1252. A Challenging Burkholderia Outbreak Investigation Across Multiple Units at an Academic Medical Center From June 2017 to February 2018

Abstract Background Most outbreak investigations involve short-term, geographically localized clusters. However, some organisms can form environmental reservoirs leading to more prolonged, widespread outbreaks. We describe a prolonged outbreak of Burkholderia at our institution. Methods An epidemiological investigation was conducted. Burkholderia isolates were genotyped using pulsed-field gel electrophoresis (PFGE) and recA gene sequencing. Initial isolates were sent to a national reference laboratory for multilocus sequence typing (MLST). Results 32 patients on 12 units (see figure) had ≥1 positive culture for Burkholderia from June 2017 to February 2018. 21 had B. cenocepacia (PFGE pattern A, recA allele 365) and 11 had B. cepacia (PFGE pattern C, recA allele 53). MLST revealed that isolates with recA allele 365 were unique compared with previously identified B. cenocepacia strains. Of 32 patients, 28 (88%) had positive respiratory cultures. Of 32 patients, 3 (9%) had bacteremia. Thirty-day mortality was 4/29 (14%). A case–control study did not reveal a common point source. All surveillance cultures from asymptomatic patients were negative (n = 53). Two of nine sink drains in rooms of cases were positive for an unrelated strain of B. cepacia. Other environmental cultures were negative for Burkholderia (n = 49). Cases continued despite routine interventions (see figure), with some incident cases detected long after potential exposures. Ventilator/respiratory equipment (V/RE) cleaning was investigated. Multiple V/RE interventions were implemented: (1) ensuring a sterilization process for ventilator temperature probes (used in heated humidification) was occurring; (2) using disposable manometers on contact isolation patients; (3) reinforcing ventilator cleaning, including those in radiology suites after use. Conclusion No definitive source of the outbreak was found. New cases continued after reinforcement of basic infection control practices, but subsided after focused attention on V/RE cleaning practices. Control of this outbreak was challenging due to the complexity of a prolonged “latency period” for Burkholderia, difficulty identifying reservoirs, and multiple possible modes of transmission, especially for organisms like Burkholderia that can persist on environmental surfaces and equipment. Disclosures All authors: No reported disclosures.

Download Full-text

Do Routine Preoperative and Intraoperative Urine Cultures Benefit Pediatric Vesicoureteral Reflux Surgery?

Advances in Urology ◽

10.1155/2017/3197869 ◽

2017 ◽

Vol 2017 ◽

pp. 1-6 ◽

Cited By ~ 1

Author(s):

Daniel R. Hettel ◽

Bradley C. Gill ◽

Audrey C. Rhee

Keyword(s):

Surgical Outcomes ◽

Medical Center ◽

Academic Medical Center ◽

Positive Culture ◽

Inclusion Criteria ◽

Culture Result ◽

Asymptomatic Patients ◽

Academic Medical ◽

Single Organism ◽

Colony Forming Units

Objective. To determine if routine preoperative and intraoperative urine cultures (UCx) are necessary in pediatric vesicoureteral (VUR) reflux surgery by identifying their association with each other, preoperative symptoms, and surgical outcomes.Materials and Methods. A retrospective review of patients undergoing ureteral reimplant(s) for primary VUR at a tertiary academic medical center between years 2000 and 2014 was done. Preoperative UCx were defined as those within 30 days before surgery. A positive culture was defined as >50,000 colony forming units of a single organism.Results. A total of 185 patients were identified and 87/185 (47.0%) met inclusion criteria. Of those, 39/87 (45%) completed a preoperative UCx. Only 3/39 (8%) preoperative cultures returned positive, and all of those patients were preoperatively symptomatic. No preoperatively asymptomatic patients had positive preoperative cultures. Intraoperative cultures were obtained in 21/87 (24.1%) patients; all were negative. No associations were found between preoperative culture results and intraoperative cultures or between culture result and postoperative complications.Conclusions. In asymptomatic patients, no associations were found between the completion of a preoperative or intraoperative UCx and surgical outcomes, suggesting that not all patients may require preoperative screening. Children presenting with symptoms of urinary tract infection (UTI) prior to ureteral reimplantation may benefit from preoperative UCx.

Download Full-text

Physician Survey of a Laboratory Medicine Interpretive Service and Evaluation of the Influence of Interpretations on Laboratory Test Ordering

Archives of Pathology & Laboratory Medicine ◽

10.5858/2004-128-1424-psoalm ◽

2004 ◽

Vol 128 (12) ◽

pp. 1424-1427 ◽

Cited By ~ 12

Author(s):

Martha E. Laposata ◽

Michael Laposata ◽

Elizabeth M. Van Cott ◽

Dion S. Buchner ◽

Mohammed S. Kashalo ◽

...

Keyword(s):

Laboratory Testing ◽

Medical Center ◽

Academic Medical Center ◽

Physician Satisfaction ◽

Patient Specific ◽

Diagnostic Process ◽

Reference Laboratory ◽

Academic Medical ◽

Coagulation Testing ◽

Test Ordering

Abstract Context.—Complex coagulation test panels ordered by clinicians are typically reported to clinicians without a patient-specific interpretive paragraph. Objectives.—To survey clinicians regarding pathologist-generated interpretations of complex laboratory testing panels and to assess the ability of the interpretations to educate test orderers. Design.—Surveys were conducted of physicians ordering complex coagulation laboratory testing that included narrative interpretation. Evaluation of order requisitions was performed to assess the interpretation's influence on ordering practices. Setting.—Physicians ordering coagulation testing at a large academic medical center hospital in Boston, Mass, and physicians from outside hospitals using the academic medical center as a reference laboratory for coagulation testing. Outcome Measures.—Physician surveys and evaluation of laboratory requisition slips. Results.—In nearly 80% of responses, the ordering clinicians perceived that the interpretive comments saved them time and improved the diagnostic process. Moreover, the interpretations were perceived by ordering clinicians to help prevent a misdiagnosis or otherwise impact the differential diagnosis in approximately 70% of responses. In addition, interpretations appeared to be able to train the ordering clinicians as to the standard ordering practices. Conclusions.—The results demonstrate physician satisfaction with an innovative information delivery approach that provides laboratory diagnostic interpretation and test-ordering education to clinicians in the context of their daily workflow.

Download Full-text

183. Optimization of an Outpatient Antimicrobial Stewardship Process for Patients Discharged from the Emergency Department at an Academic Medical Center

Open Forum Infectious Diseases ◽

10.1093/ofid/ofaa439.227 ◽

2020 ◽

Vol 7 (Supplement_1) ◽

pp. S98-S98

Author(s):

Hannah Kafisheh ◽

Matthew Hinton ◽

Amanda Binkley ◽

Christo Cimino ◽

Christopher Edwards

Keyword(s):

Emergency Department ◽

Antimicrobial Stewardship ◽

Antimicrobial Therapy ◽

Medical Center ◽

Academic Medical Center ◽

Positive Culture ◽

Culture Result ◽

Academic Medical ◽

Positive Culture Result ◽

Therapy Modification

Abstract Background Suboptimal antimicrobial therapy has resulted in the emergence of multi-drug resistant organisms. The objective of this study was to optimize the time to antimicrobial therapy modification for patients discharged from the emergency department (ED) of an academic medical center through implementation of a pharmacist-driven outpatient antimicrobial stewardship initiative (ASI). Methods This was a pre-post, quasi-experimental study that evaluated the impact of a pharmacist-driven outpatient antimicrobial stewardship initiative at a single academic medical center. The pre-cohort was evaluated through manual electronic medical record (EMR) review, while the post-cohort involved a real-time notification alert system through an electronic clinical surveillance application. The difference in time from positive culture result to antimicrobial therapy optimization before and after implementation of the pharmacist-driven ASI was collected and analyzed. Results A total of 166 cultures were included in the analysis. Of these, 12/72 (16%) in the pre-cohort and 11/94 (12%) in the post-cohort required antimicrobial therapy modification, with a 21.9-hour reduction in median time from positive culture result to antimicrobial optimization in the post-cohort (43 h vs. 21.1 h; p < 0.01). Similarly, the median time from positive culture result to review was reduced by 20 hours with pharmacist-driven intervention (21.1 h vs. 1.4 h; p < 0.01). Conclusion The implementation of a pharmacist-driven outpatient antimicrobial stewardship initiative resulted in a significant reduction in time to positive culture review and therapy optimization for patients discharged from the ED of an academic medical center set in Philadelphia, PA. Disclosures All Authors: No reported disclosures

Download Full-text

Clinical Specificity of the Enzyme Immunoassay Test for Coccidioidomycosis Varies According to the Reason for Its Performance

Clinical and Vaccine Immunology ◽

10.1128/cvi.00531-12 ◽

2012 ◽

Vol 20 (1) ◽

pp. 95-98 ◽

Cited By ~ 28

Author(s):

Janis E. Blair ◽

Neil Mendoza ◽

Shannon Force ◽

Yu-Hui H. Chang ◽

Thomas E. Grys

Keyword(s):

Enzyme Immunoassay ◽

Positive Culture ◽

Clinical History ◽

Immunoglobulin M ◽

Reference Laboratory ◽

Test Results ◽

Radiographic Findings ◽

Asymptomatic Patients ◽

Record Review

ABSTRACTThe diagnosis of coccidioidomycosis relies heavily on serologic test results in addition to clinical history, physical examination, and radiographic findings. Use of the enzyme immunoassay (EIA) has increased because it is rapidly performed and does not require referral to a reference laboratory, as do complement fixation and immunodiffusion tests. However, interpretation of immunoglobulin M (IgM) reactivity by EIA in the absence of immunoglobulin G (IgG) reactivity has been problematic. We conducted a retrospective medical record review of all patients with such IgM reactivity at our institution to identify situations where the finding was more likely to be clinically specific for coccidioidal infection. From 1 January 2004 through 31 December 2008, a total of 1,117 patients had positive EIA coccidioidal serology or EIA IgM-only reactivity; of these, 102 patients (9%) had EIA IgM-only reactivity. Among the 102 patients with EIA IgM-only reactivity, 60 were tested to evaluate symptomatic illness, 13 for follow-up of previously abnormal serology, and 29 for screening purposes. Of the 102 patients, 80 (78%) had positive serologic findings by other methods or had positive culture or histology. Fifty-four (90%) of the 60 patients whose serology was performed to evaluate symptomatic illness had coccidioidal infection, whereas 13 (45%) of 29 patients whose serology was performed for screening purposes had coccidioidal infection. Of the 102 patients with isolated IgM reactivity by EIA, 12 later seroconverted to IgG and IgM reactivity. The use of EIA for screening in 29 asymptomatic persons was associated with unconfirmable results in 13 (45%). Although the majority of patients in our study with isolated IgM reactivity by EIA had probable or confirmed coccidioidomycosis, this result must be interpreted with caution for asymptomatic patients.

Download Full-text

Umbilical Cord Drug Screening in Multiple Births: Experience from a Reference Laboratory and Academic Medical Center

Journal of Analytical Toxicology ◽

10.1093/jat/bkab077 ◽

2021 ◽

Author(s):

Heather A Nelson ◽

Kelly E Wood ◽

Gwendolyn A McMillin ◽

Matthew D Krasowski

Keyword(s):

Umbilical Cord ◽

Drug Screening ◽

Medical Center ◽

Academic Medical Center ◽

Quality Criteria ◽

Reference Laboratory ◽

Medical Chart Review ◽

Academic Medical ◽

Umbilical Cords ◽

Cutoff Threshold

Abstract The objective of this study was to review the results of umbilical cord drug screening in twins and triplets (multiples) to compare drug(s) and/or drug metabolite(s) detected. Results that did not agree between multiples were considered mismatched and were investigated. A retrospective analysis was conducted using de-identified data from a national reference laboratory, and results were compared with data from an academic medical center, where detailed medical chart review was performed. Umbilical cord was analyzed for stimulants, sedatives, opioids, and other drugs and metabolites. For the reference laboratory dataset, 23.3% (n=844) of 3,616 umbilical cords from twins (n=3,550) or triplets (n=66) were positive for one or more drugs and/or metabolites. Of these, mismatched results were identified for thirty-seven sets of twins (2.1%) and no sets of triplets. The most frequent mismatches were found in opioids (n=24), with morphine (n=5) being the most mismatched of any single analyte in the panel. Mismatches for the marijuana metabolite 11-nor-9-carboxy-delta-9-tetrahydrocannabinol (9-COOH-THC) in the reference laboratory dataset occurred in six of 737 sets of twins (0.8%) and no triplets. For the academic medical center dataset, 21.9% (n=57) of 260 umbilical cords tested positive for one or more drugs and/or metabolite(s). Of these, 4 mismatches (3.2%) were identified, including 9-COOH-THC (n=2), phentermine (n=1), and oxycodone (n=1), all involving twins. All involved cases where the discrepant analyte was likely present in the negative twin but either slightly below reporting cutoff threshold, or failed analytical quality criteria. Mismatched results of umbilical cord drug screening occur in less than 4% of twins and most often occur when the analyte is slightly above the reporting cutoff in just one infant.

Download Full-text

1705. Clinical Characteristics and Outcomes of Cryptococcosis in a Tertiary Care Center in Kentucky, 2005 to 2017

Open Forum Infectious Diseases ◽

10.1093/ofid/ofz360.1569 ◽

2019 ◽

Vol 6 (Supplement_2) ◽

pp. S624-S625

Author(s):

Mahesh Bhatt ◽

Julie A Ribes ◽

Vaneet Arora ◽

Thein Myint

Keyword(s):

Liver Disease ◽

Cryptococcal Meningitis ◽

Medical Center ◽

Care Center ◽

Academic Medical Center ◽

Tertiary Care ◽

Organ Transplant ◽

Positive Culture ◽

Solid Organ ◽

India Ink

Abstract Background Cryptococcosis is an invasive fungal infection that causes pneumonia and extrapulmonary infection. This study explores its presentations, diagnostic tests, and outcome in different groups over a 12-year period at an academic medical center. Methods This was a retrospective study of the patients treated at University of Kentucky HealthCare from October 16, 2005 to October 15, 2017. Inclusion criteria were positive cryptococcal antigen (Ag), positive culture, or presence of yeast morphologically consistent with Cryptococcus on cyto- or histopathology. Patients were divided into HIV-infected, solid-organ transplant (SOT) recipients, and non-HIV/non-transplant groups. Cryptococcal meningitis comprised of either positive CSF Ag, culture, cytology or histopathology. Results A total of 114 patients were identified; 23 HIV-infected, 11 SOT recipients and 80 non-HIV/non-transplant patients (Table 1). Cryptococcus neoformans was the most common yeast isolated (91.8%). Cryptococcal meningitis was seen in 56% of total patients whereas 27% had isolated cryptococcal pneumonia (P < 0.01). Blood cultures and serum Ag were positive in 34% and 70%, respectively. Only 8.7% of HIV-infected patients had isolated pulmonary cryptococcosis compared with 36.4% in SOT recipients (P < 0.01). In patients with cryptococcal meningitis, abnormal CSF cell count, protein, or glucose was noted in 85.3%; India ink was positive in 61.3% and CSF culture was positive in 73.4% (Table 2, Figure 1). CSF cryptococcal Ag was detected in 95.6% cases if CSF cultures were positive, whereas serum Ag was positive in only 85.1% of meningitis cases. Mortality was seen in 48.6% (17/35) of patients with cirrhosis/liver disease, compared with 21.5% (17/79) of non-cirrhosis/liver disease (P = 0.003). Transplant group had 54.5% mortality compared with 26.1% in HIV group (P = 0.016). Conclusion Cryptococcal meningitis was the most common presentation for cryptococcal disease in all three groups. Isolated pulmonary disease was least common in the HIV-infected group. Inpatient mortality rate was higher in patients with cirrhosis/liver disease and transplant group compared with those without cirrhosis/liver disease and HIV group, respectively. It is imperative to rule out meningitis in immunosuppressed patients with cryptococcal pneumonia. Disclosures All authors: No reported disclosures.

Download Full-text

161. Evaluating the Predictive Value of Blood Culture Bottle Reporting for Coagulase Negative Staphylococci-Positive Cultures: Assessing Contamination vs. True Bacteremia

Open Forum Infectious Diseases ◽

10.1093/ofid/ofz360.236 ◽

2019 ◽

Vol 6 (Supplement_2) ◽

pp. S105-S106

Author(s):

Pamela Bailey ◽

Christopher Doern

Keyword(s):

Blood Culture ◽

Chart Review ◽

Blood Stream Infection ◽

Medical Center ◽

Academic Medical Center ◽

Tertiary Care ◽

Positive Culture ◽

Antibiotic Use ◽

Coagulase Negative Staphylococci ◽

Culture Bottle

Abstract Background Coagulase-negative staphylococci (CoNS) are common blood culture (BCx) contaminants, but can also be causes of true blood stream infection (BSI). As a result, the clinical interpretation of CoNS positive BCx poses a significant challenge for providers and drives unnecessary antibiotic use, extended lengths of stay, and increased hospital costs. Despite these challenges, little is known about whether the number of positive BCx bottles within a set can be used to predict contamination vs. true BSI. Methods This study was conducted in an 865-bed tertiary care academic medical center in Richmond, VA. A retrospective chart review of CoNS-positive BCx from October to December 2018 was performed. Data collection included patient demographics, number of positive bottles within a set (i.e., were 1 or 2 bottles positive), care setting, antibiotic use, clinical judgement of contamination, and additional workup following the positive BCx result. Polymicrobic BCx were excluded. Results 50 patients (mean age 58.2 years, 60% male) with CoNS-positive BCx were included in this study. Forty (80%) of the cultures had only 1 of 2 BCx bottles positive within a set. 10 (20%) were positive from both bottles in the set. All patients were drawn in the Emergency Department and 90% were subsequently admitted to the hospital. Upon chart review, 47 (94%) and 3 (6%) of cultures were considered to be contaminants and real BSI, respectively. Of those judged to be contaminants, 10 (20%) were positive in both bottles within a set, and thus falsely suggested true BSI. Of the 3 judged to be true BSI, 2 (66%) were positive in 1 out of 2 bottles, and thus falsely suggested contamination. 42 (84%) patients had repeat BCx drawn following the initial positive culture, and 26 (52%) were continued on IV antibiotics. Forty (80%) of the cultures were judged contaminants by the primary medical service, and 77% stopped antibiotics (20/26) when CoNS was identified. Conclusion These data show that reporting the number of bottles which are positive within a set provides misleading information and should not be used to determine whether a culture result represents contamination or true BSI. Disclosures All authors: No reported disclosures.

Download Full-text

An Analysis of Reference Laboratory Testing in a Large Urban Academic Medical Center: The Impact of New Molecular Diagnostic Technologies

Laboratory Medicine ◽

10.1309/g2mm69t9c4c97w0w ◽

2007 ◽

Vol 38 (8) ◽

pp. 472-475 ◽

Cited By ~ 2

Author(s):

Linda Ardisson ◽

A. John Iafrate ◽

Kent Lewandrowski

Keyword(s):

Laboratory Testing ◽

Medical Center ◽

Academic Medical Center ◽

Molecular Diagnostic ◽

Reference Laboratory ◽

Academic Medical ◽

Diagnostic Technologies ◽

The Impact

Download Full-text

Successful Treatment of Scedosporium Sinusitis in Two Lung Transplant Recipients: Review of the Literature and Recommendations for Management

Allergy & Rhinology ◽

10.1177/2152656719827253 ◽

2019 ◽

Vol 10 ◽

pp. 215265671982725

Author(s):

Elisabeth H. Ference ◽

Bernard M. Kubak ◽

Paul Zhang ◽

Jeffrey D. Suh

Keyword(s):

Lung Transplant ◽

Medical Center ◽

Treatment Options ◽

Academic Medical Center ◽

Positive Culture ◽

Sinus Surgery ◽

Fungal Colonization ◽

Transplant Recipients ◽

Review Of The Literature ◽

Lung Transplant Recipients

Background Scedosporium fungal infection is an emerging disease which is difficult to diagnose and treat. Patients undergoing lung transplant may be colonized prior to transplantation and are at risk for lethal allograft infection after transplantation. Objectives To identify and evaluate treatment options. Methods This study is a retrospective review of patients treated at a tertiary academic medical center from 2007 to 2017 with positive sinonasal cultures. A review of the literature was also performed to identify additional cases. Results Two lung transplant patients had a positive culture for Scedosporium. The literature search resulted in 37 citations, which yielded only 2 prior cases of Scedosporium paranasal sinus colonization or infection in lung transplant recipients. Three of the 4 patients had cystic fibrosis. Two of the patients were colonized before initial transplant, while 1 patient was colonized before subsequent transplant. Three of the 4 patients survived, and all 3 had disease isolated to their sinuses and lungs treated with sinus surgery, while the fourth had disseminated disease and did not undergo sinus surgery. All patients were treated with multiple antifungals due to resistance patterns. One surviving patient cleared both sinus and lung cultures in less than 1 month, while the other 2 surviving patients achieved negative cultures after a minimum of 6 months. Conclusions Surgery may be especially important in patients with fungal sinus colonization or infection before or after lung transplantation. Chronic sinusitis is an important source for persistent fungal colonization and reinfection of the allograft which could be removed with surgical debridement before causing highly morbid pulmonary disease.

Download Full-text