Background: Upon admission, 56.8% of patients entering 6 Michigan nursing facilities from regional acute-care hospitals (ACHs) were colonized with 1 or more antibiotic-resistant organisms (AROs) (Mody 2018, CID). This observation raises 2 questions critical to regional infection control strategies: (1) Is the high ARO burden entering nursing facilities driven by dominant epidemic lineages or diverse circulating strains? and (2) What are the relative roles of patient characteristics (eg, high-risk patients) and exposure to specific ACHs (eg, high-risk facilities) in determining whether patients are colonized with AROs upon nursing facility admission? Here, we integrated whole-genome sequencing, patient transfer, and clinical data to answer these questions for the 4 most prevalent ARO species in the region: methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococcus faecalis (VREfc), Enterococcus faecium (VREfm), and ciprofloxacin-resistant Escherichia coli (CipREc). Methods: We studied colonizing isolates collected via active surveillance of 584 patients in 6 Michigan nursing facilities between 2013 and 2016. The whole genome of the first isolate of each ARO species collected from each patient was sequenced and analyzed to identify sequence types (STs) and to infer the transmission network by species. We determined the connectedness between nursing facilities based on the number of patients received from the same ACHs and assigned each ARO to the most recent ACH using curated transfer information. The associations between patient characteristics and recent ACH exposures with colonization by ARO were examined using multivariable models. Results: Most of the sequenced ARO isolates belonged to major healthcare-associated lineages: MRSA (ST5, N = 78 of 117); VREfc (ST6, N = 68 of 75); CipREc (ST131, N = 50 of 64); and closely related VREfm isolates (N = 129). Phylogenetically closely related isolates were found across study facilities, indicating that endemic ARO lineages have permeated local healthcare networks (Fig. 1). Patient characteristics played a dominant role in determining patient risk of ARO colonization on admission to a nursing facility. Only in the case of VREfm was a hospital significantly associated with colonization after adjustment for covariates (Table 1). Conclusions: ARO lineages were widely disseminated and colonization of specific ARO lineages at nursing facility entry could not be attributed to recent exposure to a specific ACH. Thus, for the ARO lineages studied here, a broader transmission system crosses ACHs, nursing facilities and probably the community. Therefore, the best indicators of ARO colonization were patient clinical characteristics, particularly poor functional status and antibiotic exposure. These findings suggest that intervention efforts targeting patients with characteristics associated with ARO colonization may help limit further spread among regional facilities.

Funding: None

Disclosures: None

Background: Antimicrobial resistance is a global public health threat. Integrated actions are necessary to reduce multidrug-resistant organisms (MDROs) in healthcare settings, including antimicrobial stewardship, infection prevention measures, and optimal environmental hygiene. We developed a project to improve hospital hygiene that involves 3 phases: (1) diagnostic, compounded by assessment of cleanliness and identification of barriers and facilitators for environment cleanliness improvement; (2) intervention, based on review of structure and processes followed by a training program focused on major weaknesses identified; and (3) evaluation, impact of the intervention assessment. Objectives: We performed group interviews to identify barriers and facilitators for improving environment cleanliness. Methods: The project was performed by the infection control team and the housekeeping manager in a 350-bed, private hospital located in the city of São Paulo (Brazil). Two group interviews were conducted, one involving supervisors and the other involving housekeeping cleaners. All professionals were invited to participate. A semistructured questionnaire was used to guide the discussion, which was compounded by the following topics: working process, availability of human and material resources, training on institutional norms and routines, perception regarding work conditions, and quality of cleanliness. Results: In total, 33 professionals attended the interviews: 12 were supervisors and 21 were housekeeping cleaners. The main facilitator identified was a good perception by the housekeeping team regarding the project. We identified several sets of barriers: (1) human resources, such as supervisor executing the cleaning, inadequate sizing of human resources in shifts, reduced scale on Sunday and holiday shifts, and lack of professional replacement for sick leave and vacation; (2) supplies and equipment, such as torn bed linen, insufficient mops, centralized and inadequate dilution of sanitizers causing delays and impacting quality of hygiene; (3) education, such as lack of training program perceived by supervisors (management) and housekeeping cleaners (basic procedures for cleaning) and knowledge regarding who cleans what; (4) motivation and relationships, such as supervisor perceptions that housekeeping cleaners are unmotivated, and this causes absenteeism. The team feels that they are disregarded by doctors, and they have relationship problems with nursing and hospital engineering staff. Also, they are afraid of being physically assaulted by coworkers. Finally, professionals reported the perception that the hospital is not clean enough and that this is related to the short time goals imposed on the staff. Conclusions: The main barriers identified were related to education strategies and management of human and material resources. The results will support the intervention phase.

Funding: None

Disclosures: None

Background: Urinary tract infections (UTIs) are common healthcare-associated infections. Evidenced-based practice (EBP) successes of catheter associated urinary tract infection (CAUTI) bundles has resulted in rates decreasing >50% in community-based nursing homes. The South Texas Community Living Center (CLC SA), our 42-bed long-term care and rehabilitation center, conducts routine infection prevention surveillance. During routine surveillance, the infection prevention team noticed an increase in UTI percentages and CAUTI rates. Thus, we sought to increase compliance with standard CAUTI bundles, and we implemented an intervention called the “bladder bundle.” Methods: A multidisciplinary team (ie, infection preventionist, clinical nurse leader, simulation director, educator, leadership and frontline staff champions) identified and evaluated practices through documentation of audits and safety rounds during April and May of 2017 (FY19 QTR 3). The comprehensive bladder bundle was initiated in June 2017, based on EBP interventions and included education for staff with audit and feedback. The team reviewed the literature and expanded the bladder bundle to include a comprehensive urinary note and oral hydration program for the veterans in addition to the standard CAUTI bundles (ie, minimize catheter use, use with appropriate indications, consider alternatives to catheters, proper insertion and securement). In May 2018, a facility-wide, hospital-wide initiative focused on a new urinary catheter insertion kit, insertion competencies and perineal care to improve outcomes. This initiative was added to our bladder bundle for CLC SA. Results: Before the intervention (FY16 Q3 to FY17 Q2), percentages of veterans with a UTI had increased to 4.65%, in FY17 Q3, this rate had increased to 11.76%. After the intervention (FY17 Q4 to FY19 Q3) the percentage dropped significantly to 0%, and this rate has now been sustained for 8 quarters. Our CLC SA has remained at zero harm and has no NHSN CAUTI has occurred since October 2017 (FY18Q1). The catheterization in bladder days has decreased from 162 days in FY14 to 49 in FY18, and for the first 2 quarters of FY19, there were only 25 days. For the last 8 quarters, documentation compliance has increased, as has use of BB interventions. Conclusions: The continuous improvement project targeted within the CLC SA, with education to staff, audit and feedback tools, and a comprehensive urinary note with the oral hydration program in combination with the standard CAUTI bundles, have improved veteran health outcomes and have expanded provider and nursing practices. The interprofessional team approach enhanced the success of this project.

Funding: None

Disclosures: None

Background: The CMS and the CDC recommend that all healthcare facilities have an effective water management program (WMP). Our WMP has been in place since 2010; it includes members from facilities operations, infection prevention and control, environmental services, and industrial hygiene. The team meets regularly to discuss current water issues, reviews validation data and water testing reports. Description of event: In April 2018, we suddenly experienced discolored water and sediment at multiple water fixtures throughout the 3.3 million square-foot hospital campus. The hospital incident command structure (HICS) was activated to assist in investigating and managing the situation. Immediate response: Water was deemed unsafe while the cause was being investigated. Bottled water was distributed to 950 hospital patients, and >8,000 staff and visitors. The impact included alternative methods for hand hygiene, the use of bottled water for food preparation and drinking, and the elimination of showers for patients and staff. The dialysis unit used an independent water supply that was not affected. Investigation and remediation: The hospital had 2 sources of domestic cold water: municipal water and a private well that had been in use since 1912. An investigation revealed that the well pump had malfunctioned, drawing gravel into the potable water supply. This overwhelmed the plumbing, blocked toilets and likely dislodged biofilm from the pipes. Early testing showed high levels of corrosion byproducts (ie, iron, copper, and lead) and bacterial contamination in the water, including presence of Legionella. Remediation involved isolating the well, switching to municipal water as the sole source of potable water, flushing the system, and retesting. Overall, 105 technicians flushed the water system including 6,000 water fixtures, 125 drinking fountains, and 95 emergency showers and eyewashes; they sanitized and cleaned 130 ice machines and tested 240 backflow preventers. We retested 437 water samples after remediation; all parameters had returned to the normal range. The existing water process flow diagrams were used to guide sampling for water testing. Conclusions: The hospital’s water system was brought back on line in 78 hours after the first report of “black water.” An active, mature WMP with multiple facilities technicians trained in water sampling enabled a quick response. Coordination through the HICS structure streamlined the response and enabled clear communication throughout the process.

Funding: None

Disclosures: None

Background: Cultivation of targeted pathogens has been long recognized as a gold standard for healthcare surveillance. However, there is an emergent need to characterize all viable microorganisms in healthcare facilities to understand the role that both clinical and nonclinical microorganisms play in healthcare-associated infections. Metagenomic sequencing allows detection of entire microbial communities, in contrast to targeted identification by cultivation. Widespread application of metagenomic sequencing has been impeded in part because the sensitivity and specificity are unknown, which inhibits our ability to interpret results for risk assessment. To assess the impact of sample preparation methods on sensitivity and specificity, we compared several pretreatment steps followed by metagenomic sequencing, and we performed culture-based analyses. Methods: We collected 120 surface swabs from the medical intensive care unit at Rush University Medical Center, which we aggregated to create a representative microbiome sample. We then subjected aliquots to different processing methods (DNA extraction methods, internal standard addition, propidium monoazide (PMA) treatment, and whole-cell serial filtration). We evaluated the effects of these methods based on DNA yields and metagenomic sequencing outcomes. We also compared the metagenomic results to the microbial identifications obtained by cultivation using environmental microbiology methods and matrix-assisted laser desorption/ionization time-of-flight mass spectrometry (MALDI-TOF MS). Results: Our results demonstrate that bead-beating and heat lysis followed by liquid-liquid extraction is the optimal method for the identification of low-biomass surface-associated microbes, as opposed to widely used column-based and magnetic bead-based methods. For low-biomass surface-associated samples, ~590,000 reads per sample are sufficient for ≍90% coverage in metagenomic sequencing (Fig. 1). The ZymoBIOMICS microbial community standard is not appropriate for methods assessing membrane integrity. For the identification of putatively viable microorganisms, PMA treatment is promising, although elimination of signals from nonviable organisms will reduce the overall detectable signal. Combining PMA-treated metagenomic sequencing with cultivation yields the most comprehensive results, particularly for low-abundance taxa, despite high sequencing coverage (Fig. 2). To distribute more detection resources to bacteria, our target domain, we tried whole-cell filtration prior to extraction, attempting to isolate bacterial cells from eukaryotic cells and other particles. For low-biomass surface-associated samples, the sample loss and the difficulties in performing filtration outweigh the slight increase of bacterial signal. Conclusions: Despite optimization, we observed certain blind spots in both cultivation and metagenomic sequencing. This information is essential for informed risk assessment. Further research is needed to identify additional limitations to ensure that results from metagenomic sequencing can be interpreted in the context of healthcare-acquired infection prevention.

Funding: This work was supported by the Centers for Disease Control and Prevention (BAA FY2018-OADS-01 Contract 02915).

Disclosures: None

Background: Blood cultures are part of the evaluation of hospital patients with fever. Patients with central lines in place, frequently have blood samples for culture drawn through lines. We sought to assess blood culturing practices at our institution. Methods: Retrospective review of BCs performed in hospitalized patients over a 12-month period (August 2018–July 2019) at an academic, tertiary-care center with 1,297 licensed beds and >62,000 admissions a year. A specialized phlebotomy team is involved in all peripherally drawn blood samples; however, the patient’s nurse obtains a blood sample through a central line. Results: Overall, 35,121 blood cultures were performed for an incidence rate of 106 BC per 1,000 patient days or 566 blood cultures per 1,000 admissions. Most blood samples (67%) were collected via peripheral venipuncture. We detected significant variation in culturing rates and the proportion of blood samples obtained through central lines among collecting units (Table 1). Overall, the blood culture contamination rate was 1.6%. Blood samples obtained through a central line had a higher contamination rate (2.2%) compared to samples obtained through peripheral venipuncture (1.3%; P < .0001). Blood culture rates were highest in intensive care units (ICUs) compared with other types of patient care units (Table 1). The blood culture positivity rate was significantly lower in ICUs (8.8%) compared with hematology-oncology (10%; HR, 0.88; CI, 0.80–0.96; P = .006), general medicine (10%; HR, 0.88; CI, 0.80–0.97; P = .013), and pediatrics (12%; HR, 0.74; CI, 0.59–0.92; P = .008). The ICUs had the lowest rate of BC contamination at 1.3%. Conclusions: Blood samples obtained through central lines for culture are more likely to be contaminated than peripherally drawn blood samples. Despite a relatively high rate of line-drawn blood samples for culture, ICUs had the lowest BC contamination rate, possibly reflecting high familiarity of ICU nurses with line draws. Blood samples collected through lines were most frequently performed in pediatrics and hematology-oncology, and these units had correspondingly higher rates of contamination. This information will be used to inform institutional guidelines on blood culturing and to identify ways to minimize blood culture contamination, which often results in additional testing and/or unnecessary antimicrobial use.

Funding: None

Disclosures: Consulting fee- Merck (Priya Sampathkumar)

Background:Staphylococcus aureus is one of the leading pathogens isolated from bloodstream infections (BSIs), and vancomycin has been the main choice to treat MRSA (methicillin-resistant S. aureus) infections. Vancomycin-intermediate S. aureus (VISA) and heteroresistant-VISA (hVISA) have been described, limiting this antibiotic use. We evaluated aspects associated with the resistance and its clonality of the S. aureus isolated from BSIs, and we determined their association with clinical aspects of patients attended at Rio de Janeiro between 2016 and 2018. The detection of MRSA and trimethoprim-sulfamethoxazole resistant isolates was performed using the disk diffusion test, while the minimum inhibitory concentrations (MICs) were evaluated for 5 antimicrobials using the broth microdilution method. The MICs for ceftaroline and vancomycin of the MRSA isolates were determined using the E test. The presence of hVISA isolates was evaluated for isolates with vancomycin MICs of 1 and 2 μg/mL by screening on BHI agar added with vancomycin. The population profile was divided by the area under the curve (ie, PAP/AUC test). SCC mec was evaluated by PCR and the clonal profile by PFGE method. Among 123 S. aureus isolates from BSI, 31% were MRSA. MIC50 and MIC90 were daptomycin 2 and 2 μg/mL; linezolid, 1 and 1 μg/mL; oxacillin 1 and 256 μg mL; teicoplanin, 0.5 and 0.5 μg/mL and vancomycin 1 and 1 μg/ml. MIC values for ceftaroline and vancomycin were 0.75 and 2 μg/mL. The frequency of isolates not susceptible to daptomycin was 75%. The clonal lineages and SCCmec types found were USA100/ST5-II (50%), USA800/ST5-IV (22%), USA300/ST8-IV (15.8%), USA1100/ST30-IV (5.3%), BEC/ST239-III (5.3%), and 1 isolate carrying SCCmecV/ST1. We found 1 VISA isolate, and the PAP/AUC analysis detected 3 hVISA isolates that were associated with the USA100 and USA300 lineages. Overall, 85% of patients had a vascular catheter. More advanced age was associated with MRSA infection as was higher mortality. Patients with end-stage renal disease were more affected by MSSA infection. Daptomycin nonsusceptibility and VISA and hVISA phenotypes associated with prevalent clonal lineages were described. In addition, MRSA infections presented higher mortality, which emphasizes the importance of epidemiological studies.

Funding: None

Disclosures: None

Background: Multiple studies have demonstrated that pathogens are present in both apparatus and stations within the fire service. Pasco County Fire Rescue’s (PCFR’s) 500+ firefighters routinely wear boots to trauma scenes and into patient’s residences and then into the dormitory and living areas of the fire stations. Pasco County Fire Rescue (PCFR) recently participated in a larger effort to identify the bacteria, yeast, and mold that firefighters, emergency medical technicians, and paramedics are exposed to on apparatuses and the station living environment during a typical shift. During these efforts to swab multiple touch points within apparatus (ambulances and engines) and common areas of the stations, firefighters’ boots were identified as a significant source of bacterial contamination. Methods: Swabs of 191 surfaces in 23 vehicles and 5 fire stations were collected, including 3 swabs from the bottom of firefighter boots. Results: Firefighter boots had the highest bacterial CFUs of all locations swabbed, with >900,000 and 378,000 CFUs per boot. Disinfection with a quaternary ammonium product sprayed through an electrostatic sprayer system effectively reduced the bacterial contamination on boots. Conclusions: PCFR recognizes firefighter boots as a critical vector of contamination between the environment encountered on emergency medical calls and the fire station environment and, as a result, has started a preliminary education campaign for agency firefighters regarding the need for regular boot disinfection. These efforts include regular submissions to the biweekly employee newsletter, as well as reminders on interoffice mailing envelopes (see example below) in hopes of increasing informal, self-directed boot cleaning and disinfection efforts. The next steps include verifying the effectiveness of specific disinfectant cleaners on boots; addressing logistical and practical barriers to routine cleaning and disinfection of boots; and developing, implementing, and evaluating a protocol for regular boot cleaning and disinfection.

Funding: None

Disclosures: None

Background: Exposure to medical devices can be a risk factor for the development of healthcare-associated infections; bronchoscopes are a leading cause of device-associated outbreaks. We describe bronchoscope-related outbreaks and pseudo-outbreaks reported to the Centers for Disease Control and Prevention’s Division of Healthcare Quality Promotion (DHQP), and we summarize investigation steps and control measures. Methods: We identified bronchoscope-related consultations with state and local health departments between July 1, 2014, and September 30, 2019, in the DHQP database. We abstracted data on patient symptoms, clinical culture results, investigation findings, and subsequent infection prevention and control interventions. Results: We identified 15 consultations involving 150 patients (range, 3–31 patients per consultation). Each consultation involved at least 1 cluster of the same organism. Organisms associated with bronchoscope-associated clusters were nontuberculous mycobacteria (n = 7), Candida spp (n = 3), Exophiala spp (n = 2), Pseudomonas aeruginosa (n = 2), Enterobacter spp (n = 2), and Raoultella planticola, Stenotrophomonas maltophilia, Achromobacter spp, Mycobacterium tuberculosis, and Aspergillus spp (1 each; 2 consultations involved multiple pathogens). Procedures from which these patient specimens were collected included bronchoalveolar lavage, bronchial wash, bronchial brushing, sputum swab, and lymph node biopsy. For the 7 outbreaks in which clinical data were available, 5 did not have patients with clinical infections related to the pathogen recovered. Two consultations involved pseudo-outbreaks: one involved contamination of specimen collection tubes and the other involved contamination of cultures within the laboratory. Potential underlying pathogen sources included contaminated bronchoscopes (inadequate reprocessing or device damage) (n = 10, 67%), use of nonsterile ice, water, or saline during the procedure (n = 4, 27%), contaminated specimen collection tubes (n = 1, 7%), contaminated bronchoscope suite (n = 1, 7%), and clinical laboratory contamination (n = 1, 7%). The most common interventions included improvement of reprocessing procedures (n = 5), removal of possibly damaged bronchoscopes (n = 4), and eliminating nonsterile ice and water exposures in bronchoscopy (n = 3). Conclusions: Water-related organisms were the most commonly identified pathogens in bronchoscope-related consultations, highlighting the important role that exposure to contaminated water during bronchoscopy and bronchoscope reprocessing might play in bronchoscopy-associated outbreaks and pseudo-outbreaks. During bronchoscope-related outbreaks identifying a common pathogen could indicate problems in bronchoscope handling or reprocessing, device damage, or exposure to nonsterile water.

Funding: None

Disclosures: None

Background: Studies on the effectiveness of hospital-based interventions often measure hospital-onset infections as the outcome of interest. However, hospital-associated infections may manifest after patient discharge (classified as hospital-associated community-onset, HACO), and the epidemiology may vary by antibiotic resistance (AR) profile. We examined the epidemiology and trends of HACO infections of AR and non–antibiotic-resistant (non-AR) bacteria. Methods: We included clinical community-onset (CO) cultures (obtained sooner than or on day 3 of hospitalization) yielding the bacterial species of interest among hospitalized patients in 260 hospitals in the Premier Healthcare Database from 2012 to 2017. HACO infections were defined as CO cultures in a patient who had a previous hospitalization in the same hospital within 30 days. We examined methicillin resistance among Staphylococcus aureus (MRSA), vancomycin resistance among Enterococcus spp (VRE), carbapenem resistance among Enterobacteriaceae (E. coli, Klebsiella spp, and Enterobacter spp) (CRE), extended-spectrum cephalosporin resistance suggestive of extended-spectrum β-lactamase (ESBL) production in Enterobacteriaceae, carbapenem resistance among Acinetobacter spp (CRAsp), and carbapenem resistance among Pseudomonas aeruginosa (CRPA). We described the proportion of CO infections that were HACO, the proportion of HACO infections from sterile sites, overall HACO rates, and annual trends for sensitive and resistant phenotypes. Generalized estimating equation regression models that accounted for hospital-level clustering were used to estimate annual trends controlling for hospital characteristics and month of discharge. Results: The rate of HACO infections by pathogen ranged from 0.78 to 38.76 per 10,000 hospitalizations; 7%–34% were sterile site infections (Table 1). For each bacterial pathogen, a significantly higher proportion of AR CO infections had a previous hospitalization compared to non-AR CO infections (all χ2, P < .05). The annual trends for AR and non-AR HACO infections between 2012 and 2017 were significantly decreasing for most pathogens, except ESBL HACO infections. Conclusions: Even when using a definition limited to readmission to the same hospital, HACO infections occur commonly with differing rates by pathogen and antibiotic resistance profile. Although these rates are decreasing for most of the pathogens studied, improving surveillance and identifying prevention strategies for these infections are necessary to further reduce the burden of hospital-associated infections.

Funding: None

Disclosures: None

Background:Candida auris and carbapenemase-producing organisms (CPO) are multidrug-resistant organisms that can colonize people for prolonged periods and can cause invasive infections and spread in healthcare settings, particularly in high-acuity long-term care facilities. Point-prevalence surveys (PPSs) conducted in long-term acute-care hospitals in the Chicago region identified median prevalence of colonization to be 31% for C. auris and 24% for CPO. Prevalence of C. auris colonization has not been described in pediatric populations in the United States, and limited data exist on CPO colonization in children outside intensive care units. The Chicago Department of Public Health (CDPH) conducted a PPS to assess C. auris and CPO colonization in a pediatric hospital serving high-acuity patients with extended lengths of stay (LOS). Methods: CDPH conducted a PPS in August 2019 in a pediatric hospital with extended LOS to screen for C. auris and CPO colonization. Medical devices (ie, gastrostomy tubes, tracheostomies, mechanical ventilators, and central venous catheters [CVC]) and LOS were documented. Screening specimens consisted of composite bilateral axillae and groin swabs for C. auris and rectal swabs for CPO testing. The Wisconsin State Laboratory of Hygiene tested all specimens. Real-time polymerase chain reaction (PCR) assays were used to detect C. auris DNA and carbapenemase genes: blaKPC, blaNDM, blaVIM, blaOXA-48, and blaIMP (Xpert Carba-R Assay, Cepheid, Sunnyvale, CA). All axillae and groin swabs were processed by PCR and culture to identify C. auris. For CPO, culture was only performed on PCR-positive specimens. Results: Of the 29 patients hospitalized, 26 (90%) had gastrostomy tubes, 24 (83%) had tracheostomies, 20 (69%) required mechanical ventilation, and 3 (10%) had CVCs. Also, 25 (86%) were screened for C. auris and CPO; 4 (14%) lacked parental consent and were not swabbed. Two rectal specimens were unsatisfactory, producing invalid CPO test results. Median LOS was 35 days (range, 1–300 days). No patients were positive for C. auris. From CPO screening, blaOXA-48 was detected in 1 patient sample, yielding a CPO prevalence of 3.4% (1 of 29). No organism was recovered from the blaOXA-48 positive specimen. Conclusions: This is the first documented screening of C. auris colonization in a pediatric hospital with extended LOS. Despite a high prevalence of C. auris and CPOs in adult healthcare settings of similar acuity in the region, C. auris was not identified and CPOs were rare at this pediatric facility. Additional evaluations in pediatric hospitals should be conducted to further understand C. auris and CPO prevalence in this population.

Funding: None

Disclosures: None

Background:Candida auris is an emerging pathogen with high mortality and challenges in detection. C. auris healthcare-associated infections are now being reported worldwide. Most isolates are resistant to fluconazole, and some show resistance to all 3 classes of antifungals. Herein, we describe C. auris surveillance in the VA. Methods: Cultures were identified using VA data sources for C. auris isolates and surveillance cultures (axilla and groin) performed January 1, 2010, through October 15, 2019. Chart reviews were performed for patients with C. auris, including isolate susceptibilities and antifungal treatment. Results: Overall, 6 C. auris isolates from 3 patients at 2 VA hospitals (located in the Midwest and Northeast) were identified. From a single patient, 3 urine isolates were identified June–July 2018, and they were susceptible to all antifungals tested (voriconazole, posaconazole, micafungin, itraconazole, flucytosine, caspofungin, anidulafungin, amphotericin B, and fluconazole). No antifungal treatment was received (presumed colonization). C. auris surveillance cultures for 32 additional patients at this facility between July 10, 2018, and July 19, 2018, were negative. From a second patient (admitted November 9, 2018), 2 C. auris blood isolates were identified at the same facility, first on February 3, 2019, and they were susceptible to all antifungals tested (same as above). The infection was deemed healthcare associated, and the patient received 2 weeks of micafungin. On October 11, 2019, C. auris was identified again (susceptibilities as above) and another course of micafungin was started. A third patient from a different VA hospital had a C. auris sputum isolate (September 5, 2018, susceptibilities not reported), which was not treated with antifungals. This patient with tracheostomy had a documented history of C. auris colonization from a non-VA long-term care facility. This VA facility screened 3 additional patients for “rule out C. auris” between July 2018 and March 2019,finalized as C. parapsilosis (1 blood and 1 wound isolate) and C. tropicalis (1 blood isolate). At 2 other VA facilities, 3 patients had C. auris surveillance cultures performed in 2019, which were negative. Additionally, at least 65 isolates of C. haemulonii, which can be difficult to distinguish from C. auris, have been identified from 51 unique individuals at 24 other VA facilities since 2010. Conclusions: Two VA facilities have identified cases of C. auris infection and colonization. Additional awareness is needed because C. auris can be difficult to identify using traditional biochemical methods and may be resistant to standard treatment. According to the CDC, screening of close healthcare contacts should be considered for patients with newly identified C. auris infection or colonization. Early and accurate diagnosis are important for improving outcomes and reducing transmission of this rapidly emerging pathogen.

Funding: None

Disclosures: None

Background: The multidrug-resistant fungus Candida auris is emerging as a major cause of healthcare-associated infection globally. Understanding the epidemiology of these infections in vulnerable groups such as cancer patients is important for hospital infection control and their effective management. In this report we present diagnostic, clinical, antifungal resistance and outcome data of 11 cases of C. auris infection from an oncology center in India. Methods:C. auris strains were identified by Sanger-based DNA sequencing of the internal transcriber spacer (ITS) gene. Antifungal susceptibility testing (AFST) was performed using the broth dilution method. Identification and AFST were checked by the WHO Collaborating Center for Reference & Research on Fungi of Medical Importance. Patients had both empirical as well as directed therapy with antifungal agents based on AFST results and clinical assessment. Results: Between November 2018 and March 2019, 11 cases of C. auris (8 from patients with solid-organ tumors and 3 from hematological malignancy) were detected. Two distinct genetic clusters were identified by ITS gene sequencing; one of these clusters showed 100% homology with a previously unknown C. auris isolate (GenBank accession no. MK881076) and the other cluster had a 100% identity score with isolates from Japan and South Korea (GenBank accession nos. MH071441, KY657027, and EU884189). All 11 strains were resistant to fluconazole. With voriconazole, 1 isolate was susceptible, 3 were resistant, and 7 showed dose-dependent susceptibility. Two isolates were resistant to amphotericin B. Resistance to caspofungin or anidulafungin was noted in 1 of 11 isolates (9%); most showed intermediate susceptibility (63% to caspofungin). Among all of the patients, 72% were from the intensive care unit (ICU) or the high-dependency unit. The 30-day all-cause mortality was 5 of 11 (45%) in the C. auris group and 4 of 11 (36%) the control group (ie, infections with other Candida spp during same period). Duration of ICU stay in the C. auris group was 12 days and in the control group it was 6 days. The median cost (in terms of hospital bill at the time of discharge or death) for management of Candida auris infection and the primary medical condition was US$10,121 for the C. auris groups and US$8,608 for the control group. Most cases (10 of 11) were detected in wards without isolation rooms, and 8 of the 11 C. auris cases (73%) were detected in patients in the intensive care unit. Conclusions: Morbidity, mortality, ICU stay, and healthcare costs are significant in C. auris infection.

Funding: None

Disclosures: None

Background:Candida auris is an emerging pathogen associated with nosocomial outbreaks. During January to May 2019, 11 invasive cases of C. auris were identified in the intensive care unit (ICU) and high-dependency unit (HDU) at a hospital in Nairobi, Kenya. We report on the interventions implemented to control the outbreak. Methods: Intensified infection prevention and control (IPC) interventions were implemented. All patients infected or colonized with C. auris were placed in single-patient rooms with strict contact precautions. Cleaning of the patient care environment was enhanced by instituting a 3-step procedure of cleaning with soap and water, disinfecting with 0.5% chlorine, and rinsing with water. Glo-Germ gel was used to evaluate the cleaning processes, and percentage of missed surfaces was calculated. Hand hygiene training and compliance observations were conducted to enforce adherence to hand hygiene. The IPC team provided training and observational feedback of IPC to staff, patients, and their families. The IPC interventions were guided by screening activities. To monitor ongoing transmission, a biweekly point-prevalence survey (PPS) was performed to screen all previously negative ICU and HDU patients for C. auris. Furthermore, admission and contact screening were added to guide patient placement. Screening was conducted by collecting a composite swab from the bilateral axilla and groin. Samples were incubated in salt dulcitol broth for 5 days at 40°C then subcultured onto Sabouraud dextrose agar. Colony identification was performed using a Vitek 2 system (bioMérieux). Results: In total, 177 patients were placed in single-patient rooms under contact precautions during May–August 2019. We conducted 123 environmental cleaning observations, and the percentage of missed surfaces decreased from 71% (10 of 14) in June to 7% (1 of 16) in August. Hand hygiene compliance among ICU and HDU staff was 79% (204 of 257) in May, 71% (159 of 223) in June, 73% (170 of 233) in July, and 81% (534 of 657) in August. In total, 283 screening swabs from 234 patients were processed during May–August 2019. Overall, 18 of 88 PPS swabs (20%), 13 of 180 admission screening swabs (7%), and 0 of 15 contact screening swabs (0%) were positive for C. auris. The PPS results showed a rapid decrease in colonization: 6 of 14 (43%) in May, 12 of 54 (22%) in June, 9 of 98 (9%) in July, and 1 of 70 (2%) in August. No new C. auris infections were identified from June to October 2019. Conclusions: The control of C. auris in a hospital outbreak requires multimodal interventions, including enhanced IPC interventions, PPS, admission and contact screening for colonization, rigorous monitoring, and team effort.

Funding: None

Disclosures: None

Objective: We conducted this study to investigate the epidemiology of candidemia in our setting and to quantify the risk factors associated with disease, overall outcome, and mortality associated with candidemia. Methods: In this prospective observational study, we conducted lab-based surveillance with clinical correlation of all cases of candidemia within our ICUs during the period (2016–2018). Clinical assessment was done on day 5 and day 30, and comorbidities, clinical features, and outcome were observed within 30 days after the diagnosis. The diagnosis was made on the basis of positive blood culture for Candida spp and a compatible clinical picture. The demographic characteristics, sequential organ failure assessment (SOFA) scores, comorbidities, use of invasive devices, antibiotics administered were observed, and antifungal susceptibility testing was performed according to CLSI guidelines. Type and duration of antifungal administered and outcomes were noted. Results: In total, 48 episodes of candidemia, with 29 (60%) males and 19 (40%) females, were identified during the study period. C. albicans was the most common specie responsible for candidemia, causing 17 of the cases (~35%), whereas rest of the cases were caused by non–albicans spp, which included C. auris, accounting for 9 (19%) C. parapsilosis and C. tropicalis 7 (15%) each, C. glabrata and C. famata 2 (6%), and C. krusei was isolated in only 2 cases (4%). Among modifiable risk factors, CVC insertion and antibiotic exposure were the leading factors, seen in 100% of patient. Candida colonization was observed in 26 patients (28%), of whom 2 (4%) had multifocal Candida colonization. Among evaluable patients, 17 (35%) died within 30 days of the onset of candidemia. C. tropicalis was associated with the highest mortality rate, 27% (n = 4) in this cohort. Regarding the crude mortality in the different units, patients in medical ICU had the highest mortality rate (54%). In vitro activity of 3 systemically active antifungal agents was tested against 48 isolates of Candida spp. Based on CLSI break points, the susceptibility to voriconazole was 98%; only 1 isolate was resistant to voriconazole. Among candidemia-positive cases, 28 patients (58%) had taken the antifungals for >14 days, whereas 18 (37.5%) were treated for <14 days and 2 (4%) died before the initiation of therapy. Conclusions: In our study, C. albicans was the most common specie responsible for candidemia, but non–albicans spp are also emerging, with higher in vitro resistance to antifungals.

Funding: None

Disclosures: None

Background: Carbapenem-resistant Enterobacteriaceae (CRE) are increasingly common in the United States and have the potential to spread widely across healthcare networks. Only a fraction of patients with CRE carriage (ie, infection or colonization) are identified by clinical cultures. Interventions to reduce CRE transmission can be explored with agent-based models (ABMs) comprised of unique agents (eg, patients) represented by a synthetic population or model-generated representation of the population. We used electronic health record data to determine CRE carriage risk, and we discuss how these results can inform CRE transmission parameters for hospitalized agents in a regional healthcare network ABM. Methods: We reviewed the laboratory data of patients admitted during July 1, 2016−June 30, 2017, to any of 7 short-term acute-care hospitals of a regional healthcare network in North Carolina (N = 118,022 admissions) to find clinically detected cases of CRE carriage. A case was defined as the first occurrence of Enterobacter spp, Escherichia coli, or Klebsiella spp resistant to any carbapenem isolated from a clinical specimen in an admitted patient. We used Poisson regression to estimate clinically detected CRE carriage risk according to variables common to data from both the electronic health records and the ABM synthetic population, including patient demographics, systemic antibiotic administration, intensive care unit stay, comorbidities, length of stay, and admitting hospital size. Results: We identified 58 (0.05%) cases of CRE carriage among all admissions. Among these cases, 30 (52%) were ≥65 years of age and 37 (64%) were female. During their admission, 47 cases (81%) were administered systemic antibiotics and 18 cases (31%) had an intensive care unit stay. Patients administered systemic antibiotics and those with an intensive care unit stay had CRE carriage risk 6.5 times (95% CI, 3.4–12.5) and 4.9 times (95% CI, 2.8–8.5) higher, respectively, than patients without these exposures (Fig. 1). Patients ≥50 years of age and those with a higher Elixhauser comorbidity index score and with longer length of stay also had increased CRE carriage risk. Conclusions: Among admissions in our dataset, CRE carriage risk was associated with systemic antibiotic exposure, intensive care unit stay, higher Elixhauser comorbidity index score, and longer length of stay. We will use these risk estimates in the ABM to inform agents’ CRE carriage status upon hospital admission and the CRE transmission parameters for short-term acute-care hospitals. We will explore CRE transmission interventions in the parameterized regional healthcare network ABM and assess the impact of CRE carriage underestimation.

Funding: This work was supported by Centers for Disease Control and Prevention (CDC) Cooperative Agreement number U01CK000527. The conclusions, findings, and opinions expressed do not necessarily reflect the official position of CDC.

Disclosures: None

Background: Carbapenem-resistant Enterobacteriaceae (CRE) cause significant morbidity and mortality each year in the United States. Treatment options for these infections are often limited, in part due to carbapenemases, which are mobile β-lactam-hydrolyzing enzymes that confer multidrug resistance in CRE. As part of the CDC’s Containment Strategy for Emerging Resistance, public health laboratories (PHLs) in the CDC Antibiotic Resistance Laboratory Network (AR Lab Network) have worked to characterize clinical isolates of CRE for rapid identification of carbapenemase genes. These data are then used by public health and healthcare partners to promote patient safety by decreasing the spread of resistance. We summarize carbapenemase gene profiles in CRE, by genus and geography, using data collected through the AR Lab Network from January 2018 through August 2019. Methods: CRE isolates were submitted to 55 PHLs, including those of all 50 states, 4 large cities, and Puerto Rico, in accordance with each jurisdiction’s reporting laws. PHLs performed phenotypic and molecular testing on isolates to detect targeted, emerging carbapenemase genes and reported results to submitters. Carbapenemase-positive (CP) isolates were defined as PCR positive for ≥1 carbapenemase gene tested: blaKPC, blaNDM, blaVIM, blaIMP, blaOXA-48–LIKE. PHLs submitted results to CDC monthly. Genera other than Enterobacter, Klebsiella, and Escherichia coli are categorized as other genera in this analysis. Data were compiled and analyzed using SAS v 9.4 software. Results: From January 2018 to August 2019, the AR Lab Network tested 25,705 CRE isolates; 8,864 of 25,705 CRE (34%) were CP. Klebsiella spp represented the largest proportion of CP-CRE at 68% (n = 6,063), followed by E. coli (12%, n = 1,052), Enterobacter spp (11%, n = 981), and other genera (9%, n = 768). Figure 1a shows the composition of CP-CRE carbapenemase genes by genus. The most common carbapenemase and genus profiles were blaKPC in Klebsiella (74%; 5,562 of 7,561 blaKPC-positive) blaNDM in E. coli (43%; 372 of 868 blaNDM-positive) blaVIM in Enterobacter spp (35%; 25 of 72 blaVIM-positive), and blaIMP among other genera (90%; 92 of 102 blaIMP-positive). Common CP-CRE genes and genera also varied by geography (Fig. 1b). Conclusions: The AR Lab Network has greatly enhanced our nation’s ability to detect and characterize CP-CRE. Our data provide a snapshot of the organisms and regions where mobile carbapenemase genes are most often detected in CRE. Geographic variation in CP gene profiles provides actionable data to inform local priorities for detection and infection control and provide clinicians with situational awareness of the genes and organisms that are circulating in their region.

Funding: None

Disclosures: In this presentation, the authors discuss the drug combination aztreonam-avibactam and acknowledge that this drug combination is not currently FDA-approved.

Background: Carbapenem-resistant Enterobacteriaceae (CRE) are an urgent public health threat associated with poor patient outcomes. CRE that produce carbapenemase (CP-CRE) are of particular concern because the mechanism-conferring genes in plasmids can be transferred to other bacteria. CRE are reportable in Tennessee (TN); isolate submission is required for CP production and resistance mechanism testing. We aimed to compare patient characteristics and outcomes between CP-CRE and non–CP-CRE patients to guide potential public health interventions. Methods: A retrospective cohort study to compare 30-day mortality, and clinical characteristics of CP-CRE to non–CP-CRE patients was conducted. Laboratory data were gathered from CRE isolates of Tennessee residents from July 1, 2015, to June 30, 2018. The most recent Council of State and Territorial Epidemiologists CRE and CP-CRE case definition was used to confirm and classify cases. Healthcare exposures within 1 year prior to onset, demographic characteristics, and clinical characteristics were obtained by linking surveillance data with the inpatient and outpatient Tennessee hospital discharge data. Cases were also matched with Tennessee vital statistics data to determine all-cause 30-day mortality from the event date. We evaluated risk ratios of 30-day mortality with a multivariable regression model. Results: Among 1,034 CRE cases that had at least 1 isolate submitted to public health, 445 (43.0%) were CP-CRE and 589 (57.0%) were non–CP-CRE. Among CP-CRE isolates, the blaKPC gene was found in 434 (98.9%). CP-CRE cases were more likely to have isolates from normally sterile sites, to have an organism with elevated resistance to meropenem (minimum inhibitory concentration, >16 µg/mL), to have prior admission to a long-term acute-care hospital, and to live in a nursing home (all P < .001). Also, 77 CP-CRE cases (17.3%) and 56 non–CP-CRE cases (9.6%) died within 30 days of infection onset. The risk of 30-day mortality was 57% higher for CP-CRE (adjusted risk ratio, 1.57; 95% CI:, 1.10–2.23) compared to non–CP-CRE patients after adjusting for comorbidities, nursing home residence, and prior healthcare exposures. Conclusions: CP-CRE cases had poorer outcomes than non–CP-CRE cases. This may be related in part to a higher proportion of sterile site infections among CP-CRE cases; our study was underpowered to analyze this subpopulation of sterile site cases. We plan to continue monitoring and performing analyses as mortality and hospital discharge data from more recent years become available and as more cases accumulate.

Funding: None

Disclosures: None

Background: Carbapenemase-producing carbapenem-resistant Acinetobacter baumannii (CP-CRAB) are a public health threat due to potential for widespread dissemination and limited treatment options. We describe CDC consultations for CP-CRAB to better understand transmission and identify prevention opportunities. Methods: We defined CP-CRAB as CRAB isolates with a molecular test detecting KPC, NDM, VIM, or IMP carbapenemases or a plasmid-mediated oxacillinase (OXA-23, OXA-24/40, OXA-48, OXA-58, OXA-235/237). We reviewed the CDC database of CP-CRAB consultations with health departments from January 1, 2017, through June 1, 2019. Consultations were grouped into 3 categories: multifacility clusters, single-facility clusters, and single cases. We reviewed the size, setting, environmental culturing results, and identified infection control gaps for each consultation. Results: We identified 29 consultations involving 294 patients across 19 states. Among 9 multifacility clusters, the median number of patients was 12 (range, 2–87) and the median number of facilities was 2 (range, 2–6). Among 9 single-facility clusters, the median number of patients was 5 (range, 2–50). The most common carbapenemase was OXA-23 (Table 1). Moreover, 16 consultations involved short-stay acute-care hospitals, and 6 clusters involved ICUs and/or burn units. Also, 8 consultations involved skilled nursing facilities. Environmental sampling was performed in 3 consultations; CP-CRAB was recovered from surfaces of portable, shared equipment (3 consultations), inside patient rooms (3 consultations) and nursing stations (2 consultations). Lapses in environmental cleaning and interfacility communication were common across consultations. Among 11 consultations for single CP-CRAB cases, contact screening was performed in 7 consultations and no additional CP-CRAB was identified. All 4 patients with NDM-producing CRAB reported recent international travel. Conclusions: Consultations for clusters of oxacillinase-producing CP-CRAB were most often requested in hospitals and skilled nursing facilities. Healthcare facilities and public health authorities should be vigilant for possible spread of CP-CRAB via shared equipment and the potential for CP-CRAB spread to connected healthcare facilities.

Funding: None

Disclosures: None

Background: Centralizing healthcare associated infection (HAI) data for 21 hospitals across several states facilitates a big picture assessment of monthly enterprise performance along with evaluation of practice, policy, and products. Variation in prevention practices has made it difficult to identify areas of focus and created confusion when attempting to standardize prevention tactics for central-line and urinary catheter care. Lack of consistent practice audits have made it difficult to evaluate actual practice. For these reasons, we performed a gap analysis to understand the current state. Methods: Gap assessment tools were developed to assess infection prevention practices for central lines and indwelling urinary catheters. Survey questions were developed with a comment option to collect qualitative data. The 2014 Compendium of Strategies to Prevent Healthcare-Associated Infection in Acute-care Hospitals was utilized as the reference point. This document facilitates the translation of essential information into clinical practice, thus providing the rationale and level of evidence needed for discussion groups. Completion occurred with various key stakeholders within each hospital. One survey per hospital was compiled. Results: All hospitals completed the survey with key themes emerging and supported by observational data. Findings included variation with education, chlorhexidine bathing, types of dressings, and compliance with alcohol port protectors. Gaps identified with urinary catheter care included confusion surrounding catheter care, breaches in seals, and optimizing alternatives to catheterization. Rather than segment solutions for identified gaps, care bundles were developed to provide focus, to facilitate evidence-based practice, and to create standard work-around clinical audits that consisted of going to the patient rather than the electronic health record. Care bundles provided the 6 items to focus on and for which to create policy and standardize products. Conclusions: Care-bundle implementation initially created resistance from clinicians and many questions regarding actual practice. The design of the tool was deliberate in that audit language, the metric, and the “why” were included and served as a medium to discuss the evidence and immediate feedback for practice. Pareto charts were posted on unit performance boards. It became evident that compliance with prevention tactics was not consistent. Although number of infections or outcome data did not appreciably decrease, standardized utilization ratio was reduced by 11% for each device after 3 quarters. Process measures from bundle audits continue to improve, as do observational data, and these are part of focused discussions at quality forums. A culture change has occurred as process measures and evidence-based practice has become a priority.

Funding: None

Disclosures: None