Genevieve L. Buser

Acute kidney injury associated with smoking synthetic cannabinoid

Abstract Context and objectives. Synthetic cannabinoids are illegal drugs of abuse known to cause adverse neurologic and sympathomimetic effects. They are an emerging health risk: 11% of high school seniors reported smoking them during the previous 12 months. We describe the epidemiology of a toxicologic syndrome of acute kidney injury associated with synthetic cannabinoids, review the toxicologic and public health investigation of the cluster, and describe clinical implications of the cluster investigation. Materials and methods. Case series of nine patients affected by the toxicologic syndrome in Oregon and southwestern Washington during May–October 2012. Cases were defined as acute kidney injury (creatinine > 1.3 mg/dL) among persons aged 13–40 years without known renal disease who reported smoking synthetic cannabinoids. Toxicology laboratories used liquid chromatography and time-of-flight mass spectrometry to test clinical and product specimens for synthetic cannabinoids, their metabolites, and known nephrotoxins. Public health alerts informed clinicians, law enforcement, and the community about the cluster and the need to be alert for toxidromes associated with emerging drugs of abuse. Results. Patients were males aged 15–27 years (median, 18 years), with intense nausea and flank or abdominal pain, and included two sets of siblings. Peak creatinine levels were 2.6–17.7 mg/dL (median, 6.6 mg/dL). All patients were hospitalized; one required dialysis; none died. No alternate causes of acute kidney injury or nephrotoxins were identified. Patients reported easily purchasing synthetic cannabinoids at convenience, tobacco, and adult bookstores. One clinical and 2 product samples contained evidence of a novel synthetic cannabinoid, XLR-11 ([1-(5-fluoropentyl)-1H-indol-3-yl](2,2,3,3-tetramethylcyclopropyl)methanone). Discussion and conclusion. Whether caused by direct toxicity, genetic predisposition, or an as-yet unidentified nephrotoxin, this association between synthetic cannabinoid exposure and acute kidney injury reinforces the need for vigilance to detect new toxicologic syndromes associated with emerging drugs of abuse. Liquid chromatography and time-of-flight mass spectrometry are useful tools in determining the active ingredients in these evolving products and evaluating them for toxic contaminants.

Establishment of a statewide network for carbapenem-resistant Enterobacteriaceae prevention in a low-incidence region

OBJECTIVE To establish a statewide network to detect, control, and prevent the spread of carbapenem-resistant Enterobacteriaceae (CRE) in a region with a low incidence of CRE infection. DESIGN Implementation of the Drug Resistant Organism Prevention and Coordinated Regional Epidemiology (DROP-CRE) Network. SETTING AND PARTICIPANTS Oregon infection prevention and microbiology laboratory personnel, including 48 microbiology laboratories, 62 acute care facilities, and 140 long-term care facilities. METHODS The DROP-CRE working group, comprising representatives from academic institutions and public health, convened an interdisciplinary advisory committee to assist with planning and implementation of CRE epidemiology and control efforts. The working group established a statewide CRE definition and surveillance plan; increased the state laboratory capacity to perform the modified Hodge test and polymerase chain reaction for carbapenemases in real time; and administered surveys that assessed the needs and capabilities of Oregon infection prevention and laboratory personnel. Results of these inquiries informed CRE education and the response plan. RESULTS Of 60 CRE reported from November 2010 through April 2013, only 3 were identified as carbapenemase producers; the cases were not linked, and no secondary transmission was found. Microbiology laboratories, acute care facilities, and long-term care facilities reported lacking carbapenemase testing capability, reliable interfacility communication, and CRE awareness, respectively. Survey findings informed the creation of the Oregon CRE Toolkit, a state-specific CRE guide booklet. CONCLUSIONS A regional epidemiology surveillance and response network has been implemented in Oregon in advance of widespread CRE transmission. Prospective surveillance will determine whether this collaborative approach will be successful at forestalling the emergence of this important healthcare-associated pathogen.

Draft Genome Sequence of blaNDM-1-Positive Escherichia coli O25b-ST131 Clone Isolated from an Environmental Sample

ABSTRACT A multidrug-resistant NDM-1 carbapenamase-producing Escherichia coli sequence type 131 (ST131) organism was obtained from vacuum cleaner dust collected from the home of a case patient. Here, we report the assembly and annotation of its genome.

Notes from the Field: Late-Onset Infant Group B Streptococcus Infection Associated with Maternal Consumption of Capsules Containing Dehydrated Placenta ? Oregon, 2016

MMWR / June 30, 2017 / Vol. 66 / No. 25 677 US Department of Health and Human Services/Centers for Disease Control and Prevention Late-Onset Infant Group B Streptococcus Infection Associated with Maternal Consumption of Capsules Containing Dehydrated Placenta — Oregon, 2016 Genevieve L. Buser, MDCM1; Sayonara Mató, MD2; Alexia Y. Zhang, MPH3; Ben J. Metcalf, PhD4; Bernard Beall, PhD4; Ann R. Thomas, MD3

Evaluation of the Carba NP test in Oregon, 2013

ABSTRACT Carbapenem-resistant Enterobacteriaceae (CRE) are an urgent public health threat. We evaluated the capacity of the Carba NP test to detect carbapenemase production in 206 isolates: 143 Enterobacteriaceae identified by Oregons CRE surveillance program in 2013 and 63 known carbapenemase-positive organisms. Overall, test sensitivity and specificity were 89% (59/66 isolates; 95% confidence interval [CI], 81 to 97%) and 100% (140/140 isolates; 95% CI, 98 to 100%), respectively. All KPC, NDM-1, VIM, and IMP producers but no (0/7 isolates) OXA-48-like strains were Carba NP positive prior to a post hoc protocol modification. We subsequently incorporated Carba NP into Oregons CRE screening algorithm.

Clinical Correlates of Surveillance Events Detected by National Healthcare Safety Network Pneumonia and Lower Respiratory Infection Definitions-Pennsylvania, 2011-2012.

OBJECTIVE To determine the clinical diagnoses associated with the National Healthcare Safety Network (NHSN) pneumonia (PNEU) or lower respiratory infection (LRI) surveillance events DESIGN Retrospective chart review SETTING A convenience sample of 8 acute-care hospitals in Pennsylvania PATIENTS All patients hospitalized during 2011-2012 METHODS Medical records were reviewed from a random sample of patients reported to the NHSN to have PNEU or LRI, excluding adults with ventilator-associated PNEU. Documented clinical diagnoses corresponding temporally to the PNEU and LRI events were recorded. RESULTS We reviewed 250 (30%) of 838 eligible PNEU and LRI events reported to the NHSN; 29 reported events (12%) fulfilled neither PNEU nor LRI case criteria. Differences interpreting radiology reports accounted for most misclassifications. Of 81 PNEU events in adults not on mechanical ventilation, 84% had clinician-diagnosed pneumonia; of these, 25% were attributed to aspiration. Of 43 adult LRI, 88% were in mechanically ventilated patients and 35% had no corresponding clinical diagnosis (infectious or noninfectious) documented at the time of LRI. Of 36 pediatric PNEU events, 72% were ventilator associated, and 70% corresponded to a clinical pneumonia diagnosis. Of 61 pediatric LRI patients, 84% were mechanically ventilated and 21% had no corresponding clinical diagnosis documented. CONCLUSIONS In adults not on mechanical ventilation and in children, most NHSN-defined PNEU events corresponded with compatible clinical conditions documented in the medical record. In contrast, NHSN LRI events often did not. As a result, substantial modifications to the LRI definitions were implemented in 2015. Infect Control Hosp Epidemiol 2016;37:818-824.

New Delhi Metallo-β-lactamase-1 (NDM-1) Escherichia coli isolated from household vacuum cleaner — Oregon, 2013

The first Oregon case of New Delhi metallo-β-lactamase-1 (NDM-1)-producing Escherichia coli was reported during November 2013. Epidemiologic investigation revealed only local outpatient medical care and no travel outside Oregon for both the patient and his household contact. Environmental sampling discovered a matching isolate from the patient’s household vacuum cleaner, suggesting environmental persistence.

Nosocomial Outbreak of Extensively Drug-Resistant Acinetobacter baumannii Isolates Containing blaOXA-237 Carried on a Plasmid

ABSTRACT Carbapenem antibiotics are among the mainstays for treating infections caused by Acinetobacter baumannii, especially in the Northwest United States, where carbapenem-resistant A. baumannii remains relatively rare. However, between June 2012 and October 2014, an outbreak of carbapenem-resistant A. baumannii occurred in 16 patients from five health care facilities in the state of Oregon. All isolates were defined as extensively drug resistant. Multilocus sequence typing revealed that the isolates belonged to sequence type 2 (international clone 2 [IC2]) and were >95% similar as determined by repetitive-sequence-based PCR analysis. Multiplex PCR revealed the presence of a blaOXA carbapenemase gene, later identified as blaOXA-237. Whole-genome sequencing of all isolates revealed a well-supported separate branch within a global A. baumannii phylogeny. Pacific Biosciences (PacBio) SMRT sequencing was also performed on one isolate to gain insight into the genetic location of the carbapenem resistance gene. We discovered that blaOXA-237, flanked on either side by ISAba1 elements in opposite orientations, was carried on a 15,198-bp plasmid designated pORAB01-3 and was present in all 16 isolates. The plasmid also contained genes encoding a TonB-dependent receptor, septicolysin, a type IV secretory pathway (VirD4 component, TraG/TraD family) ATPase, an integrase, a RepB family plasmid DNA replication initiator protein, an alpha/beta hydrolase, and a BrnT/BrnA type II toxin-antitoxin system. This is the first reported outbreak in the northwestern United States associated with this carbapenemase. Particularly worrisome is that blaOXA-237 was carried on a plasmid and found in the most prominent worldwide clonal group IC2, potentially giving pORAB01-3 great capacity for future widespread dissemination.

894Evaluating Clinical Credibility of Surveillance Definitions for Healthcare-Associated Pneumonia and Lower Respiratory Infections

Healthcare-Associated Pneumonia and Lower Respiratory Infections Isaac See, MD; Julia Chang, BA; Nicole Gualandi, RN, MS; Genevieve L. Buser, MDCM, MSHP; Pamela Rohrbach, RN, CIC; Debra Smeltz, RN; Mary Jo Bellush, MSN, CIC; Susan Coffin, MD, MPH; Jane M. Gould, MD; Patricia Hennessey, RN, BSN, MSN, CIC; Debra Hess, RN, CIC; Sydney Hubbard, MPH; Andrea Kiernan, MLT (ASCP), CIC; Judith O’donnell, MD; David Pegues, MD, FIDSA, FSHEA; Jeffrey R. Miller, MD, MPH; Shelley S. Magill, MD, PhD; Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, GA; UCLA Geffen School of Medicine, Los Angeles, CA; Acute and Communicable Disease Prevention, Oregon Health Authority, Portland, OR; Pennsylvania Department of Health, Harrisburg, PA; Excela Health Westmoreland Hospital, Greensburg, PA; The Children’s Hospital of Philadelphia, Philadelphia, PA; St. Christopher’s Hospital for Children, Philadelphia, PA; Lancaster General Hospital, Lancaster, PA; Pennsylvania Presbyterian Medical Center, Philadelphia, PA; University of Pennsylvania Health System, Philadelphia, PA; Career Epidemiology Field Officer, Office of Public Health Preparedness and Response, CDC, assigned to the Pennsylvania Department of Health, Harrisburgh, PA

1726What Defines Carbapenem-Resistant Enterobacteriaceae (CRE) in a Low Prevalence State? Oregon, 2010 — 2013

Background. Preventing the spread of carbapenem-resistant Enterobacteriaceae (CRE) is important to public health because of high infection-related morbidity, mortality, and cost. Carbapenemase producing (CP)-CRE are most concerning because of their rapid global dissemination. In 2013, CRE in Oregon were defined as Enterobacteriaceae with non-susceptibility to ≥1 carbapenem, including ertapenem, and resistance to any 3generation cephalosporin. Review of surveillance data raised concerns of poor definition specificity for CP-CRE creating burden for laboratories and public health investigators. Methods. We analyzed all CRE isolates reported in Oregon December 2010 – October 2013. We reviewed surveillance data from other states and published literature, focusing on CRE minimal inhibitory concentration breakpoints. Results. Of our 125 unique isolates, 75 (60%) were Enterobacter cloacae, 13 (10%) Enterobacter aerogenes, 11 (9%) Escherichia coli, 11 (9%) Klebsiella pneumoniae, and 14 (11%) were other species. Non-susceptibility only to ertapenem was demonstrated by 66 (53%), of which 47 (72%) were E. cloacae. Of the 34 isolates non-susceptible to multiple carbapenems, 18 (53%) were E. cloacae, 5 (15%) E. aerogenes, 4 (12%) E. coli, and 6 (18%) K. pneumoniae. Ninety-nine (81%) isolates were resistant to all 3 generation cephalosporins tested. Three were CP-CRE; all were K. pneumoniae producing K. pneumoniae carbapenemases. Review of literature and other states’ data confirmed carbapenemases were present in E. cloacae. Excluding ertapenem from the definition for laboratories using the updated Clinical Laboratory Standard Institute (CLSI) breakpoints did not greatly reduce sensitivity for the most common carbapenemases. Finally, retaining the cephalosporin-resistance requirement enhanced specificity. The new definition decreased the number of cases to investigate by 57%, without missing any CP-CRE. Conclusion. Wemodified our case definition to increase CP-CRE specificity, without losing sensitivity, thus decreasing investigation burden. For laboratories using current CLSI breakpoints, the new definition includes all Enterobacteriaceae, removes ertapenem, and requires resistance to all 3 generation cephalosporins tested. Disclosures. All authors: No reported disclosures.