Background: Bloodstream infections (BSIs) due to carbapenem-resistant Acinetobacter baumannii (CRAB) are difficult to treat and are associated with high mortality, particularly in neonates. Healthcare-associated CRAB infections have been linked to environmental reservoirs and are associated with seasonal clustering. CRAB outbreaks are being reported more frequently in sub-Saharan Africa, but published reports from this region that incorporate comprehensive surveillance data and environmental investigations are rare. Methods: We reviewed microbiology surveillance records at a 530-bed, public, tertiary-care hospital in Botswana from January 1 to December 13, 2021, and we collected data regarding age, specimen type, and onset date for all cultures from unique patients growing Acinetobacter spp. An automated blood-culture system was used for organism detection, manual biochemical tests were used for identification, and disc and agar diffusion methods were used for antimicrobial sensitivity testing. During this time, we conducted 4 point-prevalence environmental sampling surveys at this hospital’s 36-bed neonatal unit from January through June 2021 in addition to 3 neonatal CRAB cluster investigations. Environmental samples from surfaces, hands of caregivers and healthcare workers, and equipment were collected using flocked swabs. Extended-spectrum β-lactamase–producing organisms from environmental samples were identified using selective and differential chromogenic media (CHROMagarTM ESBL). Results: Overall, 48 Acinetobacter infections were identified, including 28 BSIs (among 3,699 blood cultures processed, approximately one-third of which were from neonates). More than half of cases were perinatal, which included 16 neonatal BSIs (median age, 4 days; case fatality rate, 56%), and 1 fatal case of postpartum sepsis in a 37-year-old mother. Among isolates tested, 35 (92%) of 38 demonstrated carbapenem resistance. Treatment information was not available for all neonatal patients, but delays in appropriate antimicrobial therapy were cited in all fatal cases. Most neonatal CRAB cases clustered in time and space (Fig. 1). For example, 15 (71%) of 21 neonatal cases occurred in the same unit and same week as another case. In the neonatal unit, CRAB clusters were associated with increased Acinetobacter recovery during environmental point-prevalence surveys (Fig. 1). Acinetobacter contamination was identified on feeding equipment (breast pumps, feeding tubes), respiratory equipment (suction machines or catheters, ventilator humidifiers), and hands of caregivers and healthcare workers. Conclusions: We report hyperendemic rates of CRAB infections with evidence of spatotemporal clustering, especially among neonates. Higher CRAB incidence coincided with increased Acinetobacter recovery during environmental sampling. We identified plausible transmission vehicles (respiratory or feeding devices, hands) in the neonatal care environment highlighting the value of environmental sampling to support CRAB investigations and reinforcing the importance of comprehensive and consistent disinfection practices, especially in resource-limited settings where equipment is shared or reused.

Funding: None

Disclosures: None

Among 124 older adults with advanced cancer who were hospitalized with pneumonia, 7.3% met criteria for postobstructive pneumonia. There were no differences in antibiotic duration, antibiotic spectrum, 30-day and 90-day readmissions, or mortality between those with and without postobstructive pneumonia. Bacteria were identified in 5 patients with postobstructive pneumonia.

Background: Monitoring uptake of infection prevention and control (IPC) interventions is critical for the targeted and rational use of limited resources. A national facility readiness assessment conducted in August 2020 provided key information for targeted interventions to strengthen priority IPC areas. We assessed the level of COVID-19 preparedness in the facilities, identified priority COVID-19 IPC gaps, and generated a baseline report to further guide IPC investments at all levels. Methods: The Kenya Ministry of Health in collaboration with the CDC and International Training and Education Center for Health adapted a WHO Facility Readiness Assessment tool to include COVID-19–specific areas. In August 2020, data were collected using tablets through an Android-based electronic platform and were analyzed using descriptive statistics. Assessments were conducted in public, private, and faith-based health facilities nationally after 4 months of preparedness and investment in the healthcare system. Results: We assessed 684 facilities of the targeted 844 (81%). Overall facility readiness in Kenya was rated above average (61%), and the performance score significantly increased with the Kenya Essential Package for Health level, with level 5 and 6 facilities scoring an average of 83% and 79% respectively. Of the assessed facilities, 82% had an appointed IPC coordinator. Only 14% of the facilities had all the required guidelines, policies, and the appropriate COVID-19 case definitions. 67% of the facilities had updated supply inventories for past week. Only 50% of the facilities had adequate supplies of N95 masks. The assessment revealed that 52% of healthcare facilities had trained their healthcare workforce; morticians were the least trained (only 17% of facilities). Moreover, 41% of the facilities had clear work plans for monitoring healthcare workers exposures to COVID-19, but only 33% of the facilities had policies on the management of infected healthcare workers. Conclusions: The findings provided critical information for stakeholders at all levels to be used for policy decisions, to prioritize key intervention areas in leadership and governance of facility IPC programs, for guideline development, and for capacity building and targeted investment in IPC to improve COVID-19 facility preparedness.

Funding: None

Disclosures: None

In March 2020, the coronavirus disease 2019 (COVID-19) pandemic raged, and samples from the Detroit Medical Center (DMC) were sent offsite for testing. From April 3, 2020, DMC laboratories ran rapid Cepheid Xpert Xpress severe acute respiratory coronavirus virus 2 (SARS-CoV-2) reverse-transcription polymerase chain reaction (RT-PCR) tests within hospital labs. We detected differences in length of stay (LOS) and antibiotic duration between positive results from offsite and in-house tests.

Background: Transmission of methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococcus (VRE) is of special concern among frail patients in nursing homes. To understand environmental contamination patterns in this setting, we screened a suitable section of a nursing home over time and assessed MRSA and VRE prevalence in patients and their rooms. We were especially interested in assessing whether MRSA and VRE strains persist in rooms during changes of occupancy after patient discharge. Methods: We conducted a prospective cohort study of MRSA and VRE colonization and contamination among successive patients in a cluster of 9 single-occupancy rooms. Using flocked swabs, 5 high-touch surfaces were screened 3 times a week for 34 weeks. Patients were also screened (ie, nares, groin, and hands), if they agreed to participate. Whole-genome sequencing was performed on 67 nonredundant MRSA and VRE strains. Single-nucleotide polymorphism heatmaps and similarity trees were generated to evaluate strain diversity and persistence the facility. Results: Overall, 146 distinct occupancy events were captured during the study (16.5 average per room; range, 11–22), with 387 study visits and 4,670 total swabs collected. All rooms were contaminated with VRE, and 8 of 9 were contaminated with MRSA at least once during the study period. New contamination of a room with MRSA or VRE was observed in 43 (23%) of 185 opportunities, with potential persistence during occupancy changes in 25 (32.9%) of 76 opportunities. Sequencing of 67 nonredundant isolates identified at least 6 enterococcal clades and 10 MRSA clades (6 USA100 and 4 USA300), indicating a high degree of diversity and probably multiple introductions in the facility during the study time. In 3 separate cases, whole-genome sequencing confirmed persistence of a specific MRSA strain during a change of room occupancy, including 1 case of a MRSA strain persisting in a clean room before admission of the next patient. For VRE, 2 cases of persistence during room occupancy changes were confirmed, along with 6 cases of possible persistence (contamination across noncontiguous room occupancy events). Conclusions: Active surveillance screening and a recurring evaluation of terminal cleaning procedures should be considered due to high levels of circulation and persistence of MRSA and VRE in the nursing home setting.

Funding: None

Disclosures: None

Using point-prevalence methodology and the World Health Organization (WHO) Access, Watch, and Reserve Classification, we measured antibiotic use in 5 hospitals in Okinawa, Japan, on October 1, 2020. Overall, 29% of patients were prescribed an antibiotic on the survey date and the 3 most used antibiotics in the “Watch” category were cefazolin, ampicillin-sulbactam, and ampicillin.

Background: Multidrug-resistant organisms (MDROs) are a global threat. To track and contain the spread, the Tennessee Department of Health (TDH) performs targeted surveillance of carbapenemase-producing and pan-nonsusceptible organisms. When these MDROs are identified, TDH conducts a containment response and collects epidemiological data, which includes risk factors such as indwelling devices and previous hospitalizations. The impact of the COVID-19 pandemic on these MDROs is not well understood. Therefore, we have described the characteristics of cases positive for both COVID-19 and select MDROs. Methods: MDRO investigation data from January 1, 2020–September 30, 2021 were matched with all COVID-19 case data from the TDH statewide surveillance system, National Electronic Disease Surveillance System Base System. MDRO-positive date was defined as the specimen collection date; COVID-19 case date was first defined as the date of symptom onset and if missing, then diagnosis date, and investigation creation date, respectively. Descriptive statistics and Fisher exact tests were calculated using SAS version 9.4 software. Results: Among 336 MDRO cases, 50 had a reported SARS-CoV-2–positive result. MDRO types were Enterobacterales (CRE) (n = 31), Acinetobacter spp (CRA) (n = 18), and Pseudomonas aeruginosa (n = 1). Of these 50 cases, 20 were MDRO-positive before and 30 days after the COVID-19 case date, respectively. Of the 18 CRA cases, 16 (89%), were positive after the COVID-19 case date, compared to 13 (42%) among 31 CRE cases (P < .01). Also, 35 patients (70%) had a record of hospitalization, and 22 (63%) had their MDRO specimen collected after the COVID-19 case date (P = .37). Of these 22 patients, 4 had their MDRO specimen collected during their COVID-19 hospitalization, with an average duration from admission to MDRO collection date of 17 days (range, 4–36). Among the 50 coinfected cases, 8 died, 7 (88%) of whom were MDRO-positive after their COVID-19 case date. Data on indwelling devices at time of MDRO positivity were completed for 17 cases; 14 had an indwelling device and, among these, 13 (93%) were MDRO-positive after their COVID-19 case date. Conclusions: MDRO cases with specimen collections after COVID-19 comprised the majority of hospitalized patients, patients who died, and patients with indwelling devices compared to those with MDROs collected before their COVID-19 case date. These results show a stark difference with CRA as the most common MDRO among post–COVID-19 cases. Our data were limited by reporting gaps. We recognize that patients can remain colonized with MDROs for lengthy durations, which could have result in undetected MDRO cases prior to the COVID-19 case date. More data and analyses are needed to make targeted public health recommendations. However, these findings highlight the burden of MDROs among COVID-19 cases. including adverse health outcomes.

Funding: None

Disclosures: None

Background: Efficient monitoring of devices to ensure timely removal is an ongoing challenge. There is a need for data visualization products that can aggregate disparate data streams to support device reviews, increase consistency across changes in caregiver teams, and synergize with people and operational processes within and across regional acute-care facilities. Methods: A data display application was developed to provide data from nearly any source in a consistent visual representation that could be used in real time. The infection prevention (IP) overlay combined data related to urinary catheters, central vascular catheters, and femoral vascular catheters from the electronic health record system. Clinical and data experts collaborated to develop data definitions, inclusion criteria, and report components. The application display indicated the current catheter or device status of each patient facility-wide, organized by service unit (Fig. 1). Additional patient information could be accessed from within the application, and a comment feature allowed caregivers to communicate directly through the tool (Fig. 2). Results: Pilot implementation began February 2021, and the NATE IP application was live for all users (unit and facility leaders, providers, infection preventionists, etc) as of July 2021. The tool is currently available for use at 171 acute-care hospitals within the HCA healthcare system, and it accommodated 3 different electronic medical record systems. Usage peaked in August 2021, with an average of 1,700 views per day. Daily utilization maximum ranges from 1,100 to 1,500 views per day, with an average of ~1,300 views per day. The tool is used during daily patient safety rounds, including weekends and holidays. User feedback was overwhelmingly positive, with users reporting an increase in communication, streamlined documentation, improved tracking of reasons to retain, and increased accountability for daily updates. During the proof-of-concept implementation, zero bugs were identified and several feature enhancements were implemented, including addition of port status and device-day reporting counts. Planned enhancements include mupirocin and chlorhexidine bathing use, isolation precaution use, and blood cultures ordered >3 days after admission. Conclusions: The NATE IP tool brings together data related devices into a single view for use by direct caregivers and all levels of leadership. Development of this or similar tools to consolidate various data streams into a central tool facilitates improved communication and consistency between caregiver teams. It also drives operational efficiencies and improves safety. Expansion to incorporate notifications related to potential issue will expand the proactive utility of this tool.

Funding: None

Disclosures: None

Background: Traditional infection prevention (IP) methods for outbreak detection often rely on geotemporal clustering confined to single locations. We recently developed the Enhanced Detection System for Healthcare-Associated Transmission (EDS-HAT), which combines whole-genome sequencing (WGS) surveillance and machine learning of the electronic health record (EHR). Our retrospective research findings show potential transmissions averted and cost savings using EDS-HAT in real time. Here, we describe the process and initial findings from EDS-HAT real-time implementation. Methods: Real-time whole-genome sequencing surveillance began on November 1, 2021. Patient cultures positive for select bacterial pathogens who were hospitalized for ≥3 days or had a recent healthcare exposure in the prior 30-days were collected. Isolates were deemed genetically related if ≤15 single-nucleotide polymorphisms (SNPs) were identified for all organisms except Clostridioides difficile (≤2 SNPs). Clusters were manually investigated by both research and IP teams, and interventions were performed by the IP team. Data on collection, analysis, notification, and intervention dates were gathered. Results: As of January 11, 2022, 413 isolates had undergone whole-genome sequencing. Among them, 18 unique patient isolates were genetically related to ≥1 other isolate, comprising 7 clusters (range, 2–6 patients). Notable findings include a Pseudomonas aeruginosa cluster possibly related to a shared bronchoscope, a pseudo-outbreak of Serratia marcescens related to autopsy blood culture practice, and a cluster of vancomycin-resistant Enterococcus faecium on a shared transplant unit. Only 1 cluster of 2 isolates of Klebsiella pneumoniae had no known possible transmission routes. The median turnaround time from patient’s culture date to IP notification was 19 days (range, 13–28), with noted delays over the winter holiday. Concusions: Real-time WGS can identify small clusters including potentially interruptible transmission routes. Rapid turnaround time, coordination between clinical and genomic laboratories, and a robust IP team are key factors in implementing a WGS surveillance program. Real-time WGS surveillance has the potential to reduce costs for hospitals, improve patient safety, and save lives.

Funding: None

Disclosures: None

The updated vancomycin guideline for treatment of serious methicillin-resistant Staphylococcus aureus infections prompted institutions to convert from trough to area-under-the-curve monitoring. The physician perception of the transition, coupled with that of pharmacists, was measured by pre- and postimplementation surveys. Both groups believed safety would be increased without efficacy changes.

Background: Inequities are seen in many health-related outcomes, and systemic and structural factors result in inequitable care based on social determinants of health (SDOH). However, whether disparities exist specifically in healthcare-associated infections (HAIs) based on these factors has not been well described. Furthermore, there are no national standards on whether information related to equity and SDOH should be included in HAI surveillance and how such information could be used. Methods: We surveyed US members of the SHEA Research Network (SRN), a consortium of healthcare facilities with leaders interested in healthcare epidemiology and infection prevention, via an online REDCap survey from October to December 2021. Results: Of the 68 eligible US SRN facilities, 28 (41%) responded. Among them, 27 institutions provide direct patient care and were analyzed. Of these 27 facilities, 8 (30%) collected data regarding variables related to equity including language for care, race or ethnicity, insurance status, and other. Of these faclilities, 38% are collecting but not otherwise using this information; other facilities use this information for a variety of reporting and intervention purposes (Fig. 2). Only 3 facilities (11%) analyzed whether disparities exist in any HAI rates. The most common barrier to collecting SDOH information is that facilities have not considered doing this work (Fig. 3). Of the 15 facilities not yet undertaking such work, 10 (67%) were interested in doing so. Specific recommendations about how to operationalize such collection are needed (Table 1). Conclusions: Most institutions in this sample are not collecting data that would allow for assessment of disparities in the rates of HAIs; however, there is interest in doing so. A minority of early adopter facilities are assessing whether disparities exist and are designing interventions. National guidance can play a key role in standardizing the collection of this information and translating early findings to identify and subsequently improve disparities within HAIs.

Funding: None

Disclosures: None

Management of outpatient parenteral antimicrobial therapy (OPAT) is complex, and incorporation of a pharmacist can improve outcomes. The creation of new clinical programs is often limited by staffing resources. We describe our collaborative program that utilized a failure-point–focused design process to optimize OPAT activities and management.

We describe severe acute respiratory coronavirus virus 2 (SARS-CoV-2) IgG seroprevalence and antigenemia among patients at a medical center in January–March 2021 using residual clinical blood samples. The overall seroprevalences were 17% by infection and 16% by vaccination. Spent or residual samples are a feasible alternative for rapidly estimating seroprevalence or monitoring trends in infection and vaccination.

Background: The δ (delta) variant has spread rapidly worldwide and has become the predominant strain of SARS-CoV-2. We analyzed an outbreak caused by a vaccine breakthrough infection in a hospital with an active infection control program where 91.9% of healthcare workers were vaccinated. Methods: We investigated a SARS-CoV-2 outbreak between September 9 and October 2, 2021, in a referral teaching hospital in Korea. We retrospectively collected data on demographics, vaccination history, transmission, and clinical features of confirmed COVID-19 in patients, healthcare workers, and caregivers. Results: During the outbreak, 94 individuals tested positive for SARS-CoV-2 using reverse transcription-polymerase chain reaction (rtPCR) testing. Testing identified infections in 61 health care workers, 18 patients, and 15 caregivers, and 70 (74.5%) of 94 cases were vaccine breakthrough infections. We detected 3 superspreading events: in the hospital staff cafeteria and offices (n = 47 cases, 50%), the 8th floor of the main building (n = 22 cases, 23.4%), and the 7th floor in the maternal and child healthcare center (n = 12 cases, 12.8%). These superspreading events accounted for 81 (86.2%) of 94 transmissions (Fig. 1, 2). The median interval between completion of vaccination and COVID-19 infection was 117 days (range, 18–187). There was no significant difference in the mean Ct value of the RdRp/ORF1ab gene between fully vaccinated individuals (mean 20.87, SD±6.28) and unvaccinated individuals (mean 19.94, SD±5.37, P = .52) at the time of diagnosis. Among healthcare workers and caregivers, only 1 required oxygen supplementation. In contrast, among 18 patients, there were 4 fatal cases (22.2%), 3 of whom were unvaccinated (Table 1). Conclusions: Superspreading infection among fully vaccinated individuals occurred in an acute-care hospital while the δ (delta) variant was dominant. Given the potential for severe complications, as this outbreak demonstrated, preventive measures including adequate ventilation should be emphasized to minimize transmission in hospitals.

Funding: None

Disclosures: None

In this study, we evaluated the impact of a microbiology nudge on de-escalation to first-generation cephalosporins in hospitalized patients with urinary tract infections secondary to Escherichia coli, Klebsiella pneumoniae, and Proteus mirabilis isolates with minimum inhibitory concentrations (MICs) ≤ 16 µg/mL. De-escalation to first generation-cephalosporins was uncommon at MICs = 4–16 µg/mL.

Background: In late September 2021, a cluster of patients with nosocomial COVID-19 was identified on a liver transplant unit at University of Nebraska Medical Center. Methods: The outbreak investigation included contact tracing via patient chart and employee health record reviews and serial prevalence testing for SARS-CoV-2 among potentially exposed patients and healthcare workers (HCWs). Routine admission and preprocedural screening for SARS-CoV-2 was performed, and involved patients had negative admission screening results with positive SARS-CoV-2 tests >5 days from admission. Mitigation strategies involved reinforcement of patient care and visitation procedures. Whole-genome sequencing of positive SARS-CoV-2 specimens was conducted. Results: The potential outbreak cluster included 6 patients in the same quadrant of the liver transplant unit, 1 visitor, and 11 healthcare workers (Fig. 1). Moreover, 4 patients had severe liver disease, including 2 with liver transplants. All HCWs and half of the patients had received 2 doses of mRNA vaccine, albeit >5 months from their second vaccination. Whole-genome sequencing confirmed patients 1–6 and HCWs 1–3 had related transmission of COVID-19. However, infections in HCWs 4–6, who worked in a transplant-related office setting without patient contact, were due to 2 separate introductions of SARS-CoV-2 unrelated to the hospital outbreak. Sequencing could not be performed on HCWs 7–11 due to low viral concentration in the original specimens or unavailable specimen. The SARS-CoV-2 δ (delta) variant (B.1.617.2) was identified in all sequenced samples. HCWs 8–10 were asymptomatic and had had contact with each other and had been involved with an intubation without proper PPE for SARS-CoV-2 on patient 6. HCW 8 had had contact with all 6 patients and HCW 9 had had contact with 5 patients. A clear index case could not be identified; however, we suspect that the index case was either visitor 1, who tested positive during patient 2’s admission, or an asymptomatic healthcare worker (HCWs 8–10). Conclusions: We identified a nosocomial outbreak of the SARS-CoV-2 δ (delta) variant in a solid-organ transplant unit including patients, a visitor, and vaccinated healthcare workers with multiple introductions of the virus. Further transmission was not detected after enhanced infection control measures were introduced, including universal masking and eye protection, closing patient doors, and enforcement of visitor masking policy. We describe the difficulties tracing SARS-CoV-2 transmission in the hospital setting, even with advanced sequencing techniques. This outbreak highlights the importance of booster vaccination and strict infection control practices, especially in the setting of the δ (delta) variant.

Funding: None

Disclosures: None

Background: Carbapenem-resistant Acinetobacter baumannii (CRAB) is primarily associated with hospital-acquired infections and is an urgent public health threat due to its ability to contaminate the environment and cause severe disease. In 2019, Illinois began pilot surveillance for CRAB requiring select laboratories to submit specimens for molecular characterization. On July 17, 2020, the Chicago Department of Public Health (CDPH) was notified of an increase in CRAB infections in a 20-bed ICU at an acute-care hospital in Chicago (hospital A) during the initial COVID-19 surge. We summarize the outbreak investigation findings and infection control recommendations. Methods: Clinical cultures were collected from patients in hospital A, and CRAB-positive isolates were sent to the Wisconsin State Laboratory of Hygiene for mechanism of resistance and antibiotic susceptibility testing. On-site assessments and remote follow-ups were conducted by CDPH infection preventionists to evaluate infection control practices including environmental cleaning, hand hygiene compliance, and use of personal protective equipment (PPE). The Illinois Department of Public Health and CDPH summarized the testing results, facilitated a containment response, and provided recommendations for infection control. Results: From March 18, 2020, to September 30, 2021, 56 patients with CRAB infections were identified from hospital A, and 33 (59%) of these cases were pan-nonsusceptible. Most specimen sources were sputum (n = 30, 54%), followed by blood (n = 13, 23%), urine (n = 6, 11%) and other (n = 7, 13%). Among isolates with mechanism testing (n = 54), 45 (83%) were positive for OXA-24/40 and 9 (17%) were positive for OXA-23. Of the CRAB-positive patients, 28 (50%) were previously positive for SARS-CoV-2. To date, 25 of these patients (45%) have been discharged and 31 (55%) have died. Two onsite visits and 7 remote-assistance sessions were conducted as part of the investigation. In response to increased COVID-19 hospitalizations, hospital A moved to crisis-capacity PPE use and encountered staffing shortages, which led to compromised infection control measures. Cleaning agents (Quat disinfectant cleaner) were also found to be ineffective against CRAB and required long contact times. Conclusions: In response to the CRAB outbreak at hospital A, CDPH recommended that the hospital stop crisis-capacity protocols for PPE, conduct admission screening and point-prevalence testing for CRAB, implement a hand hygiene campaign, and use an EPA-registered List K product for environmental cleaning. These recommendations were implemented in May 2021, and no CRAB cases have been reported since July 2021. To reduce CRAB transmission during the pandemic, facility leadership must commit resources to educate staff on effective infection control practices including conventional use of PPE, appropriate cleaning agents, and improved hand hygiene.

Funding: None

Disclosures: None