OBJECTIVE:Patients receiving immunosuppression for oncology treatment and solid organ transplantation are at high risk for developing hospital-onset Clostridioides difficile infection (HO-CDI). We studied the impact of a prophylactic enteral vancomycin intervention on the reduction of HO-CDI during high-risk inpatient admissions among immunocompromised patients. METHODS:The screening and targeted prophylaxis (STOP) intervention was implemented over a 2-year period. Patients admitted for solid organ transplant, autologous stem cell transplant, chimeric antigen receptor T-cell, or treatment for leukaemia were screened for colonization with C. difficile. Colonized patients were placed in contact isolation and were advised to start anti-C.difficile antibiotic prophylaxis. To assess the effect of this intervention on both C.difficile testing and incident HO-CDI, comparison was made to historical controls in the 2 years before implementation of the STOP intervention, both unweighted and weighted by treatment category and separately by treatment category and severity of illness. RESULTS:From November 2021 to December 2023, 696 patients were screened for C difficile, among whom 11.1% (77/696) were found to be colonized and received the prophylactic intervention. Compared with treatment-weighted controls, the odds of HO-CDI were significantly lower in the intervention group (6/696 [0.88%] vs. 81/1450 [5.6%]; odds ratio [OR], 0.15; 95% Credible Interval [CrI], 0.06-0.30). Significant reductions in 90-day CDI (OR 0.40, 95% CrI 0.25-0.64), stool output (incidence rate ratio, 0.84; 95% CrI, 0.77-0.92), and length of stay (-2.5 days; 95% CrI, -3.4 to -1.5) were also observed in the intervention group. There was no detected difference in vancomycin-resistant Enterococci infection (OR, 0.77; 95% CrI, 0.33-1.75) or mortality (OR, 0.44; 95% CrI, 0.11-1.49). DISCUSSION:The STOP intervention was effective at reducing HO-CDI, length of stay, and symptoms of C difficile in this high-risk cohort.

Abstract Background The SHEA/IDSA/APIC Strategies to Prevent MRSA Transmission and Infection Practice Recommendations advised that facilities consider decolonizing patients on hemodialysis. We implemented a nasal decolonization intervention in which patients self-administered povidone-iodine (PVI) at each dialysis session. We aimed to assess intervention safety and effectiveness. Methods We performed a stepped wedge cluster randomized trial at 16 outpatient hemodialysis units affiliated with 5 academic medical centers between 2020-2023. Adverse events were self-reported at 1 and 6 months. While the analysis was at the hemodialysis unit level, patients were required to give verbal informed consent for PVI use. Outcomes included National Healthcare Safety Network reportable dialysis events aggregated at hemodialysis unit level, including bloodstream infections (BSI), access-related BSI, and central venous catheter (CVC) BSI for all pathogens and for Staphylococcus aureus (SA). The primary outcome was SA BSI. A generalized linear mixed model with a negative binomial distribution, log link function, and an offset for person-months with a random intercept for each hemodialysis unit was performed. Results Overall, 1,351 patients received hemodialysis at these centers each month. Of those, 362 patients verbally consented to use PVI. Among these, 3.9% reported side effects: nasal drip, congestion or burning/stinging, unpleasant smell, headache, or minor nose bleed. A reported side effect ‘yellow tears’ was assessed via chart review and resolved by discontinuing PVI. There were no statistically significant associations between unit level randomization to the PVI intervention and infections. However, there was a non-statistically significant trend toward a protective association between unit-level randomization to PVI and SA infections, particularly SA CVC BSI.(Table) Conclusion Long-term nasal decolonization with PVI was safe with few adverse events. Unit level randomization to the PVI intervention did not significantly decrease unit-level infections. Given low patient enrollment and added infection prevention interventions due to COVID-19, the study could not determine if PVI decolonization could decrease BSI rates in the hemodialysis setting. Disclosures Marin Schweizer, PhD, 3M: Grant/Research Support Anitha Vijayan, MD, Baxter: Honoraria|NxStage: Advisor/Consultant|Qanta: Honoraria David A. Pegues, MD, DaVita/Total Renal Care: Advisor/Consultant Daniel Diekema, MD, Affinity Biosensors: Grant/Research Support|bioMerieux, Inc: Grant/Research Support Loreen Herwaldt, MD, 3M: Grant/Research Support|PDI: Grant/Research Support

Objective: Evidence-based central-line-associated bloodstream infection (CLABSI) prevention guidelines recommend the use of an antiseptic scrub to disinfect needleless connectors before device access. Guideline noncompliance may render disinfection ineffective. The goal of this study was to observe needleless-connector disinfection practices and to identify perceived facilitators and barriers to best practices of needleless-connector access.Methods: A human factors mixed-methods study involving nursing focus groups of perceived barriers and facilitators and clinical observations of compliance with instructions and protocols for use of 3.15% chlorhexidine gluconate/70% isopropyl alcohol (CHG/IPA) and 70% isopropyl alcohol (IPA) antisepsis products for central venous access device (CVAD) needleless-connector disinfection was conducted in intensive care units (ICUs) at 2 academic medical centers.Results: Access to the antiseptic product and lesser workload were identified as best-practice facilitators. Barriers were the time required per needleless-connector access and knowledge deficits. Of the 48 observed access events, 77% resulted in needleless-connector disinfection. The observed mean needleless-connector scrubbing times when using IPA were substantially below the recommended time. Drying time after product use was negligible.Conclusions: Lack of access to the disinfection product, emergency situations, and high workload were barriers to needleless-connector disinfection. Observed scrubbing and drying times were shorter than recommended, especially for IPA wipes. These needleless-connector disinfection deficits may increase the risk of CLABSI. Ongoing education and periodic competency evaluation of needleless-connector disinfection, improvement of supply management, and staffing workload are required to imbed and sustain best practices. Further study involving a larger sample size in diverse patient populations is warranted.

Background: Patients undergoing hemodialysis are at high risk for healthcare-associated infections; they are at 100 times the risk of Staphylococcus aureus bloodstream infections (BSI) compared with U.S. adults not on hemodialysis. Prior studies found that nasal decolonization with mupirocin prevented S. aureus BSI among hemodialysis patients. We implemented a nasal decolonization intervention in which patients self-administered povidone-iodine (PVI) at each dialysis session. We aimed to assess: 1) hemodialysis patients’ knowledge of their infection risk and their willingness to take an active role in infection prevention; 2) the acceptability of the PVI nasal decolonization intervention. Methods: We performed a stepped wedge cluster randomized trial at 16 outpatient hemodialysis centers. Patients were surveyed: before starting PVI, 1 month after their center started using PVI, and ~6 months after starting PVI. We used a chi-square test to compare results. Results: 469 patients completed at least 1 survey: 400 pre-intervention, 237 at 1 month and 201 at 6 months. Overall, 56% of patients thought that their risk of infection was average or below average compared with an average person in the U.S. (Figure). Over 98% agreed with the statement “One of the most important things I can do for my health is to take an active role in my health care." In the pre-intervention survey, 73% were willing to do “a lot of effort” to prevent an infection. This proportion was similar (73%) in the 2nd survey, but decreased to 63% in the final survey (p < 0 .01). Among 106 patients who reported starting PVI, 85% reported that PVI felt neutral or pleasant, 9.4% reported a side effect, and 79% reported using it during the past 3 dialysis sessions. Among 102 patients who reported using PVI at 6 months, 87% said it felt neutral/pleasant, 3.9% reported a side effect and 75% reported using it during the past 3 dialysis sessions. Side effects included nasal dripping, congestion or burning/stinging, unpleasant smell, headache, yellow tears, and minor nose bleeding. Conclusions: Hemodialysis patients are not aware of their high risk of infection. Although many were willing to expend a lot of effort to prevent an infection, this willingness decreased during an infection prevention intervention. There were few PVI side effects and most patients stated that PVI felt neutral/pleasant, yet many patients chose to not use PVI. Future research should aim to improve patient education on their risk of infection and assess barriers to adherence with infection prevention interventions.

Background: A substantial proportion of patients undergoing hemodialysis carry Staphylococcus aureus in their noses, and carriers are at increased risk of S. aureus bloodstream infections. Our pragmatic clinical trial implemented nasal povidone-iodine (PVI) decolonization for the prevention of bloodstream infections in the novel setting of hemodialysis units.Objective: We aimed to identify pragmatic strategies for implementing PVI decolonization among patients in outpatient hemodialysis units.Design: Qualitative descriptive study.Setting: Outpatient hemodialysis units affiliated with five US academic medical centers. Units varied in size, patient demographics, and geographic location.Interviewees: Sixty-six interviewees including nurses, hemodialysis technicians, research coordinators, and other personnel.Methods: We conducted interviews with personnel affiliated with all five academic medical centers and conducted thematic analysis of transcripts.Results: Hemodialysis units had varied success with patient recruitment, but interviewees reported that patients and healthcare personnel (HCP) found PVI decolonization acceptable and feasible. Leadership support, HCP engagement, and tailored patient-focused tools or strategies facilitated patient engagement and PVI implementation. Interviewees reported both patients and HCP sometimes underestimated patients' infection risks and experienced infection-prevention fatigue. Other HCP barriers included limited staffing and poor staff engagement. Patient barriers included high health burdens, language barriers, memory issues, and lack of social support.Conclusion: Our qualitative study suggests that PVI decolonization would be acceptable to patients and clinical personnel, and implementation is feasible for outpatient hemodialysis units. Hemodialysis units could facilitate implementation by engaging unit leaders, patients and personnel, and developing education for patients about their infection risk.

Background A study previously conducted in primary care practices found that implementation of an educational session and peer comparison feedback was associated with reduced antibiotic prescribing for respiratory tract diagnoses (RTDs). Here, we assess the long-term effects of this intervention on antibiotic prescribing following cessation of feedback. Methods RTD encounters were grouped into tiers based on antibiotic prescribing appropriateness: tier 1, almost always indicated; tier 2, possibly indicated; and tier 3, rarely indicated. A chi 2 test was used to compare prescribing between 3 time periods: pre-intervention, intervention, and post-intervention (14 months following cessation of feedback). A mixed-effects multivariable logistic regression analysis was performed to assess the association between period and prescribing. Results We analyzed 260 900 RTD encounters from 29 practices. Antibiotic prescribing was more frequent in the post-intervention period than in the intervention period (28.9% vs 23.0%, P < .001) but remained lower than the 35.2% pre-intervention rate (P < .001). In multivariable analysis, the odds of prescribing were higher in the post-intervention period than the intervention period for tier 2 (odds ratio [OR], 1.19; 95% confidence interval [CI]: 1.10-1.30; P < .05) and tier 3 (OR, 1.20; 95% CI: 1.12-1.30) indications but was lower compared to the pre-intervention period for each tier (OR, 0.66; 95% CI: 0.59-0.73 tier 2; OR, 0.68; 95% CI: 0.61-0.75 tier 3). Conclusions The intervention effects appeared to last beyond the intervention period. However, without ongoing provider feedback, there was a trend toward increased prescribing. Future studies are needed to determine optimal strategies to sustain intervention effects.

OBJECTIVE:To describe neutropenic fever management practices among healthcare institutions. DESIGN:Survey. PARTICIPANTS:Members of the Society for Healthcare Epidemiology of America Research Network (SRN) representing healthcare institutions within the United States. METHODS:An electronic survey was distributed to SRN representatives, with questions pertaining to demographics, antimicrobial prophylaxis, supportive care, and neutropenic fever management. The survey was distributed from fall 2022 through spring 2023. RESULTS:40 complete responses were recorded (54.8% response rate), with respondent institutions accounting for approximately 15.7% of 2021 US hematologic malignancy hospitalizations and 14.9% of 2020 US bone marrow transplantations. Most entities have institutional guidelines for neutropenic fever management (35, 87.5%) and prophylaxis (31, 77.5%), and first-line treatment included IV antipseudomonal antibiotics (35, 87.5% cephalosporin; 5, 12.5% penicillin; 0, 0% carbapenem).We observed significant heterogeneity in treatment course decisions, with roughly half (18, 45.0%) of respondents continuing antibiotics until neutrophil recovery, while the remainder having criteria for de-escalation prior to neutrophil recovery. Respondents were more willing to de-escalate prior to neutrophil recovery in patients with identified clinical (27, 67.5% with pneumonia) or microbiological (30, 75.0% with bacteremia) sources after dedicated treatment courses. CONCLUSIONS:We found substantial variation in the practice of de-escalation of empiric antibiotics relative to neutrophil recovery, highlighting a need for more robust evidence for and adoption of this practice. No respondents use carbapenems as first-line therapy, comparing favorably to prior survey studies conducted in other countries.

Background:Ordering Clostridioides difficile diagnostics without appropriate clinical indications can result in inappropriate antibiotic prescribing and misdiagnosis of hospital onset C. difficile infection. Manual processes such as provider review of order appropriateness may detract from other infection control or antibiotic stewardship activities. Methods:We developed an evidence-based clinical algorithm that defined appropriateness criteria for testing for C. difficile infection. We then implemented an electronic medical record-based order-entry tool that utilized discrete branches within the clinical algorithm including history of prior C. difficile test results, laxative or stool-softener administration, and documentation of unformed bowel movements. Testing guidance was then dynamically displayed with supporting patient data. We compared the rate of completed C. difficile tests after implementation of this intervention at 5 hospitals to a historic baseline in which a best-practice advisory was used. Results:Using mixed-effects Poisson regression, we found that the intervention was associated with a reduction in the incidence rate of both C. difficile ordering (incidence rate ratio [IRR], 0.74; 95% confidence interval [CI], 0.63-0.88; P = .001) and C. difficile-positive tests (IRR, 0.83; 95% CI, 0.76-0.91; P < .001). On segmented regression analysis, we identified a sustained reduction in orders over time among academic hospitals and a new reduction in orders over time among community hospitals. Conclusions:An evidence-based dynamic order panel, integrated within the electronic medical record, was associated with a reduction in both C. difficile ordering and positive tests in comparison to a best practice advisory, although the impact varied between academic and community facilities.

The Penn Medicine COVID-19 Therapeutics Committee-an interspecialty, clinician-pharmacist, and specialist-front line primary care collaboration-has served as a forum for rapid evidence review and the production of dynamic practice recommendations during the 3-year coronavirus disease 2019 public health emergency. We describe the process by which the committee went about its work and how it navigated specific challenging scenarios. Our target audiences are clinicians, hospital leaders, public health officials, and researchers invested in preparedness for inevitable future threats. Our objectives are to discuss the logistics and challenges of forming an effective committee, undertaking a rapid evidence review process, aligning evidence-based guidelines with operational realities, and iteratively revising recommendations in response to changing pandemic data. We specifically discuss the arc of evidence for corticosteroids; the noble beginnings and dangerous misinformation end of hydroxychloroquine and ivermectin; monoclonal antibodies and emerging viral variants; and patient screening and safety processes for tocilizumab, baricitinib, and nirmatrelvir-ritonavir.

Background: Neutropenic fever management decisions are complex and result in prolonged duration of broad-spectrum antibiotics. Strategies for antibiotic stewardship in this context have been studied, including de-escalation of antibiotics prior to resolution of neutropenia, with unclear implementation. Here, we present the first survey study to describe real-world neutropenic fever management practices in US healthcare institutions, with particular emphasis on de-escalation strategies after initiation of broad-spectrum antibiotics. Methods: Using REDCap, we conducted a survey of US healthcare institutions through the SHEA Research Network (SRN). Questions pertained to antimicrobial prophylaxis and supportive care in the management of oncology patients and neutropenic fever management (including specific antimicrobial choices and clinical scenarios). Hematologic malignancy hospitalization (2020) and bone-marrow transplantation (2016–2020) volumes were obtained from CMS and Health Resources & Services Administration databases, respectively. Results: Overall, 23 complete responses were recorded (response rate, 35.4%). Collectively, these entities account for ~11.0% of hematologic malignancy hospitalizations and 13.3% bone marrow transplantations nationwide. Of 23 facilities, 19 had institutional guidelines for neutropenic fever management and 18 had institutional guidelines for prophylaxis, with similar definitions for neutropenic fever. Firstline treatment universally utilized antipseudomonal broad-spectrum IV antibiotics (20 of 23 use cephalosporin, 3 of 23 use penicillin agent, and no respondents use carbapenem). Fluoroquinolone prophylaxis was common for leukemia induction patients (18 of 23) but was mixed for bone-marrow transplantation (10 of 23). We observed significant heterogeneity in treatment decisions. For stable neutropenic fever patients with no clinical source of infection identified, 13 of 23 respondents continued IV antibiotics until ANC (absolute neutrophil count) recovery. The remainder had criteria for de-escalation back to prophylaxis prior to this (eg, a fever-free period). Respondents were more willing to de-escalate prior to ANC recovery in patients with identified clinical sources (14 of 23 de-escalations in patients with pneumonia) or microbiological sources (15 of 23 de-escalations in patients with bacteremia) after dedicated treatment courses. In free-text responses, several respondents described opportunities for more systemic de-escalation for antimicrobial stewardship in these scenarios. Conclusions: Our results illustrate the real-world management of neutropenic fever in US hospitals, including initiation of therapy, prophylaxis, and treatment duration. We found significant heterogeneity in de-escalation of empiric antibiotics relative to ANC recovery, highlighting a need for more robust evidence for and adoption of this practice. Disclosures: None

The intent of this document is to highlight practical recommendations in a concise format designed to assist physicians, nurses, and infection preventionists at acute-care hospitals in implementing and prioritizing their catheter-associated urinary tract infection (CAUTI) prevention efforts. This document updates the Strategies to Prevent Catheter-Associated Urinary Tract Infections in Acute-Care Hospitals published in 2014. It is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America (IDSA), the Association for Professionals in Infection Control and Epidemiology (APIC), the American Hospital Association (AHA), and The Joint Commission.

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Abstract Background MDROs frequently contaminate hospital environments. We performed a multicenter cluster-randomized, crossover trial of two methods for intensive monitoring of terminal cleaning effectiveness at reducing infection and colonization with MDROs within ICUs. Methods Six medical and surgical ICUs at three medical centers received both intensive monitoring interventions sequentially, in a randomized order. The intervention included surveying a minimum of 10 surfaces each in 5 rooms weekly, after terminal cleaning, with adenosine triphosphate (ATP) monitoring or an ultraviolet fluorescent marker (UV/F). Results were delivered to environmental services (EVS) staff in real-time, with failing surfaces recleaned. The primary study outcome was the monthly rate of infection or colonization with MDROs, including methicillin-resistant Staphylococcus aureus, Clostridioides difficile, vancomycin-resistant Enterococcus, and multidrug-resistant gram-negative bacilli (MDR-GNB), assessed during a 12-month baseline comparison period and sequential 6-month intervention periods, separated by a 2-month washout. Outcomes during each intervention period were compared to the combined baseline period plus the alternative intervention period using mixed-effects Poisson regression, with study hospital as a random effect. Results The primary outcome rate varied by hospital and ICU (Figure 1). The ATP method was associated with a relative reduction in the incidence rate of infection or colonization with MDROs (incidence rate ratio (IRR) 0.887, 95% confidence-interval (CI) 0.811–0.969, P=0.008) (Table 1), infection with MDROs (IRR 0.924, 95% CI 0.855–0.998, P=0.04), and infection or colonization limited to multidrug-resistant MDR-GNB (IRR 0.856, 95% CI 0.825–0.887, P< 0.001). The UV/F intervention was not associated with a statistically significant impact on these outcomes. Room turn-around time was increased by a median of one minute with the ATP intervention and 4.5 minutes with the UV/F intervention compared to baseline. Conclusion Intensive monitoring of ICU terminal room cleaning with an ATP modality is associated with a relative reduction of infection and colonization with MDROs with a negligible impact on TAT. Disclosures Hilary Babcock, MD, MPH, FIDSA, FSHEA (nothing to disclose), David K. Warren, MD, MPH, Homburg & Partner (consultant), Ebbing Lautenbach, MD, MPH, MSCE (nothing to disclose), Jennifer Han, MD, MSCE, GlaxoSmithKline (employee, shareholder).

Background. Though detection of transmission clusters of methicillin-resistant Staphylococcus aureus (MRSA) infections is a priority for infection control personnel in hospitals, the transmission dynamics of MRSA among hospitalized patients with bloodstream infections (BSIs) has not been thoroughly studied. Whole genome sequencing (WGS) of MRSA isolates for surveillance is valuable for detecting outbreaks in hospitals, but the bioinformatic approaches used are diverse and difficult to compare. Methods. We combined short-read WGS with genotypic, phenotypic, and epidemiological characteristics of 106 MRSA BSI isolates collected for routine microbiological diagnosis from inpatients in 2 hospitals over 12 months. Clinical data and hospitalization history were abstracted from electronic medical records. We compared 3 genome sequence alignment strategies to assess similarity in cluster ascertainment. We conducted logistic regression to measure the probability of predicting prior hospital overlap between clustered patient isolates by the genetic distance of their isolates. Results. While the 3 alignment approaches detected similar results, they showed some variation. A gene family-based alignment pipeline was most consistent across MRSA clonal complexes. We identified 9 unique clusters of closely related BSI isolates. Most BSIs were healthcare associated and community onset. Our logistic model showed that with 13 single-nucleotide polymorphisms, the likelihood that any 2 patients in a cluster had overlapped in a hospital was 50%. Conclusions. Multiple clusters of closely related MRSA isolates can be identified using WGS among strains cultured from BSI in 2 hospitals. Genomic clustering of these infections suggests that transmission resulted from a mix of community spread and healthcare exposures long before BSI diagnosis.

Abstract Background: Clostridioides difficile infection (CDI) is a common and sometimes life-threatening illness. Patient-, care-, and room hygiene-specific factors are known to impact CDI genesis, but care provider training and room topography have not been explored. We sought to determine if care in specific intensive care unit (ICU) rooms asymmetrically harbored CDI cases. Patients and Methods: Surgical intensive care unit (SICU) patients developing CDI (July 2009 to June 2018) were identified and separated by service (green/gold). Each service cared for their respective 12 rooms, otherwise differing only in resident team composition (July 2009 to August 2017: green, anesthesia; gold, surgery; August 2017 to June 2018: mixed for both). Fixed/mobile room features and provider traffic in three room zones (far/middle/near in relation to the toilet) were compared between high-/low-incidence rooms using observation via telecritical care video cameras. Results: Seventy-four new CDI cases occurred in 7,834 consecutive SICU admissions. In period one, green CDI cases were almost double gold cases (39 vs. 21; p = 0.02) but were similar in period two in which trainee service allocation intermixed. High-incidence rooms had closer toilet-to-intravenous pole proximity than low-incidence rooms (7.7 + 1.8 feet vs. 3.9 + 1.5 feet; p = 0.02). High-incidence rooms consistently housed mobile objects (patient bed, table-on-wheels) farther away from the toilet. Although physician time spent in each zone was similar, nurses spending more than 15 minutes in-room more frequently stayed in the far/middle zones in high-incidence rooms. Conclusions: Distinct SICU room features relative to toilet location and bedside clinician behaviors interact to alter patient CDI acquisition risk. This suggests that CDI risk occurs as a structural aspect of ICU care, offering the potential to reduce patient risk through deliberate room redesign.

We evaluated the effect of terminal cleaning on SARS-CoV-2 RNA contamination of COVID-19 isolation rooms in an acute care hospital. SARS-CoV-2 RNA was detected on 32.1% of room surfaces after cleaning; the odds of contamination increased with month. The prevalence of elevated high-touch surface contamination was lower in terminally cleaned rooms than patient-occupied rooms.

Abstract Background We previously conducted a study in primary care practices assessing the impact of an educational session paired with peer comparison feedback on antibiotic prescribing, demonstrating a reduction in overall prescribing for respiratory tract diseases (RTDs). However, the lasting effects of this intervention on antibiotic prescribing patterns without ongoing feedback are unknown. Methods To study the long-term effects of this feedback on antibiotic prescribing, we analyzed prescribing trends for 14 months after the initial study. We collected encounter-level data, including patient and provider information, ICD-10 codes, and antibiotics prescribed. RTDs were grouped into tiers based on prescribing appropriateness: tier 1 (almost always indicated), tier 2 (may be indicated), and tier 3 (rarely indicated). A χ2 test was used to compare proportions of antibiotic prescribing between three time periods: pre-intervention, intervention, and post-intervention (following cessation of provider feedback). A mixed-effects multivariable logistic regression analysis was performed to assess the association between the period and antibiotic prescribing. Results We analyzed 260,900 encounters (127,324 pre-intervention, 58,431 during the intervention, and 75,145 post-intervention) from 28 practices, with patient, provider and practice characteristics in Table 1. Rates of antibiotic prescribing for RTD visits were higher in the post-intervention period than the intervention period (28.9% vs 23.0%, p< 0.001), but remained lower than the 35.2% pre-intervention rate (Figure 1, p< 0.001). In multivariable analyses, the odds of receiving a prescription was higher in the post-intervention compared to the intervention period for tier 2 (OR 1.19, 95% CI 1.10–1.30, p< 0.05) and tier 3 (OR 1.20, 95% CI 1.12–1.30) indications, but was still lower when compared to the pre-intervention period for each tier (OR 0.66, 95% CI 0.59–0.73 for tier 2; OR 0.68, 95% CI 0.61–0.75 for tier 3) (Table 2). Table 1 includes patient, provider, and encounter level demographics. Table 2 includes the results of the multivariable analysis. Figure 1 is a graph of proportion of encounters with an antibiotic prescribed over time. The time period associated with the intervention is highlighted and graphs are separated by tier of appropriateness of antibiotic prescribing associated with the encounter. Conclusion The effects of this targeted educational and feedback program last beyond the intervention period, but without ongoing provider feedback there is a trend toward increased prescribing. Future studies are needed to determine optimal strategies to maintain the efficacy of this intervention. Disclosures Kathleen Degnan, MD, Gilead: Grant/Research Support Michael Z. David, MD PhD, Contrafect: Grant/Research Support|GSK: Advisor/Consultant|Johnson and Johnson: Advisor/Consultant.

We prospectively surveyed SARS-CoV-2 RNA contamination in staff common areas within an acute-care hospital. An increasing prevalence of surface contamination was detected over time. Adjusting for patient census or community incidence of coronavirus disease 2019 (COVID-19), the proportion of contaminated surfaces did not predict healthcare worker COVID-19 infection on study units.

INTRODUCTION:Approximately 38% of haemodialysis patients carry Staphylococcus aureus in their noses, and carriers have a nearly four-fold increased risk of S. aureus access-related bloodstream infections (BSIs) compared with non-carriers. Our objective is to determine the clinical efficacy and effectiveness of a novel intervention using nasal povidone-iodine (PVI) to prevent BSIs among patients in haemodialysis units. We will survey patients and conduct qualitative interviews with healthcare workers to identify barriers and facilitators to implementing the intervention.METHODS AND ANALYSIS:We will perform an open-label, stepped-wedge cluster randomised trial to assess the effectiveness of nasal PVI compared with standard care. Sixteen outpatient haemodialysis units will participate in the study. The 3-year trial period will be divided into a 4-month baseline period and eight additional 4-month time blocks. The primary outcome of the study will be S. aureus BSI, defined as a S. aureus positive blood culture collected in the outpatient setting or within one calendar day after a hospital admission. The study team will evaluate characteristics of individual patients and the clusters by exposure status (control or intervention) to assess the balance between groups, and calculate descriptive statistics such as average responses separately for control and intervention survey questions.ETHICS AND DISSEMINATION:This study has received IRB approval from all study sites. A Data Safety and Monitoring Board will monitor this multicentre clinical trial. We will present our results at international meetings. The study team will publish findings in peer-reviewed journals and make each accepted peer-reviewed manuscript publicly available.TRIAL REGISTRATION NUMBER:NCT04210505.