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A number of important principles in effective risk communication established in the late 20th century can provide important scientific insight into patient response to the risks posed by COVID-19 [1-3]. Early risk communication scholars studied public perceptions of risk in response to environmental disasters, or infectious disease outbreaks. They found acceptability of risk, and any limitations and acceptability of response by experts was shaped by two key components: hazard and outrage. The number of people who are exposed, infected and fall ill can be considered the hazard. How the public and patients perceive the risk and respond to messages regarding risk mitigation relates to outrage. Social and cultural factors, immediacy, uncertainty, familiarity, personal control, scientific uncertainty and trust in institutions and media all shape acceptability of response. These outrage factors influence the ever-changing public understanding of COVID-19 risk, as well as the public’s acceptance of personal and societal mitigation strategies. Risk perceptions and acceptability of mitigation strategies are also largely shaped in the context of culture and society. In concert, hazard and outrage along with cultural and economic context shape adherence to, and overall acceptance of, personal mitigation strategies including wearing facemasks, and social distancing among the general public. The spread of misinformation on social media in the context of crisis communication provides both challenges and opportunities for experts and officials to effectively communicate and influence these outrage factors. Social media offers an opportunity for experts to quickly convey true information about hazards, but offers others the opportunity to counter this with the spread of misinformation and exacerbate outrage. We propose strategies for infectious diseases clinicians to apply risk communication principles and frameworks to improve patient care and public message development in response to COVID-19.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) asymptomatic infections may play a critical role in disease transmission. We aim to determine the prevalence of asymptomatic SARS-CoV-2 infection at 2 hospital systems in 2 counties in Wisconsin. The SARS-CoV-2 prevalence was 1% or lower at both systems despite the higher incidence of coronavirus disease 2019 (COVID-19) in Milwaukee County.

BACKGROUND Community-onset Clostridium difficile infections (CDI) are increasingly common, but there is little data on outcomes. The purpose of this study is to describe the epidemiology and outcomes of CDI in the Veterans Health Administration (VHA) system and compare these variables between hospital-onset (HCF) and community-onset (CO) cases. METHODS We conducted a retrospective cohort study that included all patients with a positive test for C. difficile (toxin or toxin genes) within the VHA Corporate Data Warehouse between 2011 and 2014. RESULTS We identified 19270 episodes of CDI, involving 15972 unique patients; 95% were male, 44% of the cases were HCF, and 42% were CO. Regarding severity, 31% percent of cases were non-severe, 40% were severe, and 21% were fulminant. Exposure to proton pump inhibitors was found in 53% of cases (47% in CO, 62% in HCF). Overall, 40% of patients received antibiotics in the 90 days before CDI (44% in HCF, 36% in CO). Recurrence was 18.2%, and 30-day all-cause mortality was 9.2%. Risk factors for a fulminant case were exposure to clindamycin (odds ratio [OR]: 1.23, P = .01) or proton pump inhibitors (OR: 1.20, P < .001) in the 90 days prior to diagnosis. CONCLUSIONS CO accounts for a significant proportion of CDI in the VHA system. CO patients are younger and their cases are less severe, but recurrence is more common than in HCF CDI. Therefore CO CDI may account for a considerable reservoir of CDI cases, and prevention efforts should include interventions to reduce CO CDI.

Clostridium difficile is the most frequently identified cause of nosocomial diarrhea and has been associated with epidemics of diarrhea in hospitals and long-term care facilities. The continued increase in C. difficile infection (CDI) suggests that it has surpassed other pathogens in causing healthcare-associated infections. The Centers for Disease Control and Prevention recently identified CDI as an "urgent threat" in its recent report on antibiotic resistance threats in the United States, highlighting the need for urgent and aggressive action to prevent this infection. The impact of antibiotics as a risk factor for new-onset CDI is well established; however, recognizing classes of antibiotics with the highest risks and reducing unnecessary antibiotic use are important strategies for prevention of CDI and subsequent recurrence. In addition, the recognition of the community as an important setting for onset of CDI presents a challenge and is an area for future research.

Catheter-associated urinary tract infection (CAUTI) is the most common healthcare-associated infection in the United States [1]. On 1 October 2008, the Centers for Medicare & Medicaid Services (CMS) stopped reimbursing hospitals for treatment of hospital-acquired CAUTI and other hospital-acquired conditions they deemed were “reasonably preventable” [1]. Since then, hospitals only receive reimbursement if a urinary tract infection was demonstrated to have been present at the time the patient was admitted to the hospital (rather than acquired during hospitalization) [2]. There is a debate over whether this policy will decrease the frequency of CAUTI or whether it may create perverse incentives for hospitals to document asymptomatic bacteriuria at the time of admission and inappropriately treat them as urinary tract infections, to avoid loss of payment if a CAUTI is diagnosed after admission. Although the policy explicitly applies to reimbursement for CAUTI, documentation of any urinary tract infection at admission would increase reimbursement. As described in a recent editorial, “if, as a result of the rule change, clinicians were pressured to test the urine of all patients on admission to the hospital, the risk of unnecessary treatment of asymptomatic bacteriuria or inflammation would be substantial” [3]. Past CMS policy designed to improve management of pneumonia has had the unintended consequence of antibiotic overuse [4]. Several groups of patients commonly have bacteria in their urine without any symptoms of infection (ie, asymptomatic bacteriuria) and do not benefit from antimicrobials [5]. For these patients, the possibility of overperformance of urine culture at admission as a screening tool to detect and document urinary tract infection as being present on admission, and thereby to avoid possible nonpayment, is real and concerning [6]. Urinary tract infection is a diagnosis based largely on clinical symptoms, with the support of nonspecific laboratory tests such as urinalysis and urine culture [6, 7]. Patients with urinary catheters are particularly prone to bacteriuria and pyuria, which would fulfill the criteria for CAUTI in the appropriate clinical setting of fever, pain, tenderness, or other nonspecific criteria [7]. Given that fever and abdominal pain are often caused by other conditions, culturing urine more frequently would be expected to yield an increased frequency of urinary tract infection diagnoses, even if symptoms in patients receiving the diagnosis were best explained by another clinical syndrome. This increase in false-positive diagnoses of urinary tract infection at admission would be expected to increase inappropriate use of antimicrobials for patients with a diagnosis of urinary tract infection, resulting in potential increases in bacterial resistance, Clostridium difficile infections, and adverse drug reactions over time. Our aim was to thus evaluate whether implementation of the CMS policy of nonreimbursement for hospital-acquired CAUTI was temporally associated with increased frequency of urine culture on hospital admission. As a secondary outcome, we examined whether implementation of the CMS policy was associated with increased use of antimicrobials commonly used for the treatment of urinary tract infection.

In a meta-analysis examining respiratory specimen Gram stain for diagnosis of ventilator-associated pneumonia, absence of bacteria on Gram stain had a high negative predictive value, but a positive Gram stain correlated poorly with organisms recovered in culture. Rapid and accurate diagnosis of ventilator-associated pneumonia (VAP) is a major challenge and no generally accepted gold standard exists for VAP diagnosis. We conducted a meta-analysis to examine the role of respiratory specimen Gram stain to diagnose VAP, and the correlation with final culture results. In 21 studies, pooled sensitivity of Gram stain for VAP was 0.79 (95% confidence interval [CI], .77-0.81; P < .0001) and specificity was 0.75 (95% CI, .73-.78; P < .0001). Negative predictive value of Gram stain for a VAP prevalence of 20%-30% was 91%, suggesting that VAP is unlikely with a negative Gram stain but the positive predictive value of Gram stain was only 40%. Pooled kappa was 0.42 for gram-positive organisms and 0.34 for gram-negative organisms, suggesting fair concordance between organisms on Gram stain and recovery by culture. Therefore, a positive Gram stain should not be used to narrow anti-infective therapy until culture results become available.

Item does not contain fulltext BACKGROUND: Invasive candidiasis (IC) is an important healthcare-related infection, with increasing incidence and a crude mortality exceeding 50%. Numerous treatment options are available yet comparative studies have not identified optimal therapy. METHODS: We conducted an individual patient-level quantitative review of randomized trials for treatment of IC and to assess the impact of host-, organism-, and treatment-related factors on mortality and clinical cure. Studies were identified by searching computerized databases and queries of experts in the field for randomized trials comparing the effect of >/=2 antifungals for treatment of IC. Univariate and multivariable analyses were performed to determine factors associated with patient outcomes. RESULTS: Data from 1915 patients were obtained from 7 trials. Overall mortality among patients in the entire data set was 31.4%, and the rate of treatment success was 67.4%. Logistic regression analysis for the aggregate data set identified increasing age (odds ratio [OR], 1.01; 95% confidence interval [CI], 1.00-1.02; P = .02), the Acute Physiology and Chronic Health Evaluation II score (OR, 1.11; 95% CI, 1.08-1.14; P = .0001), use of immunosuppressive therapy (OR, 1.69; 95% CI, 1.18-2.44; P = .001), and infection with Candida tropicalis (OR, 1.64; 95% CI, 1.11-2.39; P = .01) as predictors of mortality. Conversely, removal of a central venous catheter (CVC) (OR, 0.50; 95% CI, .35-.72; P = .0001) and treatment with an echinocandin antifungal (OR, 0.65; 95% CI, .45-.94; P = .02) were associated with decreased mortality. Similar findings were observed for the clinical success end point. CONCLUSIONS: Two treatment-related factors were associated with improved survival and greater clinical success: use of an echinocandin and removal of the CVC. 01 april 2012

The epidemiology of candiduria in renal transplantation is unknown.We performed a nested case-control study to evaluate the epidemiology of candiduria in renal transplant recipients at the University of Wisconsin (Madison) over an 8-year period.Renal transplantations were performed on 1738 patients during this period, 192 of whom had 276 episodes of candiduria. Candida glabrata, which was recovered from 98 (51%) of 192 case patients, was the most common pathogen identified. Most case patients were asymptomatic. Independent predictors of candiduria were female sex (odds ratio [OR], 12.5; 95% confidence interval [CI], 6.7-23.0), intensive care unit admission (OR, 8.8; 95% CI, 2.3-35.0), antibiotic use during the month before candiduria (OR, 3.8; 95% CI, 1.7-8.3), presence of an indwelling bladder catheter (OR, 4.4; 95% CI, 2.1-9.4), diabetes (OR, 2.2; 95% CI, 1.3-3.9), neurogenic bladder (OR, 7.6; 95% CI, 2.1-27), and malnutrition (OR, 2.4; 95% CI, 1.3-4.4). Log-rank testing of Kaplan-Meier curves revealed that 60-day, 90-day, and cumulative survival rates were significantly different between case and control patients; there was no difference in the survival rate during the first 30 days after transplantation. A variety of regimens were used for treatment; 119 case patients (62%) underwent removal of the indwelling bladder catheter within 1 week after diagnosis of candiduria. Candiduria cleared in 148 case patients (77%). Treatment of candiduria was not associated with an improved survival rate.Candiduria occurs commonly in renal transplant recipients. Risk factors for candiduria in such persons are similar to those in hospitalized patients who have not received a transplant. Candiduria is associated with reduced survival rates among persons who have undergone renal transplantation; this is likely a marker for severity of illness. Treatment of asymptomatic candiduria in renal transplant recipients does not appear to result in improved outcome.

Background. Infected hepatic fluid collections (bilomas) are a major infectious complication of liver transplantation. Limited data exist on management and outcome of biloma.Methods. We report a cohort study of 57 liver transplant recipients with posttransplantation bilomas undertaken to identify the clinical features of biloma, management strategies, and outcome.Results. Fever (44%) and abdominal pain (40%) were the most common presenting symptoms, but one-third of patients were asymptomatic; 79% had elevated hepatic enzyme levels. Patients without hepatic artery thrombosis (HAT) had the highest rates of resolution with percutaneous drainage and anti-infective therapy (64%). Retransplantation was necessary in 64% of patients with HAT and biloma. Independent predictors of resolution with nonsurgical therapy were absence of HAT (odds ratio [OR] 7.69; P = .01) and absence of Candida (OR, 9.09; P = .02) or enterococcal infection (OR, 7.69; P = .03). Patients with bilomas had significantly greater mortality (Cox proportional hazard ratio [HR], 2.38; P = .008, by log rank test) and graft loss (HR, 4.31; P < .0001). Predictors of mortality by multivariable analysis included renal insufficiency (OR, 12.51; P = .02) or infection with Candida species (OR, 4.93; P = .03) or gram-negative bacilli (OR, 9.12; P = .01).Conclusion. Posttransplantation biloma should be suspected in patients with fever or abdominal pain or abnormalities of hepatic enzymes, and it can be confirmed by computerized tomography and radiographically guided aspiration. Bilomas are most likely to be successfully treated nonsurgically in patients without HAT and without Candida or enterococcus infection.