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We reviewed the sustainability of a multifaceted intervention on catheter-associated urinary tract infection (CAUTI) in 3 intensive care units. During the 4-year postintervention period, we observed reductions in urine culture rates (from 80.9 to 47.5 per 1,000 patient days; P < .01), catheter utilization (from 0.68 to 0.58; P < .01), and CAUTI incidence rates (from 1.7 to 0.8 per 1,000 patient days; P = .16).

Objectives: To describe the epidemiology of complex colon surgical procedures (COLO), stratified by present at time of surgery (PATOS) surgical-site infections (SSIs) and non-PATOS SSIs and their impact on the epidemiology of colon-surgery SSIs. Design: Retrospective cohort study. Methods: SSI data were prospectively collected from patients undergoing colon surgical procedures (COLOs) as defined by the National Healthcare Safety Network (NHSN) at 34 community hospitals in the southeastern United States from January 2015 to June 2019. Logistic regression models identified specific characteristics of complex COLO SSIs, complex non-PATOS COLO SSIs, and complex PATOS COLO SSIs. Results: Over the 4.5-year study period, we identified 720 complex COLO SSIs following 28,188 COLO surgeries (prevalence rate, 2.55 per 100 procedures). Overall, 544 complex COLO SSIs (76%) were complex non-PATOS COLO SSIs (prevalence rate [PR], 1.93 per 100 procedures) and 176 (24%) complex PATOS COLO SSIs (PR, 0.62 per 100 procedures). Age >75 years and operation duration in the >75th percentile were independently associated with non-PATOS SSIs but not PATOS SSIs. Conversely, emergency surgery and hospital volume for COLO procedures were independently associated with PATOS SSIs but not non-PATOS SSIs. The proportion of polymicrobial SSIs was significantly higher for non-PATOS SSIs compared with PATOS SSIs. Conclusions: Complex PATOS COLO SSIs have distinct features from complex non-PATOS COLO SSIs. Removal of PATOS COLO SSIs from public reporting allows more accurate comparisons among hospitals that perform different case mixes of colon surgeries.

We performed surveillance for hospital-acquired COVID-19 (HA-COVID-19) and compared time-based, electronic definitions to real-time adjudication of the most likely source of acquisition. Without real-time adjudication, nearly 50% of HA-COVID-19 cases identified using electronic definitions were misclassified. Both electronic and traditional contact tracing methods likely underestimated the incidence of HA-COVID-19.

Background Active surveillance testing (AST) is one element of a comprehensive Carbapenem-resistant Enterobacteriaceae (CRE) prevention strategy. However, the utility of AST may be impacted by compliance with sample collection and the quality of specimens. Here, we describe strategies used to optimize a CRE AST program at a large academic medical center. Methods Tests ordered, collected, rejected, and processed were tracked weekly for each participating unit. Sample collection compliance and acceptance rates were calculated and tracked weekly. Strategies were implemented to improve collection compliance and sample acceptance rates, including computerized provider order entry, printed educational materials, and audit and feedback. Weekly dedicated Infection Preventionist (IP) time was estimated. Results Over 35 months, mean collection compliance increased from 82.7% to 91.2%, and then decreased to 86.2%. Over 27 months, sample acceptance rate increased from 57.7% to 83.6%, and then remained stable at 83.4%. Over 39 months, dedicated weekly IP time decreased 92%. Discussion Use of evidence-based quality improvement strategies optimized our CRE AST program. Optimizing the AST process aids in early CRE detection, leading to timely isolation and preventing the spread of CRE to other patients. Other hospitals may benefit from these lessons and enhance local AST programs.

Objective:To determine the impact of electronic health record (EHR)–based interventions and test restriction on Clostridioides difficile tests (CDTs) and hospital-onset C. difficile infection (HO-CDI).Design:Quasi-experimental study in 3 hospitals.Setting:957-bed academic (hospital A), 354-bed (hospital B), and 175-bed (hospital C) academic-affiliated community hospitals.Interventions:Three EHR-based interventions were sequentially implemented: (1) alert when ordering a CDT if laxatives administered within 24 hours (January 2018); (2) cancellation of CDT orders after 24 hours (October 2018); (3) contextual rule-driven order questions requiring justification when laxative administered or lack of EHR documentation of diarrhea (July 2019). In February 2019, hospital C implemented a gatekeeper intervention requiring approval for all CDTs after hospital day 3. The impact of the interventions on C. difficile testing and HO-CDI rates was estimated using an interrupted time-series analysis.Results:C. difficile testing was already declining in the preintervention period (annual change in incidence rate [IR], 0.79; 95% CI, 0.72–0.87) and did not decrease further with the EHR interventions. The laxative alert was temporally associated with a trend reduction in HO-CDI (annual change in IR from baseline, 0.85; 95% CI, 0.75–0.96) at hospitals A and B. The gatekeeper intervention at hospital C was associated with level (IRR, 0.50; 95% CI, 0.42-0.60) and trend reductions in C. difficile testing (annual change in IR, 0.91; 95% CI, 0.85–0.98) and level (IRR 0.42; 95% CI, 0.22–0.81) and trend reductions in HO-CDI (annual change in IR, 0.68; 95% CI, 0.50–0.92) relative to the baseline period.Conclusions:Test restriction was more effective than EHR-based clinical decision support to reduce C. difficile testing in our 3-hospital system.

Objective:Sparse recent data are available on the epidemiology of surgical site infections (SSIs) in community hospitals. Our objective was to provide updated epidemiology data on complex SSIs in community hospitals and to characterize trends of SSI prevalence rates over time.Design:Retrospective cohort study.Methods:SSI data were collected from patients undergoing 26 commonly performed surgical procedures at 32 community hospitals in the southeastern United States from 2013 to 2018. SSI prevalence rates were calculated for each year and were stratified by procedure and causative pathogen.Results:Over the 6-year study period, 3,561 complex (deep incisional or organ-space) SSIs occurred following 669,467 total surgeries (prevalence rate, 0.53 infections per 100 procedures). The overall complex SSI prevalence rate did not change significantly during the study period: 0.58 of 100 procedures in 2013 versus 0.53 of 100 procedures in 2018 (prevalence rate ratio [PRR], 0.84; 95% CI, 0.66–1.08; P = .16). Methicillin-sensitive Staphylococcus aureus (MSSA) complex SSIs (n = 480, 13.5%) were more common than complex SSIs caused by methicillin-resistant S. aureus (MRSA; n = 363, 10.2%).Conclusions:The complex SSI rate did not decrease in our cohort of community hospitals from 2013 to 2018, which is a change from prior comparisons. The reason for this stagnation is unclear. Additional research is needed to determine the proportion of or remaining SSIs that are preventable and what measures would be effective to further reduce SSI rates.

We analyzed the impact of a hospital tap water avoidance protocol on respiratory isolation of nontuberculous mycobacteria (NTM). After protocol implementation, hospital-onset episodes of respiratory NTM isolation on high-risk units decreased from 41.0 to 9.9 episodes per 10 000 patient-days (incidence rate ratio, 0.24; 95% confidence interval, .17–.34; P

Background The weighted incidence syndromic combination antibiogram (WISCA) is an antimicrobial stewardship tool that utilizes electronic medical record data to provide real-time clinical decision support regarding empiric antibiotic prescription in the hospital setting. The aim of this study was to determine the impact of WISCA utilization for empiric antibiotic prescription on hospital length of stay (LOS). Methods We performed a crossover randomized controlled trial of the WISCA tool at 4 hospitals. Study participants included adult inpatients receiving empiric antibiotics for urinary tract infection (UTI), abdominal-biliary infection (ABI), pneumonia, or nonpurulent cellulitis. Antimicrobial stewardship (ASP) physicians utilized WISCA and clinical guidelines to provide empiric antibiotic recommendations. The primary outcome was LOS. Secondary outcomes included 30-day mortality, 30-day readmission, Clostridioides difficile infection, acquisition of multidrug-resistant gram-negative organism (MDRO), and antibiotics costs. Results In total, 6849 participants enrolled in the study. There were no overall differences in outcomes among the intervention versus control groups. Participants with cellulitis in the intervention group had significantly shorter mean LOS compared to participants with cellulitis in the control group (coefficient estimate = 0.53 [−0.97, −0.09], P = .0186). For patients with community acquired pneumonia (CAP), the intervention group had significantly lower odds of 30-day mortality compared to the control group (adjusted odds ratio [aOR] .58, 95% confidence interval [CI], .396, .854, P = .02). Conclusions Use of WISCA was not associated with improved outcomes for UTI and ABI. Guidelines-based interventions were associated with decreased LOS for cellulitis and decreased mortality for CAP.

ObjectiveTo describe the impact of the COVID-19 pandemic on safe prescribing, using the PINCER prescribing indicators; to implement complex prescribing indicators at national scale using GP data.DesignPopulation based cohort study, with the approval of NHS England using the OpenSAFELY platform.SettingElectronic health record data from 56.8 million NHS patients’ general practice records.ParticipantsAll NHS patients registered at a GP practice using TPP or EMIS computer systems and recorded as at risk of at least one potentially hazardous PINCER indicator between September 2019 and September 2021.Main outcome measureMonthly trends and between-practice variation for compliance with 13 PINCER measures between September 2019 and September 2021.ResultsThe indicators were successfully implemented across GP data in OpenSAFELY. Hazardous prescribing remained largely unchanged during the COVID-19 pandemic, with only small reductions in achievement of the PINCER indicators. There were transient delays in blood test monitoring for some medications, particularly ACE inhibitors. All indicators exhibited substantial recovery by September 2021. We identified 1,813,058 patients at risk of at least one hazardous prescribing event.ConclusionGood performance was maintained during the COVID-19 pandemic across a diverse range of widely evaluated measures of safe prescribing.Summary boxWHAT IS ALREADY KNOWN ON THIS TOPICPrimary care services were substantially disrupted by the COVID-19 pandemic.Disruption to safe prescribing during the pandemic has not previously been evaluated.PINCER is a nationally adopted programme of activities that aims to identify and correct hazardous prescribing in GP practices, by conducting manual audit on subgroups of practices.WHAT THIS STUDY ADDSFor the first time, we were able to successfully generate data on PINCER indicators for almost the whole population of England, in a single analysis.Our study is the most comprehensive assessment of medication safety during the COVID-19 pandemic in England, covering 95% of the population using well-validated measures.Good performance was maintained across many PINCER indicators throughout the pandemic.Delays in delivering some medication-related blood test monitoring were evident though considerable recovery was made by the end of the study period.

The paradoxical relationship between standardized infection ratio and standardized utilization ratio for catheter-associated urinary tract infections (CAUTIs) in contrast to central-line–associated bloodstream infections (CLABSIs), in addition to CAUTI definition challenges, incentivizes hospitals to focus their prevention efforts on urine culture stewardship rather than catheter avoidance and care.

Background Patients with Clostridioides difficile infections (CDIs) contaminate the healthcare environment; however, the relative contribution of contamination by colonized individuals is unknown. Current guidelines do not recommend the use of contact precautions for asymptomatic C difficile carriers. We evaluated C difficile environmental contamination in rooms housing adult inpatients with diarrhea based on C difficile status. Methods We performed a prospective cohort study of inpatient adults with diarrhea who underwent testing for CDI via polymerase chain reaction (PCR) and enzyme immunoassay (EIA). Patients were stratified into cohorts based on test result: infected (PCR+/EIA+), colonized (PCR+/EIA−), or negative/control (PCR−). Environmental microbiological samples were taken within 24 hours of C difficile testing and again for 2 successive days. Samples were obtained from the patient, bathroom, and care areas. Results We enrolled 94 patients between November 2019 and June 2021. Clostridioides difficile was recovered in 93 (38%) patient rooms: 44 (62%) infected patient rooms, 35 (43%) colonized patient rooms (P = .08 vs infected 38 patient rooms), and 14 (15%) negative patient rooms (P Conclusions Patients colonized with C difficile frequently contaminated the hospital environment. Our data support the use of contact precautions when entering rooms of patients colonized with C difficile, especially when entering the bathroom.

We describe the frequency of pediatric healthcare-associated infections (HAIs) identified through prospective surveillance in community hospitals participating in an infection control network. Over a 6-year period, 84 HAIs were identified. Of these 51 (61%) were pediatric central-line–associated bloodstream infections, and they often occurred in children

Patients withWe performed a prospective cohort study of inpatient adults with diarrhea who underwent testing for CDI via polymerase chain reaction (PCR) and enzyme immunoassay (EIA). Patients were stratified into cohorts based on test result: infected (PCRWe enrolled 94 patients between November 2019 and June 2021.Patients colonized with

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We implemented universal severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) testing of patients undergoing surgical procedures as a means to conserve personal protective equipment (PPE). The rate of asymptomatic coronavirus disease 2019 (COVID-19) was

Background In 2017, our hospital was identified as a high outlier for postoperative Clostridium difficile infections (CDIs) in the American College of Surgeons NSQIP semi-annual report. The Department of Surgery initiated a CDI task force with representation from Surgery, Infectious Disease, Pharmacy, and Performance Services to analyze available data, identify opportunities for improvement, and implement strategies to reduce CDIs. Study Design Strategies to reduce CDIs were reviewed from the literature and the following multidisciplinary strategies were initiated: antimicrobial stewardship optimization of perioperative order sets to avoid cefoxitin and fluoroquinolone use was completed; penicillin allergy assessment and skin testing were implemented concomitantly; increased use of ultraviolet disinfectant strategies for terminal cleaning of CDI patient rooms; increased hand hygiene and personal protection equipment signage, as well as monitoring in high-risk CDI areas; improved diagnostic stewardship by an electronic best practice advisory to reduce inappropriate CDI testing; education through surgical grand rounds; and routine data feedback via NSQIP and National Healthcare Safety Network CDI reports. Results The observed rate of CDIs decreased from 1.27% in 2016 to 0.91% in 2017. Cefoxitin and fluoroquinolone use decreased. Clostridium difficile infection testing for patients on laxatives decreased. Terminal cleaning with ultraviolet light increased. Handwashing compliance increased. Data feedback to stakeholders was established. Conclusions Our multidisciplinary CDI reduction program has demonstrated significant reductions in CDIs. It is effective, straightforward to implement and monitor, and can be generalized to high-outlier institutions.

National guidance was issued during the COVID-19 pandemic to switch patients on warfarin to direct oral anticoagulants (DOACs) where appropriate as these require less frequent blood testing. DOACs are not recommended for patients with mechanical heart valves. We conducted a retrospective cohort study of DOAC prescribing in people with a record of a mechanical heart valve between September 2019 and May 2021, and describe the characteristics of this population. We identified 15,457 individuals with a mechanical heart valve recorded in their records, of whom 1058 (6.8%) had been prescribed a DOAC during the study period. 767 individuals with a record of a mechanical heart valve were currently prescribed a DOAC as of May 31st 2021. This is suggestive of inappropriate prescribing of DOACs in individuals with mechanical heart valves. Direct alerts have been issued to clinicians through their EHR software informing the issue. We show that the OpenSAFELY platform can be used for rapid audit and feedback to mitigate the indirect health impacts of COVID-19 on the NHS. We will monitor changes in prescribing for this risk group over the following months.

Background Data on occupational acquisition of COVID-19 in healthcare settings are limited. Contact tracing efforts are high resource investments. Methods Duke Health developed robust COVID-19 contact tracing methods as part of a comprehensive prevention program. We prospectively collected data on HCW exposures and monitored for development of symptomatic (SYX) and asymptomatic (ASYX) COVID-19 infection after documented high-, medium, and low-risk exposures. HCWs were required to self-report exposures or were identified through contact tracing as potentially exposed to COVID-19 positive HCWs, patients or visitors. Contact tracers interviewed exposed HCWs and assessed the risk of exposure as high-, medium-, or low-risk based on CDC guidance (Table 1). Testing was recommended at 6 days after high- or medium-risk exposures and was provided upon HCW request following low-risk exposures. Our vaccination campaign began in 12/2020. Results 12,916 HCWs registered in the contact tracing database. From March 2020-May 2021, we identified 6,606 occupational exposures (0.51 exposures/HCW). The highest incidence of workplace exposures per number of HCWs in each job category was among respiratory therapists (RT) (0.95 exposures/RT), nursing assistants (NA) (0.79 exposures/NA), and physicians (0.64 exposures/physician). The most common exposure risk level was medium (51.4%), followed by low (35.5%), and then high (13.1%). A total of 260 (2%) HCW had positive tests/conversions; 28 (10.8%) were ASYX at the time of testing. High-risk exposures had a significantly greater number of post-exposure infections compared to medium- and low-risk exposures (12.5% vs. 4.2%, vs. 0.4%; p < 0.001). The rate of SYX infection following exposure to a fellow HCW (179/3,198; 5.6%) was higher than that following exposure to a patient (81/3,408; 2.4%; p< 0.001). Conclusion Conversion following exposure to COVID-19 in the healthcare setting with appropriate protective equipment was low. Incomplete testing of all exposed individuals was a limitation and our data may under-estimate the true conversion rate. Our findings support our local practice of not quarantining HCWs following non-household exposures. Limiting contact tracing to only high or medium risk exposures may best utilize limited personnel resources. Disclosures Rebekah W. Moehring, MD, MPH, UpToDate, Inc. (Other Financial or Material Support, Author Royalties)

Background We aimed to describe SARS-CoV-2 (COVID-19) infections among employees in a large, academic institution. Table 1. COVID-19 Attribution Definitions Table 2. Description of 3,140 COVID 19 Infections in Employees from 3/2020 to 4/2021 Methods We prospectively tracked and traced COVID-19 infections among employees across our health system and university. Each employee with a confirmed positive test and 3 presumed positive cases were interviewed with a standard contact tracing template that included descriptive variables such as high-risk behaviors and contacts, dates worked while infectious, and initial symptoms. Using this information, the most likely location of infection acquisition was adjudicated (Table 1). We compared behavior frequency between community and unknown, likely community and community and unknown cases using descriptive statistics. Table 3. Risk Factors for Community, Likely Community, and Unknown Cases Number of SARS-CoV-2 cases among employees between 3/2020 and 4/2021 by month and stratified according to clinical employee working in the healthcare system, non-clinical employee employed by the healthcare system, and university employee Results From 3/2020 to 4/2021 we identified 3,140 COVID-19 infections in 3,119 employees out of a total of 34,562 employees (9.0%) (Figure 1). Of those 3,119 employees 1,685 (54.0%) were clinical employees working in the health system, 916 (29.4%) were non-clinical employees working in the health system, and 518 (16.6%) were university employees. Descriptive characteristics for the COVID-19 infections and adjudications are outlined in Table 2. Severe disease among employees was significantly less frequent compared to patients in the health system (15.3% vs 2.2%, p< 0.01). The frequency of travel within 14 days, masked gatherings and unmasked gatherings/activities was not significantly different between the community and unknown, likely community groups or the community and unknown groups (Table 3). Conclusion The majority of COVID-19 infections were linked to acquisition in the community, and few were attributed to workplace exposures. Employees with unknown sources of COVID-19 participated in higher-risk activities at approximately the same frequency as employees with community sources of COVID-19. The most frequently reported initial symptoms were mild and non-specific and rarely included fever. Despite a comprehensive testing and benefit program, a large proportion of COVID-positive employees worked with symptoms, highlighting ongoing challenges with presenteeism in healthcare. Disclosures Rebekah W. Moehring, MD, MPH, UpToDate, Inc. (Other Financial or Material Support, Author Royalties)

Background Our primary objective was to determine the effectiveness of 2 enhanced disinfection strategies compared with standard disinfection: “near-UV” light (Arm 1) and a persistent organosilane quaternary ammonium disinfectant (Arm 2) using a triple-blind study design. Our secondary objective was to characterize environmental contamination of outpatient clinics. Methods This trial was conducted at 2 clinics: the wound and pulmonary outpatient clinics at Duke University Health System in Durham, North Carolina. In Arm 1, room overhead lights were replaced with 405-nm near-UV visible light bulbs. In Arm 2, the organosilane quaternary ammonium disinfectant was applied to all room surfaces. The control arm received no intervention. All arms received routine disinfection. Room contamination was measured twice daily (before and after clinic) over 25 clinic days. Results The primary outcome was the change in total contamination, measured in colony forming units (CFUs), on environmental surfaces at the end of the clinic day compared with the beginning of the clinic day. Results from each intervention arm were compared against results from the control arm. The median delta total CFU for Arm 1 was 2092 CFUs (interquartile range [IQR], −1815 to 8566); the median delta for Arm 2 was 2016 CFUs (IQR, −1443 to 7430). Compared with the control arm (median delta = 1987 [IQR, −1611 to 15 857]), neither intervention led to a significant decrease in daily room contamination change (P for Arm 1 = 0.78 and P for Arm 2 = 0.71). Conclusions Neither near-UV lights or a persistent organosilane quaternary ammonium disinfectant reduced environmental contamination in 2 outpatient clinics compared with control rooms but did reduce the number of clinically important pathogens recovered.

Respiratory viral infections (RVIs) are frequent complications of hematopoietic stem cell transplant (HSCT). Surgical masks are a simple and inexpensive intervention that may reduce nosocomial spread.In this prospective single-center study, we instituted a universal surgical mask policy requiring all individuals with direct contact with HSCT patients to wear a surgical mask, regardless of symptoms or season. The primary endpoint was the incidence of RVIs in the mask period (2010-2014) compared with the premask period (2003-2009).RVIs decreased from 10.3% (95/920 patients) in the premask period to 4.4% (40/911) in the mask period (P.001). Significant decreases occurred after both allogeneic (64/378 [16.9%] to 24/289 [8.3%], P = .001) and autologous (31/542 [5.7%] to 16/622 [2.6%], P = .007) transplants. After adjusting for multiple covariates including season and year in a segmented longitudinal analysis, the decrease in RVIs remained significant, with risk of RVI of 0.4 in patients in the mask group compared with the premask group (0.19-0.85, P = .02). In contrast, no decrease was observed during this same period in an adjacent hematologic malignancy unit, which followed the same infection control practices except for the mask policy. The majority of this decrease was in parainfluenza virus 3 (PIV3) (8.3% to 2.2%, P.001).Requiring all individuals with direct patient contact to wear a surgical mask is associated with a reduction in RVIs, particularly PIV3, during the most vulnerable period following HSCT.

Background Surgical site infections (SSIs) are common causes of hospital-acquired infection. However, only sparse data are available on the recent epidemiology of SSIs in community hospitals. Methods We performed a retrospective analysis of prospectively collected SSI data at 32 community hospitals in the southeastern United States from 2013 to 2018. We calculated the annual prevalence rates (PRs) of SSI for 26 commonly performed procedures and stratified results by causative pathogen. We used log-binomial regression models to examine trends of SSI prevalence over time. Results Over the 6-year study period, 3,561 complex (i.e., deep incisional or organ space) SSIs occurred following 669,467 total procedures (PR, 0.53 infections per 100 procedures). The complex SSI PR did not change significantly during the study period (0.58/100 procedures in 2013 versus 0.53/100 procedures in 2018; PR ratio [PRR], 0.84; 95% CI 0.66–1.08, p=0.16). For commonly performed procedures, rates of SSI in community hospitals were higher than 2018 National Healthcare Safety Network (NHSN) benchmark SSI rates for colon surgery, hip arthroplasty, knee arthroplasty, and spinal fusion. (Table 1). Staphylococcus aureus was the most common pathogen to cause SSI each year and was responsible for 23.7% (n=843) of all complex SSIs. Methicillin-susceptible S. aureus (MSSA) complex SSIs [13.5%, n=480] were more common than complex SSIs caused by methicillin-resistant S. aureus (MRSA) [10.2%, n=363] (Figure 1). Compared to the 2013, the only significant decrease in S. aureus SSI PR occurred in 2017 (PRR 0.67 95% CI 0.49-0.90, p=0.01), which was primarily driven by the significant decrease in MRSA SSI PR in 2017 compared to 2013 (PRR 0.61 95% CI 0.42-0.89, p-value=0.01). The Escherichia coli SSI PRs did not change significantly during the study period, but E. coli became the second most prevalent pathogen in 2018, surpassing MRSA. Table 1. Community Hospital SSI Prevalence Rates for Commonly Performed Procedures Figure 1: Prevalence Rates of Community Hospital Complex SSIs by Causative Pathogen from 2013 to 2018 Conclusion The complex SSI rate did not significantly decline in our cohort of community hospitals from 2013 to 2018. Baseline SSI rates were low, and statistically significant decreases in SSI rates may be difficult to achieve. However, the epidemiology of community hospital SSIs may be changing with a shift away from MRSA SSIs. Disclosures All Authors: No reported disclosures

Background: Antibiotic prophylaxis choice for transrectal prostate biopsy (TRPB) has been affected by the emergence of fluoroquinolone-resistant Escherichia coli (FQRE). Prebiopsy FQRE screening and targeted antibiotic prophylaxis may reduce post-TRPB bloodstream infection (BSI). We assessed the impact of a FQRE screening program on post-TRPB BSIs at an academic medical center. Methods: We implemented a FQRE screening program and targeted TRPB antimicrobial prophylaxis guidelines on May 1, 2017 (Fig. 1). We performed a retrospective cohort study of all TRPB and compared the incidence of post-TRPB BSI (within 7 calendar days) per 100 procedures before the intervention (January, 1, 2016, to April 30, 2017) and to the incidence after the intervention (May 1, 2017, to August 31, 2019). We used a subanalysis to compare BSI incidence between patients with positive (+) and negative () FQRE screens and appropriate prophylaxis use, defined as administration of guideline-recommended antibiotics. The Fisher exact test of independence was used to analyze nominal data. Results: The analysis included 2,157 TRPB procedures: 647 in the preintervention period and 1,510 in the postintervention period. FQRE screening compliance was 61% (n = 914) in the postintervention group (Fig. 2); 168 FQRE screens (18%) were positive. The median time from FQRE screen to procedure was 40 days (IQR, 13–69). Postprocedure BSI rates were higher in than those in the preimplementation group; however, this difference was not statistically significant (0.86 vs 0.46; OR, 2.01; P = .42). Among FQRE-screened patients, BSI rates differed significantly between FQRE+ and FQRE patients (2.98 vs 0.54; OR, 5.67; 95% CI, 1.21–28.94; P = .01). Screened patients receiving appropriate prophylaxis had lower BSI rates than those receiving inappropriate prophylaxis; however, this was not statistically significant (1.10 vs 2.02; OR, 0.54; P = .35). The most common BSI pathogen was E. coli (2 (67%) before implementation and 10 (77%) after implementation). Also, 5 E. coli BSIs (50%) were fluoroquinolone resistant in the postimplementation group compared to 1 (33%) in the preimplementation group. Of 13 postimplementation BSIs, 6 occurred in patients who received aminoglycosides perioperatively; however, all 6 BSI pathogens were aminoglycoside sensitive. Conclusions: Compliance with our FQRE screening program and antimicrobial prophylaxis protocol was moderate. Although pre- and postimplementation differences in BSI rates were not statistically significant, the high failure rate among patients receiving aminoglycosides was concerning and led to a change in TRPB prophylaxis guidelines. Reasons for increased BSI risk among FQRE+ patients may include prophylaxis agent, dose, timing, or other confounding factors associated with drug-resistant pathogens. Facilities implementing FQRE screening protocols should evaluate the efficacy of their program and periodically review screening compliance, prophylaxis dosing and timing adherence, and impact on patient-level outcomes.Funding: NoneDisclosures: None

Background: Stethoscopes are a known vector for microbial transmission; however, common strategies used to clean stethoscopes pose certain barriers that prevent routine cleaning after every use. We aimed to determine whether using readily available alcohol-based hand rub (ABHR) would effectively reduce bacterial bioburden on stethoscopes in a real-world setting. Methods: We performed a randomized study on inpatient wards of an academic medical center to assess the impact of using ABHR (AlcareExtra; ethyl alcohol, 80%) on the bacterial bioburden of stethoscopes. Stethoscopes were obtained from healthcare providers after routine use during an inpatient examination and were randomized to control (no intervention) or ABHR disinfection (2 pumps applied to tubing and bell or diaphragm by study personnel, then allowed to dry). Cultures of the tubing and bell or diaphragm were obtained with premoistened cellulose sponges. Sponges were combined with 1% Tween20-PBS and mixed in the Seward Stomacher. The homogenate was centrifuged and all but ~5 mL of the supernatant was discarded. Samples were plated on sheep’s blood agar and selective media for clinically important pathogens (CIPs) including S. aureus, Enterococcus spp, and gram-negative bacteria (GNB). CFU count was determined by counting the number of colonies on each plate and using dilution calculations to calculate the CFU of the original ~5 mL homogenate. Results: In total, 80 stethoscopes (40 disinfection, 40 control) were sampled from 46 physicians (MDs) and MD students (57.5%), 13 advanced practice providers (16.3%), and 21 nurses (RNs) and RN students (26.3%). The median CFU count was ~30-fold lower in the disinfection arm compared to control (106 [IQR, 50–381] vs 3,320 [986–4,834]; P < .0001). The effect was consistent across provider type, frequency of recent usual stethoscope cleaning, age, and status of pet ownership (Fig. 1). Overall, 26 of 80 (33%) of stethoscopes harbored CIP. The presence of CIP was lower but not significantly different for stethoscopes that underwent disinfection versus controls: S. aureus (25% vs 32.5%), Enterococcus (2.5% vs 10%), and GNB (2.5% vs 5%). Conclusions: Stethoscopes may serve as vectors for clean hands to become recontaminated immediately prior to performing patient care activities. Using ABHR to clean stethoscopes after every use is a practical and effective strategy to reduce overall bacterial contamination that can be easily incorporated into clinical workflow. Larger studies are needed to determine the efficacy of ABHR at removing CIP from stethoscopes as stethoscopes in both arms were frequently contaminated with CIP. Prior cleaning of stethoscopes on the study day did not seem to impact contamination rates, suggesting the impact of alcohol foam disinfection is short-lived and may need to be repeated frequently (ie, after each use).Funding: NoneDisclosures: NoneDisclosures: NoneFunding: None

Background: Surgical site infections (SSIs) among cardiothoracic (CT) patients are associated with high rates of morbidity and mortality. Data are limited regarding SSI incidence among pediatric patients undergoing primary reparative procedures for congenital cardiac disease. Published evidence on targeted interventions to prevent pediatric CT-surgery SSI is lacking. We aimed to establish standard metrics for measuring CT-surgery SSI incidence and to implement bundled interventions for SSI prevention. Methods: A dedicated CT-surgery SSI prevention workgroup was established, consisting of hospital leadership, CT surgeons, cardiac critical care unit staff, anesthesia, perfusion, environmental services, instrument sterile processing, risk management, infection prevention and antibiotic stewardship. We created a standard definition for CT-surgery SSI and calculated retrospective SSI rates over a 24-month period (2017–2019). The outcome measured was incidence of CT-surgery SSI per 100 primary cardiac procedures with delayed ( 3 days after primary surgery) or non-delayed chest closure. The difference in proportion of SSI was reported separately for delayed closure and non-delayed closure; statistical significance was tested using a Fisher’s Exact test. We identified many potential improvement opportunities, including gaps in SSI surveillance, poor compliance with daily bathing, inconsistent perioperative antimicrobial prophylaxis, lack of controlled environment for bedside chest closures, and lapses in environmental cleaning. These issues informed the enhanced SSI prevention bundle, which included education on sterility with the operating room (OR) staff. Protocols for care of cardiac patients with delayed chest closures focused on universal daily and preoperative chlorhexidine baths. In addition, the bundle incorporated stringent environmental cleaning interventions including scheduled decluttering of patient rooms and clinical spaces, terminal cleaning of patient rooms prior to returning from the OR, and use of adjunctive ultraviolet light for the daily cleaning of operating rooms and patient rooms at discharge. Results: Surveillance definition of microbiological growth from a clinical sample obtained within 30 days of primary cardiac procedure sufficiently captured all CT-surgery SSIs. Of 551 CT-surgery procedures prior to intervention, 91 (17%) had delayed final operative closures. Prior to the intervention, 16 SSIs were identified from July 2017 – May 2019 for a rate of 2.90 per /100 procedures, and was higher among patients with delayed chest closure 6.59 per /100 procedures (6 SSIs/91 procedures) versus those with primary chest closure 2.17 per /100 procedures (10 SSIs/460 procedures; P = 0.034). Gram-positive organisms, including coagulase coagulase-negative Staphylococci, were most frequently identified as the causative organisms for SSIs. Compliance with bundled intervention, rolled out over a 2-month period, was associated with an immediate decrease in the number of SSIs for primary and delayed chest closures 6SSIs /185 procedures in the initial quarters (August – December 2019) of the post-intervention period. However, this decrease was not reflected in the overall rate (3.24 per /100 procedures) due to fewer procedures performed. Data collection to measure sustainability is ongoing. Conclusions: Bundled interventions targeting skin antisepsis and environmental cleaning may be associated with a decrease in SSIs among pediatric CT-surgery patients. Ongoing surveillance is required to determine sustainability of these interventions.Funding: NoneDisclosures: None

Background: The standardized infection ratio (SIR) is the nationally adopted metric used to track and compare catheter-associated urinary tract infections (CAUTIs) and central-line– associated bloodstream infections (CLABSIs). Despite its widespread use, the SIR may not be suitable for all settings and may not capture all catheter harm. Our objective was to look at the correlation between SIR and device use for CAUTIs and CLABSIs across community hospitals in a regional network. Methods: We compared SIR and SUR (standardized utilization ratio) for CAUTIs and CLABSIs across 43 hospitals in the Duke Infection Control Outreach Network (DICON) using a scatter plot and calculated an R2 value. Hospitals were stratified into large (>70,000 patient days), medium (30,000–70,000 patient days), and small hospitals (Results: We reviewed 24 small, 11 medium, and 8 large hospitals within DICON. Scatter plots for comparison of SIRs and SURs for CLABSIs and CAUTIs across our network hospitals are shown in Figs. 1 and 2. We detected a weak positive overall correlation between SIR and SUR for CLABSIs (0.33; R2 = 0.11), but no correlation between SIR and SUR for CAUTIs (−0.07; R2 = 0.00). Of 15 hospitals with SUR >1, 7 reported SIR 1 reported SIR Conclusions: Our data reveal a weak positive correlation between SIR and SUR for CLABSIs, suggesting that central line use impacts CLABSI SIR to some extent. However, we detected no correlation between SIR and SUR for CAUTIs in smaller hospitals and a negative correlation for medium and large hospitals. Some hospitals with low CAUTI SIRs might actually have higher device use, and vice versa. Therefore, the SIR alone does not adequately reflect preventable harm related to urinary catheters. Public reporting of SIR may incentivize hospitals to focus more on urine culture stewardship rather than reducing device utilization.Funding: NoneDisclosures: None

Background Colon surgeries are commonly performed, and surgical site infections (SSIs) following these procedures are routinely reported to the National Healthcare Safety Network (NHSN). However, the impact of infections present at the time of surgery (PATOS) and emergent surgeries on the epidemiology of colon surgery SSIs has not been well described. Methods We retrospectively analyzed prospectively collected data on complex (i.e., deep incisional or organ space) SSIs following colon surgery performed at 34 community hospitals in the southeastern United States from January 2015 to June 2019. We excluded SSIs categorized as PATOS. We then stratified colon surgery SSI rates according to age, sex, body mass index (BMI), operation duration, diabetes diagnosis, American Society of Anesthesiologists (ASA) physical status, wound class, emergent procedure, endoscopic procedure, and hospital colon surgery volume. Finally, we explored effect measure modification of emergent surgery and open surgery on hospital volume using log-binomial modeling and tests of homogeneity. Results A total of 722 complex SSIs occurred following 28,642 colon surgeries (prevalence rate [PR], 2.52 per 100 procedures). After PATOS SSIs were excluded, 545 complex SSIs remained (PR 1.90 per 100 procedures). Risk factor analysis revealed that age < 75 years and operation time > 75th percentile (188 minutes) during the 5-year study period) significantly increased risk of SSI (Table 1). The most common pathogens that caused SSIs in this study cohort were Escherichia coli, Enterococcus, and Klebsiella. (Table 2) 105 (19%) SSIs were culture-negative and 378 (69%) of the SSIs were polymicrobial. We defined hospital volume as high (>500 procedures in the 5-year period) based on the median hospital volume in the dataset. No significant effect measure modification occurred between hospital volume and either laparoscopic surgery or emergent surgery (Table 3). Table 1: Characteristics of patients who underwent colon surgery from January 2015 to June 2018 in 34 community hospitals. Table 2: Count and frequency of pathogens that caused complex surgical site infections after colon surgery Table 3: Colon surgery complex surgical site infection rates, stratified by emergent, elective, open, and laparoscopic procedures and hospital colon surgery volume Conclusion In our cohort, we found that one-fourth of colon surgery SSIs were categorized as PATOS, which are no longer publicly reported to the Centers for Medicare & Medicaid Services. While most SSI literature describes higher volume hospitals having lower SSI rates, high colon surgery volume was associated with increased SSI rates in our community hospital cohort. Disclosures All Authors: No reported disclosures

Background: UV-C light reduces contamination of high-touch clinical surfaces. Few studies have tested the relative efficacy of UV-C devices in real-world clinical environments. Methods: We assessed the efficacy of the Tru-D (SmartUVC) and Moonbeam-3 UV-C (Diversey) devices at eradicating important clinical pathogens in 2 hyperbaric chambers at a tertiary-care hospital. Formica sheets were inoculated with 106–107 CFU of MRSA (USA300) or 104–105 CFU of C. difficile (NAP1). Sheets were placed in 6 predetermined locations throughout the chambers. Two Moonbeam-3 UV-C devices were positioned in the center of each chamber and were run for 3-minute (per manufacturer’s instructions) and 5-minute cycles. One Tru-D was positioned in the center of the chamber and was run on the vegetative cycle for MRSA and the spore cycle for C. difficile. UV-C dosage was measured for both machines. Quantitative cultures were collected using Rodac plates with DE neutralizing agar and were incubated at 37C for 48 hours. C. difficile was likewise plated onto sheep’s blood agar. Results: We ran each combination of chamber, microbe, and UV-C device in triplicate for In total, 108 samples per species. For MRSA, the Tru-D vegetative cycle, the 5-minute Moonbeam cycle, and the 3-minute Moonbeam cycle resulted in average CFU log10 reductions of 7.02 (95% CI, 7.02–7.02), 6.99 (95% CI, 6.95–7.02), and 6.58 (95% CI, 6.37–6.79), respectively (Fig. 1). The Tru-D vegetative and 5-minute Moonbeam cycles were similarly effective (P > .99), and both were more effective than the 3-minute Moonbeam cycle (P < .001 and P < .001, respectively). MRSA samples receiving direct UV-C exposure had significantly greater log10 reductions (6.95; 95% CI, 6.89–7.01) than did indirect exposure (6.67; 95% CI, 6.46–6.87; P < .05) (Fig. 2). For C. difficile, the Tru-D sporicidal, the 5-, and 3-minute Moonbeam cycles resulted in average CFU log10 reductions of 1.78 (95% CI, 1.43–2.12), 0.57 (95% CI, 0.33–0.81) and 0.64 (95% CI, 0.42–0.86), respectively (Fig. 1). Tru-D was significantly more effective than either the 3- or 5-minute Moonbeam cycles (P < .00). C. difficile samples receiving direct UV-C exposure had higher dosage and significantly greater log10 reductions (1.34; 95% CI, 1.10–1.58) than did indirect exposure (0.58; 95% CI, 0.31–0.86; P < .01) (Fig. 2). Conclusions: Use of the Tru-D vegetative cycle and the Moonbeam 3- and 5-minute cycles resulted in similar reductions in MRSA; both resulted in significantly greater reductions than the manufacturer’s recommended 3-minute Moonbeam cycle. Therefore, healthcare facilities should carefully evaluate manufacturer-recommended run times in their specific clinical setting. For C. difficile, the Tru-D sporicidal cycle was significantly more effective than either of the Moonbeam cycles, likely due to higher irradiation levels. As such, direct UV-C exposure resulted in greater average reductions than indirect exposure.Funding: NoneDisclosures: None

Clostridioides difficile causes more healthcare-associated infections in the United States than any other pathogen, with an estimated 500,000 infections and 29,000 deaths per year [1]. Although C. difficile first emerged as a healthcare-associated pathogen, infections are increasingly acquired in the community [2]. Genomic epidemiology studies have shown that clinical C. difficile isolates are more diverse than previously presumed and point toward unidentified environmental reservoirs [3]. An improved understanding of C. difficile’s epidemiology is essential for future infection prevention efforts, both within healthcare settings and in the community. Here, we provide an overview of the changing epidemiology of C. difficile and current evidence for novel sources of transmission.

Summary A hospital outbreak of human parainfluenza virus type 3 (HPIV-3) in haematologic oncology patients is described in 12 patients over a four-week period. Exposure histories and molecular analysis of HPIV-3 isolates suggest that both community-acquired and nosocomially transmitted infections occurred during this outbreak. Molecular analysis of HPIV-3 isolates indicated that a chain of transmission occurred among multiple patients in an oncology ward. This transmission was later determined to be associated with the movement of fomites, visitors, and activities in the unit. The infection prevention team stopped nosocomial spread of HPIV-3 through interventions including advanced cleaning procedures.