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ABSTRACT Background Occupational heat‐related illness (HRI) is problematic in the United States. Farmworkers are disproportionately affected by HRI compared to other workers. Uncovering barriers that farmworkers face to the prevention of HRI is crucial to reducing HRI‐associated morbidity and mortality. This integrative review aimed to understand US farmworkers’ barriers to preventing HRI. Methods An integrative review occurred following Whittemore and Knafl guidelines. Literature searches occurred on PubMed, Medline, and Agricola. After applying inclusion and exclusion criteria and removing duplicates, nine articles remained for review. Results There were nine articles in the review. The majority of articles used a convenience sample. In all studies, the populations were farmworkers or agricultural workers. The study designs included cross‐sectional, mixed methods, qualitative focus groups, and a longitudinal study. The articles revealed several themes related to prevention barriers: access to prevention, education and training, work culture, and compensation. Farmworkers often lack access to proper prevention measures, education, and training. Work culture and compensation were obstacles to preventing HRI as some workers feel powerless to speak up for themselves, whereas others are tempted to forgo breaks because of the way they are compensated. Conclusions This review indicates the need for more research to understand the barriers farmworkers face to HRI prevention. Providing prevention measures without considering obstacles to their use is ineffective in reducing HRI. Because many farmworkers lack oversight and regulation of prevention measures, focusing on barriers and areas over which farmworkers have more control could have a significant impact.

Abstract Cultural transmission is the domain-general social skill that allows agents to acquire and use information from each other in real-time with high fidelity and recall. It can be thought of as the process that perpetuates fit variants in cultural evolution. In humans, cultural evolution has led to the accumulation and refinement of skills, tools and knowledge across generations. We provide a method for generating cultural transmission in artificially intelligent agents, in the form of few-shot imitation. Our agents succeed at real-time imitation of a human in novel contexts without using any pre-collected human data. We identify a surprisingly simple set of ingredients sufficient for generating cultural transmission and develop an evaluation methodology for rigorously assessing it. This paves the way for cultural evolution to play an algorithmic role in the development of artificial general intelligence.

This article focuses on a form of embedded instruction, wherein library employees work weekly within a student space, in this case the Indigenous Student Centre at Simon Fraser University in what is colonially known as British Columbia, Canada. As we continued to learn together and deepen our appreciation of Sḵwx̱wú7mesh scholarship and theory -- scholarship and theory Indigenous to the lands we occupy -- we recognized deep resonance with our understandings and approaches. In particular, Denise Findlay’s (Sḵwx̱wú7mesh) sharing about eslhélha7kwhiwsm and imperfect friendship have shaped our understandings of both our friendship and our role as teachers. Writing in an epistolary form, we dialogue about the time we spend together in the Indigenous Student Centre and how that time has allowed us to develop and appreciate a friendship-grounded approach to teaching and learning. This article invites readers into a dialogue between the authors, whose relationship initially developed through work collaborations and grew into a real-life friendship. By sharing stories, questions, and connections with what we are reading and learning, the authors encourage one another, and simultaneously the reader, to consider the possibilities of imperfection, humility, friendship, and radical care in academic library instruction beyond the classroom.

Smart microgrids are being increasingly deployed within the Department of Defense. The microgrid at Marine Corps Air Station (MCAS) Miramar is one such deployment that has fostered the integration of different technologies, including 5G and Advanced Metering Infrastructure (AMI). The objective of this paper is to develop an anomaly detection framework for the smart microgrid system at MCAS Miramar to enhance its cyber-resilience. We implement predictive analytics using machine learning to deal with cyber-uncertainties and threats within the microgrid environment. An autoencoder neural network is implemented to classify and identify specific cyber-attacks against this infrastructure. Both network traffic in the form of packet captures (PCAP) and time series data (from the AMI sensors) are considered. We train the autoencoder model on three traffic data sets: (1) Modbus TCP/IP PCAP data from the hardwired network apparatus of the smart microgrid, (2) experimentally generated 5G PCAP data that mimic traffic on the smart microgrid and (3) AMI smart meter sensor data provided by the Naval Facilities (NAVFAC) Engineering Systems Command. Distributed denial-of-service (DDoS) and false data injection attacks (FDIA) are synthetically generated. We show the effectiveness of the autoencoder on detecting and classifying these types of attacks in terms of accuracy, precision, recall, and F-scores.

Due to the advancements in real-time information communication technologies and sharing economies, rideshare services have gained significant momentum by offering dynamic and/or on-demand services. Rideshare service companies evolved from personal rideshare, where riders traveled solo or with known individuals, into pooled rideshare (PR), where riders can travel with one to multiple unknown riders. Similar to other shared economy services, pooled rideshare is beneficial as it efficiently utilizes resources, resulting in reduced energy usage, as well as reduced costs for the riders. However, previous research has demonstrated that riders have concerns about using pooled rideshare, especially regarding personal safety. A U.S. national survey with 5385 participants was used to understand human factor-related barriers and user preferences to develop a novel Pooled Rideshare Acceptance Model (PRAM). This model used a covariance-based structural equation model (CB-SEM) to identify the relationships between willingness to consider PR factors (time/cost, privacy, safety, service experience, and traffic/environment) and optimizing one’s experience of PR factors (vehicle technology/accessibility, convenience, comfort/ease of use, and passenger safety), resulting in the higher-order factor trust service. We examined the factors’ relative contribution to one’s willingness/attitude towards PR and user acceptance of PR. Privacy, safety, trust service, and convenience were statistically significant factors in the model, as were the comfort/ease of use factor and the service experience, traffic/environment, and passenger safety factors. The only two non-significant factors in the model were time/cost and vehicle technology/accessibility; it is only when a rider feels safe that individuals then consider the additional non-significant variables of time, cost, technology, and accessibility. Privacy, safety, and service experience were factors that discouraged the use of PR, whereas the convenience factor greatly encouraged the acceptance of PR. Despite the time/cost factor’s lack of significance, individual items related to time and cost were crucial when viewed within the context of convenience. This highlights that while user perceptions of privacy and safety are paramount to their attitude towards PR, once safety concerns are addressed, and services are deemed convenient, time and cost elements significantly enhance their trust in pooled rideshare services. This study provides a comprehensive understanding of user acceptance of PR services and offers actionable insights for policymakers and rideshare companies to improve their services and increase user adoption.

Substrate stratification is an emerging substrate management strategy involving layering multiple substrate materials within a single container to modify physiochemical characteristics of the substrate system. Specifically, stratifying allows growers and researchers to rearrange the air–water balance within a container to modify hydraulic characteristics. Moreover, fertilizer can be incorporated into just the upper strata to reduce leaching. Research to date has shown benefits associated with resource efficiency, production timing, and weed control. With the associated benefits for substrate stratification, interested growers will need pragmatic solutions for onsite trials. Therefore, the objective of this study was to identify a cost-effective solution for growers interested in exploring stratification options. As such, this research was designed to identify a single-screen bark separation to generate fine and coarse bark textures suitable for use as the top and bottom substrate strata. Loblolly pine bark (Pinus taeda) was screened with either a 4.0-mm, 1/4-inch, or 3/8-inch screen, with the particles passing through the screen (unders) separated from retained particles (overs). Stratified substrate systems were engineered with an individual screen wherein the fines were layered atop the coarse particles from the same screen. ‘Natchez’ crepe myrtle (Lagerstroemia indica) liners were planted in either of the three stratified substrate treatments or a nonstratified control. Substrate physical characteristics were assessed for each strata by pre- and postproduction properties to identify changes of substrate. The final growth index of the crop was unaffected by the substrate treatment (P = 0.90); however, stratified substrates did increase dry root weight (P = 0.02), with the smallest screen (4.0 mm) resulting in the greatest root weight. Separation of roots between the two strata indicated the presence of more roots in the upper strata in all substrates. However, the stratified substrates resulted in a greater shift in root location, encouraging increased rooting in the upper strata with fine particles, with the largest screen (3/8 inch) resulting in the greatest differentiation between upper and lower rooting. Each stratified treatment had increase in water-holding capacity in the lower (coarser) strata without changes in the upper strata. Thus, we conclude that single screens can be used to build stratified substrate systems. Moreover, screen aperture size may be used to achieve different outcomes with regard to root growth and development as well as water–air balance. Further research may indicate that screen selection may be used to target specific crop needs.

Abstract Background Unhealthy alcohol use is the third leading cause of preventable death in the United States. Evidence demonstrates that screening for unhealthy alcohol use and providing persons engaged in risky drinking with brief behavioral and counseling interventions improves health outcomes, collectively termed screening and brief interventions. Medication assisted therapy (MAT) is another effective method for treatment of moderate or severe alcohol use disorder. Yet, primary care clinicians are not regularly screening for or treating unhealthy alcohol use. Methods and analysis We are initiating a clinic-level randomized controlled trial aimed to evaluate how primary care clinicians can impact unhealthy alcohol use through screening, counseling, and MAT. One hundred and 25 primary care practices in the Virginia Ambulatory Care Outcomes Research Network (ACORN) will be engaged; each will receive practice facilitation to promote screening, counseling, and MAT either at the beginning of the trial or at a 6-month control period start date. For each practice, the intervention includes provision of a practice facilitator, learning collaboratives with three practice champions, and clinic-wide information sessions. Clinics will be enrolled for 6–12 months. After completion of the intervention, we will conduct a mixed methods analysis to identify changes in screening rates, increase in provision of brief counseling and interventions as well as MAT, and the reduction of alcohol intake for patients after practices receive practice facilitation. Discussion This study offers a systematic process for dissemination and implementation of the evidence-based practice of screening, counseling, and treatment for unhealthy alcohol use. Practices will be asked to implement a process for screening, counseling, and treatment based on their practice characteristics, patient population, and workflow. We propose practice facilitation as a robust and feasible intervention to assist in making changes within the practice. We believe that the process can be replicated and used in a broad range of clinical settings; we anticipate this will be supported by our evaluation of this approach. Trial registration ClinicalTrials.gov, ClinicalTrials.gov Identifier: NCT04248023 , Registered 5 February 2020.

The objective of this evaluation was to assess the use of public health detailing in a pilot program to increase Expedited Partner Therapy (EPT) uptake among community-based providers in two Maryland jurisdictions. Public health detailing is a method designed to raise awareness and increase implementation of evidence-based clinical practices by delivering educational content via one-on-one meetings with providers. EPT is a voluntary clinical practice of treating all sexual partners of patients diagnosed with STIs by prescribing medications without the provider first examining said sexual partners. The aim of EPT is to prevent STI reinfection and reduce further transmission. From April 2017 to March 2019, detailers visited community-based health care practice sites to conduct EPT detailing with providers. The effectiveness of this program was evaluated by comparing provider responses from pre- to post-detailing surveys, administered six months after detailing. Survey responses assessed EPT awareness and practices, barriers to implementation, and satisfaction with detailing. The proportion of providers (170) aware of EPT for treating chlamydia and gonorrhea increased from 61.7% (114) to 99.4% (169) (p-value

The coronavirus disease (COVID-19) pandemic has impacted the economy, livelihood, and physical and mental well-being of people worldwide. This study aimed to compare the mental health status during the pandemic in the general population of seven middle income countries (MICs) in Asia (China, Iran, Malaysia, Pakistan, Philippines, Thailand, and Vietnam). All the countries used the Impact of Event Scale-Revised (IES-R) and Depression, Anxiety and Stress Scale (DASS-21) to measure mental health. There were 4479 Asians completed the questionnaire with demographic characteristics, physical symptoms and health service utilization, contact history, knowledge and concern, precautionary measure, and rated their mental health with the IES-R and DASS-21. Descriptive statistics, One-Way analysis of variance (ANOVA), and linear regression were used to identify protective and risk factors associated with mental health parameters. There were significant differences in IES-R and DASS-21 scores between 7 MICs (p

Objective To quantify psychosocial risk in family caregivers of children with medical complexity using the Psychosocial Assessment Tool (PAT) and to investigate potential contributing sociodemographic factors.Design Cross-sectional study.Setting Family caregivers completed questionnaires during long-term ventilation and complex care clinic visits at The Hospital for Sick Children, Toronto, Ontario, Canada.Patients A total of 136 family caregivers of children with medical complexity completed the PAT questionnaires from 30 June 2017 through 23 August 2017.Main outcome measures Mean PAT scores in family caregivers of children with medical complexity. Caregivers were stratified as ‘Universal’ low risk, ‘Targeted’ intermediate risk or ‘Clinical’ high risk. The effect of sociodemographic variables on overall PAT scores was also examined using multiple linear regression analysis. Comparisons with previous paediatric studies were made using T-test statistics.Results 136 (103 females (76%)) family caregivers completed the study. Mean PAT score was 1.17 (SD=0.74), indicative of ‘Targeted’ intermediate risk. Sixty-one (45%) caregivers were classified as Universal risk, 60 (44%) as Targeted risk and 15 (11%) as Clinical risk. Multiple linear regression analysis revealed an overall significant model (p=0.04); however, no particular sociodemographic factor was a significant predictor of total PAT scores.Conclusion Family caregivers of children with medical complexity report PAT scores among the highest of all previously studied paediatric populations. These caregivers experience significant psychosocial risk, demonstrated by larger proportions of caregivers in the highest-risk Clinical category.

Canada is at an interesting point in its history, where the atrocious assimilation practices that were in place until the mid-1990s are being acknowledged in the hopes for a better relationship between Canada’s Indigenous and non-Indigenous peoples. Both the Truth and Reconciliation Commission report, and the Canadian Federation of Library Associations/Federation Canadienne des Associations de Bibliotheques (CFLA/FCAB)’s report from its Truth and Reconciliation Committee (n.d.) recognize the significant role of education needed to address changes. Where do academic libraries fit into this? I first discuss the colonial history of libraries, as extensions of education institutions, followed by a look at how library and information science (LIS) curriculum falls short in preparing students for working with Indigenous peoples and Indigenous resources. Finally, I examine how libraries can decolonize their services. Canadian academic library staff cannot continue to be so ill-equipped to serve Indigenous students and faculty.

Water quality is largely influenced by the abundance and diversity of indigenous microbes present within an aquatic environment. Physical, chemical and biological contaminants from anthropogenic activities can accumulate in aquatic systems causing detrimental ecological consequences. Approaches exploiting microbial processes are now being utilized for the detection, and removal or reduction of contaminants. Contaminants can be identified and quantified in situ using microbial whole-cell biosensors, negating the need for water samples to be tested off-site. Similarly, the innate biodegradative processes can be enhanced through manipulation of the composition and/or function of the indigenous microbial communities present within the contaminated environments. Biological contaminants, such as detrimental/pathogenic bacteria, can be specifically targeted and reduced in number using bacteriophages. This mini-review discusses the potential application of whole-cell microbial biosensors for the detection of contaminants, the exploitation of microbial biodegradative processes for environmental restoration and the manipulation of microbial communities using phages.

Electrode-associated microbial biofilms are essential to the function of bioelectrochemical systems. These systems exist in a number of different configurations but all rely on electroactive microorganisms utilizing an electrode as either an electron acceptor or an electron donor to catalyze biological processes. Investigations of the structure and function of electrode-associated biofilms are critical to further the understanding of how microbial communities are able to reduce and oxidize electrodes. The community structure of electrode-reducing biofilms is diverse and often dominated by Geobacter spp. whereas electrode-oxidizing biofilms are often dominated by other microorganisms. The application of a wide range of tools, such as high-throughput sequencing and metagenomic data analyses, provide insight into the structure and possible function of microbial communities on electrode surfaces. However, the development and application of techniques that monitor gene expression profiles in real-time are required for a more definite spatial and temporal understanding of the diversity and biological activities of these dynamic communities. This mini-review summarizes the key gene expression techniques used in bioelectrochemical systems research, which have led to a better understanding of population dynamics, cell-cell communication and molecule-surface interactions in mixed and pure BES communities

Antimicrobials are commonly prescribed and often misunderstood. With more than 50% of hospitalized patients receiving an antimicrobial agent at any point in time, judicious and optimal use of these drugs is paramount to advancing patient care. This narrative will focus on myths relevant to nuanced consultation from infectious diseases specialists, particularly surrounding specific considerations for a variety of antibiotics., Competing Interests: Potential conflicts of interest. The authors: No reported conflicts of interest. All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest., (© The Author(s) 2023. Published by Oxford University Press on behalf of Infectious Diseases Society of America. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Antimicrobial agents are among the most frequently prescribed medications during hospitalization. However, approximately 30% to 50% or more of inpatient antimicrobial use is unnecessary or suboptimal. Herein, we describe 10 common myths of diagnosis and management that often occur in the hospital setting. Further, we discuss supporting data to dispel each of these myths. This analysis will provide hospitalists and other clinicians with a foundation for rational decision-making about antimicrobial use and support antimicrobial stewardship efforts at both the patient and institutional levels., (Copyright © 2022 Elsevier Inc. All rights reserved.)

We surveyed healthcare workers within the Duke Antimicrobial Stewardship Outreach Network (DASON) to describe beliefs regarding coronavirus disease 2019 (COVID-19) vaccination and their decision-making process behind vaccination recommendations. In contrast to the type of messaging that appealed most on a personal level to the healthcare workers, they preferred a more generic message emphasizing safety and efficacy when making vaccination recommendations., (© The Author(s) 2022.)

Background: The Centers for Disease Control and Prevention (CDC) uses standardized antimicrobial administration ratios (SAARs)-that is, observed-to-predicted ratios-to compare antibiotic use across facilities. CDC models adjust for facility characteristics when predicting antibiotic use but do not include patient diagnoses and comorbidities that may also affect utilization. This study aimed to identify comorbidities causally related to appropriate antibiotic use and to compare models that include these comorbidities and other patient-level claims variables to a facility model for risk-adjusting inpatient antibiotic utilization., Methods: The study included adults discharged from Premier Database hospitals in 2016-2017. For each admission, we extracted facility, claims, and antibiotic data. We evaluated 7 models to predict an admission's antibiotic days of therapy (DOTs): a CDC facility model, models that added patient clinical constructs in varying layers of complexity, and an external validation of a published patient-variable model. We calculated hospital-specific SAARs to quantify effects on hospital rankings. Separately, we used Delphi Consensus methodology to identify Elixhauser comorbidities associated with appropriate antibiotic use., Results: The study included 11 701 326 admissions across 576 hospitals. Compared to a CDC-facility model, a model that added Delphi-selected comorbidities and a bacterial infection indicator was more accurate for all antibiotic outcomes. For total antibiotic use, it was 24% more accurate (respective mean absolute errors: 3.11 vs 2.35 DOTs), resulting in 31-33% more hospitals moving into bottom or top usage quartiles postadjustment., Conclusions: Adding electronically available patient claims data to facility models consistently improved antibiotic utilization predictions and yielded substantial movement in hospitals' utilization rankings., (© The Author(s) 2020. Published by Oxford University Press for the Infectious Diseases Society of America.)

Background: Early administration of antibiotics in sepsis is associated with improved patient outcomes, but safe and generalizable approaches to de-escalate or discontinue antibiotics after suspected sepsis events are unknown., Methods: We used a modified Delphi approach to identify safety criteria for an opt-out protocol to guide de-escalation or discontinuation of antibiotic therapy after 72 hours in non-ICU patients with suspected sepsis. An expert panel with expertise in antimicrobial stewardship and hospital epidemiology rated 48 unique criteria across 3 electronic survey rating tools. Criteria were rated primarily based on their impact on patient safety and feasibility for extraction from electronic health record review. The 48 unique criteria were rated by anonymous electronic survey tools, and the results were fed back to the expert panel participants. Consensus was achieved to either retain or remove each criterion., Results: After 3 rounds, 22 unique criteria remained as part of the opt-out safety checklist. These criteria included high-risk comorbidities, signs of severe illness, lack of cultures during sepsis work-up or antibiotic use prior to blood cultures, or ongoing signs and symptoms of infection., Conclusions: The modified Delphi approach is a useful method to achieve expert-level consensus in the absence of evidence suifficient to provide validated guidance. The Delphi approach allowed for flexibility in development of an opt-out trial protocol for sepsis antibiotic de-escalation. The utility of this protocol should be evaluated in a randomized controlled trial., (© The Author(s) 2021.)

Respiratory tract infections (RTIs) drive many outpatient encounters and, despite being predominantly viral, are associated with high rates of antibiotic prescriptions. With rising antibacterial resistance, optimization of prescribing of antibiotics in outpatients with RTIs is a critical need. Fortunately, this challenge arises at a time of increasing availability of novel RTI diagnostics to help discern which patients have bacterial infections warranting treatment. Effective implementation of antibiotic stewardship is needed, but optimal approaches for ambulatory settings are unknown. Future research needs are reviewed in this summary of a research summit convened by the Infectious Diseases Society of America in the fall of 2019., (© The Author(s) 2020. Published by Oxford University Press for the Infectious Diseases Society of America. All rights reserved. For permissions, e-mail: journals.permissions@oup.com.)

Treating fungal infections in the central nervous system (CNS) remains a challenge despite the availability of new antifungal agents. Therapy is limited by poor understanding of the kinetic properties of antifungal drugs in the CNS compounded by lack of data for many agents. In some cases, clinical response rates do not correspond to data on drug concentrations in the cerebral spinal fluid and/or brain parenchyma. In order to better characterize the use of antifungal agents in treating CNS infections, a review of the essential principles of neuroPK are reviewed. Specific data regarding antifungal drug concentrations in the cerebral spinal fluid and brain tissue are described from human data where available. Alternative dosing regimens and the role of antifungal drug concentration monitoring in treating fungal infections in the CNS are also discussed. Having a better understanding of these key concepts will help guide clinicians in determining the best treatment courses for patients with these devastating infections.

Background: Efforts to develop a Clostridium difficile vaccine are underway; identification of patients at risk for C. difficile infection (CDI) is critical to inform vaccine trials. We identified groups at high risk of CDI ≥ 2 8 days after hospital discharge., Methods: Hospital discharge data and pharmacy data from two large academic centers, in New York and Connecticut, were linked to active population-based CDI surveillance data from the Emerging Infections Program (EIP). Adult residents of the EIP surveillance area were included if they had an inpatient stay at a study hospital without prior history of CDI. The primary outcome was CDI by either toxin or molecular assay ≥ 28 days after an index hospitalization. Important predictors of CDI ≥ 28 days post discharge were initially identified through a Cox proportional hazards model (stepwise backward selection) using a derivation cohort; final model parameters were used to develop a risk score evaluated in the validation cohort., Results: Of the 35,186 index hospitalizations, 288 (0.82%) had CDI ≥ 28 days post discharge. After parameter selection, age, number of hospitalizations in the prior 90 days, admission diagnosis, and the use of 3rd/4th generation cephalosporin, clindamycin or fluoroquinolone antibiotic classes remained in the model. Using the validation cohort, the risk score was predictive (p<0.001) with a c-score of 0.75. Based on the distribution of scores in the derivation cohort, we divided the patients into low and high risk groups. In the high risk group, 1.6% experienced CDI ≥ 28 days post discharge compared to 0.3% among our low risk group., Conclusions: Our study identified specific parameters for a risk score that can be applied at discharge to identify a patient population whose risk of CDI ≥ 28 days following an acute care hospitalization was 5 times greater than other patients., (Published by Elsevier Ltd.)

Purpose of Review: This review describes the overlapping aspects of antimicrobial stewardship and patient-safety initiatives and justifies why stewardship belongs under the umbrella of patient safety., Recent Findings: Addressing the continued emergence of antibiotic resistance through the discovery of new drugs is not a sustainable strategy, particularly as antibiotics are increasingly more difficult and costly to develop. Thus, it is essential that we preserve the utility of existing antibiotics. Antimicrobial stewardship programs can assist with achieving this goal. Currently, however, the term 'antimicrobial stewardship' is generally not easily understood by regulators, hospital administrators, or the public. Perhaps more clout would be given to antimicrobial stewardship if it is associated with safety. In this review, we present concrete examples of how antimicrobial stewardship programs can focus on achieving goals already recognized as essential for patient safety., Summary: Patient safety is an integral component of antimicrobial stewardship. To make the concept of antimicrobial stewardship more palatable, the association between antimicrobial stewardship and safety needs to be emphasized.

Positive outcomes of antimicrobial stewardship programs in the inpatient setting are well documented, but the benefits for patients not admitted to the hospital remain less clear. This report describes a retrospective case-control study of patients discharged from the emergency department (ED) with subsequent positive cultures conducted to determine whether integrating antimicrobial stewardship responsibilities into practice of the emergency medicine clinical pharmacist (EPh) decreased times to positive culture follow-up, patient or primary care provider (PCP) notification, and appropriateness of antimicrobial therapy. Pre- and post-implementation groups of an EPh-managed antimicrobial stewardship program were compared. Positive cultures were identified in 177 patients, 104 and 73 in pre- and post-implementation groups, respectively. Median time to culture review in the pre-implementation group was 3 days (range 1-15) and 2 days (range 0-4) in the post-implementation group (P = .0001). There were 74 (71.2%) and 36 (49.3%) positive cultures that required notification in the pre- and post-implementation groups, respectively, and the median time to patient or PCP notification was 3 days (range 1-9) and 2 days (range 0-4) in the 2 groups (P = .01). No difference was seen in the appropriateness of therapy. In conclusion, EPh involvement reduced time to positive culture review and time to patient or PCP notification when indicated.

Despite emerging evidence that dysfunction in the accessory gene regulator (agr) locus is associated with deleterious outcomes among patients treated with vancomycin for methicillin-resistant Staphylococcus aureus (MRSA) infections, factors predictive of agr dysfunction have not been evaluated. This study describes the epidemiology of agr dysfunction, identifies predictors of agr dysfunction in MRSA isolates among those with MRSA bloodstream infections, and describes the relationship between agr dysfunction and other microbiologic phenotypes. A cross-sectional study of patients with MRSA bloodstream infections at two institutions in upstate New York was performed. Clinical data on demographics, comorbidities, disease severity, hospitalization history, and antibiotic history were collected. Microbiologic phenotypes, including agr dysfunction, MIC values by broth microdilution (BMD) and Etest, and vancomycin heteroresistance (hVISA) were tested. Multivariable analyses were performed to identify factors predictive of agr dysfunction. Among 200 patients with an MRSA bloodstream infection, the proportion of strains with agr dysfunction was 31.5%. The distribution of MICs determined by both BMD and Etest were equivalent across agr groups, and there was no association between agr dysfunction and the presence of hVISA. Severity of illness, comorbidities, and hospitalization history were comparable between agr groups. In the multivariate analysis, prior antibiotic exposure was the only factor of variables studied found to be predictive of agr dysfunction. This relationship was predominantly driven by prior beta-lactam and fluoroquinolone administration in the bivariate analysis. Identifying these institution-specific risk factors can be used to develop a process to assess the risk of agr dysfunction and guide empirical antibiotic therapy decisions.

Study Objective: To determine whether intravenous colistin therapy has an effect on the results of the phospholipid-based activated partial thromboplastin time (aPTT) clotting assays containing cephalin in patients receiving concomitant heparin therapy., Design: Retrospective medical record review., Setting: University-affiliated teaching institution., Patients: Thirty-six patients treated with intravenous colistin for at least 48 hours between January 1, 2005, and January 1, 2010, who were receiving heparin for at least 48 hours before colistin was started, and had aPTT tests performed at least 2 days before, during, and at least 2 days after treatment with colistin., Measurements and Main Results: Repeated-measures analysis of variance testing was performed to determine if significant differences in aPTT results before, during, and after colistin therapy existed. Of a total of 120 courses of colistin therapy, only 36 met the inclusion criteria. The mean ± SD aPTT was 52.3 ± 20.4 seconds before administration of colistin, 51.1 ± 16.6 seconds during colistin therapy, and 51.3 ± 13.6 seconds after administration of colistin (p=0.9). Heparin infusion rates were adjusted 12 times and heparin withheld twice at least 2 days before colistin therapy was started, infusion rates were changed 8 times and heparin withheld once during colistin therapy, and infusion rates were changed 10 times and heparin withheld once at least 2 days after colistin therapy., Conclusion: Colistin therapy had no significant effect on the cephalin-based aPTT testing results in patients receiving concomitant heparin therapy. Further analyses are required to confirm these findings.

Clostridium difficile infection is a serious condition responsible for significant morbidity and mortality, especially in patients being treated with antimicrobials. Increasing frequency of the infection and hypervirulent C. difficile strains have resulted in more severe disease as well as therapeutic failures with traditional treatment (metronidazole and vancomycin). To review the studies assessing nontraditional therapies for the prevention and treatment of primary or recurrent C. difficile infection, we conducted a literature search of the PubMed-MEDLINE databases (1984-2010). Of the 98 studies identified, 21 met our inclusion criteria. Five clinical trials and one retrospective medical record review evaluated probiotic or prebiotic formulations for the prevention of C. difficile infection. Only one of these studies, which included Lactobacillus casei and L. bulgaricus in the probiotic formulation, showed efficacy. Ten clinical trials evaluated treatment of an initial episode of C. difficile infection (primary treatment) with the anti-microbials fidaxomicin, fusidic acid, rifampin, teicoplanin, and nitazoxanide, as well as the toxin-binding polymer, tolevamer. Only nitazoxanide and teicoplanin demonstrated noninferiority when compared with vancomycin or metronidazole. Four prospective studies and one retrospective study evaluated treatment of relapsing C. difficile infection. Prebiotic formulations for the prevention and treatment of recurrent C. difficile infection have not proved to be clinically warranted. Nitazoxanide, teicoplanin, and fidaxomicin may be considered as alternatives to traditional treatment; however, clinical experience is limited with these agents for this indication. Bacteriotherapy with fecal instillation has demonstrated high clinical cure rates in case studies and in a retrospective study; however, to our knowledge, randomized clinical trials are lacking for this therapeutic approach. As C. difficile infection rates continue to increase and hypervirulent strains continue to emerge, it is important for future clinical studies to assess alternative therapies.

Aerosolized delivery of antimicrobial agents is an attractive option for management of pulmonary infections, as this is an ideal method of providing high local drug concentrations while minimizing systemic exposure. With the paucity of consensus regarding the safety, efficacy, and means with which to use aerosolized antimicrobials, a task force was created by the Society of Infectious Diseases Pharmacists to critically review and evaluate the literature on the use of aerosolized antiinfective agents. This article summarizes key findings and statements for preventing or treating a variety of infectious diseases, including cystic fibrosis, bronchiecstasis, hospital-acquired pneumonia, fungal infections, nontuberculosis mycobacterial infection, and Pneumocystis jiroveci pneumonia. Our intention was to provide guidance for clinicians on the use of aerosolized antibiotics through evidence-based pharmacotherapy. Further research with well-designed clinical trials is necessary to elucidate the optimal dosage and duration of therapy and, of equal importance, to appreciate the true risks associated with the use of aerosolized delivery systems.

Antifungal expenditures are substantial for many hospitals. Using caspofungin for the treatment of candidemia accounts for a sizable proportion of the costs. A cost minimization study that used a decision analytic model was done to compare in-hospital diagnosis and treatment costs using the Candida albicans peptide nucleic acid fluorescence in situ hybridization (PNA FISH) test versus the C. albicans screen test for differentiating C. albicans from non-albicans Candida species bloodstream infections. Assuming physician notification of yeast identity concurrent with blood culture positivity, potential savings resulting from use of the C. albicans PNA FISH test compared with the C. albicans screen test averaged $1837 per patient treated, although laboratory costs for doing the C. albicans PNA FISH test ($82.72) exceeded those for the C. albicans screen test ($2.83). Savings were realized through a decrease in antifungal drug costs, particularly caspofungin. Incorporating the C. albicans PNA FISH test as part of the initial identification algorithm for yeasts recovered from blood can result in substantial savings for hospitals.

The treatment of pulmonary infectious diseases with pharmaceutical aerosols is an attractive option considering the accessibility of the lungs for topical drug delivery. Aerosols have been targeted to the lungs for the treatment of asthma with great success. Current therapies for other diseases, including Pseudomonas aeruginosa, Pneumocystis jirovecii (formerly Pneumocystis carinii), and mycobacterial infections, remain suboptimal due to the efficacy/safety profile. This may be improved by aerosol targeted pulmonary drug delivery. Azithromycin is a broad spectrum antibiotic that acts by inhibiting protein synthesis. It is associated with side effects that might be avoided by aerosol delivery to the lungs. In the present study three concentrations of azithromycin (10, 50, and 100 mg/mL) were delivered from three nebulizers (Acorn II, Updraft, and LC Plus) operated at 8 L/min. Particles size analyses were conducted by inertial impaction and laser diffraction. In addition, emitted doses were determined. A linear proportionality existed across the concentration range between nominal dose and both fine particle dose/fraction and emitted dose, with R2 > 0.999 in all cases. The mass median aerodynamic diameter increased from 1.4 to 1.9 microm between 10 and 100 mg/mL of azithromycin solution concentration for the Acorn II. The particle size distributions were not all log-normally distributed. The median particle size delivered from the devices was largest for the Updraft (2.8 microm) and smallest for the Acorn II (1.9 microm) for 100 mg/mL azithromycin solution concentrations. The efficiencies of small particle delivery (%<4.7 microm) were as follows, LC Plus = Acorn II (85%) > UpDraft (75%). However, the emitted dose from the LC Plus (55 mg/min) was higher than the Acorn II (31 mg/min) to maximize lung exposure to the aerosol, small median diameters and broad particle size distributions would be most effective. This study demonstrates that the dose delivered to the lungs will be maximized, under the current operating conditions by adopting the LC Plus, and high (100 mg/mL) azithromycin concentrations.

A 64-year-old male with Aspergillus fumigatus infection that had disseminated from the lung to the ankle and adjacent bone was treated successfully with posaconazole after therapy with itraconazole and amphotericin B lipid complex failed. Marked clinical improvement occurred within 6 weeks of initiation of posaconazole therapy; after 6 months, infection had resolved at all sites. The patient has had no recurrence of infection.