Using a mixed-methods approach, we assessed the effect of the coronavirus disease 2019 (COVID-19) pandemic on antimicrobial stewardship programs (ASPs) in Colorado hospitals. ASP leaders reported decreased time and resources, reduced rigor of stewardship interventions, inability to complete new initiatives, and interpersonal challenges. Stewardship activities may be threatened during times of acute resource pressure.

Background: Candida auris is an emerging multidrug-resistant yeast that is transmitted in healthcare facilities and is associated with substantial morbidity and mortality. Environmental contamination is suspected to play an important role in transmission but additional information is needed to inform environmental cleaning recommendations to prevent spread. Methods: We conducted a multiregional (Chicago, IL; Irvine, CA) prospective study of environmental contamination associated with C. auris colonization of patients and residents of 4 long-term care facilities and 1 acute-care hospital. Participants were identified by screening or clinical cultures. Samples were collected from participants’ body sites (eg, nares, axillae, inguinal creases, palms and fingertips, and perianal skin) and their environment before room cleaning. Daily room cleaning and disinfection by facility environmental service workers was followed by targeted cleaning of high-touch surfaces by research staff using hydrogen peroxide wipes (see EPA-approved product for C. auris, List P). Samples were collected immediately after cleaning from high-touch surfaces and repeated at 4-hour intervals up to 12 hours. A pilot phase (n = 12 patients) was conducted to identify the value of testing specific high-touch surfaces to assess environmental contamination. High-yield surfaces were included in the full evaluation phase (n = 20 patients) (Fig. 1). Samples were submitted for semiquantitative culture of C. auris and other multidrug-resistant organisms (MDROs) including methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococcus (VRE), extended-spectrum β-lactamase–producing Enterobacterales (ESBLs), and carbapenem-resistant Enterobacterales (CRE). Times to room surface contamination with C. auris and other MDROs after effective cleaning were analyzed. Results: Candida auris colonization was most frequently detected in the nares (72%) and palms and fingertips (72%). Cocolonization of body sites with other MDROs was common (Fig. 2). Surfaces located close to the patient were commonly recontaminated with C. auris by 4 hours after cleaning, including the overbed table (24%), bed handrail (24%), and TV remote or call button (19%). Environmental cocontamination was more common with resistant gram-positive organisms (MRSA and, VRE) than resistant gram-negative organisms (Fig. 3). C. auris was rarely detected on surfaces located outside a patient’s room (1 of 120 swabs; <1%). Conclusions: Environmental surfaces near C. auris–colonized patients were rapidly recontaminated after cleaning and disinfection. Cocolonization of skin and environment with other MDROs was common, with resistant gram-positive organisms predominating over gram-negative organisms on environmental surfaces. Limitations include lack of organism sequencing or typing to confirm environmental contamination was from the room resident. Rapid recontamination of environmental surfaces after manual cleaning and disinfection suggests that alternate mitigation strategies should be evaluated.

Funding: None

Disclosures: None

We interviewed 1,208 healthcare workers with positive SARS-CoV-2 tests between October 2020 and June 2021 to determine likely exposure sources. Overall, 689 (57.0%) had community exposures (479 from household members), 76 (6.3%) had hospital exposures (64 from other employees including 49 despite masking), 11 (0.9%) had community and hospital exposures, and 432 (35.8%) had no identifiable source of exposure.

We analyzed efficacy of a centralized surveillance infection prevention (CSIP) program in a healthcare system on healthcare-associated infection (HAI) rates amid the coronavirus disease 2019 (COVID-19) pandemic. HAI rates were variable in CSIP and non-CSIP facilities. Central-line–associated bloodstream infection (CLABSI), C. difficile infection (CSI), and surgical-site infection (SSI) rates were negatively correlated with COVID-19 intensity in CSIP facilities.

We evaluated the impact of carbapenem shortage on antimicrobial practice and patient outcome at a tertiary care center. During the shortage, hospital antimicrobial practice could be safely managed through additional antimicrobial stewardship measures including treatment guidance and mandatory preauthorization. Antimicrobial shortage may present a unique opportunity for promoting antimicrobial stewardship.

Background: Diagnostic stewardship modifies the ordering, performing, and reporting of diagnostic tests to optimize clinical care and infection prevention while conserving healthcare resources. Timely and accurate diagnosis of respiratory virus infections can optimize the use of antibiotics, antivirals, ancillary tests, and inpatient beds. Influenza-like illnesses (ILIs) are frequently caused by viruses. However, before COVID-19, specific antiviral medication was commonly used only for the treatment of influenza virus infections. Methods: Eskenazi Health (EH) had 2 respiratory PCR assays: influenza/RSV ($58.18 per assay) and a 20-pathogen respiratory pathogens panel (RPP) ($129 per assay). An inpatient ILI algorithm was developed and implemented in the electronic health record (EHR) in October 2018 to guide the selection of the appropriate assay (Figure 1). Ambulatory testing defaulted to the influenza/RSV assay. Prescribers retained the ability to override recommendations. We performed a retrospective chart review of all orders for RPP and influenza/RSV assays before implementation of the ILI algorithm (October 1, 2017, to September 30, 2018) and after implementation (October 1, 2018, to September 30, 2019). The primary end point was the number of RPP assays ordered. The secondary end point was the appropriateness of RPP assays ordered (ie, met ≥1 criteria) and number of influenza/RSVs assays ordered with virus detected. Results: Before the implementation of the intervention, 1,882 orders were reviewed. After implementation 1,621 orders were reviewed. All influenza/RSV and RPP assays were included if they were ordered between October 1, 2017, and September 30, 2019, at EH. There were no exclusion criteria. After implementation, RPP assays decreased ~40% (Table 1), with associated cost savings of $35,368.68 (22.6% of total assay costs; $163,742.88 before implementation and $128,374.20 after implementation). Although some of this reduction could be attributed to the lower number of overall assays ordered, the 40% reduction in RPP assays exceeded the 14% decrease in overall orders, demonstrating improvement in utilization of RPP assays. A corresponding increase in influenza/RSV assay orders was not observed; both groups had similar total influenza/RSV orders. Both groups also had similar percentages of viruses detected with influenza/RSV and RPP (33% before vs 31% after). After implementation, 1,522 (94%) of 1,621 orders followed the recommendations of the ILI algorithm (Table 2). Several prescribers ordered influenza/RSV despite the patient meeting criteria for RPP assay; of these 26 assays, 4 (15%) resulted in virus detection. Of the 73 instances in which prescribers bypassed recommendations for the influenza/RSV assay and ordered an RPP assay, 14 (19%) of the assays resulted in virus detection; only 1 of 14 was a virus that would have been detected by the influenza/RSV. We were unable to identify any trends that would assist in developing additional order questions to capture these patients. Conclusions: Implementation of the ILI algorithm was associated with high adherence, improvement in the appropriateness of ordering, and significant cost savings.

Funding: No

Disclosures: None

Figure 1.

Table 1.

Table 2.

Our surveys of nurses modeled after the Capability, Opportunity, and Motivation Model of Behavior (COM-B model) revealed that opportunity and motivation factors heavily influence urine-culture practices (behavior), in addition to knowledge (capability). Understanding these barriers is a critical step towards implementing targeted interventions to improving urine-culture practices.

Cultures from urinary catheters are often ordered without indication, leading to possible misdiagnosis of catheter-associated urinary tract infections (CAUTI), increasing antimicrobial use, and C difficile. We implemented a diagnostic stewardship intervention for urine cultures from catheters in a community hospital that led to a reduction in cultures and CAUTIs.

We evaluated barriers and facilitators to patient adherence with a bundled intervention including chlorhexidine gluconate (CHG) bathing and decolonizing Staphylococcus aureus nasal carriers in a real-world setting. Survey data identified 85.5% adherence with home use of CHG as directed and 52.9% adherence with home use of mupirocin as directed.

Contact precautions are used to prevent the spread of extended-spectrum β-lactamase (ESBL)–producing organisms in acute-care hospitals, but supporting data are lacking. We discontinued such precautions for ESBL Escherichia coli and Klebsiella spp and found no increased prevalence of these organisms with our change in practice.

Current guidelines do not address a recommended duration of parenteral therapy for uncomplicated urinary tract infection (uUTI) treatment in the inpatient setting. We compared a 3-day course of ceftriaxone with longer antibiotic durations for inpatients with a uUTI. Our findings indicate that a 3-day course of ceftriaxone was as efficacious as longer antibiotic courses.

Background: Evidence-based hospital antimicrobial stewardship interventions, such as postprescription review with feedback, prior authorization, and handshake stewardship, involve communication between stewards and frontline prescribers. Hierarchy, asymmetric responsibility, prescribing etiquette, and autonomy can obstruct high-quality communication in stewardship. Little is known about the strategies that stewards use to overcome these barriers. The objective of this study was to identify how stewards navigate communication challenges when interacting with prescribers. Methods: We conducted semistructured interviews with antimicrobial stewards recruited from hospitals across the United States. Interviews were audio recorded, transcribed, and analyzed using a flexible coding approach and the framework method. Social identity theory and role theory were used to interpret framework matrices. Results: Interviews were conducted with 58 antimicrobial stewards (25 physicians and 33 pharmacists) from 10 hospitals (4 academic medical centers, 4 community hospitals, and 2 children’s hospitals). Respondents who felt empowered in their interactions with prescribers explicitly adopted a social identity that conceptualized stewards and prescribers as being on the “same team” with shared goals (in-group orientation). Drawing on the meaning conferred via this social role identity, respondents engaged in communication strategies to build and maintain common bonds with prescribers. These strategies included moderating language to minimize defensive recommendations when delivering stewardship recommendations, aligning the goals of stewardship with the goals of the clinical team, communicating with prescribers about things other than stewardship, compromising for the sake of future interactions, and engaging in strategic face-to-face interaction. Respondents who felt less empowered in their interactions thought of themselves as outsiders to the clinical team and experienced a heightened sense of “us versus them” mentality with the perception that stewards primarily serve a gate-keeping function (ie, outgroup orientation). These respondents expressed deference to hierarchy, a reluctance to engage in face-to-face interaction, a feeling of cynicism about the impact of stewardship, and a sense of low professional accomplishment within the role. Respondents who exhibited an in-group orientation were more likely than those who did not to describe the positive impact of stewardship mentors or colleagues on their social role identity. Conclusions: The way antimicrobial stewards perceive their role and identity within the social context of their healthcare organization influences how they approach communication with prescribers. Social role identity in stewardship is shaped by the influence of mentors and colleagues, indicating the importance of supportive relationships for the development of steward skill and confidence.

Funding: No

Disclosures: None

Background: The estimated economic cost of Clostridioides difficile infection (CDI) is $5.4 billion annually, primarily attributed to acute-care costs. We previously reported data from ECOSPOR III that SER-109, an investigational oral microbiome therapeutic, was superior to placebo in reducing recurrent CDI (rCDI) in adults at 8 weeks after treatment, with a 68% relative risk reduction. Adults with rCDI have more hospitalizations and emergency room (ER) visits (defined herein as healthcare resource utilization, HRU) compared to those without recurrence. Thus, we evaluated incidence of HRU. Methods: Adults with rCDI (≥3 episodes in 12 months) were screened at 56 US and Canadian sites and were randomized 1:1 to SER-109 (4 capsules × 3 days) or placebo following resolution of CDI with standard-of-care CDI antibiotics. The primary end point was rCDI at 8 weeks. Exploratory end points included cumulative incidence of hospitalizations through 24 weeks after treatment. Here, we report cumulative incidence of all-cause HRU through 8 weeks after treatment. Results: In total, 281 patients were screened and 182 were randomized (59.9% female; mean age 65.5 years; 98.9% outpatient). Overall, 31 patients (17%) had 38 hospitalizations or ER visits through week 8 (11 events in 10 SER-109 patients and 27 events in 21 placebo patients) (Table 1). The cumulative incidence of HRU was lower in SER-109–treated patients compared to placebo at both weeks 4 and 8 with most events (65.8%) recorded within 4 weeks after treatment. The adjusted HRU incidence rate (by person time, age, sex, and antibiotic use) was also lower in SER-109–treated patients compared to placebo at weeks 4 and 8 (0.256 [95% CI, 0.096–0.683] versus 0.417 [95% CI, 0.199–0.873], respectively). Conclusions: SER-109–treated patients had less HRU compared to placebo patients through 8 weeks after treatment in this mostly outpatient population. These data suggest a potential benefit of SER-109 in reducing HRU, thus lowering the healthcare burden of rCDI.

Funding: Seres Therapeutics

Disclosures: None