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Background Environmental contamination is suspected to play a key role in transmission of Candida auris in healthcare facilities. We recently showed that environmental surfaces near C. auris-colonized patients are commonly recontaminated within hours after disinfection. Clinical factors contributing to environmental contamination are not well characterized. Methods We conducted a multi-regional (Chicago, IL; Irvine, CA) prospective study of environmental contamination associated with C. auris colonization at six long-term care facilities (LTCF) and 1 acute-care hospital (ACH). On day of sampling, 5 participant body sites were cultured once, followed by routine daily room cleaning by facility staff, then targeted disinfection of high-touch surfaces with hydrogen peroxide wipes by research staff. Surfaces were cultured for C. auris using pre-moistened sponge-sticks and neutralizer immediately pre- and post-disinfection, and 4, 8, and 12 hours post-disinfection. We calculated the odds of surface recontamination after disinfection as a function of body site colonization with C. auris using generalized estimating equations to account for clustering among multiple surfaces within timepoints, patients, and facilities. Models included an interaction between facility type and colonization. Results C. auris was cultured from ≥1 body site in 41 participants (12 ACH and 29 LTCF patients, 205 body sites) on day of sampling. Proportion of body sites colonized did not vary by facility type (Table). Although environmental contamination rates were similar prior to disinfection [ACH 38% (n=60 samples) vs LTCF 29%, (n=145 samples), p=0.209)], the proportion of surfaces recontaminated between 4–12 hours after disinfection was higher in ACH vs LTCF (n=574 samples) (Figure). Number of body sites colonized with C. auris was associated with higher odds of environmental recontamination [ACH: OR 2.16 (95% CI 1.63–2.88), p< 0.001; LTCF: OR 1.40 (95% CI 1.07–1.84), p=0.015; Interaction ACH vs LTCF p< 0.001]. Conclusion The number of body sites colonized was associated with odds of C. auris environmental contamination. Differences in environmental recontamination by facility type may be related to greater provider-patient interactions in ACH as a driving factor. Disclosures Gabrielle M. Gussin, MS, Medline: Conducted studies in which hospitals and nursing homes received contributed antiseptic and/or environmental cleaning products|Stryker: Conducted clinical studies in which hospitals and nursing homes received contributed antiseptic products|Xttrium Laboratories: Conducted clinical studies in which hospitals and nursing homes received contributed antiseptic products Raveena D. Singh, MA, Medline: Conducted studies in which hospitals and nursing homes received contributed antiseptic and/or environmental cleaning products|Stryker: Conducted clinical studies in which hospitals and nursing homes received contributed antiseptic products|Xttrium Laboratories: Conducted clinical studies in which hospitals and nursing homes received contributed antiseptic products Raheeb Saavedra, AS, Medline: Conducted studies in which hospitals and nursing homes received contributed antiseptic and/or environmental cleaning products|Stryker: Conducted clinical studies in which hospitals and nursing homes received contributed antiseptic products|Xttrium Laboratories: Conducted clinical studies in which hospitals and nursing homes received contributed antiseptic products Nicholas M. Moore, PhD, D(ABMM), Abbott Molecular: Grant/Research Support|Cepheid: Grant/Research Support Susan S. Huang, MD, MPH, Medline: Conducted studies in which hospitals and nursing homes received contributed antiseptic and/or environmental cleaning products|Molnlyke: Conducted clinical studies in which hospitals received contributed antiseptic product|Stryker: Conducted clinical studies in which hospitals and nursing homes received contributed antiseptic products|Xttrium Laboratories: Conducted clinical studies in which hospitals and nursing homes received contributed antiseptic product Mary K. Hayden, MD, Sanofi: Member, clinical adjudication panel for an investigational SARS-CoV-2 vaccine.

We evaluated healthcare facility use of International Classification of Diseases, Tenth Revision (ICD-10) codes for culture-confirmed candidemia cases detected by active public health surveillance during 2019–2020. Most cases (56%) did not receive a candidiasis code, suggesting that studies relying on ICD-10 codes likely underestimate disease burden.

Background In March 2020, the World Health Organization declared COVID-19, caused by the SARS-CoV-2 virus, a pandemic. Patients with severe cases resulting in hospitalization and mechanical ventilation are at risk for COVID-19–associated pulmonary aspergillosis, an invasive fungal infection, and should be screened for aspergillosis if they have persistent hemodynamic instability and fever. Early detection and treatment of this fungal infection can significantly reduce morbidity and mortality in this population. Objective To develop an evidence-based care step pathway tool to help intensive care unit clinicians assess, diagnose, and treat COVID-19–associated pulmonary aspergillosis. Methods A panel of 18 infectious disease experts, advanced practice registered nurses, pharmacists, and clinical researchers convened in a series of meetings to develop the Care Step Pathway tool, which was modeled on a tool developed by advanced practice nurses to evaluate and manage side effects of therapies for melanoma. The Care Step Pathway tool addresses various aspects of disease management, including assessment, screening, diagnosis, antifungal treatment, pharmacological considerations, and exclusion of other invasive fungal coinfections. Results The Care Step Pathway tool was applied in the care of a patient with COVID-19–associated aspergillosis. The patient was successfully treated. Conclusion The Care Step Pathway is an effective educational tool to help intensive care unit clinicians consider fungal infection when caring for COVID-19 patients receiving mechanical ventilation in the intensive care unit, especially when the clinical course is deteriorating and antibiotics are ineffective.

Candida auris, an emerging multi-drug resistant organism (MDRO), is an urgent public health threat. We report on a C. auris outbreak investigation at a Virginia ventilator skilled nursing facility (vSNF). During October 2020-June 2021, we identified 28 cases among residents in the ventilator unit. Genomic evidence suggested ≥2 distinct C. auris introductions to the facility. We identified multiple infection and prevention control challenges, highlighting the importance of strengthening MDRO prevention efforts at vSNFs.

Background The COVID-19 pandemic has resulted in unprecedented healthcare challenges, and COVID-19 has been linked to secondary infections. Candidemia, a fungal healthcare-associated infection, has been described in patients hospitalized with severe COVID-19. However, studies of candidemia and COVID-19 coinfection have been limited in sample size and geographic scope. We assessed differences in patients with candidemia with and without a COVID-19 diagnosis. Methods We conducted a case-level analysis using population-based candidemia surveillance data collected through the Centers for Disease Control and Prevention’s Emerging Infections Program during April–August 2020 to compare characteristics of candidemia patients with and without a positive test for COVID-19 in the 30 days before their Candida culture using chi-square or Fisher’s exact tests. Results Of the 251 candidemia patients included, 64 (25.5%) were positive for SARS-CoV-2. Liver disease, solid-organ malignancies, and prior surgeries were each >3 times more common in patients without COVID-19 coinfection, whereas intensive care unit–level care, mechanical ventilation, having a central venous catheter, and receipt of corticosteroids and immunosuppressants were each >1.3 times more common in patients with COVID-19. All-cause in-hospital fatality was 2 times higher among those with COVID-19 (62.5%) than without (32.1%). Conclusions One-quarter of candidemia patients had COVID-19. These patients were less likely to have certain underlying conditions and recent surgery commonly associated with candidemia and more likely to have acute risk factors linked to COVID-19 care, including immunosuppressive medications. Given the high mortality, it is important for clinicians to remain vigilant and take proactive measures to prevent candidemia in patients with COVID-19.

Objective:To stop transmission of hepatitis B virus (HBV) and hepatitis C virus (HCV) infections in association with myocardial perfusion imaging (MPI) at a cardiology clinic.Design:Outbreak investigation and quasispecies analysis of HCV hypervariable region 1 genome.Setting:Outpatient cardiology clinic.Patients:Patients undergoing MPI.Methods:Case patients met definitions for HBV or HCV infection. Cases were identified through surveillance registry cross-matching against clinic records and serological screening. Observations of clinic practices were performed.Results:During 2012–2014, 7 cases of HCV and 4 cases of HBV occurred in 4 distinct clusters among patients at a cardiology clinic. Among 3 case patients with HCV infection who had MPI on June 25, 2014, 2 had 98.48% genetic identity of HCV RNA. Among 4 case patients with HCV infection who had MPI on March 13, 2014, 3 had 96.96%–99.24% molecular identity of HCV RNA. Also, 2 clusters of 2 patients each with HBV infection had MPI on March 7, 2012, and December 4, 2014. Clinic staff reused saline vials for >1 patient. No infection control breaches were identified at the compounding pharmacy that supplied the clinic. Patients seen in clinic through March 27, 2015, were encouraged to seek testing for HBV, HCV, and human immunodeficiency virus. The clinic switched to all single-dose medications and single-use intravenous flushes on March 27, 2015, and no further cases were identified.Conclusions:This prolonged healthcare-associated outbreak of HBV and HCV was most likely related to breaches in injection safety. Providers should follow injection safety guidelines in all practice settings.

Undetected infection with SARS-CoV-2, the virus that causes coronavirus disease 2019 (COVID-19) contributes to transmission in nursing homes, settings where large outbreaks with high resident mortality have occurred (1,2). Facility-wide testing of residents and health care personnel (HCP) can identify asymptomatic and presymptomatic infections and facilitate infection prevention and control interventions (3-5). Seven state or local health departments conducted initial facility-wide testing of residents and staff members in 288 nursing homes during March 24-June 14, 2020. Two of the seven health departments conducted testing in 195 nursing homes as part of facility-wide testing all nursing homes in their state, which were in low-incidence areas (i.e., the median preceding 14-day cumulative incidence in the surrounding county for each jurisdiction was 19 and 38 cases per 100,000 persons); 125 of the 195 nursing homes had not reported any COVID-19 cases before the testing. Ninety-five of 22,977 (0.4%) persons tested in 29 (23%) of these 125 facilities had positive SARS-CoV-2 test results. The other five health departments targeted facility-wide testing to 93 nursing homes, where 13,443 persons were tested, and 1,619 (12%) had positive SARS-CoV-2 test results. In regression analyses among 88 of these nursing homes with a documented case before facility-wide testing occurred, each additional day between identification of the first case and completion of facility-wide testing was associated with identification of 1.3 additional cases. Among 62 facilities that could differentiate results by resident and HCP status, an estimated 1.3 HCP cases were identified for every three resident cases. Performing facility-wide testing immediately after identification of a case commonly identifies additional unrecognized cases and, therefore, might maximize the benefits of infection prevention and control interventions. In contrast, facility-wide testing in low-incidence areas without a case has a lower proportion of test positivity; strategies are needed to further optimize testing in these settings.

Rationale & Objective Compared with conventional (rope-ladder cannulation [RLC]) methods, use of buttonhole cannulation (BHC) to access arteriovenous fistulas (AVFs) may be associated with increased risk for bloodstream infection and other vascular access–related infection. We used national surveillance data to evaluate the infection burden and risk among in-center hemodialysis patients with AVFs using BHC. Study Design Descriptive analysis of infections and related events and retrospective observational cohort study using National Healthcare Safety Network (NHSN) surveillance data. Setting & Participants US patients receiving hemodialysis treated in outpatient dialysis centers. Predictors AVF cannulation methods, dialysis facility characteristics, and infection control practices. Outcomes Access-related bloodstream infection; local access-site infection; intravenous (IV) antimicrobial start. Analytic Approach Description of frequency and rate of infections; adjusted relative risk (aRR) for infection with BHC versus RLC estimated using Poisson regression. Results During 2013 to 2014, there were 2,466 access-related bloodstream infections, 3,169 local access-site infections, and 13,726 IV antimicrobial starts among patients accessed using BHC. Staphylococcus aureus was the most common pathogen, present in half (52%) of the BHC access–related bloodstream infections. Hospitalization was frequent among BHC access–related bloodstream infections (37%). In 2014, 9% (n=271,980) of all AVF patient-months reported to NHSN were associated with BHC. After adjusting for facility characteristics and practices, BHC was associated with significantly higher risk for access-related bloodstream infection (aRR, 2.6; 95% CI, 2.4-2.8) and local access-site infection (aRR, 1.5; 95% CI, 1.4-1.6) than RLC, but was not associated with increased risk for IV antimicrobial start. Limitations Data for facility practices were self-reported and not patient specific. Conclusions BHC was associated with higher risk for vascular access–related infection than RLC among in-center hemodialysis patients. Decisions regarding the use of BHC in dialysis centers should take into account the higher risk for infection. Studies are needed to evaluate infection control measures that may reduce infections related to BHC.

Quality challenge The Sierra Leone (SL) Ministry of Health and Sanitation’s National Infection Prevention and Control Unit (NIPCU) launched National Infection and Prevention Control (IPC) Policy and Guidelines in 2015, but a 2017 assessment found suboptimal compliance with standards on environmental cleanliness (EC), waste disposal (WD) and personal protective equipment (PPE) use. Methods ICAP at Columbia University (ICAP), NIPCU and the Centers for Disease Control and Prevention (CDC) designed and implemented a Rapid Improvement Model (RIM) quality improvement (QI) initiative with a compressed timeframe of 6 months to improve EC, WD and PPE at eight purposively selected health facilities (HFs). Targets were collaboratively developed, and a 37-item checklist was designed to monitor performance. HF teams received QI training and weekly coaching and convened monthly to review progress and exchange best practices. At the final learning session, a “harvest package” of the most effective ideas and tools was developed for use at additional HFs. Results The RIM resulted in marked improvement in WD and EC performance and modest improvement in PPE. Aggregate compliance for the 37 indicators increased from 67 to 96% over the course of 4 months, with all HFs showing improvement. Average PPE compliance improved from 85 to 89%, WD from 63 to 99% and EC from 51 to 99%. Lessons learned The RIM QIC approach is feasible and effective in SL’s austere health system and led to marked improvement in IPC performance. The best practices are being scaled up and the RIM QIC methodology is being applied to other domains.

Objective To describe the epidemiology of carbapenem-resistant Enterobacteriaceae (CRE) healthcare-associated infections (HAI) in Egyptian hospitals reporting to the national HAI surveillance system. Methods Design: Descriptive analysis of CRE HAIs and retrospective observational cohort study using national HAI surveillance data. Setting: Egyptian hospitals participating in the HAI surveillance system. The patient population included patients admitted to the intensive care unit (ICU) in participating hospitals. Enterobacteriaceae HAI cases were Klebsiella, Escherichia coli, and Enterobacter isolates from blood, urine, wound or respiratory specimen collected on or after day 3 of ICU admission. CRE HAI cases were those resistant to at least one carbapenem. For CRE HAI cases reported during 2011–2017, a hospital-level and patient-level analysis were conducted using only the first CRE isolate by pathogen and specimen type for each patient. For facility, microbiology, and clinical characteristics, frequencies and means were calculated among CRE HAI cases and compared with carbapenem-susceptible Enterobacteriaceae HAI cases through univariate and multivariate logistic regression using STATA 13. Results There were 1598 Enterobacteriaceae HAI cases, of which 871 (54.1%) were carbapenem resistant. The multivariate regression analysis demonstrated that carbapenem resistance was associated with specimen type, pathogen, location prior to admission, and length of ICU stay. Between 2011 and 2017, there was an increase in the proportion of Enterobacteriaceae HAI cases due to CRE (p-value = 0.003) and the incidence of CRE HAIs (p-value = 0.09). Conclusions This analysis demonstrated a high and increasing burden of CRE in Egyptian hospitals, highlighting the importance of enhancing infection prevention and control (IPC) programs and antimicrobial stewardship activities and guiding the implementation of targeted IPC measures to contain CRE in Egyptian ICU’s .

BACKGROUND: Since the first report of Candida auris in 2016, the Colombian Instituto Nacional de Salud (INS) has implemented a national surveillance of the emerging multidrug-resistant fungus. OBJECTIVES: This report summarizes the findings of this laboratory-based surveillance from March 2016 to December 2020. RESULTS: A total of 1,720 C. auris cases were identified, including 393 (23%) colonization cases and 1,327 (77%) clinical cases. Cases were reported in 20 of 32 (62%) Departments of Colombia and involved hospitals from 33 cities. The median age of patients was 34 years; 317 (18%) cases were in children under 16 years, 54% were male. The peak number of cases was observed in 2019 (n=541). In 2020, 379 (94%) of 404 cases reported were clinical cases, including 225 bloodstream infections (BSI) and 154 non-BSI. Among the 404 cases reported in 2020, severe COVID-19 was reported in 122 (30%). Antifungal susceptibility was tested in 379 isolates. Using CDC tentative breakpoints for resistance, 35% of isolates were fluconazole resistant, 33% were amphotericin B resistant, and 0.3% isolate were anidulafungin resistant, 12% were multidrug resistant, and no pan-resistant isolates were identified. CONCLUSION: For five years of surveillance, we observed an increase in the number and geographic spread of clinical cases and an increase in fluconazole resistance. These observations emphasize the need for improved measures to mitigate spread.

Infection prevention and control (IPC) in health care facilities is essential to protecting patients, visitors, and health care personnel from the spread of infectious diseases, including Ebola virus disease (Ebola). Patients with suspected Ebola are typically referred to specialized Ebola treatment units (ETUs), which have strict isolation and IPC protocols, for testing and treatment (1,2). However, in settings where contact tracing is inadequate, Ebola patients might first seek care at general health care facilities, which often have insufficient IPC capacity (3-6). Before 2014-2016, most Ebola outbreaks occurred in rural or nonurban communities, and the role of health care facilities as amplification points, while recognized, was limited (7,8). In contrast to these earlier outbreaks, the 2014-2016 West Africa Ebola outbreak occurred in densely populated urban areas where access to health care facilities was better, but contact tracing was generally inadequate (8). Patients with unrecognized Ebola who sought care at health care facilities with inadequate IPC initiated multiple chains of transmission, which amplified the epidemic to an extent not seen in previous Ebola outbreaks (3-5,7). Implementation of robust IPC practices in general health care facilities was critical to ending health care-associated transmission (8). In August 2018, when an Ebola outbreak was recognized in the Democratic Republic of the Congo (DRC), neighboring countries began preparing for possible introduction of Ebola, with a focus on IPC. Baseline IPC assessments conducted in frontline health care facilities in high-risk districts in Uganda found IPC gaps in screening, isolation, and notification. Based on findings, additional funds were provided for IPC, a training curriculum was developed, and other corrective actions were taken. Ebola preparedness efforts should include activities to ensure that frontline health care facilities have the IPC capacity to rapidly identify suspected Ebola cases and refer such patients for treatment to protect patients, staff members, and visitors.

Objectives To examine Ebola virus disease (EVD) symptom prevalence and EVD status among pregnant women in Ebola isolation units in Sierra Leone. Methods In an observational study, data were obtained for pregnant women admitted to Ebola isolation units across four districts in Sierra Leone from June 29, 2014, to December 20, 2014. Women were admitted to isolation units if they had suspected EVD exposures or fever (temperature >38°C) and three or more self-reported symptoms suggestive of EVD. Associations were examined between EVD status and each symptom using χ2 tests and logistic regression adjusting for age/labor status. Results Of 176 pregnant women isolated, 55 (32.5%) tested positive for EVD. Using logistic regression models adjusted for age, EVD-positive women were significantly more likely to have fever, self-reported fatigue/weakness, nausea/vomiting, headache, muscle/joint pain, chest pain, vaginal bleeding, unexplained bleeding, or sore throat upon admission. In models adjusted for age/labor, only women with fever or vaginal bleeding upon admission were significantly more likely to be EVD-positive. Conclusions Several EVD symptoms and complications increased the odds of testing EVD-positive; some of these were also signs and symptoms of labor/pregnancy complications. The study results highlight the need to refine screening for pregnant women with EVD.

Background Carbapenem-resistant Enterobacterales (CRE) is a global threat. Enterobacterales develops carbapenem resistance through several mechanisms, including the production of carbapenemases. We aim to describe the prevalence of Carbapenem-resistant Enterobacterales (CRE) with and without carbapenemase production and distribution of carbapenemase-producing (CP) genes in Thailand using 2016–2018 data from a national antimicrobial resistance surveillance system developed by the Thailand National Institute of Health (NIH). Methods CRE was defined as any Enterobacterales resistant to ertapenem, imipenem, or meropenem. Starting in 2016, 25 tertiary care hospitals from the five regions of Thailand submitted the first CRE isolate from each specimen type and patient admission to Thailand NIH, accompanied by a case report form with patient information. NIH performed confirmatory identification and antimicrobial susceptibility testing and performed multiplex polymerase chain reaction testing to detect CP-genes. Using 2016–2018 data, we calculated proportions of CP-CRE, stratified by specimen type, organism, and CP-gene using SAS 9.4. Results Overall, 4,296 presumed CRE isolates were submitted to Thailand NIH; 3,946 (93%) were confirmed CRE. Urine (n = 1622, 41%) and sputum (n = 1380, 35%) were the most common specimen types, while blood only accounted for 323 (8%) CRE isolates. The most common organism was Klebsiella pneumoniae (n = 2660, 72%), followed by Escherichia coli (n = 799, 22%). The proportion of CP-CRE was high for all organism types (range: 85–98%). Of all CRE isolates, 2909 (80%) had one CP-gene and 629 (17%) had > 1 CP-gene. New Delhi metallo-beta-lactamase (NDM) was the most common CP-gene, present in 2392 (65%) CRE isolates. K. pneumoniae carbapenemase (KPC) and Verona integron-encoded metallo-β-lactamase (VIM) genes were not detected among any isolates. Conclusion CP genes were found in a high proportion (97%) of CRE isolates from hospitals across Thailand. The prevalence of NDM and OXA-48-like genes in Thailand is consistent with pattern seen in Southeast Asia, but different from that in the United States and other regions. As carbapenemase testing is not routinely performed in Thailand, hospital staff should consider treating all patients with CRE with enhanced infection control measures; in line with CDC recommendation for enhanced infection control measures for CP-CRE because of their high propensity to spread.

Background Candida auris is a fungal pathogen associated with multidrug resistance, high mortality, and healthcare transmission. Since its U.S. emergence in 2017, to March 19, 2021, 1708 clinical infections were reported nationwide, of which 235 (13.8%) were reported in New Jersey. The New Jersey Department of Health (NJDOH) maintains C. auris surveillance in healthcare facilities (HCF) such as acute care hospitals, long-term acute care hospitals (LTACHs), and skilled nursing facilities, to monitor clinical infections and patient colonization. We aimed to characterize the epidemiology of C. auris infection and colonization among HCF patients during 2017–2020. Methods HCFs report C. auris cases identified from clinical specimens and surveillance activities such as admission screenings and point prevalence surveys (PPS) to NJDOH. Cases are classified as either infection or colonization using National Notifiable Diseases Surveillance System case definitions. We analyzed cases reported during 2017–2020 to describe types of cases, facilities reporting cases, and demographics of affected patients. We analyzed PPS results to calculate percent positivity of tests from patients without previously identified infection and compared percent positivity between types of facilities. We examined quarterly trends for all variables before and after the COVID-19 pandemic peak in the second quarter of 2020. Results During 2017–2020, 614 C. auris cases identified from clinical specimens were reported to NJDOH [243 (39.6%) infection, 371 (60.4%) colonization]; of these, 139 (57.2%) and 301 (81.1%) , respectively, were identified at long-term acute care hospitals (LTACHs). PPS percent positivity was higher at LTACHs (mean 7.6%) compared with all other facility types (mean 3.6%) for 13 of 16 quarters during 2017–2020. Case reports increased 2.6-fold from the Q2 2020 peak of the COVID-19 pandemic to Q3 2020.From Q1 to Q4 2020, PPS percent positivity increased from 4.8% to 10.5%. Figure 1. Candida auris cases reported to New Jersey Department of Health, 2017–2020 Figure 2. Candida auris test percent positivity among healthcare facility patients sampled for point prevalence surveys* and total number of C. auris point prevalence tests performed, New Jersey, 2017–2020. *Excluding individuals already known to be cases Conclusion The COVID-19 pandemic may have exacerbated C. auris transmission in HCF and potential causes should be further explored. LTACHs carry a disproportionate burden of patients colonized with C. auris and should be prioritized for surveillance and containment efforts. Disclosures All Authors: No reported disclosures

Candida auris is a multidrug-resistant pathogen that represents a serious public health threat due to its rapid global emergence, increasing incidence of healthcare-associated outbreaks, and high rates of antifungal resistance. Whole-genome sequencing and genomic surveillance have the potential to bolster C. auris surveillance networks moving forward. Laboratories conducting genomic surveillance need to be able to compare analyses from various national and international surveillance partners to ensure that results are mutually trusted and understood. Therefore, we established an empirical outbreak benchmark dataset consisting of 23 C. auris genomes to help validate comparisons of genomic analyses and facilitate communication among surveillance networks. Our outbreak benchmark dataset represents a polyclonal phylogeny with three subclades. The genomes in this dataset are from well-vetted studies that are supported by multiple lines of evidence, which demonstrate that the whole-genome sequencing data, phylogenetic tree, and epidemiological data are all in agreement. This C. auris benchmark set allows for standardized comparisons of phylogenomic pipelines, ultimately promoting effective C. auris collaborations.

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.

In July 2020, the Florida Department of Health was alerted to three Candida auris bloodstream infections and one urinary tract infection in four patients with coronavirus disease 2019 (COVID-19) who received care in the same dedicated COVID-19 unit of an acute care hospital (hospital A). C. auris is a multidrug-resistant yeast that can cause invasive infection. Its ability to colonize patients asymptomatically and persist on surfaces has contributed to previous C. auris outbreaks in health care settings (1-7). Since the first C. auris case was identified in Florida in 2017, aggressive measures have been implemented to limit spread, including contact tracing and screening upon detection of a new case. Before the COVID-19 pandemic, hospital A conducted admission screening for C. auris and admitted colonized patients to a separate dedicated ward.

Background The Georgia Ministry of Labor, Health, and Social Affairs is working to strengthen its Infection Prevention and Control (IPC) Program, but until recently has lacked an assessment of performance gaps and implementation challenges faced by hospital staff. Methods In 2018, health care hospitals were assessed using a World Health Organization (WHO) adapted tool aimed at implementing the WHO’s IPC Core Components. The study included site assessments at 41 of Georgia’s 273 hospitals, followed by structured interviews with 109 hospital staff, validation observations of IPC practices, and follow up document reviews. Results IPC programs for all hospitals were not comprehensive, with many lacking defined objectives, workplans, targets, and budget. All hospitals had at least one dedicated IPC staff member, 66% of hospitals had IPC staff with some formal IPC training; 78% of hospitals had IPC guidelines; and 55% had facility-specific standard operating procedures. None of the hospitals conducted structured monitoring of IPC compliance and only 44% of hospitals used IPC monitoring results to make unit/facility-specific IPC improvement plans. 54% of hospitals had clearly defined priority healthcare-associated infections (HAIs), standard case definitions and data collection methods in their HAI surveillance systems. 85% hospitals had access to a microbiology laboratory. All reported having posters or other tools to promote hand hygiene, 29% had them for injection safety. 68% of hospitals had functioning hand-hygiene stations available at all points of care. 88% had single patient isolation rooms; 15% also had rooms for cohorting patients. 71% reported having appropriate waste management system. Conclusions Among the recommended WHO IPC core components, existing programs, infrastructure, IPC staffing, workload and supplies present within Georgian healthcare hospitals should allow for implementation of effective IPC. Development and dissemination of IPC Guidelines, implementation of an effective IPC training system and systematic monitoring of IPC practices will be an important first step towards implementing targeted IPC improvement plans in hospitals.

OBJECTIVE To describe maternal and perinatal outcomes among pregnant women with suspected Ebola virus disease (EVD) in Sierra Leone. METHODS Observational investigation of maternal and perinatal outcomes among pregnant women with suspected EVD from five districts in Sierra Leone from June to December 2014. Suspected cases were ill pregnant women with symptoms suggestive of EVD or relevant exposures who were tested for EVD. Case frequencies and odds ratios were calculated to compare patient characteristics and outcomes by EVD status. RESULTS There were 192 suspected cases: 67 (34.9%) EVD-positive, 118 (61.5%) EVD-negative, and 7 (3.6%) EVD status unknown. Women with EVD had increased odds of death (OR 10.22; 95% CI, 4.87-21.46) and spontaneous abortion (OR 4.93; 95% CI, 1.79-13.55) compared with those without EVD. Women without EVD had a high frequency of death (30.2%) and stillbirths (65.9%). One of 14 neonates born following EVD-negative and five of six neonates born following EVD-positive pregnancies died. CONCLUSION EVD-positive and EVD-negative women with suspected EVD had poor outcomes, highlighting the need for increased attention and resources focused on maternal and perinatal health during an urgent public health response. Capturing pregnancy status in nationwide surveillance of EVD can help improve understanding of disease burden and design effective interventions.

Invasive nontuberculous mycobacteria (NTM) infections may result from a previously unrecognized source of transmission, heater-cooler devices (HCDs) used during cardiac surgery. In July 2015, the Pennsylvania Department of Health notified the Centers for Disease Control and Prevention (CDC) about a cluster of NTM infections among cardiothoracic surgical patients at 1 hospital. We conducted a case-control study to identify exposures causing infection, examining 11 case-patients and 48 control-patients. Eight (73%) case-patients had a clinical specimen identified as Mycobacterium avium complex (MAC). HCD exposure was associated with increased odds of invasive NTM infection; laboratory testing identified patient isolates and HCD samples as closely related strains of M. chimaera, a MAC species. This investigation confirmed a large US outbreak of invasive MAC infections in a previously unaffected patient population and suggested transmission occurred by aerosolization from HCDs. Recommendations have been issued for enhanced surveillance to identify potential infections associated with HCDs and measures to mitigate transmission risk.

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

Objectives To determine the extent of a group A streptococcus (GAS) cluster (2 residents with invasive GAS (invasive case-patients), 2 carriers) caused by a single strain (T antigen type 2 and M protein gene subtype 2.0 (T2, emm 2.0)), evaluate factors contributing to transmission, and provide recommendations for disease control. Design Cross-sectional analysis and retrospective review. Setting Skilled nursing facility (SNF). Participants SNF residents and staff. Measurements The initial cluster was identified through laboratory notification and screening of SNF residents with wounds. Laboratory and SNF administrative records were subsequently reviewed to identify additional residents with GAS, oropharyngeal and wound (if present) swabs were collected from SNF staff and residents to examine GAS colonization, staff were surveyed to assess infection control practices and risk factors for GAS colonization, epidemiologic links between case-patients and persons colonized with GAS were determined, and facility infection control practices were assessed. Results No additional invasive case-patients were identified. Oropharyngeal swabs obtained from all 167 SNF residents were negative; one wound swab grew GAS that was the same as the outbreak strain (T2, emm 2.0). The outbreak strain was not identified in any of the 162 staff members. One of six staff members diagnosed with GAS pharyngitis worked while ill and had direct contact with invasive case-patients within a few weeks before their onset of symptoms. Additional minor breaches in infection control were noted. Conclusion Sick healthcare workers may have introduced GAS into the SNF, with propagation by infection control lapses. “Presenteeism,” or working while ill, may introduce and transmit GAS to vulnerable in SNF populations. Identification of an invasive GAS case-patient should trigger a prompt response by facilities to prevent further transmission and workplace culture, and policies should be in place to discourage presenteeism in healthcare settings.

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)

Background: Candidemia is associated with high morbidity and mortality. Although risk factors for candidemia and other bloodstream infections (BSIs) overlap, little is known about patient characteristics and the outcomes of polymicrobial infections. We used data from the CDC Emerging Infections Program (EIP) candidemia surveillance to describe polymicrobial candidemia infections and to assess clinical differences compared with Candida-only BSIs. Methods: During January 2017–December 2017 active, population-based candidemia surveillance was conducted in 45 counties in 9 states covering ~6% of the US population through the CDC EIP. A case was defined as a blood culture with Candida spp in a surveillance-area resident; a blood culture >30 days from the initial culture was considered a second case. Demographic and clinical characteristics were abstracted from medical records by trained EIP staff. We examined characteristics of polymicrobial cases, in which Candida and ≥1 non-Candida organism were isolated from a blood specimen on the same day, and compared these to Candida-only cases using logistic regression or t tests using SAS v 9.4 software. Results: Of the 1,221 candidemia cases identified during 2017, 215 (10.2%) were polymicrobial. Among polymicrobial cases, 50 (23%) involved ≥3 organisms. The most common non-Candida organisms were Staphylococcus epidermidis (n = 30, 14%), Enterococcus faecalis (n = 26, 12%), Enterococcus faecium (n = 17, 8%), and Staphylococcus aureus, Klebsiella pneumoniae, and Stenotrophomonas maltophilia (n = 15 each, 7%). Patients with polymicrobial cases were significantly younger than those with Candida-only cases (54.3 vs 60.7 years; P < .0004). Healthcare exposures commonly associated with candidemia like total parenteral nutrition (relative risk [RR], 0.82; 95% CI, 0.60–1.13) and surgery (RR, 0.99; 95% CI, 0.77–1.29) were similar between the 2 groups. Polymicrobial cases had shorter median time from admission to positive culture (1 vs 4 days, P < .001), were more commonly associated with injection drug use (RR, 1.95; 95% CI, 1.46–2.61), and were more likely to be community onset-healthcare associated (RR, 1.91; 95% CI, 1.50–2.44). Polymicrobial cases were associated with shorter hospitalization (14 vs 17 days; P = .031), less ICU care (RR, 0.7; 95% CI, 0.51–0.83), and lower mortality (RR, 0.7; 95% CI, 0.50–0.92). Conclusions: One in 10 candidemia cases were polymicrobial, with nearly one-quarter of those involving ≥3 organisms. Lower mortality among polymicrobial cases is surprising but may reflect the younger age and lower severity of infection of this population. Greater injection drug use, central venous catheter use, and long-term care exposures among polymicrobial cases suggest that injection or catheter practices play a role in these infections and may guide prevention opportunities.Funding: NoneDisclosures: None

Background: Trained infection prevention and control (IPC) practitioners are critical to reducing healthcare-associated infections (HAI) and improving patient safety. Despite having HAI rates 3 times higher than high-income countries, many low- and middle-income countries (LMICs) lack trained IPC professionals. During the 2014–2016 Ebola outbreak in West Africa, the Sierra Leone Ministry of Health and Sanitation (MoHS) recognized this need and appointed and trained IPC focal persons at all district hospitals. Following the outbreak, MoHS requested assistance from the US CDC to develop and implement a comprehensive IPC training program for IPC specialists. Methods: The CDC, alongside its partners, convened a multidisciplinary team to develop an IPC certificate course. ICAP led the curriculum development process using a “backwards design” approach, starting with development of competencies and learning objectives, then designing an evaluation framework and learning strategies, and finally, identifying course content. The curriculum was based on existing resources, primarily designed for high-income countries, which were adapted to the Sierra Leone context and aligned with national IPC policies and guidelines. Additionally, an IPC steering committee, led by MoHS, was established to provide national leadership and oversight and make country-level decisions regarding accreditation and career pathways for IPC specialists. Results: The course includes three 2-week workshops over 6 months consisting of classroom didactics and hands-on activities. Topics include standard and transmission-based precautions, microbiology, laboratory, HAI, quality improvement, leadership, and scientific writing. Between sessions, participants conduct IPC activities at their work site and share results during subsequent workshops. Participants receive electronic tablets, which contain course content, assessment tools, and references, to upload their work into a cloud-based storage system for facilitators to provide feedback. They also receive in-person mentorship and connect with peers through a group messaging platform to share lessons learned. Participants’ knowledge and skills are assessed using a before-and-after test and observing them perform IPC practices using standardized checklists. The first cohort of 25 participants will complete the course in November 2019. Conclusions: The IPC certificate course is the first comprehensive, competency-based IPC training in Sierra Leone. Successes, challenges, sustainability, and lessons learned remain to be determined; however, based on similar models, the course has the potential to significantly improve IPC in Sierra Leone. Additionally, it is a model that can be replicated in other resource-limited settings.Funding: NoneDisclosure:None

Background: In 2015, the Ministry of Internally Displaced Persons from the Occupied Territories, Labor, Health and Social Affairs (MoLHSA) of Georgia identified infection prevention and control (IPC) as a top priority. Infection control legislation was adopted and compliance was made mandatory for licensure. Participation in the universal healthcare system requires facilities to have an IPC program and infrastructure. To support facilities to improve IPC, MoLHSA and the National Center for Disease Control and Public Health (NCDC) requested assistance from the US CDC to revise the 2009 National IPC guidelines, which were translated versions of international guidelines and not adapted to the Georgian context. Methods: An IPC guideline technical working group (TWG), comprising clinical epidemiologists, IPC nurses, head nurses, and infectious diseases doctors from the NCDC, academic and healthcare organizations and the CDC was formed to lead the development of the national IPC guidelines. Additionally, an IPC steering committee was established to review and verify the guidelines’ compliance with applicable decrees and regulations. The TWG began work in April 2017 and was divided into 4 subgroups, each responsible for developing specific guideline topics. A general IPC guideline template for low- and middle-income countries was used to develop 7 of the guidelines. Additional reference materials and international guidelines were used to develop all the guidelines. Drafts were shared with the subgroups and the steering committee during 2 workshops to discuss unresolved technical issues and to validate the guidelines. Results: The revised guidelines consist of 18 topics. In addition to standard precautions (eg, hand hygiene, personal protective equipment, injection safety, etc) and transmission-based precautions, the guideline topics include laundry, environmental cleaning and disinfection, decontamination and sterilization, occupational health and safety, biosafety in clinical laboratory, blood bank and transfusion services, intensive care unit, emergency room, and mortuary. They do not include healthcare-associated infection surveillance or organism-specific guidance. To supplement the guidelines, a separate implementation manual was developed. The guidelines were approved by MoLHSA in October 2019. The TWG continues to be engaged in IPC activities, assisting with guideline rollout, training, and monitoring, and drafting the National IPC strategy and action plans. Conclusions: The Georgian Ministry of Health developed national IPC guidelines using local experts. This model can be replicated in other low- and middle-income countries that lack country-specific IPC guidelines. It can also be adapted to develop facility-level guidelines and standard operating procedures.Funding: NoneDisclosures: None

Background Candidemia is a bloodstream infection commonly associated with high morbidity and mortality. Failure to clear candidemia can lengthen hospitalization and treatment. Factors associated with candidemia clearance are unknown. Methods We analyzed 2017 candidemia surveillance data from the Centers for Disease Control and Prevention’s Emerging Infections Program. Data from eight sites (counties in California, Colorado, Georgia, Minnesota, New Mexico, New York, Oregon, and Tennessee) were included. Clearance was defined as having a blood culture negative for Candida ≤30 days after initial culture date (ICD). Cases with unknown clearance, unknown survival outcome, or death ≤30 days of ICD were excluded. Demographic and clinical factors associated with clearance were assessed with bivariate analysis using chi-square tests and multivariable logistic regression to calculate adjusted odds ratios (aOR) using backward selection (p-value< 0.10). Results Of 1,024 candidemia cases, 737 were included and 582 (79%) demonstrated clearance, of which 79% had evidence of clearance ≤5 days after ICD. In bivariate analysis, clearance was associated with central venous catheter (CVC) ≤2 days before ICD, CVC removal ≤7 days after ICD, and systemic antifungal medication within 14 days before ICD. Clearance was inversely associated with black race and admission from another hospital. In multivariable analysis, only race and admission from another hospital were significant predictors; age, sex, and CVC presence and subsequent removal were also retained for their clinical relevance. In the final model, clearance was less likely among black patients (aOR 0.51, 95% confidence interval [CI] 0.29-0.91) and those admitted from another hospital (aOR 0.28, 95% CI 0.11-0.75). Table 1. Bivariate associations for select variables between individuals with documented candidemia clearance and those without documented clearance in eight Emerging Infections Program surveillance sites, 2017 Conclusion We found failure to clear candidemia infection to be associated with black race and prior hospital exposure, but not other factors previously shown to be associated (e.g., comorbidities, CVC presence). These associations could reflect illness severity, access to care, or other obstacles to effective treatment. Additional research is needed to investigate these associations further and identify other factors (e.g., treatment type and timing) to improve outcomes. Disclosures All Authors: No reported disclosures

Background Clusters of bloodstream infections caused by Burkholderia cepacia and Stenotrophomonas maltophilia are uncommon, but have been previously identified in hemodialysis centers that reprocessed dialyzers for reuse on patients. We investigated an outbreak of bloodstream infections caused by B cepacia and S maltophilia among hemodialysis patients in clinics of a dialysis organization. Study Design Outbreak investigation, including matched case-control study. Setting & Participants Hemodialysis patients treated in multiple outpatient clinics owned by a dialysis organization. Predictors Main predictors were dialyzer reuse, dialyzer model, and dialyzer reprocessing practice. Outcomes Case patients had a bloodstream infection caused by B cepacia or S maltophilia; controls were patients without infection dialyzed at the same clinic on the same day as a case; results of environmental cultures and organism typing. Results 17 cases (9 B cepacia and 8 S maltophilia bloodstream infections) occurred in 5 clinics owned by the same dialysis organization. Case patients were more likely to have received hemodialysis with a dialyzer that had been used more than 6 times (matched OR, 7.03; 95% CI, 1.38-69.76) and to have been dialyzed with a specific reusable dialyzer (Model R) with sealed ends (OR, 22.87; 95% CI, 4.49-∞). No major lapses during dialyzer reprocessing were identified that could explain the outbreak. B cepacia was isolated from samples collected from a dialyzer header-cleaning machine from a clinic with cases and was indistinguishable from a patient isolate collected from the same clinic, by pulsed-field gel electrophoresis. Gram-negative bacteria were isolated from 2 reused Model R dialyzers that had undergone the facility's reprocessing procedure. Limitations Limited statistical power and overmatching; few patient isolates and dialyzers available for testing. Conclusions This outbreak was likely caused by contamination during reprocessing of reused dialyzers. Results of this and previous investigations demonstrate that exposing patients to reused dialyzers increases the risk for bloodstream infections. To reduce infection risk, providers should consider implementing single dialyzer use whenever possible.