Evidence-based insertion and maintenance bundles are effective in reducing the incidence of central line-associated bloodstream infections (CLABSI) in intensive care unit (ICU) settings. We studied the adoption and compliance of CLABSI prevention bundle programs and CLABSI rates in ICUs in a large network of acute care hospitals across Canada.

Background: The molecular and epidemiological landscape of C. difficile infection (CDI) has evolved markedly in the last decade; however, limited information is available contrasting differences between adult and pediatric populations. We describe a multicenter study evaluating healthcare-associated (HA) and community-associated (CA) adult and pediatric-CDI identified in the Canadian Nosocomial Infection Surveillance Program (CNISP) network from 2015 to 2022. Methods: Hospitalized patients with CDI were identified from up to 84 hospitals between 2015–2022 using standardized case definitions. Cases were confirmed by PCR, cultured, and further characterized using ribotyping and E-test. We used two-tailed tests for significance (p≤0.05). Results: Of 30,817 cases reported, 29,245 were adult cases [HA-CDI (73.2%), CA-CDI (26.8%)] and 1,572 were pediatric cases [HA-CDI (77.7%), CA-CDI (22.3%)]. From 2015 to 2022, HA-CDI rates decreased 19.7% (p=0.007) and 29.4% (p=0.004) in adult and pediatric populations, respectively (Figure 1). CA-CDI rates remained relatively stable in the adult population (p=0.797), while decreasing 60.7% in the pediatric population (p=0.013). Median ages of adult and pediatric patients were 70 (interquartile range (IQR), 58–80) and seven (IQR, 3–13) years, respectively. Thirty-day all-cause mortality was significantly higher among adult vs. Pediatric CDI patients (11.0% vs 1.4%, p < 0.0001). No significant differences in other severe outcomes were found. Ribotyping and susceptibility data were available for 4,620 samples: 3,558 adult (77.0%) and 1,062 pediatric (23.0%). The predominant adult and pediatric ribotypes (RT) were 106 (12.2/16.2%), 027 (11.4/3.2%), and 014 (8.8/8.2%). Overall, RT027 prevalence significantly decreased from 17.9% in 2015 to 3.2% in 2022 (p=0.003), while RT106 increased from 8.5% to 14.4%. Resistance rates among adult and pediatric isolates were similar for all antimicrobials tested except moxifloxacin (16.2% vs. 6.2%, p < 0.0001, respectively). Adult moxifloxacin resistance decreased from 30% to 6.3% from 2015 to 2022 (p=0.006). Adults with moxifloxacin-resistant CDI were older (median: 74 vs. 69 years, p < 0.001) and had higher thirty-day all-cause mortality (13% vs. 9.8%, p=0.041) and recurrence (10% vs. 5.7%, p < 0.001) compared to those with moxifloxacin non-resistant CDI, while these trends were not observed in pediatric patients. Among RT027 strains, moxifloxacin resistance decreased from 91.0% in 2015 to 7.1% in 2022. There was one metronidazole-resistant pediatric sample in 2018 and no resistance to vancomycin or tigecycline in either population. Conclusion: We have found differences in the epidemiological and molecular characteristics of adult and pediatric CDI, with higher thirty-day all-cause mortality among adults. Overall, RT106 has replaced RT027 as the predominant ribotype with a concomitant decrease in fluoroquinolone resistance.

Background: Adult rates of non-COVID-19-related healthcare-associated infection (HAI) initially decreased and subsequently increased during the COVID-19 pandemic. Little is known about pediatric HAI rates during this period. Methods: A retrospective review of HAIs was conducted for patients admitted to the intensive care unit (PICU) at a pediatric tertiary care hospital between January 1, 2019 and November 30, 2023. Patients who spent ≥48 hours in the PICU were included. Surgical site infections were excluded. Data were obtained from infection surveillance reports; each HAI was reviewed for validity and attribution based on National Healthcare Safety Network definitions. HAIs were grouped into 3 time periods: pre-pandemic (January 2019-February 2020), pandemic (March 2020- February 2022), and post-pandemic (March 2022-November 2023). Infection rate ratios were calculated for pre-pandemic and post-pandemic periods. Results: Among 2,959 PICU patients admitted during the study period, there were 60 HAI events (4.78 per 1,000 patient days). Rates generally remained steady throughout with slight increases and decreases between time periods (Table 1). There was no significant difference in CAUTI, CLABSI, or HAVRI rates noted in the PICU between pre-pandemic and post-pandemic periods despite a significantly higher device utilization ratio in the post-pandemic period for both urinary catheters and central lines (IRR, 0.89; p < 0 .05; 95% CI, 0.82-0.97). The most frequent HAI in all time periods was CAUTI. Conclusion: Unlike reports from adult centers, no significant variation between time periods was noted for HAIs in our pediatric center. Despite numerous COVID-19-related changes in infection prevention and control measures and contexts throughout the study period, HAI rates remained stable. This may be due in part to the lower burden of critically ill COVID-19 pediatric patients compared to adult populations. Additionally, this could indicate resiliency and consistency in practice among pediatric providers throughout the pandemic. Further evaluation of pediatric HAIs in the context of the COVID-19 pandemic may reveal practices that could be replicated elsewhere to control HAI rates.

This white paper provides clinicians and hospital leaders with practical guidance on the prevention and control of viral respiratory infections in the neonatal intensive care unit (NICU). This document serves as a companion to Centers for Disease Control and Prevention Healthcare Infection Control Practices Advisory Committee (HICPAC)’s “Prophylaxis and Screening for Prevention of Viral Respiratory Infections in Neonatal Intensive Care Unit Patients: A Systematic Review.” It provides practical, expert opinion and/or evidence-based answers to frequently asked questions about viral respiratory detection and prevention in the NICU. It was developed by a writing panel of pediatric and pathogen-specific experts who collaborated with members of the HICPAC systematic review writing panel and the SHEA Pediatric Leadership Council to identify questions that should be addressed. The document has been endorsed by SHEA, the American Hospital Association (AHA), The Joint Commission, the Pediatric Infectious Diseases Society (PIDS), the Association for Professionals in Infection Control and Epidemiology (APIC), the Infectious Diseases Society of America (IDSA), and the National Association of Neonatal Nurses (NANN).

Family caregivers are essential inpatient pediatric care partners, yet their handwashing knowledge and compliance are rarely studied. Through hand hygiene audits and self-administered questionnaires, we observed 9% compliance, significantly lower than self-reported practice. We suggest interventions to improve caregiver handwashing behaviors to decrease infection transmission risk to hospitalized children.

A survey was conducted among Canadian tertiary neonatal intensive care units. Of the 27 sites who responded, 9 did not have any form of antimicrobial stewardship, and 11 used vancomycin for empirical coverage in late-onset-sepsis evaluations. We detected significant variations in the diagnostic criteria for urinary tract infection and ventilator-associated pneumonia.

The coronavirus disease 2019 (COVID-19) pandemic has placed significant burden on healthcare systems. We compared Clostridioides difficile infection (CDI) epidemiology before and during the pandemic across 71 hospitals participating in the Canadian Nosocomial Infection Surveillance Program. Using an interrupted time series analysis, we showed that CDI rates significantly increased during the COVID-19 pandemic.

Background: Infections with extended-spectrum β-lactamase–producing Enterobacteriaceae (ESBL-E) in nonoutbreak settings have not demonstrated the presence of dominant strains. Our objective was to determine the incidence, clinical characteristics, and genetic characteristics of ESBL-E infections among a group of Canadian children. Methods: From 2012 through 2017, patients aged ≤18 years with first-episode ESBL-E infections who presented at a pediatric center were reviewed. All clinical isolates were phenotypically identified in the laboratory as ESBL-producers. Demographic and clinical data were collected, including comorbid conditions, presence of devices, and previous antibacterial exposure. Community-associated infection was defined as a positive culture from a sterile site within the first 48 hours of hospital admission and no healthcare exposure during the preceding year. Isolates were sent to the Public Health Ontario Laboratory for whole-genome sequencing. Multilocus sequence typing was used to determine clonal relationship. Results: During the study period, 102 patients were identified with first-episode ESBL-E infection, and the proportion of ESBL-E isolates among all clinical isolates of E. coli and Klebsiella spp increased from 0.6% to 2.6% between 2012 and 2017, respectively (P = .001). The median age was 1 year (interquartile range, 0.8–5 years). Women comprised 66% of cases. No comorbid conditions were noted among 58 patients (57%), and 24% had previous antibiotic exposure, most frequently a cephalosporin (16%). ESBL-E was most frequently isolated in the urine (91%) and least frequently in the blood (2.2%) and was predominantly Escherichia coli (90%). Infection was most frequently diagnosed in the outpatient setting (61%); there were 11 healthcare-associated infections. Whole-genome sequencing of ESBL-E isolates revealed predominance of blaCTX-M-15 (63 isolates, 62%) and blaCTX-M-27 (16%) genes, and sequence type (ST) 131 (41%). Mutations conferring fluoroquinolone nonsusceptibility were noted among 62 isolates (61%), most frequently associated with ST131 (38 of 62 isolates, 61%) and among all 5 isolates with ST1193, an emerging multidrug-resistant E. coli clone. In addition, 15 patients had recurrence of ESBL-E infection at median of 113 days (IQR, 26–208); blaCTX-M-27 was found in 33% of recurrent infections compared to 12% of primary infections (P = 0.045). Conclusions: This study is the first in Canada to provide whole-genome sequencing data regarding ESBL-E in a pediatric population. The gene blaCTX-M-15 and ST131 clone were predominant. More than 60% of infections were community associated and demonstrated cross resistance to fluoroquinolones. With 76% of infections in antibiotic-naïve children, ESBL-E is a public health concern, and a One Health approach is critical to understanding the epidemiology and curbing the spread of multidrug-resistant Enterobacteriaceae.

Funding: None

Disclosures: None

Background: Hand hygiene (HH) is the most effective means of preventing healthcare-associated infections (HAI). HH improvement strategies primarily focus on healthcare staff, often overlooking the significant contribution of caregivers to HAI risk. We sought to understand caregivers’ HH knowledge and practices to identify improvement opportunities. Methods: A self-administered survey was developed and distributed to families from June to August 2019; open-ended questions and Likert scales assessed caregivers’ perceptions and practices regarding HH at home and in hospital. HH compliance audits of caregivers entering and exiting inpatient rooms were performed in the same time period. Results: Among 81 caregivers surveyed, median patient age was 4.0 (IQR, 0.9–13.0) years. This was the first admission for 42 patients (53.8%). During this admission, 22 (27.2%) patients had been admitted for ≤1 day and 45 (55.6%) for >3 days. Caregivers reported good knowledge of HH practice, with strongly positive responses to knowledge of HH moments (94%) and proper technique (96%). Caregivers recognized that HH is required of hospital visitors (96%) to protect others (99%) and prevent illness in hospital (93%). Responses were less consistent for performing HH before entering a hospital room (83%), after exiting the room (70%), or after coughing or sneezing (65%). The attitudes of caregivers of children above 2 years were equivocal regarding expectations of their child to wash hands upon entering (40%), or exiting (41%) the hospital room. Multivariable modeling identified higher self-reported HH compliance in caregivers during first admission to hospital, compared to subsequent admissions (OR, 3.15; 95% CI, 1.11–9.65). Reported barriers to HH included hand irritation (27.2%) and perceived HH frequency (18.5%). At the time of survey completion, 62 caregivers (77%) reported not having received HH information during their child’s admission from a healthcare provider or volunteer. Information was most commonly gained from posters (75%) and information in the room (31%). Most caregivers (58.0%) reported that they would prefer to receive HH information in the first 24 hours of admission. Among 200 audits, overall caregiver compliance with HH was 9%; HH before entering the room was 7.2% compared to 11.2% after exiting (P = .33). Conclusions: Reported caregiver knowledge of HH was not reflected in audited practice. Fewer than 1 in 4 had received HH information from healthcare staff. HH education in the hospital environment within the first day of admission provides an opportunity for caregivers to improve compliance as partners in HAI prevention and safer pediatric care.

Funding: None

Disclosures: None

Background: Surgical site infections (SSIs) following open heart surgery involving cardiopulmonary bypass (CPB) among pediatric patients are healthcare-associated infections associated with significant morbidity and mortality. At a pediatric acute-care facility, an increase in SSI incidence prompted an epidemiologic review. We describe the incidence of cardiac SSIs at our hospital; we identified risk factors and areas of practice variation to inform improvement initiatives. Methods: SSI cases following CPB at our hospital have been identified through routine surveillance using NHSN definitions since January 2016. An increase in cases was noted in mid-2018, prompting a common cause analysis with stakeholders across the preoperative, intraoperative, and postoperative care continuum. Areas of practice variability were identified, and an epidemiologic review was performed to determine risk factors among cases compared to noncases between January 2016 and August 2018. The rate of SSIs and 95% confidence intervals were estimated, and univariate logistic regressions were fitted to estimate unadjusted odds ratios (ORs) for the association between each of the predetermined preoperative, intraoperative, and postoperative factors and developing an SSI. Results: Overall, 139 patients underwent surgery involving CPB between January 1, 2016, and August 31, 2018. Preoperative bathing was infrequently documented (9% among cases vs 5% among noncases; P = .56). Operating room observations identified frequent door openings and equipment crowding. Moreover, 11 patients (7.9%) developed a cardiac SSI, with 6 (14.3%) occurring in the first 8 months of 2018 (P = .067). There were no predominant pathogens; 3 of 11 cases were associated with methicillin-susceptible Staphylococcus aureus. Also, 9 cases were classified as deep incisional or organ-space SSI. Each hour increase in total CPB duration was associated with a 63% increase in odds of developing an SSI (OR, 1.626; 95% CI, 1.041–2.539). Each additional day of intubation (OR, 2.400; 95% CI, 1.203–4.788) and peritoneal dialysis (OR, 1.767; 95% CI, 1.070–2.919) during the first 3 days postoperatively were also associated with increased SSI risk. Postoperative documentation of wound assessment occurred in 60% of patients, with no difference between cases and noncases (55% vs 67%; P = .42). Conclusions: Using a mixed-methods approach, preoperative bathing, increased operating room traffic, and postoperative care around wounds and invasive devices were identified as areas of improvement toward safer surgical care. Although no unique organism or process explained the increased rate, determining risk factors and areas of practice variability through stakeholder engagement provided insight into opportunities to prevent SSIs.

Funding: None

Disclosures: None

Background: Healthcare services are increasingly shifting from inpatient to outpatient settings. Outpatient settings such as emergency departments (EDs), oncology clinics, dialysis clinics, and day surgery often involve invasive procedures with the risk of acquiring healthcare-associated infections (HAIs). As a leading cause of HAI, Clostridioides difficile infection (CDI) in outpatient settings has not been sufficiently described in Canada. The Canadian Nosocomial Infection Surveillance Program (CNISP) aims to describe the epidemiology, molecular characterization, and antimicrobial susceptibility of outpatient CDI across Canada. Methods: Epidemiologic data were collected from patients diagnosed with CDI from a network of 47 adult and pediatric CNISP hospitals. Patients presenting to an outpatient setting such as the ED or outpatient clinics were considered as outpatient CDI. Cases were considered HAIs if the patient had had a healthcare intervention within the previous 4 weeks, and they were considered community-associated if there was no history of hospitalization within the previous 12 weeks. Clostridioides difficile isolates were submitted to the National Microbiology Laboratory for testing during an annual 2-month targeted surveillance period. National and regional rates of CDI were stratified by outpatient location. Results: Between January 1, 2015, and June 30, 2019, 2,691 cases of outpatient-CDI were reported, and 348 isolates were available for testing. Most cases (1,475 of 2,691, 54.8%) were identified in outpatient clinics, and 72.8% (1,960 of 2,691) were classified as community associated. CDI cases per 100,000 ED visits were highest in 2015, at 10.3, and decreased to 8.1 in 2018. Rates from outpatient clinics decreased from 3.5 in 2016 to 2.7 in 2018 (Fig. 1). Regionally, CDI rates in the ED declined in Central Canada and increased in the West after 2016. Rates in outpatient clinics were >2 times higher in the West compared to other regions. RT027 associated with NAP1 was most common among ED patients (26 of 195, 13.3%), whereas RT106 associated with NAP11 was predominant in outpatient clinics (22 of 189, 11.6%). Overall, 10.4% of isolates were resistant to moxifloxacin, 0.5% were resistant to rifampin, and 24.2% were resistant to clindamycin. No resistance was observed for metronidazole, vancomycin, or tigecycline. Compared to CNISP inpatient CDI data, outpatients with CDI were younger (51.8 ± 23.3 vs 64.2 ± 21.6; P < .001), included more females (56.4% vs 50.9%; P < .001), and were more often treated with metronidazole (63.0% vs 56.1%; P < .001). Conclusions: For the first time, CDI cases identified in outpatient settings were characterized in a Canadian context. Outpatient CDI rates are decreasing overall, but they vary by region. Predominant ribotypes vary based on outpatient location. Outpatients with CDI are younger and are more likely female than inpatients with CDI.

Funding: None

Disclosures: Susy Hota reports contract research for Finch Therapeutics.

Background: Carbapenemase-producing Enterobacterales (CPE) have rapidly become a global health concern and are associated with substantial morbidity and mortality due to limited treatment options. Travel to endemic areas, especially healthcare exposure in these areas, is an important risk factor for acquisition. We describe the evolving epidemiology, molecular features, and outcomes of CPE in Canada through surveillance by the Canadian Nosocomial Infection Surveillance Program (CNISP). Methods: CNISP has conducted surveillance for CPE among inpatients and outpatients of all ages since 2010. Participating acute-care facilities submit eligible specimens to the National Microbiology Laboratory for detection of carbapenemase production, and epidemiological data are collected. Incidence rates per 10,000 patient days are calculated based on inpatient data. Results: In total, 59 CNISP hospitals in 10 Canadian provinces representing 21,789 beds and 6,785,013 patient days participated in this surveillance. From 2010 to 2018, 118 (26%) CPE-infected and 547 (74%) CPE-colonized patients were identified. Few pediatric cases were identified (n = 18). Infection incidence rates remain low and stable (0.02 per 10,000 patient days in 2010 to 0.03 per 10,000 patient days in 2018), and colonization incidence rates have increased by 89% over the surveillance period. Overall, 92% of cases were acquired in a healthcare facility: 61% (n = 278) in a Canadian healthcare facility and 31% (n = 142) in a healthcare facility outside Canada. Of the 8% of cases not acquired in a healthcare facility, 50% (16 of 32) reported travel outside of Canada in the 12 months prior to positive culture. The distribution of carbapenemases varied by region; New Delhi metallo-B-lactamase (NDM) was dominant (59%) in western Canada and Klebsiella pneumoniae carbapenemase (KPC) (66%) in central Canada. NDM and class D carbapenemase OXA-48 were more commonly identified among those who traveled outside of Canada, whereas KPC was more commonly identified among patients without travel. In addition, 30-day all-cause mortality was 14% (25 of 181) among CPE infected patients and 32% (14 of 44) among those with bacteremia. Conclusions: CPE rates remain low in Canada; however, national surveillance data suggest that the increase in CPE in Canada is now being driven by local nosocomial transmission as well as travel and healthcare within endemic areas. Changes in screening practices may have contributed to the increase in colonizations; however, these data are currently lacking and will be collected moving forward. These data highlight the need to intensify surveillance and coordinate infection control measures to prevent further spread of CPE in Canadian acute-care hospitals.

Funding: None

Disclosures: Susy Hota reports contracted research for Finch Therapeutics. Allison McGeer reports funds to her institution for projects for which she is the principal investigator from Pfizer and Merck, as well as consulting fees from the following companies: Sanofi-Pasteur, Sunovion, GSK, Pfizer, and Cidara.