Background Clinical testing detects a fraction of carbapenem-resistant Enterobacteriaceae (CRE) c... more Background Clinical testing detects a fraction of carbapenem-resistant Enterobacteriaceae (CRE) carriers. Detecting a greater proportion could lead to increased use of infection prevention and control measures but requires resources. Therefore, it is important to understand the impact of detecting increasing proportions of CRE carriers. Methods We used our Regional Healthcare Ecosystem Analyst–generated agent-based model of adult inpatient healthcare facilities in Orange County, California, to explore the impact that detecting greater proportions of carriers has on the spread of CRE. Results Detecting and placing 1 in 9 carriers on contact precautions increased the prevalence of CRE from 0% to 8.0% countywide over 10 years. Increasing the proportion of detected carriers from 1 in 9 up to 1 in 5 yielded linear reductions in transmission; at proportions >1 in 5, reductions were greater than linear. Transmission reductions did not occur for 1, 4, or 5 years, varying by facility type...
Infection Control & Hospital Epidemiology, 2015
OBJECTIVETo determine whether real-time availability of rapid molecular results of Staphylococcus... more OBJECTIVETo determine whether real-time availability of rapid molecular results of Staphylococcus aureus would impact emergency department clinician antimicrobial selection for adults with cutaneous abscesses.DESIGNWe performed a prospective, randomized controlled trial comparing a rapid molecular test with standard of care culture-based testing. Follow-up telephone calls were made at between 2 and 7 days, 1 month, and 3 months after discharge.SETTINGTwo urban, academic emergency departments.PATIENTSPatients at least 18 years old presenting with a chief complaint of abscess, cellulitis, or insect bite and receiving incision and drainage were eligible. Seven hundred seventy-eight people were assessed for eligibility and 252 met eligibility criteria.METHODSClinician antibiotic selection and clinical outcomes were evaluated. An ad hoc outcome of test performance was performed.RESULTSWe enrolled 252 patients and 126 were randomized to receive the rapid test. Methicillin-susceptible S. a...
Community-acquired, methicillin-resistant Staphylococcus aureus (MRSA) infections are on the rise... more Community-acquired, methicillin-resistant Staphylococcus aureus (MRSA) infections are on the rise among patients without risk factors for resistant microorganisms. A new, serious community-acquired MRSA manifestation, postpartum iliopsoas pyomyositis is described. A 24-year-old Hispanic female presented with back pain 9 days after a normal vaginal delivery. Magnetic resonance imaging showed extensive ill-defined edema of the left iliopsoas. Blood cultures yielded community-acquired MRSA. The patient received intravenous vancomycin for 6 days, followed by intravenous, then oral, trimethoprim-sulfamethoxazole. She was discharged on day 8 and made a full recovery. Iliopsoas pyomyositis is a new manifestation of community-acquired MRSA in the obstetric population that may masquerade as benign musculoskeletal back pain. Obstetricians must be alert to the range of presentations of this emerging pathogen.
Infection Control & Hospital Epidemiology, 2012
Objective.Vancomycin-resistant enterococci (VRE) have become a public health concern with implica... more Objective.Vancomycin-resistant enterococci (VRE) have become a public health concern with implications for patient mortality and costs. Hospital antibiotic usage may impact VRE incidence, but the relationship is poorly understood. Animal investigations suggest that ceftriaxone may be associated with VRE proliferation. We measured antimicrobial usage and VRE bloodstream infection (VRE-BSI) incidence to test our hypothesis that increased ceftriaxone usage would be associated with a higher incidence of VRE-BSI.Design.Retrospective cohort study.Setting.University of Alabama at Birmingham Medical Center, a 900-bed urban tertiary care hospital.Participants.All patients admitted during the study period contributed data.Methods.We conducted a retrospective analysis of antimicrobial usage and VRE-BSI from 2005 to 2008 (43 months). Antimicrobial usage was quantified as days of therapy (DOTs) per 1,000 patient-days. VRE-BSI incidence was calculated as cases per 1,000 patient-days. Negative bin...
Recurrent community-associated methicillin-resistant S. aureus (CA-MRSA) skin infections are an i... more Recurrent community-associated methicillin-resistant S. aureus (CA-MRSA) skin infections are an increasingly common problem. However, there are no data on the efficacy of decolonization regimens. We prospectively evaluated 31 patients with recurrent CA-MRSA skin infections who received nasal mupirocin, topical hexachlorophene body wash, and an oral anti-MRSA antibiotic. The mean number of MRSA infections after the intervention decreased significantly from baseline (0.03 vs. 0.84 infections/month, P=<0.0001). This regimen appears promising at preventing recurrent CA-MRSA infections. 4 Community-associated methicillin resistant Staphylococcus aureus (CA-MRSA) skin infections are an increasingly common reason to seek medical care in clinics, urgent care centers, and emergency departments and appear to have driven up rates of visits to practitioners for skin infections.(5, 10) Patients with CA-MRSA skin infections often report recurrent episodes with
Background: Virtually all studies of risk factors for CA-MRSA infection have been retrospective. ... more Background: Virtually all studies of risk factors for CA-MRSA infection have been retrospective. Thus, the true contribution of many important exposures has been difficult to ascertain. To our knowledge no prospective studies of CA-MRSA risk factors compare CA-MRSA-infected patients to uninfected controls. Methods: We approached consecutive patients admitted to Harbor-UCLA Medical Center with a culture positive for S. aureus within 72 hours of admission. Consenting patients were given a detailed questionnaire and had their chart reviewed. Each CA-MRSA patient was matched to a control by age, gender, race, and hospital ward. Results: Of 409 consecutive patients, 280/303 (92%) patients still hospitalized consented; 120 had CA-MRSA infection. Subjects were 76% male, 49% Hispanic and 19% Afr.-American. Mean age was 38 years; 10% were children. The most common admitting diagnoses among controls were: trauma (22%), infection (19%), and general surgical condition (18%). In a bivariate anal...
Clinical infectious diseases : an official publication of the Infectious Diseases Society of America, Jan 15, 2014
The incidence of community-onset (CO) methicillin-resistant Staphylococcus aureus (MRSA) bacterem... more The incidence of community-onset (CO) methicillin-resistant Staphylococcus aureus (MRSA) bacteremia rose from the late 1990s through the 2000s. However, hospital-onset (HO) MRSA rates have recently declined in the United States and Europe. Data were abstracted from infection prevention databases between 1 January 2008 and 31 December 2011 at 5 US academic medical centers to determine the number of single-patient blood cultures positive for MRSA and methicillin-susceptible S. aureus (MSSA) per calendar year, stratified into CO and HO infections. Across the 5 centers, 4171 episodes of bacteremia were identified. Center A (Los Angeles, California) experienced a significant decline in CO-MRSA bacteremia rates (from a peak in 2009 of 0.42 to 0.18 per 1000 patient-days in 2011 [P = .005]), whereas CO-MSSA rates remained stable. Centers B (San Francisco, California), D (Chicago, Illinois), and E (Raleigh-Durham, North Carolina) experienced a stable incidence of CO-MRSA and CO-MSSA bacterem...
We performed secondary analyses of a postdischarge decolonization trial of MRSA carriers that red... more We performed secondary analyses of a postdischarge decolonization trial of MRSA carriers that reduced MRSA infection and hospitalization by 30%. Hospitalized MRSA infection was associated with 7.9 days of non-MRSA antibiotics and CDI in 3.9%. Preventing MRSA infection and associated hospitalization may reduce antibiotic use and CDI incidence.
BACKGROUND The CLEAR trial demonstrated that a multi-site body decolonization regimen reduced pos... more BACKGROUND The CLEAR trial demonstrated that a multi-site body decolonization regimen reduced post-discharge infection and hospitalization in methicillin-resistant Staphylococcus aureus (MRSA) carriers. This report describes decolonization efficacy in clearing site-specific MRSA colonization during the trial. METHODS We performed a large, multi-center, randomized clinical trial of MRSA decolonization among adult patients after hospital discharge with MRSA infection or colonization. Participants were randomized 1:1 to either MRSA prevention education or education plus decolonization with 4% topical chlorhexidine daily, 0.12% oral chlorhexidine rinse twice daily, and 2% nasal mupirocin twice daily. The intervention was given for five consecutive days twice monthly. Participants were swabbed in the nares, throat, axilla/groin, and wound (if applicable) at baseline, 1, 3, 6, and 9 months after randomization. The primary outcomes of this report are follow-up colonization differences betw...
Background MDROs can spread between hospitals, nursing homes (NH), and long-term acute care facil... more Background MDROs can spread between hospitals, nursing homes (NH), and long-term acute care facilities (LTACs) via shared patients. SHIELD OC is a regional decolonization collaborative involving 38 of 104 countywide adult facilities identified by their high degree of direct and indirect patient sharing with one another. We report baseline MDRO prevalence in these facilities. Methods Adult patients in 38 facilities (17 hospitals, 18 NHs, 3 LTACs) underwent point-prevalence screening between September 2016–April 2017 for MRSA, VRE, ESBL, and CRE using nares, skin (axilla/groin), and peri-rectal swabs. In NHs and LTACs, residents were randomly selected until 50 sets of swabs were obtained. Swabbing in hospitals involved all patients in contact precautions. An additional set of swabs were also performed for all LTAC admissions from November 2016–February 2017. Results The overall prevalence of any MDRO among patients was 64% (44%–88%) in NHs, 80% (range 72%–86%) in LTACs, and 64% (54–84...
Background The prevalence of MDROs in nursing homes (NH) is much higher than that of hospitals. D... more Background The prevalence of MDROs in nursing homes (NH) is much higher than that of hospitals. Decolonization to reduce the reservoir of MDRO carriage in NH residents may be a strategy to address MDRO spread within and among healthcare facilities. Methods PROTECT is an 18-month cluster randomized trial of 1:1 universal decolonization vs. routine care in 28 NHs in California. Decolonization consists of chlorhexidine (CHG) bathing plus twice daily nasal iodophor on admission and Monday–Friday biweekly. We assessed pre- vs. post-intervention MDRO prevalence by sampling 50 randomly selected residents at each NH as an outcome unrelated to the trial’s primary intent (infection, hospitalization reduction). NH residents had nasal swabs cultured for methicillin-resistant S. aureus (MRSA), and skin (axilla/groin) swabs taken for MRSA, vancomycin-resistant Enterococcus (VRE), extended-spectrum β-lactamase producers (ESBL), and carbapenem-resistant Enterobacteriaceae (CRE). Generalized linear ...
Background Clinical testing detects a fraction of carbapenem-resistant Enterobacteriaceae (CRE) c... more Background Clinical testing detects a fraction of carbapenem-resistant Enterobacteriaceae (CRE) carriers. Detecting a greater proportion could lead to increased use of infection prevention and control measures but requires resources. Therefore, it is important to understand the impact of detecting increasing proportions of CRE carriers. Methods We used our Regional Healthcare Ecosystem Analyst–generated agent-based model of adult inpatient healthcare facilities in Orange County, California, to explore the impact that detecting greater proportions of carriers has on the spread of CRE. Results Detecting and placing 1 in 9 carriers on contact precautions increased the prevalence of CRE from 0% to 8.0% countywide over 10 years. Increasing the proportion of detected carriers from 1 in 9 up to 1 in 5 yielded linear reductions in transmission; at proportions >1 in 5, reductions were greater than linear. Transmission reductions did not occur for 1, 4, or 5 years, varying by facility type...
Infection Control & Hospital Epidemiology, 2015
OBJECTIVETo determine whether real-time availability of rapid molecular results of Staphylococcus... more OBJECTIVETo determine whether real-time availability of rapid molecular results of Staphylococcus aureus would impact emergency department clinician antimicrobial selection for adults with cutaneous abscesses.DESIGNWe performed a prospective, randomized controlled trial comparing a rapid molecular test with standard of care culture-based testing. Follow-up telephone calls were made at between 2 and 7 days, 1 month, and 3 months after discharge.SETTINGTwo urban, academic emergency departments.PATIENTSPatients at least 18 years old presenting with a chief complaint of abscess, cellulitis, or insect bite and receiving incision and drainage were eligible. Seven hundred seventy-eight people were assessed for eligibility and 252 met eligibility criteria.METHODSClinician antibiotic selection and clinical outcomes were evaluated. An ad hoc outcome of test performance was performed.RESULTSWe enrolled 252 patients and 126 were randomized to receive the rapid test. Methicillin-susceptible S. a...
Community-acquired, methicillin-resistant Staphylococcus aureus (MRSA) infections are on the rise... more Community-acquired, methicillin-resistant Staphylococcus aureus (MRSA) infections are on the rise among patients without risk factors for resistant microorganisms. A new, serious community-acquired MRSA manifestation, postpartum iliopsoas pyomyositis is described. A 24-year-old Hispanic female presented with back pain 9 days after a normal vaginal delivery. Magnetic resonance imaging showed extensive ill-defined edema of the left iliopsoas. Blood cultures yielded community-acquired MRSA. The patient received intravenous vancomycin for 6 days, followed by intravenous, then oral, trimethoprim-sulfamethoxazole. She was discharged on day 8 and made a full recovery. Iliopsoas pyomyositis is a new manifestation of community-acquired MRSA in the obstetric population that may masquerade as benign musculoskeletal back pain. Obstetricians must be alert to the range of presentations of this emerging pathogen.
Infection Control & Hospital Epidemiology, 2012
Objective.Vancomycin-resistant enterococci (VRE) have become a public health concern with implica... more Objective.Vancomycin-resistant enterococci (VRE) have become a public health concern with implications for patient mortality and costs. Hospital antibiotic usage may impact VRE incidence, but the relationship is poorly understood. Animal investigations suggest that ceftriaxone may be associated with VRE proliferation. We measured antimicrobial usage and VRE bloodstream infection (VRE-BSI) incidence to test our hypothesis that increased ceftriaxone usage would be associated with a higher incidence of VRE-BSI.Design.Retrospective cohort study.Setting.University of Alabama at Birmingham Medical Center, a 900-bed urban tertiary care hospital.Participants.All patients admitted during the study period contributed data.Methods.We conducted a retrospective analysis of antimicrobial usage and VRE-BSI from 2005 to 2008 (43 months). Antimicrobial usage was quantified as days of therapy (DOTs) per 1,000 patient-days. VRE-BSI incidence was calculated as cases per 1,000 patient-days. Negative bin...
Recurrent community-associated methicillin-resistant S. aureus (CA-MRSA) skin infections are an i... more Recurrent community-associated methicillin-resistant S. aureus (CA-MRSA) skin infections are an increasingly common problem. However, there are no data on the efficacy of decolonization regimens. We prospectively evaluated 31 patients with recurrent CA-MRSA skin infections who received nasal mupirocin, topical hexachlorophene body wash, and an oral anti-MRSA antibiotic. The mean number of MRSA infections after the intervention decreased significantly from baseline (0.03 vs. 0.84 infections/month, P=<0.0001). This regimen appears promising at preventing recurrent CA-MRSA infections. 4 Community-associated methicillin resistant Staphylococcus aureus (CA-MRSA) skin infections are an increasingly common reason to seek medical care in clinics, urgent care centers, and emergency departments and appear to have driven up rates of visits to practitioners for skin infections.(5, 10) Patients with CA-MRSA skin infections often report recurrent episodes with
Background: Virtually all studies of risk factors for CA-MRSA infection have been retrospective. ... more Background: Virtually all studies of risk factors for CA-MRSA infection have been retrospective. Thus, the true contribution of many important exposures has been difficult to ascertain. To our knowledge no prospective studies of CA-MRSA risk factors compare CA-MRSA-infected patients to uninfected controls. Methods: We approached consecutive patients admitted to Harbor-UCLA Medical Center with a culture positive for S. aureus within 72 hours of admission. Consenting patients were given a detailed questionnaire and had their chart reviewed. Each CA-MRSA patient was matched to a control by age, gender, race, and hospital ward. Results: Of 409 consecutive patients, 280/303 (92%) patients still hospitalized consented; 120 had CA-MRSA infection. Subjects were 76% male, 49% Hispanic and 19% Afr.-American. Mean age was 38 years; 10% were children. The most common admitting diagnoses among controls were: trauma (22%), infection (19%), and general surgical condition (18%). In a bivariate anal...
Clinical infectious diseases : an official publication of the Infectious Diseases Society of America, Jan 15, 2014
The incidence of community-onset (CO) methicillin-resistant Staphylococcus aureus (MRSA) bacterem... more The incidence of community-onset (CO) methicillin-resistant Staphylococcus aureus (MRSA) bacteremia rose from the late 1990s through the 2000s. However, hospital-onset (HO) MRSA rates have recently declined in the United States and Europe. Data were abstracted from infection prevention databases between 1 January 2008 and 31 December 2011 at 5 US academic medical centers to determine the number of single-patient blood cultures positive for MRSA and methicillin-susceptible S. aureus (MSSA) per calendar year, stratified into CO and HO infections. Across the 5 centers, 4171 episodes of bacteremia were identified. Center A (Los Angeles, California) experienced a significant decline in CO-MRSA bacteremia rates (from a peak in 2009 of 0.42 to 0.18 per 1000 patient-days in 2011 [P = .005]), whereas CO-MSSA rates remained stable. Centers B (San Francisco, California), D (Chicago, Illinois), and E (Raleigh-Durham, North Carolina) experienced a stable incidence of CO-MRSA and CO-MSSA bacterem...
We performed secondary analyses of a postdischarge decolonization trial of MRSA carriers that red... more We performed secondary analyses of a postdischarge decolonization trial of MRSA carriers that reduced MRSA infection and hospitalization by 30%. Hospitalized MRSA infection was associated with 7.9 days of non-MRSA antibiotics and CDI in 3.9%. Preventing MRSA infection and associated hospitalization may reduce antibiotic use and CDI incidence.
BACKGROUND The CLEAR trial demonstrated that a multi-site body decolonization regimen reduced pos... more BACKGROUND The CLEAR trial demonstrated that a multi-site body decolonization regimen reduced post-discharge infection and hospitalization in methicillin-resistant Staphylococcus aureus (MRSA) carriers. This report describes decolonization efficacy in clearing site-specific MRSA colonization during the trial. METHODS We performed a large, multi-center, randomized clinical trial of MRSA decolonization among adult patients after hospital discharge with MRSA infection or colonization. Participants were randomized 1:1 to either MRSA prevention education or education plus decolonization with 4% topical chlorhexidine daily, 0.12% oral chlorhexidine rinse twice daily, and 2% nasal mupirocin twice daily. The intervention was given for five consecutive days twice monthly. Participants were swabbed in the nares, throat, axilla/groin, and wound (if applicable) at baseline, 1, 3, 6, and 9 months after randomization. The primary outcomes of this report are follow-up colonization differences betw...
Background MDROs can spread between hospitals, nursing homes (NH), and long-term acute care facil... more Background MDROs can spread between hospitals, nursing homes (NH), and long-term acute care facilities (LTACs) via shared patients. SHIELD OC is a regional decolonization collaborative involving 38 of 104 countywide adult facilities identified by their high degree of direct and indirect patient sharing with one another. We report baseline MDRO prevalence in these facilities. Methods Adult patients in 38 facilities (17 hospitals, 18 NHs, 3 LTACs) underwent point-prevalence screening between September 2016–April 2017 for MRSA, VRE, ESBL, and CRE using nares, skin (axilla/groin), and peri-rectal swabs. In NHs and LTACs, residents were randomly selected until 50 sets of swabs were obtained. Swabbing in hospitals involved all patients in contact precautions. An additional set of swabs were also performed for all LTAC admissions from November 2016–February 2017. Results The overall prevalence of any MDRO among patients was 64% (44%–88%) in NHs, 80% (range 72%–86%) in LTACs, and 64% (54–84...
Background The prevalence of MDROs in nursing homes (NH) is much higher than that of hospitals. D... more Background The prevalence of MDROs in nursing homes (NH) is much higher than that of hospitals. Decolonization to reduce the reservoir of MDRO carriage in NH residents may be a strategy to address MDRO spread within and among healthcare facilities. Methods PROTECT is an 18-month cluster randomized trial of 1:1 universal decolonization vs. routine care in 28 NHs in California. Decolonization consists of chlorhexidine (CHG) bathing plus twice daily nasal iodophor on admission and Monday–Friday biweekly. We assessed pre- vs. post-intervention MDRO prevalence by sampling 50 randomly selected residents at each NH as an outcome unrelated to the trial’s primary intent (infection, hospitalization reduction). NH residents had nasal swabs cultured for methicillin-resistant S. aureus (MRSA), and skin (axilla/groin) swabs taken for MRSA, vancomycin-resistant Enterococcus (VRE), extended-spectrum β-lactamase producers (ESBL), and carbapenem-resistant Enterobacteriaceae (CRE). Generalized linear ...
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