Prescriber Behavior in Clostridioides difficile Testing: A 3-Hospital Diagnostic Stewardship Intervention.

Computerized clinical decision support (CCDS) significantly reduced Clostridioides difficile testing at 3 hospitals; from 12.6 to 9.5, from 10.1 to 6.4, and from 14.0 to 9.6 average weekly tests per 1000 inpatient days. There were no related adverse events. Senior providers were more likely than interns or residents to follow CCDS.

Pleural fluid secondary to pulmonary cryptococcal infection: a case report and review of the literature.

BACKGROUND: Pulmonary Cryptococcosis (PC) is diagnosed with increasing incidence in recent years, but it does not commonly involve the pleural space. Here, we report a HIV-negative case with advanced stage IIIB non-small cell lung cancer (NSCLC) treated with radiation therapy presented with dyspnea, a new PET-positive lung mass and bilateral pleural effusion suspecting progressive cancer. However, the patient has been diagnosed as pulmonary cryptococcal infection and successfully treated with oral fluconazole therapy. CASE PRESENTATION: A 77-year-old male with advanced stage non-small cell lung cancer treated with combined chemo-radiation therapy who presented with progressive dyspnea, a new PET-positive left lower lobe lung mass and bilateral pleural effusions. Initial diagnostic thoracentesis and bronchoscopy yielded no cancer, but instead found yeast forms consistent with cryptococcal organisms in the transbronchial biopsies of the left lower lobe lung mass. Subsequent to this, the previously collected pleural fluid culture showed growth of Cryptococcus neoformans. The same sample of pleural effusion was tested and was found to be positive for crytococcal antigen (CrAg) by a lateral flow assay (LFA). The patient has been treated with oral fluconazole therapy resulting in gradual resolution of the nodular infiltrates. CONCLUSION: PC should be considered in immunosuppressed cancer patients. Additionally, concomitant pleural involvement in pulmonary cryptococcal infections may occur. The incidence of false positive 18FDG-PET scans in granulomatous infections and the use of CrAg testing in pleural fluid to aid in diagnosis are reviewed.

Cerebrospinal fluid (1,3)-ß-D-glucan detection as an aid for diagnosis of iatrogenic fungal meningitis.

This case series highlights our experience with use of the Fungitell assay for quantifying (1,3)-ß-d-glucan in cerebrospinal fluid during the current U.S. outbreak of fungal meningitis related to contaminated methylprednisolone acetate. This test may prove a useful adjunct in diagnosis and management of exposed patients.

Iatrogenic Exserohilum infection of the central nervous system: mycological identification and histopathological findings.

An outbreak of fungal infections has been identified in patients who received epidural injections of methylprednisolone acetate that was contaminated with environmental molds. In this report, we present the mycological and histopathological findings in an index case of Exserohilum meningitis and vasculitis in an immunocompetent patient, who received a cervical spine epidural steroid injection for chronic neck pain 1 week before the onset of fulminant meningitis with subsequent multiple brain and spinal cord infarcts. The fungus was recovered from two separate cerebrospinal fluid specimens collected before initiation of antifungal therapy and at autopsy on standard bacterial and fungal culture media. The mold was identified phenotypically as Exserohilum species. DNA sequencing targeting the internal transcribed spacer region and D1/D2 region of 28S ribosomal DNA enabled further speciation as E. rostratum. Gross examination at autopsy revealed moderate brain edema with bilateral uncal herniation and a ventriculostomy tract to the third ventricle. The brainstem, cerebellum, and right orbitofrontal cortex were soft and friable, along with hemorrhages in the cerebellar vermis and thalamus. Microscopic examination demonstrated numerous fungi with septate hyphae invading blood vessel walls and inducing acute necrotizing inflammation. The leptomeninges were diffusely infiltrated by mixed inflammatory cells along with scattered foci of fungal elements. This is the first report of iatrogenic E. rostratum meningitis in humans. This report describes the microbiological procedures and histopathological features for the identification of E. rostratum (a pigmented vascularly invasive fungi), the cause of a current nationwide outbreak of fatal fungal meningitis.

The role of simulation-based training in healthcare-associated infection (HAI) prevention.

Objectives: To perform a review of the literature on the role of simulation-based training (SBT) in healthcare-associated infection (HAI) prevention and to highlight the importance of SBT as an educational tool in infection prevention. Methods: We reviewed English language publications from PubMed to select original articles that utilized SBT as the primary mode of education for infection prevention efforts in acute-care hospitals. Results: Overall, 27 publications utilized SBT as primary mode of education for HAI prevention in acute-care hospitals. Training included the following: hand hygiene in 3 studies (11%), standard precaution in 1 study (4%), disaster preparedness in 4 studies (15%), central-line-associated blood stream infection (CLABSI) prevention in 14 studies (52%), catheter-associated urinary tract infection (CAUTI) prevention in 2 studies (7%), surgical site infection prevention in 2 studies (7%), and ventilatory associated pneumonia prevention in 1 study (4%). SBT improved learner's sense of competence and confidence, increased knowledge and compliance in infection prevention measures, decreased HAI rates, and reduced healthcare costs. Conclusion: SBT can function as a teaching tool in day-to-day infection prevention efforts as well as in disaster preparedness. SBT is underutilized in infection prevention but can serve as a crucial educational tool.

Coronavirus disease 2019 (COVID-19) personal protective equipment training: Using simulation-based training to prevent healthcare-associated infection.

In this pre- and postintervention study, we demonstrate the feasibility and effectiveness of comprehensive simulation-based personal protective equipment (PPE) training amid the COVID-19 pandemic. With rapid-cycle, deliberate practice feedback, simulation-based training can improve the learners' sense of confidence and security while standardizing PPE protocols.

Factors associated with in-hospital mortality among critically ill surgical patients with multidrug-resistant Gram-negative infections.

PURPOSE: Multidrug-resistant (MDR) Gram-negative infection increases risk of mortality, other complications, and costs. The objective of this study was to determine the prevalence of and identify factors associated with in-hospital mortality among critically ill surgical patients. MATERIALS AND METHODS: This case-control study included critically ill surgical patients from 2011 to 2014 who had a carbapenem-resistant Enterobacteriaceae (CRE), MDR P. aeruginosa, or MDR Acinetobacter spp. infection. Characteristics of patients surviving to hospital discharge were compared to those of non-survivors. RESULTS: Sixty-two patients were included. Of these, 21 (33.9%) died prior to discharge. Vasopressors and mechanical ventilation prior to index culture were more common in non-survivors vs. survivors (76.2% vs. 46.3%, p=0.03; and 100% vs. 63.4%, p=0.001). ICU and hospital LOS prior to index culture was longer in non-survivors vs. survivors (median 19 vs. 4days, p=0.001; and median 25 vs. 7days, p=0.009). In multivariate logistic regression, achievement of source control was the only variable associated with decreased in-hospital mortality [0.04 (95% CI 0.003-0.52); p=0.01]. CONCLUSIONS: MDR Gram-negative infection is associated with significant in-hospital mortality among critically ill surgical patients. Source control, along with prior ICU LOS, mechanical ventilation status, vasopressor use, and definitive antibiotic choice, are important predictors of survival in this population.

Saccharomyces boulardii probiotic-associated fungemia: questioning the safety of this preventive probiotic's use.

We report a case of fungemia in an immunocompetent patient after administration of probiotic containing Saccharomyces boulardii. We demonstrated the strain relatedness of the yeast from the probiotic capsule and the yeast causing fungal infection using genomic and proteomic typing methods. Our study questions the safety of this preventative biotherapy.