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Background It is estimated that 223,900 cases of CDI occur annually in hospitalized patients resulting in 12,800 deaths and $1 billion in attributable costs. Antimicrobial use is a risk factor for CDI and the antimicrobials ordered to treat urinary tract infections have been identified as a factor in both recurrent CDI and community-acquired CDI. This real-world data analysis seeks to explore the relationship between HA-UTI and hospital-onset CDI (HO-CDI). Methods An electronic infection surveillance system was the source of de-identified real-world data from 290 hospitals. Algorithmically-derived measures of healthcare-associated infections (ADM-HAIs), and records of all-cause antimicrobial orders, for all inpatient admissions for the period 10/1/18–9/30/19 were analyzed. All patients who presented with a urine ADM-HAI – suggestive of HA-UTI – and no other healthcare-associated infection (Urine+ patients), were observed for subsequent HO-CDI. Urine+ patients were compared to patients with no HAI of any type, other than CDI (HAI-free patients), and relative risk (RR) was estimated. The analysis was repeated for the subgroup of patients who received an antimicrobial order for any reason during their stay. Results 3,050,525 inpatient admissions were analyzed. 26,634 were identified as Urine+ patients. 188 of those patients subsequently presented with HO-CDI. 2,978,507 were identified as HAI-free patients. 6,238 of those patients presented with HO-CDI. The incidence of HO-CDI was significantly higher in Urine+ patients compared to HAI-free patients (RR=3.37, 95% CL[2.92, 3.89], p< 0.0001). When the analysis was repeated to examine only patients who received antimicrobial orders, Urine+ patients continued to be at higher risk of subsequent HO-CDI compared to HAI-free patients (RR=3.28, 95% CL[2.74,3.92], p< 0.0001). Conclusion The presence of a urine ADM-HAI, suggestive of HA-UTI, was associated with an increased risk of subsequent HO-CDI. This held when only patients with antimicrobial orders were considered. These observations mirror findings from other published studies, however, other factors may have contributed to increased risk for both HA-UTI and HO-CDI. Disclosures Timothy Kelly, MS, MBA, BD (Employee) ChinEn Ai, MPH, BD (Employee) John Murray, MPH, BD (Employee) Yan Xiong, n/a, BD (Becton Dickinson) (Employee) Hanna Jokinen-Gordon, PhD, BD (Employee)

The impact of antibiotic therapy on the diagnosis of healthcare–associated ventriculitis and meningitis (HCAVM) is unknown. Antibiotics were administered before obtaining cerebrospinal fluid (CSF) in 217 out of 326 (66%) patients with HCAVM, and they impacted the sensitivity of the cerebrospinal fluid Gram stain and culture (P ≤ .004).

Background Healthcare-associated S. aureus bacteremia (HA-SAB) has traditionally been attributed to surgical site infections (SSI) or central line-associated bloodstream infections. However, peripheral IV catheters (pIV) are increasingly recognized as cause of HA-SAB. This study evaluates risk factors for HA-SAB due to pIV. Methods This is a retrospective, case-control study of adult patients hospitalized at Denver Health Medical Center with HA-SAB (SAB presenting with hospital-onset [≥3 days after hospitalization] or community-onset attributed to recent hospitalization [discharge ≤7 days prior]). The time period ranged from Jan 1, 2016 to Nov 30, 2019. Cases were reviewed by an infectious diseases physician to determine the source of SAB. PIV-related SAB was defined as phlebitis, cellulitis, and/or drainage at the site of a previous pIV AND no other source or another less likely source based on progress notes and microbiology results. Three controls were matched to each pIV-related SAB case based on the age of the patient (±5 years) and the date the pIV was placed (±3 days). Patients who were admitted for elective procedures, to psychiatry, to obstetrics, and those who died within 2 days of pIV placement were excluded. Results There were 376 episodes of SAB during the study period; 313 were community-onset while 63 were HA-SAB (50 hospital-onset and 13 community-onset attributed to hospitalization). PIV was the most common cause of HA-SAB (n=20, 29.4%); other common causes were SSI (n=10, 15.9%), source present at admission (n=8, 12.7%), and pneumonia (n=7, 11.1%). The median age of patients with pIV-related SAB was 53 years (SD 15.6), and 85% were male. The median duration of pIV was 5 days (SD 2.8). Twenty percent was MRSA. As compared to controls, pIV in immunocompromised individuals and those placed by emergency medical services (EMS) were more likely to develop SAB (OR 11.8, 95% CI 2.5–56.5 and OR 6.9, 95% CI 6.9–24.0, respectively). Age, gender, pIV location, and duration of pIV were not associated with development of SAB. Conclusion PIV placed by EMS are more likely to cause SAB than those placed in the hospital. Facilities should consider changing these pIV promptly upon admission to the hospital and work with EMS to improve pIV placement technique. Disclosures All Authors: No reported disclosures

Background Elizabethkingia (EK) are non-motile gram-negative rods found in soil and water and are an emerging cause of healthcare-associated infections (HAIs). We describe Centers for Disease Control and Prevention (CDC) consultations for healthcare-associated EK infections and outbreaks. Methods CDC maintains records of consultations with state or local health departments related to HAI outbreaks and infection control breaches. We reviewed consultations involving EK species as the primary pathogen of concern January 1, 2013 to December 31, 2019 and summarized data on healthcare settings, infection types, laboratory analysis, and control measures. Results We identified 9 consultations among 8 states involving 73 patient infections. Long-term acute-care hospitals (LTACHs) accounted for 4 consultations and 32 (43%) infections, and skilled nursing facilities with ventilated patients (VSNFs) accounted for 2 consultations and 31 (42%) infections. Other settings included an acute care hospital, an assisted living facility, and an outpatient ear, nose, and throat clinic. Culture sites included the respiratory tract (n=7 consultations), blood (n=4), and sinus tract (n=1), and E. anophelis was the most commonly identified species. Six consultations utilized whole genome sequencing (WGS); 4 identified closely related isolates from different patients and 2 also identified closely related environmental and patient isolates. Mitigation measures included efforts to reduce EK in facility water systems, such as the development of water management plans, consulting water management specialists, flushing water outlets, and monitoring water quality, as well as efforts to minimize patient exposure such as cleaning of shower facilities and equipment, storage of respiratory therapy supplies away from water sources, and use of splash guards on sinks. Conclusion EK is an important emerging pathogen that causes HAI outbreaks, particularly among chronically ventilated patients. LTACHs and VSNFs accounted for the majority of EK consultations and patient infections. Robust water management plans and infection control practices to minimize patient exposure to contaminated water in these settings are important measures to reduce infection risk among vulnerable patients. Disclosures All Authors: No reported disclosures

Background Healthcare-associated respiratory viral infections (HARVI) occur frequently at pediatric hospitals. The spectrum and attributable outcomes of these infections are unknown. Methods Using a matched historical cohort design, HARVI cases identified between July 2013 and June 2018 at a large pediatric referral hospital in Dallas, Texas were defined as patients who tested positive for one of eight respiratory viruses during their hospitalization, had new respiratory symptoms develop during hospitalization, and had symptom onset on a hospitalization day that was greater than the maximum incubation period for the specific respiratory virus. Controls were matched 1:1 for index time, meaning that the control had a hospital length of stay that was at least as long as the length of stay in the matched case prior to viral testing. Controls were also matched for year and month of infection as well as hospital unit and/or age. The primary outcome was additional length of stay following infection or index time. Additional outcomes included transfer to intensive care, need for intubation, hospital charges, and all cause in-hospital mortality. Results Over the 5-year study period, 317 definite HARVI were identified (0.62 per 1,000 admitted patient days), and only 287 (91%) had a matched control to be included in analysis. Among these cases and matched controls, the median time to index time was 19 days (IQR 10-39 days). The most common causative viruses where rhinovirus/enterovirus (188, 65.5%), RSV (30, 10.5%), parainfluenza virus (28, 9.8%), and seasonal coronaviruses (27, 9.4%). Fewer cases than controls were in an intensive care unit at index time (101 [35.2%] vs. 156 [54.4%]) The mean additional length of stay following index time was shorter in cases than controls (35.2 days vs. 48.1 days, difference = -12.9 days, 95% CI -20.95 to -4.82 days). Conclusion Hospital length of stay for cases with HARVI was not longer than for those without HARVI. Possible explanations include confounding and selection bias. Further studies with carefully selected controls are needed. Disclosures All Authors: No reported disclosures

Background The burden of healthcare-associated viral respiratory infections (HAVRIs) in children is significant, with increased healthcare costs and risk of poor outcomes. However, while healthcare workers are the main target of infection prevention measures, little is known about the impact of sick contacts during hospitalization on the incidence of HAVRIs. The objective of our study was to determine the proportion of pediatric HAVRIs following contact with an ill caregiver or visitor. Secondary objectives were to describe the characteristics of affected patients as well as the complications associated with the HAVRI episodes. Methods This is a retrospective chart review that took place in a pediatric tertiary care center with both multiple and single-bed rooms. All cases of HAVRIs that occurred between December 2017 and July 2019 in patients aged less than 18 years old were included in the study. HAVRIs were defined as a laboratory confirmed respiratory viral illness occurring after 72 hours of admission. Results Forty-four HAVRIs were included in the analysis. The majority (n=32, 72.7%) were among patients aged less than 24 months. Only 2 patients had no comorbidities and almost half (n=21, 47.7%) had multiple complex medical conditions. Rhinovirus was the most frequently isolated virus (n=20, 45.5%). Nine patients (20.5%) had a documented contact with a sick caregiver (n=8, 88.9%) or sick visitor (n=2, 22.2%) in the 7 days prior to the onset of new respiratory symptoms and subsequent HAVRI diagnosis. In the 72 hours prior to HAVRI onset, 18 patients (40.9%) were in a single-bed room and 6 patients (13.6%) were already under droplet/contact precautions. Twelve patients (27.3%) had new or increased O2 requirements and 4 (9.1%) were transferred to the intensive care unit. There were no associated deaths. Conclusion Our study suggests that having a contact with a sick caregiver or visitor is a potential risk factor for acquiring a HAVRI. This reinforces the relevance of a strict visitor-screening policy and of educating caregivers on the importance of appropriate hand hygiene when caring for their child. Of note, more than one third of HAVRI cases occurred in patients already in a single-bed room, with or without additional precautions, suggesting that those measures are not entirely protective. Disclosures All Authors: No reported disclosures

Background Healthcare-associated bloodstream infections (HABSIs) are a significant cause of mortality and morbidity in the neonatal intensive care unit (NICU) population. Our objectives were to review the epidemiology of HABSIs in our NICU and to examine the applicability of National Healthcare Safety Network (NHSN) definitions to the NICU population. Methods We performed a retrospective review of all neonates admitted to the 54-bed level IV NICU at Yale-New Haven Children’s Hospital with a HABSI between January 1, 2013 and December 31, 2018. HABSI was defined as a positive blood culture at >72 hours of life growing an organism not considered a contaminant. Clinical definitions per treating NICU team and NHSN site-specific definitions were compared for source attribution using McNemar’s Chi-square test. Results We identified 88 HABSIs with an incidence rate of 0.81 per 1,000 patient-days. Only 13% of these were central line-associated bloodstream infections (CLABSIs). Infants with a HABSI had median birth weight and gestational age of 830 grams and 26 weeks, respectively, with a high percentage requiring mechanical ventilation parenteral nutrition and vascular access (Table 1). Sepsis-related mortality was 24%. The majority of HABSIs were caused by gram-positive and gram-negative bacteria (Figure 1). Most were secondary to necrotizing enterocolitis, pneumonia or a source that was not identified (Table 2). NHSN definitions were less likely to identify a source compared with clinical definitions per NICU treating team (P < 0.001, Table 2). Fifty percent of patients without an identified source of infection by NHSN criteria were identified with a Mucosal Barrier Injury (MBI) organism, likely causing bacteremia from gut translocation. Conclusion HABSIs occur in premature babies with comorbidities, and are more prevalent than CLABSIs. Gut translocation with MBI organisms may be an important unidentified source of HABSIs in neonates. With the increasing focus on HABSI prevention, there is a need for better NHSN definitions for source attribution of bloodstream infections in neonates. Disclosures All authors: No reported disclosures.

Background National surveillance data should be validated to identify data quality issues. This study tested the validity of healthcare-associated infection (HAI) data in the Korean National Healthcare-associated Infections Surveillance System (KONIS), intensive care unit (ICU) module. Methods The validation process consisted of external (EV) and internal (IV) validation phases. For the 10 hospitals that were selected based on the HAI rate, among the 193 participating hospitals between July 2016 and June 2017, both EV and IV were performed. For the EV, the validation team reviewed 295 medical records of 60 patients with reported HAIs, including 20 urinary tract infections (UTIs), 27 bloodstream infections (BSIs), and 13 cases of pneumonia (PNEU), and 235 patients with no reported HAI during 1-day visits conducted in November and December 2017. The reviewer’s diagnosis of HAI was regarded as the reference standard. IV was conducted by the staff of each hospital and evaluated whether UTI or BSI were present. Primary IV was performed for 279 patients who were subject to EV. Secondary IV was performed on 203 patients in another 11 selected participating hospitals that did not report HAIs to KONIS during the 1-year study period. Results In the EV, the diagnosis of UTI in the participating hospitals had a sensitivity of 72.0% and specificity of 99.3%. The sensitivity of BSI and PNEU was 63.2% and 70.6%, respectively, and specificity was 98.8% and 99.6%. The agreement (kappa) between the EV and primary IV was significant, with κ = 0.754 for UTI and κ = 0.674 for BSI. The results of the secondary IV showed that the hospitals that had no reports of HAI had few hospital beds and performed few blood or urine culture tests. In the secondary IV, eight UTIs and three BSIs were newly diagnosed in three hospitals, respectively. The reasons for not reporting the HAIs were presumed to be a lack of understanding of the surveillance standards and fear of the disadvantages of disclosing the HAI. Conclusion This study shows the need for ongoing validation and continuous training of surveillance personnel to maintain the accuracy of surveillance data. We also confirmed that IV can be used as an alternative monitoring method to examine validity and accuracy. Disclosures All authors: No reported disclosures.

Background Cutaneous mucormycosis in children is a rare fungal infection which primarily occurs in patients with underlying medical conditions and is associated with significant morbidity. We describe characteristics of pediatric patients with healthcare-associated (HCA) cutaneous mucormycosis at Texas Children’s Hospital (TCH) and results of an outbreak investigation. Methods Patients at TCH were identified retrospectively through review of the TCH Microbiology Laboratory mycology culture reports from 1/1/2012–2/18/2019. Pediatric patients Results We identified 12 patients with HCA cutaneous mucormycosis. The characteristics of these patients are detailed in the table. Six cases of Rhizopus infection occurred over a narrow 7 month period from March through September of 2017 prompting an outbreak investigation. Genotyping results revealed 4 molecular types from 5 available isolates suggesting that the isolates were not clonally related. Adhesive products were suspected as a potential source. Infection Control activities included site visits to the hospital supply warehouse and linen facility. Tape practices throughout the hospital were assessed through a nursing survey. Samples of adhesive products were cultured at an environmental microbiology laboratory and no Rhizopus spp. were isolated. A source was not identified. Conclusion Mucormycosis is a life-threatening infection in children. Providers should have a low threshold of suspicion for cutaneous mucormycosis in patients with underlying medical conditions (malignancies and extreme prematurity) that develop skin lesions near medical device dressings or securement sites. Disclosures All authors: No reported disclosures.

Background Recently, overall reductions for invasive MRSA infections (isolation from a normally sterile site) have slowed. Healthcare-associated community-onset (HACO) invasive methicillin-resistant Staphylococcus aureus (MRSA) infections are those with recent healthcare exposures who develop MRSA infection outside acute care hospitals, and account for most invasive MRSA infections. HACO incidence decreased 6.6% per year during 2005–2008; the contribution of persons who inject drugs (PWID) to HACO incidence has not been reported. Methods We identified invasive MRSA infections using active, population- and laboratory-based surveillance data during 2009–2017 from 25 counties in 7 sites (CA, CT, GA, MD, MN, NY, TN). Cases were HACO if culture was obtained from an outpatient, or ≤3 days after hospitalization in a patient with ≥1 of the following healthcare exposures (HEs): hospitalization, surgery, dialysis, or residence in a long-term care facility (LTCF) in the past year; or central vascular catheter ≤2 days before culture. We calculated incidence (per census population) overall, for PWID cases and others, and for cases associated with each HE. For each HE, we calculated the proportion of overall incidence increase for PWID and others. Results HACO MRSA incidence declined overall from 2009 to 2016 but increased from 2016 to 2017 overall (8%), for both PWID (63%) and others (5%) (figure). For both PWID and non-PWID, incidence from 2016 to 2017 increased by 0.5 cases/100,000 population; 91% of the increase in PWID occurred in cases with a past year hospitalization while 78% of the increase in cases not associated with injection drug use (IDU) occurred in cases with past year LTCF residence. Past year LTCF residence was less common among PWID (16%) then among other cases (38%, P < 0.01). Conclusion After years of declines, HACO MRSA incidence increased equally in 2017 for cases associated with IDU and in cases unrelated to IDU. Increases in PWID-associated cases account for half the overall increase, indicating that efforts to reduce HACO MRSA should address PWID risk factors as these infections may be due to self-injection. In addition, increases not related to PWID, if sustained, would be a reversal of historic trends and require further investigation into causes. Disclosures All authors: No reported disclosures.

Background Burkholderia cepacia complex (Bcc) species can contaminate medical devices and water-based products, resulting in outbreaks of healthcare-associated infections. In March 2018, we investigated a cluster of 20 patients with a sinus culture positive for Bcc seen at two affiliated ENT clinics in Oregon over a 2-month period, based on reporting by a laboratorian in a central laboratory external to the clinics. Methods We conducted an epidemiologic investigation to identify potential causes for an apparent outbreak of Bcc, including review of health records and microbiologic reports, site visits, staff interviews, and cultures of common equipment and products. Results 20 patients (9 were female; age range 10 to 72 years, median age 54.5 years) had new positive Bcc cultures from the sinus. The absence of cystic fibrosis, immunosuppression or sinonasal polyposis in all patients, scant growth of Bcc in most cases with isolation of another organism in some, and the use of Bcc-directed antibiotics in a minority of patients suggested the presence of a contamination source. All patients had received lidocaine/phenylephrine (L/P) via multidose nasal spray atomizers prior to endoscopically-directed sinus cultures. Site visits revealed improper medication dispensing and storage practices (e.g., no expiration date for L/P stock, storage of L/P-containing atomizers at room temperature), and inadequate instrument reprocessing and environmental cleaning. Cultures of L/P in 2/2 in-use atomizers and 1/1 opened stock bottle, as well as swabs of 3/3 spray mechanisms, grew Bcc. Cultures of L/P from the unopened, refrigerated stock bottle, a flexible endoscope and a rigid endoscope did not yield Bcc. No negative clinical sequelae in these patients were reported. Conclusion Contaminated multidose L/P nasal spray with Bcc resulted in nosocomial transmission at these clinics. This investigation highlights the important role of laboratorians in detecting Bcc contamination events that lead to colonization, and suboptimal reporting by clinicians in the outpatient setting. It also raises the question of how often such contamination events go undetected. Injection safety training needs to be broadened to “medication administration safety” training as one and only principles could have prevented this incident. Disclosures All authors: No reported disclosures.

Background Clostridium difficile infections (CDI) affect hospitalized patients but also individuals in the community. The epidemiology of healthcare-associated (HA) CDI has received much scrutiny, but little is known regarding trends in the incidence rate of community-associated (CA) cases. We describe and compare long-term trends in the provincial incidence rate of CA-CDI and HA-CDI. Methods Hospitalized patients with CA-CDI and HA-CDI were identified prospectively between April 2008 and April 2015 through the Quebec CDI surveillance program (QCISP), a network of 95 acute-care institutions using standardized case definitions. Hospitalized CDI cases are classified as CA if they occur within 3 days of admission or >4 weeks after any inpatient or outpatient care. CDI cases are defined as HA-CDI if they occurred >3 days after admission and up to 4 weeks following discharge. Trends in the incidence of HA-CDI and CA-CDI were compared using time series with segmented regression and Poisson law. Results Between 2008 and 2015, 28,850 CDI were detected in hospitalized patients. Of these, 4,481 (15.5%) were CA and 24,369 (84.5%) HA-CDI. The annual CA-CDI incidence rate increased by 35.2% from 0.51 to 0.68 per 100,000 population (incidence rate ratio [IRR] per 4-week period, 1.005; 95% confidence interval [CI], 1.004 to 1.006; P < 0.0001) whereas the incidence of HA-CDI remained stable from 6.6 to 7.0 per 10,000 patient-days (IRR per 4-week period, 1.000; 95% CI, 0.999 to 1.000; P = 0.23). There was a significant difference between the trends in incidence of CA-CDI and HA-CDI (IRR, 1.005; 95% CI, 1.004 to 1.006; P < 0.0001). Further analysis showed an inflection point in the incidence of HA-CDI in April 2011 with a reduction in slope (change in trend, IRR, 0.997; 95% CI, 0.995 to 0.999; P = 0.007). No concomitant change was seen in the trend of CA-CDI (change in trend, IRR, 0.997; 95% CI, 0.992 to 1.002; P = 0.2) despite a slight immediate change in level at inflection point (IRR, 1.131; 95% CI, 1.000 to 1.278; P = 0.05). Conclusion Between 2008 and 2015, the provincial incidence of hospitalized CA-CDI has significantly increased while the incidence rate of HA-CDI has remained relatively stable. Further studies are required to investigate the factors underlying this increase. Disclosures Y. Longtin, Merck: Grant Investigator, Research grant. Becton Dickinson: Grant Investigator, Grant recipient.

Background Healthcare associated outbreaks of mucormycosis have been described in the literature. In 2017, the University of Colorado Hospital (UCH) had an increased number of cases of mucormycosis. The objective of this study was to evaluate possible risk factors and weather patterns associated with cases of mucormycosis diagnosed at UCH from 2012 to 2018 in order determine whether the current antifungal prophylaxis used at UCH should be modified. Methods A retrospective cohort was conducted involving patients >18 years old who were admitted to UCH between 2012 and 2018 and were diagnosed with proven or probable mucormycosis as defined by the European Organization for Research and Treatment of Cancer/Mycosis Study Group (EORTC/MSG) criteria. Medical records were reviewed, and data were collected on risk factors, antifungal prophylaxis, and mortality outcome. Weather data were collected from the National Centers for Environmental Information (NCEI). Results Twenty-five cases of proven or probable mucormycosis were identified. On average patients had at least two risk factors associated with mucormycosis. The most common risk factors included diabetes mellitus (DM) (13 patients), hematologic malignancy or hematopoietic stem cell transplant (HSCT) (11 patients), use of immunosuppressing medications (11 patients), and invasive procedures. (9 patients). At the time of diagnosis, only six patients were on an antifungal with mold activity. Eight patients died during hospitalization. The distribution of cases over time was compared with weather data for Colorado. A cluster of cases occurred in 2013 (6 cases) and in 2017 (8 cases). A majority of cases were diagnosed during the summer and fall months with July being the month with the most number of cases. There were higher levels of precipitation that occurred prior to or during the cluster of cases. Conclusion Cases of mucormycosis at UCH were associated with DM, hematologic malignancy/HSCT, use of immunosuppressive therapy, and invasive procedures. The increase of cases seen 2013 and 2017 occurred in the summer and fall months after higher levels of precipitation were observed in Colorado. Providers at UCH may consider modifying antifungal prophylaxis to include mold coverage in patients with >2 risk factors for mucormycosis who are admitted during the summer and fall. Disclosures M. Barron, Astellas Pharma: Investigator, Research support.

Background Healthcare-associated viral infections (HA-VI) are common in hospitalized children and are increasingly recognized as a cause of preventable harm. Yet, epidemiology and modifiable risk factors related to pediatric HA-VI are currently poorly understood. Methods We performed a prospective case–control study to identify the risk factors and outcomes associated with pediatric HA-VI at a quaternary care children’s hospital between November 2016 and August 2018. Prospective surveillance for HA-VI was performed hospital-wide by certified infection preventionists using NHSN definitions. Cases were matched 1:1 to controls by age, duration of hospitalization, and hospital unit. We abstracted data from the electronic medical record and conducted semi-structured interviews with patient caregivers to identify potential exposures beginning 4 days prior to HA-VI identification date. We also measured length of antibacterial therapy (LOT) in the 7 days following enrollment. Results During the study period, we identified 143 eligible patients with HA-VI and enrolled 64 matched case–control pairs. In total, 79 viruses were identified among 64 case patients, of which 53 (67.1%) were respiratory viruses and 26 (32.9%) were GI. Case patients were more frequently exposed to a sick visitor, specifically either caregiver or sibling, compared with controls (18.8% vs. 9.4%; P = 0.20, Fisher exact test). During the exposure period, case patients also had a significantly higher number of hospital procedures performed when compared with controls (n = 320 vs. 232; X2 = 58.43, P < 0.001). Case, when compared with control, patients had a greater average LOT (2.89 vs. 1.08). Conclusion Results of study show that exposure to a sick visitor is a potentially modifiable risk factor for pediatric HA-VI. In addition, hospitalized children with HA-VI have increased exposure to antibacterial antibiotics when compared with matched controls. Prevention of pediatric HA-VI may have implications for antibiotic stewardship. Our findings suggest that hospital policies may need to be revised, with emphasis on visitor screening and partnership with families, to reduce the incidence of pediatric HA-VI during hospitalization. Disclosures All authors: No reported disclosures.

Background Methicillin-resistant staphylococcus aureus (MRSA) bloodstream infection (BSI) is associated with significant morbidity and mortality. Healthcare-associated (HCA) MRSA infection (occurring >48 hours after hospitalization or in those with prior healthcare exposure) has traditionally been associated with severe invasive disease, while community-associated (CA) MRSA infection (occurring within 48 hours of hospitalization and without prior healthcare exposure) has been observed in otherwise healthy individuals. We characterized the epidemiology, resistance patterns, and clinical outcomes associated with MRSA BSI over a 5 year period comparing patients with community-onset bacteremia to those with hospital onset bacteremia. Methods We performed a retrospective chart review of 151 MRSA bloodstream infections from 2013–2018 at the University of Alberta Hospital (Edmonton, Canada). We assessed each BSI by: classification (CA vs. HCA), presence of MRSA risk factors, source of infection, MRSA resistance, rate of ICU admission, and 30-day mortality. Results The median age of all patients with MRSA BSI was 53 years (range 23–94). MRSA BSI occurred more commonly in males for both CA and HCA infection (53% and 62%). HCA-MRSA infections had a higher rate of previous MRSA colonization (64.8%) compared with CA-MRSA patients (41.7%). Injection drug use was higher in CA-MRSA infections (47% vs. 11%). The most common source of CA-BSI was bone/joint (30%) while line-associated infections were the most common in HCA-BSI. Clindamycin resistance was common (46–53% susceptible) while resistance to tetracyclines (91–97% susceptible) and trimethoprim/sulfamethoxazole (98–100% susceptible) was uncommon. HCA-MRSA BSI was associated with a higher rate of ICU admission (44% vs. 33%) and 30-day mortality (18.7% vs. 11.7%). Conclusion Invasive MRSA infection continues to be associated with significant morbidity and mortality. We found that healthcare-associated MRSA BSI was associated with a high rate of prior MRSA colonization as well as a higher rate of ICU admission and 30-day mortality. There are significant differences in the demographics of patients with CA BSI compared with HCA BSI. Interventions to prevent these infections need to be targeted to the geographic location of acquisition. Disclosures All authors: No reported disclosures.

Rotavirus and norovirus are important etiologies of gastroenteritis among hospitalized children. During 2012–2013, we tested 207 residual stool specimens from children with healthcare-associated vomiting and/or diarrhea for rotavirus and norovirus. Twenty (10%) were rotavirus positive, and 3 (3%) were norovirus positive, stressing the importance of these pathogens in hospitalized children.

Background Risk stratification of HCAP patients is a possible Antimicrobial Stewardship (AST) intervention for the treatment of multidrug resistant (MDR) Gram-negative (GN) vs. community-acquired pneumonia (CAP) pathogens. This study assessed the impact of a risk stratification guideline for empiric antimicrobial selection relative to acceptance rates and clinical outcomes. Methods In 2017, a guideline for inpatients with HCAP was launched. High risk (HR) of MDR GN was defined as patients admitted to the intensive care unit (ICU), or with >1 risk factor including: receipt of any antimicrobial within 30 days or broad spectrum antimicrobials within 90 days, hemodialysis dependence, or immunocompromised. HR patients were recommended to receive antimicrobials covering MDR GN and low-risk patients to narrower CAP regimens. Patients treated for HCAP post guideline implementation were compared with a historic 2014 cohort for guideline concordance, antimicrobial selection, and clinical outcomes. AST interventions were also assessed. Results Overall, 105 patients in the post-implementation period were compared with 309 historic patients. Guideline-concordant risk-stratified therapy increased 13% [95% CI (3%, 24%)] overall. Clinical failure rates were similar with 11% vs 10% (P = 0.608) in the pre- and post-implementation periods, with an 84% AST acceptance rate (Figure 1). Treatment length decreased [8.1 to 6.6 days (P < 0.001)] and de-escalation increased [31% to 72% (P < 0.001)] as seen in Table 1. Conclusion Introduction of a risk stratified guideline through AST intervention changed practice by matching MDR risk with empiric HCAP therapy. Failure rates were comparable. Secondary benefits included: decreased treatment duration and hospital stay, increased de-escalation rates and decreased MDR GN antimicrobial use in low-risk patients. Disclosures All authors: No reported disclosures.

Background MRSA are responsible for a high proportion of healthcare-associated infections. HA-MRSA is multidrug resistant, and infections occur most frequently among inpatients, for example, those who have undergone invasive medical procedures or those aged 50 to 60 years and older. Dominance of multidrug-resistant CC5 (Chilean and New York/Japan clones) was prevalent in infections in Latin America with the notable exception of Colombia and Ecuador where USA300-LV isolates dominate. We performed genetic characterization of HA-MRSA-CC5 isolates recovered from infections in nine countries (12 hospitals). Methods Species identification of S. aureus and presence of mecA were performed by PCR. We determined MICs to common anti-MRSA antibiotics and performed screening for VISA phenotype. Molecular characterization included detection of lukSF-PV and SCCmec typing. PFGE and MLST were performed in selected MRSA isolates with susceptibility patterns typical of the Chilean (ST5-MRSA-I) and USA300-LV (ST8-MRSA-IV) lineages. Results A total of 665 S. aureus isolates were prospectively recovered from 592 patients. A high frequency of methicillin resistance (>40%) was observed in all countries (62%, 55%, 44%, and 40% in BRA, PER, CHI and ARG, respectively). Decreased susceptibility to VAN was not observed and VAN MIC90 was 1 µg/mL. In PER and CHI, the overwhelming majority of isolates (89%) belonged to the Chilean/Cordobes clone (CC5) with susceptibility patterns typical of this lineage (Resistance to β-lactams, MLSB-type, quinolones, and aminoglycosides). The New York/Japan clone (ST5-MRSA-II) was predominant in Brazil, replacing the prevalent hospital-associated Brazilian (ST239-MRSA-III) lineage. Most Argentinian MRSA isolates exhibiting a CA (ST5-IV) pattern, previously described in this country. Conclusion A variety of MRSA genetic lineages are circulating in Latin America with geographic clustering and clonal replacement. Dissemination of the CA-USA300-LV has not occurred beyond the northern region of the subcontinent. Disclosures J. M. Munita, Pfizer: Grant Investigator, Research grant. C. Arias, Merck & Co., Inc.: Grant Investigator, Research support. MeMed: Grant Investigator, Research support. Allergan: Grant Investigator, Research support.

Background Legionnaires’ disease (LD) causes significant morbidity and mortality to hospital patients and residents of skilled nursing facilities (SNF). In California, LD is reportable to local health departments via the California Reportable Disease Information Exchange (CalREDIE) surveillance system. Cases are classified as suspected or confirmed using Centers for Disease Control and Prevention (CDC) definitions. The California Department of Public Health (CDPH) Healthcare-Associated Infections (HAI) Program maintains a database of healthcare-associated LD (HA-LD) and consults with local public health departments for single cases and outbreaks. Methods We described characteristics of confirmed HA-LD cases in 2015–2017. We classified HA-LD as definite if patient had continuous exposure in a facility for 2–10 days prior to symptom onset and possible if patient had overnight exposure in a facility for a portion of 2–10 days prior to symptom onset. Results From 2015 to 2017, 125 (8%) of 1,554 confirmed LD cases were HA-LD. Of these, 73 (58%) were definite HA-LD and 52 (42%) were possible HA-LD. The majority of HA-LD cases (N = 99, 79%) occurred in southern California. SNF were associated with 57 cases (46%) and hospitals with 44 cases (35%); 23 cases (18%) had exposures in both SNF and hospitals during the incubation period. Among the definite HA-LD cases, 50 cases (68%) had exposures in a single SNF. The median age of patients with HA-LD was 77 years. The HAI Program consulted with 15 local public health agencies on 33 HA-LD investigations, including 7 outbreaks and 26 single-case investigations. Conclusion HA-LD represented a small but important percentage of LD in California; the majority occurred in SNF. To prevent HA-LD, California hospitals and skilled nursing facilities should implement water management programs, as recommended by CDC and required by the Centers for Medicare and Medicaid Services (CMS) since June 2017. Public health agencies should respond rapidly to investigate HA-LD cases and control outbreaks. Disclosures All authors: No reported disclosures.

Background. The incidence rate of healthcare-associated Clostridium difficile infection (HA-CDI) is estimated at 1 in 100 patients. Antibiotic exposure is the most consistently reported risk factor. Strategies to reduce HA-CDI have focused on reducing antibiotic utilization. Prospective audit and feedback (PAF) is a commonly used antimicrobial stewardship intervention (ASi). The impact of this ASi on HA-CDI is equivocal. This study examines the impact of a PAF ASi on the incidence of HA-CDI. Methods. Single-site, 339 bed community-hospital in Ontario, Canada. Primary outcome is HA-CDI incidence rate. Daily PAF ASi is the exposure variable. PAF ASi is implemented across wards in a non-randomized stepped wedge design starting in July 2013. Criteria for ASi; any intravenous antibiotic use for ≥48 hours, or any fluoroquinolone or cephalosporin use for ≥48 hours. HA-CDI cases and model covariates aggregated by ward and month. Pooled statistical analyses done using generalized linear models with log link function. Potential clustering by ward and serial correlation of HA-CDI accounted for in final model. Other covariates tested for inclusion in final model were derived from previously published risk factors. Final pooled model was compared with random coefficient model (RCM). Goodness-of-fit (GOF) assessed using deviance statistics. Results. N = 430 observations with ASi implemented in 64 periods. The final model included; ASi, days of antibiotic therapy (DOT), previous month's CDI cases (LCDI), current month's community-associated-CDI cases (CA-CDI), length of stay (LOS) and days of hospitalization due to age over 65 years (Age), and interaction terms between ASi-DOT, LOS-Age and ASi-LCDI. ASi incidence rate ratio (IRR) is 0.42 (95% CI, 0.19–0.92). ASi-DOT interaction IRR was not significant. LCDI IRR was 1.20 (95% CI, 1.07–1.35) and CA-CDI IRR was 1.26 (95% CI, 1.12–1.42). Pooled model was equivalent to RCM and provided excellent GOF. Conclusion. Daily PAF ASi resulted in a significant reduction in HA-CDI; however, this effect was not mediated by an overall reduction in antibiotic utilization. In addition, the importance of CDI environmental pressure was demonstrated through the significant impact of both CA-CDI and LCDI on subsequent HA-CDI incidence rates. Disclosures. All authors: No reported disclosures.

Background The majority of pediatric healthcare encounters for influenza-like illness (ILI) take place in ambulatory settings where there may be multiple opportunities for respiratory virus transmission. Recent evidence shows that a prior clinic visit increases the risk of ILI among young children. We hypothesized that clinic factors would be associated with the risk of HA-ILI among children < 6 years old after a primary care encounter. Methods We conducted a prospective cohort study of a sample of 1308 children presenting to any of the 31 primary care clinics in a large pediatric healthcare network for a non-ILI clinic visit during three consecutive respiratory seasons (2012/13 – 2014/15). HA-ILI cases were defined as any ILI encounter within 8 days after a non-ILI visit. Clinic factors (waiting room patient density or number of ILI encounters at appointment time, time in waiting room, clinic location), sociodemographic and clinical data were obtained electronically and from parent interviews. School attendance (daycare, school or parent) and age (≤2 years and >2 years) were combined to create a 5 category composite variable. Logistic regression models after applying sampling weights evaluated associations between HA-ILI risk and patient age, daycare / school attendance, gender, influenza vaccine receipt and waiting room patient density. Results Our cohort included 367 HA-ILI cases and 941 non-cases. The majority (48.6%) were ≤2 years and did not attend school, 52.8% were male, and 18.9% received flu vaccine. Mean clinic patient density was 44.2 patients/1,000 square feet. In multivariable models, only the young age/daycare attendance composite variable was significantly associated with increased HA-ILI risk (OR 2.06, 95% CI 1.48,2.88). No clinic characteristics were associated with HA-ILI risk and risk did not vary by site. Conclusion In our cohort of young children, HA-ILI was not associated with the measured clinic characteristics that we hypothesized may increase respiratory virus transmission risk. Instead HA-ILI risk was highest in young daycare attendees who may be more likely to engage in behaviors that increase respiratory virus exposure risk or seek out healthcare services when sick. This suggests that HA-ILI may be more strongly influenced by behavioral factors rather than environmental factors. Disclosures All authors: No reported disclosures.

Background The incidence of hematogenous vertebral osteomyelitis (HVO) has increased over recent years, likely due to longer life expectancies, higher prevalence of chronic disease, and more effective diagnostic techniques. Recently, healthcare-associated infections, such as catheter-related and procedure-related bloodstream infections, also increase the risk of HVO. The aim of our study was to evaluate the clinical characteristics and outcomes of healthcare-associated HVO (HCA-HVO). Methods We conducted a retrospective chart review of adult patients with microbiologically diagnosed HVO from five tertiary-care hospitals over 8-year period. HCA-HVO was defined as onset of symptoms after 1 month of hospitalization or within 6 months after hospital discharge, or ambulatory manipulations in the 6 months before the diagnosis [Pigrau et al. Medicine (Baltimore) 2015; 94:e365]. We compared the clinical characteristics and outcomes of HCA-HVO with community-acquired HVO (CA-HVO) cases. Results In total, 358 patients with microbiologically diagnosed HVO were included in final analysis. Of these 358 cases, 256 (63.1%) were CA-HVO and 132 (36.9%) were HCA-HVO according to the predefined criteria. The main causative pathogens identified were methicillin-susceptible Staphylococcus aureus (32%), followed by methicillin-resistant S. aureus (MRSA) (26%), aerobic gram-negative bacteria (24%), and Streptococcus species (11%). Compared with CA-HVO cases, patients with HCA-HVO had more neoplasm (13.6% vs. 5.8%, P = 0.01) and end-stage renal disease (8.3% vs. 2.2%, P = 0.007). MRSA was more frequent pathogens in HCA-HVO cases than in CA-HVO (37.1% vs. 17.7%, P = 0.01). Patients with HCA-HVO were more likely to be have the higher rates of persistent bacteremia for ≥7 days (24.2% vs. 15.5%, P = 0.04), 1-year mortality (18.2% vs. 11.5%, P = 0.08) and 1-year relapse (12.1% vs. 6.2%, P = 0.051). Conclusion In this study, more than one-third of HVO is health care associated. Patients with HCA-HVO were more likely to have underlying illness, and their causative pathogens were more frequently MRSA. Outcomes of HCA-HVO were poorer, which require prevention measures and early diagnosis. Disclosures All authors: No reported disclosures.