Jennifer C. Hunter

New Delhi Metallo-β-Lactamase–Producing Carbapenem-Resistant Escherichia coli Associated With Exposure to Duodenoscopes

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.

Evolution of Ebola Virus Disease from Exotic Infection to Global Health Priority, Liberia, Mid-2014

As the disease spread, the scale of the epidemic required a multi-faceted public health response.

Transmission of Middle East Respiratory Syndrome Coronavirus Infections in Healthcare Settings, Abu Dhabi.

Early detection and adherence to infection prevention recommendations are necessary to avoid transmission.

Burden of Nursing Home-Onset Clostridium difficile Infection in the United States: Estimates of Incidence and Patient Outcomes

Background. Approximately 4 million Americans receive nursing home (NH) care annually. Nursing home residents commonly have risk factors for Clostridium difficile infection (CDI), including advanced age and antibiotic exposures. We estimated national incidence of NH-onset (NHO) CDI and patient outcomes. Methods. We identified NHO-CDI cases from population-based surveillance of 10 geographic areas in the United States. Cases were defined by C difficile-positive stool collected in an NH (or from NH residents in outpatient settings or ≤3 days after hospital admission) without a positive stool in the prior 8 weeks. Medical records were reviewed on a sample of cases. Incidence was estimated using regression models accounting for age and laboratory testing method; sampling weights were applied to estimate hospitalizations, recurrences, and deaths. Results. A total of 3503 NHO-CDI cases were identified. Among 262 sampled cases, median age was 82 years, 76% received antibiotics in the 12 weeks prior to the C difficile-positive specimen, and 57% were discharged from a hospital in the month before specimen collection. After adjusting for age and testing method, the 2012 national estimate for NHO-CDI incidence was 112 800 cases (95% confidence interval [CI], 93 400–131 800); 31 400 (28%) were hospitalized within 7 days after a positive specimen (95% CI, 25 500–37 300), 20 900 (19%) recurred within 14–60 days (95% CI, 14 600–27 100), and 8700 (8%) died within 30 days (95% CI, 6600–10 700). Conclusions. Nursing home onset CDI is associated with substantial morbidity and mortality. Strategies focused on infection prevention in NHs and appropriate antibiotic use in both NHs and acute care settings may decrease the burden of NHO CDI.

Active Tracing and Monitoring of Contacts Associated With the First Cluster of Ebola in the United States

Context After confirmation of the first case of Ebola virus disease diagnosed in the United States, contact tracing and monitoring were instituted. Contribution Challenges included the need for rapid response in a setting of evolving knowledge, institution of direct active monitoring and movement restriction for a large number of contacts, and provision of mental health and other supports. Quarantine was necessary in only a few cases. Implication Contact tracing of the first case of U.S.-diagnosed case of Ebola was unprecedented in complexity. This experience may be useful in future instances of exposure to highly communicable diseases. Tracing and monitoring contacts exposed to patients with Ebola virus disease in past epidemics in Africa have been central to effective outbreak control by ensuring that persons at higher risk for infection are identified, isolated, and evaluated as soon as possible after symptom onset (13). Such contact tracing was challenging during the 2014 western Africa Ebola epidemic, particularly after the disease extended into dense urban areas of Guinea, Liberia, and Sierra Leone (4, 5). However, contact tracing and active monitoring were critical components of containment of Ebola importations into urban Nigeria and Senegal during the summer of 2014 (6, 7). Before 25 September 2014, 4 patients with Ebola had been treated in the United States; all of them were diagnosed in western Africa and evacuated to biocontainment facilities in the United States for care (8). On 25 September, a 45-year-old man (patient 1), who had arrived in the United States from Liberia 5 days earlier, presented to a Dallas, Texas, emergency department (ED) with a 1-day history of fever, abdominal pain, and headache (9). He was prescribed antibiotics for possible sinusitis and discharged a few hours later. On 28 September, he returned to the hospital by ambulance with persistent fever, abdominal pain, and intervening onset of diarrhea. Ebola was suspected, and he was placed in a private room under standard, droplet, and contact precautions. He was transferred to the hospitals medical intensive care unit on 29 September. Ebola was confirmed on 30 September, and the patient died on 8 October. On 11 October and 15 October, 2 health care personnel (HCP) (patients 2 and 3, respectively) who had cared for patient 1 were confirmed to have Ebola (10). This domestic cluster of Ebola provided the opportunity to assess implementation of contact tracing and monitoring approaches for this high-consequence disease in both community and health care settings for the first time in the United States. Methods Case and Contact Identification The case and contact definitions used at the outset of this investigation were the extant definitions from the Centers for Disease Control and Prevention (CDC), operational as of 28 September 2014; they have since been revised (11). Possible Ebola case-patients were persons with both potential Ebola epidemiologic risk factors and consistent symptoms. Potential Ebola exposure risk factors included contact with a patient who had laboratory-confirmed Ebola or who had traveled from countries affected by the Ebola outbreak. The extant symptom criteria included temperature of 101.5F or greater (38.6C); 1 or more of the following symptoms: severe headache, sore throat, malaise, muscle pain, diarrhea, vomiting, rash, or unexplained bleeding within 21 days after exposure or travel; and no alternative diagnosis. Confirmed patients had Ebola virus detected in a blood sample by real-time reverse-transcription polymerase chain reaction performed at the CDC (12). Contact tracing was initiated for possible and confirmed Ebola cases. A contact was defined as any person, irrespective of use of personal protective equipment, who touched the skin, blood, or other body fluid of a symptomatic patient with confirmed Ebola; had been within 3 feet of a symptomatic patient with Ebola for more than 15 minutes; or who interacted with a possibly contaminated health care environment. Contacts whose Ebola exposures occurred outside of health care settings were designated as community contacts. Community contacts who interacted with the patient between symptom onset and admission were identified by interviewing patients with Ebola, their household members, and other reported potential contacts. Identification and monitoring of additional possible community contacts of patient 3 from a visit to Ohio are described elsewhere (13, 14). Contacts whose Ebola exposures occurred during ambulance transport or at the hospital were designated as health care contacts. Ambulance transport contacts were identified through emergency medical services. The HCP contacts were identified through the hospitals human resources department from a combination of information provided by department managers, records of staff movement from location-tracking badge tags, security sign-in sheets, and prospective logs used to document HCP participating in the care of the patients with Ebola. Risk Classification and Monitoring of Contacts Standardized questionnaires on the nature and duration of potential exposures were administered to contacts to stratify them into exposure risk groups termed high risk, some risk, or no known exposure (Table 1). These groups were defined according to the extant CDC classification criteria, which have since been revised (15). The no known exposure category encompassed contacts without recognized unprotected exposures to Ebola, including HCP who used recommended personal protective equipment when caring for patients with Ebola. After confirmation of patient 2s Ebola diagnosis, additional subclassifications (higher risk, lower risk, and least risk) were created to further stratify risk levels within the no known exposure group and help guide heightened monitoring and movement restrictions (Table 1). Table 1. Ebola Exposure Categories to Determine Public Health ActionsDallas, Texas, 2014 All contacts received instruction about symptom monitoring and procedures to follow in the event of illness onset. Monitoring entailed twice-daily oral temperature measurement and checking for symptoms compatible with Ebola for 21 days from the date of last exposure. Contacts in the high risk and some risk groups underwent direct active monitoring, with at least 1 of their twice-daily symptom checks directly observed by a member of the investigation team at their place of lodging, and the second reported by phone. In accordance with the extant national guidance, twice-daily self-monitoring for fever and symptoms was initially recommended to the contacts in the no known exposure risk group. After patient 2s Ebola diagnosis, all HCP contacts in the no known exposure category were transitioned to direct active monitoring, with at least 1 in-person check daily onsite at the hospital. From 1 to 7 November, the last week of monitoring in Dallas County, alternatives, such as video chat, were used when in-person checks were not feasible. Data from EPI-Info 7 (CDC) was reentered into Microsoft Access 2010 (Microsoft Corp.) and later into Maven (Consilience Software) databases and analyzed using SAS software, version 9.3 (SAS Institute). Because this investigation was part of a public health response, it was determined to be nonresearch by the CDC and therefore was not subject to CDC institutional review board review. Movement Restrictions Movement restrictions were recommended to prevent possible spread should a contact become symptomatic. Contacts with high risk and some risk exposure levels were instructed to avoid travel by commercial conveyances and public transportation during their monitoring period (15). According to the extant CDC guidance for monitoring and movement of persons with Ebola exposures, contacts in the no known exposure risk category were not initially subject to movement restrictions; however, after patient 2s Ebola diagnosis, directives for controlled movement were also applied to this risk group. On 16 October, all contacts in the no known exposure category who had ever entered the index patients room were additionally restricted from direct care activities of other patients and from public gatherings. Public health control orders for quarantine were implemented whenever voluntary adherence to active monitoring or controlled movement directives could not be ensured. Investigation of Symptomatic Contacts Contacts of the 3 patients with Ebola reporting a temperature of 100.4F (38C) or greater, or compatible symptoms (severe headache, sore throat, malaise, muscle pain, diarrhea, vomiting, rash, or unexplained bleeding) were referred to the ED, isolated, and assessed to determine whether Ebola testing was warranted. If the result of an initial reverse-transcription polymerase chain reaction test for Ebola was negative, contacts with persistent symptoms and without an alternative diagnosis underwent additional Ebola testing 72 hours or more after symptom onset. Patients were eligible for discharge after improvement or resolution of symptoms for 24 hours or a negative Ebola test result obtained 72 hours or more after symptom onset. Results From 28 September to 16 October, more than 280 reported potential contacts of the 3 Ebola case-patients were investigated, of whom 179 were confirmed as contacts and monitored (Figure). Patient 1 had 139 contacts (17 community contacts and 122 health care contacts, 2 of whom became patients 2 and 3). Patients 2 and 3 had 73 contacts (3 community and 70 HCP contacts); 33 of their HCP contacts were also contacts of patient 1. Among the 3 patients who were part of this investigation, patient 1 had the longest period of symptoms before hospital admission (5 days; 2428 September) and the longest hospital stay (11 days; 28 September8 October). Patients 2 and 3 were each symptomatic for less than 24 hours in the Dallas community before admission, and their Dallas hospital stays were also shorter (7

Response to Emergence of Middle East Respiratory Syndrome Coronavirus, Abu Dhabi, United Arab Emirates, 2013–2014

We found that this virus may be detected in mildly ill and asymptomatic case-patients.

Listeriosis Outbreaks Associated with Soft Cheeses, United States, 1998–20141

Since 2006, the number of reported US listeriosis outbreaks associated with cheese made under unsanitary conditions has increased. Two-thirds were linked to Latin-style soft cheese, often affecting pregnant Hispanic women and their newborns. Adherence to pasteurization protocols and sanitation measures to avoid contamination after pasteurization can reduce future outbreaks.

Isolates from Patients with Noninvasive Listeria monocytogenes : Are They Important?

Abstract Background From 2004–2015, CDC received 82 reports of patients with Listeria monocytogenes (Lm) cultured from non-sterile sites. Whereas invasive listeriosis (Lm isolated from typically sterile sites) is nationally notifiable and well described, information about patients with “noninvasive” Lm (isolated from other sites) is limited to a small number of case reports. We summarize the demographic and clinical characteristics of a convenience sample of patients with noninvasive Lm and compare to patients with invasive Lm reported through routine surveillance. Methods The Listeria Initiative (LI) is a national surveillance system that collects demographic, clinical, laboratory, and food exposure information on laboratory-confirmed listeriosis cases in the United States. While not nationally notifiable, public health agencies can also submit similar information to LI for patients with noninvasive Lm. We reviewed all reports to LI from 2004–2015 and used a standardized approach to characterize isolate sources as invasive or noninvasive. We then compared demographic and clinical factors between patients with invasive and noninvasive Lm using Fisher’s exact and Wilcoxon rank-sum tests. Results The most common sources of noninvasive isolates (n = 82) were skin or soft tissue (n = 35, 43%), urine (n = 19, 23%), and stool (n = 17, 21%). Compared with patients with noninvasive Lm, patients with invasive Lm (n = 4599) were more likely to be older than 65 years (66% vs. 54% P = 0.03), to be associated with an outbreak (17% vs. 7%, P = 0.02), to be hospitalized (92% vs. 54%, P < 0.01), and to die (20% vs. 4%, P < 0.01). Conclusion This is the first review of patients with noninvasive Lm using US LI surveillance data. Patients with invasive Lm were older and more likely to be associated with an outbreak, hospitalization, or death when compared with patients with noninvasive Lm. The reasons that patients with noninvasive Lm have a less severe clinical course are not well understood; however, the frequency of hospitalizations and deaths in patients with noninvasive isolates indicates their clinical relevance and public health significance. Disclosures All authors: No reported disclosures.