Background: At the onset of an outbreak, immediate infection, prevention and control (IPC) measures and strategies are critically important in stopping the transmission. During the 2022 Sudan Virus Disease (SUDV) outbreak in Uganda, the IPC technical working group (TWG) adopted the WHO ring approach for intensive and targeted IPC support to interrupt transmission in high-risk areas and healthcare facilities (HCFs). Objectives: a) Leverage surveillance and epidemiological activities to guide response efforts and implement targeted IPC interventions. b) To rapidly interrupt SUDV transmission at the source through multiple IPC interventions. Methods: The IPC TWG delineated outbreak perimeters (rings) to include health facilities and community sites within 500 meters in urban centres and 1 kilometer in rural areas around each confirmed case. A data base with this information was developed and updated daily with information provided by the surveillance team. To activate response within 12 hours, interventions included rapid needs and risk assessments , health educational materials, deployment of decontamination teams and district IPC mentors with hygiene supplies delivered within 24 hours and a 72-hour follow-up. Trained Village Task Forces (VTF) and IPC mentors conducted health education, set up screening points, holding units, and rapid notification channels. Results: 56 rings including HCFs (38) and community sites (78) were identified within the radius of confirmed cases. Using the IPC scorecard, health facility mean scores significantly increased from 18% to 61.7% at follow-up in three weeks. Community WASH baseline scores improved from 11.1% (inadequate) to 69% with a basic level in two weeks. There was marked reduction in the incidence of new cases in the epicentre within the first 32 days. Conclusion: The results suggest that the IPC ring approach is an instrumental strategy health ministries can adopt to rapidly provide targeted comprehensive support at the source to interrupt transmission. A collaborative effort across pillars and partners in the implementation of the ring approach is key through concerted efforts and information sharing across response pillars.

Background: Invasive aspergillosis (IA) poses a substantial threat to morbidity and mortality, particularly among immunocompromised individuals. In 2023, a New York City Intensive Care Unit (ICU) experienced an aspergillus outbreak following a structural water leak, resulting in two patients diagnosed with Invasive Aspergillus niger in their bronchial cultures. Immediate interventions, including patient relocation and ICU reconstruction were implemented to mitigate further impacts. This study aims to assess the impact of timely relocation of patients and renovation of the ICU, on the incidence of invasive aspergillosis. Method: A quasi-experimental study design of ICU patients over a nine month period included surveillance by the Infection Prevention department from March 1 to December 1, 2023. Surveillance included review of microbiology reports, environmental cultures, and patient chart reviews. The Pre-intervention spanned March 1 to May 1, and the post-intervention from May 4 to December 1. Indoor mold assessments of pre- and post-intervention involved testing wall surfaces for moisture, air sample collection for fungal spores, and surface swabs for direct fungal analysis. The intervention included relocating all seventeen patients from the impacted ICU and comprehensive reconstruction. Reconstruction involved the removal and replacement of all sheetrock within the unit extending four feet from the floor with moisture-resistant sheetrock. Additionally, moisture resistant single sheet welded vinyl flooring and cove-bases were installed. All heating, ventilation, and air-conditioning (HVAC) systems were inspected and cleaned. Construction activities strictly adhered to Infection Control Risk Assessment (ICRA) guidelines, with emphasis on maintaining negative pressure, to ensure a safe environment. Result: Environmental swab samples from 50% of ICU rooms indicated growth of Aspergillus/Penicillium, Chaetomium, and Stachybotrys/Memnoniella type spores during the pre-intervention phase. Environmental microbiology results strongly suggest the indoor environment as the fungal spore source, with the presence of fruiting structures indicating surface mold growth. Indoor air samples, when compared to outdoor samples collected during pre-intervention, showed rare (2-6 raw count) growth of Aspergillus in 55% of the sampled rooms and subequently no growth post-intervention. Prospective surveillance revealed no further aspergillus growth in the ICU population and environment. Conclusion: Our findings highlight a potential correlation between environmental modifications and reduced IA incidence. Swift mitigation and structural interventions are crucial in averting potentially fatal outcomes, marking a significant advancement of prevention strategies for inner-city hospital settings. Although promising, study limitations include the inability to speciate environmental aspergillus for comparison to patient bronchial cultures and the absence of baseline bronchial cultures for affected patients on admission.

We updated a descriptive analysis of national outpatient antibiotic prescribing during the COVID-19 pandemic. Prescribing volume was lower during 2020 and January–June in 2021 and 2022 compared to corresponding baseline months in 2019. Prescribing approached or exceeded baseline during July–December of 2021 and 2022 for all antibiotics, especially for azithromycin.

Carbapenamase-producing carbapenem-resistant Enterobacterales (CP-CRE) is an urgent public health threat for healthcare facilities. Solid organ transplant (SOT) recipients carry an increased risk for CRE infection and colonization due to prolonged exposures to antimicrobials, healthcare facilities and immunosuppression. CRE infection in SOT patients is associated with an increase in morbidity and mortality. Here, we describe a hospital outbreak investigation of three cases of New Delhi metallo-beta-lactamase (NDM) - CRE that led to novel findings with implications for further interdisciplinary investigations. An NDM-CRE infection in a critically-ill patient was identified during passive surveillance and prompted an investigation. Previous CP-CRE passive surveillance cases were reviewed. Rectal screening was performed for potentially exposed patients. 403 rectal swabs were tested for carbapenemase genes in active surveillance. Patients identified to have a new NDM-CRE isolate on active or passive surveillance were considered cases and underwent in-depth chart review including possible patient-to-patient exposures, hospital locations, procedures, devices, and consultations. NDM-CRE isolates were sent to the Minnesota Department of Health (MDH) for whole genome sequencing (WGS) to assess relatedness. Five NDM-CRE cases were identified, with all isolates harboring blaNDM including three NDM-Klebsiella pneumoniae (NDM-KP) cases (Figure 1). The first NDM-KP case, patient 1, developed mediastinal infection following lung transplantation. Review of United Network for Organ Sharing revealed that respiratory specimens from patient 1’s donor grew NDM-KP and a bronchial wash at the time of transplant yielded NDM-KP. The second NDM-KP case (patient 3) developed ventilator-associated pneumonia and was found to have used sequentially the same ventilator as patient 1. The third NDM-KP case (patient 4) was detected via rectal swab in active surveillance and shared wound care personnel in common with patients 1 and 3 (Figure 2). WGS demonstrated two single nucleotide polymorphisms (SNP) among all three isolates, strongly suggesting relatedness (Figure 3). Best practices for infection prevention were reviewed with wound care personnel. To date, no further NDM-KP isolates have been identified. Investigation was facilitated by in-depth chart review and WGS via the Central Region Antimicrobial Resistance Laboratory Network at MDH. Detection of the NDM-KP from a lung donor specimen appears genetically linked to clinical isolates in other patients, raising the possibility of a donor-derived hospital outbreak. This investigation is the first to describe a donor-derived NDM outbreak in a healthcare facility. Communication between organ procurement agencies, transplant centers, and infection prevention must be optimized to prevent CRE-associated morbidity in SOT receipts and CRE hospital outbreaks.

Background: On March 23, 2022, the Minnesota Department of Health (MDH) was notified of Klebsiella pneumoniae carbapenemase (KPC)-producing Klebsiella oxytoca isolated from a resident’s urine in long-term care facility A (LTCF-A). Carbapenem-resistant Enterobacterales (CRE) are reportable statewide with required isolate submission to MDH Public Health Laboratory (MDH-PHL), where carbapenemase production and mechanism identification is confirmed. Methods: MDH partnered with LTCF-A on a containment response, including infection prevention and control (IPC) measures, KPC-CRE education, and colonization screening. Rectal swabs were screened for carbapenemase genes by real-time PCR (Cepheid Xpert Carba-R), with positive specimens undergoing culture, isolation, and whole genome sequencing (WGS). MDH-PHL conducted WGS including multilocus sequence typing (MLST) and single nucleotide polymorphism (SNP) analysis to describe genetic relationships among isolates. When screening indicated a potential environmental source, due to species diversity and ongoing resident transmission, an environmental screening plan was developed including collection of premise plumbing samples from room faucets, aerators, sinks, toilets, and shared shower drains. Results: KPC-CRE was detected in 23 residents (urine, n=2; rectal swab, n=21) during March 2022–November 2023. 21 isolates comprising 10 Enterobacterales species were cultured from KPC-positive screening specimens. SNP analysis performed on bacteria of the same species demonstrated 5 distinct clusters of relatedness comprising 2-3 residents per cluster (Cluster 1: Klebsiella oxytoca, n=3; Cluster 2: Klebsiella oxytoca, n=3; Cluster 3: Escherichia coli, n=2; Cluster 4: Klebsiella pneumoniae, n=2; Cluster 5: Raoultella planticola, n=2). 7 KPC-positive resident specimens did not yield a culturable organism. KPC-CRE was detected throughout the premise plumbing including 8 of 9 shared shower room drains and 6 of 75 resident room sink drains. WGS and SNP analysis suggest relatedness among resident and environmental KPC-CRE isolates. Gaps in IPC measures including hand hygiene, use of personal protective equipment (PPE), environmental cleaning and disinfection, and sink hygiene practices were observed during onsite assessments. Use of an EPA-registered biofilm disinfectant in facility drains and repeated environmental sampling has demonstrated a decrease in KPC-harboring bacteria within the premise plumbing, but not complete elimination. Conclusion: Containing the spread of KPC-CRE within LTCF-A has been challenging due to environmental reservoirs of KPC-CRE along with insufficient implementation of IPC practices. Continued colonization screening has been necessary to detect newly colonized residents and reinforce efforts to increase IPC compliance. Strict implementation and adherence to IPC measures, including those that minimize the spread of KPC-CRE from facility premise plumbing, are needed to fully halt KPC-CRE transmission within LTCF-A.

Although the initial specimen diversion device (ISDD) has been shown to reduce blood culture contamination (BCC) rates, its impact on clinical outcomes remains unclear. This multicenter study showed that ISDD significantly decreased BCC. However, there was no reduction in length of stay, days of therapy, or central line-associated bloodstream infections.

Background: Candida auris is an opportunistic pathogen reported in the US since 2016. C. auris infections (CAI) are frequently healthcare-associated, but only one case of donor-derived CAI in a lung transplant recipient has been reported (PMID 28520901). We describe a cluster of two CAIs at a single center in South Carolina occurring in 2 different recipients from the same solid organ transplant donor. Methods: We describe two cases of invasive CAIs occurring in an academic medical center without prior CAI in Charleston, SC in October 2023. C. auris was identified using Bruker MALDI-TOF and confirmed by the state health department. Results: Patient 1: 40-49 year-old male underwent heart transplantation on day 19 from admission complicated by growth of C. auris on post-op day #15 from a drain. He was readmitted post-op days 22-63 with positive blood cultures for C. auris and underwent re-operation with debridement and hardware removal. C. auris pericarditis required multiple returns to the OR (Figure). He was discharged on micafungin/posaconazole with plans for long-term antifungal therapy. Patient 2: 50-59 year-old male underwent liver and kidney transplantation on day 25 from admission from the same donor as Patient 1 in a separate hospital complex. His course was complicated by possible infected biloma not amendable to drainage and C. auris/C. glabrata fungemia, which was further complicated by abdominal wall collection cultures growing C. auris on post-operative day 35 on washout. He was managed with dual micafungin/posaconazole however, he died of unrelated causes at 93 days after transplant (Figure). Investigation: The donor for both recipients was a 10-19 year-old male who suffered brain death after trauma and was hospitalized for 56 days prior to procurement in Atlanta, GA without known CAI. Airway cultures at the time of organ procurement were positive for rare Pseudomonas and light unidentified yeast of multiple morphologies; urine cultures also grew 40,000 cfu/ml un-identified yeast. Screening of 35 and 4 inpatients in units exposed to patients 1 & 2, respectively, with axilla/groin PCR was negative (Figure). A third organ recipient for this donor (kidney) at our center was identified and had negative urine fungus cultures. Conclusions: Despite no definitive link to a known donor infection, this cluster of CAI occurring simultaneously in 2 patients in separate hospitals/units at a single center with no known prior cases represents likely donor-derived CAI. Our experience suggests that organ procurement organizations should consider improved screening techniques for C. auris in donor cultures.

Disclosure: Scott Curry: Consultant- Ferring; Abbott Diagnostics- Speaker honorarium

Antimicrobial resistance (AMR) is positioning as one of the most relevant threats to global public health and threatens the effective treatment of an ever-growing number of bacterial infections in various healthcare settings, particularly in acute care and surgical units, as well as in the community. Among multidrug-resistant (MDR) gram-negative bacteria (MDRGNB), Enterobacterales, Pseudomonas aeruginosa, and Acinetobacter baumannii require special attention, since they account for most of the mortality associated with bacterial infections and are often MDR. It is clear that there is an important global variation in antibiotic resistance profiles among MDRGNB species. Extended-spectrum β-lactamase-producing Enterobacterales, carbapenem-resistant Enterobacterales, DTR-P. aeruginosa, and MDR-A. baumannii are the focus of this review. Here, we summarize a series of relevant studies on risk factors associated with colonization and infection with these MDRGNB. Likewise, we offer a comparative overview of those studies providing scoring systems to predict the risk of infection with these MDR pathogens, and their pros and cons. Despite the variable accuracy of published risk factors for predicting colonization or infection with MDRGNB, these scores are valuable tools that may help anticipate colonization and infection among those colonized. More importantly, they may help reduce unnecessary use of broad-spectrum antimicrobials and guiding the selection of an optimal treatment.

Background: Nontuberculous mycobacteria (NTM) are ubiquitous potential pathogens implicated in healthcare-associated outbreaks. There is a paucity of studies describing transmission risk in the healthcare setting. To estimate the potential healthcare-associated transmission of NTM, we characterized the frequency of NTM clinical isolates across our multi-facility healthcare system. Method: We performed a retrospective review of all clinical NTM isolates at 21 healthcare facilities in a large health system between January 2019 through June 2023 (inclusion criteria: all first unique species). We analyzed the quarterly frequency of isolates for each species, by facility. We identified higher-than-expected species frequencies, which was defined as a quarterly frequency ≥50% higher than the average quarterly frequency for that facility, for the entire study period (analysis omitted for any hospital with an average quarterly frequency 10 unique patient isolates in any 12-month period or >2 in a single month except for M. abscessus at Hospital A. The quarterly frequency of the three most common species among hospitals with ≥2 unique isolates per 12-month period are displayed in figure 2. An increase of 50% from the average quarterly infection count occurred 34 times for M. avium complex across 10 hospitals, 14 times for M. gordonae across 2 hospitals and 14 times for M. lentiflavum across 2 hospitals (Figure 3). Conclusion: A diverse group of NTM were isolated across our healthcare system over the study period, most commonly M. avium complex, M. gordonae, and M. lentiflavum, each with hospital-specific temporal frequencies that suggest the potential for undetected outbreaks, while frequencies of less commonly isolated species were rarely suggestive of potential undetected outbreaks. Further epidemiologic investigation of in-hospital transmission routes, with whole genome sequencing to determine genetic relatedness, is necessary to identify undetected outbreaks.

Background: The COVID-19 pandemic required an increased reliance on and utilization of the inpatient nursing workforce. We aim to examine the psychological safety of U.S. inpatient acute care nurses in the two years following the onset of COVID-19. Method: Participants were recruited for participation across two major metropolitan medical centers in the tristate area, six units per site (12 total). Anonymous Qualtrics survey invitations were distributed through work listservs in the first halves of 2022 and 2023. The invitation was open to registered nurses who provided at least 16 hours/week of direct patient care for at least six months at the hospital. The survey was open for 4-6 weeks, with reminders sent every other week. Nurses were offered a $25 gift card the firs year and $35 the second. Nurses were asked to rate how frequently they experience seven conditions indicative of psychological safety in their work environment from 1 = “Never” to 5 = “Always”. Two items were reverse coded in analysis as the prompts were negatively phrased. Blank and ineligible responses were excluded from the analytic sample. As response distributions were skewed, Wilcoxon rank-sum tests were used to analyze differences between years (alpha = 0.5). Blank and ineligible responses were excluded from the final analytic sample. Result: We achieved an overall response rate of 52% for each survey year (n=258 Year 1, n=221 Year 2). Psychological safety was found to be low overall for both years, but lowest for Year 1 (3.5 vs. 3.7, p=0.0132). The highest rated condition in both years was “When a medical error occurs at this hospital, health care workers are encouraged to discuss mistakes in order to learn how to prevent similar future errors” (4.0 Year 1 vs. 4.2 Year 2, p=0.0054). The lowest rated condition changed across years. For Year 1, “At this hospital, people are too busy to invest time in improvement” (reverse coded) received the lowest rating at 3.1 (vs. 3.3 in Year 2, p=0.0685). For Year 2, “If you make a mistake at this hospital, it is often held against you” became the lowest rating at 2.9 (vs. 3.4 year 1, <.0001). A summary of the psychological safety conditions is presented in Figure 1. Conclusion: Nurses in our study reported low psychological safety during the end of the COVID-19 pandemic. This has implications for overall patient safety and for nursing staff retention in acute care units.

Control of carbapenem-resistant Acinetobacter baumannii and Pseudomonas aeruginosa spread in healthcare settings begins with timely and accurate laboratory testing practices. Survey results show most Veterans Affairs facilities are performing recommended tests to identify these organisms. Most facilities report sufficient resources to perform testing, though medium-complexity facilities report some perceived barriers.

Background: Invasive candidiasis, including candidemia, is a significant cause of morbidity and mortality in medically complex and immunocompromised children. Understanding the epidemiology and antifungal susceptibility patterns of Candida infections could help guide empiric antifungal therapy. Methods: This fungal antibiogram was created at a large quaternary children’s health system in Georgia. Blood isolates positive for Candida spp. from 2019 through 2023 were included. The number and percentage of isolates for each Candida spp was recorded by year and then as the combined 5-year total. The Clinical and Laboratory Standards Institute (CLSI) antifungal interpretative criteria were used, and we only included one unique Candida spp isolate per patient. Due to the limited number of isolates, the combined 5 years of isolates were used to create the fungal antibiogram. Data are shown as percent susceptible using CLSI interpretative criteria and number of isolates. Results: Between 2019 and 2023 there were 124 unique blood isolates of Candida spp identified. The most common isolates were C. albicans (33%), C. parapsilosis (27%), C. glabrata (14%) and C. tropicalis (11%). Over the 5 years of the study, the percentage of C. albicans isolates decreased from 47% to 21%. The change in epidemiology was not driven by a single Candida species but varied from year to year. For C. albicans, susceptibility was 100% for fluconazole and micafungin. For C. parapsilosis, susceptibility to fluconazole and micafungin was 97% and 94%, respectively. Fluconazole susceptibility was lowest for C. glabrata (88%) and C. krusei (0%). Using CLSI epidemiological cutoff values (ECV) to evaluate the amphotericin B results, none of the isolates had results greater than the CLSI ECVs. Comparing 2019 and 2023, the percentage of Candida blood isolates resistant to fluconazole increased from 5% to 18.5%. Conclusion: C. albicans was the most frequently identified cause of candidemia in children, but there was a gradual increase in fungemia caused by other Candida spp. over the past 5 years including Candida with fluconazole resistance. Overall, our findings demonstrate high susceptibility rates to fluconazole and echinocandins in Candida spp. blood isolates. Further research is needed to identify risk factors for antifungal resistant candidemia in pediatric patients.

Disclosure: Mark Gonzalez: Honoria for a one time consulation with NaviDx consulting in May of 2022. Honoria from the American Society for Microbiology for writing of a chapter in the Clinical Microbiology Procedures Handbook.

For adult patients with Staphylococcus aureus bacteremia (SAB), Infectious Diseases consultation (IDC) significantly lowers mortality and recurrence rate. Our systematic review and meta-analysis demonstrate that IDC is also associated with significantly lower mortality in children with SAB. Analysis of the impact of IDC on pediatric recurrence rates revealed moderate heterogeneity.

Enterococcus faecium is a difficult-to-treat gram positive organism with increasing rates of resistance to vancomycin which is commonly mediated through the vanA gene cluster. There have been international reports of E. faecium isolates that are genotypically positive for vanA but phenotypically vancomycin-susceptible. These isolates, commonly called vancomycin-variable enterococci (VVE), can convert to phenotypic vancomycin resistance upon exposure to vancomycin. Multiple mechanisms for this genotypic-phenotypic mismatch have been reported and most commonly involve the regulatory components of the vanA gene cluster. VVE are challenging to identify unless microbiology labs routinely implement both genotypic and phenotypic screening methods. VVE has been associated with outbreaks and has become a prevalent pathogen in several countries. In this review, we summarize the mechanisms, microbiology and epidemiology of VVE. Clinicians must remain vigilant for VVE as diagnosis can be challenging and treatment failure on vancomycin is possible.

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.

Introduction: Neonatal sepsis (NS) is a global public health concern, particularly affecting developing countries. Challenges in diagnostics, more specifically, culture and antimicrobial susceptibility testing hinder effective management of the disease. Objective: This study aims to evaluate the burden, describe the management, and assess the evolution of NS in a hospitalized pediatric population in Haiti. Methods: A retrospective cohort study from January 2013 to December 2018 at La Paix University Hospital was conducted. All-cause hospitalizations and deaths were extracted from hospital’s Neonatology Unit records and were used to derive data regarding hospitalization and death among patients under 28 days with NS. Clinical and laboratory data were extracted from the patients’ medical records. Results: Out of 2,424 post-childbirth hospitalizations, 1,590 involved sepsis. The percentage of hospitalization due to NS was approximately 69% and the percentage of deaths, 65%. The mean age of patients with NS was 3.75 days (0 - 22 days), with a slight male predominance (55%, p < 0.001). Peaks were observed from May to August (p = 0.02). Early NS cases (NS in patients aged less than 7 days) were most prevalent (86%, p < 0.001). Specimen culture and antimicrobial susceptibility testing was less frequent (7%) than complete blood count usage (65%). Findings regarding blood count included leukopenia (3%), thrombocytopenia (30%). A positive CRP and acute renal failure were noted in 76% and 21.7% of cases, respectively. The average hospital stay was 7.3 days. With regards to treatment, 73% of patients received a 2-drug antimicrobial therapy (ampicillin-gentamycin) and 22% received a 3-drug antimicrobial therapy (ampicillin-gentamycin-cefotaxime). Of all newborns hospitalized for NS, 49% received empirical antibiotic therapy within 3 hours of admission. Conclusions: This research highlights NS as a public health emergency in Haiti. The study advocates for improved access to culture and antibiotic susceptibility testing and emphasizes the impact of timely antibiotic administration. The findings of this study serve as a baseline for informing policymakers and medical practitioners dedicated to improving existing conditions of neonates in Haiti. Suggested targeted interventions include preventive measures during prenatal visits, strengthening laboratory capacities, improving infection prevention and control measures, and developing antimicrobial stewardship programs.