bluuebunny/crossref_metadata_2025 huggingface dataset:
Resistance to Antifungals in Non-albicans Candida Species Isolates in the Southeast Region
Authors: Pineda Priscilla , Hitchingham Erin , Harriott Melphine , Rocha Cody , Drenzek Cherie , Lee Grace , Marin Ashley , Roderick Melanie , Wagner JoAnna , Stover Carolyn
Published: September 2024

Background: Antimicrobial resistance is a growing problem in Candida spp., leading to treatment challenges and increased morbidity and mortality. The World Health Organization (WHO) fungal priority pathogens list classifies C. glabrata, C. tropicalis, and C. parapsilosis as high priority and leading causes of candidemia with high fluconazole resistance. In the US, these organisms are the most frequently isolated non-albicans Candida species. In 2016, the Antibiotic Resistance Laboratory Network (ARLN) was created to monitor resistance threats, including in Candida spp. This study describes the proportion of resistance in C. glabrata, C. parapsilosis, and C. tropicalis isolates sent to the Southeast ARLN from 2017 to 2023. Methods: This study evaluated C. glabrata, C. parapsilosis, and C. tropicalis submitted to the Southeast ARLN from Alabama, Florida, Georgia, Louisiana, Mississippi, and Tennessee from February 2017- September 2023. Species identification was confirmed by Bruker Biotyper matrix assisted laser desorption-ionization time of flight (MALDI-TOF). Antifungal susceptibility testing (AFST) was performed using TREK frozen broth microdilution panels. Minimum inhibitory concentration values from the clinical instrument were used to determine susceptibility based on Clinical and Laboratory Standards Institute (CLSI) standard interpretations from the 2020 CLSI M60 guidelines. Data were extracted from the laboratory information management system. Analyses were conducted using SAS v9.4. Results: AFST testing was performed on 660 C. glabrata, 500 C. parapsilosis, and 233 C. tropicalis isolates from within the Southeast region. The predominant specimen sources by species were blood 25.30% C. glabrata; other/not specified 27.80% C. parapsilosis; and lower respiratory 36.91% C. tropicalis. Resistance to fluconazole is as follows: C. glabrata, 12.88%; C. parapsilosis, 3.41%; C. tropicalis, 36.64%. Resistance to voriconazole is as follows: C. parapsilosis, 1.00%; C. tropicalis 30.04%. Resistance to at least one echinocandin (Anidulafungin, Capsofungin, Micafungin) is as follows: C. glabrata, 1.67%; C. parapsilosis, 0.60%; C. tropicalis, 0.43%. Overall, there was a decreasing trend in resistance to fluconazole, and voriconazole in all three species between 2017 and 2023. Conclusions: Antifungal resistance in non-albicans Candida species represents an emerging public health threat, however, within the Southeast region, ARLN data has shown a decreasing trend of azole resistance. This may be due in part to changes in reporting requirements and submission criteria from within the region. Nevertheless, C. tropicalis showed high resistance to azoles within the Southeast region. These Candida species should be monitored to inform clinical decision making and identify resistance patterns in other US regions due to their increase in resistance worldwide.
First Detected Transmission of C. auris within a Minnesota Healthcare Facility Following Exposure in the Emergency Department
Authors: Tourdot Laura , Knowles Krista , Dale Jennifer , Homuth Stephanie , Dobbins Ginette , Dahlquist Tami , Connors Kristy , Garfin Jacob , Fischer Jill , Gross Annastasia , Snippes Vagnone Paula , Lynfield Ruth , Lees Christine
Published: September 2024

Background: Candida auris reporting and submission of confirmed or possible isolates has been mandatory in Minnesota since August 2019. On August 9, 2023, the Minnesota Department of Health (MDH) was notified of a C. auris isolate in hip tissue from a patient in acute care hospital A (ACH-A). Only 9 cases of C. auris were detected prior to August 2023, in Minnesota, and all from patients with a history of international healthcare or healthcare in endemic C. auris locations of the United States. Methods: The MDH Public Health Laboratory (MDH-PHL) confirmed identification of C. auris from the ACH-A isolate by MALDI-TOF. MDH partnered with ACH-A to review medical records, assess infection prevention and control (IPC) practices, conduct contact tracing, and identify patients for colonization screening. Screening was performed on all patients that overlapped with the index case (case A) and were admitted to a facility in the same healthcare system as ACH-A. Facilities accepting discharged patients who overlapped with case A were contacted for colonization screening. Overlapping patients, no longer admitted to a healthcare facility, were sent a notification letter, and offered outpatient screening. Composite axilla/groin swabs were screened for C. auris using real-time PCR at MDH-PHL, who also performed whole genome sequencing (WGS) and single nucleotide polymorphism (SNP) analysis. Results: Case A’s medical record showed only Minnesota healthcare exposures, a surgical procedure in June 2023 and indicated the case overlapped with a previous case (case B) from July 2023, who had recent international healthcare. The two cases were hospitalized at ACH-B July 12-18, on different care floors without evident links to shared services. However, the cases were in adjacent rooms in ACH-B Emergency Department (ED) on July 3 for 5 hours, when C. auris status of case B was unknown. WGS indicated both isolates were within clade I (South Asian) and separated by 2 SNPs, suggesting relatedness. Extensive colonization screening occurred among 109 potentially exposed patients, including 18 patients from the ED. No additional C. auris was detected. Conclusions: This case represents the first detected transmission of C. auris within a Minnesota healthcare facility. The role of C. auris transmission within the ED is not well understood. Medical record review in combination with WGS analysis suggests potential transmission within the ED. Clinicians should be aware of the risks for C. auris transmission in the ED and follow all IPC measures to prevent transmission of this emerging fungal pathogen.
Risk Factors and Outcomes of Candida auris in Southeast Michigan
Authors: Malik Ambreen , Shallal Anita , Alangaden George , Suleyman Geehan
Published: September 2024

Background: Candida auris is an emerging multidrug resistant fungus that presents a serious global health threat and causes severe infections with a high mortality rate in hospitalized patients with significant underlying comorbidities. We describe the risk factors and clinical outcomes associated with C. auris in Southeast Michigan. Methods: This is a retrospective case series of culture-positive C. auris patients who had contact with our healthcare facility in Detroit from 2021 to 2023. We evaluated demographics, comorbidities, risk factors, and outcomes. A comparative analysis of colonized and infected patients was performed. Results: Forty-eight (81%) colonized and 11 (19%) infected patients were included (Table); 70% were male with median age of 66 years. All variables were comparable between the two groups except chronic kidney disease, which was significantly more prevalent among colonized patients (40% vs 0, p=0.011). All patients had prior exposure to acute care hospital (ACH), 37% to long-term acute care hospital, and 42% to skilled nursing facility within 1 year of diagnosis. Chronic wounds, prior broad-spectrum antibiotic use, and indwelling devices were prevalent in both groups; more than half required mechanical ventilation in the last month, and one third had tracheostomy at the time of C. auris detection. Almost 60% had a prior history of drug-resistant organisms, including multi-drug resistant gram negative (37%) and carbapenem-resistant (20%) organisms. Blood (82%) and wound (18%) were sources of invasive candidiasis. More than half (61%) of the testing was performed at ACH. Nine patients (82%) with invasive disease were treated with echinocandins (88%); among the colonized, two (4%) were treated with echinocandins but had persistent colonization. Thirty-day mortality was not significantly different among the two groups and was nearly 20%. Conclusions: In this large cohort study, a history of healthcare exposure, drug-resistant organisms, use of broad-spectrum antibiotics, indwelling devices, and chronic wounds were common risk factors among C. auris patients. Limiting the use of broad-spectrum antimicrobials and invasive devices, adherence to infection prevention and control practices, and interfacility transfer communication are important mitigating strategies to reduce the incidence and spread of C. auris.
Presenteeism Among Healthcare Professionals (HCP) During the COVID-19 Pandemic: Survey of Perceived Barriers
Authors: Dolan Katherine , Meyer Rachel , Anderson Laura , Shirley Dan , Kessler Michael , Stevens Linda , Safdar Nasia
Published: September 2024

Background: Presenteeism when ill in healthcare personnel (HCP) can contribute to the spread of respiratory illness among HCP and patients. However, during the COVID-19 pandemic and now, there are substantial challenges preventing HCP from staying home when ill. We examined these challenges using the Systems Engineering Initiative for Patient Safety (SEIPS) framework. Method: As part of a larger anonymous electronic survey between 3/11/2022 and 4/12/2022 at an academic tertiary referral center, in inpatient and ambulatory settings where respondents were asked to describe factors impacting presenteeism when ill, we analyzed free-text responses using the SEIPS categories of tasks, tools/technology, person, organization, and physical environment. Result: 522 comments were received in response to the open-ended survey question asking individuals to describe any factors that would assist them in remaining home and/or help them get tested for COVID-19 when they have symptoms of a respiratory illness; 21 were excluded due to absent or incomplete response. Of the remaining responses (N = 501, Figure 1), 82% were associated with a single SEIPS component such as organization (N = 409), while other responses discussed factors that involved two SEIPS components, in no particular order (N = 92). A majority of the responses (N = 324, 55%) reported organizational barriers, frequently citing a strict sick call-in policy as well as a lack of protected time-off for COVID-19 testing or related absences. The next two most commonly identified components were physical environment (N= 88, 15%) and tasks (N = 72, 12%), mentioning barriers such as far distances to testing centers and prolonged waiting periods for testing Results: The person and tools/technology components were less commonly identified, with a frequency of 9% each. Conclusion: A number of systems level factors were identified that may impact the ability of HCP to stay home when ill. Interventions to help overcome HCP perceived barriers to staying home when experiencing respiratory symptoms should focus on the policies and practices within an organization. Communication from leadership should support staying home with respiratory symptoms by creating plans for coverage and back up consistently across all employee types in direct care.
Assessment of 19 Operation Room and Sterile Processing Units in Puerto Rico, 2023: Preliminary Findings using a new ICAR Tool
Authors: Nachi David , Diaz-Paris Norma I. , Gonzalez-Pagan Jonell , Jorge-Coreano Miguel A. , Rivera-Santiago Tanialy , Garcia-Segui Angelica , Luna-Anavitate Sylvianette , Marzan-Rodriguez Melissa
Published: September 2024

Background: Infection prevention and control assessments in healthcare settings serve as a primary resource for obtaining data and providing recommendations based on safety, compliance, and quality assurance guidelines. In Puerto Rico (PR), surgical site infections are underreported in the Epi Info platform used by the Puerto Rico Department of Health (PRDOH), mainly due to the complexity of their identification. By focusing on evaluating Operating Rooms/Sterile Processing and Distribution (OR/SPD) units in acute care facilities (ACFs), our goal is to generate new data within the Healthcare-Associated Infection/Antibiotic Resistance (HAI/AR) Program, specifically related to patient management throughout preoperative, intraoperative, and postoperative phases, as well as reprocessing practices. Methods: Nineteen evaluations of ACFs' OR/SPDs were conducted from May through December 2023. Direct observations, file reviews, and personnel assessments were performed using an infection control assessment and response (ICAR) tool developed collaboratively by a team from an acute facility in PR and the HAI/AR Program staff. This ICAR Tool was customized based on guidelines from the certified Board for Sterile Processing and Distribution (CBSPD), the Association of periOperative Registered Nurses (AORN), and the Association for the Advancement of Medical Instrumentation (AAMI), among other regulatory agencies. The Division of Health Quality Promotion (DHQP) reviewed and approved the tool for use in these evaluations. Results: Key findings indicate that 32% of Sterile Processing Department (SPD) units restrict access to dedicated personnel with available manufacturer’s instructions, yet only 36% of SPD personnel are certified in CBSPD and packaging practices. Only 10% of facilities had a water treatment system for sterilization and Immediate Use Steam Sterilization (IUSS) policies. Notably, 84% of endoscopy areas require additional equipment for cultivating endoscopes, and no facility possessed a borescope for visually inspecting endoscope lumens. Tray inspection occurred in 21%, and only 31% of staff knew the Spaulding Classification and Class V Indicators. Conclusion: These data underscore the necessity of evaluating OR/SPD units in ACFs to provide updated recommendations and mitigate the incidence of surgical site infections (SSI). They offer insight into the structural and functional status of OR/SPD units in Puerto Rico, aligning reporting with OR/SPD practices to enhance patient care and minimize infection risks.
Nosocomial Transmission of Mycobacterium tuberculosis in an Oncological Setting
Authors: Murray Sarah , Mustafa Mery , Usiak Shauna , Kamboj Mini
Published: September 2024

Objective: Mycobacterium tuberculosis (MTB) is a contagious airborne disease that is spread from person to person via particles in the air which are expelled when speaking or coughing1. This retrospective observational study aims to assess the nosocomial transmission of pulmonary MTB among inpatient roommates in a high-risk oncological population over a 14-year period. With limited studies on the transmissibility of MTB in such environments, the investigation focuses on evaluating the risk of nosocomial transmission and implementation of appropriate infection control measures. Design: A retrospective analysis from 2010 – April 2023 was conducted in an acute care, 500-bed oncological center. Following exposure workups performed by the Department of Infection Prevention and Control, 17 of 57 identified patients with active pulmonary MTB had inpatient stays with roommates. Source infectivity showed 7 AFB smear positive results, 4 MTB PCR positive results, and 14 MTB culture positive results. Some index patients had a combination of AFB, PCR and/or culture positivity. A high-risk exposure is defined as any patient who shared a room with an index patient for >4 cumulative hours during the infectious period. Infectious period was determined for each index patient based on the onset of symptoms and laboratory results. Workups identified 33 exposed roommates who were notified and advised to undergo testing, employing QuantifERON (QFT-GIT) serum test or Tuberculin skin (TST) PPD test at least 8 weeks following their last day of exposure. The overlap between inpatient roommates and index patients ranged from 1 to 4 days, averaging 1.5 days. Results: Of the 33 high-risk roommates, 14 (42%) patients were unable to provide follow-up testing for various reasons including: patient expiration prior to testing, patient transfer to hospice, and being lost to follow up. Nineteen (58%) patients completed post-exposure testing. 12 patients underwent PPD testing (63%) and 7 patients underwent QuantifERON testing (37%). Zero (0%) were found to have a positive QuantifERON or PPD following their exposure. 15.8% (N=3) of exposed patients had hematologic malignancies, and 84.2% (N=16) of exposed patients had solid tumor malignancies. Conclusion: The risk of active pulmonary MTB transmission in an oncological, inpatient setting was determined to be low. The absence of positive conversions among roommates of confirmed MTB patients underscores the effectiveness of infection control measures, emphasizing the importance of isolating confirmed or suspected cases promptly. Ongoing efforts should continue to focus on these preventive measures to mitigate the risk of MTB transmission in similar high-risk settings.

References: 1. How TB Spreads. CDC, 2023. https://www.cdc.gov/tb/topic/basics/howtbspreads.htm
Sustained Microbial Burden Reduction and Impact on Covid19 Cases in Long-Term Care Facility through Advanced Photocatalysis
Authors: Trosch Kim , Carenza Amy , Birx Deborah , Britton Julie , Adkins Charmarie
Published: September 2024

Background: COVID19 remains deadly to Americans over 75 years old despite vaccination and additional infection control practices in long term care (LTC). The evolution of more transmissible COVID19 variants and continued viral aerosols result in persistent COVID19 outbreaks in LTC during high community levels of COVID19. Despite the end of pandemic Federal support and the continued vulnerability of elderly to the virus, LTC facilities remain dedicated to protecting this vulnerable population. The study hypothesized that utilization of continuous, facility-wide, advanced photocatalysis (AP) disinfection technology will reduce microbial burden in air and on surfaces, demonstrating a decrease in infectious aerosols and subsequent COVID19 cases among residents and workers. Methods: A prospective facility controlled experimental study was performed in skilled nursing facilities in Pennsylvania and New Jersey from January 2023 to April 2023 to surveil aerobic bacterial and fungal colony forming units (CFUs) in air, and Methicillin-resistant Staphylococcus aureus (MRSA) and fungal CFUs on surfaces and floors prior to and post AP technology installation. Impacts on resident COVID19 cases were recorded and compared to the same extended observation period (February-July 2023) one year prior (2022) with similar year over year community COVID19 rates. In addition, two matched control centers in regional proximity to the intervention facility were also prospectively studied. A one-way analysis of variance (ANOVA) was used to analyze mean microbial burdens after each post activation period (significance p <.05). Results: From baseline to final testing, the intervention facility surface testing showed a 93% reduction in mean aerobic bacterial CFUs (p=.002); 96% reduction in mean fungal CFUs (p<.001); 97% reduction in mean MRSA CFUs (p<.001). Floor testing also showed reductions in mean CFUs for aerobic bacteria by 92% (p<.001); 96% for fungi (p<.001); 99% for MRSA (p<.001). Air testing showed reductions in mean CFUs for aerobic bacteria by 87% (p=.005); 36% for fungal (p=.005). The intervention facility observed a 94% reduction in resident COVID19 cases compared to the matched control facilities that increased 46% during the 2023 time period (Figure 1). Conclusion: This study is on the pioneering edge of demonstrating that continuous and persistent disinfection technology reduces contaminant reservoirs on surfaces, floors, and air and clearly decreases infectious aerosols and improves resident outcomes by dramatically reducing COVID19 transmission in LTC facilities.
Evaluation of Practice Changes in Therapy for Stenotrophomonas maltophilia
Authors: Peterson-Weber Alex , Donohoe Kendall , McCoy Christopher
Published: September 2024

Background: Stenotrophomonas maltophilia (SM) is a non-fermenting, Gram-negative bacillus. Its intrinsic resistance to many beta-lactams makes for challenging treatment decisions. A preprint of the latest Infectious Diseases Society of America (IDSA) guidance on managing SM infections was published in December 2022 providing a recommendation for combination therapy including trimethoprim/sulfamethoxazole (TMP/SMX) and a second agent. An evaluation of the impact on SM treatment practices following this guidance was conducted at our institution. Methods: A list of 130 patients with non-urine SM cultures from December 2021-August 2023 was generated using a pharmacovigilance platform. Patients were excluded if on comfort measures or discharged to hospice prior to therapy completion, no directed antibiotics were given, or any history of prior SM infection. Twenty-five patients were randomly selected from the pre- and post-guidance periods (before and one month after December 1, 2022) for a total of 50 patients. Data was collected via manual chart review. The primary endpoint was frequency of combination antibiotic therapy in each time period. Secondary endpoints included treatment success (defined as resolution of infection symptoms and lack of infection recurrence), in-hospital mortality, 30-day mortality, and 30-day infection recurrence. Results: Overall, baseline characteristics were similar between groups, the median age was 65 years, 64% of patients were male, 20% were immunocompromised based on prespecified criteria, the median Charlson comorbidity index was 5 (21% estimated 10-Year survival), and 76% of SM cultures were pulmonary isolates. Displayed in figure 1, combination therapy was given in 6 of 25 cases (24%) in the post-guidance group and zero patients in the pre-guidance group. Secondary endpoints of treatment success and all-cause mortality were similar between groups. Duration of therapy was similar between combination and non-combination therapy regimens (median 9 vs 10 days). Among patients who received combination therapy, all had ID consultation, 4 (66.7%) were admitted to the ICU, and 2 (33.3%) had treatment success. Conclusions: Patients treated for SM infection at our institution in the post-IDSA guidance period were more likely to receive combination therapy. A higher rate of treatment success was not observed in the post-IDSA guidance arm for SM infections. Limitations of this study include its small sample size and retrospective design, leading to inability to distinguish colonization from true infection. Additional studies are needed to evaluate the impact of combination antibiotic therapy on outcomes.
Improving Consistency and Accuracy: A Novel C. auris Colonization Screening Strategy Using a Nares + Hands Composite Swab
Authors: Lopez Cano Luisa , Arenas Sebastian , Jimenez Adriana , Lyman Meghan , Litvintseva Anastasia , Shukla Bhavarth , Sexton Joe
Published: September 2024

Background: Candida auris is often identified in healthcare settings through bilateral composite of axilla/groin skin swabs screening. Re-screening the same patient has demonstrated inconsistent results over time, complicating the understanding of longitudinal colonization and limiting confidence in negative Results: Previous studies have described identification of colonized patients using other anatomical sites. Here, we compare bilateral composite of nares/hands with bilateral composite of axilla/groin screenings in a cohort of hospitalized patients in Miami, Florida, to assess the use of screening other body sites for C. auris surveillance. Methods: This study took place in a 560-bed academic acute-care facility and included patients previously colonized with C. auris who were cohorted on a 30-bed unit. Bilateral composite samples from both the axilla/groin and nares/hands were obtained simultaneously. Swabs were collected at six different time points at biweekly intervals between March and May 2023 (Figure 1) and sent to the Centers for Disease Control and Prevention for testing with culture and Real-time PCR-based methods. Results: A total of 102 swabs (51 from each swab type) were collected from 19 patients who were each sampled a median of twice (IQR: 1-5). Among the 102 swabs, 35 of 51 (69%) axilla/groin swabs were positive compared with 45 of 51 (88%) nares/hands swabs using culture (Figure 2). Furthermore, 48 of 51 (94%) swabs were positive by culture for both methods, with 15 positive from the nares/hands and one positive from the axilla/groin (Figure 3). Among 11 patients who were tested ≥2 times with nares/hands swabs, 9/11 (81%) tested positive on all sequential swabs via culture and 10/11 (90%) tested positive via PCR (Ct threshold < 3 6.9). Among the same 11 patients but using the axilla/groin swabs, 3/11 (27%) patients tested positive on all sequential swabs using culture, and 5/11 (45%) tested positive using PCR (Figures 2-4). On average, samples collected from nares/hands swabs had lower Ct values (mean=27) compared to axilla/groin swabs (mean=31) (p-value=< 0.001) (Figure 5). Discussion: Identifying the swab site with most consistent C. auris detection is important for surveillance purposes. In our study, there were more positives and consistent positivity for nares/hands by both culture and PCR-based methods, as well as lower Ct values, suggesting that these swabs provide more reliable detection of C. auris colonization. Alternative screening methods deserve consideration as CDC continues to explore whether swabbing of other body sites (e.g., nares, hands) would improve accuracy and consistency when identifying colonized patients.
Assessing chlorhexidine resistance in MRSA isolates from hospitals in Cleveland, OH and Detroit, MI
Authors: Telchik Collin , Jinadatha Chetan , Cadnum Jennifer , Donskey Curtis , Chatterjee Piyali , Dhar Sorabh , Kaye Keith , Yakubik Taylor , Hwang Munok , Grimbergen Andrea
Published: September 2024

Background: Methicillin-resistant Staphylococcus aureus (MRSA) is one of the most common causes of procedure-related, skin, and soft-tissue infections. Hospitalized patients who are colonized with MRSA are at a higher risk of developing invasive infections after discharge. Chlorhexidine, an antiseptic/disinfectant, has been used to reduce carriage and prevent infections in these patients. Studies have shown chlorhexidine resistance among MRSA strains. Chlorhexidine resistance is associated with qac genes, which encode multidrug efflux pumps that increase bacterial tolerance to disinfectant agents. The global distribution and prevalence of qacA and qacB genes are highly variable. One study reported that qacA and qacB genes could be found in 0.9% - 83.3% of clinical MRSA isolates worldwide. The goal of this study was to determine the prevalence of chlorhexidine resistance and identify the resistance-associated genes from our MRSA samples using whole genome sequencing (WGS). Methods: 474 MRSA samples were obtained from hospitals in Detroit, MI (287) and Cleveland, OH (187). Whole genome sequencing was performed using the NextSeq (Illumina Inc., CA) platform. The sequencing data was analyzed using ResFinder 4.1, a publicly available database that can be used to identify acquired genes and chromosomal mutations mediating antimicrobial resistance. The output was organized into a data sheet to visualize the presence of the genes of interest. Results: The qacA gene was present in only one MRSA sample from the Cleveland area hospital. In the samples from Detroit, 14 out of 287 showed disinfectant resistance genes. The qacA, qacB, and qacD were present in 1, 6, and 7 samples, respectively. The prevalence of any qac gene in the Cleveland area samples was 0.5%. Meanwhile, the prevalence of any qac gene in Detroit area samples was 4.9%. Among the 7 samples that have qacD gene, 6 samples have more than one copy of qacD. Conclusions: The prevalence of the “qac” gene varied widely based on the origin of the samples. Detroit area samples had more qac genes prevalence than Cleveland area samples. Chlorhexidine is a widely used antiseptic/disinfectant, and it plays a vital role in reducing carriage and preventing infection among hospitalized patients colonized with MRSA. Monitoring and addressing MRSA-reduced susceptibility to chlorhexidine is imperative for maintaining the effectiveness of infection control practices such as decolonization.
Use of Whole Genome Sequencing for Investigation of Potential Hospital-Acquired Vancomycin Resistant Enterococcus
Authors: Svoronos Petros , Day Shandra , Colburn Nora , Liscynesky Christina , Sun Christine , Sovic Michael , Pancholi Preeti , Balada-Llasat Joan-Miquel , Murthy Shashanka , Ajaka Leama
Published: September 2024

Background: Whole genome sequencing (WGS) is a relatively new method for analyzing outbreaks and modes of transmission, particularly for multidrug resistant bacteria. This study sought to investigate clusters of patients with genetically related Vancomycin-Resistant Enterococcus spp. (VRE) bacteremia for shared hospital environmental exposures. Methods: All VRE blood culture isolates from patients from July 1, 2021 to June 30, 2022 underwent Illumina WGS. Core single nucleotide polymorphisms (SNPs) were identified, and multi-locus sequence typing (MLST) was performed across the VRE isolates. Clusters were defined as isolates with 15 or fewer core genome SNPs and were investigated for potential transmission routes. For each cluster, patients were evaluated in the 12 weeks before and after the first VRE isolate for shared hospital environmental exposures (hospital unit, patient rooms, procedural rooms, and radiology suites). Hospital units were comprised of patient rooms located geographically together on the same floor of the hospital. Results: A total of 82 VRE isolates underwent WGS. Thirty-eight (46%) clustered genetically with at least one other isolate. Clusters included 2 to 15 patients per group and represented 10 distinct MLST subgroups (Figure 1). Nine hundred and thirty-nine hospital environmental exposures were identified across the 38 patients. For each cluster, there was a total of 341 (36.3%) shared exposures. Shared environmental exposures occurred in radiology suites (35, 38.5%), patient rooms (32, 35.6%) and procedural rooms (23, 25.6%). Of the patients who shared the same hospital unit, 10 (31.3%) had the same patient room with 7 (70%) of them being in the emergency department (ED). Overall, the ED represented 7 (21.9%) of the shared hospital units. Each cluster had at least one shared hospital environmental exposure found. Conclusions: Use of WGS can help investigate outbreak clusters of resistant organisms such as VRE. In this study, nearly half of all VRE blood isolates were able to be segregated into clusters with at least one other isolate. Although VRE colonization of hospital rooms is well described, patient rooms represented the smallest proportion of shared hospital environmental exposures. This study thus suggests other environmental transmission routes such as radiology suites and procedural rooms warrant closer investigation.
Experience with Using Personal Protective Equipment among Korean Healthcare Personnel: For the Development of Better Products
Authors: Kang JaHyun , Kim EunJo
Published: September 2024

Background: Although various difficulties and self-contamination concerns have been continuously reported regarding the use of personnel protective equipment (PPE) among healthcare personnel (HCP), better PPE options are unavailable in healthcare settings. This study aimed to thoroughly examine HCP’s PPE experience to develop improved PPE. Method: By sending cooperation requests to eight academic societies (e.g., Korean Society of Infectious Disease, Korean Society of Critical Care Nursing), four hospitals (e.g., National Medical Center), and Korea Disease Control and Prevention Agency, 250 HCP who had direct patient contact with emerging infectious diseases were recruited. The questionnaire with 65 main questions (211 maximum including sub-questions and 19 open-ended questions) was developed in detail (e.g., use frequency, priority check among the options) based on literature reviews and verified by an expert panel. Through an online survey link, participants completed the questionnaire between December 6-11, 2023, and received a $53 incentive. Descriptive statistics were performed for data analysis. Results: Among 250 participants, most were female (80%), in their thirties (46.4), nurses (78%,), working at general hospitals (56%), and averaged 121.1 months of clinical experience (Table 1). Among 6 PPE sets (Figure 1), 29% of participants used Set #2 (i.e., disposable water-proof gown, gloves, goggles/face shield, hair cap, and N95 mask) and 26% used Set #3 (i.e., Level D, gloves, goggles/face shield, shoe cover, N95 mask, and hair cap). 64% of HCP preferred Set #2 due to practical aspects (e.g., simple, convenient, safer than Set #1, and easy donning/doffing). Most PPE sets were largely used for 30 minutes to 1 hour (except level D, to 2 hours). Most prioritized difficulties of PPE use were: disposable mask dampness; pressure pain on the wearing area for N95 masks; powered air purifying respirator (PAPR) wear takes a long time; sweating for gloves, waterproof gowns, and level D/C coveralls; skin exposed through torn gloves; blurry visibility for goggles/face shield; hearing difficulty for hoods; and a slippery bottom for shoe covers. Moments for self-contamination concerns were: adjusting PPE that has slipped down (e.g., masks, gowns, gloves, goggles/face shield, and hoods); doffing hood procedure (e.g., PAPR); and skin contact of shoe cover surfaces during doffing. Most difficulties when using PPE combinations were unfamiliarity with donning/doffing procedures. Participants wish to develop various PPE sizes which can be easily donned/doffed intuitively (e.g., well-ventilated integral PPE). Conclusion: Collaboration with manufacturers based on our results is necessary to develop better PPE options for HCP’s safety and satisfaction.
Whole Genome Sequencing for the Identification of a Streptococcus agalactiae Outbreak in Neonatal Intensive Care Unit
Authors: Dabaja Younis Halima , McGeer Allison , Allen Vanessa , Seguban Angelie , Morillo Andrea , Martin Irene , Golden Alyssa , Johnstone Jennie
Published: September 2024

Background: While Streptococcus agalactiae (Group B Streptococcus [GBS]) infections in infants usually result from maternal transmission, healthcare-associated cases, particularly in the neonatal intensive care unit (NICU), can occur. Whole genome sequencing (WGS) can aid in investigating GBS outbreaks among infants in hospital settings. The aim of the study is to describe the investigation of GBS infections in NICU using WGS. Methods: Infection prevention and control (IPAC) at our hospital monitors the occurrence of late-onset GBS disease (LOD) in our 57-bed NICU, which consists of all private rooms. The occurrence of 2 cases of LOD within 2 weeks triggered an investigation, including WGS of the two isolates and isolates causing invasive GBS during the last 6 months in the unit. GBS isolates underwent WGS using Illumina at Canada’s National Microbiology Laboratory. All affected patients underwent chart-review. Outbreak description and investigation: In August 2023, two NICU neonates (patients 2,3) experienced LOD two weeks apart, one with bacteremic meningitis and the other with two bacteremic episodes three weeks apart. While WGS was pending two additional cases of late-onset GBS bacteremia (patients 4,5) occurred. Isolates from Pts 2,3 and 5 were indistinguishable from each other and from an isolate from an infant admitted to the NICU with early onset bacteremia on July 27, 2023 (day 1 of life) (patient 1). Weekly point prevalence for throat and rectal colonization over 3 weeks identified five infants colonized with unrelated strains. An additional long-stay infant (patient 6) developed GBS conjunctivitis due to a strain indistinguishable from (patient 4) by pulse field gel electrophoresis, WGS for the second cluster is pending. IPAC interventions: Lapses in IPAC practices were observed, with no commonalities among cases other than similar geographic location within the unit. We hypothesized transmission was due to horizontal transmission between babies due to these lapses. Basic IPAC measures, including hand hygiene and environmental cleaning, were reinforced; Additional Precautions were not used due to private rooms’ unit structure. No environmental samples were taken due to lack of an obvious environmental point or common source. Point prevalence monitoring persisted until no new cases related to the outbreak strains were further identified in three consecutive weekly point prevalence. Conclusions: Increased awareness of healthcare-associated transmission is crucial in NICU as LOD GBS emerges. WGS plays a key role in identifying transmission. Detecting a multi-strain outbreak can appropriately redirect investigations. Legend: Figure 1: Timeline of stay at NICU and infection timing for patients 1-6
Candida auris cluster in a center with no previous infections associated with a single organ donor
Authors: Rivere Evan , Meissner Eric , Mills Alexandra , Harris Courtney , Lorek Adrienne , Curry Scott
Published: September 2024

Background: Candida auris is an opportunistic pathogen reported in the US since 2016. C. auris infections (CAI) are frequently healthcare-associated, but only one case of donor-derived CAI in a lung transplant recipient has been reported (PMID 28520901). We describe a cluster of two CAIs at a single center in South Carolina occurring in 2 different recipients from the same solid organ transplant donor. Methods: We describe two cases of invasive CAIs occurring in an academic medical center without prior CAI in Charleston, SC in October 2023. C. auris was identified using Bruker MALDI-TOF and confirmed by the state health department. Results: Patient 1: 40-49 year-old male underwent heart transplantation on day 19 from admission complicated by growth of C. auris on post-op day #15 from a drain. He was readmitted post-op days 22-63 with positive blood cultures for C. auris and underwent re-operation with debridement and hardware removal. C. auris pericarditis required multiple returns to the OR (Figure). He was discharged on micafungin/posaconazole with plans for long-term antifungal therapy. Patient 2: 50-59 year-old male underwent liver and kidney transplantation on day 25 from admission from the same donor as Patient 1 in a separate hospital complex. His course was complicated by possible infected biloma not amendable to drainage and C. auris/C. glabrata fungemia, which was further complicated by abdominal wall collection cultures growing C. auris on post-operative day 35 on washout. He was managed with dual micafungin/posaconazole however, he died of unrelated causes at 93 days after transplant (Figure). Investigation: The donor for both recipients was a 10-19 year-old male who suffered brain death after trauma and was hospitalized for 56 days prior to procurement in Atlanta, GA without known CAI. Airway cultures at the time of organ procurement were positive for rare Pseudomonas and light unidentified yeast of multiple morphologies; urine cultures also grew 40,000 cfu/ml un-identified yeast. Screening of 35 and 4 inpatients in units exposed to patients 1 & 2, respectively, with axilla/groin PCR was negative (Figure). A third organ recipient for this donor (kidney) at our center was identified and had negative urine fungus cultures. Conclusions: Despite no definitive link to a known donor infection, this cluster of CAI occurring simultaneously in 2 patients in separate hospitals/units at a single center with no known prior cases represents likely donor-derived CAI. Our experience suggests that organ procurement organizations should consider improved screening techniques for C. auris in donor cultures.

Disclosure: Scott Curry: Consultant- Ferring; Abbott Diagnostics- Speaker honorarium
Trends of Early Onset Group B Streptococcus infections and Observed Racial and Geographic Disparities Associated with GBS Infections in Tennessee, 2005-2021
Authors: Morris Jordan , Kirtz Erika , Muleta Daniel
Published: September 2024

Background: Group B Streptococcus (GBS) is one of the most common causes of bacterial sepsis in newborns. In 2002, the Center for Disease Control and Prevention (CDC) recommended universal screening of all pregnant women for GBS colonization and administering intrapartum prophylaxis to colonized pregnant women to prevent GBS infection in newborns. To identify racial disparities in GBS infections in Tennessee, we compared the incidence of early-onset GBS infection among Black and White infants from 2005-2021. Methods: GBS infections identified from normally sterile sites are reportable in Tennessee. We analyzed GBS data reported to surveillance systems from 2005 to 2021. We linked the surveillance data with the population data to calculate incidence rates. We excluded cases with unknown race status (9%) and other races (0.2%) as we do not have denominator data to calculate the incidence rate. Database linkage and data analyses were performed in SAS V.9.4. Results: A total of 399 early-onset GBS cases were reported from 2005–2021; 150 (37.59%) were Black, 212 (53.13%) were White, and 36 (9.02%) were of unknown race, and one (0.20%) reported as Other for race. While the incidence rates of early-onset GBS for all races declined from 0.23 per 1000 live births in 2005 to 0.18 per 1000 live births in 2021, Blacks experienced the largest decline in incidence from 0.6 per 1000 live births in 2005 to 0.37 in 2021. Among Whites, there was a slight decline in 2021 (0.13/1000 live births) compared to the rate in 2005 (0.21/1000 live births). The mean incidence rate of early onset GBS among Blacks (0.52 per 1000 live births) is significantly higher than the mean rates among Whites (0.20 per 1000 live births) (p value < 0 .001) from 2005 to 2021. Shelby County, one of the 95 counties in Tennessee, is predominantly Black (54.6%) and reported 27.8% of all early-onset GBS. Conclusion: There was a significant decline in early-onset GBS infections among Blacks and some reductions among Whites, indicating the effectiveness of the prevention strategies. However, Blacks have significantly higher rates than their White counterparts. In addition, 27.8% of the cases are reported from one county, signaling geographic disparities as well. Further investigation is warranted to identify risk factors and causes of observed racial and geographic disparities to help reduce the infection rate among vulnerable populations and high-risk geographic areas.
Changes in Antibiotic Use and Disruptions to Antimicrobial Resistance Detection in South Africa and Uganda, 2019 – 2020
Authors: Fazal Amara , Bancroft Elizabeth , Hartsough Kieran , Cawood Cherie , Kazooba Patrick , Upenytho George , Bitarakwate Edward , Machekano Rhoderick , Herzig Carolyn , Woelk Godfrey
Published: September 2024

Background: The COVID-19 pandemic disrupted routine health services worldwide, including systems to detect antimicrobial resistance (AR). AR is a mounting global health threat with some studies showing the highest mortality rate from AR infection is in Sub-Saharan Africa (SSA). Antibiotic use is a major contributor to AR. We sought to characterize COVID-19-related changes to antibiotic use and AR detection capacity in two countries in SSA from 2019 to 2020. Methods: Health facilities (HF) in South Africa and Uganda were surveyed as part of a larger study assessing disruptions to essential health services in SSA in the context of COVID-19. Modified stratified random sampling of HF by facility level was conducted in regions with high COVID-19 cumulative prevalence. Hospital pharmacists were surveyed to identify perceived changes in antibiotic use. Among facilities with the capacity to detect AR, surveys were conducted with AR laboratory managers to identify perceived changes in staff, equipment, training, and supplies. Descriptive data analysis was conducted using frequencies and proportions. Results: A total of 39 HFs in South Africa and 45 HFs in Uganda responded to the antibiotic use survey. Increases in total antibiotic use from 2019 to 2020 were reported by 82% (23/28) of HF in South Africa and 68% (27/40) in Uganda. Increased use of antibiotics for multi-drug resistant bacteria (per World Health Organization Reserve classification) was reported by 36% (9/25) and 38% (8/21) of HFs in South Africa and Uganda, respectively. 19 HFs in South Africa and 12 HFs in Uganda responded to the AR detection capacity survey. HFs in both countries reported decreases in laboratory staff responsible for AR (33% [13/40] in South Africa and 31% [11/35] in Uganda). Decreased availability of reagents and consumables for bacteriology and antimicrobial susceptibility testing was reported by 50% (8/16) and 33% (4/12) of HFs, and decreased availability of specimen collection supplies for bacterial cultures was reported by 41% (7/17) and 42% (5/12) of HFs in South Africa and Uganda, respectively. Diversion of laboratory supplies was reported in both countries (32% [6/19] in South Africa and 25% [3/12] of HF in Uganda). Conclusions: HFs in South Africa and Uganda reported increases in antibiotic prescribing, a risk factor for increased AR, concurrently with disruptions in AR detection capacity during the early phases of the COVID-19 pandemic. These findings emphasize the importance of investing in bacteriology and AR testing in SSA and maintaining support during infectious disease pandemics.
Case-Control Study Design to Identify Attributable Risk Factors for Rare Yet Trending Healthcare-Associated Infections
Authors: Stroever Stephanie , Hill Krystal , Conley Charity , Quattlebaum Teri
Published: September 2024

Introduction: There are a number of tools available to healthcare epidemiologists for identification and investigation of healthcare-associated infections. For example, root cause analysis (RCA) is an evidence-based strategy for identifying process failures that resulted in infection. However, RCA is most valuable on a case-by-case basis. It is not an efficient tool for investigating numerous events that trend over time. Healthcare epidemiologists must use different strategies that are both efficient and powerful. A case-control study is a valuable option to investigate rare but recurrent infection events. The objective of this study was to demonstrate the utility of a case-control study design to detect attributable risk factors of cesarean section surgical site infections (SSI). Methods: We conducted a case-control study at a Level III childbirth center with data timeframe of January 1, 2021 to May 31, 2023. The project was approved by the institutions’ Quality Improvement Review Board prior to implementation. Cases were identified using the National Healthcare Safety Network (NHSN) SSI event criteria and included all levels of SSI. Controls were selected from the NHSN surgical denominator and were matched randomly without replacement by age at a 1:4 ratio. Variables were identified in collaboration with stakeholders based on known risk factors for SSI and abstracted manually. Analyses were conducted in Stata/MP version 17.0, and we performed multivariable conditional logistic regression with an alpha of 0.05 as threshold for statistical significance. The model was built according to a priori hypotheses and results from bivariate analysis of individual risk factors. Results: There were 32 SSI among 1709 cesarean deliveries, and all cases successfully matched with 4 controls for an analytic sample of 128. Bivariate analyses identified 7 relevant variables for inclusion in the multivariable model which narrowed down significant risk factors to 3: operative time (in minutes), post-operative chlorhexidine gluconate (CHG) bathing, and number of people in the operating room. Assessment of fit indices suggested an excellent fit with pseudo R-square of 0.526. Conclusions: This study demonstrated the utility of a case-control study design to identify attributable risk factors for relatively rare but significantly trending infection events. Not only is the design more efficient (e.g., time needed to abstract 50 data points for each patient), but it also employs statistical analyses that are often lacking in case-by-case investigations or RCA. It also has the power to narrow down risk factors for focused prevention efforts to get “the most bang for the buck.”