Search

Reports, studies, and surveys have demonstrated telehealth provides opportunities to make health care more efficient, better coordinated, convenient, and affordable. Telehealth can also help address health income and access disparities in underserved communities by removing location and transportation barriers, unproductive time away from work, childcare expenses, and so on. Despite evidence showing high-quality outcomes, satisfaction, and success rates (e.g., 95% patient satisfaction rate and 84% success rate in which patients were able to completely resolve their medical concerns during a telehealth visit), nationwide adoption of telehealth has been quite low due to policy and regulatory barriers, constraints, and complexities.

Clostridioides difficile is the leading health care-associated pathogen, leading to substantial morbidity and mortality; however, there is no widely accepted model to predict C. difficile infection severity. Most currently available models perform poorly or were calibrated to predict outcomes that are not clinically relevant.

Introduction: Risk-factors for carbapenemase-producing Enterobacteriales (CPE) acquisition/infection and associated clinical outcomes have been evaluated in the context of clonal, species-specific outbreaks; equivalent analyses for complex, multi-species outbreaks, which are increasingly common, are lacking. Methods: We performed a case-control study of Klebsiella pneumoniae carbapenemase (KPC)-producing organism (KPCO) acquisition using electronic health records from inpatients in a US academic medical center and long-term acute care hospital (LTACH), Dec 2010-Jan 2017, with ongoing multi-species KPCO transmission despite a robust CPE screening program. Cases had a first KPCO-positive culture >48 hours after admission, and included colonisations and infections (defined by clinical records). Controls had ≥2 negative peri-rectal screens and 40 no positive cultures. Risk-factors for KPCO acquisition, first infection following acquisition, and 14-day mortality following each infection episode were identified using multivariable logistic regression. Results: In 303 cases (89 with ≥1 infection) and 5929 controls, risk-factors for KPCO 44 acquisition included: longer inpatient stay, transfusion, complex thoracic pathology, 45 mechanical ventilation, dialysis, and exposure to carbapenems and β-lactam/β-lactamase 46 inhibitors. Exposure to other KPCO-colonised patients was only a risk factor for acquisition in a single unit, suggesting that direct patient-to-patient transmission did not play a major role. There were 15 species of KPCO; 61 (20%) cases were colonised/infected with >1 species. 14 day mortality following non-urinary KPCO infection was 20% (20/97 episodes) and was associated with failure to achieve source control. Conclusions: Healthcare exposures, antimicrobials and invasive procedures increased risk of KPCO colonisation/infection suggesting potential targets for infection control interventions in multi-species outbreaks. Evidence for patient-to-patient transmission was limited.

Objectives:This study was performed to assess whether an intervention for critically appraising influenza vaccine exemption requests from healthcare personnel (HCP) affected (1) the overall rate of influenza vaccine exemption within a healthcare institution and/or (2) the rates of postintervention vaccine acceptance among those who inconsistently request exemption from annual vaccination and those who consistently request exemption from vaccination.Design:Retrospective, before-and-after intervention study.Setting:We conducted the study at a single academic medical center.Participants:This study included 29,663 HCP.Methods:Between 2010 and 2019, HCP were permitted to request an exemption from influenza vaccination without critical appraisal of exemption requests. After January 2019, medical center policy required critical appraisal of exemption requests. Of those employed 3 or more years who requested an exemption at least once during the preintervention period (n = 1,177), those with unchanging exemption reasons annually were termed “consistent exempters.” Those who changed reasons or accepted vaccination n ≥ 1 times were termed “inconsistent exempters.”Results:The overall exemption rate from influenza vaccine decreased from 3.8% to 1.2% (P < .001; N = 29,663) after the intervention. Of those requesting exemption at least once before the intervention, 329 (28.0%) of 1,177 were consistent exempters and 878 (72.0%) were inconsistent exempters. Of inconsistent exempters employed after the intervention, 442 (88.9%) of 497 accepted vaccine postintervention compared with 118 (59.6%) of 198 consistent exempters (P < .001). Of all exempters who changed from exemption to acceptance after the intervention, 442 (78.9%) of 560 were inconsistent exempters.Conclusions:Critical appraisal of HCP exemption requests promotes influenza vaccine acceptance, and acceptance by inconsistent exempters drives the effect of the intervention. Analysis of changes in annual exemption requests represents a novel objective method for describing those on the spectrum of vaccine hesitancy.

Background: The Covid-19 pandemic created critical challenges for hospitals and healthcare providers. Suddenly clinics were forced to close; scheduled visits were cancelled; emergency rooms were overcrowded; hospital beds, equipment and personal protective equipment (PPE) was in short supply; and staff were faced with rapidly changing circumstances, care protocols, trauma and personal risk. In order to better address the ongoing the Covid-19 pandemic and prepare for future pandemics, the National Telemedicine Technology Assessment resource Center (TTAC) was asked to develop an Pandemic Response Action Plan that would allow its user to address critical issues with available telemedicine and related technologies. The project was constructed into three phases: Phase 1. Develop a Pandemic Response Action Plan (this document) and a Policy document which identifies the regulatory challenges in the Pandemic Response as well as policy recommendations (published separately). Phase 2. Publish the plan and policy documents. Phase 3 Look at healthcare providers who used the approaches, tools and technology in the Pandemic Action Plan and document the results (to be published separately). TTAC will also assess selected technology and publish results as part of their normal course of services. Materials and Methods: A multi-disciplinary team was created representing leadership expertise and key stakeholders in healthcare delivery during a pandemic (administration, infection control, physicians, nurses, public health, contingency planning, disaster response, information technology) as well as a facilitator. The group used structured brainstorming, current literature and iterative review to identify the most critical challenges facing healthcare providers during the current Covid 19 pandemic. The team then used structured brainstorming, professional experience and current literature to take a deeper look into these impacts, identify applicable solutions and develop a plan to address the critical challenges using telemedicine and related technologies. Result: A Pandemic Action Response Plan that describes the critical challenges and then identifies approaches, tools and technology to address them as well as identifying samples of the technology. Conclusion: The impact of the Covid 19 Pandemic was severe and identified multiple critical challenges and weaknesses in most healthcare providers. Applying the approaches, tools and technology in this Pandemic Action Plan will help providers address these challenges and increase the capabilities and resilience of their organizations in the provision of care during this and future pandemics.

A 21-year-old man with a history of psychiatric comorbidities, primary vesicoureteral reflux, recurrent pyelonephritis requiring bilateral native nephrectomies, and deceased-donor kidney transplantation at age two experienced few infectious complications for several years after transplant. Both the donor and recipient were seronegative for cytomegalovirus at the time of transplant. A few days after engaging in his first lifetime unprotected sexual contact, receptive anal intercourse with a casual partner, the patient presented to an outside hospital emergency room with burning perianal pain. He denied any history of similar symptoms in the past and also denied any gastrointestinal or systemic symptoms at that time. He reported no previous sexual partners. A superficial swab of perianal ulcers confirmed a diagnosis of HSV-2 by immunofluorescence assay, and the patient was treated with a 10-day course of valacyclovir. Although the patient experienced some improvement in symptoms, residual ulcerative changes persisted at the end of his valacyclovir course, and his painful perianal lesions progressed soon after stopping antiviral therapy. Three weeks later, the patient experienced the new onset of malaise, intermittent fever, morbilliform rash, abdominal discomfort, and voluminous, watery, non-hemorrhagic diarrhea.

On May 9, 2017, the Virginia Department of Health was notified regarding a patient with suspected rabies. The patient had sustained a dog bite 6 weeks before symptom onset while traveling in India. On May 11, CDC confirmed that the patient was infected with a rabies virus that circulates in dogs in India. Despite aggressive treatment, the patient died, becoming the ninth person exposed to rabies abroad who has died from rabies in the United States since 2008. A total of 250 health care workers were assessed for exposure to the patient, 72 (29%) of whom were advised to initiate postexposure prophylaxis (PEP). The total pharmaceutical cost for PEP (rabies immunoglobulin and rabies vaccine) was approximately $235,000. International travelers should consider a pretravel consultation with travel health specialists; rabies preexposure prophylaxis is warranted for travelers who will be in rabies endemic countries for long durations, in remote areas, or who plan activities that might put them at risk for a rabies exposures.

Background Clostridioides difficile is the leading health care–associated pathogen, but clinicians lack a test that can reliably differentiate colonization from infection. Health care costs attributed to C. difficile are substantial, but the economic burden associated with C. difficile false positives is poorly understood. Methods A propensity score matching model for cost per hospitalization was developed to estimate the costs of both true infection and false positives. Predictors of C. difficile positivity used to estimate the propensity score were age, Charlson comorbidity index, white cell count, and creatinine. We used polymerase chain reaction (PCR) cycle threshold to identify and compare 3 groups: (1) true infection, (2) C. difficile colonization, and (3) C. difficile negative. Results A positive test was associated with $3018 higher unadjusted hospital cost. Among the 3 comparisons made with propensity-matched negative controls (all positives [+$179; P = .934], true positives [–$1892; P = .100], and colonized positives), only colonization was associated with significantly increased (+$3418; P = .012) cost. Differences in lengths of stay (all positives 0 days, P = .126; true 0 days, P = .919; colonized 1 day, P = .019) appeared to underly cost differences. Conclusions In the first C. difficile cost analysis to utilize PCR cycle threshold to differentiate colonization, we found high propensity-matched hospital costs associated with colonized but not true positives. This unexpected finding may be due to misdiagnosis of non–C. difficile diarrhea or unadjusted factors associated with colonization.

Evaluation of risk for breakthrough infections in vaccinated solid organ transplant recipients

Background The novel severe acute respiratory coronavirus 2 (SARS-CoV-2) that causes coronavirus disease 2019 (COVID-19) originated in December 2019 and has now infected almost 5 million people in the United States. In the spring of 2020, private laboratories and some hospitals began antibody testing despite limited evidence-based guidance. Methods We conducted a retrospective chart review of patients who received SARS-CoV-2 antibody testing from May 14, 2020, to June 15, 2020, at a large academic medical center, 1 of the first in the United States to provide antibody testing capability to individual clinicians in order to identify clinician-described indications for antibody testing compared with current expert-based guidance from the Infectious Diseases Society of America (IDSA) and the Centers for Disease Control and Prevention (CDC). Results Of 444 individual antibody test results, the 2 most commonly described testing indications, apart from public health epidemiology studies (n = 223), were for patients with a now resolved COVID-19-compatible illness (n = 105) with no previous molecular testing and for asymptomatic patients believed to have had a past exposure to a person with COVID-19-compatible illness (n = 60). The rate of positive SARS-CoV-2 antibody testing among those indications consistent with current IDSA and CDC guidance was 17% compared with 5% (P Conclusions Our findings demonstrate a dissociation between clinician-described indications for testing and expert-based guidance and a significantly different rate of positive testing between these 2 groups. Clinical curiosity and patient preference appear to have played a significant role in testing decisions and substantially contributed to testing costs.

Background Overtesting and overdiagnosis of Clostridioides difficile infection are suspected to be common. Reducing inappropriate testing through interventions designed to promote evidence-based diagnostic testing (ie, diagnostic stewardship) may improve C. difficile test utilization. However, the safety of these interventions is not well understood despite the potential risk for missed or delayed diagnoses. Methods This retrospective case–control study examined the outcomes of patients admitted to the University of Virginia Medical Center following introduction of a computerized clinical decision support tool without hard-stops designed to reduce inappropriate tests. Outcomes were compared between patients with a prevented C. difficile nucleic acid amplification test and those with a negative result. Chart reviews were performed for patients with a subsequent positive within 7 days, as well as those patients who received C. difficile–active antibiotics after implementation of the computerized clinical decision support tool. Results Multivariate analysis of 637 cases (490 negative, 147 prevented) showed that a prevented test was not significantly associated with the primary composite outcome (inpatient mortality or intensive care unit transfer) compared with a negative test (adjusted odds ratio, 0.912; P = .747). Fifty-four of 147 (37%) prevented tests were followed by a completed test within 7 days; 11 of these results were positive, resulting in a potential delay in diagnosis. Individual case reviews found that either clinical changes warranted the delay in testing or no adverse events occurred attributable to C. difficile infection. C. difficile treatment without a positive test was not identified. Conclusions Diagnostic stewardship of C. difficile testing using computerized clinical decision support may be both safe and effective for reducing inappropriate inpatient testing.

Background Overtesting and overdiagnosis of Clostridioides difficile infection are suspected to be common. Reducing inappropriate testing through interventions designed to promote evidence-based diagnostic testing (ie, diagnostic stewardship) may improve C. difficile test utilization. However, the safety of these interventions is not well understood despite the potential risk for missed or delayed diagnoses. Methods This retrospective case–control study examined the outcomes of patients admitted to the University of Virginia Medical Center following introduction of a computerized clinical decision support tool without hard-stops designed to reduce inappropriate tests. Outcomes were compared between patients with a prevented C. difficile nucleic acid amplification test and those with a negative result. Chart reviews were performed for patients with a subsequent positive within 7 days, as well as those patients who received C. difficile–active antibiotics after implementation of the computerized clinical decision support tool. Results Multivariate analysis of 637 cases (490 negative, 147 prevented) showed that a prevented test was not significantly associated with the primary composite outcome (inpatient mortality or intensive care unit transfer) compared with a negative test (adjusted odds ratio, 0.912; P = .747). Fifty-four of 147 (37%) prevented tests were followed by a completed test within 7 days; 11 of these results were positive, resulting in a potential delay in diagnosis. Individual case reviews found that either clinical changes warranted the delay in testing or no adverse events occurred attributable to C. difficile infection. C. difficile treatment without a positive test was not identified. Conclusions Diagnostic stewardship of C. difficile testing using computerized clinical decision support may be both safe and effective for reducing inappropriate inpatient testing.

Preventing infections and the transmission of disease in the radiology environment can be challenging due to the number of patients seen, the amount of equipment in use, and the rapid pace of care delivery in this setting. Hospital-acquired infections pose a threat to patients and are costly to treat. Infection prevention and control strategies mitigate risks to both patients and healthcare workers. Advanced practice nurses can provide leadership in developing a culture of teamwork and safety for both patients and healthcare workers.

Background: Up to half of all new SARS-CoV-2 infections are acquired from presymptomatic or asymptomatic individuals. Hemodialysis patients and healthcare providers (HCPs) may be at increased risk for COVID-19 due to the need for extended close contact. Universal masking and eye protection are strategies used to reduce SARS-CoV-2 exposure, particularly from presymptomatic or asymptomatic individuals. We describe an outbreak of COVID-19 in an outpatient hemodialysis center despite universal masking and universal HCP eye protection. Methods: An COVID-19 outbreak investigation was performed in a hemodialysis center where universal masking was in use by all HCPs and patients and universal eye protection (goggles, safety glasses) was in use by all HCPs when directly encountering patients. After a cluster of cases was identified in early November 2020, all patients and HCPs were tested for SARS-CoV-2 by real-time reverse transcription polymerase chain reaction (RT-PCR) when symptomatic and weekly until the conclusion of the outbreak. Results: From November 12, 2020, through December 7, 2020, 14 (23.3%) of 60 patients and 9 (28.1%) of 32 HCPs tested positive for SARS-CoV-2 by RT-PCR (Figure 1). The median ages of the patients and HCPs were 64 years (range, 42–87) and 42 years (range, 29–68), respectively. Also, 5 (5.4%) individuals (3 patients and 2 HCPs) were asymptomatic at the time of testing. Furthermore, 7 (7.6%) individuals (5 patients and 2 HPCs) were hospitalized; 2 patients and no HCPs died. No lapses in universal masking or, for HCPs, eye protection prior to or during the outbreak were identified during the investigation. All HCPs and patients wore medical-grade face masks that were discarded at the end of the day; HCPs wore safety glasses or goggles during patient interactions. Although audits of face mask and eye protection compliance were not performed, independent interviews supported high HCP and patient adherence prior to the outbreak. Neither the staff nor patients shared meals at or outside the hemodialysis center. Most patients and HCPs shared the same hemodialysis shift, suggesting the presence of an index case; however, a source case could not be identified despite an extensive investigation. Conclusions: Universal masking and eye protection have been shown to reduce transmission of SARS-CoV-2 from presymptomatic or asymptomatic individuals in the healthcare setting. This report suggests that such measures cannot prevent all outbreaks. We speculate that certain factors associated with hemodialysis care, such as prolonged close patient–HCP contact, may have facilitated this outbreak. Whether nonadherence to universal masking and eye protection or failure of empiric droplet precautions contributed to this outbreak remains unknown.Funding: NoDisclosures: None

The West African Ebola virus disease (EVD) epidemic of 2014-2015 required North American hospitals to undertake comprehensive planning and training for the potential need to care for patients with EVD. Here we describe physician contributions to EVD preparedness planning and the care of persons under investigation for or patients with EVD.

Background:Clostridiodes difficile is the leading healthcare-associated pathogen, with significant morbidity associated with acute C. difficile infection (CDI). However, polymerase chain reaction stool testing is unable to differentiate colonization from infection, leading to frequent overdiagnosis, unnecessary iatrogenesis, and additional costs. As a result, IDSA guidelines do not recommend C. difficile testing in patients with diarrheal symptoms attributed to other causes, including laxatives. Our group has previously investigated the use of a computerized clinical decision support (CCDS) tool to reduce inappropriate C. difficile testing in a single tertiary-care health system, with a subsequent 41% reduction in testing. We investigated the reduction in proportion of inappropriately completed tests with the randomized addition of a laxative alert to our existing CCDS. Methods: An existing electronic medical record-based CCDS tool was augmented by the addition of an automatic alert that notified the user if a patient received any of a set of identified laxative medications within 48 hours. During the 78-day pilot period, users encountered the existing CCDS or the CCDS with laxative alert (CCDS-LA), randomized by patient identification number. A proportional χ2 analysis was used to compare the proportion of aborted to completed tests among patients who met laxative criteria in the CCDS versus CCDS-LA groups. Results: In total, 187 test orders were attempted during the pilot period in 119 patients meeting the laxative alert criteria, with 43.3% order attempts randomized to the existing CCDS and 56.7% to the CCDS-LA. Of order attempts via the CCDS-LA, 50.0% were completed, compared to 64.2% of orders completed via the existing CCDS (22.1% relative reduction in test completion; P = .0525). Conclusions: We demonstrated substantially fewer completed C. difficile tests among patients receiving laxatives who were randomized to modified laxative-alert CCDS. Although our result did not reach statistical significance, the trend toward reduced inappropriate testing prompted the CCDS-LA alert to be adopted hospital-wide following completion of the test period. Further analyses of the pre- and postintervention periods are required to determine whether this intervention significantly impacts testing rates over time, as well as to determine the durability and safety of the CCDS-LA. Additional analyses are also needed to assess the impacts on hospital-onset CDI rate and the associated costs.Funding: NoneDisclosures: None

Background:C. difficile is the leading healthcare-associated pathogen. The C. difficile real-time polymerase chain reaction (PCR) stool test, used by >70% of hospitals, is highly sensitive but cannot differentiate colonization from infection. Inappropriate C. difficile testing may result in overdiagnosis and unnecessary treatment. Healthcare costs attributed to C. difficile are substantial, but the economic burden associated with C. difficile false positives in colonized patients is poorly understood. C. difficile PCR cycle threshold (CT) is as an inverse proxy for organism burden; high CT (≥30.9) has a high (>98%) negative predictive value compared to the reference gold standard, thus is a marker of colonization. Conversely, a low CT (≤28.0) suggests high organism burden and high specificity for true infection. Methods: A propensity score matching model for cost per hospitalization was developed to determine the costs of a hospital stay associated with C. difficile and to isolate the financial impacts of both true C. difficile infection and false positives. Relevant predictors of C. difficile positivity used in the model were age, Charlson comorbidity index, white blood cell count, and creatinine. We used CT data to identify and compare 3 inpatient groups: (1) true CDI, (2) C. difficile colonization, and (3) C. difficile negative. Results: A diagnosis of C. difficile adds significantly (>$3,000) to unadjusted hospital cost compared to a negative result. Propensity-adjusted analyses demonstrated that C. difficile colonization was associated with significantly increased (median, $5,000) hospital cost whereas any positive or true diagnoses of C. difficile were not associated with increased cost. Colonized patients also had significantly higher lengths of stay (1 day) and cost per length of stay ($218 per day). Conclusions:This is the first C. difficile cost analysis to utilize PCR CT data to differentiate colonization. Surprisingly, patients with a high CT had disproportionately higher hospital costs compared to matched C. difficile–negative patients, which was not seen among patients with a low CT or with any positive result. We hypothesize that this unexpected finding may be due to misdiagnosis and mistreatment of diarrhea not caused by C. difficile or unadjusted factors associated with high cost and non–C. difficile diarrhea. In addition, the discrepantly high cost attributed to C. difficile diagnosis cited in the literature ($3,000–11,000 per hospitalized case) could be explained by the common use of administrative data to identify C. difficile cases and controls as opposed to our study, which directly linked cost data to C. difficile–positive and –negative test results.Funding: NoneDisclosures: None

Oral streptococcal species are a rare cause of septic arthritis. We describe 4 cases of septic arthritis due to oral streptococcal species following joint injection. The routine use of face masks during joint injection may prevent this rare but serious complication.

BACKGROUND Clostridioides difficile infection (CDI) is a frequent complication of solid organ transplantation, especially in the early post-transplantation period. Overdiagnosis of CDI is likely common in hospitals using nucleic acid amplification testing (NAAT), potentially leading to unnecessary iatrogenesis and cost. Recently, multiple studies have shown that computerized clinical decision support (CCDS)-based interventions can significantly reduce inappropriate C. difficile testing and healthcare facility-onset CDI events across hospitals and health systems. We aimed to determine if a CCDS-based intervention could reduce C. difficile testing and surveillance infection events among recent solid organ transplant recipients, a population at high risk for CDI. We also sought to determine the safety of the CCDS intervention. MATERIAL AND METHODS Quasi-experimental census-adjusted interrupted time-series analyses were performed retrospectively to examine testing and CDI events pre- and post-intervention. Mortality and readmissions rates were also examined. RESULTS A significant 33% relative reduction in tests and a nonsignificant trend towards fewer CDI events were observed following the intervention, without significant differences in mortality or 30-day readmission. A review of patients with positive C. difficile NAATs after prevented tests revealed no specific adverse events attributable to a possible delay in CDI diagnosis. CONCLUSIONS CCDS may be a helpful and safe adjunctive strategy to reduce unnecessary testing in accordance with guideline recommendations among solid organ transplant recipients.

Caenorhabditis elegans can serve as a simple genetic host to study interactions between Legionellaceae and their hosts and to examine the contribution of specific gene products to virulence and immunity. C. elegans nematodes have several appealing attributes as a host organism; they are inexpensive, have robust genetic analysis tools, have a simple anatomy yet display a wide range of complex behaviors, and, as invertebrates, do not require animal ethics protocols. Use of C. elegans as a host model complements cell-based models, providing additional support and consistency of the experimental data obtained from multiple models. The C. elegans innate immune system functions similarly to that of the alveolar macrophage including the apoptosis [a.k.a. programmed cell death (PCD)] pathway located within the germline. The digestive tract of C. elegans is a primary interface between the innate immune system and bacterial pathogens. Thus, the C. elegans host model provides an alternative approach to investigate L. pneumophila immunopathogenesis, particularly in the view of the recent discovery of Legionella-containing vacuoles within the gonadal tissues of Legionella-colonized nematodes supporting the plausible evolutionary origin of the strategies employed by L. pneumophila to counteract macrophage cellular responses.

Background Infections caused by vancomycin-resistant Enterococcus faecium (VRE) are a major cause of morbidity and mortality in the liver transplant population. Daptomycin (DAP) is often used to treat infections caused by VRE, but DAP nonsusceptibility in Enterococcus is increasing. Method Patients with DAP-nonsusceptible Enterococcus (DNSE) infections who had undergone liver transplantation between January 1, 2010 and July 31, 2014 were retrospectively reviewed. A convenience sample of DNSE isolates was analyzed by pulsed-field gel electrophoresis (PFGE). Results We identified 14 liver transplant recipients (LTRs) who developed DNSE infections post transplantation. Postoperative complications were common, and most patients required repeat abdominal surgery within 90 days of transplantation. The initial DNSE culture was taken a median of 74.5 days post transplant and was secondary to an intra-abdominal infection in all but 1 patient. Half of patients were VRE colonized before or at the time of organ transplantation, and all those who were not VRE colonized at the time of transplantation later became colonized, a median of 27 days post transplant. Overall mortality in this cohort was 71%. PFGE did not demonstrate genetic relatedness among DNSE isolates. Conclusion This study, the largest published series to our knowledge of DNSE infections in LTRs, demonstrates that these infections occur in patients with serious surgical complications and are associated with high morbidity and mortality. Established risk factors for VRE infection were common, as was DAP exposure. Although many risk factors for DNSE infection cannot be changed, this case series identifies several potentially modifiable variables. Further work is needed to identify interventions to decrease the risk of developing DNSE infections in this complex patient population.

Background Hemodialysis (HD) patients are at increased risk for contracting hepatitis B (HBV). Special precautions, including patient, staff and equipment segregation, are observed while HBV positive patients undergo dialysis, because standard precautions alone are insufficient to protect patients and staff from HBV exposure during dialysis. Renal staff are familiar with HBV dialysis precautions; however non-renal healthcare teams may not be aware of the need for precautions during dialysis treatments, including continuous renal replacement therapy (CRRT). Methods Existing policies were reviewed and an extensive literature review was performed, including an attempt to identify guidance for HBV dialysis precautions during CRRT. The Inpatient Renal and Infection Prevention & Control teams collaborated on developing policy to address HBV positive patients receiving CRRT or intermittent HD in settings other than a dedicated renal unit and strategies for educating non-renal healthcare personnel. Results No institutional policies addressed HBV dialysis precautions for the CRRT population, and no guidance for HBV infection prevention during CRRT was identified in the literature. A new Clinical Practice Policy was developed to ensure compliance with national regulations in all locations and modalities of renal replacement therapy, including CRRT. House-wide standards and education for HBV dialysis isolation were developed and implemented for non-renal staff. Barriers identified and addressed included how to identify patients requiring HBV dialysis precautions (including HBV serology testing and HBV vaccination workflows), how to apply infection prevention precautions for HBV positive patients receiving CRRT, and how to communicate need for HBV dialysis precautions outside of the renal unit to non-renal healthcare personnel. Conclusions HBV dialysis precautions may be inconsistently applied to inpatient settings other than the renal unit, particularly to patients receiving CRRT. Policy development and educational efforts are required to ensure measures to prevent HBV transmission are extended to all hospitalized patients undergoing intermittent HD or CRRT.

Copper-impregnated surfaces and linens have been shown to reduce infections and multidrug-resistant organism (MDRO) acquisition in healthcare settings. However, retrospective analyses of copper linen deployment at a 40-bed long-term acute-care hospital demonstrated no significant reduction in incidences of healthcare facility-onset Clostridium difficile infection or MDRO acquisition.

PURPOSE OF REVIEW: Chlorhexidine gluconate (CHG) and mupirocin are increasingly used for Staphylococcus aureus decolonization to prevent healthcare-associated infections; however, increased use of these agents has led to concerns for growing resistance and reduced efficacy. In this review, we describe current understanding of reduced susceptibility to CHG and mupirocin in S. aureus and their potential clinical implications. RECENT FINDINGS: While emergence of S. aureus tolerant or resistant to topical antimicrobial agents used for decolonization is well described, the clinical impact of reduced susceptibility is not clear. Important challenges are that standardized methods of resistance testing and interpretation are not established, and the risk for selection for co- or cross-resistance using universal, as opposed to targeted decolonization, is unclear. SUMMARY: Evidence continues to support S. aureus decolonization in certain patient groups, although further studies are needed to determine the long-term impact of CHG and mupirocin resistance on efficacy. Strategies to mitigate further development of reduced susceptibility and the consequences of selection pressures through universal decolonization on resistance will benefit from further investigation.

We hypothesized that a computerized clinical decision support tool for Clostridium difficile testing would reduce unnecessary inpatient tests, resulting in fewer laboratory-identified events. Census-adjusted interrupted time-series analyses demonstrated significant reductions of 41% fewer tests and 31% fewer hospital-onset C. difficile infection laboratory-identified events following this intervention.Infect Control Hosp Epidemiol 2018;39:737–740

Diagnostic stewardship is an increasingly recognized means to reduce unnecessary tests and diagnostic errors. As a leading cause of healthcare-associated infection for which accurate laboratory diagnosis remains a challenge, Clostridium difficile offers an ideal opportunity to apply the principles of diagnostic stewardship. The recently updated 2017 Infectious Diseases Society of America (IDSA)-Society for Healthcare Epidemiology of America (SHEA) Clinical Practice Guidelines for C. difficile infection now recommend separate diagnostic strategies depending on whether an institution has adopted diagnostic stewardship in test decision making. IDSA-SHEA endorsement of diagnostic stewardship for C. difficile highlights the increasing role of diagnostic stewardship in hospitals. In this opinion piece, we introduce the concept of diagnostic stewardship by discussing the new IDSA-SHEA diagnostic recommendations for laboratory diagnosis of C. difficile. We outline recent examples of diagnostic stewardship, challenges to implementation, potential downsides and propose future areas of study.

The outcomes and optimal management of cirrhotic patients who develop cryptococcosis before transplantation are not fully known.We conducted a multicenter study involving consecutive patients with cirrhosis and cryptococcosis between January 2000 and March 2014. Data collected were generated as standard of care.In all, 112 patients were followed until death or up to 9 years. Disseminated disease and fungemia were present in 76.8% (86/112) and 90-day mortality was 57.1% (64/112). Of the 39 patients listed for transplant, 20.5% (8) underwent liver transplantation, including 2 with active but unrecognized disease before transplantation. Median duration of pretransplant antifungal therapy and posttransplant therapy was 43 days (interquartile range, 8-130 days) and 272 days (interquartile range, 180-630 days), respectively. Transplantation was associated with lower mortality (P = 0.002). None of the transplant recipients developed disease progression during the median follow-up of 3.5 years with a survival rate of 87.5%.Cryptococcosis in patients with cirrhosis has grave prognosis. Our findings suggest that transplantation after recent cryptococcal disease may not be a categorical exclusion and may be cautiously undertaken in liver transplant candidates who are otherwise deemed clinically stable.

Background The increasing prevalence of nosocomial carbapenemase-producing Enterobacteriaceae is a concern. However, the role of the environment in multispecies outbreaks remains poorly understood. There is increasing recognition that hospital wastewater plumbing may play a role. Methods Covers were installed on all hoppers (a "toilet-like" waste disposal system) in adult intensive care units (ICUs) of a university hospital; additionally in the surgical ICU, sink trap heating and vibration devices were also installed. Patient acquisitions of Klebsiella pneumoniae carbapenemase–producing organisms (KPCOs) for patients who were admitted to an intervention unit were compared for 18-month preintervention and intervention periods. Results Sixty hopper covers and 23 sink trap devices were installed. Fifty-six new multispecies KPCO acquisitions occurred preintervention compared to 30 during the intervention. Decreases for all KPCO acquisitions (odds ratio [OR], 0.51; 95% confidence interval [CI], 0.31–0.81; P = .003) and KPCO-positive clinical cultures (OR, 0.29; 95% CI, 0.17–0.48; P < .001) per admission in patients exposed to an intervention unit were observed. The incidence rate ratio was 0.51-fold (95% CI, 0.43–0.61) lower for all KPCO acquisitions during the intervention. The effect of the sink trap devices alone could not be determined, although the proportion of sink drain cultures positive for KPCO decreased (12/15 [80%] sites sampled preintervention vs 40/840 [5%] sampled during the intervention; P = .001). Conclusions An intervention targeting wastewater plumbing fixtures, by installation of hopper covers, demonstrated a decrease in patient KPCO acquisitions. Considering wastewater reservoirs in nosocomial transmission of multispecies carbapenemase-producing Enterobacteriaceae may be critical.

Contains fulltext : 177987.pdf (Publisher’s version ) (Open Access) BACKGROUND: Antimicrobial Stewardship Programs (ASPs) have been promoted to optimize antimicrobial usage and patient outcomes, and to reduce the emergence of antimicrobial-resistant organisms. However, the best strategies for an ASP are not definitively established and are likely to vary based on local culture, policy, and routine clinical practice, and probably limited resources in middle-income countries. The aim of this study is to evaluate structures and resources of antimicrobial stewardship teams (ASTs) in surgical departments from different regions of the world. METHODS: A cross-sectional web-based survey was conducted in 2016 on 173 physicians who participated in the AGORA (Antimicrobials: A Global Alliance for Optimizing their Rational Use in Intra-Abdominal Infections) project and on 658 international experts in the fields of ASPs, infection control, and infections in surgery. RESULTS: The response rate was 19.4%. One hundred fifty-six (98.7%) participants stated their hospital had a multidisciplinary AST. The median number of physicians working inside the team was five [interquartile range 4-6]. An infectious disease specialist, a microbiologist and an infection control specialist were, respectively, present in 80.1, 76.3, and 67.9% of the ASTs. A surgeon was a component in 59.0% of cases and was significantly more likely to be present in university hospitals (89.5%, p < 0.05) compared to community teaching (83.3%) and community hospitals (66.7%). Protocols for pre-operative prophylaxis and for antimicrobial treatment of surgical infections were respectively implemented in 96.2 and 82.3% of the hospitals. The majority of the surgical departments implemented both persuasive and restrictive interventions (72.8%). The most common types of interventions in surgical departments were dissemination of educational materials (62.5%), expert approval (61.0%), audit and feedback (55.1%), educational outreach (53.7%), and compulsory order forms (51.5%). CONCLUSION: The survey showed a heterogeneous organization of ASPs worldwide, demonstrating the necessity of a multidisciplinary and collaborative approach in the battle against antimicrobial resistance in surgical infections, and the importance of educational efforts towards this goal.

Diarrhea is a common condition after solid organ transplant (SOT); Clostridium difficile-associated colitis (CDAC) is one of the most common infections after SOT. We documented previously that some types of enteritis are associated with an elevation of tacrolimus (TAC) trough concentrations by interfering with the drug's complex metabolism.Tacrolimus concentrations of 25 SOT recipients including 12 renal and 13 liver recipients before, during, and after CDAC were analyzed retrospectively.Median age of the 25 patients was 54 y (range, 36-71), there were 15 males and 10 females. Clostridium difficile-associated colitis developed at a median of 55 d (range 2-4551) post-SOT. Median TAC concentrations prior to the outbreak of CDAC were 6.9 ng/mL (range,1.5-17.2), 5.6 ng/mL (range,1.5-13.2) during diarrhea, and 7.4 ng/mL (range,1.5-24.3) after resolution of diarrhea (p 0.05, NS). Treatment of CDAC consisted of metronidazole for 14 d in all cases. All patients recovered from CDAC but seven patients had CDAC relapse.In contrast to other types of infectious diarrhea such as rotavirus enteritis and cryptosporidiosis, CDAC is not associated with an increase in TAC concentrations. This is because C. difficile causes primarily colitis as opposed to other organisms, which are associated with enteritis.

The Klebsiella pneumoniae carbapenemase gene ( bla KPC ) is typically located within mobile transposon Tn 4401 . Enhanced KPC expression has been associated with deletions in the putative promoter region upstream of bla KPC . Illumina sequences from bla KPC -positive clinical isolates from a single institution were mapped to a Tn 4401 b reference sequence, which carries no deletions. The novel isoform Tn 4401 h (188-bp deletion [between istB and bla KPC ]) was present in 14% (39/281) of clinical isolates. MICs showed that Escherichia coli strains containing plasmids with Tn 4401 a and Tn 4401 h were more resistant to meropenem (≥16 and ≥16, respectively), ertapenem (≥8 and 4, respectively), and cefepime (≥64 and 4, respectively) than E. coli strains with Tn 4401 b (0.5, ≤0.5, and ≤1, respectively). Quantitative real-time PCR (qRT-PCR) demonstrated that Tn 4401 a had a 16-fold increase and Tn 4401 h a 4-fold increase in bla KPC mRNA levels compared to the reference Tn 4401 b. A lacZ reporter plasmid was used to test the activity of the promoter regions from the different variants, and the results showed that the Tn 4401 a and Tn 4401 h promoter sequences generated higher β-galactosidase activity than the corresponding Tn 4401 b sequence. Further dissection of the promoter region demonstrated that putative promoter P1 was not functional. The activity of the isolated P2 promoter was greatly enhanced by inclusion of the P1-P2 intervening sequence. These studies indicated that gene expression could be an important consideration in understanding resistance phenotypes predicted by genetic signatures in the context of sequencing-based rapid diagnostics.

Background Antimicrobial Stewardship Programs (ASPs) have been promoted to optimize antimicrobial usage and patient outcomes, and to reduce the emergence of antimicrobial-resistant organisms. However, the best strategies for an ASP are not definitively established and are likely to vary based on local culture, policy, and routine clinical practice, and probably limited resources in middle-income countries. The aim of this study is to evaluate structures and resources of antimicrobial stewardship teams (ASTs) in surgical departments from different regions of the world. Methods A cross-sectional web-based survey was conducted in 2016 on 173 physicians who participated in the AGORA (Antimicrobials: A Global Alliance for Optimizing their Rational Use in Intra-Abdominal Infections) project and on 658 international experts in the fields of ASPs, infection control, and infections in surgery. Results The response rate was 19.4%. One hundred fifty-six (98.7%) participants stated their hospital had a multidisciplinary AST. The median number of physicians working inside the team was five [interquartile range 4–6]. An infectious disease specialist, a microbiologist and an infection control specialist were, respectively, present in 80.1, 76.3, and 67.9% of the ASTs. A surgeon was a component in 59.0% of cases and was significantly more likely to be present in university hospitals (89.5%, p

Carbapenemase genes in Enterobacteriaceae are mostly described as being plasmid associated. However, the genetic context of carbapenemase genes is not always confirmed in epidemiological surveys, and the frequency of their chromosomal integration therefore is unknown. A previously sequenced collection of bla KPC -positive Enterobacteriaceae from a single U.S. institution (2007 to 2012; n = 281 isolates from 182 patients) was analyzed to identify chromosomal insertions of Tn 4401 , the transposon most frequently harboring bla KPC . Using a combination of short- and long-read sequencing, we confirmed five independent chromosomal integration events from 6/182 (3%) patients, corresponding to 15/281 (5%) isolates. Three patients had isolates identified by perirectal screening, and three had infections which were all successfully treated. When a single copy of bla KPC was in the chromosome, one or both of the phenotypic carbapenemase tests were negative. All chromosomally integrated bla KPC genes were from Klebsiella spp., predominantly K. pneumoniae clonal group 258 (CG258), even though these represented only a small proportion of the isolates. Integration occurred via IS 15 -ΔI-mediated transposition of a larger, composite region encompassing Tn 4401 at one locus of chromosomal integration, seen in the same strain ( K. pneumoniae ST340) in two patients. In summary, we identified five independent chromosomal integrations of bla KPC in a large outbreak, demonstrating that this is not a rare event. bla KPC was more frequently integrated into the chromosome of epidemic CG258 K. pneumoniae lineages (ST11, ST258, and ST340) and was more difficult to detect by routine phenotypic methods in this context. The presence of chromosomally integrated bla KPC within successful, globally disseminated K. pneumoniae strains therefore is likely underestimated.

Solid organ transplant (SOT) recipients carry a high risk of developing Clostridium difficile-associated colitis (CDAC) and an increased risk for recurrence. Between December 1996 and September 2007, a total of 227 patients with CDAC were identified when querying our institutional surgical infection database. This included 169 nontransplant patients and 58 SOT recipients, including 1 cardiac, 19 renal, 2 pancreas, 5 renal/pancreas, and 31 liver recipients. Overall, we recorded 556 infectious episodes at any site in the 227 patients analyzed who eventually developed CDAC (2.4 episodes/patient); the total number of CDAC episodes was 255: 204 patients had a single episode and 23 patients had multiple episodes of CDAC. There were 19 patients with two episodes, 3 with three episodes, and 1 with four episodes. Of the 23 patients with recurrent CDAC, 11 (48 %) were SOT recipients. A total of 19 % of SOT recipients had recurrent CDAC as compared with only 7 % for nontransplant patients (p = 0.0197). Time to first CDAC recurrence was a median of 58 (range, 17–1372) days for SOT recipients and a median of 30 (range, 6–108) days for nontransplant patients (p = 0.047). SOT recipients at our institution were found to be a high-risk group for CDAC and had an almost threefold risk for recurrent disease. Double-drug coverage, extended application of metronidazole, and profound reduction in the level of immunosuppression may help to cope with this emerging problem.

ObjectiveWe describe the efficacy of enhanced infection control measures, including those recommended in the Centers for Disease Control and Prevention’s 2012 carbapenem-resistant Enterobacteriaceae (CRE) toolkit, to control concurrent outbreaks of carbapenemase-producing Enterobacteriaceae (CPE) and extensively drug-resistantAcinetobacter baumannii(XDR-AB).DesignBefore-after intervention study.SettingFifteen-bed surgical trauma intensive care unit (ICU).MethodsWe investigated the impact of enhanced infection control measures in response to clusters of CPE and XDR-AB infections in an ICU from April 2009 to March 2010. Polymerase chain reaction was used to detect the presence ofblaKPCand resistance plasmids in CRE. Pulsed-field gel electrophoresis was performed to assess XDR-AB clonality. Enhanced infection-control measures were implemented in response to ongoing transmission of CPE and a new outbreak of XDR-AB. Efficacy was evaluated by comparing the incidence rate (IR) of CPE and XDR-AB before and after the implementation of these measures.ResultsThe IR of CPE for the 12 months before the implementation of enhanced measures was 7.77 cases per 1,000 patient-days, whereas the IR of XDR-AB for the 3 months before implementation was 6.79 cases per 1,000 patient-days. All examined CPE shared endemicblaKPCresistance plasmids, and 6 of the 7 XDR-AB isolates were clonal. Following institution of enhanced infection control measures, the CPE IR decreased to 1.22 cases per 1,000 patient-days (P= .001), and no more cases of XDR-AB were identified.ConclusionsUse of infection control measures described in the Centers for Disease Control and Prevention’s 2012 CRE toolkit was associated with a reduction in the IR of CPE and an interruption in XDR-AB transmission.

Background A one-step skin disinfection method containing 2% chlorhexidine-gluconate (CHG) and 70% isopropyl alcohol (IPA) is currently used by blood suppliers worldwide. Reports of bacterially contaminated platelet concentrates (PCs) indicate that skin disinfection is not fully effective. Approximately 20% of skin microflora exist as surface-attached aggregates (biofilms), known for displaying increased resistance to disinfectants. This study was aimed at determining whether skin microflora biofilm-positive Staphylococcus epidermidis and Staphylococcus capitis are resistant to CHG and/or IPA. Study Design and Methods Free-floating cells and mono or dual (1 : 1 ratio) biofilms of S. epidermidis and S. capitis were exposed to CHG, IPA, or CHG/IPA for 30 seconds, simulating skin disinfection practices. Residual viable cells were quantified by colony counting. Morphology of disinfectant-treated S. epidermidis biofilms was examined by scanning electron microscopy. Treated S. epidermidis and S. capitis biofilms were inoculated into PCs and bacterial concentrations were determined on Days 0 and 5 of storage. Results Treatment of staphylococcal biofilm cells with all disinfectants caused cell damage and significant reduction in viability, with CHG/IPA being the most effective. However, biofilms were significantly more resistant to treatment than free-floating cells. Disinfectant-treated S. epidermidis proliferated better in PCs than S. capitis, especially when grown as monospecies biofilms. Conclusion Although CHG/IPA is effective in reducing the viability of S. epidermidis and S. capitis biofilms, these organisms are not completely eliminated. Furthermore, disinfectant-treated staphylococcal biofilms multiply well in PCs. These results demonstrate that the biofilm-forming capability of the skin microflora reduces the bactericidal efficiency of blood donor skin disinfectants.

The Klebsiella pneumoniae carbapenemase-producing Klebsiella pneumoniae (KPC-KP) sequence type (ST)-258/512 clone is the dominant clone by which KPC has disseminated worldwide. Standard typing methods are time-consuming and are therefore impractical for identification of this clone in the course of an outbreak. Through comparative genomic study, we have previously identified several presumably unique genes of this clone: 1) PILV-like protein (pilv-l), 2) transposase, IS66-family (is-66), and a 3) phage-related protein (prp). Our aims were to 1) test for the presence of these genes using a multiplex PCR in a large, multinational collection of KPC-KP isolates and to 2) validate this assay as a typing method for the identification of the ST-258/512 clone. KPC-KP isolates (n=160) that included both ST-258/512 (group A, n=114) and non-ST-258 (group B, n=46) strains were collected from the following countries: Greece, 20; Israel, 93; Italy, 19; USA, 25; and Colombia, 3. Group B included 30 different STs from various lineages. The pilv-l gene was present in 111/114 of ST-258 isolates, including all of the KPC-negative isolates resulting in a sensitivity of 97%. Using primers for a unique ST-258 pilv-l allele resulted in a specificity of 100%. The sensitivity values of is-66 and prp genes for detecting KPC-KP ST-258 were 83 and 89%, respectively, and the specificity values were 67 and 93%, respectively. PCR for the unique pilv-l ST-258 allele provides a reliable tool for rapid detection of the ST-258 clone. This method can be helpful both in the setting of an outbreak and in a large-scale survey of KPC-KP strains.