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Background Most multicenter studies of US pediatric sepsis epidemiology use administrative data or focus on pediatric intensive care units. We conducted a detailed medical record review to describe sepsis epidemiology in children and young adults. Methods In a convenience sample of hospitals in 10 states, patients aged 30 days–21 years, discharged during 1 October 2014–30 September 2015, with explicit diagnosis codes for severe sepsis or septic shock, were included. Medical records were reviewed for patients with documentation of sepsis, septic shock, or similar terms. We analyzed overall and age group–specific patient characteristics. Results Of 736 patients in 26 hospitals, 442 (60.1%) had underlying conditions. Most patients (613 [83.3%]) had community-onset sepsis, although most community-onset sepsis was healthcare associated (344 [56.1%]). Two hundred forty-one patients (32.7%) had outpatient visits 1–7 days before sepsis hospitalization, of whom 125 (51.9%) received antimicrobials ≤30 days before sepsis hospitalization. Age group–related differences included common underlying conditions ( Conclusions Our data suggest potential opportunities to raise sepsis awareness among outpatient providers to facilitate prevention, early recognition, and intervention in some patients. Consideration of age-specific differences may be important as approaches are developed to improve sepsis prevention, risk prediction, recognition, and management.

The CDC's Emerging Infections Program (EIP) conducted population- and laboratory-based surveillance of US carbapenem-resistant Pseudomonas aeruginosa (CRPA) from 2016 through 2018. To characterize the pathotype, 1,019 isolates collected through this project underwent antimicrobial susceptibility testing and whole-genome sequencing. Sequenced genomes were classified using the seven-gene multilocus sequence typing (MLST) scheme and a core genome (cg)MLST scheme was used to determine phylogeny. Both chromosomal and horizontally transmitted mechanisms of carbapenem resistance were assessed. There were 336 sequence types (STs) among the 1,019 sequenced genomes, and the genomes varied by an average of 84.7% of the cgMLST alleles used. Mutations associated with dysfunction of the porin OprD were found in 888 (87.1%) of the genomes and were correlated with carbapenem resistance, and a machine learning model incorporating hundreds of genetic variations among the chromosomal mechanisms of resistance was able to classify resistant genomes. While only 7 (0.1%) isolates harbored carbapenemase genes, 66 (6.5%) had acquired non-carbapenemase β-lactamase genes, and these were more likely to have OprD dysfunction and be resistant to all carbapenems tested. The genetic diversity demonstrates that the pathotype includes a variety of strains, and clones previously identified as high-risk make up only a minority of CRPA strains in the United States. The increased carbapenem resistance in isolates with acquired non-carbapenemase β-lactamase genes suggests that horizontally transmitted mechanisms aside from carbapenemases themselves may be important drivers of the spread of carbapenem resistance in P. aeruginosa.

Healthcare personnel with severe acute respiratory coronavirus virus 2 (SARS-CoV-2) infection were interviewed to describe activities and practices in and outside the workplace. Among 2,625 healthcare personnel, workplace-related factors that may increase infection risk were more common among nursing-home personnel than hospital personnel, whereas selected factors outside the workplace were more common among hospital personnel.

Background Published bundles to reduce Clostridioides difficile Infection (CDI) frequently lack information on compliance with individual elements. We piloted a computerized clinical decision support-based intervention bundle and conducted detailed evaluation of several intervention-related measures. Methods A quasi-experimental study of a bundled intervention was performed at 2 acute care community hospitals in Maryland. The bundle had five components: (1) timely placement in enteric precautions, (2) appropriate CDI testing, (3) reducing proton-pump inhibitor (PPI) use, (4) reducing high-CDI risk antibiotic use, and (5) optimizing use of a sporicidal agent for environmental cleaning. Chi-square and Kruskal-Wallis tests were used to compare measure differences. An interrupted time series analysis was used to evaluate impact on hospital-onset (HO)-CDI. Results Placement of CDI suspects in enteric precautions before test results did not change. Only hospital B decreased the frequency of CDI testing and reduced inappropriate testing related to laxative use. Both hospitals reduced the use of PPI and high-risk antibiotics. A 75% decrease in HO-CDI immediately postimplementation was observed for hospital B only. Conclusion A CDI reduction bundle showed variable impact on relevant measures. Hospital-specific differential uptake of bundle elements may explain differences in effectiveness, and emphasizes the importance of measuring processes and intermediate outcomes.

In 2014, trained health care provider capacity was insufficient to deliver care to an estimated 70,000 persons in Maryland with chronic hepatitis C virus (HCV) infection. The goal of Maryland Community Based Programs to Test and Cure Hepatitis C, a public health implementation project, was to improve HCV treatment access by expanding the workforce. Sharing the Cure (STC) was a package of services deployed 10/1/14 to 9/30/18 that included enhanced information technology and public health infrastructure, primary care provider training, and practice transformation. Nine primary care sites enrolled. HCV clinical outcomes were documented among individuals who presented for care at sites and met criteria for HCV testing including risk factor or birth cohort (born between 1945 and 1965) based testing. Fifty-three providers completed the STC training. STC providers identified 3,237 HCV antibody positive patients of which 2,624 (81%) were RNA+. Of those HCV RNA+, 1,739 (66%) were staged, 932 (36%) were prescribed treatment, 838 (32%) started treatment, 721 (28%) completed treatment, and 543 (21%) achieved cure. Among 1,739 patients staged, 693 (40%) patients had a liver fibrosis assessment score < F2, rendering them ineligible for treatment under Maryland Medicaid guidelines. HCV RNA testing among HCV antibody positive people increased from 40% (baseline) to 95% amongst STC providers. Of 554 patients with virologic data reported, 543 (98%) achieved cure. Primary care practices can effectively serve as HCV treatment centers to expand treatment access. However, criteria by insurance providers in Maryland was a major barrier to treatment.

Background In the 2011 US hospital prevalence survey of healthcare-associated infections and antimicrobial use 50% of patients received antimicrobial medications on the survey date or day before. More hospitals have since established antimicrobial stewardship programs. We repeated the survey in 2015 to determine antimicrobial use prevalence and describe changes since 2011. Methods The Centers for Disease Control and Prevention’s Emerging Infections Program sites in 10 states each recruited ≤25 general and women’s and children’s hospitals. Hospitals selected a survey date from May–September 2015. Medical records for a random patient sample on the survey date were reviewed to collect data on antimicrobial medications administered on the survey date or day before. Percentages of patients on antimicrobial medications were compared; multivariable log-binomial regression modeling was used to evaluate factors associated with antimicrobial use. Results Of 12 299 patients in 199 hospitals, 6084 (49.5%; 95% CI, 48.6–50.4%) received antimicrobials. Among 148 hospitals in both surveys, overall antimicrobial use prevalence was similar in 2011 and 2015, although the percentage of neonatal critical care patients on antimicrobials was lower in 2015 (22.8% vs 32.0% [2011]; P = .006). Fluoroquinolone use was lower in 2015 (10.1% of patients vs 11.9% [2011]; P < .001). Third- or fourth-generation cephalosporin use was higher (12.2% vs 10.7% [2011]; P = .002), as was carbapenem use (3.7% vs 2.7% [2011]; P < .001). Conclusions Overall hospital antimicrobial use prevalence was not different in 2011 and 2015; however, differences observed in selected patient or antimicrobial groups may provide evidence of stewardship impact.

Background Efforts to prevent Clostridioides difficile infection continue to expand across the health care spectrum in the United States. Whether these efforts are reducing the national bu...

Background: Automated testing instruments (ATIs) are commonly used by clinical microbiology laboratories to perform antimicrobial susceptibility testing (AST), whereas public health laboratories may use established reference methods such as broth microdilution (BMD). We investigated discrepancies in carbapenem minimum inhibitory concentrations (MICs) among Enterobacteriaceae tested by clinical laboratory ATIs and by reference BMD at the CDC. Methods: During 2016–2018, we conducted laboratory- and population-based surveillance for carbapenem-resistant Enterobacteriaceae (CRE) through the CDC Emerging Infections Program (EIP) sites (10 sites by 2018). We defined an incident case as the first isolation of Enterobacter spp (E. cloacae complex or E. aerogenes), Escherichia coli, Klebsiella pneumoniae, K. oxytoca, or K. variicola resistant to doripenem, ertapenem, imipenem, or meropenem from normally sterile sites or urine identified from a resident of the EIP catchment area in a 30-day period. Cases had isolates that were determined to be carbapenem-resistant by clinical laboratory ATI MICs (MicroScan, BD Phoenix, or VITEK 2) or by other methods, using current Clinical and Laboratory Standards Institute (CLSI) criteria. A convenience sample of these isolates was tested by reference BMD at the CDC according to CLSI guidelines. Results: Overall, 1,787 isolates from 112 clinical laboratories were tested by BMD at the CDC. Of these, clinical laboratory ATI MIC results were available for 1,638 (91.7%); 855 (52.2%) from 71 clinical laboratories did not confirm as CRE at the CDC. Nonconfirming isolates were tested on either a MicroScan (235 of 462; 50.9%), BD Phoenix (249 of 411; 60.6%), or VITEK 2 (371 of 765; 48.5%). Lack of confirmation was most common among E. coli (62.2% of E. coli isolates tested) and Enterobacter spp (61.4% of Enterobacter isolates tested) (Fig. 1A), and among isolates testing resistant to ertapenem by the clinical laboratory ATI (52.1%, Fig. 1B). Of the 1,388 isolates resistant to ertapenem in the clinical laboratory, 1,006 (72.5%) were resistant only to ertapenem. Of the 855 nonconfirming isolates, 638 (74.6%) were resistant only to ertapenem based on clinical laboratory ATI MICs. Conclusions: Nonconfirming isolates were widespread across laboratories and ATIs. Lack of confirmation was most common among E. coli and Enterobacter spp. Among nonconfirming isolates, most were resistant only to ertapenem. These findings may suggest that ATIs overcall resistance to ertapenem or that isolate transport and storage conditions affect ertapenem resistance. Further investigation into this lack of confirmation is needed, and CRE case identification in public health surveillance may need to account for this phenomenon.Funding: NoneDisclosures: None

Background: With the emergence of antibiotic resistant threats and the need for appropriate antibiotic use, laboratory microbiology information is important to guide clinical decision making in nursing homes, where access to such data can be limited. Susceptibility data are necessary to inform antibiotic selection and to monitor changes in resistance patterns over time. To contribute to existing data that describe antibiotic resistance among nursing home residents, we summarized antibiotic susceptibility data from organisms commonly isolated from urine cultures collected as part of the CDC multistate, Emerging Infections Program (EIP) nursing home prevalence survey. Methods: In 2017, urine culture and antibiotic susceptibility data for selected organisms were retrospectively collected from nursing home residents’ medical records by trained EIP staff. Urine culture results reported as negative (no growth) or contaminated were excluded. Susceptibility results were recorded as susceptible, non-susceptible (resistant or intermediate), or not tested. The pooled mean percentage tested and percentage non-susceptible were calculated for selected antibiotic agents and classes using available data. Susceptibility data were analyzed for organisms with ≥20 isolates. The definition for multidrug-resistance (MDR) was based on the CDC and European Centre for Disease Prevention and Control’s interim standard definitions. Data were analyzed using SAS v 9.4 software. Results: Among 161 participating nursing homes and 15,276 residents, 300 residents (2.0%) had documentation of a urine culture at the time of the survey, and 229 (76.3%) were positive. Escherichia coli, Proteus mirabilis, Klebsiella spp, and Enterococcus spp represented 73.0% of all urine isolates (N = 278). There were 215 (77.3%) isolates with reported susceptibility data (Fig. 1). Of these, data were analyzed for 187 (87.0%) (Fig. 2). All isolates tested for carbapenems were susceptible. Fluoroquinolone non-susceptibility was most prevalent among E. coli (42.9%) and P. mirabilis (55.9%). Among Klebsiella spp, the highest percentages of non-susceptibility were observed for extended-spectrum cephalosporins and folate pathway inhibitors (25.0% each). Glycopeptide non-susceptibility was 10.0% for Enterococcus spp. The percentage of isolates classified as MDR ranged from 10.1% for E. coli to 14.7% for P. mirabilis. Conclusions: Substantial levels of non-susceptibility were observed for nursing home residents’ urine isolates, with 10% to 56% reported as non-susceptible to the antibiotics assessed. Non-susceptibility was highest for fluoroquinolones, an antibiotic class commonly used in nursing homes, and ≥ 10% of selected isolates were MDR. Our findings reinforce the importance of nursing homes using susceptibility data from laboratory service providers to guide antibiotic prescribing and to monitor levels of resistance.Disclosures: NoneFunding: None

Background: Certain nursing home (NH) resident care tasks have a higher risk for multidrug-resistant organisms (MDRO) transfer to healthcare personnel (HCP), which can result in transmission to residents if HCPs fail to perform recommended infection prevention practices. However, data on HCP-resident interactions are limited and do not account for intrafacility practice variation. Understanding differences in interactions, by HCP role and unit, is important for informing MDRO prevention strategies in NHs. Methods: In 2019, we conducted serial intercept interviews; each HCP was interviewed 6–7 times for the duration of a unit’s dayshift at 20 NHs in 7 states. The next day, staff on a second unit within the facility were interviewed during the dayshift. HCP on 38 units were interviewed to identify healthcare personnel (HCP)–resident care patterns. All unit staff were eligible for interviews, including certified nursing assistants (CNAs), nurses, physical or occupational therapists, physicians, midlevel practitioners, and respiratory therapists. HCP were asked to list which residents they had cared for (within resident rooms or common areas) since the prior interview. Respondents selected from 14 care tasks. We classified units into 1 of 4 types: long-term, mixed, short stay or rehabilitation, or ventilator or skilled nursing. Interactions were classified based on the risk of HCP contamination after task performance. We compared proportions of interactions associated with each HCP role and performed clustered linear regression to determine the effect of unit type and HCP role on the number of unique task types performed per interaction. Results: Intercept-interviews described 7,050 interactions and 13,843 care tasks. Except in ventilator or skilled nursing units, CNAs have the greatest proportion of care interactions (interfacility range, 50%–60%) (Fig. 1). In ventilator and skilled nursing units, interactions are evenly shared between CNAs and nurses (43% and 47%, respectively). On average, CNAs in ventilator and skilled nursing units perform the most unique task types (2.5 task types per interaction, Fig. 2) compared to other unit types (P < .05). Compared to CNAs, most other HCP types had significantly fewer task types (0.6–1.4 task types per interaction, P < .001). Across all facilities, 45.6% of interactions included tasks that were higher-risk for HCP contamination (eg, transferring, wound and device care, Fig. 3). Conclusions: Focusing infection prevention education efforts on CNAs may be most efficient for preventing MDRO transmission within NH because CNAs have the most HCP–resident interactions and complete more tasks per visit. Studies of HCP-resident interactions are critical to improving understanding of transmission mechanisms as well as target MDRO prevention interventions.Funding: Centers for Disease Control and Prevention (grant no. U01CK000555-01-00)Disclosures: Scott Fridkin, consulting fee, vaccine industry (spouse)

Importance Controlling antimicrobial resistance in health care is a public health priority, although data describing antimicrobial use in US nursing homes are limited. Objective To measure the prevalence of antimicrobial use and describe antimicrobial classes and common indications among nursing home residents. Design, Setting, and Participants Cross-sectional, 1-day point-prevalence surveys of antimicrobial use performed between April 2017 and October 2017, last survey date October 31, 2017, and including 15 276 residents present on the survey date in 161 randomly selected nursing homes from selected counties of 10 Emerging Infections Program (EIP) states. EIP staff reviewed nursing home records to collect data on characteristics of residents and antimicrobials administered at the time of the survey. Nursing home characteristics were obtained from nursing home staff and the Nursing Home Compare website. Exposures Residence in one of the participating nursing homes at the time of the survey. Main Outcomes and Measures Prevalence of antimicrobial use per 100 residents, defined as the number of residents receiving antimicrobial drugs at the time of the survey divided by the total number of surveyed residents. Multivariable logistic regression modeling of antimicrobial use and percentages of drugs within various classifications. Results Among 15 276 nursing home residents included in the study (mean [SD] age, 77.6 [13.7] years; 9475 [62%] women), complete prevalence data were available for 96.8%. The overall antimicrobial use prevalence was 8.2 per 100 residents (95% CI, 7.8-8.8). Antimicrobial use was more prevalent in residents admitted to the nursing home within 30 days before the survey date (18.8 per 100 residents; 95% CI, 17.4-20.3), with central venous catheters (62.8 per 100 residents; 95% CI, 56.9-68.3) or with indwelling urinary catheters (19.1 per 100 residents; 95% CI, 16.4-22.0). Antimicrobials were most often used to treat active infections (77% [95% CI, 74.8%-79.2%]) and primarily for urinary tract infections (28.1% [95% CI, 15.5%-30.7%]). While 18.2% (95% CI, 16.1%-20.1%) were for medical prophylaxis, most often use was for the urinary tract (40.8% [95% CI, 34.8%-47.1%]). Fluoroquinolones were the most common antimicrobial class (12.9% [95% CI, 11.3%-14.8%]), and 33.1% (95% CI, 30.7%-35.6%) of antimicrobials used were broad-spectrum antibiotics. Conclusions and Relevance In this cross-sectional survey of a cohort of US nursing homes in 2017, prevalence of antimicrobial use was 8.2 per 100 residents. This study provides information on the patterns of antimicrobial use among these nursing home residents.

Heteroresistance is an underappreciated phenomenon that may be the cause of some unexplained antibiotic treatment failures. Misclassification of heteroresistant isolates as susceptible may lead to inappropriate therapy., Heteroresistance is a form of antibiotic resistance where a bacterial strain is comprised of a minor resistant subpopulation and a majority susceptible subpopulation. We showed previously that colistin heteroresistance can mediate the failure of colistin therapy in an in vivo infection model, even for isolates designated susceptible by clinical diagnostics. We sought to characterize the extent of colistin heteroresistance among the highly drug-resistant carbapenem-resistant Enterobacterales (CRE). We screened 408 isolates for colistin heteroresistance. These isolates were collected between 2012 and 2015 in eight U.S. states as part of active surveillance for CRE. Colistin heteroresistance was detected in 10.1% (41/408) of isolates, and it was more common than conventional homogenous resistance (7.1%, 29/408). Most (93.2%, 38/41) of these heteroresistant isolates were classified as colistin susceptible by standard clinical diagnostic testing. The frequency of colistin heteroresistance was greatest in 2015, the last year of the study. This was especially true among Enterobacter isolates, of which specific species had the highest rates of heteroresistance. Among Klebsiella pneumoniae isolates, which were the majority of isolates tested, there was a closely related cluster of colistin-heteroresistant ST-258 isolates found mostly in Georgia. However, cladistic analysis revealed that, overall, there was significant diversity in the genetic backgrounds of heteroresistant K. pneumoniae isolates. These findings suggest that due to being largely undetected in the clinic, colistin heteroresistance among CRE is underappreciated in the United States.

Acute change in mental status (ACMS), defined by the Confusion Assessment Method, is used to identify infections in nursing home residents. A medical record review revealed that none of 15,276 residents had an ACMS documented. Using the revised McGeer criteria with a possible ACMS definition, we identified 296 residents and 21 additional infections. The use of a possible ACMS definition should be considered for retrospective nursing home infection surveillance.

BACKGROUND: Efforts to prevent Clostridioides difficile infection continue to expand across the health care spectrum in the United States. Whether these efforts are reducing the national burden of C. difficile infection is unclear. METHODS: The Emerging Infections Program identified cases of C. difficile infection (stool specimens positive for C. difficile in a person ≥1 year of age with no positive test in the previous 8 weeks) in 10 U.S. sites. We used case and census sampling weights to estimate the national burden of C. difficile infection, first recurrences, hospitalizations, and in-hospital deaths from 2011 through 2017. Health care–associated infections were defined as those with onset in a health care facility or associated with recent admission to a health care facility; all others were classified as community-associated infections. For trend analyses, we used weighted random-intercept models with negative binomial distribution and logistic-regression models to adjust for the higher sensitivity of nucleic acid amplification tests (NAATs) as compared with other test types. RESULTS: The number of cases of C. difficile infection in the 10 U.S. sites was 15,461 in 2011 (10,177 health care–associated and 5284 community-associated cases) and 15,512 in 2017 (7973 health care–associated and 7539 community-associated cases). The estimated national burden of C. difficile infection was 476,400 cases (95% confidence interval [CI], 419,900 to 532,900) in 2011 and 462,100 cases (95% CI, 428,600 to 495,600) in 2017. With accounting for NAAT use, the adjusted estimate of the total burden of C. difficile infection decreased by 24% (95% CI, 6 to 36) from 2011 through 2017; the adjusted estimate of the national burden of health care–associated C. difficile infection decreased by 36% (95% CI, 24 to 54), whereas the adjusted estimate of the national burden of community-associated C. difficile infection was unchanged. The adjusted estimate of the burden of hospitalizations for C. difficile infection decreased by 24% (95% CI, 0 to 48), whereas the adjusted estimates of the burden of first recurrences and in-hospital deaths did not change significantly. CONCLUSIONS: The estimated national burden of C. difficile infection and associated hospitalizations decreased from 2011 through 2017, owing to a decline in health care–associated infections. (Funded by the Centers for Disease Control and Prevention.)

In healthcare settings, Acinetobacter spp. bacteria commonly demonstrate antimicrobial resistance, making them a major treatment challenge. Nearly half of Acinetobacter organisms from clinical cultures in the United States are nonsusceptible to carbapenem antimicrobial drugs. During 2012-2015, we conducted laboratory- and population-based surveillance in selected metropolitan areas in Colorado, Georgia, Maryland, Minnesota, New Mexico, New York, Oregon, and Tennessee to determine the incidence of carbapenem-nonsusceptible A. baumannii cultured from urine or normally sterile sites and to describe the demographic and clinical characteristics of patients and cases. We identified 621 cases in 537 patients; crude annual incidence was 1.2 cases/100,000 persons. Among 598 cases for which complete data were available, 528 (88.3%) occurred among patients with exposure to a healthcare facility during the preceding year; 506 (84.6%) patients had an indwelling device. Although incidence was lower than for other healthcare-associated pathogens, cases were associated with substantial illness and death.

A Pseudomonas aeruginosa outbreak was investigated in a neonatal intensive care unit that had experienced a prior similar outbreak. The 8 cases identified included 2 deaths. An investigation found the cause of the outbreak: tap water from contaminated hospital plumbing which was used for humidifier reservoirs, neonatal bathing, and nutritional preparation. Our findings reinforce a recent Centers for Medicare & Medicaid Services memo recommending increased attention to water management to improve awareness, identification, mitigation, and prevention of water-associated, health care-associated infections.

Cyclic multiredox centered systems are currently of great interest, with new compounds being reported and developments made in understanding their behavior. Efficient, elegant, and high-yielding (for macrocyclic species) synthetic routes to two novel alkynyl-conjugated multiple ferrocene- and biferrocene-containing cyclic compounds are presented. The electronic interactions between the individual ferrocene units have been investigated through electrochemistry, spectroelectrochemistry, density functional theory (DFT), and crystallography to understand the effect of cyclization on the electronic properties and structure. published

Background Interventions to reduce community-onset (CO) Clostridioides difficile Infection (CDI) are not usually hospital-based due to the perception that they are often acquired outside the hospital. We determined the proportion of admitted CO CDI that might be associated with previous hospitalization. Methods The CDC’s Emerging Infections Program conducts population-based CDI surveillance in 10 US sites. We defined an incident case as a C. difficile-positive stool collected in 2017 from a person aged ≥ 1 year admitted to a hospital with no positive tests in the prior 8 weeks. Cases were defined as CO if stool was collected within 3 days of hospitalization. CO cases were classified into four categories: long-term care facility (LTCF)-onset if patient was admitted from an LTCF; long-term acute care hospital (LTACH)-onset if patient was admitted from an LTACH; CO-healthcare-facility associated (CO-HCFA) if patient was admitted from a private residence but had a prior healthcare-facility admission in the past 12 weeks; or community-associated (CA) if there was no admission to a healthcare facility in the prior 12 weeks. We excluded hospitals with < 10 cases among admitted catchment-area residents. Results Of 4724 cases in 86 hospitals, 2984 (63.2%) were CO (median per hospital: 65.8%; interquartile range [IQR]: 58.3%-70.7%). Among the CO cases, 1424 (47.7%) were CA (median per hospital: 48.1%; IQR: 40.3%-57.7%), 1201 (40.3%) were CO-HCFA (median per hospital: 41.0%; IQR: 32.9%-47.8%), 350 (11.7%) were LTCF-onset (median per hospital: 10.0%; IQR: 0.6%-14.4%), and 9 (0.3%) were LTACH-onset. Of 1201 CO-HCFA cases, 1174 (97.8%) had a prior hospitalization; among these, 978 (83.3%) (median per hospital: 83.3%; IQR: 69.2%-90.6%), which consists of 32.8% of all hospitalized CO cases, had been discharged from the same hospital (Figure), and 84.4% of the 978 cases (median per hospital: 88.2%: IQR: 76.5%-100.0%) had received antibiotics sometime in the prior 12 weeks. Figure. Frequency of Cases Discharged in the 12 Weeks Prior to Readmission with Clostridioides difficile Infection (N=1138*) Conclusion A third of hospitalized CO CDI had been recently discharged from the same hospital, and most had received antibiotics during or soon after the last admission. Hospital-based and post-discharge antibiotic stewardship interventions could help reduce subsequent CDI hospitalizations. Disclosures Ghinwa Dumyati, MD, Roche Diagnostics (Consultant)

Background: With an aging population, increasingly complex care, and frequent re-admissions, prevention of healthcare-associated infections (HAIs) in nursing homes (NHs) is a federal priority. However, few contemporary sources of HAI data exist to inform surveillance, prevention, and policy. Prevalence surveys (PSs) are an efficient approach to generating data to measure the burden and describe the types of HAI. In 2017, the Centers for Disease Control and Prevention (CDC) performed its first large-scale HAI PS through the Emerging Infections Program (EIP) to measure the prevalence and describe the epidemiology of HAI in NH residents. Methods: NHs from several states (CA, CO, CT, GA, MD, MN, NM, NY, OR, & TN) were randomly selected and asked to participate in a 1-day HAI PS between April and October 2017; participation was voluntary. EIP staff reviewed available medical records for NH residents present on the survey date to collect demographic and basic clinical information and infection signs and symptoms. HAIs with onset on or after NH day 3 were identified using revised McGeer infection definitions applied to data collected by EIP staff and were reported to the CDC through a web-based system. Data were reviewed by CDC staff for potential errors and to validate HAI classifications prior to analysis. HAI prevalence, number of residents with >1 HAI per number of surveyed residents ×100, and 95% CIs were calculated overall (pooled mean) and for selected resident characteristics. Data were analyzed using SAS v9.4 software. Results: Among 15,296 residents in 161 NHs, 358 residents with 375 HAIs were identified. The most common HAI sites were skin (32%), respiratory tract (29%), and urinary tract (20%). Cellulitis, soft-tissue or wound infection, symptomatic UTI, and cold or pharyngitis were the most common individual HAIs (Fig. 1). Overall HAI prevalence was 2.3 per 100 residents (95% CI, 2.1–2.6); at the NH level, the median HAI prevalence was 1.8 and ranged from 0 to 14.3 (interquartile range, 0–3.1). At the resident level (Fig. 2), HAI prevalence was significantly higher in persons admitted for postacute care with diabetes, with a pressure ulcer, receiving wound care, or with a device. Conclusions: In this large-scale survey, 1 in 43 NH residents had an HAI on a given day. Three HAI types comprised >80% of infections. In addition to identifying characteristics that place residents at higher risk for HAIs, these findings provide important data on HAI epidemiology in NHs that can be used to expand HAI surveillance and inform prevention policies and practices.Funding: NoneDisclosures: None

Background: Antibiotics are among the most commonly prescribed drugs in nursing homes; urinary tract infections (UTIs) are a frequent indication. Although there is no gold standard for the diagnosis of UTIs, various criteria have been developed to inform and standardize nursing home prescribing decisions, with the goal of reducing unnecessary antibiotic prescribing. Using different published criteria designed to guide decisions on initiating treatment of UTIs (ie, symptomatic, catheter-associated, and uncomplicated cystitis), our objective was to assess the appropriateness of antibiotic prescribing among NH residents. Methods: In 2017, the CDC Emerging Infections Program (EIP) performed a prevalence survey of healthcare-associated infections and antibiotic use in 161 nursing homes from 10 states: California, Colorado, Connecticut, Georgia, Maryland, Minnesota, New Mexico, New York, Oregon, and Tennessee. EIP staff reviewed resident medical records to collect demographic and clinical information, infection signs, symptoms, and diagnostic testing documented on the day an antibiotic was initiated and 6 days prior. We applied 4 criteria to determine whether initiation of treatment for UTI was supported: (1) the Loeb minimum clinical criteria (Loeb); (2) the Suspected UTI Situation, Background, Assessment, and Recommendation tool (UTI SBAR tool); (3) adaptation of Infectious Diseases Society of America UTI treatment guidelines for nursing home residents (Crnich & Drinka); and (4) diagnostic criteria for uncomplicated cystitis (cystitis consensus) (Fig. 1). We calculated the percentage of residents for whom initiating UTI treatment was appropriate by these criteria. Results: Of 248 residents for whom UTI treatment was initiated in the nursing home, the median age was 79 years [IQR, 19], 63% were female, and 35% were admitted for postacute care. There was substantial variability in the percentage of residents with antibiotic initiation classified as appropriate by each of the criteria, ranging from 8% for the cystitis consensus, to 27% for Loeb, to 33% for the UTI SBAR tool, to 51% for Crnich and Drinka (Fig. 2). Conclusions: Appropriate initiation of UTI treatment among nursing home residents remained low regardless of criteria used. At best only half of antibiotic treatment met published prescribing criteria. Although insufficient documentation of infection signs, symptoms and testing may have contributed to the low percentages observed, adequate documentation in the medical record to support prescribing should be standard practice, as outlined in the CDC Core Elements of Antibiotic Stewardship for nursing homes. Standardized UTI prescribing criteria should be incorporated into nursing home stewardship activities to improve the assessment and documentation of symptomatic UTI and to reduce inappropriate antibiotic use.Funding: NoneDisclosures: None

Background: Carbapenem-resistant Pseudomonas aeruginosa (CRPA) is a frequent cause of healthcare-associated infections (HAIs). The CDC Emerging Infections Program (EIP) conducted population and laboratory-based surveillance of CRPA in selected areas in 8 states from August 1, 2016, through July 31, 2018. We aimed to describe the molecular epidemiology and mechanisms of resistance of CRPA isolates collected through this surveillance. Methods: We defined a case as the first isolate of P. aeruginosa resistant to imipenem, meropenem, or doripenem from the lower respiratory tract, urine, wounds, or normally sterile sites identified from a resident of the EIP catchment area in a 30-day period; EIP sites submitted a systematic random sample of isolates to CDC for further characterization. Of 1,021 CRPA clinical isolates submitted, 707 have been sequenced to date using an Illumina MiSeq. Sequenced genomes were classified using the 7-gene multilocus sequence typing (MLST) scheme, and a core genome MLST (cgMLST) scheme was used to determine phylogeny. Antimicrobial resistance genes were identified using publicly available databases, and chromosomal mechanisms of carbapenem resistance were determined using previously validated genetic markers. Results: There were 189 sequence types (STs) among the 707 sequenced genomes (Fig. 1). The most frequently occurring were high-risk clones ST235 (8.5%) and ST298 (4.7%), which were found across all EIP sites. Carbapenemase genes were identified in 5 (ampC. More than 1 such chromosomal resistance mutation type was present in 37.8% of the isolates. Conclusions: The diversity of the sequence types demonstrates that HAIs caused by CRPA can arise from a variety of strains and that high-risk clones are broadly disseminated across the EIP sites but are a minority of CRPA strains overall. Carbapenem resistance in P. aeruginosa was predominantly driven by chromosomal mutations rather than acquired mechanisms (ie, carbapenemases). The diversity of the CRPA isolates and the lack of carbapenemase genes suggest that this ubiquitous pathogen can readily evolve chromosomal resistance mechanisms, but unlike carbapenemases, these cannot be easily spread through horizontal transfer.Funding: NoneDisclosures: None

During 2011-2015, the adjusted long-term-care facility onset Clostridium difficile infection incidence rate in persons aged ≥65 years decreased annually by 17.45% (95% confidence interval, 14.53%-20.43%) across 10 US sites. A concomitant decline in inpatient fluoroquinolone use and the C difficile epidemic strain NAP1/027 among persons aged ≥65 years may have contributed to the decrease in long-term-care facility-onset C difficile infection incidence rate.

Background Few data suggest that Clostridioides difficile infections (CDIs) detected by toxin enzyme immunoassay (EIA) are more severe and have worse outcomes than those detected by nucleic acid amplification tests (NAATs) only. We compared toxin- positive and NAAT-positive-only CDI across geographically diverse sites. Methods A case was defined as a positive C. difficile test in a person ≥1 year old with no positive tests in the prior 8 weeks. Cases were detected during 2014–2015 by a testing algorithm (specimens initially tested by glutamate dehydrogenase and toxin EIA; if discordant results, specimens were reflexed to NAAT) and classified as toxin positive or NAAT positive only. Medical charts were reviewed. Multivariable logistic regression models were used to compare CDI-related complications, recurrence, and 30-day mortality between the 2 groups. Results Of 4878 cases, 2160 (44.3%) were toxin positive and 2718 (55.7%) were NAAT positive only. More toxin-positive than NAAT-positive-only cases were aged ≥65 years (48.2% vs 38.0%; P < .0001), had ≥3 unformed stools for ≥1 day (43.9% vs 36.6%; P < .0001), and had white blood cell counts ≥15 000 cells/µL (31.4% vs 21.4%; P < .0001). In multivariable analysis, toxin positivity was associated with recurrence (adjusted odds ratio [aOR], 1.89; 95% confidence interval [CI], 1.61–2.23), but not with CDI-related complications (aOR, 0.91; 95% CI, .67–1.23) or 30-day mortality (aOR, 0.95; 95% CI, .73–1.24). Conclusions Toxin-positive CDI is more severe, but there were no differences in adjusted CDI-related complication and mortality rates between toxin-positive and NAAT-positive-only CDI that were detected by an algorithm that utilized an initial glutamate dehydrogenase screening test.

Objectives Describe antibiotic use for urinary tract infection (UTI) among a large cohort of US nursing home residents. Design Analysis of data from a multistate, 1-day point prevalence survey of antimicrobial use performed between April and October 2017. Setting and participants Residents of 161 nursing homes in 10 US states of the Emerging Infections Program (EIP). Methods EIP staff reviewed nursing home medical records to collect data on systemic antimicrobial drugs received by residents, including therapeutic site, rationale for use, and planned duration. For drugs with the therapeutic site documented as urinary tract, pooled mean and nursing home–specific prevalence rates were calculated per 100 nursing home residents, and proportion of drugs by selected characteristics were reported. Data were analyzed in SAS, version 9.4. Results Among 15,276 residents, 407 received 424 antibiotics for UTI. The pooled mean prevalence rate of antibiotic use for UTI was 2.66 per 100 residents; nursing home–specific rates ranged from 0 to 13.6. One-quarter of antibiotics were prescribed for UTI prophylaxis, with a median planned duration of 111 days compared with 7 days when prescribed for UTI treatment (P Conclusions and Implications One in 38 residents was receiving an antibiotic for UTI on a given day, and nursing home–specific prevalence rates varied by more than 10-fold. UTI prophylaxis was common with a long planned duration, despite limited evidence to support this practice among older persons in nursing homes. The planned duration was ≥7 days for half of antibiotics prescribed for treatment of a UTI. Fluoroquinolones were the most commonly used antibiotics, despite their association with significant adverse events, particularly in a frail and older adult population. These findings help to identify priority practices for nursing home antibiotic stewardship.

A series of palladium complexes bearing ferrocene substituted α-diimine ligands was synthesized and investigated for ethene polymerization at different conditions to modulate the extent of “chain-walking” mechanism and regulate branching and topology of resulting polyethylenes. All ferrocene substituted complexes catalyzed living/controlled ethene polymerization. The ability of ferrocene substituted palladium complexes to provide polyethylenes with dendritic topology was proved by measuring their Mark-Houwink plots. In-situ chemical oxidation of ferrocene moieties via silver triflate was used to affect the catalyst electronic structure and support the “chain-walking” mechanism. Oxidation of palladium catalyst led to its destabilization while the catalytic activity of newly formed sites was substantially increased. It was demonstrated that catalyst oxidation is a powerful tool to regulate the topology of resulting polyethylenes.

The majority of paediatric Clostridioides difficile infections (CDI) are community-associated (CA), but few data exist regarding associated risk factors. We conducted a case–control study to evaluate CA-CDI risk factors in young children. Participants were enrolled from eight US sites during October 2014–February 2016. Case-patients were defined as children aged 1–5 years with a positive C. difficile specimen collected as an outpatient or ⩽3 days of hospital admission, who had no healthcare facility admission in the prior 12 weeks and no history of CDI. Each case-patient was matched to one control. Caregivers were interviewed regarding relevant exposures. Multivariable conditional logistic regression was performed. Of 68 pairs, 44.1% were female. More case-patients than controls had a comorbidity (33.3% vs. 12.1%; P = 0.01); recent higher-risk outpatient exposures (34.9% vs. 17.7%; P = 0.03); recent antibiotic use (54.4% vs. 19.4%; P < 0.0001); or recent exposure to a household member with diarrhoea (41.3% vs. 21.5%; P = 0.04). In multivariable analysis, antibiotic exposure in the preceding 12 weeks was significantly associated with CA-CDI (adjusted matched odds ratio, 6.25; 95% CI 2.18–17.96). Improved antibiotic prescribing might reduce CA-CDI in this population. Further evaluation of the potential role of outpatient healthcare and household exposures in C. difficile transmission is needed.

Importance Hospital antimicrobial consumption data are widely available; however, large-scale assessments of the quality of antimicrobial use in US hospitals are limited. Objective To evaluate the appropriateness of antimicrobial use for hospitalized patients treated for community-acquired pneumonia (CAP) or urinary tract infection (UTI) present at admission or for patients who had received fluoroquinolone or intravenous vancomycin treatment. Design, Setting, and Participants This cross-sectional study included data from a prevalence survey of hospitalized patients in 10 Emerging Infections Program sites. Random samples of inpatients on hospital survey dates from May 1 to September 30, 2015, were identified. Medical record data were collected for eligible patients with 1 or more of 4 treatment events (CAP, UTI, fluoroquinolone treatment, or vancomycin treatment), which were selected on the basis of common infection types reported and antimicrobials given to patients in the prevalence survey. Data were analyzed from August 1, 2017, to May 31, 2020. Exposure Antimicrobial treatment for CAP or UTI or with fluoroquinolones or vancomycin. Main Outcomes and Measures The percentage of antimicrobial use that was supported by medical record data (including infection signs and symptoms, microbiology test results, and antimicrobial treatment duration) or for which some aspect of use was unsupported. Unsupported antimicrobial use was defined as (1) use of antimicrobials to which the pathogen was not susceptible, use in the absence of documented infection signs or symptoms, or use without supporting microbiologic data; (2) use of antimicrobials that deviated from recommended guidelines; or (3) use that exceeded the recommended duration. Results Of 12 299 patients, 1566 patients (12.7%) in 192 hospitals were included; the median age was 67 years (interquartile range, 53-79 years), and 864 (55.2%) were female. A total of 219 patients (14.0%) were included in the CAP analysis, 452 (28.9%) in the UTI analysis, 550 (35.1%) in the fluoroquinolone analysis, and 403 (25.7%) in the vancomycin analysis; 58 patients (3.7%) were included in both fluoroquinolone and vancomycin analyses. Overall, treatment was unsupported for 876 of 1566 patients (55.9%; 95% CI, 53.5%-58.4%): 110 of 403 (27.3%) who received vancomycin, 256 of 550 (46.5%) who received fluoroquinolones, 347 of 452 (76.8%) with a diagnosis of UTI, and 174 of 219 (79.5%) with a diagnosis of CAP. Among patients with unsupported treatment, common reasons included excessive duration (103 of 174 patients with CAP [59.2%]) and lack of documented infection signs or symptoms (174 of 347 patients with UTI [50.1%]). Conclusions and Relevance The findings suggest that standardized assessments of hospital antimicrobial prescribing quality can be used to estimate the appropriateness of antimicrobial use in large groups of hospitals. These assessments, performed over time, may inform evaluations of the effects of antimicrobial stewardship initiatives nationally.

In the modern era of carefully monitored renovations, construction-relatedAspergillusoutbreaks have decreased. We investigated an increase in clinical cultures growingAspergillusspecies, determining that contamination of the mycology lab caused a pseudo-outbreak. A major construction site was appropriately sealed, but unrecognized staff traffic may have facilitated laboratory contamination.Infect Control Hosp Epidemiol2016;1–4

Key Points Question What types of health care exposures occur during the 30 days before hospitalization of a patient with sepsis or septic shock, and how common are these exposures? Findings In this cohort study of 1078 US adults with sepsis and septic shock across 10 states, most patients experienced sepsis onset outside of the hospital, had recent encounters with the health care system, and had a sepsis-associated pathogen documented; 42% of patients received antimicrobial drugs, chemotherapy, wound care, dialysis, or surgery in the 30 days before sepsis occurred. After controlling for other factors, an association was found between underlying comorbidities, such as cirrhosis, immunosuppression, and vascular disease, and 30-day mortality. Meaning The findings suggest that future efforts to improve outcomes among patients with sepsis and septic shock would benefit from examination of health maintenance practices and recent health care exposures as potential opportunities among high-risk patients., Importance Current information on the characteristics of patients who develop sepsis may help in identifying opportunities to improve outcomes. Most recent studies of sepsis epidemiology have focused on changes in incidence or have used administrative data sets that provided limited patient-level data. Objective To describe sepsis epidemiology in adults. Design, Setting, and Participants This retrospective cohort study reviewed the medical records, death certificates, and hospital discharge data of adult patients with sepsis or septic shock who were discharged from the hospital between October 1, 2014, and September 30, 2015. The convenience sample was obtained from hospitals in the Centers for Disease Control and Prevention Emerging Infections Program in 10 states (California, Colorado, Connecticut, Georgia, Maryland, Minnesota, New Mexico, New York, Oregon, and Tennessee). Patients 18 years and older with discharge diagnosis codes for severe sepsis or septic shock were randomly selected. Data were analyzed between May 1, 2018, and January 31, 2019. Main Outcomes and Measures The population’s demographic characteristics, health care exposures, and sepsis-associated infections and pathogens were described, and risk factors for death within 30 days after sepsis diagnosis were assessed. Results Among 1078 adult patients with sepsis (569 men [52.8%]; median age, 64 years [interquartile range, 53-75 years]), 973 patients (90.3%) were classified as having community-onset sepsis (ie, sepsis diagnosed within 3 days of hospital admission). In total, 654 patients (60.7%) had health care exposures before their hospital admission for sepsis; 260 patients (24.1%) had outpatient encounters in the 7 days before admission, and 447 patients (41.5%) received medical treatment, including antimicrobial drugs, chemotherapy, wound care, dialysis, or surgery, in the 30 days before admission. A pathogen associated with sepsis was found in 613 patients (56.9%); the most common pathogens identified were Escherichia coli, Staphylococcus aureus, Klebsiella pneumoniae, and Clostridioides difficile. After controlling for other factors, an association was found between underlying comorbidities, such as cirrhosis (odds ratio, 3.59; 95% CI, 2.03-6.32), immunosuppression (odds ratio, 2.52; 95% CI, 1.81-3.52), vascular disease (odds ratio, 1.54; 95% CI, 1.10-2.15), and 30-day mortality. Conclusions and Relevance Most adults experienced sepsis onset outside of the hospital and had recent encounters with the health care system. A sepsis-associated pathogen was identified in more than half of patients. Future efforts to improve sepsis outcomes may benefit from examination of health maintenance practices and recent health care exposures as potential opportunities among high-risk patients., This cohort study uses medical records, death certificates, and hospital discharge data to describe health care exposures and outcomes among adult patients with sepsis and septic shock.

Infectious Diseases Society of America/Society for Healthcare Epidemiology of America (IDSA/SHEA) guidelines describe recommended therapy for Clostridioides difficile infection (CDI). To describe CDI treatment and, among those with severe CDI, determine predictors of adherence to the 2010 IDSA/SHEA treatment guidelines. We analyzed 2013–2015 CDI treatment data collected through the Centers for Disease Control and Prevention’s Emerging Infections Program. Generalized linear mixed models were used to identify predictors of guideline-adherent therapy. A CDI case was defined as a positive stool specimen in a person aged ≥ 18 years without a positive test in the prior 8 weeks; severe CDI cases were defined as having a white blood cell count ≥ 15,000 cells/μl. Prescribing and predictors of guideline-adherent CDI therapy for severe disease. Of 18,243 cases, 14,257 (78%) were treated with metronidazole, 7683 (42%) with vancomycin, and 313 (2%) with fidaxomicin. The median duration of therapy was 14 (interquartile range, 11–15) days. Severe CDI was identified in 3250 (18%) cases; of 3121 with treatment data available, 1480 (47%) were prescribed guideline-adherent therapy. Among severe CDI cases, hospital admission (adjusted odds ratio [aOR] 2.48; 95% confidence interval [CI] 1.90, 3.24), age ≥ 65 years (aOR 1.37; 95% CI 1.10, 1.71), Charlson comorbidity index ≥ 3 (aOR 1.27; 95% CI 1.04, 1.55), immunosuppressive therapy (aOR 1.21; 95% CI 1.02, 1.42), and inflammatory bowel disease (aOR 1.56; 95% CI 1.13, 2.17) were associated with being prescribed guideline-adherent therapy. Provider adherence to the 2010 treatment guidelines for severe CDI was low. Although the updated 2017 CDI guidelines, which expand the use of oral vancomycin for all CDI, might improve adherence by removing the need to apply severity criteria, other efforts to improve adherence are likely needed, including educating providers and addressing barriers to prescribing guideline-adherent therapy, particularly in outpatient settings.

BACKGROUND: A point-prevalence survey that was conducted in the United States in 2011 showed that 4% of hospitalized patients had a health care–associated infection. We repeated the survey in 2015 to assess changes in the prevalence of health care–associated infections during a period of national attention to the prevention of such infections. METHODS: At Emerging Infections Program sites in 10 states, we recruited up to 25 hospitals in each site area, prioritizing hospitals that had participated in the 2011 survey. Each hospital selected 1 day on which a random sample of patients was identified for assessment. Trained staff reviewed medical records using the 2011 definitions of health care–associated infections. We compared the percentages of patients with health care–associated infections and performed multivariable log-binomial regression modeling to evaluate the association of survey year with the risk of health care–associated infections. RESULTS: In 2015, a total of 12,299 patients in 199 hospitals were surveyed, as compared with 11,282 patients in 183 hospitals in 2011. Fewer patients had health care–associated infections in 2015 (394 patients [3.2%; 95% confidence interval {CI}, 2.9 to 3.5]) than in 2011 (452 [4.0%; 95% CI, 3.7 to 4.4]) (P

Ferrocenediyl systems offer a motif that incorporates multiple functionality and redox-active centers, enabling these units to be used as molecular scaffolds in linear and cyclic compounds. Herein, we discuss a new modular methodology for the synthesis and incorporation of ferrocenediyl motifs within extended conjugated systems. We have synthesized a family of compounds featuring ferrocenediyl-ethynyl units with various para-substituted aromatic linkages. Extended linear, open-chain species have been isolated and understanding towards the analogous cyclic compounds gained. The new compounds have been probed using NMR, mass spectrometry, cyclic voltammetry and X-ray crystallography to gain further understanding of their structural and electronic properties.

Background Clostridium difficile infection (CDI) is associated with significant morbidity and mortality. Computerized clinical decision support (CCDS) tools can aid process improvement in infection prevention and antibiotic stewardship, but implementation and health care workers (HCWs) uptake of these tools is often variable. The objective of this study was to describe HCWs' perceptions of barriers and facilitators related to uptake of CCDS tools as part of a CDI reduction bundle. Methods We conducted a qualitative study among HCWs at 2 acute care hospitals in Maryland. Semi-structured interviews and structured surveys were completed by HCWs to evaluate their perception to CCDS tools at 2 different stages: predevelopment and preimplementation. Emergent themes and patterns in the data were identified and condensed. Results Gaps in CDI-related knowledge and in communication between HCWs were identified throughout the evaluation. HCWs agreed on the potential of the tools to improve CDI diagnosis, prevention, and control. An important barrier for uptake was the perceived loss of autonomy and clinical judgment, whereas standardization and error reduction were perceived advantages. Conclusions These observations shaped the development and implementation of the CDI reduction bundle. Qualitative findings can provide valuable contextual information during the development stages of CCDS tools in infection prevention and antibiotic stewardship.

Background Despite overall progress in preventing Clostridioides difficile Infection (CDI), community-associated (CA) infections have been steadily increasing. Although the incubation period of CDI is thought to be relatively short, gastrointestinal microbial disruption from remote healthcare exposures (e.g., inpatient antibiotic use) may be associated with CA-CDI. To assess this potential association, we linked CA-CDI infections identified through CDC’s Emerging Infections Program (EIP) to Medicare claims data to describe prior healthcare utilization. Methods We defined an EIP CA-CDI case as a positive C. difficile test collected in 2014–2015 from an outpatient or inpatient within 3 days of hospital admission, provided there was no positive test in the prior 8 weeks and no admission to a healthcare facility in the prior 12 weeks. We linked EIP CA-CDI cases aged ≥65 years to a Medicare beneficiary using unique combinations of birthdate, sex, and zip code. Cases were included if they maintained continuous fee-for-service coverage for 1 year prior to the event date. To calculate exposure odds ratios for previous hospitalizations, each case was matched to 5 control beneficiaries on age, sex, and county of residence. We used logistic regression to calculate adjusted matched odds ratios (amOR) that controlled for chronic conditions. Results We successfully linked 2,287/3,367 (68%) EIP CA-CDI cases. Of these, 1,236 cases met inclusion criteria; the median age was 77 years and 63% were female. We identified 69 (5.6%) cases with misclassification of prior healthcare exposures, most of whom (48, 70%) were hospitalized in the 12 weeks prior to their event. Among the 1,167 true CA-CDI cases, 33% were hospitalized in the prior 12 weeks to 1 year. The median number of weeks from prior hospitalization to CDI was 27 (IQR 18–38, Figure 1). Cases had a higher risk of hospitalization than matched controls in the prior 3–6 months (amOR: 2.33, 95% CI: 1.87, 2.90) and 6–12 months (amOR: 1.43 95% CI: 1.18, 1.74). Conclusion Remote hospitalization in the previous year was a significant risk factor for CA-CDI, especially in the 3–6 months prior to CA-CDI. Long-lasting prevention strategies implemented at hospital discharge and enhanced inpatient antibiotic stewardship may prevent CA-CDI among older adults. Disclosures All Authors: No reported Disclosures.

A new, less restrictive definition increases detection of Klebsiella pneumoniae carbapenemase producers., Preventing transmission of carbapenemase-producing, carbapenem-resistant Enterobacteriaceae (CP-CRE) is a public health priority. A phenotype-based definition that reliably identifies CP-CRE while minimizing misclassification of non–CP-CRE could help prevention efforts. To assess possible definitions, we evaluated enterobacterial isolates that had been tested and deemed nonsusceptible to >1 carbapenem at US Emerging Infections Program sites. We determined the number of non-CP isolates that met (false positives) and CP isolates that did not meet (false negatives) the Centers for Disease Control and Prevention CRE definition in use during our study: 30% (94/312) of CRE had carbapenemase genes, and 21% (14/67) of Klebsiella pneumoniae carbapenemase–producing Klebsiella isolates had been misclassified as non-CP. A new definition requiring resistance to 1 carbapenem rarely missed CP strains, but 55% of results were false positive; adding the modified Hodge test to the definition decreased false positives to 12%. This definition should be considered for use in carbapenemase-producing CRE surveillance and prevention.

Background Large-scale, prospective, evaluation of sampling for central line–associated bloodstream infection (CLABSI) denominator data was necessary prior to National Healthcare Safety Network (NHSN) implementation. Methods In a sample of volunteer hospitals from states in the Emerging Infections Program, prospective collection of CLABSI denominators (patient days, central line days [CLDs]) was performed in eligible locations for ≥6 and ≤12 consecutive months using the current NHSN method (daily collection) and also by a second data collector who sampled the denominator data 1 d/wk. The quality of the sampled data was evaluated and used to calculate estimated CLDs and CLABSI rates, which were compared with actual CLDs and CLABSI rates (daily counts). Results In total, 89 locations in 66 acute care hospitals participated. Sampled data were collected as intended 88% of the time; the quality of the data was comparable with the data collected daily. In locations with higher CLDs per month (≥75), estimated CLDs and CLABSI rates were similar to actual CLDs and CLABSI rates; however, there were significant differences in actual and estimated values among locations with lower (≤74) CLDs per month.Sampling was successfully implemented, but significant differences in the accuracy of estimated CLDs and CLABSI rates, based on the actual number of CLDs per month, were noted. Conclusion For locations with a higher number of CLDs per month, sampling 1 d/wk is a valid and accurate alternative to daily collection of CLABSI denominator data.

Background An increasing proportion of Clostridium difficile infections (CDI) in the United States are community-associated (CA). We conducted a case-control study to identify CA-CDI risk factors. Methods We enrolled participants from 10 US sites during October 2014–March 2015. Case patients were defined as persons age ≥18 years with a positive C. difficile specimen collected as an outpatient or within 3 days of hospitalization who had no admission to a health care facility in the prior 12 weeks and no prior CDI diagnosis. Each case patient was matched to one control (persons without CDI). Participants were interviewed about relevant exposures; multivariate conditional logistic regression was performed. Results Of 226 pairs, 70.4% were female and 52.2% were ≥60 years old. More case patients than controls had prior outpatient health care (82.1% vs 57.9%; P < .0001) and antibiotic (62.2% vs 10.3%; P < .0001) exposures. In multivariate analysis, antibiotic exposure—that is, cephalosporin (adjusted matched odds ratio [AmOR], 19.02; 95% CI, 1.13–321.39), clindamycin (AmOR, 35.31; 95% CI, 4.01–311.14), fluoroquinolone (AmOR, 30.71; 95% CI, 2.77–340.05) and beta-lactam and/or beta-lactamase inhibitor combination (AmOR, 9.87; 95% CI, 2.76–340.05),—emergency department visit (AmOR, 17.37; 95% CI, 1.99–151.22), white race (AmOR 7.67; 95% CI, 2.34–25.20), cardiac disease (AmOR, 4.87; 95% CI, 1.20–19.80), chronic kidney disease (AmOR, 12.12; 95% CI, 1.24–118.89), and inflammatory bowel disease (AmOR, 5.13; 95% CI, 1.27–20.79) were associated with CA-CDI. Conclusions Antibiotics remain an important risk factor for CA-CDI, underscoring the importance of appropriate outpatient prescribing. Emergency departments might be an environmental source of CDI; further investigation of their contribution to CDI transmission is needed.

Metallocenes are a promising candidate for future spintronic devices due to their versatile and tunable magnetic properties. However, single metallocenes, e.g., ferrocene, sublimate below room temperature, and therefore the implementation for future applications is challenging. Here, a method to prepare biferrocene thin films using organic molecular beam deposition (OMBD) is presented, and the effect of substrate and deposition rate on the film structure and morphology as well as its chemical and magnetic properties is investigated. On Kapton and Si substrates, biferrocene interacts only weakly with the substrate, and distinct grains scattered over the surface are observed. By incorporating a 3,4,9,10-perylenetetracarboxylic dianhydride (PTCDA) seeding layer and depositing biferrocene at high deposition rates of 1.0 Å s–1, it is possible to achieve a well-ordered densely packed film. With spintronic applications in mind, the magnetic properties of the thin films are characterized using superconducting quantum interference device (SQUID) magnetometry. Whereas initial SQUID measurements show weak ferromagnetic behavior up to room temperature due to oxidized molecule fragments, measurements of biferrocene on PTCDA capped with LiF show the diamagnetic behavior expected of biferrocene. Through the successful deposition of biferrocene thin films and the ability to control the spin state, these results demonstrate a first step toward metallocene-based spintronics.

OBJECTIVE: Little is known about the epidemiology of Clostridium difficile infection (CDI) among children, particularly children ≤3 years of age in whom colonization is common but pathogenicity uncertain. We sought to describe pediatric CDI incidence, clinical presentation, and outcomes across age groups. METHODS: Data from an active population- and laboratory-based CDI surveillance in 10 US geographic areas during 2010–2011 were used to identify cases (ie, residents with C difficile–positive stool without a positive test in the previous 8 weeks). Community-associated (CA) cases had stool collected as outpatients or ≤3 days after hospital admission and no overnight health care facility stay in the previous 12 weeks. A convenience sample of CA cases were interviewed. Demographic, exposure, and clinical data for cases aged 1 to 17 years were compared across 4 age groups: 1 year, 2 to 3 years, 4 to 9 years, and 10 to 17 years. RESULTS: Of 944 pediatric CDI cases identified, 71% were CA. CDI incidence per 100 000 children was highest among 1-year-old (66.3) and white (23.9) cases. The proportion of cases with documented diarrhea (72%) or severe disease (8%) was similar across age groups; no cases died. Among the 84 cases interviewed who reported diarrhea on the day of stool collection, 73% received antibiotics during the previous 12 weeks. CONCLUSIONS: Similar disease severity across age groups suggests an etiologic role for C difficile in the high rates of CDI observed in younger children. Prevention efforts to reduce unnecessary antimicrobial use among young children in outpatient settings should be prioritized.

Currently, no single U.S. surveillance system can provide estimates of the burden of all types of health care-associated infections across acute care patient populations. We conducted a prevalence survey in 10 geographically diverse states to determine the prevalence of health care-associated infections in acute care hospitals and generate updated estimates of the national burden of such infections.We defined health care-associated infections with the use of National Healthcare Safety Network criteria. One-day surveys of randomly selected inpatients were performed in participating hospitals. Hospital personnel collected demographic and limited clinical data. Trained data collectors reviewed medical records retrospectively to identify health care-associated infections active at the time of the survey. Survey data and 2010 Nationwide Inpatient Sample data, stratified according to patient age and length of hospital stay, were used to estimate the total numbers of health care-associated infections and of inpatients with such infections in U.S. acute care hospitals in 2011.Surveys were conducted in 183 hospitals. Of 11,282 patients, 452 had 1 or more health care-associated infections (4.0%; 95% confidence interval, 3.7 to 4.4). Of 504 such infections, the most common types were pneumonia (21.8%), surgical-site infections (21.8%), and gastrointestinal infections (17.1%). Clostridium difficile was the most commonly reported pathogen (causing 12.1% of health care-associated infections). Device-associated infections (i.e., central-catheter-associated bloodstream infection, catheter-associated urinary tract infection, and ventilator-associated pneumonia), which have traditionally been the focus of programs to prevent health care-associated infections, accounted for 25.6% of such infections. We estimated that there were 648,000 patients with 721,800 health care-associated infections in U.S. acute care hospitals in 2011.Results of this multistate prevalence survey of health care-associated infections indicate that public health surveillance and prevention activities should continue to address C. difficile infections. As device- and procedure-associated infections decrease, consideration should be given to expanding surveillance and prevention activities to include other health care-associated infections.

Background Carbapenem-resistant Enterobacteriacae (CRE) are an urgent US public health threat. CDC reported CRE incidence to be 2.93/100,000 population in 2012–2013 in selected sites but changed the CRE surveillance case definition in 2016 to improve sensitivity for detecting carbapenemase-producing (CP) CRE. We describe CRE epidemiology before and after the change. Methods Eight CDC Emerging Infections Program sites (CO, GA, MD, MN, NM, NY, OR, TN) conducted active, population-based CRE surveillance in selected counties. A case was defined as having an isolate of E. coli, Enterobacter, or Klebsiella meeting a susceptibility phenotype (figure) at a clinical laboratory from urine or a normally sterile body site in a surveillance area resident in a 30-day period. We collected data from medical records and defined cases as community-associated (CA) if no healthcare risk factors were documented. A convenience sample of isolates were tested for carbapenemase genes at CDC by real-time PCR. We calculated incidence rates (per 100,000 population) by using US Census data. Case epidemiology and the proportion of CP-CRE isolates in 2015 versus 2016 were compared. Results In total, 442 incident CRE cases were reported in 2015, and 1,149 cases were reported in 2016. Most isolates were cultured from urine: 87% in 2015 and 92% in 2016 (P < .001). The crude overall pooled mean incidence in 2015 was 2.9 (range by site: 0.45–7.19) and in 2016 was 7.48 (range: 3.13–15.95). The most common CRE genus was Klebsiella (51%) in 2015, and in 2016 was Enterobacter (41%, P < 0.001). Of the subset of CRE isolates tested at CDC, 109/227 (48%) were CP-CRE in 2015 and 109/551 (20%) were CP-CRE in 2016. In 2015, 52/442 (12%) of cases were CA CRE, and in 2016, 267/1,149 (23%) were CA CRE (P < 0.001). In 2016, 3/111 (2.7%) of CA CRE isolates tested were CP-CRE. Conclusion A large increase in reported CRE incidence was observed after the change in the case definition. The new case definition includes a substantially larger number of Enterobacter cases. A decrease in CP-CRE prevalence appears to be driven by an increase in non-CP-CRE cases. Although CP-CRE in the community still appear to be rare, a substantial proportion of phenotypic CRE appear to be CA, and CDC is undertaking efforts to further investigate CA CRE, including CP-CRE. Disclosures G. Dumyati, Seres: Scientific Advisor, Consulting fee.

Background US laboratories are increasingly using nucleic acid amplification tests (NAAT) to diagnose Clostridium difficile infection (CDI) due to their increased sensitivity over toxin enzyme immunoassays (EIA), but NAATs may be more likely than toxin EIAs to detect colonization rather than true disease. Limited data indicate patients positive by toxin EIA (toxin+) have worse outcomes than those positive by NAAT (NAAT+) only, suggesting toxin EIA detects true infection more often than NAAT. We used multisite CDI surveillance data from the Centers for Disease Control and Prevention’s Emerging Infections Program to compare clinical course and outcomes between toxin+ and NAAT+ only patients. Methods A case was defined as a positive C. difficile test in a person ≥1 year old with no positive tests in the prior 8 weeks. Cases detected during 2014–2015 by a testing algorithm using toxin EIA and NAAT were classified as toxin+ or NAAT+ only. Medical charts were reviewed. Death data were obtained from state death registries. Multivariable logistic regression models were used to compare CDI recurrence and 90-day mortality between the two groups, adjusting for age, sex, race, Charlson comorbidity index, and receipt of oral vancomycin. For the outcome of recurrence, we also adjusted for history of CDI in the prior 6 months. Results Of 4,878 cases, 2160 (44%) were toxin+ and 2,718 (56%) were NAAT+ only. Toxin+ cases were more likely than NAAT+ only cases to be ≥65 years old (48% vs. 38%; P < 0.0001), have white blood cells ≥15,000/µL (483/1,539 [31%] vs. 423/1,978 [21%]; P < 0.0001), and have received oral vancomycin ≤3 days of diagnosis (32% vs. 29%; P = 0.03). Comparing toxin+ to NAAT+ only cases, 21% vs. 11% had a recurrence (P < 0.0001), of which 71% vs. 33% had a toxin+ recurrence (P < 0.0001), and 10% vs. 9% died ≤90 days of diagnosis (P = 0.12). In multivariable analysis, a toxin+ result was associated with recurrence (adjusted odds ratio [aOR]: 1.89, 95% CI: 1.61–2.22) but not with 90-day mortality (aOR: 0.99; 95% CI: 0.81–1.22). Conclusion Toxin+ CDI is more severe by some markers and more likely to recur as toxin+. However, there was no difference in adjusted mortality, which may reflect an effect on mortality in NAAT+ only cases from mild CDI, receipt of unnecessary CDI treatment, or other factors. Disclosures G. Dumyati, Seres: Scientific Advisor, Consulting fee.

Background Pseudomonas aeruginosa is intrinsically resistant to many commonly used antimicrobials and carbapenems are often required to treat infections. We describe the epidemiology and crude incidence of carbapenem-resistant P. aeruginosa(CRPA) in the EIP catchment area. Methods From August 1, 2016 through July 31, 2017, we conducted laboratory- and population-based surveillance for CRPA in selected metropolitan areas in Colorado, Georgia, Maryland, Minnesota, New Mexico, New York, Oregon, and Tennessee. We defined an incident case as the first isolate of P. aeruginosa-resistant to imipenem, meropenem, or doripenem from the lower respiratory tract, urine, wounds, or normally sterile sites identified from a resident of the EIP catchment area in a 30-day period. Patient charts were reviewed. A random sample of isolates was screened at CDC for carbapenemases using the modified carbapenem inactivation method (mCIM) and real-time PCR. Results During the 12-month period, we identified 3,042 incident cases among 2,154 patients. The crude incidence rate was 21.2 (95% CI, 20.4–21.9) per 100,000 persons and varied by site (range: 7.7 in Oregon to 31.1 in Maryland). The median age of patients was 64 years (range: Conclusion The burden of CRPA varied by EIP site. Most cases occurred in persons with healthcare exposures and underlying conditions. The majority of isolates were susceptible to at least one first-line antimicrobial. Carbapenemase producers were rare; a more specific phenotypic definition would greatly facilitate surveillance for these isolates. Disclosures All authors: No reported disclosures.

Background CDC released the Core Elements of Antibiotic Stewardship (Core Elements) for Nursing Homes (NHs) in 2015. In 2017, CDCs Emerging Infections Program (EIP) evaluated uptake of the Core Elements in a cohort of NHs. Methods NHs from California, Colorado, Connecticut, Georgia, Maryland, Minnesota, New Mexico, New York, Oregon, and Tennessee were randomly selected to participate in a CDC EIP antimicrobial use prevalence survey; participation was voluntary. A NH leader (typically Director of Nursing or Infection Preventionist) completed a CDC questionnaire to self-report facility implementation of 15 individual activities within the 7 domains of the Core Elements. The number and percentage of facilities reporting “Yes” to each activity and a facility stewardship score (range 0–15, 1 point per activity) were calculated. Associations between the stewardship score and facility-level factors, obtained from the questionnaire and publically available Centers for Medicare and Medicaid Services (CMS) NH quality data, were identified using Analysis of Variance (Proc GLM) in SAS 9.4; a P < 0.05 was considered significant. Results In 161 NHs (mean certified beds 118, 92% dual certified, 68% for-profit), the % of NHs reporting implementation of the 15 activities (figure) ranged from 25% (has a formulary of antibiotic agents, providers required to perform an antibiotic “time-out”) to 88% (providers required to document dose, duration and indication). The median facility stewardship score was 9 (interquartile range 7–12). A higher stewardship score was significantly associated with having: an infection preventionist who completed a certified training course (Yes vs. No, P = 0.029), higher number of attending physicians per 100 NH beds (upper quartile vs. lower three quartiles, P = 0.029), and higher CMS quality measure score (scale of 1 to 5 points, P = 0.025). Conclusion These data, collected approximately 2 years after release of the Core Elements, show NHs have begun to implement many policies or practices consistent with CDC antibiotic stewardship guidance. However, improved understanding of the uptake and barriers associated with implementation of the Core Elements can inform development of stewardship initiatives, identify NHs in need of stewardship interventions, and accelerate adoption. Disclosures All authors: No reported disclosures.