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Risk for transmission of monkeypox virus (MPXV) (clade IIb) to healthcare workers (HCWs) is low. Although many cases have been reported among HCW, only a few have been occupationally acquired. We report a case of non-needle stick MPXV transmission to an HCW in the United States.

We describe the epidemiology of COVID-19 exposure, preceding illness, and SARS-CoV-2 testing in a large population with MIS-C during the first 18 months of the COVID-19 pandemic. The majority of cases had exposure, preceding illness, or positive SARS-CoV-2 testing 4-8 weeks before MIS-C onset. Serology can help establish epidemiological link to COVID-19 when past infection or exposure are unknown.

Background The prevalence of current or past coronavirus disease 2019 in skilled nursing facility (SNF) residents is unknown because of asymptomatic infection and constrained testing capacity early in the pandemic. We conducted a seroprevalence survey to determine a more comprehensive prevalence of past coronavirus disease 2019 in Los Angeles County SNF residents and staff members. Methods We recruited participants from 24 facilities; participants were requested to submit a nasopharyngeal swab sample for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) polymerase chain reaction (PCR) testing and a serum sample for detection of SARS-CoV-2 antibodies. All participants were cross-referenced with our surveillance database to identify persons with prior positive SARS-CoV-2 results. Results From 18 August to 24 September 2020, we enrolled 3305 participants (1340 residents and 1965 staff members). Among 856 residents providing serum samples, 362 (42%) had current or past SARS-CoV-2 infection. Of the 346 serology-positive residents, 199 (58%) did not have a documented prior positive SARS-CoV-2 PCR result. Among 1806 staff members providing serum, 454 (25%) had current or past SARS-CoV-2 infection. Of the 447 serology-positive staff members, 353 (79%) did not have a documented prior positive SARS-CoV-2 PCR result. Conclusions Past testing practices and policies missed a substantial number of SARS-CoV-2 infections in SNF residents and staff members.

In March 2018, the US Food and Drug Administration (FDA), US Centers for Disease Control and Prevention, California Department of Public Health, Los Angeles County Department of Public Health and Pennsylvania Department of Health initiated an investigation of an outbreak of Burkholderia cepacia complex (Bcc) infections. Sixty infections were identified in California, New Jersey, Pennsylvania, Maine, Nevada and Ohio. The infections were linked to a no-rinse cleansing foam product (NRCFP), produced by Manufacturer A, used for skin care of patients in healthcare settings. FDA inspected Manufacturer A's production facility (manufacturing site of over-the-counter drugs and cosmetics), reviewed production records and collected product and environmental samples for analysis. FDA's inspection found poor manufacturing practices. Analysis by pulsed-field gel electrophoresis confirmed a match between NRCFP samples and clinical isolates. Manufacturer A conducted extensive recalls, FDA issued a warning letter citing the manufacturer's inadequate manufacturing practices, and federal, state and local partners issued public communications to advise patients, pharmacies, other healthcare providers and healthcare facilities to stop using the recalled NRCFP. This investigation highlighted the importance of following appropriate manufacturing practices to minimize microbial contamination of cosmetic products, especially if intended for use in healthcare settings.

The objective of the Los Angeles County, California (LAC), health care personnel (HCP) influenza vaccination improvement intervention was to increase HCP influenza vaccination coverage during the 2016–2017 influenza season via targeted outreach to LAC acute care hospitals. We selected 13 facilities for intervention and received tailored recommendations from a menu of evidence-based practices. Following the season, each hospital in the intervention group experienced a significant increase in vaccination coverage, which increased the LAC countywide average for all hospitals by 5%, from 74% to 79%.

IntroductionMore than 93,000 cases of coronavirus disease (COVID-19) have been reported worldwide. We describe the epidemiology, clinical course, and virologic characteristics of the first 12 U.S. patients with COVID-19.MethodsWe collected demographic, exposure, and clinical information from 12 patients confirmed by CDC during January 20–February 5, 2020 to have COVID-19. Respiratory, stool, serum, and urine specimens were submitted for SARS-CoV-2 rRT-PCR testing, virus culture, and whole genome sequencing.ResultsAmong the 12 patients, median age was 53 years (range: 21–68); 8 were male, 10 had traveled to China, and two were contacts of patients in this series. Commonly reported signs and symptoms at illness onset were fever (n=7) and cough (n=8). Seven patients were hospitalized with radiographic evidence of pneumonia and demonstrated clinical or laboratory signs of worsening during the second week of illness. Three were treated with the investigational antiviral remdesivir. All patients had SARS-CoV-2 RNA detected in respiratory specimens, typically for 2–3 weeks after illness onset, with lowest rRT-PCR Ct values often detected in the first week. SARS-CoV-2 RNA was detected after reported symptom resolution in seven patients. SARS-CoV-2 was cultured from respiratory specimens, and SARS-CoV-2 RNA was detected in stool from 7/10 patients.ConclusionsIn 12 patients with mild to moderately severe illness, SARS-CoV-2 RNA and viable virus were detected early, and prolonged RNA detection suggests the window for diagnosis is long. Hospitalized patients showed signs of worsening in the second week after illness onset.

Background: Outbreaks of infections in healthcare negatively impact patient outcomes and experience. Transparency is critical to engendering trust and optimizing health. Consistent guidance is not available regarding when to report a possible outbreak of healthcare-associated infections (HAIs) to public health and when to notify a limited population or to publicly disclose the occurrence of HAI. Recent analyses of state public health policies revealed that most states address reporting of outbreaks using terms such as clusters, unusual occurrences, or incidences over baseline. Specific wording about healthcare outbreaks or guidance for notifying patients or public is often absent. Thus, HAI outbreak notification and disclosure guidance and practices vary significantly around the country. A best-practice guidance document will provide clarity for when such reporting should occur. Methods: The Council for Outbreak Response: HAI and Antimicrobial-Resistant Pathogens (CORHA) has undertaken the task of developing this guidance by forming a multidiscipline policy work group with representation from its partner organizations. This work group has been tasked with creating a general framework that will guide notification and disclosure in the context of a possible HAI outbreak. The draft guidance document has been developed over several months of telephone and in-person conferences among work group members. Results: The standardized actions stemming from the guiding principles and recommended practices for conducting step 1 (immediate notification, initial and critical communications that occur when an outbreak is first suspected), were arranged in a table format with rows representing stakeholders and constituents to be notified and columns demonstrating the actions to be taken (Fig. 1). As an investigation progresses, notification should be revisited, especially if an investigation’s scope expands. The principles and practices for step 2 (expanded notification) have also been drafted in a table format. Next, the draft guidance addresses step 3 (public disclosure), outlining indications, practical guidance, and considerations in an outline and/or summary format. Real-world examples demonstrating application of the framework are being developed as supplementary resources to the framework. Current work group activities include engaging bioethicists, media reporters and patient advocates to review and comment on the guidance to ensure that it is clear, consistent and practical. Discussion: The draft guidance provides a framework for standardized actions for HAI outbreak notification and disclosure in a stepwise fashion, modeling public health practices and grounded in bioethical principles. The final product will provide valuable, practical advice for effectively sharing information with affected or potentially affected individuals and their caregivers in a timely manner.Funding: NoneDisclosures: Dawn Terashita reports that her spouse has received honoraria rom the speaker’s bureaus of Novo Nordisk and Abbott.

Context Infectious disease threats, high incidence/prevalence of health care-associated infections, and multidrug-resistant organisms challenge hospitals to improve infection prevention/control strategies and infectious disease preparedness/response efforts. Program The Los Angeles County (LAC) Department of Public Health (DPH), Hospital Outreach Unit (HOU) addressed this need with the liaison public health nurse (LPHN) project, which is designed to strengthen capacity and bridge the care continuum with hospitals to prevent/control infectious disease. Implementation The project utilizes 5 LPHNs who interface with LAC hospitals to improve reporting of infectious disease/hospital outbreaks, strengthen the surveillance infrastructure, and enhance communication/collaboration. The LPHNs communicate regularly and meet one-on-one with hospital infection preventionists with focused discussion, consultation, and assessment of infectious disease, participate in joint infection control meetings/conferences/calls, outreach on joint public health projects, and educate/train hospital staff. Evaluation Within the first 7 years of implementation (2003) of the unit, reporting of hospital outbreaks increased 27%; hospitals reporting infectious disease via a county reporting system increased 95% during the same period. Currently, 64% of hospitals are reporting via the electronic laboratory reporting system (automated transmission to public health of reportable laboratory findings). In addition, the number of hospital infection control committee meetings LPHNs were invited to increased 96% during the first 7 years. The LPHNs/HOU participate(d) in 9 joint infection prevention/control projects with hospitals. Discussion The threat of emerging infectious disease, health care-associated infections, and multidrug-resistant organisms is an ongoing challenge. Preventing infectious disease requires innovative approaches to effect and empower hospitals to respond. The LAC DPH LPHN project has proved to be an invaluable resource and key component to enable effective communication/collaboration to improve infection prevention and control strategies/preparedness efforts and protect the public's health from infectious disease.

Background There is an ongoing outbreak of Mycobacterium chimaera infections among patients exposed to contaminated heater-cooler devices used during cardiac surgery. Recognition of M. chimaera infection is hampered by its long latency and non-specific symptoms. Standard diagnostic methods using acid-fast bacilli (AFB) culture often require invasive sampling, have low sensitivity, and can take weeks to result. We describe the performance of a plasma-based next-generation sequencing test (plasma NGS) for the diagnosis of M. chimaera infection. Methods We conducted a retrospective study of 10 patients with a history of cardiac surgery who developed invasive M. chimaera infection and underwent testing by plasma NGS between February 2017 and April 2018. Results Plasma NGS detected M. chimaera in 9 of 10 patients (90%) with invasive disease in a median of 4 days from specimen collection, including all 8 patients with disseminated infection. In 7 of these 9 cases (78%), plasma NGS was the first test to provide microbiologic confirmation of M. chimaera infection. In contrast, AFB cultures required a median of 20 days to turn positive, and the median time for confirmation of M. chimaera was 41 days. Of 24 AFB blood cultures obtained in this cohort, only 4 (17%) were positive. Invasive procedures were performed in 90% of cases, and in 5 patients (50%), mycobacterial growth was achieved only by culture of these deep sites. Conclusions Plasma NGS can accurately detect M. chimaera noninvasively and significantly faster than AFB culture, making it a promising new diagnostic tool. Electronic supplementary material The online version of this article (10.1186/s12879-019-4001-8) contains supplementary material, which is available to authorized users.

Microbiological testing, including interpretation of antimicrobial susceptibility testing results using current breakpoints, is crucial for clinical care and infection control. Continued use of obsolete Enterobacteriaceae carbapenem breakpoints is common in clinical laboratories. The purposes of this study were (i) to determine why laboratories failed to update breakpoints and (ii) to provide support for breakpoint updates. The Los Angeles County Department of Public Health conducted a 1-year outreach program for 41 hospitals in Los Angeles County that had reported, in a prior survey of California laboratories, using obsolete Enterobacteriaceae carbapenem breakpoints. In-person interviews with hospital stakeholders and customized expert guidance and resources were provided to aid laboratories in updating breakpoints, including support from technical representatives from antimicrobial susceptibility testing device manufacturers. Forty-one hospitals were targeted, 7 of which had updated breakpoints since the prior survey. Of the 34 remaining hospitals, 27 (79%) assumed that their instruments applied current breakpoints, 17 (50%) were uncertain how to change breakpoints, and 10 (29%) lacked resources to perform a validation study for off-label use of the breakpoints on their systems. Only 7 hospitals (21%) were familiar with the FDA/CDC Antibiotic Resistance Isolate Bank. All hospitals launched a breakpoint update process; 16 (47%) successfully updated breakpoints, 12 (35%) received isolates from the CDC in order to validate breakpoints on their systems, and 6 (18%) were planning to update within 1 year. The public health intervention was moderately successful in identifying and overcoming barriers to updating Enterobacteriaceae carbapenem breakpoints in Los Angeles hospitals. However, the majority of targeted hospitals continued to use obsolete breakpoints despite 1 year of effort. These findings have important implications for the quality of patient care and patient safety. Other public health jurisdictions may want to utilize similar resources to bridge the patient safety gap, while manufacturers, the FDA, and others determine how best to address this growing public health issue.

Background In 2017, local public health authorities in California received reports of 2 elderly patients with suspected botulism who knew each other socially. A multijurisdictional investigation was conducted to determine the source. Methods Investigators reviewed medical records, interviewed family to establish food and drink histories, and inspected a facility that produced liquid herbal tea. Clinical specimens and product were tested for botulinum neurotoxin (BoNT). Results A total of 2 confirmed botulism cases were identified with BoNT type A; both were hospitalized, 1 died. Botulism was not suspected until several days after hospital admission. Case-patients ingested single-serving prepackaged liquid herbal tea. Inspection of the tea production facility identified conditions conducive to product contamination with C botulinum and toxin production. Samples of tea tested negative for botulinum toxin. Local and state public health authorities issued alerts and the facility recalled the liquid herbal tea. Conclusions Liquid herbal tea prepackaged in sealed pouches was the likely source of this type A botulism outbreak because the 2 cases were linked socially and shared no other foods. This type of product has not previously been described in the foodborne botulism literature. In the absence of known risk factors for botulism at the time of presentation, suspicion based on clinically compatible findings is critical so that and treatment with botulinum antitoxin is not delayed. A coordinated response by public health authorities is necessary in identifying a potential food source, inspecting facilities producing the product, alerting medical providers and the public, and preventing further illness.

On June 22, 2017, the Los Angeles County Department of Public Health (LAC DPH) was notified of seven patients who were seen at an eye care clinic on June 8, 2017, and later developed symptoms of epidemic keratoconjunctivitis (EKC). EKC is a contagious, severe form of viral conjunctivitis that can cause pain and blurred vision for up to 4 weeks (1). LAC DPH conducted an investigation, which identified 17 patients with EKC, including 15 who had visited the optometry clinic and two who were household contacts of clinic patients. Observations in the clinic found deficiencies in disinfection of tonometers (an instrument connected to a slit lamp and used to test for glaucoma by measuring intraocular pressure) and multiuse eye drop administration. Staff member education and revision of disinfection practices interrupted further transmission. Patient specimens tested positive for human adenovirus (HAdV) type D53 (HAdV-53). As the first documented EKC outbreak associated with HAdV-D53 in the United States, this outbreak highlights the need for rigorous implementation of recommended infection prevention practices in eye care settings.

Background The Clinical and Laboratory Standards Institute (CLSI) revised the carbapenem breakpoints for Enterobacteriaceae in 2010. The number of hospitals that adopted revised breakpoints and the clinical impact of delayed adoption has not been explored. Methods We performed a cross-sectional, voluntary survey of microbiology laboratories from California acute care hospitals and long-term acute care hospitals (LTAC) to determine use of revised CLSI breakpoints. Carbapenem-resistant Enterobacteriaceae (CRE) clinical isolates from a single tertiary-care hospital from 2013 to 2017 were examined. All isolates with an elevated minimum inhibitory concentration (MIC; ≥2 µg/mL) to imipenem or meropenem were tested for the presence of carbapenemase genes by polymerase chain reaction (PCR). Results We received responses from 128 laboratories that serve 264/393 (67%) of hospitals and LTACs. Current CLSI carbapenem breakpoints for Enterobacteriaceae were used by 92/128 (72%) laboratories. Among laboratories that used current breakpoints, time to implementation varied from 0 to 68 months (mean, 41 months; median, 55 months). Application of historical breakpoints to isolates with a carbapenemase gene detected by PCR resulted in susceptibility rates of 8.9%, 18.6%, and 18.6% to ertapenem, imipenem, and meropenem, respectively. By current breakpoints

Carbapenem-resistant Enterobacteriaceae (CRE) infections are difficult to treat and pose a significant threat to public health. In July 2018, an infection preventionist (IP) notified Los Angeles County Department of Public Health (LACDPH) of eight cases of healthcare-onset carbapenem-resistant Klebsiella pneumoniae (CRKP) among residents of a 54-bed long term acute care facility (LTAC). LACDPH initiated an investigation to identify risks for infection and disrupt transmission. A case was defined as a LTAC patient with laboratory confirmation for CRKP or carbapenemase-producing organism from June 28- August 7, 2018 and no previous CRE history. LACDPH conducted two site visits of the facility to observe infection prevention practices. Medical records, staff training records, and infection prevention audits were reviewed. Facility-wide surveillance cultures were collected on three dates. The first facility-wide screening yielded 13 additional cases; no further cases were identified during subsequent screenings. Medical record review found one additional case. A total of 22 cases were identified; overall prevalence was 39%. Site observations revealed missed hand hygiene opportunities, unclear contact precaution signage, and a knowledge deficit among staff regarding CRE and control measures. LACDPH recommended enhanced environmental cleaning, infection control trainings for all staff, hand hygiene and personal protective equipment audits, placing new admissions on contact precautions pending CRE screening results, and the use of an interfacility transfer form upon discharge of all known CRE patients. We identified a high prevalence of CRE in an LTAC, a setting where patients generally have higher invasive device and antibiotic utilization than other settings. However, the implementation of evidence-based infection prevention practices enabled the facility to stop the spread of infection. Identification and containment of a CRE outbreak in a healthcare facility relies on several factors, including the collaboration of a facility's IP with the local health department and continuing frontline staff education.

Infection control (IC) in the pre-hospital care setting by EMS providers is important to protect themselves and patients receiving emergency care and being transported between healthcare facilities. From 2016-17, LAC Department of Public Health (DPH) collaborated with LAC Emergency Medical Services Agency (EMSA) to assess and improve IC among EMS providers. DPH/EMSA adapted tools from the Centers for Disease Control and Prevention designed for healthcare facilities to assess EMS IC policies and practices. Large and small EMS agencies/companies were assessed to ensure a representative sample. Policies were reviewed, and observations made by DPH/EMSA nurses during ride alongs in >2 ambulances per provider. Fourteen providers were assessed. Eleven had a designated infection control officer (DICO). Thirteen had written IC policies; 12 reviewed and updated them annually. All required IC training for new staff, but only 59% assessed skills post-training and 31% audited across four IC topics. Twelve had written policies for cleaning/disinfection. Twelve had a policy for influenza vaccination; however, the median vaccination rate was only 55% (range 1-99%). Observations showed handwashing occurred before patient contact for 7% of assessments, glove use in 100% and hand hygiene after removing gloves in 79%. Staff cleaned the ambulance after each patient encounter; cleaning high touch surfaces in 79% and replaced cleaners/disinfectants when appropriate in 89%. EMS providers are an important part of the healthcare system as they transport patients in and out of hospitals and other healthcare facilities. Overall, findings were encouraging, but ensuring up-to-date policies for all areas of IC, monitoring competencies, and observing practices to assess adherence may improve IC. In 2018, LAC hosted an IC train-the-trainer course for DICOs to bring proper IC practices back to their agencies/companies. LAC DPH and EMSA will continue to work with EMS providers to improve IC policies and practices.

Background Intrapartum antibiotic prophylaxis (IAP) prevents neonatal mortality from Group B Streptococcus (GBS). Clindamycin resistance among GBS isolates complicates IAP for GBS-positive women allergic to penicillin and cephalosporins. GBS screening by nucleic acid amplification tests (NAATs) provides rapid results, but no susceptibility data to inform IAP. We sought to estimate burden of clindamycin resistance among GBS in Los Angeles County (LAC). Methods Hospital antibiogram data were gathered from all LAC acute care hospitals from 2015 to 2016. Weighted averages for GBS resistance to clindamycin, erythromycin, penicillin, and TMP/SMX were calculated. Facilities which reported clindamycin susceptibilities were interviewed regarding antimicrobial susceptibility testing methods. Results A total of 2,339 GBS isolates from 22 hospitals were reported between 2015 and 2016. Thirteen hospitals tested GBS for clindamycin (nine reported in 2015 and 2016, four hospitals reported in 2016 only). Clindamycin resistance was found in 61.7% of 1,794 GBS isolates (79.3% of 891 in 2015, 44.3% of 903 in 2016). Erythromycin resistance was 42% in 735 isolates reported, 0.1% penicillin of 1,916 isolates reported, and 1.5% TMP/SMX of = 135 isolates reported. Facilities tested GBS by manual minimum inhibitory concentration (MIC) broth dilution (n = 1), automated MIC dilution (n = 4), agar plate diffusion (n = 1), and MIC dilution followed by agar plate diffusion (n = 1). Two hospitals did not perform testing on-site. Conclusion The 62% prevalence of clindamycin-resistant GBS in LAC is three-fold higher than national CDC estimates and complicates IAP for GBS-positive women allergic to penicillin and cephalosporins. These data support CDC recommendations for susceptibility testing in addition to NAAT screening which does not include assays for common determinants of clindamycin resistance, erm-methylase, mef, and isa. There is an opportunity for diagnostic manufacturers and clinical labs to help clinicians choose appropriate IAP and prevent neonatal mortality. The CDC and public health should be aware of regional variations in clindamycin resistance. Clinicians should be aware of local resistance to inform IAP stewardship recommendations. Disclosures S. Butler-Wu, BioFire (bioMerieux): Investigator, Research support.

Background An estimated 30% of outpatient antibiotic prescriptions are unnecessary. Antimicrobial stewardship programs (ASP) are associated with decreased antibiotic prescribing and improved patterns of antimicrobial resistance. The objective of Targeting Appropriate Prescribing in Outpatient settings (TAP OUT) is to study how public health jurisdictions may assist implementation of ASP in primary and urgent care and to measure the impact on reducing inappropriate antibiotic prescribing. Methods Los Angeles County Department of Public Health (DPH) partnered with an outpatient medical group to implement an ASP in 2017. The TAP OUT ASP included public commitment, communication skills training, clinical treatment education, and prescribing audits. Implementation characteristics were collected via key informant interviews and provider surveys and were analyzed following the Consolidated Framework for Implementation Research. Historical (November 2016–March 2017) and intervention (November 2017–March 2018) period prescribing data from electronic health records were compared with calculating antibiotic prescribing rates for uncomplicated acute upper respiratory infection (URI) encounters. Results Twenty primary care and three urgent care clinics, representing 208 providers, participated in TAP OUT. The baseline inappropriate antibiotic prescribing rate for URI was 15.5% amongst all prescribers (range: 0–100%). During the intervention period, the inappropriate prescribing rate decreased to 7.6% (51% reduction, P < 0.0001) (Figure 1). Several key implementation elements were identified, such as leadership buy-in and on-site peer champions. Visible and recurring prescribing reminders were useful. To improve adoption, the ASP was integrated into existing workflow. Costs were limited and related to information technology resources to analyze prescribing data and create feedback reports. Conclusion The TAP OUT program met all of the Centers for Disease Control and Prevention (CDC) Core Elements of Outpatient Stewardship and was associated with a decrease in inappropriately prescribed antibiotics with low implementation costs. DPH will develop a TAP OUT implementation guide and work with local providers to develop ASPs. Figures: Disclosures All authors: No reported disclosures.

Pending California legislation prompted an on-line survey of methicillin-resistant Staphylococcus aureus (MRSA) active surveillance practices administered to infection preventionists of all 102 acute care licensed hospitals in Los Angeles County. We describe reported surveillance methods. Ninety-six hospitals responded with 41% performing MRSA active surveillance. Comments indicated resistance to implementation of active surveillance because its benefits remain controversial.

Background Carbapenem-resistant Enterobacteriaceae (CRE), particularly carbapenemase-producing (CP) CRE, are an urgent public health threat. CRE with blaKPC have been most commonly reported, but blaNDM and other genotypes have epidemiologic and clinical significance. We seek to define epidemiologic patterns and antimicrobial susceptibility implications of genotypic resistance (R) mechanism in LAC. Methods LAC Department of Public Health (DPH) Public Health Laboratory (PHL) conducted CRE laboratory surveillance of 31 clinical microbiology labs representing 34% (34/96) hospitals and 1 large regional lab serving 60% of SNFs from January 2015 to December 2016. Data on antimicrobial susceptibility testing (AST) was conducted by local laboratories and methodology varies by each submitting clinical lab. Isolates were sent to DPH PHL for identification of carbapenem resistance mechanism using Nanosphere Verigene BC-GN to detect carbapenemase genes; blaOXA, blaVIM, blaNDM, blaKPC, and blaIMP. Results During the study period, 843 CRE isolates were submitted to DPH for further analysis. CRE isolates were submitted from 34 hospitals (n = 604, mean 2 isolates/facility/month, range 1–7 isolates); 239 isolates submitted from regional SNF lab (range 2-54 isolates/month). Resistance mechanisms were identified in 684 Klebsiella spp., 61 E. coli, 45 Enterobacter spp., 10 Acinetobacter Baumannii, and other organisms. blaKPC was identified in 653 (77.5%) isolates, blaOXA in 17 (2%) isolates, and blaVIM in 2 isolates; 75 (9%) isolates did not have a marker detected. AST data and carbapenemase gene detection data were complete for 252 (30%) isolates, 250 isolates from hospitals and 2 SNF isolates; 29 isolates from hospitals were identified as pan-resistant, AST results for blaKPC differed from non-blaKPC isolates for tobramycin, amikacin, ciprofloxacin, aztreonam, ceftolazone tazobactam, ceftazidime avibactam (P < 0.05 for all). Conclusion CRE surveillance in a large urban setting continues to demonstrate that CRE Burden varies across individual facilities. Molecular epidemiology indicate that KPC remains the predominant carbapenemase, but NDM and other non-KPC mechanisms are recognized. Preliminary AST testing suggests that resistance mechanism has implications for antibiotic therapy. Disclosures All authors: No reported disclosures.

In March 2013, the California Department of Public Health (CDPH) identified two Doctor's First Reports of Occupational Injury or Illness (DFRs) regarding Los Angeles County residents who had worked at the same jobsite in January 2012 and had been evaluated for possible work-associated coccidioidomycosis (valley fever). Occupational exposure to Coccidioides, the causative fungi, typically is associated with soil-disrupting activities. The physicians noted that both workers were cast or crew members filming a television series episode, and the site of possible exposure was an outdoor set in Ventura County, California. On the basis of their job titles, neither would have been expected to have been engaged in soil-disrupting activities. Los Angeles County Department of Public Health (LACDPH) conducted an outbreak investigation by using CDPH-provided occupational surveillance records, traditional infectious disease surveillance, and social media searches. This report describes the results of that investigation, which identified a total of five laboratory-confirmed and five probable cases linked to this filming event. The employer and site manager were interviewed. The site manager stated that they would no longer allow soil-disruptive work at the site and would incorporate information about the potential risk for Coccidioides exposure onsite into work contracts. Public health professionals, clinicians, and the television and film industry should be aware that employees working outdoors in areas where Coccidioides is endemic (e.g., central and southern California), even those not engaged in soil-disruptive work, might be at risk for coccidioidomycosis.

This report details an outbreak investigation conducted by the Los Angeles County Department of Public Health of 3 cases of bacterial infection among patients receiving hemodialysis who were treated at the same dialysis center in 2011. Improper disinfection of reusable dialyzers was hypothesized as the source of transmission.

BACKGROUND. In the United States, Klebsiella pneumoniae carbapenemase (KPC)–producing Enterobacteriaceae are increasingly detected in clinical infections; however, the colonization burden of these organisms among short-stay and long-term acute care hospitals is unknown. METHODS. Short-stay acute care hospitals with adult intensive care units (ICUs) in the city of Chicago were recruited for 2 cross-sectional single-day point prevalence surveys (survey 1, July 2010–January 2011; survey 2, January–July 2011). In addition, all long-term acute care hospitals (LTACHs) in the Chicago region (Cook County) were recruited for a single-day point prevalence survey during January–May 2011. Swab specimens were collected from rectal, inguinal, or urine sites and tested for Enterobacteriaceae carrying bla(KPC). RESULTS. We surveyed 24 of 25 eligible short-stay acute care hospitals and 7 of 7 eligible LTACHs. Among LTACHs, 30.4% (119 of 391) of patients were colonized with KPC-producing Enterobacteriaceae, compared to 3.3% (30 of 910) of short-stay hospital ICU patients (prevalence ratio, 9.2; 95% confidence interval, 6.3–13.5). All surveyed LTACHs had patients harboring KPC (prevalence range, 10%–54%), versus 15 of 24 short-stay hospitals (prevalence range, 0%–29%). Several patient-level covariates present at the time of survey—LTACH facility type, mechanical ventilation, and length of stay—were independent risk factors for KPC-producing Enterobacteriaceae colonization. CONCLUSIONS. We identified high colonization prevalence of KPC-producing Enterobacteriaceae among patients in LTACHs. Patients with chronic medical care needs in long-term care facilities may play an important role in the spread of these extremely drug-resistant pathogens.

Objective.Carbapenem-resistant Klebsiella pneumoniae (CRKP) is an emerging multidrug-resistant pathogen associated with higher mortality, longer hospital stays, and increased costs. CRKP was thought to be sporadic in Los Angeles County (LAC); however, the actual incidence is unknown. To address this, LAC declared CRKP a laboratory-reportable disease on June 1, 2010.Design.Laboratory-based community-wide surveillance.Patients.Any individual who was identified as CRKP positive. CRKP was defined as a K. pneumoniae isolate resistant to all carbapenems by 2010 Clinical and Laboratory Standards Institute criteria.Methods.Laboratory directors of 102 LAC acute care hospitals (ACHs) and 5 reference laboratories were to submit susceptibility testing results for all CRKP-positive specimens. Positive specimens from the same patient within the same calendar month of previous culture were excluded.Results.A total of 814 reports were received from June 1, 2010, through May 31, 2011, from 69 laboratories; 675 (83%) met the case definition. Cases were reported from ACHs (387 [57%]), long-term ACHs (LTACs; 231 [34%]), and skilled nursing facilities (57 [8%]); an outbreak in 1 LTAC was identified. The pooled mean incidence rate in LAC ACHs and LTACs was 0.46 per 1,000 patient-days; the rate in LTACs (2.54 per 1,000 patient-days) was higher than that in ACHs (0.31 per 1,000 patient-days; P < .001). Sixty-five individuals had multiple incidences, accounting for 147 case reports.Conclusion.CRKP is more present in LAC than suspected. Rates were consistently higher in LTACs than in ACHs. Heightened awareness of this problem is needed in all LAC healthcare facilities, as patients access services along the continuum of care.

We describe a pseudo-outbreak of respiratory syncytial virus infection in a neonatal intensive care unit at the White Memorial Medical Center in Los Angeles, California. Investigation of a reported cluster of cases in the early fall of 2007 identified false-positive results due to cross-reactivity between surfactant and a rapid immunoassay. This highlights the need for diagnosis confirmation, especially during periods of low disease prevalence.

Introduction Although smallpox has been eradicated, health care providers in emergency departments (EDs) need to remain vigilant to its recognition. Smallpox can be confused with chickenpox. We describe suspected smallpox cases reported in Los Angeles County from 2002 to 2006 and highlight areas for education. Methods We retrospectively reviewed suspected smallpox reports from 2002 to 2006. Laboratory testing was performed. Photographs of rashes were taken. Results Five suspected smallpox cases were reported. Two presented first to an ED. Smallpox was suspected based on rash features. Previous history of chickenpox or varicella vaccination may have caused increased suspicion for smallpox. All 5 were determined to have a final diagnosis of chickenpox. Health care providers notified public health appropriately and responses were immediate. Conclusions Public health investigated 5 suspected smallpox cases in the past 5 years. Two presented initially to EDs. Education differentiating smallpox from chickenpox and collaboration between public health, EDs, and health care providers remains important. The ability to respond rapidly to a potential bioterrorism emergency was tested.

Methicillin-resistant Staphylococcus aureus (MRSA) has become increasingly common in neonatal intensive care units and can lead to severe outcomes. Baby C, of a set of quadruplets, died of MRSA sepsis. The surviving siblings were colonized with MRSA. Expressed breast milk was fed to all infants; tested breast milk samples were all MRSA-positive. Pulsed field gel electrophoresis results of isolates from the infants and breast milk were indistinguishable.

RESULTS: The incidence of nosocomial Acinetobacter cases in TICU was 3.8/1000 pt days between 6/04 9/05 and 10/1000 pt days between 10/05 3/06 (z score 13.0). During the same time periods, the incidence in RICU went from 0.8/1000 pt days to 1.8/1000 pt days (z score 6.4). The infection control plan was initiated in 4/06. From implementation to 10/06, the rate of nosocomial Acinetobacter cases dropped to 1.6/1000 pt days in TICU (z score 212.0) and 0/1000 pt days in RICU (z score 28.3). The first patient who developed a nosocomial Acinetobacter infection after implementation (6/06), was a burn patient unable to be bathed with chlorhexidine. Antibiograms from Q4 2005 compared to Q1 2006 demonstrated increased antibiotic resistance among Acinetobacter isolates in each unit. 4/06 10/06, hand hygiene compliance after patient contact was 72% in both units and housekeeping compliance for TICU and RICU was 85% and 75%, respectively. Feedback continues to be distributed to each unit.