Last data update: May 20, 2024. (Total: 46824 publications since 2009)
Records 1-26 (of 26 Records) |
Query Trace: Avery L[original query] |
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Stewardship prompts to improve antibiotic selection for pneumonia: The INSPIRE Randomized Clinical Trial
Gohil SK , Septimus E , Kleinman K , Varma N , Avery TR , Heim L , Rahm R , Cooper WS , Cooper M , McLean LE , Nickolay NG , Weinstein RA , Burgess LH , Coady MH , Rosen E , Sljivo S , Sands KE , Moody J , Vigeant J , Rashid S , Gilbert RF , Smith KN , Carver B , Poland RE , Hickok J , Sturdevant SG , Calderwood MS , Weiland A , Kubiak DW , Reddy S , Neuhauser MM , Srinivasan A , Jernigan JA , Hayden MK , Gowda A , Eibensteiner K , Wolf R , Perlin JB , Platt R , Huang SS . Jama 2024 IMPORTANCE: Pneumonia is the most common infection requiring hospitalization and is a major reason for overuse of extended-spectrum antibiotics. Despite low risk of multidrug-resistant organism (MDRO) infection, clinical uncertainty often drives initial antibiotic selection. Strategies to limit empiric antibiotic overuse for patients with pneumonia are needed. OBJECTIVE: To evaluate whether computerized provider order entry (CPOE) prompts providing patient- and pathogen-specific MDRO infection risk estimates could reduce empiric extended-spectrum antibiotics for non-critically ill patients admitted with pneumonia. DESIGN, SETTING, AND PARTICIPANTS: Cluster-randomized trial in 59 US community hospitals comparing the effect of a CPOE stewardship bundle (education, feedback, and real-time MDRO risk-based CPOE prompts; n = 29 hospitals) vs routine stewardship (n = 30 hospitals) on antibiotic selection during the first 3 hospital days (empiric period) in non-critically ill adults (≥18 years) hospitalized with pneumonia. There was an 18-month baseline period from April 1, 2017, to September 30, 2018, and a 15-month intervention period from April 1, 2019, to June 30, 2020. INTERVENTION: CPOE prompts recommending standard-spectrum antibiotics in patients ordered to receive extended-spectrum antibiotics during the empiric period who have low estimated absolute risk (<10%) of MDRO pneumonia, coupled with feedback and education. MAIN OUTCOMES AND MEASURES: The primary outcome was empiric (first 3 days of hospitalization) extended-spectrum antibiotic days of therapy. Secondary outcomes included empiric vancomycin and antipseudomonal days of therapy and safety outcomes included days to intensive care unit (ICU) transfer and hospital length of stay. Outcomes compared differences between baseline and intervention periods across strategies. RESULTS: Among 59 hospitals with 96 451 (51 671 in the baseline period and 44 780 in the intervention period) adult patients admitted with pneumonia, the mean (SD) age of patients was 68.1 (17.0) years, 48.1% were men, and the median (IQR) Elixhauser comorbidity count was 4 (2-6). Compared with routine stewardship, the group using CPOE prompts had a 28.4% reduction in empiric extended-spectrum days of therapy (rate ratio, 0.72 [95% CI, 0.66-0.78]; P < .001). Safety outcomes of mean days to ICU transfer (6.5 vs 7.1 days) and hospital length of stay (6.8 vs 7.1 days) did not differ significantly between the routine and CPOE intervention groups. CONCLUSIONS AND RELEVANCE: Empiric extended-spectrum antibiotic use was significantly lower among adults admitted with pneumonia to non-ICU settings in hospitals using education, feedback, and CPOE prompts recommending standard-spectrum antibiotics for patients at low risk of MDRO infection, compared with routine stewardship practices. Hospital length of stay and days to ICU transfer were unchanged. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT03697070. |
Stewardship prompts to improve antibiotic selection for urinary tract infection: The INSPIRE Randomized Clinical Trial
Gohil SK , Septimus E , Kleinman K , Varma N , Avery TR , Heim L , Rahm R , Cooper WS , Cooper M , McLean LE , Nickolay NG , Weinstein RA , Burgess LH , Coady MH , Rosen E , Sljivo S , Sands KE , Moody J , Vigeant J , Rashid S , Gilbert RF , Smith KN , Carver B , Poland RE , Hickok J , Sturdevant SG , Calderwood MS , Weiland A , Kubiak DW , Reddy S , Neuhauser MM , Srinivasan A , Jernigan JA , Hayden MK , Gowda A , Eibensteiner K , Wolf R , Perlin JB , Platt R , Huang SS . Jama 2024 IMPORTANCE: Urinary tract infection (UTI) is the second most common infection leading to hospitalization and is often associated with gram-negative multidrug-resistant organisms (MDROs). Clinicians overuse extended-spectrum antibiotics although most patients are at low risk for MDRO infection. Safe strategies to limit overuse of empiric antibiotics are needed. OBJECTIVE: To evaluate whether computerized provider order entry (CPOE) prompts providing patient- and pathogen-specific MDRO risk estimates could reduce use of empiric extended-spectrum antibiotics for treatment of UTI. DESIGN, SETTING, AND PARTICIPANTS: Cluster-randomized trial in 59 US community hospitals comparing the effect of a CPOE stewardship bundle (education, feedback, and real-time and risk-based CPOE prompts; 29 hospitals) vs routine stewardship (n = 30 hospitals) on antibiotic selection during the first 3 hospital days (empiric period) in noncritically ill adults (≥18 years) hospitalized with UTI with an 18-month baseline (April 1, 2017-September 30, 2018) and 15-month intervention period (April 1, 2019-June 30, 2020). INTERVENTIONS: CPOE prompts recommending empiric standard-spectrum antibiotics in patients ordered to receive extended-spectrum antibiotics who have low estimated absolute risk (<10%) of MDRO UTI, coupled with feedback and education. MAIN OUTCOMES AND MEASURES: The primary outcome was empiric (first 3 days of hospitalization) extended-spectrum antibiotic days of therapy. Secondary outcomes included empiric vancomycin and antipseudomonal days of therapy. Safety outcomes included days to intensive care unit (ICU) transfer and hospital length of stay. Outcomes were assessed using generalized linear mixed-effect models to assess differences between the baseline and intervention periods. RESULTS: Among 127 403 adult patients (71 991 baseline and 55 412 intervention period) admitted with UTI in 59 hospitals, the mean (SD) age was 69.4 (17.9) years, 30.5% were male, and the median Elixhauser Comorbidity Index count was 4 (IQR, 2-5). Compared with routine stewardship, the group using CPOE prompts had a 17.4% (95% CI, 11.2%-23.2%) reduction in empiric extended-spectrum days of therapy (rate ratio, 0.83 [95% CI, 0.77-0.89]; P < .001). The safety outcomes of mean days to ICU transfer (6.6 vs 7.0 days) and hospital length of stay (6.3 vs 6.5 days) did not differ significantly between the routine and intervention groups, respectively. CONCLUSIONS AND RELEVANCE: Compared with routine stewardship, CPOE prompts providing real-time recommendations for standard-spectrum antibiotics for patients with low MDRO risk coupled with feedback and education significantly reduced empiric extended-spectrum antibiotic use among noncritically ill adults admitted with UTI without changing hospital length of stay or days to ICU transfers. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT03697096. |
Nasal iodophor antiseptic vs nasal mupirocin antibiotic in the setting of chlorhexidine bathing to prevent infections in adult ICUs: A randomized clinical trial
Huang SS , Septimus EJ , Kleinman K , Heim LT , Moody JA , Avery TR , McLean L , Rashid S , Haffenreffer K , Shimelman L , Staub-Juergens W , Spencer-Smith C , Sljivo S , Rosen E , Poland RE , Coady MH , Lee CH , Blanchard EJ , Reddish K , Hayden MK , Weinstein RA , Carver B , Smith K , Hickok J , Lolans K , Khan N , Sturdevant SG , Reddy SC , Jernigan JA , Sands KE , Perlin JB , Platt R . JAMA 2023 330 (14) 1337-1347 IMPORTANCE: Universal nasal mupirocin plus chlorhexidine gluconate (CHG) bathing in intensive care units (ICUs) prevents methicillin-resistant Staphylococcus aureus (MRSA) infections and all-cause bloodstream infections. Antibiotic resistance to mupirocin has raised questions about whether an antiseptic could be advantageous for ICU decolonization. OBJECTIVE: To compare the effectiveness of iodophor vs mupirocin for universal ICU nasal decolonization in combination with CHG bathing. DESIGN, SETTING, AND PARTICIPANTS: Two-group noninferiority, pragmatic, cluster-randomized trial conducted in US community hospitals, all of which used mupirocin-CHG for universal decolonization in ICUs at baseline. Adult ICU patients in 137 randomized hospitals during baseline (May 1, 2015-April 30, 2017) and intervention (November 1, 2017-April 30, 2019) were included. INTERVENTION: Universal decolonization involving switching to iodophor-CHG (intervention) or continuing mupirocin-CHG (baseline). MAIN OUTCOMES AND MEASURES: ICU-attributable S aureus clinical cultures (primary outcome), MRSA clinical cultures, and all-cause bloodstream infections were evaluated using proportional hazard models to assess differences from baseline to intervention periods between the strategies. Results were also compared with a 2009-2011 trial of mupirocin-CHG vs no decolonization in the same hospital network. The prespecified noninferiority margin for the primary outcome was 10%. RESULTS: Among the 801 668 admissions in 233 ICUs, the participants' mean (SD) age was 63.4 (17.2) years, 46.3% were female, and the mean (SD) ICU length of stay was 4.8 (4.7) days. Hazard ratios (HRs) for S aureus clinical isolates in the intervention vs baseline periods were 1.17 for iodophor-CHG (raw rate: 5.0 vs 4.3/1000 ICU-attributable days) and 0.99 for mupirocin-CHG (raw rate: 4.1 vs 4.0/1000 ICU-attributable days) (HR difference in differences significantly lower by 18.4% [95% CI, 10.7%-26.6%] for mupirocin-CHG, P < .001). For MRSA clinical cultures, HRs were 1.13 for iodophor-CHG (raw rate: 2.3 vs 2.1/1000 ICU-attributable days) and 0.99 for mupirocin-CHG (raw rate: 2.0 vs 2.0/1000 ICU-attributable days) (HR difference in differences significantly lower by 14.1% [95% CI, 3.7%-25.5%] for mupirocin-CHG, P = .007). For all-pathogen bloodstream infections, HRs were 1.00 (2.7 vs 2.7/1000) for iodophor-CHG and 1.01 (2.6 vs 2.6/1000) for mupirocin-CHG (nonsignificant HR difference in differences, -0.9% [95% CI, -9.0% to 8.0%]; P = .84). Compared with the 2009-2011 trial, the 30-day relative reduction in hazards in the mupirocin-CHG group relative to no decolonization (2009-2011 trial) were as follows: S aureus clinical cultures (current trial: 48.1% [95% CI, 35.6%-60.1%]; 2009-2011 trial: 58.8% [95% CI, 47.5%-70.7%]) and bloodstream infection rates (current trial: 70.4% [95% CI, 62.9%-77.8%]; 2009-2011 trial: 60.1% [95% CI, 49.1%-70.7%]). CONCLUSIONS AND RELEVANCE: Nasal iodophor antiseptic did not meet criteria to be considered noninferior to nasal mupirocin antibiotic for the outcome of S aureus clinical cultures in adult ICU patients in the context of daily CHG bathing. In addition, the results were consistent with nasal iodophor being inferior to nasal mupirocin. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT03140423. |
REPRINT OF: Racism, sexism, and social class: Implications for studies of health, disease, and well-being
Krieger N , Rowley DL , Herman AA , Avery B , Phillips MT . Am J Prev Med 2022 62 (6) 816-863 Editor's Note: This article is a reprint of a previously published article. For citation purposes, please use the original publication details: Krieger N, Rowley DL, Herman AA, Avery B, Phillips MT. Racism, sexism, and social class: implications for studies of health, disease, and well-being. Am J Prev Med. 1993;9(6 suppl):82-122. |
Correlation between Phenotypic and In Silico Detection of Antimicrobial Resistance in Salmonella enterica in Canada Using Staramr.
Bharat A , Petkau A , Avery BP , Chen J , Folster J , Carson CA , Kearney A , Nadon C , Mabon P , Thiessen J , Alexander DC , Allen V , ElBailey S , Bekal S , German GJ , Haldane D , Hoang L , Chui L , Minion J , Zahariadis G , VanDomselaar G , Reid-Smith RJ , Mulvey MR . Microorganisms 2022 10 (2) Whole genome sequencing (WGS) of Salmonella supports both molecular typing and detection of antimicrobial resistance (AMR). Here, we evaluated the correlation between phenotypic antimicrobial susceptibility testing (AST) and in silico prediction of AMR from WGS in Salmonella enterica (n = 1321) isolated from human infections in Canada. Phenotypic AMR results from broth microdilution testing were used as the gold standard. To facilitate high-throughput prediction of AMR from genome assemblies, we created a tool called Staramr, which incorporates the ResFinder and PointFinder databases and a custom gene-drug key for antibiogram prediction. Overall, there was 99% concordance between phenotypic and genotypic detection of categorical resistance for 14 antimicrobials in 1321 isolates (18,305 of 18,494 results in agreement). We observed an average sensitivity of 91.2% (range 80.5100%), a specificity of 99.7% (98.6100%), a positive predictive value of 95.4% (68.2100%), and a negative predictive value of 99.1% (95.6100%). The positive predictive value of gentamicin was 68%, due to seven isolates that carried aac(3)-IVa, which conferred MICs just below the breakpoint of resistance. Genetic mechanisms of resistance in these 1321 isolates included 64 unique acquired alleles and mutations in three chromosomal genes. In general, in silico prediction of AMR in Salmonella was reliable compared to the gold standard of broth microdilution. WGS can provide higher-resolution data on the epidemiology of resistance mechanisms and the emergence of new resistance alleles. 2022 by the authors. Licensee MDPI, Basel, Switzerland. |
HIV prevalence and incidence among men who have sex with men and transgender women in Bangkok, 2014-2018: Outcomes of a consensus development initiative
van Griensven F , Phanuphak N , Manopaiboon C , Dunne EF , Colby DJ , Chaiphosri P , Ramautarsing R , Mock PA , Guadamuz TE , Rangsin R , Benjamaneepairoj K , Na Nakorn P , Vannakit R , de Lind van Wijngaarden JW , Avery M , Mills S . PLoS One 2022 17 (1) e0262694 To reach its goal of ending AIDS by 2030, Thailand has adopted antiretroviral treatment as prevention and HIV pre-exposure prophylaxis for men who have sex with men (MSM) and transgender women (TGW) as its core HIV control strategy. However, in the absence of reliable epidemiologic indicators, the impact of these policies on the course of the HIV epidemic in these groups remains unknown. To help answer this question, we formulated an HIV epidemic consensus initiative for Bangkok, Thailand, to analyze epidemiologic and program data and reach agreement between experts and stakeholders on the evolving state of the HIV epidemic among MSM and TGW. A customized Delphi process was used to consult and consolidate viewpoints of experts and stakeholders. Experts presented and discussed HIV prevalence and incidence data from recent and ongoing studies among MSM and TGW in Bangkok (2014 to 2018) during a meeting with stakeholders representing government, donors, and civil society. Agreement about the course of the HIV epidemic among MSM and TGW was attained by voting consensus. Based on presented data, meeting participants agreed that HIV prevalence and incidence had decreased among Bangkok MSM from 2014 to 2018. Despite these declines, HIV prevalence and incidence were found to remain high. This was particularly the case among younger MSM. Participants agreed that there was no evidence for a decrease in HIV prevalence and incidence among Bangkok TGW. Introduction of antiretroviral treatment as prevention and HIV pre-exposure prophylaxis may have contributed to these declines. However, HIV prevalence and incidence remained high, and no signs of a decrease were reported among Bangkok TGW. At the current rate of new HIV infections in MSM and TGW, Thailand will not reach its goal of ending AIDS by 2030. This HIV consensus initiative may serve as a model for building agreement and advocacy on epidemiologic and program data and their implications for a large metropolitan city. |
Risk Factors for Severe Acute Respiratory Syndrome Coronavirus 2 Infection in Homeless Shelters in Chicago, Illinois-March-May, 2020.
Ghinai I , Davis ES , Mayer S , Toews KA , Huggett TD , Snow-Hill N , Perez O , Hayden MK , Tehrani S , Landi AJ , Crane S , Bell E , Hermes JM , Desai K , Godbee M , Jhaveri N , Borah B , Cable T , Sami S , Nozicka L , Chang YS , Jagadish A , Chee M , Thigpen B , Llerena C , Tran M , Surabhi DM , Smith ED , Remus RG , Staszcuk R , Figueroa E , Leo P , Detmer WM , Lyon E , Carreon S , Hoferka S , Ritger KA , Jasmin W , Nagireddy P , Seo JY , Fricchione MJ , Kerins JL , Black SR , Butler LM , Howard K , McCauley M , Fraley T , Arwady MA , Gretsch S , Cunningham M , Pacilli M , Ruestow PS , Mosites E , Avery E , Longcoy J , Lynch EB , Layden JE . Open Forum Infect Dis 2020 7 (11) ofaa477 BACKGROUND: People experiencing homelessness are at increased risk of coronavirus disease 2019 (COVID-19), but little is known about specific risk factors for infection within homeless shelters. METHODS: We performed widespread severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) polymerase chain reaction testing and collected risk factor information at all homeless shelters in Chicago with at least 1 reported case of COVID-19 (n = 21). Multivariable, mixed-effects log-binomial models were built to estimate adjusted prevalence ratios (aPRs) for SARS-CoV-2 infection for both individual- and facility-level risk factors. RESULTS: During March 1 to May 1, 2020, 1717 shelter residents and staff were tested for SARS-CoV-2; 472 (27%) persons tested positive. Prevalence of infection was higher for residents (431 of 1435, 30%) than for staff (41 of 282, 15%) (prevalence ratio = 2.52; 95% confidence interval [CI], 1.78-3.58). The majority of residents with SARS-CoV-2 infection (293 of 406 with available information about symptoms, 72%) reported no symptoms at the time of specimen collection or within the following 2 weeks. Among residents, sharing a room with a large number of people was associated with increased likelihood of infection (aPR for sharing with >20 people compared with single rooms = 1.76; 95% CI, 1.11-2.80), and current smoking was associated with reduced likelihood of infection (aPR = 0.71; 95% CI, 0.60-0.85). At the facility level, a higher proportion of residents leaving and returning each day was associated with increased prevalence (aPR = 1.08; 95% CI, 1.01-1.16), whereas an increase in the number of private bathrooms was associated with reduced prevalence (aPR for 1 additional private bathroom per 100 people = 0.92; 95% CI, 0.87-0.98). CONCLUSIONS: We identified a high prevalence of SARS-CoV-2 infections in homeless shelters. Reducing the number of residents sharing dormitories might reduce the likelihood of SARS-CoV-2 infection. When community transmission is high, limiting movement of persons experiencing homelessness into and out of shelters might also be beneficial. |
Chlorhexidine versus routine bathing to prevent multidrug-resistant organisms and all-cause bloodstream infections in general medical and surgical units (ABATE Infection trial): a cluster-randomised trial
Huang SS , Septimus E , Kleinman K , Moody J , Hickok J , Heim L , Gombosev A , Avery TR , Haffenreffer K , Shimelman L , Hayden MK , Weinstein RA , Spencer-Smith C , Kaganov RE , Murphy MV , Forehand T , Lankiewicz J , Coady MH , Portillo L , Sarup-Patel J , Jernigan JA , Perlin JB , Platt R . Lancet 2019 393 (10177) 1205-1215 BACKGROUND: Universal skin and nasal decolonisation reduces multidrug-resistant pathogens and bloodstream infections in intensive care units. The effect of universal decolonisation on pathogens and infections in non-critical-care units is unknown. The aim of the ABATE Infection trial was to evaluate the use of chlorhexidine bathing in non-critical-care units, with an intervention similar to one that was found to reduce multidrug-resistant organisms and bacteraemia in intensive care units. METHODS: The ABATE Infection (active bathing to eliminate infection) trial was a cluster-randomised trial of 53 hospitals comparing routine bathing to decolonisation with universal chlorhexidine and targeted nasal mupirocin in non-critical-care units. The trial was done in hospitals affiliated with HCA Healthcare and consisted of a 12-month baseline period from March 1, 2013, to Feb 28, 2014, a 2-month phase-in period from April 1, 2014, to May 31, 2014, and a 21-month intervention period from June 1, 2014, to Feb 29, 2016. Hospitals were randomised and their participating non-critical-care units assigned to either routine care or daily chlorhexidine bathing for all patients plus mupirocin for known methicillin-resistant Staphylococcus aureus (MRSA) carriers. The primary outcome was MRSA or vancomycin-resistant enterococcus clinical cultures attributed to participating units, measured in the unadjusted, intention-to-treat population as the HR for the intervention period versus the baseline period in the decolonisation group versus the HR in the routine care group. Proportional hazards models assessed differences in outcome reductions across groups, accounting for clustering within hospitals. This trial is registered with ClinicalTrials.gov, number NCT02063867. FINDINGS: There were 189 081 patients in the baseline period and 339 902 patients (156 889 patients in the routine care group and 183 013 patients in the decolonisation group) in the intervention period across 194 non-critical-care units in 53 hospitals. For the primary outcome of unit-attributable MRSA-positive or VRE-positive clinical cultures (figure 2), the HR for the intervention period versus the baseline period was 0.79 (0.73-0.87) in the decolonisation group versus 0.87 (95% CI 0.79-0.95) in the routine care group. No difference was seen in the relative HRs (p=0.17). There were 25 (<1%) adverse events, all involving chlorhexidine, among 183 013 patients in units assigned to chlorhexidine, and none were reported for mupirocin. INTERPRETATION: Decolonisation with universal chlorhexidine bathing and targeted mupirocin for MRSA carriers did not significantly reduce multidrug-resistant organisms in non-critical-care patients. FUNDING: National Institutes of Health. |
Cytomegalovirus infections in lung and hematopoietic cell transplant recipients in the Organ Transplant Infection Prevention and Detection (OTIP) Study: a multi-year, multi-center prospective cohort study
Avery RK , Silveira FP , Benedict K , Cleveland AA , Kauffman CA , Schuster MG , Dubberke ER , Husain S , Paterson D , Chiller T , Pappas P . Transpl Infect Dis 2018 20 (3) e12877 BACKGROUND: Most studies of post-transplant CMV infection have focused on either solid organ or hematopoietic cell transplant (HCT) recipients. A large prospective cohort study involving both lung and HCT recipients provided an opportunity to compare the epidemiology and outcomes of CMV infections in these two groups. METHODS: Patients were followed for 30 months in a 6-center prospective cohort study. Data on demographics, CMV infections, tissue-invasive disease, recurrences, rejection, and immunosuppression were recorded. RESULTS: The overall incidence of CMV infection was 83/293 (28.3%) in the lung transplant group and 154/444 (34.7%) in the HCT group (p = 0.0706). Tissue-invasive CMV disease occurred in 8/83 (9.6%) of lung and 6/154 (3.9%) of HCT recipients with CMV infection, respectively (p=0.087). Median time to CMV infection was longer in the lung transplant group (236 vs. 40 days, p < 0.0001), likely reflecting the effects of prophylaxis vs. pre-emptive therapy. Total IgG levels of < 350 mg/dl in lung recipients and graft versus host disease (GvHD) in HCT recipients were associated with increased CMV risk. HCT recipients had a higher mean number of CMV episodes (p=0.008), although duration of viremia was not significantly different between the two groups. CMV infection was not associated with reduced overall survival in either group. CONCLUSIONS: Current CMV prevention strategies have resulted in a low incidence of tissue-invasive disease in both lung transplant and HCT, although CMV viremia is still relatively common. Differences between the lung and HCT groups in terms of time to CMV and recurrences of CMV viremia likely reflect differences in underlying host immunobiology and in CMV prevention strategies in the modern era. This article is protected by copyright. All rights reserved. |
Epidemiology and outcomes of Clostridium difficile infection in allogeneic hematopoietic cell and lung transplant recipients
Dubberke ER , Reske KA , Olsen MA , Bommarito K , Cleveland AA , Silveira FP , Schuster MG , Kauffman CA , Avery RK , Pappas PG , Chiller TM . Transpl Infect Dis 2018 20 (2) e12855 BACKGROUND: Clostridium difficile infection (CDI) is a common complication of lung and allogeneic hematopoietic cell (HCT) transplant, but the epidemiology and outcomes of CDI after transplant are poorly described. METHODS: We performed a prospective, multicenter study of CDI within 365 days post-allogeneic HCT or lung transplantation. Data were collected via patient interviews and medical chart review. Participants were followed weekly in the 12 weeks post-transplant and while hospitalized and contacted monthly up to 18 months post-transplantation. RESULTS: Six sites participated in the study with 614 total participants; 4 enrolled allogeneic HCT (385 participants) and 5 enrolled lung transplant recipients (229 participants). 150 CDI cases occurred within one year of transplantation; the incidence among lung transplant recipients was 13.1% and among allogeneic HCTs was 31.2%. Median time to CDI was significantly shorter among allogeneic HCT than lung transplant recipients (27 days vs. 90 days; p=0.037). CDI was associated with significantly higher mortality from 31-180 days post-index date among the allogeneic HCT recipients (Hazard ratio [HR]=1.80; p=0.007). There was a trend towards increased mortality among lung transplant recipients from 120-180 days post-index date (HR=4.7, p=0.09). CONCLUSIONS: The epidemiology and outcomes of CDI vary by transplant population; surveillance for CDI should continue beyond the immediate post-transplant period. This article is protected by copyright. All rights reserved. |
Infections in hematopoietic cell transplant recipients: Results from the organ transplant infection project, a multicenter, prospective, cohort study
Schuster MG , Cleveland AA , Dubberke ER , Kauffman CA , Avery RK , Husain S , Paterson DL , Silveira FP , Chiller TM , Benedict K , Murphy K , Pappas PG . Open Forum Infect Dis 2017 4 (2) ofx050 BACKGROUND: Infection is a major cause of morbidity and mortality after allogeneic hematopoietic cell transplantation (HCT). Our object was to better define the epidemiology and outcomes of infections after HCT. METHODS: This was a prospective, multicenter cohort study of HCT recipients and conducted from 2006 to 2011. The study included 4 US transplant centers and 444 HCT recipients. Data were prospectively collected for up to 30 months after HCT using a standardized data collection tool. RESULTS: The median age was 53 years, and median follow up was 413 (range, 5-980) days. The most common reason for HCT was hematologic malignancy (87%). The overall crude mortality was 52%. Death was due to underlying disease in 44% cases and infection in 21%. Bacteremia occurred in 231 (52%) cases and occurred early posttransplant (median day 48). Gram-negative bloodstream infections were less frequent than Gram-positive, but it was associated with higher mortality (45% vs 13%, P = .02). Clostridium difficile infection developed in 148 patients (33%) at a median of 27 days post-HCT. There were 53 invasive fungal infections (IFIs) among 48 patients (11%). The median time to IFI was 142 days. Of 155 patients with cytomegalovirus (CMV) infection, 4% had CMV organ involvement. Varicella zoster infection (VZV) occurred in 13 (4%) cases and was disseminated in 2. Infection with respiratory viruses was seen in 49 patients. Pneumocystis jirovecii pneumonia was rare (1%), and there were no documented cases of nocardiosis, toxoplasmosis, endemic mycoses, or mycobacterial infection. This study lacked standardized antifungal and antiviral prophylactic strategies. CONCLUSIONS: Infection remains a significant cause of morbidity and mortality after HCT. Bacteremias and C difficile infection are frequent, particularly in the early posttransplant period. The rate of IFI is approximately 10%. Organ involvement with CMV is infrequent, as are serious infections with VZV and herpes simplex virus, likely reflecting improved prevention strategies. |
Vital Signs: Epidemiology of sepsis: Prevalence of health care factors and opportunities for prevention
Novosad SA , Sapiano MR , Grigg C , Lake J , Robyn M , Dumyati G , Felsen C , Blog D , Dufort E , Zansky S , Wiedeman K , Avery L , Dantes RB , Jernigan JA , Magill SS , Fiore A , Epstein L . MMWR Morb Mortal Wkly Rep 2016 65 (33) 864-869 BACKGROUND: Sepsis is a serious and often fatal clinical syndrome, resulting from infection. Information on patient demographics, risk factors, and infections leading to sepsis is needed to integrate comprehensive sepsis prevention, early recognition, and treatment strategies. METHODS: To describe characteristics of patients with sepsis, CDC and partners conducted a retrospective chart review in four New York hospitals. Random samples of medical records from adult and pediatric patients with administrative codes for severe sepsis or septic shock were reviewed. RESULTS: Medical records of 246 adults and 79 children (aged birth to 17 years) were reviewed. Overall, 72% of patients had a health care factor during the 30 days before sepsis admission or a selected chronic condition likely to require frequent medical care. Pneumonia was the most common infection leading to sepsis. The most common pathogens isolated from blood cultures were Escherichia coli in adults aged ≥18 years, Klebsiella spp. in children aged ≥1 year, and Enterococcus spp. in infants aged <1 year; for 106 (33%) patients, no pathogen was isolated. Eighty-two (25%) patients with sepsis died, including 65 (26%) adults and 17 (22%) infants and children. CONCLUSIONS: Infection prevention strategies (e.g., vaccination, reducing transmission of pathogens in health care environments, and appropriate management of chronic diseases) are likely to have a substantial impact on reducing sepsis. CDC, in partnership with organizations representing clinicians, patients, and other stakeholders, is launching a comprehensive campaign to demonstrate that prevention of infections that cause sepsis, and early recognition of sepsis, are integral to overall patient safety. |
Chlorhexidine and mupirocin susceptibility of methicillin-resistant Staphylococcus aureus isolates in the REDUCE-MRSA trial
Hayden MK , Lolans K , Haffenreffer K , Avery TR , Kleinman K , Li H , Kaganov RE , Lankiewicz J , Moody J , Septimus E , Weinstein RA , Hickok J , Jernigan J , Perlin JB , Platt R , Huang SS . J Clin Microbiol 2016 54 (11) 2735-2742 Whether targeted or universal decolonization strategies for control of methicillin-resistant Staphylococcus aureus (MRSA) select for resistance to decolonizing agents is unresolved. The REDUCE MRSA trial provided an opportunity to investigate this question. REDUCE-MRSA was a 3-arm, cluster-randomized trial of screening and isolation without decolonization, targeted decolonization with chlorhexidine and mupirocin, or universal decolonization without screening to prevent MRSA infection in intensive care unit patients. Iisolates from baseline and intervention periods were collected and tested for susceptibility to CHG by microtiter dilution; mupirocin susceptibility was tested by E-test. Presence of qacA/B genes was determined by PCR and DNA sequence analysis. A total of 3,173 isolates were analyzed; two were non-susceptible to CHG (MICs 8 mug/mL), and 5/814 (0.6%) carried qacA/B. At baseline, 7.1% of MRSA isolates expressed low-level and 7.5% expressed high-level mupirocin resistance. In a mixed effects generalized logistic regression model, the odds of mupirocin resistance among clinical MRSA isolates or MRSA isolates acquired in ICU in intervention versus baseline periods did not differ across arms, although estimates were imprecise due to small numbers. Reduced susceptibility to chlorhexidine and carriage of qacA/B were rare among MRSA isolates in the REDUCE MRSA trial. Odds of mupirocin-resistance were no different in the intervention versus baseline periods across arms, but confidence limits were broad and results should be interpreted with caution. |
Vital Signs: Preventing antibiotic-resistant infections in hospitals - United States, 2014
Weiner LM , Fridkin SK , Aponte-Torres Z , Avery L , Coffin N , Dudeck MA , Edwards JR , Jernigan JA , Konnor R , Soe MM , Peterson K , McDonald LC . MMWR Morb Mortal Wkly Rep 2016 65 (9) 235-241 BACKGROUND: Health care-associated antibiotic-resistant (AR) infections increase patient morbidity and mortality and might be impossible to successfully treat with any antibiotic. CDC assessed health care-associated infections (HAI), including Clostridium difficile infections (CDI), and the role of six AR bacteria of highest concern nationwide in several types of health care facilities. METHODS: During 2014, approximately 4,000 short-term acute care hospitals, 501 long-term acute care hospitals, and 1,135 inpatient rehabilitation facilities in all 50 states reported data on specific infections to the National Healthcare Safety Network. National standardized infection ratios and their percentage reduction from a baseline year for each HAI type, by facility type, were calculated. The proportions of AR pathogens and HAIs caused by any of six resistant bacteria highlighted by CDC in 2013 as urgent or serious threats were determined. RESULTS: In 2014, the reductions in incidence in short-term acute care hospitals and long-term acute care hospitals were 50% and 9%, respectively, for central line-associated bloodstream infection; 0% (short-term acute care hospitals), 11% (long-term acute care hospitals), and 14% (inpatient rehabilitation facilities) for catheter-associated urinary tract infection; 17% (short-term acute care hospitals) for surgical site infection, and 8% (short-term acute care hospitals) for CDI. Combining HAIs other than CDI across all settings, 47.9% of Staphylococcus aureus isolates were methicillin resistant, 29.5% of enterococci were vancomycin-resistant, 17.8% of Enterobacteriaceae were extended-spectrum beta-lactamase phenotype, 3.6% of Enterobacteriaceae were carbapenem resistant, 15.9% of Pseudomonas aeruginosa isolates were multidrug resistant, and 52.6% of Acinetobacter species were multidrug resistant. The likelihood of HAIs caused by any of the six resistant bacteria ranged from 12% in inpatient rehabilitation facilities to 29% in long-term acute care hospitals. CONCLUSIONS: Although there has been considerable progress in preventing some HAIs, many remaining infections could be prevented with implementation of existing recommended practices. Depending upon the setting, more than one in four of HAIs excluding CDI are caused by AR bacteria. IMPLICATIONS FOR PUBLIC HEALTH PRACTICE: Physicians, nurses, and health care leaders need to consistently and comprehensively follow all recommendations to prevent catheter- and procedure-related infections and reduce the impact of AR bacteria through antimicrobial stewardship and measures to prevent spread. |
Effect of body surface decolonisation on bacteriuria and candiduria in intensive care units: an analysis of a cluster-randomised trial
Huang SS , Septimus E , Hayden MK , Kleinman K , Sturtevant J , Avery TR , Moody J , Hickok J , Lankiewicz J , Gombosev A , Kaganov RE , Haffenreffer K , Jernigan JA , Perlin JB , Platt R , Weinstein RA . Lancet Infect Dis 2015 16 (1) 70-79 BACKGROUND: Urinary tract infections (UTIs) are common health-care-associated infections. Bacteriuria commonly precedes UTI and is often treated with antibiotics, particularly in hospital intensive care units (ICUs). In 2013, a cluster-randomised trial (REDUCE MRSA Trial [Randomized Evaluation of Decolonization vs Universal Clearance to Eradicate MRSA]) showed that body surface decolonisation reduced all-pathogen bloodstream infections. We aim to further assess the effect of decolonisation on bacteriuria and candiduria in patients admitted to ICUs. METHODS: We did a secondary analysis of a three-group, cluster-randomised trial of 43 hospitals (clusters) with patients in 74 adult ICUs. The three groups included were either meticillin-resistant Staphylococcus aureus (MRSA) screening and isolation, targeted decolonisation (screening, isolation, and decolonisation of MRSA carriers) with chlorhexidine and mupirocin, and universal decolonisation (no screening, all patients decolonised) with chlorhexidine and mupirocin. Protocol included chlorhexidine cleansing of the perineum and proximal 6 inches (15.24 cm) of urinary catheters. ICUs within the same hospital were assigned the same strategy. Outcomes included high-level bacteriuria (≥50 000 colony forming units [CFU]/mL) with any uropathogen, high-level candiduria (≥50 000 CFU/mL), and any bacteriuria with uropathogens. Sex-specific analyses were specified a priori. Proportional hazards models assessed differences in outcome reductions across groups, comparing an 18-month intervention period to a 12-month baseline period. FINDINGS: 122 646 patients (48 390 baseline, 74 256 intervention) were enrolled. Intervention versus baseline hazard ratios (HRs) for high-level bacteriuria were 1.02 (95% CI 0.88-1.18) for screening or isolation, 0.88 (0.76-1.02) for targeted decolonisation, and 0.87 (0.77-1.00) for universal decolonisation (no difference between groups, p=0.26), with no sex-specific reductions (HRs for men: 1.09 [95% CI 0.85-1.40] for screening or isolation, 1.01 [0.79-1.29] for targeted decolonisation, and 0.78 [0.63-0.98] for universal decolonisation, p=0.12; HRs for women: 0.97 [0.80-1.17] for screening and isolation, 0.83 [0.70-1.00] for targeted decolonisation, and 0.93 [0.79-1.09] for universal decolonisation, p=0.49). HRs for high-level candiduria were 1.14 (0.95-1.37) for screening and isolation, 0.99 (0.83-1.18) for targeted decolonisation, and 0.83 (0.70-0.99) for universal decolonisation (p=0.05). Differences between sexes were due to reductions in men in the universal decolonisation group (HRs: 1.21 [95% CI 0.88-1.68] for screening or isolation, 1.01 [0.73-1.39] for targeted decolonisation, and 0.63 [0.45-0.89] for universal decolonisation, p=0.02). Bacteriuria with any CFU/mL was also reduced in men in the universal decolonisation group (HRs 1.01 [0.81-1.25] for screening or isolation, 1.04 [0.83-1.30] for targeted decolonisation, and 0.74 [0.61-0.90] for universal decolonisation, p=0.04). INTERPRETATION: Universal decolonisation of patients in the ICU with once a day chlorhexidine baths and short-course nasal mupirocin could be a potential preventive strategy in male patients because it significantly decreases candiduria and any bacteriuria, but not for women. FUNDING: HAI Program from AHRQ, US Department of Health and Human Services as part of the Developing Evidence to Inform Decisions about Effectiveness (DEcIDE) program, CDC Prevention Epicenters Program. |
Vital Signs: estimated effects of a coordinated approach for action to reduce antibiotic-resistant infections in health care facilities - United States
Slayton RB , Toth D , Lee BY , Tanner W , Bartsch SM , Khader K , Wong K , Brown K , McKinnell JA , Ray W , Miller LG , Rubin M , Kim DS , Adler F , Cao C , Avery L , Stone NT , Kallen A , Samore M , Huang SS , Fridkin S , Jernigan JA . MMWR Morb Mortal Wkly Rep 2015 64 (30) 826-31 BACKGROUND: Treatments for health care-associated infections (HAIs) caused by antibiotic-resistant bacteria and Clostridium difficile are limited, and some patients have developed untreatable infections. Evidence-supported interventions are available, but coordinated approaches to interrupt the spread of HAIs could have a greater impact on reversing the increasing incidence of these infections than independent facility-based program efforts. METHODS: Data from CDC's National Healthcare Safety Network and Emerging Infections Program were analyzed to project the number of health care-associated infections from antibiotic-resistant bacteria or C. difficile both with and without a large scale national intervention that would include interrupting transmission and improved antibiotic stewardship. As an example, the impact of reducing transmission of one antibiotic-resistant infection (carbapenem-resistant Enterobacteriaceae [CRE]) on cumulative prevalence and number of HAI transmission events within interconnected groups of health care facilities was modeled using two distinct approaches, a large scale and a smaller scale health care network. RESULTS: Immediate nationwide infection control and antibiotic stewardship interventions, over 5 years, could avert an estimated 619,000 HAIs resulting from CRE, multidrug-resistant Pseudomonas aeruginosa, invasive methicillin-resistant Staphylococcus aureus (MRSA), or C. difficile. Compared with independent efforts, a coordinated response to prevent CRE spread across a group of inter-connected health care facilities resulted in a cumulative 74% reduction in acquisitions over 5 years in a 10-facility network model, and 55% reduction over 15 years in a 102-facility network model. CONCLUSIONS: With effective action now, more than half a million antibiotic-resistant health care-associated infections could be prevented over 5 years. Models representing both large and small groups of interconnected health care facilities illustrate that a coordinated approach to interrupting transmission is more effective than historical independent facilitybased efforts. IMPLICATIONS FOR PUBLIC HEALTH: Public health-led coordinated prevention approaches have the potential to more completely address the emergence and dissemination of these antibiotic-resistant organisms and C. difficile than independent facility-based efforts. |
Does chlorhexidine bathing in adult intensive care units reduce blood culture contamination? A pragmatic cluster-randomized trial
Septimus EJ , Hayden MK , Kleinman K , Avery TR , Moody J , Weinstein RA , Hickok J , Lankiewicz J , Gombosev A , Haffenreffer K , Kaganov RE , Jernigan JA , Perlin JB , Platt R , Huang SS . Infect Control Hosp Epidemiol 2014 35 Suppl 3 S17-22 OBJECTIVE: To determine rates of blood culture contamination comparing 3 strategies to prevent intensive care unit (ICU) infections: screening and isolation, targeted decolonization, and universal decolonization. DESIGN: Pragmatic cluster-randomized trial. SETTING: Forty-three hospitals with 74 ICUs; 42 of 43 were community hospitals. PATIENTS: Patients admitted to adult ICUs from July 1, 2009, to September 30, 2011. METHODS: After a 6-month baseline period, hospitals were randomly assigned to 1 of 3 strategies, with all participating adult ICUs in a given hospital assigned to the same strategy. Arm 1 implemented methicillin-resistant Staphylococcus aureus (MRSA) nares screening and isolation, arm 2 targeted decolonization (screening, isolation, and decolonization of MRSA carriers), and arm 3 conducted no screening but universal decolonization of all patients with mupirocin and chlorhexidine (CHG) bathing. Blood culture contamination rates in the intervention period were compared to the baseline period across all 3 arms. RESULTS: During the 6-month baseline period, 7,926 blood cultures were collected from 3,399 unique patients: 1,099 sets in arm 1, 928 in arm 2, and 1,372 in arm 3. During the 18-month intervention period, 22,761 blood cultures were collected from 9,878 unique patients: 3,055 sets in arm 1, 3,213 in arm 2, and 3,610 in arm 3. Among all individual draws, for arms 1, 2, and 3, the contamination rates were 4.1%, 3.9%, and 3.8% for the baseline period and 3.3%, 3.2%, and 2.4% for the intervention period, respectively. When we evaluated sets of blood cultures rather than individual draws, the contamination rate in arm 1 (screening and isolation) was 9.8% (N = 108 sets) in the baseline period and 7.5% (N = 228) in the intervention period. For arm 2 (targeted decolonization), the baseline rate was 8.4% (N = 78) compared to 7.5% (N = 241) in the intervention period. Arm 3 (universal decolonization) had the greatest decrease in contamination rate, with a decrease from 8.7% (N = 119) contaminated blood cultures during the baseline period to 5.1% (N = 184) during the intervention period. Logistic regression models demonstrated a significant difference across the arms when comparing the reduction in contamination between baseline and intervention periods in both unadjusted (P = .02) and adjusted (P = .02) analyses. Arm 3 resulted in the greatest reduction in blood culture contamination rates, with an unadjusted odds ratio (OR) of 0.56 (95% confidence interval [CI], 0.044-0.71) and an adjusted OR of 0.55 (95% CI, 0.43-0.71). CONCLUSION: In this large cluster-randomized trial, we demonstrated that universal decolonization with CHG bathing resulted in a significant reduction in blood culture contamination. |
Preferences and decision needs of Boston-area travelers to countries with risk of yellow fever virus transmission: implications for health care providers
Lown BA , Chen LH , Han PV , Jentes ES , Wilson ME , Benoit CM , Avery KA , Ooi W , Hamer DH , Barnett ED . J Travel Med 2014 21 (4) 266-71 BACKGROUND: Yellow fever (YF), a potentially fatal mosquito-borne infection, is preventable with a live-attenuated vaccine, rarely associated with severe adverse events. We surveyed travelers to assess their reasons for pre-travel medical consultation, information they considered important regarding YF disease and vaccination, whether they recalled receiving this information, and whether they were involved in vaccine decision-making. METHODS: Travelers aged 18 years and older were surveyed at three Boston-area travel clinics. Only those making YF vaccination decisions were included for analyses. RESULTS: Of 831 travelers surveyed, 589 (70%) indicated making a YF vaccination decision. Travel medicine providers recommended YF vaccination to 537 (91%) of 589 travelers; 92% of these 537 received vaccine. Among 101 travelers aged 60 years and older, 9% declined the vaccine; among those younger than 60 years, 4% declined the vaccine (p = 0.06). Of 589 travelers, most agreed they needed to understand destination-specific YF risks (82%) and vaccine risks (88%), and were involved in YF vaccine decisions (87%). Less than half recalled discussing their concerns about YF vaccine with the provider (42%) or what risks and benefits mattered most to them (32%). CONCLUSION: Most participants sought YF disease and vaccine risk information and wanted to be involved in decision-making; however, fewer than half recalled discussing their opinions or concerns about YF vaccine. Providers need effective risk communication skills and the ability to elicit and respond to travelers' concerns to help them make informed, shared decisions. |
A multi-stakeholder perspective on the use of alternative test strategies for nanomaterial safety assessment
Nel AE , Nasser E , Godwin H , Avery D , Bahadori T , Bergeson L , Beryt E , Bonner JC , Boverhof D , Carter J , Castranova V , Deshazo JR , Hussain SM , Kane AB , Klaessig F , Kuempel E , Lafranconi M , Landsiedel R , Malloy T , Miller MB , Morris J , Moss K , Oberdorster G , Pinkerton K , Pleus RC , Shatkin JA , Thomas R , Tolaymat T , Wang A , Wong J . ACS Nano 2013 7 (8) 6422-33 There has been a conceptual shift in toxicological studies from describing what happens to explaining how the adverse outcome occurs, thereby enabling a deeper and improved understanding of how biomolecular and mechanistic profiling can inform hazard identification and improve risk assessment. Compared to traditional toxicology methods, which have a heavy reliance on animals, new approaches to generate toxicological data are becoming available for the safety assessment of chemicals, including high-throughput and high-content screening (HTS, HCS). With the emergence of nanotechnology, the exponential increase in the total number of engineered nanomaterials (ENMs) in research, development, and commercialization requires a robust scientific approach to screen ENM safety in humans and the environment rapidly and efficiently. Spurred by the developments in chemical testing, a promising new toxicological paradigm for ENMs is to use alternative test strategies (ATS), which reduce reliance on animal testing through the use of in vitro and in silico methods such as HTS, HCS, and computational modeling. Furthermore, this allows for the comparative analysis of large numbers of ENMs simultaneously and for hazard assessment at various stages of the product development process and overall life cycle. Using carbon nanotubes as a case study, a workshop bringing together national and international leaders from government, industry, and academia was convened at the University of California, Los Angeles, to discuss the utility of ATS for decision-making analyses of ENMs. After lively discussions, a short list of generally shared viewpoints on this topic was generated, including a general view that ATS approaches for ENMs can significantly benefit chemical safety analysis. |
Dihydropteroate synthase mutations in Pneumocystis pneumonia: impact of applying different definitions of prophylaxis, mortality endpoints and mutant in a single cohort
Yoon C , Subramanian A , Chi A , Crothers K , Meshnick SR , Taylor SM , Beard CB , Jarlsberg LG , Lawrence GG , Avery M , Swartzman A , Fong S , Roth B , Huang L . Med Mycol 2013 51 (6) 568-75 Pneumocystis jirovecii dihydropteroate synthase (DHPS) gene mutations are well-reported. Although sulfa prophylaxis generally is associated with DHPS mutant infection, whether mutant infection is associated with poorer clinical outcomes is less clear. The differing definitions of sulfa prophylaxis and the different mortality endpoints used in these studies may be one explanation for the conflicting study results. Applying different definitions of prophylaxis, mortality endpoints and DHPS mutant to 301 HIV-infected patients with Pneumocystis pneumonia, we demonstrate that prophylaxis, irrespective of definition, increased the risk of infection with pure mutant (any prophylaxis: AOR 4.00, 95% CI: 1.83-8.76, P < 0.001) but not mixed genotypes (any prophylaxis: AOR 0.78, 95% CI: 0.26-2.36, P = 0.65). However, infection with mutant DHPS, irrespective of definition, was not associated with increased mortality (all-cause or PCP death) at the three time-intervals examined (all P > 0.05). Future studies should standardize key variables associated with DHPS mutant infection as well as examine DHPS mutant subtypes (pure mutant vs. mixed infections) - perhaps even individual DHPS mutant genotypes - so that data can be pooled to better address this issue. |
Targeted versus universal decolonization to prevent ICU infection
Huang SS , Septimus E , Kleinman K , Moody J , Hickok J , Avery TR , Lankiewicz J , Gombosev A , Terpstra L , Hartford F , Hayden MK , Jernigan JA , Weinstein RA , Fraser VJ , Haffenreffer K , Cui E , Kaganov RE , Lolans K , Perlin JB , Platt R . N Engl J Med 2013 368 (24) 2255-65 BACKGROUND: Both targeted decolonization and universal decolonization of patients in intensive care units (ICUs) are candidate strategies to prevent health care-associated infections, particularly those caused by methicillin-resistant Staphylococcus aureus (MRSA). METHODS: We conducted a pragmatic, cluster-randomized trial. Hospitals were randomly assigned to one of three strategies, with all adult ICUs in a given hospital assigned to the same strategy. Group 1 implemented MRSA screening and isolation; group 2, targeted decolonization (i.e., screening, isolation, and decolonization of MRSA carriers); and group 3, universal decolonization (i.e., no screening, and decolonization of all patients). Proportional-hazards models were used to assess differences in infection reductions across the study groups, with clustering according to hospital. RESULTS: A total of 43 hospitals (including 74 ICUs and 74,256 patients during the intervention period) underwent randomization. In the intervention period versus the baseline period, modeled hazard ratios for MRSA clinical isolates were 0.92 for screening and isolation (crude rate, 3.2 vs. 3.4 isolates per 1000 days), 0.75 for targeted decolonization (3.2 vs. 4.3 isolates per 1000 days), and 0.63 for universal decolonization (2.1 vs. 3.4 isolates per 1000 days) (P=0.01 for test of all groups being equal). In the intervention versus baseline periods, hazard ratios for bloodstream infection with any pathogen in the three groups were 0.99 (crude rate, 4.1 vs. 4.2 infections per 1000 days), 0.78 (3.7 vs. 4.8 infections per 1000 days), and 0.56 (3.6 vs. 6.1 infections per 1000 days), respectively (P<0.001 for test of all groups being equal). Universal decolonization resulted in a significantly greater reduction in the rate of all bloodstream infections than either targeted decolonization or screening and isolation. One bloodstream infection was prevented per 54 patients who underwent decolonization. The reductions in rates of MRSA bloodstream infection were similar to those of all bloodstream infections, but the difference was not significant. Adverse events, which occurred in 7 patients, were mild and related to chlorhexidine. CONCLUSIONS: In routine ICU practice, universal decolonization was more effective than targeted decolonization or screening and isolation in reducing rates of MRSA clinical isolates and bloodstream infection from any pathogen. |
Inactivation of Plasmodium spp. in plasma and platelet concentrates using riboflavin and ultraviolet light
Keil SD , Kiser P , Sullivan JJ , Kong AS , Reddy HL , Avery A , Goodrich RP . Transfusion 2013 53 (10) 2278-86 BACKGROUND: Photochemical treatment of blood products could help prevent transfusion-transmitted malaria and reduce the need for donor deferrals. In this study we evaluated the effectiveness of riboflavin and ultraviolet (UV) light against both Plasmodium falciparum, which causes the most severe form of human malaria, and Plasmodium yoelii, an in vivo murine model for malaria. STUDY DESIGN AND METHODS: Plasma and platelet (PLT) concentrates were inoculated with either P. falciparum- or P. yoelii-infected red blood cells (RBCs). Aliquots from each unit were collected after inoculation, after addition of riboflavin, and after treatment. In vitro P. falciparum growth was assessed using thin blood films of duplicate samples at 24, 48, 72, and 96 hours. P. yoelii parasitemia was followed in mice for 14 days postinoculation. RESULTS: In the in vitro studies, the mean P. falciparum parasitemia increased 12- to 19-fold in pretreatment samples, both before and after addition of riboflavin, after 96-hour culture. Few parasites were observed in Mirasol-treated units at 24 hours; those that were observed were degenerating. Through the remainder of the 96-hour culture period, cultures of treated samples were negative. In the in vivo study, mouse plasma containing P. yoelii-infected RBCs had a mean starting titer of 4.6 log mouse infectious dose 50%/mL. No infectious parasite was detected in treated samples. CONCLUSION: Treatment with riboflavin and UV light was effective at reducing viable P. falciparum in both PLT and plasma products by at least 3.2 logs. Additionally, an at least 4.4-log reduction was observed with P. yoelii. |
Importance of employee vaccination against influenza in preventing cases in long-term care facilities
Wendelboe AM , Avery C , Andrade B , Baumbach J , Landen MG . Infect Control Hosp Epidemiol 2011 32 (10) 990-7 OBJECTIVE: Employees of long-term care facilities (LTCFs) who have contact with residents should be vaccinated against influenza annually to reduce influenza incidence among residents. This investigation estimated the magnitude of the benefit of this recommendation. METHODS: The New Mexico Department of Health implemented active surveillance in all of its 75 LTCFs during influenza seasons 2006-2007 and 2007-2008. Information about the number of laboratory-confirmed cases of influenza and the proportion vaccinated of both residents and direct-care employees in each facility was collected monthly. LTCFs reporting at least 1 case of influenza (defined alternately by laboratory confirmation or symptoms of influenza-like illness [ILI]) among residents were compared with LTCFs reporting no cases of influenza. Regression modeling was used to obtain adjusted odds ratios (aORs) and 95% confidence intervals (CIs) for the association between employee vaccination coverage and the occurrence of influenza outbreaks. Covariates included vaccination coverage among residents, the staff-to-resident ratio, and the proportion of filled beds. RESULTS: Seventeen influenza outbreaks were reported during this 2-year period of surveillance. Eleven of these were laboratory confirmed ([Formula: see text] residents) and 6 were defined by ILI ([Formula: see text] residents). Mean influenza vaccination coverage among direct-care employees was 51% in facilities reporting outbreaks and 60% in facilities not reporting outbreaks ([Formula: see text]). Increased vaccination coverage among direct-care employees was associated with fewer reported outbreaks of laboratory-confirmed influenza (aOR, 0.97 [95% CI, 0.95-0.99]) and ILI (aOR, 0.98 [95% CI, 0.96-1.00]). CONCLUSIONS: High vaccination coverage among direct-care employees helps to prevent influenza in LTCFs. |
Pandemic (H1N1) 2009-associated deaths detected by unexplained death and medical examiner surveillance
Lees CH , Avery C , Asherin R , Rainbow J , Danila R , Smelser C , Schmitz A , Ladd-Wilson S , Nolte KB , Nagle K , Lynfield R . Emerg Infect Dis 2011 17 (8) 1479-83 During the pandemic (H1N1) 2009 outbreak, Minnesota, New Mexico, and Oregon used several surveillance methods to detect associated deaths. Surveillance using unexplained death and medical examiner data allowed for detection of 34 (18%) pandemic (H1N1) 2009-associated deaths that were not detected by hospital-based surveillance. |
Investigation of a group A streptococcal outbreak among residents of a long-term acute care hospital
Deutscher M , Schillie S , Gould C , Baumbach J , Mueller M , Avery C , Van Beneden CA . Clin Infect Dis 2011 52 (8) 988-94 BACKGROUND: In January 2008, a long-term acute care hospital (LTACH) in New Mexico reported a cluster of severe group A Streptococcus (GAS) infections. METHODS: We defined a case as illness in a patient in the LTACH from 1 October 2007 through 3 February 2008 from whom GAS was isolated from a usually sterile site or with illness consistent with GAS infection and GAS isolated from a nonsterile site. To identify carriers, we swabbed the oropharynx and skin lesions of patients and staff. We observed facility procedures to assess possible transmission routes and adherence to infection control practices. We also conducted a case-control study to identify risk factors for infection with use of asymptomatic patients who were noncarriers as control subjects. RESULTS: We identified 11 case patients and 11 carriers (8 patients and 3 staff). No carriers became case patients. Significant risk factors for infection in univariate analysis included sharing a room with an infected or colonized patient (6 [55%] of 11 case patients vs 3 [8%] of 39 control subjects), undergoing wound debridement (64% vs 13%), and receiving negative pressure wound therapy (73% vs 33%). Having an infected or colonized roommate remained associated with case patients in multivariable analysis (odds ratio, 15.3; 95% confidence interval, 2.5-110.9). Suboptimal infection control practices were widespread. CONCLUSIONS: This large outbreak of GAS infection was the first reported in an LTACH, a setting that contains a highly susceptible patient population. Widespread infection control lapses likely allowed continued transmission. Similar to the situation in other care settings, appropriate infection control and case cohorting may help prevent and control outbreaks of GAS infection in LTACHs. (See the editorial commentary by Bisno and Baracco, on pages 995-996.) |
Pandemic 2009 influenza A(H1N1) virus illness among pregnant women in the United States
Siston AM , Rasmussen SA , Honein MA , Fry AM , Seib K , Callaghan WM , Louie J , Doyle TJ , Crockett M , Lynfield R , Moore Z , Wiedeman C , Anand M , Tabony L , Nielsen CF , Waller K , Page S , Thompson JM , Avery C , Springs CB , Jones T , Williams JL , Newsome K , Finelli L , Jamieson DJ . JAMA 2010 303 (15) 1517-25 CONTEXT: Early data on pandemic 2009 influenza A(H1N1) suggest pregnant women are at increased risk of hospitalization and death. OBJECTIVE: To describe the severity of 2009 influenza A(H1N1) illness and the association with early antiviral treatment among pregnant women in the United States. DESIGN, SETTING, AND PATIENTS: Surveillance of 2009 influenza A(H1N1) in pregnant women reported to the Centers for Disease Control and Prevention (CDC) with symptom onset from April through December 2009. MAIN OUTCOME MEASURES: Severity of illness (hospitalizations, intensive care unit [ICU] admissions, and deaths) due to 2009 influenza A(H1N1) among pregnant women, stratified by timing of antiviral treatment and pregnancy trimester at symptom onset. RESULTS: We received reports on 788 pregnant women in the United States with 2009 influenza A(H1N1) with symptom onset from April through August 2009. Among those, 30 died (5% of all reported 2009 influenza A[H1N1] influenza deaths in this period). Among 509 hospitalized women, 115 (22.6%) were admitted to an ICU. Pregnant women with treatment more than 4 days after symptom onset were more likely to be admitted to an ICU (56.9% vs 9.4%; relative risk [RR], 6.0; 95% confidence interval [CI], 3.5-10.6) than those treated within 2 days after symptom onset. Only 1 death occurred in a patient who received treatment within 2 days of symptom onset. Updating these data with the CDC's continued surveillance of ICU admissions and deaths among pregnant women with symptom onset through December 31, 2009, identified an additional 165 women for a total of 280 women who were admitted to ICUs, 56 of whom died. Among the deaths, 4 occurred in the first trimester (7.1%), 15 in the second (26.8%), and 36 in the third (64.3%); CONCLUSIONS: Pregnant women had a disproportionately high risk of mortality due to 2009 influenza A(H1N1). Among pregnant women with 2009 influenza A(H1N1) influenza reported to the CDC, early antiviral treatment appeared to be associated with fewer admissions to an ICU and fewer deaths. |
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