A plague passing over: Clinical features of the 2022 mpox outbreak in patients of color living with HIV.

INTRODUCTION: Compared with previous geographically localized outbreaks of monkeypox (MPOX), the scale of the 2022 global mpox outbreak has been unprecedented, yet the clinical features of this outbreak remain incompletely characterized. METHODS: We identified patients diagnosed with mpox by polymerase chain reaction (PCR; n = 36) from July to September 2022 at a single, tertiary care institution in the USA. Demographics, clinical presentation, infection course, and histopathologic features were reviewed. RESULTS AND CONCLUSION: Men who have sex with men (89%) and people living with HIV (97%) were disproportionately affected. While fever and chills (56%) were common, some patients (23%) denied any prodromal symptoms. Skin lesions showed a wide range of morphologies, including papules and pustules, and lesions showed localized, not generalized, spread. Erythema was also less appreciable in skin of colour patients (74%). Atypical clinical features and intercurrent skin diseases masked the clinical recognition of several cases, which were ultimately diagnosed by PCR. Biopsies showed viral cytopathic changes consistent with Orthopoxvirus infections. All patients in this case series recovered without complications, although six patients (17%) with severe symptoms were treated with tecovirimat without complication.

Comparison of cefazolin versus oxacillin for treatment of complicated bacteremia caused by methicillin-susceptible Staphylococcus aureus.

Contrary to prior case reports that described occasional clinical failures with cefazolin for methicillin-susceptible Staphylococcus aureus (MSSA) infections, recent studies have demonstrated no difference in outcomes between cefazolin and antistaphylococcal penicillins for the treatment of MSSA bacteremia. While promising, these studies described low frequencies of high-inoculum infections, such as endocarditis. This retrospective study compares clinical outcomes of cefazolin versus oxacillin for complicated MSSA bacteremia at two tertiary care hospitals between January 2008 and June 2012. Fifty-nine patients treated with cefazolin and 34 patients treated with oxacillin were included. Osteoarticular (41%) and endovascular (20%) sources were the predominant sites of infection. The rates of clinical cure at the end of therapy were similar between cefazolin and oxacillin (95% versus 88%; P=0.25), but overall failure at 90 days was higher in the oxacillin arm (47% versus 24%; P=0.04). Failures were more likely to have received surgical interventions (63% versus 40%; P=0.05) and to have an osteoarticular source (57% versus 33%; P=0.04). Failures also had a longer duration of bacteremia (7 versus 3 days; P=0.0002), which was the only predictor of failure. Antibiotic selection was not predictive of failure. Rates of adverse drug events were higher in the oxacillin arm (30% versus 3%; P=0.0006), and oxacillin was more frequently discontinued due to adverse drug events (21% versus 3%; P=0.01). Cefazolin appears similar to oxacillin for the treatment of complicated MSSA bacteremia but with significantly improved safety. The higher rates of failure with oxacillin may have been confounded by other patient factors and warrant further investigation.

Universal glove and gown use and acquisition of antibiotic-resistant bacteria in the ICU: a randomized trial.

IMPORTANCE: Antibiotic-resistant bacteria are associated with increased patient morbidity and mortality. It is unknown whether wearing gloves and gowns for all patient contact in the intensive care unit (ICU) decreases acquisition of antibiotic-resistant bacteria. OBJECTIVE: To assess whether wearing gloves and gowns for all patient contact in the ICU decreases acquisition of methicillin-resistant Staphylococcus aureus (MRSA) or vancomycin-resistant Enterococcus (VRE) compared with usual care. DESIGN, SETTING, AND PARTICIPANTS: Cluster-randomized trial in 20 medical and surgical ICUs in 20 US hospitals from January 4, 2012, to October 4, 2012. INTERVENTIONS: In the intervention ICUs, all health care workers were required to wear gloves and gowns for all patient contact and when entering any patient room. MAIN OUTCOMES AND MEASURES: The primary outcome was acquisition of MRSA or VRE based on surveillance cultures collected on admission and discharge from the ICU. Secondary outcomes included individual VRE acquisition, MRSA acquisition, frequency of health care worker visits, hand hygiene compliance, health care­associated infections, and adverse events. RESULTS: From the 26,180 patients included, 92,241 swabs were collected for the primary outcome. Intervention ICUs had a decrease in the primary outcome of MRSA or VRE from 21.35 acquisitions per 1000 patient-days (95% CI, 17.57 to 25.94) in the baseline period to 16.91 acquisitions per 1000 patient-days (95% CI, 14.09 to 20.28) in the study period, whereas control ICUs had a decrease in MRSA or VRE from 19.02 acquisitions per 1000 patient-days (95% CI, 14.20 to 25.49) in the baseline period to 16.29 acquisitions per 1000 patient-days (95% CI, 13.48 to 19.68) in the study period, a difference in changes that was not statistically significant (difference, −1.71 acquisitions per 1000 person-days, 95% CI, −6.15 to 2.73; P = .57). For key secondary outcomes, there was no difference in VRE acquisition with the intervention (difference, 0.89 acquisitions per 1000 person-days; 95% CI, −4.27 to 6.04, P = .70), whereas for MRSA, there were fewer acquisitions with the intervention (difference, −2.98 acquisitions per 1000 person-days; 95% CI, −5.58 to −0.38; P = .046). Universal glove and gown use also decreased health care worker room entry (4.28 vs 5.24 entries per hour, difference, −0.96; 95% CI, −1.71 to −0.21, P = .02), increased room-exit hand hygiene compliance (78.3% vs 62.9%, difference, 15.4%; 95% CI, 8.99% to 21.8%; P = .02) and had no statistically significant effect on rates of adverse events (58.7 events per 1000 patient days vs 74.4 events per 1000 patient days; difference, −15.7; 95% CI, −40.7 to 9.2, P = .24). CONCLUSIONS AND RELEVANCE: The use of gloves and gowns for all patient contact compared with usual care among patients in medical and surgical ICUs did not result in a difference in the primary outcome of acquisition of MRSA or VRE. Although there was a lower risk of MRSA acquisition alone and no difference in adverse events, these secondary outcomes require replication before reaching definitive conclusions. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT0131821.

Does nonpayment for hospital-acquired catheter-associated urinary tract infections lead to overtesting and increased antimicrobial prescribing?

BACKGROUND: On 1 October 2008, in an effort to stimulate efforts to prevent catheter-associated urinary tract infection (CAUTI), the Centers for Medicare & Medicaid Services (CMS) implemented a policy of not reimbursing hospitals for hospital-acquired CAUTI. Since any urinary tract infection present on admission would not fall under this initiative, concerns have been raised that the policy may encourage more testing for and treatment of asymptomatic bacteriuria. METHODS: We conducted a retrospective multicenter cohort study with time series analysis of all adults admitted to the hospital 16 months before and 16 months after policy implementation among participating Society for Healthcare Epidemiology of America Research Network hospitals. Our outcomes were frequency of urine culture on admission and antimicrobial use. RESULTS: A total of 39 hospitals from 22 states submitted data on 2 362 742 admissions. In 35 hospitals affected by the CMS policy, the median frequency of urine culture performance did not change after CMS policy implementation (19.2% during the prepolicy period vs 19.3% during the postpolicy period). The rate of change in urine culture performance increased minimally during the prepolicy period (0.5% per month) and decreased slightly during the postpolicy period (-0.25% per month; P < .001). In the subset of 10 hospitals providing antimicrobial use data, the median frequency of fluoroquinolone antimicrobial use did not change substantially (14.6% during the prepolicy period vs 14.0% during the postpolicy period). The rate of change in fluoroquinolone use increased during the prepolicy period (1.26% per month) and decreased during the postpolicy period (-0.60% per month; P < .001). CONCLUSIONS: We found no evidence that CMS nonpayment policy resulted in overtesting to screen for and document a diagnosis of urinary tract infection as present on admission.

Improving health care workers for seasonal influenza vaccination at university health system: a paradigm for closing the quality chasm.

Significant gaps in quality and patient safety in the US health-care system have been identified and were reported in the past decade by the Institute of Medicine. Despite recognition of these gaps in "knowing versus doing," change in health care is slow and difficult. The quality improvement and clinical safety movement is increasing among US medical centers. Our health science center implemented the UT System Clinical Safety and Effectiveness course, providing project-based teaching of quality-improvement tools and principles of patient safety. A quality-improvement project that increased healthcare workers' influenza vaccination rate by 17.8% from that in 2008 to a rate of 76.6% in 2009 serves as a paradigm of how physicians can lead quality-improvement project teams to narrow the quality chasm (1). Local efforts to narrow the chasm are discussed in the present paper, including inter-professional education in quality improvement and clinical safety.

A Surprising Cause of Liver Abscesses in a Post-Chemotherapy Patient: Herpes Simplex Virus.

Herpes simplex virus (HSV) hepatitis is a rare complication of HSV infection, and a rare cause of hepatitis. It is often fatal, especially if the diagnosis and treatment are delayed. Herein, we describe the case of a 31-year-old female with a history of receiving cytotoxic cancer chemotherapy five months prior who presented with a one-week history of worsening abdominal pain and fever. She was noted to have an outbreak of genital herpes at the time of presentation. Computed tomography (CT) scan of the abdomen showed innumerable hypodensities compatible with hepatic micro-abscesses. A specimen from a subsequent liver biopsy revealed HSV-type cytopathic changes and nuclear staining with an anti-HSV immunohistochemical stain. She was initially started on high-dose oral valacyclovir for genital herpes and was noted to have rapid clinical improvement prior to the histopathologic diagnosis of HSV hepatitis. She achieved full recovery while on oral valacyclovir. This is the first reported case of HSV hepatitis treated with oral valacyclovir and the third reported case of HSV hepatitis mimicking pyogenic abscesses on abdominal imaging. With the high mortality rate associated with HSV hepatitis, one should consider the diagnosis in all patients with multifocal liver lesions of unknown etiology, especially if genital herpes is present at the time of presentation, or in patients who are immunocompromised.

Detection of inducible clindamycin resistance in beta-hemolytic streptococci by using the CLSI broth microdilution test and erythromycin-clindamycin combinations.

This study assessed an erythromycin-clindamycin (ERY-CC) broth test for inducible CC resistance in beta-hemolytic streptococci. One hundred one isolates of groups A, B, C, F, and G were tested by the CLSI broth microdilution method. Combinations of 1 and 0.25 microg/ml or 0.5 and 0.25 microg/ml of ERY and CC, respectively, detected all inducible isolates.

Prior biliary tree instrumentation does not preclude hepatic arterial therapy for malignancy.

Hepatic arterial therapy (HAT) has become an accepted alternative for patients with unresectable hepatic malignancies. HAT has an acceptable toxicity profile, yet its safety for use in patients who have undergone significant biliary manipulation is undocumented. A retrospective review identified 18 consecutive patients with unresectable hepatic malignancies who had undergone significant prior biliary tree manipulation. All patients received peri-HAT antibiotics. Clinicopathologic, treatment-related, and outcomes data were collected and analyzed. Eighteen patients who had HAT were analyzed; 72 per cent were men, the median age was 61 years, and 61 per cent had greater than 25 per cent hepatic parenchymal replacement by tumor. Seventy-eight per cent of patients had an indwelling biliary stent and 22 per cent had undergone a hepaticojejunostomy. Twenty-two per cent of patients developed a complication, none of which were infectious, and there were no peri-HAT deaths. The majority of patients had evidence of either a partial response (55%) or stable disease (22%) upon follow-up. One patient had a complete response to HAT. The median survival was 27 months. Hepatic arterial therapy seems to be safe for patients with unresectable hepatic malignancies and a history of significant biliary instrumentation. There is no increased risk of infectious complications in this population after HAT.

Implementing daily chlorhexidine gluconate treatment for the prevention of healthcare-associated infections in non-intensive care settings: A multiple case analysis.

INTRODUCTION: Daily bathing with chlorhexidine gluconate (CHG) in hospitalized patients reduces healthcare-associated bloodstream infections and colonization by multidrug-resistant organisms. Achieving compliance with bathing protocols is challenging. This non-intensive care unit multicenter project evaluated the impact of organizational context on implementation of CHG and assessed compliance with and healthcare workers' perceptions of the intervention. MATERIALS AND METHODS: This was a multiple case study based on the SEIPS (Systems Engineering Initiative for Patient Safety) model of work system and patient safety. The four sites included an adult cardiovascular unit in a community hospital, a medical-surgical unit in an academic teaching pediatric hospital, an adult medical-surgical acute care unit and an adult neuroscience acute care unit in another academic teaching hospital. Complementary data collection methods included focus groups and interviews with healthcare workers (HCWs) and leaders, and direct observations of the CHG treatment process and skin swabs. RESULTS: We collected 389 bathing observations and 110 skin swabs, conducted four focus groups with frontline workers and interviewed leaders. We found variation across cases in CHG compliance, skin swab data and implementation practices. Mean compliance with the bathing process ranged from 64% to 83%. Low detectable CHG on the skin was related to immediate rinsing of CHG from the skin. Variation in the implementation of CHG treatments was related to differences in organizational education and training practices, feedback and monitoring practices, patient education or information about CHG treatments, patient preferences and general unit patient population differences. CONCLUSION: Organizations planning to implement CHG treatments in non-ICU settings should ensure organizational readiness and buy-in and consider delivering systematic and ongoing training. Clear and systematic implementation policies across patients and units may help reduce potential confusion about treatment practices and variation across HCWs. Patient populations and unit factors need to be carefully considered and procedures developed to manage unique challenges.