Background: The proportion of antimicrobial-resistant Enterobacterales that are causative pathogens for community-acquired acute pyelonephritis (CA-APN) has been increasing. We examined the effect of antimicrobial resistance on medical costs in CA-APN. Methods: A single-center retrospective cohort study was conducted at a tertiary-care hospital in Korea between January 2018 to December 2019. All hospitalized patients aged ≥19 years who were diagnosed with CA-APN were recruited, and those with Enterobacterales as a causative pathogen were included. Comparisons between CA-APN caused by extended-spectrum β-lactamase (ESBL)–producing pathogens (ESBL+ group) and those by non–ESBL-producing organisms (ESBL– group) as well as CA-APN caused by ciprofloxacin-resistant pathogens (CIP-R group) and those by ciprofloxacin-sensitive pathogens (CIP-S group) were performed. Log-linear regression was performed to determine the risk factors for medical costs. Results: In total, 241 patients were included in this study. Of these, 75 (31.1%) had an ESBL-producing pathogen and 87 (36.1%) had a ciprofloxacin-resistant pathogen. The overall medical costs were significantly higher in the ESBL+ group compared with the ESBL− group (US$3,730.18 vs US$3,119.32) P <0.001) as well as in CIP-R group compared with CIP-S group (3,730.18 USD vs. 3,119.32 USD, P =0.005). In addition, length of stay was longer in ESBL+ group compared with ESBL-group (11 vs. 8 days, P <0.001) as well as in CIP-R group compared with CIP-S group (11 vs. 8 days, P <0.001). There were no significant difference in the proportion of clinical failure between ESBL+ and ESBL- groups; CIP-R and CIP-S groups. Based on the log-linear regression model, the costs associated with ESBL-producing Enterobacterales as the causative pathogen would be, on average, 27% higher or US$1,211 higher than its counterpart (P = .026). By the same token, a patient who is a year older would incur US$23 higher cost (P = .040). Having any structural problem in urinary tract would incur US$1,231 higher cost (P = .015). A unit increase in Pitt score would incur US$767 USD higher cost (P < 0.001) higher cost, all other things constant. Conclusions: Medical costs for hospitalized patients with CA-APN are increased by the existence of ESBL-producing Enterobacterales but not by the existence of ciprofloxacin-resistant Enterobacterales.

Funding: No

Disclosures: None

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Group Name: VHA Center for Antimicrobial Stewardship and Prevention of Antimicrobial Resistance (CASPAR) Background: Antimicrobial stewardship programs (ASPs) are advised to measure antimicrobial consumption as a metric for audit and feedback. However, most ASPs lack the tools necessary for appropriate risk adjustment and standardized data collection, which are critical for peer-program benchmarking. We created a system that automatically extracts antimicrobial use data and patient-level factors for risk-adjustment and a dashboard to present risk-adjusted benchmarking metrics for ASP within the Veterans’ Health Administration (VHA). Methods: We built a system to extract patient-level data for antimicrobial use, procedures, demographics, and comorbidities for acute inpatient and long-term care units at all VHA hospitals utilizing the VHA’s Corporate Data Warehouse (CDW). We built baseline negative binomial regression models to perform risk-adjustments based on patient- and unit-level factors using records dated between October 2016 and September 2018. These models were then leveraged both retrospectively and prospectively to calculate observed-to-expected ratios of antimicrobial use for each hospital and for specific units within each hospital. Data transformation and applications of risk-adjustment models were automatically performed within the CDW database server, followed by monthly scheduled data transfer from the CDW to the Microsoft Power BI server for interactive data visualization. Frontline antimicrobial stewards at 10 VHA hospitals participated in the project as pilot users. Results: Separate baseline risk-adjustment models to predict days of therapy (DOT) for all antibacterial agents were created for acute-care and long-term care units based on 15,941,972 patient days and 3,011,788 DOT between October 2016 and September 2018 at 134 VHA hospitals. Risk adjustment models include month, unit types (eg, intensive care unit [ICU] vs non-ICU for acute care), specialty, age, gender, comorbidities (50 and 30 factors for acute care and long-term care, respectively), and preceding procedures (45 and 24 procedures for acute care and long-term care, respectively). We created additional models for each antimicrobial category based on National Healthcare Safety Network definitions. For each hospital, risk-adjusted benchmarking metrics and a monthly ranking within the VHA system were visualized and presented to end users through the dashboard (an example screenshot in Figure 1). Conclusions: Developing an automated surveillance system for antimicrobial consumption and risk-adjustment benchmarking using an electronic medical record data warehouse is feasible and can potentially provide valuable tools for ASPs, especially at hospitals with no or limited local informatics expertise. Future efforts will evaluate the effectiveness of dashboards in these settings.

Funding: No

Disclosures: None

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Background: Gaps exist in the evidence supporting the benefits of contact precautions for the prevention of methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococci (VRE). The Centers for Disease Control and Prevention allow suspending contact precautions for MRSA and VRE in cases of gown shortages, as we have seen during the COVID-19 pandemic. We evaluated the impact of discontinuing isolation precautions in hospitalized patients with MRSA and VRE infection, due to gown shortage, on the rate of hospital-acquired (HA) MRSA and VRE infections. Methods: A retrospective chart review was performed on adult patients (n = 2,200) with established MRSA or VRE infection at 5 hospitals in CommonSpirit Health, Texas Division, from March 2019 to October 2020. Data including demographics, infection site, documented symptoms, and antibiotic use were stratified based on patient location (floor vs ICU). Rates of hospital-acquired MRSA and VRE infection before and after the discontinuation of isolation (implemented in March 2020) were compared. Incidence density rate was used to assess differences in the rate of MRSA and VRE infections between pre- and postintervention groups. Results: The rate of hospital-acquired (HA) MRSA infection per 10,000 patient days before the intervention (March 19–February 20) was 12.19, compared to 10.64 after the intervention (March 20–July 20) (P = .038). The rates of HA MRSA bacteremia were 1.13 and 0.93 for the pre- and postintervention groups, respectively (P = .074). The rates of HA VRE per 10,000 patient days were 3.53 and 4.44 for the pre- and postintervention groups, respectively (P = .274). The hand hygiene rates were 0.93 before the intervention and 0.97 after the intervention (P = .028). Conclusions: Discontinuing isolation from MRSA and VRE in the hospital setting did not lead to a statistically significant increase in hospital-acquired MRSA or VRE infections. In fact, rates of hospital-acquired MRSA decreased, likely secondary to improvements in hand hygiene during this period. These results support the implementation of policies for discontinuing contact isolation for hospitalized patients with documented MRSA or VRE infection, particularly during shortages of gowns.

Funding: No

Disclosures: None

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Table 1.

Background: In the spring of 2020, we identified 3 patients with organ-space surgical site infections (SSIs) secondary to Mycobacterium abscessus (Table 1). All 3 patients underwent cardiac surgery in the same operating room (OR) during which the CardioQuip Modular Cooler-Heaters (MCHs) were used. We describe key aspects of our cluster investigation, which ultimately led to release of a national safety alert by the Food and Drug Administration (FDA). Methods: For environmental cultures, we obtained samples from 9 MCHs in circulation; 2 scrub sink samples; ice from the OR ice machine; water samples from sinks in the cardiovascular critical care unit, and water samples from floors above the cardiac ORs. All samples were sent for molecular genotyping. For pathway studies, an external environmental engineering team was consulted who conducted smoke pathway tests in 3 different ORs. The team also conducted a particle generator experiment, simulating the set-up of a cardiac bypass surgery case. To assess disinfection practices, we reviewed the manufacturer instructions for use (IFU) protocol of the MCHs and audited our own policies and procedures to ensure compliance. Results: For environmental cultures, molecular typing from 5 of 9 MCHs and all 3 patient SSI isolates returned positive for the identical hybrid species M. abscessus bolleti. All other samples with mycobacterial growth returned with different species. For pathway studies, the particle-generator experiment demonstrated particle movement from the MCH to the sterile field with facilities-guidelines–compliant OR ventilation and despite MCH manufacturing design. For disinfection practices, despite compliance with the stated IFU, and in consultation with experts, we implemented disinfection of associated Quick-connect devices (otherwise not stated in the IFU), and we also initiated a precleaning step prior to disinfection. Conclusions: Our investigation concluded that 3 patients developed SSIs with Mycobacterium abscessus that was aerosolized from the CardioQuip MCH. This finding led to the national FDA safety report alerting providers to risks associated with the device and the need for continued vigilance around disinfection. In addition, we implemented other control measures including placement of MCHs outside all ORs; creation of a separate MCH fleet for non-OR use; and use of modified disinfection protocols. To date, no additional cases have been identified.

Funding: No

Disclosures: None

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Background:Pseudomonas aeruginosa outbreaks can originate from various sources and can cause severe complications in posttransplant patients. Antibiotic prophylaxis can decrease posttransplant infections; however, consideration must be given to P. aeruginosa coverage as we outline an outbreak among the stem-cell transplant (SCT) population. Methods: A multidisciplinary outbreak investigation was conducted to evaluate sources of contamination and changes in clinical processes. Positive blood cultures from SCT patients and environmental isolates were analyzed using whole-genome sequencing (WGS). Incidence density rates for P. aeruginosa blood cultures from January 2019 through October 2020 were calculated per 10,000 patient days and stratified by unit, specimen, and transplant type. Statistical analysis was calculated with significance at p < 0.05. Results: A cluster of 8 SCT patients was identified between May and September 2020. Moreover, 10 environmental samples were positive for P. aeruginosa including drains, water sources prior to the point-of-use (POU) filter and blood-bank thaw machines. Phylogenetic analysis revealed 1 cluster of 2 patients who shared the same room, 5 patients with unique P. aeruginosa isolates, and 2 separate clusters of environmental isolates with relatedness only to each other. Review of clinical processes showed a change from fluoroquinolone prophylaxis to cephalosporin in the spring of 2020. Also, 5 P. aeruginosa bacteremia infections occurred prior to June (11.78 cases per 10,000 patient days). During the period of cephalosporin use, 8 infections were identified (58.27 cases per 10,000 patient days) (P = .006). Following the restart of fluoroquinolone, zero infections have occurred to date, as of January 28, 2021. Conclusions: Discontinuation of fluoroquinolone prophylaxis was associated with P. aeruginosa bacteremia infections in SCT patients. Use of fluoroquinolone prophylaxis in SCT patients is protective from P. aeruginosa bacteremia infections. There have been no further infections in the following 3 months after the change back to the use of fluoroquinolone. Additionally, WGS showed that most patient isolates did not have a common source, suggesting that P. aeruginosa gastrointestinal colonization may play a role in seeding these bacteremia infections.

Funding: No

Disclosures: None

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Developing and improving an antimicrobial stewardship program successfully requires evaluation of numerous factors. As technology progresses and our understanding of antimicrobial resistance grows, careful consideration should be taken to ensure that a program meets the needs of the institution and is achievable given the available resources. In this review, we explore fundamental initiatives and strategies for both new and established antimicrobial stewardship programs, including the specific areas to target and key elements required for sustainable implementation.

Background: Contaminated healthcare facility plumbing is increasingly recognized as a source of carbapenemase-producing organisms (CPOs). In August 2019, the Tennessee State Public Health Laboratory identified Tennessee’s twelfth VIM-producing carbapenem-resistant Pseudomonas aeruginosa (VIM-CRPA), from a patient in a long-term acute-care hospital. To determine a potential reservoir, the Tennessee Department of Health (TDH) reviewed healthcare exposures for all cases. Four cases (33%), including the most recent case and earliest from March 2018, had a history of admission to intensive care unit (ICU) room X at acute-care hospital A (ACH A), but the specimens were collected at other facilities. The Public Health Laboratory collaborated with ACH A to assess exposures, perform environmental sampling, and implement control measures. Methods: TDH conducted in-person infection prevention assessments with ACH A, including a review of the water management program. Initial recommendations included placing all patients admitted to room X on contact precautions, screening for CPO on room discharge, daily sink basin and counter cleaning, and other sink hygiene measures. TDH collected environmental and water samples from 5 ICU sinks (ie, the handwashing and bathroom sinks in room X and neighboring room Y [control] and 1 hallway sink) and assessed the presence of VIM-CRPA. Moreover, 5 patients and 4 environmental VIM-CRPA underwent whole-genome sequencing (WGS). Results: From February to June 2020, of 21 patients admitted to room X, 9 (43%) underwent discharge screening and 4 (44%) were colonized with VIM-CRPA. Average room X length of stay was longer for colonized patients (11.3 vs 4.8 days). Drain swabs from room X’s bathroom and handwashing sinks grew VIM-CRPA; VIM-CRPA was not detected in tap water or other swab samples. VIM-CRPA from the environment and patients were sequence type 253 and varied by 0–13 single-nucleotide variants. ACH A replaced room X’s sinks and external plumbing in July. Discharge screening and contact precautions for all patients were discontinued in November, 5 months following the last case and 12 consecutive negative patient discharge screens. Improved sink hygiene and mechanism testing for CRPA from clinical cultures continued, with no new cases identified. Conclusions: An ICU room with a persistently contaminated sink drain was a persistent reservoir of VIM-CRPA. The room X attack rate was high, with VIM-CRPA acquisition occurring in >40% of patients screened. The use of contaminated plumbing fixtures in ACH have the potential to facilitate transmission to patients but may be challenging to identify and remediate. All healthcare facilities should follow sink hygiene best practices.

Funding: No

Disclosures: None

Human parainfluenza (HPIV) is a common cause for upper respiratory tract illnesses (URTI) and lower respiratory tract illnesses (LRTI) in infants and young children. Here, we describe successful control of an HPIV type 3 (HPIV3) outbreak in a neonatal intensive care unit (NICU). NICU babies with new-onset clinical signs or symptoms of RTI and positive HPIV-3 nasopharyngeal specimen by respiratory pathogen panel (RPP) test on hospital day 14 or later were diagnosed with hospital-onset (HO) HPIV-3 infection. After 3 NICU babies were diagnosed with HO HPIV-3, an outbreak investigation was initiated on May 3, 2019, and continued for 2 incubation periods since the last identified case. Enhanced infection prevention measures were immediately implemented. All positive cases were placed in a cohort in a single pod of the NICU and were placed on contact precautions with droplet isolation precautions. Dedicated staffing and equipment were assigned. Environmental cleaning and disinfection with hospital-approved disinfectant wipes was performed daily. Visitors were restricted in the NICU. All employees entering the NICU underwent daily symptom screening for respiratory tract illness. All NICU babies were screened daily for respiratory tract illness with prompt isolation and RPP testing on positive screen. To determine the source of the HPIV3 outbreak, all HPIV3-positive specimens from the NICU and available temporally associated community-onset (CO) controls collected from non-NICU units were sent to the Centers for Disease Control and Prevention (CDC) for whole-genome sequencing (WGS) analysis. The first and last cases of HPIV-3 were diagnosed on May 1 and May 5, 2019, respectively. In total, 7 HO HPIV3 cases were reported: 1 in newborn nursery (NBN) and 6 in NICU. The case from the NBN was determined to be unrelated to the outbreak and the source was linked to a sick visitor. Of the 6 NICU babies, 5 had an LRTI and 1 had a URTI. Average time from admission to diagnosis was 71 days (range, 24–112). None had severe illnesses requiring intubation, and all had full recovery. No CO HPIV3 cases were reported from the NICU during the investigation. A maximum likelihood phylogenetic tree of HPIV3 WGS (Figure 1) showed that sequences from the 6 HO cases clustered together separately from the 3 CO controls, suggesting a single source of transmission, and 3 CO cases were not related to the HO cases or source of the outbreak. Early diagnosis and isolation of respiratory tract viral infections is important to prevent an outbreak. Successful control of outbreak in NICU requires prompt implementation of infection prevention measures with focus on symptom screening, cohorting, and disinfection practices.

Funding: No

Disclosures: None

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Challenges for infection prevention and antimicrobial stewardship programs have arisen with the fourth wave of the coronavirus disease 2019 (COVID-19) pandemic, fueled by the delta variant. These challenges include breakthrough infections in vaccinated individuals, decisions to re-escalate infection prevention measures, critical medication shortages, and provider burnout. Various strategies are needed to meet these challenges.

Group Name: Bright STAR Authorship Group

Background: Blood cultures are fundamental in the diagnosis and treatment of sepsis. Culture practices vary widely, and overuse can lead to false-positive results and unnecessary antibiotics. Our objective was to describe the implementation of a multisite quality improvement collaborative to reduce unnecessary blood cultures in pediatric intensive care unit (PICU) patients, and its 18-month impact on blood culture rates and safety metrics. Methods: In 2018, 14 PICUs joined the Blood Culture Improvement Guidelines and Diagnostic Stewardship for Antibiotic Reduction in Critically Ill Children (Bright STAR) Collaborative, designed to understand and improve blood culture practices in critically ill children. Guided by a centralized multidisciplinary study team, sites first reviewed existing evidence for safe reduction of unnecessary blood cultures and assessed local practices and barriers to change. Subsequently, local champions developed and implemented clinical decision-support tools informed by local patient needs to guide new blood-culture practices. The coordinating study team facilitated regular evaluations and discussions of project progress through monthly phone calls, site visits if requested by sites or the study team, and collaborative-wide teleconferences. The study team collected monthly blood culture rates and monitored for possible delays in obtaining blood cultures using a standardized review process as a safety balancing metric. We compared 24 months of baseline data to 18 months of postimplementation using a Poisson regression model accounting for the site-specific patient days and correlation of culture use within a site over time. Results: Across the 14 sites, before implementation, 41,768 blood cultures were collected over 259,701 PICU patient days. The mean preimplementation site-specific blood culture rate was 15.7 cultures per 100 patient days (rate range, 9.6–48.2 cultures per 100 patient days). After implementation, 22,397 blood cultures were collected over 208,171 PICU patient days. The mean postimplementation rate was 10.4 cultures per 100 patient days (rate range, 4.7–28.3 cultures per 100 patient days), which was 33.6% lower than the preimplementation (relative rate 0.66; 95% CI, 0.65–0.68 p <0.01). In 18 months post-implementation, sites reviewed 793 positive blood cultures, and identified only one suspected delay in culture collection possibly attributable to the site’s blood culture reduction program. Conclusions: Multidisciplinary quality improvement teams safely facilitated a 33.6% average reduction in blood culture use in critically ill children at 14 hospitals. Future collaborative work will determine the impact of blood culture diagnostic stewardship on antibiotic use and other important patient safety outcomes.

Funding: No

Disclosures: None

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Background:Staphylococcus aureus is the second-leading cause of late-onset sepsis among infants in US neonatal intensive care units (NICUs). Management of S. aureus bacteremia and meningitis in infants varies widely due to the lack of standardized guidelines. We examined the association between initial antibiotic duration and recurrent S. aureus infection or death among NICU infants with S. aureus bacteremia and/or meningitis. Methods: We conducted a retrospective cohort study of infants in Pediatrix Medical Group NICUs from 1997 to 2018 with first episode of S. aureus bacteremia and/or meningitis, identified as having at least 1 blood or cerebrospinal fluid (CSF) culture growing only S. aureus at any point during their NICU stay. Excluded infants were those not started on antistaphylococcal therapy within 2 days of positive culture, those with had endocarditis or osteomyelitis, or those who died or were discharged during or up to 1 day after antibiotic cessation. Antibiotic cessation was defined as last day of antibiotic given if followed by at least 3 days without antibiotics. Multivariable logistic regression was used to analyze the association between antibiotic duration categorized as <14 or ≥14 days) and recurrent SA infection (within 12 weeks of antibiotic cessation, prior to hospital discharge), or death (within 7 days of antibiotic cessation and at discharge). Results: Of 4,086 infants included, 3,991 (98%) had S. aureus bacteremia only and 95 (2%) had meningitis ± bacteremia. Of those with bacteremia only, 2,017 (50.5%), and 17 (18%) of those with meningitis received <14 days antibiotics (Figure 1). Longer antibiotic duration was associated with lower gestational age, methicillin-resistance, severe illness and bacteremia duration of ≥4 days (Table 1). There was a significant association between <14 days antibiotics and recurrent infection (p = 0.04) and 7-day mortality (p = 0.02) in the meningitis cohort. Infants with SA bacteremia who received ≥14 days antibiotics had reduced odds of recurrent SA infection (OR 0.24, 95% CI 0.18-0.32) and death (OR 0.33, 95% CI 0.25-0.44), adjusting for post-natal age, gestational age, sex, methicillin-resistance, severe illness and duration of bacteremia (Table 2). Conclusions: In the largest study thus far examining antibiotic duration among hospitalized infants with S. aureus bacteremia and/or meningitis, ≥14 days antibiotics was associated with decreased odds of recurrent infection or death. Further studies are needed to define the optimal treatment duration and identify clinical factors distinguishing infants able to safely receive a shorter antibiotic duration.

Funding: No

Disclosures: None

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Table 2.

Social media platforms allow users to share news, ideas, thoughts, and opinions on a global scale. Data processing methods allow researchers to automate the collection and interpretation of social media posts for efficient and valuable disease surveillance. Data derived from social media and internet search trends have been used successfully for monitoring and forecasting disease outbreaks such as Zika, Dengue, MERS, and Ebola viruses. More recently, data derived from social media have been used to monitor and model disease incidence during the coronavirus disease 2019 (COVID-19) pandemic. We discuss the use of social media for disease surveillance.

Background: Identification of hospitalized patients with enteric multidrug-resistant organism (MDRO) carriage, combined with implementation of targeted infection control interventions, may help reduce MDRO transmission. However, the optimal surveillance approach has not been defined. We sought to determine whether daily serial rectal surveillance for MDROs detects more incident cases (acquisition) of MDRO colonization in medical intensive care unit (MICU) patients than admission and discharge surveillance alone. Methods: Prospective longitudinal observational single-center study from January 11, 2017, to January 11, 2018. Inclusion criteria were ≥3 consecutive MICU days and ≥2 rectal or stool swabs per MICU admission. Daily rectal or stool swabs were collected from patients and cultured for MDROs, including vancomycin-resistant Enterococcus (VRE), carbapenem-resistant Enterobacterales (CRE), third-generation cephalosporin-resistant Enterobacterales (3GCR), and extended-spectrum β-lactamase–producing Enterobacterales (ESBL-E) (as a subset of 3GCR). MDRO detection at any time during the MICU stay was used to calculate prevalent colonization. Incident colonization (acquisition) was defined as new detection of an MDRO after at least 1 prior negative swab. We then determined the proportion of prevalent and incident cases detected by daily testing that were also detected when only first swabs (admission) and last swabs (discharge) were tested. Data were analyzed using SAS version 9.4 software. Results: In total, 939 MICU stays of 842 patients were analyzed. Patient characteristics were median age 64 years (interquartile range [IQR], 51–74), median MICU length of stay 5 days (IQR, 3–8), median number of samples per admission 3 (IQR, 2–5), and median Charlson index 4 (IQR, 2–7). Prevalent colonization with any MDRO was detected by daily swabbing in 401 stays (42.7%). Compared to daily serial swabbing, an admission- and discharge-only approach detected ≥86% of MDRO cases (ie, overall prevalent MDRO colonization). Detection of incident MDRO colonization by an admission- or discharge-only approach would have detected fewer cases than daily swabbing (Figure 1); ≥34% of total MDRO acquisitions would have been missed. Conclusions: Testing patients upon admission and discharge to an MICU may fail to detect MDRO acquisition in more than one-third of patients, thereby reducing the effectiveness of MDRO control programs that are targeted against known MDRO carriers. The poor performance of a single discharge swab may be due to intermittent or low-level MDRO shedding, inadequate sampling, or transient MDRO colonization. Additional research is needed to determine the optimal surveillance approach of enteric MDRO carriage.

Funding: No

Disclosures: None

Figure 1.