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In the United States, age-adjusted opioid overdose death rates increased by >200% during 1999-2015, and heroin overdose death rates increased nearly 300% during 2011-2015 (1). During 2011-2013, the rate of heroin use within the past year among U.S. residents aged ≥12 years increased 62.5% overall and 114.3% among non-Hispanic whites, compared with 2002-2004 (2). Increases in human immunodeficiency virus (HIV) and hepatitis C virus (HCV) infections related to increases in injection drug use have been recently highlighted (3,4); likewise, invasive bacterial infections, including endocarditis, osteomyelitis, and skin and soft tissue infections, have increased in areas where the opioid epidemic is expanding (5-7). To assess the effects of the opioid epidemic on invasive methicillin-resistant Staphylococcus aureus (MRSA) infections during 2005-2016, surveillance data from CDC's Emerging Infections Program (EIP) were analyzed (8). Persons who inject drugs were estimated to be 16.3 times more likely to develop invasive MRSA infections than others. The proportion of invasive MRSA cases that occurred among persons who inject drugs increased from 4.1% in 2011 to 9.2% in 2016. Infection types were frequently those associated with nonsterile injection drug use. Continued increases in nonsterile injection drug use are likely to result in increases in invasive MRSA infections, underscoring the importance of public health measures to curb the opioid epidemic.

In this work, we have removed some of the confusion surrounding the use of the name “USA500,” placed USA500 strains in the context of the CC8 group, and developed a strategy for assignment to subclades based on genome sequence. Our new phylogeny of USA300/USA500 will be a reference point for understanding the genetic adaptations that have allowed multiple highly virulent clonal strains to emerge from within CC8 over the past 50 years., USA500 isolates are clonal complex 8 (CC8) Staphylococcus aureus strains closely related to the prominent community- and hospital-associated USA300 group. Despite being relatively understudied, USA500 strains cause a significant burden of disease and are the third most common methicillin-resistant S. aureus (MRSA) strains identified in the U.S. Emerging Infections Program (EIP) invasive S. aureus surveillance. To better understand the genetic relationships of the strains, we sequenced the genomes of 539 USA500 MRSA isolates from sterile site infections collected through the EIP between 2005 and 2013 in the United States. USA500 isolates fell into three major clades principally separated by their distribution across different U.S. regions. Clade C1 strains, found principally in the Northeast, were associated with multiple IS256 insertion elements in their genomes and higher levels of antibiotic resistance. C2 was associated with Southern states, and E1 was associated with Western states. C1 and C2 strains all shared a frameshift in the gene encoding AdsA surface-attached surface protein. We propose that the term “USA500” should be used for CC8 strains sharing a recent common ancestor with the C1, C2, and E1 strains but not in the USA300 group. IMPORTANCE In this work, we have removed some of the confusion surrounding the use of the name “USA500,” placed USA500 strains in the context of the CC8 group, and developed a strategy for assignment to subclades based on genome sequence. Our new phylogeny of USA300/USA500 will be a reference point for understanding the genetic adaptations that have allowed multiple highly virulent clonal strains to emerge from within CC8 over the past 50 years.

BackgroundInternal medicine physicians are often the first providers to encounter patients with a new diagnosis of tuberculosis. Given the public health risks of missed tuberculosis cases, assessing internal medicine residents’ ability to diagnose tuberculosis is important.MethodsInternal medicine resident knowledge and practice patterns in pulmonary tuberculosis diagnosis at 7 academic hospitals were assessed utilizing (a) a 10-item validated pulmonary tuberculosis diagnosis assessment tool and (b) a retrospective chart review of 343 patients who underwent a pulmonary tuberculosis evaluation while admitted to a resident-staffed internal medicine or infectious disease service. Our primary outcomes were the mean score and percentage of correct responses per assessment tool question, and the percentage of patients who had Centers for Disease Control and Prevention–recommended tuberculosis diagnostic tests obtained.ResultsOf the 886 residents who received the assessment, 541 responded, yielding a response rate of 61%. The mean score on the assessment tool (SD) was 4.4 (1.6), and the correct response rate was 57% (311/541) or less on 9 of 10 questions. On chart review, each recommended test was obtained for ≤43% (148/343) of patients, other than chest x-ray (328/343; 96%). A nucleic acid amplification test was obtained for 18% (62/343) of patients, whereas 24% (83/343) had only 1 respiratory sample obtained. Twenty patients were diagnosed with tuberculosis.ConclusionsSignificant knowledge and practice gaps exist in internal medicine residents’ abilities to diagnose tuberculosis. As residents represent the future providers who will be evaluating patients with possible tuberculosis, such deficiencies must be addressed.

Background Antiretroviral therapy (ART) for persons with HIV infection prevents tuberculosis (TB) disease. Additionally, sequential ART after initiation of TB treatment improves outcomes. We examined ART use, retention in care, and viral suppression (VS) before, during, and 3 years following TB treatment for an inner-city cohort in the United States. Methods Retrospective cohort study among persons treated for culture-confirmed TB between 2008 and 2015 at an inner-city hospital. Results Among 274 persons with culture-confirmed TB, 96 (35%) had HIV co-infection, including 23 (24%) new HIV diagnoses and 73 (76%) previous diagnoses. Among those with known HIV prior to TB, the median time of known HIV was 6 years, and only 10 (14%) were on ART at the time of TB diagnosis. The median CD4 at TB diagnosis was 87 cells/uL. Seventy-four (81%) patients received ART during treatment for TB, and 47 (52%) has VS at the end of TB treatment. Only 32% of patients had continuous VS 3 years after completing TB treatment. There were 3 TB recurrences and 3 deaths post–TB treatment; none of these patients had retention or VS after TB treatment. Conclusions Among persons with active TB co-infected with HIV, we found that the majority had known HIV and were not on ART prior to TB diagnosis, and retention in care and VS post–TB treatment were very low. Strengthening the HIV care continuum is needed to improve HIV outcomes and further reduce rates of active TB/HIV co-infection in our and similar settings.

Background Recently, overall reductions for invasive MRSA infections (isolation from a normally sterile site) have slowed. Healthcare-associated community-onset (HACO) invasive methicillin-resistant Staphylococcus aureus (MRSA) infections are those with recent healthcare exposures who develop MRSA infection outside acute care hospitals, and account for most invasive MRSA infections. HACO incidence decreased 6.6% per year during 2005–2008; the contribution of persons who inject drugs (PWID) to HACO incidence has not been reported. Methods We identified invasive MRSA infections using active, population- and laboratory-based surveillance data during 2009–2017 from 25 counties in 7 sites (CA, CT, GA, MD, MN, NY, TN). Cases were HACO if culture was obtained from an outpatient, or ≤3 days after hospitalization in a patient with ≥1 of the following healthcare exposures (HEs): hospitalization, surgery, dialysis, or residence in a long-term care facility (LTCF) in the past year; or central vascular catheter ≤2 days before culture. We calculated incidence (per census population) overall, for PWID cases and others, and for cases associated with each HE. For each HE, we calculated the proportion of overall incidence increase for PWID and others. Results HACO MRSA incidence declined overall from 2009 to 2016 but increased from 2016 to 2017 overall (8%), for both PWID (63%) and others (5%) (figure). For both PWID and non-PWID, incidence from 2016 to 2017 increased by 0.5 cases/100,000 population; 91% of the increase in PWID occurred in cases with a past year hospitalization while 78% of the increase in cases not associated with injection drug use (IDU) occurred in cases with past year LTCF residence. Past year LTCF residence was less common among PWID (16%) then among other cases (38%, P < 0.01). Conclusion After years of declines, HACO MRSA incidence increased equally in 2017 for cases associated with IDU and in cases unrelated to IDU. Increases in PWID-associated cases account for half the overall increase, indicating that efforts to reduce HACO MRSA should address PWID risk factors as these infections may be due to self-injection. In addition, increases not related to PWID, if sustained, would be a reversal of historic trends and require further investigation into causes. Disclosures All authors: No reported disclosures.

Background Large-scale, prospective, evaluation of sampling for central line–associated bloodstream infection (CLABSI) denominator data was necessary prior to National Healthcare Safety Network (NHSN) implementation. Methods In a sample of volunteer hospitals from states in the Emerging Infections Program, prospective collection of CLABSI denominators (patient days, central line days [CLDs]) was performed in eligible locations for ≥6 and ≤12 consecutive months using the current NHSN method (daily collection) and also by a second data collector who sampled the denominator data 1 d/wk. The quality of the sampled data was evaluated and used to calculate estimated CLDs and CLABSI rates, which were compared with actual CLDs and CLABSI rates (daily counts). Results In total, 89 locations in 66 acute care hospitals participated. Sampled data were collected as intended 88% of the time; the quality of the data was comparable with the data collected daily. In locations with higher CLDs per month (≥75), estimated CLDs and CLABSI rates were similar to actual CLDs and CLABSI rates; however, there were significant differences in actual and estimated values among locations with lower (≤74) CLDs per month.Sampling was successfully implemented, but significant differences in the accuracy of estimated CLDs and CLABSI rates, based on the actual number of CLDs per month, were noted. Conclusion For locations with a higher number of CLDs per month, sampling 1 d/wk is a valid and accurate alternative to daily collection of CLABSI denominator data.

Neutrophils are increasingly associated with tuberculosis (TB) disease. Neutrophil extracellular traps (NETs), which are released by neutrophils as a host antimicrobial defense mechanism, are also associated with tissue damage. However, a link between NET levels and TB disease has not been studied. Here we investigate plasma NETs levels in patients with active pulmonary tuberculosis using an ELISA assay that is suitable for high-throughput processing. We show that plasma NETs levels at baseline correlated with disease severity and decreased with antibiotic therapy. Our study demonstrates the biologic plausibility of measuring NETs in plasma samples from patients with TB.

Human immunodeficiency virus (HIV)-infected individuals with latent Mycobacterium tuberculosis infection have substantially higher rates of progression to active tuberculosis than HIV-uninfected individuals with latent tuberculosis. To explore HIV-induced deficits in M. tuberculosis-specific CD8+ T-cell functions, we compared interferon γ production, degranulation, and proliferation of CD8+ T cells in response to M. tuberculosis peptides (ESAT-6/CFP-10) between HIV-infected (median CD4+ T-cell count, 522 cells/µL; interquartile range, 318-585 cells/µL) and HIV-uninfected individuals with latent tuberculosis from South Africa. We found that M. tuberculosis-specific degranulation and proliferative capacities were impaired in the HIV-infected group. Thus, our results suggest that HIV coinfection compromises CD8+ T-cell functions in latent tuberculosis.

To estimate the association between diabetes mellitus (DM) and all-cause mortality during tuberculosis (TB) treatment.From 2009 to 2012, a retrospective cohort study among reported TB cases in Georgia was conducted. Patients aged 16 years or older were classified by DM and human immunodeficiency virus (HIV) status at the time of TB diagnosis and followed during TB treatment to assess mortality. Hazard ratios were used to estimate the association between DM and death.Among 1325 patients with TB disease, 151 (11.4%) had DM, 147 (11.1%) were HIV-infected, and seven (0.5%) had both DM and HIV. Patients with TB-DM were more likely to have cavitary lung disease compared with those with TB alone (51.0% vs. 34.7%) and those with TB-HIV were more likely to have military/disseminated disease (12.9% vs. 3.4%) and resistance to rifampin or isoniazid (21.8% vs. 9.0%) compared with those without HIV infection (P .05). In multivariable analysis, DM was not associated with death during TB treatment (hazard ratio, 1.22; 95% confidence interval, 0.70-2.12) or any death (adjusted odds ratio, 1.05; 95% confidence interval, 0.60-1.84).Among TB patients in Georgia, the prevalence of comorbid DM and coinfection with HIV was nearly identical. In adjusted models, TB patients with DM did not have increased risk of all-cause mortality.

Objective.To describe the implementation of a population-based surveillance system for multidrug-resistant gram-negative bacilli (MDR-GNB).Design.Population-based active surveillance by the Georgia Emerging Infections Program.Setting.Metropolitan Atlanta, starting November 2010.Patients.Residents with MDR-GNB isolated from urine or a normally sterile site culture.Methods.Surveillance was implemented in 3 phases: (1) surveying laboratory antibiotic susceptibility testing practices, (2) piloting surveillance to estimate the proportion of GNB that were MDR, and (3) maintaining ongoing active surveillance for carbapenem-nonsusceptible Enterobacteriaceae and Acinetobacter baumannii using the 2010 Clinical and Laboratory Standards Institute (CLSI) breakpoints. Pilot surveillance required developing and installing queries for GNB on the 3 types of automated testing instruments (ATIs), such as MicroScan, in Atlanta's clinical laboratories. Ongoing surveillance included establishing a process to extract data from ATIs consistently, review charts, manage data, and provide feedback to laboratories.Results.Output from laboratory information systems typically used for surveillance would not reliably capture the CLSI breakpoints, but queries developed for the 3 ATIs did. In November 2010, 0.9% of Enterobacteriaceae isolates and 35.7% of A. baumannii isolates from 21 laboratories were carbapenem nonsusceptible. Over a 5-month period, 82 Enterobacteriaceae and 59 A. baumannii were identified as carbapenem nonsusceptible.Conclusions.Directly querying ATIs, a novel method of active surveillance for MDR-GNB, proved to be a reliable, sustainable, and accurate method that required moderate initial investment and modest maintenance. Ongoing surveillance is critical to assess the burden of and changes in MDR-GNB to inform prevention efforts.

Currently, no single U.S. surveillance system can provide estimates of the burden of all types of health care-associated infections across acute care patient populations. We conducted a prevalence survey in 10 geographically diverse states to determine the prevalence of health care-associated infections in acute care hospitals and generate updated estimates of the national burden of such infections.We defined health care-associated infections with the use of National Healthcare Safety Network criteria. One-day surveys of randomly selected inpatients were performed in participating hospitals. Hospital personnel collected demographic and limited clinical data. Trained data collectors reviewed medical records retrospectively to identify health care-associated infections active at the time of the survey. Survey data and 2010 Nationwide Inpatient Sample data, stratified according to patient age and length of hospital stay, were used to estimate the total numbers of health care-associated infections and of inpatients with such infections in U.S. acute care hospitals in 2011.Surveys were conducted in 183 hospitals. Of 11,282 patients, 452 had 1 or more health care-associated infections (4.0%; 95% confidence interval, 3.7 to 4.4). Of 504 such infections, the most common types were pneumonia (21.8%), surgical-site infections (21.8%), and gastrointestinal infections (17.1%). Clostridium difficile was the most commonly reported pathogen (causing 12.1% of health care-associated infections). Device-associated infections (i.e., central-catheter-associated bloodstream infection, catheter-associated urinary tract infection, and ventilator-associated pneumonia), which have traditionally been the focus of programs to prevent health care-associated infections, accounted for 25.6% of such infections. We estimated that there were 648,000 patients with 721,800 health care-associated infections in U.S. acute care hospitals in 2011.Results of this multistate prevalence survey of health care-associated infections indicate that public health surveillance and prevention activities should continue to address C. difficile infections. As device- and procedure-associated infections decrease, consideration should be given to expanding surveillance and prevention activities to include other health care-associated infections.

Background Methicillin-resistant Staphylococcus aureus (MRSA) causes >70,000 invasive infections annually in the United States, and recurrent infections pose a major clinical challenge. We examined risk factors for recurrent MRSA infections. Methods We identified patients with an initial invasive MRSA infection (isolation from a normally sterile body site) from 2006 to 2013, through active, population-based surveillance in selected counties in nine states through the Emerging Infections Program. Recurrence was defined as invasive MRSA isolation >30 days after initial isolation. We used logistic regression with backwards selection to evaluate adjusted odds ratios (aOR) associated with recurrence within 180 days, prior healthcare exposures, and initial infection type, controlling for patient demographics and comorbidities. Results Among 24,478 patients with invasive MRSA, 3,976 (16%) experienced a recurrence, including 61% (2,438) within 180 days. Risk factors for recurrence were: injection drug use (IDU) (aOR; 1.38, 95% confidence interval [CI]: 1.15–1.65), central venous catheters (aOR; 1.35, 95% CI: 1.22–1.51), dialysis (aOR; 2.00, 95% CI: 1.74–2.31), and history of MRSA colonization (aOR; 1.35, 95% CI: 1.22–1.51) (figure). Recurrence was more likely for bloodstream infections (BSI) without another infection (aOR; 2.08, 95% CI: 1.74–2.48), endocarditis (aOR; 1.46, 95% CI: 1.16–1.55), and bone/joint infections (aOR; 1.38, 95% CI: 1.20–1.59), and less likely for pneumonia (aOR: 0.75, 95% CI: 0.64–0.89), compared with other initial infection types. When assessed separately, the presence of a secondary BSI with another infection increased the odds of recurrence over that infection without a BSI (aOR: 1.96, 95% CI: 1.68–2.30). Conclusion Approximately one in six persons with invasive MRSA infection had recurrence. We identified potential opportunities to prevent recurrence through infection control (e.g., management and early removal of central catheters). Other possible areas for preventing recurrence include improving the management of patients with BSI and bone/joint infections (including both during and after antibiotic treatment) and mitigating risk of infection from IDU. Disclosures All authors: No reported disclosures.

Background Staphylococcus aureus treatment guidelines are being revised to include proposed quality measures for evaluation of patients with S. aureus bacteremia (SAB) (e.g., infectious disease [ID] consultation, echocardiogram, and documenting clearance of bacteremia). We describe current management practices of SAB to identify opportunities for quality improvement. Methods We conducted a pilot assessment of SAB cases reported to CDC’s Emerging Infections Program active, laboratory- and population-based surveillance from 24 hospitals in four states during 1–2 months in 2017 or 2018. An SAB case was the isolation of S. aureus from a blood culture among adults (≥18 years) in the catchment area. We collected clinical and demographic information and performed a descriptive analysis of management of SAB cases. Results Among 109 SAB cases identified, 50 (46%) were methicillin-resistant S. aureus (MRSA). While hospitalized, 87 (80%) patients were evaluated by ID consultation, 90 (83%) underwent an echocardiogram (26 were transesophageal), and 92 (84%) had documented clearance of bacteremia. During the hospitalization, 15 (14%) died and 12 (11%) left against medical advice (AMA). Of those who survived and did not leave AMA, median duration of hospitalization after initial culture was 10.5 days (interquartile range 7–18). In total, 10 survivors (9% of cases) completed at least 2 weeks of antibiotics while hospitalized, and 65 (60% of cases) were discharged on antibiotic therapy. Among the 25 MRSA patients discharged on antibiotics, common treatments were vancomycin (64%), daptomycin (8%), ceftaroline (8%), and linezolid (4%). Among the 40 methicillin-susceptible SAB patients discharged on antibiotics, cefazolin (56%), ceftriaxone (13%), cefepime (5%), linezolid (5%), nafcillin (3%), and vancomycin (3%) were most common. The remainder of outpatient treatments included oral β-lactams, clindamycin, doxycycline, levofloxacin, and erythromycin. Conclusion Overall, the majority of patients with SAB underwent evaluation according to the proposed quality measures and received therapy with targeted anti-staphylococcal agents, although opportunities to optimize treatment remain. Hospitalized patients who leave AMA represent a particular challenge for effective SAB therapy. Disclosures All authors: No reported disclosures.

Background Disparities in incidence of invasive methicillin-resistant S. aureus (iMRSA) infections have been examined, suggesting that differences were in part driven by socio-economic factors. An analysis was conducted to determine whether similar disparities exist for invasive methicillin-susceptible S. aureus (iMSSA). Methods The Georgia Emerging Infections Program (GA EIP) conducts active, population-based surveillance for iSA within the 8-county area of Atlanta. Cases were defined as residents of the surveillance area with SA isolated from a normally sterile site, with cultures within a 30-day period considered a single case. Age- and race-specific incidence were calculated using 2016 US census data; other/unknown race were excluded from analysis ( Results During 2016, 1,958 cases were identified (42% iMRSA and 58% iMSSA); crude incidence was 48.5/100,000. Rates were highest among those ≥ 65 years of age for both blacks and whites (Figure 1). When compared with iMSSA, iMRSA incidence was consistently lower across all age groups (aRR: 0.7; 95% CI: 0.7–0.8) (Figure 2). However, the incidence of iMRSA among black cases was double that among white cases (aRR: 2.0; CI: 1.7–2.3) across all age groups. This racial disparity was less pronounced in iMSSA: among younger cases ( Conclusion In the Atlanta area, racial disparities in iSA were noted, with higher incidence among blacks than whites for both iMSSA and iMRSA. The racial disparity is more extreme for iMRSA. Notably the racial disparity is not observed in cases age 65 and over. Causes for these disparities should be investigated. Disclosures S. Fridkin, Pfizer Inc.: Grant Investigator, Research support.

Background CDC released the Core Elements of Antibiotic Stewardship (Core Elements) for Nursing Homes (NHs) in 2015. In 2017, CDCs Emerging Infections Program (EIP) evaluated uptake of the Core Elements in a cohort of NHs. Methods NHs from California, Colorado, Connecticut, Georgia, Maryland, Minnesota, New Mexico, New York, Oregon, and Tennessee were randomly selected to participate in a CDC EIP antimicrobial use prevalence survey; participation was voluntary. A NH leader (typically Director of Nursing or Infection Preventionist) completed a CDC questionnaire to self-report facility implementation of 15 individual activities within the 7 domains of the Core Elements. The number and percentage of facilities reporting “Yes” to each activity and a facility stewardship score (range 0–15, 1 point per activity) were calculated. Associations between the stewardship score and facility-level factors, obtained from the questionnaire and publically available Centers for Medicare and Medicaid Services (CMS) NH quality data, were identified using Analysis of Variance (Proc GLM) in SAS 9.4; a P < 0.05 was considered significant. Results In 161 NHs (mean certified beds 118, 92% dual certified, 68% for-profit), the % of NHs reporting implementation of the 15 activities (figure) ranged from 25% (has a formulary of antibiotic agents, providers required to perform an antibiotic “time-out”) to 88% (providers required to document dose, duration and indication). The median facility stewardship score was 9 (interquartile range 7–12). A higher stewardship score was significantly associated with having: an infection preventionist who completed a certified training course (Yes vs. No, P = 0.029), higher number of attending physicians per 100 NH beds (upper quartile vs. lower three quartiles, P = 0.029), and higher CMS quality measure score (scale of 1 to 5 points, P = 0.025). Conclusion These data, collected approximately 2 years after release of the Core Elements, show NHs have begun to implement many policies or practices consistent with CDC antibiotic stewardship guidance. However, improved understanding of the uptake and barriers associated with implementation of the Core Elements can inform development of stewardship initiatives, identify NHs in need of stewardship interventions, and accelerate adoption. Disclosures All authors: No reported disclosures.

Background Improving antimicrobial use is a key component of controlling antimicrobial resistance. Multiple factors influence inpatient provider antimicrobial prescribing decisions, making it challenging to develop standard methods to evaluate prescribing quality in hospitals. In 2015, CDC’s Emerging Infections Program (EIP) conducted a hospital antimicrobial use prevalence survey and collected data to assess prescribing quality in selected scenarios, including fluoroquinolone (FQ) treatment. Methods EIP sites (CA, CO, CT, GA, MD, MN, NM, NY, OR, TN) each recruited up to 25 hospitals for the survey. Each hospital selected a survey date during May–September 2015. Among randomly selected inpatients on the survey date, EIP staff identified those ≥18 years old who received FQ treatment on the survey date or the day prior and reviewed medical records to gather data on underlying conditions, infections, and diagnostic tests. We used these data to update a previously developed prescribing quality assessment pathway that categorized FQ treatment as supported or unsupported based on medical record documentation. Results Among 12,299 patients in 199 hospitals, 1084 (8.7%) received FQ treatment; 756 (70%) were treated for a single infection type during their hospitalization and were ≥18 years old. The pathway categorized FQ treatment as supported for 646 (85.4%) and unsupported for 110 patients (14.6%) (figure). Almost half of unsupported treatment was due to a lack of compatible signs or symptoms of infection in a patient from whom an organism susceptible or likely susceptible to an FQ was identified from a nonsterile site (49/110 patients, 44.5%), suggesting colonization. Conclusion Utilization of a pathway that incorporates detailed clinical data enabled us to apply a standard approach to assess FQ prescribing quality in hospitals. A high percentage of FQ treatment was supported, possibly reflecting efforts in recent years to reduce inappropriate use. Our assessment approach also identified opportunities for further improvements in inpatient FQ stewardship. Incorporation of additional elements in the pathway, such as the availability of other antibiotic choices in clinical scenarios where FQ use is currently supported (e.g., pneumonia) could further enhance the pathway’s performance. Disclosures All authors: No reported disclosures.

Background Sepsis is an important contributor to mortality among children and young adults. However, recent studies focused on hospital management and burden estimation do not provide critical data to inform prevention efforts. We conducted detailed medical record reviews to describe the epidemiology and clinical characteristics of children and young adults with sepsis to inform prevention and early recognition targets. Methods We utilized the Emerging Infections Program (EIP) to collect comprehensive data via retrospective record review for patients with severe sepsis or septic shock discharge diagnosis codes from a nonrandom sample of hospitals across 10 states. Children and young adults, aged 30 days through 21 years, discharged between September 30, 2014 and October 1, 2015, were randomly selected for inclusion. We performed a descriptive analysis of these data. Results Among 734 patients hospitalized with sepsis, 92% were living in a private residence 4 days before admission, 38% had an outpatient medical encounter in the 7 days before admission, 14% had sepsis onset after hospital day 3, and 11% died within 90 days of sepsis diagnosis. The most frequently identified infection was lower respiratory tract infection (14%); for 317 (43%) no infection was documented as a cause of sepsis. The most frequently identified pathogen was Staphylococcus aureus (10%); for 326 (44%) no pathogen was identified as a cause of sepsis. Among 394 (54%) patients with ≥1 chronic underlying medical condition (CUMC), the most common were pulmonary disease (35%), hematologic/oncologic disease (31%), immune compromise (24%), and cardiovascular disease (20%). Patients with CUMC had a higher percentage of their sepsis onset after hospital day 3, death within 90 days of sepsis diagnosis, and Pseudomonas aeruginosa as a cause of sepsis (table). The percentage of patients with no pathogen identified was similar between those with CUMC and those without. Conclusion In our large cohort of children and young adults with sepsis, most had sepsis onset outside of the hospital and over half had chronic conditions. Our data suggest that distinct approaches may be needed to develop effective prevention and early recognition strategies for children and young adults depending on the presence of chronic conditions. Disclosures All authors: No reported disclosures.

Background. Approximately 15 700 invasive methicillin-resistant Staphylococcus aureus (MRSA) infections occurred in US dialysis patients in 2010. Frequent hospital visits and prolonged bloodstream access, especially via central venous catheters (CVCs), are risk factors among hemodialysis patients. We describe the epidemiology of and recent trends in invasive MRSA infections among dialysis patients. Methods. We analyzed population-based data from 9 US metropolitan areas from 2005 to 2011. Cases were defined as MRSA isolated from a normally sterile body site in a surveillance area resident who received dialysis, and were classified as hospital-onset (HO; culture collected >3 days after hospital admission) or healthcare-associated community-onset (HACO; all others). Incidence was calculated using denominators from the US Renal Data System. Temporal trends in incidence and national estimates were calculated controlling for age, sex, and race. Results. From 2005 to 2011, 7489 cases were identified; 85.7% were HACO infections, and 93.2% were bloodstream infections. Incidence of invasive MRSA infections decreased from 6.5 to 4.2 per 100 dialysis patients (annual decrease, 7.3%) with annual decreases of 6.7% for HACO and 10.5% for HO cases. Among cases identified during 2009–2011, 70% of patients were hospitalized in the year prior to infection. Among hemodialysis cases, 60.4% of patients were dialyzed through a CVC. The 2011 national estimated number of MRSA infections was 15 169. Conclusions. There has been a substantial decrease in invasive MRSA infection incidence among dialysis patients. Most cases had previous hospitalizations, suggesting that efforts to control MRSA in hospitals might have contributed to the declines. Infection prevention measures should include improved vascular access and CVC care.

Objective To evaluate the accuracy of weekly sampling of central line-associated bloodstream infection (CLABSI) denominator data to estimate central line-days (CLDs). Design Obtained CLABSI denominator logs showing daily counts of patient-days and CLD for 6-12 consecutive months from participants and CLABSI numerators and facility and location characteristics from the National Healthcare Safety Network (NHSN). Setting and participants Convenience sample of 119 inpatient locations in 63 acute care facilities within 9 states participating in the Emerging Infections Program. Methods Actual CLD and estimated CLD obtained from sampling denominator data on all single-day and 2-day (day-pair) samples were compared by assessing the distributions of the CLD percentage error. Facility and location characteristics associated with increased precision of estimated CLD were assessed. The impact of using estimated CLD to calculate CLABSI rates was evaluated by measuring the change in CLABSI decile ranking. Results The distribution of CLD percentage error varied by the day and number of days sampled. On average, day-pair samples provided more accurate estimates than did single-day samples. For several day-pair samples, approximately 90% of locations had CLD percentage error of less than or equal to ±5%. A lower number of CLD per month was most significantly associated with poor precision in estimated CLD. Most locations experienced no change in CLABSI decile ranking, and no location's CLABSI ranking changed by more than 2 deciles. Conclusions Sampling to obtain estimated CLD is a valid alternative to daily data collection for a large proportion of locations. Development of a sampling guideline for NHSN users is underway.

Multidrug-resistant tuberculosis (MDR TB), defined by resistance to the 2 most effective first-line drugs, isoniazid and rifampin, is on the rise globally and is associated with significant morbidity and mortality. Despite the increasing availability of novel rapid diagnostic tools for Mycobacterium tuberculosis (Mtb) drug susceptibility testing, the clinical applicability of these methods is unsettled. In this study, the mechanisms of action and resistance of Mtb to isoniazid and rifampin, and the utility, advantages and limitations of the available Mtb drug susceptibility testing tools are reviewed, with particular emphasis on molecular methods with rapid turnaround including line probe assays, molecular beacon-based real-time polymerase chain reaction and pyrosequencing. The authors conclude that neither rapid molecular drug testing nor phenotypic methods are perfect in predicting Mtb drug susceptibility and therefore must be interpreted within the clinical context of each patient.

Background: The USA300 methicillin-resistant Staphylococcus aureus (MRSA) strain, which initially emerged as a cause of community-associated infections, has recently become an important pathogen in healthcare-associated infections (HAIs). However, its impact on patient outcomes has not been well studied. We evaluated patients with invasive MRSA infections to assess differences in outcomes between infections caused by USA100 and those caused by USA300. Methods: Population-based data for invasive MRSA infections were used to identify 2 cohorts: (1) nondialysis patients with central line-associated bloodstream infections (CLABSIs) and (2) patients with community-onset pneumonia (PNEUMO) during 2005-2007 from 6 US metropolitan areas. Medical records of patients with confirmed MRSA USA100 or USA300 infection were reviewed. Logistic regression and, when appropriate, survival analysis was performed to evaluate mortality, early and late complications, and length of stay. Results: A total of 236 and 100 patients were included in the CLABSI and PNEUMO cohorts, respectively. USA300 was the only independent predictor of early complications for PNEUMO patients (odds ratio [OR], 2.6; P = .02). Independent predictors of CLABSI late complications included intensive care unit (ICU) admission before MRSA culture (adjusted OR [AOR], 2.1; P= .01) and Charlson comorbidity index (AOR, 2.6; P = .003), but not strain type. PNEUMO patients were significantly more likely to die if they were older (P = .02), black (P < .001), or infected with USA100 strain (P = .02), whereas those with CLABSI were more likely to die if they were older (P < .001), had comorbidities (P < .001), or had an ICU admission before MRSA culture (P = .001). Conclusions: USA300 was associated with early complications in PNEUMO patients. However, it was not associated with mortality for either PNEUMO or CLABSI patients. Concerns regarding higher mortality from HAIs caused by USA300 may not be warranted.

Each year, especially in the winter, many get sick and some die of invasive pneumococcal pneumonia. Does this type of pneumonia increase in the winter because people are in closer contact indoors? Or are people more susceptible to this bacterial disease after having had a seasonal respiratory virus infection? A season-by-season analysis found an association between pneumococcal pneumonia and two viruses (influenza and respiratory syncytial virus). The association varied by season and was strongest when the predominant influenza virus subtype was H3N2. Vaccination against influenza and RSV should also help protect against pneumococcal pneumonia., To confirm whether respiratory virus infections increase susceptibility to invasive pneumococcal pneumonia, we examined data from 11 influenza seasons (1994–2005) in the United States. Invasive pneumococcal pneumonia was significantly associated with influenza and respiratory syncytial virus activities in 5 seasons. Association strength was higher when strain H3N2 was the predominant influenza A virus strain.

Background Infectious complications of injection drug use (IDU) have increased with the expanding opioid epidemic in the southeast. We assessed the incidence, clinical presentation, and treatment outcomes of IDU-associated Staphylococcus aureus (SA) bacteremia (SAB). Methods We created a retrospective cohort of all adults with community acquired (CA) SAB over 5 years presenting to Grady Memorial Hospital, a 1,000-bed urban county hospital in Atlanta, GA. Charts were reviewed by infectious diseases physicians to obtain clinical and laboratory characteristics, including substance use disorder (SUD), and determine if SAB was IDU-associated. The study period was divided into three periods (P1 = March 2012–January 2014, P2 = January 2014–December 2015, P3 = December 2015–November 2017) to evaluate changes in the incidence of IDU-SAB over time using Poisson regression. Results Among 321 patients with a first episode of CA-SAB, 24 (7%) were IDU-SAB. The number of IDU-SAB cases in each period increased (P1 = 4, P2 = 7, and P3 = 13 [P = 0.07 for trend]). The median age of IDU-SAB patients was 38 (IQR 31–57), 11 (46%) were black, and 15 (63%) had chronic hepatitis C virus infection. Heroin was the most common injected drug (92%) followed by cocaine (25%); multiple drugs were injected in 29%. All but two patients (92%) had a complication of SAB, most commonly endocarditis (50%) and septic pulmonary emboli (38%). The median hospitalization was 23 days (IQR 19.5–37.5) and 5 patients (12%) left the hospital against medical advice (AMA). Readmission for persistent or recurrent SA infection during the study period was common (42%), and three (13%) died ≤6 months from initial presentation, including two with prior discharge AMA. Half of the discharge summaries did not mention SUD as a hospital problem. Outpatient SUD treatment was recommended to eight (33%) patients and a recommendation of abstinence was the intervention for 12 (50%). Conclusion Increasing IDU-SAB was observed over 5 years in our urban Atlanta hospital, primarily due to heroin use. Most cases were associated with complications of SAB with a long length of stay and frequent readmission, but few patients received treatment or harm reduction interventions for their SUD. These data will raise awareness and direct resources to expanding evidence-based opioid use disorder treatment for patients with infectious complications of IDU. Disclosures All authors: No reported disclosures.

Background The role of nursing homes (NH) in transmission of antimicrobial-resistant (AR) organisms is of growing concern. AR control requires evidence-based NH stewardship interventions; however, data on antimicrobial use (AU) from US NHs are scant. In the absence of other AU surveillance approaches, NH prevalence surveys can generate essential data, including rationale and indication. In 2017, an AU prevalence survey was conducted through the CDC’s Emerging Infections Program (EIP) to determine the prevalence and epidemiology of AU in NH residents. Methods NHs from California, Colorado, Connecticut, Georgia, Maryland, Minnesota, New Mexico, New York, Oregon, and Tennessee were randomly selected to participate in a 1-day AU point prevalence survey; participation was voluntary. For NH residents receiving antimicrobial drugs (AD) at the time of the survey, EIP staff reviewed available medical records to collect the AD route, rationale, and infection site(s). AD were categorized using the World Health Organization Anatomical Therapeutic Chemical classification system. Data were analyzed in SAS 9.4. Results Of 15,295 residents in 161 NHs, 1,261 (prevalence 8.2%, 95% confidence interval 7.8%-8.7%) received ≥1 AD at the time of the survey (AD range 1–4/resident). Of 1,452 total ADs, 77% were administered for treatment of an active infection, 19% for prophylaxis, 3% for noninfectious reasons, and no rationale documented in 1%. Most AD (80%) were administered by the oral/enteral route and most (87%) were antibacterials. The three most common infection sites were urinary tract (29%, of which 1/4 was for prophylaxis); wound, cellulitis or soft tissue (20%); and respiratory tract (14%). Among the 1,268 antibacterials (figure), fluoroquinolones (15%), combination penicillins (8%), third-generation cephalosporins (8%), and glycopepetides (5%) ranked among the top 10 classes in use. Conclusion This large-scale prevalence survey provides insight into AU in US NHs. On a given day, approximately 1 in 12 NH residents was receiving ≥1 AD. Notably, 30% of AD were administered for UTI, and AD in classes recommended for stewardship intervention were common. These findings highlight areas for evaluation to identify unnecessary use in NH. Prevalence survey data are important to inform and track the impact of stewardship interventions. Disclosures All authors: No reported disclosures.

Background Antimicrobial stewardship (AS) is increasingly recognized as an essential component of patient safety programs. In a US hospital prevalence survey in 2011, 50% of patients received antimicrobial drugs (ADs). The survey was repeated in 2015 to describe changes in inpatient antimicrobial use, approximately one year after CDC published the “Core Elements of Hospital Antibiotic Stewardship Programs.” Methods Emerging Infections Program (EIP) sites in 10 states recruited up to 25 hospitals each, seeking to re-engage hospitals that participated in the 2011 survey. Hospitals selected survey dates from May to September 2015 and completed AS questionnaires. Patients were randomly sampled from the hospital census on the survey date. EIP staff retrospectively reviewed medical records to collect AD data. Percentages of patients on ADs on the survey date or the day before were compared using chi-square tests (SAS 9.4, OpenEpi 3.01). Results In 2015, among 148 hospitals participating in both surveys, 29 (19.6%) reported having no AS team (AST); 63 (42.6%) had ASTs for

OBJECTIVE. The goal of this study was to define more clearly the impact of community-acquired methicillin-resistant Staphylococcus aureus clones (eg, USA300 and USA400) on colonization and infection in infants in intensive care nurseries and potential modes of transmission of community-acquired methicillin-resistant S aureus clones. METHODS. Prospective surveillance for methicillin-resistant S aureus colonization and infection was performed among infants in the intensive care nurseries at Grady Memorial Hospital (Atlanta, GA) between 1993 and 2006. Beginning in September 2004, nares surveillance cultures were collected at admission. Methicillin-resistant S aureus isolates were genotyped by using pulsed-field gel electrophoresis and multiplex polymerase chain reaction assays for staphylococcal chromosomal cassette mec gene complex type and Panton-Valentine leukocidin genes. Prevalence of and risk factors for colonization with community-acquired versus health care-associated methicillin-resistant S aureus clones (eg, USA100) were assessed. RESULTS. Between 1993 and 2006, 130 (3.5%) of 3707 infants were identified to be colonized with methicillin-resistant S aureus. Twelve (1.2%) of 996 admission nares cultures were positive for methicillin-resistant S aureus (since initiation of admission cultures in September 2004). Community-acquired methicillin-resistant S aureus clones were first recovered in 1998; the proportion of methicillin-resistant S aureus clones of community origin increased significantly between 1998 and 2004. Multivariate analysis identified vaginal delivery and maternal smoking, both among infants of mothers receiving systemic antibiotic treatment before delivery, as independent predictors for neonatal colonization with community-acquired methicillin-resistant S aureus. Systemic antibiotic therapy before delivery for nonsmoking mothers delivering through cesarean section and possibly endotracheal intubation were associated with the recovery of health care-associated methicillin-resistant S aureus clones. CONCLUSIONS. Community-acquired methicillin-resistant S aureus clones have emerged as a major cause of methicillin-resistant S aureus colonization in high-risk newborns. Community-acquired methicillin-resistant S aureus recovery was associated with acquisition during birth, whereas health care-associated methicillin-resistant S aureus clones seemed to be transmitted nosocomially.

A 51-year-old man presented with painless left testicular swelling for 1 month, with fevers, chills, night sweats, weight loss, and increased difficulty voiding over 6 months. He underwent radical orchiectomy; surgical pathology revealed granulomas containing acid-fast bacilli in the testis and epididymis. Male genital tuberculosis was diagnosed using nucleic acid amplification on urine and confirmed by positive urine and sputum cultures for Mycobacterium tuberculosis. Genital disease is an unusual extrapulmonary manifestation of tuberculosis, often seen in middle-aged men with renal or pulmonary tuberculosis. Clinical findings are variable, but commonly include dysuria with sterile pyuria or a painless testicular mass. Initial diagnosis is often incidentally made on pathological specimens and confirmed with nucleic acid amplification and cultures. Treatment using a standard four-drug regimen is usually sufficient; surgery is rarely required. This case is used to raise awareness of, and formulate a minimally invasive diagnostic approach to, this unusual but important entity.

Background.Vancomycin-resistantEnterococcusorganisms (VRE) have emerged as common nosocomial pathogens, but few population-based data are available on the impact of invasive VRE infections.Methods.We assessed the incidence of invasive VRE infections and predictors of mortality among patients identified during prospective, population-based surveillance performed in the metropolitan statistical area (MSA) of Atlanta, Georgia.Results.From July 1997 through June 2000, a total of 192 patients who resided in the Atlanta MSA developed an invasive VRE infection, for a rate of 1.57 cases per 100,000 person-years. The incidence of invasive VRE disease significantly increased from 0.91 cases per 100,000 person-years during the first year of the study to 1.73 cases per 100,000 person-years during the third year of the study (PP< .001). Blood was the most common sterile site from which VRE was recovered (161 [83%] of 193 isolates), followed by deep surgical sites (17 [9%]), peritoneal fluid (10 [5%]), pleural fluid (3 [2%]), and cerebrospinal fluid (1 [0.5%]). In multivariate analysis, a Charlson comorbidity index of 5 or greater, previous receipt of antibiotic therapy, having 2 or more sets of blood cultures positive for VRE, and receipt of central parenteral nutrition were independent predictors of mortality, whereas receipt of an antibiotic with in vitro activity against the VRE isolate was associated with a decreased risk of mortality. Molecular typing revealed 38 different pulsed-field gel electrophoresis patterns, but the 2 most common pulsed-field gel electrophoresis types were found at 3 Emory University-affiliated hospitals.Conclusions.The incidence of invasive VRE infection significantly increased in the Atlanta MSA during the 3-year study period, with significant racial disparities detected. Receipt of an antimicrobial agent with in vitro activity against VRE was associated with a lower mortality rate. Molecular typing results demonstrated polyclonal emergence of VRE in Atlanta.

Reports of bloodstream infections caused by methicillin-resistantStaphylococcus aureusamong chronic hemodialysis patients to 2 Centers for Disease Control and Prevention surveillance systems (National Healthcare Safety Network Dialysis Event and Emerging Infections Program) were compared to evaluate completeness of reporting. Many methicillin-resistantS. aureusbloodstream infections identified in hospitals were not reported to National Healthcare Safety Network Dialysis Event.Infect. Control Hosp. Epidemiol.2016;37(2):205–207

BACKGROUNDPatients with candidemia are at risk for other invasive infections, such as methicillin-resistantStaphylococcus aureus(MRSA) bloodstream infection (BSI).OBJECTIVETo identify the risk factors for, and outcomes of, BSI in adults withCandidaspp. and MRSA at the same time or nearly the same time.DESIGNPopulation-based cohort study.SETTINGMetropolitan Atlanta, March 1, 2008, through November 30, 2012.PATIENTSAll residents withCandidaspp. or MRSA isolated from blood.METHODSThe Georgia Emerging Infections Program conducts active, population-based surveillance for candidemia and invasive MRSA. Medical records for patients with incident candidemia were reviewed to identify cases of MRSA coinfection, defined as incident MRSA BSI 30 days before or after candidemia. Multivariate logistic regression was performed to identify factors associated with coinfection in patients with candidemia.RESULTSAmong 2,070 adult candidemia cases, 110 (5.3%) had coinfection within 30 days. Among these 110 coinfections, MRSA BSI usually preceded candidemia (60.9%; n=67) or occurred on the same day (20.0%; n=22). The incidence of coinfection per 100,000 population decreased from 1.12 to 0.53 between 2009 and 2012, paralleling the decreased incidence of all MRSA BSIs and candidemia. Thirty-day mortality was similarly high between coinfection cases and candidemia alone (45.2% vs 36.0%,P=.10). Only nursing home residence (odds ratio, 1.72 [95% CI, 1.03–2.86]) predicted coinfection.CONCLUSIONSA small but important proportion of patients with candidemia have MRSA coinfection, suggesting that heightened awareness is warranted after 1 major BSI pathogen is identified. Nursing home residents should be targeted in BSI prevention efforts.Infect. Control Hosp. Epidemiol.2015;36(11):1298–1304

Background Whether community-associated methicillin-resistant Staphylococcus aureus (MRSA) genotypes (e.g., USA300) are a major cause of bloodstream infections (BSIs) and health care-associated infections has been poorly defined. Methods Consecutive MRSA isolates recovered from patients with BSIs were prospectively collected at an urban public hospital. Molecular typing studies were performed. Prevalence and risk factors for the MRSA USA300 genotype were assessed. Results One hundred thirty-two cases of MRSA BSI were documented over 7.5 months in 2004 (incidence, 6.79 per 1000 admissions); 116 isolates were available for genotyping. Characteristics of the 116 evaluable cases included: a mean age 47 years; 62% were male, 82% were African American, and 22% were HIV seropositive. The crude in-hospital mortality rate was 22%. In 107 cases (92%), there was contact with a health care facility within the year prior to infection, and a nosocomial infection (defined as positive blood culture results obtained >48 h after admission) occurred in 49 cases (42%). PFGE demonstrated that 39 (34%) of the 116 isolates were the MRSA USA300 genotype; 34 (29%) were USA100; 42 (36%) were USA500; and 1 (1%) was USA800. MRSA USA300 accounted for 28% of health care-associated BSIs and 20% of nosocomial MRSA BSIs. In multivariate analysis, isolation of the USA300 genotype was associated with injectiondrug use (OR, 3.67; 95% CI, 1.10-12.28) and skin and soft tissue infection (OR, 4.26; 95% CI, 1.08-16.84). Patients who resided in long-term care facilities (OR, 0.09; 95% CI, 0.01-0.82) and those who were treated with antimicrobials in the prior year were less likely to have MRSA USA300 genotype recovered (OR, 0.10; 95% CI, 0.02-0.49). Conclusions MRSA USA300 genotype, the predominant cause of community-associated MRSA infections in our area (Atlanta, GA), has now emerged as a significant cause of health care-associated and nosocomial BSI. MRSA USA300 as a nosocomial pathogen presents new challenges to infection control programs.

Previous studies of bacterial enteric infections have suggested a disproportionate disease burden for children younger than 5 years of age.This study describes population-based incidence of culture-confirmed infections with 6 bacterial enteric pathogens in children younger than 5 years of age in the Foodborne Diseases Active Surveillance Network (FoodNet), 1996-1998.Cases were ascertained through active laboratory-based surveillance in Minnesota, Oregon and selected counties in California, Connecticut, Georgia, Maryland and New York.Twenty-one percent (5218 of 24,358) of infections were in children younger than 5 years of age, but this age group made up only 7% of the total person-years of observation. Among those younger than 5 years of age, the incidence (cases per 100,000 person-years) for each pathogen was: Salmonella, 55.3; Campylobacter, 43.4; Shigella, 32.7; E. coli O157, 10.3; Yersinia enterocolitica, 7.1; Listeria monocytogenes, 0.7. Incidence varied widely among the 7 FoodNet sites.This study confirmed a disproportionate disease burden in young children. Investigation of risk factors specific to this age group and review and enhancement of current prevention and control strategies for children younger than 5 years of age may reduce illness.

Background. Multidrug-resistant Salmonella enterica serotype Typhimurium definitive type 104 (MRDT104), with resistance to at least ampicillin, chloramphenicol, streptomycin, sulfamethoxazole, and tetracycline (R-type ACSSuT), was first detected in the United States in 1985 [1], and the prevalence increased to account for nearly 7% of Salmonella infections in 1998 [2]. Methods. A retrospective study of S. Typhimurium infections in an urban health care system assessed whether infection with an antibiotic-resistant strain-and specifically MRDT104-was associated with invasive disease or HIV infection. Sixty cases of S. Typhimurium infection were identified. Results. Of the 50 isolates available for analysis, 30 (60%) were MRDT104. Pathogens were isolated from blood in 25 (83%) of 30 patients infected with MRDT104, compared with 10 (50%) of 20 patients who were infected with non-MRDT104 strains (P = .01). Among isolates obtained from 32 HIV-infected patients, 19 (95%) of 20 MRDT104 isolates were from blood specimens, compared with 8 (66%) of 12 non-MRDT104 isolates (P = .05). Conclusions. MRDT104 accounted for the majority of S. Typhimurium infections in this patient population, and MRDT104 infections were more invasive than non-MRDT104 infections, particularly in HIV-infected persons.

To the Editor: Multidrug-resistant tuberculosis (MDR TB), i.e., TB resistant to at least the 2 most effective first-line antituberculous drugs (isoniazid [INH] and rifampin [RIF]), is increasing globally. World Health Organization estimations of 390,000–510,000 new MDR TB cases and 150,000 related deaths in 2008 highlight the need for timely drug susceptibility testing and improved therapies (1). Although novel rapid drug susceptibility testing tools are increasingly available, their clinical applicability is unsettled. We report a patient with pulmonary TB relapse with discordant genotypic and in vitro phenotypic drug susceptibility testing results associated with a mutation outside the RIF resistance determining region (RRDR) of the rpoB gene. In August 2009, a 45-year-old homeless woman with AIDS (CD4+ T-cell count 3 cells/mm3) and a history of substance abuse sought care for fever, night sweats, weight loss, and cough (Table A1). Pulmonary TB had been diagnosed in June 2008. At that time, she received, by directly observed therapy, 6 weeks of INH, RIF, pyrazinamide (PZA), and ethambutol (EMB) through the local health department and was switched to RIF, PZA, and EMB on week 7 after the isolate was determined by liquid culture with BD BACTEC MGIT 960 Mycobacterial Testing System (BD Diagnostics, Sparks, MD, USA) to be INH resistant. During that period, she resided in American Lung Association–supported housing for TB patients and had 97% medication adherence by dose count. Her condition clinically improved, infiltrates completely resolved according to chest radiograph, 12 sputum inductions failed to yield sufficient material for analysis, and she began highly active antiretroviral therapy (HAART). In December 2008, however, because of crack cocaine use and belligerent behavior, she lost housing privileges. Caseworkers could not locate her to complete the 9-month planned directly observed therapy. The woman was hospitalized in January and again in February 2009 with dyspnea and off medications. In both instances, chest radiographs showed no new changes, sputum specimens were negative for acid-fast bacilli (AFB) by microscopy and culture, and she was treated for presumptive Pneumocystis pneumonia and showed clinical improvement. In August 2009, she was readmitted with cough and new cavitation on chest radiograph. Chest computed tomographic scan demonstrated right upper lobe infiltrates, bilateral lower lobe cavitation, and hilar and mediastinal lymphadenopathy. Sputum AFB smear was positive (graded 4+), and nucleic acid amplification (Amplified Mycobacterium Direct Test; Gen-Probe, San Diego, CA, USA) was positive for Mycobacterium tuberculosis complex. INH, RIF, PZA, and EMB, along with moxifloxacin (MXF) and amikacin (AMK), were initiated in accordance with 2003 national TB treatment guidelines for possible MDR TB (2). Shortly thereafter, a line probe assay (GenoType MTBDRplus; HAIN Lifescience, Nehren, Germany) performed by Southeastern National TB Center (Gainesville, FL, USA) on the culture of the sputum specimen obtained at admission indicated an inhA point mutation but no mutation in the RRDR region of the rpoB gene, which suggested that the isolate was INH resistant but RIF susceptible. AMK was discontinued, and the patient was discharged with RIF, PZA, EMB, and MXF. One week later, drug susceptibility testing (BD BACTEC MGIT 960 System) results from the state mycobacteriology laboratory demonstrated that the M. tuberculosis isolate was resistant to INH and RIF. The patient was readmitted to resume injectable aminoglycoside therapy. After 5 weeks, sputum culture became negative, clinical and radiographic improvement was apparent, and HAART was reinitiated. She completed 2 months’ INH/PZA/EMB/MXF/AMK inpatient therapy and was discharged to complete 6 additional months of PZA/EMB/MXF and streptomycin followed by 16 months of PZA/EMB/MFX. With HAART, her plasma HIV RNA viral load became undetectable, but her CD4 count remained low (9 cells/mm3). She died from a motor vehicle accident 10 months after recurrent TB was diagnosed. In this patient, RIF resistance was not predicted by line probe assay but was identified phenotypically by an automated system (BD BACTEC MGIT 960 System) that continuously monitors for growth and detection of mycobacteria. Through genotyping and DNA sequencing of the 2008 and 2009 M. tuberculosis isolates, the Mycobacteriology Laboratory Branch at the Centers for Disease Control and Prevention (Atlanta, GA, USA) established that the 2009 infection was a relapse, not re-infection, and confirmed the inhA mutation in both isolates. Using primers extending beyond the RRDR (the rpoB region surveyed by rapid molecular tests and responsible for >95% of RIF resistance mutations) the laboratory identified a novel rpoB gene mutation at codon 480 (ACC→AAC; Thr→Asn) and another previously described (3–5) mutation at codon 176 (GTC→TTC; Val→Phe) in the 2009 isolate, which has been implicated in RIF resistance. The role of the T480N mutation in RIF resistance is being investigated. This case demonstrates the limitations of rapid molecular drug susceptibility testing (6). Rapid molecular diagnostics are valuable adjuncts to conventional phenotypic testing because they can quickly confirm clinically suspected MDR TB and have high agreement with other genotypic and phenotypic methods (7–10). However, they should not supplant phenotypic testing, and clinicians should understand their limitations. When rapid molecular tests are negative but suspicion for MDR TB is high, MDR TB treatment should be continued until phenotypic susceptibility results are available. DNA sequencing may be best suited for evaluating suspected drug-resistant M. tuberculosis isolates with discordant results for phenotypic susceptibility and rapid molecular testing.

Background Community-acquired infections caused by methicillin-resistant Staphylococcus aureus (MRSA) seem to be increasing. Characteristics permitting recognition of patients with such strains would aid infection control efforts and choice of empiric therapy pending culture and susceptibility results. Methods Retrospective review of medical records for all adults seen in the Emergency Care Center at Grady Memorial Hospital, Atlanta, Georgia, whose blood cultures taken within 24 hours of entry yielded S aureus . Risk factors for the presence of methicillin resistance in S aureus isolates recovered from patients with staphylococcal bacteremia were assessed. Results S aureus isolates from 118 (40%) of 297 study patients with bacteremia at the time of admission were methicillin-resistant. Multivariate analysis identified hospitalization in the 6 months preceding admission [odds ratio (OR) = 4.4; 95% CI, 2.0–9.8], receipt of antimicrobial agents in the past 3 months (OR = 5.6; 95% CI, 2.6–11.9], presence of indwelling urinary catheter (OR = 7.3; CI, 2.5–20.9), and nursing home residence (OR = 9.9; 95% CI, 3.9–25.6) to be independently associated with the presence of methicillin resistance. All but 4 of the 118 patients with methicillin-resistant strains had at least 1 of these factors and the proportion of resistant isolates progressively increased as more of these features were present. Conclusions The presence of these risk factors should be considered when making decisions about isolation and other infection control procedures as well as empiric antimicrobial therapy with vancomycin for patients with suspected staphylococcal infection at the time of hospital admission. Similar studies could guide practices for dealing with such patients in other centers, because the occurrence of MRSA infections at the time of admission may vary widely by geographic area.

Background A 2011 prevalence survey conducted by CDC and the Emerging Infections Program (EIP) showed that 1 in 25 hospital patients had ≥1 healthcare-associated infection (HAI). We repeated the survey in 2015 to assess changes in HAI prevalence.​ Methods In EIP sites (CA, CO, CT, GA, MD, MN, NM, NY, OR, TN) hospitals that participated in the 2011 survey were recruited for the 2015 survey. Hospitals selected 1 day from May–September 2015 on which a random patient sample was identified from the morning census. Trained EIP staff reviewed patient medical records using comparable methods and the same National Healthcare Safety Network HAI definitions used in 2011. Proportions of patients with HAIs were compared using chi-square tests; patient characteristics were compared using chi-square or median tests (OpenEpi 3.01, SAS 9.3). Results Data were available from 143 hospitals that participated in both surveys; data from 8954 patients in the 2011 survey were compared with preliminary data from 8833 patients in the 2015 survey. Patient characteristics such as median age, days from admission to survey, and critical care location were similar. Urinary catheter prevalence was lower in 2015 (1,589/8,833, 18.0%) compared with 2011 (2,052/8,954, 22.9%, P Conclusion HAI prevalence was significantly lower in 2015 compared with 2011. This is partially explained by fewer SSI and UTI, suggesting national efforts to prevent SSI, reduce catheter use and improve UTI diagnosis are succeeding. By contrast, there was no change in the prevalence of the most common HAIs in 2015, PNEU and CDI, indicating a need for increased prevention efforts in hospitals. Disclosures All authors: No reported disclosures.

Standard tuberculosis case reporting captures incarceration at diagnosis only. This retrospective analysis of 106 US-born adults with prevalent tuberculosis in 2011 found that 46.2% had documented histories of being in jail or prison, including 16.0% during the year before diagnosis.

Objectives Nosocomial pathogens such as Acinetobacter baumannii are a growing public health threat, due in part to their increasing resistance to antibiotics. Since some strains are resistant to all available antibiotics, novel therapies are urgently needed. Plasmablasts are short-lived B cells found in the blood that can be collected and harnessed to produce therapeutic antibodies. We set out to determine whether plasmablasts are induced during infection with A. baumannii and other nosocomial pathogens. Methods We obtained blood samples from patients infected with antibiotic-resistant nosocomial pathogens, and analysed their plasmablast response by flow cytometry. Results We observed a strong induction of plasmablasts in patients with antibiotic-resistant A. baumannii infection. Furthermore, plasmablasts were also induced in response to other drug-resistant nosocomial pathogens. Conclusions These data suggest that plasmablasts may be broadly harnessed to develop therapeutic antibodies to combat otherwise untreatable antibiotic-resistant infections.

Objectives:To determine the risk factors for acquisition of nosocomial primary bloodstream infections (BSIs), including the effect of nursing-staff levels, in surgical intensive care unit (SICU) patients.Design:A nested case-control study.Setting:A 20-bed SICU in a 1,000-bed inner-city public hospital.Patients:28 patients with BSI (case-patients) were compared to 99 randomly selected patients (controls) hospitalized ≥3 days in the same unit.Results:Case- and control-patients were similar in age, severity of illness, and type of central venous catheter (CVC) used. Case-patients were significantly more likely than controls to be hospitalized during a 5-month period that had lower regular-nurse-to-patient and higher pool-nurse-to-patient ratios than during an 8-month reference period; to be in the SICU for a longer period of time; to be mechanically ventilated longer; to receive more antimicrobials and total parenteral nutrition; to have more CVC days; or to die. Case-patients had significantly lower regular-nurse-to-patient and higher pool-nurse-to-patient ratios for the 3 days before BSI than controls. In multivariate analyses, admission during a period of higher pool-nurse-to-patient ratio (odds ratio [OR]=3.8), total parenteral nutrition (OR=1.3), and CVC days (OR=1.1) remained independent BSI risk factors.Conclusions:Our data suggest that, in addition to other factors, nurse staffing composition (ie, pool-nurse-to-patient ratio) may be related to primary BSI risk. Patterns in intensive care unit nurse staffing should be monitored to assess their impact on nosocomial infection rates. This may be particularly important in an era of cost containment and healthcare reform.

Tuberculosis cases have recently declined in the United States, renewing interest in disease elimination. We examined the epidemiology of tuberculosis from 1991 through 1997 at an inner-city public hospital and assessed population-based tuberculosis rates by ZIP code in the 8 metropolitan Atlanta counties. During the 7 years, 1378 new patients had tuberculosis diagnosed at our hospital (mean, 197 patients/year), accounting for 25% of tuberculosis cases in Georgia. Coinfection with human immunodeficiency virus (HIV) was common, but a significant decrease in the proportion of HIV-infected patients with tuberculosis was noted over time. Most patients were members of a minority group (93%) and were born in the United States (96%). Two inner-city ZIP code areas had annual tuberculosis rates >120 cases per 100,000 persons, and 8 ZIP code areas had annual rates of 47-88 cases per 100,000 persons between 1993 and 1997, compared with the annual national average of 8.7 cases per 100,000 persons. Our hospital continues to care for large numbers of tuberculosis patients, and rates of tuberculosis remain high in the inner city. These data mandate a concentration of efforts and resources in urban locations if tuberculosis control and elimination is to be achieved in the United States.

To determine frequency of methicillin-resistant Staphylococcus aureus infections caused by strains typically associated with community-acquired infections (USA300) among persons with healthcare-related risk factors (HRFs), we evaluated surveillance data. Of patients with HRFs, 18%-28% had a "community-associated" strain, primarily USA300; of patients without HRFs, 26% had a "healthcare-associated" strain, typically USA100.

Invasive pneumococcal disease is a significant cause of morbidity and mortality in the United States. Despite availability of an effective vaccine, many patients refuse vaccination.To investigate patient characteristics and features of the patient-provider relationship associated with pneumococcal vaccine refusal.Case-control study using chart review.Five hundred adults from the medical clinics of a 1,000-bed inner-city teaching hospital.Independent risk factors for pneumococcal vaccine refusal included patient-provider gender discordance (odds ratio (OR)=2.09, 95% confidence interval (CI) 1.07 to 4.09); a visit to a not-usual provider at the time of vaccine offering (OR=2.26, 95% CI 1.13 to 4.49); never having received influenza vaccination (OR=7.44, 95% CI 3.76 to 14.76); prior pneumococcal vaccine refusals (OR=3.45, 95% CI 1.60 to 7.43); and a history of ever having refused health maintenance tests (OR=2.86, 95% CI 1.40 to 5.84).We have identified both patient factors and factors related to the patient-provider relationship that are risk factors for pneumococcal vaccine refusal. By identifying patients at risk for pneumococcal vaccine refusal, efforts to increase vaccination rates can be better targeted.