scholarly journals United States Epilepsy Center Characteristics: A Data Analysis From the National Association of Epilepsy Centers

Neurology ◽  
2021 ◽  
pp. 10.1212/WNL.0000000000013130
Author(s):  
Adam P. Ostendorf ◽  
Stephanie M. Ahrens ◽  
Fred Alexander Lado ◽  
Susan T. Arnold ◽  
Shasha Bai ◽  
...  
Keyword(s):  
United States ◽  
Diagnostic Testing ◽  
The United States ◽  
National Association ◽  
Categorical Variables ◽  
Continuous Variables ◽  
Vagus Nerve Stimulator ◽  
Level 3 ◽  
Epilepsy Center ◽  
Drug Resistant Epilepsy

Background and Objectives:Patients with drug resistant epilepsy (DRE) may benefit from specialized testing and treatments to better control seizures and improve quality of life. Most evaluations and procedures for DRE in the United States are performed at epilepsy centers accredited by the National Association of Epilepsy Centers (NAEC). On an annual basis, the NAEC collects data from accredited epilepsy centers on hospital-based epilepsy monitoring unit (EMU) size and admissions, diagnostic testing, surgeries, and other services. This article highlights trends in epilepsy center services from 2012 through 2019.Methods:We analyzed data reported in 2012, 2016, and 2019 from all level 3 and level 4 NAEC accredited epilepsy centers. Data were described using frequency for categorical variables and median for continuous variables and were analyzed by center level and center population category. EMU beds, EMU admissions, epileptologists, and aggregate procedure volumes were also described using rates per population per year.Results:During the period studied, the number of NAEC accredited centers increased from 161 to 256, with the largest increases in adult- and pediatric-only centers. Growth in EMU admissions (41%), EMU beds (26%), and epileptologists (109%) per population occurred. Access to specialized testing and services broadly expanded. The largest growth in procedure volumes occurred in laser interstitial thermal therapy (LiTT) (61%), responsive neurostimulation (RNS) implantations (114%) and intracranial monitoring without resection (152%) over the study period. Corpus callosotomies and vagus nerve stimulator (VNS) implantations decreased (-12.8% and -2.4% respectively), while growth in temporal lobectomies (5.9%), extratemporal resections (11.9%), and hemispherectomies/otomies (13.1%) lagged center growth (59%), leading to a decrease in median volumes of these procedures per center.Discussion:During the study period, the availability of specialty epilepsy care in the U.S. improved as the NAEC implemented its accreditation program. Surgical case complexity increased while aggregate surgical volume remained stable or declined across most procedure types, with a corresponding decline in cases per center. This article describes recent data trends and current state of resources and practice across NAEC member centers and identifies several future directions for driving systematic improvements in epilepsy care.

scholarly journals Medical cannabis use in the United States: a retrospective database study

2020 ◽  
Vol 2 (1) ◽  
Author(s):  
V. Kishan Mahabir ◽  
Jamil J. Merchant ◽  
Christopher Smith ◽  
Alisha Garibaldi
Keyword(s):  
United States ◽  
Medical Condition ◽  
Statistical Tests ◽  
The United States ◽  
Categorical Variables ◽  
Continuous Variables ◽  
Medical Conditions ◽  
Comorbid Conditions ◽  
Medical Cannabis ◽  
Number Of Patients

Abstract Introduction Growing interest in the medicinal properties of cannabis has led to an increase in its use to treat medical conditions, and the establishment of state-specific medical cannabis programs. Despite medical cannabis being legal in 33 states and the District of Colombia, there remains a paucity of data characterizing the patients accessing medical cannabis programs. Methods We retrospectively reviewed a registry with data from 33 medical cannabis evaluation clinics in the United States, owned and operated by CB2 Insights. Data were collected primarily by face-to-face interviews for patients seeking medical cannabis certification between November 18, 2018 and March 18, 2020. Patients were removed from the analysis if they did not have a valid date of birth, were less than 18, or did not have a primary medical condition reported; a total of 61,379 patients were included in the analysis. Data were summarized using descriptive statistics expressed as a mean (standard deviation (SD)) or median (interquartile range (IQR)) as appropriate for continuous variables, and number (percent) for categorical variables. Statistical tests performed across groups included t-tests, chi-squared tests and regression. Results The average age of patients was 45.5, 54.8% were male and the majority were Caucasian (87.5%). Female patients were significantly older than males (47.0 compared to 44.6). Most patients reported cannabis experience prior to seeking medical certification (66.9%). The top three mutually exclusive primary medical conditions reported were unspecified chronic pain (38.8%), anxiety (13.5%) and post-traumatic stress disorder (PTSD) (8.4%). The average number of comorbid conditions reported was 2.7, of which anxiety was the most common (28.3%). Females reported significantly more comorbid conditions than males (3.1 compared to 2.3). Conclusion This retrospective study highlighted the range and number of conditions for which patients in the US seek medical cannabis. Rigorous clinical trials investigating the use of medical cannabis to treat pain conditions, anxiety, insomnia, depression and PTSD would benefit a large number of patients, many of whom use medical cannabis to treat multiple conditions.

scholarly journals Cardiac Arrests and Deaths Associated with Malignant Hyperthermia in North America from 1987 to 2006

2008 ◽  
Vol 108 (4) ◽  
pp. 603-611 ◽  
Author(s):  
Marilyn Green Larach ◽  
Barbara W. Brandom ◽  
Gregory C. Allen ◽  
Gerald A. Gronert ◽  
Erik B. Lehman
Keyword(s):  
United States ◽  
Cardiac Arrest ◽  
Malignant Hyperthermia ◽  
Odds Ratio ◽  
Anesthetic Management ◽  
The United States ◽  
Exclusion Criterion ◽  
Categorical Variables ◽  
Continuous Variables ◽  
Increased Risk

Background The authors determined associated cardiac arrest and death rates in cases from Canada and the United States as reported to The North American Malignant Hyperthermia (MH) Registry and analyzed factors associated with a higher risk of poor outcomes. Methods The authors searched the database for AMRA (adverse metabolic/musculoskeletal reaction to anesthesia) reports with inclusion criteria as follows: event date between January 1, 1987, and December 31, 2006; "very likely" or "almost certain" MH as ranked by MH Clinical Grading Scale; location in Canada or the United States; and one or more anesthetic agents given. The exclusion criterion was a pathologic condition other than MH independently judged by the authors. Severe MH outcomes were analyzed as regards clinical history and presentation, using Wilcoxon rank sum tests for continuous variables and Pearson exact chi-square tests for categorical variables. A Bonferroni correction adjusted for multiple comparisons. Results Of 291 events, 8 (2.7%) resulted in cardiac arrests and 4 (1.4%) resulted in death. The median age in cases of cardiac arrest/death was 20 yr (range, 2-31 yr). Associated factors were muscular build (odds ratio, 18.7; P = 0.0016) and disseminated intravascular coagulation (odds ratio, 49.7; P < 0.0001). Increased risk of cardiac arrest/death was related to a longer time period between anesthetic induction and maximum end-tidal carbon dioxide (216 vs. 87 min; P = 0.003). Unrelated factors included patient or family history, anesthetic management, and the MH episode. Conclusions Modern US anesthetic practice did not prevent MH-associated cardiac arrest and death in predominantly young, healthy patients undergoing low- to intermediate-risk surgical procedures.

scholarly journals 750. Retrospective Evaluation of the Three-Step EIA/PCR Algorithm as a Cost-Effective Method for Detection and Treatment of Clostridium Difficile Infection

2021 ◽  
Vol 8 (Supplement_1) ◽  
pp. S472-S473
Author(s):  
Bakri Kulla ◽  
patrick Haggerty
Keyword(s):  
United States ◽  
Clostridium Difficile ◽  
Clostridium Difficile Infection ◽  
The United States ◽  
Hospital Length Of Stay ◽  
Categorical Variables ◽  
Continuous Variables ◽  
True Positive ◽  
Positive Rate ◽  
Step Algorithm

Abstract Background Clostridium difficile infection (CDI) is the primary cause of infectious diarrhea in the United States. With an estimated 453,000-500,000 burden cases that are associated with 15,000-30,000 deaths annually in the United States. Because of its prevalence, there is a projected 3.2-4.8 billion dollar annual cost for inpatient care related to CDI. For these reasons, accurate and timely detection of CDI is crucial to reduce the morbidity, mortality, and medical costs. Methods This is a retrospective cohort study. Adult patients, aged 18 through 80 years, admitted between 9/1/2016 and 9/30/2017, who presented with diarrhea and received a CDI algorithm test. To assess bivariate associations between true positive and indeterminate positive groups, categorical variables were compared using Chi-Square or Fisher’s exact tests when appropriate, and continuous variables were analyzed using independent samples t-tests. Results The study included 1031 stool samples, of which 853 (82.7%) were CDI negative and 178 (17.3%) were CDI positive. Of the full sample, 265 (25.7%) were GDH (+), 94 (9.1%) were toxin (+), and 84 (8.1%) were PCR (+). In order to examine patient-level variables, the first positive from each patient was included to ensure independence of data points, resulting in 830 unique tests and patients. The true positive rate of this sub-sample was 9.4% (n = 78) and indeterminate positive rate was 8.7% (n = 72). An important findings of the study is that of the patients who were GDH (+)/toxin (-), 87 (50.9%) were PCR (-) and 84 (49.1%) were PCR (+).Table 1 Conclusion The study found that of the patients who are GDH (+) and Toxin (-), the PCR test serves as a proxy for the CDI test. In addition, we demonstrated that whether the patient was true positive by the GDH/Toxin test or indeterminate positive, the outcomes were the same. The only difference was the antibiotic selections for treatment. Performing PCR tests as a part of three-step algorithm prevented nearly half of discrepant patients from being unnecessarily treated with antibiotics and placed on enteric precaution, thereby extending their hospital stay. Finally, by preventing unnecessary antibiotic use, isolation and hospital length of stay, it is proposed that the three-step algorithm effectively reduces hospital cost. Disclosures All Authors: No reported disclosures

scholarly journals Fellowship program directors and trainees across the United States find parental leave policies to be inconsistent, inaccessible, and inadequate

PLoS ONE ◽  
2021 ◽  
Vol 16 (11) ◽  
pp. e0260057
Author(s):  
Daniel Sabido Jamorabo ◽  
Amrin Khander ◽  
Vasilios Koulouris ◽  
Jeremy Eli Feith ◽  
William Matthew Briggs ◽  
...  
Keyword(s):  
United States ◽  
Parental Leave ◽  
Well Being ◽  
Program Directors ◽  
The United States ◽  
Time Constraints ◽  
Categorical Variables ◽  
Continuous Variables ◽  
Fellowship Program ◽  
Fellowship Programs

Introduction Determine the consistency, accessibility, and adequacy of parental leave policies for adult and pediatric medicine fellowship programs. Methods We administered a 40-question survey to fellowship program directors (PDs) and trainees in adult and pediatric cardiology, hematology/oncology, gastroenterology, and pulmonology/critical care fellowship programs in the United States. We used Chi-square tests to compare proportions for categorical variables and t-tests to compare means for continuous variables. Results A total of 190 PDs from 500 programs (38.0%) and 236 trainees from 142 programs (28.4%) responded. Most respondents did not believe that parental leave policies were accessible publicly (322/426; 75.6%), on password-protected intranet (343/426; 80.5%), or upon request (240/426; 56.3%). The PDs and trainees broadly felt that parental leave for fellows should be 5–10 weeks (156/426; 36.6%) or 11–15 weeks (165/426; 38.7%). A majority of PDs felt that there was no increased burden upon other fellows (122/190; 64.2%) or change in overall well-being (110/190; 57.9%). When asked about the biggest barrier to parental leave support, most PDs noted time constrains of fellowship (101/190; 53.1%) and the limited number of fellows (43/190; 22.6%). Trainees similarly selected the time constraints of training (88/236; 37.3%), but nearly one-fifth chose the culture in medicine (44/236; 18.6%). There were no statistically significant differences in answers based on the respondents’ sex, specialty, or subspecialty. Discussion Parental leave policies are broadly in place, but did not feel these were readily accessible, standardized, or of optimum length. PDs and trainees noted several barriers that undermine support for better parental leave policies, including time constraints of fellowship, the limited number of fellows for coverage, and workplace culture. Standardization of parental leave policies is advisable to allow trainees to pursue fellowship training and care for their newborns without undermining their educational experiences.

Sixty-day unplanned readmissions after robot-assisted versus open-radical prostatectomy.

2021 ◽  
Vol 39 (6_suppl) ◽  
pp. 244-244
Author(s):  
Prasanth Lingamaneni ◽  
Binav Baral ◽  
Krishna Rekha Moturi ◽  
Trilok Shrivastava ◽  
Omnia Darweesh ◽  
...  
Keyword(s):  
Prostate Cancer ◽  
United States ◽  
Radical Prostatectomy ◽  
Private Insurance ◽  
The United States ◽  
Categorical Variables ◽  
Continuous Variables ◽  
Robot Assisted ◽  
Post Procedure ◽  
Comorbidity Burden

244 Background: Options for clinically localized prostate cancer include radical prostatectomy, radiation therapy and active surveillance. Robot-assisted radical prostatectomy (RARP) is increasingly being used, and now accounts for the majority of radical prostatectomies performed in the United States. The aim of our study was to evaluate differences in the patient population undergoing open versus robot-assisted prostatectomy, and to compare 60-day readmissions after index hospitalization for radical prostatectomy. Methods: We utilized the Nationwide Readmission database (NRD) to obtain data on patients with prostate cancer admitted in 2016 and 2017 for radical prostatectomy in the United States. We used T-test to compare means of continuous variables and chi-square test to compare proportions of categorical variables. Multivariable logistic regression was used evaluate risk factors for 60-day unplanned readmissions. Results: A total of 115,551 patients met the inclusion criteria, of which 80.1% underwent RARP. Patients undergoing RARP were slightly older (64.8 vs 63.1 years, p < 0.0001), more likely to have private insurance (51.7% vs 44.3%, p < 0.0001) and undergo surgery at a teaching hospital (83% vs 74.6%, p < 0.0001). Importantly, open prostatectomy (OP) patients had higher rates of co-morbidities, including, hypertension, diabetes mellitus, chronic kidney disease, obstructive lung disease, heart failure, coronary artery disease and malnutrition (p < 0.01 for these co-morbidities). Hospital stay was longer in those who underwent OP (3.1 vs 1.7 days, p < 0.0001), and they were more likely to be discharged to nursing facility (3.0% vs 0.4%, p < 0.0001) or with home health care (10.9% vs 4.8%, p < 0.0001). Hospitalization charges were higher in the RARP population ($60k vs 57k, p = 0.04). Inpatient mortality was low in both groups (0.3% for OP and ~0% for RARP, p < 0.001). 60-day readmission rate was higher in those who underwent OP (9.3% vs 5.0%, p > 0.0001). Overall, the three leading causes for readmission included sepsis (10.6%), post-procedure infection (8.4%) and venous thromboembolism (VTE, 8.3%). Even after adjustment for age and comorbidities, those who underwent OP had higher risk of all-cause readmission (aOR 1.39, 95% CI 1.25-1.53, p < 0.001) and readmissions for sepsis (aOR 1.36, 95% CI 1.02-1.81, p = 0.03) and post-procedure infection (aOR 1.38, 95% CI 1.06-1.81, p = 0.02). Risk of readmission for VTE was similar in both groups. Conclusions: Nationwide, there are differences in demographics and comorbid illness burden in prostate cancer patients selected for open and robot-assisted radical prostatectomy. Better short-term outcomes in the RARP cohort may be partially attributed to lower comorbidity burden in this group. However, despite adjustment for comorbidities, higher risk for all-cause readmissions and readmissions for infectious complications persisted in the OP group.

scholarly journals Testing telediagnostic obstetric ultrasound in Peru: a new horizon in expanding access to prenatal ultrasound

2021 ◽  
Vol 21 (1) ◽  
Author(s):  
Marika Toscano ◽  
Thomas J. Marini ◽  
Kathryn Drennan ◽  
Timothy M. Baran ◽  
Jonah Kan ◽  
...  
Keyword(s):  
Excellent Agreement ◽  
Rural Areas ◽  
Intraclass Correlation ◽  
Standard Of Care ◽  
The United States ◽  
Categorical Variables ◽  
Continuous Variables ◽  
Second Trimester ◽  
Obstetric Ultrasound ◽  
Biometric Measurements

Abstract Background Ninety-four percent of all maternal deaths occur in low- and middle-income countries, and the majority are preventable. Access to quality Obstetric ultrasound can identify some complications leading to maternal and neonatal/perinatal mortality or morbidity and may allow timely referral to higher-resource centers. However, there are significant global inequalities in access to imaging and many challenges to deploying ultrasound to rural areas. In this study, we tested a novel, innovative Obstetric telediagnostic ultrasound system in which the imaging acquisitions are obtained by an operator without prior ultrasound experience using simple scan protocols based only on external body landmarks and uploaded using low-bandwidth internet for asynchronous remote interpretation by an off-site specialist. Methods This is a single-center pilot study. A nurse and care technician underwent 8 h of training on the telediagnostic system. Subsequently, 126 patients (68 second trimester and 58 third trimester) were recruited at a health center in Lima, Peru and scanned by these ultrasound-naïve operators. The imaging acquisitions were uploaded by the telemedicine platform and interpreted remotely in the United States. Comparison of telediagnostic imaging was made to a concurrently performed standard of care ultrasound obtained and interpreted by an experienced attending radiologist. Cohen’s Kappa was used to test agreement between categorical variables. Intraclass correlation and Bland-Altman plots were used to test agreement between continuous variables. Results Obstetric ultrasound telediagnosis showed excellent agreement with standard of care ultrasound allowing the identification of number of fetuses (100% agreement), fetal presentation (95.8% agreement, κ =0.78 (p < 0.0001)), placental location (85.6% agreement, κ =0.74 (p < 0.0001)), and assessment of normal/abnormal amniotic fluid volume (99.2% agreement) with sensitivity and specificity > 95% for all variables. Intraclass correlation was good or excellent for all fetal biometric measurements (0.81–0.95). The majority (88.5%) of second trimester ultrasound exam biometry measurements produced dating within 14 days of standard of care ultrasound. Conclusion This Obstetric ultrasound telediagnostic system is a promising means to increase access to diagnostic Obstetric ultrasound in low-resource settings. The telediagnostic system demonstrated excellent agreement with standard of care ultrasound. Fetal biometric measurements were acceptable for use in the detection of gross discrepancies in fetal size requiring further follow up.

Abstract 177: Credentials of Staff Performing Echocardiography in the United States: Insights from the Intersocietal Accreditation Commission

2014 ◽  
Vol 7 (suppl_1) ◽  
Author(s):  
Matthew W Parker ◽  
Diana Sobieraj ◽  
Mary Beth Farrell ◽  
Craig I Coleman
Keyword(s):  
United States ◽  
Cardiovascular Diseases ◽  
The United States ◽  
Chi Square ◽  
Volume Number ◽  
National Board ◽  
Formal Level ◽  
Chi Square Test ◽  
Level 3 ◽  
Medical Directors

Background: Little has been published on the practice of echocardiography (echo) in the United States. We used the Intersocietal Accreditation Commission-Echocardiography (IAC-Echo) applications database to describe the personnel in echo laboratories seeking accreditation. Methods: We used de-identified data provided on IAC-Echo applications to characterize facilities by hospital association, census region, annual volume, number of sites, previous accreditation, and numbers of physicians and sonographers as well as National Board of Echocardiography (NBE) testamur status of physicians and registered credential status of sonographers. We categorized Medical Directors by board certification in cardiovascular diseases, internal medicine, other specialty, or none. Medical Director echo training could be formal Level 2 or 3 or experiential by ≥3 years of practice. Frequencies, means, and medians were compared between groups using the chi-square test, t-test, or Mann Whitney test, respectively. Results: From 2011 to 2013, 1926 echo labs representing 10618 physicians and 6870 sonographers applied for IAC-Echo accreditation or re-accreditation. The majority of medical directors were board certified in cardiovascular diseases and 34.1% of medical directors and 27.2% of staff physicians held NBE testamur status; 79.5% of sonographers held registered credentials. Most echo labs were in the Northeast or South census regions, have an average of 1.75 sites, and are based outside of hospitals (Table). Compared to nonhospital echo labs, medical directors of hospital-based echo labs were more likely to be Level 3 trained (19.8% versus 30.8%, p<0.01) and be NBE testamurs (28.9% versus 45.6%, p<0.01). Markers of echo lab size, region, previous accreditation, and credentialed sonographers were associated with accreditation versus delay decisions; there was a trend toward accreditation among facilities with NBE medical directors. Conclusion: Among facilities seeking IAC-Echo accreditation, the minority of echo physicians hold NBE testamur status. Hospital and nonhospital facilities are different in the credentials of their personnel.

Disproportionately Overrepresented: Women in Local Elected Offices

2018 ◽  
Vol 50 (3) ◽  
pp. 165-176 ◽  
Author(s):  
Ethan M. Bernick ◽  
Brianne Heidbreder
Keyword(s):  
United States ◽  
Maximum Likelihood ◽  
Gender Norms ◽  
The United States ◽  
Census Bureau ◽  
National Association ◽  
County Level ◽  
Political Factors ◽  
Using Data ◽  
The U.S

This research examines the position of county clerk, where women are numerically disproportionately over-represented. Using data collected from the National Association of Counties and the U.S. Census Bureau, the models estimate the correlation between the county clerk’s sex and county-level demographic, social, and political factors with maximum likelihood logit estimates. This research suggests that while women are better represented in the office of county clerk across the United States, when compared to other elective offices, this representation may be because this office is not seen as attractive to men and its responsibilities fit within the construct of traditional gender norms.

scholarly journals Early introductions and community transmission of SARS-CoV-2 variant B.1.1.7 in the United States

2021 ◽  
Author(s):  
Tara Alpert ◽  
Erica Lasek-Nesselquist ◽  
Anderson F. Brito ◽  
Andrew L. Valesano ◽  
Jessica Rothman ◽  
...  
Keyword(s):  
Public Health ◽  
United States ◽  
New York ◽  
Diagnostic Testing ◽  
The United States ◽  
International Travel ◽  
Health Concern ◽  
Public Health Response ◽  
Community Transmission ◽  
The Uk

SummaryThe emergence and spread of SARS-CoV-2 lineage B.1.1.7, first detected in the United Kingdom, has become a national public health concern in the United States because of its increased transmissibility. Over 500 COVID-19 cases associated with this variant have been detected since December 2020, but its local establishment and pathways of spread are relatively unknown. Using travel, genomic, and diagnostic testing data, we highlight the primary ports of entry for B.1.1.7 in the US and locations of possible underreporting of B.1.1.7 cases. New York, which receives the most international travel from the UK, is likely one of the key hubs for introductions and domestic spread. Finally, we provide evidence for increased community transmission in several states. Thus, genomic surveillance for B.1.1.7 and other variants urgently needs to be enhanced to better inform the public health response.

scholarly journals Colistin Heteroresistance Is Largely Undetected among Carbapenem-Resistant Enterobacterales in the United States

mBio ◽  
2021 ◽  
Vol 12 (1) ◽  
Author(s):  
Victor I. Band ◽  
Sarah W. Satola ◽  
Richard D. Smith ◽  
David A. Hufnagel ◽  
Chris Bower ◽  
...  
Keyword(s):  
United States ◽  
Klebsiella Pneumoniae ◽  
Diagnostic Testing ◽  
Cladistic Analysis ◽  
The United States ◽  
Clinical Diagnostics ◽  
Infection Model ◽  
Content Type ◽  
Carbapenem Resistant ◽  
Clinical Diagnostic

ABSTRACT 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. IMPORTANCE 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 to colistin was more common than conventional resistance and was overwhelmingly misclassified as susceptibility by clinical diagnostic testing. Higher proportions of colistin heteroresistance observed in certain Enterobacter species and clustering among heteroresistant Klebsiella pneumoniae strains may inform colistin treatment recommendations. Overall, the rate of colistin nonsusceptibility was more than double the level detected by clinical diagnostics, suggesting that the prevalence of colistin nonsusceptibility among CRE may be higher than currently appreciated in the United States.

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