Michael Haden’s research while affiliated with University of Colorado and other places

A healthcare-associated group A Streptococcus outbreak involving six patients, four healthcare workers, and one household contact occurred in the labor and delivery unit of an academic medical center. Isolates were highly related by whole genome sequencing. Infection prevention measures, healthcare worker screening, and chemoprophylaxis of those colonized halted further transmission.

Background Drug use associated Infective Endocarditis (DU-IE) has been noted to be increasing over the last decade(Clinical Infectious Diseases® 2020;71(7):1664–7). In this study we sought to assess the unique aspects of DU-IE compared to IE not associated with drug use. We undertook an in-depth descriptive study of patients who presented with IE over the course of 5 years at one large academic medical center. Table 1 Methods This was a retrospective chart review of patients with IE admitted to the Ohio State Wexner Medical center between 2013 and 2017. Prisoners, patients < 18 or > 89 years of age, and pregnant patients were excluded from the study. The first admission during the study period in those with definitive or probable endocarditis by Duke criteria, were included. Persons who inject drugs (PWID) with IE were compared with those with IE without documentation of drug use. DU was determined by both ICD coding and manual chart review. Given the discrepancy between the two, chart review was used for the analysis. Differences in proportion were compared using Fisher’s exact, and continuous variables using student’s t-test. Results Overall, 713 patients met inclusion criteria. Approximately half (45.6%) of the patients had DU-IE, this proportion generally increased over the 5 years, with 59.8% of the cases being DU-IE in 2017. DU-IE patients were more likely to be younger, female, and have a lower Charlson comorbidity score. DU-IE patients were significantly more likely to have MRSA, Gram Negatives and Candida species, whereas non DU-IE was more likely to have Coagulase negative staph species. DU-IE patients were less likely to have a transesophageal echocardiogram, and unsurprisingly were more likely to have tricuspid valve involvement, and pulmonary septic emboli. Conclusion The patient population with DU-IE compared to non-DU IE differ from one another, and further studies are required to better understand long-term clinical outcomes in the treatment between each group. Disclosures All Authors: No reported disclosures

Background: Carbapenem-resistant Enterobacterales (CRE) are an increasing threat to patient safety but only a small percentage of CRE identified are NDMs. Since 2018, clinical CRE isolates have been submitted to the Ohio Department of Health for sequencing and NDM cases have notably increased since that time. Candida auris is an emerging pathogen with similar risk factors for colonization as CRE. Methods: A point-prevalence study was initiated after an index patient was identified with NDM CRE infection or colonization during their inpatient admission. Two patient populations were included in the study: current patients on the same unit as the index patient and currently hospitalized patients who overlapped on any unit with the index patient for at least 72 hours. Patients had perirectal screening for CRE (via PCR) and axilla or groin screening for C. auris (via Xpert Carba-R Assay). Patients were excluded if they had been discharged, expired, or refused testing. Results: We completed 5 point-prevalence studies from March 21, 2021, to October 15, 2021. The index patients were admitted at different times and across 2 campuses including medical, cardiac, and surgical ICUs as well as medical-surgical and inpatient rehabilitation units. Moreover, 3 species of NDM were identified from urine and 2 species were identified from bronchoalveolar lavage: Enterobacter hormaechei , Citrobacter freundii , and Enterobacter cloacae complex. C. freundii and E. cloacae complex both had dual mechanisms of NDM and KPC. Although some of the index patients overlapped temporally within the health system, none overlapped in the same unit or building. None of the patients had recently received health care outside the United States, although 1 patient had emigrated from Togo >5 years prior and 4 had had prior local healthcare exposure within 12 months of admission. Also, 147 patients were identified for screening; 105 consented, 32 declined, and 10 were excluded due to being discharged, deceased, or unable to consent. Inpatient point-prevalence screening tests for all patients tested (n = 105) were negative for NDM CRE and C. auris . Conclusions: Despite an increase of inpatients with NDM CRE, evidence of patient-to-patient transmission was not identified, likely resulting from adherence to standard precautions. The diversity of species and lack of international travel suggests that these patients likely acquired NDM CRE from a local reservoir in the community or healthcare settings. Given the continued increase in NDM CRE without traditional risk factors, it is critical for hospitals and public health agencies to collaborate to identify these organisms and that they develop surveillance programs to clarify risk factors for colonization. Funding: None Disclosures: None

Background: An increase in candidemia has been observed throughout the world since the start of the COVID-19 pandemic. Patients with COVID-19 may have different risk factors, clinical presentations, and outcomes compared to patients without COVID-19. Methods: We conducted a retrospective chart review of all inpatients with candidemia at a large, academic medical center from April 30, 2019, to February 19, 2021. The first case of COVID-19 was detected at our institution March 2020 and patients were sorted into pre– versus post–COVID-19 pandemic groups. Data regarding clinical characteristics, risk factors, and outcomes were collected. The rate of candidemia per 10,000 patient days was calculated from January 2013 through February 2021. Results: In total, 202 patients were identified with candidemia: 92 cases were identified before the pandemic and 110 cases were identified after the pandemic began. Moreover, 33 (16.3%) patients were diagnosed with COVID-19 during the admission and 169 (83.7%) did not have COVID-19. Patients with COVID-19 were significantly more likely to be older (median, 64.5 vs 54.8 years; P = .0006) and to have a higher body mass index (32.8 vs 29.1; P = .03) than patients without COVID-19. Patients with COVID-19 were less likely have some of the traditional risk factors (eg, abdominal surgery, total parenteral nutrition, history of injecting drugs) for candidemia compared to patients without COVID-19. Patients with COVID-19 were significantly more likely to require ICU care (97.0% vs 67.5%; P < .001) and to require mechanical ventilation (90.9% vs 53.9%; P < .001), and they had higher mortality at 30 days (66.7% vs 31.4%; P < .001). A multivariate logistic regression model showed that COVID-19 (OR, 2.53; 95% CI, 1.09–5.90) and higher age (OR 1.45, 95% CI, 1.11–1.91) were significant predictors of 30 day mortality. Using a Poisson regression model, the incidence rate ratio for candidemia per month after the start of the COVID-19 pandemic was 2.09 (95% CI, 1.85–2.36; P < .0001) compared to the years prior. Conclusions: Rates of candidemia significantly increased after the start of the COVID-19 pandemic. Patients with candidemia in the post–COVID-19 era tend to have nontraditional risk factors, to be more critically ill, and to have increased mortality compared to patients in the pre–COVID-19 era. COVID-19 and higher age were independent predictors of mortality. More studies are needed to further define risk factors for candidemia in patients with COVID-19. Funding: None Disclosures: None

Background: Transmission-based precautions against varicella-zoster virus (VZV) in healthcare settings are determined by the extent of rash (localized vs disseminated) and the immune status of the host. At our facility, immunocompetent patients with localized disease are placed in standard precautions whereas patients with disseminated disease and/or immunocompromised status are placed in airborne and contact isolation. The use of molecular diagnostics has increased recently, and patients can have a PCR positive for VZV in cerebral spinal fluid (CSF) without evidence of pneumonia or disseminated rash. These patients are classified as disseminated disease, but it is unlikely that they are spreading VZV via respiratory aerosols in the absence of other symptoms. Infection prevention guidance is limited in this situation, and these patients may be in unneeded isolation, with the potential for adverse patient effects and overutilizing PPE resources. We have described the clinical characteristics of patients with a PCR positive for VZV in CSF, and we evaluated the risk for transmitting VZV via airborne aerosols. Methods: A retrospective, single-center chart review was performed on all patients admitted with a PCR positive for VZV in CSF between July 2017 and November 2021. Chart review was performed to gather data regarding clinical presentation, patient characteristics, and risk factors. Results: In total, 38 patients were identified who had a PCR positive for VZV in CSF; 22 (57.9%) were male and 16 (42.1%) were female. The median age was 47 years (IQR, 38–69). Also, 15 patients (39.5%) were immunocompromised. Moreover, 26 patients (68.4%) had a rash; 19 (50%) had localized rash; and 7 (18.4%) had disseminated rash involving ≥3 dermatomes. However, 12 patients (31.5%) had neither rash nor pneumonia. Furthermore, 5 patients (13.1%) had PCR positive for VZV in CSF and developed rash within the following 2–7 days (2 with disseminated rash). In addition, 6 patients (15.8%) had pneumonia. Of the 6 patients with pneumonia, 4 (10.5%) were immunocompromised and 3 (7.9%) were above 65-year-old. 32 patients (84.2%) were kept in airborne and contact precautions. 1 (2.6%) patient had a documented record of at least 1 dose of Shingrix vaccine. Conclusions: Most patients with a PCR test positive for VZV in the CSF were not immunocompromised and did not have evidence of disseminated rash or pneumonia. The risk of airborne transmission of VZV via small aerosols appears to be low in patients with a PCR test positive for VZV in the CSF without evidence of disseminated rash or pneumonia. Airborne isolation may not be required for many of these patients. Funding: None Disclosures: None

Background: The Ohio State University Wexner Medical Center identified a cluster of coronavirus disease 2019 (COVID-19) cases on an inpatient geriatric stroke care unit involving both patients and staff. The period of suspected severe acute respiratory coronavirus virus 2 (SARS-CoV-2) transmission and exposure on the unit was December 20, 2020, to January 1, 2021, with some patients and staff developing symptoms and testing positive within the 14 days thereafter. Methods: An epidemiologic investigation was conducted via chart review, staff interviews, and contact tracing to identify potential patient and staff linkages. All staff who worked on the unit were offered testing regardless of the presence of symptoms as well as all patients admitted during the outbreak period. Results: In total, 6 patients likely acquired COVID-19 in the hospital (HCA). An additional 6 patients admitted to the unit during the outbreak period subsequently tested positive but had other possible exposures outside the hospital (Fig. 1). One patient failed to undergo COVID-19 testing on admission but tested positive early in the cluster and is suspected to have contributed to patient to employee transmission. Moreover, 32 employees who worked on the unit in some capacity during this period tested positive, many of whom became symptomatic during their shifts. In addition, 18 employees elected for asymptomatic testing with 3 testing positive; these were included in the total. Some staff also identified potential community exposures. Additionally, staff reported an employee who was working while symptomatic with inconsistent mask use (index employee) early in the outbreak period. The index employee likely contributed to employee transmission but had no direct patient contact. Our epidemiologic investigation ultimately identified 12 employees felt to be linked to transmission based on significant, direct patient care provided to the patients within the outbreak period (Fig. 1). In addition, 3 employees had an exposure outside the hospital indicating likely community transmission. Conclusions: Transmission was felt to be multidirectional and included employee-to-employee, employee-to-patient, and patient-to-employee transmission in the setting of widespread community transmission. Interventions to stop transmission included widespread staff testing, staff auditing regarding temperature and symptom monitoring, and re-education on infection prevention practices. Particular focus was placed on appropriate PPE use including masking and eye protection, hand hygiene, and cleaning and disinfection practices throughout the unit. SARS-CoV-2 admission testing and limited visitation remain important strategies to minimize transmission in the hospital. Funding: No Disclosures: None

Background GAS can cause severe postpartum infections and may be transmitted from colonized healthcare workers (HCWs). Methods Two cases of GAS bacteremia following vaginal delivery were identified on the L&D unit June-July 2019 (Cluster 1), prompting a carrier-disseminator investigation. Two additional cases were identified September-October 2019 (Cluster 2), followed by an additional 3 cases late October 2019, all of whom delivered on the same night (Cluster 3). All patients and HCWs were evaluated for GAS risk factors and screened for colonization via throat, vaginal and perirectal cultures. During Clusters 1 and 2, only HCWs with patient contact were screened, but this was expanded to the entire unit in October after Cluster 3 was identified. All GAS colonized HCWs were provided chemoprophylaxis and rescreened 7-10 days after treatment to ensure eradication. GAS isolates from patients and HCWs were analyzed by whole genome sequencing (WGS). Results During Cluster 1 a total of 43 HCWs were screened and HCWA was colonized at all three sites. In Cluster 2, nine HCWs were screened; HCWA was negative at that time but HCWB was colonized in the throat only. Patient 3 was confirmed to be community acquired by pulsed-field gel electrophoresis, patient 4 was closely related by WGS. A new policy was instituted that required all HCWs present at delivery to wear gowns, gloves, masks, eye protection, and to undergo infection prevention education and practice review. Following Cluster 3, all HCWs on the unit were screened (681 total). HCWA was again positive at all 3 sites and two additional HCWs were found to be colonized with the outbreak strain on throat swab only. Isolates from patients 1, 2, 4, 5, 6, 7 and the 4 HCWs were identified as subtype emm 28 and all closely related by WGS (figure 1). A household contact of HCWA was colonized with the outbreak strain as well. Figure 1 Conclusion A carrier-disseminator investigation identified clusters of nosocomial postpartum GAS infections involving 6 patients, 4 HCWs and a HCW household contact that were highly related based on WGS. The outbreak strain of GAS was likely spread amongst HCWs via ping pong transmission on the unit. Transmission to patients was halted with implementation of strict infection prevention measures and mass screening and chemoprophylaxis of all colonized HCWs. Disclosures All Authors: No reported disclosures

COVID‐19, the clinical syndrome caused by the novel coronavirus, SARS‐CoV‐2, continues to rapidly spread, leading to significant stressors on global healthcare infrastructure. The manifestations of COVID‐19 in solid organ transplant recipients are only beginning to be understood with cases reported to date in transplant recipients on chronic immunosuppression. Herein we report the first case of COVID‐19 in a lung transplant recipient in the immediate post‐transplant period, and we describe the epidemiologic challenges in identifying the source of infection in this unique situation.

Background Opioid dependence and overdose are at epidemic levels in the United States. Ohio has the third highest rate of opioid-related overdose deaths. Infectious complications of intravenous drug use (IDU) include increased acquisition of hepatitis C, HIV and infective endocarditis. In this study, we aimed to characterize cases of infective endocarditis admitted to our healthcare system over a five-year period. We additionally sought to determine the validity of using ICD codes to identify infective endocarditis cases and IDU. Methods Patients with ICD-9 or 10 discharge diagnosis codes for infective endocarditis were identified from our institution’s electronic health record. ICD codes pertaining to substance abuse were used to classify patients according to IDU status. Readmissions during the same episode of infective endocarditis were excluded. We compared chart review to ICD code for the identification of infective endocarditis and IDU in a random sample of 296 of 1590 cases. Results Of 296 charts reviewed, 133 (44.9%) were excluded because they did not meet criteria for definite infective endocarditis by modified Duke’s criteria or because the episode was a readmission. A total of 163 (55.1%) cases met inclusion criteria, all of whom were seen in consultation by the inpatient Infectious Disease service. Of these, 52 (31.9%) had ICD 9 or 10 codes linked to substance abuse. Following manual chart review, we established that in fact 86 of these 163 cases (52.8%) had evidence of substance abuse. Conclusion Misclassification due to use of ICD codes is a well-established challenge to epidemiological research. However, the extent of misclassification in this analysis was greater than expected. If prior research on IDU and infective endocarditis has relied on medical record data alone without verification through manual chart review, the observed epidemiological trends may not be accurate. Disclosures All authors: No reported disclosures.