Common Healthcare-associated Infections Research Articles

Application of a new methodology and R package reveals a high burden of healthcare-associated infections (HAI) in Germany compared to the average in the European Union/European Economic Area, 2011 to 2012.

BackgroundHealthcare-associated infections (HAIs) pose a major challenge to health systems. Burden of disease estimations in disability-adjusted life years (DALYs) are useful for comparing and ranking HAIs.AimTo estimate the number of five common HAIs, their attributable number of deaths and burden for Germany.MethodsWe developed a new method and R package that builds on the approach used by the Burden of Communicable Diseases in Europe (BCoDE) project to estimate the burden of HAIs for individual countries. We used data on healthcare-associated Clostridioides difficile infection, healthcare-associated pneumonia, healthcare-associated primary bloodstream infection, healthcare-associated urinary tract infection and surgical-site infection, which were collected during the point prevalence survey of HAIs in European acute-care hospitals between 2011 and 2012.ResultsWe estimated 478,222 (95% uncertainty interval (UI): 421,350–537,787) cases for Germany, resulting in 16,245 (95% UI: 10,863–22,756) attributable deaths and 248,920 (95% UI: 178,693–336,239) DALYs. Despite the fact that Germany has a relatively low hospital prevalence of HAIs compared with the European Union/European Economic Area (EU/EEA) average, the burden of HAIs in Germany (308.2 DALYs/100,000 population; 95% UI: 221.2–416.3) was higher than the EU/EEA average (290.0 DALYs/100,000 population; 95% UI: 214.9–376.9). Our methodology is applicable to other countries in or outside of the EU/EEA. An R package is available from https://CRAN.R-project.org/package=BHAI.ConclusionThis is the first study to estimate the burden of HAIs in DALYs for Germany. The large number of hospital beds may be a contributing factor for a relatively high burden of HAIs in Germany. Further focus on infection prevention control, paired with reduction of avoidable hospital stays, is needed to reduce the burden of HAIs in Germany.

Psychological safety and infection prevention practices: Results from a national survey

Psychological safety is a critical factor in team learning that positively impacts patient safety. We sought to examine the influence of psychological safety on using recommended health care-associated infection (HAI) prevention practices within US hospitals. We mailed surveys to infection preventionists in a random sample of nearly 900 US acute care hospitals in 2017. Our survey asked about hospital and infection control program characteristics, organizational factors, and the use of practices to prevent common HAIs. Hospitals that scored 4 or 5 (5-point Likert scale) on 7 psychological safety questions were classified as high psychological safety. Using sample weights, we conducted multivariable regression to determine associations between psychological safety and the use of select HAI prevention practices. Survey response rate was 59%. High psychological safety was reported in approximately 38% of responding hospitals, and was associated with increased odds of regularly using urinary catheter reminders or stop-orders and/or nurse-initiated urinary catheter discontinuation (odds ratio, 2.37; P = .002) for catheter-associated urinary tract infection prevention, and regularly using sedation vacation (odds ratio, 1.93; P = .04) for ventilator-associated pneumonia prevention. We provide a snapshot of psychological safety in US hospitals and how this characteristic influences the use of select HAI prevention practices. A culture of psychological safety should be considered an integral part of HAI prevention efforts.

Effects of Healthcare-Associated Infections on Length of PICU Stay and Mortality.

To identify the effects of healthcare-associated infections on length of PICU stay and mortality. Retrospective, single-center, observational study. PICU of a tertiary children's hospital. Consecutive patients who stayed greater than 48 hours in the PICU between January 2013 and December 2017. None. Data were retrospectively collected from medical records. We identified occurrences of common healthcare-associated infections, including bloodstream infection, pneumonia, and urinary tract infection, defined according to the 2008 definitions of the Centers for Disease Control and Prevention and National Healthcare Safety Network. We assessed the effects of each healthcare-associated infection on length of PICU stay and PICU mortality using multivariable analysis. Among 1,622 admissions with a PICU stay greater than 48 hours, the median age was 299 days and male patients comprised 51% of admissions. The primary diagnostic categories were cardiovascular (58% of admissions), respiratory (21%), gastrointestinal (8%), and neurologic/muscular (6%). The median length of PICU stay was 6 days, and the PICU mortality rate was 2.5%. A total of 167 healthcare-associated infections were identified, including 67 bloodstream infections (40%), 43 pneumonias (26%), and 57 urinary tract infections (34%). There were 152 admissions with at least one healthcare-associated infection (9.4% of admissions with a stay > 48 hr). On multivariable analysis, although each healthcare-associated infection was not significantly associated with mortality, bloodstream infection was associated with an extra length of PICU stay of 10.2 days (95% CI, 7.9-12.6 d), pneumonia 14.2 days (11.3-17.2 d), and urinary tract infection 6.5 days (4.0-9.0 d). Accordingly, 9.7% of patient-days were due to these three healthcare-associated infections among patients with a stay greater than 48 hours. Although healthcare-associated infections were not associated with PICU mortality, they were associated with extra length of PICU stay. As 9.7% of patient-days were due to healthcare-associated infections, robust prevention efforts are warranted.

The outcomes of Clostridioides difficile infection in patients with diverticular disease: a nationwide analysis

Background: Clostridioides difficile infection (CDI) is one of the most common healthcare-associated infections. It contributes to significant morbidity and mortality among hospitalized patients in the United States. Prior studies suggest worse outcomes of CDI in patients with diverticulitis and increased risk for recurrent CDI. We conducted this study to evaluate the outcomes of CDI in patients with diverticular disease from a nationwide data sample (2012–2015).Methods: The National Inpatient Sample (NIS) database between January 2012 and September 2015 was queried for CDI admissions using the International Classification of Diseases, Ninth Edition, Clinical Modification [ICD-9-CM] codes 008.45, 562.11, 562.10, 562.12, and 562.13 for diagnoses of CDI and diverticular disease.Results: The study included 1,327,595 patients who were admitted between 2012 and 2105 for CDI. Out of all of the patients, 84,170 (6.34%) had a concurrent diagnosis of diverticular disease. After adjusting for confounding variables, the in-hospital mortality was lower [odd ratio (OR): 0.48, 95% CI: 0.44–0.52, p < .001] for patients with diverticular disease. The length of stay (LOS) was longer [10.5 versus 9.3 days, p < .001] and mean cost of hospitalization was significantly higher in patients without a history of diverticular disease.Discussion: In a nationwide population study, admissions with CDI, patients with a concurrent diagnosis of diverticular disease had lower in-hospital mortality. The observed results are different from prior studies and might be attributed to a higher burden of normal flora in those patients and increased use of antibiotic stewardship program across many hospitals nationwide.

1252. Development of a Surgical Site Infection at a Tertiary Hospital in Colombia: A Clinical and Microbiological Profile

BackgroundSurgical site infections (SSIs) are the most common healthcare-associated infections in developing countries, it represents a problem of patient safety and as well as evidence of quality of care. The objective of the study was to estimate the incidence of SSIs in surgical procedures of the surgical service, the microbiological profile and clinical evolution of patients.MethodsDesign: A retrospective, longitudinal cohort study using electronic health record data. Settings: Conducted between January and December of 2017 at tertiary hospital in Medellín, Colombia. Participants: Patients whose primary surgical procedures of gastrointestinal surgeries and abdominal wall hernias were included and followed up for 30 days after discharge. Main outcome measures: demographics, surgical risk scale, surgical procedures data, SSI according to NHSN-CDC criteria, microbiological isolates and clinical outcomes were registered and descriptive measures were obtained.ResultsThere were 546 clinical charts analyzed, 55% were women, the mean age was 47 years (SD: 21), 74% at intermediate or high surgical risk. Antibiotic prophylaxis was administered at least 120 minutes before the incision and the cefazolin + metronidazole scheme was the most frequent to 70% of the patients. The incidence of SSIs was 12% (64/546), 1% superficial incisional SSIs, 3% deep incisional SSIs and 8% organ / space. Among them, 52% were NHSN-2, 55% had dirty wounds and 43% contaminated. E. coli were isolated in 16% (7/10 were BLEE+), S. aureus in 10% (all MRSA−). SSI was more frequent in laparotomy due to intra-abdominal infection in 36%, 20% colectomy, and 19% appendicectomy. The SSIs were treated in 27% with imipenem and 19% imipenem + vancomycin, for a median of 7 days (p25-p75: 7–10); 36% of the patients with SSIs underwent percutaneous drainage, 30% have been reoperated, 34% were unplanned readmission and 9% died, only two death were attributable to SSIs; the median of length of post-procedure stay days was 12 (p25-p75: 7–23) and overall 14 (p25-p75: 8–32).ConclusionThe incidence of SSIs was higher than reported in the literature, perhaps due to the greater complexity and risk of the patients. It is necessary to implement preventive strategies in health personnel in order to reduce their incidence and complications.Disclosures All authors: No reported disclosures.

2385. Evaluating the Antibiotic Risk for Clostridioides difficile Infection (CDI): Comparing Piperacillin/Tazobactam to Cefepime and Ceftazidime

Background Clostridioides difficile infection (CDI) is a common healthcare-associated infection (HAI). Past studies have revealed that anti-pseudomonal cephalosporins such as cefepime (FEP) and ceftazidime (CTZ) are associated with a higher CDI risk than β-lactam/β-lactamase inhibitors (BLBLI) such as piperacillin/tazobactam (PTZ). However, there is limited data evaluating the comparative healthcare-associated CDI (HA-CDI) risk associated with BLBLI and anti-pseudomonal cephalosporin therapy.MethodsAn observational cohort study was performed with patients who received PTZ, FEP, or CTZ at Yale New Haven Hospital and Bridgeport Hospital from February 1, 2013 to June 1, 2018. Patients who received ≥ 3 days of PTZ, FEP, or CTZ therapy were included. Patients under the age of 18, those admitted to oncology, transplant, or pediatric units, and those with < 2 or ≥ 120 days of hospital admission were excluded. Multivariate logistic regression models were constructed to control and to adjust for underlying comorbidities.ResultsA total of 11,909 patient encounters met the study criteria. The median patient-days of therapy for both the PTZ and FEP/CTZ groups was 4 days (Table 1). FEP/CTZ exposure was associated with a higher CDI risk than PTZ exposure (P = 0.03) (Figure 1) even with higher C. difficile testing frequency in the PTZ group (P < 0.001) (Table 1). Using a multivariate logistic regression model controlling for high-risk antibiotic therapy (ciprofloxacin, clindamycin, ertapenem, meropenem, moxifloxacin), acid suppression therapy (famotidine, lansoprazole, pantoprazole), sex, Charlson comorbidity index score, age, and duration of hospital admission, FEP/CTZ exposure was independently associated with a higher CDI risk than PTZ exposure (Table 2) (Table 3).ConclusionFEP/CTZ exposure was associated with a higher CDI risk than PTZ exposure. PTZ may be associated with a higher risk for non-CDI antibiotic-associated diarrhea which may lead to an increased frequency of testing for CDI. The findings from this study may justify additional antibiotic stewardship efforts to limit the use of empiric FEP/CTZ therapy. Disclosures All authors: No reported disclosures.

2356. Increased Clinical Specificity with Ultrasensitive Detection of Clostridioides difficile Toxins: Reduction of Overdiagnosis Compared with Nucleic Acid Amplification Tests

Background Clostridioides difficile infection (CDI) is one of the most common healthcare-associated infections, resulting in significant morbidity, mortality, and economic burden. Diagnosis of CDI relies on the assessment of clinical presentation and laboratory tests. We have evaluated the clinical performance of ultrasensitive Single Molecule Counting technology for detection of C. difficile toxins A and B.MethodsStool specimens from 298 patients with suspected CDI were tested with nucleic acid amplification test (NAAT; BD MAX™ Cdiff assay or Xpert® C. difficile assay) and Singulex Clarity® C. difficile toxins A/B assay. Specimens with discordant results were tested with cell cytotoxicity neutralization assay (CCNA), and results were correlated with disease severity and outcome.ResultsThere were 64 NAAT-positive and 234 NAAT-negative samples. Of the 32 NAAT+/Clarity− and 4 NAAT-/Clarity+ samples, there were 26 CCNA− and 4 CCNA- samples, respectively. CDI relapse or overall death was more common in NAAT+/toxin+ patients than in NAAT+/toxin− and NAAT−/toxin− patients, and NAAT+/toxin+ patients were 3.7 times more likely to experience relapse or death (Figure 1). The clinical specificity of Clarity and NAAT was 97.4% and 89.0%, respectively, and overdiagnosis was over three times more common in NAAT+/toxin− than in NAAT+/toxin+ patients (Figure 2). Negative percent agreement between NAAT and Clarity was 98.3%, and positive percent agreement increased from 50.0% to effective 84.2% and 94.1% after CCNA testing and clinical assessment.ConclusionThe Clarity assay was superior to NAATs in diagnosis of CDI, by reducing overdiagnosis and thereby increasing clinical specificity, and presence of toxins was associated with disease severity and outcome. Disclosures All authors: No reported disclosures.

2360. Impact of a Two-Step Antimicrobial Stewardship Intervention on C. difficile Infection Diagnosis at an Urban Veteran’s Affairs Medical Center

Background C. difficile infection (CDI) is a common healthcare-associated infection and quality measure for hospitals. Diagnosis of CDI is challenging as testing modalities, i.e., nucleic acid amplification test (NAAT), are highly sensitive but cannot differentiate between colonization and infection. Therefore, judicious use of testing is critical to avoid unnecessary diagnosis and treatments.MethodsThis single-center, retrospective chart review evaluated the impact of a two-step diagnostic stewardship intervention on C. difficile diagnosis and use of oral vancomycin in the inpatient setting. For the first step of the intervention, providers were educated on appropriate diagnosis and treatment, and given access to an optional electronic CDI clinical decision support system (CDSS). For the second step of the intervention, the CDI NAAT stand-alone testing option was removed from the lab ordering menu and providers were required to use the CDSS to order testing. Clinical data including bed-days of care (BDOC), total number tests ordered, number of positive tests and use of oral vancomycin was collected for the pre-intervention period (1/1/16 – 3/31/17), post intervention period 1 (April 1, 2017–October 31/18) and post-intervention period 2 (November 1, 2018–March 31, 2019).ResultsCompared with the pre-intervention group, there were no significant differences in the number of total CDI NAATs ordered, positive CDI NAATs or vancomycin DOT/10,000 BDOC in post-intervention group 1. There was a reduction in the number of total CDI NAATs ordered (341 vs. 42 [87.7%]) and the number of positive CDI NAATs (56 vs. 7 [87.5%]) in post-intervention group 2, respectively. When this data were normalized based on bed days of care (BDOC), there were still significant reductions in NAATs ordered and number of positive CDI NAATs (64 vs. 27 [57.8%]; 11 vs. 5, respectively, [54.5%]) and with vancomycin oral DOT/10,000 BDOC (72 vs. 7 [90.3%]) (Table 1).ConclusionProvider education and an optional CDSS did not significantly impact CDI NAAT ordering or use of oral vancomycin for CDI. However, implementation of a mandatory CDSS for CDI testing was shown to significantly decrease the number of tests ordered, the number of positive tests, and the use of oral vancomycin. Disclosures All authors: No reported disclosures.

2341. Effectiveness of Interventions Targeting Stewardship of Clostridium difficile Testing

Background Clostridium difficile infection (CDI) is the most common healthcare-associated infection. C. difficile PCR assays do not differentiate between colonization (seen in up to 21% of inpatients) and symptomatic disease, highlighting the importance of testing only symptomatic patients.MethodsInterventions included system-wide implementation of C. difficile testing guidelines, face-to-face education of licensed providers, and Best Practice Alerts (BPAs) embedded in the electronic health record (EHR) C. difficile PCR order. The guidelines recommend testing only when ≥ 3 liquid bowel movements within a 24-hour period, without laxatives, oral contrast or new enteral feeds in the preceding 24 hours, and without recent C. difficile PCR test (negative ≤ 7 days or positive < 30 days). We reviewed 100 consecutive C. difficile PCR orders across two hospitals pre- and post-intervention to assess compliance with guidelines; performed weekly review of all C. difficile PCRs, all BPA responses and all hospital-onset CDI. Cost savings were calculated based on published estimates of CDI attributable costs.ResultsHospital-onset CDI rates fell from 0.75 to 0.48 cases per 1000 patient-days, with an estimated costs savings of $259,555 per quarter and $1.04 million per year. There were no deaths due to CDI and no morbidity due to delayed CDI diagnosis. C. difficile PCR guideline compliance increased from 39% to 53%; orders decreased by 50% post-intervention. Receipt of laxatives and < 3 episodes of diarrhea were the most common reasons for guideline noncompliance. BPAs fired an average of 150 times/month. The most common trigger for BPA was laxative use. Providers canceled PCR orders in 40% of BPA events.ConclusionInterventions incorporating testing guidelines, face-to-face education, and EHR-embedded decision support resulted in fewer C. difficile PCRs orders, increased guideline compliance, lower rates of hospital-onset CDI and cost savings of $1 million per year without an increase in CDI-attributable death or morbidity.Disclosures All authors: No reported disclosures.

2469. A National Intervention to Improve Infection Prevention Efforts in Hospitals with High Rates of Clostridioides difficile infection, Central Line-Associated Bloodstream Infection, Catheter-Associated Urinary Tract Infection and/or Methicillin-Resistant Staphylococcus aureus

BackgroundTo strengthen state collaborative efforts and reduce common healthcare-associated infections (HAIs) in short-stay and long-term acute care hospitals, the Centers for Disease Control and Prevention (CDC) launched “States Targeting Reduction in Infections via Engagement” (STRIVE) - a national quality improvement program.MethodsSTRIVE consisted of a multimodal intervention implemented from November 2016 to May 2018 (Figure 1). Hospitals with excess Clostridioides difficile infection (CDI) and a high burden of at least one of the following HAIs - central line-associated bloodstream infection (CLABSI), catheter-associated urinary tract infection (CAUTI) or methicillin-resistant Staphylococcus aureus (MRSA) bloodstream infection were targeted. Monthly aggregate HAI and device utilization ratios - according to CDC National Healthcare Safety Network definitions - were measured during the pre vs. post-intervention periods. Thematic analysis of qualitative interviews with state partners was conducted to understand the influence of the intervention.ResultsOverall, 387 hospitals from 23 states and the District of Columbia participated. Changes in HAI rates and catheter utilization are illustrated in Figure 2. From pre- to post-intervention, substantial changes in HAI rates above temporal trends were not observed (CDI, 7.0 to 5.7 per 10000 patient-days; CLABSI, 0.88 to 0.80 per 1000 catheter days; CAUTI, 1.12 to 1.04 per 1000 catheter days; MRSA bloodstream infection, 0.075 to 0.071 per 1,000 patient-days) Similarly, catheter utilization did not differ substantially between the pre- and post-intervention periods (24.05 to 22.07 central line days per 100 patient-days; 21.46 to 19.83 urinary catheter days per 100 patient-days). Qualitative analysis of 17 interviews with state partners showed that relationships among state partners and hospitals were strengthened, potentially facilitating collaboration on future infection prevention efforts.ConclusionThough HAI reductions were observed during STRIVE, these reductions were consistent with temporal trends. Hospitals struggling with high HAI rates may require additional novel approaches. Disclosures All authors: No reported disclosures.

Bloodstream Infection and Its Clinical Characteristics and Relevant Factors Associated with Interventional Therapy in a Large Tertiary Hospital: A Six Years Surveillance Study.

Background Interventional therapy has been widely used in the medical field as its advantages of minimally invasive, safe and quick recovery. Bloodstream infection (BSI) is the most common healthcare-associated infections (HAIs) after interventional therapy, but there are few reports about it. This study intends to analyze the clinical characteristics and relevant factors of BSI after six years of interventional therapy in a large tertiary teaching hospital, in order to provide guidances for the prevention and control of BSI after interventional operations. Methods The case information of patients with BSI after interventional therapy from 2013 to 2018 were collected through the "real-time monitoring system of healthcare-associated infections". All BSI was determined by the infection control full-time staff and clinicians. Questionnaires were designed to review case by case and register the relevant patient information into a database. A total of 18 relevant factors were counted. Statistical software was used for analysis. Results174 cases of BSI occurred in 25401 patients, the incidence was 0.69%, and BSI accounted for 50% of all infected sites. Gram-positive bacteria accounted for 56.05%, coagulase-negative Staphylococcus was the main infectious bacteria. Relevant risk factor analysis showed that hepatocellular carcinoma, had undergone surgery, biliary complications, prophylactic antibiotic, replacement of antibiotics, number of interventional operations, days of prophylactic antibiotic use were the related risk factors associated with BSI (P < 0.05). Multivariate analysis showed that days of prophylactic antibiotic use (OR = 1.586, P < 0.05) and replacement of antibiotics (OR = 13.349, P < 0.05) were the main risk factors associated with the development of BSI. Conclusions BSI is the main infection site after interventional surgery. For patients with the risk factors as hepatocellular carcinoma/biliary complications/had undergone surgery etc., the time of prophylactic antibiotic use can be prolonged properly before interventional surgery, and selection of single antibiotic appropriate for use could significantly aid preventive measures to avoid occurrence of BSI.

Development and Assessment of Objective Surveillance Definitions for Nonventilator Hospital-Acquired Pneumonia

Hospital-acquired pneumonia is the most common health care-associated infection in the United States. Most cases occur in nonventilated patients, but many hospitals track hospital-acquired pneumonia only in ventilated patients because of the complexity and subjectivity of conducting surveillance for large numbers of nonventilated patients. To propose and assess potentially objective, efficient, and reproducible surveillance definitions for nonventilator hospital-acquired pneumonia (NV-HAP) using routine clinical data stored in electronic health record systems. This cohort study was conducted in 2 tertiary referral and 2 community hospitals in Massachusetts between May 31, 2015, and July 1, 2018. All nonventilated patients aged 18 years or older who were admitted to these hospitals were included (N = 310 651). Ten candidate definitions for NV-HAP based on clinically meaningful combinations of 6 potential surveillance criteria were proposed: worsening oxygenation, temperature higher than 38 °C (fever), abnormal white blood cell count of less than 4000/μL or more than 12 000/μL, performance of chest imaging, submission of respiratory specimen for culture, and 3 or more days of new antibiotics. Incidence rates, lengths of stay, hospital mortality rates, and odds ratios (ORs) for time to discharge and mortality compared with those of matched controls were calculated for each candidate definition. The ORs were adjusted for demographics, clinical service, comorbidities, and severity of illness. The study analyzed 310 651 patients with 489 519 admissions, including 205 054 patients with 311 484 admissions of 3 or more days. Among the patients with 311 484 admissions, the mean (SD) patient age was 58.3 (19.3) years and 176 936 (56.8%) were of women. Incidence rates for candidate definitions per 100 admissions ranged from 3.4 events for worsening oxygenation alone to 0.9 event for worsening oxygenation and at least 3 days of new antibiotics to 0.6 event for worsening oxygenation, at least 3 days of new antibiotics, fever, abnormal white blood cell count, and performance of chest imaging. Crude mortality rates ranged from 16.1% (n = 2643) for patients with worsening oxygen alone to 27.7% (n = 868) for patients with worsening oxygenation, at least 3 days of antibiotics, fever or abnormal white blood cell count, and chest imaging. Patients who met NV-HAP candidate definitions remained in the hospital for twice as long as their matched controls (adjusted ORs ranged from 1.8 [95% CI, 1.7-1.8] to 2.1 [95% CI, 2.0-2.1]) and were 4 to 6 times as likely to die in the hospital (adjusted ORs ranged from 3.8 [95% CI, 3.5-4.0] to 6.5 [95% CI, 5.2-8.2]). Agreement between candidate definitions and clinical diagnoses was fair (κ = 0.33). These findings suggest that objective surveillance for NV-HAP using electronically computable definitions that incorporate common clinical criteria is feasible and generates incidence, mortality, and adjusted ORs for hospital mortality similar to estimates from manual surveillance. These definitions have the potential to facilitate widespread, automated surveillance for NV-HAP and thus inform the development and evaluation of prevention programs.

Surveillance of organisms and their drug sensitivity patterns in orthopaedics post surgical patients at a tertiary care teaching hospital

Background: Among the Health care associated infections (HAI), orthopaedic surgical site infections (OSSI) previously termed as post-operative wound infections are one of the most common HAI in low and middle income countries. Increase in OSSI is associated with increased morbidity, as well as mortality due to emergence of antimicrobial resistant pathogens. Understanding the pathogens implicated in causing the OSSIs and their antimicrobial sensitivity place a good role in reducing the mortality and morbidity. Methods: A prospective study was conducted at a tertiary care hospital to all the patients admitted in Department of Orthopaedics for 2 years from January 2017 to December 2018. The demographic data, inclusion criteria and exclusion criteria, risk factors, clinical history, laboratory data with gram stain, culture results and antibiotic sensitivity of the isolates were collected.Results: Two hundred patients were recruited in the study and the prevalence of OSSI in the study was 3.83%. Patients who underwent emergency operations and diabetics were at higher risk of acquiring OSSI. The most commonly isolated pathogens in the study were Staphylococcus aureus, Escherichia coli, and Pseudomonas aeruginosa. Pseudomonas aeruginosa was most common isolate from orthopaedic cases of OSSI.Conclusions: Study clearly explains the various causes and risk factors associated in development of OSSI. The study guides in the type of the organism isolated and possible antibiotic of choice in treatment and management of OSSI. The prevalence of OSSI was 3.83%, which is comparable with some of the studies and lower than many of the studies.

143 ATLAS Scores Are Better Than CDSS in Predicting Any ICU Requirement and 30-Day Mortality in Patients With C. difficile Infection (CDI) &gt;65 Years Old

INTRODUCTION: CDI is the most common healthcare-associated infection with significant morbidity, mortality and cost. Various scoring systems have been formulated to aide disease prognostication. Our goal was to compare the ATLAS and CDSS predictive scores, initially to validate them and subsequently establishing which score was more accurately associated with short-term mortality and colectomy. METHODS: We performed a retrospective cohort analysis on patients admitted to Yale-New Haven Hospital between 9/13 and 4/16. For each patient with CDI (≥3 liquid stools in a 24-hour period with a positive stool assay) we gathered various data points including demographics, diagnostics, risk factors, treatments and outcomes. The CDSS and ATLAS scoring systems were independently used to grade the severity in each patient and association with outcome (e.g., any ICU admission or 30-day mortality). Using Logistic regression (SAS 9.4), we used area under the ROCs to compare the ability of CDSS and ATLAS to predict adverse outcomes in these patients. Following initial analysis, we performed a sub-group analysis considering a cohort &gt; 65 years old and those ≤65. RESULTS: 488 patients were identified with CDI; 105 were excluded due to insufficient retrospective data to complete the ATLAS score. The mean age was 65.1 ± 16.1 years with females accounting for 52.7%. Mean Charlson co-morbidity score was 5.8 ± 3.1. 20.1% had prior CDI and 81.5% received antibiotics in the prior 12 weeks. Of 383 pts, 40 (10.4%) died and 122 (31.8%) required ICU admission during their stay. Both ATLAS and CDSS independently predicted adverse outcomes in these pts. In our overall cohort (all ages), there were no significant differences between the two scores in predicting 30-day mortality (Figure 1, P = 0.37), however ATLAS performed significantly better predicting ICU requirement (Figure 1, P = 0.0002). When considering only those &gt; 65 years, ATLAS performed significantly better than CDSS for 30-day mortality (Figure 2, P &lt; 0.05) and any ICU requirement (Figure 2, P &lt; 0.01). For those ≤65, ATLAS was significantly more accurate at predicting ICU admission (P &lt; 0.001) but not mortality (P = 0.92). CONCLUSION: CDI is associated with severe outcomes and prediction of these outcomes could help triage therapeutic decisions. ATLAS is superior to CDSS in prediction of ICU stay in our patient population with CDI and ICU/mortality in age &gt;65. We recommend strong consideration for usage of ATLAS in clinical practice.

859 The Impact of Inflammatory Bowel Disease on Admissions With Clostridium difficile Infection: A Nationwide Database Study

INTRODUCTION: Clostridium difficile infection (CDI) is one of the most common healthcare-associated infections. It contributes to significant morbidity and mortality amongst hospitalized patients in the United States. Prior studies suggest worse outcomes of CDI in patients with inflammatory bowel disease (IBD). We conducted this study to evaluate the outcomes of CDI in patients with IBD from a nationwide sample (2012-2015). METHODS: The National Inpatient Sample (NIS) database between January 2012 and September 2015 was queried for CDI admissions using the International Classification of Diseases, Ninth Edition, Clinical Modification [ICD-9-CM] codes 008.45, 555.X, 556.X for diagnoses of CDI and IBD In-hospital mortality, use of hospital resources, length of stay (LOS), and total charges in USD were assessed. Outcomes were adjusted for risk factors and comorbid conditions. RESULTS: The study included 1,311,085 patients who were admitted between 2012 and 2105 for CDI. Out of all of the patients, 54,655 (4.2%) had concurrent IBD. After adjusting for confounding variables, the in-hospital mortality was higher [Odd Ration (OR): 1.45, 95% CI: 1.34-1.57 P &lt; 0.001] for patients with IBD and they were more likely to have toxic megacolon (13.3% vs 4.2% P &lt; 0.001). However, in CDI without IBD, LOS was longer [10.5 vs. 9.3 days, P &lt; 0.001] and mean cost of hospitalization was significantly higher. CONCLUSION: In a nationwide population study, admissions with CDI, patients with a concurrent diagnosis of IBD had higher in-hospital mortality and were more likely to have toxic megacolon compared with non-IBD. However, hospital length of stay and total charges in USD were more in non-IBD. The discrepancy between high mortality and lower LOS and total charges in IBD vs non-IBD can be due to early mortality during hospitalization, the clinical presentation with severe CDI on admission, and/or development of grave complications in patients with CDI and IBD. Studies are needed to better understand the impact of IBD on CDI. Studies are also needed to examine the role of aggressive treatment of CDI in patients with IBD early in the course of hospitalization.

Epidemiological Typing of Methicillin Resistant Staphylococcus aureus Isolated from Surgical Site Infection Following Caesarean Section in an Egyptian University Hospital

Background: Surgical site infection (SSIs) is one of the most common healthcare-associated infections. It comprises a great risk to hospitalized patients in terms of morbidity, mortality and economic cost. Objectives: To identify the causative organism(s) responsible for surgical site infection following Cesarean section and to trace the source of that infection. Patients & methods: A total of 623 clinical samples and swabs were collected from Obstetrics & Gynecology Department at Al-Zahraa University Hospital. The study included 300 patients with provisional diagnosis of SSI from whom, wound swabs were taken, in addition to 23 swabs from medical staff and 300 environmental samples. Samples were subjected to conventional bacteriological identification, biochemical reactions, antibiogram and genotyping by Random Amplified Polymorphic DNA (RAPD) assay of the dominated isolates. Results: Out of 300 wound swabs from patients with SSI following CS surgery, 62 (20.7%) yielded aerobic microbial growth. Eighty three out of 323 swabs (26%) collected from health care workers (HCWs) & environment were positive on culture. The most common organism isolated from both sources (clinical & environmental specimens) was Methicillin resistant Staphylococcus aureus (MRSA) isolates 35/623 (5.6%). Genotyping of MRSA isolates revealed 20 distinct Random Amplified Polymorphic DNA (RAPD) patterns, indicating high rate of genetic heterogeneity among MRSA isolates. Conclusion: There were clonally related MRSA isolates obtained from operating room and from patients, indicating that the operating room was accused as a source of infection.

Qualitative Assessment of a State Partner-Facilitated Health Care-Associated Infection Prevention National Collaborative.

The Centers for Disease Control and Prevention (CDC) funded a 3-year national collaborative focused on facilitating relationships between health care-associated infection (HAI) prevention stakeholders within states and improving HAI prevention activities within hospitals. This program-STRIVE (States Targeting Reduction in Infections via Engagement)-targeted hospitals with elevated rates of common HAIs. To use qualitative methods to better understand STRIVE's effect on state partner relationships and HAI prevention efforts by hospitals. Qualitative case study, by U.S. state. 7 of 22 eligible STRIVE state partnerships. Representatives from state hospital associations, state health departments, and other participating organizations (for example, Quality Innovation Networks-Quality Improvement Organizations), referred to as "state partners." Phone interviews (n = 17) with each organization were conducted, recorded, and transcribed. State partners reported that relationships with each other and with participating hospitals improved through STRIVE participation. The partners saw improvements in hospital-level HAI prevention activities, such as improved auditing and feedback practices and inclusion of environmental services in prevention efforts; however, some noted those improvements may not be reflected in HAI rates. Many partners outlined plans to sustain their partner relationships by working on future state-level initiatives, such as opioid abuse prevention and antimicrobial stewardship. Only 7 participating states were included; direct feedback from participating hospitals was not available. Although there were no substantial changes in aggregate HAI rates, STRIVE achieved its goal of improving state partner relationships and coordination. This improved collaboration may lead to a more streamlined response to future HAI outbreaks and public health emergencies. Centers for Disease Control and Prevention.

Catheter-Associated Urinary Tract Infections in Adults: Diagnosis, Treatment, and Prevention.

Urinary tract infections (UTIs) are among the most common healthcare-associated infections, and 70%-80% are catheter-associated urinary tract infections (CAUTIs). About 25% of hospitalized patients have an indwelling urinary catheter placed during their hospital stay, and therefore, are at risk for CAUTIs, which have been associated with worse patient outcomes. Additionally, hospitals face a significant financial impact since the Centers for Medicare & Medicaid Services incentive program penalizes hospitals with higher than expected CAUTIs. Hospitalists care for many patients with indwelling urinary catheters and should be aware of and engage in processes that reduce the rate of CAUTIs. This article will discuss the diagnosis, treatment, and prevention of CAUTIs in adults.

Incidence and mortality of healthcare-associated infections in hospitalized patients with moderate to severe burns

PurposeThis study was to examine the incidence of different types, and isolated pathogens, of healthcare–associated infections (HAIs), and also to determine their prognostic factors for mortality. MethodsProspective surveillance was conducted in a medical center from 2005 through to 2016. Multiple logistic regression analysis was performed to assess prognostic factors of mortality. ResultsA total of 709 patients with moderate to severe burns were hospitalized. There were 83 patients (11.7%) with HAIs (158 episodes) and 203 isolated pathogens. The most common HAI types were bloodstream infection (BSI) at 39.2% (8.7% of all patients) and central line–associated BSI (mean 4.8 per 1000 central line days). Overall, S. aureus (13.8%) were the most common isolated pathogens, while the most commonly found type of multidrug-resistant pathogen was carbapenems–resistant Enterobacteriaceae (23%). The crude mortality rate was 15.7%, and the independent factors (p < .05) for mortality were BSI (Odds ratio [OR] 2.70), intensive care unit (OR 5.19) and total body surface area with full-thickness injuries ≥50% (OR 5.22). ConclusionsBurn patients with BSI were the most common HAI sites, and this was an independent factor for mortality. Effective integrated care and appropriate infection control can reduce the incidence of infection and death.

Creation of a Geospatially Explicit, Agent-based Model of a Regional Healthcare Network with Application to Clostridioides difficile Infection.

Agent-based models (ABMs) describe and simulate complex systems comprising unique agents, or individuals, while accounting for geospatial and temporal variability among dynamic processes. ABMs are increasingly used to study healthcare-associated infections (ie, infections acquired during admission to a healthcare facility), including Clostridioides difficile infection, currently the most common healthcare-associated infection in the United States. The overall burden and transmission dynamics of healthcare-associated infections, including C difficile infection, may be influenced by community sources and movement of people among healthcare facilities and communities. These complex dynamics warrant geospatially explicit ABMs that extend beyond single healthcare facilities to include entire systems (eg, hospitals, nursing homes and extended care facilities, the community). The agents in ABMs can be built on a synthetic population, a model-generated representation of the actual population with associated spatial (eg, home residence), temporal (eg, change in location over time), and nonspatial (eg, sociodemographic features) attributes. We describe our methods to create a geospatially explicit ABM of a major regional healthcare network using a synthetic population as microdata input. We illustrate agent movement in the healthcare network and the community, informed by patient-level medical records, aggregate hospital discharge data, healthcare facility licensing data, and published literature. We apply the ABM output to visualize agent movement in the healthcare network and the community served by the network. We provide an application example of the ABM to C difficile infection using a natural history submodel. We discuss the ABM's potential to detect network areas where disease risk is high; simulate and evaluate interventions to protect public health; adapt to other geographic locations and healthcare-associated infections, including emerging pathogens; and meaningfully translate results to public health practitioners, healthcare providers, and policymakers.