Background: Multidrug-resistant organisms (MDROs) are increasingly implicated in nosocomial outbreaks worldwide. We evaluated whole-genome sequencing (WGS) as an adjunctive epidemiological tool to identify infection clusters and MDRO transmission in the healthcare setting. Methods: Clinical isolates of carbapenem-resistant Enterobacterales (CRE) from July 1, 2021, to June 30, 2022, underwent Illumina WGS. Assembled genomes were taxonomically classified with GTDB-Tk software and were typed using multilocus sequence typing (MLST). Average nucleotide identity (ANI) was calculated between genomes. Numbers of differences among core single-nucleotide polymorphisms (SNPs) were calculated for pairs within taxonomic groups, and the data were evaluated in the context of patient dates and locations of care obtained from the electronic medical record. Results: In total, 39 CRE isolates underwent WGS (Fig. 1). Klebsiella pneumoniae represented the largest number of isolates (n = 18). Using MLST, 2 distinct groups of K. pneumoniae were identified (ST307 and ST258) with 5 and 4 isolates, respectively (Fig. 2). Within ST307, SNP differences ranged between 8 and 115. 3 isolates (CRE8, CRE10, and CRE12) were collected within 4 weeks of each other and had ≤26 pairwise SNP differences. Notably, CRE8 and CRE10 were located on the same unit at the same time and used the same MRI scanner on the same day. CRE35 had >95 SNP differences and was admitted 8 months prior to others in ST307 but had surgery in the same OR as CRE8. Within ST258, pairwise comparison of samples revealed 139–588 SNP differences. CRE21, CRE31, and CRE33 had SNP differences of ≤150. These patients were in the same hospital room (CRE33 and CRE21) and unit (CRE31 and CRE33), but they did not overlap temporally. CRE37 had >580 SNP differences, with no overlap in hospitalization dates or locations with other patients. Conclusions: Two closely related K. pneumoniae isolate populations were identified using WGS. Strong temporal and spatial commonalities were identified among isolates with few SNP differences. Isolate pairs with intermediate SNP differences shared spatial commonalities, suggesting possible indirect transmission between patients. No common exposures were identified for pairs with large numbers of SNP differences. WGS is an evolving tool to detect outbreak clonal populations of MDRO not identified through traditional epidemiologic techniques. WGS can provide insight into transmission patterns and the role of environmental contamination in propagating these nosocomial infections. More studies are needed to define the role and clinical significance of isolates with intermediate SNP differences in transmission of these pathogens between hosts and the healthcare environment.

Disclosures: None

Background: The Centers for Disease Control and Prevention’s Emerging Infections Program conducts active laboratory- and population-based surveillance for carbapenem-resistant Enterobacterales (CRE) and extended spectrum beta-lactamase-producing Enterobacterales (ESBL-E). To better understand the U.S. epidemiology of these organisms among children, we determined the incidence of pediatric CRE and ESBL-E cases and described their clinical characteristics. Methods: Surveillance was conducted among children <18 years of age for CRE from 2016–2020 in 10 sites, and for ESBL-E from 2019–2020 in 6 sites. Among catchment-area residents, an incident CRE case was defined as the first isolation of Escherichia coli, Enterobacter cloacae complex, Klebsiella aerogenes, K. oxytoca, or K. pneumoniae in a 30-day period resistant to ≥1 carbapenem from a normally sterile site or urine. An incident ESBL-E case was defined as the first isolation of E. coli, K. pneumoniae, or K. oxytoca in a 30-day period resistant to any third-generation cephalosporin and non-resistant to all carbapenems from a normally sterile site or urine. Case records were reviewed. Results: Among 159 CRE cases, 131 (82.9%) were isolated from urine and 19 (12.0%) from blood; median age was 5 years (IQR 1–10) and 94 (59.1%) were female. Combined CRE incidence rate per 100,000 population by year ranged from 0.47 to 0.87. Among 207 ESBL-E cases, 160 (94.7%) were isolated from urine and 6 (3.6%) from blood; median age was 6 years (IQR 2–15) and 165 (79.7%) were female. Annual ESBL incidence rate per 100,000 population was 26.5 in 2019 and 19.63 in 2020. Incidence rates of CRE and ESBL-E were >2-fold higher in infants (children <1 year) than other age groups. Among those with data available, CRE cases were more likely than ESBL-E cases to have underlying conditions (99/158 [62.7%] versus 59/169 [34.9%], P<0.0001), prior healthcare exposures (74/158 [46.8%] versus 38/169 [22.5%], P<0.0001), and be hospitalized for any reason around time of their culture collection (75/158 [47.5%] versus 38/169 [22.5%], P<0.0001); median duration of admission was 18 days [IQR 3–103] for CRE versus 10 days [IQR 4–43] for ESBL-E. Urinary tract infection was the most frequent infection for CRE (89/158 [56.3%]) and ESBL-E (125/169 [74.0%]) cases. Conclusion: CRE infections occurred less frequently than ESBL-infections in U.S. children but were more often associated with healthcare risk factors and hospitalization. Infants had highest incidence of CRE and ESBL-E. Continued surveillance, infection prevention and control efforts, and antibiotic stewardship outside and within pediatric care are needed

Disclosure: None

Background: Candida auris is a frequently drug-resistant yeast that can cause invasive disease and is easily transmitted in healthcare settings. Pediatric cases are rare in the United States, with <10 reported before 2022. In August 2021, the first C. auris case in Las Vegas was identified in an adult. By May 2022, 117 cases were identified across 16 healthcare facilities, including 3 pediatric cases at an acute-care hospital (ACH) with adult cases, representing the first pediatric cluster in the United States. The CDC and Nevada Division of Public and Behavioral Health (NVDPBH) sought to describe these cases and risk factors for C. auris acquisition. Methods: We defined a case as a patient’s first positive C. auris specimen. We reviewed medical records and infection prevention and control (IPC) practices. Environmental sampling was conducted on high-touch surfaces throughout affected adult and pediatric units. Isolate relatedness was assessed using whole-genome sequencing (WGS). Results: All 3 pediatric patients were born at the facility and had congenital heart defects. All were aged <6 months when they developed C. auris bloodstream infections; 2 developed C. auris endocarditis. One patient died. Patients overlapped in the pediatric cardiac intensive care unit; 2 did not leave between birth and C. auris infection. Mobile medical equipment was shared between adult and pediatric patients; lapses in cleaning and disinfection of shared mobile medical equipment and environmental surfaces were observed, presenting opportunities for transmission. Overall, 32 environmental samples were collected, and C. auris was isolated from 2 specimens from an adult unit without current cases. One was a composite sample from an adult patient’s bed handles, railings, tray table and call buttons, and the second was from an adult lift-assistance device. WGS of specimens from adult and pediatric cases and environmental isolates were in the same genetic cluster, with 2–10 single-nucleotide polymorphisms (SNPs) different, supporting within-hospital transmission. The pediatric cases varied by 0–3 SNPs; at least 2 were highly related. Conclusions: C. auris was likely introduced to the pediatric population from adults via inadequately cleaned and disinfected mobile medical equipment. We made recommendations to ensure adequate cleaning and disinfection and implement monitoring and audits. No pediatric cases have been identified since. This investigation demonstrates transmission can occur between unrelated units and populations and that robust infection prevention and control practices throughout the facility are critical for reducing C. auris environmental burden and limiting transmission, including to previously unaffected vulnerable populations, like children.

Disclosures: None

A Canadian outbreak investigation was initiated in January 2022 after a cluster of cases of Shiga-toxin-producing Escherichia coli (STEC) O157 was identified through whole genome sequencing (WGS). Exposure information was collected through case interviews. Traceback investigations were conducted, and samples from case homes, retail, and the manufacturer were tested for STEC O157. Fourteen cases were identified in two provinces in Western Canada, with isolates related by 0–5 whole genome multi-locus sequence typing allele differences. Symptom onset dates ranged from 11 December 2021 to 7 January 2022. The median age of cases was 29.5 (range 0–61); 64% were female. No hospitalisations or deaths were reported. Of 11 cases with information available on fermented vegetable exposures, 91% (10/11) reported consuming Kimchi Brand A during their exposure period. The traceback investigation identified Manufacturer A in Western Canada as the producer. One open and one closed sample of Kimchi Brand A tested positive for STEC O157, with isolates considered genetically related by WGS to the outbreak strain. Napa cabbage within the kimchi product was hypothesised as the most likely source of contamination. This paper summarises the investigation into this STEC O157 outbreak associated with kimchi, the first reported outside of East Asia.

When survey respondents rate the quality of life (QoL) associated with a health condition, they must not only evaluate the health condition itself, but must also interpret the meaning of the rating scale in order to assign a specific value. The way that respondents approach this task depends on subjective interpretations, resulting in inconsistent results across populations and tasks. In particular, patients and non-patients often give very different ratings to health conditions, a discrepancy that raises questions about the objectivity of either groups’ evaluations. In this study, we found that the perspective of the raters (i.e., their own current health relative to the health conditions they rated) influences the way they distinguish between different health states that vary in severity. Consistent with prospect theory, a mild and a severe lung disease scenario were rated quite differently by lung disease patients whose own health falls between the two scenarios, whereas healthy non-patients, whose own health was better than both scenarios, rated the two scenarios as much more similar. In addition, we found that the context of the rating task influences the way participants distinguish between mild and severe scenarios. Both patients and non-patients gave less distinct ratings to the two scenarios when each were presented in isolation than when they were presented alongside other scenarios that provided contextual information about the possible range of severity for lung disease. These results raise continuing concerns about the reliability and validity of subjective QoL ratings, as these ratings are highly sensitive to differences between respondent groups and the particulars of the rating task.

Prisons are susceptible to outbreaks. Control measures focusing on isolation and cohorting negatively affect wellbeing. We present an outbreak of coronavirus disease 2019 (COVID-19) in a large male prison in Wales, UK, October 2020 to April 2021, and discuss control measures.

We gathered case-information, including demographics, staff-residence postcode, resident cell number, work areas/dates, test results, staff interview dates/notes and resident prison-transfer dates. Epidemiological curves were mapped by prison location. Control measures included isolation (exclusion from work or cell-isolation), cohorting (new admissions and work-area groups), asymptomatic testing (case-finding), removal of communal dining and movement restrictions. Facemask use and enhanced hygiene were already in place. Whole-genome sequencing (WGS) and interviews determined the genetic relationship between cases plausibility of transmission.

Of 453 cases, 53% (n = 242) were staff, most aged 25–34 years (11.5% females, 27.15% males) and symptomatic (64%). Crude attack-rate was higher in staff (29%, 95% CI 26–64%) than in residents (12%, 95% CI 9–15%).

Whole-genome sequencing can help differentiate multiple introductions from person-to-person transmission in prisons. It should be introduced alongside asymptomatic testing as soon as possible to control prison outbreaks. Timely epidemiological investigation, including data visualisation, allowed dynamic risk assessment and proportionate control measures, minimising the reduction in resident welfare.

Background: Carbapenem-resistant Enterobacterales (CRE) are an increasing threat to patient safety but only a small percentage of CRE identified are NDMs. Since 2018, clinical CRE isolates have been submitted to the Ohio Department of Health for sequencing and NDM cases have notably increased since that time. Candida auris is an emerging pathogen with similar risk factors for colonization as CRE. Methods: A point-prevalence study was initiated after an index patient was identified with NDM CRE infection or colonization during their inpatient admission. Two patient populations were included in the study: current patients on the same unit as the index patient and currently hospitalized patients who overlapped on any unit with the index patient for at least 72 hours. Patients had perirectal screening for CRE (via PCR) and axilla or groin screening for C. auris (via Xpert Carba-R Assay). Patients were excluded if they had been discharged, expired, or refused testing. Results: We completed 5 point-prevalence studies from March 21, 2021, to October 15, 2021. The index patients were admitted at different times and across 2 campuses including medical, cardiac, and surgical ICUs as well as medical-surgical and inpatient rehabilitation units. Moreover, 3 species of NDM were identified from urine and 2 species were identified from bronchoalveolar lavage: Enterobacter hormaechei, Citrobacter freundii, and Enterobacter cloacae complex. C. freundii and E. cloacae complex both had dual mechanisms of NDM and KPC. Although some of the index patients overlapped temporally within the health system, none overlapped in the same unit or building. None of the patients had recently received health care outside the United States, although 1 patient had emigrated from Togo >5 years prior and 4 had had prior local healthcare exposure within 12 months of admission. Also, 147 patients were identified for screening; 105 consented, 32 declined, and 10 were excluded due to being discharged, deceased, or unable to consent. Inpatient point-prevalence screening tests for all patients tested (n = 105) were negative for NDM CRE and C. auris. Conclusions: Despite an increase of inpatients with NDM CRE, evidence of patient-to-patient transmission was not identified, likely resulting from adherence to standard precautions. The diversity of species and lack of international travel suggests that these patients likely acquired NDM CRE from a local reservoir in the community or healthcare settings. Given the continued increase in NDM CRE without traditional risk factors, it is critical for hospitals and public health agencies to collaborate to identify these organisms and that they develop surveillance programs to clarify risk factors for colonization.

Funding: None

Disclosures: None

Fluting is a technological and morphological hallmark of some of the most iconic North American Paleoindian stone points. Through decades of detailed artifact analyses and replication experiments, archaeologists have spent considerable effort reconstructing how flute removals were achieved, and they have explored possible explanations of why fluting was such an important aspect of early point technologies. However, the end of fluting has been less thoroughly researched. In southern North America, fluting is recognized as a diagnostic characteristic of Clovis points dating to approximately 13,000 cal yr BP, the earliest widespread use of fluting. One thousand years later, fluting occurs more variably in Dalton and is no longer useful as a diagnostic indicator. How did fluting change, and why did point makers eventually abandon fluting? In this article, we use traditional 2D measurements, geometric morphometric (GM) analysis of 3D models, and 2D GM of flute cross sections to compare Clovis and Dalton point flute and basal morphologies. The significant differences observed show that fluting in Clovis was highly standardized, suggesting that fluting may have functioned to improve projectile durability. Because Dalton points were used increasingly as knives and other types of tools, maximizing projectile functionality became less important. We propose that fluting in Dalton is a vestigial technological trait retained beyond its original functional usefulness.

Mental health problems often begin in early childhood. However, the associations of various individual and contextual risk factors with mental health in the preschool period are incompletely understood, particularly in low- to middle-income countries (LMICs) where multiple risk factors co-exist. To address this gap, we prospectively followed 981 children in a South African birth cohort, the Drakenstein Child Health Study, assessing pre-and postnatal exposures and risk factors. The predictive value of these factors for child mental health (assessed by the Child Behavior Checklist) was modeled using structural equation modeling. We identified two key pathways to greater externalizing behavior: (1) prenatal exposure to substances (alcohol and smoking) directly predicted increased externalizing behavior (β = 0.24, p < 0.001); this relationship was partially mediated by an aspect of infant temperament (negative emotionality; β = 0.05, p = 0.016); (2) lower socioeconomic status and associated maternal prenatal depression predicted more coercive parenting, which in turn predicted increased externalizing behavior (β = 0.18, p = 0.001). Findings in this high-risk LMIC cohort cohere with research from higher income contexts, and indicate the need to introduce integrated screening and intervention strategies for maternal prenatal substance use and depression, and promoting positive parenting across the preschool period.

In October 2019, public health surveillance systems in Scotland identified an increase in the number of reported infections of Shiga toxin-producing Escherichia coli (STEC) O26:H11 involving bloody diarrhoea. Ultimately, across the United Kingdom (UK) 32 cases of STEC O26:H11 stx1a were identified, with the median age of 27 years and 64% were male; six cases were hospitalised. Among food exposures there was an association with consuming pre-packed sandwiches purchased at outlets belonging to a national food chain franchise (food outlet A) [odds ratio (OR) = 183.89, P < 0.001]. The common ingredient identified as a component of the majority of the sandwiches sold at food outlet A was a mixed salad of Apollo and Iceberg lettuce and spinach leaves. Microbiological testing of food and environmental samples were negative for STEC O26:H11, although STEC O36:H19 was isolated from a mixed salad sample taken from premises owned by food outlet A. Contamination of fresh produce is often due to a transient event and detection of the aetiological agent in food that has a short-shelf life is challenging. Robust, statistically significant epidemiological analysis should be sufficient evidence to direct timely and targeted on-farm investigations. A shift in focus from testing the microbiological quality of the produce to investigating the processes and practices through the supply chain and sampling the farm environment is recommended.

Background: The Ohio State University Wexner Medical Center identified a cluster of coronavirus disease 2019 (COVID-19) cases on an inpatient geriatric stroke care unit involving both patients and staff. The period of suspected severe acute respiratory coronavirus virus 2 (SARS-CoV-2) transmission and exposure on the unit was December 20, 2020, to January 1, 2021, with some patients and staff developing symptoms and testing positive within the 14 days thereafter. Methods: An epidemiologic investigation was conducted via chart review, staff interviews, and contact tracing to identify potential patient and staff linkages. All staff who worked on the unit were offered testing regardless of the presence of symptoms as well as all patients admitted during the outbreak period. Results: In total, 6 patients likely acquired COVID-19 in the hospital (HCA). An additional 6 patients admitted to the unit during the outbreak period subsequently tested positive but had other possible exposures outside the hospital (Fig. 1). One patient failed to undergo COVID-19 testing on admission but tested positive early in the cluster and is suspected to have contributed to patient to employee transmission. Moreover, 32 employees who worked on the unit in some capacity during this period tested positive, many of whom became symptomatic during their shifts. In addition, 18 employees elected for asymptomatic testing with 3 testing positive; these were included in the total. Some staff also identified potential community exposures. Additionally, staff reported an employee who was working while symptomatic with inconsistent mask use (index employee) early in the outbreak period. The index employee likely contributed to employee transmission but had no direct patient contact. Our epidemiologic investigation ultimately identified 12 employees felt to be linked to transmission based on significant, direct patient care provided to the patients within the outbreak period (Fig. 1). In addition, 3 employees had an exposure outside the hospital indicating likely community transmission. Conclusions: Transmission was felt to be multidirectional and included employee-to-employee, employee-to-patient, and patient-to-employee transmission in the setting of widespread community transmission. Interventions to stop transmission included widespread staff testing, staff auditing regarding temperature and symptom monitoring, and re-education on infection prevention practices. Particular focus was placed on appropriate PPE use including masking and eye protection, hand hygiene, and cleaning and disinfection practices throughout the unit. SARS-CoV-2 admission testing and limited visitation remain important strategies to minimize transmission in the hospital.

Figure 1.

Funding: No

Disclosures: None

Recent models of psychopathology suggest the presence of a general factor capturing the shared variance among all symptoms along with specific psychopathology factors (e.g., internalizing and externalizing). However, few studies have examined predictors that may serve as transdiagnostic risk factors for general psychopathology from early development. In the current study we examine, for the first time, whether observed and parent-reported infant temperament dimensions prospectively predict general psychopathology as well as specific psychopathology dimensions (e.g., internalizing and externalizing) across childhood. In a longitudinal cohort (N = 291), temperament dimensions were assessed at 4 months of age. Psychopathology symptoms were assessed at 7, 9, and 12 years of age. A bifactor model was used to estimate general, internalizing, and externalizing psychopathology factors. Across behavioral observations and parent-reports, higher motor activity in infancy significantly predicted greater general psychopathology in mid to late childhood. Moreover, low positive affect was predictive of the internalizing-specific factor. Other temperament dimensions were not related with any of the psychopathology factors after accounting for the general psychopathology factor. The results of this study suggest that infant motor activity may act as an early indicator of transdiagnostic risk. Our findings inform the etiology of general psychopathology and have implications for the early identification for children at risk for psychopathology.