Background: Nursing home (NH) residents and staff were at high risk for COVID-19 early in the pandemic; several studies estimated seroprevalence of infection in NH staff to be 3-fold higher among CNAs and nurses compared to other staff. Risk mitigation added in Fall 2020 included systematic testing of residents and staff (and furlough if positive) to reduce transmission risk. We estimated risks for SARS-CoV-2 infection among NH staff during the first winter surge before widespread vaccination. Methods: Between February and May 2021, voluntary serologic testing was performed on NH staff who were seronegative for SARS-CoV-2 in late Fall 2020 (during a previous serology study at 14 Georgia NHs). An exposure assessment at the second time point covered prior 3 months of job activities, community exposures, and self-reported COVID-19 vaccination, including very recent vaccination (≤4 weeks). Risk factors for seroconversion were estimated by job type using multivariable logistic regression, accounting for interval community-incidence and interval change in resident infections per bed. Results: Among 203 eligible staff, 72 (35.5%) had evidence of interval seroconversion (Fig. 1). Among 80 unvaccinated staff, interval infection was significantly higher among CNAs and nurses (aOR, 4.9; 95% CI, 1.4–20.7) than other staff, after adjusting for race and interval community incidence and facility infections. This risk persisted but was attenuated when utilizing the full study cohort including those with very recent vaccination (aOR, 1.8; 95% CI, 0.9–3.7). Conclusions: Midway through the first year of the pandemic, NH staff with close or common resident contact continued to be at increased risk for infection despite enhanced infection prevention efforts. Mitigation strategies, prior to vaccination, did not eliminate occupational risk for infection. Vaccine utilization is critical to eliminate occupational risk among frontline healthcare providers.

Funding: None

Disclosures: None

Background: Hospitalized patients with COVID-19 often receive antimicrobial therapies due to concerns for bacterial and fungal coinfections. We analyzed patients admitted with COVID-19 to our VA facility to understand antimicrobial use, frequency of coinfections, and outcomes in our population. Methods: This retrospective study included veterans who were 18 years or older and hospitalized with COVID-19 from March 10, 2020, to March 9, 2021 at the Louis Stokes VA Medical Center in Cleveland, Ohio. We identified antimicrobials administered and coinfections with bacterial or fungal pathogens. Patients were deemed to have coinfection if there was supporting microbiological data and a consistent clinical course upon review of clinical records. Urinary tract infections were excluded because of difficulty determining infection. Odds ratios (ORs) and 95% confidence intervals (CIs) for 30-day mortality were derived using multivariate logistic regression models that included age, Charlson comorbidity index (CCI), corticosteroid use, and time of infection. Results: In our cohort of 312 patients, the median age was 70 years and 97% of the patients were male. The mean CCI was 3.7 (SD, 3.0), and 111 patients (35.6%) had a score ≥5. Oxygen was administered to 250 patients (80.1%), and 20 (6.4%) required mechanical ventilation. Antimicrobials were administered to 164 patients (52.6%) (Fig. 1). Of 20 patients (6.4%) with coinfection, 11 (3.5%) had a bloodstream infection (BSI) and 9 (2.9%) had bacterial pneumonia (Fig. 2). The overall 30-day mortality rate was 12.5% (39 of 312). Among patients with coinfection, the 30-day mortality rate was 45% (9 of 20). Diagnoses of BSI (OR, 6.35; 95% CI, 1.41–26.30) and bacterial pneumonia (OR, 9.34; 95% CI, 2.01–46.34) were associated with increased mortality. Of the data available, 12 (63%) of 19 patients with coinfection had elevated procalcitonin levels (ie, >0.50). At the time of COVID-19 diagnosis, the median absolute lymphocyte count in patients who died was 0.7 K/mm3 (95% CI, 0.6–1.12) in comparison to 1 K/mm3 (95% CI, 0.7–1.4) in patients who survived at 30 days. Conclusions: Our analysis of hospitalized COVID-19 patients with advanced age and underlying comorbid conditions demonstrated that coinfections were infrequent but that they were independently associated with increased mortality. This finding highlights the need for better tools to diagnose the presence or absence of bacterial and fungal coinfection in COVID-19 patients. Our findings also emphasize the need for judicious use of antimicrobials while discerning which patients are at risk of critical illness and mortality.

Funding: None

Disclosures: None

Antibiotic overuse is high in patients hospitalized with coronavirus disease 2019 (COVID-19) despite a low documented prevalence of bacterial infections in many studies. In this study evaluating 65 COVID-19 patients in the intensive care unit, empiric broad-spectrum antibiotics were often overutilized with an inertia to de-escalate despite negative culture results.

Background: Healthcare facilities have experienced many challenges during the COVID-19 pandemic, including limited personal protective equipment (PPE) supplies. Healthcare personnel (HCP) rely on PPE, vaccines, and other infection control measures to prevent SARS-CoV-2 infections. We describe PPE concerns reported by HCP who had close contact with COVID-19 patients in the workplace and tested positive for SARS-CoV-2. Method: The CDC collaborated with Emerging Infections Program (EIP) sites in 10 states to conduct surveillance for SARS-CoV-2 infections in HCP. EIP staff interviewed HCP with positive SARS-CoV-2 viral tests (ie, cases) to collect data on demographics, healthcare roles, exposures, PPE use, and concerns about their PPE use during COVID-19 patient care in the 14 days before the HCP’s SARS-CoV-2 positive test. PPE concerns were qualitatively coded as being related to supply (eg, low quality, shortages); use (eg, extended use, reuse, lack of fit test); or facility policy (eg, lack of guidance). We calculated and compared the percentages of cases reporting each concern type during the initial phase of the pandemic (April–May 2020), during the first US peak of daily COVID-19 cases (June–August 2020), and during the second US peak (September 2020–January 2021). We compared percentages using mid-P or Fisher exact tests (α = 0.05). Results: Among 1,998 HCP cases occurring during April 2020–January 2021 who had close contact with COVID-19 patients, 613 (30.7%) reported ≥1 PPE concern (Table 1). The percentage of cases reporting supply or use concerns was higher during the first peak period than the second peak period (supply concerns: 12.5% vs 7.5%; use concerns: 25.5% vs 18.2%; p Conclusions: Although lower percentages of HCP cases overall reported PPE concerns after the first US peak, our results highlight the importance of developing capacity to produce and distribute PPE during times of increased demand. The difference we observed among selected groups of cases may indicate that PPE access and use were more challenging for some, such as nonphysicians and nursing home HCP. These findings underscore the need to ensure that PPE is accessible and used correctly by HCP for whom use is recommended.

Funding: None

Disclosures: None

Background: Understanding SARS-CoV-2 persistence on surfaces can help inform transmission risk from surfaces in healthcare and community settings. A sensitive viral infectivity assay is crucial for the detection of infective virus in environmental investigations. The conventional cell culture-based infectivity assay is limited by the time dependence, subjectivity, and insensitivity of cytopathic effect (CPE) scoring. We validated an integrated cell-culture and reverse-transcription quantitative RT-PCR method (cc-RT-qPCR) to improve SARS-CoV-2 detection and reduce detection time. We compared cc-RT-qPCR with CPE-scored cell culture to evaluate assay sensitivity of recovered virus from stainless-steel coupons simulating nonporous healthcare surfaces. Method: Human β-coronavirus OC43, a model strain for SARS-CoV-2, was propagated on HRT-18G cells in growth medium at 33°C in a 5% CO2 incubator. The OC43 infectivity was determined by cell culture with a 10-fold dilution series of viral samples in 96-well plates, and incubation for 7 days at 33°C to confirm CPE. Plates were CPE-scored and TCID50 was calculated using the Reed-Muench method. For the cc-RT-qPCR assay, CPE-negative wells were interrogated for viral intracellular replication using RT-PCR; infectivity was based on a titer increase of ≥ 2 logs 7 days after inoculation using RT-qPCR. CPE-positive or replicative virus-harboring cells were enumerated to determine TCID50. The sensitivity of both CPE-scored cell culture and cc-RT-qPCR assays were evaluated by inoculating 105 TCID50/mL OC43 in infection media and artificial saliva matrices onto coupons and dried in an environmental chamber at 26°C and 57% relative humidity for 6 hours. Viral eluates from coupons served as test samples. Results: Low-titer infectious OC43 (0.75 log10) was detected by both methods 7 days after incubation; however, infectivity confirmation required 4 and 6 days after incubation, respectively, for cc-RT-qPCR and CPE-scored cell culture methods. When cells were inoculated with OC43 at titer range 1.75–4.75 log10, CPE presented at 4–5 days after incubation, while viral replication was already detected at 3 days after incubation via RT-PCR. Upon virus titration, cc-RT-qPCR demonstrated greater sensitivity, detecting up to 1 log10 higher of infectious OC43 than cell culture alone at 0 and 6 hours (P ≤ .05) dried in infection medium and 0 hours (P ≤ .05) in saliva. Conclusions: Our data demonstrated greater sensitivity and shorter times to detect viral replication by cc-RT-qPCR, minimizing potential for false-negative results with cell culture alone. This sensitive assay may provide investigators with quicker results for informing infection control practices to reduce risk of transmission from deposited bodily fluids on surfaces, eg, coughing and sneezing.

Funding: None

Disclosures: None

Background: The effectiveness of PPE in preventing self-contamination of healthcare workers (HCWs) and transmission of pathogens (airborne and contact) in the emergency department (ED) is highly dependent on consistent, appropriate use of and other interactions (eg, storing, cleaning, etc) with the PPE. Pre–COVID-19 studies focused primarily on individual HCW contributions to incorrect or suboptimal PPE use. We conducted an analysis of ED video recordings using a human-factors engineering framework (ie, The Systems Engineering Initiative for Patient Safety, SEIPS), to identify work-system–level contributions to inappropriate PPE usage by HCWs while they provide care in their actual clinical care environment. Methods: In total, 47 video sessions (each ~15 minute) were recorded between June 2020 and May 2021 using a GoPro camera in an 8-bed pod area, designated for persons under investigation (PUI) and confirmed COVID-19–positive patients, in an ED of a large, tertiary-care, academic medical center. These recordings captured a ‘landscape view’: 2 video cameras were set up to capture the entire ED pod area and HCWs as they provided care. A team with hemorrhagic fever expertise, infection prevention and control expertise, and ED expertise reviewed each video together and extracted data using a semistructured form. Results: Guided by the 5 components of the SEIPS work system model, (ie, task, physical environment, person, organization, tools and technology), multiple work system failure points influencing HCWs appropriate use of PPE were identified. For example, under the task component, HCWs were observed not doffing and donning in recommended sequence. Also, inconsistencies with COVID-19 status signage on a patient’s door and ambiguous labelling of work areas designated as clean (donning) and dirty (doffing) sites acted as a barrier to appropriate PPE use under the physical environment section. Conclusions: Human factors–based analysis of video recordings of actual ED work identified a variety of work system factors that impede appropriate or correct use of PPE by HCWs. Future efforts to improve appropriate PPE use should focus on eliminating or mitigating the effects of these work system factors.

Funding: US CDC

Disclosures: The authors gratefully acknowledge the CDC for funding this work. This material is based upon work supported by the Naval Sea Systems Command (under contract No. N00024-13-D-6400, Task Order NH076). Any opinions, findings and conclusions or recommendations expressed in this material are those of the author(s) and do not necessarily reflect the views of the Naval Sea Systems Command (NAVSEA) or the US CDC.

Resource-intensive interventions and education are susceptible to a lack of long-term sustainability and regression to the mean. The respiratory culture nudge changed reporting to “Commensal Respiratory Flora only: No S. aureus/MRSA or P. aeruginosa.” This study demonstrated sustained reduction in broad-spectrum antibiotic duration and long-term sustainability 3 years after implementation.

Background: Emergency departments (EDs) are complex, sociotechnical, high-paced, safety-critical work systems that have been disproportionately affected by the COVID-19 pandemic. Despite training, consistent compliance with recommended PPE use during COVID-19 pandemic has been challenging. Healthcare workers (HCWs) have had adapt to overcome these challenges to ensure their own safety and patient safety. We sought to identify barriers in the work system that impede the recommended COVID-19 PPE use in EDs. Methods: We conducted semistructured, in-depth interviews over ZoomTM from August 2020–May 2021 with 45 HCWs from the ED (ie, physicians, nurses, ancillary support staff, etc) affiliated with a large, tertiary-care, academic medical center. These audio-recorded interviews were transcribed and analyzed using a hybrid (inductive and deductive) qualitative coding approach in NVivo software. The deductive portion was guided by the SEIPS work system model, a well-known human-factors conceptual framework. Results: We identified multiple work-system factors in the ED that impede compliance with the recommended COVID-19 PPE use. In addition, ED HCWs have reported making a variety of adaptations or developing strategies to overcome these barriers. Some of these adaptations were made to the PPE physically (eg, trimming portions of PPE), and others were related to the tasks and/or processes associated with PPE, such as filming their own training video demonstrating PPE donning and doffing techniques, and environment services staff checking a patient’s status with nurses prior to entering the patient’s room when there was no COVID-19 signage on the door. Conclusions: Consistent compliance with COVID-19 PPE use in ED clinical practice is challenging and can be negatively affected by a variety of work system factors. Resilience strategies developed by HCWs can provide critical information with regards to HCW needs and potential directions for innovation. Future efforts should focus on not only changing individual HCW behavior through training but also on improving the PPE and ED work system design.

Funding: US CDC

Disclosures: The authors gratefully acknowledge the US CDC for funding this work. This material is based upon work supported by the Naval Sea Systems Command (under contract no. N00024-13-D-6400, task order NH076). Any opinions, findings, and conclusions or recommendations expressed in this material are those of the authors and do not necessarily reflect the views of the Naval Sea Systems Command (NAVSEA) or the US CDC.

Antibiotic treatment of asymptomatic bacteriuria (ASB) is considered inappropriate and may lead to adverse events. This 2-center, retrospective cohort study including emergency department or inpatient adults identified pyuria (odds ratio, 2.43; 95% confidence interval, 1.17–5.01; P = .02) as the only independent risk factor for antibiotic treatment of ASB.

Background: Admission laboratory screening for asymptomatic COVID-19 has been utilized to mitigate healthcare-associated SARS-CoV-2 transmission. A better understanding of the impact of such testing across a variety of patient populations is needed. Methods: Beginning April 2020, every patient admitted within an academic healthcare system underwent SARS-CoV-2 PCR testing upon admission. Between April 20, 2020 through June 14, 2021, results were analyzed in asymptomatic patients across 4 inpatient facilities: a tertiary-care adult hospital, a free-standing pediatric hospital, a community-based hospital, and a behavioral health hospital. Positivity rates and the number needed to test (NNT) to identify 1 asymptomatic infected patient were calculated overall, by hospital type, by patient vaccination status, and by CDC-defined levels of community transmission. Weekly community incidence rates of COVID-19 for the system’s metropolitan service area (8 central Tennessee counties) were obtained from Tennessee Department of Health records. Weekly COVID-19 incidence rates per 100,000 people were calculated using US Census Bureau data. Using a national survey of hospital epidemiologists, a clinically meaningful NNT was identified (ie, 1 positive patient per 100 patients tested). A crude admission testing cost (covering testing supplies, reagents, and lab personnel costs) was obtained from operational data ($50 per test) to assess testing utility. Results: In total, 51,187 tests were collected during the study period with a positivity rate of 1.8%. No periods of low transmission were observed (Table 1). During high transmission periods, the NNT met the clinically relevant threshold in all populations. In addition, the NNT approached or met the 1:100 threshold for most locations during periods of less transmission, suggesting continued benefit even as infection rates decline. In all transmission periods, the NNT for non–fully vaccinated patients met the clinically meaningful threshold, in contrast to testing of fully vaccinated patients (Table 2). Discussion: Implementing an asymptomatic patient admission testing program can provide clinically relevant value based on the NNT, even during lower periods of transmission and in different patient populations. Limiting admission testing to non–fully vaccinated patients during periods of lower transmission may be a strategy to address cost and resource concerns around this practice. Further investigations into the impact of booster vaccination and newer SARS-CoV-2 variants on admission testing programs are also necessary. Although the impact of such testing on healthcare-associated COVID-19 among patients and healthcare workers could not be clearly determined, these data provide important information as facilities weigh the costs and benefits of such testing.

Funding: None

Disclosures: None

We surveyed healthcare professionals at a cancer center regarding their knowledge and perceptions of antibiotic use. Most knew the term “antimicrobial stewardship.” Nurses and other staff were less likely than pharmacists or providers to answer knowledge-based questions correctly. Opportunities exist to improve antibiotic knowledge among cancer center staff.

Background: Antimicrobials are often given to patients with COVID-19 despite the absence of a bacterial coinfection. Procalcitonin (PCT), when elevated, often indicates the presence of a bacterial infection and is used to guide empiric antibiotic therapy. We sought to determine the utility of PCT and the optimal cutoff value of PCT among patients with COVID-19. Methods: We retrospectively reviewed all COVID-19 confirmed ca-ses hospitalized in our institution from March to December 2020. Of 729 cases, we included 403 (55.3%) who had baseline PCT and blood or respiratory tract specimens (eg, sputum, endotracheal aspirate) within 48 hours of admission. Participants were classified according to PCT levels and COVID-19 severity. A receiver operating characteristic (ROC) curve analysis was performed. The area under the curve (AUC) obtained was used to compute the possible optimal cutoff value using the Youden index. A χ2 test was used to define association between groups according to the characteristics of variables. Results: Of a total cohort of 403, 245 (57%) were male, with an overall median age of 60 years (range, 22–94). Overall, 28 presented with mild COVID-19, 194 presented with moderate COVID-19, and 181 presented with severe or critical COVID-19. Moreover, 363 (90%) were given antibiotics. Of 28 with mild COVID-19, 22 (79%) received empiric antibiotics. The rate of bacterial coinfection was high at 28% (113 of 403). Klebsiella pneumoniae was the most commonly identified microorganism: 52 (19.5%) of 266 patients. Based on the ROC curve, the optimal cutoff for PCT was 4.72 ng/mL, with 97% specificity and only 6% sensitivity. Only 17 participants had PCT > 4.72 ng/mL. Of these, 1 was mild, 5 were moderate COVID-19, 8 had severe COVID-19, and 3 had critical COVID-19; all received antibiotic therapy. Conclusions: In our cohort, the rate of bacterial coinfection was high. A PCT of >4.72 ng/mL increased the likelihood of a coinfection. However, PCT had poor sensitivity and may not detect the presence of bacterial coinfection, especially when used alone. Serial PCT monitoring, its use in conjunction with other markers, or as a prognostic tool, need to be explored further.

Funding: None

Disclosures: None

Carbapenemase-producing organisms commonly carry a single carbapenemase gene conferring resistant to carbapenems and other β-lactam antibiotics. Here, we report rare cases of multidrug-resistant Pseudomonas aeruginosa, Klebsiella pneumoniae, and Acinetobacter baumannii strains that coproduce multiple carbapenemases and exhibit extensive drug resistance. Such resistant strains are rarely identified in the United States.

Background: The NIH Clinical Center implemented multiple testing protocols to facilitate early detection and isolation of SARS-CoV-2 infected patients and rooming-in family members (RIFMs). Beginning in February 2020, all symptomatic patients were tested; in March 2020, all patients were tested prior to aerosol-generating procedures (AGPs); and in May 2020, all patients and RIFMs were tested on admission. We sought to determine the value of SARS-CoV-2 testing practices in our hospital. Methods: Respiratory specimens collected March 2020 through June 2021 tested for SARS-CoV-2 by RT-PCR were reviewed, and corresponding patient clinical and demographic variables were collected. Repeated tests from SARS-CoV-2–positive persons were excluded from the data. Results associated with multiple testing indications were assigned the highest priority reason based on a predetermined hierarchy. Data were analyzed using the χ2 test and logistic regression. Results: Of 12,706 results from 5,704 patients, primary testing reasons were pre-AGP (n = 5,387, 43.0%), admission (n = 2,733; 21.8%), and symptomatic testing (n = 2,701; 21.6%). Overall, 159 tests (1.25%) were positive for SARS-CoV-2. Asymptomatic patients tested on admission were 1.8 times more likely to be positive than outpatients tested for any reason (P = .003) and 4.2 times more likely than asymptomatic inpatients tested prior to AGP (P = .003). Within asymptomatic pre-AGP testing, there was no difference between inpatients (0.46%) and outpatients (0.65%). Hispanic patients were 1.9 times more likely to be positive. (p Conclusions: At a hospital with a geographically broad referral base, admissions COVID-19 testing was far more fruitful than pre-AGP testing of inpatients. Pre-AGP used the most testing resources yet had the lowest yield. Admissions testing remains beneficial regardless of community transmission rates, while testing prior to AGP could be pared back when community rates of COVID-19 are low and redeployed when community rates rise. Conclusions: Our findings that Hispanic persons had higher risk and that transplant patients had lower risk of testing positive suggests differences in the extent to which each subgroup may have been able to shelter from COVID-19 in the community during this earlier phase of the pandemic. Keeping immunocompromised patients safe from COVID-19 while they undergo longitudinal care involves layered precautions in the hospital and in the community that must evolve in response to evidence and epidemiological trends.

Funding: None

Disclosures: None

Background: Previously, we reported decreasing postadmission urine-culture rates in hospitalized patients between 2012 and 2017, indicating a possible decrease in hospital-onset urinary tract infections or changes in diagnostic practices in acute-care hospitals (ACHs). In this study, we re-evaluated the trends using more recent data from 2017–2020 to assess whether new trends in hospital urine-culturing practices had emerged. Method: We conducted a longitudinal analysis of monthly urine-culture rates using microbiology data from 355 ACHs participating in the Premier Healthcare Database in 2017–2020. All cultures from the urinary tract collected on or before day 3 were defined as admission urine cultures and those collected on day 4 or later were defined as postadmission urine cultures. We included discharges from months where a hospital reported at least 1 urine culture with microbiology and antimicrobial susceptibility test results. Annual estimates of rates of admission culture and postadmission urine-culture rates were assessed using general estimating equation models with a negative binomial distribution accounting for hospital-level clustering and adjusting for hospital bed size, teaching status, urban–rural designation, discharge month, and census division. Estimated rate for each year (2018, 2019, and 2020) was compared to previous year’s estimated rate using rate ratios (RRs) and 95% confidence intervals (CIs) generated through the multivariable GEE models. Results: From 2017 to 2020, we included 8.7 million discharges and 1,943,540 urine cultures, of which 299,013 (15.4%) were postadmission urine cultures. In 2017–2020, unadjusted admission culture rates were 20.0, 19.6, 17.9, and 18.2 per 100 discharges respectively; similarly, unadjusted postadmission urine-culture rates were 8.6, 7.8, 7.0, and 7.5 per 1,000 patient days. In the multivariable analysis, adjusting for hospital characteristics, no significant changes in admission urine-culture rates were detected during 2017–2019; however, in 2020, admission urine-culture rates increased 6% compared to 2019 (RR, 1.06; 95% CI, 1.02–1.09) (Fig. 1). Postadmission urine-culture rates decreased 4% in 2018 compared to 2017 (RR, 0.96; 95% CI, 0.91–0.99) and 8% in 2019 compared to 2018 (RR, 0.92; 95% CI, 0.87–0.96). In 2020, postadmission urine-culture rates increased 10% compared to 2019 (RR, 1.10; 95% CI, 1.06–1.14) (Fig. 2). Factors significantly associated with postadmission urine-culture rates included discharge month and hospital bed size. For admission urine cultures, discharge month was the only significant factor. Conclusions: Between 2017–2019, postadmission urine-culture rates continued a decreasing trend, while admission culture rates remained unchanged. However, in 2020 both admission and postadmission urine culture rates increased significantly in comparison to 2019.

Funding: None

Disclosures: None