Background: To estimate hand hygiene compliance using electronic hand hygiene monitoring, the number of hand hygiene opportunities (HHOs) per period must be known in a given setting. Data on the number of HHOs in a neonatal ICU (NICU) are limited. We measured HHOs per hour and identified factors that may influence the number of HHOs per hour to calibrate compliance estimates for electronic hand hygiene monitoring. Methods: The study was conducted in 2 large NICUs in Ontario, Canada (72 and 42 beds, respectively). We centrally trained observers to identify HHOs using the Ontario-based “Four Moments of Hand Hygiene,” which is similar to combining moments 4 and 5 of the WHO “Five Moments of Hand Hygiene.” To apply the moments of hand hygiene to the NICU setting, the following modifications were made: moment 1 was entering the incubator or contact with anything within the ‘baby space’ directly around the incubator, and moment 4 was when hands exited the incubator and, as such, the ‘baby space.’ Using a standardized tool, the investigators conducted direct observation of HHOs during randomized observation periods from July 1, 2022, to January 9, 2023. In addition to HHOs, data on covariables potentially associated with the frequency of HHOs were collected: time and day of the week, acuity, additional precautions, corrected gestational age, and private versus multibed room or open pod. Results: We audited HHOs for 146 hours including 26 at site A and 120 at site B. Overall, 804 HHOs (69.2%) occurred during weekdays and 739 (63.6%) occurred during day shifts from 7:00 a.m. to7:00 p.m. The most frequent moments of hand hygiene were moment 1 (47.8%, before contact) and moment 4 (36.8%, after contact). The average numbers of HHOs were 7.8 per hour overall, 7.6 per hour on weekdays, 7.7 per hour on weekends, 8.8 per hour on day shifts, and 6.8 per hour on night shifts. The breakdown of HHOs by profession was 92.8% nurses, 0.6% physicians, 4.5% allied health, and 2.1% for others. Discussion: The rate of HHOs in NICU varied over a 24-hour period and was similar between 2 different NICUs. Evenings and weekends had considerably fewer average HHOs, and peaks were observed following nursing shift changes. The rate of HHOs may be influenced by other factors including unit design, patient acuity, and use of transmission-based precautions. Further analysis using a Poisson regression model will help to explore these factors and to calibrate electronic monitoring for this population.

Disclosures: None

In this prospective study, universal admission testing for severe acute respiratory coronavirus virus 2 (SARS-CoV-2) averted transmission in shared patient rooms especially since the emergence of the SARS-CoV-2 omicron variant when the yield in identifying infectious asymptomatic cases more than doubled. This change may be due to the higher rate of asymptomatic infection with the omicron variant, the broader community prevalence during the omicron era, or both.

A policy mandating the completion of an online learning module for healthcare workers intending to decline influenza immunization was associated with a nearly 25% relative increase in immunization and significant reduction in healthcare-associated influenza. In the absence of mandatory vaccination, this model may help to augment severe acute respiratory coronavirus virus 2 (SARS-CoV-2) vaccine efforts.

Background: Bloodstream infections (BSIs) due to methicillin-resistant Staphylococcus aureus (MRSA) are important causes of morbidity and mortality in hospitalized patients. Long-term national MRSA BSI surveillance establishes rates for internal and external comparison and provide insight into epidemiologic, molecular, and resistance trends. Here, we present and discuss National MRSA BSI incidence rates and trends over time in Canadian acute-care hospitals from 2008 to 2018. Methods: The Canadian Nosocomial Infection Surveillance Programme (CNISP) is a collaborative effort of the Association of Medical Microbiology and Infectious Disease Canada and the Public Health Agency of Canada. Since 1995, the CNISP has conducted hospital-based sentinel surveillance of MRSA BSIs. Data were collected using standardized definitions and forms from hospitals that participate in the CNISP (48 hospitals in 2008 to 62 hospitals in 2018). For each MRSA BSI identified, the medical record was reviewed for clinical and demographic information and when possible, 1 blood-culture isolate per patient was submitted to a central laboratory for further molecular characterization and susceptibility testing. Results: From 2008 to 2013, MRSA BSI rates per 10,000 patient days were relatively stable (0.60–0.56). Since 2014, MRSA BSI rates have gradually increased from 0.66 to 1.05 in 2018. Although healthcare-associated (HA) MRSA BSI has shown a minimal increase (0.40 in 2014 to 0.51 in 2018), community-acquired (CA) MRSA BSI has increased by 150%, from 0.20 in 2014 to 0.50 in 2018 (Fig. 1). Laboratory characterization revealed that the proportion of isolates identified as CMRSA 2 (USA 100) decreased each year, from 39% in 2015 to 28% in 2018, while CMRSA 10 (USA 300) has increased from 41% to 47%. Susceptibility testing shows a decrease in clindamycin resistance from 82% in 2013 to 41% in 2018. Conclusions: Over the last decade, ongoing prospective MRSA BSI surveillance has shown relatively stable HA-MRSA rates, while CA-MRSA BSI rates have risen substantially. The proportion of isolates most commonly associated with HA-MRSA BSI (CMRSA2/USA 100) are decreasing and, given that resistance trends are tied to the prevalence of specific epidemic types, a large decrease in clindamycin resistance has been observed. MRSA BSI surveillance has shown a changing pattern in the epidemiology and laboratory characterization of MRSA BSI. The addition of hospitals in later years that may have had higher rates of CA-MRSA BSI could be a confounding factor. Continued comprehensive national surveillance will provide valuable information to address the challenges of infection prevention and control of MRSA BSI in hospitals.

Funding: None

Disclosures: None

Background:Candida auris is an emerging pathogen that has recently disseminated globally and caused challenging outbreaks in healthcare facilities (HCFs), in part because it is commonly multidrug-resistant. Candida auris remains rare in Canada, with ~20 known cases to date. We describe the emergence of a novel subclade of C. auris in Ontario, Canada, using whole-genome sequencing (WGS). Methods: In Ontario, many HCFs submit yeast isolates from sterile sites requiring species-level characterization and antifungal susceptibility testing (AFST) to the provincial reference laboratory. Yeasts were identified using a combination of standard methods (morphology, API 20C, MALDI-ToF MS) including ITS2 sequencing. Sensititre YO9 panels were used for AFST. Genomic analysis of C. auris was performed using an Illumina HiSeq platform with at least 50× coverage; variants were called against the reference genome by using the previously published North Arizona SNP pipeline (NASP). Phylogenetic trees were produced by maximum parsimony method (MEGA7.0). Results: Between 2014 and 2018, yeast isolates from 5 different patients from 4 HCFs in the same region of Ontario were confirmed to be C. auris by ITS2 PCR and sequence analysis (Table 1). Based on interim CDC criteria for antifungal drug break points, all isolates were pansusceptible to common antifungals. WGS analysis demonstrated that the C. auris isolates were part of the South American clade (IV) and formed an isolated subclade that is well supported by bootstrap analysis, indicating clonal relationships among these isolates (Fig. 1). Conclusions: Although C. auris isolates are usually drug resistant, all 5 initial Ontario isolates were pansusceptible. WGS determined that these isolates clustered within clade IV and were clonal. This cluster of C. auris appears to represent a new subclade of the South American clade that has been transmitted among patients within a region of Ontario. C. auris may have been present in Ontario for some time, escaping earlier detection due to lack of screening programs in HCFs, historical challenges with microbiologic detection of C. auris, and the antifungal susceptibility of the circulating isolates. Investigations are underway to determine clinical features and epidemiologic relatedness among patients in this cluster.

Funding: None

Disclosures: Susy Hota, Contracted Research - Finch Therapeutics

Background: The association between antimicrobial use (AMU) and emergence of antimicrobial resistance is well documented. The Canadian Nosocomial Infection Surveillance Program (CNISP) has conducted sentinel surveillance of AMU at participating Canadian hospitals since 2009 resulting in the largest pan-Canadian hospital database of dispensed antimicrobials. Objectives: Describe interhospital variability of AMU across Canada. Methods: Hospitals submit annual AMU data based on patient days (PD). Antimicrobials were measured in defined daily doses (DDD) for adults using the WHO Anatomical Therapeutic Chemical (ATC) system. The AMU data among pediatric patients have been available since 2017 using days of therapy (DOT). Surveillance includes systemic antibacterial agents (J01 ATC codes), oral metronidazole, and oral vancomycin. AMU was assessed using quintiles, interquartile ranges (IQR), and relative IQRs (upper- and lower-quartile values divided by the median). Results: Between 2009 and 2018, 20–26 hospitals participated in adult surveillance each year (35 teaching hospitals and 3 nonteaching hospitals participated in ≥1 year). Over this period, overall AMU decreased by 13% at participating adult hospitals from 645 to 560 DDD per 1,000 PD. AMU varied substantially between hospitals, but this variability decreased over time (Fig. 1). In 2009, the IQRs for overall AMU spanned 309 DDD per 1,000 PD, and in 2018 it spanned only 103 DDD per 1,000 PD. This decrease in variability was due to large decreases in use among hospitals with high use in 2009–2010. Among hospitals in the highest use quintile in 2009–2010, AMU decreased, on average, 44 DDD per 1,000 PD each year. Among hospitals in the lowest use quintile in 2009–2010, AMU increased, on average, 6 DDD per 1,000 PD each year. In 2018, antibiotics with the largest absolute IQR variability were cefazolin (61–113 DDD per 1,000 PD), piperacillin-tazobactam (32–64 DDD per 1,000 PD), and vancomycin (24–49 DDD per 1,000 PD). Among antibiotics with ≥1 DDD per 1,000 PD, antibiotics with the largest relative IQR variability were tobramycin (0.3–6 DDD per 1,000 PD), cefadroxil (0.08–9 DDD per 1,000 PD), and linezolid (0.2–3 DDD per 1,000 PD). In 2018, the IQR for overall pediatric AMU (n = 7 teaching hospitals) was 426–581 DOT per 1,000 PD. Antibiotics with the largest IQRs were vancomycin (0.6–58 DOT per 1,000 PD), cefazolin (33–88 DOT per 1,000 PD), and tobramycin (3–57 DOT per 1,000 PD). Among antibiotics with ≥1 DOT per 1,000 PD in 2018, antibiotics with the largest relative IQRs were tobramycin (3–57 DOT per 1,000 PD), cefuroxime (1–6 DOT per 1,000 PD), and amoxicillin (8–42 DOT per 1,000 PD). Conclusions: There is wide variation in overall antibiotic use across hospitals. Variation between AMU at adult hospitals has decreased between 2009 and 2018; in 2018, antibiotics with the largest IQRs were cefazolin and piperacillin-tazobactam. Benchmarking AMU is crucial for informing antimicrobial stewardship efforts.

Funding: CNISP is funded by the Public Health Agency of Canada.

Disclosures: Allison McGeer reports funds to her institution from Pfizer and Merck for projects for which she is the principal investigator. She also reports consulting fees from Sanofi-Pasteur, Sunovion, GSK, Pfizer, and Cidara.

Background: Carbapenemase-producing Enterobacterales (CPE) have rapidly become a global health concern and are associated with substantial morbidity and mortality due to limited treatment options. Travel to endemic areas, especially healthcare exposure in these areas, is an important risk factor for acquisition. We describe the evolving epidemiology, molecular features, and outcomes of CPE in Canada through surveillance by the Canadian Nosocomial Infection Surveillance Program (CNISP). Methods: CNISP has conducted surveillance for CPE among inpatients and outpatients of all ages since 2010. Participating acute-care facilities submit eligible specimens to the National Microbiology Laboratory for detection of carbapenemase production, and epidemiological data are collected. Incidence rates per 10,000 patient days are calculated based on inpatient data. Results: In total, 59 CNISP hospitals in 10 Canadian provinces representing 21,789 beds and 6,785,013 patient days participated in this surveillance. From 2010 to 2018, 118 (26%) CPE-infected and 547 (74%) CPE-colonized patients were identified. Few pediatric cases were identified (n = 18). Infection incidence rates remain low and stable (0.02 per 10,000 patient days in 2010 to 0.03 per 10,000 patient days in 2018), and colonization incidence rates have increased by 89% over the surveillance period. Overall, 92% of cases were acquired in a healthcare facility: 61% (n = 278) in a Canadian healthcare facility and 31% (n = 142) in a healthcare facility outside Canada. Of the 8% of cases not acquired in a healthcare facility, 50% (16 of 32) reported travel outside of Canada in the 12 months prior to positive culture. The distribution of carbapenemases varied by region; New Delhi metallo-B-lactamase (NDM) was dominant (59%) in western Canada and Klebsiella pneumoniae carbapenemase (KPC) (66%) in central Canada. NDM and class D carbapenemase OXA-48 were more commonly identified among those who traveled outside of Canada, whereas KPC was more commonly identified among patients without travel. In addition, 30-day all-cause mortality was 14% (25 of 181) among CPE infected patients and 32% (14 of 44) among those with bacteremia. Conclusions: CPE rates remain low in Canada; however, national surveillance data suggest that the increase in CPE in Canada is now being driven by local nosocomial transmission as well as travel and healthcare within endemic areas. Changes in screening practices may have contributed to the increase in colonizations; however, these data are currently lacking and will be collected moving forward. These data highlight the need to intensify surveillance and coordinate infection control measures to prevent further spread of CPE in Canadian acute-care hospitals.

Funding: None

Disclosures: Susy Hota reports contracted research for Finch Therapeutics. Allison McGeer reports funds to her institution for projects for which she is the principal investigator from Pfizer and Merck, as well as consulting fees from the following companies: Sanofi-Pasteur, Sunovion, GSK, Pfizer, and Cidara.

Background: The current approach to measuring hand hygiene (HH) relies on human auditors who capture <1% of HH opportunities and rapidly become recognized by staff, resulting in inflation in performance. Our goal was to assess the impact of group electronic monitoring coupled with unit-led quality improvement on HH performance and prevention of healthcare-associated transmission and infection. Methods: A stepped-wedge cluster randomized quality improvement study was undertaken across 5 acute-care hospitals in Ontario, Canada. Overall, 746 inpatient beds were electronically monitored across 26 inpatient medical and surgical units. Daily HH performance as measured by group electronic monitoring was reported to inpatient units who discussed results to guide unit-led improvement strategies. The primary outcome was monthly HH adherence (%) between baseline and intervention. Secondary outcomes included transmission of antibiotic resistant organisms such as methicillin resistant Staphylococcus aureus (MRSA) and other healthcare-associated infections. Results: After adjusting for the correlation within inpatient units, there was a significant overall improvement in HH adherence associated with the intervention (IRR, 1.73; 95% CI, 1.47–1.99; P < .0001). Monthly HH adherence relative to the intervention increased from 29% (1,395,450 of 4,544,144) to 37% (598,035 of 1,536,643) within 1 month, followed by consecutive incremental increases up to 53% (804,108 of 1,515,537) by 10 months (P < .0001). We identified a trend toward reduced healthcare-associated transmission of MRSA (0.74; 95% CI, 0.53–1.04; P = .08). Conclusions: The introduction of a system for group electronic monitoring led to rapid, significant, and sustained improvements in HH performance within a 2-year period.

Funding: None

Disclosures: None

Objective: We investigated whether whole-genome sequencing (WGS) data altered interpretations of clonal transmission as determined by conventional epidemiology and pulsed-field gel electrophoresis (PFGE) at a tertiary-care hospital (hospital Z, HZ). Methods: We included all carbapenemase-producing Enterobacterales (CPE)–colonized or –infected patients identified via population-based surveillance from 2007 through 2018, who were admitted to HZ during and/or in the year prior to or following CPE detection. HZ reported clonal transmission clusters using epidemiology and PFGE for CPE identified at HZ or reported to HZ by other hospitals as potentially acquired at HZ. We assessed single-nucleotide polymorphism (SNP) phylogenies and case epidemiology. Results: Overall, 85 CPE-colonized or -infected patients were included: 50 were detected at HZ and 35 were detected at another local hospital but were admitted to HZ in the previous or following year. HZ reported 6 transmission clusters (Table 1). SNP analyses confirmed clusters B, C, E, and F. In cluster A, SNP analyses cast doubt on 2 of 9 cases (possibly representing plasmid transmission) but also identified 2 additional cases with isolates highly related (0–3 SNP differences) to other isolates. One case may be the index case: a travel-related case who stayed on the same unit as case 1, 4 months before case 1 detection. The second case stayed in a room previously occupied by 5 cluster A cases. In cluster D, SNP analyses found 1 additional case whose isolate was highly related (ie, 17–19 SNP differences) to other isolates. This case was identified a year before cluster D at another hospital that shares patients with HZ; however, the case’s admission to HZ was after all cluster D cases were detected and no direct epidemiologic link was identified. Conclusions: WGS data can identify cases belonging to transmission clusters that conventional epidemiologic methods missed.

Funding: None

Disclosures: Allison McGeer reports funds to her institution from Pfizer and Merck for projects for which she is the principal investigator. She also reports consulting fees from Sanofi-Pasteur, Sunovion, GSK, Pfizer, and Cidara

Background: Annual influenza immunization of healthcare workers (HCWs) is widely recommended to reduce the risk of healthcare-associated influenza (HAI). Although there is a clear association between higher HCW immunization and reduced incidence of HAI, data in acute care are lacking compared to the nursing home setting. Objective: Our goal was to assess the association between HCW influenza immunization and the incidence of HAI across 2 acute-care facilities. Methods: A multicenter prospective cohort study was undertaken at 2 acute-care hospitals including 1 university and 1 community-based academic hospital. Any patient prospectively identified with HAI was included between 2013–2014 and 2018–2019, whereas 2017–2018 was excluded due to vaccine mismatch. The HCW influenza immunization rate was defined as the proportion of HCWs (nurses and other allied and support staff but excluding physicians) immunized prior to December 15. A case of HAI was defined as laboratory-confirmed influenza A or B with symptom onset >72 hours after admission. The association between inpatient ward HCW influenza immunization rate and the incidence of HAI was compared using a Poisson regression analysis adjusting for hospital and influenza season. Results: Over 5 influenza seasons, the incidences of HAI at either facility were 0.24 and 0.22 per 1,000 patient days, whereas the median HCW influenza immunization rates were 57.3% (IQR, 42.5%–66.4%) and 66.6% (IQR, 50.6%–76.8%), respectively. When adjusting for hospital and influenza season in the multivariate analysis, HCW influenza immunization rates of 65% and 70% were not associated with HAI incidence. In contrast, HCW influenza immunization rates ≥75% was associated with a trend toward reduced HAI (IRR, 0.65; 95% CI, 0.39–1.08; P = .096) whereas inpatient wards above 80% immunization had significantly lower risk of HAI (IRR, 0.28; 95% CI, 0.089–0.89; P = .03). Conclusions: The risk of HAI across 2 acute-care hospitals was significantly lower among inpatient wards achieving HCW influenza immunization rates >80%. Acute-care facilities should aim for this minimum HCW immunization rate to protect patients from the complications of HAI.

Funding: None

Disclosures: None