National Healthcare Safety Network Criteria Research Articles

Epidemiology of healthcare-associated Pseudomonas aeruginosa in intensive care units: are sink drains to blame?

Pseudomonas aeruginosa (PA) is a common cause of healthcare-associated infection (PA-HAI) in the intensive care unit (ICU). To describe the epidemiology of PA-HAI in ICUs in Ontario, Canada, and to identify episodes of sink-to-patient PA transmission. This was a prospective cohort study of patients in six ICUs from 2018 to 2019, with retrieval of PA clinical isolates, and PA-screening of antimicrobial-resistant organism surveillance rectal swabs, and of sink drain, air, and faucet samples. All PA isolates underwent whole-genome sequencing. PA-HAI was defined using US National Healthcare Safety Network criteria. ICU-acquired PA was defined as PA isolated from specimens obtained ≥48h after ICU admission in those with prior negative rectal swabs. Sink-to-patient PA transmission was defined as ICU-acquired PA with close genomic relationship to isolate(s) previously recovered from sinks in a room/bedspace occupied 3-14 days prior to collection date of the relevant patient specimen. Over ten months, 72PA-HAIs occurred among 60/4263 admissions. The rate of PA-HAI was 2.40 per 1000 patient-ICU-days; higher in patients who were PA-colonized on admission. PA-HAI was associated with longer stay (median: 26 vs 3 days uninfected; P < 0.001) and contributed to death in 22/60 cases (36.7%). Fifty-eight admissions with ICU-acquired PA were identified, contributing 35/72 (48.6%) PA-HAIs. Four patients with five PA-HAIs (6.9%) had closely related isolates previously recovered from their room/bedspace sinks. Nearly half of PA causing HAI appeared to be acquired in ICUs, and 7% of PA-HAIs were associated with sink-to-patient transmission. Sinks may be an under-recognized reservoir for HAIs.

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.

Classification of posttransfusion adverse events using a publicly available artificial intelligence system.

Correct classification of transfusion reactions is important not only for effective patient care and donor management but also for accurate tracking of events in hemovigilance systems. We compared the ability of a generative artificial intelligence (AI) system to correctly diagnose hypothetical clinical situations as transfusion reactions in comparison to previous studies reporting the accuracy of transfusion medicine (TM) specialists in assessing these cases. An AI system was requested to assess 36 case scenarios to provide a diagnosis, severity, and imputability of the transfusion reactions using the CDC National Healthcare Safety Network (NHSN) criteria. Responses were compared to an expert panel's classifications and to the published responses of a panel of TM specialists. Additionally, the AI's responses were compared to the TM specialists' prior attempts to use the TrDDx web-based algorithm for the five most challenging cases. The AI's classification accuracy varied widely depending on the NHSN category. The AI accurately classified all transfusion-associated circulatory overload and transfusion-related acute lung injury cases, exceeding TM specialists' assessments. Conversely, it did not correctly identify any cases in select NHSN categories such as DSTR. Overall accuracy among all diagnostic categories was 48.7% for AI responses versus 72.1% for prior TM specialist responses (p = 0.005). AI-generated responses included non-standard terminology, limited severity assessments, and no imputability determinations. A generative AI system may have a role in helping healthcare providers to consider transfusion reaction categories that might be missed, but caution is advised in applying the AI's output to transfusion reaction classification at present.

Clinical Impacts and Risk Factors for Central Line-Associated Bloodstream Infection: A Systematic Review.

Background A central line-associated bloodstream infection (CLABSI) is defined as a primary bloodstream infection (BSI) in a patient that had a central line within the 48-hour period before the development of the BSI and is not bloodstream-related to an infection at another site. CLABSI is a common healthcare-associated infection and a significant cause of morbidity and mortality. Methods This systematic review included studies published within the past 13 years that examined risk factors and clinical impact variables associated with CLABSI, using the Centers for Disease Control (CDC)/National Healthcare Safety Network (NHSN) criteria for defining catheter-associated infection, and included participants of all ages. The terms "CLABSI," "central line-associated bloodstream infection," "risk factors," "predictors," "morbidity," "mortality," "healthcare costs," and "length of hospital stay" were used to find relevant publications on PubMed/Medline, Google Scholar, and Science Direct. The quality assessment of the included publications utilized the modified Newcastle-Ottawa scale (NOS) for observational studies. Results After the full-text screening, we identified 15 articles that met our inclusion and exclusion criteria. The majority of these studies were of good quality and had a low risk of bias based on our bias assessment. The studies included a total of 32,198 participants and covered a time period from 2010 to 2023. The mean age of the male patients included in the studies ranged from 0.1 months to 69.1 years. All of the included studies were either observational cohort studies, cross sectional studies, case-control studies, or case reports. The major study parameters/outcomes extracted were risk factors, CLABSI-associated mortality, hospital cost, length of hospital stay, and catheter days. With respect to predisposing factors, multilumen access catheters were identified as risk factors in three studies, use of more than one central venous catheter per case in four studies, hematologic malignancy in three studies, catheterization duration in four studies, surgical complexity in four studies, length of ICU stays in three studies, and parenteral nutrition in two studies. Conclusion The decision to place a venous device should be carefully considered by evaluating individual risk factors for the development of CLABSI. This is important due to the potential for severe clinical consequences and significant healthcare expenses associated with this complication.

Identifying and Mitigating Disparities in Central Line–Associated Bloodstream Infections in Minoritized Racial, Ethnic, and Language Groups

Although inequitable care due to racism and bias is well documented in health care, the impact on health care-associated infections is less understood. To determine whether disparities in first central catheter-associated bloodstream infection (CLABSI) rates existed for pediatric patients of minoritized racial, ethnic, and language groups and to evaluate the outcomes associated with quality improvement initiatives for addressing these disparities. This cohort study retrospectively examined outcomes of 8269 hospitalized patients with central catheters from October 1, 2012, to September 30, 2019, at a freestanding quaternary care children's hospital. Subsequent quality improvement interventions and follow-up were studied, excluding catheter days occurring after the outcome and episodes with catheters of indeterminate age through September 2022. Patient self-reported (or parent/guardian-reported) race, ethnicity, and language for care as collected for hospital demographic purposes. Central catheter-associated bloodstream infection events identified by infection prevention surveillance according to National Healthcare Safety Network criteria were reported as events per 1000 central catheter days. Cox proportional hazards regression was used to analyze patient and central catheter characteristics, and interrupted time series was used to analyze quality improvement outcomes. Unadjusted infection rates were higher for Black patients (2.8 per 1000 central catheter days) and patients who spoke a language other than English (LOE; 2.1 per 1000 central catheter days) compared with the overall population (1.5 per 1000 central catheter days). Proportional hazard regression included 225 674 catheter days with 316 infections and represented 8269 patients. A total of 282 patients (3.4%) experienced a CLABSI (mean [IQR] age, 1.34 [0.07-8.83] years; female, 122 [43.3%]; male, 160 [56.7%]; English-speaking, 236 [83.7%]; LOE, 46 [16.3%]; American Indian or Alaska Native, 3 [1.1%]; Asian, 14 [5.0%]; Black, 26 [9.2%]; Hispanic, 61 [21.6%]; Native Hawaiian or Other Pacific Islander, 4 [1.4%]; White, 139 [49.3%]; ≥2 races, 14 [5.0%]; unknown race and ethnicity or refused to answer, 15 [5.3%]). In the adjusted model, a higher hazard ratio (HR) was observed for Black patients (adjusted HR, 1.8; 95% CI, 1.2-2.6; P = .002) and patients who spoke an LOE (adjusted HR, 1.6; 95% CI, 1.1-2.3; P = .01). Following quality improvement interventions, infection rates in both subgroups showed statistically significant level changes (Black patients: -1.77; 95% CI, -3.39 to -0.15; patients speaking an LOE: -1.25; 95% CI, -2.23 to -0.27). The study's findings show disparities in CLABSI rates for Black patients and patients who speak an LOE that persisted after adjusting for known risk factors, suggesting that systemic racism and bias may play a role in inequitable hospital care for hospital-acquired infections. Stratifying outcomes to assess for disparities prior to quality improvement efforts may inform targeted interventions to improve equity.

Bloodstream Infections in Infants and Children With Congenital Heart Disease Undergoing Cardiac Surgery

Children with congenital heart disease undergoing cardiac surgery are at risk for laboratory-confirmed bloodstream infections (LCBIs). These infections can lead to morbidity, mortality, and increased health care costs. The role of mucosal barrier injury in causing LCBIs is unknown. To describe characteristics of LCBIs in patients admitted to cardiac intensive care and step-down units and to assess frequencies of National Healthcare Safety Network infection types and associations with organism classification, patient clinical factors, and infection outcomes. A retrospective cohort analysis using manual electronic medical record data abstraction included children with congenital heart disease who developed an LCBI while receiving inpatient cardiac care between August 2011 and November 2018 at one institution. Demographic, clinical, laboratory, and outcome variables were collected and analyzed with descriptive and inferential statistics. Eighty-seven patients with congenital heart disease developed 103 LCBIs during the study time frame. The most common causative microorganisms were gram-positive bacteria, including Enterococcus faecalis and Staphylococcus epidermidis. Sixty-three percent of causative organisms were characterized as originating from mucosal barrier injury, although no infections met National Healthcare Safety Network criteria for mucosal barrier injury LCBIs. Translocation of bacteria through injured gut mucosa may cause bloodstream infections in children with congenital heart disease. Further investigation is warranted to understand microbiome changes that adversely select pathogenic gut organisms. Preventive care to maintain intact gut function and a healthy microbiome should be explored for this patient population.

Electronic surveillance criteria for non-ventilator-associated hospital-acquired pneumonia: Assessment of reliability and validity.

Surveillance of non-ventilator-associated hospital-acquired pneumonia (NV-HAP) is complicated by subjectivity and variability in diagnosing pneumonia. We compared a fully automatable surveillance definition using routine electronic health record data to manual determinations of NV-HAP according to surveillance criteria and clinical diagnoses. We retrospectively applied an electronic surveillance definition for NV-HAP to all adults admitted to Veterans' Affairs (VA) hospitals from January 1, 2015, to November 30, 2020. We randomly selected 250 hospitalizations meeting NV-HAP surveillance criteria for independent review by 2 clinicians and calculated the percent of hospitalizations with (1) clinical deterioration, (2) CDC National Healthcare Safety Network (CDC-NHSN) criteria, (3) NV-HAP according to a reviewer, (4) NV-HAP according to a treating clinician, (5) pneumonia diagnosis in discharge summary; and (6) discharge diagnosis codes for HAP. We assessed interrater reliability by calculating simple agreement and the Cohen κ (kappa). Among 3.1 million hospitalizations, 14,023 met NV-HAP electronic surveillance criteria. Among reviewed cases, 98% had a confirmed clinical deterioration; 67% met CDC-NHSN criteria; 71% had NV-HAP according to a reviewer; 60% had NV-HAP according to a treating clinician; 49% had a discharge summary diagnosis of pneumonia; and 82% had NV-HAP according to any definition according to at least 1 reviewer. Only 8% had diagnosis codes for HAP. Interrater agreement was 75% (κ = 0.50) for CDC-NHSN criteria and 78% (κ = 0.55) for reviewer diagnosis of NV-HAP. Electronic NV-HAP surveillance criteria correlated moderately with existing manual surveillance criteria. Reviewer variability for all manual assessments was high. Electronic surveillance using clinical data may therefore allow for more consistent and efficient surveillance with similar accuracy compared to manual assessments or diagnosis codes.

2029. Risk factors for a Central Line Associated Bloodstream Infection Amongst Hospitalized Patients with COVID

Abstract Background Central line associated bloodstream infections (CLABSI) are serious healthcare associated infections. During the COVID pandemic, we observed an increased incidence of CLABSIs in our healthcare system. We sought to identify risk factors for CLABSI among patients with COVID. Methods We performed a single-center, matched case-control study in patients admitted between Mar 2020 and Dec 2020 who were 1) diagnosed with COVID based on laboratory results or diagnosis code, and who were 2) at risk for developing a CLABSI based on the presence of a central line for ≥3 days. Cases were those diagnosed, based on National Healthcare Safety Network criteria, with CLABSI; controls were patients not diagnosed with CLABSI. Cases and controls were 1:4 matched based on age at admission (+/- 5 years) and COVID diagnosis date (+/- 45 days). Descriptive statistics were calculated for continuous and categorical variables. For comparisons, p values are from generalized estimating equations accounting for clustering by case-control matches. All analyses were performed in SAS version 9.4 (SAS Institute Inc., Cary, NC). Approval was granted by our institutional IRB. Results Characteristics of the patients who were diagnosed with COVID and at risk for developing a CLABSI are presented in table 1. Compared to patients with COVID and no CLABSI, patients with a CLABSI were more likely to be of a non-white race (p=0.0435). A longer length of stay was observed among CLABSI patients, (p=0.0011) and patients with CLABSI were less likely to be discharged to home (p=0.0084). There was a non-statistically significant trend toward a history of diabetes (p=0.0554), receipt of corticosteroids (p=0.052) and receipt of tocilizumab (p=0.0952) among CLABSI patients. Conclusion Patients hospitalized for COVID who developed a CLABSI had longer hospitalizations and were less likely to be discharged home. Race other than white was a risk factor for CLABSI among patients with COVID. The relationships between race, racism, and CLABSI should be further explored. Disclosures All Authors: No reported disclosures.

162. Assessment of Guideline-Concordant Testing for Legionella pneumophila and Streptococcus pneumoniae in Community-Acquired Pneumonia

Abstract Background Urinary antigen testing for Streptococcus pneumoniae and Legionella pneumophila is only recommended in patients with severe pneumonia according to the 2019 guidelines from the American Thoracic Society (ATS) and Infectious Diseases Society of America (IDSA). Unnecessary testing for these organisms may increase antibiotic utilization. This quality improvement project evaluated whether patients who received a Streptococcus pneumoniae or Legionella pneumophila urine antigen met criteria for testing. Methods We conducted a cohort study of patients who received a urinary antigen test for Streptococcus pneumoniae or Legionella pneumophila within 3 days of admission to the Veterans Affairs Connecticut Healthcare System between September 1, 2018 and September 1, 2021. We determined whether patients had clinically defined pneumonia per National Healthcare Safety Network criteria. Among patients that met criteria for clinically defined pneumonia, the subset with severe pneumonia according to the ATS/IDSA guidelines was identified. We used the ATS/IDSA guidelines to determine whether patients received guideline-concordant choice of therapy. Results We identified 352 patients who received a urinary antigen test within 3 days of admission. Mean age was 72.6 years, 97% (n=278) were male sex, and 86% (n=301) were White race. Common comorbidities included heart disease (76%, n=268), lung disease (58%, n=203), and diabetes (30%, n=106). Overall, 36% (n=127) of patients met criteria for clinically defined pneumonia, and 7% (n=25) met criteria for severe pneumonia. 9 patients had a positive Streptococcus pneumoniae antigen test and 1 patient had a positive test for Legionella. Among patients with clinically defined pneumonia, 74% (n=75) received guideline-concordant choice of therapy and 74% (n=75) received an antibiotic duration &amp;gt;5 days Diagnostic and Therapeutic Characteristics of Veterans According to Presence of Pneumonia Conclusion Only 7% of patients who underwent urine antigen testing for Streptococcus pneumoniae or Legionella pneumophila met criteria for testing per ATS/IDSA guidelines, and length of therapy was prolonged in the vast majority of patients. These data support the need for a clinical decision-making tool to reduce unnecessary testing and treatment for pneumonia at our institution. Disclosures All Authors: No reported disclosures.

2014. Central Line - Associated Bloodstream Infections and Their Increase With the COVID-19 Pandemic at Veterans Affairs in San Antonio, Texas

Abstract Background Coronavirus disease-19 (COVID-19) has been associated with an increase in healthcare-associated infections (HAI). This increase is likely multifactorial (i.e. higher hospitalization rates, COVID-19 and post-COVID-19 complications, lower staffing, delayed care among others). The objective of this study was to determine the association between COVID-19 hospitalization rates and central line- associated blood stream infections (CLABSI). Methods We conducted a retrospective study in acute care unit hospitalizations in a Veterans Affairs (VA) hospital in San Antonio, Texas from October 2017 to December 2021. Individuals over 18 years of age admitted with a new diagnosis of COVID-19, determined by the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) polymerase chain reaction (PCR) were included in the study. CLABSIs were defined by the National Healthcare Safety Network (NHSN) criteria for laboratory confirmed bloodstream infections. Pearson correlation was used to determine correlation of CLABSI and COVID-19 disease hospitalization rates. CLABSI rates were also compared pre-COVID-19 (Oct 2017-Feb 2020) to COVID-19 (Mar 2020-Dec 2021) periods using the chi-square test. Results During the study period, a total of 0.69 CLABSIs per 1,000 central line days occurred in the pre-COVID-19 period compared to 1.98 per 1,000 in the COVID-19 period (p=0.004). There was a significant correlation between CLABSI and ICU COVID-19 hospitalization rates (R=0.459; p=0.001) as well as CLABSI and acute care COVID-19 hospitalization rates (R=0.341; p=0.014). During the COVID-19 period only, there continued to be a significant correlation between CLABSI and COVID-19 ICU hospitalization rates (R=0.426; p=0.048). Conclusion CLABSI rates significantly increased during the COVID-19 period compared to the pre-COVID-19 period and CLABSI rates were significantly correlated with COVID-19 ICU and acute care hospitalizations. Accounting for this variable allows us to factor in impact of post-COVID-19 related complications and association with CLABSI rate. We urge for careful implementation of HAI prevention strategies during the pandemic. Awareness of anticipated increase is important in allocating resources essential for prevention of HAIs. Disclosures All Authors: No reported disclosures.

Infection profile of patients with extracorporeal membrane oxygenation in paediatric cardiac surgery ICU.

We investigated the risk of increased nosocomial infections and the associated pathogens in patients who underwent paediatric cardiovascular surgery and were put on extracorporeal membrane oxygenation support. We studied the duration of extracorporeal membrane oxygenation use and other variables that may be associated with increased nosocomial infection risk. Patients who were treated with an extracorporeal membrane oxygenation in paediatric cardiovascular surgery ICU between 2010 and 2020 were included in this retrospective study. We analysed the site of infection and microbiological profile of infections occurring in these patients according to CDC and National Healthcare Safety Network criteria. The onset of infection development in patients after extracorporeal membrane oxygenation was found to be median 8 (3-15, 25-75 IQR) days in the whole group, and median 11 (3-16, 25-75 IQR) days in those who developed infection without being put on extracorporeal membrane oxygenation. When patients were divided into those with and without infection, duration of ICU was found to be 19 (16-28, IQR 25-75) days in patients with infection vs. 8 (2-16, IQR 25-75; p: <0.001) days in patients without infection. Duration of extracorporeal membrane oxygenation support was found to be 14 (10-25, IQR 25-75) days in patients with infection versus 5 (2-10, IQR 25-75; p: <0.001) days in patients without infection and total hospital stay was 26 (18-33, IQR 25-75) days in patients with infection versus 8 (2-23, IQR 25-75) days in those without infection. A total of 24 patients out of the 70 patients experienced 32 infectious episodes during extracorporeal membrane oxygenation support. Culture-positive infections were detected at a single site in 19 patients, and multiple sites in 5 patients. We propose that prolonged extracorporeal membrane oxygenation support is associated with an increased risk of infection. Although extracorporeal membrane oxygenation is a life-saving treatment method, prolonged extracorporeal membrane oxygenation may increase the development of infectious complications and the associated mortality and morbidity of the patient.

The impact of COVID-19 on health care–associated infections in intensive care units in low- and middle-income countries: International Nosocomial Infection Control Consortium (INICC) findings

BackgroundThis study examines the impact of the COVID-19 pandemic on health care–associated infection (HAI) incidence in low- and middle-income countries (LMICs).MethodsPatients from 7 LMICs were followed up during hospital intensive care unit (ICU) stays from January 2019 to May 2020. HAI rates were calculated using the International Nosocomial Infection Control Consortium (INICC) Surveillance Online System applying the Centers for Disease Control and Prevention's National Healthcare Safety Network (CDC-NHSN) criteria. Pre–COVID-19 rates for 2019 were compared with COVID-19 era rates for 2020 for central line–associated bloodstream infections (CLABSIs), catheter-associated urinary tract infections (CAUTIs), ventilator-associated events (VAEs), mortality, and length of stay (LOS).ResultsA total of 7,775 patients were followed up for 49,506 bed days. The 2019 to 2020 rate comparisons were 2.54 and 4.73 CLABSIs per 1,000 central line days (risk ratio [RR] = 1.85, p = .0006), 9.71 and 12.58 VAEs per 1,000 mechanical ventilator days (RR = 1.29, p = .10), and 1.64 and 1.43 CAUTIs per 1,000 urinary catheter days (RR = 1.14; p = .69). Mortality rates were 15.2% and 23.2% for 2019 and 2020 (RR = 1.42; p < .0001), respectively. Mean LOS for 2019 and 2020 were 6.02 and 7.54 days (RR = 1.21, p < .0001), respectively.DiscussionThis study documents an increase in HAI rates in 7 LMICs during the first 5 months of the COVID-19 pandemic and highlights the need to reprioritize and return to conventional infection prevention practices.

759. Impact of Clostridium difficile (CD) Nucleic Acid Amplification Test (NAAT) Approval on Hospital-Onset C. difficile Infection (HO-CDI): A Diagnostic Stewardship Intervention

BackgroundNAAT is highly sensitive in detecting toxigenic CD but if used inappropriately can lead to overdiagnosis and financial penalties. Despite diligent infection control (IC) measures, HO-CDI rates at our hospital remained above target benchmarks. We implemented mandatory CD testing approval to decrease HO-CDI rates. MethodsOn 7/1/2019, we implemented CD testing approval for stool samples collected after admission day 3 in our 129-bed community hospital. An algorithm instructed providers about approval granted by IC 7 days-a-week. The micro-lab would not process samples unless pre-approved. We prospectively collected data on demographics, ICU, laxative, antibiotic use, CDI signs/symptoms, prior CDI and outcomes (length of stay, in-hospital death) and estimated unadjusted relative risk ratios comparing those whose test was approved vs not approved. We also performed an interrupted time series analysis to assess the trend change of CD testing and HO-CDI per 1000 patient days (x 1000-PD) in the 18 months following the intervention (7/2019 - 12/2020) compared to the pre-intervention period (01/2018 - 6/2019). Lastly, using the National Healthcare Safety Network criteria, we calculated pre and post-intervention Standard Infection Ratios (SIR). ResultsA total of 72 samples required CD testing authorization; 65 (90%) were approved. Baseline demographics, in-hospital death and length of stay were similar in both groups, but approved patients were 4 times as likely to have ≥ 3 loose stools in 24h compared to not approved. The number of CD tests was 13 at baseline with a decrease of 6 tests in the 1st month of intervention (95% CI: -10.0, - 1.35), followed by an insignificant decline in the monthly trend (-0.14; 95%CI: -0.49, 0.20). There were 22 HO-CDI pre-intervention and 10 post-intervention. Pre-intervention, incidence of HO-CDI was 0.51 cases x 1000-PD and increased every month by 0.11 (95% CI: 0.07,0.16). In July 2019, there was a significant decline of 1.16 case x 1000-PD (95% CI: -1.99, -0.33), followed by monthly decline (-0.16; 95% CI: -0.23, -0.09). Our calculated SIR after the intervention decreased to 0.77 from 1.03. Trends of CD testing and HO-CDI in the pre-intervention and post-intervention period ConclusionCD testing approval is a successful strategy to optimize testing and lower HO-CDI rates, without resulting in worst outcomes even when CD test was not approved. Disclosures All Authors: No reported disclosures

771. COVID-19 on the Line: A Significant Increase in CLABSI in Hospitalized Patients with COVID-19 at a Major Teaching Hospital

BackgroundWe observed an increase in central line associated bloodstream infections (CLABSI) associated with the 2020 COVID-19 pandemic and performed a retrospective analysis to better understand the impact of COVID-19 on CLABSI rates.Figure 1. CLABSI rate in 2019 vs CLABSI rate in 2020 A comparison of CLABSI rates (displayed in infections/1000 catheter days) in all adult inpatients at our institution for calendar-years 2019 and 2020MethodsRetrospective review was done for all CLABSI in adults meeting National Healthcare Safety Network (NHSN) criteria in 2020 at an 889-bed teaching hospital. CLABSIs in encounters with PCR-confirmed COVID-19 (COVID CLABSI) were compared with CLABSIs in encounters without a COVID diagnosis (non-COVID CLABSI). As a secondary analysis, we also reviewed all CLABSI occurrence in 2019. Characteristics were compared using Mid-P Exact (Poisson) and Chi Squared (categorical) Tests. Subjective data collected by infection preventionists during real-time case reviews with clinical staff of each CLABSI was also reviewed.ResultsIn 2020, the rate of COVID CLABSI (CLABSI/1000 catheter days) was 6.6 times greater than the rate of non-COVID CLABSI (5.47 vs. 0.83, p< 0.001). In the COVID CLABSI group we observed higher rates of occurrence in the ICU setting (94% vs 28%, p< 0.001), in house mortality (53% vs 26% P=0.0187), presence of arterial lines (91% vs 20%, p< 0.001) and increased number of catheter lumens (4 vs 3, p< 0.001). No significant difference was observed in the distribution of pathogens. No significant differences were observed between 2019 CLABSI and 2020 non-COVID CLABSI. Real-time case reviews identified changes in nurse staffing, increased nurse: patient ratios, delays in routine central line dressing changes, and inconsistent use of alcohol-impregnated port protectors as possible contributing factors. Table 1. 2020 COVID CLABSI vs 2020 non-COVID CLABSI A comparison of selected patient and catheter characteristics in COVID CLABSI vs non-COVID CLABSI in 2020Table 2. 2019 CLABSI vs 2020 non-COVID CLABSI A comparison of selected patient and catheter characteristics in CLABSI in 2019 vs non-COVID CLABSI in 2020Figure 2. CLABSI rate in 2019 vs COVID CLABSI and non-COVID CLABSI in 2020 A comparison of CLABSI rates (displayed in infections/1000 catheter days) in all adult inpatients at our institution for calendar years 2019 and 2020, with the infections in 2020 divided into those that occurred during an encounter with a PCR -confirmed diagnosis of COVID-19 and those without.ConclusionWe observed a dramatically higher rate of CLABSI in patients with COVID-19 in 2020, while the rate of CLABSI in patients without COVID-19 remained unchanged from the year prior. Higher rates of ICU admission, critical illness, increased numbers of lumens, increased presence of arterial lines, nurse staffing changes, and gaps in routine line prevention processes associated with emergency measures in the COVID-19 cohort ICU may have contributed to this finding. Further work is needed to better understand how to minimize process-related disruptions in central line care during a hospital response to a pandemic. Disclosures Jonathan Grein, MD, Gilead (Other Financial or Material Support, Speakers fees)

Bloodstream Infection Risk, Incidence, and Deaths for Hospitalized Patients during Coronavirus Disease Pandemic.

Hospital-acquired infections are emerging major concurrent conditions during the coronavirus disease (COVID-19) pandemic. We conducted a retrospective review of hospitalizations during March‒October 2020 of adults tested by reverse transcription PCR for severe acute respiratory syndrome coronavirus 2. We evaluated associations of COVID-19 diagnosis with risk for laboratory-confirmed bloodstream infections (LCBIs, primary outcome), time to LCBI, and risk for death by using logistic and competing risks regression with adjustment for relevant covariates. A total of 10,848 patients were included in the analysis: 918 (8.5%) were given a diagnosis of COVID-19, and 232 (2.1%) had LCBIs during their hospitalization. Of these patients, 58 (25%) were classified as having central line‒associated bloodstream infections. After adjusting for covariates, COVID-19‒positive status was associated with higher risk for LCBI and death. Reinforcement of infection control practices should be implemented in COVID-19 wards, and review of superiority and inferiority ranking methods by National Healthcare Safety Network criteria might be needed.

A comparison of diagnostic algorithms and clinical parameters to diagnose ventilator-associated pneumonia: a prospective observational study

BackgroundSuspicion and clinical criteria continue to serve as the foundation for ventilator-associated pneumonia (VAP) diagnosis, however the criteria used to diagnose VAP vary widely. Data from head-to-head comparisons of clinical diagnostic algorithms is lacking, thus a prospective observational study was performed to determine the performance characteristics of the Johanson criteria, Clinical Pulmonary Infection Score (CPIS), and Centers for Disease Control and Prevention’s National Healthcare Safety Network (CDC/NHSN) criteria as compared to Hospital in Europe Link for Infection Control through Surveillance (HELICS) reference standard.MethodsA prospective observational cohort study was performed in three mixed medical-surgical ICUs from one academic medical center from 1 October 2016 to 30 April 2018. VAP diagnostic criteria were applied to each patient including CDC/NHSN, CPIS, HELICS and Johanson criteria. Tracheal aspirate cultures (TAC) and serum procalcitonin values were obtained for each patient.ResultsEighty-five patients were enrolled (VAP 45, controls 40). Using HELICS as the reference standard, the sensitivity and specificity for each of the assessed diagnostic algorithms were: CDC/NHSN (Sensitivity 54.2%; Specificity 100%), CPIS (Sensitivity 68.75%; Specificity 95.23%), Johanson (Sensitivity 67.69%; Specificity 95%). The positive TAC rate was 81.2%. The sensitivity for positive TAC with the serum procalcitonin level > 0.5 ng/ml was 51.8%.ConclusionVAP remains a considerable source of morbidity and mortality in modern intensive care units. The optimal diagnostic method remains unclear. Using HELICS criteria as the reference standard, CPIS had the greatest comparative diagnostic accuracy, whereas the sensitivity of the CDC/NHSN was only marginally better than a positive TAC plus serum procalcitonin > 0.5 ng/ml. Algorithm accuracy was improved by adding serum procalcitonin > 0.5 ng/ml, but not positive quantitative TAC.Trial Registration: Not indicated for this study type.

Concordance between the National Healthcare Safety Network (NHSN) Surveillance Criteria and Clinical Pulmonary Infection Score (CPIS) Criteria for Diagnosis of Ventilator-associated Pneumonia (VAP).

Background: Ventilator-associated pneumonia (VAP) is one of the most common hospital-acquired infections among mechanically ventilated patients and the incidence rates are widely used as an index of quality of care given in an ICU. Since there is no gold standard method available to diagnose VAP, the incidence rate varies based on different criteria used for calculation. Therefore, we conducted a study to determine the concordance between the National Healthcare Safety Network (NHSN) surveillance criteria and clinical pulmonary infection score (CPIS) criteria for the diagnosis of VAP.Materials and methods: This was a prospective study that evaluated patients in the medical intensive care units (MICUs) of a tertiary care hospital, India, who were intubated for >48 hours between October 2018 and September 2019. All the patients (n = 273) were followed up daily and assessed using both CPIS and NHSN surveillance criteria for diagnosing VAP.Results: Of these 273 patients, 93 patients (34.1%) had VAP according to CPIS criteria as compared with 33 patients (12.1%) using the NHSN criteria. The corresponding rates of VAP were 39.59 vs 11.53 cases per 1,000 ventilator days, respectively. The agreement of the two sets of criteria was fairly good (kappa statistics, 0.42)Conclusion: The NHSN surveillance criteria have a lower sensitivity in detecting VAP cases and have to be modified to achieve better results.How to cite this article: Gunalan A, Sistla S, Sastry AS, Venkateswaran R. Concordance between the National Healthcare Safety Network (NHSN) Surveillance Criteria and Clinical Pulmonary Infection Score (CPIS) Criteria for Diagnosis of Ventilator-associated Pneumonia (VAP). Indian J Crit Care Med 2021;25(3):296–298.

Financial and Mortality Modeling as a Tool to Present Infection Prevention Data: What a SIR of 1.2 Means for the Hospital

Background: Presenting to hospital leadership is an annual requirement of many infection prevention (IP) programs. Most presentations include current statistical data of hospital-acquired infections (HAIs) and whether the hospital has met its goals according to the National Healthcare Safety Network (NHSN) criteria. We presented HAI data in a novel way, with financial and mortality modeling, to show the impact of IP interventions to leadership not attuned to NHSN metrics. Method: We looked at 4 HAIs, their trends, and their effect on our hospital, Santa Clara Valley Medical Center (SCVMC). To estimate the impact of specific HAIs, we used 2 metrics derived from a meta-analysis by the US Department of Health and Human Services (HHS): excess mortality and excess cost. Excess mortality is defined as the difference between the underlying population mortality and the affected population mortality expressed as deaths per 1,000 population. Excess cost is defined as the additional cost introduced per patient with a specific HAI versus a similarly admitted patient without that HAI. HHS data were multiplied by the number of HAI events at SCVMC to generate estimates. Result: In our presentation, we elucidated a previously unseen cost savings and decreased mortality with 2 HAIs, central-line–associated blood stream infections (CLABSIs) and catheter associated urinary tract infections (CAUTIs), which were below NHSN targets due to IP-led interventions. We then showed 2 other HAIs, Clostridium difficile infection (CDI) and surgical site infections (SSIs), which did not meet our expected NHSN and institutional goals and were estimated to increase costs and potential mortalities in the upcoming year. We argued that proactive monies directed toward expanding our IP program and HAI mitigation efforts would cost a fraction of the impending healthcare expenditures as predicted by the model. Conclusion: By applying financial and mortality modeling, we helped our leadership perceive the concrete effect of IP-led interventions versus presenting abstract NHSN metrics. We also emphasized that without proactive leadership investment, we would continue to overspend healthcare dollars while not meeting our goals. This format of presentation gave us critical leverage to advocate for and successfully expand our IP department. Further SHEA-led cost-analysis modeling and education are needed to help IP departments promote their efforts in an effective manner.Funding: NoneDisclosures: None

2021 Young Investigator Award Winner: Anatomic Gradients in the Microbiology of Spinal Fusion Surgical Site Infection and Resistance to Surgical Antimicrobial Prophylaxis.

Retrospective hospital-registry study. To characterize the microbial epidemiology of surgical site infection (SSI) in spinal fusion surgery and the burden of resistance to standard surgical antibiotic prophylaxis. SSI persists as a leading complication of spinal fusion surgery despite the growth of enhanced recovery programs and improvements in other measures of surgical quality. Improved understandings of SSI microbiology and common mechanisms of failure for current prevention strategies are required to inform the development of novel approaches to prevention relevant to modern surgical practice. Spinal fusion cases performed at a single referral center between January 2011 and June 2019 were reviewed and SSI cases meeting National Healthcare Safety Network criteria were identified. Using microbiologic and procedural data from each case, we analyzed the anatomic distribution of pathogens, their differential time to presentation, and correlation with methicillin-resistant Staphylococcus aureus screening results. Susceptibility of isolates cultured from each infection were compared with the spectrum of surgical antibiotic prophylaxis administered during the index procedure on a per-case basis. Susceptibility to alternate prophylactic agents was also modeled. Among 6727 cases, 351 infections occurred within 90 days. An anatomic gradient in the microbiology of SSI was observed across the length of the back, transitioning from cutaneous (gram-positive) flora in the cervical spine to enteric (gram-negative/anaerobic) flora in the lumbosacral region (correlation coefficient 0.94, P < 0.001). The majority (57.5%) of infections were resistant to the prophylaxis administered during the procedure. Cephalosporin-resistant gram-negative infection was common at lumbosacral levels and undetected methicillin-resistance was common at cervical levels. Individualized infection prevention strategies tailored to operative level are needed in spine surgery. Endogenous wound contamination with enteric flora may be a common mechanism of infection in lumbosacral fusion. Novel approaches to prophylaxis and prevention should be prioritized in this population.Level of Evidence: 3.

Eliminating Catheter-Associated Urinary Tract Infections in a Pediatric Cardiac ICU.

To eliminate catheter-associated urinary tract infections in a pediatric cardiac ICU. Quality improvement methodology. Twenty-five bed cardiac ICU in a quaternary freestanding children's hospital. All patients with an indwelling urinary catheter admitted to the cardiac ICU. Catheter-associated urinary tract infection was defined according to National Healthcare Safety Network criteria. Failure modes and effects analysis and Pareto charts were used to determine etiology of process failures. We implemented a team-based multi-interventional approach in 2012 using the Model for Improvement, which included as follows: 1) establish indications for inserting and/or maintaining bladder catheterization, 2) standardization of maintenance care for the indwelling urinary catheters, 3) protocol for management of the leaking urinary catheters, 4) incorporation of urinary catheter days and prompts for removal in daily rounds, and 5) review of all cases of prolonged indwelling urinary catheter use (> 3 d). Process control charts were used to evaluate change. From 2011 to 2018, we showed an early and sustained improvement in catheter-associated urinary tract infection prevention standards compliance from 44% to 96% (52% improvement). These interventions showed a reduction and then elimination of catheter-associated urinary tract infections from January 2012 to the present day, despite fluctuations in total indwelling urinary catheter days. Utilization of quality improvement methodology allowed us to identify components of care that contributed to catheter-associated urinary tract infections. After addressing these issues, we noted a substantial reduction and then elimination of catheter-associated urinary tract infections in our pediatric cardiac ICU. Widely disseminating these interventions across multiple pediatric hospitals to determine the ability to achieve similar results are important next steps.