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We used a self-reporting system to compare symptom frequency of hospital personnel with coronavirus disease 2019 before and after the emergence of the Omicron variant. Omicron was more likely to result in asymptomatic carriage (7% vs 12%; P = .009), and fewer symptoms were observed in those with booster vaccination.
In this retrospective study of 105 severe acute respiratory coronavirus virus 2 (SARS-CoV-2)–infected cancer patients with longitudinal nasopharyngeal sampling, the duration of viral shedding and time to attain cycle threshold >30 was longer in patients with hematologic malignancy than in those with solid tumors. These findings have important public health implications.
Background:Clostridioides difficile is a toxin-producing bacterium that is the foremost cause of healthcare-associated diarrhea in the United States. Recent epidemiologic and genomic evidence indicates that divergent C. difficile strains have varying propensities for transmission within healthcare settings. We investigated whether and how these differences are reflected in the genomic epidemiology of 2 common C. difficile strains—sequence type (ST) 1 (analogous to Ribotype 027) and ST2 (associated with Ribotypes 014/020)—across 3 geographically distinct US medical centers. Methods: Between 2011 and 2017, a convenience sample of ST1 and ST2 C. difficile clinical isolates were collected from 3 US sites: The University of Michigan Medical Center, Texas Medical Center Hospitals, and Memorial Sloan Kettering Cancer Center. Isolates underwent whole-genome sequencing and in silico multilocus sequence typing to verify strain types. Sequences were mapped to ST1 and ST2 reference genomes and single nucleotide variants (SNVs) were identified, filtered, and used to construct pairwise SNV distance matrices. A range of pairwise SNV distance thresholds were applied to assess genetic linkages consistent with recent transmission within ST1 compared to within ST2. Proportions of genetically linked isolates were compared using 2 tests. Results: We identified 200 ST1 and 188 ST2 isolates across the 3 collection sites. Overall, ST2 was more genetically diverse than ST1 (pairwise SNV distance range, 0–156 SNVs and 0–78 SNVs, respectively). ST2 isolates displayed significantly less evidence of recent transmission: 10 ST2 isolates (5.3%) were within 2 SNVs of another isolate compared to 88 (44%) ST1 isolates (P .001) (Fig. 1). As the SNV threshold increased to 5 and 10 SNVs, this trend was maintained (all P < .001). ST2 isolates were also more likely to be genetically linked to an isolate from a different collection site than ST1 isolates. Among isolates with genetic links to at least 1 other isolate at the 5 SNV and 10 SNV thresholds, 21 of 37 and 74 of 89 ST2 isolates (57%, 83%) were linked to an isolate from a different collection site, compared to 2 of 88 and 48 of 157 ST1 isolates (2% and 31%, respectively; both P < .001). Conclusions: Compared to C. difficile ST1 isolates, ST2 isolates displayed less evidence of recent healthcare transmission and were more likely to be genetically linked to isolates from divergent collection sites. Interpreting genetic linkages among C. difficile isolates requires an understanding of regional and strain-specific genetic diversity to avoid misattribution of genetic linkages to recent transmission.
Clostridioides difficile infection (CDI) is prevalent in pediatric oncology patients, but the transmission risk to peers is unknown. In 224 children with CDI, multilocus sequence typing (MLST) identified only 7 alleged transmission events (18%) originating from children <3 years old. None of these events were corroborated by WGS.
Oncolytic viral immunotherapy is an emerging treatment modality for cancer that exploits in vivo replication and other viral properties to enhance immune killing of malignant cells. The potential for horizontal transmission of native or engineered oncolytic viruses creates several unique infection control challenges. In 2015, talimogene laherparepvec (TVEC) became the first agent in this class to gain FDA approval for treatment of melanoma, and several others are being developed. Although some data on the transmissibility of TVEC are available from clinical studies, the aftermarket or real-world experience remains limited. We conducted a PUBMED-based search of the medical literature focusing on the safety and risk of TVEC transmission to close contacts including healthcare workers. The findings are summarized in this review and are intended to provide infection preventionists with practical guidance on handling issues related to administration and care of patients receiving TVEC. Additionally, we describe the current mechanism for evaluating the risk related to similar new agents entering clinical trials at our institution. Development of standarized approaches for the safe administration and precautions for ongoing care, especially in immunocompromised patients, are essential to support the broad adoption of this novel therapy.
To determine the effectiveness of ultraviolet (UV) environmental disinfection system on rates of hospital-acquired vancomycin-resistant enterococcus (VRE) and Clostridium difficile.
Using active surveillance and an interrupted time-series design, hospital-acquired acquisition of VRE and C. difficile on a bone marrow transplant (BMT) unit were examined before and after implementation of terminal disinfection with UV on all rooms regardless of isolation status of patients. The main outcomes were hospital-based acquisition measured through (1) active surveillance: admission, weekly, and discharge screening for VRE and toxigenic C. difficile (TCD) and (2) clinical surveillance: incidence of VRE and CDI on the unit.
Bone marrow transplant unit at a tertiary-care cancer center.
Stem cell transplant (SCT) recipients.
Terminal disinfection of all rooms with UV regardless of isolation status of patients.
During the 20-month study period, 579 patients had 704 admissions to the BMT unit, and 2,160 surveillance tests were performed. No change in level or trend in the incidence of VRE (trend incidence rate ratio [IRR], 0.96; 95% confidence interval [CI], 0.81–1.14; level IRR, 1.34; 95% CI, 0.37–1.18) or C. difficile (trend IRR, 1.08; 95% CI, 0.89–1.31; level IRR, 0.51; 95% CI, 0.13–2.11) was observed after the intervention.
Utilization of UV disinfection to supplement routine terminal cleaning of rooms was not effective in reducing hospital-acquired VRE and C. difficile among SCT recipients.
Two distinct clusters of gastroenteritis due to Salmonellae and Entamoeba histolytica (EH) were identified using a multiplex gastrointestinal pathogen panel (GPP) at a tertiary-care cancer center. Despite temporo-spatial overlap, our investigation did not corroborate transmission or true infection. In clinical practice, GPPs may render false-positive results.
Surgical site infections (SSIs) following colorectal surgery (CRS) are among the most common healthcare-associated infections (HAIs). Reduction in colorectal SSI rates is an important goal for surgical quality improvement.
To examine rates of SSI in patients with and without cancer and to identify potential predictors of SSI risk following CRS
American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) data files for 2011–2013 from a sample of 12 National Comprehensive Cancer Network (NCCN) member institutions were combined. Pooled SSI rates for colorectal procedures were calculated and risk was evaluated. The independent importance of potential risk factors was assessed using logistic regression.
Of 22 invited NCCN centers, 11 participated (50%). Colorectal procedures were selected by principal procedure current procedural technology (CPT) code. Cancer was defined by International Classification of Disease, Ninth Revision, Clinical Modification (ICD-9-CM) codes.
The primary outcome of interest was 30-day SSI rate.
A total of 652 SSIs (11.06%) were reported among 5,893 CRSs. Risk of SSI was similar for patients with and without cancer. Among CRS patients with underlying cancer, disseminated cancer (SSI rate, 17.5%; odds ratio [OR], 1.66; 95% confidence interval [CI], 1.23–2.26; P=.001), ASA score ≥3 (OR, 1.41; 95% CI, 1.09–1.83; P=.001), chronic obstructive pulmonary disease (COPD; OR, 1.6; 95% CI, 1.06–2.53; P=.02), and longer duration of procedure were associated with development of SSI.
Patients with disseminated cancer are at a higher risk for developing SSI. ASA score >3, COPD, and longer duration of surgery predict SSI risk. Disseminated cancer should be further evaluated by the Centers for Disease Control and Prevention (CDC) in generating risk-adjusted outcomes.
In this study, we sought to evaluate the performance of the Xpert MTB/RIF (Cepheid) assay for the detection of Mycobacterium tuberculosis (MTB) complex DNA on fresh and formalin-fixed, paraffin-embedded (FFPE) tissue specimens from oncology patients in an area with a low prevalence of tuberculosis. We also aimed to retrospectively assess the potential impact of Xpert MTB/RIF on the duration of airborne infection isolation (AII).
A 473-bed, tertiary-care cancer center in New York City.
A total of 203 tissue samples (101 FFPE and 102 fresh) were tested using Xpert MTB/RIF, including 133 pulmonary tissue samples (65.5%) and 70 extrapulmonary tissue samples (34.5%). Acid-fast bacilli (AFB) culture was used as the diagnostic gold standard. The limit of detection (LOD) and reproducibility were also evaluated for both samples types using contrived specimens. The potential impact of the Xpert MTB PCR assay on tissue samples from AII patients on AII duration was retrospectively assessed.
Using the Xpert MTB/RIF for fresh tissue specimens, the sensitivity was 50% (95% CI, 1.3%–98.7%) and the specificity was 99% (95% CI, 94.5%–99.9%). For FFPE tissue specimens, the sensitivity was 100% (95% CI, 63.1%–100%) and the specificity was 98.3% (95% CI, 95.5%–100%. The LOD was 103 colony-forming units (CFU)/mL for both fresh and FFPE tissue specimens, and the Xpert MTB/RIF was 100% reproducible at concentrations 10 times that of the LOD. With an expected turnaround time of 24 hours, the Xpert MTB PCR could decrease the duration of AII from a median of 8 days to a median of 1 day.
The Xpert MTB/RIF assay offers a valid option for ruling out Mycobacterium tuberculosis complex (MTBC) on tissue samples from oncology patients and for minimizing AII resource utilization.
To describe the utilization of electronic medical data resources, including health records and nursing scheduling resources, to conduct a tuberculosis (TB) exposure investigation in a high-risk oncology unit.
A 42-bed inpatient unit with a mix of surgical and medical patients at a large tertiary-care cancer center in New York City.
High-risk subjects and coworkers exposed to a healthcare worker (HCW) with cavitary smear positive lung TB.
During the 3-month exposure period, 270 patients were admitted to the unit; 137 of these (50.7%) received direct care from the index case HCW. Host immune status and intensity of exposure were used to establish criteria for postexposure testing, and 63 patients (45%) met these criteria for first-tier postexposure testing. No cases of active TB occurred. Among coworkers, 146 had significant exposure (ie, >8 hours cumulative). In the 22-month follow-up period after the exposure, no purified protein derivative or interferon gamma release assay conversions or active cases of TB occurred among exposed HCWs or patients.
Electronic medical records and employee scheduling systems are useful resources to conduct otherwise labor-intensive contact investigations. Despite the high-risk features of our index case, a highly vulnerable immunocompromised patient population, and extended proximity to coworkers, we did not find any evidence of transmission of active or latent tuberculosis infection among exposed individuals.
The contribution of mixed infection in recurrent Clostridium difficile infection (CDI) episodes is not known. Among paired isolates from 52 patients, mixed infection due to >1 toxigenic strain of C. difficile was identified in 8% of first episodes. Among recurrences, relapse from 1 or both co-infecting strains was uncommon; it was detected in a single case each.
To determine the role of unit-based transmission that accounts for cases of early Clostridium difficile infection (CDI) during hospitalization for allogeneic stem cell transplant.
Stem cell transplant unit at a tertiary care cancer center.
Serially collected stool from patients admitted for transplant was screened for toxigenic C. difficile through the hospital stay and genotyping was performed by multilocus sequence typing. In addition, isolates retrieved from cases of CDI that occurred in other patients hospitalized on the same unit were similarly characterized. Transmission links were established by time-space clustering of cases and carriers of shared toxigenic C. difficile strains.
During the 27-month period, 1,099 samples from 264 patients were screened, 69 of which had evidence of toxigenic C. difficile; 52 patients developed CDI and 17 were nonsymptomatic carriers. For the 52 cases, 41 had evidence of toxigenic C. difficile on the first study sample obtained within a week of admission, among which 22 were positive within the first 48 hours. A total of 24 sequence types were isolated from this group; 1 patient had infection with the NAP1 strain. A total of 11 patients had microbiologic evidence of acquisition; donor source could be established in half of these cases.
Most cases of CDI after stem cell transplant represent delayed onset disease in nonsymptomatic carriers. Transmission on stem cell transplant unit was confirmed in 19% of early CDI cases in our cohort with a probable donor source established in half of the cases.
In this study, we examined the impact of routine use of a passive disinfection cap for catheter hub decontamination in hematology–oncology patients.
A tertiary care cancer center in New York City
In this multiphase prospective study, we used 2 preintervention phases (P1 and P2) to establish surveillance and baseline rates followed by sequential introduction of disinfection caps on high-risk units (HRUs: hematologic malignancy wards, hematopoietic stem cell transplant units and intensive care units) (P3) and general oncology units (P4). Unit-specific and hospital-wide hospital-acquired central-line–associated bloodstream infection (HA-CLABSI) rates and blood culture contamination (BCC) with coagulase negative staphylococci (CONS) were measured.
Implementation of a passive disinfection cap resulted in a 34% decrease in hospital-wide HA-CLABSI rates (combined P1 and P2 baseline rate of 2.66–1.75 per 1,000 catheter days at the end of the study period). This reduction occurred only among high-risk patients and not among general oncology patients. In addition, the use of the passive disinfection cap resulted in decreases of 63% (HRUs) and 51% (general oncology units) in blood culture contamination, with an estimated reduction of 242 BCCs with CONS. The reductions in HA-CLABSI and BCC correspond to an estimated annual savings of $3.2 million in direct medical costs.
Routine use of disinfection caps is associated with decreased HA-CLABSI rates among high-risk hematology oncology patients and a reduction in blood culture contamination among all oncology patients.
Infect. Control Hosp. Epidemiol. 2015;36(12):1401–1408
A multicenter survey of 11 cancer centers was performed to determine the rate of hospital-onset Clostridium difficile infection (HO-CDI) and surveillance practices. Pooled rates of HO-CDI in patients with cancer were twice the rates reported for all US patients (15.8 vs 7.4 per 10,000 patient-days). Rates were elevated regardless of diagnostic test used.
The success of central line-associated bloodstream infection (CLABSI) prevention programs in intensive care units (ICUs) has led to the expansion of surveillance at many hospitals. We sought to compare non-ICU CLABSI (nCLABSI) rates with national reports and describe methods of surveillance at several participating US institutions.
Design and Setting.
An electronic survey of several medical centers about infection surveillance practices and rate data for non-ICU Patients.
Ten tertiary care hospitals.
In March 2011, a survey was sent to 10 medical centers. The survey consisted of 12 questions regarding demographics and CLABSI surveillance methodology for non-ICU patients at each center. Participants were also asked to provide available rate and device utilization data.
Hospitals ranged in size from 238 to 1,400 total beds (median, 815). All hospitals reported using Centers for Disease Control and Prevention (CDC) definitions. Denominators were collected by different means: counting patients with central lines every day (5 hospitals), indirectly estimating on the basis of electronic orders (n = 4), or another automated method (n = 1). Rates of nCLABSI ranged from 0.2 to 4.2 infections per 1,000 catheter-days (median, 2.5). The national rate reported by the CDC using 2009 data from the National Healthcare Surveillance Network was 1.14 infections per 1,000 catheter-days.
Only 2 hospitals were below the pooled CLABSI rate for inpatient wards; all others exceeded this rate. Possible explanations include differences in average central line utilization or hospital size in the impact of certain clinical risk factors notably absent from the definition and in interpretation and reporting practices. Further investigation is necessary to determine whether the national benchmarks are low or whether the hospitals surveyed here represent a selection of outliers.
Recent surveillance from US hospitals shows that more than 99.5% of vancomycin-resistant enterococci (VRE) isolates remain susceptible to daptomycin. This report describes emergence of daptomycin-resistant VRE at a major cancer center. The percentage of patients with daptomycin-resistant VRE bacteremia increased from 3.4% in 2007 to 15.2% in 2009 (P = .03). Without susceptibility data, empiric daptomycin therapy for VRE infections should be used with caution.
In 2007–2008, several US hospitals reported summertime increases in the number of clinical blood cultures positive for Bacillus species, which are common environmental bacteria.
To investigate increased rates of isolation of Bacillus species from blood cultures, identify risk factors, and recommend control strategies.
Survey and case-control study.
Multiple hospitals, including a cancer center.
We surveyed 24 facilities that reported increases. We also conducted a field investigation at a hospital with a high rate, reviewing charts, collecting clinical and environmental isolates, and observing infection control procedures. A case-control study compared inpatient case patients who had any blood culture positive for Bacillus with unmatched control patients who had a blood culture with no growth during June-August 2008.
Among surveyed facilities, mean monthly rates rose from 25 to a peak of 75 Bacillus-positive blood cultures per 10,000 blood cultures performed during the period June-August. At the hospital where the case-control investigation was conducted, for most case patients (75%), the Bacillus-positive blood cultures represented contamination or device colonization rather than infection. We enrolled 48 case patients and 48 control patients; in multivariate analysis, only central venous access device use was significantly associated with case status (odds ratio, 14.0; P < .01). Laboratory testing identified at least 12 different Bacillus species (non-anthracis) among the isolates. Observation of infection control procedures revealed variability in central line care and blood sample collection techniques.
Periodic increases in the environmental load of Bacillus species may occur in hospitals. Our investigation indicated that at one facility, these increases likely represented a pseudo-outbreak of Bacillus species colonizing central venous lines or their accessories, such as needleless connector devices. Vigilant attention should be paid to infection control practices when collecting blood samples for culture, to minimize the risk of contamination by environmental microorganisms.
Persons who receive live attenuated vaccine may occasionally transmit the vaccine strain to others. The risk of such transmission is a concern, especially for persons who provide care to immunocompromised patients (ie, family and healthcare workers [HCWs]). Since the Advisory Committee on Immunization Practices released guidelines 10 years ago, several new live attenuated products have been introduced, and additional information on older vaccines has become available. To better define the risk of transmission associated with live vaccines, we reviewed the currently available literature.
A review of the medical literature revealed no major risk of transmission associated with any live attenuated vaccine. A theoretical risk continues to exist for the live attenuated intranasal influenza vaccine and the smallpox vaccine.
The available data support routine vaccination with live attenuated vaccines for all household contacts of immunocompromised patients and for HCWs caring for such Patients. The benefit for immunocompromised patients of providing herd immunity against this group of potentially devastating pathogens outweighs the risk, if any, of secondary transmission.
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