Lauren Epstein

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.

Incidence and Trends of Sepsis in US Hospitals Using Clinical vs Claims Data, 2009-2014

Importance Estimates from claims-based analyses suggest that the incidence of sepsis is increasing and mortality rates from sepsis are decreasing. However, estimates from claims data may lack clinical fidelity and can be affected by changing diagnosis and coding practices over time. Objective To estimate the US national incidence of sepsis and trends using detailed clinical data from the electronic health record (EHR) systems of diverse hospitals. Design, Setting, and Population Retrospective cohort study of adult patients admitted to 409 academic, community, and federal hospitals from 2009-2014. Exposures Sepsis was identified using clinical indicators of presumed infection and concurrent acute organ dysfunction, adapting Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3) criteria for objective and consistent EHR-based surveillance. Main Outcomes and Measures Sepsis incidence, outcomes, and trends from 2009-2014 were calculated using regression models and compared with claims-based estimates using International Classification of Diseases, Ninth Revision, Clinical Modification codes for severe sepsis or septic shock. Case-finding criteria were validated against Sepsis-3 criteria using medical record reviews. Results A total of 173 690 sepsis cases (mean age, 66.5 [SD, 15.5] y; 77 660 [42.4%] women) were identified using clinical criteria among 2 901 019 adults admitted to study hospitals in 2014 (6.0% incidence). Of these, 26 061 (15.0%) died in the hospital and 10 731 (6.2%) were discharged to hospice. From 2009-2014, sepsis incidence using clinical criteria was stable (+0.6% relative change/y [95% CI, −2.3% to 3.5%], P = .67) whereas incidence per claims increased (+10.3%/y [95% CI, 7.2% to 13.3%], P < .001). In-hospital mortality using clinical criteria declined (−3.3%/y [95% CI, −5.6% to −1.0%], P = .004), but there was no significant change in the combined outcome of death or discharge to hospice (−1.3%/y [95% CI, −3.2% to 0.6%], P = .19). In contrast, mortality using claims declined significantly (−7.0%/y [95% CI, −8.8% to −5.2%], P < .001), as did death or discharge to hospice (−4.5%/y [95% CI, −6.1% to −2.8%], P < .001). Clinical criteria were more sensitive in identifying sepsis than claims (69.7% [95% CI, 52.9% to 92.0%] vs 32.3% [95% CI, 24.4% to 43.0%], P < .001), with comparable positive predictive value (70.4% [95% CI, 64.0% to 76.8%] vs 75.2% [95% CI, 69.8% to 80.6%], P = .23). Conclusions and Relevance In clinical data from 409 hospitals, sepsis was present in 6% of adult hospitalizations, and in contrast to claims-based analyses, neither the incidence of sepsis nor the combined outcome of death or discharge to hospice changed significantly between 2009-2014. The findings also suggest that EHR-based clinical data provide more objective estimates than claims-based data for sepsis surveillance.

Post-Ebola Signs and Symptoms in U.S. Survivors

Limited data are available on the health sequelae of Ebola virus disease. In this report, follow-up data for Ebola survivors who were treated in the United States are presented.

The association of visit length and measures of patient-centered communication in HIV care: A mixed methods study

OBJECTIVE Patient centered clinical communication may be associated with longer encounters. METHODS We used the General Medical Interaction Analysis System (GMIAS) to code transcripts of routine outpatient visits in HIV care, and create 5 measures of patient-centeredness. We defined visit length as number of utterances. To better understand properties of encounters reflected in these measures, we conducted a qualitative analysis of the 15 longest and 15 shortest visits. RESULTS All 5 measures were significantly associated with visit length (p<0.05, rank order correlations 0.21-0.44). In multivariate regressions, association of patient centeredness with visit length was attenuated for 4 measures, and increased for 1; two were no longer statistically significant (p>0.05). Black and Hispanic race were associated with shorter visits compared with White race. Some of the longest visits featured content that could be considered extraneous to appropriate care. CONCLUSION Patient centeredness is weakly related to visit length, but may reflect inefficient use of time in long encounters. PRACTICE IMPLICATIONS Efforts to make visits more patient centered should focus on improving dialogue quality and efficient use of time, not on making visits longer. Shorter visits for Black and Hispanic patients could contribute to health disparities related to race and ethnicity.

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

Risk Factors for Invasive Methicillin-Resistant Staphylococcus aureus Infection After Recent Discharge From an Acute-Care Hospitalization, 2011-2013.

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.

Antimicrobial Stewardship in a Long-Term Acute Care Hospital Using Offsite Electronic Medical Record Audit

OBJECTIVE To offer antimicrobial stewardship to a long-term acute care hospital using telemedicine. METHODS We conducted an uninterrupted time-series analysis to measure the impact of antimicrobial stewardship on hospital-acquired Clostridium difficile infection (CDI) rates and antimicrobial use. Simple linear regression was used to analyze changes in antimicrobial use; Poisson regression was used to estimate the incidence rate ratio in CDI rates. The preimplementation period was April 1, 2010-March 31, 2011; the postimplementation period was April 1, 2011-March 31, 2014. RESULTS During the preimplementation period, total antimicrobial usage was 266 defined daily doses (DDD)/1,000 patient-days (PD); it rose 4.54 (95% CI, -0.19 to 9.28) per month then significantly decreased from preimplementation to postimplementation (-6.58 DDD/1,000 PD [95% CI, -11.48 to -1.67]; P=.01). The same trend was observed for antibiotics against methicillin-resistant Staphylococcus aureus (-2.97 DDD/1,000 PD per month [95% CI, -5.65 to -0.30]; P=.03). There was a decrease in usage of anti-CDI antibiotics by 50.4 DDD/1,000 PD per month (95% CI, -71.4 to -29.2; P<.001) at program implementation that was maintained afterwards. Anti-Pseudomonas antibiotics increased after implementation (30.6 DDD/1,000 PD per month [95% CI, 4.9-56.3]; P=.02) but with ongoing education this trend reversed. Intervention was associated with a decrease in hospital-acquired CDI (incidence rate ratio, 0.57 [95% CI, 0.35-0.92]; P=.02). CONCLUSION Antimicrobial stewardship using an electronic medical record via remote access led to a significant decrease in antibacterial usage and a decrease in CDI rates.

Evaluation of a Novel Intervention to Reduce Unnecessary Urine Cultures in Intensive Care Units at a Tertiary Care Hospital in Maryland, 2011–2014

We assessed the impact of a reflex urine culture protocol, an intervention aimed to reduce unnecessary urine culturing, in intensive care units at a tertiary care hospital. Significant decreases in urine culturing rates and reported rates of catheter-associated urinary tract infection followed implementation of the protocol.

Safety and efficacy of fidaxomicin in the treatment of Clostridium difficile-associated diarrhea

Clostridium difficile-associated diarrhea (CDAD) is the most common cause of healthcare-associated diarrhea. The current recommended treatment regimens of metronidazole and vancomycin have not changed in nearly 25 years. Fidaxomicin, an exceedingly narrow spectrum macrolide antibiotic, was recently approved for the treatment of CDAD. In phase III clinical trials, fidaxomicin was noninferior to vancomycin in achieving clinical cure of CDAD. Furthermore, fidaxomicin was associated with fewer recurrences of CDAD compared with vancomycin in clinical trials. These results, combined with the ease of administration and a good safety profile, make fidaxomicin an attractive treatment option for treating CDAD.

Risk of Subsequent Sepsis Within 90 Days After a Hospital Stay by Type of Antibiotic Exposure

Background We examined the risk of sepsis within 90 days after discharge from a previous hospital stay by type of antibiotic received during the previous stay. Methods We retrospectively identified a cohort of hospitalized patients from the Truven Health MarketScan Hospital Drug Database. We examined the association between the use of certain antibiotics during the initial hospital stay, determined a priori, and the risk of postdischarge sepsis controlling for potential confounding factors in a multivariable logistic regression model. Our primary exposure was receipt of antibiotics more strongly associated with clinically important microbiome disruption. Our primary outcome was a hospital stay within 90 days of the index stay that included an International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) discharge diagnosis of severe sepsis (ICD-9-CM code 995.92) or septic shock (785.52). Results Among 516 hospitals, we randomly selected a single stay for eligible patients. In 0.17% of these patients, severe sepsis/septic shock developed within 90 days after discharge. The risk of sepsis associated with exposure to our high-risk antibiotics was 65% higher than in those without antibiotic exposure. Conclusions Our study identified an increased risk of sepsis within 90 days of discharge among patients with exposure to high-risk antibiotics or increased quantities of antibiotics during hospitalization. Given that a significant proportion of inpatient antimicrobial use may be unnecessary, this study builds on previous evidence suggesting that increased stewardship efforts in hospitals may not only prevent antimicrobial resistance, Clostridium difficile infection, and other adverse effects, but may also reduce unwanted outcomes potentially related to disruption of the microbiota, including sepsis.