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La muerte materna es un grave problema de salud pública mundial. Las cifras de muertes maternas son inaceptablemente altas en todo el mundo, en especial en los países en desarrollo. Cada día mueren en todo el mundo unas 830 mujeres por complicaciones relacionadas con el embarazo o el parto. El diagnóstico temprano y manejo oportuno mediante la utilización de medidas generales de soporte vital aunado a medidas específicas de contención del sangrado, a través de la creación de estrategias y protocolos por los servicios de salud, corresponde a la medida más efectiva para disminuir los eventos adversos derivados, y reducir la morbimortalidad materna general. En consecuencia, el objetivo de la presente revisión es compendiar los aspectos generales de la hemorragia en el embarazo y el parto. La investigación se realizó bajo una metodología de tipo documental bibliográfica, bajo la modalidad de revisión. Las principales causas de la hemorragia en el embarazo son el desprendimiento prematuro de placenta normoinserta, la placenta previa, la rotura uterina y la rotura de vasa previa. Mientras que las causas de la hemorragia en el parto son la inercia o atonía uterina, los restos placentarios, el acretismo placentario, la inversión uterina y el trauma de canal del parto. La hemorragia en el embarazo y parto representa una importante causa de mortalidad y morbilidad materna, en consecuencia, resulta fundamental conocer la forma cómo se presenta, sus síntomas, factores de riesgo, causas, a los fines de realizar los diagnósticos precisos y tempranos y realizar la intervención precoz que mejoren el pronóstico de estas pacientes.

Para Ecuador las recaudaciones tributarias desempeñan un rol preponderante dentro del financiamiento del Estado, debido a que dichos ingresos permiten sostener el gasto público gubernamental. Durante los últimos años las reformas tributarias se han encaminado a aumentar la carga tributaria con la finalidad de aumentar los ingresos impositivos, sin embargo, el incremento de impuestos según la teoría, no necesariamente permite obtener resultados positivos. Por tal motivo, el objetivo del presente estudio consiste en estimar el efecto de la presión fiscal sobre la recaudación tributaria, mediante la aplicación empírica y econométrica de la curva de Laffer, para determinar el punto de maximización de los ingresos fiscales en la economía ecuatoriana durante el periodo 2000 a 2020. Se aplican las metodologías de Mínimos Cuadrados Ordinarios (MCO) y cointegración de Johansen y Juselius (1990) juntamente con un modelo de corrección de error. Los resultados son estadísticamente significativos y el signo de los coeficientes corresponden a la teoría, por lo tanto, se ratifica la validez de la curva de Laffer para Ecuador, de tal forma que, en el corto plazo el nivel óptimo de presión fiscal es 19,71% así mismo, los hallazgos encontrados a largo plazo y mediante MCO señalan que el punto óptimo de presión fiscal que maximiza las recaudaciones tributarias está entre 25,39% y 26,49%. Una implicación de política económica es que a corto plazo se puede aumentar la presión fiscal 0,21% y a largo plazo en promedio puede incrementar 6,44%. Dicho incremento debería estar orientado hacia los impuestos progresivos.

Multilevel barriers can arise after a cancer diagnosis, especially in underserved racial/ethnic minority patient populations, raising the need for diverse and contextually adapted interventions. However, limited data exists on Arab American (ArA) cancer patients’ needs, partly due to their racial/ethnic misclassification as Whites. This study leveraged the perspectives of cancer survivors and community stakeholders (i.e., healthcare and community leaders) to identify ArA cancer patients’ needs, as well as their preferred intervention strategies to address them. Using a hybrid inductive-deductive content analysis approach, we analyzed qualitative data from interviews with 18 ArA community stakeholders recruited through community partners in Chicago. Participants associated cancer stigma to ArA patients’ concealment of their diagnosis and aversion to cancer support groups. Economic and language barriers to treatment were emphasized. A lack of resources for ArA cancer patients was also noted and was partly attributed to their misclassification as White. In response to these needs, participants suggested peer mentorship programs to overcome privacy concerns, hospital-based patient navigation to address language and economic barriers in healthcare, diversification of the healthcare workforce to overcome language barriers, and community coalitions to recognize ArA as an ethnic group and increase cancer support resources. Such advocacy will be essential to accurately characterize patients’ cancer burden and obtain funding to support community programs and resources. Our findings suggest that multilevel interventions at the patient, healthcare, and community levels are needed to address ArA cancer patients’ needs.

Community-based public health advocacy efforts are crucial to sustaining the low-cost/free breast cancer services that support underserved populations.We introduce two ways in which narrative theory may be a useful tool for developing advocacy materials and provide an example, using a community-academic partnership to promote Latina breast health in Chicago, Illinois.Community and academic partners 1) engaged 25 Spanish-speaking Latinas in an advocacy workshop, 2) leveraged narrative theory to develop multi-media advocacy materials, and 3) disseminated materials to policymakers.Our project highlights 1) that narrative theory may be useful to describe how Latinas engage policy-makers in relation to their needs and cultural norms, 2) the importance of flexibility and offering community members multiple options to engage policymakers, and 3) the importance of leveraging partners' complementary strengths.Narrative theory may be a useful tool for developing advocacy materials in community-academic partnerships.

espanolRESUMEN Segun la Organizacion Mundial Salud, la anemia afecta en todo el mundo, cerca de 1620 millones de personas, lo que corresponde al 24,8% de la poblacion, la anemia es una situacion compleja, que puede indicar decenas de enfermedades. Por medio del diagnostico laboratorio clinico se puede determinar la causa y el tipo de anemia. En la anemia hemolitica, se produce una reduccion de la vida media de los hematies por destruccion anormalmente elevada (hemolisis). La medula osea intenta compensarla aumentando la produccion eritroide, respuesta mediada por la eritropoyetina. Como consecuencia, se incrementa el porcentaje de reticulocitos en sangre periferica (>2%) y se elevan los indices reticulocitarios. La metodologia de la investigacion, es una revision bibliografica, apoyada en medios electronicos como fuente primaria de obtencion de la informacion. La anemia hemolitica tiene diferentes ramas como se ha podido leer en la presente investigacion, esta claro que es una afeccion que involucra a la sangre y todos sus elementos relacionados como los globulos rojos y la medula osea. Sin embargo, independientemente del tipo de anemia que se llegue a padecer, la prueba de laboratorio en sangre por medio del hemograma, es uno de las pruebas mas rutinarias, donde se podra detectar baja de hemoglobina y existencia de macrocitosis e hipercromia, asi como la valoracion de otros elementos como niveles de acido folico y bilirrubina EnglishAccording to the World Health Organization, anemia affects around the world, about 1.62 billion people, which corresponds to 24.8% of the population, anemia is a complex situation, which can indicate dozens of diseases. Through clinical labora-tory diagnosis, the cause and type of anemia can be determined. In hemolytic anemia, there is a reduction in the half-life of the red cells due to abnormally high destruction (hemolysis). The bone marrow tries to compensate by increasing erythroid production, a response mediated by erythropoietin. As a consequence, the percentage of reticulocytes in peripheral blood increases (> 2%) and reticulocyte indices rise. The research methodology is a bibliographic review, supported by electron-ic media as the primary source for obtaining information. Hemolytic anemia has different branches, as has been read in the present investigation, it is clear that it is a condition that involves the blood and all its related elements such as red blood cells and bone marrow. However, regardless of the type of anemia that is suffered, the laboratory test in blood through the hemogram is one of the most routine tests, where low hemoglobin and the existence of macrocytosis and hyperchromia can be detected, as well as the assessment of other elements such as levels of folic acid and bilirubin

Antecedentes: El pie diabético es la entidad clínica que se representa como la principal complicación de la diabetes, un 20% de los diabéticos necesitará una internación anual y de esta el 25% es a causa del pie diabético. El objetivo principal del estudio fue presentar y establecer las características demográficas mediante escalas de clasificación del pie diabético en los pacientes que acuden al departamento de Emergencias del Hospital General Guasmo Sur. Métodos: Se realizó un estudio retrospectivo, descriptivo, observacional en pacientes con pie diabético durante el año 2018 y 2019. Se analizó edad, género, tiempo de evolución para presentar pie diabético, características clínicas según la escala de Wagner y Texas. Se usó Microsoft Excel y se procesó la información para obtención de porcentajes de variables cualitativa y cuantitativa, se empleó el índice de correlación de Pearson para cada clasificación. Resultados: Se evaluó 70 pacientes con pie diabético, de género masculino el 60%, grupo etario predominante de 51 a 60 años con el 36%. Tipo de diabetes mellitus 2 con el 86%, el tiempo de evolución para presentación clínica del pie diabético con mayor frecuencia de 16 a 20 años con el 36%. Se usó la escala de Texas y Wagner para las características clínicas, las tasas de mortalidad se encontraron a favor con mayor porcentaje para la escala de Wagner con el 17% vs 5% para Texas. Conclusiones: La estadificación del pie diabético de acuerdo a las escalas empleadas, y las características clínicas encontradas tiene importancia médica, la promoción de salud, la prevención de la diabetes mellitus y un buen manejo de las complicaciones es decisivo desde el primer nivel de atención en salud.

En algunos casos médicos, como cirugías y tratamiento de enfermedades cardiovasculares, o traumatismos es necesario el uso de la transfusión de sangre debido al riesgo o la presencia de hemorragia. Sin embargo, puede haber inconvenientes como la disponibilidad limitada de sangre, por falta de donantes, así como incompatibilidad de grupo sanguíneo o factor Rh, el riesgo de transmisión de enfermedades a través de la transfusión o el rechazo del procedimiento por parte del paciente. Por ello, se ha hecho necesario desarrollar sustancias denominadas hemosustituto, o hemoglobinas modificadas, que puedan sustituir a la sangre en su función de transporte de oxígeno. Uno de los fenómenos a evaluar para determinar la seguridad de los hemosustitutos, es el esfuerzo cortante sobre el endotelio. Tanto los esfuerzos elevados como muy bajos pueden generar daños en la función del endotelio produciendo arterias rígidas cuando se tiene un esfuerzo cortante elevado o el colapso de la arteria cuando el esfuerzo cortante disminuye o tiende a cero. Este fenómeno puede observarse mediante secuencias de imágenes de microscopía. En esta evaluación se requiere un grado importante de experticia, ya que los vasos capilares son muy pequeños y determinar la velocidad del flujo sanguíneo es difícil manualmente. Por ello, en este trabajo se propone una nueva técnica para la medición del flujo sanguíneo, desarrollada como un plugin para el programa imageJ. Emplea el canal de color con mayor entropía, sobre el que se realiza una detección de simetría y una transformación de producto de gradiente para la extracción del eje central y la estimación de la velocidad del flujo arteriolar hemostático. Los resultados fueron comparados con los obtenidos manualmente, presentando una mayor precisión y una estimación más rápida al permitir una mejor localización del punto por el que transita el hemosustituto en un tiempo determinado.

Los ninos menores de cinco anos que fallecen cada ano son al menos 40% lactantes recien nacidos, muchos de estos casos son previsibles. El cuidado del feto desde su concepcion y durante el embarazo es requerido, asi como los cuidados inmediatos que se suministran al momento del parto y posterior a este. Revisar los cuidados en todas sus fases desde el parto y consecutivos, analizar los cuidados tanto en el centro de salud como los que deben procurarse en casa, son los principales objetivos planteados por este estudio, la revision documental permite recopilar recomendaciones y mejores practicas en el cuidado del recien nacido para incidir en la formacion y futuras investigaciones y en consecuencia dar a conocer la importancia de los cuidados del Neonato.

Este articulo busca comparar la isquemia en apendicetomia convencional vs laparoscopica, factores de riesgos y complicaciones, por ello, se hace una revision previa de diferentes documentos para asi relacionarla con la investigacion documental y al mismo tiempo permite indicar que en el campo de las urgencias medicas las sintomatologias relacionada con el abdomen especificamente con el apendice se convierte en una practica con alta frecuencia, esto lleva a realizar una intervencion quirurgica conocida como apendicetomia, aplicado ante la presencia de una apendicitis aguda, la misma puede ser efectuada de manera convencional; es decir, se realiza una incision en el lado inferior derecho para extirpar el apendices. Asimismo, existe una cirugia minimamente invasiva (laparoscopica) que representa un avance reciente en la apendicetomia, utiliza una sola incision menos invasiva y utiliza un unico puerto multiluminal o puertos multiples monoluminales, a traves de una unica incision en la piel. Sin embargo, hoy se dan controversias cientificas en relacion a estos procedimientos quirurgicos, el convencional o abierta, ha sido durante mas de un siglo, el mas utilizado para resolver el cuadro clinico, y ha probado largamente su eficacia. Entre las complicaciones comunes en ambas tecnicas, pueden mencionarse la aparicion de abscesos intraabdominales, dehiscencia del munon apendicular, obstruccion intestinal por bridas e infecciones de las heridas quirurgicas. Asimismo, se puede aportar que dichas tecnicas no ofrecen mayores ventajas con respecto al tiempo de internacion, recuperacion del transito intestinal, dolor postoperatorio entre otros. En consecuencia, su eleccion depende del cirujano. Para concluir, que la utilizacion de las tecnicas citadas se encuentra directamente relacionadas con el diagnostico medico y su seleccion es responsabilidad del especialista, pues, ambas de acuerdo a diferentes estudios cientificos presentan ventajas, complicaciones y factores de riesgos que pueden ser debidamente canalizados por el medico.

En algunas situaciones médicas como cirugías y tratamiento de enfermedades cardiovasculares, traumas o hemorragias, se hace necesario el procedimiento de la transfusión sanguínea. Sin embargo, este procedimiento puede presentar inconvenientes como no tener disponibilidad suficiente de sangre, una posible incompatibilidad en el grupo sanguíneo o el factor Rh, el riesgo de contagio de enfermedades a través de la transfusión, y el rechazo por parte del paciente o sus familiares al procedimiento de transfusión debido a creencias personales. Por esta razón, se hace necesario desarrollar sustancias denominadas hemosustitutos, o hemoglobinas modificadas, que puedan reemplazar la sangre en su función de transportar oxígeno a las células y tejidos del cuerpo a través de las vías circulatorias. Para evaluar la eficiencia de los hemosustitutos, se estudia el efecto de estos fluidos sobre el endotelio de arteriolas en modelos animales como son los conejos. Se observa si se producen lesiones o daños vasculares, debido al esfuerzo cortante derivado de la velocidad del flujo sanguíneo y la variación del diámetro de las arteriolas. Este fenómeno puede ser observado a través de secuencias de imágenes de microscopía, y por medio de técnicas de procesamiento de imágenes es posible implementar una herramienta semi-automática que permita realizar el análisis cuantitativo de las características del hemosustituto de forma rápida y objetiva. El presente trabajo introduce un nuevo método basado en técnicas de procesamiento digital de imágenes para la identificación de las arteriolas en el modelo animal, para la medición de la variación de su diámetro a lo largo del tiempo y para la estimación de la velocidad de flujo del hemosustituto.

316 Background: 5FU, Ox, Iri, and Tax are each active in upper GI cancers. Triplet cytotoxic therapies (txs) improved survival compared to doublets/singlets. However, combination of all 4 agents (FOLFOXIRITAX) has not been studied. UGT1A1 polymorphisms reduce UGT enzymatic activity predisposing to Iri toxicity. We sought to determine the maximum tolerated dose (MTD) in the 1st month of tx among each of the low (L), intermediate (I) and high (H) risk UGT1A1 genotype (UGT) groups. Methods: Previously untx’d advanced upper GI cancer patients (pts) with ECOG PS 0/1 received gFOLFOXIRITAX (+ trastuzumab if HER2+) with pegfilgrastim. 5FU 2400mg/m2 over 46 hrs, LV 400mg/m2, Ox 85mg/m2, and Tax 25mg/m2 were given IV Q14 days. UGT-L, I, and H risk groups received starting Iri dose levels (DL1) of 120, 105 and 45mg/m2, respectively; Iri doses were escalated in each UGT group by 15mg/m2 increments and Tax to DL2 of 37.5mg/m2 using a I3+3 novel design (Liu & Ji. J Biopharm Stat 2020). Other endpoints included overall safety (thru up to 8 cycles before maintenance 5FU +/- Iri/tras), ORR (RECIST1.1), & ctDNA response (> 50% decrease in highest MAF) by G360 (Guardant Health). Results: From 6/30/2020-8/6/2021 20 pts (8F, 12M) enrolled: median age 50 (range 21-76); 8 ECOG PS 1, UGT-L:I:H with 3:14:3 pts; 10 esophageal, 6 gastric, 2 pancreatic, 1 unknown GI primary and 1 bile duct cancer; 2 pts HER2+; 18 metastatic, 2 locally advanced unresectable. The median (range) of albumin and neutrophil-to-lymphocyte ratio (NLR) were 3.9 mg/dL (3.3-4.6) and 4.28 (1.89-27.6), respectively; 80% (16/20) of pts had a NLR > 2.88, a poor prognostic marker. Dose limiting toxicities (DLTs) were seen in 4 pts: one G3 diarrhea (UGT-H, DL1/DL1 Iri/Tax), two G3 sepsis not neutropenic (one UGT-I, DL2/DL2 Iri/Tax; and one UGT-I, DL3/DL1 Iri/Tax) and one G3 fatigue (UGT-I DL2/DL2 Iri/Tax). MTD has not been reached in any UGT TAX DL1 cohorts to date; currently enrolling UGT-H Iri/Tax DL1/DL1, UGT-I DL4/DL1, & UGT-L DL3/DL1. Any Gr tx related toxicities in ³ 10% pts thru up to 8 cycles: nausea (70%), fatigue (70%, 5% G3), diarrhea (65%, 5% G3), anorexia (50%), peripheral neuropathy (30%, 5% G3), anemia (30%), thrombocytopenia (25%), elevated LFTs (25%), hyponatremia (25%), vomiting (20%), mucositis (20%, 5% G3), hyperglycemia (20%), edema (15%), alopecia (15%), hypocalcemia (15%) and dysgeusia (10%). Of evaluable pts across all cohorts, PR/CR was seen in 13/16 (81%) patients, with 2 (12.5%) SD and 1 (6.25%) PD for a disease control rate of 94%. Of evaluable pts, best ctDNA response was seen in 12/13 (92%). Conclusions: gFOLFOXIRITAX demonstrated tolerability at initial dose levels of Iri/Tax, with dose escalation continuing. Efficacy is promising and could be an aggressive approach in upper GI cancers having high relapse risk in curative-intent settings. Clinical trial information: NCT04361708.

This study aimed to describe real-life microbiological testing of adults hospitalised with community-acquired pneumonia (CAP) and to assess concordance with the 2007 Infectious Diseases Society of America (IDSA)/American Thoracic Society (ATS) and 2011 European Respiratory Society (ERS) CAP guidelines. This was a cohort study based on the Global Initiative for Methicillin-resistant Staphylococcus aureus Pneumonia (GLIMP) database, which contains point-prevalence data on adults hospitalised with CAP across 54 countries during 2015. In total, 3702 patients were included. Testing was performed in 3217 patients, and included blood culture (71.1%), sputum culture (61.8%), Legionella urinary antigen test (30.1%), pneumococcal urinary antigen test (30.0%), viral testing (14.9%), acute-phase serology (8.8%), bronchoalveolar lavage culture (8.4%) and pleural fluid culture (3.2%). A pathogen was detected in 1173 (36.5%) patients. Testing attitudes varied significantly according to geography and disease severity. Testing was concordant with IDSA/ATS and ERS guidelines in 16.7% and 23.9% of patients, respectively. IDSA/ATS concordance was higher in Europe than in North America (21.5% versus 9.8%; p, Testing practices vary based on geography and disease severity, and IDSA/ATS/ERS testing recommendations are rarely followed http://ow.ly/80Iy30lxo1c

Background: Multiple interventions have been developed to address Latina-White breast cancer (BC) disparities. Yet, little is known about what drives successful implementation, resulting in limited and less successful translation to practice. Engaging participants, community staff, and academicians in program evaluation may enhance identification of factors driving implementation, given differences in lived experience and intervention roles. Objective: We engaged 20 Latina participants, 3 community health workers (CHWs), and 3 research staff to identify determinants of: (1) intervention appropriateness (extent to which interventions addressed BC disparities), (2) feasibility (extent to which intervention delivery/participation was possible), and (3) acceptability (extent to which interventions were satisfactory). Method: The “Empowering Latinas to Obtain Breast Cancer Screenings” trial compared the efficacy of two interventions on BC screening uptake among 142 Latinas who were non-adherent to US Preventive Services Task Force (USPSTF) BC screening guidelines. Both interventions employed CHWs with personal/family history of BC to deliver 3 group sessions and refer patients to navigation services. The current study focuses on a qualitative program evaluation of the trial. All participants completed audio-recorded semi-structured interviews. A sample question was “What helped make it possible to participate in/lead the intervention?.” We conducted deductive content analysis, guided by the Consolidated Framework for Implementation Science, on verbatim transcripts. Results: Emergent themes suggest distinct multilevel determinants of different implementation outcomes. Intervention acceptability and appropriateness were driven by (1) characteristics at intervention (e.g., adaptability to personal needs – e.g., personalized literacy assistance; addressing diverse barriers to BC screening); (2) characteristics of the CHW interventionists (e.g., information delivered via BC survivors' personal experiences); and, (3) characteristics of organizations (e.g., trusted service providers). Intervention feasibility was driven by (1) organizational (e.g., intervention compatibility with mission; clear delineated a priori tasks for intervention delivery) and (2) partnership characteristics (e.g., strength of relationships between academics, community leaders, and clinical navigation BC services). Differences in stakeholder perspectives aligned with their lived experiences. For example, participants' personal challenges with BC screening, CHWs' past experiences leading BC programs, and researchers' awareness of past research on BC disparities affected perceptions about intervention appropriateness. Conclusions: Our findings highlight the value of multi-stakeholder analysis and specify the types of intervention and study team characteristics that are needed to make interventions appropriate, acceptable, and feasible for Latina-White BC equity. Citation Format: Yamilé Molina, Perla Chebli, Stephanie A. Torres, Joanna Olazar, Jeanette Olazar, Katherine Reyes, Juanita Arroyo, Maria Medina, Nora Coronado, Araceli Lucio, Garth H. Rauscher, Lauren Green, Pamela Ganschow, Candyce H. Kroenke, Marc Atkins. Successful implementation of Latina breast health programs: A multi-stakeholder analysis to answer a multilevel question [abstract]. In: Proceedings of the AACR Virtual Conference: 14th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2021 Oct 6-8. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2022;31(1 Suppl):Abstract nr PO-028.

Background E. faecalis (Efc) isolates are usually susceptible to ampicillin (AMP). AMP-based regimens are the standard of care for enterococcal infections, although other antibiotics are often used as definitive treatment. We thus compared outcomes of patients with cancer and Efc bacteremia treated with AMP-containing (ACR) and non-AMP-containing antibiotic regimens (NACR). Methods A multicenter, prospective, observational cohort study conducted at MD Anderson Cancer Center, Henry Ford Hospital, and Memorial Hermann Health System. Eligible patients were ≥ 18 years old, diagnosed with cancer, and had at least one Efc bloodstream isolate collected from 12/2015 to 12/2018. Patients with polymicrobial infections were excluded. Patients were divided into two groups: i) ACR and ii) NACR. ACR included patients who received AMP at any time during treatment; other antimicrobials were permitted. NACR patients did not receive AMP at any time. The primary outcome compared desirability of outcome ranking (DOOR) between ACR and NACR at day 14. The DOOR consisted of six hierarchical levels: 1 - death; 2 - inpatient without microbiological cure (MC) and with acute kidney injury (AKI); 3 - inpatient without MC and without AKI; 4 - inpatient admitted with MC and with AKI; 5 - inpatient with MC and without AKI; 6 - alive and discharged. Comparison of DOORs between ACR and NACR was performed using inverse probability of treatment weighted (IPTW) ordered logistic regression. Results Seventy-one patients were included (ACR, n = 35; NACR, n = 36). No difference was seen in DOORs at day 14 between ACR and NACR (odds ratio [OR] 1.14, 95% Confidence Interval [CI] 0.45 – 2.92, p=0.78). No difference was observed for all-cause mortality at day 14 (OR 0.6, 95% CI 0.09 – 3.77, p=0.58) or day 30 (OR 0.42, 95% CI 0.09 – 1.94, p=0.27). Patients treated with ACR received a lower median duration of other antibiotics at any point during treatment compared to NACR: daptomycin (2 v 4 days) vancomycin (2 v 4 days), and linezolid (1 v 2 days). Conclusion Patients with cancer and Efc bloodstream infections had similar outcomes when treated with ACR and NACR. ACR were associated with less use of broad-spectrum antimicrobials. Future research should focus on the ecologic impact of use of NACR. Disclosures Marcus Zervos, MD, Melinta Therapeutics (Grant/Research Support) Cesar A. Arias, MD, MSc, PhD, FIDSA, Entasis Therapeutics (Scientific Research Study Investigator)MeMed (Scientific Research Study Investigator)Merck (Grant/Research Support)

Vancomycin-resistant enterococci (VRE) infections have acquired prominence as a leading cause of health care-associated infections. Understanding VRE epidemiology, transmission modes in health care settings, risk factors for colonization, and infection is essential to prevention and control of VRE infections. Infection control strategies are pivotal in management of VRE infections and should be based on patient characteristics, hospital needs, and available resources. Hand hygiene is basic to decrease acquisition of VRE. The effectiveness of surveillance and contact precautions is variable and controversial in endemic settings, but important during VRE outbreak investigations and control. Environmental cleaning, chlorhexidine bathing, and antimicrobial stewardship are vital in VRE prevention and control.

OBJECTIVENosocomial outbreaks caused by Salmonella are rare. We describe the investigation and control of a cluster of novel extended-spectrum β-lactamase (ESBL) Salmonella enterica serotype Isangi in a hospital in southeastern Michigan.METHODSAn epidemiologic investigation, including case-control study, assessment of infection control practices and environmental cultures, was performed to identify modes of transmission. Healthcare workers (HCWs) exposed to case patients were screened. Strain relatedness was determined using pulsed-field gel electrophoresis (PFGE); ESBL confirmation was conducted using real-time PCR. Control measures were implemented to prevent further transmission.RESULTSBetween September 2 and October 22, 2015, 19 surgical patients, including 10 organ transplant recipients and 1 HCW, had positive S. Isangi cultures. Of these case patients and HCW, 13 had gastroenteritis, 2 had bacteremia, 1 had surgical-site infection, and 4 were asymptomatic. Pulsed-field gel electrophoresis (PFGE) showed 89.5% similarity among the isolates in these cases. Isolates with resistant-phenotypes possessed plasmid-mediated CTX-M15 ESBL. A total of 19 case patients were compared with 57 control participants. Case patients had significantly higher odds of exposure to an intraoperative transesophageal (TEE) probe (adjusted odds ratio 9.0; 95% confidence interval, 1.12–72.60; P=.02). Possible cross-transmission occurred in the HCW and 2 patients. Cultures of TEE probes and the environment were negative. The outbreak ended after removal of TEE probes, modification of reprocessing procedures, implementation of strict infection control practices, and enhanced environmental cleaning.CONCLUSIONSWe report the first nosocomial ESBL S. Isangi outbreak in the United States. Multiple control measures were necessary to interrupt transmission of this gastrointestinal pathogen. Exposure to possibly contaminated TEE probes was associated with transmission. Periodic monitoring of reprocessing procedures of TEE probes may be required to ensure optimal disinfection.Infect Control Hosp Epidemiol 2016;37:954–961

Background There are limited controlled data demonstrating contact precautions (CPs) prevent methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococcus (VRE) infections in endemic settings. We evaluated changes in hospital-acquired MRSA and VRE infections after discontinuing CPs for these organisms. Methods This is a retrospective study done at an 800-bed teaching hospital in urban Detroit. CPs for MRSA and VRE were discontinued hospital-wide in 2013. Data on MRSA and VRE catheter-associated urinary tract infections (CAUTIs), ventilator-associated pneumonia (VAP), central line–associated bloodstream infections (CLABSIs), surgical site infections (SSIs), and hospital-acquired MRSA bacteremia (HA-MRSAB) rates were compared before and after CPs discontinuation. Results There were 36,907 and 40,439 patients hospitalized during the two 12-month periods: CPs and no CPs. Infection rates in the CPs and no-CPs periods were as follows: (1) MRSA infections: VAP, 0.13 versus 0.11 ( P = .84); CLABSI, 0.11 versus 0.19 ( P = .45); SSI, 0 versus 0.14 ( P = .50); and CAUTI, 0.025 versus 0.033 ( P = .84); (2) VRE infections: CAUTI, 0.27 versus 0.13 ( P = .19) and CLABSI, 0.29 versus 0.3 ( P = .94); and (3) HA-MRSAB rates: 0.14 versus 0.11 ( P = .55), respectively. Conclusions Discontinuation of CPs did not adversely impact endemic MRSA and VRE infection rates.

Background The impact of healthcare personnel hand contamination in multidrug-resistant organism (MDRO) transmission is important and well studied; however, the role of patient hand contamination needs to be characterized further. Methods Patients from 2 hospitals in southeast Michigan were recruited within 24 hours of arrival to their room and followed prospectively using microbial surveillance of nares, dominant hand, and 6 high-touch environmental surfaces. Sampling was performed on admission, days 3 and 7, and weekly until discharge. Paired samples of methicillin-resistant Staphylococcus aureus (MRSA) isolated from the patients’ hand and room surfaces were evaluated for relatedness using pulsed-field gel electrophoresis and staphylococcal cassette chromosome mec, and Panton-Valentine leukocidin typing. Results A total of 399 patients (mean age, 60.8 years; 49% male) were enrolled and followed for 710 visits. Fourteen percent (n = 56/399) of patients were colonized with an MDRO at baseline; 10% (40/399) had an MDRO on their hands. Twenty-nine percent of rooms harbored an MDRO. Six percent (14/225 patients with at least 2 visits) newly acquired an MDRO on their hands during their stay. New MDRO acquisition in patients occurred at a rate of 24.6/1000 patient-days, and in rooms at a rate of 58.6/1000 patient-days. Typing demonstrated a high correlation between MRSA on patient hands and room surfaces. Conclusions Our data suggest that patient hand contamination with MDROs is common and correlates with contamination on high-touch room surfaces. Patient hand hygiene protocols should be considered to reduce transmission of pathogens and healthcare-associated infections., In a prospective study of 399 hospital patients, we show that multidrug-resistant organisms (MDROs) on patient hands are common on admission and correlate with room contamination. New MDRO acquisition is frequent, suggesting a need to develop patient hand hygiene protocols in hospitals.

We compared interventions to improve urinary catheter care and urine culturing in adult intensive care units of 2 teaching hospitals. Compared to hospital A, hospital B had lower catheter utilization, more compliance with appropriate indications and maintenance, but higher urine culture use and more positive urine cultures per 1,000 patient days.

Application of the new 2015 NHSN definition of catheter-associated urinary tract infection (CAUTI) in intensive care units reduced CAUTI rates by ~50%, primarily due to exclusion of candiduria. This significant reduction in CAUTI rates resulting from the changes in the definition must be considered when evaluating effectiveness of CAUTI prevention programs.Infect Control Hosp Epidemiol2017;38:239–241

Background Hepatitis A (Hep A) is a self-limiting diarrheal illness occurring in underdeveloped countries. August 2016 marked the onset of an outbreak in Southeast Michigan. Our study characterizes the presentation and clinical course of Hep A patients that presented to our healthcare system. Methods This study included all Hep A positive cases that presented to Henry Ford Health System from August 2016 to December 2017. Electronic medical records were reviewed for demographics, sexual history, travel history, food exposure, illicit drug use, signs, symptoms and outcomes. Data were also collected on healthcare units of presentation, screening, and care including emergency department, clinic, inpatient hospitalization, or transfer from another facility. Outcomes included hospitalization, consultations with hepatology and transplant, re-admission, and death. Results A total of 166 cases were reviewed; Figure 1 displays the cases per month. The average age was 51 years and 54% were male. The most common symptoms were abdominal pain (47%) and nausea (42.8). Underlying conditions included illicit drug use (23%), alcohol abuse (22%), and diabetes (18.6%). Three percent of cases traveled outside of the state within 2 weeks prior to diagnosis. Twenty-three percent had history of illicit drug use and 4.2% were food handlers. Table 1 displays the healthcare unit where Hep A serology was ordered. One hundred Twenty-two (73.5%) cases were hospitalized, 44 (26.5%) required ICU admission and seven (4.2%) were readmitted within 30 days. Ninety-two cases (55%) required hepatology evaluation, 25 were evaluated for transplantation and one (0.6%) received a liver transplant. Eighteen (10.8%) patients died, two of which were never hospitalized). Figure 1. Number of cases per month and year. Table 1. Healthcare Unit Where Hep A Serology Was Ordered Admission 114 (68.6%) Office visit 31 (18.7) Lab encounter 13 (7.8) ED 8 (4.8) Total 166 Conclusion High clinical suspicion is crucial during an outbreak. Most of our cases were diagnosed with Hep A during inpatient admission after presenting with abdominal pain and nausea. In an outbreak setting, consider testing for immunity from history of previous exposure or vaccination. High hospital admission, morbidity and mortality were seen. Disclosures All authors: No reported disclosures.

Background Vancomycin-resistant enterococci (VRE) are a major cause of nosocomial bloodstream infections. Enterococci exhibit remarkable genomic plasticity and can recombine through the acquisition of genetic material via mobile genetic elements (MGEs), including resistance genes. The accessory genome plays a major role in the evolution of enterococci within the human host. Thus, dissecting the entire genome (pan-genome) is of paramount importance to characterize the population structure of enterococci causing disease. Methods VENOUS is an ongoing prospective, observational study of adults with enterococcal bacteremia. From September 2016 to March 2018, E. faecalis (Efs) and E. faecium (Efm) were collected in 14 hospitals of a single hospital system and a major cancer center in Houston, TX, and a general hospital in Detroit, MI. Short- and long-read genomic sequencing were performed with Illumina MiSeq and Oxford Nanopore Technologies GridION X5, respectively. A proprietary bioinformatics pipeline was utilized for genome assembly and further analyses. Results 156 Efs and 98 Efm isolates from single patients were analyzed. The average proportion of core genes in each genome was 64.6% (53.0–74.1) and 49.1% (45.2–51.0) for Efs and Efm, respectively. The vanA gene cluster was identified in 5.1% (8/157) of Efs and 57.1% (56/98) of Efm. The plasmid-encoded aac(6′)-Ie-aph(2″)-Ia gene conferring high-level resistance to aminoglycosides was found in 37.6% (59/157) Efs, seven of which also possessed vanA. Long-read sequencing of vanA-harboring plasmids from a subset of VRE revealed that the vanA cluster was carried in plasmids ranging from 31.7 to 132.3 kb. Although the vanA operon was fairly conserved, insertions of MGE were identified in the intergenic regions of vanS/vanH and vanX/vanY. Furthermore, a variety of MGE insertions mediated integration of the vanA operon, including IS1216 and IS256 (figure). Conclusion Accessory genes, including AMR genes, comprise a significant proportion of the enterococcal pan-genome, indicating major genetic plasticity within these organisms. Acquired resistance genes seem to have a high degree of recombination and play a substantial role in the expansion of the genomic repertoire in clinical isolates. Disclosures Samuel L. Aitken, PharmD, Melinta Therapeutics: Grant/Research Support, Research Grant; Merck, Sharpe, and Dohme: Advisory Board; Shionogi: Advisory Board.

Enterococci (once called group D streptococci) were first described as human pathogens in 1899, historically thought to be endogenously acquired pathogens from human intestinal flora. Enterococcus faecalis is the most common pathogen, while Enterococcus faecium has become prevalent in hospital-acquired infections. Enterococci have resurfaced with reports of changes in epidemiology, treatment failures, and increasing complexity in antimicrobial resistance patterns. Enterococci have a variety of intrinsic antibiotic resistances and have shown the ability to acquire new resistance genes and mutations. Vancomycin resistance in enterococci is predominantly a healthcare-associated phenomenon. Urinary tract infections and bacteremia are the most common infections caused by enterococci, while endocarditis is the most serious. Enterococci are also commonly found in intra-abdominal, pelvic, and soft tissue infections, often part of a mixed flora. Less common infections are meningitis, osteomyelitis, and septic arthritis. Immunosuppression, long-term colonization, the ability to disseminate widely between patients, and the capacity to form biofilms have made enterococci major pathogens in hospitals, prompting enhanced efforts to identify optimal infection control measures and best therapeutic approaches to improve outcomes.

Vancomycin-resistant enterococci (VRE) infections have acquired prominence as a leading cause of health care-associated infections. Understanding VRE epidemiology, transmission modes in health care settings, risk factors for colonization, and infection is essential to prevention and control of VRE infections. Infection control strategies are pivotal in management of VRE infections and should be based on patient characteristics, hospital needs, and available resources. Hand hygiene is basic to decrease acquisition of VRE. The effectiveness of surveillance and contact precautions is variable and controversial in endemic settings, but important during VRE outbreak investigations and control. Environmental cleaning, chlorhexidine bathing, and antimicrobial stewardship are vital in VRE prevention and control.

BACKGROUND The 2014-2015 influenza season was severe, with circulating influenza A (H3N2) viruses that were antigenically drifted from the vaccine virus. Reported vaccine effectiveness (VE) estimates from ambulatory care settings were markedly decreased. METHODS Adults, hospitalized at 2 hospitals in southeast Michigan for acute respiratory illnesses, defined by admission diagnoses, of ≤10 days duration were prospectively enrolled. Throat and nasal swab specimens were collected, combined, and tested for influenza by real-time reverse transcription polymerase chain reaction. VE was estimated by comparing the vaccination status of those testing positive for influenza with those testing negative in logistic regression models adjusted for age, sex, hospital, calendar time, time from illness onset to specimen collection, frailty score, and Charlson comorbidity index (CCI). RESULTS Among 624 patients included in the analysis, 421 (68%) were vaccinated, 337 (54%) were female, 220 (35%) were age ≥65 years, and 92% had CCI > 0, indicating ≥1 comorbid conditions. Ninety-eight (16%) patients tested positive for influenza A (H3N2); among 60 (61%) A (H3N2) viruses tested by pyrosequencing, 53 (88%) belonged to the drifted 3C.2a genetic group. Adjusted VE was 43% (95% confidence interval [CI], 4-67) against influenza A (H3N2); 40% (95% CI, -13 to 68) for those

Background Enterococci often cause hospital-associated bloodstream infections in critically ill and immunocompromised patients. Prospective studies to assess the clinical impact of enterococcal bacteremia (EB) are lacking. We conducted a prospective study to investigate the clinical and microbiological factors associated with mortality in EB. Methods Adults with EB were prospectively followed in three US tertiary hospitals from September 2016 to March 2018. Individuals with EB for whom follow-up blood culture data within 7 days of index culture were available were included. Microbiologic failure (MF) was defined as clearance of bacteremia ≥4 days after the first blood culture. The main outcome was hospital mortality. Results A total of 282 patients were included with 69 (24%) infected with vancomycin-resistant enterococci (VRE). The majority of patients were male (60%) with a median age of 63 years. Median length of hospitalization for VRE patients was longer (25 d) than non-VRE (13 days, P < 0.001). E. faecium corresponded to 77% of VRE isolates, whereas E. faecalis comprised 72% of non-VRE. The average time to first blood culture was 16 days for VRE vs. 4 days for non-VRE (P < 0.001). Patients with VRE were more likely to have hematological malignancy or bone marrow transplant (P < 0.003), whereas patients infected non-VRE were more likely to have solid tumors (P = 0.02). The most common antibiotic used was daptomycin as monotherapy for both VRE and non-VRE with a median dose of 8 mg/kg for both groups. Overall mortality was 25% (43% vs. 20% in VRE vs. non-VRE patients, respectively; P < 0.0001). Factors significantly associated with mortality in univariate analyses included ICU admission, prolonged hospitalization, hematological malignancy, use of immunosuppressive therapy, hemodialysis, neutropenia (3, infection with VRE and MF. ICU admission (RR 3.3; 95% CI 1.7–7.5, neutropenia (RR 4.1; 95% CI 1.3–12.9), Pitt bacteremia score >3 (RR 6.8; 95% CI 2.6–18.0), MF (RR 4.7; 95% CI 2.2–10.3) and infection with VRE (RR 4.1; 95% CI 1.1–16.6) remained significantly associated with mortality in multivariate analyses. Conclusion The presence of VRE in EB and MF are associated with increased mortality. EB represent a major burden of disease in hospital settings. Disclosures C. Arias, Merck & Co., Inc.: Grant Investigator, Research support. MeMed: Grant Investigator, Research support. Allergan: Grant Investigator, Research support.

BACKGROUND: While the clinical and economic consequences of S. aureus pneumonia in healthcare settings have been well documented, much less is known about community-acquired S. aureus pneumonia (CAP). METHODS: We retrospectively identified all patients admitted to a large US urban teaching hospital between January 2005 and May 2008 with pneumonia and positive blood or respiratory cultures for S. aureus within 48 hours of admission. Patients with suspected healthcare-associated pneumonia (HCAP) were excluded from the study sample, using established criteria (eg, recent hospitalization, admission from nursing home, hemodialysis). Patients were designated as having methicillin-resistant (MRSA) or methicillin-susceptible (MSSA) CAP based on initial S. aureus isolates. Initial therapy was designated “appropriate” vs. “inappropriate” based on expected susceptibility of the organism to the regimen received. RESULTS: We identified a total of 128 CAP patients with S. aureus isolates; mean (standard deviation [SD]) age was 60 (17) years. A total of 55 patients (43%) had initial cultures positive for MRSA. Patients with MRSA CAP were more likely to receive inappropriate initial therapy (24 [44%] vs. 13 [18%] for MSSA; P = 0.002). Approximately 25% of all patients underwent surgery for pneumonia, 69% received mechanical ventilation, 79% were admitted to intensive care unit (ICU), and 24% died in hospital. Mean (SD) length of stay was 17.0 (15.7) days, and total hospital charges averaged $127,922 ($154,605) per patient; there were no significant differences between patients with MRSA vs. MSSA CAP. CONCLUSION: Outcomes are poor, hospital stays are long, and costs of care are high in patients with S. aureus CAP, and do not differ between those with MRSA vs. MSSA. Journal of Hospital Medicine 2010. © 2010 Society of Hospital Medicine.

Background:Escherichia coli is the leading cause of urinary tract infections (UTI). Current Infectious Diseases Society of America (IDSA) guidelines recommend the use of fluoroquinolones when resistance to trimethoprim-sulfamethoxazole is greater than 10% to 20%. Identification of risk factors for f

Methicillin-resistant Staphylococcus aureus (MRSA) USA300 clone is commonly found in the community and is being increasingly reported in the healthcare setting. A retrospective analysis was conducted to compare the epidemiology and outcomes between community-associated (CA) and healthcare-associated (HA) USA300 MRSA infections. The study enrolled 160 subjects with USA300 MRSA infections (47.5% CA-MRSA and 52.5% HA-MRSA). Failure in the HA group was higher (38.1%) compared with the CA group (23.7%) (P = 0.05). Predictors of failure included male gender, age, presence of any co-morbidity, coronary artery disease, chronic kidney disease, history of MRSA, previous admission, fluoroquinolone exposure, HA infection and osteomyelitis (P ≤ 0.05). Independent predictors of failure were osteomyelitis, history of MRSA, male gender and pneumonia. Recurrent disease was found in 32.6% of cases. Overall, USA300 MRSA most commonly causes infection of the skin and skin structure, however, 20% of subjects can experience more invasive disease with infection of the bloodstream, lung or bone. Failure rates are higher in subjects with healthcare risk factors or if the infection was acquired in the hospital, with these subjects experiencing more invasive infections such as bacteraemia, pneumonia or osteomyelitis.

This review summarizes infection prevention resources on the Internet. Web sites are presented in 8 categories: guidelines, policies, and regulatory bodies; health care-associated infection and multidrug-resistant organisms; surveillance, reporting, and initiatives; antibiotic use; employee health; long-term care facilities; facility and environmental infection control; and professional societies, educational opportunities, and listserves. For example, links to the National Surgical Quality Improvement Program and National Healthcare Safety Network reports are provided among resources for infection surveillance, reporting, and initiatives. A link to guidelines for infection prevention in health care workers is listed with other information regarding employee health. The Web address for the Society for Healthcare Epidemiology of America guidelines for infection control in long-term care facilities is listed with resources for long-term care facilities. Guidelines for construction and environmental services are summarized with other information regarding facility and environmental infection control. This review summarizes the most useful and up-to-date infection prevention resources on the Internet and will simplify the search for pertinent information.

Aerobic gram-negative bacilli are rare causes of endocarditis. The epidemiology and risk factors for developing gram-negative endocarditis are evolving. New pathogens, some of which are multidrug resistant, are emerging. The role of nosocomial infections, particularly central venous catheter infections, is increasing. Medical and surgical outcomes appear to be improving with more effective antimicrobial therapy and aggressive surgical management.

Background Daptomycin has become a front-line antibiotic for multidrug-resistant Enterococcus faecium bloodstream infections (BSIs). We previously showed that E. faecium strains with daptomycin minimum inhibitory concentrations (MICs) in the higher end of susceptibility frequently harbor mutations associated with daptomycin resistance. We postulate that patients with E. faecium BSIs exhibiting daptomycin MICs of 3-4 µg/mL treated with daptomycin are more likely to have worse clinical outcomes than those exhibiting daptomycin MICs ≤2 µg/mL. Methods We conducted a multicenter retrospective cohort study that included adult patients with E. faecium BSI for whom initial isolates, follow-up blood culture data, and daptomycin administration data were available. A central laboratory performed standardized daptomycin MIC testing for all isolates. The primary outcome was microbiologic failure, defined as clearance of bacteremia ≥4 days after the index blood culture. The secondary outcome was all-cause in-hospital mortality. Results A total of 62 patients were included. Thirty-one patients were infected with isolates that exhibited daptomycin MICs of 3-4 µg/mL. Overall, 34 patients had microbiologic failure and 25 died during hospitalization. In a multivariate logistic regression model, daptomycin MICs of 3-4 µg/mL (odds ratio [OR], 4.7 [1.37-16.12]; P = .014) and immunosuppression (OR, 5.32 [1.20-23.54]; P = .028) were significantly associated with microbiologic failure. Initial daptomycin dose of ≥8 mg/kg was not significantly associated with evaluated outcomes. Conclusions Daptomycin MICs of 3-4 µg/mL in the initial E. faecium blood isolate predicted microbiological failure of daptomycin therapy, suggesting that modification in the daptomycin breakpoint for enterococci should be considered.

Purpose Clinical studies comparing vancomycin with alternative therapy for methicillin-resistant Staphylococcus aureus (MRSA) bacteremia are limited. The objective of this study was to compare outcomes of early daptomycin versus vancomycin treatment for MRSA bacteremia with high vancomycin MICs in a geographically diverse multicenter evaluation. Methods This nationwide, retrospective, multicenter (N = 11), matched, cohort study compared outcomes of early daptomycin with vancomycin for MRSA bloodstream infection (BSI) with vancomycin MICs 1.5 to 2 µg/mL. Matching variables, based on propensity regression analysis, included age, intensive care unit (ICU), and type of BSI. Outcomes were as follows: (1) composite failure (60-day all-cause mortality, 7-day clinical or microbiologic failure, 30-day BSI relapse, or end-of-treatment failure (EOT; discontinue/change daptomycin or vancomycin because of treatment failure or adverse event]); (2) nephrotoxicity; and (2) day 4 BSI clearance. Findings A total of 170 patients were included. The median (interquartile range) age was 60 years (50–74); the median (range) Acute Physiology and Chronic Health Evaluation II score was 15 (10–18); 31% were in an ICU; and 92% had an infectious disease consultation. BSI types included endocarditis/endovascular (39%), extravascular (55%), and central catheter (6%). The median daptomycin dose was 6 mg/kg, and the vancomycin trough level was 17 mg/L. Overall composite failure was 35% (59 of 170): 15% due to 60-day all-cause mortality, 14% for lack of clinical or microbiologic response by 7 days, and 17% due to failure at end of therapy (discontinue/change because of treatment failure or adverse event). Predictors of composite failure according to multivariate analysis were age >60 years (odds ratio, 3.7; P P = 0.03). Notable differences between treatment groups were seen with: (1) end of therapy failure rates (11% vs 24% for daptomycin vs vancomycin; P = 0.025); (2) acute kidney injury rates (9% vs 23% for daptomycin vs vancomycin; P = 0.043); and (3) day 4 bacteremia clearance rates for immunocompromised patients (n = 26) (94% vs 56% for daptomycin vs vancomycin; P = 0.035). Implications Results from this multicenter study provide, for the first time, a geographically diverse evaluation of daptomycin versus vancomycin for patients with vancomycin-susceptible MRSA bacteremia with vancomycin MIC values >1 µg/mL. Although the overall composite failure rates did not differ between the vancomycin and daptomycin groups when intensively matched according to risks for failure, the rates of acute kidney injury were significantly lower in the daptomycin group. These findings suggest that daptomycin is a useful therapy for clinicians treating patients who have MRSA bacteremia. Prospective, randomized trials should be conducted to better assess the potential significance of elevated vancomycin MIC.

OBJECTIVETo determine whether gowning and gloving for all patient care reduces contamination of healthcare worker (HCW) clothing, compared to usual practice.DESIGNCross-sectional surveys.SETTINGFive study sites were recruited from intensive care units (ICUs) randomized to the intervention arm of the Benefits of Universal Gown and Glove (BUGG) study.PARTICIPANTSAll HCWs performing direct patient care in the study ICUs were eligible to participate.METHODSSurveys were performed first during the BUGG intervention study period (July–September 2012) with universal gowning/gloving and again after BUGG study conclusion (October–December 2012), with resumption of usual care. During each phase, HCW clothing was sampled at the beginning and near the end of each shift. Cultures were performed using broth enrichment followed by selective media. Acquisition was defined as having a negative clothing culture for samples taken at the beginning of a shift and positive clothing culture at for samples taken at the end of the shift.RESULTSA total of 348 HCWs participated (21–92 per site), including 179 (51%) during the universal gowning/gloving phase. Overall, 51 (15%) HCWs acquired commonly pathogenic bacteria on their clothing: 13 (7.1%) HCWs acquired bacteria during universal gowning/gloving, and 38 (23%) HCWs acquired bacteria during usual care (odds ratio [OR], 0.3; 95% confidence interval [CI], 0.2–0.6). Pathogens identified includedS. aureus(25 species, including 7 methicillin-resistantS. aureus[MRSA]),Enterococcusspp. (25, including 1 vancomycin-resistantEnterococcus[VRE]),Pseudomonasspp. (4),Acinetobacterspp. (4), andKlebsiella(2).CONCLUSIONNearly 25% of HCWs practicing usual care (gowning and gloving only for patients with known resistant bacteria) contaminate their clothing during their shift. This contamination was reduced by 70% by gowning and gloving for all patient interactions.Infect Control Hosp Epidemiol 2014;00(0): 1–7

Background. In the United States (US) the 2014–2015 influenza season was severe, with widespread circulation of influenza A (H3N2) viruses that were antigenically drifted from the vaccine virus. We assessed influenza vaccine effectiveness (VE) against influenza illness requiring hospitalization during the 2014–2015 season; low VE was anticipated due to circulation of drifted viruses. Method. Adults hospitalized at two hospitals in Southeast Michigan for treatment of acute respiratory illnesses, broadly defined by admission diagnoses, of ≤10 days duration were prospectively enrolled. Throat and nasal swab specimens were collected, combined, and tested for influenza by RT-PCR. Patients were considered vaccinated if receipt of influenza vaccine ≥14 days prior to illness onset was documented in medical records or state registry, or self-reported at enrollment with plausible location and timing of vaccination. VE was estimated by comparing the vaccination status of those who tested positive for influenza with those who tested negative and calculated as 100 × (1-odds ratio) in logistic regression models; models were adjusted for age, sex, hospital, calendar time, time from illness onset to specimen collection, frailty score, and Charlson Comorbidity Index (CCI). Result. Among 642 patients included in the analysis, 430 (67%) were considered vaccinated, 345 (54%) were female, 228 (36%) were age ≥65 years, and 92% had CCI > 0 indicating ≥1 comorbid condition. One hundred sixteen (18%) patients tested positive for influenza, including 98 (84%) influenza A (H3N2), 9 (8%) influenza A that was not subtyped, and 9 (8%) influenza B Yamagata; 88% of influenza A (H3N2) viruses tested by pyrosequencing belonged to the drifted 3C.2a genetic group. Adjusted VE was 45% (95% CI: 10 to 67) against all influenza, 44% (95% CI: 4 to 68) against A(H3N2) and 82% (95% CI: −7 to 97) against B Yamagata. Adjusted VE against all influenza was 41% (95% CI: −6 to 67) for those

Purpose In light of recent evidence suggesting enhancement of daptomycin activity against vancomycin-resistant Enterococcus (VRE) by ampicillin and other β-lactam antibiotics, we evaluated the safety profile and clinical efficacy of daptomycin with and without concomitant β-lactam antimicrobials in the treatment of VRE ( faecium or faecalis ) bacteremia from multiple centers across the United States. Methods Data were collected retrospectively as part of a larger multicenter registry (The Cubicin Outcomes Registry and Experience). Efficacy and clinical outcomes in patients with VRE bacteremia who received at least 3 days of daptomycin with or without concomitant β-lactams were analyzed. Although all the cases involved daptomycin-susceptible VRE, additional analysis was performed to examine whether the adjunctive β-lactam would play a more pivotal role in cases where the daptomycin MIC was in the upper limit of the susceptibility range, indicating that daptomycin monotherapy efficacy may be relatively compromised compared with cases with lower daptomycin MICs. Findings Two hundred sixty-two patients from 33 hospitals were evaluated. Most patients had at least one significant comorbidity, such as solid-organ or bone marrow transplantation (16%), neutropenia (36%), dialysis dependency (20%), or critical illness (36%) requiring care in an intensive care unit. Overall treatment success was 86% (n = 225/262), and treatment success for patients taking concomitant β-lactams was 86% (n = 105/122). Logistic regression identified treatment failure to be associated with sepsis (odds ratio=3.42; P = 0.009) and an elevated daptomycin MIC (3–4 µg/mL) (odds ratio=3.23, P = 0.013). No significant increase in clinical failure was seen among patients with elevated daptomycin MIC who received concomitant β-lactam therapy (clinical success, 88% vs 79% for MIC ≤2 vs 3–4 µg/mL, respectively; P = 0.417). Of 262 patients, 33 (13%) experienced ≥1 adverse event possibly related to daptomycin (increased creatine kinase in 8 patients). Implications Overall, daptomycin was effective and well tolerated for VRE bacteremia, with lower effectiveness noted with daptomycin MIC of 3 to 4 µg/mL. Concomitant β-lactam therapy with daptomycin may improve clinical outcomes in this setting. Further studies are needed to characterize the potential benefit of concomitant β-lactams with daptomycin.

Using data from the 2000–2004 US Healthcare Cost and Utilization Project National Inpatient Sample, we found that total hospital admissions for skin and soft tissue infections increased by 29% during 2000–2004; admissions for pneumonia were largely unchanged. These results are consistent with recent reported increases in community-associated methicillin-resistant Staphylococcus aureus infections.

Enteroccocal infective endocarditis is a major challenge to clinicians. There are an increasing number of reports of nosocomial acquisition and multidrug-resistant strains complicating management. The therapy of choice for enterococcal endocarditis remains ampicillin and gentamicin; however, high levels of aminoglycoside resistance, vancomycin-resistance, and toxicity of gentamicin with prolonged therapy have necessitated the use of other options in some patients. When the combination of cell wall drug and aminoglycoside cannot be used, the optimal regimen is not well established, due to limited information from clinical trials. There is thus an urgent need to better understand pathogenesis, resistance mechanisms, and optimal management strategies. Clinicians need to explore both antimicrobial and nonantimicrobial strategies for management, including evaluation of those at risk, early diagnosis, appropriate combination, and infection prevention.

Background Methicillin-resistant S. aureus (MRSA) and Vancomycin-resistant enterococci (VRE) are endemic in post-acute care (PAC) settings. We characterize their transmission between patients and environment in 6 PAC facilities in SE Michigan. Methods In a multicenter prospective observational cohort study we collected surveillance cultures of nares, oropharynx, groin, perianal area, wounds, device site(s) and 10 environmental sites collected at enrollment, day 14, and every 30 days thereafter from 651 newly admitted patients. Pulsed-field gel electrophoresis (PFGE) and PCR for SCCmec, agr, and Panton–Valentine leukocidin (pvl) were performed for MRSA. PFGE, and vanA/vanB genotyping were performed for VRE. Results 386/651 (59%) participants were not colonized with MRSA at baseline, had more than 1 follow-up visit and were observed for 15,683 patient-days, over which 5,558 patient and 11,108 environmental swabs were collected. Of these 386 patients, 47 (12%) newly acquired MRSA and had complete strain typing available. 42% of strains were USA 100 HA-MRSA, and 31% were USA 300 CA-MRSA. 14% of strains were non USA 100–1100 strains. For 11/47 (23%), a related MRSA strain was isolated from the environment during the previous visit (Figure 1). 24/47 had a subsequent follow-up visit. In 13/24 (54%) a related MRSA strain was found in the environment on the next visit, suggesting transmission from the patient to the environment (Figure 1). For VRE, PFGE profiles showed high heterogeneity. Among 76 of 296 patients (followed for 11,580 days) who newly acquired VRE, a related VRE was found in the previous visit in 12% of patients, no VRE was found in the previous visit for 42 (55%), and an unrelated strain was present for 33%. In 37 patients for whom a follow-up visit was available, 22% had a related VRE strain in the environment on the subsequent visit and 27% had a new VRE strain. Conclusion New acquisition of VRE was more common than MRSA in this PAC population. Using molecular epidemiologic methods in this large prospective cohort, we show active, frequent and immediate bi-directional transmission between patients and environment. Diminishing environmental contamination has the potential to reduce MDRO transmission to patients in a setting where MRSA and VRE are endemic. Disclosures M. Cassone, National Institute on Aging: Grant Investigator, Research grant; Centers for Disease Control and Prevention: Investigator, Research support; C. Armbruster, Centers for Disease Control and Prevention: Investigator, Research support; E. S. Snitkin, Centers for Disease Control and Prevention: Investigator, Research support; K. Gibson, National Institute on Aging: Investigator, Research grant; Centers for Disease Control and Prevention: Investigator, Research support J. Mantey, National Institute on Aging: Investigator, Research grant; Centers for Disease Control and Prevention: Investigator, Research support; K. C. Reyes, Centers for Disease Control and Prevention: Investigator, Research support S. Altamimi, Centers for Disease Control and Prevention: Investigator, Research support; M. B. Perri, Centers for Disease Control and Prevention: Investigator, Research support; M. J. Zervos, Centers for Disease Control and Prevention: Investigator, Research support; L. Mody, National Institute on Aging: Grant Investigator, Research grant; Centers for Disease Control and Prevention: Investigator, Research support

Vancomycin-resistant enterococci are a major cause of nosocomial infections but are rarely found in humans in the community and have not been identified in food animals in the United States. We evaluated a total of 360 fecal specimens from humans and their animals being raised for exhibit at three county fairs in Michigan. Fecal samples from 158 humans, 55 swine, 50 cattle, 25 horses, 57 sheep, 14 goats, and 1 llama were obtained and plated onto Enterococcosel agar containing 16 μg/ml of vancomycin. Vancomycin-resistant Enterococcus faecium (VREF) was isolated from six pigs but not from humans or any animal other than pigs. All six VREF isolates had a MIC to vancomycin of ≥256 μg/ml and contained the vanA gene. Pulsed-field gel electrophoresis (PFGE) patterns of the six VREF isolates were ≥80% similar. Multilocus sequence typing (MLST) revealed sequence type 5 (ST5) ( n = 2), ST6 ( n = 3), and ST185 ( n = 1), which are E. faecium sequence types belonging to clonal complex 5 (CC5). These findings show the dissemination of VREF strains among pigs in three Michigan counties. This is the first report of VRE found in food animals in the United States.

Background Methicillin-resistant Staphylococcus aureus (MRSA) is a leading cause of hospital-acquired pneumonia (HAP), ventilator-associated pneumonia (VAP), and health-care-associated pneumonia (HCAP). These infections are associated with significant morbidity, mortality, and cost. The impact of vancomycin minimum inhibitory concentration (MIC) on mortality for patients with MRSA pneumonia has not been determined. Methods Adult patients in ICUs with a diagnosis of MRSA HAP, VAP, or HCAP were entered in the study. Clinical and laboratory information were prospectively collected. Vancomycin MIC and heteroresistance were determined for each MRSA isolate. Data were collected from February 2006 through August 2007. The primary outcome variable was all-cause mortality at day 28. A propensity score approach was used to adjust for confounding variables. Results The study sample consisted of 158 patients. All-cause mortality at day 28 was 32.3%. The majority of MRSA isolates had a vancomycin MIC ≥ 1.5 mg/mL (115/158, 72.8%). Propensity score analysis demonstrated an increase in 28-day mortality as vancomycin MIC increased from 0.75 to 3 mg/mL (P ≤ .001). Heteroresistance to vancomycin, demonstrated in 21.5% isolates, was not associated with mortality. Conclusions Mortality in patients with MRSA HAP, VAP, and HCAP increases as a function of the vancomycin MIC, even for strains with MIC values within the susceptible range. Evaluation of vancomycin MICs should be contemplated at the institutional level and for individual cases of MRSA pneumonia. The use of vancomycin therapy in patients with MRSA pneumonia caused by isolates with MICs between 1 and 2 mg/mL should be undertaken with caution, and alternative therapies should be considered.