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In June 2018, the Ministry of Health received notification from 2 hospitals about 2 patients who presented with overwhelming Enterobacter kobei sepsis that developed within 24 hours after a dental procedure. We describe the investigation of this outbreak.
The epidemiologic investigation included site visits in 2 dental clinics and interviews with all involved healthcare workers. Chart reviews were conducted for case and control subjects. Samples were taken from medications and antiseptics, environmental surfaces, dental water systems, and from the involved healthcare professionals. Isolate similarity was assessed using repetitive element sequence-based polymerase chain reaction (REP-PCR).
The 2 procedures were conducted in different dental clinics by different surgeons and dental technicians. A single anesthesiologist administered the systemic anesthetic in both cases. Cultures from medications, fluids and healthcare workers’ hands were negative, but E. kobei was detected from the anesthesiologist’s portable medication cart. The 2 human isolates and the environmental isolate shared the same REP-PCR fingerprinting profile. None of the 21 patients treated by the anesthesiologist in a general hospital during the same period, using the hospital’s medications, developed infection following surgery.
An outbreak of post–dental-procedure sepsis was linked to a contaminated medication cart, emphasizing the importance of medication storage standards and strict aseptic technique when preparing intravenous drugs during anesthesia. Immediate reporting of sepsis following these outpatient procedures enabled early identification and termination of the outbreak.
We characterized 57 isolates from a 2-phase clonal outbreak of New Delhi metallo-β-lactamase–producing Eschericha coli, involving 9 Israeli hospitals; all but 1 isolate belonged to sequence-type (ST) 410. Most isolates in the second phase harbored blaKPC-2 in addition to blaNDM-5. Genetic sequencing revealed most dual-carbapenemase–producing isolates to be monophyletically derived from a common ancestor.
Background: Two affiliated teaching hospitals in Chicago, Illinois, participated in an ethnographic study of hospital-based inpatient antimicrobial stewardship programs and interventions between 2017 and 2018. Although antimicrobial stewardship is now a requirement in medical practice, it is not clear how infectious disease physicians perceive and understand antimicrobial stewardship. Over a period of 18 months, we directly observed infectious disease practice to better understand how antimicrobial stewardship is conducted among physicians within the same specialty. Methods: A doctoral candidate medical anthropologist conducted semistructured interviews with infectious disease attending physicians and fellow physicians (N = 18) at 2 affiliated teaching hospitals in Chicago, IL, between July 2017 and March 2018 as part of an ethnographic study involving direct observation of inpatient care. Interview questions focused on 3 key domains: (1) descriptions of antimicrobial use among hospital-based physicians, (2) solicited definitions of antimicrobial stewardship, and (3) experiences practicing as an infectious disease consultant. Physicians who were directly involved with the antimicrobial stewardship program were excluded from this analysis. Transcriptions of the data were analyzed using thematic coding aided by MAXQDA qualitative analysis software. Results: Infectious disease physicians have a robust understanding of antimicrobial stewardship (Table 1). Infectious disease physicians described other hospital-based physicians as regularly overusing and misusing antimicrobials, compared with their practice, which they described as “thoughtful.” Definitions in response to the question “What is antimicrobial stewardship?” centered on guiding the prescribing behavior of others. Infectious disease physicians valued stewardship and were concerned with lack of adherence to antimicrobial prescribing recommendations among other hospital-based physicians, behaviors which infectious disease physicians viewed as perpetuating antibiotic resistance. Finally, infectious disease physicians found serving as antimicrobial stewards during their everyday practice to be challenging based on their role as consultants to the primary service. Conclusions: Our qualitative analysis revealed that infectious disease physicians not regularly involved in antimicrobial stewardship are highly motivated stewards who perceive their hospital-based colleagues to be less effective at appropriately prescribing antimicrobials. As consultants, infectious disease physicians are not autonomous decision makers. However, as antimicrobial stewardship programs search for champions, infectious disease physicians could be better utilized as knowledgeable and motivated individuals who can make the case for stewardship.
The diagnosis of Postural Orthostatic Tachycardia syndrome traditionally involves orthostatic vitals evaluation. The Compensatory Reserve Index is a non-invasive, FDA-cleared algorithm that analyses photoplethysmogram waveforms in real time to trend subtle waveform features associated with varying degrees of central volume loss, from normovolemia to decompensation. We hypothesised that patients who met physiologic criteria for Postural Orthostatic Tachycardia syndrome would have greater changes in Compensatory Reserve Index with orthostatic vitals.
Orthostatic vitals and Compensatory Reserve Index values were assessed in individuals previously diagnosed with Postural Orthostatic Tachycardia syndrome and healthy controls aged 12–21 years. Adolescents were grouped for comparison based on whether they met heart rate criteria for Postural Orthostatic Tachycardia syndrome (physiologic Postural Orthostatic Tachycardia syndrome).
Sixty-one patients were included. Eighteen percent of patients with an existing Postural Orthostatic Tachycardia syndrome diagnosis met heart rate criteria, and these patients had significantly greater supine to standing change in Compensatory Reserve Index (0.67 vs. 0.51; p<0.001). The optimal change in Compensatory Reserve Index for physiologic Postural Orthostatic Tachycardia syndrome was 0.60. Patients with physiologic Postural Orthostatic Tachycardia syndrome were more likely to report previous diagnoses of anxiety or depression (p = 0.054, 0.042).
An accurate diagnosis of Postural Orthostatic Tachycardia syndrome may be confounded by related comorbidities. Only 18% (8/44) of previously diagnosed Postural Orthostatic Tachycardia syndrome patients met heart rate criteria. Findings support the utility of objective physiologic measures, such as the Compensatory Reserve Index, to more accurately identify patients with true autonomic dysfunction.
We compared the yield of culturing various body sites to detect carriage of carbapenem-resistant Acinetobacter baumannii (CRAB). Culturing the skin using a premoistened sponge, with overnight enrichment and plating on CHROMagar MDR Acinetobacter, had the highest yield: 92%. Skin is satisfactory as a single site for active surveillance of CRAB.
OBJECTIVES/GOALS: Metabolic syndrome (MetSyn) is a risk for World Trade Center-Lung Injury (WTC-LI; defined as developing FEV1<lower limit of normal [LLN]). Metabolic health is a modifiable disease risk factor. We propose to characterize how time-dependent covariates of MetSyn are longitudinally associated with WTC-LI. METHODS/STUDY POPULATION: WTC-particulate exposed firefighters, consented, with pre-9/11 FEV1 LLN (N = 5,746). Data assessed from last pre-9/11 till August 1, 2017. Longitudinal MetSyn characteristics were assessed using 3 models: i. A linear mixed effect model to assess the effect size of longitudinal MetSyn and its components on longitudinal FEV1% predicted as an outcome; ii. a time-dependent Cox regression to assess the associations of MetSyn to time of onset of WTC-LI; iii. a novel, partially linear single index regression model with repeatedly measured MetSyn to assess their joint effects and delineate their relative contribution on the longitudinal lung function in the WTC-FDNY cohort. RESULTS/ANTICIPATED RESULTS: In Model I, BMI 30 kg/m2 had the largest effect size compared to ever-smoking, with −2.524 (95%CI: −2.708,−2.340) compared to −1.681(−2.325,−1.038) respectively. Having MetSyn, defined as 3/5 risk factors, had an effect size of −2.319(−2.526,−2.112). In Model II, hazards of triglycerides 150mg/dL were highest at 1.497(1.336, 1.677), followed by BMI 30 kg/m2 at 1.406(1.256, 1.575), and HDL<40mg/dL 1.355(1.176-1.561), compared to ever-smoking (1.201, p = 0.002). Having high exposure to PM by being present in the morning of 9/11 was a significant covariate only in Model II investigating HDL<40mg/dL or triglycerides 150mg/dL. Model III The proposed methods will be applied to our cohort study. DISCUSSION/SIGNIFICANCE OF IMPACT: MetSyn is both a predictor and concurrent marker of WTC-LI. The single index model can not only reduce dimensionality of the covariates, but also provides efficient estimates of the joint MetSyn effects, allowing linear or nonlinear effects. Future studies will investigate dietary intervention as a potential disease-modifying factor. CONFLICT OF INTEREST DESCRIPTION: NA, nothing to disclose.
Recent political contests across Europe and North America have been propelled by a wave of populist, anti-immigrant resentment, and it was widely expected that these populist victories would further fan the flames of xenophobia. This article reports the results of an experiment around the Brexit referendum, designed to test how populist victories shape anti-immigrant attitudes. The study finds that anti-immigrant attitudes actually softened after the Brexit referendum, among both Leave and Remain supporters, and these effects persisted for several months. How could a right-wing, populist victory soften anti-immigrant attitudes? The authors use causal mediation analysis to understand this ‘populist paradox’. Among Leavers, a greater sense of control over immigration channelled the effects of the Brexit outcome onto anti-immigrant attitudes. Individuals' efforts to distance themselves from accusations of xenophobia and racism explains the softening of attitudes towards immigration observed among both Leavers and Remainers.
Patients with carbapenem-resistant Acinetobacter baumannii-positive clinical cultures during a prior hospitalization were screened using high sensitivity methods upon first readmission. Of 38 patients, 31.6% screened positive; 42% screened positive within 2 months from discharge, and 14% screened positive more than 5 months from discharge. Carriage was persistent up to 285 days.
To assess the safety of, and subsequent allergy documentation associated with, an antimicrobial stewardship intervention consisting of test-dose challenge procedures prompted by an electronic guideline for hospitalized patients with reported β-lactam allergies.
Retrospective cohort study.
Large healthcare system consisting of 2 academic and 3 community acute-care hospitals between April 2016 and December 2017.
We evaluated β-lactam antibiotic test-dose outcomes, including adverse drug reactions (ADRs), hypersensitivity reactions (HSRs), and electronic health record (EHR) allergy record updates. HSR predictors were examined using a multivariable logistic regression model. Modification of the EHR allergy record after test doses considered relevant allergy entries added, deleted, and/or specified.
We identified 1,046 test-doses: 809 (77%) to cephalosporins, 148 (14%) to penicillins, and 89 (9%) to carbapenems. Overall, 78 patients (7.5%; 95% confidence interval [CI], 5.9%–9.2%) had signs or symptoms of an ADR, and 40 (3.8%; 95% CI, 2.8%–5.2%) had confirmed HSRs. Most HSRs occurred at the second (ie, full-dose) step (68%) and required no treatment beyond drug discontinuation (58%); 3 HSR patients were treated with intramuscular epinephrine. Reported cephalosporin allergy history was associated with an increased odds of HSR (odds ratio [OR], 2.96; 95% CI, 1.34–6.58). Allergies were updated for 474 patients (45%), with records specified (82%), deleted (16%), and added (8%).
This antimicrobial stewardship intervention using β-lactam test-dose procedures was safe. Overall, 3.8% of patients with β-lactam allergy histories had an HSR; cephalosporin allergy histories conferred a 3-fold increased risk. Encouraging EHR documentation might improve this safe, effective, and practical acute-care antibiotic stewardship tool.
We measured droplet aerosol dissemination of carbapenem-resistant Acinetobacter baumannii (CRAB) by sampling air surrounding 10 ventilated patients with CRAB isolated in sputum. Over 70 hours, we sampled 252,000 L of air; CRAB was detected in 39,600 L (16%). CRAB growth was higher during patient care, notably suctioning and sheet changing.
Since 2006, Israel has been confronting an outbreak of carbapenem-resistant Enterobacteriaceae (CRE), and in 2007 Israel implemented a national strategy to contain spread. The intervention was initially directed toward acute-care hospitals and later expanded to include an established reservoir of carriage in long-term-care hospitals. It included regular reporting of CRE cases to a central registry and daily oversight of management of the outbreak at the institutional level. Microbiological methodologies were standardized in clinical laboratories nationwide. Uniform requirements for carrier screening and isolation were established, and a protocol for discontinuation of carrier status was formulated. In response to the evolving epidemiology of CRE in Israel and the continued need for uniform guidelines for carrier detection and isolation, the Ministry of Health in 2016 issued a regulatory circular updating the requirements for CRE screening, laboratory diagnosis, molecular characterization, and carrier isolation, as well as reporting and discontinuation of isolation in healthcare institutions nationwide. The principal elements of the circular are contained herein.
Background: Neurosurgical residents face a unique combination of challenges, including long duty hours, technically challenging cases, and uncertain employment prospects. We sought to assess the demographics, interests, career goals, self-rated happiness, and overall well-being of Canadian neurosurgery residents. Methods: A cross-sectional survey was developed and sent through the Canadian Neurosurgery Research Collaborative to every resident enrolled in a Canadian neurosurgery program as of April 1, 2016. Results: We analyzed 76 completed surveys of 146 eligible residents (52% response rate). The median age was 29 years, with 76% of respondents being males. The most popular subspecialties of interest for fellowship were spine, oncology, and open vascular neurosurgery. The most frequent self-reported number of worked hours per week was the 80- to 89-hour range. The majority of respondents reported a high level of happiness as well as stress. Sense of accomplishment and fatigue were reported as average to high and overall quality of life was low for 19%, average for 49%, and high for 32%. Satisfaction with work-life balance was average for 44% of respondents and was the only tested domain in which significant dissatisfaction was identified (18%). Overall, respondents were highly satisfied with their choice of specialty, choice of program, surgical exposure, and work environment; however, intimidation was reported in 36% of respondents and depression by 17%. Conclusions: Despite a challenging residency and high workload, the majority of Canadian neurosurgery residents are happy and satisfied with their choice of specialty and program. However, work-life balance, employability, resident intimidation, and depression were identified as areas of active concern.
OBJECTIVES/SPECIFIC AIMS: Inflammatory bowel disease (IBD) patients are at an increased risk of Clostridium difficile infection (CDI) but the impact of CDI on disease severity is unclear. The aim of this study was to determine the effect of CDI on long-term disease outcome in a cohort of IBD patients. METHODS/STUDY POPULATION: We analyzed patients enrolled in a prospective IBD natural history registry. Patients who tested positive at least once formed the CDI positive group. We generated a 2:1 propensity matched control cohort based on risk factors of CDI in the year before infection. Healthcare utilization data (emergency department use, subsequent hospitalizations, telephone encounters), medications, labs, disease activity, and quality of life metrics were temporally organized. RESULTS/ANTICIPATED RESULTS: A total of 198 patients (66 CDI, 132 matched controls) were included [56.6% female; 60.1% Crohn’s disease (CD), 39.9% ulcerative colitis (UC)]. Groups were not significantly different in the year before infection in all metrics but in the year of infection, having CDI was significantly associated with more steroid and antibiotic exposure, elevated C-reactive protein or erythrocyte sedimentation rate, and low vitamin D (all p<0.01). Infection was associated with increased disease activity metrics (UC: p=0.036, CD: p=0.003), worse disease-related quality of life (p=0.003), and increased healthcare utilization (p<0.001). In the next year after infection those with prior CDI continued to have increased exposure to vancomycin or fidaxomicin (p<0.001) and all other antibiotics (p=0.01). They also continued to have more clinic visits (p=0.006), telephone encounters (p=0.001), and worse disease-related quality of life (p=0.03), but disease activity and biomarkers of severity were not significantly different between groups. DISCUSSION/SIGNIFICANCE OF IMPACT: CDI infection in IBD is significantly associated with various surrogate markers of disease severity, increased healthcare utilization and poor quality of life during the year of infection. CDI patients continue to experience poor quality of life after infection with increased clinic visits and antibiotic exposure while disease activity is no longer significantly increased. These findings suggest that CDI infection may have a lasting effect on healthcare utilization beyond the acute treatment period.
Clinician education and prospective audit and feedback interventions, deployed separately and concurrently, did not reduce antimicrobial use errors or rates compared to a control group of general medicine inpatients at our public hospital. Additional research is needed to define the optimal scope and intensity of hospital antimicrobial stewardship interventions.
Carbapenemase-producing carbapenem-resistant Enterobacteriaceae (CP-CRE) are extremely drug-resistant pathogens. Screening of contacts of newly identified CP-CRE patients is an important step to limit further transmission. We aimed to determine the risk factors for CP-CRE acquisition among patients exposed to a CP-CRE index patient.
A matched case-control study was performed in a tertiary care hospital in Israel. The study population was comprised of patients who underwent rectal screening for CP-CRE following close contact with a newly identified CP-CRE index patient. Cases were defined as positive tests for CP-CRE. For each case patient, 2 matched controls were randomly selected from the pool of contacts who tested negative for CP-CRE following exposure to the same index case. Bivariate and multivariate analyses were conducted using conditional logistic regression.
In total, 53 positive contacts were identified in 40 unique investigations (896 tests performed on 735 contacts) between October 6, 2008, and June 7, 2012. blaKPC was the only carbapenemase identified. In multivariate analysis, risk factors for CP-CRE acquisition among contacts were (1) contact with an index patient for ≥3 days (odds ratio [OR], 9.8; 95% confidence interval [CI], 2.0–48.9), (2) mechanical ventilation (OR, 4.1; 95% CI, 1.4–11.9), and (3) carriage or infection with another multidrug-resistant organism (MDRO; OR, 2.6; 95% CI, 1.0–7.1). Among patients who received antibiotics, cephalosporins were associated with a lower risk of acquisition.
Patient characteristics (ventilation and carriage of another MDRO) as well as duration of contact are risk factors for CP-CRE acquisition among contacts. The role of cephalosporins requires further study.
To determine the association between household food security and infant complementary feeding practices in rural Bangladesh.
Prospective, cohort study using structured home interviews during pregnancy and 3 and 9 months after delivery. We used two indicators of household food security at 3-months’ follow-up: maternal Food Composition Score (FCS), calculated via the World Food Programme method, and an HHFS index created from an eleven-item food security questionnaire. Infant feeding practices were characterized using WHO definitions.
Two rural sub-districts of Kishoreganj, Bangladesh.
Mother–child dyads (n 2073) who completed the 9-months’ follow-up.
Complementary feeding was initiated at age ≤4 months for 7 %, at 5–6 months for 49 % and at ≥7 months for 44 % of infants. Based on 24 h dietary recall, 98 % of infants were still breast-feeding at age 9 months, and 16 % received ≥4 food groups and ≥4 meals (minimally acceptable diet) in addition to breast milk. Mothers’ diet was more diverse than infants’. The odds of receiving a minimally acceptable diet for infants living in most food-secure households were three times those for infants living in least food-secure households (adjusted OR=3·0; 95 % CI 2·1, 4·3). Socio-economic status, maternal age, literacy, parity and infant sex were not associated with infant diet.
HHFS and maternal FCS were significant predictors of subsequent infant feeding practices. Nevertheless, even the more food-secure households had poor infant diet. Interventions aimed at improving infant nutritional status need to focus on both complementary food provision and education.
A segment of the debate surrounding the commercialization and use of glyphosate-resistant (GR) crops focuses on the theory that the implementation of these traits is an extension of the intensification of agriculture that will further erode the biodiversity of agricultural landscapes. A large field-scale study was initiated in 2006 in the United States on 156 different field sites with a minimum 3-yr history of GR-corn, -cotton or -soybean in the cropping system. The impact of cropping system, crop rotation, frequency of using the GR crop trait, and several categorical variables on seedbank weed population density and diversity was analyzed. The parameters of total weed population density of all species in the seedbank, species richness, Shannon's H′ and evenness were not affected by any management treatment. The similarity between the seedbank and aboveground weed community was more strongly related to location than management; previous year's crops and cropping systems were also important while GR trait rotation was not. The composition of the weed flora was more strongly related to location (geography) than any other parameter. The diversity of weed flora in agricultural sites with a history of GR crop production can be influenced by several factors relating to the specific method in which the GR trait is integrated (cropping system, crop rotation, GR trait rotation), the specific weed species, and the geographical location. Continuous GR crop, compared to fields with other cropping systems, only had greater species diversity (species richness) of some life forms, i.e., biennials, winter annuals, and prostrate weeds. Overall diversity was related to geography and not cropping system. These results justify further research to clarify the complexities of crops grown with herbicide-resistance traits to provide a more complete characterization of their culture and local adaptation to the weed seedbank.