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Objective: To establish the epidemiology of cardiac implantable electronic device (CIED) infections in Alberta, Canada, using validated administrative data. Design: Retrospective, population-based cohort study. Setting: Alberta Health Services is a province-wide health system that services all of Alberta, Canada. Participants: Adult patients who underwent first-time CIED implantation or generator replacement in Alberta, Canada, between January 1, 2011, and December 31, 2019. Methods: CIED implant patients were identified from the Paceart database. Patients who developed an infection within 1 year of the index procedure were identified through validated administrative data (International Classification of Diseases, Tenth Revision in Canada). Demographic characteristics of patients were summarized. Logistic regression models were used to analyze device type, comorbidities, and demographics associated with infection rates and mortality. Results: Among 27,830 CIED implants, there were 205 infections (0.74%). Having 2 or more comorbidities was associated with higher infection risk. Generator replacement procedures (odds ratio [OR], 0.55; 95% confidence interval [CI], 0.34–0.84; P = .008), age increase of every 10 years (OR, 0.73; 95% CI, 0.66–0.82; P ≤ .001), and index procedure after 2014 were associated with decreased risk. Comparing the infected to uninfected groups, the hospitalization rates were 2.63 compared to 0.69, and the mortality rates were 10.73% compared to 3.49%, respectively (P < .001). Conclusions: There is a slightly lower overall rate of CIED infections Alberta, Canada compared to previously described epidemiology. Implants after 2014, and generator replacements showed a decreased burden of infection. Patients with younger age, and 2 or more comorbidities are at greatest risk of CIED infection. The burden of hospitalization and mortality is substantially higher in infected patients.

Background Decolonization is an important infection prevention and control strategy in the surgical context. Preoperative decolonization of hip and knee replacement patients reduces the incidence of surgical site infections (SSIs), but the implementation of decolonization protocols has been uneven. Understanding the clinical level barriers and facilitators that affect implementation may increase the effectiveness of preoperative decolonization strategies. Methods Leveraging ongoing quality improvement (QI) activity to reduce SSIs amongst hip and knee replacement patients in Alberta, Canada, qualitative methods were deployed. Semi-structured interviews (n=2) were conducted with surgeons, and focus groups (n=9) were conducted with seven nurses and two administrative staff to understand barriers and facilitators to the implementation of a provincial decolonization strategy. Interview questions were developed in conjunction with the Theoretical Domains Framework (TDF) and the research team. An inductive analysis derived from a Grounded Theory (GT) approach was conducted with the assistance of NVivo software. Results Knowledge and understanding of the decolonization strategy were central to implementation. When present, they acted as facilitators, but when absent or inconsistent, they were significant barriers to implementation. Specifically, clinics needed more knowledge and direction on how to deliver the decolonization strategy to patients receiving homecare; who had repeat surgeries; who required surgery during COVID-19 outbreaks. Conclusions Knowledge and understanding was a core category which summarized seven subcategories found within our GT analysis. A successful decolonization strategy will benefit from adopting further planning and development for specific patients and respiratory outbreaks such as COVID-19. Further aspects that may act as facilitators include having a champion in each clinic, regular reporting, and audit and feedback strategies. Findings from our study can provide information on the barriers and facilitators of a decolonization strategy and can be used in making the decolonization strategy successful.

Background Gram-negative pathogens, such as Escherichia coli, are common causes of bloodstream infections (BSIs) and increasingly demonstrate antimicrobial resistance. Molecular rapid diagnostic tests (mRDTs) offer faster pathogen identification and susceptibility results, but higher costs compared with conventional methods. We determined the cost-effectiveness of the BioFire FilmArray Blood Culture Identification (BCID) Panel, as a type of mRDT, compared with conventional methods in the identification of E. coli BSIs. Methods We constructed a decision analytic model comparing BCID with conventional methods in the identification and susceptibility testing of hospitalized patients with E. coli BSIs from the perspective of the public healthcare payer. Model inputs were obtained from published literature. Cost-effectiveness was calculated by determining the per-patient admission cost, the QALYs garnered and the incremental cost-effectiveness ratios (ICERs) where applicable. Monte Carlo probabilistic sensitivity analyses and one-way sensitivity analyses were conducted to assess the robustness of the model. All costs reflect 2019 Canadian dollars. Results The Monte Carlo probabilistic analyses resulted in cost savings ($27 070.83 versus $35 649.81) and improved QALYs (8.65 versus 7.10) in favour of BCID. At a willingness to pay up to $100 000, BCID had a 72.6%–83.8% chance of being cost-effective. One-way sensitivity analyses revealed length of stay and cost per day of hospitalization to have the most substantial impact on costs and QALYs. Conclusions BCID was found to be cost-saving when used to diagnose E. coli BSI compared with conventional testing. Cost savings were most influenced by length of stay and cost per day of hospitalization.

BackgroundManagement of suspected Clostridioides difficile infection (CDI) in the hospital setting typically results in patient isolation, laboratory testing, infection control, and presumptive treatment. We investigated whether implementation of rapid near-patient testing (NPT) reduced patient isolation time, hospital length of stay (LOS), antibiotic usage, and cost.MethodsA 2-period pragmatic cluster randomized crossover trial was conducted. Thirty-nine wards were randomized into 2 study arms. The primary outcome measure was effect of NPT on patient isolation time using a mixed-effects generalized linear regression model. Secondary outcomes examined were hospital LOS and antibiotic therapy based on a negative binomial regression model. Natural experiment (NE), intention-to-treat (ITT), and per-protocol (PP) analyses were conducted.ResultsDuring the entire study period, a total of 656 patients received NPT for CDI and 1667 received standard-of-care testing. For the primary outcome, a significant decrease of patient isolation time with NPT was observed (NE, 9.4 hours [P < .01]; ITT, 2.3 hours [P < .05]; PP, 6.7 hours [P < .1]). A significant reduction in hospital LOS was observed with NPT for short stay (NE, 47.4% [P < .01]; ITT, 18.4% [P < .01]; PP, 34.2% [P < .01]). Each additional hour delay for a negative result increased metronidazole use (24 defined daily doses per 1000 patients; P < .05) and non-CDI-treating antibiotics by 70.13 mg (P < .01). NPT was found to save 25.48 US dollars per patient when including test cost to the laboratory and patient isolation in the hospital.ConclusionsThis pragmatic cluster randomized crossover trial demonstrated that implementation of CDI NPT can contribute to significant reductions in isolation time, hospital LOS, antibiotic usage, and healthcare cost.Clinical Trials Registration. NCT03857464.

Wastewater-based SARS-CoV-2 surveillance enables unbiased and comprehensive monitoring of defined sewersheds. We performed real-time monitoring of hospital wastewater that differentiated Delta and Omicron variants within total SARS-CoV-2-RNA, enabling correlation to COVID-19 cases from three tertiary-care facilities with2100 inpatient beds in Calgary, Canada. RNA was extracted from hospital wastewater between August/2021 and January/2022, and SARS-CoV-2 quantified using RT-qPCR. Assays targeting R203M and R203K/G204R established the proportional abundance of Delta and Omicron, respectively. Total and variant-specific SARS-CoV-2 in wastewater was compared to data for variant specific COVID-19 hospitalizations, hospital-acquired infections, and outbreaks. Ninety-six percent (188/196) of wastewater samples were SARS-CoV-2 positive. Total SARS-CoV-2 RNA levels in wastewater increased in tandem with total prevalent cases (Delta plus Omicron). Variant-specific assessments showed this increase to be mainly driven by Omicron. Hospital-acquired cases of COVID-19 were associated with large spikes in wastewater SARS-CoV-2 and levels were significantly increased during outbreaks relative to non-outbreak periods for total SARS-CoV2, Delta and Omicron. SARS-CoV-2 in hospital wastewater was significantly higher during the Omicron-wave irrespective of outbreaks. Wastewater-based monitoring of SARS-CoV-2 and its variants represents a novel tool for passive COVID-19 infection surveillance, case identification, containment, and potentially to mitigate viral spread in hospitals. This article is protected by copyright. All rights reserved.

Background WW surveillance enables real time monitoring of SARS-CoV-2 burden in defined sewer catchment areas. Here, we assessed the occurrence of total, Delta and Omicron SARS-CoV-2 RNA in sewage from three tertiary-care hospitals in Calgary, Canada. Methods Nucleic acid was extracted from hospital (H) WW using the 4S-silica column method. H-1 and H-2 were assessed via a single autosampler whereas H-3 required three separate monitoring devices (a-c). SARS-CoV-2 RNA was quantified using two RT-qPCR approaches targeting the nucleocapsid gene; N1 and N200 assays, and the R203K/G204R and R203M mutations. Assays were positive if Cq< 40. Cross-correlation function analyses (CCF) was performed to determine the time-lagged relationships between WW signal and clinical cases. SARS-CoV-2 RNA abundance was compared to total hospitalized cases, nosocomial-acquired cases, and outbreaks. Statistical analyses were conducted using R. Results Ninety-six percent (188/196) of WW samples collected between Aug/21-Jan/22 were positive for SARS-CoV-2. Omicron rapidly supplanted Delta by mid-December and this correlated with lack of Delta-associated H-transmissions during a period of frequent outbreaks. The CCF analysis showed a positive autocorrelation between the RNA concentration and total cases, where the most dominant cross correlations occurred between -3 and 0 lags (weeks) (Cross-correlation values: 0.75, 0.579, 0.608, 0.528 and 0.746 for H-1, H-2, H-3a, H-3b and H-3c; respectively). VOC-specific assessments showed this positive association only to hold true for Omicron across all hospitals (cross-correlation occurred at lags -2 and 0, CFF value range between 0.648 -0.984). We observed a significant difference in median copies/ml SARS-CoV-2 N-1 between outbreak-free periods vs outbreaks for H-1 (46 [IQR: 11-150] vs 742 [IQR: 162-1176], P< 0.0001), H-2 (24 [IQR: 6-167] vs 214 [IQR: 57-560], P=0.009) and H-3c (2.32 [IQR: 0-19] vs 129 [IQR: 14-274], P=0.001). Conclusion WW surveillance is a powerful tool for early detection and monitoring of circulating SARS-CoV-2 VOCs. Total SARS-CoV-2 and VOC-specific WW signal correlated with hospitalized prevalent cases of COVID-19 and outbreak occurrence. Disclosures All Authors: No reported disclosures.

Background New tools capable of dynamic assessment of the varying burden of Clostridioides difficile infections are required to mitigate increased patient morbidity, mortality, and health costs. Wastewater (WW)-based epidemiology (WBE) is an emerging science, enabling comprehensive, inclusive, and unbiased assessment of populations, spatially and temporally. We sought to detect, quantify and track C. difficile across a range of scales using WBE. Methods WW collected from two hospitals; the Rockyview General Hospital (RGH; 600 beds) and Peter Lougheed Centre (PLC; 550 beds) both based in Calgary, were compared to that from a municipal WW Treatment Plant (WWTP) in Calgary, Canada. DNA was extracted from pellets collected after WW centrifugation. A multiplexed quantitative PCR assay was used to quantify the abundance of C. difficile 16S rRNA and toxin A (tcdA) genes. These were then assessed as raw values or as normalized ratios to three fecal biomarker genes: total bacterial 16S rRNA, human 18S rRNA, and Bacteroides HF183 16S rRNA. Kruskal-Wallis and Mann-Whitney tests were performed using RStudio and GraphPad Prism (version 9.3.1). Results Eight weekly samples collected from the RGH demonstrated significant changes in the levels of total C. difficile 16S rRNA gene and tcdA over time (P=0.0004 and P=0.0005, respectively, Kruskal-Wallis). Similar trends in total C. difficile and tcdA burden over time were observed when gene copies were normalized with the three fecal biomarker genes. Over a separate 13-week comparison, C. difficile and tcdA gene target abundance was greater in hospital WW (RGH and PLC) than in community-based samples from the WWTP (P=0.048 and P=0.012, respectively, Mann-Whitney). There was no significant difference in C. difficile and tcdA gene target abundance between RGH and PLC (P=0.896 and P=0.343, respectively, Mann-Whitney). Clostridioides difficile genes in wastewater measured by quantitative PCR. C. difficile 16S rRNA and tcdA gene abundance normalized as a ratio against total bacterial load (16S rRNA) varies over time and is markedly increased in hospitals relative to a municipal wastewater treatment plant in Calgary, Canada. Conclusion WW surveillance is a powerful tool that can monitor the burden the C. difficile across a range of scales in real-time. This tool could augment infection prevention and control and antimicrobial stewardship programs to better understand factors that contribute to colonization and infection. Disclosures Thomas J. Louie, MD, Artugen: Advisor/Consultant|Artugen: Grant/Research Support|Crestone: Advisor/Consultant|Crestone: Grant/Research Support|Finch Therapeutics: Advisor/Consultant|Finch Therapeutics: Grant/Research Support|Rebiotix: Advisor/Consultant|Rebiotix: Grant/Research Support|Seres Therapeutics: Advisor/Consultant|Seres Therapeutics: Grant/Research Support|summit plc: Advisor/Consultant|summit plc: Grant/Research Support|Vedanta Biosciences: Advisor/Consultant|Vedanta Biosciences: Grant/Research Support.

Objective:To evaluate the cost of 1-stage and 2-stage revisions, debridement, antibiotic and implant retention (DAIR) and DAIR with liner exchange for complex surgical site infections (SSIs) following hip and knee replacements.Design:Retrospective population-based economic analysis of patients undergoing intervention for SSIs between April 1, 2012 and March 31, 2019.Setting:The study was conducted in the Calgary zone of Alberta Health Services (AHS) in Canada.Participants:Individuals >18 years with complex SSI following hip or knee replacement.Methods:Patients with complex SSIs were identified using the AHS infection prevention and control database. A combination of microcosting and gross costing methods were used to estimate 12- and 24-month costs following the initial hospital admission for arthroplasty. Subgroup, inverse Gaussian and γ regression analyses were used to evaluate the impact of age and comorbidities on cost.Results:In total, 142 patients with complex SSIs were identified, with a mean age of 66.8 years. Total direct medical costs in United States dollars of 2-stage revisions were ($100,992 (95% CI, 34,587–167,396) at 12 months. The 1-stage revision ($41,176; 95% CI, 23,361–58,991), DAIR with liner exchange ($41,267; 95% CI, 29,923–52,612) and DAIR ($46,605; 95% CI, 15,277–76,844) were associated with fewer costs at 12 months. Age >65 years and chronic complications of diabetes and hypertension were associated with increased costs in subgroup and regression analysis.Conclusions:Medical costs are highest at 12 months and for 2-stage revisions in hip and knee complex SSI cases. Further work should explore surgical outcomes correlated with costs to enhance patient care.

Objective Surgical site infections (SSIs) are a serious and costly post-op complication. Generating SSI rates often requires labor-intensive methods, but increasing numbers of publications reported SSI rates using administrative data. Methods Index laminectomy and spinal fusion procedures were identified using Canadian Classification of Health Interventions (CCI) procedure codes for inpatients and outpatients in the province of Alberta, Canada between 2008 and 2015. SSIs occurring in the year postsurgery were identified using the International Classification of Diseases, 10th Revision, Canada (ICD-10-CA) diagnosis and CCI procedure codes indicative of post-op infection. Rates of SSIs and case characteristics were reported. Results Over the 8-year study period, 21,222 index spinal procedures were identified of which 12,027 (56.7%) were laminectomy procedures, with 322 SSIs identified, an SSI rate of 2.7 per 100 procedures. Of the 9,195 (43.3%) fusion procedures, 298 were identified as an SSI, an SSI rate of 3.2 per 100 procedures. This study found SSI rates increased from 2008 and 2015, and rates were the highest in the 0-18 year age group. Conclusions The rates reported in this study were similar to published SSI rates using traditional surveillance methods, suggesting administrative data may be a viable method for reporting SSI rates following spinal procedures. Further work is needed to validate SSIs identified using administrative data by comparing to traditional surveillance.

Asymptomatic coronavirus disease 2019 (COVID-19) has been reported as a significant driver of COVID-19 outbreaks. Our hospital ward outbreak analysis suggests that comprehensive symptoms and signs assessment, in combination with adequate follow-up, allows a more precise determination of COVID-19 symptoms. Asymptomatic infection was quite uncommon among adults in this setting.

Background Clostridioides difficile infection (CDI) is one of the most common health care-associated infections. This study assessed the validity of the Discharge Abstract Database (DAD) compared to a traditional clinical surveillance method for identifying CDI. Methods Retrospective analysis of all DAD records with International Statistical Classification of Diseases and Related Health Problems 10th Revision (ie, ICD-10) diagnostic code A04.7 (enterocolitis due to CDI) between April 2015 and March 2019 were compared to a clinical dataset of positive inpatient CDI for all acute care facilities in Alberta, Canada. Sensitivity and positive predictive values were calculated using R version 3.6.0. Results The DAD had a sensitivity of 85.0% (95% confidence interval: 84.1%-85.8%) and a positive predictive value of 80.0% (95% confidence interval: 79.2%-80.0%). The CDI rate per 1,000 admissions over the study period was 28% higher in the DAD compared to Infection Prevention and Control surveillance. Discussion The DAD does not distinguish symptomatic cases from asymptomatic cases and so indicators to identify symptomatic disease would need to be applied, potentially through a linkage to antibiotic treatment orders available in patient management systems. Conclusions The DAD is moderately sensitive for identifying symptomatic CDI cases in Alberta, Canada and caution should be applied when interpreting rates based on administrative data.

Objective:Adverse outcomes following Clostridioides difficile infection (CDI) are not often reported for long-term care facility (LTCF) residents. We focused on the adverse outcomes due to CDI identified in Alberta LTCFs.Methods:All positive Clostridioides difficile stool specimens identified by laboratory-identified (LabID) event surveillance in Alberta from 2011 to 2018, along with Alberta Continuing Care Information System, were used to define CDI in Alberta LTCFs. CDI cases were classified as long-term care onset, hospital onset, and community onset. Laboratory records were linked to provincial databases to analyze acute-care admissions and mortality within 30-day post CDI. Age, sex, case classification, episode, and operator type, were investigated using logistic regression.Results:Overall, 902 CDI cases were identified in 762 LTCF residents. Of all CDI events, 860 (95.3%) were long-term care onset, 38 (4.2%) were hospital onset, and 4 (0.4%) were community onset. The CDI rate was 2.0 of 100,000 resident days. In total, 157 residents (20.6%) had 30-day all-cause mortality, 126 CDI cases (14.0%) had 30-day all-cause acute-care admissions. The 30-day all-cause mortality rate was significantly higher in residents aged >80 versus ≤80 years (24.9 vs 12.3 per 100 residents; P < .05). Residents aged >80 years, with hospital-onset CDI, and those staying in private or voluntary LTCFs were more likely to have 30-day all-cause acute-care admissions.Conclusions:The prevalence of CDI adverse outcomes is in LTCFs was found to be high using LabID event surveillance. Annual review of CDI adverse outcomes using LabID event can minimize the burden of surveillance and standardize the process across all Alberta LTCFs.

Complex surgical site infections (SSIs) and revisions for these infectious complications following total knee and hip arthroplasties are associated with significant economic costs.To evaluate the cost of one-stage and two-stage revisions; debridement, antibiotic, and implant retention (DAIR) and DAIR with liner exchange for complex hip or knee SSIs in Alberta, Canada.We used the Alberta Health Services Infection Prevention and Control database to identify individuals18 years old from the two major urban centers in Alberta, Calgary, and Edmonton zone, with complex hip or knee SSIs who underwent surgical intervention between April 1, 2012, and March 31, 2019. Micro-costing and gross-costing methods were used to estimate 12 and 24-month costs following the initial hospital admission for arthroplasty. Subgroup, inverse gaussian and gamma regression analysis were used to evaluate the associations of the revision procedure, age, sex, and comorbidities on cost.A total of 382 patients with complex SSIs were identified with a mean age of 66.1 years. DAIR and DAIR with liner exchange resulted in the lowest 12- and 24-month costs at $53,197 (95% CI, $38,006 - $68,388) and $57,340 (95% CI, $48,576 - $66,105), respectively; two-stage revision was the costliest procedure. Most of the incurred costs (98%) were accrued within the first 12 months following the initial procedure.Medical costs are highest 12 months following initial arthroplasty and for two-stage revisions in hip and knee complex SSI.

1ABSTRACTObjectivesTo review the literature from 2011 until March 31st, 2020 to identify the risk of transmission of ARIs to healthcare workers caring for patients undergoing AGMPs compared with the risk of transmission when caring for patients not undergoing AGMPs.ResultsOnly two prospective cohort studies were identified meeting inclusion criteria. One found that performance or assistance with AGMP during the previous week was significantly associated with symptomatic influenza (adjusted OR: 2.29, 95% CI: 1.3 to 4.2). The second study found that performance of AGMP was significantly associated with clinical respiratory infections (RR 2.9, 95% CI 1.42-5.87, p

In a population-based, five-year retrospective cohort study of 5304 adult patients with hospital-acquired Clostridioides difficile infection across Alberta (N=101 hospitals), 30-day all-cause and attributable mortality were 12.2% and 4.5%, respectively. Patients >75 years of age had the highest odds of attributable mortality (odds ratio (OR) 9.34, 95% confidence interval (CI) 2.92-29.83) and largest difference in mean length of stay (11.7 days, 95% CI 8.2-15.2). A novel finding was that elevated white blood cell count at admission was associated with reduced attributable mortality (OR 0.67, 95% CI 0.50-0.90) which deserves further study. Advancing age was incrementally and significantly associated with all outcomes.

Objective:To determine the attributable cost and length of stay of hospital-acquired Clostridioides difficile infection (HA-CDI) from the healthcare payer perspective using linked clinical, administrative, and microcosting data.Design:A retrospective, population-based, propensity-score–matched cohort study.Setting:Acute-care facilities in Alberta, Canada.Patients:Admitted adult (≥18 years) patients with incident HA-CDI and without CDI between April 1, 2012, and March 31, 2016.Methods:Incident cases of HA-CDI were identified using a clinical surveillance definition. Cases were matched to noncases of CDI (those without a positive C. difficile test or without clinical CDI) on propensity score and exposure time. The outcomes were attributable costs and length of stay of the hospitalization where the CDI was identified. Costs were expressed in 2018 Canadian dollars.Results:Of the 2,916 HA-CDI cases at facilities with microcosting data available, 98.4% were matched to 13,024 noncases of CDI. The total adjusted cost among HA-CDI cases was 27% greater than noncases of CDI (ratio, 1.27; 95% confidence interval [CI], 1.21–1.33). The mean attributable cost was $18,386 (CAD 2018; USD $14,190; 95% CI, $14,312–$22,460; USD $11,046-$17,334). The adjusted length of stay among HA-CDI cases was 13% greater than for noncases of CDI (ratio, 1.13; 95% CI, 1.07–1.19), which corresponds to an extra 5.6 days (95% CI, 3.10–8.06) in length of hospital stay per HA-CDI case.Conclusions:In this population-based, propensity score matched analysis using microcosting data, HA-CDI was associated with substantial attributable cost.

SARS-CoV-2 has been detected in wastewater and its abundance correlated with community COVID-19 cases, hospitalizations and deaths. We sought to use wastewater-based detection of SARS-CoV-2 to assess the epidemiology of SARS-CoV-2 in hospitals. Between August and December 2020, twice-weekly wastewater samples from three tertiary-care hospitals (totaling >2100 dedicated inpatient beds) were collected. Hospital-1 and Hospital-2 could be captured with a single sampling point whereas Hospital-3 required three separate monitoring sites. Wastewater samples were concentrated and cleaned using the 4S-silica column method and assessed for SARS-CoV-2 gene-targets (N1, N2 and E) and controls using RT-qPCR. Wastewater SARS-CoV-2 as measured by quantification cycle (Cq), genome copies and genomes normalized to the fecal biomarker PMMoV were compared to the total daily number of patients hospitalized with active COVID-19, confirmed cases of hospital-acquired infection, and the occurrence of unit-specific outbreaks. Of 165 wastewater samples collected, 159 (96%) were assayable. The N1-gene from SARS-CoV-2 was detected in 64.1% of samples, N2 in 49.7% and E in 10%. N1 and N2 in wastewater increased over time both in terms of the amount of detectable virus and the proportion of samples that were positive, consistent with increasing hospitalizations at those sites with single monitoring points (Pearson's r=0.679, P, Graphical Abstract Image, graphical abstract

Background As a result of the novel coronavirus disease 2019 (COVID-19), there have been widespread changes in healthcare access. We conducted a retrospective population-based study in Alberta, Canada (population 4.4 million), where there have been approximately 1550 hospital admissions for COVID-19, to determine the impact of COVID-19 on hospital admissions and emergency department (ED visits), following initiation of a public health emergency act on March 15, 2020. Methods We used multivariable negative binomial regression models to compare daily numbers of medical/surgical hospital admissions via the ED between March 16-September 23, 2019 (pre COVID-19) and March 16-September 23, 2020 (post COVID-19 public health measures). We compared the most frequent diagnoses for hospital admissions pre/post COVID-19 public health measures. A similar analysis was completed for numbers of daily ED visits for any reason with a particular focus on ambulatory care sensitive conditions (ACSC). Findings There was a significant reduction in both daily medical (incident rate ratio (IRR) 0.86, p Conclusions Despite a relatively low volume of COVID-19 hospital admissions in Alberta, there was an extensive impact on our healthcare system with fewer admissions to hospital and ED visits. This work generates hypotheses around causes for reduced hospital admissions and ED visits which warrant further investigation. As most publicly funded health systems struggle with health-system capacity routinely, understanding how these reductions can be safely sustained will be critical.

BackgroundSARS-CoV-2 has been detected in wastewater and its abundance correlated with community COVID-19 cases, hospitalizations and deaths. We sought to use wastewater-based detection of SARS-CoV-2 to assess the epidemiology of SARS-CoV-2 in hospitals.MethodsBetween August and December 2020, twice-weekly wastewater samples from three tertiary-care hospitals (totaling >2100 dedicated inpatient beds) were collected. Wastewater samples were concentrated and cleaned using the 4S-silica column method and assessed for SARS-CoV-2 gene-targets (N1, N2 and E) and controls using RT-qPCR. Wastewater SARS-CoV-2 as measured by quantification cycle (Cq), genome copies and genomes normalized to the fecal biomarker PMMoV were compared to the total daily number of patients hospitalized with active COVID-19, confirmed cases of hospital-acquired infection, and the occurrence of unit-specific outbreaks.ResultsOf 165 wastewater samples collected, 159 (96%) were assayable. The N1-gene from SARS-CoV-2 was detected in 64.1% of samples, N2 in 49.7% and E in 10%. N1 and N2 in wastewater increased over time both in terms of amount of detectable virus and the proportion of samples that were positive, consistent with increasing hospitalizations (Pearson’s r=0.679, PConclusionsWastewater-based monitoring of SARS-CoV-2 represents a promising tool for SARS-CoV-2 passive surveillance and case identification, containment, and mitigation in acute-care medical facilities.Supplemental Material includedKey-points summarySAS-CoV-2 RNA is detectable in hospital wastewater. Wastewater SARS-CoV-2 RNA increases in conjunction with COVID-19-related hospitalizations. Spikes in SARS-CoV-2 wastewater signal correspond to incident hospital-acquired cases and outbreaks, suggesting passive surveillance via wastewater has great promise for COVID-19 monitoring.

Adverse outcomes following Clostridioides difficile infection (CDI) are not often reported for long-term care facility (LTCF) residents. We focused on the adverse outcomes due to CDI identified in Alberta LTCFs.All positive Clostridioides difficile stool specimens identified by laboratory-identified (LabID) event surveillance in Alberta from 2011 to 2018, along with Alberta Continuing Care Information System, were used to define CDI in Alberta LTCFs. CDI cases were classified as long-term care onset, hospital onset, and community onset. Laboratory records were linked to provincial databases to analyze acute-care admissions and mortality within 30-day post CDI. Age, sex, case classification, episode, and operator type, were investigated using logistic regression.Overall, 902 CDI cases were identified in 762 LTCF residents. Of all CDI events, 860 (95.3%) were long-term care onset, 38 (4.2%) were hospital onset, and 4 (0.4%) were community onset. The CDI rate was 2.0 of 100,000 resident days. In total, 157 residents (20.6%) had 30-day all-cause mortality, 126 CDI cases (14.0%) had 30-day all-cause acute-care admissions. The 30-day all-cause mortality rate was significantly higher in residents aged80 versus ≤80 years (24.9 vs 12.3 per 100 residents; P.05). Residents aged80 years, with hospital-onset CDI, and those staying in private or voluntary LTCFs were more likely to have 30-day all-cause acute-care admissions.The prevalence of CDI adverse outcomes is in LTCFs was found to be high using LabID event surveillance. Annual review of CDI adverse outcomes using LabID event can minimize the burden of surveillance and standardize the process across all Alberta LTCFs.

AimsRecent evidence suggests that an antibiotic impregnated envelope inserted at time of cardiac implantable electronic device (CIED) implantation may reduce risk of subsequent CIED infection compared with standard of care (SoC). The objective of the current work was to perform a cost-effectiveness analysis comparing an antibiotic impregnated envelope with SoC at time of CIED insertion.Methods and resultsDecision analytic models were used to project healthcare costs and benefits of two strategies, an antibiotic impregnated envelope plus SoC (Env+SoC) vs. SoC alone, in a cohort of patients undergoing CIED implantation over a 1-year time horizon. Evidence from published literature informed the model inputs. Probabilistic and deterministic sensitivity analyses were performed. The primary outcome was the incremental cost per infection prevented, assessed from the Canadian healthcare system perspective. Envelope plus SoC was associated with fewer CIED infection (7 CIED infections/1000 patients) at higher total costs ($29 033 000/1000 patients) compared with SoC (11 CIED infections and $27 926 000/1000 patients). The incremental cost per infection prevented over 1 year was $274 416. Use of Env+SoC was cost saving only when baseline CIED infection risk was increased to 6% (vs. base case of 1.2%).ConclusionsA strategy of Env+SoC was not economically favourable compared with SoC alone, and the opportunity cost of widescale implementation should be considered. Future work is required to develop validated risk stratification tools to identify patients at greatest risk of CIED infection. The value proposition of Env+SoC improves when applying this intervention to patients at greatest infection risk.

Background: Microbial invasion of the bloodstream is associated with a major burden of illness. Despite its importance, there is inconsistency in utilization of terms used to define it. Objective: To characterize the contemporary use of terms to define microbial invasion of the bloodstream for surveillance and research purposes. Methods: Structured review of publications reported from 2000 to 2019. Results: The search strategy retrieved 10,095 citations of which bloodstream infection, bacteraemia and fungaemia were included in 2813, 6900 and 1054 articles, respectively. There was a tripling of the number of annual citations during the study and although bacteraemia was most frequent, there was a progressive increase in the use of the term bloodstream infection. Among the 100 reports randomly selected for detailed review, the terms bacteraemia, bloodstream infection and fungaemia were used in 57, 51 and 19 publications, respectively. Explicit definitions for bloodstream infection (26/51; 51%), bacteraemia (13/57; 23%) and fungaemia (7/19; 37%) were included in reports where these terms were used. Although nearly all (95%) of the studies indicated a positive blood culture as an inclusion criteria and/or definition, only a minority indicated means to exclude contaminants (33%) or specific attributes to support clinical significance (38%). Use of explicit definitions was more common among reports that exclusively used the term bloodstream infection as compared to bacteraemia. Conclusions: Terms have been inconsistently defined and imprecisely used to refer to microbial invasion of the bloodstream. Clinically relevant and objective definitions that are widely acceptable are needed for surveillance and research purposes.

Background Increasing antibiotic resistance is a global problem. By detecting individuals colonized with antimicrobial resistant organisms (AROs) through hospital admission screening, enhanced precautions can be implemented to interrupt transmission during their hospitalization. The objective is to understand current practices of ARO screening in Alberta hospitals by evaluating completeness of an electronic ARO screening tool. Methods A retrospective cohort study using electronic medical record (EMR) data from Connect Care (Epic Systems Corp.) at one adult and one pediatric tertiary hospital in Edmonton, Alberta between January 1, and December 31, 2020 was conducted. All hospital admissions were included. Outcomes included proportion of admissions with a completed ARO tool and a comparison of the best practice actions triggered (e.g. ARO screening swab and/or isolate) between those with and without a completed ARO tool. Test of proportions was used, with a two-sided α of 0.05 and was conducted using STATA/SE 16.1. Results During the study period, there were 32,600 total admissions, of which 16,342 (50.1%) had the ARO tool completed. The overall compliance was greater in the adult hospital (53.9%) compared to the pediatric hospital (36.3%) (< 0.001). For both hospitals, the compliance rate in December 2020 was 30.0% lower than in January 2020, with a continuous decline during the 12 months. An isolation order or screening swab was ordered in 40.6% of admissions without an ARO tool completed compared to 56.5% of admissions with the ARO tool completed. Based on responses in the completed ARO tool, 81.2% of patient admissions had a microbiologic swab ordered when indicated, of which only 4.7% were positive. However, only 35.9% of patient admissions had additional precautions ordered when indicated. Conclusion ARO screening is a required organizational practice and although standardized across all Alberta hospitals and embedded within an EMR, compliance was poor. Further work is needed to understand point-of-care risk assessment processes to inform future interventions aimed at early identification and decreased transmission of ARO in hospitals. Disclosures All Authors: No reported disclosures

Background:Clostridioides difficile infection (CDI) is the most common cause of infectious diarrhea in hospitalized patients. Probiotics have been studied as a measure to prevent CDI. Timely probiotic administration to at-risk patients receiving systemic antimicrobials presents significant challenges. We sought to determine optimal implementation methods to administer probiotics to all adult inpatients aged 55 years receiving a course of systemic antimicrobials across an entire health region. Methods: Using a randomized stepped-wedge design across 4 acute-care hospitals (n = 2,490 beds), the probiotic Bio-K+ was prescribed daily to patients receiving systemic antimicrobials and was continued for 5 days after antimicrobial discontinuation. Focus groups and interviews were conducted to identify barriers, and the implementation strategy was adapted to address the key identified barriers. The implementation strategy included clinical decision support involving a linked flag on antibiotic ordering and a 1-click order entry within the electronic medical record (EMR), provider and patient education (written/videos/in-person), and local site champions. Protocol adherence was measured by tracking the number of patients on therapeutic antimicrobials that received BioK+ based on the bedside nursing EMR medication administration records. Adherence rates were sorted by hospital and unit in 48- and 72-hour intervals with recording of percentile distribution of time (days) to receipt of the first antimicrobial. Results: In total, 340 education sessions with >1,800 key stakeholders occurred before and during implementation across the 4 involved hospitals. The overall adherence of probiotic ordering for wards with antimicrobial orders was 78% and 80% at 48 and 72 hours, respectively over 72 patient months. Individual hospital adherence rates varied between 77% and 80% at 48 hours and between 79% and 83% at 72 hours. Of 246,144 scheduled probiotic orders, 94% were administered at the bedside within a median of 0.61 days (75th percentile, 0.88), 0.47 days (75th percentile, 0.86), 0.71 days (75th percentile, 0.92) and 0.67 days (75th percentile, 0.93), respectively, at the 4 sites after receipt of first antimicrobial. The key themes from the focus groups emphasized the usefulness of the linked flag alert for probiotics on antibiotic ordering, the ease of the EMR 1-click order entry, and the importance of the education sessions. Conclusions: Electronic clinical decision support, education, and local champion support achieved a high implementation rate consistent across all sites. Use of a 1-click order entry in the EMR was considered a key component of the success of the implementation and should be considered for any implementation strategy for a stewardship initiative. Achieving high prescribing adherence allows more precision in evaluating the effectiveness of the probiotic strategy.Funding: Partnerships for Research and Innovation in the Health System, Alberta Innovates/Health Solutions Funding: AwardDisclosures: None

Background: Hospital-acquired Clostridioides difficile infection (HA-CDI) rates are highly variable over time, posing problems for research assessing interventions that might improve rates. By understanding seasonality in HA-CDI rates and the impacts that other factors such as influenza admissions might have on these rates, we can account for them when establishing the relationship between interventions and infection rates. We assessed whether there were seasonal trends in HA-CDI and whether they could be accounted for by influenza rates. Methods: We assessed HA-CDI rates per 10,000 patient days, and the rate of hospitalized patients with influenza per 1,000 admissions in 4 acute-care facilities (n = 2,490 beds) in Calgary, Alberta, from January 2016 to December 2018. We used 4 statistical approaches in R (version 3.5.1 software): (1) autoregressive integrated moving average (ARIMA) to assess dependencies and trends in each of the monthly HA-CDI and influenza series; (2) cross correlation to assess dependencies between the HA-CDI and influenza series lagged over time; (3) Poisson harmonic regression models (with sine and cosine components) to assess the seasonality of the rates; and (4) Poisson regression to determine whether influenza rates accounted for seasonality in the HA-CDI rates. Results: Conventional ARIMA approaches did not detect seasonality in the HA-CDI rates, but we found strong seasonality in the influenza rates. A cross-correlation analysis revealed evidence of correlation between the series at a lag of zero (R = 0.41; 95% CI, 0.10–0.65) and provided an indication of a seasonal relationship between the series (Fig. 1). Poisson regression suggested that influenza rates predicted CDI rates (P < .01). Using harmonic regression, there was evidence of seasonality in HA-CDI rates (2 [2 df] = 6.62; P < .05) and influenza rates (2 [2 df] = 1,796.6; P < .001). In a Poisson model of HA-CDI rates with both the harmonic components and influenza admission rates, the harmonic components were no longer predictive of HA-CDI rates. Conclusions: Harmonic regression provided a sensitive means of identifying seasonality in HA-CDI rates, but the seasonality effect was accounted for by influenza admission rates. The relationship between HA-CDI and influenza rates is likely mediated by antibiotic prescriptions, which needs to be assessed. To improve precision and reduce bias, research on interventions to reduce HA-CDI rates should assess historic seasonality in HA-CDI rates and should account for influenza admissions.Funding: NoneDisclosures: None

Impact of isolation precautions on psychological wellbeing of patients has yet to be fully quantified. To assess the impact of isolation precautions on patients' health-related quality of life and depression or anxiety scales and estimate per day cost of anxiety and depression. Literature pertaining to impact of isolation precautions was searched on EMBASE and PubMed databases and Google Scholar. A two-step independent screening of the articles was performed. Articles that compared isolated and non-isolated patients using different quality of life and psychological burden scales were included. A meta-analysis was conducted using the Hospital Anxiety and Depression Scales (HADS-A and HADS-D). Psychological burden measures from selected literature were presented in a graph as effect sizes. Per day cost of anxiety and depression was estimated using pooled mean difference from meta-analysis. Out of 106 articles, 94 were excluded due to inclusion criteria, leaving 12 for full text review. After review of full text of the articles, seven articles were shortlisted for empirical analysis and four out of these seven for meta-analysis. The pooled mean difference estimates for HADS-A was -1.4 (P=0.15) and that for HADS-D was -1.85 (P=0.09). In the empirical analysis of psychological burden scales, the effect in all studies except one was negative. Results from meta-analysis and empirical analysis of psychological burden implied that isolated patients are worse off in general. The implied estimated per day cost of anxiety and depression in terms of quality-adjusted life years (QALYs) is approximately US$10.

Background Clostridioides difficile infection (CDI) is one of the most common health care–associated infections. This study assessed the validity of a laboratory-based surveillance method as compared with a traditional, clinical surveillance method to identify hospital-acquired CDIs. Methods Retrospective analysis of positive C difficile laboratory records between April 2015 and March 2017 were compared with a clinical dataset of positive inpatient C difficile cases for all acute care facilities in Alberta, Canada. Sensitivity, specificity, positive predictive value, and negative predictive value were calculated using STATA/IC 13.0. Results The laboratory surveillance method had a sensitivity of 96.6% (95% confidence interval [CI], 95.7%-97.3%) and a specificity of 65.7% (95% CI, 63.6%-67.8%); positive predictive value and negative predictive value were 74.3% (95% CI, 73.2%-75.5%) and 94.9% (95% CI, 93.7%-95.9%), respectively. Discussion To date, the breadth of research on alternate CDI surveillance systems has focused on the use of International Statistical Classification of Diseases and Related Health Problems 9th and 10th Revision coding mechanisms. Our results expand on the published literature, as a laboratory approach may provide more timely information, with a smaller amount of misclassified cases. Conclusions Using a laboratory surveillance method to capture hospital-acquired CDI cases is highly sensitive but not overly specific. Changes to improve the specificity of this method are provided.

SUMMARYPatients with methicillin-resistant Staphylococcus aureus (MRSA) clones, which were traditionally seen in the community setting (USA400/CMRSA7 and USA300/CMRSA10), are often identified as hospital-acquired (HA) infections using Infection Prevention and Control (IPC) surveillance definitions. This study examined the demographics and healthcare risk factors of patients with HA-MRSA to help understand if community MRSA clones are from a source internal or external to the hospital setting. Despite USA300/CMRSA10 being the predominant clone in Alberta, hospital clones (USA100/CMRSA2) still dominated in the acute care setting. In the Alberta hospitalized population, patients with USA400/CMRSA7 and USA300/CMRSA10 clones were significantly younger, had fewer comorbidities, and a greater proportion had none or ambulatory care-only healthcare exposure. These findings suggest that there are two distinct populations of HA-MRSA patients, and the patients with USA400/CMRSA7 and USA300/CMRSA10 clones identified in hospital more greatly resemble patients affected by those clones in the community. It is possible that epidemiological assessment overidentifies HA acquisition of MRSA in patients unscreened for MRSA on admission to acute care.

Background Recurrent surgical site infections (SSIs) are associated with decreased quality of life for patients and increased economic burden to healthcare systems. Positive cultures at reimplantation and patient co-morbidities have been shown to increase the risk of recurrent SSI in hip and knee surgical site infections. Two-stage exchange has been considered for the most appropriate surgical management for these SSI’s, however, it is unclear whether the type of revision arthroplasty and pathogen of the first SSI impacts recurrence rates. Methods A retrospective review of prospectively collected data on all complex SSIs following primary hip and knee arthroplasties between April 1 2012 and March 31, 2019, in Calgary, Alberta was performed. Patients were followed for two years post-index arthroplasty to determine initial management of first complex SSI (Debridement, antibiotics and implant retention (DAIR) vs DAIR+liner exchange vs one-stage vs two-stage), rate of recurrent complex SSI, and microbiological data for first and subsequent SSI’s. Results Of the 142 complex SSIs, 95 (66.9%) were managed with DAIR and liner exchange, 25 (17.6%) were managed with DAIR, 13 (9.1%) with one-stage and 8 (5.6%) with two-stage procedures. The recurrence rate was 19/95 (20%) for DAIR and liner, 8/25 (32%) for DAIR alone, 2/13 (15%) with one stage, and 3/8 (37.5%) with two-stage. There was no significant difference in recurrence rates of complex SSI when stratified by surgical management. Of the pathogens, Staphylococcus aureus (S.aureus) (including methicillin-resistant S. aureus (MRSA)) accounted for 35.2% of total first SSI and 50% of recurrences. A significantly higher proportion of S.aureus infections (including MRSA) ended up with a recurrent infection compared to all other pathogens (p=0.045). Of the 32 recurrences, 28.1% were due to the same pathogen as the initial SSI. Conclusion S.aureus was the most common pathogen causing initial and recurrent SSIs. This reinforces that S.aureus complex SSIs would likely benefit from early recognition and aggressive treatment. Recurrence of SSI was not impacted by type of revision arthroplasty. This study is limited by a small sample size. These findings contribute to the paucity of literature in this area and suggest a need for expansion to larger populations. Disclosures All Authors: No reported disclosures