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Background: Patients with end-stage renal disease (ESRD) on maintenance dialysis receive dialysis in common spaces with other patients and have a higher risk of severe SARS-CoV-2 infections. They may have persistently or intermittently positive SARS-CoV-2 reverse-transcription polymerase chain reaction (RT-PCR) tests after infection. We describe the clinical course of SARS-CoV-2 infection and the serologic response in a convenience sample of patients with ESRD to understand the duration of infectivity. Methods: From August to November 2020, we enrolled patients on maintenance dialysis with SARS-CoV-2 infections from outpatient dialysis facilities in Atlanta, Georgia. We followed participants for approximately 42 days. We assessed COVID-19 symptoms and collected specimens. Oropharyngeal (OP), anterior nasal (AN), and saliva (SA) specimens were tested for the presence of SARS-CoV-2 RNA, using RT-PCR, and sent for viral culture. Serology, including neutralizing antibodies, was measured in blood specimens. Results: Fifteen participants with a median age of 58 (range 37‒77) years were enrolled. Median duration of RT-PCR positivity from diagnosis was 18 days (interquartile range (IQR): 8‒24 days). Ten participants had at least one, for a total of 41, positive RT-PCR specimens ≥10 days after symptoms onset. Of these 41 specimens, 21 underwent viral culture; one (5%) was positive 14 days after symptom onset. Thirteen participants developed SARS-CoV-2 specific antibodies, 11 of which included neutralizing antibodies. RT-PCRs remained positive following seroconversion in eight participants and following detection of neutralizing antibodies in four participants; however, all these samples were culture negative. Conclusions: Patients with ESRD on maintenance dialysis remained persistently and intermittently SARS-CoV-2 RT-PCR positive. However, of the 15 participants, only one had infectious virus, on day 14 after symptom onset. Most participants mounted an antibody response, including neutralizing antibodies. Participants continued having RT-PCR-positive in the presence of SARS-CoV-2 specific antibodies, but without replication-competent virus detected.

Background: The COVID-19 pandemic in the United States is on-going and has impacted healthcare practices substantially. Consistent access to healthcare and, particularly, dialysis services are essential to the management of end stage renal disease (ESRD). The objective of this analysis was to examine patterns of outpatient hemodialysis utilization and outcomes of ESRD and COVID-19 in the 5 states with highest incidence of COVID-19 during the early stages of the pandemic. Methods: We used data from the Centers for Medicare and Medicaid Services (CMS) to examine trends in receipt of outpatient hemodialysis in 2019 and 2020 among Medicare beneficiaries with fee-for-service (FFS) coverage. Results: We found that average monthly hemodialysis rates for beneficiaries with ESRD without COVID-19 were stable over time at average monthly rates of between 2.5 and 2.8 sessions per person per week in both 2019 and 2020. Beneficiaries with COVID-19, both with and without pre-existing ESRD, had hemodialysis rates that varied monthly with an average of 2.5 sessions per week per person. Adjusted death rates were highest among beneficiaries with COVID-19 and pre-existing ESRD, followed by beneficiaries with COVID-19 and no pre-existing ESRD. There was little within-group variation in hemodialysis utilization by race/ethnicity but age- and sex- adjusted death rates varied considerably by racial and ethnic group. Conclusions: Dialysis facilities were able to provide hemodialysis sessions at typical rates despite challenges during the COVID-19 pandemic. However, patients with ESRD who contracted COVID-19 had remarkably high death rates, highlighting the need for ongoing efforts to protect at-risk populations from COVID-19.

Background Performing catheter-care observations in outpatient hemodialysis facilities are one of the CDC9s core interventions, which have been proven to reduce bloodstream infections. However, staff have many competing responsibilities. Efforts to increase and streamline the process of performing observations are needed. We developed an electronic catheter checklist, formatted for easy access with a mobile device, and conducted a pilot project to determine the feasibility of implementing it in outpatient dialysis facilities. Methods The tool contained the following content: (1) patient education videos; (2) catheter-care checklists (connection, disconnection, and exit-site care); (3) prepilot and postpilot surveys; and (4) a pilot implementation guide. Participating hemodialysis facilities performed catheter-care observations on either a weekly or monthly schedule and provided feedback on implementation of the tool. Results The pilot data were collected from January 6 through March 12, 2020, at seven participating facilities. A total of 954 individual observations were performed. The catheter-connection, disconnection, and exit-site steps were performed correctly for most individual steps; however, areas for improvement were (1) allowing for appropriate antiseptic dry time, (2) avoiding contact after antisepsis, and (3) applying antibiotic ointment to the exit site. Postpilot feedback from staff was mostly favorable. Use of the electronic checklists facilitated patient engagement with staff and was preferred over paper checklists, because data are easily downloaded and available for use in facility Quality Assurance and Performance Improvement (QAPI) meetings. The educational video content was a unique learning opportunity for both patients and staff. Conclusions Converting the CDC9s existing catheter checklists to electronic forms reduced paperwork and improved the ease of collating data for use during QAPI meetings. An additional benefit was the educational content provided on the tablet, which was readily available for viewing by patients and staff while in the hemodialysis facility.

SARS-CoV-2, the virus that causes coronavirus disease 2019 (COVID-19), can spread rapidly in nursing homes once it is introduced (1,2). To prevent outbreaks, more data are needed to identify sources of introduction and means of transmission within nursing homes. Nursing home residents who receive hemodialysis (dialysis) might be at higher risk for SARS-CoV-2 infections because of their frequent exposures outside the nursing home to both community dialysis patients and staff members at dialysis centers (3). Investigation of a COVID-19 outbreak in a Maryland nursing home (facility A) identified a higher prevalence of infection among residents undergoing dialysis (47%; 15 of 32) than among those not receiving dialysis (16%; 22 of 138) (p

Summary Background Despite large reductions from 2005 to 2012, hospital-onset meticillin-resistant Staphylococcus aureus bloodstream infections (HO MRSA BSIs) continue to be a major source of morbidity and mortality. Aim To describe risk factors for and underlying sources of HO MRSA BSIs. Methods This study investigated HO MRSA BSIs at eight high-burden short-stay acute care hospitals. A case was defined as first isolation of MRSA from a blood specimen collected in 2016 on or after hospital day 4 from a patient without an MRSA-positive blood culture in the preceding 2 weeks. Case demographics and risk factors were reviewed by medical record abstraction. The potential clinical source(s) of infection were determined by consensus by a clinician panel. Findings Of the 195 eligible cases, 186 were investigated. Cases were predominantly male (63%) and the median age was 57 years (range 0–92 years). In the 2 weeks preceding BSI, 88% of cases had indwelling devices, 31% underwent a surgical procedure and 18% underwent dialysis. The most common locations of attribution were intensive care units (ICUs) (46%) and step-down units (19%). The most commonly identified non-mutually exclusive clinical sources were central venous catheters (46%), non-surgical wounds (17%), surgical site infections (16%), non-ventilator healthcare-associated pneumonia (13%) and ventilator-associated pneumonia (11%). Conclusions Device- and procedure-related infections were common sources of HO MRSA BSIs. Prevention strategies focused on improving adherence to existing prevention bundles for device-and procedure-associated infections and on source control for ICU patients, patients with certain indwelling devices, and patients undergoing certain high-risk surgeries are being pursued to decrease the burden of HO MRSA BSIs at these facilities.

Objective:To describe pathogen distribution and rates for central-line–associated bloodstream infections (CLABSIs) from different acute-care locations during 2011–2017 to inform prevention efforts.Methods:CLABSI data from the Centers for Disease Control and Prevention (CDC) National Healthcare Safety Network (NHSN) were analyzed. Percentages and pooled mean incidence density rates were calculated for a variety of pathogens and stratified by acute-care location groups (adult intensive care units [ICUs], pediatric ICUs [PICUs], adult wards, pediatric wards, and oncology wards).Results:From 2011 to 2017, 136,264 CLABSIs were reported to the NHSN by adult and pediatric acute-care locations; adult ICUs and wards reported the most CLABSIs: 59,461 (44%) and 40,763 (30%), respectively. In 2017, the most common pathogens were Candida spp/yeast in adult ICUs (27%) and Enterobacteriaceae in adult wards, pediatric wards, oncology wards, and PICUs (23%–31%). Most pathogen-specific CLABSI rates decreased over time, excepting Candida spp/yeast in adult ICUs and Enterobacteriaceae in oncology wards, which increased, and Staphylococcus aureus rates in pediatric locations, which did not change.Conclusions:The pathogens associated with CLABSIs differ across acute-care location groups. Learning how pathogen-targeted prevention efforts could augment current prevention strategies, such as strategies aimed at preventing Candida spp/yeast and Enterobacteriaceae CLABSIs, might further reduce national rates.

Oral fluids offer a noninvasive sampling method for the detection of Abs. Quantification of IgA and IgG Abs in saliva allows studies of the mucosal and systemic immune response after natural infection or vaccination. We developed and validated an enzyme immunoassay (EIA) to detect and quantify salivary IgA and IgG Abs against the prefusion-stabilized form of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) spike protein expressed in suspension-adapted HEK-293 cells. Normalization against total Ab isotype was performed to account for specimen differences, such as collection time and sample volume. Saliva samples collected from 187 SARS-CoV-2 confirmed cases enrolled in 2 cohorts and 373 prepandemic saliva samples were tested. The sensitivity of both EIAs was high (IgA, 95.5%; IgG, 89.7%) without compromising specificity (IgA, 99%; IgG, 97%). No cross-reactivity with endemic coronaviruses was observed. The limit of detection for SARS-CoV-2 salivary IgA and IgG assays were 1.98 ng/ml and 0.30 ng/ml, respectively. Salivary IgA and IgG Abs were detected earlier in patients with mild COVID-19 symptoms than in severe cases. However, severe cases showed higher salivary Ab titers than those with a mild infection. Salivary IgA titers quickly decreased after 6 wk in mild cases but remained detectable until at least week 10 in severe cases. Salivary IgG titers remained high for all patients, regardless of disease severity. In conclusion, EIAs for both IgA and IgG had high specificity and sensitivity for the confirmation of current or recent SARS-CoV-2 infections and evaluation of the IgA and IgG immune response.

Rationale & Objective Contaminated water and other fluids are increasingly recognized to be associated with health care–associated infections. We investigated an outbreak of Gram-negative bloodstream infections at 3 outpatient hemodialysis facilities. Study Design Matched case-control investigations. Setting & Participants Patients who received hemodialysis at Facility A, B, or C from July 2015 to November 2016. Exposures Infection control practices, sources of water, dialyzer reuse, injection medication handling, dialysis circuit priming, water and dialysate test findings, environmental reservoirs such as wall boxes, vascular access care practices, pulsed-field gel electrophoresis, and whole-genome sequencing of bacterial isolates. Outcomes Cases were defined by a positive blood culture for any Gram-negative bacteria drawn July 1, 2015 to November 30, 2016 from a patient who had received hemodialysis at Facility A, B, or C. Analytical Approach Exposures in cases and controls were compared using matched univariate conditional logistic regression. Results 58 cases of Gram-negative bloodstream infection occurred; 48 (83%) required hospitalization. The predominant organisms were Serratia marcescens (n=21) and Pseudomonas aeruginosa (n=12). Compared with controls, cases had higher odds of using a central venous catheter for dialysis (matched odds ratio, 54.32; lower bound of the 95% CI, 12.19). Facility staff reported pooling and regurgitation of waste fluid at recessed wall boxes that house connections for dialysate components and the effluent drain within dialysis treatment stations. Environmental samples yielded S marcescens and P aeruginosa from wall boxes. S marcescens isolated from wall boxes and case-patients from the same facilities were closely related by pulsed-field gel electrophoresis and whole-genome sequencing. We identified opportunities for health care workers' hands to contaminate central venous catheters with contaminated fluid from the wall boxes. Limitations Limited patient isolates for testing, on-site investigation occurred after peak of infections. Conclusions This large outbreak was linked to wall boxes, a previously undescribed source of contaminated fluid and biofilms in the immediate patient care environment.

Facility-wide testing performed at four outpatient hemodialysis facilities in the absence of an outbreak or escalating community incidence did not identify new SARS-CoV-2 infections and illustrated key logistical considerations essential to successful implementation of SARS-CoV-2 screening. Facilities could consider prioritizing facility-wide SARS-CoV-2 testing during suspicion of an outbreak in the facility or escalating community spread without robust infection control strategies in place. Being prepared to address operational considerations will enhance implementation of facility-wide testing in the outpatient dialysis setting.

This quality improvement study assesses COVID-19 vaccination in dialysis clinics, vaccination coverage, and disparities from December 1, 2020, to June 13, 2021.

Catheter-associated urinary tract infections (CAUTI) and central line-associated bloodstream infections (CLABSI) represent a substantial portion of health care-associated infections (HAIs) reported in the United States. The Targeted Assessment for Prevention Strategy is a quality improvement framework to reduce health care-associated infections. Data from the Targeted Assessment for Prevention Facility Assessments were used to determine common infection prevention gaps for CAUTI and CLABSI.Data from 2,044 CAUTI and 1,680 CLABSI assessments were included in the analysis. Items were defined as potential gaps if ≥33% respondents answered Unknown, ≥33% No, or ≥50% No or Unknown or Never, Rarely, Sometimes, or Unknown to questions pertaining to those areas. Review of response frequencies and stratification by respondent role were performed to highlight opportunities for improvement.Across CAUTI and CLABSI assessments, lack of physician champions (35% Yes) and nurse champions (55% Yes), along with lack of awareness of competency assessments, audits, and feedback were reported. Lack of practices to facilitate timely removal of urinary catheters were identified for CAUTI and issues with select device insertion practices, such as maintaining aseptic technique, were perceived as areas for improvement for CLABSI.These data suggest common gaps in critical components of infection prevention and control programs. The identification of these gaps has the potential to inform targeted CAUTI and CLABSI prevention efforts.

IntroductionMore than 93,000 cases of coronavirus disease (COVID-19) have been reported worldwide. We describe the epidemiology, clinical course, and virologic characteristics of the first 12 U.S. patients with COVID-19.MethodsWe collected demographic, exposure, and clinical information from 12 patients confirmed by CDC during January 20–February 5, 2020 to have COVID-19. Respiratory, stool, serum, and urine specimens were submitted for SARS-CoV-2 rRT-PCR testing, virus culture, and whole genome sequencing.ResultsAmong the 12 patients, median age was 53 years (range: 21–68); 8 were male, 10 had traveled to China, and two were contacts of patients in this series. Commonly reported signs and symptoms at illness onset were fever (n=7) and cough (n=8). Seven patients were hospitalized with radiographic evidence of pneumonia and demonstrated clinical or laboratory signs of worsening during the second week of illness. Three were treated with the investigational antiviral remdesivir. All patients had SARS-CoV-2 RNA detected in respiratory specimens, typically for 2–3 weeks after illness onset, with lowest rRT-PCR Ct values often detected in the first week. SARS-CoV-2 RNA was detected after reported symptom resolution in seven patients. SARS-CoV-2 was cultured from respiratory specimens, and SARS-CoV-2 RNA was detected in stool from 7/10 patients.ConclusionsIn 12 patients with mild to moderately severe illness, SARS-CoV-2 RNA and viable virus were detected early, and prolonged RNA detection suggests the window for diagnosis is long. Hospitalized patients showed signs of worsening in the second week after illness onset.

Background Coronavirus disease 2019 (COVID-19) is a disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), first detected in China in December, 2019. In January, 2020, state, local, and federal public health agencies investigated the first case of COVID-19 in Illinois, USA. Methods Patients with confirmed COVID-19 were defined as those with a positive SARS-CoV-2 test. Contacts were people with exposure to a patient with COVID-19 on or after the patient's symptom onset date. Contacts underwent active symptom monitoring for 14 days following their last exposure. Contacts who developed fever, cough, or shortness of breath became persons under investigation and were tested for SARS-CoV-2. A convenience sample of 32 asymptomatic health-care personnel contacts were also tested. Findings Patient 1-a woman in her 60s-returned from China in mid-January, 2020. One week later, she was hospitalised with pneumonia and tested positive for SARS-CoV-2. Her husband (Patient 2) did not travel but had frequent close contact with his wife. He was admitted 8 days later and tested positive for SARS-CoV-2. Overall, 372 contacts of both cases were identified; 347 underwent active symptom monitoring, including 152 community contacts and 195 health-care personnel. Of monitored contacts, 43 became persons under investigation, in addition to Patient 2. These 43 persons under investigation and all 32 asymptomatic health-care personnel tested negative for SARS-CoV-2. Interpretation Person-to-person transmission of SARS-CoV-2 occurred between two people with prolonged, unprotected exposure while Patient 1 was symptomatic. Despite active symptom monitoring and testing of symptomatic and some asymptomatic contacts, no further transmission was detected. Funding None.

Coronavirus disease 2019 (COVID-19), the respiratory disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), was first identified in Wuhan, China and has since become pandemic. In response to the first cases identified in the United States, close contacts of confirmed COVID-19 cases were investigated to enable early identification and isolation of additional cases and to learn more about risk factors for transmission. Close contacts of nine early travel-related cases in the United States were identified and monitored daily for development of symptoms (active monitoring). Selected close contacts (including those with exposures categorized as higher risk) were targeted for collection of additional exposure information and respiratory samples. Respiratory samples were tested for SARS-CoV-2 by real-time reverse transcription polymerase chain reaction at the Centers for Disease Control and Prevention. Four hundred four close contacts were actively monitored in the jurisdictions that managed the travel-related cases. Three hundred thirty-eight of the 404 close contacts provided at least basic exposure information, of whom 159 close contacts had ≥1 set of respiratory samples collected and tested. Across all actively monitored close contacts, two additional symptomatic COVID-19 cases (i.e., secondary cases) were identified; both secondary cases were in spouses of travel-associated case patients. When considering only household members, all of whom had ≥1 respiratory sample tested for SARS-CoV-2, the secondary attack rate (i.e., the number of secondary cases as a proportion of total close contacts) was 13% (95% CI: 4-38%). The results from these contact tracing investigations suggest that household members, especially significant others, of COVID-19 cases are at highest risk of becoming infected. The importance of personal protective equipment for healthcare workers is also underlined. Isolation of persons with COVID-19, in combination with quarantine of exposed close contacts and practice of everyday preventive behaviors, is important to mitigate spread of COVID-19.

In 2016, Zika virus disease developed in a man (patient A) who had no known risk factors beyond caring for a relative who died of this disease (index patient). We investigated the source of infection for patient A by surveying other family contacts, healthcare personnel, and community members, and testing samples for Zika virus. We identified 19 family contacts who had similar exposures to the index patient; 86 healthcare personnel had contact with the index patient, including 57 (66%) who had contact with body fluids. Of 218 community members interviewed, 28 (13%) reported signs/symptoms and 132 (61%) provided a sample. Except for patient A, no other persons tested had laboratory evidence of recent Zika virus infection. Of 5,875 mosquitoes collected, none were known vectors of Zika virus and all were negative for Zika virus. The mechanism of transmission to patient A remains unknown but was likely person-to-person contact with the index patient.

Background: The Targeted Assessment for Prevention (TAP) strategy is a quality improvement framework created by the Centers for Disease Control and Prevention (CDC) to facilitate the reduction of healthcare-associated infections (HAIs). TAP facility assessments are a component of the TAP strategy and are completed by staff across the facility to help identify perceptions of and target infection prevention gaps. We have described the gaps most commonly reported by facilities completing TAP facility assessments for catheter-associated urinary tract infections (CAUTIs) and central-line–associated bloodstream infections (CLABSIs). Methods: TAP CAUTI and CLABSI assessments were completed by acute-care facilities across the nation, with CDC technical assistance, from December 2014 to August 2019. Similar questions across 2 versions of CAUTI assessments and 3 versions of CLABSI assessments were combined. Analysis was limited to facilities with ≥10 assessments. Infection prevention gaps were defined as ≥33% respondents answering Unknown, ≥33% respondents answering “no,” or ≥50% of respondents answering “no” and “unknown” or “never” and “rarely” “sometimes” “unknown.” The analysis was completed at the facility level, and the gaps most commonly reported across facilities were identified. Results: In total, 1,942 CAUTI assessments from 42 facilities in 12 states and 1,623 CLABSI assessments from 29 facilities in 11 states were included for analysis. The mean numbers of assessments per facility were 46.2 for CAUTIs and 56.0 for CLABSIs. Across both CAUTIs and CLABSIs, commonly reported perceptions about infection prevention gaps included lack of physician and nurse champions for prevention activities, failure to conduct competency assessments, and inconsistency in select device insertion practices (Fig. 1). For CAUTIs, lack of practices to facilitate timely removal of urinary catheters were also commonly reported, with one-third of facilities reporting inconsistency in use of alerts for catheter removal, 78.6% reporting lack of physician response to these alerts, and 90.5% reporting deficiencies in removing unnecessary catheters in the postanesthesia care unit. For CLABSIs, 79.3% of facilities reported failure to replace central lines within 48 hours after emergent insertion, and 62.1% reported that feedback was not provided to staff on central-line device utilization ratios. Conclusion: For both assessments, absence of CAUTI and CLABSI prevention champions, failure to conduct competency assessments, and inconsistency in performing device insertion practices were commonly reported across facilities. These common gaps have and will continue to inform the development of tools and resources to improve infection prevention practices as well as help to better target the implementation of interventions.Funding: NoneDisclosures: None

Background: More than 450,000 patients receive outpatient hemodialysis in the United States. Patients on hemodialysis are at high risk of bloodstream infections (BSIs), which are associated with significant morbidity and mortality. National prevention efforts targeting hemodialysis facilities have resulted in widespread changes in practice, including modifications to central venous catheter (CVC) maintenance procedures. We analyzed dialysis event surveillance data submitted to the CDC NHSN to describe changes in BSI rates among hemodialysis outpatients from 2014 to 2018. Methods: Outpatient hemodialysis facilities report BSIs (ie, positive blood cultures collected in the outpatient setting or within 1 calendar day after hospital admission) and the number of hemodialysis outpatients treated during the first 2 working days of each month to the NHSN. For each BSI, the suspected source (ie, vascular access, another site, contamination, or uncertain) and vascular access type are indicated: CVC, arteriovenous fistula (AVF) or arteriovenous graft (AVG). Pooled mean rates (per 100 patient months) were calculated for BSIs, access-related BSIs (ARBSIs), and BSIs and ARBSIs were stratified by vascular access type. Annual BSI rate trends were evaluated using a negative binomial regression model, which treated patient months as an offset variable and included access type, year, and an access-year interaction variable. Results: More than 6,000 outpatient hemodialysis facilities reported 134,961 BSIs from 2014 to 2018. Of these BSIs, 102,505 (76%) were categorized as access related. CVCs were present in 63% of BSIs and 70% of ARBSIs. Pooled mean BSI rates decreased 27% from 0.64 to 0.47 per 100 patient months; rates of ARBSIs decreased 27% from 0.49 to 0.36 per 100 patient months. Significant decreases in event rates occurred across vascular access strata (Fig. 1). The reduction in BSI and ARBSI burden was most pronounced among patients with CVCs. BSI rates in patients with CVCs decreased 32% from 2.16 per 100 patient months to 1.46 (annual average decrease, 9.5%), and ARBSI rates in patients with CVCs decreased 32% from 1.83 per 100 patient months to 1.24 (annual average decrease, 9.4%). Conclusions: Substantial reductions in BSI and ARBSI rates among hemodialysis outpatients occurred during this 5-year period, and these reductions appear to be most prominent among CVC and AVF patients. Improvements in infection prevention and control practices, including CVC care, have likely contributed to these reductions. Additional efforts to increase the uptake of known prevention practices and to identify new strategies for prevention might contribute to continued decreases in infections among this highly vulnerable population.Funding: NoneDisclosures: None

Background: Peritoneal dialysis is a type of dialysis performed by patients in their homes; patients receive training from dialysis clinic staff. Peritonitis is a serious complication of peritoneal dialysis, most commonly caused by gram-positive organisms. During March‒April 2019, a dialysis provider organization transitioned ~400 patients to a different manufacturer of peritoneal dialysis equipment and supplies (from product A to B). Shortly thereafter, patients experienced an increase in peritonitis episodes, caused predominantly by gram-negative organisms. In May 2019, we initiated an investigation to determine the source. Methods: We conducted case finding, reviewed medical records, observed peritoneal dialysis procedures and trainings, and performed patient home visits and interviews. A 1:1 matched case–control study was performed in 1 state. A case had ≥2 of the following: (1) positive peritoneal fluid culture, (2) high peritoneal fluid white cell count with ≥50% polymorphonuclear cells, or (3) cloudy peritoneal fluid and/or abdominal pain. Controls were matched to cases by week of clinic visit. Conditional logistic regression was used to estimate univariate matched odds ratios (mOR) and 95% confidence intervals (CIs). We conducted microbiological testing of peritoneal dialysis fluid bags to rule out product contamination. Results: During March‒September 2019, we identified 157 cases of peritonitis across 15 clinics in 2 states (attack rate≍39%). Staphylococcus spp (14%), Serratia spp (12%) and Klebsiella spp (6.3%) were the most common pathogens. Steps to perform peritoneal dialysis using product B differed from product A in several key areas; however, no common errors in practice were identified to explain the outbreak. Patient training on transitioning products was not standardized. Outcomes of the 73 cases in the case–control study included hospitalization (77%), peritoneal dialysis failure (40%), and death (7%). The median duration of training prior to product transition was 1 day for cases and controls (P = .86). Transitioning to product B (mOR, 18.00; 95% CI, 2.40‒134.83), using product B (mOR, 18.26; 95% CI, 3.86‒∞), drain-line reuse (mOR, 4.67; 95% CI, 1.34‒16.24) and performing daytime exchanges (mOR, 3.63; 95% CI, 1.71‒8.45) were associated with peritonitis. After several interventions, including transition of patients back to product A (Fig. 1), overall cases declined. Sterility testing of samples from 23 unopened product B peritoneal dialysis solution bags showed no contamination. Conclusions: Multiple factors may have contributed to this large outbreak, including a rapid transition in peritoneal dialysis products and potentially inadequate patient training. Efforts are needed to identify and incorporate best training practices, and product advances are desired to improve the safety of patient transitions between different types of peritoneal dialysis equipment.Funding: NoneDisclosures: None

BACKGROUND Sepsis is a serious and often fatal clinical syndrome, resulting from infection. Information on patient demographics, risk factors, and infections leading to sepsis is needed to integrate comprehensive sepsis prevention, early recognition, and treatment strategies. METHODS To describe characteristics of patients with sepsis, CDC and partners conducted a retrospective chart review in four New York hospitals. Random samples of medical records from adult and pediatric patients with administrative codes for severe sepsis or septic shock were reviewed. RESULTS Medical records of 246 adults and 79 children (aged birth to 17 years) were reviewed. Overall, 72% of patients had a health care factor during the 30 days before sepsis admission or a selected chronic condition likely to require frequent medical care. Pneumonia was the most common infection leading to sepsis. The most common pathogens isolated from blood cultures were Escherichia coli in adults aged ≥18 years, Klebsiella spp. in children aged ≥1 year, and Enterococcus spp. in infants aged

Mycobacterium abscessus is often resistant to multiple antimicrobial drugs, and data supporting effective drugs or dosing regimens are limited. To better identify treatment approaches and associated toxicities, we collected a series of case reports from the Emerging Infections Network. Side effects were common and often led to changing or discontinuing therapy.

Background: Exposure to medical devices can be a risk factor for the development of healthcare-associated infections; bronchoscopes are a leading cause of device-associated outbreaks. We describe bronchoscope-related outbreaks and pseudo-outbreaks reported to the Centers for Disease Control and Prevention’s Division of Healthcare Quality Promotion (DHQP), and we summarize investigation steps and control measures. Methods: We identified bronchoscope-related consultations with state and local health departments between July 1, 2014, and September 30, 2019, in the DHQP database. We abstracted data on patient symptoms, clinical culture results, investigation findings, and subsequent infection prevention and control interventions. Results: We identified 15 consultations involving 150 patients (range, 3–31 patients per consultation). Each consultation involved at least 1 cluster of the same organism. Organisms associated with bronchoscope-associated clusters were nontuberculous mycobacteria (n = 7), Candida spp (n = 3), Exophiala spp (n = 2), Pseudomonas aeruginosa (n = 2), Enterobacter spp (n = 2), and Raoultella planticola, Stenotrophomonas maltophilia, Achromobacter spp, Mycobacterium tuberculosis, and Aspergillus spp (1 each; 2 consultations involved multiple pathogens). Procedures from which these patient specimens were collected included bronchoalveolar lavage, bronchial wash, bronchial brushing, sputum swab, and lymph node biopsy. For the 7 outbreaks in which clinical data were available, 5 did not have patients with clinical infections related to the pathogen recovered. Two consultations involved pseudo-outbreaks: one involved contamination of specimen collection tubes and the other involved contamination of cultures within the laboratory. Potential underlying pathogen sources included contaminated bronchoscopes (inadequate reprocessing or device damage) (n = 10, 67%), use of nonsterile ice, water, or saline during the procedure (n = 4, 27%), contaminated specimen collection tubes (n = 1, 7%), contaminated bronchoscope suite (n = 1, 7%), and clinical laboratory contamination (n = 1, 7%). The most common interventions included improvement of reprocessing procedures (n = 5), removal of possibly damaged bronchoscopes (n = 4), and eliminating nonsterile ice and water exposures in bronchoscopy (n = 3). Conclusions: Water-related organisms were the most commonly identified pathogens in bronchoscope-related consultations, highlighting the important role that exposure to contaminated water during bronchoscopy and bronchoscope reprocessing might play in bronchoscopy-associated outbreaks and pseudo-outbreaks. During bronchoscope-related outbreaks identifying a common pathogen could indicate problems in bronchoscope handling or reprocessing, device damage, or exposure to nonsterile water.Funding: NoneDisclosures: None

Infectious Diseases Society of America/Society for Healthcare Epidemiology of America (IDSA/SHEA) guidelines describe recommended therapy for Clostridioides difficile infection (CDI). To describe CDI treatment and, among those with severe CDI, determine predictors of adherence to the 2010 IDSA/SHEA treatment guidelines. We analyzed 2013–2015 CDI treatment data collected through the Centers for Disease Control and Prevention’s Emerging Infections Program. Generalized linear mixed models were used to identify predictors of guideline-adherent therapy. A CDI case was defined as a positive stool specimen in a person aged ≥ 18 years without a positive test in the prior 8 weeks; severe CDI cases were defined as having a white blood cell count ≥ 15,000 cells/μl. Prescribing and predictors of guideline-adherent CDI therapy for severe disease. Of 18,243 cases, 14,257 (78%) were treated with metronidazole, 7683 (42%) with vancomycin, and 313 (2%) with fidaxomicin. The median duration of therapy was 14 (interquartile range, 11–15) days. Severe CDI was identified in 3250 (18%) cases; of 3121 with treatment data available, 1480 (47%) were prescribed guideline-adherent therapy. Among severe CDI cases, hospital admission (adjusted odds ratio [aOR] 2.48; 95% confidence interval [CI] 1.90, 3.24), age ≥ 65 years (aOR 1.37; 95% CI 1.10, 1.71), Charlson comorbidity index ≥ 3 (aOR 1.27; 95% CI 1.04, 1.55), immunosuppressive therapy (aOR 1.21; 95% CI 1.02, 1.42), and inflammatory bowel disease (aOR 1.56; 95% CI 1.13, 2.17) were associated with being prescribed guideline-adherent therapy. Provider adherence to the 2010 treatment guidelines for severe CDI was low. Although the updated 2017 CDI guidelines, which expand the use of oral vancomycin for all CDI, might improve adherence by removing the need to apply severity criteria, other efforts to improve adherence are likely needed, including educating providers and addressing barriers to prescribing guideline-adherent therapy, particularly in outpatient settings.

Pulmonary nontuberculous mycobacteria (NTM) disease is a chronic, nonreportable illness, making it difficult to monitor. Although recent studies suggest an increasing prevalence of NTM disease in the United States, the incidence and temporal trends are unknown.To describe incident cases and calculate the incidence and temporal trends of pulmonary NTM disease in Oregon.We contacted all laboratories performing mycobacterial cultures on Oregon residents and collected demographic and specimen information for patients with NTM isolated during 2007 to 2012. We defined a case of pulmonary NTM disease using the 2007 American Thoracic Society/Infectious Disease Society of America microbiologic criteria. We used similar state-wide mycobacterial laboratory data from 2005 to 2006 to exclude prevalent cases from our calculations. We calculated annual pulmonary NTM disease incidence within Oregon during 2007 to 2012, described cases demographically and microbiologically, and evaluated incidence trends over time using a Poisson model.We identified 1,146 incident pulmonary NTM cases in Oregon residents from 2007 to 2012. The median age was 69 years (range, 0.9-97 yr). Cases were more likely female (56%), but among patients less than 60 years old, disease was more common in male subjects (54%). Most (86%) were Mycobacterium avium/intracellulare cases; 68 (6%) were Mycobacterium abscessus/chelonae cases. Although not statistically significant, incidence increased from 4.8/100,000 in 2007 to 5.6/100,000 in 2012 (P for trend, 0.21). Incidence increased with age, to more than 25/100,000 in patients 80 years of age or older.This is the first population-based estimate of pulmonary NTM disease incidence in a region within the United States. In Oregon, disease incidence rose slightly during 2007 to 2012, and although more common in female individuals overall, disease was more common among male individuals less than 60 years of age.

The natural history of nontuberculous mycobacteria (NTM) respiratory infection in the general population is poorly understood.To describe the long-term clinical, microbiologic, and radiographic outcomes of patients with respiratory NTM isolates.We previously identified a population-based cohort of patients with respiratory NTM isolation during 2005-2006 and categorized patients as cases or noncases using the American Thoracic Society/Infectious Diseases Society of America pulmonary NTM disease criteria at that time. During 2014-2015, we reviewed medical charts of patients alive on January 1, 2007. Outcomes of interest were the proportion of baseline noncases who later met case criteria and the proportions of patients with culture conversion or findings consistent with persistent disease at least 2-5 years and at least 5 years after first isolation. We defined disease persistence radiographically as infiltrate, nodules, or cavities and microbiologically as a positive respiratory mycobacterial culture. We used logistic regression to evaluate factors associated with evidence of persistence.The study included 172 patients (62% of 278 eligible); those not included either refused consent (n = 47) or were not located (n = 56). One hundred two (59%) included patients met case criteria at baseline. Mycobacterium avium complex was commonly isolated among baseline cases (n = 91 [89%]) and noncases (n = 52 [74%]). Overall, 57 (55%) baseline cases had died, as compared with 43 (61%) noncases (P = 0.47). Among baseline noncases, only four (5.7%) later met case criteria. Overall, 55 (54%) baseline cases and 6 (9%) noncases initiated NTM treatment. Among cases, cultures were converted in 25 (64.1%) treated versus 4 (40%) untreated patients (P = 0.04). Of 89 cases alive 2 years after isolation, 61 (69%) had additional radiography, and 35 (39%) had respiratory cultures. Of these individuals, 54 (89%) had radiographic evidence and 17 (49%) had microbiologic evidence of disease persistence. At 5 years after first isolation these figures were 36 (82%) and 13 (54%), respectively. Women were more likely to have persistent radiographic findings and microbiologic persistence, and patients with chronic obstructive pulmonary disease were less likely to have microbiologic persistence.In the general population, follow-up beyond 2 years of patients with respiratory NTM isolation is limited. Among those with additional evaluations, at least half of individuals have persistent positive cultures or radiographic findings consistent with NTM at least 2 years after isolation.

Rationale The mortality of patients with respiratory tract isolates of nontuberculous mycobacteria (NTM) and their risk factors for death are not well described. Objectives To determine age-adjusted mortality rates for patients with respiratory NTM isolates and their causes of death and to examine whether American Thoracic Society/Infectious Diseases Society of America (ATS/IDSA) diagnostic criteria identify those at higher risk of death after NTM isolation. Methods We linked vital records registries with a previously identified Oregon population-based cohort of patients with NTM respiratory isolation. We excluded patients with Mycobacterium gordonae (n = 33) and those who died (n = 21) at the time of first isolation. We calculated 5-year age-adjusted mortality rates. We used Kaplan-Meier and Cox proportional hazards analysis to examine the association of ATS/IDSA criteria and other risk factors with death. Results Of 368 subjects with respiratory NTM isolates in 2005-2006, 316 were included in the survival analysis. Most (84%) of their cultures isolated Mycobacterium avium complex. 35.1% died in the 5 years following respiratory isolation. Five-year age-adjusted mortality rates were slightly higher for those meeting (28.7/1,000) versus not meeting (23.4/1,000) ATS/IDSA criteria. In multivariate analysis, older age (adjusted hazard ratio [aHR], 1.06; 95% confidence interval [CI], 1.04-1.07) and lung cancer (aHR, 2.77; 95% CI, 1.51-5.07) were associated with an increased risk of death. A trend was noted between meeting ATS/IDSA criteria and subsequent death (aHR, 1.37; 95% CI, 0.95-1.97). Among cases, male sex, older age, and immunosuppressive therapy use were independent risk factors for death. Conclusions In the State of Oregon, patients with NTM respiratory isolates have high mortality, regardless of whether they meet ATS/IDSA criteria for pulmonary NTM disease. Most patients die as a result of causes other than NTM infection.

Background Mycoplasma hominis is a commensal genitourinary tract organism that can cause infections outside the genitourinary tract. We investigated a cluster of M. hominis surgical site infections in patients who underwent spine surgery, all associated with amniotic tissue linked to a common donor. Methods Laboratory tests of tissue product from the donor, including culture, quantitative real-time polymerase chain reaction (qPCR), and whole-genome sequencing were performed. Use of this amniotic tissue product was reviewed. A multistate investigation to identify additional cases and locate any unused products was conducted. Results Twenty-seven tissue product vials from a donor were distributed to facilities in 7 states; at least 20 vials from this donor were used in 14 patients. Of these, 4 of 14 (29%) developed surgical site infections, including 2 M. hominis infections. Mycoplasma hominis was detected by culture and qPCR in 2 unused vials from the donor. Sequencing indicated >99% similarity between patient and unopened vial isolates. For 5 of 27 (19%) vials, the final disposition could not be confirmed. Conclusions Mycoplasma hominis was transmitted through amniotic tissue from a single donor to 2 recipients. Current routine donor screening and product testing does not detect all potential pathogens. Clinicians should be aware that M. hominis can cause surgical site infections, and may not be detected by routine clinical cultures. The lack of a standardized system to track tissue products in healthcare facilities limits the ability of public health agencies to respond to outbreaks and investigate other adverse events associated with these products.

Patients with rheumatoid arthritis and other immune-mediated inflammatory diseases are at higher risk for infectious morbidity and mortality, partially due to the therapies used to treat these conditions. Both prednisone and targeted biologic therapies such as tumor necrosis factor antagonists have been implicated to various degrees, although in some cases firm data are lacking with regard to certain types of infections. To date, there is a paucity of information regarding the infectious risks associated with the newer biologic agents. As new biologic agents become available for use, their potential infectious risks will challenge infectious disease clinicians who must work to prevent, diagnose, and treat infections in this setting. This article reviews our current understanding of infectious risk in the setting of targeted therapies and provides an update of the immune system targets and potential infectious sequelae of both current and emerging biologic therapies.

Corticosteroids are frequently used to treat rheumatic diseases. Their use comes with a number of well-established risks including osteoporosis, avascular necrosis, glaucoma, and diabetes. The risk of infection is of utmost concern and is well-documented, although randomized controlled trials (RCTs) of short term and lower dose steroids have generally shown little or no increased risk. Observational studies from the “real world”, however, have consistently shown dose-dependent increases in risk for serious infections as well as certain opportunistic infections (e.g. herpes zoster, tuberculosis, and PJP). In patients who begin chronic steroid therapy, vaccination and screening strategies should be utilized in an attempt to mitigate this risk.

No consensus has previously been formed regarding the types and presentations of infectious pathogens to be considered as ‘opportunistic infections’ (OIs) within the setting of biologic therapy. We systematically reviewed published literature reporting OIs in the setting of biologic therapy for inflammatory diseases. The review sought to describe the OI definitions used within these studies and the types of OIs reported. These findings informed a consensus committee (infectious diseases and rheumatology specialists) in deliberations regarding the development of a candidate list of infections that should be considered as OIs in the setting of biologic therapy. We reviewed 368 clinical trials (randomised controlled/long-term extension), 195 observational studies and numerous case reports/series. Only 11 observational studies defined OIs within their methods; no consistent OI definition was identified across studies. Across all study formats, the most numerous OIs reported were granulomatous infections. The consensus group developed a working definition for OIs as ‘indicator’ infections, defined as specific pathogens or presentations of pathogens that ‘indicate’ the likelihood of an alteration in host immunity in the setting of biologic therapy. Using this framework, consensus was reached upon a list of OIs and case-definitions for their reporting during clinical trials and other studies. Prior studies of OIs in the setting of biologic therapy have used inconsistent definitions. The consensus committee reached agreement upon an OI definition, developed case definitions for reporting of each pathogen, and recommended these be used in future studies to facilitate comparison of infection risk between biologic therapies.

Background In December 2016, bacterial contamination of an organ preservation solution (OPS) was reported by Transplant Center A in Iowa. Annually, >20,000 abdominal organs are transplanted in the United States; OPS is used for organ storage. We investigated the scope of OPS contamination and its association with adverse events in patients. Methods We assessed infection control practices related to OPS at Transplant Centers A and B in Iowa and the local organ procurement organization (OPO). We issued national notifications about OPS contamination and requested transplant centers to report product-related concerns or potential patient harm. Among transplant recipients at Center A, we compared adverse events (fever, bacteremia, surgical site infection, peritonitis, or pyelonephritis within 14 days of transplantation) during October–December 2015 with October–December 2016, the presumed window of exposure to contaminated OPS. Isolates from OPS were characterized. Results No infection control deficiencies were identified at Transplant Centers A, B, or the OPO. In January 2017, contaminated OPS from the same manufacturer was reported by Transplant Center C in Texas. Nationally, there were no reports of patient harm definitively linked to OPS. Post-transplant adverse events at Center A did not increase between fourth quarter 2015 (5/12 [42%]) and 2016 (2/15 [13%]). Organisms recovered from OPS included Pantoea agglomerans and Enterococcus gallinarum (Center A) and Pseudomonas koreensis (Center C). Five Pantoea isolates from ≥3 opened OPS bags were indistinguishable by pulsed-field gel electrophoresis. The OPS distributor issued recalls and suspended production. The US Food and Drug Administration identified deficiencies in current good manufacturing practices at manufacturing and distribution facilities, including inadequate validation of OPS sterility. Conclusion Bacterial contamination of a nationally distributed product was identified by astute clinicians. The investigation found no illnesses were directly linked to the product. Prompt reporting of concerns about potentially contaminated healthcare products, which might put patients at risk, is critical for swift public health action. Disclosures All authors: No reported disclosures.

Asthma is a disease with distinct phenotypes that have implications for both prognosis and therapy. Epidemiologic studies have demonstrated an association between asthma and obesity. Further studies have shown that obese asthmatics have poor asthma control and more severe asthma. This obese-asthma group may represent a unique phenotype. The mechanisms behind poor asthma control in obese subjects remain unclear, but recent research has focused on adipokines and their effects on the airways as well as the role of oxidative stress. Both surgical and nonsurgical weight loss therapy have shown promising results with improvements in asthma control and decreased asthma severity. Comorbid conditions such as gastroesophageal reflux disease and obstructive sleep apnea may also have a role in poor asthma control in obese asthmatics. Further research is needed to define the mechanisms behind this phenotype which will guide the development of targeted therapies.

Chronic obstructive pulmonary disease (COPD) and bronchiectasis are two different but related diseases that occur separately, but can coexist. In this review, we will examine the recent research regarding patients with COPD who have coexisting bronchiectasis.Recent research has focused on defining distinct COPD phenotypes with the ultimate goal of changing the outcomes using tailored therapies. A frequent exacerbator phenotype has been identified. COPD patients with Pseudomonas aeruginosa are a phenotype with worse outcomes. Patients with coexisting COPD and bronchiectasis may represent a unique phenotype.Patients with coexisting COPD and bronchiectasis could represent a unique phenotype with more severe disease, worse outcomes, more isolation of potentially pathogenic microorganisms, and more frequent exacerbations, with the potential for targeted therapies.