVAP pathogens reported annually were examined, and the percentages and ranks for each were calculated. Among pediatric and neonatal locations, PedVAE IDR were calculated as the number of events per 1,000 ventilator days and were compared between the pre-pandemic and pandemic years. All comparisons were conducted using a mid-P exact test, and P<0.05 was considered statistically significant. Results: Between 1,266 - 1,357 ACHs reported VAE data each year. A total of 24,836 (2019), 37,592 (2020), and 50,362 (2021) VAEs were reported. The proportion of VAC events in 2020 (64.1%) was significantly higher than in 2019 (62.9%), while the 2020 and 2021 PVAP proportions (8.7% and 9.2%, respectively) were significantly lower than in 2019 (10.0%). The majority of VAEs were reported from the same location types annually. The top 3 PVAP pathogens reported for each year remained unchanged: Staphylococcus aureus, Pseudomonas aeruginosa, Klebsiella. However, the proportion identified as Haemophilus influenzae decreased significantly each year from 2019-2021, with the rank dropping from #5 in 2019 (6.6%) to #10 in 2021 (2.3%). Between 199 – 257 ACHs conducted PedVAE surveillance. PedVAE IDR were significantly lower in 2020 (0.8), 2021 (1.1), and the first half of 2022 (0.8) when compared to 2019 (1.3). Conclusions: This study provides a national view of specific VAEs before and during the COVID-19 pandemic. Some changes in the associated pathogens, and the proportions of VAC and PVAP, were observed. This study is the first to produce national benchmarks for PedVAE IDR. Additional ACHs conducting PedVAE surveillance in NHSN would improve the representativeness of our results.

Disclosures: None

Background: Western State Hospital (WSH) is an 800-bed, state-owned psychiatric hospital in Washington State which services individuals in 20 counties. WSH provides services and inpatient treatment to patients referred via behavioral health providers and/or the civil court system. Because many patients are admitted with serious, long-term illness, WSH also provides primary care and addresses infectious syndromes encountered in admitted patients. In January 2016, WSH officially began their antimicrobial stewardship program (ASP). In 2017 WSH joined the UW Center for Stewardship in Medicine (UW-CSiM) to grow and optimize their ASP. Methods: The lead pharmacist at WSH participated in weekly hour-long education and tele-mentoring sessions through the UW-CSiM program. Educational materials were adapted from UW-CSiM didactics and delivered to providers during regular meetings and grand rounds. Daily pharmacist led prospective audit with feedback was conducted. Antibiotic use data were collected and measured by days of therapy (DOT) per 1000-patient days from pharmacy dispensing records from 2015 to 2022. Results: From 1/1/15 to 12/31/22, there was a consistent trend of decreasing antibiotic consumption annually. In particular, antibiotic use decreased by over 65% ranging from 35-43 DOT per 1000 patient-days in 2015 to 9-11 DOT per 1000 patient-days in 2022 (Figure 1). This translates to approximately 1000 antibiotic days of therapy in 2015 and 200 days of antibiotic therapy in 2022. As of 2022, the two most common antibiotics used were cephalexin and sulfamethoxazole/trimethoprim Conclusion: Although treating infections is not a principal focus of a psychiatric hospital, patients receiving care in inpatient psychiatric facilities do experience common infections and receive antibiotics during their stay. At WSH, initiation of an antimicrobial stewardship program was associated with sustained decrease in total antibiotic DOT over 7 years. These data highlight the impact of tele-education and tele-mentoring in infectious diseases and antimicrobial stewardship as a path to build a successful antimicrobial stewardship even without formal infectious diseases training. Our single center experience at a large psychiatric hospital demonstrates the use of antimicrobials in these facilities and the opportunity for a large impact of an antimicrobial stewardship program in inpatient psychiatric facilities.

Disclosures: None.