Outbreak of postpartum group a Streptococcus infections on a labor and delivery unit.

A healthcare-associated group A Streptococcus outbreak involving six patients, four healthcare workers, and one household contact occurred in the labor and delivery unit of an academic medical center. Isolates were highly related by whole genome sequencing. Infection prevention measures, healthcare worker screening, and chemoprophylaxis of those colonized halted further transmission.

Pharmacist involvement in blood culture follow up for patients discharged from the emergency department.

STUDY OBJECTIVE: This study evaluates the time to attempted patient contact for positive blood cultures in patients discharged from the Emergency Department (ED) resulting when an Emergency Medicine (EM) pharmacist is on-duty compared to off-duty. METHODS: This single center, retrospective study included patients who were discharged from the ED and had subsequent positive blood cultures. Blood cultures were reviewed utilizing an algorithm previously approved and implemented by an interdisciplinary team in 2016. Standard practice was for the microbiology lab to notify the ED charge nurse of the positive blood culture, however, the algorithm placed the pharmacist as the responsible reviewer when on duty, leaving charge nurses and physicians as the responsible reviewers when a pharmacist was off duty and not on site. The primary outcome was time from ED notification of the positive gram stain of the blood culture to first attempted patient contact; we compared this outcome for cultures resulting when an EM pharmacist was on duty to those resulting when an EM pharmacist was off duty. Despite being off duty, a pharmacist may have reviewed these cultures if they remained unaddressed when the pharmacist returned on-site. In this case, the blood culture review was included in the off-duty cohort. Secondary outcomes included evaluation for appropriateness of the recommendation made to the patient during contact, 30-day infection-related readmission rates, patient's adherence to the recommendations, and barriers to patient contact. An infectious disease attending physician independently reviewed cases where the algorithm was not followed. RESULTS: A total of 127 patients identified by a query of our institution's database were screened against inclusion/exclusion criteria and 56 were excluded, leaving 71 patients for final analysis (54 and 17 in the on- and off-duty cohorts, respectively). Baseline demographics with respect to sex, age and risk factors for bacteremia were not different between groups, except there were more immunocompromised patients in the on-duty cohort (35.2%) compared to off-duty cohort (5.9%) [p = 0.01]. Median [IQR] time to first attempted patient contact was significantly shorter in the on-duty cohort at 0.8 h [0.4-2.8] vs 5.6 h [1.4-11.7] (p = 0.025). A pharmacist acted upon 93% of all cultures, including several resulting during off-duty hours. Secondary outcomes did not differ. Fourteen (25.9%) of on-duty cultures and six (35.3%) of off-duty cultures were deemed contaminants. Two recommendations in the off-duty group were inappropriate based on the infectious disease attending physician review. The lack of active voicemail was the main barrier to contacting a patient. CONCLUSIONS: In patients discharged from the ED with subsequent positive blood cultures, time to attempted patient contact was significantly shorter when a pharmacist was on-duty. Our data emphasizes the importance of having a standardized practice in place to optimize ED patient care and outcomes and the benefit of a pharmacist's involvement in the process.

Experiential learning and mentorship as the foundation of clinical epidemiology training during infectious diseases fellowship: Response to "Training infectious diseases fellows for a new era of hospital epidemiology".

A specific, clinical-epidemiology, month-long rotation for all infectious disease fellows as well as a 1-year subspecialty track provides education in clinical epidemiology during infectious disease fellowship training. We describe the educational process created at our institution to provide this training.

Evaluation of central line salvage for mucosal barrier injury laboratory-confirmed bloodstream infection (MBI-LCBI) management practices in patients with hematologic malignancies.

Patients with underlying hematologic malignancy (HM) and/or allogeneic hematopoietic stem cell transplant (HCT) recipients are at risk for mucosal barrier injury laboratory-confirmed bloodstream infection (MBI-LCBI) secondary to bacterial translocation. There is sparse data comparing MBI-LCBI management practices, in particular central venous catheter (CVC) salvage versus removal. We created a 22-item poll of Infectious Disease specialists at major US cancer centers on management controversies. Response rate was 44% (31/70). CVC salvage was a common practice among 87.5%. This was followed by a single center retrospective study (2017-2019) comparing outcomes related to CVC practices. We identified 115 patients, 52% (60/115) admitted for chemotherapy and 33% (38/115) for allogeneic HCT. The majority of patients (78%, 90/115) had their CVC removed. There was no difference in 72 h defervescence, microbiological clearance, in-hospital mortality, and 90-day recurrent infection between CVC salvage versus removal. CVC salvage is a safe approach in certain clinical scenarios.

Impaired neutralizing antibody response to COVID-19 mRNA vaccines in cancer patients.

There is currently a critical need to determine the efficacy of SARS-CoV-2 vaccination for immunocompromised patients. In this study, we determined the neutralizing antibody response in 160 cancer patients diagnosed with chronic lymphocytic leukemia (CLL), lung cancer, breast cancer, and various non-Hodgkin's lymphomas (NHL), after they received two doses of mRNA vaccines. Serum from 46 mRNA vaccinated health care workers (HCWs) served as healthy controls. We discovered that (1) cancer patients exhibited reduced neutralizing antibody titer (NT50) compared to HCWs; (2) CLL and NHL patients exhibited the lowest NT50 levels, with 50-60% of them below the detection limit; (3) mean NT50 levels in patients with CLL and NHL was ~2.6 fold lower than those with solid tumors; and (4) cancer patients who received anti-B cell therapy exhibited significantly reduced NT50 levels. Our results demonstrate an urgent need for novel immunization strategies for cancer patients against SARS-CoV-2, particularly those with hematological cancers and those on anti-B cell therapies.

Impaired Neutralizing Antibody Response to COVID-19 mRNA Vaccines in Cancer Patients.

There is currently a critical need to determine the efficacy of SARS-CoV-2 vaccination for immunocompromised patients. In this study, we determined the neutralizing antibody response in 160 cancer patients diagnosed with chronic lymphocytic leukemia (CLL), lung cancer, breast cancer, and various non-Hodgkin's lymphomas (NHL), after they received two doses of mRNA vaccines. Serum from 46 mRNA vaccinated health care workers (HCWs) served as healthy controls. We discovered that (1) cancer patients exhibited reduced neutralizing antibody titer (NT 50 ) compared to HCWs; (2) CLL and NHL patients exhibited the lowest NT 50 levels, with 50-60% of them below the detection limit; (3) mean NT 50 levels in patients with CLL and NHL was ∼2.6 fold lower than those with solid tumors; and (4) cancer patients who received anti-B cell therapy exhibited significantly reduced NT 50 levels. Our results demonstrate an urgent need for novel immunization strategies for cancer patients against SARS-CoV-2, particularly those with hematological cancers and those on anti-B cell therapies.

Fluoroquinolone Prophylaxis in Autologous Stem Cell Transplantation: Worthy of a Second Look.

Prophylaxis with fluoroquinolone (FQ) for patients undergoing autologous stem cell transplantation (ASCT) remains controversial. We performed a retrospective review of patients undergoing ASCT with and without bacterial prophylaxis to compare endpoints of interest. In accordance with institutional policy, patients undergoing ASCT for multiple myeloma routinely receive levofloxacin prophylaxis during their period of neutropenia, whereas patients undergoing the ASCT for lymphoma do not. We retrospectively examined patients with multiple myeloma (MM) or lymphoma undergoing ASCT between July 2015 and July 2018 for evidence of positive blood cultures. A total of 172 patients underwent ASCT for lymphoma and 343 underwent ASCT for MM. The 2 cohorts were similar in terms of baseline characteristics. Almost 20% (35 of 172) of the patients with lymphoma and 5.2% (18 of 342) of those with MM had a bloodstream infection (BSI). BSI occurred an average of 2 days earlier in patients with lymphoma compared with patients with MM (day +5 versus day +7; P = .0003). The 2 cohorts recovered absolute neutrophil count at the same time. Hospital length of stay was 2 days shorter for patients with MM (median, 20 days versus 18 days; P = .01). The majority of the organisms were gram-negative in both cohorts. Of the organisms commonly tested for FQ sensitivity, only 1 of 25 was resistant in the lymphoma cohort, compared with 7 of 9 in the MM cohort (P < .0001), with 4 being multidrug resistant. The odds of developing a BSI were 4.6 times greater in the lymphoma cohort compared with the MM cohort (95% confidence interval [CI], 2.52 to 8.40; P < .0001). In total, 23 of 172 patients with lymphoma (13.4%) and 28 of 342 patients with MM (8.2%) developed Clostridium difficile infection (odds ratio, 1.73; 95% CI, .96 to 3.11; P = .066). Two infection-related deaths occurred in the MM cohort. Our data indicate that FQ prophylaxis reduces the risk of BSI in patients undergoing ASCT but increases the incidence of resistant organisms. We recommend routine antimicrobial prophylaxis in patients undergoing ASCT to reduce the risk of BSI, along with a systematic and regular review of outcomes.

Prospective evaluation of peripherally inserted central catheter complications in both inpatient and outpatient settings.

We describe a prospective observational cohort (N = 187) to evaluate peripherally inserted central catheter line complications concurrently from the time of placement until removal. A significantly higher percentage of patients who experienced intraluminal thrombosis were receiving total parenteral nutrition (P ≤ .001) and had a dual lumen catheter (P = .01). Among patients with a confirmed or suspected infection, a significantly higher proportion received total parenteral nutrition (P = .01), had dual-lumen catheters (P = .04), and were neutropenic (P = .04).