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OBJECTIVETo identify the source of a pseudo-outbreak ofMycobacterium gordonaeDESIGNOutbreak investigation.SETTINGUniversity Hospital in Chicago, Ilinois.PATIENTSHospital patients withM. gordonae-positive clinical cultures.METHODSAn increase in isolation ofM. gordonaefrom clinical cultures was noted immediately following the opening of a newly constructed hospital in January 2012. We reviewed medical records of patients withM. gordonae-positive cultures collected between January and December 2012 and cultured potable water specimens in new and old hospitals quantitatively for mycobacteria.RESULTSOf 30 patients withM. gordonae-positive clinical cultures, 25 (83.3%) were housed in the new hospital; of 35 positive specimens (sputum, bronchoalveolar lavage, gastric aspirate), 32 (91.4%) had potential for water contamination.M. gordonaewas more common in water collected from the new vs. the old hospital [147 of 157 (93.6%) vs. 91 of 113 (80.5%),P=.001]. Median concentration ofM. gordonaewas higher in the samples from the new vs. the old hospital (208 vs. 48 colony-forming units (CFU)/mL;PM. gordonaewere lower in water samples from ice and water dispensers [13 of 28 (46.4%) and 0 CFU/mL] compared with water samples from patient rooms and common areas [225 of 242 (93%) and 146 CFU/mL,PCONCLUSIONSM. gordonaewas common in potable water. The pseudo-outbreak ofM. gordonaewas likely due to increased concentrations ofM. gordonaein the potable water supply of the new hospital. A silver ion-impregnated 0.5-μm filter may have been responsible for lower concentrations ofM. gordonaeidentified in ice/water dispenser samples. Hospitals should anticipate that construction activities may amplify the presence of waterborne nontuberculous mycobacterial contaminants.Infect Control Hosp Epidemiol 2014;00(0): 1–6

Objective To develop and validate a Zika virus disease syndrome definition within the GUARDIAN (Geographic Utilization of Artificial Intelligence in Real-Time for Disease Identification and Alert Notification) surveillance system. Introduction In 2016, the World Health Organization declared Zika virus a global public health emergency. Zika infection during pregnancy can cause microcephaly and other fetal brain defects. To facilitate clinicians’ ability to detect Zika, various syndrome definitions have been developed. Methods To create and validate a detailed syndrome definition for Zika, we utilized the literature based methodology developed and documented by GUARDIAN researchers. 1,2 The syndrome definition utilized clinical signs and symptoms that were documented in historical Zika cases. A testing sample of 1000 randomly selected emergency department cases (i.e., true negative cases) and 200 synthetically generated cases (i.e., true positive cases) was created. These 1,200 sample cases were evaluated by the GUARDIAN surveillance system to determine the probability of matching the Zika syndrome definition. A probability of ≥ 90% was utilized to designate positive Zika cases. We identified the main signs and symptoms contributing to the identification of Zika cases and conducted statistical performance metrics. Clinical review of the false positive and false negative cases along with a sample of true positive and true negative cases was conducted by a board certified emergency physician. Results The Zika syndrome definition was developed with eleven articles (six used for developing the syndrome definition, and five used for testing the definition). The sample size for these articles was between 1 and 72 positive Zika cases, with a total of 139 cases across the 11 articles. The article with the most number of Zika cases was based on pregnant women with rash. The publication timeframe for the articles was from 1962 to 2016. Some of the main signs and symptoms from the historical cases that contribute to the Zika syndrome definition are presented in Table 1. The initial results for the sample testing data showed accuracy, sensitivity, and specificity were 94.7%, 93%, and 95% respectively. There were a total of 14 false negative and 50 false positive cases. Conclusions The initial Zika syndrome definition utilized by the GUARDIAN surveillance system contains similar signs and symptoms to the current CDC case definition, but also includes additional signs and symptoms such as pruritus/itching, malaise/fatigue/generalized weakness, headache, retro-orbital pain, myalgia/muscle pain, and lymphadenopathy In addition, the GUARDIAN system provides the relative importance of identified signs and symptoms and allows for proactive surveillance of emergency department patients in real-time. Though we did not include epidemiologic risk factors, such as travel to an infected region or contact with an infected person in the syndrome definition, GUARDIAN has above 90% sensitivity and specificity. Thus, inclusion of epidemiologic risk factors would further enhance the early detection of Zika, when used with the appropriate high risk population. Table 1. Main signs and symptoms of Zika syndrome definition *Signs and symptoms included in the Centers for Disease Control and Prevention (CDC)’s Zika clinical case definition

Objective To explain the utility of using an automated syndromic surveillance program with advanced natural language processing (NLP) to improve clinical quality measures reporting for influenza immunization. Introduction Clinical quality measures (CQMs) are tools that help measure and track the quality of health care services. Measuring and reporting CQMs helps to ensure that our health care system is delivering effective, safe, efficient, patient-centered, equitable, and timely care. The CQM for influenza immunization measures the percentage of patients aged 6 months and older seen for a visit between October 1 and March 31 who received (or reports previous receipt of) an influenza immunization. Centers for Disease Control and Prevention recommends that everyone 6 months of age and older receive an influenza immunization every season, which can reduce influenza- related morbidity and mortality and hospitalizations. Methods Patients at a large academic medical center who had a visit to an affiliated outpatient clinic during June 1 - 8, 2016 were initially identified using their electronic medical record (EMR). The 2,543 patients who were selected did not have documentation of influenza immunization in a discrete field of the EMR. All free text notes for these patients between August 1, 2015 and March 31, 2016 were retrieved and analyzed using the sophisticated NLP built within Geographic Utilization of Artificial Intelligence in Real-Time for Disease Identification and Alert Notification (GUARDIAN) – a syndromic surveillance program – to identify any mention of influenza immunization. The goal was to identify additional cases that met the CQM measure for influenza immunization and to distinguish documented exceptions. The patients with influenza immunization mentioned were further categorized by GUARDIAN NLP into Received, Recommended, Refused, Allergic, and Unavailable. If more than one category was applicable for a patient, they were independently counted in their respective categories. A descriptive analysis was conducted, along with manual review of a sample of cases per each category. Results For the 2,543 patients who did not have influenza immunization documentation in a discrete field of the EMR, a total of 78,642 free text notes were processed using GUARDIAN. Four hundred fifty three (17.8%) patients had some mention of influenza immunization within the notes, which could potentially be utilized to meet the CQM influenza immunization requirement. Twenty two percent (n=101) of patients mentioned already having received the immunization while 34.7% (n=157) patients refused it during the study time frame. There were 27 patients with the mention of influenza immunization, who could not be differentiated into a specific category. The number of patients placed into a single category of influenza immunization was 351 (77.5%), while 75 (16.6%) were classified into more than one category. See Table 1. Conclusions Using GUARDIAN’s NLP can identify additional patients who may meet the CQM measure for influenza immunization or who may be exempt. This tool can be used to improve CQM reporting and improve overall influenza immunization coverage by using it to alert providers. Next steps involve further refinement of influenza immunization categories, automating the process of using the NLP to identify and report additional cases, as well as using the NLP for other CQMs. Table 1. Categorization of influenza immunization documentation within free text notes of 453 patients using NLP

Objective To examine the baseline influenza-like illness (ILI) rates in the emergency departments (ED) of a large academic medical center (AMC), community hospital (CH), and neighboring adult and pediatric primary care clinics. Introduction The primary goal of syndromic surveillance is early recognition of disease trends, in order to identify and control infectious disease outbreaks, such as influenza. For surveillance of influenza-like illness (ILI), public health departments receive data from multiple sources with varying degrees of patient acuity, including outpatient clinics and emergency departments. However, the lack of standardization of these data sources may lead to varying baseline levels of ILI activity within a local area. Methods Geographic Utilization of Artificial Intelligence in Real-Time for Disease Identification and Alert Notification (GUARDIAN) – a syndromic surveillance program – was used to automate ILI detection using free text chief complaint/reason for visit fields and vital signs for a large AMC - ED, CH - ED, and neighboring outpatient clinics during the summer (June 15, 2016 to August 18, 2016) in order to create a baseline. The GUARDIAN system defined ILI as fever (temperature ≥ 100°F) and cough and/or sore throat. Descriptive analysis of the observed ILI rates along with bivariate ANOVA with post hoc Bonferroni and t-test were utilized to examine the difference within the settings. Results The average ILI rate for EDs is higher than the clinics by at least 0.39%. The CH- ED had 4.23% baseline ILI rate as compared to 1.35% for AMC-ED. While the AMC – Clinics have 0.96% baseline ILI rate as compared to 0.25% for CH – Clinics. The CH- ED and AMC – Clinics represented higher variations. Based on bivariate test, CH – ED was significantly different than AMC – ED, AMC - Clinics, and CH – Clinics (F= 10.58, df = 1238, p

Processing free-text clinical information in an electronic medical record may enhance surveillance systems for early identification of influenza-like illness outbreaks. However, processing clinical text using natural language processing (NLP) poses a challenge in preserving the semantics of the original information recorded. In this study, we discuss several NLP and technical issues as well as potential solutions for implementation in syndromic surveillance systems.

This was a retrospective cross-sectional study of 100 emergency department positive influenza-like illness (ILI) patients at an academic medical center to investigate which section(s) of a patient's electronic medical record (EMR) contains the most relevant information for timely detection of ILI. The history of present illness and review of systems, followed by the nursing notes sections of the EMR were information rich and the most relevant sections for ILI surveillance for the study site.

Emergency department (ED) data are key components for syndromic surveillance systems. However, the lack of standardization for the content in chief complaint (CC) free-text fields may make it challenging to use these elements in syndromic surveillance systems. Furthermore, little is known regarding how ED data sources should be structured or combined to increase sensitivity without elevating false positives. In this study, we constructed two different models of ED data sources and evaluated the resulting ILI rates obtained in two different institutions.

Background Two strains of influenza B virus, B/Yamagata and B/Victoria, co-circulate in the USA, typically appearing in late March. This year, influenza B virus (FluB) co-circulated consistently with influenza A virus (FluA). We hypothesized that this could be explained by an increased use of influenza trivalent vaccine, which lacks the B/Yamagata strain, over the quadrivalent vaccine. Methods We performed a retrospective, observational cohort study of patients with laboratory-diagnosed influenza from October 2016 through April 2017. Age, comorbidity categories, pregnancy status, symptoms, The presence of opacity on chest film, ICU admission, death, and receipt of oseltamivir were reviewed for 256 patients. A subset of FluB specimens were subtyped for lineage using RT–PCR. Results Influenza was detected in 495 (10.4%) of 4,754 samples collected, including 305 FluA and 190 FluB. The H3 strain represented 97% of FluA cases. FluB subtypes were: 70, B/Victoria; 21, B/Yamagata; and 41, not subtyped. Chart review was conducted for 124 randomly selected FluA and 132 sequential FluB patients. Median age of patients with FluA was 44 compared with 27 with FluB (P < 0.001). Forty-three (34.7%) FluA patients had heart disease compared with 21 (15.9%) FluB patients (P < 0.001). Otherwise, there were no differences in comorbidities, pregnancy status, clinical symptoms, or infectious complications between FluA vs. FluB patients. Ninety-three (75%) FluA patients and 78 (59.1%) FluB patients received oseltamivir. ICU admission occurred in 15 (12.1%) FluA and 9 (6.8%) FluB patients (OR 1.414; 95% CI 0.83-2.4). Seventy-seven (30%) patients received flu vaccine, 39 with FluA, and 38 with FluB; 97 (37.9%) were not vaccinated and 82 (32%) were missing data. Of those vaccinated, 6 patients received trivalent vaccine, and 71 received quadrivalent. Only 24 patients with B/Victoria and 7 patients with B/Yamagata were vaccinated. Conclusion The proportion of infected patients who had received vaccination was low, limiting our ability to detect the effect of the trivalent vaccine on the incidence of infection with B/Yamagata. In contrast to conventional thought, when compared with influenza B, influenza A (predominantly H3N2) did not appear to disproportionally affect those with most medical comorbidities, and was not disproportionately associated with our identified clinical complications. Disclosures All authors: No reported disclosures.

Description of a statistical model to account for weather variation in influenza-like illness surveillance.

Description of the development of an auto-generated color coded map showing an academic medical centers current seven day moving average influenza-like illness rate by zip code.

OBJECTIVETo identify clinical signs and symptoms (ie, “terms”) that accurately predict laboratory-confirmed influenza cases and thereafter generate and evaluate various influenza-like illness (ILI) case definitions for detecting influenza. A secondary objective explored whether surveillance of data beyond the chief complaint improves the accuracy of predicting influenza.DESIGNRetrospective, cross-sectional study.SETTINGLarge urban academic medical center hospital.PARTICIPANTSA total of 1,581 emergency department (ED) patients who received a nasopharyngeal swab followed by rRT-PCR testing between August 30, 2009, and January 2, 2010, and between November 28, 2010, and March 26, 2011.METHODSAn electronic surveillance system (GUARDIAN) scanned the entire electronic medical record (EMR) and identified cases containing 29 clinical terms relevant to influenza. Analyses were conducted using logistic regressions, diagnostic odds ratio (DOR), sensitivity, and specificity.RESULTSThe best predictive model for identifying influenza for all ages consisted of cough (DOR=5.87), fever (DOR=4.49), rhinorrhea (DOR=1.98), and myalgias (DOR=1.44). The 3 best case definitions that included combinations of some or all of these 4 symptoms had comparable performance (ie, sensitivity=89%–92% and specificity=38%–44%). For children CONCLUSIONSA simplified case definition of fever and cough may be suitable for implementation for all ages, while inclusion of rhinorrhea may further improve influenza detection for the 0–4-year-old age group. Finally, ILI surveillance based on the entire EMR is recommended.Infect Control Hosp Epidemiol 2015;00(0): 1–8

Describes the development and validation of an Ebola virus disease syndrome definition within the GUARDIAN (Geographic Utilization of Artificial Intelligence in Real-Time for Disease Identification and Alert Notification) surveillance system.

Background. This study was designed to examine the relationship between the timing of antibiotic treatment and both survival rates and hemodynamic/inflammatory correlates of survival in a murine model of Escherichia coli septic shock. Methods. Surgical implantation of an E. coli (018:Kl:H7)-laced, gelatin capsule-encased fibrinogen clot was used to generate a bacteremic model of murine septic shock. Survival duration, hemodynamic responses, and circulating serum tumor necrosis factor (TNF)-α , interleukin (IL)-6, and lactate levels were assessed in relation to increasing delays in or absence of antibiotic treatment. Results. A critical inflection point with respect to survival occurred between 12 and 15 h after implantation. When initiated at or before 12 h, antibiotic treatment resulted in ≤20% mortality, but, when initiated at or after 15 h, it resulted in >85% mortality. Physiologically relevant hypotension developed in untreated septic mice by 12 h after implantation. Values for heart rate differed between untreated septic mice and sham-infected control mice by 6 h after implantation, whereas values for cardiac output and stroke volume did not differ until at least 18-24 h after implantation. Antibiotic treatment initiated ≥ 12 h after implantation was associated with persistence of increased circulating serum lactate, TNF-a, and IL-6 levels. Conclusions. The timing of antibiotic treatment relative to hypotension is closely associated with survival in this murine model of septic shock. Delay in antibiotic treatment results in the persistence of inflammatory/stress markers even after antibiotic treatment is initiated.

Physicians in postgraduate training are expected to learn research methods but how best to achieve that curricular goal is unclear. This article describes a novel educational approach to develop research skills among infectious disease fellows. Five infectious disease fellows and two faculty members participated in a collaborative research project as a vehicle for active, problem-based learning. During the learning experience several tasks with specific learning objectives were achieved. The authors evaluated the weaknesses and strengths of the collaborative research project as an educational program. This problem-based approach for learning research methods seems more effective than traditional methods and may be applicable to a broad range of training programs.

Background. Left ventricular assist device (LVAD) implantation has become an effective treatment option for patients with severe heart failure awaiting transplantation. Significant infection rates have been reported among LVAD recipients. However, few reports have focused specifically on device infection, its treatment, and the impact of LVAD-related infection on clinical outcome. Methods. Forty-six LVAD-related infections were diagnosed in 38 (50%) of 76 patients who underwent LVAD implantation as a bridge to transplantation. Twenty-nine episodes of LVAD-related bloodstream infection (BSI) (including 5 that were cases of LVAD endocarditis) and 17 episodes of local LVAD infection were identified. Results. Diabetes mellitus appeared to increase the risk of BSI among patients with LVAD infection. LVAD- related infection delayed transplantation, as reflected by longer device-support times (a mean durationSEM of days, compared with days; ). Continuous antimicrobial treatment before, during, 66.3 � 8.8 P.001 and after transplantation was associated with fewer relapses than was a limited course of antibiotics ( ). A P ! .001 trend for longer hospital stays after receipt of a transplant and increased early mortality was observed in the cohort with LVAD-related infection, although long-term survival was similar to that associated with patients without LVAD-related infection. Posttransplantation invasive vancomycin-resistant Enterococcus faecium (VREF) infection was diagnosed in 6 patients with LVAD-related infection; 4 of these patients died. No VREF infections were identified in patients without LVAD-related infection. Conclusions. Our observations suggest that LVAD-related infection is common and may require antimicrobial therapy before, during, and after transplantation, but that it does not prevent successful transplantation. However, patients with LVAD-related infection appear to be at increased risk for invasive VREF infection, which may contribute to early mortality after transplantation. For more than a decade, left ventricular assist device (LVAD) implantation has been an effective treatment option for patients with end-stage heart failure awaiting transplantation. Normalization of hemodynamics im- proves end-organ function, with ∼70% of patients sur- viving until heart transplantation ( 1-3). In spite of this success, LVAD-related infection is a common compli- cation that may delay or prevent transplantation in some patients, and it is a significant cause of death among nontransplant candidates who undergo LVAD implantation as long-term myocardial replacement

The effectiveness of an infectious diseases (ID) consultation is dependent on adherence to the recommendations. To delineate the factors that affect adherence, we conducted a prospective cohort study of 465 consultations at 2 academic institutions in which we evaluated the consultation process, patient and consultant characteristics, types of recommendations, and compliance with recommendations. The overall compliance rate was 80%, with 85% adherence to crucial recommendations. Multivariate analysis revealed that adherence to ID recommendations was higher when the recommendations were therapeutic instead of diagnostic, when they related to a specific clinical question, when recommendations were deemed crucial by the ID service, if the primary service was medicine, and if the consultation note was legible and organized. Whether modification of consultant practice will lead to improved recommendation compliance and patient outcomes warrants further study.

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.

Lipoprotein phospholipid (PL) plays a major role in neutralization of endotoxin. This study tested the hypothesis that prophylactic administration of a PL-enriched emulsion (PRE), which augments PL content of serum lipoproteins and neutralizes endotoxin in vitro, would preserve cardiovascular function and improve survival in porcine septic peritonitis. A control group was compared with low-, mid-, and high-dose treatment groups that received PRE by primed continuous infusion for 48 h. A fibrin clot containing live Escherichia coli 0111.B4 was implanted intraperitoneally 30 min after the priming dose. Survival increased in a dose-dependent manner and was correlated with serum PL. Infused PL was associated with high-density lipoprotein in the low-dose group and all serum lipoproteins at higher doses. Treatment significantly lowered serum endotoxin and tumor necrosis factor (TNF)-α, preserved cardiac output and ejection fraction, and attenuated increases in systemic and pulmonary vascular resistances. This study demonstrated that augmentation of lipoprotein PL via administration of PRE improved survival and offered a novel therapeutic approach to sepsis.

We describe 22 patients from a multistate outbreak ofSerraría marcescensbacteremia that was linked to contaminated prefilled syringes of heparin and saline supplied by 1 manufacturer. Contents of unused syringes were cultured in pools samples from 25 (5.3%) of 472 syringes grewS. marcescens. Despite good clinical outcomes overall, patients had substantial morbidity.

Laboratory diagnosis of influenza is important for treatment, surveillance, infection control, chemoprophylaxis, and monitoring of resistance. Rapid and sensitive nucleic acid amplification tests have widely replaced virus isolation as the reference standard ([9][1]). However, despite improvements

Infective endocarditis remains a serious and potentially fatal disease. Even with appropriate therapy, mortality rates remain at about 10% to 20%. Common errors in treatment include starting antibiotics before obtaining at least three blood cultures, failing to use bactericidal drugs, stopping therapy too early, and delaying heart surgery when it is indicated. The epidemiology of endocarditis will continue to evolve, and we will see more cases that are hospital acquired, more cases associated with the presence of cardiac support devices, and cases associated with line-related bacteremia. Therefore, organisms associated with endocarditis will also likely evolve. We will see more cases due to multiresistant organisms (eg, vancomycin-resistant enterococci, glycopeptide-resistant staphylococci, and multidrug-resistant gram-negative rods) as well as yeast and fungi.

The left ventricular assist device (LVAD) has revolutionized the care of patients with heart failure who are awaiting transplantation. Despite reports of significant infection rates associated with LVAD implantation, few data are available concerning the management of LVAD-related infections and their impact on transplantation. Eight (40%) of our first 20 LVAD recipients developed infections. LVAD-related bloodstream infection occurred in three (15%) patients; infection was due to Staphylococcus aureus in one case, coagulase-negative staphylococci in the second case, and S. aureus and Candida tropicalis in the third case. All three patients were treated with courses of antibiotics that were appropriate for prosthetic valve endocarditis and received antibiotics for at least 6 weeks. All infected patients underwent successful transplantation and had no evidence of recurrence of infection up to 16 months postoperatively. Our experience suggests that LVAD infections can be successfully treated without device removal and that cardiac transplantation can be performed in individuals with LVAD-related bloodstream infection.

Objective To determine the incidence of infection with Escherichia coli O157:H7 in a tertiary referral left in Chicago, where a similar study had been performed in 1984, to evaluate cases of disease reported to the Illinois Department of Public Health (IDPH) in 1993, and to determine laboratory practices used to detect this infection throughout the state. Methods During a 6-month period in 1993, all stool specimens at Rush-Presbyterian-St Luke's Medical Left (RPSLMC) were tested for E. coli O157:H7. Reports of diagnosed E. coli O157:H7 cases investigated by IDPH were also reviewed. A survey of 73 hospitals in the Chicago area was performed to determine routine culturing practices, specifically, the selection of stool specimens for evaluation for this pathogen. Results In the RPSLMC survey, two cases were identified among 1985 samples (incidence 0.1%), similar to the 0.08% incidence detected in a similar study conducted at the same institution in 1984. Through passive surveillance, the IDPH received 44 reports of E. coli O157:H7 in 1993. The hospital survey revealed that, in the seven labs testing all stool specimens for E. coli O157:H7, an incidence of 16/8137 specimens (0.2%) was determined. Conclusions These data suggest that sporadic E. coli O157:H7 remains uncommon in Illinois and that the incidence may not have changed over a 9-year period. The low yield and substantial cost of culturing all stools suggest that only specimens from patients with bloody diarrhea should be evaluated routinely in areas of low endemicity.

Adverse drug reactions are a common clinical problem. It is estimated that 6% to 15% of hospitalized patients experience some sort of adverse drug event.n Clinical manifestations of adverse drug events include anaphylaxis, rash, serum sickness, hepatitis, aseptic meningitis, colitis, and pneumonitis. Many of these adverse events are unrelated to hypersensitivity reactions. Actual allergic or immunologic drug reactions probably account for less than 25% of overall adverse drug events.ll Once a particular reaction is labeled as a hypersensitivity reaction, however, that particular drug or class of drugs is likely to be avoided. Unfortunately, obtaining a clear history of allergic reaction is often difficult or impossible. Patients who have a medically documented allergic reaction should be given a card with the name of the drug and a description of the reaction. Too often an antibiotic is avoided because of a history of allergy when the reaction was actually nausea or minor diarrhea. In such situations, appropriate skin testing may prove beneficial in ruling out allergic drug reaction.9 Skin testing, however, is usually not done in the patient with a strong history of penicillin allergy.9 Therefore, in many clinical situations, an alternative agent is sought when a history of immediate hypersensitivity reaction is obtained. In this article, the types of allergic reactions associated with antibiotics are described. The empiric use of alternative agents for various clinical syndromes is then discussed as well as alternative antibiotics for patients with proven infection.

Objective.To describe the identification, management, and clinical characteristics of hospitalized patients with influenza-like illness (ILI) during the peak period of activity of the 2009 pandemic strain of influenza A virus subtype H1N1 (2009 H1N1).Design.Retrospective review of electronic medical records.Patients and Setting.Hospitalized patients who presented to the emergency department during the period October 18 through November 14, 2009, at 4 hospitals in Cook County, Illinois, with the capacity to perform real-time reverse-transcriptase polymerase chain reaction testing for influenza.Methods.Vital signs and notes recorded within 1 calendar day after emergency department arrival were reviewed for signs and symptoms consistent with ILI. Cases of ILI were classified as recognized by healthcare providers if an influenza test was performed or if influenza was mentioned as a possible diagnosis in the physician notes. Logistic regression was used to determine the patient attributes and symptoms that were associated with ILI recognition and with influenza infection.Results.We identified 460 ILI case patients, of whom 412 (90%) had ILI recognized by healthcare providers, 389 (85%) were placed under airborne or droplet isolation precautions, and 243 (53%) were treated with antiviral medication. Of 401 ILI case patients tested for influenza, 91 (23%) had a positive result. Fourteen (3%) ILI case patients and none of the case patients who tested positive for influenza had sore throat in the absence of cough.Conclusions.Healthcare providers identified a high proportion of hospitalized ILI case patients. Further improvements in disease detection can be made through the use of advanced electronic health records and efficient diagnostic tests. Future studies should evaluate the inclusion of sore throat in the ILI case definition.

raphy. J Nucl Med. 1992;33:1972–1980. 9. Hunder GG, Bloch DA, Michel BA, et al. The American College of Rheumatology 1990 criteria for the classification of giant cell arteritis. Arthritis Rheum. 1990;33:1122–1128. 10. Liuzzo G, Biasucci LM, Gallimore JR, et al. The prognostic value of C-reactive protein and serum amyloid A protein in severe unstable angina. NEJM. 1994;331:417– 424. 11. Blockmans D, Maes A, Stroobants S, et al. New arguments for a vasculitic nature of polymyalgia rheumatica using positron emission tomography. Rheumatology. 1999;38:444 – 447. 12. Ghose MK, Shensa S, Lerner PI. Arteritis of the aged (giant cell arteritis) and fever of unexplained origin. Am J Med. 1976;60:429 – 436. 13. Knockaert DC, Vanneste LJ, Vanneste SB, Bobbaers HJ. Fever of unknown origin in the 1980s. An update of the diagnostic spectrum. Arch Intern Med 1992;152: 51–55. 14. Schmidt WA, Kraft HE, Vorpahl K, et al. Color duplex ultrasonography in the diagnosis of temporal arteritis. NEJM. 1997;337:1336 – 1342. 15. Evans JM, Bowles CA, Bjornsson J, et al. Thoracic aortic aneurysm and rupture in giant cell arteritis. Arthritis Rheum. 1994;37:1539 – 1547. 16. Weyand CM, Hicok KC, Hunder GG, Goronzy JJ. Tissue cytokine patterns in patients with polymyalgia rheumatica and giant cell arteritis. Ann Intern Med. 1994;121:484 – 491.

We retrospectively analyzed data from 75 hospitalized patients with a first episode of Pneumocystis carinii pneumonia to compare the ability of four parameters, including admission serum albumin, serum lactate dehydrogenase (LDH), alveolar-arterial oxygen gradient, and the APACHE II score, to predict mortality and response to initial antipneumocystis therapy. The eight patients who died due to pneumocystosis and the 12 who failed initial antipneumocystis therapy had significantly higher admission mean APACHE II scores and serum LDH levels and lower mean serum albumin levels than did the 65 who survived and the 61 who responded to initial therapy (p less than 0.05 for each). Differences in mean alveolar-arterial oxygen gradients were not statistically significant with respect to survival or response to initial therapy. In a stepwise discriminant analysis of parameters associated with mortality, APACHE II score and LDH level were statistically significant (p less than 0.0001 for each). In a stepwise discriminant analysis of parameters associated with response to initial therapy, APACHE II score and LDH level were again statistically significant (p less than 0.0001, respectively). The addition of the alveolar-arterial oxygen gradient and serum albumin level did not further increase the predictive ability of the discriminant analyses. When analyzed alone, neither the alveolar-arterial oxygen gradient nor the serum albumin were statistically significant in each discriminant analysis. The APACHE II score combined with the serum LDH may be more useful than other parameters, singly or combined, to more closely match patients with regard to severity of illness due to first episode Pneumocystis carinii pneumonia when comparing experimental new therapies with standard agents.

The bacterium Aeromonas hydrophila is commonly found in natural bodies of water, and is a potential invasive pathogen for those who suffer trauma while submerged in water. Five patients treated by the authors and 18 previously reported patients were reviewed to further define the characteristics of A. hydrophila wound infections. Although Aeromonas has been isolated from salt and brackish water, all 23 cases occurred following contact with fresh water. Signs of infection usually appeared 8-48 hours following puncture or laceration injury. The foot or leg were most commonly involved. Infection was frequently rapidly progressive; fascia, tendon, muscle, bone, or joint involvement occurred in 39% of cases. In addition to A. hydrophila, other aerobic and anaerobic bacteria were found in 48% of cases. Aeromonas infection should be suspected in cases of early and rapidly progressive wound infection following trauma in fresh water. Broad-spectrum antimicrobial therapy and appropriate surgical care should be promptly instituted.

Background: Commonly encountered nosocomially acquired gram-negative bacteria, especially Klebsiella pneumoniae, produce extended-spectrum ß-lactamases (ESBLs) as an antibiotic resistance mechanism. Objective: To determine whether microbiology laboratories should report the presence of ESBLs and to establish the infection-control implications of ESBL-producing organisms. Design: Prospective observational study. Setting: 12 hospitals in South Africa, Taiwan, Australia, Argentina, the United States, Belgium, and Turkey. Patients: 440 patients with 455 consecutive episodes of K. pneumoniae bacteremia between 1 January 1996 and 31 December 1997; of these, 253 episodes were nosocomially acquired. Measurements: The K. pneumoniae isolates were examined for the presence of ESBLs. Pulsed-field gel electrophoresis was used to analyze the molecular epidemiology of nosocomial bacteremia with ESBL-producing K. pneumoniae. Results: Overall, 30.8% (78 of 253) episodes of nosocomial bacteremia and 43.5% (30 of 69) episodes acquired in intensive care units were due to ESBL-producing organisms. After adjustment for potentially confounding variables, previous administration of ß-lactam antibiotics containing an oxyimino group (cefuroxime, cefotaxime, ceftriaxone, ceftazidime, or aztreonam) was associated with bacteremia due to ESBL-producing strains (risk ratio, 3.9 [95% CI, 1.1 to 13.8]). In 7 of 10 hospitals with more than 1 ESBL-producing isolate, multiple strains with the same genotypic pattern were observed, indicating patient-to-patient spread of the organism. Conclusions: Production of ESBLs by Klebsiella pneumoniae is a widespread nosocomial problem. Appropriate infection control and antibiotic management strategies are needed to stem the spread of this emerging form of resistance.

The prevalence of extended-spectrum beta-lactamase (ESBL) production by Klebsiella pneumonia approaches 50% in some countries, with particularly high rates in eastern Europe and Latin America. No randomized trials have ever been performed on treatment of bacteremia due to ESBL-producing organisms; existing data comes only from retrospective, single-institution studies. In a prospective study of 455 consecutive episodes of Klebsiella pneumoniae bacteremia in 12 hospitals in 7 countries, 85 episodes were due to an ESBL-producing organism. Failure to use an antibiotic active against ESBL-producing K. pneumoniae was associated with extremely high mortality. Use of a carbapenem ( primarily imipenem) was associated with a significantly lower 14-day mortality than was use of other antibiotics active in vitro. Multivariate analysis including other predictors of mortality showed that use of a carbapenem during the 5-day period after onset of bacteremia due to an ESBL-producing organism was independently associated with lower mortality. Antibiotic choice is particularly important in seriously ill patients with infections due to ESBL-producing K. pneumoniae.

A prospective observational study of 153 patients transferred from long-term care facilities and admitted to acute-care hospitals who had microbiologically confirmed infections was undertaken to determine the risk factors, outcomes, and resource use associated with isolation of antibiotic-resistant bacteria (ARB). Eighty patients (52%) were infected with ARB. In multivariable logistic analysis, the presence of a feeding tube (odds ratio, 3.0) or polymicrobial infection (odds ratio, 4.6) was associated with isolation of ARB. Forty-nine percent of patients infected with ARB received an initial antibiotic regimen to which their isolate was not susceptible. Fifty-one percent of all patients had a change in their antibiotic regimen during their hospital course. For these patients, length of stay, number of days of antibiotic therapy, and cost of hospitalization were significantly higher. However, neither infection with ARB nor appropriateness of initial treatment regimen was significantly related to outcome or resource use.

We initiated a worldwide collaborative study, including 455 episodes of bacteremia, to elucidate the clinical patterns of Klebsiella pneumoniae. Historically, community-acquired pneumonia has been consistently associated with K. pneumoniae. Only four cases of community-acquired bacteremic K. pneumoniae pneumonia were seen in the 2-year study period in the United States, Argentina, Europe, or Australia; none were in alcoholics. In contrast, 53 cases of bacteremic K. pneumoniae pneumonia were observed in South Africa and Taiwan, where an association with alcoholism persisted (p=0.007). Twenty-five cases of a distinctive syndrome consisting of K. pneumoniae bacteremia in conjunction with community-acquired liver abscess, meningitis, or endophthalmitis were observed. A distinctive form of K. pneumoniae infection, often causing liver abscess, was identified, almost exclusively in Taiwan.

Gloving reduces acquisition of vancomycin-resistant Enterococcus species (VRE) on the hands, and it should be considered for routine inpatient care, even for contact with the intact skin of patients who may be colonized with VRE. However, gloving does not completely prevent contamination of the hands, and hand washing is necessary after glove removal.

Early recognition of the sepsis syndrome, prompt administration of broad-spectrum antibiotics, surgical intervention when indicated, and aggressive supportive care in intensive care units remain the therapeutic strategies for patients with sepsis. Antibiotic selection is based on many factors including the most probable source of infection, the most likely pathogens, and knowledge of antibiotic susceptibility patterns for community- and hospital-acquired infections. Unfortunately, with this approach, mortality remains unacceptably high. Adjuvant therapies such as antiendotoxin antibodies, cytokine antagonists, and anti-inflammatory agents aimed at blunting the host immune response to bacterial infection have provided little clinical benefit to date. As our understanding of the pathophysiology of sepsis progresses, perhaps newer modalities will improve clinical outcome. At this time, preventive strategies, including optimal vaccine use, effective infection control practices, judicious use and care of intravascular lines and indwelling urinary catheters, and appropriate use of anti-infective agents to prevent microbial resistance should be used to decrease the incidence of infection and subsequent sepsis.

A prospective study of Klebsiella pneumoniae bacteremia was performed in 12 hospitals in 7 countries, Of 452 episodes of bacteremia, 25 (5.5%) were caused by ii, pneumoniae that was resistant in vitro to ciprofloxacin. Extended-spectrum beta-lactamase (ESBL) production was detected in 15 (60%) of 25 ciprofloxacin-resistant isolates, compared with 68 (16%) of 427 ciprofloxacin-susceptible strains (P = .0001), Multivariate analysis revealed that risk factors for ciprofloxacin resistance in ii. pneumoniae included prior receipt of a quinolone (P = .0065) and an ESBL-producing strain (P = .012), In all, 18% of ESBL-producing isolates were also ciprofloxacin-resistant. Pulsed-held gel electrophoresis showed that 11 of the 15 ciprofloxacin-resistant ESBL-producing strains belonged to just 4 genotypes, suggesting that patient-to-patient transmission of such strains occurred. The close relationship between ESBL production and ciprofloxacin resistance is particularly worrisome because the first reported instance of plasmid-mediated ciprofloxacin resistance has been in an isolate of K. pneumoniae also possessing an ESBL.

Prolonged suppressive antibiotic therapy may be an alternative to removal of infected orthopedic prostheses in some patients. However, the efficacy of prolonged suppressive antibiotics is not well established. We retrospectively reviewed 18 patients with infected orthopedic prostheses who had been treated with prolonged antimicrobial suppression during the last 10 years. Eighteen episodes of infection were identified in these 18 patients. There were nine men and nine women, and the mean age was 66 years (range, 31-83 years). All patients had a functional prosthesis and were treated with surgical debridement, retention of the prosthesis, and administration of intravenous antibiotics for 6-8 weeks, followed by prolonged oral antibiotic suppression. Fifteen of the 18 patients appear to have had a good response and have been able to retain a functional prosthesis. Complications related to antibiotic suppression occurred in 22% but did not necessitate discontinuation of the antibiotic therapy. Prolonged antibiotic suppression is a reasonable alternative to surgery in selected patients with infected orthopedic prostheses.

To assess the prevalence of skin and rectal colonization by vancomycin-resistant enterococci (VRE) in hospitalized bacteremic patients and to determine the relation between colonization and bacteremia, we compared 14 case patients who had bacteremia due to VRE with 30 control patients who had bacteremia due to other pathogens. Rectal colonization and skin (inguinal area and/or antecubital fossa) colonization with VRE were common among both case patients (100% had rectal colonization, and 86% had skin colonization) and control patients (37% had rectal colonization and 23% had skin colonization). Among patients with rectal colonization, skin colonization was more common when diarrhea or fecal incontinence was present. The bloodstream cleared without appropriate antimicrobial therapy in nine of the 14 patients with bacteremia due to VRE. The high prevalence of skin colonization with VRE may increase the risk of catheter-related sepsis, cross-infection, or blood culture contamination (which may explain the frequent spontaneous resolution of bacteremia due to VRE).

Cardiovascular responses to systemic bacteremia were evaluated in a pre-instrumented, conscious pigs. Basal observations were obtained 5-7 days after instrumentation. On the next day, Escherichia coli 0111.B4 (1.1 to 33 x 10(9) CFU/kg)-laden fibrin clots were implanted intraperitoneally. Nonsurvivors (9/18) demonstrated rapid cardiovascular decompensation. Survivors (9/18) demonstrated significant cardiovascular injury, which was reversed by 5-7 days postimplant. Cardiac inotropicity was significantly reduced in this period, but recovered by day 7. Circulating myocardial depressant substance activity (assayed by serum-induced depression of beating neonatal rat myocytes) was present on days 1-4 of bacteremia and recovered to basal values on day 6. No clinical or cardiovascular changes were seen in pigs implanted with sterile clots (n = 4). These data demonstrate that implantation of bacteria-laden fibrin clots in pigs induces cardiovascular alterations that mimic responses seen in human sepsis.

In 1994, we isolated Borrelia burgdorferi sensu lato from 231 patients with erythema migrans who presented to the University Medical Center in Ljubljana, Slovenia. Samples of erythema migrans-affected skin were placed in media to support the growth of Borrelia species and evaluated in Ljubljana and Chicago. Patients whose cultures were positive included 132 women and 99 men; 136 of these 231 patients recalled a tick bite. Patients noted a rash an average of 24 days after a bite and presented a mean of 34 days after the bite with erythema migrans (mean diameter. 16 cm). Itching (44%) burning (18%), and pain (11%) were the most common local symptoms. Systemic complaints (40%) included headache, fatigue, malaise, and arthralgia. Other than erythema migrans, findings on physical examination were minimal (< 5% had fever, and in < 10% local lymph nodes were affected). Serial serological studies using indirect immunofluorescence assay, ELISA, and Western blot methods were performed, and antibodies to B, burgdorferi sensu lato were detected in < 50% of samples from patients. This is the largest series reported to date of patients with culture-confirmed Lyme borreliosis. It highlights the deficiencies of serological tests in early disease, demonstrates the sensitivity of direct detection methods for evaluation of patients with erythema migrans, and suggests that patients with early Lyme borreliosis in Slovenia may suffer a milder illness than those in the United States.

Fever is common in the solid organ transplant patient and may be produced by a variety of processes. The approach to the febrile transplant patient must include an extensive search for infection, which may be aided by considering the organ transplanted, time after transplantation, and the patient's immunosuppressed state. In addition, a number of noninfectious causes of fever exist in this population, including allograft rejection, drug fever, and thromboembolic disease. A review of the pathogens commonly noted in posttransplant patients is presented, emphasizing risk factors for disease, typical time of presentation, and particular organ groups affected. In addition, the authors review the noninfectious causes of fever in the solid organ transplant patient.

The in vitro activities of levofloxacin and other antibiotics against 133 clinical isolates of vancomycin-resistant and vancomycin-susceptible enterococci were evaluated. Only 14 (39%) of the vancomycin-susceptible isolates and 11 (11%) of the vancomycin-resistant isolates were susceptible to levofloxacin. Levofloxacin exhibited a marked inoculum effect for all enterococci tested. These results suggest that levofloxacin may be of limited use in the treatment of serious enterococcal infections.