Clinical and Environmental Surveillance for the Prevention of Legionellosis.

Legionella is a Gram-negative bacterium whose natural hosts are aquatic protozoa, in which the microorganism replicates and is protected from adverse environmental conditions [...].

A scabies outbreak in an inpatient rehabilitation setting.

BACKGROUND: Scabies is a skin infection transmitted by close person-to-person contact. Crusted scabies is a more severe type which is more contagious. Delayed diagnosis of scabies could lead to an outbreak. METHODS: The outbreak occurred at a 435-bed academic medical center with 76 inpatient rehabilitation beds. The index patient was incarcerated and admitted to our hospital in February 2022. The patient developed crusted scabies after steroids treatment. RESULTS: The patient was treated with oral ivermectin (200 mcg/kg, maximum dose 15 mg) and topical permethrin 5%. All units were followed for 6 weeks since diagnosis of the index patient. A total of 46 healthcare workers (20 nurses and 26 physical therapists) were exposed. Twenty-nine presented symptoms and were treated with ivermectin and permethrin or only ivermectin. No physicians, other patients, or prison guards were affected. There was no secondary household transmission of those exposed healthcare workers. CONCLUSIONS: Scabies is highly contagious in high-risk patients. Early diagnosis and effective infection control are of vital importance.

Genomic characterization of lytic bacteriophages targeting genetically diverse Pseudomonas aeruginosa clinical isolates.

Pseudomonas aeruginosa infections can be difficult to treat and new therapeutics are needed. Bacteriophage therapy is a promising alternative to traditional antibiotics, but large numbers of isolated and characterized phages are lacking. We collected 23 diverse P. aeruginosa isolates from people with cystic fibrosis (CF) and clinical infections, and used them to screen and isolate over a dozen P. aeruginosa-targeting phages from hospital wastewater. Phages were characterized with genome sequencing, comparative genomics, and lytic activity screening against all 23 bacterial host isolates. We evolved bacterial mutants that were resistant to phage infection for four different phages, and used genome sequencing and functional analysis to study them further. We also tested phages for their ability to kill P. aeruginosa grown in biofilms in vitro and ex vivo on CF airway epithelial cells. Overall, this study demonstrates how systematic genomic and phenotypic characterization can be deployed to develop bacteriophages as precision antibiotics.

Coronavirus disease 2019 (COVID-19) research agenda for healthcare epidemiology.

This SHEA white paper identifies knowledge gaps and challenges in healthcare epidemiology research related to coronavirus disease 2019 (COVID-19) with a focus on core principles of healthcare epidemiology. These gaps, revealed during the worst phases of the COVID-19 pandemic, are described in 10 sections: epidemiology, outbreak investigation, surveillance, isolation precaution practices, personal protective equipment (PPE), environmental contamination and disinfection, drug and supply shortages, antimicrobial stewardship, healthcare personnel (HCP) occupational safety, and return to work policies. Each section highlights three critical healthcare epidemiology research questions with detailed description provided in supplementary materials. This research agenda calls for translational studies from laboratory-based basic science research to well-designed, large-scale studies and health outcomes research. Research gaps and challenges related to nursing homes and social disparities are included. Collaborations across various disciplines, expertise and across diverse geographic locations will be critical.

Multiorganism HIV-associated diarrhea and telescoping bowel.

Diarrhea in individuals with human immunodeficiency virus (HIV) remains a diagnostic challenge. We treated a 53-year-old woman from Africa who presented with acute diarrhea, which yielded a diagnosis of HIV and severe immune deficiency. The patient's diarrhea resulted in hypovolemic shock and acute abdominal pain. Evaluation revealed an intestinal intussusception. Pathology findings were consistent with Cryptosporidium, Entamoeba, Giardia, and cytomegalovirus infections. The actual prevalence of multiple microorganisms causing HIV-associated diarrhea is unknown. A nonmalignant-related adult intussusception in this context is exceedingly rare and of noteworthy significance.

Unusual community-associated carbapenem-resistant Acinetobacter baumannii infection, Pennsylvania, USA.

We report a rare case of community-acquired pneumonia and bacteremia caused by multidrug resistant Acinetobacter baumannii. The patient was critically ill, intubated for 11 days and subsequently was discharged from the hospital in good condition after 21 days. Whole genome sequencing was performed, and Acinetobacter baumannii isolate belonged to Sequence Type 451, which is prevalent in Asia. The case highlights the blurring margin between healthcare-associated and community-acquired infections.

Delftia acidovorans pseudo outbreak in portable reverse osmosis machines: Interventions to ensure safe and cost-effective hemodialysis.

INTRODUCTION: Reverse osmosis (RO), a major advance in hemodialysis (HD) safety, effectively clears most water organisms. Delftia acidovorans is an environmental water-borne pathogen that is rarely reported to cause human infections. We report a pseudo outbreak caused by colonization of RO machines with D acidovorans with no reported human infections and interventions to improve HD safety. METHODS: Repeated positive RO product water cultures triggered our hospital to initiate an investigation, RO machines were examined for mechanical integrity by biomedical engineers. Cultures of product water as well as RO parts were done. Testing for bacterial relatedness after identification was performed. An investigation was conducted in a systematic fashion to determine the cause and the extent of the problem. RESULTS: Upon formal review of policies and procedures, there were minor deficiencies. Rectifying these deviations from policies did not stop the repeated positive water cultures. A 7-step investigation and correction was successfully conducted. City water testing with filtration and concentration methods was positive for D acidovorans. Major renovation of the HD unit with replacement of all RO machines and a 2-step water filtration resulted in elimination of the pseudo outbreak. CONCLUSION: City water was the source of biofilm formation of D acidovorans in RO machines that was not possible to eradicate. Application of incoming water filters was an effective preventive strategy. Replacement of RO machines after 4 failed disinfection attempts is the most cost-effective strategy as well for persistent positive water cultures. The HD remains RO water culture negative 2 years after changes.

Evaluation of Recommended Water Sample Collection Methods and the Impact of Holding Time on Legionella Recovery and Variability from Healthcare Building Water Systems.

Water safety and management programs (WSMP) utilize field measurements to evaluate control limits and monitor water quality parameters including Legionella presence. This monitoring is important to verify that the plan is being implemented properly. However, once it has been determined when and how to sample for Legionella, it is important to choose appropriate collection and processing methods. We sought to compare processing immediate and flushed samples, filtration of different volumes collected, and sample hold times. Hot water samples were collected immediately and after a 2-min flush. These samples were plated directly and after filtration of either 100 mL, 200 mL, or 1 L. Additionally, unflushed samples were collected and processed immediately and after 1, 24, and 48 h of hold time. We found that flushed samples had significant reductions in Legionella counts compared to immediate samples. Processing 100 mL of that immediate sample both directly and after filter concentration yielded the highest concentration and percent sample positivity, respectively. We also show that there was no difference in culture values from time 0 compared to hold times of 1 h and 24 h. At 48 h, there were slightly fewer Legionella recovered than at time 0. However, Legionella counts were so variable based on sampling location and date that this hold time effect was minimal. The interpretation of Legionella culture results depends on the sample collection and processing methods used, as these can have a huge impact on the success of sampling and the validation of control measures.

Primary Laryngeal Blastomycosis: Diagnostic Challenges and Advances in a Rare Cause of Laryngitis.

Blastomyces dermatitidis is a fungal organism endemic to the central and southern United States and capable of causing numerous diseases. Primary blastomycosis of the larynx is a rare clinical entity with a limited number of reported cases in the literature. Diagnosis is challenging as a result of nonspecific physical exam findings, difficulty of histopathologic detection and culture, and need for operative laryngeal biopsy for definitive identification. Molecular and serologic testing is not widely available. The authors present a case of laryngeal blastomycosis, the diagnosis of which was facilitated by in-office biopsy, and discuss diagnostic challenges. Laryngoscope, 129:2531-2533, 2019.

Hospital-associated Clostridium difficile infection and reservoirs within the hospital environment.

BACKGROUND: Clostridium difficile infection (CDI) is a leading cause of hospital-associated infections. Antibiotic stewardship, environmental disinfection, and reduction of transmission via health care workers are the major modes of CDI prevention within hospitals. METHODS: The aim of this study was to evaluate the role of the environment in the spread of CDI within hospital rooms. Bed tracing of positive-CDI inpatients was performed to detect the strength of association to specific rooms. Environmental cultures were conducted to identify adequacy of environmental C difficile (CD) spores. Whole-genome sequencing was performed to evaluate the degree of CD relatedness. RESULTS: Bed tracing performed for 211 CDI patients showed a limited list of high-burden rooms. Environmental cultures for surfaces disinfected with a sporicidal agent were almost entirely negative, whereas the floors were positive for CDI in 15% of the studied patient rooms. Whole-genome sequencing did not detect any close genetic relatedness. CONCLUSIONS: Unlike in an outbreak setting, bed tracing did not yield conclusive results of room reservoirs. The C diff Banana Broth culture was inexpensive, sensitive, and easy to incubate under aerobic conditions. Sporicidal disinfectants were effective in eliminating CD from the environment. CD spores were found on floors and hard-to-clean surfaces.

Prescribing trends and revisit rates following a pharmacist-driven protocol change for community-acquired pneumonia in an emergency department.

OBJECTIVE: To compare pharmacist-led prescribing changes and associated 30-day revisit rates across different regimens for patients discharged from an emergency department (ED) with a diagnosis of community-acquired pneumonia (CAP). METHODS: An observational, retrospective cohort analysis was conducted of patients who were discharged from an ED over a 4-year period with a diagnosis of CAP. Patient demographics, clinical characteristics, antibiotic selection and comorbidity and condition severity scores were collected for two cohorts: 2012-13 (before protocol change) and 2014-15 (post-protocol change). During January 2014, a pharmacist-led protocol change with prescriber education was implemented to better align ED treatment practices with clinical practice guidelines. The primary endpoint was the change in prescribing practices across the two cohorts. KEY FINDINGS: A total of 741 patients with CAP were identified, including 411 (55.5%) patients in 2012-13 and 330 (44.5%) in 2014-15. Prescribing of macrolide monotherapy regimens decreased significantly following protocol change (70.1% versus 42.7%; difference: 27.4%, 95% CI: 23.8-31.0%) with a reciprocal increase in macrolide/ß-lactam combination prescribing (6.3-21.8%; difference: 15.5%, 95% CI: 12.9-18.1%). A total of 12.2% of patients who received macrolide/ß-lactam combination treatment revisited a network ED within 30 days due to worsening pneumonia, compared to 8.6% of patients who received macrolide monotherapy treatment (P = NS). CONCLUSIONS: The current study showed a significant increase in antibiotic prescribing compliance following a pharmacist-driven protocol change and education, but no statistical difference in rates of return for macrolide monotherapy versus other regimens.

Preventing Healthcare-Associated Legionellosis: Results after 3 Years of Continuous Disinfection of Hot Water with Monochloramine and an Effective Water Safety Plan.

The purpose of this study is to report the experience of the implementation and application of a 3-year Water Safety Plan (WSP) together with the secondary disinfection of water by monochloramine to control and prevent healthcare-associated legionellosis in an Italian hospital strongly colonized by Legionella. Risk assessment was carried out by the WSP team. The main critical control points focused on in developing the WSP for the control of Legionella was the water distribution system. A sampling plan for the detection of Legionella was implemented. A widespread contamination of the hot water distribution system by L. pneumophila sg5 was found. Results after 3 years of the continuous disinfection of hot water with monochloramine indicate the eradication of Legionella. The implementation and application of a WSP in a hospital, together with the disinfection of the water distribution system with monochloramine, can be effective in controlling the growth of Legionella and in preventing nosocomial legionellosis.

Disposable Bronchoscope Model for Simulating Endoscopic Reprocessing and Surveillance Cultures.

BACKGROUND Endoscope-associated infections are reported despite following proper reprocessing methods. Microbiological testing can confirm the adequacy of endoscope reprocessing. Multiple controversies related to the method and interpretation of microbiological testing cultures have arisen that make their routine performance a complex target. OBJECTIVE We conducted a pilot study using disposable bronchoscopes (DBs) to simulate different reprocessing times and soaking times and to compare high-level disinfection versus ethylene oxide sterilization. We also reviewed the time to reprocessing and duration of the procedures. METHODS Bronchoscopes were chosen because an alternative disposable scope is commercially available and because bronchoscopes are more prone to delays in processing. Disposable bronchoscopes were contaminated using a liquid bacterial suspension and were then incubated for 1-4 hours. Standard processing and high-level disinfection were performed on 36 endoscopes. Ethylene oxide sterilization was performed on 21 endoscopes. Endoscope cultures were performed using the standard "brush, flush, brush" technique. RESULTS After brushing was performed, a final water-flush culture procedure was the most effective method of detecting bacterial persistence on the disposable scopes. Klebsiella pneumoniae was the most commonly recovered organism after reprocessing. Ethylene oxide sterilization did not result in total elimination of viable bacteria. CONCLUSION Routine endoscopy cultures may be required to assess the adequacy of endoscopic processing. Infect Control Hosp Epidemiol 2017;38:136-142.

Infection and readmission rate of cardiac implantable electronic device insertions: An observational single center study.

BACKGROUND: Infection is one of the most serious complications following surgical placement of cardiac implantable electronic devices (CIEDs). Infection prevention efforts are necessary in reducing CIED infectious outcomes. These devices, however, are commonly inserted in higher risk patients, which may explain the ongoing risk of surgical site infection (SSI) in this population. The rates of CIED infection and utilization vary widely in the literature. The definitions of infection may also vary between clinical definitions and the National Healthcare Safety Network (NHSN) criteria. METHODS: The primary objective of this study was to review patient data to identify risk factors for infection and readmission after CIED placement at an academic medical center. The secondary objectives were to compare the rates of SSI identified by NHSN criteria compared to that obtained by applying clinical infection definitions. RESULTS: The overall rate of infection (SSI) was 1.9%, which was identical in both the clinical definition and NHSN reported data. The 30 day readmission rate and the 90 day readmission rate were 12.7% and 25.6% respectively with the most readmissions related to the patients' underlying medical conditions. A lower ejection fraction (EF) was identified as an independent risk factor for readmission, inpatient procedures, smoking and device infection were also significantly associated with readmission after CIED insertion.

Safety and utilization of peripherally inserted central catheters versus midline catheters at a large academic medical center.

BACKGROUND: Peripherally inserted central catheters (PICCs) are a commonly used central intravenous (IV) access device, which can be associated with significant complications. Midline catheters (MCs) are peripheral IV access devices that may reduce the need for central lines and hence decrease central line-associated bloodstream infections. The objective of this study is to compare the utilization and safety of PICCs and MCs. METHODS: This was a retrospective study comparing the use and outcomes of PICCs and MCs at a large academic medical center between January and May 2015. Data were collected using electronic medical records and IV team insertion data. Statistical software was used for analysis. RESULTS: A total of 206 PICCs and 200 MCs were inserted in 367 patients within the study duration. Patients with MCs were more likely to have complications than those with PICCs (19.5% vs 5.8%, P < .0001). CONCLUSIONS: MCs were associated with a higher risk of non-life-threatening complications versus PICCs, which showed fewer but more serious complications, including bacteremia. The decision to move toward more use of MCs is not without risk. Institutions should continue to review the utilization and safety data of IV catheter use to determine the most appropriate use of these devices.

Cardiac Implantable Electronic Device Infection: From an Infection Prevention Perspective.

A cardiac implantable electronic device (CIED) is indicated for patients with severely reduced ejection fraction or with life-threatening cardiac arrhythmias. Infection related to a CIED is one of the most feared complications of this life-saving device. The rate of CIED infection has been estimated to be between 2 and 25; though evidence shows that this rate continues to rise with increasing expenditure to the patient as well as healthcare systems. Multiple risk factors have been attributed to the increased rates of CIED infection and host comorbidities as well as procedure related risks. Infection prevention efforts are being developed as defined bundles in numerous hospitals around the country given the increased morbidity and mortality from CIED related infections. This paper aims at reviewing the various infection prevention measures employed at hospitals and also highlights the areas that have relatively less established evidence for efficacy.

A case of chronic progressive lyme encephalitis as a manifestation of late lyme neuroborreliosis.

A 54-year-old female living in Europe presented with gait ataxia, dizziness, and bilateral hearing loss. Magnetic resonance imaging (MRI) revealed non-specific white matter changes. The patient's condition gradually deteriorated over two years without diagnosis. The patient continued to decline cognitively and neurologically with worsening ataxia and upper motor neuron signs. Repeat MRI showed worsening white matter changes. Lumbar puncture, not previously done, showed positive Lyme testing. Treatment with intravenous ceftriaxone resulted in marked neurological improvement. Four years after symptom, the patient has short-term memory deficits and chronic fatigue, but is otherwise neurologically, cognitively, and functionally intact. Follow up MRI findings remain largely unchanged. Because cases of intraparenchymal or encephalopathic neuroborreliosis in America are lacking, so are treatment options. We present a rare case and discuss our experience with antibiotic treatment. This case lends evidence to define optimal treatment of this disease, imperative for hastening neurological recovery.

Infection and hemodialysis access: an updated review.

The incidence of end-stage renal disease (ESRD) has almost doubled over past 2 decades. Despite decreasing overall hospital admission rates for ESRD population, the rate of infection-related hospitalizations has steadily increased. Infection remains the second most common cause of mortality in this patient population. Specifically, in the hemodialysis (HD) patients, the vascular access related infections are the most common identifiable source of infection. This concise review provides an update on the bacteremia related to vascular access primarily the catheters (Catheter Related Blood Stream Infection- CRBSI) in HD patients emphasizing on the determinants ranging from the epidemiology to pathogenesis, risk factors, cost implications and prevention. Staphylococcus aureus, coagulase negative Staphylococci, and Enterococci are the most common causative microorganisms implicated in CRBSI. The pathogenesis of CRBSI includes organism entry into the blood stream followed by adherence to catheter, colonization and biofilm formation. Vascular access type, catheter position, and prior bacteremic episodes are strongly associated with blood stream infection. Preventive measures should be multidisciplinary in nature and should include avoidance of central venous catheters, best practices for catheter care, surveillance, antimicrobial catheter lock solutions, and use of antibiotic impregnated catheters.

Role of ultraviolet (UV) disinfection in infection control and environmental cleaning.

Ultraviolet (UV) radiation is capable of disinfecting surfaces, water and air. The UV technology was used for many years. However, safer and more effective delivery systems of UV radiation, make it a very useful option for disinfection. Effective disinfection of environmental surfaces is a key step in the prevention of spread of infectious agents. The traditional manual cleaning is essential in assuring adequate elimination of contamination. However, terminal cleaning is frequently suboptimal or unpredictable in many circumstances. UV-C radiation is an adjunctive disinfectant new technology that could kill a wide array of microorganisms including both vegetative and spore forming pathogens. The technology is getting more affordable and has produced consistent reproducible significant reduction of bacterial contamination.