Background: Infectious diseases and the rapid emergence of multidrug-resistant pathogens continue to pose a threat to global health. The development of antimicrobial-resistant organisms is an alarming issue caused by inappropriate use of antibiotic agents. It is estimated that death from antimicrobial resistant pathogens could increase >10-fold to ~10 million deaths annually by 2050 if action is not taken. “It is essential to have reliable data on how medicines are used in order to identify areas to develop targeted interventions” (WHO 2011). Investigating antimicrobial use in hospitals is the first step in evaluating the underlying causes of AMR. In Sierra Leone, no other study related to antibiotic prescribing patterns in hospital setting has been undertaken. Objective: To investigate antibiotic prescription patterns using the WHO hospital antimicrobial use indicator tool at the Kingharman Hospital for 1 month. Methods: Data were collected from patient charts for 1 month, January 1–31, 2019. A data extraction tool was used to capture information on patient demographics, diagnosis, and antibiotics prescription details regarding dosage, duration, and frequency of administration. The tool adopted 6 selected indicators from the WHO antimicrobial use manual to measure the extent of antibiotic use in hospital and performance among prescribers. Results: Of the 189 charts reviewed, 175 included antibiotic prescriptions. The percentage of prescriptions involving antibiotics was 92.5%. The average number of drugs prescribed was 2, with an average duration of 5.2 days. Moreover, 50.5% of antibiotics prescribed were generic, and 96.6% were from the Ministry of Health and Sanitation Essential Medicine List (EML). The most commonly used antibiotics were ciprofloxacin (38.8%), followed by ceftriaxone (23.0%), amoxicillin (16.8%), metronidazole (8.5%), and others(12.7%). Typhoid accounted for 34.8% of broad-spectrum antibiotics, UTI accounted for 17.7%, malaria accounted for 12.5%, 25.5% were unspecified, and 9.5% were for unclear diagnoses. Typically, combinations of fluroquinolones and cephalosporins were used to treat typhoid and UTIs. Conclusions: This cross-sectional study represents a broad picture of antibiotic prescribing patterns at the King Harman Hospital. There was no strict adherence to the WHO recommended prescribing guidelines. These findings also indicate the degree of irrational and inappropriate prescribing of broad-spectrum antibiotics. This study highlights the need for a comprehensive assessment of antimicrobial use to gain a better understanding of national antibiotic use and to guide interventions to reducing AMR.

Funding: None

Disclosures: None

If I am discussing specific healthcare products or services, I will use generic names to extent possible. If I need to use trade names, I will use trade names from several companies when available, and not just trade names from any single company.

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Christiana Kallon

Background: Colorectal surgery is associated with a high risk of surgical site infections (SSIs), with an incidence ranging from 16.9% to 20%, and SSIs are associated with significant morbidity and mortality, prolonged length of hospitalization, and increased health care costs. Staphylococcal decolonization is an attempt to alter the microbiome to prevent staphylococcal and other skin flora from accessing the surgical site, and This practice effectively reduces SSIs in orthopedic, neurologic, and cardiac surgeries. A staphylococcal decolonization protocol was enacted in colorectal surgeries at our institution beginning in October 2016. We compared patient outcomes between patients who did and did not undergo preoperative staphylococcal decolonization. Methods: All patients undergoing nonemergent NHSN-defined colorectal procedures from July 2015 until June 2019 at a tertiary-care medical center were included in this retrospective study. Staphylococcal decolonization was performed using chlorhexidine 2% body wash solution, mupirocin nasal ointment, and chlorhexidine 0.12% oral rinse all twice daily for 5 days prior to surgery. All SSIs were defined by NSHN criteria. The primary outcome was SSI, and secondary outcomes were superficial wound infection (SIP) and organ-space infection (IAB). Predictive variables included decolonization status (yes or no), age, gender, body mass index, procedure duration, American Society of Anesthesiologists (ASA) score, diabetes, smoking, and surgical oncology service. Surgical antimicrobial prophylaxis with cefazolin and metronidazole OR cefoxitin, and chlorhexidine skin preparation were standard throughout the study period. Univariate analysis was performed using a χ2 or t test. Multivariable logistic regression was performed to control for all clinically important variables above. All statistical analyses were done using SAS version 9.4 software (Cary, NC). Results: In total, 1,139 patients underwent nonemergent colorectal surgery from July 2015 to June 2019. There were 74 SSIs: 42 IABs and 32 SIPs. Decolonization was performed in 332 of 1,139 cases (29%). There was no difference in overall SSIs between those decolonized and not decolonized (P = .50). However, SIPs were reduced in the group receiving decolonization: 1.2% (4 of 332) versus 3.5% (28 of 807) (P = .04. When controlling for known SSI risk factors, those not receiving decolonization remained at increased risk of SIPs (OR, 3.79; 95% CI, 1.14–12.61; P = .03. Conclusions: Staphylococcal decolonization may prevent a subset of SSIs in patients undergoing colorectal surgery.

Funding: None

Disclosures: Michelle Doll reports a research Grant from Molnlycke Healthcare.

Background: Improved infection prevention and control (IPC) reduces healthcare-associated infections (HAIs). Following the Ebola virus disease (EVD) outbreak in West Africa (2014–2016), Sierra Leone made substantial investments in strengthening IPC in health facilities. The WHO identified 8 core components of IPC and developed an accompanying assessment framework (IPCAF) to monitor IPC capacity and progress. The IPCAF reflects the 8 WHO core components of IPC. The core component constitute a consistent universal outline that supports guidance to healthcare decision makers and service providers at national and international levels. We conducted an in-depth assessment of IPC practices in Sierra Leone using the IPCAF tool. Methods: This assessment was conducted in in July 2019 over a 2-week period. Data were collected through interview with IPC focal persons as well as observations and corroboration of document and immediate feedback on findings given to facilities through brief exit meetings. All areas of the facility were assessed (ie, all wards, operation theatres, laboratories maternity units, sterile service departments, waste management units, etc). The main objective was to identify the gaps and challenges faced by health facilities. Each component was scored based on the responses and observations, with the scores ranging from zero to 100 and the maximum score was 800. The IPCAF allocated hospitals to 4 different “IPC levels”: inadequate, basic, intermediate, and advanced. Results: Moreover, 13 hospitals were assessed, including 12 primary level hospitals and 1 secondary level hospital. The median score was 367. 5 (IQR, 110), which corresponds to a basic level of IPC. Primary-level hospitals scored higher (median, 373; IQR, 112.5) compared to secondary-level hospitals (median, 280; IQR, 0). The lowest score was in healthcare-associated infection surveillance (median, 0; IQR, 5), and the highest score was in the built environment, availability of materials, and equipment to support IPC (median, 62.5; IQR, 22.5). Conclusions: The assessment provides a baseline of the status of IPC in Sierra Leone in the post-EVD period using the IPCAF tool. These results can be used to guide healthcare facilities and policy makers in developing strategies for IPC quality improvement projects to improve low-performing healthcare facilities. Significant gaps were observed in key IPC areas, especially in secondary-level health facilities. There is need to establish national surveillance for healthcare-associated infections, to institutionalize monitoring of IPC practices, and to ensure an appropriate staffing–workload ratio in health facilities.

Funding: None

Disclosures:

If I am presenting research funded by a commercial company, the information presented will be based on generally accepted scientific principals and methods, and will not promote the commercial interest of the Funding: company. Disagree

Anna Maruta

If I am discussing specific healthcare products or services, I will use generic names to extent possible. If I need to use trade names, I will use trade names from several companies when available, and not just trade names from any single company.

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Christiana Kallon

Background: Trained infection prevention and control (IPC) practitioners are critical to reducing healthcare-associated infections (HAI) and improving patient safety. Despite having HAI rates 3 times higher than high-income countries, many low- and middle-income countries (LMICs) lack trained IPC professionals. During the 2014–2016 Ebola outbreak in West Africa, the Sierra Leone Ministry of Health and Sanitation (MoHS) recognized this need and appointed and trained IPC focal persons at all district hospitals. Following the outbreak, MoHS requested assistance from the US CDC to develop and implement a comprehensive IPC training program for IPC specialists. Methods: The CDC, alongside its partners, convened a multidisciplinary team to develop an IPC certificate course. ICAP led the curriculum development process using a “backwards design” approach, starting with development of competencies and learning objectives, then designing an evaluation framework and learning strategies, and finally, identifying course content. The curriculum was based on existing resources, primarily designed for high-income countries, which were adapted to the Sierra Leone context and aligned with national IPC policies and guidelines. Additionally, an IPC steering committee, led by MoHS, was established to provide national leadership and oversight and make country-level decisions regarding accreditation and career pathways for IPC specialists. Results: The course includes three 2-week workshops over 6 months consisting of classroom didactics and hands-on activities. Topics include standard and transmission-based precautions, microbiology, laboratory, HAI, quality improvement, leadership, and scientific writing. Between sessions, participants conduct IPC activities at their work site and share results during subsequent workshops. Participants receive electronic tablets, which contain course content, assessment tools, and references, to upload their work into a cloud-based storage system for facilitators to provide feedback. They also receive in-person mentorship and connect with peers through a group messaging platform to share lessons learned. Participants’ knowledge and skills are assessed using a before-and-after test and observing them perform IPC practices using standardized checklists. The first cohort of 25 participants will complete the course in November 2019. Conclusions: The IPC certificate course is the first comprehensive, competency-based IPC training in Sierra Leone. Successes, challenges, sustainability, and lessons learned remain to be determined; however, based on similar models, the course has the potential to significantly improve IPC in Sierra Leone. Additionally, it is a model that can be replicated in other resource-limited settings.

Funding: None

Disclosure:None

Background: Hand hygiene (HH) is considered a primary measure necessary for reducing healthcare-associated infections (HAIs). Despite its significance, the lack of compliance among healthcare workers continues to be a problem throughout the world. The Ebola outbreak in our country has accelerated efforts to strengthen the health system in Sierra Leone. The WHO multimodal strategy on HH is an integral approach to the reduction of HAIs. Objectives: We sought to improve HH compliance among healthcare workers, to maintain a culture of safety in the healthcare facility, and to implement evidence-based practices for improved patient outcomes. Methods: A WHO multimodal strategy for direct observation of HH was adapted. We observed clinical staff (doctors, nurses and community health officers) in the intensive care unit (ICU), resuscitation ward (Resus) and emergency room (ER) from August to September 2019. A 4-day training session was conducted in 3 weeks. Provision of locally produced alcohol-based hand rub (ABHR), soap, and water emphasize the importance of HH. HH reminders were posted in all clinical areas. Healthcare worker knowledge about HH was assessed before and after the intervention. Results: We observed 1,535 HH opportunities, and only 706 HH actions were performed. Locally produced ABHR was used in 470 HH actions. Handwashing with soap and water was used in the remaining HH actions. Baseline compliance was 36% and increased to 50% in the first and second months. Healthcare worker knowledge scores at the baseline averaged 25% and increased to 65% after 2 months. HH compliance was highest in the ICU (44%), followed by the emergency ward (30%). The resuscitation ward had the lowest compliance (26%). Compliance among doctors was 32%, nurses 46%, and CHOs 22%. Conclusions: Promotion of HH is feasible and attainable and can be sustained in a resource- constrained setting using a multimodal improvement strategy. The local production, availability, and use of ABHR have significantly increased HH compliance. However, absolute compliance remains low, and a strong commitment by hospital management and healthcare workers may be needed for further improvement.

Disclosures:

If I am providing recommendations involving clinical medicine, they will be based on evidence that is accepted within the profession of medicine as adequate justification for their indications and contraindications in the care of patients. All scientific research referred to will conform to the generally accepted standard of experimental design, data collection and analysis.

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If I am presenting research funded by a commercial company, the information presented will be based on generally accepted scientific principals and methods, and will not promote the commercial interest of the funding company.

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If I am discussing specific healthcare products or services, I will use generic names to extent possible. If I need to use trade names, I will use trade names from several companies when available, and not just trade names from any single company.

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I have disclosed all relevant financial relationships and I will disclose this information to learners.:

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Isata Adama Bangura

Funding: None

Background: Methicillin-resistant Staphylococcus aureus (MRSA) colonization conveys a higher risk of invasive infection. The transplant cohort is a group of immunocompromised patients who are at higher risk of infection. We conducted an outbreak investigation of hospital-acquired MRSA colonization within the transplant unit, which led to the discovery of positive isolates within our environment and to changes in our hospital disinfection policies. Methods: Our transplant unit consists of 8 single, positive-pressure rooms housed separately at the side of a larger ward. Staffing from this unit differs from the rest of the shared ward that houses up to 60 patients. As part of hospital screening, we found that a patient admitted for a stem-cell transplant had acquired nosocomial MRSA colonization. Given the unusual occurrence of such an event, a root-cause analysis was conducted. Results: A meeting was convened together with nursing, medical staff, and ancillary staff. Identified areas of potential transmission were deemed equipment, staff, and patients, and screening was performed. Shared equipment included the portable electrocardiogram (ECG) machines and portable x-ray machines and boards. In particular, ECG machines were shared with the adjoining nontransplant oncology ward. The usual practice was to clean the machine after use but not prior to the next use. This was deemed a possible exposure risk in view of a recent MRSA outbreak in a separate section of the ward. Positive isolates were found on both the x-ray and ECG machines. All healthcare workers were screened and were negative for MRSA. Furthermore, 7 patients admitted during the same time period were also screened for MRSA and were negative. Given the concurrent outbreak within the ward, pulsed-field gel electrophoresis was performed for all MRSA isolates obtained and the outbreak strain. These were found to be nonclonal (Table 1). Work processes for both the cleaning of ECG and x-ray machines were enhanced and modified. Hand hygiene measures to ward and radiology staff were reinforced. Thus far, no further cases have been detected. Conclusions: The environment is an important part of outbreak investigation. Shared equipment is often overlooked during day to day processes but should not be neglected. This can result in changes to hospital disinfection policy.

Funding: None

Disclosures: Indumathi Venkatachalam reports receiving honoraria for speaking engagements for bioMérieux and Pfizer and serving on an expert panel for MSD Pharma.

Background: The NHSN methods for central-line–associated bloodstream infection (CLABSI) surveillance do not account for additive CLABSI risk of concurrent central lines. Past studies were small and modestly risk adjusted but quantified the risk to be ~2-fold. If the attributable risk is this high, facilities that serve high-acuity patients with medically indicated concurrent central-line use may disproportionally incur CMS payment penalties for having high CLABSI rates. We aimed to build evidence through analysis using improved risk adjustment of a multihospital CLABSI experience to influence NHSN CLABSI protocols to account for risks attributed to concurrent central lines. Methods: In a retrospective cohort of adult patients at 4 hospitals (range, 110–733 beds) from 2012 to 2017, we linked central-line data to patient encounter data (age, comorbidities, total parenteral nutrition, chemotherapy, CLABSI). Analysis was limited to patients with >2 central-line days, with either a single central line or concurrence of no more than 2 central lines where insertion and removal dates overlapped by >1 day. Propensity-score matching for likelihood of concurrence and conditional logistic regression modeling estimated the risk of CLABSI attributed to concurrence of >1 day. To evaluate in Cox proportional hazards regression of time to CLABSIs, we also analyzed patients as unique central-line episodes: low risk (ie, ports, dialysis central lines, or PICC) or high risk (ie, temporary or nontunneled) and single versus concurrent. Results: In total, 64,575 central lines were used in 50,254 encounters. Among these patients, 517 developed a CLABSI; 438 (85%) with a single central line and 74 (15%) with concurrence. Moreover, 4,657 (9%) patients had concurrence (range, 6%–14% by hospital); of these, 74 (2%) had CLABSI, compared to 71 of 7,864 propensity-matched controls (1%). Concurrence patients had a median of 17 NHSN central-line days and 21 total central-line days. In multivariate modeling, patients with more concurrence (>2 of 3 of concurrent central-line days) had an higher risk for CLABSI (adjusted risk ratio, 1.62; 95% CI, 1.1–2.3) compared to controls. In survival analysis, 14,610 concurrent central-line episodes were compared to 31,126 single low-risk central-line episodes; adjusting for comorbidity, total parenteral nutrition, and chemotherapy, the daily excess risk of CLABSI attributable to the concurrent central line was ~80% (hazard ratio 1.78 for 2 high-risk or 2 low-risk central lines; hazard ratio 1.80 for a mix of high- and low-risk central lines) (Fig. 1). Notably, the hazard ratio attributed to a single high-risk line compared to a low-risk line was 1.44 (95% CI, 1.13–1.84). Conclusions: Since a concurrent central line nearly doubles the risk for CLABSI compared to a single low-risk line, the CDC should modify NHSN methodology to better account for this risk.

Funding: None

Disclosures: Scott Fridkin reports that his spouse receives consulting fees from the vaccine industry.

Background: Antimicrobial resistance is a disturbing problem in the health system. A relationship between the use of certain antimicrobials and a resistance increase has been proposed. Since this phenomenon is not usually attributed to specific uses of antimicrobials but preferably to its evolution over the years, the analysis of the antimicrobial consumption over time can justify the epidemiological situation of a given region in terms of resistance and possible increases and decreases for specific microorganisms. The objective of this study was to analyze the evolution of the use of antimicrobials in Catalonia during 2008–2018 through the VINCat program (Infection Control and Antimicrobial Stewardship Catalonian Program). Methods: The number of hospitals participating in the VINCat increased from 46 in 2008 to 63 in 2018 (ie, 68.8% and 85.7% of all adult acute-care hospital beds in Catalonia, respectively). Hospitalization days recorded at the participating hospitals increased from 2,991,053 in 2008 to 3,714,938 in 2018. The Anatomical Therapeutic Chemical Classification (ATC) defined daily dose (DDD) index was used for monitoring antimicrobial consumption. Simple linear regressions were performed, the linear relationship was checked by ANOVA tests, and the Pearson correlation (Pc) coefficients were obtained. Values of P ≤ .05 were considered statistically significant. Results: From 2008 to 2018, there was a statistically significant increase of global antibacterial consumption (65.50 vs 71.73 DDD per 100 bed days; P = .001) and antimycotic consumption (3.09 vs 3.45 DDD per 100 bed days, P = .012) due to an increase of consumption in the surgical units. At the same time, there was a decrease in the consumption of antimycotics in the medical units (4.35 vs 3.90 DDD per 100 bed days; P =.029). Cephalosporins and carbapenem consumption increased both globally (10.88 vs 13.86 DDD per 100 bed days; P < .001) and in medical and surgical units (3.26 vs 5.38 DDD per 100 bed days; P < .001). This increase was mainly associated with ceftriaxone (3.45 vs 5.46 DDD per 100 bed days; P < .001) and meropenem (1.12 vs 3.08 DDD per 100 bed days; P < .001). There was a global decrease in the consumption of penicillins (26.10 vs 24.24 DDD per 100 bed days; P = .012) and quinolones (11.63 vs 9.61 DDD per 100 bed days; P = .004). This trend was observed also in ICUs and medical units but not in surgical units, for which only quinolones showed a significant decrease. Decreases in the use of amoxicillin/clavulanate acid (17.80 vs 14.24 DDD per 100 bed days; P < .001) and ciprofloxacin (5.68 vs 4.01 DDD per 100 bed days; P < .001) were observed. Conclusions: The increase in the use of antimicrobials in Catalonia is concerning. This increase is attributable to the use of these drugs in surgical units. Antibiotic stewardship measures should be aimed primarily at these units. The increasing use of carbapenems should be analyzed.

Funding: None

Disclosures: Juan Pablo Horcajada reports consulting fees from MSD, Pfizer, and Menarini as well as speaker honoraria from MSD, Pfizer, and Zambon.

Background: Patients with hematologic malignancies are at increased risk for respiratory virus infections (RVIs) and may experience prolonged asymptomatic viral shedding contributing to transmission. In response to 2 extensive RVI outbreaks in our adult cancer center, a universal masking policy was implemented whereby inpatients on malignant hematology units and their visitors were required to wear procedure masks whenever they were walking outside their rooms. Visitors were required to mask when inside patient rooms. Staff were not included in the policy. Here, we describe the impact of universal masking on the incidence of nosocomial RVI in malignant hematology patients. Methods: In this before-and-after study, we examined the effects of universal masking in malignant hematology units of a 170-bed adult cancer hospital in Toronto, Canada, between January 1, 2015, and September 30, 2019. Nosocomial RVI incidence, RVI outbreak descriptions, and hand hygiene compliance rates were collected from hospital infection control databases. Mask utilization was extracted from hospital purchasing records. Staff influenza vaccination rates were obtained from occupational health records. RVI incidence rates before and after the intervention were compared using Wilcoxon rank-sum test. Results: The preimplementation phase ran from January 1, 2015, to February 28, 2017, and the postimplementation phase spanned March 1, 2017, to September 30, 2019. Monthly mask utilization on malignant hematology units increased by 105% after implementing the universal masking policy. Nosocomial RVI incidence decreased significantly after implementing the universal masking policy, and the number of cases involved in RVI outbreaks also decreased (Table 1). There was a 14% increase in nasopharyngeal swab orders after implementation. Staff influenza vaccination rates, hand hygiene compliance and infection control policies remained stable throughout the study. Conclusions: A reduction in the incidence of nosocomial RVI and number of RVI cases in outbreaks was observed after implementing the universal masking policy. Although we were unable to directly measure compliance with the intervention, increased mask utilization after the intervention implied adherence to the policy. Our experience suggests that universal masking in malignant hematology inpatients may be an effective RVI prevention strategy. Further rigorous study is warranted.

Funding: None

Disclosures: Susy Hota reports contract research for Finch Therapeutics.

Background: A penicillin allergy guidance document containing an algorithm for challenging penicillin allergic patients with β-lactams was developed by the antimicrobial stewardship program (ASP). As part of this algorithm, a “graded challenge” order set was created containing antimicrobial orders and safety medications along with monitoring instructions. The process is designed to challenge patients at low risk of reaction with infusions of 1% of the target dose, then 10%, and finally the full dose, each 30 minutes apart. We evaluated outcomes from the order set. Methods: Orders of the graded challenge over 17 months (March 2018 through July 2019) were reviewed retrospectively. Data were collected on ordering and outcomes of the challenges and allergy documentation. Use was evaluated based on ASP-recommended indications: history of IgE-mediated or unknown reaction plus (1) no previous β-lactam tolerance and the reaction occurred >10 years ago, or (2) previous β-lactam tolerance, now requiring a different β-lactam for treatment. Only administered challenges were included and descriptive statistics were utilized. Results: Of 67 orders, 57 graded challenges were administered to 56 patients. The most common allergies were penicillins (87.7%) and cephalosporins (38.6%), with the most common reactions being unknown (41.7%) or hives (22%). The most common antibiotics challenged were ceftriaxone (43.9%), cefepime (21.1%), and cefazolin (5.3%). Antibiotics given prior to challenge included vancomycin (48.2%), fluoroquinolones (35.7%), carbapenems (21.4%), aztreonam (19.6%), and clindamycin (12.5%). The median duration of challenged antibiotic was 6 days. The infectious diseases service was consulted on 59.6% of challenges and 75.4% of challenges were administered in non-ICU settings. There was 1 reaction (1.8%) involving a rash with the second infusion, which was treated with oral diphenhydramine and had no lasting effects. Based on indications, 80.7% of challenges were aligned with ASP guidance criteria. The most common use outside of these criteria was in patients without IgE-mediated reactions (10.5%). Most of these had minor rashes and could have received a full dose of a cephalosporin. Allergy information was updated in the electronic health record after 91.2% of challenges. Conclusions: We demonstrated the utility of a graded challenge process at our academic medical center. It was well tolerated, ordered frequently by noninfectious diseases clinicians, administered primarily in non-ICU settings, and regularly resulted in updated allergy information in the medical record. With many patients initially receiving broad-spectrum antibiotics with high costs or increased rates of adverse effects, graded challenges can potentially prevent the use of suboptimal therapies with minimal time and resource investment.

Funding: None

Disclosures: Scott Bergman reports a research grant from Merck.

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: In spring of 2019, 2 positive sputum cases of Pseudomonas aeruginosa in the cardiac critical care unit (CCU) were reported to the UFHJ infection prevention (IP) department. The initial 2 cases, detected within 3 days of each other, were followed shortly by a third case. Epidemiological evidence was initially consistent with a hospital-acquired infection (HAI): 2 of the 3 patients roomed next to each other, and all 3 patients were ventilated, 2 of whom shared the same respiratory therapist. However, no other changes in routine or equipment were noted. The samples were cultured and processed using Illumina NGS technology, generating 1–2 million short (ie, 250-bp) reads across the P. aeruginosa genome. As an additional positive control, 8 P. aeruginosa NGS data sets, previously shown to be from a single outbreak in a UK facility, were included. Reads were mapped back to a reference sequence, and single-nucleotide polymorphisms (SNPs) between each sample and the reference were extracted. Genetic distances (ie, the number of unshared SNPs) between all UFHJ and UK samples were calculated. Genetic linkage was determined using hierarchical clustering, based on a commonly used threshold of 40 SNPs. All UFHJ patient samples were separated by >18,000 SNPs, indicating genetically distinct samples from separate sources. In contrast, UK samples were separated from each other by <16 SNPs, consistent with genetic linkage and a single outbreak. Furthermore, the UFHJ samples were separated from the UK samples by >17,000 SNPs, indicating a lack of geographical distinction of the UFHJ samples (Fig. 1). These results demonstrated that while the initial epidemiological evidence pointed towards a single HAI, the high-precision and relatively inexpensive (<US$1500) NGS analysis conclusively demonstrated that all 3 CCU P. aeruginosa cases derived from separate origins. The hospital avoided costly and invasive infection prevention interventions in an attempt to track down a single nonexistent source on the CCU, and no further cases were found. This finding supports the conclusion reached from the NGS that this represented a pseudo-outbreak. Furthermore, these genomes serve as an ongoing record of P. aeruginosa infection, providing even higher resolution for future cases. Our study supports the use of NGS technology to develop rational and data-driven strategies. Furthermore, the ability of NGS to discriminate between single-source and multiple-source outbreaks can prevent inaccurate classification and reporting of HAIs, avoiding unnecessary costs and damage to hospital reputations.

Funding: None

Disclosures: Susanna L. Lamers reports salary from BioInfoExperts and contract research for the NIH, the University of California - San Francisco, and UMASS Medical School.

Background: The CDC considers methicillin-resistant Staphylococcus aureus (MRSA) one of the most important hospital-acquired infections (HAIs) in the United States. However, infection control departments (ICDs) often rely on subjective data to determine whether multiple MRSA cases are a true outbreak and whether the hospital is responsible (community- vs hospital-acquired). Objective: Our objective was to determine whether whole-genome sequencing (WGS) of MRSA provided new insights into on transmission dynamics at large, inner-city hospital in Jacksonville, Florida. Methods: Over a 4-month period, MRSA samples were obtained from 44 infected patients at 3 campuses within a single hospital system. Limited nonpatient identifying information was obtained, including date of collection, campus, unit, reason for admission, and days post admission (DPA) of MRSA diagnosis. Whole-genome sequences were generated using the Illumina platform. Raw reads were processed, and genetic distances were calculated and used to identify genetically linked bacterial infections using FoxSeq version 1.0 software. Results: Based on their length of stay, 10 patients were reported by the ICD as obtaining an HAI. Three distinct “episodes” were evident in which >5 MRSA cases were observed within a 3–5-day period. Genomic analysis identified 5 clusters of linked infections: 4 clusters contained 2 patients and another contained 3. Of these clusters, only 1 contained multiple cases that were reported as HAIs; however, because these case were separated by 2 weeks, it is unlikely that they came from a source in the hospital. The results suggest that HAIs were overreported and that most MRSA present in the hospital likely came from community sources. Conclusions: WGS provided clear evidence that temporally clustered MRSA cases do not imply an outbreak is occurring. Furthermore, ongoing detection of the same community-acquired infections over several months is indicative of a shared source outside of the hospital, which could be uncovered through examination of clinical records. Considering the implications of HAIs, best approaches to combat them should include identifying their sources. As molecular surveillance approaches to infection control are rapidly becoming easier and less expensive, the methods can be used to bring objective clarity to the ICD.

Funding: None

Disclosures: Susanna L. Lamers reports salary from BioInfoExperts and contract research for the NIH, the University of California - San Francisco, and UMASS Medical School.

Background: The rate of inappropriate antibiotic prescribing for acute respiratory tract infections (ARTIs) is 45% among urgent care centers across the United States. To contribute to the US National Action Plan for Combating Antibiotic-Resistant Bacteria, which aims to decrease rates of inappropriate prescribing, we implemented 2 behavioral nudges using the evidence-based MITIGATE tool kit from urgent-care settings, at 3 high-volume, rural, urgent-care centers. Methods: An interrupted time series (ITS) analysis was conducted comparing a preintervention phase during the 2017–2018 influenza season (October through March) to the intervention phase during the 2018–2019 influenza season. We compared the rate of inappropriate or non–guideline-concordant antibiotic prescribing for ARTIs across 3 urgent-care locations. The 2 intervention behavioral nudges were (1) staff and patient education and (2) peer comparison. Provider education included presentations at staff meetings and grand rounds, and patient education print materials were distributed to the 3 locations coupled with news media and social media. We utilized the CDC “Be Antibiotics Aware” campaign materials, with our hospital’s logo added, and posted them in patient rooms and waiting areas. For the peer comparison behavioral intervention, providers were sent individual feedback e-mails with their prescribing data during the intervention period and a blinded ranking e-mail in which they were ranked in comparison to their peers. In the blinded ranking email, providers were placed into categories of “low prescribers,” those with a ≤23% inappropriate antibiotic prescribing rate based on the US National Action Plan for Combating Antibiotic-Resistance Bacteria 2020 goal, or “high prescribers,” those with a rate greater than the national average (45%) of inappropriate antibiotic prescribing for ARTI. Results: Our results show that fewer inappropriate antibiotic prescriptions were written during the intervention period (58.8%) than during the preintervention period (73.0%), resulting in a 14.5% absolute decrease in rates of inappropriate prescribing among urgent-care locations over a 6-month period (Fig. 1). The largest percentage decline in rates was seen in the month of April (−35.8%) when compared to April of the previous year. The ITS analysis revealed that the rate of inappropriate prescribing was statistically significantly different during the preintervention period compared to the intervention period (95% CI, −4.59 to −0.59; P = .0142). Conclusions: Using interventions outlined in the MITIGATE tool kit, we were able to reduce inappropriate antibiotic prescribing for ARTI in 3 rural, urgent-care locations.

Funding: None

Disclosures: Larissa May repo, Speaking honoraria-Cepheid Research grants-Roche Consultant-BioRad Advisory Board-Qvella Consultant-Nabriva

Background: Epidemiological studies have utilized administrative discharge diagnosis codes to identify methicillin-resistant and methicillin-sensitive Staphylococcus aureus (MRSA and MSSA) infections and trends, despite debate regarding the accuracy of utilizing codes for this purpose. We assessed the sensitivity and positive predictive value (PPV) of MRSA- and MSSA-specific diagnosis codes, trends, characteristics, and outcomes of S. aureus hospitalizations by method of identification. Methods: Clinical micro biology results and discharge data from geographically diverse US hospitals participating in the Premier Healthcare Database from 2012–2017 were used to identify monthly rates of MRSA and MSSA. Positive MRSA or MSSA clinical cultures and/or a MRSA- or MSSA-specific International Classification of Diseases, Ninth/Tenth Revision, Clinical Modification (ICD-9/10 CM) diagnosis codes from adult inpatients (aged ≥18 years) were included as S. aureus hospitalizations. Septicemia was defined as a positive blood culture or a MRSA or MSSA septicemia code. Sensitivity and PPV for codes were calculated for hospitalizations where admission status was not listed as transfer; true infection was considered a positive clinical culture. Negative binominal regression models measured trends in rates of MRSA and MSSA per 1,000 hospital discharges. Results: We identified 168,634 MRSA and 148,776 MSSA hospitalizations in 256 hospitals; 17% of MRSA and 21% of MSSA were septicemia. Less than half of all S. aureus hospitalizations (49% MRSA, 46% MSSA) and S. aureus septicemia hospitalizations (37% MRSA, 38% MSSA) had both a positive culture and diagnosis code (Fig. 1). Sensitivity of MRSA codes in identifying positive cultures was 61% overall and 56% for septicemia, PPV was 62% overall and 53% for septicemia. MSSA codes had a sensitivity of 49% in identifying MSSA cultures and 52% for MSSA septicemia; PPV was 69% overall and 62% for septicemia. Despite low sensitivity, MRSA trends are similar for cultures and codes, and MSSA trends are divergent (Fig. 2). For hospitalizations with septicemia, mortality was highest among those with a blood culture only (31.3%) compared to hospitalizations with both a septicemia code and blood culture (16.6%), and septicemia code only (14.7%). Conclusions: ICD diagnosis code sensitivity and PPV for identifying infections were consistently poor in recent years. Less than half of hospitalizations have concordant microbiology laboratory results and diagnosis codes. Rates and trend estimates for MSSA differ by method of identification. Using diagnosis codes to identify S. aureus infections may not be appropriate for descriptive epidemiology or assessing trends due to significant misclassification.

Funding: None

Disclosures: Scott Fridkin reports that his spouse receives consulting fees from the vaccine industry.

Background: The association between antimicrobial use (AMU) and emergence of antimicrobial resistance is well documented. The Canadian Nosocomial Infection Surveillance Program (CNISP) has conducted sentinel surveillance of AMU at participating Canadian hospitals since 2009 resulting in the largest pan-Canadian hospital database of dispensed antimicrobials. Objectives: Describe interhospital variability of AMU across Canada. Methods: Hospitals submit annual AMU data based on patient days (PD). Antimicrobials were measured in defined daily doses (DDD) for adults using the WHO Anatomical Therapeutic Chemical (ATC) system. The AMU data among pediatric patients have been available since 2017 using days of therapy (DOT). Surveillance includes systemic antibacterial agents (J01 ATC codes), oral metronidazole, and oral vancomycin. AMU was assessed using quintiles, interquartile ranges (IQR), and relative IQRs (upper- and lower-quartile values divided by the median). Results: Between 2009 and 2018, 20–26 hospitals participated in adult surveillance each year (35 teaching hospitals and 3 nonteaching hospitals participated in ≥1 year). Over this period, overall AMU decreased by 13% at participating adult hospitals from 645 to 560 DDD per 1,000 PD. AMU varied substantially between hospitals, but this variability decreased over time (Fig. 1). In 2009, the IQRs for overall AMU spanned 309 DDD per 1,000 PD, and in 2018 it spanned only 103 DDD per 1,000 PD. This decrease in variability was due to large decreases in use among hospitals with high use in 2009–2010. Among hospitals in the highest use quintile in 2009–2010, AMU decreased, on average, 44 DDD per 1,000 PD each year. Among hospitals in the lowest use quintile in 2009–2010, AMU increased, on average, 6 DDD per 1,000 PD each year. In 2018, antibiotics with the largest absolute IQR variability were cefazolin (61–113 DDD per 1,000 PD), piperacillin-tazobactam (32–64 DDD per 1,000 PD), and vancomycin (24–49 DDD per 1,000 PD). Among antibiotics with ≥1 DDD per 1,000 PD, antibiotics with the largest relative IQR variability were tobramycin (0.3–6 DDD per 1,000 PD), cefadroxil (0.08–9 DDD per 1,000 PD), and linezolid (0.2–3 DDD per 1,000 PD). In 2018, the IQR for overall pediatric AMU (n = 7 teaching hospitals) was 426–581 DOT per 1,000 PD. Antibiotics with the largest IQRs were vancomycin (0.6–58 DOT per 1,000 PD), cefazolin (33–88 DOT per 1,000 PD), and tobramycin (3–57 DOT per 1,000 PD). Among antibiotics with ≥1 DOT per 1,000 PD in 2018, antibiotics with the largest relative IQRs were tobramycin (3–57 DOT per 1,000 PD), cefuroxime (1–6 DOT per 1,000 PD), and amoxicillin (8–42 DOT per 1,000 PD). Conclusions: There is wide variation in overall antibiotic use across hospitals. Variation between AMU at adult hospitals has decreased between 2009 and 2018; in 2018, antibiotics with the largest IQRs were cefazolin and piperacillin-tazobactam. Benchmarking AMU is crucial for informing antimicrobial stewardship efforts.

Funding: CNISP is funded by the Public Health Agency of Canada.

Disclosures: Allison McGeer reports funds to her institution from Pfizer and Merck for projects for which she is the principal investigator. She also reports consulting fees from Sanofi-Pasteur, Sunovion, GSK, Pfizer, and Cidara.

Background: Although antibiotic stewardship programs (ASP) are now required in nursing homes, assimilating and responding to data to improve prescribing in nursing homes is novel. Four Atlanta-based skilled nursing facilities (SNFs) began collaborating (EASIL: Emory Antibiotic Stewardship in Long-Term Care) to share standardized prescribing data to allow interfacility comparisons and action. Methods: After SNF ASPs were evaluated and trained, standardized prescribing logs were submitted (January 2019 to June 2019) including the following data: start date, treatment site, prescriber attribution of order (ie, SNF order vs hospital order) and monthly resident days. SNF-specific point estimates of usage rates were calculated as pooled means for all antibiotic starts, SNF-order starts, and days of therapy (DOT), by treatment site per 1,000 resident days. Duration of urinary tract infection (UTI) therapy was assessed by calculating percentage of SNF-UTI starts over recommended duration defined by the local treatment guideline. Rate ratios (RRs) of use were calculated to compare SNF-specific rates to the largest SNF. The 95% CIs were calculated using normal approximation. Results: Monthly starts ranged from 124 to 177, with a pooled mean of 7.8 antibiotic starts (any type), 4.5 SNF-order starts, and 1.2 SNF-UTI starts per 1,000 resident days. Approximately half of all starts were SNF starts (range, 43%–53%), and less than half of DOT were attributed to SNF starts (range, 35%–45%). Overall, SNF-order treatment sites were most often UTIs (29%), lower respiratory infections (17%), and skin and soft-tissue infections (17%). SNF-order UTI starts per 1,000 patient days varied at 1 SNF (SNF B RR, 1.57; 95% CI, 1.04–2.36). SNF-order UTI DOT per 1,000 patient days was more variable, with SNFs B and C having significantly higher rates (B RR, 1.49, 1.24, and 1.82; C RR, 5.42; 95% CI, 4.65–6.34) than SNF A (Fig. 1). The percentage of SNF-order UTI starts that were over recommended duration ranged from 8% (nitrofurantoin, SNF A) to 100% (fluoroquinolones, SNF C) (Fig. 1). Conclusions: Although UTIs are the single most common reason to prescribe antibiotics after arriving in a SNF, they account for a small fraction of overall starts and an even smaller fraction of DOT. We identified outlier prescribing by different SNFs using 3 metrics, suggesting that distinct corrective actions are necessary to target distinct prescribing challenges (starts, duration, and transitions of care).

Funding: None

Disclosures: Scott Fridkin reports that his spouse receives consulting fees from the vaccine industry.

Background: Current NHSN denominator reporting for central-line–associated bloodstream infection (CLABSI) counts each patient day with n central lines as 1 central-line day. The NHSN does not directly adjust for potential increased risk of CLABSI from concurrent central lines, but the current NHSN standardized infection ratio (SIR) methods may account for differences in concurrence by adjusting for location type. Objective: We examined differences in central-line concurrence by NHSN location type among CLABSI patients. Methods: In a retrospective cohort of adults with CLABSI at 4 hospitals from 2012 to 2017, we linked central-line data to encounter and CLABSI data. Central lines were considered concurrent if they overlapped for >1 day. We calculated proportion of patients with concurrence at both NHSN location and SIR group levels; risk ratios for concurrence between NHSN location types within each SIR group (ie,, locations defined by SIR models as equal “risk”) were determined. Results: In total, 930 CLABIs were identified from 19 NHSN-defined locations that map to 7 SIR groups. Most CLABSIs occurred in locations mapped to either of 2 SIR groups: wards (227, 16% concurrence) and ICUs (294, 33% concurrence). The ward group had 3 NHSN locations (median, 78 CLABSIs) with concurrence range 8% (medical-surgical ward) to 20% (surgical ward). The ICU group had 6 NHSN locations (median, 47.5 CLABSIs) and concurrence ranged from 20% (neurosurgical ICU) to 39% (medical ICU). Despite the noted variations, no risk ratio was statistically different within each SIR group (Table 1). Conclusions: In patients with CLABSIs, the frequency of concurrence varied up to 2-fold between location types within the current NHSN SIR groups, though not statistically significantly. Assessing whether this difference in magnitude persists in all patients with central lines is an important next step in refining risk adjustment methods to account for concurrent central-line use.

Funding: None

Disclosures: Scott Fridkin reports that his spouse receives consulting fees from the vaccine industry.

Background: The need for screening and isolation for patients colonized with vancomycin-resistant Enterococcus (VRE) remains controversial. In this study, we examined the effects of discontinuation and reinstatement of these practices on VRE infection and colonization incidence within a multisite, tertiary-care hospital center, including its effects on specific at-risk groups. Methods: We retrospective analyzed VRE clinical isolate, infection, and bacteremia incidence rates at our hospital (1) prior to discontinuation of universal screening and isolation (January 2010–June 2012), (2) during discontinuation (July 2012–April 2017), and (3) after reinstatement of screening and isolation in high-risk wards (intensive care and multiple-organ transplant units, June 2017–April 2019). Monthly incidence rates were calculated for each of 3 sites at our tertiary-care hospital: site A, which includes the transplant program, site B, an adult cancer hospital, and site C, which includes orthopedic and neurology programs. To understand the differential effect of screening and isolation on various risk groups, incidence rates were also calculated for individual programs within our hospital, including medicine, surgery, intensive care, oncology, and transplant programs. Results: During the period of study, 3,167 cases of VRE isolates were identified. Patient colonizations of VRE across the institution increased throughout the study period, with the monthly number of newly colonized patients increasing from 10.4 in the first period of study to 20.6 in the last period. The overall VRE clinical isolate, infection, and bacteremia incidence rates did not increase following the cessation of VRE screening and isolation precautions; however, a significant increase was seen among the patients at site B (Fig. 1, infection rates). Furthermore, there was a significant decrease in VRE clinical isolate, infection, and bacteremia incidence following the reinstatement of screening in the ICU and transplant programs at site A, but no effect was seen in the other programs (Fig. 2, infection rates). Conclusions: The risk associated with discontinuing VRE screening and isolation measures appears depend on the subgroup of patients within a hospital environment. Furthermore, risk-based or unit-based VRE screening and isolation appears to be effective at controlling VRE incidence, even after measures had previously been discontinued. Additional study of other inpatient settings is warranted to determine the effects of screening and isolation for VRE on other patient subgroups.

Funding: None

Disclosures: Susy Hota reports contract research for Finch Therapeutics.

Background: Most cases of Legionnaires’ disease are diagnosed by the urinary antigen test (UAT). Single cases of suspected healthcare-acquired Legionnaires’ disease are often investigated by local and state health departments. Such investigations can result in disruptive and expensive interventions. We report a case of a urine-antigen–positive patient whose clinical presentation was inconsistent with Legionnaires’ disease. Within the same year, an employee at this hospital was diagnosed with presumed community-acquired Legionnaires’ disease; however, the case was considered by the health department to be healthcare acquired. The occurrence of 2 cases, as determined by the health department, fulfilled the definition for an outbreak investigation and triggered water restrictions and extensive testing of the environment and patients for Legionella. The cases and the implications of these actions are reviewed in the context of new information about false-positive urinary-antigen tests and changes to the outbreak case definitions for Legionnaires’ disease by the Council of State and Territorial Epidemiologists (CTSE). This includes “probable” cases that have no positive diagnostic tests.

Funding: None

Disclosures: Janet E. Stout reports salary from the Special Pathogens Laboratory and is an owner.