Hospital-onset Bloodstream Infection Research Articles

Comparative epidemiology of hospital-onset bloodstream infections (HOBSIs) and central line-associated bloodstream infections (CLABSIs) across a three-hospital health system.

To evaluate the comparative epidemiology of hospital-onset bloodstream infection (HOBSI) and central line-associated bloodstream infection (CLABSI). Retrospective observational study of HOBSI and CLABSI across a three-hospital healthcare system from 01/01/2017 to 12/31/2021. HOBSIs were identified as any non-commensal positive blood culture event on or after hospital day 3. CLABSIs were identified based on National Healthcare Safety Network (NHSN) criteria. We performed a time-series analysis to assess comparative temporal trends among HOBSI and CLABSI incidence. Using univariable and multivariable regression analyses, we compared demographics, risk factors, and outcomes between non-CLABSI HOBSI and CLABSI, as HOBSI and CLABSI are not exclusive entities. HOBSI incidence increased over the study period (IRR 1.006 HOBSI/1,000 patient days; 95% CI 1.001-1.012; P=.03), while no change in CLABSI incidence was observed (IRR .997 CLABSIs/1,000 central line days, 95% CI .992-1.002, P=.22). Differing demographic, microbiologic, and risk factor profiles were observed between CLABSIs and non-CLABSI HOBSIs. Multivariable analysis found lower odds of mortality among patients with CLABSIs when adjusted for covariates that approximate severity of illness (OR .27; 95% CI .11-.64; P<.01). HOBSI incidence increased over the study period without a concurrent increase in CLABSI in our study population. Furthermore, risk factor and outcome profiles varied between CLABSI and non-CLABSI HOBSI, which suggest that these metrics differ in important ways worth considering if HOBSI is adopted as a quality metric.

A comparison of National Healthcare Safety Network surveillance definitions to physician review for central-line-associated bloodstream infections.

For 147 hospital-onset bloodstream infections, we assessed the sensitivity, specificity, positive predictive value, and negative predictive value of the National Healthcare Safety Network surveillance definitions of central-line-associated bloodstream infections against the gold standard of physician review, examining the drivers of discrepancies and related implications for reporting and infection prevention.

Evaluation of hospital-onset bloodstream infections compared to central line...associated bloodstream infections at an acute, tertiary care hospital

CLABSI is the current benchmark used in HAI surveillance and effective interventions have greatly reduced the incidence in recent years. However, BSIs continue to be a major source of morbidity and mortality in hospitals. HOBSI, which includes central and peripheral line surveillance, may be a more sensitive indicator of preventable BSI. Our objective is to assess the impact of a change to HOBSI surveillance by comparing the incidence of BSIs using the NHSN LabID and BSI definitions compared to CLABSI. Utilizing electronic medical charts, we determined if each blood culture met the HOBSI criteria according to the NHSN LabID and BSI definitions. We calculated the incidence rates per 10,000 patient-days for both definitions and compared them to the CLABSI rate per 10,000 patient-days for the same period. The incidence rate (IR) of HOBSI using the LabID definition was 10.25. Using the BSI definition, we found an IR of 3.77. The IR of CLABSI for the same period was 1.84. After excluding secondary BSIs, the HOBSI rate is still double that of the CLABSI rate. HOBSI surveillance is a more sensitive indicator of BSI than CLABSI, and thus a better target for monitoring effectiveness of interventions.

2018. Comparison of Trends in Hospital-Onset Bloodstream Infections (HOBSIs) and Central Line Associated Bloodstream Infections (CLABSIs) across a Three-Hospital Health System in the COVID Era

Abstract Background Hospital-onset bloodstream infection (HOBSI) incidence has been proposed as a complementary quality metric to central line-associated bloodstream infection (CLABSI) surveillance. Several recent studies have detailed increases in median HOBSI and CLABSI rates during the COVID-19 pandemic. We sought to understand trends in HOBSI and CLABSI rates at a single health system in the context of COVID-19. Methods We conducted a retrospective analysis of HOBSIs and CLABSIs at a three-hospital health system from 2017 to 2021 (Figure 1). We compared counts, denominators, and demographic data for HOBSIs and CLABSIs between the pre-pandemic (1/1/2017-3/30/2020) and pandemic period (4/1/2020-12/31/2021) (Table 1). We applied Poisson or negative binomial regression models to estimate the monthly change in incidence of HO-BSI and CLABSI rates over the study period. Figure 1:Definitions applied for hospital-onset bloodstream infections (HO-BSIs) and central line-associated bloodstream infections (CLABSIs). Potentially contaminated blood cultures were identified by microbiology laboratory technicians as any set of blood culture in which a single bottle was positive for organisms typically considered as skin contaminants. Uncertain cases undergo secondary review by senior lab technicians. Table 1:Count, denominator, and device utilization ratio data for hospital-onset bloodstream infections (HO-BSIs) and central line-associated bloodstream infections (CLABSIs)Note that central line utilization increased upon regression analysis (p&amp;lt;0.001). Results The median monthly HOBSI rate per 1,000 patient days increased from 1.0 in the pre-pandemic to 1.3 (p&amp;lt; 0.01) in the pandemic period, whereas the median monthly CLABSI rate per central line days was stable (1.01 to 0.88; p=0.1; Table 2). Our regression analysis found that monthly rates of HO-BSIs increased throughout the study, but the increase was not associated with the onset of the COVID-19 pandemic based on comparisons of model fit (Figure 2; Table 3). Despite an increase in central line utilization, regression modelling found no changes in monthly CLABSIs rates with respect to time and the COVID-19 pandemic. Incidence of HOBSIs and CLABSIs by common nosocomial organisms generally increased over this time period, though time to infection onset remained unchanged in our studied population (Table 2). Table 2:Epidemiology and demographic characteristics of hospital-onset bloodstream infections (HO-BSIs) and central line-associated bloodstream infections (CLABSIs).Figure 2:Regression analysis of monthly rates of HO-BSIs and CLABSIs over time per patient days (left) and CLABSIs per central line days (right). Gray areas denote COVID-19 pandemic period (April 2020 to December 2021). Provided p values refer to the statistical significance of the coefficient of the time variable in each model. Table 3:Likelihood ratio tests comparing regression models.No statistical significance was noted between models that included COVID-19 variables (including a time-trended post-pandemic variable) and models that were only time-dependent. Conclusion HOBSIs rates did not correlate with CLABSI incidence across a three-hospital health system from 2017 and 2021, as rates of HOBSI increased but CLABSI rates remained flat. Our observed increase in HOBSI rates did not correlate with the onset of the COVID-19 pandemic, and caution should be used in modeling the effects of COVID-19 without time-trended analysis. Further evaluation is needed to understand the etiology, epidemiology, and preventability of HO-BSI. Disclosures All Authors: No reported disclosures.

739. The High Burden of Bloodstream Infection in Adults: A Nation-Wide Population- Based Study

Abstract Background Limited data exist on the long-term consequences of bloodstream infections (BSI). We examined incidence, 1-year mortality, and years of potential life lost (YPLL) following BSI by eight sentinel bacteria in adults. We also estimated the relative contribution of hospital-onset BSI (HO-BSI) and of antibiotic-resistant BSI to the burden of BSI. Methods We used data from Israel's national BSI surveillance system (covering E. coli, K. pneumoniae, P. aeruginosa, A. baumannii, S. pneumoniae, S. aureus, E. faecalis and E. faecium, comprising 70% of all BSI) and the national death registry. Adults with BSI between 1/1/2018 and 31/12/2019 were included. The outcomes were all-cause 30-day and 1-year mortality. We constructed Kaplan-Meier curves and used the log-rank test to compare survival between age groups. We calculated the age-standardized mortality rate and YPLL using the Global Burden of Disease reference population and life expectancy tables. Results A total of 25,376 BSI occurred over 2 years in the adult Israeli population (mean adult population: 6,068,580). Drug-resistant BSI comprised 32% of all events (41.1% of HO-BSI). The annual BSI incidence was 209 per 100,000 population. The case fatality rate (CFR) was 25.6% at 30 days and 46.4% at 1 year. The 1-year CFR was higher among males than females (RR=1.17, 95% CI 1.14–1.20) and it increased with age (OR=1.37 per decade, 95% CI 1.36–1.39). In all age groups survival continued to decline up to 1 year (Figure). For the outcome of 1-year mortality, the annual age-standardized mortality rate and YPLL per 100,000 population following BSI were 48.6 and 1002.2, respectively. For comparison, the global mortality rate and YPLL from ischemic stroke are 36.6 and 521.8 per 100,000, respectively. HO-BSI represented 27.4% of BSI but contributed to 33.9% of deaths and 39.9% of YPLL. HO-BSI by drug-resistant bacteria represented 11.3% of BSI, 14.8% of deaths, and 17.4% of YPLL. Conclusion BSI have grave long-term consequences: nearly 50% of affected adult patients died within 1 year. The burden of BSI is higher than that of ischemic stroke. HO-BSI and drug-resistant BSI contribute disproportionately to BSI mortality and YPLL. Attention and resources should be directed to prevention of BSI, as well as to advances in early diagnosis and better treatment. Disclosures Yehuda Carmeli, MD, Allecra Therapeutics: Advisor/Consultant|MSD: Advisor/Consultant|Nabriva: Advisor/Consultant|Pfizer: Advisor/Consultant|Qpex Pharmaceuticals: Advisor/Consultant|Roche: Advisor/Consultant|Shinogi: Advisor/Consultant|Spero Therapeutics: Advisor/Consultant.

One-year mortality and years of potential life lost following bloodstream infection among adults: A nation-wide population based study.

SummaryBackgroundLimited data exist on long-term consequences of bloodstream infections (BSIs). We aimed to examine incidence, 1-year mortality, and years of potential life lost (YPLL) following BSI. We estimated the relative contribution of hospital-onset BSI (HO-BSI) and antibiotic-resistant BSI to incidence, mortality and YPLL.MethodsWe used data from Israel's national BSI surveillance system (covering eight sentinel bacteria, comprising 70% of all BSIs) and the national death registry. Adults with BSI between January 2018 and December 2019 were included. The outcomes were all-cause 30-day and 1-year mortality, with no adjustment for co-morbidities. We calculated the age-standardized mortality rate and YPLL using the Global Burden of Disease reference population and life expectancy tables.FindingsIn total, 25,376 BSIs occurred over 2 years (mean adult population: 6,068,580). The annual incidence was 209·1 BSIs (95% CI 206·5–211·7) per 100,000 population. The case fatality rate was 25·6% (95% CI 25·0-26·2) at 30 days and 46·4% (95% CI 45·5-47·2) at 1 year. The hazard of death increased by 30% for each decade of age (HR=1·3 [95% CI 1·2-1·3]). The annual age-standardized mortality rate and YPLL per 100,000 were 50·8 (95% CI 49·7-51·9) and 1,012·6 (95% CI 986·9-1,038·3), respectively. HO-BSI (6,962 events) represented 27·4% (95% CI 26·9-28·0) of BSIs, 33·9% (95% CI 32·6-35·0) of deaths and 39·9% (95% CI 39·5-40·2) of YPLL. HO-BSI by drug-resistant bacteria (3,072 events) represented 12·1% (95% CI 11·7-12·5) of BSIs, 15·6% (95% CI 14·7-16·5) of deaths, and 18·4% (95% CI 18·1-18·7) of YPLL.InterpretationOne-year mortality following BSI is high. The burden of BSI is similar to that of ischemic stroke. HO-BSI and drug-resistant BSI contribute disproportionately to BSI mortality and YPLL.FundingNone.

Evaluation of Hospital-onset Bloodstream Infections in Comparison to Central Line-associated Bloodstream Infections at an Acute, Tertiary Care Hospital

Background Central line-associated bloodstream infections (CLABSI) is the current benchmark used in hospital-associated infection (HAI) surveillance, and effective interventions have greatly reduced the incidence in recent years. However, bloodstream infections (BSI) continue to be a major source of morbidity and mortality in hospitals. Therefore, using hospital-onset bloodstream infections (HOBSI) as a benchmark may be a more sensitive indicator of preventable BSI. Our objective is to calculate the rate of HOBSI from all intravenous and intra-arterial catheters, not just those that end in the great vessels near the heart. We will then compare CLABSI and HOBSI rates to evaluate whether HOBSI will better represent the number of preventable BSIs and thus improve HAI surveillance. Methods We conducted a retrospective analysis of all positive blood cultures (n=763) among patients admitted to an acute, tertiary hospital from July 2018 to June 2019. We collected information from electronic medical charts to determine if each blood culture met the HOBSI criteria according to the Centers for Disease Control and Prevention's National Healthcare and Safety Network (NHSN) LabID and BSI definitions. Finally, we calculated the incidence rates per 10,000 patient-days for both definitions and compared them to the CLABSI rate for the same period. Results The incidence rate (IR) of HOBSI using the NHSN LabID definition was 10.25 per 10,000 patient-days. After excluding all HOBSIs that were secondary to other infections using the NHSN BSI definition, we found an IR of 3.77 per 10,000 patient-days. The IR of CLABSI for the same period was 1.84 per 10,000 patient-days. Conclusions After excluding secondary BSIs, the HOBSI rate is still double that of the CLABSI rate. HOBSI surveillance is a more sensitive indicator of BSI than CLABSI, and thus a better target for monitoring effectiveness of interventions. Central line-associated bloodstream infections (CLABSI) is the current benchmark used in hospital-associated infection (HAI) surveillance, and effective interventions have greatly reduced the incidence in recent years. However, bloodstream infections (BSI) continue to be a major source of morbidity and mortality in hospitals. Therefore, using hospital-onset bloodstream infections (HOBSI) as a benchmark may be a more sensitive indicator of preventable BSI. Our objective is to calculate the rate of HOBSI from all intravenous and intra-arterial catheters, not just those that end in the great vessels near the heart. We will then compare CLABSI and HOBSI rates to evaluate whether HOBSI will better represent the number of preventable BSIs and thus improve HAI surveillance. We conducted a retrospective analysis of all positive blood cultures (n=763) among patients admitted to an acute, tertiary hospital from July 2018 to June 2019. We collected information from electronic medical charts to determine if each blood culture met the HOBSI criteria according to the Centers for Disease Control and Prevention's National Healthcare and Safety Network (NHSN) LabID and BSI definitions. Finally, we calculated the incidence rates per 10,000 patient-days for both definitions and compared them to the CLABSI rate for the same period. The incidence rate (IR) of HOBSI using the NHSN LabID definition was 10.25 per 10,000 patient-days. After excluding all HOBSIs that were secondary to other infections using the NHSN BSI definition, we found an IR of 3.77 per 10,000 patient-days. The IR of CLABSI for the same period was 1.84 per 10,000 patient-days. After excluding secondary BSIs, the HOBSI rate is still double that of the CLABSI rate. HOBSI surveillance is a more sensitive indicator of BSI than CLABSI, and thus a better target for monitoring effectiveness of interventions.

Hospital-Onset Bloodstream Infections Caused by Eight Sentinel Bacteria: A Nationwide Study in Israel, 2018-2019.

Nationwide studies on hospital-onset bloodstream infections (HO-BSIs) are scarce. To describe incidence, mortality and antimicrobial resistance (AMR) of HO-BSI caused by eight sentinel bacteria in Israel, we used laboratory-based BSI surveillance data from 1 January 2018 to 31 December 2019. All hospitals reported positive blood cultures growing Escherichia coli, Klebsiella pneumoniae, Pseudomonas aeruginosa, Acinetobacter baumannii, Streptococcus pneumoniae, Staphylococcus aureus, Enterococcus faecalis and Enterococcus faecium. We calculated HO-BSI incidence and 14-day, 30-day and 1-year mortality in adults. We performed multivariable logistic regression to identify predictors of 30-day mortality. The study included 6752 HO-BSI events: K. pneumoniae (1659, 22.1%), E. coli (1491, 19.8%), S. aureus (1315, 17.5%), P. aeruginosa (1175, 15.6%), E. faecalis (778, 10.4%), A. baumannii (654, 8.7%), E. faecium (405, 5.4%) and S. pneumoniae (43, 0.6%). Overall incidence was 2.84/1000 admissions (95% CI: 2.77–2.91) and 6.88/10,000 patient-days (95% CI: 6.72–7.05). AMR isolates accounted for 44.2% of events. Fourteen-day, thirty-day and one-year mortality were 30.6% (95% CI: 28.5%–32.8%), 40.2% (95% CI: 38.2%–42.1%) and 66.5% (95% CI: 64.7%–68.3%), respectively. Organisms with highest risk for 30-day mortality (compared with E. coli) were A. baumannii (OR 2.85; 95% CI: 2.3–3.55), E. faecium (OR 2.16; 95% CI: 1.66–2.79) and S. pneumoniae (OR 2.36; 95% CI: 1.21–4.59). Mortality was higher in AMR isolates (OR 1.57; 95% CI: 1.4–1.77). This study highlights the incidence, associated high mortality and important role of antibiotic resistance in HO-BSI.

Impact of COVID-19 pandemic on hospital onset bloodstream infections (HOBSI) at a large health system

BackgroundThe COVID-19 pandemic has had a considerable impact leading to increases in health care-associated infections, particularly bloodstream infections (BSI). MethodsWe evaluated the impact of COVID-19 in 69 US hospitals on BSIs before and during the pandemic. Events associated with 5 pathogens (Staphylococcus aureus, Escherichia coli, Klebsiella pneumoniae, Pseudomonas aeruginosa, and Candida sp.) were stratified by community onset (CO) if ≤ 3 days from admission or hospital onset (HO) if > 3 days after admission. We compared pre-pandemic CO and HO rates with pandemic periods and the rates of BSI for those with and without COVID-19. ResultsCOVID-19 patients were less likely to be admitted with COBSI compared to others (10.85 vs 22.35 per 10,000 patient days; P < .0001). There was a significant increase between pre-pandemic and pandemic HOBSI rates (2.78 vs 3.56 per 10,000 patient days; P < .0001). Also, COVID-19 infected patients were 3.5 times more likely to develop HOBSI compared to those without COVID-19 infection (9.64 vs 2.74 per 10,000 patient-days; P < .0001). ConclusionsThe COVID-19 pandemic period was associated with substantial increases in HOBSI and largely attributed to COVID-19 infected patients. Future research should evaluate whether such measures would be beneficial to incorporate in evaluating infection prevention trends.

A nationwide population-based study of Escherichia coli bloodstream infections: incidence, antimicrobial resistance and mortality

ObjectivesEscherichia coli is the leading cause of bloodstream infection (BSI). The incidence of E. coli BSI caused by antibiotic-resistant strains is increasing. We aimed to describe the nationwide incidence and resistance profile of E. coli BSI in Israel and its impact on mortality, to compare E. coli BSI mortality with all-cause mortality, and community-onset with hospital-onset E. coli BSIs. MethodsWe used mandatory BSI surveillance reports submitted by all Israeli hospitals to the Ministry of Health and the national death registry. All E. coli BSIs from 1 January 2018 to 31 December 31 2019 in patients aged 18 and over were included. ResultsA total of 11 113 E. coli BSIs occurred in 10 218 patients; 85% (9012/10 583) were community onset. Median age was 76 (IQR 65–85), and 57% (6304/11 113) of cases occurred in women. The annual incidence was 92.5 per 100 000 population. Antibiotic resistance was frequent and significantly more common in hospital-onset than in community-onset BSI; 65% (1021/1571) vs. 45% (4049/9012) were multidrug-resistant (MDR) (p < 0.001). The case fatality rate (CFR) was higher following hospital-onset BSI than community-onset: 23% (276/1214) vs. 12% (926/7620) at 14 days, 31% (378/1214) vs. 16% (1244/7620) at 30 days, and 55% (418/766) vs. 34% (1645/4903) at 1 year (p < 0.001 for all comparisons). The 1-year CFR was 47% (1258/2707) for MDR vs. 28% (928/3281) for non-MDR (p < 0.001). The annual mortality rate was 31.0 per 100 000 population, comprising 4.2% (31.0/734.8) of all causes of deaths. DiscussionE. coli BSI carries a high burden, with a large proportion of MDR isolates, which are associated with increased incidence and CFR.

171. The Impact of COVID-19 on Healthcare-Associated Infections

BackgroundThe profound changes wrought by COVID-19 on routine hospital operations may have influenced performance on hospital measures, including healthcare-associated infections (HAIs). ObjectiveEvaluate the association between COVID-19 surges and HAI or cluster ratesMethods Design: Prospective cohort studySetting148 HCA Healthcare-affiliated hospitals, 3/1/2020-9/30/2020, and a subset of hospitals with microbiology and cluster data through 12/31/2020PatientsAll inpatientsMeasurementsWe evaluated the association between COVID-19 surges and HAIs, hospital-onset pathogens, and cluster rates using negative binomial mixed models. To account for local variation in COVID-19 pandemic surge timing, we included the number of discharges with a laboratory-confirmed COVID-19 diagnosis per staffed bed per month at each hospital.ResultsCentral line-associated blood stream infections (CLABSI), catheter-associated urinary tract infections (CAUTI), and methicillin-resistant Staphylococcus aureus (MRSA) bacteremia increased as COVID-19 burden increased (P ≤ 0.001 for all), with 60% (95% CI, 23 to 108%) more CLABSI, 43% (95% CI, 8 to 90%) more CAUTI, and 44% (95% CI, 10 to 88%) more cases of MRSA bacteremia than expected over 7 months based on predicted HAIs had there not been COVID-19 cases. Clostridioides difficile infection (CDI) was not significantly associated with COVID-19 burden. Microbiology data from 81 of the hospitals corroborated the findings. Notably, rates of hospital-onset bloodstream infections and multidrug resistant organisms, including MRSA, vancomycin-resistant enterococcus and Gram-negative organisms were each significantly associated with COVID-19 surges (P < 0.05 for all). Finally, clusters of hospital-onset pathogens increased as the COVID-19 burden increased (P = 0.02).LimitationsVariations in surveillance and reporting may affect HAI data.Table 1. Effect of an increase in number of COVID-19 discharges on HAIs and hospital-onset pathogens Figure 1. Predicted mean HAI rates as COVID-19 discharges increase Predicted mean HAI rate by increasing monthly COVID-19 discharges. Panel a. CLABSI, Panel b, CAUTI Panel c. MRSA Bacteremia, Panel d. CDI. Data are stratified by small, medium and large hospitals.Figure 2. Monthly comparison of COVID discharges to clusters COVID-19 discharges and the number of clusters of hospital-onset pathogens are correlated throughout the pandemic.ConclusionCOVID-19 surges adversely impact HAI rates and clusters of infections within hospitals, emphasizing the need for balancing COVID-related demands with routine hospital infection prevention. Disclosures Kenneth Sands, MD, MPH, Medline (Other Financial or Material Support, Conducted studies in which participating hospitals received contributed antiseptic product) Susan S. Huang, MD, MPH, Medline (Other Financial or Material Support, Conducted studies in which participating hospitals and nursing homes received contributed antiseptic and cleaning products)Molnlycke (Other Financial or Material Support, Conducted studies in which participating hospitals and nursing homes received contributed antiseptic and cleaning products)Stryker (Sage) (Other Financial or Material Support, Conducted studies in which participating hospitals and nursing homes received contributed antiseptic and cleaning products)Xttrium (Other Financial or Material Support, Conducted studies in which participating hospitals and nursing homes received contributed antiseptic and cleaning products) Ken Kleinman, PhD, Medline (Other Financial or Material Support, Conducted studies in which participating hospitals received contributed antiseptic products)Molnlycke (Other Financial or Material Support, Conducted studies in which participating hospitals received contributed antiseptic products) Edward Septimus, MD, Medline (Other Financial or Material Support, Conducted studies in which participating hospitals received contributed antiseptic products)Molnlycke (Other Financial or Material Support, Conducted studies in which participating hospitals received contributed antiseptic products) Eunice J. Blanchard, MSN RN, Medline (Other Financial or Material Support, Conducted studies in which participating hospitals received contributed antiseptic product) Russell Poland, PhD, Medline (Other Financial or Material Support, Conducted studies in which participating hospitals received contributed antiseptic product) Micaela H. Coady, MS, Medline (Other Financial or Material Support, Conducted studies in which participating hospitals received contributed antiseptic product)Molnlycke (Other Financial or Material Support, Conducted studies in which participating hospitals received contributed antiseptic product) Deborah S. Yokoe, MD, MPH, Nothing to disclose Julia Moody, MS, Medline (Other Financial or Material Support, Conducted studies in which participating hospitals received contributed antiseptic product)Molnlycke (Other Financial or Material Support, Conducted studies in which participating hospitals received contributed antiseptic product) Richard Platt, MD, MSc, Medline (Research Grant or Support, Other Financial or Material Support, Conducted studies in which participating hospitals received contributed antiseptic product)Molnlycke (Other Financial or Material Support, Conducted studies in which participating hospitals received contributed antiseptic product) Jonathan B. Perlin, MD, PhD, Medline (Other Financial or Material Support, Conducted studies in which participating hospitals received contributed antiseptic product)Molnlycke (Other Financial or Material Support, Conducted studies in which participating hospitals received contributed antiseptic product)

The Impact of Coronavirus Disease 2019 (COVID-19) on Healthcare-Associated Infections.

BackgroundThe profound changes wrought by COVID-19 on routine hospital operations may have influenced performance on hospital measures, including healthcare-associated infections (HAIs). We aimed to evaluate the association between COVID-19 surges and HAI and cluster rates.MethodsIn 148 HCA Healthcare-affiliated hospitals, 3/1/2020-9/30/2020, and a subset of hospitals with microbiology and cluster data through 12/31/2020, we evaluated the association between COVID-19 surges and HAIs, hospital-onset pathogens, and cluster rates using negative binomial mixed models. To account for local variation in COVID-19 pandemic surge timing, we included the number of discharges with a laboratory-confirmed COVID-19 diagnosis per staffed bed per month.ResultsCentral line-associated blood stream infections (CLABSI), catheter-associated urinary tract infections (CAUTI), and methicillin-resistant Staphylococcus aureus (MRSA) bacteremia increased as COVID-19 burden increased. There were 60% (95% CI, 23-108%) more CLABSI, 43% (95% CI, 8-90%) more CAUTI, and 44% (95% CI, 10-88%) more cases of MRSA bacteremia than expected over 7 months based on predicted HAIs had there not been COVID-19 cases. Clostridioides difficile infection was not significantly associated with COVID-19 burden. Microbiology data from 81 of the hospitals corroborated the findings. Notably, rates of hospital-onset bloodstream infections and multidrug resistant organisms, including MRSA, vancomycin-resistant enterococcus and Gram-negative organisms were each significantly associated with COVID-19 surges. Finally, clusters of hospital-onset pathogens increased as the COVID-19 burden increased.ConclusionCOVID-19 surges adversely impact HAI rates and clusters of infections within hospitals, emphasizing the need for balancing COVID-related demands with routine hospital infection prevention.

Pediatric research priorities in healthcare-associated infections and antimicrobial stewardship.

To develop a pediatric research agenda focused on pediatric healthcare-associated infections and antimicrobial stewardship topics that will yield the highest impact on child health. The study included 26 geographically diverse adult and pediatric infectious diseases clinicians with expertise in healthcare-associated infection prevention and/or antimicrobial stewardship (topic identification and ranking of priorities), as well as members of the Division of Healthcare Quality and Promotion at the Centers for Disease Control and Prevention (topic identification). Using a modified Delphi approach, expert recommendations were generated through an iterative process for identifying pediatric research priorities in healthcare associated infection prevention and antimicrobial stewardship. The multistep, 7-month process included a literature review, interactive teleconferences, web-based surveys, and 2 in-person meetings. A final list of 12 high-priority research topics were generated in the 2 domains. High-priority healthcare-associated infection topics included judicious testing for Clostridioides difficile infection, chlorhexidine (CHG) bathing, measuring and preventing hospital-onset bloodstream infection rates, surgical site infection prevention, surveillance and prevention of multidrug resistant gram-negative rod infections. Antimicrobial stewardship topics included β-lactam allergy de-labeling, judicious use of perioperative antibiotics, intravenous to oral conversion of antimicrobial therapy, developing a patient-level "harm index" for antibiotic exposure, and benchmarking and or peer comparison of antibiotic use for common inpatient conditions. We identified 6 healthcare-associated infection topics and 6 antimicrobial stewardship topics as potentially high-impact targets for pediatric research.

Is Hospital-Onset Bloodstream Infection (HOBSI) a Useful Measure to Evaluate Infection Prevention Progress?

Background: Acute-care hospitals in the United States are required to submit 6 healthcare-associated infection (HAI) metrics to the CMS for reporting and performance purposes prior to payment. We examined the association between HAI rate trends and hospital-onset bloodstream infection (HO-BSI) rate trends across a large, multihospital health system. Methods: HO-BSI events were identified across 52 hospitals attributable to Staphylococcus aureus, Pseudomonas aeruginosa, Escherichia coli, Klebsiella pneumoniae, or Candida spp using the NHSN Lab ID event definition of ≥day 4 of admission. We compared the performance from January 2016 to March 2019 for HO-BSI and the 6 NHSN-defined HAIs: central-line–associated bloodstream infection (CLABSI), catheter-associated urinary tract infection (CAUTI), Clostridioides difficile, methicillin-resistant Staphylococcus aureus (MRSA) bacteremia, abdominal hysterectomy surgical site infections (SSIs), and colon SSI. We calculated 2 “infection composite scores” to account for the 6 HAIs based on all observed or predicted events (score 1) and an average of the 6 HAI standardized infection ratios (SIRs; score 2). We normalized both measures to 1 for a 12-months rolling baseline. We evaluated the HO-BSI rate change over time and compared it to the change in the infection score over the same period. We compared the change in the 12-month rolling rates of the 2 HAI scores and the HO-BSI rate. Results: During the 39-month period, 3,288 HO-BSI events occurred over 9,775,118 patient days. The source of HO-BSI events included S. aureus (33.5%), P. aeruginosa (10.2%), E. coli (19.7%), K. pneumoniae (13.8%), and Candida spp (22.8%). HO-BSI event rates decreased by 17.3% from 12-month rolling baseline to last 12 months (3.70 vs 3.06 per 10,000 patient days). Similarly, 7,648 HAI events were observed, with the source of events being Clostridioides difficile (57.0%), CAUTI (15.1%), CLABSI (12.8%), MRSA (7.0%), colon SSI (6.4%), and abdominal hysterectomy SSI (1.7%). The 2 HAI scores and the HO-BSI rate all showed a notable decrease from the 2016 baseline period (Fig. 1). The reductions in the HAI scores were both strongly correlated with the reduction in the HO-BSI rate, with the HAI score 1 having a stronger correlation (r = 0.949; P &lt; .001) than was observed for HAI score 2 (r = 0.867; P &lt; .001). Conclusions: Utilization of a HO-BSI measure may prove useful as a correlated but distinct marker of infection prevention improvement or trends. HO-BSI could be useful as an objective electronically obtainable measure to assist in the evaluation of performance within and across facilities.Funding: NoneDisclosures: None

Population-Level Burden of Delayed or In Vitro Discordant Empiric Antibiotics Among Bacteremic Patients at US Hospitals

Background: Delayed or in vitro inactive empiric antibiotic therapy may be detrimental to survival in patients with bloodstream infections (BSIs). Understanding the landscape of delayed or discordant empiric antibiotic therapy (DDEAT) across different patient, pathogen, and hospital types, as well as by their baseline resistance milieu, may enable providers, antimicrobial stewardship programs, and policy makers to optimize empiric prescribing. Methods: Inpatients with clinically suspected serious infection (based on sampling of blood cultures and receiving systemic antibiotic therapy on the same or next day) found to have BSI were identified in the Cerner Healthfacts EHR database. Patients were considered to have received DDEAT when, on culture sampling day, they received either no antibiotic(s) or none that displayed in vitro activity against the pathogenic bloodstream isolate. Antibiotic-resistant phenotypes were defined by in vitro resistance to taxon-specific prototype antibiotics (eg, methicillin/oxacillin resistance in S. aureus) and were used to estimate baseline resistance prevalence encountered by the hospital. The probability of DDEAT was examined by bacterial taxon, by time of BSI onset, and by presence versus absence of antibiotic-resistance phenotypes, sepsis or septic shock, hospital type, and baseline resistance. Results: Of 26,036 assessable patients with a BSI at 131 US hospitals between 2005 and 2014, 14,658 (56%) had sepsis, 3,623 (14%) had septic shock, 5,084 (20%) had antibiotic-resistant phenotypes, and 8,593 (33%) received DDEAT. Also, 4,428 (52%) recipients of DDEAT received no antibiotics on culture sampling day, whereas the remaining 4,165 (48%) received in vitro discordant therapy. DDEAT occurred most often in S. maltophilia (87%) and E. faecium (80%) BSIs; however, 75% of DDEAT cases and 76% of deaths among recipients of DDEAT collectively occurred among patients with S. aureus and Enterobacteriales BSIs. For every 8 bacteremic patients presenting with septic shock, 1 patient did not receive any antibiotics on culture day (Fig. 1A). Patients with BSIs of hospital (vs community) onset were twice as likely to receive no antibiotics on culture day, whereas those with bloodstream pathogens displaying antibiotic-resistant (vs susceptible) phenotypes were 3 times as likely to receive in vitro discordant therapy (Fig. 1B). The median proportion of DDEAT ranged between 25% (14, 37%) in eight &lt;300-bed teaching hospitals in the lowest baseline resistance quartile and 40% (31, 50%) at five ≥300-bed teaching hospitals in the third baseline resistance quartile (Fig. 2). Conclusions: Delayed or in vitro discordant empiric antibiotic therapy is common among patients with BSI in US hospitals regardless of hospital size, teaching status, or local resistance patterns. Prompt empiric antibiotic therapy in septic shock and hospital-onset BSI needs more support. Reliable detection of S. aureus and Enterobacteriales bloodstream pathogens and their resistance patterns earlier with rapid point-of-care diagnostics may mitigate the population-level impact of DDEAT in BSI.Funding: This study was funded in part by the National Institutes of Health Clinical Center, National Institutes of Allergy and Infectious Diseases, National Cancer Institute (NCI contract no. HHSN261200800001E) and the Agency for Healthcare Research and Quality.Disclosures: None

Performance of the Hospital-Acquired Complication (HAC) algorithm for detecting hospital-onset bloodstream infections

Performance of the Hospital-Acquired Complication (HAC) algorithm for detecting hospital-onset bloodstream infections

998. Missclassification of Community and Hospital Onset Bloodstream Infections Using Laboratory-Identified Events

BackgroundLaboratory-identified bloodstream infections (LAB-ID-BSI) are classified as community onset (CO) if blood culture (BC) is collected within 3 days after facility admission and hospital onset if ≥4 days. This classification is often based on a computer-generated subtraction of the day of admission from day of onset. This method may miss recent prior hospitalizations at the same or different facilities.MethodsWe reviewed BC results (January 1, 2010–December 31, 2016), selected patients with BSI and defined the place of onset as CO (day 0–3) and HO (≥4 days) of admission based on LABID-BSI. All patients with CO were further evaluated to determine whether they were recently hospitalized. The source and microbiology of patients with hospitalization within 14 days of the onset of BSI was compared with HO and CO without prior admission within 6 months.ResultsWe encountered 5,179 BSI episodes, 3866 (74.6%) were CO. Prior hospitalization in any hospital within 1–14 and 15–180 days of onset was documented in 659 (17.0%) and 1,465 (37.9%), respectively. Source of bacteremia and type of organisms in patients with prior hospitalization within 1–14 days were closer to HO than patients without prior hospitalization with higher frequency of Intravenous catheters (IVC), polymicrobial bacteremia, and candidemia (table).ConclusionUsing Lab-ID events to classify BSI, one in six patients may risk being misclassified as CO. This underestimates BSI related to hospital setting. Onset classification should be based on thorough historical information and not a computer-generated subtraction of admission and Lab event dates.Source of Bacteremia (%)Type of Organisms (%)IVC aIESTBaUTIaPneAbdaUK/MPolyaGPGNAnaCanaNo Hosp (1745)9.45.018.930.49.513.113.810.043.540.26.01.1Prior Hosp (659)17.54.716.122.07.911.120.618.942.141.05.33.6HO (1313)20.93.513.012.510.717.422.314.447.846.25.16.5Infective endocarditis; soft tissue/bone; pneumonia; abdomen; unknown/miscellaneous; polymicrobial. Gram-positive; Gram-negative; anaerobes; Candida spp. a: P < 0.01; chi square test.Disclosures All authors: No reported disclosures.

Incidence and antimicrobial resistance trends in bloodstream infections caused by ESKAPE and Escherichia coli at a large teaching hospital in Rome, a 9-year analysis (2007-2015).

The proportion of antimicrobial resistance (AMR) among the ESKAPE and Escherichia coli (ESKAPEEc) pathogens causing bloodstream infection (BSI) increased worldwide. We described longitudinal trends in ESKAPEEc BSI and AMR over 9years (2007-2015) at a large teaching hospital in Italy. Of 9720 unique BSI episodes, 6002 (61.7%) were caused by ESKAPEEc pathogens. The majority of these episodes (4374; 72.9%) were hospital-onset infections. The most frequent pathogen was E. coli (32.8%), followed by Staphylococcus aureus (20.6%), Klebsiella pneumoniae (16.1%), and Pseudomonas aeruginosa (11.6%). There was a significant increase of hospital-onset K. pneumoniae (from 2.3 to 5.0 per 10,000 patient-days; P= 0.001) and community-onset E. coli (from 3.3 to 9. 1 per 10,000 emergency admissions; P= 0.04) BSIs. Among hospital-onset BSIs, increases of extended-spectrum β-lactamase (ESBL)-producing E. coli (from 25.4 to 35.2%, P =0.006), carbapenemase-producing K. pneumoniae (from 4.2 to 51.6%, P< 0.001), and methicillin-resistant S. aureus (from 33.9 to 44.4%, P< 0.001) BSIs were observed between the 2007-2009 and 2010-2012 study periods. In contrast, a decrease of BSIs caused by P. aeruginosa resistant to ceftazidime (from 45.5 to 28.2%, P< 0.001), ciprofloxacin (from 46 to 36.3%, P= 0.05), and meropenem (from 55 to 39.9%, P= 0.03) was observed through all 9years of the study period. Among community-onset BSIs, increases of BSIs caused by ESBL-producing E. coli (from 28.6 to 42.2%, P= 0.002) and carbapenemase-producing K. pneumoniae (from 0 to 17.6%) were observed between the 2007-2009 and 2010-2012 study periods. Our findings show increased rates of BSI and relative AMR for specific pathogen-health care setting combinations, and call for continued active surveillance and infection control policies.

Epidemiology of Inappropriate Empiric Antibiotic Therapy for Bacteremia Based on Discordant In vitro Susceptibilities: Risk factors and Taxon-level Variation in Burden and Outcome in 156 US hospitals, 2000–2014

BackgroundDiscordance between in vitro susceptibility and empiric antibiotic therapy is inextricably linked to antibiotic resistance and decreased survival in bloodstream infections (BSI). However, its prevalence, patient- and hospital-level risk factors, and impact on outcome in a large cohort and across different pathogens remain unclear.MethodsWe examined in vitro susceptibility interpretations for bacterial BSI and corresponding antibiotic therapy among inpatient encounters across 156 hospitals from 2000 to 2014 in the Cerner Healthfacts database. Discordance was defined as nonsusceptibility to initial therapy administered from 2 days before pathogen isolation to 1 day before final susceptibility reporting. Discordance prevalence was compared across taxa; risk factors and its association with in-hospital mortality were evaluated by logistic regression. Adjusted odds ratios (aOR) were estimated for pathogen-, patient- and facility-level factors.ResultsOf 33,161 unique encounters with BSIs, 4,219 (13%) at 123 hospitals met criteria for discordant antibiotic therapy, ranging from 3% for pneumococci to 55% for E. faecium. Discordance was higher in recent years (2010–2014 vs. 2005–2009) and was associated with older age, lower baseline SOFA score, urinary (vs. abdominal) source and hospital-onset BSI, as well as ≥500-bed, Midwestern, non-teaching, and rural hospitals. Discordant antibiotic therapy increased the risk of death [aOR = 1.3 [95% CI 1.1–1.4]). Among Gram-negative taxa, discordant therapy increased risk of mortality associated with Enterobacteriaceae (aOR = 1.3 [1.0–1.6]) and non-fermenters (aOR = 1.7 [1.1–2.5]). Among Gram-positive taxa, risk of mortality from discordant therapy was significantly higher for S. aureus (aOR = 1.3 [1.1–1.6]) but unchanged for streptococcal or enterococcal BSIs.ConclusionThe prevalence of discordant antibiotic therapy displayed extensive taxon-level variability and was associated with patient and institutional factors. Discordance detrimentally impacted survival in Gram-negative and S. aureus BSIs. Understanding reasons behind observed differences in discordance risk and their impact on outcomes could inform stewardship efforts and guidelines for empiric therapy in sepsis.Disclosures All authors: No reported disclosures.

Introducing Hospital Onset Bloodstream Infection (HOBSI) as a Tool to Evaluate Infection Prevention: Assessment of 51 US Hospitals

Background Currently, publicly reported infections include a few types of events, and do not provide a comprehensive picture on overall infection prevention practices. Hospital onset bloodstream infection (HOBSI), regardless of source, reflects invasive infection from an at risk patient population in inpatient healthcare settings.Methods Using one infection prevention surveillance system, we identified all positives blood cultures for 5 organisms commonly associated with healthcare infections (Staphylococcus aureus, Escherichia coli, Klebsiella pneumoniae, Pseudomonas aeruginosa, and Candida species) over the 12 months of 2016, across 51 acute care hospitals. Each HOBSI was counted once per patient and was classified based on the NHSN definition. Validation was performed comparing individual site laboratory microbiology data to the surveillance system report.ResultsA total of 1,053 HOBSI events occurred over 2,797,568 patient-days at an aggregate rate of 3.76 per 10,000 patient-days. Small (<100 beds) hospitals had very low event rates. There were significant differences between medium (100–300 beds) size and large (>300 beds) hospitals, specifically candidemia and Gram-negative bacteremia (table). S. Aureus and Candida species represented 57% of all HOBSIs. Facility and system events were trended monthly over time based on individual and all organisms combined and provided an objective assessment of invasive infections over time (figure).Conclusion Automated reporting of HOBSI for common organisms associated with invasive disease provides an objective method to evaluate infection prevention in medium and large hospitals and potentially benchmarking based on hospital characteristics in the future.Disclosures All authors: No reported disclosures.