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We describe an epidemiologic investigation and successful control measures for the first reported outbreak of bla NDM-1 -carrying Pseudomonas aeruginosa in Texas occurring in a veteran with transmission of the same organism and a bla NDM-5 -carrying Escherichia coli , respectively, to two roommates and bla NDM -carrying organism/s to a patient cared for by common staff.

BackgroundThere is a paucity of data evaluating the strategy of suppressing broader-spectrum antibiotic susceptibilities on utilization. Cascade reporting (CR) is a strategy of reporting antimicrobial susceptibility test results in which secondary (eg, broader-spectrum, costlier) agents may only be reported if an organism is resistant to primary agents within a particular drug class. Our objective was to evaluate the impact of ceftriaxone-based cascade reporting on utilization of cefepime and clinical outcomes in patients with ceftriaxone-susceptible Escherichia and Klebsiella clinical cultures.MethodsWe compared post-CR (July 2014–June 2015) with baseline (July 2013–June 2014), evaluating utilization of cefepime, cefazolin, ceftriaxone, ampicillin derivatives, fluoroquinolones, piperacillin/tazobactam, ertapenem, and meropenem; new Clostridium difficile infection; and length of stay (LOS) after the positive culture, 30-day readmission, and in-hospital all-cause mortality.ResultsMean days of therapy (DOT) among patients who received any antibiotic for cefepime decreased from 1.229 days during the baseline period to 0.813 days post-CR (adjusted relative risk, 0.668; P < .0001). Mean DOT of ceftriaxone increased from 0.864 days to 0.962 days, with an adjusted relative risk of 1.113 (P = .004). No significant differences were detected in other antibiotics including ertapenem and meropenem, demonstrating the direct association of the decrease in cefepime utilization with CR based on ceftriaxone susceptibility. Average LOS in the study population decreased from 14.139 days to 10.882 days from baseline to post-CR and was found to be statistically significant (P < .0001).ConclusionsIn conclusion, we demonstrated significant association of decreased cefepime utilization with the implementation of a CR based on ceftriaxone susceptibility. We demonstrated the safety of deescalation, with LOS being significantly lower during the post-CR period than in the baseline period, with no change in in-hospital mortality.Implementation of ceftriaxone-based cascade reporting (CR) for Escherichia and Klebsiella clinical cultures resulted in significant reduction in the utilization of broader spectrum antibiotics. CR is a valuable tool to promote better prescription practices among clinicians with minimal resource utilization.

Pandemic influenza caused significant increases in healthcare utilization across several continents including the use of high-intensity rescue therapies like extracorporeal membrane oxygenation (ECMO) or high-frequency oscillatory ventilation (HFOV). The severity of illness observed with pandemic influenza in 2009 strained healthcare resources. Because lung injury in ARDS can be influenced by daily management and multiple organ failure, we performed a retrospective cohort study to understand the severity of H1N1 associated ARDS after adjustment for treatment. Sixty subjects were identified in our hospital with ARDS from \"direct injury\" within 24 hours of ICU admission over a three month period. Twenty-three subjects (38.3%) were positive for H1N1 within 72 hours of hospitalization. These cases of H1N1-associated ARDS were compared to non-H1N1 associated ARDS patients. Subjects with H1N1-associated ARDS were younger and more likely to have a higher body mass index (BMI), present more rapidly and have worse oxygenation. Severity of illness (SOFA score) was directly related to worse oxygenation. Management was similar between the two groups on the day of admission and subsequent five days with respect to tidal volumes used, fluid balance and transfusion practices. There was, however, more frequent use of \"rescue\" therapy like prone ventilation, HFOV or ECMO in H1N1 patients. First morning set tidal volumes and BMI were significantly associated with increased severity of lung injury (Lung injury score, LIS) at presentation and over time while prior prescription of statins was protective. After assessment of the effect of these co-interventions LIS was significantly higher in H1N1 patients. Patients with pandemic influenza-associated ARDS had higher LIS both at presentation and over the course of the first six days of treatment when compared to non-H1N1 associated ARDS controls. The difference in LIS persisted over the duration of observation in patients with H1N1 possibly explaining the increased duration of mechanical ventilation.

A case of probable zoonotic leprosy acquired in the United States is described in a patient infected with HIV. The immune reconstitution inflammatory syndrome developed when antiretroviral therapy was initiated. To the Editor: Borderline tuberculoid leprosy with type 1 reaction can have an acute presentation in persons infected with HIV. This reaction may develop as part of the immune reconstitution inflammatory syndrome after the initiation of effective antiretroviral therapy. 1 – 3 Despite advances in diagnosing leprosy, 4 the diagnosis may be missed or delayed in patients in whom leprosy is not anticipated. Armadillos have been shown to be a potential natural reservoir for Mycobacterium leprae, and leprosy may be a zoonosis in areas where armadillos are prevalent. 5 We report a case of indigenous leprosy that was probably associated with exposure to an . . .

Burn injuries result in loss of skin barrier and altered immune responses that in turn make patients especially vulnerable to healthcare-associated infections. Despite prolonged exposures of these patients to hospital environments, burn-specific infection prevention strategies are understudied. We present a research agenda identifying key research gaps and organizing them into priority areas to guide future investigations in this high-risk population. Members of the Society for Healthcare Epidemiology of America (SHEA) Burn Infection Prevention and Control Special Interest Group and the American Burn Association (ABA) collaborated to develop this research agenda, combining expertise in infection prevention, antimicrobial stewardship, and burn care. We identified five priority areas: (1) improving surveillance and epidemiologic data on burn infections; (2) better understanding of microbiology, including biofilms and the microbiome; (3) evaluating wound healing strategies; (4) refining infection prevention and control practices unique to burn units; and (5) building burn patient specific risk assessment and predictive models. The agenda highlights the need for standardized definitions and shared data platforms. It calls for evaluation of practical strategies for infection prevention, stewardship, and environmental control. This research agenda intends to help guide future studies aimed at furthering knowledge and improving outcomes in burn care.