Background: Catheter-Associated Urinary Tract Infections (CAUTI) are preventable hospital acquired infections that contributes to patient morbidity, prolonged hospital stays and increased healthcare costs. Complete compliance to the CAUTI bundle is critical for preventing infection—not only reducing catheter days, but also ensuring appropriate indications are present for urine culture collection. Methods: This retrospective study included 145 patients diagnosed with CAUTI per NHSN definitions from July 1, 2020 to June 30, 2023. Data collected included laboratory data, catheter duration, catheter indication, urinalysis/culture indication and if foley was appropriately removed/changed prior to specimen collection. A urinary catheter indication order was implemented in February 2021 requiring providers to select specific criteria for catheter placement/maintenance. In July 2023, the threshold for urinalysis to reflex to culture was increased to ≥10 WBCs and this criteria was applied to these cases to estimate the effect on diagnosis of CAUTI. Results: The most common indications for urinary catheters were input and output monitoring 76 (52%) and urinary retention/obstruction 34 (23%). No indication was entered on 22 (15%) patients. No difference was seen in the number of catheters without an indication before or after the 2021 order update. Mean catheter duration was 11.5 days with a median of 7 days. The most common indications for obtaining a urine specimen were leukocytosis/fever/sepsis 91 (63%), urinary symptoms/abdominal/flank pain 13 (9%), urine appearance 6 (4%), and altered mental status 4 (3%). In 31 (21%) patients, no indication was identified. A urinalysis with reflex to culture was completed in 105 (72%) and the catheter was removed prior to culture collection in 68 (47%). Of the 127 patients with a urinalysis and culture, 11 had 0-5 WBCs, 16 had 6-9 WBCs, 15 had 10-20 WBCs and 85 had >20 WBCs. Using the new pyuria criteria for urinalysis to reflex to culture, 27 (19%) CAUTIs could have been avoided. Conclusion: Review of CAUTI cases identified opportunities for improving documentation and education of appropriate indications for urinary catheters and evaluation of urinary tract infection. The majority of urine cultures were obtained due to non-specific symptoms and less than 10% had specific urinary symptoms indicating need for continued education and diagnostic stewardship. Increasing the pyuria threshold needed to reflex to culture has the potential to significantly reduce CAUTIs but additional education is needed to ensure catheters are changed prior culture collection and specimens are only sent when signs and symptoms of urinary tract infection are present.

Background: CAUTIs constitute forty percent of nosocomial infections, yet their direct link with mortality remains debated. In 2009, NHSN estimated the economic burden of CAUTIs in the U.S. to be over $340 million. Limited data exist on inter-physician concordance in diagnosing CAUTIs, especially in patients with abnormal genitourinary (GU) anatomy. Our study assessed inter-provider variability in diagnosing CAUTI in 50 such patients, including those meeting NHSN(National healthcare safety network) criteria. Methods: We included a random set of 50 adults (18+) with abnormal GU anatomy admitted to the University of Miami hospitals from January 2018 to November 2021 who had a urinary foley catheter and at least one positive urine culture during their hospitalization. Three Infectious disease fellows and three board-certified Infectious disease physicians independently reviewed each patient’s chart, classifying them as having or not having a CAUTI. Inter-physician reliability was assessed using kappa statistics. Results: Our findings highlight substantial variation in clinician-determined CAUTI incidence among the 50 patients with abnormal GU anatomy, ranging from 8% to 32% (Figures 2,3). Inter-rater agreement on CAUTI diagnosis was generally poor (Kappa Hollenbeak CS, et al. The attributable cost of catheter-associated urinary tract infections in the United States: A systematic review. Am J Infect Control. 2018 Jul;46(7):751-757. Trautner BW, et al. Development and validation of an algorithm to recalibrate mental models and reduce diagnostic errors associated with catheter-associated bacteriuria. BMC Med Inform Decis Mak. 2013 Apr 15;13:48. Gafary M, et al. Catheter Associated Urinary Tract Infections (CAUTI) in Bladder Cancer Patients Post Cystectomy With a Neobladder, Open Forum Infectious Diseases, Volume 2, Issue suppl_1, December 2015, 293.

Background: Multi-drug resistant organisms (MDROs) are a common cause of healthcare-associated infections, particularly central line-associated bloodstream infections (CLABSIs). Prior research has shown that MDROs cause up to 67% of CLABSIs and have up to a 37% increase in 30 day readmission, which is higher than readmission rates for other conditions reported to the Centers for Medicare and Medicaid Services (CMS). The objective of the study was to determine overall 90-day readmission rates, and if there was a difference in readmission rate within 90 days post discharge for patients who had a MDRO as the causative pathogen of their CLABSI compared to patients who did not have an MDRO. Methods: A retrospective analysis of patient data from a nine-hospital system was performed on patients who had a CLABSI and were discharged alive between January 1st, 2018, and December 31st, 2019. Basic descriptive statistics were performed, and the potential differences in readmission rates were examined using Chi-square analyses. Results: The overall readmission rate for all CLABSIs was 46.9%. The chi-square analysis determined there was not a significant difference in readmission rates in patients who had a MDRO CLABSI compared to patients with a non-MDRO CLABSI (59.1% vs. 44.6%, x2= 1.564 , p= 0.211). Conclusion: There was not a significant difference in readmission rates between patients with an MDRO CLABSI compared to a non-MDRO CLABSI. However, the overall readmission rate for this patient population was much higher than seen in previous literature and other publicly reported readmission rates. Additional research is recommended to explore if the increased CLABSI readmission rates seen are a unique finding to this health system.

Background: Central venous catheter (CVC) utilization and central-line associated bloodstream infection (CLABSI) have increased nationwide. Busy providers can easily overlook the recommended practice of daily assessment of the ongoing indication for CVC. Prospective audit and feedback (PAF) is widely used and the gold standard for antibiotic stewardship programs (ASP), but reports involving PAF for device use are scarce. Therefore, we decided to evaluate the usefulness and feasibility of PAF for reducing device utilization and ultimately CLABSI rates at our 528-bed tertiary care hospital. Methods: A PAF-based Central Line Stewardship (CLS) initiative was launched in February 2023, with a team of hospitalists, infectious diseases physicians, health informatics, vascular access nurses, and infection preventionists. On business days, CVC line-lists were exported from the electronic medical record (EMR), into a REDCap (Research Electronic Data Capture) database for team members to evaluate, in real-time, all non-ICU CVCs in place for more >72 hours (Figures 1 and 2). For CVCs eligible for stewardship, CLS members placed Legal-approved note into the patient’s EMR, advising CVC removal or alternative IV access (Figure 3). CVCs continued to be audited until removal or patient discharge. Recommendation outcomes were tracked over the subsequent 72 hours for acceptance. Standardized Utilization Rates (SUR) and Infection Rates (SIR) were calculated and compared using the National Healthcare Safety Network. Results: Between February and August 2023, the CLS team reviewed 861 CVCs, representing 581 unique patient encounters, and made 622 recommendations. Recommendations to remove or replace the CVC represented 23.5% (146) of reviews, and 57% of these CVCs were removed within 3 days. 95% of removed lines had no adverse outcomes and did not require reinsertion. Hospital-wide CVC utilization decreased 18.7% from a SUR of 1.006 in the previous year, to 0.818 during the 7-month pilot period (p < 0 .001). In the 4 months following the pilot period, decreased CVC utilization was sustained with an SUR of 0.797. Non-ICU CLABSI SIR decreased from 1.282 in 2022 to 1.024 in 2023 (p=0.36). Average time physician required for CLS review approximated a 0.4 full-time equivalent a week. The intervention was well received, with requests for expansion to urinary catheters. Conclusion: CLS safely and significantly reduced device-utilization; directly via documentation and recommendation, and indirectly through increased awareness and the Hawthorne Effect. Examples of the “art” of CLS include when to leave a discoverable note and how to determine ongoing need for CVC in a fragile patient.

Background: Hospital acquired infections (HAI) are of interest given their resultant morbidity, mortality, and hospital utilization. Among HAIs, central line associated bloodstream infections result in the highest rates of mortality and additional costs. While all central venous catheters (CVC) carry risk for BSI, long-term catheter use is at increased risk. One population that utilize CVCs for extended durations are those undergoing hemodialysis. While data are available characterizing BSI impacts on outpatient hemodialysis patients, little data exist describing inpatients. The purpose of this study was to characterize the demographics, outcomes, and economics associated with the development of hospital acquired BSI (HA-BSI) in patients undergoing hemodialysis through a CVC (HD-CVC). Methods: All admissions of adult patients in the Premier Healthcare Database with hospital stays including HD-CVC with discharge dates during 2020-2022 were retrospectively evaluated. BSIs were identified by ICD-10 codes and blood culture collection dates. A BSI was deemed hospital acquired if the blood culture date was ≥3 calendar days after admission. Descriptive analyses were undertaken for HA-BSI patients including: baseline demographics, clinical characteristics, and outcomes. Length of stay (LOS), ICU utilization, and estimated costs were evaluated for HAI-BSI and non-BSI populations. Results: 166,394 admissions from 91,448 patients were identified. Of these, 5,722 patients (6.3%) had 5,842 admissions with a HA-BSI. These patients were 58.9% white, 28.3% black, 56.8% male, and 62.9% were aged ≥60years. Patients had considerable comorbidities at baseline with 88.9% having ≥2 Charlson comorbid conditions and 46.9% with ≥6. During the study period, all-cause mortality was 27.8% for HA-BSI patients with 85.5% of deaths occurring while inpatient. Median LOS for patients with HA-BSI was 25 days compared with 6 days for HD-CVC without BSI; patients with HA-BSI were also more likely to require the ICU (65.6% vs. 27.6%). The median ICU LOS was 12 days for HA-BSI versus 34 days for HD-CVC without BSI. Greater intensity of healthcare utilization was reflected in median costs of $402K for HA-BSI, compared with $43K for HD-CVC without BSI. Discussion: We described the characteristics of HD-CVC patients that developed HA-BSI. These patients had many comorbidities and relatively high rates of all-cause in-hospital mortality. Patients were likely to have long LOS, both in-hospital and within the ICU. Collectively, care of these patients was associated with considerable healthcare costs, particularly as compared with HD-CVC patients not developing a HA-BSI. Future studies should characterize risk factors and evaluate potential prevention strategies for this high-risk population.

Background: Mie Prefecture in Japan established a Cluster Response Team within the Headquarters for COVID-19 and registered prefectural staff as well as certified Nurse in Infection Control (CNICs) and other experts, who were promptly dispatched to the site of the cluster and provided other support. However, the extent to which they were dispatched, what activities they performed, and what contributions they made have not been analyzed. Method: The Mie prefectural government officials who were responsible for coordinating the dispatch were interviewees regarding the cluster response situation from November 2020 to August 2022. In addition, a questionnaire survey was conducted with CNICs on the supporting side and facility managers on the receiving side regarding the activities and roles of CNICs. Result: Of the 275 cluster cases, cluster response teams were dispatched in 59 cases (64% to nursing facilities, 34% to medical institutions). Nineteen of the 46 CNICs registered in Mie Prefecture were dispatched. The number of days CNICs were dispatched ranged from 1 to 4 days, with 1 day being the most common (69.5%). The dispatch coordinators commented that the CNICs they requested were biased, but that they would have liked to request all CNICs to be dispatched. In a survey of CNICs, 36 of 46 (78.3%) responded to the survey. Support was provided for zoning (92%), PPE donning and doffing instruction (92%), infection control evaluation and instruction (85%), cleaning and disinfection services (54%), and training sessions (54%). The tasks that CNIC believed should be performed were generally consistent with the tasks that were actually performed. However, cleaning and disinfection tasks and nursing tasks that were not indicated as tasks to be performed were actually performed. In a questionnaire targeting recipients, 31 of 67 facilities (46.3%) responded to the survey. Respondents indicated that the dispatch of staff improved their knowledge of infection control measures (90.3%), reduced anxiety (87.1%), ensured thorough hand disinfection (61.3%), and standardized the PPE donning and doffing method (58.1%). Requests to the CNIC included regular on-site guidance, sharing and disseminating information, and holding training sessions. Conclusion: Administrative staff and infection control staff, mainly CNICs, paired up to provide effective cluster response. However, the uneven distribution of the dispatched CNICs and the unexpected tasks they had to perform indicated the need to re-establish a community-wide infection control system in preparation for the next pandemic.

Background: Nursing home (NH) residents are at high risk of COVID-19 from exposure to infected staff and other residents. Understanding SARS-CoV-2 viral RNA kinetics in residents and staff can guide testing, isolation, and return to work recommendations. We sought to determine the duration of antigen test and polymerase chain reaction (PCR) positivity in a cohort of NH residents and staff. Methods: We prospectively collected data on SARS-CoV-2 viral kinetics from April 2023 through November 2023. Staff and residents could enroll prospectively or upon a positive test (identified through routine clinical testing, screening, or outbreak response testing). Participating facilities performed routine clinical testing; asymptomatic testing of contacts was performed within 48 hours if an outbreak or known exposure occurred and upon (re-) admission. Enrolled participants who tested positive for SARS-CoV-2 were re-tested daily for 14 days with both nasal antigen and nasal PCR tests. All PCR tests were run by a central lab with the same assay. We conducted a Kaplan-Meier survival analysis on time to first negative test restricted to participants who initially tested positive (day zero) and had at least one test ≥10 days after initially testing positive with the same test type; a participant could contribute to both antigen and PCR survival curves. We compared survival curves for staff and residents using the log-rank test. Results: Twenty-four nursing homes in eight states participated; 587 participants (275 residents, 312 staff) enrolled in the evaluation, participants were only tested through routine clinical or outbreak response testing. Seventy-two participants tested positive for antigen; of these, 63 tested PCR-positive. Residents were antigen- and PCR-positive longer than staff (Figure 1), but this finding is only statistically significant (p=0.006) for duration of PCR positivity. Five days after the first positive test, 56% of 50 residents and 59% of 22 staff remained antigen-positive; 91% of 44 residents and 79% of 19 staff were PCR-positive. Ten days after the first positive test, 22% of 50 residents and 5% of 22 staff remained antigen-positive; 61% of 44 residents and 21% of 19 staff remained PCR-positive. Conclusions: Most NH residents and staff with SARS-CoV-2 remained antigen- or PCR-positive 5 days after the initial positive test; however, differences between staff and resident test positivity were noted at 10 days. These data can inform recommendations for testing, duration of NH resident isolation, and return to work guidance for staff. Additional viral culture data may strengthen these conclusions.

Disclosure: Stefan Gravenstein: Received consulting and speaker fees from most vaccine manufacturers (Sanofi, Seqirus, Moderna, Merck, Janssen, Pfizer, Novavax, GSK, and have or expect to receive grant funding from several (Sanofi, Seqirus, Moderna, Pfizer, GSK). Lona Mody: NIH, VA, CDC, Kahn Foundation; Honoraria: UpToDate; Contracted Research: Nano-Vibronix

Background: Patients undergoing hemodialysis are at high risk for healthcare-associated infections; they are at 100 times the risk of Staphylococcus aureus bloodstream infections (BSI) compared with U.S. adults not on hemodialysis. Prior studies found that nasal decolonization with mupirocin prevented S. aureus BSI among hemodialysis patients. We implemented a nasal decolonization intervention in which patients self-administered povidone-iodine (PVI) at each dialysis session. We aimed to assess: 1) hemodialysis patients’ knowledge of their infection risk and their willingness to take an active role in infection prevention; 2) the acceptability of the PVI nasal decolonization intervention. Methods: We performed a stepped wedge cluster randomized trial at 16 outpatient hemodialysis centers. Patients were surveyed: before starting PVI, 1 month after their center started using PVI, and ~6 months after starting PVI. We used a chi-square test to compare results. Results: 469 patients completed at least 1 survey: 400 pre-intervention, 237 at 1 month and 201 at 6 months. Overall, 56% of patients thought that their risk of infection was average or below average compared with an average person in the U.S. (Figure). Over 98% agreed with the statement “One of the most important things I can do for my health is to take an active role in my health care." In the pre-intervention survey, 73% were willing to do “a lot of effort” to prevent an infection. This proportion was similar (73%) in the 2nd survey, but decreased to 63% in the final survey (p < 0 .01). Among 106 patients who reported starting PVI, 85% reported that PVI felt neutral or pleasant, 9.4% reported a side effect, and 79% reported using it during the past 3 dialysis sessions. Among 102 patients who reported using PVI at 6 months, 87% said it felt neutral/pleasant, 3.9% reported a side effect and 75% reported using it during the past 3 dialysis sessions. Side effects included nasal dripping, congestion or burning/stinging, unpleasant smell, headache, yellow tears, and minor nose bleeding. Conclusions: Hemodialysis patients are not aware of their high risk of infection. Although many were willing to expend a lot of effort to prevent an infection, this willingness decreased during an infection prevention intervention. There were few PVI side effects and most patients stated that PVI felt neutral/pleasant, yet many patients chose to not use PVI. Future research should aim to improve patient education on their risk of infection and assess barriers to adherence with infection prevention interventions.

Disclosure: Marin Schweizer: Speaker- 3M; Contracted research-3M; Anitha Vijayan: Honoraria - Quanta, Baxter, Fresenius Consulting, Astute, NxStage

Background: Staphylococcus aureus (SA) is the most common pathogen causing surgical site infections (SSIs). In the past decade, strategies incorporating new SA decolonization products have been implemented to prevent SSIs in surgical patients. The objective of this cross-sectional study was to determine which pre-operative screening and decolonization strategies are currently utilized in healthcare institutions. Methods: A survey was programmed in REDCap and emailed to members of the Society for Healthcare Epidemiology of America Research Network, the Minnesota chapter of the Association of Practitioners in Infection Control and Epidemiology, and the Minnesota Hospital Association between May-August 2023. We report the prevalence of institutional screening and decolonization strategies and decolonization products used for the prevention of SA SSIs. Results: A total of 153 unique institutions initiated the survey and 111 provided complete data on their institutional screening and decolonization strategies. The most commonly reported strategies included universal decolonization (decolonization of pre-operative patients without screening for carrier status) (n=31, 27.9%), no screening or decolonization (n=24, 21.6%), targeted screening for methicillin-sensitive Staphylococcus aureus (MSSA) or methicillin-resistant Staphylococcus aureus (MRSA) and decolonization based on carrier status (n=24, 21.6%), or MRSA only screening and decolonization (n=11, 9.9%) (Figure 1). Institutions that utilized targeted screening and decolonization strategies frequently reported using nasal mupirocin (n=18, 66.7%MSSA, n=29, 60.4%MRSA), chlorhexidine gluconate (CHG) bathing (n=16, 59.3%MSSA, n=28, 58.3%MRSA), and CHG cloths (n=7, 25.9%MSSA, n=14, 29.2%MRSA) (Figure 2). Among the 31 institutions that reported implementing the universal decolonization strategy, CHG bathing (n=18, 58.1%), CHG cloths (n=15, 48.4%), and nasal povidone iodine (n=14, 45.2%) were the most prevalent decolonization products. Additionally, a smaller percentage of institutions used nasal alcohol gel (n=5, 16.1%) for universal decolonization. Conclusion: Compared to the survey we conducted in 2012, we report a new shift towards universal decolonization and a small increase in targeted SA screening and decolonization.1 In the 2012 survey we reported 37% of respondents’ institutions screened pre-operative patients for SA carriage and the majority of those institutions decolonized carriers.1 Universal decolonization was not reported in the 2012 survey.1 We highlight the continued heterogeneity in practice at this time, which may reflect the ongoing uncertainty in optimal decolonization practices and emphasizes the need for future research. References: 1. Kline, S. et al. Infect Control Hosp Epidemiol 2014;35(7):880-882.

Background: Only a few studies have assessed the relationship between deprivation and excessive antibiotic use. In Texas, antimicrobial prescription is particularly high compared with the rest of the US. This study analyzed the association between local area socioeconomic deprivation and providers’ fluoroquinolone claim rates among beneficiaries 65 years and older in Texas. Method: This ecological study utilized provider- and area-level data from Medicare Part D Prescribers and the Social Deprivation Index (SDI) repositories. To identify geographic patterns and autocorrelation in and between SDI and fluoroquinolone claims, spatial dependence of these two variables was assessed by bivariate Local Indicators of Spatial Association (LISA) cluster mapping along with the global and local Moran’s I analyses. Negative binomial regression models were employed to evaluate the relationship between provider- and area-level characteristics (prescriber’s gender, specialty, rural-urban community area, beneficiaries' demographics, area-level population, and normalized SDI) and fluoroquinolone claim rates per 1,000 beneficiaries. Result: A total of 11,996 providers were included. There was no spatial dependence between SDI and rates of fluoroquinolone claims in Texas (Global Moran’s I =0.01, P=0.618). Bivariant LISA maps showed 85 high-high and 38 low-low spatial clusters. Higher SDI (incidence rate ratio (IRR) 0.98, 95% confidence interval (CI) 0.97-0.99 per 1-unit increment) and male providers (IRR 0.96, 95%CI 0.94-0.99) were associated with lower claim rates. In contrast, several factors were associated with higher claim rates, including non-metropolitan areas (1.04, 95%CI 1.00-1.09), and practices with a high proportion of male patients (IRR 1.12, 95%CI 1.10-1.14), Black patients (IRR 1.05, 95%CI 1.03-1.07), or Medicaid beneficiaries (IRR 1.15, 95%CI 1.12-1.17). Effect modification was observed between SDI and rurality, with higher SDI in non-metropolitan areas associated with higher claim rates, whereas SDI in metropolitan areas was inversely related to claim rates. Conclusion: This study showed that the distribution of high and low SDI and rates of fluoroquinolone claims were more geographically clustered than expected by random chance alone. Lower fluoroquinolone claim rates among Texas Medicare providers were seen in metropolitan areas with higher SDI, indicating potential barriers to care. Conversely, higher claim rates were observed in rural areas with higher SDI, signifying a possible knowledge or attitude gap towards fluoroquinolone use. These findings provide opportunities for public health professionals to explore gaps in the knowledge and attitudes of patients and providers related to antimicrobial use, particularly in rural regions, and investigate barriers to healthcare access in metropolitan areas.

Background: Incorporating diversity, equity, inclusion, and justice into healthcare ensures equitable opportunity to achieve optimal health. Infectious diseases, antimicrobial stewardship, and infection prevention teams rely on consultative recommendations to improve patient care which may be influenced by implicit and explicit biases of the recipient treatment teams. Little is known about how race, ethnicity, and other characteristics impact stewardship and infection control recommendations. Methods: A survey of infectious diseases, antimicrobial stewardship, and infection prevention practitioners was developed through the Society of Healthcare Epidemiology of America (SHEA) Antimicrobial Stewardship Committee. The survey was sent electronically to members of the SHEA Research Network and was promoted to attendees of two sessions at IDWeek 2022 and SHEA Spring 2023. Survey questions included demographics, awareness of (and participation in) unconscious bias and microaggression training at their institutions, antibiotic prescribing bias observations, and perceptions of how race, ethnicity, and other characteristics have influenced participants' antimicrobial stewardship and infection prevention recommendations. Descriptive statistics were performed using SAS V.9.4 . Results: Among 175 survey respondents, 75% (n=129) were White, 16% (n=27) were Asian, 4% (n=7) were Black, 85% (n=150) were non-Hispanic, 5% (n=8) were Hispanic, and 3% (n=5) reported ethnicity as multiethnic. 76% of respondents identified as female, and 2% as non-binary or gender-fluid. 29% of respondents had a medical degree, 12% had a nursing degree, 7% had a pharmacy degree, and 52% had a degree listed as other (7% had a PhD, 23% had an MPH/MSPH degree, and 15% had an MS degree). 65% and 49% of respondents had participated in unconscious bias and microaggression training, respectively. 18% (n=22) of White respondents, 43% (n=3) of Black respondents, and 30% (n=8) of Asian respondents reported witnessing antimicrobial prescribing influenced by race, ethnicity, or other characteristics. 17% and 15% of respondents felt that their antimicrobial stewardship and infection prevention recommendations, respectively, had not been accepted due to their race, ethnicity, gender identity, or other personal identifiers. Conclusion: This survey showed demographic characteristics of professionals working in infectious diseases and their perceptions of how certain aspects of their identity have influenced their recommendations. Differences between racial groups were observed in how frequently respondents witnessed inequities in antimicrobial prescribing, and many respondents felt their recommendations had not been accepted due to their identity. A limitation of this analysis is that few Black individuals completed the survey, which makes comparisons by race difficult; however, the respondents were consistent with SHEA membership demographics.

Background: Inequities in healthcare-associated infections (HAI) incidence and prevention measures are critically important to understand (Chen,2021). While evaluations are beginning to characterize these disparities by infection type (Gettler, 2023), our work expands this by characterizing disparities by prevention strategies. By better understanding how evidence-based prevention strategies are implemented at the patient level, infection preventionists and hospital epidemiologists can better design strategies that provide equitable care to all patients. Methods: Beginning January 2023, gender, race, ethnicity, spoken language, and age group fields were added to daily chlorhexidine gluconate (CHG) treatment and C. difficile test order compliance data captured via electronic medical record. In July 2023, fields on recorded race, ethnicity, and gender were added to well-established foley and vascular access real-time peer audit tools that are used by infection preventionists (IPs). Each prevention strategy variable was summarized by demographic variables and differences in compliance were measured using chi-square tests. Results: 899 vascular audits and 420 foley audits were completed by IPs between July – December 2023. In 2023, there were 114,066 opportunities for CHG Treatment and 1,991 C. difficile test orders. Missing data varied by metric but ranged from 0-60%. Statistically significant differences by race were found in 3 of 8 components (i.e., intact seal, secured catheter and absence of dependent loop) in the foley audit (p < 0 .01) and compliance with C. difficile test ordering (p < 0 .01). No differences in race were found in vascular access audits or CHG treatment. No differences in gender or ethnicity were noted in foley, vascular access audits, CHG treatment compliance, or C. difficile testing. Differences in gender and age were found in CHG treatment compliance (p < 0 .001). Conclusions: By focusing more on patient level process measures rather than only presenting stratified outcomes data, we can identify targeted opportunities for improvement in health equity before our patients develop an HAI. Further evaluations should also focus on assessing the clinical relevance of statistical findings to better inform intervention strategies. Separately, efforts are needed to improve completeness and integrity of demographic data in the electronic medical record.

Background: Among children who start antibiotics for suspected urinary tract infection (UTI) in emergency departments (EDs), 40-60% have negative urine cultures or other results inconsistent with UTI. Practices contributing to excess antibiotic exposure are not well understood. The goal of this study was to understand diagnostic and post-encounter follow-up processes in children who received antibiotics, in order to define targets for intervention. Methods: We identified encounters by children evaluated in two pediatric EDs, over 2 months in the first ED and 9 months in the second ED, to balance different visit volumes. Children 2 months-17 years old were included if they had a urinalysis (UA) and/or urine culture performed, were assigned a primary or secondary diagnosis code for UTI, and initiated antibiotics. Patients were excluded if they received antibiotics prior to the encounter, had prior urologic surgery or device placement, or were immunocompromised or pregnant. Data abstracted by chart review included demographics, documented symptoms, test results, and documented urine culture review and management. Possible UTI symptoms per pediatric criteria included fever, dysuria, urinary frequency, urgency, or hesitancy, suprapubic, abdominal or flank pain, foul smelling urine, or new urinary incontinence. In both EDs, nurses review urine cultures and document changes to treatment plans. Final urine culture results were considered inconsistent with UTI if there was 1) no growth or 2) only mixed growth reported with quantity < 1 00,000 colony forming units/ml. Results: Of 150 eligible children, 146 (97%) had at least one UTI symptom and 146 (97%) had abnormal UA Results: Urine cultures were not performed in 27 (18%) children. Of 123 encounters with urine cultures performed, 71 (58%) had results inconsistent with UTI. Though 67/71 cultures were marked as reviewed, 43/67 (64%) of the patients who could have stopped antibiotics per guideline recommendations did not have documented plans to stop. In those who had documented plans to stop antibiotics, nurses reached 20/23 (87%) caregivers by phone to communicate these recommendations. Conclusion: Many children suspected to have UTI at the time of ED evaluation do not meet criteria for UTI. We found that the most frequent departures from evidence-based practice recommendations were 1) not sending urine cultures, and 2) not stopping antibiotics when culture results did not support the suspected UTI diagnosis. Further investigation should explore barriers and facilitators to these evidence-based practices to develop population- and context-specific diagnostic stewardship strategies.

Background: The Streptococcal pneumoniae urine antigen (SPUA) test was developed to increase microbiologic diagnosis of pneumonia. Concerns have been raised about the test’s low sensitivity and failure to alter outcomes by de-escalating antibiotics (PMID:31956656). However, the cost-effectiveness and real-world clinical utility of the test remain unclear. Methods: From June 1, 2022 - May 31, 2023, all patients with a SPUA test in the MUSC Health System were identified via Epic SlicerDicer. Those with a positive test underwent chart review. Antibiotics were classified as a “broad” or “targeted” regimen for S. pneumoniae. Targeted regimens included penicillins without beta-lactamase inhibitors, 1st-3rd generation cephalosporins, doxycycline, levofloxacin or moxifloxacin (with or without azithromycin), as well as azithromycin monotherapy. Broad regimens included 4th generation or higher cephalosporins, carbapenems, penicillins with beta-lactamase inhibitors, and vancomycin. Results: In one year, 1,518 patients had a SPUA test ordered. 62 (4%) patients had a positive test. Of those 62 patients, 14 patients were discharged before the test resulted (Table). The average turnaround time for the test was 2.2 days. When comparing antibiotic therapy on the day before the SPUA test resulted to two days after the test resulted, only 7 additional patients were switched to a targeted regimen (Figure). Conclusion: Of 1,518 SPUA tests ordered in a year, most (1,456 or 96%) were negative, with minimal changes to antibiotic therapy based on positive Results: These results are similar to other real-world studies, which showed a positive test prevalence between 4-8% (PMID:30265290) with 15-30% of patients changed to targeted antibiotics following a positive result (PMID:23111919, PMID: 28053969). The SPUA test cost approximately $44,022 (based on $29 test price) but has limited utility in a real-world setting.

Disclosure: Krutika Hornback: Speaker’s Bureau - Cepheid Diagnostics

Background: Multiplex molecular tests for infectious diseases can provide highly sensitive results rapidly; however, these tests may more readily detect asymptomatic colonization. There are reports of non-FDA approved laboratory-developed multiplex tests for the diagnosis of urinary tract infections (UTI). Differentiating UTI from asymptomatic bacteriuria is challenging, especially in older adults. The increased sensitivity of multiplex tests may exacerbate this challenge. We sought to describe the use of multiplex testing for UTIs in Medicare claims. Methods: Multiplex testing was identified using carrier claims submitted by non-institutional providers using the Chronic Conditions Warehouse for 2016 – 2022. Because there are no CPT-4 codes specifying UTI multiplex testing, we included claims as described in Figure 1 and categorized claims based on the primary ICD-10-CM diagnosis. The payment amounts for line items related to testing for infectious agents were summed. Laboratories were counted using CLIA numbers listed on corresponding claims. Beneficiaries residing in a nursing home at the time of their claim were identified using stay information derived from the Minimum Dataset 3.0. For comparison, similar characteristics among carrier claims with a CPT-4 code indicating urine culture were also described. Results: Claims for unspecified multiplex molecular tests overall have increased, driven by increases in claims with a primary UTI diagnosis (from 8,521 in 2016 to 386,943 in 2022), while urine cultures have not (Figure 1). In 2022, 65% of all unspecified multiplex tests were linked to a diagnosis of UTI; UTI multiplex claims were associated with 647 laboratories. For UTI claims, the median cost per claim for line items related to multiplex testing was $589 compared to $13 for urine culture-related line items. Overall, 8% of UTI multiplex claims were for beneficiaries residing in a nursing home. Conclusions: Claims for non-FDA approved unspecified multiplex tests associated with a primary diagnosis of UTI have increased >45-times between 2016-2021 and have >45-times higher median costs than urine cultures. The use of this testing in the Medicare population, including nursing home residents, is of potential concern given that inappropriate treatment of asymptomatic bacteriuria has been described to be common in older adults. Research is needed to outline use cases where UTI multiplex testing may be beneficial. Appropriate use of diagnostic testing is important to minimize diagnostic errors and avoid unnecessary antibiotic use.

Background: Clostridioides difficile infection (CDI) is associated with 500,000 infections and 30,000 deaths per year. Inappropriate testing and treatment of patients with asymptomatic colonization occurs frequently (between 15% and 41%). The VA CDI guidelines emphasize avoidance of CDI testing in patients with laxative use within the previous 48 hours due to the high likelihood of non-infectious diarrhea. The objective of this study was to assess laxative administration among inpatients tested for CDI in VA hospitals and identify factors associated with guideline discordance. Methods: Adults hospitalized in Illinois, Wisconsin, and Michigan VA Medical Centers from January 2019-December 2022 with a CDI test performed during the admission were included. CDI tests included Toxin B gene Polymerase Chain Reaction or Toxin Enzyme Immunoassay. Tests were defined as positive, negative, or cancelled according to the diagnostic protocols of the VA testing laboratories. Laxative use, patient demographics, admission data, and comorbidities were collected from the VA Corporate Data Warehouse. Guideline discordant testing was defined as a diagnostic test for CDI ordered within 48 hours of a recorded laxative dose. Factors associated with discordant testing were analyzed using clustered binomial logistic regression models. Analyses were completed using SAS 9.4. Results: There were 7,326 tests ordered for 4,888 patients during the study. Patients were predominantly White (61.8%), male (95.6%), and elderly (mean age=70.0 standard deviation=12.1). Most (59.0%) patients had received at least one dose of laxative in the 48 hours preceding their CDI test. Being Black (Odds Ratio (OR)=0.86 (95%Confidence Interval (95%CI) =0.76,0.98) or Hispanic (OR (95%CI) =0.62(0.48,0.82) vs White) was associated with a decreased likelihood of inappropriate testing due to recent laxative use. Being tested at a rural facility (OR (95%CI) =1.23 (1.07,1.41) vs urban), within a long-term care (LTC) unit (OR (95%CI) =1.67 (1.41,1.97) vs inpatient), or within an intensive care unit (ICU) (OR (95%CI) =1.40 (1.24,1.59)) were all associated with an increased likelihood of being inappropriately tested. Guideline discordant tests were more likely to have negative results (OR (95%CI) =1.25 (1.05,1.49)) compared to guideline concordant tests. Discussion: Laxative administration in the 48 hours preceding CDI testing was common among hospitalized Veterans and associated with a lower likelihood of positive Results: This echoes non-VA studies where laxative use was reported at 44%. An increased likelihood of guideline discordant testing in ICU and LTC settings suggests the need for greater diagnostic stewardship interventions. Additionally, further work to determine negative outcomes associated with inappropriate testing are needed.

Background: Carbapenem-resistant Acinetobacter baumannii (CRAB) and Pseudomonas aeruginosa (CRPA) are drug-resistant pathogens causing high mortality rates with limited treatment options. Understanding the incidence of these organisms and laboratory knowledge of testing protocols is important for controlling their spread in healthcare settings. This project assessed how often Veterans Affairs (VA) healthcare facilities identify CRAB and CRPA and testing practices used. Method: An electronic survey was distributed to 126 VA acute care facilities September-October 2023. The survey focused on CRAB and CRPA incidence, testing and identification, and availability of testing resources. Responses were analyzed by complexity of patients treated at VA facilities (High, Medium, Low) using Fisher’s exact tests. Result: 77 (61.1%) facilities responded, most in urban settings (85.4%). Most respondents were lead or supervisory laboratory technologists (84.2%) from high complexity facilities (69.0%). Few facilities detected CRAB ≥ once/month (4.4%), with most reporting that they have not seen CRAB at their facility (55.0%). CRPA was detected more frequently: 19% of facilities with isolates ≥ once/month, 29.2% a few times per year, and 26.9% reporting had not seen the organism. No differences in CRAB or CRPA incidence was found by facility complexity. Nearly all facilities, regardless of complexity, utilize the recommended methods of MIC or disk diffusion to identify CRAB or CRPA (91.9%) with remaining facilities reporting that testing is done off-site (7.8%). More high complexity facilities perform on-site testing compared to low complexity facilities (32.0% vs 2.7%, p=0.04). 83% of laboratories test for Carbapenemase production, with one-fourth using off-site reference labs. One-fourth of facilities perform additional antibiotic susceptibility testing for CRAB and CRPA isolates, most of which test for susceptibility to combination antibiotics; no differences between complexities were found. Agreement that sufficient laboratory and equipment resources were available was higher in high complexity than in medium complexity facilities (70.7% vs 33.3%, p=0.01), but not low complexity facilities (43.8%). Conclusion: Having timely and accurate testing protocols for CRAB and CRPA are important to quickly control spread and reduce associated mortality. This study shows that most VA protocols follow recommended testing and identification guidelines. Interestingly, there was no difference in CRAB or CRPA incidence for facilities providing higher vs lower complexity of care. While high and low complexity facilities generally reported sufficient resources for CRAB and CRPA evaluation, some medium-complexity labs, who may feel more compelled than low-complexity labs to bring testing in house, reported that additional resources would be required.

Background: Clinically non-indicated asymptomatic bacteriuria (ASB) identification precipitates higher reported catheter-associated urinary tract infection (CAUTI) rates and urinary tract infection (UTI)-directed antimicrobial overuse. Published diagnostic stewardship interventions to reduce ASB were mostly tested individually and heterogeneously; hence the optimal bundle approach is yet to be defined. Methods: We performed a single-center sequential quasi-experimental study involving hospitalized, emergency, and long-term care patients at a VA healthcare facility, retrospectively comparing standard of care (period 1: 1/1/2022-6/30/2022) to adding dedicated provider education on facility-approved urine-culturing indications (period 2: 7/1/2022-1/19/2023), then adding an electronic clinical decision support (CDS) tool (Figure 1) mandating urine-culturing indications selections (period 3: 1/20/2023-6/30/2023), then prospectively adding real-time case-based physician-generated audit/feedback emails on ordering appropriateness (period 4: 7/1/2023-12/31/2023). We randomly sampled approximately 500 orders from each period and measured the impact on the rate of urine reflex/culture orders, the percentage of non-indicated orders and ASB, UTI-directed antimicrobial usage, and facility-wide CAUTI rates. Results: We analyzed 2140 urine reflex/culture orders (Table 1 and Figure 2). The mean monthly orders per 1000 bed-days and percentage of non-indicated orders decreased with each intervention to one-fourth of the initial values by period 4 (p=0.0002). The ASB rate among positive cultures was unchanged from periods 1 to 2 but started to decrease in period 3 with the biggest impact in period 4 (p=0.01). Non-indicated and ASB-directed antimicrobial courses both followed the previous pattern, dropping from 28% and 26% baseline to 6% and 4% by the study conclusion (p=0.015 and 0.008), respectively. Estimated UTI-directed antimicrobials decreased by 34% (363/551) with antimicrobial-days saved from 4093 to 2846 per 6-month period. CAUTI rate relatively declined with each intervention, along with a reduction in ASB-attributed CAUTI’s from 45% (5/11) initially to 20% (1/5) in period 4. Conclusion: A stepwise urine-culturing diagnostic stewardship approach of clinical education, electronic CDS tool, plus real-time audit/feedback decreased overall urine reflex/cultures, non-indicated ordering, ASB identification, unnecessary antimicrobials, and CAUTI rates, with the greatest impact after bundling all interventions including order appropriateness audit/feedback.

Background: Infectious Diseases Society of America guidelines recommend antibiotic prescribing for urinary tract infections (UTIs) when there is a positive culture and signs and symptoms of infection. Despite these guidelines, prescribing for asymptomatic bacteriuria remains prevalent. We conducted a chart review of UTI outpatient encounters to determine the prevalence of antibiotic prescribing as well as patient and provider factors associated with inappropriate prescribing for UTIs. Methods: Patients who were seen at any Department of Veterans Affairs (VA) outpatient clinic with a positive urine culture from 1/1/2019-12/31/2022 were evaluated for inclusion. Exclusion criteria were pregnancy, neutropenia, neurogenic bladder, spinal cord injury/disorder, chronic kidney disease stage III and above, and those undergoing urologic surgical procedures within 7 days. Inappropriate prescribing was defined as an antibiotic prescription given for UTI treatment when no signs or symptoms of infection were recorded during the patient encounter. Chi-square, Fisher’s exact and t-tests were used to evaluate the association between patient and provider characteristics and antibiotic prescribing. Results: Among 341 visits, most patients were male (70%), White (40%), older (mean age of 65.8 ± 15.9 years) and treated at an urban facility (57%). Antibiotics were prescribed for 67% (229/341) of visits. Of the 229 antibiotic courses prescribed, 119 (52%) were appropriate; issued to patients with > = 1 sign or symptom consistent with a urinary tract infection. The most common symptom recorded was dysuria, followed by frequency, urgency, and hematuria (Figure 1). The remaining 110 (48%) antibiotic prescriptions were inappropriate; given to patients without documented UTI-related signs or symptoms. The proportion of inappropriate prescribing was higher among advanced practice practitioners (39/56; 69%) compared to physicians (68/113; 60%; P < 0 .0001). Prescribing of an antibiotic did not differ by gender (p-value=0.3779), race (p-value=0.3972), age (p-value=0.7461) or urban versus rural geography (p-value=0.3647). Discussion: In outpatient clinics, nearly half of antibiotics prescribed to patients with a positive urine culture occurred in the absence of documented of signs or symptoms of a UTI. These results suggest that interventions to improve antibiotic use for UTI-related concerns in the outpatient setting should address UTI-related signs and symptoms as well as asymptomatic bacteriuria. Advanced practice practitioners were more likely to prescribe without documentation of relevant signs or symptoms than physicians. Improving meaningful documentation about the presence or absence of signs and symptoms of a UTI may help reduce inappropriate antibiotic prescriptions in the outpatient setting.

Disclosure: Robin Jump: Research support to my institution from Merck and Pfizer; Advisory boards for Pfizer

Background: Inappropriate diagnosis and treatment of urinary tract infections (UTI) contributes to antibiotic overuse. The Inappropriate Diagnosis of UTI (ID-UTI) measure—which quantifies the percentage of treated bacteriuria that is asymptomatic (ASB) using a standard definition of UTI—has been validated in acute care hospitals, but not in critical access hospitals (CAHs) where resources differ. Methods: From October 2022-July 2023, ten CAHs participated in a program to reduce ASB treatment, including education, coaching, and hospital feedback using the ID-UTI measure. Our primary aim was to assess performance characteristics of the ID-UTI standard definition and measure in CAHs (Figure 1). Non-physician abstractors from each CAH submitted clinical data (e.g., signs/symptoms) via REDCap for consecutive adult patients who were admitted or discharged from the emergency department and received antibiotics for bacteriuria. The case abstraction goal for each CAH was 5-6 cases/month. To assess feasibility, we evaluated the ability of each CAH to achieve goal case abstractions. To assess validity and reliability of the ID-UTI standard definition, two physicians reviewed 10% of submitted cases using deidentified patient notes and assessed agreement with the standard ID-UTI definition and consensus clinical opinion. Based on submitted data, we provided bi-monthly feedback reports to CAHs including the hospital-level ID-UTI measure to benchmark progress and for peer comparison. We measured monthly change in the ID-UTI measure using a mixed-effects logistic regression model (Figure 1, Figure 2). Results: Among 10 CAHs, 4 (40%) submitted >59 cases over 10 months (goal) while 3 (30%) submitted >35 cases (secondary goal). Physician reviewers assessed 9.5% (58/608) of cases. Utilizing the ID-UTI standard definition, there was high agreement (93%) in ASB vs UTI designation between each physician reviewer and the CAH’s REDCap assessment (Figure 3). Compared to clinical opinion, the ID-UTI standard definition identified 48% (16/33) of ASB cases and 100% (25/25) of UTI cases (Figure 4). Over the program, the percentage of cases treated for UTI that were ASB decreased from 28.4% (range 0-63%) to 18.6% (range, 0-33%; p=0.055) (Figure 5). Conclusions: Case abstraction with use of the ID-UTI measure was feasible and reliable to implement with modifications for CAHs. Data collection by untrained staff was as reliable as physician adjudication. Though the ID-UTI standard definition undercounted ASB cases (low sensitivity), cases reported as ASB were always ASB when adjudicated (high specificity). The program, including performance feedback using the ID-UTI measure, was associated with a trend toward lower treatment of ASB.