Yoona Rhee

Evolving Epidemiology of Staphylococcus aureus Bacteremia

BACKGROUND Methicillin-resistant Staphylococcus aureus (MRSA) infections due to USA300 have become widespread in community and healthcare settings. It is unclear whether risk factors for bloodstream infections (BSIs) differ by strain type. OBJECTIVE To examine the epidemiology of S. aureus BSIs, including USA300 and non-USA300 MRSA strains. DESIGN Retrospective observational study with molecular analysis. SETTING Large urban public hospital. PATIENTS Individuals with S. aureus BSIs from January 1, 2007 through December 31, 2013. METHODS We used electronic surveillance data to identify cases of S. aureus BSI. Available MRSA isolates were analyzed by pulsed-field gel electrophoresis. Poisson regression was used to evaluate changes in BSI incidence over time. Risk factor data were collected by medical chart review and logistic regression was used for multivariate analysis of risk factors. RESULTS A total of 1,015 cases of S. aureus BSIs were identified during the study period; 36% were due to MRSA. The incidence of hospital-onset (HO) MRSA BSIs decreased while that of community-onset (CO) MRSA BSIs remained stable. The rate of CO- and HO- methicillin-susceptible S. aureus infections both decreased over time. More than half of HO-MRSA BSIs were due to the USA300 strain type and for 4 years, the proportion of HO-MRSA BSIs due to USA300 exceeded 60%. On multivariate analysis, current or former drug use was the only epidemiologic risk factor for CO- or HO-MRSA BSIs due to USA300 strains. CONCLUSIONS USA300 MRSA is endemic in communities and hospitals and certain populations (eg, those who use illicit drugs) may benefit from enhanced prevention efforts in the community.

Modifiable Risk Factors for the Spread of Klebsiella pneumoniae Carbapenemase-Producing Enterobacteriaceae Among Long-Term Acute-Care Hospital Patients

OBJECTIVE To identify modifiable risk factors for acquisition of Klebsiella pneumoniae carbapenemase-producing Enterobacteriaceae (KPC) colonization among long-term acute-care hospital (LTACH) patients. DESIGN Multicenter, matched case-control study. SETTING Four LTACHs in Chicago, Illinois. PARTICIPANTS Each case patient included in this study had a KPC-negative rectal surveillance culture on admission followed by a KPC-positive surveillance culture later in the hospital stay. Each matched control patient had a KPC-negative rectal surveillance culture on admission and no KPC isolated during the hospital stay. RESULTS From June 2012 to June 2013, 2,575 patients were admitted to 4 LTACHs; 217 of 2,144 KPC-negative patients (10.1%) acquired KPC. In total, 100 of these patients were selected at random and matched to 100 controls by LTACH facility, admission date, and censored length of stay. Acquisitions occurred a median of 16.5 days after admission. On multivariate analysis, we found that exposure to higher colonization pressure (OR, 1.02; 95% CI, 1.01-1.04; P=.002), exposure to a carbapenem (OR, 2.25; 95% CI, 1.06-4.77; P=.04), and higher Charlson comorbidity index (OR, 1.14; 95% CI, 1.01-1.29; P=.04) were independent risk factors for KPC acquisition; the odds of KPC acquisition increased by 2% for each 1% increase in colonization pressure. CONCLUSIONS Higher colonization pressure, exposure to carbapenems, and a higher Charlson comorbidity index independently increased the odds of KPC acquisition among LTACH patients. Reducing colonization pressure (through separation of KPC-positive patients from KPC-negative patients using strict cohorts or private rooms) and reducing carbapenem exposure may prevent KPC cross transmission in this high-risk patient population. Infect Control Hosp Epidemiol 2017;38:670-677.

Successful Treatment of Cerebral Toxoplasmosis Using Pyrimethamine Oral Solution Compounded From Inexpensive Bulk Powder

Abstract A price increase of pyrimethamine tablets in the United States has made the life-saving drug difficult to acquire for hospitalized patients who need it most. We report the successful use of a pyrimethamine oral suspension compounded from an economical bulk powder in a patient with acute toxoplasmic encephalitis.

Differential Effects of Chlorhexidine Skin Cleansing Methods on Residual Chlorhexidine Skin Concentrations and Bacterial Recovery

BACKGROUND Bathing intensive care unit (ICU) patients with 2% chlorhexidine gluconate (CHG)-impregnated cloths decreases the risk of healthcare-associated bacteremia and multidrug-resistant organism transmission. Hospitals employ different methods of CHG bathing, and few studies have evaluated whether those methods yield comparable results. OBJECTIVE To determine whether 3 different CHG skin cleansing methods yield similar residual CHG concentrations and bacterial densities on skin. DESIGN Prospective, randomized 2-center study with blinded assessment. PARTICIPANTS AND SETTING Healthcare personnel in surgical ICUs at 2 tertiary-care teaching hospitals in Chicago, Illinois, and Boston, Massachusetts, from July 2015 to January 2016. INTERVENTION Cleansing skin of one forearm with no-rinse 2% CHG-impregnated polyester cloth (method A) versus 4% CHG liquid cleansing with rinsing on the contralateral arm, applied with either non-antiseptic-impregnated cellulose/polyester cloth (method B) or cotton washcloth dampened with sterile water (method C). RESULTS In total, 63 participants (126 forearms) received method A on 1 forearm (n=63). On the contralateral forearm, 33 participants received method B and 30 participants received method C. Immediately and 6 hours after cleansing, method A yielded the highest residual CHG concentrations (2500 µg/mL and 1250 µg/mL, respectively) and lowest bacterial densities compared to methods B or C (P<.001). CONCLUSION In healthy volunteers, cleansing with 2% CHG-impregnated cloths yielded higher residual CHG concentrations and lower bacterial densities than cleansing with 4% CHG liquid applied with either of 2 different cloth types and followed by rinsing. The relevance of these differences to clinical outcomes remains to be determined. Infect Control Hosp Epidemiol 2018;39:405-411.

Longitudinal comparison of the microbiota during Klebsiella pneumoniae carbapenemase-producing Klebsiella pneumoniae (KPC-Kp) acquisition in Long-Term Acute Care Hospital (LTACH) patients

Abstract Background Colonization with KPC-Kp precedes infection and represents a potential target for intervention. To identify microbial signatures associated with KPC-Kp acquisition, we conducted a prospective, longitudinal study of the fecal microbiota in LTACH patients at risk of acquiring KPC-Kp. Methods We collected admission and weekly rectal swab samples from patients admitted to one LTACH from May 2015 to May 2016. Patients were screened for KPC-Kp by PCR at each sampling time. KPC acquisition was confirmed by culture of KPC-Kp. To assess changes in the microbiota related to acquisition, we sequenced the 16S rRNA gene (V4 region) from collected rectal swabs. Diversity, intra-individual changes, and the relative abundance of the operational taxonomic unit (OTU) that contains KPC-Kp were compared in patients who were KPC-Kp negative upon admission and who had at least one additional swab sample collected. Results 318 patients (1247 samples) were eligible for analysis; 3.7 samples (mean) were collected per patient. Sixty-two patients (19.5%) acquired KPC-Kp (cases) and 256 patients remained negative for all carbapenem-resistant Enterobacteriaceae throughout their stay (controls). Median length of stay before KPC-Kp detection was 14.5 days. At time of KPC-Kp acquisition, levels of an Enterobacteriaceae OTU increased significantly compared with pre-acquisition samples and to samples from control patients (Wilcoxon test, P < 0.0001). Similarly, we observed a decrease in total diversity of the fecal microbiota at time of acquisition in cases (P < 0.01). Compared with controls, cases exhibited decreased intra-individual fecal microbiota similarity immediately prior to acquisition of KPC-Kp (P < 0.01). Comparison of microbial features at time of admission using random forest revealed a higher abundance of Enterococcus and Escherichia OTUs in controls vs cases. Conclusion We observed intra-individual changes in the fecal microbiota of case patients prior to acquisition of KPC-Kp. Compared with patients who did not acquire KPC-Kp, cases exhibited significant changes in microbiota diversity and increased abundance of potential KPC-Kp at acquisition. Our results suggest that shifts in the microbiota may precede colonization by KPC-Kp. Disclosures N. M. Moore, Cepheid: Research Contractor, Funded and provided reagents for associated research projects; R. A. Weinstein, OpGen: Receipt of donated laboratory services for project, Research support; CLorox: Receipt of contributed product, Conducting studies in healthcare facilities that are receiving contributed product; Molnlycke: Receipt of contributed product, Conducting studies in healthcare facilities that are receiving contributed product; Sage Products: Receipt of contributed product, Conducting studies in healthcare facilities that are receiving contributed product; M. Y. Lin, Sage, Inc.: receipt of contributed product, Conducting studies in healthcare facilities that are receiving contributed product; OpGen, Inc.: receipt of in-kind laboratory services, Conducting studies in healthcare facilities that are receiving contributed product; M. K. Hayden, OpGen, Inc.: Receipt of donated laboratory services for project, Research support; Clorox: Receipt of contributed product, Conducting studies in healthcare facilities that are receiving contributed product; Molnlycke: Receipt of contributed product, Conducting studies in healthcare facilities that are receiving contributed product; Sage Products: Receipt of contributed product, Conducting studies in healthcare facilities that are receiving contributed product.