Syndemic of Substance Abuse, Depression, and Type 2 Diabetes and Their Association with Retention in Care Among People Living with HIV.

Substance abuse (SA), depression, and type 2 diabetes (DM2) often co-occur among people living with HIV (PLHIV). Guided by a syndemic framework, this cross-sectional retrospective study examined the cumulative and interaction effects of SA, depression, and DM2 on retention in HIV care (RIC) among 621 PLHIV receiving medical care in central Pennsylvania. We performed logistic regression analysis to test the associations between SA, depression, and DM2 and RIC. To test the "syndemic" model, we assessed additive and multiplicative interactions. In an unadjusted model, a dose-response pattern between the syndemic index (total number of health conditions) and RIC was detected (OR for 1 syndemic factor vs. none: 1.01, 95% CI: 0.69-1.47; 2 syndemic factors: 1.59, 0.89-2.84; 3 syndemic factors: 1.62, 0.44-5.94), but no group reached statistical significance. Interactions on both additive and multiplicative scales were not significant, demonstrating no syndemic effect of SA, depression, and DM2 on RIC among our study sample. Our findings highlight that comorbid conditions may, in some populations, facilitate RIC rather than act as barriers, which may be due to higher levels of engagement with medical care.

Long-term follow-up of post-cardiac surgery Mycobacterium chimaera infections: A 5-center case series.

OBJECTIVES: In multiple countries, endovascular/disseminated Mycobacterium chimaera infections have occurred in post-cardiac surgery patients in association with contaminated, widely-distributed cardiac bypass heater-cooler devices. To contribute to long-term characterization of this recently recognized infection, we describe the clinical course of 28 patients with 3-7 years of follow-up for survivors. METHODS: Identified at five hospitals in the United States 2010-2016, post-cardiac surgery patients in the cohort had growth of Mycobacterium avium complex (MAC)/M. chimaera from a sterile site or surgical wound, or a clinically compatible febrile illness with granulomatous inflammation on biopsy. Case follow-up was conducted in May 2019. RESULTS: Of 28 patients, infection appeared to be localized to the sternum in four patients. Among 18 with endovascular/disseminated infection who received combination anti-mycobacterial treatment and had sufficient follow-up, 39% appeared to have controlled infection (>12 months), 56% died, and one patient is alive with relapsed bacteremia. While the number of patients is small and interpretation is limited, four (67%) of six patients who had cardiac prosthesis removal/replacement appeared to have controlled infection compared to three (25%) of 12 with retained cardiac prosthesis (p >0.14; Fisher's exact test). CONCLUSIONS: Given poor response to treatment and potential for delayed relapses, post-cardiac surgery M. chimaera infection warrants aggressive treatment and long-term monitoring.

Improving Outcomes in Patients With Sepsis.

Sepsis mortality may be improved by early recognition and appropriate treatment based on evidence-based guidelines. An intervention was developed that focused on earlier identification of sepsis, early antimicrobial administration, and an educational program that was disseminated throughout all hospital units and services. There were 1331 patients with sepsis during the intervention period and 1401 patients with sepsis during the control period. After controlling for expected mortality, patients in the intervention period had 30% lower odds of dying (odds ratio = 0.70, 95% confidence interval [CI] = 0.57 to 0.84). They also had 1.07 fewer days on average in the intensive care unit (95% CI = -1.98 to -0.16), 2.15 fewer hospital days (95% CI = -3.45 to -0.86), and incurred on average $1949 less in hospital costs, although the effect on costs was not statistically significant. Continued incremental improvement and sustainment is anticipated through organizational oversight, continued education, and initiation of an automated electronic sepsis alert function.

Risk of methicillin-resistant Staphylococcus aureus surgical site infection in patients with nasal MRSA colonization.

BACKGROUND: Patients colonized with methicillin-resistant Staphylococcus aureus (MRSA) are at increased risk for invasive infection compared with noncolonized patients; however, the magnitude of risk for MRSA surgical site infection (SSI) is unclear. To aid in planning of infection prevention strategies, we sought to assess the incidence of MRSA SSI in MRSA carriers. METHODS: We conducted a retrospective cohort study at our tertiary care center of inpatients who underwent MRSA polymerase chain reaction (PCR) screen of the nares within 30 days before a National Healthcare Safety Network principal procedure between April 2008 and July 2010. RESULTS: The rate of MRSA SSI was 1.86% in the MRSA PCR-positive group (n = 431) and 0.20% in the MRSA PCR-negative group (n = 9432). Multivariate analysis identified MRSA PCR-positive status as an independent risk factor for MRSA SSI (odds ratio, 9.20; 95% confidence interval, 3.81-20.47; P < .0001); other risk factors included duration of surgery ≥137 minutes, American Society of Anesthesiologists score ≥3, and abdominal surgery. CONCLUSIONS: Surgical patients with a positive nasal MRSA PCR screen had a 9-fold greater odds of developing a subsequent MRSA SSI compared with patients with a negative nasal MRSA PCR screen. The incidence of MRSA SSI in PCR-positive patients was low (1.86%), however, and identifying subsets of patients at greatest risk for SSI may help target decolonization and other interventions.

Household risk factors for colonization with multidrug-resistant Staphylococcus aureus isolates.

Antimicrobial resistance, particularly in pathogens such as methicillin-resistant Staphylococcus aureus (MRSA), limits treatment options and increases healthcare costs. To understand patient risk factors, including household and animal contact, potentially associated with colonization with multidrug-resistant MRSA isolates, we performed a prospective study of case patients colonized with MRSA on admission to a rural tertiary care hospital. Patients were interviewed and antimicrobial resistance patterns were tested among isolates from admitted patients colonized with MRSA in 2009-10. Prevalence of resistance was compared by case-patient risk factors and length-of-stay outcome among 88 MRSA case patients. Results were compared to NHANES 2003-04. Overall prevalence of multidrug resistance (non-susceptibility to ≥ four antimicrobial classes) in MRSA nasal isolates was high (73%) and was associated with a 1.5-day increase in subsequent length of stay (p = 0.008). History of hospitalization within the past six months, but not antimicrobial use in the same time period, was associated with resistance patterns. Within a subset of working-age case patients without recent history of hospitalization, animal contact was potentially associated with multidrug resistance. History of hospitalization, older age, and small household size were associated with multidrug resistance in NHANES data. In conclusion, recent hospitalization of case patients was predictive of antimicrobial resistance in MRSA isolates, but novel risk factors associated with the household may be emerging in CA-MRSA case patients. Understanding drivers of antimicrobial resistance in MRSA isolates is important to hospital infection control efforts, relevant to patient outcomes and to indicators of the economic burden of antimicrobial resistance.

Francisella novicida bacteremia after a near-drowning accident.

We describe a rare case of Francisella novicida bacteremia following a near-drowning event in seawater. We highlight the challenges associated with laboratory identification of F. novicida and differences in the epidemiology of F. novicida and Francisella tularensis infections.

Molecular and phenotypic characteristics of healthcare- and community-associated methicillin-resistant Staphylococcus aureus at a rural hospital.

BACKGROUND: While methicillin-resistant Staphylococcus aureus (MRSA) originally was associated with healthcare, distinct strains later emerged in patients with no prior hospital contact. The epidemiology of MRSA continues to evolve. METHODS: To characterize the current epidemiology of MRSA-colonized patients entering a hospital serving both rural and urban communities, we interviewed patients with MRSA-positive admission nasal swabs between August 2009 and March 2010. We applied hospitalization risk factor, antimicrobial resistance phenotype, and multi-locus sequence genotype (MLST) classification schemes to 94 case-patients. RESULTS: By MLST analysis, we identified 15 strains with two dominant clonal complexes (CCs)-CC5 (51 isolates), historically associated with hospitals, and CC8 (27 isolates), historically of community origin. Among patients with CC5 isolates, 43% reported no history of hospitalization within the past six months; for CC8, 67% reported the same. Classification by hospitalization risk factor did not correlate strongly with genotypic classification. Sensitivity of isolates to ciprofloxacin, clindamycin, or amikacin was associated with the CC8 genotype; however, among CC8 strains, 59% were resistant to ciprofloxacin, 15% to clindamycin, and 15% to amikacin. CONCLUSIONS: Hospitalization history was not a strong surrogate for the CC5 genotype. Conversely, patients with a history of hospitalization were identified with the CC8 genotype. Although ciprofloxacin, clindamycin, and amikacin susceptibility distinguished CC8 strains, the high prevalence of ciprofloxacin resistance limited its predictive value. As CC8 strains become established in healthcare settings and CC5 strains disseminate into the community, community-associated MRSA definitions based on case-patient hospitalization history may prove less valuable in tracking community MRSA strains.

Molecular and epidemiologic characteristics of linezolid-resistant coagulase-negative staphylococci at a tertiary care hospital.

We investigated emergence of linezolid resistance among coagulase-negative staphylococci at our tertiary care center in 2007. All 17 cases were healthcare associated, and prior administration of linezolid was documented

First year of mandatory reporting of healthcare-associated infections, Pennsylvania: an infection control-chart abstractor collaboration.

BACKGROUND: In 2004, the Commonwealth of Pennsylvania mandated hospitals to report healthcare-associated infections (HAIs). The increased workload led our Infection Control staff to collaborate with Atlas, a group of chart abstractors. OBJECTIVE: The objective of this study was to assess our first year of experience with mandatory reporting of HAIs--specifically, to assess Atlas' contribution to surveillance. DESIGN: Cases were selected if they had 1 or more of the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) codes designated by Pennsylvania as a possible HAI. After training by the Infection Control staff, Atlas applied National Nosocomial Infection Surveillance (NNIS) system case definitions for catheter-associated urinary tract infections (UTIs) and surgical site infections (SSIs), and they applied NNIS chest imaging criteria to eliminate cases that were not ventilator-associated pneumonia (VAP). To assess Atlas' performance, Infection Control staff conducted a parallel review. RESULTS: For discharges from the hospital during the fourth quarter of 2004, a total of 410 UTIs, 59 SSIs, and 56 VAPs were identified on the basis of state-designated ICD-9-CM codes; review by Atlas/Infection Control determined that 15%, 15%, and 16% of cases met case definitions, respectively. Of cases reviewed by both Infection Control and Atlas, 87% of the assessments made by Atlas were correct for UTI, and 96% were correct for SSI. For VAP, Infection Control concluded that 39% of cases could be ruled out on the basis of chest imaging criteria; Atlas correctly dismissed these 12 cases but incorrectly dismissed an additional 6 (error, 19%). Surveillance was not timely: 1-2 months elapsed between the time of HAI onset and the earliest case review. CONCLUSIONS: With ongoing training by Infection Control, Atlas successfully demonstrated a role in retrospective HAI surveillance. However, despite a major effort to comply with mandates, time lags and other design limitations rendered the data of low utility for Infection Control. States that are planning HAI-reporting programs should standardize an efficient surveillance methodology that yields data capable of guiding interventions to prevent HAI.

Vancomycin-resistant Staphylococcus aureus in the absence of vancomycin exposure.

We report findings from our investigation of the world's second clinical isolate of vancomycin-resistant Staphylococcus aureus (VRSA). An elderly man was hospitalized with an infected chronic heel ulcer and osteomyelitis. Before hospital admission, he received multiple courses of antibiotic therapy but, notably, no vancomycin. Numerous cultures of ulcer specimens (performed on an outpatient basis) grew methicillin-resistant, vancomycin-susceptible S. aureus and vancomycin-resistant Enterococcus species. At admission, an additional culture of a specimen from the heel ulcer grew S. aureus that was identified as VRSA (minimal inhibitory concentration for vancomycin [by broth-microdilution], 32 microg/mL). Further evaluation confirmed the presence of the vanA gene mediating vancomycin resistance. To assess VRSA transmission, we performed a carriage study of 283 identified contacts and an environmental survey of the patient's home; no VRSA isolates were recovered. This case illustrates that recent exposure by patients to vancomycin is not necessary for development of vanA-containing VRSA. For clinical and public health reasons, it is essential that microbiology laboratories adequately test for vancomycin-resistance in S. aureus.