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Undetected infection with SARS-CoV-2, the virus that causes coronavirus disease 2019 (COVID-19) contributes to transmission in nursing homes, settings where large outbreaks with high resident mortality have occurred (1,2). Facility-wide testing of residents and health care personnel (HCP) can identify asymptomatic and presymptomatic infections and facilitate infection prevention and control interventions (3-5). Seven state or local health departments conducted initial facility-wide testing of residents and staff members in 288 nursing homes during March 24-June 14, 2020. Two of the seven health departments conducted testing in 195 nursing homes as part of facility-wide testing all nursing homes in their state, which were in low-incidence areas (i.e., the median preceding 14-day cumulative incidence in the surrounding county for each jurisdiction was 19 and 38 cases per 100,000 persons); 125 of the 195 nursing homes had not reported any COVID-19 cases before the testing. Ninety-five of 22,977 (0.4%) persons tested in 29 (23%) of these 125 facilities had positive SARS-CoV-2 test results. The other five health departments targeted facility-wide testing to 93 nursing homes, where 13,443 persons were tested, and 1,619 (12%) had positive SARS-CoV-2 test results. In regression analyses among 88 of these nursing homes with a documented case before facility-wide testing occurred, each additional day between identification of the first case and completion of facility-wide testing was associated with identification of 1.3 additional cases. Among 62 facilities that could differentiate results by resident and HCP status, an estimated 1.3 HCP cases were identified for every three resident cases. Performing facility-wide testing immediately after identification of a case commonly identifies additional unrecognized cases and, therefore, might maximize the benefits of infection prevention and control interventions. In contrast, facility-wide testing in low-incidence areas without a case has a lower proportion of test positivity; strategies are needed to further optimize testing in these settings.

It has been hoped that rapid SARS-CoV-2 antigen testing could reduce the tragic toll of COVID-19 in nursing homes. The performance of the BinaxNOW antigen test in a nursing home during an ongoing SARS-CoV-2 outbreak was evaluated., Visual Abstract. Serial SARS-CoV-2 Rapid Antigen Testing During a Nursing Home Outbreak. It has been hoped that rapid SARS-CoV-2 antigen testing could reduce the tragic toll of COVID-19 in nursing homes. The performance of the BinaxNOW antigen test in a nursing home during an ongoing SARS-CoV-2 outbreak was evaluated., Background: To address high COVID-19 burden in U.S. nursing homes, rapid SARS-CoV-2 antigen tests have been widely distributed in those facilities. However, performance data are lacking, especially in asymptomatic people. Objective: To evaluate the performance of SARS-CoV-2 antigen testing when used for facility-wide testing during a nursing home outbreak. Design: A prospective evaluation involving 3 facility-wide rounds of testing where paired respiratory specimens were collected to evaluate the performance of the BinaxNOW antigen test compared with virus culture and real-time reverse transcription polymerase chain reaction (RT-PCR). Early and late infection were defined using changes in RT-PCR cycle threshold values and prior test results. Setting: A nursing home with an ongoing SARS-CoV-2 outbreak. Participants: 532 paired specimens collected from 234 available residents and staff. Measurements: Percentage of positive agreement (PPA) and percentage of negative agreement (PNA) for BinaxNOW compared with RT-PCR and virus culture. Results: BinaxNOW PPA with virus culture, used for detection of replication-competent virus, was 95%. However, the overall PPA of antigen testing with RT-PCR was 69%, and PNA was 98%. When only the first positive test result was analyzed for each participant, PPA of antigen testing with RT-PCR was 82% among 45 symptomatic people and 52% among 343 asymptomatic people. Compared with RT-PCR and virus culture, the BinaxNOW test performed well in early infection (86% and 95%, respectively) and poorly in late infection (51% and no recovered virus, respectively). Limitation: Accurate symptom ascertainment was challenging in nursing home residents; test performance may not be representative of testing done by nonlaboratory staff. Conclusion: Despite lower positive agreement compared with RT-PCR, antigen test positivity had higher agreement with shedding of replication-competent virus. These results suggest that antigen testing could be a useful tool to rapidly identify contagious people at risk for transmitting SARS-CoV-2 during nascent outbreaks and help reduce COVID-19 burden in nursing homes. Primary Funding Source: None.

Background Background. Understanding the viral load and potential infectivity of individuals in nursing homes (NH) with repeat positive SARS-CoV-2 tests ≥ 90 days after initial infection has important implications for safety related to transmission in this high-risk setting. Methods Methods. We collected epidemiologic data by reviewing records of a convenience sample of NH residents and staff with respiratory specimens who had positive SARS-CoV-2 rRT-PCR test results from July 2020 through March 2021 and had a SARS-CoV-2 infection diagnosed ≥ 90 days prior. No fully vaccinated individuals were included. Each contributed one repeat positive specimen ≥ 90 days after initial, which was sent to CDC and retested using rRT-PCR. Specimens were assessed for replication-competent virus in cell culture if Cycle threshold (Ct) < 34 and sequenced if Ct < 30. Using Ct values as a proxy for viral RNA load, specimens were categorized as high (Ct < 30) or low (if Ct ≥ 30 or rRT-PCR negative at retesting). Continuous variables were compared using Wilcoxon signed-rank tests. Proportions were compared using Chi-squared or Fisher’s exact tests. Results Results. Of 64 unvaccinated individuals with specimens from 61 unique NHs, 14 (22%) were sent for culture and sequencing. Ten of 64 (16%) had a high viral RNA load, of which four (6%) were culture positive and none were known variants of interest or concern (Figure 1). Median days to repeat positive test result were 122 (Interquartile range (IQR): 103–229) and 201 (IQR: 139–254), respectively, for high versus low viral load specimens (p=0.13). More individuals with high viral loads (5/10, 50%) reported COVID-19 symptoms than with a low viral load (1/27, 4%, p=0.003). Most individuals (46/58, 79%) were tested following known or suspected exposures, with no significant differences between high and low viral load (p=0.18). Conclusion In this study, nearly 1 in 6 NH residents and staff with repeat positive tests after 90 days demonstrated high viral RNA loads and viable virus, indicating possible infectivity. While individuals with high RNA viral load may be more likely to be symptomatic, distinguishing asymptomatic individuals who have high viral loads may be difficult with timing since initial infection, other test results, or exposure history alone. Disclosures John A. Jernigan, MD, MS, Nothing to disclose.

Background Community-onset urinary tract infections (coUTIs) are one of the most common indications for antibiotic prescribing. It is important to understand patient demographic factors associated with microorganisms causing coUTI and their antibiotic resistance profiles, to tailor antibiotic prescribing practices. We analyzed microbiology data to understand factors associated with coUTI in the United States (US). Methods CoUTIs were identified in the Premier Healthcare Database and Cerner Health Facts among patients treated at participating healthcare facilities in the US between 2012-2017. Cases were defined by urine cultures yielding a bacterial organism and were collected in outpatient settings or within three days of hospitalization. Only the first specimen for each encounter was included in the analysis. Data on the organisms isolated, patient’s age, sex, and US census regions of the submitting facilities were described and compared using chi-square tests for associations. Encounters were classified as inpatient (INPT), observation (OBS), emergency department (ED), and outpatient (OTPT) based on the setting in which the culture was submitted. Results Using data from 637 acute care hospitals, urine samples from 3,291,561 encounters were included, with 776,653 (25.7%) INPT, 1,063,219 (34.8%) ED, 107,760 (3.5%) OBS, and 1,092,658 (35.8%) OTPT. The pathogens most frequently associated with coUTIs were Escherichia coli (57.3%), Klebsiella pneumoniae (9.7%), Enterococcus faecalis (5.1%), Proteus mirabilis (4.9%), and Pseudomonas aeruginosa (2.9%). Female sex, age < 65y and OTPT and ED settings were associated with higher relative frequency of E. coli (all p < 0.0001). Male sex, INPT setting and age >65 y were associated with higher relative frequency of P. aeruginosa, P. mirabilis and E. faecalis (all p < 0.0001, Figure). K. pneumoniae was found at higher relative frequency in those >45y, and in INPT and OBS settings (all p < 0.0001). Figure. Distribution of pathogens most frequently associated with community onset urinary tract infections Conclusion Understanding patient factors associated with the microbiology of coUTIs is an important step in developing treatment recommendations and antibiotic stewardship efforts. Further analyses will include assessing the impact of major antibiotic resistance phenotypes, geographic and healthcare settings. Disclosures All Authors: No reported disclosures

Background Few data suggest that Clostridioides difficile infections (CDIs) detected by toxin enzyme immunoassay (EIA) are more severe and have worse outcomes than those detected by nucleic acid amplification tests (NAATs) only. We compared toxin- positive and NAAT-positive-only CDI across geographically diverse sites. Methods A case was defined as a positive C. difficile test in a person ≥1 year old with no positive tests in the prior 8 weeks. Cases were detected during 2014–2015 by a testing algorithm (specimens initially tested by glutamate dehydrogenase and toxin EIA; if discordant results, specimens were reflexed to NAAT) and classified as toxin positive or NAAT positive only. Medical charts were reviewed. Multivariable logistic regression models were used to compare CDI-related complications, recurrence, and 30-day mortality between the 2 groups. Results Of 4878 cases, 2160 (44.3%) were toxin positive and 2718 (55.7%) were NAAT positive only. More toxin-positive than NAAT-positive-only cases were aged ≥65 years (48.2% vs 38.0%; P < .0001), had ≥3 unformed stools for ≥1 day (43.9% vs 36.6%; P < .0001), and had white blood cell counts ≥15 000 cells/µL (31.4% vs 21.4%; P < .0001). In multivariable analysis, toxin positivity was associated with recurrence (adjusted odds ratio [aOR], 1.89; 95% confidence interval [CI], 1.61–2.23), but not with CDI-related complications (aOR, 0.91; 95% CI, .67–1.23) or 30-day mortality (aOR, 0.95; 95% CI, .73–1.24). Conclusions Toxin-positive CDI is more severe, but there were no differences in adjusted CDI-related complication and mortality rates between toxin-positive and NAAT-positive-only CDI that were detected by an algorithm that utilized an initial glutamate dehydrogenase screening test.

Key Points Question What are the estimated sample sizes needed to adequately power parallel cluster-randomized trials with common health care–associated infection outcomes, and how do the parameters affect these estimates in the field of hospital infection control and antimicrobial stewardship? Findings This cohort study found that large sample sizes were needed to appropriately power cluster-randomized trials in the field of hospital epidemiology, because the outcomes are rare. The expected effectiveness of the intervention and the strength of correlation within a cluster had the greatest association with the estimated sample size. Meaning These findings suggest that better-designed cluster-randomized trials in the field of hospital epidemiology and antimicrobial stewardship that appropriately account for clustering and realistic effect sizes will provide a more reliable evidence base for advancing recommendations and best practices., This study of national rates of health care–associated infections estimates the number of hospitals needed to power parallel cluster-randomized trials of interventions and evaluates how different parameters such as coefficient of variation and expected effect size are associated with the sample size estimates in practice., Importance An important step in designing, executing, and evaluating cluster-randomized trials (CRTs) is understanding the correlation and thus nonindependence that exists among individuals in a cluster. In hospital epidemiology, there is a shortage of CRTs that have published their intraclass correlation coefficient or coefficient of variation (CV), making prospective sample size calculations difficult for investigators. Objectives To estimate the number of hospitals needed to power parallel CRTs of interventions to reduce health care–associated infection outcomes and to demonstrate how different parameters such as CV and expected effect size are associated with the sample size estimates in practice. Design, Setting, and Participants This longitudinal cohort study estimated parameters for sample size calculations using national rates developed by the Centers for Disease Control and Prevention for methicillin-resistant Staphylococcus aureus (MRSA) bacteremia, central-line–associated bloodstream infections (CLABSI), catheter-associated urinary tract infections (CAUTI), and Clostridium difficile infections (CDI) from 2016. For MRSA and vancomycin-resistant enterococci (VRE) acquisition, outcomes were estimated using data from 2012 from the Benefits of Universal Glove and Gown study. Data were collected from June 2017 through September 2018 and analyzed from September 2018 through January 2019. Main Outcomes and Measures Calculated number of clusters needed for adequate power to detect an intervention effect using a 2-group parallel CRT. Results To study an intervention with a 30% decrease in daily rates, 73 total clusters were needed (37 in the intervention group and 36 in the control group) for MRSA bacteremia, 82 for CAUTI, 60 for CLABSI, and 31 for CDI. If a 10% decrease in rates was expected, 768 clusters were needed for MRSA bacteremia, 875 for CAUTI, 631 for CLABSI, and 329 for CDI. For MRSA or VRE acquisition, 50 or 40 total clusters, respectively, were required to observe a 30% decrease, whereas 540 or 426 clusters, respectively, were required to detect a 10% decrease. Conclusions and Relevance This study suggests that large sample sizes are needed to appropriately power parallel CRTs targeting infection prevention outcomes. Sample sizes are most associated with expected effect size and CV of hospital rates.

Background Escherichia coli is a common cause of community-onset (CO) infections, including urinary tract and abdominal infections, and CO sepsis. Fluoroquinolones (FQ) are used in the empiric treatment of E. coli infections, but FQ-resistance may limit their effectiveness. We examined trends and regional differences in FQ-resistant E. coli clinical cultures among hospitalized adult patients in the U.S. Methods We measured the incidence of E. coli clinical cultures among hospitalized adults in a cohort of hospitals in the Premier Healthcare Database and Cerner Health Facts from 2012 through 2017. FQ resistance was defined as resistance to ciprofloxacin, levofloxacin, or moxifloxacin. Only cultures collected prior to day 4 of hospitalization, defined as CO, were considered. We extrapolated national estimates using a raking procedure to generate weighted adjustments matching the American Hospital Association distribution for U.S. acute care hospitals. Weights were based on U.S. census division, bed size category, teaching status, and urban/rural designation. We used a weighted means survey procedure to calculate national estimates and weighted multivariable logistic regression to examine trends and regional differences. Results In 2017, we estimated 949,393 CO E. coli infections with FQ susceptibility testing; 312,304 (33%) were due to E. coli resistant to FQ. Of FQ-resistant E. coli isolates, 76% were isolated from urine. We did not observe a significant trend in FQ-resistant E. coli from 2012 to 2017 (p = 0.85). Percent FQ-resistant varied significantly by region (p < 0.0001) with an estimated range of 19% (Mountain) to 42% (Southeast Central) in 2017. We also found variability by hospital (2017 Q1: 26% and Q3: 39%). FQ-resistance rates were higher in urine (36%: 95% CI 34-38%) than blood isolates (27%: 95% CI 26-29%) and higher for males (40%: 95% CI 38-42%) than females (33%: 95% CI 31-35%). Conclusion FQ-resistance is common in CO E. coli infections with significant variability by region and hospital. Empiric FQ treatment for infectious syndromes commonly caused by E. coli may need to be reconsidered. Clinicians should consult with local antibiograms and antibiotic stewardship programs to determine the most appropriate empiric treatment of E. coli infections in hospitalized adults. Disclosures All Authors: No reported disclosures

BackgroundAs the US population ages, the number of hip and knee arthroplasties is expected to increase. Because surgical site infections (SSIs) following these procedures contribute substantial morbidity, mortality, and costs, we projected SSIs expected to occur from 2020 through 2030.MethodsWe used a stochastic Poisson process to project the number of primary and revision arthroplasties and SSIs. Primary arthroplasty rates were calculated using annual estimates of hip and knee arthroplasty stratified by age and gender from the 2012–2014 Nationwide Inpatient Sample and standardized by census population data. Revision rates, dependent on time from primary procedure, were obtained from published literature and were uniformly applied for all ages and genders. Stratified complex SSI rates for arthroplasties were obtained from 2012–2015 National Healthcare Safety Network data. To evaluate the possible impact of prevention measures, we recalculated the projections with an SSI rate reduced by 30%, the national target established by the US Department of Health and Human Services (HHS).ResultsWithout a reduction in SSI rates, we projected an increase in complex SSIs following hip and knee arthroplasty of 14% between 2020 and 2030. We projected a total burden of 77,653 SSIs; however, meeting the 30% rate reduction could prevent 23,297 of these SSIs.ConclusionsGiven current SSI rates, we project that complex SSI burden for primary and revision arthroplasty may increase due to an aging population. Reducing the SSI rate to the national HHS target could prevent 23,000 SSIs and reduce subsequent morbidity, mortality, and Medicare costs.

Background Opioid misuse is epidemic in the United States (US), and persons who inject drugs are at increased risk for serious bacterial and fungal infections, including Candida bloodstream infections. Historically, candidemia has occurred almost exclusively among patients with severe underlying illness and extensive healthcare exposure. We examined whether the opioid crisis may be having an impact on the epidemiology of candidemia in the United States. Methods Using data from 200 US hospitals reporting to the Premier Healthcare Database (PHD) between 2012–2017, we conducted a retrospective study among hospitalized persons ≥ 18 years. Candidemia was defined by any blood culture yielding Candida species. Drug use-associated (DUA)-candidemia hospitalizations were defined as hospitalizations having both candidemia and at least one ICD-9-CM or ICD-10-CM diagnostic code for recreational drug use; drugs were classified as opioids, cocaine, amphetamines, or other drugs (excluding cannabis, alcohol, and nicotine). We described the characteristics and annual trends of candidemia hospitalizations, stratified by drug use. Results Of 7,590 candidemia hospitalizations during 2012–2017, 679 (9%) were DUA-candidemia. During this time, the rate of DUA-candidemia increased from 3.6 to 9.1 per 100,000 hospitalizations, while the rate of non-DUA-candidemia decreased from 64.7 to 55.6 per 100,000 hospitalizations. Patients with DUA-candidemia were younger (median 40 vs. 64 years), had a longer lengths of stay (median 14 vs. 13 days), and had lower in-hospital mortality (12% vs. 26%). Among DUA-candidemia hospitalizations, opioids accounted for 78% of substances identified. Among patients aged 18–44 years, the proportion of candidemia hospitalizations associated with drug use more than tripled from 13% in 2012 to 44% in 2017 (Figure 1). Conclusion DUA-candidemia hospitalizations increased almost 3-fold during 2012–2017, with drug use identified in nearly half of candidemia patients ages 18–44 years in 2017. These data suggest that the opioid crisis is having an impact on the epidemiology of candidemia in the United States, especially among young adults, underscoring an additional negative consequence of the ongoing crisis. Disclosures All authors: No reported disclosures.

Background Difficult-to-treat resistance (DTR) is a metric for clinically relevant “pan-resistance” to available high-efficacy, low-toxicity antibiotic treatment options at any given time. Previous DTR prevalence estimates in Gram-negative (GN) bloodstream isolates from 2009 to 2014 have ranged between 1 and 1.5%. We sought to estimate the national burden of DTR GN isolates and more recent trends by region, site, and species. Methods Clinical cultures with GN isolates were identified from inpatient encounters in hospitals reporting at least one culture with susceptibility testing for a given month to Premier Healthcare Database or Cerner Health Facts Database from 2012 to 2017. DTR was defined as intermediate susceptibility or resistance to all tested carbapenems, other β-lactams, and fluoroquinolones, but not including agents introduced 2014 onwards. For each year, a raking procedure generated weights to extrapolate the sample estimate to match American Hospital Association distributions based on US census division, hospital bed capacity, teaching status, and urban designation. A weighted means survey procedure was used to extrapolate the sample estimate to obtain national DTR burden. Trends in DTR incidence were examined by using weighted multivariable logistic regression. Results Extrapolating from a 373-hospital sample, the estimated 2017 US inpatient burden of DTR isolates was 3,315 (1.3%) among sterile-site and 31,509 (1.7%) among all cultures, ranging from 0.5% to 3.3% in Mountain and New England regions respectively. P. aeruginosa was the most common species overall (37%), while A. baumannii was most common among sterile sites (31%). Between 2012 and 2017, there was no annual percent change in DTR incidence for sterile sites [OR 0.99 (0.93, 1.06)] but for all cultures it decreased 4.1% annually [OR 0.95 (0.91, 0.99)], including 9% annually for A. baumannii [OR 0.905 (0.860, 0.953)] and K. pneumonia [OR 0.903 (0.824, 0.991)], respectively. Conclusion The US inpatient burden of GN isolates displaying DTR is relatively low, varies by region, and has remained stable or declined slightly in recent years. Periodic inclusion of emerging antibiotics in the DTR classification will allow for a dynamic index between resistance and available agents. Disclosures All Authors: No reported Disclosures.

Background Despite overall progress in preventing Clostridioides difficile Infection (CDI), community-associated (CA) infections have been steadily increasing. Although the incubation period of CDI is thought to be relatively short, gastrointestinal microbial disruption from remote healthcare exposures (e.g., inpatient antibiotic use) may be associated with CA-CDI. To assess this potential association, we linked CA-CDI infections identified through CDC’s Emerging Infections Program (EIP) to Medicare claims data to describe prior healthcare utilization. Methods We defined an EIP CA-CDI case as a positive C. difficile test collected in 2014–2015 from an outpatient or inpatient within 3 days of hospital admission, provided there was no positive test in the prior 8 weeks and no admission to a healthcare facility in the prior 12 weeks. We linked EIP CA-CDI cases aged ≥65 years to a Medicare beneficiary using unique combinations of birthdate, sex, and zip code. Cases were included if they maintained continuous fee-for-service coverage for 1 year prior to the event date. To calculate exposure odds ratios for previous hospitalizations, each case was matched to 5 control beneficiaries on age, sex, and county of residence. We used logistic regression to calculate adjusted matched odds ratios (amOR) that controlled for chronic conditions. Results We successfully linked 2,287/3,367 (68%) EIP CA-CDI cases. Of these, 1,236 cases met inclusion criteria; the median age was 77 years and 63% were female. We identified 69 (5.6%) cases with misclassification of prior healthcare exposures, most of whom (48, 70%) were hospitalized in the 12 weeks prior to their event. Among the 1,167 true CA-CDI cases, 33% were hospitalized in the prior 12 weeks to 1 year. The median number of weeks from prior hospitalization to CDI was 27 (IQR 18–38, Figure 1). Cases had a higher risk of hospitalization than matched controls in the prior 3–6 months (amOR: 2.33, 95% CI: 1.87, 2.90) and 6–12 months (amOR: 1.43 95% CI: 1.18, 1.74). Conclusion Remote hospitalization in the previous year was a significant risk factor for CA-CDI, especially in the 3–6 months prior to CA-CDI. Long-lasting prevention strategies implemented at hospital discharge and enhanced inpatient antibiotic stewardship may prevent CA-CDI among older adults. Disclosures All Authors: No reported Disclosures.

Background Carbapenem-nonsusceptible Acinetobacter spp. (CNAB) and carbapenem-resistant Pseudomonas aeruginosa (CRPA) are recognized causes of severe and difficult to treat healthcare-associated infections. This study estimated and compared the incidence of CNAB and CRPA among patients admitted to US acute care hospitals in 2012–2017. Methods We measured the incidence of positive clinical cultures from inpatient encounters in a cohort of over 300 hospitals submitting data to the Premier Healthcare Database and Cerner Health Facts in 2012–2017. We included clinical cultures from any body site yielding Acinetobacter spp./P. aeruginosa non-susceptible/resistant to imipenem, meropenem, or doripenem. Cultures collected on days 1–3 of hospitalization were considered community-onset (CO) and cultures from later were hospital-onset (HO). Duplicate isolates identified within 14 days of an incident culture and surveillance cultures were excluded. For each year, a raking procedure generated weights to extrapolate the sample estimate to match the American Hospital Association distributions based on US census division, hospital bed capacity, teaching status, and urban designation. We compared estimated rates in 2017 vs. 2012 using weighted multivariable logistic regression adjusting for hospital characteristics and hospital-level clustering. Results In 2017, the estimated rates of HO and CO CNAB rates were 0.77 and 1.39/10,000 discharges, and HO and CO CRPA rates were 3.14 and 6.57, respectively. Compared with 2017, rates of HO CNAB decreased 49% (Odds Ratio (OR) 0.51; 95% CI: 0.34–0.75) and rates of CO CNAB decreased 29% (OR 0.71; 95% CI: 0.54–0.92). For CRPA, the incidence of HO decreased (OR 0.66; CI: 0.49–0.88) with no change in CO rates (OR 0.93; CI: 0.79–1.11). Assessment of cultures from sterile sites alone showed similar results, but they did not reach statistical significance, Figure 1. Conclusion We estimate significant national decreases in the rates of HO and CO CNAB, and HO CRPA. Risk factors and effective interventions to reduce CO CRPA might differ from CNAB and HO CRPA. Additional prevention strategies are needed to address CO CRPA. Disclosures All authors: No reported disclosures.

Background The age-adjusted rate of drug overdose deaths in the United States tripled from 1999 to 2016. Public health surveillance data indicate that an increasing proportion of infections due to bacterial and fungal pathogens is associated with injection drug use (IDU). We describe healthcare encounters (HCEs) of PWID as potential opportunities to prevent infections related to IDU by identifying risks and treating SUD, including with medication-assisted treatment (MAT) for opioid use disorder. Methods At six hospitals in western New York, we abstracted medical records from hospital admissions and emergency department (ED) visits for PWID (i.e., IDU in the preceding year) who had positive cultures for Staphylococcus aureus (any clinical specimen, April–July 2017), group A Streptococcus (invasive specimens, all of 2017) or Candida spp. (blood specimens, all of 2017). We reviewed hospital admission and ED records for 1 year preceding the positive culture to identify visits during which opportunities to prevent infection and treat SUD by addressing SUD and IDU were missed. Results We identified 99 PWID with positive cultures. The median age was 33 years (range 19–68) and 61 were female. Sixty-nine had a skin and soft-tissue infection, 44 had a bloodstream infection, and 20 had both. Thirty-one PWID left against medical advice during a hospital admission or an ED visit. Seventy-nine PWID were hospitalized, of whom 4 died. Ninety-five used opioids and 71 used cocaine in the preceding year. Seventy-five PWID had an HCE in the 12 months prior to the index visit, with a median of two HCE per person (interquartile range 1–4); 53 of PWID had a previous HCE for infection and 28 for opioid overdose. SUD was documented during a prior HCE at the same hospital for 61 PWID, but only 10 (16%) were offered MAT during any prior HCE and for 24 (39%) there was no documentation that any form of treatment for SUD was offered. Conclusion In this cohort, PWID frequently had one or more healthcare encounters documented at the same hospital in the year prior to a serious bacterial or fungal infection. These prior HCEs were often for infections or overdose that signaled the need for MAT, demonstrating that there are critical missed opportunities to identify risks, prevent infection, and treat SUD. Disclosures All Authors: No reported Disclosures.

Background Clostridium difficile infection (CDI) is a common healthcare-associated infection, particularly among older adults. We used laboratory-confirmed CDI surveillance data from 8 states participating in the Centers for Disease Control and Prevention’s Emerging Infections Program linked to claims data for Centers for Medicare and Medicaid Services (CMS) beneficiaries to measure variation in 1-year outcomes associated with CDI. Methods A CDI case was defined as a positive C. difficile stool test in 2014 in a person without a positive test in the prior 8 weeks. Cases aged ≥65 years were linked to their CMS beneficiary ID using unique combinations of date of birth, sex, and zip code. Each case was matched to five control beneficiaries who did not link to any case and were residents of the same catchment area. Inclusion criteria were continuous fee-for-service Medicare for the entire study period (1 year before and after event date), and no hospitalization or skilled nursing facility stay with an ICD-9-CM code for CDI in the year prior to their match date. Multivariable logistic regression models were used to compare mortality and hospitalization for 1 year following the event date between beneficiaries with and without CDI, adjusting for age, sex, race, catchment area, chronic conditions, number of hospitalizations in the prior year, and hospitalization status at the time of and 7 days preceding the event date. Results Of 5,097 cases aged ≥65, 3,082 (60%) were linked to a CMS ID, and 1,832 (59%) met inclusion criteria. In crude analysis, 34% of beneficiaries with CDI died within 1 year, compared with 5% of beneficiaries without CDI. Beneficiaries with CDI were also more likely to be hospitalized in the subsequent year (54% vs. 17%). Beneficiaries with CDI had a higher adjusted odds of death (adjusted OR 3.01, 95% CI: 2.46, 3.69) and hospitalization within 1 year (adjusted OR 1.93, 95% CI: 1.65, 2.25) than those without CDI. Conclusion Older adults with CDI were three times more likely to die in the year following infection and nearly two times more likely to be hospitalized compared with those without CDI, revealing independent long-term risk of poor outcomes. This excess morbidity and mortality supports the need to develop novel CDI prevention strategies for this population. Disclosures All authors: No reported disclosures.

Background Both Medicaid and private health insurance support important access to care for many pregnant women in the United States. The role of health insurance on many outcomes, such as surgical site infection (SSI) following Cesarean delivery (CD), has not been adequately investigated. Methods This retrospective cohort study investigated SSI risk following CDs performed in California hospitals in 2011 among women covered by Medicaid or private health insurance. All CDs were obtained from identifiable state inpatient discharge (SID) data and linked with National Healthcare Safety Network (NHSN) data to ascertain post-delivery SSI. Characteristics including age, race/ethnicity, BMI, prior CD planned admission, emergency CD, active labor and labor duration, ASA physical status, general anesthesia, wound class, hospital ownership, hospital annual CD count, intern/resident-to-bed ratio, case mix index, disproportionate share adjustment, urban location, and area wage index were obtained from CMS facility, NHSN, and SID data. Potential effect modification of the payer-SSI relationship was assessed using a multivariable logistic regression model. Results 90% of eligible NHSN records linked with a SID record. The analytic dataset consisted of 387 SSIs following 57,143 CDs performed in 196 hospitals. Payer distribution across CDs was 49% Medicaid, 51% private insurer. SSIs were reported following 0.74% of CDs among Medicaid recipients and 0.62% among those privately insured (unadjusted risk ratio: 1.2, 95% confidence interval: 1.0–1.5, P = 0.09). In for-profit hospitals women with Medicaid had a 2.6-fold (95% CI: 1.2–5.4, P = 0.01) increase in adjusted SSI risk compared with women with private insurance. There were no differences in adjusted SSI risk by payer in government (RR: 1.1, 95% CI 0.7–1.8, P = 0.92) or not-for-profit hospitals (RR: 0.9, 95% CI 0.7–1.2, P = 0.52). Conclusion Despite accounting for various patient and facility-level factors, Medicaid-insured women experienced higher SSI risk than privately-insured women in for-profit hospitals, but not in government owned or not-for-profit hospitals. Additional studies to understand underlying causes may help target efforts to prevent SSIs following CDs among vulnerable patients. Disclosures All authors: No reported disclosures.