Extensively Drug-Resistant Pseudomonas aeruginosa Outbreak Associated With Artificial Tears.

BACKGROUND: Carbapenemase-producing, carbapenem-resistant Pseudomonas aeruginosa (CP-CRPA) are extensively drug-resistant bacteria. We investigated the source of a multistate CP-CRPA outbreak. METHODS: Cases were defined as a US patient's first isolation of P. aeruginosa sequence type 1203 with carbapenemase gene blaVIM-80 and cephalosporinase gene blaGES-9 from any specimen source collected and reported to the Centers for Disease Control and Prevention during 1 January 2022-15 May 2023. We conducted a 1:1 matched case-control study at the post-acute care facility with the most cases, assessed exposures associated with case status for all case-patients, and tested products for bacterial contamination. RESULTS: We identified 81 case-patients from 18 states, 27 of whom were identified through surveillance cultures. Four (7%) of 54 case-patients with clinical cultures died within 30 days of culture collection, and 4 (22%) of 18 with eye infections underwent enucleation. In the case-control study, case-patients had increased odds of receiving artificial tears versus controls (crude matched OR, 5.0; 95% CI, 1.1-22.8). Overall, artificial tears use was reported by 61 (87%) of 70 case-patients with information; 43 (77%) of 56 case-patients with brand information reported use of Brand A, an imported, preservative-free, over-the-counter (OTC) product. Bacteria isolated from opened and unopened bottles of Brand A were genetically related to patient isolates. Food and Drug Administration inspection of the manufacturing plant identified likely sources of contamination. CONCLUSIONS: A manufactured medical product serving as the vehicle for carbapenemase-producing organisms is unprecedented in the United States. The clinical impacts from this outbreak underscore the need for improved requirements for US OTC product importers.

Candida auris in US Correctional Facilities.

Candida auris is an emerging fungal pathogen that typically affects patients in healthcare settings. Data on C. auris cases in correctional facilities are limited but are needed to guide public health recommendations. We describe cases and challenges of providing care for 13 patients who were transferred to correctional facilities during January 2020-December 2022 after having a positive C. auris specimen. All patients had positive specimens identified while receiving inpatient care at healthcare facilities in geographic areas with high C. auris prevalence. Correctional facilities reported challenges managing patients and implementing prevention measures; those challenges varied by whether patients were housed in prison medical units or general population units. Although rarely reported, C. auris cases in persons who are incarcerated may occur, particularly in persons with known risk factors. Measures to manage cases and prevent C. auris spread in correctional facilities should address setting-specific challenges in healthcare and nonhealthcare correctional environments.

Vital Signs: Health Disparities in Hemodialysis-Associated Staphylococcus aureus Bloodstream Infections - United States, 2017-2020.

INTRODUCTION: Racial and ethnic minorities are disproportionately affected by end-stage kidney disease (ESKD). ESKD patients on dialysis are at increased risk for Staphylococcus aureus bloodstream infections, but racial, ethnic, and socioeconomic disparities associated with this outcome are not well described. METHODS: Surveillance data from the 2020 National Healthcare Safety Network (NHSN) and the 2017-2020 Emerging Infections Program (EIP) were used to describe bloodstream infections among patients on hemodialysis (hemodialysis patients) and were linked to population-based data sources (CDC/Agency for Toxic Substances and Disease Registry [ATSDR] Social Vulnerability Index [SVI], United States Renal Data System [USRDS], and U.S. Census Bureau) to examine associations with race, ethnicity, and social determinants of health. RESULTS: In 2020, 4,840 dialysis facilities reported 14,822 bloodstream infections to NHSN; 34.2% were attributable to S. aureus . Among seven EIP sites, the S. aureus bloodstream infection rate during 2017-2020 was 100 times higher among hemodialysis patients (4,248 of 100,000 person-years) than among adults not on hemodialysis (42 of 100,000 person-years). Unadjusted S. aureus bloodstream infection rates were highest among non-Hispanic Black or African American (Black) and Hispanic or Latino (Hispanic) hemodialysis patients. Vascular access via central venous catheter was strongly associated with S. aureus bloodstream infections (NHSN: adjusted rate ratio [aRR] = 6.2; 95% CI = 5.7-6.7 versus fistula; EIP: aRR = 4.3; 95% CI = 3.9-4.8 versus fistula or graft). Adjusting for EIP site of residence, sex, and vascular access type, S. aureus bloodstream infection risk in EIP was highest in Hispanic patients (aRR = 1.4; 95% CI = 1.2-1.7 versus non-Hispanic White [White] patients), and patients aged 18-49 years (aRR = 1.7; 95% CI = 1.5-1.9 versus patients aged ≥65 years). Areas with higher poverty levels, crowding, and lower education levels accounted for disproportionately higher proportions of hemodialysis-associated S. aureus bloodstream infections. CONCLUSIONS AND IMPLICATIONS FOR PUBLIC HEALTH PRACTICE: Disparities exist in hemodialysis-associated S. aureus infections. Health care providers and public health professionals should prioritize prevention and optimized treatment of ESKD, identify and address barriers to lower-risk vascular access placement, and implement established best practices to prevent bloodstream infections.

Cluster of Carbapenemase-Producing Carbapenem-Resistant Pseudomonas aeruginosa Among Patients in an Adult Intensive Care Unit - Idaho, 2021-2022.

Treatment of carbapenemase-producing carbapenem-resistant Pseudomonas aeruginosa (CP-CRPA) infections is challenging because of antibiotic resistance. CP-CRPA infections are highly transmissible in health care settings because they can spread from person to person and from environmental sources such as sink drains and toilets. During September 2021-January 2022, an Idaho hospital (hospital A) isolated CP-CRPA from sputum of two patients who stayed in the same intensive care unit (ICU) room (room X), 4 months apart. Both isolates had active-on-imipenem metallo-beta-lactamase (IMP) carbapenemase gene type 84 (blaIMP-84) and were characterized as multilocus sequence type 235 (ST235). A health care-associated infections team from the Idaho Division of Public Health visited hospital A during March 21-22, 2022, to discuss the cluster investigation with hospital A staff members and to collect environmental samples. CP-CRPA ST235 with blaIMP-84 was isolated from swab samples of one sink in room X, suggesting it was the likely environmental source of transmission. Recommended prevention and control measures included application of drain biofilm disinfectant, screening of future patients who stay in room X (e.g., the next 10 occupants) upon reopening, and continuing submission of carbapenem-resistant P. aeruginosa (CRPA) isolates to public health laboratories. Repeat environmental sampling did not detect any CRPA. As of December 2022, no additional CP-CRPA isolates had been reported by hospital A. Collaboration between health care facilities and public health agencies, including testing of CRPA isolates for carbapenemase genes and implementation of sink hygiene interventions, was critical in the identification of and response to this CP-CRPA cluster in a health care setting.

Vital Signs: Health Disparities in Hemodialysis-Associated Staphylococcus aureus Bloodstream Infections - United States, 2017-2020.

Introduction: Racial and ethnic minorities are disproportionately affected by end-stage kidney disease (ESKD). ESKD patients on dialysis are at increased risk for Staphylococcus aureus bloodstream infections, but racial, ethnic, and socioeconomic disparities associated with this outcome are not well described. Methods: Surveillance data from the 2020 National Healthcare Safety Network (NHSN) and the 2017-2020 Emerging Infections Program (EIP) were used to describe bloodstream infections among patients on hemodialysis (hemodialysis patients) and were linked to population-based data sources (CDC/Agency for Toxic Substances and Disease Registry [ATSDR] Social Vulnerability Index [SVI], United States Renal Data System [USRDS], and U.S. Census Bureau) to examine associations with race, ethnicity, and social determinants of health. Results: In 2020, 4,840 dialysis facilities reported 14,822 bloodstream infections to NHSN; 34.2% were attributable to S. aureus. Among seven EIP sites, the S. aureus bloodstream infection rate during 2017-2020 was 100 times higher among hemodialysis patients (4,248 of 100,000 person-years) than among adults not on hemodialysis (42 of 100,000 person-years). Unadjusted S. aureus bloodstream infection rates were highest among non-Hispanic Black or African American (Black) and Hispanic or Latino (Hispanic) hemodialysis patients. Vascular access via central venous catheter was strongly associated with S. aureus bloodstream infections (NHSN: adjusted rate ratio [aRR] = 6.2; 95% CI = 5.7-6.7 versus fistula; EIP: aRR = 4.3; 95% CI = 3.9-4.8 versus fistula or graft). Adjusting for EIP site of residence, sex, and vascular access type, S. aureus bloodstream infection risk in EIP was highest in Hispanic patients (aRR = 1.4; 95% CI = 1.2-1.7 versus non-Hispanic White [White] patients), and patients aged 18-49 years (aRR = 1.7; 95% CI = 1.5-1.9 versus patients aged ≥65 years). Areas with higher poverty levels, crowding, and lower education levels accounted for disproportionately higher proportions of hemodialysis-associated S. aureus bloodstream infections. Conclusions and implications for public health practice: Disparities exist in hemodialysis-associated S. aureus infections. Health care providers and public health professionals should prioritize prevention and optimized treatment of ESKD, identify and address barriers to lower-risk vascular access placement, and implement established best practices to prevent bloodstream infections.

Extensively Drug-Resistant Carbapenemase-Producing Pseudomonas aeruginosa and Medical Tourism from the United States to Mexico, 2018-2019.

Carbapenem-resistant Pseudomonas aeruginosa (CRPA) producing the Verona integron‒encoded metallo-ß-lactamase (VIM) are highly antimicrobial drug-resistant pathogens that are uncommon in the United States. We investigated the source of VIM-CRPA among US medical tourists who underwent bariatric surgery in Tijuana, Mexico. Cases were defined as isolation of VIM-CRPA or CRPA from a patient who had an elective invasive medical procedure in Mexico during January 2018‒December 2019 and within 45 days before specimen collection. Whole-genome sequencing of isolates was performed. Thirty-eight case-patients were identified in 18 states; 31 were operated on by surgeon 1, most frequently at facility A (27/31 patients). Whole-genome sequencing identified isolates linked to surgeon 1 were closely related and distinct from isolates linked to other surgeons in Tijuana. Facility A closed in March 2019. US patients and providers should acknowledge the risk for colonization or infection after medical tourism with highly drug-resistant pathogens uncommon in the United States.

Gram-Negative Bacteria Harboring Multiple Carbapenemase Genes, United States, 2012-2019.

Reports of organisms harboring multiple carbapenemase genes have increased since 2010. During October 2012-April 2019, the Centers for Disease Control and Prevention documented 151 of these isolates from 100 patients in the United States. Possible risk factors included recent history of international travel, international inpatient healthcare, and solid organ or bone marrow transplantation.

Syphilis testing practices in the Americas.

OBJECTIVE: To present the findings of the Pan American Health Organization's 2014 survey on syphilis testing policies and practices in the Americas. METHODS: Representatives of national/regional reference and large, lower-level laboratories from 35 member states were invited to participate. A semi-structured, electronically administered questionnaire collected data on syphilis tests, algorithms, equipment/commodities, challenges faced and basic quality assurance (QA) strategies employed (i.e. daily controls, standard operating procedures, technician training, participating in external QA programmes, on-site evaluations). RESULTS: The 69 participating laboratories from 30 (86%) member states included 41 (59%) national/regional reference and 28 (41%) lower-level laboratories. Common syphilis tests conducted were the rapid plasma reagin (RPR) (62% of surveyed laboratories), venereal disease research laboratory (VDRL) (54%), fluorescent treponemal antibody absorption (FTA-ABS) (41%) and Treponema pallidum haemagglutination assay (TPHA) (32%). Only three facilities reported using direct detection methods, and 28 (41% overall, 32% of lower-level facilities) used rapid tests. Most laboratories (62%) used only traditional testing algorithms (non-treponemal screening and treponemal confirmatory testing); however, 12% used only a reverse sequence algorithm (treponemal test first), and 14% employed both algorithms. Another nine (12%) laboratories conducted only one type of serologic test. Although most reference (97%) and lower-level (89%) laboratories used at least one QA strategy, only 16% reported using all five basic strategies. Commonly reported challenges were stock-outs of essential reagents or commodities (46%), limited staff training (73%) and insufficient equipment (39%). CONCLUSIONS: Many reference and clinical laboratories in the Americas face challenges in conducting appropriate syphilis testing and in ensuring quality of testing.

Health Care Use and HIV Testing of Males Aged 15-39 Years in Physicians' Offices - United States, 2009-2012.

In 2014, 81% of new human immunodeficiency virus (HIV) infection diagnoses in the United States were in males, with the highest number of cases among those aged 20-29 years. Racial and ethnic minorities continue to be disproportionately affected by HIV; there are 13 new diagnoses each year per 100,000 white males, 94 per 100,000 black males, and 42 per 100,000 Hispanic males (1). Despite the recommendation by CDC for HIV testing of adults and adolescents (2), in 2014, only 36% of U.S. males aged ≥18 years reported ever having an HIV test (3), and in 2012, an estimated 15% of males living with HIV had undiagnosed HIV infection (4). To identify opportunities for HIV diagnosis in young males, CDC analyzed data from the 2009-2012 National Ambulatory Medical Care Survey (NAMCS) and U.S. Census data to estimate rates of health care use at U.S. physicians' offices and HIV testing at these encounters. During 2009-2012, white males visited physicians' offices more often (average annual rate of 1.6 visits per person) than black males (0.9 visits per person) and Hispanic males (0.8 visits per person). Overall, an HIV test was performed at 1.0% of visits made by young males to physicians' offices, with higher testing rates among black males (2.7%) and Hispanic males (1.4%), compared with white males (0.7%). Although higher proportions of black and Hispanic males received HIV testing at health care visits compared with white males, this benefit is likely attenuated by a lower rate of health care visits. Interventions to routinize HIV testing at U.S physicians' offices could be implemented to improve HIV testing coverage.

Regional impact of multidrug-resistant organism prevention bundles implemented by facility type: A modeling study.

BACKGROUND: Emerging multidrug-resistant organisms (MDROs), such as carbapenem-resistant Enterobacterales (CRE), can spread rapidly in a region. Facilities that care for high-acuity patients with longer stays may have a disproportionate impact on this spread. OBJECTIVE: We assessed the impact of implementing preventive interventions, directed at a subset of facilities, on regional prevalence. METHODS: We developed a deterministic compartmental model, parametrized using CRE and patient transfer data. The model included the community and healthcare facilities within a US state. Individuals may be either susceptible or infectious with CRE. Individuals determined to be infectious through admission screening, periodic prevalence surveys (PPSs), or interfacility communication were placed in a state of lower transmissibility if enhanced infection prevention and control (IPC) practices were in place at a facility. RESULTS: Intervention bundles that included PPS and enhanced IPC practices at ventilator-capable skilled nursing facilities (vSNFs) and long-term acute-care hospitals (LTACHs) had the greatest impact on regional prevalence. The benefits of including targeted admission screening in acute-care hospitals, LTACHs, and vSNFs, and improved interfacility communication were more modest. Daily transmissions in each facility type were reduced following the implementation of interventions primarily focused at LTACHs and vSNFs. CONCLUSIONS: Our model suggests that interventions that include screening to limit unrecognized MDRO introduction to, or dispersal from, LTACHs and vSNFs slow regional spread. Interventions that pair detection and enhanced IPC practices within LTACHs and vSNFs may substantially reduce the regional burden.

Clusters of emerging multidrug-resistant organisms in US health care facilities during the initial months of the SARS-CoV-2 pandemic.

BACKGROUND: Outbreaks of emerging multidrug-resistant organisms (eMDROs), including carbapenem-resistant Enterobacterales, carbapenem-resistant Acinetobacter baumannii, and Candida auris, have been reported among severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) patients. We describe eMDRO clusters in SARS-CoV-2 units and associated infection control (IC) practices early in the SARS-CoV-2 pandemic. METHODS: We conducted a retrospective survey of a convenience sample of health departments in 11 states to describe clusters of eMDROs that began before November 1, 2020 and involved SARS-CoV-2 units. Cluster characteristics and IC practices during the cluster period were assessed using a standardized outbreak report form, and descriptive analyses were performed. RESULTS: Overall, 18 eMDRO clusters (10 carbapenem-resistant Enterobacterales, 6 C auris, 1 carbapenem-resistant Pseudomonas aeruginosa, and 1 carbapenem-resistant A baumannii) in 18 health care facilities involving 397 patients were reported from 10 states. During the cluster period, 60% of facilities reported a shortage of isolation gowns, 69% extended use of gowns, and 67% reported difficulty obtaining preferred disinfectants. Reduced frequency of hand hygiene audits was reported in 85% of acute care hospitals during the cluster period compared with before the pandemic. CONCLUSIONS: Changes in IC practices and supply shortages were identified in facilities with eMDRO outbreaks during the SARS-CoV-2 pandemic and might have contributed to eMDRO transmission.

Trimethoprim-sulfamethoxazole resistance patterns among Staphylococcus aureus in the United States, 2012-2018.

We reviewed trimethoprim-sulfamethoxazole antibiotic susceptibility testing data among Staphylococcus aureus using 3 national inpatient databases. In all 3 databases, we observed an increases in the percentage of methicillin-resistant Staphylococcus aureus that were not susceptible to trimethoprim-sulfamethoxazole. Providers should select antibiotic regimens based on local resistance patterns and should report changes to the public health department.

SHEA/IDSA/APIC Practice Recommendation: Strategies to prevent methicillin-resistant Staphylococcus aureus transmission and infection in acute-care hospitals: 2022 Update.

Previously published guidelines have provided comprehensive recommendations for detecting and preventing healthcare-associated infections (HAIs). The intent of this document is to highlight practical recommendations in a concise format designed to assist acute-care hospitals in implementing and prioritizing efforts to prevent methicillin-resistant Staphylococcus aureus (MRSA) transmission and infection. This document updates the "Strategies to Prevent Methicillin-Resistant Staphylococcus aureus Transmission and Infection in Acute Care Hospitals" published in 2014.1 This expert guidance document is sponsored by the Society for Healthcare Epidemiology of America (SHEA). It is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America (IDSA), the Association for Professionals in Infection Control and Epidemiology (APIC), the American Hospital Association (AHA), and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise.

A comprehensive approach to ending an outbreak of rare blaOXA-72 gene-positive carbapenem-resistant Acinetobacter baumannii at a Community Hospital, Kansas City, MO, 2018.

We identified a cluster of extensively drug-resistant, carbapenemase gene-positive, carbapenem-resistant Acinetobacter baumannii (CP-CRAB) at a teaching hospital in Kansas City. Extensively drug-resistant CRAB was identified from eight patients and 3% of environmental cultures. We used patient cohorting and targeted environmental disinfection to stop transmission. After implementation of these measures, no additional cases were identified.

Investigation of Hospital-Onset Methicillin-Resistant Staphylococcus aureus Bloodstream Infections at Eight High Burden Acute Care Facilities in the United States, 2016.

BACKGROUND: Despite large reductions from 2005-2012, hospital-onset methicillin-resistant Staphylococcus aureus bloodstream infections (HO MRSA BSIs) continue be a major source of morbidity and mortality. AIM: To describe risk factors for and underlying sources of HO MRSA BSIs. METHODS: We investigated HO MRSA BSIs at eight high-burden short-stay acute care hospitals. A case was defined as first isolation of MRSA from a blood specimen collected in 2016 on hospital day ≥4 from a patient without an MRSA-positive blood culture in the 14 days prior. We reviewed case-patient demographics and risk factors by medical record abstraction. The potential clinical source(s) of infection were determined by consensus by a clinician panel. FINDINGS: Of the 195 eligible cases, 186 were investigated. Case-patients were predominantly male (63%); median age was 57 years (range 0-92). In the two weeks prior to the BSI, 88% of case-patients had indwelling devices, 31% underwent a surgical procedure, and 18% underwent dialysis. The most common locations of attribution were intensive care units (ICUs) (46%) and step-down units (19%). The most commonly identified non-mutually exclusive clinical sources were CVCs (46%), non-surgical wounds (17%), surgical site infections (16%), non-ventilator healthcare-associated pneumonia (13%), and ventilator-associated pneumonia (11%). CONCLUSIONS: Device-and procedure-related infections were common sources of HO MRSA BSIs. Prevention strategies focused on improving adherence to existing prevention bundles for device-and procedure-associated infections and on source control for ICU patients, patients with certain indwelling devices, and patients undergoing certain high-risk surgeries are being pursued to decrease HO MRSA BSI burden at these facilities.

HIV Testing at Visits to Physicians' Offices in the U.S., 2009-2012.

INTRODUCTION: HIV testing serves as an entry point for HIV care services for those who test HIV positive, and prevention services for those who test HIV negative. The Centers for Disease Control and Prevention recommends routine testing of adults and adolescents in healthcare settings. To identify missed opportunities for HIV testing at U.S. physicians' offices, data from the National Ambulatory Care Surveys from 2009 to 2012 were analyzed. METHODS: The mean annual number and percentage of visits with an HIV test among HIV-uninfected nonpregnant females and males aged 15-65 years was estimated using weighted survey data. Factors associated with HIV testing at visits to physicians' offices were identified. RESULTS: The mean annual number of U.S. physicians' office visits with an HIV test conducted was 1,396,736 (0.4% of all visits) among nonpregnant females and 986,891 (0.5% of all visits) among males. For both nonpregnant females and males, HIV testing prevalence was highest among those aged 20-29 years (1.3% of all visits by nonpregnant females; 1.7% of all visits by males) and non-Hispanic blacks (1.1% of all visits by nonpregnant females; 1.0% of all visits by males). An HIV test was not conducted at 98.5% of visits at which venipuncture was performed for both nonpregnant females and males. CONCLUSIONS: Important opportunities exist to increase HIV testing coverage at U.S. physicians' offices. Structural interventions, such as routine opt-out testing policies, electronic medical record notifications, and use of non-clinical staff for testing could be implemented to increase HIV testing in these settings.

Improving global estimates of syphilis in pregnancy by diagnostic test type: A systematic review and meta-analysis.

BACKGROUND: "Probable active syphilis," is defined as seroreactivity in both non-treponemal and treponemal tests. A correction factor of 65%, namely the proportion of pregnant women reactive in one syphilis test type that were likely reactive in the second, was applied to reported syphilis seropositivity data reported to WHO for global estimates of syphilis during pregnancy. OBJECTIVES: To identify more accurate correction factors based on test type reported. SEARCH STRATEGY: Medline search using: "Syphilis [Mesh] and Pregnancy [Mesh]," "Syphilis [Mesh] and Prenatal Diagnosis [Mesh]," and "Syphilis [Mesh] and Antenatal [Keyword]. SELECTION CRITERIA: Eligible studies must have reported results for pregnant or puerperal women for both non-treponemal and treponemal serology. DATA COLLECTION AND ANALYSIS: We manually calculated the crude percent estimates of subjects with both reactive treponemal and reactive non-treponemal tests among subjects with reactive treponemal and among subjects with reactive non-treponemal tests. We summarized the percent estimates using random effects models. MAIN RESULTS: Countries reporting both reactive non-treponemal and reactive treponemal testing required no correction factor. Countries reporting non-treponemal testing or treponemal testing alone required a correction factor of 52.2% and 53.6%, respectively. Countries not reporting test type required a correction factor of 68.6%. CONCLUSIONS: Future estimates should adjust reported maternal syphilis seropositivity by test type to ensure accuracy.