Multidrug-resistant Organism Acquisition Research Articles

Fecal Microbiota Functional Gene Effects Related to Single-Dose Antibiotic Treatment of Travelers' Diarrhea.

Travelers' diarrhea (TD) is common among military personnel deployed to tropical and subtropical regions. It remains unclear how TD and subsequent antibiotic treatment impact the resident microflora within the gut, especially given increased prevalence of antibiotic resistance among enteric pathogens and acquisition of multidrug-resistant organisms. We examined functional properties of the fecal microflora in response to TD, along with subsequent antibiotic treatment. Fecal samples from US and UK military service members deployed to Djibouti, Kenya, and Honduras who presented with acute watery diarrhea were collected. A sample was collected at acute presentation to the clinic (day 0, before antibiotics), as well as 7 and/or 21 days following a single dose of antibiotics (azithromycin [500 mg], levofloxacin [500 mg], or rifaximin [1650 mg], all with loperamide). Each stool sample underwent culture and TaqMan reverse transcription polymerase chain reaction analyses for pathogen and antibiotic resistance gene detection. Purified DNA from each sample was analyzed using the HumiChip3.1 functional gene array. In total, 108 day 1 samples, 50 day 7 samples, and 94 day 21 samples were available for analysis from 119 subjects. Geographic location and disease severity were associated with distinct functional compositions of fecal samples. There were no overt functional differences between pre- and postantibiotic treatment samples, nor was there increased acquisition of antibiotic resistance determinants for any of the antibiotic regimens. These results indicate that single-dose antibiotic regimens may not drastically alter the functional or antibiotic resistance composition of fecal microflora, which should inform clinical practice guidelines and antimicrobial stewardship. NCT01618591.

Travel-associated multidrug-resistant organism acquisition and risk factors among US military personnel.

International travel is a risk factor for incident colonization with extended spectrum beta-lactamase (ESBL)-producing organisms. These and other multidrug-resistant (MDR) bacteria are major pathogens in combat casualties. We evaluated risk factors for colonization with MDR bacteria in US military personnel travelling internationally for official duty. TravMil is a prospective observational study enrolling subjects presenting to military travel clinics. We analysed surveys, antimicrobial use data, and pre- and post-travel perirectal swabs in military travellers to regions outside the continental USA, Canada, Western or Northern Europe, or New Zealand, presenting to one clinic from 12/2015 to 12/2017. Recovered Gram-negative isolates underwent identification and susceptibility testing (BD Phoenix). Characteristics of trip and traveller were analysed to determine risk factors for MDR organism colonization. 110 trips were planned by 99 travellers (74% male, median age 38years [IQR 31, 47.25]); 72 trips with returned pre- and post-travel swabs were completed by 64 travellers. Median duration was 21days (IQR 12.75, 79.5). 17% travelled to Mexico/Caribbean/Central America, 15% to Asia, 57% to Africa and 10% to South America; 56% stayed in hotels and 50% in dormitories/barracks. Travellers used doxycycline (15%) for malaria prophylaxis, 11% took an antibiotic for travellers' diarrhoea (TD) treatment (fluoroquinolone 7%, azithromycin 4%). Incident MDR organism colonization occurred in 8 travellers (incidence density 3.5/1000 travel days; cumulative incidence 11% of trips [95% CI: 4-19%]), all ESBL-producing Escherichia coli. A higher incidence of ESBL-producing E. coli acquisition was associated with travel to Asia (36% vs 7%, P = 0.02) but not with travel to other regions, TD or use of antimicrobials. No relationship was seen between fluoroquinolone or doxycycline exposure and resistance to those antimicrobials. Incident colonization with MDR organisms occurs at a lower rate in this military population compared with civilian travellers, with no identified modifiable risk factors, with highest incidence of ESBL acquisition observed after South Asia travel.

When Multidrug-Resistant Organism (MDRO)-Positive ICU Patient Isolation and Cohorting Is Not Feasible, What Comes Next?

BackgroundThe need for the implementation of an infection prevention strategy that included patient isolation and a cohorting procedure emerged in our ICU. Yet, isolation, as well as cohorting, were not feasible due to certain barriers associated with a high colonization pressure, open-plan ICU, inadequate bed separation, a limited number of isolation rooms, and nursing shortage. Despite these limitations, we tried to upgrade our ICU’s infection prevention efforts by developing the "universal use of contact precautions approach" for infection prevention and control for all the patients with and without multidrug-resistant organisms (MDROs), cohorting, and single room isolation. The study aimed to evaluate the effectiveness of our approach.MethodsA prospective cohort study using surveillance screening cultures for Methicillin-resistant Staphylococcus aureus (MRSA) and MDROs for a period of 18 weeks from October 1, 2018, to January 31, 2019. The main purpose of the approach was to isolate all patients (regardless of their MDRO/MRSA status) in their own bed space as if they were in an isolation room for the entire duration of their ICU hospitalization, in such a way as to prevent horizontal transmission of infection (infection acquisition) in our open-plan ICU. ResultsSeventy-eight patients were admitted to our ICU for a total of 942 patient-days; a total of 432 swabs were collected during the study period. A total of 17 (21.8%) patients were admitted with a pre-existing infection while two (2.5%) patients acquired an infection during their ICU stay (one with Acinetobacter baumannii andone with Pseudomonas aeruginosa; 1.28 acquisition per 1000 patient-days). No transmission was documented for Klebsiella pneumoniae, Enterococcus faecalis, and Staphylococcus aureus.ConclusionsOur MDRO acquisition rates suggested that the implementation of our infection control strategy potentially prevents the horizontal transmission of pathogens in an open-plan ICU, despite the high colonization pressure and the lack of isolation and cohorting procedures.

Acquisition and carriage of multidrug-resistant organisms in dogs and cats presented to small animal practices and clinics in Switzerland.

BackgroundThe emergence and spread of multidrug‐resistant organisms (MDRO) present a threat to human and animal health.ObjectivesTo assess acquisition, prevalence of and risk factors for MDRO carriage in dogs and cats presented to veterinary clinics or practices in Switzerland.AnimalsPrivately owned dogs (n = 183) and cats (n = 88) presented to 4 veterinary hospitals and 1 practice.MethodsProspective, longitudinal, observational study. Oronasal and rectal swabs were collected at presentation and 69% of animals were sampled again at discharge. Methicillin‐resistant (MR) staphylococci and macrococci, cephalosporinase‐, and carbapenemase‐producing (CP) Enterobacterales were isolated. Genetic relatedness of isolates was assessed by repetitive sequence‐based polymerase chain reaction and multilocus sequence typing. Risk factors for MDRO acquisition and carriage were analyzed based on questionnaire‐derived and hospitalization data.ResultsAdmission prevalence of MDRO carriage in pets was 15.5% (95% confidence interval [CI], 11.4‐20.4). The discharge prevalence and acquisition rates were 32.1% (95% CI, 25.5‐39.3) and 28.3% (95% CI, 22‐35.4), respectively. Predominant hospital‐acquired isolates were extended spectrum β‐lactamase‐producing Escherichia coli (ESBL‐E coli; 17.3%) and β‐lactamase‐producing Klebsiella pneumoniae (13.7%). At 1 institution, a cluster of 24 highly genetically related CP (bla oxa181 and bla oxa48) was identified. Multivariate analysis identified hospitalization at clinic 1 (odds ratio [OR], 5.1; 95% CI, 1.6‐16.8) and days of hospitalization (OR 3‐5 days, 4.4; 95% CI, 1.8‐10.9; OR > 5 days, 6.2; 95% CI, 1.3‐28.8) as risk factors for MDRO acquisition in dogs.ConclusionsVeterinary hospitals play an important role in the selection and transmission of MDRO among veterinary patients.

Healthcare Worker Perceptions of Germs and Personal Hygiene Routines in a Ventilator-Capable Skilled Nursing Facility (vSNF)

Background: During a 2017–2019 intervention in Chicago-area vSNFs to control carbapenem-resistant Enterobacteriaceae, healthcare worker adherence to hand hygiene and personal protective equipment was stubbornly inadequate (hand hygiene adherence, ~16% and 56% on entry and exit), despite educational and monitoring efforts. Little is known about vSNF staff understanding of multidrug-resistant organism (MDRO) transmission. We conducted a qualitative analysis of staff members at a vSNF that included assessment of staff perceptions of personal MDRO acquisition risk and associated personal hygiene routines transitioning from work to home. Methods: Between September 2018 and November 2018, a PhD-candidate medical anthropologist conducted semistructured interviews with management (N = 5), nursing staff (N = 6), and certified nursing assistants (N = 6) at a vSNF in the Chicago region (Illinois) who had already received 1 year of MDRO staff education and hand hygiene adherence monitoring. More than 11 hours of semistructured interviews were collected and transcribed. Data collection and analysis included identifying how staff members related to their own risk of MDRO acquisition/infection and what personal hygiene routines they followed. Transcriptions of the data were analyzed using thematic coding aided by MAXQDA qualitative analysis software. Results: Staff members at all levels were able to describe their perceptions related to the risk of acquiring an MDRO and personal hygiene in great detail. The risk of acquiring an MDRO was perceived as a constant threat by staff members, who described germs as bad and everywhere (Table 1). The perceived threat of MDRO acquisition was connected to individual personal hygiene routines (eg, changing shoes before leaving work), which were considered important by staff members (Table 2). Nursing staff and certified nursing assistants noted that personal hygiene was a critical factor keeping their residents, themselves, and their families free from MDROs. Conclusions: In the context of a quality improvement campaign, vSNF healthcare workers are aware of the transmissibility of microscopic MDROs and are highly motivated in preventing transmission of MDROs to themselves. Such perceptions may explain actions such as why workers may be differentially adherent with infection control interventions (eg, more likely to perform hand hygiene leaving a room rather than going into a room, or less likely to change gowns in between residents in multibed rooms if they believe they are already personally protected with a gown). Our findings suggest that interventions to improve staff adherence to infection control measures may need to address other factors related to adherence besides knowledge deficit (eg, understaffing) and may need to acknowledge self-protection as a driving motivator for staff adherence.Funding: NoneDisclosures: None

Chlorhexidine Bathing Strategies for Multidrug-Resistant Organisms: A Summary of Recent Evidence.

ObjectiveThe aim of the study was to summarize the latest evidence for patient bathing with a 2% to 4% chlorhexidine gluconate solution to reduce multidrug-resistant organism (MDRO) transmission and infection.MethodsWe searched 3 databases (CINAHL, MEDLINE, and Cochrane) for a combination of the key words “chlorhexidine bathing” and MeSH terms “cross-infection prevention,” “drug resistance, multiple, bacterial,” and “drug resistance, microbial.” Articles from January 1, 2008, to December 31, 2018, were included, as well as any key articles published after December 31.ResultsOur findings focused on health care–associated infections (HAIs) and 3 categories of MDROs: methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococcus (VRE), and carbapenem-resistant Enterobacteriaceae (CRE). Chlorhexidine bathing reduces MRSA acquisition and carriage, but not all studies found significant reductions in MRSA infections. Several studies found that chlorhexidine bathing reduced VRE acquisition and carriage, and one study showed lower VRE infections in the bathing group. Two studies found that bathing reduced CRE carriage (no studies examined CRE infections). Two very large studies (more than 140,000 total patients) found bathing significantly reduced HAIs, but these reductions may be smaller when HAIs are already well controlled by other means.ConclusionsThere is a high level of evidence supporting chlorhexidine bathing to reduce MDRO acquisition; less evidence is available on reducing infections. Chlorhexidine bathing is low cost to implement, and adverse events are rare and resolve when chlorhexidine use is stopped. There is evidence of chlorhexidine resistance, but not at concentrations in typical use. Further research is needed on chlorhexidine bathing’s impact on outcomes, such as mortality and length of stay.

A Pilot Study to Delineate Factors Contributing to Multi-Drug Resistant Organism (MDRO) Outbreak and Control at the Sangre Grande Hospital

BACKGROUND The Sangre Grande Hospital (SGH) experienced several Multi Drug Resistant Organism (MDRO) outbreaks for 2015. In this regard, a study was conducted to understand factors contributing to MDRO acquisition and control, for policy and implementation of prevention and control measures. METHODOLOGY A Case-Control Study Design was chosen to execute this research project in order to determine risk factors and factors associated with control of the outbreaks. This was done retrospectively from January to March 2015. Cases and controls were unmatched. Cases were defined as patients admitted to wards with a contracted MDRO, discharged or died and had a medical or surgical diagnosis. MDROs included Methicillin resistant Staphylococcus aureus (MRSA) and Multi Drug Resistant Gram-Negative Bacilli (MDRGNB). Controls were any other patients on the wards with similar demographics and diagnosis and disposition, not infected or colonized with a MDRO and had a medical or surgical diagnosis. RESULTS Eight (8) cases and ten (10) Controls were incorporated in the study. Patients recently hospitalized had 14 times the odds of the group not recently hospitalized, of developing a MDRO, 95% CI: 1.1352 – 172.6502, p = 0.05. Length of Stay (LOS) on the ward for a minimum of five days showed a significant association with MDRO acquisition (p < 0.036). The main contributory factors to increased MDRO acquisition: greater than one (1) invasive devices, urinary catheter and/or central venous catheter (p < 0.043 and p < 0.007 respectively). Most MDRO cases had at least one invasive device attached to them during their stay on the ward: Central Venous Catheter (CVC), a Urinary Catheter or both. MDRO cases mean LOS: 29.5 days (19.27 S.D.) as opposed to the controls with 5.2 days (4.29 S.D.). CONCLUSION There is a significant association between recent hospitalization and developing an MDRO. Patients with an MDRO also stayed a mean of 29.5 days compared to 5.2 days for controls.

Multidrug Resistant Organism Burden in Critically-Ill Burn Patients

<h3>Background</h3> The National Burn Repository 2019 reports burn-related data from July 2017- June 2018 of 1,101 hospitals and 221,519 patients. Large total body surface area (TBSA) burns and inhalational lung injury (ILI) are major risks for a complicated course requiring critical care support and infections are the most serious and most common complications of burns. The aim of this study is to evaluate the burden of multidrug resistant organisms (MDRO) in critically-ill burn patients. <h3>Methods</h3> Our burn center receives 3,000 visits and provides treatment for around 1300 patients annually. In 2018, 225 patients were admitted to the hospital's 9-bed critical-care burn unit. Patients who had burns more than 10% TBSA and/or ILI were included in the study if they survived more than 48 hours. The records were reviewed for length of stay (LOS), mortality, as well as MDRO clinical as well surveillance cultures. <h3>Results</h3> 55 patients were included in the study with 39 (71%) male and with an average LOS of 11 days. Inhalational lung injury was found to be present in 58% of patients. 8 patients died who had an average TBSA burn of 60%. While patients who were discharged alive had average TBSA burns of 29% and average LOS of 26 days. 22% of discharged patients were found to have MDRO acquisition detected by clinical cultures and 14% of patients had MRSA detected by follow-up nasal screening. <h3>Conclusions</h3> MDRO colonization is common in severely-ill burn patients. This highlights the importance of more aggressive MDRO surveillance in this population for early detection and prevention of hospital-associated infections and outbreaks.

70 Chlorhexidine Gluconate for Burn Wound Cleansing: Reduction in Multi-drug Resistant Organism Acquisition

Abstract Introduction Daily wound care is an important part of burn wound management to help prevent infection. Literature suggests that daily Chlorhexidine Gluconate (CHG) bathing can reduce the risk of acquiring Multi-Drug Resistant Organisms (MDRO). The purpose of this study was to identify change in overall MDRO acquisition in the Burn Unit with the addition of a 1% CHG solution for wound care to the CHG bathing protocol for burn patients. Methods Prior to March 2018, routine bathing and wound care involved use of CHG-incompatible antibacterial soap and water followed by 2% chlorhexidine gluconate cloths to intact skin. In March 2018, the bathing protocol changed, in consultation with the hospital’s infection prevention program, to involve a 1% CHG solution for burn wounds followed by 2% CHG cloths to intact skin in order to prevent the loss of protective residual CHG due to rinsing with CHG-incompatible soap and water. A solution of 1% CHG was chosen by staff as an acceptable concentration for wound bathing. Adherence was measured through review of daily documentation of bathing in the electronic medical record. Incidences of burn unit-attributable hospital-onset MDRO cultures were reviewed for the following periods: Baseline (Aug 2016-Aug 2017), Phase-In (Sept 2017 – Aug 2018) and Post-Implementation (Sept 2018 – Aug 2019). Results Adherence was &amp;gt;85% throughout the intervention period. No adverse events were noted. Incidences of hospital-onset burn unit MDROs during the following time periods were: 22 cases (Baseline), 15 cases (Phase-In), and 10 cases (Post-Implementation). The most common organisms in the baseline period were Extended-Spectrum b-Lactamase (ESBL) Escherichia coli, MRSA, and Multi Drug Resistant Pseudomonas; and post-implementation, the most common organisms were: MRSA and MDR-Pseudomonas. Conclusions A change to a 1% CHG solution for rinsing burn wounds in the setting of 2% CHG cloths to intact skin was well tolerated and associated with a decline in MDRO acquisition attributable to the burn ICU in the one-year post implementation. Applicability of Research to Practice The use of a 1% CHG solution for burn wounds may help prevent MDRO acquisition in the highly susceptible and unique burn population.

Impact of colonization pressure on acquisition of extended-spectrum β-lactamase-producing Enterobacterales and meticillin-resistant Staphylococcus aureus in two intensive care units: a 19-year retrospective surveillance

Colonization pressure is a risk factor for intensive care unit (ICU)-acquired multi-drug-resistant organisms (MDROs). To measure the long-term respective impact of colonization pressure on ICU-acquired extended-spectrum β-lactamase-producing Enterobacterales (ESBL-PE) and meticillin-resistant Staphylococcus aureus (MRSA). All patients admitted to two ICUs (medical and surgical) between January 1997 and December 2015 were included in this retrospective observational study. Rectal and nasal surveillance cultures were obtained at admission and weekly thereafter. Contact precautions were applied for colonized or infected patients. Colonization pressure was defined as the ratio of the number of MDRO-positive patient-days (PDs) of each MDRO to the total number of PDs. Single-level negative binomial regression models were used to evaluate the incidence of weekly MDRO acquisition. Among the 23,423 patients included, 2327 (10.0%) and 1422 (6.1%) were colonized with ESBL-PE and MRSA, respectively, including 660 (2.8%) and 351 (1.5%) acquisitions. ESBL-PE acquisition increased from 0.51/1000 patient-exposed days (PEDs) in 1997 to 6.06/1000 PEDs in 2015 (P<0.001). In contrast, MRSA acquisition decreased steadily from 3.75 to 0.08/1000 PEDs (P<0.001). Controlling for period-level covariates, colonization pressure in the previous week was associated with MDRO acquisition for ESBL-PE (P<0.001 and P=0.04 for medical and surgical ICU, respectively), but not for MRSA (P=0.34 and P=0.37 for medical and surgical ICU, respectively). The increase in colonization pressure was significant above 100/1000 PDs for ESBL-PE. Colonization pressure contributed to the increasing incidence of ESBL-PE but not MRSA. This study suggests that preventive control measures should be customized to MDROs.

2849. Gut Microbiota Differences at the Time of Medical Intensive Care Unit (MICU) Admission Are Associated with Acquisition of Multi-drug-Resistant Organisms (MDROs) Among Patients Not Already Colonized with an MDRO

BackgroundAmong hospitalized patients, underlying variation in gut microbiota may confer differential risk for gut MDRO acquisition.MethodsRectal swab samples were collected from patients ≤2 days of MICU admission and then daily in the 27-bed MICU of an acute care hospital in Chicago, IL over 1 year. Patients were screened for MDRO colonization by selective culture (see Figure 1 for MDRO types); those with ≥2 swabs and MICU stays ≥3 days were studied. Bacterial 16S rRNA gene amplicon sequences were used for microbiota analysis. Medical records were reviewed.ResultsIn preliminary analysis, 2,480 samples were collected from 627 patients who acquired 170 MDROs (Figure 1). Debilitation, co-morbidities, and certain medical devices were associated with MDRO acquisition, though admission MDRO status was not (table). While no interactions were detected between admission MDRO status and clinical predictors of MDRO acquisition, there were significant differences in gut microbiota composition at the time of MICU admission between patients colonized with an MDRO on admission and those not colonized (P < 0.001, using analysis of molecular variance (AMOVA) on distances). Therefore, we stratified our analysis by admission MDRO colonization status. For patients MDRO-colonized at admission, there were no significant differences in microbiota of patients who later did or did not acquire a new MDRO (AMOVA P-value = 0.32). For patients not MDRO-colonized on admission, there was a significant difference in microbiota of patients who later acquired an MDRO and those who did not (AMOVA P-value: 0.026). Differentially abundant operational taxonomic units (OTUs, based on 3% sequence difference) included OTUs classified as Anaerococcus and as other Clostridiales (higher in patients who remained uncolonized) and as Enterococcus (higher in patients who acquired an MDRO) (Figure 2). Diversity was also higher in patients who remained uncolonized (Wilcoxon test P-value: 0.035) (Figure 3).ConclusionAmong patients not already colonized with an MDRO on admission, we identified gut microbiota differences associated with MDRO acquisition that could help explain patient-level variation in MDRO colonization resistance. Disclosures All Authors: No reported Disclosures.

2846. Perirectal Samples for Analysis of the Gut Microbiota as a Predictive Tool for Multi-drug-Resistant Organism (MDRO) Acquisition in Nursing Facility (NF) Patients

BackgroundMost research examining the association between gut microbiota disruption and MDRO acquisition has been done in acute care settings. Obtaining stool samples in older NF adults is challenging. We hypothesized that perirectal samples can be used as a proxy of the gut microbiota. This prospective cohort study investigated the association between perirectal swab-derived gut microbiota features in newly admitted NF patients and the acquisition of vancomycin-resistant Enterococcus and/or resistant Gram-negative bacteria (rGNB) within 14 days.MethodsPatients were recruited at 6 MI NFs from September 2016 to October 2018 as part of a larger NIH-funded trial. Colonization status was determined by culture swabs collected from multiple body sites at enrollment, d7, and d14. Our analysis focused on patients with no MDRO at baseline, a perirectal swab collected at baseline, and at least one follow-up visit. The V4 region of the 16S rRNA gene was sequenced from samples and processed with the mothur bioinformatics pipeline. Sequences typically associated with the skin microbiota were removed. The primary outcome was any MDRO acquisition. Exposures of interest included patient and microbiota characteristics. The Microbiome Health Index (MHI) was used to assess microbiota health. An MHI of 0 indicates a balanced abundance between taxa associated with protection and dysbiosis; an MHI above/below 0 suggests better/poorer health, respectively (Figure 1).ResultsAmong 60 eligible patients (Table 1), 18 (30%) acquired MDROs within 14 days of enrollment (3 VRE, 13 rGNB, 2 both). The baseline microbiota features differed significantly in those who acquired a new MDRO. Of the major 8 phyla found across samples, patients who acquired an MDRO were depleted in the number of phyla present (4.4 ± 1.1 vs. 5 ± 1.1; P = 0.08) (Figure 2). The log-transformed relative abundance of Enterococcus was enriched in patients who acquired an MDRO (−0.7 ± 3.41) compared with those who did not (−4.2 ± 4.8; P < 0.01) (Figure 3). An MHI below 0 was predictive of MDRO acquisition after adjusting for catheter use within 30 days before baseline (adjusted OR 4.9; 95% CI 1.1–21.1).ConclusionMicrobiota metrics calculated from perirectal samples are predictive of MDRO acquisition. The clinical utility of perirectal samples warrants further assessment. Disclosures All Authors: No reported Disclosures.

894. Universal Decolonization in Nursing Homes: Effect of Chlorhexidine and Nasal Povidone–Iodine on Prevalence of Multi-Drug-Resistant Organisms (MDROs) in the PROTECT Trial

BackgroundThe prevalence of MDROs in nursing homes (NH) is much higher than that of hospitals. Decolonization to reduce the reservoir of MDRO carriage in NH residents may be a strategy to address MDRO spread within and among healthcare facilities.MethodsPROTECT is an 18-month cluster randomized trial of 1:1 universal decolonization vs. routine care in 28 NHs in California. Decolonization consists of chlorhexidine (CHG) bathing plus twice daily nasal iodophor on admission and Monday–Friday biweekly. We assessed pre- vs. post-intervention MDRO prevalence by sampling 50 randomly selected residents at each NH as an outcome unrelated to the trial’s primary intent (infection, hospitalization reduction). NH residents had nasal swabs cultured for methicillin-resistant S. aureus (MRSA), and skin (axilla/groin) swabs taken for MRSA, vancomycin-resistant Enterococcus (VRE), extended-spectrum β-lactamase producers (ESBL), and carbapenem-resistant Enterobacteriaceae (CRE). Generalized linear mixed models (GLM) assessed the difference in differences of MDRO prevalence using an arm by period interaction term, clustering by NH.ResultsFour NHs dropped from the trial. Among the 24 NHs that remained, MDRO colonization at baseline was 49.4% and 47.5% of residents in control (N = 650) vs. decolonization (N = 550) NHs, with no difference in MRSA, VRE, ESBL, and CRE (Table 1). Among remaining NHs, decolonization was associated with 28.8% raw decrease in MDRO prevalence in decolonization sites (GLM OR = 0.51, P < 0.001), 24.3% raw decrease in MRSA (OR = 0.66, P = 0.03), 61.0% raw decrease in VRE (OR = 0.17, P < 0.001), and 51.9% raw decrease in ESBL (OR = 0.40, P < 0.001). CRE increased, but numbers were small (Control arm: 10 in baseline, 4 in intervention; intervention arm: 1 in baseline, 2 in intervention, P = NS).ConclusionUniversal NH decolonization with CHG bathing and nasal iodophor resulted in a marked decrease in Gram-positive and Gram-negative MDRO prevalence. This decrease may lower MDRO acquisition, infection, and antibiotic use within NHs, as well as regional MDRO spread to other healthcare facilities. Disclosures All Authors: No reported Disclosures.

1169 Travelers' Diarrhea, Single Dose Antibiotics, Acquisition of Multi-Drug Resistance and Associations With Functional Microbiome Characterization: Is There Any There There?

INTRODUCTION: Travelers’ diarrhea (TD) is a commonly diagnosed acute illness among those visiting tropical and sub-tropical regions with substantial consequences. While antibiotic treatment (with lopermaide) substantially reduces TD symptoms and duration, a growth in concerns about the off-target effects of TD treatment on the impact of resident microflora and the potential adverse effects associated with acquisition of multi-drug resistant organisms (MDRO). To date, most microbiome analyses have studied microbial structure/composition, while the functional capabilities of the gut microbiota remain largely unstudied. We set out to understand the functional properties of the gut microflora in response to TD acquired in diverse geographic regions, associations with different single-dose therapies, MDRO acquisition. METHODS: Fecal samples from USA &amp; UK military service members in 3 continents that presented with acute watery TD were collected at acute presentation (day 1, prior to antibiotics), as well as 7 and/or 21 days following a single-dose of antibiotics (azithromycin (500 mg), levofloxacin (500 mg), or rifaximin (1650 mg) with loperamide). Each sample underwent culture and TaqMan RT-PCR analyses for pathogen detection and a limited set of ESBL-PE genetic probes. Purified DNA from each sample was analyzed using the HumiChip v2.0 microarray which contains over 150,000 DNA probes specific for genes involved in various functional processes including antibiotic resistance, virulence, stress responses, and nutrient metabolism. RESULTS: In total, 125 Day 1 samples, 64 Day 7 samples, and 105 Day 21 samples were available for analysis from 135 subjects. Ordination analysis revealed that subjects enrolled in each country had distinct functional profiles. While we did not observe overt differences in functional profiles between treatment groups, we observed an increase in functional diversity from day 1 to day 21 in the levofloxacin treatment group, relative to azithromycin and rifaximin groups. Additionally, we noted distinct geographical patterns of resistome patterns at baseline and post-illness, but lesser influence of antibiotic effects on post-treatment functional genomic composition. CONCLUSION: A thorough understanding of how antibiotics impact the functional properties of the gut microbiota will help inform future treatment options, antibiotic stewardship in TD patients, and the reduction of potential post-infective complications due to MDRO pathobionts.

Fecal Microbiome Characteristics and the Resistome Associated With Acquisition of Multidrug-Resistant Organisms Among Elderly Subjects.

Infections caused by multidrug-resistant organisms (MDRO) lead to considerable morbidity and mortality. The elderly population residing in nursing homes are a major reservoir of MDRO. Our objective was to characterize the fecal microbiome of 82 elderly subjects from 23 nursing homes and compare their resistome to that of healthy young persons. Comparisons of microbiome composition and the resistome between subjects who acquired MDRO or not were analyzed to characterize specific microbiome disruption indices (MDI) associated with MDRO acquisition. An approach based on both 16S rRNA amplicon and whole metagenome shotgun (WMS) sequencing data was used. The microbiome of the study cohort was substantially perturbed, with Bacteroides, Firmicutes, and Proteobacteria predominating. Compared to healthy persons, the cohort of elderly persons had an increased number, abundance, and diversity of antimicrobial resistance genes. High proportions of study subjects harbored genes for multidrug-efflux pumps (96%) and linezolid resistance (52%). Among the 302 antimicrobial resistance gene families identified in any subject, 60% were exclusively detected within the study cohort, including Class D beta-lactamase genes. Subjects who acquired MDRO or not had significant differences in bacterial taxa; Odoribacter laneus, and Akkermansia muciniphila were significantly greater among subjects who did not acquire MDRO whereas Blautia hydrogenotrophica predominated among subjects who acquired MDRO. These findings suggest that specific MDI may identify persons at high risk of acquiring MDRO.

Impact of an Infectious Disease Specialist on an Antimicrobial Stewardship Program at a Resource-Limited, Non-Academic Community Hospital in Korea.

Background: Implementing a successful antimicrobial stewardship program (ASP) is difficult for non-academic community (NAC) hospitals due to insufficient infrastructure. Aim: We evaluated the impact of an infectious disease specialist (IDS) on implementing an ASP in a resource-limited setting in Korea. Methods: A retrospective study was performed at a NAC hospital between June 2015 and August 2018. An IDS has led an ASP at the hospital since June 2017. We used an interrupted time series analysis to evaluate longitudinal effects of the IDS-led ASP on the amount of antibiotic use and incidence of multidrug-resistant organism (MDRO) acquisition. Findings: Total antibiotic use changed from 698.82 ± 74.41 to 602.09 ± 69.94 defined daily dose/1000 patient-days (PDs) after intervention. An immediate reduction in the use of carbapenems, glycopeptides, penicillins, and other antibiotics followed the IDS-led ASP. The 3rd/4th generation cephalosporins and carbapenems prescription rates decreased in slope after the intervention. Incidence of MDRO acquisition changed from 1.38, 0.78, and 0.21/1000 PDs to 1.06, 0.15, and 0.32/1000 PDs in methicillin-resistant Staphylococcus aureus, multidrug-resistant Acinetobacter baumannii, and multidrug-resistant Pseudomonas aeruginosa, respectively. The incidence of methicillin-resistant Staphylococcus aureus and multidrug-resistant Acinetobacter baumannii acquisition immediately decreased following intervention. Conclusion: An IDS can implement a successful ASP by reducing antibiotic consumption and MDRO acquisition at resource-limited NAC hospitals.

Prior antibiotic use and acquisition of multidrug-resistant organisms in hospitalized children: A systematic review.

Multidrug-resistant organisms (MDROs) cause ~5%-10% of infections in hospitalized children, leading to an increased risk of death, prolonged hospitalization, and additional costs. Antibiotic exposure is considered a driving factor of MDRO acquisition; however, consensus regarding the impact of antibiotic factors, especially in children, is lacking. We conducted a systematic review to examine the relationship between antibiotic use and subsequent healthcare-associated infection or colonization with an MDRO in children. Systematic review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guideline. We searched PubMed and Embase for all English, peer-reviewed original research studies published before September 2018. Included studies evaluated hospitalized children, antibiotic use as an exposure, and bacterial MDRO as an outcome. Of the 535 studies initially identified, 29 met the inclusion criteria. Overall, a positive association was identified in most studies evaluating a specific antibiotic exposure (17 of 21, 81%), duration of antibiotics (9 of 12, 75%), and number of antibiotics received (2 of 3, 67%). Those studies that evaluated any antibiotic exposure had mixed results (5 of 10, 50%). Study sites, populations, and definitions of antibiotic use and MDROs varied widely. Published studies evaluating this relationship are limited and are of mixed quality. Limitations include observation bias in recall of antibiotic exposure, variations in case definitions, and lack of evaluation of antibiotic dosing and appropriateness. Additional studies exploring the impact of antibiotic use and MDRO acquisition may be needed to develop effective antibiotic stewardship programs for hospitalized children.

Multidrug-resistant Organisms in Hospitals: What Is on Patient Hands and in Their Rooms?

BackgroundThe impact of healthcare personnel hand contamination in multidrug-resistant organism (MDRO) transmission is important and well studied; however, the role of patient hand contamination needs to be characterized further.MethodsPatients from 2 hospitals in southeast Michigan were recruited within 24 hours of arrival to their room and followed prospectively using microbial surveillance of nares, dominant hand, and 6 high-touch environmental surfaces. Sampling was performed on admission, days 3 and 7, and weekly until discharge. Paired samples of methicillin-resistant Staphylococcus aureus (MRSA) isolated from the patients’ hand and room surfaces were evaluated for relatedness using pulsed-field gel electrophoresis and staphylococcal cassette chromosome mec, and Panton-Valentine leukocidin typing.ResultsA total of 399 patients (mean age, 60.8 years; 49% male) were enrolled and followed for 710 visits. Fourteen percent (n = 56/399) of patients were colonized with an MDRO at baseline; 10% (40/399) had an MDRO on their hands. Twenty-nine percent of rooms harbored an MDRO. Six percent (14/225 patients with at least 2 visits) newly acquired an MDRO on their hands during their stay. New MDRO acquisition in patients occurred at a rate of 24.6/1000 patient-days, and in rooms at a rate of 58.6/1000 patient-days. Typing demonstrated a high correlation between MRSA on patient hands and room surfaces.ConclusionsOur data suggest that patient hand contamination with MDROs is common and correlates with contamination on high-touch room surfaces. Patient hand hygiene protocols should be considered to reduce transmission of pathogens and healthcare-associated infections.

The politics and ethics of hospital infection prevention and control: a qualitative case study of senior clinicians\u2019 perceptions of professional and cultural factors that influence doctors\u2019 attitudes and practices in a large Australian hospital

BackgroundHospital infection prevention and control (IPC) programs are designed to minimise rates of preventable healthcare-associated infection (HAI) and acquisition of multidrug resistant organisms, which are among the commonest adverse effects of hospitalisation. Failures of hospital IPC in recent years have led to nosocomial and community outbreaks of emerging infections, causing preventable deaths and social disruption. Therefore, effective IPC programs are essential, but can be difficult to sustain in busy clinical environments. Healthcare workers’ adherence to routine IPC practices is often suboptimal, but there is evidence that doctors, as a group, are consistently less compliant than nurses. This is significant because doctors’ behaviours disproportionately influence those of other staff and their peripatetic practice provides more opportunities for pathogen transmission. A better understanding of what drives doctors’ IPC practices will contribute to development of new strategies to improve IPC, overall.MethodsThis qualitative case study involved in-depth interviews with senior clinicians and clinician-managers/directors (16 doctors and 10 nurses) from a broad range of specialties, in a large Australian tertiary hospital, to explore their perceptions of professional and cultural factors that influence doctors’ IPC practices, using thematic analysis of data.ResultsProfessional/clinical autonomy; leadership and role modelling; uncertainty about the importance of HAIs and doctors’ responsibilities for preventing them; and lack of clarity about senior consultants’ obligations emerged as major themes. Participants described marked variation in practices between individual doctors, influenced by, inter alia, doctors’ own assessment of patients’ infection risk and their beliefs about the efficacy of IPC policies. Participants believed that most doctors recognise the significance of HAIs and choose to [mostly] observe organisational IPC policies, but a minority show apparent contempt for accepted rules, disrespect for colleagues who adhere to, or are expected to enforce, them and indifference to patients whose care is compromised.ConclusionsFailure of healthcare and professional organisations to address doctors’ poor IPC practices and unprofessional behaviour, more generally, threatens patient safety and staff morale and undermines efforts to minimise the risks of dangerous nosocomial infection.

Bacterial Contamination of Military and Civilian Uniforms in an Emergency Department

IntroductionThe emergency department is a fast-paced, high-volume environment, serving patients with diverse and evolving acuities. Personnel providing direct care are continually exposed to pathogenic microorganisms from patients and everyday surfaces, to which the organisms may spread. Indeed, hospital items—such as electronic devices, stethoscopes, and staff clothing—have demonstrated high rates of contamination. Despite this, policies governing the use, disinfection, and wear of various environmental surfaces remain relaxed, vague, and/or difficult to enforce. This study aimed to examine the bacterial contamination on 2 hospital uniform types in a large military hospital within the emergency department. MethodsEnvironmental sampling of military and civilian nursing staff uniforms was performed on 2 separate occasions. Emergency nurses wore hospital-provided freshly laundered scrubs on the first sampling day and home-laundered personally owned uniforms complicit with ED policy on the second sampling day. Samples were collected by impressing of contact blood agar growth medium at arrival (0 hour), 4 hours, and 8 hours of wear. Microbiological methods were used to enumerate and identify bacterial colonies. ResultsBacterial contamination of personally owned uniforms was significantly higher than freshly laundered hospital-provided scrubs on 4 different sampling sites and across the span of an 8-hour workday. No significant differences were observed between military and civilian personally owned uniforms. However, several risk factors for nosocomial infection were increased in the military subgroup. DiscussionRe-evaluating organizational factors (such as uniform policies) that increase the propensity for pathogenic contamination are critical for mitigating the spread and acquisition of multidrug-resistant organisms in the emergency department.