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Rabaan AA, Eljaaly K, Alhumaid S, Albayat H, Al-Adsani W, Sabour AA, Alshiekheid MA, Al-Jishi JM, Khamis F, Alwarthan S, Alhajri M, Alfaraj AH, Tombuloglu H, Garout M, Alabdullah DM, Mohammed EAE, Yami FSA, Almuhtaresh HA, Livias KA, Mutair AA, Almushrif SA, Abusalah MAHA, Ahmed N. An Overview on Phenotypic and Genotypic Characterisation of Carbapenem-Resistant Enterobacterales. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:1675. [PMID: 36422214 PMCID: PMC9696003 DOI: 10.3390/medicina58111675] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 11/16/2022] [Accepted: 11/18/2022] [Indexed: 08/26/2023]
Abstract
Improper use of antimicrobials has resulted in the emergence of antimicrobial resistance (AMR), including multi-drug resistance (MDR) among bacteria. Recently, a sudden increase in Carbapenem-resistant Enterobacterales (CRE) has been observed. This presents a substantial challenge in the treatment of CRE-infected individuals. Bacterial plasmids include the genes for carbapenem resistance, which can also spread to other bacteria to make them resistant. The incidence of CRE is rising significantly despite the efforts of health authorities, clinicians, and scientists. Many genotypic and phenotypic techniques are available to identify CRE. However, effective identification requires the integration of two or more methods. Whole genome sequencing (WGS), an advanced molecular approach, helps identify new strains of CRE and screening of the patient population; however, WGS is challenging to apply in clinical settings due to the complexity and high expense involved with this technique. The current review highlights the molecular mechanism of development of Carbapenem resistance, the epidemiology of CRE infections, spread of CRE, treatment options, and the phenotypic/genotypic characterisation of CRE. The potential of microorganisms to acquire resistance against Carbapenems remains high, which can lead to even more susceptible drugs such as colistin and polymyxins. Hence, the current study recommends running the antibiotic stewardship programs at an institutional level to control the use of antibiotics and to reduce the spread of CRE worldwide.
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Affiliation(s)
- Ali A. Rabaan
- Molecular Diagnostic Laboratory, Johns Hopkins Aramco Healthcare, Dhahran 31311, Saudi Arabia
- College of Medicine, Alfaisal University, Riyadh 11533, Saudi Arabia
- Department of Public Health and Nutrition, The University of Haripur, Haripur 22610, Pakistan
| | - Khalid Eljaaly
- Department of Pharmacy Practice, Faculty of Pharmacy, King Abdulaziz University, Jeddah 21589, Saudi Arabia
- Pharmacy Practice and Science Department, College of Pharmacy, University of Arizona, Tucson, AZ 85716, USA
| | - Saad Alhumaid
- Administration of Pharmaceutical Care, Al-Ahsa Health Cluster, Ministry of Health, Al-Ahsa 31982, Saudi Arabia
| | - Hawra Albayat
- Infectious Disease Department, King Saud Medical City, Riyadh 7790, Saudi Arabia
| | - Wasl Al-Adsani
- Department of Medicine, Infectious Diseases Hospital, Kuwait City 63537, Kuwait
- Department of Infectious Diseases, Hampton Veterans Administration Medical Center, Hampton, VA 23667, USA
| | - Amal A. Sabour
- Department of Botany and Microbiology, College of Science, King Saud University, Riyadh 11451, Saudi Arabia
| | - Maha A. Alshiekheid
- Department of Botany and Microbiology, College of Science, King Saud University, Riyadh 11451, Saudi Arabia
| | - Jumana M. Al-Jishi
- Internal Medicine Department, Qatif Central Hospital, Qatif 635342, Saudi Arabia
| | - Faryal Khamis
- Infection Diseases Unit, Department of Internal Medicine, Royal Hospital, Muscat 1331, Oman
| | - Sara Alwarthan
- Department of Internal Medicine, College of Medicine, Imam Abdulrahman Bin Faisal University, Ammam 34212, Saudi Arabia
| | - Mashael Alhajri
- Department of Internal Medicine, College of Medicine, Imam Abdulrahman Bin Faisal University, Ammam 34212, Saudi Arabia
| | - Amal H. Alfaraj
- Pediatric Department, Abqaiq General Hospital, First Eastern Health Cluster, Abqaiq 33261, Saudi Arabia
| | - Huseyin Tombuloglu
- Department of Genetics Research, Institute for Research and Medical Consultations (IRMC), Imam Abdulrahman Bin Faisal University, Dammam 34221, Saudi Arabia
| | - Mohammed Garout
- Department of Community Medicine and Health Care for Pilgrims, Faculty of Medicine, Umm Al-Qura University, Makkah 21955, Saudi Arabia
| | - Duaa M. Alabdullah
- Molecular Diagnostic Laboratory, Dammam Regional Laboratory and Blood Bank, Dammam 31411, Saudi Arabia
| | - Elmoeiz Ali Elnagi Mohammed
- Department of Clinical Laboratory Sciences, Prince Sultan Military College of Health Sciences, Dhahran 34313, Saudi Arabia
| | - Fatimah S. Al Yami
- Department of Medical Laboratory, King Fahad Military Medical Complex, Dhahran 34313, Saudi Arabia
| | - Haifa A. Almuhtaresh
- Department of Clinical Laboratories Services, Dammam Medical Complex, Dammam Health Network, Dammam 5343, Saudi Arabia
| | - Kovy Arteaga Livias
- Facultad de Ciencias de la Salud, Universidad Científica del Sur, Lima 15001, Peru
- Facultad de Medicina, Universidad Nacional Hermilio Valdizán, Huánuco 10000, Peru
| | - Abbas Al Mutair
- Research Center, Almoosa Specialist Hospital, Al-Ahsa 36342, Saudi Arabia
- College of Nursing, Princess Norah Bint Abdulrahman University, Riyadh 11564, Saudi Arabia
- School of Nursing, Wollongong University, Wollongong, NSW 2522, Australia
- Nursing Department, Prince Sultan Military College of Health Sciences, Dhahran 33048, Saudi Arabia
| | - Shawqi A. Almushrif
- Department of Microbiology and Hematology Laboratory, Dammam Comprehensive Screening Centre, Dammam 31433, Saudi Arabia
| | | | - Naveed Ahmed
- Department of Medical Microbiology and Parasitology, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian 16150, Malaysia
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Modelling of the transmission dynamics of carbapenem-resistant Klebsiella pneumoniae in hospitals and design of control strategies. Sci Rep 2022; 12:3805. [PMID: 35264643 PMCID: PMC8907197 DOI: 10.1038/s41598-022-07728-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Accepted: 02/21/2022] [Indexed: 01/13/2023] Open
Abstract
Carbapenem-resistant Klebsiella pneumoniae (CRKP) has emerged as a major threat to global public health. Epidemiological and infection controls associated with CRKP are challenging because of several potential elements involved in a complicated cycle of transmission. Here, we proposed a comprehensive mathematical model to investigate the transmission dynamics of CRKP, determine factors affecting the prevalence, and evaluate the impact of interventions on transmission. The model includes the essential compartments, which are uncolonized, asymptomatic colonized, symptomatic colonized, and relapsed patients. Additionally, symptomatic colonized and relapsed patients were further classified into subpopulations according to their number of treatment failures or relapses. We found that the admission of colonized patients and use of antibiotics significantly impacted the endemic transmission in health care units. Thus, we introduced the treatment efficacy, defined by combining the treatment duration and probability of successful treatment, to characterize and describe the effects of antibiotic treatment on transmission. We showed that a high antibiotic treatment efficacy results in a significantly reduced likelihood of patient readmission in the health care unit. Additionally, our findings demonstrate that CRKP transmission with different epidemiological characteristics must be controlled using distinct interventions.
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Cost-effectiveness of carbapenem-resistant Enterobacteriaceae (CRE) surveillance in Maryland. Infect Control Hosp Epidemiol 2021; 43:1162-1170. [PMID: 34674791 PMCID: PMC9023597 DOI: 10.1017/ice.2021.361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Objective: We analyzed the efficacy, cost, and cost-effectiveness of predictive decision-support systems based on surveillance interventions to reduce the spread of carbapenem-resistant Enterobacteriaceae (CRE). Design: We developed a computational model that included patient movement between acute-care hospitals (ACHs), long-term care facilities (LTCFs), and communities to simulate the transmission and epidemiology of CRE. A comparative cost-effectiveness analysis was conducted on several surveillance strategies to detect asymptomatic CRE colonization, which included screening in ICUs at select or all hospitals, a statewide registry, or a combination of hospital screening and a statewide registry. Setting: We investigated 51 ACHs, 222 LTCFs, and skilled nursing facilities, and 464 ZIP codes in the state of Maryland. Patients or participants: The model was informed using 2013–2016 patient-mix data from the Maryland Health Services Cost Review Commission. This model included all patients that were admitted to an ACH. Results: On average, the implementation of a statewide CRE registry reduced annual CRE infections by 6.3% (18.8 cases). Policies of screening in select or all ICUs without a statewide registry had no significant impact on the incidence of CRE infections. Predictive algorithms, which identified any high-risk patient, reduced colonization incidence by an average of 1.2% (3.7 cases) without a registry and 7.0% (20.9 cases) with a registry. Implementation of the registry was estimated to save $572,000 statewide in averted infections per year. Conclusions: Although hospital-level surveillance provided minimal reductions in CRE infections, regional coordination with a statewide registry of CRE patients reduced infections and was cost-effective.
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Chen HY, Jean SS, Lee YL, Lu MC, Ko WC, Liu PY, Hsueh PR. Carbapenem-Resistant Enterobacterales in Long-Term Care Facilities: A Global and Narrative Review. Front Cell Infect Microbiol 2021; 11:601968. [PMID: 33968793 PMCID: PMC8102866 DOI: 10.3389/fcimb.2021.601968] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Accepted: 04/06/2021] [Indexed: 01/15/2023] Open
Abstract
The emergence of carbapenem-resistant Enterobacterales (CRE) has become a major public health concern. Moreover, its colonization among residents of long-term care facilities (LTCFs) is associated with subsequent infections and mortality. To further explore the various aspects concerning CRE in LTCFs, we conducted a literature review on CRE colonization and/or infections in long-term care facilities. The prevalence and incidence of CRE acquisition among residents of LTCFs, especially in California, central Italy, Spain, Japan, and Taiwan, were determined. There was a significant predominance of CRE in LTCFs, especially in high-acuity LTCFs with mechanical ventilation, and thus may serve as outbreak centers. The prevalence rate of CRE in LTCFs was significantly higher than that in acute care settings and the community, which indicated that LTCFs are a vital reservoir for CRE. The detailed species and genomic analyses of CRE among LTCFs reported that Klebsiella pneumoniae is the primary species in the LTCFs in the United States, Spain, and Taiwan. KPC-2-containing K. pneumoniae strains with sequence type 258 is the most common sequence type of KPC-producing K. pneumoniae in the LTCFs in the United States. IMP-11- and IMP-6-producing CRE were commonly reported among LTCFs in Japan. OXA-48 was the predominant carbapenemase among LTCFs in Spain. Multiple risk factors associated with the increased risk for CRE acquisition in LTCFs were found, such as comorbidities, immunosuppressive status, dependent functional status, usage of gastrointestinal devices or indwelling catheters, mechanical ventilation, prior antibiotic exposures, and previous culture reports. A high CRE acquisition rate and prolonged CRE carriage duration after colonization were found among residents in LTCFs. Moreover, the patients from LTCFs who were colonized or infected with CRE had poor clinical outcomes, with a mortality rate of up to 75% in infected patients. Infection prevention and control measures to reduce CRE in LTCFs is important, and could possibly be controlled via active surveillance, contact precautions, cohort staffing, daily chlorhexidine bathing, healthcare-worker education, and hand-hygiene adherence.
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Affiliation(s)
- Hsin-Yu Chen
- Division of Infectious Disease, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Shio-Shin Jean
- Department of Emergency, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.,Department of Emergency Medicine, Department of Emergency Medicine and Critical Care Medicine, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
| | - Yu-Lin Lee
- Department of Internal Medicine, Changhua Christian Hospital, Changhua, Taiwan
| | - Min-Chi Lu
- Division of Infectious Diseases, Department of Internal Medicine, China Medical University Hospital, Taichung, Taiwan.,Department of Microbiology and Immunology, School of Medicine, China Medical University, Taichung, Taiwan
| | - Wen-Chien Ko
- Department of Internal Medicine and Center for Infection Control, College of Medicine, National Cheng Kung University Hospital, Tainan, Taiwan.,Department of Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Po-Yu Liu
- Division of Infectious Disease, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan.,Rong Hsing Research Center for Translational Medicine, National Chung Hsing University, Taichung, Taiwan.,Ph.D. Program in Translational Medicine, National Chung Hsing University, Taichung, Taiwan
| | - Po-Ren Hsueh
- Division of Infectious Disease, Department of Internal Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan.,Department of Laboratory Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
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Jimenez A, Trepka MJ, Munoz-Price LS, Pekovic V, Ibrahimou B, Abbo LM, Martinez O, Sposato K, dePascale D, Perez-Cardona A, McElheny CL, Bachman WC, Fowler EL, Doi Y, Fennie K. Epidemiology of carbapenem-resistant Enterobacteriaceae in hospitals of a large healthcare system in Miami, Florida from 2012 to 2016: Five years of experience with an internal registry. Am J Infect Control 2020; 48:1341-1347. [PMID: 32334004 DOI: 10.1016/j.ajic.2020.04.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Revised: 04/10/2020] [Accepted: 04/16/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Carbapenem-resistant Enterobacteriaceae (CRE) is an urgent public health threat globally. Limited data are available regarding the epidemiology of CRE in South Florida. We describe the epidemiology of CRE within a large public healthcare system in Miami, FL, the experience with an internal registry, active surveillance testing, and the impact of infection prevention practices. METHODS Retrospective cohort study in 4 hospitals from a large healthcare system in Miami-Dade County, FL from 2012 to 2016. The internal registry included all CRE cases from active surveillance testing from rectal and/or tracheal screening occurring in the intensive care units of 2 of the hospitals and clinical cultures across the healthcare system. All CRE cases were tagged in the electronic medical record and automatically entered into a platform for automatic infection control surveillance. The system alerted about new cases, readmissions, and transfers. RESULTS A total of 371 CRE cases were identified. The overall prevalence was 0.077 cases per 100 patient-admissions; the admission prevalence was 0.019 per 100 patient-admissions, and the incidence density was 1.46 cases per 10,000 patient-days. Rates increased during the first 3 years of the study and declined later to a lower level than at the beginning of study period. CONCLUSIONS Active surveillance testing and the use of an internal registry facilitated prompt identification of cases contributing to control increasing rates of CRE by rapid implementation of infection prevention strategies.
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McKinnell JA, Singh RD, Miller LG, Kleinman K, Gussin G, He J, Saavedra R, Dutciuc TD, Estevez M, Chang J, Heim L, Yamaguchi S, Custodio H, Gohil SK, Park S, Tam S, Robinson PA, Tjoa T, Nguyen J, Evans KD, Bittencourt CE, Lee BY, Mueller LE, Bartsch SM, Jernigan JA, Slayton RB, Stone ND, Zahn M, Mor V, McConeghy K, Baier RR, Janssen L, O'Donnell K, Weinstein RA, Hayden MK, Coady MH, Bhattarai M, Peterson EM, Huang SS. The SHIELD Orange County Project: Multidrug-resistant Organism Prevalence in 21 Nursing Homes and Long-term Acute Care Facilities in Southern California. Clin Infect Dis 2020; 69:1566-1573. [PMID: 30753383 DOI: 10.1093/cid/ciz119] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Accepted: 02/05/2019] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Multidrug-resistant organisms (MDROs) spread between hospitals, nursing homes (NHs), and long-term acute care facilities (LTACs) via patient transfers. The Shared Healthcare Intervention to Eliminate Life-threatening Dissemination of MDROs in Orange County is a regional public health collaborative involving decolonization at 38 healthcare facilities selected based on their high degree of patient sharing. We report baseline MDRO prevalence in 21 NHs/LTACs. METHODS A random sample of 50 adults for 21 NHs/LTACs (18 NHs, 3 LTACs) were screened for methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococcus spp. (VRE), extended-spectrum β-lactamase-producing organisms (ESBL), and carbapenem-resistant Enterobacteriaceae (CRE) using nares, skin (axilla/groin), and peri-rectal swabs. Facility and resident characteristics associated with MDRO carriage were assessed using multivariable models clustering by person and facility. RESULTS Prevalence of MDROs was 65% in NHs and 80% in LTACs. The most common MDROs in NHs were MRSA (42%) and ESBL (34%); in LTACs they were VRE (55%) and ESBL (38%). CRE prevalence was higher in facilities that manage ventilated LTAC patients and NH residents (8% vs <1%, P < .001). MDRO status was known for 18% of NH residents and 49% of LTAC patients. MDRO-colonized adults commonly harbored additional MDROs (54% MDRO+ NH residents and 62% MDRO+ LTACs patients). History of MRSA (odds ratio [OR] = 1.7; confidence interval [CI]: 1.2, 2.4; P = .004), VRE (OR = 2.1; CI: 1.2, 3.8; P = .01), ESBL (OR = 1.6; CI: 1.1, 2.3; P = .03), and diabetes (OR = 1.3; CI: 1.0, 1.7; P = .03) were associated with any MDRO carriage. CONCLUSIONS The majority of NH residents and LTAC patients harbor MDROs. MDRO status is frequently unknown to the facility. The high MDRO prevalence highlights the need for prevention efforts in NHs/LTACs as part of regional efforts to control MDRO spread.
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Affiliation(s)
- James A McKinnell
- Infectious Disease Clinical Outcomes Research, LA Biomed at Harbor-University of California Los Angeles Medical Center, Torrance
| | - Raveena D Singh
- Division of Infectious Diseases, University of California Irvine School of Medicine, Orange
| | - Loren G Miller
- Infectious Disease Clinical Outcomes Research, LA Biomed at Harbor-University of California Los Angeles Medical Center, Torrance
| | - Ken Kleinman
- University of Massachusetts Amherst School of Public Health and Health Sciences, Orange
| | - Gabrielle Gussin
- Division of Infectious Diseases, University of California Irvine School of Medicine, Orange
| | - Jiayi He
- Division of Infectious Diseases, University of California Irvine School of Medicine, Orange
| | - Raheeb Saavedra
- Division of Infectious Diseases, University of California Irvine School of Medicine, Orange
| | - Tabitha D Dutciuc
- Division of Infectious Diseases, University of California Irvine School of Medicine, Orange
| | - Marlene Estevez
- Division of Infectious Diseases, University of California Irvine School of Medicine, Orange
| | - Justin Chang
- Division of Infectious Diseases, University of California Irvine School of Medicine, Orange
| | - Lauren Heim
- Division of Infectious Diseases, University of California Irvine School of Medicine, Orange
| | - Stacey Yamaguchi
- Division of Infectious Diseases, University of California Irvine School of Medicine, Orange
| | - Harold Custodio
- Division of Infectious Diseases, University of California Irvine School of Medicine, Orange
| | - Shruti K Gohil
- Division of Infectious Diseases, University of California Irvine School of Medicine, Orange
| | - Steven Park
- University of California Irvine Health, Orange
| | - Steven Tam
- Division of Geriatrics, Department of Medicine, University of California Irvine, Orange
| | | | - Thomas Tjoa
- Division of Infectious Diseases, University of California Irvine School of Medicine, Orange
| | - Jenny Nguyen
- Division of Infectious Diseases, University of California Irvine School of Medicine, Orange
| | | | | | - Bruce Y Lee
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Leslie E Mueller
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Sarah M Bartsch
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - John A Jernigan
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Rachel B Slayton
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Nimalie D Stone
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Matthew Zahn
- Epidemiology and Assessment, Orange County Health Care Agency, Santa Ana, California
| | - Vincent Mor
- Department of Health Services, Policy and Practice, Brown University School of Public Health, Rhode Island.,Center of Innovation in Long-Term Services and Supports, Veterans Affairs Medical Center, Providence VA Medical Center, Rhode Island.,Center for Long-Term Care Quality and Innovation, Brown University School of Public Health, Providence, Rhode Island
| | - Kevin McConeghy
- Department of Health Services, Policy and Practice, Brown University School of Public Health, Rhode Island.,Center of Innovation in Long-Term Services and Supports, Veterans Affairs Medical Center, Providence VA Medical Center, Rhode Island.,Center for Long-Term Care Quality and Innovation, Brown University School of Public Health, Providence, Rhode Island
| | - Rosa R Baier
- Department of Health Services, Policy and Practice, Brown University School of Public Health, Rhode Island.,Center for Long-Term Care Quality and Innovation, Brown University School of Public Health, Providence, Rhode Island
| | - Lynn Janssen
- Healthcare-associated Infections Program, Center for Healthcare Quality, California Department of Public Health, Richmond, California
| | - Kathleen O'Donnell
- Epidemiology and Assessment, Orange County Health Care Agency, Santa Ana, California.,Healthcare-associated Infections Program, Center for Healthcare Quality, California Department of Public Health, Richmond, California
| | - Robert A Weinstein
- Cook County Health and Hospitals System, Chicago, Illinois.,Department of Medicine, Rush University Medical Center, Chicago, Illinois
| | - Mary K Hayden
- Department of Medicine, Rush University Medical Center, Chicago, Illinois
| | - Micaela H Coady
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts
| | - Megha Bhattarai
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts
| | | | - Susan S Huang
- Division of Infectious Diseases, University of California Irvine School of Medicine, Orange.,Health Policy Research Institute, University of California Irvine School of Medicine
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Eli M, Maman-Naor K, Feder-Bubis P, Nativ R, Borer A, Livshiz-Riven I. Perceptions of patients' and healthcare workers' experiences in cohort isolation units: a qualitative study. J Hosp Infect 2020; 106:43-52. [PMID: 32562724 DOI: 10.1016/j.jhin.2020.05.044] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Accepted: 05/29/2020] [Indexed: 11/16/2022]
Abstract
BACKGROUND Given the scarce therapeutic options for carbapenemase-producing Enterobacterales (CPE), aggressive interventions are implemented to limit its spread among hospitalized patients. One such option is contact isolation by cohorting patients in designated units. AIM To describe the experiences in a cohort isolation unit (CIU) due to CPE from the perspectives of patients admitted to this unit and their families, and those of healthcare workers (HCWs) who served in the same unit. METHODS Qualitative study. Face-to-face, semi-structured interviews were conducted in a large tertiary hospital. Twenty-four participants were interviewed, including 15 HCWs, three patients and six family members. Data were coded using thematic analysis. FINDINGS The CIU provoked negative feelings such as fear, risk, loneliness, distrust and unfairness. They also created a sense of conflict with the curative assumptions of hospital care. The poor CIU infrastructure was echoed in perceptions of crowdedness in the site. Moreover, family members described HCWs' inconsistent protective behaviours that led them to a state of vigilance. The hospital infection control unit imparted and refreshed HCWs' knowledge and expected behaviours regarding the CIU. However, patients and families expressed dissatisfaction with the information, guidance and education regarding the 'why and how' of the CIU. They were not guided consistently about recommended behaviours after discharge. In retrospect, HCWs found that the CIU took a psychological, physical and professional toll. CONCLUSION The CIU was planned as a temporary containment mechanism. It needs to develop into a permanent system, capable of addressing the various needs of all involved.
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Affiliation(s)
- M Eli
- Clalit Community Healthcare Services, Southern District, Beer-Sheva, Israel
| | - K Maman-Naor
- Department of Nursing, Recanati School for Community Health Professions, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel; Department of Internal Medicine, Soroka University Medical Centre, Beer-Sheva, Israel
| | - P Feder-Bubis
- Department of Health Systems Management, Faculty of Health Sciences, Guilford Glazer Faculty of Business and Management, Ben-Gurion University of the Negev, Beer-Sheva, Israel.
| | - R Nativ
- Infection Control and Hospital Epidemiology Unit, Soroka University Medical Centre, Beer-Sheva, Israel
| | - A Borer
- Infection Control and Hospital Epidemiology Unit, Soroka University Medical Centre, Beer-Sheva, Israel
| | - I Livshiz-Riven
- Department of Nursing, Recanati School for Community Health Professions, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel; Clinical Quality Unit, Soroka University Medical Centre, Beer-Sheva, Israel
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Use of a cohorting-unit and systematic surveillance cultures to control a Klebsiella pneumoniae carbapenemase (KPC)-producing Enterobacteriaceae outbreak. Infect Control Hosp Epidemiol 2019; 40:767-773. [PMID: 31084655 DOI: 10.1017/ice.2019.99] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Describe the epidemiological and molecular characteristics of an outbreak of Klebsiella pneumoniae carbapenemase (KPC)-producing organisms and the novel use of a cohorting unit for its control. DESIGN Observational study. SETTING A 566-room academic teaching facility in Milwaukee, Wisconsin. PATIENTS Solid-organ transplant recipients. METHODS Infection control bundles were used throughout the time of observation. All KPC cases were intermittently housed in a cohorting unit with dedicated nurses and nursing aids. The rooms used in the cohorting unit had anterooms where clean supplies and linens were placed. Spread of KPC-producing organisms was determined using rectal surveillance cultures on admission and weekly thereafter among all consecutive patients admitted to the involved units. KPC-positive strains underwent pulsed-field gel electrophoresis and whole-genome sequencing. RESULTS A total of 8 KPC cases (5 identified by surveillance) were identified from April 2016 to April 2017. After the index patient, 3 patients acquired KPC-producing organisms despite implementation of an infection control bundle. This prompted the use of a cohorting unit, which immediately halted transmission, and the single remaining KPC case was transferred out of the cohorting unit. However, additional KPC cases were identified within 2 months. Once the cohorting unit was reopened, no additional KPC cases occurred. The KPC-positive species identified during this outbreak included Klebsiella pneumoniae, Enterobacter cloacae complex, and Escherichia coli. blaKPC was identified on at least 2 plasmid backbones. CONCLUSIONS A complex KPC outbreak involving both clonal and plasmid-mediated dissemination was controlled using weekly surveillances and a cohorting unit.
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Fitzpatrick MA, Suda KJ, Ramanathan S, Guihan M, Brown C, Safdar N, Evans M, Jones MM, Pfeiffer CD, Klutts JS, Icardi M, Perencevich E, Rubin M, Evans CT. Laboratory practices for identification and reporting of carbapenem-resistant Enterobacteriaceae in Department of Veterans Affairs facilities. Infect Control Hosp Epidemiol 2019; 40:463-466. [PMID: 30829187 PMCID: PMC8552218 DOI: 10.1017/ice.2019.24] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Laboratory identification of carbapenem-resistant Enterobacteriaceae (CRE) is a key step in controlling its spread. Our survey showed that most Veterans Affairs laboratories follow VA guidelines for initial CRE identification, whereas 55.0% use PCR to confirm carbapenemase production. Most respondents were knowledgeable about CRE guidelines. Barriers included staffing, training, and financial resources.
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Affiliation(s)
- Margaret A. Fitzpatrick
- Department of Veterans Affairs, Center of Innovation for Complex Chronic Healthcare, Edward Hines, Jr. VA Hospital, Hines, IL
- Department of Medicine, Division of Infectious Diseases, Loyola University Stritch School of Medicine, Maywood, IL
| | - Katie J. Suda
- Department of Veterans Affairs, Center of Innovation for Complex Chronic Healthcare, Edward Hines, Jr. VA Hospital, Hines, IL
- Department of Pharmacy Systems, Outcomes and Policy, University of Illinois at Chicago, Chicago, IL
| | - Swetha Ramanathan
- Department of Veterans Affairs, Center of Innovation for Complex Chronic Healthcare, Edward Hines, Jr. VA Hospital, Hines, IL
| | - Marylou Guihan
- Department of Veterans Affairs, Center of Innovation for Complex Chronic Healthcare, Edward Hines, Jr. VA Hospital, Hines, IL
- Department of Physical Medicine and Rehabilitation, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Charnetta Brown
- Department of Veterans Affairs, Houston Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey VA Medical Center, Houston, TX
| | - Nasia Safdar
- Department of Veterans Affairs, William S. Middleton Memorial VA Medical Center, Madison, WI, USA
- Department of Medicine, Division of Infectious Diseases, University of Wisconsin School of Public Health and Medicine, Madison, WI, USA
| | - Martin Evans
- Department of Veterans Affairs, Lexington VA Medical Center, Lexington, KY, USA
| | - Makoto M. Jones
- Department of Veterans Affairs, VA Salt Lake City Healthcare System, Salt Lake City, UT, USA
- Department of Medicine, Division of Epidemiology, University of Utah, Salt Lake City, UT, USA
| | - Christopher D. Pfeiffer
- Department of Veterans Affairs, Portland VA Healthcare System, Portland, OR, USA
- Department of Medicine, Division of Infectious Diseases, Oregon Health Science University, Portland, OR, USA
| | - J. Stacey Klutts
- Department of Veterans Affairs, Iowa City VA Health Care System, Iowa City, IA, USA
- Department of Pathology, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Michael Icardi
- Department of Veterans Affairs, Iowa City VA Health Care System, Iowa City, IA, USA
- Department of Pathology, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Eli Perencevich
- Department of Veterans Affairs, Iowa City VA Health Care System, Iowa City, IA, USA
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Michael Rubin
- Department of Veterans Affairs, VA Salt Lake City Healthcare System, Salt Lake City, UT, USA
- Department of Medicine, Division of Epidemiology, University of Utah, Salt Lake City, UT, USA
| | - Charlesnika T. Evans
- Department of Veterans Affairs, Center of Innovation for Complex Chronic Healthcare, Edward Hines, Jr. VA Hospital, Hines, IL
- Center for Healthcare Studies and Department of Preventive Medicine Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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10
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Bernard H, Hackbarth D, Olmsted RN, Murphy D. Creation of a competency-based professional development program for infection preventionists guided by the APIC Competency Model: steps in the process. Am J Infect Control 2018; 46:1202-1210. [PMID: 29887164 DOI: 10.1016/j.ajic.2018.04.225] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Revised: 04/12/2018] [Accepted: 04/12/2018] [Indexed: 10/14/2022]
Abstract
BACKGROUND Infection Preventionists have varying levels of educational preparation. Many have no prior experience in IP. The diversity makes design of professional development programs challenging. Recent surveys suggest that only about half of practicing IPs are board certified. There is an urgent need to employ competent IP's to drive improvement in patient outcomes. METHODS This is a project that utilized the APIC Competency Model to create a professional development program characterizing three career stages. Methods included a review of literature on professional development; a survey of IP competence; an assessment of job descriptions and performance evaluations; and a crosswalk of IP competencies. RESULTS The professional development program includes competency - based IP job descriptions and performance evaluations for each career stage; a professional portfolio; and a toolkit for supervisors. DISCUSSION Participants agreed that application of the model resulted in tools which are more closely aligned with current roles for IPs; and increased satisfaction and motivation with the new program. CONCLUSION Competent and knowledgeable IP's are crucial to optimizing efficacy of IPC programs. A professional development program has the potential to guide staff orientation, improve satisfaction and retention, improve patient outcomes and promote a positive trajectory in advancing practice.
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11
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Senchyna F, Gaur RL, Sandlund J, Truong C, Tremintin G, Kültz D, Gomez CA, Tamburini FB, Andermann T, Bhatt A, Tickler I, Watz N, Budvytiene I, Shi G, Tenover FC, Banaei N. Diversity of resistance mechanisms in carbapenem-resistant Enterobacteriaceae at a health care system in Northern California, from 2013 to 2016. Diagn Microbiol Infect Dis 2018; 93:250-257. [PMID: 30482638 DOI: 10.1016/j.diagmicrobio.2018.10.004] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Revised: 09/26/2018] [Accepted: 10/07/2018] [Indexed: 11/20/2022]
Abstract
The mechanism of resistance in carbapenem-resistant Enterobacteriaceae (CRE) has therapeutic implications. We comprehensively characterized emerging mechanisms of resistance in CRE between 2013 and 2016 at a health system in Northern California. A total of 38.7% (24/62) of CRE isolates were carbapenemase gene-positive, comprising 25.0% (6/24) blaOXA-48 like, 20.8% (5/24) blaKPC, 20.8% (5/24) blaNDM, 20.8% (5/24) blaSME, 8.3% (2/24) blaIMP, and 4.2% (1/24) blaVIM. Between carbapenemases and porin loss, the resistance mechanism was identified in 95.2% (59/62) of CRE isolates. Isolates expressing blaKPC were 100% susceptible to ceftazidime-avibactam, meropenem-vaborbactam, and imipenem-relebactam; blaOXA-48 like-positive isolates were 100% susceptible to ceftazidime-avibactam; and metallo β-lactamase-positive isolates were nearly all nonsusceptible to above antibiotics. Carbapenemase gene-negative CRE were 100% (38/38), 92.1% (35/38), 89.5% (34/38), and 31.6% (12/38) susceptible to ceftazidime-avibactam, meropenem-vaborbactam, imipenem-relebactam, and ceftolozane-tazobactam, respectively. None of the CRE strains were identical by whole genome sequencing. At this health system, CRE were mediated by diverse mechanisms with predictable susceptibility to newer β-lactamase inhibitors.
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Affiliation(s)
- Fiona Senchyna
- Department of Pathology, Stanford University School of Medicine, Stanford, CA, USA
| | - Rajiv L Gaur
- Department of Pathology, Stanford University School of Medicine, Stanford, CA, USA
| | - Johanna Sandlund
- Department of Pathology, Stanford University School of Medicine, Stanford, CA, USA
| | - Cynthia Truong
- Department of Pathology, Stanford University School of Medicine, Stanford, CA, USA
| | | | - Dietmar Kültz
- Department of Animal Sciences, University of California, Davis, Davis, CA, USA
| | - Carlos A Gomez
- Department of Pathology, Stanford University School of Medicine, Stanford, CA, USA; Division of Infectious Diseases and Geographic Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Fiona B Tamburini
- Division of Hematology, Department of Genetics, Stanford University School of Medicine, Stanford, CA, USA
| | - Tessa Andermann
- Division of Infectious Diseases and Geographic Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA; Division of Hematology, Department of Genetics, Stanford University School of Medicine, Stanford, CA, USA
| | - Ami Bhatt
- Division of Hematology, Department of Genetics, Stanford University School of Medicine, Stanford, CA, USA
| | | | - Nancy Watz
- Clinical Microbiology Laboratory, Stanford University Medical Center, Palo Alto, CA, USA
| | - Indre Budvytiene
- Clinical Microbiology Laboratory, Stanford University Medical Center, Palo Alto, CA, USA
| | - Gongyi Shi
- Bruker Daltonics, Inc., San Jose, CA, USA
| | | | - Niaz Banaei
- Department of Pathology, Stanford University School of Medicine, Stanford, CA, USA; Division of Infectious Diseases and Geographic Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA; Clinical Microbiology Laboratory, Stanford University Medical Center, Palo Alto, CA, USA.
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12
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Livorsi DJ, Chorazy ML, Schweizer ML, Balkenende EC, Blevins AE, Nair R, Samore MH, Nelson RE, Khader K, Perencevich EN. A systematic review of the epidemiology of carbapenem-resistant Enterobacteriaceae in the United States. Antimicrob Resist Infect Control 2018; 7:55. [PMID: 29719718 PMCID: PMC5926528 DOI: 10.1186/s13756-018-0346-9] [Citation(s) in RCA: 66] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2018] [Accepted: 04/13/2018] [Indexed: 01/11/2023] Open
Abstract
Background Carbapenem-resistant Enterobacteriaceae (CRE) pose an urgent public health threat in the United States. An important step in planning and monitoring a national response to CRE is understanding its epidemiology and associated outcomes. We conducted a systematic literature review of studies that investigated incidence and outcomes of CRE infection in the US. Methods We performed searches in MEDLINE via Ovid, CDSR, DARE, CENTRAL, NHS EED, Scopus, and Web of Science for articles published from 1/1/2000 to 2/1/2016 about the incidence and outcomes of CRE at US sites. Results Five studies evaluated incidence, but many used differing definitions for cases. Across the entire US population, the reported incidence of CRE was 0.3–2.93 infections per 100,000 person-years. Infection rates were highest in long-term acute-care (LTAC) hospitals. There was insufficient data to assess trends in infection rates over time. Four studies evaluated outcomes. Mortality was higher in CRE patients in some but not all studies. Conclusion While the incidence of CRE infections in the United States remains low on a national level, the incidence is highest in LTACs. Studies assessing outcomes in CRE-infected patients are limited in number, small in size, and have reached conflicting results. Future research should measure a variety of clinical outcomes and adequately adjust for confounders to better assess the full burden of CRE. Electronic supplementary material The online version of this article (10.1186/s13756-018-0346-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Daniel J Livorsi
- 1Center for Comprehensive Access Delivery & Research, Iowa City VA Health Care System, Iowa City, USA.,2Department of Internal Medicine, Carver College of Medicine, University of Iowa, Iowa City, USA
| | | | - Marin L Schweizer
- 1Center for Comprehensive Access Delivery & Research, Iowa City VA Health Care System, Iowa City, USA.,2Department of Internal Medicine, Carver College of Medicine, University of Iowa, Iowa City, USA
| | - Erin C Balkenende
- 1Center for Comprehensive Access Delivery & Research, Iowa City VA Health Care System, Iowa City, USA
| | - Amy E Blevins
- 4Hardin Library for the Health Sciences, University of Iowa, Iowa City, USA.,5Ruth Lilly Medical Library, Indiana University School of Medicine, Indianapolis, Indiana USA
| | - Rajeshwari Nair
- 1Center for Comprehensive Access Delivery & Research, Iowa City VA Health Care System, Iowa City, USA.,2Department of Internal Medicine, Carver College of Medicine, University of Iowa, Iowa City, USA
| | - Matthew H Samore
- Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah USA.,7Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah USA
| | - Richard E Nelson
- Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah USA.,7Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah USA
| | - Karim Khader
- Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah USA.,7Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah USA
| | - Eli N Perencevich
- 1Center for Comprehensive Access Delivery & Research, Iowa City VA Health Care System, Iowa City, USA.,2Department of Internal Medicine, Carver College of Medicine, University of Iowa, Iowa City, USA
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13
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Liu J, Yu J, Chen F, Yu J, Simner P, Tamma P, Liu Y, Shen L. Emergence and establishment of KPC-2-producing ST11 Klebsiella pneumoniae in a general hospital in Shanghai, China. Eur J Clin Microbiol Infect Dis 2018; 37:293-299. [PMID: 29282569 PMCID: PMC5780533 DOI: 10.1007/s10096-017-3131-4] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Accepted: 11/02/2017] [Indexed: 11/24/2022]
Abstract
The aim of this study was to investigate the characteristics of carbapenem-resistant Klebsiella pneumoniae (CRKP) collected during an outbreak in a Chinese teaching hospital and to provide insights into the prevention and control of nosocomial infection. We collected unique CRKP clinical isolates from 2009 to 2013. Antibiotic-resistant genes were identified by polymerase chain reaction (PCR) and sequencing. The isolates were typed using pulsed-field gel electrophoresis (PFGE) and multilocus sequence typing (MLST). Plasmids were classified using a PCR-based incompatibility/replicon typing method and a replicon sequence typing method. Conjugation experiments were performed to evaluate the transferability of carbapenem-resistant genes. Whole genome sequencing (WGS) was conducted to further investigate the genetic background of the isolates. Infection control practices were reviewed throughout the study period. Klebsiella pneumoniae sequence type (ST) 11 emerged in 2010 and acquired the bla KPC-2 gene by 2011. From 2011 to 2013, ST11 KPC-2-producing CRKP (G type) prevailed as the most common CRKP in our hospital, causing a prolonged outbreak. The majority of these CRKP strains possess an IncFII plasmid, with Tn1721-bla KPC-2-ΔTn3-IS26 bearing the genetic structure for bla KPC-2. Infection prevention control measures available at the time contained the initial outbreak, but had no effect on the spread of CRKP later. This study demonstrated the seriousness concerning the spread of KPC-2-producing ST11 CRKP in a Chinese hospital, indicating that current prevention and control strategies for carbapenem-resistant Enterobacteriaceae (CRE) nosocomial infection need to be investigated and adjusted.
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Affiliation(s)
- Jingxian Liu
- Department of Clinical Laboratory, Xin Hua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jing Yu
- Department of Clinical Laboratory, Xin Hua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Feng Chen
- Department of Clinical Laboratory, Xin Hua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jiajia Yu
- Department of Clinical Laboratory, Xin Hua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Patricia Simner
- Department of Pathology, Johns Hopkins Hospital, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Pranita Tamma
- Department of Pathology, Johns Hopkins Hospital, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ying Liu
- Department of Clinical Laboratory, Xin Hua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
| | - Lisong Shen
- Department of Clinical Laboratory, Xin Hua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
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