Advancement of antimicrobial stewardship (AS) programs requires partnership with clinicians, quality assurance teams, and laboratorians. Inevitably, AS programs also practice diagnostic stewardship (DS), as stewards are aptly placed to connect key stakeholders and help steer processes toward higher value care for pediatric patients. In this review, we illustrate five moments of collaboration between stakeholders in the interplay between AS and DS in pediatrics. These moments include (1) Observation, (2) Reflection, (3) Exploration, (4) Enactment and (5) Evaluation. We offer a targeted narrative of examples in current literature using common relatable scenarios (ie, endotracheal aspirates, blood cultures, gastrointestinal samples, and urine testing) including impact on financial and environmental waste.

Background: Candida auris, an emerging multidrug-resistant fungus, is often difficult to control in hospital outbreaks. We report the hospital investigation and findings of a transmission of C. auris from patients hospitalized in an adult unit to a pediatric unit, the first in Maryland. Methods: Between June and September 2023, C. auris was recovered from two patients admitted to an adult Neuroscience Intensive Care Unit (ICU) and a patient admitted to a pediatric ICU. Infection control initiated an investigation involving staff interviews, observations and chart reviews. Cases were defined as any patient with clinical or surveillance cultures growing C. auris. Point prevalence surveillance was conducted by collecting nares and composite axilla/groin swabs from patients on the affected units. Environmental cultures collected using moistened E-Swabs (Copan, Murrieta, CA) from shared supplies were plated on CHROMagar Candida (BD, Sparks, MD). C. auris isolates from patients hospitalized at the facility between February 2022 and October 2023 were analyzed by WGS for relatedness. WGS was performed using Illumina NextSeq 300 bp paired-end sequencing (Illumina, San Diego, CA). Single nucleotide polymorphism (SNP) analysis was performed by comparing raw reads to the reference C. auris B8441 genome for subsequent clustering analysis (Ares Genetics, Vienna, Austria). Results: WGS demonstrated isolates from two adults and one pediatric patient were less than three SNPs different, suggesting a shared isolate. One additional pediatric case was identified from surveillance cultures collected from 27 patients. Investigation into possible transmission routes revealed healthcare personnel serving both units, specifically clinical teams and continuous electroencephalography (cEEG) technologists. Additionally, cEEG equipment was used on both adult and pediatric patients and twelve equipment surface swabs and three samples each of measuring tape and gel were collected. C. auris was not isolated, however sensitivity of environmental sampling is unclear and suspicion for possible fomite/environmental transmission persisted. Other possible transmission routes included gaps in hand hygiene, isolation, disinfection of shared equipment, and reuse of single-use items. Interventions included improving and monitoring infection prevention practices, educating multi-disciplinary personnel and heightened environmental cleaning. Conclusion: This case highlights the feasibility of transmission of C. auris between patients admitted to a geographically distant unit. Our investigation revealed multiple possible routes of transmission including direct contact (from healthcare personnel or equipment) or indirect environmental sources. Prevention of hospital-associated C. auris transmission likely necessitates meticulous adherence to hand hygiene, contact precautions, and careful cleaning and disinfection of patient environments and equipment used by all disciplines.

Disclosure: Patricia Simner: Research Contracts: BD Diagnostics, OpGen Inc., Qiagen Sciences Inc, T2 Diagnostics, Accelerate Diagnostics; Research Collaborators:Ares Genetics, CosmosID, IDbyDNA, Illumina; Consulting: OpGen Inc., BD Diagnostics, Shionogi Inc., GeneCapture, Qiagen Sciences Inc, Entasis, Day Zero Diagnostics, Next Gen Diagnostics

Background: Respiratory cultures are commonly obtained from patients with suspicion for ventilator-associated infections (VAIs). In the absence of specimen ordering and collection guidelines, management practices may differ. We characterized current respiratory culture collection practices and perceptions and identified potential barriers to changing practices among a national collaborative of pediatric intensive care units (PICUs). Methods: We conducted an electronic survey of PICU physicians, advanced practice providers (APPs), respiratory therapists (RTs), and nurses at 16 US academic pediatric hospitals across the United States. Positive Likert-scale responses (eg, “agree” and “strongly agree”) were grouped. To account for varying hospital representation, we analyzed the results as the median proportion of participants with that response across the hospitals. Results: After excluding incomplete responses, 568 (44%) of 1,301 invited participants responded (range, 16–107 per site); the median hospital response rate was 60% (range, 17%–83%). Roles included physicians (35%), APPs (10%), RTs (24%), and nurses (31%). Moreover, 44% of the participating units cared for cardiac surgery patients. Across hospitals, specimens are often collected by RTs, followed by nurses, typically via inline endotracheal aspirate for either endotracheal tubes or tracheostomies. Saline lavage is a common practice, but only 4% reported a standardized approach. Examining the likeliness to obtain cultures for different clinical symptoms, the widest variation in responses were for fever and inflammatory markers without respiratory symptoms (median proportion, 68%; IQR, 54%–79%), isolated change in secretion characteristics (67%; IQR, 54%–78%), isolated increased secretions (55%; IQR, 40%–65%), isolated inflammatory markers (49%; IQR, 38%–57%) or isolated fever (49%; IQR, 38%–61%). Overall, 75% (IQR, 70%–86%) of reported respiratory cultures were likely to be obtained as a “pan culture.” Most respondents (median proportion, 69%) felt confident about the indications to obtain cultures, but 60% felt that clinicians had a low threshold, and 84% reported clinical practice variation. Barriers to change included reluctance to change (70%), opinion of consultants (64%), and fear of missing a diagnosis of VAI (62%). Respondents agreed that they would find clinical decision support (CDS) tools helpful (79%). In addition, 83% expected that they would follow CDS, and 82% thought that CDS would help align ICU and/or consulting teams. Conclusions: Among 16 participating hospitals, we detected a lack of standardized respiratory-culture specimen collection and ordering practices. Most respondents agreed that CDS tools would be helpful. Diagnostic stewardship of respiratory cultures using CDS must account for potential reluctance to change and needs to address stakeholder perspectives, including fear of missing infections.

Disclosure: None

We provide an overview of diagnostic stewardship with key concepts that include the diagnostic pathway and the multiple points where interventions can be implemented, strategies for interventions, the importance of multidisciplinary collaboration, and key microbiologic diagnostic tests that should be considered for diagnostic stewardship. The document focuses on microbiologic laboratory testing for adult and pediatric patients and is intended for a target audience of healthcare workers involved in diagnostic stewardship interventions and all workers affected by any step of the diagnostic pathway (ie, ordering, collecting, processing, reporting, and interpreting results of a diagnostic test). This document was developed by the Society for Healthcare Epidemiology of America Diagnostic Stewardship Taskforce.

The epidemiology of community-onset Staphylococcus aureus infections is evolving. We performed a multihospital, retrospective study of pediatric community-onset S. aureus susceptibilities between 2015 and 2020. Oxacillin and clindamycin susceptibility remained lower at 67% and 75%, respectively. Tetracycline and trimethoprim-sulfamethoxazole susceptibility remained high at >90%. Oxacillin susceptibility was highest in invasive infections.

In a large healthcare worker cohort, we quantified the association between behaviors and risk of coronavirus disease 2019 (COVID-19) during different pandemic phases, adjusting for prior infection and vaccination. Individual characteristics, including personal concerns, were associated with these behaviors. Public health messaging should target high-risk populations and behaviors as the pandemic evolves.

Severe acute respiratory coronavirus virus 2 (SARS-CoV-2) transmissions among healthcare workers and hospitalized patients are challenging to confirm. Investigation of infected persons often reveals multiple potential risk factors for viral acquisition. We combined exposure investigation with genomic analysis confirming 2 hospital-based clusters. Prolonged close contact with unmasked, unrecognized infectious, individuals was a common risk.

We analyzed the impact of a 7-day recurring asymptomatic SARS-CoV-2 testing protocol for all patients hospitalized at a large academic center. Overall, 40 new cases were identified, and 1 of 3 occurred after 14 days of hospitalization. Recurring testing can identify unrecognized infections, especially during periods of elevated community transmission.

ABSTRACT IMPACT: Optimizing the use of endotracheal aspirate cultures (EACs) has the potential to improve the care of complex mechanically ventilated children by improving testing practices and avoiding unnecessary antibiotic treatment for false-positive results. OBJECTIVES/GOALS: An electronic survey has previously been employed to characterize the practices and attitudes around blood cultures among critically ill children. The objective of this work was to develop and pilot a new survey as a tool to understand practices and attitudes that could inform quality improvement initiatives to optimize EAC practices. METHODS/STUDY POPULATION: Informed by prior experience of diagnostic stewardship of EAC in other settings and using a similar structure to the blood culture practice survey, we developed an electronic self-administered survey sent to respiratory therapists, advanced practice providers, and physicians at the Johns Hopkins All Children’s pediatric intensive care unit. RESULTS/ANTICIPATED RESULTS: A total of 27 of 87 clinicians (37%) responded to the survey (22 respiratory therapists, 9 attending physicians and 1 advanced practice provider). Responses indicated samples are typically collected by respiratory therapists via in-line (endotracheal) or open suctioning (tracheostomy). Most respondents did not feel EACs could lead to unintended negative consequences (71%), agreed practices vary between people (89%), and felt an algorithm would help align the clinical team (79%). Most respondents agreed some clinicians may be reluctant to change practice (82%) and may not change practice due to concern for missing diagnosis of ventilator-associated pneumonia or tracheitis (78%). Surveillance cultures were not used in this unit and there were no prior EAC diagnostic stewardship efforts. DISCUSSION/SIGNIFICANCE OF FINDINGS: This survey captured practices, perceptions and barriers to changes that will inform the implementation of quality improvement initiatives to optimize EAC use in this unit. Future studies can consider utilizing an electronic survey to describe practice variation, clinician believes and attitudes about EAC testing in ventilated patients.

Background: Measles is a highly contagious virus that reemerged in 2019 with the highest number of reported cases in the United States since 1992. Beginning in March 2019, The Johns Hopkins Hospital (JHH) responded to an influx of patients with concern for measles as a result of outbreaks in Maryland and the surrounding states. We report the JHH Department of Infection Control and Hospital Epidemiology (HEIC) response to this measles outbreak using a multidisciplinary measles incident command system (ICS). Methods: The JHH HEIC and the Johns Hopkins Office of Emergency Management established the HEIC Clinical Incident Command Center and coordinated a multipronged response to the measles outbreak with partners from occupational health services, microbiology, the adult and pediatric emergency departments, marketing and communication and local and state public health departments. The multidisciplinary structure rapidly developed, approved, and disseminated tools to improve the ability of frontline providers to quickly identify, isolate, and determine testing needs for patients suspected to have measles infection and reduce the risk of secondary transmission. The tools included a triage algorithm, visitor signage, staff and patient vaccination guidance and clinics, and standard operating procedures for measles evaluation and testing. The triage algorithms were developed for phone or in-person and assessed measles exposure history, immune status, and symptoms, and provided guidance regarding isolation and the need for testing. The algorithms were distributed to frontline providers in clinics and emergency rooms across the Johns Hopkins Health System. The incident command team also distributed resources to community providers to reduce patient influx to JHH and staged an outdoor measles evaluation and testing site in the event of a case influx that would exceed emergency department resources. Results: From March 2019 through June 2019, 37 patients presented with symptoms or concern for measles. Using the ICS tools and algorithms, JHH rapidly identified, isolated, and tested 11 patients with high suspicion for measles, 4 of whom were confirmed positive. Of the other 26 patients not tested, none developed measles infection. Exposures were minimized, and there were no secondary measles transmissions among patients. Conclusions: Using the ICS and development of tools and resources to prevent measles transmission, including a patient triage algorithm, the JHH team successfully identified, isolated, and evaluated patients with high suspicion for measles while minimizing exposures and secondary transmission. These strategies may be useful to other institutions and locales in the event of an emerging or reemerging infectious disease outbreak.

Funding: None

Disclosures: Aaron Milstone reports consulting for Becton Dickinson.

Background: Hospital-onset bacteremia and fungemia (HOB) may be a preventable hospital-acquired condition and a potential healthcare quality measure. We developed and evaluated a tool to assess the preventability of HOB and compared it to a more traditional consensus panel approach. Methods: A 10-member healthcare epidemiology expert panel independently rated the preventability of 82 hypothetical HOB case scenarios using a 6-point Likert scale (range, 1= “Definitively or Almost Certainly Preventable” to 6= “Definitely or Almost Certainly Not Preventable”). Ratings on the 6-point scale were collapsed into 3 categories: Preventable (1–2), Uncertain (3–4), or Not preventable (5–6). Consensus was defined as concurrence on the same category among ≥70% expert raters. Cases without consensus were deliberated via teleconference, web-based discussion, and a second round of rating. The proportion meeting consensus, overall and by predefined HOB source attribution, was calculated. A structured HOB preventability rating tool was developed to explicitly account for patient intrinsic and extrinsic healthcare-related risks (Fig. 1). Two additional physician reviewers independently applied this tool to adjudicate the same 82 case scenarios. The tool was iteratively revised based on reviewer feedback followed by repeat independent tool-based adjudication. Interrater reliability was evaluated using the Kappa statistic. Proportion of cases where tool-based preventability category matched expert consensus was calculated. Results: After expert panel round 1, consensus criteria were met for 29 cases (35%), which increased to 52 (63%) after round 2. Expert consensus was achieved more frequently for respiratory or surgical site infections than urinary tract and central-line–associated bloodstream infections (Fig. 2a). Most likely to be rated preventable were vascular catheter infections (64%) and contaminants (100%). For tool-based adjudication, following 2 rounds of rating with interim tool revisions, agreement between the 2 reviewers was 84% for cases overall (κ, 0.76; 95% CI, 0.64–0.88]), and 87% for the 52 cases with expert consensus (κ, 0.79; 95% CI, 0.65–0.94). Among cases with expert consensus, tool-based rating matched expert consensus in 40 of 52 (77%) and 39 of 52 (75%) cases for reviewer 1 and reviewer 2, respectively. The proportion of cases rated “uncertain“ was lower among tool-based adjudicated cases with reviewer agreement (15 of 69) than among cases with expert consensus (23 of 52) (Fig. 2b). Conclusions: Healthcare epidemiology experts hold varying perspectives on HOB preventability. Structured tool-based preventability rating had high interreviewer reliability, matched expert consensus in most cases, and rated fewer cases with uncertain preventability compared to expert consensus. This tool is a step toward standardized assessment of preventability in future HOB evaluations.

Funding: None

Disclosures: None