Epidemiology of carbapenem-resistant organisms (CRO) has focused on transmission in acute care hospital or long-term care facility (LTCF) settings. Few investigations have examined community-associated (CA)-CRO, with no consensus about common exposures. To explore possible exposures, the New York City (NYC) Department of Health and Mental Hygiene investigated suspected CA-CRO cases through routine surveillance among NYC residents with specimens collected during December 2020-May 2023. CA-CRO cases were defined as urine or skin specimens with bacterial cultures exhibiting carbapenem resistance, among individuals aged ≤70 years with no international travel, hospitalization, or LTCF stays within 12 months before specimen collection. Inclusion was determined by reviewing data from health information exchanges, when available electronic medical records, and telephone screening for those not excluded through record review. We identified 426 suspected cases for review, those not meeting the case definition were excluded; 44 individuals were not reached for screening. A preliminary questionnaire was fielded with 12 individuals and then refined to capture additional potential exposures. Analyses were completed with 23 individuals interviewed with the refined questionnaire. Of the 23, 70% were female; 39% were Hispanic, 17% Black, and 17% White; their median age was 60 years (range: 26-70 years). Further, 83% reported an outpatient appointment, 48% reported an outpatient procedure/surgery, and 9% reported having a hospitalized household member, all within 12 months before specimen collection; 26% had a urinary catheter or indwelling device within 2 days of specimen collection. Additionally, 30% reported taking antibiotics within 3 months of specimen collection, 52% denied taking antibiotics, 9% were unsure about antibiotic use, and 9% did not answer the question. Whole genome sequencing (WGS) was performed on 14 available isolates from CA-CRO cases by the NYC Public Health Laboratory or Wadsworth Center (WC), of which only 7 could be compared with isolates previously sequenced at WC (2017-2023). Six isolates were separated by >50 mutation events, suggesting no close genomic relationship. One isolate from 2021 was 11 mutation events from a 2018 isolate from the same individual, consistent with the expected evolutionary rate. While infrequent, CA-CRO cases occur in NYC. Outpatient healthcare, antibiotic use, and urinary catheters or indwelling devices were common self-reported exposures. Analyses were limited by screening non-response. Increased specimen availability for WGS could enhance investigation of CA-CRO exposure patterns. Health information exchange data were often incomplete and future surveillance could benefit from healthcare and public health partnerships and better documentation for more complete electronic medical histories.

Background: Methicillin-resistant Staphylococcus aureus (MRSA) is one of the most common causes of procedure-related, skin, and soft-tissue infections. Hospitalized patients who are colonized with MRSA are at a higher risk of developing invasive infections after discharge. Chlorhexidine, an antiseptic/disinfectant, has been used to reduce carriage and prevent infections in these patients. Studies have shown chlorhexidine resistance among MRSA strains. Chlorhexidine resistance is associated with qac genes, which encode multidrug efflux pumps that increase bacterial tolerance to disinfectant agents. The global distribution and prevalence of qacA and qacB genes are highly variable. One study reported that qacA and qacB genes could be found in 0.9% - 83.3% of clinical MRSA isolates worldwide. The goal of this study was to determine the prevalence of chlorhexidine resistance and identify the resistance-associated genes from our MRSA samples using whole genome sequencing (WGS). Methods: 474 MRSA samples were obtained from hospitals in Detroit, MI (287) and Cleveland, OH (187). Whole genome sequencing was performed using the NextSeq (Illumina Inc., CA) platform. The sequencing data was analyzed using ResFinder 4.1, a publicly available database that can be used to identify acquired genes and chromosomal mutations mediating antimicrobial resistance. The output was organized into a data sheet to visualize the presence of the genes of interest. Results: The qacA gene was present in only one MRSA sample from the Cleveland area hospital. In the samples from Detroit, 14 out of 287 showed disinfectant resistance genes. The qacA, qacB, and qacD were present in 1, 6, and 7 samples, respectively. The prevalence of any qac gene in the Cleveland area samples was 0.5%. Meanwhile, the prevalence of any qac gene in Detroit area samples was 4.9%. Among the 7 samples that have qacD gene, 6 samples have more than one copy of qacD. Conclusions: The prevalence of the “qac” gene varied widely based on the origin of the samples. Detroit area samples had more qac genes prevalence than Cleveland area samples. Chlorhexidine is a widely used antiseptic/disinfectant, and it plays a vital role in reducing carriage and preventing infection among hospitalized patients colonized with MRSA. Monitoring and addressing MRSA-reduced susceptibility to chlorhexidine is imperative for maintaining the effectiveness of infection control practices such as decolonization.

This study aimed to evaluate the impact of the COVID-19 pandemic on antimicrobial consumption (AMC) in Belgian hospitals from 2017 to 2021, using data from the European Surveillance of Antimicrobial Consumption Network (ESAC-Net) and the Belgian Hospitals Surveillance of Antimicrobial Consumption (BeH-SAC). Antimicrobial volume was quantified in Defined Daily Doses (DDDs), and AMC was expressed in DDDs/1000 inhabitants/day (DIDs), DDDs/1000 patient days and DDDs/1000 admissions. Linear regressions were employed to analyze 5-year trends for the ATC J01 group, at the ATC-3 level and for broad-spectrum antimicrobials. Broad-spectrum antibiotics included combinations of penicillins, incl. beta-lactamase inhibitors (J01CR), second-generation cephalosporins (J01DC), third-generation cephalosporins (J01DD), macrolides, lincosamides and streptogramins (J01F, excluding erythromycin J01FA01), and fluoroquinolones (J01MA). The compound annual growth rate (CAGR) calculated for the years preceding the pandemic was used to forecast 2020 and 2021 AMC, enabling a comparison with the actual use. Hospital AMC measured as DIDs decreased by 12% from 2019 to 2020. In contrast, when expressed as DDDs/1000 patient days and DDDs/1000 admissions, a 5% and 7% increase was observed, respectively. Antibacterials for systemic use (J01) showed a significant decrease over the 5 years only when expressed in DIDs. Notable trends included a negative trend for quinolone antibacterials (J01M) when expressed in the three incidence units, as for amphenicols (J01B) when using hospital denominators only. Positive trends were observed for sulfonamides and trimethoprim (J01E) using hospital denominators and for other beta-lactam antibacterials (J01D) with the ‘patient days’ denominator. While the consumption of all J01 antimicrobial subclasses deviated negatively from predicted use both in 2020 and 2021 when expressed in DIDs, positive deviations were recorded using hospital denominators, except for macrolides (J01F). The use of broad-spectrum antimicrobials showed a notable decrease between 2017 and 2021 when expressed in DIDs. However, when using hospital denominators, the observed use of broad-spectrum antimicrobials exceeded the forecasted values in 2020, to regress below the forecasted levels in 2021 (Figure 1). Contrary to results obtained using the widely applied country’s population as the denominator, a notable surge in AMC, particularly for broad-spectrum antimicrobials, was observed in 2020 when using hospital-specific denominators. This increase coincided with the onset of the COVID-19 crisis. These findings emphasize the need for a national hospital surveillance system that uses denominators that accurately represent the specific population being monitored. Implementing robust hospital-specific surveillance mechanisms would improve the precision of evaluations and facilitate targeted interventions aimed at optimizing antimicrobial utilization.

Background: Alberta Health Services (AHS) measures hand hygiene compliance through direct observations performed by trained site-based reviewers (SBRs) and facilitated by the Infection Prevention and Control (IPC) program. Within AHS there are >100 acute care facilities, ranging in bed size from four beds to more than 1,000, with catchment populations ranging from one million. A time-in-motion study using trained AHS IPC staff was proposed to validate the completeness and accuracy of data being collected by the SBRs. Methods: The AHS IPC staff performed direct observations at pre-selected facilities across all five zones and four different unit types (emergency, medical, surgical, and intensive care) for four 30-minute periods during weekdays between June and September 2023. An iPad app was used to capture results from all four moments of hand hygiene. The reviewer indicated the day and time of the review and captured as many representative hand hygiene moments and healthcare providers as possible. The distributions of the four moments of hand hygiene, healthcare provider group and overall compliance were compared at the unit type and facility level (tertiary, large urban, regional, pediatric, and small sites) between this time-in-motion study and SBR data collected June-September 2023. Results: The study collected 175 reviews and 4,683 observations from 14 facilities and 48 units. Between June and September 2023, SBRs collected 2,625 reviews and 61,506 observations from these same facility and unit types. Across all facility and unit types, the distribution of the four moments was similar between the study and SBRs. Similar proportions of healthcare providers were also observed. However, the overall hand hygiene compliance collected in the study was approximately 10% lower across all unit types as compared to that collected by the SBRs (study: 63%-84%; SBRs: 75%-92%). Conclusions: In public health surveillance, completeness and accuracy are two characteristics of high-quality data. A time-in-motion study identified that the hand hygiene observations collected by SBRs were complete, as the range of healthcare providers observed, and the distribution of their moments, mirrored that collected in the study. However, the SBRs reported higher compliance than the study participants and the true hand hygiene compliance is likely lower than what is currently being reported. Since this difference was seen consistently across all unit and facility types, trending data over time should still identify areas in need of improvement and may help to suggest causes of the over-reporting.

Background: Clostridioides difficile infections (CDI) are a crucial public health threat becoming a worldwide problem. In 2017, there were 223,900 incident cases and 12,800 deaths in the United States. Underlying conditions, such as diabetes mellitus (DM), put individuals at a greater risk for developing an infection. Whereas CDI was once believed to be mostly healthcare-associated, increasing evidence points to transmission in community settings (CA). We investigated characteristics of CA CDI and associations between pre-existing conditions and CA incident CDI cases using data from Tennessee’s CDI surveillance program, an active population- and laboratory-based surveillance system conducted through CDC’s Emerging Infections Program. CA incident CDI case data were downloaded from the Incident Case Management System from 2017 to 2021. Count and percentages were determined for each underlying condition, number of underlying conditions, and biological sex. Chi-square analyses determined associations between underlying conditions and sex. Statistical analyses were conducted using SAS v9.4. 2,326 CA incident CDI cases were identified from the catchment area. The case rates per 100,000 population between 2017 and 2021 were 79.7, 81.9, 73.7, 50.7, and 49.6. A total of 39% of the cases were 65 years or older. Most cases were women (64.8%). The overall prevalence for any underlying condition among CA CDI cases was 67.4%. A total of 29.4% of incident cases had one condition, 18.5% had two conditions, and 19.4% had three or more conditions. The most frequently reported pre-existing conditions was DM (22.9%) and gastrointestinal disease (21.7%). We looked at the prevalence of underlying conditions separated in men and women. Men with CA CDI were more likely to have chronic kidney disease (CKD) (19.1% vs 12.7%), DM (26.0% vs 21.2%), immunocompromised conditions (6.4% vs 3.6%), liver diseases (6.5% vs 2.8%), and plegias (1.0% vs 0.2%) than women with CA CDI. Women with CA CDI were more likely to have chronic lung diseases (17.4% vs 12.6%) and connective tissue diseases (4.9% vs 2.2%) than men with CA CDI. Although the incident CA CDI case rate in Davidson County decreased from 2018 to 2021, it remains a significant threat. In this analysis, underlying conditions in persons with CA CDI were highly prevalent. Men were more likely to have underlying conditions in general, and specifically CKD and DM, than women. Improving understanding of the prevalence of these conditions with CA CDI cases, along with their antibiotic use and community exposures, can help drive prevention strategies to mitigate CA CDI transmission.

Background: The COVID-19 pandemic has placed an enormous strain on the healthcare system, including infection prevention and control. The response to the COVID-19 pandemic required extraordinary resources, which were often diverted from routine infection prevention and control activities and may have contributed to increased rates of HAI in the acute care setting. However, the impact of the COVID-19 pandemic on infection prevention and control departments, including staffing and resources, and on routine infection prevention and control activities is not well-described. The objective of this study was to describe the impact of the COVID-19 pandemic on IPC departments and department response to the pandemic. Methods: Between August and December of 2023, we conducted an electronic survey of all acute care facilities participating in the National Healthcare Safety Network. Survey data were analyzed using descriptive statistics. Results: Over 594 infection control departments participated in the survey, representing 1,400 NHSN facilities (20% response rate based on number of eligible NHSN facilities). Half of the respondents reported that their hospital experienced increases in the following HAI rates during the first two years of the pandemic: central-line associated bloodstream infections (54%), catheter-associated urinary tract infections (46%) and ventilator associated pneumonia (45%). When asked to identify the top three contributors to increased HAI rates in their facility, respondents cited the following factors: staffing shortages (70%), patient acuity (69%), use of travel nurses (48%), increased device utilization (37%), and reduced bedside acuity (31%). Respondents reported that their department utilized the following actions to decrease these HAI rates: increased rounding and monitoring of IPC procedures (81%), reeducation of frontline staff on IPC policies and procedures (77%), environmental care rounds (69%), monitoring of isolation compliance (66%), HAI Task Force/Committee (57%), nurse-driven catheter removal protocols (53%), and insertion prevention protocols (53%). When asked if the department experienced applied pressure or attempts to influence HAI reporting due to the increase in HAI rates in the facility experienced in the wake of the pandemic, 19% of respondents reported increased pressure from management/C-suite and 7% reported increased pressure from providers. Conclusion: The COVID-19 pandemic had a substantial impact on IPC departments in acute care hospitals and had a profound effect on IPC staffing, resources and routine IPC activities. Future work needs to identify best practices and lessons learned from the pandemic to inform future pandemic preparedness.

Background: Multi-drug resistant organisms (MDROs) are a common cause of healthcare-associated infections, particularly central line-associated bloodstream infections (CLABSIs). Prior research has shown that MDROs cause up to 67% of CLABSIs and have up to a 37% increase in 30 day readmission, which is higher than readmission rates for other conditions reported to the Centers for Medicare and Medicaid Services (CMS). The objective of the study was to determine overall 90-day readmission rates, and if there was a difference in readmission rate within 90 days post discharge for patients who had a MDRO as the causative pathogen of their CLABSI compared to patients who did not have an MDRO. Methods: A retrospective analysis of patient data from a nine-hospital system was performed on patients who had a CLABSI and were discharged alive between January 1st, 2018, and December 31st, 2019. Basic descriptive statistics were performed, and the potential differences in readmission rates were examined using Chi-square analyses. Results: The overall readmission rate for all CLABSIs was 46.9%. The chi-square analysis determined there was not a significant difference in readmission rates in patients who had a MDRO CLABSI compared to patients with a non-MDRO CLABSI (59.1% vs. 44.6%, x2= 1.564 , p= 0.211). Conclusion: There was not a significant difference in readmission rates between patients with an MDRO CLABSI compared to a non-MDRO CLABSI. However, the overall readmission rate for this patient population was much higher than seen in previous literature and other publicly reported readmission rates. Additional research is recommended to explore if the increased CLABSI readmission rates seen are a unique finding to this health system.

Background: Extrapulmonary nontuberculous mycobacteria (ENTM) infections are difficult to treat and often require prolonged therapy or surgery. Few population-based studies describe ENTM epidemiology, though well-known healthcare-associated outbreaks have occurred. Using the first year of multi-site ENTM surveillance, we characterized rates and how frequently ENTM infections may be related to healthcare. Methods: CDC’s Emerging Infections Program conducted active, laboratory- and population-based surveillance for ENTM cases in 4 sites (Colorado [5 counties], Minnesota [statewide], New York [1 county], and Oregon [statewide]) in 2021. An incident ENTM case was NTM isolation from a non-pulmonary specimen, excluding stool or rectal swabs, in a resident of the surveillance area without either medical record documentation of prior ENTM infection or isolation of ENTM in the prior 12 months. Demographic, clinical, information on selected healthcare and community exposures, and laboratory data were collected via medical record review. We calculated incidence per 100,000 population using U.S. Census population estimates and performed descriptive analyses. Results: A total of 180 incident ENTM cases were reported in 2021. The crude annual incidence rate was 1.3 per 100,000 persons. Incidence increased with age (from 0.95 per 100,000 among 0–17 year-olds to 2.65 per 100,000 among persons ≥65), ranged from 0.8 among non-Hispanic Asian persons to 1.6 per 100,000 in non-Hispanic Black persons, and was similar among males (1.3 per 100,000) and females (1.4 per 100,000; Figure 1). Mycobacterium avium complex (64 [35.6%]) was the most frequently isolated species group, followed by Mycobacterium chelonae complex (31 [17.2%]). Skin and soft tissue infections were the most frequent infection type (37 [20.6%]); 27 cases (15.0%) were associated with disseminated and/or only bloodstream infection, and 56 cases (31.1%) had no infection type documented. Among 93 cases with localized ENTM infections (i.e., infections that were not disseminated and/or only bloodstream infections), 38.7% had only healthcare-related exposures, 14% had only community-related exposures and 6.5% had both exposure types at the site of infection (Figure 2). Healthcare-related exposures at the infection site included surgery (23.7%), injection/infusion (21.5%), and medical devices (18.3%). The most frequent community-related exposure at the infection site was trauma (17.2%). Only one case was part of a known outbreak, which was healthcare-associated. Conclusions: ENTM infections are relatively rare, but nearly half of patients with localized ENTM infections had prior healthcare-related exposures. This indicates that the burden of ENTM infections related to healthcare may be much larger than what has been suggested from reported outbreaks.

Background: Chlorhexidine gluconate bathing (CHGB) prevents healthcare associated infections (HAIs). CHGB quality is rarely assessed; prior studies identified that concentrations of CHG can be suboptimal, particularly at the neck, and if rinsed after application. In the setting of increased HAI rates on 3 high-risk units, we evaluated CHG skin concentrations, comparing results to bathing documentation and patient reports as part of a quality improvement initiative. Methods: All patients admitted to 3 high-risk units were swabbed for CHG concentration testing at the neck, bilateral upper arms, and groin. Swabs were processed using a semi-quantitative colorimetric CHG assay. A threshold of 0.001875% CHG was used to determine adequacy based on prior studies. Adequacy was assessed by body site, timing of bath, and patient-reported skin care activities using Chi-square tests in SAS 9.4. Per hospital policy, all admitted patients are bathed daily with 2% CHG pre-packed wipes. Patients without a documented CHGB for the duration of the admission were excluded. Results: CHG testing was completed on 63 patients: 23 on medical ICU, 18 surgical ICU, 22 oncology ward, yielding 249 samples. Only ward patients could report the time of last CHGB, which agreed with nursing documentation for 12/21(57%) Adequacy by sample was no different across units: 59/88(67%) Oncology, 68/90(76%) MICU, 56/71(79%) SICU, p=0.2091. Site adequacy was different by site: neck 36/63(57%), left arm 49/62(79%), right arm 50/62(81%), groin 48/62(77%), p=0.0083. Samples taken from the 11 patients with > = 24 hours since last CHGB were more likely to be below threshold concentration: 19/47(40%) versus 47/202(23%) not adequate in the recent treatment grouping. Three patients reported showering soon after the CHGB and 8 patients used moisturizing lotion. The percent of samples below threshold for the showering patients (6/12, 50%) and lotion-users (11/32, 34%) were not significantly different from the non-showering or non-lotion using patient samples (p=0.0588 and 0.2800 respectively). Conclusion: In a facility with longstanding daily CHGB policies in place, 66/249 samples from 63 patients lacked adequate concentrations of CHG for optimal HAI prevention. Even in patients with recent CHGB, 23% of sites tested revealed inadequate levels of CHG, while 60% of those overdue for CHGB kept adequate concentrations. Reliable implementation strategies are required for CHGB so as to ensure maximal infection prevention impact.

Background: Nonsterile ice is frequently used in healthcare settings for a wide array of patient care activities and clinical procedures. However, this ice can harbor pathogenic organisms which can threaten patient safety and cause outbreaks. We sought to characterize recent Centers for Disease Control and Prevention (CDC) consultations involving ice leading to healthcare-associated infections (HAIs). Methods: We reviewed internal CDC records from the Division of Healthcare Quality Promotion (DHQP) to identify investigations of outbreaks and potential outbreaks involving the use of ice in healthcare facilities. We searched records from January 1, 2016, through November 30, 2023, for keywords related to ice. We excluded consultations in which ice was not thought to be a potential transmission pathway as well as those in which only sterile ice products (e.g., saline slush) were investigated. Results: We identified 45 consultations for ice-related investigations, involving a total of 533 patients. Nontuberculous mycobacteria were the most frequently implicated organisms, appearing in 40% (n=18) of investigations. Eighty-four percent (n=38) of investigations occurred in acute care hospitals. The most frequently implicated hospital settings were intensive care units (13%, n=6), operating rooms (13%, n=6), and bronchoscopy suites (13%, n=6). We identified a variety of plausible exposure pathways, including direct ingestion of ice by patients, use of ice during the bronchoscopy procedure, use of nonsterile ice in heater-cooler devices during cardiothoracic surgery, and the use of ice to chill saline for respiratory care. Environmental sampling directly of ice machines was performed in 62% of investigations (n=28) and nonsterile ice from these machines was sampled in 9% of investigations (n=4). Among those investigations in which ice machines were sampled, the organism implicated in the outbreak was isolated in 54% of investigations (n=15). Among those investigations in which ice itself was sampled, the organism implicated in the outbreak was isolated in 75% of investigations (n=3). These organisms included Mycobacterium mucogenicum, Burkholderia multivorans, and Acanthamoeba spp. Conclusions: The use of nonsterile ice during clinical care is a potential source of pathogens that cause patient infections and HAI outbreaks. Healthcare personnel should be aware of the risk posed by nonsterile ice and consider avoiding its use, especially when caring for patients who are critically ill or immunocompromised. Healthcare facilities should ensure regular cleaning and disinfection of ice machines to decrease their microbial burden. When HAI outbreaks involving water-associated organisms are identified, nonsterile ice should be considered as a potential mode of transmission.

Background: Appropriate antibiotic use has been described as one of the key strategies in tackling antibiotic resistance. Although the majority of antimicrobial therapy is completed following discharge, there lacks clear guidance in addressing antibiotic stewardship in the outpatient setting. Particularly, broader coverage as well as longer durations of therapy are often encountered following hospitalization. In our study we examine the various antibiotic prescribing practices on hospital discharge for management of urinary tract infections (UTI). Methods: We conducted a single-center, retrospective observational chart review of patients discharged from St. Francis Hospital and Medical Center in Hartford between May and July 2022. Medical records were reviewed for patients who were prescribed antibiotic therapy for management of UTI and met inclusion criteria. Variables of interest included type of UTI treated, antibiotic used, duration of antibiotics during and following hospitalization, fluoroquinolone use, as well reported adverse events. Total duration of therapy was defined as days on susceptible antimicrobials with appropriate source control. Results: A total of 84 patients met inclusion criteria. 44 received treatment for simple UTI (sUTI) and 40 for complicated UTI (cUTI). Figure 1 shows the various organisms identified on culture. The most common antimicrobials prescribed on discharge were cefpodoxime and ciprofloxacin [figure 2]. Quinolones were prescribed in 11.4% of sUTIs and 39.1% of cUTIs on hospital discharge. Of those, only one patient had no alternative to quinolone use due to drug allergies. The mean duration of therapy for treatment of sUTI was 6.4 days total (SD 2.40) with 3.9 days outpatient (SD 1.78). The mean duration of therapy for treatment of cUTI was 10.9 days total (SD 3.62) with 6.7 days outpatient (SD 2.99). Comparison of mean durations is shown in figure 3. In 49% of all cases (including both sUTI and cUTI) patients received greater than 7 days of antimicrobial therapy. Conclusion: There is increased evidence favoring shorter courses of antimicrobial therapy for management of both simple and complicated UTIs. A 7-day course has been shown as effective duration of therapy for cUTI with appropriate source control, regardless of presence of bacteremia. Results from our single center-study show both sUTI and cUTI are subject to unnecessarily prolonged durations of therapy on hospital discharge. In addition we noted a significant use of fluoroquinolones in cUTI treatment. We believe stewardship interventions at time of discharge may particularly benefit shorter courses of therapy for cUTI as well as reduced quinolone use.

Background: Quality improvement (QI) efforts within Infection prevention and control (IP&C) programs to reduce risk of device-related infections in the acute care setting are well described. However, less focus has been placed on continued prevention in the homecare setting. This QI project illustrates the benefits of IP&C involvement in reducing tracheitis in pediatric homecare patients. Methods: The homecare multidisciplinary IP&C team implemented a series of QI initiatives aimed at reducing incidence of tracheitis beginning in 2016. Initial interventions included increasing oral care frequency to every four hours, inpatient training for new tracheostomy patients and families before discharge, and an optional inpatient simulation training resource to provide hands-on practice. Enhanced educational interventions included caregiver learning modules and competencies completed with their primary nurse in the home every ninety days and following a tracheitis infection. Practice changes and education efforts were further sustained with the creation and distribution of laminated tracheostomy care teaching sheets to patient homes. Quarterly tracheitis infection rates were tracked using a U-chart. Organism distribution in tracheitis cases were compared across the baseline (2015-2018) and post-intervention periods (2019-2023) using the Chi square test. Analyses were performed using Stata Statistical Software: Release 18 (College Station, TX: StataCorp, LLC) with two-tailed alpha level of 0.05. Results: Quarterly tracheitis infection rates from 2015 through 2023 are displayed in the Figure. Notably, the baseline period, established Q1 2015 through Q4 2017, revealed a consistent rate of 1.08 tracheitis infections per 1000 tracheostomy days. During this initial phase, changes in oral care frequency and enhanced educational resources were implemented to decrease rates. Following these interventions, a significant shift was observed in Q1 2019, with the new baseline rate drastically reduced to 0.32 infections per 1000 tracheostomy days. This denotes a remarkable 70% improvement from the prior average infection rate which has been sustained through Q4 2023 with the laminated teaching sheets. The most frequently identified organisms across both time periods are displayed in the Table. Pathogen distribution was similar following QI interventions (p = 0.50). Conclusions: Tracheitis infections were reduced by 70% through implementation of multidisciplinary homecare IP&C QI efforts. IP&C programs are integral to pediatric homecare.

Background: The use of antibiotics and the occurrence of antimicrobial resistance in Bangladesh are very high. Inappropriate use of antibiotics among hospitalized children has contributed to a high rise in antimicrobial resistance in Bangladesh. Data on the rational use of antibiotics in Bangladeshi hospitals are limited. This study documented current antimicrobial usage among children under five in selected tertiary hospitals in Bangladesh. Methods: From August to September 2022, we conducted a point prevalence survey in four tertiary hospitals in Bangladesh. We used the World Health Organization’s Point Prevalence Survey (PPS) methods and guidelines to conduct the study. Study participants were hospitalized under the age of five years children, and we collected information from the pediatric and neonatal wards of each hospital. Antibiotic-suggesting shapes were analyzed according to WHO AWaRe metrics and Anatomical Therapeutic Chemical (ATC) Classification. Results: The assessment included 189 children under the age of five, with the majority (78.8%, 149/189) being under one year children. Approximately three-fourths (75.1%) of children had peripheral vascular catheters following admission. Overall, 86.2% (163/189) of children were given antibiotics after being admitted to the hospital, with infants receiving the most (81.0%, 132/163). The majority of antibiotics were administered by parents (84.7%). Antibiotics from the Watch Group were most commonly prescribed (73.0%, 119/163), followed by a combination of the Watch and Access Groups (23.3%) to treat the children. Ceftriaxone (63.8%), Meropenem (16.0%), and Ceftazidime/Amikacin (8.0%) were the most regularly prescribed antibiotics. Young children (< 1 year) were more likely to get antibiotics (AOR: 3.54, p-value: 0.003) than the other children under the age of five. Conclusion: The data showed that most children received empirical antibiotics during hospitalization, and overuse of broad-spectrum Watch group antibiotics was common practice in hospital settings. Developing and implementing antibiotic use guidelines is critical to limit the inappropriate use of antibiotics for young children

Background: Surgical site infections (SSIs) are associated with increased morbidity, monetary loss and mortality. The physical aspects of the operation room (OR) including airflow, humidity, pressure, and particulate counts are essential part of SSI prevention. Humidity control is vital to avoid static electricity buildup.Temperature control helps prevent hypothermia. Limiting OR traffic and door opening are essential to prevent airflow disturbance and minimze particles in OR environment. We have recently studied electronic monitoring of OR traffic and the traffic was higher than what was expected. Our aim was to evaluate our real-life measurement of these OR parameters as part of SSI prevention bundle. Methods: This is a prospective study focused on the OR physical environmental factors as part of operative SSI prevention bundle. The study was conducted for 4 weeks at an academic medical center. The study was conducted in two different generations of OR for neurosurgical and ophthalmologic procedures. We performed direct observation of OR traffic as well as environmental parameters (temperature, humidity, pressure, and particulate count) for the entire length of the procedure. We used both directly measured data as well as automated data generated by facilities. Results: The study showed that temperature, humidity, and pressure wer tightly controlled in the OR. This observation was consistent between manual data and automatically generated data. The OR traffic was not easily monitored by the current automatic data and was measured by direct observation. The correlations between particulate count and OR traffic was strongest for 0.3μm (0.7370, and weakest for 1.0μm ( 0.087). The 5.0μm particulate size had a moderate positive correlation of 0.344, Additionally, shorter procedures had less particulate matter in the OR environment. Automated data were only available in the new ORs but could not predict traffic without automated door monitors. But the automated data could easily portray the temperature, humidity and pressure minute by minute. Conclusion: OR traffic increases the particle count particularly the small size. Other physical aspects of the OR environment were tightly controlled. The ability to automatically monitor OR parameters could be extremely helpful for assuring patient safety as well as reviewing OR factors in SSI cases.

Background: Approximately half of antibiotics used in nursing home (NHs) are initiated in acute care hospitals prior to NH admission. Optimizing antibiotic prescribing on hospital discharge to these facilities presents an opportunity to improve NH antibiotic use. We aimed to identify intervention targets to optimize antibiotic use on discharge from the hospital to NHs. Methods: This was a multicenter, cross-sectional study across 9 acute care hospitals in Oregon, Wisconsin, and Washington. We selected a 20% random sample of adult (age >18) inpatients prescribed at least one antibiotic on discharge from the hospital to a NH between 2016-2018. We excluded patients discharged from the emergency department or an intensive care unit. Study data were electronically extracted from patients’ electronic health records and supplemented with manual chart review. Antibiotic optimization opportunities were determined by an infectious diseases (ID) physician or ID pharmacist and classified as definitely, possibly, or unlikely. Expert reviewers also recorded the type of optimization opportunity and the rationale for each determination. A gamma lasso algorithm was used to identify patient-level characteristics associated with definite optimization opportunity, which were then included in a logistic regression model. Results: There were 2761 antibiotic prescriptions among 2215 patients. Mean (standard deviation) age was 71.9 (14.3) years and 48.8% were male. Most discharges (83.1%) were prescribed one antibiotic, 15.2% were prescribed two antibiotics, and 1.8% were prescribed three antibiotics. The most frequently prescribed antibiotics were cephalexin (10.4%), vancomycin (9.8%), and amoxicillin clavulanate (8.4%). Among the 2761 antibiotic prescriptions, expert reviewers determined that 18.4% could definitely be optimized, 36.0% could possibly be optimized, and 45.3% unlikely could have been optimized. Among the 508 definite antibiotic optimization opportunities, 25.2% were to subtract the antibiotic, 56.3% were to change the antibiotic, 11.0% were to change the dose, 25.0% were to change the duration, 0.8% were to change the route, and 1.8% were to change the schedule. Patient-level characteristics found to be associated with definite antibiotic optimization opportunity included age over 80 years (odds ratio (OR)=1.44, 95% confidence interval (CI): [1.14, 1.82]), length of stay < 8 days (OR=1.40, 95% CI: [1.09, 1.81]), discharge with multiple antibiotic prescriptions (OR=1.92, 95% CI: [1.39, 2.63]), and discharge with prescription for oral vs intravenous (IV) antibiotics (OR=2.08, 95% CI: [1.49, 2.95]). Conclusion: We identified several patient and antibiotic characteristics which may serve as intervention targets to optimize antibiotic prescribing on discharge from the hospital to nursing homes.

Our interviews of inpatient clinicians (physicians, physician assistants) modeled after the Capability, Opportunity, and Motivation Model of Behavior model revealed opportunity and motivation as important drivers for overdiagnosis and overprescribing for asymptomatic bacteriuria in older adults. Understanding these barriers is an important step toward implementing age-friendly stewardship interventions.

Background: While Streptococcus agalactiae (Group B Streptococcus [GBS]) infections in infants usually result from maternal transmission, healthcare-associated cases, particularly in the neonatal intensive care unit (NICU), can occur. Whole genome sequencing (WGS) can aid in investigating GBS outbreaks among infants in hospital settings. The aim of the study is to describe the investigation of GBS infections in NICU using WGS. Methods: Infection prevention and control (IPAC) at our hospital monitors the occurrence of late-onset GBS disease (LOD) in our 57-bed NICU, which consists of all private rooms. The occurrence of 2 cases of LOD within 2 weeks triggered an investigation, including WGS of the two isolates and isolates causing invasive GBS during the last 6 months in the unit. GBS isolates underwent WGS using Illumina at Canada’s National Microbiology Laboratory. All affected patients underwent chart-review. Outbreak description and investigation: In August 2023, two NICU neonates (patients 2,3) experienced LOD two weeks apart, one with bacteremic meningitis and the other with two bacteremic episodes three weeks apart. While WGS was pending two additional cases of late-onset GBS bacteremia (patients 4,5) occurred. Isolates from Pts 2,3 and 5 were indistinguishable from each other and from an isolate from an infant admitted to the NICU with early onset bacteremia on July 27, 2023 (day 1 of life) (patient 1). Weekly point prevalence for throat and rectal colonization over 3 weeks identified five infants colonized with unrelated strains. An additional long-stay infant (patient 6) developed GBS conjunctivitis due to a strain indistinguishable from (patient 4) by pulse field gel electrophoresis, WGS for the second cluster is pending. IPAC interventions: Lapses in IPAC practices were observed, with no commonalities among cases other than similar geographic location within the unit. We hypothesized transmission was due to horizontal transmission between babies due to these lapses. Basic IPAC measures, including hand hygiene and environmental cleaning, were reinforced; Additional Precautions were not used due to private rooms’ unit structure. No environmental samples were taken due to lack of an obvious environmental point or common source. Point prevalence monitoring persisted until no new cases related to the outbreak strains were further identified in three consecutive weekly point prevalence. Conclusions: Increased awareness of healthcare-associated transmission is crucial in NICU as LOD GBS emerges. WGS plays a key role in identifying transmission. Detecting a multi-strain outbreak can appropriately redirect investigations. Legend: Figure 1: Timeline of stay at NICU and infection timing for patients 1-6