Implementing nasal povidone-iodine decolonization to reduce infections in hemodialysis units: a qualitative assessment

BACKGROUND

A substantial proportion of patients undergoing hemodialysis carry Staphylococcus aureus in their noses, and carriers are at increased risk of S. aureus bloodstream infections. Our pragmatic clinical trial implemented nasal povidone-iodine (PVI) decolonization for the prevention of bloodstream infections in the novel setting of hemodialysis units.

OBJECTIVE

We aimed to identify pragmatic strategies for implementing PVI decolonization among patients in outpatient hemodialysis units.

DESIGN

Qualitative descriptive study.

SETTING

Outpatient hemodialysis units affiliated with five US academic medical centers. Units varied in size, patient demographics, and geographic location.

INTERVIEWEES

Sixty-six interviewees including nurses, hemodialysis technicians, research coordinators, and other personnel.

METHODS

We conducted interviews with personnel affiliated with all five academic medical centers and conducted thematic analysis of transcripts.

RESULTS

Hemodialysis units had varied success with patient recruitment, but interviewees reported that patients and healthcare personnel (HCP) found PVI decolonization acceptable and feasible. Leadership support, HCP engagement, and tailored patient-focused tools or strategies facilitated patient engagement and PVI implementation. Interviewees reported both patients and HCP sometimes underestimated patients' infection risks and experienced infection-prevention fatigue. Other HCP barriers included limited staffing and poor staff engagement. Patient barriers included high health burdens, language barriers, memory issues, and lack of social support.

CONCLUSION

Our qualitative study suggests that PVI decolonization would be acceptable to patients and clinical personnel, and implementation is feasible for outpatient hemodialysis units. Hemodialysis units could facilitate implementation by engaging unit leaders, patients and personnel, and developing education for patients about their infection risk.

Impact of a syndrome-based stewardship intervention on antipseudomonal beta-lactam use, antimicrobial resistance, C. difficile rates, and cost in a safety-net community hospital

Broad-spectrum antimicrobials are commonly used without indication and contribute to antimicrobial resistance (AMR). We implemented a syndrome-based stewardship intervention in a community hospital that targeted common infectious syndromes and antipseudomonal beta-lactam (APBL) use. Our intervention successfully reduced AMR, C. difficile rates, use of APBLs, and cost.

Impact of a midline catheter prioritization initiative on device utilization and central line-associated bloodstream infections at an urban safety-net community hospital

Overuse of peripherally inserted central catheters (PICCs) can lead to idle central line (CL) days and increased risk for CL-associated bloodstream infections (CLABSIs). We established a midline prioritization initiative at a safety-net community hospital. This initiative led to possible CLABSI avoidance and a decline in PICC use.

Changing the culture: impact of a diagnostic stewardship intervention for urine culture testing and CAUTI prevention in an urban safety-net community hospital

Cultures from urinary catheters are often ordered without indication, leading to possible misdiagnosis of catheter-associated urinary tract infections (CAUTI), increasing antimicrobial use, and C difficile. We implemented a diagnostic stewardship intervention for urine cultures from catheters in a community hospital that led to a reduction in cultures and CAUTIs.

Antimicrobial stewardship and drug formulary restrictions during COVID-19: what is restricted and who decides?

COVID-19 therapies were challenging to deploy due to evolving literature and conflicting guidelines. Antimicrobial stewardship can help optimize drug use. We conducted a survey to understand the role of stewardship and formulary restrictions during the pandemic. Restrictions for COVID-19 therapies were common and approval by infectious disease physicians often required.

Decreased hospital readmissions after programmatic strengthening of an outpatient parenteral antimicrobial therapy (OPAT) program

OBJECTIVE

To determine whether a structured OPAT program supervised by an infectious disease physician and led by an OPAT nurse decreased hospital readmission rates and OPAT-related complications and whether it affected clinical cure. We also evaluated predictors of readmission while receiving OPAT.

PATIENTS

A convenience sample of 428 patients admitted to a tertiary-care hospital in Chicago, Illinois, with infections requiring intravenous antibiotic therapy after hospital discharge.

METHODS

In this retrospective, quasi-experimental study, we compared patients discharged on intravenous antimicrobials from an OPAT program before and after implementation of a structured ID physician and nurse-led OPAT program. The preintervention group consisted of patients discharged on OPAT managed by individual physicians without central program oversight or nurse care coordination. All-cause and OPAT-related readmissions were compared using the χ² test. Factors associated with readmission for OPAT-related problems at a significance level of P < .10 in univariate analysis were eligible for testing in a forward, stepwise, multinomial, logistic regression to identify independent predictors of readmission.

RESULTS

In total, 428 patients were included in the study. Unplanned OPAT-related hospital readmissions decreased significantly after implementation of the structured OPAT program (17.8% vs 7%; P = .003). OPAT-related readmission reasons included infection recurrence or progression (53%), adverse drug reaction (26%), or line-associated issues (21%). Independent predictors of hospital readmission due to OPAT-related events included vancomycin administration and longer length of outpatient therapy. Clinical cure increased from 69.8% before the intervention to 94.9% after the intervention (P < .001).

CONCLUSION

A structured ID physician and nurse-led OPAT program was associated with a decrease in OPAT-related readmissions and improved clinical cure.

Remdesivir use and antimicrobial stewardship restrictions during the coronavirus disease 2019 (COVID-19) pandemic in the United States: A cross-sectional survey

Deploying therapeutics for coronavirus disease 2019 (COVID-19) has proved challenging due to evolving evidence, supply shortages, and conflicting guideline recommendations. We conducted a survey on remdesivir use and the role of stewardship. Use differs significantly from guidelines. Hospitals with remdesivir restrictions were more guideline concordant. Formulary restrictions can be important for pandemic response.

1109. Rise and Fall of COVID-19 Therapies Throughout Different Waves of the Pandemic: Results of a Nationwide Survey

Background

The COVID-19 pandemic has caused a major public health crisis and is now a leading cause of death. At the start of the COVID-19 pandemic, treatment was limited to supportive care and off-label use of a variety of agents as we awaited the results of randomized controlled trials (RCTs). Our understanding of the disease has evolved and multiple evidence-based (EBM) treatment strategies supported by RCTs are now approved for use. Interpreting emerging data while responding to the pandemic can been challenging. We seek to understand the use of common medications during the COVID-19 pandemic.

Methods

A survey was developed and disseminated through Infectious Diseases Society of America (IDSA) IDea network, IDSA Antimicrobial Stewardship Centers for Excellence and the Society for Healthcare Epidemiology messaging boards. Data collected included city, therapeutic options including convalescent plasma (CP), hydroxychloroquine (HCQ), baricitinib and tocilizumab during each COVID-19 wave.

Results

A total of 78 responses were collected, representing wide geographic reach in the US (Figure 1). Use of HCQ declined by 96% and use of CP declined by 85% (Figure 2). The decline in CP was gradual each wave despite RCTs showing lack of benefit. Tocilizumab was used in 71% and 76% of hospitals during the first wave, prior to RCT data supporting its use. Baricitinib was used in 42% of hospitals prior to RCT data supporting its use. There was a 90% increase in baricitinib use after RCT data emerged. Figure 1Geographic distribution of hospitals represented in the survey

Figure 2 Use of Hydroxychloroquine, Convalescent Plasma, Tocilizumab and Baricitinib Throughout Different COVID-19 Waves

Conclusion

The use of therapies before proven benefit was common through the pandemic. Similarly, the use of therapies after benefit was in question continued. Hydroxychloroquine was widely used in the first wave and then halted by the majority of hospitals in subsequent COVID-19 surges. IL-6 and JAK-2 inhibitors were commonly used prior to evidence of benefit and were more widely adopted once evidence emerged. Convalescent plasma use was common despite lack of evidence and its use continued despite multiple negative RCTs. Overall, our survey shows a gap between evidence and practice. Communicating evidence-based treatment strategies is a vital priority for major professional societies. Translating evidence into practice remains challenging during public health emergencies like the COVID-19 pandemic.

Disclosures

All Authors: No reported disclosures.

929. A Nationwide Survey on the Role of Antimicrobial Stewardship Programs during the COVID-19 Pandemic: What is restricted and who decides?

Background

During the COVID-19 pandemic, evolving literature and emerging therapies have led to significant controversies on what constitutes optimal therapy for hospitalized patients with COVID-19. In addition, multiple guidelines emerged exhibiting variable recommendations in key areas of therapeutic management. Thus, interpreting emerging data and deploying novel therapeutics during the pandemic has been challenging. Antimicrobial stewardship programs (ASP) have been proven to help promote evidence-based practices and are now common the United States (US). We seek to further understand the role of ASP during the COVID-19 pandemic.

Methods

A survey was developed and disseminated through Infectious Diseases Society of America (IDSA) IDea network, IDSA Antimicrobial Stewardship Centers for Excellence and the Society for Healthcare Epidemiology messaging boards. Data collected included city, hospital size, facility type, and existence of active ASP. COVID-19 therapeutic restrictions and type of provider who decides on treatment allocation was surveyed.

Results

A total of 92 surveys were completed, representing wide geographic reach within the United States (Figure 1). Hospital size by beds were 14% less than 200 (13), 18.5% 201-300 beds (17), 15.2% 301-400 beds (14), and 52.2% over 400 beds (48). Community hospitals accounted for 31.5% (29), county/public hospital 3.3% (3, 3.3%), University-affiliated Community-Based Teaching Hospitals 10.9% (10), University-based Teaching Hospital 45.7% (42), and 8.7% selected other. ASP were present in 97.2% of hospitals. COVID-19 therapeutic restrictions were common (Figure 2). Infectious diseases (ID) approval was required in 87.9% of facilities (Figure 3). Figure 1Geographic distribution of hospitals represented in the survey

Figure 2. Restricted COVID-19 therapies by medication type (%)

Figure 3 Specialties or providers that are able to order or approve restricted COVID-19 therapies (%)

Conclusion

COVID-19 therapeutics were commonly restricted during the COVID-19 pandemic. Approval by ID clinicians was required almost universally (87.9%). The role of other specialties was significantly lower, representing less than 45% of hospitals. ID clinicians have played a vital role in guiding therapy and supporting ASP during the COVID-19 pandemic. This survey highlights the value of ID clinicians to healthcare systems in allocating resources and promoting evidence-based practices through ASP.

Disclosures

All Authors: No reported disclosures.

1107. A Survey on Remdesivir Use and Antimicrobial Stewardship Restrictions Throughout the COVID-19 Pandemic

Background

Remdesivir (RDV) was the first agent with proven clinical benefit against COVID-19, shortening the time to recovery in a randomized placebo-controlled trial (RCT). Based on this trial, the Food and Drug Administration approved RDV via emergency use authorization. Despite its wide use, RDV remains controversial. Early use of RDV in patients requiring low flow nasal canula has robust evidence. However, benefit in mechanical ventilation (MV), high-flow nasal canula (HFNC) and non-invasive positive pressure ventilation (NIPPV) is conflicting. Multiple studies, most notably the SOLIDARITY and DisCoVeRy trial, have conflicting results on who benefits from RDV. Deploying novel therapeutics in this changing landscape is challenging. We seek to understand RDV practices and the role of antimicrobial stewardship (ASP) in hospitals across the US.

Methods

A survey was developed and disseminated through Infectious Diseases Society of America (IDSA) IDea network, IDSA Antimicrobial Stewardship Centers for Excellence and the Society for Healthcare Epidemiology messaging boards. Data collected included city, presence of RDV therapeutic restrictions, and RDV use by degree of oxygen needs for each COVID-19 wave.

Results

A total of 78 responses were collected, representing wide geographic reach in the US (Figure 1). RDV was restricted in 53% of facilities. Hospitals without restrictions commonly used RDV for patients on MV, NIPPV and HFNC, with more use on HFNC than on NC during the first winter, Delta and Omicron waves (Figure 2). Use on MV declined with each surge. Hospitals with RDV restrictions had more use of RDV on NC than all other ordinal scales (Figure 3). Use in MV, NIPPV and HFNC compared to NC declined in the restricted group with each COVID-19 surge. Figure 1.Geographic distribution of hospitals represented in the survey

Figure 2. Remdesivir use by oxygen requirements in hospitals without remdesivir therapeutic restrictions.

Figure 3 Remdesivir use by oxygen requirements in hospitals without remdesivir therapeutic restrictions.

Conclusion

A wide gap between evidence-based guidelines and actual practice exists. This gap was wider in hospitals without COVID-19 therapeutic restrictions in place for RDV. In the unrestricted group, RDV was commonly used for MV, HFNC and NIPPV, where robust RCT evidence of benefit is lacking. Though this practice occurred in both groups, the restricted RDV group prioritized RDV use in NC and did so at higher percentages each subsequent COVID-19 surge. ASP restrictions can have an important role in guiding COVID-19 therapy.

Disclosures

All Authors: No reported disclosures.

1666. Sources and Preventability of Hospital-onset Bacteremia and Fungemia in the United States: Evaluation of a Potential Healthcare Quality Measure

Background

Hospital-onset bacteremia and fungemia (HOB) is being proposed as a potential healthcare quality measure due to its clinical significance, objectivity, and ease of detection. However, information is lacking on sources of HOB and the proportion and types of cases considered preventable.

Methods

We evaluated sources and potential preventability of HOB cases at 12 hospitals using retrospective chart review. HOB was defined as a positive blood culture &gt;= day 4 (admission date=day 1) for one or more organisms. Stratified sampling of cases by commensal and noncommensal organisms was used. Infectious disease physicians determined the source of HOB and rated preventability from 1-6 (1=definitely preventable to 6=definitely not preventable) using a previously validated guide. Ratings of 1–3 were collectively considered potentially preventable and 4–6 likely not preventable.

Results

We evaluated sources and potential preventability of HOB cases at 12 hospitals using retrospective chart review. HOB was defined as a positive blood culture &gt;= day 4 (admission date=day 1) for one or more organisms. Stratified sampling of cases by commensal and noncommensal organisms was used. Infectious disease physicians determined the source of HOB and rated preventability from 1–6 (1=definitely preventable to 6=definitely not preventable) using a previously validated guide. Ratings of 1–3 were collectively considered potentially preventable and 4–6 likely not preventable.

Conclusion

Gastrointestinal and endovascular sources account for a large majority of noncommensal HOB cases. A high proportion of noncommensal HOB cases are likely not preventable. The presence of non-preventable events should be considered when using HOB as a quality measure. Approaches to identifying the subset of preventable noncommensal HOB events should be explored.

Disclosures

Scott Fridkin, MD, Pfizer: Grant/Research Support Andi L. Shane, MD, MPH, MSc, International Scientific Association for Probiotics and Prebiotics (ISAPP): travel and lodging to attend international meeting to deliver a presentation, June 2022 Aaron Milstone, MD, Merck: Grant/Research Support Rajeshwari Nair, MBBS, PhD, Vertex Pharmaceuticals: Salary.

1664. Impact of a Midline Catheter Prioritization Project on Central Venous Access and Central Line Associated Bloodstream Infections at an Urban Safety-net Community Hospital

Background

The use of peripherally inserted central catheters (PICCs) has increased in the past decade. PICCs are central lines (CLs) commonly used for venous access. Midline catheters (MLs) can provide access when the need for a CL, such as vasopressors, is no longer present. MLs have a lower rate of BSI compared to PICCs and CLs, while providing dwell times comparable to PICCs. We established a project prioritizing ML use.

Methods

This is a quasi-experimental study in a 151-bed safety net community hospital. The pre-intervention period was January-December 2018 and post period was January 2019-December 2021. MLs were prioritized when new PICCs are requested without CL indications, such as total parenteral nutrition, hyperosmolar solutions and vasopressors. PICCs and CLs are transitioned to a ML once indications are no longer met and peripheral IVs are not feasible. Data on utilization and complications, such as deep venous thrombus (DVT) and BSIs, were reviewed and compared.

Results

A total of 63 peripherally inserted lines occurred prior to the intervention, of which 55 (87%) were PICC and 8 (13%) were ML (Figure 1). Post-intervention, 76 lines were placed the first year, of which 48 were ML (63%). This upward trend was sustained throughout the pandemic, with 116 lines in 2020 (80% ML) and 96 in 2021 (88% ML). No BSIs occurred during the pre-intervention and first post-intervention year. During the pandemic, 8 BSIs in MLs and 3 in PICCs occurred. The most common organism was Candida (Figure 2). The majority had COVID-19 (72%) and all (100%) BSIs were in the setting of shock. Case review demonstrated suspected secondary sources other than central venous catheters (CVCs). All BSIs with ML would have met NHSN criteria if CL present. No upper extremity DVTs were found.

Conclusion

A midline prioritization project was successfully implemented and sustained during the COVID-19 pandemic. The decline of PICC use from 87% to 12% suggests use for access without CL needs. High acuity during the pandemic led to BSIs that were likely secondary to shock and complications of COVID-19. All cases would have met NHSN criteria for CLABSI. The cost of a CLABSI is estimated at $48,108. Thus, this midline prioritization project may have led to CLABSI avoidance and an estimated cost savings of $384,864.

Disclosures

All Authors: No reported disclosures.

A nationwide survey of antimicrobial dispensation practices in pharmacies and bodegas in the Dominican Republic

In many developing countries, antimicrobials are available without prescriptions in pharmacies and stores. We performed a survey to describe antimicrobial availability, training, and use recommendations for common symptoms in the Dominican Republic. Pharmacy recommendations varied, whereas aminopenicillins are routinely recommended at bodegas. Frontline staff are gatekeepers and potential targets for stewardship education.

Development and evaluation of a structured guide to assess the preventability of hospital-onset bacteremia and fungemia

OBJECTIVE

To assess preventability of hospital-onset bacteremia and fungemia (HOB), we developed and evaluated a structured rating guide accounting for intrinsic patient and extrinsic healthcare-related risks.

DESIGN

HOB preventability rating guide was compared against a reference standard expert panel.

PARTICIPANTS

A 10-member panel of clinical experts was assembled as the standard of preventability assessment, and 2 physician reviewers applied the rating guide for comparison.

METHODS

The expert panel independently rated 82 hypothetical HOB scenarios using a 6-point Likert scale collapsed into 3 categories: preventable, uncertain, or not preventable. Consensus was defined as concurrence on the same category among ≥70% experts. Scenarios without consensus were deliberated and followed by a second round of rating.Two reviewers independently applied the rating guide to adjudicate the same 82 scenarios in 2 rounds, with interim revisions. Interrater reliability was evaluated using the κ (kappa) statistic.

RESULTS

Expert panel consensus criteria were met for 52 scenarios (63%) after 2 rounds.After 2 rounds, guide-based rating matched expert panel consensus in 40 of 52 (77%) and 39 of 52 (75%) cases for reviewers 1 and 2, respectively. Agreement rates between the 2 reviewers were 84% overall (κ, 0.76; 95% confidence interval [CI], 0.64-0.88]) and 87% (κ, 0.79; 95% CI, 0.65-0.94) for the 52 scenarios with expert consensus.

CONCLUSIONS

Preventability ratings of HOB scenarios by 2 reviewers using a rating guide matched expert consensus in most cases with moderately high interreviewer reliability. Although diversity of expert opinions and uncertainty of preventability merit further exploration, this is a step toward standardized assessment of HOB preventability.

Characteristics of Pregnant Women with Syphilis and Factors Associated with Congenital Syphilis at a Chicago Hospital

Background

Congenital syphilis incidence has more than tripled in recent years, in parallel with the resurgence of syphilis among reproductive-aged women. An understanding of risk factors associated with maternal syphilis infection can guide prevention of congenital syphilis through prenatal diagnosis and treatment. We aimed to describe factors associated with maternal syphilis and congenital syphilis at a public medical center in Chicago, Illinois.

Methods

Maternal syphilis diagnoses were identified using a database for local health department reporting. Medical records were reviewed for infant congenital syphilis diagnoses, sociodemographic information, medical history, and other behavioral factors. Maternal characteristics associated with congenital syphilis were assessed using logistic regression.

Results

Of 106 maternal syphilis diagnoses between 2014 and 2018, 76 (72%) had a known pregnancy outcome; of these, 8 (11%) delivered an infant with congenital syphilis. Women with psychiatric illness and noninjection substance use each had a >5-fold increased odds of having an infant with congenital syphilis. Cases with congenital syphilis were more likely to have late or scant prenatal care and initiated treatment nearly 3 months later in pregnancy. None were human immunodeficiency virus positive or reported incarceration, intravenous substance use, sex work, or having sex with men who have sex with men.

Conclusions

Maternal psychiatric illness and substance use may have complicated prenatal care and delayed syphilis treatment, describing a population in need of public health intervention. Women experiencing such barriers to care may benefit from closer follow-up after a prenatal syphilis diagnosis to prevent congenital transmission.

408. Impact of the COVID-19 Pandemic on Antimicrobial Use and Resistance in the United States and the Dominican Republic

Background

The disease caused by SARS-CoV-2, COVID-19, has caused a global public health crisis. Lower respiratory tract infections (LRTIs) caused by COVID-19 has led to an increase in hospitalizations. Disease severity and concerns for bacterial co-infections can increase antimicrobial pressure. Our aim is to define and compare the impact of COVID-19 on antimicrobial use (AU) and antimicrobial resistance (AMR) in the Dominican Republic (DR) and the United States (US).

Methods

We performed a retrospective review of AU and antimicrobial susceptibility patterns from 2019-20 at a hospital in the US (H-US) and the DR (H-DR). Our sites are community teaching hospitals with 151 beds in H-US and 295 beds in H-DR. After AU was tabulated, percent changes between 2019-20 were calculated. Resistance patterns for extended-spectrum beta-lactamase producing (ESBL) E coli, ESBL Klebsiella pneumoniae (ESBL-Kp), carbapenem resistant Pseudomonas aeruginosa (CR-PSAR) and Klebsiella pneumoniae (CR-Kp) were tabulated and percent changes between 2019-20 were calculated.

Results

AU increased by 10% in H-US and 25% in H-DR, with carbapenem use increasing by 268% and 144% respectively. Ceftriaxone use increased by 30% in H-US and 33% in H-DR. Azithromycin increased 54% in H-US and 338% in the H-DR. Resistance increased from 10% to 28% for ESBL-Kp and from 10% to 12% for ESBL E coli at H-US. CR-PSAR decreased from 20% to 12%, while cefepime and piperacillin resistance increased from 5% to 20% and 3% to 16% respectively (Figure 1). At H-DR, ESBL-Kp resistance decreased from 68% to 64% and increased from 58% to 59% for ESBL E coli. CR-PSAR and cefepime resistance increased from 5% to 19% and from 9% to 29% respectively (Figure 2).

Figure 1. Antimicrobial resistance (%) for select organisms at H-US in 2019 and 2020

Conclusion

COVID-19 had a major impact on antimicrobial consumption and resistance in the US and DR. A greater impact was seen on ESBL rates in the US whilst a greater impact on carbapenem resistance was seen in the DR. The rise in carbapenem use in H-US reflected a rise in ESBL rates. In the DR, ESBL producing organisms were common prior to COVID-19 and carbapenem use was more widespread. The impact of the COVID-19 pandemic on AU may accelerate AMR worldwide. The scale up of antimicrobial stewardship across the globe is urgently needed to curb AMR.

Disclosures

All Authors: No reported disclosures

417. COVID-19 Aerostudy: Evaluation of SARS-CoV-2 Virus in the Air of Patients Hospitalized with COVID-19

Background

At the onset of the COVID-19 pandemic, hospitals implemented infection control measures with limited data on predictors of nosocomial SARS-CoV-2 transmission. We aimed to quantify SARS-CoV-2 presence in an inpatient setting to understand nosocomial risk.

Methods

Patients admitted with confirmed SARS-CoV-2 infection at an urban academic hospital were enrolled. Demographic/clinical characteristics, a PCR nasal swab(NS), and air samples on filter media in the near- (< 6ft) and far-field ( >6ft) of each patient for 3.5 hours were collected. PCR was used to detect SARS-CoV-2 on filter media. Associations between clinical characteristics and presence of SARS-CoV-2 in air samples used Fisher’s exact and Wilcoxon rank sum tests.

Results

Of 52 subjects, 46% had no detectable virus by nasal swab on the day of sampling. Of 104 room air samples, 16% had detectable virus from 25% of rooms, including 10 near and 7 far field samples. Subjects with a positive room air sample had fewer days from symptom-onset compared with those with a negative air sample (median 6 vs. 8, p=0.24). Being on room air and having a nasal swab positive increased the odds of detecting virus in air samples but were not statistically significant.

Conclusion

A small number of air samples with detectable SARS-CoV-2 may suggest lower nosocomial risk than previously anticipated. Multiple subject and environmental factors may have contributed to this finding including patient source control masking, anti-viral therapies and HEPA filtration. The decreased association of virus in the air of those with more days of symptoms but with the need for supplemental oxygen may be related to what is now known about the COVID-19 inflammatory response after the infectious period.

Disclosures

All Authors: No reported disclosures

559. A Nationwide Survey of COVID-19 Management in the Dominican Republic Over the Course of the Pandemic

Background

COVID-19 was declared a global Public Health Emergency by the WHO in January 2020. Limited treatment options existed early in the pandemic. As COVID-19 spread across the globe and new therapeutics emerged, different interpretations of the literature grew, and major societies relayed conflictive recommendations. There is a paucity of data on COVID-19 management in low- and middle-income countries. As a result, we performed a nationwide survey of local treatment practices in the Dominican Republic (DR).

Methods

We performed an anonymous survey of infectious diseases specialists in the DR and US. The survey collected hospital characteristics and COVID-19 management protocols during different quarters of 2020-21. Management was categorized by drug and disease severity based on supplemental oxygen requirements. A convenience sample in the US representing community and academic sites was surveyed for point comparison between the US and DR.

Results

The survey was completed by physicians from a total of 11 sites located in 4 cities of the DR: Santo Domingo (3), Santiago (4), La Vega (2) and San Francisco (2). These cities were representative of all regions in the country. The survey included 7 (64%) hospitals with &lt; 200 beds, 3 (27%) with 201-300 beds, and 1 (9%) with &gt;400 beds. Seven (47%) were private, 2 (13%) public, and 6 (40%) were teaching hospitals. In the US, 2 academic hospitals with &gt;400 beds and 2 community hospitals with &lt; 200 beds in a major city were surveyed. Management of COVID-19 at sites in the DR and US throughout the pandemic is plotted in Figure 1. Remdesivir use by disease severity is plotted in Figure 2.

Figure 1. Management of COVID-19 at sites in the US and DR throughout the COVID-19 pandemic

Conclusion

Throughout the pandemic, as therapeutic options evolved, hospitals and physicians had to adapt to changing guidelines and availability of novel drugs. Variability between countries and sites emerged. The use of hydroxychloroquine and convalescent plasma waned more rapidly in the US. Dexamethasone was widely used at all sites. Tocilizumab and remdesivir were used more liberally in the DR. Antimicrobial stewardship limited these agents at US sites to more narrow therapeutic windows which could explain the discrepancies seen between the US and DR. Uncertainty of benefit in certain disease states, limited availability, and cost may also play a role.

Disclosures

All Authors: No reported disclosures

Asymptomatic SARS-CoV-2 Infection and COVID-19 Mortality During an Outbreak Investigation in a Skilled Nursing Facility

Background

Outbreaks of coronavirus disease 2019 (COVID-19) have been reported in nursing homes and assisted living facilities; however, the extent of asymptomatic and presymptomatic severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in this high-risk population remains unclear.

Methods

We conducted an investigation of the first known outbreak of SARS-CoV-2 at a skilled nursing facility (SNF) in Illinois on 15 March 2020 and followed residents for 30 days. We tested 126/127 residents for SARS-CoV-2 via reverse-transcription polymerase chain reaction and performed symptom assessments. We calculated the point prevalence of SARS-CoV-2 and assessed symptom onset over 30-day follow-up to determine: (1) the proportion of cases who were symptomatic, presymptomatic, and asymptomatic and (2) incidence of symptoms among those who tested negative. We used the Kaplan-Meier method to determine the 30-day probability of death for cases.

Results

Of 126 residents tested, 33 had confirmed SARS-CoV-2 on 15 March. Nineteen (58%) had symptoms at the time of testing, 1 (3%) developed symptoms over follow-up, and 13 (39%) remained asymptomatic. Thirty-five residents who tested negative on 15 March developed symptoms over follow-up; of these, 3 were re-tested and 2 were positive. The 30-day probability of death among cases was 29%.

Conclusions

SNFs are particularly vulnerable to SARS-CoV-2, and residents are at risk of severe outcomes. Attention must be paid to preventing outbreaks in these and other congregate care settings. Widespread testing and infection control are key to help prevent COVID-19 morbidity and mortality in these high-risk populations.

The Emperor's New Clothes: PRospective Observational Evaluation of the Association Between Initial VancomycIn Exposure and Failure Rates Among ADult HospitalizEd Patients With Methicillin-resistant Staphylococcus aureus Bloodstream Infections (PROVIDE)

BACKGROUND

Vancomycin is the most commonly administered antibiotic in hospitalized patients, but optimal exposure targets remain controversial. To clarify the therapeutic exposure range, this study evaluated the association between vancomycin exposure and outcomes in patients with methicillin-resistant Staphylococcus aureus (MRSA) bacteremia.

METHODS

This was a prospective, multicenter (n = 14), observational study of 265 hospitalized adults with MRSA bacteremia treated with vancomycin. The primary outcome was treatment failure (TF), defined as 30-day mortality or persistent bacteremia ≥7 days. Secondary outcomes included acute kidney injury (AKI). The study was powered to compare TF between patients who achieved or did not achieve day 2 area under the curve to minimum inhibitory concentration (AUC/MIC) thresholds previously found to be associated with lower incidences of TF. The thresholds, analyzed separately as co-primary endpoints, were AUC/MIC by broth microdilution ≥650 and AUC/MIC by Etest ≥320.

RESULTS

Treatment failure and AKI occurred in 18% and 26% of patients, respectively. Achievement of the prespecified day 2 AUC/MIC thresholds was not associated with less TF. Alternative day 2 AUC/MIC thresholds associated with lower TF risks were not identified. A relationship between the day 2 AUC and AKI was observed. Patients with day 2 AUC ≤515 experienced the best global outcomes (no TF and no AKI).

CONCLUSIONS

Higher vancomycin exposures did not confer a lower TF risk but were associated with more AKI. The findings suggest that vancomycin dosing should be guided by the AUC and day 2 AUCs should be ≤515. As few patients had day 2 AUCs <400, further study is needed to define the lower bound of the therapeutic range.

Prácticas de retiro del equipo de protección personal para personal sanitario

RESUMENCuando se retira el equipo de protección personal (EPP), los patógenos pueden transferirse desde el EPP al cuerpo de los trabajadores de la salud, poniendo en riesgo de exposición e infección tanto a ellos mismos como a sus pacientes. Entre marzo de 2017 y abril de 2018 se observaron las prácticas de retirada del EPP del personal sanitario que atendía pacientes con infecciones respiratorias virales en un hospital de atención de enfermedades agudas. Un observador capacitado registró el desempeño del personal sanitario cuando retiraba el EPP dentro de las habitaciones de los pacientes, utilizando una lista de verificación predefinida basada en las directrices de los Centros para el Control y Prevención de Enfermedades (Centers for Disease Control and Prevention, CDC). Se observaron 162 prácticas de retirada durante el cuidado de 52 pacientes infectados con patógenos virales respiratorios. De estos 52 pacientes, 30 estaban en aislamiento por gota y contacto, 21 en aislamiento por gota y uno en aislamiento de contacto. En general, en 90% de los casos la retirada del EPP observada se realizó de manera incorrecta, ya sea en cuanto a la secuencia de retirada, la técnica de retirada o el uso del EPP apropiado. Los errores más comunes consistieron en quitarse la bata por adelante, retirar la pantalla facial de la mascarilla y tocar superficies y EPP potencialmente contaminados durante el proceso. Las desviaciones del protocolo recomendado para retirar el EPP son comunes y pueden aumentar el potencial de contaminación de la ropa o la piel del personal sanitario después de proporcionar atención. Existe una clara necesidad de cambiar el enfoque utilizado para capacitar al personal en las prácticas de retirada del EPP.

600. Decreased Hospital Readmission After Programmatic Strengthening of an Outpatient Parenteral Antimicrobial Therapy (OPAT) Program

Background

Although it is recommended that an OPAT program should be managed by a formal OPAT team that supports the treating physician, many OPAT programs face challenges in obtaining necessary program staff (i.e nurses or pharmacists) due to limited data examining the impact of a dedicated OPAT team on patient outcomes. Our objective was to compare OPAT-related readmission rates among patients receiving OPAT before and after the implementation of a strengthened OPAT program.

Methods

This retrospective quasi-experiment compared adult patients discharged on intravenous (IV) antibiotics from the University of Illinois Hospital before and after implementation of programmatic changes to strengthen the OPAT program. Data from our previous study were used as the pre-intervention group (1/1/2012 to 8/1/2013), where only individual infectious disease (ID) physicians coordinated OPAT. Post-intervention (10/1/2017 to 1/1/2019), a dedicated OPAT nurse provided full time support to the treating ID physicians through care coordination, utilization of protocols for lab monitoring and management, and enhanced documentation. Factors associated with readmission for OPAT-related problems at a significance level of p< 0.1 in univariate analysis were eligible for testing in a forward stepwise multinomial logistic regression to identify independent predictors of readmission.

Results

Demographics, antimicrobial indications, and OPAT administration location of the 428 patients pre- and post-intervention are listed in Table 1. After implementation of the strengthened OPAT program, the readmission rate due to OPAT-related complications decreased from 17.8% (13/73) to 6.5% (23/355) (p=0.001). OPAT-related readmission reasons included: infection recurrence/progression (56%), adverse drug reaction (28%), or line-associated issues (17%). Independent predictors of hospital readmission due to OPAT-related problems are listed in Table 2.

Table 1. OPAT Patient Demographics and Factors Pre- and Post-intervention

Table 2. Factors independently associated with hospital readmission in OPAT patients

Conclusion

An OPAT program with dedicated staff at a large academic tertiary care hospital was independently associated with decreased risk for readmission, which provides critical evidence to substantiate additional resources being dedicated to OPAT by health systems in the future.

Disclosures

All Authors: No reported disclosures

1142. Increased Odds of Psychiatric Illness Among Mothers of Infants with Congenital Syphilis

Background

Syphilis can be transmitted mother to child during pregnancy leading to multisystem birth defects if untreated. In Illinois, screening is mandated for pregnant women at first and third trimesters. The University of Illinois Hospital (UIH) serves a vulnerable patient population with a high syphilis prevalence. An understanding of risk factors associated with maternal syphilis infection can guide prevention of congenital syphilis (CS) with early prenatal diagnosis and treatment. The aim of this retrospective case control study is to describe maternal risk factors associated with CS in a clinical setting.

Methods

Using a database used for health department reporting from 2014-2018 at UIH, 106 maternal syphilis diagnoses were identified. Medical records were reviewed for CS infant diagnosis, sociodemographic information, medical history, and potential risk factors, including multiple sex partners, HIV status, drug use, history of incarceration or sex work, and having sex with men who have sex with men (MSM). Cases were matched with controls of pregnant women with syphilis testing that was not indicative of infection.

Results

Of the maternal syphilis diagnoses identified, there were 8 cases in which CS was possible or highly probable, 68 in which CS was less likely or unlikely, and 30 that were lost to follow up. Of the possible and probable infants’ mothers, 38% had a psychiatric illness (6.80 OR, 95% CI 1.06-43.48) and 25% were homeless (12.00 OR, 95% CI 0.94-153.89). Late or scant prenatal care was seen in 75% (4.15 OR, 95% CI 0.72-23.95) and 75% had inadequate syphilis treatment. None were HIV positive or reported incarceration, intravenous drug use, sex work, or having sex with MSM.

Conclusion

Among infants with probable or possible CS, there was a 6.80 increased odds of maternal psychiatric illness compared to those born to mothers not diagnosed with syphilis, which may have complicated prenatal care and delayed diagnosis or treatment. Psychiatric illness outnumbered several other known risk factors; however, these may be less often discussed during clinical encounters. Psychiatric illness history may be a risk factor and means to identify women in the clinical setting who need close follow up and outreach after a prenatal syphilis diagnosis to prevent or mitigate congenital transmission.

Disclosures

All Authors: No reported disclosures

Going for the Gold: A Description of the Centers of Excellence Designation by the Infectious Diseases Society of America

Antimicrobial stewardship programs (ASPs) are recommended by the Centers for Disease Control and Prevention and World Health Organization and mandated by the Joint Commission to curb antimicrobial resistance. However, <50% of institutions have optimal ASPs in place. Building on its experience of antimicrobial stewardship (AMS) advocacy, the Infectious Diseases Society of America (IDSA) developed the AMS Centers of Excellence (CoE) program, which will serve as a conduit to share best practices and highlight the standards for other hospitals to achieve in order to advance the field of AMS. A designation of CoE signifies that these institutions deliver high-quality care consistently, serve as the "gold" standard for executing novel AMS principles, and demonstrate commitment to their ASP. Here, we describe the process and purpose of designating institutions as AMS CoEs, provide awareness to clinicians on opportunities available through IDSA with this CoE designation, and discuss the evolution of the program.

Impact of a hospital-wide huddle on device utilisation and infection rates: a community hospital's journey to zero

Background

Device utilisation ratios (DUR) correlate with device-associated complications and rates of infection. We implemented a hospital-wide Daily Interdisciplinary Safety Huddle (DISH) with infection control and device components. The aim of this study was to evaluate the impact of DISH on DURs and rates of infection for indwelling urinary catheters (IUC) and central venous catheters (CVC).

Methods

A quasi-experimental study assessing DURs and rates of infection before and after implementation of DISH. At DISH, usage of IUC and CVC is reported by managers and the infection preventionist reviews indications and plans for removal. Data before and after implementation were compared. Paired T-test was used to assess for differences between both groups.

Results

DISH was successfully implemented at a community hospital. The average DUR for IUC in intensive care unit (ICU) and non-ICU settings was reduced from 0.56 to 0.35 and 0.27 to 0.12, respectively. CVC DUR decreased from 0.29 to 0.26 in the ICU and 0.14 to 0.12 in non-ICU settings. Catheter-associated urinary tract infections (CAUTIs) decreased by 87% and central line-associated bloodstream infections (CLABSIs) by 96%.

Conclusion

DISH was associated with hospital-wide reductions in DUR and device-associated healthcare-associated infections. Reduction of CLABSIs and CAUTIs had estimated cost savings of $688,050. The impact was more profound in non-ICU settings. To our knowledge, an infection prevention hospital-wide safety huddle has not been reported in the literature. DISH increased device removal, accountability and promoted a culture of safety.

Early Infectious Diseases Specialty Intervention Is Associated With Shorter Hospital Stays and Lower Readmission Rates: A Retrospective Cohort Study

Background

Intervention by infectious diseases (ID) physicians improves outcomes for inpatients in Medicare, but patients with other insurance types could fare differently. We assessed whether ID involvement leads to better outcomes among privately insured patients under age 65 years hospitalized with common infections.

Methods

We performed a retrospective analysis of administrative claims data from community hospital and postdischarge ambulatory care. Patients were privately insured individuals less than 65 years old with an acute-care stay in 2014 for selected infections, classed as having early (by day 3) or late (after day 3) ID intervention, or none. Key outcomes were mortality, cost, length of the index stay, readmission rate, mortality, and total cost of care over the first 30 days after discharge.

Results

Patients managed with early ID involvement had shorter length of stay, lower spending, and lower mortality in the index stay than those patients managed without ID involvement. Relative to late, early ID involvement was associated with shorter length of stay and lower cost. Individuals with early ID intervention during hospitalization had fewer readmissions and lower healthcare payments after discharge. Relative to late, those with early ID intervention experienced lower readmission, lower spending, and lower mortality.

Conclusions

Among privately insured patients less than 65 years old, treated in a hospital, early intervention with an ID physician was associated with lower mortality rate and shorter length of stay. Patients who received early ID intervention during their hospital stay were less likely to be readmitted after discharge and had lower total healthcare spending.

A systematic risk-based strategy to select personal protective equipment for infectious diseases

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Selection of personal protective equipment (PPE) can be systematic and risk-based.

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Potential exposures are compared with sites susceptible to infection.

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Facilitates transparent decision-making about personal protective equipment.

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PPE evaluation includes: donning/doffing/changing, usability, and fit for purpose.

Background

Personal protective equipment (PPE) is a primary strategy to protect health care personnel (HCP) from infectious diseases. When transmission-based PPE ensembles are not appropriate, HCP must recognize the transmission pathway of the disease and anticipate the exposures to select PPE. Because guidance for this process is extremely limited, we proposed a systematic, risk-based approach to the selection and evaluation of PPE ensembles to protect HCP against infectious diseases.

Methods

The approach used in this study included the following 4 steps: (1) job hazard analysis, (2) infectious disease hazard analysis, (3) selection of PPE, and (4) evaluation of selected PPE. Selected PPE should protect HCP from exposure, be usable by HCP, and fit for purpose.

Results

The approach was demonstrated for the activity of intubation of a patient with methicillin-resistant Staphylococcus aureus or Severe Acute Respiratory Syndrome coronavirus. As expected, the approach led to the selection of different ensembles of PPE for these 2 pathogens.

Discussion

A systematic risk-based approach to the selection of PPE will help health care facilities and HCP select PPE when transmission-based precautions are not appropriate. Owing to the complexity of PPE ensemble selection and evaluation, a team with expertise in infectious diseases, occupational health, the health care activity, and related disciplines, such as human factors, should be engaged.

Conclusions

Participation, documentation, and transparency are necessary to ensure the decisions can be communicated, critiqued, and understood by HCP.

757. Impact of a Sepsis Improvement Team with Prospective Audit and Feedback on SEP-1 Core Measure Adherence in an Urban Community Hospital

Background

Adherence to the CMS sepsis core measure (SEP-1) has been a challenge for facilities nationwide. Checklists, electronic medical record (EMR) alerts and order sets have been shown to improve compliance. We implemented a comprehensive SEP-1 guideline with order sets, checklists and EMR alerts at an urban community hospital. Subsequently, a SEP-1 improvement team with an infectious disease physician and a nurse led a prospective audit and feedback (PAF) program to help improve adherence and reduce errors. We seek to understand the impact of PAF on SEP-1 compliance.

Methods

Quasi-experimental pre- and post-intervention study of SEP-1 compliance at a 151-bed urban community hospital from January 2015 to December 2018. PAF intervention was started on July 2017. Cases were reviewed, SEP-1 failures identified, and feedback given to nurses and clinicians involved within 48 hours of admission. Gaps in adherence are identified, education given, and corrective actions taken. SEP-1 adherence before and after PAF implementation was reviewed.

Results

A total of 307 cases met the SEP-1 inclusion criteria. PAF was successfully implemented. There were 169 SEP-1 cases before and 138 after implementation of PAF. The success rate increased from 44% to 52% with PAF (Figure 1). The most common reasons for failure were initial and repeat lactic acid on both groups (Figure 2).

Conclusion

Prospective audit and feedback for SEP-1 improved compliance rates at our facility. Prospective audit can help identify core measure failures early and provide immediate feedback to clinicians, nurses and laboratory personnel. Immediate feedback by the SEP-1 improvement team may help increase SEP-1 awareness, strengthen existing protocols and promote a culture of safety. SEP-1 is a complex core measure that may transition to pay-for-performance. An ID physician-led SEP-1 improvement team with PAF may be an area for future value-based care opportunities for ID physicians.

Disclosures

All authors: No reported disclosures.

487. Prevalence of Antimicrobial Resistance in Gram-Negative Bacilli Bloodstream Infections at a Tertiary Teaching Hospital in the Dominican Republic

Background

Bloodstream infections (BSI) with gram-negative bacilli (GNB) are a major cause of morbidity and mortality worldwide. Sepsis due to BSI can carry a mortality rate as high as 40%, with higher mortality in developing nations. Early and appropriate empiric therapeutic selection plays an important role in survival. The rising incidence of antimicrobial resistance (AMR) limits empiric treatment options. Local susceptibility patterns can vary per region, institution or setting. Understanding local AMR may help guide empiric treatment choices. We seek to describe resistance rates for GNB BSI in the Dominican Republic (DR).

Methods

This is a retrospective review of antimicrobial susceptibility patterns from bloodstream infections in a tertiary hospital in the DR. Susceptibility data from all adult inpatient blood cultures were collected from January 1 to December 31, 2017.

Results

A total of 124 blood cultures were reported. The most common organisms were Escherichia coli (43%) and Klebsiella pneumoniae (23%). Fluoroquinolone resistance was present in 70% of E. coli. Phenotypic susceptibility patterns consistent with extended-spectrum β-lactamase (ESBL) producing GNB were present in 46% of isolates. Carbapenem resistance was found in 4 samples and was most common in P. aeruginosa. Susceptibility profile is described on Table 1.

Conclusion

AMR was high in GNB BSIs in the DR. High rates of ESBL render common cephalosporins sub-optimal for empiric treatment. PTZ retains in vitro susceptibilities despite cefepime resistance but clinical efficacy is controversial. CTX-M ESBLs may cause these resistance pattern in vitro. Further studies are needed to determine genetic mechanisms of resistance. Establishing antimicrobial stewardship programs with rapid diagnostic testing that identify mechanisms of resistance may promote judicious use of carbapenems and reduce further the risk of further development of AMR.

Disclosures

All authors: No reported disclosures.

2028. A Survey of Antimicrobial Availability, Training, and Antimicrobial Recommendations by Staff in Pharmacies and Non-pharmacy Stores in the Dominican Republic

Background

Antimicrobial resistance (AMR) is a rising global health challenge. Antimicrobial use (AU) is a key factor in the development of AMR, but knowledge gaps remain on AU and dispensation in low- and middle-income countries (LMICs). AU can be purchased without prescriptions in many LMICs and are available in pharmacies and non-pharmacy stores. We seek to describe the availability, training and AU recommendations in pharmacies and non-pharmacy stores in the Dominican Republic (DR).

Methods

We conducted a survey of pharmacies and non-pharmacy stores that dispense antimicrobials from March to April 2019 in randomly selected locations throughout metropolitan Santo Domingo. Data on the availability of antimicrobials and training on AU was obtained. Antimicrobial of choice for common symptoms such as dysuria, throat pain, diarrhea, fever, and cough were queried, and data tabulated. Availability of antimicrobials by phone and online delivery was assessed.

Results

A total of 35 stores were surveyed. Ten pharmacies and 15 nonpharmacy stores agreed to participate. Ten refused and were excluded. Fifty AU recommendations were given in pharmacies and 16 in non-pharmacy stores. The most common type of antimicrobial recommended were aminopenicillins (Figure 1). Staff received prior training on antimicrobials in 70% of pharmacies and 0% of non-pharmacy stores. Antimicrobial recommendations by symptom in pharmacies and non-pharmacy stores are seen in Figure 2 and 3. Antimicrobials are available for phone delivery in 100% of pharmacies and 90% of non-pharmacy stores. No antimicrobials were available via online delivery apps.

Conclusion

Antimicrobials are widely available in the DR without prescriptions and can be purchased in person or via phone delivery. Aminopenicillins are commonly prescribed and may contribute to high rates of ESBL in the DR. Pharmacy staff gave more specific symptom-based recommendations than non-pharmacy staff and commonly had prior training on antibiotic use. In LMICs with easy access to antimicrobials, frontline staff in pharmacies and non-pharmacy stores are gatekeepers for AU and may benefit from further education and training. Further studies on attitudes and perceptions related to antimicrobial use in the community are needed.

Disclosures

All authors: No reported disclosures.

2004. Impact of Procalcitonin Roll-out Without Antimicrobial Stewardship Guidance in a Community Hospital Emergency Department

Background

Lower respiratory tract infections (LRTIs) are one of the most common infectious disease-related emergency department (ED) visits in the United States. The ID Society of America and the Agency for Healthcare Research and Quality support the use of procalcitonin (PCT) for antimicrobial stewardship (ASP) in LRTI. Though not widely available, awareness and access to PCT is rising. At our facility, PCT became available in February 2018. The aim of our study is to assess the impact of PCT at an urban community hospital and identify possible targets for ASP interventions.

Methods

Retrospective review of cases from February to August 2018. Cases from the ED were selected for review. Appropriateness of testing was assessed, defined as guideline-based use for cessation of antibiotics in uncomplicated LRTIs without critical illness or immunosuppression. Demographic variables and clinical characteristics, such as, diagnosis, antimicrobial use and PCT levels were obtained.

Results

PCT was ordered 268 times hospital-wide, of which 160 (60%) were in the ED. Ages ranged from 0–90, with an average of 47. Most cases were male (51%). Appropriate testing for LRTI occurred in 33 (29%) cases. Antimicrobials were used in 75% of cases with low (< 0.5) PCT levels (Figure 1). Length of stay (LOS) was higher in groups that received antimicrobials (Figure 2). Testing was not appropriate in 127 cases (71%), with upper respiratory (21%), soft-tissue (17%), genitourinary (15%) and abdominal (13%) infections as the most common reasons for testing. Other diagnosis included alcohol withdrawal, seizures and altered mental status. Cumulative cost of PCT testing was $24000, of which $19050 was not consistent with guidelines.

Conclusion

Clinicians routinely ordered PCT in the ED. Antimicrobials were used for LRTIs despite low PCT levels. This may have contributed to higher LOS and excess antimicrobial use. Unwarranted PCT testing had a cost of $19050. As PCT becomes widely available in hospitals across the United States, education and decision support by ASP to clinicians may be needed to enhance guideline-appropriate evidence-based use of PCT. Targeted ASP interventions in the ED may have cost savings by reducing excess testing, length of stay and improving antimicrobial use.

Disclosures

All authors: No reported disclosures.

1692. Epidemiology, Clinical Characteristics, and Outcomes of Candidemia in a Tertiary Hospital in the Dominican Republic

Background

Methods

Results

Conclusion

Disclosures

1059. Impact of a Syndrome-Based Antimicrobial Stewardship Intervention on Anti-Pseudomonal β-Lactam Use, C. difficile Rates and Cost in an Urban Community Hospital

Background

The use of anti-Pseudomonal β-lactam (APBL) agents has significantly increased in the past decade, carrying higher costs and contributing to antimicrobial pressure. Antimicrobial stewardship (ASP) can promote evidence-based antimicrobial selection and mitigate excess APBL use. We implemented a comprehensive ASP with syndrome-based prospective audit and feedback (PAF) at an urban community hospital. The goal of this study is to assess the impact of syndrome-based PAF on APBL use, C. difficile rates and cost.

Methods

ASP with all CDC core elements was implemented at a 151-bed community hospital in October 2017. Syndrome-based guidelines and PAF was established and overseen via direct communication with an ID physician. Days of therapy (DOT), cost and C. difficile rates were assessed 12 months before and after ASP. DOT for APBL and non-APBL utilization was tabulated by unit and paired t-test performed.

Results

Most cases reviewed by PAF (51%) were represented in our syndrome-based treatment guidelines (Figure 1). Soft tissue (33%) and intra-abdominal (24%) infections were the most common syndromes. Change to guideline was the most common PAF intervention (62%) followed by de-escalation (30%). At 12 months, total DOT/1,000 increased (392.5 vs. 404) while the proportion of parenteral antimicrobials used decreased (71% vs. 65%). Antibiotic expenditures decreased by 23%, with a reduction in APBL of 20% and non-APBL of 10% (Table 1). Statistically significant reductions APBL use in non-ICU settings (P = 0.0139) and statistically significant increases in non-APBL in ICU settings occurred (P = 0.0001) (Figure 2 and 3). C difficile rates decreased from 21% (3.27 vs. 2.56).

Conclusion

Syndrome-based PAF was successfully implemented. A reduction in APBL use was seen in non-ICU settings, where evidence-based de-escalation may be more feasible. APBL use remained high in the ICU but was guideline consistent. A rise in non-APBL use also occurred. Certain critical illness syndromes warrant APBLs, but PAF may promote culture-directed and syndrome-specific treatments. ASP increased guideline-based therapy and contributed to decreased broad-spectrum antimicrobial use, antimicrobial expenditures and C difficile rates. Syndrome based PAF can be successfully implemented in community settings.

Disclosures

All authors: No reported disclosures.

Environmental Contact and Self-contact Patterns of Healthcare Workers: Implications for Infection Prevention and Control

BACKGROUND

Respiratory viruses on fomites can be transferred to sites susceptible to infection via contact by hands or other fomites.

METHODS

Care for hospitalized patients with viral respiratory infections was observed in the patient room for 3-hour periods at an acute care academic medical center for over a 2 year period. One trained observer recorded the healthcare activities performed, contacts with fomites, and self-contacts made by healthcare workers (HCWs), while another observer recorded fomite contacts of patients during the encounter using predefined checklists.

RESULTS

The surface contacted by HCWs during the majority of visits was the patient (90%). Environmental surfaces contacted by HCWs frequently during healthcare activities included the tray table (48%), bed surface (41%), bed rail (41%), computer station (37%), and intravenous pole (32%). HCWs touched their own torso and mask in 32% and 29% of the visits, respectively. HCWs' self-contacts differed significantly among HCW job roles, with providers and respiratory therapists contacting themselves significantly more times than nurses and nurse technicians (P < .05). When HCWs performed only 1 care activity, there were significant differences in the number of patient contacts and self-contacts that HCWs made during performance of multiple care activities (P < .05).

CONCLUSIONS

HCWs regularly contact environmental surfaces, patients, and themselves while providing care to patients with infectious diseases, varying among care activities and HCW job roles. These contacts may facilitate the transmission of infection to HCWs and susceptible patients.

Experience of Chicagoland acute care hospitals in preparing for Ebola virus disease, 2014-2015

During the 2014-2015 Ebola Virus Disease (EVD) outbreak, hospitals in the United States selected personal protective equipment (PPE) and trained healthcare personnel (HCP) in anticipation of receiving EVD patients. To improve future preparations for high-consequence infectious diseases, it was important to understand factors that affected PPE selection and training in the context of the EVD outbreak. Semistructured interviews were conducted with HCP involved with decision-making during EVD preparations at acute care hospitals in the Chicago, IL area to gather information about the PPE selection and training process. HCP who received training were surveyed about elements of training and their perceived impact and overall experience by email invitation. A total of 28 HCP from 15 hospitals were interviewed, and 55 HCP completed the survey. Factors affecting PPE selection included: changing guidance, vendor supply, performance evaluations, and perceived risk and comfort for HCP. Cost did not affect selection. PPE acquisition challenges were mitigated by: sharing within hospital networks, reusing PPE during training, and improvising with existing PPE stock. Selected PPE ensembles were similar across sites. Training included hands-on activities with trained observers, instructional videos, and simulations/drills, which were felt to increase HCP confidence. Many felt refresher training would be helpful. Hands-on training was perceived to be effective, but there is a need to establish the appropriate frequency of refresher training frequency to maintain competence. Lacking confidence in the CDC guidance, interviewed trainers described turning to other sources of information and developing independent PPE evaluation and selection. Response to emerging and/or high consequence infectious diseases would be enhanced by transparent, risk-based guidance for PPE selection and training that addresses protection level, ease of use, ensembles, and availability.

Personal protective equipment doffing practices of healthcare workers

During the doffing of personal protective equipment (PPE), pathogens can be transferred from the PPE to the bodies of healthcare workers (HCWs), putting HCWs and patients at risk of exposure and infection. PPE doffing practices of HCWs who cared for patients with viral respiratory infections were observed at an acute care hospital from March 2017 to April 2018. A trained observer recorded doffing performance of HCWs inside the patient rooms using a pre-defined checklist based on the Centers for Disease Control and Prevention (CDC) guideline. Doffing practices were observed 162 times during care of 52 patients infected with respiratory viral pathogens. Out of the 52 patients, 30 were in droplet and contact isolation, 21 were in droplet isolation, and 1 was in contact isolation. Overall, 90% of observed doffing was incorrect, with respect to the doffing sequence, doffing technique, or use of appropriate PPE. Common errors were doffing gown from the front, removing face shield of the mask, and touching potentially contaminated surfaces and PPE during doffing. Deviations from the recommended PPE doffing protocol are common and can increase potential for contamination of the HCW's clothing or skin after providing care. There is a clear need to change the approach used to training HCWs in PPE doffing practices.

The Impact of Antibiotic Stewardship Program Resources on Infection Prevention Programs

Doernberg and colleagues describe the role and resourcing of the infectious disease (ID) physician for an effective hospital-based antibiotic stewardship program (ASP). There are similar resource requirements for the ID physician leader in an effective infection prevention (IP) program. This ID physician partnership is supported by professional organizations and predates the imperative of ID physician leadership in ASP. There are regulatory requirements for established IP programs, but they do not specify leadership structure to the same degree as ASP regulations. The Centers for Medicare and Medicaid and The Joint Commission have specified the inclusion of an ID-trained physician leader in ASP, and this has led to the development of curriculum to train more ASP physicians. More robust advocacy may ensure a similar regulatory mandate supporting the participation of ID-trained physicians in IP programs. This may encourage the development of a curriculum to meet the workforce.

Development of High-Level Echinocandin Resistance in a Patient With Recurrent Candida auris Candidemia Secondary to Chronic Candiduria

Objective

Candida auris is a globally emerging pathogen associated with significant mortality. This pathogen frequently is misidentified by traditional biochemical methods and is resistant to commonly used antifungals. The echinocandins currently are recommended as the first-line treatment for C. auris infections. The objective of this work is to demonstrate the challenges associated with C. auris in the real-world setting.

Methods

A 54-year-old male presented to our institution for concerns of sepsis on multiple occasions over a 5-month period. Eleven urine cultures were positive over this timeframe for yeast (9 unidentified Candida isolates and 2 C. lusitaniae isolates). On day 27, the patient developed echinocandin-susceptible candidemia, which was initially identified as C. haemulonii but later accurately identified as C. auris at an outside mycology reference laboratory. Approximately 10 weeks later, the patient had a recurrence of candidemia, this time caused by an echinocandin-resistant C. auris strain.

Results

Genomic DNA sequencing performed at the outside mycology reference laboratory identified a single serine to proline base pair change at position 639 (S639P) in the hotspot 1 region of the FKS1 gene of the echinocandin-resistant strain.

Conclusions

Our experiences highlight 4 major concerns associated with C. auris: misidentification, persistent colonization, infection recurrence despite the receipt of appropriate initial therapy, and development of resistance.

Utilizing the focused conversation method in qualitative public health research: a team-based approach

Background

Qualitative research studies are becoming increasingly necessary to understand the complex challenges in the healthcare setting. Successfully integrating interdisciplinary teams of investigators can be challenging, as investigators inherently view data through their disciplinary lens. Thus, new methods, such as focused conservation, are needed to facilitate qualitative data analysis by interdisciplinary teams. The purpose of this manuscript is to provide a clear description of how we implemented the focused conversation method to facilitate an organized data-driven discussion that responded to our study objectives and ensured participation of our interdisciplinary team. The focused conversation method has not, to our knowledge, been utilized for this purpose to date.

Methods

To better understand the experience of healthcare personnel (HCP) during preparations for the 2014–2015 Ebola Virus Disease (EVD) outbreak, we interviewed HCP who participated in decision making about EVD preparations and training of workers in the use of enhanced personal protective equipment ensembles in the metropolitan Chicagoland area of Illinois to attain a priori research objectives. We identified a systematic method – the focused conversation method – that enabled our interdisciplinary team to interactively contribute to the framing, analysis and interpretation of the data that would enable us to focus on our research objectives.

Results

The focused conversation developed to support our a priori research objective about the training of HCP in preparations included objective, reflective, interpretive and decisional questions. These questions grounded the conversation in the data, while leveraging discipline-specific lenses and professional experience in the analysis and interpretation. Insights from the conversation were reviewed later against interview transcripts to ensure validity. The conversation identified areas for future research directions and deficiencies in the interview instrument.

Conclusions

The focused conversation is an efficient, organized method for analysis of qualitative data by an interdisciplinary team.

Successful Implementation of an Antibiotic Stewardship Program in an Academic Dental Practice

BACKGROUND

Most antibiotic use in the United States occurs in the outpatient setting, and 10% of these prescriptions are generated by dentists. The development of comprehensive antibiotic stewardship programs (ASPs) in the dental setting is nascent, and therefore we describe the implementation of a dental ASP.

METHODS

A collaborative team of dentist, pharmacist, and physician leaders conducted a baseline needs assessment and literature evaluation to identify opportunities to improve antibiotic prescribing by dentists within Illinois' largest oral health care provider for Medicaid recipients. A multimodal intervention was implemented that included patient and provider education, clinical guideline development, and an assessment of the antibiotic prescribing rate per urgent care visit before and after the educational interventions.

RESULTS

We identified multiple needs, including standardization of antibiotic prescribing practices for patients with acute oral infections in the urgent care clinics. A 72.9% decrease in antibiotic prescribing was observed in urgent care visits after implementation of our multimodal intervention (preintervention urgent care prescribing rate, 8.5% [24/283]; postintervention, 2.3% [8/352]; P < .001).

CONCLUSIONS

We report the successful implementation of a dental ASP that is concordant with the Centers for Disease Control and Prevention Core Elements of Antibiotic Stewardship in the Outpatient Setting. Our approach may be adapted to other dental practices to improve antibiotic prescribing.

1815. Effects of Syndrome-Based Antimicrobial Stewardship Prospective Audit and Feedback Interventions on Antimicrobial Use in an Urban Community Hospital

Background

Establishing antimicrobial stewardship programs (ASP) in community hospitals with limited resources can be challenging. Many hospitals do not have infectious disease (ID) trained pharmacists (PharmD) available. We implemented a comprehensive ASP with syndrome-based prospective audit and feedback at an urban community hospital.

Methods

ASP was implemented at a 151-bed urban community hospital in October 2017. PharmD training on syndrome-based treatment guidelines, including definitions, severity, empiric regimens, de-escalation, and duration was created. Prospective audit by PharmDs was established. This program was implemented and overseen by an ID physician. Days of therapy per 1,000 patient-days (DOT/1,000) was assessed 3 months before and after ASP. Prospective audit and feedback data were reviewed.

Results

At 3 months, antimicrobial use decreased (370 vs. 350 DOT/1,000) while the proportion of oral antimicrobials used increased (32% vs. 43%). Antibiotic expenditures decreased by 11% ($42,500 vs. $37,900). Most cases reviewed by prospective audit (58%) fit pre-determined syndromes (Figure 1). Soft tissue and urinary tract infections were the most common syndromes. Interventions occurred in 53% of cases. De-escalation from broad-spectrum agents was more successful in noncritical care settings (Figure 2).

Conclusion

Syndrome-based prospective audit and feedback was successfully implemented in an urban community hospital with non-ID trained PharmDs using ID physician leadership. Our program led to a decrease in antibiotic use, increase use of oral alternatives, and decreased antibiotic expenditures. Empiric use of broad-spectrum agents was common at our facility. ASP likely contributed to an increase in ceftriaxone and decrease in piperacillin–tazobactam use in medical-surgical floors. Stewardship in critically ill patients remains a challenge. Clear guidelines and access to an ID physician are necessary to provide adequate support for PharmDs without ID-specific training and can help curb antibiotic use. Expanding the list of syndromes may further impact antimicrobial use.

Disclosures

All authors: No reported disclosures.

207. Impact of Educational Interventions on Antibiotic Prescribing for Acute Upper Respiratory Tract Infections in the Ambulatory Care Setting

Background

Methods

Results

Conclusion

Disclosures

2111. Changing the Culture: A Quasi-Experimental Study Assessing the Burden of Urine Cultures and the Impact of Stewardship of Testing in an Urban Community Hospital

Background

Indwelling urinary catheters (IUC) may cause inflammation and colonization, decreasing the diagnostic yield of urinalysis and urine cultures (UC). Indiscriminate testing can lead to misinterpretation of positive results as a catheter associated urinary tract infection (CAUTI), increasing antibiotic use and CAUTI rates. We studied the burden of UC and implemented a UC stewardship initiative (UCSI) as part of a comprehensive CAUTI reduction program.

Methods

A retrospective review of cases with IUC and positive UC in 2014 was performed. UCSI was implemented in March 2017 (Figure 1). Nursing staff were instructed to contact the infectious diseases physician when UC from IUC were ordered. Cases were reviewed and, if no UC indication based on IDSA guidelines was met, cultures were discontinued after conferring with ordering physician. Twelve months pre- and post-intervention data were collected; including case description, catheter days, UC ordered, alternative cause of fever, and recommendations.

Results

The pre-USCI cohort had 23 UC in 19 cases. One UC (4%) met indication (Figure 2). Three (16%) met NHSN criteria for CAUTI and did not meet UC indication. The USCI cohort had 21 UC orders in 13 cases. Most UC did not meet indication and were cancelled (90%, 19/21). Alternative causes for fever were found in all cases with cancelled UC orders (19/19), including pneumonitis, pneumonia, pancreatitis and tuberculosis. Antimicrobials were used in 53% (7/13). UC orders per hospitalization ranged 1–4 (average 1.7). IUC days ranged from 3 to 18 days (average 8). In both cohorts, UC with indication (3) did not meet NHSN criteria for CAUTI and did not receive antimicrobials.

Conclusion

Patients with IUC frequently underwent UC without evidence-based indications. This may lead clinicians down the wrong diagnostic path and contribute to antimicrobial use. Critically ill patients with inflammatory conditions are at high risk of UC testing. USCI is a cost-effective intervention that reduced indiscriminate testing, antibiotic use and CAUTIs. USCI can play an important role in CAUTI prevention strategies and antibiotic stewardship programs.

Disclosures

All authors: No reported disclosures.