Stephen M. Kralovic

Cost-effectiveness of Interferon Gamma Release Assays vs Tuberculin Skin Tests in Health Care Workers

BACKGROUND Interferon gamma release assays (IGRAs) offer alternatives to tuberculin skin tests (TSTs) for diagnosing latent tuberculosis infection (LTBI). Unlike TSTs, IGRAs require only a single patient visit and are not affected by prior BCG vaccination, providing greater specificity. Of 2 Food and Drug Administration-approved IGRAs, the newer QuantiFERON-TB Gold in Tube test (QFT-GIT) requires less manual processing time than the QuantiFERON-TB Gold test (QFT-G). We compared the cost-effectiveness of the QFT-G, QFT-GIT, and TST for detecting LTBI in new health care workers (HCWs). METHODS A Markov state-transition decision analytic model using the societal perspective and lifetime horizon was constructed to compare costs and quality-adjusted life-years (QALYs) associated with the 3 strategies for hypothetical 35-year-old HCWs with or without prior BCG vaccination. Direct and indirect costs and probabilities were based on manufacturer data, national Veterans Health Administration records, and the published literature. Future costs and QALYs were discounted at 3% per year. RESULTS Both IGRAs were more effective and less costly than the TST, whether or not the HCW had been vaccinated with BCG previously. The incremental cost-effectiveness ratio of the QFT-G compared with the QFT-GIT was

Phaeohyphomycosis caused by Dactylaria (human dactylariosis): Report of a case with review of the literature

14,092/QALY for non-BCG-vaccinated HCWs and

Nationwide reduction of health care-associated methicillin-resistant Staphylococcus aureus infections in Veterans Affairs long-term care facilities.

103,047/QALY for BCG-vaccinated HCWs. There was no prevalence of LTBI at which the TST became the most effective or least costly strategy. If the sensitivity of the QFT-GIT exceeds that of the QFT-G, then the QFT-GIT is the most effective and least costly strategy. CONCLUSION Use of the QFT-G and QFT-GIT leads to superior clinical outcomes and lower costs than the TST and should be considered in screening non-BCG-vaccinated and BCG-vaccinated new HCWs for LTBI.

Veterans Affairs methicillin-resistant Staphylococcus aureus prevention initiative associated with a sustained reduction in transmissions and health care-associated infections

Phaeohyphomycosis due to Dactylaria (Ochroconis) spp. is a rare infection of man. It was first reported in 1986. All patients have had significant immunosuppression. To our knowledge, this is the second case of phaeohyphomycosis caused by Dactylaria constricta var. gallopava in a liver transplant patient and it developed even though he had been receiving fungal prophylaxis with fluconazole. Moreover, this case may represent nosocomial acquisition. In addition, we have reviewed the English language literature of previously reported patients with phaeohyphomycosis caused by Dactylaria spp.

Clostridium difficile Infections in Veterans Health Administration Long-Term Care Facilities.

The Veterans Affairs methicillin-resistant Staphylococcus aureus (MRSA) Prevention Initiative was implemented in its 133 long-term care facilities in January 2009. Between July 2009 and December 2012, there were ~12.9 million resident-days in these facilities nationwide. During this period, the mean quarterly MRSA admission prevalence increased from 23.3% to 28.7% (P < .0001, Poisson regression for trend), but the overall rate of MRSA health care-associated infections decreased by 36%, from 0.25 to 0.16/1,000 resident-days (P < .0001, Poisson regression for trend).

Cutaneous cryptococcosis in a patient on corticosteroid therapy for rheumatoid arthritis

Implementation of a methicillin-resistant Staphylococcus aureus (MRSA) Prevention Initiative was associated with significant declines in MRSA transmission and MRSA health care-associated infection rates in Veterans Affairs acute care facilities nationwide in the 33-month period from October 2007 through June 2010. Here, we show continuing declines in MRSA transmissions (P = .004 for trend, Poisson regression) and MRSA health care-associated infections (P < .001) from July 2010 through June 2012. The Veterans Affairs Initiative was associated with these effects, sustained over 57 months, in a large national health care system.

Laboratory Reporting of Staphylococcus aureus with Reduced Susceptibility to Vancomycin in United States Department of Veterans Affairs Facilities

OBJECTIVE A nationwide initiative was implemented in February 2014 to decrease Clostridium difficile infections (CDI) in Veterans Affairs (VA) long-term care facilities. We report a baseline of national CDI data collected during the 2 years before the Initiative. METHODS Personnel at each of 122 reporting sites entered monthly retrospective CDI case data from February 2012 through January 2014 into a national database using case definitions similar to those used in the National Healthcare Safety Network Multidrug-Resistant Organism/CDI module. The data were evaluated using Poisson regression models to examine infection occurrences over time while accounting for admission prevalence and type of diagnostic test. RESULTS During the 24-month analysis period, there were 100,800 admissions, 6,976,121 resident days, and 1,558 CDI cases. The pooled CDI admission prevalence rate (including recurrent cases) was 0.38 per 100 admissions, and the pooled nonduplicate/nonrecurrent community-onset rate was 0.17 per 100 admissions. The pooled long-term care facility-onset rate and the clinically confirmed (ie, diarrhea or evidence of pseudomembranous colitis) long-term care facility-onset rate were 1.98 and 1.78 per 10,000 resident days, respectively. Accounting for diagnostic test type, the long-term care facility-onset rate declined significantly (P=.05), but the clinically confirmed long-term care facility-onset rate did not. CONCLUSIONS VA long-term care facility CDI rates were comparable to those in recent reports from other long-term care facilities. The significant decline in the long-term care facility-onset rate but not in the clinically confirmed long-term care facility-onset rate may have been due to less testing of asymptomatic patients. Efforts to decrease CDI rates in long-term care facilities are necessary as part of a coordinated approach to decrease healthcare-associated infections.

The Effect of a Nationwide Infection Control Program Expansion on Hospital-Onset Gram-Negative Rod Bacteremia in 130 Veterans Health Administration Medical Centers: An Interrupted Time-Series Analysis

Jorge Lobo’s disease (keloid blastomycosis) is an illness that catches the observer’s interest even though it is extremely infrequent. The reasons are its striking clinical features and enigmatic but interesting pathogenesis. Venezuela is one of the countries in which this ailment has been described. The authors supplied two additional cases and performed a fair review of the salient features of the disease and of conventional wisdom about its pathogenesis. Regretfully, Paniz-Mondolfi et al . failed to mention two papers that I coauthored that provide useful information. In the first, in 1961, Reyes et al . 2 described the third case of this condition in Venezuela, with probably the most extensive lesions ever reported. These were thick, hard lesions on the feet, legs, knees, hands, forearms, and elbows which progressed in a sporotrichoid fashion. The patient was aged 80 years and in good general health, and remembered clearly that the disease had started after trauma to the left sole 10 years before consultation. We also showed, for the first time, a distinct increase in serum γ -globulin. There was no evidence whatsoever of ill health or immune deficiency. Long-acting oral sulfonamides were tried, but the patient did not remain under control for long enough to judge the results of treatment. The second paper, in 1989, by Goihman-Yahr et al . 3 studied polymorphonuclear leukocyte function in the cells of another patient with Jorge Lobo’s disease. These were compared with cells from patients with diverse granulomatous diseases (including paracoccidioidomycosis and leishmaniasis), as well as healthy controls. The main objectives were as follows: (i) to determine whether there were any nonspecific deficiencies in neutrophil function; and (ii) to evaluate whether the specific inability of neutrophils from patients with paracoccidioidomycosis to digest in vitro Paracoccidioides brasiliensis was present or not in neutrophils from the patient with Jorge Lobo’s disease. The results were clear. Neutrophils from the patient with keloid blastomycosis phagocytosed and digested well Candida albicans and, most importantly, P. brasiliensis in vitro , and showed a normal myeloperoxidase reaction. The patient’s serum showed no antibodies against deep fungi, such as P. brasiliensis , Histoplasma capsulatum , C. albicans , Coccidioides immitis , or Aspergillus spp. In this way, the specificity of the digestive defect against P. brasiliensis by neutrophils from patients with paracoccidioidomycosis was confirmed, as well as the individuality of Jorge Lobo’s disease. The overall leukocyte function was basically normal in keloid blastomycosis. This occurred despite the fact that blood had to be flown from Ciudad Bolívar to Caracas airport, and from there driven to the laboratory to perform in vitro tests (normally, neutrophils are isolated from freshly drawn blood). I do feel that a review on Jorge Lobo’s disease in Venezuela (or elsewhere) should have mentioned these two papers. Interestingly, Paniz-Mondolfi et al . currently work in the same institution in which this writer headed the Section of Immunology for several decades. I would also like to stress that no ill will should be attributed to Paniz-Mondolfi et al . Indeed, the first author of the 1961 paper 2 was Dr Oscar Reyes-Flores, the father of Oscar Reyes-Jaimes, one of the coauthors of the paper by Paniz-Mondolfi et al . 1

A Report of the Efforts of the Veterans Health Administration National Antimicrobial Stewardship Initiative

A national survey was sent to all appropriate Veterans Health Administration (VA) medical facilities asking abut the ability to test for Staphylococcus aureus with reduced susceptibility to vancomycin (SARV) (MICs >4 μg/mL). Also, a request was made for the number of patients having SARV isolated during a 1-year period. Nineteen patients from eight sites across the country had isolation of SARV. Of these, MicroScan (Dade Behring, Inc, MicroScan Division, West Sacramento, CA) technology was used for 17 patients, Vitek (Hazelwood, MO) was used for 1 of the remaining 2 patients, and E-test (AB Biiodisk North America, Inc, Piscataway, NJ) for the other. All patients with this organism had microbiology testing done onsite in the reporting VA facility’s College of American Pathologists-approved laboratory. For comparison, similar data were obtained for a 1-year period 2 years prior to the current survey; seven patients from four sites were verified to have a SARV. Between the two survey periods the reported cases of SARV increased 170%, indicating a need for continued surveillance and potentially a need to initiate a collection of isolates for further analysis.

Prevention of methicillin-resistant Staphylococcus aureus infections in spinal cord injury units.

BACKGROUND The Veterans Health Administration (VHA) introduced the Methicillin-Resistant Staphylococcus aureus (MRSA) Prevention Initiative in March 2007. Although the initiative has been perceived as a vertical intervention focusing on MRSA, it also expanded infection prevention and control programs and resources. We aimed to assess the horizontal effect of the initiative on hospital-onset (HO) gram-negative rod (GNR) bacteremia. METHODS This retrospective cohort included all patients who had HO bacteremia due to Escherichia coli, Klebsiella species, or Pseudomonas aeruginosa at 130 VHA facilities from January 2003 to December 2013. The effects were assessed using segmented linear regression with autoregressive error models, incorporating autocorrelation, immediate effect, and time before and after the initiative. Community-acquired (CA) bacteremia with same species was also analyzed as nonequivalent dependent controls. RESULTS A total of 11 196 patients experienced HO-GNR bacteremia during the study period. There was a significant change of slope in HO-GNR bacteremia incidence rates from before the initiative (+0.3%/month) to after (-0.4%/month) (P < .01), while CA GNR incidence rates did not significantly change (P = .08). Cumulative effect of the intervention on HO-GNR bacteremia incidence rates at the end of the study period was estimated to be -43.2% (95% confidence interval, -51.6% to -32.4%). Similar effects were observed in subgroup analyses of each species and antimicrobial susceptibility profile. CONCLUSIONS Within 130 VHA facilities, there was a sustained decline in HO-GNR bacteremia incidence rates after the implementation of the MRSA Prevention Initiative. As these organisms were not specifically targeted, it is likely that horizontal components of the initiative contributed to this decline.