Background:Candida auris is an emerging fungus that presents a serious threat to healthcare facilities. Because Chicago is a locus of high prevalence, the Illinois Department of Public Health (IDPH) released guidelines for acute-care hospitals to screen and isolate patients who are directly admitted from either a skilled nursing or long-term acute-care facility (SNF or LTAC) with a tracheostomy or on a ventilator. This project was undertaken to evaluate applicability of IDPH criteria to our inpatient population and to develop effective tools to implement a surveillance system. Methods: To assess IDPH criteria, we reviewed local case epidemiology and conducted a point-prevalence survey of all inpatients on May 22, 2019. To implement a new surveillance program, we convened a multidisciplinary team to assess the functionality of the electronic health record (EHR), to create clinician education, and to develop new electronic tools. Results: Between June 2018 and August 2019, 20 unique C. auris patients were admitted to our facility, and only 2 (10%) met IDPH criteria. During the point-prevalence survey, 609 inpatients were assessed, and only 7 (1%) met IDPH criteria (Table 1). Therefore, we created a new surveillance program tailored to our local epidemiology. To do this, we convened a multidisciplinary team with representatives from infection prevention, nursing informatics, patient care, microbiology and information technology (IT). The IT build took 5 months, and the work products included a screening questionnaire integrated into the nurse admission navigator, new microbiology laboratory orders for C. auris culture, a new internal isolation category that we deemed prior location-based isolation (PLI), and an electronic report to automatically aggregate data. To streamline workflow, best-practice alerts (BPAs) were designed to automatically order isolation and laboratory tests based on responses to the admission questionnaire (Fig. 1). Additionally, tools were created catch missed opportunities for isolation and to automatically update isolation status based on final culture results. Conclusions: Local epidemiology must be considered when designing C. auris surveillance programs. Stakeholder engagement and informatics were key to successful program implementation. The EHR must be nimble to address updated recommendations for organisms of concern. Data must be continuously evaluated to measure success of a targeted screening and surveillance program.

Funding: None

Disclosures: None

Background: Weekly surveillance to identify neonatal intensive care unit (NICU) infants with methicillin-resistant S. aureus (MRSA) nasal colonization was performed using Remel Spectra MRSA chromogenic media. An increased MRSA colonization rate from baseline was detected in 2019, prompting additional review of all positive MRSA NICU screening cultures from 2019. Methods: A subset of 23 positive cultures were interrogated in detail. Species-level identification was confirmed using matrix-assisted laser desorption/ionization-time of flight (MALDI-TOF) with a Bruker Biotyper. Penicillin-binding protein 2a (PBP2a) testing was performed using the Alere culture colony test, and cefoxitin and oxacillin susceptibility were assessed via Kirby-Bauer disk-diffusion methods (for the purpose of this analysis, oxacillin zone sizes 18 mm were considered susceptible). Molecular detection of mecA and mecC genes using PCR was performed. Results: All 23 isolates in the subset group were confirmed as S. aureus based on MALDI-TOF testing. Moreover, 8 isolates (35%) were confirmed as MRSA based on cefoxitin susceptibility, positive rapid PBP2a testing, and mecA PCR results. Overall, 15 isolates (65%) tested cefoxitin-susceptible and PBP2a negative with negative mecA and mecC gene testing. Of these, 1 (7%) tested oxacillin-susceptible based on disk-diffusion testing, consistent with methicillin-susceptible S. aureus (MSSA). The remaining 14 isolates (93%) tested oxacillin resistant based on oxacillin zone size. Conclusions: Our findings indicate the detection of mecA/mecC negative S. aureus isolates demonstrating oxacillin resistance and growth on Remel Spectra MRSA chromogenic media. These results have important implications for infection prevention surveillance efforts to detect MRSA and raise questions regarding optimal antibiotic therapy in patients with isolates displaying this phenotype.

Funding: None

Disclosures: None

Background: Carbapenemase-producing Enterobacteriaceae (CPE) causes infections associated with high mortality rates among hospitalized patients. CPE transmission occurs frequently, and prevention of patient-to-patient transmission is a priority. However, transmission pathways are not yet completely understood. The colonization of the respiratory tract with a CPE may lead to a higher risk of contamination of the patient’s environment increasing the spread of CPE. Objective: We estimated the rate of CPE spread when respiratory tract infection or colonization is present. Methods: We studied CPE dissemination analyzing a cohort of patients admitted between January 2013 and December 2018 at the university hospital complex of A Corua, a tertiary-care hospital. All patients who were hospitalized in the same room as a patient colonized or infected with a CPE (index case) for at least 24 hours were screened for CPE carriage. The microbiological screening was performed with conventional culture or polymerase chain reaction (PCR) to identified possible CPE patient-to-patient transmission. The screening test included several samples: rectal swab, perineal swab, wound or drainage swab, and low respiratory tract sample. Results: Active screening for CPE carriage was performed in 84 contact patients. Men represent 57.1% of the sample, and the mean age was 78.5 years (men, 68.0 years and women, 80.8 years), with significant differences between sexes (12.9; 95% CI, 19.6 to 6.1). The major group of cases (86.9%) were hospitalized in medical wards. Transmission confirmed by PCR occurred in 13 (15.5%) of 84 contact patients, after a mean exposure to the index case of 13.3 days. No significant differences were detected in terms of mean exposure to index cases between those contact patients who result negative and those who result positive. The 35 index cases (41.7%) tested positive for CPE on the respiratory sample, and exposure to them led to 8 positive contact patients (61.5%). Conclusions: CPE transmission in a tertiary-care hospital occurred frequently. The spread rate is even higher when CPE is present at the respiratory level. Understanding the mode of spread is important for designing effective control measures and adding a respiratory sample to CPE screening could be a key consideration.

Funding: None

Disclosures: None

Background: Use of the WHO 5 Moments of Hand Hygiene (HH) by operating room (OR) anesthesia personnel has been called by some logistically unfeasible, despite evidence that HH can reduce patients’ risk of pathogen acquisition. We developed and implemented a set of 7 moments based on WHO guidance (Fig 1) with high adherence. We conducted this study 6 months later to determine whether the improvement was sustained. In addition, we sought to understand practices, beliefs, barriers, and perceptions among anesthesia providers regarding HH. Methods: We measured HH adherence by direct observation using locally developed 7 moments tailored to the anesthesia workflow during June–August 2019. Adherence was defined as the percentage of observed HH performed when a moment occurred. We used the theory of planned behavior (TPB) as a framework to conduct 11 individual interviews (8 attending anesthesiologists and 3 certified nurse anesthetists) with a semistructured instrument that included Likert scale and open-ended questions. Interview transcripts were reviewed and a codebook of themes was created through inductive thematic analysis. Resultant themes and Likert scale averages were grouped by the 3 key TPB variables. Results: In total, 294 HH moments were observed for 50 anesthesia providers during 36 cases. The average HH adherence was 21.1% with the highest adherence moment being after patient contact (61.7%). Interview participants stated universally that HH was important for patient care, but acknowledged barriers to performance. Barriers cited included interruption in workflow, a lack of evidence, lack of clarity of HH standard, and limited availability of product. Conclusions: Adherence to the 7 moments of HH for anesthesia providers was not sustained after 6 months. Providers identified numerous barriers to HH, including a lack of knowledge of a standard, as reasons for suboptimal adherence. These data suggest future interventions could be designed to address gaps in knowledge and remove barriers to improve HH adherence among OR anesthesia providers.

Funding: None

Disclosures: None

Background: Surgical site infections (SSIs) can be attributed to increased patient morbidity and mortality, prolonged hospital stays, and overall increased healthcare costs. The Surgical Care Improvement Project (SCIP) was implemented in 2002 but has made limited impact on SSI rates across our facilities, which has led to the creation of a bundled approach of current evidence-based strategies. Methods: In January 2019, a comprehensive SSI prevention bundle of strategies was implemented across a multihospital health system. The bundle was comprised of 8 interventions focusing on the preoperative, intraoperative, and postoperative continuum of care, and refining documentation in the electronic medical record. From January to September 2019 (preointervention period), data were collected from 7,163 adult inpatient and observation elective patients undergoing colon surgery (COLO), abdominal hysterectomy (HYST), hip arthroplasty (HPRO), knee arthroplasty (KPRO), and cardiac bypass graft (CBGB/CBGC). The preintervention period for SSI standardized infection ratios (SIRs) and retrospective review of process measures was set as January–December 2018 (postintervetnion period). Each process measure had outlined targets along with primary outcome measures of overall SSI SIRs and SIRs for each of the 5 reported procedure categories. SSIs were validated to meet CDC and NHSN surveillance case definitions. Secondary outcomes evaluated included length of stay (LOS), readmission rates, and mortality. Results: Overall SIR for all 5 monitored surgical categories decreased by 5% to 1.131 from January to September 2019, compared to SIR of 1.190 in 2018. Hip and knee arthroplasties demonstrated 40% and 38% reductions after the intervention, respectively. Completion of 7 or 8 interventions of the SSI bundle were correlated with lower readmission rates (P = .0488). When any portion of the bundle was used, this was correlated with shorter LOS (P < .0001). Adherence to standardized antimicrobial prophylaxis was associated with decreased mortality (P = .017), for all 5 surgical categories. Conclusions: With the implementation of a focused SSI reduction bundle, our institution has realized reductions in surgical readmissions, length of stay, and mortality. Additionally, SSI rates in certain procedure categories have shown marked improvement. The initial success of this bundle has garnered development of additional procedure focused supplemental strategies for the future year.

Funding: None

Disclosures: Aarikha D’Souza, Banner Health

Background: Little is known about how best to implement infection prevention and control programs in low-resource settings. The quality improvement approach using plan-do-study-act (PDSA) cycles provides a framework for data-driven infection prevention and control implementation. We used quality improvement techniques and training to improve infection prevention and control practices in 2 model hospitals in Kenya. Methods: The 2 hospitals were chosen by the Kenya Ministry of Health for capacity building on infection prevention and control. At each site, the project team (the University of Washington International Training for Education and Training in Health, Ministry of Health, and Centers for Disease Control) conducted infection prevention and control training to infection prevention and control committee members. Infection prevention and control quality improvement activities were introduced in a staggered manner, focusing on hand hygiene and waste management practices. For hand hygiene, the project team’s technical assistance focused on facility hand hygiene infrastructure, hand hygiene practice adherence, hand hygiene supply quantification, and monitoring and evaluation using WHO hand hygiene audit tools. Waste management technical assistance focused on availability of policy, guidelines, equipment and supplies, waste segregation, waste quantification, and monitoring and evaluation using a data collection tool customized based on previously published tools. Regular interactive video conference sessions between the project team and the sites that included didactic sessions and sharing of data provided ongoing mentorship and feedback on quality improvement implementation, data interpretation, and data use. Results: Hand hygiene data collection began in April 2018. In hospital A, hand hygiene compliance increased from a baseline of 3% to 51% over 9 months. In Hospital B, hand hygiene compliance rates increased from 23% at baseline to 44% after 9 months. Waste management data collection began in November 2018. At hospital A, waste segregation compliance scores increased from 73% at baseline to 80% over 6 months, whereas hospital B, waste segregation compliance went from 44% to 80% over 6 months. Conclusions: A quality improvement approach appears to be a feasible means of infection prevention and control program strengthening in low resource settings.

Funding: None

Disclosures: None

Background: Children aged <1 year are usually colonized with Clostridium difficile: colonization rates range between 30% and 70%. In children, other infectious causes of diarrhea are more common than C. difficile. Molecular testing for C. difficile yields very high sensitivity. Clinical judgement is required for testing children with suspected infectious diarrhea. Inappropriate C. difficile testing may lead to antibiotic overuse. Methods: Initially, for the years 2016–2018, we collected data for positive C. difficile nucleic acid amplification tests (NAATs) at Sanford Children’s Hospital. In 2017, a physician-driven protocol was implemented to replace the current nurse-driven protocol for testing. We implemented national guidelines for testing and treatment in pediatric patients. Microbiology lab was given autonomy to use Bristol stool criteria to process stool samples for C. difficile. Formed stools were rejected for testing for C. difficile. The result was suppressed in patients aged <1 year. We presented the available data at the SHEA spring conference in 2020. We collected new data until June of 2019 to measure the sustainability of the intervention. Results: In 2016, there were 78 C. difficile tests: 17 were positive and 11 were categorized as an HAI. From January 1 to June 30, 2017, there were 26 C. difficile tests: 8 were positive and 3 were categorized as an HAI. Furthermore, 16 C. difficile tests were obtained from July 7 to December 31, 2017: 4 were positive and 1 categorized as an HAI. In 2018, there were 18 tests and 2 were positive; 1 was categorized as an HAI. In 2019, there were 16 tests and 2 were positive; 1 of these was categorized as an HAI. Conclusions: Implementing 2 interventions (removal of a nurse-driven protocol and microbiology lab autonomy for rejecting formed stool samples) for improving C. difficile testing accomplished a reduction of >80% in the number of tests obtained. Overall, there was a sustained reduction in the number of positive tests and HAIs in the years 2018 and 2019. The 2 interventions have been sustainable over time.

Funding: None

Disclosures: None

Background: In July 2017, the Ethiopian Public Health Institute (EPHI) launched an antimicrobial resistance (AMR) surveillance network at 4 sentinel laboratories. The National Clinical Bacteriology and Mycology Laboratory (NRL) at EPHI performs monthly confirmatory testing on a subset of isolates submitted by these sites. We assessed the existing confirmatory testing program to identify gaps and develop solutions, including a monitoring and evaluation (M&E) system. Methods: We assembled a technical working group (TWG) of key stakeholders. Laboratory site visits included workflow observation, process mapping, document review, and technologist interviews. Proposed solutions to observed gaps were drafted in formats consistent with their intended application. Feedback from the TWG was incorporated into final drafts. Available AMR network staff members were trained remotely, and they will train remaining staff. Results: Table 1 describes major gaps and solutions identified. Conclusions: Confirmatory testing provides a mechanism to evaluate laboratory testing proficiency, target improvements, and estimate surveillance data quality, yet standardized methods were lacking. Our efforts highlight key components of confirmatory testing programs and provide a model for use in laboratories with similar needs.

Funding: None

Disclosures: None

Background: A recent study using minimally invasive tissue sampling at Chris Hani Baragwanath Academic Hospital (CHBAH), a public tertiary-care hospital in South Africa, reported that 70% of preterm neonatal deaths were due to healthcare-associated infections (HAIs). Based on these findings, CHBAH in collaboration with the CDC conducted an infection prevention and control (IPC) assessment and identified IPC gaps: limited training and mentorship of staff, medication preparation near the patient zone, and inadequate equipment cleaning and a high infection rates. We implemented a program from February 2019 to February 2020 to address these identified gaps, with the aim of reducing the neonatal sepsis rate. Methods: We focused our interventions on 3 essential activities in the neonatal wards: (1) conducting medication compounding in a safe environment with dedicated trained clinical pharmacy personnel; (2) improving cleaning and reprocessing of medical equipment through use of dedicated ward assistants; and (3) improving infection control–related behavior of frontline healthcare staff through on-site IPC mentorship and training. We captured data on process measures including medication errors and hand hygiene and outcome measures. We also looked at rates of infection, defined as positive cultures from blood and CSF per 1,000 patient days. Results: A NICU satellite pharmacy was established in February 2019 and was managed by a lead pharmacist and pharmacy assistants. Following the intervention, medication errors were reduced from 17% in March to 2% in September; nursing staff previously dedicated to medication preparation were able to spend more time in patient care. Furthermore, 4 full-time ward-assistants were hired in February 2019, and equipment is now cleaned using a standardized protocol in a dedicated cleaning area. A dedicated IPC team was assembled in January 2019 to develop standard operating procedures and conduct frequent trainings with healthcare personnel on IPC practices. Since these trainings were implemented, hand hygiene compliance improved from 25% to 48% over a 4-month period. There has been no significant change in blood/CSF infection rates from before implementation (2018): 17.7 per 1,000 patient days (95% CI, 16.7–18.8) compared to rate of 19.1 per 1,000 patient days (95% CI, 17.7–20.6) after implementation (March–September 2019), with a rate ratio of 1.08 (95% CI, 0.98–1.19). Conclusions: The impact of this program was demonstrated through process improvements and reduction in medication errors. However, to date there has been no change in the overall infection rates, suggesting that additional IPC interventions are needed or that other factors are contributing to the high infection rates.

Funding: None

Disclosures: None

Background: The Australian Antimicrobial Stewardship Clinical Care Standard states that patients should receive information about their antimicrobial therapy, including their indication, how and when to take them, their duration, and potential side effects. The level of information provided to hospital inpatients about their prescribed antimicrobial therapy is not well understood. Our objective was to evaluate whether adult inpatients received specific information about their antimicrobials in accordance with antimicrobial stewardship clinical care standards, to identify any gaps that needed to be addressed. Methods: Patients receiving 1 or more antimicrobials for >72 hours who were admitted on an acute or subacute ward were recruited. A survey tool was designed and conducted to establish the current status of information provision to patients. The information gathered was used to develop and deliver activities and resources to facilitate better communication about antimicrobial therapy. Results: In total, 54 patients were surveyed. Most patients (83%) were informed that they were taking antimicrobials, and of these, 96% said they knew the indication, 18% were informed of potential side effects, and 36% knew the duration. Only 22% were informed of the review plan, and only 27% knew whether antimicrobials would be continued on discharge. Written information was given to 11% of patients. Over half of these patients (56%) either wanted more information or had concerns about their antimicrobials. Patients reported difficulty in obtaining information with some receiving information via “word-of-mouth from other patients.” Moreover, 58% of patients received antimicrobial information from doctors, 13% from nurses, and 12% from pharmacists. However, most patients stated that they expected information from all 3 professional groups. In response to these survey findings, a focus group of antimicrobial stewardship experts was convened to discuss methods of improving delivery of information to patients regarding their antimicrobial therapy. We undertook nursing education to empower nurses to discuss information about antimicrobials with their patients, and we developed consumer information sheets. Conclusions: More needs to be done to inform patients about the antimicrobials used in their treatments to empower them to participate in their treatment. This factor will be the focus of future antimicrobial stewardship interventions.

Funding: None

Disclosures: None

Background: Antimicrobial stewardship (AMS) is recommended in hospital, postacute, and outpatient settings. Transitions of care (TOC) are important in each of these settings; however, AMS efforts during TOC have been limited. Beginning in October 2018, we sequentially implemented a pharmacist-led multidisciplinary review of oral antimicrobial therapy prescribed at hospital discharge from general and specialty medicine wards across a health system. Pharmacists facilitated data input of discharge prescriptions following early identification and collaborative discussion of patients to be discharged on oral antimicrobials The purpose of this study was to evaluate the impact of AMS during TOC. Methods: This project was an IRB-approved stepped-wedge, quasi-experimental study in a 5-hospital health system that included hospitalized adults with skin, urinary, intra-abdominal, and respiratory tract infections who had been discharged from general and specialty wards with oral antimicrobials. Patients with complicated infections, neutropenia, or who were transferred from an outside hospital were excluded. The primary end point was optimization of antimicrobial therapy at time of hospital discharge, defined by correct selection, dose, and duration according to institutional guidance. Outcomes were compared before and after the intervention. Results: In total, 800 patients were included: 400 in the preintervention period and 400 in the postintervention period. Among this cohort, 252 (63%) received the intervention by a pharmacist per protocol during TOC. Patients had similar comorbid conditions before and after the intervention. Preintervention patients were more likely to be discharged from community hospitals. Before the intervention, 36% of discharge regimens were considered optimized, compared to 81.5% after the intervention (P < .001); this difference was largely driven by a reduction in patients receiving a duration of therapy beyond the clinical indication (44.5 vs 10%; P < .001). We observed similar clinical resolution, 30-day readmission, and adverse drug events (ADEs) between the pre- and postintervention periods. Postdischarge antimicrobial duration of therapy was reduced from 4 days (range, 3–5) to 3 days (range, 2–4) (P < .001) Severe ADEs occurred more frequently in the preintervention group (9 vs 3.3%; P = .001), which was driven by isolation of multidrug-resistant pathogens (7 vs 2.5%; P = .003) and Clostridioides difficile (1.8 vs 0.5%; P = .094). Patients who received optimal therapy at discharge were less likely to develop an ADE (aOR, 0.530; 95% CI, 0.363–0.773). Conclusions: Implementation of an AMS TOC protocol reduced antimicrobial days, optimized therapy selection, and reduced duration. This intervention was associated with improved safety without compromise of clinical effectiveness. To increase patient safety, AMS programs should target antimicrobial optimization during TOC.

Funding: This work was completed under CDC contract number 200-2018-02928.

Disclosures: None

Background: Pneumonia (PNA) is an important cause of morbidity and mortality among nursing home residents. The McGeer surveillance definitions were revised in 2012 to help NHs better monitor infections for quality improvement purposes. However, the concordance between surveillance definitions and clinically diagnosed PNA has not been well studied. Our objectives were to identify nursing home residents who met the revised McGeer PNA definition, to compare them with residents with clinician documented PNA, and determine whether modifications to the surveillance criteria could increase concordance. Methods: We analyzed respiratory tract infection (RTI) data from 161 nursing homes in 10 states that participated in a 1-day healthcare-associated infection point-prevalence survey in 2017. Trained surveillance officers from the CDC Emerging Infections Program collected data on residents with clinician documentation, signs, symptoms, and diagnostic testing potentially indicating an RTI. Clinician-documented pneumonia was defined as any resident with a diagnosis of pneumonia identified in the medical chart. We identified the proportion of residents with clinician documented PNA who met the revised McGeer PNA definition. We evaluated the criteria reported to develop 3 modified PNA surveillance definitions (Box), and we compared them to residents with clinician documented PNA.

Results: Among the 15,296 NH residents surveyed, 353 (2%) had >1 signs and/or symptoms potentially indicating RTI. Among the 353 residents, the average age was 76 years, 105 (30%) were admitted to postacute care or rehabilitation, and 108 (31%) had clinician-documented PNA. Among those with PNA, 28 (26%) met the Revised McGeer definition. Among 81 residents who did not meet the definition, 39 (48%) were missing the chest x-ray requirement, and among the remaining 42, only 3 (7%) met the constitutional criteria requirement (Fig. 1). Modification of the constitutional criteria requirement increased the detection of clinically documented PNA from 28 (26%) to 36 (33%) using modified definition 1; to 51 (47%) for modified definition 2; and to 55 (51%) for modified definition 3. Conclusions: Tracking PNA among nursing home residents using a standard definition is essential to improving detection and, therefore, informing prevention efforts. Modifying the PNA criteria increased the identification of clinically diagnosed PNA. Better concordance with clinically diagnosed PNA may improve provider acceptance and adoption of the surveillance definition, but additional research is needed to test its validity.

Funding: None

Disclosures: None

Background: Respiratory syncytial virus (RSV) and influenza virus (flu) contribute substantially to the overall burden of severe respiratory tract infection in children. However, the molecular etiological diagnostic methods of viral infection are still insufficiently accessible in public hospitals. Rapid immunochromatographic tests can add important information at the point of care, including antiviral or antibiotic indication, viral , and effective precaution measures to prevent outbreaks. The aim of this study was to evaluate this impact for pediatric patients under 5 years of age in our hospital. Methods: We conducted a retrospective, observational study of clinical outcomes of children under 5 years requiring hospitalization from 2013 to 2018 for viral respiratory disease, and who had positive RSV and/or flu immunochromatographic rapid test results. Results: In total, we identified 221 cases: RSV, 193; flu, 6; codetections, 19. (Table 1). The mortality rate was 1.8% (2 cases), and 88% of our patients were <1 year of age. Variables significantly associated with orotracheal intubation, the most intensive intervention, were younger age in months, comorbidities, RSV and flu codetection, and bacterial pneumonia diagnosis during hospitalization. Conclusions: In the multivariate analysis, RSV and flu codetection was associated with the least favorable clinical prognoses. Rapid test diagnosis may provide important information at the point of care, and molecular panels are not yet widely accessible in public hospitals. Hence, we believe that immunochromatographic rapid tests represent a valuable and feasible diagnostic alternative facilitating timely evaluation and treatment implementation.

Funding: None

Disclosures: None

Background: New antimicrobials are being developed as a response to the global threat of multidrug-resistant and panresistant bacterial pathogens. Cefiderocol (FDC; Shionogi & Co) is a novel parenteral siderophore cephalosporin with activity against gram-negative rods. Here, we report on the in vitro activity of FDC against multidrug-resistant gram-negative isolates collected by the CDC, including isolates available through the CDC and FDA Antibiotic Resistance Isolate Bank (AR Isolate Bank). Methods: The challenge set of gram-negative isolates (n = 339), most of which were obtained from the AR isolate bank (n = 258), comprised 188 Enterobacteriaceae (ENT), 72 Pseudomonas aeruginosa (PSA), and 79 Acinetobacter baumannii (ACB). Minimum inhibitory concentrations (MICs) for FDC in iron-depleted cation-adjusted Mueller-Hinton broth were determined using frozen reference broth microdilution panels (IHMA, Schaumburg, IL) according to CLSI guidelines. Isolates displaying nonsusceptibility to FDC (MIC >4 µg/mL) underwent additional testing with β-lactamase inhibitors (FDC with 4 µg/mL avibactam, FDC with 100 µg/ml dipicolinic acid (DPA), and FDC with both 100 µg/mL dipicolinic acid (DPA) and 4 µg/mL avibactam). Results: Cefiderocol MICs ranged from ≤0.03 to >64 µg/mL, and 313 (92.3%) isolates displayed susceptibility to FDC (MIC ≤4 μg/mL). The proportions of susceptible ENT, PSA, and ACB were 93.1%, 94.4%, and 88.6%, respectively. Among isolates harboring Ambler class A, class B, or class D carbapenemases, the proportions of susceptible isolates were 96.5%, 79.5%, and 94.0%, respectively. Overall, 26 (7.7%) isolates were categorized as FDC nonsusceptible (MIC ≥ 8 µg/mL); 65% of these were NDM producers. We selected 23 isolates for testing with β-lactamase inhibitors. The combination FDC-avibactam reduced the MIC to susceptible for all isolates harboring an Ambler class A or D carbapenemase, except for 1 OXA-71–producing ACB and 1 KPC-producing Citrobacter farmeri. The combination FDC-DPA reduced the MIC to susceptible for 9 of 13 (69.2%) NDM-producing and 4 of 4 (100%) OXA-23–producing ACB. By combining FDC with both DPA and avibactam, the MIC was reduced to susceptible (91%) for all but 1 KPC-producing and 1 NDM-producing Enterobacteriaceae isolate. Conclusions: Cefiderocol (FDC) demonstrated potent activity against a diverse collection of multidrug-resistant, gram-negative isolates, including producers of Ambler class A, B, and D carbapenemases. Among the 26 FDC nonsusceptible isolates, 65% were NDM positive. Our data indicate that FDC combined with β-lactamase inhibitors may restore susceptibility in FDC nonsusceptible isolates. Additional studies are needed to understand the underlying mechanism(s) of FDC resistance and to further explore the use of β-lactamase inhibitors in combination with FDC.

Funding: None

Disclosures: None

Background:Candida auris is an emerging fungal pathogen that is often resistant to major classes of antifungal drugs. It is considered a serious global health threat because it has caused severe infections with frequent mortality in over a dozen countries. C. auris can survive on healthcare environmental surfaces for at least 7 days, and it causes outbreaks in healthcare facilities. C. auris has an environmental route of transmission. Thus, infection prevention strategies, such as surface disinfection and room decontamination technologies (eg, ultraviolet [UV-C] light), will be essential to controlling transmission. Unfortunately, data are limited regarding the activity of UV-C to inactivate this pathogen. In this study, a UV-C device was evaluated for its antimicrobial activity against C. auris and C. albicans. Methods: We tested the antifungal activity of a single UV-C device using the vegetative bacteria cycle, which delivers a reflected dose of 12,000 µW/cm2. This testing was performed using Formica sheets (7.6 × 7.6 cm; 3 × 3 inches). The carriers were inoculated with C. auris or C. albicans and placed horizontal on the surface or vertical (ie, perpendicular) to the vertical UV-C lamp and at a distance from 1. 2 m (~4 ft) to 2.4 m (~8 ft). Results: Direct UV-C, with or without FCS (log10 reduction 4.57 and 4.45, respectively), exhibited a higher log10 reduction than indirect UV-C for C. auris (log10 reduction 2.41 and 1.96, respectively), which was statistically significant (Fig. 1 and Table 1). For C. albicans, although direct UV-C had a higher log10 reduction (log10 reduction with and without FCS, 5.26 and 5.07, respectively) compared to indirect exposure (log10 reduction with and without FCS, 3.96 and 3.56, respectively), this difference was not statistically significant. The vertical UV had statistically higher log10 reductions than horizontal UV against C. auris and C. albicans with FCS and without FCS. For example, for C. auris with FCS the log10 reduction for vertical surfaces was 4.92 (95% CI 3.79, 6.04) and for horizontal surfaces the log10 reduction was 2.87 (95% CI, 2.36–3.38). Conclusions:C. auris can be inactivated on environmental surfaces by UV-C as long as factors that affect inactivation are optimized (eg, exposure time). These data and other published UV-C data should be used in developing cycle parameters that prevent contaminated surfaces from being a source of acquisition by staff or patients of this globally emerging pathogen.

Funding: None

Disclosures: None

Background: According to the CDC Core Elements of Outpatient Stewardship, the first step in optimizing outpatient antibiotic use the identification of high-priority conditions in which antibiotics are commonly used inappropriately. Azithromycin is a broad-spectrum antimicrobial commonly used inappropriately in clinical practice for nonspecific upper respiratory infections (URIs). In 2017, a medication use evaluation at Grady Health System (GHS) revealed that 81.4% of outpatient azithromycin prescriptions were inappropriate. In an attempt to optimize outpatient azithromycin prescribing at GHS, a tool was designed to direct the prescriber toward evidence-based therapy; it was implemented in the electronic medical record (EMR) in January 2019. Objective: We evaluated the effect of this tool on the rate of inappropriate azithromycin prescribing, with the goal of identifying where interventions to improve prescribing are most needed and to measure progress. Methods: This retrospective chart review of adult patients prescribed oral azithromycin was conducted in 9 primary care clinics at GHS between February 1, 2019, and April 30, 2019, to compare data with that already collected over a 6-month period in 2017 before implementation of the antibiotic prescribing guidance tool. The primary outcome of this study was the change in the rate of inappropriate azithromycin prescribing before and after guidance tool implementation. Appropriateness was based on GHS internal guidelines and national guidelines. Inappropriate prescriptions were classified as inappropriate indication, unnecessary prescription, excessive or insufficient treatment duration, and/or incorrect drug. Results: Of the 560 azithromycin prescriptions identified during the study period, 263 prescriptions were included in the analysis. Overall, 181 (68.8%) of azithromycin prescriptions were considered inappropriate, representing a 12.4% reduction in the primary composite outcome of inappropriate azithromycin prescriptions. Bronchitis and unspecified upper respiratory tract infections (URI) were the most common indications where azithromycin was considered inappropriate. Attending physicians prescribed more inappropriate azithromycin prescriptions (78.1%) than resident physicians (37.0%) or midlevel providers (37.0%). Also, 76% of azithromycin prescriptions from nonacademic clinics were considered inappropriate, compared with 46% from academic clinics. Conclusions: Implementation of a provider guidance tool in the EMR lead to a reduction in the percentage of inappropriate outpatient azithromycin prescriptions. Future targeted interventions and stewardship initiatives are needed to achieve the stewardship program’s goal of reducing inappropriate outpatient azithromycin prescriptions by 20% by 1 year after implementation.

Funding: None

Disclosures: None

Background: Neurosurgeries are at high risk of surgical site infections (SSI), a complication associated with increased morbidity, mortality, and cost. Our aim was to measure SSI incidence and risk factors following pediatric neurosurgery at CHU Sainte-Justine, the provincial center for pediatric craniofacial surgery in Québec, Canada. Methods: Retrospective cohort study of all patients with elective neurosurgery performed at CHUSJ between October 2014 and October 2018. Medical records were reviewed to compare demographics, clinical presentations, and outcomes of patients. SSIs occurring within 30 days of a procedure without implant and up to 90 days with implant, were identified. SSI incidence was measured in patient years, and risk factors were assessed using univariate logistic regressions. Results: In total, 379 patients were included with an overall SSI incidence of 3.96 patient years. We found a higher SSI incidence in 2014–2015 compared to 2016–2018 (1.82 vs 4.83 patient years). The median age was 3.90 years, and cases seemed younger than controls (1.45 vs 4.15 years). No difference between groups was found for sex, body mass index, prematurity, and length of hospitalization. The proportion of deep SSIs was greater than superficial SSIs (53.3% vs 46.7%). Cases were more likely to present with a more severe ASA score, previous history of neurosurgery, neurological conditions, and pulmonary conditions than controls: OR, 3.90 (95% CI, 1.36–11.49); OR, 2.59 (95% CI, 0.88–7.40); OR, 2.77 (95% CI, 0.98–8.41), and OR, 3.21 (95% CI, 0.86–9.94), respectively. Among patients with history of neurosurgery, a higher proportion of cases experienced a cerebrospinal fluid leak (28.6% vs 2.2%). Most patients (85.8%) received preoperative prophylactic antibiotic. Of those, 49.3% were considered appropriate based on antibiotic and timing of administration. When antibiotic dosage was also considered, the number of patients who received an appropriate antibiotic therapy decreased radically. Conclusions: Patients with comorbidities, especially neurological and pulmonary conditions, are at higher risk of SSI after neurosurgery. We are currently working on a detailed analysis to explain the increase in SSI incidence after 2016. Finally, prophylactic antibiotic therapy needs to be improved and its impact on SSI rates needs to be monitored.

Funding: None

Disclosures: None

Background: The NHSN collects data on mucosal barrier injury, laboratory-confirmed, bloodstream infections (MBI-LCBIs) as part of bloodstream infection (BSI) surveillance. Specialty care areas (SCAs), which include oncology patient care locations, tend to report the most MBI-LCBI events compared to other location types. During the update of the NSHN aggregate data and risk models in 2015, MBI-LCBI events were excluded from central-line–associated BSI (CLABSI) model calculations; separate models were generated for MBI-LCBIs, resulting in MBI-specific standardized infection ratios (SIRs). This is the first analysis to describe risk-adjusted incidence of MBI-LCBIs at the national level. Methods: Data were analyzed for MBI-LCBIs attributed to oncology locations conducting BSI surveillance from January 2015 through December 2018. We generated annual national MBI-LCBI SIRs using risk models developed from 2015 data and compared the annual SIRs to the baseline (2015) using a mid-P exact test. To account for the impact of an expansion in the MBI-LCBI organism list in 2017 from 489 organisms (32 genera) to 1,003 organisms (89 genera), we removed the MBI-LCBI events that met the newly added MBI organisms and generated additional MBI SIRs for 2017 and 2018. Results: The annual SIRs remained above 1 since 2015, indicating a greater number of MBI-LCBIs identified than were predicted based on the 2015 national data (Fig. 1). Each year’s SIR was significantly different than the national baseline, and the highest SIR was observed in 2017 (SIR, 1.377). In 2017, 12% of MBI events were attributed to an organism that was added to the MBI organism list, and in 2018 it was 10%. After removal of MBIs attributed to the expanded organisms, the 2017 and 2018 SIRs remained higher than those of previous years (1.241 and 1.232, respectively). Conclusions: The distinction of MBI-LCBIs from all other CLABSIs provides an opportunity to assess the burden of this infection type within specific patient populations. Since 2015, the increase of these events in the oncology population highlights the need for greater attention on prevention strategies pertinent to MBI-LCBI in this vulnerable population.

Funding: None

Disclosures: None

Background: Recurrence rates and risk factors of Clostridium difficile infection (CDI) are well established in adults, though little is known about the rate of recurrent CDI (rCDI) within the pediatric population. The purpose of this study was to identify rates and risk factors of rCDI in pediatric at-risk groups to guide the optimization of targeted prevention efforts against disease recurrence. Methods: We report on the ongoing retrospective cohort study of pediatric patients at the CHU Sainte-Justine with a laboratory confirmed diagnosis of CDI between April 1, 2012, and March 31, 2017. Incidence rates of rCDI were obtained per 100 cases. Frequencies of rCDI were compared using the Fisher exact test. Univariate and multivariate logistic regression were used to identify risk factors for rCDI. Two-tailed P < .05 was considered significant. All statistical calculations were performed using R version 3.5.2 software. Results: Of 80 patients analyzed with CDI, 16 had rCDI, for a rCDI rate in this population of 20%. Most recurrences were observed in secondarily immunosuppressed patients including, but not limited to, oncology patients undergoing chemotherapy and/or radiotherapy (30.4%) and patients with inflammatory bowel disease (IBD, 29.2%). Patients that were administered vancomycin orally (PO) had recurrent infection less often than patients that administered metronidazole PO or IV (8.3% vs 23.4%, respectively). This trend was observed in all at-risk patient groups. Patients with secondary immunodeficiency had 7.4 times increased odds of recurrence compared to nonimmunodeficient patients (adjusted OR, 7.43,; 95% CI, 1.84–50.4; P = .0126). Conclusions: Initial vancomycin PO therapy seems to be associated with a lower risk of recurrence. Pediatric patients with IBD and with secondary immunodeficiency are at increased risk of rCDI. Given that these populations have an increased underlying risk of diarrhea, it would be worthwhile to determine whether toxin is actually produced (EIA testing) and to prioritize prevention efforts.

Funding: None

Disclosures: None

Background: Central-line–associated bloodstream infections (CLABSIs) are an important cause of healthcare-associated morbidity and mortality in the United States. CLABSI surveillance in the CDC NHSN began in 2005 and has been propelled by state CLABSI reporting requirements, first introduced in 2005, and subsequently by the CMS requirements for intensive care units (ICUs) in 2011 and select ward locations in 2015. Although trend analyses were previously reported, no recent assessment of the NHSN CLABSI incidence rate changes has been performed. In this analysis, we evaluated trends in CLABSI rates in nonneonatal ICUs and all wards reported from acute-care hospitals. Methods: CLABSI rates, including blood stream infections attributed to mucosal barrier injury reported to the NHSN from 2009 to 2018, were analyzed. To evaluate trends in CLABSI incidence and to account for the potential impact of definitional changes in catheter-associated urinary tract infections (CAUTIs) that indirectly impacted CLABSI rates, as well as the CMS mandate for select wards, we conducted an interrupted time-series analysis using negative binomial random-effects modeling with an interruption in 2015. ICUs and ward locations were analyzed separately. Models were adjusted for patient care location type and hospital-level characteristics: hospital type, medical affiliation, teaching status, bed size, number of ICU beds, and average length of inpatient stay. Random intercept and slope models were used to account for differential baseline incidence and trends among reporting hospitals. Results: The overall crude incidence of CLABSI per 1,000 central-line days decreased from 1.6 infections in 2009 to 0.9 infections in 2018, except for an increase in 2015. Similar trends were observed by location type. Among the ICUs, adjusted CLABSI incidence decreased by 10% annually in 2009–2014, increased nearly 29% in 2015, and thereafter decreased at an average of 6.8% per year. Among the wards, adjusted CLABSI incidence decreased at an average of 7.9% annually, except for a 29.3% increase in 2015. Conclusions: Substantial progress has been made in reducing CLABSIs in both ICUs and wards over the last 10 years. Indirect effects of CAUTI definitional changes may explain the immediate increase in ICUs, whereas the CMS mandate may explain the similar increase in wards in 2015. Despite this increase, these findings suggest that policies and practices aimed at prevention of CLABSI have likely been effective on a national level.

Funding: None

Disclosures: None