Background: Prescribing of antibiotics for viral upper respiratory infection (URI) remains a pressing public health problem. We sought to reduce inappropriate prescribing of antibiotics for viral URIs at primary-care practices at Mayo Clinic Arizona (MCA). Methods: Diagnostic codes for URIs commonly caused by viruses were categorized as tier 3 (ie, never prescribe). The inappropriate prescribing rate was defined as the number of tier 3 encounters resulting in a prescription for a URI antibiotic divided by the total number of tier 3 encounters. MCA primary-care departments, including family medicine, community internal medicine, emergency medicine, and women’s health internal medicine, were included in the intervention. Each department was briefed on the project, including baseline department prescribing data, and was provided education. Education topics included appropriate indications for antibiotics, patient-centered strategies for reducing antibiotic use, and a review of electronic resources developed specifically for the project. Resources included a syndromic ambulatory order panel (EZ ID Respiratory Order Panel) and a viral prescription pad, which contains simplified over-the-counter recommendations for symptomatic management of viral URIs and patient education. Quarterly peer comparison reports were provided to the department chairs and/or site leads. Our goal was to reduce inappropriate prescribing by 22% in 2022. An Epic dashboard (SlicerDicer model) was developed to track data on an ongoing basis. We used χ2 tests to compare categorical variables. Results: Department education was completed by June 2022 (Fig. 1). The annual antibiotic prescribing rate for tier 3 encounters decreased by 29% from a baseline rate 23.6% in 2021 to 16.4% in 2022 (P < .001). The posteducation prescribing rate (June 2022–December 2022) was 13.1%. Utilization of the EZ ID ambulatory order panel increased from an average of 1.5 uses per month in 2021 to 13.3 uses per month in 2022 (Fig. 2). Repeated healthcare contact for URIs within 14 days of tier 3 encounters did not differ among patients prescribed and not prescribed an antibiotic in all of 2022 (3.8% vs 3.9%; P = .91) or during the posteducation period (1.8% vs 4.2%; P = .14). There was no appreciable diagnostic shift over the course of 2022 (Fig. 3). Conclusions: A multifaceted intervention, which included baseline education, promotion of syndrome-specific order panels, dissemination of resources for symptomatic management, and distribution of peer comparison reports, resulted in significant reduction of inappropriate antibiotic prescribing for URIs.

Disclosure: None

Background: Traditional hospital outbreak-detection methods are typically limited to select multidrug-resistant pathogens in a single unit, which can miss transmission of many medically important healthcare-transmissible pathogens. Whole-genome sequencing (WGS) enables comprehensive genomic resolution for accurate identification of clonal transmission. Previously, lack of scalability limited the use of WGS for hospital surveillance. Methods: We conducted prospective surveillance of select bacteria from all inpatient clinical cultures plus all bacteria from clinical cultures from ICUs and oncology units at the University of California Irvine (UCI) Clinical Microbiology Laboratory from September 2021 to February 2022. Due to pandemic stressors, this pilot test was a prelude to a real-time demonstration project. Its goal was to demonstrate the efficiency and scalability of the WGS platform when receiving samples monthly and analyzing results quarterly without the intent for real-time response. Bacterial isolates slated for discard were collected weekly and sent monthly to Day Zero Diagnostics for sequencing. In total, 1,036 samples from 926 patients were analyzed for genomic relatedness, a scalable and automated analysis pipeline already in use for rapid (days) characterization of genomic-relatedness in small and large sets of isolates. Mapping and SNP calling was performed against high-quality, best-match reference genomes. Sets of samples with pairwise distance of 2 persons with genomically related isolates and were denoted as “clusters.” Separately, we also investigated within-patient diversity by quantifying the genomic relatedness of isolates collected from individual patients. Results: Isolates represented 28 distinct species. We identified 10 Escherichia coli clusters (range, 2–4 patients; median, 2 patients), 2 Klebsiella pneumoniae clusters (range, 2–4 patients), and 1 Enterococcus faecium cluster (3 patients). All but 1 involved genomically matched isolates from multiple hospital locations. There were 4 Escherichia coli ST131 clusters spanning 4 months, including 1 with 4 patients across 3 different hospital locations. At a species level, there were distinct differences between the observed SNP distances between samples isolated from the same versus different patients (Fig. 1). All identified clusters had not been flagged by routine outbreak detection methods used by the UCI infection prevention program. Conclusions: Comprehensive WGS-based surveillance of hospital clinical isolates identified multiple potential transmission events between patients not in the same unit at the time cultures were taken. Combining WGS detection and real-time epidemiologic investigation may identify new avenues of transmission risk and could provide early warnings of clonal transmission to prevent larger outbreaks. High-volume surveillance of hospital isolates can also provide species- and context-specific clonality.

Financial support: This study was funded by Day Zero Diagnostics.

Disclosures: None

Background: Existing training for resident bathing in nursing homes (NHs) is brief and limited, likely because bathing is assumed to be intuitive. However, residents have complex skin issues, devices, dressings, and limited ability for self-care. We sought to assess bathing quality and to identify barriers to proper bathing techniques. Methods: We conducted a prospective observational study of bathing in 8 NHs in Orange County, California, involving a convenience sample of observed bed baths and showers conducted for quality improvement. NH staff were told that observation was occurring, and no feedback was given during or after bathing. Survey elements included cleansing of 6 specific body sites and adherence to bathing procedures (11 for bed baths and 17 for showers). Surveys also included queries to staff to further assess knowledge and perceived barriers. Observed lapses were documented, along with observer-determined reasons for noncompliance (ie, training issue, time pressure, facility issue (insufficient water temperature), resident refusal/behavior). Frequency of noncompliance with each element was tabulated for bed-baths and showers separately. Reasons for failure were displayed graphically. Results: In total, 50 bed baths (NH range, 5–8) and 50 showers (NH range, 4–7) were observed across 8 NHs. Lapses in bathing quality and process were extremely common for both bed baths and showers (Fig.). Inadequate body cleansing occurred for all observed body sites (88%–100% failure for bed baths, 58%–100% failure for showers). Most body areas were either skipped or sprayed with water without soaping. Procedural failures were high for both bed baths and showers (insufficient lather: 100% for bed bath and 40% for shower) lack of firm massage for cleaning (94% for bed bath and 90% for shower), failure to change wipes or cloths when dirty (100% for bed bath and 96% for shower), failure to follow clean-to-dirty sequence (100% for bed bath and 96% shower). In addition, failing to wrap or unwrap devices (73%) and failing to towel dry (94%) were common after showering. Reasons for failure were largely based on training or facility shortcomings (eg, insufficient hot water, inflexible showerhead attachment). Also, 86% of residents complained of being cold. Timing constraints and resident combativeness or refusal were rare. Staff-to-staff bathing advice most commonly involved competing for the “better shower” and “bathing early to get hot water.” Conclusions: Knowing how to appropriately bathe NH residents is not intuitive, and current training is brief and insufficient for high-quality resident care. Unacceptably high failures in proper bathing techniques in NHs necessitate re-evaluation of formal training and standardized practices to better cleanse residents. Moreover, common failures in facility processes for ensuring adequate water temperature and showerhead mobility for bathing or showering should be addressed.

Disclosures: None

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

Background: A regional decolonization intervention (SHIELD-OC) involving universal chlorhexidine for routine bathing and 5 days of twice-daily nasal iodophor every other week in nursing homes (NHs) recently demonstrated marked reductions in multidrug-resistant organisms, all-cause hospitalizations, and infection-related hospitalizations in Orange County, California. Specific to methicillin-resistant Staphylococcus aureus (MRSA), NH prevalence (nares, skin, or perirectal) decreased from 43% to 29%. Methods: We conducted a retrospective cohort study evaluating the impact of decolonization on factors associated with MRSA carriage. The cohort included residents from 18 SHIELD-OC NHs who were sampled for MRSA using nares, axilla, groin, and perirectal cultures. A point-prevalence survey was conducted in 2016–2017 (before decolonization, 50 randomly sampled residents per NH) and in 2018–2019 (decolonization, all residents sampled). Resident characteristics were obtained from their most proximal admission, quarterly, and/or discharge assessment using data mandated for NH reporting (CMS minimum data set), and included demographics, medical devices, comorbidities (including Alzheimer’s disease and related dementias or ADRD), and mobility and hygiene needs. We used generalized-linear mixed models stratified by decolonization and clustered by NH to identify differences in factors associated with MRSA carriage. Results: Of the 2,351NH residents, 2,255 (96%) had characteristics available in the CMS data set. Of the 2,255 residents included, 774 (34%) were MRSA carriers. Before decolonization, medical devices (OR, 2.5), limited mobility (OR, 1.6), and diabetes (OR, 1.4) were significantly associated with MRSA carriage in an adjusted model (Table). During decolonization, these effects were mitigated (medical device OR, 2.5–1.1; diabetes OR, 1.4–0.9) and were no longer significantly associated with MRSA carriage. Male sex appeared to have more of an effect in the decolonization phase (OR, 1.3–1.6), but limited mobility remained stable (OR, 1.6–1.7). Several variables were collinear. Presence of a medical device was collinear with postacute stays (<100 days) and Medicaid insurance. Limited mobility was associated with limited ability for hygienic self-care. ADRD was collinear with age. Final adjusted models accounted for medical devices, limited mobility, diabetes, ADRD, cancer, sex, and ethnicity. Conclusions: In a large interventional cohort of 18 NHs, factors associated with MRSA carriage changed after adoption of universal decolonization. Specifically, the increased risk of MRSA associated with medical devices and diabetes were substantially mitigated by decolonization, suggesting that these risks are modifiable. These long-term care findings are consistent with clinical trials showing reductions in MRSA carriage after implementing chlorhexidine bathing in ICUs and in non-ICU patients with devices. The ability of decolonization to attenuate the risk of MRSA carriage among diabetics or other potential high-risk groups deserves further study.

Disclosures: None

Background: Staphylococcus aureus infections are a significant cause of morbidity in neonatal intensive care units (NICUs), and they are typically preceded by nasal colonization. Mupirocin decolonization protocols as an infection prevention tool can halt S. aureus outbreaks and prevent infections. We examined the effect of a mupirocin treatment protocol on S. aureus incidence, prevalence, decolonization, and infections in a level IV NICU. Methods: We conducted a retrospective before-and-after observational study from June 1, 2018, to May 31, 2020. Beginning June 1, 2019, patients identified with either methicillin-sensitive or -resistant S. aureus (MSSA or MRSA) received mupirocin ointment to bilateral nares 3 times daily for 5 days. Patients with central lines or surgical incisions were treated every 30 days. All NICU patients were screened weekly unless positive for MRSA. We defined MSSA decolonization as 3 consecutive negative screens following mupirocin treatment. We calculated monthly S. aureus incidence as any new positive per 1,000 patient days and monthly prevalence as a percentage of the average daily number of patients with S. aureus per the average monthly census. Total number of infections were compared. Statistical significance was determined using a 2 sample proportions test and P < .05. Decolonization was calculated as percentage of occurrences among treated patients. Results: Overall, 190 patients received mupirocin; 142 patients received 1 course and 48 received 2 or more courses. There was no difference in incidence of MSSA (P = .09), but prevalence decreased from 18.8% to 14.4% (P < .05) (Fig. 1). Of 66 patients with MSSA, 35% were decolonized. An additional mupirocin treatment for 16 of these patients had a 50% decolonization rate. For MRSA, incidence decreased from 0.24 to 0.20 (P = .36) and prevalence decreased from 21.9% to 18.6% (P < .05) (Fig. 1). There was no statistical difference in the number of total S. aureus infections (P = .91) or when stratified by MSSA (P = .72) or MRSA (P = .82). In the postmupirocin population, there were 5 MRSA and 7 MSSA infections. Of the MSSA-infected patients, 6 remained colonized at the time of infection. Conclusions: Implementing a single mupirocin treatment course for S. aureus decolonization in NICU was only effective in one-third of patients and had no effect on infection occurrence. Changes in incidence and prevalence could be confounded by other infection prevention practices. Further study is needed to determine whether continued screening and additional mupirocin treatment could improve effectiveness of S. aureus decolonization programs.

Disclosure: None

During the COVID-19 pandemic, there was an increase in online gaming behaviour among college students. This study aimed to examine the impact of online self-help interventions consisting of different components within the Acceptance and Commitment Therapy (ACT) framework on college students’ gaming disorder and gaming frequency. Additionally, it evaluated the effectiveness of both interventions in addressing psychological distress among college students during the COVID-19 pandemic. One intervention was a full ACT program, which consists of six core components, while the other intervention focused on the engaged components of ACT (specifically targeting value-based actions). The study employed a 2 conditions (Full ACT vs. Engaged ACT) × 3 times (pre-, mid- and post-program) design to examine the effectiveness of these interventions. Each intervention consisted of 10 sessions, delivered at a frequency of five sessions per week over a 2-week period for both groups. The participants in this study were enrolled in two online classes. Participants with gaming disorder scores in the top 20% were selected and assigned to either the Full group (N = 49) or the Engaged group (N = 41) for the interventions. The study assessed outcome variables, including gaming disorder, psychological flexibility, daily gaming hours, weekly gaming days and psychological distress, at pre-intervention, mid-intervention, post-intervention and one-month follow-up for both groups. No significant differences were observed between the two groups on these outcomes at the pre-intervention stage. The findings of this study indicate that both interventions effectively reduced gaming disorder and weekly gaming frequency, while enhancing psychological flexibility. Nonetheless, the Engaged group exhibited a significant reduction in daily gaming hours. There was no substantial change in psychological distress in either group during and after the intervention. The implications and limitations of this study were also reported.

The aim was to explore the implications of follicular output rate (FORT), ovarian sensitivity index (OSI), ovarian response prediction index (ORPI), and follicle-to-oocyte index (FOI) in low-prognosis patients defined by POSEIDON criteria. In total, 4030 fresh in vitro fertilization (IVF) cycles from January 2013 to October 2021 were included in this retrospective cohort analysis and were categorized into four groups based on the POSEIDON criteria. The FORT between Groups 1 and 2 (0.61 ± 0.34 vs. 0.65 ± 0.35, P = 0.081) and Groups 3 and 4 (1.08 ± 0.82 vs. 1.09 ± 0.94, P = 0.899) were similar. The OSI in the order from the highest to the lowest were 3.01 ± 1.46 in Group 1, 2.28 ± 1.09 in Group 2, 1.54 ± 1.04 in Group 3, and 1.34 ± 0.96 in Group 4 (P < 0.001). The trend in the ORPI values was consistent with that in the OSI. FORT, OSI, ORPI, and FOI complemented each other and offered excellent effectiveness in reflecting ovarian reserve and response, but they were not good predictors of clinical pregnancy rate (CPR) from IVF.

Understanding the nature of meaning and its extensions (with metaphor as one typical kind) has been one core issue in figurative language study since Aristotle’s time. This research takes a computational cognitive perspective to model metaphor based on the assumption that meaning is perceptual, embodied, and encyclopedic. We model word meaning representation for metaphor detection with embodiment information obtained from behavioral experiments. Our work is the first attempt to incorporate sensorimotor knowledge into neural networks for metaphor detection, and demonstrates superiority, consistency, and interpretability compared to peer systems based on two general datasets. In addition, with cross-sectional analysis of different feature schemas, our results suggest that metaphor, as a device of cognitive conceptualization, can be ‘learned’ from the perceptual and actional information independent of several more explicit levels of linguistic representation. The access to such knowledge allows us to probe further into word meaning mapping tendencies relevant to our conceptualization and reaction to the physical world.

Submerged vegetation plays a subtle role in exchanging the fluid mass and energy in the vegetated flow zone, where the swaying motions of flexible plants are the important source of turbulent kinetic energy production. Flume experiments were conducted to study the modes, characteristics and factors of swaying of individual submerged flexible plants. A modified plant model in a new form, representing the highly flexible vegetation with clustered leaves, was employed. A ‘rigid-like’ synchronous swaying mode and a ‘whip-like’ asynchronous flapping mode are found to appear alternately for the individual plants. The interaction between these modes depends on the resulting local flow structure affected by the plants. Compared with a plant in isolation with the same flow Reynolds number, the swaying motions of a plant within the vegetation patch are less frequent but more prone to the synchronous mode. The eigen frequency of the motions increases linearly with an increase in flow Reynolds number in the range of 2 × 104–5 × 104, but the normalised amplitude reaches a saturation at a high flow Reynolds number. Moreover, the in-line and spanwise motions have a 2 : 1 frequency ratio for an ‘8’ shaped trajectory on the horizontal plane and a 1 : 1 ratio for a ‘0’ shaped circular trajectory, or a combination of both.