Background: We evaluated the impact of a comprehensive SARS-CoV-2 (COVID-19) infection prevention (IP) bundle on rates of non–COVID-19 healthcare-acquired respiratory viral infection (HA-RVI). Methods: We performed a retrospective analysis of prospectively collected respiratory viral data using an infection prevention database from April 2017 to January 2021. We defined HA-RVI as identification of a respiratory virus via nasal or nasopharyngeal swabs collected on or after hospital day 7 for COVID-19 and non–COVID-19 RVI. We compared incident rate ratios (IRRs) of HA-RVI for each of the 3 years (April 2017 to March 2020) prior to and 10 months (April 2020 to January 2021) following full implementation of a comprehensive COVID-19 IP bundle at Duke University Health System. The COVID-19 IP bundle consists of the following elements: universal masking; eye protection; employee, patient, and visitor symptom screening; contact tracing; admission and preprocedure testing; visitor restrictions; discouraging presenteeism; population density control and/or physical distancing; and ongoing attention to basic horizontal IP strategies including hand hygiene, PPE compliance, and environmental cleaning. Results: During the study period, we identified 715 HA-RVIs over 1,899,700 inpatient days, for an overall incidence rate of 0.38 HA-RVI per 1,000 inpatient days. The HA-RVI IRR was significantly higher during each of the 3 years prior to implementing the COVID-19 IP bundle (Table 1). The incidence rate of HA-RVI decreased by 60% after bundle implementation. COVID-19 became the dominant HA-RVI, and no cases of HA-influenza occurred in the postimplementation period (Figure 1). Conclusions: Implementation of a comprehensive COVID-19 IP bundle likely contributed to a reduction in HA-RVI for hospitalized patients in our healthcare system. Augmenting traditional IP interventions in place during the annual respiratory virus season may be a future strategy to reduce rates of HA-RVI for inpatients.

Table 1.

Figure 1.

Background: Nursing home (NH) residents and staff were at high risk for COVID-19 early in the pandemic; several studies estimated seroprevalence of infection in NH staff to be 3-fold higher among CNAs and nurses compared to other staff. Risk mitigation added in Fall 2020 included systematic testing of residents and staff (and furlough if positive) to reduce transmission risk. We estimated risks for SARS-CoV-2 infection among NH staff during the first winter surge before widespread vaccination. Methods: Between February and May 2021, voluntary serologic testing was performed on NH staff who were seronegative for SARS-CoV-2 in late Fall 2020 (during a previous serology study at 14 Georgia NHs). An exposure assessment at the second time point covered prior 3 months of job activities, community exposures, and self-reported COVID-19 vaccination, including very recent vaccination (≤4 weeks). Risk factors for seroconversion were estimated by job type using multivariable logistic regression, accounting for interval community-incidence and interval change in resident infections per bed. Results: Among 203 eligible staff, 72 (35.5%) had evidence of interval seroconversion (Fig. 1). Among 80 unvaccinated staff, interval infection was significantly higher among CNAs and nurses (aOR, 4.9; 95% CI, 1.4–20.7) than other staff, after adjusting for race and interval community incidence and facility infections. This risk persisted but was attenuated when utilizing the full study cohort including those with very recent vaccination (aOR, 1.8; 95% CI, 0.9–3.7). Conclusions: Midway through the first year of the pandemic, NH staff with close or common resident contact continued to be at increased risk for infection despite enhanced infection prevention efforts. Mitigation strategies, prior to vaccination, did not eliminate occupational risk for infection. Vaccine utilization is critical to eliminate occupational risk among frontline healthcare providers.

Funding: None

Disclosures: None

Background: The use of antibiotics and the occurrence of antimicrobial resistance in Bangladesh are very high. Inappropriate use of antibiotics among hospitalized children has contributed to a high rise in antimicrobial resistance in Bangladesh. Data on the rational use of antibiotics in Bangladeshi hospitals are limited. This study documented current antimicrobial usage among children under five in selected tertiary hospitals in Bangladesh. Methods: From August to September 2022, we conducted a point prevalence survey in four tertiary hospitals in Bangladesh. We used the World Health Organization’s Point Prevalence Survey (PPS) methods and guidelines to conduct the study. Study participants were hospitalized under the age of five years children, and we collected information from the pediatric and neonatal wards of each hospital. Antibiotic-suggesting shapes were analyzed according to WHO AWaRe metrics and Anatomical Therapeutic Chemical (ATC) Classification. Results: The assessment included 189 children under the age of five, with the majority (78.8%, 149/189) being under one year children. Approximately three-fourths (75.1%) of children had peripheral vascular catheters following admission. Overall, 86.2% (163/189) of children were given antibiotics after being admitted to the hospital, with infants receiving the most (81.0%, 132/163). The majority of antibiotics were administered by parents (84.7%). Antibiotics from the Watch Group were most commonly prescribed (73.0%, 119/163), followed by a combination of the Watch and Access Groups (23.3%) to treat the children. Ceftriaxone (63.8%), Meropenem (16.0%), and Ceftazidime/Amikacin (8.0%) were the most regularly prescribed antibiotics. Young children (< 1 year) were more likely to get antibiotics (AOR: 3.54, p-value: 0.003) than the other children under the age of five. Conclusion: The data showed that most children received empirical antibiotics during hospitalization, and overuse of broad-spectrum Watch group antibiotics was common practice in hospital settings. Developing and implementing antibiotic use guidelines is critical to limit the inappropriate use of antibiotics for young children

We conducted a retrospective review of a hybrid antimicrobial restriction process demonstrating adherence to appropriate use criteria in 72% of provisional-only orders, in 100% of provisional orders followed by ID orders, and in 97% of ID-initiated orders. Therapy interruptions occurred in 24% of provisional orders followed by ID orders.

Group Name: The Emory COVID-19 Quality and Clinical Research Collaborative

Background: Patients hospitalized with COVID-19 are at risk of secondary infections—10%–33% develop bacterial pneumonia and 2%–6% develop bloodstream infection (BSI). We conducted a retrospective cohort study to identify the prevalence, microbiology, and outcomes of secondary pneumonias and BSIs in patients hospitalized with COVID-19. Methods: Patients aged ≥18 years with a positive SARS-CoV-2 real-time polymerase chain reaction assay admitted to 4 academic hospitals in Atlanta, Georgia, between February 15 and May 16, 2020, were included. We extracted electronic medical record data through June 16, 2020. Microbiology tests were performed according to standard protocols. Possible ventilator-associated pneumonia (PVAP) was defined according to Centers for Disease Control and Prevention (CDC) criteria. We assessed in-hospital mortality, comparing patients with and without infections using the χ2 test. SAS University Edition software was used for data analyses. Results: In total, 774 patients were included (median age, 62 years; 49.7% female; 66.6% black). In total, 335 patients (43.3%) required intensive care unit (ICU) admission, 238 (30.7%) required mechanical ventilation, and 120 (15.5%) died. Among 238 intubated patients, 65 (27.3%) had a positive respiratory culture, including 15 with multiple potential pathogens, for a total of 84 potential pathogens. The most common organisms were Staphylococcus aureus (29 of 84; 34.5%), Pseudomonas aeruginosa (16 of 84; 19.0%), and Klebsiella spp (14 of 84; 16.7%). Mortality did not differ between intubated patients with and without a positive respiratory culture (41.5% vs 35.3%; P = .37). Also, 5 patients (2.1%) had a CDC-defined PVAP (1.7 PVAPs per 1,000 ventilator days); none of them died. Among 536 (69.3%) nonintubated patients, 2 (0.4%) had a positive Legionella urine antigen and 1 had a positive respiratory culture (for S. aureus). Of 774 patients, 36 (4.7%) had BSI, including 5 with polymicrobial BSI (42 isolates total). Most BSIs (24 of 36; 66.7%) had ICU onset. The most common organisms were S. aureus (7 of 42; 16.7%), Candida spp (7 of 42; 16.7%), and coagulase-negative staphylococci (5 of 42; 11.9%); 12 (28.6%) were gram-negative. The most common source was central-line–associated BSI (17 of 36; 47.2%), followed by skin (6 of 36; 16.7%), lungs (5 of 36; 13.9%), and urine (4 of 36; 11.1%). Mortality was 50% in patients with BSI versus 13.8% without (p < 0.0001). Conclusions: In a large cohort of patients hospitalized with COVID-19, secondary infections were rare: 2% bacterial pneumonia and 5% BSI. The risk factors for these infections (intubation and central lines, respectively) and causative pathogens reflect healthcare delivery and not a COVID-19–specific effect. Clinicians should adhere to standard best practices for preventing and empirically treating secondary infections in patients hospitalized with COVID-19.

Funding: No

Disclosures: None

Background: In the last 2 years of the COVID-19 pandemic, Singapore has been forced to explore alternative sites to quarantine persons or manage infected cases during surge periods in a national effort not to overwhelm the public healthcare facilities. External quarantine facilities were created at the EXPO and further extended to D’Resort and other hotels in May 2020. Infection prevention (IP) practices were implemented at these external facilities, where training non–healthcare staff to quickly learn and understand these required practices has been challenging. A team of staff from different clinical disciplines was formed to manage the COVID-19 patients at these facilities. The Infection Prevention and Epidemiology (IPE) department was invited to train all staff, including the clinical team, management agency, and security staff, regarding IP measures. We have described the system and approach used in the rapid training of all staff in IP measures where the goal is zero transmission while providing care to COVID-19 patients. Methods: Training materials were developed to facilitate rapid learning by all staff; medical jargon was avoided. Curriculum included precautions to be taken while performing terminal cleaning of patient rooms, serving meals, disinfecting phones and thermometers, as well as donning and doffing personal protective equipment (PPE). “Green” and “red” zones were created to assist staff in remembering appropriate PPE to be used. PPE training was provided using slides and video. Posters were created as a guide for staff at donning and doffing stations. Additionally, the IPE training team utilized an online data collection tool to capture staff completion on IP training and PPE competency for record keeping. We used a ‘soft’ approach because staff members were fearful of the unknown when caring for COVID-19 patients. Daily audits were conducted with immediate concurrent feedback to engage the relevant stakeholders. Infection prevention liaison officers (IPLOs) were appointed to assist in the daily audits. An electronic audit tool was used to facilitate audit and quick analysis. Conclusions: The experience gained in the last 2 years has been useful and may provide a template if new external sites are needed in the future because of the potential surge associated with the ο (omicron) variant.

Funding: None

Disclosures: None

The escalating threat of antimicrobial resistance (AMR) necessitates impactful, reproducible, and scalable antimicrobial stewardship strategies. This review addresses the critical need to enhance the quality of antimicrobial stewardship intervention research. We propose five considerations for authors planning and evaluating antimicrobial stewardship initiatives. Antimicrobial stewards should consider the following mnemonic ABCDE: (A) plan Ahead using implementation science; (B) Be clear and thoroughly describe the intervention by using the TidIER checklist; (C) Use a Checklist to comprehensively report study components; (D) Select a study Design carefully; and (E) Assess Effectiveness and implementation by selecting meaningful outcomes. Incorporating these recommendations will help strengthen the evidence base of antimicrobial stewardship literature and support optimal implementation of strategies to mitigate AMR.

Advancement in solid organ transplantation and hematopoietic stem cell transplant continues to improve the health outcomes of patients and widens the number of eligible patients who can benefit from the medical progress. Preserving the effectiveness of antimicrobials remains crucial, as otherwise transplant surgeries would be unsafe due to surgical site infections, and the risk of sepsis with neutropenia would preclude stem cell transplant. In this review, we provide updates on three previously discussed stewardship challenges: febrile neutropenia, Clostridioides difficile infection, and asymptomatic bacteriuria. We also offer insight into four new stewardship challenges: the applicability of the “shorter is better” paradigm shift to antimicrobial duration; antibiotic allergy delabeling and desensitization; colonization with multidrug-resistant gram-negative organisms; and management of cytomegalovirus infections. Specifically, data are accumulating for “shorter is better” and antibiotic allergy delabeling in transplant patients, following successes in the general population. Unique to transplant patients are the impact of multidrug-resistant organism colonization on clinical decision-making of antibiotic prophylaxis in transplant procedure and the need for antiviral stewardship in cytomegalovirus. We highlighted the expansion of antimicrobial stewardship interventions as potential solutions for these challenges, as well as gaps in knowledge and opportunities for further research.

We developed and validated a set of fully automated surveillance algorithms for healthcare-onset CDI using electronic health records. In a validation data set of 750 manually annotated admissions, the algorithm based on International Classification of Disease, Tenth Revision (ICD-10) code A04.7 had insufficient sensitivity. Algorithms based on microbiological test results with or without addition of symptoms performed well.

A pharmacist-driven protocol for methicillin-resistant Staphylococcus aureus nares screening and empiric vancomycin discontinuation was instituted in a community healthcare system utilizing a tele-antimicrobial stewardship program to reduce inappropriate use of vancomycin. The protocol and associated intervention resulted in a significant decrease in both vancomycin utilization and the rate of acute kidney injury.

Methicillin-resistant Staphylococcus aureus (MRSA) infections in neonates can result in significant morbidity and mortality. However, comparatively to adults, neonatal MRSA data remains relatively scarce. Additionally, while evidence-driven practices for adults have seen considerable progress, neonatal infection prevention strategies remain poorly described. The Leeds Newborn Service adopted a series of infection prevention and control (IPC) measures following a rise in MRSA cases in 2008–2009. This narrative review presents IPC measures for neonatal MRSA and methicillin-sensitive Staphylococcus aureus (MSSA) infections and reflects upon local challenges and successes of these interventions. Our experience underscores the importance of an adaptive, evidence-based strategy, tailored to the neonatal population. Effectively addressing MRSA/MSSA requires continuous monitoring with sustained targeted interventions. Our key learning points highlight the intertwined difficulties of specific neonatal requirements and lack of definitive IPC guidance, suggesting a holistic approach is key for successful IPC outcomes in the neonatal intensive care unit setting.

Background: Admission laboratory screening for asymptomatic COVID-19 has been utilized to mitigate healthcare-associated SARS-CoV-2 transmission. A better understanding of the impact of such testing across a variety of patient populations is needed. Methods: Beginning April 2020, every patient admitted within an academic healthcare system underwent SARS-CoV-2 PCR testing upon admission. Between April 20, 2020 through June 14, 2021, results were analyzed in asymptomatic patients across 4 inpatient facilities: a tertiary-care adult hospital, a free-standing pediatric hospital, a community-based hospital, and a behavioral health hospital. Positivity rates and the number needed to test (NNT) to identify 1 asymptomatic infected patient were calculated overall, by hospital type, by patient vaccination status, and by CDC-defined levels of community transmission. Weekly community incidence rates of COVID-19 for the system’s metropolitan service area (8 central Tennessee counties) were obtained from Tennessee Department of Health records. Weekly COVID-19 incidence rates per 100,000 people were calculated using US Census Bureau data. Using a national survey of hospital epidemiologists, a clinically meaningful NNT was identified (ie, 1 positive patient per 100 patients tested). A crude admission testing cost (covering testing supplies, reagents, and lab personnel costs) was obtained from operational data ($50 per test) to assess testing utility. Results: In total, 51,187 tests were collected during the study period with a positivity rate of 1.8%. No periods of low transmission were observed (Table 1). During high transmission periods, the NNT met the clinically relevant threshold in all populations. In addition, the NNT approached or met the 1:100 threshold for most locations during periods of less transmission, suggesting continued benefit even as infection rates decline. In all transmission periods, the NNT for non–fully vaccinated patients met the clinically meaningful threshold, in contrast to testing of fully vaccinated patients (Table 2). Discussion: Implementing an asymptomatic patient admission testing program can provide clinically relevant value based on the NNT, even during lower periods of transmission and in different patient populations. Limiting admission testing to non–fully vaccinated patients during periods of lower transmission may be a strategy to address cost and resource concerns around this practice. Further investigations into the impact of booster vaccination and newer SARS-CoV-2 variants on admission testing programs are also necessary. Although the impact of such testing on healthcare-associated COVID-19 among patients and healthcare workers could not be clearly determined, these data provide important information as facilities weigh the costs and benefits of such testing.

Funding: None

Disclosures: None

In a large healthcare worker cohort, we quantified the association between behaviors and risk of coronavirus disease 2019 (COVID-19) during different pandemic phases, adjusting for prior infection and vaccination. Individual characteristics, including personal concerns, were associated with these behaviors. Public health messaging should target high-risk populations and behaviors as the pandemic evolves.

Background: Antibiotic use during end-of-life (EOL) care is an increasingly important target for antimicrobial stewardship given the high prevalence of antibiotic use in this setting with limited evidence on safety and effectiveness to guide antibiotic decision making. We estimated antibiotic use during the last 6 months of life for patients under hospice or palliative care, and we identified potential targets (ie time points) during the EOL period when antimicrobial stewardship interventions could be targeted for maximal benefit. Methods: We conducted a retrospective cohort study of nationwide Veterans’ Affairs (VA) patients, 18 years and older who died between January 1, 2014, and December 31, 2019, and who had been hospitalized within 6 months prior to death. Data from the VA’s integrated electronic medical record (EMR) were collected including demographics, comorbid conditions, and duration of inpatient antibiotics administered, along with outpatient antibiotics dispensed. A propensity-score matched-cohort analysis was conducted to compare antibiotic use between patients placed into palliative care or hospice matched to patients not receiving palliative care or hospice care. Repeated measures ANOVA and repeated measures linear regression methods were used to analyze difference in difference (D-I-D) of days of therapy (DOT) between the 2 cohorts. Results: There were 251,822 patients in the cohort, including 23,746 in hospice care, 89,768 in palliative care, and 138,308 without palliative or hospice care. The median days from last discharge to death was 9 days. The most common comorbidities were chronic obstructive pulmonary diseases (50%), malignancy (46%), and diabetes mellitus (43%). Overall, 18,296 (77%) of 23,746 hospice patients, and 71,812 (80%) of 89,768 palliative care patients received at least 1 antibiotic, whereas 95,167 (69%) of 138,308 who were not placed in hospice or did not receive palliative care received antibiotics. In the primary matched cohort analysis that compared patients placed into hospice or palliative care to propensity-score matched controls, entry into palliative care was associated with a 11% absolute increase in antibiotic prescribing, and entry into hospice was associated with a 4% absolute increase during the 7–14 days after entry versus the 7–14 days before entry (Fig. 1). The stratified cohorts had very similar balanced covariates as the overall cohort. Conclusions: In our large cohort study, we observed that patients receiving EOL care had high levels of antibiotic exposure across VA population, particularly on entry to hospice or during admissions when they received palliative care consultation. Future studies are needed to identify the optimal EOL strategies for collaboration between antimicrobial stewardship and palliative care.

Funding: None

Disclosures: None

Background: Burkholderia multivorans are gram-negative bacteria typically found in water and soil. B. multivorans outbreaks among patients without cystic fibrosis have been associated with exposure to contaminated medical devices or nonsterile aqueous products. Acquisition can also occur from exposure to environmental reservoirs like sinks or other hospital water sources. We describe an outbreak of B. multivorans among hospitalized patients without cystic fibrosis at 2 hospitals within the same healthcare system in California (hospitals A and B) between August 2021 and July 2022. Methods: We defined confirmed case patients as patients without cystic fibrosis hospitalized at hospital A or hospital B between January 2020 to July 2022 with B. multivorans isolated from any body site matching the outbreak strain. We reviewed medical records to describe case patients and to identify common exposures. We evaluated infection control practices and interviewed staff to detect exposures to nonsterile water. Select samples from water, ice, drains, and sink splash zone surfaces were collected and cultured for B. multivorans in March 2022 and July 2022 from both hospitals. Common aqueous products used among case patients were tested for B. multivorans. Genetic relatedness between clinical and environmental samples was determined using random amplified polymorphic DNA (RAPD) and repetitive extragenic palindromic polymerase chain reaction (Rep-PCR). Results: We identified 23 confirmed case patients; 20 (87%) of these were identified at an intensive care unit (ICU) in hospital A. B. multivorans was isolated from respiratory sources in 18 cases (78%). We observed medication preparation items, gloves, and patient care items stored within sink splash zones in ICU medication preparation rooms and patient rooms. Nonsterile water and ice were used for bed baths, swallow evaluations, and ice packs. B. multivorans was cultured from ice and water dispensed from an 11-year-old ice machine in the ICU at hospital A in March 2022 but no other water sources. Additional testing in July 2022 yielded B. multivorans from ice and a drain pan from a new ice machine in the same ICU location at hospital A. All products were negative. Clinical and environmental isolates were the same strain by RAPD and Rep-PCR. Conclusions: The use of nonsterile water and ice from a contaminated ice machine contributed to this outbreak. Water-related fixtures can serve as reservoirs for Burkholderia, posing infection risk to hospitalized and immunocompromised patients. During outbreaks of water-related organisms, such as B. multivorans , nonsterile water and ice use should be investigated as potential sources of transmission and other options should be considered, especially for critically ill patients.

Disclosures: None

Antibiotic prescribing errors at hospital discharge are common. We designed a pharmacist-driven antimicrobial stewardship program to evaluate prescriptions prior to being transmitted to community pharmacies. Drug-related problems were identified in prescriptions for 48 of 149 patients, resulting in 55 interventions. Review at discharge improves outpatient prescribing of antimicrobials.

We surveyed trainees about their urine culture practices and assessed the impact of an educational intervention delivered electronically and in person. Trainee scores improved across all levels of training and across all questions on the postintervention survey, but there was no difference in scores by mode of education (P = .91).