Russell Ryono

Concurrent outbreaks with co-infection of norovirus and Clostridium difficile in a long-term-care facility.

We describe an outbreak of simultaneous Clostridium difficile and norovirus infections in a long-term-care facility. Thirty patients experienced acute gastroenteritis, and four had co-infection with identical C. difficile 027 and genotype II.4 New Orleans norovirus strains. Co-occurring infection requires improved understanding of risk factors, clinical impact, and testing strategies.

Comparative assessment of antimicrobial usage measures in the Department of Veterans Affairs.

We compared 2 data sources--antimicrobial orders and bar-coded medication administration (BCMA)--for calculating the number of grams used, grams used based on defined daily dose, and days of therapy at one Veterans Affairs Medical Center for 2009-2010. The number of grams used calculated from BCMA data provided the most informative antimicrobial utilization measure.

PRESCRIBING PRACTICE AND COST OF ANTIBACTERIAL PROPHYLAXIS FOR SURGERY AT A US VETERANS AFFAIRS HOSPITAL

This study retrospectively compared the actual drug-related cost of antibacterial prophylaxis for specific operative procedures with the theoretical costs based on recommendations published in Medical Letter on DruRs and Therapeutics. the Surgical Infection Society, and those of the chiefs of each surgical subspecialty at our institution.We identified all inpatients who received an intravenous antibacterial for prophylaxis before a clean or clean-contaminated operation between 1st January and 30th September 1993, using the medical centre’s computerised information system. The information included comprehensive surgical case histories, and pharmacy and microbiology records. Only those operations in which recommendations for surgical prophylaxis were present in all 3 guidelines were included. The outcome measures were antibacterial-related costs (drug acquisition and administration cost), the number of antibacterial doses dispensed, and choice of antibacterial agents.During the study period, 3322 operations were performed, 2993 of which were excluded. Thus, 329 patients undergoing operations in 6 subspecialties were included in the analysis. The actual mean cost per patient significantly exceeded the projected costs using Medical Letter Consultants’ and Surgical Infection Society guidelines for all 6 subspecialties [mean excess cost per patient:

Zika virus infection in the Veterans Health Administration (VHA), 2015-2016

US49.04 and

Factors for Hospitalizations and Neurologic Complications in Zika Virus Infection in the Department of Veterans Affairs (VA)

US34.95, respectively (1994 values») and institutional guidelines for 4 of the 6 subspecialties (mean excess cost per patient:

Comparative Effectiveness of High-Dose versus Standard-Dose Influenza Vaccines among Veterans: 2015-2016 and 2016-2017 Seasons

US24.36). The actual mean number of doses per patient significantly exceeded those projected using Medical Letter Consultant’s and Surgical Infection Society guidelines for all 6 subspecialties (mean excess number of doses per patient: 6.0 and 4.0, respectively) and institutional guidelines for 4 of the 6 subspecialties (mean excess number of doses per patient: 2.9). The choice of antibacterial was appropriate in approximately 90% of cases.We conclude that the practice of antibacterial prophylaxis for specitic operative procedures performed by 6 sUbspecialties is not in accordance with institutional or published guidelines, and the excess cost is primarily a result of prolonged duration of antibacterial prophylaxis.

Epidemiologic Review of Veterans Health Administration Patients with Isolation of Nontuberculous Mycobacteria after Cardiopulmonary Bypass Procedures

Background Zika virus (ZIKV) is an important flavivirus infection. Although ZIKV infection is rarely fatal, risk for severe disease in adults is not well described. Our objective was to describe the spectrum of illness in U.S. Veterans with ZIKV infection. Methodology Case series study including patients with laboratory-confirmed or presumed positive ZIKV infection in all Veterans Health Administration (VHA) medical centers. Adjusted odds ratios of clinical variables associated with hospitalization and neurologic complications was performed. Principal findings Of 1,538 patients tested between 12/2015-10/2016 and observed through 3/2017, 736 (48%) were RT-PCR or confirmed IgM positive; 655 (89%) were male, and 683 (93%) from VA Caribbean Healthcare System (VACHCS). Ninety-four (13%) were hospitalized, 91 (12%) in the VACHCS. Nineteen (3%) died after ZIKV infection. Hospitalization was associated with increased Charlson co-morbidity index (adjusted odds ratio [OR] 1.2; 95% confidence interval [CI], 1.1–1.3), underlying connective tissue disease (OR, 29.5; CI, 3.6–244.7), congestive heart failure (OR, 6; CI, 2–18.5), dementia (OR, 3.6; CI, 1.1–11.2), neurologic symptom presentation (OR, 3.9; CI, 1.7–9.2), leukocytosis (OR, 11.8; CI, 4.5–31), thrombocytopenia (OR, 7.8; CI, 3.3–18.6), acute kidney injury (OR, 28.9; CI, 5.8–145.1), or using glucocorticoids within 30 days of testing (OR, 13.3; CI 1.3–133). Patients presenting with rash were less likely to be hospitalized (OR, 0.29; CI, 0.13–0.66). Risk for neurologic complications increased with hospitalization (OR, 5.9; CI 2.9–12.2), cerebrovascular disease (OR 4.9; CI 1.7–14.4), and dementia (OR 2.8; CI 1.2–6.6). Conclusion Older Veterans with multiple comorbidities or presenting with neurologic symptoms were at increased risk for hospitalization and neurological complications after ZIKV infection.

Epidemiologic Review of Carbapenem-Resistant Enterobacteriaceae, Duodenoscopes, and Endoscopic Ultrasonography in the Department of Veterans Affairs

Abstract Background Zika virus (ZIKV) is an important flavivirus, but severity of infection is poorly described in adults. We investigated factors associated with hospitalization and neurologic complications as measures of severity. Methods ZIKV cases from December 1, 2015 to October 31, 2016 were identified from clinical samples tested in VA, state and commercial laboratories, and patients were followed until 3/31/2017. ZIKV positive patients (RT-PCR or screening IgM positive confirmed by a plaque-reduction neutralization test [PRNT] IgM positive for ZIKV alone or including dengue virus) were reviewed for demographic and clinical factors. Logistic regression analysis was performed to evaluate factors associated with 1) hospitalization and 2) neurologic complications in VA ZIKV positive patients. Results 736 of 1,538 (48%) patients tested were ZIKV positive; 655 (89%) were male and 683 (93%) were diagnosed at the VA Caribbean Healthcare System (VACHCS). In total, 94 (13%) were hospitalized with 91 (12%) at VACHCS. 19 (3%) patients, all at VACHCS, died from any cause after ZIKV diagnosis. Hospitalization was more likely with increased age, co-morbidities, neurologic symptoms, thrombocytopenia, or preadmission glucocorticoid use, and less likely if rash was present (Table 1). Hospitalization, prior cerebrovascular disease and dementia were associated with neurologic complications. Conclusion Older Veterans with multiple comorbidities or presenting with neurologic symptoms were more likely to be hospitalized after ZIKV infection, and those with a prior history of cerebrovascular disease and dementia were at increased risk for neurological complications. Table 1. Factors associated with hospitalization and neurologic complications among Veterans with ZIKV infection, December 1, 2015–October 31, 2016. Hospitalization Factors ORadj 95% CI Age group (10 years) 1.3 1.0, 1.8 Charlson co-morbidity index (age-adjusted) 1.2 1.1, 1.4 Connective tissue disease 15.0 1.7, 130.7 Congestive heart failure 4.9 1.8, 13.5 Neurological symptoms 5.3 2.4, 11.7 Thrombocytopenia (<155 platelets/μL) 4.7 2.2, 10.0 Glucocorticoid use (within 30 days of ZIKV testing) 16.8 1.8, 157.0 Rash 0.23 0.11, 0.47 Neurologic complication factors Hospitalized 5.9 2.9, 12.2 Cerebrovascular disease 4.9 1.7, 14.4 Dementia 2.8 1.2, 6.6 Oradj, adjusted odds ratio; CI , confidence interval. Disclosures All authors: No reported disclosures.

Epidemiologic Review of Carbapenem-Resistant Enterobacteriaceae and Duodenoscopes in the Department of Veterans Affairs.

Abstract Background Utilization of high-dose (HD) influenza vaccine in VA increased to 16% of all influenza vaccine given for 2016–17. HD vaccine is costlier than standard dose (SD) and no preferential recommendation has been made by the Advisory Committee on Immunization Practices. Herein, we evaluate the effectiveness of HD vs. SD vaccine for two influenza seasons. Methods This retrospective cohort study identified patients receiving HD or SD influenza vaccines in all VA facilities using Current Procedural Terminology and Bar-Coded Medication Administration data from 8/1/2015–3/25/2017. Outcomes were laboratory-confirmed influenza and influenza-coded hospitalization >2 weeks after vaccine receipt. Sub-analysis was performed for patients ≥65 years at time of vaccination. Results We evaluated 451,899 HD and 3,039,743 SD vaccine recipients. The rate of laboratory-confirmed influenza was lower in the HD group for 2015–16 season (0.095% vs. 0.11%, P = 0.03) but not for the 2016–17 season. The rate of influenza hospitalization was lower among the SD group for 2016–17 (0.091% vs. 0.12%, P < 0.01), but was not different for the 2015–16 season. For patients ≥65 years there were no differences in rate of laboratory-confirmed influenza or influenza hospitalization for either season (Table). Conclusion For the two seasons evaluated, HD vaccine was not found to be more effective than SD vaccine, particularly among patients ≥65 years, in reducing the occurrence of influenza or influenza-related hospitalizations.Table Laboratory-confirmed Influenza and Influenza-coded Hospitalizations for Patients Receiving High-dose (HD) vs. Standard-Dose (SD) Influenza Vaccine HD Cohort, No. (%) SD Cohort, No. (%) Risk Ratio (95% CI) P Value HD (≥65 yrs), No. (%) SD (≥65 yrs), No. (%) Risk Ratio (95% CI) P Value 2016–17 Season n = 274923 n = 1441940 n = 
256654 n = 758982 Lab-confirmed influenza 658 
(0.24) 3316 
(0.23) 1.04 
(0.96–
1.13) 0.35 577 
(0.22) 1802 
(0.24) 0.95 
(0.86–
1.04) 0.26 Influenza hospitalization 335 
(0.12) 1305 
(0.091) 1.35 
(1.19–
1.52) <0.01 321 
(0.13) 930 
(0.12) 1.02 
(0.89–
1.16) 0.75 2015–16 Season n = 176976 n = 1597803 n = 
164111 n = 854707 Lab-confirmed influenza 168 
(0.095) 1801 
(0.11) 0.84 
(0.72–
0.99) 0.03 155 
(0.094) 808 
(0.095) 1.0 
(0.84–
1.19) 1.0 Influenza hospitalization 124 
(0.07) 937 
(0.059) 1.19 
(0.99–
1.44) 0.06 114 
(0.069) 568 
(0.066) 1.05 
(0.85–
1.28) 0.68 Disclosures All authors: No reported disclosures.

355Carbapenem-Resistant Enterobacteriaceae (CRE) Distribution within the Veterans Affairs Healthcare System: 2013

We evaluated the isolation of postoperative nontuberculous mycobacteria (NTM) associated with heater-cooler devices (HCDs) used during cardiopulmonary bypass (CPB) surgery in the Veterans Health Administration from January 1, 2010, to December 31, 2016. In more than 38,000 CPB procedures, NTM was isolated in 111 patients; 1 Mycobacterium chimaera mediastinitis case and 1 respiratory isolate were found. Infect Control Hosp Epidemiol 2017;38:1103-1106.