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OBJECTIVETo determine the source of a healthcare-associated outbreak ofPantoea agglomeransbloodstream infections.DESIGNEpidemiologic investigation of the outbreak.SETTINGOncology clinic (clinic A).METHODSCases were defined asPantoeaisolation from blood or catheter tip cultures of clinic A patients during July 2012–May 2013. Clinic A medical charts and laboratory records were reviewed; infection prevention practices and the facility’s water system were evaluated. Environmental samples were collected for culture. Clinical and environmentalP. agglomeransisolates were compared using pulsed-field gel electrophoresis.RESULTSTwelve cases were identified; median (range) age was 65 (41–78) years. All patients had malignant tumors and had received infusions at clinic A. Deficiencies in parenteral medication preparation and handling were identified (eg, placing infusates near sinks with potential for splash-back contamination). Facility inspection revealed substantial dead-end water piping and inadequate chlorine residual in tap water from multiple sinks, including the pharmacy clean room sink.P. agglomeranswas isolated from composite surface swabs of 7 sinks and an ice machine; the pharmacy clean room sink isolate was indistinguishable by pulsed-field gel electrophoresis from 7 of 9 available patient isolates.CONCLUSIONSExposure of locally prepared infusates to a contaminated pharmacy sink caused the outbreak. Improvements in parenteral medication preparation, including moving chemotherapy preparation offsite, along with terminal sink cleaning and water system remediation ended the outbreak. Greater awareness of recommended medication preparation and handling practices as well as further efforts to better define the contribution of contaminated sinks and plumbing deficiencies to healthcare-associated infections are needed.Infect Control Hosp Epidemiol2017;38:314–319

Despite 61 contacts with unprotected exposure, no secondary cases occurred., In May 2014, a traveler from the Kingdom of Saudi Arabia was the first person identified with Middle East respiratory syndrome coronavirus (MERS-CoV) infection in the United States. To evaluate transmission risk, we determined the type, duration, and frequency of patient contact among health care personnel (HCP), household, and community contacts by using standard questionnaires and, for HCP, global positioning system (GPS) tracer tag logs. Respiratory and serum samples from all contacts were tested for MERS-CoV. Of 61 identified contacts, 56 were interviewed. HCP exposures occurred most frequently in the emergency department (69%) and among nurses (47%); some HCP had contact with respiratory secretions. Household and community contacts had brief contact (e.g., hugging). All laboratory test results were negative for MERS-CoV. This contact investigation found no secondary cases, despite case-patient contact by 61 persons, and provides useful information about MERS-CoV transmission risk. Compared with GPS tracer tag recordings, self-reported contact may not be as accurate.

This report highlights the first two cases of MERS coronavirus in the United States. Although these patients were not transplant recipients, it is important for transplant professionals to be aware of this infection and to consider it when evaluating patients with respiratory illnesses and travel to the Arabian peninsula.

Background CAUTIs are one of the most common preventable adverse events in hospitalized patients. Prior to the start of this intervention, CAUTI rates in our ICU’s throughout our multicenter acute care system were significantly above the national average. Our hypothesis was that we could decrease CAUTI’s by daily review of the urine culture orders for patients with a Foley catheter. Methods We implemented guidelines for appropriate ordering of urine culture for patients with Foley catheters in 2014. The culture was deemed appropriate if the patient had a fever >100.4°F within 48 hours or leukocytosis with no other identifiable source of infection and has one or more of the following: costovertebral angle/flank pain, suprapubic pain, increase in urinary frequency; urgency, frequency or dysuria after catheter removal, acute mental status change, worsening of clinical status. The ordering prescriber was called to cancel the order that did not meet the urine culture ordering guideline. If the ordering prescriber questioned the guidelines, Epidemiologists intervened to explain the rationale. This was a prospective, observational study. Chi-squared analysis was used to compare the reduction of CAUTIs. Results The data showed sustained improvement. Compared with the 2012 baseline rate of 4.28 cases per 1,000 device days, the 2013 rate was 2.70 (P = 0.085), the 2014 rate was 1.38 (P = 0.00046), the 2015 rate was 0.73 (P < 0.0001), and the 2016 rate was 0.63 (P < 0.0001). Conclusion We found that using guidelines combined with an Infection Preventionist review to determine the appropriateness of urine cultures was associated with a significant reduction in the rate of ICU CAUTI’s. Real-time culture order review is a sustainable process that has continued the success of our CAUTI reduction program. Disclosures All authors: No reported disclosures.

Background Surveillance for asymptomatic carriage of multidrug-resistant (MDR) pathogens is useful to determine the burden of these organisms and help guide infection prevention strategy. We currently perform surveillance cultures for Gram-negative multidrug-resistant pathogens (GNMDR) in the ICUs on a monthly basis. We added a quarterly point prevalence survey to all hospital units for these and other key pathogens over one year to determine whether our program should expand beyond the ICU and include other organisms. Methods Rectal samples were collected quarterly for 1 year starting June 2016 at NorthShore University HealthSystem, a four-hospital, 789 bed system. All hospitalized patients present on the day of the point prevalence testing had a double-headed rectal swab collected. One swab was plated to VACC agar (Remel) for culture of GNMDR and VRE, and the second was plated to CCFAHT (Anaerobe Systems) for C. difficile (Cdif) culture. All samples were collected on a specified day at each of our 4 hospitals, one hospital per week, and sent to the central microbiology lab for processing. Testing for GNMDR included the following pathogens: Carbapenem-resistant Enterobacteriaceae (CRE), ESBLs, and Gram negative organisms susceptible to ≤2 drug classes. Results A total of 987 surveillance samples were collected. The number of patients with MDR in the ICU vs. non-ICU units is described in Table 1. There was an 11% greater difference in the percentage of patients colonized with GNMDR and Cdif in non-ICU patients compared with ICU patients (P = 0.006). An important discovery was three patients colonized with CRE outside the ICU that were previously unknown. The burden of ESBL, VRE and Cdif carriage was also greater outside the ICU. Table 1. Comparison of Patients in ICU vs. Non-ICU with Important Hospital Pathogens Number of Patients With: No. Tests Important Pathogens (%) ESBL CRE MDR VRE Toxigenic Cdif Non-ICU 833 175 (21%) 79 3 5 64 47 ICU 154 17 (11%) 10 2 1 1 7 Conclusion The point prevalence surveillance uncovered a significant amount of MDRs in our non-ICU units, particularly three CREs that were previously unknown. These results suggest there is a large burden of MDR organisms outside the ICU. Disclosures All authors: No reported disclosures.

OBJECTIVES: To establish the etiology for outbreaks of hepatitis B virus (HBV) infections at two assisted living facilities (ALFs) and devise appropriate control measures. DESIGN: Multisite outbreak investigations, retrospective cohort. SETTING: Two ALFs in Illinois. PARTICIPANTS: Facility A residents (n=120) and Facility B residents (n=105) and nursing staff (n=6). MEASUREMENTS: For Facility A, a retrospective cohort study to identify risk factors for HBV infection through serological testing of all residents and a medical record extraction. For Facility A and B, investigation of fingerstick blood glucose monitoring techniques. For Facility B, serological HBV testing of nurses and residents receiving fingerstick blood glucose monitoring. RESULTS: At Facility A, five confirmed acute, two probable acute, and one probable chronic HBV infections were identified in the 109 residents tested. All of the eight identified residents with HBV infection had diabetes mellitus. HBV deoxyribonucleic acid (DNA) sequences from the chronic and acute cases were identical. Transmission of HBV was associated with fingerstick blood glucose monitoring (relative risk (RR)=28.5, 95% confidence interval (CI)=1.6–498; P

Background Human adenovirus type 3 (HAdV-3) causes severe respiratory illness in children, but outbreaks in long-term care facilities have not been frequently reported. We describe an outbreak of HAdV-3 infection in a long-term care facility for children with severe neurologic impairment, where only 3 of 63 residents were ambulatory. Methods A clinical case of HAdV-3 was defined as fever (temperature, > or = 38.0 degrees C) and either a worsening of respiratory symptoms or conjunctivitis in a resident, with illness onset from June through August 2005. We reviewed medical records; conducted surveillance for fever, conjunctivitis, and respiratory symptoms; and collected nasopharyngeal and conjunctival specimens from symptomatic residents. Specimens were cultured in HAdV-permissive cell lines or were analyzed by HAdV-specific polymerase chain reaction assay. Results Thirty-five (56%) of 63 residents had illnesses that met the case definition; 17 patients (49%) were admitted to intensive care units, and 2 (6%) died. Patients were hospitalized in the intensive care unit for a total of 233 patient-days. Illness onset dates ranged from 1 June through 24 August 2005. Thirty-two patients (91%) had respiratory infection, and 3 (9%) had conjunctivitis. HAdV was identified by culture or PCR in 20 patients. Nine isolates were characterized as HAdV-3 genome type a2. Conclusions Considering the limited mobility of residents and their reliance on respiratory care, transmission of HAdV-3 infection during this outbreak likely occurred through respiratory care provided by staff. In environments where patients with susceptible underlying conditions reside, HAdV infection should be considered when patients are identified with worsening respiratory disease, and rapid diagnostic tests for HAdV infection should be readily available to help identify and curtail the spread of this pathogen.

During the investigation of an outbreak of Escherichia coli O157:H7 in a child care center, illness logs were reviewed and parents interviewed to identify classroom and household exposures. Costs incurred by the center and the public health laboratory were estimated from self-administered questionnaires. We conclude that household transmission played a role in this outbreak and estimate the cost of investigation and intervention at over $6,000 per case.

Automated bloodstream infection surveillance using electronic data is an accurate alternative to surveillance using manually collected data., We compared manual and computer-assisted bloodstream infection surveillance for adult inpatients at two hospitals. We identified hospital-acquired, primary, central-venous catheter (CVC)-associated bloodstream infections by using five methods: retrospective, manual record review by investigators; prospective, manual review by infection control professionals; positive blood culture plus manual CVC determination; computer algorithms; and computer algorithms and manual CVC determination. We calculated sensitivity, specificity, predictive values, plus the kappa statistic (κ) between investigator review and other methods, and we correlated infection rates for seven units. The κ value was 0.37 for infection control review, 0.48 for positive blood culture plus manual CVC determination, 0.49 for computer algorithm, and 0.73 for computer algorithm plus manual CVC determination. Unit-specific infection rates, per 1,000 patient days, were 1.0–12.5 by investigator review and 1.4–10.2 by computer algorithm (correlation r = 0.91, p = 0.004). Automated bloodstream infection surveillance with electronic data is an accurate alternative to surveillance with manually collected data.

We determined risk factors for hand contamination and compared the efficacy of 3 randomly allocated hand hygiene agents in a group of surgical intensive care unit nurses. We cultured samples of one of the subjects' hands before and samples of the other hand after hand hygiene was performed. Ring wearing was associated with 10-fold higher median skin organism counts; contamination with Staphylococcus aureus, gram-negative bacilli, or Candida species; and a stepwise increased risk of contamination with any transient organism as the number of rings worn increased (odds ratio [OR] for 1 ring worn, 2.6; OR for >1 ring worn, 4.6). Compared with use of plain soap and water, hand contamination with any transient organism was significantly less likely after use of an alcohol-based hand rub (OR, 0.3; 95% confidence interval [CI], 0.1-0.8) but not after use of a medicated hand wipe (OR, 0.9; 95% CI, 0.5-1.6). Ring wearing increased the frequency of hand contamination with potential nosocomial pathogens. Use of an alcohol-based hand rub resulted in significantly less frequent hand contamination.

Objective In May 2012, thousands of protesters, descended on Chicago during the NATO Summit to voice their concern about social and economic inequality. Given the increased numbers of international and domestic visitors to the Windy City and the tension surrounding protesting during the summit, increased monitoring for health events within the city and Chicago metropolitan region was advised. This project represents the first use of cloud technology to support monitoring for a high profile event. Introduction Hospital emergency departments in Cook and surrounding counties currently send data to the Cook County Department of Public Health (CCDPH) instance of ESSENCE on CCDPH servers. The cloud instance of ESSENCE has been enhanced to receive and export all meaningful use data elements in the meaningful use format. The NATO summit provided the opportunity for a demonstration project to assess the ability of an Amazon GovCloud instance of ESSENCE to ingest and process meaningful use data, and to export meaningful use surveillance data to the Cook County Locker in BioSense 2.0. Methods In the three weeks leading up to the NATO Summit, HL7 data extracts were sent to BioSense 2.0 and a data feed was established to the Amazon GovCloud instance of ESSENCE. Queries specific to anticipated health events associated with the summit such as injuries, tear gas exposure, and general exposure, were developed. Several features of the cloud instance of ESSENCE enhanced the ability of CCDPH staff epidemiologists to conduct analyses, including the sharing capabilities of queries and the myESSENCE dashboard feature. The sharing capabilities within the cloud instance of ESSENCE allowed queries to be easily shared with multiple staff epidemiologists and across health jurisdictions. The myESSENCE dashboard feature was used to create dashboards of surveillance results, including time series graphs, maps, and records of interest for relevant queries, that were shared with public health staff monitoring population health during the summit. This information was used to provide situational awareness on a daily basis in the Chicago Metropolitan region. Results Data feeds to BioSense 2.0 and the Amazon GovCloud instance of ESSENCE were successful. The NATO Summit did not produce any remarkable public health concerns in suburban Cook County. The use of the cloud instance of ESSENCE enhanced the timeliness of generating situational awareness reports for distribution to public health partners in the Chicago Metropolitan region. Conclusions While further evaluation of cloud resources to conduct syndromic surveillance is warranted, use of the cloud instance of ESSENCE during the NATO Summit demonstrated the ability of the cloud to support surveillance for both routine and high profile events.

Objective.Describe the clinical and molecular epidemiology of incidentClostridium difficileinfection (CDI) cases in Chicago area acute healthcare facilities (HCFs).Design and Setting.Laboratory, clinical, and epidemiologic information was collected for patients with incident CDI who were admitted to acute HCFs in February 2009. Stool cultures and restriction endonuclease analysis typing of the recoveredC. difficileisolates was performed.Patients.Two hundred sixty-three patients from 25 acute HCFs.Results.Acute HCF rates ranged from 2 to 7 patients with CDI per 10,000 patient-days. The crude mortality rate was 8%, with 20 deaths occurring in patients with CDI. Forty-two (16%) patients had complications from CDI, including 4 patients who required partial, subtotal, or total colectomy, 3 of whom died.C. difficilewas isolated and typed from 129 of 178 available stool specimens. The BI strain was identified in 79 (61%) isolates. Of patients discharged to long-term care who had their isolate typed, 36 (67%) had BI-associated CDI.Conclusions.Severe disease was common and crude mortality was substantial among patients with CDI in Chicago area acute HCFs in February 2009. The outbreak-associated BI strain was the predominant endemic strain identified, accounting for nearly two-thirds of cases. Focal HCF outbreaks were not reported, despite the presence of the BI strain. Transfer of patients between acute and long-term HCFs may have contributed to the high incidence of BI cases in this investigation.

Objective.To determine whether a multimodal intervention could improve adherence to hand hygiene and glove use recommendations and decrease the incidence of antimicrobial resistance in different types of healthcare facilities.Design.Prospective, observational study performed from October 1, 1999, through December 31, 2002. We monitored adherence to hand hygiene and glove use recommendations and the incidence of antimicrobial-resistant bacteria among isolates from clinical cultures. We evaluated trends in and predictors for adherence and preferential use of alcohol-based hand rubs, using multivariable analyses.Setting.Three intervention hospitals (a 660-bed acute and long-term care hospital, a 120-bed community hospital, and a 600-bed public teaching hospital) and a control hospital (a 700-bed university teaching hospital).Intervention.At the intervention hospitals, we introduced or increased the availability of alcohol-based hand rub, initiated an interactive education program, and developed a poster campaign; at the control hospital, we only increased the availability of alcohol-based hand rub.Results.We observed 6,948 hand hygiene opportunities. The frequency of hand hygiene performance or glove use significantly increased during the study period at the intervention hospitals but not at the control hospital; the maximum quarterly frequency of hand hygiene performance or glove use at intervention hospitals (74%, 80%, and 77%) was higher than that at the control hospital (59%). By multivariable analysis, preferential use of alcohol-based hand rubs rather than soap and water for hand hygiene was more likely among workers at intervention hospitals compared with nonintervention hospitals (adjusted odds ratio, 4.6 [95% confidence interval, 3.3-6.4]) and more likely among physicians (adjusted odds ratio, 1.4 [95% confidence interval, 1.2-1.8]) than among nurses at intervention hospitals. A significantly reduced incidence of antimicrobial-resistant bacteria among isolates from clinical culture was found at a single intervention hospital, which had the greatest increase in the frequency of hand hygiene performance.Conclusions.During a 3-year period, a multimodal intervention program increased adherence to hand hygiene recommendations, especially to the use of alcohol-based hand rubs. In one hospital, a concomitant reduction was found in the incidence of antimicrobial-resistant bacteria among isolates from clinical cultures.

We developed criteria for justifiable CVC use and evaluated CVC use in a public hospital. Unjustified CVC-days were more common for non-ICU patients compared with ICU patients. Also, insertion-site dressings were less likely to be intact on non-ICU patients. Interventions to reduce CVC-associated bloodstream infections should include non-ICU patients.

We observed adherence with hand hygiene in 14 units at 4 hospitals with varying sink-to-bed ratios (range, 1:1 to 1:6). Adherence was less than 50% in all units and there was no significant trend toward improved hand hygiene with increased sink-to-bed ratios.

Importance Carbapenem-resistant Enterobacteriaceae (CRE) producing the New Delhi metallo-β-lactamase (NDM) are rare in the United States, but have the potential to add to the increasing CRE burden. Previous NDM-producing CRE clusters have been attributed to person-to-person transmission in health care facilities. Objective To identify a source for, and interrupt transmission of, NDM-producing CRE in a northeastern Illinois hospital. Design, Setting, and Participants Outbreak investigation among 39 case patients at a tertiary care hospital in northeastern Illinois, including a case-control study, infection control assessment, and collection of environmental and device cultures; patient and environmental isolate relatedness was evaluated with pulsed-field gel electrophoresis (PFGE). Following identification of a likely source, targeted patient notification and CRE screening cultures were performed. Main Outcomes and Measures Association between exposure and acquisition of NDM-producing CRE; results of environmental cultures and organism typing. Results In total, 39 case patients were identified from January 2013 through December 2013, 35 with duodenoscope exposure in 1 hospital. No lapses in duodenoscope reprocessing were identified; however, NDM-producingEscherichia coliwas recovered from a reprocessed duodenoscope and shared more than 92% similarity to all case patient isolates by PFGE. Based on the case-control study, case patients had significantly higher odds of being exposed to a duodenoscope (odds ratio [OR], 78 [95% CI, 6.0-1008],P Conclusions and Relevance In this investigation, exposure to duodenoscopes with bacterial contamination was associated with apparent transmission of NDM-producingE coliamong patients at 1 hospital. Bacterial contamination of duodenoscopes appeared to persist despite the absence of recognized reprocessing lapses. Facilities should be aware of the potential for transmission of bacteria including antimicrobial-resistant organisms via this route and should conduct regular reviews of their duodenoscope reprocessing procedures to ensure optimal manual cleaning and disinfection.

Objective: Gram stain of amniotic fluid (AF) is used to detect intraamniotic infection. The purpose of this study was to determine if centrifugation improved the ability of AF Gram stain to detect bacteria. Methods: AF obtained by amniocentesis from patients with preterm labor (PTL) or preterm premature rupture of membranes (PPROM) was pooled. Individual AF samples as well as the pooled sample had a negative Gram stain for microorganisms or white blood cells (WBCs) and negative cultures. With pure bacterial cultures, a suspension equivalent to a 0.5 McFarland turbidity standard was prepared and then serially diluted in the AF to either 106, 105, 104, or 103 colony forming units (cfu)/ml. Each sample was divided into 2 equal portions, with 1 undergoing centrifugation. The Gram stains were interpreted by technologists in the clinical microbiology laboratory in a blinded fashion. Fisher's exact test was used to compare the bacterial detection rate in centrifuged vs. uncentrifuged AF samples at each concentration. Results: Centrifugation of AF significantly improved the ability of the Gram stain to detect bacteria at bacterial concentrations ≤104 cfu/ml (P < 0.01). At concentrations ≥105 cfu/ml, centrifugation did not improve the ability of the Gram stain to dtect bacteria. Conclusions: At low bacterial concentrations, centrifugation of AF increases the bacterial detection rate of AF Gram stain.

Background Historically, methods of interrupting pathogen transmission have focused on improving health care workers' adherence to recommended infection control practices. An adjunctive approach may be to use source control (eg, to decontaminate patients' skin). Methods We performed a prospective sequential-group single-arm clinical trial in a teaching hospital's medical intensive care unit from October 2002 to December 2003. We bathed or cleansed 1787 patients and assessed them for acquisition of vancomycin-resistant enterococci (VRE). We performed a nested study of 86 patients with VRE colonization and obtained culture specimens from 758 environmental surfaces and 529 health care workers' hands. All patients were cleansed daily with the procedure specific to the study period as follows: period 1, soap and water baths; period 2, cleansing with cloths saturated with 2% chlorhexidine gluconate; and period 3, cloth cleansing without chlorhexidine. We measured colonization of patient skin by VRE, health care worker hand or environmental surface contamination by VRE, and patient acquisition of VRE rectal colonization. Results Compared with soap and water baths, cleansing patients with chlorhexidine-saturated cloths resulted in 2.5 log 10 less colonies of VRE on patients' skin and less VRE contamination of health care workers' hands (risk ratio [RR], 0.6; 95% confidence interval [CI], 0.4-0.8) and environmental surfaces (RR, 0.3; 95% CI, 0.2-0.5). The incidence of VRE acquisition decreased from 26 colonizations per 1000 patient-days to 9 per 1000 patient-days (RR, 0.4; 95% CI, 0.1-0.9). For all measures, effectiveness of cleansing with nonmedicated cloths was similar to that of soap and water baths. Conclusion Cleansing patients with chlorhexidine-saturated cloths is a simple, effective strategy to reduce VRE contamination of patients' skin, the environment, and health care workers' hands and to decrease patient acquisition of VRE.