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While many aspects of infection prevention and control (IPC) mirror institutional efforts, optimization of IPC practices in the neonatal intensive care unit (NICU) requires careful consideration of its unique population and environment, addressed here for key IPC domains. Additionally, innovative mitigation efforts to address challenges specific to limited resource settings are discussed.

This SHEA white paper identifies knowledge gaps and challenges in healthcare epidemiology research related to coronavirus disease 2019 (COVID-19) with a focus on core principles of healthcare epidemiology. These gaps, revealed during the worst phases of the COVID-19 pandemic, are described in 10 sections: epidemiology, outbreak investigation, surveillance, isolation precaution practices, personal protective equipment (PPE), environmental contamination and disinfection, drug and supply shortages, antimicrobial stewardship, healthcare personnel (HCP) occupational safety, and return to work policies. Each section highlights three critical healthcare epidemiology research questions with detailed description provided in supplementary materials. This research agenda calls for translational studies from laboratory-based basic science research to well-designed, large-scale studies and health outcomes research. Research gaps and challenges related to nursing homes and social disparities are included. Collaborations across various disciplines, expertise and across diverse geographic locations will be critical.

The COVID-19 pandemic resulted in large-scale school closures in an effort to reduce the spread of disease. This article reviews the potential impact of COVID-19-related school closures on the health of children in North Carolina, with particular attention to the impact of school closures on drivers of child health.

Understanding the role that children play in the clinical burden and propagation of severe acute respiratory syndrome coronavirus 2, responsible for coronavirus disease 2019 (COVID-19) infections, is emerging. While the severe manifestations and acute clinical burden of COVID-19 have largely spared children compared with adults, understanding the epidemiology, clinical presentation, diagnostics, management, and prevention opportunities and the social and behavioral impacts on child health is vital. Foremost is clarifying the contribution of asymptomatic and mild infections to transmission within the household and community and the clinical and epidemiologic significance of uncommon severe post-infectious complications. Here, we summarize the current knowledge, identify resources, and outline research opportunities. Pediatric infectious diseases clinicians have a unique opportunity to advocate for the inclusion of children in epidemiological, clinical, treatment, and prevention studies to optimize their care as well as to represent children in the development of guidance and policy during pandemic response.

We describe the frequency of pediatric healthcare-associated infections (HAIs) identified through prospective surveillance in community hospitals participating in an infection control network. Over a 6-year period, 84 HAIs were identified. Of these 51 (61%) were pediatric central-line–associated bloodstream infections, and they often occurred in children

We implemented universal severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) testing of patients undergoing surgical procedures as a means to conserve personal protective equipment (PPE). The rate of asymptomatic coronavirus disease 2019 (COVID-19) was

Objectives To examine the effect of maternal reverse-sequence (RS) syphilis screening on management of infants at risk for congenital syphilis (CS) using a standardized approach. Study design A retrospective study from 2011 to 2014 at an academic medical center using RS testing, involving chemiluminescent immunoassay (CIA), rapid plasma reagin (RPR), and fluorescent treponemal antibody-absorption (FTA-ABS) assays for syphilis. Clinical management and outcomes of infants born to mothers with discordant (CIA+/RPR-/FTA+) serology were compared with national or internal guidelines. Results Sixty-three infants were classified as discordant (n = 21), presumed false positive (CIA+/RPR-/FTA-; n = 16), or true positive (CIA+/RPR+; n = 26) based on maternal serology. Only 24% of cases in the discordant group underwent recommended full evaluation. None of the evaluated infants in the discordant group (n = 8) were diagnosed with CS. Conclusions Management of infants with discordant maternal RS serology remained reliant on clinical judgment. In our high-risk population, RS testing did not identify additional cases of CS.

BACKGROUND AND OBJECTIVES: As schools reopen nationwide, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in youth settings remains a concern. Here, we describe transmission of SARS-CoV-2 among >6800 youth and staff at YMCA of the Triangle day camps in North Carolina (March to August 2020). METHODS: We performed a retrospective analysis of deidentified SARS-CoV-2 cases reported by YMCA day camps in 6 counties (Chatham, Durham, Johnston, Lee, Orange, Wake) over 147 days. Inclusion criteria were youth and staff who enrolled or worked in camps during the study period. Individual-level youth and staff demographics (age, sex, race and ethnicity) were self-reported and linked to SARS-CoV-2 case data by using unique identifiers. RESULTS: Youth (n = 5344; 66% white, 54% male, mean age 8.5 years) had a mean camp attendance rate of 88%; staff (n = 1486) were 64% white and 60% female (mean age 22 years). Seventeen primary SARS-CoV-2 infections occurred during the study period among 9 youth (mean age 9.7 years) and 8 staff (mean age 27 years) who were linked to 3030 contacts present in-person during the week before positive cases. Only 2 secondary infections (1 youth and 1 staff) were linked to primary cases. SARS-CoV-2 primary case attack rate was 0.6% (17/3030), and secondary case transmission rate was 0.07% (2/3011). CONCLUSIONS: Extremely low youth and staff symptomatic SARS-CoV-2 attack and transmission rates were observed over a 147-day period across 54 YMCA camps from March to August 2020, when local coronavirus disease 2019 prevalence peaked. These findings suggest that the benefit of in-person programming in recreation settings with appropriate mitigation may outweigh the risk of viral transmission.

BACKGROUND: In an effort to mitigate the spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), North Carolina closed prekindergarten through grade 12 public schools to in-person instruction on March 14, 2020. On July 15, 2020, North Carolina’s governor announced schools could open via remote learning or a hybrid model that combined in-person and remote instruction. In August 2020, 56 of 115 North Carolina school districts joined The ABC Science Collaborative (ABCs) to implement public health measures to prevent SARS-CoV-2 transmission and share lessons learned. We describe secondary transmission of SARS-CoV-2 within participating school districts during the first 9 weeks of in-person instruction in the 2020–2021 academic year. METHODS: From August 15, 2020 to October 23, 2020, 11 of 56 school districts participating in ABCs were open for in-person instruction for all 9 weeks of the first quarter and agreed to track incidence and secondary transmission of SARS-CoV-2. Local health department staff adjudicated secondary transmission. Superintendents met weekly with ABCs faculty to share lessons learned and develop prevention methods. RESULTS: Over 9 weeks, 11 participating school districts had >90 000 students and staff attend school in person. Among these students and staff, 773 community-acquired SARS-CoV-2 infections were documented by molecular testing. Through contact tracing, health department staff determined an additional 32 infections were acquired within schools. No instances of child-to-adult transmission of SARS-CoV-2 were reported within schools. CONCLUSIONS: In the first 9 weeks of in-person instruction in North Carolina schools, we found extremely limited within-school secondary transmission of SARS-CoV-2, as determined by contact tracing.

Background Bloodstream infections (BSIs) occur frequently after hematopoietic stem cell transplantation (HSCT). We examined the microbiology of BSI in pediatric HSCT recipients over a 2-decade period at our institution to inform empirical antimicrobial prescribing and infection prevention strategies. Methods We conducted a retrospective cohort study of children (, The hazard of bloodstream infections (BSIs) among 1311 pediatric hematopoietic stem cell transplant recipients was relatively stable over a 21-year period. However, the hazard of fungal BSIs declined, and the prevalence of vancomycin resistance among Enterococcus faecium BSIs markedly increased.

Background Children undergoing hematopoietic stem cell transplantation (HSCT) are at high risk for hospital-associated bloodstream infections (HA-BSIs). This study aimed to describe the incidence, microbiology, and risk factors for HA-BSI in pediatric HSCT recipients. Methods We performed a single-center retrospective cohort study of children and adolescents ( Results Of 1294 patients, the majority (86%) received an allogeneic HSCT, most commonly with umbilical cord blood (63%). During the initial HSCT hospitalization, 334 HA-BSIs occurred among 261 (20%) patients. These were classified as gram-positive bacterial (46%), gram-negative bacterial (24%), fungal (12%), mycobacterial ( Conclusions Over the past 2 decades, the incidence of HA-BSIs has declined among pediatric HSCT recipients at our institution. Older age, umbilical cord blood donor source, and nonmyeloablative conditioning regimens are independent risk factors for HA-BSI among children undergoing HSCT.

ObjectivesTo examine neonatal risk factors associated with recurrent Staphylococcus aureus colonization and to determine the genetic relatedness of S. aureus strains cultured from neonates before and after decolonization.Study designSingle-center retrospective cohort study of neonates admitted to the neonatal intensive care unit (NICU) from April 2013 to December 2015, during which weekly nasal cultures from hospitalized NICU patients were routinely obtained for S. aureus surveillance.SettingJohns Hopkins Hospital’s 45-bed level IV NICU in Baltimore, Maryland.MethodsDemographics and clinical data were collected on all neonates admitted to the NICU with S. aureus nasal colonization who underwent mupirocin-based decolonization during the study period. A decolonized neonate was defined as a neonate with ≥1 negative culture after intranasal mupirocin treatment. Pulsed-field gel electrophoresis was used for strain typing.ResultsOf 2,060 infants screened for S. aureus, 271 (13%) were colonized, and 203 of these 271 (75%) received intranasal mupirocin. Of those treated, 162 (80%) had follow-up surveillance cultures, and 63 of these 162 infants (39%) developed recurrent colonization after treatment. The S. aureus strains were often genetically similar before and after decolonization. The presence of an endotracheal tube or nasal cannula/mask was associated with an increased risk of recurrent S. aureus colonization (hazard ratio [HR], 2.65; 95% confidence interval [CI], 1.19–5.90; and HR, 2.21; 95% CI, 1.02–4.75, respectively).ConclusionStrains identified before and after decolonization were often genetically similar, and the presence of invasive respiratory devices increased the risk of recurrent S. aureus nasal colonization in neonates. To improve decolonization efficacy, alternative strategies may be needed.

Background:Staphylococcus aureus is the second-leading cause of late-onset sepsis among infants in US neonatal intensive care units (NICUs). Management of S. aureus bacteremia and meningitis in infants varies widely due to the lack of standardized guidelines. We examined the association between initial antibiotic duration and recurrent S. aureus infection or death among NICU infants with S. aureus bacteremia and/or meningitis. Methods: We conducted a retrospective cohort study of infants in Pediatrix Medical Group NICUs from 1997 to 2018 with first episode of S. aureus bacteremia and/or meningitis, identified as having at least 1 blood or cerebrospinal fluid (CSF) culture growing only S. aureus at any point during their NICU stay. Excluded infants were those not started on antistaphylococcal therapy within 2 days of positive culture, those with had endocarditis or osteomyelitis, or those who died or were discharged during or up to 1 day after antibiotic cessation. Antibiotic cessation was defined as last day of antibiotic given if followed by at least 3 days without antibiotics. Multivariable logistic regression was used to analyze the association between antibiotic duration categorized as Results: Of 4,086 infants included, 3,991 (98%) had S. aureus bacteremia only and 95 (2%) had meningitis ± bacteremia. Of those with bacteremia only, 2,017 (50.5%), and 17 (18%) of those with meningitis received Conclusions: In the largest study thus far examining antibiotic duration among hospitalized infants with S. aureus bacteremia and/or meningitis, ≥14 days antibiotics was associated with decreased odds of recurrent infection or death. Further studies are needed to define the optimal treatment duration and identify clinical factors distinguishing infants able to safely receive a shorter antibiotic duration.Funding: NoDisclosures: None

Background: Surgical site infections (SSIs) among cardiothoracic (CT) patients are associated with high rates of morbidity and mortality. Data are limited regarding SSI incidence among pediatric patients undergoing primary reparative procedures for congenital cardiac disease. Published evidence on targeted interventions to prevent pediatric CT-surgery SSI is lacking. We aimed to establish standard metrics for measuring CT-surgery SSI incidence and to implement bundled interventions for SSI prevention. Methods: A dedicated CT-surgery SSI prevention workgroup was established, consisting of hospital leadership, CT surgeons, cardiac critical care unit staff, anesthesia, perfusion, environmental services, instrument sterile processing, risk management, infection prevention and antibiotic stewardship. We created a standard definition for CT-surgery SSI and calculated retrospective SSI rates over a 24-month period (2017–2019). The outcome measured was incidence of CT-surgery SSI per 100 primary cardiac procedures with delayed ( 3 days after primary surgery) or non-delayed chest closure. The difference in proportion of SSI was reported separately for delayed closure and non-delayed closure; statistical significance was tested using a Fisher’s Exact test. We identified many potential improvement opportunities, including gaps in SSI surveillance, poor compliance with daily bathing, inconsistent perioperative antimicrobial prophylaxis, lack of controlled environment for bedside chest closures, and lapses in environmental cleaning. These issues informed the enhanced SSI prevention bundle, which included education on sterility with the operating room (OR) staff. Protocols for care of cardiac patients with delayed chest closures focused on universal daily and preoperative chlorhexidine baths. In addition, the bundle incorporated stringent environmental cleaning interventions including scheduled decluttering of patient rooms and clinical spaces, terminal cleaning of patient rooms prior to returning from the OR, and use of adjunctive ultraviolet light for the daily cleaning of operating rooms and patient rooms at discharge. Results: Surveillance definition of microbiological growth from a clinical sample obtained within 30 days of primary cardiac procedure sufficiently captured all CT-surgery SSIs. Of 551 CT-surgery procedures prior to intervention, 91 (17%) had delayed final operative closures. Prior to the intervention, 16 SSIs were identified from July 2017 – May 2019 for a rate of 2.90 per /100 procedures, and was higher among patients with delayed chest closure 6.59 per /100 procedures (6 SSIs/91 procedures) versus those with primary chest closure 2.17 per /100 procedures (10 SSIs/460 procedures; P = 0.034). Gram-positive organisms, including coagulase coagulase-negative Staphylococci, were most frequently identified as the causative organisms for SSIs. Compliance with bundled intervention, rolled out over a 2-month period, was associated with an immediate decrease in the number of SSIs for primary and delayed chest closures 6SSIs /185 procedures in the initial quarters (August – December 2019) of the post-intervention period. However, this decrease was not reflected in the overall rate (3.24 per /100 procedures) due to fewer procedures performed. Data collection to measure sustainability is ongoing. Conclusions: Bundled interventions targeting skin antisepsis and environmental cleaning may be associated with a decrease in SSIs among pediatric CT-surgery patients. Ongoing surveillance is required to determine sustainability of these interventions.Funding: NoneDisclosures: None

The epidemiology of Staphylococcus aureus infection in children is dynamic. We conducted a retrospective observational study on pediatric clinical cultures, performed between 2005 and 2017, that grew S aureus to determine temporal trends in antibiotic resistance. Although methicillin resistance declined, clindamycin and trimethoprim-sulfamethoxazole resistance increased significantly, especially among community-onset isolates.

Background: We evaluated the impact of a comprehensive SARS-CoV-2 (COVID-19) infection prevention (IP) bundle on rates of non–COVID-19 healthcare-acquired respiratory viral infection (HA-RVI). Methods: We performed a retrospective analysis of prospectively collected respiratory viral data using an infection prevention database from April 2017 to January 2021. We defined HA-RVI as identification of a respiratory virus via nasal or nasopharyngeal swabs collected on or after hospital day 7 for COVID-19 and non–COVID-19 RVI. We compared incident rate ratios (IRRs) of HA-RVI for each of the 3 years (April 2017 to March 2020) prior to and 10 months (April 2020 to January 2021) following full implementation of a comprehensive COVID-19 IP bundle at Duke University Health System. The COVID-19 IP bundle consists of the following elements: universal masking; eye protection; employee, patient, and visitor symptom screening; contact tracing; admission and preprocedure testing; visitor restrictions; discouraging presenteeism; population density control and/or physical distancing; and ongoing attention to basic horizontal IP strategies including hand hygiene, PPE compliance, and environmental cleaning. Results: During the study period, we identified 715 HA-RVIs over 1,899,700 inpatient days, for an overall incidence rate of 0.38 HA-RVI per 1,000 inpatient days. The HA-RVI IRR was significantly higher during each of the 3 years prior to implementing the COVID-19 IP bundle (Table 1). The incidence rate of HA-RVI decreased by 60% after bundle implementation. COVID-19 became the dominant HA-RVI, and no cases of HA-influenza occurred in the postimplementation period (Figure 1). Conclusions: Implementation of a comprehensive COVID-19 IP bundle likely contributed to a reduction in HA-RVI for hospitalized patients in our healthcare system. Augmenting traditional IP interventions in place during the annual respiratory virus season may be a future strategy to reduce rates of HA-RVI for inpatients.

Importance Escherichia coliis a leading cause of serious infection among term and preterm newborn infants. Surveillance of antibiotic susceptibility patterns ofE coliamong infants admitted to neonatal intensive care units should inform empirical antibiotic administration. Objective To assess the epidemiologic characteristics and antibiotic susceptibility patterns ofE coliin infants admitted to neonatal intensive care units in the US over time. Design, Setting, and Participants This retrospective cohort study used the Premier Health Database, a comprehensive administrative database of inpatient encounters from academic and community hospitals across the US. Participants included newborn infants admitted to centers contributing microbiology data from January 1, 2009, to December 31, 2017, withE coliisolated from blood, cerebrospinal fluid, or urine cultures. Data were collected and analyzed from December 1, 2018, to November 30, 2019. Main Outcomes and Measures Changes in annual antibiotic susceptibility ofE coliduring the study period. The proportion of infants with nonsusceptible organisms (resistant or intermediate susceptibility) in antibiotic categories by year, birth weight, infection source, and timing of infection and patient and center characteristics associated with neonatalE coliinfection and antibiotic susceptibility were assessed. Results A total of 721 infants (434 male [60.2%]; median age atE coliinfection, 14 days [interquartile range, 1-33 days]) from 69 centers had at least 1 episode ofE coliinfection and available susceptibility results. No significant changes were observed over time in the overall annual proportions of antibiotic nonsusceptibility to ampicillin (mean [SD], 66.8% [1.5%]; range, 63.3% to 68.6%; estimated yearly change, −0.28% [95% CI, −1.75% to 1.18%]), nonsusceptibility to aminoglycosides (mean [SD], 16.8% [4.5%]; range, 10.7% to 23.2%; estimated yearly change, −0.85% [95% CI, −1.93% to 0.23%]), or extended-spectrum β-lactamase phenotype (mean [SD], 5.0% [3.7%]; range, 0% to 11.1%; estimated yearly change, 0.46% [95% CI, −0.18% to 1.11%]). No isolates with nonsusceptibility to carbapenems were identified. Among 218 infants with early-onset infection, 22 (10.1%) had isolates with nonsusceptibility to both ampicillin and gentamicin, the antibiotics most commonly administered to newborns as empirical therapy. Conclusions and Relevance In this cohort study, nonsusceptibility to commonly administered antibiotics was found in substantial proportions of neonatalE coliisolates, with no significant change from 2009 to 2017. These findings may inform empirical antibiotic choices for newborn infants.

Antibiotic stewardship is a quality improvement and patient safety initiative focused on optimizing antibiotic use to improve patient outcomes, limit the emergence of antibiotic resistance, and adverse drug effects. Here, we discuss the Centers for Diseases Control and Prevention Core Elements of Antibiotic Stewardship-leadership commitment, accountability, pharmacy expertise, action, tracking, reporting, and education-as they apply to the care of patients in the neonatal intensive care unit. Specifically, we consider neonatal intensive care unit-specific data and unique practices to frame some of the important targets necessary for successful antibiotic stewardship implementation in this setting.

Background Adenoviruses (Adv) are non-enveloped viruses that can survive for long periods on environmental surfaces. However, only 1 prior publication describes an adenovirus pseudo-outbreak associated with bronchoscopes. In 1/ 2020 infectious disease physicians noted a cluster of Adv PCR-positive bronchiolar lavage (BAL) samples, which prompted an outbreak investigation. Methods We reviewed medical charts, clinical microbiology, procedure logs, bronchoscope reprocessing logs, bronchoscope cleaning, and high-level disinfection (HLD) practices. Results On 1/28/20 an infectious diseases physician alerted infection prevention to a cluster of 5 lung transplant patients diagnosed with Adv positive BAL samples. Four out of the 5 patients had the bronchoscopy in the same bronchoscopy suite. We reviewed BAL results from all bronchoscopies performed in this suite from 11/1/19 to 1/24/20 and found a total of 10 patients with positive Adv PCR results. Eight out of the 10 patients had bronchoscopies with one of two bronchoscopes. Of all patients who had a bronchoscopy with the bronchoscope from 11/1/19 to 1/24/20 and had respiratory viral panel sent at that time, 6 of 11 (55%) who underwent procedure with Scope A and 4 of 24 (17%) who underwent procedure with Scope B had positive Adv PCR results. Sham BALs were performed on both bronchoscopes and testing for Adv was negative. However, on inspection by the manufacturer, one scope failed both wet and dry leak tests and had several physical defects. Following removal of both bronchoscopes from service we did not find any positive Adv samples from the bronchoscopy unit. Conclusion Previously, very few pseudo-outbreaks of Adv have been linked to bronchoscopes. We identified a pseudo-outbreak of Adv associated with 2 bronchoscopes in a hospital-based bronchoscopy suite that stopped once we removed the associated bronchoscopes from the procedural unit. Bronchoscopy-related pseudo-outbreaks occur despite standardized procedures for HLD. Bronchoscopy clinics, particularly those with a high volume of immunocompromised patients, should prospectively review BAL cultures to identify unusual pathogen trends. These trends may be a sign of damaged equipment that would otherwise go undetected. Disclosures All Authors: No reported disclosures

Staphylococcus aureus (S. aureus) remains a leading cause of hospital-acquired infections (HAIs) in neonates.1 Some neonatal intensive care units (NICUs) use active surveillance cultures (ASC) and decolonization to prevent methicillin-resistant S. aureus (MRSA) transmission and infections.2 However, methicillin-susceptible S. aureus (MSSA) infections occur more frequently and have similar mortality in neonates.3 In The Johns Hopkins’ NICU, prior to April 2013, neonates were screened for MRSA colonization and carriers were decolonized.4 In April 2013, the program expanded to include MSSA screening and decolonization. Previously, we showed that after implementation of MSSA ASC and targeted decolonization, S. aureus clinical cultures and infections decreased.4 Our objective was to assess whether the reduction was sustained over 3-years.

Background Healthcare-associated infections (HAI) remain the leading cause of morbidity and mortality among hospitalized children. Within community hospitals with targeted infection prevention efforts, participation in an infection control network has led to significant decreases in device or procedure-related infections among adult patients. The impact of these interventions has not been assessed in pediatric patients admitted to community hospitals. Methods We conducted a retrospective cohort study to describe the burden of HAI among hospitalized infants (< 1 year old) within 53 community hospitals participating in the Duke Infection Control Outreach Network (DICON) from 2013–2018. We determined the frequency of device-related HAI, central line-associated bloodstream infections (CLABSI), catheter-associated urinary tract infections (CAUTI) and hospital-associated pneumonia or ventilator-associated events (HAP/VAE) using National Healthcare Safety Network (NHSN) definitions; and the burden of HAIs among neonatal intensive care units (NICU) and non-NICU centers. The trend of HAI was analyzed with Spearman’s correlation. Results Thirty hospitals reported 150 HAI among 141 infants over the 6-year period. Median (IQR) time to infection was 10 (4, 20) days after admission. Hospitals with a NICU (15) reported more HAI (median 5, (IQR: 3, 12)) than hospitals without a NICU (median 2 (IQR: 1, 2)) (P = 0.031). CLABSI represented 35% of HAI, HAP/VAE were 23% and CAUTI were 12%. The most frequently isolated primary organism for all HAI was Escherichia coli (22 HAI, 15%) which was also isolated in 39% of CAUTI. Methicillin-resistant and methicillin-susceptible Staphylococcus aureus (S. aureus) were the most commonly isolated organisms among CLABSI (17%) and HAP/VAE (33%). Nine centers with ≥4 years of NICU and Central line (CL) use data reported a median (IQR) rate of 1.2 (0, 2.4) CLABSIs/1,000 central line days. There was no change in median CLABSI rate over time (P = 0.47), Figure 1. Conclusion CLABSI, most commonly caused by S. aureus, represented the majority of HAI reported from hospitalized infants within community hospitals participating in an infection control network. Further research into device utilization practices may inform future interventions to reduce HAI. Disclosures All authors: No reported disclosures.

Human T-cell lymphotropic virus (HTLV), an infection that is endemic in certain parts of Asia, Africa, and South America, has been associated with malignancy and neurological deficits. Here, we describe a pediatric patient with chronic HTLV-I infection who developed complications associated with HTLV-I (ie, adult T-cell leukemia/lymphoma and HTLV-I–associated myelopathy/tropical spastic paraparesis). To our knowledge, this presentation in a child has never been described. The patient underwent a bone marrow transplant and, at the time of this writing, was in remission. This case report highlights the fact that HTLV-related complications, previously expected to occur after decades of infection, also can occur in pediatric patients, particularly those who acquired HTLV-I perinatally.

OBJECTIVES: Young children in resource-poor settings remain inadequately immunized. We evaluated the role of compliance-linked incentives versus mobile phone messaging to improve childhood immunizations. METHODS: Children aged ≤24 months from a rural community in India were randomly assigned to either a control group or 1 of 2 study groups. A cloud-based, biometric-linked software platform was used for positive identification, record keeping for all groups, and delivery of automated mobile phone reminders with or without compliance-linked incentives (Indian rupee Rs30 or US dollar $0.50 of phone talk time) for the study groups. Immunization coverage was analyzed by using multivariable Poisson regression. RESULTS: Between July 11, 2016, and July 20, 2017, 608 children were randomly assigned to the study groups. Five hundred and forty-nine (90.3%) children fulfilled eligibility criteria, with a median age of 5 months; 51.4% were girls, 83.6% of their mothers had no schooling, and they were in the study for a median duration of 292 days. Median immunization coverage at enrollment was 33% in all groups and increased to 41.7% (interquartile range [IQR]: 23.1%–69.2%), 40.1% (IQR: 30.8%–69.2%), and 50.0% (IQR: 30.8%–76.9%) by the end of the study in the control group, the group with mobile phone reminders, and the compliance-linked incentives group, respectively. The administration of compliance-linked incentives was independently associated with improvement in immunization coverage and a modest increase in timeliness of immunizations. CONCLUSIONS: Compliance-linked incentives are an important intervention for improving the coverage and timeliness of immunizations in young children in resource-poor settings.

Background Antibiotic stewardship (AS) is a fundamental aspect of medical training. Neonatal Intensive Care Units (NICU) often have unique stewardship needs as they are ideal settings for the emergence and spread of drug-resistant bacteria. Assessing neonatology fellowship trainees’ knowledge and perceptions will highlight deficits in AS education and inform future curriculum development. Methods Prospective electronic survey study, distributed by Accreditation Council for Graduate Medical Education (ACGME) program directors to neonatology fellows in the United States over 4 months (January to April 2018). The objective was to assess neonatology fellows’ knowledge, attitudes and perceptions about AS to inform sustainable NICU-specific AS programs. Results Of 99 programs and 700 fellows, 159 respondents (23%) from 40 neonatology training programs (40%) responded to the survey and 139 (87%) provided complete responses. Respondents were equally spread across all 3 years of training Seventy-two percent confirmed an institutional AS program existed, yet, only 33% were able to identify the components of AS programs and 66% either did not or were unsure if they had received AS training during fellowship. Furthermore, only 51% identified the appropriate empiric antibiotic for neonatal meningitis and 12% identified optimal methicillin-susceptible Staphylococcus aureus (MSSA) treatment while answering clinical case study questions. Notably, fellowship training year was not significantly related to the proportion of incorrect responses (P = 0.40). Small group sessions were identified as the best teaching format (35%). This was followed by audit and feedback of individual prescribing behavior and didactic lectures which had an equal proportion of respondents (22%). Seventy-eight percent of respondents preferred a trainee-led AS program targeting necrotizing enterocolitis, antifungal prophylaxis and appropriate surgical prophylaxis. Conclusion Antibiotic stewardship is a critical part of physician training. While most institutions have a stewardship program, a dedicated curriculum incorporating small group sessions and didactics may be beneficial for educating neonatology trainees. Disclosures All authors: No reported disclosures

Rat bite fever is a rare infection usually caused by Streptobacillus moniliformis . A case of septic arthritis and possible osteomyelitis as sequelae of rat bite fever in a pediatric patient is described.