A multi-species outbreak of VIM-producing carbapenem-resistant bacteria in a burn unit and subsequent investigation of rapid development of cefiderocol resistance.

Carbapenem resistance due to metallo-ß-lactamases (MBLs) such as the Verona integron-encoded metallo-ß-lactamase (VIM) is particularly problematic due to the limited treatment options. We describe a case series of bacterial infections in a tertiary care hospital due to multi-species acquisition of a VIM gene along with our experience using novel ß-lactam antibiotics and antibiotic combinations to treat these infections. Four patients were treated with the combination of ceftazidime-avibactam and aztreonam, with no resistance to the combination detected. However, cefiderocol-resistant Klebsiella pneumoniae isolates were detected in two out of the five patients who received cefiderocol within 3 weeks of having started the antibiotic. Strain pairs of sequential susceptible and resistant isolates from both patients were analyzed using whole-genome sequencing. This analysis revealed that the pairs of isolates independently acquired point mutations in both the cirA and fiu genes, which encode siderophore receptors. These point mutations were remade in a laboratory strain of K. pneumoniae and resulted in a significant increase in the MIC of cefiderocol, even in the absence of a beta-lactamase enzyme or a penicillin-binding protein 3 (PBP3) mutation. While newer ß-lactam antibiotics remain an exciting addition to the antibiotic armamentarium, their use must be accompanied by diligent monitoring for the rapid development of resistance.

Progression patterns and therapeutic sequencing following immune checkpoint inhibition for hepatocellular carcinoma: An international observational study.

BACKGROUND AND AIMS: Different approaches are available after the progression of disease (PD) to immune checkpoint inhibitors (ICIs) for hepatocellular carcinoma (HCC), including the continuation of ICI, treatment switching to tyrosine kinase inhibitors (TKIs) and cessation of anticancer therapy. We sought to characterise the relationship between radiological patterns of progression and survival post-ICI, also appraising treatment strategies. METHODS: We screened 604 HCC patients treated with ICIs, including only those who experienced PD by data cut-off. We evaluated post-progression survival (PPS) according to the treatment strategy at PD and verified its relationship with radiological patterns of progression: intrahepatic growth (IHG), new intrahepatic lesion (NIH), extrahepatic growth (EHG), new extrahepatic lesion (NEH) and new vascular invasion (nVI). RESULTS: Of 604 patients, 364 (60.3%) experienced PD during observation. Median PPS was 5.3 months (95% CI: 4.4-6.9; 271 events). At the data cut-off, 165 patients (45%) received no post-progression anticancer therapy; 64 patients (17.6%) continued ICI beyond PD. IHG (HR 1.64 [95% CI: 1.21-2.22]; p = .0013) and nVI (HR 2.15 [95% CI: 1.38-3.35]; p = .0007) were associated with shorter PPS. Multivariate models adjusted for progression patterns, treatment line and albumin-bilirubin grade and Eastern Cooperative Oncology Group performance status at PD confirmed receipt of ICI beyond PD with (HR 0.17, 95% CI: 0.09-0.32; p < .0001) or without subsequent TKI (HR 0.39, 95% CI: 0.26-0.58; p < .0001) as predictors of prolonged PPS versus no anticancer therapy. CONCLUSIONS: ICI-TKI sequencing is a consolidated option in advanced HCC. nVI and IHG predict a poorer prognosis. Despite lack of recommendation, the continuation of ICI beyond progression in HCC is adopted clinically: future efforts should appraise which patients benefit from this approach.

New Frontiers in the Medical Therapy of Hepatocellular Carcinoma.

BACKGROUND: Hepatocellular carcinoma (HCC) is the most common primary liver tumor, and it rates fourth as a cause of cancer-related death. The presence of underlying liver disease and poor chemosensitivity pose major treatment challenges in the management of HCC. However, in the last few years, the therapeutic scenario has substantially changed, and immunotherapy in the form of immune checkpoint inhibitors (ICPIs) has become an essential therapeutic strategy in this field. SUMMARY: After controversial results of monotherapy, ICPIs have been mainly investigated in association with antiangiogenic agents or as dual checkpoint inhibition. The combination of atezolizumab plus bevacizumab has become the new therapeutic standard for unresectable HCC. Currently, a number of ICPI-based combinations are being studied in phase III clinical trials as front-line therapy for advanced HCC, with growing interest in integration of early-stage disease management in the form of adjuvant or neoadjuvant therapies. With most of the trials investigating ICPIs as first-line treatment, the second-line scenario relies mainly on tyrosine kinase inhibitors, which however have not been formally trialed after ICPIs. KEY MESSAGES: In this review, we summarize the main therapeutic advances in the systemic management of HCC focusing on the most relevant ongoing trials. We also discuss the main issues arising from a such rapidly evolving field including therapeutic sequencing and patient stratification.

PD-1/PD-L1 checkpoint inhibitors during late stages of life: an ad-hoc analysis from a large multicenter cohort.

BACKGROUND: The favourable safety profile and the increasing confidence with immune checkpoint inhibitors (ICIs) might have boosted their prescription in frail patients with short life expectancies, who usually are not treated with standard chemotherapy. METHODS: The present analysis aims to describe clinicians' attitudes towards ICIs administration during late stages of life within a multicenter cohort of advanced cancer patients treated with single agent PD-1/PD-L1 checkpoint inhibitors in Italy. RESULTS: Overall, 1149 patients with advanced cancer who received single agent PD-1/PD-L1 checkpoint inhibitors were screened. The final study population consisted of 567 deceased patients. 166 patients (29.3%) had received ICIs within 30 days of death; among them there was a significantly higher proportion of patients with ECOG-PS ≥ 2 (28.3% vs 11.5%, p < 0.0001) and with a higher burden of disease (69.3% vs 59.4%, p = 0.0266). In total, 35 patients (6.2%) started ICIs within 30 days of death; among them there was a higher proportion of patients with ECOG-PS ≥ 2 (45.7% vs 14.5%, p < 0.0001) and with a higher burden of disease (82.9% vs 60.9%, p = 0.0266). Primary tumors were significantly different across subgroups (p = 0.0172), with a higher prevalence of NSCLC patients (80% vs 60.9%) among those who started ICIs within 30 days of death. Lastly, 123 patients (21.7%) started ICIs within 3 months of death. Similarly, within this subgroup there was a higher proportion of patients with ECOG-PS ≥ 2 (29.3% vs 12.8%, p < 0.0001), with a higher burden of disease (74.0% vs 59.0%, p = 0.0025) and with NSCLC (74.0% vs 58.8%, p = 0.0236). CONCLUSION: Our results confirmed a trend toward an increasing ICIs prescription in frail patients, during the late stages of life. Caution should be exercised when evaluating an ICI treatment for patients with a poor PS and a high burden of disease.

Immunotherapy in Hepatocellular Carcinoma.

OPINION STATEMENT: Patients with hepatocellular carcinoma (HCC) have been traditionally deprived from highly effective systemic therapy options in the past decades. The multi-targeted tyrosine kinase inhibitor sorafenib, approved in 2008, remained the only treatment option for advanced HCC for over a decade. A number of molecularly targeted therapies such as lenvatinib, regorafenib, cabozantinib, and ramucirumab have significantly widened treatment options in patients with advanced HCC. However, emergence of resistance and long-term toxicity from treatment are barriers to long-term survivorship. Immunotherapy is at the focus of intense research efforts in HCC. Whilst targeting of programmed cell death 1 (PD-1) and cytotoxic T lymphocyte 4 (CTLA-4) is associated with radiologically measurable disease-modulating effects in HCC, monotherapies fell short of demonstrating evidence of significant survival extension in advanced disease. Atezolizumab and bevacizumab were the first immunotherapy regimen to demonstrate clear superiority in improving the survival of patients with unresectable HCC compared to sorafenib, paving the way for immunotherapy combinations. As the treatment landscape of HCC rapidly evolves, with immunotherapy integrating within early- and intermediate-stage disease treatment algorithms, lack of level 1 evidence on sequencing of therapeutic strategies and lack of head-to-head comparisons across immunotherapy combinations will affect prescribing of immunotherapy in routine practice. In the absence of predictive biomarkers, choice of immunotherapy over kinase inhibitors will continue to remain an empirical exercise, guided by balancing anti-tumour efficacy with toxicity considerations in the individual patient.

A Process for Assessing Products for Infection Prevention in Health Care Settings: A Framework From the Healthcare Infection Control Practices Advisory Committee of the Centers for Disease Control and Prevention.

Infection control is a complex task that spans people, products, and practices in diverse settings. For years, the Healthcare Infection Control Practices Advisory Committee (HICPAC) has provided advice and guidance to the Centers for Disease Control and Prevention (CDC) on how best to prevent infections. These recommendations have focused largely on health care delivery practices and occasionally on general categories of products. With an influx of novel infection control products and growing use of these products by frontline clinicians, an efficient process for developing transparent, rigorous product recommendations that includes myriad data sources was necessary. To address this gap, the CDC asked HICPAC to develop a process that would help inform committees considering product-related recommendations. This article describes the process to develop this approach and provides an outline of how the tool may be used when products with infection control claims are recommended in guidelines or recommendations for infection prevention.

A Virtual Standardized Patient-Based Assessment Tool to Evaluate Psychiatric Residents' Psychopharmacology Proficiency.

OBJECTIVES: A virtual standardized patient-based assessment simulator was developed to address biases and practical limitations in existing methods for evaluating residents' proficiency in psychopharmacological knowledge and practice. METHODS: The simulator was designed to replicate an outpatient psychiatric clinic experience. The virtual patient reported symptoms of a treatment-resistant form of major depressive disorder (MDD), requiring the learner to use various antidepressants in order for the patient to fully remit. Test scores were based on the proportion of correct responses to questions asked by the virtual patient about possible side effects, dosing, and titration decisions, which depended upon the patient's tolerability and response to the learner's selected medications. The validation paradigm included a novice-expert performance comparison across 4th year medical students, psychiatric residents from all four post-graduate year classes, and psychiatry department faculty, and a correlational analysis of simulator performance with the PRITE Somatic Treatments subscale score. Post-test surveys evaluated the test takers' subjective impressions of the simulator. RESULTS: Forty-three subjects completed the online exam and survey. Total mean scores on the exam differed significantly across all the learner groups in a step-wise manner from students to faculty (F = 6.10, p = 0.0001). Total mean scores by residency class correlated with PRITE Somatic Therapies subscale scores (p < 0.01). The post-test survey mean Likert results ranged from 3.33 ± 1.20 to 4.4 ± 0.79, indicating neutral to favorable responses for use of the simulator. CONCLUSIONS: This simulator demonstrated strong construct validity and high participant acceptability for assessing proficiency in the psychopharmacologic treatment of MDD.

Effect of Statin Coadministration on the Risk of Daptomycin-Associated Myopathy.

Background: Daptomycin-associated myopathy has been identified in 2%-14% of patients, and rhabdomyolysis is a known adverse effect. Although risk factors for daptomycin-associated myopathy are poorly defined, creatine phosphokinase (CPK) monitoring and temporary discontinuation of 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors, or "statins," has been recommended. Methods: We conducted a single-center, retrospective, matched case-control risk factor analysis in adult and pediatric patients from 2004 to 2015. Patients in whom myopathy (defined as CPK values above the upper limit of normal) developed during daptomycin treatment were matched 1:1 to no-myopathy controls with at least the same duration of therapy. Risk factors independently associated with myopathy were determined using multivariable conditional logistic regression. Secondary analysis was performed in patients with rhabdomyolysis, defined as CPK values ≥10 times the upper limit of normal. Results: Of 3042 patients reviewed, 128 (4.2%) were identified as having daptomycin-associated myopathy, 25 (0.8%) of whom had rhabdomyolysis; 121 (95%) of the 128 were adults, and the mean duration of therapy before CPK elevation was 16.7 days (range, 1-58 days). In multivariate analysis, deep abscess treatment (odds ratio, 2.80; P = .03), antihistamine coadministration (3.50; P = .03), and statin coadministration (2.60; P = .03) were independent risk factors for myopathy. Obesity (odds ratio, 3.28; P = .03) and statin coadministration (4.67; P = .03) were found to be independent risk factors for rhabdomyolysis, and older age was associated with reduced risk (0.97; P = .05). Conclusions: Statin coadministration with daptomycin was independently associated with myopathy and rhabdomyolysis. This is the first study to provide strong evidence supporting this association. During coadministration, we recommend twice-weekly CPK monitoring and consideration of withholding statins.

An Evidence-Based Protocol for Antibiotic Use Prior to Cystoscopy Decreases Antibiotic Use without Impacting Post-Procedural Symptomatic Urinary Tract Infection Rates.

PURPOSE: Symptomatic urinary tract infection is a complication of office based cystourethroscopy. Studies are mixed regarding the efficacy of antibiotic prophylaxis to prevent urinary tract infections. Our aim was to develop and evaluate an evidence-based protocol that reduces unnecessary antibiotic use while avoiding an increase in urinary tract infections. MATERIALS AND METHODS: We created a clinic antibiogram based on all urology office visits performed during a 2-year period. Bacterial resistance rates, institutional risk related data and clinical guidelines were applied to create a protocol for antibiotic administration before cystourethroscopy. We then analyzed 1,245 consecutive patients without a renal transplant who underwent outpatient cystourethroscopy, including 610 after protocol initiation. Urinary tract infection rates and antibiotic use were analyzed for an association with the protocol change using the Fisher exact test. RESULTS: Cultures had an overall 20% rate of resistance to fluoroquinolones, representing 40% of the cultures that grew Escherichia coli. Before the protocol change 602 of 635 patients (94.8%) received a preprocedural antibiotic compared to 426 of 610 (69.9%) after protocol initiation (p <0.01). A total of 19 patients (3.0%) had a symptomatic urinary tract infection prior to the protocol change while 16 (2.6%) had a urinary tract infection after the change (p = 0.69). Regarding resistance, fluoroquinolone resistant organisms grew in the cultures of 12 of 19 patients (63.2%) with a urinary tract infection before the protocol change compared to 5 of 16 (31.3%) with a urinary tract infection after the change. Recent antibiotic administration, hospitalization and chronic catheterization were associated with urinary tract infection in the entire cohort (all p ≤0.01). CONCLUSIONS: A local antibiogram with infection related risk data effectively risk stratifies patients before cystourethroscopy, decreasing the use of antibiotics without increasing the rate of symptomatic urinary tract infection.

Calculating census tract-based life expectancy in New York state: a generalizable approach.

BACKGROUND: Life expectancy at birth (LE) has been calculated for states and counties. LE estimates at these levels mask health disparities in local communities. There are no nationwide estimates at the sub-county level. We present a stepwise approach for calculating LE using census tracts in New York state to identify health disparities. METHODS: Our study included 2751 census tracts in New York state, but excluded New York City. We used population data from the 2010 United States Census and 2008-2010 mortality data from the state health department. Tracts were assigned to 99.97% of the deaths. We removed tracts which had a majority of people living in group quarters. Deaths in these tracts are often recorded elsewhere. Of the remaining 2679 tracts, 6.6% of the tracts had standard errors ≥ 2 years. A geographic aggregation tool was used to aggregate tracts with fewer than 60 deaths, and then aggregate areas that had standard errors of ≥ 2 years. RESULTS: Aggregation resulted in a 9.9% reduction in the number of areas. Tracts with < 2% of population living below the poverty level had a LE of 82.8 years, while tracts with a poverty level ≥ 25% had a LE of 75.5. We observed differences in LE in border areas, of up to 10.4 years, when excluding or including deaths of study area residents that occurred outside the study area. The range and standard deviation at the county level (77.5-82.8, SD = 1.2 years) were smaller than our final sub-county areas (64.7-92.0, SD = 3.3 years). The correlation between LE and poverty were similar and statistically significant (p < 0.0001) at the county (r = - 0.58) and sub-county level (r = - 0.58). The correlations between LE and percent African-American at the county level were (r = 0.11, p = 0.43) and at the sub-county level (r = - 0.25, p < 0.0001). CONCLUSION: The proposed approach for geocoding and aggregation of mortality and population data provides a solution for health departments to produce stable empirically-derived LE estimates using data coded to the tract. Reliable estimates within sub-county areas are needed to aid public health officials in focusing preventive health programs in areas where health disparities would be masked by county level estimates.

Carbapenems versus alternative antibiotics for the treatment of bloodstream infections caused by Enterobacter, Citrobacter or Serratia species: a systematic review with meta-analysis.

OBJECTIVES: This systematic review and meta-analysis compared effects of different antibiotics on mortality in patients with bloodstream infections caused by Enterobacteriaceae with chromosomal AmpC ß-lactamase. METHODS: Databases were systematically searched for studies reporting mortality in patients with bloodstream infections caused by AmpC producers treated with carbapenems, broad-spectrum ß-lactam/ß-lactamase inhibitors (BLBLIs), quinolones or cefepime. Pooled ORs for mortality were calculated for cases that received monotherapy with these agents versus carbapenems. REGISTRATION: PROSPERO international prospective register of systematic reviews (CRD42014014992; 18 November 2014). RESULTS: Eleven observational studies were included. Random-effects meta-analysis was performed on studies reporting empirical and definitive monotherapy. In unadjusted analyses, no significant difference in mortality was found between BLBLIs versus carbapenems used for definitive therapy (OR 0.87, 95% CI 0.32-2.36) or empirical therapy (OR 0.48; 95% CI 0.14-1.60) or cefepime versus carbapenems as definitive therapy (OR 0.61; 95% CI 0.27-1.38) or empirical therapy (0.60; 95% CI 0.17-2.20). Use of a fluoroquinolone as definitive therapy was associated with a lower risk of mortality compared with carbapenems (OR 0.39; 95% CI 0.19-0.78). Three studies with patient-level data were used to adjust for potential confounders. The non-significant trends favouring non-carbapenem options in these studies were diminished after adjustment for age, sex and illness severity scores, suggestive of residual confounding. CONCLUSIONS: Despite limitations of available data, there was no strong evidence to suggest that BLBLIs, quinolones or cefepime were inferior to carbapenems. The reduced risk of mortality observed with quinolone use may reflect less serious illness in patients, rather than superiority over carbapenems.

Identifying areas at risk of low birth weight using spatial epidemiology: A small area surveillance study.

OBJECTIVES: To assess the geographic distribution of Low Birth Weight (LBW) in New York State among singleton births using a spatial regression approach in order to identify priority areas for public health actions. METHODS: LBW was defined as birth weight less than 2500g. Geocoded data from 562,586 birth certificates in New York State (years 2008-2012) were merged with 2010 census data at the tract level. To provide stable estimates and maintain confidentiality, data were aggregated to yield 1268 areas of analysis. LBW prevalence among singleton births was related with area-level behavioral, socioeconomic and demographic characteristics using a Poisson mixed effects spatial error regression model. RESULTS: Observed low birth weight showed statistically significant auto-correlation in our study area (Moran's I 0.16 p value 0.0005). After over-dispersion correction and accounting for fixed effects for selected social determinants, spatial autocorrelation was fully accounted for (Moran's I-0.007 p value 0.241). The proportion of LBW was higher in areas with larger Hispanic or Black populations and high smoking prevalence. Smoothed maps with predicted prevalence were developed to identify areas at high risk of LBW. Spatial patterns of residual variation were analyzed to identify unique risk factors. CONCLUSION: Neighborhood racial composition contributes to disparities in LBW prevalence beyond differences in behavioral and socioeconomic factors. Small-area analyses of LBW can identify areas for targeted interventions and display unique local patterns that should be accounted for in prevention strategies.

Assessing the impact of fine particulate matter (PM2.5) on respiratory-cardiovascular chronic diseases in the New York City Metropolitan area using Hierarchical Bayesian Model estimates.

An enhanced research paradigm is presented to address the spatial and temporal gaps in fine particulate matter (PM2.5) measurements and generate realistic and representative concentration fields for use in epidemiological studies of human exposure to ambient air particulate concentrations. The general approach for research designed to analyze health impacts of exposure to PM2.5 is to use concentration data from the nearest ground-based air quality monitor(s), which typically have missing data on the temporal and spatial scales due to filter sampling schedules and monitor placement, respectively. To circumvent these data gaps, this research project uses a Hierarchical Bayesian Model (HBM) to generate estimates of PM2.5 in areas with and without air quality monitors by combining PM2.5 concentrations measured by monitors, PM2.5 concentration estimates derived from satellite aerosol optical depth (AOD) data, and Community-Multiscale Air Quality (CMAQ) model predictions of PM2.5 concentrations. This methodology represents a substantial step forward in the approach for developing representative PM2.5 concentration datasets to correlate with inpatient hospitalizations and emergency room visits data for asthma and inpatient hospitalizations for myocardial infarction (MI) and heart failure (HF) using case-crossover analysis. There were two key objective of this current study. First was to show that the inputs to the HBM could be expanded to include AOD data in addition to data from PM2.5 monitors and predictions from CMAQ. The second objective was to determine if inclusion of AOD surfaces in HBM model algorithms results in PM2.5 air pollutant concentration surfaces which more accurately predict hospital admittance and emergency room visits for MI, asthma, and HF. This study focuses on the New York City, NY metropolitan and surrounding areas during the 2004-2006 time period, in order to compare the health outcome impacts with those from previous studies and focus on any benefits derived from the changes in the HBM model surfaces. Consistent with previous studies, the results show high PM2.5 exposure is associated with increased risk of asthma, myocardial infarction and heart failure. The estimates derived from concentration surfaces that incorporate AOD had a similar model fit and estimate of risk as compared to those derived from combining monitor and CMAQ data alone. Thus, this study demonstrates that estimates of PM2.5 concentrations from satellite data can be used to supplement PM2.5 monitor data in the estimates of risk associated with three common health outcomes. Results from this study were inconclusive regarding the potential benefits derived from adding AOD data to the HBM, as the addition of the satellite data did not significantly increase model performance. However, this study was limited to one metropolitan area over a short two-year time period. The use of next-generation, high temporal and spatial resolution satellite AOD data from geostationary and polar-orbiting satellites is expected to improve predictions in epidemiological studies in areas with fewer pollutant monitors or over wider geographic areas.

Linking air pollution data and adverse birth outcomes: environmental public health tracking in New York State.

BACKGROUND: Studies investigating associations between ambient air pollution and fetal growth and gestational duration have reported inconclusive findings. OBJECTIVES: The study goal was to use the Environmental Public Health Tracking Network to describe the association between exposure to particulate matter (PM2.5) and ozone and term low birth weight (TLBW) in New York State. METHODS: Birth data for the years 2001-2006 were linked to Census data and hierarchical Bayesian modeled air pollution data. Daily 8-hour maximums for ozone and daily average PM2.5 estimates were averaged by trimester and exposure quartiles. The Environmental Public Health Tracking Academic Center for Excellence at Rutgers University partnered with New York and several other states to create a statistical program that uses logistic regression to determine the association between air pollution exposure and TLBW. RESULTS: There were no consistent dose-response relationships between the pollutants and TLBW. Ozone exposure was associated with a higher risk of TLBW only in the first trimester, but these results were not statistically significant. Exposure to the third quartile of ozone for the full gestational period had negative associations with TLBW (odds ratio = 0.86; 95% confidence interval, 0.81-0.92). CONCLUSION: Collaboration within the Environmental Public Health Tracking Network to share methods and data for research proved feasible and efficient in assessing the relationship of air pollutants to adverse birth outcomes. This study finds little evidence to support positive associations between exposure to ozone or PM2.5 and TLBW in New York State.

Infection control and prevention considerations.

Due to the nature of their underlying illness and treatment regimens, cancer patients are at increased risk of infection. Though the advent and widespread use of anti-infective agents has allowed for the application of ever-greater immune-suppressing therapies with successful treatment of infectious complications, prevention of infection remains the primary goal. The evolutionary changes of microorganisms, whereby resistance to anti-infective therapy is increasingly common, have facilitated a paradigm shift in the field of healthcare epidemiology. No longer is the focus on "control" of infection once established in a healthcare environment. Rather, the emphasis is on prevention of infection before it occurs. The most basic tenet of infection prevention, and the cornerstone of all well-designed infection prevention and control programs, is hand hygiene. The hands of healthcare workers provide a common potential source for transmission of infectious agents, and effective decontamination of the hands reduces the risk of transmission of infectious material to other patients. Once infection is suspected or established; however, implementation of effective control strategies is important to limit the spread of infection within a healthcare environment. This chapter outlines the basic tenets of infection prevention, principles of isolation precautions and control measures, and elements for a successful infection control and prevention program.

Public reporting of health care-associated surveillance data: recommendations from the healthcare infection control practices advisory committee.

Health care-associated infection (HAI) rates are used as measures of a health care facility's quality of patient care. Recently, these outcomes have been used to publicly rank quality efforts and determine facility reimbursement. The value of comparing HAI rates among health care facilities is limited by many factors inherent to HAI surveillance, and incentives that reward low HAI rates can lead to unintended consequences that can compromise medical care surveillance efforts, such as the use of clinical adjudication panels to veto events that meet HAI surveillance definitions.The Healthcare Infection Control Practices Advisory Committee, a federal advisory committee that provides advice and guidance to the Centers for Disease Control and Prevention (CDC) and the Secretary of the Department of Health and Human Services about strategies for surveillance, prevention, and control of HAIs, assessed the challenges associated with using HAI surveillance data for external quality reporting, including the unintended consequences of clinician veto and clinical adjudication panels. Discussions with stakeholder liaisons and committee members were then used to formulate recommended standards for the use of HAI surveillance data for external facility assessment to ensure valid comparisons and to provide as level a playing field as possible.The final recommendations advocate for consistent, objective, and independent application of CDC HAI definitions with concomitant validation of HAIs and surveillance processes. The use of clinician veto and adjudication is discouraged.