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To understand hospital policies and practices as the COVID-19 pandemic accelerated, the Society for Healthcare Epidemiology of America (SHEA) conducted a survey through the SHEA Research Network (SRN). The survey assessed policies and practices around the optimization of personal protection equipment (PPE), testing, healthcare personnel policies, visitors of COVID-19 patients in relation to procedures, and types of patients. Overall, 69 individual healthcare facilities responded in the United States and internationally, for a 73% response rate.

Distinguished Oral Background: Shared Healthcare Intervention to Eliminate Life-threatening Dissemination of MDROs in Orange County, California (SHIELD OC) was a CDC-funded regional decolonization intervention from April 2017 through July 2019 involving 38 hospitals, nursing homes (NHs), and long-term acute-care hospitals (LTACHs) to reduce MDROs. Decolonization in NH and LTACHs consisted of universal antiseptic bathing with chlorhexidine (CHG) for routine bathing and showering plus nasal iodophor decolonization (Monday through Friday, twice daily every other week). Hospitals used universal CHG in ICUs and provided daily CHG and nasal iodophor to patients in contact precautions. We sought to evaluate whether decolonization reduced hospitalization and associated healthcare costs due to infections among residents of NHs participating in SHIELD compared to nonparticipating NHs. Methods: Medicaid insurer data covering NH residents in Orange County were used to calculate hospitalization rates due to a primary diagnosis of infection (counts per member quarter), hospital bed days/member-quarter, and expenditures/member quarter from the fourth quarter of 2015 to the second quarter of 2019. We used a time-series design and a segmented regression analysis to evaluate changes attributable to the SHIELD OC intervention among participating and nonparticipating NHs. Results: Across the SHIELD OC intervention period, intervention NHs experienced a 44% decrease in hospitalization rates, a 43% decrease in hospital bed days, and a 53% decrease in Medicaid expenditures when comparing the last quarter of the intervention to the baseline period (Fig. 1). These data translated to a significant downward slope, with a reduction of 4% per quarter in hospital admissions due to infection (P < .001), a reduction of 7% per quarter in hospitalization days due to infection (P < .001), and a reduction of 9% per quarter in Medicaid expenditures (P = .019) per NH resident. Conclusions: The universal CHG bathing and nasal decolonization intervention adopted by NHs in the SHIELD OC collaborative resulted in large, meaningful reductions in hospitalization events, hospitalization days, and healthcare expenditures among Medicaid-insured NH residents. The findings led CalOptima, the Medicaid provider in Orange County, California, to launch an NH incentive program that provides dedicated training and covers the cost of CHG and nasal iodophor for OC NHs that enroll. Funding: None Disclosures: Gabrielle M. Gussin, University of California, Irvine, Stryker (Sage Products): Conducting studies in which contributed antiseptic product is provided to participating hospitals and nursing homes. Clorox: Conducting studies in which contributed antiseptic product is provided to participating hospitals and nursing homes. Medline: Conducting studies in which contributed antiseptic product is provided to participating hospitals and nursing homes. Xttrium: Conducting studies in which contributed antiseptic product is provided to participating hospitals and nursing homes.

Leukemic relapse remains a major barrier to successful allogeneic hematopoietic stem cell transplantation (allo-HSCT) for aggressive hematologic malignancies. The basis for relapse of advanced lymphoid malignancies remains incompletely understood and may involve escape from the graft-versus-leukemia (GvL) effect. We hypothesized that for patients with chronic lymphocytic leukemia (CLL) treated with allo-HSCT, leukemic cell-intrinsic features influence transplant outcomes by directing the evolutionary trajectories of CLL cells. Integrated genetic, transcriptomic, and epigenetic analyses of CLL cells from 10 patients revealed that the clinical kinetics of post-HSCT relapse are shaped by distinct molecular dynamics. Early relapses after allo-HSCT exhibited notable genetic stability; single CLL cell transcriptional analysis demonstrated a cellular heterogeneity that was static over time. In contrast, CLL cells relapsing late after allo-HSCT displayed notable genetic evolution and evidence of neoantigen depletion, consistent with marked single-cell transcriptional shifts that were unique to each patient. We observed a greater rate of epigenetic change for late relapses not seen in early relapses or relapses after chemotherapy alone, suggesting that the selection pressures of the GvL bottleneck are unlike those imposed by chemotherapy. No selective advantage for human leukocyte antigen (HLA) loss was observed, even when present in pretransplant subpopulations. Gain of stem cell modules was a common signature associated with leukemia relapse regardless of posttransplant relapse kinetics. These data elucidate the biological pathways that underlie GvL resistance and posttransplant relapse.

PurposeVenetoclax-based therapy is a standard-of-care option in first-line and relapsed/refractory chronic lymphocytic leukemia (CLL). Patient management following venetoclax discontinuation remains nonstandard and poorly understood.Experimental designTo address this, we conducted a large international study to identify a cohort of 326 patients who discontinued venetoclax and have been subsequently treated. Coprimary endpoints were overall response rate (ORR) and progression-free survival for the post-venetoclax treatments stratified by treatment type [Bruton's tyrosine kinase inhibitor (BTKi), PI3K inhibitor (PI3Ki), and cellular therapies].ResultsWe identified patients with CLL who discontinued venetoclax in the first-line (4%) and relapsed/refractory settings (96%). Patients received a median of three therapies prior to venetoclax; 40% were BTKi naïve (n = 130), and 81% were idelalisib naïve (n = 263). ORR to BTKi was 84% (n = 44) in BTKi-naïve patients versus 54% (n = 30) in BTKi-exposed patients. We demonstrate therapy selection following venetoclax requires prior novel agent exposure consideration and discontinuation reasons.ConclusionsFor BTKi-naïve patients, selection of covalently binding BTKis results in high ORR and durable remissions. For BTKi-exposed patients, covalent BTK inhibition is not effective in the setting of BTKi resistance. PI3Kis following venetoclax do not appear to result in durable remissions. We conclude that BTKi in naïve or previously responsive patients and cellular therapies following venetoclax may be the most effective strategies.See related commentary by Rogers, p. 3501.

Novel coronavirus disease 2019 (COVID-19) is a highly infectious, rapidly spreading viral disease with an alarming case fatality rate up to 5%. The risk factors for severe presentations are concentrated in patients with chronic kidney disease, particularly patients with end-stage renal disease (ESRD) who are dialysis dependent. We report the first US case of a 56-year-old nondiabetic male with ESRD secondary to IgA nephropathy undergoing thrice-weekly maintenance hemodialysis for 3 years, who developed COVID-19 infection. He has hypertension controlled with angiotensin receptor blocker losartan 100 mg/day and coronary artery disease status-post stent placement. During the first 5 days of his febrile disease, he presented to an urgent care, 3 emergency rooms, 1 cardiology clinic, and 2 dialysis centers in California and Utah. During this interval, he reported nausea, vomiting, diarrhea, and low-grade fevers but was not suspected of COVID-19 infection until he developed respiratory symptoms and was admitted to the hospital. Imaging studies upon admission were consistent with bilateral interstitial pneumonia. He was placed in droplet-eye precautions while awaiting COVID-19 test results. Within the first 24 h, he deteriorated quickly and developed acute respiratory distress syndrome (ARDS), requiring intubation and increasing respiratory support. Losartan was withheld due to hypotension and septic shock. COVID-19 was reported positive on hospital day 3. He remained in critical condition being treated with hydroxychloroquine and tocilizumab in addition to the standard medical management for septic shock and ARDS. Our case is unique in its atypical initial presentation and highlights the importance of early testing.

ObjectiveTo assess the impact of a newly developed Central-Line Insertion Site Assessment (CLISA) score on the incidence of local inflammation or infection for CLABSI prevention.DesignA pre- and postintervention, quasi-experimental quality improvement study.Setting and participantsAdult inpatients with central venous catheters (CVCs) hospitalized in an intensive care unit or oncology ward at a large academic medical center.MethodsWe evaluated CLISA score impact on insertion site inflammation and infection (CLISA score of 2 or 3) incidence in the baseline period (June 2014-January 2015) and the intervention period (April 2015-October 2017) using interrupted times series and generalized linear mixed-effects multivariable analyses. These were run separately for days-to-line removal from identification of a CLISA score of 2 or 3. CLISA score interrater reliability and photo quiz results were evaluated.ResultsAmong 6,957 CVCs assessed 40,846 times, percentage of lines with CLISA score of 2 or 3 in the baseline and intervention periods decreased by 78.2% (from 22.0% to 4.7%), with a significant immediate decrease in the time-series analysis (P < .001). According to the multivariable regression, the intervention was associated with lower percentage of lines with a CLISA score of 2 or 3, after adjusting for age, gender, CVC body location, and hospital unit (odds ratio, 0.15; 95% confidence interval, 0.06-0.34; P < .001). According to the multivariate regression, days to removal of lines with CLISA score of 2 or 3 was 3.19 days faster after the intervention (P < .001). Also, line dwell time decreased 37.1% from a mean of 14 days (standard deviation [SD], 10.6) to 8.8 days (SD, 9.0) (P < .001). Device utilization ratios decreased 9% from 0.64 (SD, 0.08) to 0.58 (SD, 0.06) (P = .039).ConclusionsThe CLISA score creates a common language for assessing line infection risk and successfully promotes high compliance with best practices in timely line removal.

In eukaryotes, cellular respiration is driven by mitochondrial cytochrome c oxidase (CcO), an enzyme complex that requires copper cofactors for its catalytic activity. Insertion of copper into its catalytically active subunits, including COX2, is a complex process that requires metallochaperones and redox proteins including SCO1, SCO2, and COA6, a recently discovered protein whose molecular function is unknown. To uncover the molecular mechanism by which COA6 and SCO proteins mediate copper delivery to COX2, we have solved the solution structure of COA6, which reveals a coiled-coil-helix-coiled-coil-helix domain typical of redox-active proteins found in the mitochondrial inter-membrane space. Accordingly, we demonstrate that COA6 can reduce the copper-coordinating disulfides of its client proteins, SCO1 and COX2, allowing for copper binding. Finally, our determination of the interaction surfaces and reduction potentials of COA6 and its client proteins provides a mechanism of how metallochaperone and disulfide reductase activities are coordinated to deliver copper to CcO.

Abstract Background Post-operative wound care can be an important strategy to prevent surgical site infection (SSI) following craniotomy. Insufficient wound care, blood clots, and oily hair near the incision can increase SSI risk. Methods We conducted a pre-post prospective cohort evaluation of a quality improvement intervention to address inpatient post-operative craniotomy wounds at an academic hospital. A post-op wound care protocol was jointly developed by neurosurgical wound care nurses, clinicians, and infection preventionists. The protocol began on postoperative day 1, and included use of soft ties to keep adjacent hair away from the incision, use of 2% CHG cloths to clean skin and hair within 2 inches of the incision as well as the proximal 6 inches of any surgical drain, and use of 2% CHG cloths to remove blood clots. Selection of 2% CHG cloths for blood clot removal was made following comparison to several concentrations of peroxide. A twice-weekly photo-survey of all inpatients undergoing craniotomy was undertaken during the baseline period (October–December 2018) and intervention period (March–April 2019), with feedback to wound care nurses occurring during the intervention period only. The proportion of redness, extensive blood clots (>50% incision), and oily hair near the incision were compared between the baseline period and the intervention period using Fisher’s exact tests. Results A total of 156 photo assessments were performed in 71 patients (101 assessments in 45 patients in the baseline period, and 55 photo assessments in 26 patients in the intervention period). Demographics, body mass index, emergent status, and prior craniotomy were similar across the baseline and intervention periods. The intervention was associated with significant reductions in redness (27.7% vs. 11%, P = 0.015), blood clots (33.7% vs. 10.9%, P = 0.002), and oily hair near the incision (76.7% vs. 28.6%, P < 0.001) (Figure 1). Conclusion The care of post-operative craniotomy wounds and adjacent hair was significantly improved through a standardized protocol to remove blood clots and ensure clean skin and hair adjacent to the incision during the post-operative inpatient stay. Photo documentation and feedback to wound care nurses helped ensure protocol adherence. Disclosures All authors: No reported disclosures.

Abstract Background Higher CHG skin levels may be needed to adequately control infection and transmission of pathogens in the ICU. We assessed whether measurement and feedback of patient CHG skin concentrations could improve CHG bathing quality and identified factors associated with higher CHG skin concentrations. Methods We conducted 6 one-day surveys from January 2018 to February 2019 in 7 academic hospital MICUs with established daily CHG bathing. Adults admitted >1 day were assessed for CHG skin levels with a semi-quantitative colorimetric assay using swabbed 25 cm2 areas of anterior neck, axilla, and inguinal skin. Prior to survey 4, results from the first 3 surveys (baseline) were reported to ICU leadership and front-line staff to retrain and reeducate on bathing technique. Feedback of results from prior surveys also occurred before surveys 5 and 6. For statistical analysis, mixed-effects models accounted for clustering of CHG measurements within patients and ICUs. We categorized CHG product type as “cloth” for no-rinse 2% CHG-impregnated cloth and “liquid” for 4% CHG liquid or foam. Results In total, 681 of 704 (97%) patients were enrolled. Three ICUs used CHG cloth, 3 ICUs used CHG liquid, and 1 ICU switched from liquid to cloth after the second survey. Median CHG skin concentrations were higher in both the baseline and feedback period for institutions using CHG cloth, as compared with liquid (table). Across all time points, axillary and inguinal regions had higher skin CHG concentrations than the neck (median 39.1, 78.1, 19.5 µg/mL, respectively, P < 0.001). After controlling for age, mechanical ventilation, presence of a central venous catheter, body site, and hours since last CHG bath, institutions that used CHG cloth had a 3-fold increase in adjusted CHG skin concentrations in the feedback period compared with the baseline period (P = 0.001, Figure). There was no significant change in CHG skin concentrations from baseline to feedback period for institutions that used liquid CHG. Conclusion CHG skin concentrations on MICU patients receiving daily CHG bathing varied by body site and CHG product type. The use of CHG cloth was associated with higher CHG skin levels, compared with CHG liquid. For ICUs using CHG cloth, feedback of CHG skin concentration results to ICU staff improved CHG bathing quality. Disclosures All Authors: No reported Disclosures.

Abstract Background CHG bathing is used to suppress patients’ microbial skin colonization, in order to prevent infections and transmission of multidrug-resistant organisms. Prior work has suggested that microbial growth is inhibited when CHG skin concentrations exceed threshold levels. Methods We conducted 6 single-day surveys from January 2018 to February 2019 in 7 academic hospital MICUs with established CHG patient bathing. Adult patients were eligible to have skin swabbed from adjacent 25 cm2 areas on the neck, axilla, and inguinal region for culture and CHG concentration determination. CHG skin concentrations were measured by a semi-quantitative colorimetric assay. Selective media were used to isolate targeted microorganisms (Table 1). Species were confirmed by matrix-assisted laser desorption ionization time-of-flight mass spectrometry; antibiotic susceptibility was determined by MicroScan (Beckman Coulter). We modeled the relationship between CHG skin concentrations (log2-transformed) and microorganism recovery (yes/no as primary outcome) using multilevel models controlling for clustering of body sites within patients and within ICUs, assessing slope and threshold effects. Results We enrolled 736/759 (97%) patients and sampled 2176 skin sites. Gram-positive bacteria were detected most frequently (Table 1). The adjusted odds of identifying gram-positive organisms decreased linearly as CHG skin levels increased (Figure 1a), without evidence of a threshold effect. We also found significant negative linear slopes without evidence of threshold effects for other pathogens tested (Table 2; Figure 1), with the exception of gram-negative bacteria and vancomycin-resistant enterococci. When modeling quantitative culture results (colony-forming units) for gram-positive organisms as a continuous outcome variable, a similar relationship was found. Conclusion Higher concentrations of CHG were associated with less frequent recovery of gram-positive bacteria and Candida species on the skin of MICU patients who were bathed routinely with CHG. For microbial inhibition, we did not identify a threshold concentration of CHG on the skin; rather, increasing CHG skin concentrations led to additional gains in inhibition. For infection prevention, aiming for high CHG skin levels may be beneficial. Disclosures All authors: No reported disclosures.

Abstract Background Patient movement between hospitals, nursing homes (NH), and long-term acute care facilities (LTACs) contributes to MDRO spread. SHIELD OC is a regional decolonization collaborative among adult facilities with high patient sharing designed to reduce countywide MDRO prevalence. We report pre- and post-intervention MDRO colonization prevalence. Methods Decolonization included chlorhexidine bath (CHG) (4% liquid or 2% cloth) and twice-daily nasal swab 10% povidone–iodine (PI). LTAC and NH used CHG for all baths and PI 5 days on admission and Monday–Friday every other week. Patients in contact precautions (CP) at hospitals had daily CHG and 5-days PI on admission. Point-prevalence screening for MRSA, VRE, ESBL, and CRE using nares, axilla/groin, and peri-rectal swabs was conducted pre-intervention (September 2016–March 2017) and post-intervention (August 2018–April 2019); 50 random LTAC and 50 CP hospitalized patients were sampled; for NH up to 50 were sampled at baseline and all residents post-intervention. Raw impact of the intervention was assessed by the average change in colonization prevalence, with each facility carrying equal weight. Generalized linear mixed models (GLM) stratified by facility type were used to assess the impact on MDRO colonization when clustering by facility. Results Across 35 facilities (16 hospitals, 16 NHs, 3 LTACs), the overall MDRO prevalence was reduced 22% in NHs (OR 0.58, P < 0.001), 34% LTACs (OR = 0.27, P < 0.001), and 11% CP patients (OR = 0.67, P < 0.001, Table 1). For MRSA, raw reductions were 31% NHs (OR = 0.58, P < 0.001), 39% LTACs (OR = 0.51, P = 0.01), and 3% CP patients (OR = 0.88, P = NS). For VRE, raw reductions were 40% NHs (OR = 0.62, P = 0.001), 55% LTACs (OR = 0.26, P < 0.001), and 15% CP patients (OR = 0.67, P = 0.004). For ESBLs, raw reductions were 24% NHs (OR = 0.65, P < 0.001), 34% LTACs (OR = 0.53, P = 0.01), and 26% CP patients (OR = 0.64, P < 0.001). For CRE, raw reductions were 24% NHs (OR = 0.70, P = NS), and 23% LTACs (OR = 0.75, P = NS). CRE increased by 26% in CP averaged across hospitals, although patient -level CRE declined 2.4% to 1.8% (OR = 0.74, P = NS). Conclusion MDRO carriage was common in highly inter-connected NHs, LTACs and hospitals. A regional collaborative of universal decolonization in long-term care and targeted decolonization of CP patients in hospitals led to sizeable reductions in MDRO carriage. Disclosures All Authors: No reported Disclosures.

BackgroundMultidrug-resistant organisms (MDROs) spread between hospitals, nursing homes (NHs), and long-term acute care facilities (LTACs) via patient transfers. The Shared Healthcare Intervention to Eliminate Life-threatening Dissemination of MDROs in Orange County is a regional public health collaborative involving decolonization at 38 healthcare facilities selected based on their high degree of patient sharing. We report baseline MDRO prevalence in 21 NHs/LTACs.MethodsA random sample of 50 adults for 21 NHs/LTACs (18 NHs, 3 LTACs) were screened for methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococcus spp. (VRE), extended-spectrum β-lactamase-producing organisms (ESBL), and carbapenem-resistant Enterobacteriaceae (CRE) using nares, skin (axilla/groin), and peri-rectal swabs. Facility and resident characteristics associated with MDRO carriage were assessed using multivariable models clustering by person and facility.ResultsPrevalence of MDROs was 65% in NHs and 80% in LTACs. The most common MDROs in NHs were MRSA (42%) and ESBL (34%); in LTACs they were VRE (55%) and ESBL (38%). CRE prevalence was higher in facilities that manage ventilated LTAC patients and NH residents (8% vs

Introduction: Sjogren's syndrome (SS) is an autoimmune chronic inflammatory disorder affecting women in their fourth to sixth decade, affecting gastrointestinal, and musculoskeletal systems. A 35-year-old female with SS with polymyositis (PM) presented with symptoms of weakness in all four limbs, difficulty in sitting, rising, swallowing solid foods, vomiting, and difficulty in climbing stairs. She was diagnosed with SS in 2018 and was treated with prednisolone, Vitamin D, calcium, pyridoxine, methylcobalamin, artificial tears, pilocarpine, and painkillers. However, a muscle biopsy was never done. Methods: The data were collected from the patient's file along with her consent when she came for follow-up. Results: A muscle biopsy was done at our center to confirm the diagnosis of PM. The patient was prescribed IV prednisolone and other symptomatic treatment until symptoms resolved and was discharged with oral drugs when they were manageable. Conclusion: The diagnosis of primary SS along with PM is a rare occurrence. Although it does not change the treatment plan much, its diagnosis is very important for managing any complications that may arise from it. Patients' noncompliance and loss of follow-up can create issues in the treatment. Such cases help in forming the guidelines for the future and restructuring the classification of autoimmune conditions. [ABSTRACT FROM AUTHOR]

A high velocity is rarely accessible in water streams such as rivers, canals, and outlets of sewage and common effluent treatment plants. However, an average velocity of 0.5 - 1.0 m/s is reported to be available in many water streams most of the time. Hydrokinetic (HK) turbines can extract power from the flowing water in these streams. Considering the small quantum of power generated, the economic factor is more significant than efficiency. A Savonius-type HK turbine can generate energy from low-velocity magnitudes of around 0.5 m/s, although it remains a low-speed and low-efficiency turbine. In this study, an attempt has been made to computationally investigate the performance of the Savonius turbine in a water stream channel. It is observed that the performance of the Savonius turbine is not significant, and the generated power cannot be utilized constructively for different applications. Therefore, it is necessary to develop and investigate variant constructive systems to enhance turbine performance. This manuscript focuses on exploring these variant systems and understanding their performance characteristics. Four variant systems have been selected: (i) System-1: Solely Savonius turbine, (ii) System-2: Savonius turbine with a flume, (iii) System-3: Deflector section used before the flume, and (iv) System-4: Deflector section used before the turbine. The investigation was carried out for these four variant systems using the Fluent commercial code. The results indicate that the Coefficient of performance (Cp) is low for System-1, solely Savonius turbine, with a value of 0.052. For the other variants, Cp values were found to be 0.357, 1.385, and 0.579 for the turbine with a flume, deflector before the flume, and deflector before the turbine respectively at the Tip Speed Ratio (TSR) is 1. Moreover, the study also extends to optimizing Cp under different TSR for the different variant systems. The intention is to use this study to install an HK turbine with an optimum constructive structure for maximizing and stabilizing the power that can be used for an isolated application. [ABSTRACT FROM AUTHOR]

C. difficile PCR testing identifies both colonized and infected patients, making it critical to only test patients that meet clinical criteria for C. difficile infection (CDI). We implemented an automated order-entry protocol that reduced inappropriate testing by 64% and hospital-onset (HO) CDI Standardized Infection Ratio (SIR) from 1.62 to 0.82.

BackgroundThe east-to-west spread of carbapenem-resistant Enterobacteriaceae (CRE) represents an opportunity to explore strategies to limit spread in nonendemic areas. We evaluated CRE emergence and regional support for containment strategies.MethodsA 17-question cross-sectional survey was administered to infection prevention programs in Orange County, CA (31 hospitals serving 3 million residents), between January and September 2014. Questions addressed newly detected hospital- and community-onset CRE cultures (2008-2013), current CRE control strategies, and support for prevention strategies for a hypothetical regional intervention.ResultsAmong 31 hospitals, 21 (68%, representing 17 infection prevention programs) completed the survey. CRE was scarcely detected between 2009-2010; within 4 years, 90% of hospitals reported CRE, with 2.5-fold higher community-onset than hospital-onset CRE. Between 2011 and 2013, annual CRE incidence increased 4.7-fold (1.4-6.3 cases/10,000 admissions). Support for a regional CRE prevention bundle was unanimous. Although 22% bathed patients positive for CRE with chlorhexidine gluconate and 11% actively screened for CRE, 86% and 57%, respectively, would consider these strategies in a regional intervention.ConclusionsCRE epidemiology in Orange County parallels early progression previously seen in now-endemic areas, representing an opportunity to consider interventions to prevent endemic spread. Many facilities would consider proactive strategies, such as chlorhexidine bathing, in the setting of a regional collaborative.

Abstract Background MDROs can spread between hospitals, nursing homes (NH), and long-term acute care facilities (LTACs) via shared patients. SHIELD OC is a regional decolonization collaborative involving 38 of 104 countywide adult facilities identified by their high degree of direct and indirect patient sharing with one another. We report baseline MDRO prevalence in these facilities. Methods Adult patients in 38 facilities (17 hospitals, 18 NHs, 3 LTACs) underwent point-prevalence screening between September 2016–April 2017 for MRSA, VRE, ESBL, and CRE using nares, skin (axilla/groin), and peri-rectal swabs. In NHs and LTACs, residents were randomly selected until 50 sets of swabs were obtained. Swabbing in hospitals involved all patients in contact precautions. An additional set of swabs were also performed for all LTAC admissions from November 2016–February 2017. Results The overall prevalence of any MDRO among patients was 64% (44%–88%) in NHs, 80% (range 72%–86%) in LTACs, and 64% (54–84%) in hospitals (contact precaution patients) (Table 1). Only 25%, 64%, and 81% of patients were already known to harbor an MDRO in NHs, LTACs, and hospitals, respectively. Known MDRO patients also harbored another MDRO 49%, 63%, and 34% of the time for NHs, LTACs, and hospitals, respectively. In LTACs, MDRO point prevalence was 38% higher than the usual admission prevalence (65% higher for MRSA, 34% higher for VRE, 95% higher for ESBL, and 50% higher for CRE). Conclusion MDRO carriage in highly inter-connected NHs and LTACs was widespread, rivaling that found in hospitalized patients on contact precautions. MRSA, VRE, and ESBL carriage far outnumbered CRE carriage. A history of MDRO was insensitive for identifying MDRO carriers, and many patients carried multiple MDROs. The extensive MDRO burden and transmission in long-term care settings suggests that regional MDRO prevention efforts must include MDRO control in long-term care facilities. Disclosures R. D. Singh, Sage Products: Receipt of contributed product, Conducting studies in healthcare facilities that are receiving contributed product; 3M: Receipt of contributed product, Conducting studies in healthcare facilities that are receiving contributed product; Xttrium Laboratories: Receipt of contributed product, Conducting studies in healthcare facilities that are receiving contributed product; Clorox: Receipt of contributed product, Conducting studies in healthcare facilities that are receiving contributed product; J. A. McKinnell, Sage Products: Receipt of contributed product, Conducting studies in healthcare facilities that are receiving contributed product; 3M: Receipt of contributed product, Conducting studies in healthcare facilities that are receiving contributed product; Xttrium: Receipt of contributed product, Conducting studies in healthcare facilities that are receiving contributed product; Clorox: Receipt of contributed product, Conducting studies in healthcare facilities that are receiving contributed product; L. G. Miller, Sage Products: Receipt of contributed product, Conducting studies in healthcare facilities that are receiving contributed product; Xttrium: Receipt of contributed product, Conducting studies in healthcare facilities that are receiving contributed product; Clorox: Receipt of contributed product, Conducting studies in healthcare facilities that are receiving contributed product; 3M: Receipt of contributed product, Conducting studies in healthcare facilities that are receiving contributed product; K. Kleinman, Sage Products: Receipt of contributed product, Conducting studies in healthcare facilities that are receiving contributed product; Clorox: Receipt of contributed product, Conducting studies in healthcare facilities that are receiving contributed product; Xttrium Laboratories: Receipt of contributed product, Conducting studies in healthcare facilities that are receiving contributed product; Molnlycke: Receipt of contributed product, Conducting studies in healthcare facilities that are receiving contributed product; 3M: Receipt of contributed product, Conducting studies in healthcare facilities that are receiving contributed product; L. Heim, Clorox: Receipt of contributed product, Conducting studies in healthcare facilities that are receiving contributed product; Sage Products: Receipt of contributed product, Conducting studies in healthcare facilities that are receiving contributed product; Xttrium: Receipt of contributed product, Conducting studies in healthcare facilities that are receiving contributed product; 3M: Receipt of contributed product, Conducting studies in healthcare facilities that are receiving contributed product; T. D. Dutciuc, Sage Products: Receipt of contributed product, Conducting studies in healthcare facilities that are receiving contributed product; Xttrium: Receipt of contributed product, Conducting studies in healthcare facilities that are receiving contributed product; Clorox: Receipt of contributed product, Conducting studies in healthcare facilities that are receiving contributed product; 3M: Receipt of contributed product, Conducting studies in healthcare facilities that are receiving contributed product; M. Estevez, Sage Products: Receipt of contributed product, Conducting studies in healthcare facilities that are receiving contributed product; Xttrium: Receipt of contributed product, Conducting studies in healthcare facilities that are receiving contributed product; Clorox: Receipt of contributed product, Conducting studies in healthcare facilities that are receiving contributed product; 3M: Receipt of contributed product, Conducting studies in healthcare facilities that are receiving contributed product; G. Gussin, Sage Products: Receipt of contributed product, Conducting studies in healthcare facilities that are receiving contributed product; Clorox: Receipt of contributed product, Conducting studies in healthcare facilities that are receiving contributed product; Xttrium Laboratories: Receipt of contributed product, Conducting studies in healthcare facilities that are receiving contributed product; L’Oreal: Consultant, Consulting fee; J. Chang, Sage Products: Receipt of contributed product, Conducting studies in healthcare facilities that are receiving contributed product; Xttrium Laboratories: Receipt of contributed product, Conducting studies in healthcare facilities that are receiving contributed product; Clorox: Receipt of contributed product, Conducting studies in healthcare facilities that are receiving contributed product; 3M: Receipt of contributed product, Conducting studies in healthcare facilities that are receiving contributed product; E. M. Peterson, Sage Products: Receipt of contributed product, Conducting studies in healthcare facilities that are receiving contributed product; Xttrium Laboratories: Receipt of contributed product, Conducting studies in healthcare facilities that are receiving contributed product; Clorox: Receipt of contributed product, Conducting studies in healthcare facilities that are receiving contributed product; B. Y. Lee, GSK: Consultant, Consulting fee; R. A. Weinstein, Sage Products: Receipt of contributed product, Conducting studies in healthcare facilities that are receiving contributed product; Molnlycke: Receipt of contributed product, Conducting studies in healthcare facilities that are receiving contributed product; Clorox: Receipt of contributed product, Conducting studies in healthcare facilities that are receiving contributed product; OpGen Company: Study support, Provided services at no charge; M. K. Hayden, Sage Products: Receipt of contributed 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: Receipt of contributed product, Research support; CDC: Grant Investigator and Receipt of contributed product, Research grant; Molnlycke: Receipt of contributed product, Conducting studies in healthcare facilities that are receiving contributed product; OpGen Company: Study support, Provided services at no charge for studies; S. K. Gohil, Sage Products: Receipt of contributed product, Conducting studies in healthcare facilities that are receiving contributed product; Xttrium Laboratories: Receipt of contributed product, Conducting studies in healthcare facilities that are receiving contributed product; Clorox: Receipt of contributed product, Conducting studies in healthcare facilities that are receiving contributed product; S. Park, Sage Products: Receipt of contributed product, Conducting studies in healthcare facilities that are receiving contributed product; Clorox: Receipt of contributed product, Conducting studies in healthcare facilities that are receiving contributed product; Xttrium Laboratories: Receipt of contributed product, Conducting studies in healthcare facilities that are receiving contributed product; S. Tam, Sage Products: Receipt of contributed product, Conducting studies in healthcare facilities that are receiving contributed product; 3M: Receipt of contributed product, Conducting studies in healthcare facilities that are receiving contributed product; Xttrium Laboratories: Receipt of contributed product, Conducting studies in healthcare facilities that are receiving contributed product; Clorox: Receipt of contributed product, Conducting studies in healthcare facilities that are receiving contributed product; R. Saavedra, Sage Products: Receipt of contributed product, Conducting studies in healthcare facilities that are receiving contributed product; Xttrium Laboratories: Receipt of contributed product, Conducting studies in healthcare facilities that are receiving contributed product; Clorox: Receipt of contributed product, Conducting studies in healthcare facilities that are receiving contributed product; S. Yamaguchi, Sage Products: Receipt of contributed product, Conducting studies in healthcare facilities that are receiving contributed product; Xttrium Laboratories: Receipt of contributed product, Conducting studies in healthcare facilities that are receiving contributed product; Clorox: Receipt of contributed product, Conducting studies in healthcare facilities that are receiving contributed product; H. Custodio, Xttrium Laboratories: Study coordination, Conducting studies in healthcare facilities that are receiving contributed product; Sage Products: Study coordination, Conducting studies in healthcare facilities that are receiving contributed product; Clorox: Study coordination, Conducting studies in healthcare facilities that are receiving contributed product; J. Nguyen, Sage Products: Receipt of contributed product, Conducting studies in healthcare facilities that are receiving contributed product; Xttrium Laboratories: Receipt of contributed product, Conducting studies in healthcare facilities that are receiving contributed product; Clorox: Receipt of contributed product, Conducting studies in healthcare facilities that are receiving contributed product; T. Tjoa, Sage Products: Receipt of contributed product, Conducting studies in healthcare facilities that are receiving contributed product; Xttrium Laboratories: Receipt of contributed product, Conducting studies in healthcare facilities that are receiving contributed product; Clorox: Receipt of contributed product, Conducting studies in healthcare facilities that are receiving contributed product; 3M: Receipt of contributed product, Conducting studies in healthcare facilities that are receiving contributed product; J. He, Sage Products: Receipt of contributed product, Conducting studies in healthcare facilities that are receiving contributed product; Xttrium Laboratories: Receipt of contributed product, Conducting studies in healthcare facilities that are receiving contributed product; Clorox: Receipt of contributed product, Conducting studies in healthcare facilities that are receiving contributed product; 3M: Receipt of contributed product, Conducting studies in healthcare facilities that are receiving contributed product; M. H. Coady, Sage Products: Receipt of contributed product, Conducting studies in healthcare facilities that are receiving contributed product; Molnlycke: Receipt of contributed product, Conducting studies in healthcare facilities that are receiving contributed product; Xttrium Laboratories: Receipt of contributed product, Conducting studies in healthcare facilities that are receiving contributed product; Clorox: Receipt of contributed product, Conducting studies in healthcare facilities that are receiving contributed product; R. Platt, Sage Products: Receipt of contributed product, Conducting clinical studies in which participating healthcare facilities are receiving contributed product; Xttrium Laboratories: Receipt of contributed product, Conducting clinical studies in which participating healthcare facilities are receiving contributed product; Clorox: Receipt of contributed product, Conducting clinical studies in which participating healthcare facilities are receiving contributed product; receive research funds from Clorox, but Clorox has no role in the design; Molnlycke: Receipt of contributed product, Conducting studies in healthcare facilities that are receiving contributed product; S. S. Huang, Sage Products: Receipt of contributed product, Conducting studies in which participating healthcare facilities are receiving contributed product (no contribution in submitted abstract), Participating healthcare facilities in my studies received contributed product; Xttrium Laboratories: Receipt of contributed product, Conducting studies in which participating healthcare facilities are receiving contributed product (no contribution in submitted abstract), Participating healthcare facilities in my studies received contributed product; Clorox: Receipt of contributed product, Conducting studies in which participating healthcare facilities are receiving contributed product (no contribution in submitted abstract), Participating healthcare facilities in my studies received contributed product; 3M: Receipt of contributed product, Conducting studies in which participating healthcare facilities are receiving contributed product (no contribution in submitted abstract), Participating healthcare facilities in my studies received contributed product; Molnlycke: Receipt of contributed product, Conducting studies in which participating healthcare facilities are receiving contributed product (no contribution in submitted abstract), Participating healthcare facilities in my studies received contributed product

Abstract Background The majority of healthcare-associated infections due to MDROs occur in the post-discharge setting. Understanding MDRO spread and containment in NHs can help identify infection prevention activities needed to care for vulnerable patients in a medical home setting. Methods We conducted a baseline point prevalence study of MDRO colonization in residents of 28 Southern California NHs participating in a decolonization trial. In Fall 2016, residents were randomly sampled to obtain a set of 50 nares and skin (axilla/groin) swabs from each NH. Nasal swabs were processed for MRSA and skin swabs were processed for MRSA, VRE, ESBL, and CRE. In addition, environmental swabs were collected from high touch objects in resident rooms (bedrail, call button/TV remote, door knobs, light switch, bathroom) and common areas (nursing station, table, chair, railing, and drinking fountain). Results A total of 2,797 body swabs were obtained from 1400 residents. Overall, 48.6% (N = 680) of residents harbored MDROs. MRSA was found in 37% of residents (29.5% nares, 24.4% skin), followed by ESBL in 16% (Table 1). Resident MDRO status was only known for 11% of MRSA (59/518), 18% ESBL (40/228), 4% VRE (4/99), and none of the CRE (0/13) carriers. Colonization did not differ between long stay (48.8%, 534/1094) vs. post-acute (47.7%, 146/306) residents (P = NS), but bedbound residents were more likely to be MDRO colonized (58.7%, 182/310) vs. ambulatory residents (45.7%, 497/1088, P

A streamlined transition from inpatient to outpatient care can decrease 30-day readmissions. Outpatient parenteral antibiotic therapy (OPAT) programs have not reduced readmissions; an OPAT bundle has been suggested to improve outcomes. We implemented a transition-of-care (TOC) OPAT bundle and assessed the effects on all-cause, 30-day hospital readmission.Retrospectively, patients receiving postdischarge intravenous antibiotics were evaluated before and after implementation of a TOC-OPAT program in Bronx, New York, between July, 2015 and February, 2016. Pearson's χ2test was used to compare 30-day readmissions between groups, and logistic regression was used to adjust for covariates. Time from discharge to readmission was analyzed to assess readmission risk, using log-rank test to compare survival curves and Cox proportional hazards model to adjust for covariates. Secondary outcomes, 30-day emergency department (ED) visits, and mortality were analyzed similarly.Compared with previous standard care (n = 184), the TOC-OPAT group (n = 146) had significantly lower 30-day readmissions before (13.0% vs 26.1%,P< .01) and after adjustment for covariates (odds ratio [OR] = 0.51; 95% confidence interval [CI], 0.27-0.94;P= .03). In time-dependent analyses, TOC-OPAT patients were at significantly lower risk for readmission (log-rank test,P< .01; hazard ratio = 0.56; 95% CI, 0.32-0.97;P= .04). Propensity-matched sensitivity analysis showed lower readmissions in the TOC-OPAT group (13.6% vs 24.6%,P= .04), which was attenuated after adjustment (OR = 0.51; 95% CI, 0.25-1.05;P= .07). Mortality and ED visits were similar in both groups.Our TOC-OPAT patients had reduced 30-day readmissions compared with the previous standard of care. An effective TOC-OPAT bundle can successfully improve patient outcomes in an economically disadvantaged area.