Background: Scabies is a contagious dermatosis caused by human mites, (Sarcoptes scabei, variant hominis). In crusted (Norwegian) scabies, the burden of mite infestation is higher and up to 2 million per person, facilitating easy skin-to-skin transmission and nosocomial transmission. We describe a case of undiagnosed crusted scabies and subsequent transmission to employees in our hospital. Methods: A 90-year-old female was admitted to our 636-bed, nonprofit, academic hospital for 22 days prior to diagnosis of crusted scabies by skin scraping. The patient was admitted to 2 different medical-surgical wards and the medical intensive care unit. We collected healthcare worker (HCW) demographics, including department of service, age, sex, pregnancy, and breastfeeding status in those who were at risk of exposure. We interviewed HCWs at 2 time points and collected information related to infestation, allergies to treatment, acceptance of empiric treatment, and whether employee was furloughed. Results: On initial screening, 20 of 124 at-risk HCWs had symptoms (Fig.). Most had a “new onset raised red rash or new pimple like rash (not on face), or linear rash” and 4 had “new onset uncontrollable itching.” All 124 HCWs were contacted 28 days later. One HCW that had not been compliant with prophylaxis became symptomatic and was diagnosed with scabies by dermatology. Of the remaining 20 HCWs, 3 were still having symptoms (2 had itching and 1 had a rash and a scrape performed by dermatology with confirmation of mites). All 3 were retreated with ivermectin. Overall, 21 of 124 exposed HCWs were ultimately symptomatic. Conclusions: During a 22-day admission of an undiagnosed and unisolated elderly patient with crusted scabies, the scabies mite was transmitted to 21 HCWs for an acquisition rate of 17%. Persistence of symptoms after treatment with permethrin occurred in 14%. The infectivity of this disease necessitates early recognition and infection control measures.

Funding: None

Disclosures: None

Background: Surgical site infections (SSI) related to colorectal procedures are detrimental to patients and publicly reportable events. Our institution implemented a successful bundle of interventions to decrease SSI rates in 2014. In 2018, compliance started to wane, with a concurrent increase in infections. In an effort to enhance compliance and incorporate up-to-date information, we convened a multidisciplinary team to streamline this process. Methods: Our team evaluated published studies on successful bundle components and updates to professional guidelines for SSI prevention to determine adjustments. Modifications included allowing surgeon preference for (rather than mandating) wound protector use and simplification of clean closure protocol (determined by intraoperative contamination, leading to more efficient closure time). In addition, measures were added to achieve perioperative patient optimization (maintenance of normothermia, prevention of intraoperative hypoxia, tighter glucose control and postoperative bathing). The bundle was implemented in stages starting January 2019. SSI rates were monitored throughout the process using NHSN definitions, and rates were compared using χ2 analysis (Epi Info, CDC). Results: From 2015 to 2017, bundle compliance was 90%, and 8 SSIs (rate, 3.8 per 100 procedures) were detected (Table 1). In 2018, compliance was 82%, with 4 SSIs (rate, 6.6 per 100 procedures). From January through September 2019, SSI rates decreased to a rate of 4.8 per 100 procedures, with notable increase in superficial SSI, with zero cases of deep or organ-space infections. Feedback from operating-room personnel indicated their commitment to bundle compliance and perceived intraoperative time savings. Conclusions: Revamping an existing colorectal SSI bundle, including relaxation of time-intensive and expensive intraoperative measures and increased focus on evidence-based guidelines, resulted in decreased deep-organ space SSI rates, as well as increased satisfaction from procedural team members. Successful implementation of care pathways to prevent infections is an iterative process and requires the engagement of practitioners.

Funding: None

Disclosures: None

Background: Surveillance for surgical site infections (SSI) is recommended by the CDC. Currently, colon and abdominal hysterectomy SSI rates are publicly available and impact hospital reimbursement. However, the CDC NHSN allows surgical procedures to be abstracted based on International Classification of Diseases, Tenth Revision (ICD-10) or current procedural terminology (CPT) codes. We assessed the impact of using ICD and/or CPT codes on the number of cases abstracted and SSI rates. Methods: We retrieved administrative codes (ICD and/or CPT) for procedures performed at the University of Iowa Hospitals & Clinics over 1 year: October 2018–September 2019. We included 10 procedure types: colon, hysterectomy, cesarean section, breast, cardiac, craniotomy, spinal fusion, laminectomy, hip prosthesis, and knee prosthesis surgeries. We then calculated the number of procedures that would be abstracted if we used different permutations in administration codes: (1) ICD codes only, (2) CPT codes only, (3) both ICD and CPT codes, and (4) at least 1 code from either ICD or CPT. We then calculated the impact on SSI rates based on any of the 4 coding permutations. Results: In total, 9,583 surgical procedures and 180 SSIs were detected during the study period using the fourth method (ICD or CPT codes). Denominators varied according to procedure type and coding method used. The number of procedures abstracted for breast surgery had a >10-fold difference if reported based on ICD only versus ICD or CPT codes (104 vs 1,109). Hip prosthesis had the lowest variation (638 vs 767). For SSI rates, cesarean section showed almost a 3-fold increment (2.6% when using ICD only to 7.32% with both ICD & CPT), whereas abdominal hysterectomy showed nearly a 2-fold increase (1.14% when using CPT only to 2.22% with both ICD & CPT codes). However, SSI rates remained fairly similar for craniotomy (0.14% absolute difference), hip prosthesis (0.24% absolute difference), and colon (0.09% absolute difference) despite differences in the number of abstracted procedures and coding methods. Conclusions: Denominators and SSI rates vary depending on the coding method used. Variations in the number of procedures abstracted and their subsequent impact on SSI rates were not predictable. Variations in coding methods used by hospitals could impact interhospital comparisons and benchmarking, potentially leading to disparities in public reporting and hospital penalties.

Funding: None

Disclosures: None

Background:Candida auris is a highly transmissible healthcare-associated pathogen that can cause severe infection as well as long-lasting colonization. C. auris is often resistant to the antifungals that are commonly used to treat Candida infections, which may lead to clinical failure. Therefore, healthcare facilities must identify the organism quickly and implement strict precautions to prevent its spread. In 2019, the NIH Clinical Center instituted C. auris admission screening among its high-risk patient populations. Methods: Patients admitted to the NIH Clinical Center, a 200-bed research hospital, were identified on admission as having been hospitalized outside the United States in the prior 6 months. Admission screening began in August 2019. In September 2019, due to evolving regional epidemiology, we expanded surveillance criteria to include patients housed in any healthcare facility in the District of Columbia, Maryland, and Virginia metro area in the previous 6 months. Screening was performed as routine clinical care, and therefore did not require written informed consent. Swabs were obtained from nares, axilla and groin, with subsequent addition of mouth and toe web (BD ESwabs). Patients were placed on empiric contact isolation for at least 48 hours and concurrently screened for carbapenemase-producing organisms. Swabs were cultured on CHROMagar Candida and in Sabouraud dextrose broth with 10% NaCL and 50 mg/L chloramphenicol and gentamicin, and incubated for 14 days at 30°C and 40°C, respectively. Positive broth tubes were subcultured onto CHROMagar Candida. C. auris was identified by MALDI-TOF MS and ITS sequence analysis. Susceptibility testing was performed using Sensititre YeastOne Colorimetric assay. Whole-genome sequencing was used to identify clonal designations and genetic relatedness of isolates. Results: Since August 2019, 1 to 2 patients per week have been screened for C. auris. As of November 2019, 1 of 15 patients screened on admission grew C. auris from a groin swab. The patient, who had been hospitalized abroad, was found to be cocolonized with blaNDM-1+ E. coli and K. pneumoniae. Subsequent screening of other patients on the same ward identified no evidence of spread. Admission surveillance is ongoing. Conclusions: Healthcare-associated outbreaks can originate from C. auris–colonized patients. Admission surveillance of high-risk patients is intended to prevent transmission from undetected reservoirs. Our sampling of multiple sites, though laborious, may add to the data on C. auris colonization. Future plans include incorporating molecular testing and streamlining geographic criteria. C. auris admission screening has already identified one colonized patient, and will continue as a new and important patient safety measure at our hospital.

Funding: None

Disclosures: None

Background:Clostridium difficile infection (CDI) is the most common healthcare-associated infection (HAI) and is often associated with increased medical costs and longer lengths of hospital stay. Previous studies have highlighted that hematopoietic stem cell transplant (HSCT) recipients are at an increased risk for CDI of up to 33% from other hospitalized patients. Studies have also supported the prevalence of asymptomatic colonization with C. difficile among HSCT patients. Asymptomatic colonization with C. difficile is a significant risk factor for transmission of infection to other patients developing hospital onset (HO-CDI). Therefore, targeted infection prevention efforts, such as early identification of patients with community-onset (CO-CDI) and patients with asymptomatic colonization with CDI in HSCT patients, may be effective in reducing the occurrence of HO-CDI. We discuss the CDI admission screening protocol in Emory University Hospital’s (EUH) bone marrow transplant (BMT) unit. Methods: As part of an infection prevention initiative, a CDI screening protocol was implemented in December 2018 for all patients that admitted to the EUH inpatient BMT unit. Upon admission, patients were screened for CO-CDI symptoms, specifically loose or unformed stools. A C. difficile toxin assay PCR would be collected within the first 3 calendar days of admission for all patients screened. Patients with symptoms were placed on isolation precautions pending results of the C. difficile toxin assay. If a patient had a positive C. difficile toxin assay result, isolation precautions would be maintained for the duration of hospitalization regardless of symptoms. Patients who are were unable to produce a stool specimen on the first 3 days of admission were excluded from the screening protocol. Patients with positive C. difficile toxin assay PCRs were classified as CO-CDI and were treated. Results: Since implementation of the CDI screening protocol, 109 CDI events were identified from January 2019 to October 2019. Moreover, 79% of positive C. difficile toxin assays were collected within the first 3 calendar days of admission. HO-CDI has decreased from 78% in 2018 to 21% during the designated time frame. Conclusions: CDI screening upon admission of BMT populations has shown a decrease among HO-CDI by early identification of CO-CDI and CO asymptomatic colonization with C. difficile. This early identification has allowed rapid implementation of infection preventions precautions, thus reducing risk of unit-based transmission.

Funding: None

Disclosures: None

Background: Central-line–associated bloodstream infections (CLABSIs) result in increased patient morbidity. Guidelines recommend against peripheral venous catheters when access is required for longer than 6 days, often leading to central venous catheter (CVC) placement. To improve vascular access device choice and reduce the potential risk of CLABSI, we implemented a quality improvement initiative comprised of a vascular access algorithm and introduction of a midline vascular access device (MVAD). We report complications associated with MVAD use including deep vein thrombosis (DVT), thrombophlebitis, and BSI. Methods: A prospective quality improvement assessment from October 2017 through March 2018. All MVADs were monitored for DVT, thrombophlebitis, and BSI. Insertion time and removal of MVAD were tracked, as well as presence of other vascular access devices. Results: From October 2017 through March 2018, 858 MVADs were inserted in 726 different patients, yielding 3,588 MVD days. In total, 6 primary BSIs occurred in patients with MVADs. In patients with only a MVAD, the rate was 0.72 BSI per 1,000 MVAD days, whereas patients with an MVAD as well as a CVC had a rate of 1.98 per 1,000 MVAD days. The overall CLABSI rate at the institution during this period of time was 1.24 per 1,000 CVC days. Also, 29 cases of thrombophlebitis occurred, for a rate of 3.84 per 1,000 catheter days in patients with only an MVAD compared to 4.63 per 1,000 catheter days in patients with an MVAD and a CVC. Also, 25 DVTs occurred during this time, resulting in a rate of 2.88 per 1,000 catheter days in patients with only an MVAD and 4.63 per 1,000 catheter days in patients with multiple vascular-access devices. A significant correlation was noted between MVAD indwell time and BSI (P = .0021) and thrombophlebitis (P = .0041). The median indwell time for patients experiencing BSI was 16.17 days ± 8.04 days, whereas the median indwell time for patients experiencing thrombophlebitis was 9.24 days ± 7.99 days. Conclusions: The implementation of a vascular-access algorithm including MVAD may effectively reduce CVC insertions and BSIs. The rate of BSI in MVAD was below that of CLABSI during the assessment period. Known complications associated with MVAD include DVTs and thrombophlebitis, which correlates with the duration of catheterization, and these risks appear to be further compounded in patients requiring multiple devices for vascular access. Further research into comparing the risk of vascular access of MVAD with CVC is warranted.

Funding: None

Disclosures: None

Background: Stethoscopes are a known vector for microbial transmission; however, common strategies used to clean stethoscopes pose certain barriers that prevent routine cleaning after every use. We aimed to determine whether using readily available alcohol-based hand rub (ABHR) would effectively reduce bacterial bioburden on stethoscopes in a real-world setting. Methods: We performed a randomized study on inpatient wards of an academic medical center to assess the impact of using ABHR (AlcareExtra; ethyl alcohol, 80%) on the bacterial bioburden of stethoscopes. Stethoscopes were obtained from healthcare providers after routine use during an inpatient examination and were randomized to control (no intervention) or ABHR disinfection (2 pumps applied to tubing and bell or diaphragm by study personnel, then allowed to dry). Cultures of the tubing and bell or diaphragm were obtained with premoistened cellulose sponges. Sponges were combined with 1% Tween20-PBS and mixed in the Seward Stomacher. The homogenate was centrifuged and all but ~5 mL of the supernatant was discarded. Samples were plated on sheep’s blood agar and selective media for clinically important pathogens (CIPs) including S. aureus, Enterococcus spp, and gram-negative bacteria (GNB). CFU count was determined by counting the number of colonies on each plate and using dilution calculations to calculate the CFU of the original ~5 mL homogenate. Results: In total, 80 stethoscopes (40 disinfection, 40 control) were sampled from 46 physicians (MDs) and MD students (57.5%), 13 advanced practice providers (16.3%), and 21 nurses (RNs) and RN students (26.3%). The median CFU count was ~30-fold lower in the disinfection arm compared to control (106 [IQR, 50–381] vs 3,320 [986–4,834]; P < .0001). The effect was consistent across provider type, frequency of recent usual stethoscope cleaning, age, and status of pet ownership (Fig. 1). Overall, 26 of 80 (33%) of stethoscopes harbored CIP. The presence of CIP was lower but not significantly different for stethoscopes that underwent disinfection versus controls: S. aureus (25% vs 32.5%), Enterococcus (2.5% vs 10%), and GNB (2.5% vs 5%). Conclusions: Stethoscopes may serve as vectors for clean hands to become recontaminated immediately prior to performing patient care activities. Using ABHR to clean stethoscopes after every use is a practical and effective strategy to reduce overall bacterial contamination that can be easily incorporated into clinical workflow. Larger studies are needed to determine the efficacy of ABHR at removing CIP from stethoscopes as stethoscopes in both arms were frequently contaminated with CIP. Prior cleaning of stethoscopes on the study day did not seem to impact contamination rates, suggesting the impact of alcohol foam disinfection is short-lived and may need to be repeated frequently (ie, after each use).

Funding: None

Disclosures: None

Disclosures: None

Funding: None

Background: Surveillance metrics for catheter-associated urinary tract infections (CAUTIs) are subject to ongoing debate and refinement to best capture infectious catheter-related harm (ICRH) and noninfectious catheter-related harm (NCRH). Indwelling urinary catheters cause 5 times more NCRH than ICRH. The commonly used standardized infection ratio (SIR) does not fully capture NCRH nor the impact of prevention efforts in all settings. Alternatively, device utilization rates and ratios (DUR) do not reflect differences in other factors that may describe levels of device use. DUR lose comparability over time and across settings and can mask truly effective interventions by selecting for a higher risk group of catheterized patients. Experts now advocate use of the standardized utilization ratio (SUR). We sought to implement a multidimensional intervention to reduce exposure risk, CAUTI, and NCRH across a 5-hospital healthcare system, totaling 1,692 acute-care beds. Methods: The intervention comprised the following elements: (1) an interactive educational campaign comprising one-on-one engagements between infection preventionists and frontline providers, encouraging the use of female external urinary collection devices and male custom-fitted condom catheters, rewarding overall participation, device utilization, hand hygiene, and CAUTI rates; (2) educational emails to all staff from top executives; (3) increasing the urinalysis reflex to culture threshold from >5 to ≥10 WBCs; and (4) clinical decision support (CDS) for ordering urine cultures for patients with indwelling catheters and for encouraging Foley catheter alternatives and catheter removal. Monthly, quality department representatives discuss unit level DURs with managers, who then discuss patient-level device use at daily huddles with physicians and advanced practice providers. Significance was determined using the 2-tailed t test. The results are listed in Table 1. Discussion: One year after the intervention, use of device alternatives increased 5-fold, CDS-driven ordering predominated, and the SIR and SUR remained significantly decreased. These successes are especially notable because , a ventricular-assist device program was launched in the postintervention period. By the end of the study, the program became the second-busiest of its type in the United States, resulting in a group of patients at high risk of device use and infection in the postintervention period, but absent in the preintervention period. numerous reports of effective interventions for reducing CAUTI have been published, we found no large studies using the SUR as the main metric. The limitations of this study include the lack of a population SIR and data pertaining to catheter-related bacteriuria and antibiotic usage. However, this approach is easily customizable to any infection, device, and diagnostic test.

Disclosures: None

Funding: None

Background: There is great enthusiasm for the potential of decision support tools embedded in the electronic medical record to improve antimicrobial use in hospitals. Yet they are often limited in their ability to change prescriber behavior. Analyzing these tools using an interactive sociotechnical approach (ISTA) can identify barriers and facilitators to the implementation of electronic decision support (EDS) in antimicrobial stewardship. Objective: To examine prescriber and antimicrobial steward perceptions of EDS using an ISTA approach in the preimplementation phase of an antimicrobial stewardship intervention. Methods: We conducted semistructured interviews with prescribers and stewards from 4 hospitals in 2 health systems in the context of a multicomponent intervention to improve the use of fluoroquinolones and extended-spectrum cephalosporins. Sites planned to implement various EDS elements including order sets, antimicrobial time outs, and audit with feedback stewardship notes in the medical record. Interviews elicited respondent perceptions about the planned intervention. Two analysts systematically coded transcripts using an ISTA framework in NVivo12 software. Results: Interviews with 64 respondents were conducted: 38 physicians, 7 nurses, 6 advanced practice providers, and 13 pharmacists. We identified 4 key sociotechnical interaction types likely to influence stewardship EDS implementation. First, EDS changes the communication patterns and practices of antimicrobial stewards in a way that improves efficiency but decreases vital social interaction with prescribers to facilitate behavior change. Second, there is a gap between what stewards envision for EDS and that which is possible to build in a timely manner by hospital information technology specialists. As a result, there is often a months- to years-long delay from proposal to implementation, which negatively affects intervention acceptance. Third, prescribers expressed great enthusiasm for stewardship EDS that would simplify their workload, allow them to complete important work tasks, and save time. They strongly objected to stewardship EDS that was disruptive without a compelling purpose or did not integrate smoothly with pre-existing technology infrastructure. Fourth, physician prescribers attributed social and emotional meaning to stewardship EDS, suggesting that these tools can undermine professional authority, autonomy, and confidence. Conclusions: Implementing stewardship EDS in a way that improves the use of antimicrobials while minimizing unintended negative consequences requires attention to the interplay between new EDS and an organization’s existing workflow, culture, social interactions and technologies. Implementing EDS in stewardship will require attention to these domains to realize the full potential of these tools and to avoid negative unintended consequences.

Funding: None

Disclosures: None

Background: This study explores the perspectives of healthcare workers on the healthcare-associated infection (HAI) and infection control measures in a tertiary-care unit, through a self-administered questionnaire, semi-structured interviews, and reflexive sessions based on video-recorded sterile procedures performed in respondents’ work contexts. Video reflexive ethnography (VRE) is a method that provides feedback to medical practitioners through reflection analysis, whereby practitioners identify problems and find solutions. Methods: Quantitative questionnaire data were used to assess the knowledge of HAI among 50 healthcare workers and their attitude toward practice of infection control measures. Semistructured interviews based on an interview guide were used to collect qualitative data from 25 doctors and nurses. The interviews were audio recorded and transcribed verbatim immediately. Also, routine sterile procedures in the wards and intensive care unit were video recorded, and the footage was discussed by the infection control team and the personnel involved in the videos. This discussion was video recorded and transcribed. Both interview data and reflexive discussion of video-graph were analyzed using a thematic analysis. The quantitative data were analyzed using the Kruskal–Wallis test. Results: The quantitative data revealed no difference in the knowledge, attitude, and practice scores used to evaluate the infection control practices among the healthcare workers. We identified 4 themes from the qualitative data: (1) knowledge of HAI and infection control, (2) infection control measures in practice, (3) the shortfall in infection control measures and HAI, and (4) required implementation. Although the qualitative data indicated that the participants had excellent compliance with hand hygiene and personal protective equipment (PPE) use, the VRE and reflective sessions indicated otherwise. Some astounding lapses were revealed, like failure to engage in boundary maintenance between sterile and nonsterile areas, failure to observe proper hand hygiene measures, and use of traditional hijab face covers (used in an unsterile environment as well) instead of surgical masks. These findings demonstrate the advantage of combining VRE with qualitative and quantitative methodology to deduct the lapses in the practice of infection control among healthcare workers. Conclusions: Introduction of training programs focused on HAI and infection control measures in the educational system will help better inform medical and nursing students. Live video demonstrations of appropriate infection control practices during sterile procedures would be highly beneficial to educate the healthcare workers on correct infection control practices. Lapses in the use of PPE can be a possible reason for the outbreak of MERS-CoV, an endemic disease, in this part of Saudi Arabia.

Disclosures: None

Funding: None

Background: The NHSN has used positive laboratory tests for surveillance of Clostridioides difficile infection (CDI) LabID events since 2009. Typically, CDIs are detected using enzyme immunoassays (EIAs), nucleic acid amplification tests (NAATs), or various test combinations. The NHSN uses a risk-adjusted, standardized infection ratio (SIR) to assess healthcare facility-onset (HO) CDI. Despite including test type in the risk adjustment, some hospital personnel and other stakeholders are concerned that NAAT use is associated with higher SIRs than are EIAs. To investigate this issue, we analyzed NHSN data from acute-care hospitals for July 1, 2017 through June 30, 2018. Methods: Calendar quarters for which CDI test type was reported as NAAT (includes NAAT, glutamate dehydrogenase (GDH)+NAAT and GDH+EIA followed by NAAT if discrepant) or EIA (includes EIA and GDH+EIA) were selected. HO CDI SIRs were calculated for facility-wide inpatient locations. We conducted the following analyses: (1) Among hospitals that did not switch their test type, we compared the distribution of HO incident rates and SIRs by those reporting NAAT vs EIA. (2) Among hospitals that switched their test type, we selected quarters with a stable switch pattern of 2 consecutive quarters of each of EIA and NAAT (categorized as pattern EIA-to-NAAT or NAAT-to-EIA). Pooled semiannual SIRs for EIA and NAAT were calculated, and a paired t test was used to evaluate the difference of SIRs by switch pattern. Results: Most hospitals did not switch test types (3,242, 89%), and 2,872 (89%) reported sufficient data to calculate SIRs, with 2,444 (85%) using NAAT. The crude pooled HO CDI incidence rates for hospitals using EIA clustered at the lower end of the histogram versus rates for NAAT (Fig. 1). The SIR distributions of both NAAT and EIA overlapped substantially and covered a similar range of SIR values (Fig. 1). Among hospitals with a switch pattern, hospitals were equally likely to have an increase or decrease in their SIR (Fig. 2). The mean SIR difference for the 42 hospitals switching from EIA to NAAT was 0.048 (95% CI, −0.189 to 0.284; P = .688). The mean SIR difference for the 26 hospitals switching from NAAT to EIA was 0.162 (95% CI, −0.048 to 0.371; P = .124). Conclusions: The pattern of SIR distributions of both NAAT and EIA substantiate the soundness of NHSN risk adjustment for CDI test types. Switching test type did not produce a consistent directional pattern in SIR that was statistically significant.

Disclosures: None

Funding: None

Background: The CDC and The Joint Commission have called for an interdisciplinary approach to antibiotic stewardship implementation. The healthcare team should consist of infectious disease physicians, pharmacists, infectious disease pharmacists, infection preventionists, microbiologists, and nurses. The scant literature to date has looked at nurses’ attitudes and beliefs toward participating in antibiotic stewardship and have identified several factors that contribute to the lack of uptake by nurses: lack of education around stewardship, poor communication among healthcare providers, and hospital or unit culture, among others. Additionally, nurses’ lack of interest in what would be more work or not within their scope of work was put forth as an additional factor by infection preventionists and pharmacists as a barrier to implementation. Method: An investigator-developed online survey was used to assess the usefulness of 3 investigator-developed educational e-learning modules that encompassed the role of nurses in antibiotic stewardship, pharmacy and laboratory topics related to antimicrobial stewardship, as well as the nurses’ attitudes toward their participation in such activities. Results: Participants took the survey after review of the 3 e-learning modules. The results indicate that, contrary to what pharmacists and infection preventionists thought, 82% of nurses felt they should contribute to and be part of the antimicrobial stewardship team. Additionally, after completing the modules, 73% felt more empowered to participate in stewardship discussions with an additional 23% wanting more education. 100% felt that they learned information that they could utilize in their everyday work. Barriers to implementation of stewardship activities on their unit included lack of education (41%), hospital or unit culture (27%), with only 4% citing they did not feel it was their job or that they had anything to contribute to a discussion. Also, 24% felt that there were no obstacles to participation. Conclusions: Surprisingly, most nurses who took this educational series and survey felt that they should be part of the antibiotic stewardship team. As cited previously from the literature, education and culture need to be addressed to overcome the nurses’ barriers to stewardship involvement. E-learning can provide an easy first step to educating nurses when time permits and can provide a good springboard for discussion on the units and with physicians and pharmacists. For a copy of the modules, please contact the author.

Funding: None

Disclosures: None

Background: With the emergence of antibiotic resistant threats and the need for appropriate antibiotic use, laboratory microbiology information is important to guide clinical decision making in nursing homes, where access to such data can be limited. Susceptibility data are necessary to inform antibiotic selection and to monitor changes in resistance patterns over time. To contribute to existing data that describe antibiotic resistance among nursing home residents, we summarized antibiotic susceptibility data from organisms commonly isolated from urine cultures collected as part of the CDC multistate, Emerging Infections Program (EIP) nursing home prevalence survey. Methods: In 2017, urine culture and antibiotic susceptibility data for selected organisms were retrospectively collected from nursing home residents’ medical records by trained EIP staff. Urine culture results reported as negative (no growth) or contaminated were excluded. Susceptibility results were recorded as susceptible, non-susceptible (resistant or intermediate), or not tested. The pooled mean percentage tested and percentage non-susceptible were calculated for selected antibiotic agents and classes using available data. Susceptibility data were analyzed for organisms with ≥20 isolates. The definition for multidrug-resistance (MDR) was based on the CDC and European Centre for Disease Prevention and Control’s interim standard definitions. Data were analyzed using SAS v 9.4 software. Results: Among 161 participating nursing homes and 15,276 residents, 300 residents (2.0%) had documentation of a urine culture at the time of the survey, and 229 (76.3%) were positive. Escherichia coli, Proteus mirabilis, Klebsiella spp, and Enterococcus spp represented 73.0% of all urine isolates (N = 278). There were 215 (77.3%) isolates with reported susceptibility data (Fig. 1). Of these, data were analyzed for 187 (87.0%) (Fig. 2). All isolates tested for carbapenems were susceptible. Fluoroquinolone non-susceptibility was most prevalent among E. coli (42.9%) and P. mirabilis (55.9%). Among Klebsiella spp, the highest percentages of non-susceptibility were observed for extended-spectrum cephalosporins and folate pathway inhibitors (25.0% each). Glycopeptide non-susceptibility was 10.0% for Enterococcus spp. The percentage of isolates classified as MDR ranged from 10.1% for E. coli to 14.7% for P. mirabilis. Conclusions: Substantial levels of non-susceptibility were observed for nursing home residents’ urine isolates, with 10% to 56% reported as non-susceptible to the antibiotics assessed. Non-susceptibility was highest for fluoroquinolones, an antibiotic class commonly used in nursing homes, and ≥ 10% of selected isolates were MDR. Our findings reinforce the importance of nursing homes using susceptibility data from laboratory service providers to guide antibiotic prescribing and to monitor levels of resistance.

Disclosures: None

Funding: None

Background: Improving the use of antibiotics across the care continuum will be necessary as we strive to protect our patients from antimicrobial resistance. One potential target for antimicrobial stewardship is during end-of-life care of patients with advanced dementia. We aimed to perform a systematic literature review measuring the burden of antibiotic use during end-of-life care in patients with dementia. Methods: We searched PubMed, CINAHL, and Embase through July 2019 for studies with the following inclusion criteria in the initial analysis: (1) end-of-life patients (ie, dementia, cancer, organ failure, frailty or multi-morbidity); (2) antibiotic use in the end-of-life care; with the final analysis restricted to (3) patients with advanced dementia. Only randomized controlled trials (RCTs) and cohort studies were included. Results: Of the 93 full-text articles, 17 studies (18.3%) met the selection criteria for further analysis. Most of the included studies were retrospective (n = 8) or prospective (n = 8) cohort studies. These studies in combination included 2,501 patients with advanced dementia. Also, 5 studies (698 patients, [27.9%]) were restricted to patients with Alzheimer’s disease. In 5 studies in which data were available, fewer than one-quarter of patients (19.9%, 498) with advanced dementia were referred to palliative care. In 12 studies >50% of patients received antibiotics during the end-of-life period. Also, 15 studies did not report the duration of antimicrobial therapy. Only 2 studies reported the antimicrobial consumption in days of therapy per 1,000 resident days. Only 6 studies studied whether the use of antibiotics was associated with beneficial outcomes (survival or comfort), and none of them evaluated potential adverse effects associated with antibiotic use. Conclusions: There are significant gaps in the literature surrounding antimicrobial use at the end of life in patients with advanced dementia. Future studies are needed to evaluate the benefits and harms of using antibiotics for patients during end-of-life care in this patient population.

Acknowledgement. We thank Jennifer Deberg from Hardin Library for the Health Sciences, University of Iowa Libraries on the search methods.

Disclosures: None

Funding: None

Background: Incidence of community-associated (CA) and healthcare-associated, community-onset (HACO) USA300 methicillin-resistant Staphylococcus aureus (MRSA) bloodstream infections has remained unchanged in recent years. Traditionally considered a CA strain, USA300 is increasingly associated with healthcare settings. We examined whether antimicrobial nonsusceptibility among USA300 strains could distinguish epidemiologic class (community vs hospital), and whether divergences in susceptibility were occurring over time. Methods: We used data on invasive MRSA infections from active, population, and laboratory-based surveillance during 2005–2016 from 11 counties in 3 states. Invasive cases were defined as MRSA isolation from a normally sterile site in a surveillance area resident. Cases were considered hospital-onset (HO) if the culture was obtained >3 days after hospitalization and HACO if ≥1 of the following risk factors was present: hospitalization, surgery, dialysis, or residence in a long-term care facility in the past year; or central vascular catheter ≤2 days before culture. Otherwise, cases were considered CA. Sites submitted a convenience sample of clinical MRSA isolates for molecular typing and antimicrobial susceptibility testing. Molecular typing was performed by pulsed-field gel electrophoresis until 2008, when typing was inferred using a validated algorithm based on molecular characteristics. Reference broth microdilution was performed for 8 antimicrobials and interpreted based on CLSI interpretive criteria. We compared USA300 nonsusceptibility for HO and CA isolates. For antimicrobials with >5% nonsusceptibility and for which HO isolates had greater nonsusceptibility than CA isolates, we compared nonsusceptibility for HACO and CA and analyzed annual trends in nonsusceptibility within each epidemiologic class (ie, CA, HACO, and HO) using linear regression. Results: Of 17,947 MRSA cases during 2005–2016, isolates were available for 6,685 (37%), and 2,120 were USA300 (34% CA, 52% HACO, 14% HO). HO isolates had more nonsusceptibility than CA isolates to gentamicin (2.2% vs 0.6%; P = .03), levofloxacin (47.8% vs 39.7%; P = .02), rifampin (3.7 vs 1.1%; P = .01), and trimethoprim-sulfamethoxazole (3.4% vs 0.6%; P = .04). HACO isolates also had more nonsusceptibility than CA isolates to levofloxacin (50.9% vs 39.7%; P < .01). Levofloxacin nonsusceptibility increased during 2005–2016 for HACO and CA isolates (P < .01), but not among HO isolates (P = .36) (Fig. 1). Conclusions: Overall, nonsusceptibility across drugs cannot distinguish USA300 isolates causing HO versus CA disease. Although HO isolates had higher levofloxacin nonsusceptibility than CA and HACO isolates early on, USA300 MRSA HACO isolates now have levofloxacin nonsusceptibility most similar to that of HO isolates. Further study could help to explore whether increases in fluoroquinolone nonsusceptibility among CA and HACO cases may be contributing to the persistence of USA300 strains.

Disclosures: None

Funding: None

Background: Untreated staphylococcal ocular infections may cause injuries in the ocular structure and lead to visual impairments, lesions in the anatomical ocular surface, and blindness. The aim of the study was to describe the characteristic of 90 Staphylococcus aureus (SA) strains from hospital and community treated ocular infections with a special emphasis on ability of biofilm formation and drug resistance. The biofilm formation was carried out using the Congo red agar (CRA) method applying Congo red dye. Studies have demonstrated that the CRA method is simple, fast, and repeatable and that modifications of some components can easily increase its accuracy. Methods: Biofilm formation was examined by the method with CRA test. On CRA, slime-producing strains formed black colonies, whereas nonproducing strains developed red colonies in 6 kinds of colors, from very red to very black: very red, red, burgundy, almost black, black, and very black. Antimicrobial susceptibility testing was performed by disc diffusion or the E-test method according to the current guidelines of the EUCAST. The MRSA, and MLSB phenotypes were detected. Polymerase chain reaction (PCR) was used to detect the mecA, and mupA genes. Erythromycin resistance genes (ermA, ermB, ermC, and msr) were detected by multiplex PCR. Results: A positive result of the CRA test was accomplished in 66.2% cases; significantly more often in hospital strains (73.4% vs 45.4%; OR, 3.3; 55% CI, 1.2–9.3). Moreover, 73.4% isolates were fully susceptible. In hospitalized patients, the level of resistance to at least 1 antimicrobial category has been identified as 40.9%, and this rate was 27.2% in outpatients. Among the tested strains, 5 (6.0%) had the resistance phenotype MRSA and 22 (26.5%) the resistance phenotype MLSB; 4 strains manifested both mechanisms; erythromycin resistance was 25.3% in those resistant to fluoroquinolones. Resistance to fluoroquinolones was 5 times more often found in ambulatory patients. All of the tested isolates were vancomycin sensitive. Conclusions: Biofilm formation is an important risk factor for developmental staphylococcal hospital-acquired ocular infections. Our results prove that hospital strains have demonstrated much greater biofilm-forming ability than nonhospital strains. Studies indicate the high efficacy of chloramphenicol and fluoroquinolones treatments, as well as the need to implement new solutions due to the aforementioned bacteria’s high resistance to neomycin and anatomic barriers difficulties.

Disclosures: None

Funding: None

Background: In April 2019, the Montgomery County Office of Public Health (MCOPH) was notified by the Pennsylvania Department of Health (PADOH) of a tier 2 carbapenemase mechanism in a resident of a Pennsylvania skilled nursing facility that was detected through targeted surveillance. Production of the New Delhi metallo-β-lactamase (NDM) carbapenemase was detected using polymerase chain reaction (PCR). The initial follow-up revealed that the patient resided at a 148-bed skilled nursing facility that specializes in spinal cord injury, neurological diseases, ventilator dependence, and pulmonary diseases. MCOPH and PADOH initiated an investigation to identify additional cases and prevent transmission. Methods: Over a series of 9 point-prevalence surveys, we collected 518 specimens for colonization screening. Screening was conducted on the wing of the index case and was later expanded to include the entire unit (n = 90), after evidence of transmission was noted. Perirectal swabs were submitted to the regional antibiotic resistance laboratory for testing using the Cepheid GeneXpert Carba-R assay. Together with screening, MCOPH and PADOH conducted a series of on-site visits involving the completion of the CDC infection control assessment and response (ICAR) tool and direct care observations, including 409 hand hygiene observations. Results: In addition to NDM, Klebsiella pneumoniae carbapenemase (KPC) and Verona integron-encoded metallo-β-lactamase (VIM) were also detected. ICAR results and direct care observations revealed numerous deficiencies in the domains of hand hygiene, personal protective equipment, and environmental cleaning. In addition to 2 cases of carbapenemase-producing organisms (CPO) being detected through clinical specimens, an additional 27 CPO cases were identified through screening coordinated by public health. This large, multimechanism outbreak is attributed to a combination of intrafacility transmission and imported cases. Based on these findings, recommendations for infection prevention and control were provided on site and in writing. Our continued work with this facility lead to improvements in infection control, including a HH success rate improvement of 53%. Conclusions: Novel or targeted multidrug-resistant organisms are effectively contained when healthcare facilities and state and local public health work together to reduce transmission to baseline and to improve infection control practices.

Funding: None

Disclosures: None

Background: Implementing robust antimicrobial stewardship programs within long-term care facilities (LTCFs) presents unique challenges not typically seen in other healthcare settings. These facilities tend to care for older adults, rely on limited on-site clinician availability and experience higher-than-normal staff turnover. Many LTCFs lack the resources and expertise to track and analyze antibiotics usage. Through a collaborative effort between the Arizona Department of Health Services and the University of Arizona College of Pharmacy, support for carrying out stewardship activities was provided to these healthcare facilities. Our objective was to assess the viability of using pharmacy prescribing data to evaluate antibiotics usage among LTCFs throughout Arizona to assist in development of antimicrobial stewardship interventions. Methods: We invited interested LTCFs to participate in the development and enhancement of antimicrobial stewardship programs. We analyzed antibiotic prescribing data from November 2017 through November 2018 to assess the types and quantities of antibiotics prescribed. We worked with pharmacies to obtain a deidentified dataset that included unique patient identifiers, transaction (start) date, agent name, directions for use, route of administration, quantity dispensed, and stop dates. We estimated duration of treatment by assessing antibiotic starts using the number of transaction dates and unique patient identifiers for repeat prescriptions. Each agent was evaluated individually and assigned to an antibiotic category to better assess cumulative prescribing. Results: Through assistance from our community partners, we recruited 11 facilities to participate and worked with 5 servicing pharmacies to obtain a complete dataset for 6 LTCFs. For the facilities evaluated, there were a total of 4,654 antibiotic prescriptions. The most commonly prescribed antibiotic categories were fluroquinolones (24.3% of prescriptions) and oral β-lactams (17.8% of prescriptions). The third most commonly prescribed antibiotics were agents utilized against methicillin-resistant Staphylococcus aureus (MRSA) (13.7% of prescriptions). Antibiotic duration ranged from 1 to 304 days of therapy. Conclusions: Working directly with servicing pharmacies is an efficient way to obtain antibiotic prescribing data for LTCFs. During the 1-year period evaluated, antibiotic prescription rates varied between LTCFs. Despite numerous warnings, the fluroquinolone class continue to be among the most commonly prescribed antibiotics. Visualizing trends in LTCFs antibiotic data is an optimal way to develop and enhance antimicrobial stewardship programs in LTCFs. This fundamental information can help identify areas in which a facility can focus their stewardship efforts and provide a baseline for monitoring progress over time.

Funding: None

Disclosures: None

Background: Implementation of antimicrobial stewardship programs (ASPs) in acute-care facilities may optimize antibiotic use and decrease antibiotic resistance. To explore the relationship between ASPs and clinical outcomes, we reviewed bivariate relationships between VA Medical Center (VAMC) complexity level and presence of an ASP, presence of an ASP and inpatient antibiotic use, and antibiotic use and antibiotic resistance or Clostridioides difficile infection (CDI). Methods: We conducted a cross-sectional study of national data using the following elements: a detailed survey of antimicrobial stewardship practices at VAMCs in 2012 which included facility complexity designations; data from the VA national Electronic Health Record (EHR) for inpatient antibiotic use (2009–2012 in days of therapy per 1,000 bed days of care); EHR laboratory data in 2013 for antibiotic resistance in E. coli isolates; and 2013 CDI rate data from the VA Inpatient Evaluation Center. These data were reviewed for assessment of the presence of ASPs and for antibiotic use and resistance. We assessed 4 groups of antibiotics for use and resistance: total antibiotics, fluoroquinolones, cephalosporins, and carbapenems. Categorical, t test, or nonparametric analyses were performed, as appropriate. Results: 120 VAMCs were evaluated; 71% had ASPs. Proportions of VAMCs with ASPs were not significantly different by facility complexity level. Differences were observed between presence or absence of ASP and some antibiotic use groups (Table). Presence or absence of an ASP was not statistically associated with a difference in E. coli resistance (any antibiotic group examined) or CDI rates. In addition, antibiotic use (any group) did not statistically associate with E. coli resistance rates, and this result remained unchanged when stratified by presence or absence of an ASP. Conclusions: Total antibiotic use and fluroquinolone use were lower among facilities with ASPs than without, a finding consistent with ASP implementation reducing the amount of antibiotics prescribed. Although we did not find an association between facilities with an ASP and antibiotic resistance or CDI rates in this preliminary review, it sets the stage for future multivariate analyses. Furthermore, given the years of antibiotic use needed for development of resistance, the limited years evaluated may not have been sufficient to determine an impact, highlighting the need for further research into understanding clinical outcomes.

Funding: None

Disclosures: None

Background: Pertussis continues to be an important health issue in Vietnam despite infant vaccination programs. In Vietnam, the incidence rates of pertussis per 100,000 population rose from 0.09 in 2014 to 0.33 in 2015 and to 0.58 in 2017. Macrolides, especially erythromycin, are the treatment of choice. However, erythromycin-resistant cases, caused by transition at A2047G position in 23S rRNA, have been reported in the region. Few data are available on antimicrobial resistance in Bordetella pertussis to guide treatment in Vietnam. We report antimicrobial susceptibility of the circulating strains in southern Vietnam during 2015–2017. Methods: Tracheal aspirates from 263 suspected pertussis cases were subject to multiplex real-time PCR to identify B. pertussis and Bordetella spp. Samples were cultured on Regan Lowe agar with 10% sheep blood containing cephalexin (40 µg/mL) and incubated at 37°C for 10 days. The antimicrobial susceptibilities to erythromycin, azithromycin, clarithromycin, and trimethoprim/sulfamethoxazole were determined using the disc diffusion method (CLSI-2017) on Regan Lowe and Mueller Hinton agar. Erythromycin minimum inhibitory concentrations (MICs) were determined using an E-test. The results were recorded after days 3 and 7 of incubation. Sequencing of the 23S rRNA gene was performed to detect mutations conferring macrolide resistance. Results: Of 263 cases, 119 were positive for B. pertussis (45.2%) by real-time PCR, and 15 of 263 strains (5.7%) were successfully cultured. All 15 isolates were susceptible to macrolides and no heterogeneous phenotype was recorded after 7 days; erythromycin MICs were ≤0.094 µg/mL (Fig. 1). We observed no difference in results generated on Regan Lowe and Mueller Hinton media. However, for testing trimethoprim/sulfamethoxazole, results on were superior, as those on Regan Lowe media were unclear. Sequencing of 23S rRNA identified no mutations known to confer macrolide resistance. Conclusions: None of 15 B. pertussis isolates tested were nonsusceptible to erythromycin and macrolides. Similarly, no mutation at the erythromycin-binding site in the 23S rRNA gene was identified. The low isolation rate of B. pertussis by culture means that few positive specimens were tested for antimicrobial susceptibility. To overcome this limitation, detection of resistance directly from clinical specimens needs to be investigated. Ongoing screening for B. pertussis and antimicrobial susceptibility is recommended to support efforts to control the spread of this respiratory tract infection agent.

Funding: None

Disclosures: None