Two-Phase Hospital-Associated Outbreak of Mycobacterium abscessus: Investigation and Mitigation.

BACKGROUND: Nontuberculous mycobacteria (NTM) commonly colonize municipal water supplies and cause healthcare-associated outbreaks. We investigated a biphasic outbreak of Mycobacterium abscessus at a tertiary care hospital. METHODS: Case patients had recent hospital exposure and laboratory-confirmed colonization or infection with M. abscessus from January 2013 through December 2015. We conducted a multidisciplinary epidemiologic, field, and laboratory investigation. RESULTS: The incidence rate of M. abscessus increased from 0.7 cases per 10000 patient-days during the baseline period (January 2013-July 2013) to 3.0 cases per 10000 patient-days during phase 1 of the outbreak (August 2013-May 2014) (incidence rate ratio, 4.6 [95% confidence interval, 2.3-8.8]; P < .001). Thirty-six of 71 (51%) phase 1 cases were lung transplant patients with positive respiratory cultures. We eliminated tap water exposure to the aerodigestive tract among high-risk patients, and the incidence rate decreased to baseline. Twelve of 24 (50%) phase 2 (December 2014-June 2015) cases occurred in cardiac surgery patients with invasive infections. Phase 2 resolved after we implemented an intensified disinfection protocol and used sterile water for heater-cooler units of cardiopulmonary bypass machines. Molecular fingerprinting of clinical isolates identified 2 clonal strains of M. abscessus; 1 clone was isolated from water sources at a new hospital addition. We made several water engineering interventions to improve water flow and increase disinfectant levels. CONCLUSIONS: We investigated and mitigated a 2-phase clonal outbreak of M. abscessus linked to hospital tap water. Healthcare facilities with endemic NTM should consider similar tap water avoidance and engineering strategies to decrease risk of NTM infection.

Multicenter Clinical Evaluation of BacT/Alert Virtuo Blood Culture System.

BacT/Alert Virtuo is an advanced, automated blood culture system incorporating improved automation and an enhanced detection algorithm to shorten time to detection. A multicenter study of the investigational Virtuo system (bioMérieux, Inc., Durham, NC) compared to BacT/Alert 3D (BTA3D) for detection of bacteremia/fungemia in four bottle types, SA and FA Plus (aerobic) and SN and FN Plus (anaerobic), was performed in a clinical setting with patient samples in a matched system design clinical trial. Blood was added to paired aerobic or anaerobic bottles, with the volume in each bottle in each pair required to be ≤10 ml and with the volumes required to be within 30% of each other. Of 5,709 bottle sets (52.5% aerobic pairs and 47.5% anaerobic pairs), 430 (7.5%) were positive for bacterial or fungal growth, with 342 (6.0%) clinically significant and 83 (1.5%) contaminated. A total of 3,539 sets (62.0%) were volume compliant, with 203 sets (5.7%) clinically significant. The positivity rates for volume-compliant bottle pairs determined by the two systems were comparable, with 68.7% of clinically significant isolates detected by both instruments, 15.7% by Virtuo only, and 15.7% by BTA3D only. Virtuo detected microbial growth nearly 2 h sooner overall than BTA3D (mean, 15.9 h versus 17.7 h). Shorter time to detection by Virtuo was related to organism group, with the time to detection being significantly shorter for enteric Gram-negative bacilli and enterococci (means, 3.6 h and 2.3 h shorter, respectively). This large clinical study demonstrated that the Virtuo blood culture system produced results comparable to those seen with the long-established BTA3D system, with significantly shorter time to detection.

Challenges in Preparation of Cumulative Antibiogram Reports for Community Hospitals.

Knowledge of local antimicrobial resistance is critical for management of infectious diseases. Community hospitals' compliance with Clinical and Laboratory Standards Institute (CLSI) guidance for creation of cumulative antibiograms is uncertain. This descriptive cohort study of antibiogram reporting practices included community hospitals enrolled in the Duke Infection Control Outreach Network. Cumulative antibiograms from 2012 were reviewed for criteria on reporting practices and compliance with CLSI guidelines. Microbiology personnel were sent a voluntary, electronic survey on antibiogram preparation practices. Data were compiled using descriptive statistics. Thirty-two of 37 (86%) hospitals provided antibiograms; 26 of 37 (70%) also provided survey responses. Twelve (38%) antibiograms specified methods used for compiling data and exclusion of duplicates. Eight (25%) reported only species with >30 isolates. Of the 24 that did not follow the 30-isolate rule, 3 (13%) included footnotes to indicate impaired statistical validity. Twenty (63%) reported at least 1 pathogen-drug combination not recommended for primary or supplemental testing per CLSI. Thirteen (41%) separately reported methicillin-resistant and -susceptible Staphylococcus aureus. Complete compliance with CLSI guidelines was observed in only 3 (9%) antibiograms. Survey respondents' self-assessment of full or partial compliance with CLSI guidelines was 50% and 15%, respectively; 33% reported uncertainty with CLSI guidelines. Full adherence to CLSI guidelines for hospital antibiograms was uncommon. Uncertainty about CLSI guidelines was common. Alternate strategies, such as regional antibiograms using pooled data and educational outreach efforts, are needed to provide reliable and appropriate susceptibility estimates for community hospitals.

Modified Hodge test versus indirect carbapenemase test: prospective evaluation of a phenotypic assay for detection of Klebsiella pneumoniae carbapenemase (KPC) in Enterobacteriaceae.

The currently recommended phenotypic test for the detection of carbapenemase-producing members of the family Enterobacteriaceae is the modified Hodge test (MHT). However, the MHT lacks specificity. Here we demonstrate an alternative phenotypic test, the indirect carbapenemase test, for the detection of blaKPC-producing isolates that has specificity superior to that of the MHT for non-Klebsiella Enterobacteriaceae.

First clinical cases of OXA-48-producing carbapenem-resistant Klebsiella pneumoniae in the United States: the "menace" arrives in the new world.

OXA-48 has emerged as a major carbapenemase associated with the Enterobacteriaceae in Europe, North Africa, and Asia. We report the first two clinical cases of OXA-48-type carbapenemase-producing Enterobacteriaceae in the United States from patients recently hospitalized in Saudi Arabia and India. Each is more carbapenem resistant than nearly all previously reported OXA-48-type-producing Enterobacteriaceae.

Exhibition of antifungal resistance by sterol-auxotrophic strains of Candida glabrata with intact virulence.

Background: Candida glabrata is an emerging fungal pathogen in immune-compromised hosts. Previously undetected C. glabrata isolates were successfully recovered from clinical specimens by adding sterols to the growth medium. The clinical isolates are unable to synthesize ergosterol but can take up exogenous sterols under aerobic conditions. Objectives: This study characterizes the sterol-auxotrophic C. glabrata strains, examines the mutation(s) in sterol synthesis genes, characterizes the drug susceptibility and evaluates the virulence in a mouse infection model. Methods: Drug susceptibility of the C. glabrata strains was evaluated in a sterol-supplemented medium. The coding sequences of the sterol synthesis genes were analysed in six sterol-auxotrophic strains of C. glabrata. The fungal burden of mice infected with C. glabrata strain was determined. Results: The sterol-auxotrophic strains showed high-level resistance to both azoles and amphotericin B when sterols were supplied in the test medium. Additionally, the strains harbour missense mutations in either ERG1 or ERG7. Significant differences in fungal burden were not observed between the sterol-auxotrophic strain and the sterol-competent strain with the mice infection models. Conclusions: The sterol-auxotrophic C. glabrata strain investigated in this study seemed to maintain intact virulence, probably due to the supply of exogenous sterols from host organ(s). This suggests that exogenous sterol uptake develops antifungal resistance during infection.

Temperature affects the susceptibility of Cryptococcus neoformans biofilms to antifungal agents.

The fungal opportunist Cryptococcus neoformans forms biofilms in vitro and in vivo. C. neoformans has an unusual ability to grow over a wide range of temperatures, and is one of only two species in the genus able to grow at 37 degrees C. The optimum growth temperature in the laboratory is 30 degrees C, but Clinical and Laboratory Standards Institute (CLSI) planktonic susceptibility testing is performed at 35 degrees C. We investigated whether these growth temperatures affected C. neoformans biofilm formation and drug resistance. Biofilms of 30 strains of C. neoformans were grown at 30 degrees C or 35 degrees C, and antifungal susceptibilities evaluated at 30 degrees C or 35 degrees C using minimum biofilm eradication endpoints. At 35 degrees C, biofilms from 40% of the strains were more susceptible to flucytosine, 30% were more susceptible to nystatin, 27% were more susceptible to amphotericin, and 20% were more susceptible to fluconazole, as compared to 30 degrees C. The reverse, that is an increased susceptibility at 30 degrees C, only occurred with a single strain using nystatin or fluconazole. For the remaining strains, biofilm susceptibility was equivalent at the two temperatures. Biofilm colony forming units (CFU)s, as measured indirectly by 2,3-bis(2-methoxy-4-nitro-5-sulfophenyl)-2H-tetrazolium-5-carboxanilide (XTT) reduction, were greater at 35 degrees C than at 30 degrees C for the majority of the strains. Thus, growth temperature does affect C. neoformans biofilm properties, but factors other than relative biofilm CFUs/ml must be involved in the increased drug susceptibility at 35 degrees C.

Microbiology of Bloodstream Infections in Children After Hematopoietic Stem Cell Transplantation: A Single-Center Experience Over Two Decades (1997-2017).

BACKGROUND: Bloodstream infections (BSIs) occur frequently after hematopoietic stem cell transplantation (HSCT). We examined the microbiology of BSI in pediatric HSCT recipients over a 2-decade period at our institution to inform empirical antimicrobial prescribing and infection prevention strategies. METHODS: We conducted a retrospective cohort study of children (<18 years) who underwent HSCT at Duke University between 1997 and 2015. We used recurrent-event gap-time Cox proportional hazards models to determine the hazards of all-cause and cause-specific BSI according to HSCT year. We compared the median time to BSI by causative organism type and evaluated for temporal trends in the prevalence of antibiotic resistance among causative organisms. RESULTS: A total of 865 BSI occurred in 1311 children, including 412 (48%) Gram-positive bacterial, 196 (23%) Gram-negative bacterial, 56 (6%) fungal, 23 (3%) mycobacterial, and 178 (21%) polymicrobial BSI. The hazard of all BSIs did not change substantially over time during the study period, but the hazard of fungal BSIs declined over time during the study period (P = .04). Most fungal BSIs (82%) occurred in the first 100 days after HSCT, whereas mycobacterial BSIs occurred later after HSCT than BSIs caused by other organisms (P < .0001). The prevalence of vancomycin resistance among BSIs caused by Enterococcus faecium increased during the study period (P = .0007). The risk of 2-year mortality in children was increased with BSI (P = .02), Gram-negative bacterial BSI (P = .02), and fungal BSI (P < .0001). CONCLUSIONS: Despite expanded practices for BSI prevention over the past several decades, the incidence of BSI remains high in pediatric HSCT recipients at our institution. Additional strategies are urgently needed to effectively prevent BSIs in this high-risk population.

Microbiology and Risk Factors for Hospital-Associated Bloodstream Infections Among Pediatric Hematopoietic Stem Cell Transplant Recipients.

BACKGROUND: Children undergoing hematopoietic stem cell transplantation (HSCT) are at high risk for hospital-associated bloodstream infections (HA-BSIs). This study aimed to describe the incidence, microbiology, and risk factors for HA-BSI in pediatric HSCT recipients. METHODS: We performed a single-center retrospective cohort study of children and adolescents (<18 years of age) who underwent HSCT over a 20-year period (1997-2016). We determined the incidence and case fatality rate of HA-BSI by causative organism. We used multivariable Poisson regression to identify risk factors for HA-BSI. RESULTS: Of 1294 patients, the majority (86%) received an allogeneic HSCT, most commonly with umbilical cord blood (63%). During the initial HSCT hospitalization, 334 HA-BSIs occurred among 261 (20%) patients. These were classified as gram-positive bacterial (46%), gram-negative bacterial (24%), fungal (12%), mycobacterial (<1%), or polymicrobial (19%). During the study period, there was a decline in the cumulative incidence of HA-BSI (P = .021) and, specifically, fungal HA-BSIs (P = .002). In multivariable analyses, older age (incidence rate ratio [IRR], 1.03; 95% confidence interval [CI], 1.01-1.06), umbilical cord blood donor source (vs bone marrow; IRR, 1.69; 95% CI, 1.19-2.40), and nonmyeloablative conditioning (vs myeloablative; IRR, 1.85; 95% CI, 1.21-2.82) were associated with a higher risk of HA-BSIs. The case fatality rate was higher for fungal HA-BSI than other HA-BSI categories (21% vs 6%; P = .002). CONCLUSIONS: Over the past 2 decades, the incidence of HA-BSIs has declined among pediatric HSCT recipients at our institution. Older age, umbilical cord blood donor source, and nonmyeloablative conditioning regimens are independent risk factors for HA-BSI among children undergoing HSCT.

Determination of Echinocandin MICs for Candida species in less than 8 hours: comparison of the rapid susceptibility assay with the Clinical and Laboratory Standards Institute's broth microdilution assay.

The echinocandins prevent fungal cell wall synthesis by inhibiting beta-1,3-glucan synthesis, a significant glucose-consuming process. Previous studies suggested that echinocandin inhibitory activity is evident within 1 h of exposure. We hypothesized that a susceptibility assay based on glucose consumption may provide clinically useful MICs rapidly. The rapid susceptibility assay (RSA), which provides MICs in less than 8 h, was compared with the standard broth microdilution susceptibility assay (Clinical and Laboratory Standards Institute, document M27-A3, 2008) for 56 Candida species strains. Variables which are known to influence MICs determined by the M27-A3 method were also assessed for their effects on the RSA results. Excellent agreement (>90%) between the results of the RSA and M27-A3 methods was achieved for all three FDA-approved echinocandins (micafungin, caspofungin, and anidulafungin). Candida lusitaniae strains were responsible for most of the discordant results. Assay variables such as the test medium, the age of the inoculum culture, and the presence of human serum affected MIC results from the RSA and the M27-A3 method similarly. The RSA is equivalent to the standard M27-A3 method for determining echinocandin MICs for Candida species. The RSA provides MIC results in less than 8 h and can be applied to old and young yeast colonies. The assay could potentially provide clinically useful MICs on the same day that yeast growth from a specimen is first detected on solid medium.

Performance of the Accelerate Diagnostics PhenoTM system with resin-containing BacT/ALERT® Plus blood culture bottles.

Bacteremia and septicemia require rapid identification (ID) and antimicrobial susceptibility testing (AST) to start targeted, appropriate therapy. To answer this need, Accelerate Diagnostics, Inc., developed the Accelerate Pheno™ system (AXDX), a fast ID and phenotypic AST platform. Performance of a pre-FDA clearance version of AXDX was evaluated using 261 positive BacT/ALERT® Plus bottles and compared with standard of care (SOC). Average time to ID was reduced by 24.9±6.9 h and AST by 36.7±18.9 h compared with SOC. AXDX reports ID and AST of blood pathogens in 1.9 and 7.1 h. Positive percent agreement and negative percent agreement of AXDX ID were 94.5% and 98.9%, respectively. AXDX AST had an essential agreement of 96.5% and categorical agreement of 94.6% with 4 major errors and 7 very major errors. AXDX performance was acceptable for all 3 bottle types. Rapid ID and AST with AXDX could impact patient care and antimicrobial stewardship.

Patterns of fungal colonization in preterm infants weighing less than 1000 grams at birth.

BACKGROUND: Colonization with Candida spp. is an important risk factor for systemic infection in very low birth weight (VLBW; <1500 g) and extremely low birth weight (ELBW, <1000 g) infants. ELBW infants are at a higher risk than VLBW infants for fungal sepsis and its associated mortality, but few studies have examined fungal colonization exclusively in ELBW infants. METHODS: Fungal colonization data were analyzed retrospectively in 50 high risk ELBW infants. Weekly surveillance fungal cultures of the skin, gastrointestinal tract, respiratory tract and umbilicus had been performed from birth through the first 6 weeks of life. Colonization was analyzed for time of initial colonization, site, species and spread of Candida from one site to another. RESULTS: Candida was isolated from surveillance cultures in 31 of 50 (62%) infants. Colonization was inversely proportional to gestational age. Initial week of both the fungal colonization of the skin [1 (0-6) week, median (range)] and gastrointestinal tract [2 (0-6)] preceded colonization of the respiratory tract [3 (1-6)] (P = 0.0001). Among infants colonized by only 1 of the species, colonization at 2 or more sites occurred similarly with Candida albicans (77%) and Candida parapsilosis (85%), whereas colonization at 3 or more sites occurred more frequently with C. albicans (69%) compared with C. parapsilosis (23%) (P = 0.047). CONCLUSIONS: Fungal colonization occurs on the skin and gastrointestinal tract before the respiratory tract. In addition, C. albicans is more likely than C. parapsilosis to colonize multiple sites.

Evaluation of a Fully Automated Research Prototype for the Immediate Identification of Microorganisms from Positive Blood Cultures under Clinical Conditions.

UNLABELLED: A clinical laboratory evaluation of an intrinsic fluorescence spectroscopy (IFS)-based identification system paired to a BacT/Alert Virtuo microbial detection system (bioMérieux, Inc., Durham, NC) was performed to assess the potential for fully automated identification of positive blood cultures. The prototype IFS system incorporates a novel method combining a simple microbial purification procedure with rapid in situ identification via spectroscopy. Results were available within 15 min of a bottle signaling positive and required no manual intervention. Among cultures positive for organisms contained within the database and producing acceptable spectra, 75 of 88 (85.2%) and 79 of 88 (89.8%) were correctly identified to the species and genus level, respectively. These results are similar to the performance of existing rapid methods. IMPORTANCE: A fully automated research platform was developed to identify microbial growth from positive blood cultures in <15 min. Because of the automated format, results can be generated during all shifts, with or without staffing, which in turn could promote more timely administration of target antimicrobial therapy.

Isolation of cholesterol-dependent Candida glabrata from clinical specimens.

In the past few years, we have detected in the United Kingdom and in the United States several isolates of Candida glabrata that grew poorly unless bile was available. Cholesterol, a component of bile, stimulated equivalent growth of the bile-dependent isolates. The bile-dependent C. glabrata isolates appeared resistant to amphotericin B, but their resistance to fluconazole was unclear. These results demonstrate that occasional isolates of C. glabrata require cholesterol to grow, they may not be detected in specimens set up on standard primary plating media, and they may be difficult to eradicate in patients with antifungal agents directed against ergosterol and its synthetic pathway.

Sterol uptake in Candida glabrata: rescue of sterol auxotrophic strains.

Candida glabrata is emerging as a more common and important human pathogen. It is less susceptible to azole antifungals than Candida albicans, thus, posing some unique treatment challenges. Previously undetected C. glabrata isolates were identified from clinical specimens by adding bile to the growth medium. Cholesterol was found to be the responsible ingredient in bile. Six bile-dependent isolates were characterized and were found to exhibit wild-type equivalent growth when provided human or bovine serum or free cholesterol. Sterol profiles of the 6 isolates and a C. glabrata matching wild-type strain not requiring cholesterol indicated that 2 were defective in squalene epoxidase (encoded by the ERG1 gene) activity, 3 were defective in lanosterol synthase (encoded by the ERG7 gene) activity, and the sixth was defective in heme biosynthesis. All 7 isolates produced profiles that contained cholesterol transported from the media. Because Saccharomyces cerevisiae mutants unable to synthesize heme will take up exogenous sterol under aerobic conditions, hem1 nulls of C. glabrata and C. albicans were generated and tested for growth on ergosterol media. Only the C. glabrata hem1 was able to grow indicating significant differences in exogenous sterol uptake between the 2 organisms. The ability of C. glabrata to replace ergosterol with host sterol may be responsible for its elevated azole resistance.

Contribution of cell surface hydrophobicity protein 1 (Csh1p) to virulence of hydrophobic Candida albicans serotype A cells.

The CSH1 gene product is the first protein implicated to affect the phenotype of cell surface hydrophobicity in Candida albicans. Ablation of expression of CSH1 resulted in a 75% loss of the cell surface hydrophobicity (CSH) phenotype. When the C. albicans csh1 knockout derivative was cultured from frozen stocks, it had reacquired CSH levels similar to the parent strain and isogenic reintegrant in the absence of Csh1p re-expression through an unknown mechanism. Prior to reacquisition of CSH, the knockout was less adherent to fibronectin than the parent. Comparison of the csh1 knockout and CSH1 reintegrant in a hematogenous dissemination model allows analysis of Csh1p contribution to virulence using matched strains with similar levels of CSH. No statistical significance between the knockout and reintegrant was found in virulence based on median day of survival, although a reproducible delay in onset of lethal infection for the knockout was observed. A modest difference in mucosal colonization in a vaginal infection model was also observed between the knockout and reintegrant. The present study demonstrates that Csh1p contributes to virulence of C. albicans in mice, but other gene products also contribute to the CSH phenotype and virulence.

The Incidence of Propionibacterium acnes in Open Shoulder Surgery: A Controlled Diagnostic Study.

BACKGROUND: Propionibacterium acnes has arisen as the most common microorganism identified at the time of revision shoulder arthroplasty. There is limited evidence to suggest how frequently false-positive cultures occur. The purpose of this prospective controlled study was to evaluate culture growth from specimens obtained during open shoulder surgery. METHODS: Patients undergoing an open deltopectoral approach to the shoulder were prospectively enrolled. Patients with a history of shoulder surgery or any concern for active or previous shoulder infection were excluded. Three pericapsular soft-tissue samples were taken from the shoulder for bacterial culture and were incubated for fourteen days. A sterile sponge was also analyzed in parallel with the tissue cultures. In addition, similar cultures were obtained from patients who had undergone previous shoulder surgery. RESULTS: Overall, 20.5% of surgeries (twenty-four of 117) yielded at least one specimen removed for culture that was positive for bacterial growth, and 13.0% of sterile control specimens (seven of fifty-four) had positive culture growth (p = 0.234). P. acnes represented 83.0% of all positive cultures (thirty-nine of forty-seven) at a median incubation time of fourteen days. Among the subjects who had not undergone previous surgery, 17.1% (fourteen of eighty-two) had at least one positive P. acnes culture. Male sex was univariably associated with a greater likelihood of bacterial growth (p < 0.01), and patients who had not undergone previous surgery and had received two or more preoperative corticosteroid injections had a higher likelihood of bacterial growth (p = 0.047). CONCLUSIONS: The clinical importance of positive P. acnes cultures from specimens obtained from open shoulder surgery remains uncertain. Male sex and preoperative corticosteroid injections were associated with a higher likelihood of bacterial growth on culture and are risk factors that merit further investigation. Previously reported incidences of positive P. acnes culture results from specimens from primary and revision shoulder arthroplasty may be overestimated because of a substantial level of culture contamination. CLINICAL RELEVANCE: P. acnes is isolated via culture at a substantial rate from shoulders undergoing a deltopectoral approach. The clinical importance of culture growth by this low-virulence organism still remains uncertain. Further study is necessary to more specifically characterize culture growth by P. acnes as an infection, commensal presence, or contaminant.

Respiratory fungal infections: molecular diagnostic tests.

Fungal infection of the respiratory tract can take several forms, the most common of which is pneumonia. Fungal infection can occur in the immunocompetent typically as a result of inhalation of a large inoculum of fungal elements. However, the number of etiologic agents attacking immunocompetent individuals and causing significant infection is limited. Molecular assays are a potential additional and sensitive weapon that can be added to the diagnostic arsenal used by physicians to determine whether a fungus is definitively, probably, or possibly causing infection in a patient.

Clinical microbiology costs for methods of active surveillance for Klebsiella pneumoniae carbapenemase-producing Enterobacteriaceae.

OBJECTIVE: To compare direct laboratory costs of different methods for perirectal screening for carbapenemase-producing Enterobacteriaceae (CPE) colonization. DESIGN: Cost-benefit analysis. SETTING: A university hospital and affiliated long-term acute care hospital (LTACH). PARTICIPANTS: Inpatients from the hospital or LTACH. METHODS: Perirectal samples were collected from inpatients at risk for exposure to CPE. In 2009, we compared the accuracy of the Centers for Disease Control and Prevention (CDC)-recommended CPE screening method with similar methods incorporating a chromogenic agar (CA). We then performed a cost projection analysis using 2012 screening results for the CA method, the CDC method, and a molecular assay with wholesale pricing based on the 2009 analysis. Comparisons of turnaround and personnel time were also performed. RESULTS: A total of 185 (2.7%) of 6,860 samples were confirmed as CPE positive during 2012. We previously found that the CDC protocol had a lower sensitivity than the CA method and predicted that the CDC protocol would have missed 92 of the CPE-positive screening results, whereas the modified protocol using CA would have missed 26, assuming similar prevalence and performance. Turnaround time was 3 days using the CDC and CA-modified protocols compared with 1 day for molecular testing. The estimated annual total program cost and total technologist's hours would be the following: CA-modified protocol, $37,441 and 376 hours; CDC protocol, $22,818 and 482 hours; and molecular testing, $224,596 and 343 hours. CONCLUSIONS: The CDC screening protocol appeared to be the least expensive perirectal screening method. However, expense must be weighed against a lower sensitivity and extra labor needed for additional work-up of non-CPE isolates. The molecular test has the shortest turnaround time but the greatest expense.