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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

BackgroundMost 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.MethodsA 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.ResultsWe 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).ConclusionsWe 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.

Background Candidemia is a major cause of morbidity and mortality in hospitalized patients. The global epidemiology of invasive Candidiasis is changing, with distribution of species and resistance varying in different geographic and healthcare settings. There is a paucity of data on candidemia in the Dominican Republic (DR). Understanding epidemiologic risk factors and resistance rates may improve early diagnosis and empiric antifungal selection. Methods We performed a retrospective review of patients with positive Candida blood cultures from January 2017 to December 2018. Data were extracted from medical records. Clinical and demographic information, including co-morbidities, antifungal sensitivities, and outcomes were collected. Results A total of 52 cases were identified, 34 in 2017 and 18 in 2018. Ages ranged from Conclusion Candidemia with non-albicans Candida species was common (87%). Susceptibilities and species varied by year but did not affect mortality. Resistance to fluconazole is rising but remains low and other antifungals retain susceptibility. Indwelling catheters, mechanical ventilation and antibiotic exposure were common risk factors in our cohort. Mortality for candidemia was high. Rapid diagnostic testing and early empiric therapy with echinocandins for patients at risk may curb mortality. Disclosures All authors: No reported disclosures.

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.

Background Resistant Staphylococcus aureus (SA) poses a major challenge to clinicians. The prevalence of methicillin-resistant SA (MRSA) has increased over the past decades, while vancomycin resistance remains rare. Only 14 cases of vancomycin-resistant SA (VRSA) have been described in the United States since 2002. VRSA and SA with reduced susceptibility to vancomycin (VISA) cause high morbidity and mortality. There is a paucity of data on VRSA in developing nations. We seek to define the prevalence and resistance profile of SA in the Dominican Republic (DR). Methods This is a retrospective review of resistance patterns of SA isolates from a clinical laboratory in the DR (Amadita Laboratories). Amadita provides services nationwide. Data collected from 2016 to 2017 included SA phenotypic sensitivity patterns and geographic location and income level. VISA and VRSA were defined as having minimum inhibitory (MIC) concentrations between 4 and 8 and MIC >16. Results Of 5,372 SA samples, 2,735 (51%) were MRSA, 21 were VISA and 39 were VRSA. VRSA samples were more commonly from Santo Domingo (SD) (Figure 1). Communities in SD with mixed and low incomes had greater burden of VRSA (Figure 2). Antimicrobial susceptibilities are shown in Table 1. Conclusion In this nationwide sample, we found an alarming number of VISA and VRSA. Most cases were in metropolitan SD, with lower income communities carrying a higher case burden. Linezolid and TMP-SMX retain activity against VISA and VRSA in the DR. The rise of vancomycin resistance in developing countries and the disproportionate burden on communities of low income is concerning and requires further study. Infection control measures and antimicrobial stewardship interventions may help prevent further spread of resistant strains. Disclosures All authors: No reported disclosures.

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.

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.

Background The prevalence of multi-drug-resistant organisms (MDRO) is on the rise globally. MDRO infections carry high morbidity and mortality. There is a paucity of data on Carbapenem-resistant Klebsiella pneumoniae (CRKp) in the Dominican Republic (DR). Evaluating CRKp in various settings will provide data on contrasting epidemiologic risk factors. We evaluated the epidemiology of CKRp in three contrasting settings, a 495-bed urban academic center (AC), a 151-bed urban community hospital (CH) and a 200 bed teaching hospital in the DR (DRH). Methods We performed a retrospective cohort study of patients with CRKp cultures from 2014 to 2016 from AC, CH and DRH. A comparative evaluation of the epidemiology of CRKp between the cohorts was performed. Demographics, co-morbid conditions, antibiotic sensitivity, and outcomes were compared between hospital cohorts. Results Cohort AC had 64 patients, compared with eight from CH and eight from DRH. AC (59%) and CH (62%) cohorts included more men than the DRH cohort (25%). Average age was 62, 66, and 51, respectively. History of MDRO, antibiotic use in the past 6 months and hospitalization within the past year were common risk factors (Figure 1). Diabetes and end-stage renal disease were common comorbidities at all facilities (Figure 2). Charleston Comorbidity Index (CCI) score was highest at AC (6.6) and DRH (6.4) compared with CH (4). Mortality was highest in DRH (63%, 6/8) and AC (11%, 7/64) while CH had no deaths. Urine was the most common source at AC (67%) and CH (75%) while blood was most common at DRH (62.5%). CRKp isolates were susceptible to colistin at varying rates (AC=85%, CH = 63%, DRH = 80%). Conclusion Prior antibiotic use and hospitalization were common risk factors in all settings. Mortality and CCI scores for CRKp was highest at AC and DRH, which are tertiary referral centers. CH had less overall mortality and higher rates of colistin resistance. Further studies are needed to understand these risk factors. Strengthening antimicrobial stewardship and infection control practices in the United States and abroad may help curb the spread of resistance in different clinical settings. Disclosures All authors: No reported disclosures.

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). Figure 1. ASP syndrome-based prospective audit and feedback. Figure 2. Antimicrobial use in medical surgical units after implementation of ASP. 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.

Background A cluster of 8 Mycobacterium avium Complex (MAC) clinical acid-fast bacilli (AFB) cultures were identified in a 2-week period at an urban public university hospital system. A review of AFB cultures from the past year showed a surge of cases during the months of October to November from the typical 1-3 cases per month. Methods An internal evaluation demonstrated that the number of cultures growing MAC from 9/30/16-11/30/16 was considerably greater than it had been in preceding months. Chart review was performed to determine the clinical relevance of the MAC cultures. Of 8 initial patients identified 6 had no clinical syndrome consistent with MAC infection. In addition, there were no common collection locations to suggest contamination at collection. Microbiology laboratory practices were reviewed and AFB smear and culture preparation and genetic probe identification of AFB were observed. Reagents and stains were cultured and local laboratory and reagent manufacturers were contacted. Results MAC was identified in 22 cultures from October to December 2016. Culture sites included sputum (induced and bronchoalveolar lavage), tissue, body fluid and organ preservation fluid. Prior history of mycobacterial pulmonary disease was seen in 5 patients during this time. Providers did not start patients without a history of MAC on therapy. Species identification by rpoB gene sequencing was performed in 17 of 22 cultures. Nine (53%) isolates were M. chimaera followed by M. Avium with 5 (29%)isolates. One grew both M. Avium and Mycobacterium tuberculosis (MTB), while another isolate was identified as MTB. Review of laboratory practices, revealed opportunities for cross contamination when tasks were batched and alternated while awaiting incubation or amplification as all AFB processing took place under one hood. Culture of PANTA™ reagent grew M. chimera. Conclusion Increased MAC cultures above baseline incidence identified a contamination of laboratory reagent causing a pseudo-outbreak of M. chimera. The pseudo-outbreak did not have clinical implication as patients lacked clinical signs and were not treated. Separation of amplification and culture preparation tasks both spatially and temporally are recommended to decrease cross contamination. Disclosures All authors: No reported disclosures.

Background Hospital epidemiologists at 2 Veterans Affairs Medical Centers (VAMCs A and B) within the same metropolitan area were alerted in 2015 by a shared VA reference laboratory to a possible cluster of Mycobacterium fortuitum complex (MFC) isolates, including M. farcinogenes/senegalense, from patients at both facilities. Methods Clinical samples were cultured for mycobacteria using standard methods and isolates were initially identified using AccuProbe (Hologic) or MALDI-TOF (Bruker). Stored MFC isolates from 2012-2015 were then analyzed using hsp and rpoB gene population sequencing, and compared with reference MFC sequences to determine species and genetic relatedness. One-liter water samples from sinks and ice machines on critical care units of both hospitals were cultured for nontuberculous mycobacteria using CDC published methods. Cohort clinical data were abstracted from electronic health records. Results We determined that 31 of 38 MFC isolates (19 VAMC A, 12 VAMC B) were an identical strain of M. conceptionense by rpoB sequencing. The same strain was found in a critical care unit ice machine at VAMC A. No other water samples from either facility contained this species. Ten additional MFC isolates from other VAMCs were also sequenced and none were M. conceptionense. Isolates came from critical care patients (27/31, 87%), inpatient non-critical care units (3, VAMC A) and 1 outpatient (VAMC B Pulmonary Clinic). Infection occurred in 2 patients (6%): bacteremia and mediastinitis 15 days after cardiac surgery (VAMC A), and pneumonia in an immunocompromised patient (VAMC B). Both patients received targeted antimicrobial therapy and recovered. The remaining 29 isolates were of respiratory origin and determined not to be clinically significant. Conclusion M. conceptionense was isolated from multiple patients over 4 years at 2 VAMCs in the same metropolitan area. Conventional methods (AccuProbe, MALDI-TOF) and hsp did not adequately differentiate MFC species; only rpoB sequencing identified M. conceptionense. An ice machine may have been one source at VAMC A; no source was determined for VAMC B. M. conceptionense is an unusual pathogen, causing infection in only 2 cases in our cluster. Disclosures All authors: No reported disclosures.

Background Implementation of interventions to increase provider awareness of central venous catheters (CVC) and indwelling urinary catheters (IUC) and indications can impact device utilization rates. Device utilization rates (DUR) correlate with device-associated complications. We implemented a Daily Interdisciplinary Safety Huddle (DISH) involving all hospital units. Devices were reported and plans for removal reviewed. Barriers identified were addressed within 24 hours. The purpose of this study was to evaluate the impact of DISH on DUR and HAI at a 151-bed urban, community hospital. Methods This is a retrospective review of DUR for IUC, CVC and the relationship to HAI. DISH is a daily 15-minute meeting at 8am. Key participants include the chief nursing officer (CNO), infection control practitioner (ICP), and managers of all hospital units. CVC and IUC usage are reported by nurse managers. The ICP reviews indications, duration, and plans for device removal. When barriers for removal remain, such as provider preference, the CNO, Medical Director of Infection Control or Chief Quality Officer are involved. Data before and after implementation of DISH was compared. Paired T-test was used to assess for differences between DUR means of both groups. Results Mean DUR for CVC was reduced from 0.2858 to 0.178 (device days/patient-days, P