Background: Outbreaks of carbapenemase-producing (CP) organisms (CPOs), including carbapenem-resistant Enterobacterales (CRE), in neonatal intensive care units (NICUs) are not well documented. The Centers for Disease Control and Prevention (CDC) identifies CP-CRE as an urgent threat to United States (US) healthcare facilities. Wadsworth Center, the New York State (NYS) Department of Health’s (NYSDOH’s) public health laboratory, participates in CDC’s Antimicrobial Resistance Laboratory Network to provide CPO identification, characterization, and surveillance. NYSDOH investigated an outbreak of CP-CRE Escherichia coli (E. coli) infections in NICU patients reported by one hospital. Method: Hospital A reported a CRE E. coli outbreak in their NICU to NYSDOH, as required by NYS Sanitary Code. In response, epidemiologists reviewed case data, conducted case finding, and provided infection control guidance to the hospital. Hospital A continued NICU clinical surveillance and conducted colonization screening to detect additional cases of CRE E. coli. The Wadsworth Center Antimicrobial Resistance Laboratory Network tested isolates from affected patients for CP genes and performed whole genome sequencing (WGS) to determine the CP gene variant, multilocus sequence type (MLST), and relatedness by mutation event (ME) analysis. NYSDOH epidemiologists assessed Hospital A’s infection control practices in affected areas and provided recommendations. Result: Hospital A identified two CRE E. coli infections in NICU patients with overlapping admissions in June-July 2023. Retrospective surveillance identified a third CRE E. coli case in an adult medical intensive care unit patient on admission to Hospital A in June 2023, with prior hospitalization April-May 2023. WGS analysis identified the blaNDM-5 gene in all three CRE E. coli patient isolates. The two NICU patients’ isolates had the same MLST (361/650) and differed by 9 MEs, indicating relatedness to each other and not the adult patient’s (MLST 167/2). NICU patient colonization screening identified no additional blaNDM-5 E. coli cases. NYSDOH’s NICU infection control assessment found that both cases were in adjacent isolettes within three feet of each other. Clean isolettes, equipment, and supplies for new admissions were stored in the clinical care space, not in a separate clean area. Conclusion: CP-CRE is an urgent threat to US healthcare facilities, including hospital NICUs. Though the incidence and prevalence of CP-CRE blaNDM-5 E. coli are not well-defined in NY, single healthcare-associated cases in NICU populations represent an outbreak. The Wadsworth Center Antimicrobial Resistance Laboratory Network’s contributions complement traditional epidemiologic surveillance and investigation methods to provide more specific, comprehensive infection

Background: Mycobacterium tuberculosis transmission through contaminated bone allograft product is unusual and was first described in 2021 with a second outbreak in 2023. In July 2023, Michigan Medicine conducted contact tracing for healthcare personnel (HCP), patients, and visitors following exposure to an immunocompromised patient with surgical site infection and subsequent widely disseminated tuberculosis (bacteremia, pulmonary, lymphadenopathy) following spinal fusion with bone allograft in April 2023. The patient was in the emergency department, operating room (OR), and inpatient units for 9 days prior to initiation of Airborne Precautions (AP). Methods: Michigan Medicine is a 1,107 bed academic hospital. HCP are screened for tuberculosis with interferon-gamma release assay (IGRA) testing upon hire and following tuberculosis exposure. Exposure testing includes baseline IGRA testing and follow-up testing at 10-12 weeks post exposure. Exposure criteria for this investigation was defined as sharing room airspace with the tuberculosis patient prior to initiation of airborne precautions or Central Sterile Processing Department (CSPD) staff involved with instrument decontamination without the use of a respirator. Of note, universal masking with surgical masks was not required during this time for staff and patients/visitors, with the exception of CSPD and OR staff. Contact tracing was performed by Infection Prevention and Occupational Health Services managed all test results and conversions. Results: 176 employees from perioperative care areas (n=30), CSPD (n=7), OR (n=9) and inpatient units (n=130) were IGRA tested. Five employee conversions were identified: one surgeon, one circulating OR nurse, two CSPD decontamination staff, and one respiratory therapist. At time of detection, none of the conversions had evidence of active tuberculosis. Additionally, 46 patients and visitors were tested with zero conversions. HCP compliance with IGRA testing was initially 15% before engagement from hospital and unit leadership and human resources. With intervention, employee compliance reached 100%. Conclusion: Despite standard use of surgical masks for OR and CSPD staff, aerosolization of infected bone graft material played an important role in tuberculosis transmission during surgery and instrument cleaning. Respiratory therapy practices in the ICU setting likely also increased risk for pulmonary tuberculosis transmission. Achieving 100% HCP compliance for baseline and follow-up IGRA testing is challenging and requires engagement of both unit and hospital leadership and human resources to ensure all HCP are tested.

Background: At the onset of an outbreak, immediate infection, prevention and control (IPC) measures and strategies are critically important in stopping the transmission. During the 2022 Sudan Virus Disease (SUDV) outbreak in Uganda, the IPC technical working group (TWG) adopted the WHO ring approach for intensive and targeted IPC support to interrupt transmission in high-risk areas and healthcare facilities (HCFs). Objectives: a) Leverage surveillance and epidemiological activities to guide response efforts and implement targeted IPC interventions. b) To rapidly interrupt SUDV transmission at the source through multiple IPC interventions. Methods: The IPC TWG delineated outbreak perimeters (rings) to include health facilities and community sites within 500 meters in urban centres and 1 kilometer in rural areas around each confirmed case. A data base with this information was developed and updated daily with information provided by the surveillance team. To activate response within 12 hours, interventions included rapid needs and risk assessments , health educational materials, deployment of decontamination teams and district IPC mentors with hygiene supplies delivered within 24 hours and a 72-hour follow-up. Trained Village Task Forces (VTF) and IPC mentors conducted health education, set up screening points, holding units, and rapid notification channels. Results: 56 rings including HCFs (38) and community sites (78) were identified within the radius of confirmed cases. Using the IPC scorecard, health facility mean scores significantly increased from 18% to 61.7% at follow-up in three weeks. Community WASH baseline scores improved from 11.1% (inadequate) to 69% with a basic level in two weeks. There was marked reduction in the incidence of new cases in the epicentre within the first 32 days. Conclusion: The results suggest that the IPC ring approach is an instrumental strategy health ministries can adopt to rapidly provide targeted comprehensive support at the source to interrupt transmission. A collaborative effort across pillars and partners in the implementation of the ring approach is key through concerted efforts and information sharing across response pillars.

Background: Invasive aspergillosis (IA) poses a substantial threat to morbidity and mortality, particularly among immunocompromised individuals. In 2023, a New York City Intensive Care Unit (ICU) experienced an aspergillus outbreak following a structural water leak, resulting in two patients diagnosed with Invasive Aspergillus niger in their bronchial cultures. Immediate interventions, including patient relocation and ICU reconstruction were implemented to mitigate further impacts. This study aims to assess the impact of timely relocation of patients and renovation of the ICU, on the incidence of invasive aspergillosis. Method: A quasi-experimental study design of ICU patients over a nine month period included surveillance by the Infection Prevention department from March 1 to December 1, 2023. Surveillance included review of microbiology reports, environmental cultures, and patient chart reviews. The Pre-intervention spanned March 1 to May 1, and the post-intervention from May 4 to December 1. Indoor mold assessments of pre- and post-intervention involved testing wall surfaces for moisture, air sample collection for fungal spores, and surface swabs for direct fungal analysis. The intervention included relocating all seventeen patients from the impacted ICU and comprehensive reconstruction. Reconstruction involved the removal and replacement of all sheetrock within the unit extending four feet from the floor with moisture-resistant sheetrock. Additionally, moisture resistant single sheet welded vinyl flooring and cove-bases were installed. All heating, ventilation, and air-conditioning (HVAC) systems were inspected and cleaned. Construction activities strictly adhered to Infection Control Risk Assessment (ICRA) guidelines, with emphasis on maintaining negative pressure, to ensure a safe environment. Result: Environmental swab samples from 50% of ICU rooms indicated growth of Aspergillus/Penicillium, Chaetomium, and Stachybotrys/Memnoniella type spores during the pre-intervention phase. Environmental microbiology results strongly suggest the indoor environment as the fungal spore source, with the presence of fruiting structures indicating surface mold growth. Indoor air samples, when compared to outdoor samples collected during pre-intervention, showed rare (2-6 raw count) growth of Aspergillus in 55% of the sampled rooms and subequently no growth post-intervention. Prospective surveillance revealed no further aspergillus growth in the ICU population and environment. Conclusion: Our findings highlight a potential correlation between environmental modifications and reduced IA incidence. Swift mitigation and structural interventions are crucial in averting potentially fatal outcomes, marking a significant advancement of prevention strategies for inner-city hospital settings. Although promising, study limitations include the inability to speciate environmental aspergillus for comparison to patient bronchial cultures and the absence of baseline bronchial cultures for affected patients on admission.

Carbapenamase-producing carbapenem-resistant Enterobacterales (CP-CRE) is an urgent public health threat for healthcare facilities. Solid organ transplant (SOT) recipients carry an increased risk for CRE infection and colonization due to prolonged exposures to antimicrobials, healthcare facilities and immunosuppression. CRE infection in SOT patients is associated with an increase in morbidity and mortality. Here, we describe a hospital outbreak investigation of three cases of New Delhi metallo-beta-lactamase (NDM) - CRE that led to novel findings with implications for further interdisciplinary investigations. An NDM-CRE infection in a critically-ill patient was identified during passive surveillance and prompted an investigation. Previous CP-CRE passive surveillance cases were reviewed. Rectal screening was performed for potentially exposed patients. 403 rectal swabs were tested for carbapenemase genes in active surveillance. Patients identified to have a new NDM-CRE isolate on active or passive surveillance were considered cases and underwent in-depth chart review including possible patient-to-patient exposures, hospital locations, procedures, devices, and consultations. NDM-CRE isolates were sent to the Minnesota Department of Health (MDH) for whole genome sequencing (WGS) to assess relatedness. Five NDM-CRE cases were identified, with all isolates harboring blaNDM including three NDM-Klebsiella pneumoniae (NDM-KP) cases (Figure 1). The first NDM-KP case, patient 1, developed mediastinal infection following lung transplantation. Review of United Network for Organ Sharing revealed that respiratory specimens from patient 1’s donor grew NDM-KP and a bronchial wash at the time of transplant yielded NDM-KP. The second NDM-KP case (patient 3) developed ventilator-associated pneumonia and was found to have used sequentially the same ventilator as patient 1. The third NDM-KP case (patient 4) was detected via rectal swab in active surveillance and shared wound care personnel in common with patients 1 and 3 (Figure 2). WGS demonstrated two single nucleotide polymorphisms (SNP) among all three isolates, strongly suggesting relatedness (Figure 3). Best practices for infection prevention were reviewed with wound care personnel. To date, no further NDM-KP isolates have been identified. Investigation was facilitated by in-depth chart review and WGS via the Central Region Antimicrobial Resistance Laboratory Network at MDH. Detection of the NDM-KP from a lung donor specimen appears genetically linked to clinical isolates in other patients, raising the possibility of a donor-derived hospital outbreak. This investigation is the first to describe a donor-derived NDM outbreak in a healthcare facility. Communication between organ procurement agencies, transplant centers, and infection prevention must be optimized to prevent CRE-associated morbidity in SOT receipts and CRE hospital outbreaks.

Background: On March 23, 2022, the Minnesota Department of Health (MDH) was notified of Klebsiella pneumoniae carbapenemase (KPC)-producing Klebsiella oxytoca isolated from a resident’s urine in long-term care facility A (LTCF-A). Carbapenem-resistant Enterobacterales (CRE) are reportable statewide with required isolate submission to MDH Public Health Laboratory (MDH-PHL), where carbapenemase production and mechanism identification is confirmed. Methods: MDH partnered with LTCF-A on a containment response, including infection prevention and control (IPC) measures, KPC-CRE education, and colonization screening. Rectal swabs were screened for carbapenemase genes by real-time PCR (Cepheid Xpert Carba-R), with positive specimens undergoing culture, isolation, and whole genome sequencing (WGS). MDH-PHL conducted WGS including multilocus sequence typing (MLST) and single nucleotide polymorphism (SNP) analysis to describe genetic relationships among isolates. When screening indicated a potential environmental source, due to species diversity and ongoing resident transmission, an environmental screening plan was developed including collection of premise plumbing samples from room faucets, aerators, sinks, toilets, and shared shower drains. Results: KPC-CRE was detected in 23 residents (urine, n=2; rectal swab, n=21) during March 2022–November 2023. 21 isolates comprising 10 Enterobacterales species were cultured from KPC-positive screening specimens. SNP analysis performed on bacteria of the same species demonstrated 5 distinct clusters of relatedness comprising 2-3 residents per cluster (Cluster 1: Klebsiella oxytoca, n=3; Cluster 2: Klebsiella oxytoca, n=3; Cluster 3: Escherichia coli, n=2; Cluster 4: Klebsiella pneumoniae, n=2; Cluster 5: Raoultella planticola, n=2). 7 KPC-positive resident specimens did not yield a culturable organism. KPC-CRE was detected throughout the premise plumbing including 8 of 9 shared shower room drains and 6 of 75 resident room sink drains. WGS and SNP analysis suggest relatedness among resident and environmental KPC-CRE isolates. Gaps in IPC measures including hand hygiene, use of personal protective equipment (PPE), environmental cleaning and disinfection, and sink hygiene practices were observed during onsite assessments. Use of an EPA-registered biofilm disinfectant in facility drains and repeated environmental sampling has demonstrated a decrease in KPC-harboring bacteria within the premise plumbing, but not complete elimination. Conclusion: Containing the spread of KPC-CRE within LTCF-A has been challenging due to environmental reservoirs of KPC-CRE along with insufficient implementation of IPC practices. Continued colonization screening has been necessary to detect newly colonized residents and reinforce efforts to increase IPC compliance. Strict implementation and adherence to IPC measures, including those that minimize the spread of KPC-CRE from facility premise plumbing, are needed to fully halt KPC-CRE transmission within LTCF-A.

Background: Candida auris is an opportunistic pathogen reported in the US since 2016. C. auris infections (CAI) are frequently healthcare-associated, but only one case of donor-derived CAI in a lung transplant recipient has been reported (PMID 28520901). We describe a cluster of two CAIs at a single center in South Carolina occurring in 2 different recipients from the same solid organ transplant donor. Methods: We describe two cases of invasive CAIs occurring in an academic medical center without prior CAI in Charleston, SC in October 2023. C. auris was identified using Bruker MALDI-TOF and confirmed by the state health department. Results: Patient 1: 40-49 year-old male underwent heart transplantation on day 19 from admission complicated by growth of C. auris on post-op day #15 from a drain. He was readmitted post-op days 22-63 with positive blood cultures for C. auris and underwent re-operation with debridement and hardware removal. C. auris pericarditis required multiple returns to the OR (Figure). He was discharged on micafungin/posaconazole with plans for long-term antifungal therapy. Patient 2: 50-59 year-old male underwent liver and kidney transplantation on day 25 from admission from the same donor as Patient 1 in a separate hospital complex. His course was complicated by possible infected biloma not amendable to drainage and C. auris/C. glabrata fungemia, which was further complicated by abdominal wall collection cultures growing C. auris on post-operative day 35 on washout. He was managed with dual micafungin/posaconazole however, he died of unrelated causes at 93 days after transplant (Figure). Investigation: The donor for both recipients was a 10-19 year-old male who suffered brain death after trauma and was hospitalized for 56 days prior to procurement in Atlanta, GA without known CAI. Airway cultures at the time of organ procurement were positive for rare Pseudomonas and light unidentified yeast of multiple morphologies; urine cultures also grew 40,000 cfu/ml un-identified yeast. Screening of 35 and 4 inpatients in units exposed to patients 1 & 2, respectively, with axilla/groin PCR was negative (Figure). A third organ recipient for this donor (kidney) at our center was identified and had negative urine fungus cultures. Conclusions: Despite no definitive link to a known donor infection, this cluster of CAI occurring simultaneously in 2 patients in separate hospitals/units at a single center with no known prior cases represents likely donor-derived CAI. Our experience suggests that organ procurement organizations should consider improved screening techniques for C. auris in donor cultures.

Disclosure: Scott Curry: Consultant- Ferring; Abbott Diagnostics- Speaker honorarium

Background: Nontuberculous mycobacteria (NTM) are ubiquitous potential pathogens implicated in healthcare-associated outbreaks. There is a paucity of studies describing transmission risk in the healthcare setting. To estimate the potential healthcare-associated transmission of NTM, we characterized the frequency of NTM clinical isolates across our multi-facility healthcare system. Method: We performed a retrospective review of all clinical NTM isolates at 21 healthcare facilities in a large health system between January 2019 through June 2023 (inclusion criteria: all first unique species). We analyzed the quarterly frequency of isolates for each species, by facility. We identified higher-than-expected species frequencies, which was defined as a quarterly frequency ≥50% higher than the average quarterly frequency for that facility, for the entire study period (analysis omitted for any hospital with an average quarterly frequency 10 unique patient isolates in any 12-month period or >2 in a single month except for M. abscessus at Hospital A. The quarterly frequency of the three most common species among hospitals with ≥2 unique isolates per 12-month period are displayed in figure 2. An increase of 50% from the average quarterly infection count occurred 34 times for M. avium complex across 10 hospitals, 14 times for M. gordonae across 2 hospitals and 14 times for M. lentiflavum across 2 hospitals (Figure 3). Conclusion: A diverse group of NTM were isolated across our healthcare system over the study period, most commonly M. avium complex, M. gordonae, and M. lentiflavum, each with hospital-specific temporal frequencies that suggest the potential for undetected outbreaks, while frequencies of less commonly isolated species were rarely suggestive of potential undetected outbreaks. Further epidemiologic investigation of in-hospital transmission routes, with whole genome sequencing to determine genetic relatedness, is necessary to identify undetected outbreaks.

Background: The COVID-19 pandemic required an increased reliance on and utilization of the inpatient nursing workforce. We aim to examine the psychological safety of U.S. inpatient acute care nurses in the two years following the onset of COVID-19. Method: Participants were recruited for participation across two major metropolitan medical centers in the tristate area, six units per site (12 total). Anonymous Qualtrics survey invitations were distributed through work listservs in the first halves of 2022 and 2023. The invitation was open to registered nurses who provided at least 16 hours/week of direct patient care for at least six months at the hospital. The survey was open for 4-6 weeks, with reminders sent every other week. Nurses were offered a $25 gift card the firs year and $35 the second. Nurses were asked to rate how frequently they experience seven conditions indicative of psychological safety in their work environment from 1 = “Never” to 5 = “Always”. Two items were reverse coded in analysis as the prompts were negatively phrased. Blank and ineligible responses were excluded from the analytic sample. As response distributions were skewed, Wilcoxon rank-sum tests were used to analyze differences between years (alpha = 0.5). Blank and ineligible responses were excluded from the final analytic sample. Result: We achieved an overall response rate of 52% for each survey year (n=258 Year 1, n=221 Year 2). Psychological safety was found to be low overall for both years, but lowest for Year 1 (3.5 vs. 3.7, p=0.0132). The highest rated condition in both years was “When a medical error occurs at this hospital, health care workers are encouraged to discuss mistakes in order to learn how to prevent similar future errors” (4.0 Year 1 vs. 4.2 Year 2, p=0.0054). The lowest rated condition changed across years. For Year 1, “At this hospital, people are too busy to invest time in improvement” (reverse coded) received the lowest rating at 3.1 (vs. 3.3 in Year 2, p=0.0685). For Year 2, “If you make a mistake at this hospital, it is often held against you” became the lowest rating at 2.9 (vs. 3.4 year 1, <.0001). A summary of the psychological safety conditions is presented in Figure 1. Conclusion: Nurses in our study reported low psychological safety during the end of the COVID-19 pandemic. This has implications for overall patient safety and for nursing staff retention in acute care units.

Background: Invasive candidiasis, including candidemia, is a significant cause of morbidity and mortality in medically complex and immunocompromised children. Understanding the epidemiology and antifungal susceptibility patterns of Candida infections could help guide empiric antifungal therapy. Methods: This fungal antibiogram was created at a large quaternary children’s health system in Georgia. Blood isolates positive for Candida spp. from 2019 through 2023 were included. The number and percentage of isolates for each Candida spp was recorded by year and then as the combined 5-year total. The Clinical and Laboratory Standards Institute (CLSI) antifungal interpretative criteria were used, and we only included one unique Candida spp isolate per patient. Due to the limited number of isolates, the combined 5 years of isolates were used to create the fungal antibiogram. Data are shown as percent susceptible using CLSI interpretative criteria and number of isolates. Results: Between 2019 and 2023 there were 124 unique blood isolates of Candida spp identified. The most common isolates were C. albicans (33%), C. parapsilosis (27%), C. glabrata (14%) and C. tropicalis (11%). Over the 5 years of the study, the percentage of C. albicans isolates decreased from 47% to 21%. The change in epidemiology was not driven by a single Candida species but varied from year to year. For C. albicans, susceptibility was 100% for fluconazole and micafungin. For C. parapsilosis, susceptibility to fluconazole and micafungin was 97% and 94%, respectively. Fluconazole susceptibility was lowest for C. glabrata (88%) and C. krusei (0%). Using CLSI epidemiological cutoff values (ECV) to evaluate the amphotericin B results, none of the isolates had results greater than the CLSI ECVs. Comparing 2019 and 2023, the percentage of Candida blood isolates resistant to fluconazole increased from 5% to 18.5%. Conclusion: C. albicans was the most frequently identified cause of candidemia in children, but there was a gradual increase in fungemia caused by other Candida spp. over the past 5 years including Candida with fluconazole resistance. Overall, our findings demonstrate high susceptibility rates to fluconazole and echinocandins in Candida spp. blood isolates. Further research is needed to identify risk factors for antifungal resistant candidemia in pediatric patients.

Disclosure: Mark Gonzalez: Honoria for a one time consulation with NaviDx consulting in May of 2022. Honoria from the American Society for Microbiology for writing of a chapter in the Clinical Microbiology Procedures Handbook.

Background: Quality improvement (QI) efforts within Infection prevention and control (IP&C) programs to reduce risk of device-related infections in the acute care setting are well described. However, less focus has been placed on continued prevention in the homecare setting. This QI project illustrates the benefits of IP&C involvement in reducing tracheitis in pediatric homecare patients. Methods: The homecare multidisciplinary IP&C team implemented a series of QI initiatives aimed at reducing incidence of tracheitis beginning in 2016. Initial interventions included increasing oral care frequency to every four hours, inpatient training for new tracheostomy patients and families before discharge, and an optional inpatient simulation training resource to provide hands-on practice. Enhanced educational interventions included caregiver learning modules and competencies completed with their primary nurse in the home every ninety days and following a tracheitis infection. Practice changes and education efforts were further sustained with the creation and distribution of laminated tracheostomy care teaching sheets to patient homes. Quarterly tracheitis infection rates were tracked using a U-chart. Organism distribution in tracheitis cases were compared across the baseline (2015-2018) and post-intervention periods (2019-2023) using the Chi square test. Analyses were performed using Stata Statistical Software: Release 18 (College Station, TX: StataCorp, LLC) with two-tailed alpha level of 0.05. Results: Quarterly tracheitis infection rates from 2015 through 2023 are displayed in the Figure. Notably, the baseline period, established Q1 2015 through Q4 2017, revealed a consistent rate of 1.08 tracheitis infections per 1000 tracheostomy days. During this initial phase, changes in oral care frequency and enhanced educational resources were implemented to decrease rates. Following these interventions, a significant shift was observed in Q1 2019, with the new baseline rate drastically reduced to 0.32 infections per 1000 tracheostomy days. This denotes a remarkable 70% improvement from the prior average infection rate which has been sustained through Q4 2023 with the laminated teaching sheets. The most frequently identified organisms across both time periods are displayed in the Table. Pathogen distribution was similar following QI interventions (p = 0.50). Conclusions: Tracheitis infections were reduced by 70% through implementation of multidisciplinary homecare IP&C QI efforts. IP&C programs are integral to pediatric homecare.

Introduction: Neonatal sepsis (NS) is a global public health concern, particularly affecting developing countries. Challenges in diagnostics, more specifically, culture and antimicrobial susceptibility testing hinder effective management of the disease. Objective: This study aims to evaluate the burden, describe the management, and assess the evolution of NS in a hospitalized pediatric population in Haiti. Methods: A retrospective cohort study from January 2013 to December 2018 at La Paix University Hospital was conducted. All-cause hospitalizations and deaths were extracted from hospital’s Neonatology Unit records and were used to derive data regarding hospitalization and death among patients under 28 days with NS. Clinical and laboratory data were extracted from the patients’ medical records. Results: Out of 2,424 post-childbirth hospitalizations, 1,590 involved sepsis. The percentage of hospitalization due to NS was approximately 69% and the percentage of deaths, 65%. The mean age of patients with NS was 3.75 days (0 - 22 days), with a slight male predominance (55%, p < 0.001). Peaks were observed from May to August (p = 0.02). Early NS cases (NS in patients aged less than 7 days) were most prevalent (86%, p < 0.001). Specimen culture and antimicrobial susceptibility testing was less frequent (7%) than complete blood count usage (65%). Findings regarding blood count included leukopenia (3%), thrombocytopenia (30%). A positive CRP and acute renal failure were noted in 76% and 21.7% of cases, respectively. The average hospital stay was 7.3 days. With regards to treatment, 73% of patients received a 2-drug antimicrobial therapy (ampicillin-gentamycin) and 22% received a 3-drug antimicrobial therapy (ampicillin-gentamycin-cefotaxime). Of all newborns hospitalized for NS, 49% received empirical antibiotic therapy within 3 hours of admission. Conclusions: This research highlights NS as a public health emergency in Haiti. The study advocates for improved access to culture and antibiotic susceptibility testing and emphasizes the impact of timely antibiotic administration. The findings of this study serve as a baseline for informing policymakers and medical practitioners dedicated to improving existing conditions of neonates in Haiti. Suggested targeted interventions include preventive measures during prenatal visits, strengthening laboratory capacities, improving infection prevention and control measures, and developing antimicrobial stewardship programs.

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.”