Corresponding author: Shelley S. Magill, MD, PhD, Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, 1600 Clifton Rd., MS A-24, Atlanta, GA 30333, Phone: (404) 639-0291, smagill@cdc.gov. a Current affiliation: Mayo Clinic, Jacksonville, FL, USA b Current affiliation: Tanner Medical Center, Villa Rica, GA, USA The study described herein was presented in abstract form at the Fifth Decennial International Conference on Healthcare-Associated Infections, March 18-22, 2010, Atlanta, GA (Abstract #911). Objective-To determine healthcare-associated infection (HAI) prevalence in nine Jacksonville, FL hospitals, evaluate the performance of proxy indicators for HAIs, and refine methodology in preparation for a multi-state survey. HHS Public Access Design-Point prevalence survey.Patients-Acute care inpatients of any age.Methods-HAIs were defined using National Healthcare Safety Network criteria. In each facility a trained Primary Team (PT) of infection prevention (IP) staff performed the survey on 1 day, reviewing records and collecting data on a random sample of inpatients. PTs assessed patients with ≥1 proxy indicator (abnormal white blood cell count, abnormal temperature, or antimicrobial therapy) for the presence of HAIs. An external IP expert team collected data from a subset of patient records reviewed by PTs to assess proxy indicator performance and PT data collection.Results-Of 851 patients surveyed by PTs, 51 had ≥1 HAI (6.0%, 95% confidence interval 4.5-7.7%). Surgical site infections (n=18), urinary tract infections (n=9), pneumonia (n=9), and bloodstream infections (n=8) accounted for 75.8% of 58 HAIs detected by PTs. Staphylococcus aureus was the most common pathogen, causing 9 HAIs (15.5%). Antimicrobial therapy was the most sensitive proxy indicator, identifying 95.5% of patients with HAIs.

The mean time to appropriate antimicrobial therapy was 23.4 h longer in the preintervention group than in the postintervention group (P ‫؍‬ 0.0054). A nonsignificant decrease in the mean time to appropriate antimicrobial therapy was seen for patients infected with vancomycin-susceptible Enterococcus isolates (P ‫؍‬ 0.1145). For patients with vancomycin-resistant Enterococcus bacteremia, the mean time to appropriate antimicrobial therapy was 31.1 h longer in the preintervention group than in the postintervention group (P < 0.0001). In the postintervention group, the hospital length of stay was significantly 21.7 days shorter (P ‫؍‬ 0.0484) and mean hospital costs were $60,729 lower (P ‫؍‬ 0.02) than in the preintervention group. The rates of attributed deaths in the two groups were not statistically different. Microarray technology, supported by pharmacy and microbiology departments, can decrease the time to appropriate antimicrobial therapy, the hospital length of stay, and health care costs.

BACKGROUND Infants in the neonatal intensive care unit (NICU) are at increased risk for methicillin-resistant Staphylococcus aureus (MRSA) acquisition. Outbreaks may be difficult to identify due in part to limitations in current molecular genotyping available in clinical practice. Comparison of genome-wide single nucleotide polymorphisms (SNPs) may identify epidemiologically distinct isolates among a population sample that appears homogenous when evaluated using conventional typing methods. OBJECTIVE To investigate a putative MRSA outbreak in a NICU utilizing whole-genome sequencing and phylogenetic analysis to identify recent transmission events. DESIGN Clinical and surveillance specimens collected during clinical care and outbreak investigation. PATIENTS A total of 17 neonates hospitalized in a 43-bed level III NICU in northeastern Florida from December 2010 to October 2011 were included in this study. METHODS We assessed epidemiological data in conjunction with 4 typing methods: antibiograms, PFGE, spa types, and phylogenetic analysis of genome-wide SNPs. RESULTS Among the 17 type USA300 isolates, 4 different spa types were identified using pulsed-field gel electrophoresis. Phylogenetic analysis identified 5 infants as belonging to 2 clusters of epidemiologically linked cases and excluded 10 unlinked cases from putative transmission events. The availability of these results during the initial investigation would have improved infection control interventions. CONCLUSION Whole-genome sequencing and phylogenetic analysis are invaluable tools for epidemic investigation; they identify transmission events and exclude cases mistakenly implicated by traditional typing methods. When routinely applied to surveillance and investigation in the clinical setting, this approach may provide actionable intelligence for measured, appropriate, and effective interventions.

A Gram-negative (GN) blood culture microarray assay with an antimicrobial stewardship program (ASP) intervention was evaluated in 126 patients with GN bacteremia. The median time to optimal therapy was shorter in the postintervention group than in the preintervention group (49.3 h versus 38.5 h, respectively; P ‫؍‬ 0.0199). ASP can utilize microarray technology to decrease the time to optimal antimicrobial therapy. The treatment of Gram-negative bloodstream infections (GN-BSI) is particularly complicated due to high rates of resistance from multiple resistance mechanisms, including the production of extended-spectrum ␤-lactamase (ESBL) and carbapenemase enzymes, leaving limited treatment options (1, 2). Molecular diagnostic assays can produce results faster than traditional identification and susceptibility testing methods and may help decrease the time to appropriate antimicrobial therapy (3-18). The Verigene Gram-negative blood culture (BC-GN) assay (Nanosphere, Inc., Northbrook, IL) is a qualitative in vitro diagnostic test for the rapid detection and identification of select Gram-negative bacteria and resistance markers (17). The purpose of this study was to evaluate the impact of an antimicrobial stewardship program (ASP) on the time to optimal antimicrobial therapy, utilizing rapid organism and resistance identification via the BC-GN test, on patients with GN-BSI.This was a retrospective, quasiexperimental, and preintervention/postintervention study conducted at University of Florida Health and was approved by the University of Florida Health Science Center Jacksonville institutional review board. All inpatient adults with documented GN-BSI between 15 September 2013 and 15 February 2014 (pre-BC-GN period) and between 15 September 2014 and 15 February 2015 (post-BC-GN period) were evaluated for inclusion. Exclusion criteria included polymicrobial BSI, documented infections caused by organisms not identified by the BC-GN test, incarcerated patients, involvement with other investigational protocols, or death prior to culture results. During the pre-BC-GN period, the ASP reviewed the prescribed antimicrobial agents and provided pharmacotherapeutic recommendations to prescribers as microbiology information became available during normal business hours. In the postintervention period, the BC-GN test was performed according to the manufacturer's specifications (17), and the results were reported in a similar fashion as done previously (10). Microbiology paged the ASP 24 h per day, 7 days per week with BC-GN test results. The ASP contacted physicians during normal business hours with pharmacotherapeutic recommendations based on BC-GN test results. All BC-GN test results were confirmed by conventional microbiological methods, including rapid spot tests (oxidase and indole) and the Vitek 2 GN identification and GN-73 susceptibility cards (bioMérieux, Durham, NC).After retrospective identification of patients with GN-BSI, the electronic health record (EHR) was used to identify patients for inclusion and exclusion cri...

HTLV type 1 and 2 are both involved in actively spreading epidemics, affecting over 15 million people worldwide. HTLV-1 has been described as the more clinically significant one, being associated with diseases such as adult T-cell leukemia and tropical spastic paraparesis. We report here a case of tropical spastic paraparesis in an HIV-positive patient who did not report any history of travel or residence in an HTLV endemic area.A 57 year old African-American male was admitted to the hospital due to bilateral upper and lower extremity weakness associated with stiffness. He had recently been diagnosed with HIV. His physical examination showed mild to moderate decreased motor strength, in both upper extremities and marked loss in both lower extremities. This was associated with hyperreflexia and clonus. Sensory function was intact. He looked cachectic and had several psoriatic plaques on both lower and upper extremities. Laboratory work-up showed a CD4 count decreased to 94 cells/mm3 and a HIV viral load of 273,000 copies/mL. Based on serum positivity for HTLV type 1 and the patient's clinical presentation suggestive of upper and lower motor neuron dysfunction, the diagnosis of tropical spastic paraparesis was made.HTLV and HIV share the same routes of transmission and the same tropism for T-lymphocytes. Co-infection occurs probably more frequently than we are aware, since testing for HTLV is not routinely performed in outpatient HIV clinics.

The incidence of tuberculosis is increasing in the United States. Extra-pulmonary involvement is more common in patients with HIV/AIDS. The diagnosis of Tuberculosis osteomyelitis requires a high degree of suspicion for accurate and timely diagnosis.We present a case of a 49 year old Caucasian male with HIV/AIDS who presented with a four-month history of soft tissue swelling in the left proximal thigh unresponsive to various broad spectrum antibiotics who was eventually diagnosed with Mycobacterium tuberculosis osteomyelitis of the left proximal femur.

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