Background: In the United States, carbapenemases are rarely the cause of carbapenem resistance in Pseudomonas aeruginosa. Detection of carbapenemase production (CP) in carbapenem-resistant P. aeruginosa (CRPA) is critical for preventing its spread, but testing of many isolates is required to detect a single CP-CRPA. The CDC evaluates CRPA for CP through (1) the Antibiotic Resistance Laboratory Network (ARLN), in which CRPA are submitted from participating clinical laboratories to public health laboratories for carbapenemase testing and antimicrobial susceptibility testing (AST) and (2) laboratory and population-based surveillance for CRPA in 8 sites through the Emerging Infection Program (EIP). Objective: We used data from ARLN and EIP to identify AST phenotypes that can help detect CP-CRPA. Methods: We defined CRPA as P. aeruginosa resistant to meropenem, imipenem, or doripenem, and we defined CP-CRPA as CRPA with molecular identification of carbapenemase genes (blaKPC, blaIMP, blaNDM, or blaVIM). We applied CLSI break points to 2018 ARLN CRPA AST data to categorize isolates as resistant, intermediate, or susceptible, and we evaluated the sensitivity and specificity of AST phenotypes to detect CP among CRPA; isolates that were intermediate or resistant were called nonsusceptible. Using EIP data, we assessed the proportion of isolates tested for a given drug in clinical laboratories, and we applied definitions to evaluate performance and number needed to test to identify a CP-CRPA. Results: Only 203 of 6,444 of CRPA isolates (3%) tested through AR Lab Network were CP-CRPA harboring blaVIM (n = 123), blaKPC (n = 53), blaIMP (n = 16), or blaNDM (n = 13) genes. Definitions with the best performance were resistant to ≥1 carbapenem AND were (1) nonsusceptible to ceftazidime (sensitivity, 93%; specificity, 61%) (Table 1) or (2) nonsusceptible to cefepime (sensitivity, 83%; specificity, 53%). Most isolates not identified by definition 2 were sequence type 111 from a single-state blaVIM CP-CRPA outbreak. Among 4,209 CRPA isolates identified through EIP, 80% had clinical laboratory AST data for ceftazidime and 96% had clinical laboratory AST data for cefepime. Of 967 CRPA isolates that underwent molecular testing at the CDC, 7 were CP-CRPA; both definitions would have detected all 7. Based on EIP data, the number needed to test to identify 1 CP-CRPA would decrease from 135 to 42 for definition 1 and to 50 using definition 2. Conclusions: AST-based definitions using carbapenem resistance combined with ceftazidime or cefepime nonsusceptibility would rarely miss a CP-CRPA and would reduce the number needed to test to identify CP-CRPA by >60%. These definitions could be considered for use in laboratories to decrease the testing burden to detect CP-CRPA.

Funding: None

Disclosures: In the presentation we will discuss the drug combination aztreonam-avibactam and acknowledge that this drug combination is not currently FDA approved.

Background: In October 2018 a patient presented to hospital A’s emergency department (ED) for a work injury, arm spasms, and inability to drink liquids. He developed rapid neurologic decline and was transferred to hospital B for neurocritical care. He developed a fever, was intubated, and had an unrevealing infectious diseases (ID) consultation. He became comatose, had refractory seizures, and was transferred to hospital C. A second ID consultation revealed that he had many bats in his home, and his symptoms were consistent with rabies encephalitis. Antemortem specimens of serum, CSF, skin biopsy, and saliva were all positive for rabies virus PCR, and/or rabies serologies. Objective: We describe the response of a multihospital system to the exposure of employees across 3 facilities to rabies-infected body fluids. Methods: Three hospitals in 1 system (222 caregivers) cared for the index patient (hospital A, n = 8; hospital B, n = 107; hospital C, n = 107; 19 students and residents), as did 2 additional facilities outside the system. These included physicians (n = 21), registered nurses (n = 57), respiratory therapists (n = 29), imaging technicians (n = 24), phlebotomists (n = 12), laboratorians (n = 8) and others (n = 71). Infection prevention, employee health, and pharmacy leadership created a centralized team to ensure that all exposed caregivers were screened, and if exposed, were vaccinated. An electronic screening tool developed and administered by the Utah Department of Health via Research Electronic Data Capture (Redcap), rapidly assessed caregiver body fluid exposure risks (saliva, tears, neurologic tissue), and use of personal protective equipment in patient care. After completion, caregivers received notification that he or she (1) had no exposure (no further action), (2) had exposure and should report to employee health for vaccination, or (3) had unclear exposure and should contact the employee health department. Results: Caregivers feared that the tool underestimated exposure risk. Many caregivers (n = 48), repeated the assessment more than once, changing answers. The most common reasons cited were incomplete forms (n = 21), caregiver did not recall using personal protective equipment with contact with saliva (n = 8) or did not understand rabies transmission (n = 3). All vaccinations were initiated by 11 of 26 care givers, 18 days after initial deployment of the tool. All exposed caregivers completed the course. No caregivers developed symptoms of rabies encephalitis. Conclusions: An online tool can safely assess large healthcare exposure such as rabies. A team comprising infection preventionists, employee health representatives, pharmacists, and public health department representatives made the assessment of many geographically dispersed caregivers rapid and effective. Caregivers should employ the basic tenets of standard precautions in the daily care of patients to avoid unknown exposures to common bodily fluids.

Funding: None

Disclosures: None

Background: Cardiovascular implantable electronic device (CIED) infections are highly morbid, yet infection control resources dedicated to preventing them are limited. Infection surveillance in outpatient care is also challenging because there are no infection reporting mandates, and monitoring patients after discharge is difficult. Objective: Thus, we sought to develop a replicable electronic infection detection methodology that integrates text mining with structured data to expand surveillance to outpatient settings. Methods: Our methodology was developed to detect 90-day CIED infections. We tested an algorithm to accurately flag only cases with a true CIED-related infection using diagnostic and therapeutic data derived from the Veterans Affairs (VA) electronic medical record (EMR), including administrative data fields (visit and hospital stay dates, diagnoses, procedure codes), structured data fields (laboratory microbiology orders and results, pharmacy orders and dispensed name, quantity and fill dates, vital signs), and text files (clinical notes organized by date and type containing unstructured text). We evenly divided a national dataset of CIED procedures from 2016–2017 to create development and validation samples. We iteratively tested various infection flag types to estimate a model predicting a high likelihood of a true infection, defined using chart review, to test criterion validity. We then applied the model to the validation data and reviewed cases with high and low likelihood of infection to assess performance. Results: The algorithm development sample included 9,606 CIED procedures in 67 VA hospitals. Iterative testing over 381 chart reviewed cases with 47 infections produced a final model with a C-statistic of 0.95 (Table 1). We applied the model to the 9,606 CIED procedures in our validation sample and found 100 infections of the 245 cases identified by the model to have a high likelihood of infection We identified no infections among cases the model as having low likelihood. The final model included congestive heart failure and coagulopathy as comorbidities, surgical site infection diagnosis, a blood or cardiac microbiology order, and keyword hits for infection diagnosis and history of infection from clinical notes. Conclusions: Evolution of infection prevention programs to include ambulatory and procedural areas is crucial as healthcare delivery is increasingly provided outside traditional settings. Our method of algorithm development and validation for outpatient healthcare-associated infections using EMR-derived data, including text-note searching, has broad application beyond CIED infections. Furthermore, as integrated healthcare systems employ EMRs in more outpatient settings, this approach to infection surveillance could be replicated in non-VA care.

Funding: None

Disclosures: None

Background: Audit-and-feedback interventions track clinician practice patterns for a targeted practice behavior. Audit and feedback of antibiotic prescribing data for acute respiratory infections (ARI) is an effective stewardship strategy that relies on administrative coding to identify eligible visits for audit. Diagnostic shifting is the misclassification of a patient’s diagnosis in response to audit and feedback and is a potential unintended consequence of audit and feedback. Objective: To develop a method to identify patterns consistent with diagnostic shifting including both positive shifting (improved diagnosis and documentation) and negative shifting (intentionally altering documentation of diagnosis to justify antibiotic prescribing), after implementation of an audit-and-feedback intervention to improve ARI management. Methods: We evaluated the intervention effect on diagnostic shifting within 12 University of Utah pediatric clinics (293 providers). Data included 66,827 ARI diagnoses: pneumonia, sinusitis, bronchitis, pharyngitis, upper respiratory infection (URI), acute otitis media (AOM), or serous otitis with effusion (OME). To determine whether rates of ARI diagnoses changed after the intervention, we developed logistic generalized estimating equation (GEE) models with robust sandwich standard error estimates to account for clinic-wise clustering. Outcomes included the change in each ARI diagnosis relative to the competing 6 diagnoses included in audit-and-feedback reports before and after intervention implementation. Models tested for a change in outcomes after the intervention (ie, diagnostic shift) after adjustment for month of diagnosis. For each diagnosis, we estimated the population attributable fraction (PAF) for antibiotic prescriptions due to combined shifts in diagnostic frequencies and prescription rates for each diagnosis. The PAF is the estimated fraction of antibiotic prescriptions that would have changed under a population-level intervention. Results: In month-adjusted analyses, diagnoses of pneumonia and OME decreased after the intervention: odds ratio (OR), 0.46 (95% CI, 0.31–0.68) and OR, 0.81 (95% CI, 0.67–0.99), respectively. In addition, URI diagnoses increased: OR, 1.05 (95% CI 1.00, 1.11). We did not detect changes in the diagnosis rates of sinusitis, AOM, bronchitis, and pharyngitis post intervention. The intervention effect on the PAF for antibiotics prescriptions was consistently positive but relatively small in magnitude. PAF was highest for URIs (PAF, 8.87%), followed by AOM (PAF, 3.56%) and sinusitis (PAF, 2.76%), and was lowest for pneumonia and bronchitis (PAF, 0.41% for both). Conclusions: Our analysis found minimal evidence overall of diagnostic shifting after a stewardship intervention using audit and feedback in these pediatric clinics. Small changes in diagnostic coding may reflect more appropriate diagnosis and coding, a positive effect of audit and feedback, rather than intentional negative diagnostic shift.

Funding: None

Disclosures: None

Background: Hand hygiene (HH) is critical to prevent hospital-acquired infections. Running a successful HH program requires valid and accurate HH data to monitor the status and progress of HH improvement efforts. HH data are frequently subject to variable forms of bias, for which considerations must be made to enhance the validity of HH data. Objective: We assessed the extent to which observers may be prone to report more favorable HH rates when observing healthcare workers from the same professional group versus members of other job categories. Methods: We analyzed HH data from 48,543 electronically collected observations conducted by frontline healthcare workers in a 793-bed acute-care hospital from January 1, 2019, through July 31, 2019. All auditors received training on HH observations and proper use of the data collection application. Compliance data were sorted into peer versus nonpeer observations by profession. We compared HH compliance rates for members of each professional group when monitoring peers versus nonpeers. We further stratified results by ancillary professions (central transport, unit associates, food services, pharmacy, phlebotomy, rehabilitation services, and respiratory therapy) versus nonancillary professions (doctors, nurses, physician assistants, patient care assistants). Results: Of 12,488 ancillary observations, 7,184 (57.5%) were peer observations and 36,055 were nonancillary observations, of which 15,942 (44.2%) were peer observations. The percentage of peer-to-peer observations versus nonpeer observations varied by profession, ranging from 96% of central transport workers and 91% of environmental services observations to 21% of patient care assistants and 34% of physician’s assistants. Average compliance rates for peer versus nonpeer observations in ancillary groups were 98% (95% CI, 98.7%–99.2%) versus 83% (95% CI, 82.5%–84.5%). Average compliance rates nonancillary groups were 92% (95% CI, 92.0%–92.8%) for peers versus 88% (95% CI, 87.8%–88.7%) for nonpeers (Table 1). Conclusions: We documented a propensity for some categories of healthcare workers to record discrepant rates of HH compliance when observing members of the same peer group versus others. This effect was more pronounced amongst ancillary versus nonancillary services. This study adds to the literature of potential sources of bias in HH monitoring programs. Operational changes in HH program data collection may be warranted to try to mitigate these biases such as increasing the frequency of validation exercises conducted by nonaffiliated observers, weighting peer versus nonpeer observations differently, or switching to automated electronic monitoring systems.

Funding: None

Disclosures: None

Background: Disseminated varicella zoster virus (dVZV) infection is a feared complication of varicella zoster virus (VZV) reactivation in immunocompromised patients. The CDC recommends contact and airborne precautions for localized VZV in immunocompromised patients until dissemination has been ruled out. Pre-emptive isolation can be problematic for medical centers without access to negative-pressure rooms. When we identify a case of dVZV at our facility, we perform an investigation to identify occupational exposures. Methods: We conducted a retrospective, descriptive review of occupational exposure investigations related to dVZV from January 2016 to December 2018. We collected baseline characteristics of the dVZV patient, and we evaluated whether the exposure occurred due to a delay in diagnosis or a progression from “localized” to disseminated VZV disease. Results: We identified 21 immunosuppressed patients with dVZV whose infection resulted in an occupational exposure during the specified study period. Average age was 58.6 years, with 10 males and 12 females. The immunocompromised patients included 11 with hematologic malignancy, 5 with solid-organ malignancy, 3 with rheumatologic disease on immunosuppressive therapy, and 2 with a solid-organ transplant. Most of the exposures (72.7%) occurred in an inpatient setting. The exposures resulted from either delayed recognition of dVZV or delayed initiation of appropriate precautions for all of the immunosuppressed patients. Two additional exposures occurred as a result of a change from “localized” to “disseminated” VZV. These patients whose diagnosis changed from localized to dVZV were considered previously immunocompetent, and dissemination took place 2 days after seeking healthcare evaluation. Conclusions: Most occupational exposures to varicella zoster are the result of delayed initiation of appropriate isolation precautions due to delayed diagnosis of dVZV infection or failure to recognize the need for instituting precautions in disseminated disease. Instituting preemptive airborne precautions for immunocompromised patients with localized varicella zoster would be unlikely to reduce occupational exposures.

Funding: None

Disclosures: Consulting fee- Merck Priya Sampathkumar

Background: Occupational injuries are important public health issues, especially among healthcare workers. The medical waste handler is at risk of hazards posed by medical waste as well as from the environment. The aim of the study was to determine occupational hazards that hospital waste handlers in Ahmadu Bello University Teaching Hospital, Zaria, were exposed to and to assess their knowledge and practice of safety measures. Methods: A cross-sectional descriptive study was conducted among 79 medical waste handlers in Ahmadu Bello University Zaria using a multistage sampling technique. Data were collected using structured self-administered and interviewer administered questionnaire and analyzed using SPSS version 20 software with significance set at P < .05. Results: More than half of the respondents (56.4%) were men, and most (70.3%) had <5 years work experience. Most of the respondents (60.8%) had had an injury in the previous 6 months. The most common injuries were falling on a slippery floor (48.1%), contact/irritant dermatitis (40.5%), and 34.2% from stress. Only 45.6% received treatment following injury at the work place. Most respondents (75.9%) were aware of safety devices, and more than half (51.9%) received their information from special safety training. More than half of the respondents (51.1%) had poor knowledge of use of safety devices, and 60% had special training in occupational safety. Most respondents (89.9%) used heavy-duty rubber hand gloves, but only 5.1% used aprons. Also, 82.3% of respondents used these devices regularly at work, and more than half of respondents (62%) had been immunized against hepatitis. Also, 65.8% practiced universal precautions. Occupational injury was higher among those aged 15–19 years (occupational injury rate, 75%) compared to those aged 34–39 years (occupational injury rate, 16%). A positive association was detected between gender and injury in the last 6 months; injury was more common among men (43%) than among women (15%). Conclusions: Among respondents, there was a high level of injury and poor knowledge of the use of protective devices. Regular use of protective measures was not commensurate with the reported level of awareness. Concerted efforts are needed to ensure the safety of the medical waste handlers in his work place.

Funding: None

Disclosures: None

Background: Methicillin-resistant Staphylococcus aureus (MRSA) is highly prevalent in Singapore hospitals. The Ministry of Health (MOH) has set a reduction of MRSA bacteremia as a key performance indicator for publicly funded hospitals, resulting in the adoption of various strategies to achieve this goal. Decolonization regimens have been implemented in different institutions with variable outcomes. In Tan Tock Seng hospital (TTSH), octenidine was chosen instead of chlorhexidine for its gentler action on the skin, and nasal octenidine was chosen instead of mupirocin (which has a high resistance rate) for nasal decolonization. Methods: All patients admitted to TTSH are screened for MRSA on admission. Patients who are either colonized or infected with MRSA are either placed in isolation rooms (when available) or are placed in cohorts in MRSA wards. The Department of Infection Prevention and Control (IPC) keeps a database of all patients with positive cultures for MRSA, including bacteremia. We used this database to implement and evaluate targeted strategies in such MRSA wards. In January 2018 we began a pilot project in 1 ward, whereby all patients had intranasal octenidine gel applied twice a day for 5 days, as well as daily octenisan baths throughout their stay in the ward. The outcome of interest was MRSA bacteremia occurring ≥3 days after admission. This quasi-experimental before-and-after study was conducted from January 2016 to September 2019 with January 2018 excluded as a washout month. Results: In total, 44 observational months (24 months before the intervention 20 months after the intervention) and 4,309 patients were included. In the preintervention period, 12 bacteremia cases occurred among 2,333 patients (0.5%); in the postintervention period, 4 MRSA bacteremia cases occurred in 1,976 patients (0.2%): RR, 0.49 (95% CI, 0.13–1.22), 1-sided P = .07. The rate of MRSA bacteremia was halved, but it did not reach statistical significance due to the small number of cases overall. The products were well tolerated by patients and staff who applied them to nonambulant patients. Conclusions: Octenidine baths and nasal gel reduced risk of MRSA bacteremia in a cohort of MRSA-positive patients, and this strategy may be preferable to the universal use of antiseptic baths.

Funding: None

Disclosures: None

Background: Well-designed infection prevention programs include basic elements aimed at reducing the risk of transmission of infectious agents in healthcare settings. Although most acute-care facilities have robust infection prevention programs, data are sporadic and often lacking in other healthcare settings. Infection control assessment tools were developed by the CDC to assist health departments in assessing infection prevention preparedness across a wide spectrum of health care including acute care, long-term care, outpatient care, and hemodialysis. Methods: The North Carolina Division of Public Health collaborated with the North Carolina Statewide Program for Infection Control and Epidemiology (SPICE) to conduct a targeted number of on-site assessments for each healthcare setting. Three experienced infection preventionists recruited facilities, conducted on-site assessments, provided detailed assessment findings, and developed educational resources. Results: The goal of 250 assessments was exceeded, with 277 on-site assessments completed across 75% of North Carolina counties (Table 1). Compliance with key observations varied by domain and type of care setting (Table 2). Conclusions: Comprehensive on-site assessments of infection prevention programs are an effective way to identify gaps or breaches in infection prevention practices. Gaps identified in acute care primarily related to competency validation: however, gaps presenting a threat to patient safety (ie, reuse of single dose vials, noncompliance with sterilization and/or high-level disinfection processes) were identified in other care settings. Infection control assessment and response findings underscore the need for ongoing assessment, education, and collaboration among all healthcare settings.

Funding: None

Disclosures: None

Background: Surgical site infections (SSIs) are a major cause of morbidity and mortality with an estimated cost of $3–10 billion annually in the United States. Laminar air flow in the operating room (OR) is 1 factor in reducing SSIs. Opening the OR door results in interruption of laminar air flow. As a part of annual infection prevention evaluation of our facility, we observed cases in the OR in which we identified excessive unnecessary door openings during surgical cases. We report an intervention in door openings in the OR and the effect on infection rate after surgery. Methods: We conducted an observational analytical study using prospective audit and feedback. Door-opening counters were placed on 4 OR doors. Each day, they were reset and the number was logged for each case by the circulating nurse. A baseline number of door openings was established between April 18, 2019, and May 2, 2019. Subsequently, daily feedback sheets were provided to all persons involved in the previous day’s procedures detailing the rationale to limit unnecessary door openings and the number of door openings that had occurred during the case(s) in which they were specifically involved from May 3, 2019, to June 4, 2019. Analyses of postoperative infection rates compared with historical controls were conducted. Using Stata version 15 statistical software, independent sample t tests were performed to see the difference between control and intervention groups. A CI 95% was set for significance. Results: There were no differences between control and intervention groups with the number of procedures (71 vs 80), OR, duration of procedure, or type of case. Outliers due to vibration of doors triggering the counters were removed, and door stabilizations were performed throughout the study. After removing outliers, there were no differences in control groups and interventions groups (39 vs 43). An independent sample t test showed a significant difference in the mean number of door openings between the control and intervention groups: 32.13 versus 24.84 (P < .05 and P = .0072). There have been no postoperative infections in any of the cases in the study to date compared to an overall annual rate of 1.5% in 2018 at our facility. Conclusions: Prospective audit and feedback to OR staff can reduce the number of unnecessary door openings during operating procedures. The baseline number of door openings from this study was 25 per case. No postoperative infections occurred in the patients receiving surgery in this study.

Funding: None

Disclosures: None

Background: Surgical site infection (SSI) stands out among healthcare-related infections as one of the most important globally due to its associated morbidity and mortality. However, it is well known that the transoperative period is recognized as one of the most critical moments for the prevention of SSI. Objective: We evaluated the knowledge of the operating room (OR) nurse coordinators regarding SSI prevention measures. Methods: We conducted a cross-sectional study in 30 large hospitals in the state of Minas Gerais, Brazil, from February 2018 to April 2019. Data were collected through interviews with OR nurse coordinators. Results: Administration time of prophylactic antibiotic administered between 30 and 60 minutes prior to surgery was reported by 84% of the professionals and the suspension of this agent in the first 24 hours was reported by 47.8%. Preoperative hair removal within the operating room was mentioned by 60% of respondents and 36.7% mentioned using a razor. The Safe Surgery program of the WHO was unknown to 6.7% of nurses. Among those who knew about it, 20.8% stated that there was no surgical site demarcation. Presentation of the surgical team occurred before the beginning of the procedure in only 53.3% of the institutions. Patient surveillance for SSI was reported by 93.3% of respondents, but the criteria adopted for the diagnosis of SSI were unknown, even though SSI rates were given for 90% of services, predominantly via meetings (53.5%). Conclusions: The knowledge of nurses related to the prevention of SSI was not satisfactory, pointing to the need for immediate efforts in education and awareness programs. Such programs may facilitate changes in practice through the recognition of surgical patient risk by these professionals, thus leading to better planning and practice during the trans-operative period.

Funding: None

Disclosures: None

Background: Successful containment of regional outbreaks of emerging multidrug-resistant organisms (MDROs) relies on early outbreak detection. However, deploying regional containment is resource intensive; understanding the distribution of different types of outbreaks might aid in further classifying types of responses. Objective: We used a stochastic model of disease transmission in a region where healthcare facilities are linked by patient sharing to explore optimal strategies for early outbreak detection. Methods: We simulated the introduction and spread of Candida auris in a region using a lumped-parameter stochastic adaptation of a previously described deterministic model (Clin Infect Dis 2019 Mar 28. doi:10.1093/cid/ciz248). Stochasticity was incorporated to capture early-stage behavior of outbreaks with greater accuracy than was possible with a deterministic model. The model includes the real patient sharing network among healthcare facilities in an exemplary US state, using hospital claims data and the minimum data set from the CMS for 2015. Disease progression rates for C. auris were estimated from surveillance data and the literature. Each simulated outbreak was initiated with an importation to a Dartmouth Atlas of Health Care hospital referral region. To estimate the potential burden, we quantified the “facility-time” period during which infectious patients presented a risk of subsequent transmission within each healthcare facility. Results: Of the 28,000 simulated outbreaks initiated with an importation to the community, 2,534 resulted in patients entering the healthcare facility network. Among those, 2,480 (98%) initiated a short outbreak that died out or quickly attenuated within 2 years without additional intervention. In the simulations, if containment responses were initiated for each of those short outbreaks, facility time at risk decreased by only 3%. If containment responses were initiated for the 54 (2%) outbreaks lasting 2 years or longer, facility time at risk decreased by 79%. Sentinel surveillance through point-prevalence surveys (PPSs) at the 23 skilled-nursing facilities caring for ventilated patients (vSNF) in the network detected 50 (93%) of the 54 longer outbreaks (median, 235 days to detection). Quarterly PPSs at the 23 largest acute-care hospitals (ie, most discharges) detected 48 longer outbreaks (89%), but the time to detection was longer (median, 716 days to detection). Quarterly PPSs also identified 76 short-term outbreaks (in comparison to only 14 via vSNF PPS) that self-terminated without intervention. Conclusions: A vSNF-based sentinel surveillance system likely provides better information for guiding regional intervention for the containment of emerging MDROs than a similarly sized acute-care hospital–based system.

Funding: None

Disclosures: None

Background: Contaminated chlorhexidine produced by a single company has been implicated in the outbreak or pseudo-outbreak of Burkholderia cepacia complex (BCC). However, simultaneous occurrence of multiple brands of contaminated chlorhexidine supplied by different manufacturers resulting in a persistent outbreak for >1 year has not been well described. Objective: We report an outbreak of BCC with epidemiological investigation and using whole-genome sequencing (WGS) analysis of patient and environmental isolates in Hong Kong. Methods: Upon the investigation of a cohort of renal patients undergoing peritoneal dialysis colonized or infected with BCC in their exit sites, different brands of 0.05% aqueous chlorhexidine (aqCHX) used for exit site dressing, supplied from hospital or purchased from community pharmacies by patients, were cultured. A risk factor analysis for exit-site acquisition of BCC was performed. A site visit to a local manufacturer was conducted to investigate the process of production and to collect environmental samples for culture, which were further analyzed by WGS along with the BCC isolates cultured from patients and aqCHX purchased from community pharmacies. Results: Four patients undergoing peritoneal dialysis had cultures positive for BCC in the exit site swab in September 2019. A snapshot screening revealed 88 (32.0%) of 275 renal dialysis patients colonized with BCC. Of these patients, 47 (17.1%) were newly diagnosed and 41 (14.9%) were known to be colonized or infected with BCC according to retrospective data retrieval from January 1, 2018. A significantly greater proportion of patients with newly diagnosed BCC (cases) had used contaminated aqCHX for exit-site dressing than those with culture negative for BCC (controls): 38 of 47 (80.9%) versus 54 of 187 (28.9%) (P < .001). Of 161 aqCHX samples, 10 brands from 4 manufacturers (purchased from community pharmacies), 125 (77.6%) were culture positive for BCC, whereas all 77 aqCHX samples supplied by the hospital, which are different brands and are produced by different manufacturers, were proven to be sterile. Of the 28 environmental samples taken from a local manufacturer during the site visit, 19 samples (67.9%, 3 collected from the instrument for production of aqCHX and all 16 newly produced aqCHX samples) were culture positive for BCC. WGS revealed 3 major clusters characterized by B. cenocepacia genomovar IIIA ST1547 and 2 novel MLST clusters from 52 patients and 26 environmental isolates selected. Conclusions: This outbreak was terminated by product recall, and the government has decided to take regulatory actions to ensure the sterility of antiseptics, including aqCHX.

Funding: None

Disclosures: None

Background: Outbreaks of healthcare-associated infections (HAI) are relevant causes of morbidity and mortality. Healthcare-authorities should monitor them to allow prompt interventions, identify tendencies along the time, and develop large scale strategies to avoid new cases and clusters. According to the Brazilian legislation, any outbreak should be reported to health authorities. Sao Paulo State Health Department (Brazil) has a system in place since 2011 to monitor HAI outbreaks. This study aims at describing the 3.5 last year’s results of surveillance system for monitoring HAI outbreaks. Methods:Study design: Quantitative descriptive study. Source of information: Database from HAI outbreak reports, Division of Hospital Infection at Sao Paulo State Health Department. Reports were filled out online by professionals from healthcare settings or regional health authorities according to predefined criteria. Interventions were put in place by the health authorities based on the analysis of each situation in a timely manner. Variables analyzed: Number of reports, local, infection site, type of care unit, causative microorganisms, number of cases, and number of deaths. Results: The number of reports have been stable for 3 years: 2016 (n = 34, 34.7%), 2017 (n = 28, 28.6%), 2018 (n = 25, 25.5%) and the first semester of 2019 (n = 11, 11.2%). These reports encompassed 712 confirmed cases and 123 deaths. The reports were mainly about infection outbreaks; 6 reports were about colonization of multidrug-resistant microorganisms. The bloodstream was the most frequent infection site in the HAI outbreak reports (n = 37, 37.7%), followed by respiratory tract (n = 25, 25.5%), urinary tract (n = 10, 10.2%), and surgical wound (n = 9, 9.2%). HAI outbreaks happened more frequently in intensive care units, including neonatal, pediatric, and adult ICUs (n = 38, 38.8%), followed by clinical and general wards (n = 20, 20.4%), hemodialysis (n = 6, 6.1%), and surgical wards (n = 5, 5.1%). Among reported outbreaks, 62.2% occurred in the capital and the metropolitan region of São Paulo. Microorganisms causing the HAI outbreaks reports were mainly carbapenem resistant, both Klebsiella pneumoniae (n = 28, 28.5%) and Acinetobacter baumannii (n = 12, 12.2%), but carbapenem-susceptible Pseudomonas aeruginosa (n = 7, 7.1%) was also reported. Conclusions: HAI outbreaks reported to health authorities in Sao Paulo may represent only a minute percentage of the total outbreaks, most of which are still not being reported, despite the normative. However, the available data emphasize the importance of developing strategies for intensive care units and hemodialysis units that focus on reducing bloodstream infections caused by multidrug-resistant gram-negative organisms.

Funding: None

Disclosures: None

Background: Empiric therapy with a cephalosporin antibiotic is the current standard of care for children with urinary tract infections (UTIs). However, as the rate of UTI due to extended-spectrum β-lactamase (ESBL)–producing organisms rises, there is concern that treatment failures may increase. Carbapenems are the most reliable antimicrobials for treating ESBL organisms, but empiric coverage with carbapenems necessitates hospitalization for intravenous therapy. Objective: We evaluated whether empiric noncarbapenem therapy in patients with ESBL Escherichia coli UTI is associated with poorer outcomes. Methods: We conducted a case-control study of patients with UTIs treated with empiric penicillin- or cephalosporin-based antibiotics from January 1, 2017, to December 31, 2018. We compared outcomes in cases with ESBL E. coli UTI with age-matched controls with a cephalosporin-susceptible E. coli UTI. Logistic regression was used to compare the odds of clinical failure (persistent symptoms and/or fever) at 48–72 hours. We further evaluated the odds of hospitalization and UTI recurrence between groups. Results: Of the 228 enrolled patients, 51 were cases and 177 controls. Cases were more likely to have underlying medical conditions (45% vs 21%). The odd ratio of clinical failure at 48–72 hours after initiation for cases compared to controls was 4.83 (95% CI, 0.94–24.92; P = .06). These odds were was not influenced by age, presence of an underlying medical condition, or fever. The overall adjusted odd ratio of hospitalization for cases compared to controls was 12.09 (95% CI, 0.995–4.38, P = .052). Most patients admitted at presentation had an underlying medical condition (30 of 64, 47%) and/or fever (54 of 64, 84%). Among 30 cases initially managed as outpatients, only 2 (7%) were later admitted due to clinical failure. There was no difference in the likelihood of UTI recurrence within 60 days for the 2 groups (adjusted OR, 1.34; 95% CI, 0.47–3.78; P = .58). Conclusions: At 48–72 hours, there was no significant difference in the odds of clinical failure for patients with ESBL E. coli UTI compared to patients with non-ESBL E. coli UTI receiving empiric noncarbapenem therapy. Although we detected a trend toward a higher odds of hospitalization among cases, this result was largely due to a higher clinical complexity among cases at baseline. Only 2 cases required admission for failure of outpatient therapy. There was no increased risk of UTI recurrence among cases. This study suggests that initial discordant antibiotic therapy may not increase the risk of a poor outcome in children with ESBL E. coli UTI.

Funding: None

Disclosures: None

Background: The rising prevalence of infections caused by extended-spectrum β-lactamase (ESBL)–producing bacteria increases reliance on carbapenems, which intensifies selection pressure for the emergence of carbapenem-resistant Enterobacteriaceae (CRE). Whether noncarbapenem (nC) antibiotics can be safely used in this setting remains incompletely understood. Objective: To examine the safety of carbapenem stewardship in this population, we compared outcomes of uncomplicated ESBL bacteremia treated with a carbapenem to those treated with a noncarbapenem regimen. Methods: A retrospective chart review of patients with ESBL bacteremia from 2014 to 2018 in a 5-hospital regional health system was conducted. Patients aged <18 years, with polymicrobial bacteremia, whose infections required a prolonged length of antibiotic therapy (LOT), or who died on antibiotic treatment or transitioned to hospice, were excluded. Groups were stratified based on the antibiotic regimen with the highest number of treatment days during the treatment course. Outcome measures included empiric and definitive length of therapy (LOT), 30-day all-cause mortality, 90-day readmission, recurrence of ESBL bacteremia, hospital length of stay (LOS), incidence of Clostridioides difficile infection (CDI) and adverse drug events, obtained by Wilcoxon rank-sum testing, χ2 test, and Fisher exact test, as applicable. Results: In total, 112 unique patients had ESBL bacteremia; 42 were excluded, leaving 70 for analysis. Of these, 57 were treated with a carbapenem regimen and 13 patients were treated with a noncarbapenem regimen: 9 ciprofloxacin, 3 gentamicin, 1 TMP-SMX. Patient baseline and antibiotic regimen characteristics were similar (Table 1). The most common organism was E. coli, and the most common source was urinary. A similar proportion of each group received ESBL-active empiric antibiotics. There were no significant differences in total effective antibiotic LOT, 30-day all-cause mortality, 90-day readmission, or recurrence of ESBL bacteremia (Table 2). A nonsignificant trend in hospital LOS was observed in the noncarbapenem group (11 vs 6 days; P = .055). Conclusions: Although the sample size was small, these multicenter data suggest that noncarbapenem treatment of ESBL bacteremia may be safe and effective. Pending confirmatory studies, ESBL bacteremia may be an important target for carbapenem stewardship.

Funding: None

Disclosures: None

Background: Data from Clostridium difficile infection (CDI) in neutropenic patients are still scarce. Objective: To assess outcomes of CDI in patients with and without neutropenia. Methods: The study included a retrospective cohort of adult patients at 3 academic hospitals between January 2013 and December 2017. The 2 study arms were neutropenic patients (neutrophil count <500/mm3) and nonneutropenic patients with confirmed CDI episodes. The primary outcome evaluated the composite end point of all-cause in-hospital mortality, intensive care unit (ICU) admissions, and treatment failure at 7 days. The secondary outcome evaluated hospital length of stay. Results: Of 962 unique cases of CDI, 158 were neutropenic (59% men) and 804 were nonneutropenic (46% men). The median age was 57 years (IQR, 44–64) in the neutropenic group and 68 years (IQR, 56–79) in the nonneutropenic group. The median Charlson comorbidity score was 5 (IQR, 3–7.8) and 4 (IQR, 3–5) in the neutropenic and nonneutropenic groups, respectively. Regarding severity, 88.6% versus 48.9% were nonsevere, 8.2% versus 47% were severe, and 3.2% versus 4.1% were fulminant in the neutropenic and nonneutropenic groups, respectively. Also, 63% of patients (60.9% in nonneutropenic, 65.2% in neutropenic) were exposed to proton-pump inhibitors. A combination CDI treatment was required in 53.2% of neutropenic patients and 50.1% of nonneutropenic patients. The primary composite end point occurred in 27% of neutropenic patients versus 22% of nonneutropenic patients (P = .257), with an adjusted odds ratio of 1.30 (95% CI, 0.84–2.00). The median hospital length of stay after controlling for covariates was 21.3 days versus 14.2 days in the neutropenic and nonneutropenic groups, respectively (P < .001). Complications (defined as hypotension requiring vasopressors, ileus, or bowel perforation) were seen in 6.0% of the nonneutropenic group and 4.4% of the neutropenic group (P = .574), with an adjusted odds ratio of 0.61 (95% CI, 0.28–1.45). Conclusions: Neutropenic patients were younger and their cases were less severe; however, they had lower incidences of all-cause in-hospital mortality, ICU admissions, and treatment failure. Hospital length of stay was significantly shorter in the neutropenic group than in the nonneutropenic group.

Funding: None

Disclosures: None

Background: Hospital-acquired influenza (HA flu) lacks a consensus definition. However, it is known to be associated with increased inpatient morbidity and mortality. Objective: To describe the clinical course of HA flu in a cohort population. Methods: A retrospective cohort study was conducted at a tertiary-care adult and pediatric teaching hospital. Patients with HA flu during 3 seasons, 2016 through 2019, were identified from medical record information based on timing of the onset of signs and symptoms and positive virologic testing >72 hours after admission. Influenza infection was confirmed by multiplex respiratory PCR, influenza A/B PCR, or direct fluorescent antibody tests. Chart review was performed to abstract patient demographics and comorbidities, length of stay, testing, and timing to antiviral administration as well as diagnosis of pneumonia, coinfections, and 30-day mortality. Escalation of care during hospitalization was defined as a new requirement of supplemental oxygen, invasive or noninvasive ventilation, and transfer to an intensive care unit. Results: During the 3 flu seasons, 132 patients were identified with HA flu; 76 (58%) were women, 6 (4.6%) were aged <18 years, and 126 (95.4%) were adults. Annually, HA-flu patients accounted for 5%–7.8% of all patients hospitalized with laboratory-proven influenza. The median duration between hospitalization and positive flu test was 15 days, and the median length of stay after influenza diagnosis was 6 days. Antiviral treatment was received by 96% of the patients. In total, 41 patients (31%) showed radiographic evidence for pneumonia. Coinfection with either a viral or bacterial pathogen was identified in 25% of the cases. In addition, 26% of the patients experienced an escalation of care, and 20 patients (15%) were transferred to the intensive care unit after HA flu diagnosis. Furthermore, 4 deaths (3%) were attributed to influenza during their hospitalization. Conclusions: HA flu was a frequent cause for escalation in care and was associated with a mortality rate substantially higher than is typically seen in community-based populations with influenza. Coinfection was mostly related to bacteremia and pneumonia, yet not all pneumonias had an associated microbiological diagnosis other than influenza, and there was no significant association between coinfection and mortality. Future work should explore more precise definitions for HA flu as well as its complications.

Funding: None

Disclosures: None

Background: Rapid diagnostic tests designed to provide bacterial identification and detection of resistance genes directly from positive blood cultures can significantly reduce the time to definitive results, ensuring appropriate and timely antibiotic administration while simultaneously decreasing antibiotic overuse and development of antimicrobial resistance. However, their impact on in-hospital mortality and length of stay (LOS) is yet to be fully assessed. Methods: We retrospectively reviewed bacteremia cases in patients hospitalized over a 6-month period before (n = 78) and after (n = 93) the implementation of Verigene bacterial nanoparticle testing. Exclusion criteria included age >90 years, bacteremia thought to be a contaminant, polymicrobial bacteremia, or hospice admission. Verigene was performed at a central laboratory from 6 a.m. to 11 p.m. Pharmacists notified physicians of results and assisted with antibiotic modifications. Patient demographics, time to organism identification, time to effective antimicrobial therapy, and other key clinical parameters were compared. The primary outcomes were in-hospital LOS, 14-day mortality, and 30-day mortality. Secondary outcomes included time to effective antibiotic therapy and intensive care unit (ICU) LOS. Results: Organism identification was achieved more quickly (4.9 hours vs 44.5 hours; P < .001) and effective antibiotic therapy was started earlier after Verigene implementation. The mean in-hospital LOS decreased from 13.15 days to 10.02 days (P = .0071) after the Verigene intervention, despite a higher mean Charlson comorbidity index among the cases. Mortality was similar between groups. Conclusions: Rapid identification of gram-positive and gram-negative bacteremia with an antimicrobial stewardship intervention can decrease time to effective antibiotic therapy and total LOS.

Funding: None

Disclosures: None

Background: Fluoroquinolones (FQs) are one of the most commonly prescribed antibiotic classes in the United States. In recent years, their widespread use has come under heightened scrutiny due potential adverse drug reactions including risks of mental health side effects, serious blood sugar disturbances, and Food and Drug Administration (FDA) black-box warnings for tendinopathy, aortic aneurysm, and dissection. These warnings prompted the Department of Veterans Affairs Pharmacy Benefits Management Service to perform a nationwide FQ utilization review, which identified our facility for potential overuse of FQs in the outpatient setting: 82.2 prescriptions per 1,000 unique patients compared to an average of 48 prescriptions per 1,000 unique patients across all VHA facilities. We then embarked on a FQ medication use evaluation (MUE). Objective: To determine appropriateness of FQ prescribing practices in the outpatient setting. Methods: The study setting was a 399-bed tertiary-care Veterans Hospital with >250 affiliated outpatient clinics in Richmond, Virginia. A retrospective chart review was conducted on a convenience sample of consecutive patients prescribed an FQ from each quarter between April 1, 2018, and March 31, 2019. Chart review included patient demographics, location, FQ used, dose, indication, appropriateness, prescriber, and documentation of patient counseling on FDA black box warnings. Appropriate treatment was defined by national and local antimicrobial therapy guidelines. Results: In total, 265 patients were included the study. Among them, 233 patients (88%) were men and the mean age was 68 years. Overall, 127 patients (48%) were prescribed FQs inappropriately. Primary care clinics and the emergency department (ED) had the highest frequency of inappropriate FQ prescriptions (Fig. 1). Moreover, 92 patients (35%) were prescribed FQs for surgical prophylaxis prior to urological procedures. FQs were most commonly inappropriately prescribed for urinary tract infection (UTI, n =74, 84%) and upper respiratory tract infection (URI, n=27, 84%) (Fig. 2). Documented counseling on FDA black box warnings occurred in 82 cases (31%). Conclusions: In our MUE, outpatient prescribing of FQs was inappropriate nearly 50% of the time. The most commonly documented indications for FQs determined to be inappropriate included UTI and URI. Inappropriate prescriptions most commonly originated from primary care and the emergency department. Urology had the highest volume of FQ prescriptions, which were mostly appropriate surgical prophylaxis based on indication (though an alternative agent would be preferred based on local resistance rates). Documentation of patient counseling for FDA black-box warnings on FQs was uncommon.

Funding: None

Disclosures: None