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Background Most multicenter studies of US pediatric sepsis epidemiology use administrative data or focus on pediatric intensive care units. We conducted a detailed medical record review to describe sepsis epidemiology in children and young adults. Methods In a convenience sample of hospitals in 10 states, patients aged 30 days–21 years, discharged during 1 October 2014–30 September 2015, with explicit diagnosis codes for severe sepsis or septic shock, were included. Medical records were reviewed for patients with documentation of sepsis, septic shock, or similar terms. We analyzed overall and age group–specific patient characteristics. Results Of 736 patients in 26 hospitals, 442 (60.1%) had underlying conditions. Most patients (613 [83.3%]) had community-onset sepsis, although most community-onset sepsis was healthcare associated (344 [56.1%]). Two hundred forty-one patients (32.7%) had outpatient visits 1–7 days before sepsis hospitalization, of whom 125 (51.9%) received antimicrobials ≤30 days before sepsis hospitalization. Age group–related differences included common underlying conditions ( Conclusions Our data suggest potential opportunities to raise sepsis awareness among outpatient providers to facilitate prevention, early recognition, and intervention in some patients. Consideration of age-specific differences may be important as approaches are developed to improve sepsis prevention, risk prediction, recognition, and management.

Background: With the emergence of antibiotic resistant threats and the need for appropriate antibiotic use, laboratory microbiology information is important to guide clinical decision making in nursing homes, where access to such data can be limited. Susceptibility data are necessary to inform antibiotic selection and to monitor changes in resistance patterns over time. To contribute to existing data that describe antibiotic resistance among nursing home residents, we summarized antibiotic susceptibility data from organisms commonly isolated from urine cultures collected as part of the CDC multistate, Emerging Infections Program (EIP) nursing home prevalence survey. Methods: In 2017, urine culture and antibiotic susceptibility data for selected organisms were retrospectively collected from nursing home residents’ medical records by trained EIP staff. Urine culture results reported as negative (no growth) or contaminated were excluded. Susceptibility results were recorded as susceptible, non-susceptible (resistant or intermediate), or not tested. The pooled mean percentage tested and percentage non-susceptible were calculated for selected antibiotic agents and classes using available data. Susceptibility data were analyzed for organisms with ≥20 isolates. The definition for multidrug-resistance (MDR) was based on the CDC and European Centre for Disease Prevention and Control’s interim standard definitions. Data were analyzed using SAS v 9.4 software. Results: Among 161 participating nursing homes and 15,276 residents, 300 residents (2.0%) had documentation of a urine culture at the time of the survey, and 229 (76.3%) were positive. Escherichia coli, Proteus mirabilis, Klebsiella spp, and Enterococcus spp represented 73.0% of all urine isolates (N = 278). There were 215 (77.3%) isolates with reported susceptibility data (Fig. 1). Of these, data were analyzed for 187 (87.0%) (Fig. 2). All isolates tested for carbapenems were susceptible. Fluoroquinolone non-susceptibility was most prevalent among E. coli (42.9%) and P. mirabilis (55.9%). Among Klebsiella spp, the highest percentages of non-susceptibility were observed for extended-spectrum cephalosporins and folate pathway inhibitors (25.0% each). Glycopeptide non-susceptibility was 10.0% for Enterococcus spp. The percentage of isolates classified as MDR ranged from 10.1% for E. coli to 14.7% for P. mirabilis. Conclusions: Substantial levels of non-susceptibility were observed for nursing home residents’ urine isolates, with 10% to 56% reported as non-susceptible to the antibiotics assessed. Non-susceptibility was highest for fluoroquinolones, an antibiotic class commonly used in nursing homes, and ≥ 10% of selected isolates were MDR. Our findings reinforce the importance of nursing homes using susceptibility data from laboratory service providers to guide antibiotic prescribing and to monitor levels of resistance.Disclosures: NoneFunding: None

Importance Controlling antimicrobial resistance in health care is a public health priority, although data describing antimicrobial use in US nursing homes are limited. Objective To measure the prevalence of antimicrobial use and describe antimicrobial classes and common indications among nursing home residents. Design, Setting, and Participants Cross-sectional, 1-day point-prevalence surveys of antimicrobial use performed between April 2017 and October 2017, last survey date October 31, 2017, and including 15 276 residents present on the survey date in 161 randomly selected nursing homes from selected counties of 10 Emerging Infections Program (EIP) states. EIP staff reviewed nursing home records to collect data on characteristics of residents and antimicrobials administered at the time of the survey. Nursing home characteristics were obtained from nursing home staff and the Nursing Home Compare website. Exposures Residence in one of the participating nursing homes at the time of the survey. Main Outcomes and Measures Prevalence of antimicrobial use per 100 residents, defined as the number of residents receiving antimicrobial drugs at the time of the survey divided by the total number of surveyed residents. Multivariable logistic regression modeling of antimicrobial use and percentages of drugs within various classifications. Results Among 15 276 nursing home residents included in the study (mean [SD] age, 77.6 [13.7] years; 9475 [62%] women), complete prevalence data were available for 96.8%. The overall antimicrobial use prevalence was 8.2 per 100 residents (95% CI, 7.8-8.8). Antimicrobial use was more prevalent in residents admitted to the nursing home within 30 days before the survey date (18.8 per 100 residents; 95% CI, 17.4-20.3), with central venous catheters (62.8 per 100 residents; 95% CI, 56.9-68.3) or with indwelling urinary catheters (19.1 per 100 residents; 95% CI, 16.4-22.0). Antimicrobials were most often used to treat active infections (77% [95% CI, 74.8%-79.2%]) and primarily for urinary tract infections (28.1% [95% CI, 15.5%-30.7%]). While 18.2% (95% CI, 16.1%-20.1%) were for medical prophylaxis, most often use was for the urinary tract (40.8% [95% CI, 34.8%-47.1%]). Fluoroquinolones were the most common antimicrobial class (12.9% [95% CI, 11.3%-14.8%]), and 33.1% (95% CI, 30.7%-35.6%) of antimicrobials used were broad-spectrum antibiotics. Conclusions and Relevance In this cross-sectional survey of a cohort of US nursing homes in 2017, prevalence of antimicrobial use was 8.2 per 100 residents. This study provides information on the patterns of antimicrobial use among these nursing home residents.

Background: With an aging population, increasingly complex care, and frequent re-admissions, prevention of healthcare-associated infections (HAIs) in nursing homes (NHs) is a federal priority. However, few contemporary sources of HAI data exist to inform surveillance, prevention, and policy. Prevalence surveys (PSs) are an efficient approach to generating data to measure the burden and describe the types of HAI. In 2017, the Centers for Disease Control and Prevention (CDC) performed its first large-scale HAI PS through the Emerging Infections Program (EIP) to measure the prevalence and describe the epidemiology of HAI in NH residents. Methods: NHs from several states (CA, CO, CT, GA, MD, MN, NM, NY, OR, & TN) were randomly selected and asked to participate in a 1-day HAI PS between April and October 2017; participation was voluntary. EIP staff reviewed available medical records for NH residents present on the survey date to collect demographic and basic clinical information and infection signs and symptoms. HAIs with onset on or after NH day 3 were identified using revised McGeer infection definitions applied to data collected by EIP staff and were reported to the CDC through a web-based system. Data were reviewed by CDC staff for potential errors and to validate HAI classifications prior to analysis. HAI prevalence, number of residents with >1 HAI per number of surveyed residents ×100, and 95% CIs were calculated overall (pooled mean) and for selected resident characteristics. Data were analyzed using SAS v9.4 software. Results: Among 15,296 residents in 161 NHs, 358 residents with 375 HAIs were identified. The most common HAI sites were skin (32%), respiratory tract (29%), and urinary tract (20%). Cellulitis, soft-tissue or wound infection, symptomatic UTI, and cold or pharyngitis were the most common individual HAIs (Fig. 1). Overall HAI prevalence was 2.3 per 100 residents (95% CI, 2.1–2.6); at the NH level, the median HAI prevalence was 1.8 and ranged from 0 to 14.3 (interquartile range, 0–3.1). At the resident level (Fig. 2), HAI prevalence was significantly higher in persons admitted for postacute care with diabetes, with a pressure ulcer, receiving wound care, or with a device. Conclusions: In this large-scale survey, 1 in 43 NH residents had an HAI on a given day. Three HAI types comprised >80% of infections. In addition to identifying characteristics that place residents at higher risk for HAIs, these findings provide important data on HAI epidemiology in NHs that can be used to expand HAI surveillance and inform prevention policies and practices.Funding: NoneDisclosures: None

Background: Antibiotics are among the most commonly prescribed drugs in nursing homes; urinary tract infections (UTIs) are a frequent indication. Although there is no gold standard for the diagnosis of UTIs, various criteria have been developed to inform and standardize nursing home prescribing decisions, with the goal of reducing unnecessary antibiotic prescribing. Using different published criteria designed to guide decisions on initiating treatment of UTIs (ie, symptomatic, catheter-associated, and uncomplicated cystitis), our objective was to assess the appropriateness of antibiotic prescribing among NH residents. Methods: In 2017, the CDC Emerging Infections Program (EIP) performed a prevalence survey of healthcare-associated infections and antibiotic use in 161 nursing homes from 10 states: California, Colorado, Connecticut, Georgia, Maryland, Minnesota, New Mexico, New York, Oregon, and Tennessee. EIP staff reviewed resident medical records to collect demographic and clinical information, infection signs, symptoms, and diagnostic testing documented on the day an antibiotic was initiated and 6 days prior. We applied 4 criteria to determine whether initiation of treatment for UTI was supported: (1) the Loeb minimum clinical criteria (Loeb); (2) the Suspected UTI Situation, Background, Assessment, and Recommendation tool (UTI SBAR tool); (3) adaptation of Infectious Diseases Society of America UTI treatment guidelines for nursing home residents (Crnich & Drinka); and (4) diagnostic criteria for uncomplicated cystitis (cystitis consensus) (Fig. 1). We calculated the percentage of residents for whom initiating UTI treatment was appropriate by these criteria. Results: Of 248 residents for whom UTI treatment was initiated in the nursing home, the median age was 79 years [IQR, 19], 63% were female, and 35% were admitted for postacute care. There was substantial variability in the percentage of residents with antibiotic initiation classified as appropriate by each of the criteria, ranging from 8% for the cystitis consensus, to 27% for Loeb, to 33% for the UTI SBAR tool, to 51% for Crnich and Drinka (Fig. 2). Conclusions: Appropriate initiation of UTI treatment among nursing home residents remained low regardless of criteria used. At best only half of antibiotic treatment met published prescribing criteria. Although insufficient documentation of infection signs, symptoms and testing may have contributed to the low percentages observed, adequate documentation in the medical record to support prescribing should be standard practice, as outlined in the CDC Core Elements of Antibiotic Stewardship for nursing homes. Standardized UTI prescribing criteria should be incorporated into nursing home stewardship activities to improve the assessment and documentation of symptomatic UTI and to reduce inappropriate antibiotic use.Funding: NoneDisclosures: None

Objectives Describe antibiotic use for urinary tract infection (UTI) among a large cohort of US nursing home residents. Design Analysis of data from a multistate, 1-day point prevalence survey of antimicrobial use performed between April and October 2017. Setting and participants Residents of 161 nursing homes in 10 US states of the Emerging Infections Program (EIP). Methods EIP staff reviewed nursing home medical records to collect data on systemic antimicrobial drugs received by residents, including therapeutic site, rationale for use, and planned duration. For drugs with the therapeutic site documented as urinary tract, pooled mean and nursing home–specific prevalence rates were calculated per 100 nursing home residents, and proportion of drugs by selected characteristics were reported. Data were analyzed in SAS, version 9.4. Results Among 15,276 residents, 407 received 424 antibiotics for UTI. The pooled mean prevalence rate of antibiotic use for UTI was 2.66 per 100 residents; nursing home–specific rates ranged from 0 to 13.6. One-quarter of antibiotics were prescribed for UTI prophylaxis, with a median planned duration of 111 days compared with 7 days when prescribed for UTI treatment (P Conclusions and Implications One in 38 residents was receiving an antibiotic for UTI on a given day, and nursing home–specific prevalence rates varied by more than 10-fold. UTI prophylaxis was common with a long planned duration, despite limited evidence to support this practice among older persons in nursing homes. The planned duration was ≥7 days for half of antibiotics prescribed for treatment of a UTI. Fluoroquinolones were the most commonly used antibiotics, despite their association with significant adverse events, particularly in a frail and older adult population. These findings help to identify priority practices for nursing home antibiotic stewardship.

Key Points Question What types of health care exposures occur during the 30 days before hospitalization of a patient with sepsis or septic shock, and how common are these exposures? Findings In this cohort study of 1078 US adults with sepsis and septic shock across 10 states, most patients experienced sepsis onset outside of the hospital, had recent encounters with the health care system, and had a sepsis-associated pathogen documented; 42% of patients received antimicrobial drugs, chemotherapy, wound care, dialysis, or surgery in the 30 days before sepsis occurred. After controlling for other factors, an association was found between underlying comorbidities, such as cirrhosis, immunosuppression, and vascular disease, and 30-day mortality. Meaning The findings suggest that future efforts to improve outcomes among patients with sepsis and septic shock would benefit from examination of health maintenance practices and recent health care exposures as potential opportunities among high-risk patients., Importance Current information on the characteristics of patients who develop sepsis may help in identifying opportunities to improve outcomes. Most recent studies of sepsis epidemiology have focused on changes in incidence or have used administrative data sets that provided limited patient-level data. Objective To describe sepsis epidemiology in adults. Design, Setting, and Participants This retrospective cohort study reviewed the medical records, death certificates, and hospital discharge data of adult patients with sepsis or septic shock who were discharged from the hospital between October 1, 2014, and September 30, 2015. The convenience sample was obtained from hospitals in the Centers for Disease Control and Prevention Emerging Infections Program in 10 states (California, Colorado, Connecticut, Georgia, Maryland, Minnesota, New Mexico, New York, Oregon, and Tennessee). Patients 18 years and older with discharge diagnosis codes for severe sepsis or septic shock were randomly selected. Data were analyzed between May 1, 2018, and January 31, 2019. Main Outcomes and Measures The population’s demographic characteristics, health care exposures, and sepsis-associated infections and pathogens were described, and risk factors for death within 30 days after sepsis diagnosis were assessed. Results Among 1078 adult patients with sepsis (569 men [52.8%]; median age, 64 years [interquartile range, 53-75 years]), 973 patients (90.3%) were classified as having community-onset sepsis (ie, sepsis diagnosed within 3 days of hospital admission). In total, 654 patients (60.7%) had health care exposures before their hospital admission for sepsis; 260 patients (24.1%) had outpatient encounters in the 7 days before admission, and 447 patients (41.5%) received medical treatment, including antimicrobial drugs, chemotherapy, wound care, dialysis, or surgery, in the 30 days before admission. A pathogen associated with sepsis was found in 613 patients (56.9%); the most common pathogens identified were Escherichia coli, Staphylococcus aureus, Klebsiella pneumoniae, and Clostridioides difficile. After controlling for other factors, an association was found between underlying comorbidities, such as cirrhosis (odds ratio, 3.59; 95% CI, 2.03-6.32), immunosuppression (odds ratio, 2.52; 95% CI, 1.81-3.52), vascular disease (odds ratio, 1.54; 95% CI, 1.10-2.15), and 30-day mortality. Conclusions and Relevance Most adults experienced sepsis onset outside of the hospital and had recent encounters with the health care system. A sepsis-associated pathogen was identified in more than half of patients. Future efforts to improve sepsis outcomes may benefit from examination of health maintenance practices and recent health care exposures as potential opportunities among high-risk patients., This cohort study uses medical records, death certificates, and hospital discharge data to describe health care exposures and outcomes among adult patients with sepsis and septic shock.

This cross-sectional study examines the respiratory and nonrespiratory diagnoses reported for US adults hospitalized with laboratory-confirmed influenza between 2010 and 2018., Key Points Question Which types of respiratory and nonrespiratory diagnoses were associated with influenza in hospitalized adult patients since the 2009 influenza pandemic? Findings In this cross-sectional analysis of more than 80 000 adults hospitalized with laboratory-confirmed influenza between 2010 and 2018 in the United States, 95% of patients had a respiratory diagnosis, and 46% had a nonrespiratory diagnosis, including 5% with exclusively nonrespiratory diagnoses. Meaning Influenza virus infection may be associated with both respiratory and nonrespiratory diagnoses, highlighting the broad scope of influenza burden of disease., Importance Seasonal influenza virus infection is a major cause of morbidity and mortality and may be associated with respiratory and nonrespiratory diagnoses. Objective To examine the respiratory and nonrespiratory diagnoses reported for adults hospitalized with laboratory-confirmed influenza between 2010 and 2018 in the United States. Design, Setting, and Participants This cross-sectional study used data from the US Influenza Hospitalization Surveillance Network (FluSurv-NET) from October 1 through April 30 of the 2010-2011 through 2017-2018 influenza seasons. FluSurv-NET is a population-based, multicenter surveillance network with a catchment area that represents approximately 9% of the US population. Patients are identified by practitioner-ordered influenza testing. Adults (aged ≥18 years) hospitalized with laboratory-confirmed influenza were included in the study. Exposures FluSurv-NET defines laboratory-confirmed influenza as a positive influenza test result by rapid antigen assay, reverse transcription–polymerase chain reaction, direct or indirect fluorescent staining, or viral culture. Main Outcomes and Measures Acute respiratory or nonrespiratory diagnoses were defined using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) and International Statistical Classification of Diseases and Related Health Problems, 10th Revision (ICD-10) discharge diagnosis codes. The analysis included calculation of the frequency of acute respiratory and nonrespiratory diagnoses with a descriptive analysis of patient demographic characteristics, underlying medical conditions, and in-hospital outcomes by respiratory and nonrespiratory diagnoses. Results Of 89 999 adult patients hospitalized with laboratory-confirmed influenza, 76 649 (median age, 69 years; interquartile range, 55-82 years; 55% female) had full medical record abstraction and at least 1 ICD code for an acute diagnosis. In this study, 94.9% of patients had a respiratory diagnosis and 46.5% had a nonrespiratory diagnosis, including 5.1% with only nonrespiratory diagnoses. Pneumonia (36.3%), sepsis (23.3%), and acute kidney injury (20.2%) were the most common acute diagnoses. Fewer patients with only nonrespiratory diagnoses received antiviral therapy for influenza compared with those with respiratory diagnoses (81.4% vs 88.9%; P

Background The 2018–19 influenza season was characterized by prolonged co-circulation of Influenza A H3N2 (H3) and H1N1pdm09 (H1) viruses. We used data from the Influenza Hospitalization Surveillance Network (FluSurv-NET) to describe age-related differences in the distribution of influenza A subtypes. Methods We included all cases residing within a FluSurv-NET catchment area and hospitalized with laboratory-confirmed influenza during October 1, 2018–April 30, 2019. We multiply imputed influenza A subtype for 63% of cases with unknown subtype and based imputation on factors that could be associated with missing subtype including surveillance site, 10-year age groups and month of hospital admission. We calculated influenza hospitalization rates and 95% confidence intervals (95% CI) by type and subtype per 100,000 population. We compared the proportion of cases with H1 by year of age in FluSurv-NET to the distribution obtained from US public health laboratories participating in virologic surveillance and providing specimen-level influenza Results. Results Based on available data, 18,669 hospitalizations were reported; 41% received influenza vaccination ≥2 weeks prior to hospitalization and 90% received antivirals. Cumulative hospitalization rates per 100,000 population were as follows: H1 32.5 (95% CI 31.7–33.3), H3 29.3 (95% CI 28.5–30.1) and B 2.5 (95% CI 2.3–2.7). Based on weekly rates, H1 hospitalizations peaked during February (week 8) and H3 hospitalizations during March (week 11) (Figure A). FluSurv-NET data showed distinct patterns of subtype distribution by age, with H1 predominating among cases 0–9 and 24–70 years, and H3 predominating among cases 10–23 and ≥71 years. Data on the proportion of H1 results by age correlated well between FluSurv-NET and US virologic surveillance (Figure B). Conclusion Influenza A H1 and H3 virus circulation patterns varied by age group during the 2018–2019 season. The proportion of cases with H1 relative to H3 was low among those born between 1996 and 2009 and those born before 1948. These findings may indicate protection against H1 viruses in age groups with exposure to H1N1pdm09 during the 2009 pandemic or to older antigenically similar H1N1 viruses as young children. Disclosures Evan J. Anderson, MD, AbbVie (Consultant), GSK (Grant/Research Support), Merck (Grant/Research Support), Micron (Grant/Research Support), PaxVax (Grant/Research Support), Pfizer (Consultant, Grant/Research Support), sanofi pasteur (Grant/Research Support), Keipp Talbot, MD, MPH, Sequirus (Other Financial or Material Support, On Data Safety Monitoring Board).

Background Seasonal influenza vaccine may attenuate disease severity among people infected with influenza despite vaccination, but vaccine effectiveness may decrease with increasing time between vaccination and infection. Patient characteristics may play a role in the timing of vaccine receipt. Methods We used data from the Influenza Hospitalization Surveillance Network (FluSurv-NET) and included patients ≥ 9 years hospitalized with laboratory-confirmed influenza during October 1–April 30 of influenza seasons 2013–2014 through 2016–2017 who received seasonal influenza vaccine ≥ 14 days prior to admission. Vaccine history was obtained from vaccine registries, medical charts, and patient interviews. We defined “early vaccination” as vaccine receipt before October 15 and “late vaccination” as receipt after (date selected using typical season onset and median vaccination dates). Early and late groups were compared using Chi-square or Fisher exact tests. Results Among 21,751 vaccinated patients, 61% received vaccine before October 15, and distribution of vaccination date was similar across seasons (figure). Vaccination occurred earlier with increasing age (45% were vaccinated early among those 9–17 years but 65% in those ≥ 80 years, P < 0.01). White non-Hispanic patients were more likely to receive vaccine early compared with black non-Hispanic and Hispanic patients (63% vs. 55% and 54%; P < 0.01). Those with metabolic disorders, cardiovascular disease, kidney disease, and cancer were vaccinated earlier whereas those with HIV and liver disease were vaccinated later. Vaccine timing also varied by state (P < 0.01) but not by sex. Conclusion Among influenza-vaccinated older children and adults hospitalized with influenza, older age, white race, and certain medical conditions were associated with early receipt of influenza vaccination in unadjusted analysis. This may be due to frequent healthcare encounters and targeted public health strategies in high-risk groups. Understanding how timing of vaccine receipt varies among populations can provide insights into variables that must be controlled for in studying possible vaccine effectiveness waning and attenuation of disease among those who are infected despite vaccination. Disclosures All authors: No reported disclosures.

Background Influenza virus infection most commonly causes acute respiratory tract illness, however may also lead to non-respiratory complications including acute cardiovascular (CV) events. We describe the frequency of and risk factors for acute CV events in adults hospitalized with influenza in the United States. Methods We included adults aged > 18 years hospitalized during influenza seasons 2010–2011 through 2017–2018 in FluSurv-NET, a multi-state population-based surveillance system that includes detailed medical chart review of patients hospitalized with laboratory-confirmed influenza. We defined acute CV events by International Classification of Diseases (ICD) primary and secondary discharge diagnosis codes for acute heart failure (aHF), acute ischemic heart disease (aIHD), hypertensive crisis, cardiogenic shock, acute myocarditis, acute pericarditis and cardiac tamponade. We calculated the frequency of acute CV events and used multivariable logistic regression among the 87% treated with influenza antivirals to identify independent factors associated with aHF and aIHD, the two most common diagnoses. Results Of 80,374 adults hospitalized with laboratory-confirmed influenza, 12% had > 1 acute CV event. We found that aHF (46%) and aIHD (42%) were the most common, followed by hypertensive crisis (8%), cardiogenic shock (3%), acute myocarditis (0.7%), acute pericarditis (0.4%) and cardiac tamponade (0.2%). Compared with treated patients without an acute cardiovascular event, treated patients with aHF (Figure A) and aIHD (Figure B) were more likely to be older, currently/formerly use tobacco and have underlying conditions including cardiovascular disease, diabetes mellitus, and kidney disease. Conclusion Among adults hospitalized with laboratory-confirmed influenza, acute CV events are common, particularly among those with prior cardiovascular disease. During the influenza season, clinicians should consider influenza virus infection in hospitalized adults who present with acute CV events. Non-respiratory complications, specifically aHF and aIHD, may be an under-recognized contributor to the burden of influenza. Disclosures All authors: No reported disclosures.

Background CDC released the Core Elements of Antibiotic Stewardship (Core Elements) for Nursing Homes (NHs) in 2015. In 2017, CDCs Emerging Infections Program (EIP) evaluated uptake of the Core Elements in a cohort of NHs. Methods NHs from California, Colorado, Connecticut, Georgia, Maryland, Minnesota, New Mexico, New York, Oregon, and Tennessee were randomly selected to participate in a CDC EIP antimicrobial use prevalence survey; participation was voluntary. A NH leader (typically Director of Nursing or Infection Preventionist) completed a CDC questionnaire to self-report facility implementation of 15 individual activities within the 7 domains of the Core Elements. The number and percentage of facilities reporting “Yes” to each activity and a facility stewardship score (range 0–15, 1 point per activity) were calculated. Associations between the stewardship score and facility-level factors, obtained from the questionnaire and publically available Centers for Medicare and Medicaid Services (CMS) NH quality data, were identified using Analysis of Variance (Proc GLM) in SAS 9.4; a P < 0.05 was considered significant. Results In 161 NHs (mean certified beds 118, 92% dual certified, 68% for-profit), the % of NHs reporting implementation of the 15 activities (figure) ranged from 25% (has a formulary of antibiotic agents, providers required to perform an antibiotic “time-out”) to 88% (providers required to document dose, duration and indication). The median facility stewardship score was 9 (interquartile range 7–12). A higher stewardship score was significantly associated with having: an infection preventionist who completed a certified training course (Yes vs. No, P = 0.029), higher number of attending physicians per 100 NH beds (upper quartile vs. lower three quartiles, P = 0.029), and higher CMS quality measure score (scale of 1 to 5 points, P = 0.025). Conclusion These data, collected approximately 2 years after release of the Core Elements, show NHs have begun to implement many policies or practices consistent with CDC antibiotic stewardship guidance. However, improved understanding of the uptake and barriers associated with implementation of the Core Elements can inform development of stewardship initiatives, identify NHs in need of stewardship interventions, and accelerate adoption. Disclosures All authors: No reported disclosures.

Background Influenza vaccination may reduce illness severity among those with influenza; however, data are limited. We determined whether outcomes were less severe among vaccinated compared with unvaccinated adults hospitalized with influenza over 5 seasons. Methods We included adults (≥18 years) hospitalized with laboratory-confirmed influenza during seasons 2013–2014 through 2017–2018 and identified through the US Influenza Hospitalization Surveillance Network (FluSurv-NET). Vaccination status was obtained through medical records, vaccine registries, and interviews. We excluded patients who were institutionalized, did not receive antivirals, or had unknown vaccine status or vaccine receipt Results Among 67,452 adults hospitalized with influenza, 43,608 were included; 47% were 18–64 years (38% vaccinated) and 53% were ≥65 years (65% vaccinated). Among patients with influenza A(H1N1)pdm09, vaccination was associated with decreased odds of ICU admission (odds ratio (OR) 0.81; OR 0.72) and MV (OR 0.66; OR 0.54) in adults 18–64 and ≥65 years, respectively; decreased odds of pneumonia (OR 0.83), death (OR 0.64) and shortened ICU LOS (relative hazard (RH) 0.82) in adults 18–64 years; and shortened hospital LOS (RH 0.91) in adults ≥65 years (figure). Vaccination was not associated with attenuation of severe outcomes in patients with influenza A(H3N2) and B. Conclusion Vaccination was associated with reduced odds of severe outcomes, including death, by up to 36% in adults hospitalized with influenza A(H1N1)pdm09. All adults without contraindications should receive annual influenza vaccination as there is evidence that it can improve outcomes among those who develop influenza despite vaccination. Disclosures All Authors: No reported Disclosures.

Background Sepsis is an important contributor to mortality among children and young adults. However, recent studies focused on hospital management and burden estimation do not provide critical data to inform prevention efforts. We conducted detailed medical record reviews to describe the epidemiology and clinical characteristics of children and young adults with sepsis to inform prevention and early recognition targets. Methods We utilized the Emerging Infections Program (EIP) to collect comprehensive data via retrospective record review for patients with severe sepsis or septic shock discharge diagnosis codes from a nonrandom sample of hospitals across 10 states. Children and young adults, aged 30 days through 21 years, discharged between September 30, 2014 and October 1, 2015, were randomly selected for inclusion. We performed a descriptive analysis of these data. Results Among 734 patients hospitalized with sepsis, 92% were living in a private residence 4 days before admission, 38% had an outpatient medical encounter in the 7 days before admission, 14% had sepsis onset after hospital day 3, and 11% died within 90 days of sepsis diagnosis. The most frequently identified infection was lower respiratory tract infection (14%); for 317 (43%) no infection was documented as a cause of sepsis. The most frequently identified pathogen was Staphylococcus aureus (10%); for 326 (44%) no pathogen was identified as a cause of sepsis. Among 394 (54%) patients with ≥1 chronic underlying medical condition (CUMC), the most common were pulmonary disease (35%), hematologic/oncologic disease (31%), immune compromise (24%), and cardiovascular disease (20%). Patients with CUMC had a higher percentage of their sepsis onset after hospital day 3, death within 90 days of sepsis diagnosis, and Pseudomonas aeruginosa as a cause of sepsis (table). The percentage of patients with no pathogen identified was similar between those with CUMC and those without. Conclusion In our large cohort of children and young adults with sepsis, most had sepsis onset outside of the hospital and over half had chronic conditions. Our data suggest that distinct approaches may be needed to develop effective prevention and early recognition strategies for children and young adults depending on the presence of chronic conditions. Disclosures All authors: No reported disclosures.

Background The role of nursing homes (NH) in transmission of antimicrobial-resistant (AR) organisms is of growing concern. AR control requires evidence-based NH stewardship interventions; however, data on antimicrobial use (AU) from US NHs are scant. In the absence of other AU surveillance approaches, NH prevalence surveys can generate essential data, including rationale and indication. In 2017, an AU prevalence survey was conducted through the CDC’s Emerging Infections Program (EIP) to determine the prevalence and epidemiology of AU in NH residents. Methods NHs from California, Colorado, Connecticut, Georgia, Maryland, Minnesota, New Mexico, New York, Oregon, and Tennessee were randomly selected to participate in a 1-day AU point prevalence survey; participation was voluntary. For NH residents receiving antimicrobial drugs (AD) at the time of the survey, EIP staff reviewed available medical records to collect the AD route, rationale, and infection site(s). AD were categorized using the World Health Organization Anatomical Therapeutic Chemical classification system. Data were analyzed in SAS 9.4. Results Of 15,295 residents in 161 NHs, 1,261 (prevalence 8.2%, 95% confidence interval 7.8%-8.7%) received ≥1 AD at the time of the survey (AD range 1–4/resident). Of 1,452 total ADs, 77% were administered for treatment of an active infection, 19% for prophylaxis, 3% for noninfectious reasons, and no rationale documented in 1%. Most AD (80%) were administered by the oral/enteral route and most (87%) were antibacterials. The three most common infection sites were urinary tract (29%, of which 1/4 was for prophylaxis); wound, cellulitis or soft tissue (20%); and respiratory tract (14%). Among the 1,268 antibacterials (figure), fluoroquinolones (15%), combination penicillins (8%), third-generation cephalosporins (8%), and glycopepetides (5%) ranked among the top 10 classes in use. Conclusion This large-scale prevalence survey provides insight into AU in US NHs. On a given day, approximately 1 in 12 NH residents was receiving ≥1 AD. Notably, 30% of AD were administered for UTI, and AD in classes recommended for stewardship intervention were common. These findings highlight areas for evaluation to identify unnecessary use in NH. Prevalence survey data are important to inform and track the impact of stewardship interventions. Disclosures All authors: No reported disclosures.

Sensitivities of 120 strains of Staphylococcus aureus to methicillin, cetylpyridinium chloride (CPC) and chlorhexidine (CH) were measured by the agar dilution technique. The MICs for CPC and CH were 2 micrograms/ml in 81 and 83% of methicillin-resistant S. aureus (MRSA), respectively. Overall, the MICs for CPC and CH were 5-10 times greater in the methicillin-resistant than in the methicillin-sensitive strains (p < 0.001). The MICs for CPC and CH also predicted the relative susceptibilities of S. aureus strains to the bactericidal action of these agents in growth and time-kill studies. The possibility that antiseptics and disinfectants contribute to the selection and maintenance of multiply resistant MRSA is considered.

Cryptococcal meningitis, often seen in immunocompromised hosts, is also a disease of the immune-competent individual. The diagnosis of cryptococcal meningitis requires a lumbar puncture with measurement of the opening pressure, standard laboratory assessment including cell count, protein and glucose, fungal culture, and cryptococcal polysaccharide antigen. Serum cryptococcal antigen is of great diagnostic value in individuals infected with HIV. Hospital admission for initial therapy with amphotericin B desoxycholate is required. Adjuvant oral therapy with flucytosine for the first 2 weeks of therapy is strongly recommended. If flucytosine is not well tolerated, it may be discontinued with close monitoring and follow-up of cerebrospinal fluid (CSF) response to therapy. Good hydration and appropriate premedication concomitant to the use of amphotericin B are useful interventions preventing side effects. Occasionally, amphotericin B needs to be discontinued due to intolerance or side effects. After CSF sterilization is completed, therapy can be switched to oral fluconazole. Fluconazole is well absorbed orally. There is rarely a need to give intravenous fluconazole.