Search

Diagnosis of acute severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection relies on detection of viral antigens or amplified viral nucleic acids. Serology, although invaluable for epidemiology, is not routinely needed clinically. However, in some settings, serologic data may have direct clinical utility: for example, in evaluation of persistent symptoms in patients without a prior diagnosis of acute infection. In contrast, SARS-CoV-2 serologic testing is sometimes used or requested in situations in which existing data do not support it, such as determination of need for vaccination. In this study, we describe available methods of serologic testing and provide cases supported by clinical vignettes of where such tests can be helpful, as well as examples where they are not. These examples may help clarify clinical decision making in this rapidly evolving area.

BackgroundThe COVID-19 pandemic caused by the SARS-CoV-2 virus greatly affected healthcare workers and healthcare systems. It also challenged schools and universities worldwide negatively affecting in-person education. We conducted this study is to assess the evolution of SARs-CoV-2 virulence over the course of the pandemic.MethodsA combined cohort of affiliates from the University of Navarra, two hospitals in Spain, and one healthcare system in the Greater Boston area was followed prospectively from March 8th, 2020, to January 31st, 2022 for diagnosis with COVID-19 by PCR testing and related sequelae. Follow-up time was divided into four periods according to distinct waves of infection during the pandemic. Severity of COVID-19 was measured by case-hospitalization rate. Descriptive statistics and multivariable-adjusted statistics using the Poisson mixed-effects regression model were applied.ResultsFor the last two periods of the study (January 1stto December 15th, 2021 and December 16th, 2021 to January 31st, 2022) and relative to the first period (March 8thto May 31st, 2020), the incidence rate ratios (IRRs) of hospitalization were 0.08 (95% CI, 0.03-0.17) and 0.03 (95% CI, 0.01-0.15), respectively.InterpretationThe virulence of COVID-19 and immunity of our populations evolved over time, resulting in a decrease in case severity. We found the case-hospitalization rate decreased more than 90% in our cohort despite an increase in incidence.

Background: Indiscriminate orders for urinalysis and urine cultures (UC) drive inappropriate antibiotic treatment (Abx), especially in older adults with mental health disorders. Lack of data regarding the prevalence of and treatment for infections in acute geriatric psychiatric units (GPU) motivated us to initiate this project. Aim: Our goal was to improve urine test utilization and reduce unnecessary Abx for asymptomatic bacteriuria (ASB) and contaminated UC. Methods: This retrospective review and prospective evaluation of bundled interventions was conducted in a 22- bed GPU in a community-based teaching hospital. Four hundred twenty-seven (427) patient records were reviewed for Abx and indication and 157 patients were assessed for the impact of bundled interventions. Results: Near 27% received Abx, primarily for a misdiagnosed urinary tract infection. Only 20% met clinical criteria; 80% were unnecessarily treated for ASB or contaminated cultures. Over two-thirds of the Abx consisted of fluoroquinolones or trimethoprim-sulfamethoxazole, neither of which are recommended due to adverse events and/or resistance. The impact of bundled interventions was marginally effective. Conclusion: Urinalysis and UC are indiscriminately ordered in older adults, resulting in inappropriate Abx with non-recommended agents. Urinalysis should not be a requirement for admission in asymptomatic patients given the high prevalence of ASB and pyuria in older adults. There is an opportunity for more collaboration within referring networks to standardize best practice.

ImportanceAssociations between prenatal SARS-CoV-2 exposure and neurodevelopmental outcomes have substantial public health relevance. A previous study found no association between prenatal SARS-CoV-2 infection and parent-reported infant neurodevelopmental outcomes, but standardized observational assessments are needed to confirm this finding.ObjectiveTo assess whether mild or asymptomatic maternal SARS-CoV-2 infection vs no infection during pregnancy is associated with infant neurodevelopmental differences at ages 5 to 11 months.Design, Setting, and ParticipantsThis cohort study included infants of mothers from a single-site prospective cross-sectional study (COVID-19 Mother Baby Outcomes [COMBO] Initiative) of mother-infant dyads and a multisite prospective cohort study (Epidemiology of Severe Acute Respiratory Syndrome Coronavirus 2 in Pregnancy and Infancy [ESPI]) of pregnant individuals. A subset of ESPI participants was subsequently enrolled in the ESPI COMBO substudy. Participants in the ongoing COMBO study were enrolled beginning on May 26, 2020; participants in the ESPI study were enrolled from May 7 to November 3, 2021; and participants in the ESPI COMBO substudy were enrolled from August 2020 to March 2021. For the current analysis, infant neurodevelopment was assessed between March 2021 and June 2022. A total of 407 infants born to 403 mothers were enrolled (204 from Columbia University Irving Medical Center in New York, New York; 167 from the University of Utah in Salt Lake City; and 36 from the University of Alabama in Birmingham). Mothers of unexposed infants were approached for participation based on similar infant gestational age at birth, date of birth, sex, and mode of delivery to exposed infants.ExposuresMaternal symptomatic or asymptomatic SARS-CoV-2 infection.Main Outcomes and MeasuresInfant neurodevelopment was assessed using the Developmental Assessment of Young Children, second edition (DAYC-2), adapted for telehealth assessment. The primary outcome was age-adjusted standard scores on 5 DAYC-2 subdomains: cognitive, gross motor, fine motor, expressive language, and receptive language.ResultsAmong 403 mothers, the mean (SD) maternal age at delivery was 32.1 (5.4) years; most mothers were of White race (240 [59.6%]) and non-Hispanic ethnicity (253 [62.8%]). Among 407 infants, 367 (90.2%) were born full term and 212 (52.1%) were male. Overall, 258 infants (63.4%) had no documented prenatal exposure to SARS-CoV-2 infection, 112 (27.5%) had confirmed prenatal exposure, and 37 (9.1%) had exposure before pregnancy or at an indeterminate time. In adjusted models, maternal SARS-CoV-2 infection during pregnancy was not associated with differences in cognitive (β = 0.31; 95% CI, −2.97 to 3.58), gross motor (β = 0.82; 95% CI, −1.34 to 2.99), fine motor (β = 0.36; 95% CI, −0.74 to 1.47), expressive language (β = −1.00; 95% CI, −4.02 to 2.02), or receptive language (β = 0.45; 95% CI, −2.15 to 3.04) DAYC-2 subdomain scores. Trimester of exposure and maternal symptom status were not associated with DAYC-2 subdomain scores.Conclusions and RelevanceIn this study, results of a novel telehealth-adapted observational neurodevelopmental assessment extended a previous finding of no association between prenatal exposure to maternal SARS-CoV-2 infection and infant neurodevelopment. Given the widespread and continued high prevalence of COVID-19, these data offer information that may be helpful for pregnant individuals who experience asymptomatic or mild SARS-CoV-2 infections.

Objective:To better understand coronavirus disease 2019 (COVID-19) transmission among healthcare workers (HCWs), we investigated occupational and nonoccupational risk factors associated with cumulative COVID-19 incidence among a Massachusetts HCW cohort.Design, setting, and participants:The retrospective cohort study included adult HCWs in a single healthcare system from March 9 to June 3, 2020.Methods:The SARS-CoV-2 nasopharyngeal RT-PCR results and demographics of the study participants were deidentified and extracted from an established occupational health, COVID-19 database at the healthcare system. HCWs from each particular job grouping had been categorized into frontline or nonfrontline workers. Incidence rate ratios (IRRs) and odds ratios (ORs) were used to compare subgroups after excluding HCWs involved in early infection clusters before universal masking began. A sensitivity analysis was performed comparing jobs with the greatest potential occupational risks with others.Results:Of 5,177 HCWs, 152 (2.94%) were diagnosed with COVID-19. Affected HCWs resided in areas with higher community attack rates (median, 1,755.2 vs 1,412.4 cases per 100,000; P < .001; multivariate-adjusted IRR, 1.89; 95% CI, 1.03–3.44 comparing fifth to first quintile of community rates). After multivariate adjustment, African-American and Hispanic HCWs had higher incidence of COVID-19 than non-Hispanic white HCWs (IRR, 2.78; 95% CI, 1.78–4.33; and IRR, 2.41, 95% CI, 1.42–4.07, respectively). After adjusting for race and residential rates, frontline HCWs had a higher IRR (1.73, 95% CI, 1.16–2.54) than nonfrontline HCWs overall, but not within specific job categories nor when comparing the highest risk jobs to others.Conclusions:After universal masking was instituted, the strongest risk factors associated with HCW COVID-19 infection were residential community infection rate and race.

ObjectiveTo investigate COVID-19 vaccine efficacy (VE) among healthcare workers (HCWs) in an ethnically diverse community healthcare system, during its initial immunization campaign. MethodsHCWs of the system were retrospectively included from the beginning of a COVID-19 vaccination program (December 16, 2020) until March 31, 2021. Those with a prior COVID-19 infection before December 15 were excluded. The Occupational Health department of the system ran a COVID-19 screening and testing referral program for workers, consistently throughout the study period. A master database had been established and updated comprising of the demographics, COVID-19 PCR assays, and vaccinations of each HCW. Andersen-Gill extension of the Cox models were built to estimate the VE of fully/partially vaccinated person-days at risk. ResultsAmong the 4317 eligible HCWs, 3249 (75%) received any vaccination during the study period. Vaccinated HCWs were older, less likely to be Black/African American, Hispanic/Latino or identify as two or more races, and more likely to be medical providers. After adjusting for age, sex, race, and the statewide background incidence at the time of vaccination, we observed a VE of 80.2% (95% CI: 57.5-90.8%) for [greater double equals]14 days after the first dose of Pfizer/Moderna, and 95.5% (95% CI: 88.2-98.3%) among those fully vaccinated (i.e. [greater double equals]14 days after the second dose of Pfizer/Moderna or the single dose of J&J/Janssen). ConclusionCOVID-19 vaccine effectiveness in the real world is promising, and these data in concert with culturally appropriate may decrease vaccine hesitancy.

The hypothesis of attenuating SARS-CoV-2 virulence has been raised. We examined the temporal distribution of COVID-19 complications (ER visits, hospitalization, intubation/code, and/or death) among healthcare workers in one system that applied uniform screening criteria throughout the research period, and found the complication rate significantly decreased after April 15, 2020.

SARS-CoV-2 antibody seroprevalence among health-care workers (HCW) can assess past exposure and possible immunity, which varies across different regions, populations and times. We investigated the seroprevalence among HCW in Massachusetts (a region suffering high COVID-19 mortality) at the end of first wave of the SARS-CoV-2 pandemic. All HCW at Cambridge Health Alliance were invited to participate in this cross-sectional survey in June 2020. Those who volunteered, consented and provided a blood sample were included. Dried blood specimens from finger-prick sampling collected either at home by each HCW or onsite by the study team were analyzed for anti-SARS-CoV-2 IgM and IgG to the virus’ receptor binding domain, using an enzyme-linked immunosorbent assay. IgM and IgG antibody abundance were categorized based on the number of standard deviations above the cross-reacting levels found in existing, pre-pandemic blood samples previously obtained by the Ragon Institute and analyzed by the Broad Institute (Cambridge, MA). Seroprevalence estimates were made based on ‘positive’ IgM or IgG using ‘low’ (>6 SD), ‘medium’ (>4.5 SD), and ‘high’ prevalence cutoffs (>3 SD). A total of 433 out of 5,204 eligible HCWs consented and provided samples. Participating HCWs had a lower cumulative incidence (from the start of the pandemic up to the bloodspot collections) of SARS-CoV-2 RT-PCR positivity (1.85%) compared to non-participants (3.29%). The low, medium, and high seroprevalence estimates were 8.1%, 11.3%, and 14.5%, respectively. The weighted estimates based on past PCR positivity were 13.9%, 19.4%, and 24.9%, respectively, for the entire healthcare system population after accounting for participation bias.

Background Healthcare workers (HCWs) and other essential workers are at risk of occupational infection during the COVID-19 pandemic. Several infection control strategies have been implemented. Evidence shows that universal masking can mitigate COVID-19 infection, though existing research is limited by secular trend bias. Aims To investigate the effect of hospital universal masking on COVID-19 incidence among HCWs compared to the general population. Methods We compared the 7-day average incidence rates between a Massachusetts (USA) healthcare system and Massachusetts residents statewide. The study period was from 17 March (the date of first incident case in the healthcare system) to 6 May (the date Massachusetts implemented public masking). The healthcare system implemented universal masking on 26 March, we allotted a 5-day lag for effect onset and peak COVID-19 incidence in Massachusetts was 20 April. Thus, we categorized 17–31 March as the pre-intervention phase, 1–20 April the intervention phase and 21 April to 6 May the epidemic decline phase. Temporal incidence trends (i.e. 7-day average slopes) were compared using standardized coefficients from linear regression models. Results The standardized coefficients were similar between the healthcare system and the state in both the pre-intervention and epidemic decline phases. During the intervention phase, the healthcare system’s epidemic slope became negative (standardized β: −0.68, 95% CI: −1.06 to −0.31), while Massachusetts’ slope remained positive (standardized β: 0.99, 95% CI: 0.94 to 1.05). Conclusions Universal masking was associated with a decreasing COVID-19 incidence trend among HCWs, while the infection rate continued to rise in the surrounding community.

Background: Coronavirus 2019 disease (COVID-19) is caused by the virus SARS-CoV-2, transmissible both person-to-person and from contaminated surfaces. Early COVID-19 detection among healthcare workers (HCWs) is crucial for protecting patients and the healthcare workforce. Because of limited testing capacity, symptom-based screening may prioritize testing and increase diagnostic accuracy. Methods: We performed a retrospective study of HCWs undergoing both COVID-19 telephonic symptom screening and nasopharyngeal SARS-CoV-2 assays during the period, March 9 – April 15, 2020. HCWs with negative assays but progressive symptoms were re-tested for SARS-CoV-2. Findings: Among 592 HCWs tested, 83 (14%) had an initial positive SARS-CoV-2 assay. Fifty-nine of 61 HCWs (97%) who were asymptomatic or reported only sore throat/nasal congestion had negative SARS-CoV-2 assays (P=0·006). HCWs reporting three or more symptoms had an increased multivariate-adjusted odds of having positive assays, 1·95 (95% CI: 1·10–3·64), which increased to 2·61 (95% CI: 1·50–4·45) for six or more symptoms. The multivariate-adjusted odds of a positive assay were also increased for HCWs reporting fever and a measured temperature ≥ 37·5°C (3·49 (95% CI: 1·95–6·21)), and those with myalgias (1·83 (95% CI: 1·04–3·23)). Anosmia/ageusia was reported less frequently (16%) than other symptoms by HCWs with positive assays, but associated with more than a seven-fold multivariate-adjusted odds of a positive test: OR=7·21 (95% CI: 2·95–17·67). Of 509 HCWs with initial negative SARS-CoV-2 assays, nine had symptom progression and positive re-tests, yielding an estimated negative predictive value of 98·2% (95% CI: 96·8–99·0%) for the exclusion of clinically relevant COVID-19. Interpretation: Symptom and temperature reports are useful screening tools for predicting SARS-CoV-2 assay results in HCWs. Anosmia/ageusia and fever were the two strongest independent predictors of positive assays. The absence of symptoms or symptoms limited to nasal congestion/sore throat were associated with negative assays. Funding Statement: None. Declaration of Interests: None Ethics Approval Statement: The Institutional Review Board of the healthcare system reviewed the study protocol, determined it to be exempt and waived informed consent based on the use of existing, HIPAA-deidentified data.

Background: The Infectious Diseases Society of America released updated community-acquired pneumonia (CAP) guidelines in October 2019. One of the recommendations, with a low quality of supporting evidence, is the standard administration of antibiotics in adult patients with influenza and radiographic evidence of pneumonia. Procalcitonin (PCT) is not endorsed as a strategy to withhold antibiotic therapy, but it could be used to de-escalate appropriate patients after 48–72 hours. Radiographic findings are not indicative of the etiology of pneumonia. Prescribing antibiotics for all influenza-positive patients with an infiltrate has significant implications for stewardship. Therefore, we reviewed hospitalized, influenza-positive patients at our institution during the 2018–2019 season, and we sought to assess the impact of an abnormal chest x-ray (CXR) and PCT on antibiotic prescribing and outcomes. Methods: We conducted a retrospective chart review of all influenza-positive admissions at 2 urban, community-based, teaching hospitals. Demographic data, vaccination status, PCT levels, CXR findings, and treatment regimens were reviewed. The primary outcome was the difference in receipt of antibiotics between patients with a negative (Results: We reviewed the medical records of 117 patients; 43 (36.7%) received antibiotics. The vaccination rate was 36.7%. Also, 11% of patients required intensive care unit (ICU) admission and 84% received antibiotics. Moreover, 109 patients had a CXR: 61 (55.9%) were negative, 29 (26.6%) indeterminate, and 19 (17.4%) positive per radiologist interpretation. Patients with a positive PCT (OR, 12.7; 95% CI, 3.43–60.98; P < .0007) and an abnormal CXR (OR, 7.4; 95% CI, 2.9–20.1; P = .000003) were more likely to receive antibiotics. There was no significant difference in 30-day readmission (11.6% vs 13.5%; OR, 0.89; 95% CI, 0.21–3.08; P = 1) and 90-day mortality (11.6% vs 5.4%; OR, 2.37; 95% CI, 0.48–12.75; P = .28) between those that received antibiotics and those that did not, respectively. Furthermore, 30 patients (62.5%) with an abnormal CXR received antibiotics and 21 (43.7%) had negative PCT. There was no difference in 30-day readmission or 90-day mortality between those that did and did not receive antibiotics. Conclusions: Utilization of PCT allowed selective prescribing of antibiotics without impacting readmission or mortality. Antibiotics should be initiated for critically ill patients and based on clinical judgement, rather than for all influenza-positive patients with CXR abnormalities.Funding: NoneDisclosures: None

Background A prior investigation alerted us to a common practice of obtaining UAs and UCs for admission to our geriatric psychiatry unit (GPU). These findings compelled us to assess antibiotic use (AU) on our 22-bed unit at Cambridge Health Alliance, Everett, a community-based teaching hospital, from February 1, 2016 to January 31, 2017. Among 427 patients, 115 (27%) received an antibiotic. Urinary tract infection (UTI) was the most common diagnosis (53%); however, only 12 patients (20%) met diagnostic criteria. Contaminated (CT) specimens and asymptomatic bacteriuria (ASB) were more prevalent (26% and 22%, respectively). UC orders were not triggered by symptoms. Methods We evaluated the impact of education to the GPU (August 14, 2017), removing a requirement for UA (September 6, 2017) which was communicated to EM leadership, and clinical decision support (CDS) during computerized order entry for UC (October 1, 2017) on UA and UC utilization. AU appropriateness was determined for patients who received at least four doses of an antibiotic for UTI. Pre-(discharge June 3, 2017–August 14, 2017) and post-intervention (admitted after October 1, 2017 and discharged prior to January 17, 2018) periods were compared. Results There were nonsignificant (NS) decreases in UAs and UCs and an NS increase in UAs among asymptomatic patients, largely ordered by EM providers. There was a 23% decrease in unjustified AU for UTI (NS). CT specimens and ASB were far more common than UTIs. Pre-Intervention Period Post-Intervention Period P-value Number of patients 48 109 UAs ordered 38 (79.2%) 79 (72.5%) 0.74 UAs in asymptomatic patients 19 (50%) 50 (63.3%) 0.49 Urine cultures 15 (31.3%) 25 (22.9%) 0.41 Unjustified antibiotic Rx UTI 4 (8.3%) 7 (6.4%) 0.68 Contaminated 6 (40%) 12 (48%) 0.78 ASB 4 (26.7%) 6 (24%) 0.88 UTI 1 (6.7%) 2 (8%) 0.93 Conclusion Education, removal of the UA requirement for medical clearance, and CDS were minimally effective in improving UA and UC utilization and reducing inappropriate antibiotic therapy. Efforts are undermined by a requirement for UA by other psychiatric units in our referral network. We intend to collaborate with medical directors in our psychiatry network to expand this improvement work, provide more robust education to our EM providers and implement a UA with reflex to UC for > 10 WBC/hpf. Disclosures All authors: No reported disclosures.

Background In patients with bacteremia, delay in appropriate therapy is associated with higher morbidity and mortality. Matrix-assisted laser desorption/ionization time-of-flight (MALDI-TOF) reduces the time to identification (ID) to approximately 30 minutes. Previously published studies show rapid diagnostics need to be coupled with antibiotic stewardship intervention for maximal benefit. Methods Retrospective, observational review at Cambridge and Everett Hospitals, two inpatient community, teaching hospitals that are part of Cambridge Health Alliance. The purpose is to evaluate the impact of MALDI-TOF by reviewing data in three phases: Microscan ID (January 1 to November 30, 2017), MALDI-TOF alone (December 1, 2017 to December 9, 2018), and MALDI-TOF coupled antimicrobial stewardship (December 10, 2018 to April 30, 2019). The laboratory batches all positive blood cultures to be run via MALDI-TOF mid-morning. In phase 3, a pharmacy resident is notified of the result via an automatic page. The resident determines appropriate empiric therapy using an algorithm developed by the Antimicrobial Stewardship Team and contacts the primary team. Data were collected via a laboratory report and chart review. The primary outcome is time to targeted antimicrobial therapy after ID. Secondary outcomes include time to ID, time to susceptibilities, duration of therapy for blood culture contaminants, and number of pharmacy interventions in phase 3. Results Preliminary data indicate mean time targeted antibiotic therapy was 41:45, 35:58, and 27:39 hours:minutes in phases 1, 2, and 3, respectively. Mean time to ID and final susceptibilities was also reduced in phases 2 and 3. The duration of therapy for blood culture contaminants decreased from 53:50 in phase 1 to 32:48 hours:minutes in phase 2. Pharmacy residents in phase 3 successfully implemented 47 total interventions, 24 (51%) after identification. Conclusion Implementation of MALDI-TOF with and without stewardship intervention successfully decreased time to targeted antibiotic therapy in two community hospitals. Future directions include adding an evening MALDI-TOF run and simplifying pharmacy resident standard operating procedure. Disclosures All authors: No reported disclosures.

This study examines the assertion that culture influences conflict style preference. Data were gathered in India (n = 657), Ireland (n = 311), Thailand (n = 232), and the United States (n = 592). Conflict was measured using Oetzel's Conflict Style Measure. Results confirm that high-context nations (India and Thailand) prefer the avoiding and obliging conflict styles more than low-context nations (Ireland and the United States), whereas low-context nations prefer the dominating conflict style more than high-context nations. However, results of this study are contrary to previous research in that high-context nations prefer the compromising style more than do low-context nations, and the nations are mixed in their level of preference for the integrating style.

Background Our goal was to reduce the rate of hospital-onset (HO) C. difficile (CD) by prompt testing in patients with diarrhea on hospital day (HD) 1–3 using a nurse-driven testing protocol (NTP) with PCR and improve identification of disease after HD 3 using a combined toxin/antigen assay (TAA). Methods An automated best practice advisory/NTP was developed in Epic, triggered by documentation of diarrhea during HD 1–3, to facilitate prompt stool collection, testing and initiation of contact precautions. Education was provided. The NTP was fully implemented at 2 community-teaching hospitals mid-February 2016. The TAA was adopted 7/27/16 for testing after HD 3. Results In 2016, the standardized infection ratio (SIR) at Cambridge and Everett was 0.43 (P = 0.009) and 0.5 (P = 0.017), respectively, reflecting a 48–61% decrease from 2015. There was a 14–28% improvement in identifying cases as community-onset. The TAA led to a further decline in HO-CD by 10–61%. Refer to the graph for quarterly SIRs before and after implementation. Despite a 26% increase in testing volume, costs are less with the current strategy. Conclusion Prompt identification of CD improves care and prevents inflation of HO-CD. This strategy has enhanced our efforts to reduce our SIR (observed/expected cases) and resulted in a substantial incentive payment for CHA. Disclosures All authors: No reported disclosures.

Background Complicated skin and skin structure infections (cSSSIs) frequently result in hospitalization with significant morbidity and mortality. Methods In this phase 3b/4 parallel, randomized, open-label, comparative study, 531 subjects with cSSSI received tigecycline (100 mg initial dose, then 50 mg intravenously every 12 hrs) or ampicillin-sulbactam 1.5-3 g IV every 6 hrs or amoxicillin-clavulanate 1.2 g IV every 6-8 hrs. Vancomycin could be added at the discretion of the investigator to the comparator arm if methicillin-resistant Staphylococcus aureus (MRSA) was confirmed or suspected within 72 hrs of enrollment. The primary endpoint was clinical response in the clinically evaluable (CE) population at the test-of-cure (TOC) visit. Microbiologic response and safety were also assessed. The modified intent-to-treat (mITT) population comprised 531 subjects (tigecycline, n = 268; comparator, n = 263) and 405 were clinically evaluable (tigecycline, n = 209; comparator, n = 196). Results In the CE population, 162/209 (77.5%) tigecycline-treated subjects and 152/196 (77.6%) comparator-treated subjects were clinically cured (difference 0.0; 95% confidence interval [CI]: -8.7, 8.6). The eradication rates at the subject level for the microbiologically evaluable (ME) population were 79.2% in the tigecycline treatment group and 76.8% in the comparator treatment group (difference 2.4; 95% CI: -9.6, 14.4) at the TOC assessment. Nausea, vomiting, and diarrhea rates were higher in the tigecycline group. Conclusions Tigecycline was generally safe and effective in the treatment of cSSSIs. Trial registration ClinicalTrials.gov NCT00368537

To determine the thoroughness of terminal disinfection and cleaning of patient rooms in hospital intensive care units and to assess the value of a structured intervention program to improve the quality of cleaning as a means of reducing environmental transmission of multidrug-resistant organisms within the intensive care unit.Prospective, multicenter, and pre- and postinterventional study.Intensive care unit rooms in 27 acute care hospitals. Hospitals ranged in size from 25 beds to 709 beds (mean, 206 beds).A fluorescent targeting method was used to objectively evaluate the thoroughness of terminal room cleaning before and after structured educational, procedural, and administrative interventions. Systematic covert monitoring was performed by infection control personnel to assure accuracy and lack of bias.In total, 3532 environmental surfaces (14 standardized objects) were assessed after terminal cleaning in 260 intensive care unit rooms. Only 49.5% (1748) of surfaces were cleaned at baseline (95% confidence interval, 42% to 57%). Thoroughness of cleaning at baseline did not correlate with hospital size, patient volume, case mix index, geographic location, or teaching status. After intervention and multiple cycles of objective performance feedback to environmental services staff, thoroughness of cleaning improved to 82% (95% confidence interval, 78% to 86%).Significant improvements in intensive care unit room cleaning can be achieved in most hospitals by using a structured approach that incorporates a simple, highly objective surface targeting method and repeated performance feedback to environmental services personnel. Given the documented environmental transmission of a wide range of multidrug-resistant pathogens, our findings identify a substantial opportunity to enhance patient safety by improving the thoroughness of intensive care unit environmental hygiene.

BACKGROUND Norovirus infection outbreaks (NoVOs) occur frequently in closed populations, such as cruise ship passengers. Environmental contamination is believed to play an important role in NoVO propagation. METHODS Trained health care professionals covertly evaluated the thoroughness of disinfection cleaning (TDC) of 6 standardized objects (toilet seat, flush handle or button, toilet stall inner handhold, stall inner door handle, restroom inner door handle, and baby changing table surfaces) with high potential for fecal contamination in cruise ship public restrooms, by means of a previously validated novel targeting method. RESULTS Fifty-six cruise ships (approximately 30% of 180 vessels operated by 9 large cruise lines) were evaluated from July 2005 through August 2008. Overall, 37% (range, 4%-100%; 95% confidence interval, 29.2%-45.4%) of 8344 objects in 273 randomly selected public restrooms were cleaned daily. The TDC did not differ by cruise line and did not correlate with the Centers for Disease Control and Prevention (CDC) Vessel Sanitation Program inspection scores (r(2), .002; P = .75). More than half the vessels had overall TDC scores

Bell's palsy is one of the most common neurologic disorders affecting the seventh cranial nerve. Several disease states have been associated with facial paralysis. Drugs, however, have been rarely implicated as an etiology. We describe a 49-year-old man who developed peripheral facial paralysis after 3 weeks of linezolid therapy, along with recurrence of symptoms on rechallenge. He had insulin-dependent diabetes mellitus and a longstanding history of bilateral diabetes-related foot problems. After hospitalization, debridement, and vancomycin therapy for methicillin-resistant Staphylococcus aureus osteomyelitis, the patient was discharged to home with oral linezolid therapy. On day 23 of linezolid therapy, he developed signs and symptoms that were consistent with Bell's palsy. Linezolid was discontinued; the Bell's palsy gradually improved, with complete resolution occurring at month 3. On rechallenge with linezolid for recurrent osteomyelitis, the patient developed a second episode of Bell's palsy within a similar time frame as in the first episode. Assessment of causality using the Naranjo adverse drug reaction probability scale revealed a probable relationship between this adverse drug event and linezolid therapy. Clinicians should be aware that Bell's palsy may be another neuropathic adverse effect associated with linezolid.

Objective:To assess the feasibility of a quarterly antibiotic cycling program at two community hospitals and to evaluate its safety and impact on antibiotic use, expenditures, and resistance.Design:Nonrandomized, longitudinal cohort study.Setting:Two community hospitals, one teaching and one non-teaching.Patients:Adult medical and surgical inpatients requiring empiric antibiotic therapy.Intervention:We developed and implemented a treatment protocol for the empiric therapy of common infections. Between July 2000 and June 2002, antibiotics were cycled quarterly; quinolones, beta-lactam–inhibitor combinations, and cephalosporins were used. Protocol adherence, adverse drug events, nosocomial infections, antibiotic use and expenditures, resistance among clinical isolates, and length of stay were assessed during eight quarters.Results:Physicians adhered to the protocol for more than 96% of 2,494 eligible patients. No increases in nosocomial infections or adverse drug events were attributed to the cycling protocol. Antibiotic acquisition costs increased 31%; there was a 14.7% increase in antibiotic use. Length of stay declined by 1 day. Quarterly variability in the prevalence of vancomycin-resistant enterococci and ceftazidime resistance among combined gram-negative organisms were noted.Conclusions:Implementation of an antibiotic cycling program is feasible in a community hospital setting. No adverse safety concerns were identified. Antibiotic cycling was more expensive, partly due to an increase in antibiotic use to optimize initial empiric therapy. Quarterly antibiogram patterns suggested that antibiotic cycling may have impacted resistance, although the small number of isolates precluded statistical analysis. Further assessment of this approach is necessary to determine its relationship to antimicrobial resistance.

CONCLUSIONS Twelve surfaces in 2 ORs, including the anesthesia keyboard, anesthesia cart, anesthesia controls, intravenous infusion pole, overhead lamp, bed control, Bair hugger control, floor, nurse’s mouse, cautery power control, inside door surface and Mayo stand, were sampled before and after between-case SC. Contact agar plates (Remel) were used and colony counts determined after incubation at 35°C for 48 h. 60 before and 60 after SC cultures were obtained followed by 72 cultures after a QC and PX-UVD. Four 5 minute PX-UV treatment cycles were performed at standardized locations in the OR, based upon mapping conducted by Xenex personnel utilizing a UV-C radiometer (International Light Technologies 1700) to determine the optimal treatment time. Two devices were utilized simultaneously to reduce total room treatment time to 10 minutes. Airborne contamination was measured by placing 59cm blood agar (TSA II) settle plates near the operative field for 8 h during cases and for 8 h following the terminal clean on 2 separate days. Air sampling was repeated after a QC plus PX-UVD between cases and following the terminal clean plus PX-UVD. Negative binomial regression, sign-rank test and two sample Wilcoxon-Mann-Whitney analyses were performed using Stata. SC did not significantly decrease surface contamination or bioburden in our OR. However, a QC and PX-UVD resulted in a significant reduction (55%) in positive surface cultures and bioburden (81%) compared to SC. PX-UVD also significantly decreased air contamination during cases (46%) and after the terminal clean (100%). The impact of PX-UVD may even be greater in a busy OR since we observed a significant decrease in bioburden after QC and PX-UVD as compared to SC after the third case. This finding warrants further investigation. We plan to identify whether the cultured organisms are typical pathogens associated with infections. There is evidence that environmental contamination and insufficient surface disinfection contribute to the transmission of pathogens associated with healthcareacquired infections (HAI).1 Among HAI, surgical site infections are the most expensive. Germicidal irradiation produced by the pulsed xenon ultraviolet (PX-UV) portable device produces energy in the 200-320 nm range which is cidal for microorganisms.2 60

Bacillus cereus is a ubiquitous organism that infrequently causes serious infections. We report a patient with B. cereus endocarditis involving a mechanical aortic valve. Data for 10 cases of B. cereus endocarditis reported in the literature are summarized. B. cereus is resistant to many commonly used antibiotics, a finding that has clinical significance for empirical antibiotic selection in patients with suspected endocarditis. Infection in patients with valvular heart disease in the few cases reported is associated with significant mortality and morbidity.