A study of severe acute respiratory coronavirus virus 2 (SARS-CoV-2) seroprevalence at a healthcare institution prior to the availability of vaccine showed that seroprevalence in the cohort increased over 6 months from 25% to 55%. The number of employees with antibodies was higher than the number who reported an exposure or diagnosis at each time point.

Background: Ice is used in healthcare facilities for medical purposes and consumption by the medical staff and the patients, but some studies have revealed significant microbial contamination of ice machines leading to nosocomial outbreaks or pseudooutbreaks and infections by opportunistic pathogens, including the fungi Candida, the bacteria Pseudomonas aeruginosa, and nontuberculous mycobacteria (NTM). Although ice machines are complex devices that are prone to contamination, very little is known about their potential as vectors of infections for populations at risk in hospitals. Only few studies document efficient maintenance regimes, specifically cleaning procedures and microbial indicators that would ensure their safe use. Method: In this prospective study, combined samples of water and ice, and drain biofilm samples were collected from 36 ice and cold-water distribution machines of a recently built hospital, for a total of 72 samples. Physicochemical parameters (total and free chlorine, temperature, etc) were measured in water, and several opportunistic pathogens (ie, Candida spp, P. aeruginosa, NTM) and biological indicators (ie, heterotrophic plate counts (HPCs), total and viable bacteria and enterococci) were monitored in water and ice and biofilm. Culture methods were used for HPCs, Candida spp, P. aeruginosa, and enterococci, and total and viable bacterial populations were estimated using flow cytometry. NTM were monitored by quantitative polymerase chain reaction (qPCR). Results: We observed clear differences between the machines in terms of biological contamination, with frequent detection of NTM and presumed Candida. Thus, NTM were detected in the 36 samples of ice and water with concentrations from 0.5 to 2×104 gene copies/mL. Among the several species of fungi detected in the ice machines, some were identified as C. parapsilosis and C. guilliermondii, which are organisms of concern in healthcare facilities. Factors affecting the level of contamination in ice machines include the location of the machines and water quality (ie, temperature and chlorine residual concentration). Depending on the location in the building and the model of ice machine sampled, the biological indicators measurements indicated more or less significant contamination. No link was established between environmental strains recovered from the machines and clinical infections. Conclusions: Monitoring results showed that ice machines, while subject to few regulations and controls, can be reservoirs of unsuspected opportunistic pathogens that could lead to nosocomial infections of vulnerable patients. Cleaning procedures should be based on the disinfection of resistant opportunistic pathogens, such as Candida and NTM, and the use of general indicators, such as HPCs, should be questioned.

Funding: None

Disclosures: None

Background: Surgical site infections (SSIs) incur up to $10 billion annually due to their excessive morbidity. SSI prevention bundles have had variable success in colorectal surgery. For example, at the University of Wisconsin Hospital, a 505-bed regional referral center, SSI rates have remained high despite the introduction of a 14-element SSI prevention bundle in 2016. To aid in the implementation of this complex bundle, the hospital started Strike Teams in 2019. We have described the impact of Strike Teams on colorectal SSI rates in our tertiary-care hospital. Methods: A Strike Team with key stakeholders from colorectal surgery (ie, surgeon, OR director, nurses, surgical technicians), anesthesia, pharmacy, infection prevention, and infectious disease was formed, supported by the hospital’s executive leadership. The Strike Team met monthly throughout 2019 to review each SSI case, discussed barriers to adherence for the SSI prevention bundle elements with implementation difficulties (Table 1), and proposed actionable feedback to increase adherence. The latter was disseminated to frontline clinicians by the teams’ surgical leaders during everyday clinical practice. The Strike Team was paused in 2020 due to resource reallocation in response to the COVID-19 pandemic. Monthly and quarterly SSI surveillance was conducted according to CDC guidance. Results: Colorectal SSI rates before, after, and during Strike Team activity are shown in Fig. 1. Adherence rates to the bundle elements targeted by the Strike Team are shown in Fig. 2. Conclusions: Adherence to the preferred antibiotic prophylaxis increased, although adherence to other bundle elements of focus did not change significantly. SSI rates decreased below our expectation while the Strike Team was active in our hospital, although SSI reduction was not sustained. Further research should study the effectiveness of Strike Teams as a long-term implementation strategy for SSI prevention in colorectal surgery.

Funding: None

Disclosures: None

Background: Multidrug-resistant organisms (MDROs), such as carbapenem-resistant Enterobacterales (CRE), can spread rapidly in a region. Facilities that care for high-acuity patients with long average lengths of stay (eg, long-term acute-care hospitals or LTACHs and ventilator-capable skilled nursing facilities or vSNFs) may amplify this spread. We assessed the impact of interventions on CRE spread within a region individually, bundled, and implemented at different facility types. Methods: We developed a deterministic compartmental model, parametrized using CRE data reported to the NHSN and patient transfer data from the CMS specific to a US state. The model includes the community and the healthcare facilities within the state. Individuals may be either susceptible or infected and infectious. Infected patients determined to have CRE through admission screening or point-prevalence surveys at a facility are placed in a state of lower transmissibility if enhanced infection prevention and control (IPC) practices are in place. Results: Intervention bundles that included periodic point-prevalence surveys and enhanced IPC at high-acuity postacute-care facilities had the greatest impact on regional prevalence 10 years into an outbreak; the benefits of including admission screening and improved interfacility communication were more modest (Fig. 1A). Delaying interventions by 3 years is predicted to result in smaller reductions in prevalence (Fig. 1B). Increasing the frequency of point-prevalence surveys from biannually to quarterly resulted in a substantial relative reduction in prevalence (from 25% to 44%) if conducted from the start of an outbreak. IPC improvements in vSNFs resulted in greater relative reductions than in LTACHs. Admission screening at LTACHs and vSNFs was predicted to have a greater impact on prevalence if in place prior to CRE introduction (~20% reduction), and the impact decreased by approximately half if implementation was delayed until 3 years after CRE introduction. In contrast, the effect of admission screening in ACH was less (~10% reduction in prevalence) and did not change with implementation delays. Conclusions: Our model suggests that interventions that limit unrecognized MDRO introduction to, or dispersal from, LTACHs and vSNFs through screening are predicted to slow distribution regionally. Interventions to detect colonization and improve IPC practices within LTACHs and vSNFs may substantially reduce the regional burden. Prevention strategies are predicted to have the greatest impact when interventions are bundled and implemented before an MDRO is identified in a region, but reduction in overall prevalence is still possible if implemented after initial MDRO spread.

Funding: None

Disclosures: None

Antimicrobial resistance is a well-known global health threat that has higher prevalence in the refugee population. Although guidance has been provided by the World Health Organization and Centers for Disease Control and Prevention on implementing antimicrobial stewardship in lower- and middle-income countries, as well as by the United Nations Refugee Agency on other infection prevention and control efforts, no specific guidance exists for implementation of stewardship in this population. We highlight challenges specific to this population, review recent studies of interest within this space, and propose a research agenda to help move stewardship forward in the refugee population. We advocate for the importance of this issue, particularly given recent current events of geopolitical volatility that render this population more vulnerable, in the setting of its already well-known numerous health challenges.

Background: Urinalysis and urine culture are frequently ordered diagnostic tests among hospitalized patients, often for nonspecific symptoms. Diagnostic testing stewardship with urinalysis with reflex culture (UARC) is a practice shown to reduce institutional culture rates by selecting patients who are more likely to have a true infection. Optimal reflex criteria are not well established, and downstream effects, such as antibiotic use, have not been well studied. Methods: We compared outcomes in the preimplementation period (December 2018 – October 2019) and postintervention period (November 2019–October 2020) at an academic medical center. The intervention was changing the UARC reflex criteria. The primary outcomes were urine-culture rate per 1,000 patient days, urine-culture positivity, antibiotic prescription for suspected urinary tract infection (UTI) and catheter-associated urinary tract infection (CAUTI) rate per 1,000 Foley catheter days. Analysis was performed using interrupted time-series negative binomial regression or Poisson regression where appropriate. Results: We detected a significant decrease in the rate of cultures performed (32.5 cultures per 1,000 patient days before the intervention vs 8.6 cultures per 1,000 patient days after the intervention; P = 0.10). Fig. 1 summarizes these results graphically. In an adverse events analysis, of 646 patients in the postintervention period, 130 patients were reviewed for the outcome of sepsis secondary to a urinary tract infection, with only 1 patient meeting criteria for this diagnosis. Conclusions: Changing the UARC reflex criteria resulted in the expected decrease in rate of cultures performed with increase in culture positivity, and the stricter criteria appeared to more effectively identify true UTIs. Minimal adverse events were associated with the UARC criteria change, demonstrating that these criteria are also safe. We detected a significant change in antibiotic prescriptions, but much of the decrease occurred during the preintervention period, which likely reflected educational and stewardship interventions performed at that time. Although the intervention affected culture performance, which does decrease institutional costs, continued provider education is needed to influence clinical outcomes.

Funding: None

Disclosures: None

Background: Drawing blood cultures in the emergency room (ER) is essential for detecting bloodstream infections (BSIs). Although a practice of drawing blood culture usually indicates a presence of severe infection requiring hospitalization, some patients may nonetheless be safely discharged from the ER. Previous studies demonstrated that patients with a positive blood culture after ER discharge had favorable clinical outcomes. Moreover, given the increasing incidence of febrile illnesses, especially in the era of COVID-19, the shortage of inpatient hospital beds may lend further justification to this practice. We investigated the prevalence, outcomes, and factors associated with patient discharge from the ER after blood collection. Method: The present, nested, case–control study comparing patients initially discharged from the ER with those directly admitted to the study institution was conducted at a 790-bed tertiary-care medical center in Tokyo, Japan. The ratio of the respective patients was 1:3. Factors associated with ER discharge after a blood-culture collection were identified using multivariate logistic regression analysis. Results: From January 2014 through December 2020, 153,432 patients visited the ER. Blood cultures were obtained for 19,010 patients; 2,575 (13.5%) of these had a true BSI, and of the latter, 142 (5.5%) were initially discharged from the ER. During 2020, the proportion of patients with ER discharge increased 1.7 times over previous years. There was no significant difference in 28-day mortality between the groups (2.1% vs 4.5%; P = .31). On multivariate logistic regression analysis, factors significantly associated with the decision to discharge after blood culture collection were the absence of hypotension (aOR], 14,92; 95% CI, 3.38–65.93), lack of altered mental status (aOR, 8.44; 95% CI, 3.28–21.71) at ER presentation, unknown diagnosis at ER discharge (aOR, 3.75; 95% CI, 1.97–7.16), high level C-reactive protein (aOR, 0.91; 95% CI, 0.87–0.94), and a diagnosis of intra-abdominal or hepatobiliary infection (aOR, 0.11; 95% CI, 0.04–0.29). Conclusions: ER discharge after drawing blood for a culture was more frequently seen in the current COVID-19 era and was deemed acceptable under certain circumstances, such as patients with no systemic illnesses or specific diagnosis who may be managed safely without compromising clinical outcomes.

Funding: None

Disclosures: None

Background: Attendance policies for common pediatric illnesses vary widely across childcare centers despite nationally published guidelines from the American Academy of Pediatrics. The COVID-19 pandemic has exacerbated this problem, leading to economic loss from parental work absenteeism and excess medicalization of children with common illnesses. We sought to understand barriers to and recommendations for adopting best practices on attendance policies at Early Head Start and Head Start (EHS/HS) childcare centers. Methods: We conducted 19 semistructured qualitative interviews: 9 with childcare leadership and 10 with parents from EHS/HS childcare centers across Colorado. Interviews took place between April and December 2021. Interviews were audio-recorded, transcribed, and coded in ATLAS.ti using a priori and emergent coding strategies. Descriptive content analysis was used to identify central themes, which were iteratively revised by 2 authors. Results: We derived 7 convergent and 4 divergent themes from leadership and parents addressing attendance decisions. Overlapping themes on barriers to adopting best practices included difficulty assessing symptom severity, limited medical provider understanding of childcare requirements, parent employment pressures, and the impact of the COVID-19 pandemic on exclusion durations. Leadership and parent perspectives differed on resources utilized, understanding of exclusionary symptoms, and role of medical providers in making attendance decisions. Overlapping themes on recommendations for best practices included access to registered nursing, concrete guidance on symptoms, and partnering with health departments. Leadership and parents agree that the COVID-19 pandemic led to increased guideline use in making attendance decisions and increased rates of excluding children from class for minor illness compared to prepandemic times. Both leadership and parents recommended consistency in exclusion practices, but leadership and parents identified medical providers and childcare leadership, respectively, as current sources of inconsistency. Salient findings showed variability in defining a fever by age from both leadership and parents. Conclusions: Coordination is needed between childcare centers, medical facilities, and health departments to improve attendance decisions for common pediatric illnesses. Future work should (1) develop concrete symptom guidance for parents with specific exclusion criteria (eg, via a decision aid), (2) assess the utility and feasibility of regular classroom access to registered nursing, and (3) advocate for employee protections to care for sick children at home.

Funding: None

Disclosures: None

In total, 20 severe acute respiratory coronavirus virus 2 (SARS-CoV-2) clusters were analyzed in a tertiary-care hospital from the beginning of the pandemic until July 2021. After the second pandemic wave, the number of clusters decreased with increasing vaccination rates and community infections increased again. These findings should motivate healthcare workers to participate in SARS-CoV-2 vaccination campaigns.

As of December 2021, the coronavirus disease 2019 (COVID-19) pandemic has claimed millions of deaths and caused disruptions in health systems around the world. The short- and long-term effects of COVID-19 on antimicrobial resistance (AMR), which was already a global threat before the pandemic, are manifold and complex. In this expert review, we summarize how COVID-19 might be affecting AMR in the short term (by influencing the key determinants antibiotic use, infection control practices and international/local mobility) and which additional factors might play a role in the long term. Whereas reduced outpatient antibiotic use in high-income countries, increased awareness for hand hygiene, and reduced mobility have likely mitigated the emergence and spread of AMR in the short term, factors such as overuse of antibiotics in COVID-19 patients, shortage of personal protective equipment, lack of qualified healthcare staff, and patient overcrowding have presumably facilitated its propagation. Unsurprisingly, international and national AMR surveillance data for 2020 show ambiguous trends. Although disruptions in antibiotic stewardship programs, AMR surveillance and research might promote the spread of AMR, other developments could prove beneficial to the cause in the long term. These factors include the increased public awareness for infectious diseases and infection control issues, the strengthening of the One Health perspective as outlined by the Centers for Disease Control and Prevention, and the unprecedented number of international research collaborations and platforms. These factors could even serve as leverage and provide opportunities to better combat AMR in the future.

Background: Rapid response is critical to control healthcare-associated infection (HAI) and antibiotic resistance threats within healthcare facilities to prevent illness among patients, residents, and healthcare personnel. Through this analysis, we aimed to quantify public health response activities, by healthcare setting type, for (1) novel and targeted multidrug-resistant organisms or mechanisms (MDROs), (2) SARS-CoV-2, and (3) other possible outbreaks. Method: We reviewed response activity data submitted by US state, territorial, and local health department HAI/AR programs to the CDC as part of funding requirements. We performed descriptive analyses of response activities conducted during the funding reporting period (August 2019–July 2020). SARS-CoV-2 response activities were reported from January through July 2020. Data were analyzed by response category (novel or targeted MDRO, SARS-CoV-2, other HAI/AR responses), and healthcare setting type. Results: During August 2019–July 2020, 57 HAI/AR Programs (50 state, 1 territorial, 5 local health departments, and District of Columbia) reported 18,306 public health responses involving healthcare facilities. These data included 3,860 responses to 1 or more cases of novel or targeted MDROs, 13,992 responses to SARS-CoV-2 outbreaks (beginning in January 2020), and 454 responses to other possible outbreaks. Novel and targeted MDRO responses most frequently occurred in acute-care hospitals (ACHs, 64.5%), skilled nursing facilities (SNFs, 24.5%), and long-term acute-care hospitals (LTACHs, 5.8%). SARS-CoV-2 responses most frequently occurred in SNFs (55%), and assisted living facilities (24%). Other HAI/AR responses most frequently occurred in ACH (50%), SNF (28.4%), and outpatient settings (19.6%). Of the “other” HAI/AR responses, 76% were responses to cases, clusters, or outbreaks, and 23.8% were responses to serious infection control breaches including device and instrument reprocessing, injection safety, and other deficient practices. Conclusions: During the study period, public health programs performed a high volume of HAI/AR response activities largely focused on SARS-CoV-2 in nursing homes and assisted living facilities. Other important response activities occurred across a range of other healthcare settings, including responses to novel and targeted MDROs, HAI outbreaks, and serious infection control breaches. Whereas SARS-CoV-2 response activities largely centered in long-term care settings, MDRO and other HAI/AR responses occurred mostly in acute-care settings. These data demonstrate the importance of building and sustaining public health response capacity for a broad array of healthcare settings, pathogens, and patient populations to meet the range of current and emerging HAI/AR threats.

Funding: None

Disclosures: None

Background: The impacts of health inequities on healthcare access, utilization, and outcomes have been highlighted by the COVID-19 pandemic, but these issues have been ongoing, yet understudied, in infectious disease epidemiology. Health inequities affect access to care, quality of care, and health outcomes in all healthcare settings. One healthcare setting that has yet to be fully studied in the context of health inequities is nursing homes. Nursing homes have a host of facility and population-specific issues that differ from other healthcare settings, making the impacts of health inequities likely unique and imperative to understand. The impacts of health inequities on nursing homes are unclear, and they likely have downstream effects on trends in morbidity, mortality, and transmission of multidrug-resistant organisms (MDROs) and other pathogens. Method: Here, we present a descriptive analysis, integrating multiple datasets relating to nursing home facility factors (data from the CMS Provider of Services and the CDC NHSN), nursing-home staffing trends (data from the CMS Payroll-Based Journal data), and social vulnerability (data from the CDC Social Vulnerability Index). We conducted a spatial analysis of nursing-home locations and the social vulnerability of the area. Results: Investigations of facilities and health inequities are best conducted in small spatial geographies. Analyses with less detailed spatial geographies miss high levels of heterogeneity in social vulnerability. Figure 1 provides an example, showing that analyzing nursing homes at a smaller spatial scale (ie, healthcare service area or HSA) shows heterogeneity in poverty levels that might be overlooked at a rough spatial scale, like Hospital Referral Regions (HRR). The poverty level associated with a nursing home will differ greatly depending on the geography of the analysis. Conclusions: These findings highlight that health inequities affect the quality and quantity of care of in nursing homes and that research conducted at larger geographical scales may overlook important mechanistic factors. This work will inform epidemiological models for disease transmission in nursing homes, accounting for the impacts of health inequities on transmission. Abating health inequities in all healthcare settings is a necessity to improve public health for the entire United States.

Funding: None

Disclosures: None

In this pre- and postintervention study, we demonstrate the feasibility and effectiveness of comprehensive simulation-based personal protective equipment (PPE) training amid the COVID-19 pandemic. With rapid-cycle, deliberate practice feedback, simulation-based training can improve the learners’ sense of confidence and security while standardizing PPE protocols.

Mixed flora in urine cultures usually occur due to preanalytic contamination. In our outpatient urology clinic, we detected a high prevalence of mixed flora (46.2%), which was associated with female sex and older age. Patient education did not influence the rate of mixed flora. Future efforts should target high-risk patients.

Background: Antibiotics are frequently prescribed–and overprescribed–at hospital discharge, leading to adverse-events and patient harm. Our understanding of how to optimize prescribing at discharge is limited. Recently, we published the ROAD (Reducing Overuse of Antibiotics at Discharge) Home Framework, which identified potential strategies to improve antibiotic prescribing at discharge across 3 tiers: Tier 1–Critical infrastructure, Tier 2–Broad inpatient interventions, Tier 3–Discharge-specific strategies. Here, we used the ROAD Home Framework to assess the association of stewardship strategies with antibiotic overuse at discharge and to describe pathways toward improved discharge prescribing. Methods: In fall 2019, we surveyed 39 Michigan hospitals on their antibiotic stewardship strategies. For patients hospitalized at participating hospitals July 1, 2017, through July 30, 2019, and treated for community-acquired pneumonia (CAP) and urinary tract infection (UTI), we assessed the association of reported strategies with days of antibiotic overuse at discharge. Days of antibiotic overuse at discharge were defined based on national guidelines and included unnecessary therapy, excess duration, and suboptimal fluoroquinolone use. We evaluated the association of stewardship strategies with days of discharge antibiotic overuse 2 ways: (1) all stewardship strategies were assumed to have equal weight, and (2) strategies weighted using the ROAD Home Framework with tier 3 (discharge-specific) strategies had the highest weight. Results: Overall, 39 hospitals with 20,444 patients (56.5% CAP; 43.5% UTI) were included. The survey response rate was 100% (39 of 39). Hospitals reported a median of 12 (IQR, 9–14) of 33 possible stewardship strategies (Fig. 1). On bivariable analyses, review of antibiotics prior to discharge was the only strategy consistently associated with lower antibiotic overuse at discharge (aIRR, 0.543; 95% CI, 0.335–0.878). On multivariable analysis, weighting by ROAD Home tier predicted antibiotic overuse at discharge for both CAP and UTI. For diseases combined, having more weighted strategies was associated with lower antibiotic overuse at discharge (aIRR per weighted intervention, 0.957; 95% CI, 0.927–0.987). Discharge-specific stewardship strategies were associated with a 12.4% relative decrease in antibiotic overuse days at discharge. Based on these findings, 3 pathways emerged to improve antibiotic use at discharge (Fig. 2): inpatient-focused strategies, “doing it all,” and discharge-focused strategies. Conclusions: The more stewardship strategies reported, the lower a hospitals’ antibiotic overuse at discharge. However, different pathways to improve discharge antibiotic use exist. Thus, discharge stewardship strategies should be tailored. Specifically, hospitals with limited stewardship resources and infrastructure should consider implementing a discharge-specific strategy straightaway. In contrast, hospitals that already have substantial inpatient infrastructure may benefit from proactively incorporating discharge into their existing strategies.

Funding: None

Disclosures: None

Background: Urinary tract infections (UTIs) are common in the inpatient, observation, and emergency department settings. Although many UTI-causing pathogens are susceptible to oral β-lactams, these agents are not tested directly, and susceptibility is extrapolated from other agents. To improve the use of these agents, the University of North Carolina Medical Center (UNCMC) added cephalexin to the susceptibility profile generated with urine culture results in the electronic health record (EHR). We evaluated prescribing trends of cephalexin, other oral β-lactams, fluoroquinolones, and other antibiotics for UTIs in the inpatient setting, before and after the susceptibility reporting change. Methods: An interrupted time-series analysis was conducted. Among 1,491 patients who had positive urine cultures with susceptibilities and received at least 1 antibiotic with a listed UTI indication during their inpatient stay at UNCMC, we measured the weekly prevalence (%) of patients who received each antibiotic group: cephalexin, other oral β-lactams (amoxicillin-clavulanate, cefdinir, cefuroxime), fluoroquinolones (levofloxacin, ciprofloxacin), and ceftriaxone. The study comprised a preintervention period (September 2018–March 2019) and a postintervention period (September 2019–March 2020). The prevalence of each antibiotic or group was plotted over time, and segmented linear regression was used to estimate the impact of the intervention on each antibiotic groups’ time trend. Results: At study baseline in September 2018, the weekly prevalence of antibiotic use was 11% for cephalexin, 26% for other oral β-lactams, 51% for ceftriaxone, and 29% for fluoroquinolones. Fluoroquinolone use decreased steadily throughout the study period, by 11% during the 7-month preintervention period (95% CI, −17% to −5%) and by 8% (95% CI, −13% to −3%) after the intervention (P for trend deflection, .70). In contrast, during the preintervention period, trends were flat for cephalexin, ceftriaxone, and other oral β-lactams (all P for nonzero preintervention slope were >.40). During the postintervention period, use increased for ceftriaxone (6%; 95% CI, 3%–9%). Post-intervention use also increased for cephalexin (5%; 95% CI, −3% to 12%) and other oral β-lactams (4%; 95% CI, −8%, 15%), but these trends were imprecise and not statistically significant at α = .05. Fig. 1 displays trends and raw data for each antibiotic group. Conclusions: The urine culture susceptibility reporting change was associated with small increases in cephalexin and ceftriaxone use, coincident with continued decreasing use of fluoroquinolones, for hospitalized patients with positive urine cultures and a listed UTI indication. Low-resource EHR-based interventions may confer considerable benefit for antimicrobial stewardship efforts in this clinical setting, and larger real-world studies are needed to replicate and contextualize these findings.

Funding: None

Disclosures: None