Objectives Early diagnosis of tuberculosis (TB) and multidrug-resistant TB (MDR-TB) is a priority for Viet Nam’s National TB Control Programme. In many laboratories, quality systems are weak; few have attained accreditation. We implemented a structured training and mentoring program for TB laboratories and measured impact on quality. Methods Six TB culture laboratories implemented the Strengthening TB Laboratory Management Towards Accreditation (TB SLMTA) program, consisting of three training workshops and on-site mentoring between workshops to support improvement projects. Periodic audits, using standardized checklists, monitored laboratories’ progress toward accreditation readiness. Results At baseline, all six laboratories achieved a zero-star level. At exit, five laboratories attained three stars and another one star. Overall checklist scores increased by 44.2% on average, from 29.8% to 74.0%; improvements occurred across all quality system essentials. Conclusions The program led to improved quality systems. Sites should be monitored to ensure sustainability of improvements and country capacity expanded for national scaleup.

Background: Carbapenem-resistant gram-negative bacteria are an urgent threat to healthcare safety around the world. In Vietnam, Although surveillance and control of multidrug-resistant organisms is a national priority, information on the burden of these resistant pathogens is still scarce. At University Medical Center Ho Chi Minh City, Vietnam, we aimed to better understand carbapenem-resistance through 2 phases: (1) assess proportion of carbapenem-resistant gram-negative organisms that are carbapanemase-producing (CP-CRO) and (2) assess transmission burden of carbapenemase-producing carbapenem-resistant Enterobacterieacea (CP-CRE) in the general intensive care unit (ICU). Methods: In the first phase, all gram-negative clinical isolates collected between November 2018 and April 2019 were tested for carbapenem-resistance using the disc-diffusion method and were defined as meropenem resistant using the Clinical and Laboratory Standards Institute 2018 break point (M100-Performance Standards for Antimicrobial Susceptibility Testing, 28th Edition). Carbapenem-resistant bacteria were tested for phenotypic carbapenemase-production using the Becton Dickinson Phoenix CPO Detect assay. In the second phase, we instituted CP-CRE rectal screening using CHROMagar mSuperCARBA media for all ICU patients from July through September 2019. Patients were screened on admission, and negative patients were rescreened every 2 days until discharge, death, or CRE-positive screening or culture. Admission prevalence and incidence of CP-CRE transmission was calculated among CP-CRE infected or colonized patients. Results: From November 2018 through April 2019, 599 gram-negative clinical isolates from 543 patient samples were identified. Of these, 108 were carbapenem-resistant; 107 (99%) of carbapenem-resistant isolates were carbapenemase-producing by phenotypic method. Most CP-CRO were Acinetobacter baumannii (45 of 107, 42%) or Klebsiella pneumoniae (39 of 107, 36%). During ICU CP-CRE colonization screening, the July positivity rate on admission was 40% (32 of 81), the August positivity rate on admission was 30% (21 of 71), and the September positivity rate on admission was 40% (30 of 75). Of those with negative admission screen, the proportion of new CP-CRE colonization in July was 45% (22 of 49), the proportion of new CP-CRE colonization in August was 64% (32 of 50), and the proportion of new CP-CRE colonization in September was 44% (20 of 45). Across all 3 months of screening, the proportions of CP-CRE that were Klebsiella, Citrobacter, or Enterobacter were 68% (118 of 174) and the proportion of CP-CRE that were Eschericia coli was 37% (56 of 174). The average number of days to turn from negative to positive screening result was 4.1. Conclusions: Our analysis demonstrates that nearly all carbapenem-resistant organisms at our hospital are carbapenemase producing. In the ICU, we identified a high burden of CP-CRE, attributable to high presence on admission and new acquisition in the ICU. An intervention package based on CDC-recommended enhanced infection control measures is being implemented to decrease CP-CRE transmission in the ICU.Funding: NoneDisclosures: None

Background: Catheter-associated urinary tract infections (CAUTIs) are among the most prevalent healthcare-associated infections (HAIs) globally, contributing to increased morbidity, prolonged hospital stays, and increased healthcare costs. Interventions that support prompt removal of the urinary catheter are evidence-based actions to effectively reduce CAUTI rates.1Objective: At the National Hospital of Tropical Disease (NHTD), catheter removal interventions in the intensive care unit (ICU) were implemented using quality improvement (QI) methodology to reduce CAUTI incidence and urinary catheter device utilization. Methods: Training was performed for ICU clinical staff with knowledge checks before and after the program. A bedside visual reminder of CAUTI risk and checklist to assess catheter need were implemented. Weekly compliance of provided visual reminders and checklists were measured using a simple audit tool. Device utilization ratios (DURs, ratios of device days to patient days), and CAUTI incidence rates (per 1,000 device days) were collected at baseline (July–September 2018) and quarterly thereafter until June 2019. Statistical significance was determined by an independent t test. Results: In the first quarter (October–December 2018), the CAUTI incidence rate decreased from 8.9 to 1.3 per 1,000 device days (P = .036). The ICU staff trained in CAUTI prevention, mean knowledge scores before and after training increased from 68% to 87%. The DUR decreased slightly from 0.59 to 0.55 after the first-quarter training then steadily increased in the following quarter (0.60; January–March 2019) and after the intervention (0.54; April–June 2019). CAUTI incidence rates also increased but were still lower than at baseline: 4.8 and 6.3 per 1,000 days of device use. Compliance of reminders was 51% during the first quarter, increased slightly in the second quarter 62%, then decreased to 40% during the last quarter. The nurses’ adherence to the daily checklist remained stable (>75%). Conclusions: This CAUTI prevention project was the first use of quality improvement methodology to implement change at NHTD. A trend decrease in CAUTI was observed, though a greater decrease occurred at the beginning of the intervention. Limited compliance of daily reminders is likely reflected in no statistically significant decrease in DUR. Possibly, this quality improvement project raised awareness among clinicians to improve general CAUTI prevention practices in the ICU without decreasing DUR. Given limited compliance with reminder and checklists, the intervention will be revised during the next PDSA cycle to improve adherence.1Meddings J, Rogers MA, Krein SL, Fakih MG, Olmsted RN, Saint S. Reducing unnecessary urinary catheter use and other strategies to prevent catheter-associated urinary tract infection: an integrative review. BMJ Qual Saf 2014;23:277–289.Funding: NoneDisclosures: None

Background: Antibiotic overuse has led to increasing rates of antibiotic resistant infections and unnecessary antibiotic costs. Clinical pharmacists can play a key role in optimizing appropriate use of antimicrobials and reducing antimicrobial resistance. However, the role of clinical pharmacists in antimicrobial stewardship is new and not well established in Viet Nam. Objective: We evaluated the use of clinical pharmacists for improved antimicrobial prescribing. Methods: We assembled an antibiotic stewardship program (ASP) team consisting of a clinical pharmacist and a specialist in infection prevention and control in a 60-bed medical intensive care unit (MICU) at Hue Central Hospital in central Viet Nam. During January–September 2018, the ASP team collected baseline antibiotic prescribing days of therapy (DOT) for all antibiotics administered in the MICU. Then, from October 2018 through June 2019, the ASP team reviewed daily positive clinical bacterial cultures and susceptibility results for all patients present in the MICU. They reviewed medical charts, including antimicrobial prescriptions, during week days and only if patient was still in the ICU at the time of ASP rounds. The team recommended changes to antibiotic therapy verbally to physicians and left the decision to change antibiotic therapy to their discretion. The ASP team documented whether their recommendations were accepted or rejected. Statistical significance was determined using the Student t test. Results: The ASP team reviewed 160 medical charts and made 169 ASP recommendations: 122 (72%) to continue current treatment; 24 (14%) to monitor drug levels or obtain diagnostic tests; 10 (6%) to discontinue therapy; 6 (4%) to de-escalate therapy; 5 (3%) to adjust doses; and 2 (1%) to broaden therapy. Only 8 of the recommended changes (5%) were declined by the clinicians. The average monthly DOT for all types of antibiotics declined significantly from 2,213 to 1,681 (24% decrease; P = .04). Reductions in DOT for the most common broad-spectrum antibiotics included colistin from 303 to 276 (P = .75); imipenem-cilastatin 434 to 248 (P = .06); doripenem 150 to 144 (P = .85). Piperacillin-tazobactam increased from 122 to 142 (P = 0.75). Conclusions: We demonstrated that daily review of cultures and antibiotic use decreased overall antibiotic prescribing. Given that few recommendations included discontinuation of therapy, ASP rounds likely raised awareness for clinicians to optimize antibiotic use.Funding: NoneDisclosures: None

Background: Central-line–associated bloodstream infections (CLABSIs) increase the length of hospital stay, healthcare costs, and patient mortality. Objective: We conducted a quality improvement (QI) approach with plan-do-study-act (PDSA) cycle to strengthen adherence to a central-line (CL) maintenance bundle and to reduce CLABSI rate in a surgical intensive care unit (ICU) of children’s hospital 1 (CH1). Methods: The baseline CLABSI rate per 1,000 CL days and the ratio of CL days to patient days (device utilization ration; DUR) were captured for 12 months preceding the intervention. Baseline process indicators were captured for 2 months preceding implementation, including hand hygiene adherence, sterile technique for dressing change and CL access, CL hub cleaning, dating of CL components and daily chlorhexidine bathing. A multimodal intervention of clinician training, bedside checklist, and poster reminders of best practices was implemented. Process and outcome measures were monitored over 12 months of implementation. Z-test was used to calculate statistical significance before and after intervention. Results: Among 46 clinical ICU staff trained on a CLABSI maintenance bundle, mean pre- and posttest knowledge scores increased from 63% to 86%. Staff adherence to each CL care bundle element improved significantly (P < .001) and sustainably over the intervention period: hand hygiene adherence increased from 54% to 82%; sterile technique for dressing increased from 60% to 94%; sterile technique for CL access increased from 51% to 97%; hub scrubbing increased from 52% to 93%; dating of CL elements increased from 63% to 85%; daily chlorhexidine bathing increased from 52% to 87%. During the first 9 months, the CLABSI rate and the DUR decreased from 5.8 to 3.7 and from 0.43 to 0.41, respectively. In the following 2 months, the CLABSI rate increased to 12.7 while bundle adherence remained high. A root-cause analysis identified inadequate environmental hygiene and use of multidose saline bottles for multiple patients as potential factors. A PDSA cycle to improve these elements (enhanced cleaning; single-patient saline bottles) led to a decrease in the CLABSI rate from 12.7 to 3.0 after these efforts. Conclusions: This is the first time CH1 has used quality improvement methodology to implement an HAI prevention enhancement, which proved effective at creating and sustaining adherence to a multimodal CL maintenance bundle and an overall decrease in CLABSI rates. A 2-month increase in CLABSI rates highlights the unique challenges faced in low-resource settings and demonstrates the need for IPC elements not captured in a typical CLABSI prevention bundle. The quality improvement methodology provided a structured approach to implementing change. This methodology will be used for additional patient safety improvements at CH1 and other Viet Nam hospitals interested in CLABSI prevention.Funding: NoneDisclosures: None