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Background. Pseudomonas aeruginosa is a common cause of healthcare-associated infection. Multidrug-resistant (MDR) (>3 classes) and carbapenem-resistant (CR) P aeruginosa are significant threats globally. We used a large reference-laboratory database to study the epidemiology of P aeruginosa in children in the United States. Methods. Antimicrobial susceptibility data from the Surveillance Network were used to phenotypically identify MDR and CR P aeruginosa isolates in children aged 1 to 17 years between January 1999 and July 2012. Logistic regression analysis was used to calculate trends in the prevalence of MDR and CR P aeruginosa. Isolates from infants (<1 year old) and patients with cystic fibrosis were excluded. Results. Among the isolates tested, the crude proportion of MDR P aeruginosa increased from 15.4% in 1999 to 26% in 2012, and the proportion of CR P aeruginosa increased from 9.4% in 1999 to 20% in 2012. The proportion of both MDR and CR P aeruginosa increased each year by 4% (odds ratio [OR], 1.04 [95% confidence interval (CI), 1.03-1.04] and 1.04 [95% CI, 1.04-1.05], respectively). In multivariable analysis, both MDR and CR P aeruginosa were more common in the intensive care setting, among children aged 13 to 17 years, in respiratory specimens, and in the West North Central region. In addition, resistance to other antibiotic classes (aminoglycosides, fluoroquinolones, cephalosporins, and piperacillin-tazobactam) often used to treat P aeruginosa increased. Conclusions. Rates of MDR and CR P aeruginosa infection in children are rising nationally. Aggressive prevention strategies, including instituting antimicrobial stewardship programs in pediatric settings, are essential for combating antimicrobial resistance. [ABSTRACT FROM AUTHOR]

The prevalence of carbapenem-resistant Enterobacteriaceae (CRE) infections is increasing in the United States. However, few studies have addressed their epidemiology in children. To phenotypically identify CRE isolates cultured from patients 1-17 years of age, we used antimicrobial susceptibilities of Enterobacteriaceae reported to 300 laboratories participating in The Surveillance Network-USA database during January 1999-July 2012. Of 316,253 isolates analyzed, 266 (0.08%) were identified as CRE. CRE infection rate increases were highest for Enterobacter species, blood culture isolates, and isolates from intensive care units, increasing from 0.0% in 1999-2000 to 5.2%, 4.5%, and 3.2%, respectively, in 2011-2012. CRE occurrence in children is increasing but remains low and is less common than that for extended-spectrum β-lactamase-producing Enterobacteriaceae. The molecular characterization of CRE isolates from children and clinical epidemiology of infection are essential for development of effective prevention strategies. [ABSTRACT FROM AUTHOR]

The article discusses the usage of Prophylaxis antibiotic for Cesarean delivery. Topics discussed include association of mother with risk of endometritis with infusion of pathogens, involvement of cefazolin antibiotic usage in the delivery process, observation of several prophylaxis drugs usage such as azithromycin, illustration of infectious complications among mothers with increment in obesity and recommendation for cefazolin with azithromycin for microbiologic activity among mothers.

Redundant antibiotic combinations are a potentially remediable source of antibiotic overuse. At a public teaching hospital, we determined the incidence, cost, and indications for such combinations and measured the effects of a pharmacist-based intervention. Of 1189 inpatients receiving &ges; 2 antibiotics, computer-assisted screening identified 192 patients (16.1%) receiving potentially redundant combinations. Chart reviews showed that 137 episodes (71%) were inappropriate. Physician overprescribing errors were found in 77 episodes (56%); most involved redundant coverage for gram-positive or anaerobic organisms. In 76 episodes (55%), lapses in the medication ordering and distribution system led to the persistence in the pharmacy records of regimens no longer active according to the patient charts. The incidence of redundant antibiotic combinations was significantly higher in the intensive care unit and surgery services, compared with medical services. Interventions to discontinue redundant agents were successful in 134 (98%) of the 137 episodes. Potential drug cost savings and reduction in redundant antibiotic combination days were $10,800 and 584 days, respectively; pharmacist time for patient review and intervention cost $2880. Use of redundant antibiotic combinations was common, and a pharmacist-based intervention was feasible, with a potential annualized cost savings of $48,000. [ABSTRACT FROM AUTHOR]

The article presents information on selective decontamination of the digestive tract. Since its introduction as a prophylactic strategy for intensive care unit (ICU) patients 20 years ago, selective decontamination of the digestive tract (SDD) has driven scientific opinions towards extremes. Although intense scrutiny often stimulates discovery, at times polarization can stifle progress. For 20 years researchers have been unable to demonstrate a significant reduction in patients' mortality rates in individual studies. Antibiotic resistance is an emerging global problem, driven in large part by antibiotic use. Rational and restrictive use of antibiotics, limitation of cross-infections, and prevention of device-associated infections are the tools that we have for controlling resistance.

Previous surveillance studies have documented increasing rates of antimicrobial resistance in US intensive care units (ICUs) in the early 1990s. Out objectives were to assess national rates of antimicrobial resistance among gram-negative aerobic isolates recovered from ICU patients and to compare these rates to antimicrobial use. Participating institutions, representing a total of 43 US states plus the District of Columbia, provided antibiotic susceptibility results for 35 790 nonduplicate gram-negative aerobic isolates recovered from ICU patients between 1994 and 2000. Each institution tested approximately 100 consecutive gram-negative aerobic isolates recovered from ICU patients. Organisms were identified to the species level. Susceptibility tests were performed, and national fluoroquinolone consumption data were obtained.The activity of most antimicrobial agents against gram-negative aerobic isolates showed an absolute decrease of 6% or less over the study period. The overall susceptibility to ciprofloxacin decreased steadily from 86% in 1994 to 76% in 2000 and was significantly associated with increased national use of fluoroquinolones. This study documents the increasing incidence of ciprofloxacin resistance among gram-negative bacilli that has occurred coincident with increased use of fluoroquinolones. More judicious use of fluoroquinolones will be necessary to limit this downward trend. [ABSTRACT FROM AUTHOR]

Antimicrobial-drug resistance in hospitals is driven by failures of hospital hygiene, selective pressures created by overuse of antibiotics, and mobile genetic elements that can encode bacterial resistance mechanisms. Attention to hand hygiene is constrained by the time it takes to wash hands and by the adverse effects of repeated handwashing on the skin. Alcohol-based hand rubs can overcome the time problem and actually improve skin condition. Universal glove use could close gaps left by incomplete adherence to hand hygiene. Various interventions have been described to improve antibiotic use. The most effective have been programs restricting use of antibiotics and computer-based order forms for health providers. [ABSTRACT FROM AUTHOR]

Traditional infection control measures in intensive care units (ICUs) have been directed at limiting person to person spread of infection and improving care of invasive devices. These measures often fail because they have little effect on patients' endogenous flora, which is an important source of infection in ICUs. Improvements in the design and aseptic care of invasive devices have helped to decrease the risk of progression from colonization to infection in individual patients. Interest is growing also in use of selective decontamination to decrease ICU infection rates. Despite these advances, basic hygiene and appropriate, prospectively monitored use of antibiotics remain essential components of ICU care. [ABSTRACT FROM AUTHOR]

Presents a study which assessed the effect of colonization pressure, compliance with infection control measures, antibiotic use, and identified risk factors in the transmission of vancomycin-resistant enterococci. Definition of colonization pressure; What inhibits the transmission of nosocomial multi-resistant microorganisms; Methodology used to conduct study; Results of study.

Focuses on the use of oral antibiotics for intestinal decontamination in an outbreak of infection with multiply-resistant enterobacteriaceae. Logic behind the use of selective decontamination; Control options to prevent cross-colonization; Benefits from selective decontamination; Factors attributed to the outbreak.

Background AmpC producing Ent are an important cause of multidrug-resistant (MDR) infections in pediatrics. Since most AmpC Ent studies have been conducted in adults, we characterized the molecular epidemiology of AmpC Ent strains with transmissible resistance and identified factors associated with AmpC Ent infections in children. Methods A case–control study of children (0–18 years) at 4 Chicago hospitals during 2011–18 was performed. Cases were 44 children with infections due to Ent harboring an AmpC as detected by DNA microarray (Check-Points®). PCR, DNA sequencing, MLST, and phylogenetic analyses were performed. Controls (ctrls) were 132 children with expanded-spectrum cephalosporin-susceptible Ent infections matched by age and hospital. Demographics; residence; comorbidities; device, antibiotic, and healthcare exposures were evaluated. Predictors of AmpC Ent infection were assessed by logistic regression. Results The median age of AmpC Ent patients was 3.0 years; 50% were male. Of bla AmpC genes, 68% were bla ACT/MIR-type and 25% bla CMY-type. Predominant organisms were Enterobacter cloacae (59%) and Escherichia coli (32%); 27% of AmpC E. cloacae belonged to ST114 and 62% co-harbored a bla ESBL gene, predominately bla SHV (94%). Most AmpC E. coli strains were unrelated; 71% carried bla CMY, 64% belonged to phylogroups B2/D, and 50% co-harbored bla CTX-M. On bivariate analysis vs. ctrls, AmpC Ent infections were more likely to be respiratory (39% vs. 18%, P < 0.01) and less likely to be urinary tract (41% vs. 67%, P < 0.01) or community-acquired (14% vs. 33%, P < 0.02). By multivariable analysis, children with AmpC Ent infections were more likely to be nonwhite, non-black, non-Hispanic (OR 4.7, CI 1.4–16.1) and have infections due to Enterobacter (OR 7.7, CI 3.5–17). Differences in gender, healthcare location, residential neighborhood, antibiotic exposures, comorbidities, devices or outcomes were not found. Conclusion AmpC Ent infections often had healthcare onset, were due to Enterobacter , and occurred in nonwhite, non-black, non-Hispanic children. AmpC Ent commonly co-harbored bla SHV and bla CTX-M ESBL genes which affects therapeutic options and suggests the need for contact precautions. Control of AmpC Ent infections in children will require validating sources and risk factors. Disclosures All authors: No reported disclosures. [ABSTRACT FROM AUTHOR]

Background: Urinary tract infections (UTIs) are common health-care-associated infections. Bacteriuria commonly precedes UTI and is often treated with antibiotics, particularly in hospital intensive care units (ICUs). In 2013, a cluster-randomised trial (REDUCE MRSA Trial [Randomized Evaluation of Decolonization vs Universal Clearance to Eradicate MRSA]) showed that body surface decolonisation reduced all-pathogen bloodstream infections. We aim to further assess the effect of decolonisation on bacteriuria and candiduria in patients admitted to ICUs.Methods: We did a secondary analysis of a three-group, cluster-randomised trial of 43 hospitals (clusters) with patients in 74 adult ICUs. The three groups included were either meticillin-resistant Staphylococcus aureus (MRSA) screening and isolation, targeted decolonisation (screening, isolation, and decolonisation of MRSA carriers) with chlorhexidine and mupirocin, and universal decolonisation (no screening, all patients decolonised) with chlorhexidine and mupirocin. Protocol included chlorhexidine cleansing of the perineum and proximal 6 inches (15·24 cm) of urinary catheters. ICUs within the same hospital were assigned the same strategy. Outcomes included high-level bacteriuria (≥50 000 colony forming units [CFU]/mL) with any uropathogen, high-level candiduria (≥50 000 CFU/mL), and any bacteriuria with uropathogens. Sex-specific analyses were specified a priori. Proportional hazards models assessed differences in outcome reductions across groups, comparing an 18-month intervention period to a 12-month baseline period.Findings: 122 646 patients (48 390 baseline, 74 256 intervention) were enrolled. Intervention versus baseline hazard ratios (HRs) for high-level bacteriuria were 1·02 (95% CI 0·88-1·18) for screening or isolation, 0·88 (0·76-1·02) for targeted decolonisation, and 0·87 (0·77-1·00) for universal decolonisation (no difference between groups, p=0·26), with no sex-specific reductions (HRs for men: 1·09 [95% CI 0·85-1·40] for screening or isolation, 1·01 [0·79-1·29] for targeted decolonisation, and 0·78 [0·63-0·98] for universal decolonisation, p=0·12; HRs for women: 0·97 [0·80-1·17] for screening and isolation, 0·83 [0·70-1·00] for targeted decolonisation, and 0·93 [0·79-1·09] for universal decolonisation, p=0·49). HRs for high-level candiduria were 1·14 (0·95-1·37) for screening and isolation, 0·99 (0·83-1·18) for targeted decolonisation, and 0·83 (0·70-0·99) for universal decolonisation (p=0·05). Differences between sexes were due to reductions in men in the universal decolonisation group (HRs: 1·21 [95% CI 0·88-1·68] for screening or isolation, 1·01 [0·73-1·39] for targeted decolonisation, and 0·63 [0·45-0·89] for universal decolonisation, p=0·02). Bacteriuria with any CFU/mL was also reduced in men in the universal decolonisation group (HRs 1·01 [0·81-1·25] for screening or isolation, 1·04 [0·83-1·30] for targeted decolonisation, and 0·74 [0·61-0·90] for universal decolonisation, p=0·04).Interpretation: Universal decolonisation of patients in the ICU with once a day chlorhexidine baths and short-course nasal mupirocin could be a potential preventive strategy in male patients because it significantly decreases candiduria and any bacteriuria, but not for women.Funding: HAI Program from AHRQ, US Department of Health and Human Services as part of the Developing Evidence to Inform Decisions about Effectiveness (DEcIDE) program, CDC Prevention Epicenters Program. [ABSTRACT FROM AUTHOR]

The article offers an update of American Society of Health System Pharmacists (ASHP) Therapeutic Guidelines on Antimicrobial Prophylaxis in Surgery, jointly developed by the Infectious Diseases Society of America (IDSA), the Surgical Infection Society (SIS) and the Society for Healthcare Epidemiology of America (SHEA). The guidelines provide practitioners with a standardized approach to the rational and effective use of antimicrobial agents for prevention of surgical-site infections (SSIs).

Coxiella burnetii, which causes Q fever, is a highly infectious agent that is widespread among livestock around the world. Although the culture process for coxiella is laborious, large amounts of infectious material can be produced. If used as an aerosolised biological weapon, coxiella may not cause high mortality, but could provoke acute disabling disease. In its late course, Q fever can be complicated by fatal (eg, endocarditis) or debilitating (eg, chronic fatigue syndrome) disorders. The diagnosis of Q fever might be delayed because of non-specific and protean presentations. Effective antibiotic treatment is available for the acute form of disease but not for the chronic complications. Vaccination and chemoprophylaxis in selected individuals may be used in the event of bioterrorism. [Copyright &y& Elsevier]