Last data update: Apr 29, 2024. (Total: 46658 publications since 2009)
Records 1-30 (of 30 Records) |
Query Trace: Kainer MA[original query] |
---|
Epidemiology of extended-spectrum β-lactamase-producing Enterobacterales in five US sites participating in the Emerging Infections Program, 2017.
Duffy N , Karlsson M , Reses HE , Campbell D , Daniels J , Stanton RA , Janelle SJ , Schutz K , Bamberg W , Rebolledo PA , Bower C , Blakney R , Jacob JT , Phipps EC , Flores KG , Dumyati G , Kopin H , Tsay R , Kainer MA , Muleta D , Byrd-Warner B , Grass JE , Lutgring JD , Rasheed JK , Elkins CA , Magill SS , See I . Infect Control Hosp Epidemiol 2022 43 (11) 1-9 OBJECTIVE: The incidence of infections from extended-spectrum β-lactamase (ESBL)-producing Enterobacterales (ESBL-E) is increasing in the United States. We describe the epidemiology of ESBL-E at 5 Emerging Infections Program (EIP) sites. METHODS: During October-December 2017, we piloted active laboratory- and population-based (New York, New Mexico, Tennessee) or sentinel (Colorado, Georgia) ESBL-E surveillance. An incident case was the first isolation from normally sterile body sites or urine of Escherichia coli or Klebsiella pneumoniae/oxytoca resistant to ≥1 extended-spectrum cephalosporin and nonresistant to all carbapenems tested at a clinical laboratory from a surveillance area resident in a 30-day period. Demographic and clinical data were obtained from medical records. The Centers for Disease Control and Prevention (CDC) performed reference antimicrobial susceptibility testing and whole-genome sequencing on a convenience sample of case isolates. RESULTS: We identified 884 incident cases. The estimated annual incidence in sites conducting population-based surveillance was 199.7 per 100,000 population. Overall, 800 isolates (96%) were from urine, and 790 (89%) were E. coli. Also, 393 cases (47%) were community-associated. Among 136 isolates (15%) tested at the CDC, 122 (90%) met the surveillance definition phenotype; 114 (93%) of 122 were shown to be ESBL producers by clavulanate testing. In total, 111 (97%) of confirmed ESBL producers harbored a blaCTX-M gene. Among ESBL-producing E. coli isolates, 52 (54%) were ST131; 44% of these cases were community associated. CONCLUSIONS: The burden of ESBL-E was high across surveillance sites, with nearly half of cases acquired in the community. EIP has implemented ongoing ESBL-E surveillance to inform prevention efforts, particularly in the community and to watch for the emergence of new ESBL-E strains. |
Molecular Characterization of Carbapenem-Resistant Enterobacterales Collected in the United States.
Karlsson M , Lutgring JD , Ansari U , Lawsin A , Albrecht V , McAllister G , Daniels J , Lonsway D , McKay S , Beldavs Z , Bower C , Dumyati G , Gross A , Jacob J , Janelle S , Kainer MA , Lynfield R , Phipps EC , Schutz K , Wilson L , Witwer ML , Bulens SN , Walters MS , Duffy N , Kallen AJ , Elkins CA , Rasheed JK . Microb Drug Resist 2022 28 (4) 389-397 Carbapenem-resistant Enterobacterales (CRE) are a growing public health concern due to resistance to multiple antibiotics and potential to cause health care-associated infections with high mortality. Carbapenemase-producing CRE are of particular concern given that carbapenemase-encoding genes often are located on mobile genetic elements that may spread between different organisms and species. In this study, we performed phenotypic and genotypic characterization of CRE collected at eight U.S. sites participating in active population- and laboratory-based surveillance of carbapenem-resistant organisms. Among 421 CRE tested, the majority were isolated from urine (n = 349, 83%). Klebsiella pneumoniae was the most common organism (n = 265, 63%), followed by Enterobacter cloacae complex (n = 77, 18%) and Escherichia coli (n = 50, 12%). Of 419 isolates analyzed by whole genome sequencing, 307 (73%) harbored a carbapenemase gene; variants of bla(KPC) predominated (n = 299, 97%). The occurrence of carbapenemase-producing K. pneumoniae, E. cloacae complex, and E. coli varied by region; the predominant sequence type within each genus was ST258, ST171, and ST131, respectively. None of the carbapenemase-producing CRE isolates displayed resistance to all antimicrobials tested; susceptibility to amikacin and tigecycline was generally retained. |
Carbapenemase production among less-common Enterobacterales genera: 10 US sites, 2018.
Shugart A , Mahon G , Huang JY , Karlsson M , Valley A , Lasure M , Gross A , Pattee B , Vaeth E , Brooks R , Maruca T , Dominguez CE , Torpey D , Francis D , Bhattarai R , Kainer MA , Chan A , Dubendris H , Greene SR , Blosser SJ , Shannon DJ , Jones K , Brennan B , Hun S , D'Angeli M , Murphy CN , Tierney M , Reese N , Bhatnagar A , Kallen A , Brown AC , Spalding Walters M . JAC Antimicrob Resist 2021 3 (3) dlab137 BACKGROUND: Historically, United States' carbapenem-resistant Enterobacterales (CRE) surveillance and mechanism testing focused on three genera: Escherichia, Klebsiella, and Enterobacter (EsKE); however, other genera can harbour mobile carbapenemases associated with CRE spread. OBJECTIVES: From January through May 2018, we conducted a 10 state evaluation to assess the contribution of less common genera (LCG) to carbapenemase-producing (CP) CRE. METHODS: State public health laboratories (SPHLs) requested participating clinical laboratories submit all Enterobacterales from all specimen sources during the surveillance period that were resistant to any carbapenem (Morganellaceae required resistance to doripenem, ertapenem, or meropenem) or were CP based on phenotypic or genotypic testing at the clinical laboratory. SPHLs performed species identification, phenotypic carbapenemase production testing, and molecular testing for carbapenemases to identify CP-CRE. Isolates were categorized as CP if they demonstrated phenotypic carbapenemase production and ≥1 carbapenemase gene (bla (KPC), bla (NDM), bla (VIM), bla (IMP), or bla (OXA-48-like)) was detected. RESULTS: SPHLs tested 868 CRE isolates, 127 (14.6%) were from eight LCG. Overall, 195 (26.3%) EsKE isolates were CP-CRE, compared with 24 (18.9%) LCG isolates. LCG accounted for 24 (11.0%) of 219 CP-CRE identified. Citrobacter spp. was the most common CP-LCG; the proportion of Citrobacter that were CP (11/42, 26.2%) was similar to the proportion of EsKE that were CP (195/741, 26.3%). Five of 24 (20.8%) CP-LCG had a carbapenemase gene other than bla (KPC). CONCLUSIONS: Participating sites would have missed approximately 1 in 10 CP-CRE if isolate submission had been limited to EsKE genera. Expanding mechanism testing to additional genera could improve detection and prevention efforts. |
Antimicrobial Use in a Cohort of US Nursing Homes, 2017
Thompson ND , Stone ND , Brown CJ , Penna AR , Eure TR , Bamberg WM , Barney GR , Barter D , Clogher P , DeSilva MB , Dumyati G , Frank L , Felsen CB , Godine D , Irizarry L , Kainer MA , Li L , Lynfield R , Mahoehney JP , Maloney M , Nadle J , Ocampo VLS , Pierce R , Ray SM , Davis SS , Sievers M , Srinivasan K , Wilson LE , Zhang AY , Magill SS . JAMA 2021 325 (13) 1286-1295 IMPORTANCE: Controlling antimicrobial resistance in health care is a public health priority, although data describing antimicrobial use in US nursing homes are limited. OBJECTIVE: To measure the prevalence of antimicrobial use and describe antimicrobial classes and common indications among nursing home residents. DESIGN, SETTING, AND PARTICIPANTS: Cross-sectional, 1-day point-prevalence surveys of antimicrobial use performed between April 2017 and October 2017, last survey date October 31, 2017, and including 15 276 residents present on the survey date in 161 randomly selected nursing homes from selected counties of 10 Emerging Infections Program (EIP) states. EIP staff reviewed nursing home records to collect data on characteristics of residents and antimicrobials administered at the time of the survey. Nursing home characteristics were obtained from nursing home staff and the Nursing Home Compare website. EXPOSURES: Residence in one of the participating nursing homes at the time of the survey. MAIN OUTCOMES AND MEASURES: Prevalence of antimicrobial use per 100 residents, defined as the number of residents receiving antimicrobial drugs at the time of the survey divided by the total number of surveyed residents. Multivariable logistic regression modeling of antimicrobial use and percentages of drugs within various classifications. RESULTS: Among 15 276 nursing home residents included in the study (mean [SD] age, 77.6 [13.7] years; 9475 [62%] women), complete prevalence data were available for 96.8%. The overall antimicrobial use prevalence was 8.2 per 100 residents (95% CI, 7.8-8.8). Antimicrobial use was more prevalent in residents admitted to the nursing home within 30 days before the survey date (18.8 per 100 residents; 95% CI, 17.4-20.3), with central venous catheters (62.8 per 100 residents; 95% CI, 56.9-68.3) or with indwelling urinary catheters (19.1 per 100 residents; 95% CI, 16.4-22.0). Antimicrobials were most often used to treat active infections (77% [95% CI, 74.8%-79.2%]) and primarily for urinary tract infections (28.1% [95% CI, 15.5%-30.7%]). While 18.2% (95% CI, 16.1%-20.1%) were for medical prophylaxis, most often use was for the urinary tract (40.8% [95% CI, 34.8%-47.1%]). Fluoroquinolones were the most common antimicrobial class (12.9% [95% CI, 11.3%-14.8%]), and 33.1% (95% CI, 30.7%-35.6%) of antimicrobials used were broad-spectrum antibiotics. CONCLUSIONS AND RELEVANCE: In this cross-sectional survey of a cohort of US nursing homes in 2017, prevalence of antimicrobial use was 8.2 per 100 residents. This study provides information on the patterns of antimicrobial use among these nursing home residents. |
Assessment of the Appropriateness of Antimicrobial Use in US Hospitals
Magill SS , O'Leary E , Ray SM , Kainer MA , Evans C , Bamberg WM , Johnston H , Janelle SJ , Oyewumi T , Lynfield R , Rainbow J , Warnke L , Nadle J , Thompson DL , Sharmin S , Pierce R , Zhang AY , Ocampo V , Maloney M , Greissman S , Wilson LE , Dumyati G , Edwards JR , Chea N , Neuhauser MM . JAMA Netw Open 2021 4 (3) e212007 IMPORTANCE: Hospital antimicrobial consumption data are widely available; however, large-scale assessments of the quality of antimicrobial use in US hospitals are limited. OBJECTIVE: To evaluate the appropriateness of antimicrobial use for hospitalized patients treated for community-acquired pneumonia (CAP) or urinary tract infection (UTI) present at admission or for patients who had received fluoroquinolone or intravenous vancomycin treatment. DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional study included data from a prevalence survey of hospitalized patients in 10 Emerging Infections Program sites. Random samples of inpatients on hospital survey dates from May 1 to September 30, 2015, were identified. Medical record data were collected for eligible patients with 1 or more of 4 treatment events (CAP, UTI, fluoroquinolone treatment, or vancomycin treatment), which were selected on the basis of common infection types reported and antimicrobials given to patients in the prevalence survey. Data were analyzed from August 1, 2017, to May 31, 2020. EXPOSURE: Antimicrobial treatment for CAP or UTI or with fluoroquinolones or vancomycin. MAIN OUTCOMES AND MEASURES: The percentage of antimicrobial use that was supported by medical record data (including infection signs and symptoms, microbiology test results, and antimicrobial treatment duration) or for which some aspect of use was unsupported. Unsupported antimicrobial use was defined as (1) use of antimicrobials to which the pathogen was not susceptible, use in the absence of documented infection signs or symptoms, or use without supporting microbiologic data; (2) use of antimicrobials that deviated from recommended guidelines; or (3) use that exceeded the recommended duration. RESULTS: Of 12 299 patients, 1566 patients (12.7%) in 192 hospitals were included; the median age was 67 years (interquartile range, 53-79 years), and 864 (55.2%) were female. A total of 219 patients (14.0%) were included in the CAP analysis, 452 (28.9%) in the UTI analysis, 550 (35.1%) in the fluoroquinolone analysis, and 403 (25.7%) in the vancomycin analysis; 58 patients (3.7%) were included in both fluoroquinolone and vancomycin analyses. Overall, treatment was unsupported for 876 of 1566 patients (55.9%; 95% CI, 53.5%-58.4%): 110 of 403 (27.3%) who received vancomycin, 256 of 550 (46.6%) who received fluoroquinolones, 347 of 452 (76.8%) with a diagnosis of UTI, and 174 of 219 (79.5%) with a diagnosis of CAP. Among patients with unsupported treatment, common reasons included excessive duration (103 of 174 patients with CAP [59.2%]) and lack of documented infection signs or symptoms (174 of 347 patients with UTI [50.1%]). CONCLUSIONS AND RELEVANCE: The findings suggest that standardized assessments of hospital antimicrobial prescribing quality can be used to estimate the appropriateness of antimicrobial use in large groups of hospitals. These assessments, performed over time, may inform evaluations of the effects of antimicrobial stewardship initiatives nationally. |
Association between socioeconomic status and incidence of community-associated Clostridioides difficile infection - United States, 2014-2015
Skrobarcek KA , Mu Y , Ahern J , Basiliere E , Beldavs ZG , Brousseau G , Dumyati G , Fridkin S , Holzbauer SM , Johnston H , Kainer MA , Meek J , Ocampo VLS , Parker E , Perlmutter R , Phipps EC , Winston L , Guh A . Clin Infect Dis 2021 73 (4) 722-725 We evaluated the association between socioeconomic status (SES) and community-associated Clostridioides difficile infection (CA-CDI) incidence across 2474 census tracts in 10 states. Highly correlated community-level SES variables were transformed into distinct factors using factor analysis. We found low SES communities were associated with higher CA-CDI incidence. |
Nosocomial hepatitis A outbreak among healthcare workers and patients in a community hospital during an ongoing statewide outbreak.
Brennan J , Mullins H , Tobey K , Jones C , Kainer MA , Fiscus M , May S , Dunn JR , Schaffner W , Jones TF . Infect Control Hosp Epidemiol 2020 42 (2) 1-3 OBJECTIVE: The Tennessee Department of Health (TDH) investigated a hepatitis A virus (HAV) outbreak to identify risk factors for infection and make prevention recommendations. DESIGN: Case series. SETTING: Community hospital. PARTICIPANTS: Healthcare workers (HCWs) or patients with laboratory-confirmed acute HAV infection during October 1, 2018-January 10, 2019. METHODS: HCWs with suspected or confirmed hepatitis A infections were interviewed to assess their exposures and activities. Patient medical records and hospital administrative records were reviewed to identify common exposures. We conducted a site investigation to assess knowledge of infection control practices among HCWs. Serum specimens from ill persons were tested for HAV RNA by polymerase chain reaction (PCR) and genotyped. RESULTS: We identified 6 HCWs and 2 patients with laboratory-confirmed HAV infection. All cases likely resulted from exposure to a homeless patient with a history of recreational substance use and undiagnosed HAV infection. Breaches in hand hygiene and use of standard precautions were identified. HAV RNA was detected in 7 serum specimens and all belonged to an identical strain of HAV genotype 1b. CONCLUSIONS: A hepatitis A outbreak among hospital patients and HCWs resulted from exposure to a single patient with undiagnosed HAV infection. Breakdowns in infection control practices contributed to the outbreak. The likelihood of nosocomial transmission can be reduced with proper hand hygiene, standard precautions, and routine disinfection. During community outbreaks, medical providers can better prevent ongoing transmission by including hepatitis A in the differential diagnosis among patients with a history of recreational substance use and homelessness. |
Web-based interactive tool to identify facilities at risk of receiving patients with multidrug-resistant organisms
Octaria R , Chan A , Wolford H , Devasia R , Moon TD , Zhu Y , Slayton RB , Kainer MA . Emerg Infect Dis 2020 26 (9) 2046-2053 To identify facilities at risk of receiving patients colonized or infected with multidrug-resistant organisms (MDROs), we developed an interactive web-based interface for visualization of patient-sharing networks among healthcare facilities in Tennessee, USA. Using hospital discharge data and the Centers for Medicare and Medicaid Services' claims and Minimum Data Set, we constructed networks among hospitals and skilled nursing facilities. Networks included direct and indirect transfers, which accounted for <365 days in the community outside of facility admissions. Authorized users can visualize a facility of interest and tailor visualizations by year, network dataset, length of time in the community, and minimum number of transfers. The interface visualizes the facility of interest with its connected facilities that receive or send patients, the number of interfacility transfers, and facilities at risk of receiving transfers from the facility of interest. This tool will help other health departments enhance their MDRO outbreak responses. |
Antimicrobial use in US hospitals: Comparison of results from Emerging Infections Program Prevalence Surveys, 2015 and 2011
Magill SS , O'Leary E , Ray SM , Kainer MA , Evans C , Bamberg WM , Johnston H , Janelle SJ , Oyewumi T , Lynfield R , Rainbow J , Warnke L , Nadle J , Thompson DL , Sharmin S , Pierce R , Zhang AY , Ocampo V , Maloney M , Greissman S , Wilson LE , Dumyati G , Edwards JR . Clin Infect Dis 2020 72 (10) 1784-1792 BACKGROUND: In the 2011 US hospital prevalence survey of healthcare-associated infections and antimicrobial use 50% of patients received antimicrobial medications on the survey date or day before. More hospitals have since established antimicrobial stewardship programs. We repeated the survey in 2015 to determine antimicrobial use prevalence and describe changes since 2011. METHODS: The Centers for Disease Control and Prevention's Emerging Infections Program sites in 10 states each recruited </=25 general and women's and children's hospitals. Hospitals selected a survey date from May-September 2015. Medical records for a random patient sample on the survey date were reviewed to collect data on antimicrobial medications administered on the survey date or day before. Percentages of patients on antimicrobial medications were compared; multivariable log-binomial regression modeling was used to evaluate factors associated with antimicrobial use. RESULTS: Of 12 299 patients in 199 hospitals, 6084 (49.5%; 95% CI, 48.6-50.4%) received antimicrobials. Among 148 hospitals in both surveys, overall antimicrobial use prevalence was similar in 2011 and 2015, although the percentage of neonatal critical care patients on antimicrobials was lower in 2015 (22.8% vs 32.0% [2011]; P = .006). Fluoroquinolone use was lower in 2015 (10.1% of patients vs 11.9% [2011]; P < .001). Third- or fourth-generation cephalosporin use was higher (12.2% vs 10.7% [2011]; P = .002), as was carbapenem use (3.7% vs 2.7% [2011]; P < .001). CONCLUSIONS: Overall hospital antimicrobial use prevalence was not different in 2011 and 2015; however, differences observed in selected patient or antimicrobial groups may provide evidence of stewardship impact. |
Documentation of acute change in mental status in nursing homes highlights opportunity to augment infection surveillance criteria
Penna AR , Sancken CL , Stone ND , Eure TR , Bamberg W , Barney G , Barter D , Carswell S , Clogher P , Dumyati G , Felsen CB , Frank L , Godine D , Johnston H , Kainer MA , Li L , Lynfield R , Mahoehney JP , Nadle J , Pierce R , Ray SM , Davis SS , Sievers M , Wilson LE , Zhang AY , Magill SS , Thompson ND . Infect Control Hosp Epidemiol 2020 41 (7) 1-3 Acute change in mental status (ACMS), defined by the Confusion Assessment Method, is used to identify infections in nursing home residents. A medical record review revealed that none of 15,276 residents had an ACMS documented. Using the revised McGeer criteria with a possible ACMS definition, we identified 296 residents and 21 additional infections. The use of a possible ACMS definition should be considered for retrospective nursing home infection surveillance. |
Trends in U.S. burden of Clostridioides difficile infection and outcomes
Guh AY , Mu Y , Winston LG , Johnston H , Olson D , Farley MM , Wilson LE , Holzbauer SM , Phipps EC , Dumyati GK , Beldavs ZG , Kainer MA , Karlsson M , Gerding DN , McDonald LC . N Engl J Med 2020 382 (14) 1320-1330 BACKGROUND: Efforts to prevent Clostridioides difficile infection continue to expand across the health care spectrum in the United States. Whether these efforts are reducing the national burden of C. difficile infection is unclear. METHODS: The Emerging Infections Program identified cases of C. difficile infection (stool specimens positive for C. difficile in a person >/=1 year of age with no positive test in the previous 8 weeks) in 10 U.S. sites. We used case and census sampling weights to estimate the national burden of C. difficile infection, first recurrences, hospitalizations, and in-hospital deaths from 2011 through 2017. Health care-associated infections were defined as those with onset in a health care facility or associated with recent admission to a health care facility; all others were classified as community-associated infections. For trend analyses, we used weighted random-intercept models with negative binomial distribution and logistic-regression models to adjust for the higher sensitivity of nucleic acid amplification tests (NAATs) as compared with other test types. RESULTS: The number of cases of C. difficile infection in the 10 U.S. sites was 15,461 in 2011 (10,177 health care-associated and 5284 community-associated cases) and 15,512 in 2017 (7973 health care-associated and 7539 community-associated cases). The estimated national burden of C. difficile infection was 476,400 cases (95% confidence interval [CI], 419,900 to 532,900) in 2011 and 462,100 cases (95% CI, 428,600 to 495,600) in 2017. With accounting for NAAT use, the adjusted estimate of the total burden of C. difficile infection decreased by 24% (95% CI, 6 to 36) from 2011 through 2017; the adjusted estimate of the national burden of health care-associated C. difficile infection decreased by 36% (95% CI, 24 to 54), whereas the adjusted estimate of the national burden of community-associated C. difficile infection was unchanged. The adjusted estimate of the burden of hospitalizations for C. difficile infection decreased by 24% (95% CI, 0 to 48), whereas the adjusted estimates of the burden of first recurrences and in-hospital deaths did not change significantly. CONCLUSIONS: The estimated national burden of C. difficile infection and associated hospitalizations decreased from 2011 through 2017, owing to a decline in health care-associated infections. (Funded by the Centers for Disease Control and Prevention.). |
Epidemiology of antibiotic use for urinary tract infection in nursing home residents
Thompson ND , Penna A , Eure TR , Bamberg WM , Barney G , Barter D , Clogher P , DeSilva MB , Dumyati G , Epson E , Frank L , Godine D , Irizarry L , Kainer MA , Li L , Lynfield R , Mahoehney JP , Nadle J , Ocampo V , Perry L , Ray SM , Davis SS , Sievers M , Wilson LE , Zhang AY , Stone ND , Magill SS . J Am Med Dir Assoc 2019 21 (1) 91-96 OBJECTIVES: Describe antibiotic use for urinary tract infection (UTI) among a large cohort of US nursing home residents. DESIGN: Analysis of data from a multistate, 1-day point prevalence survey of antimicrobial use performed between April and October 2017. SETTING AND PARTICIPANTS: Residents of 161 nursing homes in 10 US states of the Emerging Infections Program (EIP). METHODS: EIP staff reviewed nursing home medical records to collect data on systemic antimicrobial drugs received by residents, including therapeutic site, rationale for use, and planned duration. For drugs with the therapeutic site documented as urinary tract, pooled mean and nursing home-specific prevalence rates were calculated per 100 nursing home residents, and proportion of drugs by selected characteristics were reported. Data were analyzed in SAS, version 9.4. RESULTS: Among 15,276 residents, 407 received 424 antibiotics for UTI. The pooled mean prevalence rate of antibiotic use for UTI was 2.66 per 100 residents; nursing home-specific rates ranged from 0 to 13.6. One-quarter of antibiotics were prescribed for UTI prophylaxis, with a median planned duration of 111 days compared with 7 days when prescribed for UTI treatment (P < .001). Fluoroquinolones were the most common (18%) drug class used. CONCLUSIONS AND IMPLICATIONS: One in 38 residents was receiving an antibiotic for UTI on a given day, and nursing home-specific prevalence rates varied by more than 10-fold. UTI prophylaxis was common with a long planned duration, despite limited evidence to support this practice among older persons in nursing homes. The planned duration was >/=7 days for half of antibiotics prescribed for treatment of a UTI. Fluoroquinolones were the most commonly used antibiotics, despite their association with significant adverse events, particularly in a frail and older adult population. These findings help to identify priority practices for nursing home antibiotic stewardship. |
Carbapenem-resistant Pseudomonas aeruginosa at US Emerging Infections Program Sites, 2015
Walters MS , Grass JE , Bulens SN , Hancock EB , Phipps EC , Muleta D , Mounsey J , Kainer MA , Concannon C , Dumyati G , Bower C , Jacob J , Cassidy PM , Beldavs Z , Culbreath K , Phillips WEJr , Hardy DJ , Vargas RL , Oethinger M , Ansari U , Stanton R , Albrecht V , Halpin AL , Karlsson M , Rasheed JK , Kallen A . Emerg Infect Dis 2019 25 (7) 1281-1288 Pseudomonas aeruginosa is intrinsically resistant to many antimicrobial drugs, making carbapenems crucial in clinical management. During July-October 2015 in the United States, we piloted laboratory-based surveillance for carbapenem-resistant P. aeruginosa (CRPA) at sentinel facilities in Georgia, New Mexico, Oregon, and Tennessee, and population-based surveillance in Monroe County, NY. An incident case was the first P. aeruginosa isolate resistant to antipseudomonal carbapenems from a patient in a 30-day period from any source except the nares, rectum or perirectal area, or feces. We found 294 incident cases among 274 patients. Cases were most commonly identified from respiratory sites (120/294; 40.8%) and urine (111/294; 37.8%); most (223/280; 79.6%) occurred in patients with healthcare facility inpatient stays in the prior year. Genes encoding carbapenemases were identified in 3 (2.3%) of 129 isolates tested. The burden of CRPA was high at facilities under surveillance, but carbapenemase-producing CRPA were rare. |
Vital Signs: Epidemiology and recent trends in methicillin-resistant and in methicillin-susceptible Staphylococcus aureus bloodstream infections - United States
Kourtis AP , Hatfield K , Baggs J , Mu Y , See I , Epson E , Nadle J , Kainer MA , Dumyati G , Petit S , Ray SM , Ham D , Capers C , Ewing H , Coffin N , McDonald LC , Jernigan J , Cardo D . MMWR Morb Mortal Wkly Rep 2019 68 (9) 214-219 INTRODUCTION: Staphylococcus aureus is one of the most common pathogens in health care facilities and in the community, and can cause invasive infections, sepsis, and death. Despite progress in preventing methicillin-resistant S. aureus (MRSA) infections in health care settings, assessment of the problem in both health care and community settings is needed. Further, the epidemiology of methicillin-susceptible S. aureus (MSSA) infections is not well described at the national level. METHODS: Data from the Emerging Infections Program (EIP) MRSA population surveillance (2005-2016) and from the Premier and Cerner Electronic Health Record databases (2012-2017) were analyzed to describe trends in incidence of hospital-onset and community-onset MRSA and MSSA bloodstream infections and to estimate the overall incidence of S. aureus bloodstream infections in the United States and associated in-hospital mortality. RESULTS: In 2017, an estimated 119,247 S. aureus bloodstream infections with 19,832 associated deaths occurred. During 2005-2012 rates of hospital-onset MRSA bloodstream infection decreased by 17.1% annually, but the decline slowed during 2013-2016. Community-onset MRSA declined less markedly (6.9% annually during 2005-2016), mostly related to declines in health care-associated infections. Hospital-onset MSSA has not significantly changed (p = 0.11), and community-onset MSSA infections have slightly increased (3.9% per year, p<0.0001) from 2012 to 2017. CONCLUSIONS AND IMPLICATIONS FOR PUBLIC HEALTH PRACTICE: Despite reductions in incidence of MRSA bloodstream infections since 2005, S. aureus infections account for significant morbidity and mortality in the United States. To reduce the incidence of these infections further, health care facilities should take steps to fully implement CDC recommendations for prevention of device- and procedure-associated infections and for interruption of transmission. New and novel prevention strategies are also needed. |
Inappropriate ceftriaxone use in outpatient acute respiratory infection management
King LM , Talley P , Kainer MA , Evans CD , Adre C , Hicks LA , Fleming-Dutra KE . Infect Control Hosp Epidemiol 2019 40 (4) 1-3 Ceftriaxone, a parenteral third-generation cephalosporin, is used to treat serious bacterial infections and sexually transmitted diseases.1 Inappropriate ceftriaxone use contributes to resistance to this important antibiotic and threatens patient safety due to antibiotic-associated adverse events and Clostridioides difficile infections.2 Previous studies of inappropriate antibiotic prescribing in outpatient acute respiratory infections (ARIs) have focused on oral, rather than parenteral, antibiotics.3,4 Our objective was to describe ceftriaxone use in adult outpatient ARI visits. |
Toxin enzyme immunoassays detect Clostridioides difficile infection with greater severity and higher recurrence rates
Guh AY , Hatfield KM , Winston LG , Martin B , Johnston H , Brousseau G , Farley MM , Wilson L , Perlmutter R , Phipps EC , Dumyati GK , Nelson D , Hatwar T , Kainer MA , Paulick AL , Karlsson M , Gerding DN , McDonald LC . Clin Infect Dis 2019 69 (10) 1667-1674 Background: Few data suggest Clostridioides difficile infections (CDI) detected by toxin enzyme immunoassays (EIA) are more severe and have worse outcomes than those detected by nucleic acid amplification tests (NAAT) only. We compared toxin-positive and NAAT-positive only CDI across geographically-diverse sites. Methods: A case was defined as a positive C. difficile test in a person >/=1 year old with no positive tests in the prior 8 weeks. Cases were detected during 2014-15 by a testing algorithm (specimens initially tested by glutamate dehydrogenase [GDH] and toxin EIA; if discordant results, specimens were reflexed to NAAT) and classified as toxin-positive or NAAT-positive only. Medical charts were reviewed. Multivariable logistic regression models were used to compare CDI-related complications, recurrence, and 30-day mortality between the two groups. Results: Of 4878 cases, 2160 (44.3%) were toxin-positive and 2718 (55.7%) were NAAT-positive only. More toxin-positive than NAAT-positive only cases were aged >/=65 years (48.2% vs 38.0%; P<0.0001), had >/=3 unformed stool for >/=1 day (43.9% vs 36.6%; P<0.0001), and had white blood cells >/=15,000/microl (31.4% versus 21.4%; P<0.0001). In multivariable analysis, toxin-positivity was associated with recurrence (adjusted odds ratio [aOR]: 1.89, 95% CI: 1.61-2.23), but not with CDI-related complications (aOR: 0.91, 95% CI: 0.67-1.23) or 30-day mortality (aOR: 0.95; 95% CI: 0.73-1.24). Conclusions: Toxin-positive CDI is more severe, but there were no differences in adjusted CDI-related complication and mortality rates between toxin-positive and NAAT-positive only CDI that were detected by an algorithm that utilized an initial GDH screening test. |
Changes in prevalence of health care-associated infections in U.S. hospitals
Magill SS , O'Leary E , Janelle SJ , Thompson DL , Dumyati G , Nadle J , Wilson LE , Kainer MA , Lynfield R , Greissman S , Ray SM , Beldavs Z , Gross C , Bamberg W , Sievers M , Concannon C , Buhr N , Warnke L , Maloney M , Ocampo V , Brooks J , Oyewumi T , Sharmin S , Richards K , Rainbow J , Samper M , Hancock EB , Leaptrot D , Scalise E , Badrun F , Phelps R , Edwards JR . N Engl J Med 2018 379 (18) 1732-1744 BACKGROUND: A point-prevalence survey that was conducted in the United States in 2011 showed that 4% of hospitalized patients had a health care-associated infection. We repeated the survey in 2015 to assess changes in the prevalence of health care-associated infections during a period of national attention to the prevention of such infections. METHODS: At Emerging Infections Program sites in 10 states, we recruited up to 25 hospitals in each site area, prioritizing hospitals that had participated in the 2011 survey. Each hospital selected 1 day on which a random sample of patients was identified for assessment. Trained staff reviewed medical records using the 2011 definitions of health care-associated infections. We compared the percentages of patients with health care-associated infections and performed multivariable log-binomial regression modeling to evaluate the association of survey year with the risk of health care-associated infections. RESULTS: In 2015, a total of 12,299 patients in 199 hospitals were surveyed, as compared with 11,282 patients in 183 hospitals in 2011. Fewer patients had health care-associated infections in 2015 (394 patients [3.2%; 95% confidence interval {CI}, 2.9 to 3.5]) than in 2011 (452 [4.0%; 95% CI, 3.7 to 4.4]) (P<0.001), largely owing to reductions in the prevalence of surgical-site and urinary tract infections. Pneumonia, gastrointestinal infections (most of which were due to Clostridium difficile [now Clostridioides difficile]), and surgical-site infections were the most common health care-associated infections. Patients' risk of having a health care-associated infection was 16% lower in 2015 than in 2011 (risk ratio, 0.84; 95% CI, 0.74 to 0.95; P=0.005), after adjustment for age, presence of devices, days from admission to survey, and status of being in a large hospital. CONCLUSIONS: The prevalence of health care-associated infections was lower in 2015 than in 2011. To continue to make progress in the prevention of such infections, prevention strategies against C. difficile infection and pneumonia should be augmented. (Funded by the Centers for Disease Control and Prevention.). |
Vital Signs: Containment of novel multidrug-resistant organisms and resistance mechanisms - United States, 2006-2017
Woodworth KR , Walters MS , Weiner LM , Edwards J , Brown AC , Huang JY , Malik S , Slayton RB , Paul P , Capers C , Kainer MA , Wilde N , Shugart A , Mahon G , Kallen AJ , Patel J , McDonald LC , Srinivasan A , Craig M , Cardo DM . MMWR Morb Mortal Wkly Rep 2018 67 (13) 396-401 BACKGROUND: Approaches to controlling emerging antibiotic resistance in health care settings have evolved over time. When resistance to broad-spectrum antimicrobials mediated by extended-spectrum beta-lactamases (ESBLs) arose in the 1980s, targeted interventions to slow spread were not widely promoted. However, when Enterobacteriaceae with carbapenemases that confer resistance to carbapenem antibiotics emerged, directed control efforts were recommended. These distinct approaches could have resulted in differences in spread of these two pathogens. CDC evaluated these possible changes along with initial findings of an enhanced antibiotic resistance detection and control strategy that builds on interventions developed to control carbapenem resistance. METHODS: Infection data from the National Healthcare Safety Network from 2006-2015 were analyzed to calculate changes in the annual proportion of selected pathogens that were nonsusceptible to extended-spectrum cephalosporins (ESBL phenotype) or resistant to carbapenems (carbapenem-resistant Enterobacteriaceae [CRE]). Testing results for CRE and carbapenem-resistant Pseudomonas aeruginosa (CRPA) are also reported. RESULTS: The percentage of ESBL phenotype Enterobacteriaceae decreased by 2% per year (risk ratio [RR] = 0.98, p<0.001); by comparison, the CRE percentage decreased by 15% per year (RR = 0.85, p<0.01). From January to September 2017, carbapenemase testing was performed for 4,442 CRE and 1,334 CRPA isolates; 32% and 1.9%, respectively, were carbapenemase producers. In response, 1,489 screening tests were performed to identify asymptomatic carriers; 171 (11%) were positive. CONCLUSIONS: The proportion of Enterobacteriaceae infections that were CRE remained lower and decreased more over time than the proportion that were ESBL phenotype. This difference might be explained by the more directed control efforts implemented to slow transmission of CRE than those applied for ESBL-producing strains. Increased detection and aggressive early response to emerging antibiotic resistance threats have the potential to slow further spread. |
Trends in incidence of long-term-care facility onset Clostridium difficile infections in 10 US geographic locations during 2011-2015
Guh AY , Mu Y , Baggs J , Winston LG , Bamberg W , Lyons C , Farley MM , Wilson LE , Holzbauer SM , Phipps EC , Beldavs ZG , Kainer MA , Karlsson M , Gerding DN , Dumyati G . Am J Infect Control 2018 46 (7) 840-842 During 2011-2015, the adjusted long-term-care facility onset Clostridium difficile infection incidence rate in persons aged >/=65 years decreased annually by 17.45% (95% confidence interval, 14.53%-20.43%) across 10 US sites. A concomitant decline in inpatient fluoroquinolone use and the C difficile epidemic strain NAP1/027 among persons aged >/=65 years may have contributed to the decrease in long-term-care facility-onset C difficile infection incidence rate. |
Risk Factors for Community-Associated Clostridium difficile Infection in Adults: A Case-Control Study
Guh AY , Adkins SH , Li Q , Bulens SN , Farley MM , Smith Z , Holzbauer SM , Whitten T , Phipps EC , Hancock EB , Dumyati G , Concannon C , Kainer MA , Rue B , Lyons C , Olson DM , Wilson L , Perlmutter R , Winston LG , Parker E , Bamberg W , Beldavs ZG , Ocampo V , Karlsson M , Gerding DN , McDonald LC . Open Forum Infect Dis 2017 4 (4) ofx171 BACKGROUND: An increasing proportion of Clostridium difficile infections (CDI) in the United States are community-associated (CA). We conducted a case-control study to identify CA-CDI risk factors. METHODS: We enrolled participants from 10 US sites during October 2014-March 2015. Case patients were defined as persons age ≥18 years with a positive C. difficile specimen collected as an outpatient or within 3 days of hospitalization who had no admission to a health care facility in the prior 12 weeks and no prior CDI diagnosis. Each case patient was matched to one control (persons without CDI). Participants were interviewed about relevant exposures; multivariate conditional logistic regression was performed. RESULTS: Of 226 pairs, 70.4% were female and 52.2% were ≥60 years old. More case patients than controls had prior outpatient health care (82.1% vs 57.9%; P < .0001) and antibiotic (62.2% vs 10.3%; P < .0001) exposures. In multivariate analysis, antibiotic exposure-that is, cephalosporin (adjusted matched odds ratio [AmOR], 19.02; 95% CI, 1.13-321.39), clindamycin (AmOR, 35.31; 95% CI, 4.01-311.14), fluoroquinolone (AmOR, 30.71; 95% CI, 2.77-340.05) and beta-lactam and/or beta-lactamase inhibitor combination (AmOR, 9.87; 95% CI, 2.76-340.05),-emergency department visit (AmOR, 17.37; 95% CI, 1.99-151.22), white race (AmOR 7.67; 95% CI, 2.34-25.20), cardiac disease (AmOR, 4.87; 95% CI, 1.20-19.80), chronic kidney disease (AmOR, 12.12; 95% CI, 1.24-118.89), and inflammatory bowel disease (AmOR, 5.13; 95% CI, 1.27-20.79) were associated with CA-CDI. CONCLUSIONS: Antibiotics remain an important risk factor for CA-CDI, underscoring the importance of appropriate outpatient prescribing. Emergency departments might be an environmental source of CDI; further investigation of their contribution to CDI transmission is needed. |
Increases in acute hepatitis B virus infections - Kentucky, Tennessee, and West Virginia, 2006-2013
Harris AM , Iqbal K , Schillie S , Britton J , Kainer MA , Tressler S , Vellozzi C . MMWR Morb Mortal Wkly Rep 2016 65 (3) 47-50 As many as 2.2 million persons in the United States are chronically infected with hepatitis B virus (HBV) (1), and approximately 15%-25% of persons with chronic HBV infection will die prematurely from cirrhosis or liver cancer (2). Since 2006, the overall U.S. incidence of acute HBV infection has remained stable; the rate in 2013 was 1.0 case per 100,000 persons (3). Hepatitis B vaccination is highly effective in preventing HBV infection and is recommended for all infants (beginning at birth), all adolescents, and adults at risk for HBV infection (e.g., persons who inject drugs, men who have sexual contact with men, persons infected with human immunodeficiency virus [HIV], and others). Hepatitis B vaccination coverage is low among adults: 2013 National Health Interview Survey data indicated that coverage with ≥3 doses of hepatitis B vaccine was 32.6% for adults aged 19-49 years (4). Injection drug use is a risk factor for both hepatitis C virus (HCV) and HBV. Among young adults in some rural U.S. communities, an increased incidence of HCV infection has been associated with a concurrent increase of injection drug use (5); and recent data indicate an increase of acute HCV infection in the Appalachian region associated with injection drug use (6). Using data from the National Notifiable Diseases Surveillance System (NNDSS) during 2006-2013, CDC assessed the incidence of acute HBV infection in three of the four Appalachian states (Kentucky, Tennessee, and West Virginia) included in the HCV infection study (6). Similar to the increase of HCV infections recently reported, an increase in incident cases of acute HBV infection in these three states has occurred among non-Hispanic whites (whites) aged 30-39 years who reported injection drug use as a common risk factor. Since 2009, cases of acute HBV infection have been reported from more non-urban than urban regions. Evidence-based services to prevent HBV infection are needed. |
Evaluation of manual and automated bloodstream infection surveillance in outpatient dialysis centers
Thompson ND , Wise M , Belflower R , Kanago M , Kainer MA , Lovell C , Patel PR . Infect Control Hosp Epidemiol 2016 37 (4) 1-3 Outpatient hemodialysis bloodstream infection rates, now used for performance measurement and were significantly higher for manual compared with automated surveillance (P<.001), largely owing to the absence of blood culture data in the dialysis electronic health record. Improvement in data sharing between hospitals and outpatient dialysis centers is necessary. |
Notes from the Field: Hepatitis C Outbreak in a Dialysis Clinic - Tennessee, 2014.
Muleta D , Kainer MA , Moore-Moravian L , Wiese A , Ward J , McMaster S , Nguyen D , Forbi JC , Mixson-Hayden T , Collier M . MMWR Morb Mortal Wkly Rep 2016 64 1386-7 Outbreaks of hepatitis C virus (HCV) infections can occur among hemodialysis patients when recommended infection control practices are not followed (1). On January 30, 2014, a dialysis clinic in Tennessee identified acute HCV in a patient (patient A) during routine screening and reported it to the Tennessee Department of Health. Patient A had enrolled in the dialysis clinic in March 2010 and had annually tested negative for HCV (including a last HCV test on December 19, 2012), until testing positive for HCV antibodies (anti-HCV) on December 18, 2013 (confirmed by a positive HCV nucleic acid amplification test). Patient A reported no behavioral risk factors, but did have multiple health care exposures. |
Improved Phenotype-Based Definition for Identifying Carbapenemase Producers among Carbapenem-Resistant Enterobacteriaceae.
Chea N , Bulens SN , Kongphet-Tran T , Lynfield R , Shaw KM , Vagnone PS , Kainer MA , Muleta DB , Wilson L , Vaeth E , Dumyati G , Concannon C , Phipps EC , Culbreath K , Janelle SJ , Bamberg WM , Guh AY , Limbago B , Kallen AJ . Emerg Infect Dis 2015 21 (9) 1611-6 Preventing transmission of carbapenemase-producing, carbapenem-resistant Enterobacteriaceae (CP-CRE) is a public health priority. A phenotype-based definition that reliably identifies CP-CRE while minimizing misclassification of non-CP-CRE could help prevention efforts. To assess possible definitions, we evaluated enterobacterial isolates that had been tested and deemed nonsusceptible to >1 carbapenem at US Emerging Infections Program sites. We determined the number of non-CP isolates that met (false positives) and CP isolates that did not meet (false negatives) the Centers for Disease Control and Prevention CRE definition in use during our study: 30% (94/312) of CRE had carbapenemase genes, and 21% (14/67) of Klebsiella pneumoniae carbapenemase-producing Klebsiella isolates had been misclassified as non-CP. A new definition requiring resistance to 1 carbapenem rarely missed CP strains, but 55% of results were false positive; adding the modified Hodge test to the definition decreased false positives to 12%. This definition should be considered for use in carbapenemase-producing CRE surveillance and prevention. |
The epidemiology of acute hepatitis B in the United States from population-based surveillance, 2006-2011
Iqbal K , Klevens RM , Kainer MA , Baumgartner J , Gerard K , Poissant T , Sweet K , Vonderwahl C , Knickerbocker T , Khudyakov Y , Xia GL , Roberts H , Teshale E . Clin Infect Dis 2015 61 (4) 584-92 BACKGROUND: An estimated 20,000 new hepatitis B virus (HBV) infections occur each year in the United States. We describe the results of enhanced surveillance for acute hepatitis B at seven federally funded sites over a six-year period. METHODS: Health departments in Colorado, Connecticut, Minnesota, Oregon, Tennessee, 34 counties in New York state, and New York City were supported to conduct enhanced, population-based surveillance for acute HBV from 2006 through 2011. Demographic and risk factor data were collected on symptomatic cases using a standardized form. Sera from a subset of cases were also obtained for molecular analysis. RESULTS: In the six-year period, 2,220 acute hepatitis B cases were reported from the seven sites. For all sites combined, the incidence rate of HBV infection declined by 19%, but in Tennessee incidence increased by 90%, mainly among persons of white race/ethnicity and those aged 40-49 years. Of all reported cases, 66.1% were male, 57.1% were white, 58.4% were aged 30-49 years, and 60.1% were born in the United States. The most common risk factor identified was any drug use, notably in Tennessee; healthcare exposure was also frequently reported. The most common genotype for all reported cases was HBV genotype A (82%). CONCLUSIONS: Despite an overall decline in HBV infection, attributable to successful vaccination programs, a rise in incident HBV infection related to drug use is an increasing concern in some localities. |
Prevalence of antimicrobial use in US acute care hospitals, May-September 2011
Magill SS , Edwards JR , Beldavs ZG , Dumyati G , Janelle SJ , Kainer MA , Lynfield R , Nadle J , Neuhauser MM , Ray SM , Richards K , Rodriguez R , Thompson DL , Fridkin SK . JAMA 2014 312 (14) 1438-46 IMPORTANCE: Inappropriate antimicrobial drug use is associated with adverse events in hospitalized patients and contributes to the emergence and spread of resistant pathogens. Targeting effective interventions to improve antimicrobial use in the acute care setting requires understanding hospital prescribing practices. OBJECTIVE: To determine the prevalence of and describe the rationale for antimicrobial use in participating hospitals. DESIGN, SETTING, AND PARTICIPANTS: One-day prevalence surveys were conducted in acute care hospitals in 10 states between May and September 2011. Patients were randomly selected from each hospital's morning census on the survey date. Data collectors reviewed medical records retrospectively to gather data on antimicrobial drugs administered to patients on the survey date and the day prior to the survey date, including reasons for administration, infection sites treated, and whether treated infections began in community or health care settings. MAIN OUTCOMES AND MEASURES: Antimicrobial use prevalence, defined as the number of patients receiving antimicrobial drugs at the time of the survey divided by the total number of surveyed patients. RESULTS: Of 11,282 patients in 183 hospitals, 5635 (49.9%; 95% CI, 49.0%-50.9%) were administered at least 1 antimicrobial drug; 77.5% (95% CI, 76.6%-78.3%) of antimicrobial drugs were used to treat infections, most commonly involving the lower respiratory tract, urinary tract, or skin and soft tissues, whereas 12.2% (95% CI, 11.5%-12.8%) were given for surgical and 5.9% (95% CI, 5.5%-6.4%) for medical prophylaxis. Of 7641 drugs to treat infections, the most common were parenteral vancomycin (1103, 14.4%; 95% CI, 13.7%-15.2%), ceftriaxone (825, 10.8%; 95% CI, 10.1%-11.5%), piperacillin-tazobactam (788, 10.3%; 95% CI, 9.6%-11.0%), and levofloxacin (694, 9.1%; 95% CI, 8.5%-9.7%). Most drugs administered to treat infections were given for community-onset infections (69.0%; 95% CI, 68.0%-70.1%) and to patients outside critical care units (81.6%; 95% CI, 80.4%-82.7%). The 4 most common treatment antimicrobial drugs overall were also the most common drugs used for both community-onset and health care facility-onset infections and for infections in patients in critical care and noncritical care locations. CONCLUSIONS AND RELEVANCE: In this cross-sectional evaluation of antimicrobial use in US hospitals, use of broad-spectrum antimicrobial drugs such as piperacillin-tazobactam and drugs such as vancomycin for resistant pathogens was common, including for treatment of community-onset infections and among patients outside critical care units. Further work is needed to understand the settings and indications for which reducing antimicrobial use can be most effectively and safely accomplished. |
Multistate point-prevalence survey of health care-associated infections
Magill SS , Edwards JR , Bamberg W , Beldavs ZG , Dumyati G , Kainer MA , Lynfield R , Maloney M , McAllister-Hollod L , Nadle J , Ray SM , Thompson DL , Wilson LE , Fridkin SK . N Engl J Med 2014 370 (13) 1198-208 BACKGROUND: Currently, no single U.S. surveillance system can provide estimates of the burden of all types of health care-associated infections across acute care patient populations. We conducted a prevalence survey in 10 geographically diverse states to determine the prevalence of health care-associated infections in acute care hospitals and generate updated estimates of the national burden of such infections. METHODS: We defined health care-associated infections with the use of National Healthcare Safety Network criteria. One-day surveys of randomly selected inpatients were performed in participating hospitals. Hospital personnel collected demographic and limited clinical data. Trained data collectors reviewed medical records retrospectively to identify health care-associated infections active at the time of the survey. Survey data and 2010 Nationwide Inpatient Sample data, stratified according to patient age and length of hospital stay, were used to estimate the total numbers of health care-associated infections and of inpatients with such infections in U.S. acute care hospitals in 2011. RESULTS: Surveys were conducted in 183 hospitals. Of 11,282 patients, 452 had 1 or more health care-associated infections (4.0%; 95% confidence interval, 3.7 to 4.4). Of 504 such infections, the most common types were pneumonia (21.8%), surgical-site infections (21.8%), and gastrointestinal infections (17.1%). Clostridium difficile was the most commonly reported pathogen (causing 12.1% of health care-associated infections). Device-associated infections (i.e., central-catheter-associated bloodstream infection, catheter-associated urinary tract infection, and ventilator-associated pneumonia), which have traditionally been the focus of programs to prevent health care-associated infections, accounted for 25.6% of such infections. We estimated that there were 648,000 patients with 721,800 health care-associated infections in U.S. acute care hospitals in 2011. CONCLUSIONS: Results of this multistate prevalence survey of health care-associated infections indicate that public health surveillance and prevention activities should continue to address C. difficile infections. As device- and procedure-associated infections decrease, consideration should be given to expanding surveillance and prevention activities to include other health care-associated infections. |
Fungal infections associated with contaminated methylprednisolone injections - preliminary report
Smith RM , Schaefer MK , Kainer MA , Wise M , Finks J , Duwve J , Fontaine E , Chu A , Carothers B , Reilly A , Fiedler J , Wiese AD , Feaster C , Gibson L , Griese S , Purfield A , Cleveland AA , Benedict K , Harris JR , Brandt ME , Blau D , Jernigan J , Weber JT , Park BJ . N Engl J Med 2012 369 (17) 1598-609 BACKGROUND: Fungal infections are rare complications of injections for treatment of chronic pain. In September 2012, we initiated an investigation into fungal infections associated with injections of preservative-free methylprednisolone acetate that was purchased from a single compounding pharmacy. METHODS: Three lots of methylprednisolone acetate were recalled by the pharmacy; examination of unopened vials later revealed fungus. Notification of all persons potentially exposed to implicated methylprednisolone acetate was conducted by federal, state, and local public health officials and by staff at clinical facilities that administered the drug. We collected clinical data on standardized case-report forms, and we tested for the presence of fungi in isolates and specimens by examining cultures and performing polymerase-chain-reaction assays and histopathological and immunohistochemical testing. RESULTS: As of October 19, 2012, more than 99% of 13,534 potentially exposed persons had been contacted. As of December 10, there were 590 reported cases of infection in 19 states, with 37 deaths (6%). As of November 26, laboratory evidence of Exserohilum rostratum was present in specimens from 100 case patients (17%). Additional data were available for 386 case patients (65%); 300 of these patients (78%) had meningitis. Case patients had received a median of 1 injection (range, 1 to 6) of implicated methylprednisolone acetate. The median age of the patients was 64 years (range, 16 to 92), and the median incubation period was 20 days (range, 0 to 120); 33 patients (9%) had a stroke. CONCLUSIONS: Analysis of preliminary data from a large multistate outbreak of fungal infections showed substantial morbidity and mortality. The infections were associated with injection of a contaminated glucocorticoid medication from a single compounding pharmacy. Rapid public health actions included prompt recall of the implicated product, notification of exposed persons, and early outreach to clinicians. |
Fungal infections associated with contaminated methylprednisolone in Tennessee
Kainer MA , Reagan DR , Nguyen DB , Wiese AD , Wise ME , Ward J , Park BJ , Kanago ML , Baumblatt J , Schaefer MK , Berger BE , Marder EP , Min JY , Dunn JR , Smith RM , Dreyzehner J , Jones TF . N Engl J Med 2012 367 (23) 2194-203 BACKGROUND: We investigated an outbreak of fungal infections of the central nervous system that occurred among patients who received epidural or paraspinal glucocorticoid injections of preservative-free methylprednisolone acetate prepared by a single compounding pharmacy. METHODS: Case patients were defined as patients with fungal meningitis, posterior circulation stroke, spinal osteomyelitis, or epidural abscess that developed after epidural or paraspinal glucocorticoid injections. Clinical and procedure data were abstracted. A cohort analysis was performed. RESULTS: The median age of the 66 case patients was 69 years (range, 23 to 91). The median time from the last epidural glucocorticoid injection to symptom onset was 18 days (range, 0 to 56). Patients presented with meningitis alone (73%), the cauda equina syndrome or focal infection (15%), or posterior circulation stroke with or without meningitis (12%). Symptoms and signs included headache (in 73% of the patients), new or worsening back pain (in 50%), neurologic symptoms (in 48%), nausea (in 39%), and stiff neck (in 29%). The median cerebrospinal fluid white-cell count on the first lumbar puncture among patients who presented with meningitis, with or without stroke or focal infection, was 648 per cubic millimeter (range, 6 to 10,140), with 78% granulocytes (range, 0 to 97); the protein level was 114 mg per deciliter (range, 29 to 440); and the glucose concentration was 44 mg per deciliter (range, 12 to 121) (2.5 mmol per liter [range, 0.7 to 6.7]). A total of 22 patients had laboratory confirmation of Exserohilum rostratum infection (21 patients) or Aspergillus fumigatus infection (1 patient). The risk of infection increased with exposure to lot 06292012@26, older vials, higher doses, multiple procedures, and translaminar approach to epidural glucocorticoid injection. Voriconazole was used to treat 61 patients (92%); 35 patients (53%) were also treated with liposomal amphotericin B. Eight patients (12%) died, seven of whom had stroke. CONCLUSIONS: We describe an outbreak of fungal meningitis after epidural or paraspinal glucocorticoid injection with methylprednisolone from a single compounding pharmacy. Rapid recognition of illness and prompt initiation of therapy are important to prevent complications. (Funded by the Tennessee Department of Health and the Centers for Disease Control and Prevention.). |
Outbreak of late-onset group B Streptococcus in a neonatal intensive care unit
Macfarquhar JK , Jones TF , Woron AM , Kainer MA , Whitney CG , Beall B , Schrag SJ , Schaffner W . Am J Infect Control 2009 38 (4) 283-8 BACKGROUND: In September 2007, the Tennessee Department of Health was notified of a cluster of late-onset group B streptococcal (GBS) infections in a neonatal intensive care unit (NICU). Outbreaks of late-onset GBS are rare. METHODS: A case was defined as culture-confirmed invasive GBS infection in a neonate aged ≥7 days, identified in hospital A during August 23 to September 6, 2007. We reviewed medical records; examined NICU microbiology reports; and performed serotyping, pulsed-field gel electrophoresis (PFGE), and multilocus sequence typing (MLST) on invasive isolates. Maternal GBS screening, prophylaxis, and infection control policies were reviewed and staff practices observed. RESULTS: Five cases of late-onset GBS were identified. None of the mothers of the infants received optimal GBS prophylaxis. Patient isolates were of 2 serotypes, 3 PFGE patterns, and 2 MLST patterns. Three isolates were indistinguishable on subtyping. These 3 cases were clustered in time. No common health care providers were identified. Infection control deviations in the NICU were observed. CONCLUSION: We identified a multiclonal cluster of 5 late-onset GBS cases. Multiple factors likely contributed to the outbreak, including nosocomial transmission of GBS. Further efforts to prevent late-onset GBS disease are necessary. |
- Page last reviewed:Feb 1, 2024
- Page last updated:Apr 29, 2024
- Content source:
- Powered by CDC PHGKB Infrastructure