Background: Data on the patient outcomes for newer β-lactam–β-lactamase inhibitor (BLBI) drugs compared to carbapenem-containing combination antibiotics for multidrug-resistant (MDR)–Pseudomonas aeruginosa infections are limited. Methods: This retrospective, case–control observational study was based on chart review of the patients managed at the University of Kentucky. Results: In total, 143 patients with MDRO Pseudomonas aeruginosa infections were identified and divided into 2 groups: 1 group received newer BLBI combinations with or without aminoglycosides or polymyxins, for at least 72 hours, and the control group received carbapenem containing combination antibiotics or other antibiotics. Baseline characteristics and patient outcomes are shown in Table 1. Discussion: The newer BLBI combinations group consisted of 60.8% MDR Pseudomonas bacteremia, whereas the control group had 68.4% of MDR Pseudomonas respiratory cultures. Overall, the use of newer BLBI combinations such as ceftazidime/avibactam, ceftolozane/tazobactam, and meropenem/vaborbactam was associated with lower rates of acute kidney injury (AKI), shorter LOS, and lower mortality rates compared to the control group, and these differences were statistically significant. Because the 2 populations of patient differed significantly based on the site of infection (sepsis vs pneumonia), the data were reanalyzed to evaluate the impact of therapy on the occurrence of AKI, LOS, and mortality based on the site of infection. Only those patients with sepsis who received the newer combination drugs had significantly better rates of AKI, lower LOS, and had lower rates of mortality. The 2 treatment arms were not statistically different when comparing patients with pneumonia. Additionally, the use of these new combination therapies did not make a difference regarding readmission rates or duration of bacteremia for the patients included in the study.

Funding: No

Disclosures: None

Table 1.

Table 2.

Background: Despite the development of new β-lactam agents, gram-negative resistance continues to be an increasing concern in the healthcare setting. The understanding and optimizing antimicrobial pharmacokinetics and pharmacodynamics are essential to enhance activity of appropriate therapy, improve clinical outcomes, and reduce the development of resistance. Methods: A pharmacodynamic analysis was performed for 4 β-lactams (aztreonam, cefepime, piperacillin/tazobactam, and meropenem) and 14 dosage regimens as either intermittent bolus (IB) or prolonged infusion (PI) against 7 gram-negative pathogens: Klebsiella pneumoniae, K. oxytoca, Escherichia coli, Enterobacter cloacae, E. aerogenes, Acinetobacter baumannii, and Pseudomonas aeruginosa. Unit-specific minimum inhibitory concentration (MIC) distribution data were generated using antibiogram data over a decade for 4 intensive care units within our institution: medical ICU, cardiovascular ICU, surgical ICU, and neurosurgical ICU. Published pharmacokinetic parameter estimates in critically ill patients, combined with this MIC distribution data, were utilized to perform Monte Carlo simulations for each antimicrobial regimen. The percentage of time for which the unbound concentration of antibiotic remained above the MIC (ƒT>MIC) was utilized as the pharmacodynamic target for each agent: 40% ƒT>MIC for meropenem, 50% ƒT>MIC for piperacillin/tazobactam, 60% ƒT>MIC for aztreonam, and 70% ƒT>MIC for cefepime. Regimens were modeled using Oracle Crystal Ball software to determine the likelihood of achieving >90% probability of target attainment (PTA). Because resistance rates were significantly higher for P. aeruginosa and A. baumannii, cumulative PTAs for K. pneumoniae, K. oxytoca, E. coli, E. cloacae, and E. aerogenes were analyzed separately to determine the relative PTA for Enterobacterales in each ICU. Results: No intermittent infusion regimens of piperacillin/tazobactam, aztreonam, or cefepime achieved >90% PTA for any organism. Piperacillin/tazobactam 4.5 g infused over 4 hours (PI q6h) and aztreonam 2 g PI q6h failed to achieve adequate PTA for Enterobacterales with only 84% and 85% PTA, respectively. For Enterobacterales, the only regimens to achieve >90% PTA included cefepime 2 g infused over 3 hours (PI q8h) and meropenem 1g IB q8h with 95% and 99% PTA, respectively. Meropenem 2 g PI q8h was the only regimen capable of achieving >90% PTA for both A. baumannii and P. aeruginosa with 97% and 92% PTA, respectively. Conclusions: Although utilization of high doses and prolonged infusions dramatically improve the pharmacodynamics of β-lactam therapy, the only regimen capable of achieving adequate PTA for all organisms analyzed was meropenem 2g PI q8h. To reduce carbapenem use, combination therapy may be considered for critically ill patients receiving aztreonam, cefepime, or piperacillin/tazobactam for empiric treatment of gram-negative infections.

Funding: No

Disclosures: None

Background: Carbapenem-resistant Enterobacteriaceae (CRE) remain among the most urgent infectious threats according to the CDC Threats Reports. Although focus has often been placed on carbapenemase-producing phenotypes, there is increasing interest in distinguishing the optimal treatment and outcomes of carbapenemase-producing (CP) and non–carbapenemase-producing (NCP) CRE. We compare antimicrobial susceptibility patterns between CP-CRE and NCP-CRE isolated from patients at our academic medical center. Methods: All CRE isolates of Enterobacter cloacae, Escherichia coli, Klebsiella aerogenes, K. oxytoca, and K. pneumoniae in adult inpatients from 2010 to 2019 were included in this study. Susceptibility testing was performed using the BD Phoenix Automated System (BD Diagnostics, Sparks, MD). CLSI susceptibility break points were utilized in the susceptibility analyses of all antimicrobials tested. To determine carbapenemase production, isolates resistant only to ertapenem were considered NCP-CRE, and those resistant to both ertapenem and meropenem were considered CP-CRE. Statistical comparisons of susceptibility profiles were performed using either the χ2 test or the Fisher exact test. All data preprocessing and statistical analyses were performed using Python software. Results: Over the decade, we identified 291 CRE isolates (216 isolates resistant only to ertapenem and 75 resistant to ertapenem and meropenem). The ertapenem-resistant–only phenotype comprises ~66% of the total CRE population and is largely composed of E. cloacae (67%). As expected, most β-lactam susceptibilities were negligibly low between the 2 groups; however, other clinically relevant antimicrobials (aminoglycosides, fluoroquinolones, and sulfamethoxazole/trimethoprim) exhibited starkly different susceptibility profiles (P value Conclusions: These findings suggest that the most predominant CRE phenotype at our institution is not carbapenemase production. Evaluation of outcomes between CP- and NCP-CRE should be pursued further. The large differences in the MIC distributions may lead to differing outcomes for the affected patients.

Funding: No

Disclosures: None

Background: The Centers for Disease Control and Prevention reported 32,600 cases, 2,700 deaths, and healthcare costs of 767 million dollars attributed to multidrug-resistant Pseudomonas aeruginosa. A recent study of 128 patients with nosocomial pneumonia due to P. aeruginosa showed the noninferiority of ceftolozane-tazobactam compared to meropenem. However, the resistance of ceftolozane-tazobactam due to AmpC mutations has been described. Compared with 2019, we observed an increase from 2 to 13 cases of ceftolozane-tazobactam–resistant P. aeruginosa (CRPA) during the COVID-19 pandemic at our institution in the Bronx, New York. Methods: A report of patients with CRPA between March and August 2020 was obtained. Data collected included demographics, hospitalization/IV antibiotic use in prior 90 days, SARS-CoV-2 PCR result, ICU admission, length of stay, antibiotic days of therapy, mortality, etc. Results: In total, 13 patients with CRPA infection were reviewed (Table 1). Among them, 2 patients were on the same inpatient medical-surgical unit but separated by 5 months. Also, 11 patients were from different medical-surgical units or ICUs. In addition, 5 patients (38%) were SARS-CoV-2 PCR positive. None of these COVID-19 patients were cohorted on the same unit, making horizontal spread of CRPA or COVID-19 unlikely. Finally, 8 of these patients died while hospitalized (4 were COVID-19 patients). Conclusions: We found a high incidence of mortality in patients with CRPA infection. Many patients had prolonged hospital stay and required ICU admission. Few patients were from long-term care facilities. Given the associated morbidity and mortality, increased surveillance and intensified antimicrobial stewardship efforts are needed to mitigate the impact of CRPA during the COVID-19 pandemic.

Funding: No

Disclosures: None

Table 1.

Background: Infections caused by Acinetobacter spp are often healthcare acquired and associated with high mortality. Extensively drug-resistant (XDR) Acinetobacter are nonsusceptible to at least 1 agent in all but 2 or fewer antibiotic classes. Few of the new antibiotics targeting multidrug-resistant gram-negative bacteria are effective against XDR Acinetobacter. Recent national guidelines for treatment of resistant gram-negative infections do not include Acinetobacter, leaving a knowledge gap in best practices. Methods: This retrospective cohort study included microbiology, clinical, and pharmacy data from all patients hospitalized between 2012 and 2018 at any Veterans’ Affairs medical center who had cultures that grew XDR Acinetobacter spp. Bivariate unadjusted analyses compared clinical outcomes by monotherapy versus combination therapy. Using mixed-effects ordinal logistic regression, propensity score–adjusted models accounting for severity of illness and other variables associated with treatment were fit to compare outcomes. Results: Of 11,546 patients with 15,364 cultures that grew Acinetobacter spp, 408 patients (3.5%) had 666 cultures (4.3%) with XDR Acinetobacter. Moreover, 276 of these patients (67.6%) had gram-negative targeted antibiotic treatment within −2 to +5 days from the culture. Furthermore, 118 patients (42.8%) received monotherapy, most commonly piperacillin-tazobactam (n = 54, 45.7%) or an anti-Pseudomonas cephalosporin (n = 21, 17.8%). Also, 158 (57.2%) patients received combination therapy, most commonly a carbapenem (n = 93, 58.9%) and/or polymyxin (n = 68, 43.0%). Moreover, 41 patients (25.9%) received both a carbapenem and polymyxin. In both unadjusted and adjusted analyses, there were no significant differences in the odds of 30-day mortality (aOR, 1.43; 95% CI, 0.86–2.38) or 1-year mortality (aOR, 1.04; 95% CI, 0.68–1.60) between combination therapy and monotherapy groups. Among 264 patients (96%) whose cultures occurred during an inpatient or long-term care admission, unadjusted analyses showed increased odds of in-hospital mortality (OR, 1.89; 95% CI, 1.08–3.29) and longer postculture length of stay in the combination therapy group: median, 23 days (IQR, 11–57) versus 14 days (IQR, 7–32) (P = .02). However, with propensity score adjustment, these associations were no longer significant. Furthermore, there was no significant difference in odds of 90-day readmission between groups in either unadjusted or adjusted analyses (aOR, 1.20; 95% CI, 0.74–1.95). Conclusions: In this large national cohort of patients with XDR Acinetobacter cultures, more patients received combination therapy than monotherapy, and carbapenems and polymyxins were the most-used classes. However, there were no significant differences in outcomes between patients receiving combination therapy and monotherapy, suggesting lack of clinical benefit to the common practice of treating XDR Acinetobacter infections with multiple antibiotics. Further research is needed to determine optimal treatment strategies for this pathogen.

Funding: No

Disclosures: None

Background: A significant increasing trend in the prevalence of Escherichia coli strains that produce extended-spectrum β-lactamases (ESBLs) has been observed in recent years, both in the community setting and in the healthcare arena. We aimed to provide a snapshot of the current situation with E. coli β-lactamase–producing strains in a single general hospital by appraising their β-lactamase content and plasmid types, which will inform further clinical and research efforts. Methods: Our study population consisted of all hospitalized patients in different clinical units of the General Hospital in Slavonski Brod during a 1-year period: internal medicine, infectious disease, surgery, urology and ICU. Phenotypic tests for the detection of ESBLs and plasmid-mediated AmpC β-lactamases were initially pursued, followed by the molecular detection (polymerase chain reaction, PCR) of resistance genes using primers for blaTEM, blaCTX-M, and blaSHV. PCR-based replicon typing (PBRT) was conducted to type resistance plasmids carrying ESBL genes. Results: During the study period, 30 E. coli isolates with reduced susceptibility to third-generation cephalosporins (ie, ceftazidime, cefotaxime, and ceftriaxone) were detected in hospitalized patients. These isolates stemmed from blood culture (66.7%), wound swabs (13.3%), urine (13.3%), and drainage content (6.7%). Alongside complete resistance to β-lactam antimicrobial agents, they were also characterized by high resistance to gentamicin (93.3%) and ciprofloxacin (96.7%), whereas 23.3% of isolates were also resistant to ertapenem. Most isolates harbored both blaCTX-M and blaTEM genes concurrently (46.7%), while solitary blaTEM and blaCTX-M genes were found in 33.3% and 20% of these isolates, respectively. The presence of SHV β-lactamases was not found in any of the isolates. PBRT revealed a wide array of diverse plasmid groups, with most of the isolates harboring different combinations; however, 80% of isolates were characterized by plasmid incompatibility group B/O (IncB/O). Conclusions: We detected increased frequency of both TEM and CTX-M type β-lactamases in E. coli isolates from a single-hospital setting, with significant consequences for further treatment approaches. The high prevalence of broad- and extended-spectrum β-lactamase producers tends to prompt an increased carbapenem use (potentially resulting in increased resistance to carbapenems); thus, this type of analytical work should become a standard approach (where possible) in hospital centers in our country and worldwide.

Funding: No

Disclosures: None

Background: Understanding the epidemiology and risk factors for nosocomial infections with vancomycin-resistant enterococci (VRE) is necessary for the prevention and control of VRE infections in the hospital setting. We sought to determine the incidence of nosocomial infections of VRE and to ascertain predictors associated with nosocomial infection. Methods: In this retrospective cohort study, data were collected from patients with VRE infection from January 2019 to December 2020 at a tertiary-care center in northern California. VRE infections were designated as hospital onset (HO) if the specimen was collected >3 days after hospital admission or community onset (CO) if the specimen was collected ≤3 days after admission. Associations between HO infections with time, unit, and specimen were identified. Results: Over the 2-year period, 214 unique VRE infections were identified in hospitalized patients; 115 infections were CO and 99 were HO. HO-VRE were associated most frequently with stay in medical/telemetry units (68%), followed by oncology–transplant units (15%) and ICUs (12%). There were ~4.7 and ~3.6 HO-VRE infections per month in 2019 and 2020, respectively. No differences were identified between HO-VRE infections in 2 medical units regarding glycopeptide and cephalosporin use in those units. The sources of VRE infections were urinary 45%, bloodstream 15%, stool 10%, and other 30%. Of the 45 infections in urine, 51% were identified from catheters (Foley and straight) and 27% were identified from clean-catch urine. Interestingly, 71% of patients with VRE identified from urine did not report urinary tract infection (UTI) symptoms at the time of collection. Urine was most often collected for urinalysis and culture from patients with nonspecific symptoms such as fever, leukocytosis, hypotension, tachycardia, or altered mental status. All urine collected from patients who reported UTI symptoms grew >100,000 CFU/mL in culture, while only 75% of cultures from patients without symptoms grew >100,000 CFU/mL. The most common antibiogram was resistance to ampicillin, cefazolin, levofloxacin, minocycline, penicillin, tetracycline, and/or vancomycin (42% of cases) and susceptibility to both daptomycin and linezolid (60% of cases). Conclusions: HO-VRE infections were frequently identified with urinary sources and were often associated with catheter use. However, the frequent lack of concurrent UTI symptoms suggests VRE colonization rather than infection in many cases. Understanding the epidemiology and risk factors for HO-VRE infections is essential for developing infection prevention protocols to reduce the incidence of those infections.

Funding: No

Disclosures: None

Background: Operation room (OR) nurses are at a high risk for bloodborne pathogen (BBP) exposures because they are constantly in contact with blood and body fluid (BBF) through surgical sites, and they frequently use sharp surgical instruments and sutures during surgeries. We explored occupational experiences with BBP exposures among OR nurses in South Korea. Methods: With an institutional review board’s approval, this qualitative research was performed with 12 OR nurses who had worked for >3 months and had experienced BBP exposures. Based on the main research question “How is the experience of BBP exposure among OR nurses?” the semistructured questions for in-depth interview were prepared. Narrative data were collected through 1-hour individual interviews from June to September 2020 and were analyzed using a thematical analysis method. Results: The average age of the participants was 34.4 years with an average 9.75 years of clinical experience. The main theme extracted was “The nurses are alerted to their safety after experiencing the aftereffects and emotional trauma from BBP exposures,” with 4 subthemes and 14 concepts. The first subtheme, “OR nurses risking exposure to BBF,” included (1) hurried doctors and hasty nurses; (2) sharp surgical instruments everywhere; (3) deprioritized self-protection due to ongoing surgery; (4) inattentive to BBF risk; and (5) uncomfortable, foggy goggles and receded safety devices. The second subtheme, “BBP exposures occurred in a flash,” included (1) sharp injury occurred in a split second; (2) temporarily treat sharp wounds while hiding frightened feelings; and (3) OR nurses concentrated on surgery by suppressing anxiety and sharp wounds. The third subtheme, “Burdened time that could be overwhelmed alone,” included (1) BBP exposures moments that I wish to reverse; (2) anger over dangerous environments and the turmoil of anxiety; (3) exhausted body and facial discoloration due to taking postexposure prophylaxis; and (4) exposure to BBP that I want to hide from family and friends. The fourth subtheme, “Voice for everyone’s safety,” included (1) establishing a safety culture, which requires everyone’s efforts, and (2) necessity of practical resources for decreasing BBP exposures. Conclusions: The participating OR nurses felt that they were working with a high risk to BBF exposures and called for institutional interventions to reduce the risks, including surgeons’ attentive collaboration. Korean hospitals should make greater efforts to establish safety culture in ORs and to provide repeated, tailored education to prevent BBF exposures. They should also supply high-quality protective equipment and safety-engineered devices for OR nurses.

Funding: No

Disclosures: None

Background: The ongoing COVID-19 pandemic tests the healthcare system in many ways. The scarcity of resources poses challenges to infection prevention (IP) practices. We describe our experience in managing such scarcity in our care of COVID-19 patients in the hospital as well as community settings. Methods: The hospital pandemic plan traditionally included only plans for healthcare delivery management within the hospital. However, on March 25, 2020, a decision was made by the Ministry of Health to set up swab isolation (SIFs) and community care facilities (CCFs) to meet the growing demand for isolation beds for migrant workers infected by COVID-19. The CCFs were located in convention halls and resort centers and the SIFs were located in facilities previously functioning as hotels. Mobile medical teams were activated to run clinics at the dormitories housing 200,000 migrant workers. The IP team of an acute- and tertiary-care hospital in Singapore was activated to oversee IP measures at facilities managed by medical teams from the hospital, with the goal of zero healthcare-associated COVID-19 cases among staff. Two IP leaders were set up to oversee the IP program at 8 dormitories, 4 SIFs, and 2 CCFs. In total, 12 IP staff and 15 infection prevention liaison officers (IPLOs) were deployed from 2 acute-care hospitals and 3 specialty centers to conduct training in hand hygiene and the use of personal protective equipment, and to conduct daily audits of compliance to practice guidelines. Education on personal hygiene was also given to patients in these facilities in at least 7 languages. In the SIFs and dormitories, IPLOs were recruited to perform daily audits and feedback to the IP team on issues related to IP at the sites. Results: Since our first COVID-19 patient on January 23, 2020, there has been no report of healthcare-associated COVID-19 within the hospital nor among the medical, administrative, and support service staff working in the external operation facilities. Daily audits showed an average of 99.4% compliance to IP guidelines. Conclusions: IPLOs or IP champions play a significant role in ensuring compliance to IP guidelines. This compliance allows the IP professional to focus on the evaluation of the IP program, managing IP consultations, and planning and implementation of the IP program in nontraditional healthcare settings. The key success factors of the program included the ability to contextualize the planning and implementation of IP programs in various settings, strong leadership support, cohesive teamwork, and effective communication at various levels.

Funding: No

Disclosures: None

Group Name: Duke Center for Antimicrobial Stewardship and Infection Prevention

Background: Wastewater drains in hospital patient rooms have been identified as environmental reservoirs for multidrug-resistant organisms, and they have been linked to outbreaks of carbapenem-resistant Enterobacteriaceae (CRE). We studied the colonization of wastewater drains in a new hospital bed tower. Methods: A patient care unit in a new bed tower opened on July 18, 2020. In-room sinks were located in each hospital room opposite the patient head wall. Patients admitted to this unit underwent weekly rectal cultures to survey for carbapenemase-producing CRE. Additionally, infection preventionists performed routine surveillance of all clinical cultures for CRE. Cultures were performed from all patient room sinks in this unit monthly beginning September 14, 2020. Samples were obtained from the drain cover, handles, and top of bowl using sponges soaked in neutralizing buffer and processed using the stomacher technique. The tail-pipe was sampled using a flocked mini-tip swab soaked in neutralizing buffer; the P-trap water was sampled with sterile tubing attached to a 50-mL syringe. All samples were plated on HARDYCHROM-ESBL and KPC Colorex media and were incubated at 37°C for 24 hours. Results: The first identified CRE-positive patient was admitted to the new unit on December 4, 2020; urine culture obtained at the time of admission grew KPC–producing Klebsiella pneumoniae (KPC-KP). The sink in this patient’s room had been sampled 3 prior times (most recently on November 9, 2020) and was negative for CRE. On December 7, 2020, KPC-KP was found on the drain cover (6,750 colony-forming units, CFU) and in the sink’s P-trap (1,840 CFU) of the index patient’s room during routine sink surveillance. Additional samples from other room surfaces were taken on December 9, 2020, and KPC-KP was recovered from the computer keyboard (452 CFU) and patient bedrails (880 CFU). The patient was discharged from this room December 13, 2020, and the room underwent enhanced terminal room cleaning including UV-C light. On the next routine sink sampling on January 4, 2021, KPC-KP was recovered again in the index room sink P-trap (9,800 CFU) but at no additional sites. MLST was performed, and all isolates were ST-258. Conclusions: In a new bed tower with no prior evidence of CRE-positive patients, the first identified case of a CRE (KPC-KP) in a patient resulted in widespread environmental contamination of the room after only 3 days of hospitalization and contamination of the in-room sink drain that persisted after 1 month. Given the ease with which CRE colonizes wastewater drains, new strategies are needed to mitigate drain colonization and to prevent CRE transmission to subsequent patients.

Funding: No

Disclosures: None

Background: Care bundles comprise evidence-based practices and interventions that are easily and consistently implemented while improving patient outcomes. As patient acuity and task overload continue to increase, infection prevention bundle and process measure compliance and data collection may become a lower priority for registered nurses (RNs). In early 2019, a certified nursing assistant (CNA) began full-time quality liaison work on a 53-bed inpatient adult oncology unit at UNC Medical Center to provide targeted compliance data collection and to correct deficits in real time when possible and within the appropriate scope of practice. Methods: The quality liaison CNA is highly motivated, with a relevant clinical background and effective communication skills. After conducting a gap analysis, the unit developed specific responsibilities for several areas of quality improvement, including infection prevention. In addition to rounding on all patients daily, the quality liaison (1) performs direct patient care tasks like Foley catheter care, (2) conducts patient education on topics such as chlorhexidine gluconate treatments, (3) performs all relevant process measure audits, and (4) easily relays missed or needed care to RNs with a door sign created as part of this initiative. High-risk findings, such as a loose central-line dressing, prompt immediate communication to the RN, with follow-up and escalation when necessary. Results: Patients and staff received the quality liaison well, and the increased attention to care bundle components and auditing ensured consistent, evidence-based care along with accurate and reliable data collection. Compared to the previous calendar year, the number of central-line audits on the unit increased by >1,400 by the end of 2019. Patient outcomes improved, and during 1 fiscal year, the unit achieved rate reductions between 40% and 55% for central-line–associated bloodstream infections, catheter-associated urinary tract infections, and healthcare-associated C. difficile infections. Staffing and logistical challenges imposed by the COVID-19 global pandemic have hampered this work because the quality liaison was redeployed to direct patient care intermittently. Correspondingly, from July to October 2020, the same infection rates increased between 30% and 353%. Conclusions: Having a designated quality liaison is an effective means to achieving quality improvements while remaining an integral member of the patient care team. As staffing has improved on this unit, the quality liaison has refocused efforts, and infection rates are beginning to improve. Given the success of the quality liaison role in improving quality outcomes on this unit, the hospital is exploring expansion of this model to additional units.

Funding: No

Disclosures: None

Group Name: Watussi Study Group

Background: A positive safety climate is an important precursor of safe care outcomes. However, only limited evidence supports the association of low surgical-site infection (SSI) rates and positive safety climate. We investigated the role that perceptions of SSI prevention measures play for both safety climate level and strength as a subjective norm, that is, the social pressure perceived to perform the prevention measures, commitment to observe SSI prevention measures despite other situational pressures, and the level of knowledge about the prevention measures. Methods: The safety climate scale of the Safety Attitudes Questionnaire and 3 scales assessing subjective norm, commitment, and knowledge were used. All items were translated and retranslated from German to French and to Italian. All translated scales were pretested for understandability. Operating room (OR) personnel in 54 Swiss acute-care hospitals were surveyed, resulting in 2,769 analyzed responses with data aggregated on the hospital level. Two regression analyses were conducted: one using the percentage of positive responses per hospital as a safety climate level indicator, and another using the standard deviation of the safety climate ratings per hospital as a safety climate strength indicator. As independent variables, the hospital means of subjective norm, commitment, and knowledge were investigated and appropriately adjusted for number of respondents and sample composition. Results: The sample consisted of 1,495 nurses (54%) and 1,101 physicians (40%). Commitment and subjective norm were significant predictors (p < 0.001 and p < .05, respectively) of safety climate level, in the expected positive direction, but KNOW was not (R2, adjusted: 0.48); for safety climate strength, only COM was significant p < 0.001 (R2, adjusted: 0.27). Conclusions: The extent to which OR personnel were committed to perform the measures, such as timely administration of antibiotics, was associated with their safety climate rating level and strength. Thus, the rather general safety climate assessments are related to more specific safety behaviors necessary to achieve good outcomes such as low infection rates. Subjective norm was related to safety climate level only, indicating that in work environments with a good safety climate, the perceived social pressure to adhere to infection prevention measures may be higher. Knowledge about SSI prevention had no significant impact on safety climate, pointing to future research regarding the role of education in implementing prevention measures. Investigating how attitudes and knowledge about measures to prevent specific patient safety outcomes furthers our understanding of the role of safety climate in patient safety improvement.

Funding: No

Disclosures: None

Background: Infection following ambulance transport, or medical-transport–associated infection (MTAI), is understudied. Although medical-transport vehicles are routinely contaminated with methicillin-resistant Staphylococcus aureus (MRSA) and/or vancomycin-resistant Enterococcus (VRE), an association between vehicle exposure and disease development has not been identified. We estimated the relative risk (RR) of developing MRSA or VRE colonization or infection within 30 days of ambulance exposure. Methods: We performed a retrospective cohort study of patients with a principal diagnosis of chest pain presenting to our emergency department (ED) from January 1, 2016, through December 31, 2019. To control for confounding by healthcare exposure, patients were included if they presented from and were discharged to nonhealthcare locations without being admitted to the hospital. Encounters were stratified by whether the patient arrived at the ED via ambulance or private vehicle. Propensity scores were calculated using multivariable logistic regression with ambulance exposure as the dependent variable. Age, smoking status, history of myocardial infarction, congestive heart failure, peripheral vascular disease, cerebrovascular disease, dementia, diabetes mellitus, and chronic kidney disease were included as covariates because their standard differences were >0.10. Propensity score matching was performed in a 2:1 ratio, but not all exposed patients received 2 matching unexposed patients due to a low sample size. A multivariable logistic regression was performed on the matched cohort to estimate the RR of newly diagnosed MRSA or VRE infection or colonization within 30 days following ambulance exposure. Results: In total, 321,229 patients had ED encounters during the study period. After applying inclusion criteria and propensity score-matching there were 11,324 patients: 3,903 in the ambulance group and 7,421 in the unexposed group. Moreover, 12 patients (0.11%) had the outcome of interest, including 9 (0.08%) with MRSA and 3 (0.03%) with VRE. The 30-day prevalences of MRSA and VRE were larger in the ambulance group than in the unexposed group: 8 (0.20%) and 4 (0.05%), respectively (P = .02). Patients who presented to the ED via ambulance were almost 4 times more likely to have MRSA or VRE within 30 days of their encounter (RR, 3.72; 95% CI, 1.09–12.71; P = .04). The RRs for MRSA and VRE alone were 3.33 (95% CI, 0.79–13.94; P = .10) and 4.14 (95% CI, 0.37–46; P = .25), respectively. Conclusions: To our knowledge, our cohort study is the first to demonstrate an association between ambulance exposure and the development of disease. These results represent the first step in evaluating MTAI burden to eventually develop targeted interventions with the purpose of reducing it.

Funding: No

Disclosures: None

Background:Pseudomonas aeruginosa uncommonly causes illness in neonatal intensive care units (NICU). A cluster of 4 infections was appreciated over 6 weeks in our inborn–delivery NICU, prompting an investigation. Methods: Upon recognition of a cluster of infections, we retrospectively audited all cultures positive for P. aeruginosa from all sites (sterile and nonsterile) over the prior year in the index NICU (NICU 1, inborn) and for comparison in the adjacent NICU (NICU 2, larger, outborn–surgical). We performed multilocus sequence testing (MLST) of available clinical isolates to identify clonality. We initiated quarterly prospective surveillance of P. aeruginosa colonization of infants through nares, perirectal swabs, and tracheal aspirates of intubated infants or oropharyngeal swabs of nonintubated infants. We also swabbed incubators, ventilatory equipment, and sinks for selective P. aeruginosa culturing. Results: We identified 7 invasive P. aeruginosa infections in the inborn NICU (5 bloodstream and 2 pneumonia) over an 11-month period (Figure 1). Over the same period, there were no P. aeruginosa bloodstream infections in the adjacent NICU. Affected neonates were high risk: gestational age ranged from 22 weeks and 4 days to 26 weeks and 3 days; day of life at infection ranged from 6 to 37; 6 infants were on a jet ventilator; and all infants were receiving enteral nutrition (6 of 7 with donor human milk and 7 of 7 with expressed mother’s milk). Two infants died from their infection, and 5 infants survived to hospital discharge. All 7 isolates were pansusceptible to routine antimicrobials. MLST of the first 4 available isolates demonstrated 4 different sequence types; however, the first 2 were from the same clonal complex, indicating relatedness (Figure 1). For environmental samples, 8 obtained 8 cultures (swabs) of incubators and ventilatory equipment, and 24 cultures of faucets and drains of all sinks. Only sink cultures were positive, yielding 3 isolates identified as P. aeruginosa and 4 isolates identified as P. aeruginosa–like. Whole-genome sequencing (WGS) is underway to identify relatedness to the clinical isolates. We initiated quarterly infant surveillance by swab culture for P. aeruginosa nasal colonization then escalated to perirectal and oropharyngeal swab or tracheal aspirate cultures (intubated infants) in subsequent quarters. We did not detect any infants colonized with P. aeruginosa. Conclusions: We identified a cluster of P. aeruginosa in high-risk neonates with no point source. Molecular typing indicated a multiclonal cluster. This finding poses a management dilemma. A colonized water system is suspected and WGS of environmental samples is underway.

Funding: No

Disclosures: None

Figure 1.

Background: Healthcare-associated infections (HAIs) affect patient health and are tracked closely by infection prevention. Patients in a pediatric intensive care unit (PICU) acquired viral respiratory infections had longer use of respiratory support. We sought to determine the types of viral respiratory HAIs (VR-HAIs) acquired in the PICU and the characteristics of those affected. Methods: CHOC Children’s Hospital is a 334-bed tertiary-care center. Charts were reviewed on patients with VR-HAIs from fiscal years (FY) 2005–2020. High-risk VR-HAI (HR-VR-HAI) were influenza A and B, respiratory syncytial virus (RSV), adenovirus, parainfluenza, and human metapneumovirus (hMPV, added in FY 2014). Patients in the PICU, cardiovascular ICU (CVICU), and oncology ICU (OICU) with HR-VR-HAIs were reviewed. Patients were categorized according to underlying pathology, immunosuppression, and isolation prior to HR-VR-HAI. Increased respiratory support was defined as any increase from a patient’s baseline support ±24 hours of viral diagnosis: increase in oxygen flow or transition from nasal cannula to high-flow nasal cannula or ventilator support. Antibiotic escalation, defined as initiation of antibiotic therapy for ≥2 days ±24 hours of viral diagnosis or broadening the spectrum of antimicrobials for ≥2 days ±24 hours of viral diagnosis. Results: During FY 2005–2020, there were 204 VR-HAIs: 143 HR-VR-HAIs (70%), of which 39 (27.2%) occurred in ICUs (Figure 1). Most of the HR-VR-HAIs were RSV, parainfluenza, and hMPV (Figure 2). Of 39 patients, 10 (25.6%) had underlying oncologic conditions, 9 of whom were immunosuppressed. Of 39 patients, 16 (41%) had structural cardiac disease, 4 (10.3%) had pulmonary disease, 5 (12.8%) had neurologic disease, and the remaining 4 (10.3%) had other comorbidities. Of 39 patients, 12 (31%) required an increase in respiratory support and 13 (33%) had escalation of antibiotics. Of 39 HR-VR-HAI patients, 2 died within 2 weeks of acquisition. Conclusions: HR-VR-HAIs are uncommon in ICUs. RSV, parainfluenza, and hMPV are the most common, and 1 of 3 of patients required escalation in respiratory support and/or escalation in antibiotics. All patients had underlying comorbidities. In our series, there were 2 deaths within 2 weeks of infection.

Funding: No

Disclosures: None

Figure 1.

Figure 2.

Background: Healthcare personnel (HCP) in crowded and resource-poor countries (eg Bangladesh), might be at risk of exposure to and transmission of respiratory illnesses to coworkers, patients, and caregivers. The infection control practices in public hospitals are inadequate in Bangladesh. We estimated the incidence of respiratory illness episodes among HCP, and proportion of HCP who worked during respiratory illnesses, including influenza virus infection, at 2 tertiary-care public hospitals in Bangladesh. Methods: From May 2008 to February 2016, HCP (defined as physicians, nurses, interns, patient care assistant, cleaners, and administrative staff working in adult and pediatric medicine wards) were asked to self-report to study physicians when they experienced new onset of cough, rhinorrhea, difficulty breathing, or fever during the April–September influenza epidemic period each year. Study physicians followed HCP throughout their respiratory illness episodes and recorded respiratory symptoms, onset dates, duration of illness, and days of presenteeism and absenteeism during illness. Nasopharyngeal and oropharyngeal swabs were collected after informed written consent and were tested for influenza by rRT-PCR. We used hospital records to enumerate total HCP working in the study wards during influenza season and multiplied by 6-months follow-up per year to calculate person-time contribution for estimating respiratory illness incidence. Results: HCP self-reported 107 episodes of respiratory illness during 656 person years of follow-up, for an estimated incidence of 16.3 per 100 person years (95% CI, 13–20). Of 107 episodes, 33 (31%) included fever and cough. The mean illness length was 3.9 days (SD, ±1.8). HCP worked an average of 3.4 days (SD, ±1.4) while ill. HCP missed work for a median of 1 day (IQR, 1–2) during 29 (27%) of 107 illness episodes. HCP consented to collect swabs during 56 (52%) episodes, and among them 8 (14%) of 56 tested positive for influenza (flu-A, n = 5; flu-B, n = 3). Also, 63% of HCP with influenza reported fever and cough. HCP experiencing either respiratory illness or influenza worked for similar periods of days while ill: mean, 4 (SD, ±2.2) versus mean, 3.3 (SD, ±1.4) (P = .257). HCP worked during 105 (98%) of 107 respiratory illness and 7 (88%) of 8 influenza episodes. Conclusions: Most HCP in Bangladesh, including those with influenza, worked during respiratory illnesses. The potential value of stay-at-home policies, compensation for sick days, and influenza vaccination in reducing HCP-associated respiratory pathogen transmission could be assessed in Bangladesh and similar settings.

Funding: No

Disclosures: None

Background: Despite significant morbidity and mortality, estimates of the burden of healthcare-associated viral respiratory infections (HA-VRI) for noninfluenza infections are limited. Of the studies assessing the burden of respiratory syncytial virus (RSV), cases are typically classified as healthcare associated if a positive test result occurred after the first 3 days following admission, which may miss healthcare exposures prior to admission. Utilizing an expanded definition of healthcare-associated RSV, we assessed the estimates of disease prevalence. Methods: This study included laboratory-confirmed cases of RSV in adult and pediatric patients admitted to acute-care hospitals in a catchment area of 8 counties in Tennessee identified between October 1, 2016, and April 30, 2019. Surveillance information was abstracted from hospital and state laboratory databases, hospital infection control databases, reportable condition databases, and electronic health records as a part of the Influenza Hospitalization Surveillance Network by the Emerging Infections Program. Cases were defined as healthcare-associated RSV if laboratory confirmation of infection occurred (1) on or after hospital day 4 (ie, “traditional definition”) or (2) between hospital day 0 and 3 in patients transferred from a chronic care facility or with a recent discharge from another acute-care facility in the 7 days preceding the current index admission (ie, “enhanced definition”). The proportion of laboratory-confirmed RSV designated as HA-VRI using both the traditional definition as well as with the added enhanced definition were compared. Results: We identified 900 cases of RSV in hospitalized patients over the study period. Using the traditional definition for HA-VRI, only 41 (4.6%) were deemed healthcare associated. Adding the cases identified using the enhanced definition, an additional 12 cases (1.3%) were noted in patients transferred from a chronic care facility for the current acute-care admission and 17 cases (1.9%) were noted in patients with a prior acute-care admission in the preceding 7 days. Using our expanded definition, the total proportion of healthcare-associated RSV in this cohort was 69 (7.7%) of 900 compared to 13.1% of cases for influenza (Figure 1). Although the burden of HA-VRI due to RSV was less than that of influenza, when stratified by age, the rate increased to 11.7% for those aged 50–64 years and to 10.1% for those aged ≥65 years (Figure 2). Conclusions: RSV infections are often not included in estimates of HA-VRI, but the proportion of cases that are healthcare associated are substantial. Typical surveillance methods likely underestimate the burden of disease related to RSV, especially for those aged ≥50 years.

Funding: No

Disclosures: None

Figure 1.

Figure 2.

Background: Research testing human study participants regarding the effectiveness of face masks in preventing influenza transfer or transmission is limited. In this pilot study, we investigated the following question: In influenza-positive veterans, what is the effect of face-mask wearing in comparison to not wearing a face mask on influenza transfer to bedside tables measured for 2 hours per condition over a 10-week period during the 2019–2020 influenza season Methods: Influenza-positive veterans with influenza symptom onset ≤ 120 hours admitted to the Salem Veterans Affairs Medical Center were recruited to participate in this study. Exclusion criteria included critical illness requiring an oxygen mask or intubation. The Precept® FluidGard® 160 Procedure Mask 15300, Precept Medical Products, Inc., Arden, NC was worn by all participants during the two-hour intervention period. Surface swabs were used to measure the presence of influenza on bedside tables. CDC/NIOSH tested for influenza A and B from surface samples and facemasks using real-time polymerase chain reaction (PCR) assay (TaqMan ThermoFisher Scientific). Demographic information was collected (Table 1). A study questionnaire collected qualitative data on tolerability and feasibility of wearing a facemask when hospitalized with influenza. Institutional Review Board approval was granted. Results: From January 2, 2020, to March 11, 2020, 8 participants completed the study. Mean age was 67 years, all were male. Of these 8 participants, 6 had influenza A and 2 had influenza B. Half were diabetic; all received oseltamivir. Relative room humidity ranged from 15.6% to 39.8%. Neither influenza A nor B was detected by qPCR on bedside tables for any of the 8 participants under either face-mask–wearing condition. All participants reported that wearing the face mask was easy or very easy; of these, 5 reported experiencing warmth from the mask. Also, 50% of participants selected 2 hours as the time they could tolerate wearing a mask; the other 25% specified they could wear the face mask for 3 hours or 5 hours or more, respectively. Conclusions: In this pilot study, we demonstrated that wearing face masks is a tolerable infection control practice for providing source control for inpatients with influenza and will guide future research. Because a major limitation was the small size of the study, associated with lack of viral capture, a larger study is planned. Using face masks for source control among inpatients with influenza and other respiratory virus infections should be considered a standard infection control practice.

Funding: No

Disclosures: None

Table 1.

Table 2.

Table 3.

Background: Deep and organ-space surgical site infections (SSIs) are serious complications of coronary artery bypass graft (CABG) procedures. It is unclear whether the use of bilateral versus single internal mammary artery (BIMA vs SIMA) and surgical approach to internal mammary artery (IMA) harvest (pedicled vs skeletonized) are independent risk factors for SSI. The use of BIMA grafting redirects blood flow away from the sternum to the heart and may increase SSI risk due to lower tissue perfusion. A skeletonized approach to graft harvest, wherein the IMA is dissected free of surrounding tissue to preserve collateral sternal blood flow, may decrease SSI risk as compared to a pedicled approach in which the IMA is mobilized within a tissue pedicle. We describe the incidence and potential risk factors for post-CABG SSI in an academic tertiary-care center performing ~500 IMA procedures annually. Methods: Data were abstracted on adult patients who underwent a CABG procedure using at least 1 IMA graft between July 2017 and June 2020. Additional data on potential risk factors for SSI were obtained electronically from hospital data marts and the Division of Cardiac Surgery database, including demographics, comorbidities, number of arterial grafts, surgical approach, surgeon, and discharge location. Using standard NHSN definitions, infection control practitioners identified post-CABG deep and organ-space SSIs. Patient and procedure characteristics were evaluated as potential risk factors for deep and organ-space SSI using the Fisher exact test. Results: Of 1,591 CABG procedures performed during the study period, 1,244 (78.2%) were performed using a SIMA technique and 347 (21.8%) were performed using a BIMA technique. The overall post-CABG SSI incidence was 1.2 per 100 procedures, with 1.0 SSIs per 100 SIMA procedures and 1.7 SSIs per 100 BIMA procedures. Table 1 demonstrates an increase over time in proportion of CABG procedures performed using SIMA and skeletonized IMA grafts. We also observed a decrease in overall SSI incidence over this period. See Table 2 for univariate predictors of post-CABG SSI. Conclusions: Female sex, BMI ≥40, age ≥75 years, diabetes, and discharge to a rehabilitation setting were associated with development of post-CABG SSI. Although the overall incidence of deep and organ-space SSI in our cohort was very low, making it difficult to draw conclusions about potentially modifiable risk factors, an increase in the use of SIMA and skeletonized grafts appears to be accompanied by a decrease in SSI incidence. More data from our institution and others are needed to determine the significance of this trend.

Funding: No

Disclosures: None

Table 1.

Table 2.

Background: Left-ventricular-assist device (LVAD)–related infections occur in 20%–40% of LVAD recipients and may result in up to 10% of LVAD-related deaths. Optimal surgical infection prophylaxis for LVAD implantation is not well defined. Our institution historically used a 4-drug surgical infection prophylaxis regimen of fluconazole, ciprofloxacin, rifampin, and vancomycin as recommended by the device manufacturer. In January 2020, a 2-drug surgical infection prophylaxis regimen of vancomycin and cefazolin was implemented to reduce broad-spectrum antibiotic use while preserving gram-positive coverage. The primary objective of this study was to compare LVAD-associated infection rates before and after changing surgical infection prophylaxis. Methods: A retrospective review of patients who underwent LVAD implantation between January 2018 and January 1, 2021, was performed. Definitions of LVAD-associated infections and non-LVAD infections were based on the International Society for Heart and Lung Transplantation guidelines. Infection rates at 2 weeks and 30 days after implantation and 30-day mortality were compared between the 4-drug surgical infection prophylaxis regimen (January 2018–December 2019) and the 2-drug regimen (January 2020–January 2021). Additional data collected included demographics, cause of cardiomyopathy, type of infection, and causative organism. Results: In total, 51 patients were in the 4-drug surgical infection prophylaxis group and 23 patients were in the 2-drug surgical infection prophylaxis group. Baseline characteristics between the groups were similar. The cause of cardiomyopathy in both groups was predominantly nonischemic (67% vs 70%, = .81), and most patients received a Heartmate III device (84% vs 100%, P = .06). There was no statistical difference between infection rates in the 4-drug and 2-drug prophylaxis groups at 2 weeks or 30 days (Table 1). The 30-day mortality rate was 4% in the 4-drug group versus 13% in the 2-drug group (P = .17). No deaths were due to infections. Gram-negative and fungal LVAD–associated infections were rare: 4% versus 4% (P = .99) for gram-negative infections and 2% versus 0% (P = .99) for fungal infections. The most commonly isolated organisms were Staphylococcus aureus and coagulase-negative Staphylococcus in both groups. Pneumonia was the most common infection in both groups (Figure 1). Conclusions: We did not observe a significant increase in infection or mortality with narrowing of perioperative antibiotics. However, these results should be interpreted cautiously given the small sample size. Larger studies are needed to confirm these findings.

Funding: No

Disclosures: None

Table 1.

Figure 1.