Publications by authors named "Carolyn V Gould"

56 Publications

Fatal Human Infection with Evidence of Intrahost Variation of Eastern Equine Encephalitis Virus, Alabama, USA, 2019.

Emerg Infect Dis 2021 07;27(7):1886-1892

Eastern equine encephalitis virus (EEEV) is an arbovirus in the family Togaviridae, genus Alphavirus, found in North America and associated with freshwater/hardwood swamps in the Atlantic, Gulf Coast, and Great Lakes regions. EEEV disease in humans is rare but causes substantial illness and death. To investigate the molecular epidemiology and microevolution of EEEV from a fatal case in Alabama, USA, in 2019, we used next-generation sequencing of serum and cerebrospinal fluid (CSF). Phylogenetic inference indicated that the infecting strain may be closely related to isolates from Florida detected during 2010-2014, suggesting potential seeding from Florida. EEEV detected in serum displayed a higher degree of variability with more single-nucleotide variants than that detected in the CSF. These data refine our knowledge of EEEV molecular epidemiologic dynamics in the Gulf Coast region and demonstrate potential quasispecies bottlenecking within the central nervous system of a human host.
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http://dx.doi.org/10.3201/eid2707.210315DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8237905PMC
July 2021

Cost effectiveness and impact of a targeted age- and incidence-based West Nile virus vaccine strategy.

Clin Infect Dis 2021 Jun 12. Epub 2021 Jun 12.

Division of Vector-Borne Diseases, Centers for Disease Control and Prevention (CDC), Fort Collins, Colorado, USA.

Background: West Nile virus (WNV) is the leading cause of arboviral disease in the United States and is associated with significant morbidity and mortality. A previous analysis found that a vaccination program targeting persons aged ≥60 years was more cost effective than universal vaccination, but costs remained high.

Methods: We used a mathematical Markov model to evaluate cost-effectiveness of an age- and incidence-based WNV vaccination program. We grouped states and large counties (≥100,000 persons aged ≥60 years) by median annual WNV incidence rates from 2004 to 2017 for persons aged ≥60 years. We defined WNV incidence thresholds, in increments of 0.5 cases per 100,000 persons ≥60 years. We calculated potential cost per WNV vaccine-prevented case and per quality adjusted life years (QALYs) saved.

Results: Vaccinating persons aged ≥60 years in states with an annual incidence of WNV neuroinvasive disease of ≥0.5 per 100,000 resulted in approximately half the cost per health outcome averted compared to vaccinating persons aged ≥60 years in all the contiguous United States. This approach could potentially prevent 37% of all neuroinvasive disease cases and 63% of WNV-related deaths nationally. Employing such a threshold at a county-level further improved cost-effectiveness ratios while preventing 19% and 30% of WNV-related neuroinvasive disease cases and deaths, respectively.

Conclusions: An age- and incidence-based WNV vaccination program could be a more cost-effective strategy than an age-based program while still having a substantial impact on lowering WNV-related morbidity and mortality.
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http://dx.doi.org/10.1093/cid/ciab540DOI Listing
June 2021

Fatal Case of Chronic Jamestown Canyon Virus Encephalitis Diagnosed by Metagenomic Sequencing in Patient Receiving Rituximab.

Emerg Infect Dis 2021 01 1;27(1). Epub 2020 Dec 1.

A 56-year-old man receiving rituximab who had months of neurologic symptoms was found to have Jamestown Canyon virus in cerebrospinal fluid by clinical metagenomic sequencing. The patient died, and postmortem examination revealed extensive neuropathologic abnormalities. Deep sequencing enabled detailed characterization of viral genomes from the cerebrospinal fluid, cerebellum, and cerebral cortex.
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http://dx.doi.org/10.3201/eid2701.203448DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7774567PMC
January 2021

Evaluation for Arboviral Infection Among Children Hospitalized in Colorado With Aseptic Meningitis and Encephalitis.

Pediatr Infect Dis J 2020 11;39(11):e382-e384

From the Arboviral Diseases Branch, Centers for Disease Control and Prevention, Fort Collins, Colorado and.

Among 39 children hospitalized in Colorado with aseptic meningitis or encephalitis, 16 (41%) had an etiology identified, including 2 (5%) with West Nile virus infection. Despite extensive testing, no other arboviral infections were identified. Arboviral infection should be considered in children with neuroinvasive disease during arboviral season with testing directed toward viruses endemic to the region and type of exposure.
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http://dx.doi.org/10.1097/INF.0000000000002856DOI Listing
November 2020

Powassan Virus Infection Likely Acquired Through Blood Transfusion Presenting as Encephalitis in a Kidney Transplant Recipient.

Clin Infect Dis 2021 03;72(6):1051-1054

Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA.

A kidney transplant patient without known tick exposure developed encephalitis 3 weeks after transplantation. During the transplant hospitalization, the patient had received a blood transfusion from an asymptomatic donor later discovered to have been infected with Powassan virus. Here, we describe a probable instance of transfusion-transmitted Powassan virus infection.
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http://dx.doi.org/10.1093/cid/ciaa738DOI Listing
March 2021

Reverse Transcription-Polymerase Chain Reaction Testing on Filter Paper-Dried Serum for Laboratory-Based Dengue Surveillance-American Samoa, 2018.

Am J Trop Med Hyg 2020 03;102(3):622-624

Division of Vector-Borne Diseases, Centers for Disease Control and Prevention (CDC), Fort Collins, Colorado.

Laboratory-based surveillance for arboviral diseases is challenging in resource-limited settings. We evaluated the use of filter paper-dried sera for detection of dengue virus (DENV) RNA during an outbreak in American Samoa. Matched liquid and filter paper-dried sera were collected from patients with suspected dengue and shipped to a reference laboratory for diagnostic testing. RNA was extracted from each sample and tested for DENV RNA by real-time reverse transcription-polymerase chain reaction (RT-PCR). Of 18 RT-PCR-positive liquid specimens, 14 matched filter paper-dried specimens were positive for a sensitivity of 78% (95% CI, 55-91%). Of 82 RT-PCR-negative liquid specimens, all filter paper-dried specimens were negative for a specificity of 100% (95% CI, 96-100%). Shipping of filter paper-dried specimens was similarly timely but less expensive than shipping liquid sera. Using filter paper-dried serum or blood can be a cost-effective and sustainable approach to surveillance of dengue and other arboviral diseases in resource-limited settings.
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http://dx.doi.org/10.4269/ajtmh.19-0800DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7056409PMC
March 2020

Implementation of the Targeted Assessment for Prevention Strategy in a healthcare system to reduce infection rates.

Infect Control Hosp Epidemiol 2020 03 13;41(3):295-301. Epub 2020 Jan 13.

Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia.

Background: Prevention of Clostridioides difficile infection (CDI) is a national priority and may be facilitated by deployment of the Targeted Assessment for Prevention (TAP) Strategy, a quality improvement framework providing a focused approach to infection prevention. This article describes the process and outcomes of TAP Strategy implementation for CDI prevention in a healthcare system.

Methods: Hospital A was identified based on CDI surveillance data indicating an excess burden of infections above the national goal; hospitals B and C participated as part of systemwide deployment. TAP facility assessments were administered to staff to identify infection control gaps and inform CDI prevention interventions. Retrospective analysis was performed using negative-binomial, interrupted time series (ITS) regression to assess overall effect of targeted CDI prevention efforts. Analysis included hospital-onset, laboratory-identified C. difficile event data for 18 months before and after implementation of the TAP facility assessments.

Results: The systemwide monthly CDI rate significantly decreased at the intervention (β2, -44%; P = .017), and the postintervention CDI rate trend showed a sustained decrease (β1 + β3; -12% per month; P = .008). At an individual hospital level, the CDI rate trend significantly decreased in the postintervention period at hospital A only (β1 + β3, -26% per month; P = .003).

Conclusions: This project demonstrates TAP Strategy implementation in a healthcare system, yielding significant decrease in the laboratory-identified C. difficile rate trend in the postintervention period at the system level and in hospital A. This project highlights the potential benefit of directing prevention efforts to facilities with the highest burden of excess infections to more efficiently reduce CDI rates.
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http://dx.doi.org/10.1017/ice.2019.358DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8054466PMC
March 2020

West Nile Virus and Other Domestic Nationally Notifiable Arboviral Diseases - United States, 2018.

MMWR Morb Mortal Wkly Rep 2019 Aug 9;68(31):673-678. Epub 2019 Aug 9.

Arthropodborne viruses (arboviruses) are transmitted to humans primarily through the bites of infected mosquitoes and ticks. West Nile virus (WNV) is the leading cause of domestically acquired arboviral disease in the continental United States (1). Other arboviruses, including eastern equine encephalitis, Jamestown Canyon, La Crosse, Powassan, and St. Louis encephalitis viruses, cause sporadic cases of disease and occasional outbreaks. This report summarizes surveillance data reported to CDC for 2018 on nationally notifiable arboviruses. It excludes dengue, chikungunya, and Zika viruses because they are primarily nondomestic viruses typically acquired through travel. In 2018, 48 states and the District of Columbia (DC) reported 2,813 cases of domestic arboviral disease, including 2,647 (94%) WNV disease cases. Of the WNV disease cases, 1,658 (63%) were classified as neuroinvasive disease (e.g., meningitis, encephalitis, and acute flaccid paralysis), for a national incidence of 0.51 cases of WNV neuroinvasive disease per 100,000 population. Because arboviral diseases continue to cause serious illness and have no definitive treatment, maintaining surveillance is important to direct and promote prevention activities. Health care providers should consider arboviral infections in patients with aseptic meningitis or encephalitis, perform appropriate diagnostic testing, and report cases to public health authorities.
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http://dx.doi.org/10.15585/mmwr.mm6831a1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6687196PMC
August 2019

Transmission of Eastern Equine Encephalitis Virus From an Organ Donor to 3 Transplant Recipients.

Clin Infect Dis 2019 07;69(3):450-458

Division of Vector-Borne Diseases, NCEZID, CDC, Fort Collins, Colorado.

Background: In fall 2017, 3 solid organ transplant (SOT) recipients from a common donor developed encephalitis within 1 week of transplantation, prompting suspicion of transplant-transmitted infection. Eastern equine encephalitis virus (EEEV) infection was identified during testing of endomyocardial tissue from the heart recipient.

Methods: We reviewed medical records of the organ donor and transplant recipients and tested serum, whole blood, cerebrospinal fluid, and tissue from the donor and recipients for evidence of EEEV infection by multiple assays. We investigated blood transfusion as a possible source of organ donor infection by testing remaining components and serum specimens from blood donors. We reviewed data from the pretransplant organ donor evaluation and local EEEV surveillance.

Results: We found laboratory evidence of recent EEEV infection in all organ recipients and the common donor. Serum collected from the organ donor upon hospital admission tested negative, but subsequent samples obtained prior to organ recovery were positive for EEEV RNA. There was no evidence of EEEV infection among donors of the 8 blood products transfused into the organ donor or in products derived from these donations. Veterinary and mosquito surveillance showed recent EEEV activity in counties nearby the organ donor's county of residence. Neuroinvasive EEEV infection directly contributed to the death of 1 organ recipient and likely contributed to death in another.

Conclusions: Our investigation demonstrated EEEV transmission through SOT. Mosquito-borne transmission of EEEV to the organ donor was the likely source of infection. Clinicians should be aware of EEEV as a cause of transplant-associated encephalitis.
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http://dx.doi.org/10.1093/cid/ciy923DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6488434PMC
July 2019

West Nile Virus and Other Nationally Notifiable Arboviral Diseases - United States, 2017.

MMWR Morb Mortal Wkly Rep 2018 Oct 19;67(41):1137-1142. Epub 2018 Oct 19.

Arthropodborne viruses (arboviruses) are transmitted to humans primarily through the bites of infected mosquitoes or ticks. West Nile virus (WNV) is the leading cause of domestically acquired arboviral disease in the continental United States (1). Other arboviruses, including Jamestown Canyon, La Crosse, Powassan, St. Louis encephalitis, and eastern equine encephalitis viruses, cause sporadic cases of disease and occasional outbreaks. This report summarizes surveillance data reported to CDC from U.S. states in 2017 for nationally notifiable arboviruses. It excludes dengue, chikungunya, and Zika viruses because, in the continental United States, these viruses are acquired primarily through travel. In 2017, 48 states and the District of Columbia (DC) reported 2,291 cases of domestic arboviral disease, including 2,097 (92%) WNV disease cases. Among the WNV disease cases, 1,425 (68%) were classified as neuroinvasive disease (e.g., meningitis, encephalitis, or acute flaccid paralysis), for a national rate of 0.44 cases per 100,000 population. More Jamestown Canyon and Powassan virus disease cases were reported in 2017 than in any previous year. Because arboviral diseases continue to cause serious illness, maintaining surveillance is important to direct and promote prevention activities.
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http://dx.doi.org/10.15585/mmwr.mm6741a1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6193690PMC
October 2018

Transmission of Clostridium difficile from asymptomatically colonized or infected long-term care facility residents.

Infect Control Hosp Epidemiol 2018 08 31;39(8):909-916. Epub 2018 May 31.

6Edward Hines,Jr Veterans Affairs Hospital,Hines,Illinois.

Objective: To test the hypothesis that long-term care facility (LTCF) residents with Clostridium difficile infection (CDI) or asymptomatic carriage of toxigenic strains are an important source of transmission in the LTCF and in the hospital during acute-care admissions.

Design: A 6-month cohort study with identification of transmission events was conducted based on tracking of patient movement combined with restriction endonuclease analysis (REA) and whole-genome sequencing (WGS).

Setting: Veterans Affairs hospital and affiliated LTCF.ParticipantsThe study included 29 LTCF residents identified as asymptomatic carriers of toxigenic C. difficile based on every other week perirectal screening and 37 healthcare facility-associated CDI cases (ie, diagnosis >3 days after admission or within 4 weeks of discharge to the community), including 26 hospital-associated and 11 LTCF-associated cases.

Results: Of the 37 CDI cases, 7 (18·9%) were linked to LTCF residents with LTCF-associated CDI or asymptomatic carriage, including 3 of 26 hospital-associated CDI cases (11·5%) and 4 of 11 LTCF-associated cases (36·4%). Of the 7 transmissions linked to LTCF residents, 5 (71·4%) were linked to asymptomatic carriers versus 2 (28·6%) to CDI cases, and all involved transmission of epidemic BI/NAP1/027 strains. No incident hospital-associated CDI cases were linked to other hospital-associated CDI cases.

Conclusions: Our findings suggest that LTCF residents with asymptomatic carriage of C. difficile or CDI contribute to transmission both in the LTCF and in the affiliated hospital during acute-care admissions. Greater emphasis on infection control measures and antimicrobial stewardship in LTCFs is needed, and these efforts should focus on LTCF residents during hospital admissions.
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http://dx.doi.org/10.1017/ice.2018.106DOI Listing
August 2018

Clinical Practice Guidelines for Clostridium difficile Infection in Adults and Children: 2017 Update by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA).

Clin Infect Dis 2018 03;66(7):987-994

Leeds Teaching Hospitals NHS Trust, United Kingdom.

A panel of experts was convened by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA) to update the 2010 clinical practice guideline on Clostridium difficile infection (CDI) in adults. The update, which has incorporated recommendations for children (following the adult recommendations for epidemiology, diagnosis, and treatment), includes significant changes in the management of this infection and reflects the evolving controversy over best methods for diagnosis. Clostridium difficile remains the most important cause of healthcare-associated diarrhea and has become the most commonly identified cause of healthcare-associated infection in adults in the United States. Moreover, C. difficile has established itself as an important community pathogen. Although the prevalence of the epidemic and virulent ribotype 027 strain has declined markedly along with overall CDI rates in parts of Europe, it remains one of the most commonly identified strains in the United States where it causes a sizable minority of CDIs, especially healthcare-associated CDIs. This guideline updates recommendations regarding epidemiology, diagnosis, treatment, infection prevention, and environmental management.
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http://dx.doi.org/10.1093/cid/ciy149DOI Listing
March 2018

Update: Noncongenital Zika Virus Disease Cases - 50 U.S. States and the District of Columbia, 2016.

MMWR Morb Mortal Wkly Rep 2018 Mar 9;67(9):265-269. Epub 2018 Mar 9.

Zika virus is a flavivirus primarily transmitted to humans by Aedes aegypti mosquitoes (1). Zika virus infections also have been documented through intrauterine transmission resulting in congenital infection; intrapartum transmission from a viremic mother to her newborn; sexual transmission; blood transfusion; and laboratory exposure (1-3). Most Zika virus infections are asymptomatic or result in mild clinical illness, characterized by acute onset of fever, maculopapular rash, arthralgia, or nonpurulent conjunctivitis; Guillain-Barré syndrome, meningoencephalitis, and severe thrombocytopenia rarely have been associated with Zika virus infection (1). However, congenital Zika virus infection can result in fetal loss, microcephaly, and other birth defects (1,2). In 2016, a total of 5,168 noncongenital Zika virus disease cases were reported from U.S. states and the District of Columbia. Most cases (4,897, 95%) were in travelers returning from Zika virus-affected areas. A total of 224 (4%) cases were acquired through presumed local mosquitoborne transmission, and 47 (1%) were acquired by other routes. It is important that providers in the United States continue to test symptomatic patients who live in or recently traveled to areas with ongoing Zika virus transmission or had unprotected sex with someone who lives in or traveled to those areas. All pregnant women and their partners should take measures to prevent Zika virus infection during pregnancy. A list of affected areas and specific recommendations on how to prevent Zika virus infection during pregnancy are available at https://www.cdc.gov/pregnancy/zika/protect-yourself.html.
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http://dx.doi.org/10.15585/mmwr.mm6709a1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5844284PMC
March 2018

Clinical Practice Guidelines for Clostridium difficile Infection in Adults and Children: 2017 Update by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA).

Clin Infect Dis 2018 03;66(7):e1-e48

Leeds Teaching Hospitals NHS Trust, United Kingdom.

A panel of experts was convened by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA) to update the 2010 clinical practice guideline on Clostridium difficile infection (CDI) in adults. The update, which has incorporated recommendations for children (following the adult recommendations for epidemiology, diagnosis, and treatment), includes significant changes in the management of this infection and reflects the evolving controversy over best methods for diagnosis. Clostridium difficile remains the most important cause of healthcare-associated diarrhea and has become the most commonly identified cause of healthcare-associated infection in adults in the United States. Moreover, C. difficile has established itself as an important community pathogen. Although the prevalence of the epidemic and virulent ribotype 027 strain has declined markedly along with overall CDI rates in parts of Europe, it remains one of the most commonly identified strains in the United States where it causes a sizable minority of CDIs, especially healthcare-associated CDIs. This guideline updates recommendations regarding epidemiology, diagnosis, treatment, infection prevention, and environmental management.
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http://dx.doi.org/10.1093/cid/cix1085DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6018983PMC
March 2018

Ability To Serologically Confirm Recent Zika Virus Infection in Areas with Varying Past Incidence of Dengue Virus Infection in the United States and U.S. Territories in 2016.

J Clin Microbiol 2018 01 26;56(1). Epub 2017 Dec 26.

Division of Vector-Borne Diseases, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Fort Collins, Colorado, USA.

Cross-reactivity within flavivirus antibody assays, produced by shared epitopes in the envelope proteins, can complicate the serological diagnosis of Zika virus (ZIKAV) infection. We assessed the utility of the plaque reduction neutralization test (PRNT) to confirm recent ZIKAV infections and rule out misleading positive immunoglobulin M (IgM) results in areas with various levels of past dengue virus (DENV) infection incidence. We reviewed PRNT results of sera collected for diagnosis of ZIKAV infection from 1 January through 31 August 2016 with positive ZIKAV IgM results, and ZIKAV and DENV PRNTs were performed. PRNT result interpretations included ZIKAV, unspecified flavivirus, DENV infection, or negative. For this analysis, ZIKAV IgM was considered false positive for samples interpreted as a DENV infection or negative. In U.S. states, 208 (27%) of 759 IgM-positive results were confirmed to be ZIKAV compared to 11 (21%) of 52 in the U.S. Virgin Islands (USVI), 15 (15%) of 103 in American Samoa, and 13 (11%) of 123 in Puerto Rico. In American Samoa and Puerto Rico, more than 80% of IgM-positive results were unspecified flavivirus infections. The false-positivity rate was 27% in U.S. states, 18% in the USVI, 2% in American Samoa, and 6% in Puerto Rico. In U.S. states, the PRNT provided a virus-specific diagnosis or ruled out infection in the majority of IgM-positive samples. Almost a third of ZIKAV IgM-positive results were not confirmed; therefore, providers and patients must understand that IgM results are preliminary. In territories with historically higher rates of DENV transmission, the PRNT usually could not differentiate between ZIKAV and DENV infections.
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http://dx.doi.org/10.1128/JCM.01115-17DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5744200PMC
January 2018

Pseudomonas aeruginosa Outbreak in a Neonatal Intensive Care Unit Attributed to Hospital Tap Water.

Infect Control Hosp Epidemiol 2017 07 18;38(7):801-808. Epub 2017 May 18.

3Division of Healthcare Quality Promotion,Centers for Disease Control and Prevention,Atlanta,Georgia.

OBJECTIVE To investigate an outbreak of Pseudomonas aeruginosa infections and colonization in a neonatal intensive care unit. DESIGN Infection control assessment, environmental evaluation, and case-control study. SETTING Newly built community-based hospital, 28-bed neonatal intensive care unit. PATIENTS Neonatal intensive care unit patients receiving care between June 1, 2013, and September 30, 2014. METHODS Case finding was performed through microbiology record review. Infection control observations, interviews, and environmental assessment were performed. A matched case-control study was conducted to identify risk factors for P. aeruginosa infection. Patient and environmental isolates were collected for pulsed-field gel electrophoresis to determine strain relatedness. RESULTS In total, 31 cases were identified. Case clusters were temporally associated with absence of point-of-use filters on faucets in patient rooms. After adjusting for gestational age, case patients were more likely to have been in a room without a point-of-use filter (odds ratio [OR], 37.55; 95% confidence interval [CI], 7.16-∞). Case patients had higher odds of exposure to peripherally inserted central catheters (OR, 7.20; 95% CI, 1.75-37.30) and invasive ventilation (OR, 5.79; 95% CI, 1.39-30.62). Of 42 environmental samples, 28 (67%) grew P. aeruginosa. Isolates from the 2 most recent case patients were indistinguishable by pulsed-field gel electrophoresis from water-related samples obtained from these case-patient rooms. CONCLUSIONS This outbreak was attributed to contaminated water. Interruption of the outbreak with point-of-use filters provided a short-term solution; however, eradication of P. aeruginosa in water and fixtures was necessary to protect patients. This outbreak highlights the importance of understanding the risks of stagnant water in healthcare facilities. Infect Control Hosp Epidemiol 2017;38:801-808.
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http://dx.doi.org/10.1017/ice.2017.87DOI Listing
July 2017

Establishing a Timeline to Discontinue Routine Testing of Asymptomatic Pregnant Women for Zika Virus Infection - American Samoa, 2016-2017.

MMWR Morb Mortal Wkly Rep 2017 Mar 24;66(11):299-301. Epub 2017 Mar 24.

The first patients with laboratory-confirmed cases of Zika virus disease in American Samoa had symptom onset in January 2016 (1). In response, the American Samoa Department of Health (ASDoH) implemented mosquito control measures (1), strategies to protect pregnant women (1), syndromic surveillance based on electronic health record (EHR) reports (1), Zika virus testing of persons with one or more signs or symptoms of Zika virus disease (fever, rash, arthralgia, or conjunctivitis) (1-3), and routine testing of all asymptomatic pregnant women in accordance with CDC guidance (2,3) All collected blood and urine specimens were shipped to the Hawaii Department of Health Laboratory for Zika virus testing and to CDC for confirmatory testing. Early in the response, collection and testing of specimens from pregnant women was prioritized over the collection from symptomatic nonpregnant patients because of limited testing and shipping capacity. The weekly numbers of suspected Zika virus disease cases declined from an average of six per week in January-February 2016 to one per week in May 2016. By August, the EHR-based syndromic surveillance (1) indicated a return to pre-outbreak levels. The last Zika virus disease case detected by real-time, reverse transcription-polymerase chain reaction (rRT-PCR) occurred in a patient who had symptom onset on June 19, 2016. In August 2016, ASDoH requested CDC support in assessing whether local transmission had been reduced or interrupted and in proposing a timeline for discontinuation of routine testing of asymptomatic pregnant women. An end date (October 15, 2016) was determined for active mosquito-borne transmission of Zika virus and a timeline was developed for discontinuation of routine screening of asymptomatic pregnant women in American Samoa (conception after December 10, 2016, with permissive testing for asymptomatic women who conceive through April 15, 2017).
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http://dx.doi.org/10.15585/mmwr.mm6611a5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5657887PMC
March 2017

Update: Interim Guidance for Preconception Counseling and Prevention of Sexual Transmission of Zika Virus for Persons with Possible Zika Virus Exposure - United States, September 2016.

MMWR Morb Mortal Wkly Rep 2016 Oct 7;65(39):1077-1081. Epub 2016 Oct 7.

Zika Response, CDC.

CDC has updated its interim guidance for persons with possible Zika virus exposure who are planning to conceive (1) and interim guidance to prevent transmission of Zika virus through sexual contact (2), now combined into a single document. Guidance for care for pregnant women with possible Zika virus exposure was previously published (3). Possible Zika virus exposure is defined as travel to or residence in an area of active Zika virus transmission (http://www.cdc.gov/zika/geo/index.html), or sex* without a condom with a partner who traveled to or lived in an area of active transmission. Based on new though limited data, CDC now recommends that all men with possible Zika virus exposure who are considering attempting conception with their partner, regardless of symptom status, wait to conceive until at least 6 months after symptom onset (if symptomatic) or last possible Zika virus exposure (if asymptomatic). Recommendations for women planning to conceive remain unchanged: women with possible Zika virus exposure are recommended to wait to conceive until at least 8 weeks after symptom onset (if symptomatic) or last possible Zika virus exposure (if asymptomatic). Couples with possible Zika virus exposure, who are not pregnant and do not plan to become pregnant, who want to minimize their risk for sexual transmission of Zika virus should use a condom or abstain from sex for the same periods for men and women described above. Women of reproductive age who have had or anticipate future Zika virus exposure who do not want to become pregnant should use the most effective contraceptive method that can be used correctly and consistently. These recommendations will be further updated when additional data become available.
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http://dx.doi.org/10.15585/mmwr.mm6539e1DOI Listing
October 2016

A Program to Prevent Catheter-Associated Urinary Tract Infection in Acute Care.

N Engl J Med 2016 Jun;374(22):2111-9

From the Hospital Outcomes Program of Excellence, Veterans Affairs (VA) Ann Arbor Healthcare System (S.S., M.T.G., S.L.K., D.R., K.E.F.), the Department of Internal Medicine, University of Michigan (UM) Medical School (S.S., M.T.G., S.L.K., M.A.M.R.), and the VA/UM Patient Safety Enhancement Program (S.S., M.T.G., S.L.K., M.A.M.R., D.R., K.E.F.), Ann Arbor, the Michigan Health and Hospital Association, Okemos (S.R.W., B.M.-L., M.M.), and St. John Hospital and Medical Center, Detroit (M.G.F.) - all in Michigan; the Health Research and Educational Trust, Chicago (B.S.E., K.F.); the Centers for Disease Control and Prevention, Atlanta (C.V.G.); and the Agency for Healthcare Research and Quality, Rockville, MD ( J.B.).

Background: Catheter-associated urinary tract infection (UTI) is a common device-associated infection in hospitals. Both technical factors--appropriate catheter use, aseptic insertion, and proper maintenance--and socioadaptive factors, such as cultural and behavioral changes in hospital units, are important in preventing catheter-associated UTI.

Methods: The national Comprehensive Unit-based Safety Program, funded by the Agency for Healthcare Research and Quality, aimed to reduce catheter-associated UTI in intensive care units (ICUs) and non-ICUs. The main program features were dissemination of information to sponsor organizations and hospitals, data collection, and guidance on key technical and socioadaptive factors in the prevention of catheter-associated UTI. Data on catheter use and catheter-associated UTI rates were collected during three phases: baseline (3 months), implementation (2 months), and sustainability (12 months). Multilevel negative binomial models were used to assess changes in catheter use and catheter-associated UTI rates.

Results: Data were obtained from 926 units (59.7% were non-ICUs, and 40.3% were ICUs) in 603 hospitals in 32 states, the District of Columbia, and Puerto Rico. The unadjusted catheter-associated UTI rate decreased overall from 2.82 to 2.19 infections per 1000 catheter-days. In an adjusted analysis, catheter-associated UTI rates decreased from 2.40 to 2.05 infections per 1000 catheter-days (incidence rate ratio, 0.86; 95% confidence interval [CI], 0.76 to 0.96; P=0.009). Among non-ICUs, catheter use decreased from 20.1% to 18.8% (incidence rate ratio, 0.93; 95% CI, 0.90 to 0.96; P<0.001) and catheter-associated UTI rates decreased from 2.28 to 1.54 infections per 1000 catheter-days (incidence rate ratio, 0.68; 95% CI, 0.56 to 0.82; P<0.001). Catheter use and catheter-associated UTI rates were largely unchanged in ICUs. Tests for heterogeneity (ICU vs. non-ICU) were significant for catheter use (P=0.004) and catheter-associated UTI rates (P=0.001).

Conclusions: A national prevention program appears to reduce catheter use and catheter-associated UTI rates in non-ICUs. (Funded by the Agency for Healthcare Research and Quality.).
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http://dx.doi.org/10.1056/NEJMoa1504906DOI Listing
June 2016

Beyond Infection: Device Utilization Ratio as a Performance Measure for Urinary Catheter Harm.

Infect Control Hosp Epidemiol 2016 Mar;37(3):327-33

8VA Ann Arbor Healthcare System,Ann Arbor,Michigan.

Catheter-associated urinary tract infection (CAUTI) is considered a reasonably preventable event in the hospital setting, and it has been included in the US Department of Health and Human Services National Action Plan to Prevent Healthcare-Associated Infections. While multiple definitions for measuring CAUTI exist, each has important limitations, and understanding these limitations is important to both clinical practice and policy decisions. The National Healthcare Safety Network (NHSN) surveillance definition, the most frequently used outcome measure for CAUTI prevention efforts, has limited clinical correlation and does not necessarily reflect noninfectious harms related to the catheter. We advocate use of the device utilization ratio (DUR) as an additional performance measure for potential urinary catheter harm. The DUR is patient-centered and objective and is currently captured as part of NHSN reporting. Furthermore, these data are readily obtainable from electronic medical records. The DUR also provides a more direct reflection of improvement efforts focused on reducing inappropriate urinary catheter use.
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http://dx.doi.org/10.1017/ice.2015.287DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6502466PMC
March 2016

Evaluation of a Novel Intervention to Reduce Unnecessary Urine Cultures in Intensive Care Units at a Tertiary Care Hospital in Maryland, 2011-2014.

Infect Control Hosp Epidemiol 2016 May 2;37(5):606-9. Epub 2016 Feb 2.

5University of Maryland School of Medicine,Baltimore,Maryland.

We assessed the impact of a reflex urine culture protocol, an intervention aimed to reduce unnecessary urine culturing, in intensive care units at a tertiary care hospital. Significant decreases in urine culturing rates and reported rates of catheter-associated urinary tract infection followed implementation of the protocol.
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http://dx.doi.org/10.1017/ice.2016.9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6557164PMC
May 2016

Necessary Infrastructure of Infection Prevention and Healthcare Epidemiology Programs: A Review.

Infect Control Hosp Epidemiol 2016 Apr 1;37(4):371-80. Epub 2016 Feb 1.

9University of Washington,Seattle,Washington.

The scope of a healthcare institution's infection prevention and control/healthcare epidemiology program (IPC/HE) should be driven by the size and complexity of the patient population served, that population's risk for healthcare-associated infection (HAI), and local, state, and national regulatory and accreditation requirements. Essential activities of all IPC/HE programs include but are not limited to the following: ∙ Surveillance.∙ Performance improvement to reduce HAI ∙ Acute event response, including outbreak investigation ∙ Education and training of both healthcare personnel and patients ∙ Reporting of HAI to the Centers for Disease Control and Prevention's National Healthcare Safety Network as well as entities required by law.
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http://dx.doi.org/10.1017/ice.2015.333DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6481289PMC
April 2016

Investigation of a cluster of Clostridium difficile infections in a pediatric oncology setting.

Am J Infect Control 2016 Feb 23;44(2):138-45. Epub 2015 Oct 23.

Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, GA.

Background: We investigated an increase in Clostridium difficile infection (CDI) among pediatric oncology patients.

Methods: CDI cases were defined as first C difficile positive stool tests between December 1, 2010, and September 6, 2012, in pediatric oncology patients receiving inpatient or outpatient care at a single hospital. A case-control study was performed to identify CDI risk factors, infection prevention and antimicrobial prescribing practices were assessed, and environmental sampling was conducted. Available isolates were strain-typed by pulsed-field gel electrophoresis.

Results: An increase in hospital-onset CDI cases was observed from June-August 2012. Independent risk factors for CDI included hospitalization in the bone marrow transplant ward and exposure to computerized tomography scanning or cefepime in the prior 12 weeks. Cefepime use increased beginning in late 2011, reflecting a practice change for patients with neutropenic fever. There were 13 distinct strain types among 22 available isolates. Hospital-onset CDI rates decreased to near-baseline levels with enhanced infection prevention measures, including environmental cleaning and prolonged contact isolation.

Conclusion: C difficile strain diversity associated with a cluster of CDI among pediatric oncology patients suggests a need for greater understanding of modes and sources of transmission and strategies to reduce patient susceptibility to CDI. Further research is needed on the risk of CDI with cefepime and its use as primary empirical treatment for neutropenic fever.
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http://dx.doi.org/10.1016/j.ajic.2015.09.004DOI Listing
February 2016

Reply to Jones et al.

Infect Control Hosp Epidemiol 2015 Dec;36(12):1477-8

Division of Healthcare Quality Promotion,Centers for Disease Control and Prevention,Atlanta,Georgia.

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http://dx.doi.org/10.1017/ice.2015.232DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6707375PMC
December 2015

Targeted Assessment for Prevention of Healthcare-Associated Infections: A New Prioritization Metric.

Infect Control Hosp Epidemiol 2015 Dec 27;36(12):1379-84. Epub 2015 Aug 27.

Division of Healthcare Quality Promotion,Centers for Disease Control and Prevention,Atlanta,Georgia.

Objective: To develop a method for calculating the number of healthcare-associated infections (HAIs) that must be prevented to reach a HAI reduction goal and identifying and prioritizing healthcare facilities where the largest reductions can be achieved.

Setting: Acute care hospitals that report HAI data to the Centers for Disease Control and Prevention's National Healthcare Safety Network. METHODS :The cumulative attributable difference (CAD) is calculated by subtracting a numerical prevention target from an observed number of HAIs. The prevention target is the product of the predicted number of HAIs and a standardized infection ratio goal, which represents a HAI reduction goal. The CAD is a numeric value that if positive is the number of infections to prevent to reach the HAI reduction goal. We calculated the CAD for catheter-associated urinary tract infections for each of the 3,639 hospitals that reported such data to National Healthcare Safety Network in 2013 and ranked the hospitals by their CAD values in descending order.

Results: Of 1,578 hospitals with positive CAD values, preventing 10,040 catheter-associated urinary tract infections at 293 hospitals (19%) with the highest CAD would enable achievement of the national 25% catheter-associated urinary tract infection reduction goal.

Conclusion: The CAD is a new metric that facilitates ranking of facilities, and locations within facilities, to prioritize HAI prevention efforts where the greatest impact can be achieved toward a HAI reduction goal.
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http://dx.doi.org/10.1017/ice.2015.201DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4658253PMC
December 2015

In pursuit of appropriate urinary catheter indications: details matter.

Authors:
Carolyn V Gould

Ann Intern Med 2015 May;162(9 Suppl):S35-6

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http://dx.doi.org/10.7326/M14-1610DOI Listing
May 2015

Causes, Burden, and Prevention of Infection.

Infect Dis Clin Pract (Baltim Md) 2015 May;23(6):281-288

Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, GA.

infection (CDI) is a potentially deadly cause of diarrhea that is virtually always connected to healthcare system exposures, both inpatient and outpatient. Once a disease mainly of hospitals, 75% of CDI cases are now diagnosed outside of hospitals. However, the diagnosis location may not reflect where spores were acquired or antibiotic exposure occurred. Changing epidemiology and increasing awareness about the role of every segment of the healthcare system in mediating this disease makes it clear that reducing its burden will also require active participation from all US healthcare professionals.
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http://dx.doi.org/10.1097/IPC.0000000000000331DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6488933PMC
May 2015

Outbreak of Clostridium difficile Infections at an Outpatient Hemodialysis Facility-Michigan, 2012-2013.

Infect Control Hosp Epidemiol 2015 Aug 27;36(8):972-4. Epub 2015 Apr 27.

2Division of Healthcare Quality Promotion,Centers for Disease Control and Prevention,Atlanta,Georgia.

Investigation of an outbreak of Clostridium difficile infection (CDI) at a hemodialysis facility revealed evidence that limited intrafacility transmission occurred despite adherence to published infection control standards for dialysis clinics. Outpatient dialysis facilities should consider CDI prevention, including environmental disinfection for C. difficile, when formulating their infection control plans.
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http://dx.doi.org/10.1017/ice.2015.90DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4697730PMC
August 2015
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