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Background Late-onset infection is a serious cause of mortality and long-term morbidity in NICU patients. Healthcare worker hands are the most common vehicle for transmission of pathogenic organisms to neonates. Studies have suggested a reduction in infections in neonatal and pediatric patients cared for with universal nonsterile glove use. Methods We developed an online survey (https://fhspeds.mcmaster.ca/pedsCapOne/surveys/?s=9RDX7EHT79) for clinicians to understand the current glove use and hand hygiene practices in NICUs in North America. The survey was sent to neonatologists and Pediatric Infectious Disease Specialists via the AAP Neonatal-Perinatal Section listserv, SHEA and the Canadian Neonatal Network. Results Of 336 responses; the majority were from physicians at level 3 to 4 NICUs (97%), and from the United States (96.1%). Beyond sterile procedures, sterile gloves were used for central line dressing changes (88.4%), contact with central nervous system shunts (61.0%), and direct contact with central lines (57.4%). Nonsterile gloves were used most commonly for universal precautions and diaper changes (Table 1). Almost half of participants also used nonsterile gloves for all patients and 37.5% for extremely low birth weight (<1000 g) infants. While most sites (76.8%) stated that nonsterile gloves were not required for parents, 15.8% requested gloves also for parents. 58% of respondents felt there was not enough evidence for a practice change at this time and 53.3% felt further study was needed to assess the effect of nonsterile gloves and infection (Figures 2 and 3). Almost a third of respondents (n = 109) would be interested in participating in a randomized study to assess glove-based care. Major concerns with this approach included a possible reduction in hand hygiene compliance, environmental waste, and glove contamination (Figure 4). Conclusion There is variability in gloving practices across NICUs in North America, with equipoise and interest in a potential randomized study to further explore the hypothesis that nonsterile gloves prevent late-onset infections in neonates. Disclosures All authors: No reported disclosures. [ABSTRACT FROM AUTHOR]

Background Empiric therapy for possible late-onset sepsis (LOS) due to Gram-positive bacteria in the neonatal intensive care unit (NICU) has included vancomycin to cover, among other pathogens, coagulase-negative staphylococci (CoNS) which are the most frequent cause of bloodstream infections (BSI). In 2015, Nationwide Children's Hospital (NCH) neonatal antimicrobial stewardship (nASP) team recommended nafcillin rather than vancomycin, in combination with gentamicin, as the preferred agent for empiric therapy of LOS in infants not colonized with methicillin-resistant Staphylococcus aureus , irrespective of presence of a central venous catheter. The NCH nASP team provides oversight for 6 Columbus NICUs, and Our objective was to evaluate the impact of the vancomycin reduction program, with secondary objectives including duration of therapy, recurrence of BSI within 14 days of completion of therapy, and mortality. Methods The pharmacy database at NCH was queried with respect to all nafcillin and vancomycin use from 2013–2018. Pertinent clinical and laboratory data were obtained from the electronic health record (EHR) on all infants who had nafcillin or vancomycin therapy initiated, with each initiation defined as an antibiotic "course." Results From 1/2013 to December 2014 (pre-vancomycin reduction), there was an average of 112 vancomycin and 42 nafcillin courses provided to infants each year. From 1/2015 to December 2018, the use of nafcillin increased to an average of 90 courses while vancomycin decreased to 55 courses per year (P < 0.01). Since the institution of the vancomycin reduction program, preliminary EHR review of 50 infants has shown that 9 had a positive blood culture (7 CoNS; 2 methicillin-susceptible S. aureus ; 1 Escherichia coli). All CoNS isolates were resistant to nafcillin, and all infants sterilized the blood culture within 24 hours of vancomycin. The overall median length of therapy was 3 days with nafcillin or vancomycin. However, when excluding rule outs, the median duration of therapy was 9.5 days. There was no BSI recurrence or infection-related death. Conclusion An empiric antibiotic regimen that includes nafcillin rather than vancomycin for possible LOS in high-risk infants in the NICU effectively and safely reduced overall vancomycin use. Disclosures All authors: No reported disclosures. [ABSTRACT FROM AUTHOR]

Background Congenital cytomegalovirus (cCMV) infection is the most common cause of non-genetic sensorineural hearing loss in infancy. Screening of newborns for cCMV infection has been performed utilizing saliva due to ease of collection and high sensitivity. Positive saliva screens for CMV DNA by polymerase chain reaction (PCR) testing has been reported to occur secondary to breast milk feeding without signifying congenital infection. The NICUs of Nationwide Children's Hospital recently began universal saliva screening of all admissions. We report 3 neonates whose saliva CMV screen was positive yet the urine CMV PCR test was negative in order to inform CMV screening strategies. Methods Retrospective review of the electronic health records of neonates admitted to the neonatal intensive unit (NICU) at Nationwide Children's Hospital, Columbus, OH who had CMV detected by PCR from saliva specimens but not from urine. Pertinent demographic and clinical data were obtained. Results Three female neonates had a positive saliva CMV DNA PCR test but urine CMV PCR was negative. The first infant (gestational age [GA] 34 weeks, birth weight [BW]1790 Grams) was a monochorionic diamionic twin gestation and born vaginally with unknown duration of rupture of membranes (ROM). At 16 days of age, the infant had a positive saliva CMV PCR but a negative urine CMV PCR test. The infant received maternal milk. The twin's CMV PCR tests of saliva and urine were negative. The second infant (GA 38 weeks, BW 2952 grams) was born vaginally after 9 hours of ROM. On the first day of age, the infant had a positive saliva CMV PCR test that was followed by a negative urine CMV PCR on the third day of age. The infant had not been breastfed. The third infant (GA 33 weeks, BW 1762 grams) was born by C-section delivery with ROM at delivery. Saliva CMV PCR screen was positive on the second day of age but urine PCR was negative twice (days 5 and 7). All 3 infants had no signs/symptoms of cCMV infection and passed the newborn hearing screen. Conclusion Testing of saliva for CMV DNA by PCR is not always confirmatory for cCMV infection as contamination of saliva specimens with CMV could result from exposure to maternal milk and possibly vaginal secretions. Definitive diagnosis of cCMV infection requires additional confirmatory testing preferably with urine. Disclosures All authors: No reported disclosures. [ABSTRACT FROM AUTHOR]

Background Infants admitted to the neonatal intensive care unit (NICU) are at high risk for healthcare-associated infections (HAIs) due to their immature immune systems and need for invasive devices. Parents have frequent contact with their infants and present an opportunity for prevention practices. The objective of this study was to evaluate parental opinions related to infection prevention and control (IPAC) in the NICU. Methods An online survey was sent to a network of 2,000 parents from the Canadian Premature Babies Foundation. The survey included questions about patient-centered outcomes, IPAC practices experienced during their infants' NICU admission, and specifically, opinions regarding nonsterile glove use by both healthcare workers (HCWs) and parents. Results A total of 72 parents responded to the survey. The majority were parents of infants born at less than 37 weeks (94%) and had been admitted to an NICU after 2010 (89%). When asked about preventing infections in the NICU, 82% of parents indicated they had been given information on how the NICU prevents infection and 96% had been told how they can prevent infection in their infant (Table 1). The most common information was related to hand hygiene (96%) and what to do if they were unwell (89%). Opportunities for improvement included being bare below the elbow, nail care, and feeding human milk. With respect to IPAC outcomes of interest, 96% agreed that it was important to study interventions to reduce bloodstream infections (BSIs). Other outcomes of interest (Table 2) included necrotizing enterocolitis (72%), antibiotic-resistant organism acquisition (69%), and length of stay (67%). With respect to glove use, 89% of parents felt that it was acceptable for HCWs to wear gloves when caring for their infant. Only 37% of parents indicated that they would want to wear gloves if HCWs were wearing gloves, but 47% would consider wearing gloves if there was evidence that it reduced infection in their infant. Conclusion Reducing infections, specifically BSIs, in infants admitted to the NICU is an outcome of interest for parents. Nonsterile gloving by HCWs is considered an acceptable strategy by parents to reduce infections. Missed opportunities exist for the education of parents in the NICU on IPAC practices. Disclosures All authors: No reported disclosures. [ABSTRACT FROM AUTHOR]

Background Disseminated neonatal herpes simplex virus (dHSV) infection is associated with substantial morbidity and an estimated case fatality rate of ~25% despite antiviral therapy. Contemporary data on predictors of mortality among infants with dHSV infection are limited. Methods From January 2012 to December 2018, neonates with HSV infection were identified by the Virology database at Nationwide Children's Hospital. Demographic, clinical, laboratory, and radiographic data were obtained from the infants' electronic healthcare records to identify cases of dHSV infection and to determine possible predictor(s) of mortality. dHSV was defined as detection of HSV DNA by polymerase chain reaction (PCR) in blood, cerebrospinal fluid, or skin/eye/mouth, and evidence of hepatitis, pneumonitis, sepsis, or coagulopathy, with or without central nervous system involvement. Results Of 43 neonates with HSV infection, 12 (28%) infants (median [IQR] age: 8.5 [7–11] days) had dHSV and 6 (50%) died. Clinical and laboratory findings of neonates who survived vs. those who died are presented in Table 1. The median duration of symptoms at presentation was 1.5 [1–2] days. Among infants who died, the median duration of hospitalization to time of death was 1.5 days (range, 0 to 4 days). Clinical signs at presentation and blood semiquantiative viral loads (cycle threshold, Ct) were not different between infants who survived (Ct 18.0 [15.4–23.3]) and those who died (16.6 [13.4–23.3]; P > 0.05). Initial serum alanine aminotransferase (ALT), INR or lactate were not different between the two groups. However, initial serum median albumin concentration was lower among those who died vs. survivors (1.8 g/dL vs. 2.7 g/dL, P = 0.004). To assess the sensitivity and specificity of potential laboratory predictors of mortality, serum laboratory values were evaluated as follows (sensitivity, specificity): ALT > 800 (67%, 80%), INR > 2.7 (67%, 80%), serum lactate > 3 mmol/L (80%, 100%), and initial serum albumin < 2 g/dL (100%, 100%). Conclusion Albumin concentrations < 2 g/dL at presentation correlated highly with mortality in neonatal dHSV infection, suggesting that hypoalbuminemia may reflect components of both viral sepsis and poor synthetic liver function. Larger cohorts of neonates with dHSV infection are needed to confirm this result. Disclosures All authors: No reported disclosures. [ABSTRACT FROM AUTHOR]

Background The diagnosis of congenital cytomegalovirus (cCMV) infection requires that CMV be detected in a body fluid before 3 weeks of age. After 3 weeks, a diagnosis of cCMV infection is difficult since one cannot differentiate between prenatal, natal, and postnatal CMV acquisition. Infants who refer on the newborn hearing screen often are diagnosed with hearing loss after 3 weeks of age. Our objective was to describe the use of the newborn dried blood spot (DBS) for detection of CMV DNA in infants who are evaluated for sensorineural hearing loss (SNHL). Methods Retrospective review of the electronic health records of infants who were referred to the Neonatal Infectious Disease (NEO-ID) Clinic at Nationwide Children's Hospital, Columbus, OH since 2015 for evaluation of SNHL. Demographic, clinical, laboratory, and radiographic data were reviewed. With maternal informed consent, the newborn DBS was obtained from the Ohio Department of Health for detection of CMV DNA by polymerase chain reaction (PCR) testing as previously described (Boppana et al. JAMA , 2010). Results Eighteen infants (gestational age [mean ± SD], 38 ± 4 weeks; birth weight, 3,094 ± 705 g) with SNHL were referred by Otolaryngology for evaluation of possible cCMV infection; 17 (94%) had referred on the newborn hearing screen. The 18 infants were first tested for CMV at 151 ± 124 days of age (mean ±SD; range, 21–521 days), and 3 (17%) had a positive CMV DBS. Fourteen (78%) of the 18 infants had a positive serum CMV IgG antibody while 5 (63%) of 8 infants had CMV DNA detected in urine by PCR. Of the 3 infants with a positive CMV DBS, 2 were tested for CMV DNA PCR in urine and both were positive. Of the 3 infants, 1 had a negative serum CMV IgG antibody test at 174 days of age but the urine CMV PCR test was positive. In comparison, of 54 infants with cCMV infection confirmed by a positive urine CMV PCR in the first 3 weeks of age, 37 (68%) had a positive CMV DBS. Conclusion DBS testing for CMV DNA by PCR testing identified a small minority of infants with SNHL and thus confirming congenital infection. However, the overall sensitivity of CMV DBS testing in our cohort was 68%, suggesting that some infants with SNHL due to congenital CMV infection are missed. Disclosures All authors: No reported disclosures. [ABSTRACT FROM AUTHOR]

An abstract of the article "Neonatal Candidiasis: Epidemiology, Risk Factors, and Clinical Judgment," by Daniel K. Benjamin and colleagues is presented.