Background: In September 2019, the Louisiana Department of Health (LDH) was notified of a possible outbreak of influenza in a nursing home. Upon investigation, the infectious agent was determined to be human metapneumovirus (HMPV). By the conclusion of the outbreak, 35 (31.3%) symptomatic cases were identified of which 15 were laboratory-confirmed HMPV. Public health coordination, infection control interventions, environmental cleaning audits, halting new admissions, and ceasing group activities are credited with stopping transmission. Considering the high attack rate, LDH epidemiologists examined scenarios wherein the aforementioned interventions were not utilized. The aim of this analysis is to describe transmission of HMPV in a 112-bed nursing home using mathematical models under conditions wherein interventions were not readily implemented. Methods: Two deterministic and 1 stochastic susceptible–preinfectious–infectious–recovered (SEIR) models are presented. Although recovered persons can be susceptible to HMPV following an infection experience, the potential for reinfection was not considered for this analysis. Fixed variables considered include a 5-day incubation period, basic reproduction number of 2, 14-day infectious period, and 112 susceptible patients. Three counterfactual modeling conditions are considered: delaying notification of an outbreak to public health epidemiologists (model 1), staff hand hygiene compliance of 50% (model 2), and continuing to accept new admissions (model 3). Average rate of recovery per day was and other metrics are used to demonstrate the number of susceptible individuals. Excel workbooks developed by Vynnycky and White (2010) were used for analysis. Results: In model 1, the average rate of onset of infectiousness per day = 0.20, and the average recovery rate per day = 0.07. With no notification to public health epidemiologists, all 112 patients would have been infected with HMPV after 94 days. The reproductive number was doubled to 4 in model 2 to posit poor healthcare worker hand hygiene of 50% compliance. Given this, the number of days until all patients are infected with HMPV decreases to 39 days. Finally, the stochastic scenario (model 3) demonstrates that the number of newly infected persons per day = 0.86, and the hazard rate for infectious individuals becoming immune = 0.07. Conclusions: Infection control interventions are extremely useful for containing viral respiratory diseases for which there is no vaccine or treatment. Mathematical models can communicate utility of public health interventions in the presence of outbreaks. These models demonstrate worst-case scenarios for infection spread.

Funding: None

Disclosures: None

Background: In March 2012, the Veterans’ Health Administration (VHA) published the Guideline for the Prevention of Clostridium difficile infection (CDI) in VHA Inpatient Acute-Care Facilities, with a goal of 30% reduction of cases within 2 years. In March 2011, this facility, along with 31 others, served as a pilot site to develop the guidelines. Methods: The CDI prevention bundle was implemented to prevent new onset CDI cases in the facility with 4 core measures: (1) environmental cleaning (EMS), (2) hand hygiene, (3) contact precautions, and (4) cultural transformation. Education was provided to EMS staff, nursing, and care providers on the CDI case definition, criteria for testing, empiric isolation for patients with diarrhea, hand hygiene, and PPE to control spread. In 2014, antimicrobial stewardship was added, and within 5 years an algorithm for isolation and testing was published. Cases were reviewed weekly using TheraDoc software and were reported monthly to the national VHA Inpatient Evaluation Center (IPEC). Isolation was communicated using a ward roster/isolation list in TheraDoc for all unit champions to consult daily. CDI cases were classified using NHSN definitions for a laboratory-identified (LabID) event, recurrent cases, and community-onset cases. Real-time case review and weekly multidisciplinary case discussions identified opportunities for improved compliance with the core measures. Results: Over an 8-year period, CDI healthcare-onset LabID events decreased by 73%. The cases decreased from 149 to 40 over the 8-year period. The infection rate decreased 70% from 16.19 per 10,000 bed days of care in FY2011 (October 2010) to 4.88 in FY2019. The incidence of community onset infections increased from 75 in FY2011 to a high of 146 in FY2018 for a rate of 8.15 to 18.17. In FY2019, there was a decrease in both LabID events and community-onset cases to lows of 40 and 102, respectively. Inappropriate testing decreased by 84% from 50 in FY2011 to 8 in FY2019. Conclusions: A multidisciplinary team approach that included support from leadership and clinical providers as well as front line staff involvement, daily rounding, and case review by infection preventionists has reduced all CDI cases over an 8-year period using the modified VHA CDI bundle. TheraDoc enabled case review, correct isolation, changes to cleaning practices, and more appropriate lab testing. The antimicrobial stewardship program that includes clinical pharmacists working daily with providers was a strong driver for change.

Funding: None

Disclosures: None

Background: Whooping cough is a serious respiratory illness in infants caused by Bordetella pertussis. In spite of the vaccination program, the incidence rates of whooping cough per 100,000 population in Vietnam increased from 0.33 in 2015 to 0.58 in 2017. If this represents a pertussis resurgence, contributors may include pathogen adaptation, the spread of specific variants, vaccine failure, and failure to effectively treat cases and contacts. There has been little research in Vietnam on B. pertussis strains. Therefore, we investigated the molecular epidemiology of circulating B. pertussis strains in Southern Vietnam by applying multilocus sequence typing (MLST) for 7 housekeeping genes and 4 antigenic determinant genes as components in the acellular vaccine including prn, ptxP, ptxS1, and fim3. Methods: DNA was extracted from 15 isolates collected from 263 case patients during 2015–2017 and was subject to MLST using primers and cycling conditions from the Bordetella pubMLST website (www.Pubmlst.org/Bordetella/). The products were analyzed using BioEdit version 7.2.5 software and then were aligned and compared to reference sequences of each genotype in the database. The evolutionary relationship among sequence types (STs) from housekeeping genes was performed as a minimum spanning tree via the goeBURST algorithm, whereas the correlation of different variants from 4 antigenic determinant genes was built up and clarified with phylogenetic trees based on the UPGMA method by MEGA 7 program. Results: The 15 isolates were all classified as ST2 (100%) by MLST of housekeeping genes, and they belonged to a common global clonal group (Fig. 1). Sequencing of antigenic determinant genes prn2 – ptxP3 – ptxS1-1 – fim3-1 determined that all were identical to each another and the reference sequences (Fig. 2). Conclusions:B. pertussis isolates circulating in Southern Vietnam appeared to be the same as the common global strain. Few isolates were available for testing; therefore, continued surveillance is important to confirm these findings and to monitor population changes over time.

Funding: None

Disclosures: None

Background: Carbapenem-resistant Acinetobacter baumannii (CRAB) are an urgent public health threat because they cause healthcare-associated infections that are difficult to treat and can spread in healthcare environments. Acinetobacter spp may develop resistance to carbapenems through various mechanisms, including decreased permeability, overexpression of efflux pumps, and production of carbapenemases. Carbapenemases found in CRAB commonly belong to the group of carbapenem-hydrolyzing class D β-lactamases, which can be either intrinsic or acquired. The most clinically relevant class D enzymes are the OXA-23-like, OXA-24/40–like, and OXA-58–like because they are commonly plasmid mediated and thereby have the potential for rapid dissemination. We describe the molecular epidemiology of CRAB in the United States using a convenience sample of isolates collected from reference submissions, an isolate-based surveillance system, and the Antibiotic Resistance Laboratory Network (ARLN). Methods: Beginning in August 2017, 7 public health laboratories in the ARLN began testing CRAB isolates submitted by participating sentinel clinical laboratories across their region. Carbapenem-resistant isolates were identified by resistance to imipenem, meropenem, or doripenem. Testing included molecular detection of 4 targeted carbapenemase genes: blaKPC, blaNDM, blaVIM, and blaIMP. Participating labs reported testing results to CDC at least monthly. A separate collection of isolates from CDC reference and surveillance activities between 2013 and 2015 underwent whole-genome sequencing (WGS) to evaluate the presence of acquired carbapenemase genes, including class D OXA-variants. Results: From August 2017 through July 2019, the ARLN tested 2,368 CRAB isolates across 44 states. Only 12 (0.5%) of these harbored a bla- gene: blaKPC (n = 5), blaNDM (n = 5), blaIMP (n = 1), and blaVIM (n = 1). Of 95 reference and surveillance isolates sequenced, none harbored these targeted carbapenemases. However, 69 (73%) harbored at least 1 acquired class D OXA gene; OXA-23 was the most commonly acquired OXA variant (n = 46, 48.4%). Conclusions: Using a multipronged approach, our studies indicate that the presence of class D β-lactamases of the OXA type are common in CRAB among surveillance and reference samples that underwent WGS analysis. Other acquired carbapenemases appear to be rare. To prevent the spread of highly resistant CRAB, particularly those carrying the targeted, emerging carbapenemase genes, continued testing, and rapid infection control are necessary to improve patient safety and maintain situational awareness.

Funding: None

Disclosures: None

Background: Hospitals in the United States have been encouraged to report antimicrobial use (AU) to the CDC NHSN since 2011. Through the NHSN Antimicrobial Use Option module, health systems may compare standardized antimicrobial administration ratios (SAARs) across specific facilities, patient care locations, time periods, and antimicrobial categories. To date, participation in the NHSN Antimicrobial Use Option remains voluntary and the value of reporting antimicrobial use and receiving monthly SAARs to multihospital healthcare systems has not been clearly demonstrated. In this cohort study. we examined potential applications of SAAR within a healthcare system comprising multiple local hospitals. Methods: Three hospitals within Prisma Health-Midlands (hospitals A, B, and C) became participants in the NHSN Antimicrobial Use Option in July 2017. SAAR reports were presented initially in October 2017 and regularly (every 3–4 months) thereafter during interprofessional antimicrobial stewardship system-wide meetings until end of study in June 2019. Through interfacility comparisons and by analyzing SAAR categories in specific patient-care locations, primary healthcare providers and pharmacists were advised to incorporate results into focused antimicrobial stewardship initiatives within their facility. Specific alerts were designed to promote early de-escalation of antipseudomonal β-lactams and vancomycin. The Student t test was used to compare mean SAAR in the preintervention period (July through October 2017) to the postintervention period (November 2017 through June 2019) for all antimicrobials and specific categories and locations within each hospital. Results: During the preintervention period, mean SAAR for all antimicrobials in hospitals A, B, and C were 0.69, 1.09, and 0.60, respectively. Notably, mean SAARs at hospitals A, B, and C in intensive care units (ICU) during the preintervention period were 0.67, 1.36, and 0.83 for broad-spectrum agents used for hospital-onset infections and 0.59, 1.27, and 0.68, respectively, for agents used for resistant gram-positive infections. After antimicrobial stewardship interventions, mean SAARs for all antimicrobials in hospital B decreased from 1.09 to 0.83 in the postintervention period (P < .001). Mean SAARs decreased from 1.36 to 0.81 for broad-spectrum agents used for hospital-onset infections and from 1.27 to 0.72 for agents used for resistant gram-positive infections in ICU at hospital B (P = .03 and P = .01, respectively). No significant changes were noted in hospitals A and C. Conclusions: Reporting AU to the CDC NHSN and the assessment of SAARs across hospitals in a healthcare system had motivational effects on antimicrobial stewardship practices. Enhancement and customization of antimicrobial stewardship interventions was associated with significant and sustained reductions in SAARs for all antimicrobials and specific antimicrobial categories at those locations.

Funding: None

Disclosures: None

Background:Staphylococcus aureus–colonized hospitalized patients are at risk for invasive infection and can transmit S. aureus to other patients in the absence of symptoms. Infection isolation precautions do not reduce the risk of infection in colonized patients and are untenable in health systems with high rates of S. aureus colonization. Objective: We implemented an inpatient S. aureus screening and targeted decolonization program across hospital campuses to reduce transmission and invasive infection. We screen and decolonize for methicillin-susceptible S. aureus (MSSA) and methicillin-resistant S. aureus (MRSA) because MSSA makes up more than half of all S. aureus isolated from clinical cultures in our health system. Methods: All medicine, pediatrics, and transplant patients receive S. aureus nares culture at admission and upon change in level of care for medicine, and at admission and weekly for pediatrics and transplant patients. All S. aureus–colonized patients receive decolonization with nasal mupirocin ointment and chlorhexidine baths. Two implementation frameworks guide our processes for S. aureus screening and decolonization: the Consolidated Framework for Implementation Research, to evaluate factors affecting implementation at different levels of the health system, and the Dynamic Sustainability Framework, to account for iterative changes as the hospital setting and patient population change over time. Implementation interventions focus on education of patients and bedside nurses who perform S. aureus screening and decolonization; utilization of the electronic health record to identify patients for screening and/or decolonization and avoid human error; and introduction of a clinical nurse specialist to oversee the program and to provide iterative feedback. Results: At baseline, 21% of patients had S. aureus colonization, 20% of which was MRSA, and the MRSA bloodstream infection rate was 0.06 per 1,000 patient days. After program implementation, there was no change in S. aureus colonization and the MRSA bloodstream infection rate fell to 0.04 per 1,000 patient days. Screening compliance improved from 39% (N = 1,805) of eligible patients in the 6-month period before the introduction of the clinical nurse specialist to 52% (N = 2,024) after the introduction of the clinical nurse specialist. In the same periods, decolonization increased from 18.6% to 41% of eligible patients. Conclusions: We used 2 implementation frameworks to design our S. aureus screening and decolonization program and to make iterative changes to the program as it evolved to include new patient populations and different hospital settings. This resulted in a large-scale, sustainable, health system program for S. aureus control that avoids reliance on infection isolation precautions.

Funding: None

Disclosures: None

Background: Methicillin-resistant Staphylococcus aureus (MRSA) is a frequent source of infection in the neonatal intensive care unit (NICU). Due to the serious consequences associated with MRSA infections in neonates, much effort has been made to prevent and control epidemics in NICUs. Since 2006, our hospital has performed MRSA nasal surveillance screening of all newborns in the NICU in accordance with the recommendations of the Chicago-Area Neonatal MRSA Working Group. In 2017, a MRSA infection was identified in a newborn shortly after transfer from an outside hospital and who had an initial negative MRSA admission screen. As a result, we modified the admission screening process for all transfers from outside NICUs. Methods: The Evanston Hospital Infant Special Care Unit is a level 3 NICU in the northern suburbs of Chicago with 44 NICU beds and 450 admissions per year. Effective July 1, 2017, all NICU transfers have a nasal MRSA screen performed upon admission and after 48 hours. The transferred baby is placed on contact isolation until both screening results return negative. Nasal MRSA testing is performed using both PCR on the BD MAX MRSA Assay platform and is confirmed by culture using MRSA CHROMagar TM. Results: Between July 1, 2017, and October 31, 2019, 112 neonates were transferred from outside NICUs. Moreover, 105 (94%) had at least 1 MRSA screen completed and 99 (88%) had both MRSA screens completed. Of 99 with 2 screens, only 1 neonate had an initial positive nasal MRSA screen. Of the remaining 98 negative babies, none had a repeat positive nasal MRSA screen within 48 hours of admission. of 99 neonates with 2 serial admission MRSA screens, 82 (83%) were transferred within 48 hours of birth. In addition, 17 neonates were transferred >48 hours after birth, including the 1 MRSA-positive baby. Conclusions: In an attempt to identify all potential MRSA-positive neonates transferred to our NICU, we instituted a policy of 2 admission nares swabs. However, our data suggest that a single initial MRSA swab may be sufficient. If continued collection of a second screen is performed, it may be sufficient to screen babies who have been hospitalized for at least 48 hours prior to transfer, which eliminates 83% of admission testing and results in a cost savings.

Funding: None

Disclosures: None

Background: The risk factors for methicillin-resistant Staphylococcus aureus (MRSA) colonization can differ between acute-care, subacute-care, and long-term care facilities, but comparative information is lacking. We compared risk factors for MRSA colonization contemporaneously between an acute-care hospital (ACH) and its affiliated intermediate- and long-term care facilities (ILTCFs). Methods: Serial cross-sectional studies were conducted in a 1,600-bed tertiary-care ACH and its 6 affiliated ILTCFs in Singapore, in June–July 2014–2016. Separate nasal, axillary, and groin swabs were taken and cultured for MRSA. MRSA isolates were subject to whole-genome sequencing. Clinical and epidemiological data were obtained from medical records. To account for clustering, multivariable 2-level multinomial logistic regression models were constructed to assess factors associated with colonization of specific MRSA clones, in the ACH and ILTCFs, respectively. Results: In total, 8,873 samples from 2,985 patients in the ACH and 7,172 samples from 2,409 patients and residents in ILTCFs were included in the study. Patients and residents in the ILTCFs (29.7%) were more likely to be colonized with MRSA than patients in the ACH (12.6%) (P < .0001). The predominant MRSA clones were clonal complexes (CC)22 (n = 692, 46.7%) and CC45 (n = 494, 33.4%), contributing to 80% of MRSA isolates. For ACH patients, after adjusting for age, gender, comorbidities, prior exposures to antibiotics and percutaneous devices, presence of wounds, and screening year, prior MRSA carriage in the preceding 12 months was the strongest predictor of colonization with all MRSA clones: CC22 (aOR, 14.71; 95% CI, 6.17–34.48); CC45 (aOR, 7.75; 95% CI, 2.70–22.22); and others (aOR, 22.22; 95% CI, 3.83–125.00). Hospital stay >14 days was also positively associated with colonization with MRSA CC22 (aOR, 2.67; 95% CI, 1.22–5.88), but not the other clones. For ILTCF patients and residents, after adjusting for age, comorbidities, prior exposure to antibiotics, presence of wounds, and screening year, prior MRSA carriage was a significant predictor of colonization with MRSA CC22 (aOR, 2.72; 95% CI, 1.35–5.46), and CC45 (aOR, 2.36; 95 % CI, 1.06–5.24), but not with other clones. Additionally, prior exposure to a percutaneous device and being male were respectively positively associated with colonization by MRSA CC22 (aOR, 2.70; 95% CI, 1.19–6.17) and CC45 (aOR, 2.17; 95% CI, 1.11–4.26). Conclusions: Prior MRSA carriage was a common risk factor for colonization with the predominant MRSA clones in both the ACH and ILTCFs. Hospital stay >14 days and exposure to percutaneous devices were additional risk factors for CC22 colonization in the ACH and ILTCFs, respectively. Pre-emptive contact precautions for prior MRSA-carriers on admission and active screening for long-stayers in the ACH could prevent intra- and interinstitutional MRSA transmission.

Funding: None

Disclosures: None

Background: Central venous catheter (CVC) maintenance bundle elements, including labeling IV tubing and dressings, consistently changing them, intact dressings, and dry healthy insertion sites, together have been shown to reduce risks of developing central-line–associated bloodstream infections (CLABSIs).1,2 CLABSIs are a significant, but preventable, cause of mortality among critically ill patients.3 In the last 12 months, the 16-bed medical intensive care unit (MICU) at a large, urban, academic facility had 2,621 central-line days, presenting many opportunities for CLABSI prevention. During that time, weekly observations assessed compliance with CVC maintenance bundle elements. Interventions: Multidisciplinary rounds were conducted to monitor nursing staff adherence to CVC maintenance bundle elements. The following bundle elements observed during rounds: (1) Is central-line dressing occlusive/intact? (2) Is CVC insertion site healthy with no redness/drainage? (3) Is CVC dressing labeled with insertion date? (4) Date/time of last dressing change adheres to policy? (4) All CVC tubing is labeled with date/time? (5) All CVC tubing dates adhere to policy? (6) If stopcock is present, is cap present over unused port? “Just-in-time” staff coaching was employed when noncompliance was observed. Findings were sent to leadership for manager follow-up. Staff were informed about products available within the hospital, which can improve dressing adherence and mitigate insertion-site bleeding. Education was provided to staff defining exact requirements for CVC dressings. The acronym “IDOL” was used to help remind staff of these fundamentals: (1) Intact dressing borders are well adhered, with <50% of the white border detached. (2) Drainage should be within the chlorhexidine square. (3) Occlusive means no bubbles, kinks, or wrinkles in the dressing. (4) Labeling is required and must include insertion date, date/time of change, and initials. Results: In the first 2 months of rounds, overall compliance averaged 85%. Compliance increased to an average of 91% during the subsequent 10 months. Early on, most fallouts were found with dressings not occlusive or intact and excessive drainage from insertion sites. Initially, 71% of sites were without excess drainage, and 57% of dressings were occlusive or intact. These measures increased to 83% and 89%, respectively, after the interventions. A 50% decrease in the number of CLABSIs was observed during the observation period, compared to the previous 12-month period. Conclusions: Consistent use of bundles has been shown to significantly improve patient outcomes with regard to hospital-acquired infections (HAIs).3 Frequent observations, education to define staff expectations, and holding staff accountable have all helped improve compliance with maintenance bundle elements. Preventing CLABSIs is not only important for patient safety and quality of care. Regulatory and accrediting agencies are now increasing their focus on infections and are tying them to reimbursement.

Funding: None

Disclosures: None

Background: Hospital-acquired infections (HAIs) are a leading cause of healthcare morbidity and cost for the health community. It is widely recognized that hand hygiene is the leading contributor infections, but hand hygiene still remains a major problem for nearly all healthcare systems. A longitudinal study was conducted over a 4-year period in a community-based health system. Methods: An electronic hand hygiene reminder system was installed in 2 different facilities including both critical care and noncritical units. This system collects data on individual healthcare provider hand hygiene and provides a real-time voice reminder in the event that a provider forgets to perform hand hygiene. The primary study was designed to investigate the impact of a real-time voice reminder to improve hand hygiene. A baseline period of hand hygiene was established prior to the interventions after installing the system without any access to data reporting or the voice reminder. Each of the hospitals had the voice reminder turned on and off 3 times. The baseline HAI rates were established by comparing in each facility for the 12 months prior to the implementation of the system. During the study period, there were no significant changes to other common infection control practices. Results: In both facilities, every time the voices were turned on, hand hygiene improved significantly and each clinical unit saw a >200% improvement in hand hygiene within 3 months of turning the voice reminder. HAIs fell by a statistically significant in all clinical areas by 51%. After a period of stabilization, the voice reminder was turned off hand hygiene compliance fell and HAI rates then increased. The voice reminder was then turned back on and off 2 more times. In every case, hand hygiene rates fell back to the baseline and HAIs returned to their baseline. When the voice reminder was then turned back on, HAIs dropped to 54%–81% of the baseline in each of the clinical units. The system also captured individual providers’ hand hygiene performance data and displayed it in a simple and engaging way, allowing managers easily understand who was struggling with hand hygiene. These data were then leveraged through a series of competitions to systematically drive hand hygiene performance improvement. These included traditional interventions to address an education issue in addition to interventions to identify workflow problems. Conclusions: Using this highly targeted approach, the leadership were able to efficiently drive sustained hand hygiene improvement and a further reduction in HAIs.

Funding: None

Disclosures: None

Background: Nosocomial influenza infections can be caused by direct patient-to-patient transmission, as well as bidirectionally between patient and healthcare workers (HCWs). Lapses in infection control practices (droplet precautions), and HCWs who come to work despite influenza-like illness (ILI, ie, “presenteeism”) can potentiate transmission. Cocirculation of >1 strain of influenza may complicate efforts to track infections. We describe a multidisciplinary response that helped control a late winter nosocomial influenza outbreak at a time when both influenza A/H3 and A/H1(2009) were prevalent in the community. Methods: Infection control practitioners detected a potential cluster of influenza A/H3 cases on an adult general medicine unit during the middle of March. The patients were spread out in nonadjacent rooms in a 30-bed unit, which suggested a possible common shared source. Further investigation revealed other potential clusters. Hospital incident command (HIC) was deployed to assess and respond to the outbreak; the incident commander was the chief medical officer (CMO) and the hospital epidemiologist was the subject matter expert. Other HIC roles were manned by nursing leadership, hospital administration, employee health, and the clinical laboratory. The group met at least daily (teleconference on weekends) until the extent of the outbreak was known and no new cases were identified. Results: A multipronged approach was used to control the outbreak. HCWs who reported to work with ILI symptoms were referred to employee health, tested with a PCR-based influenza screening panel, and sent home. Inpatients with ILI symptoms were tested with a comprehensive respiratory virus panel that could distinguish influenza A/H1(2009) from A/H3. Inpatients who were newly positive for influenza were evaluated to determine whether they were epidemiologically linked to an existing cluster, represented a new case of nosocomial acquisition, or were presumed to be community-acquired. The outbreak involved separate clusters caused by A/H3 and A/H1(2009) that affected 40 patients on 9 clinical units. Conclusions: A key component of the response was implementation of a local “mask rule”: all physicians, nurses, other employees, students, and visitors were required to wear surgical masks on affected floors regardless of their vaccination status. In addition, the hospital IT team developed a dynamic spreadsheet that listed information about all nosocomial cases (location, date of onset, etc), as well as ILI call-ins for HCWs. A password-protected version was posted on the hospital intranet and facilitated cohorting of infected patients. Additionally, it allowed timely discontinuation of the local mask rule on specific units, once 2 incubation periods concluded without new cases.

Funding: None

Disclosures: None

Background: Children attending daycare are at increased risk of carrying multidrug-resistant organisms (MDROs) compared to children not attending daycare. Carriage of MDROs greatly increases the risk of infection, not only in the child but also for others living in the household. Understanding the epidemiology of MDRO carriage in children is essential to devising effective containment strategies. Here, we present the findings from a cross-sectional study assessing MDRO carriage in daycare-attending and nonattending children in Wisconsin. Methods: We applied the following enrollment criteria: Children aged between 6 months and <6 years and not enrolled in kindergarten; children who did not have an MDRO infection in the previous 6 months and did not receive any antimicrobials in the previous month; and children who did not have a gluten allergy, asthma, eczema, allergic rhinitis, cystic fibrosis, or an immunodeficiency. Children were enrolled by a parent or guardian who filled out a questionnaire on MDRO risk factor history and diet. Samples were collected from the nares, axilla or groin (pooled swab), and stool. Nasal samples were cultured for H. influenzae, S. pneumoniae, M. catarrhalis, and methicillin-resistant S. aureus (MRSA). Skin samples were cultured for MRSA, and stool samples were cultured for MRSA, C. difficile, vancomycin-resistant enterococci (VRE), and extended-spectrum β-lactamase–producing Gram-negative bacilli (ie, ESBL GNR). Results: In total, 44 children were enrolled in this study. The average age was 2.6 years and 50% were girls. Furthermore, 30 (68.2%) were identified by their parents as white, 9 (20.5%) as black, and 5 (11.3%) as other or multiracial. Incidentally, 23 children (52.3%) were enrolled in daycare. Overall, 18 children were positive for at least 1 organism, 9 of which had daycare exposure, and 5 children (1 in daycare) were positive for >1 organism (11.4%). From stool samples, 6 children (13.6%, 2 in daycare) were C. difficile carriers, 3 were VRE carriers (6.8%, 1 in daycare), 8 carried an ESBL GNR (18.2%, 4 in daycare), and 3 carried MRSA (6.8%, 1 in daycare). One child was positive for H. influenzae (2.3%, not in daycare) and 2 were positive for S. pneumoniae (4.6%, 1 in daycare) from nares swabs. One child was positive for MRSA (2.3%, not in daycare) from a skin swab. We detected no significant differences between children with and without daycare exposure for any organism. Conclusions: Children in this population had higher than expected rates of ESBL GNRs and MRSA for a community population. Daycare exposure was not correlated with increased carriage in this small pilot study, though larger longitudinal studies are needed.

Funding: None

Disclosures: None

Background: The transmission of pathogenic organisms in healthcare settings is a major cause of healthcare-associated infections (HAIs). In recent years, infections with carbapenem-resistant Enterobacteriaceae (CRE) have become a significant public health threat, in part because many patients are arriving at the hospital already colonized, and colonization is a major risk factor for infection. Reducing transmission requires understanding how patient movement drives the spread of CRE; however, analysis of this issue has mostly been modeled at a hospital-level without much consideration for the population dynamics that occur outside of the hospital setting and how patients move between healthcare settings. Patients move between hospitals, other healthcare settings, such as long-term care facilities (LTCFs), and the community, all of which pose different colonization risks. Thus, studying each environment in isolation fails to realistically address the consequences of large-scale policy interventions. One such intervention is a statewide electronic registry to track patients who are known to be colonized or have had a CRE infection. Understanding the potential for reducing CRE morbidity and mortality requires consideration of small- and large-scale effects on patients’ movement and transmission. Methods: We developed a multiscale, metapopulation model for hospitals, communities, and LTCFs in the state of Maryland. In our computational simulation, we included a regional- as well as a local-scale model that were informed by the patient-mix data from the Maryland Health Service Cost Review Commission. We examined the impact of implementing a registry compared to less coordinated scenarios. Results: The most effective policy was the implementation of an electronic registry which resulted in 9.6% median reduction in CRE HAIs in Maryland for simulated outcomes (Fig. 1). Other interventions included colonization screening at various or all hospitals and using a predictive algorithm to determine at-risk patients that need to be screened. These interventions only resulted in ~1%–3% reductions in HAIs. We also observed that coupling other interventions with an electronic registry does not aid in reducing more HAIs.

Funding: None

Disclosures: None

Boxplot of simulated outcomes of all scenarios compared to the baseline scenario. The scenarios include (1) complete screening with no electronic registry, (2) selective screening with no electronic registry, (3) predictive screening with no electronic registry, (4) baseline with an electronic registry, (5) complete screening with an electronic registry, (6) selective screening with an electronic registry, and (7) predictive screening with an electronic registry. Scenarios 5-7 include the same interventions as 1–3 coupled with an electronic registry.

Background: Several decades of animal and basic science research have demonstrated that certain opioids have immunosuppressive properties, but the clinical relevance of opioid-related immunosuppression remains unclear. Although experts have called for epidemiologic research to inform clinical practice, prioritization of that research depends partly on a determination of the number of people potentially affected. To date, population-level estimates of administering or prescribing immunosuppressive opioids (ISOs) have not been measured. Our objective was to estimate the overall frequency of ambulatory visits involving ISOs, and to estimate the frequency of these visits among immunocompromised patients. Methods: We used the CDC National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey–Emergency Departments (NHAMCS-ED) data sets (2006–2016) to compute average annual frequencies of patient visits involving ISOs. We accounted for survey sampling design and visit weights using SAS version 9.4 software. We adopted a definition of ISOs from the literature as ‘alone or in-combination’ formulas of codeine, morphine, and fentanyl. We approximated patients’ immunocompromised status by the administering or prescribing of anti-infective drugs, and by chronic conditions indicative of immunocompromised status. We stratified visits with mentions of ISOs by co-occurring clinical-use of anti-infective drugs, and by selected chronic conditions. Results: From 2006 to 2016, annual averages of 7.9% (N = 10,383,000; SE, 447,000) of all ED visits and 1.3% (N = 12,674,000; SE, 558,000) of all outpatient office visits involved the administering or prescribing of 1 or more ISO. Over the same period, coprescribing or administering of anti-infective drugs alongside ISOs occurred during 2.1% (N = 2,782,000; SE, 130,000) of all ED visits, and 0.4% (N = 3,525,000; SE, 219,000) of all outpatient office visits. ED visits by patients with selected chronic conditions who were administered or prescribed ISOs include cancer—499,000 (SE, 39,000), diabetes—1,369,000 (SE, 82,000), and HIV—45,000 (SE, 7,000). Outpatient office visits by patients with selected chronic conditions who were administered or prescribed ISOs include cancer—1,032,000 (SE, 92,000), diabetes—1,802,000 (SE, 142,000), and chronic renal failure—138,000 (SE, 22,000). Conclusions: More than 10 million ED visits and 12 million outpatient office visits involved the clinical use of ISOs on average, from 2006 to 2016. These averages include visits by immunocompromised patients who could potentially benefit from nonimmunosuppressive analgesic alternatives, when appropriate. Until further research is conducted on the clinical relevance of these opioids’ immunosuppressive properties, their use to treat immunocompromised patients may represent unrecognized patterns of inappropriate drug use.

Funding: None

Disclosures: None

Background: Urinary tract infections (UTIs) are one of the most common hospital-acquired infections; ~70%–80% are attributable to an indwelling urethral catheter. Daily risk of bacteriuria acquisition varies from 3% to 7% with a catheter. CAUTIs are associated with increased mortality, cost, and inappropriate treatment of asymptomatic bacteriuria which promotes antimicrobial resistance and Clostridium difficile infection. NHSN CAUTI criteria is most commonly met when a patient has a positive urine culture and a fever. Although fever can be associated with many sources, it cannot be excluded from UTI determination even when attributable to another recognized source. Given the high prevalence of bacteriuria in catheterized patients and the many sources of fever, the NHSN definition lacks specificity. Objective: To better classify CAUTI using enhanced criteria to so that appropriate reduction efforts would be utilized. Methods: A retrospective review was conducted to evaluate NHSN-defined CAUTIs from July 2017 to December 2018. Patients with NHSN defined CAUTI were evaluated to determine elements present to meet criteria. Overcaptured (O-CAUTIs) were defined as follows: (1) O-CAUTI 1, a positive culture with fever attributable to an infectious source; (2) O-CAUTI 2, a positive culture with fever attributable noninfectious source; (3) O-CAUTI 3, repeated positive cultures outside the RI period; (4) O-CAUTI 4, a positive culture with symptoms attributable to another source and no fever. Classifications were discussed with the medical and clinical leadership to determine appropriate opportunities for improvement. Results: Overall, 49 NHSN CAUTIs were identified with 11 of 49 (22%) being true CAUTIs and 38 of 49 (78%) O-CAUTI. O-CAUTI 1 was most common, with 17 of 38 (45%). The most frequent attributable source of fever for O-CAUTI 1 (infectious source) was respiratory (7 of 17, 59%) followed by gastrointestinal (6 of 17, 35%). Also, 14 of 38 (37%) were O-CAUTI 2. Central fever was the most frequent source of fever for the noninfectious source (9 of 14, 64%) followed by drug fever (2 of 14, 14%). Of 38 patients, 3 (8%) had both an infectious and noninfectious reason for fever (CAUTI 1 and 2); 4 patients had no fever. Furthermore, 2 were O-CAUTI 3 (repeat culture positive) and 2 were O-CAUTI 4 (1 with hematuria and renal cell carcinoma and 1 with dysuria without leukocytosis). Conclusions: NHSN CAUTI definitions capture UTIs and other events. In FY2018, there were no true CAUTIs in 5 of 12 months (42%). Also, 50% of CDC CAUTIs were not UTI but could lead to inappropriate antibiotic use. Reviewing only CAUTI reduction work in O-CAUTIs prevents the assessment of other appropriate opportunities for improvement.

Funding: None

Disclosures: None

Background: An indwelling urinary catheter is used in ~12%–16% of adult hospital inpatients during their hospitalization, which poses risks for acquiring a catheter-associated urinary tract infection (CAUTI). CAUTI data have been reported to the NHSN since 2005, and national benchmarks are annually reported in NHSN progress reports. Trends analyses in the incidence of CAUTI reported to the NHSN over long time have not been previously assessed. Objective: We investigated the national trends of CAUTI incidence separately for intensive care units (ICUs) and wards in acute-care hospitals (ACHs) from 2009 through 2018. Methods: We analyzed CAUTI data from ACHs reported to NHSN in 2009–2018. To evaluate trends of CAUTI incidence (per 1,000 catheter days), we conducted interrupted time-series analysis using negative-binomial mixed-effects modeling, separately for ICUs (nonneonatal ICUs) and wards. Due to the reporting requirement for adult and pediatric ICUs in 2012, and medical, surgical, and medical-surgical wards in 2015 by the CMS and the institution of the NHSN CAUTI definitional changes in 2015, calendar years 2012 and 2015 were treated as interruptions to the outcome in ICU models, and year 2015 was treated as a single interruption in the ward models. Regression models were assessed and adjusted, as appropriate, for patient care location type and facility-level characteristics such as hospital type, teaching status, bed size, number (and percentage) of ICU beds, and average length of inpatient stay. Random intercept and slope models were evaluated with covariance tests and were included to account for differential baseline incidence and trends among reporting hospitals. Results: The volume of patient care locations and hospitals reporting to the NHSN increased over time. Among the ICUs, the CAUTI incidence rate did not change in 2009–2012 and increased at an average of 5.6% per year in 2012–2014 (Fig. 1). CAUTI incidence rate dropped nearly 40% in 2015; thereafter, it decreased at an average of 8.9% per year. Among the wards, CAUTI incidence rate decreased at an average of 4.3% per year beginning 2009 (Fig. 2). The CAUTI incidence rate dropped almost 28% in 2015 and then decreased at an average of 4.3% per year. Conclusions: CAUTI incidence decreased substantially in 2015 among both ICUs and wards, which was partially attributable to CAUTI definitional change (see also Fig. 7 at https://www.cdc.gov/hai/data/archive/data-summary-assessing-progress.html). The significant decline of CAUTI incidence in both location types since 2015 is encouraging, and continued efforts in prevention of CAUTI are vital to sustaining this decline in the future.

Funding: None

Disclosures: None

Background: Escherichia coli is the third most common pathogen responsible for healthcare-associated infections (HAIs), but it is increasingly resistant to multiple antibiotics. Antimicrobial susceptibility test (AST) results for fluoroquinolones (FQs) among E. coli implicated in select HAIs are reported to the NHSN surveillance system. Trend analyses in the prevalence of FQ resistance among healthcare-associated E. coli infections reported to NHSN have not been previously assessed. Objective: We investigated the national trends of prevalence of FQ resistance among E. coli HAIs in acute-care hospitals from 2009 through 2018. Method: We analyzed E. coli AST data from central-line–associated bloodstream infections (CLABSIs), catheter-associated urinary tract infections (CAUTIs), and surgical site infections (SSIs) reported to the NHSN between 2009 and 2018. Fluoroquinolone resistance is defined as the number of E. coli isolates that tested resistant or intermediate to at least 1 of 3 quinolones (ciprofloxacin, levofloxacin, and moxifloxacin), divided by number of pathogens tested for susceptibility, multiplied by 100. To evaluate the trends of fluoroquinolone resistance over time, we conducted an interrupted time-series analysis using a generalized linear mixed model with a logistic function. Substantial HAI definitional changes, most consequentially CAUTI in 2015 and a directional incidence change in 2018, were treated as interruptions to the outcome. Regression models adjusted for patient-level (ie, age, gender, HAI type) and facility-level characteristics (ie, facility type, teaching status, number of beds in intensive care units, and average length of stay) were obtained from the NHSN annual hospital surveys. Random-intercept and slope models were evaluated with covariance tests and were included to account for differential baseline fluoroquinolone resistance and trends among reporting facilities. Data were analyzed using SAS with statistical significance defined at alpha = 0.05. Results: During 2009–2018, the number of E. coli isolates with AST results for FQ reported to NHSN (Fig. 1) increased. After adjusting for covariates, fluoroquinolone resistance significantly increased from 2009 through 2015 at an average of 4.2% per year (Fig. 2, β1). There was no significant change in fluoroquinolone resistance from 2015 through 2017 (Fig. 2, β1+ β3). In 2018, there was 6.4% decline in fluoroquinolone resistance compared to 2017 (Fig. 2, β4) Conclusions: An increasing trend of fluoroquinolone resistance from 2009 through 2015 was observed, and fluoroquinolone resistance was stable during 2015–2017. Despite a relatively brief decline in fluoroquinolone resistance in 2018, the absolute change was small (~2%). Sustaining this decline warrants continued efforts in infection prevention and antimicrobial stewardship.

Funding: None

Disclosures: None

Background: Antimicrobial use in low- and middle-income countries (LMICs) can play a major role in the development of antimicrobial resistance (AMR). In many LMICs, antimicrobials can be dispensed without prescriptions; they often available in pharmacies and nonpharmacy stores alike. We conducted a nationwide survey to describe the availability and antimicrobial dispensation practices in pharmacies and nonpharmacy stores in the Dominican Republic. Methods: A survey was administered to staff responsible for dispensing antimicrobials at pharmacies and nonpharmacy stores in the Dominican Republic. Stores were randomly selected from March through November 2019 in 7 cities representing all geographic regions of the Dominican Republic. Data on availability of antimicrobials and staff education on antimicrobial use were obtained. Case scenarios with commons symptoms were used to survey staff on antimicrobial use recommendations. Symptoms included dysuria, throat pain, diarrhea, fever, and cough. The availability of antimicrobials ordering by phone and via online delivery was assessed for each store. Results: Staff from 125 stores were invited to participate; 34 pharmacies and 48 nonpharmacy stores participated and 43 refused to participate. Overall, 200 antimicrobial use recommendations were given in pharmacies and 43 in nonpharmacy stores. The most common type of antimicrobial use recommendations were aminopenicillins (Fig. 1). Staff received prior training or education on antimicrobials in 61% of pharmacies and 0% of nonpharmacy stores. Antimicrobial recommendations by case scenario in pharmacies and nonpharmacy stores are shown in Figs. 2 and 3. Antimicrobials are available for phone order in 80% of pharmacies and 90% of nonpharmacy stores. No antimicrobials were available via online delivery apps. Conclusions: Antimicrobials are widely available in the Dominican Republic and can be obtained without a prescription, in person or via delivery. Staff at pharmacy stores recommended different antimicrobials by symptom, whereas staff at nonpharmacy stores commonly recommended aminopenicillins for all symptoms. Training or education on antimicrobial use was common for staff at pharmacy stores but nonexistent for staff at nonpharmacy stores. In LMICs with easy access to antimicrobials, frontline staff in pharmacies and nonpharmacy stores are gatekeepers for antimicrobial use and may represent an important target for outpatient antimicrobial stewardship initiatives.

Funding: None

Disclosures: None

Background: Mobility patterns of healthcare workers (HCWs) (ie, the spatiotemporal distribution of patient rooms they visit) have a significant impact on the spread of healthcare acquired infections (HAIs). Objective: In this project, we used fine-grained data from a sensor deployment at the medical intensive care unit (MICU) in the University of Iowa Hospitals and Clinics (UIHC) to study the mobility patterns of HCWs and their impact on HAI spread. Methods: We analyzed 10 days of data from a 20-bed MICU sensor deployment. For parameters t1 and t2, each pair of rooms i and j is assigned a weight W(i, j) representing the number of times an HCW spends at least t1 seconds in room i followed by at least t1 seconds in room j, within t2 seconds of each other. W(i, j) is a measure of HCW traffic going from room i to room j; we study the correlation between W(i, j) and the distance between rooms i and j. Additionally, we perform 2 disease-spread simulations: (1) a base simulation, obtained by replaying observed HCW mobility traces and (2) a perturbed simulation, which is the same as the base simulation, except that we replace each HCW who visits a room by a random available HCW. Thus, the perturbed simulation removes correlations in the observed HCW mobility traces. Results: We computed W(i, j) for all room pairs i, j for parameters t1 = 30 seconds and t2 = 1,800 and 3,600 seconds. For nurses, there was a strong negative correlation of between pairwise room distance and the weights W(i, j) (−0.768 for t2 = 1,800; −0.711 for t2 = 3,600), The more distant 2 rooms were, the less they shared nurse traffic. This was not true for physicians (correlation = −0.027 for t2 = 1,800; −0.014 for t2 = 3,600). Figure 1 shows a weight versus distance scatter plot for nurses for t1 = 30 and t2 = 1,800. This spatial correlation has positive implications for disease spread; the base simulation, which preserves these spatial correlations, has between 12% and 55% fewer mean infected patients (>100 replicates) for different simulation parameters compared to the perturbed simulation. Conclusions: Our results, based on fine-grained data, show a “naturally emerging” cohorting behavior of nurses, where nurses are more likely to visit rooms close to each other within a 30–60 minute time window, than rooms further away. Through simulations, this behavior provides substantial protection against disease spread.

Funding: None

Disclosures: None

Background: The capacity to monitor the emergence of carbapenemase-producing organisms (CPO) is critical in limiting transmission. CPO-colonized patients can be identified by screening rectal specimens for carbapenemase genes and the Cepheid GeneXpert Carba-R (XCR), the only FDA-approved test, is limited to 5 carbapenemase genes and cannot identify the bacterial species. Objective: We describe the development and validation of culture-based methods for the detection of CPO in rectal cultures (RCs) and nonrectal cultures (NRCs) of tracheal aspirate and axilla-groin swabs. Methods: Colonization screening was performed at 3 US healthcare facilities; specimens of RC swabs and NRC ESwabs were collected. Each specimen was inoculated to a MacConkey broth enrichment tube for overnight incubation then were subcultured to MacConkey agar with meropenem and ertapenem 10 µg disks (BEMA) and CHROMagar KPC (KCHR) or CHROMagar Acinetobacter (ACHR). All media were evaluated for the presence of carbapenem-resistant organisms; suspect colonies were screened by real-time PCR for the most common carbapenemase genes. MALDI-TOF was performed for species identification. BEMA, a previously validated method, was the comparator for 52 RCs; clinical culture (CC) served as the comparator method for 66 NRCs. Select CPO-positive and -negative specimens underwent reproducibility testing. Results: Among 56 patients undergoing colonization screening, 12 (21%) carried a CPO. Only 1 patient had CPO solely from RC. Also, 6 patients had both CPO-positive RC and NRC, and 5 patients only had a CPO-positive NRC. Of the latter, 4 had a CPO-positive tracheal specimen, and 1 had a positive culture from both tracheal and axilla-groin specimens. Sensitivity of BEMA (70%) for NRC was lower than for KCHR (96%) and ACHR (88 %) for all specimens. All methods showed a specificity of 100% and reproducibility of 92%. The detected CPO included OXA-23–positive Acinetobacter baumannii, NDM-positive Escherichia coli, KPC-positive Pseudomonas aeruginosa and 4 genera of KPC-positive Enterobacteriaceae. Conclusions:The addition of nonrectal specimens and use of selective media contributed to increased sensitivity and enhanced identification of CPO-colonized patients. Positive cultures were equally distributed among the 3 specimen types. The addition of the nonrectal specimens resulted in the identification of more colonized patients. The culture-based method was successful in detecting an array of different CPOs and target genes, including genes not detected by the Carba-R assay (eg, blaOXA-23-like). Enhanced isolation and characterization of CPOs will be key in aiding epidemiologic investigations and strengthening targeted guidance for containment strategies.

Funding: None

Disclosures: We discuss the drug combination aztreonam-avibactam and acknowledge that this drug combination is not currently FDA approved.