Search

Tribolium castaneum, a red flour beetle is now-a-days used as a sophisticated model system for the development and evolutionary studies. As its mode of development is more insect typical than that of Drosophila, Tribolium has become a well-known subject for studies of the evolution of development while both are holometabolous. Insect life-histories show adaptations to withstand cold and dry conditions. The holometabolous group has distinct larval and pupal stages and undergoes some of the most complex transformations seen in animal kingdom. Key words : Tribolium castaneum, weight, protein, variation REFERENCES Abrams, J.M. (1999), An emerging blueprint for apoptosis in Drosophila, Trends Cell Biol. 9, 435-440. Ashok, M., Dutta-Gupta, A. (Ray) (1988), Ecdysteroid mediated fat body acid phosphatase activity during larval development of rice moth, Corcyra cephalonica (Lepidoptera). Biochem Int. 17, 1087-1091. Brown, S.J., Parrish, J.K., Denell, R.E., Beeman. R.W., (1994). Genetic control of early embryogenesis in the red flour beetle, Tribolium castaneum. Am Zool. 34:343-352 Burmester, T., Scheller, K. (1997a), Developmentally controlled cleavage of Calliphora arylphorins receptor and post-translational action of the steroid hormone 20-hydroxyecdysone. Eur. J. Biochem. 247, 695-702. Burmester, T., Scheller, K. (1999), Ligand and receptors: common theme in insect storage protein transport. Naturwissenchften, 86, 468-474. Bradford, M. (1976) A rapid and sensitive method for the quantization of microgram quantities of protein utilizing the principle of protein dye-binding. Anal. Biochem. 72: 248–254. Chung, S.O., Kubo, T., Natori, S. (1995). Molecular cloning and sequencing of arylphorins binding protein in protein granules of the Sarcophaga fat body. J. Biol. Chem. 270, 4624-4631. Numbers of living species in Australia and the World. Canberra: Australian Biological Resources Study. pp.60pp. ISBN978-0-642-568502. Henrich et al., 1999; Riddiford etal., 2001, Verkuil, E.V.P. (1979), Hormone mediated induction of acid phosphatase activity in the fat body of Calliphora erythrocephala prior to metamorphosis. J. Insect Physiol. 25, 965-973. Haas, M.S., Brown, S.J., Beeman, R.W., (2001) Homeotic evidence for the appendicular origin of the labrum in Tribolium castaneum. Dev Genes Evol. 211:96-102. Ismail, S. M., Dutta- Gupta, A. (1990a). Effect of 20-Hydroxyecdysone and inhibitors on the protein synthesis in male accessory reproductive glands of Chilo partellus. Biochem. Arch. 6,321-329. Lawrence, D. (2005). Biomass accumulation after 10–200 years of shifting cultivation in Bornean rainforest. Ecology 86: 26–33. Lee, Y.L., Bachriecke, E.H. (2001). Steroid regulation of autophagic programmed cell death during development. Development 128, 1443-1451. Thumnel 2001). Lockshin, R.A., Beaulton, J. (1974) Programmed cell death. Cytochemical evidence for lysosomes during the normal breakdown of the intersegmental muscles. J. Ultrastuct. Res., 46 : 43-62Dean 1978; Sass and Kovacs 1975, 1977, 1980 Lorenzen, M.D., Brown, S.J., Denell, R.E., Beeman, R.W., (2002). Cloning and characterization of the Tribolium castaneum eye-color genes encoding tryptophan oxygenase and kynurenine 3-monooxygenase. Genetics 160: 225-234. Majid Shafiei, A., Mo Czek, Frderiknijhout, H. (2001), Food availability controls the onset of metamorphosis in the dung beetle Onthophagus taurus (Coleoptera: Scarabaeidae), Physiological Entomology 26, 173-180 Ray, A., Memmel, N.A., Kumaran, A.K. (1987a). Developmental regulation of the larval hemolymph protein genes in Galleria mellonella. Roux’s Arch. Dev. Biol., 196, 414-420. Ray, A., Memmel, N.A., Orcheknowski, R.P., Kumaran, A.K. (1987b). Isolation of two cDNA clones coding for larval haemolymph proteins of Galleria mellonella. Insect Biochem. 17, 603-617. Sass, M., Kovacs, J. (1980). The effect of actinomycin D, cycloheximide and puromycin on 20-hydroxyecdysone induced autophagocytosis in larval fat body cells of Pieris brassicae. J. Insect Physiol. 180, 569-577 Sass, M., Komuves, L., Csikos, G., Kovacs, J. (1989). Changes in the activities of lysosomal enzymes in the fat body and mid gut of two lepidopteran insects (Mamestra brassicae and pieris brassicae) during metamorphosis. Comp. Biochem. Physiol. 92A, 285-289. Sehnal, F., Svacha, P., Zrzavy, J. (1996). Evolution of insect metamorphosis. In “Metamorphosis: postembryonic reprogramming of gene expression in amphibian and insect cells”. (Eds. Gilbert L.I., Tata J.R., Atkinson H.G)., pp.3-58, Academic Press, San Diego. Shippy, T. D., J. Guo, S. J. Brown, R. W. Beeman, M. S. Haas, (2000b). Analysis of maxillopedia expression pattern and larval cuticular phenotypes of wild-type and mutant Tribolium. Genetics. 155, 721-731.Sulston and Anderson, 1998; Wade and Beeman, 1994). Sridevi, R. Bajaj, P., Dutta-Gupta, A. (Ray). (1988a) Ecdysteroid stimulated protein synthesis in the male accessory reproductive glands of Spodoptera litura. Int. J. Invert. Rep. Dev. 14, 177-186. Sridevi, R., Ray, A., Ramamurty, P.S. (1988b) 20-hydroxyecdysone stimulated DNA synthesis in early larval testes of Spodoptera litura. Int. J. Invert. Rep. Dev. 13, 199-201. Shanavas, A., Nayak, B.P., Dutta-Gupta, A. (1996). Ecdysteroid mediated muscle actin synthesis during the larval development of rice moth, Corcyra cephalonica. Biochem. Mol. Biol. Int. 40, 955-963. Scheller, K, Karlson, P., (1977). Effects of ecdysteroids on RNA synthesis of fat body cells in Calliphora vicina. J. Insect Physiol. 23, 285-291. Schenkel, H., Scheller, K. (1986). Stage and tissue specific expression of the genes encoding calliphorin, the major larval serum proteins of calliphora. Roux’s Arch. Dev. Biol. 195, 290-295. Tomaschko, K.H. (1999) Nongenomic effects of ecdysteroids. Arch. Insect Biochem. Physiol. 41, 89-98. Truman, J.W. (1996) Steroid receptors and nervous system metamorphosis in insects. Dev. Nunrosci. 18, 87-101. Truman, J.W., Riddiford, L.M, (1999) The origin of insect metamorphosis. Nature 401, 447-452. Ueno, K., Ohsawa, F., Natori, S. (1983) Identification and activation of storage protein receptor of Sarcophaga peregrine fat body by 20-hydroxyecdysone. J. Biol. Chem. 258, 12210-12211. Ueno, K., Natori, S., (1984) Identification of storage protein receptor and its precursor in the fat body membrane of Sarcophaga peregrine. J. Biol. Chem. 259, 12107-12111. Verkuil, E.V.P. (1979), Hormone mediated induction of acid phosphatase activity in the fat body of Calliphora erythrocephala prior to metamorphosis. J. Insect Physiol. 25, 965-973. Verkuil, E.V.P. (1980) The induction of lysosomal enzyme activity in the fat body of Calliphora erythrocephala: Changes in the internal environment. J. Insect Physiol. 26, 91-101. Verkuil, E.V.P., van Ronger, E., de Priester, W. (1979) Normal and experimentally induced lysosomal activity in fat body cell of Calliphora erythrocephala meigen. Cell. Tiss. Res., 203, 443-445. &nbsp

BackgroundAn academic safety-net hospital leveraged the federally funded state Delivery System Reform Incentive Payment programme to implement a hospital-wide initiative to reduce healthcare-associated infections (HAIs) and improve sepsis care.MethodsThe study period was from 2013 to 2017. The setting is a 770-bed urban hospital with six intensive care units and a large emergency department. Key interventions implemented were (1) awareness campaign and clinician engagement, (2) implementation of HAI and sepsis bundles, (3) education of clinical personnel using standardised curriculum on bundles, (4) training of key managers, leaders and personnel in quality improvement methods, and (5) electronic medical record-based clinical decision support. Throughout the 5-year period, staff received frequent, clear, visible and consistent messages from leadership regarding the importance of their participation in this initiative, performing hand hygiene and preventing potential regulatory failures. Several process measures including bundle compliance, hand hygiene and culture of safety were monitored. The primary outcomes were rates of central line-associated bloodstream infection (CLABSI), catheter-associated urinary tract infection (CAUTI), surgical site infection (SSI) and sepsis mortality.ResultsFrom 2013 to 2017, the hospital-wide rates of HAI reduced: CLABSI from 1.6 to 0.8 per 1000 catheter-days (Poisson regression estimate: −0.19; 95% CI −0.29 to −0.09; p=0.0002), CAUTI from 4.7 to 1.3 per 1000 catheter-days (−0.34; −0.43 to −0.26; pConclusionA hospital-wide initiative incentivised by the Delivery System Reform Incentive Payment programme succeeded in reducing HAI and sepsis mortality over 5 years in a sustainable manner.

This chapter is an overview of types of harm in healthcare and how patient safety is approached in hospitals and healthcare systems. Person-level strategies and organization-level strategies to improve patient safety are discussed. The chapter closes with a call to action for patients, professionals in healthcare, policymakers, payers, and the public.

BACKGROUND Little is known about population-level sexually transmitted disease (STD) testing in emergency departments (EDs). We sought to explore STD testing patterns in EDs in a large, urban metroplex in North Texas, a high prevalence region. METHODS Emergency department claims data were extracted from the Dallas Fort Worth Hospital Council databank for patients attending 54 EDs in 4 counties (Dallas, Tarrant, Collin, and Denton) who were tested for an STD during an ED visit between July 2014 and June 2015. We analyzed patterns of testing for 3 types of STD tests: (1) combined gonorrhea and chlamydia DNA-based tests, (2) human immunodeficiency virus (HIV) antibody tests, and (3) syphilis serological tests. RESULTS Emergency departments administered at least 1 STD test to 65,702 unique patients over 1 year; most were ethnoracial minorities (73%), female (72%), and had no known insurance (59%). Only 8% of patients received more than 1 of these tests at that same visit; of those, 90% were cotested for HIV. The most common diagnosis code associated with STD testing was "genital/urinary symptoms" (31%). The majority of tests took place at the ED of a single county-funded hospital (42%). Only 36% of all patients had visits that were deemed true emergencies. CONCLUSIONS Most patients tested for syphilis, HIV, or chlamydia/gonorrhea in EDs received only 1 test type at that visit, and most visits were nonemergent in nature. Given shared risk factors for multiple STD and high coinfection rates, EDs serving high-risk populations could consider STD cotesting to help reduce transmission of undiagnosed, untreated infections.

Background: In the setting of global warming, natural disasters are increasing in pace and scope. Although natural disasters themselves do not cause outbreaks, the breakdowns in sanitary infrastructure and the displacement of populations, often to crowded shelters, have caused outbreaks. On August 26, 2017, category 4 hurricane Harvey made landfall near Corpus Christi, Texas, causing catastrophic flooding and displacing >30,000 residents from the Southern Gulf Coast region. Dallas accepted >3,800 evacuees at the Kay Bailey Hutchison Convention Center mega-shelter for 23 days, where a medical clinic was erected in the convention center parking garage. The medical clinic uniquely included a dedicated infection prevention team composed of local volunteer infection preventionists, healthcare epidemiologists, infectious diseases providers, and health department personnel. Methods: Evacuees were housed at the Dallas mega-shelter from August 29 through September 20. The infection prevention team maintained a presence of 3–4 members during clinical operations in shifts. The team conducted an initial needs assessment upon opening of the shelter medical clinic, facilitated acquisition of adequate numbers of hand sanitizer stations, sinks with running water, portable hand-washing stations, portable toilets and showers, and cleaning products. The infection prevention team coordinated and oversaw environmental cleaning services (EVS) carried out by local hospital EVS staff. Protocols for cleaning, disinfection, communicable disease testing, isolation, and treatment were created. In addition, education and training materials for the implementation of these protocols were distributed to volunteer staff. The infection preventionists created and provided oversight of the designated isolation units for respiratory, gastrointestinal and dermatologic infections of outbreak potential. Infection prevention rounding tools were developed and executed daily in the clinic, at the on-site daycare center, dining area, and the general shelter dormitory. Vaccination for influenza was formalized under a protocol and administered at the clinic and via mobile vaccination teams in the chronic illness section of the dormitory. Results: In tota3,829 residents were housed at the mega-shelter for 23 days. Moreover, 1,560 patients were seen in 2,654 clinic visits at the shelter medical clinic. In total, 48 (19%) clinic visits were for respiratory symptoms, 228 (9%) were for dermatologic problems, and 215 (8%) were for gastrointestinal symptoms. Also, 32 patients were referred to the isolation unit within the clinic. Overall, 98 influenza vaccines were administered. There was 1 confirmed case of influenza and 1 confirmed case of norovirus. Conclusions: No known transmission of communicable diseases occurred in this long-term, natural disaster–related mega-shelter, likely attributed to having a comprehensive infection prevention team of on-site volunteers available throughout the shelter operation. This model should be considered in future large-scale shelter settings to prevent disease transmission.Disclosures: NoneFunding: None

Background:Mycobacterium tuberculosis (TB) is one of the leading causes of morbidity and mortality worldwide. At our health system, 50–100 patients are diagnosed with tuberculosis every year. One risk factor for TB is residence within a homeless shelter. In response to an increased number of cases in local homeless shelters, the health department sought assistance with contact tracing of individuals potentially exposed to tuberculosis. We report the results of contact tracing performed at our health system. Methods: The setting is a 770-bed, safety-net, academic hospital with community clinics and a correctional health center. Name, date of birth, and social security number of contacts potentially exposed during February 2009 to July 2013 were programmed into the electronic medical records to create a decision support tool upon entering the health system. The best practice alert (BPA) informed physicians of the exposure and offered a link to a screening test, T-spot.TB, and a link to an information sheet. This intervention was implemented from July 2013 to July 2015. After excluding patients with active TB, data on the magnitude of exposure in each homeless shelter and screening test results were analyzed with ANOVA using SPSS v 26 software. Results: Of the 8,649 identified exposed contacts, 2,118 entered our health system. Of those for whom the BPA was triggered, 1,117 had a T-spot.TB done, with 313 positive results and 57 borderline results. Table 1 shows that shelter 3 was correlated with a positive T-spot.TB. Conclusions: The BPA, which prompted physicians to evaluate an individual for TB, was effective at capturing high-risk, exposed individuals. Clinical decision support tools enabled our safety-net health system to respond effectively to a local public health need.Funding: NoneDisclosures: None

Background Health care–associated infections (HAIs) are a socio-technical problem. We evaluated the impact of a social change intervention on health care personnel (HCP), called “positive deviance” (PD), on patient safety culture related to infection prevention among HCP. Methods This observational study was done in 6 medical wards at an 800-bed public academic hospital in the United States. Three of these wards were randomly assigned to receive PD intervention on HCP. After a retrospective 6-month baseline period, PD was implemented over 9 months, followed by 9 months of follow-up. Patient safety culture and social networks among HCP were surveyed at 6, 15, and 24 months. Rates of HAI were measured among patients. Results The measured patient safety culture was steady over time at 69% aggregate percent positive responses in wards with PD vs decline from 79% to 75% in wards without PD (F statistic 10.55; P = .005). Social network maps suggested that nurses, charge nurses, medical assistants, ward managers, and ward clerks play a key role in preventing infections. Fitted time series of monthly HAI rates showed a decrease from 4.8 to 2.8 per 1000 patient-days (95% confidence interval [CI], 2.1 to 3.5) in wards without PD, and 5.0 to 2.1 per 1000 patient-days (95% CI, –0.4 to 4.5) in wards with PD. Conclusions A positive deviance approach appeared to have a significant impact on patient safety culture among HCP who received the intervention. Social network analysis identified HCP who are likely to help disseminate infection prevention information. Systemwide interventions independent of PD resulted in HAI reduction in both intervention and control wards.

Background Pseudomonas aeruginosa infection can lead to morbidity, mortality and increased hospital length of stay especially in Burn Intensive Care Units (BICU) patients. Reports of multi-drug-resistant Pseudomonas aeruginosa outbreaks in the BICU are increasing. We investigated the epidemiology of Carbapenem-Resistant Pseudomonas aeruginosa (CRPA) in our BICU. Methods Clinical and laboratory characteristics of all CRPA isolates identified between 5/8/16 and 3/14/19, in an 11-bed BICU in an academic 870-bed public safety-net hospital were reviewed and defined as Meropenem MIC 4 or greater. Retained isolates were sent for pulse-field gel electrophoresis (PFGE). Infection prevention (IP) observations and interventions were intensified and environmental cultures were collected. Patient charts were reviewed. Results 27 patients between ages 5–61 years old were found to have CRPA (only 2 patients < 18 years). 21/27 (77.7%) were male. 21/27 (77.7%) had >40% total body surface area (TBSA) burns, 3/27 (11.1%) had 20–39% TBSA burn and 1/27 (3.7%) had < 20% TBSA burn. 19/27 (70.3%) patients had bacteremia, 6 had respiratory infections with 3 (11.1%) Infection-related Ventilator-Associated Complications (IVAC), 3 had urinary tract infection, and 1 had CRPA from a central venous catheter tip. There were very few co-morbidities. Twenty isolates from 11 different patients were typed and revealed 2 different clonal strains. 5/11 (45%) patients had strain A, and 2/11 (18%) patients had strain B. 3/11 (27.2%) patients had unique strains. CRPA was isolated from 5 different rooms. Water cultures did not reveal CRPA. Failure of hand hygiene, non-adherence to isolation/PPE protocols and clutter were found. Each failure was corrected. No new CRPA patient isolates have been identified. Conclusion Transmission was halted by reinforcement of IP measures. Importantly water was not a source of CRPA in this setting and the data suggest transmission due to environmental contamination. Disclosures Trish M. Perl, MD; MSc, 7–11: Advisory Board; medimmune: Research Grant

OBJECTIVEThis study had 2 objectives: (1) to describe the epidemiology of catheter-related bloodstream infections (CRBSI) in patients with end-stage renal disease (ESRD) who have no access to scheduled dialysis and (2) to evaluate whether a positive culture of the heparin-lock solution is associated with subsequent development of bacteremia.DESIGNRetrospective observational cohort design for objective 1; and prospective cohort design for objective 2.SETTING AND PARTICIPANTSThe study was conducted in a 770-bed public academic tertiary hospital in Dallas, Texas. The participants were patients with ESRD undergoing scheduled or emergent hemodialysis.METHODSWe reviewed the records of 147 patients who received hemodialysis between January 2011 and May 2011 and evaluated the rate of CRBSI in the previous 5 years. For the prospective study, we cultured the catheter heparin-lock solution in 62 consecutive patients between June 2012 and August 2012 and evaluated the incidence of CRBSI at 6 months.RESULTSOf the 147 patients on emergent hemodialysis, 125 had a tunneled catheter, with a CRBSI rate of 2.61 per 1,000 catheter days. The predominant organisms were Gram-negative rods (GNR). In the prospective study, we found that the dialysis catheter was colonized more frequently in patients on emergent hemodialysis than in those on scheduled hemodialysis. Colonization with GNR or Staphylococcus aureus was associated with subsequent CRBSI at 6 months follow-up.CONCLUSIONSPatients undergoing emergent hemodialysis via tunneled catheter are predisposed to Gram-negative CRBSI. Culturing the heparin-lock solution may predict subsequent episodes of CRBSI if it shows colonization with GNR or Staphylococcus aureus. Prevention approaches in this population need to be studied further.Infect. Control Hosp. Epidemiol. 2016;37(3):301–305

Airborne isolation of patients and use of respirators are a foundational strategy to prevent transmission of pathogens like tuberculosis and novel respiratory viruses via airborne route in healthcare settings. Healthcare personnel respiratory protection programs utilize respirators, which may or may not require fit testing for each individual. This chapter reviews the different types of respirators, which include the more common N95 respirator masks and the somewhat less commonly used powered air-purifying respirators, and the levels of protection offered by each type. The chapter also reviews considerations and controversies regarding use of N95 respirators and PAPRs and situations when a PAPR-only approach might work. In each healthcare facility, the epidemiology and risk assessment of the facility, available evidence in published literature, and certain regulatory standards must inform the clinical policies, protocols, and procedures. Key unanswered questions and further areas for research are outlined.

Setting Five health care systems in Texas. Objective To describe the epidemiology of inadequate isolation for pulmonary tuberculosis leading to tuberculosis (TB) exposures from confirmed TB patients and the patient factors that led to the exposures. Design A retrospective cohort and case-control study of adult patients with TB resulting in exposures (cases) vs those TB patients who did not result in exposures (controls) during January 2005 to December 2012. Results There were 335 patients with pulmonary TB disease, 199 cases and 136 controls. There was no difference between groups in age (46 ± 14.6 vs 45 ± 17 years; P > .05), race, or substance abuse. Cases were more likely to be transplant recipients (adjusted odds ratio [AOR], 18.90; 95% CI, 1.9–187.76), have typical TB chest radiograph (AOR, 2.23; 95% CI, 1.1–4.51), and have positive acid-fast bacilli stains (AOR, 2.36; 95% CI, 1.31–4.27). Cases were less likely to have extrapulmonary disease (AOR, 0.47; 95% CI, 0.24–0.95). Conclusions TB exposure resulting from inadequate isolation is frequent in health care settings. Extrapulmonary involvement resulted in earlier airborne isolation. Being a transplant recipient, having chest radiograph findings typical for TB, and sputum positivity acid-fast bacilli upon staining were associated with increased risk of inadequate isolation.

The goal of this review is to evaluate best practices for preventing healthcare-associated infections (HAI) and to identify opportunities beyond best practice. Achieving an infection-free hospital stay for patients will require integration of infection prevention into routine bedside clinical care. The objectives are (1) to summarize the best practices for prevention of HAI; (2) to discuss the limitations of known best practices; and (3) to discuss potential approaches beyond best practice to prevent HAI. Rationale for comprehensive horizontal approaches with active caregiver participation is discussed.

Background Vancomycin-resistant Enterococcus faecium (VREfm) is commonly associated with hospital outbreaks and has been found to be associated with increased morbidity, mortality, length of stay, and health care costs. Methods We sought to investigate and control an outbreak of VREfm in the neonatal intensive care unit (NICU) of a public academic hospital with a level III NICU. The index case was an infant in the NICU incidentally identified with urinary colonization with VREfm. Aggressive control measures were initiated promptly. Investigation included active surveillance cultures in infants, parents of colonized infants, and birth mothers of newborn admitted to NICU; molecular strain typing of available isolates of VREfm including adult inpatients; and medical record review. Results After identification of index case, 13 additional infants were identified with VREfm colonization. Age at culture was 6 to 87 days; birth weight was 1,070 to 2,834 g. VREfm isolated from majority of infants (12/14 [85.7%]), the birth mother of a pair of colonized twins, and a pulse oximeter device used in adult inpatients belonged to a single strain. Outbreak control measures were successful in the NICU. The outbreak-causing strain was found to be endemic among adult inpatients. Adult patients with the outbreak-causing strain of VREfm were more likely to have received previous therapy with meropenem (Mann-Whitney 2-tailed P value = .038). VRE colonization was identified in 0.3% (1/310) of birth mothers with newborn admitted to NICU. Conclusion An endemic strain of VREfm among adult inpatients was responsible for a subsequently controlled outbreak in the NICU.

Background The aim of this study was to examine clinical factors associated with the recurrence of community-onset skin and soft tissue infections caused by methicillin-resistant Staphylococcus aureus. Methods An observational case-comparison study based on a retrospective review of medical records was conducted in a public health system. All patients with community-onset skin and soft tissue infections caused by methicillin-resistant S aureus who underwent operative debridement from January 1999 to December 2003 were included. The outcome of interest was recurrence within 1 year. Results Two hundred fifty-three patients met the criteria for inclusion. Fifty-three (21%) patients returned with recurrent episodes. These patients were compared with 200 patients (79%) who did not develop recurrence. On multivariate analysis, factors independently predictive of recurrence were medical history of abscess requiring surgical debridement within the previous year (adjusted odds ratio, 2.6; 95% confidence interval, 1.4–5.0; P = .002) and obesity (adjusted odds ratio, 3.4; 95% confidence interval, 1.4–8.8; P = .008). Conclusions Patients with obesity or histories of methicillin-resistant S aureus infection are at significantly increased risk for recurrent soft tissue infection.

Objectives.To examine the relative proportions of central line-associated bloodstream infection (BSI) due to gram-negative bacteria and due to gram-positive bacteria among patients who had undergone surgery and patients who had not. The study also evaluated clinical predictive factors and unadjusted outcomes associated with central line-associated BSI caused by gram-negative bacteria in the postoperative period.Design.Observational, case-control study based on a retrospective review of medical records.Setting.University of Chicago Medical Center, a 500-bed tertiary care center located on Chicago's south side.Patients.Adult intensive care unit (ICU) patients who developed central line-associated BSI.Results.There were a total of 142 adult patients who met the Centers for Disease Control and Prevention National Nosocomial Infection Surveillance System definition for central line-associated BSI. Of those, 66 patients (46.5%) had infections due to gram-positive bacteria, 49 patients (34.5%) had infections due to gram-negative bacteria, 23 patients (16.2%) had infections due to yeast, and 4 patients (2.8%) had mixed infections. Patients who underwent surgery were more likely to develop central line-associated BSI due to gram-negative bacteria within 28 days of the surgery, compared with patients who had not had surgery recently (57.6% vs 27.3%; P = .002). On multivariable logistic regression analysis, diabetes mellitus (adjusted odds ratio [OR], 4.6 [95% CI, 1.2-18.1]; P = .03) and the presence of hypotension at the time of the first blood culture positive for a pathogen (adjusted OR, 9.8 [95% CI, 2.5-39.1]; P = .001 ) were found to be independently predictive of central line-associated BSI caused by gram-negative bacteria. Unadjusted outcomes were not different in the group with BSI due to gram-negative pathogens, compared to the group with BSI due to gram-positive pathogens.Conclusions.Clinicians caring for critically ill patients after surgery should be especially concerned about the possibility of central line-associated BSI caused by gram-negative pathogens. The presence of diabetes and hypotension appear to be significant associated factors.

The purpose of this study is to improve the quality of care and patient outcomes for Staphylococcus aureus bacteremia.A quasi-experimental pre- and postintervention study design was used to compare process and clinical endpoints before and after a quality-improvement initiative. All inpatients18 years of age with a positive blood culture for S. aureus during the specified pre- and postintervention period with clinical information available in the electronic medical record were included. An institutional protocol for the care of patients with S. aureus bacteremia was developed, formalized, and distributed to providers using a pocket card, an electronic order set, and targeted lectures over a 9-month period.There were 167 episodes of S. aureus bacteremia (160 patients) identified in the preintervention period, and 127 episodes (123 patients) in the postintervention period. Guideline adherence improved in the postintervention period for usage of transesophageal echocardiogram (43.9% vs 20.2%, P.01) and adequate duration of intravenous therapy (71% vs 60%, P = .05). In a multivariate Cox proportional hazard model, the variables associated with increased relapse-free survival were postintervention period (hazard ratio [HR] 0.48; confidence interval [CI], 0.24-0.95; P .035) and appropriate source control (HR 0.53; CI, 0.24-0.92; P .027). Regardless of intervention, presence of cancer was associated with an increased risk of relapse or mortality at 90 days (HR 2.88; P.0001; CI, 1.35-5.01).A bundled educational intervention to promote adherence to published guidelines for the treatment of S. aureus bacteremia resulted in a significant improvement in provider adherence to guidelines as well as increased 90-day relapse-free survival.

The incidence of infections caused by Candida glabrata and Candida krusei , which are generally more resistant to fluconazole than Candida albicans , is increasing in hospitalized patients. However, the extent to which prior exposure to specific antimicrobial agents increases the risk of subsequent C. glabrata or C. krusei candidemia has not been closely studied. A retrospective case-case-control study was performed at a university hospital. From 1998 to 2003, 60 patients were identified with hospital-acquired non- C. albicans candidemia ( C. glabrata or C. krusei ; case group 1). For comparison, 68 patients with C. albicans candidemia (case group 2) and a common control group of 121 patients without candidemia were studied. Models were adjusted for demographic and clinical risk factors, and the risk for candidemia associated with exposure to specific antimicrobial agents was assessed. After adjusting for both nonantimicrobial risk factors and receipt of other antimicrobial agents, piperacillin-tazobactam (odds ratio [OR], 4.15; 95% confidence interval [CI], 1.04 to 16.50) and vancomycin (OR, 6.48; CI, 2.20 to 19.13) were significant risk factors for C. glabrata or C. krusei candidemia. For C. albicans candidemia, no specific antibiotics remained a significant risk after adjusted analysis. Prior fluconazole use was not significantly associated with either C. albicans or non- C. albicans ( C. glabrata or C. krusei ) candidemia. In this single-center study, exposure to antibacterial agents, specifically vancomycin or piperacillin-tazobactam, but not fluconazole, was associated with subsequent hospital-acquired C. glabrata or C. krusei candidemia. Further studies are needed to prospectively analyze specific antimicrobial risks for nosocomial candidemia across multiple hospital centers.

We undertook this study to investigate whether treatment with a higher dose of trimethoprim-sulfamethoxazole (TMP/SMX) led to greater clinical resolution in patients with skin and soft tissue infections (SSTIs) caused by methicillin-resistant Staphylococcus aureus (MRSA). A prospective, observational cohort with nested case-control study was performed at a public tertiary health system. Among patients with MRSA SSTIs during the period from May 2008 to September 2008 who received oral monotherapy with TMP/SMX and whose clinical outcome was known, the clinical characteristics and outcomes were compared between patients treated with a high dose of TMP/SMX (320 mg/1,600 mg twice daily) for 7 to 15 days and patients treated with the standard dose of TMP/SMX (160 mg/800 mg twice daily) for 7 to 15 days. In patients with MRSA SSTIs, those treated with the high dose of TMP/SMX ( n = 121) had clinical characteristics similar to those of patients treated with the standard dose of TMP/SMX ( n = 170). The only exception was a higher proportion of patients with a history of trauma upon admission among the patients treated with the higher dose. The proportion of patients with clinical resolution of infection was not different in the two groups (88/121 [73%] versus 127/170 [75%]; P = 0.79). The lack of significance remained in patients with abscess upon stratified analysis by whether surgical drainage was performed. The study found that patients with MRSA SSTIs treated with the higher dose of TMP/SMX (320/1,600 mg twice daily) for 7 to 15 days had a similar rate of clinical resolution as patients treated with the standard dose of TMP/SMX (160/800 mg twice daily) for 7 to 15 days.

Background This study describes the epidemiology of patients with fungal mold infection or colonization at a large academic medical center during a period of ongoing construction of a new hospital building. Methods This is an observational retrospective cohort study performed at a public academic hospital. We performed focused medical record review of all patients with fungal mold isolated on microbiologic culture over a 3-year period from May 2009 through April 2012. We established case definitions by modifying criteria used in previously published studies. We established 4 categories for invasiveness: proven invasive fungal disease (IFD), probable IFD, clinical infection not meeting IFD criteria, or colonization/contamination. We also established 3 categories for association with our health care facilities: health care–associated hospital onset (HO), health care–associated community onset (HACO), or community associated (CA). Results Of the 188 cases included in the study, 15 (7.9%) and 23 (12.2%) met criteria for proven and probable IFD, respectively. Of the cases, 114 (60.6%) represented contamination or colonization, and 36 (19.1%) had clinical infection not meeting IFD criteria. Epidemiologically, 46 (24.5%) cases were HO, 42 (22.3%) cases were HACO, and 100 (53.2%) cases were CA. Conclusion The surveillance methods we established were helpful for characterizing and monitoring fungal mold infections at the study institution.

Practicum education in healthcare epidemiology and infection control (HEIC) for postgraduate physician trainees in infectious diseases is necessary to prepare them to be future participants and leaders in patient safety. Voss et al suggested that training in HEIC should be offered as a “common trunk” for physicians being trained in clinical microbiology or infectious diseases. A 1-month rotation has been recommended previously. A survey by Joiner et al indicated that only 50% of infectious diseases fellows found the infection control training adequate. The objective of this article is to report our 2-year experience with a 1-month practicum rotation we designed and implemented at our institution.The setting is the Adult Infectious Diseases fellowship program at the University of Texas Southwestern Medical Center (UTSW), Dallas, Texas. The fellows have clinical rotations at the Parkland Health and Hospital System, UTSW University hospitals, North Texas Veterans Affairs Health Care System, and Children's Medical Center Dallas. The 2-year program recruits 7 fellows every 2 years. The 1-month core rotation was established in July 2011 and is ongoing. Fellows who completed the rotation during the period July 2011 to April 2013 are included in this study.

Background It is believed that compliance with all 3 components of perioperative antimicrobial prophylaxis, ie, timing, choice, and duration, yields greater reduction in surgical site infections (SSI). Methods An observational study was performed among patients in the surgical care improvement project at a tertiary public academic hospital in the United States. The rates of SSI among patients who received appropriate antimicrobial agent(s) per current guidelines were compared with patients who did not. Medical record review was performed to compare the clinical characteristics of patients with SSI (cases) and an equal number of patients without SSI (matched controls). Results From January 2008 to June 2009, 762 patients underwent 763 eligible surgical procedures. Forty-seven (6.2%) developed SSI. The rate of SSI in patients who received appropriate antimicrobial prophylaxis per guidelines was not different from those who did not (42/611, 6.9% vs 5/152, 3.3%, respectively; P value = .13). Patients with SSI were more likely to have an elevated body mass index (median and interquartile range in cases: 28.7 [27.0-34.9] vs 25.0 [22.4-30.4] in controls; P value = .02) and more likely to have diabetes (36% vs 9%, respectively; odds ratio, 5.71; 95% confidence interval: 1.43-22.8; P value = .02). Conclusion Compliance with timing, choice, and duration of antimicrobial prophylaxis as a whole did not lead to lower SSI. Elevated body mass index and diabetes were associated with a higher rate of SSI.

Background This study was conducted to identify clinical factors associated with development of infection caused by methicillin-resistant Staphylococcus aureus (MRSA) among hospitalized patients with nasal MRSA colonization. Methods We conducted a prospective cohort with nested case-control study at a 672-bed, public, academic hospital in Dallas, Texas. The study duration was from January 1, 2008, to July 28, 2009. From the cohort of patients who had presence of nasal colonization with MRSA at admission, we identified patients who developed subsequent infection with MRSA during a 3-month period. We compared these patients (cases) with colonized patients who remained uninfected (controls; 2 controls per case). We collected demographic and clinical data and performed statistical analyses. Results During the 19-month study period, 426 patients were found to have nasal colonization with MRSA. Of these, 36 (8.5%) developed a subsequent infection with MRSA within 3 months. When these 36 cases were compared with 72 controls, the factors independently associated with the development of subsequent infection were development of pressure ulcer during hospital stay (adjusted odds ratio, 5.82; 95% confidence interval: 2.21–15.31; P value = .000) and preadmission steroid therapy (adjusted odds ratio, 13.2; 95% confidence interval: 2.44–70.97; P value = .003). Conclusion History of steroid therapy prior to admission and development of pressure ulcer are associated with increased risk of subsequent MRSA infection in patients nasally colonized with MRSA.

In this prospective, observational study of 618 consecutive adult patients with skin and soft tissue infections (SSTI) caused by methicillin-resistant Staphylococcus aureus (MRSA), the clinical characteristics, molecular epidemiology, and outcome of patients with clindamycin-resistant MRSA (n = 64) and clindamycin-susceptible MRSA (n = 554) were compared (including factors predictive of clindamycin-resistant MRSA SSTI). Patients with clindamycin-resistant MRSA were more likely to have had antibiotic exposure within 3 months (37.5% versus 17%, P < 0.01), surgery (25% versus 8%, P < 0.01), MRSA infection/colonization within 12 months (23% versus 7%, P < 0.01), or intravascular catheters (5% versus 0.5%, P = 0.02). On multivariate analysis, previous surgery (adjusted odds ratio [AOR] 2.97; 95% confidence interval [CI] 1.5-6.0), history of MRSA (AOR 3.4; 95% CI 1.7-7.1), and exposure to clindamycin (AOR 8.5; 95% CI 2.3-32) and to macrolides (AOR 7.2, 95% CI 1.6-31.8) were independently associated with presence of clindamycin-resistant MRSA. Clinical resolution was similar between groups (77% versus 68%; P = 0.26). Clindamycin-resistant MRSA was less often USA-300 (82% versus 98%, P = 0.004). Clindamycin resistance did not affect MRSA-SSTI clinical outcomes.

This pilot, observational study involving 286 patients who underwent cardiac surgery found that patients who had endotracheal colonization with gram-negative bacteria at 1 week after surgery were more likely to develop subsequent infection compared to those without colonization (8 of 23 vs. 4 of 40; relative risk 2.3 [95% confidence interval, 1.3–4.1;Pvalue < .05]).

Results:Quality of results. Both methods were similar; 83.4% of high touch surfaces evaluated were clean; 23.2% of rooms had all high touch surfaces cleaned. Usability and time to perform: the swab method was superior. Cost: the cost of the swab method was higher. The swab method was recommended for routine monitoring, based on ease-of-use, shorter time to perform, immediacy of feedback and perception that results are more objective. The spray method was recommended for training new custodians and on-going education. EVS has purchased luminometers and is implementing a monitoring program. Student data and initial data will be included.