Real-Time Investigation of a Large Nosocomial Influenza A Outbreak Informed by Genomic Epidemiology.

BACKGROUND: Nosocomial respiratory virus outbreaks represent serious public health challenges. Rapid and precise identification of cases and tracing of transmission chains is critical to end outbreaks and to inform prevention measures. METHODS: We combined conventional surveillance with influenza A virus (IAV) genome sequencing to identify and contain a large IAV outbreak in a metropolitan healthcare system. A total of 381 individuals, including 91 inpatients and 290 healthcare workers (HCWs), were included in the investigation. RESULTS: During a 12-day period in early 2019, infection preventionists identified 89 HCWs and 18 inpatients as cases of influenza-like illness (ILI), using an amended definition without the requirement for fever. Sequencing of IAV genomes from available nasopharyngeal specimens identified 66 individuals infected with a nearly identical strain of influenza A H1N1pdm09 (43 HCWs, 17 inpatients, and 6 with unspecified affiliation). All HCWs infected with the outbreak strain had received the seasonal influenza virus vaccination. Characterization of 5 representative outbreak viral isolates did not show antigenic drift. In conjunction with IAV genome sequencing, mining of electronic records pinpointed the origin of the outbreak as a single patient and a few interactions in the emergency department that occurred 1 day prior to the index ILI cluster. CONCLUSIONS: We used precision surveillance to delineate a large nosocomial IAV outbreak, mapping the source of the outbreak to a single patient rather than HCWs as initially assumed based on conventional epidemiology. These findings have important ramifications for more-effective prevention strategies to curb nosocomial respiratory virus outbreaks.

Putative invasive pulmonary aspergillosis in critically ill patients with COVID-19: An observational study from New York City.

BACKGROUND: Critically ill patients with coronavirus disease-2019 (COVID-19) are at the theoretical risk of invasive pulmonary aspergillosis (IPA) due to known risk factors. PATIENTS/METHODS: We aimed to describe the clinical features of COVID-19-associated pulmonary aspergillosis at a single centre in New York City. We performed a retrospective chart review of all patients with COVID-19 with Aspergillus isolated from respiratory cultures. RESULTS: A total of seven patients with COVID-19 who had one or more positive respiratory cultures for Aspergillus fumigatus were identified, all of whom were mechanically ventilated in the ICU. Four patients were classified as putative IPA. The median age was 79 years, and all patients were male. The patients had been mechanically ventilated for a mean of 6.8 days (range: 1-14 days) before Aspergillus isolation. Serum galactomannan level was positive for only one patient. The majority of our cases received much higher doses of glucocorticoids than the dosage with a proven mortality benefit. All four patients died. CONCLUSIONS: Vigilance for secondary fungal infections will be needed to reduce adverse outcomes in critically ill patients with COVID-19.

Molecular Detection of Candida auris Using DiaSorin Molecular Simplexa® Detection Kit: A Diagnostic Performance Evaluation.

Candida auris is a globally emerging fungal pathogen that is associated with healthcare-related infections. The accurate and rapid detection of C. auris is crucial for effective infection prevention, control, and patient management. This study aimed to validate the analytical and diagnostic performance of the DiaSorin Molecular C. auris Detection Kit. The analytical specificity, sensitivity, and reproducibility of the assay were evaluated. The limit of detection (LOD) was determined to be 266 CFU/µL using the ZeptoMetrix Candida auris Z485 strain and standard calibration curves. The assay demonstrated high analytical specificity and showed no amplification against a diverse panel of bacteria and fungi. Clinical validation was conducted using deidentified residual axillary/groin surveillance culture specimens from C. auris culture-positive and culture-negative patients. The DiaSorin Molecular Detection Kit exhibited 100% agreement in sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) when compared to cultures coupled with MALDI-TOF identification. Intra- and inter-reproducibility testing demonstrated consistent and reliable diagnostic performance. This validated assay offers rapid and accurate detection of C. auris, facilitating timely implementation of infection control measures and appropriate patient care. The DiaSorin Molecular C. auris Detection Kit has the potential to aid in controlling the outbreaks caused by this emerging fungal pathogen. Providing a reliable diagnostic tool can contribute to the effective management and containment of C. auris infections in healthcare settings and ultimately improve patient outcomes.

Multisociety statement on coronavirus disease 2019 (COVID-19) vaccination as a condition of employment for healthcare personnel.

This consensus statement by the Society for Healthcare Epidemiology of America (SHEA) and the Society for Post-Acute and Long-Term Care Medicine (AMDA), the Association for Professionals in Epidemiology and Infection Control (APIC), the HIV Medicine Association (HIVMA), the Infectious Diseases Society of America (IDSA), the Pediatric Infectious Diseases Society (PIDS), and the Society of Infectious Diseases Pharmacists (SIDP) recommends that coronavirus disease 2019 (COVID-19) vaccination should be a condition of employment for all healthcare personnel in facilities in the United States. Exemptions from this policy apply to those with medical contraindications to all COVID-19 vaccines available in the United States and other exemptions as specified by federal or state law. The consensus statement also supports COVID-19 vaccination of nonemployees functioning at a healthcare facility (eg, students, contract workers, volunteers, etc).

Disruption of the Body Temperature Circadian Rhythm in Hospitalized Patients.

BACKGROUND: Dysregulation of the circadian rhythm is linked to immune response deficiencies. Diurnal temperature variation-a surrogate for the circadian rhythm, exists in humans, yet its preservation during illness is not well understood. MATERIALS AND METHODS: Temperatures measured within one-half hour of 8 am, 12 pm, 4 pm, 8 pm, 12 am, and 4 am from 16,245 hospitalized patients were statistically analyzed. RESULTS: Although we found a diurnal pattern when analyzing the ensemble of temperatures from all patients, stratified by measurement site, the trough-to-peak difference was only 0.2°F, while that for healthy volunteers had been in the 0.5°F to 1.9°F range. The peaks occurred at 8 pm for all patients, regardless of age or sex, which is similar to healthy people. However, the troughs were shifted to later times compared with the 6 am in healthy people-for young patients (age 20-30 years) the trough was at 8 am and for elderly patients (age 70-80 years), at 12 pm, again regardless of patients' sex. Analysis of individual patients showed that less than 20% of patients exhibited diurnal variation and among those showing variation, the trend was present only on the minority of hospitalization days. The presence or absence of an infectious process or fever did not influence the proportion of patients showing diurnal variation. CONCLUSIONS: Hospitalization is associated with disruption in the circadian rhythm as reflected by patients' body temperature. Since abnormality in body temperature is known to affect patient outcomes, an understanding of the diurnal cycle during hospitalization is the first step towards devising approaches to re-establish the circadian rhythm.

Utilizing technology to enhance screening for highly infectious diseases.

Quick identification and isolation of patients with highly infectious diseases is extremely important in healthcare settings today. This study focused on the creation of a digital screening tool using a free and publicly available digital survey application to screen patients during a measles outbreak in New York City. The results indicate that digital tools are an effective alternative to paper tools due to their ease of use and remote compliance monitoring capabilities.

Comprehensive Analysis of Temperature in Hospitalized Patients.

BACKGROUND: Human body temperature is believed to be linked to clinical diagnoses. However, most of the available data stems from healthy individuals, with no large-scale studies addressing body temperature in the inpatient setting, which is the focus of our study. MATERIALS AND METHODS: This is a retrospective analysis of a total of 695,107 temperature readings from 16,245 patients hospitalized over a 1-year period at a tertiary medical center, ages 0-105 years, 50% female, with rectal, monotherm, axillary, oral, temporal and tympanic measurement sites. The average temperature (Tave) per patient and per measurement site was used in all calculations. Descriptive statistics, Student's t-test, and Pearson's correlation were used, where appropriate, with statistical significance set at P < 0.05. RESULTS: Tave from all measurement sites was 98.13 ± 0.48(SD)F(36.74 ± 0.27°C). Tave varied by the site of measurement, in decreasing order highest-to-lowest being rectal, monotherm, axillary, oral, temporal, and tympanic, all of which were higher than the available reported averages for healthy subjects. Tave decreased as patients' age increased. There was only slight and likely clinically insignificant difference between the sexes. There were differences in Tave between the intensive care units (ICUs), listed from highest-to-lowest: Neuro ICU, Pediatric ICU, Surgical ICU, Cardiac ICU and Medical ICU. However, there was no difference between all ICU and non-ICU patients. CONCLUSIONS: Our inpatient data demonstrate that previously identified body temperature trends among healthy subjects are preserved, to an extent, in the inpatient setting. To our knowledge, ours is the first study that evaluates the temperatures of all hospitalized patients at a large tertiary medical center.

Normal Body Temperature: A Systematic Review.

PubMed was searched from 1935 to December 2017 with a variety of search phrases among article titles. The references of the identified manuscripts were then manually searched. The inclusion criteria were as follows: (1) the paper presented data on measured normal body temperature of healthy human subjects ages 18 and older, (2) a prospective design was used, and (3) the paper was written in or translated into the English language. Thirty-six articles met the inclusion criteria. This comprised 9227 measurement sites from 7636 subjects. The calculated ranges (mean ± 2 standard deviations) were 36.32-37.76 (rectal), 35.76-37.52 (tympanic), 35.61-37.61 (urine), 35.73-37.41 (oral), and 35.01-36.93 (axillary). Older adults (age ≥60) had lower temperature than younger adults (age <60) by 0.23°C, on average. There was only insignificant gender difference. Compared with the currently established reference point for normothermia of 36.8°C, our means are slightly lower but the difference likely has no physiological importance. We conclude that the most important patient factors remain site of measurement and patient's age.

NMR metabolomics of cerebrospinal fluid differentiates inflammatory diseases of the central nervous system.

BACKGROUND: Myriad infectious and noninfectious causes of encephalomyelitis (EM) have similar clinical manifestations, presenting serious challenges to diagnosis and treatment. Metabolomics of cerebrospinal fluid (CSF) was explored as a method of differentiating among neurological diseases causing EM using a single CSF sample. METHODOLOGY/PRINCIPAL FINDINGS: 1H NMR metabolomics was applied to CSF samples from 27 patients with a laboratory-confirmed disease, including Lyme disease or West Nile Virus meningoencephalitis, multiple sclerosis, rabies, or Histoplasma meningitis, and 25 controls. Cluster analyses distinguished samples by infection status and moderately by pathogen, with shared and differentiating metabolite patterns observed among diseases. CART analysis predicted infection status with 100% sensitivity and 93% specificity. CONCLUSIONS/SIGNIFICANCE: These preliminary results suggest the potential utility of CSF metabolomics as a rapid screening test to enhance diagnostic accuracies and improve patient outcomes.

Streptococcus anginosus Group Bacterial Infections.

BACKGROUND: The Streptococcus anginosus group (SAG) causes a variety of infections in adults. To better understand the burden of SAG infections and their associated morbidity and mortality, we conducted a retrospective analysis of these infections in adults at a tertiary care center. METHODS: A retrospective review of all cultures positive for SAG in adults and a corresponding review of the patients' medical records were conducted at a tertiary care facility in central New York. Patients with these cultures during the period of January 2007-December 2011 were included. Demographic data, area of residence, clinical features and underlying illnesses, site of infection, length of hospital stay, antibiotic susceptibility and antibiotic therapy were recorded and analyzed. RESULTS: There were 332 SAG cases; most patients were males (59%), mean age of 47 years and 84% lived in urban areas. Overall mortality was 3% with underlying conditions common such as diabetes (25%), hypertension (31%) and immunodeficiency (22%). Most of the infections were related to skin and soft tissue (72%) and polymicrobial (70%) with gram-negative anaerobes and Enterobacteriaceae commonly isolated with SAG. CONCLUSIONS: We present the largest study, thus far, reviewing the clinical presentation, management and outcome of infections due to the SAG of organisms. Notable findings from our study are the low mortality associated with SAG infection, and the propensity to present as a skin and tissue and polymicrobial infection. Our findings will assist clinicians in managing patients with SAG infections and recognizing that S anginosus may be one of several organisms responsible for infection.

Klebsiella pneumoniae Liver Abscess: An Emerging Disease.

Most of the cases of Klebsiella pneumoniae liver abscess reported early on were from Asia, predominantly Taiwan, with a significant number of patients being middle aged diabetic men, and developing metastatic complications, especially endophthalmitis. The entity is now being increasingly recognized in the United States. In this article, the authors review those reported cases, and also the literature regarding the pathophysiology of this intriguing syndrome.

Role of procalcitonin in guiding antibiotic therapy.

PURPOSE: The role of procalcitonin in guiding antibiotic therapy is reviewed. SUMMARY: Procalcitonin is a prohormone for calcitonin, which is secreted by the parafollicular cells of the thyroid gland. The biological activity of procalcitonin is significantly different from calcitonin and is believed to be part of the complex inflammatory cascade of the immune system. Procalcitonin has been shown to be elevated in bacterial infections but not in viral infections or other inflammatory conditions. The first published study that suggested that procalcitonin levels increased in the presence of bacterial infection was conducted in France in the early 1990s. Numerous studies have been conducted using procalcitonin-guided therapy to reduce antibiotic use. These studies were performed in one of three clinical settings: outpatient primary care (two multicenter, noninferiority studies of patients with upper- and lower-respiratory-tract infections), emergency room and inpatient (five studies in patients with chronic obstructive pulmonary disease, exacerbation, bronchitis, or community-acquired pneumonia), and the intensive care unit (ICU) (two studies in medical ICU patients and two in postoperative ICU patients with infection or sepsis). Based on the findings of these studies, a cutoff value of 0.25 µg/L in non-ICU patients or of 0.5 µg/L in ICU patients seems appropriate for making a decision about the initiation and discontinuation of antibiotic therapy. In patients with a significantly elevated baseline procalcitonin level, a subsequent drop of >80% appears to be reasonable for discontinuing antibiotics. CONCLUSION: Published evidence supports the use of procalcitonin as a biomarker of bacterial infection that can be used to reduce antibiotic exposure.