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No abstract available. Article truncated at 150 words. A 46-year-old Hispanic man with no known past medical history presents to his primary care physician for a progressively worsening “rash” located over his right thigh. Patient described the lesion as raised, scaly, and itchy. It has been “growing” for the past one year and started out as a small “pimple”. Patient denied any trauma to the effected region over this time period. Surgical history was significant for a splenectomy 15 years prior that was needed after a traumatic accident. He works in construction and lives in southern Arizona. He denied alcohol, tobacco and or illicit drug use. Patient has attempted to treat this skin lesion with over the counter hydrocortisone ointment with no relief. He denied any other associated symptoms including fever/chills, headache, vision changes, night sweats, weight loss, cough, shortness of breath, and or joint pains. Vital signs were stable upon presentation. Physical exam was entirely benign other ...

We assessed adverse events in hospitalized patients receiving selected vesicant antibiotics or vasopressors administered through midline catheters or peripherally inserted central catheters (PICC). The rates of catheter-related bloodstream infections, thrombosis, and overall events were similar across the two groups, while occlusion was higher in the PICC group., Competing Interests: All authors have nothing to disclose., (© Cambridge University Press 2024.)

Objective: Assess whether direct inoculation of ascites into blood culture bottles would improve ascites culture yield., Design: Pre-post-study., Setting: The study was performed at a quaternary academic medical center in Houston, Texas, including all inpatient and emergency department encounters., Patients: Ascites cultures collected from November 2020 to December 2022 were reviewed and screened for spontaneous bacterial peritonitis. Patients were excluded if a prior ascites culture from the same patient was already included in the study or if there was evidence of secondary bacterial peritonitis., Intervention: In the pre-intervention period, ascites cultures were collected into a sterile container and inoculated onto/into solid and liquid media. In the post-intervention period, ascites cultures were instead directly inoculated into bioMérieux© blood culture bottles at the bedside., Results: 114 patients met inclusion and exclusion criteria, 61 pre-intervention and 53 post-intervention. Overall ascites culture positivity was 15.8% (18/114), 11.5% (7/61) pre-intervention vs 20.8% (11/53) post-intervention. After adjusting for confounders, the intervention had a trend toward a significant effect on ascites culture positivity ( P = 0.077). No significant differences were seen in time to positivity, hospital length of stay, or 30-day readmission., Conclusions: Direct inoculation of ascitic fluid into blood culture bottles led to a small increase in culture yield but lacked statistical significance. This lack of significance may be due to the study being underpowered. Further studies are required to investigate if this is due to procedural inefficiencies (eg, inadequate inoculation volumes) or pragmatic clinical practice considerations (ie, high rates of pre-culture antibiotics)., Competing Interests: All authors report no conflicts of interest relevant to this article., (© The Author(s) 2024.)

Blood-culture overutilization is associated with increased cost and excessive antimicrobial use. We implemented an intervention in the adult intensive care unit (ICU), combining education based on the DISTRIBUTE algorithm and restriction to infectious diseases and ICU providers. Our intervention led to reduced blood-culture utilization without affecting safety metrics.

A survey of advanced practice clinicians (APCs), physicians, residents, and medical students at an academic medical center and community practices in southeastern Texas revealed a gap in knowledge and practice related to testing and treatment for asymptomatic bacteriuria (ASB) in older adults.

Background: Metagenomic next-generation sequencing (mNGS) is a novel diagnostic tool increasingly used in the field of infectious diseases. Little guidance is available regarding its appropriate use in different patient populations and clinical syndromes. We aimed to review the clinical utility of mNGS in patients with a specific clinical syndrome and identify factors that may increase its utility., Methods: We retrospectively reviewed charts of 72 non-immunocompromised adults hospitalized with the clinical syndrome of 'fever of undetermined origin' and underwent mNGS testing. Standardized criteria from a previously published study were used to determine the clinical impact of mNGS testing. We applied logistic regression to identify factors associated with a positive clinical impact., Results: Of the 72 patients identified, 62.5% were males with a median age of 56. All patients had a fever at the time of evaluation. At least one organism was identified in 65.3% of cases; most commonly were Epstein-Barr virus (13.9%), cytomegalovirus (12.5%), and Rickettsia typhi (11.1%). Of those determined to have an infectious etiology of their febrile syndrome, 89.5% ( n  = 34/38) had a positive mNGS. Consistency between the organism(s) on mNGS and the clinically determined infectious etiology was 82.4%. mNGS had a positive clinical impact in 40.3% of cases, a negative impact in 2.8%, and no impact in 56.9% of cases. Besides age, we did not identify other factors associated with a higher likelihood of positive clinical impact., Conclusion: In our review, mNGS had a positive clinical impact in a large proportion of adults with fever of undetermined origin, with minimal negative impact. However, mNGS results should be interpreted carefully given the high rate of detection of pathogens of unclear clinical significance. Randomized clinical trials are needed to assess the clinical utility of this novel diagnostic tool., (© The Author(s), 2024.)

Introduction: Only a few studies have assessed the relationship between deprivation and excessive antibiotic use. In Texas, antimicrobial prescription rates are particularly high compared with the rest of the US. This study analyzed the association between local area socioeconomic deprivation and providers' fluoroquinolone claim rates among beneficiaries 65 years and older in Texas., Methods: This ecological study utilized provider- and area-level data from Medicare Part D Prescribers and the Social Deprivation Index (SDI) repositories. Negative binomial regression models were employed to evaluate the relationship between provider- and area-level characteristics (prescriber's gender, specialty, rural-urban community area, beneficiaries' demographics, area-level population, and SDI) and fluoroquinolone claim rates per 1,000 beneficiaries., Results: A total of 11,996 providers were included. SDI (IRR 0.98, 95% CI 0.97-0.99) and male providers (IRR 0.96, 95% CI 0.94-0.99) were inversely associated with claim rates. In contrast, several factors were associated with higher claim rates, including non-metropolitan areas (1.04, 95% CI 1.00-1.09), and practices with a high proportion of male (IRR 1.12, 95% CI 1.10-1.14), Black (IRR 1.05, 95% CI 1.03-1.07), or Medicaid beneficiaries (IRR 1.15, 95% CI 1.12-1.17). Effect modification was observed between SDI and rurality, with higher SDI in non-metropolitan areas associated with higher claim rates, whereas SDI in metropolitan areas was inversely related to claim rates., Conclusion: Lower fluoroquinolone claim rates were observed among Texas Medicare providers in metropolitan areas with higher SDI. Conversely, higher rates were observed in rural areas with higher SDI. More studies are needed to understand the underlying causes of this variation and develop effective stewardship interventions., Competing Interests: All authors have nothing to disclose., (© The Author(s) 2024.)

Variations in the literature support the benefit of contact precautions for methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococci (VRE) infections in the hospital setting. During personal protective equipment shortages throughout the COVID-19 pandemic, contact precautions were discontinued for MRSA and VRE-infected patients. Rates of hospital-acquired MRSA and VRE infections were compared before and after this intervention, along with hand hygiene proportions. Contact precaution discontinuation did not lead to an increase in hospital-acquired MRSA or VRE infections., Competing Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2023.)

We report 9 patients with invasive Bartonella infections, including 5 with endocarditis, who were diagnosed with microbial cell-free DNA next-generation sequencing and Bartonella serology studies. Diagnosis with plasma mcfDNA NGS enabled a faster clinical and laboratory diagnosis in 8 patients. Prompt diagnosis impacted antibiotic management in all 9 patients., Competing Interests: Authors FC, AH, TL, and MA report no conflict of interest or financial disclosure., (© The Author(s) 2024.)

Antimicrobial stewardship programs (ASPs) exist to optimize antibiotic use, reduce selection for antimicrobial-resistant microorganisms, and improve patient outcomes. Rapid and accurate diagnosis is essential to optimal antibiotic use. Because diagnostic testing plays a significant role in diagnosing patients, it has one of the strongest influences on clinician antibiotic prescribing behaviors. Diagnostic stewardship, consequently, has emerged to improve clinician diagnostic testing and test result interpretation. Antimicrobial stewardship and diagnostic stewardship share common goals and are synergistic when used together. Although ASP requires a relationship with clinicians and focuses on person-to-person communication, diagnostic stewardship centers on a relationship with the laboratory and hardwiring testing changes into laboratory processes and the electronic health record. Here, we discuss how diagnostic stewardship can optimize the "Four Moments of Antibiotic Decision Making" created by the Agency for Healthcare Research and Quality and work synergistically with ASPs.

Purpose  This report is intended to analyze the root causes for the current gap between the nursing workforce and population needs in the United States. It aims to consolidate what is known about these contributing reasons and provide evidence-based recommendations for action. Methods  The report utilized the Sample, Phenomenon of Interest, Design, Evaluation, Research type framework to develop the research question and the 5 Whys methodology for the root cause analysis. Results  This report highlighted six major causative problems, including workforce market mismatch, poor financing design, inadequate governance, flawed technologies, insufficient research, and suboptimal service delivery. A detailed evaluation of root causes with supported evidence is presented. Conclusion  The report provided seven actionable recommendations based on the analysis: (1) strengthening the nursing role in advancing equity, (2) investing in nursing well-being, (3) changing policies and payment structure, (4) including nursing in technology design, (5) strengthening nursing education, (6) developing a robust public health emergencies preparedness plan, and (7) investing in relevant research., Competing Interests: Conflict of Interest None declared., (The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. ( https://creativecommons.org/licenses/by/4.0/ ).)

The Joint United Nations Program on human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) (Joint United Nations Program on HIV/AIDS, UNAIDS) has recommended 90-90-90 goals to increase the number of patients who are aware of their status, on antiretroviral therapy, and have undetectable viral loads. Mexico City has made several achievements to aid in prevention, early diagnosis, and treatment; however, the incidence of HIV has not decreased over the past decade. This article reviews global initiatives that were successful in achieving some or all these metrics and provide a road map for Mexico to reach the desired goals., Competing Interests: Conflict of Interest None declared., (The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. ( https://creativecommons.org/licenses/by/4.0/ ).)

Multiplex stool polymerase chain reaction (PCR) panels offer rapid comprehensive testing for patients with infectious diarrhea. We compared antibiotic utilization among hospitalized patients with suspected infectious diarrhea who underwent diagnostic testing with either a stool culture or stool PCR panel. No significant differences in antibiotic utilization were identified., Competing Interests: All authors report no conflicts of interest relevant to this article., (© The Author(s) 2023.)

Blood culture contamination is associated with increased antimicrobial use, length of stay, and hospital cost. To address this problem, blood culture diversion has been developed as an additional measure to reduce contamination to targeted goals. Three different versions were proposed, including an open technique and 2 commercially available devices. This study aims to review the existing literature and analyze evidence for these 3 techniques., Competing Interests: Potential conflicts of interest. All authors: No reported conflicts., (© The Author(s) 2023. Published by Oxford University Press on behalf of Infectious Diseases Society of America.)

Objective: To describe the use of next-generation sequencing (NGS) and to determine whether NGS leads to changes in antimicrobial management., Design and Setting: This retrospective cohort study included patients aged ≥18 years admitted to a single tertiary-care center in Houston, Texas, with an NGS test performed between January 1, 2017, and December 31, 2018., Patients: In total, 167 NGS tests were performed. Most patients were of non-Hispanic ethnicity (n = 129), white (n = 106), and male (n = 116), with a mean age of 52 years (SD, 16). Moreover, 61 patients were immunocompromised: solid-organ transplant (n = 30), patients with human immunodeficiency virus (n = 14), and rheumatology patients on immunosuppressive therapy (n = 12)., Results: Of the 167 NGS tests performed, 118 (71%) were positive. Test results associated with a change in antimicrobial management were found in 120 (72%) of 167 cases, with an average of 0.32 (SD, 1.57) fewer antimicrobials after the test. The largest change in antimicrobial management was in glycopeptide use (36 discontinuations) followed by antimycobacterial drug use (27 additions among 8 patients). Also, 49 patients had negative NGS results, but only 36 patients had their antibiotics discontinued., Conclusions: Plasma NGS testing is associated with a change in antimicrobial management in most cases. We observed a decrease in glycopeptide use after NGS results, which highlights physicians' comfort in withdrawing methicillin-resistant Staphylococcus aureus (MRSA) coverage. In addition, antimycobacterial coverage increased, corresponding with early mycobacterial detection by NGS. Further studies are needed to determine effective ways to use NGS testing as an antimicrobial stewardship tool., (© The Author(s) 2023.)

Objective: To investigate the relationship between the systemic inflammatory response syndrome (SIRS), early antibiotic use, and bacteremia in solid-tumor patients., Design, Setting, and Participants: We conducted a retrospective observational study of adults with solid tumors admitted to a tertiary-care hospital through the emergency department over a 2-year period. Patients with neutropenic fever, organ transplant, trauma, or cardiopulmonary arrest were excluded., Methods: Rates of SIRS, bacteremia, and early antibiotics (initiation within 8 hours of presentation) were compared using the χ 2 and Student t tests. Binomial regression and receiver operator curves were analyzed to assess predictors of bacteremia and early antibiotics., Results: Early antibiotics were administered in 507 (37%) of 1,344 SIRS-positive cases and 492 (22%) of 2,236 SIRS-negative cases ( P < .0001). Of SIRS-positive cases, 70% had blood cultures drawn within 48 hours and 19% were positive; among SIRS negative cases, 35% had cultures and 13% were positive (19% vs 13%; P = .003). Bacteremic cases were more often SIRS positive than nonbacteremic cases (60% vs 50%; P =.003), but they received early antibiotics at similar rates (50% vs 49%, P = .72). Three SIRS components predicted early antibiotics: temperature (OR, 1.7; 95% CI, 1.31-2.29; P = .0001), tachycardia (OR, 1.4; 95% CI, 1.10-1.69; P < .0001), and white blood-cell count (OR, 1.8; 95% CI, 1.56-2.14; P < .0001). Only temperature (OR, 1.6; 95% CI, 1.09-2.41; P = .01) and tachycardia (OR, 1.5; 95% CI, 1.09-2.06; P = .01) predicted bacteremia. SIRS criteria as a composite were poorly predictive of bacteremia (AUC, 0.57)., Conclusions: SIRS criteria are frequently used to determine the need for early antibiotics, but they are poor predictors of bacteremia in solid-tumor patients. More reliable models are needed to guide judicious use of antibiotics in this population.

Objective: Vancomycin is a glycopeptide antibacterial indicated for serious gram-positive infections. Pharmacokinetics (PK) of vancomycin have not been described in pregnant women. This study aims to characterize the PK disposition of vancomycin in pregnant women based on data acquired from a database of routine hospital care for therapeutic drug monitoring to better inform dosing decisions. Methods: In this study, plasma drug concentration data from 34 pregnant hospitalized women who were administered intravenous vancomycin was analyzed. A population pharmacokinetic (PPK) model was developed using non-linear mixed effects modeling. Model selection was based on statistical criterion, graphical analysis, and physiologic relevance. Using the final model AUC 0-24 (PK efficacy index of vancomycin) was compared with non-pregnant population. Results: Vancomycin PK in pregnant women were best described by a two-compartment model with first-order elimination and the following parameters: clearance (inter individual variability) of 7.64 L/hr (32%), central volume of 67.35 L, inter-compartmental clearance of 9.06 L/h, and peripheral volume of 37.5 L in a typical patient with 175 ml/min creatinine clearance (CRCL) and 45 kg fat-free mass (FFM). The calculated geometric mean of AUC 0-24 for the pregnant population was 223 ug.h/ ml and 226 ug.h/ ml for the non-pregnant population. Conclusion: Our analysis suggests that vancomycin PK in pregnant women is consistent with non-pregnant adults and the dosing regimens used for non-pregnant patients may also be applicable to pregnant patients., Competing Interests: JG is a co-founder of Pumas-AI that commercializes Pumas software. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Goyal, Moffett, Gobburu and Al Mohajer.)

The increased focus on professional-led, continuous health care improvement has not produced formalized processes for identifying, recognizing, and rewarding excellence in quality improvement. Moreover, the team-based nature of improvement requires a mechanism to document interprofessional contributions. In 2018, the authors created a health care improvement portfolio to document and demonstrate individual impact for the purpose of promotion. A draft portfolio was developed from a review of the literature and publicly available quality improvement and educational portfolios. The portfolio was further refined through a 2-round, modified Delphi consensus process with a panel of interprofessional experts across North America. In the first round, 35 panelists gave feedback through open-ended comments on the design and content of the portfolio. In the second round, 34 panelists rated the comprehensiveness and clarity of the portfolio on a scale of 1-9 (1 = lowest, 9 = highest) and provided comments. Consensus was defined as an average score over 8.0. Panelists in the second round achieved consensus, with average scores of 8.4 in comprehensiveness and 8.3 in clarity (range, 6-9). The finalized portfolio includes the following sections: personal statement; health care improvement training and certification; leadership and administrative roles; health care improvement project activities; health care improvement coaching, teaching, and curricular activities; health care improvement honors, awards, and recognitions; and supporting documents. The portfolio facilitates the documentation of health care professionals' contributions to and impact in health care improvement and covers the breadth of interprofessional health care improvement (i.e., projects, leadership, education, scholarship). The portfolio can be tailored to an individual's area of specific expertise. While this portfolio was originally developed for interprofessional faculty at academic institutions, the content and structure of the portfolio are easily adapted for health care providers in other health care settings., Competing Interests: Other disclosures: The authors report no conflicts of interest.

Vaccine uptake is a multifactor measure of successful immunization outcomes that includes access to healthcare and vaccine hesitancy for both healthcare workers and communities. The present coronavirus disease (COVID-19) pandemic has highlighted the need for novel strategies to expand vaccine coverage in underserved regions. Mobile clinics hold the promise of ameliorating such inequities, although there is a paucity of studies that validate environmental infection in such facilities. Here, we describe community-based management of COVID-19 through a Smart Pod mobile clinic deployed in an underserved community area in the United States (Aldine, Harris County, TX, USA). In particular, we validate infection control and biological decontamination of the Smart Pod by testing surfaces and the air-filtration system for the COVID-19 virus and bacterial pathogens. We show the Smart Pod to be efficacious in providing a safe clinical environment for vaccine delivery. Moreover, in the Smart Pod, up-to-date education of community healthcare workers was provided to reduce vaccine hesitancy and improve COVID-19 vaccine uptake. The proposed solution has the potential to augment existing hospital capacity and combat the COVID-19 pandemic locally and globally.

An abundance of literature interested in sexually transmitted infections-related disclosure attitudes among MSM (men who have sex with men) exists. However, comparatively few studies have examined these with respect to genital herpes. This cross-sectional study examined attitudes about herpes-related disclosure among Houston MSM. Convenience sampling at Houston-based MSM venues and events was conducted during December 2018 and January 2019 with 302 participants recruited. Participants were asked if an individual with genital herpes should disclose to others and if they would disclose to others if they had/have genital herpes. Factors associated with decreased belief that someone should disclose a genital herpes infection to others were history of genital herpes (OR 0.14, 95% CI [0.04, 0.55]) and race other than white, black, or Hispanic/Latino (OR 0.34, 95% CI [0.15, 0.77]). History of 0 to 1 sexual partner(s) in the past year was associated with increased belief that an individual should disclose (OR 2.43, 95% CI [1.19, 4.98]), while self-reported history of genital herpes was associated with decreased intent to disclose one's own infection to potential partners (OR 0.30, 95% CI [0.10, 0.91]). Self-reported history of genital herpes was associated with decreased belief that someone with genital herpes should tell others and with decreased likelihood to disclose one's own status. Lastly, race other than white, black, or Hispanic/Latino was associated with increased belief that someone with genital herpes should not tell others. Normalization of genital herpes could bolster intent to disclose genital herpes infection and improve sexual outcomes., (© 2021. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

We implemented universal face shield use for all healthcare personnel upon entry to facility in order to counter an increase in SARS-COV2 cases among healthcare personnel and hospitalized patients. There was a marked reduction of infections in both healthcare personnel and hospitalized patients between pre and post intervention. Our results support universal face shield use as part of a multifaceted approach in areas of high SARS-COV2 community transmission., (Copyright © 2021 The Authors. Published by Elsevier Ltd.. All rights reserved.)

We present 10 patients with Rickettsia typhi infection in whom next-generation sequencing of microbial cell-free deoxyribonucleic acid (mcfDNA) was used as a diagnostic tool. Rickettsia typhi mcfDNA was detected in all cases and was more rapid and specific than rickettsial serology. Rickettsia typhi mcfDNA impacted antibiotic management in 50% of patients., (© The Author(s) 2021. Published by Oxford University Press on behalf of Infectious Diseases Society of America.)

Introduction: Updated international guidelines recommend the use of a two-step algorithm (glutamate dehydrogenase [GDH] or nucleic-acid amplification test [NAAT] plus toxin) rather than NAAT alone for the diagnosis of Clostridioides difficile (formerly Clostridium difficile ) infections. The goal of our project was to evaluate the impact of a new bundle on the rate of hospital-acquired C. difficile infections (CDIs), hospital-acquired CDI standardized infection ratio (SIR), antibiotic days of therapy (DOT), and financial cost., Materials and Methods: The new bundle was implemented in April 2018. This bundle was implemented across five hospitals in Catholic Health Initiatives (CHI) Texas Division. The bundle included a switch from NAAT to a two-step process (GDH and toxin). We placed the new test in an order panel which included enteric isolation and required indications for C. difficile testing. We used quarterly data pre- and post-intervention to calculate SIR and DOT., Results: In the pre-intervention period, 15.5% of the total 3513 C. difficile NAAT was positive. In the post-intervention period, 5.7% of a total of 2845 GDH and toxin assays was positive for both GDH and toxin ( P < 0.0001). SIR, which adjusts for denominator and change in testing methodology, also dropped from 1.02 to 0.43. The estimated cost associated with positive C. difficile cases dropped from 1,932,150 USD to 1,113,800 USD with an estimated yearly cost saving of 794,150 USD. Compliance with enteric isolation improved from 73.1% to 92.5% ( P = 0.008)., Conclusion: The new testing bundle led to a marked reduction in hospital-acquired CDI and unnecessary treatment, reduction in C. difficile testing, an increase in compliance with enteric isolation, and significant cost savings., Competing Interests: There are no conflicts of interest., (Copyright: © 2021 Avicenna Journal of Medicine.)

Objective: Despite evidence to the contrary, many practitioners continue to inappropriately screen for and treat bacteria in the urine of clinically asymptomatic patients. The purpose of this study was to evaluate the impact of a new order set on the number of urine culture performed, antibiotic days of therapy (DOT), catheter-associated urinary tract infections (CAUTI), and associated financial impact., Design: A quasi-experimental before-and-after intervention., Setting: We conducted this study at 5 Catholic Health Initiative (CHI) hospitals in Texas that use the same electronic health record (EHR) system., Patients: The study populations included adult patients who had urine culture performed from June 2017 to June 2019., Intervention: The intervention (implemented June 25, 2018) was the addition of a new order set in the electronic health record that required practitioners to choose an indication for the type of urine study. The primary outcome was number of urine cultures performed adjusted for the number of total patient days., Results: Following implementation of the new order set, the number of urine cultures performed among the 5 sites decreased from 1,175.8 tests per 10,000 patient days before the intervention to 701.4 after the intervention (40.4% reduction; P < .01). Antibiotic DOT for patients with a urinary tract infection indication decreased from 102.5 to 86.9 per 1,000 patient days (15.2% reduction; P < .01). The CAUTI standardized infection ratio was 1.0 before the intervention and 0.8 after the intervention (P = .23). The estimated yearly savings following the intervention was US$535,181., Conclusions: The addition of a new order set resulted in decreases in the number of urine cultures performed and the antibiotic DOT, as well as substantial financial savings.

Purpose: We aimed to assess factors associated with therapy failure in patients with community-acquired pneumonia in the intensive care unit (ICU)., Methods: Electronic charts of patients with International Classification of Diseases , Ninth Revision , codes of pneumonia who were admitted to the ICU at a tertiary academic medical center in Southern Arizona were reviewed., Results: Antipseudomonal coverage and anti-methicillin-resistant Staphylococcus aureus (MRSA) coverage were often prescribed (58.4% and 54.1%, respectively). Antipseudomonal coverage was rarely necessary as pseudomonal pneumonia was found in only one case (0.9%). Antipseudomonal and anti-MRSA coverage was not associated with improved outcomes., Conclusion: Overprescription of antibiotics in this population remains a significant problem. More work is needed to further limit unnecessary antibiotic use., Competing Interests: There are no conflicts of interest.

In August 2017, Hurricane Harvey caused unprecedented flooding and devastation to the Houston metropolitan area (1). Mold exposure was a serious concern because investigations after Hurricanes Katrina and Rita (2005) had documented extensive mold growth in flood-damaged homes (2,3). Because mold exposure can cause serious illnesses known as invasive mold infections (4,5), and immunosuppressed persons are at high risk for these infections (6,7), several federal agencies recommend that immunosuppressed persons avoid mold-contaminated sites (8,9). To assess the extent of exposure to mold and flood-damaged areas among persons at high risk for invasive mold infections after Hurricane Harvey, CDC and Texas health officials conducted a survey among 103 immunosuppressed residents in Houston. Approximately half of the participants (50) engaged in cleanup of mold and water-damaged areas; these activities included heavy cleanup (23), such as removing furniture or removing drywall, or light cleanup (27), such as wiping down walls or retrieving personal items. Among immunosuppressed persons who performed heavy cleanup, 43% reported wearing a respirator, as did 8% who performed light cleanup. One participant reported wearing all personal protective equipment (PPE) recommended for otherwise healthy persons (i.e., respirator, boots, goggles, and gloves). Immunosuppressed residents who are at high risk for invasive mold infections were exposed to mold and flood-damaged areas after Hurricane Harvey; recommendations from health care providers to avoid exposure to mold and flood-damaged areas could mitigate the risk to immunosuppressed persons., Competing Interests: Luis Ostrosky-Zeichner reports grants and personal fees from Astellas, personal fees from Merck & Co., grants and personal fees from Pfizer, grants and personal fees from Cidara, grants and personal fees from Scynexis, personal fees from F2G, grants from Amplyx, personal fees from Mayne, personal fees from Gilead, personal fees from NovaDigm, personal fees from United Medical, and personal fees from Stendhal outside the submitted work. Dimitrios P. Kontoyiannis reports honoraria for lectures from Merck & Co., Gilead, and United Medicine and also reports consulting fees from Merck & Co., Astellas, Cidara, Amplyx, and Mayne. No other potential conflicts of interest were disclosed.

Purpose: To identify the factors associated with total Hospital-Acquired Condition Reduction Program (HACRP) score and with receiving a Centers for Medicare and Medicaid Services (CMS) penalty (1% reduction in payment to those hospitals in the lowest-performing quartile of HACRP scores) for fiscal years (FYs) 2015-2017 with a particular focus on trends over this period., Method: The authors evaluated the following variables: (1) type of hospital (teaching vs. nonteaching); (2) disproportionate patient percentage; (3) case mix index (CMI); (4) number of staffed beds; (5) length of stay (LOS); (6) gross patient revenue; and (7) region, using data from CMS and the American Hospital Directory. They conducted multivariate linear and logistic regressions., Results: A total of 2,249 hospitals were included. The mean total HACRP scores across hospitals for FY15, FY16, and FY17 were 5.38, 5.35, and 5.18, respectively. In FY15, 21.2% (476/2,249) of hospitals received a penalty compared with 22.6% (508/2,249) in FY16 and 31.3% (704/2,249) in FY17 (P < .001). The logistic regression model showed that teaching hospitals, larger hospitals (> 400 beds), hospitals with high CMI or long LOS, and hospitals in the Northeast and Western United States were more likely to receive a penalty. Teaching hospitals and larger hospitals did not improve their scores over time compared with nonteaching and small hospitals., Conclusions: A reevaluation of the scoring methodology for the HACRP is needed. CMS could stratify hospitals into homogeneous categories and apply penalties to those that have the worst scores in each category.

The significance of bacteriuria in patients with end-stage renal disease (ESRD) on hemodialysis (HD) is unclear. It is not known whether treatment of asymptomatic bacteriuria is associated with lower rates of urinary tract infection or readmission. Adult patients with ESRD on HD were retrospectively evaluated to assess factors associated with the recurrence of bacteriuria and readmission. We included 68 patients in the analysis. There were 20 patients (29.4%) with urinary symptoms. All symptomatic patients received antibiotic therapy, whereas half of the asymptomatic patients received antibiotics. Antibiotic use was not associated with lower rates of readmission or the recurrence of bacteriuria., Competing Interests: There are no conflicts of interest.

A 56-year-old man with a history of injection drug use and two prior episodes of native valve infective endocarditis presented with dyspnoea on exertion. Our preliminary work-up revealed bacteraemia with reported growth of ' Mycobacterium abscessus group' on multiple blood cultures. The patient was later found to have eustachian valve and prosthetic pulmonic valve endocarditis. Initially, he responded to standard antimycobacterial therapy for rapidly growing mycobacteria (RGM) with supporting laboratory susceptibilities. However, he later developed refractory disease and persistent bacteraemia in the setting of these alleged susceptible antibiotics. Further molecular testing revealed a functional and inducible erm( 41) gene which confers macrolide resistance. A subspecies analysis of the M abscessus group revealed the subspecies to be abscessus We present a challenging case of M abscessus subsp. abscessus bacteraemia and prosthetic valve endocarditis with further discussion on treatment and management of this infection along with the taxonomic complexity of this ubiquitous RGM., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Ltd (unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Background: Both typical and atypical bacteria can cause community-acquired pneumonia (CAP); however, the need for empiric atypical coverage remains controversial. Our objective was to evaluate the impact of antibiotic regimens with atypical coverage (a fluoroquinolone or combination of a macrolide/doxycycline with a β-lactam) to a regimen without atypical antibiotic coverage (β-lactam monotherapy) on rates of clinical failure (primary endpoint), mortality, bacteriologic failure, and adverse events, (secondary endpoints)., Methods: We searched the PubMed, EMBASE and Cochrane Library databases for relevant RCTs of hospitalized CAP adults. We estimated risk ratios (RRs) with 95% confidence intervals (CIs) using a fixed-effect model, but used a random-effects model if significant heterogeneity (I 2 ) was observed., Results: Five RCTs with a total of 2011 patients were retained. A statistically significant lower clinical failure rate was observed with empiric atypical coverage (RR, 0.851 [95% CI, 0.732-0.99; P = 0.037]; I 2  = 0%). The secondary outcomes did not differ between the two study groups: mortality (RR = 0.549 [95% CI, 0.259-1.165, P = 0.118], I 2  = 61.434%) bacteriologic failure (RR = 0.816 [95% CI, 0.523-1.272, P = 0.369], I 2  = 0%), diarrhea (RR = 0.746 [95% CI, 0.311-1.790, P = 0.512], I 2  = 65.048%), and adverse events requiring antibiotic discontinuation (RR = 0.83 [95% CI, 0.542-1.270, P = 0.39], I 2  = 0%)., Conclusions: Empiric atypical coverage was associated with a significant reduction in clinical failure in hospitalized adults with CAP. Reduction in mortality, bacterial failure, diarrhea, and discontinuation due to adverse effects were not significantly different between groups, but all estimates favored atypical coverage. Our findings provide support for the current guidelines recommendations to include empiric atypical coverage.

To assess the severity of inflammation associated with diabetic foot infection (DFI), values of inflammatory markers such as white blood count (WBC), C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), and neutrophil to lymphocyte ratio (NLR) are often measured and tracked over time. It remains unclear if these markers can aid the clinician in the diagnosis and management of DFI, and ensure more rational use of antibiotics. Hospitalized adult patients (n = 379) with DFI were retrospectively assessed for abnormal inflammatory markers, correlation between values of inflammatory markers, and clinical diagnosis on initial admission and on last follow-up. At admission, WBC, ESR and NLR were each elevated in patients with osteomyelitis and only ESR was significantly elevated in patients with soft tissue infection only. Only WBC was significantly elevated in patients with osteomyelitis compared with uninfected diabetic feet on last follow-up. Considering the predictive performance of these inflammatory markers, they demonstrated excellent positive predictive value at admission, and excellent negative predictive value at the last follow-up visit. Moreover, the number of elevated markers was further associated with probability of infection both at admission and last follow-up.

We developed a questionnaire to assess the knowledge and practice of nursing staff, patient care assistants, phlebotomists, and laboratory technicians regarding blood culture collection and contamination at 2 tertiary care academic centers. Our study showed there were several gaps in knowledge and practice regarding obtaining blood cultures., (Copyright © 2017 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.)

Central Nervous System (CNS) vasculitis is the most common life-threatening complication of coccidioidal meningitis. It is manifested by cerebral ischemia, hemorrhage, and infarction. We report a case of CNS vasculitis in a patient receiving chemotherapy and review of the literature on coccidioidal meningitis. The patient was treated with combination antifungal therapy and a short course of high dose corticosteroids with a modest improvement in her neurological examination after initiation of steroids.

A 72-year-old man with a history of blastoid variant stage IV relapsed refractory mantle cell lymphoma presented with new central nervous system (CNS) symptoms. Brain imaging was positive for rim-enhancing lesions along with a mitral valve mass on the echocardiogram. It was a challenge to establish the exact aetiology of these lesions in this patient. He was empirically treated with chemotherapy on the presumption that the brain lesions were secondary to progressive malignancy. However, brain biopsy was negative for malignancy and blood cultures were found positive for Nocardia kroppenstedtii sp nov. He subsequently improved with antibiotic therapy. Disseminated Nocardia can present with multiorgan involvement. Clinical and microbiological diagnosis can be challenging. Antimicrobial treatment-related side effects require close monitoring, and dosage changes or therapy adjustments may be necessary., Competing Interests: Conflicts of Interest: None declared., (2017 BMJ Publishing Group Ltd.)

We developed an interactive online module to improve the knowledge of students and physicians regarding respiratory infections. Our study showed that the completion of this module was associated with substantial improvement in knowledge, with modest retention after 2 months., (Copyright © 2017 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.)

Candida albicans is a common human pathogen. Occasionally, it can cause peritonitis in immunocompromised and postsurgical patients. We report a case of a male patient who presented with abdominal pain and distention. He had a history of end-stage liver disease secondary to alcoholism. His peritoneal fluid culture revealed C albicans, and (1-3)-β-d glucan (BDG) level was elevated. His hospital course was complicated by sepsis and renal failure. He was treated with antifungals for spontaneous fungal peritonitis. Fungal peritonitis should be suspected in patients with chronic liver disease particularly with elevated BDG levels., Competing Interests: Conflicts of Interest: None declared., (2016 BMJ Publishing Group Ltd.)

Fungal endocarditis is an extremely debilitating disease associated with high morbidity and mortality. Candida spp. are the most common isolated organisms in fungal endocarditis. It is most prevalent in patients who are immunosuppressed and intravenous drug users. Most patients present with constitutional symptoms, which are indistinguishable from bacterial endocarditis, hence a high index of suspicion is required for pursuing diagnosis. Diagnosis of fungal endocarditis can be very challenging: most of the time, blood cultures are negative or take a long time to yield growth. Fungal endocarditis mandates an aggressive treatment strategy. A medical and surgical combined approach is the cornerstone of therapy., (Copyright © 2016 Elsevier Inc. All rights reserved.)

The skin is colonized by a diverse collection of microorganisms which, for the most part, peacefully coexist with their hosts. Skin and soft tissue infections (SSTIs) encompass a variety of conditions; in immunocompromised hosts, SSTIs can be caused by diverse microorganisms-most commonly bacteria, but also fungi, viruses, mycobacteria, and protozoa. The diagnosis of SSTIs is difficult because they may commonly masquerade as other clinical syndromes or can be a manifestation of systemic disease. In immunocompromised hosts, SSTI poses a major diagnostic challenge, and clinical dermatological assessment should be initially performed; to better identify the pathogen and to lead to appropriate treatment, etiology should include cultures of lesions and blood, biopsy with histology, specific microbiological analysis with special stains, molecular techniques, and antigen-detection methodologies. Here, we reviewed the epidemiology, pathophysiology, clinical presentation, and diagnostic techniques, including molecular biological techniques, used for SSTIs, with a focus on the immunocompromised host, such as patients with cellular immunodeficiency, HIV, and diabetic foot infection.