Background: Hand hygiene (HH) is fundamental to preventing the transmission of pathogens between patients. Unfortunately, adherence to HH is suboptimal and monitoring adherence is challenging. Electronic HH monitoring systems (EHHMS) are emerging potential solutions to increase the number of HH observations and eliminate the potential for observation bias. This aim of this study is to assess the impact of improved HH adherence after the introduction of an EHHMS on the rates of healthcare facility-onset multidrug-resistant organisms and Clostridioides difficile (HO-MDRO). Methods: We performed a retrospective, quasi-experimental study to evaluate the impact of HH on HO-MDROs across 4 acute care facilities (59 hospital units, 14 of which were ICUs) from January 2021 - September 2022 after implementing an EHHMS in a large academic healthcare system. Clinical cultures from all sources were included; routine surveillance cultures were not collected during this period. HO determination was made using National Healthcare Safety Network (NHSN) definitions. The association between monthly unit-level HH adherence (%) and HO-MDRO rate per 1000 patient-days was assessed using mixed-effects Poisson regression using rate ratios (RR), which accounts for unobserved heterogeneity between units while controlling for number of tests ordered per month per hospital unit. HH adherence was stratified in quartiles (Q1: 24-43%, Q2: 43-51%, Q3: 52-61%, Q4: 61-84%). Results: During the study period, there were 23 million HH opportunities and 1875 MDROs in 772,930 patient-days. HH adherence increased from 41% January 2021 to 57% September 2022. ESBL, MSSA, and CDIFF accounted for most MDROs (Figure 1). The mean monthly HH adherence rate was 52% per unit, with a median of 1.66 (IQR: 0-3.5) MDROs/1000 patient-days. Mixed-effects Poisson regression suggested no significant overall relationship between HH adherence and MDRO rate (Figure 2). A close to null association was observed when comparing quartile two to quartile one (RR: 0.97, 95% CI: 0.82, 1.15), quartile three to quartile one (RR: 0.96, 95% CI: 0.79, 1.17), and quartile four to quartile one (RR: 1.05, 95% CI: 0.86, 1.28). Results were similar across hospitals (Figure 3). Conclusions: Although implementing an EHHMS led to an improvement in HH adherence, we were not able to demonstrate a resultant decrease in HO-MDROs. Potential explanations include the relatively rare outcomes of interest, unrecognized confounders, and the complex interaction between HH and HO-MDROs, since poor HH adherence on a unit may lead to increased attention from infection prevention and therefore increased focus on other MDRO prevention measures.

Background: The Clinical & Laboratory Standards Institute (CLSI) recommends use of annual antibiograms to help guide empiric antibiotic therapy. Because CLSI periodically updates minimum inhibitory concentration (MIC) breakpoints, we assessed the impact of these updates on longitudinal trends in antibiotic susceptibility rates for Escherichia coli and Klebsiella pneumoniae at a single academic medical center in Atlanta, GA. Methods: Susceptibilities for cefepime, ceftazidime, and levofloxacin in E. coli and K. pneumoniae were extracted from hospital antibiograms from 1988 to 2022. Starting in 1995, intensive care units (ICUs) and wards had separate annual antibiograms, which we combined using weighted averages to create annual overall hospital antibiograms. After summarizing the frequency of isolates tested and susceptibilities using medians and interquartile ranges (IQR), we conducted an interrupted time series analysis using linear segmented regression models, to evaluate the level changes and trends in susceptibility, before and after CLSI MIC breakpoints were updated for ceftazidime (2010 and 2017), cefepime (2014 and 2017), and levofloxacin (2013). Results: Among 21,214 E. coli, there was a median of 291 [IQR: 104, 555] isolates tested annually. Similarly, among 8,686 K. pneumoniae isolates, the median was 125 per year (IQR: 76, 178). Prior to the MIC breakpoint changes, baseline susceptibility trends of both organisms to all 3 antibiotics significantly declined at a rate between 0.2% to 2.4% per year (Table 1). For cefepime (Figure 1), susceptibility decreased annually during 1988 – 2013 for both E. coli (-0.5%) and K. pneumoniae (-1.2%). There were no significant level changes but there were trend changes after 2018, for E. coli (+2.1%) and K. pneumoniae (– 5.5%). For ceftazidime (Figure 2), significant level changes occurred after 2010 for both organisms (E. coli: -5.7%; K. pneumoniae: -5.2%). For levofloxacin (Figure 3), the breakpoint update in 2013 lead to significant level change in susceptibility (E. coli: +8.4%; K. pneumoniae: +11.4%). Conclusion: Overall, we observed a consistent decrease in antibiotic susceptibility in E. coli and K. pneumoniae over three decades, with immediate increases in the level change of susceptibility when MIC breakpoints were changed, followed by a decreasing trend. These findings highlight the importance of longitudinal surveillance and MIC breakpoint changes to inform antimicrobial stewardship strategies.

Research has suggested that childhood-onset conduct problems (CPs) are more strongly related to individual predispositions, whereas adolescent-onset CP is more strongly associated with social factors, such as peer delinquency. Neighborhood disadvantage (ND) increases the risk for associating with deviant peers. Thus, peer delinquency could mediate the relationship between ND and adolescent-onset CP. This mediational hypothesis has not been tested previously. We tested this hypothesis in 1,127 justice-involved adolescent males using self-reported delinquency and official arrest records over 3 years after the youth’s first arrest as outcomes. Predictors were self-reported and census-derived indicators of ND and self-reported peer delinquency. Age of onset moderated the associations between self-reported ND and arrests and between self-report of peer delinquency and arrests. In both cases, the association was stronger for those with adolescent-onset CP. Peer delinquency mediated all relationships between ND and CP. Our results also showed some unexpected differences in associations depending on whether self-reported ND or census-derived indicators were used as predictors. Specifically, census-derived ND was negatively related to self-reported offending, which could be due to the use of an arrested sample and the need for youth in more advantaged neighborhoods to show a more severe pattern of antisocial behavior to be arrested.

Research on proactive and reactive aggression has identified covariates unique to each function of aggression, but hypothesized correlates have often not been tested with consideration of developmental changes in or the overlap between the types of aggression. The present study examines the unique developmental trajectories of proactive and reactive aggression over adolescence and young adulthood and tests these trajectories’ associations with key covariates: callous–unemotional (CU) traits, impulsivity, and internalizing emotions. In a sample of 1,211 justice-involved males (ages 15–22), quadratic growth models (i.e., intercepts, linear slopes, and quadratic slopes) of each type of aggression were regressed onto quadratic growth models of the covariates while controlling for the other type of aggression. After accounting for the level of reactive aggression, the level of proactive aggression was predicted by the level of CU traits. However, change in proactive aggression over time was not related to the change in any covariates. After accounting for proactive aggression, reactive aggression was predicted by impulsivity, both at the initial level and in change over time. Results support that proactive and reactive aggression are unique constructs with separate developmental trajectories and distinct covariates.

Considerable progress continues to be made with regards to the value and use of disease associated polygenic scores (PGS). PGS aim to capture a person’s genetic liability to a condition, disease, or a trait, combining information across many risk variants and incorporating their effect sizes. They are already available for clinicians and consumers to order in Australasia. However, debate is ongoing over the readiness of this information for integration into clinical practice and population health. This position statement provides the viewpoint of the Human Genetics Society of Australasia (HGSA) regarding the clinical application of disease-associated PGS in both individual patients and population health. The statement details how PGS are calculated, highlights their breadth of possible application, and examines their current challenges and limitations. We consider fundamental lessons from Mendelian genetics and their continuing relevance to PGS, while also acknowledging the distinct elements of PGS. Use of PGS in practice should be evidence based, and the evidence for the associated benefit, while rapidly emerging, remains limited. Given that clinicians and consumers can already order PGS, their current limitations and key issues warrant consideration. PGS can be developed for most complex conditions and traits and can be used across multiple clinical settings and for population health. The HGSA’s view is that further evaluation, including regulatory, implementation and health system evaluation are required before PGS can be routinely implemented in the Australasian healthcare system.

Among 353 healthcare personnel in a longitudinal cohort in 4 hospitals in Atlanta, Georgia (May–June 2020), 23 (6.5%) had severe acute respiratory coronavirus virus 2 (SARS-CoV-2) antibodies. Spending >50% of a typical shift at the bedside (OR, 3.4; 95% CI, 1.2–10.5) and black race (OR, 8.4; 95% CI, 2.7–27.4) were associated with SARS-CoV-2 seropositivity.

Background: Through participation in a system-wide healthcare-associated infection-reduction task force, we leveraged our ability to standardize best practices across hospitals in a university-owned healthcare system to reduce central-line–associated bloodstream infection (CLABSI) rates. Methods: Our multidisciplinary team had representation from all hospitals in our healthcare system. The team benchmarked practices in place and compared CLABSI standardized infection ratios (SIRs). One hospital had a robust vascular access team (VAT) and consistently low CLABSI SIRs; expanding and standardizing VAT across the hospitals in the system became the primary goal of the team. We developed a business case to justify VAT expansion that considered savings from decreasing CLABSIs and benefits to interventional radiology revenue by decreasing PICC insertion and comparing costs for added full-time equivalents (FTEs). CLABSI rates before and after VAT team expansion at 2 large hospitals were compared to the hospital with existing robust VAT. Other process improvement activities were implemented across all hospitals. The expanded VAT assumed responsibility for central-line maintenance, promoted removal of unneeded lines, expanded education efforts, and enhanced capacity for insertions. Results: The VAT expansion from 5.4 FTEs to 15.9 FTEs at 2 large hospitals (1,100 total beds) began in April 2017 and was phased over ~6 months. CLABSI SIRs for the 15 months preceding expansion were compared to the SIRs for the 15-month period after expansion for the 2 hospitals with expanded VAT (hospitals A and B) and for hospital C with preexisting robust VAT (Table 1). We observed a 33% decrease in PICC insertions in interventional radiology department in hospitals A and B. Overall return on investment (ROI) estimates using lower and upper cost per CLABSI ranged from a loss of $156,000 to a net gain of $623,000. Conclusions: A significant decrease in CLABSI rates temporally related to expansion of VAT occurred in 2 hospitals, whereas the hospital with existing robust VAT demonstrated a modest decrease in CLABSI rates. We were able to demonstrate a favorable ROI from the VAT expansion without an impact on HAC penalties. Using the model of standardizing best practices across a system and creative ROIs may help justify the addition of scarce resources.

Funding: None

Disclosures: None

Background: The NHSN methods for central-line–associated bloodstream infection (CLABSI) surveillance do not account for additive CLABSI risk of concurrent central lines. Past studies were small and modestly risk adjusted but quantified the risk to be ~2-fold. If the attributable risk is this high, facilities that serve high-acuity patients with medically indicated concurrent central-line use may disproportionally incur CMS payment penalties for having high CLABSI rates. We aimed to build evidence through analysis using improved risk adjustment of a multihospital CLABSI experience to influence NHSN CLABSI protocols to account for risks attributed to concurrent central lines. Methods: In a retrospective cohort of adult patients at 4 hospitals (range, 110–733 beds) from 2012 to 2017, we linked central-line data to patient encounter data (age, comorbidities, total parenteral nutrition, chemotherapy, CLABSI). Analysis was limited to patients with >2 central-line days, with either a single central line or concurrence of no more than 2 central lines where insertion and removal dates overlapped by >1 day. Propensity-score matching for likelihood of concurrence and conditional logistic regression modeling estimated the risk of CLABSI attributed to concurrence of >1 day. To evaluate in Cox proportional hazards regression of time to CLABSIs, we also analyzed patients as unique central-line episodes: low risk (ie, ports, dialysis central lines, or PICC) or high risk (ie, temporary or nontunneled) and single versus concurrent. Results: In total, 64,575 central lines were used in 50,254 encounters. Among these patients, 517 developed a CLABSI; 438 (85%) with a single central line and 74 (15%) with concurrence. Moreover, 4,657 (9%) patients had concurrence (range, 6%–14% by hospital); of these, 74 (2%) had CLABSI, compared to 71 of 7,864 propensity-matched controls (1%). Concurrence patients had a median of 17 NHSN central-line days and 21 total central-line days. In multivariate modeling, patients with more concurrence (>2 of 3 of concurrent central-line days) had an higher risk for CLABSI (adjusted risk ratio, 1.62; 95% CI, 1.1–2.3) compared to controls. In survival analysis, 14,610 concurrent central-line episodes were compared to 31,126 single low-risk central-line episodes; adjusting for comorbidity, total parenteral nutrition, and chemotherapy, the daily excess risk of CLABSI attributable to the concurrent central line was ~80% (hazard ratio 1.78 for 2 high-risk or 2 low-risk central lines; hazard ratio 1.80 for a mix of high- and low-risk central lines) (Fig. 1). Notably, the hazard ratio attributed to a single high-risk line compared to a low-risk line was 1.44 (95% CI, 1.13–1.84). Conclusions: Since a concurrent central line nearly doubles the risk for CLABSI compared to a single low-risk line, the CDC should modify NHSN methodology to better account for this risk.

Funding: None

Disclosures: Scott Fridkin reports that his spouse receives consulting fees from the vaccine industry.

Background: Current NHSN denominator reporting for central-line–associated bloodstream infection (CLABSI) counts each patient day with n central lines as 1 central-line day. The NHSN does not directly adjust for potential increased risk of CLABSI from concurrent central lines, but the current NHSN standardized infection ratio (SIR) methods may account for differences in concurrence by adjusting for location type. Objective: We examined differences in central-line concurrence by NHSN location type among CLABSI patients. Methods: In a retrospective cohort of adults with CLABSI at 4 hospitals from 2012 to 2017, we linked central-line data to encounter and CLABSI data. Central lines were considered concurrent if they overlapped for >1 day. We calculated proportion of patients with concurrence at both NHSN location and SIR group levels; risk ratios for concurrence between NHSN location types within each SIR group (ie,, locations defined by SIR models as equal “risk”) were determined. Results: In total, 930 CLABIs were identified from 19 NHSN-defined locations that map to 7 SIR groups. Most CLABSIs occurred in locations mapped to either of 2 SIR groups: wards (227, 16% concurrence) and ICUs (294, 33% concurrence). The ward group had 3 NHSN locations (median, 78 CLABSIs) with concurrence range 8% (medical-surgical ward) to 20% (surgical ward). The ICU group had 6 NHSN locations (median, 47.5 CLABSIs) and concurrence ranged from 20% (neurosurgical ICU) to 39% (medical ICU). Despite the noted variations, no risk ratio was statistically different within each SIR group (Table 1). Conclusions: In patients with CLABSIs, the frequency of concurrence varied up to 2-fold between location types within the current NHSN SIR groups, though not statistically significantly. Assessing whether this difference in magnitude persists in all patients with central lines is an important next step in refining risk adjustment methods to account for concurrent central-line use.

Funding: None

Disclosures: Scott Fridkin reports that his spouse receives consulting fees from the vaccine industry.

The current study advanced research on the link between community violence exposure and aggression by comparing the effects of violence exposure on different functions of aggression and by testing four potential (i.e., callous–unemotional traits, consideration of others, impulse control, and anxiety) mediators of this relationship. Analyses were conducted in an ethnically/racially diverse sample of 1,216 male first-time juvenile offenders (M = 15.30 years, SD = 1.29). Our results indicated that violence exposure had direct effects on both proactive and reactive aggression 18 months later. The predictive link of violence exposure to proactive aggression was no longer significant after controlling for proactive aggression at baseline and the overlap with reactive aggression. In contrast, violence exposure predicted later reactive aggression even after controlling for baseline reactive aggression and the overlap with proactive aggression. Mediation analyses of the association between violence exposure and reactive aggression indicated indirect effects through all potential mediators, but the strongest indirect effect was through impulse control. The findings help to advance knowledge on the consequences of community violence exposure on justice-involved youth.

We propose that the kelps (Laminariales) radiated in the North Pacific following the onset of late Cenozoic polar cooling. The evidence is that (1) extant kelps occur exclusively in cold-water habitats; (2) all but one of 27 kelp genera occur in the North Pacific, 19 of these exclusively; and (3) limpets and herbivorous marine mammals obligately associated with kelps or other stipitate brown algae appeared late in the Cenozoic, even though more generalized forms of both groups are much older. We propose, further, that sea otters and perhaps other groups of benthic-feeding predatory mammals, whose late Cenozoic distributions all were limited to the North Pacific, created an environment for the evolution of kelps in which the intensity of herbivory was unusually low. We hypothesize that this interaction created predictable differences among habitats in the intensity of herbivory on several spatial scales, with resulting trade-offs between anti-herbivore defenses and plant competitive abilities in their respective floras. Sea otters incur time and energy costs for diving, resulting in depth-related reductions to foraging efficiency and thus increased sizes and densities of herbivorous sea urchins. Thus, the deep-water flora is well defended, but competitively subordinate, compared with the shallow-water flora. Similarly, we argue that during the same period of earth history, predation had less of a limiting influence on herbivorous invertebrates in the temperate southwestern Pacific. We hypothesize that (1) consequent biogeographical differences in the intensity of herbivory may have selected the phenolic-rich brown algal flora in temperate Australia/New Zealand; and (2) tightly coevolved plant/herbivore interactions may explain why Australian and New Zealand herbivores are undeterred by phenolics and why other classes of secondary compounds in the Australian/New Zealand flora significantly deter herbivores.

The viability of freshwater turtle populations is largely dependent on the survivorship of reproducing females but females are frequently killed on roads as they move to nesting sites. Installing artificial nesting mounds may increase recruitment and decrease the risk of mortality for gravid females by enticing them to nest closer to aquatic habitats. We evaluated the effectiveness of artificial nesting mounds installed in Algonquin Park, Canada. Artificial mounds were monitored for 2 years to determine if turtles would select them for nest sites. We also simulated turtle paths from wetlands to nests to determine the probability that females would encounter the new habitat. A transplant experiment with clutches of Chrysemys picta and Chelydra serpentina eggs compared nest success and incubation conditions in the absence of predation between artificial mounds and natural sites. More turtles than expected used the artificial mounds, although mounds comprised a small proportion of the available nesting habitat and the simulations predicted that the probability of females encountering mounds was low. Hatching success was higher in nests transplanted to artificial mounds (93%) than in natural nests (56%), despite no differences in heat units. Greater use than expected, high hatching success, and healthy hatchlings emerging from nests in artificial mounds suggest promise for their use as conservation tools.