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Engagement of frontline staff, along with senior leadership, in competition-style healthcare-associated infection reduction efforts, combined with electronic clinical decision support tools, appeared to reduce antibiotic regimen initiations for urinary tract infections (P = .01). Mean monthly standardized infection and device utilization ratios also decreased (P < .003 and P < .0001, respectively).

Pseudomonas aeruginosa is intrinsically resistant to many antimicrobial drugs, making carbapenems crucial in clinical management. During July-October 2015 in the United States, we piloted laboratory-based surveillance for carbapenem-resistant P. aeruginosa (CRPA) at sentinel facilities in Georgia, New Mexico, Oregon, and Tennessee, and population-based surveillance in Monroe County, NY. An incident case was the first P. aeruginosa isolate resistant to antipseudomonal carbapenems from a patient in a 30-day period from any source except the nares, rectum or perirectal area, or feces. We found 294 incident cases among 274 patients. Cases were most commonly identified from respiratory sites (120/294; 40.8%) and urine (111/294; 37.8%); most (223/280; 79.6%) occurred in patients with healthcare facility inpatient stays in the prior year. Genes encoding carbapenemases were identified in 3 (2.3%) of 129 isolates tested. The burden of CRPA was high at facilities under surveillance, but carbapenemase-producing CRPA were rare.

BackgroundCleanliness of hospital surfaces helps prevent healthcare-associated infections, but larger evaluations of the effectiveness of various cleaning strategies during SARS-CoV-2 surges and worker shortages are scarce.MethodsIn an acute care hospital (ACH) and a long-term care facility (LTCF), 417 surfaces were tested for SARS-CoV-2 and adenosine triphosphate before and after various cleaning strategies, including ultraviolet light (UV-C), electrostatic spraying, and room fogging.ResultsACH surface contamination differed among outbreak and non-outbreak wards (p = 0.001). RNA was detected on 66% of surfaces before cleaning and on 23% of those surfaces immediately after terminal cleaning, for a 65% post-cleaning reduction (p = 0.001). UV-C resulted in an 87% reduction (p = 0.023), while spraying with electrostatic bleach resulted in a 47% reduction (p = 0.010). LTCF contamination rates differed between the dementia, rehabilitation, and the residential units (p = 0.005). 67% of surfaces had RNA after room fogging without terminal-style wiping. Fogging with wiping led to an 11% reduction in the proportion of positive surfaces.DiscussionBaseline contamination varied by type of unit and outbreak conditions, but not facility type. Removal of viral RNA varied according to strategy. Unlike previous reports, time spent cleaning was associated with cleaning thoroughness.

Heteroresistance is an underappreciated phenomenon that may be the cause of some unexplained antibiotic treatment failures. Misclassification of heteroresistant isolates as susceptible may lead to inappropriate therapy., Heteroresistance is a form of antibiotic resistance where a bacterial strain is comprised of a minor resistant subpopulation and a majority susceptible subpopulation. We showed previously that colistin heteroresistance can mediate the failure of colistin therapy in an in vivo infection model, even for isolates designated susceptible by clinical diagnostics. We sought to characterize the extent of colistin heteroresistance among the highly drug-resistant carbapenem-resistant Enterobacterales (CRE). We screened 408 isolates for colistin heteroresistance. These isolates were collected between 2012 and 2015 in eight U.S. states as part of active surveillance for CRE. Colistin heteroresistance was detected in 10.1% (41/408) of isolates, and it was more common than conventional homogenous resistance (7.1%, 29/408). Most (93.2%, 38/41) of these heteroresistant isolates were classified as colistin susceptible by standard clinical diagnostic testing. The frequency of colistin heteroresistance was greatest in 2015, the last year of the study. This was especially true among Enterobacter isolates, of which specific species had the highest rates of heteroresistance. Among Klebsiella pneumoniae isolates, which were the majority of isolates tested, there was a closely related cluster of colistin-heteroresistant ST-258 isolates found mostly in Georgia. However, cladistic analysis revealed that, overall, there was significant diversity in the genetic backgrounds of heteroresistant K. pneumoniae isolates. These findings suggest that due to being largely undetected in the clinic, colistin heteroresistance among CRE is underappreciated in the United States.

A simple, sensitive, and rapid chemiluminescence method was developed for the detection and quantification of selected derivatives of artemisinin. It was found that the chemiluminescence (CL) signal resulting from the alkaline luminol reaction of the artemisinin derivatives in the presence of hematin was linear over a wide concentration range. We report results that suggest that a visual test or a test involving digital image capture may be used in addition to a field-ready instrumental approach to combat drug counterfeiting of malarial therapies.

Various subsets of extranodal marginal zone lymphomas of mucosa-associated lymphoid tissues (MALT lymphomas) have been associated with infectious organisms. Most notable of these is the association of gastric MALT lymphomas with Helicobacter pylori infection. In a recent publication Ferreri et al. [Ferreri AJ, Guidoboni M, Ponzoni M, De Conciliis C, Dell'Oro S, Fleischhauer K, et al. Evidence for an association between Chlamydia psittaci and ocular adnexal lymphomas. J Natl Cancer Inst 2004;96:586-94] reported the presence of C. psittaci DNA in 80% of 40 ocular adnexal lymphomas. Similar to the gastric MALT lymphoma data, a subset of these patients responded well to antibiotic treatment. We analyzed a set of ocular adnexal lymphomas and benign (non-neoplastic) lesions for evidence of C. psittaci DNA in patients from New York State. No evidence of C. psittaci DNA was seen in seven MALT-type ocular adnexal lymphomas, four non-MALT ocular lymphomas, one Langerhans histiocytosis, and five reactive lymphoproliferations. We eliminated several possible reasons that would cause our study to fail to find C. psittaci DNA, including the presence of PCR inhibitors, inadequate template DNA, and sequence diversity in the target region in C. psittaci. The positive data were based primarily on patients from Italy, while our study involved only patients living in the Northeastern United States. This would suggest possible geographic differences in the etiology of ocular adnexal lymphomas.

Background Candida auris, an emerging multidrug-resistant pathogen associated with increased mortality, can disseminate on hospital surfaces and resist disinfection. Transmission dynamics remain poorly understood at community hospitals. Immediately following identification of a C. auris infection in an unsuspected patient admitted to a semi-private room 6 days previously, we sought to limit and determine the extent of C. auris contamination at Rochester General (RG), a 528-bed hospital in New York, using available resources. Methods The index and roommate were placed on enhanced contact precautions and moved to private rooms. Their former room was terminally cleaned with peracetic acid/hydrogen peroxide (PAHP) and UV light. Ten high-touch environmental surfaces in the new rooms of the index and roommate, the nursing stations, and throughout the ward were sampled immediately before and after, and between daily cleaning. The nares, axillae, and groin of the index, the roommate, and all concurrent ward patients were also sampled. All patients on the involved ward were sequentially moved from their initial rooms into vacated rooms that were terminally cleaned with PAHP and UV light. Prior to the index event, RG laboratory began sending all possible C. auris isolates to the state public health laboratory for confirmation, and using PAHP for all cleaning. RG also leverages preexisting agreements with other referral laboratories to support outbreak investigations. Hand-hygiene compliance averaged 80–90% on the ward. Hospital leaders, laboratory, nursing, environmental services, and local public health personnel regularly participate in infection prevention efforts. Results C. auris was isolated from 3 of 132 surface samples on the eighth, nineth, and 15th day of ward occupancy, and 0 of 48 patient samples from 18 co-located patients. The index remained colonized until death on hospital Day 21. No surfaces were C. auris-positive 1 month later. Conclusion Compared with prior reports, dissemination at RG was limited. This, the first such quantitative assessment, illustrates how community hospitals can enhance surveillance and patient safety when formal agreements, vigilance, and multi-disciplinary and interagency teamwork exist before outbreaks occur. Disclosures All authors: No reported disclosures.

A biopsy of a nasal mass that had morphologic and immunostaining features consistent with a B-cell lymphoma was studied for clonality using PCR of the IgH gene. An unexpectedly low molecular weight DNA fragment of approximately 140bp (acceptable size limit: 250-295bp) was obtained using FR2 and JH primers. The sequence of this DNA was consistent with a clonal IgH rearrangement followed by a deletion that removed most of the downstream portion of the V segment. Thus, the biopsy contained a monoclonal population of B-lymphocytes, consistent with a diagnosis of lymphoma. This work illustrates that bands outside of the size range expected from PCR of the antigen receptor genes may still be consistent with a monoclonal result.

Various subsets of extranodal marginal zone lymphomas of mucosa-associated lymphoid tissues (MALT lymphomas) have been associated with infectious organisms. Most notable of these is the association of gastric MALT lymphomas with Helicobacter pylori infection. In a recent publication Ferreri et al. [Ferreri AJ, Guidoboni M, Ponzoni M, De Conciliis C, Dell'Oro S, Fleischhauer K, et al. Evidence for an association between Chlamydia psittaci and ocular adnexal lymphomas. J Natl Cancer Inst 2004;96:586-94] reported the presence of C. psittaci DNA in 80% of 40 ocular adnexal lymphomas. Similar to the gastric MALT lymphoma data, a subset of these patients responded well to antibiotic treatment. We analyzed a set of ocular adnexal lymphomas and benign (non-neoplastic) lesions for evidence of C. psittaci DNA in patients from New York State. No evidence of C. psittaci DNA was seen in seven MALT-type ocular adnexal lymphomas, four non-MALT ocular lymphomas, one Langerhans histiocytosis, and five reactive lymphoproliferations. We eliminated several possible reasons that would cause our study to fail to find C. psittaci DNA, including the presence of PCR inhibitors, inadequate template DNA, and sequence diversity in the target region in C. psittaci. The positive data were based primarily on patients from Italy, while our study involved only patients living in the Northeastern United States. This would suggest possible geographic differences in the etiology of ocular adnexal lymphomas.

A biopsy of a nasal mass was received from another institution for a hematopathology consultation. The specimen had morphologic and immunostaining features consistent with a B-cell lymphoma, histologically low-grade, and suggestive for an extranodal marginal cell lymphoma of mucosa associated lymphoid tissue (MALT) type. We used PCR of the IgH gene to evaluate clonality on DNA derived from this specimen. The primers were from the BIOMED-2 report (van Dongen et al. 2003, Leukemia17:2257) and the amplicons were subjected to heteroduplex formation prior to PAGE. A homoduplex of approximately 140 bp was obtained reproducibly from the FR2 and JH primers, which is below the usually acceptable size limits of 250–295 bps. No homoduplex was obtained using FR3 and JH primers. We sequenced the FR2/JH amplicon using the PCR primers as sequencing primers. The amplicon was 137 bps, with 92 bps between the primers. After the upstream VH3 FR2 primer there were approximately 25 bps from the FR2 region of several members of the VH3 family, with VH3-49 (allele *03) being the best match. Adjacent to the downstream consensus JH primer there were approximately 30 bp from the J6 segment. Between the identifiable sequences there were 37 bp that we could not identify. Blast searches turned up several matches of 18 bp, but nothing that gave convincing evidence for its origin. We interpret these results as indicating a clonal IgH rearrangement followed by a deletion that removed most of the downstream portion of the V segment, including the FR3 region. It is likely that the 37 bp in between the identified IgH segments consists of randomly inserted nucleotides and IgH sequence that has been somatically mutated beyond recognition, although other interpretations are possible. However, the amplicon does appear to be derived from an IgH rearrangement, which is consistent with derivation from a monoclonal population of B-lymphocytes. This work illustrates that DNA fragments outside of the size range expected from PCR of the antigen receptor genes may still be consistent with a monoclonal result. Thus, this type of result should not be dismissed, but should be subjected to further analysis.

Chronic myelogenous leukemia (CML) is caused by a balanced translocation between chromosomes 9 and 22 that creates the BCR-ABL fusion gene (FG) and activates the ABL tyrosine kinase (TK). Imatinib inhibits this TK and causes long-term remission in most CML patients. Relapse during imatinib therapy is often associated with mutations in the BCR-ABL FG that cause resistance to inhibition by imatinib. The usual procedure for detecting imatinib resistance mutations involves reverse transcription, PCR of the BCR-ABL FG, then nested PCR of the ABL TK to generate a template for sequencing. This procedure is suboptimal in a clinical laboratory because of the risk of carryover contamination, and extra time and workload, all due to the use of nested PCR. We describe a procedure for preparing sequencing template from the BCR-ABL FG that does not require nested PCR. The initial PCR employs a mixture of thermostable DNA polymerases that increases the sensitivity of the reaction for limiting concentrations of the desired target. One round of PCR provides enough template for sequencing. The PCR products are sequenced directly without gel purification, using three internal primers plus the downstream PCR primer as sequencing primers. The internal primers provide additional specificity resulting in a high quality sequence even if the PCR produces undesired products. Using this methodology we analyzed a series of eleven CML patient specimens selected because of a four-fold or greater increase in expression of the BCR-ABL FG during treatment with imatinib. The expression of BCR-ABL RNA was measured using a reverse transcription Q-PCR assay. The leftover cDNA from the expression assay was used as template for the PCR to generate the sequencing template. Five patients lacked a detectable mutation, and six had a mutation in the BCR-ABL TK. The six mutations found, G279E, F317L, L248V, M351T, F359C, and H396R, had all been seen previously and associated with resistance to imatinib. We conclude that detection of imatinib resistance mutations in the BCR-ABL FG is feasible without using nested PCR, although with a reduced analytical sensitivity. Elimination of the nested PCR step makes the procedure easier, quicker and less likely to suffer from carryover contamination. This method is a viable alternative for the detection of imatinib resistance mutations in the clinical laboratory.

Several subsets of extranodal marginal zone lymphomas of mucosa-associated lymphoid tissues (MALT lymphomas) have been associated with infectious organisms. This finding is of particular significance in the treatment of these conditions because it suggests that eliminating the source of the antigen may result in regression of the malignancy. For example, gastric MALT lymphoma is associated with Helicobacter pylori infection. Antibiotic therapy that eliminates the H. pylori infection frequently causes regression of the lymphoma. Ferreri et al (2004, J Natl Cancer Inst. 96:586) reported the presence of Chlamydia psittaci DNA in 80% of 40 ocular adnexal lymphomas. Consistent with the gastric MALT lymphoma data, a subset of these patients responded well to antibiotic treatment. We used a PCR based assay similar to that of Ferreri et al to analyze a set of ocular adnexal lymphomas and benign (non-neoplastic) lesions for evidence of C. psittaci DNA in patients from New York State. No evidence of C. psittaci DNA was seen in seven MALT-type ocular adnexal lymphomas, four non-MALT B-cell ocular adnexal lymphomas, one Langerhans histiocytosis, and five reactive lymphoproliferations. In addition, we found no evidence for C. psittaci in DNA samples from 21 monoclonal B-cell lymphomas from sites other than the ocular adnexa. We confirmed the negative results using an alternate PCR target in the 23S ribosomal RNA gene. In addition, we used appropriate controls to demonstrate that PCR inhibition and DNA template degradation did not affect our results. We conclude that C. psittaci infection did not play a role in the ocular adnexal lymphoproliferations in our survey. The difference in results with the previous report (Ferreri et al) suggests geographical differences in the incidence of C. psittaci infection, or other unknown disease cofactors.

Background Screening and determining the immune status of individuals for hepatitis B is usually done by detecting hepatitis B surface antigen (HBsAg) and hepatitis B surface antigen-specific antibodies (HBsAb). In some countries with the highest viral burden, performing these assays is currently impractical. This paper explores the use of filter paper as a blood specimen transport medium. Methods Samples, chosen from routine clinical laboratory pool, were applied and dried onto filter paper. Eluates, from the paper samples, were analyzed as routine clinical specimens on ADVIA Centaur 5634® immunoassay analyzers using the standard HBsAg and HBsAb kits. Dried blood samples were subjected to a range of environmental conditions in order to assess stability. Results After drying and elution the assays showed linearity and precision comparable to clinical assays performed on fresh serum. Elutions at various times during a 149 day incubation period showed very little variability in the Index numbers. All analytes were temperature stable except for a decrease in the HBsAg signal at 42°C. Conclusions Filter paper is an acceptable storage and transport medium for serum to be used in the detection of hepatitis B markers if atmospheric variability can be controlled. HBsAg, HBsAb and HBcAb are all stable for at least five months under storage conditions below room temperature. Drying specimens, particularly serum, on filter paper at remote locations, offers a reasonable solution to the problem of hepatitis surveillance in underdeveloped regions, although some attempt at temperature control might be desirable.