This article describes 22 cases of breakthrough SARS‐CoV‐2 infection among over 14,000 fully vaccinated skilled nursing facility residents and staff. The majority of such infections were asymptomatic ...or were associated with mild symptoms, and there was no intra‐ facility spread related to these cases. This report suggests that postvaccination breakthrough infections are rare, but also confirms that vaccines do not offer 100% protection even in nonimmunosuppressed hosts, thus underscoring the need for studies of vaccine efficacy in immunosuppressed transplant recipients.
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BFBNIB, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Background:
Carbapenem-resistant
Acinetobacter baumannii
(CRAB) is primarily associated with hospital-acquired infections and is an urgent public health threat due to its ability to contaminate the ...environment and cause severe disease. In 2019, Illinois began pilot surveillance for CRAB requiring select laboratories to submit specimens for molecular characterization. On July 17, 2020, the Chicago Department of Public Health (CDPH) was notified of an increase in CRAB infections in a 20-bed ICU at an acute-care hospital in Chicago (hospital A) during the initial COVID-19 surge. We summarize the outbreak investigation findings and infection control recommendations.
Methods:
Clinical cultures were collected from patients in hospital A, and CRAB-positive isolates were sent to the Wisconsin State Laboratory of Hygiene for mechanism of resistance and antibiotic susceptibility testing. On-site assessments and remote follow-ups were conducted by CDPH infection preventionists to evaluate infection control practices including environmental cleaning, hand hygiene compliance, and use of personal protective equipment (PPE). The Illinois Department of Public Health and CDPH summarized the testing results, facilitated a containment response, and provided recommendations for infection control.
Results:
From March 18, 2020, to September 30, 2021, 56 patients with CRAB infections were identified from hospital A, and 33 (59%) of these cases were pan-nonsusceptible. Most specimen sources were sputum (n = 30, 54%), followed by blood (n = 13, 23%), urine (n = 6, 11%) and other (n = 7, 13%). Among isolates with mechanism testing (n = 54), 45 (83%) were positive for OXA-24/40 and 9 (17%) were positive for OXA-23. Of the CRAB-positive patients, 28 (50%) were previously positive for SARS-CoV-2. To date, 25 of these patients (45%) have been discharged and 31 (55%) have died. Two onsite visits and 7 remote-assistance sessions were conducted as part of the investigation. In response to increased COVID-19 hospitalizations, hospital A moved to crisis-capacity PPE use and encountered staffing shortages, which led to compromised infection control measures. Cleaning agents (Quat disinfectant cleaner) were also found to be ineffective against CRAB and required long contact times.
Conclusions:
In response to the CRAB outbreak at hospital A, CDPH recommended that the hospital stop crisis-capacity protocols for PPE, conduct admission screening and point-prevalence testing for CRAB, implement a hand hygiene campaign, and use an EPA-registered List K product for environmental cleaning. These recommendations were implemented in May 2021, and no CRAB cases have been reported since July 2021. To reduce CRAB transmission during the pandemic, facility leadership must commit resources to educate staff on effective infection control practices including conventional use of PPE, appropriate cleaning agents, and improved hand hygiene.
Funding:
None
Disclosures:
None
Abstract
Background
Since the identification of the first 2 Candida auris cases in Chicago, Illinois, in 2016, ongoing spread has been documented in the Chicago area. We describe C. auris emergence ...in high-acuity, long-term healthcare facilities and present a case study of public health response to C. auris and carbapenemase-producing organisms (CPOs) at one ventilator-capable skilled nursing facility (vSNF-A).
Methods
We performed point prevalence surveys (PPSs) to identify patients colonized with C. auris and infection-control (IC) assessments and provided ongoing support for IC improvements in Illinois acute- and long-term care facilities during August 2016–December 2018. During 2018, we initiated a focused effort at vSNF-A and conducted 7 C. auris PPSs; during 4 PPSs, we also performed CPO screening and environmental sampling.
Results
During August 2016–December 2018 in Illinois, 490 individuals were found to be colonized or infected with C. auris. PPSs identified the highest prevalence of C. auris colonization in vSNF settings (prevalence, 23–71%). IC assessments in multiple vSNFs identified common challenges in core IC practices. Repeat PPSs at vSNF-A in 2018 identified increasing C. auris prevalence from 43% to 71%. Most residents screened during multiple PPSs remained persistently colonized with C. auris. Among 191 environmental samples collected, 39% were positive for C. auris, including samples from bedrails, windowsills, and shared patient-care items.
Conclusions
High burden in vSNFs along with persistent colonization of residents and environmental contamination point to the need for prioritizing IC interventions to control the spread of C. auris and CPOs.
This report describes Candida auris emergence in Chicago during August 2016–December 2018, and public health response at one ventilator-capable skilled nursing facility with high colonization burden. Improved adherence to infection control and environmental disinfection is needed to control spread.
Early studies suggest that COVID-19 vaccines protect against severe illness (1); however, postvaccination SARS-CoV-2 infections (i.e., breakthrough infections) can occur because COVID-19 vaccines do ...not offer 100% protection (2,3). Data evaluating the occurrence of breakthrough infections and impact of vaccination in decreasing transmission in congregate settings are limited. Skilled nursing facility (SNF) residents and staff members have been disproportionately affected by SARS-CoV-2, the virus that causes COVID-19 (4,5), and were prioritized for COVID-19 vaccination (6,7). Starting December 28, 2020, all 78 Chicago-based SNFs began COVID-19 vaccination clinics over several weeks through the federal Pharmacy Partnership for Long-Term Care Program (PPP).
In February 2021, through routine screening, the Chicago Department of Public Health (CDPH) identified a SARS-CoV-2 infection in a SNF resident >14 days after receipt of the second dose of a two-dose COVID-19 vaccination series. SARS-CoV-2 cases, vaccination status, and possible vaccine breakthrough infections were identified by matching facility reports with state case and vaccination registries. Among 627 persons with SARS-CoV-2 infection across 75 SNFs since vaccination clinics began, 22 SARS-CoV-2 infections were identified among 12 residents and 10 staff members across 15 facilities ≥14 days after receiving their second vaccine dose (i.e., breakthrough infections in fully vaccinated persons). Nearly two thirds (14 of 22; 64%) of persons with breakthrough infections were asymptomatic; two residents were hospitalized because of COVID-19, and one died. No facility-associated secondary transmission occurred. Although few SARS-CoV-2 infections in fully vaccinated persons were observed, these cases demonstrate the need for SNFs to follow recommended routine infection prevention and control practices and promote high vaccination coverage among SNF residents and staff members.
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DOBA, IZUM, KILJ, NUK, ODKLJ, OILJ, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK, VSZLJ
Abstract
Background
U.S. Antibiotic Awareness Week (USAAW) is an annual campaign to increase knowledge of antimicrobial resistance (AMR) threats and the importance of appropriate antibiotic use. ...USAAW will be observed November 18-24, 2021 in cadence with World Antimicrobial Awareness Week.
Methods
In October 2019, the Chicago Department of Public Health (CDPH) surveyed 25 Chicago acute care hospital (ACH) antimicrobial stewardship programs (ASPs) via REDCap, an electronic data capture system, to assess their planned activities for USAAW in November 2019. Survey results from 14 (56%) respondent ACHs were collated and disseminated to all 25 ACHs prior to USAAW.
Results
ACH ASP survey responses were categorized by ACH size: smaller hospitals (SH) < 350 beds (n=7) and larger hospitals (LH) > 350 beds (n=7) and displayed in the Table. Nine respondents were Infectious Disease (ID) Pharmacists, 3 were ID Physicians, 1 was an Administrator and 1 was an Infection Prevention Nurse. Among SHs, the ASP was funded for an ID Pharmacist salaried position (FTE) < 0.5 at 4 ACHs, 0.5 in 2, and 1 FTE at 1 ACH. LHs reported ID Pharmacist funding ranging from < 0.5 – 2.5 FTE, with the majority with 1 FTE at 3 LHs. All ACHs reported 0.5 FTE or less ID Physician support for their ASPs. Eleven (79%) of respondent ACHs did not report an annual budget for ASP activities. Ten (71%) ACHs disagreed or strongly disagreed that funding was adequate in the outpatient setting compared to inpatient both for adult and pediatric ASP services. Types of planned activities for USAAW included social media posts, provider education, digital displays, and/or go-live with a new antimicrobial policy. Top three barriers to ASP advancements were financial considerations (n=9), competing responsibilities for ASP leads (n=7), and tied for third was personnel shortages (n=6) and other clinical initiatives with higher priority (n=6).
Conclusion
Public Health Departments can facilitate assessment of ACH ASPs within their jurisdiction to identify ways to advance the ASP agenda and combat AMR. A variety of strategies were used by Chicago ACHs to promote ASP initiatives during USAAW. Challenges continue with inadequate funding, especially in outpatient settings.
Disclosures
All Authors: No reported disclosures
Abstract
Background
Antimicrobial Stewardship Programs (ASPs) in long-term care facilities are a Center for Medicare and Medicaid Services requirement as of 2017. The CDC estimates 40–75% of ...antibiotic prescribing in skilled nursing facilities (SNFs) is inappropriate. Overuse of antibiotics can cause harm by increasing the risk of adverse drug events (including C. difficile infections) and antimicrobial resistance.
Methods
The GAIN Collaborative was launched to assist SNFs in improving antibiotic prescribing. A list of antibiotics prescribed was generated from the electronic health records, and a chart review was performed.
Results
Antibiotic orders from September 2018 to March 2019 were randomly selected at 4 SNFs, and 120 antibiotic courses were reviewed (23, 40, 25, and 32 at SNFs A-D). Bed size ranged from 72 to 156 (median 88). Inappropriate antibiotic prescribing ranged from 60 to 78% (median 71%) among facilities. Urinary tract infections (UTIs) were the most frequent indication (40%), followed by lower respiratory tract infections (LRTIs), and skin and soft-tissue infections (SSTIs), accounting for 26% and 19% of indications, respectively. Inappropriate prescribing rates by indication were 90% for UTIs, 78% for SSTIs, and 47% for LRTIs. The most common reasons for inappropriate antibiotic prescribing were: insufficient signs and symptoms based on the Loeb minimum criteria for starting antibiotics (43%), inappropriate agent selection (30%), and lengthy treatment durations (29%). The majority of antibiotics prescribed were β-lactams (42%) or fluoroquinolones (29%). The median antibiotic prescription duration for non-catheter-associated UTIs was 5 days, LRTIs was 7 days, catheter-associated UTIs was 10 days, prophylaxis was 10 days, and SSTIs was 13 days.
Conclusion
Inappropriate antibiotic use was common in the four Chicago SNFs assessed. Results were presented at each facility’s Quality Assurance meeting to deliver provider-focused feedback. Additionally, provider and nursing education has been conducted at the four SNFs aimed at reducing unnecessary treatment of asymptomatic bacteriuria. Any improvements in antibiotic use will be captured through repeat point prevalence surveys post-implementation of a UTI SBAR communication tool and common infection treatment guidelines.
Disclosures
All authors: No reported disclosures.
Abstract
Background
Antimicrobial Stewardship Programs (ASPs) in long-term care facilities is a Centers for Medicare and Medicaid Services requirement as of 2017. The CDC recommends that ASPs in ...skilled nursing facilities (SNFs) fulfill 7 Core Elements: leadership commitment, accountability, drug expertise, action, tracking, reporting and education.
Methods
An electronic survey utilizing REDCap was sent to the 76 Chicago SNFs representatives (Administrator, Director of Nursing, and/or Assistant Director of Nursing). Survey questions were adopted from the CDC Core Elements of Antimicrobial Stewardship for Nursing Homes Checklist.
Results
Twenty-seven (36%) of Chicago SNFs responded. Bed size ranged from 36 – 307 (median 150). Although 93% of facilities had a written statement of leadership support for antimicrobial stewardship, only 22% cited any budgeted financial support for antimicrobial stewardship activities. While Pharmacist Consultants visited all SNFs (most visiting monthly), only 33% of SNFs had an Infectious Disease Provider that consulted on-site. Dedicated time for antimicrobial stewardship activities was less than 10 hours per week in 78% of facilities, with half of all respondents reporting less than 5 hours per week. Treatment guidelines were in place for 63% of SNFs, 56% had an antibiogram, and only 7% utilized the Loeb criteria to guide appropriate antibiotic prescribing. Many facilities tracked antimicrobial stewardship metrics (93%) and reported out to staff (70%). Annual nursing training on antimicrobial stewardship occurs more frequently (85%) than prescriber education (56%). The top 3 barriers identified in implementing ASPs were financial limitations (33%), lack of clinical expertise (33%), and provider opposition (30%). Facilities’ compliance in all seven core elements varied from partially compliant (65%), majority compliant (19%), and majority non-compliant (16%).
Conclusion
Data from this baseline survey informed focused antimicrobial stewardship initiatives for the GAIN Collaborative. Targeted areas to incorporate into facility action plans include treatment guideline development, antibiograms, annual staff antimicrobial stewardship education, and adoption of the Loeb minimum criteria for antibiotic prescribing into clinical practice.
Disclosures
All authors: No reported disclosures.
Abstract
Background
Emerging CPO in the Chicago area poses clinical and infection control challenges across the spectrum of care. Since November 2013, CPO are reportable to the Illinois’ Extensively ...Drug-resistant Organism (XDRO) registry. We examined trends in mechanism of resistance (MOR) among CPO reported through December 2018.
Methods
MOR reported into the XDRO registry were identified by clinical laboratories performing molecular methods on routine clinical cultures, by public health laboratories during point prevalence surveys (PPS) in response to clusters and as part of a project to assess CPO prevalence in high-risk Chicago area healthcare settings. Chicago patients with known MOR other than Klebsiella pneumoniae carbapenemase (KPC) are investigated by Chicago Department of Public Health (CDPH) to implement containment strategies and identify risk factors within 6 months of culture date.
Results
MOR was identified in 40% (1,216/3,587) of CPO-positive specimens collected from unique Chicago patients; 87% were KPC, 7% New Delhi metallo-β-lactamase (NDM), 5% Verona integron-mediated metallo-β-lactamase (VIM), 0.6% OXA-48-type carbapenemases, and 0.01% Imipenemase metallo-β-lactamase (IMP) (figure). Since 2017, 15 patients with CPO expressed more than one MOR; 14 were identified during PPS at ventilator capable skilled nursing facilities (vSNF) or long-term acute care hospitals (LTACH), and one was hospitalized in India. Among 156 patients with non-KPC CPO, the median age was 64 years (range, 20–97), 107 (69%) were identified from rectal screening and 49 (31%) were from clinical specimens, most of which were urine 23 (47%) or blood 6 (12%). Among 134 patients with risk factor history, 64% had history of tracheostomy (Table 1). Among 113 patients without documented travel outside of the United States, all stayed overnight at an Illinois healthcare facility; 62% stayed in a vSNF and 24% in an LTACH within 6 months of identification (Table 2).
Conclusion
We have increasingly detected non-KPC CPO in Chicago; however, estimates of prevalence are limited by lack of systematic surveillance and molecular testing. The high proportion of CPO patients without travel who stayed in vSNF or LTACH underscores the need for infection control training and surveillance in these settings.
Disclosures
All Authors: No reported Disclosures.
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