Background: The patient environment is increasingly considered a major source of transmission of nosocomial bacteria to patients. In May 2019, a cluster of 3 patients with multiresistant Enterobacter cloacae was discovered in the hematology-oncology department of the Maastricht University Medical Center (built in 1991). The strains had an identical antibiogram: ESBL-positive, ciprofloxacin R, cotrimoxazole R, meropenem S, and colistin S. One neutropenic patient had a positive blood culture for this strain, resistant to the empiric treatment with piperacillin-tazobactam, but the patient recovered after switching the antibiotic regimen to meropenem. All strains were determined to be identical by amplified-fragment length polymorphism and whole-genome multi-locus sequencing typing (genotype A). New cases occurred, despite the introduction of contact isolation of positive and contact patients. Therefore, weekly point-prevalence screening was introduced, in which more newly colonized patients were identified in the subsequent weeks. Attention to hand hygiene was enforced, and the hypothesis of contamination from “wet” environmental locations was tested by performing cultures of sinks and shower drains. In June and July, 47 of 241 environmental cultures (19.5%) were positive for E. cloacae with an identical antibiogram, among which some were typed as genotype A. To diminish the environmental contamination, all siphons of sinks were replaced, and disinfection of sinks and shower drains was intensified using chlorine and soda on a daily basis. Replacement of shower drains was not possible. After this intervention, the incidence of newly colonized patients declined gradually. A change in the regimen of selective gut decontamination in hematology patients was considered as an alternative intervention, but with the decrease in new patient cases, this was not implemented. A final round of environmental cultures at the end of August revealed 8 positive cultures, of which 5 were positive for genotype A. In retrospect, this finding could be explained by the fact that the cleaning team did not follow the intensified instructions for disinfection. From week 29, genotype A E. cloacae was no longer cultured in weekly patient screenings. Based on this observation, it is important that in (re)building plans for hospitals, a master plan for the prevention of nosocomial transmission from environment to patients is incorporated.

Funding: None

Disclosures: None

Background: Rotavirus is a leading cause of viral acute gastroenteritis (AGE) in infants. Neonates hospitalized in neonatal intensive care units (NICUs) are at risk of rotavirus infections with severe outcomes. The administration of rotavirus vaccines is only recommended, in the United States and Canada, upon discharge from the NICU despite rotavirus vaccine being proven safe and effective in these populations, due to risks of live-attenuated vaccine administration in immunocompromised patients and theoretical risks of rotavirus vaccines strains shedding and transmission. We summarized recent evidence regarding rotavirus vaccines administration in the NICU setting and safety of rotavirus vaccines in preterm infants. Methods: We conducted a rapid review of the literature from the past 10 years, searching Medline and Embase, including all study types except reviews, reporting on rotavirus vaccine 1 and rotavirus vaccine 5; NICU setting; shedding or transmission; and/or safety in preterm. One reviewer performed data extraction and quality assessment. Results: In total, 31 articles were analyzed. Vaccine-derived virus shedding following rotavirus vaccination existed for nearly all infants, mostly during the first week after dose 1, with rare transmission described only in the household setting. No case of transmission in the NICU was reported. Adverse events were mild to moderate, occurring in 10%–60% of vaccinated infants. Extreme premature infants or with underlying gastrointestinal failure requiring surgery presented more severe adverse events. Conclusions: Recommendations regarding rotavirus vaccine administration in the NICU should be reassessed in light of the relative safety and absence of transmission of rotavirus vaccine strains in the NICU.

Funding: None

Disclosures: Sicard Mélanie: I reference the use of rotavirus vaccines in the NICU setting, which is not recommended; I discuss possible reassessment of these recommendations.

Background: Countries that have good rubella surveillance, report ∼10,000–20,000 rubella cases annually. In India, not many cases of rubella are reported. The Hebballi Agasi ward of Dharwad district in Karnataka state, India, reported rubella cases on the last week of January 2015. Objective: We investigated the outbreak by time, place, person, and clinical symptoms. Methods: We performed a cross-sectional study. We defined a case as any resident of Heballi Agasi who had fever and rash, with or without lymphadenopathy, arthralgia, conjunctivitis, coryza, and cough, after December 15, 2014. We collected sociodemographic details and clinical symptoms of patients. We collected 5 serum samples and sent them to the National Measles Laboratory, Bangalore. We tested for measles and rubella antibodies. We drew an epidemic curve and a spot map. We computed mean age of cases, and we calculated attack rates by mean age and gender. We calculated proportions to describe clinical symptoms, and we interviewed stakeholders regarding rubella vaccination. We continued surveillance until March 2015. Results: The population of Heballi Agasi was 1,458. We identified 15 rubella cases (9 girls and 6 boys). The outbreak lasted between December 10, 2014, and February 21, 2015, with a peak on January 16, 2015. The overall attack rate was 1% (15 of 1,458). The mean age of the cases was 6 years (range, 1–23). The attack rate was high (7.7%) among those aged 1–6 years (11 of 143). The attack rate among those aged >6 years was 0.3% (4 of 1,315). In addition to fever and rash, 93% of cases (14 of 15) had coryza, 47% had cough (7 of 15), and 40% had conjunctivitis (6 of 15). Lymphadenopathy was present in only 1 case (1 of 15), and arthralgia was absent among all 15 cases. There was no death among the cases. All 5 sera were positive for rubella and negative for measles. Rubella vaccination was not given for any of the cases because no rubella vaccination is provided in the routine immunization program. Conclusions: There was a rubella outbreak in Heballi Agasi ward. Children aged 1–6 years were most affected. We recommend rubella vaccination in the routine immunization.

Funding: None

Disclosures: None

Background: Infections caused by multidrug-resistant gram-negative bacilli (MDR GNB) are a therapeutic challenge to clinicians. Combination antimicrobial therapy with empirically selected antibiotics is often used to treat these infections. This approach is ill advised because the antibiotics selected may not be optimal because of different killing activity. We aimed to determine the in vitro efficacy of antibiotic combinations devoid of carbapenems to explore potential synergy between antibiotics of different chemical classes. Methods: Prospective, experimental descriptive study of 85 MDR GNB isolated from clinical samples. The minimum inhibitory concentrations (MICs) of ceftazidime, amikacin, imipenem, and ciprofloxacin were determined by broth microdilution. The in-vitro effects of CAZ–AMK, CAZ–CIPRO, IMP–AMK and IMP–CIPRO combinations were studied by checker-board assay. Results: ESBL, AmpC, and MBL production was observed among 62.35%, 27.05%, and 44.70% of the MDR GNB, respectively. Moreover, 27.05% coproduced multiple β-lactamases. The MIC90 ranges were 16 to ≥1028 μg/mL for CAZ; 0.25 to ≥256 μg/mL for Amk, 0.25 to 12 μg/mL for CIPRO; and 0.125 to 512 μg/mL for IMP. CAZ–AMK and IMP–AMK combinations showed synergistic effects in >85% of MDR-GNB, with a fractional inhibitory concentration index ≤0.5. Higher rates of indifference and antagonism were observed with combinations including fluroquinolones. Conclusions: The in vitro antimicrobial activity of antibiotic combinations having third- or fourth-generation cephalosporin with aminoglycosides was comparable to that of imipenem alone or in combination therapy. Combinations devoid of carbapenems should be advocated to prolong the clinical usefulness of this antibiotic group

Funding: None

Disclosures: None

Background: Infection prevention and control (IPAC) and bloodborne pathogen (BBP) education are required for all healthcare workers at least annually by the Occupational Safety and Health Administration and The Joint Commission. An inventory in 2016 at a large health system with >60,000 employees identified 46 different training modules used to fulfill this regulatory mandate. Objective: Using quality improvement tools and management, we sought to reduce duplication of effort, to enhance education, and to improve employee engagement. Methods: A multidisciplinary team that included IPAC, physician, nursing, educational designn and occupational safety was formed. The team reviewed regulatory standards, cross checked site-specific practices, and identified gaps in the current training structure. The goal was to create a module with multiple pathways that tailored regulatory content and delivery to the employee’s job responsibilities (Figs. 1 and 2). Results: The 46 individual training modules were replaced with 1 module that averaged 24.46 minutes to complete. Branching was incorporated that customized education to the employee’s role. The employee completion rate was 99% (n = 61,456). The scenario-based interactive approach engaged learners by challenging them to respond to real-life activities tailored to their level of risk. Most responders (87.4%) rated the learning activity as “good” or “excellent,” and 92.4% of responders agreed or strongly agreed that the activities in the course aided their learning. Conclusions: We leveraged adult learning principles and industry-proven instructional design activities to deliver interactive and relevant infection control training that met regulatory requirements and engaged employees through action-driven tasks. In 2018, the work group created fast paths for employees who had previously completed this module whereby they could revisit the original content and/or focus only on updates and targeted areas of interest. A pathway for laboratory workers involved in specimen handling and processing is planned next.

Funding: None

Disclosures: None

Background: The prevalence of multidrug-resistant organisms (MDROs) in acute healthcare settings is increasing worldwide. Active screening for MDROs carriers on admission permits the prompt implementation of the appropriate precautions to decrease the probability of cross transmission to other inpatients. Objective: To report the spectrum of bacterial nasal, axilla, and perianal colonization among in patients at Najah National University Hospital (NNUH) during 2018. Methods: A retrospective observational study was performed at NNUH, a tertiary-care referral university hospital in Nablus, north of Palestine, that includes medical and surgical ICUs for both adults and children from January to August 2018. Nasal, axilla, and perianal swabs were collected within the first 24 hours of admission according to hospital policy. Patients who were referred from another hospital, who were admitted to a hospital for at least 2 nights during the previous 8 months, and who are known to have an MDROs in the past were included. Swab samples were processed for isolation and identification of these multidrug-resistant strains. Transmission-based precautions were implemented if positive results were reported (ie, contact isolation) and decolonization regimens were applied according to the CDC recommendations (muporocin ointment for nasal MRSA, daily bathing with chlorhexidine 2% soap for the rest). A daily isolation list was circulated among bed managers and senior nurses and head of departments for appropriate management of beds and reallocation of patients. The antibiotic susceptibility pattern was assessed using the disc-diffusion method on Mueller–Hinton agar and a Vitek-2 system. Results: During the period of the study, 1,425 nasal swabs, 1,245 axilla swabs, and 300 perianal swabs were collected according to the inclusion criteria. Positive results were reportedin 7%, 4%, and 44% for nasal, axilla, and perianal specimens, respectively. Regarding the distribution of bacterial colonization in the nasal swab, 73% were MRSA; for the axial, 29% were Pseudomonas; and from the perianal swab, the most prevalent pathogen was ESBL (56%) (Figs. 1–3). A discrepancy between the number of nasal or axilla and perianal swabs was observed, which was mainly due to the refusal of many patients to have the sample collected by the nurse. Conclusions: Colonization of the skin and mucous membranes of inpatients with MDROs is considered a risk factor for developing future infections. Therefore, active screening for those pathogens is critical for infection prevention and control programs and patient safety in acute-care settings.

Funding: None

Disclosures: None

Background: Enterobacteriaceae that develop resistance to carbapenems are a family of different types of bacteria that cause hospital-acquired infections. We evaluated the incidence of nosocomial infections caused by carbapenem-resistant Enterobacteriaceae (CRE) in 13 Brazilian hospitals over 25 years from 1995 to 2019. Methods: CRE was defined as Enterobacteriaceae that is nonsusceptible to any of the a carbapenem (doripenem, meropenem, or imipenem) AND is resistant to all of the following third-generation cephalosporins: ceftriaxone, cefotaxime, and ceftazidime. Hospital-acquired infections (HAIs) were diagnosed according to the CDC NHSN protocols in 13 hospitals from Belo Horizonte, Brazil, between January 1995 to June 2019. Results: In total, 33,922 HAIs caused by Enterobacteriaceae were diagnosed in 25 years across all 13 hospitals. The percentage of CRE varied among hospitals from a minimum of 3% in hospital to a maximum of 30% in hospital E (Fig. 2). The percentage of CRE varied along time as well: for 1995–1999, 0.1% (2 of 1,414) were CRE; for 2000–2004, 0.5% (28 of 5,160) were CRE; for 2005–2009, 2.0% (160 of 8,068) were CRE; for 2010–2014, 11.1% (971 of 8,771) were CRE; and for 2015–2019, 20.2% (2,127 of 10,509) were CRE (Fig. 1). ICU patients and elderly were the most affected by CRE, which has increased lethality, compared to non-CRE Enterobacteriaceae. Conclusions: Over 25 years, CRE percentage increase from almost zero in 1995–1999, to >20% in 2015–2019.

Funding: None

Disclosures: None

Background: High-level personal protective equipment (PPE) protects healthcare workers (HCWs) during the care of patients with serious communicable diseases. Doffing body fluid–contaminated PPE presents a risk of self-contamination. A study assessing HCW failure modes and self-contamination with viruses during PPE doffing found that, of all PPE items, the highest number of doffing failure modes and highest self-contamination risk occurred during removal of the 1-layer powered air-purifying respirator (PAPR) hood. Hood type may affect contamination risk; however, no experimental evidence exists comparing hood types. Objective: We quantified and compared the risk of self-contamination with viruses during doffing of a 1e-layer versus a 2-layer PAPR hood. Methods: In this study, 8 HCWs with experience using high-level PPE donned PPE contaminated on 4 prespecified areas with 2 surrogate human viruses, bacteriophage MS2 (a nonenvelope virus) and Φ6 (an enveloped virus). They completed a clinical task then doffed PPE according to a standard protocol. Following doffing, inner gloves, hands, face, and scrubs were sampled for viral contamination using infectivity assays. HCWs performed the entire sequence twice, first with a 1-layer hood with 1 shroud then with a 2-layer hood with 2 shrouds. The Wilcoxon rank-sum test was used to compare viral contamination between the 2 hood types. HCWs were video-recorded to identify failure modes in their doffing process using a failure modes and effects analysis to identify ways that individual actions deviated from optimal behavior. Results: Φ6 transfer to hands, inner gloves, and scrubs were observed for 1 HCW using the 1-layer hood versus scrubs only for 1 HCW using the 2-layer hood. MS2 transfer to hands was observed for 2 HCWs using the 1-layer hood versus none using the 2-layer hood. Inner glove contamination was observed for 6 of 8 HCWs using the 1-layer hood versus 2 of 8 using the 2-layer hood. Conclusions: A significantly higher number of MS2 virus was recovered on the inner gloves of HCWs using the 1-layer versus the 2-layer hood (median difference, 2.27×104; P = .03). In addition, 31 failure modes were identified during removal of the 2-layer hood versus 13 failure modes for the 1-layer hood. The magnitude of self-contamination depends on the type of PAPR hood used. The 2-layer hood resulted in significantly less inner glove contamination than the 1-layer hood. However, more failure modes were identified during the doffing process for the 2-layer hood. In conclusion, the failure modes identified during the use of the 2-layer hood were less likely to result in self-contamination compared to the failure modes identified during use of the 1-layer hood.

Funding: None

Disclosures: None

Background: Personal protective equipment (PPE) effectiveness can be undermined by inappropriate doffing methods. Objective: We used human factors engineering methods to evaluate self-contamination during PPE doffing. Methods: In this study, 30 participants at a Midwestern academic hospital (A) donned and doffed 3 mask styles (n = 10), 2 gown styles (n = 10), and 2 glove styles (n = 10; the Doffy glove has a tab to facilitate doffing). Also, 30 additional participants at hospital A (residents or fellows, nurses, special isolation trained staff [SITS]) and 10 SITS at academic hospital B doffed a surgical mask, a breakaway neck gown, and exam gloves (PPE ensemble) twice: once while distracted with conversation and once when not distracted. We randomized the order in which participants used different PPE styles or they did the doffing scenario. We collected demographic data. We applied Glo Germ Mist (1.5 dilution in water) with a mucosal atomizer to participants’ PPE before they doffed. We video-recorded participants as they doffed, and we photographed their scrubs and exposed skin before and after each donning and doffing episode. We reviewed videos for doffing errors and photographs for fluorescent spots. We counted fluorescent spots and noted their locations. Results: Overall, 45 (64.3%) participants were women, 31 (44.3%) were nurses, 24 (34.3%) were physicians. Among the participants, 25 (35.7%) had >15 years of experience and 61 (87.1%) had some training in doffing. Participants frequently contaminated their skin or clothing while doffing (Table 1). For all scenarios, hands followed by the torso were contaminated most frequently. Analysis of the videos found that touching the gown front with bare hands was the most common doffing error. Fewer participants self-contaminated when using the Doffy glove without training than when using the standard exam glove. Although most participants in the glove trial indicated that they did not need to watch the Doffy glove training video again, most had difficulty doffing the Doffy glove with the beak method. Many participants stopped doffing to answer questions when they doffed the PPE ensemble during the interruption scenario. Conclusions: Self-contamination was very common with all PPE styles and during all scenarios. Distraction did not increase the risk of contamination. However, participants often stopped doffing to answer questions, which they rarely do in practice. Watching a video was inadequate training for the beak glove-doffing method. The Doffy glove, which decreased contamination compared with the standard glove in the untrained scenario, may have advantages over standard exam gloves and should be evaluated further.

Funding: None

Disclosures: None

Background: Clean surgical procedures such as hip and knee replacement and spine surgery have a low infection complication rate; however, if infections occur, there is substantial morbidity and increased cost. Staphylococcus aureus causes 30% of surgical site infections (SSIs). S. aureus colonization increases the risk of developing SSI. Nasal povidone-iodine 5% application reduces the S. aureus colonization burden. Objective: We aimed to reduce SSIs by applying nasal povidone-iodine 5% prior to hip and knee replacement and spine surgery. Methods: Adult patients hospitalized for elective hip replacement, knee replacement, or spine surgeries from February 2018 through August 2019 comprised the study cohort. All patients received preoperative guidance in the outpatient clinic. On admission, the evening before surgery, a nasal swab for S. aureus colonization was performed, followed by povidone-iodine 5% application in both nostrils and body chlorhexidine gluconate 4% bathing. Application of these substances was repeated in the morning before surgery. Within 24 hours after surgery, an additional nasal swab for S. aureus colonization was taken. A 90-day follow-up for SSI was done. Data were compared with a similar 2016–2017 cohort without the preoperative measures. Results: In total, 186 patients were included: 85 underwent hip or knee replacement (age 69 ± 13.2 y, 66% men), and 101 spine surgery (age 55 ± 15.4 y, 52% men). At screening, 18.3% were colonized with methicillin-sensitive S. aureus and 1.6% colonized with methicillin-resistant S. aureus. Pre- and postsurgery data for the cohort appear in Table 1. The SSI rate per 100 patient days for hip and knee replacement and for spine surgery decreased from 0.29 and 4.0, respectively, in the 2016–2017 cohort to 0 and 0.99, respectively, in the present cohort. Conclusions: Nasal povidone-iodine 5% reduced the S. aureus colonization burden. The SSI rate in elective hip and knee replacement and spine surgery significantly decreased. We show that there is no need for S. aureus eradication presurgery; semiquantitative S. aureus nasal colony reduction should suffice in reducing SSIs. Further research is needed using quantitative measurements for S. aureus colonization.

Funding: None

Disclosures: None

Background: Measles is a highly contagious disease that is transmissible by airborne particles but is preventable by vaccination. South Korea has maintained a highly immunized adult population; however, small local outbreaks of measles continued to occur, and there have been some reports of pockets of underimmunity among the young adult population. It is important to know the seroepidemiology of healthcare workers (HCWs) for policy-making process, but data on the seroprevalence of measles in HCWs in South Korea are limited. Methods: We investigated the seroprevalence of HCWs at Asan Medical Center, a 2,705-bed tertiary-care hospital in Seoul, South Korea, with 8,329 HCWs. In 2014, after an outbreak of measles occurred in a university in Seoul, Asan Medical Center required measles IgG tests for all HCWs born in and after 1967 for point-prevalence surveillance. In addition, we have routinely performed measles antibody test for new HCWs since 2014. In 2018, antibody tests were administered to HCWs who were born before 1967 or who had taken a leave of absence in 2014. We provided MMR vaccination to all HCWs whose antibody tests yielded negative results. Results: In total, 7,411 HCWs (89%) underwent measles antibody tests from 2014 to 2018. The overall seropositivity was 73% (95% CI, 72%–74%); seroprevalence was 73% in HCWs born in of after 1967, whereas the seroprevalence in HCWs born before 1967 was 98%. The seroprevalence sharply decreased from 85% in the 1986 birth cohort to 42% in the 1995 birth cohort. Conclusions: In conclusion, the proportion of measles-susceptible individuals was substantially high in HCWs, especially in young adults. Because the impact of measles outbreak in healthcare facilities would be critical, a policy regarding routine serologic screening followed by measles vaccination or routine measles vaccination in healthcare facilities should be considered, especially for young Korean HCWs.

Funding: None

Disclosures: None

Background: Mumps, a contagious disease, is transmissible by respiratory droplet particles and is preventable by vaccination. In South Korea, mandatory vaccination against mumps has markedly reduced its incidence. However, both the incidence and the number of reported cases of mumps have persistently increased in South Korea since 2007. Despite high vaccination rates, mumps outbreaks continue to occur, and many studies have been conducted on mumps seroprevalence in children and adolescents. In comparison, few reports have been published regarding mumps seroprevalence in healthcare workers (HCWs) in South Korea. Objective: We investigated the seroprevalence of HCWs in South Korea. Methods: This study was conducted at Asan Medical Center, a 2,705-bed tertiary-care hospital in Seoul, South Korea, with 8,329 HCWs. In 2018, we performed mumps antibody testing for HCWs. We administered MMR vaccination to all HCWs whose antibody test yielded equivocal or negative results. However, we did not repeat mumps antibody testing after MMR vaccination. Results: In total, 6,055 HCWs (73%) underwent mumps antibody testing. The overall mumps seropositivity rate was 87% (95% CI, 86%–87%). Seropositivity rates of all birth cohorts ranged from 72% to 92%. Mumps seropositivity rates were 88% in HCWs born before 1970, 87% in those born between 1970 and 1989, and 88% in those born between 1990 and 1995 (P = .59). Mumps seropositivity rates for both women and men HCWs were 87% (3,770 of 4,311 women and 1,517 of 1,744 men); the difference was not statistically significant (P = .62). The overall mumps seropositivity rate was 87%, which was above the herd immunity threshold of 75%–86%. Conclusions: Our results revealed that the overall mumps seropositivity rate in South Korean HCWs was above the herd immunity threshold. On the basis of this finding, we recommend that MMR vaccination after serologic testing may be a more reasonable approach than universal MMR vaccination alone in Korea.

Funding: None

Disclosures: None

Background: The medical device reprocessing department (MDRD) is a crucial patient safety area with checkpoints to ensure appropriate reprocessing. Objective: We report the application of molecular pathology in the investigation of potential blood and body fluid exposure (BBFE) during endoscopy. Methods: When there is a potential BBFE from a medical device, our hospital has a systematic process whereby the clinical area involves the MDRD and the infection prevention control (IPC) team. The MDRD provides reprocessing documentation, including detailed information regarding the prior use of the devices. The clinician and the IPC physician discuss the risk of BBFE. If patient disclosure occurs, the IPC physician provides follow-up as appropriate. This report illustrates the collaboration of clinicians, the IPC team, the MDRD, pathologists, and molecular pathologists in investigating the possibility of residual human tissue and BBFE during endoscopy. Case reports: Two independent but similar events occurred in September 2016 and September 2019 in the pediatric endoscopy suite at our site, a tertiary-care pediatric hospital with 163 beds in Edmonton, Canada. During both endoscopies, the pediatric gastroenterologists observed a piece of tissue ejected from the gastroscope into the intestinal lumen when the biopsy forceps were pushed out of the channel for the first time. This observation raised concerns of possible gaps in the reprocessing of the endoscope and residual tissue remaining in the working channel after its last use. Both gastroenterologists were able to retrieve the presumed foreign tissue; however, both patients had possible BBFE because the mucosal surface was breached by the biopsy forceps. The MDRD reprocessing of both endoscopes was reviewed, and no gap was identified. In discussion with the pathologists and molecular pathologists, human identity testing using genetic markers was performed on the biopsy blocks of the previous patient on whom the endoscope was used, the potentially exposed patient, and the presumed foreign tissue for each event. The test results indicated that the presumed foreign tissue was in fact from the potentially exposed patient and therefore there was no BBFE. It is presumed that the working channel itself captured a small amount of the patient’s tissue during scope insertion. The results were a relief to the patients and families. Conclusions: It is prudent to investigate residual foreign tissue in a medical device that is being used on patients with mucosal breaches. Molecular pathology involving human identity testing is a very useful tool in the investigation of these types of events.

Funding: None

Disclosures: None

Background: Healthcare-associated infections (HAIs) are a serious threat to patient safety; they account for substantial morbidity, mortality, and healthcare costs. Healthcare practices, such as inappropriate use of antimicrobials, can also amplify the problem of antimicrobial resistance. Data collected to target HAI prevention and antimicrobial stewardship efforts and measure progress are an important resource for assuring transparency and accountability in healthcare, tracking adverse outcomes, investigating healthcare practices that may spread or protect against disease, detecting and responding to the spread of resistant pathogens, preventing infections, and saving lives. Methods: We discuss 3 healthcare-associated infection and antimicrobial Resistant infection (HAI-AR) reporting types: NHSN HAI-AR reporting, reportable diseases, and nationally notifiable diseases. HAI-AR reporting requirements outline facilities and data to report to NHSN and the health department to comply with state laws. Reportable diseases are those that facilities, providers, and laboratories are required to report to the health department. Nationally notifiable diseases are those reported by health departments to the CDC for nationwide surveillance and analysis as determined by Council of State and Territorial Epidemiologists (CSTE) and the CDC. Data presented are based on state and federal policy; NHSN data are based on CDC reporting statistics. Results: Since the 2005 launch of the CDC NHSN and publication of federal advisory committee HAI reporting guidance, most states have established policies stipulating healthcare facilities in their jurisdiction report HAIs and resistant infections to the NHSN to gain access to those data, increasing from 2 states in 2005, to 18 in 2010, and to 36 states, Washington, DC, and Philadelphia in 2019. Reporting policies and NHSN participation expanded greatly following the 2011 inception of CMS HAI quality reporting requirements, with several states aligning state requirements with CMS reporting. States listing carbapenem-resistant Enterobacteriaceae (CRE) as a reportable disease increased from 7 in 2013 to 41 states and the District of Columbia in 2019. Vancomycin-intermediate and vancomycin-resistant Staphylococcus aureus (VISA/VRSA) was added as a nationally notifiable disease in 2004, carbapenemase-producing CRE (CP-CRE) was added in 2018, and Candida auris clinical infections were added in 2019. The CDC and most jurisdictions with HAI reporting mandates issue public reports based on aggregate state data and/or facility-level data. States may also alert healthcare providers and health departments of emerging threats and to assist in notifying patients of potential exposure. Conclusions: Through efforts by health departments, facilities, patient advocates, partners, the CDC, and other federal agencies, HAI-AR reporting has steadily increased. Although reporting laws and data uses vary between jurisdictions, data provided serves as valuable tools to inform prevention.

Funding: None

Disclosures: None

Background: Most dental clinics lack resources and oversight related to infection prevention and control (IPC) practices. Few dental clinics undergo inspections by regulatory authorities unless the state licensing authorities receive a specific complaint. Many states, including Pennsylvania, do not have continuing IPC education requirements for dental providers. In 2018–2019, the Philadelphia Department of Public Health (PDPH) received and responded to multiple complaints and concerns related to IPC practices at dental clinics. Complaints were investigated in collaboration with the Pennsylvania Department of State (PADOS). Methods: Unannounced site visits were conducted at 7 Philadelphia dental clinics from December 2018 through September 2019 as part of the public health responses. Clinic evaluations and observations by PDPH certified infection preventionists focused on (1) IPC policies and procedures, (2) staff IPC training, (3) hand hygiene, (4) personal protective equipment, (5) instrument reprocessing and sterilization, (6) injection safety, and (7) environmental cleaning and disinfection. The CDC and the Organization of Safety, Antisepsis and Prevention (OSAP) checklists were adapted for this purpose. Results: Most dental practices we visited were small, unaffiliated, owner-operated clinics. The most common gaps we identified were associated with instrument reprocessing and sterilization practices, including inadequate separation between clean and dirty work areas, limited space and availability of sinks, inappropriate use of glutaraldehyde products for instrument cleaning (n = 3, 43%), extended reuse of cleaning brushes (n = 5, 71%), sterilization or storage of sterilized instruments without appropriate packaging (n = 2, 29%), lack of spore testing or reviewing results (n = 2, 29%), and lack of documentation of sterilizer run cycles and maintenance (n = 7, 100%). Additionally, most clinics did not have well-developed IPC policies and procedures, and staff IPC trainings were neither documented nor conducted annually. Alcohol-based hand sanitizer was often not available at the point of use. Conclusions: In Philadelphia, dental clinics often lacked IPC support and oversight. Lapses across multiple key IPC domains were common. These findings suggest that public health may have a role in providing IPC support to unaffiliated dental clinics. Licensing entities can also serve a role in improving IPC practices by more widely mandating continuing IPC education as part of the dental license renewal process.

Funding: None

Disclosures: None

Background: Research on the association between the standardized antimicrobial administration ratio (SAAR) and clinical outcomes is lacking. Objective: We compared SAAR and patient outcomes in 97 acute-care facilities affiliated with a large healthcare system. Methods: Facilities were classified using the broad-spectrum hospital-onset (BSHO) SAAR for medical, surgical, and medical-surgical wards as low, moderate, or high antimicrobial use: low use SAAR, <0.8; moderate use SAAR, 0.95–1.05; and high-use SAAR, >1.2. Data were included from patients aged ≥18 years who were discharged between the first quarter of 2018 and the second quarter of 2019, had nonmissing matching criteria, BMI between 10 and 90, and at least 1 BSHO medication administered in a medical, surgical, or medical-surgical ward. Patients were matched for gender, age group, BMI category, year and quarter of discharge, ICU stay, and diagnosis-related group (DRG). Eligible drugs included all routes for cefepime, ceftazidime, doripenem, imipenem/cilastatin, meropenem, and piperacillin/tazobactam and IV only for amikacin, aztreonam, gentamicin, and tobramycin. Outcomes were evaluated in a pairwise manner using t tests or χ2 tests. Results: Each of the 3 study groups consisted of 6,327 patients, 51% of whom were men; average age, 63 years; 70% of whom were obese or overweight, and 19% of whom had an ICU stay. The most common DRG code was infectious and parasitic diseases (57%) followed by digestive system (9%), respiratory system (7%), and kidney and urinary tract (6%). High antibiotic use was associated with longer length of stay and a higher estimated cost per visit. Low antibiotic use was associated with higher rate of mortality and a lower rate of readmissions compared to moderate use. The low-usage group did not exhibit a statistically significant difference in mortality, readmissions, or rate of C. difficile compared to the high-usage group. Conclusions: The optimal antibiotic utilization group varied among outcomes. Further evaluation of outcomes is needed for the SAAR to understand the ranges and the relationship between the measure and clinical outcomes.

Funding: None

Disclosures: None

Background: Although guidelines recommend the use of chlorhexidine gluconate (CHG) for hand hygiene (HH), the impact of its routine use on antimicrobial resistance is not clear. Objective: To analyze the impact on the CHG susceptibility among isolates obtained from hands of HCW during its routine use for HH. Methods: We conducted a crossover study at 4 medical-surgical wards of a tertiary-care hospital in São Paulo, Brazil. In 2 units (intervention group), we established routine use of CHG for HH. For the other 2 units (control group), regular soap was provided. The availability of alcohol formulation for HH was not changed during the study. Every 4 months we swapped the units, ie, those using CHG changed for regular soap and vice versa. At baseline, we cultured the hands of HCWs. Only nursing staff hands were investigated. For hand culturing, HCWs placed their hands inside a sterile bag containing a solution of phosphate-buffered saline, Tween 80, and sodium thiosulfate. After the solution incubated overnight, it was inoculated onto brain-heart infusion. Next, it was plated on McConkey and Mannitol agar. MALDI-TOF was used for identification. Agar dilution was performed for Staphylococcus spp. We selected all Staphylococcus spp with MIC ≥ 8 and performed inhibition of efflux pump test. For isolates that showed a decrease of 2 dilutions, we searched the gene qacA/B by polymerase chain reaction. Results: We obtained 262 samples from HCW hands yielding 428 isolates. The most frequent genera were Staphylococcus spp (58%), Acinetobacter spp (8%), Enterobacter spp (8%), Stenotrophomonas spp (5%), Klebsiella spp (4%), Pseudomonas spp (3%), and others (14%). Staphylococcus spp were less frequent in the intervention compared to control group (43% vs 61%; OR, 0.48; 95% CI, 0.29–0.69; P = .005). Among all Staphylococcus spp, the proportion of chlorhexidine resistance (RCHG; MIC ≥ 8) was 12%. All resistant isolates recovered susceptibility after inoculation with pump-efflux inhibitor. For pump-inhibited isolates, 53% had the gene qacA/B amplified by PCR. We did not investigate RCHG among gram-negative isolates. There was a nonsignificant increase in Staphylococcus spp RCHG in the intervention group (4% to 6%; P = .90). Healthcare-acquired infection rates did not change significantly during the intervention. The consumption of CHG increased from 7.3 to 13.9 mL per patient day. Conclusions: We did not detect a significant difference in RCHG during the routine use of CHG for HH, although we observed increasing resistance. Further investigation is needed to clarify other reasons for increasing MIC to CHG.

Funding: None

Disclosures: None

Background: Hospital-acquired methicillin-resistant Staphylococcus aureus bloodstream infections (MRSA BSIs) are associated with serious morbidity and mortality in immunocompromised patients. Of all MRSA BSIs at our academic medical center, 63% occurred in the oncology units. A multidisciplinary team was formed to address the improvement opportunity: the clinical nurse specialist, hospital epidemiologist, unit leaders, nurse champions and representatives from infection prevention, pharmacy and information technology. The goal was to decrease the incidence of hospital-onset MRSA BSI in the oncology wards by 10 infections in 2016 by implementing daily chlorohexidine (CHG) bathing and weekly nasal povidone-iodine antisepsis in July 2016. Methods: The strategically targeting oncology with povidone-iodine nasal antisepsis and bathing with CHG Staph reduction initiative (STOP-BSI) was a quality improvement project consisting of daily CHG baths for all oncology patients and nasal povidone-iodine on admission and weekly thereafter. Nurses and patient care technicians were trained on how to administer CHG treatments. Education was also provided to patients on how to use CHG bath wipes to self-administer the nasal antisepsis. Education resources were created to help answer concerns of the staff, patient, or family, and an escalation process was developed for treatment refusal. CHG bath audits were performed to measure compliance and to identify barriers to the process. Results: By the end of 2016, the number of infections decreased by 5 on the oncology units. The number of infections continued to decrease each year. The bone marrow transplant (BMT) unit decreased from 8 infections in 2015 to 3 in 2018. The hematology oncology unit infections decreased from 5 infections in 2015 to 0 in 2018. The medical oncology unit infections decreased from 2 infections in 2015 to 0 in 2018. The CLABSI rates per 1,000 line days trended downward after some time. Conclusions: Implementing daily CHG baths and weekly povidone-iodine nasal antisepsis reduced the number of MRSA BSI infections in the oncology population. The CLABSI rates decreased after barriers to the process were removed.

Funding: None

Disclosures: None

Background: Healthcare-related infections (HAIs) imply higher morbidity and mortality, length of hospitalization, and costs to institutions and the health system. An important practice for HAI control is hand hygiene. Due to the need for greater adherence to the practice of hand hygiene, as well as understanding about behavior and motivations related to actions associated with infection control, we conducted this study based on inquiry and intervention. Objectives: To describe the increase in adherence to hand hygiene through a multimodal strategy based on realistic simulation, inquiry, change of alcohol and training on actions related to infection control. Methods: In May 2018, a survey was administered to healthcare workers (HCW) regarding structure, process, and behavior related to hand hygiene. Training was also performed, which simulated a bed marked with GloGerm (later revealed with the application of black light), performing tasks by professionals, and completing a test. In November 2018, the structure of hand hygiene and points at which the alcoholic product was offered were redefined, and the alcohol-based product and its dispensers were exchanged. In December 2018, an educational campaign on hand hygiene and change disclosure was held. In February 2019, a new survey was applied to employees. Alcohol consumption was measured per patient day in the periods and compared with the historical average. Results: In the first application of the survey, 263 HCW reported dissatisfaction with hand hygiene structure (46% preferred water and soap). Most reported that training and structure would improve adherence. The training took place for 540 HCWs from many different professional positions. Alcohol gel consumption had a sustained increase from an average of 37 mL per patient day in the first semester to 49 mL per patient day in the second semester. After the product change and the new hand hygiene campaign, a second relevant and sustained increase has took place: the first 4-month average in 2019 was 67 mL per patient day. In the second survey, conducted with 187 HCWs, there was an increase in preference for alcohol-based product from a wall dispenser (from 38% to 62%).

Funding: None

Disclosures: None

Background: Central-line–associated bloodstream infections (CLABSIs) increase the length of hospital stay, healthcare costs, and patient mortality. Objective: We conducted a quality improvement (QI) approach with plan-do-study-act (PDSA) cycle to strengthen adherence to a central-line (CL) maintenance bundle and to reduce CLABSI rate in a surgical intensive care unit (ICU) of children’s hospital 1 (CH1). Methods: The baseline CLABSI rate per 1,000 CL days and the ratio of CL days to patient days (device utilization ration; DUR) were captured for 12 months preceding the intervention. Baseline process indicators were captured for 2 months preceding implementation, including hand hygiene adherence, sterile technique for dressing change and CL access, CL hub cleaning, dating of CL components and daily chlorhexidine bathing. A multimodal intervention of clinician training, bedside checklist, and poster reminders of best practices was implemented. Process and outcome measures were monitored over 12 months of implementation. Z-test was used to calculate statistical significance before and after intervention. Results: Among 46 clinical ICU staff trained on a CLABSI maintenance bundle, mean pre- and posttest knowledge scores increased from 63% to 86%. Staff adherence to each CL care bundle element improved significantly (P < .001) and sustainably over the intervention period: hand hygiene adherence increased from 54% to 82%; sterile technique for dressing increased from 60% to 94%; sterile technique for CL access increased from 51% to 97%; hub scrubbing increased from 52% to 93%; dating of CL elements increased from 63% to 85%; daily chlorhexidine bathing increased from 52% to 87%. During the first 9 months, the CLABSI rate and the DUR decreased from 5.8 to 3.7 and from 0.43 to 0.41, respectively. In the following 2 months, the CLABSI rate increased to 12.7 while bundle adherence remained high. A root-cause analysis identified inadequate environmental hygiene and use of multidose saline bottles for multiple patients as potential factors. A PDSA cycle to improve these elements (enhanced cleaning; single-patient saline bottles) led to a decrease in the CLABSI rate from 12.7 to 3.0 after these efforts. Conclusions: This is the first time CH1 has used quality improvement methodology to implement an HAI prevention enhancement, which proved effective at creating and sustaining adherence to a multimodal CL maintenance bundle and an overall decrease in CLABSI rates. A 2-month increase in CLABSI rates highlights the unique challenges faced in low-resource settings and demonstrates the need for IPC elements not captured in a typical CLABSI prevention bundle. The quality improvement methodology provided a structured approach to implementing change. This methodology will be used for additional patient safety improvements at CH1 and other Viet Nam hospitals interested in CLABSI prevention.

Funding: None

Disclosures: None