cHerbaspirillum spp. are Gram-negative bacteria that inhabit soil and water. Infections caused by these organisms have been reported in immunocompromised hosts. We describe severe community-acquired pneumonia and bacteremia caused by Herbaspirillum aquaticum or H. huttiense in an immunocompetent adult male. CASE REPORT In early September 2014, a 46-year-old white male presented to a referring facility with fever, fatigue, and shortness of breath. His illness began 5 days prior to admission to our facility after he was drenched in rain during a fishing trip. He had a fever of 40°C, despite use of antipyretics, with chills, night sweats, anorexia, myalgia, and headache. Three days prior to admission, he had a transient period of dry cough for half a day that resolved spontaneously. The next day he developed sharp right-sided pleuritic chest pain, worsening dyspnea, and severe fatigue. When he presented to the referring facility, clinical findings were remarkable for a respiratory rate (RR) of 28/min with an oxygen saturation (SpO 2 ) level of 77% on room air which improved to 91% on 4 liters/min of oxygen via nasal cannula. His white blood cell (WBC) count was 7.7 ϫ 10 Ϫ3 /l with 55% bands, and bilateral alveolar infiltrates were noted on a chest X-ray. Analysis of his arterial blood gas revealed a pH level of 7.46, partial pressure of CO 2 (pCO 2 ) of 34 mm Hg, pO 2 of 53 mm Hg, SpO 2 of 89% on 4 liters/min of oxygen via nasal cannula, and HCO 3 of 24 meq/liter. Blood cultures were drawn, and he was treated with intravenous vancomycin, ceftriaxone, and azithromycin. His condition worsened and he was transferred to our university teaching hospital.The patient's past medical history was unremarkable, except for childhood asthma, atypical pneumonia as a teenager, and tonsillectomy. He was on no home medications. He lived on a farm in rural Missouri with his wife and had close contact with cattle and turkeys (he had birthed calves 6 months earlier and handled 15,000 baby turkeys 3 weeks prior to the onset of illness). A few weeks prior to admission, the patient returned from work with about 20 loosely attached ticks. He also cleaned a grain bin in his barn (contained mold and possible rat excreta) a week prior to presentation. He smoked cigarettes for 30 years and also consumed alcohol regularly. He denied sick contacts, animal bites or scratches, and recent travel.The results of a physical examination conducted on presentation to our facility were remarkable for temperature (38°C), heart rate (HR) (98 beats/min), blood pressure (BP) (141/88 mm Hg), and RR (30/min with use of accessory muscles). There was bilateral lower chest wall tenderness, coarse inspiratory crepitations were heard in left axilla and left lower chest, and diminished breath sounds were noted in the right axilla and right lower chest.The rest of the exam was unremarkable. Laboratory measurements on admission revealed a WBC count of 9.0 ϫ 10 Ϫ3 /l, granulocytes at 89.6% and no bands on automated differential determinations, hemoglobin at 13.4 g/dl, ...

Background The influenza vaccine is one of the best ways to prevent influenza infection, but little is known about influenza vaccine failure. Methods This study evaluated patients admitted for acute respiratory illness during 2015–2019 influenza seasons to compare vaccinated influenza-negative to vaccinated influenza-positive patients. Statistical analyses were performed with STATA and R using Pearson χ 2, Kruskal-Wallis, Wilcoxon rank-sum tests, and multivariate logistic regression. Results Of 1236 enrolled patients vaccinated for influenza, 235 (19%) tested positive for influenza. Demographics, vaccines, and comorbidities were similar between groups except for morbid obesity (13% influenza negative vs 8%, P = .04), and immunosuppression (63% influenza positive vs 54%, P = .01). Logistic regression analysis demonstrated older patients (odds ratio [OR], 1.47; 95% confidence interval [CI], 1.03–2.10) and immunosuppressed patients (OR, 1.56; 95% CI, 1.15–2.12) were at increased risk for influenza despite immunization. When evaluated by influenza subtype, immunosuppression increased the risk for influenza A/H3N2 (OR, 1.86; 95% CI, 1.25–2.75). Conclusions Our study demonstrated increased risk of influenza vaccine failure in older patients and immunosuppressed patients. These groups are also at increased risk for influenza complications. To improve protection of patients against influenza illnesses, more effective vaccines and strategies are needed.

Background Successful antimicrobial stewardship (AS) interventions have been described previously. Currently, a uniform operational approach to planning and implementing successful AS interventions does not exist. From 2015 to 2019, concomitant vancomycin and piperacillin-tazobactam use (CVPTU) for >48 hours at Vanderbilt University Medical Center (VUMC) significantly decreased through AS efforts. We analyzed the interventions that led to this change and created a model to inform future intervention planning and development. Methods VUMC adult admissions from January 2015 to August 2019 were evaluated for CVPTU. Percentage of admissions receiving CVPTU >48 hours, the primary outcome, was evaluated using statistical process control charts. We created the Three Antimicrobial Stewardship E’s (TASE) framework and Association between Stewardship Interventions and intended Results (ASIR) analysis to assess potential intensity and impact of interventions associated with successful change during this time period and to identify guiding principles for development of future initiatives. Results The mean percentage of admissions receiving CVPTU per month declined from 4.2% to 0.7%. Over 8 time periods, we identified 4 high, 3 moderate and 1 low intervention intensity periods. Continuous provider-level AS education was present throughout. Creation and dissemination of division and department algorithms and reinforcement via computerized provider order entry sets preceded the largest reduction in CVPTU and sustained prescribing practice changes. Conclusions The TASE framework and ASIR analysis successfully identified pivotal interventions and strategies needed to effect and sustain change at VUMC. Further research is needed to validate its effectiveness as a stewardship intervention planning tool at our institution and others.

Background Correct personal protective equipment (PPE) use is key to prevent infection. Observations on a single unit at the Veterans Affairs (VA) Tennessee Valley Healthcare System (TVHS) prior to COVID-19 (October 2019-February 2020) showed low rates of correct PPE use among healthcare workers (HCWs) (Figure 1). In response to the COVID-19 epidemic, the VA implemented new PPE protocols. Based on our initial observations, we were concerned that incorrect use of PPE may increase the risk of COVID-19 exposure among HCWs. Resident physicians, who work at many sites, may be at high-risk for incorrect PPE use due to rapid turnover and limited site-specific PPE training. We aimed to assess and improve COVID-19 PPE use among internal medicine residents rotating at the VA TVHS. Figure 1: Pre-COVID-19 Observations of Adherence to Contact Precaution Protocols at the Veterans Affairs Tennessee Valley Healthcare System Methods We used the plan, do, study, act (PDSA) model. Prior to starting VA rotations, residents were emailed PPE education to review. We implemented a 1-hour video conference PPE protocol review at rotation start followed by in-person PPE use evaluations for residents performed by infectious diseases fellows on day 2 and day 5-6 post-review to provide just-in-time educational intervention. Errors at each PPE don/doff step were tracked. Correct PPE use data from both observations were compared using McNemar’s test. Baseline and post-implementation resident surveys assessed PPE use knowledge and comfort. Results Pre-implementation survey response rate was 72% (21/29); 19/21(91%) reported knowing which PPE to use and 16/21(76%) reported knowing how to safely don/doff PPE. Twenty of 29 (69%) residents completed both observations. Errors decreased by 55% (p=0.0045) from 17/20 (85%) to 6/20 (30%) between initial and follow up observations. Errors in hand hygiene, inclusion of all donning/doffing steps, and PPE reuse decreased, but PPE don/doff order errors increased (Figure 2). Post-project survey response rate was 16/29 (55%). All 16 reported knowing which PPE to use and how to safely don/doff PPE, and 11/16 (69%) residents felt both online and in-person interventions were helpful. Figure 2: COVID-19 PPE Errors and Correction Types by Observation Conclusion Correct COVID-19 PPE use is essential to protect HCWs and patients. Just-in-time education intervention for PPE training may yield higher correct use compared to pre-recorded or online training. Disclosures All Authors: No reported disclosures

Background Concomitant vancomycin and piperacillin-tazobactam use (CVPTU) for >2 days is associated with increased nephrotoxicity. At Vanderbilt University Medical Center, a sustained decline in CVPTU was achieved. A retrospective review of CVPTU and antimicrobial stewardship (AS) interventions was performed to develop a model for future AS quality improvement (QI) initiatives. Methods Data for adults receiving CVPTU January 2015 - August 2019 were extracted. No patients were excluded. Change in monthly incidence of CVPTU >2 days in relation to AS interventions was the primary outcome. CVPTU was analyzed with statistical process control (SPC) charts (QI Macros 2019). AS interventions were amassed from AS emails, meeting minutes, presentations and patient-specific interventions. We created a new intervention evaluation tool using the Hierarchy of Effectiveness (1-Education, 2-Policy, 3-Reminders, 4-Simplification, 5-Automation, 6-Forced Function) and a self-designed scale of impact (1-divisional subgroup, 2-division, 3-department, 4-center-wide). Scores were summed for each 6-month period and rated as low, moderate or high intervention strength. Periods were mapped against their corresponding CVPTU rate (Figure 1). Results CVPTU Data: During periods 1–5 (January 2015 - February 2018), an average 4% of admitted patients received >2 days CVPTU, decreasing to < 1% from period 5 (March 2018) onward (Figure 1). From period 1–5, an average 52.8% of patients with CVPTU received >2 days and dropped to 41.3% from period 5 onward (Figure 2). Intervention Data: There was 1 low, 3 moderate and 4 high intensity periods. Intensity decreased as initiatives transitioned from behavior change to sustained behavior (Figure 1). The main interventions were education and patient-specific feedback. Division-specific antibiotic algorithms and computerized order sets re-enforced behavior. Infectious diseases consults and team pharmacists embedded the concept in daily practice. Figure 1: Proportion of All Admissions with Concomitant Vancomycin and Piperacillin-Tazobactam Use (CVPTU) for >2 Days Mapped Against Simultaneous Quality Improvement Interventions. Figure 2: Proportion of Patients with Concomitant Vancomycin and Piperacillin-Tazobactam Use (CVPTU) for >2 Days. Conclusion Persistent, repetitive center-wide intervention is key to driving and sustaining change. More analysis of specific intervention types and impact of external factors would enhance understanding and future use of this AS change implementation model. Disclosures All Authors: No reported disclosures