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Background Anterior nares (AN) MRSA PCR can help identify MRSA colonization as a risk factor for MRSA pneumonia and can be especially useful, given high NPV, in making treatment decisions when lower respiratory tract (LRT) cultures are lacking. Oropharynx (OP) MRSA carriage without AN colonization can occur suggesting the potential benefit of duel site screening, but doubles resource utilization. We evaluated concordance between the AN and OP sites and whether the addition of OP MRSA PCR testing provides clinical benefit. Methods MRSA PCR was performed using Xpert SA Nasal Complete (Cepheid; FDA-cleared and modified). Results were retrieved from January 2017 to July 2018 for adult in-patients who received both AN and OP testing within the same calendar day. Medical charts were reviewed for a clinical course, respiratory culture results, and effect of discordant PCR results. Results AN and OP MRSA PCRs were performed on 1,419 adult inpatients, concordance was 96.5% (n = 1370, see Table). In 38 of 49 discordant cases, PCR was used to evaluate the etiology of pneumonia. Of those, 22 (58%) had LRT culture results available within 48 h to direct therapy. We further evaluated the value of OP PCR by focusing on AN-/OP+ (n = 22) discordant results, of which 16 were used to evaluate pneumonia. LRT culture results were available in 7 (44%) of these cases. Three had isolation of MRSA; however, the remaining 4 were culture-negative but still received vancomycin for an average of 5 days. Of the 9 that were AN−, OP+, and without culture results, only 4 had clinical signs and symptoms consistent with MRSA pneumonia. OP MRSA PCR is $303. Conclusion OP and AN MRSA PCR screening are highly concordant in patients with pneumonia. 355 AN/OP PCRs (4/1419), at > $100,000 in additional healthcare costs, were needed to detect one potentially missed MRSA pneumonia compared with AN PCR only approach. Our results suggest addition of OP MRSA PCR: (1) has limited clinical utility for pneumonia evaluation as it is unlikely to be discordant with AN testing, which will not significantly alter the very high NPV and when discordant (AN-/OP+) has a Disclosures Alexander Lepak, MD, Paratek Pharmaceuticals: Research Grant; Tetraphase Pharmaceuticals: Research Grant.

Background Staphylococcus aureus (Sa) outbreaks are serious infections that if not controlled in time can be life-threating. The aim of this study was to describe the investigation and control of a Sa outbreak in an intensive care unit including analysis of MP. Methods During a microbiological research of MP conducted in December 2018 in a clinical intensive care unit (ICU) of a tertiary university hospital two patients had an MRSA infection. Since this unit had not reported MRSA infections during the last year it was recognized as an outbreak. The CDC criteria was applied to define MRSA colonization and infection. Hand hygiene (HH) adhesion in this unit was 47%,it has 9 beds and 30 Healthcare professionals (HP). Nasal Swab (NS) of all the HPs and of the patients in the same unit as well. HP’s MP were also analyzed. The samples were subjected to MALDI-TOF (Biomerieux), phenotypical tests, PCR for detection of gene coA and mecA, pulsed-field gel electrophoresis (PFGE), and whole-genome sequence to access resistance, virulence profile and sequence type. Feedback of microbiology results, reinforcement of hand hygiene and MP cleaning was discussed with the unit staff. Results A total of 34 samples were collected, 25 were Sa, 13 NS of all HPs and patients, 7 from the MPs and 3 from HPs hands. During the time of the outbreak 5 patients were in the unit. Patients with infection by MRSA (n = 2), had Methicillin-susceptible Sa in their NSs. Another patient that from the same unit had a MRSA in the NS that when submitted to PFGE was seen to be closely related with the MRSA that originated the outbreak. The patients isolates were assigned to different STs and they had more virulent and resistance genes in comparison with two samples of MPs. The Sa recovered from the MPs belonged to the same ST, same resistance gene and same virulent genes. Figure 1, Table1. Since the feedback to the unit no cases of MRSA have been reported in the last 4 months. Conclusion The outbreak was controlled using simply measures (feedback, reinforcement of HH and MP cleaning). The ST398 from the MP has already been described in outbreaks in literature. It seems that MP can be a reservoir for Sa There was more than one Sa lineage in the ICU. Our findings highlighted the need of rethinking the MP cleaning policy in our hospital. Disclosures All authors: No reported disclosures.

Background A trial of universal decolonization (alcohol-based nasal antiseptic plus chlorhexidine gluconate bathing) was instituted for 12 months, in a 536-bed short-term acute care hospital, as a replacement for nasal screening, contact precautions (CP) and decolonization of methicillin-resistant Staphylococcus aureus (MRSA)-colonized patients. The impact on the rate of MRSA bacteremia and costs associated with nasal screening tests, isolation, and gown use was assessed. Methods Prior to the universal decolonization trial, patients at high-risk for MRSA colonization were screened using a nasal polymerase chain reaction (PCR) test, and those that tested positive were decolonized with 5 days of mupirocin nasal ointment and daily CHG bathing, and were placed in CP. Starting in April 2018, a universal decolonization protocol was instituted for all hospitalized patients, with a twice-daily alcohol-based nasal antiseptic (in place of mupirocin), and daily bathing with CHG foam soap (in place of CHG cloths). Nasal screening of high-risk patients, targeted decolonization and CP for MRSA-colonized patients, was discontinued during the 12-month universal decolonization trial period. Outcome measures for the trial included MRSA bacteremia per National Healthcare Surveillance Network (NHSN) multi-drug-resistant organism (MDRO) Lab ID definition, isolation day count, utilization of gowns, and nasal screening tests with estimated costs associated. Measures for the 12-month trial period were compared with those of the prior 12-month period, i.e., April 2017–March 2018. Results Compared with prior 12-month period, during the universal decolonization trial, there was a 42% reduction in isolation days ($118/day), a 74% reduction in nasal PCR tests ($36/each), and an 11% decrease in the monthly use of gowns ($12/each). The total cost avoidance (after accounting for the cost of the alcohol-based nasal antiseptic and CHG soap) was $1,394,685. There was no statistical change in the MRSA bacteremia rate (0.067 to 0.070) per 1,000 patient-days. Conclusion Replacement of nasal screening, decolonization, and CP for colonized MRSA patients with universal decolonization, using twice daily alcohol-based nasal antiseptic paired with daily CHG bathing, was found to be a safe and cost-saving protocol. Disclosures All Authors: No reported Disclosures.

Background MRSA colonization is a common neonatal problem and is associated with invasive infection. Good hand-washing and contact precautions reduce transmission. However, long-term contact isolation, sometimes for months, causes dissatisfaction among neonatal intensive care unit (NICU) care providers and parents. We examined the effectiveness of MRSA decolonization among neonates over 3 years. Methods Our NICU patients are routinely screened for MRSA colonization by PCR testing of nasal and rectal swabs upon admission and every 2 weeks. Patients with a history of MRSA infection or colonization became eligible for MRSA eradication upon reaching 2000g. Our protocol included intranasal muporocin 2% ointment applied to both nares twice daily for 5 days and 2% chlorhexidine wipe bath daily for 7 days. Wipes were used for bathing from the neck down for at least 20 sec per wipe. Two wipes were used for patient’s < 10 kg with the first wipe being used on the neck, chest, arms, and back, and the second wipe being used on the legs, buttocks, and perineum. Patients were excluded from chlorhexidine bathing if they had a known allergy, were < 27 weeks gestation, < 1 week chronological age, receiving phototherapy, or had severe skin disease, open wounds, or burns. Contact isolation was discontinued if 2 sets of nares and rectal PCR swabs 5 days apart were negative and the patient had not been on antibiotics during the screening period. Surveillance MRSA PCR testing continued. Contact isolation was to be re-initiated if subsequent MRSA screening was positive. Patients were not decolonized a second time. Results Among infants admitted to the NICU during from 2016 to 2018 MRSA colonization was identified in 102 patients. Fifty-six were noted to have colonization present on admission and 46 were acquired on or after hospital day 3. The decolonization protocol with follow-up screening was completed in 33 infants. Successful decolonization was achieved for only 5 (15%) of infants. There were no adverse reactions noted among neonates and no MRSA decolonized patients reverted to positive by PCR screening while in hospital. Conclusion 85% of neonates with MRSA failed decolonization. Using mupirocin intranasally and chlorhexidine bathing to decolonize neonates with MRSA was welcomed by staff and families, but was poorly effective. 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.

Background USA300 MRSA is endemic in certain communities, with congregate settings such as urban jails potentially facilitating spread. The extent of MRSA transmission in jail is unclear, a controversy that impacts prevention strategies. We determined the prevalence of MRSA colonization at jail entrance and defined the acquisition rate during incarceration. Methods Men incarcerated at the Cook County Jail, one of the largest US single-site jails, were enrolled within 72 hours of intake. Surveillance cultures (nares, throat, groin) were collected to determine prevalence of MRSA colonization. A survey was administered to identify predictors of colonization. Detainees still in jail at Day30 had cultures repeated to determine MRSA acquisition rate. Univariate and multivariate analysis was performed to identify predictors of MRSA colonization. Results A total o 402 men (447 unique incarcerations) have so far been enrolled (77% AA, 11% Hispanic) with 92% previously in jail (20% in past 6 months). The prevalence of MRSA colonization at intake was 18.6% (83/447), with 39% of those colonized solely in the throat or groin. At 30 days: 10% (9/92) of initially negative men acquired MRSA; 14 admission positives remained colonized while 11 lost colonization. On univariate (Table), predictors of MRSA colonization at entrance to the jail were: methamphetamine use (METH), unstable housing, current skin infection, and care at an outpatient Clinic A that emphasizes comprehensive care to the LGBTQ community. In this cohort, METH use was associated with reporting being a man who has sex with men vs. not (35% vs. 9%, P Conclusion We found that a relatively high proportion of individuals enter the jail colonized with MRSA and the jail may amplify rates. Entrance colonization risk factors point to possible community reservoirs. Enrollment is ongoing but results suggest an intervention in jail could impact MRSA rates in the jail and in the surrounding community. Disclosures M. K. Hayden, Sage, Inc: Sage is contributing product to healthcare facilities participating in a regional collaborative on which I am a co-investigator. Neither I nor my hospital receive product., Sage is contributing product to healthcare facilities participating in a regional collaborative on which I am a co-investigator. Neither I nor my hospital receive product.; Clorox, Inc.: I have received funding from Clorox for an investigator-initiated clinical trial., Research support; CDC: Grant Investigator, Research grant

Background Methicillin-resistant Staphylococcus aureus (MRSA) remains a major threat to patient safety in the neonatal intensive care unit (NICU). The aim of this study was to assess the effectiveness of active surveillance cultures (ASC) and decolonization in reducing MRSA transmission in the NICU. Methods Retrospective cohort data, including admission and discharge times, weekly surveillance culture results and mupirocin-administration information, were collected from three urban, tertiary care NICU in the US. The study period was 2007–2014, during which ASC and decolonization strategies were employed for MRSA control. We used Markov-Chain Monte Carlo methods to fit a probabilistic transmission model to the data. To account for the interval-censored nature of weekly surveillance screening, we used an integrated Bayesian framework to impute the date of conversion to MRSA-positive. We estimated the risk of MRSA acquisition associated with non-patient sources, undetected MRSA carriers, detected MRSA carriers on contact precautions, and MRSA carriers on contact precautions that also received decolonization treatment. Results Of the 12,677 neonates that were screened for MRSA colonization at study sites, 533 (4.2%) had a MRSA-positive surveillance culture. Neonates with undetected MRSA colonization were estimated to be the source of 67% (95% credible interval [CI]: 0.64–0.69) of MRSA acquisition. Compared with undetected MRSA carriers, detection and placement on contact precautions deceased the odds of transmission by 99.8% (odds ratio [OR]: 0.0016, 95% CI: 0.0000026–0.033), 99.6% (OR = 0.0036, 95% CI: 0.0000025–0.13), and 99.8% (OR = 0.0024; 95% CI: 0.00000042–0.043) at sites A, B, C, respectively. A 99.9% reduction in transmissibility was sustained among MRSA carriers who also received decolonization treatment (OR = 0.0014, 95% CI: 0.0000080–0.024). Conclusion In this multi-centered NICU cohort, ASC and decolonization programs were highly effective in reducing transmission risk from MRSA carriers. Detection of MRSA carriers and the use of contact precautions, alone, were associated with a near-complete reduction in transmission risk. Improving time-to-detection as well as prioritizing nonpatient reservoirs of MRSA could further reduce MRSA acquisition in the NICU. Disclosures All authors: No reported disclosures.