Asymptomatic Testing of Hospital Admissions for SARS-CoV-2: Is it OK to Stop?

Universal severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) testing of all persons admitted to acute care hospitals has become common practice. We describe why 1 hospital discontinued this practice after weighing potential benefits against known harms. Considerations around the benefits shifted as we saw a decline in SARS-CoV-2 community transmission and coronavirus disease 2019 (COVID-19) severity of illness, increased availability of vaccines and treatments, and better understood the many other transmission pathways in the healthcare environment. Considerations around harms included the additional strain on laboratory and infection prevention resources, and several unintended adverse consequences of admission screening for patients, including unnecessary isolation, antiviral treatments, and delays in care delivery. Poor test performance for detection of infectiousness also played a significant role in determining to stop universal screening. No increase in hospital-onset COVID-19 has been documented since discontinuation of admission testing. We continue to apply other established layers of prevention while monitoring for any change in incidence of within-facility transmission of SARS-CoV-2.

Descriptive epidemiology of central line-associated bloodstream infections at an academic medical center in Iowa, 2019-2022.

BACKGROUND: Central line-associated bloodstream infections (CLABSIs) increased nationally during the COVID-19 pandemic. We described CLABSIs at our institution during 2019 to 2022. METHODS: This retrospective observational study examined CLABSIs among adult inpatients at an 866-bed teaching hospital in the Midwest. CLABSI incidence was trended over time and compared to monthly COVID-19 admissions. Manual chart review was performed to obtain patient demographics, catheter-associated variables, pathogens, and clinical outcomes. RESULTS: We identified 178 CLABSIs. The CLABSI incidence (cases per 1,000 line days) tripled in October 2020 as COVID-19 admissions increased. CLABSIs in 2020 were more frequently caused by coagulase-negative staphylococci and more frequently occurred in the intensive care units 7+ days after central line insertion. The CLABSI incidence normalized in early 2021 and did not increase during subsequent COVID-19 surges. Throughout 2019 to 2022, about half of the nontunneled central venous catheters involved in CLABSI were placed emergently. One-quarter of CLABSIs involved multiple central lines. Chlorhexidine skin treatment adherence was limited by patient refusal. CONCLUSIONS: The increase in CLABSIs in late 2020 during a surge in COVID-19 admissions was likely related to central line maintenance but has resolved. Characterizing CLABSI cases can provide insight into adherence to guideline-recommended prevention practices and identify areas for improvement at individual institutions.

Association between job role and coronavirus disease 2019 (COVID-19) among healthcare personnel, Iowa, 2021.

We describe the association between job roles and coronavirus disease 2019 (COVID-19) among healthcare personnel. A wide range of hazard ratios were observed across job roles. Medical assistants had higher hazard ratios than nurses, while attending physicians, food service workers, laboratory technicians, pharmacists, residents and fellows, and temporary workers had lower hazard ratios.

Acute rheumatic fever and erythema marginatum in an adult patient.

A 41-year-old woman presented for evaluation of a pruritic eruption with an abrupt onset, starting on her flanks and then spreading to her arms and legs. She had 2 weeks of fever, chills, malaise, migratory joint pain, nausea, and mental confusion. An antistreptolysin O titer was positive. Upon hospital admission, bilateral lower-extremity chorea movements were observed, and her C-reactive protein level was elevated (3.7 mg/dL). Biopsy results supported erythema marginatum. Based on these clinical and laboratory findings, the diagnosis of acute rheumatic fever was established.

COVID-19-from emerging global threat to ongoing pandemic crisis.

In December 2019, China witnessed the emergence of a novel coronavirus, SARS-CoV-2. Its ability to spread quickly made it a global pandemic. The United States has been greatly affected, with more than 980,000 lives lost so far. Diagnosis is made primarily through nasopharyngeal swab for polymerase chain reaction. Point-of-care testing by antigen is less sensitive and specific and may require polymerase chain reaction confirmation. Management of the COVID-19 patient remains largely supportive. Steroids are now a therapy mainstay if the patient is hypoxic. Direct antivirals, such as nirmatrelvir/ritonavir, remdesivir, or molnupirivir, can be used if certain criteria are met. SARS-CoV-2 is transmitted primarily by inhalation of large droplets, though transmission by aerosolization may occur, particularly via certain procedures. In the hospital setting, use of personal protective equipment for the care of COVID-19 patients has largely remained the same, with full use of gowns, gloves, respirators, and eye protection. Inadequate supply at the start of the pandemic required innovative ways to reprocess and extend the use of personal protective equipment. Three vaccines are now available in the US, all with excellent efficacy against severe disease and hospitalization, though booster doses are needed to bolster waning antibody levels. The possibility of emerging variants continues to remain a threat to control of the pandemic. The leader of the World Health Organization, Dr. Tedros, has stated, "The pandemic will not be over anywhere until it's over everywhere."

Cirrhosis, gastrointestinal bleed, and cryptococcal peritonitis.

Disseminated Cryptococcus neoformans infection rarely causes peritonitis in non-HIV-infected patients but does affect cirrhotic patients. Diagnostic challenges delay treatment, and mortality is high. We performed a literature search of proven cryptococcal peritonitis cases in HIV-negative adults with underlying cirrhosis, included our own case, and collected demographic, infection risk factor, diagnostic, treatment, and outcomes data. We identified 16 articles and 21 cases. Most patients were men. Alcohol abuse was the leading cause of underlying cirrhosis (n = 10, 48%). Eight (38%) patients experienced an upper gastrointestinal bleed (UGIB) within a month before peritonitis presentation. Peritoneal fluid analysis was abnormal and lymphocytic predominant. Half the patients were fungemic. When performed, peritoneal fluid cryptococcal antigen (CrAg) test results were positive. Amphotericin B was the primary treatment. Mortality was high at 76%. In conclusion, C. neoformans is an opportunistic pathogen that causes peritonitis in non-HIV, cirrhotic patients. People with recent UGIB seem to be at risk. Cryptococcus species infection should be suspected in patients with clinical signs and symptoms of spontaneous bacterial peritonitis whose lymphocytic-predominant peritoneal fluid and cultures are negative for bacterial growth. Peritoneal CrAg testing expedites diagnosis because growth on fungal media is slow. Mortality remains high, despite standard therapy with amphotericin B.

2019 novel coronavirus: an emerging global threat.

The coronavirus (CoV) epidemic that began in China in December 2019 follows earlier epidemics of severe acute respiratory syndrome CoV in China and Middle East respiratory syndrome CoV in Saudi Arabia. The full genome of the 2019 novel coronavirus (2019-nCoV) has now been shared, and data have been gathered from several case series. As of February 11, 2020, there have been 45,182 laboratory-confirmed cases, the vast majority in China, with 1115 deaths, for an overall case-fatality rate of 2.5%. Cases have been confirmed in 27 countries. On average, each patient infects 2.2 other people. Symptomatic infection appears to predominantly affect adults, with a 5-day estimated incubation period between infection and symptom onset. The most common presenting symptoms are fever, cough, dyspnea, and myalgias and/or fatigue. All cases reported to date have shown radiographic evidence of pneumonia. 2019-nCoV is diagnosed by real-time reverse transcriptase polymerase chain reaction. Treatment is largely supportive, with regimens including antiviral therapy. Corticosteroids are not routinely recommended. Hand hygiene, prompt identification and isolation of suspect patients, and appropriate use of personal protective equipment are the most reliable methods to contain the epidemic.

Mycobacterial Infections in Patients With Chronic Kidney Disease and Kidney Transplantation.

Patients with chronic kidney disease have impaired immunity that increases their risk of infection. Increased incidence of mycobacterial infections, in particular Mycobacterium tuberculosis, is described in patients undergoing hemodialysis and peritoneal dialysis as well as after kidney transplantation in low-prevalence and high-prevalence settings. Diagnosis of this infection can be challenging because of atypical presentations that may lead to treatment delay and, consequently, increased mortality; however, recent advances in molecular testing have improved diagnostic accuracy. It is imperative to try to identify those patients at increased risk and offer adequate prophylaxis. There are controversies and insufficient data regarding treatment agents, duration, and dosages. Most studies in nontuberculous mycobacteria are based on case series and retrospective studies.

Management of a renal fungal bezoar caused by multidrug-resistant Candida glabrata.

We describe our management of an immunocompetent individual who developed obstructive uropathy and candidemia as a result of a fungal bezoar in the kidney. These sequelae arose from candiduria, provoked after several courses of antibiotics. Successful treatment included therapy with both culture-appropriate intravenous antifungals and operative intervention, including direct irrigation of the affected kidney with amphotericin B, relief of renal obstruction with a ureteral stent, a percutaneous nephrostomy tube, and ultimately endoscopic removal of the fungal bezoar. Our patient was successfully treated as evidenced by negative urine culture and lack of ongoing symptomatology.

Cardiothoracic surgical site phaeohyphomycosis caused by Bipolaris mould, multiple US states, 2008-2013: a clinical description.

Bipolaris mould surgical site infections (SSIs) are exceedingly rare. We describe 21 cases of Bipolaris SSIs in pediatric and adult cardiothoracic surgery patients at ten hospitals in Texas, Arkansas, and Florida during 2008-2013. Median case-patient age was 55 years (range: 3 days-82 years), and 19 (90%) were male. Ten (48%) had coronary artery bypass or valve surgery, and seven (33%) had heart transplantation. Fifteen (71%) had more than one cardiothoracic procedure (median: 3, range: 1-11). Thirteen (62%) case-patients (all 5 pediatric patients, and 8 (50%) of 16 adult patients) had delayed sternal closure (chest closed >1 day [median = 8 days; range: 2-22] following the initial cardiothoracic procedure). Thirteen (62%) had mediastinitis. Median time from initial surgery to positive Bipolaris culture was 20 days (range: 6-497). Sixteen (76%) case-patients died.