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Background The optimal duration of transmission-based precautions among immunocompromised patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is unknown. Methods Retrospective review of patients with solid organ transplant with positive SARS-CoV-2 polymerase chain reaction result from nasopharyngeal specimens admitted to the hospital between March 13, 2020 and May 15, 2020. Results Twenty-one percent of solid organ transplant recipients with positive SARS-CoV-2 polymerase chain reaction detected ≥20 d after symptom onset (or after first positive test among asymptomatic individuals) had a low cycle threshold (ie, high viral load). The majority of these patients were asymptomatic or symptomatically improved. Conclusions Solid organ transplant recipients may have prolonged high viral burden of SARS-CoV-2. Further data are needed to understand whether cycle threshold data can help inform strategies for prevention of healthcare-associated transmission of SARS-CoV-2 and for appropriate discontinuation of transmission-based precautions.

BACKGROUND: Urinary tract infections (UTIs) are a frequent cause of hospital transfer for home health care (HHC) patients, particularly among patients with urinary catheters. METHODS: We conducted a cross-sectional, nationally representative HHC agency-level survey (2018–2019) and combined it with patient-level data from the Outcome and Assessment Information Set (OASIS) and Medicare inpatient data (2016–2018) to evaluate the association between HHC agencies’ urinary catheter policies and hospital transfers due to UTI. Our sample included 28,205 patients with urinary catheters who received HHC from 473 Medicare-certified agencies between 2016–2018. Our survey assessed whether agencies had written policies in place for (1) replacement of indwelling catheters at fixed intervals and (2) emptying the drainage bag. We used adjusted logistic regression to estimate the association of these policies with probability of hospital transfer due to UTI during a 60-day HHC episode. RESULTS: Probability of hospital transfer due to UTI during a HHC episode ranged from 5.62% among agencies with neither urinary catheter policy to 4.43% among agencies with both policies. Relative to agencies with neither policy, having both policies was associated with 21% lower probability of hospital transfer due to UTI (p

An observational study was conducted to characterize high-touch surfaces in emergency departments and hemodialysis facilities. Certain surfaces were touched with much greater frequency than others. A small number of surfaces accounted for the majority of touch episodes. Prioritizing disinfection of these surfaces may reduce pathogen transmission within healthcare environments.

Background: The healthcare environment can serve as a reservoir for many microorganisms and, in the absence of appropriate cleaning and disinfection, can contribute to pathogen transmission. Identification of high-touch surfaces (HTS) in hospital patient rooms has allowed the recognition of surfaces that represent the greatest transmission risk and prioritization of cleaning and disinfection resources for infection prevention. HTS in other healthcare settings, including high-volume and high-risk settings such as emergency departments (EDs) and hemodialysis facilities (HDFs), have not been well studied or defined. Methods: Observations were conducted in 2 EDs and 3 HDFs using structured observation tools. All touch episodes, defined as hand-to-surface contact regardless of hand hygiene and/or glove use, were recorded. Touches by healthcare personnel, patients, and visitors were included. Surfaces were classified as being allocated to individual patients or shared among multiple patients. The number of touch episodes per hour was calculated for each surface to rank surfaces by frequency of touch. Results: In total, 28 hours of observation (14 hours each in EDs and HDFs) were conducted. 1,976 touch episodes were observed among 62 surfaces. On average, more touch episodes were observed per hour in HDFs than in EDs (89 vs 52, respectively). The most frequently touched surfaces in EDs included stretcher rails, privacy curtains, visitor chair arm rests and seats, and patient bedside tables, which together accounted for 68.8% of all touch episodes in EDs (Fig. 1). Frequently touched surfaces in HDFs included both shared and single-patient surfaces: 27.8% and 72.2% of HDF touch episodes, respectively. The most frequently touched surfaces in HDFs were supply cart drawers, dialysis machine control panels and keyboards, handwashing faucet handles, bedside work tables, and bed rail or dialysis chair armrests, which accounted for 68.4% of all touch-episodes recorded. Conclusions: To our knowledge, this is the first quantitative study to identify HTSs in EDs and HDFs. Our observations reveal that certain surfaces within these environments are subject to a substantially greater frequency of hand contact than others and that a relatively small number of surfaces account for most touch episodes. Notably, whereas HTSs in EDs were primarily single-patient surfaces, HTSs in HDFs included surfaces shared in the care of multiple patients, which may represent an even greater risk of patient-to-patient pathogen transmission than single-patient surfaces. The identification of HTSs in EDs and HDFs contributes to a better understanding of the risk of environment-related pathogen transmission in these settings and may allow prioritization and optimization of cleaning and disinfection resources within facilities.Funding: NoneDisclosures: None

Purpose To share challenges and opportunities for antimicrobial stewardship programs based on one center’s experience during the early weeks of the coronavirus disease 2019 (COVID-19) pandemic. Summary In the spring of 2020, New York City quickly became a hotspot for the COVID-19 pandemic in the United States, putting a strain on local healthcare systems. Antimicrobial stewardship programs faced diagnostic and therapeutic uncertainties as well as healthcare resource challenges. With the lack of effective antivirals, antibiotic use in critically ill patients was difficult to avoid. Uncertainty drove antimicrobial use and thus antimicrobial stewardship principles were paramount. The dramatic influx of patients, drug and equipment shortages, and the need for prescribers to practice in alternative roles only compounded the situation. Establishing enhanced communication, education, and inventory control while leveraging the capabilities of the electronic medical record were some of the tools used to optimize existing resources. Conclusion New York City was a unique and challenging environment during the initial peak of the COVID-19 pandemic. Antimicrobial stewardship programs can learn from each other by sharing lessons learned and practice opportunities to better prepare other programs facing COVID-19 case surges.

Background Patients with COVID-19 may be at increased risk for secondary bacterial infections with MDR pathogens, including carbapenemase-producing Enterobacterales (CPE). Objectives We sought to rapidly investigate the clinical characteristics, population structure and mechanisms of resistance of CPE causing secondary infections in patients with COVID-19. Methods We retrospectively identified CPE clinical isolates collected from patients testing positive for SARS-CoV-2 between March and April 2020 at our medical centre in New York City. Available isolates underwent nanopore sequencing for rapid genotyping, antibiotic resistance gene detection and phylogenetic analysis. Results We identified 31 CPE isolates from 13 patients, including 27 Klebsiella pneumoniae and 4 Enterobacter cloacae complex isolates. Most patients (11/13) had a positive respiratory culture and 7/13 developed bacteraemia; treatment failure was common. Twenty isolates were available for WGS. Most K. pneumoniae (16/17) belonged to ST258 and encoded KPC (15 KPC-2; 1 KPC-3); one ST70 isolate encoded KPC-2. E. cloacae isolates belonged to ST270 and encoded NDM-1. Nanopore sequencing enabled identification of at least four distinct ST258 lineages in COVID-19 patients, which were validated by Illumina sequencing data. Conclusions While CPE prevalence has declined substantially in New York City in recent years, increased detection in patients with COVID-19 may signal a re-emergence of these highly resistant pathogens in the wake of the global pandemic. Increased surveillance and antimicrobial stewardship efforts, as well as identification of optimal treatment approaches for CPE, will be needed to mitigate their future impact.

Background There is a growing recognition of the need to partner with nurses to promote effective antibiotic stewardship. In this study, we explored the attitudes of nurses and infection preventionists toward 5 nurse-driven antibiotic stewardship practices: 1) questioning the need for urine cultures; 2) ensuring proper culturing technique; 3) recording an accurate penicillin drug allergy history; 4) encouraging the prompt transition from intravenous (IV) to oral (PO) antibiotics; and 5) initiating an antibiotic timeout. Methods Nine focus groups and 4 interviews with 49 clinical nurses, 5 nurse managers, and 7 infection preventionists were conducted across 2 academic pediatric and adult hospitals. Results Nurse-driven antibiotic stewardship was perceived as an extension of the nurses' role as patient advocate. Three practices were perceived most favorably: questioning the necessity of urinary cultures, ensuring proper culturing techniques, and encouraging the prompt transition from IV to PO antibiotics. Remaining recommendations were perceived to lack relevance or to challenge traditionally held nursing responsibilities. Prescriber and family engagement were noted to assist the implementation of select recommendations. Infection preventionists welcomed the opportunity to assist in providing nurse stewardship education. Conclusions Nurses appeared to be enthusiastic about participating in antibiotic stewardship. Efforts to engage nurses should address knowledge needs and consider the contexts in which nurse-driven antibiotic stewardship occurs.

OBJECTIVETo assess antimicrobial prescriber knowledge, attitudes, and practices (KAP) regarding antimicrobial stewardship (AS) and associated barriers to optimal prescribing.DESIGNCross-sectional survey.SETTINGOnline survey.PARTICIPANTSA convenience sample of 2,900 US antimicrobial prescribers at 5 acute-care hospitals within a hospital network.INTERVENTIONThe following characteristics were assessed with an anonymous, online survey in February 2015: attitudes and practices related to antimicrobial resistance, AS programs, and institutional AS resources; antimicrobial prescribing and AS knowledge; and practices and confidence related to antimicrobial prescribing.RESULTSIn total, 402 respondents completed the survey. Knowledge gaps were identified through case-based questions. Some respondents sometimes selected overly broad therapy for the susceptibilities given (29%) and some “usually” or “always” preferred using the most broad-spectrum empiric antimicrobials possible (32%). Nearly all (99%) reported reviewing antimicrobial appropriateness at 48–72 hours, but only 55% reported “always” doing so. Furthermore, 45% of respondents felt that they had not received adequate training regarding antimicrobial prescribing. Some respondents lacked confidence selecting empiric therapy using antibiograms (30%), interpreting susceptibility results (24%), de-escalating therapy (18%), and determining duration of therapy (31%). Postprescription review and feedback (PPRF) was the most commonly cited AS intervention (79%) with potential to improve patient care.CONCLUSIONSBarriers to appropriate antimicrobial selection and de-escalation of antimicrobial therapy were identified among front-line prescribers in acute-care hospitals. Prescribers desired more AS-related education and identified PPRF as the most helpful AS intervention to improve patient care. Educational interventions should be preceded by and tailored to local assessment of educational needs.Infect Control Hosp Epidemiol 2018;39:316–322

Background: Infections are a frequent cause of hospital (re)admissions for older adults receiving home health care (HHC) in the United States. However, previous investigators have likely underestimated the prevalence of infections leading to hospitalization due to limitations of identifying infections using Outcome and Assessment Information Set (OASIS), the standardized assessment tool mandated for all Medicare-certified HHC agencies. By linking OASIS data with inpatient data from the Medicare Provider Analysis and Review (MedPAR) file, we were able to better quantify infection hospitalization trends and subsequent mortality among HHC patients. Method: After stratification (by census region, ownership, and urban or rural location) and random sampling, our data set consisted of 2,258,113 Medicare beneficiaries who received HHC services between January 1, 2013, and December 31, 2018, from 1,481 Medicare-certified HHC agencies. The 60-day HHC episodes were identified in OASIS. Hospital transfers reported in OASIS were linked with corresponding MedPAR records. Our outcomes of interest were (1) hospitalization with infection present on admission (POA); (2) hospitalization with infection as the primary cause; and (3) 30-day mortality following hospitalization with infection as the primary cause. We identified bacterial (including suspected) infections based on International Classification of Disease, Ninth Revision (ICD-9) and ICD-10 codes in MedPAR. We classified infections by site: respiratory, urinary tract, skin/soft tissue, intravenous catheter-related, and all (including other or unspecified infection site). We also identified sepsis diagnoses. Result: From 2013 through 2018, the percentage of 60-day HHC episodes with 1 or more hospital transfers ranged from 15% to 16%. Approximately half of all HHC patients hospitalized had an infection POA. Over the 6 years studied, infection (any type) was the primary cause of hospitalization in more than a quarter of all transfers (25.86%–27.57%). The percentage of hospitalizations due to sepsis increased from 7.51% in 2013 to 11.49% in 2018, whereas the percentage of hospitalizations due to respiratory, urinary tract, or skin/soft-tissue infections decreased (p Conclusion: HHC is an important source of post-acute care for those aging in place. Our findings demonstrate that infections are a persistent problem in HHC and are associated with substantial 30-day mortality, particularly following hospitalizations caused by sepsis, emphasizing the importance of infection prevention in HHC. Effective policies to promote best practices for infection prevention and control in the home environment are needed to mitigate infection risk.Funding: NoDisclosures: None

Background: The focus on infection prevention in nursing homes is growing, but little is known about the role infections play in transfers from nursing home to hospital. Our goals were (1) to identify rates of infection-related transfers to the hospital and (2) to identify trends in these rates from 2011 to 2014. Methods: Using a nationally representative sample of 2,501 nursing homes (2011–2014), elderly resident data from the Minimum Data Set 3.0 were combined with CMS inpatient data (MedPAR). We classified transfers from nursing home to hospital as caused by infection (1) if infection was the primary diagnosis and present on admission (POA) or (2) if infection was indicated as the MedPAR admitting diagnosis code and POA. We classified all transfers, including those caused by infection, for which infection was POA in any of the 25 diagnosis codes as transfers with infection. Types of infection included respiratory, sepsis, urinary tract infection (UTI), and all (including ‘other’). Results: Table 1 shows the number of all-cause transfers and the percentage caused by infections. From 2011 to 2014, the rate of all-cause transfers declined from 0.479 to 0.396 per patient; infections were primarily responsible for ~1 in 3 transfers each year. The rate of transfers caused by sepsis increased by 37% from 2011 to 2014, and the rate for respiratory infections fell by 18%. More than half of all transfers from nursing home to hospital in each year had an infection POA. Although the percentage of transfers caused by any kind of infection increased by >7% during the period, the number of transfers per patient dropped by 17%. Conclusions: A large number of elderly nursing home residents are transferred to hospitals with infection each year. Many of these transitions may be avoidable with improved infection prevention and surveillance in nursing homes. Reduced infection rates would improve health and quality of life of nursing home residents and reduce infection-related inpatient costs.Funding: NoneDisclosures: None

In a retrospective study conducted over 12 months in a multi-hospital system, the incidence of bloodstream infections associated with midline catheters was not significantly lower than that associated with central venous catheters (0.88 vs 1.10 infections per 1,000 catheter-days). Additional research is needed to further characterize the infectious risks of midline catheters and to determine optimal strategies to minimize these risks.

Little is known about prescribers’ attitudes regarding clinical nurses and antimicrobial stewardship. We conducted focus groups of prescribers and inquired about attitudes regarding nurses and stewardship. During 6 focus groups, prescribers were receptive to nursing involvement in stewardship activities, but noted structural barriers and knowledge gaps that should be addressed.

Objective:To sustainably improve cleaning of high-touch surfaces (HTSs) in acute-care hospitals using a multimodal approach to education, reduction of barriers to cleaning, and culture change for environmental services workers.Design:Prospective, quasi-experimental, before-and-after intervention study.Setting:The study was conducted in 2 academic acute-care hospitals, 2 community hospitals, and an academic pediatric and women’s hospital.Participants:Frontline environmental services workers.Intervention:A 5-module educational program, using principles of adult learning theory, was developed and presented to environmental services workers. Audience response system (ARS), videos, demonstrations, role playing, and graphics were used to illustrate concepts of and the rationale for infection prevention strategies. Topics included hand hygiene, isolation precautions, personal protective equipment (PPE), cleaning protocols, and strategies to overcome barriers. Program evaluation included ARS questions, written evaluations, and objective assessments of occupied patient room cleaning. Changes in hospital-onset C. difficile infection (CDI) and methicillin-resistant S. aureus (MRSA) bacteremia were evaluated.Results:On average, 357 environmental service workers participated in each module. Most (93%) rated the presentations as ‘excellent’ or ‘very good’ and agreed that they were useful (95%), reported that they were more comfortable donning/doffing PPE (91%) and performing hand hygiene (96%) and better understood the importance of disinfecting HTSs (96%) after the program. The frequency of cleaning individual HTSs in occupied rooms increased from 26% to 62% (P < .001) following the intervention. Improvement was sustained 1-year post intervention (P < .001). A significant decrease in CDI was associated with the program.Conclusion:A novel program that addressed environmental services workers’ knowledge gaps, challenges, and barriers was well received and appeared to result in learning, behavior change, and sustained improvements in cleaning.

MotivationCatheter-associated urinary tract infections (CAUTI) are a common and serious healthcare-associated infection. Despite many efforts to reduce the occurrence of CAUTI, there remains a gap in the literature about CAUTI risk factors, especially pertaining to the effect of catheter dwell-time on CAUTI development and patient comorbidities.ObjectiveTo examine how the risk for CAUTI changes over time. Additionally, to assess whether time from catheter insertion to CAUTI event varied according to risk factors such as age, sex, patient type (surgical vs medical) and comorbidities.DesignRetrospective cohort study of all patients who were catheterised from 2012 to 2016, including those who did and did not develop CAUTIs. Both paediatric and adult patients were included. Indwelling urinary catheterisation is the exposure variable. The variable is interval, as all participants were exposed but for different lengths of time.SettingUrban academic health system of over 2500 beds. The system encompasses two large academic medical centres, two community hospitals and a paediatric hospital.ResultsThe study population was 47 926 patients who had 61 047 catheterisations, of which 861 (1.41%) resulted in a CAUTI. CAUTI rates were found to increase non-linearly for each additional day of catheterisation; CAUTI-free survival was 97.3% (CI: 97.1 to 97.6) at 10 days, 88.2% (CI: 86.9 to 89.5) at 30 days and 71.8% (CI: 66.3 to 77.8) at 60 days. This translated to an instantaneous HR of. 49%–1.65% in the 10–60 day time range. Paraplegia, cerebrovascular disease and female sex were found to statistically increase the chances of a CAUTI.ConclusionsUsing a very large data set, we demonstrated the incremental risk of CAUTI associated with each additional day of catheterisation, as well as the risk factors that increase the hazard for CAUTI. Special attention should be given to patients carrying these risk factors, for example, females or those with mobility issues.

This cohort study uses data from the Minimum Data Set and Medicare hospitalization records to assess the association between infection-related hospitalization and cognitive function among nursing home residents 65 years or older., Key Points Question Are infection-related hospitalizations associated with sustained changes in cognitive function among nursing home residents? Findings In this cohort study of administrative data for 20 698 US nursing home residents, infection-related hospitalization was significantly associated with a sustained decrease in cognitive function, especially among those who had experienced sepsis, those aged 85 years or older, and those with Alzheimer disease and related dementias. Meaning The findings suggest that identification of nursing home residents at highest risk of cognitive decline after an infection-related hospitalization is important to ensure that their care needs are addressed to prevent further cognitive decline., Importance Hospitalizations for infections among nursing home (NH) residents remain common despite national initiatives to reduce them. Cognitive impairment, which markedly affects quality of life and caregiving needs, has been associated with hospitalizations, but the association between infection-related hospitalizations and long-term cognitive function among NH residents is unknown. Objective To examine whether there are changes in cognitive function before vs after infection-related hospitalizations among NH residents. Design, Setting, and Participants This cohort study used data from the Minimum Data Set 3.0 linked to Medicare hospitalization data from 2011 to 2017 for US nursing home residents aged 65 years or older who had experienced an infection-related hospitalization and had at least 2 quarterly Minimum Data Set assessments before and 4 or more after the infection-related hospitalization. Analyses were performed from September 1, 2019, to December 21, 2020. Exposure Infection-related hospitalization lasting 1 to 14 days. Main Outcomes and Measures Using an event study approach, associations between infection-related hospitalizations and quarterly changes in cognitive function among NH residents were examined overall and by sex, age, Alzheimer disease and related dementias (ADRD) diagnosis, and sepsis vs other infection-related diagnoses. Resident-level cognitive function was measured using the Cognitive Function Scale (CFS), with scores ranging from 1 (intact) to 4 (severe cognitive impairment). Results Of the sample of 20 698 NH residents, 71.0% were women and 82.6% were non-Hispanic White individuals; the mean (SD) age at the time of transfer to the hospital was 82 (8.5) years. The mean CFS score was 2.17, and the prevalence of severe cognitive impairment (CFS score, 4) was 9.0%. During the first quarter after an infection-related hospitalization, residents experienced a mean increase of 0.06 points in CFS score (95% CI, 0.05-0.07 points; P

Candida auris, an emerging fungus that can cause invasive infections, is associated with high mortality and is often resistant to multiple antifungal drugs. C. auris was first described in 2009 after being isolated from external ear canal discharge of a patient in Japan (1). Since then, reports of C. auris infections, including bloodstream infections, have been published from several countries, including Colombia, India, Israel, Kenya, Kuwait, Pakistan, South Africa, South Korea, Venezuela, and the United Kingdom (2-7). To determine whether C. auris is present in the United States and to prepare for the possibility of transmission, CDC issued a clinical alert in June 2016 informing clinicians, laboratorians, infection control practitioners, and public health authorities about C. auris and requesting that C. auris cases be reported to state and local health departments and CDC (8). This report describes the first seven U.S. cases of C. auris infection reported to CDC as of August 31, 2016. Data from these cases suggest that transmission of C. auris might have occurred in U.S. health care facilities and demonstrate the need for attention to infection control measures to control the spread of this pathogen.

Proton Pump Inhibitors Do Not Increase Risk for Clostridium difficile Infection in the Intensive Care Unit

In this study, we used an online survey to assess knowledge, attitudes, and practices related to environmental cleaning and other infection prevention strategies among environmental services workers (ESWs) at 5 hospitals. Our findings suggest that ESWs could benefit from additional education and feedback as well as new strategies to address workflow challenges.Infect Control Hosp Epidemiol 2016;1492–1495

In 2013, New York State mandated that, during influenza season, unvaccinated healthcare personnel (HCP) wear a surgical mask in areas where patients are typically present. We found that this mandate was associated with increased HCP vaccination and decreased HCP visits to the hospital Workforce Health and Safety Department with respiratory illnesses and laboratory-confirmed influenza.Infect Control Hosp Epidemiol 2017;38:1361–1363

ObjectiveTo integrate electronic clinical decision support tools into clinical practice and to evaluate the impact on indwelling urinary catheter (IUC) use and catheter-associated urinary tract infections (CAUTIs).Design, Setting, and ParticipantsThis 4-phase observational study included all inpatients at a multicampus, academic medical center between 2011 and 2015.InterventionsPhase 1 comprised best practices training and standardization of electronic documentation. Phase 2 comprised real-time electronic tracking of IUC duration. In phase 3, a triggered alert reminded clinicians of IUC duration. In phase 4, a new IUC order (1) introduced automated order expiration and (2) required consideration of alternatives and selection of an appropriate indication.ResultsOverall, 2,121 CAUTIs, 179,070 new catheters, 643,055 catheter days, and 2,186 reinsertions occurred in 3·85 million hospitalized patient days during the study period. The CAUTI rate per 10,000 patient days decreased incrementally in each phase from 9·06 in phase 1 to 1·65 in phase 4 (relative risk [RR], 0·182; 95% confidence interval [CI], 0·153–0·216; PPPP=·0017).ConclusionsThe phased introduction of decision support tools was associated with progressive declines in new catheters, total catheter days, and CAUTIs. Clinical decision support tools offer a viable and scalable intervention to target hospital-wide IUC use and hold promise for other quality improvement initiatives.

OBJECTIVETo evaluate the impact of universal contact precautions (UCP) on rates of multidrug-resistant organisms (MDROs) in intensive care units (ICUs) over 9 yearsDESIGNRetrospective, nonrandomized observational studySETTINGAn 800-bed adult academic medical center in New York CityPARTICIPANTSAll patients admitted to 6 ICUs, 3 of which instituted UCP in 2007METHODSUsing a comparative effectiveness approach, we studied the longitudinal impact of UCP on MDRO incidence density rates, including methicillin-resistant Staphylococcus aureus, vancomycin-resistant enterococci, and carbapenem-resistant Klebsiella pneumoniae. Data were extracted from a clinical research database for 2006–2014. Monthly MDRO rates were compared between the baseline period and the UCP period, utilizing time series analyses based on generalized linear models. The same models were also used to compare MDRO rates in the 3 UCP units to 3 ICUs without UCPs.RESULTSOverall, MDRO rates decreased over time, but there was no significant decrease in the trend (slope) during the UCP period compared to the baseline period for any of the 3 intervention units. Furthermore, there was no significant difference between UCP units (6.6% decrease in MDRO rates per year) and non-UCP units (6.0% decrease per year; P=.840).CONCLUSIONThe results of this 9-year study suggest that decreases in MDROs, including multidrug-resistant gram-negative bacilli, were more likely due to hospital-wide improvements in infection prevention during this period and that UCP had no detectable additional impact.Infect Control Hosp Epidemiol 2018;39:534–540

Background Prompt diagnosis of pulmonary Mycobacterium tuberculosis (TB) infection can prevent nosocomial exposure. However, sputum smears are insensitive, and turnaround time for cultures can take weeks. Rapid diagnostics, such as nucleic acid amplification testing (NAAT), on respiratory specimens of patients suspected to have TB can improve diagnostic accuracy. Current practice at our institution is to obtain ≥ 3 NAATs in high-risk patients prior to discontinuing airborne isolation, but some studies have suggested that 2 negative NAATs may be sufficient. We conducted a retrospective study of patients at our institution diagnosed with TB. Methods The study was conducted at an academic adult hospital, an academic pediatric hospital, and a community hospital in New York City. Line lists of positive cultures for TB and positive NAATs from 2014 to mid-2018 were obtained from microbiology. Chart review was performed. Patient demographics, comorbidities, and radiographic findings were collected. Concordance between culture results and NAATs was evaluated. Incidence of inpatient TB exposure was noted. Results 82 cases of TB were found in the study period (see Figure 1). 45 cases were new inpatient diagnoses of pulmonary TB. The most common presenting symptoms were cough (69%), weight loss (49%), and fever (42%, see Table 1). 38/45 (84%) of patients were originally from a country other than the United States. 43/45 (96%) of patients had abnormal lung imaging. Cavitary disease was seen in 29%; other upper lobe disease was seen in 42%. Among smear-negative pulmonary TB cases, NAAT was positive in 11/16 (69%) of patients. Within this subgroup, the sensitivity of one NAAT was 41% when compared with culture. In smear-negative, NAAT-positive patients, NAATs were fully concordant with cultures in 4/11 patients (36%, see Table 2). The median number of positive NAATs was 1; the median number of positive cultures was 2. Five patients with pulmonary TB had negative NAATs altogether (median = 3); 2/5 resulted in TB exposure investigations after airborne precautions were discontinued following NAAT results. Overall, 13/45 (28%) of new diagnoses resulted in an exposure investigation. Conclusion Obtaining ≥ 3 NAATs in patients suspected of pulmonary TB improved diagnostic accuracy compared with obtaining 2 or fewer. Disclosures All authors: No reported disclosures.

Background Distinguishing between Clostridioides difficile infection (CDI) and asymptomatic colonization with a PCR-based test can be difficult and can lead to unnecessary antibiotic use, longer lengths of stay and inflated hospital-onset (HO) CDI rates. Additionally, inappropriate testing for CDI complicates this challenge. The Infectious Disease Society of America’s (IDSA) 2018 guidelines discourage CDI testing for patients who received laxatives within 48 hours. Our hospital implemented a two-phase clinical decision support order set (DSOS) to improve appropriateness of CDI testing. Methods The DSOS was implemented at a hospital system in New York City (2 large academic medical centers, 2 community hospitals, 1 pediatric hospital: total 2,200 beds). The electronic health record is Allscripts SCM tm. The first iteration of the DSOS required providers to document the indication for CDI testing, as well as a soft stop (SS) pop-up message prompting providers to reconsider testing in patients who received laxatives within 24 hours. The second phase of the DSOS utilized a hard stop (HS) that prevented providers from ordering CDI testing for patients who received laxatives within 24 hours. Providers received a pop-up with IDSA recommendations for CDI testing and contact information for the Clinical Microbiology Laboratory. If testing was still desired, the ordering provider had to discuss the case with a Pathology resident or Infectious Disease specialist before the laboratory staff placed the order. The monthly number of orders and tests sent in the different time periods, pre-SS (April 2016–April 2017), post-SS (May 2017–2019, 2018), and post-HS (November 2018–March 2019), were compared using ANOVA. The National Healthcare Safety Network calculator was used to compare CDI incidence density ratios and SIRs between the three periods. Results SS implementation significantly reduced mean monthly orders (18%) and HO-CDI SIR (31%) but SIR remained above national benchmarks. Adding a HS further reduced orders (25%) and SIR (18%) (table). Conclusion A DSOS designed to reduce inappropriate CDI testing among patients who received laxatives within 24 hours was associated with a reduction in CDI testing and the CDI SIR. While use of a soft stop reduced CDI testing, the addition of a hard stop was associated with additional significant reductions in the CDI SIR. Disclosures All authors: No reported disclosures.

The rapidly expanding use of electronic records in health-care settings is generating unprecedented quantities of data available for clinical, epidemiological, and cost-effectiveness research. Several challenges are associated with using these data for clinical research, including issues surrounding access and information security, poor data quality, inconsistency of data within and across institutions, and a paucity of staff with expertise to manage and manipulate large clinical data sets. In this article, we describe our experience with assembling a data-mart and conducting clinical research using electronic data from four facilities within a single hospital network in New York City. We culled data from several electronic sources, including the institution’s admission-discharge-transfer system, cost accounting system, electronic health record, clinical data warehouse, and departmental records. The final data-mart contained information for more than 760,000 discharges occurring from 2006 through 2012. Using categories identified by the National Institutes of Health Big Data to Knowledge initiative as a framework, we outlined challenges encountered during the development and use of a domain-specific data-mart and recommend approaches to overcome these challenges.

Background Knowing the temporal trend central line–associated bloodstream infection (CLABSI) rates among U.S. pediatric intensive care units (PICUs), the current extent of central line bundle compliance, and the impact of compliance on rates is necessary to understand what has been accomplished and can be improved in CLABSI prevention. Methods This is a longitudinal study of PICUs in National Healthcare Safety Network hospitals and a cross-sectional survey of directors and managers of infection prevention and control departments regarding PICU CLABSI prevention practices, including self-reported compliance with elements of central line bundles. Associations between 2011-2012 PICU CLABSI rates and infection prevention practices were examined. Results Reported CLABSI rates decreased during the study period, from 5.8 per 1,000 line days in 2006 to 1.4 in 2011-2012 ( P Conclusion There was a nonsignificant trend in decreasing CLABSI rates as PICUs improved bundle policy compliance. Given that few PICUs reported full compliance with these policies, PICUs increasing their efforts to comply with these policies may help reduce CLABSI rates.

The spread of mcr-1 in the United States remains poorly defined. mcr-1-producing Escherichia coli that also carried blaSHV-12 was detected in a hospitalized patient. No additional cases were identified during screening of 801 Gram-negative isolates. Genomic sequencing identified an IncX4 mcr-1- harboring plasmid and ST117 clonal background associated with avian pathogenic E coli.

HIV positive patients are a high risk population due to the alteration in their immune status. Healthcare associated infections (HAI) have not been well described in this population, with some risk factors reported inconsistently in the literature. The aim of this study was to describe the epidemiology as well as the underlying risk factors for HAI, specifically urinary tract infection (UTI), bloodstream infection (BSI) and respiratory tract infection (RTI). This was a retrospective cohort study conducted in three hospitals at an academic health system in New York City, over a two year period from 2006 to 2008. There were 3,877 HIV positive patient discharges in 1,911 patients. There were a total of 142 UTI, 106 BSI, and 100 RTI. The incidence rates were 4.35 for UTI, 3.16 for BSI and 2.98 for RTI. CD4 count and antiretroviral therapy were not associated with HAI. Significant predictors of UTI included urinary catheter, length of stay, female gender, steroids and trimethoprim-sulphamethoxazole (TMP-SMX); of BSI were steroids and TMP-SMX; and RTI were mechanical ventilation, steroids and TMP-SMX. Multivariable analysis indicated that TMP-SMX was significantly associated with an increased risk of infection for all three types of HAI [BSI odds ratio 2.55, 95% confidence interval (1.22–5.34); UTI odds ratio 3.1, 95% confidence interval (1.41–7.22); RTI odds ratio 5.15, 95% confidence interval (1.70–15.62)]. HIV positive patients are at significant risk for developing HAI, but the risk factors differ depending on the specific type of infection. The fact that TMP-SMX is a risk factor in these patients warrants further research as this may have significant health policy implications.

ObjectiveTo determine the association between state legal mandates for data submission of central line–associated bloodstream infections (CLABSIs) in neonatal intensive care units (NICUs) with process and outcome measures.DesignCross-sectional study.Participants. National sample of level II/III and III NICUs participating in National Healthcare Safety Network (NHSN) surveillance.MethodsState mandates for data submission of CLABSIs in NICUs in place by 2011 were compiled and verified with state healthcare-associated infection coordinators. A web-based survey of infection control departments in October 2011 assessed CLABSI prevention practices, ie, compliance with checklist/bundle components (process measures) in ICUs including NICUs. Corresponding 2011 NHSN NICU CLABSI rates (outcome measures) were used to calculate standardized infection ratios (SIRs). Association between mandates and process and outcome measures was assessed by multivariable logistic regression.ResultsAmong 190 study NICUs, 107 (56.3%) were located in states with mandates, with mandates in place >3 years in 52 (49%). More NICUs in states with mandates reported ≥95% compliance to at least 1 CLABSI prevention practice (52.3%–66.4%) than NICUs in states without mandates (28.9%–48.2%). Mandates were predictors of ≥95% compliance with all practices (odds ratio, 2.8; 95% confidence interval, 1.4–6.1). NICUs in states with mandates reported lower mean CLABSI rates in the ≤750-g birth weight group (2.4 vs 5.7 CLABSIs/1,000 central line–days) but not in others. Mandates were not associated with SIR ConclusionsState mandates for NICU CLABSI data submission were significantly associated with ≥95% compliance with CLABSI prevention practices, which declined with the duration of mandate but not with lower CLABSI rates.Infect Control Hosp Epidemiol 2014;35(9):1133-1139

Background Bundles and checklists have been shown to decrease the rates of central line–associated bloodstream infections (CLABSIs), but implementation of these practices and association with CLABSI rates have not been described nationally. We describe implementation and levels of compliance with preventive practices in a sample of US neonatal intensive care units (NICUs) and assess their association with CLABSI rates. Methods An online survey assessing infection prevention practices was sent to hospitals participating in National Healthcare Safety Network CLABSI surveillance in October 2011. Participating hospitals permitted access to their NICU CLABSI rates. Multivariable regressions were used to test the association between compliance with NICU-specific CLABSI prevention practices and corresponding CLABSI rates. Results Overall, 190 level II/III and level III NICUs participated. The majority of NICUs had written policies (84%-93%) and monitored compliance with bundles and checklists (88%-91%). Reporting ≥95% compliance for any of the practices ranged from 50%-63%. Reporting of ≥95% compliance with insertion checklist and assessment of daily line necessity were significantly associated with lower CLABSI rates ( P Conclusions Most of the NICUs in this national sample have instituted CLABSI prevention policies and monitor compliance, although reporting compliance ≥95% was suboptimal. Reporting ≥95% compliance with select CLABSI prevention practices was associated with lower CLABSI rates. Future studies should focus on identifying and improving compliance with effective CLABSI prevention practices in neonates.

Background Extremely drug-resistant gram-negative bacilli (XDR-GNB) increasingly cause health care-associated infections (HAIs) in intensive care units (ICUs). Methods A matched case-control (1:2) study was conducted from February 2007 to January 2010 in 16 ICUs. Case and control subjects had HAIs caused by GNB susceptible to ≤1 antibiotic versus ≥2 antibiotics, respectively. Logistic and Cox proportional hazards regression assessed risk factors for HAIs and predictors of mortality, respectively. Results Overall, 103 case and 195 control subjects were enrolled. An immunocompromised state (odds ratio [OR], 1.55; P = .047) and exposure to amikacin (OR, 13.81; P P = .005), or trimethoprim-sulfamethoxazole (OR, 3.42; P = .009) were factors associated with XDR-GNB HAIs. Multiple factors in both case and control subjects significantly predicted increased mortality at different time intervals after HAI diagnosis. At 7 days, liver disease (hazard ratio [HR], 5.52), immunocompromised state (HR, 3.41), and bloodstream infection (HR, 2.55) predicted mortality; at 15 days, age (HR, 1.02 per year increase), liver disease (HR, 3.34), and immunocompromised state (HR, 2.03) predicted mortality; and, at 30 days, age (HR, 1.02 per 1-year increase), liver disease (HR, 3.34), immunocompromised state (HR, 2.03), and hospitalization in a medical ICU (HR, 1.85) predicted mortality. Conclusion HAIs caused by XDR-GNB were associated with potentially modifiable factors. Age, liver disease, and immunocompromised state, but not XDR-GNB HAIs, were associated with mortality.

Background: This report provides a national cross-sectional snapshot of infection prevention and control programs and clinician compliance with the implementation of processes to prevent health caree associated infections (HAIs) in intensive care units (ICUs). Methods: All hospitals, except Veterans Affairs hospitals, enrolled in the National Healthcare Safety Network (NHSN) were eligible to participate. Participation involved completing a survey assessing the presence of evidence-based prevention policies and clinician adherence and joining our NHSN research group. Descriptive statistics were computed. Facility characteristics and HAI rates by ICU type were compared between respondents and nonrespondents. Results: Of the 3,374 eligible hospitals, 975 provided data (29% response rate) on 1,653 ICUs, and there were complete data on the presence of policies in 1,534 ICUs. The average number of infection preventionists (IPs) per 100 beds was 1.2. Certification of IP staff varied across institutions, and the average hours per week devoted to data management and secretarial support were generally low. There was variation in the presence of policies and clinician adherence to these policies. There were no differences in HAI rates between respondents and nonrespondents. Conclusions: Guidelines for IP staffing in acute care hospitals need to be updated. In future work, we will analyze the associations between HAI rates and infection prevention and control program characteristics

Background Outpatient parenteral antibiotic therapy (OPAT) is a key part of the treatment of severe infection. One indication for OPAT is methicillin-resistant Staphylococcus aureus (MRSA) bacteremia. Few data have been published regarding long-term follow-up and outcomes among patients in an OPAT program (OPAT-P). We describe OPAT-P outcomes at an academic medical center with a focus on MRSA bacteremia (MRSA-B). Methods A retrospective chart review was performed. Two cohorts of patients were studied. The first comprised all adult inpatients enrolled in OPAT-P at discharge from July 2016 to December 2017. The second cohort was a subset of these patients treated for MRSA-B. Outcomes (including readmissions, emergency room [ER] visits, microbiological recurrences, and death) were compared with outcomes among non-OPAT-P patients discharged on IV antibiotics for MRSA-B between January 2015 and December 2017. Statistical measures including chi squared tests or Fisher’s exact tests were used. Results Five hundred sixty-one patients were enrolled in OPAT-P from July 2016 to December 2017. Common indications were osteomyelitis (n = 219, 39%), bacteremia (n = 73, 13%), and endocarditis (n = 73, 13%); 22% had polymicrobial infection. Sixty-one (11%) were rehospitalized and 24 (4%) had an ER visit for an infectious or OPAT issue while on therapy. Fifty-one adverse events occurred that did not result in ER visit or a readmission. Ninety-three (17%) required antibiotic dose changes. Twenty-five patients were treated for MRSA-B; 83 additional non-OPAT-P patients were discharged on IV therapy for MRSA-B from January 2015 to December 2017. Common sources of bacteremia included central line (n = 24, 22%), cellulitis (n = 18, 16%), and osteomyelitis (n = 9, 8%). No MRSA-B patients died within 30 days of discharge. Overall 6-month readmission and ER visit rates did not differ based on OPAT-P enrollment (54%, P = 0.46 and 57%, P = 0.43, respectively). Three of 25 (12%) MRSA-B OPAT-P patients and 9/83 (74%) MRSA-B non-OPAT-P patients were readmitted for OPAT or infectious complications (P = NS). Microbiological recurrence was rare. Conclusion Adverse events in OPAT are common and antibiotic monitoring is crucial for OPAT safety. A dedicated OPAT-P has the potential to proactively identify adverse events and change therapy to prevent unplanned admission or ER visit. Further data are needed to clarify whether an OPAT-P may improve MRSA-B post-discharge outcomes. Disclosures All authors: No reported disclosures.

Background The Centers for Disease Control and Prevention and the American Nurses Association (CDC/ANA) outline specific responsibilities for RNs in AS efforts. Responsibilities expand traditional RN roles and are perceived to require prescriber engagement. We explored prescribers’ attitudes toward RNs’ involvement in AS and barriers and facilitators to the following RN responsibilities specified by the CDC/ANA: (1) RNs facilitate accurate antibiotic allergy histories; (2) RNs encourage the switch from intravenous (IV) to oral (PO) antibiotics; and (3) RNs initiate an antibiotic time out with prescribers. Methods Four focus groups and two interviews with 37 prescribers (10 medicine residents, 10 adult hospitalists, nine pediatricians, and eight critical care nurse practitioners) were conducted between July 2017 and March 2018 at two academic adult and pediatric hospitals. Transcripts were coded using a conventional content analysis in NVivo 11. Results Prescribers agreed that RNs should play an important role in AS and described positive experiences when interacting with RNs who actively aimed to improve antibiotic use. While CDC/ANA recommendations were perceived to improve patient care, recommendation-specific challenges were noted to pose important barriers: (1) understanding that RNs are not exclusively responsible for antibiotic allergy histories; (2) possible prescriber pushback if the rationale for an IV to PO switch and the potential severity of the problem locally is not well understood; and (3) competing RN and prescriber schedules and a lack of clearly defined RN roles during antibiotic timeouts. To overcome barriers, prescribers recommended: (1) RNs initiate conversations with prescribers re: questionable drug allergies to facilitate accurate documentation and shared responsibility of drug allergy information; (2) prescriber education and the sharing of local data to address prescriber pushback; and (3) integration of antibiotic timeouts during interprofessional rounds and specified RN responsibilities to ensure meaningful conversation. Conclusion Prescribers were receptive to formal RN involvement in AS activities, but noted the successful adoption of CDC/ANA recommendations would require an interprofessional approach. Disclosures All authors: No reported disclosures.

Objective.To assess the impact of an electronic surveillance system on isolation practices and rates of methicillin-resistant Staphylococcus aureus (MRSA).Design.A pre-post test intervention.Setting.Inpatient units (except psychiatry and labor and delivery) in 4 New York City hospitals.Patients.All patients for whom isolation precautions were indicated, May 2009–December 2011.Methods.Trained observers assessed isolation sign postings, availability of isolation carts, and staff use of personal protective equipment (PPE). Infection rates were obtained from the infection control department. Regression analyses were used to examine the association between the surveillance system, infection prevention practices, and MRSA infection rates.Results.A total of 54,159 isolation days and 7,628 staff opportunities for donning PPE were observed over a 31-month period. Odds of having an appropriate sign posted were significantly higher after intervention than before intervention (odds ratio [OR], 1.10 [95% confidence interval {CI}, 1.01–1.20]). Relative to baseline, postintervention sign posting improved significantly for airborne and droplet precautions but not for contact precautions. Sign posting improved for vancomycin-resistant enterococci (OR, 1.51 [95% CI, 1.23–1.86]; P = .0001), Clostridium difficile (OR, 1.59 [95% CI, 1.27–2.02]; P = .00005), and Acinetobacter baumannii (OR, 1.41 [95% CI, 1.21–1.64]; P = .00001) precautions but not for MRSA precautions (OR, 1.11 [95% CI, 0.89–1.39]; P = .36). Staff and visitor adherence to PPE remained low throughout the study but improved from 29.1% to 37.0% after the intervention (OR, 1.14 [95% CI, 1.01–1.29]). MRSA infection rates were not significantly different after the intervention.Conclusions.An electronic surveillance system resulted in small but statistically significant improvements in isolation practices but no reductions in infection rates over the short term. Such innovations likely require considerable uptake time.

Objective.To assess how healthcare professionals caring for patients in intensive care units (ICUs) understand and use antimicrobial susceptibility testing (AST) for multidrug-resistant gram-negative bacilli (MDR-GNB).Design.A knowledge, attitude, and practice survey assessed ICU clinicians' knowledge of antimicrobial resistance, confidence interpreting AST results, and beliefs regarding the impact of AST on patient outcomes.Setting.Sixteen ICUs affiliated with NewYork-Presbyterian Hospital.Participants.Attending physicians and subspecialty residents with primary clinical responsibilities in adult or pediatric ICUs as well as infectious diseases subspecialists and clinical pharmacists.Methods.Participants completed an anonymous electronic survey. Responses included 4-level Likert scales dichotomized for analysis. Multivariate analyses were performed using generalized estimating equation logistic regression to account for correlation of respondents from the same ICU.Results.The response rate was 51% (178 of 349 eligible participants); of the respondents, 120 (67%) were ICU physicians. Those caring for adult patients were more knowledgeable about antimicrobial activity and were more familiar with MDR-GNB infections. Only 33% and 12% of ICU physicians were familiar with standardized and specialized AST methods, respectively, but more than 95% believed that AST improved patient outcomes. After adjustment for demographic and healthcare provider characteristics, those familiar with treatment of MDR-GNB bloodstream infections, those aware of resistance mechanisms, and those aware of AST methods were more confident that they could interpret AST results and/or request additional in vitro testing.Conclusions.Our study uncovered knowledge gaps and educational needs that could serve as the foundation for future interventions. Familiarity with MDR-GNB increased overall knowledge, and familiarity with AST increased confidence interpreting the results.

The spread of mcr-1 in the United States remains poorly defined. mcr-1-producing Escherichia coli that also carried blaSHV-12 was detected in a hospitalized patient. No additional cases were identified during screening of 801 Gram-negative isolates. Genomic sequencing identified an IncX4 mcr-1- harboring plasmid and ST117 clonal background associated with avian pathogenic E coli.

Objective To examine the effect of mandated state health care–associated infection (HAI) reporting laws on central line–associated bloodstream infection (CLABSI) rates in adult intensive care units (ICUs). Data Sources We analyzed 2006–2012 adult ICU CLABSI and hospital annual survey data from the National Healthcare Safety Network. The final analytic sample included 244 hospitals, 947 hospital years, 475 ICUs, 1,902 ICU years, and 16,996 ICU months. Study Design We used a quasi-experimental study design to identify the effect of state mandatory reporting laws. Several secondary models were conducted to explore potential explanations for the plausible effects of HAI laws. Principal Findings Controlling for the overall time trend, ICUs in states with laws had lower CLABSI rates beginning approximately 6 months prior to the law's effective date (incidence rate ratio = 0.66; p

Background. Carbapenem-resistant Klebsiella pneumoniae (CRKP) infection is a rising public health threat since its first outbreaks in New York City (NYC) in the early 2000s. We investigated annual trends of CRKP infection in hospital-acquired infections (HAIs) and community-onset infections (COIs) treated in 3 NYC hospitals from 2006 to 2014. Methods. We extracted K pneumoniae infection data including carbapenem susceptibility and anatomical sites, compared clinical characteristics between CRKP and carbapenem-susceptible K pneumoniae infections, and determined CRKP infection proportions in total K pneumoniae infections in HAI and COI to identify statistically significant trends from 2006 to 2014 using the Cochran-Armitage trend test. Results. Carbapenem-resistant K pneumoniae contributed 17.3% (601 of 3477) of hospital-acquired K pneumoniae infection compared with 7.7% (149 of 1926) in COI from 2006 to 2014. Carbapenem-resistant K pneumoniae proportions in HAI and COI were positively correlated over time (r = 0.83, P < .01), and there were downward annual trends of CRKP proportions from 2006 to 2014 in both HAI and COI (25.8% to 10.5% in HAI, P < .001; 13.6% to 3.1% in COI, P < .001). By anatomical site, significant downward annual trends were present only in urinary tract infection (P < .001 for both HAI and COI) from 2006 to 2014. Conclusions. Annual trends of CRKP proportions from 2006 to 2014 were downward in both HAI and COI, and HAI and COI were positively correlated. Efforts to reduce and prevent CRKP infections in both hospital and community settings were successful and warrant continuation.

We previously reported the epidemiology of 2009 Influenza A (H1N1) in our pediatric healthcare facility in New York City during the first wave of illness (May-July 2009). We hypothesized that compared with the first wave, the second wave would be characterized by increased severity of illness and mortality.: Case series conducted from May 2009 to April 2010.Pediatric emergency departments and inpatient facilities of New York-Presbyterian Hospital.All hospitalized patients ÷ 18 yrs of age with positive laboratory tests for influenza A.We compared severity of illness during the first and second wave assessed by the number of hospitalized children, including those in the pediatric intensive care unit, bacterial superinfections, and mortality rate. Compared to the first wave, fewer children were hospitalized during the second wave (n = 115 vs. 76), but a comparable portion were admitted to the pediatric intensive care unit (30.4% vs. 19.7%; p = .10). Pediatric Risk of Mortality III scores, length of hospitalization in the pediatric intensive care unit, incidence of respiratory failure and pneumonia, and peak oxygenation indices were similar during both waves. Bacterial superinfections were comparable in the first vs. second wave (3.5% vs. 1.3%). During the first wave, no child received extracorporeal membrane oxygenation and one died, while during the second wave, one child received extracorporeal membrane oxygenation and there were no deaths.At our pediatric healthcare facility in New York City, fewer children were hospitalized with 2009 Influenza A (H1N1) during the second wave, but both waves had a similar spectrum of illness severity and low mortality rate.

Background Most outbreak investigations involve short-term, geographically localized clusters. However, some organisms can form environmental reservoirs leading to more prolonged, widespread outbreaks. We describe a prolonged outbreak of Burkholderia at our institution. Methods An epidemiological investigation was conducted. Burkholderia isolates were genotyped using pulsed-field gel electrophoresis (PFGE) and recA gene sequencing. Initial isolates were sent to a national reference laboratory for multilocus sequence typing (MLST). Results 32 patients on 12 units (see figure) had ≥1 positive culture for Burkholderia from June 2017 to February 2018. 21 had B. cenocepacia (PFGE pattern A, recA allele 365) and 11 had B. cepacia (PFGE pattern C, recA allele 53). MLST revealed that isolates with recA allele 365 were unique compared with previously identified B. cenocepacia strains. Of 32 patients, 28 (88%) had positive respiratory cultures. Of 32 patients, 3 (9%) had bacteremia. Thirty-day mortality was 4/29 (14%). A case–control study did not reveal a common point source. All surveillance cultures from asymptomatic patients were negative (n = 53). Two of nine sink drains in rooms of cases were positive for an unrelated strain of B. cepacia. Other environmental cultures were negative for Burkholderia (n = 49). Cases continued despite routine interventions (see figure), with some incident cases detected long after potential exposures. Ventilator/respiratory equipment (V/RE) cleaning was investigated. Multiple V/RE interventions were implemented: (1) ensuring a sterilization process for ventilator temperature probes (used in heated humidification) was occurring; (2) using disposable manometers on contact isolation patients; (3) reinforcing ventilator cleaning, including those in radiology suites after use. Conclusion No definitive source of the outbreak was found. New cases continued after reinforcement of basic infection control practices, but subsided after focused attention on V/RE cleaning practices. Control of this outbreak was challenging due to the complexity of a prolonged “latency period” for Burkholderia, difficulty identifying reservoirs, and multiple possible modes of transmission, especially for organisms like Burkholderia that can persist on environmental surfaces and equipment. Disclosures All authors: No reported disclosures.

The nature of infection prevention and control is changing; however, little is known about current staffing and structure of infection prevention and control programs.Our objectives were to provide a snapshot of the staffing and structure of hospital-based infection prevention and control programs in the United States. A Web-based survey was sent to 441 hospitals that participate in the National Healthcare Safety Network.The response rate was 66% (n = 289); data were examined on 821 professionals. Infection preventionist (IP) staffing was significantly negatively related to bed size, with higher staffing in smaller hospitals (P.001). Median staffing was 1 IP per 167 beds. Forty-seven percent of IPs were certified, and 24 percent had less than 2 years of experience. Most directors or hospital epidemiologists were reported to have authority to close beds for outbreaks always or most of the time (n = 225, 78%). Only 32% (n = 92) reported using an electronic surveillance system to track infections.This study is the first to provide a comprehensive description of current infection prevention and control staffing, organization, and support in a select group of hospitals across the nation. Further research is needed to identify effective staffing levels for various hospital types as well as examine how the IP role is changing over time.