Nasal Screening Research Articles

Performance of nasal methicillin-resistant Staphylococcus aureus screening for intra-abdominal infections in critically ill adult patients.

Intra-abdominal infections (IAIs) are a common reason for intensive care unit (ICU) admissions, and methicillin-resistant Staphylococcus aureus (MRSA) is an uncommon pathogen in IAIs. Although more data are available in the setting of non-abdominal sources, there are limited data on the performance of nasal MRSA screening for MRSA IAIs. The primary objective of this study was to evaluate the performance of nasal MRSA screening for MRSA IAIs in critically ill adult patients. This was a multicenter, retrospective, cohort study. A 14-hospital healthcare system between January 1, 2014, and August 31, 2019. Adult patients admitted to an ICU for at least 24 h with a diagnosis code for an IAI, a nasal MRSA surveillance screen within 30 days, and an intra-abdominal culture were eligible for inclusion. The primary outcome was to evaluate the performance of nasal MRSA screening for MRSA IAIs by calculating the accuracy, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV). Out of 863 patients randomly screened, a total of 192 patients were included. The study population had a mean age of 60 (SD ±15) years, and 101 (53%) patients were male. Six (3.1%) patients were positive for an MRSA IAI, of which four (66.7%) demonstrated a positive nasal MRSA screen. A total of 186 (96.8%) patients were negative for a MRSA IAI, of which 19 (10.2%) were nasal MRSA-positive and 167 (89.8%) were nasal MRSA-negative. Nasal MRSA screening demonstrated the following performance: accuracy 89.1% (95% CI: 83.8%-93.1%), sensitivity 66.7% (95% CI: 22.3%-95.7%), specificity 89.8% (95% CI: 84.5%-93.7%), PPV 17.4% (95% CI: 9.4%-30.0%), and NPV 98.8% (95% CI: 96.4%-99.6%). There were no significant differences in clinical outcomes, including renal replacement-free days, ICU and hospital length of stay, and in-hospital mortality. Among critically ill adult patients with IAIs, a negative nasal MRSA screen within 30days may help to empirically exclude MRSA as a causative pathogen.

Periprosthetic infection risks and predictive value of C-reactive protein / albumin ratio for total joint arthroplasty.

Background and aim:There are no gold standard markers to estimate the risk of developing periprosthetic infections. Our aim is to compare the risks of periprosthetic infection in patients with THA and THA and to investigate the predictive significance of the CRP / albumin ratio.Methods:This is a retrospective study containing data from 241 osteoarthritis patients and 19 patients with periprosthetic infections who underwent TKA and THA in our hospital from January 2014 to January 2019.12 risk factors(CRP/ albumin, albumin, CRP, age, gender, BMI, DM, ASA, nasal culture, urine culture, hospital stay, operation time) were analyzed.Results:In the binary logistic regression model and multivariate regression analysis, the rate of CRP / albumin was 17.161 times higher than the patients with ≤0.16 cut-off value. (CRP / albumin ratio (odds ratio (OR) = 17.16, 95% CI: 1.55-189.03, P: 0.02). High BMI increased the risk of periprosthetic infection 1.3 times. Nasal bacterial colonization (OR = 0.99, 95% CI: 0.868-1.38, P: 0.7) and bacterium in urine (OR = 0.502, 95% CI: 0.07-3.598, P: 0.703) did not pose a significant risk for periprosthetic infection.Conclusion:According to our findings, the CRP / albumin ratio has a more prognostic capacity than other risks in determining the risk of periprosthetic infection for total joint arthroplasty. CRP / albumin ratio is a cheap and easy to apply marker. Routine urine and nasal bacteria screening is not required before total joint arthroplasty.

1489. Safety and Performance of a Pharmacist-Driven Nasal MRSA PCR Protocol for De-escalation of Empiric Vancomycin for Suspected Pneumonia at an Academic Medical Center

BackgroundLimited published data supports the de-escalation of empiric anti-methicillin resistant Staphylococcus aureus (MRSA) antibiotics for suspected pneumonia upon negative nasal MRSA screening. Besides limited sample sizes, special populations, such as those who are immunocompromised and/or critically ill, have been underrepresented in these reports. We describe real-world efficacy and safety of a pharmacist-driven nasal MRSA PCR testing protocol implemented at Stanford Health Care in May 2018 across a diverse patient population.MethodsThis was an observational cohort study of adult patients who received vancomycin for empiric pneumonia before (PRE) vs after (POST) implementation of a pharmacist-driven nasal MRSA PCR testing protocol (between 05/01/2017 - 08/31/2017 (PRE) and 5/7/2018 - 12/31/2019 (POST). The primary outcome measure was duration of vancomycin administration. Secondary outcomes included time to vancomycin discontinuation, frequency of restarting vancomycin for empiric pneumonia within 7 days, acute kidney injury (defined as “risk” by RIFLE criteria), and MRSA respiratory cultures. Statistical methods are described in Figure A.Figure A. Statistical methods ResultsTotal of 610 patients were included in this study with 116 in the PRE group and 494 in the POST group. Over 40% were critically ill and approximately 37% were immunocompromised in both groups (Table 1). For the primary outcome, median vancomycin duration was significantly shorter in the POST group (1.29 days; 95% CI 1.13-1.45) vs. PRE group (1.98 days; 95% CI 1.49-2.46) (p < 0.0005), a 34.8% reduction (Figure 1). Median vancomycin duration was lower in patients with a negative vs positive nasal MRSA PCR (1.20 days [95% CI 1.08-1.33] vs 2.53 days [95% CI 1.77-3.29], p < 0.0005), a 52.6% reduction (Figure 2). MRSA was recovered in respiratory cultures in 1.7% vs 1.4% in the PRE vs POST groups. One (0.002%) patient had a negative nasal MRSA PCR but culture-confirmed MRSA pneumonia and recovered after completing a treatment course. Secondary safety outcomes were similar between groups (Table 2).Tables 1 and 2: Baseline Characteristics and Secondary Outcomes Figure 1. Primary Outcome: Kaplan–Meier Estimates of Cumulative Active Vancomycin Therapy Before and After Implementation of Nasal MRSA PCR protocol Figure 2. Secondary Outcome: Figure 2. Kaplan–Meier Estimates of Cumulative Active Vancomycin Therapy in Patients with Negative vs Positive Nasal MRSA PCR ConclusionPharmacist-driven nasal MRSA PCR testing is effective and safe in early de-escalation of empiric vancomycin used for pneumonia treatment in a diverse population including critically ill and immunocompromised patients.Disclosures All Authors: No reported disclosures

102. Effects of an Antimicrobial Stewardship-guided MRSA Nasal Screening Review on Vancomycin Utilization for Respiratory Infections: A Quasi-Experimental Study

BackgroundMethicillin-resistant Staphylococcus aureus (MRSA) remains a significant pathogen in patients with respiratory infections. Guidelines recommend empiric MRSA coverage in patients at increased risk, resulting in substantial vancomycin use. Recent literature highlights the use of MRSA nasal assays as a rapid screening tool for MRSA pneumonia, demonstrating high negative predictive values and allowing for shorter empiric coverage. We aimed to evaluate the impact of MRSA nasal screening review by the antimicrobial stewardship program (ASP) on vancomycin utilization for respiratory infections.MethodsThis was a retrospective, quasi-experimental, pre-post intervention study. The intervention saw the addition of an MRSA screening review tool into the ASP electronic record, highlighting patients on vancomycin (actively or recently administered) with a negative MRSA screening. Vancomycin days of therapy (DOT) was collected for all orders indicated for a respiratory infection in the two weeks following a negative screening. Additional outcomes include vancomycin total dose and DOT per 1,000 patient days. Outcomes were compared via independent samples t-tests.Results1,110 MRSA screenings resulted across 2 months, of which the majority were excluded for either not having vancomycin ordered, or for having vancomycin ordered for a non-respiratory indication, leaving 37 and 35 evaluable screenings in the pre- and post-intervention groups, respectively. Regarding vancomycin DOT, we did not identify a significant difference between pre- and post-intervention groups with respective means of 2.45 (SD=1.52) and 2.14 (SD=1.12) (p=0.35). We identified a total 8.78 vancomycin DOT per 1,000 patient days in the pre-intervention group versus 6.69 in the post-intervention group. ConclusionASP-guided review of MRSA screenings was associated with a nonsignificant decrease in mean vancomycin DOT and lower total DOT per 1,000 patient days for respiratory infections following a negative screen. Given the recent implementation of our intervention, our analysis covered a small sample size, highlighting the need for continued data collection. MRSA screenings are not always fully or immediately utilized in our institution, demonstrating room to de-escalate MRSA-targeted antibiotics.Disclosures All Authors: No reported disclosures

1494. Validation of Methicillin-Resistant Staphylococcus aureus (MRSA) Risk Factors in Predicting MRSA Community-Acquired Pneumonia at an Academic Medical Center

BackgroundThe 2019 Infectious Diseases Society of America community-acquired pneumonia (CAP) guidelines recommend anti-methicillin-resistant Staphylococcus aureus (MRSA) therapy in patients with CAP based on previously identified risk factors for MRSA with an emphasis on local epidemiology and institutional validation of risk. Thus, we sought to assess the ability of guideline-recognized risk factors to predict MRSA CAP at our institution.MethodsThis was a single-center, retrospective cohort study from January 2016 to March 2020. Patients were included if they were >18 years old, diagnosed with CAP, and had a MRSA nasal screen and a respiratory culture obtained on admission. Patients were excluded if CAP diagnosis was not met, respiratory cultures were not obtained within 48 hours of antibiotic initiation, or they had cystic fibrosis. Sensitivity, specificity, negative predictive value, positive predictive value, and likelihood ratios (LR) were calculated using Vassar Stats 2019. Pre/post-test odds and pre/post-test probabilities were calculated using Microsoft Excel 2019.ResultsOf 705 screened patients, 221 were included. MRSA prevalence in CAP patients at our institution was 3.6%. History of MRSA isolated from a respiratory specimen had high specificity (98%), high positive LR of 20 (95% CI 5.3 – 74.8), and high post-test probability of 42.8%. Receipt of IV antibiotics during hospitalization within the past 90 days had a positive LR of 1.9 (95% CI 0.74 – 4.84). A positive MRSA nasal screen on admission had a positive LR of 6.9 (95% CI 4.0 – 12.1), negative LR 0.28 (95% CI 0.08 – 0.93), positive post-test probability of 20.7%, and negative post-test probability of 1.04%.ConclusionOur study utilized institutional data to validate guideline-recognized risk factors for MRSA CAP specifically at our institution. Risk factors including history of MRSA isolated from a respiratory specimen, and positive post-admission MRSA nasal screen were validated as significant risk factors; receipt of IV antibiotics during hospitalization within the past 90 days was not shown to be a risk factor for MRSA CAP based on our institutional data. Validated risk factors may help providers discern which patients with CAP at our institution would benefit most from empiric MRSA treatment.Disclosures Jeffrey Steele, PharMD, Paratek Pharmaceuticals (Advisor or Review Panel member) Wesley D. Kufel, PharmD, Melinta (Research Grant or Support)Merck (Research Grant or Support)Theratechnologies, Inc. (Advisor or Review Panel member)

Risk Factors, Screening, and Treatment Challenges in Staphylococcus aureus Native Septic Arthritis.

Background Staphylococcus aureus is the most common cause of native septic arthritis. Few studies have characterized this disease during the US opioid epidemic. The role of methicillin-resistant Staphylococcus aureus (MRSA) nasal screening in this disease has not been elucidated. We sought to identify risk factors and outcomes for S. aureus native septic arthritis and to evaluate MRSA screening in this disease.MethodsA retrospective cohort study of native septic arthritis patients (2012–2016) was performed. Demographics, risk factors, and outcomes were compared between Staphylococcus aureus and other native septic arthritis infections. Sensitivity, specificity, and predictive values of MRSA screening were assessed.ResultsTwo hundred fifteen cases of native septic arthritis were included. S. aureus was cultured in 64% (138/215). MRSA was cultured in 23% (50/215). S. aureus was associated with injection drug use (odds ratio [OR], 4.33; 95% CI, 1.74–10.81; P = .002) and switching antibiotics (OR, 3.92; 95% CI, 1.01–21.38; P = .032). For every 10-year increase in age, the odds of S. aureus decreased (OR, 0.72; 95% CI, 0.60–0.87; P = .001). For 1-unit increases in Charlson comorbidity index score, the odds of S. aureus decreased (OR, 0.82; 95% CI, 0.73–0.91; P = .0004). MRSA screening during admission demonstrated a sensitivity of 0.59, specificity of 0.96, positive predictive value of 0.85, and negative predictive value of 0.84 for MRSA native septic arthritis.ConclusionsThe opioid epidemic may be contributing to a demographic shift in native septic arthritis to younger, healthier individuals. S. aureus native septic arthritis has unique risks, including injection drug use. MRSA screening may be useful to rule in MRSA native septic arthritis.

Prevention of Periprosthetic Joint Infection (PJI): A Clinical Practice Protocol in High-Risk Patients.

Background: Periprosthetic joint infection (PJI) represents 25% of failed total knee arthroplasties (TKA). The European Knee Associates (EKA) formed a transatlantic panel of experts to perform a literature review examining patient-related risk factors with the objective of producing perioperative recommendations in PJI high-risk patients. Methods: Multiple databases (Pubmed/MEDLINE, EMBASE, Scopus, Cochrane Library) and recommendations on TKA PJI prevention measures from the International Consensus Meetings on PJI from the AAOS and AAHKS were reviewed. This represents a Level IV study. Results: Strong evidence was found on poor glycemic control, obesity, malnutrition, and smoking being all associated with increased rates of PJI. In the preoperative period, patient optimization is key: BMI < 35, diet optimization, Hemoglobin A1c < 7.5, Fructosamine < 292 mmol/L, smoking cessation, and MRSA nasal screening all showed strong evidence on reducing PJI risk. Intraoperatively, a weight-based antibiotic prophylaxis, accurate fluid resuscitation, betadine and chlorhexidine dual skin preparation, diluted povidone iodine solution irrigation, tranexamic acid administration, and monofilament barbed triclosan-coated sutures for soft tissues closure all represented effective prevention measures. In the postoperative period, failure to reach normalization of ESR, CRP, D-dimer, and IL-6 six weeks postoperatively suggested early PJI. Conclusion: The current recommendations from this group of experts, based on published evidence, support risk stratification to identify high-risk patients requiring implementation of perioperative measures to reduce postoperative PJI.

Preoperative decolonization and periprosthetic joint infections-A randomized controlled trial with 2-year follow-up.

Preoperative decolonization, especially of Staphylococcus aureus carriers, has been proposed to reduce periprosthetic joint infections (PJI), but the evidence-based consensus is still lacking and data on long-term outcomes is scarce. In a previous randomized, single-blinded trial, decolonization produced no significant reduction of surgical site infections in overall elective orthopedic surgery at 3-month follow-up. A 2-year follow-up was then performed to specifically detect the impact of decolonization on delayed-onset PJI (3-24 months after surgery). Between November 2015 and September 2017, 613 of 1318 recruited patients underwent prosthetic surgery. Individuals were allocated into either the S. aureus carrier group (34%, 207 of 613 patients) or the noncarrier group (406 of 613 patients), according to nasal swab screening results. Both groups were then randomized into intervention and control arms. In the S. aureus group, the intervention consisted of daily chlorhexidine showers and application of mupirocin nasal ointment twice a day for 5 days before surgery. In noncarriers, only chlorhexidine showers were prescribed. Sample size calculation was based on the initial trial for overall and not for the prosthetic surgery group. No PJI was found at 2years in either the carrier or in the noncarrier group. Therefore, no definite conclusion about the efficacy of preoperative decolonization to reduce PJI can be drawn. PJI proportions in this study were lower than described in the literature (mostly around 0.3%). Despite the insufficient sample size, this trial is the largest randomized trial on decolonization with a long-term follow-up, and results may be helpful for future meta-analyses.

Methicillin-Resistant Staphylococcus aureus (MRSA) Admission Screening in the Neonatal Intensive Care Unit (NICU): Algorithm for Hospital Transfers

Background: Methicillin-resistant Staphylococcus aureus (MRSA) is a frequent source of infection in the neonatal intensive care unit (NICU). Due to the serious consequences associated with MRSA infections in neonates, much effort has been made to prevent and control epidemics in NICUs. Since 2006, our hospital has performed MRSA nasal surveillance screening of all newborns in the NICU in accordance with the recommendations of the Chicago-Area Neonatal MRSA Working Group. In 2017, a MRSA infection was identified in a newborn shortly after transfer from an outside hospital and who had an initial negative MRSA admission screen. As a result, we modified the admission screening process for all transfers from outside NICUs. Methods: The Evanston Hospital Infant Special Care Unit is a level 3 NICU in the northern suburbs of Chicago with 44 NICU beds and 450 admissions per year. Effective July 1, 2017, all NICU transfers have a nasal MRSA screen performed upon admission and after 48 hours. The transferred baby is placed on contact isolation until both screening results return negative. Nasal MRSA testing is performed using both PCR on the BD MAX MRSA Assay platform and is confirmed by culture using MRSA CHROMagar TM. Results: Between July 1, 2017, and October 31, 2019, 112 neonates were transferred from outside NICUs. Moreover, 105 (94%) had at least 1 MRSA screen completed and 99 (88%) had both MRSA screens completed. Of 99 with 2 screens, only 1 neonate had an initial positive nasal MRSA screen. Of the remaining 98 negative babies, none had a repeat positive nasal MRSA screen within 48 hours of admission. of 99 neonates with 2 serial admission MRSA screens, 82 (83%) were transferred within 48 hours of birth. In addition, 17 neonates were transferred &gt;48 hours after birth, including the 1 MRSA-positive baby. Conclusions: In an attempt to identify all potential MRSA-positive neonates transferred to our NICU, we instituted a policy of 2 admission nares swabs. However, our data suggest that a single initial MRSA swab may be sufficient. If continued collection of a second screen is performed, it may be sufficient to screen babies who have been hospitalized for at least 48 hours prior to transfer, which eliminates 83% of admission testing and results in a cost savings.Funding: NoneDisclosures: None

USING METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS SCREENS TO GUIDE VANCOMYCIN ADMINISTRATION

SESSION TITLE: Critical Care Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: October 18-21, 2020 PURPOSE: In June of 2018 an article describing the utility of Methicillin-Resistant Staphylococcus Aureus (MRSA) Nasal Screening to Rule out MRSA Pneumonia was published. Our goal was to incorporate this information into our ICU practice. MRSA Nasal Screen Meta-analysis • CID 2018:67 (1 July) Parente et al. METHODS: For the time period 7/1/2016 to 6/30/2018 we evaluated all nares and groin MRSA screens, and all blood and sputum cultures on our ICU patients. We then calculated the sensitivities (SEN), specificities (SP), positive predictive values (PPV) and negative predictive values (NPV) for patients with respiratory and undifferentiated sepsis diagnoses. When we saw that our NPV were the same as reported, we started ordering nares and groin screens on ICU patients with these diagnoses to help guide vancomycin use. To see if our treatment pattern changed with this information, we compared vancomycin administered from 1/1/2016 to 6/30/2018 with 7/1/2018 to 12/31/2019. We looked at what percentage of patients were treated with vancomycin for more than 2, 3 and 4 days and compared this to the time periods before and after our intervention in July of 2018. We also looked at the average duration of treatment and the average grams of vancomycin administered. All ICU patients, respiratory and undifferentiated sepsis patients were compared. RESULTS: From 7/1/2016 to 6/30/2018 the SEN, SP, PPV, and NPV for nares screens for respiratory diagnoses were 67%, 91%, 10%, and 99% (n=195) and for undifferentiated sepsis were 80%, 9%, 27%, and 99% (n=233). The SEN, SP, PPV, and NPV for groin screens for respiratory diagnoses were 33%, 98%, 25%, and 99% (n=154) and for undifferentiated sepsis were 25%, 95%, 17%, and 97% (n=191). The baseline percentage of patients on vancomycin more than 2, 3, and 4 days were 85%, 71% and 60%. The percentages post intervention were 79%, 59%, and 47%. The percent decrease post intervention for more than 2, 3 or 4 days were 7.1%, 16.9% and 21.7% (p<0.021 for day 2 and p<0.001 for days 3 and 4). Average treatment days decreased from 2.73 to 2.19 (p<.009). While the average total vancomycin administered decreased from 11.24 to 8.70 grams, it did not reach statistical significance. We collected MRSA groin screens for undifferentiated sepsis, but we did not implement a protocol. We did see a decrease in the average total vancomycin administered, 5.08 from 7.04 grams (p<.03), but no change in duration of therapy. When looking at all ICU patients there was no decrease in vancomycin use per day of treatment, average treatment days or grams administered. CONCLUSIONS: Nares and groin MRSA screens can identify patients with respiratory diagnoses who are not infected with MRSA. CLINICAL IMPLICATIONS: They can be used in guiding discontinuation of vancomycin therapy for patients with respiratory diagnoses. DISCLOSURES: Consultant relationship with Monaghan Medical Please note: $1001 - $5000 Added 03/02/2020 by Russell Acevedo, source=Web Response, value=Travel Consultant relationship with Vapotherm Please note: $1001 - $5000 Added 03/02/2020 by Russell Acevedo, source=Web Response, value=Travel Consultant relationship with Fisher & Paycal Please note: $1001 - $5000 Added 03/02/2020 by Russell Acevedo, source=Web Response, value=Grant/Research Support No relevant relationships by Andrea Call, source=Web Response No relevant relationships by Nauman Hamid, source=Web Response No relevant relationships by Viren Kaul, source=Web Response No relevant relationships by David Landsberg, source=Web Response Owner/Founder relationship with Cormac Life Sciences, LLC Please note: $1-$1000 Added 04/08/2020 by Stephen Thomas, source=Web Response, value=Ownership interest Owner/Founder relationship with GreenMark Partners Please note: $1-$1000 Added 04/08/2020 by Stephen Thomas, source=Web Response, value=Ownership interest Advisory Committee Member relationship with Sanofi Pasteur Please note: $20001 - $100000 Added 04/08/2020 by Stephen Thomas, source=Web Response, value=Consulting fee Advisory Committee Member relationship with Takeda Vaccines Please note: $20001 - $100000 Added 04/08/2020 by Stephen Thomas, source=Web Response, value=Consulting fee Advisory Committee Member relationship with PrimeVax Please note: $1-$1000 Added 04/08/2020 by Stephen Thomas, source=Web Response, value=Ownership interest Consultant relationship with Tremeau Pharm Please note: $1001 - $5000 Added 04/08/2020 by Stephen Thomas, source=Web Response, value=Consulting fee Advisory Committee Member relationship with Merck Please note: $1001 - $5000 Added 04/08/2020 by Stephen Thomas, source=Web Response, value=Consulting fee Advisory Committee Member relationship with Moderna Please note: $1-$1000 Added 04/08/2020 by Stephen Thomas, source=Web Response, value=Consulting fee

Impact of Screening for Methicillin-Resistant Staphylococcus aureus (MRSA) in Pneumonia on Vancomycin Utilization

Background: Methicillin-Resistant Staphylococcus aureus (MRSA) is frequently targeted with empiric treatment for pneumonia in the hospital. Obtaining quality lower respiratory tract cultures to promote appropriate de-escalation can be difficult or impractical. Nasal screening for MRSA has a high negative predictive value for MRSA pneumonia and can be an effective tool for early de-escalation. Methods: A pharmacist-driven process for nasopharyngeal MRSA screening of patients prescribed intravenous vancomycin was implemented in October 2018. Vancomycin utilization was extracted from the electronic medical record (EMR) and summarized as days of therapy per 1,000 patient days (DOT/1,000 PD). Vancomycin utilization data for the 6 months following process implementation (November 2018–April 2019) were compared to the same period from the previous year (November 2017–April 2018). Specific patient outcomes data were manually collected for patients prescribed vancomycin for pneumonia during the first 2 months following process implementation (November–December 2018; postintervention group) and comparable months (November–December 2017; preintervention group). Data were analyzed using the 2 test (nominal data) and Mann–Whitney U test (continuous data). Results: Total vancomycin utilization decreased from a monthly average of 114 to 95 DOT/1,000 PD (17% reduction) and from 27 to 14 DOT/1,000 PD for pneumonia (48% reduction). In-patient mortality was unchanged following process implementation at 17.2% versus 17.5% in the pre- and postintervention groups, respectively. Other clinical outcomes were also similar between the pre- and postintervention groups (Table 1). Fewer vancomycin levels were obtained following implementation with 34.4% of patients (0.61 levels per patient) having a level obtained in the preintervention group compared to 21.6% (0.30 levels per patient; P .001) in the postintervention group. Conclusions: Nasopharyngeal MRSA screening of patients prescribed vancomycin for pneumonia is an effective antimicrobial stewardship strategy to reduce unnecessary use of anti-MRSA therapy without negatively impacting clinical outcomes.Funding: NoneDisclosures: None

Effectiveness of Methicillin-Resistant Staphylococcus aureus (MRSA) Nasal Screening for Reduction of Vancomycin Use for Pneumonia

Background: Methicillin-resistant Staphylococcus aureus (MRSA) nasal colonization has been a well-established risk for developing MRSA pneumonia. In previous studies, the MRSA nasal screening test has shown an excellent negative predictive value (NPV) for MRSA pneumonia in patients without exclusion criteria such as mechanical ventilation, hemodynamic instability, cavitary lesions, and underlying pulmonary disease. MRSA nasal screening can be used as a stewardship tool to de-escalate broad antibiotic coverage, such as vancomycin. Objective: The purpose of this study was to determine whether implementation of a MRSA nasal screening questionnaire improves de-escalation of vancomycin for patients with pneumonia. Methods: A retrospective review was performed on 250 patients from October 2018 to January 2019 who received MRSA nasal screening due to their prescriber choosing only “respiratory” on the vancomycin dosing consult form. Data obtained included demographics and clinical outcomes. Statistical analyses were performed, and P &lt; .05 was considered significant. Results: Of the 250 patients screened, only 19 patients (8%) were positive for MRSA. Moreover, 40% of patients met exclusion criteria. In 149 patients without exclusion criteria, the MRSA nasal swab had a 98% NPV. Although not statistically significant, vancomycin days of therapy (DOT) based on MRSA nasal swab result was 1 day shorter in those with negative swabs (3.49 days negative vs 4.58 days positive; P = .22). Vancomycin DOT was significantly reduced in pneumonia patients without exclusion criteria (3.17 days “no” vs 4.17 days “yes”; P = .037). Conclusions: The implementation of an electronic MRSA nasal screening questionnaire resulted in reduced vancomycin DOT in pneumonia patients at UAB Hospital. The MRSA nasal swab is an effective screening tool for antibiotic de-escalation based on its 98% NPV for MRSA pneumonia if utilized in the correct patient population.Funding: NoneDisclosures: Rachael Anne Lee reports a speaker honoraria from Prime Education, LLC.

Pharmacist-Driven MRSA Nasal PCR Screening and the Duration of Empirical Vancomycin Therapy for Suspected MRSA Respiratory Tract Infections.

ObjectiveTo assess the effect of a pharmacist-driven, polymerase chain reaction (PCR)−based nasal screening protocol for methicillin-resistant Staphylococcus aureus (MRSA) on vancomycin therapy duration and on rates of adverse drug events and 30-day hospital readmission.Patients and MethodsFrom July 8, 2017, through January 31, 2019, we performed a retrospective, multicenter, preimplementation-postimplementation study. Patients with a vancomycin order to treat lower respiratory tract infection (LRTI) underwent MRSA PCR screening; tests were ordered by health care providers, including physicians, physician assistants, and advanced practice registered nurses. During the preimplementation period (July 8, 2017, through September 30, 2018), pharmacists could order MRSA PCR screening only after receiving a verbal order from a health care provider. During the postimplementation period (October 1, 2018, through January 31, 2019), a collaborative practice agreement allowed pharmacists to order MRSA PCR screening tests.ResultsThe preimplementation group included 241 patients, and the postimplementation group included 74 patients. Of these patients, 124 in the preimplementation group and 62 in the postimplementation group received MRSA PCR screening. Twenty patients (16.1%) in the preimplementation group and 9 (14.5%) in the postimplementation group had a positive MRSA PCR screening test result (between-group difference, 1.6%; P=.80). Duration of therapy was significantly shorter in the postimplementation group (median [interquartile range], 14.3 [5.0-28.6] hours vs 24.0 [12.4-47.0] hours; P<.001).ConclusionVancomycin therapy carries a risk of adverse events and may increase health care costs. A pharmacist-driven protocol for MRSA nasal swab PCR screening effectively reduces the duration of vancomycin therapy for patients with lower respiratory tract infection.

Staphylococcus aureus nasal decolonization before cardiac and orthopaedic surgeries: first descriptive survey in France

The objective was to describe French hospital nasal screening and decolonization procedures before clean surgery procedures. Information for participants was sent to the French Society for Infection Control members in June 2018. Seventy hospitals participated in the survey; 40% (N= 28) declared having institutional decolonization procedures: 64% (N= 18) in orthopaedic and 56% (N= 15) in cardiac surgeries. All hospitals used mupirocin for nasal decolonization and body decolonization with chlorhexidine (N= 16) or povidone iodine (N= 10). This study is the first to be performed in France giving information in this field. Screening/decolonization procedures are heterogeneous and the evaluation of their clinical impact remains complex.

Methicillin-resistant Staphylococcus aureus (MRSA) screening upon inpatient hospital admission: Is there concordance between nasal swab results and samples taken from skin and soft tissue?

Methicillin-resistant Staphylococcus aureus (MRSA) infections are associated with increased mortality and healthcare costs. In 2007, a Veterans' Affairs (VA) hospital implemented a MRSA nasal screening program, following a nationwide VA mandate, in an effort to reduce healthcare-associated MRSA infections. To evaluate the correlation between the nasal screening results for MRSA and culture results of wound and tissue sites. This retrospective study was conducted on inpatients at our VA hospital. Patients were included if they had undergone nasal screening for MRSA plus culture of a wound or tissue site within 30 days of hospital admission. In total, 337 patients underwent nasal screening and wound culture and 211 underwent nasal screening and wound and tissue cultures. The prevalence of MRSA nasal colonization was 14.2% for wound samples and 15.2% for tissue samples. The sensitivities of MRSA nasal screening for detecting MRSA were 64.6% for wound cultures and 65.5% for tissue cultures. Specificities were 86.2% and 88.8% for wound and tissue cultures, respectively. The positive predictive values (PPVs) were 43.7% and 51.2% for wound and tissue cultures, respectively, and the negative predictive values (NPVs) were high at 93.6% and 93.5%, respectively. In cases of wound or tissue samples for which culture results are pending, a negative MRSA nasal swab may be a component of the decision to withhold or discontinue MRSA-active agents.

Multidrug Resistant Organism Burden in Critically-Ill Burn Patients

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

Reply to Sfeir, "Methicillin-Resistant Staphylococcus aureus (MRSA) Nasal Screening: Clinical Use for Excluding Diabetic Foot Infection with MRSA".

We sincerely appreciate the efforts and comments by Dr. Sfeir regarding our article (1). We agree with the premise of understanding the local epidemiology of methicillin-resistant Streptococcus aureus (MRSA) when applying this study to patients with diabetic foot infection. Furthermore, we agree that our study should only be applied to non-critically ill patients because we do not know the negative predictive value threshold at which it would be acceptable to withhold treatment for MRSA.

Nasal colonization with methicillin-resistant Staphylococcus aureus at admission among high-risk Turkish and international patients.

The aim of this study was to detect the frequency of methicillin-resistant Staphylococcus aureus (MRSA) colonization at admission in a group of presumably high-risk international or Turkish patients referred to our center for elective operations, some of whom were from countries with an unknown prevalence of MRSA infection or colonization. The results of nasal swab screening for MRSA colonization performed using a specific algorithm between 2011 and 2018 in a private medical center were retrospectively reviewed. Presence of MRSA was ascertained using culture and/or real-time polymerase chain reaction (real-time PCR). A total of 3,795 patients were included in the study. More than half of the patients were ≤19 years of age (2,094, 55.2%), and MRSA positivity was more common among these patients. Turkish patients constituted 24.5% of the study population. International patients were most frequently referred from Iraq (55.92%), Libya (11.44%), Romania (2.69%), and Bulgaria (1.98%). MRSA positivity was significantly more common among patients referred from other countries when compared to Turkish nationals (11.5% vs. 4.4%, P = 0.00001). Countries with the highest prevalence rates of MRSA colonization were as follows with decreasing order: United Arab Emirates, 25.0%; Georgia, 23.1%; Russia, 22.7%; Iraq, 13.0%, Romania, 12.7%. Other countries with high number of admitted patients (>70 patients) had the following MRSA rates: Turkey, 4.4%; Libya, 6.0%; Bulgaria, 5.3%. Although MRSA has a low prevalence in our center, a variation in the rate of MRSA positivity was observed across patients from different countries. Absence hospital acquired contamination or outbreaks in our institution may be attributed to the screening algorithm used and underscores the importance of risk analysis for patients referred from geographical locations with unknown MRSA frequency, to reduce the risk of transmission.

Screening for and decolonization of Staphylococcus aureus carriers before total joint replacement is associated with lower S aureus prosthetic joint infection rates

Prosthetic joint infections (PJI) can be devastating postoperative complications after total joint replacement (TJR). The role of decolonization of Staphylococcus aureus carriers prior to surgery still remains unclear, and the most recent guidelines do not state a formal recommendation for such strategy. Our purpose was to seek further evidence supporting preoperative screening and S aureus decolonization in patients undergoing TJR. This was a quasiexperimental quality improvement study comparing a 5-year baseline of deep and organ-space PJIs (2005- 2010) to a 1-year intervention period (May 2015 to July 2016). The intervention consisted of nasal and throat screening forS aureus preoperatively and decolonization of carriers over 5 days prior to surgery. Prior to the intervention, we identified 42 deep and/or organ-space PJIs in 8,505 patients undergoing TJR (0.5%). S aureus was the causal microorganism in 28 of 42 (66.6%) cases. During the intervention, 22.5% (424 of 1,883) of patients were S aureus carriers. The PJI rate was similar overall (0.4%, 7 of 1,883; odds ratio, 0.75; 95% confidence interval, 0.34-1.67; P = .58), but there was a significant reduction in S aureus PJI to only 1 case during the intervention (odds ratio, 0.15; 95% confidence interval, 0.004-0.94; P = .039). Active screening forS aureusand decolonization of carriers prior to TJR was associated with a reduction in PJI due toS aureus, but no changes in overall PJI rates were observed.

896. A Safe, More Cost-Effective Protocol: Universal Decolonization vs. MRSA Screening and Contact Precautions

BackgroundA trial of universal decolonization (alcohol-based nasal antiseptic plus chlorhexidine gluconate bathing) was instituted for 12 months, in a 536-bed short-term acute care hospital, as a replacement for nasal screening, contact precautions (CP) and decolonization of methicillin-resistant Staphylococcus aureus (MRSA)-colonized patients. The impact on the rate of MRSA bacteremia and costs associated with nasal screening tests, isolation, and gown use was assessed.MethodsPrior to the universal decolonization trial, patients at high-risk for MRSA colonization were screened using a nasal polymerase chain reaction (PCR) test, and those that tested positive were decolonized with 5 days of mupirocin nasal ointment and daily CHG bathing, and were placed in CP. Starting in April 2018, a universal decolonization protocol was instituted for all hospitalized patients, with a twice-daily alcohol-based nasal antiseptic (in place of mupirocin), and daily bathing with CHG foam soap (in place of CHG cloths). Nasal screening of high-risk patients, targeted decolonization and CP for MRSA-colonized patients, was discontinued during the 12-month universal decolonization trial period. Outcome measures for the trial included MRSA bacteremia per National Healthcare Surveillance Network (NHSN) multi-drug-resistant organism (MDRO) Lab ID definition, isolation day count, utilization of gowns, and nasal screening tests with estimated costs associated. Measures for the 12-month trial period were compared with those of the prior 12-month period, i.e., April 2017–March 2018.ResultsCompared with prior 12-month period, during the universal decolonization trial, there was a 42% reduction in isolation days ($118/day), a 74% reduction in nasal PCR tests ($36/each), and an 11% decrease in the monthly use of gowns ($12/each). The total cost avoidance (after accounting for the cost of the alcohol-based nasal antiseptic and CHG soap) was $1,394,685. There was no statistical change in the MRSA bacteremia rate (0.067 to 0.070) per 1,000 patient-days.ConclusionReplacement of nasal screening, decolonization, and CP for colonized MRSA patients with universal decolonization, using twice daily alcohol-based nasal antiseptic paired with daily CHG bathing, was found to be a safe and cost-saving protocol.Disclosures All Authors: No reported Disclosures.