Implementation Of Contact Precautions Research Articles

Community Healthcare-Associated Infections: Enhancing Control with Software and Tailored Protocols

Abstract Issue/Problem Healthcare-associated infections are major global public health challenges. In Portugal, the prevalence of resistant Enterobacteriaceae is particularly alarming. Studies typically focus on hospitals and long-term care facilities, neglecting community settings where patients, particularly the elderly with multiple comorbidities, often transition between hospital and home. Description of the problem Effective control measures are vital across all healthcare environments. In home care, sporadic implementation of Contact Precautions, due to the lack of specific guidelines and challenges in accessing colonization information, has been a major gap. This project aimed to close this gap by integrating a software, previously used only in hospitals, to enhance infection control in domiciliary care. The intervention adapted contact transmission-based precautions for home settings and used data from the previous year’s infections and colonization to tailor recommendations for each patient, preventing transmission between homes and enhancing caregiver education. Results Preliminary data from a two-month monitoring period involved 40 patients under the care of three domiciliary teams. Eleven had records of infections involving 19 microorganisms, including 7 Enterobacteriaceae, five of which were carbapenemase producers. This led to five customized recommendations for improved precautions. The intervention also heightened nurses’ awareness of patients’ microbiological histories, evidenced by increased inquiries to the infection control team. Lessons Adapting measures to the unique dynamics of home care, distinct from hospital settings, is critical. Involvement of care teams in decision-making ensures practical adherence and enhances measure effectiveness. Regular monitoring is crucial for compliance, making this approach a model for other settings. Key messages • Adapting hospital protocols to community settings and offering close support to caregiving teams increases compliance. • Implementing software that facilitates communication about infection and colonization enhances infection control effectiveness in community settings.

Investigating transmission patterns among preterm neonates during an outbreak of necrotizing enterocolitis related to Clostridium butyricum using whole-genome sequencing

BackgroundNecrotizing enterocolitis is the most severe life-threatening acquired gastrointestinal disorder among preterm neonates. We describe here an outbreak of Clostridium butyricum-related necrotizing enterocolitis in preterm neonates that occurred in three different neonatal centres, in southeast France. MethodsWe defined a confirmed case of C. butyricum-related necrotizing enterocolitis in preterm neonates by the presence of clinical signs according to modified Bell criteria and C. butyricum identified from stools sample using real-time polymerase chain reaction or culture. A phylogenetic analysis of the isolated strains by whole genome sequencing was also performed. ResultsBetween 5 and 27 January 2022, we identified ten confirmed cases of C. butyricum-related necrotizing enterocolitis, including five from neonatal centre 1, four from neonatal centre 2, and one from neonatal centre 3. The attack rate of necrotizing enterocolitis in neonatal centre 1 was 7.1% (5/70). The positivity rate of C. butyricum detected from stool samples was higher during the outbreak period (37/276; 13.4%) than outside this period (7/369; 1.9%), while systematic screening was maintained (P<0.001). Phylogenetic analysis showed a clonality between strains inside four clusters. Two clusters included neonates hospitalised in different neonatal centres, suggesting the transmission of C. butyricum strains during the transfer of neonates between neonatal centres. ConclusionsThis outbreak of C. butyricum-related necrotizing enterocolitis confirms a cross-transmission between preterm neonates, including twin or triplet siblings, and involving necrotizing enterocolitis cases together with asymptomatic carriers. After three months of follow-up, no further cases were identified following the implementation of contact precautions with sporicidal agents.

Implementation of contact precautions for multidrug-resistant organisms in the post-COVID-19 pandemic era: An updated national Emerging Infections Network (EIN) survey.

To understand how healthcare facilities employ contact precautions for patients with multidrug-resistant organisms (MDROs) in the post-coronavirus disease 2019 (COVID-19) era and explore changes since 2014. Cross-sectional survey. Emerging Infections Network (EIN) physicians involved in infection prevention or hospital epidemiology. In September 2022, we sent via email an 8-question survey on contact precautions and adjunctive measures to reduce MDRO transmission in inpatient facilities. We also asked about changes since the COVID-19 pandemic. We used descriptive statistics to summarize data and compared results to a similar survey administered in 2014. Of 708 EIN members, 283 (40%) responded to the survey and 201 reported working in infection prevention. A majority of facilities (66% and 69%) routinely use contact precautions for methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococci (VRE) respectively, compared to 93% and 92% in 2014. Nearly all (>90%) use contact precautions for Candida auris, carbapenem-resistant Enterobacterales (CRE), and carbapenem-resistant Acinetobacter baumannii. More variability was reported for carbapenem-resistant Pseudomonas aeruginosa and extended-spectrum β-lactamase-producing gram-negative organisms. Compared to 2014, fewer hospitals perform active surveillance for MRSA and VRE. Overall, 90% of facilities used chlorhexidine gluconate bathing in all or select inpatients, and 53% used ultraviolet light or hydrogen peroxide vapor disinfection at discharge. Many respondents (44%) reported changes to contact precautions since COVID-19 that remain in place. Heterogeneity exists in the use of transmission-based precautions and adjunctive infection prevention measures aimed at reducing MDRO transmission. This variation reflects a need for updated and specific guidance, as well as further research on the use of contact precautions in healthcare facilities.

Genomic surveillance of Clostridioides difficile transmission and virulence in a healthcare setting.

Clostridioides difficile infection remains a leading cause of hospital-associated diarrhea, despite increased antibiotic stewardship and transmission prevention strategies. This suggests a changing genomic landscape of C. difficile. Our study provides insight into the nature of prevalent C. difficile strains in a hospital setting and transmission patterns among carriers. Longitudinal sampling of surfaces and patient stool revealed that both toxigenic and nontoxigenic strains of C. difficile clade 1 dominate these two wards. Moreover, quantification of transmission in carriers of these clade 1 isolates underscores the need to revisit infection prevention measures in this patient group. We identified unique genetic signatures associated with virulence in this clade. Our data highlight the complexities of preventing transmission of this pathogen in a hospital setting and the need to investigate the mechanisms of in vivo persistence and virulence of prevalent lineages in the host gut microbiome.

Facility- and patient-level factors associated with implementation of contact precautions in hospitalized VA patients with positive CRE cultures.

Decreasing the time to contact precautions (CP) is critical to carbapenem-resistant Enterobacterales (CRE) prevention. Identifying factors associated with delayed CP can decrease the spread from patients with CRE. In this study, a shorter length of stay was associated with being placed in CP within 3 days.

Effect of contact precautions on preventing meticillin-resistant Staphylococcus aureus transmission in intensive care units: a review and modelling study of field trials

Contact precautions (CPs) have been widely implemented in hospitals, particularly in intensive care units (ICUs), as the standard approach for managing meticillin-resistant Staphylococcus aureus (MRSA). However, the effectiveness of CPs in preventing MRSA transmission remains a subject of debate. To assess the effectiveness of CPs in reducing MRSA transmission within ICUs. A comprehensive analysis was conducted using data from 16 sets of parameters collected from 13 field studies investigating the effectiveness of CPs in ICUs, and an epidemiologic model was developed to simulate the dynamics of MRSA incidence in the hospital setting. The analysis demonstrated a mean reduction of 20.52% (95% confidence interval -30.52 to 71.60%) in the MRSA transmission rate associated with the implementation of CPs. Furthermore, reducing the time-delay of screening tests and increasing the percentage of patients identified with MRSA through screening at admission were found to contribute to the effectiveness of CPs. Proper implementation of CPs, with a particular emphasis on early identification of MRSA-colonized/infected patients, demonstrated a strong association with reduced MRSA transmission within the hospital setting. However, further research is necessary to investigate the effectiveness and safety of decolonization and other interventions used in conjunction with CPs to mitigate the risk of infection among colonized patients.

Comparing practices to prevent infectious diseases transmission among Veterans Affairs and Nonveterans Affairs hospitals: Results from a national survey in the United States

Ournational cross-sectional survey of United States hospitals found greater implementation of contact precautions for multidrug-resistant organisms and a higher percentage reporting the use of supplemental no-touch disinfection devices among Veterans Affairs (VA) versus non-VA hospitals. Nationally coordinated infection prevention initiatives within the VA could account for these practice differences.

Severe SARS-CoV-2 and respiratory syncytial virus co-infection in two children.

The Coronavirus Disease 2019 (COVID-19) caused by a novel coronavirus (SARS-CoV-2) affects mainly older adults. Those with comorbidities are at a higher risk of severe disease and even death. The symptomatic infection rate of children is lower, manifestations are milder, and severe forms are scarce. We present here two children with severe COVID-19 and a respiratory syncytial virus, with the goal of emphasizing the possibility of coinfection with a severe course and a different result. The microbiological diagnosis was made using multiplex PCR. This assay not only provided an early and accurate diagnosis but also aided in the implementation of contact precautions. Further research should be done to determine the influence of coinfection on the clinical course and outcome of pediatric patients.

Candida auris as a pathogen that can cause emerging infectious disease: a literature review

Candida auris is a fungal pathogen that can cause emerging infectious disease and infections related to health services (healthcare-associated infections) and threaten global health. It is one of the causes of candidemia, which has been connected to outbreaks and high mortality rates in medical facilities all over the world. Hospitalized patients who are critically ill, primarily in intensive care unit settings, account for the majority of reported infections. C. auris can be multi-resistant to various antifungal classes commonly used to treat other Candida infections. Invasive infection due to C. auris causes high mortality and morbidity rates. C. auris easily survives long enough in the surrounding environment to cause the rapid spread of outbreaks in health facilities. The critical need for novel, candidate antifungal medicines for C. auris therapies is driven by the pathogenicity, drug resistance, and widespread distribution of C. auris. In limiting the spread of C. auris, prompt investigations and aggressive interventions are required. These include alerting public health agencies, implementing contact precautions, thoroughly cleaning and disinfecting the environment, performing infection control assessments, tracing and screening contacts for colonization, reviewing the history of microbiology tests, and conducting prospective surveillance for cases at labs. C. auris poses a unique challenge in clinical settings due to its identification challenges, multidrug resistance traits, evolution of virulence factors, associated high patient fatality rates, and long-term survival on surfaces in the environment. This study aims to understand the epidemiology, clinical manifestations, characteristics, virulence factors, methods of identification, therapy and prevention control of infection by C. auris.

Isolation of Methicillin-Resistant Staphylococcus aureus from Wound Samples during the COVID-19 Pandemic: A Retrospective Study

Introduction: On March 11th, 2020, the World Health Organisation (WHO) declared the outbreak of the novel coronavirus disease caused by the Severe Acute Respiratory Syndrome Corona Virus 2 (SARSCoV-2) virus as a pandemic. This recently discovered β-coronavirus spread instantaneously across mainland China due to human-tohuman transmission and crossed international borders aided by intercontinental travel. In most nations, the logarithmic growth of the cases very quickly overwhelmed the healthcare system which led to the overcrowding of the hospitals and led to a sudden surge in Hospital-Acquired Infections (HAIs). Implementation of contact precautions was implemented to control cross-infection. Aim: To determine the effect of Coronavirus Disease-2019 (COVID-19) on the prevalence of HAIs with special emphasis on Staphylococcus aureus (S. aureus). Materials and Methods: This three-year retrospective study (September 2018-August 2021) was undertaken at an apex tertiary care institute in Northern India. Wound swabs were collected and processed in the laboratory for the presence of aerobic bacterial isolates. S. aureus was identified using conventional methods and antimicrobial sensitivity was performed by the Kirby-Bauer disc diffusion method. Data was entered in Microsoft Excel and later analysed in International Business Machines (IBM) Statistical Package for the Social Sciences (SPSS) version 22.0. Results: A steady increase in the isolation of MethicillinResistant Staphylococcus aureus (MRSA) was noted during the study period (60.5% in 2018 to 78.1% in 2021). A statistically significant increase was noted in the detection of MRSA after the onset of the COVID-19 pandemic (p=0.018) despite the reduced number of surgeries conducted in the institution and rigorous execution of contact precautions. Conclusion: There was an increase in the rate of MRSA isolation during the study period. The increase was significantly affected by the onset of COVID-19. To contain the spread of MRSA, novel methods including preoperative screening of patients undergoing elective surgeries and periodic screening of hospital staff need to be implemented along with standard infection control precautions at all times.

Measuring Epidemiologic Effects of Enterococcal Bacteremia and Outcomes From a Nationwide Inpatient Sample Database.

IntroductionEnterococcus is a gram-positive, non-sporing, facultative anaerobe. It is a common cause of nosocomial infections in the United States. Enterococcal bacteremia is primarily a nosocomial infection in the medical intensive care unit (ICU), with a preference for elderly patients with multiple comorbidities. Material and methodsThis is a retrospective cohort study using the publicly accessible National (Nationwide) Inpatient Sample (NIS) database from October 2015 to December 2017. We examined data from 75,430 patients aged 18 years and older in the NIS who developed enterococcal bacteremia, as identified from the ICD-10 CM codes (B95), to discuss the epidemiologic effects and outcomes of enterococcal bacteremia. Patients were classified based on demographics, and comorbidities were identified. Three primary outcomes were studied: in-hospital mortality, length of stay, and healthcare cost. The secondary outcome was identifying any comorbidities associated with enterococcal bacteremia. Length of stay was defined as days from admission to discharge or death. Healthcare costs were estimated from the hospital perspective from hospital-level ratios of costs-to-charges. SAS 9.4 (2013; SAS Institute Inc., Cary, North Carolina, United States) was used for univariate and multivariate analyses. For data analysis, mortality was modeled using logistic regression. Length of stay and costs were modeled using linear regression, controlling for patient and hospital characteristics. Statistical analyses were performed using SAS. Statistical significance was defined as P<0.05.ResultsA total of 75,430 patients with enterococcal bacteremia were included in the study. Of this, 44,270 were males and 31,160 females. A total of 50,270 (68.67%) were Caucasians, 11,210 (15.31%) were African Americans, 6,445 (8.80%) were Hispanic and 2,025 (2.77%) were native Americans. Important comorbidities were congestive heart failure (25.91%), valvular disease (8.08%), neurological complications (11.87%), diabetes mellitus with complications (18.89%), renal failure (28.52%), and obesity (11.61%). In-hospital mortality was 11.07%, length of stay was 13.8 days, and a healthcare cost of 41,232.6 USD. ConclusionsEnterococcal bacteremia is a nosocomial infection with a preference for the elderly with renal failure, cardiac failure, cardiac valvular diseases, stroke, obesity, and diabetes with complications. Further studies are needed to see whether the mortality caused by enterococcal bacteremia is attributable to comorbidities or to the bacteremia. It is associated with a more extended hospital stay and higher healthcare expenditure. Implementing contact precautions to contain the spread of methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococcus(VRE) has also checked the spread of enterococci. Further prospective studies can be planned using chart-based data.

An interventional quasi-experimental study to evaluate the impact of a rapid screening strategy in improving control of nosocomial extended-spectrum beta-lactamase-producing Enterobacterales and carbapenemase-producing organisms in critically ill patients

IntroductionRapid molecular tests could accelerate the control of extended-spectrum beta-lactamase-producing Enterobacterales (ESBL-PE) and carbapenemase-producing organisms (CPO) in intensive care units (ICUs).Objective and methodsThis interventional 12-month cohort study compared a loop-mediated isothermal amplification (LAMP) assay performed directly on rectal swabs with culturing methods (control period, 6 months), during routine ICU screening. Contact precautions (CP) were implemented for CPO or non-E. coli ESBL-producing Enterobacterales (nEcESBL-PE) carriers. Using survival analysis, we compared the time intervals from admission to discontinuation of unnecessary preemptive CP among patients at-risk and the time intervals from screening to implementation of CP among newly identified carriers. We also compared diagnostic performances, and nEcESBL-PE/CPO acquisition rates. This study is registered, ISRCTN 23588440.ResultsWe included 1043 patients. During the intervention and control phases, 92/147 (62.6%) and 47/86 (54.7%) of patients at-risk screened at admission were candidates for early discontinuation of preemptive CP. The LAMP assay had a positive predictive value (PPV) of 44.0% and a negative predictive value (NPV) of 99.9% for CPO, and 55.6% PPV and 98.2% NPV for nEcESBL-PE. Due to result notification and interpretation challenges, the median time from admission to discontinuation of preemptive CP increased during the interventional period from 80.5 (95% CI 71.5–132.1) to 88.3 (95% CI 57.7–103.7) hours (p = 0.47). Due to the poor PPV, we had to stop using the LAMP assay to implement CP. No difference was observed regarding the incidence of nEcESBL-PE and CPO acquisition.ConclusionA rapid screening strategy with LAMP assays performed directly on rectal swabs had no benefit for infection control in a low-endemicity setting.

Carbapenemase-producing Enterobacterales and vancomycin-resistant Enterococcus faecium carriage in patients who have traveled in foreign countries: A single center 5-year prospective study

Numerous patients carrying carbapenemase-producing Enterobacterales (CPE) and/or vancomycin-resistant Enterococcus faecium (VRE) in France have previously travelled abroad. The risk of spreading CPE/VRE by patients who have stayed abroad without hospitalization is underexplored. This prompted us to screen and isolate all patients who travelled abroad in the previous 12 months upon admission to our hospital. Our aim was to evaluate the efficiency of this CPE/VRE-related risk policy. From 2014 to 2018, patients who had travelled abroad in the previous year before their admission underwent microbiological screening and were pre-emptively isolated. Contact precautions were verified and CPE/VRE cross-transmission events investigated. Among 1,780 screened patients, 59 (3.3%) were colonized with CPE and/or VRE, of whom 17 (29.3%) were not hospitalized abroad. Nine generated 18 readmissions. No episodes of CPE/VRE cross-transmission were related to patients with a stay abroad without hospitalization, whereas 2 patients hospitalized abroad generated one episode each, despite implementation of contact precautions reaching values from 73.6% to 87.5%. Throughout 17 admissions and 18 readmissions, patients who stayed abroad without hospitalization represented a true risk of spreading CPE/VRE, without generating cross-transmission. Our strategy of CPE/VRE-related risk policy is successful.

The Role of the Perioperative Nurse in Implementing Contact Precautions to Prevent Transmission of Multidrug-Resistant Organisms.

The World Health Organization and Centers for Disease Control and Prevention consider the global increase in multidrug-resistant organisms (MDROs) to be one of the greatest modern threats to public health. Limited treatment options exist for microorganisms such as carbapenem-resistant Enterobacterales and Candida auris; as a result, infected patients may experience poor outcomes. Perioperative nurses should use infection prevention measures (eg, contact precautions) to prevent the spread of emerging MDROs when transporting patients to and from procedures, caring for patients during procedures, and completing between-procedure cleaning. Because nurses are involved with all phases of perioperative care, they are well-positioned to serve as infection prevention champions and provide education to personnel, patients, and caregivers. This article describes actions and steps the perioperative nurse should take during implementation of contact precautions to prevent the transmission of MDROs-specifically, emerging pathogens carbapenem-resistant Enterobacterales and C auris.

Perioperative Infection Prevention Beyond COVID‐19

Perioperative Infection Prevention Beyond COVID‐19

Effectiveness of SARS-CoV-2 Decontamination and Containment in a COVID-19 ICU.

Background: Health care systems in the United States are continuously expanding and contracting spaces to treat patients with coronavirus disease 2019 (COVID-19) in intensive care units (ICUs). As a result, hospitals must effectively decontaminate and contain severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in constructed and deconstructed ICUs that care for patients with COVID-19. We assessed decontamination of a COVID-19 ICU and examined the containment efficacy of combined contact and droplet precautions in creating and maintaining a SARS-CoV-2–negative ICU “antechamber”. Methods: To examine the efficacy of chemical decontamination, we used high-density, semi-quantitative environmental sampling to detect SARS-CoV-2 on surfaces in a COVID-19 ICU and COVID-19 ICU antechamber. Quantitative real-time polymerase chain reaction was used to measure viral RNA on surfaces. Viral location mapping revealed the distribution of viral RNA in the COVID-19 ICU and COVID-19 ICU antechamber. Results were further assessed using loop-mediated isothermal amplification. Results: We collected 224 surface samples pre-decontamination and 193 samples post-decontamination from a COVID-19 ICU and adjoining COVID-19 ICU antechamber. We found that 46% of antechamber objects were positive for SARS-CoV-2 pre-decontamination despite the construction of a swinging door barrier system, implementation of contact precautions, and installation of high-efficiency particulate air filters. The object positivity rate reduced to 32.1% and viral particle rate reduced by 95.4% following decontamination. Matched items had an average of 432.2 ± 2729 viral copies/cm2 pre-decontamination and 19.2 ± 118 viral copies/cm2 post-decontamination, demonstrating significantly reduced viral surface distribution (p < 0.0001). Conclusions: Environmental sampling is an effective method for evaluating decontamination protocols and validating measures used to contain SARS-CoV-2 viral particles. While chemical decontamination effectively removes detectable viral RNA from surfaces, our approach to droplet/contact containment with an antechamber was not highly effective. These data suggest that hospitals should plan for the potential of aerosolized virions when creating strategies to contain SARS-CoV-2.

Evaluating the economic effects of genomic sequencing of pathogens to prioritise hospital patients competing for isolation beds.

Objective This study compared the costs and patient movements of a new hospital protocol to discontinue contact precautions for patients with non-multiresistant methicillin-resistant Staphylococcus aureus (nmMRSA), based on whole-genome sequencing (WGS) of pathogens with current practice. Methods A hybrid simulation model was constructed and analysed over a 12-month time horizon. Six multidrug-resistant organisms and influenza were modelled concurrently where infected patients competed for isolation beds. Model inputs included pathogen incidence, resources for WGS, staff and contact precautions, hospital processes, room allocations and their associated costs. Data were sourced from aggregated records of patient admissions during 2017-18, clinical records and published reports. Results The WGS protocol resulted in 389 patients isolated (44% of current practice), 5223 'isolation bed days' (56%) and 268 closed-bed days (88%). Over 1 year, the mean (±s.d.) total cost for the WGS protocol was A$749243±126667; compared with current practice, the overall cost savings were A$690864±300464. Conclusion Using WGS to inform infection control teams of pathogen transmission averts patients from isolation rooms and reduces significant resources involved in implementing contact precautions. What is known about the topic? There are an estimated 265000 hospital-acquired infections (HAI) in Australia each year. WGS can accurately identify the genetic lineage among HAIs and determine transmission clusters that can help infection control staff manage patients. Economic appraisals are lacking to inform whether pathogen genomics services should be adopted within already-stretched hospital budgets. What does this paper add? An isolation protocol using pathogen genomics to provide additional information on the relatedness of a pathogen between colonised patients showed favourable results for healthcare costs and patient flow. Using WGS, in a confirmatory role, to discontinue certain patients from contact precautions and isolation rooms resulted in cost savings of A$690864 across 1 year for a single major hospital. What are the implications for practitioners? Using pathogen WGS services for infection control potentially curbs hospital spending, averts patient isolations and improves patient flow within hospitals.

CDIFFerently: A Bundled Approach to Clostridium difficile Reduction

Background: Since 2015 the rate of healthcare facility-onset Clostridium difficile infections (HO CDI) at Faxton-St Luke’s Healthcare (FSLH) has remained higher than both New York state and federal benchmarks, despite the use of traditional prevention efforts. Methods: We used the define-measure-analyze-improve-control (DMAIC) process improvement model to better understand the reasons that our rates remained high and to develop a comprehensive reduction strategy.•Define: High HO CDI rates. NHSN SIR consistently above 1.0•Measure•Diagnostic stewardship. Are patients being tested appropriately?•Antibiotic stewardship: Do prescribing practices follow best-practice recommendations?•Environmental cleanliness: Are staff following standard and transmission based precautions? How effective are current cleaning practices? What is being done to limit contamination of the environment of care?•Perform a gap analysis of CDI prevention strategies at FSLH vs current best practice recommendations, emerging strategies in scientific literature and successful approaches at other health-care facilities.•Analyze•Staff do not have a clear understanding of symptoms and risk factors of CDI and often initiate testing inappropriately.•Overuse of broad spectrum antimicrobial agents. No antibiotic time outs. Limited Pharmacy staff available for auditing and feedback regarding prescribing practices.•UV disinfection system under-utilized. Shared patient care equipment not cleaned between uses. Delay in implementation of contact precautions. Lack of opportunities for patient hand hygiene.•Improve•Algorithms for screening and testing built into Electronic Medical Record Orders for testing coupled with orders for contact precautions•Align antimicrobial prescribing with best practice•Audit and reward compliance with UV light utilization, environmental cleaning Reduce shared patient care equipment, replace with disposable items•Provide products for patient hand hygiene•Implement marketing campaign to tie elements together•Control•Audit compliance with testing and isolation policies•Laboratory rejection of formed stools•Audit cleaning processes with adenosine triphosphate (ATP) monitor•Track ultraviolet light usageFunding: NoneDisclosures: None

Characteristics of Candida auris Patients at a Tertiary-Care Hospital, 2017–2019, Nairobi, Kenya

Background:Candida auris is of global concern due to its increasing frequency in intensive care units (ICUs), reported resistance to antifungal agents, propensity to cause outbreaks, and persistence in clinical environments. We investigated an increase in C. auris cases in an ICU in Kenya to determine the source of transmission and to control the spread of the disease. Methods: To identify cases, we reviewed laboratory records of patients with blood cultures yielding C. auris and organisms for which it is commonly misidentified by Vitek 2 v 8.01 software (ie, C. haemulonii, C. duobushaemulonii and C. famata) during January 2018–May 2019. We retrospectively reviewed medical charts of C. auris patients to extract information on demographics, underlying conditions, hospital procedures, treatments, and outcomes. We also enhanced infection control efforts by implementing contact precautions, equipment, and environmental disinfection, and hand hygiene training and compliance observations. Results: We identified 32 C. auris patients (Fig. 1). Median patient age was 55 years (IQR, 43–65), and 57% were male. Length of hospitalization before C. auris isolation was 30 days (IQR, 14–36). All had been admitted to the ICU. The most common reasons for admission were sepsis (50%), pneumonia (34%), surgery (25%), and stroke or other neurologic diagnosis (25%). Underlying comorbidities included hypertension (38%), diabetes mellitus (25%), and malignancy (29%). Two patients had HIV. Moreover, 61% of cultures yielded multidrug-resistant bacteria. Also, 33% of the patients had been admitted to this hospital in the preceding 3 months; 21% had been admitted to a hospital outside of Kenya; and 10% had been admitted to another hospital in Kenya in the previous year. Almost all (97%) had a central venous catheter, 45% had an acute dialysis catheter, 66% had an endotracheal tube, and 34% had a tracheostomy, with 69% receiving mechanical ventilation before C. auris isolation. Most (94%) had urinary catheters, 84% had nasogastric tubes, 91% had received total parenteral nutrition, and 75% had received blood products. All patients received broad-spectrum antibiotics and 49% received an antifungal before C. auris isolation. All-cause in-hospital mortality was 64% for the 28 patients whose outcomes were available. Following implementation of a hand hygiene campaign and improved equipment and environmental disinfection, no further cases were identified. Conclusions: We identified C. auris bloodstream infections associated with high all-cause mortality in a Kenyan hospital ICU. All patients had treatments and procedures suggesting severe underlying illness. Enhanced infection control contained the outbreak.Funding: NoneDisclosures: None

Epidemiology of NDM-Producing Enterobacteriaceae in Michigan

Background: Carbapenem-resistant Enterobacteriaceae (CRE) are classified as an urgent antibiotic-resistant threat by the CDC, and they are listed on the critical priority list by the World Health Organization due to the lack of antibiotic treatment options. New-Delhi metallo-β-lactamase (NDM) is an emerging mechanism of carbapenem resistance in the United States. We sought to understand the risk factors and clinical characteristics of patients with NDM CRE in Michigan to improve surveillance. Methods:A retrospective descriptive study was conducted in collaboration with the Michigan Department of Health and Human Services (MDHHS). CRE isolates submitted to MDHHS between April 2014 and July 2019 were tested for the presence of NDM using CDC PCR protocols. Additional information on case demographics, laboratory results, healthcare and antibiotic exposure history, and travel history were collected. Results: In total, 30 NDM cases were identified in Michigan during the study period. Of these 30 cases, 15 (50%) were men, and the median age was 73.5 years (range, 20–88 20). Also, 2 of these patients (6.6%) were immunocompromised; 2 patients (6.6%) had had extensive abdominal surgery, and 2 patients (6.6%) had recurrent hospitalization. Furthermore, 12 case isolates (40%) were collected in outpatient settings, whereas 16 (53%) were collected from inpatient settings. In addition, 13 (43%) patients were admitted from home and 4 (13%) presented from an extended-care facility. Urine was the most common site of isolation in 19 of 30 (63%) cases, followed by blood and tissue culture in 4 of 30 (13%) each. Escherichia coli was the most common organism (17 of 30, 57%), followed by Klebsiella pneumoniae (9 of 30, 30%). Also, 15 of 30 cases (50%) had a recent history of international travel, and of these, 9 of 15 (60%) reported travel to India. Among these 15 cases, 12 (80%) sought medical care in the countries they visited. Two cases (6.6%) had a documented history of multidrug-resistant organism colonization or infection. The mortality rate was 6.6% (2 of 30). The mean time from admission to implementation of contact precautions was 7.3 days (range, 0–20). Conclusions: Suspicion of NDM CRE strains should remain high in patients with a travel history from areas known as major reservoirs of NDM. Delay in implementing contact precautions, as noted in the present study, can lead to a greater risk of transmission. Early detection and subsequent isolation of NDM patients are essential strategies for preventing transmission within healthcare facilities. Future efforts include performing whole-genome sequencing of these isolates to assist in identifying potential epidemiological links among the affected patients.Funding: NoneDisclosures: None