The coronavirus disease 2019 (COVID-19) pandemic has demonstrated the importance of stewardship of viral diagnostic tests to aid infection prevention efforts in healthcare facilities. We highlight diagnostic stewardship lessons learned during the COVID-19 pandemic and discuss how diagnostic stewardship principles can inform management and mitigation of future emerging pathogens in acute-care settings. Diagnostic stewardship during the COVID-19 pandemic evolved as information regarding transmission (eg, routes, timing, and efficiency of transmission) became available. Diagnostic testing approaches varied depending on the availability of tests and when supplies and resources became available. Diagnostic stewardship lessons learned from the COVID-19 pandemic include the importance of prioritizing robust infection prevention mitigation controls above universal admission testing and considering preprocedure testing, contact tracing, and surveillance in the healthcare facility in certain scenarios. In the future, optimal diagnostic stewardship approaches should be tailored to specific pathogen virulence, transmissibility, and transmission routes, as well as disease severity, availability of effective treatments and vaccines, and timing of infectiousness relative to symptoms. This document is part of a series of papers developed by the Society of Healthcare Epidemiology of America on diagnostic stewardship in infection prevention and antibiotic stewardship.1

Antimicrobial stewardship programs (ASPs) exist to optimize antibiotic use, reduce selection for antimicrobial-resistant microorganisms, and improve patient outcomes. Rapid and accurate diagnosis is essential to optimal antibiotic use. Because diagnostic testing plays a significant role in diagnosing patients, it has one of the strongest influences on clinician antibiotic prescribing behaviors. Diagnostic stewardship, consequently, has emerged to improve clinician diagnostic testing and test result interpretation. Antimicrobial stewardship and diagnostic stewardship share common goals and are synergistic when used together. Although ASP requires a relationship with clinicians and focuses on person-to-person communication, diagnostic stewardship centers on a relationship with the laboratory and hardwiring testing changes into laboratory processes and the electronic health record. Here, we discuss how diagnostic stewardship can optimize the “Four Moments of Antibiotic Decision Making” created by the Agency for Healthcare Research and Quality and work synergistically with ASPs.

Of the 2,668 patients admitted with coronavirus disease 2019 (COVID-19), 4% underwent prolonged isolation for >20 days. Reasons for extended isolation were inconsistent with Centers for Disease Control and Prevention (CDC) guidelines in 25% of these patients and were questionable in 54% due to an ongoing critically ill condition at day 20 without CDC-defined immunocompromised status.

We provide an overview of diagnostic stewardship with key concepts that include the diagnostic pathway and the multiple points where interventions can be implemented, strategies for interventions, the importance of multidisciplinary collaboration, and key microbiologic diagnostic tests that should be considered for diagnostic stewardship. The document focuses on microbiologic laboratory testing for adult and pediatric patients and is intended for a target audience of healthcare workers involved in diagnostic stewardship interventions and all workers affected by any step of the diagnostic pathway (ie, ordering, collecting, processing, reporting, and interpreting results of a diagnostic test). This document was developed by the Society for Healthcare Epidemiology of America Diagnostic Stewardship Taskforce.

We describe the association between job roles and coronavirus disease 2019 (COVID-19) among healthcare personnel. A wide range of hazard ratios were observed across job roles. Medical assistants had higher hazard ratios than nurses, while attending physicians, food service workers, laboratory technicians, pharmacists, residents and fellows, and temporary workers had lower hazard ratios.

We evaluated povidone-iodine (PVI) decolonization among 51 fracture-fixation surgery patients. PVI was applied twice on the day of surgery. Patients were tested for S. aureus nasal colonization and surveyed. Mean S. aureus concentrations decreased from 3.13 to 1.15 CFU/mL (P = .03). Also, 86% of patients stated that they felt neutral or positive about their PVI experience.

We describe COVID-19 cases among nonphysician healthcare personnel (HCP) by work location. The proportion of HCP with coronavirus disease 2019 (COVID-19) was highest in the emergency department and lowest among those working remotely. COVID-19 and non–COVID-19 units had similar proportions of HCP with COVID-19 (13%). Cases decreased across all work locations following COVID-19 vaccination.

Background: Nasal decolonization significantly decreases the incidence of Staphylococcus aureus surgical-site infections (SSIs). Patient adherence with self-administration of a decolonization ointment (ie, mupirocin) is low, especially among patients having urgent surgery. Povidone-iodine decolonization may overcome patient adherence challenges because povidone-iodine needs to be applied only on the day of surgery. We assessed the effectiveness and acceptability of povidone-iodine decolonization given on the day of surgery among patients having orthopedic trauma surgery. Methods: Adult patients who underwent operative fixation of traumatic lower extremity fractures were consented to receive 10% intranasal povidone-iodine solution. Povidone-iodine was applied ~1 hour before surgical incision and was reapplied the evening after surgery. Patients were tested for S. aureus nasal colonization before surgery, the evening after surgery (before povidone-iodine reapplication), and the day after surgery. Swabs were inoculated into Dey-Engley neutralizer and processed in a vortexer. A series of dilutions were performed and plated on mannitol salt agar plates. S. aureus cultures were quantitatively assessed to determine the reduction in S. aureus after povidone-iodine use. Reductions in S. aureus nasal growth were evaluated using the Skillings-Mack test. SSIs manifesting within 30 and 90 days of surgery were identified using NHSN definitions. A survey was administered the morning after surgery to determine the acceptability of intranasal povidone-iodine. Results: In total, 51 patients participated in this pilot study between February 2020 and June 2021. Nasal samples from 12 participants (23.5%) grew S. aureus. The S. aureus concentration decreased significantly across the time points (P = .03) (Fig. 1). No SSIs were identified within 30 days of surgery. One SSI occurred within 90 days of surgery; this patient did not carry S. aureus, and cultures from the infected site were negative. Also, 31% of patients reported at least 1 mild side effect while using povidone-iodine: dripping (n = 7), itching (n = 6), dryness (n = 4), stinging (n = 4), staining (n = 3), unpleasant taste (n = 3), runny nose (n = 2), burning (n = 1), sneezing (n = 1), sore throat (n = 1), tickling (n = 1), and/or cough (n = 1). Also, 86% of patients stated that povidone-iodine felt neutral, pleasant, or very pleasant, and only 14% stated that it felt unpleasant or very unpleasant. Discussion: In this pilot study, 2 applications of nasal povidone-iodine on the day of surgery were acceptable for patients, and this protocol significantly reduced S. aureus concentration in nares of patients. Future large clinical trials should evaluate whether this 2-application regimen of povidone-iodine significantly decreases rates of SSI among orthopedic trauma surgery patients.

Funding: PDI Healthcare

Disclosures: None

Background: Whether working on COVID-19 designated units put healthcare workers (HCWs) at higher risk of acquiring COVID-19 is not fully understood. We report trends of COVID-19 incidence among nonphysician HCWs and the association between the risk of acquiring COVID-19 and work location in the hospital. Methods: The University of Iowa Hospitals & Clinics (UIHC) is an 811-bed, academic medical center serving as a referral center for Iowa. We retrospectively collected COVID-19–associated data for nonphysician HCWs from Employee Health Clinic between June 1st 2020 and July 31th 2021. The data we abstracted included age, sex, job title, working location, history of COVID-19, and date of positive COVID-19 test if they had a history of COVID-19. We excluded HCWs who did not have a designated working location and those who worked on multiple units during the same shift (eg, medicine resident, hospitalist, etc) to assess the association between COVID-19 infections and working location. Job titles were divided into the following 5 categories: (1) nurse, (2) medical assistant (MA), (3) technician, (4) clerk, and (5) others (eg patient access, billing office, etc). Working locations were divided into the following 6 categories: (1) emergency department (ED), (2) COVID-19 unit, (3) non–COVID-19 unit, (4) Clinic, (5) perioperative units, and (6) remote work. Results: We identified 6,971 HCWs with work locations recorded. During the study period, 758 HCWs (10.8%) reported being diagnosed with COVID-19. Of these 758 COVID-19 cases, 658 (86.8%) were diagnosed before vaccines became available. The location with the highest COVID-19 incidence was the ED (17%), followed by both COVID-19 and non–COVID-19 units (12.7%), clinics (11.0%), perioperative units (9.4%) and remote work stations (6.6%, p Conclusions: Strict and special infection control strategies may be needed for HCWs in the ED, especially where vaccine uptake is low. The administrative control of HCWs working remotely may be associated with a lower incidence of COVID-19. Given that the difference in COVID-19 incidence among HCWs by location was lower and comparable after the availability of COVID-19 vaccines, facilities should make COVID-19 vaccination mandatory as a condition of employment for all HCWs, especially in areas where the COVID-19 incidence is high.

Funding: None

Disclosures: None

Background: The IDSA has a clinical definition for catheter-related bloodstream infection (CRBSI) that requires ≥1 set of blood cultures from the catheter and ≥1 set from a peripheral vein. However, because blood cultures obtained from a central line may represent contamination rather than true infection, many institutions discourage blood cultures from central lines. We describe blood culture ordering practices in patients with a central line. Methods: The University of Iowa Hospitals & Clinics is an academic medical center with 860 hospital beds. We retrospectively collected data for blood cultures obtained from adult patients (aged ≥18 years) in the emergency department or an inpatient unit during 2020. We focused on the first blood cultures obtained during each admission because they are usually obtained before antibiotic initiation and are the most important opportunity to diagnose bacteremia. We classified blood-culture orders as follows: CRBSI workup, non-CRBSI sepsis workup, or incomplete workup. We defined CRBSI workup as ≥1 blood culture from a central line and ≥1 peripheral blood culture (IDSA guidelines). We defined non-CRBSI sepsis workup as ≥2 peripheral blood cultures without cultures from a central line because providers might have suspected secondary bacteremia rather than CRBSI. We defined incomplete workup as any order that did not meet the CRBSI or non-CRBSI sepsis workup. This occurred when only 1 peripheral culture was obtained or when ≥1 central-line culture was obtained without peripheral cultures. Results: We included 1,150 patient admissions with 4,071 blood cultures. In total, 349 patient admissions with blood culture orders (30.4%) met CRBSI workup. 62.8% were deemed non-CRBSI sepsis workup, and 6.9% were deemed an incomplete workup. Stratified by location, ICUs had the highest percentage of orders with incomplete workups (8.8%), followed by wards (7.2%) and the emergency department (5.1%). In total, 204 patient admissions had ≥1 positive blood culture (17.7%). The most frequently isolated organisms were Staphylococcus epidermidis (n = 33, 16.2%), Staphylococcus aureus (n = 16, 7.8%), and Escherichia coli (n = 15, 7.4%) Conclusions: Analysis of blood culture data allowed us to identify units at our institute that were underperforming in terms of ordering the necessary blood cultures to diagnose CRBSI. Being familiar with CRBSI guidelines as well as decreasing inappropriate ordering will help lead to early and proper diagnosis of CRBSI which can reduce its morbidity, mortality, and cost.

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.

We described the epidemiology of bat intrusions into a hospital and subsequent management of exposures during 2018–2020. Most intrusions occurred in older buildings during the summer and fall months. Hospitals need bat intrusion surveillance systems and protocols for bat handling, exposure management, and intrusion mitigation.

Background: COVID-19 in hospitalized patients may be the result of community acquisition or in-hospital transmission. Molecular epidemiology can help confirm hospital COVID-19 transmission and outbreaks. We describe large COVID-19 clusters identified in our hospital and apply molecular epidemiology to confirm outbreaks. Methods: The University of Iowa Hospitals and Clinics is an 811-bed academic medical center. We identified large clusters involving patients with hospital onset COVID-19 detected during March–October 2020. Large clusters included ≥10 individuals (patients, visitors, or HCWs) with a laboratory confirmed COVID-19 diagnosis (RT-PCR) and an epidemiologic link. Epidemiologic links were defined as hospitalization, work, or visiting in the same unit during the incubation or infectious period for the index case. Hospital onset was defined as a COVID-19 diagnosis ≥14 days from admission date. Admission screening has been conducted since May 2020 and serial testing (every 5 days) since July 2020. Nasopharyngeal swab specimens were retrieved for viral whole-genome sequencing (WGS). Cluster patients with a pairwise difference in ≤5 mutations were considered part of an outbreak. WGS was performed using Oxford Nanopore Technology and protocols from the ARTIC network. Results: We identified 2 large clusters involving patients with hospital-onset COVID-19. Cluster 1: 2 hospital-onset cases were identified in a medical-surgical unit in June 2020. Source and contact tracing revealed 4 additional patients, 1 visitor, and 13 employees with COVID-19. Median age for patients was 62 (range, 38–79), and all were male. In total, 17 samples (6 patients, 1 visitor, and 10 HCWs) were available for WGS. Cluster 2: A hospital-onset case was identified via serial testing in a non–COVID-19 intensive care unit in September 2020. Source investigation, contact tracing, and serial testing revealed 3 additional patients, and 8 HCWs. One HCW also had a community exposure. Patient median age was 60 years (range, 48–68) and all were male. In total, 11 samples (4 patients and 7 HCWs) were sequenced. Using WGS, cluster 1 was confirmed to be an outbreak: WGS showed 0–5 mutations in between samples. Cluster 2 was also an outbreak: WGS showed less diversity (0–3 mutations) and ruled out the HCW with a community exposure (20 mutations of difference). Conclusion: Whole-genome sequencing confirmed the outbreaks identified using classic epidemiologic methods. Serial testing allowed for early outbreak detection. Early outbreak detection and implementation of control measures may decrease outbreak size and genetic diversity.

Funding: No

Disclosures: None

Figure 1.

Background: Bats are recognized as important vectors in disease transmission. Frequently, bats intrude into homes and buildings, increasing the risk to human health. We describe bat intrusions and exposure incidents in our hospital over a 3-year period. Methods: The University of Iowa Hospitals and Clinics (UIHC) is an 811-bed academic medical center in Iowa City, Iowa. Established in 1928, UIHC currently covers 209,031.84 m2 (~2,250,000 ft2) and contains 6 pavilions built between 1928 and 2017. We retrospectively obtained bat intrusion calls from the infection prevention and control program call database at UIHC during 2018–2020. We have also described the event management for intrusions potentially associated with patient exposures. Results: In total, 67 bat intrusions occurred during 2018–2020. The most frequent locations were hallways or lounges 28 (42%), nonclinical office spaces 19 (14%), and stairwells 8 (12%). Most bat intrusions (65%) occurred during the summer and fall (June–November). The number of events were 15 in 2018, 28 in 2019, and 24 in 2020. We observed that the number of intrusions increased with the age of each pavilion (Figure 1). Of 67 intrusions, 2 incidents (3%) were associated with potential exposure to patients. In the first incident, reported in 2019, the bat was captured in a patient care area and released before an investigation of exposures was completed and no rabies testing was available. Also, 10 patients were identified as having had potential exposure to the bat. Among them, 9 patients (90%) received rabies postexposure prophylaxis. In response to this serious event, we provided facility-wide education on our bat control policy, which includes the capture and safe handling of the bat, assessment of potential exposures, and potential need for rabies testing. We also implemented a bat exclusion project focused on the exterior of the oldest hospital buildings. The second event, 1 patient was identified to have potential exposure to the bat. The bat was captured, tested negative for rabies, no further action was needed. Conclusions: Bat intrusions can be an infection prevention and control challenge in facilities with older buildings. Hospitals may need animal intrusion surveillance systems, management protocols, and remediation efforts.

Funding: No

Disclosures: None

Figure 1.

Background: Hospital semiprivate rooms may lead to coronavirus disease 2019 (COVID-19) patient exposures. We investigated the risk of COVID-19 patient-to-patient exposure in semiprivate rooms and the subsequent risk of acquiring COVID-19. Methods: The University of Iowa Hospitals & Clinics is an 811-bed tertiary care center. Overall, 16% of patient days are spent in semiprivate rooms. Most patients do not wear masks while in semiprivate rooms. Active COVID-19 surveillance included admission and every 5 days nasopharyngeal SARS-CoV-2 polymerase chain reaction (PCR) testing. We identified inpatients with COVID-19 who were in semiprivate rooms during their infectious periods during July–December 2020. Testing was repeated 24 hours after the first positive test. Cycle threshold (Ct) values of the two tests (average Ct <30), SARS-CoV-2 serology results, clinical assessment, and COVID-19 history were used to determine patient infectiousness. Roommates were considered exposed if in the same semiprivate room with an infectious patient. Exposed patients were notified, quarantined (private room), and follow-up testing was arranged (median seven days). Conversion was defined as having a negative test followed by a subsequent positive within 14 days after exposure. We calculated the risk of exposure: number of infectious patients in semiprivate rooms/number of semiprivate patient-days (hospitalization days in semiprivate rooms). Results: There were 16,427 semiprivate patient days during July–December 2020. We identified 43 COVID-19 inpatients who roommates during their infectious periods. Most infectious patients (77%) were male; the median age was 67 years; and 22 (51%) were symptomatic. Most were detected during active surveillance: admission testing (51%) and serial testing (28%). There were 57 exposed roommates. The risk of exposure was 3 of 1,000 semiprivate patient days. In total, 16 roommates (28%) did not complete follow-up testing. Of 41 exposed patients with follow-up data, 8 (20%) converted following their exposure. Median time to conversion was 5 days. The risk of exposure and subsequent conversion was 0.7 of 1,000 semiprivate patient days. Median Ct value of the source patient was 20 for those who converted and 23 for those who did not convert. Median exposure time was 45 hours (range, 3–73) for those who converted and 12 hours (range, 1–75) for those who did not convert. Conclusions: The overall risk of exposure in semiprivate rooms was low. The conversion rate was comparable to that reported for household exposures. Lower Ct values and lengthier exposures may be associated with conversion. Active COVID-19 surveillance helps early detection and decreases exposure time.

Funding: No

Disclosures: None

Background: Hospitalized patients may unknowingly carry severe acute respiratory coronavirus virus 2 (SARS-CoV-2), even if they are admitted for other reasons. Because SARS-CoV-2 may remain positive by reverse-transcriptase polymerase chain reaction (RT-PCR) for months after infection, patients with a positive result may not necessarily be infectious. We aimed to determine the frequency of SARS-CoV-2 infections in patients admitted for reasons unrelated to coronavirus disease 2019 (COVID-19). Methods: The University of Iowa Hospitals and Clinics is an 811-bed tertiary-care center. We use a nasopharyngeal SARS-CoV-2 RT-PCR to screen admitted patients without signs or symptoms compatible with COVID-19. Patients with positive tests undergo a repeat test to assess cycle threshold (Ct) value kinetics. We reviewed records for patients with positive RT-PCR screening admitted during July–October 2020. We used a combination of history, serologies, and RT-PCR Ct values to assess and qualify likelihood of infectiousness: (1) likely infectious, if Ct values were <29, or (2) likely not infectious, if 1 or both samples had Cts <30 with or without a positive SARS-CoV-2 antinucleocapsid IgG/IgM test or history of a positive result in the past 90 days. Contact tracing was only conducted for patients likely to be infectious. We describe the isolation duration and contact tracing data. Results: In total, 6,447 patients were tested on hospital admission for any reason (persons under investigation or admitted for reasons other than COVID-19). Of these, 240 (4%) had positive results, but 65 (27%) of these were admitted for reasons other than COVID-19. In total, 55 patients had Ct values available and were included in this analysis. The median age was 56 years (range, 0–91), 28 (51%) were male, and 12 (5%) were children. The most frequent admission syndromes were neurological (36%), gastrointestinal (16%), and trauma (16%). Our assessment revealed 23 likely infections (42%; 14 definite, 9 possible) and 32 cases likely not infectious (58%). The mean Ct for patients who were likely infectious was 22; it was 34 for patients who were likely not infectious. Mean duration of in-hospital isolation was 6 days for those who were likely infectious and 2 days for those who were likely not infectious. We detected 8 individuals (1 healthcare worker and 7 patients) who were exposed to a likely infectious patient. Conclusions: SARS-CoV-2 infection in patients hospitalized for other reasons was infrequent. An assessment of the likelihood of infectiousness including history, RT-PCR Cts, and serology may help prioritize patients in need of isolation and contact investigations.

Funding: No

Disclosures: None