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Background Performing high-quality surveillance for influenza-associated hospitalization (IAH) is challenging, time-consuming, and essential. Objectives Our objectives were to develop a fully automated surveillance system for laboratory-confirmed IAH at our multihospital health system, to evaluate the performance of the automated system during the 2018 to 2019 influenza season at eight hospitals by comparing its sensitivity and positive predictive value to that of manual surveillance, and to estimate the time and cost savings associated with reliance on the automated surveillance system. Methods Infection preventionists (IPs) perform manual surveillance for IAH by reviewing laboratory records and making a determination about each result. For automated surveillance, we programmed a query against our Enterprise Data Vault (EDV) for cases of IAH. The EDV query was established as a dynamic data source to feed our data visualization software, automatically updating every 24 hours.To establish a gold standard of cases of IAH against which to evaluate the performance of manual and automated surveillance systems, we generated a master list of possible IAH by querying four independent information systems. We reviewed medical records and adjudicated whether each possible case represented a true case of IAH. Results We found 844 true cases of IAH, 577 (68.4%) of which were detected by the manual system and 774 (91.7%) of which were detected by the automated system. The positive predictive values of the manual and automated systems were 89.3 and 88.3%, respectively.Relying on the automated surveillance system for IAH resulted in an average recoup of 82 minutes per day for each IP and an estimated system-wide payroll redirection of $32,880 over the four heaviest weeks of influenza activity. Conclusion Surveillance for IAH can be entirely automated at multihospital health systems, saving time, and money while improving case detection.

The authors review the rationale behind and approaches to testing for COVID-19, the quality of currently available tests, the role of data analytics in strategizing testing, and using the electronic medical record and other programs designed to steward COVID-19 testing and follow-up of patients.

Background Clinical practice guidelines provide recommendations for surgical prophylaxis in patients undergoing cardiothoracic procedures. However, currently no recommendations guide the management of antibiotic prophylaxis in patients who require delayed sternal closure after cardiothoracic operation. Methods This is a single-center, retrospective analysis. Data were extracted from The Society of Thoracic Surgery database and electronic medical record from July 2011 through January 2016. Patients included are adults (≥18 years old) after cardiothoracic operation with delayed sternal closure. Results A total of 167 patients were included for analysis. The majority of patients (131, 78.4%) were continued on routine antibiotics and 36 patients (21.6%) were switched to broad-spectrum antibiotics for prophylaxis. Of patients on routine antibiotic prophylaxis, 6 (4.6%) experienced a sternal surgical site infection, whereas 3 patients (8.3%) switched to broad-spectrum agents before chest closure experienced a sternal surgical site infection ( p = 0.407). Eleven patients (6.6%) received an abbreviated duration of antibiotics, 52 patients (31.1%) were continued on antibiotics until the time of sternal closure, and 104 patients (62.3%) were continued on antibiotics past the time of sternal closure. The incidence of infection based on duration of prophylactic antibiotic was 0, 1 (1.9%), and 8 (7.7%), respectively ( p = 0.352). Conclusions Substantial variation was found in the duration and selection of antibiotic prophylaxis for patients with delayed sternal closure after cardiothoracic operation. Broad-spectrum antimicrobial agents and extended durations of antibiotic prophylaxis were not associated with benefits in the incidence of sternal wound infection and may increase the risk of adverse effects.

The addition of toxin enzyme immunoassay (EIA) to nucleic acid amplification tests, including PCR, creates challenges in the diagnosis and management of Clostridioides difficile infection (CDI). There are limited data in large cohorts, with discordant results, that is, PCR-positive/EIA-negative (PCR(+)/EIA(−)) results. We conducted a retrospective cohort study on all PCR(+)/EIA(−) adult inpatients and assessed CDI-related complications and clinical failure. We identified 240 individuals. Twenty-three (9.6%) patients experienced a CDI-related complication, including 2 cases of megacolon, 1 colectomy, and 22 intensive care unit (ICU) admissions. In multivariable logistic regression analyses, baseline severe disease by Infectious Diseases Society of America (IDSA) criteria (odds ratio [OR], 5.84; 95% confidence interval [CI], 1.88 to 18.1; P = 0.002), baseline fulminant colitis (OR, 84.7; 95% CI, 14.3 to 500; P 38.5°C (OR, 4.61; 95% CI, 1.42 to 15.0; P = 0.011), and proton pump inhibitor (PPI) use (OR, 3.50; 95% CI, 1.19 to 10.3; P = 0.023) were associated with increased odds of CDI-related complications. For 67 PCR(+)/EIA(−) patients who did not receive complete treatment, clinical failure was observed in 10 (15%) patients. A comparison of PCR(+)/EIA(−) patients who received complete treatment to all 112 PCR(+)/EIA(+) patients showed no differences in CDI-related complications (11% and 13% for PCR(+)/EIA(−) and PCR(+)/EIA(+) patients, respectively), 60-day all-cause mortality (17% and 18% for PCR(+)/EIA(−) and PCR(+)/EIA(+) patients, respectively), or recurrent CDI (7% and 9% for PCR(+)/EIA(−) and PCR(+)/EIA(+) patients, respectively). Predictors of CDI-attributable complications among PCR(+)/EIA(−) patients include baseline severe disease by IDSA criteria, baseline fulminant colitis, and fever of >38.5°C. Identifying the subgroup of PCR(+)/EIA(−) patients who could have true disease, and therefore allowing them to be targeted for treatment, is critical.

Objectives The study sought to assess the impact of previously abandoned leads on the clinical management of cardiac device infections, notably transvenous lead extraction and subsequent clinical course. Background The population of patients with cardiac implantable electronic devices continues to grow with a disproportionate increase in device infections, which are invariably life threatening. A potentially complicating issue is the widely practiced strategy of device lead abandonment at the time of system revision, change, or upgrade, which is affecting an increasing number of patients. Methods The study assessed the impact of previously abandoned leads in a prospectively maintained registry of consecutive patients undergoing percutaneous extraction of infected cardiac devices at the Cleveland Clinic between August 1996 and September 2012. The primary clinical endpoint was complete procedural and clinical success defined as the successful removal of the device and all lead material from the vascular space, in the absence of a major complication. Results Of 1,386 patients with infected cardiac devices, 323 (23.3%) had previously abandoned leads. Failure to achieve the primary endpoint occurred more frequently in patients with abandoned leads (13.0% vs. 3.7%; p Conclusions Previously abandoned leads complicate the management of cardiac device infections, leading to worse clinical outcomes.

Background The addition of toxin enzyme immunoassay to molecular tests creates challenges in the diagnosis and management of Clostridiodes difficile infection (CDI). In limited samples of PCR+/ toxin- patients, CDI-attributable complications are thought to be rare, even nonexistent. We aimed to characterize outcomes of a large PCR+/ toxin− cohort within 60 days of initial testing date. Methods We conducted a retrospective cohort study on all PCR+/toxin- adult inpatients from June–December 2018. Patients were placed into 3 groups to analyze outcomes: (1) complete treatment (guideline concordant); (2) incomplete treatment; and (3) no treatment. The primary outcome in group (1) was CDI-related complication, defined as megacolon, colectomy, or ICU care. For groups (2) and (3), clinical failure was defined as a composite of: need for repeat CDI testing or subsequent treatment. Results We identified 240 individuals (Figure 1). Mean age was 60 years, and 122 (51%) were female. 173 (72%) received complete treatment (85% vancomycin monotherapy), 41 (17%) incomplete treatment, and 26 (11%) none. Baseline conditions included high severity comorbidities (Figure 2). In the complete treatment group, 10/173 (5.8%) patients met criteria for fulminant colitis. 21/173 (12%) experienced CDI-attributable complications (2 megacolon, 1 colectomy, 18 ICU care). A significantly higher proportion of these patients had leukocytosis >15,000 (57 vs. 23%; P = 0.001), creatinine >1.5 (57 vs. 27%; P = 0.005), and were receiving concomitant proton pump inhibitors (65 vs. 43%; P = 0.05) and antibiotics (65 vs 44%; P = 0.05) compared with those without CDI-related complications. In patients who received incomplete treatment, there were 10 clinical failures (7 had repeat testing; 3 were administered complete treatment) compared with 4 in the no treatment group (Figure 3). Interestingly, 4/9 (44%) patients who had incomplete or no treatment and underwent repeat testing were found to be PCR+/ toxin+. There were 4 (1.7%) deaths related to CDI in the cohort. All occurred in the complete treatment group. Conclusion CDI-attributable complications and clinical failure occur in PCR+/toxin− patients. The challenge of distinguishing colonization from disease remains. Additional studies are needed to identify predictors of disease in PCR+/ toxin− patients. Disclosures All authors: No reported disclosures.

Background In an effort to optimize diagnostic testing for Clostridioides difficile infection (CDI) our health system changed from stand-alone PCR testing to a “2-step” approach wherein all positive PCR results reflexed to an EIA. We report the effects of this change on publicly reported CDI metrics and treatment days of therapy (DOT). Methods The setting includes 10 Cleveland Clinic Health System hospitals in northeast Ohio and one in Florida. On June 12, 2018, 9 NE Ohio hospitals changed from PCR alone to PCR followed by EIA. Stand-alone PCR testing remained at one and GDH / EIA / PCR for discordant for another. Testing volumes were obtained from the microbiology laboratory. C. difficile LabID event SIRs were obtained from NHSN. Public reporting interpretative categories were identified based on SIR for second half of 2018. DOT for CDI agents were obtained from an antimicrobial stewardship database. Results Among hospitals that changed strategy the volume of PCR testing and the percent PCR + was similar between time periods. EIA positivity ranged from 23% to 53%. 4/11 hospitals improved their public reporting category: 3/9 that changed testing strategy and 1/2 that did not (Table 1). Two of 3 that changed strategy and improved public reporting also had a decrease in DOT. DOT increased in the 2 hospitals that did not change strategy. Conclusion Six months after adopting a 2-step CDI testing strategy 7 of 9 hospitals had a lower SIR with 3 also demonstrating an improvement in public reporting category favorably impacting reputational and reimbursement risk for our healthcare system. CDI agent DOT was similar before and after the change. The impact of choice of test on publicly reported metrics demonstrates the difficulty of utilizing a proxy for hospital onset CDI, the CDI LabID event, as a measure of quality of care provided. Disclosures All authors: No reported disclosures.

Background Diagnosis of Clostridioides difficile infection (CDI) is problematic. Adding toxin enzyme immunoassay (EIA) to molecular tests may differentiate disease from colonization and reduce treatment. Detailed descriptions of prescribing patterns following the introduction of EIA testing are not well characterized, particularly in PCR+/ EIA− patients. Methods In June 2018, Cleveland Clinic added EIA testing to PCR+ specimens. We conducted a retrospective cohort study on all adult inpatients who were PCR+/ EIA- from June–December 2018. Patients were placed into 3 groups for comparison: (1) complete treatment (guideline concordant); (2) incomplete treatment; and (3) no treatment. Associations with prescribing complete treatment were determined. Results We identified 240 patients (Figure 1). Mean age was 60 years, and 122 (51%) were female. Baseline conditions included many high severity comorbidities (Figure 2). 38 (16%) had history of prior CDI. 110/ 240 (46%) patients were receiving concomitant systemic antibiotics. 173 (72%) patients received complete CDI treatment, 41 (17%) incomplete treatment, and 26 (11%) none. 158/ 173 (91%) were prescribed vancomycin amounting to 2,107 days of therapy, averaging 13 PO vancomycin days each. Hematologic malignancy (P = 0.03) and leukocytosis > 15,000/ mm3 (P = 0.04) were significantly associated with complete treatment whereas Infectious Disease (I.D.) consultation was associated with not prescribing complete treatment (P = 0.001). Prior CDI was also associated with not prescribing complete treatment but did not reach statistical significance due to small sample with prior CDI (P = 0.09). There was no association with concomitant systemic antibiotic use or use in the past 1 month. Conclusion In the first 6 months after adding toxin EIA to an existing molecular test for CD, 89% of PCR+/ EIA− patients were prescribed some treatment. Hematologic malignancy and leukocytosis were associated with treatment. I.D. consultation was associated with not prescribing treatment. Although we suspect a learning curve with the 2-step approach to testing, it appears the challenge of optimizing testing and management remains. Improved understanding of the clinical significance of a sensitive test on a non-sterile specimen is required. Disclosures All authors: No reported disclosures.

Valvular involvement in Lyme disease is rare. Confirmation of Borrelia species as the causative agent with polymerase chain reaction was done in a few cases in Europe and the United States. We describe a case of mitral regurgitation with a preoperative diagnosis of myxomatous mitral valve degeneration. During surgery, the surgeon suspected infective rather than degenerative etiology; the results of tissue cultures were negative. However, universal bacterial polymerase chain reaction on explanted valve tissue detected Borrelia burgdorferi DNA. If a surgeon suspects infective endocarditis at the time surgery, appropriate specimens should be sent for histopathologic analysis, culture, and polymerase chain reaction assay.

BACKGROUNDCatheter-associated urinary tract infections (CAUTIs) are among the most common hospital-acquired infections (HAIs). Reducing CAUTI rates has become a major focus of attention due to increasing public health concerns and reimbursement implications.OBJECTIVETo implement and describe a multifaceted intervention to decrease CAUTIs in our ICUs with an emphasis on indications for obtaining a urine culture.METHODSA project team composed of all critical care disciplines was assembled to address an institutional goal of decreasing CAUTIs. Interventions implemented between year 1 and year 2 included protocols recommended by the Centers for Disease Control and Prevention for placement, maintenance, and removal of catheters. Leaders from all critical care disciplines agreed to align routine culturing practice with American College of Critical Care Medicine (ACCCM) and Infectious Disease Society of America (IDSA) guidelines for evaluating a fever in a critically ill patient. Surveillance data for CAUTI and hospital-acquired bloodstream infection (HABSI) were recorded prospectively according to National Healthcare Safety Network (NHSN) protocols. Device utilization ratios (DURs), rates of CAUTI, HABSI, and urine cultures were calculated and compared.RESULTSThe CAUTI rate decreased from 3.0 per 1,000 catheter days in 2013 to 1.9 in 2014. The DUR was 0.7 in 2013 and 0.68 in 2014. The HABSI rates per 1,000 patient days decreased from 2.8 in 2013 to 2.4 in 2014.CONCLUSIONSEffectively reducing ICU CAUTI rates requires a multifaceted and collaborative approach; stewardship of culturing was a key and safe component of our successful reduction efforts.Infect Control Hosp Epidemiol 2017;38:186–188

OBJECTIVEAn estimated 20–30% of patients with primary Clostridium difficile infection (CDI) develop recurrent CDI (rCDI) within 2 weeks of completion of therapy. While the actual mechanism of recurrence remains unknown, a variety of risk factors have been suggested and studied. The aim of this systematic review and meta-analysis was to evaluate current evidence on the risk factors for rCDI.DESIGNWe searched MEDLINE and 5 other databases for subject headings and text related to rCDI. All studies investigating risk factors of rCDI in a multivariate model were eligible. Information on study design, patient population, and assessed risk factors were collected. Data were combined using a random-effects model and pooled relative risk ratios (RRs) were calculated.RESULTSA total of 33 studies (n=18,530) met the inclusion criteria. The most frequent independent risk factors associated with rCDI were age≥65 years (risk ratio [RR], 1.63; 95% confidence interval [CI], 1.24–2.14; P=.0005), additional antibiotics during follow-up (RR, 1.76; 95% CI, 1.52–2.05; PP=.008), and renal insufficiency (RR, 1.59; 95% CI, 1.14–2.23; P=.007). The risk was also greater in patients previously on fluoroquinolones (RR, 1.42; 95% CI, 1.28–1.57; PCONCLUSIONSMultiple risk factors are associated with the development of rCDI. Identification of modifiable risk factors and judicious use of antibiotics and PPI can play an important role in the prevention of rCDI.Infect Control Hosp Epidemiol 2015;00(0): 1–9

We have noticed that patients colonized with methicillin-susceptible Staphylococcus aureus (MSSA) rarely get methicillin-resistant S. aureus (MRSA) infections. The purpose of this study was to compare the odds of a Staphylococcus aureus (SA) infection being an MRSA infection in MSSA carriers, MRSA carriers and non-carriers of SA.Hospitalizations of adult patients at the Cleveland Clinic Health System from 2008 to 2015 were screened to identify those where the patient was tested for SA colonization. The first such hospitalization was identified. Among these 90 891 patients, those who had an SA infection during the hospitalization were included. SA carrier status (MRSA, MSSA, or non-carrier), was defined based on the first nasal SA test result. The association of carrier status and MRSA infection was examined.The mean (±standard deviation (SD)) age of the 1999 included patients was 61 (17) years, and 1160 (58%) were male. Thirty percent, 26%, and 44%, were MRSA carriers, MSSA carriers and non-carriers, respectively. Of the 601 SA infections in MRSA carriers (reference group), 552 (92%) were MRSA infections compared with 42 (8%) of 516 in MSSA carriers (odds ratio (OR) 0.008, 95% confidence interval (CI) 0.005-0.012, p0.0001) and 430 (49%) of 882 in non-carriers (OR 0.072, 95% CI 0.051-0.100, p 0.0001), after controlling for age, sex, hospital length of stay and calendar year.Among patients with SA infection, the odds of the infection being an MRSA infection are 125-times lower in an MSSA carrier than in an MRSA carrier.

Background In September 2018, pharmacy antimicrobial stewardship services were expanded to include weekends at Cleveland Clinic. Activities performed by antimicrobial stewardship (AMS) pharmacists on the weekend include blood culture rapid diagnostic (RDT) review, antiretroviral therapy (ART) review, prospective audit and feedback (PAF) utilizing clinical decision support, vancomycin dosing, and operational support. The purpose of this study was to assess the operational and clinical impact of these expanded AMS services. Methods This single-center, the quasi-experimental study included data from 13 weekends before (9/2017 – November 2017) and after (9/2018 – November 2018) implementation of weekend services. The primary outcome was the number of reviews relating to each stewardship activity. Secondary outcomes were time to AMS opportunity resolution, time to escalation or de-escalation following PAF or RDT alert, time to resolution of other AMS-related opportunities, length of stay (LOS), and antimicrobial use outcomes. Patients were included in time to resolution outcomes if they had an RDT, ART, or select PAF review requiring intervention. Time to opportunity resolution was defined as the time from AMS alert to implementation of the recommendation in the electronic health record. Results During the post-intervention period 1261 reviews were conducted, averaging 97/weekend. This included 187 RDT, 432 PAF, 124 ART, 331 vancomycin dosing notes and 187 other. Inclusion criteria for time to resolution outcomes were met by 72 patients pre-intervention compared with 59 patients post. No significant differences were seen in baseline characteristics between groups with 43% of patients requiring ID consultation and 58% requiring ICU admission. The median time to opportunity resolution improved significantly overall (P < 0.01), with de-escalation (P = 0.03), and with time to other AMS opportunity (P = 0.01) (Figure 1). A numerical reduction was seen with time to escalation (P = 0.1). LOS was a median of 13 and 14 days pre- and post-intervention, respectively (P = 0.4). No differences were seen in antimicrobial use outcomes. Conclusion Presence of pharmacist-driven weekend AMS services significantly reduced time to resolution of AMS interventions. These data support the value of weekend AMS services. Disclosures All authors: No reported disclosures.

Background In the United States in 2014, 266 million outpatient antibiotic prescriptions were dispensed. The Center for Disease Control and Prevention estimates that 30% of outpatient antibiotic prescriptions are inappropriate. These inappropriate prescriptions contribute to increased resistance, adverse events, and healthcare costs. Methods This was a retrospective study of patients presenting to 22 urgent care centers within a large healthcare system between September 1, 2018 and February 28, 2019. Data were collected from a dashboard designed to track antimicrobial prescribing data by indication, location, and provider. ICD-9 and -10 codes associated with otitis media, pharyngitis, sinusitis, cystitis, and upper respiratory infections (URI) were included. Guideline-concordant antimicrobial prescribing was determined based on compliance with national guideline recommendations, after taking patient allergies into account. The URI category includes disease states in which antimicrobials are rarely appropriate (e.g., acute rhinitis, nasopharyngitis, and acute bronchitis). Results A total of 57,799 encounters were included in this analysis (19,242 pediatric and 38,557 adult) and 60% of patients received an antibiotic prescription. Overall antimicrobial guideline concordance was higher in pediatrics (84%) than adults (62%). Rates of guideline-concordant antimicrobial selection are shown in Table 1. The most common guideline-discordant prescriptions were tetracyclines (39%), amoxicillin/clavulanate (26%), and macrolides (17%) in adult patients with sinusitis, pharyngitis, or otitis media. In pediatric patients, the most common discordant prescriptions were macrolides (32%), third-generation cephalosporins (30%), and amoxicillin/clavulanate (19%). Unnecessary antimicrobial prescribing for URI occurred in 23% of pediatric patients and 36% of adult patients. Conclusion Guideline-discordant antimicrobial prescribing is common in urgent care centers, particularly in adult patients. In addition to encouraging utilization of order sets, emphasis on education and feedback may be important to improve and sustain guideline-concordant prescribing rates and reduce prescribing for URI. Disclosures All Authors: No reported Disclosures.

Background The purpose of this study was to evaluate antimicrobial consumption metrics as a means for differentiating patient populations and antimicrobial stewardship (AMS) opportunities. Methods This single-center, retrospective, descriptive study included all patients from January 1, 2018 to June 30, 2018 that received ≥1 day of therapy (DOT) of any antimicrobial included in the National Healthcare Safety Network Antimicrobial Use and Resistance (NHSN AUR) module. The cohort was then grouped into 4 quartiles based on DOT (Q1 lowest; Q4 highest). The primary outcome was a Lorenz Curve of DOT per patient over the study period. Secondary outcomes included a comparison of patient characteristics and number/type of AMS-related opportunities present (using a randomized convenience sample of 25 patients per quartile). AMS opportunities were defined as any unnecessary, inappropriate, or suboptimal antimicrobial use with pharmacist intervention or potential for intervention occurring 24 hours after the antimicrobial initiation. Results During the 6 month study period, 24,743 patients accounted for 163,859 days present, and 13,039 (52%) received ≥ 1 DOT. After dividing the population into quartiles of antimicrobial use, median (range) DOT were as follows: Q1 [2 (1–2)], Q2 [4 (3–4)], Q3 [7 (5–10)], Q4 [20 (11–636)] (Figure 1). The top 24% of patients according to antimicrobial use accounted for 74% of total antimicrobial DOT. Patient-level DOT data are displayed by SAAR grouping in Figure 2. In the cohort of 100 patients, differences between quartiles included Infectious diseases consultation in 76% of patients in Q4 compared with 4–24% in other quartiles, ICU admission during hospitalization in 68% in Q4 compared with 28–40% in other quartiles, and any surgical procedure in 88% in Q1 compared with 48–60% in Q2–4. The number of AMS opportunities present were 4 (0.5/1000 DOT) in Q1, 13 (1.6/1000 DOT) in Q2, 28 (1.4/1000 DOT) in Q3, and 86 (0.8/1000 DOT) in Q4. The most common type of AMS opportunity differed by quartile: inappropriate prophylaxis for Q1-3, and de-escalation in Q4. Conclusion Evaluating antimicrobial consumption from a patient-level perspective at a large academic medical center reveals heterogeneity and variable AMS opportunities across quartiles Disclosures All authors: No reported disclosures.

Background Guidelines for antimicrobial prophylaxis in surgery recommend cefazolin dose be adjusted based on patient weight. Adults weighing ≥120 kg should receive a 3 g dose, all other adult patients should receive a 2 g dose pre-operatively. To promote guideline adherence, an antimicrobial stewardship pharmacist-driven dose optimization intervention was implemented. Methods Retrospective, pre (February 1, 2017–March 31, 2017)/post (February 1, 2018–March 31, 2018) study evaluating the impact of a pharmacist-driven cefazolin dose optimization intervention at a large health system. An alert within the electronic health record notified pharmacists during order verification when cefazolin dose from a surgical prophylaxis order set did not match weight-based recommendations. All patients with cefazolin orders for surgical prophylaxis were included; pediatric and pregnant patients were excluded. Results Pre-group included 9,830 patients, post-group 10,025 patients. In both groups, the mean age was 58 years, mean weight 87 kg, and 8% of patients weighed ≥120 kg. Approximately 21% of patients were seen at the academic medical center, 8% at ambulatory surgery centers, and the remainder amongst 10 community hospitals. Most common surgical procedure types were orthopedic (26%), general surgery (21%) and urologic (10%). Primary cefazolin dose was 2 g in 89.8% vs. 88.7%, followed by 3 g 6.6% vs. 6.9% and 1 g in 3.9% vs. 4.4%, pre- and post-intervention, respectively. Overall adherence to weight-based cefazolin dosing was 92.2% pre-group and 92.4% post-group. In patients weighing ≥120 kg, adherence improved from 62% (514/827) to 71% (582/817) post-intervention, P < 0.001. Adherence was better both pre- and post-intervention when an order set was used (pre: order set 95.0% vs. no order set 85.9%, P < 0.001; post: order set 96.4% vs. no order set 84.8%, P < 0.001). There were no differences between surgical services or hospital locations. Investigation of guideline nonadherent cases found order sets without updated dosing recommendations and allowed for targeted education efforts. Conclusion Overall adherence to cefazolin weight-based dosing recommendations for surgical prophylaxis was high, especially with the use of order sets. Pharmacist-driven dose optimization intervention improved guideline adherence in patients weighing ≥120 kg. Disclosures All authors: No reported disclosures.

Objective.To review and describe device utilization and central line-associated bloodstream (CLABSI) events among patients in a non-intensive care unit (ICU) setting and to examine the morbidity and mortality associated with these events.Design. One-year descriptive review.Setting.A single tertiary center with a 1,200-bed hospital and 209 adult ICU beds.Patients.Hospitalized patients identified as having a CLABSI event attributed to a non-ICU setting.Methods.The cohort was identified from a prospective infection prevention database. Charts and administrative data sets were reviewed to further characterize the patients. Device utilization ratios (DURs) and CLABSI rates were calculated using National Health and Safety Network (NHSN) CLABSI definitions. Need for ICU stay and crude mortality rates were recorded.Results.A total of 136 patients with 156 CLABSIs were identified, of whom 78 (57%) were being treated for a hematological malignancy (HM). The overall DUR was 0.27. A tunneled line was in place for 118 (76%) of the CLABSI events, and a peripherally inserted central catheter was in place for 32 (21%) of the CLABSI events. The non-ICU CLABSI rate was significantly higher than the concurrent ICU rate (2.1 CLABSIs per 1,000 catheter-days vs 1.5 CLABSIs per 1,000 catheter-days; P = .02). Hospital mortality was 23% in the affected group and was significantly higher in patients with HM.Conclusions.CLABSI rates over a 1-year period were higher in patients outside the ICU at our hospital and were associated with significant mortality.

To determine the value of surgery for infective endocarditis (IE) in patients on hemodialysis by comparing the nature and invasiveness of endocarditis in hemodialysis and nonhemodialysis patients and their hospital and long-term outcomes, and identifying risk factors for time-related mortality after surgery.From January 1997 to January 2013, 144 patients on chronic hemodialysis and 1233 nonhemodialysis patients underwent valve surgery for IE at our institution. Propensity matching identified 99 well-matched hemodialysis and nonhemodialysis patient pairs for comparison of outcomes.Staphylococcus aureus infection was more common in hemodialysis patients than in nonhemodialysis patients (42% vs 21%; P .0001), but invasive disease was similar in the 2 groups (47%; P = .3). Hospital mortality was 13% and 5-year survival was 20% for hemodialysis patients, 20% below that expected in a general hemodialysis population but 15% above that of hemodialysis patients treated nonsurgically for IE. For matched patients, hospital mortality was 13% for hemodialysis patients versus 5.1% for nonhemodialysis patients (P = .05), and survival at 1 and 5 years was 56% versus 83% and 24% versus 59%, respectively (P .004). Use of an arteriovenous graft for dialysis access (P = .01) and preoperative placement of a pacemaker (P .0001) were risk factors for late mortality in hemodialysis patients. For matched patients, freedom from reoperation was similar in the hemodialysis and nonhemodialysis groups (P .9).Intermediate-term survival after surgery for IE in hemodialysis patients is substantially worse than that in nonhemodialysis patients, but only slightly worse than that in the general hemodialysis population and substantially better than that in hemodialysis patients with IE treated nonsurgically, supporting continued surgical intervention for IE.

Objective.To develop a modified surveillance definition of central line-associated bloodstream infection (mCLABSI) specific for our population of patients with hematologic malignancies to better support ongoing improvement efforts at our hospital.Design.Retrospective cohort study.Patients.Hematologic malignancies population in a 1,200-bed tertiary care hospital on a 22-bed bone marrow transplant (BMT) unit and a 22-bed leukemia unit.Methods.An mCLABSI definition was developed, and pathogens and rates were compared against those determined using the National Healthcare Safety Network (NHSN) definition.Results.By the NHSN definition the CLABSI rate on the BMT unit was 6.0 per 1,000 central line-days, and by the mCLABSI definition the rate was 2.0 per 1,000 line-days (P < .001). On the leukemia unit, the NHSN CLABSI rate was 14.4 per 1,000 line-days, and the mCLABSI rate was 8.2 per 1,000 line-days (P = .009). The top 3 CLABSI pathogens by the NHSN definition were Enterococcus species, Klebsiella species, and Escherichia coli. The top 3 CLABSI pathogens by the mCLABSI definition were coagulase-negative Staphylococcus (CONS), Pseudomonas aeruginosa, and Staphylococcus aureus. The difference in the incidence of CONS as a cause of CLABSI under the 2 definitions was statistically significant (P < .001).Conclusions.A modified surveillance definition of CLABSI was associated with an increase in the identification of staphylococci as the cause of CLABSIs, as opposed to enteric pathogens, and a decrease in CLABSI rates.

Context.—Endovascular infection is an uncommon but devastating manifestation of histoplasmosis, which is often diagnosed late in disease. Objectives.—To evaluate the clinical and pathologic characteristics of patients with endovascular infections caused by Histoplasma capsulatum. Design.—All cases of patients with documented endovascular histoplasmosis at a single tertiary care center in an endemic region during the period 1993–2010 were reviewed. Results.—Patients presented with a subacute febrile illness and a history of endovascular devices. All patients had positive Histoplasma serology. Routine bacterial culture results were negative for all patients. In addition to yeast forms typical of histoplasmosis, pathologic findings also revealed mycelial forms in 4 of 5 patients. Inflammation was scant. Urinary antigen detection was positive in 4 of 5 patients and Histoplasma blood culture results were positive for 3 of 5 patients. Four patients were treated with a combination of surgical and medical therapy, which consisted of amphotericin B followed by itraconazole; these 4 patients had complete resolution of symptoms and no documented relapse. One patient died before planned surgery. Conclusions.—Histoplasma capsulatum endovascular infections are clinically characterized by a subacute febrile illness with negative bacterial cultures in patients with prosthetic endografts or valves. Noninvasive diagnostics are often the initial clue to the diagnosis. Combined medical and surgical treatment is associated with survival. On histopathologic examination both mycelial and yeast forms are often observed, with absent to minimal tissue inflammatory reaction.

Background The risk of death and complications of infective endocarditis (IE) treated medically has to be balanced against those from surgery in constructing a therapeutic approach. Recent literature has drawn conflicting conclusions on the benefit of surgery for IE. We reviewed patients treated surgically for IE at the Cleveland Clinic from 2003 to 2007 to examine their outcomes. Methods A retrospective review of consecutive patients who underwent surgery for native and prosthetic valve endocarditis between January 1, 2003, and December 31, 2007, was conducted. Surgical outcomes were reviewed to include survival and postoperative complications. Survival was evaluated at end of hospital stay, 30 days, 1 year, and at last follow-up. Results Four hundred twenty-eight patients underwent surgery for IE during the study period: 248 (58%) had native valve endocarditis and 180 (42%) had prosthetic valve endocarditis. Overall 90% of patients survived to hospital discharge. When compared with patients with native valve infection, patients with prosthetic infection had significantly higher 30-day mortality (13% versus 5.6%; p p = 0.19). Patients with IE caused by Staphylococcus aureus had significantly higher hospital mortality (15% versus 8.4%; p p = 0.05), and 1-year mortality (28% versus 18%; p = 0.02) compared with non–S aureus IE. Conclusions Surgical treatment of IE was associated with 90% hospital survival. Outcomes within the 30 days were better for native valve than for prosthetic valve endocarditis. Long-term outcomes were similar. Finally, S aureus was associated with significantly higher mortality compared with other pathogens.

The accepted approach to surveillance for hospital-acquired bloodstream infection (HABSI) due to central venous catheters requires use of the National Health and Safety Network (NHSN) definition for catheter-associated bloodstream infection (CLABSI). In this commentary, we discuss our experience with the application of current NHSN surveillance definitions for CLABSI and the impact that public reporting of CLABSI rates in settings with a high prevalence of special populations has on infection prevention (IP) programs. For IP programs to serve the continuous improvement needs of their organizations, surveillance methodologies need to accurately capture the burden of preventable HABSI among immunocompromised individuals with inherent risk for infection. Current NHSN CLABSI definitions lack specificity for complex and heterogeneous patient populations and require modification. Beyond definitions, IP programs must critically assess the value of their current approach to surveillance to assure that patient-centered outcomes are the focus of prevention efforts.

Background Infectious Diseases Society of America and Society for Healthcare Epidemiology Guidelines for Implementing an Antibiotic Stewardship Program (ASP) and the CDC Core Elements of Hospital ASP include antimicrobial time-outs (ATO) as an example of a recommended action. There are limited data evaluating the impact of ATOs on antimicrobial use. Cleveland Clinic Health-System (CCHS) implemented a 72-hour ATO for antimicrobials with an empiric indication and no stop date within the electronic health record. This study aimed to assess the effect of an ATO on antimicrobial utilization. Methods Retrospective, quasi-experimental study of patients between October 1–December 31, 2016 and 2017 who received at least one systemic antimicrobial agent while admitted to a US-based CCHS hospital. Primary objective was to compare the days of therapy (DOT) per 1,000 patient-days of broad-spectrum agents before and after ATO implementation. Secondary objectives included comparing indications for use, actions taken as a result of the ATO, and rate of Clostridium difficile. Antimicrobial groupings per National Healthcare Safety Network AUR Module. Results In 4Q2016, there were 75,982 antimicrobial orders in 31,945 encounters, of which 5,029 encounters had an empiric antimicrobial active at 72 hours. In 4Q2017, there were 78,418 antimicrobial orders in 33,378 encounters, which led to 38,129 ATOs in 6,138 encounters. Mean duration of therapy was 71 hours in 4Q2016 vs. 62 hours in 4Q2017, P < 0.05 (Figure 1). DOT/1,000 patient-days did not differ (Figure 2). Orders with the indication of pathogen directed did not change (14.1% vs. 14.4%; P = 0.11). Of 16,009 ATOs acknowledged by clinicians, 2,195 (14%) prompted antimicrobial discontinuation, while 684 alerts (4%) prompted de-escalation. There was no difference in encounters with positive C. difficile PCR, 123 (2.4%) vs. 152 (2.5%). Conclusion Implementation of an ATO for all antimicrobials within an electronic health record decreased duration of therapy but not DOT/1,000 patient-days. Further study is needed to define optimal ATO characteristics (targeted vs. all antimicrobials, 48 vs. 72 hours, etc.) and potential impact on utilization and appropriate antimicrobial usage. Figure 1. Figure 2. Disclosures All authors: No reported disclosures.

Objective.To evaluate the effects of an active surveillance program for Staphylococcus aureus linked to a decolonization protocol on the incidence of healthcare-associated infection and new nasal colonization due to S. aureus.Design.Retrospective quasi-experimental study.Setting.An 18-bed medical intensive care unit at a tertiary care center in Cleveland, Ohio.Methods.From January 1, 2006, through December 31, 2007, all patients in the medical intensive care unit were screened for S. aureus nasal carriage at admission and weekly thereafter. During the preintervention period, January 1 through September 30,2006, only surveillance occurred. During the intervention period, January 1 through December 31,2007, S. aureus carriers received mupirocin intranasally. Beginning in February 2007, carriers also received Chlorhexidine gluconate baths.Results.During the preintervention period, 604 (73.7%) of 819 patients were screened for S. aureus nasal carriage, yielding 248 prevalent carriers (30.3%). During the intervention period, 752 (78.3%) of 960 patients were screened, yielding 276 carriers (28.8%). The incidence of S. aureus carriage decreased from 25 cases in 3,982 patient-days (6.28 cases per 1,000 patient-days) before intervention to 18 cases in 5,415 patient-days (3.32 cases per 1,000 patient-days) (P = .04; relative risk [RR], 0.53 [95% confidence interval {CI}, 0.28-0.97]) and from 9.57 to 4.77 cases per 1,000 at-risk patient-days (P = .02; RR, 0.50 [95% CI, 0.27-0.91]). The incidence of S. aureus hospital-acquired bloodstream infection during the 2 periods was 2.01 and 1.11 cases per 1,000 patient-days, respectively (P = .28). The incidence of S. aureus ventilator-associated pneumonia decreased from 1.51 to 0.18 cases per 1,000 patient-days (P = .03; RR, 0.12 [95% CI, 0.01-0.83]). The total incidence of S. aureus hospital-acquired infection decreased from 3.52 to 1.29 cases per 1,000 patient-days (P = .03; RR, 0.37 [95% CI, 0.14-0.90]).Conclusions.Active surveillance for S. aureus nasal carriage combined with decolonization was associated with a decreased incidence of S. aureus colonization and hospital-acquired infection.

From the Cleveland Clinic, Cleveland, Ohio. Disclosures: J.L.N. serves as a consultant to Cryolife Inc, Kennesaw, Ga. Received for publication May 1, 2009; accepted for publication May 17, 2009; available ahead of print July 13, 2009. Address for reprints: Jose L. Navia MD, FACC, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH 44195. J Thorac Cardiovasc Surg 2010;139:1077-81 0022-5223/$36.00 Copyright 2010 by The American Association for Thoracic Surgery doi:10.1016/j.jtcvs.2009.05.017

Staphylococcus aureus infections after cardiac surgery result in significant morbidity and mortality. Identifying patients at elevated risk for these infections preoperatively could facilitate efforts to reduce infection rates. The objectives of this study were to estimate the incidence of postoperative S. aureus infections in cardiac surgery patients, to identify preoperative risk factors for these infections, and to establish a patient risk profile by means of data available to clinicians prior to surgery.Cohort study.Eight medical centers that participate in the Society of Thoracic Surgeons National Cardiac Database.Patients who were undergoing elective cardiac surgery during the period January 1, 2000 through December 31, 2004.Clinical and microbiological data from 16,386 patients were combined. Multivariable stepwise logistic regression analysis was performed to predict S. aureus infection, which was defined by culture results.Of the 16,386 patients, 205 (1.3%) developed S. aureus bloodstream or chest wound infection within 90 days after surgery. On multivariable analysis, bootstrap-validated preoperative risk factors for S. aureus bloodstream or chest wound infection included a body mass index greater than 40 (adjusted odds ratio [aOR], 1.9 [95% confidence interval {CI}, 1.1-3.2]), chronic renal failure (aOR, 1.8 [95% CI, 1.1-2.9]), and chronic lung disease (aOR, 1.4 [95% CI, 1.0-2.0]). Only 8 patients had all 3 risk factors.Although preoperative risk factors can be easily identified, the majority of patients who developed S. aureus infections after cardiac surgery did not have any risk factors. Preventive measures should not be restricted to a select group of cardiac surgery patients and should rather address the entire patient population.

Four newer antibiotics are available to treat gram-positive bacterial infections that are resistant to traditional antibiotics and to vancomycin. They should preferably be used with the help of an infectious-disease consultant: specific therapy should be chosen on the basis of the bacteria involved, the site of infection, whether the patient has kidney or liver disease, other medications the patient is taking, and side effects that develop.

We identified Mycobacterium tuberculosis DNA using real-time polymerase chain reaction on a specimen from an osteolytic lesion of a femoral condyle, in which the frozen section demonstrated granulomas. The process was much more rapid than is possible with culture. The rapid detection of M tuberculosis and the concomitant exclusion of granulomatous disease caused by nontuberculous mycobacteria or systemic fungi are necessary to appropriately treat skeletal tuberculosis. The detection and identification of M tuberculosis by culture may require several weeks using traditional methods. The real-time polymerase chain reaction method used has been shown to be rapid and reliable, and is able to detect and differentiate both tuberculous and nontuberculous mycobacteria. Real-time polymerase chain reaction may become a diagnostic standard for the evaluation of clinical specimens for the presence of mycobacteria; this case demonstrates the potential utility of this assay for the rapid diagnosis of skeletal tuberculosis.

Infections with methicillin-resistant Staphylococcus aureus (MRSA), long endemic in hospitals and nursing homes, are now being reported in the community as well. While we await further epidemiological and microbiological study of this emerging pathogen, current clinical practice requires a reconsideration of the empiric use of beta-lactam agents for the seriously ill patient with a gram-positive infection.

Background An algorithm promoted in the United Kingdom reflexes specimens positive for C. difficile by a nucleic acid amplification test (NAAT) to toxin EIA. Samples positive by NAAT and negative by toxin EIA are reported as “C. difficile could be present (ie, potential C. difficile excretor).” We explored the potential utility of this algorithm to distinguish C. difficile infection (CDI) from colonization compared with retrospective clinical assessment. Methods Liquid stool specimens (n = 300) from inpatients (or the Emergency Department) submitted to the Cleveland Clinic Microbiology laboratory for C. difficile PCR testing (Cepheid Xpert C. difficile/Epi) with positive results were included in the study. The CDIFF QUICK CHEK COMPLETE GDH/toxin EIA assay (Alere) was performed according to manufacturer’s instructions. The charts of all patients were reviewed by Infectious Diseases physicians blinded to the EIA results. Using the American College of Gastroenterology (ACG) classification system, CDI status was determined to be mild, moderate, severe, or complicated. Patients without significant diarrhea ( Results Most of the PCR positive specimens (75%) were toxin EIA negative. Correlation of clinical assessment with toxin EIA is summarized in the table below. Among patients colonized vs. those with CDI, the percentages with negative toxin EIA results were 80% and 73%, respectively. GDH antigen results were negative for 25 specimens—17 were from patients considered to have CDI. Conclusion Toxin EIA performed on samples positive for C. difficile by PCR does not reliably identify patients considered to have CDI with ACG criteria applied. GDH as an initial screen would not have detected 6.8% of patients with CDI. Disclosures S. S. Richter, bioMerieux: Investigator, Research support; BD Diagnostics: Investigator, Research support; Roche: Investigator, Research support; BioFire: Investigator, Research support; OpGen: Investigator, Research support

Background Nearly 154 million ambulatory visits in the United States result in an outpatient antibiotic prescription (OAP) annually, 30% of which are unnecessary. Remaining prescriptions may benefit from improved antibiotic selection. At our institution, a quarterly OAP report associated with 4 common encounter diagnoses was developed. The objectives of this study were to assess OAP rate for each diagnosis, and to assess the rate of guideline-concordant selection when an OAP was issued. Methods OAP report from January 2016 – March 2017 was queried to conduct a retrospective pharmacoepidemiology study including data from 106 outpatient sites, 33 care institutes, and 1400 providers in Northeast Ohio. The report aggregated OAPs for all office and telephone encounters with a diagnosis code for otitis media, pharyngitis, sinusitis, or urinary tract infection. For each diagnosis, encounters that resulted in an OAP were then categorized as guideline-concordant or -discordant based on the antibiotic selected and includes consideration of labeled penicillin allergy and consensus guideline recommendations (Figure 1). All data were filterable to the practice site, care institute, or prescriber level. Results A total of 135,177 patient encounters were captured during the study period (9766 otitis media, 39570 pharyngitis, 60940 sinusitis, 24901 urinary tract infection). Mean patient age was 50 (±15) years. At least 1 OAP was issued in 8444 (86%) otitis media, 16143 (41%) pharyngitis, 46343 (76%) sinusitis, and 15464 (62%) urinary tract infection encounters. For encounters in which an OAP was issued, the rate of guideline-concordant antibiotic selection by diagnosis was 46% for otitis media, 58% for pharyngitis, 64% for sinusitis, and 50% for urinary tract infection. Antibiotic selection for pharyngitis and sinusitis during Q1 2017 are detailed in Figures 2 and 3, respectively. Conclusion Audit of outpatient prescribing data revealed a high rate of OAP issuance for these four common diagnoses. The use of guideline-discordant antibiotics was also prevalent and commonly consisted of macrolides, fluoroquinolones, tetracyclines, and cephalosporins. These data provide an important baseline that underscores the need for outpatient stewardship and facilitates targeted prospective interventions. Disclosures All authors: No reported disclosures.

Background:Nosocomial infections due to medical devices are of increasing concern to infection control practitioners. Attempts to prevent such infections have included surveillance cultures of endoscopes and bronchoscopes. In July 2002, the infectious disease consultation service was asked to see three patients with sepsis due to multidrug-resistantPseudomonas aeruginosaafter endoscopic retrograde cholangiopancreatography (ERCP).Objective:To describe an outbreak of multidrug-resistantP. aeruginosasepsis after ERCP at an institution that performs routine surveillance cultures of endoscopes.Design:A traditional outbreak investigation supplemented by pulsed-field gel electrophoresis (PFGE) was undertaken, including a case-control analysis based on the hypothesis that all infected individuals had their ERCP performed with the same endoscope.Setting:A tertiary-care academic medical center.Results:The case-control analysis confirmed the hypothesis that undergoing ERCP with the implicated endoscope was associated with a culture positive forPseudomonas(P= .01). The available strains were identical by PFGE. This outbreak occurred despite a negative surveillance culture of the implicated endoscope 1 month earlier.Conclusions:Infectious morbidity can occur after endoscopy despite negative surveillance cultures. The practice of routine endoscope cultures does not prevent device-related infectious morbidity.

Loop-mediated isothermal DNA amplification (LAMP) are currently used as standalone diagnostic test for C. difficile infection (CDI). We assessed the diagnostic accuracy of LAMP for the diagnosis of CDI. We searched 5 databases to identify studies that compared LAMP with culture cytotoxicity neutralization assay or anaerobic toxigenic culture (TC) of C. difficile. We used the random-effects model to calculate pooled sensitivities, specificities, diagnostic odds ratios and their 95% confidence intervals (CIs). The search of the databases yielded 16 studies (6,979 samples) that met inclusion criteria. When TC was used as the gold standard (6,572 samples), bivariate analysis yielded a mean sensitivity of 0.95 (95%CI, 0.93-0.97; I2 = 67.4) and a mean specificity of 0.99 (95%CI, 0.96-1.00; I2 = 97.0). LAMP is a useful diagnostic tool with high sensitivity and specificity for detecting CDI. The results should however be interpreted only in the presence of clinical suspicion and symptoms of CDI. Revisión por pares

Cerebral angiography is an invasive procedure utilized without supporting guidelines in preoperative evaluations of infective endocarditis (IE). It is used to identify mycotic intracranial aneurysm, which is suspected to increase the risk of intracranial bleeding during cardiac surgery. Our objectives were to: (1) assess the utility of cerebral angiography by determining which subset of IE patients benefit from its performance; and (2) identify clinical and noninvasive screening tests that can preclude the need for invasive cerebral angiography. Retrospective analysis was performed of all patients treated surgically for IE from 7/2007 to 1/2012 and discharged with medical treatment for IE from 7/2007 to 7/2009 presenting to a large academic center. Of the 151 patients who underwent cerebral angiography, mycotic aneurysm was identified in seven (prevalence=4.6%; 95% CI 2.3–9.3%). Five had viridans group streptococci as the causative IE microorganism ( p=0.0017). Noninvasive imaging and particularly absence of intracranial bleed on magnetic resonance imaging conveys a negative predictive value (NPV) of 0.977 (95% CI 0.879–0.996). Absence of a focal neurologic deficit or altered mental status convey a NPV of 0.990 (95% CI 0.945–0.998) and 0.944 (95% CI 0.883–0.974), respectively. Clinical suspicion for mycotic aneurysm and thus utilization of cerebral angiography is likely necessary only in the setting of acute neurologic deficits and when noninvasive imaging demonstrates acute intracranial bleed. A novel association between viridans group streptococci and intracranial mycotic aneurysm is demonstrated.

In this article, we describe our comparison of the Cleveland Clinic surveillance definition of Clostridium difficile–associated diarrhe and the definition mandated by the Ohio Department of Health. We found the definitions to be concordant only 71% of the time; the Ohio Department of Health definition identified 278 of the 391 cases identified by the Cleveland Clinic definition. Surveillance definitions mandated by the Ohio Department of Health overrepresented the number of cases attributable to nosocomial transmission at our institution.

We describe a healthcare worker with a previously positive tuberculin skin test result who developed active tuberculosis. An investigation revealed 280 potential contacts, 3 of whom had positive tuberculin skin test results. Our experience demonstrates the potential benefits of therapy for latent tuberculosis infection as a component of a tuberculosis-control program.

Background: Influenza vaccination may be less immunogenic in transplant recipients than in healthy people. Influenza A (H1N1) and B circulating viruses during the 2007-2008 epidemic were different from those contained in that season’s vaccine. In that epidemic, influenza vaccine effectiveness against culture-confirmed influenza was 44%. Objective: To describe clinical, immunological, and virological characteristics of 18 transplant recipients who developed influenza during the 2007-08 epidemic despite influenza vaccination (tx-vac-flu), and compare them to 6 transplant recipients who developed influenza in the absence of influenza vaccination (tx-no vac-flu), 12 previously healthy people who developed influenza (healthy-flu), and 13 transplant recipients who received influenza vaccination and did not develop influenza (tx-vac-no flu). Methods: Case ascertainment was through microbiology and electronic medical records. A case of influenza was defined by a clinical presentation of an influenza-like illness, plus a positive influenza A or B multiplex real time polymerase chain reaction (Prodesse, Inc. Waukesha, WI) on a nasopharyngeal swab. Results: Of the 36 patients with influenza, 22 had influenza A, and 15 had influenza B (1 transplant recipient had both serotypes simultaneously). Types of transplant were lung (11), hematopoietic stem cell (8), heart (7), liver (3), kidney (3), kidney + pancreas (3), liver + kidney (1), and liver + pancreas (1). Patients in the tx-vac-flu group were significantly older than patients in the tx-no vac-flu group [median 61 vs. 50.5 year, (P=0.02), the healthy-flu group [median 49.5 years (P=0.04)], and the tx-vac-no flu group [median 53 years (P=0.02)]. Influenza occurred 1,410 (261-3,467) days {median [interquartile (IQR) range]} after transplant in the tx-vac-flu group, compared to 175 (40-1,064] days in the tx-no vac-flu group (P=0.18). Influenza occurred 114 days (median [IQR 99-137]) after vaccination in the tx-vac-flu group. Immunoglobulin G levels and immune function assay levels were not significantly different between the 3 transplant groups. There were no statistically significant differences in the incidence of fever, headache, cough, rhinorrhea, sore throat, malaise, shortness of breath, exposure to contacts with similar symptoms, presence of infiltrates on chest roentgenograms, or the estimated influenza viral loads among the 3 groups who had influenza. Patients in the tx-vac-flu group were treated with oseltamivir significantly more frequently than the healthy-flu group [94% vs. 50% (P=0.0006)], but not the tx-no vac-flu group [100% (P=0.7)]. Duration of treatment with oseltamivir was not significantly different among the 3 groups who had influenza. Patients in the tx-vac-flu group had concomitant infections significantly more frequently than the healthy-flu group [44% vs. 8% (P=0.043)], but not the tx-no vac-flu group. Patients in the tx-vac-flu group developed pneumonia, and were hospitalized for management of influenza significantly more frequently than patients in the healthy-flu group (P=0.031 and P=0.00007; respectively). Only one patient (6%) in the tx-vac-flu group and none in the tx-no vac-flu or healthy-flu groups required admission to an intensive care unit and mechanical ventilation following influenza. No patients died as a result of influenza. Conclusions: Influenza vaccination did not alter clinical presentation of influenza in transplant recipients, but these patients were hospitalized and developed pneumonia more frequently than healthy people. Transplant recipients who developed influenza despite influenza vaccination were not more immunosuppressed than transplant recipients who were vaccinated and did not develop influenza. Transplant recipients who developed influenza despite influenza vaccination were more likely to have concomitant infections than healthy people with influenza.

Objective.The success of central line-associated bloodstream infection (CLABSI) prevention programs in intensive care units (ICUs) has led to the expansion of surveillance at many hospitals. We sought to compare non-ICU CLABSI (nCLABSI) rates with national reports and describe methods of surveillance at several participating US institutions.Design and Setting.An electronic survey of several medical centers about infection surveillance practices and rate data for non-ICU Patients.Participants.Ten tertiary care hospitals.Methods.In March 2011, a survey was sent to 10 medical centers. The survey consisted of 12 questions regarding demographics and CLABSI surveillance methodology for non-ICU patients at each center. Participants were also asked to provide available rate and device utilization data.Results.Hospitals ranged in size from 238 to 1,400 total beds (median, 815). All hospitals reported using Centers for Disease Control and Prevention (CDC) definitions. Denominators were collected by different means: counting patients with central lines every day (5 hospitals), indirectly estimating on the basis of electronic orders (n = 4), or another automated method (n = 1). Rates of nCLABSI ranged from 0.2 to 4.2 infections per 1,000 catheter-days (median, 2.5). The national rate reported by the CDC using 2009 data from the National Healthcare Surveillance Network was 1.14 infections per 1,000 catheter-days.Conclusions.Only 2 hospitals were below the pooled CLABSI rate for inpatient wards; all others exceeded this rate. Possible explanations include differences in average central line utilization or hospital size in the impact of certain clinical risk factors notably absent from the definition and in interpretation and reporting practices. Further investigation is necessary to determine whether the national benchmarks are low or whether the hospitals surveyed here represent a selection of outliers.

The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey was used to measure the effect of isolation on patient satisfaction. Isolated patients reported lower scores for questions regarding physician communication and staff responsiveness. Overall scores for these domains were lower in isolated than in nonisolated patients.