Examination of the Clostridioides (Clostridium) difficile VanZ ortholog, CD1240.

Clostridioides (Clostridium) difficile causes severe diarrheal disease that is directly associated with antibiotic use and resistance. Although C. difficile demonstrates intrinsic resistance to many antimicrobials, few genetic mechanisms of resistance have been characterized in this pathogen. In this study, we investigated the putative resistance factor, CD1240 (VanZ1), an ortholog of the teicoplanin resistance factor, VanZ, of Enterococcus faecium. In C. difficile, the vanZ1 gene is located within the skin element of the sporulation factor σK, which is excised from the mother cell compartment during sporulation. This unique localization enabled us to create a vanZ1 deletion mutant by inducing excision of the skin element. The Δskin mutant exhibited moderately decreased resistance to teicoplanin and had small effects on growth in some other cell-surface antimicrobials tested. Examination of vanZ1 expression revealed induction of vanZ1 transcription by the antimicrobial peptide LL-37; however, LL-37 resistance was not impacted by VanZ1, and none of the other tested antimicrobials induced vanZ1 expression. Further, expression of vanZ1 via an inducible promoter in the Δskin mutant restored growth in teicoplanin. These results demonstrate that like the E. faecium VanZ, C. difficile VanZ1 contributes to low-level teicoplanin resistance through an undefined mechanism.

Implementing team-based telemedicine workflows in safety-net primary care.

OBJECTIVES: Challenges in implementing telemedicine disproportionately affect patients served in safety-net settings. Few studies have elucidated pragmatic, team-based strategies for successful telemedicine implementation in primary care, especially with a safety-net population. STUDY DESIGN: We conducted in-depth, semistructured qualitative interviews with primary care clinicians and staff in a large urban safety-net health care system on the facilitators, challenges, and impact of implementing team workflows for synchronous telemedicine video and audio-only visits. METHODS: Interviews were analyzed using modified grounded theory with multistage coding. Common themes were identified and reviewed to describe within-group and between-group variations. We used the Practical, Robust Implementation Sustainability Model framework to organize the final themes with an implementation science lens. RESULTS: Four themes emerged from 11 interviews: (1) having a dedicated individual preparing patients for video visits is a prerequisite for the successful introduction of video visits to patients with limited digital literacy; (2) health care maintenance during video and audio-only visits benefits from standardized workflows and communication; (3) the increased flexibility and accessibility of telemedicine visits were perceived benefits to patient care, despite barriers for subsets of patients; and (4) telemedicine visits generally have a positive impact on work experience for clinicians and staff due to increased efficiency, despite audio-only visits feeling less engaging. CONCLUSIONS: Understanding how to strategically use team-based workflows to expand video visit access while ensuring care quality of all telemedicine visits will allow primary care practices to maximize telemedicine's benefits to patients in the safety-net setting.