During the coronavirus disease 2019 pandemic, mathematical modeling has been widely used to understand epidemiological burden, trends, and transmission dynamics, to facilitate policy decisions, and, to a lesser extent, to evaluate infection prevention and control (IPC) measures. This review highlights the added value of using conventional epidemiology and modeling approaches to address the complexity of healthcare-associated infections (HAI) and antimicrobial resistance. It demonstrates how epidemiological surveillance data and modeling can be used to infer transmission dynamics in healthcare settings and to forecast healthcare impact, how modeling can be used to improve the validity of interpretation of epidemiological surveillance data, how modeling can be used to estimate the impact of IPC interventions, and how modeling can be used to guide IPC and antimicrobial treatment and stewardship decision-making. There are several priority areas for expanding the use of modeling in healthcare epidemiology and IPC. Importantly, modeling should be viewed as complementary to conventional healthcare epidemiological approaches, and this requires collaboration and active coordination between IPC, healthcare epidemiology, and mathematical modeling groups.

What explains right-wing radicalization in the United States? Existing research emphasizes demographic changes, economic insecurity, and elite polarization. This paper highlights an additional factor: the impact of foreign wars on society at home. We argue communities that bear the greatest costs of foreign wars are prone to higher rates of right-wing radicalization. To support this claim, we present robust correlations between activity on Parler, a predominantly right-wing social media platform, and fatalities among residents who served in U.S. wars in Iraq and Afghanistan, at both the county and census tract level. The findings contribute to understanding right-wing radicalization in the US in two key respects. First, it examines widespread, nonviolent radical-right activity that, because it is less provocative than protest and violence, has eluded systematic measurement. Second, it highlights that U.S. foreign wars have important implications for domestic politics beyond partisanship and voting, to potentially include radicalization.

Background: Statistically significant decreases in methicillin-resistant Staphylococcus aureus (MRSA) healthcare-associated infections (HAIs) occurred in Veterans Health Administration (VA) facilities from 2007 to 2019 using active surveillance for facility admissions and contact precautions for patients colonized (CPC) or infected (CPI) with MRSA, but the value of these interventions is controversial. Objective: To determine the impact of active surveillance, CPC, and CPI on prevention MRSA HAIs, we conducted a prospective cohort study between July 2020 and June 2022 in all 123 acute-care VA medical facilities. In April 2020, all facilities were given the option to suspend any combination of active surveillance, CPC, or CPI to free up laboratory resources for COVID-19 testing and conserve personal protective equipment. We measured MRSA HAIs (cases per 1,000 patient days) in intensive care units (ICUs) and non-ICUs by the infection control policy. Results: During the analysis period, there were 917,591 admissions, 5,225,174 patient days, and 568 MRSA HAIs. Only 20% of facilities continued all 3 MRSA infection control measures in July 2020, but this rate increased to 57% by June 2022. The MRSA HAI rate for all infection sites in non-ICUs was 0.07 (95% CI, 0.05–0.08) for facilities practicing active surveillance plus CPC plus CPI compared to 0.12 (95% CI, 0.08–0.19; P = .01) for those not practicing any of these strategies, and in ICUs the MRSA HAI rates were 0.20 (95% CI, 0.15–0.26) and 0.65 (95% CI, 0.41–0.98; P < .001) for the respective policies. Similar differences were seen when the analyses were restricted to MRSA bloodstream HAIs. Accounting for monthly COVID-19 admissions to facilities over the analysis period using a negative binomial regression model did not change the relationships between facility policy and MRSA HAI rates in the ICUs or non-ICUs. There was no statistically significant difference in monthly facility urinary catheter-associated infection rates, a nonequivalent dependent variable, in the categories during the analysis period in either ICUs or non-ICUs. Conclusions: In Veterans Affairs medical centers, there were fewer MRSA HAIs when facilities practiced active surveillance and contact precautions for colonized or infected patients during the COVID-19 pandemic. The effect was greater in ICUs than non-ICUs.

Disclosures: None

We explored experiences and perceptions surrounding the Self-Stewardship Time-Out Program (SSTOP) intervention across implementation sites to improve antimicrobial use. Semistructured qualitative interviews were conducted with Antibiotic Stewardship physicians and pharmacists, from which 5 key themes emerged. SSTOP may serve to achieve sustainable promotion of antibiotic use improvements.

In The Early 1920s Two American Companies Battled for the Rights to develop an oil concession in northern Persia: Standard Oil Company of New Jersey (later to become Exxon) and the smaller, but none the less formidable, Sinclair Consolidated Oil Corporation (later to merge into ARCO). American industry was a new variable in the equation, since Russia and Britain had been the primary beneficiaries of concessions granted by the Persian government to outsiders. Ultimately neither company won out—for several reasons. The British did not welcome the new presence and sought to stymie it; the Persian press misunderstood the relationship between business and government in the U.S., leading some Persians into unrealistic expectations; and one of the competitors, Sinclair, became tangled up in scandal.

Effective stewardship strategies such as an “antibiotic timeout” to encourage prescriber reflection on the use of broad-spectrum antibiotics are critical to reduce the threat of multidrug-resistant organisms. We sought to understand the facilitators and barriers of the implementation of the Antibiotic Self-Stewardship Timeout Program (SSTOP), which used a template note integrated into the electronic health record system to guide decision making regarding anti- methicillin-resistant S. aureus (MRSA) therapy after 3 days of hospitalization. We conducted interviews at 10 Veterans’ Affairs medical centers (VAMCs) during the preimplementation period (N = 16 antibiotic stewards) and postimplementation (N = 13 antibiotic stewards) ~12 months after program initiation. Preimplementation interviews focused on current stewardship programs, whereas postimplementation interviews addressed the implementation process and corresponding challenges. We also directly asked about the impact of COVID-19 on stewardship activities at each facility. Interviews were transcribed and analyzed using consensus-based inductive and deductive coding. Codes were iteratively combined into barrier and facilitator groupings. Barriers identified in the preimplementation interviews included challenges with staffing, the difficulties of changing prescribing culture, and academic affiliates (eg, rotating physician trainees). Facilitators included intellectual support (eg, providers who understand the concept of stewardship), facility support, individual strengths of antibiotic stewards (eg, diplomacy, strong relationships with surgeons), and resources such as VA policies mandating stewardship. By the postimplementation phase, all sites reported a high volume of COVID-19 cases. Additional demands were placed on infectious disease providers who comprise the antibiotic stewardship teams, which complicated the implementation of SSTOP. Many barriers and facilitators mentioned were similar to those identified during preimplementation interviews. Staffing problems and specific providers not “getting it [stewardship activities]” continued, whereas facilitators centered around strong institutional support. Specific pandemic-related barriers included slow down or stoppage of stewardship activities including curbing of regular MRSA screening practices, halting weekly stewardship rounds, and delaying stewardship committee planning. Pandemic-specific staffing problems occurred due to the need for “all hands on deck” and challenges with staff working from home, as well as being pulled in multiple directions, (eg, writing COVID-19 policies). Furthermore, an increase in antibiotic use was also reported at sites during COVID-19 surges. Our findings indicate that SSTOP implementation met with barriers at most times; however, pandemic-specific barriers were particularly powerful. Sites with strong staffing resources were better equipped to deal with these challenges. Understanding how the program evolves with subsequent COVID-19 surges will be important to support the broad implementation of SSTOP.

Funding: No

Disclosures: None

Antibiotic prescribing practices across the Veterans’ Health Administration (VA) experienced significant shifts during the coronavirus disease 2019 (COVID-19) pandemic. From 2015 to 2019, antibiotic use between January and May decreased from 638 to 602 days of therapy (DOT) per 1,000 days present (DP), while the corresponding months in 2020 saw antibiotic utilization rise to 628 DOT per 1,000 DP.

Background: Carbapenem-resistant Enterobacteriaceae (CRE) are gram-negative bacteria resistant to at least 1 carbapenem and are associated with high mortality (50%). Carbapenemase-producing CRE (CP-CRE) are particularly serious because they are more likely to transmit carbapenem resistance genes to other gram-negative bacteria and they are resistant to all carbapenem antibiotics. Few studies have evaluated risk factors associated with CP-CRE colonization. The goal of this study was to determine the risk factors associated with CP-CRE colonization in a cohort of US veterans. Methods: We conducted a retrospective cohort study of patients seen at VA medical centers between 2013 and 2018 who had positive cultures for CRE from any site, defined by resistance to at least 1 of the following carbapenems: imipenem, meropenem, doripenem, or ertapenem. CP-CRE was defined via antibiotic sensitivity data that coded the culture as being ‘carbapenemase producing,’ being ‘Hodge test positive,’ or ‘KPC producing.’ Only the first positive culture for CRE was included. Patient demographics (year of culture, age, sex, race, major comorbidities, infectious organism, culture site, inpatient status, and CP-CRE status) and facility demographics (rurality, geographic region, and facility complexity) were collected. Bivariate analysis and multiple logistic regression were performed to determine variables associated with CP-CRE versus non–CP-CRE. Results: In total, 3,322 patients were identified with a positive CRE culture: 546 (16.4%) with CP-CRE and 2,776 (83.63%) with non–CP-CRE. Most patients were men (95%) and were older (mean age, 71; SD, 12.5) and were diagnosed at a high-complexity VA medical center (65%). Most of the cultures were urine (63%), followed by sputum (13%), and blood (7%). Most were from inpatients (46%), followed by outpatients (42%), and long-term care facilities (12%). Multivariable analysis showed the following variables to be associated with CP-CRE positive cultures: congestive heart failure (P = .0136), African American (P = .0760), Klebsiella spp (P < .0001), GI cancers (P = .0087), culture collected in 2017 (P = .0004), and culture collected in 2018 (P < .0001). There were also significant differences CP-CRE frequencies by geographic region (P < .001). Discussion: CP-CRE diagnoses are relatively rare; however, the serious complications associated make them important infections to investigate. In our analysis, we found that congestive heart failure and gastric cancer were comorbidities strongly associated with CP-CRE. In 2017, the VA formalized their CP-CRE definition, which led to more accurate reporting. Conclusions: After the guideline was implemented, CP-CRE detection dramatically increased in noncontinental US facilities. More work should be done in the future to determine the different risk factors between non–CP-CRE and CP-CRE infections.

Funding: None

Disclosures: None

Background: Contamination of healthcare workers and patient environments likely play a role in the spread of antibiotic-resistant organisms. The mechanisms that contribute to the distribution of organisms within and between patient rooms are not well understood, but they may include movement patterns and patient interactions of healthcare workers. We used an innovative technology for tracking healthcare worker movement and patient interactions in ICUs. Methods: The Kinect system, a device developed by Microsoft, was used to detect the location of a person’s hands and head over time, each represented with 3-dimensional coordinates. The Kinects were deployed in 2 intensive care units (ICUs), at 2 different hospitals, and they collected data from 5 rooms in a high-acuity 20-bed cardiovascular ICU (unit 1) and 3 rooms in a 10-bed medical-surgical ICU (unit 2). The length of the Kinect deployment varied by room (range, 15–48 days). The Kinect data were processed to included date, time, and location of head and hands for all individuals. Based on the coordinates of the bed, we defined events indicating bed touch, distance 30 cm (1 foot) from the bed, and distance 1 m (3 feet) from the bed. The processed Kinect data were then used to generate heat maps showing density of person locations within a room and summarizing bed touches and time spent in different locations within the room. Results: The Kinect systems captured In total, 2,090 hours of room occupancy by at least 1 person within ~1 m of the bed (Table 1). Approximately half of the time spent within ~1 m from the bed was at the bedside (within ~30 cm). The estimated number of bed touches per hour when within ~1 m was 13–23. Patients spent more time on one side of the bed, which varied by room and facility (Fig. 1A, 1B). Additionally, we observed temporal variation in intensity measured by person time in the room (Fig. 1C, 1D). Conclusions: High occupancy tends to be on the far side (away from the door) of the patient bed where the computers are, and the bed touch rate is relatively high. These results can be used to help us understand the potential for room contamination, which can contribute to both transmission and infection, and they highlight critical times and locations in the room, with a potential for focused deep cleaning.

Funding: None

Disclosures: None

Background: Between 2007 and 2015, inpatient fluoroquinolone use declined in US Veterans’ Affairs (VA) hospitals. Whether fluoroquinolone use at discharge has also declined, in particular since antibiotic stewardship programs became mandated at VA hospitals in 2014, is unknown. Methods: In this retrospective cohort study of hospitalizations with infection between January 1, 2014, and December 31, 2017, at 125 VA hospitals, we assessed inpatient and discharge fluoroquinolone (ciprofloxacin, levofloxacin, and moxifloxacin) use as (1) proportion of hospitalizations with a fluoroquinolone prescribed and (2) fluoroquinolone days per 1,000 hospitalizations. After adjusting for illness severity, comorbidities, and age, we used multilevel logit and negative binomial models to assess for hospital-level variation and longitudinal prescribing trends. Results: Of 560,219 hospitalizations meeting inclusion criteria as hospitalizations with infection (Fig. 1), 209,602 of 560,219 (37.4%) had a fluoroquinolone prescribed either during hospitalization (182,337 of 560,219, 32.5%) or at discharge (110,003 of 560,219, 19.6%) (Fig. 1). Hospitals varied appreciably in inpatient, discharge, and total fluoroquinolone use, with 71% of hospitals in the highest prescribing quartile located in the southern United States. Nearly all measures of fluoroquinolone use decreased between 2014 and 2017, with the largest decreases found in inpatient fluoroquinolone and ciprofloxacin use (Fig. 2). In contrast, there was minimal decline in fluoroquinolone use at discharge (Fig. 2), which accounted for 1,433 of 2,339 (61.3%) of hospitalization-related fluoroquinolone days by 2017. Between 2014 and 2017, fluoroquinolone use decreased in VA hospitals, largely driven by a decrease in inpatient fluoroquinolone (especially ciprofloxacin) use. Fluoroquinolone prescribing at discharge, and levofloxacin prescribing overall, remain prime targets for stewardship.

Funding: This work was funded by a locally initiated project grant from the Center for Clinical Management Research at the VA Ann Arbor Healthcare System.

Disclosures:Valerie M. Vaughn reports contract research for Blue Cross and Blue Shield of Michigan, the Department of Veterans’ Affairs, the NIH, the SHEA, and the APIC. She also reports fees from the Gordon and Betty Moore Foundation Speaker’s Bureau, the CDC, the Pew Research Trust, Sepsis Alliance, and The Hospital and Health System Association of Pennsylvania.

Disclaimer The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the US government.

A survey of Veterans’ Affairs Medical Centers on control of carbapenem-resistant Enterobacteriaceae (CRE) and carbapenem-producing CRE (CP-CRE) demonstrated that most facilities use VA guidelines but few screen for CRE/CP-CRE colonization regularly or regularly communicate CRE/CP-CRE status at patient transfer. Most respondents were knowledgeable about CRE guidelines but cited lack of adequate resources.