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Karlsson M, Lutgring JD, Ansari U, Lawsin A, Albrecht V, McAllister G, Daniels J, Lonsway D, McKay S, Beldavs Z, Bower C, Dumyati G, Gross A, Jacob J, Janelle S, Kainer MA, Lynfield R, Phipps EC, Schutz K, Wilson L, Witwer ML, Bulens SN, Walters MS, Duffy N, Kallen AJ, Elkins CA, Rasheed JK. Molecular Characterization of Carbapenem-Resistant Enterobacterales Collected in the United States. Microb Drug Resist 2022; 28:389-397. [PMID: 35172110 DOI: 10.1089/mdr.2021.0106] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
Carbapenem-resistant Enterobacterales (CRE) are a growing public health concern due to resistance to multiple antibiotics and potential to cause health care-associated infections with high mortality. Carbapenemase-producing CRE are of particular concern given that carbapenemase-encoding genes often are located on mobile genetic elements that may spread between different organisms and species. In this study, we performed phenotypic and genotypic characterization of CRE collected at eight U.S. sites participating in active population- and laboratory-based surveillance of carbapenem-resistant organisms. Among 421 CRE tested, the majority were isolated from urine (n = 349, 83%). Klebsiella pneumoniae was the most common organism (n = 265, 63%), followed by Enterobacter cloacae complex (n = 77, 18%) and Escherichia coli (n = 50, 12%). Of 419 isolates analyzed by whole genome sequencing, 307 (73%) harbored a carbapenemase gene; variants of blaKPC predominated (n = 299, 97%). The occurrence of carbapenemase-producing K. pneumoniae, E. cloacae complex, and E. coli varied by region; the predominant sequence type within each genus was ST258, ST171, and ST131, respectively. None of the carbapenemase-producing CRE isolates displayed resistance to all antimicrobials tested; susceptibility to amikacin and tigecycline was generally retained.
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Affiliation(s)
- Maria Karlsson
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Joseph D Lutgring
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Uzma Ansari
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Adrian Lawsin
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Valerie Albrecht
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Gillian McAllister
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Jonathan Daniels
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - David Lonsway
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Susannah McKay
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | | | - Chris Bower
- Georgia Emerging Infections Program, Atlanta, Georgia, USA
| | - Ghinwa Dumyati
- New York Emerging Infections Program at the University of Rochester Medical Center, Rochester, New York, USA
| | | | - Jesse Jacob
- Georgia Emerging Infections Program, Atlanta, Georgia, USA.,Emory University School of Medicine, Atlanta, Georgia, USA
| | - Sarah Janelle
- Colorado Department of Public Health and Environment, Denver, Colorado, USA
| | - Marion A Kainer
- Tennessee Department of Public Health, Nashville, Tennessee, USA
| | - Ruth Lynfield
- Minnesota Department of Health, St. Paul, Minnesota, USA
| | - Erin C Phipps
- New Mexico Emerging Infections Program, Santa Fe, New Mexico, USA
| | - Kyle Schutz
- Colorado Department of Public Health and Environment, Denver, Colorado, USA
| | - Lucy Wilson
- Maryland Department of Health, Baltimore, Maryland, USA
| | | | - Sandra N Bulens
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Maroya Spalding Walters
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Nadezhda Duffy
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Alexander J Kallen
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Christopher A Elkins
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - J Kamile Rasheed
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
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2
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de Man TJB, Yaffee AQ, Zhu W, Batra D, Alyanak E, Rowe LA, McAllister G, Moulton-Meissner H, Boyd S, Flinchum A, Slayton RB, Hancock S, Spalding Walters M, Laufer Halpin A, Rasheed JK, Noble-Wang J, Kallen AJ, Limbago BM. Multispecies Outbreak of Verona Integron-Encoded Metallo-ß-Lactamase-Producing Multidrug Resistant Bacteria Driven by a Promiscuous Incompatibility Group A/C2 Plasmid. Clin Infect Dis 2021; 72:414-420. [PMID: 32255490 DOI: 10.1093/cid/ciaa049] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Accepted: 01/17/2020] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Antibiotic resistance is often spread through bacterial populations via conjugative plasmids. However, plasmid transfer is not well recognized in clinical settings because of technical limitations, and health care-associated infections are usually caused by clonal transmission of a single pathogen. In 2015, multiple species of carbapenem-resistant Enterobacteriaceae (CRE), all producing a rare carbapenemase, were identified among patients in an intensive care unit. This observation suggested a large, previously unrecognized plasmid transmission chain and prompted our investigation. METHODS Electronic medical record reviews, infection control observations, and environmental sampling completed the epidemiologic outbreak investigation. A laboratory analysis, conducted on patient and environmental isolates, included long-read whole-genome sequencing to fully elucidate plasmid DNA structures. Bioinformatics analyses were applied to infer plasmid transmission chains and results were subsequently confirmed using plasmid conjugation experiments. RESULTS We identified 14 Verona integron-encoded metallo-ß-lactamase (VIM)-producing CRE in 12 patients, and 1 additional isolate was obtained from a patient room sink drain. Whole-genome sequencing identified the horizontal transfer of blaVIM-1, a rare carbapenem resistance mechanism in the United States, via a promiscuous incompatibility group A/C2 plasmid that spread among 5 bacterial species isolated from patients and the environment. CONCLUSIONS This investigation represents the largest known outbreak of VIM-producing CRE in the United States to date, which comprises numerous bacterial species and strains. We present evidence of in-hospital plasmid transmission, as well as environmental contamination. Our findings demonstrate the potential for 2 types of hospital-acquired infection outbreaks: those due to clonal expansion and those due to the spread of conjugative plasmids encoding antibiotic resistance across species.
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Affiliation(s)
- Tom J B de Man
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Anna Q Yaffee
- Epidemic Intelligence Service, Division of Scientific Education and Professional Development, Centers for Disease Control and Prevention, Atlanta, Georgia, USA.,Kentucky Department for Public Health, Frankfort, Kentucky, USA
| | - Wenming Zhu
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Dhwani Batra
- Division of Scientific Resources, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Efe Alyanak
- Division of Scientific Resources, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Lori A Rowe
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Gillian McAllister
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Heather Moulton-Meissner
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Sandra Boyd
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Andrea Flinchum
- Kentucky Department for Public Health, Frankfort, Kentucky, USA
| | - Rachel B Slayton
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Steven Hancock
- School of Chemistry and Molecular Biosciences, The University of Queensland, Brisbane, Australia.,Australian Infectious Diseases Research Centre, University of Queensland, Brisbane, Australia
| | - Maroya Spalding Walters
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Alison Laufer Halpin
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - James Kamile Rasheed
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Judith Noble-Wang
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Alexander J Kallen
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Brandi M Limbago
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
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Paul P, Slayton RB, Kallen AJ, Walters MS, Jernigan JA. Modeling Regional Transmission and Containment of a Healthcare-associated Multidrug-resistant Organism. Clin Infect Dis 2021; 70:388-394. [PMID: 30919885 DOI: 10.1093/cid/ciz248] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Accepted: 03/20/2019] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND The Centers for Disease Control and Prevention (CDC) recently published interim guidance for a public health response to contain novel or targeted multidrug-resistant organisms (MDROs). We assessed the impact of implementing the strategy in a US state using a mathematical model. METHODS We used a deterministic compartmental model, parametrized via a novel analysis of carbapenem-resistant Enterobacteriaceae data reported to the National Healthcare Safety Network and patient transfer data from the Centers for Medicare and Medicaid Services. The simulations assumed that after the importation of the MDRO and its initial detection by clinical culture at an index hospital, fortnightly prevalence surveys for colonization and additional infection control interventions were implemented at the index facility; similar surveys were then also implemented at those facilities known to be connected most strongly to it as measured by patient transfer data; and prevalence surveys were discontinued after 2 consecutive negative surveys. RESULTS If additional infection-control interventions are assumed to lead to a 20% reduction in transmissibility in intervention facilities, prevalent case count in the state 3 years after importation would be reduced by 76% (interquartile range: 73-77%). During the third year, these additional infection-control measures would be applied in facilities accounting for 42% (37-46%) of inpatient days. CONCLUSIONS CDC guidance for containing MDROs, when used in combination with information on transfer of patients among hospitals, is predicted to be effective, enabling targeted and efficient use of prevention resources during an outbreak response. Even modestly effective infection-control measures may lead to a substantial reduction in transmission events.
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Affiliation(s)
- Prabasaj Paul
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Rachel B Slayton
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Alexander J Kallen
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Maroya S Walters
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - John A Jernigan
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
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4
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Schaefer MK, Perkins KM, Link-Gelles R, Kallen AJ, Patel PR, Perz JF. Outbreaks and infection control breaches in health care settings: Considerations for patient notification. Am J Infect Control 2020; 48:718-724. [PMID: 32284161 DOI: 10.1016/j.ajic.2020.02.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Revised: 02/26/2020] [Accepted: 02/26/2020] [Indexed: 11/19/2022]
Affiliation(s)
- Melissa K Schaefer
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention (CDC), Atlanta, GA.
| | - Kiran M Perkins
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention (CDC), Atlanta, GA
| | - Ruth Link-Gelles
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention (CDC), Atlanta, GA
| | - Alexander J Kallen
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention (CDC), Atlanta, GA
| | - Priti R Patel
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention (CDC), Atlanta, GA
| | - Joseph F Perz
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention (CDC), Atlanta, GA
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5
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Ham DC, See I, Novosad S, Crist M, Mahon G, Fike L, Spicer K, Talley P, Flinchum A, Kainer M, Kallen AJ, Walters MS. Investigation of Hospital-Onset Methicillin-Resistant Staphylococcus aureus Bloodstream Infections at Eight High Burden Acute Care Facilities in the United States, 2016. J Hosp Infect 2020; 105:S0195-6701(20)30182-1. [PMID: 32283173 PMCID: PMC7857529 DOI: 10.1016/j.jhin.2020.04.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Accepted: 04/06/2020] [Indexed: 11/17/2022]
Abstract
BACKGROUND Despite large reductions from 2005-2012, hospital-onset methicillin-resistant Staphylococcus aureus bloodstream infections (HO MRSA BSIs) continue be a major source of morbidity and mortality. AIM To describe risk factors for and underlying sources of HO MRSA BSIs. METHODS We investigated HO MRSA BSIs at eight high-burden short-stay acute care hospitals. A case was defined as first isolation of MRSA from a blood specimen collected in 2016 on hospital day ≥4 from a patient without an MRSA-positive blood culture in the 14 days prior. We reviewed case-patient demographics and risk factors by medical record abstraction. The potential clinical source(s) of infection were determined by consensus by a clinician panel. FINDINGS Of the 195 eligible cases, 186 were investigated. Case-patients were predominantly male (63%); median age was 57 years (range 0-92). In the two weeks prior to the BSI, 88% of case-patients had indwelling devices, 31% underwent a surgical procedure, and 18% underwent dialysis. The most common locations of attribution were intensive care units (ICUs) (46%) and step-down units (19%). The most commonly identified non-mutually exclusive clinical sources were CVCs (46%), non-surgical wounds (17%), surgical site infections (16%), non-ventilator healthcare-associated pneumonia (13%), and ventilator-associated pneumonia (11%). CONCLUSIONS Device-and procedure-related infections were common sources of HO MRSA BSIs. Prevention strategies focused on improving adherence to existing prevention bundles for device-and procedure-associated infections and on source control for ICU patients, patients with certain indwelling devices, and patients undergoing certain high-risk surgeries are being pursued to decrease HO MRSA BSI burden at these facilities.
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Affiliation(s)
- D Cal Ham
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, GA.
| | - Isaac See
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, GA
| | - Shannon Novosad
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, GA
| | - Matthew Crist
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, GA
| | - Garrett Mahon
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, GA
| | - Lucy Fike
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, GA
| | - Kevin Spicer
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, GA
| | | | | | | | - Alexander J Kallen
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, GA
| | - Maroya Spalding Walters
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, GA
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6
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See I, Mu Y, Albrecht V, Karlsson M, Dumyati G, Hardy DJ, Koeck M, Lynfield R, Nadle J, Ray SM, Schaffner W, Kallen AJ. Trends in Incidence of Methicillin-resistant Staphylococcus aureus Bloodstream Infections Differ by Strain Type and Healthcare Exposure, United States, 2005-2013. Clin Infect Dis 2020; 70:19-25. [PMID: 30801635 PMCID: PMC6708714 DOI: 10.1093/cid/ciz158] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Accepted: 02/21/2019] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Previous reports suggested that US methicillin-resistant Staphylococcus aureus (MRSA) strain epidemiology has changed since the rise of USA300 MRSA. We describe invasive MRSA trends by strain type. METHODS Data came from 5 Centers for Disease Control and Prevention Emerging Infections Program sites conducting population-based surveillance and collecting isolates for invasive MRSA (ie, from normally sterile body sites), 2005-2013. MRSA bloodstream infection (BSI) incidence per 100 000 population was stratified by strain type and epidemiologic classification of healthcare exposures. Invasive USA100 vs USA300 case characteristics from 2013 were compared through logistic regression. RESULTS From 2005 to 2013, USA100 incidence decreased most notably for hospital-onset (6.1 vs 0.9/100 000 persons, P < .0001) and healthcare-associated, community-onset (10.7 vs 4.9/100 000 persons, P < .0001) BSIs. USA300 incidence for hospital-onset BSIs also decreased (1.5 vs 0.6/100 000 persons, P < .0001). However, USA300 incidence did not significantly change for healthcare-associated, community-onset (3.9 vs 3.3/100 000 persons, P = .05) or community-associated BSIs (2.5 vs 2.4/100 000 persons, P = .19). Invasive MRSA was less likely to be USA300 in patients who were older (adjusted odds ratio [aOR], 0.97 per year [95% confidence interval {CI}, .96-.98]), previously hospitalized (aOR, 0.36 [95% CI, .24-.54]), or had central lines (aOR, 0.44 [95% CI, .27-.74]), and associated with USA300 in people who inject drugs (aOR, 4.58 [95% CI, 1.16-17.95]). CONCLUSIONS Most of the decline in MRSA BSIs was from decreases in USA100 BSI incidence. Prevention of USA300 MRSA BSIs in the community will be needed to further reduce burden from MRSA BSIs.
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Affiliation(s)
- Isaac See
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Yi Mu
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Valerie Albrecht
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Maria Karlsson
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | | | | | | | | | | | - Susan M Ray
- Emory University School of Medicine, Atlanta, Georgia
| | | | - Alexander J Kallen
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
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7
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Bulens SN, Yi SH, Walters MS, Jacob JT, Bower C, Reno J, Wilson L, Vaeth E, Bamberg W, Janelle SJ, Lynfield R, Vagnone PS, Shaw K, Kainer M, Muleta D, Mounsey J, Dumyati G, Concannon C, Beldavs Z, Cassidy PM, Phipps EC, Kenslow N, Hancock EB, Kallen AJ. Carbapenem-Nonsusceptible Acinetobacter baumannii, 8 US Metropolitan Areas, 2012-2015. Emerg Infect Dis 2019; 24:727-734. [PMID: 29553339 PMCID: PMC5875254 DOI: 10.3201/eid2404.171461] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
In healthcare settings, Acinetobacter spp. bacteria commonly demonstrate antimicrobial resistance, making them a major treatment challenge. Nearly half of Acinetobacter organisms from clinical cultures in the United States are nonsusceptible to carbapenem antimicrobial drugs. During 2012–2015, we conducted laboratory- and population-based surveillance in selected metropolitan areas in Colorado, Georgia, Maryland, Minnesota, New Mexico, New York, Oregon, and Tennessee to determine the incidence of carbapenem-nonsusceptible A. baumannii cultured from urine or normally sterile sites and to describe the demographic and clinical characteristics of patients and cases. We identified 621 cases in 537 patients; crude annual incidence was 1.2 cases/100,000 persons. Among 598 cases for which complete data were available, 528 (88.3%) occurred among patients with exposure to a healthcare facility during the preceding year; 506 (84.6%) patients had an indwelling device. Although incidence was lower than for other healthcare-associated pathogens, cases were associated with substantial illness and death.
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8
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Clegg WJ, Pacilli M, Kemble SK, Kerins JL, Hassaballa A, Kallen AJ, Walters MS, Halpin AL, Stanton RA, Boyd S, Gable P, Daniels J, Lin MY, Hayden MK, Lolans K, Burdsall DP, Lavin MA, Black SR. Notes from the Field: Large Cluster of Verona Integron-Encoded Metallo-Beta-Lactamase-Producing Carbapenem-Resistant Pseudomonas aeruginosa Isolates Colonizing Residents at a Skilled Nursing Facility - Chicago, Illinois, November 2016-March 2018. MMWR Morb Mortal Wkly Rep 2018; 67:1130-1131. [PMID: 30307908 PMCID: PMC6181260 DOI: 10.15585/mmwr.mm6740a6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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9
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Shehab N, Brown MN, Kallen AJ, Perz JF. U.S. Compounding Pharmacy-Related Outbreaks, 2001-2013: Public Health and Patient Safety Lessons Learned. J Patient Saf 2018; 14:164-173. [PMID: 26001553 PMCID: PMC4668233 DOI: 10.1097/pts.0000000000000188] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Pharmacy-compounded sterile preparations (P-CSPs) are frequently relied upon in U.S. health care but are increasingly being linked to outbreaks of infections. We provide an updated overview of outbreak burden and characteristics, identify drivers of P-CSP demand, and discuss public health and patient safety lessons learned to help inform prevention. METHODS Outbreaks of infections linked to contaminated P-CSPs that occurred between January 1, 2001, and December 31, 2013, were identified from internal Centers for Disease Control and Prevention reports, Food and Drug Administration drug safety communications, and published literature. RESULTS We identified 19 outbreaks linked to P-CSPs, resulting in at least 1000 cases, including deaths. Outbreaks were reported across two-thirds of states, with almost one-half (8/19) involving cases in more than 1 state. Almost one-half of outbreaks were linked to injectable steroids (5/19) and intraocular bevacizumab (3/19). Non-patient-specific compounding originating from nonsterile ingredients and repackaging of already sterile products were the most common practices associated with P-CSP contamination. Breaches in aseptic processing and deficiencies in sterilization procedures or in sterility/endotoxin testing were consistent findings. Hospital outsourcing, preference for variations of commercially available products, commercial drug shortages, and lower prices were drivers of P-CSP demand. CONCLUSIONS Recognized outbreaks linked to P-CSPs have been most commonly associated with non-patient-specific repackaging and nonsterile to sterile compounding and linked to lack of adherence to sterile compounding standards. Recently enhanced regulatory oversight of compounding may improve adherence to such standards. Additional measures to limit and control these outbreaks include vigilance when outsourcing P-CSPs, scrutiny of drivers for P-CSP demand, as well as early recognition and notification of possible outbreaks.
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10
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Walters MS, Witwer M, Lee YK, Albrecht V, Lonsway D, Rasheed JK, Anacker M, Snippes-Vagnone P, Lynfield R, Kallen AJ. Notes from the Field: Carbapenemase-Producing Carbapenem-Resistant Enterobacteriaceae from Less Common Enterobacteriaceae Genera - United States, 2014-2017. MMWR Morb Mortal Wkly Rep 2018; 67:668-669. [PMID: 29902165 PMCID: PMC6002034 DOI: 10.15585/mmwr.mm6723a4] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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11
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Toth DJA, Khader K, Slayton RB, Kallen AJ, Gundlapalli AV, O'Hagan JJ, Fiore AE, Rubin MA, Jernigan JA, Samore MH. The Potential for Interventions in a Long-term Acute Care Hospital to Reduce Transmission of Carbapenem-Resistant Enterobacteriaceae in Affiliated Healthcare Facilities. Clin Infect Dis 2018; 65:581-587. [PMID: 28472233 DOI: 10.1093/cid/cix370] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2016] [Accepted: 04/18/2017] [Indexed: 01/01/2023] Open
Abstract
Background Carbapenem-resistant Enterobacteriaceae (CRE) are high-priority bacterial pathogens targeted for efforts to decrease transmissions and infections in healthcare facilities. Some regions have experienced CRE outbreaks that were likely amplified by frequent transmission in long-term acute care hospitals (LTACHs). Planning and funding of intervention efforts focused on LTACHs is one proposed strategy to contain outbreaks; however, the potential regional benefits of such efforts are unclear. Methods We designed an agent-based simulation model of patients in a regional network of 10 healthcare facilities including 1 LTACH, 3 short-stay acute care hospitals (ACHs), and 6 nursing homes (NHs). The model was calibrated to achieve realistic patient flow and CRE transmission and detection rates. We then simulated the initiation of an entirely LTACH-focused intervention in a previously CRE-free region, including active surveillance for CRE carriers and enhanced isolation of identified carriers. Results When initiating the intervention at the first clinical CRE detection in the LTACH, cumulative CRE transmissions over 5 years across all 10 facilities were reduced by 79%-93% compared to no-intervention simulations. This result was robust to changing assumptions for transmission within non-LTACH facilities and flow of patients from the LTACH. Delaying the intervention until the 20th CRE detection resulted in substantial delays in achieving optimal regional prevalence, while still reducing transmissions by 60%-79% over 5 years. Conclusions Focusing intervention efforts on LTACHs is potentially a highly efficient strategy for reducing CRE transmissions across an entire region, particularly when implemented as early as possible in an emerging outbreak.
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Affiliation(s)
- Damon J A Toth
- Department of Veterans Affairs, Salt Lake City Health Care System, Utah.,Department of Internal Medicine, Division of Epidemiology, University of Utah, Salt Lake City
| | - Karim Khader
- Department of Veterans Affairs, Salt Lake City Health Care System, Utah.,Department of Internal Medicine, Division of Epidemiology, University of Utah, Salt Lake City
| | - Rachel B Slayton
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Alexander J Kallen
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Adi V Gundlapalli
- Department of Veterans Affairs, Salt Lake City Health Care System, Utah.,Department of Internal Medicine, Division of Epidemiology, University of Utah, Salt Lake City
| | - Justin J O'Hagan
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Anthony E Fiore
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Michael A Rubin
- Department of Veterans Affairs, Salt Lake City Health Care System, Utah.,Department of Internal Medicine, Division of Epidemiology, University of Utah, Salt Lake City
| | - John A Jernigan
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Matthew H Samore
- Department of Veterans Affairs, Salt Lake City Health Care System, Utah.,Department of Internal Medicine, Division of Epidemiology, University of Utah, Salt Lake City
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12
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Lin MY, Hayden MK, Lyles RD, Lolans K, Fogg LF, Kallen AJ, Weber SG, Weinstein RA, Trick WE. Regional Epidemiology of Methicillin-Resistant Staphylococcus aureus Among Adult Intensive Care Unit Patients Following State-Mandated Active Surveillance. Clin Infect Dis 2018; 66:1535-1539. [PMID: 29228133 PMCID: PMC6484427 DOI: 10.1093/cid/cix1056] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2017] [Accepted: 12/04/2017] [Indexed: 01/29/2023] Open
Abstract
Background In 2007, Illinois became the first state in the United States to mandate active surveillance of methicillin-resistant Staphylococcus aureus (MRSA). The Illinois law applies to intensive care unit (ICU) patients; contact precautions are required for patients found to be MRSA colonized. However, the effectiveness of a legislated "search and isolate" approach to reduce MRSA burden among critically ill patients is uncertain. We evaluated whether the prevalence of MRSA colonization declined in the 5 years after the start of mandatory active surveillance. Methods All hospitals with an ICU having ≥10 beds in Chicago, Illinois, were eligible to participate in single-day serial point prevalence surveys. We assessed MRSA colonization among adult ICU patients present at time of survey using nasal and inguinal swab cultures. The primary outcome was region-wide MRSA colonization prevalence over time. Results All 25 eligible hospitals (51 ICUs) participated in serial point prevalence surveys over 8 survey periods (2008-2013). A total of 3909 adult ICU patients participated in the point prevalence surveys, with 432 (11.1%) found to be colonized with MRSA (95% confidence interval [CI], 10.1%-12.0%). The MRSA colonization prevalence among patients was unchanged during the study period; year-over-year relative risk for MRSA colonization was 0.97 (95% CI, .89-1.05; P = .48). Conclusions MRSA colonization prevalence among critically ill adult patients did not decline during the time period following legislatively mandated MRSA active surveillance. Our findings highlight the limits of legislated MRSA active surveillance as a strategy to reduce MRSA colonization burden among ICU patients.
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Affiliation(s)
| | | | - Rosie D. Lyles
- Cook County Health and Hospitals System, Chicago, Illinois
| | - Karen Lolans
- Rush University Medical Center, Chicago, Illinois
| | | | | | | | - Robert A. Weinstein
- Rush University Medical Center, Chicago, Illinois,Cook County Health and Hospitals System, Chicago, Illinois
| | - William E. Trick
- Rush University Medical Center, Chicago, Illinois,Cook County Health and Hospitals System, Chicago, Illinois
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Woodworth KR, Walters MS, Weiner LM, Edwards J, Brown AC, Huang JY, Malik S, Slayton RB, Paul P, Capers C, Kainer MA, Wilde N, Shugart A, Mahon G, Kallen AJ, Patel J, McDonald LC, Srinivasan A, Craig M, Cardo DM. Vital Signs: Containment of Novel Multidrug-Resistant Organisms and Resistance Mechanisms - United States, 2006-2017. MMWR Morb Mortal Wkly Rep 2018; 67:396-401. [PMID: 29621209 PMCID: PMC5889247 DOI: 10.15585/mmwr.mm6713e1] [Citation(s) in RCA: 92] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
BACKGROUND Approaches to controlling emerging antibiotic resistance in health care settings have evolved over time. When resistance to broad-spectrum antimicrobials mediated by extended-spectrum β-lactamases (ESBLs) arose in the 1980s, targeted interventions to slow spread were not widely promoted. However, when Enterobacteriaceae with carbapenemases that confer resistance to carbapenem antibiotics emerged, directed control efforts were recommended. These distinct approaches could have resulted in differences in spread of these two pathogens. CDC evaluated these possible changes along with initial findings of an enhanced antibiotic resistance detection and control strategy that builds on interventions developed to control carbapenem resistance. METHODS Infection data from the National Healthcare Safety Network from 2006-2015 were analyzed to calculate changes in the annual proportion of selected pathogens that were nonsusceptible to extended-spectrum cephalosporins (ESBL phenotype) or resistant to carbapenems (carbapenem-resistant Enterobacteriaceae [CRE]). Testing results for CRE and carbapenem-resistant Pseudomonas aeruginosa (CRPA) are also reported. RESULTS The percentage of ESBL phenotype Enterobacteriaceae decreased by 2% per year (risk ratio [RR] = 0.98, p<0.001); by comparison, the CRE percentage decreased by 15% per year (RR = 0.85, p<0.01). From January to September 2017, carbapenemase testing was performed for 4,442 CRE and 1,334 CRPA isolates; 32% and 1.9%, respectively, were carbapenemase producers. In response, 1,489 screening tests were performed to identify asymptomatic carriers; 171 (11%) were positive. CONCLUSIONS The proportion of Enterobacteriaceae infections that were CRE remained lower and decreased more over time than the proportion that were ESBL phenotype. This difference might be explained by the more directed control efforts implemented to slow transmission of CRE than those applied for ESBL-producing strains. Increased detection and aggressive early response to emerging antibiotic resistance threats have the potential to slow further spread.
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Hunter JC, Nguyen D, Aden B, Al Bandar Z, Al Dhaheri W, Abu Elkheir K, Khudair A, Al Mulla M, El Saleh F, Imambaccus H, Al Kaabi N, Sheikh FA, Sasse J, Turner A, Abdel Wareth L, Weber S, Al Ameri A, Abu Amer W, Alami NN, Bunga S, Haynes LM, Hall AJ, Kallen AJ, Kuhar D, Pham H, Pringle K, Tong S, Whitaker BL, Gerber SI, Al Hosani FI. Transmission of Middle East Respiratory Syndrome Coronavirus Infections in Healthcare Settings, Abu Dhabi. Emerg Infect Dis 2016; 22:647-56. [PMID: 26981708 PMCID: PMC4806977 DOI: 10.3201/eid2204.151615] [Citation(s) in RCA: 104] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Early detection and adherence to infection prevention recommendations are necessary to avoid transmission. Middle East respiratory syndrome coronavirus (MERS-CoV) infections sharply increased in the Arabian Peninsula during spring 2014. In Abu Dhabi, United Arab Emirates, these infections occurred primarily among healthcare workers and patients. To identify and describe epidemiologic and clinical characteristics of persons with healthcare-associated infection, we reviewed laboratory-confirmed MERS-CoV cases reported to the Health Authority of Abu Dhabi during January 1, 2013–May 9, 2014. Of 65 case-patients identified with MERS-CoV infection, 27 (42%) had healthcare-associated cases. Epidemiologic and genetic sequencing findings suggest that 3 healthcare clusters of MERS-CoV infection occurred, including 1 that resulted in 20 infected persons in 1 hospital. MERS-CoV in healthcare settings spread predominantly before MERS-CoV infection was diagnosed, underscoring the importance of increasing awareness and infection control measures at first points of entry to healthcare facilities.
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15
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Snyder GM, Patel PR, Kallen AJ, Strom JA, Tucker JK, D'Agata EM. Factors associated with the receipt of antimicrobials among chronic hemodialysis patients. Am J Infect Control 2016; 44:1269-1274. [PMID: 27184209 DOI: 10.1016/j.ajic.2016.03.034] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2015] [Revised: 03/05/2016] [Accepted: 03/07/2016] [Indexed: 12/14/2022]
Abstract
BACKGROUND Antimicrobial use is common among patients receiving chronic hemodialysis (CHD) and may represent an important antimicrobial stewardship opportunity. The objective of this study is to characterize CHD patients at increased risk of receiving antimicrobials, including not indicated antimicrobials. METHODS We conducted a prospective cohort study over a 12-month period among patients receiving CHD in 2 outpatient dialysis units. Each parenteral antimicrobial dose administered was characterized as indicated or not indicated based on national guidelines. Patient factors associated with receipt of antimicrobials and receipt of ≥1 inappropriate antimicrobial dose were analyzed. RESULTS A total of 89 of 278 CHD patients (32%) received ≥1 antimicrobial doses and 52 (58%) received ≥1 inappropriately indicated dose. Patients with tunneled catheter access, a history of colonization or infection with a multidrug-resistant organism, and receiving CHD sessions during daytime shifts were more likely to receive antimicrobials (odds ratio [OR], 5.16; 95% confidence interval [CI], 2.72-9.80; OR, 5.43; 95% CI, 1.84-16.06; OR, 4.59; 95% CI, 1.20-17.52, respectively). Patients with tunneled catheter access, receiving CHD at dialysis unit B, and with a longer duration of CHD prior to enrollment were at higher risk of receiving an inappropriately indicated antimicrobial dose (incidence rate ratio, 2.23; 95% CI, 1.16-4.29; incidence rate ratio, 2.67; 95% CI, 1.34-5.35; incidence rate ratio, 1.11; 95% CI, 1.01-1.23, respectively). CONCLUSIONS This study of all types of antimicrobials administered in 2 outpatient dialysis units identified several important factors to consider when developing antimicrobial stewardship programs in this health care setting.
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16
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Kline KE, Shover J, Kallen AJ, Lonsway DR, Watkins S, Miller JR. Investigation of First Identifiedmcr-1Gene in an Isolate from a U.S. Patient — Pennsylvania, 2016. MMWR Morb Mortal Wkly Rep 2016; 65:977-8. [DOI: 10.15585/mmwr.mm6536e2] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
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Patel PR, Shugart A, Mbaeyi C, Goding Sauer A, Melville A, Nguyen DB, Kallen AJ. Dialysis Event Surveillance Report: National Healthcare Safety Network data summary, January 2007 through April 2011. Am J Infect Control 2016; 44:944-7. [PMID: 27040568 DOI: 10.1016/j.ajic.2016.02.009] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2015] [Revised: 02/01/2016] [Accepted: 02/04/2016] [Indexed: 11/17/2022]
Abstract
A total of 24,092 adverse events in hemodialysis outpatients during January 2007 through April 2011 were reported to the National Healthcare Safety Network. Of 2,656 bloodstream infections, 67.3% were in patients with central venous catheters. For all events, rates associated with central venous catheters were higher than for other vascular access types.
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Affiliation(s)
- Priti R Patel
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, GA.
| | - Alicia Shugart
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, GA
| | - Chukwuma Mbaeyi
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, GA
| | - Ann Goding Sauer
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, GA
| | - Anna Melville
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, GA
| | - Duc B Nguyen
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, GA
| | - Alexander J Kallen
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, GA
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18
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Chea N, Bulens SN, Kongphet-Tran T, Lynfield R, Shaw KM, Vagnone PS, Kainer MA, Muleta DB, Wilson L, Vaeth E, Dumyati G, Concannon C, Phipps EC, Culbreath K, Janelle SJ, Bamberg WM, Guh AY, Limbago B, Kallen AJ. Improved Phenotype-Based Definition for Identifying Carbapenemase Producers among Carbapenem-Resistant Enterobacteriaceae. Emerg Infect Dis 2016; 21:1611-6. [PMID: 26290955 PMCID: PMC4550143 DOI: 10.3201/eid2109.150198] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
A new, less restrictive definition increases detection of Klebsiella pneumoniae carbapenemase producers. Preventing transmission of carbapenemase-producing, carbapenem-resistant Enterobacteriaceae (CP-CRE) is a public health priority. A phenotype-based definition that reliably identifies CP-CRE while minimizing misclassification of non–CP-CRE could help prevention efforts. To assess possible definitions, we evaluated enterobacterial isolates that had been tested and deemed nonsusceptible to >1 carbapenem at US Emerging Infections Program sites. We determined the number of non-CP isolates that met (false positives) and CP isolates that did not meet (false negatives) the Centers for Disease Control and Prevention CRE definition in use during our study: 30% (94/312) of CRE had carbapenemase genes, and 21% (14/67) of Klebsiella pneumoniae carbapenemase–producing Klebsiella isolates had been misclassified as non-CP. A new definition requiring resistance to 1 carbapenem rarely missed CP strains, but 55% of results were false positive; adding the modified Hodge test to the definition decreased false positives to 12%. This definition should be considered for use in carbapenemase-producing CRE surveillance and prevention.
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19
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Lee BY, Bartsch SM, Wong KF, McKinnell JA, Slayton RB, Miller LG, Cao C, Kim DS, Kallen AJ, Jernigan JA, Huang SS. The Potential Trajectory of Carbapenem-Resistant Enterobacteriaceae, an Emerging Threat to Health-Care Facilities, and the Impact of the Centers for Disease Control and Prevention Toolkit. Am J Epidemiol 2016; 183:471-9. [PMID: 26861238 PMCID: PMC4772438 DOI: 10.1093/aje/kwv299] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2015] [Accepted: 10/22/2015] [Indexed: 11/14/2022] Open
Abstract
Carbapenem-resistant Enterobacteriaceae (CRE), a group of pathogens resistant to most antibiotics and associated with high mortality, are a rising emerging public health threat. Current approaches to infection control and prevention have not been adequate to prevent spread. An important but unproven approach is to have hospitals in a region coordinate surveillance and infection control measures. Using our Regional Healthcare Ecosystem Analyst (RHEA) simulation model and detailed Orange County, California, patient-level data on adult inpatient hospital and nursing home admissions (2011-2012), we simulated the spread of CRE throughout Orange County health-care facilities under 3 scenarios: no specific control measures, facility-level infection control efforts (uncoordinated control measures), and a coordinated regional effort. Aggressive uncoordinated and coordinated approaches were highly similar, averting 2,976 and 2,789 CRE transmission events, respectively (72.2% and 77.0% of transmission events), by year 5. With moderate control measures, coordinated regional control resulted in 21.3% more averted cases (n = 408) than did uncoordinated control at year 5. Our model suggests that without increased infection control approaches, CRE would become endemic in nearly all Orange County health-care facilities within 10 years. While implementing the interventions in the Centers for Disease Control and Prevention's CRE toolkit would not completely stop the spread of CRE, it would cut its spread substantially, by half.
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Affiliation(s)
- Bruce Y. Lee
- Correspondence to Dr. Bruce Y. Lee, Public Health Computational and Operations Research, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD 21205 (e-mail: )
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21
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Guh AY, Bulens SN, Mu Y, Jacob JT, Reno J, Scott J, Wilson LE, Vaeth E, Lynfield R, Shaw KM, Vagnone PMS, Bamberg WM, Janelle SJ, Dumyati G, Concannon C, Beldavs Z, Cunningham M, Cassidy PM, Phipps EC, Kenslow N, Travis T, Lonsway D, Rasheed JK, Limbago BM, Kallen AJ. Epidemiology of Carbapenem-Resistant Enterobacteriaceae in 7 US Communities, 2012-2013. JAMA 2015; 314:1479-87. [PMID: 26436831 PMCID: PMC6492240 DOI: 10.1001/jama.2015.12480] [Citation(s) in RCA: 246] [Impact Index Per Article: 27.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
IMPORTANCE Carbapenem-resistant Enterobacteriaceae (CRE) are increasingly reported worldwide as a cause of infections with high-mortality rates. Assessment of the US epidemiology of CRE is needed to inform national prevention efforts. OBJECTIVE To determine the population-based CRE incidence and describe the characteristics and resistance mechanism associated with isolates from 7 US geographical areas. DESIGN, SETTING, AND PARTICIPANTS Population- and laboratory-based active surveillance of CRE conducted among individuals living in 1 of 7 US metropolitan areas in Colorado, Georgia, Maryland, Minnesota, New Mexico, New York, and Oregon. Cases of CRE were defined as carbapenem-nonsusceptible (excluding ertapenem) and extended-spectrum cephalosporin-resistant Escherichia coli, Enterobacter aerogenes, Enterobacter cloacae complex, Klebsiella pneumoniae, or Klebsiella oxytoca that were recovered from sterile-site or urine cultures during 2012-2013. Case records were reviewed and molecular typing for common carbapenemases was performed. EXPOSURES Demographics, comorbidities, health care exposures, and culture source and location. MAIN OUTCOMES AND MEASURES Population-based CRE incidence, site-specific standardized incidence ratios (adjusted for age and race), and clinical and microbiological characteristics. RESULTS Among 599 CRE cases in 481 individuals, 520 (86.8%; 95% CI, 84.1%-89.5%) were isolated from urine and 68 (11.4%; 95% CI, 8.8%-13.9%) from blood. The median age was 66 years (95% CI, 62.1-65.4 years) and 284 (59.0%; 95% CI, 54.6%-63.5%) were female. The overall annual CRE incidence rate per 100<000 population was 2.93 (95% CI, 2.65-3.23). The CRE standardized incidence ratio was significantly higher than predicted for the sites in Georgia (1.65 [95% CI, 1.20-2.25]; P < .001), Maryland (1.44 [95% CI, 1.06-1.96]; P = .001), and New York (1.42 [95% CI, 1.05-1.92]; P = .048), and significantly lower than predicted for the sites in Colorado (0.53 [95% CI, 0.39-0.71]; P < .001), New Mexico (0.41 [95% CI, 0.30-0.55]; P = .01), and Oregon (0.28 [95% CI, 0.21-0.38]; P < .001). Most cases occurred in individuals with prior hospitalizations (399/531 [75.1%; 95% CI, 71.4%-78.8%]) or indwelling devices (382/525 [72.8%; 95% CI, 68.9%-76.6%]); 180 of 322 (55.9%; 95% CI, 50.0%-60.8%) admitted cases resulted in a discharge to a long-term care setting. Death occurred in 51 (9.0%; 95% CI, 6.6%-11.4%) cases, including in 25 of 91 cases (27.5%; 95% CI, 18.1%-36.8%) with CRE isolated from normally sterile sites. Of 188 isolates tested, 90 (47.9%; 95% CI, 40.6%-55.1%) produced a carbapenemase. CONCLUSIONS AND RELEVANCE In this population- and laboratory-based active surveillance system in 7 states, the incidence of CRE was 2.93 per 100<000 population. Most CRE cases were isolated from a urine source, and were associated with high prevalence of prior hospitalizations or indwelling devices, and discharge to long-term care settings.
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Affiliation(s)
- Alice Y Guh
- Division of Healthcare Quality Promotion, US Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Sandra N Bulens
- Division of Healthcare Quality Promotion, US Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Yi Mu
- Division of Healthcare Quality Promotion, US Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Jesse T Jacob
- Emory University School of Medicine, Atlanta, Georgia3Georgia Emerging Infections Program, Decatur
| | - Jessica Reno
- Georgia Emerging Infections Program, Decatur4Atlanta Research and Education Foundation, Decatur, Georgia5Atlanta Veterans Affairs Medical Center, Atlanta, Georgia
| | - Janine Scott
- Georgia Emerging Infections Program, Decatur4Atlanta Research and Education Foundation, Decatur, Georgia5Atlanta Veterans Affairs Medical Center, Atlanta, Georgia
| | - Lucy E Wilson
- Maryland Department of Health and Mental Hygiene, Baltimore
| | | | | | | | | | - Wendy M Bamberg
- Colorado Department of Public Health and Environment, Denver
| | - Sarah J Janelle
- Colorado Department of Public Health and Environment, Denver
| | - Ghinwa Dumyati
- New York Emerging Infections Program and University of Rochester Medical Center, Rochester
| | - Cathleen Concannon
- New York Emerging Infections Program and University of Rochester Medical Center, Rochester
| | | | | | | | | | | | - Tatiana Travis
- Division of Healthcare Quality Promotion, US Centers for Disease Control and Prevention, Atlanta, Georgia
| | - David Lonsway
- Division of Healthcare Quality Promotion, US Centers for Disease Control and Prevention, Atlanta, Georgia
| | - J Kamile Rasheed
- Division of Healthcare Quality Promotion, US Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Brandi M Limbago
- Division of Healthcare Quality Promotion, US Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Alexander J Kallen
- Division of Healthcare Quality Promotion, US Centers for Disease Control and Prevention, Atlanta, Georgia
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22
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Epstein L, Mu Y, Belflower R, Scott J, Ray S, Dumyati G, Felsen C, Petit S, Yousey-Hindes K, Nadle J, Pasutti L, Lynfield R, Warnke L, Schaffner W, Leib K, Kallen AJ, Fridkin SK, Lessa FC. Risk Factors for Invasive Methicillin-Resistant Staphylococcus aureus Infection After Recent Discharge From an Acute-Care Hospitalization, 2011-2013. Clin Infect Dis 2015; 62:45-52. [PMID: 26338787 DOI: 10.1093/cid/civ777] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2015] [Accepted: 08/21/2015] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Significant progress has been made in reducing methicillin-resistant Staphylococcus aureus (MRSA) infections among hospitalized patients. However, the decreases in invasive MRSA infections among recently discharged patients have been less substantial. To inform prevention strategies, we assessed risk factors for invasive MRSA infection after acute-care hospitalizations. METHODS We conducted a prospective, matched case-control study. A case was defined as MRSA cultured from a normally sterile body site in a patient discharged from a hospital within the prior 12 weeks. Eligible case patients were identified from 15 hospitals across 6 US states. For each case patient, 2 controls were matched for hospital, month of discharge, and age group. Medical record reviews and telephone interviews were performed. Conditional logistic regression was used to identify independent risk factors for postdischarge invasive MRSA. RESULTS From 1 February 2011 through 31 March 2013, 194 case patients and 388 matched controls were enrolled. The median time between hospital discharge and positive culture was 23 days (range, 1-83 days). Factors independently associated with postdischarge MRSA infection included MRSA colonization (matched odds ratio [mOR], 7.71; 95% confidence interval [CI], 3.60-16.51), discharge to a nursing home (mOR, 2.65; 95% CI, 1.41-4.99), presence of a chronic wound during the postdischarge period (mOR, 4.41; 95% CI, 2.14-9.09), and discharge with a central venous catheter (mOR, 2.16; 95% CI, 1.13-4.99) or a different invasive device (mOR, 3.03; 95% CI, 1.24-7.39) in place. CONCLUSIONS Prevention efforts should target patients with MRSA colonization or those with invasive devices or chronic wounds at hospital discharge. In addition, MRSA prevention efforts in nursing homes are warranted.
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Affiliation(s)
- Lauren Epstein
- Division of Healthcare Quality Promotion Epidemic Intelligence Service, Centers for Disease Control and Prevention
| | - Yi Mu
- Division of Healthcare Quality Promotion
| | | | | | - Susan Ray
- Emory University School of Medicine, Atlanta Georgia Emerging Infections Program, Decatur
| | | | | | - Susan Petit
- Connecticut Department of Public Health, Hartford
| | | | | | | | | | | | - William Schaffner
- Vanderbilt University School of Medicine Tennessee Emerging Infections Program, Nashville
| | - Karen Leib
- Vanderbilt University School of Medicine Tennessee Emerging Infections Program, Nashville
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23
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Chung WM, Smith JC, Weil LM, Hughes SM, Joyner SN, Hall EM, Ritch J, Srinath D, Goodman E, Chevalier MS, Epstein L, Hunter JC, Kallen AJ, Karwowski MP, Kuhar DT, Smith C, Petersen LR, Mahon BE, Lakey DL, Schrag SJ. Active Tracing and Monitoring of Contacts Associated With the First Cluster of Ebola in the United States. Ann Intern Med 2015; 163:164-73. [PMID: 26005809 DOI: 10.7326/m15-0968] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Following hospitalization of the first patient with Ebola virus disease diagnosed in the United States on 28 September 2014, contact tracing methods for Ebola were implemented. OBJECTIVE To identify, risk-stratify, and monitor contacts of patients with Ebola. DESIGN Descriptive investigation. SETTING Dallas County, Texas, September to November 2014. PARTICIPANTS Contacts of symptomatic patients with Ebola. MEASUREMENTS Contact identification, exposure risk classification, symptom development, and Ebola. RESULTS The investigation identified 179 contacts, 139 of whom were contacts of the index patient. Of 112 health care personnel (HCP) contacts of the index case, 22 (20%) had known unprotected exposures and 37 (30%) did not have known unprotected exposures but interacted with a patient or contaminated environment on multiple days. Transmission was confirmed in 2 HCP who had substantial interaction with the patient while wearing personal protective equipment. These HCP had 40 additional contacts. Of 20 community contacts of the index patient or the 2 HCP, 4 had high-risk exposures. Movement restrictions were extended to all 179 contacts; 7 contacts were quarantined. Seven percent (14 of 179) of contacts (1 community contact and 13 health care contacts) were evaluated for Ebola during the monitoring period. LIMITATION Data cannot be used to infer whether in-person direct active monitoring is superior to active monitoring alone for early detection of symptomatic contacts. CONCLUSION Contact tracing and monitoring approaches for Ebola were adapted to account for the evolving understanding of risks for unrecognized HCP transmission. HCP contacts in the United States without known unprotected exposures should be considered as having a low (but not zero) risk for Ebola and should be actively monitored for symptoms. Core challenges of contact tracing for high-consequence communicable diseases included rapid comprehensive contact identification, large-scale direct active monitoring of contacts, large-scale application of movement restrictions, and necessity of humanitarian support services to meet nonclinical needs of contacts. PRIMARY FUNDING SOURCE None.
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Affiliation(s)
- Wendy M. Chung
- From Dallas County Department of Health and Human Services and Texas Health Resources, Dallas, Texas; Centers for Disease Control and Atlanta, Georgia; and Texas Department of State Health Services, Austin, Texas
| | - Jessica C. Smith
- From Dallas County Department of Health and Human Services and Texas Health Resources, Dallas, Texas; Centers for Disease Control and Atlanta, Georgia; and Texas Department of State Health Services, Austin, Texas
| | - Lauren M. Weil
- From Dallas County Department of Health and Human Services and Texas Health Resources, Dallas, Texas; Centers for Disease Control and Atlanta, Georgia; and Texas Department of State Health Services, Austin, Texas
| | - Sonya M. Hughes
- From Dallas County Department of Health and Human Services and Texas Health Resources, Dallas, Texas; Centers for Disease Control and Atlanta, Georgia; and Texas Department of State Health Services, Austin, Texas
| | - Sibeso N. Joyner
- From Dallas County Department of Health and Human Services and Texas Health Resources, Dallas, Texas; Centers for Disease Control and Atlanta, Georgia; and Texas Department of State Health Services, Austin, Texas
| | - Emily M. Hall
- From Dallas County Department of Health and Human Services and Texas Health Resources, Dallas, Texas; Centers for Disease Control and Atlanta, Georgia; and Texas Department of State Health Services, Austin, Texas
| | - Julia Ritch
- From Dallas County Department of Health and Human Services and Texas Health Resources, Dallas, Texas; Centers for Disease Control and Atlanta, Georgia; and Texas Department of State Health Services, Austin, Texas
| | - Divya Srinath
- From Dallas County Department of Health and Human Services and Texas Health Resources, Dallas, Texas; Centers for Disease Control and Atlanta, Georgia; and Texas Department of State Health Services, Austin, Texas
| | - Edward Goodman
- From Dallas County Department of Health and Human Services and Texas Health Resources, Dallas, Texas; Centers for Disease Control and Atlanta, Georgia; and Texas Department of State Health Services, Austin, Texas
| | - Michelle S. Chevalier
- From Dallas County Department of Health and Human Services and Texas Health Resources, Dallas, Texas; Centers for Disease Control and Atlanta, Georgia; and Texas Department of State Health Services, Austin, Texas
| | - Lauren Epstein
- From Dallas County Department of Health and Human Services and Texas Health Resources, Dallas, Texas; Centers for Disease Control and Atlanta, Georgia; and Texas Department of State Health Services, Austin, Texas
| | - Jennifer C. Hunter
- From Dallas County Department of Health and Human Services and Texas Health Resources, Dallas, Texas; Centers for Disease Control and Atlanta, Georgia; and Texas Department of State Health Services, Austin, Texas
| | - Alexander J. Kallen
- From Dallas County Department of Health and Human Services and Texas Health Resources, Dallas, Texas; Centers for Disease Control and Atlanta, Georgia; and Texas Department of State Health Services, Austin, Texas
| | - Mateusz P. Karwowski
- From Dallas County Department of Health and Human Services and Texas Health Resources, Dallas, Texas; Centers for Disease Control and Atlanta, Georgia; and Texas Department of State Health Services, Austin, Texas
| | - David T. Kuhar
- From Dallas County Department of Health and Human Services and Texas Health Resources, Dallas, Texas; Centers for Disease Control and Atlanta, Georgia; and Texas Department of State Health Services, Austin, Texas
| | - Charnetta Smith
- From Dallas County Department of Health and Human Services and Texas Health Resources, Dallas, Texas; Centers for Disease Control and Atlanta, Georgia; and Texas Department of State Health Services, Austin, Texas
| | - Lyle R. Petersen
- From Dallas County Department of Health and Human Services and Texas Health Resources, Dallas, Texas; Centers for Disease Control and Atlanta, Georgia; and Texas Department of State Health Services, Austin, Texas
| | - Barbara E. Mahon
- From Dallas County Department of Health and Human Services and Texas Health Resources, Dallas, Texas; Centers for Disease Control and Atlanta, Georgia; and Texas Department of State Health Services, Austin, Texas
| | - David L. Lakey
- From Dallas County Department of Health and Human Services and Texas Health Resources, Dallas, Texas; Centers for Disease Control and Atlanta, Georgia; and Texas Department of State Health Services, Austin, Texas
| | - Stephanie J. Schrag
- From Dallas County Department of Health and Human Services and Texas Health Resources, Dallas, Texas; Centers for Disease Control and Atlanta, Georgia; and Texas Department of State Health Services, Austin, Texas
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Albrecht VS, Zervos MJ, Kaye KS, Tosh PK, Arshad S, Hayakawa K, Kallen AJ, McDougal LK, Limbago BM, Guh AY. Prevalence of and Risk Factors for Vancomycin-Resistant Staphylococcus aureus Precursor Organisms in Southeastern Michigan. Infect Control Hosp Epidemiol 2015. [DOI: 10.1086/593316] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
We assessed for vancomycin-resistantStaphylococcus aureus(VRSA) precursor organisms in southeastern Michigan, an area known to have VRSA. The prevalence was 2.5% (pSK41-positive methicillin-resistantS. aureus, 2009–2011) and 1.5% (Inc18-positive vancomycin-resistantEnterococcus, 2006–2013); Inc18 prevalence significantly decreased after 2009 (3.7% to 0.82%). Risk factors for pSK41 included intravenous vancomycin exposure.Infect Control Hosp Epidemiol2014;35(12):1531–1534
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Kallen AJ, Lederman E, Balaji A, Trevino I, Petersen EE, Shoulson R, Saiman L, Horn EM, Gomberg-Maitland M, Barst RJ, Srinivasan A. Bloodstream Infections in Patients Given Treatment With Intravenous Prostanoids. Infect Control Hosp Epidemiol 2015; 29:342-9. [DOI: 10.1086/529552] [Citation(s) in RCA: 77] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Objective.In September 2006, the Centers for Disease Control and Prevention was notified of cases of gram-negative bloodstream infection (BSI) occurring among outpatients who received an intravenous formulation of the prostanoid treprostinil. An investigation was conducted to determine rates of prostanoid-associated BSI in this patient population and possible risk factors for infection.Methods.We performed a retrospective cohort study of patients who had received intravenous formulations of at least 1 of the 2 approved prostanoids (epoprostenol and treprostinil) from January 1, 2004, through late 2006. Chart reviews were conducted at 2 large centers for pulmonary arterial hypertension, and a survey of infection control practices was conducted at 1 center.Results.A total of 224 patients were given intravenous prostanoid treatment, corresponding to 146,093 treatment-days during the study period. Overall, there were 0.55 cases of BSI and 0.18 cases of BSI due to gram-negative organisms per 1,000 treatment-days. BSI rates were higher for patients who received intravenous treprostinil than for patients who received intravenous epoprostenol (1.13 vs. 0.42 BSIs per 1,000 treatment-days; P < .001), as were rates of BSI due to gram-negative organisms (0.81 vs. 0.04 BSIs per 1,000 treatment-days; P < .001). Adjusted hazard ratios for all BSIs and for BSIs due to gram-negative organisms were higher among patients given treatment with intravenous treprostinil. The survey identified no significant differences in medication-related infection control practices.Conclusion.At 2 centers, BSI due to gram-negative pathogens was more common than previously reported and was more frequent among patients given treatment with intravenous treprostinil than among patients given treatment with intravenous epoprostenol. Whether similar results would be found at other centers for pulmonary arterial hypertension warrants further investigation. This investigation underscores the importance of surveillance and evaluation of healthcare-related adverse events in patients given treatment primarily as outpatients.
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26
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Feng PJI, Kallen AJ, Ellingson K, Muder R, Jain R, Jernigan JA. Clinical Incidence of Methicillin-Resistant Staphylococcus aureus (MRSA) Colonization or Infection as a Proxy Measure for MRSA Transmission in Acute Care Hospitals. Infect Control Hosp Epidemiol 2015; 32:20-5. [DOI: 10.1086/657668] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Background.The incidence of methicillin-resistant Staphylococcus aureus (MRSA) colonization or infection has been used as a proxy measure for MRSA transmission, but incidence calculations vary depending on whether active surveillance culture (ASC) data are included.Objective.To evaluate the relationship between incidences of MRSA colonization or infection calculated with and without ASCs in intensive care units and non-intensive care units.Setting.A Veterans Affairs medical center.Methods.From microbiology records, incidences of MRSA colonization or infection were calculated with and without ASC data. Correlation coefficients were calculated for the 2 measures, and Poisson regression was used to model temporal trends. A Poisson interaction model was used to test for differences in incidence trends modeled with and without ASCs.Results.The incidence of MRSA colonization or infection calculated with ASCs was 4.9 times higher than that calculated without ASCs. Correlation coefficients for incidences with and without ASCs were 0.42 for intensive care units, 0.59 for non-intensive care units, and 0.48 hospital-wide. Trends over time for the hospital were similar with and without ASCs (incidence rate ratio with ASCs, 0.95 [95% confidence interval, 0.93-0.97]; incidence rate ratio without ASCs, 0.95 [95% confidence interval, 0.92-0.99]; P = .68). Without ASCs, 35% of prevalent cases were falsely classified as incident.Conclusions.At 1 Veterans Affairs medical center, the incidence of MRSA colonization or infection calculated solely on the basis of clinical culture results commonly misclassified incident cases and underestimated incidence, compared with measures that included ASCs; however, temporal changes were similar. These findings suggest that incidence measured without ASCs may not accurately reflect the magnitude of MRSA transmission but may be useful for monitoring transmission trends over time, a crucial element for evaluating the impact of prevention activities.
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Kallen AJ, Hidron AI, Patel J, Srinivasan A. Multidrug Resistance among Gram-Negative Pathogens That Caused
Healthcare-Associated Infections Reported to the National Healthcare Safety
Network, 2006–2008. Infect Control Hosp Epidemiol 2015; 31:528-31. [DOI: 10.1086/652152] [Citation(s) in RCA: 119] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
We evaluated isolates of Klebsiella pneumoniae, Pseudomonas
aeruginosa, and Acinetobacter
baumannii that were reported to the National Healthcare Safety
Network from January 2006 through December 2008 to determine the proportion that
represented multidrug-resistant phenotypes. The pooled mean percentage of
resistance varied by the definition used; however, multidrug resistance was
relatively common and widespread.
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28
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Wise ME, Weber SG, Schneider A, Stojcevski M, France AM, Schaefer MK, Lin MY, Kallen AJ, Cochran RL. Hospital Staff Perceptions of a Legislative Mandate for Methicillin-Resistant Staphylococcus aureus Screening. Infect Control Hosp Epidemiol 2015; 32:573-8. [DOI: 10.1086/660016] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Objective.In August 2007, Illinois passed legislation mandating methicillin-resistant Staphylococcus aureus (MRSA) admission screening for intensive care unit patients. We assessed hospital staff perceptions of the implementation of this law.Design.Mixed-methods evaluation using structured focus groups and questionnaires.Setting.Eight Chicago-area hospitals.Participants.Three strata of staff (leadership, midlevel, and frontline) at each hospital.Methods.All participants completed a questionnaire and participated in a focus group. Focus group transcripts were thematically coded and analyzed. The proportion of staff agreeing with statements about MRSA and the legislation was compared across staff types.Results.Overall, 126 hospital staff participated in 23 focus groups. Fifty-six percent of participants agreed that the legislation had a positive effect at their facility; frontline staff were more likely to agree than midlevel and leadership staff (P < .01). Perceived benefits of the legislation included increased awareness of MRSA among staff and better knowledge of the epidemiology of MRSA colonization. Perceived negative consequences included the psychosocial effect of screening and contact precautions on patients and increased use of resources. Most participants (59%) would choose to continue the activities associated with the legislation but advised facilities in states considering similar legislation to educate staff and patients about MRSA screening and to draft clear implementation plans.Conclusion.Staff from Chicago-area hospitals perceived that mandatory MRSA screening legislation resulted in some benefits but highlighted implementation challenges. States considering similar initiatives might minimize these challenges by optimizing messaging to patients and healthcare staff, drafting implementation plans, and developing program evaluation strategies.
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29
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Kallen AJ, Srinivasan A. Current Epidemiology of Multidrug-Resistant Gram-Negative Bacilli in the United States. Infect Control Hosp Epidemiol 2015; 31 Suppl 1:S51-4. [DOI: 10.1086/655996] [Citation(s) in RCA: 56] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Gram-negative bacilli are an important cause of infection in healthcare and community settings. Antimicrobial resistance, including resistance to multiple antimicrobial classes, is an ongoing problem among gram-negative bacilli. This synopsis reviews the incidence of multidrug resistance among gram-negative bacilli in the United States and describes emerging issues in their epidemiology.
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Epson EE, Pisney LM, Wendt JM, MacCannell DR, Janelle SJ, Kitchel B, Rasheed JK, Limbago BM, Gould CV, Kallen AJ, Barron MA, Bamberg WM. Carbapenem-resistant Klebsiella pneumoniae producing New Delhi metallo-β-lactamase at an acute care hospital, Colorado, 2012. Infect Control Hosp Epidemiol 2014; 35:390-7. [PMID: 24602944 DOI: 10.1086/675607] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To investigate an outbreak of New Delhi metallo-β-lactamase (NDM)-producing carbapenem-resistant Enterobacteriaceae (CRE) and determine interventions to interrupt transmission. DESIGN, SETTING, AND PATIENTS Epidemiologic investigation of an outbreak of NDM-producing CRE among patients at a Colorado acute care hospital. METHODS Case patients had NDM-producing CRE isolated from clinical or rectal surveillance cultures (SCs) collected during the period January 1, 2012, through October 20, 2012. Case patients were identified through microbiology records and 6 rounds of SCs in hospital units where they had resided. CRE isolates were tested by real-time polymerase chain reaction for blaNDM. Medical records were reviewed for epidemiologic links; relatedness of isolates was evaluated by pulsed-field gel electrophoresis (PFGE) and whole genome sequencing (WGS). Infection control (IC) was assessed through staff interviews and direct observations. RESULTS Two patients were initially identified with NDM-producing CRE during July-August 2012. A third case patient, admitted in May, was identified through microbiology records review. SC identified 5 additional case patients. Patients had resided in 11 different units before identification. All isolates were highly related by PFGE. WGS suggested 3 clusters of CRE. Combining WGS with epidemiology identified 4 units as likely transmission sites. NDM-producing CRE positivity in certain patients was not explained by direct epidemiologic overlap, which suggests that undetected colonized patients were involved in transmission. CONCLUSIONS A 4-month outbreak of NDM-producing CRE occurred at a single hospital, highlighting the risk for spread of these organisms. Combined WGS and epidemiologic data suggested transmission primarily occurred on 4 units. Timely SC, combined with targeted IC measures, were likely responsible for controlling transmission.
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Affiliation(s)
- Erin E Epson
- Epidemic Intelligence Service, Centers for Disease Control and Prevention, Atlanta, Georgia
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Pereira EC, Shaw KM, Vagnone PMS, Harper JE, Kallen AJ, Limbago BM, Lynfield R. Thirty-day laboratory-based surveillance for carbapenem-resistant Enterobacteriaceae in the Minneapolis-St. Paul metropolitan area. Infect Control Hosp Epidemiol 2014; 35:423-5. [PMID: 24602949 DOI: 10.1086/675602] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Carbapenem-resistant Enterobacteriaceae (CRE) are a growing problem in the United States. We explored the feasibility of active laboratory-based surveillance of CRE in a metropolitan area not previously considered to be an area of CRE endemicity. We provide a framework to address CRE surveillance and to monitor changes in the incidence of CRE infection over time.
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Affiliation(s)
- Edwin C Pereira
- Division of Infectious Diseases and International Medicine; University of Minnesota, Minneapolis, Minnesota
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32
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Albrecht VS, Zervos MJ, Kaye KS, Tosh PK, Arshad S, Hayakawa K, Kallen AJ, McDougal LK, Limbago BM, Guh AY. Prevalence of and risk factors for vancomycin-resistant Staphylococcus aureus precursor organisms in Southeastern Michigan. Infect Control Hosp Epidemiol 2014; 35:1531-4. [PMID: 25419776 DOI: 10.1086/678605] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
We assessed for vancomycin-resistant Staphylococcus aureus (VRSA) precursor organisms in southeastern Michigan, an area known to have VRSA. The prevalence was 2.5% (pSK41-positive methicillin-resistant S. aureus, 2009-2011) and 1.5% (Inc18-positive vancomycin-resistant Enterococcus, 2006-2013); Inc18 prevalence significantly decreased after 2009 (3.7% to 0.82%). Risk factors for pSK41 included intravenous vancomycin exposure.
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Affiliation(s)
- Valerie S Albrecht
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
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33
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Epstein L, Hunter JC, Arwady MA, Tsai V, Stein L, Gribogiannis M, Frias M, Guh AY, Laufer AS, Black S, Pacilli M, Moulton-Meissner H, Rasheed JK, Avillan JJ, Kitchel B, Limbago BM, MacCannell D, Lonsway D, Noble-Wang J, Conway J, Conover C, Vernon M, Kallen AJ. New Delhi metallo-β-lactamase-producing carbapenem-resistant Escherichia coli associated with exposure to duodenoscopes. JAMA 2014; 312:1447-55. [PMID: 25291580 PMCID: PMC10877559 DOI: 10.1001/jama.2014.12720] [Citation(s) in RCA: 297] [Impact Index Per Article: 29.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
IMPORTANCE Carbapenem-resistant Enterobacteriaceae (CRE) producing the New Delhi metallo-β-lactamase (NDM) are rare in the United States, but have the potential to add to the increasing CRE burden. Previous NDM-producing CRE clusters have been attributed to person-to-person transmission in health care facilities. OBJECTIVE To identify a source for, and interrupt transmission of, NDM-producing CRE in a northeastern Illinois hospital. DESIGN, SETTING, AND PARTICIPANTS Outbreak investigation among 39 case patients at a tertiary care hospital in northeastern Illinois, including a case-control study, infection control assessment, and collection of environmental and device cultures; patient and environmental isolate relatedness was evaluated with pulsed-field gel electrophoresis (PFGE). Following identification of a likely source, targeted patient notification and CRE screening cultures were performed. MAIN OUTCOMES AND MEASURES Association between exposure and acquisition of NDM-producing CRE; results of environmental cultures and organism typing. RESULTS In total, 39 case patients were identified from January 2013 through December 2013, 35 with duodenoscope exposure in 1 hospital. No lapses in duodenoscope reprocessing were identified; however, NDM-producing Escherichia coli was recovered from a reprocessed duodenoscope and shared more than 92% similarity to all case patient isolates by PFGE. Based on the case-control study, case patients had significantly higher odds of being exposed to a duodenoscope (odds ratio [OR], 78 [95% CI, 6.0-1008], P < .001). After the hospital changed its reprocessing procedure from automated high-level disinfection with ortho-phthalaldehyde to gas sterilization with ethylene oxide, no additional case patients were identified. CONCLUSIONS AND RELEVANCE In this investigation, exposure to duodenoscopes with bacterial contamination was associated with apparent transmission of NDM-producing E coli among patients at 1 hospital. Bacterial contamination of duodenoscopes appeared to persist despite the absence of recognized reprocessing lapses. Facilities should be aware of the potential for transmission of bacteria including antimicrobial-resistant organisms via this route and should conduct regular reviews of their duodenoscope reprocessing procedures to ensure optimal manual cleaning and disinfection.
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Affiliation(s)
- Lauren Epstein
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia2Epidemic Intelligence Service, Division of Scientific Education and Professional Development, Centers for Disease Control and Prevention, Atlanta, Georg
| | - Jennifer C Hunter
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia2Epidemic Intelligence Service, Division of Scientific Education and Professional Development, Centers for Disease Control and Prevention, Atlanta, Georg
| | - M Allison Arwady
- Epidemic Intelligence Service, Division of Scientific Education and Professional Development, Centers for Disease Control and Prevention, Atlanta, Georgia3Illinois Department of Public Health, Chicago, Illinois
| | - Victoria Tsai
- Illinois Department of Public Health, Chicago, Illinois
| | - Linda Stein
- Advocate Lutheran General Hospital, Park Ridge, Illinois
| | | | - Mabel Frias
- Cook County Department of Public Health, Oak Forest, Illinois
| | - Alice Y Guh
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Alison S Laufer
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | | | | | - Heather Moulton-Meissner
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - J Kamile Rasheed
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Johannetsy J Avillan
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Brandon Kitchel
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Brandi M Limbago
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Duncan MacCannell
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - David Lonsway
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Judith Noble-Wang
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Judith Conway
- Illinois Department of Public Health, Chicago, Illinois
| | - Craig Conover
- Illinois Department of Public Health, Chicago, Illinois
| | - Michael Vernon
- Cook County Department of Public Health, Oak Forest, Illinois
| | - Alexander J Kallen
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
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Gupta N, Hocevar SN, Moulton-Meissner HA, Stevens KM, McIntyre MG, Jensen B, Kuhar DT, Noble-Wang JA, Schnatz RG, Becker SC, Kastango ES, Shehab N, Kallen AJ. Outbreak of Serratia marcescens bloodstream infections in patients receiving parenteral nutrition prepared by a compounding pharmacy. Clin Infect Dis 2014; 59:1-8. [PMID: 24729502 DOI: 10.1093/cid/ciu218] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Compounding pharmacies often prepare parenteral nutrition (PN) and must adhere to rigorous standards to avoid contamination of the sterile preparation. In March 2011, Serratia marcescens bloodstream infections (BSIs) were identified in 5 patients receiving PN from a single compounding pharmacy. An investigation was conducted to identify potential sources of contamination and prevent further infections. METHODS Cases were defined as S. marcescens BSIs in patients receiving PN from the pharmacy between January and March 2011. We reviewed case patients' clinical records, evaluated pharmacy compounding practices, and obtained epidemiologically directed environmental cultures. Molecular relatedness of available Serratia isolates was determined by pulsed-field gel electrophoresis (PFGE). RESULTS Nineteen case patients were identified; 9 died. The attack rate for patients receiving PN in March was 35%. No case patients were younger than 18 years. In October 2010, the pharmacy began compounding and filter-sterilizing amino acid solution for adult PN using nonsterile amino acids due to a national manufacturer shortage. Review of this process identified breaches in mixing, filtration, and sterility testing practices. S. marcescens was identified from a pharmacy water faucet, mixing container, and opened amino acid powder. These isolates were indistinguishable from the outbreak strain by PFGE. CONCLUSIONS Compounding of nonsterile amino acid components of PN was initiated due to a manufacturer shortage. Failure to follow recommended compounding standards contributed to an outbreak of S. marcescens BSIs. Improved adherence to sterile compounding standards, critical examination of standards for sterile compounding from nonsterile ingredients, and more rigorous oversight of compounding pharmacies is needed to prevent future outbreaks.
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Affiliation(s)
- Neil Gupta
- Epidemic Intelligence Service Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Susan N Hocevar
- Epidemic Intelligence Service Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | | | | | | | - Bette Jensen
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - David T Kuhar
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Judith A Noble-Wang
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Rick G Schnatz
- Healthcare Quality Standards, United States Pharmacopeia, Rockville, Maryland
| | - Shawn C Becker
- Healthcare Quality Standards, United States Pharmacopeia, Rockville, Maryland
| | | | - Nadine Shehab
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Alexander J Kallen
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
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Abstract
Carbapenem-resistant Enterobacteriaceae (CRE) are multidrug-resistant organisms with few treatment options that cause infections associated with substantial morbidity and mortality. CRE outbreaks have been increasingly reported worldwide and are mainly due to the emergence and spread of strains that produce carbapenemases. In the United States, transmission of CRE is primarily driven by the spread of organisms carrying the Klebsiella pneumoniae carbapenemase enzyme, but other carbapenemase enzymes, such as the New-Delhi metallo-β-lactamase, have also emerged. Currently recommended control strategies for healthcare facilities include the detection of patients infected or colonized with CRE and implementation of measures to prevent further spread. In addition to efforts in individual facilities, effective CRE control requires coordination across all healthcare facilities in a region. This review describes the current epidemiology and surveillance of CRE in the United States and the recommended approach to prevention.
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Affiliation(s)
- Alice Y Guh
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, GA, USA
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36
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Patel PR, Kallen AJ. Bloodstream Infection Prevention in ESRD: Forging a Pathway for Success. Am J Kidney Dis 2014; 63:180-2. [DOI: 10.1053/j.ajkd.2013.11.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2013] [Accepted: 11/05/2013] [Indexed: 11/11/2022]
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38
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See I, Shugart A, Lamb C, Kallen AJ, Patel PR, Sinkowitz-Cochran RL. Infection control and bloodstream infection prevention: the perspective of patients receiving hemodialysis. Nephrol Nurs J 2014; 41:37-40. [PMID: 24689263 PMCID: PMC4697925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Patients on hemodialysis, particularly those dialyzed through central lines, are at risk of acquiring bloodstream infections. Strategies to prevent bloodstream infections in patients on dialysis include educating patients about infection prevention, although patients' perspectives on this topic are not known. During focus groups conducted to explore these issues, patients reported that education on infection prevention should begin early in the process of dialysis, and that patients should be actively engaged as partners in infection prevention.
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Peterson AE, Chitnis AS, Xiang N, Scaletta JM, Geist R, Schwartz J, DeMent J, Lawlor E, LiPuma JJ, O'Connell H, Noble-Wang J, Kallen AJ, Hunt DC. Clonally related Burkholderia contaminans among ventilated patients without cystic fibrosis. Am J Infect Control 2013; 41:1298-300. [PMID: 23973426 DOI: 10.1016/j.ajic.2013.05.015] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2013] [Revised: 05/13/2013] [Accepted: 05/14/2013] [Indexed: 10/26/2022]
Abstract
We investigated a cluster of 10 Burkholderia cepacia complex-positive cultures among ventilated patients and those with a tracheostomy in an acute care hospital. Isolates from 5 patients had outbreak-strain-related Burkholderia contaminans. Isolates of B. cepacia complex unrelated to the outbreak strain were cultured from a sink drain. The investigation identified practices that might have led to contamination of patient respiratory care supplies with tap water, which might have contributed to the cluster.
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40
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Rasheed JK, Kitchel B, Zhu W, Anderson KF, Clark NC, Ferraro MJ, Savard P, Humphries RM, Kallen AJ, Limbago BM. New Delhi metallo-β-lactamase-producing Enterobacteriaceae, United States. Emerg Infect Dis 2013; 19:870-8. [PMID: 23731823 PMCID: PMC3713825 DOI: 10.3201/eid1906.121515] [Citation(s) in RCA: 111] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
We characterized 9 New Delhi metallo-β-lactamase-producing Enterobacteriaceae (5 Klebsiella pneumoniae, 2 Escherichia coli, 1 Enterobacter cloacae, 1 Salmonella enterica serovar Senftenberg) isolates identified in the United States and cultured from 8 patients in 5 states during April 2009-March 2011. Isolates were resistant to β-lactams, fluoroquinolones, and aminoglycosides, demonstrated MICs ≤1 µg/mL of colistin and polymyxin, and yielded positive metallo-β-lactamase screening results. Eight isolates had blaNDM-1, and 1 isolate had a novel allele (blaNDM-6). All 8 patients had recently been in India or Pakistan, where 6 received inpatient health care. Plasmids carrying blaNDM frequently carried AmpC or extended spectrum β-lactamase genes. Two K. pneumoniae isolates and a K. pneumoniae isolate from Sweden shared incompatibility group A/C plasmids with indistinguishable restriction patterns and a common blaNDM fragment; all 3 were multilocus sequence type 14. Restriction profiles of the remaining New Delhi metallo-β-lactamase plasmids, including 2 from the same patient, were diverse.
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Affiliation(s)
- J Kamile Rasheed
- Antimicrobial Resistance and Characterization Laboratory, Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, 1600 Clifton Rd NE, Mailstop G08, Atlanta, GA 30329, USA.
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41
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Tosh PK, Agolory S, Strong BL, Verlee K, Finks J, Hayakawa K, Chopra T, Kaye KS, Gilpin N, Carpenter CF, Haque NZ, Lamarato LE, Zervos MJ, Albrecht VS, McAllister SK, Limbago B, Maccannell DR, McDougal LK, Kallen AJ, Guh AY. Prevalence and risk factors associated with vancomycin-resistant Staphylococcus aureus precursor organism colonization among patients with chronic lower-extremity wounds in Southeastern Michigan. Infect Control Hosp Epidemiol 2013; 34:954-60. [PMID: 23917910 DOI: 10.1086/671735] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BACKGROUND Of the 13 US vancomycin-resistant Staphylococcus aureus (VRSA) cases, 8 were identified in southeastern Michigan, primarily in patients with chronic lower-extremity wounds. VRSA infections develop when the vanA gene from vancomycin-resistant enterococcus (VRE) transfers to S. aureus. Inc18-like plasmids in VRE and pSK41-like plasmids in S. aureus appear to be important precursors to this transfer. OBJECTIVE Identify the prevalence of VRSA precursor organisms. DESIGN Prospective cohort with embedded case-control study. PARTICIPANTS Southeastern Michigan adults with chronic lower-extremity wounds. METHODS Adults presenting to 3 southeastern Michigan medical centers during the period February 15 through March 4, 2011, with chronic lower-extremity wounds had wound, nares, and perirectal swab specimens cultured for S. aureus and VRE, which were tested for pSK41-like and Inc18-like plasmids by polymerase chain reaction. We interviewed participants and reviewed clinical records. Risk factors for pSK41-positive S. aureus were assessed among all study participants (cohort analysis) and among only S. aureus-colonized participants (case-control analysis). RESULTS Of 179 participants with wound cultures, 26% were colonized with methicillin-susceptible S. aureus, 27% were colonized with methicillin-resistant S. aureus, and 4% were colonized with VRE, although only 17% consented to perirectal culture. Six participants (3%) had pSK41-positive S. aureus, and none had Inc18-positive VRE. Having chronic wounds for over 2 years was associated with pSK41-positive S. aureus colonization in both analyses. CONCLUSIONS Colonization with VRSA precursor organisms was rare. Having long-standing chronic wounds was a risk factor for pSK41-positive S. aureus colonization. Additional investigation into the prevalence of VRSA precursors among a larger cohort of patients is warranted.
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Affiliation(s)
- Pritish K Tosh
- Epidemic Intelligence Service, Centers for Disease Control and Prevention, Atlanta, Georgia, USA.
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Patel PR, Yi SH, Booth S, Bren V, Downham G, Hess S, Kelley K, Lincoln M, Morrissette K, Lindberg C, Jernigan JA, Kallen AJ. Bloodstream infection rates in outpatient hemodialysis facilities participating in a collaborative prevention effort: a quality improvement report. Am J Kidney Dis 2013; 62:322-30. [PMID: 23676763 DOI: 10.1053/j.ajkd.2013.03.011] [Citation(s) in RCA: 79] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2012] [Accepted: 03/06/2013] [Indexed: 12/17/2022]
Abstract
BACKGROUND Bloodstream infections (BSIs) cause substantial morbidity in hemodialysis patients. In 2009, the US Centers for Disease Control and Prevention (CDC) sponsored a collaborative project to prevent BSIs in outpatient hemodialysis facilities. We sought to assess the impact of a set of interventions on BSI and access-related BSI rates in participating facilities using data reported to the CDC's National Healthcare Safety Network (NHSN). STUDY DESIGN Quality improvement project. SETTING & PARTICIPANTS Patients in 17 outpatient hemodialysis facilities that volunteered to participate. QUALITY IMPROVEMENT PLAN Facilities reported monthly event and denominator data to NHSN, received guidance from the CDC, and implemented an evidence-based intervention package that included chlorhexidine use for catheter exit-site care, staff training and competency assessments focused on catheter care and aseptic technique, hand hygiene and vascular access care audits, and feedback of infection and adherence rates to staff. OUTCOMES Crude and modeled BSI and access-related BSI rates. MEASUREMENTS Up to 12 months of preintervention (January 2009 through December 2009) and 15 months of intervention period (January 2010 through March 2011) data from participating centers were analyzed. Segmented regression analysis was used to assess changes in BSI and access-related BSI rates during the preintervention and intervention periods. RESULTS Most (65%) participating facilities were hospital based. Pooled mean BSI and access-related BSI rates were 1.09 and 0.73 events per 100 patient-months during the preintervention period and 0.89 and 0.42 events per 100 patient-months during the intervention period, respectively. Modeled rates decreased 32% (P = 0.01) for BSIs and 54% (P < 0.001) for access-related BSIs at the start of the intervention period. LIMITATIONS Participating facilities were not representative of all outpatient hemodialysis centers nationally. There was no control arm to this quality improvement project. CONCLUSIONS Facilities participating in a collaborative successfully decreased their BSI and access-related BSI rates. The decreased rates appeared to be maintained in the intervention period. These findings suggest that improved implementation of recommended practices can reduce BSIs in hemodialysis centers.
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Affiliation(s)
- Priti R Patel
- Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA 30333, USA.
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Abstract
Bloodstream infections (BSIs) are a prominent clinical problem in patients undergoing hemodialysis. These infections appear to be more common among patients who have a central line as their dialysis access and can be associated with substantial morbidity and mortality. Accurately diagnosing BSIs clearly influences patient management, but is also an important part of an infection prevention program; particularly as facility BSI rates are becoming a recognized quality measure for which dialysis facilities might be held accountable. Blood cultures remain the gold standard for diagnosing BSIs and a number of practices can affect the sensitivity and specificity of this important laboratory test. Optimizing the collection of blood cultures can assist providers with interpretation of positive blood cultures and can help minimize the impact of false-positive and false-negative cultures. This review will describe differences between BSI definitions, examine the use of blood cultures to identify these infections including the use of recommended best practices to maximize culture yield, and highlight characteristics that can assist in the clinical interpretation of positive blood cultures.
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Affiliation(s)
- Alexander J Kallen
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, GA, USA.
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Snyder GM, Patel PR, Kallen AJ, Strom JA, Tucker JK, D'Agata EMC. Antimicrobial use in outpatient hemodialysis units. Infect Control Hosp Epidemiol 2013; 34:349-57. [PMID: 23466906 DOI: 10.1086/669869] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
OBJECTIVE To quantify and characterize overall antimicrobial use, including appropriateness of indication, among patients receiving chronic hemodialysis. DESIGN Retrospective and prospective observational study. SETTING Two outpatient hemodialysis units. PATIENTS All patients receiving chronic hemodialysis. METHODS The rate of parenteral antimicrobial use (number of doses per 100 patient-months) was calculated retrospectively from September 2008 through July 2011. Indication and appropriateness of antimicrobial doses were characterized prospectively from August 2010 through July 2011. Inappropriate administration was defined as occasions when criteria for infection based on national guidelines were not met, failure to choose a more narrow-spectrum antimicrobial on the basis of culture data, or occasions when indications for surgical prophylaxis were not met. RESULTS Over the 35-month retrospective study period, the rate of parenteral antimicrobial use was 32.9 doses per 100 patient-months. Vancomycin was the most commonly prescribed antimicrobial, followed by cefazolin and third- or fourth-generation cephalosporins. Over the 12-month prospective study, 1,003 antimicrobial doses were prescribed. Among the 926 (92.3%) doses for which an indication for administration was available, 276 (29.8%) were classified as inappropriate. Of these, a total of 146 (52.9%) did not meet criteria for infection, 74 (26.8%) represented failure to choose a more narrow-spectrum antimicrobial, and 56 (20.3%) did not meet criteria for surgical prophylaxis. The most common inappropriately prescribed antimicrobials were vancomycin and third- or fourth- generation cephalosporins. CONCLUSIONS Parenteral antimicrobial use was extensive, and as much as one-third was categorized as inappropriate. The findings of this study provide novel information toward minimizing inappropriate antimicrobial use.
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Affiliation(s)
- Graham M Snyder
- Division of Infectious Diseases, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, USA.
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Kallen AJ, Patel PR, Hess S. Intolerance of chlorhexidine as a skin antiseptic in patients undergoing hemodialysis. Infect Control Hosp Epidemiol 2012; 32:1144-6. [PMID: 22011549 DOI: 10.1086/662591] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Magill SS, Black SR, Wise ME, Kallen AJ, Lee SJ, Gardner T, Husain F, Srinivasan A, Gerber SI, Jhung M. Investigation of an outbreak of 2009 pandemic influenza A virus (H1N1) infections among healthcare personnel in a Chicago hospital. Infect Control Hosp Epidemiol 2011; 32:611-5. [PMID: 21558775 DOI: 10.1086/660097] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
In May 2009, we investigated a hospital outbreak of pandemic H1N1 (pH1N1) infection among healthcare personnel (HCP). Thirteen (65%) of 20 HCP with pH1N1 infection had healthcare-associated cases, which were primarily attributed to transmission among HCP. Eleven (55%) of HCP with pH1N1 infection worked for 1 day or more after the onset of illness. Personnel working with mild illness may have contributed to transmission among HCP.
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Affiliation(s)
- Shelley S Magill
- Centers for Disease Control and Prevention, Atlanta, Georgia 30333, USA.
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Jaeger JL, Patel M, Dharan N, Hancock K, Meites E, Mattson C, Gladden M, Sugerman D, Doshi S, Blau D, Harriman K, Whaley M, Sun H, Ginsberg M, Kao AS, Kriner P, Lindstrom S, Jain S, Katz J, Finelli L, Olsen SJ, Kallen AJ. Transmission of 2009 pandemic influenza A (H1N1) virus among healthcare personnel-Southern California, 2009. Infect Control Hosp Epidemiol 2011; 32:1149-57. [PMID: 22080652 DOI: 10.1086/662709] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
OBJECTIVE In April 2009, 2009 pandemic influenza A (H1N1) (hereafter, pH1N1) virus was identified in California, which caused widespread illness throughout the United States. We evaluated pH1N1 transmission among exposed healthcare personnel (HCP) and assessed the use and effectiveness of personal protective equipment (PPE) early in the outbreak. DESIGN Cohort study. SETTING Two hospitals and 1 outpatient clinic in Southern California during March 28-April 24, 2009. PARTICIPANTS Sixty-three HCP exposed to 6 of the first 8 cases of laboratory-confirmed pH1N1 in the United States. METHODS Baseline and follow-up questionnaires were used to collect demographic, epidemiologic, and clinical data. Paired serum samples were obtained to test for pH1N1-specific antibodies by microneutralization and hemagglutination-inhibition assays. Serology results were compared with HCP work setting, role, and self-reported PPE use. RESULTS Possible healthcare-associated pH1N1 transmission was identified in 9 (14%) of 63 exposed HCP; 6 (67%) of 9 seropositive HCP had asymptomatic infection. The highest attack rates occurred among outpatient HCP (6/19 [32%]) and among allied health staff (eg, technicians; 8/33 [24%]). Use of mask or N95 respirator was associated with remaining seronegative (P = .047). Adherence to PPE recommendations for preventing transmission of influenza virus and other respiratory pathogens was inadequate, particularly in outpatient settings. CONCLUSIONS pH1N1 transmission likely occurred in healthcare settings early in the pandemic associated with inadequate PPE use. Organizational support for a comprehensive approach to infectious hazards, including infection prevention training for inpatient- and outpatient-based HCP, is essential to improve HCP and patient safety.
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Affiliation(s)
- Jenifer L Jaeger
- Epidemic Intelligence Service, Centers for Disease Control and Prevention (CDC), Atlanta, Georgia, USA
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Abstract
Over the past 10 years, dissemination of Klebsiella pneumoniae carbapenemase (KPC) has led to an increase in the prevalence of carbapenem-resistant Enterobacteriaceae (CRE) in the United States. Infections caused by CRE have limited treatment options and have been associated with high mortality rates. In the previous year, other carbapenemase subtypes, including New Delhi metallo-β-lactamase, have been identified among Enterobacteriaceae in the United States. Like KPC, these enzymes are frequently found on mobile genetic elements and have the potential to spread widely. As a result, preventing both CRE transmission and CRE infections have become important public health objectives. This review describes the current epidemiology of CRE in the United States and highlights important prevention strategies.
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Affiliation(s)
- Neil Gupta
- Epidemic Intelligence Service, Centers for Disease Control and Prevention, 1600 Clifton Road NE, MS A-35, Atlanta, GA 30333, USA.
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Kallen AJ, Jernigan JA, Patel PR. Decolonization to Prevent Infections with Staphylococcus aureus in Patients Undergoing Hemodialysis: A Review of Current Evidence. Semin Dial 2011; 24:533-9. [DOI: 10.1111/j.1525-139x.2011.00959.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Wise ME, De Perio M, Halpin J, Jhung M, Magill S, Black SR, Gerber SI, Harriman K, Rosenberg J, Borlaug G, Finelli L, Olsen SJ, Swerdlow DL, Kallen AJ. Transmission of pandemic (H1N1) 2009 influenza to healthcare personnel in the United States. Clin Infect Dis 2011; 52 Suppl 1:S198-204. [PMID: 21342895 DOI: 10.1093/cid/ciq038] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
After identification of pandemic 2009 influenza (pH1N1) in the United States, the Centers for Disease Control and Prevention (CDC) worked with state and local health officials to characterize infections among healthcare personnel (HCP). Detailed information, including likely routes of exposure, was reported for 70 HCP from 22 states. Thirty-five cases (50%) were classified as being infected in healthcare settings, 18 cases (26%) were considered to have been infected in community settings, and no definitive source was identified for 17 cases (24%). Of the 23 HCP infected by ill patients, only 20% reported using an N95 respirator or surgical mask during all encounters and more than half worked in outpatient clinics. In addition to community transmission, likely patient-to-HCP and HCP-to-HCP transmission were identified in healthcare settings, highlighting the need for comprehensive infection control strategies including administration of influenza vaccine, appropriate management of ill HCP, and adherence to infection control precautions.
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Affiliation(s)
- Matthew E Wise
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia 30333, USA
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