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Background:Limited data are available on the implementation of an area under the concentration-time curve (AUC)–based dosing protocol with multidisciplinary team (MT) support to improve adherence with vancomycin dosing protocol.Objective:To evaluate the effectiveness of an AUC-based dosing protocol with MT support intervention with adherence to a hospital-wide vancomycin dosing protocol at Thammasat University Hospital.Method:We conducted a quasi-experimental study in patients who were prescribed intravenous vancomycin. The study was divided into 2 periods; (1) the preintervention period when the vancomycin dosing protocol was already applied in routine practice and (2) the post-intervention period when the implementation of an AUC-based dosing protocol with MT support was added to the existing vancomycin dosing protocol. The primary outcome was the rate of adherence, and the secondary outcomes included acute kidney injury events, vancomycin-related adverse events, and 30-day mortality rate.Results:In total, 240 patients were enrolled. The most common infections were skin and soft-tissue infections (24.6%) and bacteremia (24.6%). The most common pathogens were coagulase-negative staphylococci (19.6%) and Enterococcus spp (15.4%). Adherence with the vancomycin dosing protocol was significantly higher in the postintervention period (90.8% vs 55%; P ≤ .001). By multivariate analysis, an AUC-based dosing protocol with MT support was the sole predictor for adherence with the vancomycin dosing protocol (adjusted odds ratio, 10.31; 95% confidence interval, 4.54–23.45; P ≤ .001). The 30-day mortality rate was significantly lower during the postintervention period (8.3% vs 20%; P = .015).Conclusions:AUC-based dosing protocol with MT support significantly improved adherence with vancomycin dosing protocol and was associated with a lower 30-day mortality rate.

A large-scale surveillance is an important measure to monitor the regional spread of antimicrobial resistance. We prospectively studied the prevalence and molecular characteristics of clinically important Gram-negative bacilli, including Escherichia coli, Klebsiella pneumoniae, Acinetobacter baumannii complex (ABC), and Pseudomonas aeruginosa, from blood, respiratory tract, urine, and sterile sites at 47 hospitals across Thailand. Among 187,619 isolates, 93,810 isolates (50.0%) were critically drug resistant, of which 12,915 isolates (13.8%) were randomly selected for molecular characterization. E. coli was most commonly isolated from all specimens, except the respiratory tract, in which ABC was predominant. Prevalence of extended-spectrum cephalosporin resistance (ESCR) was higher in E. coli (42.5%) than K. pneumoniae (32.0%), but carbapenem-resistant (CR)-K. pneumoniae (17.2%) was 4.5-fold higher than CR-E. coli (3.8%). The majority of ESCR/CR-E. coli and K. pneumoniae isolates carried blaCTX-M (64.6% to 82.1%). blaNDM and blaOXA-48-like were the most prevalent carbapenemase genes in CR-E. coli/CR-K. pneumoniae (74.9%/52.9% and 22.4%/54.1%, respectively). In addition, 12.9%/23.0% of CR-E. coli/CR-K. pneumoniae cocarried blaNDM and blaOXA-48-like. Among ABC isolates, 41.9% were extensively drug resistant (XDR) and 35.7% were multidrug resistant (MDR), while P. aeruginosa showed XDR/MDR at 6.3%/16.5%. A. baumannii was the most common species among ABC isolates. The major carbapenemase gene in MDR-A. baumannii/XDR-A. baumannii was blaOXA-23-like (85.8%/93.0%), which had much higher rates than other ABC species. blaIMP, blaVIM, blaOXA-40-like, and blaOXA-58-like were also detected in ABC at lower rates. The most common carbapenemase gene in MDR/XDR-P. aeruginosa was blaIMP (29.0%/30.6%), followed by blaVIM (9.5%/25.3%). The findings reiterate an alarming situation of drug resistance that requires serious control measures.

The ST131 multilocus sequence type (MLST) of Escherichia coli is a globally successful pathogen whose dissemination is increasing rates of antibiotic resistance. Numerous global surveys have demonstrated the pervasiveness of this clone; in some regions ST131 accounts for up to 30% of all E. coli isolates. However, many regions are underrepresented in these published surveys, including Africa, South America, and Asia. We collected consecutive bloodstream E. coli isolates from three countries in Southeast Asia; ST131 was the most common MLST type. As in other studies, the C2/H30Rx clade accounted for the majority of ST131 strains. Clinical risk factors were similar to other reported studies. However, we found that nearly all of the C2 strains in this study were closely related, forming what we denote the SEA-C2 clone. The SEA-C2 clone is enriched for strains from Asia, particularly Southeast Asia and Singapore. The SEA-C2 clone accounts for all of the excess resistance and virulence of ST131 relative to non-ST131 E. coli. The SEA-C2 strains appear to be locally circulating and dominant in Southeast Asia, despite the intuition that high international connectivity and travel would enable frequent opportunities for other strains to establish themselves.

Asian Medical Journal and Alternative Medicine, 21, Supplement 1, S18

Objective: To assess the impact of chlorhexidine gluconate (CHG) bathing on skin bacterial burden in neonates Study Design: In this prospective observational study, arm and groin skin bacterial growth was measured in 40 CHG-exposed and non-exposed neonates admitted to the NICU. Exposed neonates received 2% CHG baths per protocol for central line-associated bloodstream infection (CLABSI) prevention or Staphylococcus aureus decolonization. Results: Forty neonates were enrolled, 18 of whom were CHG-exposed. Mean baseline Gram-positive (GP) bacterial burden was 2.19 log CFU/ml on the arm and 1.81 log CFU/ml on the groin. Bacterial burden decreased after the first bath, but returned to baseline by 72 hours. Residual skin CHG concentration declined over time, with a corresponding increase in GP bacterial burden. Conclusions: CHG bathing reduces skin bacterial burden, but burden returns to baseline after 72 hours. Twice weekly CHG bathing may be inadequate to suppress skin bacterial growth in hospitalized neonates.

Background Small-colony variants (SCVs) are a distinct phenotype of Staphylococcus aureus, known for their role in chronic, difficult to treat infections, including cystic fibrosis (CF) lung disease. The goal of this study was to characterize SCV MRSA infection in an adult and pediatric CF population and to identify antibiotic susceptibility patterns unique to SCV MRSA. Methods We recovered methicillin-resistant S. aureus (MRSA) from respiratory culture samples from CF patients at the Johns Hopkins Hospital during a 6 month study period. Results Of 1161 samples, 200 isolates (17%) were identified as MRSA, and 37 isolates from 28 patients were identified as SCV MRSA. A higher proportion of MRSA was found among SCV isolates (37/66, 56%) compared to normal colony variant (NCV) isolates (163/417, 39%), p = 0.02. All SCV MRSA isolates from individual patients were susceptible to vancomycin and ceftaroline, but they demonstrated higher rates of antibiotic resistance to trimethoprim/sulfamethoxazole, moxifloxacin, and erythromycin, compared to NCV MRSA isolates. Additionally, individuals with SCV MRSA had lower lung function, higher rates of persistent MRSA infection, and higher rates of previous antibiotic use, compared to individuals with NCV MRSA. Conclusions A significant proportion of MRSA isolates recovered from patients with CF have the SCV morphology. Compared to individuals with NCV MRSA, those with SCV MRSA have higher rates of persistent MRSA infection and lower lung function. SCV MRSA isolates were more resistant than NCV, but they are highly susceptible to vancomycin, linezolid and ceftaroline.

A prospective study conducted in a Thai general practice clinic demonstrated a high prevalence (91.3%) of inappropriate empirical antibiotic use in women with uncomplicated cystitis and 42.6% Escherichia coli fluoroquinolone resistance. An annual update of antimicrobial resistance surveillance data of uropathogens may permit targeted treatment of patients in hospital care.

Background: Recent reports suggest that infections due to fluoroquinolone-resistant Escherichia coli ( E. coli ) are an increasingly common complication of transrectal biopsy of the prostate (TBP) in the United States. A better understanding of the magnitude and scope of these infections is needed to guide prevention efforts. Our objective is to determine whether the incidence of infections due to fluoroquinolone-resistant E. coli after TBP has increased nationwide in the Veterans Affairs Health Care System and to identify risk factors for infection. Methods: We performed a retrospective, observational cohort study and a nested case-control study within the US Deparment of Veterans Affairs Healthcare System. The primary outcomes were the incidence of urinary tract infection (UTI) and bacteremia with E. coli and with fluoroquinolone-resistant E. coli strains within 30 days after TBP. Secondary endpoints focused on the correlation between fluoroquinolone-resistance in all urinary E. coli isolates and post-TBP infection and risk factors for infection due to fluoroquinolone-resistant E. coli infection. Results: 245 618 patients undergoing 302 168 TBP procedures from 2000 through 2013 were included in the cohort study, and 59 469 patients undergoing TBP from 2011 through 2013 were included in the nested case-control study. Between 2000 and 2013, there was a 5-fold increase in the incidence of E. coli UTI (0.18%–0.93%) and a 4-fold increase in the incidence of E. coli bacteremia (0.04%–0.18%) after TBP that was attributable to an increase in the incidence of fluoroquinolone-resistant E. coli UTI (0.03%–0.75%) and bacteremia (0.01%–0.14%). The increasing incidence of fluoroquinolone-resistant E. coli infections after TBP occurred in parallel with increasing rates of fluoroquinolone-resistance in all urinary E. coli isolates. By multivariable logistic regression analysis, independent risk factors for fluoroquinolone-resistant E. coli UTI after TBP included diabetes mellitus, fluoroquinolone exposure, prior hospitalization, and prior cultures with fluoroquinolone-resistant gram-negative bacilli. Conclusion: In the Veterans Affairs Healthcare System, the incidence of E. coli infection after TBP has increased significantly since 2000 due to a dramatic rise in infections with fluoroquinolone-resistant E. coli . Keywords: bacteremia; case-control studies; cohort studies; early detection of cancer; Escherichia coli infections; microbial drug resistance; postoperative complications; prostate; retrospective studies; United States Department of Veterans Affairs; urinary tract infections.

Background Multidrug-resistant Gram-negative bacteria (MDRGN), including extended-spectrum β-lactamases (ESBLs) and multidrug-resistant glucose-nonfermenting Gram-negative bacilli (nonfermenters), have emerged and spread throughout Southeast Asia. Methods We reviewed and summarized current critical knowledge on the epidemiology and molecular characterization of MDRGN in Southeast Asia by PubMed searches for publications prior to 10 March 2016 with the term related to “MDRGN definition” combined with specific Southeast Asian country names (Thailand, Singapore, Malaysia, Vietnam, Indonesia, Philippines, Laos, Cambodia, Myanmar, Brunei). Results There were a total of 175 publications from the following countries: Thailand (77), Singapore (35), Malaysia (32), Vietnam (23), Indonesia (6), Philippines (1), Laos (1), and Brunei (1). We did not find any publications on MDRGN from Myanmar and Cambodia. We did not include publications related to Shigella spp., Salmonella spp., and Vibrio spp. and non-human related studies in our review. English language articles and abstracts were included for analysis. After the abstracts were reviewed, data on MDRGN in Southeast Asia from 54 publications were further reviewed and included in this study. Conclusions MDRGNs are a major contributor of antimicrobial-resistant bacteria in Southeast Asia. The high prevalence of ESBLs has been a major problem since 2005 and is possibly related to the development of carbapenem resistant organisms in this region due to the overuse of carbapenem therapy. Carbapenem–resistant Acinetobacter baumannii is the most common pathogen associated with nosocomial infections in this region followed by carbapenem-resistant Pseudomonas aeruginosa. Although Southeast Asia is not an endemic area for carbapenem-resistant Enterobacteriaceae (CRE), recently, the rate of CRE detection has been increasing. Limited infection control measures, lack of antimicrobial control, such as the presence of active antimicrobial stewardship teams in the hospital, and outpatient antibiotic restrictions, and travel throughout this region have likely contributed to the increase in MDRGN prevalence.

In an observational study, we demonstrated that hospitalized patients frequently had direct or indirect interactions with medical equipment and other fomites that are shared among patients, and these items were often contaminated with health care-associated pathogens. There is a need for protocols to ensure routine cleaning of shared portable equipment.

Background Streptococcus agalactiae (GBS) is a common pathogen known to cause neonatal and maternal infectious morbidity. Streptococcus pseudoporcinus (S pseudoporcinus) is a separate, recently identified β-hemolytic gram-positive coccus that can cause false-positive results on standard GBS agglutination testing assays. Objective To determine the prevalence and clinical implications of Streptococcus pseudoporcinus colonization in pregnancy. Materials and Methods This is a 2-year retrospective cohort study comparing pregnant women colonized with GBS to those colonized with S. pseudoporcinus. A proteomics method of identification, namely, matrix-assisted laser desorption ionization time-of-flight mass spectrometry, was used to distinguish between S. pseudoporcinus and GBS colonization. Antibiotic susceptibility testing was carried out on all specimens. Maternal and neonatal chart reviews were conducted to identify predictors of S. pseudoporcinus colonization and to compare maternal and neonatal outcomes. Results S. pseudoporcinus colonization occurred in 1.6% of all pregnancies. A total of 2.5% of all GBS-positive results by agglutination assay were false positive, instead reflecting S. pseudoporcinus colonization. Clindamycin resistance among S. pseudoporcinus isolates is uncommon. S. pseudoporcinus colonization in pregnancy is independently associated with African American race, tobacco use, and body mass index ≥35. Preterm premature rupture of membranes or spontaneous preterm birth was more common in patients colonized with S. pseudoporcinus. Conclusion Although the prevalence of S. pseudoporcinus colonization is low, it primarily occurs in African American women and is associated with preterm premature rupture of membranes or spontaneous preterm birth when compared to individuals colonized with GBS.

Syphilis is a sexually transmitted systemic infection caused by Treponema pallidum. We report a case of a heterosexual, HIV-positive man who presented with secondary syphilis and a lung abscess. A bacterial lung abscess was suspected and a computed tomography-guided percutaneous needle aspiration of the lung abscess was performed. Direct pulmonary involvement by T. pallidum was suggested by a positive PCR result on the aspirated fluid specimen. The clinical signs of secondary syphilis improved, and the lung abscess was resolved after treatment with benzathine penicillin G and amoxicillin-clavulanate. The final diagnosis was secondary pulmonary syphilis. Few reports of secondary syphilis with pulmonary involvement have been reported to date.

BACKGROUNDStaphylococcus aureus is a common cause of healthcare-associated infections in neonates.OBJECTIVETo examine the impact of methicillin-susceptible S. aureus (MSSA) decolonization on the incidence of MSSA infection and to measure the prevalence of mupirocin resistance.METHODSWe retrospectively identified neonates admitted to a tertiary care neonatal intensive care unit (NICU) from April 1, 2011, through September 30, 2014. We compared rates of MSSA-positive cultures and infections before and after implementation of an active surveillance culture and decolonization intervention for MSSA-colonized neonates. We used 2 measurements to identify the primary outcome, NICU-attributable MSSA: (1) any culture sent during routine clinical care that grew MSSA and (2) any culture that grew MSSA and met criteria of the National Healthcare Safety Network’s healthcare-associated infection surveillance definitions. S. aureus isolates were tested for mupirocin susceptibility. We estimated incidence rate ratios using interrupted time-series models.RESULTSBefore and after the intervention, 1,523 neonates (29,220 patient-days) and 1,195 neonates (22,045 patient-days) were admitted to the NICU, respectively. There was an immediate reduction in the mean quarterly incidence rate of NICU-attributable MSSA-positive clinical cultures of 64% (incidence rate ratio, 0.36 [95% CI, 0.19–0.70]) after implementation of the intervention, and MSSA-positive culture rates continued to decrease by 21% per quarter (incidence rate ratio, 0.79 [95% CI, 0.74–0.84]). MSSA infections also decreased by 73% immediately following the intervention implementation (incidence rate ratio, 0.27 [95% CI, 0.10–0.79]). No mupirocin resistance was detected.CONCLUSIONActive surveillance cultures and decolonization may be effective in decreasing S. aureus infections in NICUs.Infect. Control Hosp. Epidemiol. 2016;37(4):381–387

Background: Corynebacterium species and gram-positive coryneform-like bacteria (coryneforms) are increasingly reported causes of opportunistic infections in immunocompromised patients. Biochemical identification methods for these bacteria are often inaccurate. We evaluated matrix-assisted laser desorption ionization–time of flight mass spectrometry (MALDI-TOF MS) for routine Corynebacterium and coryneform identification. Methods: A total of 286 Corynebacterium species and coryneforms recovered from patients were identified by MALDI-TOF MS analysis using the Bruker Microflex instrument, Biotyper software version 3.0, and database version 3.1.66 (Bruker Daltonics, Billerica, MA) following formic acid–based, direct on-plate extraction. The spectral cutoff scores used for interpretation were 2.0 or more for species-level identification and 1.7 or more for genus level. Scores lower than 1.7 were considered as no reliable identification. The results were compared with API Coryne (bioMerieux, Durham, NC) and sequencing of 16S ribosomal RNA genes. Results: Of the 231 Corynebacterium (19 species), 99.6% were correctly identified to the genus level and 88.7% to the species level. Of the 55 coryneforms (14 genera), 90.9% were correctly identified to the genus level and 67.3% to the species level. API Coryne was able to identify 89.2% of Corynebacterium species (species level) and 63.6% of coryneforms (genus level). Conclusions: Rapid on-plate testing yielded identification of more Corynebacterium species and related bacteria than biochemical methods.

During a 14-month period of using matrix-assisted laser desorption ionization–time of flight mass spectrometry (MALDI-TOF MS) for group B streptococcus (GBS) identification, we recovered 32 (1%) Streptococcus pseudoporcinus isolates from 3,276 GBS screening cultures from female genital sources (25 isolates from pregnant women and 7 from nonpregnant women). An additional two S. pseudoporcinus isolates were identified from a urine culture and a posthysterectomy wound culture. These isolates were found to cross-react with three different GBS antigen agglutination kits, PathoDx (Remel) (93%), Prolex (Pro-Lab Diagnostics) (38%), and Streptex (Remel) (53%). New approaches to bacterial identification in routine clinical microbiology laboratories may affect the prevalence of S. pseudoporcinus .

This work was primarily funded by the Ministry of Health, Singapore, awarded through the Singapore Infectious Disease Initiative grant (SIDI/2015/001). We were also supported by the Molecular Biology Laboratory and the Department of Laboratory Medicine, TTSH, Singapore. The culture analysis of fish was primarily funded by the National Environment Agency, Singapore. The statistical work was funded by the Project MODUS grant, while whole-genome sequencing and analysis were conducted at the Genome Institute of Singapore, partially funded by the POLARIS program, Agency for Science, Technology and Research (A*STAR) and the Singapore Ministry of Health’s National Medical Research Council (NMRC/CIRG/1357/2013). Background : Streptococcus agalactiae (group B Streptococcus [GBS]) has not been described as a foodborne pathogen. However, in 2015, a large outbreak of severe invasive sequence type (ST) 283 GBS infections in adults epidemiologically linked to the consumption of raw freshwater fish occurred in Singapore. We attempted to determine the scale of the outbreak, define the clinical spectrum of disease, and link the outbreak to contaminated fish. Methods : Time-series analysis was performed on microbiology laboratory data. Food handlers and fishmongers were screened for enteric carriage of GBS. A retrospective cohort study was conducted to assess differences in demographic and clinical characteristics of patients with invasive ST283 and non-ST283 infections. Whole-genome sequencing was performed on human and fish ST283 isolates from Singapore, Thailand, and Hong Kong. Results : The outbreak was estimated to have started in late January 2015. Within the study cohort of 408 patients, ST283 accounted for 35.8% of cases. Patients with ST283 infection were younger and had fewer comorbidities but were more likely to develop meningoencephalitis, septic arthritis, and spinal infection. Of 82 food handlers and fishmongers screened, none carried ST283. Culture of 43 fish samples yielded 13 ST283-positive samples. Phylogenomic analysis of 161 ST283 isolates from humans and fish revealed they formed a tight clade distinguished by 93 single-nucleotide polymorphisms. Conclusions : ST283 is a zoonotic GBS clone associated with farmed freshwater fish, capable of causing severe disease in humans. It caused a large foodborne outbreak in Singapore and poses both a regional and potentially more widespread threat. Postprint

Carbapenems are a mainstay of treatment for infections caused by Pseudomonas aeruginosa. Carbapenem resistance mediated by metallo-β-lactamases (MBLs) remains uncommon in the United States, despite the worldwide emergence of this group of enzymes. Between March 2012 and May 2013, we detected MBL-producing P. aeruginosa in a university-affiliated health care system in northeast Ohio. We examined the clinical characteristics and outcomes of patients, defined the resistance determinants and structure of the genetic element harboring the blaMBL gene through genome sequencing, and typed MBL-producing P. aeruginosa isolates using pulsed-field gel electrophoresis (PFGE), repetitive sequence-based PCR (rep-PCR), and multilocus sequence typing (MLST). Seven patients were affected that were hospitalized at three community hospitals, a long-term-care facility, and a tertiary care center; one of the patients died as a result of infection. Isolates belonged to sequence type 233 (ST233) and were extensively drug resistant (XDR), including resistance to all fluoroquinolones, aminoglycosides, and β-lactams; two isolates were nonsusceptible to colistin. The blaMBL gene was identified as blaVIM-2 contained within a class 1 integron (In559), similar to the cassette array previously detected in isolates from Norway, Russia, Taiwan, and Chicago, IL. Genomic sequencing and assembly revealed that In559 was part of a novel 35-kb region that also included a Tn501-like transposon and Salmonella genomic island 2 (SGI2)-homologous sequences. This analysis of XDR strains producing VIM-2 from northeast Ohio revealed a novel recombination event between Salmonella and P. aeruginosa, heralding a new antibiotic resistance threat in this region's health care system Fil: Perez, Federico. Louis Stokes Cleveland Department of Veterans Affairs Medical Center. Cleveland; Estados Unidos. Case Western Reserve University School of Medicine. Cleveland; Estados Unidos Fil: Hujer, Andrea M.. Louis Stokes Cleveland Department of Veterans Affairs Medical Center. Cleveland; Estados Unidos. Case Western Reserve University School of Medicine. Cleveland; Estados Unidos Fil: Marshall, Steven H.. Louis Stokes Cleveland Department of Veterans Affairs Medical Center. Cleveland; Estados Unidos Fil: Ray, Amy, J.. Case Western Reserve University School of Medicine. Cleveland; Estados Unidos. University Hospitals Case Medical Center. Cleveland; Estados Unidos Fil: Rather, Philip N.. Emory University School of Medicine. Atlanta; Estados Unidos. Department of Veterans Affairs Medical Center. Decatur; Estados Unidos Fil: Suwantaratf, Nuntra. University Hospitals Case Medical Center. Cleveland; Estados Unidos Fil: Dumford III, Donald. University Hospitals Case Medical Center. Cleveland; Estados Unidos Fil: O'Shea, Patrick. Louis Stokes Cleveland Department of Veterans Affairs Medical Center. Cleveland; Estados Unidos Fil: Domitrovic, T. Nicholas J.. Louis Stokes Cleveland Department of Veterans Affairs Medical Center. Cleveland; Estados Unidos Fil: Salata, Robert A.. Case Western Reserve University School of Medicine. Cleveland; Estados Unidos. University Hospitals Case Medical Center. Cleveland; Estados Unidos Fil: Chavda, Kalyan D.. Rutgers University; Estados Unidos Fil: Chen, Liang. Rutgers University; Estados Unidos Fil: Kreiswirth, Barry N. Rutgers University; Estados Unidos Fil: Vila, Alejandro Jose. Consejo Nacional de Investigaciones Científicas y Técnicas. Centro Científico Tecnológico Conicet - Rosario. Instituto de Biología Molecular y Celular de Rosario. Universidad Nacional de Rosario. Facultad de Ciencias Bioquímicas y Farmacéuticas. Instituto de Biología Molecular y Celular de Rosario; Argentina Fil: Haussler, Susanne. Hannover Medical School and Helmholtz Center for Infection Research; Alemania Fil: Jacobs, Michael R.. Case Western Reserve University School of Medicine. Cleveland; Estados Unidos Fil: Bonomo, Robert A.. Louis Stokes Cleveland Department of Veterans Affairs Medical Center. Cleveland; Estados Unidos. Case Western Reserve University School of Medicine. Cleveland; Estados Unidos

Herbaspirillum spp. are rare causes of human infections associated primarily with bacteremia in cancer patients. We report the first fatal case of bacteremia secondary to pneumonia caused by Herbaspirillum seropedicae in a 65-year-old man with end-stage renal disease and multiple myeloma.

Vancomycin-resistant enterococcal (VRE) blood stream infections (BSIs) pose significant hazards to patients with hematologic malignancy. We compared and examined VRE BSI rates, patient characteristics and clinical outcomes for two cohorts of patients: those who did and did not undergo hematopoietic cell transplant (HCT). In this single institution study, we retrospectively analyzed records of consecutive patients from 1998 through 2011. Over this 14-year period, VRE was identified in 14% of all BSIs in patients with HCT with a cumulative rate of 1.9% (48/2581 BSIs/patients). VRE was identified in 10% of all BSIs in non-HCT patients with a cumulative rate of 1.1% (35/3154 BSIs/patients). Transplant patients who developed VRE BSI tended to be younger, hospitalized more frequently, were exposed to vancomycin therapy frequently, and were more likely to have had a central venous catheter removed. VRE remains a significant cause of morbidity and mortality, as 22 deaths were directly or indirectly attributed to this infection. Both HCT and non-HCT patients are susceptible to VRE infection and are equally at risk for adverse outcomes related to VRE BSI.

Recent reports suggest that infections due to fluoroquinolone-resistantWe performed a retrospective, observational cohort study and a nested case-control study within the US Deparment of Veterans Affairs Healthcare System. The primary outcomes were the incidence of urinary tract infection (UTI) and bacteremia with245 618 patients undergoing 302 168 TBP procedures from 2000 through 2013 were included in the cohort study, and 59 469 patients undergoing TBP from 2011 through 2013 were included in the nested case-control study. Between 2000 and 2013, there was a 5-fold increase in the incidence ofIn the Veterans Affairs Healthcare System, the incidence of

SUMMARY Carbapenem-resistant Gram-negative bacteria, in particular the Acinetobacter baumannii-calcoaceticus complex and Enterobacteriaceae , are escalating global public health threats. We review the epidemiology and prevalence of these carbapenem-resistant Gram-negative bacteria among countries in South and Southeast Asia, where the rates of resistance are some of the highest in the world. These countries house more than a third of the world's population, and several are also major medical tourism destinations. There are significant data gaps, and the almost universal lack of comprehensive surveillance programs that include molecular epidemiologic testing has made it difficult to understand the origins and extent of the problem in depth. A complex combination of factors such as inappropriate prescription of antibiotics, overstretched health systems, and international travel (including the phenomenon of medical tourism) probably led to the rapid rise and spread of these bacteria in hospitals in South and Southeast Asia. In India, Pakistan, and Vietnam, carbapenem-resistant Enterobacteriaceae have also been found in the environment and community, likely as a consequence of poor environmental hygiene and sanitation. Considerable political will and effort, including from countries outside these regions, are vital in order to reduce the prevalence of such bacteria in South and Southeast Asia and prevent their global spread.

OBJECTIVETo determine the prevalence and acquisition of extended-spectrum β-lactamases (ESBLs), plasmid-mediated AmpCs (pAmpCs), and carbapenemases (“MDR Enterobacteriaceae”) colonizing children admitted to a pediatric intensive care unit (PICU).DESIGNProspective study.SETTING40-bed PICU.METHODSAdmission and weekly thereafter rectal surveillance swabs were collected on all pediatric patients during a 6-month study period. Routine phenotypic identification and antibiotic susceptibility testing were performed. Enterobacteriaceae displaying characteristic resistance profiles underwent further molecular characterization to identify genetic determinants of resistance likely to be transmitted on mobile genetic elements and to evaluate relatedness of strains including DNA microarray, multilocus sequence typing, repetitive sequence-based PCR, and hsp60 sequencing typing.RESULTSEvaluating 854 swabs from unique children, the overall prevalence of colonization with an MDR Enterobacteriaceae upon admission to the PICU based on β-lactamase gene identification was 4.3% (n=37), including 2.8% ESBLs (n=24), 1.3% pAmpCs (n=11), and 0.2% carbapenemases (n=2). Among 157 pediatric patients contributing 603 subsequent weekly swabs, 6 children (3.8%) acquired an incident MDR Enterobacteriaceae during their PICU stay. One child acquired a pAmpC (E. coli containing blaDHA) related to an isolate from another patient.CONCLUSIONSApproximately 4% of children admitted to a PICU were colonized with MDR Enterobacteriaceae (based on β-lactamase gene identification) and an additional 4% of children who remained in the PICU for at least 1 week acquired 1 of these organisms during their PICU stay. The acquired MDR Enterobacteriaceae were relatively heterogeneous, suggesting that a single source was not responsible for the introduction of these resistance mechanisms into the PICU setting.Infect Control Hosp Epidemiol 2016;37:535–543

We report a case of Nocardia farcinica ruptured intracranial mycotic aneurysm associated with bortezomib and corticosteroid treatment in a multiple myeloma patient. The patient was treated with trimethoprim-sulfamethoxazole and moxifloxacin together with surgical repairment of intracranial mycotic aneurysm. Keywords: Nocardia, Nocardia farcinica, Mycotic aneurysm, Multiple myeloma, Proteasome inhibitor

Bifidobacterium breve is a rare cause of human infections. Previously, bacteremia and meningitis caused by this organism linked to probiotic use have been reported in a neonate. We report the first case of a ventriculoperitoneal shunt infection caused by B. breve in an adult without a history of probiotic use.

Clostridium difficile infection (CDI) is a leading cause of nosocomial infections and the most important cause of health care-associated diarrhea worldwide. Standard treatment of CDI consists of modifying underlying antibiotic exposure, aggressive supportive measures, and therapy with specific antibiotics, most commonly metronidazole or vancomycin. This general approach to CDI has remained largely unchanged for decades. In an effort to improve outcomes and reduce recurrences of CDI, interest has been renewed in the development of nonantibiotic and adjunct approaches to therapy. In this review, we highlight some of these recent, resurrected, and novel nonantibiotic treatments.

Background There are limited data on routine use of anaerobic blood cultures and the prevalence of patients with anaerobic bacteremia in Thailand. Methods Thammasat University Hospital is a 650-bed university hospital located in central Thailand. We implemented routine blood culture work up for adults using paired aerobic/anaerobic bottles using the BACTEC FX system (BD Diagnostics) as a standard practice. Gram stain and inoculation of positive blood cultures on aerobic and anaerobic culture media were performed and maintained in anaerobic conditions by the Anoxomat™ system (Mart Microbiology). Vitek2 system (BioMerieux) was used for bacterial identification. Data on positive blood cultures, bacterial identification, and time to positivity (TTP) between aerobic and anaerobic bottles were compared. Characteristics of patients with bacteremia were reviewed. Results During December 2016–October 2017, 323 blood culture sets were processed (one BACTEC anaerobic Plus bottle and two aerobic bottles). Majority of samples received were from patients hospitalized in an intensive care unit (surgical ICU 28% and medical ICU 25%) followed by general medical unit (19%) and surgical unit (16%). There were 21 positive cultures from anaerobic bottles (21/323, 6.5%) vs. 30 positive cultures from aerobic bottle (30/646, 4.6%) (P = 0.3). Bacteria isolated from anaerobic bottles included Staphylococcus aureus (n = 8), coagulase-negative staphylococci (n = 3), viridans group streptococci (n = 1), Klebsiella pneumoniae (n = 8), and Escherichia coli (n = 1). Positivity rate of Gram-positive bacteria (GP) from anaerobic bottle was slightly higher than the rate of GP from aerobic bottle (12/203, 3.1% vs. 12/646, 1.9%; P = 0.08) There was no isolation of anaerobic bacteria. TTP from anaerobic bottles (mean of 15.6 hours, range 11–26 hours) was significantly faster than TTP from aerobic bottles (mean of 49.5 hours, range 13–100 hours) (P

We report the first case of a child in the United States infected with an organism producing a Verona Integron-Encoded Metallo-β-Lactamase. This child succumbed to a ventilator-associated pneumonia caused by a Klebsiella pneumoniae producing this resistance mechanism.

Anti-interferon (IFN)-γ autoantibodies are increasingly recognized as a cause of adult-onset immunodeficiency and increased risk for infections with intracellular pathogens. We report on disseminated Talaromyces (Penicillium) marneffei and Mycobacterium abscessus infection in a 72-year-old, human immunodeficiency virus noninfected, Thai man with anti-IFN-γ autoantibody. The patient was successfully treated with antimicrobial therapy and rituximab to control B cell-derived autoantibodies.

PURPOSE OF REVIEW Several viral diseases have emerged and impacted healthcare systems worldwide. Healthcare personnels (HCPs) are at high risk of acquiring some emerging infections while caring for patients. We provide a review of risk factors, evidence of infection in HCPs, and prevention strategies with Middle East respiratory syndrome coronavirus, Ebola virus disease (Ebola), severe acute respiratory syndrome (SARS), and avian influenza. RECENT FINDINGS HCP-related infections with Middle East respiratory syndrome coronavirus, Ebola, and SARS have been reported among 1-27%, 2.5-12%, and 11-57% of total cases, respectively. The case fatality rate of Ebola in HCPs has been reported up to 73%. The WHO guidelines for the global surveillance of SARS were developed in 2004 and used as a template for other emerging diseases preparedness. Risks to HCPs with emerging diseases are related to inappropriate and insufficient infection control measures during an initial encounter, at the beginning of outbreak and with an overwhelming number of patient cases. To date, there are no reports of avian influenza transmission to HCPs from affected cases. SUMMARY Early and rapid detection of suspected infected patients with communicable diseases along with appropriate infection control practice, education, national and global preparedness guidelines would help to prevent disease transmission to HCPs.

Background There is limited data on incidence of MDROs colonization and outcome in patients undergoing elective orthopedic surgery. Methods We performed MDROs surveillance screening (swabs from nose, throat, groins, and rectum) in patients undergoing elective orthopedic surgery at the Thammasat University Hospital between March and August 2016. MDROs were defined as Gram-negative bacteria (GNB) possessing extended-spectrum β-lactamases (ESBLs), Carbapenem-resistant Enterobacteriaceae (CRE), and non-lactose fermenting GNB resistant to at least 3 antibiotic classes, methicillin-resistant Staphylococcus aureus (MRSA), and vancomycin resistant enterococci (VRE). MDROs were identified by the Vitek®2 automated system. Antimicrobial susceptibility testing (disk diffusion test) was performed using the CLSI Interpretive Guidelines. Incidence of MDROs colonization upon admission was determined. Patient’s clinical characteristics, risk factors for MDROs infection, procedure types and antibiotic prophylaxis were prospectively collected. Surgical sites infections (SSIs) and complications up to 6 months after surgery among the patients with and without MDROs colonization were compared. Results Of 384 swabs tested from 96 patients (median age, 58 years), ESBL-producing Escherichia coli (ESBL-E. coli) was identified in 31 rectal swabs (32.3%) and 7 groin swabs (7.3%). Seven patients (7.3%) were diagnosed with SSIs. A higher rate of SSIs was found among patients with ESBL-E. coli colonization (6/31, 19.4%) compared with patient without ESBL-E. coli colonization (1/65, 1.5%; P = 0.004, OR 15.4, 95% CI 1.7–356.3). From the multivariate logistic regression analysis, SSIs were significantly associated with ESBL-E.coli colonization (P = 0.009, adjusted OR 18.3, 95% CI 2.1–162.9). In addition, from the multivariate logistic regression analysis, ESBL-E.coli was a significantly risk factor associated with SSIs (6/7, 85.7%, P = 0.014, adjusted OR 16.5, 95% CI 1.8–153.4). Conclusion We found a high incidence of ESBL-E. coli colonization and rate of SSIs in patients who had elective orthopedic surgery. These patients did not have any other risk factors for MDROs infection. Active screening for colonization of ESBL-producing pathogens may be necessary to guide appropriate antibiotic prophylaxis to reduce rates of SSIs. Disclosures All authors: No reported disclosures.

Five chromogenic agars, evaluated using 400 stool specimens, were found to be superior in sensitivity (range, 89.9 to 93.9%) to bile esculin azide agar with vancomycin (BEAV) agar (84.8%) for detecting vancomycin-resistant enterococci (VRE), and the results were available 24 to 48 h sooner. The time to detection, need for supplemental testing, color distinction, and breakthrough of non-VRE organisms vary among the chromogenic media tested and may factor into the decision to use a particular medium.

In units that bathe patients daily with chlorhexidine gluconate (CHG), organisms causing central line–associated bloodstream infections (CLABSIs) were more likely to have reduced CHG susceptibility than organisms causing CLABSIs in units that do not bathe patients daily with CHG (86% vs 64%; P = .028). Surveillance is needed to detect reduced CHG susceptibility with widespread CHG use.Infect Control Hosp Epidemiol 2014;35(9):1183-1186

With interest, we read the paper by Korem et al. describing a case of Exserohilum rostratum sinusitis from which serum galactomannan (GM) levels were elevated upon diagnosis ([1][1]). They further demonstrated that the extract of the E. rostratum clinical isolate yielded positive GM results