Publications by authors named "Mary Elizabeth Sexton"

14 Publications

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Clinical characteristics and outcomes of toxoplasmosis among transplant recipients at two US academic medical centers.

Transpl Infect Dis 2021 May 15:e13636. Epub 2021 May 15.

Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA.

Toxoplasma gondii can cause severe opportunistic infection in immunocompromised individuals, but diagnosis is often delayed. We conducted a retrospective review of solid organ transplant (SOT) and hematopoietic stem cell transplant (HSCT) recipients with toxoplasmosis between 2002 and 2018 at two large US academic transplant centers. Patients were identified by ICD-9 or ICD-10 toxoplasmosis codes, positive Toxoplasma polymerase chain reaction test result, or pathologic diagnosis. Data were collected regarding transplant type, time from transplant to toxoplasmosis diagnosis, clinical and radiographic features, and mortality at 30 and 90 days. Twenty patients were identified: 10 HSCT recipients (80% allogeneic HSCT) and 10 SOT recipients (60% deceased donor renal transplants). Rejection among SOT recipients (70%) and graft-versus-host disease (GVHD) prophylaxis among HSCT recipients (50%) were frequent. Median time from transplant to toxoplasmosis diagnosis was longer for SOT than HSCT (1385 vs. 5 days, P-value .002). Clinical manifestations most commonly were encephalitis (65%), respiratory failure (40%), renal failure (40%), and distributive shock (40%). Cohort 30-day mortality was 45%, and 90-day mortality was 55%. Diagnosis was postmortem in 25% of the cohort. Further evaluation of toxoplasmosis screening is needed for noncardiac SOT recipients, HSCT recipients with GVHD, and periods of increased net immunosuppression.
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http://dx.doi.org/10.1111/tid.13636DOI Listing
May 2021

Immediate reactions following the first dose of the SARS-CoV2 mRNA vaccines do not preclude second dose administration.

Clin Infect Dis 2021 May 14. Epub 2021 May 14.

Division of Pulmonary, Allergy and Critical Care, Emory University School of Medicine, Atlanta, Georgia, U.S.A.

Addressing COVID19 vaccine hesitancy and minimizing potential vaccine contraindications are critical to combat the ongoing pandemic. We describe a practical approach to immediate adverse events after the first dose of the SARS-CoV2 mRNA vaccines, focusing on allergic reactions with respect to their diagnosis and management.
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http://dx.doi.org/10.1093/cid/ciab448DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8194535PMC
May 2021

Carbapenem-resistant Enterobacterales bacteriuria and subsequent bacteremia: A population-based study.

Infect Control Hosp Epidemiol 2020 Dec 10:1-6. Epub 2020 Dec 10.

Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia.

Objective: To describe the epidemiology of carbapenem-resistant Enterobacterales (CRE) bacteriuria and to determine whether urinary catheters increase the risk of subsequent CRE bacteremia.

Design: Using active population- and laboratory-based surveillance we described a cohort of patients with incident CRE bacteriuria and identified risk factors for developing CRE bacteremia within 1 year.

Setting: The study was conducted among the 8 counties of Georgia Health District 3 (HD3) in Atlanta, Georgia.

Patients: Residents of HD3 with CRE first identified in urine between 2012 and 2017.

Results: We identified 464 patients with CRE bacteriuria (mean yearly incidence, 1.96 cases per 100,000 population). Of 425 with chart review, most had a urinary catheter (56%), and many resided in long-term care facilities (48%), had a Charlson comorbidity index >3 (38%) or a decubitus ulcer (37%). 21 patients (5%) developed CRE bacteremia with the same organism within 1 year. Risk factors for subsequent bacteremia included presence of a urinary catheter (odds ratio [OR], 8.0; 95% confidence interval [CI], 1.8-34.9), central venous catheter (OR, 4.3; 95% CI, 1.7-10.6) or another indwelling device (OR, 4.3; 95% CI, 1.6-11.4), urine culture obtained as an inpatient (OR, 5.7; 95% CI, 1.3-25.9), and being in the ICU in the week prior to urine culture (OR, 2.9; 95% CI, 1.1-7.8). In a multivariable analysis, urinary catheter increased the risk of CRE bacteremia (OR, 5.3; 95% CI, 1.2-23.6).

Conclusions: In patients with CRE bacteriuria, urinary catheters increase the risk of CRE bacteremia. Future interventions should aim to reduce inappropriate insertion and early removal of urinary catheters.
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http://dx.doi.org/10.1017/ice.2020.1325DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8190175PMC
December 2020

Novel approach to deployment of crisis situation supply of N95 respirator models in a healthcare system.

Am J Infect Control 2021 04 5;49(4):500-502. Epub 2020 Nov 5.

Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, GA.

Given supply constraints of N95s in the United States during the COVID-19 pandemic, healthcare facilities have turned to extended use protocols and new sources of N95s. Because fit testing every employee for every new mask is not feasible, our Infection Prevention Department developed a method for rapid deployment of new N95s.
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http://dx.doi.org/10.1016/j.ajic.2020.11.001DOI Listing
April 2021

Serosurvey on healthcare personnel caring for patients with Ebola virus disease and Lassa virus in the United States.

Infect Control Hosp Epidemiol 2020 04 20;41(4):385-390. Epub 2020 Jan 20.

Division of Infectious Diseases, Department of Medicine, School of Medicine, Emory University, Atlanta, Georgia.

Objective: Healthcare personnel (HCP) were recruited to provide serum samples, which were tested for antibodies against Ebola or Lassa virus to evaluate for asymptomatic seroconversion.

Setting: From 2014 to 2016, 4 patients with Ebola virus disease (EVD) and 1 patient with Lassa fever (LF) were treated in the Serious Communicable Diseases Unit (SCDU) at Emory University Hospital. Strict infection control and clinical biosafety practices were implemented to prevent nosocomial transmission of EVD or LF to HCP.

Participants: All personnel who entered the SCDU who were required to measure their temperatures and complete a symptom questionnaire twice daily were eligible.

Results: No employee developed symptomatic EVD or LF. EVD and LF antibody studies were performed on sera samples from 42 HCP. The 6 participants who had received investigational vaccination with a chimpanzee adenovirus type 3 vectored Ebola glycoprotein vaccine had high antibody titers to Ebola glycoprotein, but none had a response to Ebola nucleoprotein or VP40, or a response to LF antigens.

Conclusions: Patients infected with filoviruses and arenaviruses can be managed successfully without causing occupation-related symptomatic or asymptomatic infections. Meticulous attention to infection control and clinical biosafety practices by highly motivated, trained staff is critical to the safe care of patients with an infection from a special pathogen.
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http://dx.doi.org/10.1017/ice.2019.349DOI Listing
April 2020

Approach to Cataract Surgery in an Ebola Virus Disease Survivor with Prior Ocular Viral Persistence.

Emerg Infect Dis 2020 07;26(7):1553-1556

A 46-year-old patient with previously documented Ebola virus persistence in his ocular fluid, associated with severe panuveitis, developed a visually significant cataract. A multidisciplinary approach was taken to prevent and control infection. Ebola virus persistence was assessed before and during the operation to provide safe, vision-restorative phacoemulsification surgery.
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http://dx.doi.org/10.3201/eid2607.191559DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7323527PMC
July 2020

The impact of an electronic medical record nudge on reducing testing for hospital-onset infection.

Infect Control Hosp Epidemiol 2020 04 10;41(4):411-417. Epub 2020 Feb 10.

Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia.

Objective: To determine the effect of an electronic medical record (EMR) nudge at reducing total and inappropriate orders testing for hospital-onset Clostridioides difficile infection (HO-CDI).

Design: An interrupted time series analysis of HO-CDI orders 2 years before and 2 years after the implementation of an EMR intervention designed to reduce inappropriate HO-CDI testing. Orders for C. difficile testing were considered inappropriate if the patient had received a laxative or stool softener in the previous 24 hours.

Setting: Four hospitals in an academic healthcare network.

Patients: All patients with a C. difficile order after hospital day 3.

Intervention: Orders for C. difficile testing in patients administered a laxative or stool softener in <24 hours triggered an EMR alert defaulting to cancellation of the order ("nudge").

Results: Of the 17,694 HO-CDI orders, 7% were inappropriate (8% prentervention vs 6% postintervention; P < .001). Monthly HO-CDI orders decreased by 21% postintervention (level-change rate ratio [RR], 0.79; 95% confidence interval [CI], 0.73-0.86), and the rate continued to decrease (postintervention trend change RR, 0.99; 95% CI, 0.98-1.00). The intervention was not associated with a level change in inappropriate HO-CDI orders (RR, 0.80; 95% CI, 0.61-1.05), but the postintervention inappropriate order rate decreased over time (RR, 0.95; 95% CI, 0.93-0.97).

Conclusion: An EMR nudge to minimize inappropriate ordering for C. difficile was effective at reducing HO-CDI orders, and likely contributed to decreasing the inappropriate HO-CDI order rate after the intervention.
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http://dx.doi.org/10.1017/ice.2020.12DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7909614PMC
April 2020

Left Ventricular Assist Device Infections and the Potential Role for Dalbavancin: A Case Report.

Open Forum Infect Dis 2019 Sep 4;6(9):ofz235. Epub 2019 Sep 4.

Division of Infectious Diseases, Atlanta, Georgia.

Left ventricular assist device infections (LVADIs) are common but challenging to treat, often requiring prolonged courses of intravenous antibiotics. Dalbavancin could have a role in treating patients with chronic LVADIs given its less frequent dosing requirements. Here, we illustrate a case in which dalbavancin was used as suppressive therapy for an LVADI for greater than 7 months.
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http://dx.doi.org/10.1093/ofid/ofz235DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6736362PMC
September 2019

Variability of Antibiotic Prescribing in a Large Healthcare Network Despite Adjusting for Patient-Mix: Reconsidering Targets for Improved Prescribing.

Open Forum Infect Dis 2019 Feb 18;6(2):ofz018. Epub 2019 Jan 18.

Rollins School of Public Health, Emory University, Atlanta, Georgia.

Background: In the outpatient setting, the majority of antibiotic prescriptions are for acute respiratory infections (ARIs), but most of these infections are viral and antibiotics are unnecessary. We analyzed provider-specific antibiotic prescribing in a group of outpatient clinics affiliated with an academic medical center to inform future interventions to minimize unnecessary antibiotic use.

Methods: We conducted a cross-sectional study of patients who presented with an ARI to any of 15 The Emory Clinic (TEC) primary care clinic sites between October 2015 and September 2017. We performed multivariable logistic regression analysis to examine the impact of patient, provider, and clinic characteristics on antibiotic prescribing. We also compared provider-specific prescribing rates within and between clinic sites.

Results: A total of 53.4% of the 9600 patient encounters with a diagnosis of ARI resulted in an antibiotic prescription. The odds of an encounter resulting in an antibiotic prescription were independently associated with patient characteristics of white race (adjusted odds ratio [aOR] = 1.59; 95% confidence interval [CI], 1.47-1.73), older age (aOR = 1.32, 95% CI = 1.20-1.46 for patients 51 to 64 years; aOR = 1.32, 95% CI = 1.20-1.46 for patients ≥65 years), and comorbid condition presence (aOR = 1.19; 95% CI, 1.09-1.30). Of the 109 providers, 13 (12%) had a rate significantly higher than predicted by modeling.

Conclusions: Antibiotic prescribing for ARIs within TEC outpatient settings is higher than expected based on prescribing guidelines, with substantial variation in prescribing rates by site and provider. These data lay the foundation for quality improvement interventions to reduce unnecessary antibiotic prescribing.
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http://dx.doi.org/10.1093/ofid/ofz018DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6386112PMC
February 2019

Severe Community-Acquired Pneumonia due to in North America: Case Report and Review of the Literature.

Open Forum Infect Dis 2018 Mar 10;5(3):ofy044. Epub 2018 Mar 10.

Division of Infectious Diseases, Department of Medicine, Atlanta, Georgia.

is a rare but emerging cause of fulminant community-acquired pneumonia (CAP-AB). We describe a patient from a rural area who developed acute respiratory distress syndrome and septic shock. We describe risk factors and characteristics of this syndrome and review published cases of CAP-AB from North America.
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http://dx.doi.org/10.1093/ofid/ofy044DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5846288PMC
March 2018

Commentary on: Incidence and Risk Factors for Major Surgical Site Infections in Aesthetic Surgery: Analysis of 129,007 Patients.

Aesthet Surg J 2017 01 17;37(1):100-102. Epub 2016 Oct 17.

From the Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, GA

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http://dx.doi.org/10.1093/asj/sjw167DOI Listing
January 2017

A forgotten population: older adults with newly diagnosed HIV.

AIDS Patient Care STDS 2014 Oct 11;28(10):530-6. Epub 2014 Sep 11.

1 Division of Infectious Diseases, Columbia University , College of Physicians and Surgeons, New York, New York.

Limited data are available regarding adults age ≥50 at initial HIV diagnosis. Improved understanding of this group is critical in designing interventions to facilitate earlier diagnosis and linkage to HIV care. We characterize individuals newly diagnosed with HIV, particularly those ≥50 years old, and examine the relationship between age and late diagnosis defined as concurrent HIV and AIDS diagnoses. This is a retrospective study of individuals newly diagnosed with HIV from 2006-2011 at an academic medical center in New York City. Multivariable logistic regression was performed to evaluate the effect of age, gender, race/ethnicity, risk factor, and prior medical visits on late diagnosis. Adults age ≥50 comprised 21.3% of all newly diagnosed individuals. Among these older adults, 70.0% were diagnosed as inpatients and 68.9% concurrent with AIDS, compared to 41.7% and 38.9% of younger adults, respectively. On adjusted analyses, age ≥50 (OR 3.13, 95% CI 1.63, 5.98) and injection drug use (OR 4.4, 95% CI 1.31, 14.75) were positively associated with late diagnosis, whereas female gender was negatively associated with late diagnosis (OR 0.52, 95% CI 0.28, 0.98). Our data suggest that HIV testing efforts targeting older adults are essential to address the unmet needs of this population, including implementation of HIV screening guidelines in primary care settings.
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http://dx.doi.org/10.1089/apc.2014.0152DOI Listing
October 2014

How reliable is self-testing for gonorrhea and chlamydia among men who have sex with men?

J Fam Pract 2013 Feb;62(2):70-8

Emory University School of Medicine, Atlanta, GA, USA.

Background: Recent studies have demonstrated a high prevalence of pharyngeal (P) and rectal (R) Neisseria gonorrhoeae (GC) and Chlamydia trachomatis (CT) infections among men who have sex with men (MSM). Guidelines by the Centers for Disease Control and Prevention recommend testing at least annually. But surveys of medical providers suggest that adherence to these guidelines is minimal as a result of limited time and staff. Because of these concerns, we evaluated the feasibility and accuracy of patient self-testing.

Methods: Three-hundred seventy-four patients at a Washington, DC clinic who identified themselves as MSM and requested testing for sexually transmitted infections (STIs) participated in the study. Patients performed self-screening using the Gen-Probe APTIMA Combo 2 (AC2) kit after viewing written and pictorial instructions. Trained providers also screened patients. We randomized the order in which patients or providers performed testing.

Results: Among those receiving specific tests, 8% of patients tested positive for R-GC, 9.3% for P-GC, 12.7% for R-CT, and 1.3% for P-CT. We performed McNemar tests, stratified by infection type and anatomic site to evaluate concordance. Self-administered testing was significantly better at identifying P-GC (discordant: 3%) and R-GC (discordant: 2.9%) (P ≤.01), and had results similar to provider- administered testing for P-CT (discordant: 0.5%) and R-CT (discordant: 1.1%) detection.

Conclusions: The equivalent or better detection rates for rectal and oral gonorrhea and chlamydia among patients suggest that patients are capable of performing their own screening for STIs, which may increase infection detection and treatment.
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February 2013