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Testing of asymptomatic patients for severe acute respiratory coronavirus virus 2 (SARS-CoV-2) (ie, “asymptomatic screening) to attempt to reduce the risk of nosocomial transmission has been extensive and resource intensive, and such testing is of unclear benefit when added to other layers of infection prevention mitigation controls. In addition, the logistic challenges and costs related to screening program implementation, data noting the lack of substantial aerosol generation with elective controlled intubation, extubation, and other procedures, and the adverse patient and facility consequences of asymptomatic screening call into question the utility of this infection prevention intervention. Consequently, the Society for Healthcare Epidemiology of America (SHEA) recommends against routine universal use of asymptomatic screening for SARS-CoV-2 in healthcare facilities. Specifically, preprocedure asymptomatic screening is unlikely to provide incremental benefit in preventing SARS-CoV-2 transmission in the procedural and perioperative environment when other infection prevention strategies are in place, and it should not be considered a requirement for all patients. Admission screening may be beneficial during times of increased virus transmission in some settings where other layers of controls are limited (eg, behavioral health, congregate care, or shared patient rooms), but widespread routine use of admission asymptomatic screening is not recommended over strengthening other infection prevention controls. In this commentary, we outline the challenges surrounding the use of asymptomatic screening, including logistics and costs of implementing a screening program, and adverse patient and facility consequences. We review data pertaining to the lack of substantial aerosol generation during elective controlled intubation, extubation, and other procedures, and we provide guidance for when asymptomatic screening for SARS-CoV-2 may be considered in a limited scope.

Background The correlation between SARS-CoV-2 RNA and infectious viral contamination of the hospital environment is poorly understood. Methods housed in a dedicated COVID-19 unit at an academic medical center. Environmental samples were taken within 24 hours of the first positive SARS-CoV-2 test (day 1) and again on days 3, 6, 10 and 14. Patients were excluded if samples were not obtained on days 1 and 3. Surface samples were obtained with flocked swabs pre-moistened with viral transport media from seven locations inside (bedrail, sink, medical prep area, room computer, exit door handle) and outside the room (nursing station computer). RNA extractions and RT-PCR were completed on all samples. RT-PCR positive samples were used to inoculate Vero E6 cells for 7 days and monitored for cytopathic effect (CPE). If CPE was observed, RT-PCR was used to confirm the presence of SARS-CoV-2. Results We enrolled 14 patients (Table 1, Patient Characteristics) between October 2020 and May 2021. A total of 243 individual samples were obtained – 97 on day 1, 98 on day 3, 34 on day 6, and 14 on day 10. Overall, 18 (7.4%) samples were positive via RT-PCR – 9 from bedrails (12.9%), 4 from sinks (11.4%), 4 from room computers (11.4%) and 1 from the exit door handle (2.9%). Notably, all medical prep and nursing station computer samples were negative (Figure 1). Of the 18 positive samples, 5 were from day 1, 10 on day 3, 1 on day 6 and 2 on day 10. Only one sample, obtained from the bedrails of a symptomatic patient with diarrhea and a fever on day 3, was culture-positive (Figure 2). Table 1. Patient Characteristics Figure 1. Proportion of RT-PCR Positive Samples by Sample Day and Location Figure 2. Cell cultures of negative control (left) and CPE positive sample (right) Conclusion Overall, the amount of environmental contamination of viable SARS-CoV-2 virus in rooms housing COVID-19 infected patients was low. As expected, more samples were considered contaminated via RT-PCR compared to cell culture, supporting the conclusion that the discovery of genetic material in the environment is not an indicator of contamination with live infectious virus. More studies including RT-PCR and viral cell culture assays are needed to determine the significance of discovering SARS-CoV-2 RNA versus infectious virus in the clinical environment. Disclosures David J. Weber, MD, MPH, PDI (Consultant)

Background Recent changes in CLSI microbiologic interpretations of daptomycin and enterococci include the “susceptible-dose dependent” (SDD) category. The effectiveness of SDD for directing clinicians to employ higher dosing of daptomycin is unknown. The study objective was to determine if implementation of SDD paired with a comment recommending higher doses of daptomycin (8-12mg/kg) and ID consultation in 2019 was associated with changes in rates of daptomycin use and prescribed doses for enterococcal bloodstream infections (BSI). Methods Single-center, retrospective cohort study of adult inpatients with enterococcal BSI and daptomycin susceptibility results reported from Aug 2016-Jul 2020. Chart review was performed to collect demographics, source of infection, and clinical management strategy. Rate of daptomycin use for definitive therapy (antimicrobial on day 4 after final susceptibilities) and median prescribed dose were compared for BSI caused by S and SDD isolates. Annual (Aug 1-Jul 31) trends in infections and daptomycin use were tabulated. Results 189 blood cultures were reviewed, yielding 56 unique episodes of enterococcal BSI. Patients had a mean age of 59 years and majority had an immunocompromising disease or medication. Of the cases in which it was a clinically appropriate option, clinicians selected daptomycin for definitive treatment in 81% of S and 71% of SDD cases (p = 0.46, Chi-square). Median daptomycin dose prescribed was 10mg/kg for both interpretations; dose range was 6-12mg/kg for S and 9.5-12mg/kg for SDD isolates. No temporal trend in prescribed dose noted over the 4-year study period. Repeat blood cultures performed in 50/56 (89%). Within 90 days, rates of relapse were low but mortality was 26/56 (46%). Table 1. Infection and Treatment Characteristics Chart 1. Frequency of prescribed daptomycin dose (mg/kg) for susceptible (A) and SDD (B) enterococci BSI isolates. Conclusion No difference detected in rate of daptomycin use nor median prescribed dose based on microbiologic interpretation. While the majority of doses were adequate (10mg/kg) based on current guidance for enterococcal BSI, the use of a directive comment to guide dosing and ID consultation may have recused outliers. Additional data is needed to characterize the impact of specific microbiologic interpretations on clinician prescribing and determine the most effective messaging strategies. Disclosures David J. Weber, MD, MPH, PDI (Consultant)

Background Early assessments of COVID19 preparedness reported resource shortages, use of crisis capacity strategies, variations in testing, personal protective equipment (PPE), and policies in US hospitals. One year later, we performed a follow-up survey to assess changes in infection prevention practice and policies in our diverse network of community and academic hospitals. Methods This was a cross-sectional electronic survey of infection preventionists in 58 hospitals within the Duke Infection Control Outreach Network (community) and Duke/UNC Health systems (academic) in April-May 2021 to follow-up our initial survey from April 2020. The follow-up survey included 26 questions related to resource availability, crisis capacity strategies, procedures, changes to PPE and testing, and staffing challenges. Results We received 54 responses (response rate, 93%). Facilities reported significantly fewer PPE and resource shortages in the follow-up survey compared to our initial survey (Figure 1, P< 0.05). Only 32% of respondents were still reprocessing N95 respirators (compared to 73% in initial survey, P< 0.05). All hospitals performed universal masking, universal symptom screening on entry, and 30% required eye protection. In 2020, most hospitals suspended elective surgical procedures in March-April, and restarted in May-June. Approximately 92% reported in-house testing for SARS-COV-2 by April 2020, at least a third of which had a weekly capacity of >100 tests. Almost 80% performed universal pre-operative testing, while 61% performed universal preadmission testing for SARS-COV-2. Almost all hospitals switched from test-based to time-based strategy for discontinuing isolation precautions, majority in August-September 2020. Twenty-five percent hospitals reported infection prevention furloughs, staffing cuts, and or reassignments, while 81% reported increased use of agency nursing during the pandemic. Conclusion Our follow-up survey reveals improvement in resource availability, evolution of PPE guidance, increase in testing capacity, and burdensome staffing changes. Our serial surveys suggest increasing uniformity in infection prevention policies, but also highlight the increase in staff turnover and infection prevention staffing shortages. Disclosures Sonali D. Advani, MBBS, MPH, Nothing to disclose David J. Weber, MD, MPH, PDI (Consultant)

Previously published guidelines are available that provide comprehensive recommendations for detecting and preventing healthcare-associated infections (HAIs). The intent of this document is to highlight practical recommendations in a concise format designed to assist acute care hospitals in implementing and prioritizing their Clostridium difficile infection (CDI) prevention efforts. This document updates “Strategies to Prevent Clostridium difficile Infections in Acute Care Hospitals,” published in 2008. This expert guidance document is sponsored by the Society for Healthcare Epidemiology of America (SHEA) and is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America (IDSA), the American Hospital Association (AHA), the Association for Professionals in Infection Control and Epidemiology (APIC), and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise. The list of endorsing and supporting organizations is presented in the introduction to the 2014 updates.