To save content items to your account,
please confirm that you agree to abide by our usage policies.
If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your account.
Find out more about saving content to .
To save content items to your Kindle, first ensure firstname.lastname@example.org
is added to your Approved Personal Document E-mail List under your Personal Document Settings
on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part
of your Kindle email address below.
Find out more about saving to your Kindle.
Note you can select to save to either the @free.kindle.com or @kindle.com variations.
‘@free.kindle.com’ emails are free but can only be saved to your device when it is connected to wi-fi.
‘@kindle.com’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.
We provide an overview of diagnostic stewardship with key concepts that include the diagnostic pathway and the multiple points where interventions can be implemented, strategies for interventions, the importance of multidisciplinary collaboration, and key microbiologic diagnostic tests that should be considered for diagnostic stewardship. The document focuses on microbiologic laboratory testing for adult and pediatric patients and is intended for a target audience of healthcare workers involved in diagnostic stewardship interventions and all workers affected by any step of the diagnostic pathway (ie, ordering, collecting, processing, reporting, and interpreting results of a diagnostic test). This document was developed by the Society for Healthcare Epidemiology of America Diagnostic Stewardship Taskforce.
To describe national trends in testing and detection of carbapenemases
produced by carbapenem-resistant Enterobacterales (CRE) and associate
testing with culture and facility characteristics.
Retrospective cohort study.
Department of Veterans’ Affairs medical centers (VAMCs).
Patients seen at VAMCs between 2013 and 2018 with cultures positive for CRE,
defined by national VA guidelines.
Microbiology and clinical data were extracted from national VA data sets.
Carbapenemase testing was summarized using descriptive statistics.
Characteristics associated with carbapenemase testing were assessed with
Of 5,778 standard cultures that grew CRE, 1,905 (33.0%) had evidence of
molecular or phenotypic carbapenemase testing and 1,603 (84.1%) of these had
carbapenemases detected. Among these cultures confirmed as
carbapenemase-producing CRE, 1,053 (65.7%) had molecular testing for
≥1 gene. Almost all testing included KPC (n = 1,047, 99.4%), with KPC
detected in 914 of 1,047 (87.3%) cultures. Testing and detection of other
enzymes was less frequent. Carbapenemase testing increased over the study
period from 23.5% of CRE cultures in 2013 to 58.9% in 2018. The South US
Census region (38.6%) and the Northeast (37.2%) region had the highest
proportion of CRE cultures with carbapenemase testing. High complexity (vs
low) and urban (vs rural) facilities were significantly associated with
carbapenemase testing (P < .0001).
Between 2013 and 2018, carbapenemase testing and detection increased in the
VA, largely reflecting increased testing and detection of KPC. Surveillance
of other carbapenemases is important due to global spread and increasing
antibiotic resistance. Efforts supporting the expansion of carbapenemase
testing to low-complexity, rural healthcare facilities and standardization
of reporting of carbapenemase testing are needed.
This SHEA white paper identifies knowledge gaps and challenges in healthcare epidemiology research related to coronavirus disease 2019 (COVID-19) with a focus on core principles of healthcare epidemiology. These gaps, revealed during the worst phases of the COVID-19 pandemic, are described in 10 sections: epidemiology, outbreak investigation, surveillance, isolation precaution practices, personal protective equipment (PPE), environmental contamination and disinfection, drug and supply shortages, antimicrobial stewardship, healthcare personnel (HCP) occupational safety, and return to work policies. Each section highlights three critical healthcare epidemiology research questions with detailed description provided in supplementary materials. This research agenda calls for translational studies from laboratory-based basic science research to well-designed, large-scale studies and health outcomes research. Research gaps and challenges related to nursing homes and social disparities are included. Collaborations across various disciplines, expertise and across diverse geographic locations will be critical.
This is an epidemiological study of carbapenem-resistant Enterobacteriaceae (CRE) in Veterans’ Affairs medical centers (VAMCs). In 2017, almost 75% of VAMCs had at least 1 CRE case. We observed substantial geographic variability, with more cases in urban, complex facilities. This supports the benefit of tailoring infection control strategies to facility characteristics.
A survey of Veterans’ Affairs Medical Centers on control of carbapenem-resistant Enterobacteriaceae (CRE) and carbapenem-producing CRE (CP-CRE) demonstrated that most facilities use VA guidelines but few screen for CRE/CP-CRE colonization regularly or regularly communicate CRE/CP-CRE status at patient transfer. Most respondents were knowledgeable about CRE guidelines but cited lack of adequate resources.
Laboratory identification of carbapenem-resistant Enterobacteriaceae (CRE) is a key step in controlling its spread. Our survey showed that most Veterans Affairs laboratories follow VA guidelines for initial CRE identification, whereas 55.0% use PCR to confirm carbapenemase production. Most respondents were knowledgeable about CRE guidelines. Barriers included staffing, training, and financial resources.
We analyzed the impact of a fluoroquinolone patient safety initiative on the weekly fluoroquinolone prescription rate in Veterans Affairs community-based outpatient clinics. We observed a significant initial but unsustained reduction. Such an initiative can function as an antimicrobial stewardship intervention; however, strategies to promote sustainability should be explored.
To directly observe healthcare workers in a nursing home setting to measure frequency and duration of resident contact and infection prevention behavior as a factor of isolation practice
SETTING AND PARTICIPANTS
Healthcare workers in 8 VA nursing homes in Florida, Maryland, Massachusetts, Michigan, Washington, and Texas
Over a 15-month period, trained research staff without clinical responsibilities on the units observed nursing home resident room activity for 15–30-minute intervals. Observers recorded time of entry and exit, isolation status, visitor type (staff, visitor, etc), hand hygiene, use of gloves and gowns, and activities performed in the room when visible.
A total of 999 hours of observation were conducted across 8 VA nursing homes during which 4,325 visits were observed. Residents in isolation received an average of 4.73 visits per hour of observation compared with 4.21 for nonisolation residents (P<.01), a 12.4% increase in visits for residents in isolation. Residents in isolation received an average of 3.53 resident care activities per hour of observation, compared with 2.46 for residents not in isolation (P<.01). For residents in isolation, compliance was 34% for gowns and 58% for gloves. Healthcare worker hand hygiene compliance was 45% versus 44% (P=.79) on entry and 66% versus 55% (P<.01) on exit for isolation and nonisolation rooms, respectively.
Healthcare workers visited residents in isolation more frequently, likely because they required greater assistance. Compliance with gowns and gloves for isolation was limited in the nursing home setting. Adherence to hand hygiene also was less than optimal, regardless of isolation status of residents.
To determine the scope, source, and mode of transmission of a multifacility outbreak of extensively drug-resistant (XDR) Acinetobacter baumannii.
SETTING AND PARTICIPANTS
Residents and patients in skilled nursing facilities, long-term acute-care hospital, and acute-care hospitals.
A case was defined as the incident isolate from clinical or surveillance cultures of XDR Acinetobacter baumannii resistant to imipenem or meropenem and nonsusceptible to all but 1 or 2 antibiotic classes in a patient in an Oregon healthcare facility during January 2012–December 2014. We queried clinical laboratories, reviewed medical records, oversaw patient and environmental surveillance surveys at 2 facilities, and recommended interventions. Pulsed-field gel electrophoresis (PFGE) and molecular analysis were performed.
We identified 21 cases, highly related by PFGE or healthcare facility exposure. Overall, 17 patients (81%) were admitted to either long-term acute-care hospital A (n=8), or skilled nursing facility A (n=8), or both (n=1) prior to XDR A. baumannii isolation. Interfacility communication of patient or resident XDR status was not performed during transfer between facilities. The rare plasmid-encoded carbapenemase gene blaOXA-237 was present in 16 outbreak isolates. Contact precautions, chlorhexidine baths, enhanced environmental cleaning, and interfacility communication were implemented for cases to halt transmission.
Interfacility transmission of XDR A. baumannii carrying the rare blaOXA-237 was facilitated by transfer of affected patients without communication to receiving facilities.
Currently it is estimated that about 1 billion people globally have non-alcoholic fatty liver disease (NAFLD), a condition in which liver fat exceeds 5 % of liver weight in the absence of significant alcohol intake. Due to the central role of the liver in metabolism, the prevalence of NAFLD is increasing in parallel with the prevalence of obesity, insulin resistance and other risk factors of metabolic diseases. However, the contribution of liver fat to the risk of type 2 diabetes mellitus and CVD, relative to other ectopic fat depots and to other risk markers, is unclear. Various studies have suggested that the accumulation of liver fat can be reduced or prevented via dietary changes. However, the amount of liver fat reduction that would be physiologically relevant, and the timeframes and dose–effect relationships for achieving this through different diet-based approaches, are unclear. Also, it is still uncertain whether the changes in liver fat per se or the associated metabolic changes are relevant. Furthermore, the methods available to measure liver fat, or even individual fatty acids, differ in sensitivity and reliability. The present report summarises key messages of presentations from different experts and related discussions from a workshop intended to capture current views and research gaps relating to the points above.
(See the article by Thaden et al, on pages 978–983.)
It is critical to the future of public health to understand the burden of carbapenem-resistant Enterobacteriaceae (CRE) so that we can effectively target efforts to limit potential spread. The Centers for Disease Control and Prevention (CDC) classifies CRE as 1 of 3 “urgent” antibiotic resistance threats to public health because of the high mortality associated with CRE infection and its rapid dissemination in the United States.
What is the current burden of CRE disease? We can glean a snapshot of the national epidemiology of CRE from the CDC’s national surveillance. Rapid geographic spread is evident in the CDC’s national map of CRE, which indicates that all but 3 states now have identified CRE. Incidence by facility type, procedure, device, and organism all have considerable variation, providing preliminary indications where future prevention efforts might best be focused. The 2013 CRE Vital Signs states that 3.9% of short-stay acute care hospitals and 17.8% of long-term acute care hospitals have identified cases of CRE infection among those with catheter-associated urinary tract infection (CAUTI) or central line–associated bloodstream infection (CLABSI). The CDC also reported that 10% of Klebsiella species in intensive care unit (ICU) CLABSIs, ICU CAUTIs, and surgical site infections after colon surgery or coronary artery bypass grafting in 2011 were carbapenem resistant. Although CRE have been reported in most states, it is increasingly clear that wide regional variation exists, from regions of hyperendemicity, such as parts of New York City, to regions apparently free of CRE, such as Maine.
To establish a statewide network to detect, control, and prevent the spread of carbapenem-resistant Enterobacteriaceae (CRE) in a region with a low incidence of CRE infection.
Implementation of the Drug Resistant Organism Prevention and Coordinated Regional Epidemiology (DROP-CRE) Network.
Setting and Participants.
Oregon infection prevention and microbiology laboratory personnel, including 48 microbiology laboratories, 62 acute care facilities, and 140 long-term care facilities.
The DROP-CRE working group, comprising representatives from academic institutions and public health, convened an interdisciplinary advisory committee to assist with planning and implementation of CRE epidemiology and control efforts. The working group established a statewide CRE definition and surveillance plan; increased the state laboratory capacity to perform the modified Hodge test and polymerase chain reaction for carbapenemases in real time; and administered surveys that assessed the needs and capabilities of Oregon infection prevention and laboratory personnel. Results of these inquiries informed CRE education and the response plan.
Of 60 CRE reported from November 2010 through April 2013, only 3 were identified as carbapenemase producers; the cases were not linked, and no secondary transmission was found. Microbiology laboratories, acute care facilities, and long-term care facilities reported lacking carbapenemase testing capability, reliable interfacility communication, and CRE awareness, respectively. Survey findings informed the creation of the Oregon CRE Toolkit, a state-specific CRE guide booklet.
A regional epidemiology surveillance and response network has been implemented in Oregon in advance of widespread CRE transmission. Prospective surveillance will determine whether this collaborative approach will be successful at forestalling the emergence of this important healthcare-associated pathogen.
Email your librarian or administrator to recommend adding this to your organisation's collection.