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This is a clinical case presentation of a Catholic hospital chaplain, who, like thousands of deeply wounded children from around the world, was sexually abused by his parish priest. Believing he had received 'a special blessing' contributed to his denial, rationalization and ultimate identification with his abuser. For 58 years, having repressed his earlier experience, this man lived as a Catholic cleric, abusing others. Entering analysis provided him with an opportunity to work with his dreams and memories. Analysis enabled him to consciously come to terms with and benefit from a future that fostered his individuation and allowed him to become a spokesman for the rehabilitation of others suffering a similar fate.Ceci est la présentation d’un cas clinique, celui d’un aumônier catholique des hôpitaux qui, comme des milliers d’enfants profondément blessés dans le monde entier, fut abusé sexuellement par le prêtre de sa paroisse. Sa croyance - qu’il avait reçu « une bénédiction spéciale » - contribua à son déni, à sa rationalisation et finalement à son identification avec son agresseur. Pendant 58 années, ayant réprimé ses expériences précoces, cet homme a vécu comme un membre du clergé catholique, abusant d’autres personnes. Entrer en analyse lui a fourni l’opportunité de travailler avec ses rêves et ses souvenirs. L’analyse l’a rendu capable de faire face consciemment à un avenir qui soutiendrait son individuation et lui permettrait de devenir un porte-parole pour la réhabilitation d’autres personnes victimes d’un même destin.Dies ist die klinische Falldarstellung eines katholischen Krankenhauspfarrers, der, wie Tausende von tief verletzten Kindern aus der ganzen Welt, von seinem Pfarrer sexuell mißbraucht wurde. Der Glaube, er habe 'einen besonderen Segen' erhalten, trug zu Verleugnung, Rationalisierung und letztendlichen Identifikation mit seinem Täter bei. 58 Jahre lang lebte dieser Mann, nachdem er seine früheren Erfahrungen verdrängt hatte, als katholischer Geistlicher und mißbrauchte andere. Der Einstieg in die Analyse bot ihm die Möglichkeit, mit seinen Träumen und Erinnerungen zu arbeiten. Die Analyse ermöglichte es ihm, sich bewußt mit einer Zukunft auseinanderzusetzen und davon zu profitieren, die seine Individuation förderte und es ihm ermöglichte, zum Sprecher für die Rehabilitation ähnlicher Schicksale zu werden.Questa è una presentazione di un caso clinico di un cappellano in un ospedale cattolico, che, come migliaia di bambini profondamente feriti in tutto il mondo, è stato abusato sessualmente dal suo parroco. Credere di aver ricevuto ‘una benedizione speciale’ ha contribuito alla sua negazione, razionalizzazione e identificazione finale con il suo aggressore. Per 58 anni, avendo represso la sua precedente esperienza, quest’uomo ha vissuto come un religioso cattolico abusando degli altri. Entrare in analisi gli ha fornito l’opportunità di lavorare con i suoi sogni e i suoi ricordi. L’analisi gli ha permesso di venire a patti con -e di beneficiare di- un futuro che ha favorito la sua individuazione e gli ha permesso di farsi portavoce della riabilitazione di altri che soffrono un destino simile.Это презентация клинического случая священника католической больницы, который, как и тысячи глубоко раненых детей со всего мира, подвергся сексуальному насилию со стороны своего приходского священника. Вера в то, что он получил «особое благословение», способствовала отрицанию, рационализации и идентификации с абьюзером. В течение 58 лет, подавляя свой ранний опыт, этот человек жил как католический священнослужитель, занимаясь абьюзом. Начало анализа дало ему возможность работать со своими мечтами и воспоминаниями. Анализ помог ему сознательно прийти к согласию и извлечь выгоду из будущего, которое способствовало его индивидуации, и позволил ему стать во главе движения реабилитации других людей с подобной судьбой.Esta es la presentación de un caso clínico de un capellán católico de un hospital, quien, como miles de niños profundamente heridos de alrededor del mundo, fue abusado sexualmente por el sacerdote de su parroquia. La creencia de que había recibido ‘una bendición especial’ contribuyó a su negación, racionalización, y a la identificación con su abusador. Habiendo reprimido esta experiencia temprana, este hombre vivió como un clérigo católico, abusando de otros, durante 58 años. El inicio de análisis le dio la oportunidad de trabajar con sus sueños y memorias. El análisis le permitió una confrontación consciente y también la posibilidad de beneficiarse de un futuro que favorezca su individuación, permitiéndole devenir en portavoz para la rehabilitación de otros que sufren destinos similares.我以为我是被祝福的 这篇文章展现了一个个案报告。这名个案来自于天主教医院的一名牧师。他正如全球千百个被深深伤害的儿童一样, 曾经被自己教区的神父性侵。他以为自己是受到了“特殊的祝福”, 这导致他对于真相采取否认、理智化的应付方式, 并最终认同了他的施虐者。他把这一早期经历压抑了58年, 并作为一名天主教的牧师, 也在侵犯他人。进入分析中, 使得他有机会来对自己的梦和记忆进行工作。分析让他可以有意识地面向未来, 并受益于未来, 这可以助长他的自性化并允许他为那些有类似遭遇的人代言。.Esta é uma apresentação de caso clínico de um capelão do hospital católico, que, como milhares de crianças profundamente feridas de todo o mundo, foi abusada sexualmente por seu pároco. Acreditar que ele havia recebido “uma bênção especial” contribuiu para sua negação, racionalização e identificação final com seu agressor. Por 58 anos, tendo reprimido sua experiência anterior, esse homem viveu como clérigo católico, abusando dos outros. Entrar na análise proporcionou a ele a oportunidade de trabalhar com seus sonhos e memórias. A análise permitiu que ele concordasse conscientemente e se beneficiasse de um futuro que promoveu sua individuação e lhe permitiu se tornar um porta-voz da reabilitação de outros que sofrem um destino semelhante.

Background Candidemia is a common opportunistic infection causing substantial morbidity and mortality. Because of an increasing proportion of non-albicans Candida species and rising antifungal drug resistance, the Infectious Diseases Society of America (IDSA) changed treatment guidelines in 2016 to recommend echinocandins over fluconazole as first-line treatment for adults with candidemia. We describe candidemia treatment practices and adherence to the updated guidelines. Methods During 2017–2018, the Emerging Infections Program conducted active population-based candidemia surveillance at 9 US sites using a standardized case definition. We assessed factors associated with initial antifungal treatment for the first candidemia case among adults using multivariable logistic regression models. To identify instances of potentially inappropriate treatment, we compared the first antifungal drug received with species and antifungal susceptibility testing (AFST) results from initial blood cultures. Results Among 1835 patients who received antifungal treatment, 1258 (68.6%) received an echinocandin and 543 (29.6%) received fluconazole as initial treatment. Cirrhosis (adjusted odds ratio = 2.06; 95% confidence interval, 1.29–3.29) was the only underlying medical condition significantly associated with initial receipt of an echinocandin (versus fluconazole). More than one-half (n = 304, 56.0%) of patients initially treated with fluconazole grew a non-albicans species. Among 265 patients initially treated with fluconazole and with fluconazole AFST results, 28 (10.6%) had a fluconazole-resistant isolate. Conclusions A substantial proportion of patients with candidemia were initially treated with fluconazole, resulting in potentially inappropriate treatment for those involving non-albicans or fluconazole-resistant species. Reasons for nonadherence to IDSA guidelines should be evaluated, and clinician education is needed.

Background Infection prevention (IP) strategies are implemented to limit the transmission of healthcare-associated infections (HAIs), which are estimated to occur in 1 out of 31 hospitalized patients per day in the United States. Carbapenem-resistant Acinetobacter (CRA) cause HAIs classified as an urgent threat by CDC. When carbapenemase-producing CRA (CP-CRA) are identified, containment strategies are implemented, including screening patients at high risk for colonization with CP-CRA. Point prevalence surveys (PPS) are conducted to assist with HAI outbreak investigations and identify colonized patients. Methods Herein, we describe results from culture-based CP-CRA colonization testing of multiple specimen sources (rectal, skin [axilla/groin or groin], respiratory, and/or wound). A total of 744 PPS specimens from 356 patients, across six states, were obtained from February 2019 to May 2021 for CP-CRA colonization screening including 30% (224/744) rectal, 52% (390/744) skin, 10% (73/744) respiratory, and 8% (57/744) wound sources. The specimens were plated onto both non-selective (blood agar) and selective media (MacConkey, ESBL CHROMagar, Acinetobacter CHROMagar), and RT-PCR was performed for detection of the Acinetobacter-specific carbapenemase genes blaOXA-23, blaOXA-24, and blaOXA-58. Results Twelve percent (90/744) of specimens, representing 17% (62/356) of patients, were positive for detection of blaOXA-23 and/or blaOXA-24 CP-CRA. The majority (96%) of CP-CRA harbored blaOXA-24. Of the 62 colonized patients, 52% (32/62) had more than one collection source and 47% (15/32) of those had more than one source positive for CP-CRA. There was no consensus regarding a single source type across positive specimens. However, rectal or skin swab collection alone would potentially miss 2% (4/163) or 8% (14/186) of positive specimens, respectively. Conclusion These data suggest that rectal or skin source collection alone could be sufficient for detection of CP-CRA. Overall, multiple factors should be considered to guide the source(s) for CP-CRA specimen collection, such as infection type, regional prevalence, patient factors, and/or IP gap(s) within a facility. Disclosures All Authors: No reported disclosures

Background Many U.S. clinical laboratories lack capacity to definitively identify fungi or perform antifungal susceptibility testing (AFST). To expand testing access, CDC’s Antibiotic Resistance Laboratory Network (AR Lab Network) provides Candida species identification and AFST to U.S. facilities for clinical and public health purposes. We describe the first three years of Candida AR Lab Network resistance data. Methods Isolates from any body site with species identification and AFST performed July 2016–June 2019 are included. Submissions were based on clinical and public health need. Patients may have multiple isolates. The 7 AR Lab Network regional laboratories used matrix-assisted laser desorption ionization-time of flight (MALDI-TOF) or DNA sequencing for species identification. AFST was performed using broth microdilution for azoles and echinocandins (anidulafungin and micafungin) and Etest for amphotericin B. This analysis focuses on non-albicans Candida species with Clinical and Laboratory Standards Institute M60 minimum inhibitory concentration breakpoints and C. auris, which has CDC-proposed tentative breakpoints. Results Participation increased from healthcare facilities from 2 states submitting in 2016 to 35 states in 2019. Species identification was performed on 5,234 non-albicans isolates. AFST was performed on 4,222 (81%) isolates, including 2,395 C. glabrata, 815 C. auris, 267 C. parapsilosis, 125 C. tropicalis, 35 C. guilliermondii, and 32 C. krusei. Of isolates with AFST and body site indicated, 22% (900/4,102) were from blood. We found 85% of C. auris, 8% of C. glabrata, and 5% of C. parapsilosis isolates were resistant to azoles; 33% of C. auris isolates were resistant to amphotericin B; and 2% of C. glabrata, 1% of C. auris, and 1% of C. parapsilosis isolates were resistant to echinocandins. Although intrinsically resistant to fluconazole, C. krusei isolates were not resistant to voriconazole. Multidrug resistance was present in 32% of C. auris and 1% of C. glabrata isolates. Conclusion AR Lab Network has expanded access to rapid Candida testing, including AFST, and provides real-time surveillance. Results can be used to detect emerging species and resistance and guide public health action and healthcare practices. Disclosures All Authors: No reported disclosures

Background:Candida auris is a globally emerging, multidrug-resistant fungal pathogen that causes healthcare-associated outbreaks and can be misidentified in clinical laboratories. Most US C. auris cases occur in hospitalized or long-term care patients with underlying medical conditions. Also, 4 global phylogenetic C. auris clades largely cluster geographically. Receiving health care abroad is a risk factor for US C. auris cases. In December 2019, the Minnesota Department of Health (MDH) confirmed Minnesota’s first C. auris case, isolated from the external ear canal of a healthy young adult outpatient with right-sided otitis externa. We describe the investigation and response for this uncommon US presentation of C. auris. Methods: The MDH initiated mandatory reporting and submission of confirmed or possible C. auris isolates in August 2019. The MDH Public Health Laboratory (MDH-PHL) confirmed C. auris by MALDI-TOF (Bruker) from an isolate submitted by a hospital laboratory as C. duobushaemulonii to rule out C. auris. The MDH-PHL performed broth microdilution antifungal susceptibility testing (AFST). The CDC Mycotics Diseases Branch laboratory performed whole-genome sequencing (WGS). The MDH epidemiologists obtained a patient history through interviews with healthcare staff and the patient, and they collected environmental samples from otoscopes. The MDH-PHL tested environmental samples by C. auris RT-PCR and culture. The MDH recommended disinfection of examination rooms and otoscopes and 3 months of C. auris surveillance for patients evaluated with otoscopes who later returned with otic inflammation. Swabs from the patient’s axilla, groin, and external ear canals were tested for C. auris by PCR at the MDH-PHL. Results: The patient reported recurrent right ear infections in 2016 during a 16-month visit to South Korea, with treatment in multiple ENT clinics. December 2019 otitis resolved after treatment with oral amoxicillin/clavulanate and otic ciprofloxacin/dexamethasone. AFST showed resistance to fluconozale and susceptibility to 8 antifungals, including echinocandins. WGS placed the isolate in the East Asian clade, indicating similarity to isolates from South Korea and Japan. Environmental cultures were negative. The asymptomatic left ear was colonized with C. auris; other sites were negative. As of January29, 2020, no additional cases were detected. Conclusions: We identified prolonged colonization of C. auris in the external ear canals of a healthy patient. WGS and travel in South Korea, including ENT clinic exposure, provide strong evidence of C. auris acquisition in South Korea. No spread has been reported in Minnesota. Deliberate communication with clinical laboratories regarding ruling out C. auris was key to case discovery. Clinicians should be aware of C. auris epidemiology, including healthcare exposure abroad, particularly in young, healthy patients.Funding: NoneDisclosures: None

Background Multidrug resistant Candida is an increasing concern. C. parapsilosis in particular has decreased in vitro susceptibility to echinocandins. As a result, fluconazole had been favored for C. parapsilosis treatment. However, there is growing concern about increasing azole resistance among Candida species. We report on antifungal susceptibility patterns of C. parapsilosis in the US from 2008 through 2018. Methods Active, population-based surveillance for candidemia through the Centers for Disease Control and Prevention’s (CDC) Emerging Infections Program was conducted between 2008–2018, eventually encompassing 9 states (GA, MD,OR, TN, NY, CA, CO, MN, NM). Each incident isolate was sent to the CDC for species confirmation and antifungal susceptibility testing (AFST). Frequency of resistance was calculated and stratified by year and state using SAS 9.4 Results Of the 8,704 incident candidemia isolates identified, 1,471 (15%) were C. parapsilosis; the third most common species after C. albicans and C. glabrata. AFST results were available for 1,340 C. parapsilosis isolates. No resistance was detected to caspofungin (MIC50 0.25) or micafungin (MIC50 1.00) with only one (< 1%) isolate resistant to anidulafungin (MIC50 1.00). In contrast, 84 (6.3%) isolates were resistant to fluconazole and another 44 (3.3%) isolates had dose-dependent susceptibility to fluconazole (MIC50 1.00). Fluconazole resistance increased sharply from an average of 4% during 2008–2014 to a peak of 14% in 2016 with a subsequent decline to 6% in 2018 (see figure). Regional variation is also observed with fluconazole resistance ranging from 0% (CO, MN, NM) to 42% (NY) of isolates by site. Conclusion The recent marked increase in fluconazole resistance among C. parapsilosis highlights this pathogen as an emerging drug resistant pathogen of concern and the need for ongoing antifungal resistance surveillance among Candida species. Our data support the empiric use of echinocandins for C. parapsilosis bloodstream infections and underscore the need to obtain AFST prior to fluconazole treatment. Furthermore, regional variation in fluconazole resistance emphasizes the importance of understanding local Candida susceptibility patterns. Disclosures Lee Harrison, MD, GSK (Consultant)Merck (Consultant)Pfizer (Consultant)Sanofi Pasteur (Consultant)