Background: Carbapenem-resistant Enterobacteriaceae (CRE) represent one of the most critical emerging antimicrobial-resistance threats globally. Data from low-and middle-income countries (LMICs) are increasingly reported as a part of global efforts to improve surveillance, and they demonstrate a high and increasing burden of CRE. However, containment of CRE using all recommended infection prevention and control (IPC) strategies requires substantial resources, which may be limited in LMICs. We conducted a review of the literature to better understand how approaches to CRE containment in LMICs have varied. Methods: We conducted a literature search using electronic databases (Medline, Embace, Cochrane Library, and Global Health) with no limit to study design or publication year. Search terms consisted of 3 categories: CRE, IPC, and LMIC. Additional publications were also identified from the references of identified articles. Publications were screened for eligibility; non-English articles and studies on other gram-negative organisms were excluded from the analysis. Control measures in included studies were categorized as active surveillance, hand hygiene, contact precautions, isolation, education, environmental control, monitoring and feedback, and other. Results: In total, 2,667 publications were identified using the databases and an additional 24 were manually identified. After deduplicating and screening for eligibility, 27 publications were included in the analysis. Overall, 21 publications (78%) were outbreak reports and 3 (11%) were quasi-experimental studies in settings of high rates of CRE. Also, 23 (85%) described a successful reduction in CRE. Among those 23 publications, 22 publications described adequate descriptions of IPC measures implemented, and the median number of IPC measures was 4.5 (range, 1–8). Environmental control was the most commonly utilized intervention (n = 19, 86%), followed by hand hygiene (n = 14, 64%) and contact precautions (n = 14, 64%). Three publications did not show a reduction in CRE despite the combination of IPC measures (median, 4.5). Overall, 13 publications utilized some method of active surveillance, but complete details on methodology were often lacking. In addition, 4 studies (15%) used only horizontal measures (defined as hand hygiene, environmental control, and/or education) and successfully controlled the CRE outbreaks. Conclusions: Among published reports, successful approaches to CRE control have been reported from LMICs. Use of only horizontal approaches, which are often lower cost and simpler to implement than some vertical strategies, have demonstrated some success; however, additional experience with identifying and implementing cost-effective strategies is needed.

Funding: None

Disclosures: None

Background: Acute bacterial meningitis is a medical emergency, and early initiation of appropriate therapy is important to improving outcomes. Culture-based methods are still the standards for the detection of microorganisms in cerebrospinal fluid (CSF). Automated blood culture systems yield better results in cultures sterile body fluids, including CSF. However, the high sensitivity of this technology does not negate the danger of contamination compromising the final outcome. Thus, we tried to study the culture yield in suspected meningitis to determine the rate of contamination. Methods: We conducted a retrospective cohort study of CSF samples collected for culture over 1 year from January 2018 to December 2018 from patients who presented with signs and symptoms indicative of meningitis. The bacterial etiologies and rates of contamination were extracted from laboratory records. Descriptive statistics from Microsoft Excel software were used to analyze patient data. Limited statistical analysis (ie, the Fisher exact test) was performed using SPSS for Windows version 18 software. Results: In total, 1,053 CSF samples were received for aerobic culture, of which the most frequent were conventional cultures (685 of 1053, 65%), whereas BacT/ALERT cultures were requested for 368 of 1,053 cases (35%). Of 685 conventional CSF cultures, pathogens were isolated in 28 of 685 (4.1%), most commonly Acinetobacter baumannii complex (10 of 28, 35.7%). Contaminants were identified in 0.58% samples (4 of 685). In the 368 BacT/ALERT cultures, pathogens were detected in 15 (4.1%), most commonly Streptococcus spp (5 of 15, 33.3%). The contamination rate was 51.1% (188 of 368 cases). The overall rate of contamination was 18.2% (192 of 1,053 cases). The most CSF cultures were received from patients in neurosurgery (350 of 1,053, 33.2%) followed by medicine wards (270 of 1,053, 25.6%). Aerobic spore bacilli was by far the most common contaminant (109 of 1,053, 10.35%).

Conclusions: We believe efforts to decrease contamination are among the most cost-effective, but targeted clinical re-evaluation for all patients with positive CSF cultures remains vital. Due to the high sensitivity of the automated culture system, it is a imperative to maintain strict aseptic conditions while collecting CSF samples. Failure to do so may lead to overgrowth of contaminants masking the growth of the true pathogens in culture.

Disclosures: None

Funding: None

Background: There is a critical need for comprehensive and effective healthcare- associated infection and antibiotic resistance (HAI/AR) programs in the United States. Since 2009, the CDC has funded and engaged public health, healthcare, academic, community, corporate, federal, and other stakeholders to develop effective HAI programs that rely upon such these stakeholders for success. State and local public health programs play a central role in these programs because they bridge healthcare and the community. They may regulate and assess facilities, collect and validate data on infections, and implement prevention programs. Myriad other state, federal, and privately supported stakeholders play essential roles. CDC is developing a framework for highly effective state HAI/AR programs that describes core program elements and can be used as a strategic tool, both in day to day processes and in a public health crisis, such the COVID-19 response. Program elements may include engaged leaders and champions, reliable data for action, effective policies, evaluation, program innovation, communications, and partner networks. This presentation describes a success framework for developing and leveraging HAI/AR partner networks to achieve and sustain their capacities and impact.

Methods: CDC collected qualitative data in select states and combined with expert opinion to draft core elements for success among a network of partners working to achieve HAI/AR and COVID-19 response and prevention in states. The core elements serve as a foundation for the framework. Ongoing analyses will inform refinement of the core elements and framework. The CDC is gathering stakeholders’ input on the framework for applicability and usability in states, with the goal of national implementation. Results: Currently, data indicate the following core elements for partner networks: leadership, strategy and structure; policies; innovation and adaptability; implementation; expertise and resources; communications; and monitoring and evaluation. The framework includes a process for partner network development and sustenance, maturity levels, and supporting tools. States have reported support for core elements and agreed that a success framework is beneficial to achieving core elements. Multiple states have reported support for a process that includes building partner networks and clearly defining roles, as a critical step toward full implementation of Program core elements. Conclusions: A framework for building high-level strategy and competency in partner networks has never been developed for HAI/AR programs. Effective partner networks represent an essential core element of a comprehensive state HAI/AR program. This framework could be applied to a variety of programs and public health contexts, increasing the effectiveness of partner networks.

Funding: None

Disclosures: None

Background: Outpatients with uncomplicated urinary tract infections (UTIs) are often treated empirically without culture, whereas urine cultures are typically collected from patients with complicated UTI. Susceptibilities for fosfomycin (a first-line agent) are not routinely performed or reported in the antibiogram. Understanding the prevalence of antibiotic resistance for UTI is critical for empiric treatment and antibiotic stewardship in primary care. Methods: We developed a UTI-focused antibiogram from a prospective sample of outpatients (women and men) with UTIs from 2 public family medicine clinics in an urban area with a diverse, international population (November 2018 to present). During the study period, providers ordered a urine culture for any adult patient presenting with UTI symptoms, including uncomplicated and complicated infections. We estimated the prevalence of resistance to UTI-relevant antibiotics in the overall study population and compared it between patients born in the United States and other countries. Results: We collected 678 urine cultures from 644 unique patients (79% female). Of these cultures, 158 (23.3%) had no growth, 330 (48.7%) grew mixed urogenital flora, and 190 (28.0%) were positive (>10,000 CFU/mL). Patients with positive cultures were mostly female (88.2%), and their mean age was 46.6 ± 14.8 years. Among patients with positive cultures, 42.7% were born in the United States and 57.3% were born Mexico or Central America. Escherichia coli was the most commonly isolated organism (Fig. 1). Susceptibility results for E. coli and all gram-negative organisms combined are presented in Fig. 2. Susceptibility of uropathogens to TMP-SMX was significantly higher in patients born in the United States compared to patients from Mexico or Central America (82% vs 61%; P = .03). Susceptibility to ciprofloxacin was similar in patients born in the United States and other countries (79% vs 72%; P = .50). Of 77 E. coli isolates, 11 (14%) were positive for extended-spectrum β-lactamase production, including 8 isolates from patients whose country of origin was Mexico or a Central American country. Conclusions: More than 20% of outpatients presenting with UTI symptoms had a negative urine culture. Among outpatients with uncomplicated and complicated UTI, uropathogens had a high prevalence of resistance to ciprofloxacin and TMP-SMX, but susceptibility to fosfomycin (restricted in our system) was 100%. Resistance rates for TMP-SMX were higher in patients from Mexico and Central America. Our findings question whether TMP-SMX should remain a first-line agent in US primary-care settings.

Funding: This project was supported by the National Institute of Allergy and Infectious Diseases of the National Institutes of Health under Award Number UM1AI104681.

Disclosures: None

Background: Antimicrobial stewardship programs (ASPs) consist of coordinated interventions designed to improve and measure appropriate antimicrobial use. Understanding the current structure of ASPs hospitals will support interventions for improvement or implementation of these programs. Objective: We aimed to describe the current status of ASP in hospitals in the state of São Paulo, Brazil. Methods: We conducted a cross-sectional survey regarding ASP of hospitals in São Paulo state, Brazil, from March to July 2018. Through interviews by telephone or e-mail, we asked participants which components of IDSA/SHEA and CDC guidelines had been implemented. Results: The response rate was 30% (28 of 93 hospitals) and 26 of the hospitals (85%) reported having a formal ASP. Policies, practices, and strategies of surveyed ASP are detailed in Table 1. The most frequently implemented strategies were (1) antimicrobial surgical prophylaxis guideline (100%), (2) empiric sepsis guideline (93%), and (3) presence of ASP team member during bedside rounds (96%). The least commonly implemented strategies included prior authorization for all antimicrobials (11%), pharmacokinetic monitoring and adjustment program for patients on IV aminoglycosides (3%). Regarding metrics of the ASP, the most common indicator was the rates of antimicrobial resistance (77%). Overall, 18 hospitals (19%) used defined daily dose and only 29% used days of therapy. Moreover, 61% of hospitals reported their results to hospital the administration and 39% of hospitals reported their results to the prescribers. Conclusions: Most hospitals have a formal ASP, but there are opportunities for improvement. Future efforts should prioritize tracking and reporting ASP metrics.

Funding: None

Disclosures: None

Background: Early de-escalation of antibiotics in sepsis may be safe and effective. In our study, we performed a retrospective chart review of patients admitted to a large municipal hospital who were treated for severe sepsis or septic shock to compare outcomes in patients who experienced early de-escalation (DEG) with outcomes of those who did not (NDG).

Methods: The observational study was conducted at Bellevue Hospital Center (an 850-bed municipal hospital affiliated with New York University School of Medicine, New York, NY). Patients admitted from January 1 to December 31, 2015, who were treated for severe sepsis or septic shock during any time of their hospital stay were reviewed for the study. De-escalation was defined as narrowing or discontinuation of 1 or more antimicrobial therapies < 3 days after sepsis onset. Results: Overall, 277 patients were included (DEG, 90 patients, 32%; NDG, 187 patients, 68%). The groups were similar in terms of sex, comorbidities, length of stay, and severity of illness: septic shock (47% DEG vs 49% NDG; P = .693) and ICU stay (27% DEG vs 32% NDG; P = .406). DEG patients were slightly older than NDG patients: (DEG age, 63+16 years vs NDE age, 58+16 years; P = .028). There was no difference in hospital mortality (8% DEG vs 12% NDE; P = .257). Nearly half of the patients in both groups (46% DEG and 47% NDG) had no causative microorganisms identified using conventional microbiology culture. The common sources of primary infection were respiratory, urinary tract, and gastrointestinal infections, and these were not different between groups. Also, 69% of DEG patients and 79% of NDG patients received antibiotics for >7 days (P = .002). Empiric intravenous vancomycin was initiated in 83% in DEG patients and 74% in NDG patients at sepsis diagnosis. Although organisms covered by intravenous vancomycin were isolated from only 17% of patients in DEG and 23% in NDG, vancomycin was continued for >5 days in 34% of DEG patients and 50.3% of NDG patients (P < .001). 60% of patients in DEG and 61% in NDG were seen by infectious diseases specialists (ID). Patients with infectious diseases consultations had significantly more comorbidities, were more frequently in the ICU, had higher MDRO isolation and longer hospital stays, but they were still de-escalated without a difference in mortality. Conclusions: Microbiology data did not contribute to early de-escalation of antibiotics in this study. This finding may be related to the high percentage of negative culture and unavailability of rapid molecular diagnostic tests. Shorter duration of antibiotics (including vancomycin) was not associated with worse outcome in these severely ill patients.

Funding: None

Disclosures: None

Background:Mycobacterium tuberculosis (TB) is one of the leading causes of morbidity and mortality worldwide. At our health system, 50–100 patients are diagnosed with tuberculosis every year. One risk factor for TB is residence within a homeless shelter. In response to an increased number of cases in local homeless shelters, the health department sought assistance with contact tracing of individuals potentially exposed to tuberculosis. We report the results of contact tracing performed at our health system. Methods: The setting is a 770-bed, safety-net, academic hospital with community clinics and a correctional health center. Name, date of birth, and social security number of contacts potentially exposed during February 2009 to July 2013 were programmed into the electronic medical records to create a decision support tool upon entering the health system. The best practice alert (BPA) informed physicians of the exposure and offered a link to a screening test, T-spot.TB, and a link to an information sheet. This intervention was implemented from July 2013 to July 2015. After excluding patients with active TB, data on the magnitude of exposure in each homeless shelter and screening test results were analyzed with ANOVA using SPSS v 26 software. Results: Of the 8,649 identified exposed contacts, 2,118 entered our health system. Of those for whom the BPA was triggered, 1,117 had a T-spot.TB done, with 313 positive results and 57 borderline results. Table 1 shows that shelter 3 was correlated with a positive T-spot.TB. Conclusions: The BPA, which prompted physicians to evaluate an individual for TB, was effective at capturing high-risk, exposed individuals. Clinical decision support tools enabled our safety-net health system to respond effectively to a local public health need.

Funding: None

Disclosures: None

Background: A quantitative understanding of the impact of delays to concordant antibiotic treatment on patient mortality is important for designing hospital antibiotic policies. Acinetobacter spp are among the most prevalent pathogens causing multidrug-resistant hospital-acquired infections in developing countries. We aimed to determine the causal effect of delays in concordant antibiotic treatment on 30-day survival of patients with hospital-acquired Acinetobacter spp bacteremia in a resource-limited setting. Methods: We included patients with Acinetobacter spp–related hospital-acquired bacteremia (HAB) in a hospital in Thailand over a 13-year period. We classified patients into 4 groups: those with no delays to concordant antibiotic treatment; those with a 1-day delay; those with 2-day delays; and those with >2 days of delay. We adopted an analytical approach that aimed to emulate a randomized controlled trial and compared the expected potential outcomes of patients between the exposure groups using a marginal structural model with inverse-probability weightings to adjust for confounders and immortal time bias. Results: Between January 2003 and December 2015, 1,203 patients had HAB with Acinetobacter spp., of which 682 patients (56.7%) had ≥1 days of delay in concordant antibiotic treatment. These delays were associated with an absolute increase in 30-day mortality of 6.6% (95% CI 0.2%-13.0%), from 33.8% to 40.4%. Among the 1,203 patients, 521 had no delays to concordant antibiotic treatment (i.e. concordant therapy on the day of blood collection), 224 patients had a 1-day delay, 119 had a 2-day delay, and 339 had a delay of ≥3 days. The crude 30-day mortality was substantially lower in patients with ≥3 days of delay in concordant treatment compared to those with 1 to 2-days of delays. After adjusting for measured confounders and immortal time bias, the expected probability of dying in the hospital within 30-days of blood collection if patient had no delays in concordant therapy was 39.7% (95% CI: 32.3-47.2%), for a 1-day delay it was 42.7% (95% CI: 29.8-55.7%), for a 2-day delay it was 51.0% (95% CI: 38.9-63.2%), and for a ≥3 days was 40.9% (36.0-45.7%).

Conclusions: Delays to concordant antibiotic therapy are linked to increased mortality among patients with HAB due to Acinetobacter spp. Accounting for confounders and immortal time bias is necessary when attempting to estimate causal effects of delayed concordant treatment and, in this case, it helped resolve paradoxical results in crude data.

Funding: The Mahidol Oxford Tropical Medicine Research Unit (MORU) is funded by the Wellcome Trust [grant number 106698/Z14/Z]. CL is funded by a Wellcome Trust Research Training Fellowship [grant number 206736/Z/17/Z]. MY is supported by a Singapore National Medical Research Council Research Fellowship [grant number NMRC/Fellowship/0051/2017]. BSC is funded by the UK Medical Research Council and Department for International Development [grant number MR/K006924/1]. DL is funded by a Wellcome Trust Intermediate Training Fellowship [grant number 101103]. The funder has no role in the design and conduct of the study, data collection, or in the analysis and interpretation of the data.

Disclosures: None

Background: In 2019, a measles community outbreak resulted in a secondary case in a health care worker (HCW) working in a pediatric hospital in Montral, Canada. Following the event, HCWs were screened to identify individuals susceptible to measles infection based on serology results. Objective: Our aim was to assess measles seroprotection rates and to evaluate vaccine responses of susceptible HCWs using commercial enzyme immunoassay (EIA) or enzyme linked immunosorbent assay (ELISA). Methods: Emergency department (ED) employees, including doctors, were screened for measles susceptibility as part of a postoutbreak measure by the hospital occupational health service. Demographic information was collected. Measles history and vaccination information were collected using a personal vaccination booklet, employee vaccination profile, or the Qubec vaccination registry. According to the Quebec Immunization Protocol (PIQ), individuals born before 1970, or who have received 2 doses of a measles-containing vaccines are considered protected. Individuals with undetectable or equivocal antibody levels were considered at risk of measles infection. These individuals were offered vaccination and were tested for vaccine response 4 weeks after vaccination. Results: Anti-IgG measles antibody results, demographic information, and vaccination information were obtained for 257 employees. The results are currently available for 233 HCWs: 224 HCWs (96%) were seropositive, 7 (3%) were seronegative, and 2 were equivocal. Among seronegative individuals, 6 (85.7%) were born after 1980 and 3 (42.9%) had received 2 doses of a measles-containing vaccine. Of those with an equivocal result, 1 (50%) had received 2 doses and 1 (50%), born after 1970, did not confirm vaccination status. Finally, 9 (4%) of seropositive individuals were not vaccinated; of whom 8 (88.9%) were born before 1970. Conclusions: Our preliminary results suggest that the 95% immunity threshold that is usually required to prevent secondary transmission of measles has been reached in our ED HCW cohort. Even years after the second MMR dose, HCWs remain well protected. Relying on documented vaccination status is thus acceptable.

Funding: None

Disclosures: None

Background: Antibiotic stewardship is an area of great concern in long-term care facilities nationwide. The CDC promotes 7 core elements of antimicrobial stewardship. Based on information obtained from the Infection Control Assessment and Response (ICAR) Program, the 2 core elements most infrequently achieved by LTCFs are tracking and reporting. Currently, minimal data are available on antibiotic use (AU) in LTCFs in Tennessee. To address both issues, the Tennessee Department of Health (TDH) developed a monthly antibiotic use (AU) point-prevalence (PP) survey to provide LTCFs with a free tool to both track and report their AU and to gather data on how LTCFs are using antibiotics. Methods: We used REDCap to create a questionnaire to collect information on selected antibiotics administered in Tennessee LTCFs. This self-administered survey was promoted through the TDH monthly antimicrobial stewardship and infection control (ASIC) call as well as at various conferences and speaking engagements across the state. Antimicrobial stewardship leads for each facility were targeted. Antibiotics were grouped into 4 classes according to their indications: C. difficile infections, urinary tract infections, skin and soft-tissue infections (SSTIs) and respiratory infections. We determined AU percentage by dividing the number of days of therapy for a drug by a facility’s average census. Individualized reports are provided to each participating facility on a quarterly basis. Results: Currently, 16 facilities have participated in the survey. Overall, 40.7% of antibiotics prescribed were in the common for SSTI category and 39.3% were common for respiratory infections. The top 33 most commonly prescribed antibiotics were amoxicillin (156 days of therapy [DOT]), nitrofurantoin (92 DOT), and levofloxacin (88 DOT). The average percentage of residents on antimicrobials on the day of survey was 12.3%; within this group, 57% of antibiotics were initiated in the LTCF, whereas 43% were present upon admission. Conclusions: Early results from the TDH AU PP survey revealed that drugs commonly used for SSTIs and respiratory infection were the most common antibiotic prescriptions and a potential area of focus for TDH’s antimicrobial stewardship efforts. None of the 3 most frequently prescribed antibiotics, however, fall under the SSTI indication, despite SSTI being the most commonly prescribed indication based on the survey’s evaluation metrics. This finding could be related to the larger number of antibiotics that fall under the SSTI indication. Preliminary data are being used to guide the direction of TDH’s future ASIC calls to better suit disease states, which have room for improvement.

Funding: None

Disclosures: None

Background: Norovirus causes a significant disease burden of 20 million cases per year in the United States. Hospitals and long-term care facilities constitute the most commonly reported settings for noroviral outbreaks and clusters and thus represent a critically important site for prevention. Our institutional surveillance and response system identified 10–14 clusters or outbreaks of gastrointestinal viral disease per year, predominantly affecting staff. We sought to develop a compartmental mathematical model to examine the potential efficacy of various infection control practices in the management of noroviral clusters. Methods: We developed a set of parallel compartments representing both patient and staff categories (nursing, nurse assistants, etc) involved in a prototypical outbreak, using a 38-bed mixed medium- and high-acuity medical unit as the model basis. A susceptible–exposed–infected–recovered/immune (SEIR) model structure was used (Fig. 1). We conducted interviews with infection preventionists and nursing management to parameterize the model with data on (1) staff-to-patient ratios, (2) staff-patient contact time, (3) staff-staff contact time, (4) spatial distribution of patient assignments, and (5) baseline and intraoutbreak infection prevention practices. With these data, we proceeded to develop submodels, building on the primary model, that examined the effects of additional parallel compartmentalization of granular groups of staff, including resident physicians, environmental services, and clinical nursing assistants. Model parameters for these subanalyses were informed by interviews with clinical experts and review of internal data. Results and Conclusions: An SEIR model was developed that allowed for examination of a modeled outbreak of norovirus and comparison with a known prior outbreak on the same modeled unit for fidelity. Submodeling was performed with more staffing detail, allowing for the addition of further parallel SEIR tracks that delineated more granular staffing patterns. Staff interviews proved critical in the parameterization of these submodels, allowing for a more faithful representation of real-world dynamics. This work, through modification of model parameterization, can be used to assess the efficacy of hypothetical infection control interventions (eg, earlier unit closure, longer staff furlough) in altering transmission dynamics during an outbreak.

Funding: None

Disclosures: None

Background: Antimicrobial resistance (AR), including Clostridioides difficile infection (CDI), can spread across the healthcare continuum when patients move between facilities. In 2015, the CDC recommended that healthcare facilities (HCFs) and local public health departments (LPH) coordinate their efforts to prevent the spread of AR and CDI. Accordingly, the California Department of Public Health (CDPH) Healthcare-Associated Infections (HAI) Program developed a model for implementing regionally based AR/CDI prevention collaboratives within HCF networks. Methods: The CDPH HAI Program began identifying regions in California with high AR/CDI incidence or risk for AR/CDI emergence using NHSN data. During 2015–2019, we organized AR/CDI prevention collaboratives in these regions. We recruited HCFs for participation by presenting at local professional organization meetings and engaging skilled nursing facility corporate leadership. HAI Program infection preventionists conducted onsite infection prevention assessments at each participating HCF. HAI Program and LPH staff convened quarterly in-person learning and discussion sessions focused on infection prevention and antimicrobial stewardship best practices. Participating HCFs committed to facility-tailored process improvement plans and conducted self-assessments to evaluate infection prevention practice changes at the conclusion of the collaborative. For CDI-focused collaboratives, we used data reported to CDPH via NHSN to assess changes in hospital- and community-onset CDI incidence among participating hospitals before and after the collaboratives. Results: Since 2015, 205 HCFs in 15 LPH jurisdictions have participated in 6 regional AR/CDI prevention collaboratives. Participating HCFs reported improved implementation of AR/CDI prevention strategies. For CDI-focused collaboratives, hospital-onset CDI incidence decreased by ~3% per month among participating hospitals. The collaboratives created forums for communication and relationship building, which previously did not exist among LPH and the HCF networks. We used our experience and feedback from partners to develop an HAI Program AR Prevention Collaborative Tool Kit to help LPHs and healthcare organizations develop and implement regional AR/CDI prevention collaboratives in other at-risk or high AR/CDI prevalence areas in California. The tool kit includes materials developed for each of our collaboratives, which may be adapted to meet local needs. Conclusions: Regionally coordinated AR/CDI prevention initiatives among LPHs and HCFs can contribute to increased AR awareness, improved AR prevention practices, and decreased AR/CDI incidence. The effectiveness of regional AR/CDI prevention collaboratives may be the result of concurrent efforts to improve AR prevention practices both within individual HCFs and across patient sharing networks.

Funding: None

Disclosures: None

Background: Nosocomial infections cause 4%–56% mortality in newborns. Several epidemiological studies have shown that transmission of opportunistic pathogens from the sink to the patient, including Pseudomonas aeruginosa, Stenotrophomonas maltophilia, and Serratia marcescens are associated with nosocomial infections in neonatal intensive care units (NICUs). In this project, we aimed to develop fast, accurate, and high-throughput multilocus sequence typing assays (HiMLST-Illumina) to detect opportunistic pathogens to assess their distribution in the sink environment of NICUs and their transfer to patients. Methods: Genome sequences of P. aeruginosa (n = 45), S. maltophilia (n = 23) and S. marcescens (n = 34) strains were retrieved from public genome databases to build their pangenomes, using the open-source PGAdb-builder server. The core genome was identified for each opportunistic pathogen and was searched for genes displaying the highest polymorphism. The minimal number of loci to include in a HiMLST-Illumina assay was determined by comparing topology of phylogenetic trees of concatenated loci based on genome similarity, computed as the average nucleotide identity (ANI) score. The primers used for HiMLST-Illumina schemes were designed in silico on a conserved domain and were tested on reference strains of each species. Results: Bioinformatics analyses showed that 3–4 loci (<300 base pairs per locus) distinguished strains with the same performances than ANI scores. The assays were tested using opportunistic pathogen isolates and environmental DNA originating from NICU sinks. The HiMLST-Illumina analysis of environmental DNA revealed the presence of at least 1 of the 3 studied opportunistic pathogens in 50% of sampled drains (n = 20). In a previous sampling, P. aeruginosa was isolated on selective culture media before and 48 hours after disinfection of a sink drain with chlorine. S. marcescens was also isolated from another sink 2 weeks after disinfection. Identification of the isolates was confirmed by HiMLST-Illumina analyses and will be typed to compare with clinical isolates. Conclusions: Initial in silico tests predict a high discriminating power of the HiMLST-Illumina method, suggesting that it would be possible to quickly identify strains of interest in a large number of samples. The power of this method is also in the possibility for molecular typing without a need for cultivation. Preliminary results suggest that sinks are readily colonized by opportunistic pathogens. This HiMLST-Illumina scheme will be applied in a 2-year intensive survey of NICUs in 3 hospitals in Montreal to evaluate the performance of new sink designs in limiting bioaerosol production and transmission of opportunistic pathogens to patients.

Funding: None

Disclosures: None

Background: With >3,000 cases and 2,000 deaths, the current outbreak of Ebola virus disease (EVD) in the Democratic Republic of the Congo (DRC) is the second-largest reported EVD outbreak in history. Healthcare-associated transmission of EVD has been a persistent amplifier of transmission due, in part, to fragility of the healthcare system, lack of basic infection prevention and control (IPC) infrastructure, and large number of healthcare facilities (HCFs). A central component of the strategy to rapidly strengthen IPC in HCFs is the provision of IPC supervisors to oversee standardized risk assessments and improvements and provide mentorship to HCF staff. To support these activities, we designed skills based training for IPC supervisors. Methods: Staff recruited by the Ministry of Health (MoH) to strengthen IPC are part of an outbreak-specific cadre known as IPC supervisors. IPC supervisors, who originally lacked technical knowledge and mentoring experience, were trained to provide technical support and mentorship to staff at HCFs, with the objective of improving IPC-related processes and behaviors. A competency-based training course was designed by conducting informal assessments of IPC supervisors during daily tasks to identify areas for performance improvement. We developed competencies based on activities designated for IPC supervisors according to MoH guidelines. We planned an iterative training rollout to allow for continuous, real-time modifications based on lessons learned throughout the implementation phase. Results: Although IPC supervisors displayed technical knowledge of IPC recommendations, we observed large gaps in implementation. IPC supervisors frequently failed to recognize behaviors that are high-risk for infection transmission. In addition, IPC supervisors lacked the ability to develop prioritized action plans and to implement interventions aimed at rapidly improving IPC practices. The course, designed as an interactive, skills-based training, is rooted in instructional design principles and addresses 4 key competencies: risk recognition and prioritization, IPC assessment completion, action plan development, and effective leadership and communication. The course will be pilot tested in the DRC to an audience of 25 IPC supervisors. Conclusions: In an outbreak setting, strong mentorship and problem-solving skills are needed to support effective implementation of IPC quality improvement. Trainings that are informed by field experiences and teach problem-solving, coaching, and communication skills are critical and can be developed rapidly. The strategy employed by the Ministry of Health to rapidly achieve IPC capacitation at HCFs might be adapted for use in future outbreaks.

Funding: None

Disclosures: None

Background: Antibiotic overuse contributes to antibiotic resistance and unnecessary adverse drug effects. Antibiotic stewardship interventions have primarily focused on acute-care settings. Most antibiotic use, however, occurs in outpatients with acute respiratory tract infections such as pharyngitis. The electronic health record (EHR) might provide an effective and efficient tool for outpatient antibiotic stewardship. We aimed to develop and validate an electronic algorithm to identify inappropriate antibiotic use for pediatric outpatients with pharyngitis. Methods: This study was conducted within the Children’s Hospital of Philadelphia (CHOP) Care Network, including 31 pediatric primary care practices and 3 urgent care centers with a shared EHR serving >250,000 children. We used International Classification of Diseases, Tenth Revision (ICD-10) codes to identify encounters for pharyngitis at any CHOP practice from March 15, 2017, to March 14, 2018, excluding those with concurrent infections (eg, otitis media, sinusitis), immunocompromising conditions, or other comorbidities that might influence the need for antibiotics. We randomly selected 450 features for detailed chart abstraction assessing patient demographics as well as practice and prescriber characteristics. Appropriateness of antibiotic use based on chart review served as the gold standard for evaluating the electronic algorithm. Criteria for appropriate use included streptococcal testing, use of penicillin or amoxicillin (absent β-lactam allergy), and a 10-day duration of therapy. Results: In 450 patients, the median age was 8.4 years (IQR, 5.5–9.0) and 54% were women. On chart review, 149 patients (33%) received an antibiotic, of whom 126 had a positive rapid strep result. Thus, based on chart review, 23 subjects (5%) diagnosed with pharyngitis received antibiotics inappropriately. Amoxicillin or penicillin was prescribed for 100 of the 126 children (79%) with a positive rapid strep test. Of the 126 children with a positive test, 114 (90%) received the correct antibiotic: amoxicillin, penicillin, or an appropriate alternative antibiotic due to b-lactam allergy. Duration of treatment was correct for all 126 children. Using the electronic algorithm, the proportion of inappropriate prescribing was 28 of 450 (6%). The test characteristics of the electronic algorithm (compared to gold standard chart review) for identification of inappropriate antibiotic prescribing were sensitivity (99%, 422 of 427); specificity (100%, 23 of 23); positive predictive value (82%, 23 of 28); and negative predictive value (100%, 422 of 422). Conclusions: For children with pharyngitis, an electronic algorithm for identification of inappropriate antibiotic prescribing is highly accurate. Future work should validate this approach in other settings and develop and evaluate the impact of an audit and feedback intervention based on this tool.

Funding: None

Disclosures: None

Background: In 2015, the Ministry of Internally Displaced Persons from the Occupied Territories, Labor, Health and Social Affairs (MoLHSA) of Georgia identified infection prevention and control (IPC) as a top priority. Infection control legislation was adopted and compliance was made mandatory for licensure. Participation in the universal healthcare system requires facilities to have an IPC program and infrastructure. To support facilities to improve IPC, MoLHSA and the National Center for Disease Control and Public Health (NCDC) requested assistance from the US CDC to revise the 2009 National IPC guidelines, which were translated versions of international guidelines and not adapted to the Georgian context. Methods: An IPC guideline technical working group (TWG), comprising clinical epidemiologists, IPC nurses, head nurses, and infectious diseases doctors from the NCDC, academic and healthcare organizations and the CDC was formed to lead the development of the national IPC guidelines. Additionally, an IPC steering committee was established to review and verify the guidelines’ compliance with applicable decrees and regulations. The TWG began work in April 2017 and was divided into 4 subgroups, each responsible for developing specific guideline topics. A general IPC guideline template for low- and middle-income countries was used to develop 7 of the guidelines. Additional reference materials and international guidelines were used to develop all the guidelines. Drafts were shared with the subgroups and the steering committee during 2 workshops to discuss unresolved technical issues and to validate the guidelines. Results: The revised guidelines consist of 18 topics. In addition to standard precautions (eg, hand hygiene, personal protective equipment, injection safety, etc) and transmission-based precautions, the guideline topics include laundry, environmental cleaning and disinfection, decontamination and sterilization, occupational health and safety, biosafety in clinical laboratory, blood bank and transfusion services, intensive care unit, emergency room, and mortuary. They do not include healthcare-associated infection surveillance or organism-specific guidance. To supplement the guidelines, a separate implementation manual was developed. The guidelines were approved by MoLHSA in October 2019. The TWG continues to be engaged in IPC activities, assisting with guideline rollout, training, and monitoring, and drafting the National IPC strategy and action plans. Conclusions: The Georgian Ministry of Health developed national IPC guidelines using local experts. This model can be replicated in other low- and middle-income countries that lack country-specific IPC guidelines. It can also be adapted to develop facility-level guidelines and standard operating procedures.

Funding: None

Disclosures: None

Background:Clostridioides difficile infection (CDI) accounts for >500,000 community-, nursing-, and hospital-acquired infections (HAIs), as well as 15,000–30,000 deaths, and =$4.8 billion in the United States annually. C. difficile toxin B gene nucleic acid amplification testing (NAAT) cannot distinguish between active CDI and colonization, particularly in the setting of laxative use or enteral feeding. Lack of judicious testing can result in the incorrect diagnosis of CDI, unnecessary CDI treatment, increased costs, and falsely augmented HAI rates. Like many healthcare facilities, the VA San Diego Healthcare System (VASDHS) solely utilizes C. difficile NAAT for CDI diagnosis. The aim of this study was to implement and evaluate a facility-wide initiative at the VASDHS to reduce healthcare onset, healthcare facility associated CDI (HO-HCFA CDI), including the use of a test ordering algorithm. Methods: From fiscal year (FY) 2015–2018, various measures were implemented including a hand hygiene initiative, reduction in fluoroquinolone usage, prompt isolation of patients with CDI, thorough terminal cleaning of rooms, and, lastly, a test-ordering algorithm starting FY2018. A retrospective study was performed to assess VASDHS HO-HCFA CDI case incidence, risk factors for infection, laxative or enteral feeding use at the time of testing, and CDI treatment. Results: Patient demographic data, medical history, CDI history, laxative use, treatment, and cost of CDI treatment were reviewed. From 2015 to 2018, 127 cases of HO-HCFA CDI were identified. The total number of HO-HCFA CDI cases and medication cost for CDI treatment were dramatically reduced from 2017 to 2018 following implementation of the test-ordering algorithm (Table 1, Fig. 1). This trend corresponded to a significant reduction in median HO-HCFA CDI cases per month (P = .02), medication cost of CDI treatment (P = .02), and proton pump inhibitor (PPI) use at the time of testing (P = .01). The number of positive HO-HCFA CDI cases associated with laxative use or escalation at the time of CDI testing (accounting for those on chronic laxatives) also decreased across the study period—most dramatically from 2015 vs 2016 (20 vs 14) and 2017 vs 2018 (11 vs 4) (Table 1). Conclusions: At the VASDHS, diagnostic stewardship of C. difficile NAAT with the use of a test-ordering algorithm significantly reduced HO-HCFA CDI incidence and treatment cost. This trend also corresponded with significantly less PPI use at the time of testing and reduced detection of colonization among patients with laxative-induced diarrhea. Diagnostic stewardship may serve as an effective tool to correctly diagnose and treat HO-HCFA CDI, while significantly reducing treatment costs.

Funding: None

Disclosures: None

Background: Vertical interventions in public health are disease focused, whereas horizontal interventions are systems based. The new concept of “diagonal interventions” merging these 2 approaches is also applicable to infection prevention (IP). During fiscal year (FY) 2016, our facility identified 14 central-line–associated blood stream infections (CLABSIs), resulting in a rate of 1.44 cases per 1,000 catheter days, twice that of FY2015 (0.75 cases per 1,000 catheter days). Methods: Focusing on a horizontal “systems building” approach, the IP team used previously developed informal relationships to mobilize a formal multidisciplinary team comprised of IP, nursing educators, the intravenous therapy team, and frontline staff. Initially charged with implementation of disinfecting caps for needleless connectors, the IP team capitalized on this multidisciplinary resource to launch a multifaceted communication and education campaign supporting CLABSI-specific interventions. For vertical interventions, an IP risk assessment revealed variations in care and maintenance of central lines and the need for staff education. A literature search was conducted to identify evidence-based strategies for reducing CLABSIs, leading to the development of a nursing-led bundle of the following elements: (1) education on CDC hand hygiene guidelines, (2) central-line competency validation and assessment for nurses on hire and annually, (3) standardized processes across all wards for central-line dressing changes (“timed on Tuesdays”), and (4) a pilot program for disinfecting caps on 3 inpatient wards. The IP team identified CLABSIs using standard NHSN definitions. Catheter days were obtained on each inpatient ward. Unit-specific rates were calculated per 1,000 catheter days. Mann-Kendall Test was used to assess rate trends over time, whereas the Fisher exact test was used for rate comparisons. A P < .05 was considered significant. Results: CLABSI rates decreased from 1.44 in FY2016 to 0.12 in FY2019 (Kendall τ = −0.5; P < .001) (Fig. 1). During the 3-month pilot phase of disinfecting caps, no CLABSIs were identified on 3 intervention wards versus 3 CLABSIs on control wards (rate, 0 vs 2.57; P = .27) and 1 CLABSI in the 3-month baseline period prior to the intervention (0 vs 0.40; P > .99). Disinfecting caps were expanded house-wide beginning in FY2018. The multidisciplinary team evolved into a sustained collaborative (“Scrub Club”) meeting biweekly. They have now broadened their focus to quality improvement initiatives for multiple healthcare-associated infections (HAIs). Conclusions: The IP team has traditionally utilized vertical models of intervention. The use of “diagonal” models that incorporate horizontal health systems strengthening can transform multidisciplinary partnerships into long-term collaboratives essential for sustained reduction of HAIs.

Funding: None

Disclosures: None

Background: Antimicrobial resistance is a growing global health problem predominantly driven by overuse of antibiotics. In humans, most antibiotics are used outside the hospital. Overprescribing for acute respiratory infections (ARIs) is common despite clear guidelines. The need for further training of general practitioners is well known. Objective: To develop and evaluate a massive open online course (MOOC) on antibiotic therapy of common infectious diseases in general practice. Methods: A 4-week MOOC was developed on the basis of previous face-to-face trainings (platform, Hasso Plattner Institute for Digital Engineering) and was conducted 3 times between July 10, 2017, and May 31, 2019. The course was promoted through various general practitioner (GP) networks, local multipliers, and conferences and in the local trade press. In addition to epidemiological background information, the focus was on guideline-based diagnostics and treatment of ARI, side effects of antibiotics, correct drug selection, dosage and duration of indicated antibiotic therapy, as well as aspects of doctor–patient communication. Content included videos, self-tests, additional written material, and an optional exam. At the end of the course, participants were asked to complete a voluntary, anonymous online assessment questionnaire (LimeSurveyPro software). Usage data from the MOOC platform and data from the questionnaire were analyzed using IBM SPSS statistical software. Results: In total, 2,177 registered persons retrieved content (= learners). The proportion of learners dropped from 99.6% in week 1 to 40.7% in week 4. However, among those attending week 4, the average proportion of content used was still high (74.5%). Furthermore, 27.5% of learners completed the course, 23.8% took the exam, and 19.7% passed the exam. Moreover, 284 learners answered the assessment questionnaire (response rate, 13.0%); 62.3% were women, and the mean age was 45.9 years. Also, 225 participants (79.2%) stated that they were physicians; 122 of these worked as general practitioners (54.2% of physicians). Among the other physicians, 23% stated were in specialist training and 15.6% had a different specialist designation. The average overall rating of the course was 1.31 (1 = very good to 6 = not sufficient). General practitioners rated it slightly better than other physicians (1.23 vs 1.41). The clinical relevance was rated at 1.27 (GPs vs other physicians, 1.18 vs 1.35). For all scores, see Table 1. Conclusions: A massive open online course appears to be an appropriate format in which to deliver clinical relevant content concerning prudent antibiotic use in the outpatient setting. It is a good complement to existing face-to-face formats and helps to cover needs related to antibiotic training.

Funding: None

Disclosures: None

Background: Patients with methicillin-resistant Staphylococcus aureus (MRSA) colonization often shed MRSA, resulting in contamination of surfaces in their room. It is not known whether MRSA-colonized patients also frequently contaminate surfaces during medical appointments and other activities outside their room. Methods: We conducted an observational cohort study of MRSA-colonized long-term care facility (LTCF) residents to determine the frequency and mechanisms of contamination of surfaces outside patient rooms. Nares, skin, and clothing of patients in contact precautions for MRSA were cultured for MRSA, and high-touch surfaces in the residents’ room were contaminated with the live virus bacteriophage MS2 and cauliflower mosaic virus DNA. The participants were observed during activities and medical appointments outside their rooms for 3 days, and sites that were contacted were sampled for recovery of MRSA, bacteriophage MS2, and cauliflower mosaic virus DNA. Results: As shown in Fig. 1, bacteriophage MS2 and cauliflower mosaic virus DNA was transferred to 1 or more surfaces outside the resident’s room by 5 of the 7 participants, and MRSA was recovered from surfaces touched by 6 (86%) participants. MRSA was recovered during 16 of 35 episodes (46%) where sampling was performed, and recovery was similar for medical appointments (eg, hemodialysis, physical therapy) and nonmedical activities (eg, using the dining room or activity center). Moreover, MRSA, MS2, and the viral DNA marker were recovered both from sites contacted only by participants’ hands and from sites contacted only by clothing. Bacteriophage MS2 and the viral DNA marker were also recovered from portable equipment and from the nursing station. Conclusions: MRSA-colonized LTCF residents frequently disseminated MRSA and viral surrogate markers to surfaces outside their rooms through contact with contaminated hands and clothing. Efforts to reduce contamination of hands and clothing might reduce the risk for pathogen transmission.

Funding: None

Disclosures: None