Risk Factors for Invasive Methicillin-Resistant Staphylococcus aureus Infection After Recent Discharge From an Acute-Care Hospitalization, 2011-2013.

BACKGROUND: Significant progress has been made in reducing methicillin-resistant Staphylococcus aureus (MRSA) infections among hospitalized patients. However, the decreases in invasive MRSA infections among recently discharged patients have been less substantial. To inform prevention strategies, we assessed risk factors for invasive MRSA infection after acute-care hospitalizations. METHODS: We conducted a prospective, matched case-control study. A case was defined as MRSA cultured from a normally sterile body site in a patient discharged from a hospital within the prior 12 weeks. Eligible case patients were identified from 15 hospitals across 6 US states. For each case patient, 2 controls were matched for hospital, month of discharge, and age group. Medical record reviews and telephone interviews were performed. Conditional logistic regression was used to identify independent risk factors for postdischarge invasive MRSA. RESULTS: From 1 February 2011 through 31 March 2013, 194 case patients and 388 matched controls were enrolled. The median time between hospital discharge and positive culture was 23 days (range, 1-83 days). Factors independently associated with postdischarge MRSA infection included MRSA colonization (matched odds ratio [mOR], 7.71; 95% confidence interval [CI], 3.60-16.51), discharge to a nursing home (mOR, 2.65; 95% CI, 1.41-4.99), presence of a chronic wound during the postdischarge period (mOR, 4.41; 95% CI, 2.14-9.09), and discharge with a central venous catheter (mOR, 2.16; 95% CI, 1.13-4.99) or a different invasive device (mOR, 3.03; 95% CI, 1.24-7.39) in place. CONCLUSIONS: Prevention efforts should target patients with MRSA colonization or those with invasive devices or chronic wounds at hospital discharge. In addition, MRSA prevention efforts in nursing homes are warranted.

Early-onset group B streptococcal disease in the United States: potential for further reduction.

OBJECTIVE: To describe lapses in adherence to group B streptococcus (GBS) prevention guidelines among cases of early-onset GBS disease in term and preterm neonates and to estimate the potential for further reduction in disease burden under current prevention strategies. METHODS: We reviewed labor and delivery and prenatal records of mothers of neonates with early-onset GBS disease (aged younger than 7 days with GBS isolated from a normally sterile site) identified at population-based surveillance sites in 2008-2009. We interviewed prenatal care providers about GBS screening practices and obtained relevant laboratory records. We evaluated the data for errors in prenatal screening, laboratory methods, communication of results, and intrapartum antibiotic prophylaxis. Using published data on screening sensitivity and intrapartum prophylaxis effectiveness, we estimated the potential reduction in cases under optimal prevention implementation. RESULTS: Among 309 cases, 179 (57.9%) had one or more implementation errors. The most common error type in term and preterm case-patients was prenatal screening (80 of 222 [36.0%]) and intrapartum prophylaxis (46 of 85 [54.1%]), respectively. We estimated that under optimal implementation, cases of early-onset GBS disease could be reduced by 26-59% with the largest benefit from a single intervention coming from improved use of intrapartum prophylaxis (16% decrease). CONCLUSION: Further reduction of early-onset GBS disease burden is possible under current prevention strategies, particularly with improved implementation of antibiotic prophylaxis. However, even with perfect adherence to recommended practices, the decline in cases may be modest. Therefore, novel prevention approaches such as improved intrapartum assays and vaccines are also needed.

Assessment of physician knowledge and practices concerning Shiga toxin-producing Escherichia coli infection and enteric illness, 2009, Foodborne Diseases Active Surveillance Network (FoodNet).

BACKGROUND: Shiga toxin-producing Escherichia coli (STEC) infections cause acute diarrheal illness and sometimes life-threatening hemolytic uremic syndrome (HUS). Escherichia coli O157 is the most common STEC, although the number of reported non-O157 STEC infections is growing with the increased availability and use of enzyme immunoassay testing, which detects the presence of Shiga toxin in stool specimens. Prompt and accurate diagnosis of STEC infection facilitates appropriate therapy and may improve patient outcomes. METHODS: We mailed 2400 surveys to physicians in 8 Foodborne Diseases Active Surveillance Network (FoodNet) sites to assess their knowledge and practices regarding STEC testing, treatment, and reporting, and their interpretation of Shiga toxin test results. RESULTS: Of 1102 completed surveys, 955 were included in this analysis. Most (83%) physicians reported often or always ordering a culture of bloody stool specimens; 49% believed that their laboratory routinely tested for STEC O157, and 30% believed that testing for non-O157 STEC was also included in a routine stool culture. Forty-two percent of physicians were aware that STEC, other than O157, can cause HUS, and 34% correctly interpreted a positive Shiga toxin test result. All STEC knowledge-related factors were strongly associated with correct interpretation of a positive Shiga toxin test result. CONCLUSIONS: Identification and management of STEC infection depends on laboratories testing for STEC and physicians ordering and correctly interpreting results of Shiga toxin tests. Although overall knowledge of STEC was low, physicians who had more knowledge were more likely to correctly interpret a Shiga toxin test result. Physician knowledge of STEC may be modifiable through educational interventions.

Influenza testing and antiviral prescribing practices among emergency department clinicians in 9 states during the 2006 to 2007 influenza season.

STUDY OBJECTIVE: Influenza causes significant widespread illness each year. Emergency department (ED) clinicians are often first-line providers to evaluate and make treatment decisions for patients presenting with influenza. We sought to better understand ED clinician testing and treatment practices in the Emerging Infections Program Network, a federal, state, and academic collaboration that conducts active surveillance for influenza-associated hospitalizations. METHODS: During 2007, a survey was administered to ED clinicians who worked in Emerging Infections Program catchment area hospitals' EDs. The survey encompassed the role of the clinician, years since completing clinical training, hospital type, influenza testing practices, and use of antiviral medications during the 2006 to 2007 influenza season. We examined factors associated with influenza testing and antiviral use. RESULTS: A total of 1,055 ED clinicians from 123 hospitals responded to the survey. A majority of respondents (85.3%; n=887) reported they had tested their patients for influenza during the 2006 to 2007 influenza season (Emerging Infections Program site range: 59.3 to 100%; P<.0001). When asked about antiviral medications, 55.7% (n=576) of respondents stated they had prescribed antiviral medications to some of their patients in 2006 to 2007 (Emerging Infections Program site range 32.9% to 80.3%; P<.0001). A positive association between influenza testing and prescribing antiviral medications was observed. Additionally, the type of hospital, location in which an ED clinician worked, and the number of years since medical training were associated with prescribing antiviral influenza medications. CONCLUSION: There is much heterogeneity in clinician-initiated influenza testing and treatment practices. Additional exploration of the role of hospital testing and treatment policies, clinicians' perception of influenza disease, and methods for educating clinicians about new recommendations is needed to better understand ED clinician testing and treatment decisions, especially in an environment of rapidly changing influenza clinical guidelines. Until influenza testing and treatment guidelines are better promulgated, clinicians may continue to test and treat influenza with inconsistency.

Prevalence of Trichomonas vaginalis infection among young reproductive age women in India: implications for treatment and prevention.

BACKGROUND: Trichomonas vaginalis infection is the most common curable sexually transmissible infection (STI) worldwide. The present study describes the burden and correlates of T. vaginalis infection among young reproductive age women in Mysore, India. METHODS: Between November 2005 and March 2006, sexually active women aged 15-30 years were recruited from low-income peri-urban and rural neighbourhoods of Mysore, India. Participants were interviewed and offered a physical examination and testing for T. vaginalis, bacterial vaginosis, vaginal candidiasis, Neisseria gonorrheoea and herpes simplex virus type-2 antibodies. RESULTS: Of the 898 participating women, 76 had a T. vaginalis infection (8.5%, 95% confidence interval [95% CI]: 6.7-10.5%). Nearly all (98%) participants were married and most reported their spouse as their main sex partner. The mean age at marriage was 16.9 years (s.d. 2.9 years) and two-thirds of the sample reported having first sexual intercourse before the age of 19 years. Risk factors independently associated with T. vaginalis infection included early age at first intercourse (adjusted odds ratio [OR] 2.09; 95% CI: 1.09-4.00), concurrent bacterial vaginosis (OR 8.21; 95% CI: 4.30-15.66), vaginal candidiasis (OR 2.40; 95% CI: 1.48-3.89) and herpes simplex virus type-2 infection (OR 3.44; 95% CI: 1.97-6.02). CONCLUSION: The burden of T. vaginalis infection at 8.5% is relatively high among a community sample of young reproductive aged women. Because this infection increases the risk of HIV transmission and is associated with adverse pregnancy outcomes, there is a need for increased screening and treatment of this easily curable sexually transmissible infection in India.

Evaluation of denaturing gradient gel electrophoresis to differentiate Escherichia coli populations in secondary environments.

The development of methodology to differentiate mixed populations of Escherichia coli in the secondary habitat might improve monitoring of fecal pollution indicators and facilitate the development of strategies to mitigate bacterial pollution. The objective of this study was to determine the ability of denaturing gradient gel electrophoresis (DGGE) to differentiate mixed assemblages of E. coli in the natural environment. After confirming the identity of 184 environmental bacterial isolates as E. coli, each was subjected to polymerase chain reaction (PCR) of the beta-glucuronidase gene (uidA) followed by DGGE fingerprinting. The ability of DGGE to discriminate individual isolates at the strain level was determined by comparing fingerprints to those resulting from a standard, library-dependent fingerprinting method, BOX-PCR. Computerized analysis of fingerprints indicated that DGGE and BOX-PCR identified 15 and 21 unique phylotypes respectively. Rank-abundance plots comparing the numerical distribution of unique E. coli phylotypes detected by both methods revealed no difference in resolution at the population level. In water and sediment samples from two beaches, DGGE effectively distinguished indigenous E. coli populations with an average rate of correct classification (site-based) of 83%. Denaturing gradient gel electrophoresis of uidA genes isolated and PCR-amplified from environmental samples appears to be an effective tool to differentiate unique E. coli populations and should be useful to characterize E. coli dynamics in the secondary environment.