A hospital-onset bacteremia and fungemia (HOB) metric will expand hospital surveillance of bloodstream infections beyond current state and provide an opportunity to re-evaluate infection prevention strategies. Here we consider the added value and potential pitfalls of HOB surveillance and present a framework for the standardized assessment of HOB events.

Background: Healthcare activities that include instrumentation or manipulation of mucosal tissue or normally sterile sites, such as the eye and its associated structures, place patients at risk of infectious and other complications. We reviewed queries to the CDC Prevention and Response Branch that were focused on ophthalmologic procedures and settings to examine opportunities to improve infection prevention and control (IPC) practices in these settings. Methods: We reviewed internal CDC consultation records received from January 1, 2016, through December 31, 2021, to identify those involving ophthalmologic procedures or settings. Consultations were reviewed to determine setting type, number of patients affected, organisms identified, nature of infection control breaches, and whether medical products were implicated. Descriptive statistics were calculated. Results: We identified 24 consultations among 19 states and US territories. Of these, 21 (87.5%) involved outpatient settings, of which 9 (43%) were ambulatory surgery centers. Consultations included the following non–mutually exclusive categories. There were 18 adverse postsurgical events (75%), such as mycobacterial infection after laser surgery and toxic anterior segment syndrome following cataract surgery (n = 5). There were 11 infections following ophthalmologic clinical care (46%), such as epidemic keratoconjunctivitis due to adenovirus 8. There were 8 suspected medication-related events (33%) including contamination of ophthalmic medication when manufactured or compounded offsite. There were 8 medical-device reprocessing concerns (33%) including inappropriate high-level disinfection. There were 8 instances of improper environmental cleaning and disinfection (33%), for example, during an adenovirus outbreak. There were 3 cases of potential mishandling of medications onsite (12.5%), such as multiuse eye drops. Also, 3 events (12.5%) were associated with potentially contaminated donor tissue, such as corneas for transplantation. When a consultation included identification of a pathogen (n = 11), organisms included bacteria (n = 7, 64%), viruses (n = 2, 18%), and fungi (n = 3, 27%). In total, 202 patients had confirmed ophthalmologic infections or adverse events. Conclusions: Based on our review of recent outbreaks, healthcare personnel in ophthalmologic settings may have deficits in training related to instrument reprocessing and environmental cleaning specific to ophthalmic equipment and settings that can result in harm to patients. These settings could benefit from targeted training to improve IPC practices specific to ophthalmologic examinations and procedures. This review was limited to analysis of investigations that were voluntarily reported to the CDC. A formal surveillance system for adverse outcomes in this setting could clarify the nature and frequency of IPC issues of greatest concern.

Disclosures: None

In this overview, we articulate research needs and opportunities in the field of infection prevention that have been identified from insights gained during operative infection prevention work, our own research in healthcare epidemiology, and from reviewing the literature. The 10 areas of research need are: 1) transmissions and interruptions, 2) personal protective equipment and other safety issues in occupational health, 3) climate change and other crises, 4) device, diagnostic, and antimicrobial stewardship, 5) implementation and de-implementation, 6) health care outside the acute care hospital, 7) low- and middle-income countries, 8) networking with the “neighbors”, 9) novel research methodologies, and 10) the future state of surveillance. An introduction and chapters 1–5 are presented in part I of the article, and chapters 6–10 and the discussion in part II. There are many barriers to advancing the field, such as finding and motivating the future IP workforce including professionals interested in conducting research, a constant confrontation with challenges and crises, the difficulty of performing studies in a complex environment, the relative lack of adequate incentives and funding streams, and how to disseminate and validate the often very local quality improvement projects. Addressing research gaps now (i.e., in the postpandemic phase) will make healthcare systems more resilient when facing future crises.

Background: The CDC’s new Public Health Strategies to Prevent the Spread of Novel and Targeted Multidrug-Resistant Organisms (MDROs) were informed by mathematical models that assessed the impact of implementing preventive strategies directed at a subset of healthcare facilities characterized as influential or highly connected based on their predicted role in the regional spread of MDROs. We developed an interactive tool to communicate mathematical modeling results and visualize the regional patient transfer network for public health departments and healthcare facilities to assist in planning and implementing prevention strategies. Methods: An interactive RShiny application is currently hosted in the CDC network and is accessible to external partners through the Secure Access Management Services (SAMS). Patient transfer volumes (direct and indirect, that is, with up to 30 days in the community between admissions) were estimated from the CMS fee-for-service claims data from 2019. The spread of a carbapenem-resistant Enterobacterales (CRE)–like MDROs within a US state was simulated using a deterministic model with susceptible and infectious compartments in the community and healthcare facilities interconnected through patient transfers. Individuals determined to be infectious through admission screening, point-prevalence surveys (PPSs), or notified from interfacility communication were assigned lower transmissibility if enhanced infection prevention and control practices were in place at a facility. Results: The application consists of 4 interactive tabs. Users can visualize the statewide patient-sharing network for any US state and select territories in the first tab (Fig. 1). A feature allows users to highlight a facility of interest and display downstream or upstream facilities that received or sent transfers from the facility of interest, respectively. A second tab lists influential facilities to aid in prioritizing screening and prevention activities. A third tab lists all facilities in the state in descending order of their dispersal rate (ie, the rate at which patients are shared downstream to other facilities), which can help identify highly connected facilities. In the fourth tab, an interactive graph displays the predicted reduction of MDRO prevalence given a range of intervention scenarios (Fig. 2). Conclusions: Our RShiny application, which can be accessed by public health partners, can assist healthcare facilities and public health departments in planning and tailoring MDRO prevention activity bundles.

Disclosures: None

We present the investigation and control of an extensively drug-resistant Serratia marcescens outbreak in a 30-bed intensive care unit (ICU). Within 6 weeks, 4 critically ill trauma patients were infected by the same strain. Intensive containment measures limited the spread of this strain while sustaining the capacity of the trauma ICU.

Background: Antimicrobial resistance (AMR) presents a global health threat. Training laboratory technicians to accurately identify and report AMR is critical in low- and middle-income countries (LMICs) to control the spread of AMR. Ethiopia and Kenya implemented a telementoring program, ECHO AMR, via the Project ECHO learning platform to improve laboratory technician capacity to isolate, identify, and report AMR organisms; to perform antimicrobial susceptibility testing (AST); and to develop a community of learning. Between January 2018 and January 2022, biweekly 1-hour sessions were held for 8 and 22 laboratories averaging 19 or 43 participants per session in Ethiopia and Kenya, respectively. Each session included a lecture, a laboratory challenge case presentation, and discussion. An evaluation was conducted to assess perceived strengths and weaknesses of the program and its usefulness in improving bacteriology capacity. Methods: In July–August 2022, semistructured key informant interviews of purposively and randomly selected laboratorians were conducted to understand participant perspectives of ECHO AMR, including session structure and content, changes in laboratory performance, and the virtual learning platform. Eligible participants attended at least one-third of available sessions in Ethiopia (8 of 26 sessions) or Kenya (5 of 16 sessions) during 2021. Key informant interviews were transcribed and systematically reviewed to identify key themes. Results: In total, 22 laboratory technicians participated in the key informant interviews: 12 in Ethiopia and 10 in Kenya. Participants reported that the ECHO AMR session structure was well organized but recommended increasing session duration to allow more time for discussion. Technical content was presented at an appropriate level and was highly rated. However, participants suggested including more subject-matter experts to provide the lectures. All participants reported positive change in laboratory practice, including implementation of international standards for AST, better quality control, improved confidence and critical thinking, and increased AMR awareness and reporting. Participants learned well in the virtual environment, with the platform providing wide-ranging geographic interactions to share skills and knowledge among sites without travel. However, there were connectivity issues, competing work priorities during sessions, and a lack of dedicated space for team participation. Conclusions: Laboratory technicians reported that virtual laboratory training was well-received, efficient, and impactful. Participants benefited both individually and collectively, as a laboratory. Suggested improvements included increasing session duration, connectivity support, and including more subject-matter experts to broaden technical content. Further assessment is needed to evaluate the ECHO AMR’s impact on laboratory practices through observation and laboratory data. Virtual programs, requiring less time and resources than traditional in-country trainings, can be optimized and used to share and increase bacteriology knowledge in LMICs.

Disclosures: None

The ability to provide feedback to a colleague is a key skill required for professional growth and patient safety. However, these conversations are limited by time constraints, differences in values, and a culture of “noninterference.” This advocacy-inquiry-identify-teach framework creates an organized approach to initiating successful “challenging” conversations with peers.

Background: Considering the threat of antimicrobial resistance (AMR), Ethiopia implemented strategies to combat AMR, including partnering with the American Society for Microbiology (ASM) to conduct an AMR training program using the Project ECHO learning platform. ECHO AMR was used to virtually connect subject-matter experts with participating sentinel laboratories in remote locations to provide ongoing education, telementoring, and foster peer-to-peer learning and problem-solving in microbiology. In phase 1, the ASM had primary leadership in conducting sessions and project administration. In phase 2, roles and responsibilities transitioned from the ASM to the Ethiopian Public Health Laboratory (EPHI) with support from ECHO India. Here we describe the transition process and lessons learned. Methods: From December 2020–2021, biweekly 1-hour sessions were conducted for 8 sentinel laboratories. Each virtual session included a lecture led by a subject-matter expert, a case presentation by a participating laboratory, open discussion, and feedback via an end-of-session online survey. Following a transition plan, initial ASM-EPHI transition activities included formal administrative and logistical training, including participation in a 3-day Project ECHO-immersion program provided by ECHO India. Selected administrative and technical roles and responsibilities, including further developing their own SMEs, were transitioned from ASM to EPHI every 4 sessions. ASM conducted postsession reviews with EPHI and ECHO India to discuss successes and suggested improvements. Results: Leadership of ECHO AMR was fully transitioned to EPHI over 12 months. End-of-session surveys and postsession reviews indicated the transition process was successful, with EPHI staff leading the lectures, session coordination, and facilitation, and positive feedback from session participants. Challenges included variable sentinel site participation due to competing priorities such as COVID-19 testing and poor internet connectivity during the rainy season. Lessons learned included the need to use a gradual transition strategy with close monitoring, training facilitators to maintain implementation fidelity (level of reproducibility to conduct ECHO AMR as in phase 1) and improve participation, and assessing individual learning, using pretests and posttests. Recommendations included that ASM should remain as an external technical advisor to ensure program technical depth and session facilitators be trained to improve participation in the discussions. Implementation fidelity compared to phase 1 was considered moderate, with the gap primarily due to the need for dedicated release time from laboratory duties to ensure session leadership, coordination, and facilitation. Conclusions: Leadership and laboratory workforce capacity-building responsibility for AMR training was successfully transitioned from ASM to EPHI, promoting self-sufficiency in training and with far-reaching benefits in the global fight against AMR.

Disclosures: None

Background: Among US acute-care hospitals (ACHs) reporting to the NHSN, significant increases in the incidence of Ventilator-Associated Events (VAEs) were observed during the COVID-19 pandemic years in comparison with 2019. We assessed changes in the national event-level VAE data, including the incidence of specific event-types: Ventilator-Associated Condition (VAC), Infection-related Ventilator-Associated Complication (IVAC) and Possible Ventilator-Associated Pneumonia (PVAP). We also examined changes in associated pathogens, and we evaluated incidence density rates (IDRs) of pediatric VAE (PedVAE) before and during the pandemic years. Methods: We analyzed data on VAE and PedVAE reported to NHSN between 2019 through the second quarter of 2022 (2022Q2) in ACHs. Annual proportions of VAC, IVAC, or PVAP were calculated; changes versus 2019 were assessed. The 10 most common PVAP pathogens reported annually were examined, and the percentages and ranks for each were calculated. Among pediatric and neonatal locations, PedVAE IDR were calculated as the number of events per 1,000 ventilator days and were compared between the pre-pandemic and pandemic years. All comparisons were conducted using a mid-P exact test, and P<0.05 was considered statistically significant. Results: Between 1,266 - 1,357 ACHs reported VAE data each year. A total of 24,836 (2019), 37,592 (2020), and 50,362 (2021) VAEs were reported. The proportion of VAC events in 2020 (64.1%) was significantly higher than in 2019 (62.9%), while the 2020 and 2021 PVAP proportions (8.7% and 9.2%, respectively) were significantly lower than in 2019 (10.0%). The majority of VAEs were reported from the same location types annually. The top 3 PVAP pathogens reported for each year remained unchanged: Staphylococcus aureus, Pseudomonas aeruginosa, Klebsiella. However, the proportion identified as Haemophilus influenzae decreased significantly each year from 2019-2021, with the rank dropping from #5 in 2019 (6.6%) to #10 in 2021 (2.3%). Between 199 – 257 ACHs conducted PedVAE surveillance. PedVAE IDR were significantly lower in 2020 (0.8), 2021 (1.1), and the first half of 2022 (0.8) when compared to 2019 (1.3). Conclusions: This study provides a national view of specific VAEs before and during the COVID-19 pandemic. Some changes in the associated pathogens, and the proportions of VAC and PVAP, were observed. This study is the first to produce national benchmarks for PedVAE IDR. Additional ACHs conducting PedVAE surveillance in NHSN would improve the representativeness of our results.

Disclosures: None

Background: Western State Hospital (WSH) is an 800-bed, state-owned psychiatric hospital in Washington State which services individuals in 20 counties. WSH provides services and inpatient treatment to patients referred via behavioral health providers and/or the civil court system. Because many patients are admitted with serious, long-term illness, WSH also provides primary care and addresses infectious syndromes encountered in admitted patients. In January 2016, WSH officially began their antimicrobial stewardship program (ASP). In 2017 WSH joined the UW Center for Stewardship in Medicine (UW-CSiM) to grow and optimize their ASP. Methods: The lead pharmacist at WSH participated in weekly hour-long education and tele-mentoring sessions through the UW-CSiM program. Educational materials were adapted from UW-CSiM didactics and delivered to providers during regular meetings and grand rounds. Daily pharmacist led prospective audit with feedback was conducted. Antibiotic use data were collected and measured by days of therapy (DOT) per 1000-patient days from pharmacy dispensing records from 2015 to 2022. Results: From 1/1/15 to 12/31/22, there was a consistent trend of decreasing antibiotic consumption annually. In particular, antibiotic use decreased by over 65% ranging from 35-43 DOT per 1000 patient-days in 2015 to 9-11 DOT per 1000 patient-days in 2022 (Figure 1). This translates to approximately 1000 antibiotic days of therapy in 2015 and 200 days of antibiotic therapy in 2022. As of 2022, the two most common antibiotics used were cephalexin and sulfamethoxazole/trimethoprim Conclusion: Although treating infections is not a principal focus of a psychiatric hospital, patients receiving care in inpatient psychiatric facilities do experience common infections and receive antibiotics during their stay. At WSH, initiation of an antimicrobial stewardship program was associated with sustained decrease in total antibiotic DOT over 7 years. These data highlight the impact of tele-education and tele-mentoring in infectious diseases and antimicrobial stewardship as a path to build a successful antimicrobial stewardship even without formal infectious diseases training. Our single center experience at a large psychiatric hospital demonstrates the use of antimicrobials in these facilities and the opportunity for a large impact of an antimicrobial stewardship program in inpatient psychiatric facilities.

Disclosures: None.

Objectives: To address the importation of multi-drug-resistant organisms (MDROs) when a colonized or infected patient is transferred from another VA facility, the Veterans Health Administration (VHA) launched the Inpatient Pathogen Tracker (IPT) in 2020. IPT tracks MDRO-infected/colonized patients and alerts MDRO Program Coordinators (MPCs) and Infection Preventionists (IPs) when such patients are admitted to their facility to facilitate rapid identification and isolation of infected/colonized patients. IPT usage has been low during initial rollout (32.5%). The VHA and the CARRIAGE QUERI Program developed targeted implementation strategies to increase utilization of IPT’s second iteration, VA Bug Alert (VABA). Methods: Familiarity with IPT was assessed via pre-education survey (3/2022). All sites received standard VABA implementation including: 1) adaptation of VABA features based on end-user feedback (completed 4/2022), 2) development and delivery of an educational module regarding the revised tool (completed 4/2022), and 3) internal facilitation from the VHA MDRO Program Office (ongoing) (see Figure for all key timepoints). Intent to register for VABA was assessed via post-education survey (4-5/2022). Sites (125 eligible) not registered for VABA by 6/1/2022 were randomly assigned to receive one of two conditions from 6/2022–8/2022: continued standard implementation alone or enhanced implementation. Enhanced implementation added the following to standard implementation: 1) audit and feedback reports and 2) external facilitation, including interviews and education about VABA. We compared the number of sites with ≥1 MPC/IP registered for VABA to-date between implementation conditions. Results: Pre-education survey. 168 MPC/IPs across 117 sites responded (94% of eligible sites). Among respondents, 25% had used IPT, 35.1% were familiar with but had not used IPT, and 39.9% were unfamiliar with IPT. Post-education survey. 93 MPC/IPs across 80 sites responded (59% of eligible sites). Of these, 81.7% said they planned to register for VABA, 4.3% said they would not register, and 14.0% said they were unsure. Post-6/1/2022 Registrations. By 6/1/2022, 71% of sites had ≥1 registered VABA user. Of the 28 unregistered sites eligible for enhanced implementation, thirteen were assigned to receive enhanced implementation, and fifteen were assigned to receive continued standard implementation. Eight sites in the enhanced implementation condition (61.5%) registered for VABA. Seven standard-implementation-only sites (46.7%) registered. The number of registered sites did not significantly differ by implementation condition (Fisher’s exact p=0.476). Conclusions: Standard and enhanced implementation were equally effective at encouraging VABA registration, suggesting that allocating resources to enhanced implementation may not be necessary.

Disclosures: None.

The COVID-19 pandemic led to an initial increase in the incidence of carbapenem-resistant Enterobacterales (CRE) from clinical cultures in South-East Asia hospitals, which was unsustained as the pandemic progressed. Conversely, there was a decrease in CRE incidence from surveillance cultures and overall combined incidence. Further studies are needed for future pandemic preparedness.

The detection rate of multidrug-resistant Pseudomonas aeruginosa in patients admitted to 2 wards and the intensive care unit decreased from 20.3% (129 of 636 isolates) to 4.2% (37 of 889 isolates) after the start of disinfection of hand washing sinks using alkyl diaminoethylglycine hydrochloride.