Publications by authors named "David T Kuhar"

27 Publications

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Impact of COVID-19 pandemic on central-line-associated bloodstream infections during the early months of 2020, National Healthcare Safety Network.

Infect Control Hosp Epidemiol 2021 Mar 15:1-4. Epub 2021 Mar 15.

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

Data reported to the Centers for Disease Control and Prevention's National Healthcare Safety Network (CDC NHSN) were analyzed to understand the potential impact of the COVID-19 pandemic on central-line-associated bloodstream infections (CLABSIs) in acute-care hospitals. Descriptive analysis of the standardized infection ratio (SIR) was conducted by location, location type, geographic area, and bed size.
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http://dx.doi.org/10.1017/ice.2021.108DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8047389PMC
March 2021

Gaps in infection prevention practices for catheter-associated urinary tract infections and central line-associated bloodstream infections as identified by the Targeted Assessment for Prevention Strategy.

Am J Infect Control 2021 07 22;49(7):874-878. Epub 2021 Jan 22.

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

Background: Catheter-associated urinary tract infections (CAUTI) and central line-associated bloodstream infections (CLABSI) represent a substantial portion of health care-associated infections (HAIs) reported in the United States. The Targeted Assessment for Prevention Strategy is a quality improvement framework to reduce health care-associated infections. Data from the Targeted Assessment for Prevention Facility Assessments were used to determine common infection prevention gaps for CAUTI and CLABSI.

Methods: Data from 2,044 CAUTI and 1,680 CLABSI assessments were included in the analysis. Items were defined as potential gaps if ≥33% respondents answered Unknown, ≥33% No, or ≥50% No or Unknown or Never, Rarely, Sometimes, or Unknown to questions pertaining to those areas. Review of response frequencies and stratification by respondent role were performed to highlight opportunities for improvement.

Results: Across CAUTI and CLABSI assessments, lack of physician champions (<35% Yes) and nurse champions (<55% Yes), along with lack of awareness of competency assessments, audits, and feedback were reported. Lack of practices to facilitate timely removal of urinary catheters were identified for CAUTI and issues with select device insertion practices, such as maintaining aseptic technique, were perceived as areas for improvement for CLABSI.

Conclusions: These data suggest common gaps in critical components of infection prevention and control programs. The identification of these gaps has the potential to inform targeted CAUTI and CLABSI prevention efforts.
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http://dx.doi.org/10.1016/j.ajic.2021.01.014DOI Listing
July 2021

Update: Characteristics of Health Care Personnel with COVID-19 - United States, February 12-July 16, 2020.

MMWR Morb Mortal Wkly Rep 2020 Sep 25;69(38):1364-1368. Epub 2020 Sep 25.

As of September 21, 2020, the coronavirus disease 2019 (COVID-19) pandemic had resulted in 6,786,352 cases and 199,024 deaths in the United States.* Health care personnel (HCP) are essential workers at risk for exposure to patients or infectious materials (1). The impact of COVID-19 on U.S. HCP was first described using national case surveillance data in April 2020 (2). Since then, the number of reported HCP with COVID-19 has increased tenfold. This update describes demographic characteristics, underlying medical conditions, hospitalizations, and intensive care unit (ICU) admissions, stratified by vital status, among 100,570 HCP with COVID-19 reported to CDC during February 12-July 16, 2020. HCP occupation type and job setting are newly reported. HCP status was available for 571,708 (22%) of 2,633,585 cases reported to CDC. Most HCP with COVID-19 were female (79%), aged 16-44 years (57%), not hospitalized (92%), and lacked all 10 underlying medical conditions specified on the case report form (56%). Of HCP with COVID-19, 641 died. Compared with nonfatal COVID-19 HCP cases, a higher percentage of fatal cases occurred in males (38% versus 22%), persons aged ≥65 years (44% versus 4%), non-Hispanic Asians (Asians) (20% versus 9%), non-Hispanic Blacks (Blacks) (32% versus 25%), and persons with any of the 10 underlying medical conditions specified on the case report form (92% versus 41%). From a subset of jurisdictions reporting occupation type or job setting for HCP with COVID-19, nurses were the most frequently identified single occupation type (30%), and nursing and residential care facilities were the most common job setting (67%). Ensuring access to personal protective equipment (PPE) and training, and practices such as universal use of face masks at work, wearing masks in the community, and observing social distancing remain critical strategies to protect HCP and those they serve.
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http://dx.doi.org/10.15585/mmwr.mm6938a3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7727493PMC
September 2020

Strategies for Optimizing the Supply of N95 Filtering Facepiece Respirators During the Coronavirus Disease 2019 (COVID-19) Pandemic.

Disaster Med Public Health Prep 2020 10 19;14(5):658-669. Epub 2020 May 19.

National Personal Protective Technology Laboratory, National Institute for Occupational Safety and Health, Centers for Disease Control and Prevention, Pittsburgh, PA.

N95 respirators are personal protective equipment most often used to control exposures to infections transmitted via the airborne route. Supplies of N95 respirators can become depleted during pandemics or when otherwise in high demand. In this paper, we offer strategies for optimizing supplies of N95 respirators in health care settings while maximizing the level of protection offered to health care personnel when there is limited supply in the United States during the 2019 coronavirus disease pandemic. The strategies are intended for use by professionals who manage respiratory protection programs, occupational health services, and infection prevention programs in health care facilities to protect health care personnel from job-related risks of exposure to infectious respiratory illnesses. Consultation with federal, state, and local public health officials is also important. We use the framework of surge capacity and the occupational health and safety hierarchy of controls approach to discuss specific engineering control, administrative control, and personal protective equipment measures that may help in optimizing N95 respirator supplies.
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http://dx.doi.org/10.1017/dmp.2020.160DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7303467PMC
October 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

Reported variability in healthcare facility policies regarding healthcare personnel working while experiencing influenza-like illnesses: An emerging infections network survey.

Infect Control Hosp Epidemiol 2020 01 14;41(1):80-85. Epub 2019 Nov 14.

University of Iowa Carver College of Medicine, Iowa City, Iowa.

Background: Presenteeism, or working while ill, by healthcare personnel (HCP) experiencing influenza-like illness (ILI) puts patients and coworkers at risk. However, hospital policies and practices may not consistently facilitate HCP staying home when ill.

Objective And Methods: We conducted a mixed-methods survey in March 2018 of Emerging Infections Network infectious diseases physicians, describing institutional experiences with and policies for HCP working with ILI.

Results: Of 715 physicians, 367 (51%) responded. Of 367, 135 (37%) were unaware of institutional policies. Of the remaining 232 respondents, 206 (89%) reported institutional policies regarding work restrictions for HCP with influenza or ILI, but only 145 (63%) said these were communicated at least annually. More than half of respondents (124, 53%) reported that adherence to work restrictions was not monitored or enforced. Work restrictions were most often not perceived to be enforced for physicians-in-training and attending physicians. Nearly all (223, 96%) reported that their facility tracked laboratory-confirmed influenza (LCI) in patients; 85 (37%) reported tracking ILI. For employees, 109 (47%) reported tracking of LCI and 53 (23%) reported tracking ILI. For independent physicians, not employed by the facility, 30 (13%) reported tracking LCI and 11 (5%) ILI.

Conclusion: More than one-third of respondents were unaware of whether their institutions had policies to prevent HCP with ILI from working; among those with knowledge of institutional policies, dissemination, monitoring, and enforcement of these policies was highly variable. Improving communication about work-restriction policies, as well as monitoring and enforcement, may help prevent the spread of infections from HCP to patients.
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http://dx.doi.org/10.1017/ice.2019.305DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7018563PMC
January 2020

An Introduction to STRIVE.

Ann Intern Med 2019 10;171(7_Suppl):S1

Centers for Disease Control and Prevention, Atlanta, Georgia (M.R.B., D.T.K.).

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http://dx.doi.org/10.7326/M18-3440DOI Listing
October 2019

Improving the Use of Personal Protective Equipment: Applying Lessons Learned.

Clin Infect Dis 2019 Sep;69(Suppl 3):S165-S170

Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia.

Unrecognized transmission of pathogens in healthcare settings can lead to colonization and infection of both patients and healthcare personnel. The use of personal protective equipment (PPE) is an important strategy to protect healthcare personnel from contamination and to prevent the spread of pathogens to subsequent patients. However, optimal PPE use is difficult, and healthcare personnel may alter delivery of care because of the PPE. Here, we summarize recent research from the Prevention Epicenters Program on healthcare personnel contamination and improvement of the routine use of PPE as well as Ebola-specific PPE. Future efforts to optimize the use of PPE should include increasing adherence to protocols for PPE use, improving PPE design, and further research into the risks, benefits, and best practices of PPE use.
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http://dx.doi.org/10.1093/cid/ciz619DOI Listing
September 2019

A national survey of testing and management of asymptomatic carriage of C. difficile.

Infect Control Hosp Epidemiol 2019 07 20;40(7):801-803. Epub 2019 May 20.

Infectious Disease Society of America Emerging Infections Network,Arlington,Virginia.

A nationwide survey indicated that screening for asymptomatic carriers of C. difficile is an uncommon practice in US healthcare settings. Better understanding of the role of asymptomatic carriage in C. difficile transmission, and of the measures available to reduce that risk, are needed to inform best practices regarding the management of carriers.
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http://dx.doi.org/10.1017/ice.2019.109DOI Listing
July 2019

Tuberculosis Screening, Testing, and Treatment of U.S. Health Care Personnel: Recommendations from the National Tuberculosis Controllers Association and CDC, 2019.

MMWR Morb Mortal Wkly Rep 2019 May 17;68(19):439-443. Epub 2019 May 17.

The 2005 CDC guidelines for preventing Mycobacterium tuberculosis transmission in health care settings include recommendations for baseline tuberculosis (TB) screening of all U.S. health care personnel and annual testing for health care personnel working in medium-risk settings or settings with potential for ongoing transmission (1). Using evidence from a systematic review conducted by a National Tuberculosis Controllers Association (NTCA)-CDC work group, and following methods adapted from the Guide to Community Preventive Services (2,3), the 2005 CDC recommendations for testing U.S. health care personnel have been updated and now include 1) TB screening with an individual risk assessment and symptom evaluation at baseline (preplacement); 2) TB testing with an interferon-gamma release assay (IGRA) or a tuberculin skin test (TST) for persons without documented prior TB disease or latent TB infection (LTBI); 3) no routine serial TB testing at any interval after baseline in the absence of a known exposure or ongoing transmission; 4) encouragement of treatment for all health care personnel with untreated LTBI, unless treatment is contraindicated; 5) annual symptom screening for health care personnel with untreated LTBI; and 6) annual TB education of all health care personnel.
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http://dx.doi.org/10.15585/mmwr.mm6819a3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6522077PMC
May 2019

Opportunities to bridge gaps between respiratory protection guidance and practice in US health care.

Infect Control Hosp Epidemiol 2019 04 18;40(4):476-481. Epub 2019 Feb 18.

National Personal Protective Technology Laboratory (NPPTL),National Institute for Occupational Safety Health (NIOSH),Pittsburgh,Pennsylvania.

Healthcare organizations are required to provide workers with respiratory protection (RP) to mitigate hazardous airborne inhalation exposures. This study sought to better identify gaps that exist between RP guidance and clinical practice to understand issues that would benefit from additional research or clarification.
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http://dx.doi.org/10.1017/ice.2018.361DOI Listing
April 2019

Transmission of Hepatitis A Virus through Combined Liver-Small Intestine-Pancreas Transplantation.

Emerg Infect Dis 2017 04;23(4):590-596

Although transmission of hepatitis A virus (HAV) through blood transfusion has been documented, transmission through organ transplantation has not been reported. In August 2015, state health officials in Texas, USA, were notified of 2 home health nurses with HAV infection whose only common exposure was a child who had undergone multi-visceral organ transplantation 9 months earlier. Specimens from the nurses, organ donor, and all organ recipients were tested and medical records reviewed to determine a possible infection source. Identical HAV RNA sequences were detected from the serum of both nurses and the organ donor, as well as from the multi-visceral organ recipient's serum and feces; this recipient's posttransplant liver and intestine biopsy specimens also had detectable virus. The other organ recipients tested negative for HAV RNA. Vaccination of the donor might have prevented infection in the recipient and subsequent transmission to the healthcare workers.
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http://dx.doi.org/10.3201/eid2304.161532DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5367420PMC
April 2017

Early Identification and Prevention of the Spread of Ebola - United States.

MMWR Suppl 2016 Jul 8;65(3):75-84. Epub 2016 Jul 8.

Division of Bacterial Diseases, National Center for Immunization and Respiratory Diseases, CDC.

In response to the 2014-2016 Ebola virus disease (Ebola) epidemic in West Africa, CDC prepared for the potential introduction of Ebola into the United States. The immediate goals were to rapidly identify and isolate any cases of Ebola, prevent transmission, and promote timely treatment of affected patients. CDC's technical expertise and the collaboration of multiple partners in state, local, and municipal public health departments; health care facilities; emergency medical services; and U.S. government agencies were essential to the domestic preparedness and response to the Ebola epidemic and relied on longstanding partnerships. CDC established a comprehensive response that included two new strategies: 1) active monitoring of travelers arriving from countries affected by Ebola and other persons at risk for Ebola and 2) a tiered system of hospital facility preparedness that enabled prioritization of training. CDC rapidly deployed a diagnostic assay for Ebola virus (EBOV) to public health laboratories. Guidance was developed to assist in evaluation of patients possibly infected with EBOV, for appropriate infection control, to support emergency responders, and for handling of infectious waste. CDC rapid response teams were formed to provide assistance within 24 hours to a health care facility managing a patient with Ebola. As a result of the collaborations to rapidly identify, isolate, and manage Ebola patients and the extensive preparations to prevent spread of EBOV, the United States is now better prepared to address the next global infectious disease threat.The activities summarized in this report would not have been possible without collaboration with many U.S. and international partners (http://www.cdc.gov/vhf/ebola/outbreaks/2014-west-africa/partners.html).
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http://dx.doi.org/10.15585/mmwr.su6503a11DOI Listing
July 2016

Notes from the Field: Health Care-Associated Hepatitis A Outbreak - Texas, 2015.

MMWR Morb Mortal Wkly Rep 2016 Apr 29;65(16):425-6. Epub 2016 Apr 29.

On August 27-28, 2015, the Texas Department of State Health Services received calls from Fort Bend County and Harris County health departments requesting postexposure prophylaxis (PEP) recommendations for contacts of two nurses (patients A and B) with confirmed hepatitis A virus (HAV) infection. Both nurses had symptom onset during August 15-19 and worked for the same pediatric home health care agency in another jurisdiction. Because of the proximity of the onset dates, a common source exposure was suspected. The state and local health departments began an investigation to identify potentially exposed patients, their families, and other agency personnel; offer PEP; and identify the source of exposure.
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http://dx.doi.org/10.15585/mmwr.mm6516a5DOI Listing
April 2016

Active Tracing and Monitoring of Contacts Associated With the First Cluster of Ebola in the United States.

Ann Intern Med 2015 Aug;163(3):164-73

Background: Following hospitalization of the first patient with Ebola virus disease diagnosed in the United States on 28 September 2014, contact tracing methods for Ebola were implemented.

Objective: To identify, risk-stratify, and monitor contacts of patients with Ebola.

Design: Descriptive investigation.

Setting: Dallas County, Texas, September to November 2014.

Participants: Contacts of symptomatic patients with Ebola.

Measurements: Contact identification, exposure risk classification, symptom development, and Ebola.

Results: The investigation identified 179 contacts, 139 of whom were contacts of the index patient. Of 112 health care personnel (HCP) contacts of the index case, 22 (20%) had known unprotected exposures and 37 (30%) did not have known unprotected exposures but interacted with a patient or contaminated environment on multiple days. Transmission was confirmed in 2 HCP who had substantial interaction with the patient while wearing personal protective equipment. These HCP had 40 additional contacts. Of 20 community contacts of the index patient or the 2 HCP, 4 had high-risk exposures. Movement restrictions were extended to all 179 contacts; 7 contacts were quarantined. Seven percent (14 of 179) of contacts (1 community contact and 13 health care contacts) were evaluated for Ebola during the monitoring period.

Limitation: Data cannot be used to infer whether in-person direct active monitoring is superior to active monitoring alone for early detection of symptomatic contacts.

Conclusion: Contact tracing and monitoring approaches for Ebola were adapted to account for the evolving understanding of risks for unrecognized HCP transmission. HCP contacts in the United States without known unprotected exposures should be considered as having a low (but not zero) risk for Ebola and should be actively monitored for symptoms. Core challenges of contact tracing for high-consequence communicable diseases included rapid comprehensive contact identification, large-scale direct active monitoring of contacts, large-scale application of movement restrictions, and necessity of humanitarian support services to meet nonclinical needs of contacts.

Primary Funding Source: None.
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http://dx.doi.org/10.7326/M15-0968DOI Listing
August 2015

Measles in Healthcare Facilities in the United States During the Postelimination Era, 2001-2014.

Clin Infect Dis 2015 Aug 15;61(4):615-8. Epub 2015 May 15.

Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia.

Between 2001 and 2014, 78 reported measles cases resulted from transmission in US healthcare facilities, and 29 healthcare personnel were infected from occupational exposure, 1 of whom transmitted measles to a patient. The economic impact of preventing and controlling measles transmission in healthcare facilities was $19 000-$114 286 per case.
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http://dx.doi.org/10.1093/cid/civ387DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4646220PMC
August 2015

Health care worker contact with MERS patient, Saudi Arabia.

Emerg Infect Dis 2014 Dec;20(12):2148-51

To investigate potential transmission of Middle East respiratory syndrome coronavirus (MERS-CoV) to health care workers in a hospital, we serologically tested hospital contacts of the index case-patient in Saudi Arabia, 4 months after his death. None of the 48 contacts showed evidence of MERS-CoV infection.
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http://dx.doi.org/10.3201/eid2012.141211DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4257796PMC
December 2014

Hospital-associated outbreak of Middle East respiratory syndrome coronavirus: a serologic, epidemiologic, and clinical description.

Clin Infect Dis 2014 Nov 14;59(9):1225-33. Epub 2014 May 14.

Division of Viral Diseases, National Center for Immunization and Respiratory Diseases.

Background: In April 2012, the Jordan Ministry of Health investigated an outbreak of lower respiratory illnesses at a hospital in Jordan; 2 fatal cases were retrospectively confirmed by real-time reverse transcription polymerase chain reaction (rRT-PCR) to be the first detected cases of Middle East respiratory syndrome (MERS-CoV).

Methods: Epidemiologic and clinical characteristics of selected potential cases were assessed through serum blood specimens, medical record reviews, and interviews with surviving outbreak members, household contacts, and healthcare personnel. Cases of MERS-CoV infection were identified using 3 US Centers for Disease Control and Prevention serologic tests for detection of anti-MERS-CoV antibodies.

Results: Specimens and interviews were obtained from 124 subjects. Seven previously unconfirmed individuals tested positive for anti-MERS-CoV antibodies by at least 2 of 3 serologic tests, in addition to 2 fatal cases identified by rRT-PCR. The case-fatality rate among the 9 total cases was 22%. Six subjects were healthcare workers at the outbreak hospital, yielding an attack rate of 10% among potentially exposed outbreak hospital personnel. There was no evidence of MERS-CoV transmission at 2 transfer hospitals having acceptable infection control practices.

Conclusions: Novel serologic tests allowed for the detection of otherwise unrecognized cases of MERS-CoV infection among contacts in a Jordanian hospital-associated respiratory illness outbreak in April 2012, resulting in a total of 9 test-positive cases. Serologic results suggest that further spread of this outbreak to transfer hospitals did not occur. Most subjects had no major, underlying medical conditions; none were on hemodialysis. Our observed case-fatality rate was lower than has been reported from outbreaks elsewhere.
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http://dx.doi.org/10.1093/cid/ciu359DOI Listing
November 2014

First confirmed cases of Middle East respiratory syndrome coronavirus (MERS-CoV) infection in the United States, updated information on the epidemiology of MERS-CoV infection, and guidance for the public, clinicians, and public health authorities - May 2014.

MMWR Morb Mortal Wkly Rep 2014 May;63(19):431-6

Since mid-March 2014, the frequency with which cases of Middle East respiratory syndrome coronavirus (MERS-CoV) infection have been reported has increased, with the majority of recent cases reported from Saudi Arabia and United Arab Emirates (UAE). In addition, the frequency with which travel-associated MERS cases have been reported and the number of countries that have reported them to the World Health Organization (WHO) have also increased. The first case of MERS in the United States, identified in a traveler recently returned from Saudi Arabia, was reported to CDC by the Indiana State Department of Health on May 1, 2014, and confirmed by CDC on May 2. A second imported case of MERS in the United States, identified in a traveler from Saudi Arabia having no connection with the first case, was reported to CDC by the Florida Department of Health on May 11, 2014. The purpose of this report is to alert clinicians, health officials, and others to increase awareness of the need to consider MERS-CoV infection in persons who have recently traveled from countries in or near the Arabian Peninsula. This report summarizes recent epidemiologic information, provides preliminary descriptions of the cases reported from Indiana and Florida, and updates CDC guidance about patient evaluation, home care and isolation, specimen collection, and travel as of May 13, 2014.
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May 2014

Outbreak of Serratia marcescens bloodstream infections in patients receiving parenteral nutrition prepared by a compounding pharmacy.

Clin Infect Dis 2014 Jul 11;59(1):1-8. Epub 2014 Apr 11.

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

Background: Compounding pharmacies often prepare parenteral nutrition (PN) and must adhere to rigorous standards to avoid contamination of the sterile preparation. In March 2011, Serratia marcescens bloodstream infections (BSIs) were identified in 5 patients receiving PN from a single compounding pharmacy. An investigation was conducted to identify potential sources of contamination and prevent further infections.

Methods: Cases were defined as S. marcescens BSIs in patients receiving PN from the pharmacy between January and March 2011. We reviewed case patients' clinical records, evaluated pharmacy compounding practices, and obtained epidemiologically directed environmental cultures. Molecular relatedness of available Serratia isolates was determined by pulsed-field gel electrophoresis (PFGE).

Results: Nineteen case patients were identified; 9 died. The attack rate for patients receiving PN in March was 35%. No case patients were younger than 18 years. In October 2010, the pharmacy began compounding and filter-sterilizing amino acid solution for adult PN using nonsterile amino acids due to a national manufacturer shortage. Review of this process identified breaches in mixing, filtration, and sterility testing practices. S. marcescens was identified from a pharmacy water faucet, mixing container, and opened amino acid powder. These isolates were indistinguishable from the outbreak strain by PFGE.

Conclusions: Compounding of nonsterile amino acid components of PN was initiated due to a manufacturer shortage. Failure to follow recommended compounding standards contributed to an outbreak of S. marcescens BSIs. Improved adherence to sterile compounding standards, critical examination of standards for sterile compounding from nonsterile ingredients, and more rigorous oversight of compounding pharmacies is needed to prevent future outbreaks.
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http://dx.doi.org/10.1093/cid/ciu218DOI Listing
July 2014

Reply to Tan et al.

Infect Control Hosp Epidemiol 2014 Mar;35(3):328-9

Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia.

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http://dx.doi.org/10.1086/675350DOI Listing
March 2014

Updated US Public Health Service guidelines for the management of occupational exposures to human immunodeficiency virus and recommendations for postexposure prophylaxis.

Infect Control Hosp Epidemiol 2013 Sep;34(9):875-92

Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia 30333, USA.

This report updates US Public Health Service recommendations for the management of healthcare personnel (HCP) who experience occupational exposure to blood and/or other body fluids that might contain human immunodeficiency virus (HIV). Although the principles of exposure management remain unchanged, recommended HIV postexposure prophylaxis (PEP) regimens and the duration of HIV follow-up testing for exposed personnel have been updated. This report emphasizes the importance of primary prevention strategies, the prompt reporting and management of occupational exposures, adherence to recommended HIV PEP regimens when indicated for an exposure, expert consultation in management of exposures, follow-up of exposed HCP to improve adherence to PEP, and careful monitoring for adverse events related to treatment, as well as for virologic, immunologic, and serologic signs of infection. To ensure timely postexposure management and administration of HIV PEP, clinicians should consider occupational exposures as urgent medical concerns, and institutions should take steps to ensure that staff are aware of both the importance of and the institutional mechanisms available for reporting and seeking care for such exposures. The following is a summary of recommendations: (1) PEP is recommended when occupational exposures to HIV occur; (2) the HIV status of the exposure source patient should be determined, if possible, to guide need for HIV PEP; (3) PEP medication regimens should be started as soon as possible after occupational exposure to HIV, and they should be continued for a 4-week duration; (4) new recommendation-PEP medication regimens should contain 3 (or more) antiretroviral drugs (listed in Appendix A ) for all occupational exposures to HIV; (5) expert consultation is recommended for any occupational exposures to HIV and at a minimum for situations described in Box 1 ; (6) close follow-up for exposed personnel ( Box 2 ) should be provided that includes counseling, baseline and follow-up HIV testing, and monitoring for drug toxicity; follow-up appointments should begin within 72 hours of an HIV exposure; and (7) new recommendation-if a newer fourth-generation combination HIV p24 antigen-HIV antibody test is utilized for follow-up HIV testing of exposed HCP, HIV testing may be concluded 4 months after exposure ( Box 2 ); if a newer testing platform is not available, follow-up HIV testing is typically concluded 6 months after an HIV exposure.
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http://dx.doi.org/10.1086/672271DOI Listing
September 2013

Assessment of management policies and practices for occupational exposure to bloodborne pathogens in dialysis facilities.

Am J Kidney Dis 2012 Oct 26;60(4):617-25. Epub 2012 Jun 26.

Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, GA 30333, USA.

Background: Occupational exposure management is an important element in preventing the transmission of bloodborne pathogens in health care settings. In 2008, the US Centers for Disease Control and Prevention conducted a survey to assess procedures for managing occupational bloodborne pathogen exposures in outpatient dialysis facilities in the United States.

Study Design: A cross-sectional survey of randomly selected outpatient dialysis facilities.

Setting & Participants: 339 outpatient dialysis facilities drawn from the 2006 US end-stage renal disease database.

Predictors: Hospital affiliation (free-standing vs hospital-based facilities), profit status (for-profit vs not-for-profit facilities), and number of health care personnel (≥100 vs <100 health care personnel).

Outcomes: Exposures to hepatitis B virus (HBV), hepatitis C virus (HCV), and human immunodeficiency virus (HIV); provision of HBV and HIV postexposure prophylaxis.

Measurements: We calculated the proportion of facilities reporting occupational bloodborne pathogen exposures and offering occupational exposure management services. We analyzed bloodborne pathogen exposures and provision of postexposure prophylaxis by facility type.

Results: Nearly all respondents (99.7%) had written policies and 95% provided occupational exposure management services to health care personnel during the daytime on weekdays, but services were provided infrequently during other periods of the week. Approximately 10%-15% of facilities reported having HIV, HBV, or HCV exposures in health care personnel in the 12 months prior to the survey, but inconsistencies were noted in procedures for managing such exposures. Despite 86% of facilities providing HIV prophylaxis for exposed health care personnel, only 37% designated a primary HIV postexposure prophylaxis regimen. For-profit and free-standing facilities reported fewer exposures, but did not as reliably offer HBV prophylaxis or have a primary HIV postexposure prophylaxis regimen relative to not-for-profit and hospital-based facilities.

Limitations: The survey response rate was low (37%) and familiarity of individuals completing the survey with facility policies or national guidelines could not be ascertained.

Conclusions: Significant improvements are required in the implementation of guidelines for managing occupational exposures to bloodborne pathogens in outpatient dialysis facilities.
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http://dx.doi.org/10.1053/j.ajkd.2012.05.013DOI Listing
October 2012

Pandemic (H1N1) 2009 and HIV co-infection.

Emerg Infect Dis 2011 Feb;17(2):328; author reply 328

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http://dx.doi.org/10.3201/eid1702.101866DOI Listing
February 2011
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