Fatal Clostridium septicum myonecrosis from gastric perforation: A case report.

Clostridial myonecrosis is a medical and surgical emergency which requires early and aggressive intervention to reduce mortality. We report a rare case of Clostridium septicum myonecrosis that disseminated hematogenously from a gastric perforation. The patient was afebrile and hemodynamically stable upon admission. He rapidly developed spontaneous clostridial myonecrosis and succumbed to septic shock 36 hours after presentation. In our extensive literature review this is the only case with blood cultures confirming Clostridium septicum bacteremia with a surgically confirmed gastric perforation source in the setting of spontaneous clostridial myonecrosis.

Outbreak of Severe Acute Respiratory Syndrome Coronavirus 2 in a Rural Community Hospital during Omicron Predominance.

Healthcare-associated infections due to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has increased since the discovery of the Omicron variant. We describe a SARS-CoV-2 outbreak in the medicine-surgery unit of a rural community hospital at the time of high community transmission of Omicron variant in our county. The outbreak occurred in the medicine-surgery unit of an 89-bed rural community hospital in northern Maine. The characteristics of the patients and healthcare workers (HCWs) affected by the outbreak are described. Patient and HCW data collected as part of the outbreak investigation were used in this report. The outbreak control measures implemented are also described. A total of 24 people tested positive for SARS-CoV-2 including 11 patients and 13 HCWs. A total of 12 of the 24 (50%) persons were symptomatic, and rhinorrhea was the most common symptom noted (8/12, 67%). None of the symptomatic persons had gastrointestinal symptoms or symptoms of a loss of sense of smell or taste. All HCWs were vaccinated and 8 of the 11 patients were vaccinated. Outbreak control measures in the affected unit included implementation of full PPE (N95 respirators, eye protection, gowns and gloves) during all patient care, serial testing of employees and patients in the affected unit, cohorting positive patients, closing visitation and thorough environmental cleaning including use of ultraviolet (UV) light disinfection. This outbreak exemplifies the high transmissibility of the Omicron variant of SARS-CoV-2. The outbreak occurred despite a well-established infection control program. We noted that serial testing, use of N95 respirators during all patient care and UV disinfection were some of the measures that could be successful in outbreak control.

Epidemiology of bloodstream infections caused by Acinetobacter baumannii and impact of drug resistance to both carbapenems and ampicillin-sulbactam on clinical outcomes.

Acinetobacter baumannii has become a leading cause of bloodstream infections (BSI) in health care settings. Although the incidence of infection with carbapenem- and ampicillin-sulbactam-resistant (CASR) A. baumannii has increased, there is a scarcity of studies which investigate BSI caused by CASR A. baumannii. A retrospective cohort study was conducted on adult patients with BSI caused by A. baumannii and who were admitted to the Detroit Medical Center between January 2006 and April 2009. Medical records were queried for patients' demographics, antimicrobial exposures, comorbidities, hospital stay, and clinical outcomes. Bivariate analyses and logistic regression were employed in the study. Two hundred seventy-four patients with BSI caused by A. baumannii were included in the study: 68 (25%) caused by CASR A. baumannii and 206 (75%) caused by non-CASR A. baumannii. In multivariate analysis, factors associated with BSI caused by CASR A. baumannii included admission with a rapidly fatal condition (odds ratio [OR] = 2.83, 95% confidence interval [CI] = 1.27 to 6.32, P value = 0.01) and prior use of antimicrobials (OR = 2.83, 95% CI = 1.18 to 6.78, P value = 0.02). In-hospital mortality rates for BSI caused by CASR A. baumannii were significantly higher than those for non-CASR A. baumannii-induced BSI (43% versus 20%; OR = 3.0, 95% CI = 1.60 to 5.23, P value < 0.001). However, after adjusting for potential confounders, the association between BSI caused by CASR A. baumannii and increased risk of in-hospital mortality was not significant (OR = 1.15, 95% CI = 0.51 to 2.63, P value = 0.74). This study demonstrated that CASR A. baumannii had a distinct epidemiology compared to more susceptible A. baumannii strains; however, clinical outcomes were similar for the two groups. Admission with a rapidly fatal condition was an independent predictor for both CASR A. baumannii and in-hospital mortality.

Prevention of Infection due to Clostridium (Clostridioides) difficile.

Clostridium (Clostridioides) difficile infection (CDI) causes significant morbidity and mortality in the United States every year. Prevention of CDI is difficult because of spore durability and requires implementation of multipronged strategies. Two categories of prevention strategies are infection control and prevention and risk factor reduction. Hand hygiene, contact precautions, patient isolation, and environmental decontamination are cornerstones of infection control and prevention. Risk factor reduction should focus on antibiotic stewardship to reduce unnecessary antibiotic use. If CDI incidence remains higher than the institution's goal despite these measures, then special measures should be considered.

Diagnosis, Treatment, and Prevention of Urinary Tract Infections in Post-Acute and Long-Term Care Settings: A Consensus Statement From AMDA's Infection Advisory Subcommittee.

The diagnosis and management of urinary tract infections (UTIs) among residents of post-acute and long-term care (PALTC) settings remains challenging. Nonspecific symptoms, complex medical conditions, insufficient awareness of diagnostic criteria, and unnecessary urine studies all contribute to the inappropriate diagnosis and treatment of UTIs in PALTC residents. In 2017, the Infection Advisory Subcommittee at AMDA-The Society for Post-Acute and Long-Term Care Medicine convened a workgroup comprised of experts in geriatrics and infectious diseases to review recent literature regarding UTIs in the PALTC population. The workgroup used evidence as well as their collective clinical expertise to develop this consensus statement with the goal of providing comprehensive guidance on the diagnosis, treatment, and prevention of UTIs in PALTC residents. The recommendations acknowledge limitations inherent to providing medical care for frail older adults, practicing within a resource limited setting, and prevention strategies tailored to PALTC populations. In addition, the consensus statement encourages integrating antibiotic stewardship principles into the policies and procedures used by PALTC nursing staff and by prescribing clinicians as they care for residents with a suspected UTI.

Impact of a Multidisciplinary Infection Prevention Initiative on Central Line and Urinary Catheter Utilization in a Long-term Acute Care Hospital.

BACKGROUND: Prolonged central line (CL) and urinary catheter (UC) use can increase risk of central line-associated bloodstream infection (CLABSI) and catheter-associated urinary tract infection (CAUTI). METHODS: This interventional study conducted in a 76-bed long-term acute care hospital (LTACH) in Southeast Michigan was divided into 3 periods: pre-intervention (January 2015-June 2015), intervention (July-November 2015), and postintervention (December 2015-March 2017). During the intervention period, a multidisciplinary infection prevention team (MIPT) made weekly recommendations to remove unnecessary CL/UC or switch to alternate urinary/intravenous access. Device utilization ratios (DURs) and infection rates were compared between the study periods. Interrupted time series (ITS) and 0-inflated poisson (ZIP) regression were used to analyze DUR and CLABSI/CAUTI data, respectively. RESULTS: UC-DUR was 31% in the pre- and postintervention periods and 21% in the intervention period. CL-DUR decreased from 46% (pre-intervention) to 39% (intervention) to 37% (postintervention). The results of ITS analysis indicated nonsignificant decrease and increase in level/trend in DURs coinciding with our intervention. The CAUTI rate per catheter-days did not decrease during intervention (4.36) compared with pre- (2.49) and postintervention (1.93). The CLABSI rate per catheter-days decreased by 73% during intervention (0.39) compared with pre-intervention (1.45). Rates again quadrupled postintervention (1.58). ZIP analysis indicated a beneficial effect of intervention on infection rates without reaching statistical significance. CONCLUSIONS: We demonstrated that a workable MIPT initiative focusing on removal of unnecessary CL and UC can be easily implemented in an LTACH requiring minimal time and resources. A rebound increase in UC-DURs to pre-intervention levels after intervention end indicates that continued vigilance is required to maintain performance.

Epidemiology of Carbapenem-Resistant Enterobacteriaceae at a Long-term Acute Care Hospital.

BACKGROUND: Residents of long-term acute care hospitals (LTACHs) are considered important reservoirs of multidrug-resistant organisms, including Carbapenem-resistant Enterobacteriaceae (CRE). We conducted this study to define the characteristics of CRE-infected/colonized patients admitted to an LTACH and the molecular characteristics of the CRE isolates. METHODS: This retrospective study was conducted to collect information on demographic and comorbid conditions in CRE-colonized/infected patients admitted to a 77-bed LTACH in Detroit between January 2011 and July 2012. Data pertaining to hospital-related exposures were collected for 30 days before positive CRE culture. Polymerase chain reaction (PCR) gene amplification, repetitive sequence-based PCR, and multilocus sequence typing (MLST) were performed on 8 of the CRE isolates. RESULTS: The study cohort included 30 patients with CRE-positive cultures, 24 (80%) with infections, and 6 (20%) with colonization. The mean age of cohort was 69 ±12.41 years; 19 (63%) patients were ventilator-dependent, and 20 (67%) were treated with at least 1 antibiotic. Twenty-three (77%) patients had CRE detected following LTACH admission, and the median days from admission to CRE detection in these patients (interquartile range) was 25 (11-43). Seven more patients were already positive for CRE at the time of LTACH admission. Molecular genotyping and MLST of 8 CRE isolates demonstrated that all isolates belonged to the same strain type (ST258) and contained the bla KPC-3 sequence. CONCLUSIONS: The majority of patients with CRE presented several days to weeks after LTACH admission, indicating possible organism acquisition in the LTACH itself. The genetic similarity of the CRE isolates tested could further indicate the occurrence of horizontal transmission in the LTACH or simply be representative of the regionally dominant strain.

Comparison of complications in midlines versus central venous catheters: Are midlines safer than central venous lines?

BACKGROUND: With the rising use of midline catheters (MCs), validation of their safety is essential. Our study aimed to evaluate the incidence of bloodstream infections (BSIs) and other complications related to the use of MCs and central venous catheters (CVCs). METHODS: A retrospective cohort study was performed at a tertiary care hospital in Detroit, Michigan, from March-September 2016. Adult patients with either MC or CVC were included. Outcomes assessed were catheter-related BSI (CRBSI), mechanical complications, hospital length of stay, readmission within 90 days of discharge (RA), and mortality. Statistical analysis was performed using SAS software. RESULTS: A total of 411 patients with MC and 282 patients with CVC were analyzed. More CRBSIs were seen in patients with CVC (10/282) than MC (1/411) (3.5% vs 0.2%, respectively; P = .0008). More mechanical complications were seen in patients with MC (2.6%) than CVC (0.3%; P = .03). Patients with CVC had a higher crude mortality (17.3% vs 5.3%; P < .0001), RA (58% vs 35%; P ≤ .0001), line-related RA (2.8% vs 0.2%; P = .0041), and transfer to intensive care unit after line placement (9% vs 5%; P = .01). CVC was a significant exposure for a composite of mortality, CRBSI, mechanical issues, thrombosis, and readmission because of a line-related complication (odds ratio, 3.2; 95% confidence interval, 1.8-5.8). CONCLUSIONS: Our findings show use of MC is safer than CVC, but larger studies are needed to confirm our findings.

Implementing an antibiotic stewardship program at a long-term acute care hospital in Detroit, Michigan.

BACKGROUND: The objective of the study was to assess health care providers' (HCPs) knowledge and attitude toward antimicrobial resistance (AMR) and implement an antimicrobial stewardship program (ASP) in a long-term acute care hospital (LTACH). METHODS: A questionnaire on antibiotic use and resistance was administered to HCP in an LTACH in Detroit, Michigan, between August 2011 and October 2011. Concurrently, a retrospective review of common antibiotic prescription practices and costs was conducted. Then, a tailored ASP was launched at the LTACH followed by 2-phase postimplementation assessment aiming at evaluating the impact of the ASP on antibiotic expenditure. RESULTS: Of all respondents (N = 26), 65% viewed AMR as a national problem, but only 38% perceived AMR as a problem at their facility. Most respondents were familiar with infections caused by resistant organisms such as methicillin-resistant Staphylococcus aureus, vancomycin-resistant enterococci, and extended-spectrum ß-lactamase; however, only 35% expressed confidence in treating infected patients. In the preimplementation phase, 15% of antimicrobial doses were inappropriate and 10 of 13 de-escalation opportunities were missed, resulting in additional $23,524.00 expenditure. In the first postimplementation phase, there was a 42% and 58% decrease in the use of daptomycin and tigecycline, respectively, resulting in $55,000 savings. In the second postintervention phase, total antimicrobial cost for treating a cohort of 28 patients in 2016 and 2017 was $26,837.85 and $22,397.15, respectively. CONCLUSIONS: Introduction of an ASP in an LTACH improves antimicrobial prescribing practices, reduces cost, and is sustainable.

Prevalence of Clostridium difficile infection in acute care hospitals, long-term care facilities, and outpatient clinics: Is Clostridium difficile infection underdiagnosed in long-term care facility patients?

Clostridium difficile infection is a common cause of diarrhea in long-term care facility (LTCF) patients. The high prevalence of C difficile infection in LTCFs noted in our study calls for a critical need to educate LTCF staff to send diarrheal stool for C difficile testing to identify more cases and prevent transmission.