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The coronavirus disease 2019 (COVID-19) pandemic has had a profound and often devastating impact on global healthcare systems. Healthcare systems have had to repurpose programs and staff as part of COVID-19 relief efforts. The infrastructure and skilled personnel of antimicrobial stewardship programs (ASPs) have been utilized in new ways as part of COVID-19 pandemic response efforts. A critical focus of ASPs both before and during the pandemic has been on limiting the development of antimicrobial resistance. Fortunately, existing data indicate that rates of bacterial co-infection are relatively low and ASPs should continue aggressive efforts to limit unnecessary antimicrobial use. ASPs have taken a lead role in COVID-19 focused guideline creation and curation, as well as in helping to steward access to potential novel therapeutic agents. Disparities in ASP program resources and personnel exist, and ASP activities focused on the COVID-19 response should be tailored to individual settings. There is an urgent need for research to help inform ASP best practices within pandemic response efforts that take into account local resources. Investment in infrastructure and personnel is urgently needed both in the context of current relief efforts and to prepare for future pandemics.

The relationship between nursing staffing levels and healthcare-associated infections (HAIs) has been explored previously with conflicting results. This study uses daily shift records from 2 intensive care units (ICUs) to evaluate whether nuanced changes in nursing team composition impacts subsequent risk for device associated HAIs. Staffing deficiencies may be associated with periods of risk prior to central line-associated bloodstream infection in the ICU.

Background A 29-year-old male with recently diagnosed biventricular failure from myopericarditis and subsequent constrictive pericarditis on home milrinone presented to the Emergency Department with fevers/chills. Case summary On arrival to the Emergency Department, he was found to have septic shock and required vasopressor therapy. Chryseobacterium indologenes grew on his admission blood cultures, and he was treated with ciprofloxacin and piperacillin/tazobactam. He quickly improved, allowing for a successful pericardiectomy, was weaned off inotropes and discharged from the hospital. Discussion Chryseobacterium indologenes is an environmental Gram-negative rod found in groundwater. It is rarely associated with human infection, but is associated with indwelling lines and has been documented in immunocompromised patients. Treatment typically involves line removal and a fluoroquinolone or piperacillin/tazobactam; the most optimal antimicrobial regimen and duration of treatment are unknown.

As healthcare continues to evolve, economic forces and technological advancements have facilitated the transition of healthcare delivery from acute care hospitals to a myriad of different outpatient care settings such as ambulatory surgery centers, physician offices, dialysis centers, home care, and other specialized settings (Friedman C, Barnette M, Buck AS et al, Infect Control Hosp Epidemiol 20(10):695–705. doi:10.1086/501569, 1999). The number of outpatient visits and procedures continues to rise, with 929 million physician office visits occurring in the United States in 2012, or 301 visits per 100 persons (Ashman J, Hing E, Talwalkar A, NCHS data brief: variation in physician office visit rates by patient characteristics and state, 2012. http://www.cdc.gov/nchs/data/databriefs/db212.htm. Updated 2015. Accessed 01/14, 2016). Surgical procedures occurring in ambulatory surgical centers rose threefold between 1999 and 2005 and now represent 75% of all surgical procedures performed (Barie PS, JAMA 303(22):2295–2297. doi:10.1001/jama.2010.760, 2010). Outpatient oncologic care is also significant, with an estimated 1.1 million cancer patients per year receiving outpatient chemotherapy or radiation (Halpern MT, Yabroff KR, Cancer Investig 26(6):647–651. doi:10.1080/07357900801905519, 2008). Approximately 500,000 patients per year receive infusion therapy for maintenance hemodialysis, nutritional support, home intravenous antimicrobial therapy, or cancer chemotherapy in the outpatient setting (Williams DN, Rehm SJ, Tice AD, Bradley JS, Kind AC, Craig WA, Clin Infect Dis 25(4):787–801, 1997). While healthcare in the outpatient setting is on the rise, the overall number of inpatient hospital admissions is decreasing (35,522,000 in 2008 to 34,217,000 in 2012) (American Hospital Association. Fast facts on US hospitals. http://www.aha.org/research/rc/stat-studies/fast-facts.shtml. Updated 2015. Accessed 01/14, 2016. n.d.). These pivotal trends provide a major impetus to develop sound infection control processes and practices in the outpatient setting.

Background: Colorectal surgery is associated with a high risk of surgical site infections (SSIs), with an incidence ranging from 16.9% to 20%, and SSIs are associated with significant morbidity and mortality, prolonged length of hospitalization, and increased health care costs. Staphylococcal decolonization is an attempt to alter the microbiome to prevent staphylococcal and other skin flora from accessing the surgical site, and This practice effectively reduces SSIs in orthopedic, neurologic, and cardiac surgeries. A staphylococcal decolonization protocol was enacted in colorectal surgeries at our institution beginning in October 2016. We compared patient outcomes between patients who did and did not undergo preoperative staphylococcal decolonization. Methods: All patients undergoing nonemergent NHSN-defined colorectal procedures from July 2015 until June 2019 at a tertiary-care medical center were included in this retrospective study. Staphylococcal decolonization was performed using chlorhexidine 2% body wash solution, mupirocin nasal ointment, and chlorhexidine 0.12% oral rinse all twice daily for 5 days prior to surgery. All SSIs were defined by NSHN criteria. The primary outcome was SSI, and secondary outcomes were superficial wound infection (SIP) and organ-space infection (IAB). Predictive variables included decolonization status (yes or no), age, gender, body mass index, procedure duration, American Society of Anesthesiologists (ASA) score, diabetes, smoking, and surgical oncology service. Surgical antimicrobial prophylaxis with cefazolin and metronidazole OR cefoxitin, and chlorhexidine skin preparation were standard throughout the study period. Univariate analysis was performed using a χ2 or t test. Multivariable logistic regression was performed to control for all clinically important variables above. All statistical analyses were done using SAS version 9.4 software (Cary, NC). Results: In total, 1,139 patients underwent nonemergent colorectal surgery from July 2015 to June 2019. There were 74 SSIs: 42 IABs and 32 SIPs. Decolonization was performed in 332 of 1,139 cases (29%). There was no difference in overall SSIs between those decolonized and not decolonized (P = .50). However, SIPs were reduced in the group receiving decolonization: 1.2% (4 of 332) versus 3.5% (28 of 807) (P = .04. When controlling for known SSI risk factors, those not receiving decolonization remained at increased risk of SIPs (OR, 3.79; 95% CI, 1.14–12.61; P = .03. Conclusions: Staphylococcal decolonization may prevent a subset of SSIs in patients undergoing colorectal surgery.Funding: NoneDisclosures: Michelle Doll reports a research Grant from Molnlycke Healthcare.

OBJECTIVE This study aimed to evaluate the use of levofloxacin for the prevention of bacterial infections in pediatric patients with acute myeloid leukemia or those undergoing hematopoietic stem cell transplantation. METHODS This study was a single-center, retrospective review designed to assess the frequency of bacteremia with levofloxacin prophylaxis compared with historical controls that used other, clinician-directed antibacterial prophylaxis. The primary outcome of the study was microbiologically documented bacteremia. Secondary outcomes included febrile neutropenia, clinically documented infection, duration of neutropenia, treatment antibiotic exposure days, Clostridioides difficile infection, and infection-related mortality. RESULTS Of the 60 patients included, 24 patients with 32 hospital admissions received levofloxacin and 36 patients with 48 hospital admissions received clinician-directed prophylaxis. There was no difference found in the frequency of bacteremia between levofloxacin and clinician-directed prophylaxis (15.6% vs 10.4%, p = 0.49). There was no difference in the incidence of febrile neutropenia, clinically documented infection, treatment antibiotic exposure days, or 30-day infection-related mortality between the 2 groups. The levofloxacin group had a longer mean duration of neutropenia compared with clinician-directed prophylaxis (26.8 days vs 16.4 days, p = 0.01). CONCLUSIONS There was no difference in bacteremia between levofloxacin prophylaxis and clinician-directed prophylaxis in pediatric patients with acute myeloid leukemia or those undergoing hematopoietic stem cell transplantation. Levofloxacin prophylaxis is an appropriate alternative for the prevention of serious bacterial infections in this patient population, although further studies are needed to confirm these results.

Background The coronavirus disease 2019 (COVID-19) has swept the globe and is causing significant morbidity and mortality. Given that the virus is transmitted via droplets, open airway procedures such as bronchoscopy pose a significant risk to health-care workers (HCWs). The goal of this guideline was to examine the current evidence on the role of bronchoscopy during the COVID-19 pandemic and the optimal protection of patients and HCWs. Study Design and Methods A group of approved panelists developed key clinical questions by using the Population, Intervention, Comparator, and Outcome (PICO) format that addressed specific topics on bronchoscopy related to COVID-19 infection and transmission. MEDLINE (via PubMed) was systematically searched for relevant literature and references were screened for inclusion. Validated evaluation tools were used to assess the quality of studies and to grade the level of evidence to support each recommendation. When evidence did not exist, suggestions were developed based on consensus using the modified Delphi process. Results The systematic review and critical analysis of the literature based on six PICO questions resulted in six statements: one evidence-based graded recommendation and 5 ungraded consensus-based statements. Interpretation The evidence on the role of bronchoscopy during the COVID-19 pandemic is sparse. To maximize protection of patients and HCWs, bronchoscopy should be used sparingly in the evaluation and management of patients with suspected or confirmed COVID-19 infections. In an area where community transmission of COVID-19 infection is present, bronchoscopy should be deferred for nonurgent indications, and if necessary to perform, HCWs should wear personal protective equipment while performing the procedure even on asymptomatic patients.

The Fibrosis-4 Index (FIB-4), developed to predict fibrosis in liver disease, was used to identify patients with coronavirus disease 2019 who will require ventilator support as well as those associated with 30-day mortality. Multivariate analysis found obesity (odds ratio [OR], 4.5), diabetes mellitus (OR, 2.55), and FIB-4 ≥2.67 (OR, 3.09) independently associated with need for mechanical ventilation. When controlling for ventilator use, sex, and comorbid conditions, FIB-4 ≥2.67 was also associated with increased 30-day mortality (OR, 8.4 [95% confidence interval, 2.23–31.7]). Although it may not be measuring hepatic fibrosis, its components suggest that increases in FIB-4 may be reflecting systemic inflammation associated with poor outcomes.

The United States (US) spends more on healthcare than any other country with little evidence of better, or even comparable, outcomes. We reflect on the US and the COVID-19 pandemic and focus on cultural, economic and structural barriers that threaten both current and future responses to infectious diseases emergencies. These include the US healthcare delivery model, the defunding of public health, a scarcity of infectious diseases physicians, the market failure of vaccines and anti-infectives and the concept of American exceptionalism. Without institutionalizing the lessons learned, the US will be positioned to repeat the missteps of COVID-19 with the next pandemic.

Objective:To assess the impact of major interventions targeting infection control and diagnostic stewardship in efforts to decrease Clostridioides difficile hospital onset rates over a 6-year period.Design:Interrupted time series.Setting:The study was conducted in an 865-bed academic medical center.Methods:Monthly hospital-onset C. difficile infection (HO-CDI) rates from January 2013 through January 2019 were analyzed around 5 major interventions: (1) a 2-step cleaning process in which an initial quaternary ammonium product was followed with 10% bleach for daily and terminal cleaning of rooms of patients who have tested positive for C. difficile (February 2014), (2) UV-C device for all terminal cleaning of rooms of C. difficile patients (August 2015), (3) “contact plus” isolation precautions (June 2016), (4) sporicidal peroxyacetic acid and hydrogen peroxide cleaning in all patient areas (June 2017), (5) electronic medical record (EMR) decision support tool to facilitate appropriate C. difficile test ordering (March 2018).Results:Environmental cleaning interventions and enhanced “contact plus” isolation did not impact HO-CDI rates. Diagnostic stewardship via EMR decision support decreased the HO-CDI rate by 6.7 per 10,000 patient days (P = .0079). When adjusting rates for test volume, the EMR decision support significance was reduced to a difference of 5.1 case reductions per 10,000 patient days (P = .0470).Conclusion:Multiple aggressively implemented infection control interventions targeting CDI demonstrated a disappointing impact on endemic CDI rates over 6 years. This study adds to existing data that outside of an outbreak situation, traditional infection control guidance for CDI prevention has little impact on endemic rates.

The purpose of this article is to critically assess the literature on engaging internal medicine hospitalists in antimicrobial stewardship. Few studies exist that describe hospitalist-led antimicrobial stewardship initiatives. Most studies in this review employed quasi-experimental or quality improvement methods. Across the studies included in our analysis, those with interventions that focused on single disease processes (e.g., pneumonia, UTI, SSTI) had a more robust impact on their selected outcomes. In the reviewed literature, engaging internal medicine hospitalists in antimicrobial stewardship efforts resulted in improved antimicrobial appropriateness and decreased broad-spectrum antibiotic usage. Despite being identified as key stakeholders and potential leaders in antimicrobial stewardship efforts, there is a paucity of literature to guide the best incorporation of hospitalists in this work.

Background Gram-negative organisms (GNOs) have increasing resistance rates to levofloxacin at Virginia Commonwealth University Health System (VCUHS), where levofloxacin is the most common agent added to provide double coverage of gram-negative infections. The goal of this study was to determine the adequacy of empiric gram-negative coverage for septic patients at our institution. Methods A retrospective review of patients admitted to VCUHS, from January 1, 2014, to December 31, 2014, with a diagnosis of sepsis, severe sepsis, or septic shock and documented infection, was performed to determine the adequacy of various empiric antibiotic combinations. Results Of 219 patients who met the inclusion criteria, 56% of patients received monotherapy and 21% of patients received combination therapy (2 antibiotics) covering GNOs. GNOs (84%) were susceptible to piperacillin-tazobactam. When used in combination with cefepime and meropenem, levofloxacin did not increase coverage. However, levofloxacin provided an 8% increase in coverage and gentamicin provided an additional 13% increase in coverage, respectively, when used in combination with piperacillin-tazobactam. Conclusions Among septic patients at VCUHS, gentamicin provided increased gram-negative coverage when compared with levofloxacin. Although susceptibility to piperacillin-tazobactam alone was relatively low, the combination of piperacillin-tazobactam and gentamicin provided nearly equivalent coverage to meropenem and gentamicin.

Purpose of Review We describe the similarities between antimicrobial stewardship programs (ASPs) and infection prevention programs (IPPs), and we discuss how these similarities lend themselves to synergy between programs. We also discuss how the COVID-19 pandemic has generated further opportunities for future collaborations that could benefit both programs. Recent Findings The COVID-19 pandemic has created new needs, such as real-time data and access to personnel important to both programs, such as information technologists and infectious diseases specialists. It has also increased concerns about rising rates of antimicrobial resistance and healthcare-associated infections, both of which overlap significantly and are key focus areas for both ASPs and IPPs. These emergent issues have highlighted the need for enhanced program infrastructure and new team models. The shift towards telecommunication and telework has facilitated the creation of enhanced infrastructures for collaboration on activities ranging from data access and reporting to providing telehealth services to remote hospitals. These enhanced infrastructures can be leveraged in future collaborative efforts between ASPs and IPPs. Summary Collaboration between IPPs and ASPs can mitigate setbacks experienced by health systems during the current pandemic, enhance the performance of both programs in the post-pandemic era and increase their preparedness for future pandemic threats. As health systems plan for the post-pandemic era, they should invest in opportunities for synergy between ASPs and IPPs highlighted during the pandemic.

Outpatient empiric urinary tract infection (UTI) prescribing is an area of interest for antimicrobial stewardship efforts. We conducted a retrospective chart review evaluating optimal antibiotic prescribing for UTIs in our internal medicine and urology clinics and found significant differences in prescribing patterns between provider type and UTI category. These data will inform our antimicrobial stewardship efforts in these clinics.

Objective:To determine whether cascade reporting is associated with a change in meropenem and fluoroquinolone consumption.Design:A quasi-experimental study was conducted using an interrupted time series to compare antimicrobial consumption before and after the implementation of cascade reporting.Setting:A 399-bed, tertiary-care, Veterans’ Affairs medical center.Participants:Antimicrobial consumption data across 8 inpatient units were extracted from the Center for Disease Control and Prevention (CDC) National Health Safety Network (NHSN) antimicrobial use (AU) module from April 2017 through March 2019, reported as antimicrobial days of therapy (DOT) per 1,000 days present (DP).Intervention:Cascade reporting is a strategy of reporting antimicrobial susceptibility test results in which secondary agents are only reported if an organism is resistant to primary, narrow-spectrum agents. A multidisciplinary team developed cascade reporting algorithms for gram-negative bacteria based on local antibiogram and infectious diseases practice guidelines, aimed at restricting the use of fluoroquinolones and carbapenems. The algorithms were implemented in March 2018.Results:Following the implementation of cascade reporting, mean monthly meropenem (P =.005) and piperacillin/tazobactam (P = .002) consumption decreased and cefepime consumption increased (P < .001). Ciprofloxacin consumption decreased by 2.16 DOT per 1,000 DP per month (SE, 0.25; P < .001). Clostridioides difficile rates did not significantly change.Conclusion:Ciprofloxacin consumption significantly decreased after the implementation of cascade reporting. Mean meropenem consumption decreased after cascade reporting was implemented, but we observed no significant change in the slope of consumption. cascade reporting may be a useful strategy to optimize antimicrobial prescribing.

We employed an interrupted time series analysis to assess the impact of ultraviolet-C light disinfection at terminal discharge in an oncology unit and a bone marrow transplant unit on the incidence of hospital-acquired infections. The deployment of ultraviolet-C light disinfection was associated with a significant decrease in the rate of Clostridioides difficile infections and a significant decrease in the rate of central line-associated blood stream infections in the bone marrow transplant unit.

Background Multiple studies have shown that bathing with chlorhexidine gluconate (CHG) wipes reduces hospital-acquired infections (HAIs). We employed a mathematical model to assess the impact of CHG patient bathing on central line–associated bloodstream infections (CLABSIs), catheter-associated urinary tract infections (CAUTIs), and hospital-onset Clostridium difficile (C diff) infections and the associated costs. Methods Using a Markov chain, we examined the effect of CHG bathing compliance on HAI outcomes and the associated costs. Using estimates from 2 different studies on CHG bathing effectiveness for CLABSI, CAUTI, and C diff, the number of HAIs per year were estimated along with associated costs. The simulations were conducted, assuming CHG bathing at varying compliance rates. Results At 32% reduction in HAI incidence, increasing CHG bathing compliance from 60% to 90% results in 20 averted infections and $815,301.75 saved cost. Conclusions As CHG bathing compliance increases, yearly HAIs decrease, and the overall cost associated with the HAIs also decreases.

A primary strategy of central line-associated bloodstream infection (CLABSI) prevention is standardized, aseptic insertion of central lines. We compared hospital-wide CLABSI rate pre- and post-implementation of a dedicated procedure team as well as central line checklist completion and patient-specific variables between the procedure team and other providers. No significant differences were found. Further CLABSI prevention should focus on central line maintenance.

We systematically review the literature on antibiotics approved by the Food and Drug Administration since 2015 or that are in development through phase III trials for the treatment of infections due to gram-negative organisms. The crisis of antimicrobial resistance creates a dire need for the development of novel antimicrobials with enhanced activity against resistant bacteria. Of the agents that are currently in the pipeline or recently approved, few are from new classes and most represent modifications of preexisting agents. There continues to be a lack of treatment options especially for infections caused by organisms that produce metallo-β-lactamases. Furthermore, there is a paucity of data investigating the efficacy of these new antimicrobials for treatment of infections due to multidrug-resistant organisms. This review outlines the antimicrobials in development for the treatment of infections due to gram-negative bacteria. There are various agents in development that seem promising, but more studies are needed to evaluate the efficacy of these agents in treating infections, especially those due to multidrug-resistant organisms. The development of new antimicrobials is critical to combat the crisis of antimicrobial resistance.

Background Health care workers routinely contaminate skin and clothing when doffing personal protective equipment (PPE). Alternative doffing strategies, such as hand hygiene on gloved hands and double gloving, have been suggested but not validated by comparison against the standard Centers for Disease Control and Prevention procedures. Methods Participants were assigned to doff PPE following 1 of 4 specific strategies. Prior to doffing, PPE was “contaminated” with Glo Germ and fluorescing Staphylococcus epidermidis at the recommended level of 1.5 × 108 colony forming units/mL. After doffing, areas of self-contamination were detected using a black light. Cultures were taken from these areas using cotton swabs, inoculated onto blood agar plates, and incubated for 48hours. Each participant completed a survey regarding usability. The Fisher exact test and the Kruskal-Wallis test were used for data analysis with SAS 9.4. Results There were 51 participants who completed the study. Breaches in PPE were observed in only 5 of 51 doffs (10%). However, 46 of 51 (90%) had areas of self-contamination that was apparent by transfer of Glo Germ to skin or clothing. A subset (16%) of these sites also grew fluorescing S epidermidis. Assigned doffing strategy was associated with bacterial contamination (P = .0151), but not usability (P = .2372). Conclusions Participants experienced self-contamination when doffing PPE with both a surrogate marker and live bacteria. Close attention to doffing technique is necessary for optimal results, and one-step procedures may be more effective.

Background Pediculosis capitis is a neglected tropical disease (NTD) that receives little attention in countries where it continues to be endemic. This study aimed to understand the impact of Pediculus humanus capitis infestations in the lives of Honduran children living in extreme poverty. Methods A qualitative study on head lice infestation was conducted in June 2016 in a rural community in Honduras. Parents were invited to bring their children for head lice inspection using a dry-combing technique with a stainless steel-toothed comb with suction power. A semistructured questionnaire was administered to participants. Questions were broadly grouped into knowledge about transmission, control practices, barriers to treatment, and the overall impact of these infestations in children's wellbeing. Responses were coded, categorized, and organized through a theme-based approach. Results In total, 52 children aged 2-14 years (42 girls) and their mothers were enrolled in the study. The overall proportion of children with an infestation was 83%. Response analysis revealed a lack of understanding regarding lice transmission and stigmatization of infested children and the widespread belief that head lice were acquired during bathing in the slow-flowing river running through the village. An agricultural plaguicide was commonly used to rid children of head lice. Conclusions The study underscores the dire situation of the rural poor, their physical and mental health affected by pediculosis capitis as well as other NTDs. These results highlight the need to reassess approaches and action towards combating NTDS under an integrated framework.

Simple tests of routine data are needed for those with severe acute respiratory syndrome coronavirus 2, which causes corona virus disease 2019 (COVID-19), to help identify those who may need mechanical ventilation (MV). In this study, we aimed to determine if fibrosis-4 (FIB-4) is associated with the need for MV in patients with COVID-19 and if there is an association to determine the optimal FIB-4 cutoff. This was a retrospective, national, multiethnic cohort study of adults seen in an ambulatory or emergency department setting who were diagnosed with COVID-19. We used the TriNetX platform for analysis. Measures included demographics, comorbid diseases, and routine laboratory tests. A total of 4,901 patients with COVID-19 were included. Patients had a mean age of 56, 48% were women, 42% were obese, 38% were white, 40% were black, 15% had cardiac disease, 39% had diabetes mellitus, 20% had liver disease, and 50% had respiratory disease. The need for MV was 6%. The optimal FIB-4 cutoff for the need for MV was 3.04 (area under the curve, 0.735), which had sensitivity, specificity, and positive and negative predictive values of 42%, 77%, 11%, and 95%, respectively, with 93% accuracy. When stratified by race, increased FIB-4 remained associated with the need for MV in both white and black patients. Conclusion: FIB-4 can be used by frontline providers to identify patients that may require MV.

Purpose of Review Syndromic multiplex polymerase chain reaction (mPCR) panels offer the antimicrobial steward a rapid tool for optimizing and de-escalating antimicrobials. In this review, we analyze the role of syndromic mPCR in respiratory, gastrointestinal, and central nervous system infections within the context of antimicrobial stewardship efforts. Recent Findings For all mPCR syndromic panels, multiple studies analyzed the pre-and-post implementation impact of mPCR on antimicrobial utilization. Prospective studies and trials of respiratory mPCR stewardship interventions, including diagnostic algorithms, educational efforts, co-testing with procalcitonin, and targeted provider feedback currently exist. For gastrointestinal and cerebrospinal fluid mPCR, fewer peer-reviewed reports exist for the use of mPCR in antimicrobial stewardship. These studies demonstrated an inconsistent trend towards decreasing antibiotic use with mPCR. This is further limited by a lack of statistical significance, the absence of controlled, prospective trials, and issues with data generalizability. Summary Antibiotic overuse may improve when mPCR is coupled with electronic medical record algorithm-based approaches and direct provider feedback by an antimicrobial stewardship professional. mPCR may prove a useful tool for antimicrobial stewardship but future studies are needed to define the best practice for its utilization.

Background Guidance on the recommended durations of antibiotic therapy, the use of oral antibiotic therapy, and the need for repeat blood cultures remain incomplete for gram-negative bloodstream infections. We convened a panel of infectious diseases specialists to develop a consensus definition of uncomplicated gram-negative bloodstream infections to assist clinicians with management decisions. Methods Panelists, who were all blinded to the identity of other members of the panel, used a modified Delphi technique to develop a list of statements describing preferred management approaches for uncomplicated gram-negative bloodstream infections. Panelists provided level of agreement and feedback on consensus statements generated and refined them from the first round of open-ended questions through 3 subsequent rounds. Results Thirteen infectious diseases specialists (7 physicians and 6 pharmacists) from across the United States participated in the consensus process. A definition of uncomplicated gram-negative bloodstream infection was developed. Considerations cited by panelists in determining if a bloodstream infection was uncomplicated included host immune status, response to therapy, organism identified, source of the bacteremia, and source control measures. For patients meeting this definition, panelists largely agreed that a duration of therapy of ~7 days, transitioning to oral antibiotic therapy, and forgoing repeat blood cultures, was reasonable. Conclusions In the absence of professional guidelines for the management of uncomplicated gram-negative bloodstream infections, the consensus statements developed by a panel of infectious diseases specialists can provide guidance to practitioners for a common clinical scenario.

Challenges for infection prevention and antimicrobial stewardship programs have arisen with the fourth wave of the coronavirus disease 2019 (COVID-19) pandemic, fueled by the delta variant. These challenges include breakthrough infections in vaccinated individuals, decisions to re-escalate infection prevention measures, critical medication shortages, and provider burnout. Various strategies are needed to meet these challenges.

Background: Data regarding outpatient antibiotic prescribing for urinary tract infections (UTIs) are limited, and they have never been formally summarized in Virginia. Objective: We describe outpatient antibiotic prescribing trends for UTIs based on gender, age, geographic region, insurance payer and International Classification of Disease, Tenth Revision (ICD-10) codes in Virginia. Methods: We used the Virginia All-Payer Claims Database (APCD), administered by Virginia Health Information (VHI), which holds data for Medicare, Medicaid, and private insurance. The study cohort included Virginia residents who had a primary diagnosis of UTI, had an antibiotic claim 0–3 days after the date of the diagnosis and who were seen in an outpatient facility in Virginia between January 1, 2016, and December 31, 2016. A diagnosis of UTI was categorized as cystitis, urethritis or pyelonephritis and was defined using the following ICD-10 codes: N30.0, N30.00, N30.01, N30.9, N30.90, N30.91, N39.0, N34.1, N34.2, and N10. The following antibiotics were prescribed: aminoglycosides, sulfamethoxazole/trimethoprim (TMP-SMX), cephalosporins, fluoroquinolones, macrolides, penicillins, tetracyclines, or nitrofurantoin. Patients were categorized based on gender, age, location, insurance payer and UTI type. We used χ2 and Cochran-Mantel-Haenszel testing. Analyses were performed in SAS version 9.4 software (SAS Institute, Cary, NC). Results: In total, 15,580 patients were included in this study. Prescriptions for antibiotics by drug class differed significantly by gender (P < .0001), age (P < .0001), geographic region (P < .0001), insurance payer (P < .0001), and UTI type (P < .0001). Cephalosporins were prescribed more often to women (32.48%, 4,173 of 12,846) than to men (26.26%, 718 of 2,734), and fluoroquinolones were prescribed more often to men (53.88%, 1,473 of 2,734) than to women (47.91%, 6,155 of 12,846). Although cephalosporins were prescribed most frequently (42.58%, 557 of 1,308) in northern Virginia, fluoroquinolones were prescribed the most in eastern Virginia (50.76%, 1677 of 3,304). Patients with commercial health insurance, Medicaid, and Medicare were prescribed fluoroquinolones (39.31%, 1,149 of 2,923), cephalosporins (56.33%, 1,326 of 2,354), and fluoroquinolones (57.36%, 5,910 of 10,303) most frequently, respectively. Conclusions: Antibiotic prescribing trends for UTIs varied by gender, age, geographic region, payer status and UTI type in the state of Virginia. These data will inform future statewide antimicrobial stewardship efforts. Funding: None Disclosures: Michelle Doll reports a research grant from Molnlycke Healthcare.

The use of an electronic hand hygiene monitoring system (EHHMS) decreased due to the coronavirus disease 2019 (COVID-19) pandemic. We analyzed dispenser use, hand hygiene (HH) badge use, and HH compliance to determine the effect of COVID-19 on EHHMS use and HH compliance. HH product shortages and other pandemic-induced challenges influenced EHHMS use.

Background Contact precautions (CP) are a widely adopted strategy to prevent cross-transmission of organisms, commonly methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococcus (VRE). Some hospitals have discontinued CP for patients with MRSA or VRE; however, the impact on hospital-acquired infection rates (HAI) has not been assessed systematically. Methods Retrospective multicenter interrupted time series between 2002 and 2017 at three academic hospitals. Participating hospitals discontinued CP for patients with contained body fluids who were colonized or infected with MRSA or VRE. The primary intervention was stopping the use of CP. Secondary interventions were horizontal infection prevention strategies. The primary outcomes were rates of central line-associated bloodstream infections, catheter-associated urinary tract infections, mediastinal surgical site infection, and ventilator-associated pneumonia due to MRSA, VRE, or any organism using Centers for Disease Control and Prevention National Healthcare Safety Network surveillance definitions. Results Central line-associated bloodstream infections, catheter-associated urinary tract infections, mediastinal surgical site infection, and ventilator-associated pneumonia rates trended down at each institution. There were no statistically significant increases in these infections associated with discontinuing CP. Individual horizontal infection prevention strategies variably impacted HAI outcomes. Conclusions Stopping the routine use of CP for patients with contained body fluids who are colonized or infected with MRSA or VRE did not result in increased HAIs. Bundled horizontal infection prevention strategies resulted in sustained HAI reductions.

A novel betacoronavirus, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has spread rapidly across the globe since December 2019. Coronavirus disease 2019 (COVID-19) has a significantly higher mortality rate than seasonal influenza and has disproportionately affected older adults, especially those with cardiovascular disease and related risk factors. Adverse cardiovascular sequelae, such as myocarditis, acute myocardial infarction, and heart failure, have been reported in patients with COVID-19. No established treatment is currently available; however, several therapies, including remdesivir, hydroxychloroquine and chloroquine, and interleukin (IL)-6 inhibitors, are being used off-label and evaluated in ongoing clinical trials. Considering these therapies are not familiar to cardiovascular clinicians managing these patients, this review describes the pharmacology of these therapies in the context of their use in patients with cardiovascular-related conditions.

Antibiotic stewardship programs (ASPs) play a crucial role in controlling the emergence of resistant organisms, reducing rates of Clostridium difficile infections and associated hospital length of stay, promoting judicious use of antibiotics, and minimizing associated adverse events. There is a significant overlap between the goals of infection control programs and ASPs, and both programs can benefit from a synergistic relationship. Hospital epidemiologists can support these programs by providing leadership support, sharing surveillance data, bridging gaps between ASPs and departments such as microbiology, integrating educational programs with ASPs, sharing outbreak alerts, and assisting with the development of treatment algorithms.

Background The Centers for Medicare and Medicaid Services (CMS) implemented a core measure sepsis (SEP-1) bundle in 2015. One element was initiation of broad-spectrum antibiotics within 3 hours of diagnosis. The policy has the potential to increase antibiotic use and Clostridioides difficile infection (CDI). We evaluated the impact of SEP-1 implementation on broad-spectrum antibiotic use and CDI occurrence rates. Methods Monthly adult antibiotic data for 4 antibiotic categories (surgical prophylaxis, broad-spectrum for community-acquired infections, broad-spectrum for hospital-onset/multidrug-resistant [MDR] organisms, and anti–methicillin-resistant Staphylococcus aureus [MRSA]) from 111 hospitals participating in the Clinical Data Base Resource Manager were evaluated in periods before (October 2014–September 2015) and after (October 2015–June 2017) policy implementation. Interrupted time series analyses, using negative binomial regression, evaluated changes in antibiotic category use and CDI rates. Results At the hospital level, there was an immediate increase in the level of broad-spectrum agents for hospital-onset/MDR organisms (+2.3%, P = .0375) as well as a long-term increase in trend (+0.4% per month, P = .0273). There was also an immediate increase in level of overall antibiotic use (+1.4%, P = .0293). CDI rates unexpectedly decreased at the time of SEP-1 implementation. When analyses were limited to patients with sepsis, there was a significant level increase in use of all antibiotic categories at the time of SEP-1 implementation. Conclusions SEP-1 implementation was associated with immediate and long-term increases in broad-spectrum hospital-onset/MDR organism antibiotics. Antimicrobial stewardship programs should evaluate sepsis treatment for opportunities to de-escalate broad therapy as indicated.

The recently described proportion of carbapenem consumption metric was used to assess the effectiveness of formulary restriction for carbapenems for 2 units housing predominantly immunocompromised patients at a large academic medical center. Interrupted time series analysis revealed a significant decrease in meropenem use for hematology-oncology and bone marrow transplant units after restriction.

The impact of formulary restriction and preauthorization (FRPA) on prescribing trends was examined over a 5-year period at an academic medical center. Ordinary least squares regression was used to identify hospital units demonstrating statistically significant trends in prescription of restricted agents. Significant decreases in restricted drug use were seen on 2 of 7 medicine units subject to FRPA, whereas a significant increase was seen in 1 of 4 surgical units subject to FRPA.

We assessed the impact of an embedded electronic medical record decision-support matrix (Cerner software system) for the reduction of hospital-onset Clostridioides difficile. A critical review of 3,124 patients highlighted excessive testing frequency in an academic medical center and demonstrated the impact of decision support following a testing fidelity algorithm.

We investigated the impact of discontinuation of contact precautions for methicillin-resistant Staphylococcus aureus and vancomycin-resistant Enterococcus infected or colonized patients on central-line associated bloodstream infection rates at an academic children’s hospital. Discontinuation of contact precautions with a bundled horizontal infection prevention platform resulted in no adverse impact on CLABSI rates.

Highlights • Fungal superinfection is a concern in patients who are hospitalized with COVID-19. • There is concern that the COVID-19 pandemic will lead to the overuse of antifungals. • Antifungal use was not increased early in the COVID-19 pandemic at an academic medical center.

Background Cascade reporting (CR) is a strategy of reporting antimicrobial susceptibility test results in which secondary agents are only reported if an organism is resistant to primary, narrow spectrum agents within a drug class. A multidisciplinary team developed CR algorithms for Gram-negative bacteria based on the local antibiogram and infectious diseases practice guidelines. Methods CR was implemented at a 399-bed tertiary care VAMC in March 2018. In a quasi-experimental study, antimicrobial use data across 8 inpatient units were extracted from the CDC’s NHSN AU module from April 2017 – March 2019 (12 months pre- and post-implementation of CR), reported as antimicrobial days of therapy (DOT) per 1000 days present (DP). T-tests and linear mixed models accounting for seasonal and random unit effects were used to compare antimicrobial use pre- and post-CR implementation. Figure 1A. Cascade reporting algorithm for antimicrobial susceptibility reporting for Enterobacteriaceae Figure 1B. Cascade reporting algorithm for antimicrobial susceptibility reporting for Pseudomonas aeruginosa Results Following CR implementation, mean monthly meropenem (p=0.005) and piperacillin/tazobactam (p=0.002) use decreased, while cefepime use increased (p< 0.001). The slope of ciprofloxacin use decreased by 2.16 DOTs/1,000 DP per month (SE=0.25, p< 0.001). The slope of cefpodoxime and moxifloxacin use decreased by 18% (p< 0.001), and 7% (p< 0.001), respectively. The slope of cephalexin use decreased by 0.55 DOTs/1,000 DP (SE=0.26, p< 0.001). The slope of ceftriaxone and cefepime use increased by 1.51 (SE=0.59, p=0.011) and 1.06 (SE=.32, p=0.002) DOTs/1000 DP per month, respectively. There were no significant changes in the slope of amoxicillin/clavulanate, levofloxacin, or meropenem consumption. Rates of Clostridioides difficile infection did not significantly change. Figure 2A. Average monthly use of oral antibiotics across all units in average days of therapy (DOTs) per 1000 days present. CR = Cascade reporting. *For Cefpodoxime and moxifloxacin medians were reported as data was not normally distributed. Figure 2B. Average monthly use of intravenous antibiotics across all units in average days of therapy (DOTs) per 1000 days present. CR = Cascade reporting. Table 1. Slope of Antimicrobial Utilization Pre and Post-Cascade Reporting Implementation. Conclusion After implementation of CR, the slope of ciprofloxacin use decreased and mean monthly meropenem use decreased. CR is a valuable tool that can be employed by ASPs to encourage optimal use of antibiotics. Disclosures All Authors: No reported disclosures

Background: Central-line–associated blood stream infections (CLABSIs) are linked with significant morbidity and mortality. A NHSN laboratory-confirmed bloodstream infection (LCBSI) has specific criteria to ascribe an infection to the central line or not. The criteria used to associate the pathogen to another site are restrictive. This objective to better classify CLABSIs using enhanced criteria to gain a comprehensive understanding of the error so that appropriate reduction efforts are utilized. Methods: We conducted a retrospective review of medical records with NHSN-identified CLABSI from July 2017 to December 2018 at 2 geographically proximate hospitals. Trained infectious diseases personnel from tertiary-care academic medical centers, the University of Virginia Health System, a 600-bed medical center in Charlottesville, Virginia, and Virginia Commonwealth University Health System with 865 beds in Richmond, Virginia, reviewed charts. We defined “overcaptured” or O-CLABSI into different categories: O-CLABSI-1 is bacteremia attributable to a primary infectious source; O-CLABSI-2 is bacteremia attributable to neutropenia with gastrointestinal translocation not meeting mucosal barrier injury criteria; O-CLABSI-3 is a positive blood culture attributable to a contaminant; and O-CLABSI-4 is a patient injecting line, though not officially documented. Descriptive analyses were performed using the χ2 and the Fisher exact tests. Results: We found a large number of O-CLABSIs on chart review (79 of 192, 41%). Overall, 56 of 192 (29%) LCBSIs were attributable to a primary infectious source not meeting NHSN definition. O-CLABSI proportions between the 2 hospitals were statistically different; hospital A identified 34 of 59 (58%) of their NHSN-identified CLABSIs as O-CLABSIs, and hospital B identified a 45 of 133 (34%) as O-CLABSIs (P = .0020) (Table 1). When comparing O-CLABSI types, hospital B had a higher percentage of O-CLABSI-1 compared to hospital B: 76% versus 64%. Hospital A had a higher proportion of O-CLABSI-2: 21 versus 7%. Hospitals A and B had similar proportion of O-CLABSI-3: 15% versus 18%. These values were all statistically significant (P < .0001). Discussions: The results of these 2 geographically proximate systems indicate that O-CLABSIs are common. Attribution can vary significantly between institutions, likely depending on differences in incidence of true CLABSI, patient populations, protocols, and protocol compliance. These findings have implications for interfacility comparisons of publicly reported data. Most importantly, erroneous attribution can result in missed opportunity to direct patient safety efforts to the root cause of the bacteremia and could lead to inappropriate treatment.Funding: NoneDisclosures: Michelle Doll, Research Grant from Molnlycke Healthcare

Background: Quantification of the magnitude of CRE both within a facility and regionally poses a challenge to healthcare institutions. Periodic point-prevalence surveys are recommended by the CDC CRE tool kit as a facility-level prevention strategy. A 2016 point-prevalence survey of 2 high-risk units at a tertiary-care center in the United States for CRE colonization found that all patients surveyed were negative for CRE. The infection prevention (IP) team repeated the study in 2019 to reassess the prevalence of CRE in the healthcare facility. Methods: A point-prevalence survey was performed in November 2019 on the same 2 high-risk units surveyed in 2016. A perirectal flocked swab was collected from all patients unless a patient refused and/or a contraindication to rectal swab was present. Swabs were inoculated onto HardyChrom TM CRE agar for incubation in ambient air at 35°C for 24 hours. Organism identification was performed using MALDI-TOF mass spectrometry on a MBT Smart by Bruker. Results: None of the patients on either high-risk unit was known to be colonized or infected with CRE at the time of the point-prevalence survey. Of 41 perirectal swabs collected, 4 (9.8%) were positive for CRE. None (0 of 20) were surgical ICU patients and 4 of 21 (19%) were medical ICU patients. All positive swabs revealed different organisms identified as follows: Escherichia coli, Enterobacter cloacae, Enterobacter kobai, and Enterobacter aerogenes. All 4 positive patients had had recent contact with multiple acute-care hospitals. Also, 2 had been transferred for liver transplant evaluation. None of these patients had received a carbapenem during their admission to the facility. Conclusion: CRE are increasingly identified in healthcare centers in the United States. Centers previously classified as low prevalence will need to maintain preventive strategies to limit transmission risks as colonized patients arrive in the facility for care. Adoption of a robust horizontal infection prevention program may be an effective strategy to avoid the spread of CRE.Funding: NoneDisclosures: Michelle Doll reports a research grant from Molnlycke Healthcare.