Facklamia Species and Streptococcus pneumoniae Meningitis: A Case Report and Review of the Literature.

Facklamia sp are Gram-positive cocci that are often mistaken for viridans streptococci, but they rarely cause invasive disease. In this report, we describe a case of mixed Facklamia sp and Streptococcus pneumoniae meningitis in an immunocompetent host with sinusitis. This case demonstrates that Facklamia sp may be part of normal human flora but can be associated with invasive disease.

Screening for Intermediately Vancomycin-Susceptible and Vancomycin-Heteroresistant Staphylococcus aureus by Use of Vancomycin-Supplemented Brain Heart Infusion Agar Biplates: Defining Growth Interpretation Criteria Based on Gold Standard Confirmation.

BHI agars supplemented with vancomycin 4 (BHI-V4) and 3 (BHI-V3) mg/liter have been proposed for screening vancomycin intermediately susceptible Staphylococcus aureus (VISA) and heteroresistant (hVISA) phenotypes, respectively, but growth interpretation criteria have not been established. We reviewed the growth results (CFU) during population analysis profile-area under the curve (PAP-AUC) of consecutive methicillin-resistant Staphylococcus aureus (MRSA) blood isolates, which were saved intermittently between 1996 and 2012. CFU counts on BHI-V4 and BHI-V3 plates were stratified according to PAP-AUC interpretive criteria: <0.90 (susceptible [S-MRSA]), 0.90 to 1.3 (hVISA), and >1.3 (VISA). CFU cutoffs that best predict VISA and hVISA were determined with the use of receiver operating characteristic (ROC) curves. Mu3, Mu50, and methicillin-susceptible S. aureus (MSSA) controls were included. We also prospectively evaluated manufacturer-made BHI-V3/BHI-V4 biplates for screening of 2010-2012 isolates. The PAP-AUC of 616 clinical samples was consistent with S-MRSA, hVISA, and VISA in 550 (89.3%), 48 (7.8%), and 18 (2.9%) instances, respectively. For VISA screening on BHI-V4, a cutoff of 2 CFU/droplet provided 100% sensitivity and 97.7% specificity. To distinguish VISA from hVISA, a cutoff of 16 CFU provided 83.3% sensitivity and 94.7% specificity; the specificity was lowered to 89.5% with a 12-CFU cutoff. For detecting hVISA/VISA on BHI-V3, a 2-CFU/droplet cutoff provided 98.5% sensitivity and 93.8% specificity. These results suggest that 2-CFU/droplet cutoffs on BHI-V4 and BHI-V3 best approximate VISA and hVISA gold standard confirmation, respectively, with minimal overlap in samples with borderline PAP-AUC. Simultaneous screening for VISA/hVISA on manufacturer-made BHI-V4/BHI-V3 biplates is easy to standardize and may reduce the requirement for PAP-AUC confirmation.

Clinician practice and the National Healthcare Safety Network definition for the diagnosis of catheter-associated urinary tract infection.

BACKGROUND: The National Healthcare Safety Network (NHSN) definition for catheter-associated urinary tract infection (CAUTI) is used to evaluate improvements in CAUTI prevention efforts. We assessed whether clinician practice was reflective of the NHSN definition. METHODS: We evaluated all adult inpatients hospitalized between July 2010 and June 2011, with a first positive urine culture > 48 hours of admission obtained while catheterized or within 48 hours of catheter discontinuation. Data comprised patients' signs, symptoms, and diagnostic tests; clinician's diagnosis; and the impression of the infectious diseases (ID) consultant. The clinician's practice was compared with the NHSN definition and the ID consultant's impression. RESULTS: Antibiotics were initiated by clinicians to treat CAUTI in 216 of 387 (55.8%) cases, with 119 of 387 (30.7%) fitting the NHSN CAUTI definition, and 63 of 211 (29.9%) considered by ID to have a CAUTI. The sensitivity, specificity, and positive and negative predictive values of a clinician diagnosis of CAUTI were 62.2%, 47%, 34.3%, and 73.7% when compared with NHSN CAUTI definition (n = 387) and 100%, 57.4%, 50%, and 100% when compared with the ID consultant evaluation (n = 211), respectively. The positive predictive value of the NHSN CAUTI definition was 35.1% when compared with the ID consultant's impression (n = 211). CONCLUSION: NHSN CAUTI definition did not reflect clinician or ID consultant practices. Our findings reflect the differences between surveillance definitions and clinical practice.

Decreasing incidence of Staphylococcus aureus bacteremia over 9 years: greatest decline in community-associated methicillin-susceptible and hospital-acquired methicillin-resistant isolates.

BACKGROUND: The impact of community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) emergence on the epidemiology of S aureus bacteremia (SAB) is not well documented. METHODS: This was an observational study of adult (aged ≥18 years) inpatients with SAB in a single 808-bed teaching hospital during 2002-2003, 2005-2006, 2008-2009, and 2010 with period-stratified SAB rate, onset mode, patient characteristics, and outcome. RESULTS: We encountered a total of 1,098 cases over the entire study period. The rate decreased steadily over time (from 6.64/10(3) discharges in 2002-2003 to 6.49/10(3) in 2005-2006, 5.24/10(3) in 2008-2009, and 5.00/10(3) in 2010; P = .0001), with a greater decline in community-associated cases (0.99/10(3), 0.77/10(3), 0.58/10(3), and 0.40/10(3), respectively; P = .0005) compared with health care-associated cases (5.65/10(3), 5.72/10(3), 4.66/10(3), and 4.60/10(3), respectively; P = .005). The decline was principally in MSSA (3.11/10(3), 2.21/10(3), 2.24/10(3), and 1.75/10(3), respectively; P = .00006), including both community-associated (P = .0002) and health care-associated cases (P = .006). Although overall rate changes in MRSA were not significant (P = .09), hospital-onset MRSA decreased markedly (P < .00001), whereas CA-MRSA increased (P = .03). The all-cause 100-day mortality rate did not change significantly (25.6% for 2002-2003, 25.2% for 2005-2006, 28.1% for 2008-2009, and 32.2% for 2010; P = .10). Differences in MSSA/MRSA-associated mortality decreased (20.1% vs 30.6%, P = .03 for 2002-2003; 18.1% vs 28.9%, P = .05 for 2005-2006; 21.7% vs 32.9%, P = .05 for 2008-2009; and 29.3% vs 34.9, P = .5 for 2010). CONCLUSIONS: SAB incidence is decreasing, with the greatest decline in community-associated MSSA and hospital-onset MRSA cases. Most health care-associated cases currently are community-onset. MRSA/MSSA-related mortality is comparable. These changes are likely related to the emergence of CA-MRSA and the inpatient-to-outpatient shift in health care.