Leveraging Bluetooth low-energy technology to improve contact tracing among healthcare personnel in hospital setting during the coronavirus disease 2019 (COVID-19) pandemic.

To improve contact tracing for healthcare workers, we built and configured a Bluetooth low-energy system. We predicted close contacts with great accuracy and provided an additional contact yield of 14.8%. This system would decrease the effective reproduction number by 56% and would unnecessarily quarantine 0.74% of employees weekly.

Spatial Epidemiologic Analysis and Risk Factors for Nontuberculous Mycobacteria Infections, Missouri, USA, 2008-2019.

Nontuberculous mycobacteria (NTM) infections are caused by environmental exposure. We describe spatial distribution of NTM infections and associations with sociodemographic factors and flooding in Missouri, USA. Our retrospective analysis of mycobacterial cultures reported to the Missouri Department of Health and Social Services surveillance system during January 1, 2008-December 31, 2019, detected geographic clusters of infection. Multilevel Poisson regression quantified small-area geographic variations and identified characteristics associated with risk for infection. Median county-level NTM infection rate was 66.33 (interquartile range 51-91)/100,000 persons. Risk of clustering was significantly higher in rural areas (rate ratio 2.82, 95% CI 1.90-4.19) and in counties with >5 floodings per year versus no flooding (rate ratio 1.38, 95% CI 1.26-1.52). Higher risk for NTM infection was associated with older age, rurality, and more flooding. Clinicians and public health professionals should be aware of increased risk for NTM infections, especially in similar environments.

Genomic Analyses of Longitudinal Mycobacterium abscessus Isolates in a Multicenter Cohort Reveal Parallel Signatures of In-Host Adaptation.

BACKGROUND: Nontuberculous mycobacteria (NTM) are ubiquitous in the environment and an increasingly frequent cause of opportunistic infections. Mycobacterium abscessus complex (MABC) is one of the major NTM lung pathogens that disproportionately colonize and infect the lungs of individuals with cystic fibrosis (CF). MABC infection can persist for years, and antimicrobial treatment is frequently ineffective. METHODS: We sequenced the genomes of 175 isolates longitudinally collected from 30 patients with MABC lung infection. We contextualized our cohort amidst the broader MABC phylogeny and investigated genes undergoing parallel adaptation across patients. Finally, we tested the phenotypic consequences of parallel mutations by conducting antimicrobial resistance and mercury-resistance assays. RESULTS: We identified highly related isolate pairs across hospital centers with low likelihood of transmission. We further annotated nonrandom parallel mutations in 22 genes and demonstrated altered macrolide susceptibility co-occurring with a nonsynonymous whiB1 mutation. Finally, we highlighted a 23-kb mercury-resistance plasmid whose loss during chronic infection conferred phenotypic susceptibility to organic and nonorganic mercury compounds. CONCLUSIONS: We characterized parallel genomic processes through which MABC is adapting to promote survival within the host. The within-lineage polymorphisms we observed have phenotypic effects, potentially benefiting fitness in the host at the putative detriment of environmental survival.

Missed Opportunities in the Diagnosis of Tuberculosis Meningitis.

Background: Tuberculosis meningitis (TBM) has high mortality and morbidity. Diagnostic delays can impact TBM outcomes. We aimed to estimate the number of potentially missed opportunities (MOs) to diagnose TBM and determine its impact on 90-day mortality. Methods: This is a retrospective cohort of adult patients with a central nervous system (CNS) TB International Classification of Diseases, Ninth/Tenth Revision (ICD-9/10) diagnosis code (013*, A17*) identified in the Healthcare Cost and Utilization Project, State Inpatient and State Emergency Department (ED) Databases from 8 states. Missed opportunity was defined as composite of ICD-9/10 diagnosis/procedure codes that included CNS signs/symptoms, systemic illness, or non-CNS TB diagnosis during a hospital/ED visit 180 days before the index TBM admission. Demographics, comorbidities, admission characteristics, mortality, and admission costs were compared between those with and without a MO, and 90-day in-hospital mortality, using univariate and multivariable analyses. Results: Of 893 patients with TBM, median age at diagnosis was 50 years (interquartile range, 37-64), 61.3% were male, and 35.2% had Medicaid as primary payer. Overall, 407 (45.6%) had a prior hospital or ED visit with an MO code. In-hospital 90-day mortality was not different between those with and without an MO, regardless of the MO coded during an ED visit (13.7% vs 15.2%, P = .73) or a hospitalization (28.2% vs 30.9%, P = .74). Independent risk of 90-day in-hospital mortality was associated with older age, hyponatremia (relative risk [RR], 1.62; 95% confidence interval [CI], 1.1-2.4; P = .01), septicemia (RR, 1.6; 95% CI, 1.03-2.45; P = .03), and mechanical ventilation (RR, 3.4; 95% CI, 2.25-5.3; P < .001) during the index admission. Conclusions: Approximately half the patients coded for TBM had a hospital or ED visit in the previous 6 months meeting the MO definition. We found no association between having an MO for TBM and 90-day in-hospital mortality.

Body Imaging of Bacterial and Parasitic Zoonoses: Keys to Diagnosis.

Zoonotic infections, which are transmitted from animals to humans, have been a substantial source of human disease since antiquity. As the human population continues to grow and human influence on the planet expands, humans frequently encounter both domestic and wild animals. This has only increased as deforestation, urbanization, agriculture, habitat fragmentation, outdoor recreation, and international travel evolve in modern society, all of which have resulted in the emergence and reemergence of zoonotic infections. Zoonotic infections pose a diagnostic challenge because of their nonspecific clinical manifestations and the need for specialized testing procedures to confirm these diagnoses. Affected patients often undergo imaging during their evaluation, and a radiologist familiar with the specific and often subtle imaging patterns of these infections can add important clinical value. The authors review the multimodality thoracic, abdominal, and musculoskeletal imaging findings of zoonotic bacterial (eg, Bartonella henselae, Pasteurella multocida, Francisella tularensis, Coxiella burnetii, and Brucella species), spirochetal (eg, Leptospira species), and parasitic (eg, Echinococcus, Paragonimus, Toxocara, and Dirofilaria species) infections that are among the more commonly encountered zoonoses in the United States. Relevant clinical, epidemiologic, and pathophysiologic clues such as exposure history, occupational risk factors, and organism life cycles are also reviewed. Although many of the imaging findings of zoonotic infections overlap with those of nonzoonotic infections, granulomatous diseases, and malignancies, radiologists' familiarity with the imaging patterns can aid in the differential diagnosis in a patient with a suspected or unsuspected zoonotic infection. © RSNA, 2023 Quiz questions for this article are available through the Online Learning Center.

Impact of risk-based sexually transmitted infection screening in the emergency department.

OBJECTIVES: Sexually transmitted infections (STIs), including chlamydia, gonorrhea, and human immunodeficiency virus (HIV) pose a significant health burden in adolescents. Many adolescents receiving care in the emergency department (ED) are in need of testing, regardless of their chief complaint. Our objective was to determine whether an electronic, risk-based STI screening program in our ED was associated with an increase in STI testing among at-risk adolescents. METHODS: We conducted a retrospective cohort analysis of patient outcomes in our pediatric ED after integrating an Audio-enhanced Computer-Assisted Self-Interview (ACASI) as standard of care. It obtained a focused sexual history and generated STI testing recommendations. Patient answers and testing recommendations were integrated in real-time into the electronic health record. Patients who tested positive received treatment according to our standard-of-care practices. All patients 15-21 years of age were asked to complete this on an opt-out basis, regardless of the reason for their ED visit. Exclusions included those unable to independently use a tablet, severe illness, sexual assault, or non-English speaking. Our primary outcome was to describe STI-testing recommendations and test results among ACASI participants. We also compared STI testing between ACASI participants and those who were eligible but did not use it. RESULTS: In the first 13 months, 28.9% (1788/6194) of eligible adolescents completed the ACASI and 44.2% (321/790) accepted recommended STI testing. The mean age of participants was 16.6 ± 1.3 years, with 65.4% (1169) being female. Gonorrhea/chlamydia testing was significantly higher among participants vs. non-participants (20.1% [359/1788] vs 4.8% [212/4406]; p < 0.0001). The proportion of positive STI tests was similar between the two groups: 24.8% (89/359) vs. 24.5% (52/212; p = 0.94) were positive for chlamydia and/or gonorrhea, while 0.6% (2/354) participants vs. 0% non-participants (p > 0.99) were positive for HIV. Among participants whose chief complaints were unlikely to be related to STIs but accepted recommended testing, 20.9% (37/177) were positive for gonorrhea or chlamydia. CONCLUSIONS: Our program facilitated STI testing in the ED and identified many adolescents with STIs, even when their ED complaint was for unrelated reasons. More rigorous implementation is needed to determine the impact of deployment of ACASI to all eligible adolescents and addressing barriers to accepting STI testing recommendations.

Risk factors for mortality and multidrug resistance in pulmonary tuberculosis in Guatemala: A retrospective analysis of mandatory reporting.

BACKGROUND: Risk factors for mortality and MDR-TB in Guatemala are poorly understood. We aimed to identify risk factors to assist in targeting public health interventions. METHODS: We performed a retrospective study of adults with pulmonary TB reported to the Guatemalan TB Program between January 1, 2016 and December 31, 2017. The primary objective was to determine risk factors for mortality in pulmonary TB. The secondary objective was to determine risk factors associated with MDR-TB. RESULTS: Among 3,945 patients with pulmonary TB, median age was 39 years (IQR 25-54), 59% were male, 25% of indigenous ethnicity, 1.1% had MDR-TB and 3.9% died. On multivariable analysis, previous TB treatment (odds ratio [OR] 3.57, CI 2.24-5.68 [p < 0.001]), living with HIV (OR 3.98, CI 2.4-6.17 [p < 0.001]), unknown HIV diagnosis (OR 2.65, CI 1.68-4.18 [p < 0.001]), indigenous ethnicity (OR 1.79, CI 1.18-2.7 [p = 0.005]), malnutrition (OR 7.33, CI 3.24-16.59 [p < 0.001]), and lower educational attainment (OR 2.86, CI 1.43-5.88 [p = 0.003]) were associated with mortality. Prior treatment (OR 53.76, CI 25.04-115.43 [p < 0.001]), diabetes (OR 4.13, CI 2.04-8.35 [p < 0.001]), and indigenous ethnicity (OR 11.83, CI 1.46-95.73 [p = 0.02]) were associated with MDR-TB. CONCLUSIONS: In Guatemala, both previous TB treatment and indigenous ethnicity were associated with higher TB mortality and MDR-TB risk among patients with pulmonary TB.

Comparative Genomics of Mycobacterium avium Complex Reveals Signatures of Environment-Specific Adaptation and Community Acquisition.

Nontuberculous mycobacteria, including those in the Mycobacterium avium complex (MAC), constitute an increasingly urgent threat to global public health. Ubiquitous in soil and water worldwide, MAC members cause a diverse array of infections in humans and animals that are often multidrug resistant, intractable, and deadly. MAC lung disease is of particular concern and is now more prevalent than tuberculosis in many countries, including the United States. Although the clinical importance of these microorganisms continues to expand, our understanding of their genomic diversity is limited, hampering basic and translational studies alike. Here, we leveraged a unique collection of genomes to characterize MAC population structure, gene content, and within-host strain dynamics in unprecedented detail. We found that different MAC species encode distinct suites of biomedically relevant genes, including antibiotic resistance genes and virulence factors, which may influence their distinct clinical manifestations. We observed that M. avium isolates from different sources-human pulmonary infections, human disseminated infections, animals, and natural environments-are readily distinguished by their core and accessory genomes, by their patterns of horizontal gene transfer, and by numerous specific genes, including virulence factors. We identified highly similar MAC strains from distinct patients within and across two geographically distinct clinical cohorts, providing important insights into the reservoirs which seed community acquisition. We also discovered a novel MAC genomospecies in one of these cohorts. Collectively, our results provide key genomic context for these emerging pathogens and will facilitate future exploration of MAC ecology, evolution, and pathogenesis. IMPORTANCE Members of the Mycobacterium avium complex (MAC), a group of mycobacteria encompassing M. avium and its closest relatives, are omnipresent in natural environments and emerging pathogens of humans and animals. MAC infections are difficult to treat, sometimes fatal, and increasingly common. Here, we used comparative genomics to illuminate key aspects of MAC biology. We found that different MAC species and M. avium isolates from different sources encode distinct suites of clinically relevant genes, including those for virulence and antibiotic resistance. We identified highly similar MAC strains in patients from different states and decades, suggesting community acquisition from dispersed and stable reservoirs, and we discovered a novel MAC species. Our work provides valuable insight into the genomic features underlying these versatile pathogens.

Diagnostic Accuracy of Health Care Administrative Diagnosis Codes to Identify Nontuberculous Mycobacteria Disease: A Systematic Review.

BACKGROUND: Health care administrative database research frequently uses standard medical codes to identify diagnoses or procedures. The aim of this review was to establish the diagnostic accuracy of codes used in administrative data research to identify nontuberculous mycobacterial (NTM) disease, including lung disease (NTMLD). METHODS: We searched Ovid Medline, Embase, Scopus, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov from inception to April 2019. We included studies assessing the diagnostic accuracy of International Classification of Diseases, 9th edition, Clinical Modification (ICD-9-CM) diagnosis codes to identify NTM disease and NTMLD. Studies were independently assessed by 2 researchers, and the Quality Assessment of Diagnostic Accuracy Studies 2 tool was used to assess bias and quality. RESULTS: We identified 5549 unique citations. Of the 96 full-text articles reviewed, 7 eligible studies of moderate quality (3730 participants) were included in our review. The diagnostic accuracy of ICD-9-CM diagnosis codes to identify NTM disease varied widely across studies, with positive predictive values ranging from 38.2% to 100% and sensitivity ranging from 21% to 93%. For NTMLD, 4 studies reported diagnostic accuracy, with positive predictive values ranging from 57% to 64.6% and sensitivity ranging from 21% to 26.9%. CONCLUSIONS: Diagnostic accuracy measures of codes used in health care administrative data to identify patients with NTM varied across studies. Overall the positive predictive value of ICD-9-CM diagnosis codes alone is good, but the sensitivity is low; this method is likely to underestimate case numbers, reflecting the current limitations of coding systems to capture NTM diagnoses.

Outcomes of Outpatient Parenteral Antimicrobial Therapy With Ceftriaxone for Methicillin-Susceptible Staphylococcus aureus Bloodstream Infections-A Single-Center Observational Study.

BACKGROUND: Staphylococcus aureus bloodstream infections (BSIs) are associated with significant morbidity and mortality. Ceftriaxone is convenient for outpatient parenteral antimicrobial therapy (OPAT), but data for this indication are limited. METHODS: Adult patients with methicillin-susceptible Staphylococcus aureus (MSSA) BSI discharged on OPAT with cefazolin, oxacillin, or ceftriaxone for at least 7 days were included. We compared outcomes of ceftriaxone vs either oxacillin or cefazolin. Ninety-day all-cause mortality, readmission due to MSSA infection, and microbiological failure were examined as a composite outcome and compared among groups. Rates of antibiotic switches due to intolerance were assessed. RESULTS: Of 243 patients included, 148 (61%) were discharged on ceftriaxone and 95 (39%) were discharged on either oxacillin or cefazolin. The ceftriaxone group had lower rates of intensive care unit care, endocarditis, and shorter duration of bacteremia, but higher rates of cancer diagnoses. There was no significant difference in the composite adverse outcome in the oxacillin or cefazolin group vs the ceftriaxone group (18 [19%] vs 31 [21%]; P = .70), comprising microbiological failure (6 [6.3%] vs 9 [6.1%]; P = .94), 90-day all-cause mortality (7 [7.4%] vs 15 [10.1%]; P = .46), and readmission due to MSSA infection (10 [10.5%] vs 13 [8.8%]; P = .65). Antibiotic intolerance necessitating a change was similar between the 2 groups (4 [4.2%] vs 6 [4.1%]; P = .95). CONCLUSIONS: For patients with MSSA BSI discharged on OPAT, within the limitations of the small numbers and retrospective design we did not find a significant difference in outcomes for ceftriaxone therapy when compared with oxacillin or cefazolin therapy.

Tobacco Use Prevalence and Smoking Cessation Pharmacotherapy Prescription Patterns Among Hospitalized Patients by Medical Specialty.

INTRODUCTION: Effective smoking cessation medications are readily available but may be underutilized in hospital settings. In our large, tertiary care hospital, we aimed to (1) characterize patient tobacco use prevalence across medical specialties, (2) determine smoking cessation pharmacotherapy prescription variation across specialties, and (3) identify opportunities for improvement in practice. METHODS: Using electronic health records at Barnes Jewish Hospital, we gathered demographic data, admitting service, admission route, length of stay, self-reported tobacco use, and smoking cessation prescriptions over a 6-year period, from 2010 to 2016. We then compared tobacco use prevalence and smoking cessation prescriptions across medical specialties using a cross-sectional, retrospective design. RESULTS: Past 12-month tobacco use was reported by patients in 27.9% of inpatient admissions; prescriptions for smoking cessation pharmacotherapy were provided during 21.5% of these hospitalizations. The proportion of patients reporting tobacco use was highest in psychiatry (55.3%) and lowest in orthopedic surgery (17.1%). Psychiatric patients who reported tobacco use were most likely to receive pharmacotherapy (71.8% of admissions), and plastic surgery patients were least likely (4.7% of admissions). Compared with Caucasian tobacco users, African American patients who used tobacco products were less likely to receive smoking cessation medications (adjusted odds ratio [aOR] = 0.65; 95% confidence interval [CI] = 0.62 to 0.68). CONCLUSIONS: Among hospitalized tobacco users, safe and cost-effective pharmacotherapies are under-prescribed. We identified substantial variation in prescribing practices across different medical specialties and demographic groups, suggesting the need for an electronic medical record protocol that facilitates consistent tobacco use cessation pharmacotherapy treatment. IMPLICATIONS: Tobacco use cessation pharmacotherapy is underutilized during hospitalization, and prescription rates vary greatly across medical specialties and patient characteristics. Hospitals may benefit from implementing policies and practices that standardize and automate the offer of smoking pharmacotherapy for all hospitalized patients who use tobacco.

Emergency Department Directors Are Willing to Expand Reproductive Health Services for Adolescents.

STUDY OBJECTIVE: Nearly 20 million adolescents receive emergency department (ED) care each year, many of whom have untreated reproductive health issues. ED visits represent an opportunity to provide appropriate care, however, ED physician reproductive health care practices and capabilities in the United States have not been described. We sought to characterize pediatric ED director's individual practice and ED system resources for providing adolescent reproductive health care. DESIGN, SETTING, PARTICIPANTS, AND INTERVENTIONS: We invited pediatric ED division and/or medical directors nationally to participate in an anonymous, online survey. MAIN OUTCOME MEASURES: Outcomes included ED directors' personal practice regarding providing adolescent patients reproductive health care, and their ED's resources and standard practice regarding screening adolescents for sexually transmitted infections (STIs) and other reproductive health concerns. RESULTS: One hundred thirty-five of 442 (30.5%) ED directors responded. Respondents were 73% (90/124) male, with a median of 18 (interquartile range, 13-23) years of experience and 63% (84/134) working in urban EDs. Seventy-one percent (90/130) preferred face-to-face interviews for obtaining a sexual history, but only 59% (77/130) of participants "always ask parents to leave the room for sensitive questions." Eighty-four percent (106/127) were receptive to pregnancy prevention interventions being initiated in the ED, with 75% (80/106) of those willing to provide an intervention. Only 16% (21/128) indicated their ED has a universal STI screening program, and only 18% (23/126) "always" successfully notify patients of a positive STI test. CONCLUSION: ED directors are comfortable providing adolescent reproductive health care, and many individual- and ED-level opportunities exist to provide improved reproductive health care for adolescents in the ED.

A Cluster of Cefepime-induced Neutropenia During Outpatient Parenteral Antimicrobial Therapy.

A cluster of cefepime-induced neutropenia (CIN) was identified from June 2017 to May 2018 in a regional outpatient parenteral antimicrobial therapy population. Our data suggest prolonged courses of cefepime (≥2 weeks), administered by rapid intravenous push, were associated with a higher risk of CIN.

Using wearable technology to predict health outcomes: a literature review.

Objective: To review and analyze the literature to determine whether wearable technologies can predict health outcomes. Materials and methods: We queried Ovid Medline 1946 -, Embase 1947 -, Scopus 1823 -, the Cochrane Library, clinicaltrials.gov 1997 - April 17, 2018, and IEEE Xplore Digital Library and Engineering Village through April 18, 2018, for studies utilizing wearable technology in clinical outcome prediction. Studies were deemed relevant to the research question if they involved human subjects, used wearable technology that tracked a health-related parameter, and incorporated data from wearable technology into a predictive model of mortality, readmission, and/or emergency department (ED) visits. Results: Eight unique studies were directly related to the research question, and all were of at least moderate quality. Six studies developed models for readmission and two for mortality. In each of the eight studies, data obtained from wearable technology were predictive of or significantly associated with the tracked outcome. Discussion: Only eight unique studies incorporated wearable technology data into predictive models. The eight studies were of moderate quality or higher and thereby provide proof of concept for the use of wearable technology in developing models that predict clinical outcomes. Conclusion: Wearable technology has significant potential to assist in predicting clinical outcomes, but needs further study. Well-designed clinical trials that incorporate data from wearable technology into clinical outcome prediction models are required to realize the opportunities of this advancing technology.

Epidemiology and Outcomes of Nontuberculous Mycobacterial Infections in Solid Organ Transplant Recipients at a Midwestern Center.

BACKGROUND: Nontuberculous mycobacterial (NTM) infections have the potential to affect outcomes in solid organ transplant (SOT) recipients. METHODS: Retrospective cohort of adults who underwent SOT at a Midwestern hospital between January 1, 2004, and December 31, 2013. NTM-infected patients had at least 1 positive culture for NTM posttransplant. NTM disease was defined by 1) American Thoracic Society/Infectious Disease Society of America criteria for respiratory specimens or 2) NTM cultured from a sterile site with a compatible clinical syndrome. The remaining NTM infected patients were classified as colonized. Cox regression analysis was used to determine the association of NTM with mortality among lung transplant recipients. RESULTS: Of 3338 SOT recipients, 50 (1.5%) had NTM infection during a median 1038 days (range, 165-3706) follow-up posttransplant. Forty-three patients (86%) with NTM infection were lung transplant recipients; 18 of 43 (41.8%) were treated for NTM and 6 (13.9%) met disease criteria. Isolation of the same species on multiple occasions was associated with treatment among the colonized lung transplant recipients (8/12 [67%] vs 3/25 [12%] who were not treated, P = 0.014). NTM infection was not associated with increased mortality in lung transplant recipients (9/43 [20.9%] in infected died versus 161/510 [31.6%] in uninfected, age-adjusted hazard ratio, 0.56; 95% confidence interval, 0.2-1.1; P = 0.091). Three of 6 lung transplant recipients with NTM disease died compared with 6 of 37 colonized (hazard ratio, 7.0; 95% confidence interval, 1.5-31.5; P = 0.003). CONCLUSIONS: Among SOT patients, NTM were most frequently identified from lung transplant recipients. NTM infection was not associated with increased mortality, although NTM disease was associated with increased mortality compared with colonization in lung transplant recipients.