Background: In 2020, the American Society of Health System Pharmacist (ASHP) and Infectious Diseases Society of America (IDSA) published a consensus guideline for vancomycin management, recommending area under the curve (AUC) as the preferred monitoring strategy. These guidelines recommend doses of 15-20 mg/kg every 8 to 12 hours for most patients with normal renal function. However, in extreme body weights, standard dosing may deviate to provide a therapeutic AUC. The primary objective of this pharmacokinetic study is to evaluate the optimal vancomycin weight-based dosing strategy that achieves a therapeutic AUC of 400-600 stratified by body mass index (BMI). The secondary objective is to evaluate the incidence of acute kidney injury (AKI) based on BMI. Methods: Patients were identified from two sites within the Department of Veterans Affairs who received vancomycin for at least 48 hours and had at least one steady-state level from January 2015 through July 2022. Regimens with a frequency of ≤8 hours or patients with baseline creatine clearance of < 5 0 ml/min were excluded. Patients were categorized based on the Center for Disease Control BMI groups: healthy weight, overweight, or obese. The online vancomycin calculator, VancoPK©, was utilized to calculate AUC. Renal function at baseline and during vancomycin therapy was collected. Descriptive statistics were used for data analysis. Continuous outcomes were summarized using mean and standard deviation. The primary and secondary endpoints were analyzed using the analysis of variance and Fisher’s exact tests, respectively. Statistical significance was established at a p-value of < 0 .05. Results: A total of 347 unique vancomycin regimens were included: 120 in the healthy weight group, 101 in the overweight group, and 126 in the obese group. The average total daily doses that achieved a therapeutic AUC were 1971mg (15.6mg/kg/dose), 2298mg (15mg/kg/dose), and 2524mg (12.6mg/kg/dose) for the healthy weight, overweight, and obese groups, respectively. There was a statistically significant difference among these groups. AKI occurred in 10/254 (3.9%) unique patients: 2/89 (2.2%) in the healthy weight group, 3/71 (4.2%) in the overweight group, and 5/94 (5.3%) in the obese group. This did not reach statistical significance. Conclusions: Vancomycin dosing regimens largely followed guideline recommendations. However, the average vancomycin mg/kg/dose that achieved a therapeutic AUC decreased as BMI increased, which was a statistically significant trend. While further research is needed to draw clinically impactful conclusions, these findings suggest that a lower mg/kg vancomycin dose in obesity may be needed to achieve therapeutic targets.

Background: Group B Streptococcus (GBS) is one of the most common causes of bacterial sepsis in newborns. In 2002, the Center for Disease Control and Prevention (CDC) recommended universal screening of all pregnant women for GBS colonization and administering intrapartum prophylaxis to colonized pregnant women to prevent GBS infection in newborns. To identify racial disparities in GBS infections in Tennessee, we compared the incidence of early-onset GBS infection among Black and White infants from 2005-2021. Methods: GBS infections identified from normally sterile sites are reportable in Tennessee. We analyzed GBS data reported to surveillance systems from 2005 to 2021. We linked the surveillance data with the population data to calculate incidence rates. We excluded cases with unknown race status (9%) and other races (0.2%) as we do not have denominator data to calculate the incidence rate. Database linkage and data analyses were performed in SAS V.9.4. Results: A total of 399 early-onset GBS cases were reported from 2005–2021; 150 (37.59%) were Black, 212 (53.13%) were White, and 36 (9.02%) were of unknown race, and one (0.20%) reported as Other for race. While the incidence rates of early-onset GBS for all races declined from 0.23 per 1000 live births in 2005 to 0.18 per 1000 live births in 2021, Blacks experienced the largest decline in incidence from 0.6 per 1000 live births in 2005 to 0.37 in 2021. Among Whites, there was a slight decline in 2021 (0.13/1000 live births) compared to the rate in 2005 (0.21/1000 live births). The mean incidence rate of early onset GBS among Blacks (0.52 per 1000 live births) is significantly higher than the mean rates among Whites (0.20 per 1000 live births) (p value < 0 .001) from 2005 to 2021. Shelby County, one of the 95 counties in Tennessee, is predominantly Black (54.6%) and reported 27.8% of all early-onset GBS. Conclusion: There was a significant decline in early-onset GBS infections among Blacks and some reductions among Whites, indicating the effectiveness of the prevention strategies. However, Blacks have significantly higher rates than their White counterparts. In addition, 27.8% of the cases are reported from one county, signaling geographic disparities as well. Further investigation is warranted to identify risk factors and causes of observed racial and geographic disparities to help reduce the infection rate among vulnerable populations and high-risk geographic areas.

Background: The COVID-19 pandemic disrupted routine health services worldwide, including systems to detect antimicrobial resistance (AR). AR is a mounting global health threat with some studies showing the highest mortality rate from AR infection is in Sub-Saharan Africa (SSA). Antibiotic use is a major contributor to AR. We sought to characterize COVID-19-related changes to antibiotic use and AR detection capacity in two countries in SSA from 2019 to 2020. Methods: Health facilities (HF) in South Africa and Uganda were surveyed as part of a larger study assessing disruptions to essential health services in SSA in the context of COVID-19. Modified stratified random sampling of HF by facility level was conducted in regions with high COVID-19 cumulative prevalence. Hospital pharmacists were surveyed to identify perceived changes in antibiotic use. Among facilities with the capacity to detect AR, surveys were conducted with AR laboratory managers to identify perceived changes in staff, equipment, training, and supplies. Descriptive data analysis was conducted using frequencies and proportions. Results: A total of 39 HFs in South Africa and 45 HFs in Uganda responded to the antibiotic use survey. Increases in total antibiotic use from 2019 to 2020 were reported by 82% (23/28) of HF in South Africa and 68% (27/40) in Uganda. Increased use of antibiotics for multi-drug resistant bacteria (per World Health Organization Reserve classification) was reported by 36% (9/25) and 38% (8/21) of HFs in South Africa and Uganda, respectively. 19 HFs in South Africa and 12 HFs in Uganda responded to the AR detection capacity survey. HFs in both countries reported decreases in laboratory staff responsible for AR (33% [13/40] in South Africa and 31% [11/35] in Uganda). Decreased availability of reagents and consumables for bacteriology and antimicrobial susceptibility testing was reported by 50% (8/16) and 33% (4/12) of HFs, and decreased availability of specimen collection supplies for bacterial cultures was reported by 41% (7/17) and 42% (5/12) of HFs in South Africa and Uganda, respectively. Diversion of laboratory supplies was reported in both countries (32% [6/19] in South Africa and 25% [3/12] of HF in Uganda). Conclusions: HFs in South Africa and Uganda reported increases in antibiotic prescribing, a risk factor for increased AR, concurrently with disruptions in AR detection capacity during the early phases of the COVID-19 pandemic. These findings emphasize the importance of investing in bacteriology and AR testing in SSA and maintaining support during infectious disease pandemics.

Long-Term Care Facility (LTCF) residents are particularly vulnerable to infections due to factors such as advanced age, co-morbidities, and regular medication use. Data from American and European sources indicate an anticipated occurrence rate of 2 to 11 infections per 1000 patient-days (pds) in LTCFs. The incidence rate of Clostridioides difficile infections (CDI) is reported at 0.52 per 10,000 resident days. The research objectives aimed to assess infection epidemiology in Polish LTCFs. An observational prospective study was conducted on residents from five LTCFs (2 residential homes and 3 nursing homes) in southern Poland between September 2022 and September 2023, utilizing the definition from the pan-European HALT study. The study received approval from the Bioethics Committee of the JU (1072.6120.73.2022) and was funded by the Polish NCN grant No.2021/41/B/NZ6/00749. CDI was defined by positive toxins A and B enzyme immunoassays (EIA) and positive glutamate dehydrogenase (DHA) EIA. Results from the study, involving 250 residents, revealed 157 cases of Healthcare-Associated Infections (HAIs) excluding gastrointestinal and CDI, with an incidence rate of 1.97/1000 pds. Lower respiratory tract infections dominated with 77 cases, including 36 pneumonia cases (47%). Additionally, 25 cases of gastrointestinal infections were reported, including only 7 CDI cases, resulting in an incidence rate of 0.88 CDI per 10,000 pds. Norovirus was detected in only one case, while the microbiological results were negative in the remaining cases. The incidence rate among Polish LTCF residents was lower than expected, contrasting with the CDI incidence that aligned with other research findings. Notably, the etiology of diarrhea remained undetermined in 68% of cases.

Introduction: Social determinants of health can impact healthcare-associated infections. Hospital-onset bacteremia (HOB) may lead to poor outcomes, increased length of stay, and increased cost of care. We explored the association of social determinants of health and HOB. Methods: We retrieved blood culture data at Stanford Health Care from May 2019 to October 2023. We identified blood cultures ordered ≥4 days of admission. To evaluate the association between social determinants of health and HOB, we employed an unsupervised machine learning approach (K-Means clustering) to discern patterns in HOB rates based on the Social Vulnerability Index (SVI). The SVI indicates the relative vulnerability of every U.S. Census tract. It ranks the tracts on 16 measures of vulnerability across 4 themes: socioeconomic factors, household characteristics, racial and ethnic minority status, and housing/transportation aspects. The number of clusters was determined using the Elbow Method (Figure 1). Results: Out of 209,947 blood cultures from 23,938 unique patients with a California address, we identified 81,653 blood cultures collected after 4 days (40%). The K-Means clustering algorithm identified 3 distinct clusters within the Californian census tracts, suggesting heterogeneity in the relationship between SVI and HOB (Figure 2). Cluster 1 had a higher SVI (median 0.73, range 0.46 – 0.99), with logistic regression indicating a positive SVI-HOB association (OR 4.84, 95% CI 4.02 – 4.81, p <.001). Cluster 2, had a median SVI of 0.29 (range 0.0009 – 0.78), also showed a positive association between SVI and HOB (OR 1.67, 95% CI 1.4 – 1.89, p <.001), aligning with trends of higher infection risks in more vulnerable groups. In contrast, Cluster 3 had a median SVI of 0.22 (range 0.002 –0.84). In this cluster, the SVI showed a negative association with HOB (OR 0.24, 95% CI 0.18 – 0.31, p <.001). Cluster 3 was the cluster with the least number of subjects (15,000, versus 21,761 for Cluster 1 and 29,762 for Cluster 2). Most subjects in Cluster 3 resided in Santa Clara County, whereas those in Clusters 1 and 2 were spread across Santa Clara, San Mateo, Alameda, Merced, and Sacramento Counties (Figure 3). Conclusions: Advanced techniques can be used to explore the complex interplay between social determinants of health and healthcare-associated infections and could guide the development of community-specific strategies to improve outcomes.

Background: Environmental contamination of surfaces is known to be one of the most common causes of healthcare associated infections (HAIs), with cleaning and disinfection of surfaces shown to reduce the incidence of HAIs and contribute to overall hospital cleanliness. Prior research showed that there was a relationship between a hospital’s performance on the Hospital Consumer Assessment of Healthcare Providers and Systems survey question on patient perception of cleanliness and their HAC score. However, this research was done prior to the COVID-19 pandemic. This study looked to examine if the pandemic changed the relationship between patient perception of cleanliness and HAC score performance. Method: A retrospective correlational study was performed to examine if the relationship between patient perception of cleanliness and the incidence of Clostridioides difficile (CDI) and Methicillin-Resistant Staphylococcus aureus (MRSA) HAIs, as defined by the facility’s HAC score, were affected by the COVID-19 pandemic. Multiple Center for Medicare and Medicaid Services (CMS) datasets were utilized for the study. There were approximately 2700 acute care facilities that reported data on the HCAHPS perception of cleanliness question and either a MRSA or CDI HAC score for the period of January 1, 2021, to December 31st, 2021. Basic descriptive statistics and Spearman’s rho correlation analyses were performed to examine the potential associations between the two scores. Result: For MRSA, the study found that as the percentage of patients who reported that their room was “always” clean increased, the hospital’s HAC score decreased (r= −0.141, p = < 0.001). Additionally, as the percentage of patients who reported their room was “never” clean increased, the hospital’s HAC score increased (r= 0.175, p = <0.001) For C. difficile, the analysis also revealed that as the percentage of patients who reported their room was “always” clean increased, there was not a significant change in the hospital’s HAC score (r= −0.023, p = 0.237). There was also not a significant change in the HAC score when the percentage of patients who reported their room as “never” clean increased (r= −0.012, p = 0.527).

Conclusion: The study found that for MRSA, a hospital’s performance on the HCAHPS performance on patient perception of cleanliness is related to their performance on their HAC score. This did not hold true when looking at C. difficile infections, which is in contrast to the prior evidence. Further research is needed to determine if there are specific factors that may have influenced this change.

Disclosure: Caitlin Crews-Stowe: Employee- ActivePure Medical

Background: Infection is one of the most common complications of cancer and cancer treatment. Most patients admitted for fever or infection come through the Emergency Department (ED), which is a primary site for blood culture collection. Contamination of blood cultures complicates the diagnoses, compromises quality of care, leads to unnecessary antibiotic exposure and increases financial burdens. It may also lead to unnecessary removal of central venous access devices or delay of critical therapy or procedures. At our institution, the contamination rate of blood cultures drawn in the ED was over twice that of the remainder of the hospital (2.8 versus 0.8), prompting this quality improvement project. Unlike on hospital floors, nurses, instead of phlebotomists, draw most blood cultures due to the urgency of managing suspected sepsis. Our aim was to decrease the ED contamination rate by 20 percent after the first PDSA cycle, and ultimately bring it on par with the remainder of the hospital. Methods: First, we compared ED contamination rates versus other hospital inpatient floors and outpatient centers over a three-month period. We then evaluated the contamination rates of ED nurses versus ED phlebotomists and peripheral versus central line blood draws. Process mapping and fishbone analysis helped identify practices contributing to higher contamination rates. Key drivers of these practices were diagrammed, and potential interventions were ranked on a prioritization matrix. Results: We identified use of alcohol rather than chlorhexidine swabs for peripheral disinfection and inconsistent techniques of blood draw by nurses as critical contributors to increased contamination rates in the ED. Our intervention was creating premade blood culture kits promoting the use of chlorhexidine swabs through availability and easy access in the fast-paced ED environment. Ten cubic centimeter (cc) syringes in the kits encouraged withdrawal of adequate blood samples in compliance with the 7-10 cc guideline. Designated nursing team leaders checked off ED nurses at the bedside, implementing education and adherence in using the blood culture collection kits. The average number of blood cultures in the emergency department was 1,400. A reduction in blood culture contamination from 2.46 percent to 1.89 percent was seen after two months. Conclusions: A guideline-driven, standardized blood culture collection process followed by ED nurses is vital to reducing blood culture contamination. Chlorhexidine is necessary to maintain the lowest contamination rates. Readily available premade blood culture kits improve compliance with materials and techniques associated with best practices.

Introduction: There are a number of tools available to healthcare epidemiologists for identification and investigation of healthcare-associated infections. For example, root cause analysis (RCA) is an evidence-based strategy for identifying process failures that resulted in infection. However, RCA is most valuable on a case-by-case basis. It is not an efficient tool for investigating numerous events that trend over time. Healthcare epidemiologists must use different strategies that are both efficient and powerful. A case-control study is a valuable option to investigate rare but recurrent infection events. The objective of this study was to demonstrate the utility of a case-control study design to detect attributable risk factors of cesarean section surgical site infections (SSI). Methods: We conducted a case-control study at a Level III childbirth center with data timeframe of January 1, 2021 to May 31, 2023. The project was approved by the institutions’ Quality Improvement Review Board prior to implementation. Cases were identified using the National Healthcare Safety Network (NHSN) SSI event criteria and included all levels of SSI. Controls were selected from the NHSN surgical denominator and were matched randomly without replacement by age at a 1:4 ratio. Variables were identified in collaboration with stakeholders based on known risk factors for SSI and abstracted manually. Analyses were conducted in Stata/MP version 17.0, and we performed multivariable conditional logistic regression with an alpha of 0.05 as threshold for statistical significance. The model was built according to a priori hypotheses and results from bivariate analysis of individual risk factors. Results: There were 32 SSI among 1709 cesarean deliveries, and all cases successfully matched with 4 controls for an analytic sample of 128. Bivariate analyses identified 7 relevant variables for inclusion in the multivariable model which narrowed down significant risk factors to 3: operative time (in minutes), post-operative chlorhexidine gluconate (CHG) bathing, and number of people in the operating room. Assessment of fit indices suggested an excellent fit with pseudo R-square of 0.526. Conclusions: This study demonstrated the utility of a case-control study design to identify attributable risk factors for relatively rare but significantly trending infection events. Not only is the design more efficient (e.g., time needed to abstract 50 data points for each patient), but it also employs statistical analyses that are often lacking in case-by-case investigations or RCA. It also has the power to narrow down risk factors for focused prevention efforts to get “the most bang for the buck.”

Background: At a comprehensive cancer center, hundreds of patients are screened daily for infections requiring the implementation of isolation precautions. Discontinuation of precautions is determined by negative testing, resolution of infection, or other criteria. Determining appropriate discontinuation of isolation precautions is labor intensive for Infection Preventionists (IPs). An unintended consequence of manual discontinuation is that numerous patients remain on isolation indefinitely. This was amplified during the COVID-19 pandemic when thousands of patients were placed on isolation precautions. Using electronic health record (EHR) tools, opportunities for process improvements were developed. Our goal was to establish an automated method to resolve isolation precautions. We aimed to decrease the number of manually resolved precautions by 25% each fiscal year (FY), compared to our baseline of activity in FY 2019 (FY19). Our secondary aim was to automate adding and resolving precautions when testing is initiated for suspected transmissible conditions (rule-out testing features).

Methods: Infection Control (IC) collaborated with EHR analysts to build tools to automate a process for appropriate isolation discontinuation. We reviewed our internal data in conjunction with evidence-based guidelines and started with acute, short-term infections that do not require repeat testing or cultures. Expiration dates were established for these infections to resolve automatically after meeting criteria. A secondary review determined that additional infections could be added safely to this process. The secondary aim of establishing rule-out testing was implemented for respiratory viral panels (including SARS-COV-2) and C. difficile testing. When testing was ordered for these conditions, a suspect-infection status and alert for precautions were automatically added to patients’ EHR banners. If the assay resulted negative, the suspect-infection status was automatically removed from their chart. Results: Our baseline of active infections in FY19 was approximately 2,700 cases. From FY19 through FY23, 123,115 infections were added to our patients, and 128,422 infections were resolved. In the first year of implementation, there was a 58% decrease in the number of manually resolved cases. From the initiation of our project through the end of FY23, manual discontinuation of precautions has decreased by 88%. Conclusions: We successfully implemented a process improvement project to appropriately remove patients from isolation precautions automatically using EHR tools, which resulted in reduced labor on our IPs and patient time spent on isolation restrictions. Additional benefits from this process improvement extend to decreasing unnecessary costs to the patient and the organization, better stewardship of supply/resources, and improving patient satisfaction.

Background: Infection Prevention (IP) practices in ambulatory care are often reactive and many communicable diseases in the community often do not fall onto IP’s radar until the patient becomes ill enough to seek inpatient services. The gap between ambulatory and inpatient care can lead to increased transmission and illness severity. Early identification has substantial impacts on timely implementation of IP mitigation strategies, appropriate handoff upon entry into other care settings, and timely reporting to public health organizations. Current IP processes underutilize electronic health record (EHR) capabilities by relying upon lab driven notifications. This project sought to redesign the IP’s workflows, advancing the health system beyond the acute care setting and into the ambulatory care setting by adding the power of diagnosis codes to close a practice gap. Method: Infection Prevention and Information Technology collaborated to build silent best practice advisories (BPAs) in the EHR that utilized diagnosis codes related to Varicella zoster (VZV) infection charted by ambulatory care providers. These BPAs function by triggering infection statuses that populate the patient chart and include instructions to front line staff on personal protective equipment (PPE) requirements. These BPAs also trigger real-time notifications to the IP team to determine the validity of the infection status and exposure work-up necessity. Chart reviews of diagnosis codes utilized in pre and post intervention timeframes were completed to understand the impact of the silent BPAs. Percentages of patients captured, and Healthcare Worker (HCW) exposure reviews reported were evaluated to demonstrate effectiveness. Plan, Do, Study, Act (PDSA) was utilized to respond to gaps, increase efficiency, and limit erroneous infection statuses. Result: The one-year pre-intervention period revealed 36 total diagnosis codes used for Varicella zoster (VZV) infection; 3% of these infection cases were captured and 4% of eligible cases were reported for HCW exposure review. The one-year post intervention period revealed 40 total diagnosis codes used for VZV infection; 80% of these infection cases were captured and 70% of eligible cases were reported for HCW exposure review. PDSA quality improvement cycles allowed for refinement of the BPA logic that further increased infection cases captured to 100% with 100% of eligible cases reported for HCW exposure review. Conclusion: Utilizing the EHR, the organization appreciated enhanced identification of patients in real-time with VZV infection that allowed for appropriate mitigation strategies to be implemented. This proactive workflow design helps minimize the risk of transmission between ambulatory and acute settings and facilitated HCW exposure reviews.

Introduction: The obesity pandemic presents numerous challenges in radiography, including patients exceeding the weight limits of imaging equipment, difficulties in palpating anatomical landmarks and inadequate penetration resulting in inaccurate diagnoses and need for repeat imaging resulting in increased radiation exposure. Pneumonia is a common reason for hospitalization, but identifying an infiltrate on the chest radiograph (CXR) in obese patients can be challenging. Conversely, motion artefacts may be misinterpreted as areas of pneumonia resulting in over-diagnosis and consequently the overuse of antibiotics. This study evaluated the diagnostic utility of CXR for identifying pneumonia in obese patients by comparing it with computed tomography (CT scan) performed within 72 hours. We also evaluated the impact on initiation or discontinuation of antibiotics – a very important aspect of antibiotic stewardship. Methods: All patients admitted between July 2020 and 2022 with a diagnosis of pneumonia who underwent both CXR and chest CT scan within a 72-hour window were included. Patients were divided into two groups obese and non-obese based on BMI. The results were evaluated to determine the concordance between the two modalities in diagnosing pneumonia, as well as its influence on antibiotic therapy. Results: A total of 320 patients were included, with a mean age of 65.3 years. 146 (45.6%) were male, and 174 (54.4%) were female. 202 (63.1%) were classified as obese (BMI > 30). CXR was performed as first modality in 313 (97.8%) cases, while 7 (2.2%) underwent CT scan first. In the obese group the overall concordance between the 2 modalities for diagnosing pneumonia was 67.5%. In the non-obese group the concordance was 80.2% (p < 0 .001). Among the obese patients who underwent CXR first, 11 (5%) had antibiotics discontinued after the CT scan results, while the number was 4 (3%) in the non-obese group. Additionally, 3 patients in the obese group had antibiotics initiated after the CT scan. Conclusions: Obesity poses unique challenges to healthcare facilities and imaging equipment. Diagnosing pneumonia in obese patients using CXR alone may result in over-diagnosis. This may lead to unnecessary antibiotic use and delayed diagnosis of alternate disease, or in some cases, missing a pneumonia and under-treatment. A chest CT scan is more sensitive and may be more helpful to identify a pneumonia accurately in these patients and thus facilitate appropriate antibiotic use.

Background and Objectives: Catheter associated urinary tract infections (CAUTIs) are a source of preventable harm in children. Insertion and maintenance bundles have significantly reduced CAUTIs, but infections still occur. Starting in mid-2019, we experienced an increase in CAUTIs in our pediatric intensive care unit (PICU). The objective was to identify preventable causes of CAUTI and develop and test interventions to reduce them. Methods: This quality improvement project was initiated in the PICU of a large tertiary children’s hospital. Interdisciplinary rounds led by the hospital epidemiologist and unit nursing leader with the bedside nurse occurred weekly (starting October 2019) for patients with urinary catheters in place for greater than three days. Discussions included strategies to optimize maintenance of the urinary catheter and identify catheters that could be removed. Additional interventions included no diapers for patients with a urinary catheter (starting March 2021) and use of a urine collection device that prevented both urine stasis in the drainage tube and retrograde flow of urine into the bladder (starting August 2021). Hand hygiene and CAUTI prevention bundle compliance was measured by direct observation of staff. CAUTIs were identified by prospective surveillance by infection prevention using standard definitions. The rate of CAUTIs over time was analyzed using statistical process control charts. Results: The baseline CAUTI rate (January 2017 - June 2019) was 0.5 infections/1000 catheter days with an average of 349 days between CAUTIs. Between July 2019 and February 2021, the CAUTI rate increased to 3.3 with an average of 88 days between CAUTIs. Annual compliance with hand hygiene and the CAUTI prevention bundle elements remained above 90% throughout all time periods. No improvement was seen after the institution of weekly interdisciplinary rounds. Starting in March 2021 after removal of diapers and implementation of the urine collection device that prevented retrograde flow, the CAUTI rate decreased to 0.9 and an average of 200 days between CAUTIs. Currently, it has been 512 days since the last CAUTI. Conclusion: CAUTIs decreased after removing diapers in children with urinary catheters and use of the urine collection device. Removal of diapers likely reduced stool contamination around the catheter and urethral opening. The urine collection device prevented inadvertent retrograde flow of urine into the bladder. These interventions could augment current CAUTI prevention strategies.

Background: Blood culture contamination is common in healthcare and contributes to diagnostic uncertainty, unnecessary treatments and follow-up testing, increased length of stay, higher rates of reportable healthcare-associated infections and events, over utilization of resources and staff including consultative care, and undue emotional stress to patients. The national benchmark for institutional blood culture contamination rates as recommended by The American Society for Microbiology (ASM) and the Clinical Laboratory Standards Institute (CLSI) is < 3 %. Our institution’s overall rate was 8.9% with the highest burden being from our Emergency Department (ED) locations. We formed a multidisciplinary team aimed to reduce these rates through efforts centered around education and simplification of the collection process. Method: Working closely with and gathering feedback from nursing staff, nurse educators, and supply chain, we developed a blood culture collection kit that included all items necessary for blood culture collection thus eliminating the need for nurses to gather these items individually prior to collection. Additionally, simple step-by-step educational materials (Fig. 1) detailing the collection technique were provided. Education was presented at nursing huddles and skills fairs prior to kit roll-out. Blood culture kits were then stocked in place of individual blood culture collection bottles in all ED stock rooms in August 2022. Result: The 12-week pre-intervention period found 249 contamination events from 4265 total collections deriving a contamination rate of 5.8% across our health system’s four ED locations. During a 12-week post-intervention period following kit roll-out, 116 contamination events occurred from 3629 total collections deriving a contamination rate of 3.2% across our four ED locations. Given our results, we ultimately rolled this out to all units in all locations of our health system. When including all time from kit rollout to present (August 2022 to November 2023, 16 months), there were 1077 contamination events from 43379 total collections deriving an overall contamination rate of 2.5%. When compared to the 16 months prior to the kit rollout (April 2021 to July 2022) there were 1803 contamination events in 49335 total collections (3.7% contamination rate) deriving an overall percent reduction of 32.1%. Conclusion: We were able to decrease our health system’s blood culture contamination rate through simple interventions aimed at reducing the mental burden on nursing staff by developing a blood culture collection kit and educational materials. Since implementation of the kits, we have continued to maintain lower contamination rates as evident by our 16 month follow up period.

Background: Central line-associated bloodstream infections (CLABSI) and catheter-associated urinary tract infections (CAUTI) are key healthcare-associated infection (HAI) quality metrics. In this qualitative analysis, we aimed to identify common issues contributing to CLABSIs and CAUTIs occurring during the COVID-19 pandemic. Methods: In an academic healthcare network in Atlanta, GA, four hospitals perform real-time, apparent cause analyses (ACAs) for all CLABSIs and CAUTIs. Contributing factors are entered as free text into an electronic database. We analyzed data from 8/2020–8/2022. We first performed a qualitative open card sort of all reported contributing factors to CLABSI and created a novel framework based on mutually defined critical tasks (e.g., line insertion) and cross-cutting issues (e.g., communication breakdown). Contributing factors could describe ≥1 critical task and/or ≥1 cross-cutting issue. After establishing interrater reliability, a multidisciplinary group applied this framework to classify each contributing factor. For CAUTI, we used the same set of cross-cutting issues but identified new critical tasks via open card sorting. We then used the framework to classify each CAUTI contributing factor. We used descriptive statistics to identify frequent critical tasks and cross-cutting issues. Results: We reviewed 350 CLABSI ACAs with 602 contributing factors and 240 CAUTI ACAs with 405 contributing factors (Figure 1). Our classification framework comprised 11 cross-cutting issues and 9 critical tasks for CLABSI and 7 critical tasks for CAUTI (Figure 2). CLABSI: The critical tasks most often reported were bathing (19%), central line dressing maintenance (15%), and assessing central line indication (8%; Figure 3). Within these tasks, the most frequent issues described for bathing were the task not being performed (20%) and unclear documentation (18%); for dressing maintenance, the task was not performed (15%), not documented (15%), or poorly performed due to lack of competency (15%); and for assessing line indication, there was frequent communication breakdown (33%). CAUTI: The critical tasks most often reported were urinary catheter care (26%) and assessing the indication for urinary catheter (22%; Figure 4). Within these tasks, urinary catheter care was frequently not documented (38%) or not performed (16%); assessing urinary catheter necessity was often not documented (29%) or involved breakdown of communication (19%). Conclusion: We created a novel framework to evaluate common causes of HAIs in an academic healthcare network. This framework can be used to identify and track gaps over time and to develop quality improvement initiatives targeting key tasks and associated factors, such as communication difficulties when assessing device indications.

Disclosure: Colleen Kraft: Consultant - REbiotix/Ferring; Scientific Advisory Board - Seres, LLC

Background: Contact precautions (CP) to prevent transmission of multidrug-resistant gram-negative (MDRGN) Enterobacteriaceae are recommended, although studies of discontinuation of CP (DcCP) have found no change in healthcare associated infections (HAI) due to extended-spectrum beta-lactamase (ESBL) producing Enterobacteriaceae. Limited data exists on DcCP for MDRGN in a large health system. Methods: We performed a retrospective observational study analyzing the relationship between use of CP and HAI due to two definitions of MDRGN Enterobacteriaceae: ESBL, and non-susceptibility to ≥3 drug classes (3DC-GNR), with carbapenem resistant Enterobacteriaceae (CRE) serving as control. The study included all inpatient admissions from 2/2017 through 9/2022 at 21 acute care hospitals. Hospitals had latitude to determine CP practices based on local risk assessment, but in 2/2018, system-wide transmission-based precautions guidance was updated to recommend DcCP for MDRGN Enterobacteriaceae and in 12/2019 was updated to clarify DcCP specifically for ESBL and 3DC-GNR while continuing CP for carbapenem-resistant organism carriage. We interviewed infection preventionists to define when CP were used for CRE, ESBL, and 3DC-GNR Enterobacteriaceae. HAI were defined using National Healthcare Safety Network criteria including all HAI categories. We compared the incidence rate of HAI attributable to the two MDRGN types in hospital months with and without use of CP, with HAI due to CRE as a comparison group since all hospitals used CP for CRE throughout the study period. Results: The periods of CP use, by hospital, are shown in Figure 1. Throughout the study period, there were 987 HAI attributed to ESBL Enterobacteriaceae, 579 due to 3DC-GNR Enterobacteriaceae, and 329 due to CRE. Figure 2 shows the unadjusted aggregate rate of HAI for each of the three MRGN types, including among hospitals with and without CP in each month, for ESBL and 3DC-GNR. In months with and without CP, the rate of HAI was 1.482/10,000 and 1.093/10,000 patient days (incidence rate ratio [IRR], 1.356 [95% confidence interval, 1.195-1.540]) for ESBL Enterobacteriaceae. In months with and without CP, the rate of HAI was 1.071/10,000 and 0.493/10,000 patient days (IRR,2.173[95% confidence interval, 1.838-2.569]) for 3DC-GNR Enterobacteriaceae. Conclusion: DcCP was not associated with an increase in HAI due to ESBL and 3DC-GNR Enterobacteriaceae in aggregated facilities that self-selected for DcCP. Facilities that used CP were associated with significantly higher rates of ESBL and 3DC-GNR Enterobacteriaceae, a relationship that did not change as hospitals DcCP for these MDRGN. Further analyses are necessary to assess for a causal relationship.

Background: Patients in the intensive care unit (ICU) have invasive lines increasing their risk for healthcare-associated infections (HAIs). Our objective was to determine if antimicrobial bathing with 2% chlorhexidine gluconate (CHG) compared to the colloidal silver-based antimicrobial product would reduce the incidents of central line–associated bloodstream infections (CLABSI) and catheter-associated urinary tract infections (CAUTI). Methods: We performed a before-and-after study in four adult ICUs at a two-hospital facility in California. Prospective surveillance of CLABSI and CAUTI prevention bundles monitoring was established. The intervention consisted of daily bathing with CHG for all patients in the ICUs. A baseline period of one year was followed by an intervention period of one year. The incidence rates of CLABSIs and CAUTIs were compared between the baseline and intervention periods utilizing a t-test analysis. Results: A total of 10103 patients were included. At Facility A, a mean CLABSI rate of 2.43/1000 central line catheter days (CL) with 2149 patients days (Mean differences 95% CI -0.5–3.1; P>0.0975), during the baseline period followed by 1.11/1000 CL days with 2193 patient days in the intervention period. At Facility B, the mean CLABSI rate of 1.82/1000 CL days with 2976 patient days (Mean differences 95% CI -0.6–2.31; P>0.161) during the baseline period was followed by 1.01/1000 CL days with 2785 patient days in the intervention period. At Facility A, the mean CAUTI rate of 1.37/1000 indwelling catheter days (IUC) with 2149 ICU patient days (Mean difference 95% CI is 0.28–1.97; P 0.2160) was noted in the baseline period, followed by 0.45/1000 IUC days with 2785 in the intervention period. Conclusion: Daily bathing with CHG significantly reduced the incidence of CAUTI at Facility A. It is unclear why Facility A saw a statistically significant reduction in CAUTI, but Facility B did not. The difference in outcomes may be related to hospital size, service lines, supply constraints, and discrepancies in staffing. CHG bathing was not directly associated with a reduced risk of CLABSI at Facility A and B during our limited study, but it was encouraging enough that our organization will continue this intervention to obtain additional data to determine if bathing with CHG will reduce CLABSI and CAUTI.

Background: This study investigated viral load in surgical masks worn by adult patients infected with respiratory viruses. Method: Surgical masks were dissected into eight pieces at pre-selected sites: inner, middle, and outer layers at the nose (N1-N3) and mouth (M1-M3), as well as full-thickness on the right (RS) and left (LS) sides. Viral load was detected, correlated with nasopharyngeal specimens and patients' demographics. Result: Among 230 patients infected with influenza A virus (n=91), respiratory syncytial virus (RSV) (n=61), and SARS-CoV-2 (n=78) from April 1 to August 31, 2023, 90.9% (209/230) were from the medical specialty. Of the 230 surgical masks collected, viral RNA was detected in 79.6% at one or more sites, with 75.7% positive at N1 or M1, 55.2% positive at N3 or M3, and 22.6% exhibiting viral RNA at all sites. Pearson correlation showed viral load correlation between nasopharyngeal specimens and N1 (0.244, p=0.002) and M1 (0.174, p=0.031). The mean viral load at N1 (4.14 ± 1.46 log10 copies/ml) was significantly higher than M1 (3.74 ± 1.32 log10 copies/ml, p=0.014) and N3 (3.58 ± 1.27 log10 copies/ml, p=0.003). Significant differences in viral load were observed across N1-N3 and M1-M3 in RSV patients, but not in influenza A or SARS-CoV-2 patients. SARS-CoV-2 patients exhibited significantly lower viral load at RS and LS sites compared to influenza A or RSV patients. Conclusion: Viral RNA was detected in N3 or M3 sites in our masks, highlighting the potential risk associated in these areas. Differential viral load across various sites in surgical masks worn by patients infected with different respiratory viruses warrants further investigation.

Background: The impact of universal masking on transmission of endemic respiratory viruses in children’s hospitals is unknown. Our objective was to measure the association between universal masking by healthcare personnel and the incidence of non-SARS-CoV-2 healthcare-associated viral respiratory infections (HA-VRIs) in a free-standing academic pediatric medical center during the COVID-19 pandemic. Methods: In this quasi-experimental study, we measured the incidence rate of non-SARS-CoV-2 HA-VRIs (VRI diagnosed on or after hospital day 3 by one of several molecular assays) during three time periods: prior to the COVID-19 pandemic (pre-intervention: September 2013 - February 2020); during universal masking (intervention: May 2021 - March 2023); and after universal masking was lifted (post-intervention: April 2023 - November 2023). Although universal masking was implemented in late March 2020, we exclude the lockdown period of strict COVID-19-related public health mitigations (i.e., school closures and shelter-in-place advisories) during which community prevalence of non-SARS-CoV-2 respiratory viruses was minimal in our region (March 2020 to April 2021). By negative binomial regression analysis, we compared the level and trend of HA-VRIs between the pre-intervention and intervention periods. Results: Figure 1 illustrates the incidence rate of non-SARS-CoV-2 HA-VRI during the pre-intervention, lockdown, intervention, and post-intervention periods. The aggregate non-SARS-CoV-2 HA-VRI incidence rate during the pre-intervention, intervention, and post-intervention periods was 1.25, 1.84, and 1.96 HA-VRIs per 1000 patient days, respectively. There was no significant difference in the level (p = 0.96) or trend (p = 0.67) of HA-VRI incidence rate between the pre-intervention and intervention periods. Conclusion: Universal masking was not associated with a decrease in the incidence rate of non-SARS-CoV-2 HA-VRIs at our children’s hospital during the COVID-19 pandemic. These findings suggest that universal masking may not be an effective infection prevention measure in children’s hospitals during periods of increased endemic respiratory viral transmission in the community.

Disclosure: Larry Kociolek: Research Support - Merck

Background: Antimicrobial resistance is a growing public health threat. To alleviate selective pressure which leads to the emergence and proliferation of resistance, and to preserve the utility of treatments where they are needed the most, antimicrobial stewardship programs (ASPs) could consider revising surgical antibacterial prophylaxis protocols for low-risk procedures such as laparoscopic cholecystectomy. Methods: Publicly available data was used from a well-powered randomized controlled trial conducted by Matsui and colleagues during 2007-2013 in Japan on the effectiveness of prophylactic antibacterial treatment on reducing post-operative infections following laparoscopic cholecystectomy in low-risk patients. A total of 1037 patients were randomized to receive treatment or no treatment. After randomization, laparoscopic cholecystectomies were converted to open procedures in 28 patients, 14 in each arm, constituting a deviation from the protocol and the administration of additional antibacterial treatment. The original study included both intention-to-treat and per-protocol analyses, finding statistically significant reductions in post-operative infections in the treatment vs no treatment arm (1.2% vs 6.7%, p<0.0001; 1.0% vs 5.9%, p<0.0001, respectively). In the present analysis I assessed the extent to which type of procedure modified the effect of antibacterial prophylaxis on post-operative infection using both additive and multiplicative interaction. Risk and risk differences were estimated using a linear-binomial model and risk ratios were estimated using a log-binomial model. Alpha was set to 0.10. The lowest risk categories for each variable, being assigned to treatment and receiving a laparoscopic procedure, defined the common reference category. Results: A 35 percentage point (pp) increase in the risk of post-op infections relative to the reference category was attributable to the joint effects of omitting prophylaxis and conversion to an open procedure (90% CI 14, 56), compared to a 5 pp increase attributable to omission of prophylaxis (90% CI 3, 7) or a 6 pp increase attributable to conversion to an open procedure (90% CI -5, 18) by themselves. The interaction contrast capturedthis super-additive 24 pp increase in risk (90% CI -1, 47). The relative excess risk due to interaction was 23.81 (90% CI -5.56, 53.19), suggesting a departure from additivity as well. Conclusions: Patients undergoing open cholecystectomies stand to benefit the most from antibacterial prophylaxis compared to patients who have laparoscopic cholecystectomies. ASPs could consider reducing or eliminating surgical prophylaxis in low-risk procedures such as laparoscopic cholecystectomy to alleviate selection pressure for antibacterial resistant organisms and preserve its effectiveness for people undergoing higher risk procedures.

Although the National Healthcare Safety Network (NHSN) recommends the reporting of superficial incisional SSIs, the standardized infection ratio (SIR) models used by the NSHN exclude superficial incisional SSIs cases. Yet, some superficial incisional SSIs may lead to serious adverse patient outcomes. We previously proposed a new category of such infections: serious superficial incisional surgical site infections (SSISSIs), defined as a superficial incisional SSI that (1) required debridement in an operating room and/or (2) led to a hospital readmission within 30 days of surgery. The objective of our study was to determine the prevalence of SSISSIs in a large network of community hospitals and compare hospital rankings of SSI rates of organ/space and deep SSIs (complex SSIs) with and without SSISSIs. We performed a retrospective descriptive analysis of prospectively collected data on 35 NHSN surgical categories in 47 community hospitals within the Duke Infection Control Outreach Network (DICON) from 1/1/2013-12/31/2022. All hospitals used standardized surveillance and data collection strategies throughout the study period. The Wilcoxon rank-sum was used to test for differences in performance rankings of hospitals sorted by rates of complex SSIs alone compared to complex and SSISSI rates. A two-tailed P value of .05 or less was considered significant. Overall, 11,617 SSIs occurred after 1,272,257 surgeries (0.91 SSIs/100 procedures). Out of 3,996 superficial SSIs, 2,038 (17.5% overall, 51.0% of superficial incisional) met criteria for SSISSI. 112 (5.5%) were diagnosed during the current admission and required takeback to the OR for infection; 1,926 (94.5%) were diagnosed during a readmission; and 3841 (33.1%) were diagnosed during readmission and returned to the OR. (Table1) The highest proportion of SSISSIs was diagnosed in patients who underwent gastrointestinal surgery (32.0%) or orthopedic surgery (24.0%). (Table2) Performance ranking of individual hospitals based on rates of complex SSIs, differed significantly when including SSISSIs (p= 0.02). (Table3) Discussion Our findings suggest that SSISSIs make up a moderate but important proportion of SSIs in community hospitals. SSISSIs can be identified through established database surveillance looking at objective measures of returning to the OR for debridement and/or readmission within 30 days. Hospital rankings differed significantly when SSISSIs were added to complex SSIs to calculate SSI rates. As such, including SSISSIs likely provides a more accurate depiction of SSIs with important outcomes and is not as subjective to surveillance bias. Next steps would be specifically to look at outcomes data for complex SSIs compared to SSISSIs to fully evaluate the

Disclosure: Jessica Seidelman: UptoDate- Section Editor; BoneSupport- Consultant