Background: Clostridioides difficile infection (CDI) is a major contributor to morbidity and mortality in patients with hematologic malignancy. Due to both immunosuppression and frequent antibiotic exposures, up to one-third of inpatients receiving chemotherapy or stem-cell transplant develop CDI. Transmission of C. difficile in healthcare facilities occurs due to environmental surface contamination and hand carriage by healthcare workers from colonized and infected patients. We investigated the effectiveness of enhanced room cleaning in collaboration with environmental services (EVS) staff to prevent CDI transmission and infection.

Methods: From April 1, 2018, to September 30, 2018, a multimodal enhanced cleaning intervention was implemented on 2 oncology units at the Hospital of the University of Pennsylvania. This intervention included real-time feedback to EVS staff following ATP bioluminescence monitoring. Additionally, all rooms on the intervention units underwent UV disinfection after terminal cleaning. We performed a system-level cohort study, comparing rates of CDI on the 2 study units to historic and 2 concurrent control units. Historic and concurrent control units received UV disinfection only for rooms with prior occupants with MRSA or CDI. All units during the intervention period received education on the importance of environmental cleaning for infection prevention. Mixed-effects Poisson regression was used to adjust for system-level confounders. Results: A median of 1.34 CDI cases per 1,000 patient days (IQR, 1.20–3.62) occurred during the 12-month baseline period. There was a trend toward a reduced rate of CDI across all units during the intervention period (median, 1.19; IQR, 0.00–2.47; P = .13) compared with all units during the historical period. Using mixed-effects Poisson regression, accounting for the random effects of study units, the intervention was associated with an incidence rate ratio for C. difficile of 0.72 compared to control units (95% CI, 0.53–0.97; P = .03). Average room turnaround time (TAT) increased across all units during the study period, from 78 minutes (IQR 74–81) to 92 minutes (IQR, 85–96; P < .001). Within the intervention period, TAT was higher on intervention units (median, 94 minutes; IQR, 92–98) compared to concurrent control units (median, 85; IQR, 80–92; P = .005). Conclusions: Enhanced environmental cleaning, including UV disinfection of all patient rooms and ATP bioluminescent monitoring with real-time feedback, was associated with a reduction in the incidence of CDI.

Funding: None

Disclosures: None

Background:Clostridioides difficile is a major cause of antibiotic-associated colitis and the most common healthcare-associated pathogen in the United States. Interrupting the known transmission mechanisms of C. difficile in hospitals requires appropriate hand hygiene, disinfection of potentially contaminated surfaces, and patient equipment. However, only limited data are available on the effectiveness of germicides against various strains of C. difficile, with and without fetal calf serum, and at multiple exposure times. For this reason, we undertook the following evaluation to determine the effectiveness of germicides. Methods: The effectiveness of the sporicidal activity of the germicides against 5 strains of C. difficile was evaluated using a quantitative carrier test, a standard of ASTM International developed by Sattar et al. In this protocol, metal carriers (1 cm diameter 0.7 mm thick) were inoculated with 10 L spore suspension, containing ~103 or 106 C. difficile spores, and we then exposed them to 50 L germicide for 1, 5, 10, or 20 minutes. The following C. difficile strains were used in these studies: ATCC strains 9689; J9; BI-9; 630; and CF-4. To determine whether C. difficile spore susceptibility was similar to other spores, we also tested Bacillus atrophaeus spores, ATCC strain 19659. Fetal calf serum (FCS) was used to simulate organic matter. Results: In general, high-level disinfectants (eg, OPA, glutaraldehyde), chemical sterilants (eg, peracetic acid), and high concentrations of chlorine (>5,000 ppm) were generally sporicidal (>3 log10 reduction) in 5–10 minutes (and sometimes 1 minute). This level of sporicidal activity was demonstrated for the various strains of C. difficile spores and B. atrophaeus spores (Table 1). There did not appear to be any significant differences in inactivation of C. difficile spores (BI-9 strain) in the presence or absence of FCS (Table 2). Discussion: The sporicidal activity of disinfectants is critical because such formulations are routinely used to eliminate the risk associated with noncritical and semicritical instruments and environmental surfaces. Our data suggest that immersion in most (but not all) high-level disinfectants for 10 minutes is likely to be successful in eradicating C. difficile spores (>4 log10 reduction) from semicritical equipment (eg, endoscopes). Additionally, high concentrations of chlorine and some high-level disinfectants will kill C. difficile spores in 1 or 2 minutes.

Funding: None

Disclosures: Drs. Rutala and Weber are consultants to PDI (Professional Disposable International)

Background: Discontinuation of contact precautions for methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococci (VRE) have failed to show an increase in associated transmission or infections in adult healthcare settings. Pediatric experience is limited. Objective: We evaluated the impact of discontinuing contact precautions for MRSA, VRE, and extended-spectrum β-lactamase–producing gram-negative bacilli (ESBLs) on device-associated healthcare-associated infections (HAIs). Methods: In October 2018, contact precautions were discontinued for children with MRSA, VRE, and ESBLs in a large, tertiary-care pediatric healthcare system comprising 2 hospitals and 620 beds. Coincident interventions that potentially reduced HAIs included blood culture diagnostic stewardship (June 2018), a hand hygiene education initiative (July 2018), a handshake antibiotic stewardship program (December 2018) and multidisciplinary infection prevention rounding in the intensive care units (November 2018). Compliance with hand hygiene and HAI prevention bundles were monitored. Device-associated HAIs were identified using standard definitions. Annotated run charts were used to track the impact of interventions on changes in device-associated HAIs over time. Results: Average hand hygiene compliance was 91%. Compliance with HAI prevention bundles was 81% for ventilator-associated pneumonias, 90% for catheter-associated urinary tract infections, and 97% for central-line–associated bloodstream infections. Overall, device-associated HAIs decreased from 6.04 per 10,000 patient days to 3.25 per 10,000 patient days after October 2018 (Fig. 1). Prior to October 2018, MRSA, VRE and ESBLs accounted for 10% of device-associated HAIs. This rate decreased to 5% after October 2018. The decrease in HAIs was likely related to interventions such as infection prevention rounds and handshake stewardship. Conclusions: Discontinuation of contact precautions for children with MRSA, VRE, and ESBLs were not associated with increased device-associated HAIs, and such discontinuation is likely safe in the setting of robust infection prevention and antibiotic stewardship programs.

Funding: None

Disclosures: None

Background: The role of surface contamination in infections is of interest in healthcare as well as other industries, especially where infections incur high cost. One such industry is professional sports, where infections pose significant risks to players and the organizations that employ them. Sports training facilities experience highly variable occupancy rates due to differing seasonal activities, presenting a measurement challenge because the relationship between occupancy and surface contamination is not well described. In a recent publication, a continuously active antimicrobial (CAA) surface coating demonstrated a reduction in bacterial bioburden in ICUs alongside a reduction in healthcare-associated infections (HAIs). Objective: We investigated the impact of a CAA surface coating on bioburden in 2 professional sports training facilities, despite changes in occupancy. Methods: A CAA surface coating was applied using an electrostatic sprayer to all surfaces in both facilities during a period of high-occupancy at facility A and during low occupancy at facility B. Surface cultures were taken using 3M Sponge-Sticks from lockers, gym equipment, and physiotherapy surfaces before treatment, 4–13 weeks after treatment at facility A and 4–23 weeks after treatment at facility B. Total aerobic bacteria counts were obtained by plating on tryptic soy agar, and geometric means of aerobic plate counts (APCs) were used to compare bioburden before and after treatment at both facilities and for an out-of-efficacy period at facility B (17–23 weeks). Occupancy rates were monitored as person days per week (pd/w) over the course of the study. Results: APC counts at facility A decreased 61% (585 CFU/100 cm2 to 226 CFU/100 cm2) from baseline to posttreatment, and occupancy remained constant (165 pd/w to 171 pd/w). At facility B, there was no significant change in APC (76 CFU/100 cm2 to 80 CFU/100 cm2), although occupancy increased >13,000% during the treatment period (3 pd/w to 386 pd/w). During the out-of-efficacy period at facility B, total bacteria increased 170% (217 CFU/100 cm2) compared to the treatment period, and the occupancy remained relatively constant (344 pd/w). Conclusions: Levels of bioburden were significantly influenced by the application of the CAA surface coating, especially considering the variation in occupancy in both facilities before, during, and after the efficacy period. Facility A saw a significant reduction in bioburden during the treatment period (P < .0001), and a significant increase was observed at facility B during the out-of-efficacy period (P < .0001) despite constant occupancy rates, demonstrating the ability of the surface coating to reduce bioburden levels despite large changes in occupancy.

Funding: Allied BioScience, Inc, provided Funding: for this study.

Disclosures: Gavri Grossman, Valerie Beck, and Daniel S Watson report salary from Allied BioScience.

Background: Handwashing sinks in healthcare environments are reservoirs for healthcare pathogens and antibiotic-resistant microorganisms (ARO). We investigated the distribution of HCP and ARO within and among handwashing sinks in healthcare settings. To do this, we determined the differences in the number of ARO between samples within a sink (biofilm vs planktonic samples), between sink types (healthcare worker [HCW] vs patient room sinks), and between hospitals in the same city. Methods: Tap water, sink surface, drain cover, tail pipe, p-trap water and p-trap samples were collected from 2 patient room sinks and 2 HCW sinks over 11 months in 2 acute-care hospitals. Suspected pathogens were isolated from selective media (Pseudosel, Chromagar KPC, and MacConkey with 2 mg/L cefotaxime) and identified via MALDI-ToF. Isolates confirmed to be healthcare pathogens were characterized via disk diffusion to determine their antibiotic susceptibility according to CLSI guidelines. Isolates not susceptible to carbapenems (meropenem or ertapenem) were tested further via the modified carbapenem inactivation method to detect carbapenemase production. Results:Pseudomonas aeruginosa and Enterobacteriaceae (Enterobacter spp, Klebsiella spp, and Citrobacter spp) were the most frequently isolated pathogens. Among these isolates (195 P. aeruginosa and 42 Enterobacteriaceae isolates), 28.5% of P. aeruginosa and 85.7% of Enterobacteriaceae were nonsusceptible to 1 or more of the antibiotics tested. Of the isolates that were nonsusceptible to a carbapenem (46 of 237; 19%), none displayed phenotypic carbapenemase production. Other mechanisms of resistance have not been confirmed. There was no significant difference in the percentage of nonsusceptible HCP isolated from biofilm samples (from p-trap and tail pipe) compared to planktonic (p-trap water) samples (P > .05 for P. aeruginosa and Enterobacteriaceae). A greater percentage of resistant or intermediate isolates was recovered from patient room sinks than from HCW sinks (P < .05) for both P. aeruginosa and Enterobacteriaceae isolates (76.4 vs 32.9% for Enterobacteriaceae, 25.6 vs 0.3% for P. aeruginosa). We detected no significant difference in percentage of nonsusceptible isolates between the 2 hospitals sampled (P > .05). Conclusions: This survey of healthcare sinks supports previous work citing that they are reservoirs for HCP and ARO. This work further examines the distribution of HCP and ARO within and among sinks in these environments. Our findings thus far in the 2 hospitals studied reveal a higher percentage of ARO in patient sinks than in HCW sinks. This finding may suggest a higher input of ARO from patient use or greater selective pressure in patient room sinks.

Disclosures: None

Funding: Lauren Franco, Centers for Disease Control and Prevention

Background:Candida auris is an emerging multidrug-resistant pathogen associated with outbreaks in hospitals and skilled nursing facilities (SNFs). Patients with C. auris can have invasive disease or asymptomatic colonization. Because C. auris can be difficult to treat and eradicate in the environment, the CDC recommends using contact precautions and sporicidal agents during patient care. After C. auris was identified in a patient from an LA County SNF (SNF-X), our institution initiated surveillance screening on high-risk patients. Methods: Nurses identified patients residing at SNF-X on admission and contacted infection prevention. These patients were placed on contact or spore precautions. Bilateral axilla and inguinal folds were swabbed with an Eswab and sent for testing by a clinical laboratory-developed RT PCR assay, which can detect C. auris with high sensitivity and specificity with a rapid turnaround time (4–6 hours). This PCR assay was based on a commercial platform IntegratedCycler (Diasorin) and reagents from the same vendor. Environmental swabs from the index patient’s room were sent for PCR by HardyCHROM Candida agar (Hardy Diagnostics) before and after cleaning with OxyCideTM. PCR-positive samples were set up for culture. Results: In total, 27 patients from SNF-X were screened by PCR. Of these patients, 15 (55%) had a tracheostomy present on admission. Moreover, 26 swabs were negative; 1 was positive in the index patient (cycle threshold [Ct] value, 26). Clinical specimens from the index patient’s blood did not grow C. auris; the tracheostomy sample grew predominantly C. albicans which made identification of C. auris challenging by culture. However, investigational testing of this sample by PCR was positive (Ct value, 31). Environmental swabs collected from the patient room were obtained before and after cleaning (Table 1); all environmental cultures were negative at 5 days. Conclusions: Developing hospital-based, high-risk patient screening for C. auris is feasible and may be useful for controlling the spread of C. auris within the community. Further study is needed to determine the usefulness of PCR for environmental testing to assess the risk of nosocomial transmission of C. auris.

Funding: None

Disclosures: None

Background: Healthcare exposure results in significant microbiome disruption, particularly in the setting of critical illness, which may contribute to risk for healthcare-associated infections (HAIs). Patients admitted to long-term acute-care hospitals (LTACHs) have extensive prior healthcare exposure and critical illness; significant microbiome disruption has been previously documented among LTACH patients. We compared the predictive value of 3 respiratory tract microbiome disruption indices—bacterial community diversity, dominance, and absolute abundance—as they relate to risk for ventilator-associated pneumonia (VAP) and adverse ventilator-associated events (VAE), which commonly complicate LTACH care. Methods: We enrolled 83 subjects on admission to an academic LTACH for ventilator weaning and performed longitudinal sampling of endotracheal aspirates, followed by 16S rRNA gene sequencing (Illumina HiSeq), bacterial community profiling (QIIME2) for diversity, and 16S rRNA quantitative PCR (qPCR) for total bacterial abundance. Statistical analyses were performed with R and Stan software. Mixed-effects models were fit to relate the admission MDIs to subsequent clinically diagnosed VAP and VAE. Results: Of the 83 patients, 19 had been diagnosed with pneumonia during the 14 days prior to LTACH admission (ie, “recent past VAP”); 23 additional patients were receiving antibiotics consistent with empiric VAP therapy within 48 hours of admission (ie, “empiric VAP therapy”); and 41 patients had no evidence of VAP at admission (ie, “no suspected VAP”). We detected no statistically significant differences in admission Shannon diversity, maximum amplicon sequence variant (ASV)–level proportional abundance, or 16S qPCR across the variables of interest. In isolation, all 3 admission microbiome disruption indices showed poor predictive performance, though Shannon diversity performed better than maximum ASV abundance. Predictive models that combined (1) bacterial diversity or abundance with (2) recent prior VAP diagnosis and (3) concurrent antibiotic exposure best predicted 14-day VAP (type S error < 0.05) and 30-day VAP (type S error < 0.003). In this cohort, VAE risk was paradoxically associated with higher admission Shannon diversity and lower admission maximum ASV abundance. Conclusions: In isolation, respiratory tract microbiome disruption indices obtained at LTACH admission showed poor predictive performance for subsequent VAP and VAE. But diversity and abundance models incorporating recent VAP history and admission antibiotic exposure performed well predicting 14-day and 30-day VAP.

Disclosures: None

Funding: None

Background: Nipah encephalitis outbreaks mostly involve multiple patients. We report a case of Nipah virus encephalitis (NVE), which had no documented secondary cases in spite of many having prolonged and close contact with the patient. Methods: A 21-year-old male was admitted with NVE on May 30, 2019. Before the confirmatory report, there was close contact with multiple healthcare workers (HCWs), defined as exposure for >1 hour to the patient or his immediate environment and/or exposure to body fluids. We conducted extensive contact tracing of all HCWs who had come into close contact with the proven NVE case from the time of admission to the time of discharge. This contact tracing included those who had nursed him before the diagnosis with usual standard precautions and those who had nursed him after the diagnosis with full PPE. These HCWs were reviewed daily for fever and respiratory symptoms. All those who developed these symptoms within the 3 weeks of exposure where tested for NEV with a throat swab using RT-PCR. This testing was conducted twice over 3 days to confirm negative results. For the close family contacts that were asymptomatic, both throat swab and serum for Nipah IgM were tested. Results: In total, 169 HCW contacts were identified at our hospital. Of these, 94 were at high risk according the predetermined criteria and others were low-risk contacts. Moreover, 7 HCWs developed fever and respiratory symptoms within the defined surveillance period; 5 had symptoms before the diagnosis (using only standard precautions) and 2 were in contact with full PPE after the diagnosis. All of these symptomatic contacts were tested for NEV (throat swab and serology), and all were negative. The family members of the patient (his mother and aunt) who had cared for him throughout his illness period of 12 days before the diagnosis were also tested and were seronegative for NEV. Conclusions: This NEV case had very low transmission capability; even close family members who cared for him for 12 days without any precautions and had exposure to urine (which was positive for NEV) did not contract the disease. The absence of overt respiratory involvement and young age of the affected patient could have contributed to low transmissibility both prior to hospitalization and during the hospitalization.

Funding: None

Disclosures: None

Background: Catheter-associated urinary tract infections (CAUTIs) have gained popularity in recent years for increasing morbidity and mortality in multiple healthcare settings. In fact, they are the most common type of healthcare-associated infection (HAI) in US hospitals, and they account for ~35% of HAIs. Objectives: At our institution, CAUTI rates were higher than the national average; therefore, various preventative protocols were implemented. Southeast Health’s Medical ICU (MICU) has taken many measures to decrease the CAUTI incidence. Methods: We conducted an observational study with a retrospective analysis of the data beginning in 2014 after a poor performance at prevention of CAUTIs as noted in the Leapfrog Hospital Survey. As part of improving prevention measures in MICU, we started a lean project in 2015 that primarily focused on systems-based practices and improvements in the existing nurse protocols. Results: We were successful in this endeavor and in August 2018 the Alabama Department of Public Health (ADPH) reported that we still lower than the national average in prevention of CAUTIs. This finding led us to tighten the protocols and to appoint 2 infection preventionists in the MICU. With the assistance of the infection preventionists, we were able to actively decrease indwelling catheter and device days with daily multidisciplinary rounds to access the necessity for catheter use. We also set monthly attainable targets and reinforced nurse driven protocols with educational in-service programs. One of the most significant additions was the introduction of female external catheters (Purewick) in December 2019 and male external catheters (Liberty) in May, 2019. Our results showed a significant reduction in the number of CAUTIs divided by number of Foley catheter days in the MICU from 32 of 7,435 in 2014 to 1 of 5,934 in 2019. We are excited to see reduction in the CAUTIs with our above measures. We will continue our measures to reach our target of 0 CAUTIs, and we plan to remain above the national average.

Funding: None

Disclosures: None