Background: In healthcare facilities, hand hygiene is important for infection control. The WHO recommends monitoring the consumption of alcohol-based handrub (ABHR) and direct observation of hand hygiene practices to ensure compliance with hand hygiene practices. Monitoring of ABHR is widely used, but direct observation is not widely performed, particularly in small facilities and non–acute-care facilities. We evaluated the effects of direct observation of hand hygiene practices and monitoring of ABHR consumption, with feedback to staff, on ABHR consumption and hand hygiene compliance. Methods: We conducted a prospective intervention study over a 4-year period. Monitoring of ABHR consumption and direct observation of hand hygiene practices, with periodic feedback to staff, was implemented in 17 facilities of varying types: 5 large-scale acute-care facilities, 6 middle-to-small-scale acute-care facilities, and 6 non–acute-care facilities. Statistics for ABHR consumption were calculated before and after the implementation of direct observation of hand hygiene practices, and the change in ABHR consumption was calculated. The paired t test was used to assess the statistical significance of changes. A generalized linear mixed model analysis was performed to assess factors associated with ABHR consumption. Results: The total observation time was 1,225 months (625 months before direct observation, 600 months after direct observation), and the average observation time per facility was 36.0 months (± 27.5). All facilities implemented ABHR consumption monitoring within 1 month of starting the study. However, the mean time required to implement direct observation of hand hygiene practices was 24.7 (±19.1) months. There was a significant increase in ABHR consumption in large and middle-to-small-scale acute-care facilities (P < .0001) after implementing the direct observation. However, there was not a significant increase for ABHR consumption in non–acute-care facilities (P = .14). Multivariable regression analysis showed that the hospital ward type, duration of ABHR consumption monitoring, and duration of direct observation of hand hygiene practices were independently associated with ABHR consumption. Conclusions: ABHR consumption increased in all facilities that implemented direct observation, but the change was not statistically significant in non–acute-care facilities. The generalized linear mixed model analysis showed significant associations between ABHR consumption and hospital ward type and time to monitoring of ABHR consumption and direct observation of hand hygiene practices. Direct observation of hand hygiene practices should be implemented more widely. The effect of intervention intensity should be evaluated in future studies.

Disclosures: None

Background: Healthcare workers (HCWs) are at increased risk of influenza exposure and represent a potential transmission source. The Department of Health and Human Services (HHS) set a goal for 2020 to have 90% of all HCWs in acute-care hospitals (ACHs) vaccinated. Vaccination against influenza decreases symptomatic illness and absenteeism and protects HCWs and their contacts. We assessed characteristics of facility intervention programs based on their success in meeting this benchmark. Methods: Data from the NHSN were utilized, including answers to the Annual Flu Survey for 2014–2022 and the rate of vaccine compliance by facility. Flu surveys detail facility-specific programs implemented for each influenza season, from October to March. We used SAS version 9.4 software for univariate analyses to determine factors significantly associated with meeting the HHS benchmark target of ≥90% vaccination among all HCWs, split into categories for employees, students or volunteers, and licensed independent practitioners. Facilities were excluded if they were not ACHs or Critical Access Hospitals (CAH), did not complete the Annual Flu Survey for at least 1 year, or required vaccination as a condition of employment. Results: From 2014 to 2022, 745 surveys were completed. Overall, 48.58% of respondents succeeded in meeting the HHS benchmark. Also, 306 surveys completed noted that their facility did not require influenza vaccination. Among those, only 19.93% respondents succeeded. Moreover, 80.33% of successful respondents for all HCWs required personal protective equipment (PPE) upon vaccination refusal compared to 34.29% of unsuccessful respondents (P < .0001). Furthermore, 98.36% successful respondents required documentation of offsite vaccination, compared to 89.39% of unsuccessful respondents (P = .027). For employees, 64.56% of successful respondents tracked vaccination rates in some or all units compared to 45.81% of unsuccessful respondents (P = .004). Also, 63.29% successful respondents had visible vaccination of leadership, compared to 43.61% of unsuccessful respondents (P = .003). Furthermore, 86.08% of successful respondents had mobile vaccination carts, compared to 73.57% unsuccessful respondents (P = .023). For the student- or volunteer-specific benchmark, 24.59% of successful respondents provided vaccination incentives compared to 14.63% of unsuccessful respondents (P = .035). Conclusions: Facilities with ≥90% vaccination among HCWs were more likely to require PPE after vaccination refusal and documentation for offsite vaccination. Other strategies for vaccination were differentially associated by employee type for Tennessee facilities. For future outreach, a multipronged approach is more likely to be successful in addressing vaccine uptake among employees with lagging rates. Strategies for influenza vaccine uptake could also improve other occupational vaccinations. More research is needed on the barriers to vaccination among HCWs specifically.

Disclosures: None

Background: Healthcare floors are a vehicle and/or source for potential pathogens that cause healthcare associated infections, and hospital floors are often heavily contaminated with pathogens such as Clostridioides difficile and methicillin-resistant Staphylococcus aureus. However, definitive research linking reductions in floor burden to reductions in HAIs has not yet been established. We sought to evaluate emerging technology for continuous disinfection and its potential impact on HAIs. This study was designed to explore the potential relationship between the reduction of microbial burden of floors and healthcare associated infections. Methods: A prospective study was conducted in a 22-bed medical-surgical intensive care unit in a 180-bed suburban hospital near New Orleans, Louisiana, from November 2021 to June 2022. Using sterile, premoistened sponges, samples were collected from the floors of 10 areas throughout the unit including 2 nurses’ stations, the physician charting area, and 7 patient rooms. The advanced photocatalytic oxidation (aPCO) equipment was then installed in the HVAC ductwork throughout the ICU and activated. Environmental surface sampling of the same floor surfaces was then repeated every 4 weeks for the first 5 months of the study. HAIs were also tracked throughout the entire study period. The facility’s normal cleaning floor protocols using a neutralizing floor cleaner were unchanged and followed during the study. Changes in surface burden were calculated using a repeated-methods ANOVA with post hoc analyses as appropriate. Rates of healthcare associated infections were compared using χ2 analyses. Results: Overall, there was a 99.6% statistically significant decrease in floor environmental surface burden from the baseline to the final postactivation test (Fig. 1). The average colony forming unit count (CFU) decreased from 318,850 CFU per 100 cm2 to just 2,988 CFU per 100 cm2. The unit also saw a statistically significant decrease in publicly reported healthcare associated infections (HO-MRSA, CLABSI, HO-CDI) during the study period compared to the same period a year prior and in the 6 months immediately prior to the beginning of the study (Fig. 2). Conclusions: Advanced photocatalytic oxidation technology resulted in a reduction of microbial burden on the floors of a high-traffic intensive care unit. Statistically significant decreases in healthcare-associated infections was also seen. This study highlights a novel aPCO technology and its efficacy at reducing microbial burden and healthcare-associated infections despite no change in practice.

Disclosures: None

Antibiotic prescribing errors at hospital discharge are common. We designed a pharmacist-driven antimicrobial stewardship program to evaluate prescriptions prior to being transmitted to community pharmacies. Drug-related problems were identified in prescriptions for 48 of 149 patients, resulting in 55 interventions. Review at discharge improves outpatient prescribing of antimicrobials.

Background: Hospital surfaces are known to contribute to the spread of healthcare-associated infections (HAIs). Environmental sampling is often performed to locate a reservoir or to evaluate intervention strategies in healthcare facilities. Composite sampling is commonly practiced in other fields of environmental sampling and involves collection of multiple samples combined entirely or partially to form a new sample. We compared a standard CDC surface whole-tool sampling method with a composite sampling approach. Methods: Acinetobacter baumannii (AB), Klebsiella pneumoniae that produce K. pneumoniae carbapenemase (KPC), vancomycin-resistant Enterococcus faecalis (VRE), methicillin-resistant Staphylococcus aureus (MRSA), and Clostridioides difficile spores were suspended in an artificial soil and deposited as 40 µL droplets (~104 CFU total) onto steel coupons of surface areas 323 cm2, 645 cm2, or 1,290 cm2 and dried for 2 hours. The surfaces were sampled with a single pass of a cellulose sponge— either the larger side of the sponge (face) or the smaller side of the sponge (edge)—and the optimal surface area was determined. Recovery from the optimal surface area with a single pass sampling was compared to the recovery using a standard CDC method in which all sides were used (ie, whole-tool method) to sample a standard area (645 cm2). Recovery was determined by culture and total CFU were determined for each optimal surface area. Theoretical composites were constructed using the mean total CFU of optimal surface area; 2×((face) + (edge)). Significance was set at P ≤ .05. Results: Total CFU recovery using the whole-tool method was significantly greater than the single pass sample recovery for MRSA (18,300 vs 16,600 CFU) and VRE (27,600 vs 26,400 CFU) (P < .05). When comparing the theoretical composite method to the standard whole-tool area (625 cm2), the theoretical composite total CFU was significantly greater than the whole-tool method for all organisms. For example, VRE recovery with the standard CDC whole-tool method was 27,600 CFU from 625 cm2, yet a theoretical composite approach recovered 79,800 CFU from an area of 1,290 cm2. Conclusions: Many factors influence recovery when sampling the environment, and composite sampling is a promising approach when sampling large surface areas. Using a theoretical composite of single-pass samples, the potential for improved detection with composite sampling was demonstrated. A composite sampling approach will reduce time and resources for sampling and sample processing, allowing larger surface areas to be investigated which will improve infection control strategies.

Disclosures: None

Background: Infection prevention and control (IPC) is a critical feature of preventing the spread of healthcare-associated infections (HAIs) in hospitals. IPC practices are particularly important in resource-constrained and crowded hospital settings. The successful implementation of infection prevention measures depends on healthcare worker (HCW) knowledge of, attitude toward, and practice (KAP) of IPC. In this project, we assessed the KAP of HCWs and identified factors associated with IPC compliance at tertiary-care hospitals in Bangladesh. Methods: From September 2020 to January 2021, we conducted this hospital-based cross-sectional assessment at 11 tertiary-care hospitals. A semistructured questionnaire was used to conduct face-to-face interviews with physicians, nurses, and cleaning staff who were directly involved in patient care. Based on >75% of the total score, each KAP component was divided into adequate knowledge, favorable attitude, and safe practice. We performed descriptive analysis and multivariate logistic regression to determine the KAP score and associated factors influencing IPC compliance in hospital settings. Results: In total, 1,728 HCWs were interviewed; 76.8% of the participants had adequate knowledge on IPC and 54.6% reported safe practices. However, only 16.2% of HCWs had a favorable attitude toward IPC. Among the 3 HCW groups, nurses had the highest KAP scores (76.07±12.7) followed by physicians (69.8±16.2), and cleaning staff (34.4±27.3). Only 29.2% of HCWs reported having received IPC training, and they cited heavy workload as a barrier to IPC guideline adherence. HCWs having adequate knowledge showed 9 times higher odds of safe IPC practice (AOR, 9.36; 95% CI, 5.47–16.04). HCWs who had a favorable attitude toward IPC were 16 times as likely to perform safe practice toward IPC activities (AOR, 15.5; 95% CI, 10.27–23.42). Conclusions: Knowledge of safe practices and having a favorable attitude toward IPC are key components of a successful IPC program. Significant improvements are required among all levels of HCWs in Bangladesh tertiary-care hospitals, especially cleaning staff. Educational interventions to train on IPC guidelines, plus monitoring, could improve HCW safe practices.

Disclosures: None

Background: The burden of hospital-associated infections (HAIs) and antimicrobial resistance (AMR) in Latin America is high. Improving engagement by healthcare workers (HCWs) in infection prevention and control (IPC) may lead to better patient outcomes; however, little is known about HCW perceptions of IPC in the region. We sought to understand HCW perceptions of IPC processes and practices. Methods: During August–September 2022, HCWs from 30 hospitals with IPC programs in 4 Latin American countries (Panama, Guatemala, Ecuador, and Argentina) were invited to participate in an electronic, voluntary, anonymous survey about their perceptions of IPC at their hospitals. Physicians, nurses, and environmental care (EVC) personnel were prioritized for recruitment. All respondents were asked 18 questions; IPC team members were asked 5 additional questions about specific activities implemented by IPC programs, how data are used, and how IPC could be improved. Answers with 5-point Likert scale responses were categorized into 2 groups (eg, strongly agree or agree vs neutral, disagree, or strongly disagree) for analysis. Results: Of 1,252 HCWs who completed the survey, 181 (14%) were IPC team members, 1,095 (87%) had direct patient contact, and 1,156 (92%) worked >20 hours per week. Figure 1 shows participant characteristics. Most participants (56%) rated their IPC program as very good, 38% rated it as good, and 6% rated it as bad. Physicians were less likely to give a favorable rating. Compliance with prevention bundles and hand hygiene (HH) by colleagues was rated as poor by 28% and 22% of HCWs, respectively; however, only 11% and 5% indicated that their own compliance was poor, respectively. Also, 25% of participants reported not receiving or only occasionally receiving HH compliance data. Similarly, 41% of participants reported not receiving HAI data on a regular basis, and 19% of IPC nurses reported not receiving data despite being responsible for conducting surveillance. Furthermore, 41% of respondents indicated not receiving or only occasionally receiving IPC training or education relevant to their role. When asked about the safety climate, 16% of participants reported not feeling appreciated. In addition, 22% of IPC nurses and 37% of individuals in the “other” category (eg, health technicians and therapists) were more likely to report this. When IPC team members were asked how frequently specific activities were conducted (Fig. 2), several opportunities for improvement were identified, including improving HCW access to HH data and development of strategic plans. Conclusions: Improving HCW access to training on IPC and to data on HAI burden and compliance with HH and prevention bundles should be emphasized in Latin American hospitals.

Disclosures: None

Background: Infection prevention and control (IPC) is a clinical and public health discipline based on a scientific approach and practical preventive and control measures. During the 2014–2016 West African Ebola outbreak, the high number of healthcare worker infections was attributed to inadequate IPC in Sierra Leone. This stimulated the establishment of national and subnational IPC programs. Since then, IPC has remained a priority to improve the health systems and strategic interventions during public health emergencies. Therefore, we conducted a detailed review to assess the status of the IPC programs. Methods: A descriptive analysis of the status of IPC programs in Sierra Leone was done using data from IPC assessments conducted in 2022 by the national IPC team, reviews of reports on program implementation, and experts’ objective opinions. Results: Performance. The national IPC assessment revealed strengths in 4 of 6 WHO IPC core components, with an overall score of 61% positioned at the ‘intermediate’ level of implementation. The best-performing component was ‘IPC guidelines’ (92%) with evidenced-based guidelines being developed and implemented over the years. Secondly, ‘Education and training’ (71%) made progress in basic and advanced IPC training, including the development of a preservice training curriculum. Also, ‘monitoring and audit and feedback’ (69%) and ‘IPC program’ (61%) met the basic requirements of an established Monitoring & Evaluation (M&E) system. Similar progress was made at the healthcare facility level, but with major gaps in ‘workload, staffing, bed-occupancy’ and ‘safe or built environment.’ Sustainability efforts. Evidence-based data on IPC have always been scarce due to a limited capacity to conduct IPC research. The Structured Operational Research and Training Initiative (SORT-IT) on antimicrobial resistance has helped promote evidence-informed decisions and build OR capacity that is relevant to improving program performance. In 2019, Sierra Leone instituted in-country production of alcohol-based handrub and liquid soap as a strategic intervention for providing hand hygiene products for use in healthcare facilities. This intervention was essential during the peak of the COVID-19 pandemic. Although most aspects of IPC implementation are government led with strong leadership support, stable funding and sustainability planning are yet to be achieved and will be crucial for long-term success. Conclusions: Most aspects of the IPC core components have been well implemented at the national level since the establishment of the IPC program. However, the program should continue improving the scope and quality of implementation and focus on the development of long-term plans to sustain existing gains and further improve on gap areas at the national level and especially the healthcare-facility level.

Disclosures: None

We surveyed clinicians to evaluate the perceived usefulness of a mnemonic, STORY, to improve penicillin allergy evaluation. Survey responses indicated that the perceived usefulness of STORY was high, and support for nurses’ involvement in penicillin allergy assessment was high. Future research may evaluate the feasibility of STORY implementation in clinical care.

Background: SARS-CoV-2 viral load decreases over time after illness onset. However, immunocompromised patients may take longer for viral load decrease or have a more erratic viral-load trajectory. We used strand-specific assay data from admitted patients to evaluate viral-load trajectories after illness onset. Methods: We reviewed records of hospitalized patients with a positive SARS-CoV-2 PCR and tested using the strand-specific SARS-CoV-2 PCR during July 2020–April 2022. At Stanford Healthcare, we use a 2-step reverse real-time polymerase chain reaction (rRT-PCR) assay specific to the minus strand of the SARS-CoV-2 envelope gene to assess infectivity. Restricting our analysis to each patient’s first strand-specific assay, we used logistic regression models to compare patients with single versus multiple assays. Among patients with multiple tests, we compared those who had an upward trajectory in cycle threshold (Ct) values (a surrogate of decreasing viral load) versus those who did not. We analyzed presence of symptoms, immunocompromised state, immunosuppression reason, and severe COVID-19 leading to ICU care in univariate and multivariate models that further adjust for additional covariates. Significant differences were assessed using logistic regression odds ratios and an α level of 0.05. Results: In total, 848 inpatients were included. Among them, 703 were tested only once and 145 were tested 2–6 times. The longest duration of minus-strand detection was 163 days. In univariate analyses, patients with a single minus-strand assay had lower odds of being symptomatic (OR, 0.55), of being immunocompromised (OR, 0.58), and of being admitted to the ICU with severe COVID-19 (OR, 0.49). In the multivariate analysis, being admitted to the ICU with severe COVID-19 was the only significant variable associated with having >1 test (OR, 2.44). Among patients who had multiple strand-specific SARS-CoV-2 assays, 119 had upward minus-strand trends of Ct values (as expected) and 26 did not. Being immunocompromised was associated with nonrising minus-strand CT values (OR, 33.3) when holding all other covariates in the model constant. Conclusions: Immunocompromised patients with COVID-19 tend to actively replicate for longer and have unexpected viral trajectories compared to immunocompetent patients. Among immunocompromised patients, suspension of transmission-based precautions may require a case-by-case evaluation.

Disclosures: None

Background: International Classification of Diseases, Tenth Edition (ICD-10) data help track outpatient antibiotic prescribing but lack validation in immunocompromised populations or subspecialty clinics for this purpose. Asymptomatic bacteriuria (ASB) and urinary tract infection (UTI) are important stewardship targets in renal transplant (RT) patients, but they may require alternative metrics to best monitor prescribing patterns. We describe ICD-10 utilization for RT clinic encounters in which antibiotics were prescribed. We developed a metric classifying “acute urinary antibiotics” (AUA) to track antibiotic use for ASB and UTI, and we validated systematic identification of AUA to enable practical implementation. Methods: We examined RT clinic visit and telemedicine encounters from 2018 to 2021 conducted 1 month after transplant. This project was deemed non–human-subjects research by the Stanford Panel on Human Subjects in Medical Research. Results: The analytic cohort included 420 antibacterial prescriptions from 408 encounters (Fig. 1). Of 238 patients, 136 (57%) were male and 112 (47%) were Hispanic or Latino. The most common primary ICD-10 code was Z94.0 (kidney transplant status) (N = 302 of 408 encounters, 75%); 26 encounters (6%) were coded for UTI (eg, N39.0, urinary tract infection, site not specified); and 214 encounters (53%) had multiple ICD-10 codes. The R82.71 code (bacteriuria) was never used. However, 215 prescriptions (51%) were classified as AUA (Fig. 2). The validation cohort included 130 prescriptions; 59 (45%) were classified as AUA and 51 (39%) had documented intent to treat ASB or UTI (positive percent agreement, 83%; negative percent agreement, 97%) (Table 1). For patients >1 month after transplant, the positive percent agreement was 95% and the negative percent agreement was 98%. Of 51 patients receiving AUA, 32 (63%) were asymptomatic despite frequently having a code for UTI (Fig. 3). Conclusions: ICD-10 coding may not be helpful in monitoring antibiotic prescribing in RT patients. The AUA metric offers a practical alternative to track antibiotic prescribing for urinary syndromes and reliably correlates with physician intent. Monitoring AUA prescribing rates could help identify opportunities to optimize antibiotic use in this complex outpatient setting.

Disclosures: None

The standardized antibiotic administration ratio (SAAR) enables comparison of antibiotic use (AU) within and between hospitals and identifies target locations and antimicrobials for stewardship interventions. Thousands of institutions have already been submitting AU to the National Healthcare Safety Network. We highlight the benefits and meaningful utilization of SAAR in conjunction with antimicrobial stewardship interventions to improve antimicrobial prescribing in the clinical setting.

Background: Recognizing problematic central-line insertion sites is an important activity for CNAs, LVNs, and RNs in nursing homes (NHs). Although CNAs are not responsible for assessing central lines, they are often the first line of defense for noticing and relaying problems with a line because of the greater amount of time they spend with residents. We sought to assess how well CNAs, LVNs, and RNs could identify problematic insertion sites in NHs. Methods: We conducted a prospective observational study of central-line care in 8 NHs in Orange County, California. A convenience sample of central lines with a range of problematic elements was selected for quality improvement purposes. Research staff used standardized observation forms to evaluate presence of redness, cloudy drainage, and dressing integrity and change date. NH CNAs, LVNs, and RNs were asked to directly observe devices and to comment on problems or concerns. Participants were also asked open-ended questions about elements for a “picture-perfect line” and standard frequency of line checks and dressing changes. Failures to recognize existing problematic elements were tabulated for CNAs and LVNs or RNs separately. Results: In total, 50 CNAs (nursing home range, 3–6) and 50 LVNs and RNs (NH range, 4–6) directly observed lines with 131 problematic elements, including redness (N = 36), cloudy drainage (N = 30), peeling dressings (N = 29), and inappropriately dated dressing (N = 36). Failure to identify problematic elements involved redness [CNAs (50%) and LVNs or RNs (53%)], cloudy drainage [CNAs (40%) and LVNs or RNs (39%)], peeling dressings [CNAs (100%) and LVNs or RNs (87%)], and inappropriately dated dressing [CNAs (71%) and LVNs or RNs (68%)]. For both CNAs and LVNs and RNs, recognition of redness and cloudy drainage improved with severity. Failure to recognize minimal erythema [CNAs (83%) and LVNs or RNs (58%)] was higher than substantial erythema [CNAs (54%) and LVNs or RNs (50%)]. Similarly, failure to recognize minimal cloudy drainage [(CNAs (67%) and LVNs or RNs (50%)] was higher than substantial cloudy drainage [CNAs (42%) and LVNs or RNs (36%)]. Overall, identification of problematic elements did not vary by whether the staff member was assigned to care for that resident. Descriptions of “picture-perfect lines” were uniformly poor, with respondents not knowing what elements to mention. Conclusions: Failure to recognize redness, cloudy drainage, peeling dressings, and lapses in dressing change dates was common for CNAs and LVNs and RNs in nursing homes. This lack of recognition could prevent proper response to early and late signs of localized infection at central-line sites. Dedicated training regarding key elements of a “picture-perfect line” is needed, including changing the threshold for concern for both small and large amounts of redness and pus.

Disclosures: None