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Background: The CDC recommends that consultant pharmacists support antimicrobial stewardship programs (ASPs) in long-term care facilities (LTCFs). We studied CDC-recommended ASP core elements implementation and antibiotic use in LTCFs before and after training consultant pharmacists. Methods: Between August 2017 and October 2017, consultant pharmacists from a regional long-term care pharmacy attended 5 didactic sessions preparing them to assist LTCFs in implementation of CDC-recommended ASP core elements. Training also included creating a process for evaluating appropriateness of all systemic antibiotics and providing prescriber feedback during their monthly mandatory drug-regimen reviews. Once monthly “meet-the-expert” sessions were held with consultant pharmacists throughout the project (November 2017 to December 2018). LTCF enrollment began in November 2017 and >90% of facilities joined by January 2018. After enrollment, consultant pharmacists initiated ASP interventions including antibiotic reviews and feedback using standard templates. They also held regular meetings with infection preventionists to discuss Core Elements implementation and provided various ASP resources to LTCFs (eg, antibiotic policy template, guidance documents and standard assessment and communication tools). Data collection included ASP Core Elements, antibiotic starts, days of therapy (DOT), and resident days (RD). The McNemar test, the Wilcoxon signed-rank test, generalized estimating equation model, and the classic repeated measures approach were used to compare the presence of all 7 core elements and antibiotic use during the baseline (2017) and intervention (2018) year.Results: In total, 9 trained consultant pharmacists assisted 32 LTCFs with ASP implementation. When evaluating 27 LTCFs that provided complete data, a significant increase in presence of all 7 Core Elements after the intervention was noted compared to baseline (67% vs 0; median Core Elements, 7 vs 2; range, 6–7 vs 1–6; P < .001). Median monthly antibiotic starts per 1,000 RD and DOT per 1,000 RD decreased in 2018 compared to 2017: 8.93 versus 9.91 (P < .01) and 106.47 versus 141.59 (P < .001), respectively. However, variations in antibiotic use were detected among facilities (Table 1). When comparing trends, antibiotic starts and DOT were already trending downward during 2017 (Fig. 1A and 1B). On average, antibiotic starts decreased by 0.27 per 1,000 RD (P < .001) and DOT by 1.92 per 1,000 RD (P < .001) each month during 2017. Although antibiotic starts remained mostly stable in 2018, DOT continued to decline further (average monthly decline, 2.60 per 1,000 RD; P < .001). When analyzing aggregated mean, antibiotic use across all sites per month by year, DOT were consistently lower throughout 2018 and antibiotic starts were lower for the first 9 months (Fig. 1C and 1D). Conclusions: Consultant pharmacists can play an important role in strengthening ASPs and in decreasing antibiotic use in LTCFs. Educational programs should be developed nationally to train long-term care consultant pharmacists in ASP implementation.Funding: Merck & Co., Inc, provided funding for this study.Disclosures: Muhammad Salman Ashraf and Scott Bergman report receipt of a research grant from Merck.

Summary Blood culture contamination is a clinically significant problem that can be reduced through the use of an innovative device that diverts and sequesters the initial 1.5–2 mL of blood that contains the skin cells and microbes that result in contamination., Background. Blood culture contamination is a clinically significant problem that results in patient harm and excess cost. Methods. In a prospective, controlled trial at an academic center Emergency Department, a device that diverts and sequesters the initial 1.5–2 mL portion of blood (which presumably carries contaminating skin cells and microbes) was tested against standard phlebotomy procedures in patients requiring blood cultures due to clinical suspicion of serious infection. Results. In sum, 971 subjects granted informed consent and were enrolled resulting in 904 nonduplicative subjects with 1808 blood cultures. Blood culture contamination was significantly reduced through use of the initial specimen diversion device™ (ISDD) compared to standard procedure: (2/904 [0.22%] ISDD vs 16/904 [1.78%] standard practice, P = .001). Sensitivity was not compromised: true bacteremia was noted in 65/904 (7.2%) ISDD vs 69/904 (7.6%) standard procedure, P = .41. No needlestick injuries or potential bloodborne pathogen exposures were reported. The monthly rate of blood culture contamination for all nurse-drawn and phlebotomist-drawn blood cultures was modeled using Poisson regression to compare the 12-month intervention period to the 6 month before and after periods. Phlebotomists (used the ISDD) experienced a significant decrease in blood culture contamination while the nurses (did not use the ISDD) did not. In sum, 73% of phlebotomists completed a post-study anonymous survey and widespread user satisfaction was noted. Conclusions. Use of the ISDD was associated with a significant decrease in blood culture contamination in patients undergoing blood cultures in an Emergency Department setting. Clinical Trials Registration. NCT02102087.

Background We implemented a one-year antimicrobial stewardship training program that lasted through 2018 where we assisted 9 long-term care facility (LTCF) consultant pharmacists in promoting antibiotic stewardship programs (ASP) in 32 LTCF (Figure 1). Surveys were conducted during and after the training program to assess performance. Methods Infection Preventionists (IP), Directors of Nursing (DON) and Medical Directors (MD) of the LTCF received mail surveys in 2018 and online surveys in 2019. It included questions assessing the respondents’ perceptions of their ASP, barriers to ASP implementation and stewardship related knowledge, and the skills and contributions of their consultant pharmacists. Qualitative analyses categorized reported barriers into common themes. Fisher exact test compared perceptions of consultant pharmacists’ performance and frequently reported barriers during training and after the intervention was completed. Results Representatives (IP, DON and/or MD) of 18 facilities responded to the surveys at both time points of the study, with 34 individual surveys in 2018 and 25 in 2019. Most rated their consultant pharmacists as knowledgeable and helpful who regularly provided feedback and suggestions both during and after the training (Table 1). Fifty-six percent of facilities reported that their consultant pharmacists were similarly involved, and 12% felt they were more involved, in ASP implementation in 2019 compared to 2018. Top 3 reported barriers to ASP implementations were the same during 2018 and 2019 (Table 2). Overall, 84% of facilities in 2019 believed that the consultant pharmacists “definitely helped” their ASP efforts, and 80% of facilities desired to continue the partnership into the future. Table 1. Comparison of Consultant Pharmacists’ Performance Evaluations During (2018) and After (2019) Completion of Training Figure 3. Barriers to ASP implementation reported during (2018) and after (2019) training. Conclusion This study demonstrates that training consultant pharmacists resulted in meaningful actions and prolonged engagement in ASP activities. Efforts should be directed on making similar training programs available nationwide for consultant pharmacists working in LTCF. Disclosures Muhammad Salman Ashraf, MBBS, Merck & Co. Inc (Grant/Research Support)

Background Central line–associated bloodstream infections may be due to catheter connector colonization and intraluminal migration of pathogens. We assessed the colonization of the split septum catheter connector system, and subsequently the luer lock catheter connector system. Methods This was a prospective, 2 phase, quality improvement study at a tertiary referral center. Each phase of the study was performed over 3 consecutive days in hospitalized patients receiving an active infusion; first with a split septum lever lock connector and second with a luer lock connector and alcohol port protector. The connectors were inoculated onto blood agar plates and incubated. Plates were assessed for microbial growth after 48-72 hours. Results In phase I, 98 (41.9%) of 234 split septum connectors yielded microbial growth. In phase II, 56 (23.1%) of 243 luer lock connectors yielded microbial growth. In phase II only, there was a significant increased rate of contamination in peripheral catheters compared with all other catheters, and the rate of contamination on the acute care wards was significantly higher when compared with the intensive care units. Conclusions Bacterial colonization of the lever lock system was unacceptably high among all catheter types and hospital locations. Transition to luer lock catheter connectors and alcohol port protectors decreased the colonization; however, colonization still remained substantial. Causation of colonization cannot be determined with these results.

Objective.To assess the effect of adenosine triphosphate (ATP) device measurement of hospital room cleaning and feedback of pooled results to environmental service workers (EVS) to improve cleaning efficacy.Design.Nonrandomized controlled trial conducted over 20 months.Setting.Three hospitals of varying size.Participants.EVS workers, randomly selected on the basis of convenience sample of rooms.Interventions.Environmental cleanliness composite scores were combined with layered educational interventions and used to provide feedback to EVS workers on specific hospital units. Trends in cleaning efficacy were observed after the interventions.Results.Cleaning efficacy improved significantly with each intervention (P < .01) and decreased during the washout period.Conclusions.The ATP detection device combined with educational feedback for EVS workers resulted in significant improvement in cleaning efficacy of the hospital room environment.

Background The environment is increasingly appreciated as a factor in healthcare associated infections. Several methods for measuring environmental contamination are available. Our goal was to compare quantitative microbiology to adenosine triphosphate (ATP) detection on a sample of hospital surfaces both pre- and post-cleaning, and to assess fluorescent marker results in the same rooms. Methods In a sample of 10 rooms, ATP readings by relative light units (RLU) and quantitative determination of colony forming units (CFU) were measured pre- and post-cleaning on 10 high-touch hospital environmental surfaces. Removal of fluorescent markers (FM) was evaluated post-cleaning in the same rooms. Methods were compared using correlational analyses. Results The ATP readings were usually higher than CFU readings compared with their respective norms for cleanliness. The direction of change in cleanliness assessment (usually down after cleaning) was consistent between the RLU and CFU methods. In addition, CFU and RLU values correlated pre-cleaning, but not postcleaning. Areceiver operating characteristic (ROC) curve suggested a ‘clean' cutoff of 8 RLU/cm 2 for the ATP assay, higher than 2.5 RLU/cm 2 cutoff most often used. Neither method correlated well with FM results. Conclusions The methods for measuring environmental cleanliness have shown inconsistent correlation, but measure different parameters. Additional studies are needed to assess the correlation and predictive value of the three methods for room cleanliness assessment.

Background The patient care environment plays an important role in the transmission of potential pathogens. Efforts to improve the thoroughness of environmental cleaning and disinfection have largely concentrated on ICUs and other inpatient units. The purpose of this study was to ascertain baseline data on the thoroughness of cleaning in ambulatory care clinics. Methods High touch surfaces (exam tables, chair arms, light switches, etc.) in patient rooms, waiting rooms, and clinic common areas were marked with an invisible, UV-tagged gel (DAZO®, Ecolab) in the AM and PM to assess thoroughness of cleaning by both Environmental Services (EVS) workers and clinical care medical assistants (MA). Surveys were conducted in 8 ambulatory care clinics for five consecutive days (Monday–Friday). Results Results are summarized in Table 1. A total of 14,288 environmental surfaces were assessed in the 8 ambulatory clinics and the overall rate of cleaning ranged from 31% to 74%, 29% to 77%, and 0% to 22% for examination rooms, common clinic areas, and waiting rooms, respectively. The thoroughness of cleaning for EVS workers vs. Medical Assistants (MA) was 49% vs. 46% (examination rooms) and 46% vs. 43% (common clinical areas). Waiting room surfaces were cleaned at a rate of only 6.8%. While many high touch objects were regularly cleaned, some were consistently missed by both groups (eg ophthalmoscopes, keyboards, and stethoscopes). % Surfaces cleaned Exam rooms Clinic common areas Clinic Clinic rooms (N) EVS Med Assis EVS Med Assis Waiting rooms A 35 42 38 37 34 22 B 14 42 33 42 33 8 C 28 40 26 35 24 16 D 12 38 23 33 21 8 E 9 94 57 92 67 0 F 26 66 57 59 50 0 G 9 45 59 37 54 0 H 33 44 68 40 43 0 Conclusion In ambulatory care clinics there is wide variability in the thoroughness of cleaning from clinic-to-clinic and between EVS workers and MAs as well as great room for improvement. Disclosures P. Carling, Ecolab: Consultant, Royalty

Basins, commonly used to bathe patients who are unable to bathe themselves, frequently become contaminated with potential pathogens and may serve as a source for nosocomial transmission. Chlorhexidine (CHG) has bactericidal activity against a broad spectrum of pathogens and is increasingly used in antiseptic patient baths. The purpose of this study was to ascertain whether basins used to administer CHG bed baths are likely to become contaminated.Bed bath conditions were simulated by mixing 30 mL of a 4% CHG product or soap preparation to 1 L of warm (37°C) tap water in a 6-L plastic basin (Medical Action Industries). Two commercial brands of CHG (Hibiclens, Molnlycke Health Care [hereafter, CHG-A], or Scrub Care, Cardinal Health [hereafter, CHG-B]) and 1 brand of soap (SensiCare SeptiSoft, ConvaTec) were used. Basins were inoculated with 108 colony-forming units (CFUs) of 1 species of bacteria, mixed for 30 seconds, incubated for 20 minutes at room temperature, emptied, and allowed to dry for 1 hour. A 100-cm2 area on the bottom of the basin was sampled for 10 seconds in 2 directions with a cotton swab premoistened with normal saline. Swab tips were placed in 2 mL of trypticase soy broth (Difco) and vortex-mixed for 30 seconds, and the solution was quantitatively cultured on sheep blood agar (Remel). Cultures were incubated at 37°C for 24 hours, and colonies were counted and expressed as CFUs per square centimeter. Tap water with and without a bacterial inoculum served as positive and negative controls, respectively.

Background Over 300 million peripheral intravenous catheters (PIV) are used yearly in the United States resulting in up to 146,000 cases of bloodstream infection. Despite their importance, relatively little effort has been invested in understanding their use and minimizing their risk. Methods A series of point-prevalence surveys were conducted over a 10 week period on all inpatient units at the Nebraska Medical Center, a 689-bed academic medical center, to ascertain patterns of intravascular catheter use, securement techniques, dressing integrity, and evidence of phlebitis. Results All inpatient units were surveyed at least three times by specially-trained observers resulting in assessments of 1,217 patients: 87 (7%) had no IV access, 667 (55%) had PIV only, 395 (32%) had central venous catheters (CVC) only, and 68 (6%) had both PIV and CVC. Not surprisingly, patients in the ICU were more likely to have a CVC than patients cared for on the ward (P < 0.001). PIV were located in the following anatomic sites: hand (27.1%), wrist (16.5%), forearm (26%), antecubital (25.1%), upper arm (3.9%), foot (0.5%) and other (0.9%). 99% of PIVs were covered with a transparent dressing. Only 1% of PIVs were dressed with gauze and tape and 6.5% were further covered with occlusive wraps. In addition, some PIVs were secured with tape (58.5%) or a device (9.2%). Secondary anchors, tape, or foam pads, were used to secure the IV tubing in 60.2% of patients. PIV dressing condition was assessed and 46.8% had significant edge lift and 21.5% had blood or fluid under the dressing. 24% of the PIV dressings had an application date noted. Patients in the ICU were more likely to have a PIV dressing application date noted on the dressing than ward patients (31% vs 23%, respectively, P = 0.047). Five percent of PIVs exhibited signs of phlebitis. Conclusion PIVs and other vascular access devices are nearly universal in hospitalized patients. There is great variability in the anatomic location of PIVs and in the manner they are dressed and secured – resulting in an opportunity for standardization and risk reduction. Disclosures All authors: No reported disclosures.

Background.Chlorhexidine gluconate (CHG) bathing has been used primarily in critical care to prevent central line-associated bloodstream infections and infections due to multidrug-resistant organisms. The objective was to determine the effect of hospital-wide CHG patient bathing on healthcare-associated infections (HAIs).Design.Quasi-experimental, staged, dose-escalation study for 19 months followed by a 4-month washout period, in 3 cohorts.Setting.Academic medical center.Patients.All patients except neonates and infants.Intervention and Measurements.CHG bathing in the form of bed basin baths or showers administered 3 days per week or daily. CHG bathing compliance was monitored, and the rate of HAIs was measured.Results.Over 188,859 patient-days, 68,302 CHG baths were administered. Adherence to CHG bathing in the adult critical care units (90%) was better than that observed in other units (57.7%, P< .001). A significant decrease in infections due to Clostridium difficile was observed in all cohorts of patients during the intervention period, followed by a significant rise during the washout period. For all cohorts, the relative risk of C. difficile infection compared to baseline was 0.71 (95% confidence interval [CI], 0.57–0.89; P = .003) for 3-days-per-week CHG bathing and 0.41 (95% CI, 0.29–0.59; P < .001) for daily CHG bathing. During the washout period, the relative risk of infection was 1.85 (95% CI, 1.38–2.53; P =< .001), compared to that with daily CHG bathing. A consistent effect of CHG bathing on other HAIs was not observed. No adverse events related to CHG bathing were reported.Conclusions.CHG bathing was well tolerated and was associated with a significant decrease in C. difficile infections in hospitalized patients.

Objective.Define optimum vascular catheter connector valve disinfection practices under laboratory and clinical conditions.Design.Prospective observational clinical survey and laboratory assessment of disinfection procedures.Setting.All adult inpatients at an academic healthcare center.Methods.In the clinical setting, contamination of needleless connectors was assessed in 6 weekly prevalence surveys in which the connector valves from central venous catheters (CVCs) in situ were cultured by pressing the connector diaphragm to an agar plate. Before culture, valves were disinfected by scrubbing the diaphragm with a 70% isopropyl alcohol pledget for 0, 5, 10, 15, or 30 seconds. In the laboratory, the diaphragms on 150 unused sterile connector valves were inoculated with 103, 105, or 108colony-forming units ofStaphylococcus epidermidisand allowed to dry. After disinfection of the diaphragms by scrubbing with a 70% isopropyl alcohol pledget for 0, 5, 10, 15, or 30 seconds, the valves were sampled by pressing the diaphragm to an agar plate.Results.In the clinical setting, 363 connector valves from patients with CVCs were sampled, and 66.7% of nondisinfected valves revealed bacterial contamination. After 5-second disinfection with an alcohol pledget, only 1 (1.4%) of 71 yielded microbial growth (P< .005). In the laboratory, at the 103and 105inoculum, all connector valves yielded sterile cultures when scrubbed for 5 or more seconds (P< .001). At the 108inoculum, 2 (20%) of 10 connector valves yielded minimal growth ofS. epidermidis.Conclusions.A 5-second scrub with a 70% isopropyl alcohol pledget yields adequate disinfection of a split-septum intravascular catheter connector valve under clinical and laboratory conditions.