Background: In the management of children with sepsis, inflammatory markers are often obtained upon admission and repeated frequently. It is unclear if serial monitoring of procalcitonin is useful for predicting patient outcomes. The focus of our study is to identify if the trend of procalcitonin levels was predictive of the clinical outcomes in children with sepsis. Methods: We performed a retrospective diagnostic study to evaluate the association between change in procalcitonin levels and clinical outcomes. Encounters for children 1 to 8 years old with a sepsis ICD 10 diagnosis code and meeting the clinical sepsis criteria from May 2020 to May 2022 at one quaternary care pediatric hospital were included. Encounters with fewer than two procalcitonin values and children with autoimmune diseases, trauma, new onset malignancy, and fungal infections were excluded. Procalcitonin clearance at 48 hours (CL-PCT48) was defined as the difference in procalcitonin values drawn on admission and at 48 hours divided by initial procalcitonin value. The primary outcome was good early clinical response, defined as composite measure of temperature, hemodynamic stability, supplemental oxygen requirement, and need for renal replacement therapy at 120 hours of admission. All-cause in-hospital mortality was a secondary outcome. ROC analysis was performed to measure the correlation of CL-PCT48 and initial procalcitonin value (PCT0) with the outcome. Result: There were 320 unique encounters for children who met the clinical criteria of sepsis. The median number of procalcitonin measurements was 4 (Range 2 – 111). Of these encounters, 187 had procalcitonin measurements done at eligible times. The mean age of the study participants was 9 years and 8 months, 103 (55%) were male, and the majority (54%) were Caucasian. Fifty-seven (30%) individuals had bacterial growth from a culture from sterile body fluid or urine. 78 (41.7%) individuals had good early clinical response and 177 (94.7%) survived to hospital discharge. There was no correlation identified between CL-PCT48 and good early clinical response (area under ROC curve [AUC] = 0.57, 95% CI 0.48-0.65, Figure 1) or mortality (AUC = 0.60, 95% CI 0.43-0.76, Figure 2). There was also no correlation between PCT0 and good early clinical response (AUC = 0.47, 95% CI 0.39-0.56) or and mortality (AUC = 0.50, 95% CI 0.29-0.72). Conclusion: Procalcitonin clearance at 48 hours after admission did not predict early clinical response in children with sepsis.

Background: Patients without urinary tract infection (UTI) symptoms but with a positive urine culture are considered to have asymptomatic bacteriuria (ASB). This often represents colonization and treatment is not recommended or clinically beneficial. Treatment of ASB can promote antimicrobial resistance and increased rates of Clostriodies difficile infections. Many cases of ASB are incorrectly assigned as CAUTIs due to over-culturing practices. We hypothesized that a urine culture algorithm, embedded within a best practice alert (BPA) in the electronic medical record (EMR), would reduce urine culturing practices for ASB. Methods: From Feb 2022 through May 2023, a multidisciplinary team implemented an Inpatient Urine Culturing Stewardship Guideline. A BPA fired when a provider placed a urinalysis with reflex to culture (UACC) or urine culture (UC) order for patients who met criteria (Image 1). The BPA directed providers to remove the order, select the appropriate pathway from the guideline, or provide a rationale for placing the order. The intervention was piloted on three intensive care units and two progressive care units, containing both medical and surgical patients. Monthly ordering practices, CAUTI rates, and gram-negative rod (GNR) bacteremia rates from a 13-month pre-intervention baseline period were compared to a 16-month intervention period. Over the same time periods, we also assessed changes in ordering practices for comparison units which did not implement the intervention. Pre-and-post intervention cohorts were analyzed using median two sample tests and Exact Poison Method, as appropriate. Results: On intervention units there was a 41.0% reduction in the median number of UACC and UC orders per 1000 patient days from 16.31 during the baseline period to 9.62 in the intervention period (p=0.0036). Pan cultures per 1000 patient days in which one of the orders was a UACC or UC fell by 42.2% from a median of 10.20 per 1000 patient days to 5.90 (p=0.0008). The comparison units saw no significant reductions in UACC and UC orders (p=0.21) or pan cultures (p=1.0). On the intervention units, the CAUTI rate for the baseline period was 1.31 per 1000 catheter days versus 0.79 in the intervention period (IRR = 1.65; p=0.44). GNR bacteremias remained stable on the intervention units between the baseline and intervention periods (p=0.82). Conclusion: This multidisciplinary intervention, leveraging EMR clinical decision support, reduced urine and pan culturing practices while demonstrating a trend towards a reduced CAUTI rate. The prevalence of GNR bacteremias remained consistent with baseline levels, suggesting the intervention did not cause harm.

Background: The FilmArray gastrointestinal (GI) pathogen panel (BioFire Diagnostics, Salt Lake City, UT) is a multiplex PCR assay for syndromic diagnosis of infectious gastroenteritis. This highly sensitive assay has been widely adopted as a preferred testing modality for infectious diarrhea among hospitalized patients. However, in the era of diagnostic stewardship, concerns have been raised that this approach risks unexpected findings of questionable significance. Following an increase in GI pathogen panel testing, the infection control department reviewed results among hospitalized patients at different stages of admission. Methods: From October 2022 to May 2023, we retrospectively reviewed all GI pathogen panels sent in a large tertiary cancer hospital. Count of tests ordered and positivity trends were studied by unit and organism among inpatients. We categorized an admission course into early (≤2 inpatient days) and late (≥3 inpatient days) stages and compared results across these stages. Finally, we compared reproducibility of multiple tests sent during a single admission. Results: From October 2022 to May 2023, a total of 2,763 tests were sent across the institution with 2,113 tests from inpatient units. Tests were most commonly sent on the Pediatrics and Hematology -Oncology inpatient units and together these units accounted for 60% of tests. These two units also had the highest rate of test positivity and together accounted for 60% of positive tests among hospitalized patients. The most frequently detected organisms were Norovirus (7%) and Enteropathogenic E. coli (3%) (Figure 1). Patients tested in the early stage of hospital admission were more likely to have a positive result for any target (93/509, 18.3%) compared to patients tested in the late stage (202/1604, 12.5%). Patients with a positive test in the early stage of admission were less likely to have a subsequent negative test (3/93, 3%) compared to patients who were positive in late stage of admission (39/202, 19.3% (Figure 2). Conclusions: Our findings suggest that the utility of the FilmArray GI PCR panel is highest in the early stages of a patient’s hospital admission. Testing of patients hospitalized ≥3 days is likely to be inappropriate. These findings support implementation of diagnostic stewardship standards on when syndromic testing for potentially infectious diarrhea is appropriate. Figure 1: FilmArray gastrointestinal pathogen PCR panel positivity by organism. Figure 2: FilmArray gastrointestinal pathogen PCR panel positivity by organism comparing early vs late stage of hospital admission.

Background: There is limited data regarding the benefits of direct inoculation of sterile pericardial fluid into blood culture bottles. We discovered widespread adoption of this practice at our institution during pericardiocenteses and became concerned about over-capturing of skin flora contaminants. We aimed to understand how organisms detected in pericardial fluid inoculated into blood culture bottles were interpreted clinically. Methods: We investigated a cluster of four patients with coagulase-negative Staphylococcus (CoNS) isolated in pericardial fluid inoculated blood culture bottles (PF-BCxBs) over a 2-week period; three of these patients had recent cardiac surgery and were initially flagged as potential SSIs. We further expanded to a retrospective review and identified 28 patients with ≥1 organism isolated from PF-BCxBs from 7/2021 to 6/2023. Clinical, microbiological, and pharmacy data were abstracted. The primary outcome was the proportion of patients with a clinically diagnosed infection. Results: Investigation into the initial cluster revealed a pseudo-outbreak - three of four patients had no clinical evidence of infection (CoNS was deemed a contaminant); one was treated for a potential infection. All patients had concomitant negative routine fluid cultures. Discussions with the cardiology teams revealed areas for improvement in the process for inoculating fluid into blood culture bottles. From the two-year review, 18% (5/28) of patients were clinically diagnosed with an infection (two Staphylococcus aureus; two CoNS; one Candida rugosa). Of the patients without Staphylococcus aureus, all three had a concomitant negative routine fluid culture, were receiving antibiotics prior to pericardiocentesis, and had white blood cell counts (WBC) >12 K/uL. The remaining 82% (23/28) of patients were deemed not to have an infection. Of these 23 patient without infection, organisms isolated were 16 CoNS (70%) and seven Cutibacterium species (30%). None of these patients had a fever, one (4%) was receiving pre-pericardiocentesis antibiotics, and three (9%) had WBC >12 K/uL. 70% (16/23) of these patients were started on antibiotics after gram-stain results; all were eventually discontinued (mean antibiotic days = 2, range 1-5 days). 83% (19/23) of these patients had a concomitant negative routine fluid culture. Conclusion: The majority of patients with an organism isolated from PF-BCxBs had either CoNS or Cutibacterium species and were deemed not to have a clinical infection. Within the small cohort limitations, clinical utility of blood culture bottle inoculation seems highest for patients with pre-procedural concern for infection. IPC teams should be aware of the non-pathogenic skin flora frequency and potential implication on SSI surveillance.

Objective: To describe whether detecting plasma microbial cell-free DNA by next-generation sequencing (NGS) provided additional information compared to routine cultures or led to change in antimicrobial management. Design and setting: This is a retrospective cohort study evaluating NGS tests performed on patients who were admitted to an 11-acute care hospital health system in the greater Houston area between May 2022 and May 2023. Repeat tests on the same patient encounter were included if >7 days from previous test. Routine microbiology data was compared if test was collected within 7 days before or after NGS testing. Results: During the study period there were 135 unique patient encounters identified with an NGS order. Of which, 74.1% were ≥18 years of age and 46.7% were immunocompromised. A total of 143 NGS tests were ordered, with 4 not being run due to quality control issues. Out of 139 NGS tests completed, 76 (54.7%) were positive for at least one organism. When compared to routine testing, NGS alone was positive in 29 (20.9%) instances, routine testing alone was positive in 17 (12.2%) instances, both were positive in 44 (31.7%) instances, and both were negative in 49 (35.3%) instances. In the 44 instances that both NGS and routine testing were positive, 15 (34.1%) were concordant for all organisms. In total, NGS identified 92 more organisms (69 bacterial, 8 fungal, and 15 viral) compared to routine testing and routine testing identified 42 more organisms (28 bacterial, 6 fungal, 11 viral, and 1 parasite) compared to NGS. Fifty-six changes to antibiotic therapy were made within 48 hours of the NGS test resulting, with 16 of these changes being directly attributed to NGS test. Nine of these changes being escalations and seven being de-escalations. Conclusion: NGS may aid in determining further testing, earlier detection of pathogens, and detection of pathogens outside of routine testing resulting in direct changes to antimicrobials. However, results need to be interpreted with caution. NGS can miss pertinent pathogens and is difficult to interpret when commensal organisms are detected, both of which can lead to unnecessary testing or treatment. There is an absence of a clear algorithm for the use of NGS testing and the test comes with a high price and unclear utility. Further studies are needed to determine which patients may most benefit from NGS testing.

Background: Interventions targeting urine culture stewardship can improve diagnostic accuracy for urinary tract infections (UTI) and decrease inappropriate antibiotic treatment of asymptomatic bacteriuria. We aimed to determine if a clinical decision support (CDS) tool which provided guidance on and required documentation of the indications would decrease inappropriately ordered urine cultures in an academic healthcare network that already uses conditional (e.g. reflex) urine testing. Methods: In October 2022, four hospitals within one academic healthcare network transitioned to a new electronic health record (EHR). We developed an embedded CDS tool that provided guidance on ordering either a urinalysis (UA) with reflex to urine culture or a non-reflex urine culture (e.g. for pregnant patients) based on the indication for testing (Figure 1). We compared median monthly UA with reflex culture and non-reflex urine culture order rates pre- (8/2017–9/2022) and post- (10/2022–9/2023) intervention using the Wilcoxon rank-sum test. We used interrupted time-series analyses allowing a one-month time window for the intervention effect to assess changes in monthly UA with reflex culture, non-reflex urine culture, and total urine culture order rates associated with the intervention. Using SAS 9.4, we generated Durbin-Watson statistics to assess for autocorrelation and adjusted for this using a stepwise autoregressive model. Result: The median monthly UA with reflex culture order rates per 1000 patient-days were similar pre- and post- intervention at 36.7 (interquartile range [IQR]: 31.0–39.7) and 35.4 (IQR: 32.8–37.0), respectively (Figure 2). Non-reflex and total urine culture rates per 1000 patient-days decreased from 8.5 (IQR: 8.1–9.1) to 4.9 (IQR: 4.7–5.1) and from 20.0 (IQR: 18.9–20.7) to 14.4 (IQR: 14.0–14.6) post-intervention, respectively. Interrupted time-series analyses revealed that the intervention was associated with a decrease in the monthly non-reflex urine culture by 4.8 cultures/1000 patient-days (p< 0.001) and in the total urine culture monthly order rates by 5.0 cultures/ 1000 patient-days (p < 0 .001) [Figures 3a and b]. The UA with reflex order rate did not significantly change with the intervention (not pictured). Conclusion: In an academic healthcare network that already employed conditional urine testing, the implementation of an EHR-based diagnostic stewardship tool led to additional decreases in both non-reflex and total urine cultures ordered.

Introduction: Many central line-associated bloodstream infections are identified in patients nearing the end of life. Stanford Health Care recently introduced the General Inpatient Hospice program. This program offers inpatient hospice care for patients who, due to uncontrolled symptoms, cannot be discharged to a hospice facility or receive home hospice care. We investigated whether this program would impact blood cultures practices near the time of death. Methods: We performed a retrospective cohort study at Stanford Health Care using records of blood culture events from May 2019 to October 2023. We defined a blood culture near-death as those collected within 2 days before the date of death. We performed an interrupted time series linear regression before and after the implementation of the General Inpatient Hospice program on July 1, 2022 to assess blood culture intensity near-death. Blood culture intensity was defined as the proportion of cultures collected near-death in relation to the total number of blood cultures. Additionally, we calculated blood culture positivity rate, which was defined as the proportion of positive blood cultures among all those collected during our study period. Results: Out of 220,269 blood cultures from 24,955 unique patients, a total of 6,147 cultures (9%) were obtained near the time of death. Among these subjects, the median age was 65 years (range 20–102), with 43% identifying as being of White race-ethnicity and 57% as male. Of these cultures, 3044 were positive (49.5%), with Escherichia coli (618, 24%), Klebsiella pneumoniae (341, 13%), and Staphylococcus aureus (166, 10%) being the most common organisms. After the implementation of the General Inpatient Hospice program, the median enrollment was 12 patients (range 3–18) and the median mortality rate was 2.3% (range 2–3%). The blood culture intensity near death decreased by 0.81%, a change that was not statistically significant (95% CI -2.4% to 0.8%, p=.32; Figure 1). Subsequently, the blood culture intensity showed a non-significant increasing trend of 0.05% (95% CI -0.1% to 0.2%, p=0.53). The blood culture positivity rate near the time of death increased by 16% following the intervention, but this increase was not statistically significant (95% CI – 11.8% to 43.3%, p=.26; Figure 2), and it was followed by a non-significant downtrend of 1.9% (95% CI -3.9% to 1.4%, p=.36). Conclusion: We found no significant association between the implementation of an inpatient hospice program and blood culture practices near the time of death, likely due to low patient enrollment.

Introduction: There is a need to optimize blood culture (BC) utilization among hospitalized adults. A previous study showed an evidence-based BC algorithm improved BC utilization in a medical intensive care unit (MICU) at a large academic center. Our aim is to evaluate the impact of an intervention based on this algorithm on blood culture utilization in the MICU at Stanford Health Care, a referral center known for its high volume of solid organ transplants. Methods: We conducted a before-after study evaluating the impact of a BC diagnostic stewardship program in the MICU at Stanford Health Care, a 20-bed unit with an average of 20% lung transplant patients per day. All patients ≥18 years of age admitted to the unit during the study period were included. We adopted a previously published evidence-based algorithm detailing syndromes with low and high risk for bacteremia, which was referenced during patient rounds. Additionally, education and feedback to providers about BC utilization and indication inappropriateness was performed during leadership meetings every other month. We performed an interrupted time series analysis using historical data 17 months before the implementation of the blood culture stewardship program on April 1, 2022 and 8 months after. We assessed changes on BC utilization adjusted to patient days and crude mortality rate during the same period as a balancing measure. Results: Before the implementation of the program, the median BC utilization was 216 per 1,000 patient days (range 150–250 per 1,000 patient days). Following the introduction of the program, there was a significant decrease in blood culture utilization by 5% (95% CI -10% to -1%, p=.02; Figure 1). Post-intervention, the blood culture stabilized, with no significant increase observed (0.09% increase, 95% CI -0.7% to 1%, p=.81). The mortality rate, prior to the implementation of the program, had shown a significant downward trend of 1.4% over time (95% CI -3% to -0.2%, p=.02). After the intervention, a nonsignificant decrease of 8% was observed (95% CI -44% to 27%, p=.62; Figure 2), followed by a nonsignificant upward trend of 6% (95% CI -1% to 13%, p=.10). Conclusion: We observed a significant reduction in BC utilization after implementing the BC diagnostic stewardship program in a MICU frequented by a high number of lung transplant patients.

Background: Gram-negative bacilli (GNB) bacteremia is a common and potentially fatal infection with mortality rates estimated to be 14-34%, despite effective antimicrobial treatments. Follow-up blood cultures (FUBCs) are blood cultures that are repeated after an initial positive culture and are indicated in certain clinical scenarios, such as in candidemia or Staphylococcus aureus bacteremia to ensure clearance of the bloodstream infection. FUBCs are used in bacteremia to assess the appropriateness and duration of antimicrobial therapy. Currently, there are no guidelines in place regarding the use of FUBC for GNB bacteremia. Furthermore, the utility of FUBCs is not well-studied in adults living with cancer. The purpose of this study is to identify risk factors associated with persistent GNB bacteremia in adult patients with cancer. Methods: We conducted a single-center, retrospective study in patients aged ≥18 years, hospitalized during calendar year 2022, living with cancer, and with laboratory confirmed GNB bloodstream infection. FUBC was defined as a blood culture performed within 7 days of the initial positive blood culture. Patients were grouped as having the same organism on FUBC (+/same), FUBC with no growth (NG) (+/NG), and different organism on FUBC (+/Different). Patients with a different organism on FUBC were excluded from analysis. We gathered demographic information, suspected source of bacteremia, type of malignancy, identified organisms, presence of antimicrobial resistance, and comorbidities (eg. presence of central venous catheters, urinary catheters, end-stage renal disease). Categorical variables were compared using Chi-square or Fisher’s exact test. Continuous variables were compared using Wilcoxon rank sum tests. Logistic regression analysis was used to identify the independent predictors of persistent GNB bacteremia. Results: 356 unique patients with FUBC were identified after inclusion/exclusion criteria. 93/356 (26%) of patients had persistent GNB bacteremia (+/same). Multivariate analysis identified history of bacteremia within the preceding year (OR 2.95, 95% CI [1.6-5.6]) and Achromobacter spp. bacteremia (OR 10.03, 95% CI [1.59-63.23] as independent risk factors for persistence. Organisms with multidrug resistance such as extended-spectrum beta-lactamase (OR 2.47, 95% CI [1.21-5.07]) and carbapenem-resistant organisms (OR 3.35, 95% CI [1.04-10.81]) were also associated with persistent GNB bacteremia. Conclusions: This is the first study to specifically identify risk factors for persistent GNB bacteremia in patients living with cancer. FUBC may be useful in GNB bacteremia with less common organisms and/or if they exhibit multidrug resistance on susceptibility testing. The utility of FUBC should be further explored in patients with cancer with certain risk factors.

Background: Infections lead to high mortality among patients on chronic dialysis; knowledge of multi-drug resistant infections is limited. The Centers for Disease Control and Prevention’s Emerging Infections Program (EIP) conducts laboratory- and population-based surveillance for carbapenem-resistant Enterobacterales (CRE) in 10 U.S. sites and carbapenem-resistant Acinetobacter baumannii (CRAB) in 9 U.S. sites. We investigated clinical characteristics, healthcare exposures, and outcomes of CRE and CRAB cases in persons on chronic dialysis from 2016-2021. Methods: Among EIP catchment-area residents on chronic dialysis, we defined a CRE case as the first isolation of Escherichia coli, Enterobacter cloacae complex, Klebsiella aerogenes (formerly Enterobacter aerogenes), Klebsiella oxytoca, Klebsiella pneumoniae, or Klebsiella variicola resistant to any carbapenem, from a normally sterile site or urine in a 30-day period. A CRAB case was defined as the first isolation of Acinetobacter baumannii complex resistant to any carbapenem (excluding ertapenem), from a normally sterile site or urine (or lower respiratory tract or wound since 2021) in a 30-day period. Medical records were reviewed. A case was considered colonized if the case culture had no associated infection type or colonization was documented in the medical record. Descriptive analyses, including analyses stratified by pathogen, were conducted. Results: Among 426 cases, 314 were CRE, and 112 were CRAB; most cases were male (235, 55.2%), Black (229, 53.8%), and 51-80 years old (320, 75.1%) (Table). An infection was associated with 363 (85.2%) case cultures; bloodstream infections (148; 40.8%), urinary tract infections (134; 36.9%), and pneumonia (17; 4.7%) were the most frequent. Overall, most cases had documented healthcare exposures (excluding outpatient dialysis) in the year before incident specimen collection, including: 366 (85.9%) hospitalizations, 235 (55.2%) surgeries, 209 (49.1%) long-term care facility stays, 54 (12.7%) long-term acute care facility stays. Additionally, 125 (29.3%) had an intensive care unit admission within the 7 days before incident specimen collection. Compared to CRE cases, a higher proportion of CRAB cases (a) had a long-term care facility stay (82/112 [73.2%] versus 127/314 [40.5%], P<.0001) or hospitalization (103/112 [92%] versus 263/314 [83.8%], P = .03) within the preceding year and (b) died within 30 days of incident specimen collection (40/112 [35.7%] versus 64/314 [20.4%], P = .001). Discussion: Among CRE and CRAB cases in persons on chronic dialysis, healthcare exposures were common, and mortality was high. Additional efforts to better describe the burden of these organisms and associated risk factors in the dialysis population are needed for tailoring infection prevention strategies to this vulnerable.

Background: Immediate use steam sterilization (IUSS) is a potential risk factor for surgical site infection (SSI). During a regulatory survey, it was discovered that IUSS rates for a 767-bed hospital exceeded what had been reported to Infection Prevention (IP) and surgery leaders (estimated at an average of 60 instances per month, with approximately 40 of those in orthopedic cases). A Quality Improvement (QI) project to reduce IUSS was implemented. Methods: The QI project started with the requirement of three signatures for every cycle of IUSS (surgery management, sterilization management, and IP). Additional trays were ordered to provide an ample supply for cases. Surgery personnel were no longer allowed to perform IUSS, and the number of sterilizers available for IUSS was reduced from 8 to 1. The project was fully implemented as of December 2019. To evaluate the impact, SSI rates for hip and knee prothesis were compared using chi square analysis (Epi Info, CDC); before QI project rates were measured from 2017-2019 and after QI project rates were measured for 2020-2022. No other changes were made that were anticipated to impact orthopedic SSI rates. Results: There were no instruments or implants processed by IUSS after December 2019. Prior to the project, there were 9 hip SSI (rate = 0.54 per 100 procedures) and 14 knee SSI (rate = 0.49 per 100 procedures). After the project, hip SSI decreased by 76% (2 SSI, rate = 0.13 per 100 procedures, p = < 0 .05) and knee SSI decreased by 18% (7 SSI, rate = 0.41 per 100 procedures, p=0.67). Conclusion: A multidisciplinary QI project was successful at drastically reducing the use of IUSS, and a correlating statistically significant decrease in hip SSI and clinically significant decrease in knee SSI was seen for 3 years after the project was completed.

Disclosure: Kathleen McMullen: Speaker - 3M

Background: In order to become a new, state-of-the-art orthopedic institute with additional operating rooms, and a brand new sterile processing department (SPD), construction needed to be done within a sterile environment. Expansion of the operating room (OR) included adding a whole new wing, with smaller construction work within the open and active OR. While construction for a new SPD occurred in the midst of an active and open SPD; unlike the addition of the OR, new SPD construction included heavy demolition and multiple dust generating projects. There were many lessons learned from the built of this brand new institute, which took place in the middle of a pandemic era. Method: Each project involved in the making of the new orthopedic institute required an Infection Control Risk Assessment (ICRA), as well as walkthroughs and team meetings prior to the start of work. Team meetings involved the hospital Infection Preventionist (IP), the construction project manager, and the departments [involved] managers. Requirements, to mitigate dust dispersal into the neighboring sterile environment, were listed in the ICRA. In addition, weekly rounding was conducted by the team to ensure air flow requirements were followed, and there were no accumulation of dust dispersing to the sterile side. Reprocessing was also conducted at sister facilities when existing reprocessing items (sterilizers, instrument washers, cart washers, etc) were shut down; the hospital also went on bypass a few times in order to accommodate patients who emergently needed operating services. Result: By April 2022, after two years of construction, the new orthopedic institute with 12 new operating rooms, new ambulatory surgery units (ASU), new post anesthesia care units (PACU), and a brand new SPD went live. There were more than 100 shutdown notices, over 50 alternative practices in place to continue daily operations while also allowing construction work to continue. Noncompliance to any of the requirements was immediately followed up with an urgent notice to the project manager. Conclusion: Hindsight, heavy construction in a sterile environment is not preferred and it would have been easier to add on a new SPD, similar to how the OR additions were added; instead of building within an actively open sterile environment. Multidisciplinary team meetings conducted at the very beginning of the project would have prevented many shut downs and alternate practices; . It is pertinent that IPs and clinical department managers are involved at the most earliest phases of the construction.

Background: Antimicrobial resistance is a growing problem in Candida spp., leading to treatment challenges and increased morbidity and mortality. The World Health Organization (WHO) fungal priority pathogens list classifies C. glabrata, C. tropicalis, and C. parapsilosis as high priority and leading causes of candidemia with high fluconazole resistance. In the US, these organisms are the most frequently isolated non-albicans Candida species. In 2016, the Antibiotic Resistance Laboratory Network (ARLN) was created to monitor resistance threats, including in Candida spp. This study describes the proportion of resistance in C. glabrata, C. parapsilosis, and C. tropicalis isolates sent to the Southeast ARLN from 2017 to 2023. Methods: This study evaluated C. glabrata, C. parapsilosis, and C. tropicalis submitted to the Southeast ARLN from Alabama, Florida, Georgia, Louisiana, Mississippi, and Tennessee from February 2017- September 2023. Species identification was confirmed by Bruker Biotyper matrix assisted laser desorption-ionization time of flight (MALDI-TOF). Antifungal susceptibility testing (AFST) was performed using TREK frozen broth microdilution panels. Minimum inhibitory concentration values from the clinical instrument were used to determine susceptibility based on Clinical and Laboratory Standards Institute (CLSI) standard interpretations from the 2020 CLSI M60 guidelines. Data were extracted from the laboratory information management system. Analyses were conducted using SAS v9.4. Results: AFST testing was performed on 660 C. glabrata, 500 C. parapsilosis, and 233 C. tropicalis isolates from within the Southeast region. The predominant specimen sources by species were blood 25.30% C. glabrata; other/not specified 27.80% C. parapsilosis; and lower respiratory 36.91% C. tropicalis. Resistance to fluconazole is as follows: C. glabrata, 12.88%; C. parapsilosis, 3.41%; C. tropicalis, 36.64%. Resistance to voriconazole is as follows: C. parapsilosis, 1.00%; C. tropicalis 30.04%. Resistance to at least one echinocandin (Anidulafungin, Capsofungin, Micafungin) is as follows: C. glabrata, 1.67%; C. parapsilosis, 0.60%; C. tropicalis, 0.43%. Overall, there was a decreasing trend in resistance to fluconazole, and voriconazole in all three species between 2017 and 2023. Conclusions: Antifungal resistance in non-albicans Candida species represents an emerging public health threat, however, within the Southeast region, ARLN data has shown a decreasing trend of azole resistance. This may be due in part to changes in reporting requirements and submission criteria from within the region. Nevertheless, C. tropicalis showed high resistance to azoles within the Southeast region. These Candida species should be monitored to inform clinical decision making and identify resistance patterns in other US regions due to their increase in resistance worldwide.

Candida auris is an emerging multidrug-resistant pathogenic yeast capable of causing severe illness in the healthcare environment. It spreads easily amongst patient populations, is often resistant to anti-fungal treatments and can survive on surfaces for prolonged periods. In the current study, 85 sites within hospital settings were screened for surface-contaminated Candida species and C. auris. Surface swab samples were transferred to chromogenic agar media designed to isolate and identify Candida species and were incubated at 35°C for 48 hr. Samples were confirmed using molecular techniques designed to specifically target C. auris from other Candida species. Data was compiled to show prevalence of six key Candida species (C. albicans, C. auris, C. glabrata, C. krusei and C. tropicalis). Survivability on surfaces was performed using CDC B11903 C. auris strain. Plastic, metal and fabric surfaces used were purchased from a medical supply store. Once inoculated with 500 CFU/ml in sterile distilled water, the surfaces were kept in a Class II hood with minimal airflow and ambient conditions (21°C, 60% RH) and sampled daily. Results showed 25 of the 85 (29.4%) tested sites were positive for Candida species, with 3 of those sites positive for C. auris. Anti-fungal resistance among the three isolates (tested using concentration gradient test strips) showed notable resistance to fluconazole, but not to amphotericin B nor micafungin. C. auris survivability was dependent upon surface type, with the C. auris test strain surviving for 39 days on three different types of hospital curtains, and ≥10 days on a variety of non-porous plastic or metal surfaces. With demonstrated survivability of C. auris for long periods of time on hospital surfaces, it becomes critical for healthcare facilities to consider C. auris when developing infection prevention programs.

Background: Candida auris, an emerging multidrug-resistant fungus, is often difficult to control in hospital outbreaks. We report the hospital investigation and findings of a transmission of C. auris from patients hospitalized in an adult unit to a pediatric unit, the first in Maryland. Methods: Between June and September 2023, C. auris was recovered from two patients admitted to an adult Neuroscience Intensive Care Unit (ICU) and a patient admitted to a pediatric ICU. Infection control initiated an investigation involving staff interviews, observations and chart reviews. Cases were defined as any patient with clinical or surveillance cultures growing C. auris. Point prevalence surveillance was conducted by collecting nares and composite axilla/groin swabs from patients on the affected units. Environmental cultures collected using moistened E-Swabs (Copan, Murrieta, CA) from shared supplies were plated on CHROMagar Candida (BD, Sparks, MD). C. auris isolates from patients hospitalized at the facility between February 2022 and October 2023 were analyzed by WGS for relatedness. WGS was performed using Illumina NextSeq 300 bp paired-end sequencing (Illumina, San Diego, CA). Single nucleotide polymorphism (SNP) analysis was performed by comparing raw reads to the reference C. auris B8441 genome for subsequent clustering analysis (Ares Genetics, Vienna, Austria). Results: WGS demonstrated isolates from two adults and one pediatric patient were less than three SNPs different, suggesting a shared isolate. One additional pediatric case was identified from surveillance cultures collected from 27 patients. Investigation into possible transmission routes revealed healthcare personnel serving both units, specifically clinical teams and continuous electroencephalography (cEEG) technologists. Additionally, cEEG equipment was used on both adult and pediatric patients and twelve equipment surface swabs and three samples each of measuring tape and gel were collected. C. auris was not isolated, however sensitivity of environmental sampling is unclear and suspicion for possible fomite/environmental transmission persisted. Other possible transmission routes included gaps in hand hygiene, isolation, disinfection of shared equipment, and reuse of single-use items. Interventions included improving and monitoring infection prevention practices, educating multi-disciplinary personnel and heightened environmental cleaning. Conclusion: This case highlights the feasibility of transmission of C. auris between patients admitted to a geographically distant unit. Our investigation revealed multiple possible routes of transmission including direct contact (from healthcare personnel or equipment) or indirect environmental sources. Prevention of hospital-associated C. auris transmission likely necessitates meticulous adherence to hand hygiene, contact precautions, and careful cleaning and disinfection of patient environments and equipment used by all disciplines.

Disclosure: Patricia Simner: Research Contracts: BD Diagnostics, OpGen Inc., Qiagen Sciences Inc, T2 Diagnostics, Accelerate Diagnostics; Research Collaborators:Ares Genetics, CosmosID, IDbyDNA, Illumina; Consulting: OpGen Inc., BD Diagnostics, Shionogi Inc., GeneCapture, Qiagen Sciences Inc, Entasis, Day Zero Diagnostics, Next Gen Diagnostics

Background: Extrapulmonary nontuberculous mycobacteria (ENTM) infections are difficult to treat and often require prolonged therapy or surgery. Few population-based studies describe ENTM epidemiology, though well-known healthcare-associated outbreaks have occurred. Using the first year of multi-site ENTM surveillance, we characterized rates and how frequently ENTM infections may be related to healthcare. Methods: CDC’s Emerging Infections Program conducted active, laboratory- and population-based surveillance for ENTM cases in 4 sites (Colorado [5 counties], Minnesota [statewide], New York [1 county], and Oregon [statewide]) in 2021. An incident ENTM case was NTM isolation from a non-pulmonary specimen, excluding stool or rectal swabs, in a resident of the surveillance area without either medical record documentation of prior ENTM infection or isolation of ENTM in the prior 12 months. Demographic, clinical, information on selected healthcare and community exposures, and laboratory data were collected via medical record review. We calculated incidence per 100,000 population using U.S. Census population estimates and performed descriptive analyses. Results: A total of 180 incident ENTM cases were reported in 2021. The crude annual incidence rate was 1.3 per 100,000 persons. Incidence increased with age (from 0.95 per 100,000 among 0–17 year-olds to 2.65 per 100,000 among persons ≥65), ranged from 0.8 among non-Hispanic Asian persons to 1.6 per 100,000 in non-Hispanic Black persons, and was similar among males (1.3 per 100,000) and females (1.4 per 100,000; Figure 1). Mycobacterium avium complex (64 [35.6%]) was the most frequently isolated species group, followed by Mycobacterium chelonae complex (31 [17.2%]). Skin and soft tissue infections were the most frequent infection type (37 [20.6%]); 27 cases (15.0%) were associated with disseminated and/or only bloodstream infection, and 56 cases (31.1%) had no infection type documented. Among 93 cases with localized ENTM infections (i.e., infections that were not disseminated and/or only bloodstream infections), 38.7% had only healthcare-related exposures, 14% had only community-related exposures and 6.5% had both exposure types at the site of infection (Figure 2). Healthcare-related exposures at the infection site included surgery (23.7%), injection/infusion (21.5%), and medical devices (18.3%). The most frequent community-related exposure at the infection site was trauma (17.2%). Only one case was part of a known outbreak, which was healthcare-associated. Conclusions: ENTM infections are relatively rare, but nearly half of patients with localized ENTM infections had prior healthcare-related exposures. This indicates that the burden of ENTM infections related to healthcare may be much larger than what has been suggested from reported outbreaks.

Background: Candida auris (C. auris) is a multidrug-resistant fungus that is increasingly implicated in outbreaks in healthcare facilities worldwide. The Centers for Disease Control and Prevention (CDC) and the Texas Department of State Health Services recommend healthcare facilities screen patients who are considered high-risk for C. auris, including patients with an overnight stay in a healthcare facility outside the United States (U.S.) in the previous year, or recently stayed in a rehabilitation (rehab) facility, long-term acute care (LTAC), or skilled nursing facility (SNF). Screening patients for C. auris colonization allows for early implementation of infection control measures, preventing transmission to healthcare workers and other patients. According to the CDC, most cases of C. auris result from local spread within and among healthcare facilities in the same city or state. In Texas, 160 clinical cases have been reported during the past 12 months. At present, the necessity of screening high-risk patients at our center for C. auris is not known. We aimed to determine the prevalence of C. auris colonization among our patient population. Method: During a 4-week period, we performed targeted screening of patients meeting the CDC’s high-risk definition for C. auris. Admitted patients were screened by an Infection Preventionist (IP) using the electronic health record to identify patients who were either international or admitted from a rehab or care facility. A composite swab of bilateral axilla and groin creases was collected using an eSwab™ (Becton Dickinson) and sent to a reference lab (Mayo Clinic Laboratories) for polymerase chain reaction (PCR)-based detection of C. auris. Additionally, we reviewed historic cases of C. auris diagnosed at our institution to better define our at-risk patients. Results: Between July 14 – August 8, 2023, we consecutively screened 25 high-risk patients, including 18 (72%) international and 7 (28%) patients from rehabs, LTAC, or SNF. None were positive for C. auris. Since 2019, we identified six patients with C. auris positive cultures, including five clinical cases and one colonization case. Five patients were international and one was local with no history of international travel or stay in a care facility. Interestingly, all six were known to be colonized with extended-spectrum beta-lactamase (ESBL) E. coli. Conclusion: We have a very low prevalence of C. auris among CDC-defined high-risk patients. A review of historic C. auris cases indicated an association with colonization by other multidrug-resistant organisms, specifically ESBL E. coli, which will inform future screening protocols at our institution.

Disclosure: Roy Chemaly: Contracted Research paid for my institution: Merck, Karius, AiCuris, Ansun Pharmaceuticals, Takeda, Genentech, Oxford Immunotec, and Eurofins-Viracor; Honorarium/Ad Board/Consultant: ADMA Biologics, Janssen, Merck/MSD, Partner Therapeutics, Takeda, Shinogi, AiCuris, Roche/Genentech, Astellas, Tether, Oxford Immunotec, Karius, Moderna, and Ansun Pharmaceuticals; Stock Options: Xenex

Background: Candida auris reporting and submission of confirmed or possible isolates has been mandatory in Minnesota since August 2019. On August 9, 2023, the Minnesota Department of Health (MDH) was notified of a C. auris isolate in hip tissue from a patient in acute care hospital A (ACH-A). Only 9 cases of C. auris were detected prior to August 2023, in Minnesota, and all from patients with a history of international healthcare or healthcare in endemic C. auris locations of the United States. Methods: The MDH Public Health Laboratory (MDH-PHL) confirmed identification of C. auris from the ACH-A isolate by MALDI-TOF. MDH partnered with ACH-A to review medical records, assess infection prevention and control (IPC) practices, conduct contact tracing, and identify patients for colonization screening. Screening was performed on all patients that overlapped with the index case (case A) and were admitted to a facility in the same healthcare system as ACH-A. Facilities accepting discharged patients who overlapped with case A were contacted for colonization screening. Overlapping patients, no longer admitted to a healthcare facility, were sent a notification letter, and offered outpatient screening. Composite axilla/groin swabs were screened for C. auris using real-time PCR at MDH-PHL, who also performed whole genome sequencing (WGS) and single nucleotide polymorphism (SNP) analysis. Results: Case A’s medical record showed only Minnesota healthcare exposures, a surgical procedure in June 2023 and indicated the case overlapped with a previous case (case B) from July 2023, who had recent international healthcare. The two cases were hospitalized at ACH-B July 12-18, on different care floors without evident links to shared services. However, the cases were in adjacent rooms in ACH-B Emergency Department (ED) on July 3 for 5 hours, when C. auris status of case B was unknown. WGS indicated both isolates were within clade I (South Asian) and separated by 2 SNPs, suggesting relatedness. Extensive colonization screening occurred among 109 potentially exposed patients, including 18 patients from the ED. No additional C. auris was detected. Conclusions: This case represents the first detected transmission of C. auris within a Minnesota healthcare facility. The role of C. auris transmission within the ED is not well understood. Medical record review in combination with WGS analysis suggests potential transmission within the ED. Clinicians should be aware of the risks for C. auris transmission in the ED and follow all IPC measures to prevent transmission of this emerging fungal pathogen.

Background: Candida auris is an emerging multidrug resistant fungus that presents a serious global health threat and causes severe infections with a high mortality rate in hospitalized patients with significant underlying comorbidities. We describe the risk factors and clinical outcomes associated with C. auris in Southeast Michigan. Methods: This is a retrospective case series of culture-positive C. auris patients who had contact with our healthcare facility in Detroit from 2021 to 2023. We evaluated demographics, comorbidities, risk factors, and outcomes. A comparative analysis of colonized and infected patients was performed. Results: Forty-eight (81%) colonized and 11 (19%) infected patients were included (Table); 70% were male with median age of 66 years. All variables were comparable between the two groups except chronic kidney disease, which was significantly more prevalent among colonized patients (40% vs 0, p=0.011). All patients had prior exposure to acute care hospital (ACH), 37% to long-term acute care hospital, and 42% to skilled nursing facility within 1 year of diagnosis. Chronic wounds, prior broad-spectrum antibiotic use, and indwelling devices were prevalent in both groups; more than half required mechanical ventilation in the last month, and one third had tracheostomy at the time of C. auris detection. Almost 60% had a prior history of drug-resistant organisms, including multi-drug resistant gram negative (37%) and carbapenem-resistant (20%) organisms. Blood (82%) and wound (18%) were sources of invasive candidiasis. More than half (61%) of the testing was performed at ACH. Nine patients (82%) with invasive disease were treated with echinocandins (88%); among the colonized, two (4%) were treated with echinocandins but had persistent colonization. Thirty-day mortality was not significantly different among the two groups and was nearly 20%. Conclusions: In this large cohort study, a history of healthcare exposure, drug-resistant organisms, use of broad-spectrum antibiotics, indwelling devices, and chronic wounds were common risk factors among C. auris patients. Limiting the use of broad-spectrum antimicrobials and invasive devices, adherence to infection prevention and control practices, and interfacility transfer communication are important mitigating strategies to reduce the incidence and spread of C. auris.

Background: Candida auris is an emerging threat to hospitalized patients and invasive disease is associated with high mortality. This study describes clinical and microbiological characteristics of nine patients identified with C. auris at Ohio State Wexner Medical Center discovered through active surveillance or clinical investigation and uses whole genome sequencing (WGS) to compare isolates. Methods: In November 2022, an active C. auris surveillance program was implemented to screen patients admitted to high-risk units (intensive care units and progressive care units). Bilateral axilla and groin swabs were obtained upon unit admission and, if positive, were submitted for C. auris polymerase chain reaction (PCR) with culture and sensitivity testing. Patients with a positive screening or clinical isolate from November 2022 to November 2023 underwent chart review for clinical characteristics, microbiologic data, and index admission information. For each isolate, DNA was extracted and WGS was performed. Core single nucleotide polymorphism (SNP) variation identified from the sequence data was used to infer genetic relationships among the isolates. Results: Nine patients were identified between November 2022 and November 2023. The clinical and microbiologic characteristics are summarized in Table 1. All patients were hospitalized at various acute care facilities across the state at least once in the preceding 12 months. C. auris was determined to be present on admission for 6 patients. For 5 of these patients, it was their first interaction with our healthcare system. Three patients were not in contact isolation for >3 days before C. auris was identified. Unit wide point-prevalence screening was completed in these cases and no evidence of transmission was found. WGS showed eight of the nine isolates were related with 28 or less core SNP differences between isolates (Figure 1). One isolate (8) was genetically distinct with >45000 core SNP differences. Five isolates were highly related with a range of 4-15 SNP differences. No temporal or spatial overlap at our institution was identified among these five patients. Conclusions: The active surveillance program identified several patients colonized with C. auris in addition to those found through clinical testing. Multiple risk factors for C. auris were identified with high patient mortality (67%). Majority of the isolates were closely related without association with a known outbreak or epidemiologic link, suggesting a possible diffuse common reservoir. Next steps with surveillance in acute care and long-term care facilities will be critical for early detection to halt transmission of this organism.