Background: Antimicrobial stewardship programs (ASPs) seek to reduce the prevalence of antimicrobial-resistant and healthcare-associated infections. There are limited infectious disease (ID) physicians and pharmacists to support these ASPs, particularly in rural areas. The Veterans Health Administration has a robust telehealth program in place. Our previous work has demonstrated the feasibility of using telehealth modalities to support ASPs at rural Veterans Affairs medical centers (VAMCs) by pairing them with an ID expert from a larger, geographically distant, VAMC. This program, dubbed the Videoconference Antimicrobial Stewardship Team (VAST), emphasizes discussion of patients undergoing treatment for an active infection and additional relevant clinical topics with a multidisciplinary team at the rural VA. VAST implementation is ongoing at VAMCs. To understand and compare the qualitative differences in implementation, we used process maps to describe the VAST at 3 VAMC dyads. Methods: Team members from each dyad participated in interviews at 3, 6, and 9 months after beginning their VAST sessions. Questions addressed several aspects of VAST implementation and included identifying cases and topics to discuss; advance preparation for meetings; the frequency and general structure of VAST meetings; and documentation including workload capture. The research team used the responses to develop process maps to permit visual display and comparison of VAST implementation. Results: The first dyad began in January 2022 and the third in March 2022. The sessions had 3 phases: preparation, team meeting, and documentation of experts’ recommendations. Tasks were shared between VAST champions at the rural VAMC and the ID experts (Fig. 1). The preparation phase showed the most variation among the 3 dyads. In general, champions at the rural VA identified cases and topics for discussion that were sent to the ID expert for review. The approaches used to find cases and the type of preparatory work by the ID expert differed. Team meetings differed in both frequency and participation by professionals from the rural site. Documentation of expert recommendations processes appeared similar among the dyads. Discussion: Each of the 3 dyads implemented VAST differently. These results suggest that the overall structure of the VAST is readily adaptable and that each site tailored VAST to suit the clinical needs, workflow, and culture of their partner facility. Future work will seek to determine which aspects in the preparation, team meeting, or documentation phases are associated with successful ASPs, including assessment of quantitative and qualitative outcomes.

Disclosures: None

Background: Burkholderia cepacia complex is an opportunistic environmental pathogen that has been linked to nosocomial outbreaks. We describe an outbreak of bacteremia caused by Burkholderia cenocepacia from a contaminated chlorhexidine gluconate solution. Methods: The hospital infection control team carried out an outbreak investigation on February 21, 2021, when 3 adult hemodialysis patients developed B. cenocepacia bacteremia. Patient demographics and clinical profile were reviewed retrospectively. Potential sources of infection were identified, and environmental screening was performed in several units. Processes of catheter care in the hemodialysis unit were reviewed. Water samples from the hemodialysis unit, and samples of solutions used in patient care were sent for culture. Isolates from patients and from environmental samples were sent for 16S rRNA gene sequencing to determine genetic relatedness. Results: In total, 16 patients, 8 of whom were male, developed B. cenocepacia bacteremia during the investigated period. The median age was 68 years (range, 19–83), and 15 of 16 had at least 1 comorbidity. All patients used a central venous catheter (CVC) for hemodialysis, and 11 (70%) of these 16 were temporary. Chlorhexidine gluconate solution was routinely used as part of CVC care and 1 bottle was shared among 4 hemodialysis stations. On suspicion of contamination, all identified chlorhexidine bottles were recalled on February 26, 2021, and random samples from 15 opened and 19 unopened bottles were sent for culture from the following units: hemodialysis (n = 2), ICU (n = 14), wards (n = 6), and 4 each from transplant surgery, and delivery suites. O0f 34 sampled bottles, 17 grew B. cenocepacia: 8 opened and 9 unopened bottles. The Bayesian inference tree (Fig. 1) supports the hypothesis that patient samples and the samples from the chlorhexidine solutions were most probably related to each other based on the 16S rRNA sequences. However, the individual identities of the specific sample sequences could not be determined using the analyzed region of the gene, possibly due to low quality of the sequences received. No new cases of B. cenocepacia were identified after recall of the chlorhexidine solution, and the outbreak was deemed resolved on March 24, 2021. Conclusions: Medical solutions routinely used in patient care can cause outbreaks and should be suspected as a potential source of infection by infection control teams.

Disclosures: None

Background: The NHSN Antimicrobial Resistance (AR) Option is an important avenue for acute-care hospitals to electronically report facilitywide antibiogram data. The NEDSS Base System (NBS) is the statewide surveillance system for mandatory reporting of all carbapenem-resistant Enterobacteriaceae (CRE) cases. The state health department (SHD) validated CRE case data reported through the AR Option to assess completeness and accuracy. Methods: NHSN AR Option data from July 2020–December 2021 for 24 facilities were validated by comparing reported CRE and susceptibility results to CRE isolates reported via the NBS. Isolates were matched based on specimen date, sex, birth month and day, pathogen, and specimen source. NHSN susceptibility results were dichotomized as “not resistant” and “resistant” to match the NBS results. Susceptibility discordance (differing proportions of resistant isolates) of matched pairs were evaluated using the McNemar exact test in SAS version 9.4 software. Results: The SHD identified 270 CRE cases from the NHSN and 1,254 unique CRE isolates from the NBS. Of the NHSN events, 72 (26.67%) were matched to the NBS. Among matched isolates, discordance was significant for doripenem (0 resistant isolates in the NHSN vs 13 in the NBS; P < .001) and imipenem (5 resistant isolates in the NHSN vs 23 in the NBS; P < .0001). Discordance was not significant for ertapenem nor meropenem. Sensitivity analyses maximized the match rate at 30.74% (83 matches) when NBS isolates from unknown sources were included and matching factors were specimen date and date of birth ± 1 day, and pathogen. Among all 6,325 CRE isolates in NBS, 290 (4.58%) did not have a specimen source provided. Of all 47,348 NHSN events, 7,624 (16.10%) had impossible patient birthdays. Conclusions: Many NHSN isolates could not be matched to NBS due to either isolates being missing from NBS or to data differences across the systems. This mismatch highlights the need for data validation and standardization at the point of entry for both systems. Discordant susceptibility outcomes raise concerns about using the NHSN as a method for facility and regional antibiogram data.

Disclosures: None

Background: Considering the threat of antimicrobial resistance (AMR), Ethiopia implemented strategies to combat AMR, including partnering with the American Society for Microbiology (ASM) to conduct an AMR training program using the Project ECHO learning platform. ECHO AMR was used to virtually connect subject-matter experts with participating sentinel laboratories in remote locations to provide ongoing education, telementoring, and foster peer-to-peer learning and problem-solving in microbiology. In phase 1, the ASM had primary leadership in conducting sessions and project administration. In phase 2, roles and responsibilities transitioned from the ASM to the Ethiopian Public Health Laboratory (EPHI) with support from ECHO India. Here we describe the transition process and lessons learned. Methods: From December 2020–2021, biweekly 1-hour sessions were conducted for 8 sentinel laboratories. Each virtual session included a lecture led by a subject-matter expert, a case presentation by a participating laboratory, open discussion, and feedback via an end-of-session online survey. Following a transition plan, initial ASM-EPHI transition activities included formal administrative and logistical training, including participation in a 3-day Project ECHO-immersion program provided by ECHO India. Selected administrative and technical roles and responsibilities, including further developing their own SMEs, were transitioned from ASM to EPHI every 4 sessions. ASM conducted postsession reviews with EPHI and ECHO India to discuss successes and suggested improvements. Results: Leadership of ECHO AMR was fully transitioned to EPHI over 12 months. End-of-session surveys and postsession reviews indicated the transition process was successful, with EPHI staff leading the lectures, session coordination, and facilitation, and positive feedback from session participants. Challenges included variable sentinel site participation due to competing priorities such as COVID-19 testing and poor internet connectivity during the rainy season. Lessons learned included the need to use a gradual transition strategy with close monitoring, training facilitators to maintain implementation fidelity (level of reproducibility to conduct ECHO AMR as in phase 1) and improve participation, and assessing individual learning, using pretests and posttests. Recommendations included that ASM should remain as an external technical advisor to ensure program technical depth and session facilitators be trained to improve participation in the discussions. Implementation fidelity compared to phase 1 was considered moderate, with the gap primarily due to the need for dedicated release time from laboratory duties to ensure session leadership, coordination, and facilitation. Conclusions: Leadership and laboratory workforce capacity-building responsibility for AMR training was successfully transitioned from ASM to EPHI, promoting self-sufficiency in training and with far-reaching benefits in the global fight against AMR.

Disclosures: None

Background: Healthcare settings without access to infectious diseases experts may struggle to implement effective antibiotic stewardship programs. We previously described a successful pilot project using the Veterans Affairs (VA) telehealth system to form a Videoconference Antimicrobial Stewardship Team (VAST) that connected multidisciplinary teams from rural VA medical centers (VAMCs) with infectious diseases experts at geographically distant locations. VASTs discussed patients from the rural VAMC, with the overarching goal of supporting antibiotic stewardship. This project is currently ongoing. Here, we describe preliminary outcomes describing the cases discussed, recommendations made, and acceptance of those recommendations among 4 VASTs. Methods: Cases discussed at any of the 4 participating intervention sites were independently reviewed by study staff, noting the infectious disease diagnoses, recommendations made by infectious diseases experts and, when applicable, acceptance of those recommendations at the rural VAMC within 1 week. Discrepancies between independent reviewers were discussed and, when consensus could not be reached, discrepancies were discussed with an infectious diseases clinician. Results: The VASTs serving 4 different rural VAMCs discussed 96 cases involving 92 patients. Overall, infection of the respiratory tract was the most common syndrome discussed by VASTs (Fig. 1). The most common specific diagnoses among discussed cases were cellulitis (n = 11), acute cystitis (n = 11), wounds (n = 11), and osteomyelitis (n = 10). Of 172 recommendations, 41 (24%) related to diagnostic imaging or laboratory results and 38 (22%) were to change the antibiotic agent, dose, or duration (Fig. 2). Of the 151 recommendations that could be assessed via chart review, 122 (81%) were accepted within 1 week. Conclusions: These findings indicate successful implementation of telehealth to connect clinicians at rural VAMCs with an offsite infectious diseases expert. The cases represented an array of common infectious syndromes. The most frequent recommendations pertained to getting additional diagnostic information and to adjusting, but not stopping, antibiotic therapy. These results suggest that many of the cases discussed warrant antibiotics and that VASTs may use the results of diagnostic studies to tailor that therapy. The high rate of acceptance suggests that the VASTs are affecting patient care. Future work will describe VAST implementation at 4 additional VAMCs, and we will assess whether using telehealth to disseminate infectious diseases expertise to rural VAMCs supports changes in antibiotic use that align with principles of antimicrobial stewardship.

Disclosures: None

Background: Respiratory tract infections (RTIs) in long-term care facilities (LTCFs) are particularly burdensome among residents, the COVID-19 pandemic highlighted the devastating consequences of RTIs in LTCFs. This situation has prompted the need for LTCFs to have a robust, active surveillance system to assist LTCFs with RTI identification. Such a system could assist with faster implementation of appropriate antimicrobial therapy and critical infection prevention and control. The TN Emerging Infections Program worked with CDC EIP to implement a pilot project to test the feasibility of performing RTI surveillance to inform future changes to NHSN. Methods: We recruited 6 LTCFs to collect prospective RTI surveillance for 6 consecutive months from October 2021 through March 2022. Data were collected for all residents meeting the RTI surveillance definitions: pneumonia, lower respiratory tract infection, influenza-like illness (including influenza), and COVID-19. These data were entered by facility workers into a REDCap database with a prospective RTI LTCF event form. Monthly data collection summaries were submitted using a designated denominator form. Descriptive statistics were used to analyze RTI data, and analyses were performed using SAS version 9.4 software. Results: In total, 6 facilities participated in the pilot project during the capture period. The total number of RTI cases across all facilities was 195. December had the most cases (n = 50). The most common first triggers were new RTI signs or symptoms (67.69%), laboratory results (17.44%), imaging findings (6.67%), and clinician-diagnosed RTI (8.21%). The most reported symptom was new or increased cough (57.44%). Chest radiographs were performed for 50.77% of patients. Positive viral laboratory test results were documented 29.74% of the time. Antibiotic treatments were given to 70.77% of residents. The most commonly prescribed antibiotics were cephalosporins (22.56%), macrolides (17.95%), fluoroquinolones (12.31%), and doxycycline (9.23%). Also, 17.4% of cases with antibiotic regimens had cephalosporins as monotherapy. Vaccine documentation was as follows: influenza 2020–2021 (40.51%), influenza 2021–2022 (64.1%), complete COVID-19 vaccine series (82.56%), PPSV-23 vaccine (33.85%), and PCV-13 (23.59%). Conclusions: RTI surveillance was incorporated smoothly into the daily workflow for facilities; the biggest barrier to effective implementation was staff turnover. A scheduled weekly time to collect data and fill out forms proved most effective. A high percentage of cases was treated with cephalosporins as monotherapy, which, based on the latest guidelines, may be suboptimal. Individual reports were sent back to facilities with a comparison to the aggregated data. These data will be used to evaluate antibiotic appropriateness and to guide future RTI surveillance efforts in the LTCF setting.

Disclosures: None

Background: Statistically significant decreases in methicillin-resistant Staphylococcus aureus (MRSA) healthcare-associated infections (HAIs) occurred in Veterans Health Administration (VA) facilities from 2007 to 2019 using active surveillance for facility admissions and contact precautions for patients colonized (CPC) or infected (CPI) with MRSA, but the value of these interventions is controversial. Objective: To determine the impact of active surveillance, CPC, and CPI on prevention MRSA HAIs, we conducted a prospective cohort study between July 2020 and June 2022 in all 123 acute-care VA medical facilities. In April 2020, all facilities were given the option to suspend any combination of active surveillance, CPC, or CPI to free up laboratory resources for COVID-19 testing and conserve personal protective equipment. We measured MRSA HAIs (cases per 1,000 patient days) in intensive care units (ICUs) and non-ICUs by the infection control policy. Results: During the analysis period, there were 917,591 admissions, 5,225,174 patient days, and 568 MRSA HAIs. Only 20% of facilities continued all 3 MRSA infection control measures in July 2020, but this rate increased to 57% by June 2022. The MRSA HAI rate for all infection sites in non-ICUs was 0.07 (95% CI, 0.05–0.08) for facilities practicing active surveillance plus CPC plus CPI compared to 0.12 (95% CI, 0.08–0.19; P = .01) for those not practicing any of these strategies, and in ICUs the MRSA HAI rates were 0.20 (95% CI, 0.15–0.26) and 0.65 (95% CI, 0.41–0.98; P < .001) for the respective policies. Similar differences were seen when the analyses were restricted to MRSA bloodstream HAIs. Accounting for monthly COVID-19 admissions to facilities over the analysis period using a negative binomial regression model did not change the relationships between facility policy and MRSA HAI rates in the ICUs or non-ICUs. There was no statistically significant difference in monthly facility urinary catheter-associated infection rates, a nonequivalent dependent variable, in the categories during the analysis period in either ICUs or non-ICUs. Conclusions: In Veterans Affairs medical centers, there were fewer MRSA HAIs when facilities practiced active surveillance and contact precautions for colonized or infected patients during the COVID-19 pandemic. The effect was greater in ICUs than non-ICUs.

Disclosures: None

Objectives: To address the importation of multi-drug-resistant organisms (MDROs) when a colonized or infected patient is transferred from another VA facility, the Veterans Health Administration (VHA) launched the Inpatient Pathogen Tracker (IPT) in 2020. IPT tracks MDRO-infected/colonized patients and alerts MDRO Program Coordinators (MPCs) and Infection Preventionists (IPs) when such patients are admitted to their facility to facilitate rapid identification and isolation of infected/colonized patients. IPT usage has been low during initial rollout (32.5%). The VHA and the CARRIAGE QUERI Program developed targeted implementation strategies to increase utilization of IPT’s second iteration, VA Bug Alert (VABA). Methods: Familiarity with IPT was assessed via pre-education survey (3/2022). All sites received standard VABA implementation including: 1) adaptation of VABA features based on end-user feedback (completed 4/2022), 2) development and delivery of an educational module regarding the revised tool (completed 4/2022), and 3) internal facilitation from the VHA MDRO Program Office (ongoing) (see Figure for all key timepoints). Intent to register for VABA was assessed via post-education survey (4-5/2022). Sites (125 eligible) not registered for VABA by 6/1/2022 were randomly assigned to receive one of two conditions from 6/2022–8/2022: continued standard implementation alone or enhanced implementation. Enhanced implementation added the following to standard implementation: 1) audit and feedback reports and 2) external facilitation, including interviews and education about VABA. We compared the number of sites with ≥1 MPC/IP registered for VABA to-date between implementation conditions. Results: Pre-education survey. 168 MPC/IPs across 117 sites responded (94% of eligible sites). Among respondents, 25% had used IPT, 35.1% were familiar with but had not used IPT, and 39.9% were unfamiliar with IPT. Post-education survey. 93 MPC/IPs across 80 sites responded (59% of eligible sites). Of these, 81.7% said they planned to register for VABA, 4.3% said they would not register, and 14.0% said they were unsure. Post-6/1/2022 Registrations. By 6/1/2022, 71% of sites had ≥1 registered VABA user. Of the 28 unregistered sites eligible for enhanced implementation, thirteen were assigned to receive enhanced implementation, and fifteen were assigned to receive continued standard implementation. Eight sites in the enhanced implementation condition (61.5%) registered for VABA. Seven standard-implementation-only sites (46.7%) registered. The number of registered sites did not significantly differ by implementation condition (Fisher’s exact p=0.476). Conclusions: Standard and enhanced implementation were equally effective at encouraging VABA registration, suggesting that allocating resources to enhanced implementation may not be necessary.

Disclosures: None.

Background: Antimicrobial resistance (AMR) presents a global health threat. Training laboratory technicians to accurately identify and report AMR is critical in low- and middle-income countries (LMICs) to control the spread of AMR. Ethiopia and Kenya implemented a telementoring program, ECHO AMR, via the Project ECHO learning platform to improve laboratory technician capacity to isolate, identify, and report AMR organisms; to perform antimicrobial susceptibility testing (AST); and to develop a community of learning. Between January 2018 and January 2022, biweekly 1-hour sessions were held for 8 and 22 laboratories averaging 19 or 43 participants per session in Ethiopia and Kenya, respectively. Each session included a lecture, a laboratory challenge case presentation, and discussion. An evaluation was conducted to assess perceived strengths and weaknesses of the program and its usefulness in improving bacteriology capacity. Methods: In July–August 2022, semistructured key informant interviews of purposively and randomly selected laboratorians were conducted to understand participant perspectives of ECHO AMR, including session structure and content, changes in laboratory performance, and the virtual learning platform. Eligible participants attended at least one-third of available sessions in Ethiopia (8 of 26 sessions) or Kenya (5 of 16 sessions) during 2021. Key informant interviews were transcribed and systematically reviewed to identify key themes. Results: In total, 22 laboratory technicians participated in the key informant interviews: 12 in Ethiopia and 10 in Kenya. Participants reported that the ECHO AMR session structure was well organized but recommended increasing session duration to allow more time for discussion. Technical content was presented at an appropriate level and was highly rated. However, participants suggested including more subject-matter experts to provide the lectures. All participants reported positive change in laboratory practice, including implementation of international standards for AST, better quality control, improved confidence and critical thinking, and increased AMR awareness and reporting. Participants learned well in the virtual environment, with the platform providing wide-ranging geographic interactions to share skills and knowledge among sites without travel. However, there were connectivity issues, competing work priorities during sessions, and a lack of dedicated space for team participation. Conclusions: Laboratory technicians reported that virtual laboratory training was well-received, efficient, and impactful. Participants benefited both individually and collectively, as a laboratory. Suggested improvements included increasing session duration, connectivity support, and including more subject-matter experts to broaden technical content. Further assessment is needed to evaluate the ECHO AMR’s impact on laboratory practices through observation and laboratory data. Virtual programs, requiring less time and resources than traditional in-country trainings, can be optimized and used to share and increase bacteriology knowledge in LMICs.

Disclosures: None

In discussing the relationship between genetically influenced differences and educational attainment (EA), Burt employs the concept of downward causation. I note the similarities between Burt's concept of downward causation and the sociogenomics concept of vertical pleiotropy and argue that her discussion of downward causation introduces an unnecessary normative component. The core problem concerns not the appropriateness of phenotypes that influence EA but mistaken assumptions about which phenotypes are being predicted.

The present work discusses the use of a weakly-supervised deep learning algorithm that reduces the cost of labelling pixel-level masks for complex radio galaxies with multiple components. The algorithm is trained on weak class-level labels of radio galaxies to get class activation maps (CAMs). The CAMs are further refined using an inter-pixel relations network (IRNet) to get instance segmentation masks over radio galaxies and the positions of their infrared hosts. We use data from the Australian Square Kilometre Array Pathfinder (ASKAP) telescope, specifically the Evolutionary Map of the Universe (EMU) Pilot Survey, which covered a sky area of 270 square degrees with an RMS sensitivity of 25–35 $\mu$Jy beam$^{-1}$. We demonstrate that weakly-supervised deep learning algorithms can achieve high accuracy in predicting pixel-level information, including masks for the extended radio emission encapsulating all galaxy components and the positions of the infrared host galaxies. We evaluate the performance of our method using mean Average Precision (mAP) across multiple classes at a standard intersection over union (IoU) threshold of 0.5. We show that the model achieves a mAP$_{50}$ of 67.5% and 76.8% for radio masks and infrared host positions, respectively. The network architecture can be found at the following link: https://github.com/Nikhel1/Gal-CAM

This keyword essay establishes the significance of international law for the study of Victorian globalization. The history of international law has not really been registered yet by scholars in Victorian studies, but we might obtain a number of dividends by remedying that deficit.