Background: Febrile neutropenia (FN) is the most common complication of chemotherapy-induced neutropenia that affects over 80% of patients with hematologic malignancies. National guidance and randomized controlled trial data demonstrate empiric antimicrobial therapy (EAT) can be discontinued after 72 hours of apyrexia and clinical recovery regardless of absolute neutrophil count (ANC). A 2019 internal study identified opportunity for improvement for targeted de-escalation. We aimed to reevaluate duration of EAT in patients with FN without a documented source of infection. Methods: A pharmacovigilance platform identified 110 patients from January to September 2023 without identified source of infection. Data collection was performed via manual chart review. Historic patient data from our 2019 cohort (n=50) was available in our research repository. The primary outcome was the duration of EAT in patients with at least 72 hours of apyrexia and clinical recovery, defined as normalization of vital signs. Secondary outcomes included adverse events associated with EAT, and initiation of intravenous vancomycin. Results: Baseline characteristics for 2023 were similar to historic, median age was 67.5 years, 56% were male, and median ANC at fever onset was 150 cells/μL. EAT was continued in 29 patients (58%) despite defervescence and stabilization versus 35 (70%) in 2019 (figure 1). Average duration (LOT) of EAT beyond clinical stabilization was 6 versus 7 days. Adverse effects due to EAT occurred in 13 patients in 2023 (26%) versus 4 (8%); of which, C. difficile infection (CDI) was the greatest contributor. Vancomycin was initiated in 31 patients (62%), 22 having no identifiable indication. Conclusions: Rates of EAT de-escalation for neutropenic patients after 72 hours of apyrexia and clinical stability improved by 12% as compared to 2019. Mean days of overall EAT was 3 days less in 2023. With a notable increase in CDI rates in 2023, dedicated time for antimicrobial stewardship review, clinician education and guideline driven alerts for review will be explored to help further improve practice.

Objective: Mycobacterium tuberculosis (MTB) is a contagious airborne disease that is spread from person to person via particles in the air which are expelled when speaking or coughing1. This retrospective observational study aims to assess the nosocomial transmission of pulmonary MTB among inpatient roommates in a high-risk oncological population over a 14-year period. With limited studies on the transmissibility of MTB in such environments, the investigation focuses on evaluating the risk of nosocomial transmission and implementation of appropriate infection control measures. Design: A retrospective analysis from 2010 – April 2023 was conducted in an acute care, 500-bed oncological center. Following exposure workups performed by the Department of Infection Prevention and Control, 17 of 57 identified patients with active pulmonary MTB had inpatient stays with roommates. Source infectivity showed 7 AFB smear positive results, 4 MTB PCR positive results, and 14 MTB culture positive results. Some index patients had a combination of AFB, PCR and/or culture positivity. A high-risk exposure is defined as any patient who shared a room with an index patient for >4 cumulative hours during the infectious period. Infectious period was determined for each index patient based on the onset of symptoms and laboratory results. Workups identified 33 exposed roommates who were notified and advised to undergo testing, employing QuantifERON (QFT-GIT) serum test or Tuberculin skin (TST) PPD test at least 8 weeks following their last day of exposure. The overlap between inpatient roommates and index patients ranged from 1 to 4 days, averaging 1.5 days. Results: Of the 33 high-risk roommates, 14 (42%) patients were unable to provide follow-up testing for various reasons including: patient expiration prior to testing, patient transfer to hospice, and being lost to follow up. Nineteen (58%) patients completed post-exposure testing. 12 patients underwent PPD testing (63%) and 7 patients underwent QuantifERON testing (37%). Zero (0%) were found to have a positive QuantifERON or PPD following their exposure. 15.8% (N=3) of exposed patients had hematologic malignancies, and 84.2% (N=16) of exposed patients had solid tumor malignancies. Conclusion: The risk of active pulmonary MTB transmission in an oncological, inpatient setting was determined to be low. The absence of positive conversions among roommates of confirmed MTB patients underscores the effectiveness of infection control measures, emphasizing the importance of isolating confirmed or suspected cases promptly. Ongoing efforts should continue to focus on these preventive measures to mitigate the risk of MTB transmission in similar high-risk settings.

References: 1. How TB Spreads. CDC, 2023. https://www.cdc.gov/tb/topic/basics/howtbspreads.htm

Background: The role of the infection preventionist (IP) is complex and encompasses a range of responsibilities requiring extensive knowledge in infection control practices, data analysis, surveillance, performance improvement and collaboration with multidisciplinary teams. Infection prevention certification (CIC) by the certification Board of Infection Control (CBIC) is a standardized marker of knowledge and competencies required for practice in the field. In a 2020 survey of IPs, less than half were certified or planned to become certified. Of those that do take the certification exam, less than three quarters pass on their initial exam attempt. Methods: From 2017 to 2023, fifty-two new IPs were enrolled in a competency-based training program which combined didactic and applied learning on core IP job functions, and a structured mentoring program. The initial didactic phase consisted of evidence-based learning modules with validation of competency through post-training testing and practical demonstration. Education was provided by an advanced practice IP via remote webinars, which included discussion of questions, skills coaching, and review of post-tests. Novice IPs were partnered with at least two preceptors: one advanced practice lead preceptor guided the novice IPs through assigned education modules and oversaw program management and training benchmarks. A second, near-peer preceptor or mentor collaborated with the novice IP in the facility setting. Initial training focused on facility operations, surveillance, rounding and other facility specific activities. Facility mentors were responsible for combining education module topics with practical application of skills. Mentors guided novice IPs through National Healthcare Surveillance network (NHSN) surveillance training and validated surveillance and infection coding until the novice IP had an interrater reliability validation assessing surveillance competency. After the initial training phase, the novice IPs began preparation for certification. This phase included additional training modules aligned with the CBIC certification content outline and practice exams. Results: All 52 novice IPs completed the training program and attempted the CIC examination. The initial pass rate for the certification exam among IPs in the supervised training and mentorship program was 98.1% (n=51). This is 33% higher than the initial pass rate published by CBIC, which was 73.9% (Figure 1). Conclusions: Organizing evidence-based guidelines into topic-specific modules builds a foundation of infection prevention and control knowledge, which is enhanced through remote instruction and direct application of skills under a preceptor’s supervision. This method allows IPs to be introduced to concepts covered in the board certification exam upon hire and support certification with improved outcome

Background: Hospitals are increasingly consolidating into networks and integrating infection prevention (IP) into system infection prevention programs (SIPP). Very little has been published about these programs. This survey sheds light on the current state of SIPPs. Methods: We used the survey generator Alchemer.com for setting up the questionnaire, and tested a beta version among peers. The final version was sent out to SHEA Research Network participants in August 2023. Raw data was compiled and analyzed. Results: Forty institutions responded (40/104, 38%), of which 25 (63%) had SIPPs. These SIPPS reported health systems with a median of 4.5 acute care hospitals (range, 1-33); 16 SIPPS reported a median of 2 critical access hospitals (range, 1-8); 4 SIPPs reported 1-3 LTACHs, and 6 SIPPS reported a median of 1.5 nursing homes. All except 3 (88%) contained an academic center; 48% (11/23) of the U.S. based programs operate in multiple states. Four programs have been in place >20 years, four < 2 years, and the remainder a median of 8 years (range, 2-18). Physician directors also have clinical (20/25, 80%), teaching (19/25, 76%), research (15/25, 60%), antimicrobial stewardship (8/25, 32%), quality (8/25, 32%), and/or patient safety (5/25, 20%) roles. Seventeen (68%) report having a written job description. Nineteen (76%) report having an infection preventionist in a system IP director role; only 7/25 (28%) have a dedicated system IP team that operates independent of individual hospitals. Sixteen (64%) report administrative support, 10/25 (40%) have a data manager/analyst, and 4/25 (16%) include IT expert or programmer support. 15/25 (60%) report having done a formal system-wide IP needs assessment. While 16/25 (64%) have some automation in HAI surveillance (predominantly using Bugsy [Epic] or Theradoc [Premier]), while only 5/25 (20%) run fully automated surveillance. 10/25 (40%) have implemented centralized surveillance. 12/25 (48%) have “system IP policies” that are hierarchically above individual site policies. The biggest challenges appear to be gaps in 1) clear governing structure, 2) communication, 3) consistent staffing, 4) data management support, and 5) dedicated, empowered IP expert FTEs. Conclusions: To our knowledge, this is the first U.S. survey to explore present-day system infection prevention. In this sample of hospital networks, we found heterogeneity in the structure, staffing and resources for system IP with significant opportunities for improvement. In this era of healthcare consolidation, our findings highlight the urgent need to more clearly delineate and support system IP needs in order to enhance their functionality.

Background: COVID19 remains deadly to Americans over 75 years old despite vaccination and additional infection control practices in long term care (LTC). The evolution of more transmissible COVID19 variants and continued viral aerosols result in persistent COVID19 outbreaks in LTC during high community levels of COVID19. Despite the end of pandemic Federal support and the continued vulnerability of elderly to the virus, LTC facilities remain dedicated to protecting this vulnerable population. The study hypothesized that utilization of continuous, facility-wide, advanced photocatalysis (AP) disinfection technology will reduce microbial burden in air and on surfaces, demonstrating a decrease in infectious aerosols and subsequent COVID19 cases among residents and workers. Methods: A prospective facility controlled experimental study was performed in skilled nursing facilities in Pennsylvania and New Jersey from January 2023 to April 2023 to surveil aerobic bacterial and fungal colony forming units (CFUs) in air, and Methicillin-resistant Staphylococcus aureus (MRSA) and fungal CFUs on surfaces and floors prior to and post AP technology installation. Impacts on resident COVID19 cases were recorded and compared to the same extended observation period (February-July 2023) one year prior (2022) with similar year over year community COVID19 rates. In addition, two matched control centers in regional proximity to the intervention facility were also prospectively studied. A one-way analysis of variance (ANOVA) was used to analyze mean microbial burdens after each post activation period (significance p <.05). Results: From baseline to final testing, the intervention facility surface testing showed a 93% reduction in mean aerobic bacterial CFUs (p=.002); 96% reduction in mean fungal CFUs (p<.001); 97% reduction in mean MRSA CFUs (p<.001). Floor testing also showed reductions in mean CFUs for aerobic bacteria by 92% (p<.001); 96% for fungi (p<.001); 99% for MRSA (p<.001). Air testing showed reductions in mean CFUs for aerobic bacteria by 87% (p=.005); 36% for fungal (p=.005). The intervention facility observed a 94% reduction in resident COVID19 cases compared to the matched control facilities that increased 46% during the 2023 time period (Figure 1). Conclusion: This study is on the pioneering edge of demonstrating that continuous and persistent disinfection technology reduces contaminant reservoirs on surfaces, floors, and air and clearly decreases infectious aerosols and improves resident outcomes by dramatically reducing COVID19 transmission in LTC facilities.

Background: We know relatively little about how healthcare personnel (HCP) in long-term care facilities (LTCFs) integrate hand hygiene (HH) and personal protective equipment (PPE; e.g., gloves) use into their care processes. To address this gap, we are examining HH and PPE adherence at critical and contaminating moments in LTCFs. Methods: We conducted ethnographic observations of HCP’s processes of care in 2 LTCFs in Iowa to examine HH and PPE adherence during contaminating tasks in resident care sequences. We captured care observations and additional data on topics related to our study focus (e.g., unit/room layouts, PPE storage, facility policies/procedures) in field notes. We transcribed and imported fieldnotes into MAXQDA qualitative data management software and analyzed the data using a combined deductive-inductive coding approach. Results: Between 1/2023-7/2023, we observed 60 (30 per facility) care episodes. Most observations included toileting activities and perineal care during which HCP would be expected to use gloves and/or do HH. Most HCP appropriately donned/doffed gloves and practiced HH at key moments (e.g., before clean/aseptic procedures, after perineal care), but were less compliant before/after touching residents’ clothing or bare skin during these activities. In addition, some held soiled items next to their scrubs between tasks, which could contaminate their clothing and arms and could facilitate transmission of pathogens to other residents. Moreover, HCP’s interactions with floors emerged inductively as a topic of interest during our observations and preliminary analyses. We observed HCP interact with the floor during these activities in ways that could increase risk of pathogen transmission. HCP frequently dropped soiled towels or wipes used in perineal care onto the floor during tasks for later pick up. HCP also moved or placed trash bags containing soiled or contaminated items on the floor. HCP routinely knelt on, sat on, or touched their hands on the same floor when talking with residents, helping residents change clothes or diapers, changing bedding, or adjusting wheelchair footpads. In one case, the HCP picked up clean towels that fell to the floor near soiled towels and then used the “clean towels” in resident perineal care. Conclusion: Despite practicing HH and appropriate PPE use, HCP in LTCFs may increase the risk of pathogen transmission unintentionally through their interactions with soiled items and the environment, including floors. Given the nature of resident care in LTCFs, HCP in LTCF may be more likely than HCP in acute care settings to interact with contaminated floors.

Background: Infections due to antibiotic resistant bacteria are increasing worldwide and while, the epidemiology of these pathogens is well described in adults, pediatric specific data are lacking. We sought to gain an understanding of the risk factors for multi-drug resistant Gram-negative (MDRGN) infections in our pediatric population. Methods: We performed a retrospective review of pediatric patients seen at a pediatric hospital system in 2022 who had a culture-positive MDRGN, which was defined as a gram-negative bacteria resistant or intermediate to at least 1 antibiotic in ≥ 3 antibiotic groups. Repeat positive cultures for the same MDRGN were considered a single infection episode if occurring within a 14-day period. Demographic, clinical, and microbiologic data was obtained from the electronic medical record. Fisher’s exact was used for analysis. Results: One hundred and seventy-nine children had 237 infection episodes during the study period. Eighty-one patients (45%) were male and the median age was 5.3 years. The most prevalent MDRGNs included: Escherichia coli (154, 65%), Klebsiella spp (52, 22%), and Enterobacter spp (16, 7%). Escherichia coli was significantly more likely than other pathogens to be isolated from the urine (P = 0.008). Compared to multi-drug resistant E. coli, patients with a non-E. coli MDRGN were significantly more likely to have an underlying medical condition, recent hospitalization and antibiotic use (P≤0.001 for each, Table 1). A carbapenem was administered in 32% (75/237) of infection episodes. There were only 6 carbapenem resistant organisms. Conclusions: In our study, E. coli was the most frequent MDRGN. Most patients with a non-E. coli MDRGN infection episode had an underlying medical condition, recent hospitalization and antibiotic use. Carbapenem resistance was infrequent, though surveillance studies are needed to identify changing antibiotic resistance patterns and to direct prevention measures.

Background: In August 2023, an infection preventionist at an acute care hospital in Alabama recognized an increase in cases of Stenotrophomonas maltophilia, which is an emerging pathogen in clinical settings worldwide. It was not until the facility identified the pathogen in their water system in October that it was reported to ADPH as an outbreak. The outbreak investigation was brief due to the hospital’s rapid containment response and adherence to its established water management program (WMP). As a result of inappropriate antibiotic use in hospitals, pan-resistant strains have been increasing at an alarming rate. The pathogen can employ water used in hospital settings to cause a variety of nosocomial infections, including those found in the blood, respiratory tract, urinary tract, and on the skin. Hospitalized patients, especially those with immunocompromising conditions or implanted medical devices, are at increased risk of significant morbidity and mortality. The aim of this study was to better understand the clinical and demographic characteristics of the 13 case-patients identified during this investigation. Methods: A retrospective case series was conducted by reviewing medical records for case-patients with culture-confirmed S. maltophilia admitted between July and November. The CDC Healthcare-Associated Infection Outbreak Investigation Abstraction Form was used to systematically collect details about each case-patient’s hospitalization and course of illness. A Gantt chart was developed in Microsoft Excel to illustrate key events during their hospitalization. Results: Of the 13 case-patients, 69% were male and the median age was 69 years (range: 30 to 77). All S. maltophilia infections were hospital-acquired (>3 days after admission) with 92% being respiratory and 46% resistant to more than one class of antibiotics. All case-patients were admitted to the ICU and had known risk factors associated with developing S. maltophilia infection, including intubation (100%) and receiving antibiotic therapy prior to infection (77%). Other major risk factors included invasive surgery (77%), co-infections (77%), chronic respiratory disease (62%), hypertension (54%), and renal failure (31%). All were severely immunocompromised. Forty-six percent of the case-patients died from complications associated with their illness. Conclusion: This is the first S. maltophilia outbreak reported in Alabama. The findings of this case series underscored the importance of employing strict infection prevention measures to reduce poor health outcomes and how strong antibiotic stewardship programs are needed to limit transmission among vulnerable patient populations in these settings. It is recommended that hospitals conduct routine environmental sampling and have a WMP that is effective in limiting S. maltophilia.

Background: The Colorado Department of Public Health and Environment (CDPHE) detected an increase in Klebsiella pneumoniae carbapenemase-producing carbapenem-resistant Enterobacterales (KPC-CRE) infections in October 2022. We investigated patient epidemiological links and isolate relatedness to characterize interfacility transmission of KPC-CRE in the Denver metro area and inform regional prevention strategies. Methods: We defined a case as polymerase chain reaction detection of KPC from clinical or screening specimens collected during January 2022 – January 2023. Cases were identified through statewide CRE surveillance and carbapenemase testing at the CDPHE laboratory and counted once within a 30-day period. Medical records were reviewed to identify healthcare facility admissions and patient facility overlap in the 12 months prior to sample collection. Whole genome sequencing (WGS) was performed for 34 patients with available KPC-CRE isolates using short- and long-read sequencing techniques. We performed multi-locus sequence typing, generated genome phylogenetic trees, and compared plasmid contig sequences to identify relatedness between KPC-CRE isolates. Clusters were defined as ≥2 genetically related isolates of the same organism or carbapenemase plasmid, from different patients. Results: We identified 48 cases (34 clinical and 14 screening) among 39 patients (figure). Patients had a mean age of 52 years (range 16-86) and median of three healthcare facility admissions (range 1-14). Twenty-eight patients (72%) were male. We identified 16 (41%) patients with epidemiological links to one acute care hospital (ACH), 11 (28.2%) patients to one long-term acute care hospital (LTACH), and four (10.2%) patients to each of two ventilator-capable skilled nursing facilities (vSNF). Five distinct clusters of KPC-CRE were identified by WGS among 23 patients (E. hormaechei, two distinct E. cloacae clusters, K. pneumoniae, and K. oxytoca) with linkages to ten healthcare facilities, including two vSNFs, two LTACHs, and six ACHs. Three distinct KPC genes were identified among the clusters: KPC-2, KPC-3, and KPC-4. Genomes assembled from long reads identified identical or similar KPC-gene-containing plasmids across different species or sequence types, suggesting horizontal gene transfer of KPC. Conclusions: Multiple KPC-CRE strains co-circulated and were associated with patient movement between acute and post-acute care settings. WGS allowed us to identify multi-facility clusters. Time and location of carbapenemase acquisition were challenging to determine for genetically related isolates when epidemiologic links could not be determined from medical records. This could be due to undetected cases. We notified healthcare facilities of their shared transmission risk and advocated for improved attention to infection control, carbapenemase screening, and communication upon patient transfer.

Background: Stenotrophomonas maltophilia (SM) is a non-fermenting, Gram-negative bacillus. Its intrinsic resistance to many beta-lactams makes for challenging treatment decisions. A preprint of the latest Infectious Diseases Society of America (IDSA) guidance on managing SM infections was published in December 2022 providing a recommendation for combination therapy including trimethoprim/sulfamethoxazole (TMP/SMX) and a second agent. An evaluation of the impact on SM treatment practices following this guidance was conducted at our institution. Methods: A list of 130 patients with non-urine SM cultures from December 2021-August 2023 was generated using a pharmacovigilance platform. Patients were excluded if on comfort measures or discharged to hospice prior to therapy completion, no directed antibiotics were given, or any history of prior SM infection. Twenty-five patients were randomly selected from the pre- and post-guidance periods (before and one month after December 1, 2022) for a total of 50 patients. Data was collected via manual chart review. The primary endpoint was frequency of combination antibiotic therapy in each time period. Secondary endpoints included treatment success (defined as resolution of infection symptoms and lack of infection recurrence), in-hospital mortality, 30-day mortality, and 30-day infection recurrence. Results: Overall, baseline characteristics were similar between groups, the median age was 65 years, 64% of patients were male, 20% were immunocompromised based on prespecified criteria, the median Charlson comorbidity index was 5 (21% estimated 10-Year survival), and 76% of SM cultures were pulmonary isolates. Displayed in figure 1, combination therapy was given in 6 of 25 cases (24%) in the post-guidance group and zero patients in the pre-guidance group. Secondary endpoints of treatment success and all-cause mortality were similar between groups. Duration of therapy was similar between combination and non-combination therapy regimens (median 9 vs 10 days). Among patients who received combination therapy, all had ID consultation, 4 (66.7%) were admitted to the ICU, and 2 (33.3%) had treatment success. Conclusions: Patients treated for SM infection at our institution in the post-IDSA guidance period were more likely to receive combination therapy. A higher rate of treatment success was not observed in the post-IDSA guidance arm for SM infections. Limitations of this study include its small sample size and retrospective design, leading to inability to distinguish colonization from true infection. Additional studies are needed to evaluate the impact of combination antibiotic therapy on outcomes.

Background: Early identification of patients colonized with MDROs can help healthcare facilities improve infection control and treatment. We evaluated whether a model previously validated to predict carbapenem-resistant Enterobacterales (CRE) carriage on hospital admission (area under the curve [AUC]=0.86, Lin et al. OFID 2019) would generalize to predict a patient’s likelihood of CRE and non-CRE MDRO colonization at the time of medical intensive care unit (MICU) admission. Methods: We analyzed data collected previously in a retrospective observational cohort study of patients admitted to Rush University Medical Center’s MICU from 1/2017-1/2018 and screened within the first two days for rectal MDRO colonization. Organisms of interest included CRE, carbapenem-resistant Pseudomonas aeruginosa (CRPA), vancomycin-resistant enterococci (VRE), and third-generation cephalosporin-resistant Enterobacterales (3GCR-E). Methicillin-resistant Staphylococcus aureus (MRSA) nasal colonization at admission was determined by routine clinical screening. Each patient’s first MICU admission during the study period was linked to Illinois’ hospital discharge database and assigned a CRE colonization risk probability using the existing model. Model covariates were age, and during the prior 365 days, number of short-term acute care hospitalizations (STACH) and mean STACH length of stay, number of long-term acute care hospitalizations (LTACH) and mean LTACH length of stay, prior hospital admission with an ICD-10 diagnosis code indicating bacterial infection, and current admission to LTACH. Predictive value of the model was evaluated by receiver operating characteristic (ROC) curves. Results: We analyzed 1237 MICU admissions. MDRO admission prevalence is shown in the Table. The model performed well to predict carriage of healthcare-associated MDROs, including CRE, CRPA, composite CR-MDROs (CRE & CRPA), and VRE. However, the model performed poorly for MDROs with known community reservoirs, including 3GCR-E and MRSA (Table). In general, MDRO admission prevalence increased in parallel with predicted CRE colonization risk (Figure). The number needed to screen (NNS) to detect one healthcare-associated MDRO carrier was inversely related to the CRE colonization risk score. For example, NNS in the total cohort compared to those with CRE risk score of >0.5% was: CRE 111 vs 32 patients, CRPA 333 vs 42 patients, composite CR-MDRO 83 vs 18 patients, and VRE 12 vs 4 patients. However, higher CRE risk score cutoff was inversely related to screening sensitivity. Conclusion: A prediction model using prior healthcare exposure information successfully discriminated patients likely to harbor healthcare-associated MDROs upon MICU admission. Prediction scores generated by a public-health accessible database could be used to target screening/isolation or enact protective measures for high-risk patients.

Background: Taurolidine exhibits broad antimicrobial activity and is a component of a recently FDA approved catheter lock solution (DefenCath®, taurolidine 13,500 μg/mL and heparin 1000 Units/mL) indicated for reducing the risk of catheter-related bloodstream infections (CRBSI) in adult patients receiving chronic hemodialysis through a central venous catheter (HD-CVC). FDA approval was based on a Phase 3 randomized trial (LOCK-IT-100) in which DefenCath showed a 71% reduction in CRBSI risk among HD-CVC patients as compared with heparin alone. Although individual isolates from the clinical program were not available for testing, this study evaluated the in vitro antimicrobial activity of taurolidine against a set of recent clinical isolates representative of those recovered from the LOCK-IT-100 trial and/or those commonly associated with CRBSI. Methods: 420 bacterial and 50 yeast isolates were selected from the SENTRY Antimicrobial Surveillance Program. All isolates were collected from the bloodstream of patients in the U.S. between 2018-2023. Isolates were tested for susceptibility to taurolidine and comparators using Clinical and Laboratory Standards Institute (CLSI) broth microdilution guidelines. JMI Laboratories produced susceptibility test panels for testing. CLSI-recommended quality control strains were also tested concurrently. MIC values were determined after 24 hours. Results: Taurolidine exhibited broad antimicrobial activity against all isolates tested (see table). Against gram-positive bacteria, taurolidine MIC50/90 values ranged from 256-512/512-1,024 μg/mL for S. aureus, Coagulase-negative Staphylococcus, Enterococcus species, and Viridans group streptococci. This activity was maintained regardless of methicillin susceptibility for Staphylococcal isolates or vancomycin resistance among Enterococcal species. Against gram-negative bacteria, taurolidine MIC50/90 values ranged from 256-1,024/512-2,048 μg/mL for Enterobacterales, P. aeruginosa, S. maltophilia, A. baumannii-calcoaceticus, and B. cepacia. This activity was maintained in both multidrug resistant Enterobacterales and P. aeruginosa isolates. Among Candida isolates, taurolidine MIC50/90 values ranged from 256-512/512 μg/mL for C. glabrata and C. parapsilosis while taurolidine MIC50/90 values of 4,096/4,096 μg/mL were observed for C. albicans. Conclusions: Taurolidine activity was very similar among a large collection of gram-positive, gram-negative, and yeast organisms. MIC90 values for all species/groups were ≤2,048 μg/mL, except C. albicans where an MIC90 of 4,096 μg/mL was observed. The activity of taurolidine was unaffected by resistance to antibiotics (i.e. methicillin, vancomycin, or multi-drug resistance) among gram-positive or gram-negative organisms. Based on these data, catheter lock solutions containing the broad-spectrum antimicrobial taurolidine at 13,500 μg/mL have the potential to prevent CRBSI caused by a variety of species, including those observed in the recent LOCK-IT-100 clinical trial and other common bloodstream pathogens

Background: Candida auris is often identified in healthcare settings through bilateral composite of axilla/groin skin swabs screening. Re-screening the same patient has demonstrated inconsistent results over time, complicating the understanding of longitudinal colonization and limiting confidence in negative Results: Previous studies have described identification of colonized patients using other anatomical sites. Here, we compare bilateral composite of nares/hands with bilateral composite of axilla/groin screenings in a cohort of hospitalized patients in Miami, Florida, to assess the use of screening other body sites for C. auris surveillance. Methods: This study took place in a 560-bed academic acute-care facility and included patients previously colonized with C. auris who were cohorted on a 30-bed unit. Bilateral composite samples from both the axilla/groin and nares/hands were obtained simultaneously. Swabs were collected at six different time points at biweekly intervals between March and May 2023 (Figure 1) and sent to the Centers for Disease Control and Prevention for testing with culture and Real-time PCR-based methods. Results: A total of 102 swabs (51 from each swab type) were collected from 19 patients who were each sampled a median of twice (IQR: 1-5). Among the 102 swabs, 35 of 51 (69%) axilla/groin swabs were positive compared with 45 of 51 (88%) nares/hands swabs using culture (Figure 2). Furthermore, 48 of 51 (94%) swabs were positive by culture for both methods, with 15 positive from the nares/hands and one positive from the axilla/groin (Figure 3). Among 11 patients who were tested ≥2 times with nares/hands swabs, 9/11 (81%) tested positive on all sequential swabs via culture and 10/11 (90%) tested positive via PCR (Ct threshold < 3 6.9). Among the same 11 patients but using the axilla/groin swabs, 3/11 (27%) patients tested positive on all sequential swabs using culture, and 5/11 (45%) tested positive using PCR (Figures 2-4). On average, samples collected from nares/hands swabs had lower Ct values (mean=27) compared to axilla/groin swabs (mean=31) (p-value=< 0.001) (Figure 5). Discussion: Identifying the swab site with most consistent C. auris detection is important for surveillance purposes. In our study, there were more positives and consistent positivity for nares/hands by both culture and PCR-based methods, as well as lower Ct values, suggesting that these swabs provide more reliable detection of C. auris colonization. Alternative screening methods deserve consideration as CDC continues to explore whether swabbing of other body sites (e.g., nares, hands) would improve accuracy and consistency when identifying colonized patients.

Background: Detection of outbreaks traditionally relies on passive surveillance, and often misidentify or miss outbreaks. Whole genome sequencing (WGS) surveillance has emerged as a proactive measure, enabling early detection of outbreaks and facilitating rapid intervention strategies. WGS surveillance has not been widely studied due to infrastructure, cost, and evidence barriers regarding its impact on reducing healthcare-associated infections (HAIs). This study represents findings from two years of a real-time WGS surveillance program called the Enhanced Detection System for Healthcare-associated Transmission (EDS-HAT). Methods: The study was conducted at UPMC Presbyterian hospital, a 694-bed tertiary care center. Patient isolates of select bacterial pathogens were collected and underwent WGS weekly from November 2021 to November 2023. Potential transmission was defined using single-nucleotide polymorphism thresholds (≤15 for all organisms except Clostridioides difficile). Genetically related clusters were reviewed weekly for epidemiological linkages (unit, personnel, or procedural commonalities) and appropriate interventions were initiated by the infection prevention and control team. We described the frequency of genetic relatedness and nature of epidemiological linkages. Results: Of 7,051 eligible unique patient organism isolates, 4,723 were deemed healthcare-associated and underwent WGS. EDS-HAT identified 478 (12.2%) isolates genetically related to ≥1 other isolate across 173 clusters. Epidemiological links were found in 278 (58.2%) isolates in 114 clusters, with the majority being unit-based (205 isolates, 71.9%); other epidemiological links included equipment or healthcare workers (32 isolates, 11.5%), external facilities (24 isolates, 8.6%), and shared endoscopes (17 isolates, 6.1%); all endoscope outbreaks were effectively contained at two patients. No epidemiological links could be identified for 200 (41.8%) isolates. Infection prevention initiated 134 interventions in 114 clusters, including 74 (55.2%) general staff notification and education, 25 (18.7%) enhanced cleaning efforts, 23 (17.2%) hand hygiene/personal-protective equipment compliance observations, 9 (6.7%) environmental cultures, and 3 (2.2%) enhanced microbiological surveillance. Following the detection of an epidemiological link and intervention, 94/101 (94.1%) outbreaks were effectively halted on the intervened route (Figure). Conclusion: This study demonstrates the feasibility and efficacy of EDS-HAT as an infection prevention tool. Early detection and intervention of outbreaks significantly enhance the capability of healthcare facilities to control and prevent the spread of HAIs. Investment in infrastructure and implementation costs will result in reducing pathogen transmission and improving patient safety in acute care settings.

Disclosure: Alexander Sundermann: Honoraria - Opgen

Background: Methicillin-resistant Staphylococcus aureus (MRSA) is one of the most common causes of procedure-related, skin, and soft-tissue infections. Hospitalized patients who are colonized with MRSA are at a higher risk of developing invasive infections after discharge. Chlorhexidine, an antiseptic/disinfectant, has been used to reduce carriage and prevent infections in these patients. Studies have shown chlorhexidine resistance among MRSA strains. Chlorhexidine resistance is associated with qac genes, which encode multidrug efflux pumps that increase bacterial tolerance to disinfectant agents. The global distribution and prevalence of qacA and qacB genes are highly variable. One study reported that qacA and qacB genes could be found in 0.9% - 83.3% of clinical MRSA isolates worldwide. The goal of this study was to determine the prevalence of chlorhexidine resistance and identify the resistance-associated genes from our MRSA samples using whole genome sequencing (WGS). Methods: 474 MRSA samples were obtained from hospitals in Detroit, MI (287) and Cleveland, OH (187). Whole genome sequencing was performed using the NextSeq (Illumina Inc., CA) platform. The sequencing data was analyzed using ResFinder 4.1, a publicly available database that can be used to identify acquired genes and chromosomal mutations mediating antimicrobial resistance. The output was organized into a data sheet to visualize the presence of the genes of interest. Results: The qacA gene was present in only one MRSA sample from the Cleveland area hospital. In the samples from Detroit, 14 out of 287 showed disinfectant resistance genes. The qacA, qacB, and qacD were present in 1, 6, and 7 samples, respectively. The prevalence of any qac gene in the Cleveland area samples was 0.5%. Meanwhile, the prevalence of any qac gene in Detroit area samples was 4.9%. Among the 7 samples that have qacD gene, 6 samples have more than one copy of qacD. Conclusions: The prevalence of the “qac” gene varied widely based on the origin of the samples. Detroit area samples had more qac genes prevalence than Cleveland area samples. Chlorhexidine is a widely used antiseptic/disinfectant, and it plays a vital role in reducing carriage and preventing infection among hospitalized patients colonized with MRSA. Monitoring and addressing MRSA-reduced susceptibility to chlorhexidine is imperative for maintaining the effectiveness of infection control practices such as decolonization.

Background: Most healthcare facilities in the US apply contact precautions (CP) for patients with methicillin-resistant Staphylococcus aureus (MRSA) or vancomycin-resistant enterococci (VRE) infection and/or colonization. Most individuals with MRSA or VRE colonization will clear over time; however, frontline clinicians rarely evaluate for discontinuation of CP, resulting in increased burden on infection preventionists (IPs). Automation of time- and test-based evaluation using clinical decision support systems (CDSS) embedded in electronic health records (EHR) may increase evaluation and discontinuation of CP when appropriate, while preserving IP resources. Methods: This quality improvement initiative was implemented at Mass General Brigham (MGB), an integrated healthcare system, where patients with MRSA or VRE infection/colonization are identified in the EHR with a corresponding “infection status” and CP applied. Following MGB policy (Figure 1), CDSS features included: 1) automated time-based resolution from 2/15/2023-11/13/2023 and 2) automated ordering of screening assays for patients eligible for test-based evaluation from 6/20/2023-11/14/2023 (Figure 2). Counts of CP discontinuation and automated ordering were performed. IPs at one MGB facility performing manual review of patients self-recorded the time spent evaluating for CP discontinuation. Using these time reports, the average time to complete these tasks and the projected time savings were calculated over the implementation period. Results: Four IPs recorded the time to review patients for CP discontinuation, including reviewing recent antimicrobial administration, microbiology results, ordering screening test(s), and contacting the primary team. Twenty-five patient encounters were timed with a mean of 4.7 minutes documented per encounter. Over a 9-month period after initiation of the automated time-based resolution, the monthly mean number of patients with CP for MRSA and VRE which were automatically discontinued was 247 and 100, respectively. Projected IP time savings over the same 9-month period for MRSA and VRE were 174.1 and 70.5 hours, respectively. Over a 5-month period after initiation of automated ordering of MRSA polymerase chain reaction (PCR)/culture, as well as VRE culture for test-based evaluation, the monthly mean number of MRSA culture, MRSA PCR, and VRE culture automatically ordered for patients on CP for MRSA and VRE were 176, 24, and 145, respectively. Projected IP time savings over the same 5-month period for MRSA and VRE were 78.3 and 56.8 hours, respectively.

Conclusion: Healthcare systems that enhance their EHR with CDSS to automate CP evaluations may improve frontline clinician workflow, patient flow and bed capacity, while optimizing use of IP resources.

Background: Methicillin-resistant Staphylococcus aureus (MRSA) is a common pathogen responsible for nosocomial and community-acquired infections with high morbidity and mortality1. MRSA nasal colonization is a major risk factor for developing infection in the hospital setting2,3. Decolonization of MRSA carriers is a strategy to decrease recurrence or to prevent new MRSA infections3,4. Decolonization with nasal mupirocin 2% and chlorhexidine baths has been shown to decrease the risk of MRSA infection after hospital discharge3. Mupirocin is an RNA synthetase inhibitor with activity against MRSA5. Resistance of MRSA isolates to mupirocin has been described previously6. As topical disinfectants play a crucial role in prevention of MRSA infection in a variety of settings, it is important to monitor the emergence of resistance. The goal of this study was to determine the prevalence of mupirocin resistance among MRSA samples isolated from two different regions in the United States (U.S). Methods: Our study had a total of 474 MRSA samples that were obtained from hospitals in Detroit, MI (287 samples) and Cleveland, OH (187 samples). After whole genome sequencing using NextSeq (Illumina Inc., CA) platform the data was analyzed using ResFinder 4.1, to identify antimicrobial resistance which can be either acquired or chromosomally mediated mutations. To visualize the presence of genes of interest the resistance genes were tallied on a spread sheet. Results: Mupirocin resistance gene was detected in five of 287 (1.74%) MRSA samples from the Detroit hospitals, all of which were associated with the mupA gene. Samples collected from the Cleveland area hospital demonstrated mupirocin resistance in seven samples of 187 (3.74%), all associated again with the mupA gene. One sample from the Detroit group showed resistance to both mupirocin and chlorhexidine. Conclusions: Prevalence of mupirocin resistance gene varied between the two hospital locations. Resistance to mupirocin has been documented in association with mutations in the mupA gene as well as chromosomal point mutations that can lead to either low or high-level resistance7,8. Although the mechanisms are not fully clear, mupA gene has been associated with high-level resistance9. Mupirocin resistance among MRSA isolates has increased over time9. MRSA infections remain an important etiology of nosocomial and community-acquired infections and common practice to combat this issue is universal decolonization with mupirocin10. It is critical to understand and monitor for development of mupirocin resistance as mupirocin remains one of the most effective tools to prevent invasive infection with MRSA in many patient populations.

Background: Invasive Staphylococcus aureus infections cause significant morbidity and mortality in neonatal intensive care unit (NICU) infants.1 Colonization (asymptomatic carriage in the nose, skin, or gut) is a risk factor for subsequent invasive infection (e.g., pneumonia, bone infections, bloodstream infections, etc.). Active surveillance and decolonization measures for S. aureus-colonized infants have been associated with decreased invasive infection rates. 2-4 Methods: A methicillin-resistant S. aureus (MRSA) surveillance and decolonization program, consisting of admission and weekly MRSA nasal cultures followed by intranasal mupirocin plus chlorhexidine baths for colonized infants, was implemented in our level IV NICU with 150 beds in 2006.5 Due to poor compliance with decolonization protocols5, existing practices were reviewed and multiple interventions to increase compliance were implemented in 2018. These renewed efforts included revision of the existing MRSA decolonization protocol, updating the associated electronic medical record order set, re-education of unit staff, and weekly review by the Infection Prevention (IP) and NICU leadership teams to ensure the decolonization protocol was followed for newly colonized infants. Mean MRSA bloodstream infection (BSI) rates were calculated quarterly pre- (January 2014-December 2017) and post- (January 2018-December 2023) implementation of renewed efforts and compared via unpaired t-test. In July 2020 a similar methicillin-susceptible S. aureus (MSSA) surveillance and decolonization program was implemented with an associated revision of existing documents, education campaign, and weekly review of infants with new MSSA colonization. Mean MSSA BSI rates pre- (July 2018-June 2020) and post- (July 2020-December 2023) implementation were compared via unpaired t-test. Results: Renewed implementation of MRSA surveillance and decolonization was associated with a sustained decrease in the mean MRSA BSI rate (Figure 1): 0.10 per 1000 patient-days pre-implementation, 0.03 post-implementation (p=0.02). Following implementation of MSSA surveillance and decolonization, there was no statistically significant change in the mean MSSA BSI rate (Figure 2): 0.20 per 1000 patient-days pre-implementation, 0.15 post-implementation (p=0.32). Conclusions: Implementation of a robust MRSA surveillance and decolonization program in the NICU was associated with a sustained decrease in invasive MRSA infections. No change in invasive MSSA infection rates was observed following implementation of a similar protocol for MSSA. Additional research is needed to better understand the role of MSSA surveillance and decolonization in the NICU.

References: 1. Ericson, J.E., et al., JAMA Pediatr, 2015. 2. Popoola, V.O., et al., ICHE, 2016. 3. Kotloff, K.L., et al., Pediatrics, 2019. 4. Voskertchian, A., et al., ICHE, 2018. 5. Reich, P.J., et al. Clin Microbiol Infect, 2016.

Background: Whole genome sequencing (WGS) is a relatively new method for analyzing outbreaks and modes of transmission, particularly for multidrug resistant bacteria. This study sought to investigate clusters of patients with genetically related Vancomycin-Resistant Enterococcus spp. (VRE) bacteremia for shared hospital environmental exposures. Methods: All VRE blood culture isolates from patients from July 1, 2021 to June 30, 2022 underwent Illumina WGS. Core single nucleotide polymorphisms (SNPs) were identified, and multi-locus sequence typing (MLST) was performed across the VRE isolates. Clusters were defined as isolates with 15 or fewer core genome SNPs and were investigated for potential transmission routes. For each cluster, patients were evaluated in the 12 weeks before and after the first VRE isolate for shared hospital environmental exposures (hospital unit, patient rooms, procedural rooms, and radiology suites). Hospital units were comprised of patient rooms located geographically together on the same floor of the hospital. Results: A total of 82 VRE isolates underwent WGS. Thirty-eight (46%) clustered genetically with at least one other isolate. Clusters included 2 to 15 patients per group and represented 10 distinct MLST subgroups (Figure 1). Nine hundred and thirty-nine hospital environmental exposures were identified across the 38 patients. For each cluster, there was a total of 341 (36.3%) shared exposures. Shared environmental exposures occurred in radiology suites (35, 38.5%), patient rooms (32, 35.6%) and procedural rooms (23, 25.6%). Of the patients who shared the same hospital unit, 10 (31.3%) had the same patient room with 7 (70%) of them being in the emergency department (ED). Overall, the ED represented 7 (21.9%) of the shared hospital units. Each cluster had at least one shared hospital environmental exposure found. Conclusions: Use of WGS can help investigate outbreak clusters of resistant organisms such as VRE. In this study, nearly half of all VRE blood isolates were able to be segregated into clusters with at least one other isolate. Although VRE colonization of hospital rooms is well described, patient rooms represented the smallest proportion of shared hospital environmental exposures. This study thus suggests other environmental transmission routes such as radiology suites and procedural rooms warrant closer investigation.

Background: Nursing homes (NHs) have high prevalence of multi-drug resistant organisms (MDROs) with rates exceeding those in hospitals. This study proposes quantifying patients’ risk of MDRO colonization and creating a risk profile for the NH patient populations to assist in reducing MDRO burden in health care facilities. Methods: We assessed a risk classification model using data from a prospective cohort study (2018 Pathways study). Patient sample included 783 newly admitted patients followed for up to 180 days and 9,587 samples collected from patients during 2,089 visits. Individual risk factors of MDRO colonization were assessed using unadjusted logistic regression, and patients were risk classified based on number of risk factors. Multivariate regression was performed to obtain odds of MDRO colonization for patient risk groups adjusting for patient age, sex, race, and length of NH stay (LOS). The risk classification tool developed using Pathways data was also tested among a sample of NH residents from Veterans Administration (N=190). Results: The patient sample (Pathways data) was 43.2% male, 37.2% Black with a mean age 74 years. 69.3% were colonized with a MDRO during the study. In unadjusted regression, recent antibiotic use (p<.001), open wounds (p<.05), use of urinary catheter or feeding tube (p<.001), functional disability (p<.001), diabetes (p<.01), and preadmission hospital stay over 14 days (p<.001) were associated with colonization, while Charlson comorbidity score, age, sex, and race were not. In adjusted analysis (c-statistic=0.75), a patient’s colonization risk increased with the number of risk factors (Figure 1), with 47.2% expected colonization among patients with none of the risk factors and 86.7% expected colonization among patients with four or more risk factors. The risk classification model had similar performance among male and female patients, and among Black and White patients (Figure 2). Secondary analysis using data obtained from separate, Veterans Administration facilities provided preliminary validation of the risk scoring tool. The model had acceptable fit (c-statistic=0.71). Veterans with four or more risk factors had 87.8% expected probability of MDRO colonization compared with 39.6% colonization among those without any risk factors. Veterans with less than four risk factors also had higher colonization, but these differences were not statistically significant. Conclusions. Despite system-wide efforts to reduce MDRO burden, prevalence of MDRO colonization remains high in NHs. The risk classification tool can assist in early identification of most vulnerable NH patients to direct targeted interventions such as education, enhanced environmental cleaning, and active surveillance.

Disclosure: Lona Mody: NIH, VA, CDC, Kahn Foundation; Honoraria: UpToDate; Contracted Research: Nano-Vibronix