Background: Significant increases in healthcare-associated infections (HAIs) including central-line associated blood stream infections (CLABSIs) have been reported during the COVID-19 pandemic. Acute-care hospitals have faced staffing and personal protective equipment shortages, increased critical care capacity, and diversion of resources from traditional HAI surveillance and prevention efforts. In this study, we characterized CLABSIs among patients with COVID-19 and compared demographics, comorbidities, and outcomes between patients diagnosed with CLABSI with and without COVID-19. Methods: This is an observational retrospective cohort study of all patients diagnosed with CLABSI as defined by NHSN at William P. Clements Jr. University Hospital from April 1, 2020, through September 30, 2021. A retrospective chart review was conducted to identify demographics, comorbidities, and outcomes of hospitalized patients diagnosed with CLABSI. Patients hospitalized with and without COVID-19 were compared using the independent-sample t test for means and the χ2 test for proportions. Results: Overall, 82 patients diagnosed with CLABSI between April 1, 2020, to September 30, 2021, among whom 31 (38%) were hospitalized with COVID-19 and 51 (62%) were not hospitalized with COVID-19. Patients hospitalized with COVID-19 were significantly more likely to be obese (58% for COVID-19 positive vs 26% for COVID-19 negative; P = .01) and to require extracorporeal membrane oxygenation (19% vs 4%; P = .04). However, COVID-19 patients were significantly less likely to have hematologic malignancy (7% vs 28%; P = .03), undergone bone marrow transplantation (0% vs 18%; P = .01), or have neutropenia (3% vs 22%; P = .03). There were no significant differences in line type or organism identified. Gram-positive pathogens were identified in 16 patients (52%) hospitalized with COVID-19. Gram-negative pathogens were identified in 3 patients (10%); fungal organisms were identified in 10 patients (32%), and 2 cases (7%) were polymicrobial. Patients with COVID-19 were significantly more likely to require an ICU stay (84% vs 43%). p Conclusions: High device utilization as well as prolonged hospitalization and line days among patients with COVID-19 along are contributing risk factors for CLABSI among patients hospitalized with COVID-19. This finding highlights the need for ongoing HAI surveillance and prevention efforts in patients hospitalized with COVID-19 given their characteristics and increased risk for CLABSI. Reinforcing infection prevention efforts by accentuating the importance of optimal line care and regular feedback are crucial, especially among patients hospitalized with COVID-19.

Funding: None

Disclosures: None

We assessed the prevalence of antibiotic prescriptions among ambulatory patients tested for coronavirus disease 2019 (COVID-19) in a large public US healthcare system and found a low overall rate of antibiotic prescriptions (6.7%). Only 3.8% of positive severe acute respiratory coronavirus virus 2 (SARS-CoV-2) tests were associated with an antibiotic prescription within 7 days.

Background: Patients requiring vascular catheters are at risk for bloodstream infections (BSIs), particularly those with central venous access devices (CVADs). Central-line–associated bloodstream infections (CLABSIs) may occur as a result of the introduction of pathogenic microbes during CVAD access procedures, including through the needleless connector. The use of an antiseptic scrub is recommended to disinfect the needleless connector before device access, and this procedure has been shown to reduce the risk for CLABSI. We identified perceived barriers and facilitators and assessed compliance with instructions for use of chlorhexidine or alcohol antisepsis products (CHG or IPA; 5-second scrub time plus 5-second dry time) and alcohol antisepsis products (IPA; facility protocol 15-second scrub time plus let dry) for needleless connector disinfection. Methods: We performed a multiple-methods study involving focus groups composed of a convenience sample of nurses and clinical observations of CVAD needleless-connector access procedures in 3 medical ICUs and 1 surgical ICU at 2 academic medical centers. We used open-ended questions to guide the focus-group discussions. We directly observed nursing staff performing needleless-connector disinfection following a time–motion paradigm using an electronic tool to document the observed needleless-connector access events and to measure needleless-connector antiseptic scrub times and dry times. Results: In total, 8 focus groups involving 28 nurses revealed access to the antiseptic product and lesser workload as best-practice facilitators of needleless-connector disinfection. Identified barriers were often the opposite of the facilitators, particularly the time required per needleless connector access using IPA and knowledge deficits regarding the need for disinfection between multiple needleless-connector accesses. From 36 observations, including a total of 48 access events, we determined that the mean scrub times were below the recommended times, especially for IPA (Table 1). Drying time after use of either antisepsis product was negligible. Conclusions: A lack of access to the disinfection product, emergency situations, and increased workload were perceived barriers to needleless-connector disinfection. Observed scrub times and drying times were shorter than recommended, much more so for IPA. These deficits in the performance of needleless-connector disinfection may increase the risk of CLABSI. Ongoing education and periodic competency evaluation of needleless-connector disinfection are needed to imbed and sustain best practices.

Funding: Professional Disposables, Inc.

Disclosures: None

Background: We conducted an anonymous survey in compliance with German data protections regulations among participants of the annual infectious disease and control meeting in Freiburg, Germany, in October 2021. Methods: In total, 391 surveys were returned: 188 from nurse infection control practitioners (ICPs) and 66 from specially infection control trained physicians (STPs). We report the results of these 2 subgroups regarding their perceptions and emotions during the pandemic. Descriptive statistics and χ2 test with P < .05 were used when applicable. Results: Shortages of medical masks or FFP2 masks during the first pandemic wave in 2020 were reported by 48.5% STPs and 57.4% ICPs. STPs and ICPs relied equally on information provided by the Robert Koch Institute, the WHO, the ECDC and the CDC. Occupational health information was sought significantly more often by ICPs; only 17% of ICPs never used this source versus 51.5% of STPs (P < .001). Most ICPs (58%) and STPs (51%) described their relationship to local authorities as good as well as communication with institutional leaders (69.7%). Fewer ICPs (36.1%) felt frequently appreciated during the pandemic compared to 45.5% of STPs and more ICPs (25%) reported frustration than STPs (18.2%). However, the differences were not statistically significant. Rarely, ICPs (2.1%) or STPs (1.5%) felt unsafe at work and only 1.6% of ICPs and no STPs reported loss of motivation. In addition, 13.8% of ICPs and 12.1% of STPs often felt overwhelmed, but only 3.2% of ICPs and no STPs felt hopeless. Their self-reported competency was rated as high by 75% of ICPs and 69.7% of STPs. The 5 most frequent free-text comments regarding “lessons learned” pertained to better crisis communication, better supply chain management, precise regulations, “less talking more doing,” and mandatory vaccination. The most frequent free-text general comments pertained to maintain basic hygiene measures in private and public life because of the pandemic. Conclusions: Our survey results indicate a high level of resilience among members of infections control teams in German medical institutions despite obvious shortcomings in supplies during the first wave of the pandemic. There were no significant differences between physician and nurse members of infection control teams regarding their perceptions and emotions, indicating a homogenous situation within the teams. The high level of self-perceived competency has likely helped deal with the pandemic and prevented the feeling of loss of control implied in the question items “feeling overwhelmed” and “hopeless.”

Funding: None

Disclosures: None

Background: COVID-19 occupational exposures have been examined using death certificates and employment data from the Bureau of Labor Statistics and the O*Net database in the United States. However, no studies have examined cases, hospitalizations, and deaths by occupation using hospital records.1 We analyzed COVID-19 cases using hospitalization data from a large, rural community hospital to fill this gap in the evidence base. Methods: A retrospective cross-sectional study design was used to examine patients with COVID-19 from March 1 through July 31, 2020. We examined demographic characteristics, such as age, sex, race or ethnicity, and length of stay (LOS), among those who tested positive for SARS-CoV-2. Epidemiological risk factors were also analyzed, including smoking status, body mass index (BMI), alcohol use, and occupation. Occupational data were processed using the National Institute for Occupational Safety and Health Industry and Occupation Computerized Coding System. Homemakers, disabled persons or retirees, students or minors, and listed occupations with insufficient information were excluded from the analysis. Occupations were categorized into 23 major occupation groups based on the 2018 Standard Occupational Classification System. To examine whether certain occupations are at a higher risk due to COVID-19, we stratified the analysis by overall cases, hospitalizations, and deaths. Microsoft Power BI Desktop and IBM SPSS version 28.0.0.0 software were used to analyze the data. This study was reviewed and approved by the local institutional review board. Results: In total, 2,132 COVID-19 diagnoses with 1,049 total hospitalizations were identified during the study period. Most cases were in the group aged 50–64 years, white race, and/or Hispanic ethnicity (Table 1). Most cases never or rarely drank alcohol, were nonsmokers, and had a BMI ≥30 (Table 2). The average LOS among those hospitalized for COVID-19 was 6.46 days. The occupational analysis revealed a higher frequency of cases among those in management (n = 95, 14%) and healthcare (n = 83, 12%), with those in management (n = 40, 14%) and sales (n = 29, 10%) having the highest frequency of being hospitalized. However, the highest frequency of deaths occurred among those in building and grounds cleaning and maintenance occupations (13%) (Table 3). Conclusions: This study describes the burden of COVID-19 in a rural area with a large aging population and highlights potential health disparities among severe cases and deaths in different occupational groups.

1. Baker MG, Peckham TK, Seixas NS. Estimating the burden of United States workers exposed to infection or disease: a key factor in containing risk of COVID-19 infection. PLoS One 2020;15:e0232452.

Funding: None

Disclosures: None

We analyzed blood-culture practices to characterize the utilization of the Infectious Diseases Society of America (IDSA) recommendations related to catheter-related bloodstream infection (CRBSI) blood cultures. Most patients with a central line had only peripheral blood cultures. Increasing the utilization of CRBSI guidelines may improve clinical care, but may also affect other quality metrics.

Background: Singapore General Hospital (SGH) is the largest acute tertiary-care hospital in Singapore. Healthcare workers (HCWs) are at risk of acquiring COVID-19 in both the community and workplaces. SGH has a robust exposure management process including prompt contact tracing, immediate ring fencing, lock down of affected cubicles or single room isolation for patient contacts, and home isolation orders for staff contacts of COVID-19 cases during the containment phase of the pandemic. Contacts were also placed on enhanced surveillance with PCR testing on days 1 and 4 as well as daily antigen rapid tests (ARTs) for 10 days after exposure. Here, we describe the characteristic of HCWs with COVID-19 during the third wave of the COVID-19 pandemic. Methods: This retrospective observational study included all SGH HCWs who acquired COVID-19 during the third wave (ie, the 18-week period from September 1 to December 31, 2021) of the COVID-19 pandemic. Univariate analysis was used to compare characteristics of work-associated infection (WAI) and community-acquired infection (CAI) among HCWs. Results: Among a workforce of >10,000 at SGH, 335 HCWs acquired COVID-19 during study period. CAI (exposure to known clusters or household contact) accounted for 111 HCW infections (33.1%). Also, 48 HCWs (14.3%) had a WAI (ie, acquired at their work places where there was no patient contact). Among WAsI, only 5 HCWs had hospital-acquired infection (confirmed by phylogenetic analysis). The sources of exposure for the remaining 176 HCWs were unknown. Weekly incidence of COVID-19 among HCWs was comparable to the epidemiology curve of all cases in Singapore (Fig. 1 and 2). The mean age of HCWs with COVID-19 was 39.6 years, and most were women. At the time of positive SARS-CoV-2 PCR test, 223 HCWs were symptomatic, and 67 (20.0%) of them had comorbidities. Only 16 HCWs (4.8%) required hospitalization, and all recovered fully with no mortality (Table 1). Being female was associated with community COVID-19 acquisition (OR, 4.6, P Conclusions: During the thrid wave of the COVID-19 pandemic, a higher percentage of HCWs at SGH acquired the infection from the community than from the workplace. Safe management measures, such as universal masking, social distancing, and robust exposure management processes including prompt contact tracing and environmental disinfection, can reduce the risk of COVID-19 in the hospital work environment.

Funding: None

Disclosures: None

Background: COVID-19 has had a disproportionate effect on nursing homes residents as well as people from racial and ethnic minorities. Whether differences in mortality due to COVID-19 exists for nursing-home residents from racial and ethnic minorities is less clear, with some previous studies reporting systems-level disparities. The Department of Veterans’ Affairs (VA) has nursing homes, termed community living centers (CLCs), across the United States. We hypothesized that differences in COVID-19–related mortality among racial and ethnic minorities would be less pronounced among residents of CLCs. Methods: Using data from the VA Corporate Data Warehouse, we conducted a retrospective cohort study from April 14, 2020 (implementation of population-based testing) to December 10, 2020 (availability of a COVID-19 vaccine). Inclusion criteria were residents with a positive SARS-CoV-2 test while residing in or <48 hours before admission to a CLC. Positive tests <180 days after a prior positive test were excluded. We assessed the cohort for demographics, including self-reported race or ethnicity, clinical characteristics, and survival probability including all-cause 30-day mortality. A multivariable logistic regression model was used to estimate odds ratios (ORs) and 95% confidence intervals (CIs) for all-cause 30-day mortality that included race, ethnicity, age, and Charlson comorbidity index (CCI). Results: Among 14,759 CLC residents, 651 (4.4%) had a positive SARS-COV-2 test. Their mean age was 75.7 ± 11.3 years, and self-reported race or ethnicity was 68% White (445 of 651), 23% Black (152 of 651), and 4% Hispanic/Latinx (27 of 651). The mean CCI was lower among White residents than Black residents (4.15 ± 2.6 vs 4.61 ± 3.1, respectively). All-cause 30-day mortality for CLC residents following positive SARS-COV-2 test was 25% for White patients, 14% for Black patients, and 15% for Hispanic/Latinx patients (Fig. 1). Age (in years), but neither race or ethnicity nor CCI, was independently associated with all-cause 30-day mortality (OR, 1.07; 95% CI, 1.05–1.09) in CLC residents with COVID-19. Conclusions: Among VA CLC residents with a positive COVID-19 test, minority CLC residents did not have worse outcomes than white residents, suggesting that users of the VA healthcare system may enjoy abrogation of some aspects of health disparities.

Funding: None

Disclosures: None

Lebanon, one of the smallest countries in the Middle East, has held for decades a reputation for being the premier medical hub for patients from the Arab world as well as neighboring countries and for offering world-class treatment and advanced medical services. However, this once world-renowned healthcare sector is now facing a risk of imminent collapse as overlapping crises have struck the country since October 2019. In this article, we describe the concomitant political, economic, and financial challenges that Lebanon is facing, which have strained the national healthcare system and have undermined its ability to respond to the coronavirus disease 2019 (COVID-19) pandemic. We present an overview of the political instability, the Lebanese revolution with countrywide protests, as well as the devaluation of the Lebanese currency representing one of the worst economic meltdowns since the 19th century. We describe the unprecedented energy crisis the country is facing and the disastrous consequences of the Beirut port explosion of August 2020. We review the efforts and measures taken by different stakeholders to contain the COVID-19 pandemic amid the multifaceted challenges and the large exodus of healthcare personnel.

Background: Throughout the COVID-19 pandemic, CDC Division of Healthcare Quality Promotion (DHQP) has provided technical assistance in support of state, tribal, local, and territorial health departments for COVID-19 healthcare outbreak management and infection prevention and control (IPC). We characterized the volume and trends of technical assistance provided during the pandemic to inform the future needs of health departments for COVID-19 healthcare IPC and DHQP resources required to meet these needs. Methods: In January 2020, DHQP began receiving COVID-19 IPC TA requests directly from health departments for remote assistance or from CDC staff on field deployments providing onsite support. DHQP subject-matter experts provided responses via e-mail or, for more complex inquiries, outbreaks, or field deployments, via phone consultations. Records of e-mail communications and phone consultations were entered into an inquiry database for tracking. We calculated the number, mean, and range of technical-assistance responses by jurisdiction and by month from January 2020 through December 2021. We designated months as high-volume periods for technical assistance if inquiries surpassed the 75th percentile. Results: In total, 1,869 IPC technical-assistance responses were provided. Of all technical-assistance responses, 1,725 (92%) were to state or local health departments, 115 (6%) were tribal nations, and 28 (2%) were US territories. IPC technical assistance was provided to all 50 states and the District of Columbia, 16 tribal nations, and 5 US territories. The average total number of technical assistance responses per site during the 24-month period was 34 to state and local HDs (range, 2–111), 6 to tribal nations (when tribal nation was specified; range, 1–17), and 6 to US territories (range, 1–15). E-mail communications comprised 1,164 responses (62%); phone consultations made up the remaining 705 responses (38%). Of phone consultations, 350 (50%) were with CDC field deployers providing onsite support to health departments. The average number of technical-assistance responses provided each month across all jurisdictions was 78 (range, 0–334); months with high volumes included April–August 2020 and January 2021. Conclusions: These findings highlight the high-level collaboration between federal and state, tribal, local, and territorial health department partners in remote and onsite support of COVID-19 prevention and response efforts in healthcare settings. Variations in monthly volumes of health-department COVID-19 healthcare IPC technical assistance requests may reflect factors such as fluctuations in community infection rates and changes in CDC IPC guidance. The ability to provide effective technical assistance during pandemic response depends on the CDC maintaining sufficient healthcare IPC staffing and expertise.

Funding: None

Disclosures: None

Background: In November 2020, the FDA issued an emergency use authorization (EUA) for monoclonal antibodies (mAbs) to be used in outpatients with COVID-19 infections who are at a high risk of progressing to severe disease. However, becuase the EUA had limited indications for inpatients, data on their use in hospitalized patients are limited. In this study, we have described the use of mAbs among hospitalized patients with nosocomial COVID-19. Methods: We retrospectively analyzed cases of nosocomial COVID-19 in 2 tertiary-care hospitals from November 1, 2020, to October 11, 2021, and we identified patients who received mAbs. The study period was prior to the ο (omicron) variant (B.1.1.529) being detected in the United States, and infections in the patients were likely primarily with the α alpha variant (B.1.1.7) and the δ (delta) variant (B.1.617.2) of SARS-CoV-2, which responded well to treatment with bamlanivimab and casirivimab–imdevimab. All patients had a negative SARS-CoV-2 PCR on admission. Data on clinical outcomes, including administration of medications for COVID-19, increases in oxygen requirements, ICU admission, mechanical ventilation, and death were collected by a review of the electronic medical record. The study was approved by the institutional review board with expedited approval. Descriptive statistics, such as means and standard deviations of continuous variables and proportions of categorical events or variables, were tabulated to describe patient characteristics and outcomes. Results: The 71 patients included in the study (age range, 39–89 years; median age, 70 years; 51% female) received either bamlanivimab (n = 31) or casirivimab–imdevimab (n = 40). The length of stay ranged from 6 to 242 days (median, 26 days). The comorbidities present included cardiovascular disease (56%), diabetes (45%), obesity (31%), autoimmune disease or immunosuppression (27%), kidney disease (23%), and pulmonary disease (20%). Most of the patients included in the study were incompletely vaccinated or unvaccinated (94%) and were negative for SARS-CoV-2 antibodies (81%). Prior to receiving the mAbs, 23% of patients required supplemental oxygen, including 3 patients who required mechanical ventilation. These patients required oxygen support due to non–COVID-19–related conditions. After mAb infusion, 72% of patients had no increase in their oxygen requirements, and 93% did not progress to mechanical ventilation. Overall, 7 deaths were attributed to COVID-19 among the studied patients (10%). Conclusions: Our study describes the use of mAbs in hospitalized patients with nosocomial COVID-19. Most of the patients who received mAbs had no progression to severe COVID-19, despite having significant comorbidities. The use of mAbs in nosocomial COVID-19 may be associated with beneficial outcomes.

Funding: None

Disclosures: None

Implementation of antimicrobial stewardship programs (ASPs) in well-resourced countries has been associated with reductions in antibiotic-resistant infections and improved patient outcomes. Several guidance documents providing recommendations on how to structure antimicrobial stewardship activities at the national and hospital level in resource-limited settings have been published. However, few hospitals in Latin America report having a structure or resources needed for a successful ASP. Given the alarming increases in antimicrobial resistance in Latin America, better understanding of barriers to promote implementation of effective ASPs is urgently needed. We have summarized past and present antimicrobial stewardship activities in Latin American hospitals, and we describe key elements needed in future efforts to strengthen antimicrobial stewardship in the region.

Background: In the last 2 years of the COVID-19 pandemic, Singapore has been forced to explore alternative sites to quarantine persons or manage infected cases during surge periods in a national effort not to overwhelm the public healthcare facilities. External quarantine facilities were created at the EXPO and further extended to D’Resort and other hotels in May 2020. Infection prevention (IP) practices were implemented at these external facilities, where training non–healthcare staff to quickly learn and understand these required practices has been challenging. A team of staff from different clinical disciplines was formed to manage the COVID-19 patients at these facilities. The Infection Prevention and Epidemiology (IPE) department was invited to train all staff, including the clinical team, management agency, and security staff, regarding IP measures. We have described the system and approach used in the rapid training of all staff in IP measures where the goal is zero transmission while providing care to COVID-19 patients. Methods: Training materials were developed to facilitate rapid learning by all staff; medical jargon was avoided. Curriculum included precautions to be taken while performing terminal cleaning of patient rooms, serving meals, disinfecting phones and thermometers, as well as donning and doffing personal protective equipment (PPE). “Green” and “red” zones were created to assist staff in remembering appropriate PPE to be used. PPE training was provided using slides and video. Posters were created as a guide for staff at donning and doffing stations. Additionally, the IPE training team utilized an online data collection tool to capture staff completion on IP training and PPE competency for record keeping. We used a ‘soft’ approach because staff members were fearful of the unknown when caring for COVID-19 patients. Daily audits were conducted with immediate concurrent feedback to engage the relevant stakeholders. Infection prevention liaison officers (IPLOs) were appointed to assist in the daily audits. An electronic audit tool was used to facilitate audit and quick analysis. Conclusions: The experience gained in the last 2 years has been useful and may provide a template if new external sites are needed in the future because of the potential surge associated with the ο (omicron) variant.

Funding: None

Disclosures: None

Background: Carbapenem-resistant Acinetobacter baumannii (CRAb) is considered a public health threat, and this pathogen is typically associated with hospital infections. At 3 months after opening the hospital’s dedicated COVID-19 unit, 2 patients were identified with CRAb. Infection prevention staff collaborated with staff in the COVID-19 unit, hospital leadership, and health department partners to develop mitigation strategies and to prevent additional transmission. Methods: Admissions to the COVID-19 unit were stopped. Biweekly surveillance cultures were collected to identify any patients potentially colonized with CRAb. An infection control risk assessment was conducted to determine breaches in infection prevention practices. The risk assessment included environmental rounding of the area, epidemiological investigation, environmental testing, pulsed-field gel electrophoresis (PFGE) testing, and observing infection prevention practices. Results: The risk assessment identified multiple gaps in infection control practices, for example, gaps in hand and environmental hygiene practices. The extended use of personal protective equipment (PPE), staff shortages, fatigue, and staff taking on multiple roles and tasks outside their general job duties were other gaps identified by the team. Between June and September 2020, 43 additional CRAb cases were identified in the facility, with 4 (9.8%) cases outside the COVID-19 unit. Moreover, 29 cases (64%) were considered clinical infections and 16 (36%) were identified from surveillance efforts. Environmental cultures identified 1 positive surface with CRAb. PFGE testing was completed on 44 isolates; 42 isolates had identical PFGE patterns, and 2 isolates were unrelated to the COVID-19 unit; 2 isolates were closely related (with 3-band differences) but were not identified in the COVID-19 unit. Conclusions: The inability to definitively identify the source of transmission made it challenging to determine the best approach to eradicating the pathogen. Mitigation for outbreaks should focus on not deviating from core infection control practices.

Funding: None

Disclosures: None

The 2021 focused update to the Infections Diseases Society of America/Society for Healthcare Epidemiology of America (IDSA/SHEA) guidelines for management of Clostridioides difficile infection (CDI) prioritizes the use of fidaxomicin over vancomycin for the treatment of initial and recurrent CDI. These recommendations have significant clinical and financial ramifications for hospitals and patients with CDI. Antimicrobial stewardship programs must balance the needs, goals, and barriers faced by patients and health systems when determining the best treatment strategy for CDI. In this commentary, we provide antimicrobial stewardship programs with a decision-making framework that acknowledges the fundamental principles of ethics to provide equitable patient care.