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Ceftriaxone-resistant Salmonella enterica serotype Typhi (Typhi), the bacterium that causes typhoid fever, is a growing public health threat. Extensively drug-resistant (XDR) Typhi is resistant to ceftriaxone and other antibiotics used for treatment, including ampicillin, chloramphenicol, ciprofloxacin, and trimethoprim-sulfamethoxazole (1). In March 2018, CDC began enhanced surveillance for ceftriaxone-resistant Typhi in response to an ongoing outbreak of XDR typhoid fever in Pakistan. CDC had previously reported the first five cases of XDR Typhi in the United States among patients who had spent time in Pakistan (2). These illnesses represented the first cases of ceftriaxone-resistant Typhi documented in the United States (3). This report provides an update on U.S. cases of XDR typhoid fever linked to Pakistan and describes a new, unrelated cluster of ceftriaxone-resistant Typhi infections linked to Iraq. Travelers to areas with endemic Typhi should receive typhoid vaccination before traveling and adhere to safe food and water precautions (4). Treatment of patients with typhoid fever should be guided by antimicrobial susceptibility testing whenever possible (5), and clinicians should consider travel history when selecting empiric therapy.

BackgroundSince the identification of the first 2 Candida auris cases in Chicago, Illinois, in 2016, ongoing spread has been documented in the Chicago area. We describe C. auris emergence in high-acuity, long-term healthcare facilities and present a case study of public health response to C. auris and carbapenemase-producing organisms (CPOs) at one ventilator-capable skilled nursing facility (vSNF-A).MethodsWe performed point prevalence surveys (PPSs) to identify patients colonized with C. auris and infection-control (IC) assessments and provided ongoing support for IC improvements in Illinois acute- and long-term care facilities during August 2016–December 2018. During 2018, we initiated a focused effort at vSNF-A and conducted 7 C. auris PPSs; during 4 PPSs, we also performed CPO screening and environmental sampling.ResultsDuring August 2016–December 2018 in Illinois, 490 individuals were found to be colonized or infected with C. auris. PPSs identified the highest prevalence of C. auris colonization in vSNF settings (prevalence, 23–71%). IC assessments in multiple vSNFs identified common challenges in core IC practices. Repeat PPSs at vSNF-A in 2018 identified increasing C. auris prevalence from 43% to 71%. Most residents screened during multiple PPSs remained persistently colonized with C. auris. Among 191 environmental samples collected, 39% were positive for C. auris, including samples from bedrails, windowsills, and shared patient-care items.ConclusionsHigh burden in vSNFs along with persistent colonization of residents and environmental contamination point to the need for prioritizing IC interventions to control the spread of C. auris and CPOs.

Early studies suggest that COVID-19 vaccines protect against severe illness (1); however, postvaccination SARS-CoV-2 infections (i.e., breakthrough infections) can occur because COVID-19 vaccines do not offer 100% protection (2,3). Data evaluating the occurrence of breakthrough infections and impact of vaccination in decreasing transmission in congregate settings are limited. Skilled nursing facility (SNF) residents and staff members have been disproportionately affected by SARS-CoV-2, the virus that causes COVID-19 (4,5), and were prioritized for COVID-19 vaccination (6,7). Starting December 28, 2020, all 78 Chicago-based SNFs began COVID-19 vaccination clinics over several weeks through the federal Pharmacy Partnership for Long-Term Care Program (PPP).† In February 2021, through routine screening, the Chicago Department of Public Health (CDPH) identified a SARS-CoV-2 infection in a SNF resident >14 days after receipt of the second dose of a two-dose COVID-19 vaccination series. SARS-CoV-2 cases, vaccination status, and possible vaccine breakthrough infections were identified by matching facility reports with state case and vaccination registries. Among 627 persons with SARS-CoV-2 infection across 75 SNFs since vaccination clinics began, 22 SARS-CoV-2 infections were identified among 12 residents and 10 staff members across 15 facilities ≥14 days after receiving their second vaccine dose (i.e., breakthrough infections in fully vaccinated persons). Nearly two thirds (14 of 22; 64%) of persons with breakthrough infections were asymptomatic; two residents were hospitalized because of COVID-19, and one died. No facility-associated secondary transmission occurred. Although few SARS-CoV-2 infections in fully vaccinated persons were observed, these cases demonstrate the need for SNFs to follow recommended routine infection prevention and control practices and promote high vaccination coverage among SNF residents and staff members.

Objectives Widespread global transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the virus causing coronavirus disease 2019 (COVID-19), continues. Many questions remain about asymptomatic or atypical infections and transmission dynamics. We used comprehensive contact tracing of the first 2 confirmed patients in Illinois with COVID-19 and serologic SARS-CoV-2 antibody testing to determine whether contacts had evidence of undetected COVID-19. Methods Contacts were eligible for serologic follow-up if previously tested for COVID-19 during an initial investigation or had greater-risk exposures. Contacts completed a standardized questionnaire during the initial investigation. We classified exposure risk as high, medium, or low based on interactions with 2 index patients and use of personal protective equipment (PPE). Serologic testing used a SARS-CoV-2 spike enzyme-linked immunosorbent assay on serum specimens collected from participants approximately 6 weeks after initial exposure to either index patient. The 2 index patients provided serum specimens throughout their illness. We collected data on demographic, exposure, and epidemiologic characteristics. Results Of 347 contacts, 110 were eligible for serologic follow-up; 59 (17% of all contacts) enrolled. Of these, 53 (90%) were health care personnel and 6 (10%) were community contacts. Seventeen (29%) reported high-risk exposures, 15 (25%) medium-risk, and 27 (46%) low-risk. No participant had evidence of SARS-CoV-2 antibodies. The 2 index patients had antibodies detected at dilutions >1:6400 within 4 weeks after symptom onset. Conclusions In serologic follow-up of the first 2 known patients in Illinois with COVID-19, we found no secondary transmission among tested contacts. Lack of seroconversion among these contacts adds to our understanding of conditions (ie, use of PPE) under which SARS-CoV-2 infections might not result in transmission and demonstrates that SARS-CoV-2 antibody testing is a useful tool to verify epidemiologic findings.

Background Coronavirus disease 2019 (COVID-19) is a disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), first detected in China in December, 2019. In January, 2020, state, local, and federal public health agencies investigated the first case of COVID-19 in Illinois, USA. Methods Patients with confirmed COVID-19 were defined as those with a positive SARS-CoV-2 test. Contacts were people with exposure to a patient with COVID-19 on or after the patient's symptom onset date. Contacts underwent active symptom monitoring for 14 days following their last exposure. Contacts who developed fever, cough, or shortness of breath became persons under investigation and were tested for SARS-CoV-2. A convenience sample of 32 asymptomatic health-care personnel contacts were also tested. Findings Patient 1-a woman in her 60s-returned from China in mid-January, 2020. One week later, she was hospitalised with pneumonia and tested positive for SARS-CoV-2. Her husband (Patient 2) did not travel but had frequent close contact with his wife. He was admitted 8 days later and tested positive for SARS-CoV-2. Overall, 372 contacts of both cases were identified; 347 underwent active symptom monitoring, including 152 community contacts and 195 health-care personnel. Of monitored contacts, 43 became persons under investigation, in addition to Patient 2. These 43 persons under investigation and all 32 asymptomatic health-care personnel tested negative for SARS-CoV-2. Interpretation Person-to-person transmission of SARS-CoV-2 occurred between two people with prolonged, unprotected exposure while Patient 1 was symptomatic. Despite active symptom monitoring and testing of symptomatic and some asymptomatic contacts, no further transmission was detected. Funding None.

Background:Candida auris and carbapenemase-producing organisms (CPO) are multidrug-resistant organisms that can colonize people for prolonged periods and can cause invasive infections and spread in healthcare settings, particularly in high-acuity long-term care facilities. Point-prevalence surveys (PPSs) conducted in long-term acute-care hospitals in the Chicago region identified median prevalence of colonization to be 31% for C. auris and 24% for CPO. Prevalence of C. auris colonization has not been described in pediatric populations in the United States, and limited data exist on CPO colonization in children outside intensive care units. The Chicago Department of Public Health (CDPH) conducted a PPS to assess C. auris and CPO colonization in a pediatric hospital serving high-acuity patients with extended lengths of stay (LOS). Methods: CDPH conducted a PPS in August 2019 in a pediatric hospital with extended LOS to screen for C. auris and CPO colonization. Medical devices (ie, gastrostomy tubes, tracheostomies, mechanical ventilators, and central venous catheters [CVC]) and LOS were documented. Screening specimens consisted of composite bilateral axillae and groin swabs for C. auris and rectal swabs for CPO testing. The Wisconsin State Laboratory of Hygiene tested all specimens. Real-time polymerase chain reaction (PCR) assays were used to detect C. auris DNA and carbapenemase genes: blaKPC, blaNDM, blaVIM, blaOXA-48, and blaIMP (Xpert Carba-R Assay, Cepheid, Sunnyvale, CA). All axillae and groin swabs were processed by PCR and culture to identify C. auris. For CPO, culture was only performed on PCR-positive specimens. Results: Of the 29 patients hospitalized, 26 (90%) had gastrostomy tubes, 24 (83%) had tracheostomies, 20 (69%) required mechanical ventilation, and 3 (10%) had CVCs. Also, 25 (86%) were screened for C. auris and CPO; 4 (14%) lacked parental consent and were not swabbed. Two rectal specimens were unsatisfactory, producing invalid CPO test results. Median LOS was 35 days (range, 1–300 days). No patients were positive for C. auris. From CPO screening, blaOXA-48 was detected in 1 patient sample, yielding a CPO prevalence of 3.4% (1 of 29). No organism was recovered from the blaOXA-48 positive specimen. Conclusions: This is the first documented screening of C. auris colonization in a pediatric hospital with extended LOS. Despite a high prevalence of C. auris and CPOs in adult healthcare settings of similar acuity in the region, C. auris was not identified and CPOs were rare at this pediatric facility. Additional evaluations in pediatric hospitals should be conducted to further understand C. auris and CPO prevalence in this population.Funding: NoneDisclosures: None

Background: Since the initial identification of Candida auris in 2016 in Chicago, ongoing spread has been documented in the Chicago area, primarily among older adults with complex medical issues admitted to high-acuity long-term care facilities, including long-term acute-care hospitals (LTACHs). As of October 2019, 790 cases have been reported in Illinois. Knowing C. auris colonization status on admission is important for prompt implementation of infection control precautions. We describe periodic facility point-prevalence surveys (PPSs) and admission screening at LTACH A. Methods: Beginning September 2016, we conducted repeated PPSs for C. auris colonization at LTACH A. After a baseline PPS, we initiated admission screening in May 2019 for patients without prior evidence of C. auris colonization or infection. C. auris screening specimens consisted of composite bilateral axillary/inguinal swabs tested at public health laboratories. We compared a limited set of patient characteristics based on admission screening results. Results: From September 2016 through October 2019, 277 unique patients were screened at LTACH A during 10 PPSs. Overall, 36 patients (13%) were identified to be colonized. The median facility C. auris prevalence increased from 2.8% in 2016 to 37% in 2019 (Fig. 1). During May–September 2019, among 174 unique patients admitted, 151 (87%) were screened for C. auris colonization on admission, of whom 18 (12%) were found to be colonized. Overall, 14 patients were known to have C. auris colonization on admission and were not rescreened, and 9 patients were discharged before screening specimens could be collected. A significantly higher proportion of patients testing positive for C. auris on admission had a central venous catheter or a peripherally inserted central catheter or were already on contact precautions (Table 1). The PPS conducted on October 1, 2019, revealed 5 new C. auris colonized patients who had screened negative on admission. Conclusions: Repeated PPSs at LTACH A indicated control of C. auris transmission in 2016–2017, followed by increasing prevalence beginning in May 2018, likely from patients admitted with unrecognized C. auris colonization and subsequent facility spread. Admission screening allowed for early detection of C. auris colonization. However, identification during subsequent PPS of additional colonized patients indicates that facility transmission is ongoing. Both admission screening and periodic PPSs are needed for timely detection of colonized patients. Given the high C. auris prevalence in LTACHs and challenges in identifying readily apparent differences between C. auris positive and negative patients on admission, we recommend that all patients being admitted to an LTACH in endemic areas should be screened for C. auris.Funding: NoneDisclosures: None

Background: U.S. rural populations have been disproportionately affected by the syndemic of opioid-use disorder (OUD) and the associated increase in overdoses and risk of hepatitis C virus (HCV) and human immunodeficiency virus (HIV) transmission. Local health departments (LHDs) can play a critical role in the response to this syndemic. We utilized two geospatial approaches to identify areas of discordance between LHD service availability and disease burden to inform service prioritization in rural settings. Methods: We surveyed rural Illinois LHDs to assess their OUD-related services, and calculated county-level opioid overdose, HIV, and hepatitis C diagnosis rates. Bivariate choropleth maps were created to display LHD service provision relative to disease burden in rural Illinois counties. Results: Most rural LHDs provided limited OUD-related services, although many LHDs provided HIV and HCV testing. Bivariate mapping showed rural counties with limited OUD treatment and HIV services and with corresponding higher outcome/disease rates to be dispersed throughout Illinois. Additionally, rural counties with limited LHD-offered hepatitis C services and high hepatitis C diagnosis rates were geographically concentrated in southern Illinois. Conclusions: Bivariate mapping can enable geographic targeting of resources to address the opioid crisis and related infectious disease by identifying areas with low LHD services relative to high disease burden.

Background Antimicrobial Stewardship Programs (ASPs) in long-term care facilities is a Centers for Medicare and Medicaid Services requirement as of 2017. The CDC recommends that ASPs in skilled nursing facilities (SNFs) fulfill 7 Core Elements: leadership commitment, accountability, drug expertise, action, tracking, reporting and education. Methods An electronic survey utilizing REDCap was sent to the 76 Chicago SNFs representatives (Administrator, Director of Nursing, and/or Assistant Director of Nursing). Survey questions were adopted from the CDC Core Elements of Antimicrobial Stewardship for Nursing Homes Checklist. Results Twenty-seven (36%) of Chicago SNFs responded. Bed size ranged from 36 – 307 (median 150). Although 93% of facilities had a written statement of leadership support for antimicrobial stewardship, only 22% cited any budgeted financial support for antimicrobial stewardship activities. While Pharmacist Consultants visited all SNFs (most visiting monthly), only 33% of SNFs had an Infectious Disease Provider that consulted on-site. Dedicated time for antimicrobial stewardship activities was less than 10 hours per week in 78% of facilities, with half of all respondents reporting less than 5 hours per week. Treatment guidelines were in place for 63% of SNFs, 56% had an antibiogram, and only 7% utilized the Loeb criteria to guide appropriate antibiotic prescribing. Many facilities tracked antimicrobial stewardship metrics (93%) and reported out to staff (70%). Annual nursing training on antimicrobial stewardship occurs more frequently (85%) than prescriber education (56%). The top 3 barriers identified in implementing ASPs were financial limitations (33%), lack of clinical expertise (33%), and provider opposition (30%). Facilities’ compliance in all seven core elements varied from partially compliant (65%), majority compliant (19%), and majority non-compliant (16%). Conclusion Data from this baseline survey informed focused antimicrobial stewardship initiatives for the GAIN Collaborative. Targeted areas to incorporate into facility action plans include treatment guideline development, antibiograms, annual staff antimicrobial stewardship education, and adoption of the Loeb minimum criteria for antibiotic prescribing into clinical practice. Disclosures All authors: No reported disclosures.

Background Emerging CPO in the Chicago area poses clinical and infection control challenges across the spectrum of care. Since November 2013, CPO are reportable to the Illinois’ Extensively Drug-resistant Organism (XDRO) registry. We examined trends in mechanism of resistance (MOR) among CPO reported through December 2018. Methods MOR reported into the XDRO registry were identified by clinical laboratories performing molecular methods on routine clinical cultures, by public health laboratories during point prevalence surveys (PPS) in response to clusters and as part of a project to assess CPO prevalence in high-risk Chicago area healthcare settings. Chicago patients with known MOR other than Klebsiella pneumoniae carbapenemase (KPC) are investigated by Chicago Department of Public Health (CDPH) to implement containment strategies and identify risk factors within 6 months of culture date. Results MOR was identified in 40% (1,216/3,587) of CPO-positive specimens collected from unique Chicago patients; 87% were KPC, 7% New Delhi metallo-β-lactamase (NDM), 5% Verona integron-mediated metallo-β-lactamase (VIM), 0.6% OXA-48-type carbapenemases, and 0.01% Imipenemase metallo-β-lactamase (IMP) (figure). Since 2017, 15 patients with CPO expressed more than one MOR; 14 were identified during PPS at ventilator capable skilled nursing facilities (vSNF) or long-term acute care hospitals (LTACH), and one was hospitalized in India. Among 156 patients with non-KPC CPO, the median age was 64 years (range, 20–97), 107 (69%) were identified from rectal screening and 49 (31%) were from clinical specimens, most of which were urine 23 (47%) or blood 6 (12%). Among 134 patients with risk factor history, 64% had history of tracheostomy (Table 1). Among 113 patients without documented travel outside of the United States, all stayed overnight at an Illinois healthcare facility; 62% stayed in a vSNF and 24% in an LTACH within 6 months of identification (Table 2). Conclusion We have increasingly detected non-KPC CPO in Chicago; however, estimates of prevalence are limited by lack of systematic surveillance and molecular testing. The high proportion of CPO patients without travel who stayed in vSNF or LTACH underscores the need for infection control training and surveillance in these settings. Disclosures All Authors: No reported Disclosures.

Background Antimicrobial Stewardship Programs (ASPs) in long-term care facilities are a Center for Medicare and Medicaid Services requirement as of 2017. The CDC estimates 40–75% of antibiotic prescribing in skilled nursing facilities (SNFs) is inappropriate. Overuse of antibiotics can cause harm by increasing the risk of adverse drug events (including C. difficile infections) and antimicrobial resistance. Methods The GAIN Collaborative was launched to assist SNFs in improving antibiotic prescribing. A list of antibiotics prescribed was generated from the electronic health records, and a chart review was performed. Results Antibiotic orders from September 2018 to March 2019 were randomly selected at 4 SNFs, and 120 antibiotic courses were reviewed (23, 40, 25, and 32 at SNFs A-D). Bed size ranged from 72 to 156 (median 88). Inappropriate antibiotic prescribing ranged from 60 to 78% (median 71%) among facilities. Urinary tract infections (UTIs) were the most frequent indication (40%), followed by lower respiratory tract infections (LRTIs), and skin and soft-tissue infections (SSTIs), accounting for 26% and 19% of indications, respectively. Inappropriate prescribing rates by indication were 90% for UTIs, 78% for SSTIs, and 47% for LRTIs. The most common reasons for inappropriate antibiotic prescribing were: insufficient signs and symptoms based on the Loeb minimum criteria for starting antibiotics (43%), inappropriate agent selection (30%), and lengthy treatment durations (29%). The majority of antibiotics prescribed were β-lactams (42%) or fluoroquinolones (29%). The median antibiotic prescription duration for non-catheter-associated UTIs was 5 days, LRTIs was 7 days, catheter-associated UTIs was 10 days, prophylaxis was 10 days, and SSTIs was 13 days. Conclusion Inappropriate antibiotic use was common in the four Chicago SNFs assessed. Results were presented at each facility’s Quality Assurance meeting to deliver provider-focused feedback. Additionally, provider and nursing education has been conducted at the four SNFs aimed at reducing unnecessary treatment of asymptomatic bacteriuria. Any improvements in antibiotic use will be captured through repeat point prevalence surveys post-implementation of a UTI SBAR communication tool and common infection treatment guidelines. Disclosures All authors: No reported disclosures.