On May 22, 2020, this report was posted as an MMWR Early Release on the MMWR website (https://www.cdc.gov/mmwr). On March 28, 2020, two residents of a long-term care skilled nursing facility (SNF) at the Veterans Affairs Greater Los Angeles Healthcare System (VAGLAHS) had positive test results for SARS-CoV-2, the cause of coronavirus disease 2019 (COVID-19), by reverse transcription-polymerase chain reaction (RT-PCR) testing of nasopharyngeal specimens collected on March 26 and March 27. During March 29-April 23, all SNF residents, regardless of symptoms, underwent serial (approximately weekly) nasopharyngeal SARS-CoV-2 RT-PCR testing, and positive results were communicated to the county health department. All SNF clinical and nonclinical staff members were also screened for SARS-CoV-2 by RT-PCR during March 29-April 10. Nineteen of 99 (19%) residents and eight of 136 (6%) staff members had positive test results for SARS-CoV-2 during March 28-April 10; no further resident cases were identified on subsequent testing on April 13, April 22, and April 23. Fourteen of the 19 residents with COVID-19 were asymptomatic at the time of testing. Among these residents, eight developed symptoms 1-5 days after specimen collection and were later classified as presymptomatic; one of these patients died. This report describes an outbreak of COVID-19 in an SNF, with case identification accomplished by implementing several rounds of RT-PCR testing, permitting rapid isolation of both symptomatic and asymptomatic residents with COVID-19. The outbreak was successfully contained following implementation of this strategy. VAGLAHS includes 150 long-term care beds in three SNF patient care areas, or wards; SNF wards A and B are in building 1, and ward C is in building 2. Buildings 1 and 2 do not share common areas, but residents might have indirect contact with outside persons while receiving medical services such as dialysis. These wards admit residents who require intravenous antibiotics, complex wound care, other rehabilitation needs, routine dialysis, chemotherapy, or radiation therapy; underlying conditions, including chronic obstructive pulmonary disease, hypertension, cardiovascular disease, and chronic kidney disease, are common. At the time of the outbreak, 99 (66%) beds were occupied; >95% of residents were men aged 50-100 years. All data were abstracted from the VAGLAHS

We characterized serology following a nursing home outbreak where residents were serially tested by RT-PCR and positive residents were cohorted. When tested 46-76 days later, 24/26 RT-PCR-positive residents were seropositive; none of the 124 RT-PCR-negative residents had confirmed seropositivity, supporting serial SARS-CoV-2 RT-PCR testing and cohorting in nursing homes.

Fungal prosthetic valve endocarditis (PVE) is rare and carries a high mortality rate. While uncommon, fungal endocarditis in transcatheter aortic valves has been reported. We present a unique case of Candida parapsilosis fungal PVE in a patient with a transcatheter pulmonary valve replacement.

Background In July 2015, the Accreditation Council for Graduate Medical Education (ACGME) and the American Board of Internal Medicine (ABIM) jointly outlined an approach to assessing fellow performance using milestone-based core competencies for incorporation into standardized evaluation templates of trainee performance. Limited data exist regarding the clarity, effectiveness, and reproducibility of competency-based evaluations of infectious diseases fellows. Methods From March to May 2019, program directors of ACGME-accredited infectious diseases fellowship programs were invited to complete a Qualtrics-based survey of program characteristics and evaluation methods, including a trainee vignette to gauge evaluation reproducibility. Completed surveys were analyzed with descriptive statistics. Results Forty-three program directors initiated the survey, but 29 completed it. Seventeen (59%) were men, 19 (66%) were on a teaching service for over 8 weeks a year, and 19 (66%) had fewer than four first year fellows in their program. Most respondents agreed the competencies lacking the most clarity were systems-based practice (17/29, 58%), and practice based improvement (16/29, 55%). Eighteen (62%) were at least “somewhat satisfied” with their institution’s assessment tool, and 19 (66%) reported it was at least “moderately effective” in identifying academic deficiencies. Responses rating fellow performance from the vignette ranged from 1.5 to 4 on the standard milestone-based competency scale of 1-5 with 0.5 increments (median 3). For the same scenario using a qualitative ordinal scale, 66% (19/29) categorized the fellow as “early first year” and 34% (9/29) as “advanced first year.” Respondents offered a wide range of comments on milestone-based competencies, including “it works well enough” and “the process seems bloated and educratic.” Conclusion Clarity is needed on how to evaluate specific core competencies in infectious diseases, particularly systems-based practice and practice-based improvement. Describing anchoring milestones and evaluating fellows in accordance to stage in fellowship (i.e. early first year fellow) can help standardize responses. Further exploration on improving the evaluation process is warranted. Disclosures All Authors: No reported disclosures