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Background: Ordering Clostridioides difficile diagnostics without appropriate clinical indications can result in inappropriate antibiotic prescribing and misdiagnosis of hospital onset C. difficile infection. Manual processes such as provider review of order appropriateness may detract from other infection control or antibiotic stewardship activities. Methods: We developed an evidence-based clinical algorithm that defined appropriateness criteria for testing for C. difficile infection. We then implemented an electronic medical record–based order-entry tool that utilized discrete branches within the clinical algorithm including history of prior C. difficile test results, laxative or stool-softener administration, and documentation of unformed bowel movements. Testing guidance was then dynamically displayed with supporting patient data. We compared the rate of completed C. difficile tests after implementation of this intervention at 5 hospitals to a historic baseline in which a best-practice advisory was used. Results: Using mixed-effects Poisson regression, we found that the intervention was associated with a reduction in the incidence rate of both C. difficile ordering (incidence rate ratio [IRR], 0.74; 95% confidence interval [CI], 0.63–0.88; P = .001) and C. difficile–positive tests (IRR, 0.83; 95% CI, 0.76–0.91; P < .001). On segmented regression analysis, we identified a sustained reduction in orders over time among academic hospitals and a new reduction in orders over time among community hospitals. Conclusions: An evidence-based dynamic order panel, integrated within the electronic medical record, was associated with a reduction in both C. difficile ordering and positive tests in comparison to a best practice advisory, although the impact varied between academic and community facilities.

Background We previously conducted a study in primary care practices assessing the impact of an educational session paired with peer comparison feedback on antibiotic prescribing, demonstrating a reduction in overall prescribing for respiratory tract diseases (RTDs). However, the lasting effects of this intervention on antibiotic prescribing patterns without ongoing feedback are unknown. Methods To study the long-term effects of this feedback on antibiotic prescribing, we analyzed prescribing trends for 14 months after the initial study. We collected encounter-level data, including patient and provider information, ICD-10 codes, and antibiotics prescribed. RTDs were grouped into tiers based on prescribing appropriateness: tier 1 (almost always indicated), tier 2 (may be indicated), and tier 3 (rarely indicated). A χ2 test was used to compare proportions of antibiotic prescribing between three time periods: pre-intervention, intervention, and post-intervention (following cessation of provider feedback). A mixed-effects multivariable logistic regression analysis was performed to assess the association between the period and antibiotic prescribing. Results We analyzed 260,900 encounters (127,324 pre-intervention, 58,431 during the intervention, and 75,145 post-intervention) from 28 practices, with patient, provider and practice characteristics in Table 1. Rates of antibiotic prescribing for RTD visits were higher in the post-intervention period than the intervention period (28.9% vs 23.0%, p< 0.001), but remained lower than the 35.2% pre-intervention rate (Figure 1, p< 0.001). In multivariable analyses, the odds of receiving a prescription was higher in the post-intervention compared to the intervention period for tier 2 (OR 1.19, 95% CI 1.10–1.30, p< 0.05) and tier 3 (OR 1.20, 95% CI 1.12–1.30) indications, but was still lower when compared to the pre-intervention period for each tier (OR 0.66, 95% CI 0.59–0.73 for tier 2; OR 0.68, 95% CI 0.61–0.75 for tier 3) (Table 2). Table 1 includes patient, provider, and encounter level demographics. Table 2 includes the results of the multivariable analysis. Figure 1 is a graph of proportion of encounters with an antibiotic prescribed over time. The time period associated with the intervention is highlighted and graphs are separated by tier of appropriateness of antibiotic prescribing associated with the encounter. Conclusion The effects of this targeted educational and feedback program last beyond the intervention period, but without ongoing provider feedback there is a trend toward increased prescribing. Future studies are needed to determine optimal strategies to maintain the efficacy of this intervention. Disclosures Kathleen Degnan, MD, Gilead: Grant/Research Support Michael Z. David, MD PhD, Contrafect: Grant/Research Support|GSK: Advisor/Consultant|Johnson and Johnson: Advisor/Consultant.

In this article, the editors of Clinical Infectious Diseases review some of the most important lessons they have learned about the epidemiology, clinical features, diagnosis, treatment and prevention of SARS-CoV-2 infection and identify essential questions about COVID-19 that remain to be answered., This article reviews important lessons learned to this day, October 15, 2020, about the epidemiology, clinical virology, presentation, complications, diagnosis, treatment and prevention of SARS-CoV-2 infection and identifies essential questions about the COVID-19 pandemic that remain to be answered.

In 2019, a 42-year-old African man who works as an Ebola virus disease (EVD) researcher traveled from the Democratic Republic of Congo (DRC), near an ongoing EVD epidemic, to Philadelphia and presented to the Hospital of the University of Pennsylvania Emergency Department with altered mental status, vomiting, diarrhea, and fever. He was classified as a “wet” person under investigation for EVD, and his arrival activated our hospital emergency management command center and bioresponse teams. He was found to be in septic shock with multisystem organ dysfunction, including circulatory dysfunction, encephalopathy, metabolic lactic acidosis, acute kidney injury, acute liver injury, and diffuse intravascular coagulation. Critical care was delivered within high-risk pathogen isolation in the ED and in our Special Treatment Unit until a diagnosis of severe cerebral malaria was confirmed and EVD was definitively excluded.This report discusses our experience activating a longitudinal preparedness program designed for rare, resource-intensive events at hospitals physically remote from any active epidemic but serving a high-volume international air travel port-of-entry.

BackgroundThough detection of transmission clusters of methicillin-resistant Staphylococcus aureus (MRSA) infections is a priority for infection control personnel in hospitals, the transmission dynamics of MRSA among hospitalized patients with bloodstream infections (BSIs) has not been thoroughly studied. Whole genome sequencing (WGS) of MRSA isolates for surveillance is valuable for detecting outbreaks in hospitals, but the bioinformatic approaches used are diverse and difficult to compare.MethodsWe combined short-read WGS with genotypic, phenotypic, and epidemiological characteristics of 106 MRSA BSI isolates collected for routine microbiological diagnosis from inpatients in two hospitals over 12 months. Clinical data and hospitalization history were abstracted from electronic medical records. We compared three genome sequence alignment strategies to assess similarity in cluster ascertainment. We conducted logistic regression to measure the probability of predicting prior hospital overlap between clustered patient isolates by the genetic distance of their isolates.ResultsWhile the three alignment approaches detected similar results, they showed some variation. A pangenome-based alignment method was most consistent across MRSA clonal complexes. We identified nine unique clusters of closely-related BSI isolates. Most BSI were healthcare-associated and community-onset. Our logistic model showed that with 13 single nucleotide polymorphisms the likelihood that any two patients in a cluster overlapped in a hospital was 50 percent.ConclusionsMultiple clusters of closely related MRSA isolates can be identified using WGS among strains cultured from BSI in two hospitals. Genomic clustering of these infections suggest that transmission resulted from a mix of community spread and healthcare exposures long before BSI diagnosis.SummaryMultiple clusters of closely related MRSA bloodstream infections were identified using WGS in two hospitals using three bioinformatic workflows. Genomic epidemiology suggests that transmission resulted from a mix of community spread and healthcare exposures long before symptom onset.

IntroductionApproximately 38% of haemodialysis patients carry Staphylococcus aureus in their noses, and carriers have a nearly four-fold increased risk of S. aureus access-related bloodstream infections (BSIs) compared with non-carriers. Our objective is to determine the clinical efficacy and effectiveness of a novel intervention using nasal povidone-iodine (PVI) to prevent BSIs among patients in haemodialysis units. We will survey patients and conduct qualitative interviews with healthcare workers to identify barriers and facilitators to implementing the intervention.Methods and analysisWe will perform an open-label, stepped-wedge cluster randomised trial to assess the effectiveness of nasal PVI compared with standard care. Sixteen outpatient haemodialysis units will participate in the study. The 3-year trial period will be divided into a 4-month baseline period and eight additional 4-month time blocks. The primary outcome of the study will be S. aureus BSI, defined as a S. aureus positive blood culture collected in the outpatient setting or within one calendar day after a hospital admission. The study team will evaluate characteristics of individual patients and the clusters by exposure status (control or intervention) to assess the balance between groups, and calculate descriptive statistics such as average responses separately for control and intervention survey questions.Ethics and disseminationThis study has received IRB approval from all study sites. A Data Safety and Monitoring Board will monitor this multicentre clinical trial. We will present our results at international meetings. The study team will publish findings in peer-reviewed journals and make each accepted peer-reviewed manuscript publicly available.Trial registration numberNCT04210505.

OBJECTIVES: Patients undergoing stem cell transplant (SCT) for the treatment of hematologic malignancy are at increased risk for central line-associated bloodstream infections (CLABSIs). The use of prophylactic antibiotics to prevent CLABSIs in the setting of autologous SCT is of unclear benefit. We aimed to evaluate the impact of levofloxacin prophylaxis on reducing CLABSIs in this high-risk population. METHODS: Patients undergoing autologous SCT at a tertiary-care hospital received levofloxacin prophylaxis from January 13, 2016 to January 12, 2017. Levofloxacin was administered from autologous SCT (day 0) until day 13, absolute neutrophil count > 500/mm(3), or neutropenic fever, whichever occurred first. Clinical outcomes were compared to a baseline group who underwent autologous SCT but did not receive antibacterial prophylaxis during the previous year. The primary endpoint was incidence of CLABSIs assessed using Cox proportional hazards regression. RESULTS: A total of 324 patients underwent autologous SCT during the entire study period, with 150 receiving levofloxacin prophylaxis during the intervention period. The rate of CLABSIs was reduced from 18.4% during the baseline period to 6.0% during the intervention period. On multivariable analysis, levofloxacin prophylaxis significantly reduced CLABSI incidence (hazard ratio (HR) 0.33; 95% confidence interval (CI) 0.16–0.69; P=0.003). There was also a reduction in the risk of neutropenic fever (odds ratio (OR) 0.23; 95% CI 0.14–0.39; P

Background Inappropriate antibiotic prescribing is common in primary care (PC), particularly for respiratory tract diagnoses (RTDs). However, the optimal approach for improving prescribing remains unknown. Methods We conducted a stepped-wedge study in PC practices within a health system to assess the impact of a provider-targeted intervention on antibiotic prescribing for RTDs. RTDs were grouped into tiers based on appropriateness of antibiotic prescribing: tier 1 (almost always indicated), tier 2 (may be indicated), and tier 3 (rarely indicated). Providers received education on appropriate RTD prescribing followed by monthly peer comparison feedback on antibiotic prescribing for (1) all tiers and (2) tier 3 RTDs. A χ 2 test was used to compare the proportion of visits with antibiotic prescriptions before and during the intervention. Mixed-effects multivariable logistic regression analysis was performed to assess the association between the intervention and antibiotic prescribing. Results Across 30 PC practices and 185 755 total visits, overall antibiotic prescribing was reduced with the intervention, from 35.2% to 23.0% of visits (P Conclusions A provider-focused intervention reduced overall antibiotic prescribing for RTDs without affecting prescribing for infections that likely require antibiotics. Future research should examine the sustainability of such interventions, potential unintended adverse effects on patient health or satisfaction, and provider perceptions and acceptability.

Here, we announce the complete genome sequence of an exfoliative toxin-producing strain of Staphylococcus aureus sequence type 582 (ST582), isolated from a case of staphylococcal scalded-skin syndrome. The genome consists of a single circularized unitig with a total length of 2,792,190 bp carrying 2,699 genes. The genome is the basis for future epidemiological and genomic studies.

Objective:Tracheal intubation and mechanical ventilation provide essential support for patients with respiratory failure, but the course of mechanical ventilation may be complicated by adverse ventilator-associated events (VAEs), which may or may not be associated with infection. We sought to understand how the frequency of subglottic suction, an indicator of the quantity of sputum produced by ventilated patients, relates to the onset of all VAEs and infection-associated VAEs.Design:We performed a case-crossover study including 87 patients with VAEs, and we evaluated 848 days in the pre-VAE period at risk for a VAE.Setting and participants:Critically ill patients were recruited from the medical intensive care unit of an academic medical center.Methods:We used the number of as-needed subglottic suctioning events performed per calendar day to quantify sputum production, and we compared the immediate pre-VAE period to the preceding period. We used CDC surveillance definitions for VAE and to categorize whether events were infection associated or not.Results:Sputum quantity measured by subglottic suction frequency is greater in the period immediately prior to VAE than in the preceding period. However, it does not discriminate well between infection-associated VAEs and VAEs without associated infection.Conclusions:Subglottic suction frequency may serve as a valuable marker of sputum quantity, and it is associated with risk of a VAE. However, our results require validation in a broader population of mechanically ventilated patients and intensive care settings.

In a cohort of inpatients with hematologic malignancy and positive enzyme immunoassay (EIA) or polymerase chain reaction (PCR) Clostridium difficile tests, we found that clinical characteristics and outcomes were similar between these groups. The method of testing is unlikely to predict infection in this population, and PCR-positive results should be treated with concern.Infect Control Hosp Epidemiol 2018;863–866

The unprecedented scale of the 2014–2015 Ebola virus outbreak in West Africa and the recent emergence and rapid spread of Zika virus infection and resultant neonatal sequelae show that the geographic range, spread, and effect of emerging infections are unpredictable. Lessons learned from analyzing the response of an academic medical center to care for pregnant women with suspected or confirmed Ebola virus disease can help health care professionals address future threats from emerging infections.

We implemented a guideline for appropriate acid suppressant use in hematology-oncology patients. This intervention resulted in a sustained reduction in proton pump inhibitor (PPI) use without an increase in rates of gastrointestinal bleeding. Practice guidelines are effective in reducing PPI use, which is associated with risk of Clostridioides difficile infection.

Background There are limited data regarding SARS-CoV-2 (SC2) environmental contamination in staff areas of healthcare settings. We performed environmental sampling of staff areas in wards where coronavirus disease 19 (COVID-19) patients received care and compared findings to surfaces within COVID-19 patient rooms. Methods The study was conducted at the Hospital of the University of Pennsylvania (Philadelphia, PA) from 9/15/20-1/26/21. Sampling of 20cm2 surfaces in staff common areas (breakroom high-touch surfaces comprising tables and microwave/refrigerator handles; bathroom surfaces comprising toilet, sink, and doorknob; and floors), nurse workstations (computer mice and floors), and COVID-19 patient rooms (high-touch surfaces comprising bedrail, computer mice/keyboards, and doorknobs; bathroom surfaces; and floors) was performed using flocked swabs one or more times per week. Specimens underwent RNA extraction and quantitative real-time polymerase chain reaction to detect the SC2 N1 region. Median comparisons were performed using Wilcoxon rank sum test. Trends in odds were evaluated using Score test. Results Proportions of surface specimens with detectable SC2 RNA are summarized in Table 1. Median copy numbers were lower among staff toilets compared to COVID-19 patient toilets (135.6 vs. 503.8 copies/specimen, p=0.02), lower among staff breakroom compared to patient room high-touch surfaces (104.3 vs. 220.3 copies/specimen, p=0.007), and similar between staff and patient room samples from sinks and floors. At nurse workstations, SC2 RNA was detected among 22/177 (12.4%) computer mouse and 147/178 (82.6%) floor samples. Odds of SC2 detection increased by study week among common area (p< 0.001) and nurse workstation samples (p< 0.001) (Figures 1 and 2). Table 1. SARS-CoV-2 (SC2) RNA detection on staff common area and coronavirus disease 19 (COVID-19) patient room surfaces at the Hospital of the University of Pennsylvania, 9/15/20-1/26/21. Figure 1. Proportion of environmental surface specimens with detectable SARS-CoV-2 RNA from a) staff common areas and b) nurse workstations of inpatient wards where coronavirus disease-19 patients received care at the Hospital of the University of Pennsylvania, 9/15/20-1/26/21. Figure 2. Proportion of environmental surface specimens with detectable SARS-CoV-2 RNA in staff common areas of inpatient wards where coronavirus disease-19 patients received care at the Hospital of the University of Pennsylvania, 9/15/20-1/26/21, by surface type: a) staff breakroom surfaces, b) staff bathroom surfaces, c) staff common area floors. Conclusion A low prevalence of detectable SC2 RNA was observed among staff area high-touch surfaces; however, the likelihood of detection increased over time. Environmental SC2 RNA detection may reflect primary contamination from infected healthcare workers or secondary contamination from contact with infected patients, though a direct relationship between surface SC2 RNA viral detection and transmission risk has not been established. Disclosures Michael Z. David, MD PhD, GSK (Board Member) Ebbing Lautenbach, MD, MPH, MSCE, Merck (Other Financial or Material Support, Member of Data and Safety Monitoring Board (DSMB))

Background The Centers for Disease Control and Prevention 2016 Healthcare-Associated Infections (HAI) Progress Report documented no change in catheter-associated urinary tract infections (CAUTIs) between 2009 and 2014. There is a need for investment in additional efforts to reduce HAIs, specifically CAUTI. Quality improvement fellowships are 1 approach to expand the capacity of dedicated leaders and infection prevention champions. Methods The fellowship used a model that expanded collaboration among disciplines and focused on partnership by recruiting a diverse cohort of fellows and by providing 1-on-1 mentoring to enhance leadership development. The curriculum supported the Association for Professionals in Infection Control and Prevention Competency Model in 2 domains: leadership and performance improvement and implementation science. Results The fellowship was successful. The fellows and mentors had self-reported high level of satisfaction, fellows' knowledge increased, and they demonstrated leadership, quality improvement, and implementation science competency within the completed capstone projects. Conclusions A model encompassing diverse educational topics, discussions, workshops, and mentorship can serve as a template for developing infection prevention champions. Although this project focused on CAUTI, this template can be used in a variety of settings and applied to a range of other HAIs and performance improvement projects.

OBJECTIVETo evaluate the effectiveness of a computerized clinical decision support intervention aimed at reducing inappropriate Clostridium difficile testingDESIGNRetrospective cohort studySETTINGUniversity of Pennsylvania Health System, comprised of 3 large tertiary-care hospitalsPATIENTSAll adult patients admitted over a 2-year periodINTERVENTIONProviders were required to use an order set integrated into a commercial electronic health record to order C. difficile toxin testing. The order set identified patients who had received laxatives within the previous 36 hours and displayed a message asking providers to consider stopping laxatives and reassessing in 24 hours prior to ordering C. difficile testing. Providers had the option to continue or discontinue laxatives and to proceed with or forgo testing. The primary endpoint was the change in inappropriate C. difficile testing, as measured by the number of patients who had C. difficile testing ordered while receiving laxatives.RESULTSCompared to the 1-year baseline period, the intervention resulted in a decrease in the proportion of inappropriate C. difficile testing (29.6% vs 27.3%; P=.02). The intervention was associated with an increase in the number of patients who had laxatives discontinued and did not undergo C. difficile testing (5.8% vs 46.4%; PPC. difficile related complications (5.0% vs 8.9%; P=.11).CONCLUSIONSA C. difficile order set was successful in decreasing inappropriate C. difficile testing and improving the timely discontinuation of laxatives.Infect Control Hosp Epidemiol 2017;38:1204–1208

Background MRSA BSIs have 15-50% mortality and are commonly diagnosed in US hospitals. However, the frequency of hospital transmission of MRSA causing BSI is unknown. Methods We performed Illumina shotgun whole genome sequencing (WGS) of 106 sequential MRSA isolates from different adults with a BSI at two Philadelphia academic hospitals in a single health system in July 2018-June 2019. We abstracted clinical data from the electronic medical record. Genomic data were analyzed preliminarily using the Staphopia Analysis Pipeline. Results Among 106 subjects, 51.9% were male, 47.2% were white, 46.2% were black, 23.6% were < 40 years of age, and mean age was 53.1 years (s.d. 17 years). One isolate had WGS data that were inadequate for analysis. Of 105 genomes, 52 were clonal cluster (CC) 8, 22 were sequence type (ST) 5, and 16 were ST105; the remaining 15 strains belonged to 8 other CCs. Of CC8 strains, 44 were USA300 and 6 were USA500. There were 6 clusters (i.e., < 35 SNP differences in the core genome) among the 105 isolates. Four clusters were CC5 and two were CC8 strains. One cluster of CC5 strains involved 3 subjects, and 5 clusters involved 2 subjects. One cluster of ST8/USA300 strains were separated by only 1 SNP (Fig a). This and two other clustered pairs were from subjects who had overlapping hospital stays. Two of these paired subjects had an overlap in the same unit while the third pair was in the hospital together on a number of occasions (total of 40 days overlap) but never simultaneously in the same unit. The other three clustered pairs did not have temporally overlapping hospital stays, suggesting transmission via a hospital reservoir. One of these three pairs had hospitalizations overlapping in time, one at each study hospital, before each of them had infections with the related MRSA strains. There was not a clear-cut clustering of SNP distances among the isolate genomes into transmission and non-transmission groups, with some pairs of patient isolates separated by 40-80 SNPs (Fig. b). Figure 1. Conclusion We were able to discern from WGS data alone that some MRSA BSIs in 2 hospitals were likely due to strains transmitted between patients. Universal WGS of BSI strains may detect MRSA outbreaks in real time, even in the absence of overlapping hospitalizations, and is an emerging strategy to detect healthcare transmission of MRSA. Disclosures Michael Z. David, MD PhD, GSK (Consultant)

Background We evaluated the differential impact of levofloxacin administered for the prophylaxis of bloodstream infections compared with broad-spectrum beta-lactam (BSBL) antibiotics used for the treatment of neutropenic fever on the gut microbiome in patients with hematologic malignancy. Methods Stool specimens were collected from patients admitted for chemotherapy or stem cell transplant in the setting of the evaluation of diarrhea from February 2017 until November 2017. Microbiome characteristics were compared among those exposed to levofloxacin prophylaxis vs those who received BSBL antibiotics. Results Sixty patients were included, most with acute myeloid leukemia (42%) or multiple myeloma (37%). The gut microbiome of patients with BSBL exposure had significantly reduced Shannon’s alpha diversity compared with those without (median [interquartile range {IQR}], 3.28 [1.73 to 3.71] vs 3.73 [3.14 to 4.31]; P = .01). However, those with levofloxacin exposure had increased alpha diversity compared with those without (median [IQR], 3.83 [3.32 to 4.36] vs 3.32 [2.35 to 4.02]; P = .03). Levofloxacin exposure was also associated with a trend toward lower risk of dominance of non-Bacteroidetes genera compared with those without levofloxacin exposure (3 [14%] vs 15 [38%]; P = .051). Conclusions The impact of antibiotics on the gut microbiome varies by class, and levofloxacin may disrupt the gut microbiome less than BSBLs in this patient population.

OBJECTIVETo evaluate the impact of no-touch terminal room no-touch disinfection using ultraviolet wavelength C germicidal irradiation (UVGI) on C. difficile infection (CDI) rates on inpatient units with persistently high rates of CDI despite infection control measures.DESIGNInterrupted time-series analysis with a comparison arm.SETTING3 adult hematology-oncology units in a large, tertiary-care hospital.METHODSWe conducted a 12-month prospective valuation of UVGI. Rooms of patients with CDI or on contact precautions were targeted for UVGI upon discharge using an electronic patient flow system. Incidence rates of healthcare-onset CDI were compared for the baseline period (January 2013–December 2013) and intervention period (February 2014–January 2015) on study units and non–study units using a mixed-effects Poisson regression model with random effects for unit and time in months.RESULTSDuring a 52-week intervention period, UVGI was deployed for 542 of 2,569 of all patient discharges (21.1%) on the 3 study units. The CDI rate declined 25% on study units and increased 16% on non-study units during the intervention compared to the baseline period. We detected a significant association between UVGI and decrease in CDI incidence (incidence rate ratio [IRR], 0.49; 95% confidence interval [CI], 0.26–0.94; P=.03) on the study units but not on the non-study units. The impact of UVGI use on average room-cleaning time and turnaround time was negligible compared to the baseline period.CONCLUSIONSTargeted deployment of UVGI to rooms of high-risk patients at discharge resulted in a substantial reduction of CDI incidence without adversely impacting room turnaround.Infect Control Hosp Epidemiol 2016;1–6

OBJECTIVETo determine the clinical diagnoses associated with the National Healthcare Safety Network (NHSN) pneumonia (PNEU) or lower respiratory infection (LRI) surveillance eventsDESIGNRetrospective chart reviewSETTINGA convenience sample of 8 acute-care hospitals in PennsylvaniaPATIENTSAll patients hospitalized during 2011–2012METHODSMedical records were reviewed from a random sample of patients reported to the NHSN to have PNEU or LRI, excluding adults with ventilator-associated PNEU. Documented clinical diagnoses corresponding temporally to the PNEU and LRI events were recorded.RESULTSWe reviewed 250 (30%) of 838 eligible PNEU and LRI events reported to the NHSN; 29 reported events (12%) fulfilled neither PNEU nor LRI case criteria. Differences interpreting radiology reports accounted for most misclassifications. Of 81 PNEU events in adults not on mechanical ventilation, 84% had clinician-diagnosed pneumonia; of these, 25% were attributed to aspiration. Of 43 adult LRI, 88% were in mechanically ventilated patients and 35% had no corresponding clinical diagnosis (infectious or noninfectious) documented at the time of LRI. Of 36 pediatric PNEU events, 72% were ventilator associated, and 70% corresponded to a clinical pneumonia diagnosis. Of 61 pediatric LRI patients, 84% were mechanically ventilated and 21% had no corresponding clinical diagnosis documented.CONCLUSIONSIn adults not on mechanical ventilation and in children, most NHSN-defined PNEU events corresponded with compatible clinical conditions documented in the medical record. In contrast, NHSN LRI events often did not. As a result, substantial modifications to the LRI definitions were implemented in 2015.Infect Control Hosp Epidemiol 2016;37:818–824

Background:Clostridioides difficile infection (CDI) is a major contributor to morbidity and mortality in patients with hematologic malignancy. Due to both immunosuppression and frequent antibiotic exposures, up to one-third of inpatients receiving chemotherapy or stem-cell transplant develop CDI. Transmission of C. difficile in healthcare facilities occurs due to environmental surface contamination and hand carriage by healthcare workers from colonized and infected patients. We investigated the effectiveness of enhanced room cleaning in collaboration with environmental services (EVS) staff to prevent CDI transmission and infection.Methods: From April 1, 2018, to September 30, 2018, a multimodal enhanced cleaning intervention was implemented on 2 oncology units at the Hospital of the University of Pennsylvania. This intervention included real-time feedback to EVS staff following ATP bioluminescence monitoring. Additionally, all rooms on the intervention units underwent UV disinfection after terminal cleaning. We performed a system-level cohort study, comparing rates of CDI on the 2 study units to historic and 2 concurrent control units. Historic and concurrent control units received UV disinfection only for rooms with prior occupants with MRSA or CDI. All units during the intervention period received education on the importance of environmental cleaning for infection prevention. Mixed-effects Poisson regression was used to adjust for system-level confounders. Results: A median of 1.34 CDI cases per 1,000 patient days (IQR, 1.20–3.62) occurred during the 12-month baseline period. There was a trend toward a reduced rate of CDI across all units during the intervention period (median, 1.19; IQR, 0.00–2.47; P = .13) compared with all units during the historical period. Using mixed-effects Poisson regression, accounting for the random effects of study units, the intervention was associated with an incidence rate ratio for C. difficile of 0.72 compared to control units (95% CI, 0.53–0.97; P = .03). Average room turnaround time (TAT) increased across all units during the study period, from 78 minutes (IQR 74–81) to 92 minutes (IQR, 85–96; P < .001). Within the intervention period, TAT was higher on intervention units (median, 94 minutes; IQR, 92–98) compared to concurrent control units (median, 85; IQR, 80–92; P = .005). Conclusions: Enhanced environmental cleaning, including UV disinfection of all patient rooms and ATP bioluminescent monitoring with real-time feedback, was associated with a reduction in the incidence of CDI.Funding: NoneDisclosures: None

Background Antimicrobial stewardship often focuses on inpatients, yet inappropriate antimicrobial use is common in the outpatient setting. We performed a prospective, stepped wedge interventional study to assess the impact of an educational and feedback-based intervention on prescribing practices for respiratory tract infections (RTIs) in the adult primary care ambulatory setting. Methods Family and internal medicine practices were randomly placed into 6 cohorts, which received the intervention in a stepped wedge fashion at monthly intervals. The study period was July 1, 2016 to October 31, 2018, with the intervention occurring from October 1, 2017 to October 31, 2018. The intervention consisted of a 20-minute in-person educational session on appropriate antimicrobial prescribing for RTIs followed by monthly feedback to individual providers on their proportion of antibiotic prescriptions in comparison to their peers for (1) visits with a primary diagnosis of any RTI and (2) visits with a primary diagnosis of an RTI for which an antibiotic should rarely be prescribed (tier 3 diagnoses). The outcome of interest was whether an antibiotic was prescribed in RTI visits. Chi squared testing and logistic regression were used for analysis. Results Thirty-two practices participated, with 197,814 unique visits with a primary RTI diagnosis. Of these, 141,888 (71.7%) were physician visits and 55,926 (28.3%) were advanced practitioner visits (Figure 1). The proportion of visits with antibiotic prescriptions dropped from 37.2% to 24.0% following the intervention (P < 0.0001). Antibiotic prescriptions were significantly reduced for all primary RTI visits, OR 0.53 (95% CI 0.52 to 0.54), as well as for visits with tier 3 RTI diagnoses, OR 0.64 (95% CI 0.60 to 0.68). The proportion of visits with antibiotic prescriptions also exhibited a marked seasonal variation, another finding of the study (Figure 2). Conclusion An educational intervention with provider feedback successfully reduced antibiotic prescribing for RTIs in the ambulatory setting. Additional study is necessary to assess the sustainability of response over time after discontinuation of the monthly feedback. Disclosures All authors: No reported disclosures.

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 catheter-associated urinary tract infection (CAUTI) prevention efforts. This document updates “Strategies to Prevent Catheter-Associated Urinary Tract 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.

Background.Central line-associated bloodstream infection (CLABSI) is a national target for mandatory reporting and a Centers for Medicare and Medicaid Services target for value-based purchasing. Differences in chart review versus claims-based metrics used by national agencies and groups raise concerns about the validity of these measures.Objective.Evaluate consistency and reasons for discordance among chart review and claims-based CLABSI events.Methods.We conducted 2 multicenter retrospective cohort studies within 6 academic institutions. A total of 150 consecutive patients were identified with CLABSI on the basis of National Healthcare Safety Network (NHSN) criteria (NHSN cohort), and an additional 150 consecutive patients were identified with CLABSI on the basis of claims codes (claims cohort). Ail events had full-text medical record reviews and were identified as concordant or discordant with the other metric.Results.In the NHSN cohort, there were 152 CLABSIs among 150 patients, and 73.0% of these cases were discordant with claims data. Common reasons for the lack of associated claims codes included coding omission and lack of physician documentation of bacteremia cause. In the claims cohort, there were 150 CLABSIs among 150 patients, and 65.3% of these cases were discordant with NHSN criteria. Common reasons for the lack of NHSN reporting were identification of non-CLABSI with bacteremia meeting Centers for Disease Control and Prevention (CDC) criteria for an alternative infection source.Conclusion.Substantial discordance between NHSN and claims-based CLABSI indicators persists. Compared with standardized CDC chart review criteria, claims data often had both coding omissions and misclassification of non-CLABSI infections as CLABSI. Additionally, claims did not identify any additional CLABSIs for CDC reporting. NHSN criteria are a more consistent interhospital standard for CLABSI reporting.

Background We implemented evidence-based interventions to reduce risk of surgical site infection (SSI) following low transverse cesarean section (LTCS). Methods An observational study was conducted to determine LTCS SSI rates and the impact of infection control interventions at an academic teaching hospital during the period October 2005 to December 2008, including the use of 2% chlorhexidine gluconate (CHG) for surgical skin preparation before LTCS and no-rinse CHG cloths for preoperative skin cleansing. We compared overall and risk strata specific SSI rates and standardized incidence ratios during 4 study periods and estimated cost savings. Results Of 1,844 LTCSs performed, 99 patients were identified with SSI. SSI rates per 100 LTCS declined from 6.27 at baseline and 10.84 during the outbreak period to 5.92 in intervention 1 period and 2.29 in intervention 2 period. Overall, a 63.5% reduction in SSI rate from baseline was achieved by ensuring compliance with SSI prevention guidelines and improving skin antisepsis (P = .003). In intervention 2 period, the standardized incidence ratio was 0.99 compared with 2.64 at baseline and 4.50 during the outbreak period. Conclusion A multidisciplinary approach including evidence-based SSI prevention practices, effective infection prevention products, and staff and patient engagement substantially reduced infection risk and improved patient safety following LTCS.

AND FULL-TEXT SCREENING To identify studies which were a) relevant to one or more key questions b) primary analytic research, systematic review or meta-analysis and c) written in English DATA EXTRACTION AND SYNTHESIS Data abstracted into evidence tables; study quality assessed DRAFT RECOMMENDATIONS Strength of evidence graded; summaries and recommendations drafted FINALIZE RECOMMENDATIONS Recommendations finalized; guideline published

Background The reluctance to use organs from donors who have died from severe infections is based on the potential transmission of an infectious agent to the recipient and on the uncertainty about allograft function in the setting of severe donor sepsis. Methods From 1999 to 2007, donor hospital records were reviewed which focused on microbiology cultures and sensitivity results; type and duration of antimicrobial therapy; hemodynamic data, results of echocardiogram, and imaging studies. Preliminary positive and negative results from pre-harvest blood, respiratory, urine, and cerebrospinal fluid cultures were verified with the procurement agency. The harvesting surgeon performed gross inspection of donor valvular structures. Results Nine donor hearts were transplanted from patients who expired from community onset infections with severe septic shock, meningitis, and/or pneumonia caused by Streptococcus pneumoniae ( n = 4), Streptococcus milleri ( n = 2), Neisseria meningitidis ( n = 2), and unidentified gram- positive cocci ( n = 1). Four donors had probable infection-induced intracranial hemorrhage, and all donors were vasopressor-dependent before organ procurement. No evidence of donor-transmitted infection, sepsis, or rejection was observed, and long-term function remained excellent; allograft dysfunction in three patients resolved after transplant. Our series of nine donors represents approximately 1.3% of successfully transplanted cardiac allografts during the respective period of review. Conclusions Patients succumbing to severe infections (meningitis, pneumonia, and septic shock) should not be arbitrarily excluded for possible heart donation. Assessing the suitability of donors with severe infections requires flawless communication between the donor and transplant facility, including a comprehensive evaluation of donor infection and pathogen(s), severity of sepsis, adequacy of antimicrobial treatment, and the degree of sepsis-induced myocardial dysfunction.

Object Risk factors for deep brain stimulator (DBS) infection are poorly defined. Because DBS implants are not frequently performed in the MR imaging–equipped operating room (OR), no specific data about infection of DBS implants performed in the MR imaging environment are available in the literature. In this study the authors focus on the incidence of infection in patients undergoing surgery in the conventional versus MR imaging–equipped OR. Methods To identify cases of DBS-associated infection, the authors performed a retrospective cohort study with nested case-control analysis of all patients undergoing DBS implantation at the University of California Los Angeles Medical Center. Cases of DBS infection were identified using standardized clinical and microbiological criteria. Results Between January 1998 and September 2003, 228 DBSs were implanted. Forty-seven operations (20.6%) were performed in the conventional OR and 181 (79.4%) in the MR imaging–equipped OR. There was definite infection in 13 cases (5.7%) and possible infection in 7 cases (3%), for an overall infection rate of 8.7% (20 of 228 cases). There was no significant difference in infection rates in the conventional (7 [14.89%] of 47) versus MR imaging–equipped OR (13 [7.18%] of 181) (p = 0.7). Staphylococcus aureus was isolated in 62% of cases. Twelve of 13 confirmed cases underwent complete hardware removal. On case-control analysis, younger age (≤ 58.5 years) was a significant predictor of DBS infection (odds ratio 3.4, p = 0.027) Conclusions Infection is a serious complication of DBS implantation and commonly requires device removal for cure. The authors found that DBS implantation can be safely performed in MR imaging–equipped suites, possibly allowing improved lead placement. Young age was associated with an increased risk of DBS infection.

The use of bicarbonate-based dialysis fluids in hemodialysis centers in the United States has increased with the advent of high-efficiency and high-flux hemodialysis. However, bicarbonate dialysis fluids can support rapid bacterial growth and high endotoxin concentrations. This study determined the efficacy of an ultrafiltration device in reducing the bacterial and endotoxin concentrations in bicarbonate dialysis fluids. A polysulfone hollow fiber dialyzer was used to ultrafilter bicarbonate concentrate before entering the central proportioner and bicarbonate dialysate after exiting the proportioner in single patient dialysis machines. Pre- and post-ultrafilter samples were collected for bacterial and endotoxin assays over 10 months. Ultrafiltration of bicarbonate concentrate reduced bacterial and endotoxin concentrations from 288,330 colony forming units (CFU)/ml and 42,804 pg/ml too.47CFU/mland 109 pg/ml, respectively. Ultrafiltration of the dialysate in single patient systems decreased bacterial and endotoxin concentrations from 15,889 CFU/ml and 1,746 pg/ml to 0.003 CFU/ml and 0.109 pg/ml, respectively. These results demonstrate that ultrafiltration of bicarbonate dialysis fluids is effective in reducing bacterial and endotoxin contamination inherently associated with the use of bicarbonate-based dialysates.

Previously published guidelines are available that provide comprehensive recommendations for detecting and preventing healthcare-associated infections. 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 catheter-associated urinary tract infection (CAUTI) prevention efforts. Refer to the Society for Healthcare Epidemiology of America/Infectious Diseases Society of America “Compendium of Strategies to Prevent Healthcare-Associated Infections” Executive Summary and Introduction and accompanying editorial for additional discussion.1. Burden of CAUTIsa. Urinary tract infection is the most common hospital-acquired infection; 80% of these infections are attributable to an indwelling urethral catheter.b. Twelve to sixteen percent of hospital inpatients will have a urinary catheter at some time during their hospital stay.c. The daily risk of acquisition of urinary infection varies from 3% to 7% when an indwelling urethral catheter remains in situ.2. Outcomes associated with CAUTIa. Urinary tract infection is the most important adverse outcome of urinary catheter use. Bacteremia and sepsis may occur in a small proportion of infected patients.b. Morbidity attributable to any single episode of catheterization is limited, but the high frequency of catheter use in hospitalized patients means that the cumulative burden of CAUTI is substantial.c. Catheter use is also associated with negative outcomes other than infection, including nonbacterial urethral inflammation, urethral strictures, and mechanical trauma.

Preventable healthcare-associated infections (HAIs) occur in US hospitals. Preventing these infections is a national priority, with initiatives led by healthcare organizations, professional associations, government and accrediting agencies, legislators, regulators, payers, and consumer advocacy groups. To assist acute care hospitals in focusing and prioritizing efforts to implement evidence-based practices for prevention of HAIs, the Society for Healthcare Epidemiology of America and the Infectious Diseases Society of America Standards and Practice Guidelines Committee appointed a task force to create a concise compendium of recommendations for the prevention of common HAIs. This compendium is implementation focused and differs from most previously published guidelines in that it highlights a set of basic HAI prevention strategies plus special approaches for use in locations and/or populations within the hospital when infections are not controlled by use of basic practices, recommends that accountability for implementing infection prevention practices be assigned to specific groups and individuals, and includes proposed performance measures for internal quality improvement efforts.

Previously published guidelines are available that provide comprehensive recommendations for detecting and preventing healthcare-associated infections. 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 ventilator-associated pneumonia (VAP) prevention efforts. Refer to the Society for Healthcare Epidemiology of America/Infectious Diseases Society of America “Compendium of Strategies to Prevent Healthcare-Associated Infections” Executive Summary and Introduction and accompanying editorial for additional discussion.1. Occurrence of VAP in acute care facilities.a. VAP is one of the most common infections acquired by adults and children in intensive care units (ICUs).i. In early studies, it was reported that 10%-20% of patients undergoing ventilation developed VAP. More-recent publications report rates of VAP that range from 1 to 4 cases per 1,000 ventilator-days, but rates may exceed 10 cases per 1,000 ventilator-days in some neonatal and surgical patient populations. The results of recent quality improvement initiatives, however, suggest that many cases of VAP might be prevented by careful attention to the process of care.2. Outcomes associated with VAPa. VAP is a cause of significant patient morbidity and mortality, increased utilization of healthcare resources, and excess cost.i. The mortality attributable to VAP may exceed 10%.ii. Patients with VAP require prolonged periods of mechanical ventilation, extended hospitalizations, excess use of antimicrobial medications, and increased direct medical costs.

Bartonella species are an important cause of culture-negative endocarditis, with recognized risk factors of alcoholism, homelessness, cat exposure, and pre-existing valvular disease. We report a case of Bartonella henselae endocarditis in a 36-year-old woman with complex congenital heart disease who presented with a 7-month history of hemolytic anemia, leukocytoclastic vasculitis, and recurrent fevers. Transesophageal echocardiogram revealed vegetations on the patient's native aortic valve and in the right ventricular to pulmonary artery conduit and associated bioprosthetic valve. Diagnosis of B. henselae was confirmed with serum antibody and polymerase chain reaction (PCR) testing and tissue stains. The patient was treated successfully with surgical resection and prolonged antimicrobial therapy with ceftriaxone, gentamicin, and doxycycline. A review of the literature suggests prosthetic valves and complex congenital heart disease are risk factors for Bartonella endocarditis, and a high index of suspicion with antibody and PCR testing can expedite diagnosis and improve outcomes.

The cleaning of hard surfaces in hospital rooms is critical for reducing health care-associated infections. This review describes the evidence examining current methods of cleaning, disinfecting, and monitoring cleanliness of patient rooms, as well as contextual factors that may affect implementation and effectiveness. Key informants were interviewed, and a systematic search for publications since 1990 was done with the use of several bibliographic and gray literature resources. Studies examining surface contamination, colonization, or infection with Clostridium difficile, methicillin-resistant Staphylococcus aureus, or vancomycin-resistant enterococci were included. Eighty studies were identified-76 primary studies and 4 systematic reviews. Forty-nine studies examined cleaning methods, 14 evaluated monitoring strategies, and 17 addressed challenges or facilitators to implementation. Only 5 studies were randomized, controlled trials, and surface contamination was the most commonly assessed outcome. Comparative effectiveness studies of disinfecting methods and monitoring strategies were uncommon. Future research should evaluate and compare newly emerging strategies, such as self-disinfecting coatings for disinfecting and adenosine triphosphate and ultraviolet/fluorescent surface markers for monitoring. Studies should also assess patient-centered outcomes, such as infection, when possible. Other challenges include identifying high-touch surfaces that confer the greatest risk for pathogen transmission; developing standard thresholds for defining cleanliness; and using methods to adjust for confounders, such as hand hygiene, when examining the effect of disinfecting methods.

Organ donors are not routinely screened for tuberculosis (TB) in the United States. We investigated a case of pulmonary TB in a double-lung transplant recipient. We reviewed the donor's and recipient's records, and used molecular methods to compare the lung recipient's isolate with others from three sources: her hospital, the California state health department's genotyping database, and the donor's resident-nation of Guatemala. A respiratory specimen obtained from the lung recipient 1 day after transplantation grew Mycobacterium tuberculosis. Donor chest radiograph had a previously unnoticed pulmonary opacity that was present on post-transplant recipient chest radiographs and computed tomographs. The recipient's isolate was molecularly distinct from others at her hospital and in the state database, but was identical to two isolates from Guatemala. Tuberculosis was transmitted from lung donor to recipient. As organ transplantation becomes more common worldwide, similar cases could occur. Screening for TB in potential organ donors should be considered.

Background and Aims In 2015, the U.S. Food and Drug Administration and Centers for Disease Control and Prevention (CDC) issued guidance for duodenoscope culturing and reprocessing in response to outbreaks of carbapenem-resistant Enterobacteriaceae (CRE) duodenoscope-related infections. Based on this guidance, we implemented best practices for reprocessing and developed a systematic process for culturing endoscopes with elevator levers. The aim of this study is to report the outcomes and direct costs of this program. Methods First, clinical microbiology data from 2011 to 2014 were reviewed retrospectively to assess for possible elevator lever-equipped endoscope-related CRE infections. Second, a program to systematically culture elevator lever-equipped endoscopes was implemented. Each week, about 25% of the inventory of elevator lever-equipped endoscopes is cultured based on the CDC guidelines. If any cultures return bacterial growth, the endoscope is quarantined pending repeat culturing. The costs of the program, including staff time and supplies, have been calculated. Results From 2011 to 2014, none of 17 patients with documented CRE infection had undergone ERCP or endoscopic ultrasound in the previous 36 months. From June 2015 to September 2016, 285 cultures were performed. Three (1.1%) had bacterial growth, 2 with skin contaminants and 1 with an oral contaminant. The associated endoscopes were quarantined and reprocessed, and repeat cultures were negative. The total estimated cost of our program for an inventory of 20 elevator lever-equipped endoscopes was $30,429.60 per year ($1521.48 per endoscope). Conclusions This 16-month evaluation of a systematic endoscope culturing program identified a low rate of positive cultures after elevator lever endoscope reprocessing. All positive cultures were with non-enteric microorganisms. The program was of modest cost and identified reprocessing procedures that may have led to a low rate of positive cultures.

Severity of Illness Score Minor 16 (2.6) 20 (3.4) Moderate 126 (20.5) 115 (19.3) Severe 231 (37.4) 173 (28.9) Extreme 197 (32.0) 98 (16.4) Unknown 46 (7.5) 191 (32.0) Site of Infection Bloodstream 116 (18.8) 116 (19.4) Cardiovascular 60 (9.7) 61 (10.2) Pulmonary 111 (18.0) 129 (21.6) Bone & Joint 73 (11.9) 106 (17.7) CNS 45 (7.3) 27 (4.5) Other 211 (34.3) 158 (26.6) Impact of an Infectious Diseases Transitions Service on Outcomes in Patients Discharged on Parenteral Antibiotics Requiring Therapeutic Drug Monitoring

Non-tuberculous mycobacteria are becoming increasingly important pathogens among transplant recipients. We report a case of disseminated Mycobacterium haemophilum infection in a heart transplant recipient, manifesting as cellulitis, subcutaneous nodules, septic arthritis, and pneumonitis. Our case illustrates diverse challenges in the identification and treatment of this pathogen, such as its unique culture requirements and variable antimicrobial susceptibilities. Heightened clinical suspicion is necessary to establish a timely diagnosis so that optimal treatment can be administered.

Non-tuberculous mycobacteria (NTM) have emerged as important pathogens in organ transplant recipients. Because NTM pulmonary infections vary in their clinical and radiographic presentations, heightened clinical suspicion is necessary for accurate diagnosis. We report a case of Mycobacterium abscessus empyema in a lung transplant recipient. Repeated attempts at identifying the organism from a variety of clinical specimens led to the correct diagnosis and treatment.

Data are limited on outcomes of treatment with extended-spectrum cephalosporins (ESCs) for infections caused by Enterobacteriaceae that produce extended-spectrum beta-lactamases (ESBLs). This study describes the largest treatment experience of a nonoutbreak series of bloodstream infections caused by strains of Escherichia coli (23 episodes) and Klebsiella pneumoniae (13 episodes) with a ceftazidime minimal inhibitory concentration of > or =2 microg/mL. E. coli isolates produced a greater variety of beta-lactamase types than did K. pneumoniae isolates, among which ESBL production was predominant. Five ESBL types were identified: TEM-12, TEM-71, TEM-6, SHV-12, and SHV-5. Most patients were treated empirically with an ESC-based regimen. A favorable response to treatment with a nonceftazidime ESC was observed when the causative pathogen produced either TEM-6 or TEM-12; ceftazidime treatment was associated with failure of therapy in all patients. Despite the limited clinical success, ESCs are currently not recommended for the treatment of serious infections caused by ESBL-producing strains.

The Bristol stool form scale classifies the relative density of stool samples. In a prospective cohort study, we investigated the associations between stool density, C. difficile assay positivity, hospital-onset C. difficile infection, complications, and severity of C. difficile . We describe associations between the Bristol score, assay positivity, and clinical C. difficile infection.