Carbapenem-resistant Acinetobacter baumannii complex in the United States - an epidemiological and molecular description of isolates collected through the Emerging Infections Program, 2019

BACKGROUND

Understanding the epidemiology of carbapenem-resistant A. baumannii complex (CRAB) and the patients impacted is an important step towards informing better infection prevention and control practices and improving public health response.

METHODS

Active, population-based surveillance was conducted for CRAB in 9 U.S. sites from January 1-December 31, 2019. Medical records were reviewed, isolates were collected and characterized including antimicrobial susceptibility testing and whole genome sequencing.

RESULTS

Among 136 incident cases in 2019, 66 isolates were collected and characterized; 56.5% were from cases who were male, 54.5% were from persons of Black or African American race with non-Hispanic ethnicity, and the median age was 63.5 years. Most isolates, 77.2%, were isolated from urine, and 50.0% were collected in the outpatient setting; 72.7% of isolates harbored an acquired carbapenemase gene (aCP), predominantly blaOXA-23 or blaOXA-24/40; however, an isolate with blaNDM was identified. The antimicrobial agent with the most in vitro activity was cefiderocol (96.9% of isolates were susceptible).

CONCLUSIONS

Our surveillance found that CRAB isolates in the U.S. commonly harbor an aCP, have an antimicrobial susceptibility profile that is defined as difficult-to-treat resistance, and epidemiologically are similar regardless of the presence of an aCP.

Characteristics of Patients With Initial Clostridioides difficile Infection (CDI) That Are Associated With Increased Risk of Multiple CDI Recurrences

Background

Because interventions are available to prevent further recurrence in patients with recurrent Clostridioides difficile infection (rCDI), we identified predictors of multiple rCDI (mrCDI) in adults at the time of presentation with initial CDI (iCDI).

Methods

iCDI was defined as a positive C difficile test in any clinical setting during January 2018-August 2019 in a person aged ≥18 years with no known prior positive test. rCDI was defined as a positive test ≥14 days from the previous positive test within 180 days after iCDI; mrCDI was defined as ≥2 rCDI. We performed multivariable logistic regression analysis.

Results

Of 18 829 patients with iCDI, 882 (4.7%) had mrCDI; 437 with mrCDI and 7484 without mrCDI had full chart reviews. A higher proportion of patients with mrCDI than without mrCDI were aged ≥65 years (57.2% vs 40.7%; P < .0001) and had healthcare (59.1% vs 46.9%; P < .0001) and antibiotic (77.3% vs 67.3%; P < .0001) exposures in the 12 weeks preceding iCDI. In multivariable analysis, age ≥65 years (adjusted odds ratio [aOR], 1.91; 95% confidence interval [CI], 1.55-2.35), chronic hemodialysis (aOR, 2.28; 95% CI, 1.48-3.51), hospitalization (aOR, 1.64; 95% CI, 1.33-2.01), and nitrofurantoin use (aOR, 1.95; 95% CI, 1.18-3.23) in the 12 weeks preceding iCDI were associated with mrCDI.

Conclusions

Patients with iCDI who are older, on hemodialysis, or had recent hospitalization or nitrofurantoin use had increased risk of mrCDI and may benefit from early use of adjunctive therapy to prevent mrCDI. If confirmed, these findings could aid in clinical decision making and interventional study designs.

Residential social vulnerability among healthcare personnel with and without severe acute respiratory coronavirus virus 2 (SARS-CoV-2) infection in Five US states, May-December 2020

OBJECTIVE

To characterize residential social vulnerability among healthcare personnel (HCP) and evaluate its association with severe acute respiratory coronavirus virus 2 (SARS-CoV-2) infection.

DESIGN

Case-control study.

SETTING

This study analyzed data collected in May-December 2020 through sentinel and population-based surveillance in healthcare facilities in Colorado, Minnesota, New Mexico, New York, and Oregon.

PARTICIPANTS

Data from 2,168 HCP (1,571 cases and 597 controls from the same facilities) were analyzed.

METHODS

HCP residential addresses were linked to the social vulnerability index (SVI) at the census tract level, which represents a ranking of community vulnerability to emergencies based on 15 US Census variables. The primary outcome was SARS-CoV-2 infection, confirmed by positive antigen or real-time reverse-transcriptase- polymerase chain reaction (RT-PCR) test on nasopharyngeal swab. Significant differences by SVI in participant characteristics were assessed using the Fisher exact test. Adjusted odds ratios (aOR) with 95% confidence intervals (CIs) for associations between case status and SVI, controlling for HCP role and patient care activities, were estimated using logistic regression.

RESULTS

Significantly higher proportions of certified nursing assistants (48.0%) and medical assistants (44.1%) resided in high SVI census tracts, compared to registered nurses (15.9%) and physicians (11.6%). HCP cases were more likely than controls to live in high SVI census tracts (aOR, 1.76; 95% CI, 1.37-2.26).

CONCLUSIONS

These findings suggest that residing in more socially vulnerable census tracts may be associated with SARS-CoV-2 infection risk among HCP and that residential vulnerability differs by HCP role. Efforts to safeguard the US healthcare workforce and advance health equity should address the social determinants that drive racial, ethnic, and socioeconomic health disparities.

Incomplete tissue product tracing during an investigation of a tissue-derived tuberculosis outbreak

In the United States, there is currently no system to track donated human tissue products to individual recipients. This posed a challenge during an investigation of a nationwide tuberculosis outbreak that occurred when bone allograft contaminated with Mycobacterium tuberculosis (Lot A) was implanted into 113 patients in 18 US states, including 2 patients at 1 health care facility in Colorado. A third patient at the same facility developed spinal tuberculosis with an isolate genetically identical to the Lot A outbreak strain. However, health care records indicated this patient had received bone allograft from a different donor (Lot B). We investigated the source of this newly identified infection, including the possibilities of Lot B donor infection, product switch or contamination during manufacturing, product switch at the health care facility, person-to-person transmission, and laboratory error. The findings included gaps in tissue traceability at the health care facility, creating the possibility for a product switch at the point of care despite detailed tissue-tracking policies. Nationally, 6 (3.9%) of 155 Lot B units could not be traced to final disposition. This investigation highlights the critical need to improve tissue-tracking systems to ensure unbroken traceability, facilitating investigations of recipient adverse events and enabling timely public health responses to prevent morbidity and mortality.

Trends in Incidence of Carbapenem-Resistant Enterobacterales in 7 US Sites, 2016─2020

Background

We described changes in 2016─2020 carbapenem-resistant Enterobacterales (CRE) incidence rates in 7 US sites that conduct population-based CRE surveillance.

Methods

An incident CRE case was defined as the first isolation of Escherichia coli, Klebsiella spp., or Enterobacter spp. resistant to ≥1 carbapenem from a sterile site or urine in a surveillance area resident in a 30-day period. We reviewed medical records and classified cases as hospital-onset (HO), healthcare-associated community-onset (HACO), or community-associated (CA) CRE based on healthcare exposures and location of disease onset. We calculated incidence rates using census data. We used Poisson mixed effects regression models to perform 2016─2020 trend analyses, adjusting for sex, race/ethnicity, and age. We compared adjusted incidence rates between 2016 and subsequent years using incidence rate ratios (RRs) and 95% confidence intervals (CIs).

Results

Of 4996 CRE cases, 62% were HACO, 21% CA, and 14% HO. The crude CRE incidence rate per 100 000 was 7.51 in 2016 and 6.08 in 2020 and was highest for HACO, followed by CA and HO. From 2016 to 2020, the adjusted overall CRE incidence rate decreased by 24% (RR, 0.76 [95% CI, .70-.83]). Significant decreases in incidence rates in 2020 were seen for HACO (RR, 0.75 [95% CI, .67-.84]) and CA (0.75 [.61-.92]) but not for HO CRE.

Conclusions

Adjusted CRE incidence rates declined from 2016 to 2020, but changes over time varied by epidemiologic class. Continued surveillance and effective control strategies are needed to prevent CRE in all settings.

Epidemiology of Pulmonary and Extrapulmonary Nontuberculous Mycobacteria Infections at 4 US Emerging Infections Program Sites: A 6-Month Pilot

BACKGROUND

Nontuberculous mycobacteria (NTM) cause pulmonary (PNTM) and extrapulmonary (ENTM) disease. Infections are difficult to diagnose and treat, and exposures occur in healthcare and community settings. In the United States, NTM epidemiology has been described largely through analyses of microbiology data from health departments, electronic health records, and administrative data. We describe findings from a multisite pilot of active, laboratory- and population-based NTM surveillance.

METHODS

The Centers for Disease Control and Prevention's Emerging Infections Program conducted NTM surveillance at 4 sites (Colorado, 5 counties; Minnesota, 2 counties; New York, 2 counties; and Oregon, 3 counties [PNTM] and statewide [ENTM]) from 1 October 2019 through 31 March 2020. PNTM cases were defined using published microbiologic criteria. ENTM cases required NTM isolation from a nonpulmonary specimen, excluding stool and rectal swabs. Patient data were collected via medical record review.

RESULTS

Overall, 299 NTM cases were reported (PNTM: 231, 77%); Mycobacterium avium complex was the most common species group. Annualized prevalence was 7.5/100 000 population (PNTM: 6.1/100 000; ENTM: 1.4/100 000). Most patients had signs or symptoms in the 14 days before positive specimen collection (ENTM: 62, 91.2%; PNTM: 201, 87.0%). Of PNTM cases, 145 (62.8%) were female and 168 (72.7%) had underlying chronic lung disease. Among ENTM cases, 29 (42.6%) were female, 21 (30.9%) did not have documented underlying conditions, and 26 (38.2%) had infection at the site of a medical device or procedure.

CONCLUSIONS

Active, population-based NTM surveillance will provide data for monitoring the burden of disease and characterize affected populations to inform interventions.

962. Pediatric Antimicrobial Stewardship at Colorado Hospitals

Background

Although antibiotics are essential to pediatric care, many pediatric antimicrobial prescriptions are inappropriate. Antimicrobial stewardship programs (ASPs) are implemented to mitigate these instances of inappropriate prescription, but little is known about how these programs are applied to pediatric care. To better understand extension of ASP to pediatric patients, barriers to pediatric stewardship, and desired resources for pediatric stewardship, we assessed stewardship practices as applied to pediatric patients and identified barriers to including this vulnerable population across Colorado hospitals.

Methods

We conducted a mixed-methods evaluation including a survey and semi-structured interviews with the objective of characterizing and assisting Colorado ASPs. Forty-one hospitals responded to the survey and 24 programs were interviewed, of 103 possible hospitals.

Results

Of the 41 hospitals responding to the survey and 23 hospitals interviewed, 35 (85%) and 23 (90%) cared for pediatric patients respectively. Of hospitals caring for neonatal and general pediatric patients, only 17% and 14% employed rigorous stewardship practices for the action, tracking, and reporting stewardship core elements for these populations (compared to 50% and 31% for their adult patients).

Notably, we found many programs inaptly combined adult and pediatric ASP efforts (18 hospitals, 81%), including frequent combining of adult and pediatric antibiotic use data, versus separating these patient populations (3 hospitals, 14%).

Barriers to priority pediatric stewardship included lack of pediatric expertise and perceived low priority for pediatric stewardship due to lower volumes. The most desired pediatric resources were clinical care guidelines and pediatric stewardship education.

Conclusion

Though most hospitals in Colorado care for pediatric patients, priority stewardship in pediatrics is rare. Resources to assist pediatric ASP are uncommon, and incentive to develop such resources may be low. Public health departments and pediatric hospitals can help combat antimicrobial resistance and improve pediatric care in community settings by providing easier access to pediatric expertise.

Disclosures

All Authors: No reported disclosures.

86. Antibiotic-resistant gram-negative bacterial infections among persons with or without a prior positive test for SARS-CoV-2 in 10 U.S. sites, 2020

Background

The Centers for Disease Control and Prevention’s Emerging Infections Program (EIP) conducts active laboratory- and population-based surveillance for carbapenem-resistant Enterobacterales (CRE), extended spectrum beta-lactamase-producing Enterobacterales (ESBL-E), and carbapenem-resistant Acinetobacter baumannii (CRAB) in 10 U.S. sites. To describe the impact of the COVID-19 pandemic on the epidemiology of these antibiotic-resistant gram-negative bacteria (AR-GNB), we assessed characteristics of AR-GNB patients with and without a prior SARS-CoV-2 positive (SC2+) viral test.

Methods

In 2020 among EIP catchment-area residents, an incident CRAB or CRE case was defined as the first isolation of A. baumannii complex, Escherichia coli, Enterobacter cloacae complex, Klebsiella aerogenes, K. oxytoca, K. pneumonia, or K. variicola in a 30-day period resistant to ≥1 carbapenem (excluding ertapenem for CRAB) from a normally sterile site or urine. An incident ESBL-E case was defined as the first isolation of E. coli, K. pneumonia, or K. oxytoca in a 30-day period resistant to any third-generation cephalosporin and non-resistant to all carbapenems from a normally sterile site or urine. Patient charts were reviewed.

Results

Of 3904 AR-GNB cases with data available, 163 (4%) had a prior SC2+ test (85 ESBL-E, 70 CRE, and 8 CRAB). Median time from the most recent SC2+ test to AR-GNB culture date was 20 days (IQR 1–48 days). AR-GNB cases with a SC2+ test versus those without were more likely to be Black, non-Hispanic than another race/ethnicity (31% vs 15%; P< 0.0001), aged ≥65 years (62% vs 52%; P=0.0139), and to have prior healthcare exposures (63% vs 49%; P=0.0003) and indwelling devices (51% vs 28%; P< 0.0001). They were also more likely to have bacteremia (24% vs 11%; P< 0.0001), pneumonia (6% vs 1%; P< 0.0001) and be hospitalized around the time of their AR-GNB culture (67% vs 36%; P< 0.0001); median time from SC2+ test to hospital admission was 0.5 day (IQR 0–29.5 days).

Conclusion

AR-GNB infections preceded by a SC2+ test were rare but more severe and associated with more healthcare risk factors. This underscores the need for continued infection prevention and control practices and monitoring of these infections during the COVID-19 pandemic.

Disclosures

Ghinwa Dumyati, MD, Pfizer: Grant/Research Support.

Impact of the coronavirus disease 2019 (COVID-19) pandemic on antimicrobial stewardship programs in Colorado hospitals

Using a mixed-methods approach, we assessed the effect of the coronavirus disease 2019 (COVID-19) pandemic on antimicrobial stewardship programs (ASPs) in Colorado hospitals. ASP leaders reported decreased time and resources, reduced rigor of stewardship interventions, inability to complete new initiatives, and interpersonal challenges. Stewardship activities may be threatened during times of acute resource pressure.

Low sensitivity of ICD-10 coding for culture-confirmed candidemia cases in an active surveillance system—United States, 2019–2020

We evaluated healthcare facility use of ICD-10 codes for culture-confirmed candidemia cases detected by active public health surveillance during 2019–2020. Most cases (56%) did not receive a candidiasis code, suggesting that studies relying on ICD-10 codes likely underestimate disease burden.

Risk Factors for SARS-CoV-2 Infection Among US Healthcare Personnel, May-December 2020

To determine risk factors for coronavirus disease (COVID-19) among US healthcare personnel (HCP), we conducted a case-control analysis. We collected data about activities outside the workplace and COVID-19 patient care activities from HCP with positive severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) test results (cases) and from HCP with negative test results (controls) in healthcare facilities in 5 US states. We used conditional logistic regression to calculate adjusted matched odds ratios and 95% CIs for exposures. Among 345 cases and 622 controls, factors associated with risk were having close contact with persons with COVID-19 outside the workplace, having close contact with COVID-19 patients in the workplace, and assisting COVID-19 patients with activities of daily living. Protecting HCP from COVID-19 may require interventions that reduce their exposures outside the workplace and improve their ability to more safely assist COVID-19 patients with activities of daily living.

1408. Population-based Nontuberculous Mycobacteria Surveillance in Four Emerging Infections Program Sites, October 2019–March 2020

Background

Nontuberculous mycobacteria (NTM) cause pulmonary (PNTM) and extrapulmonary (ENTM) disease. NTM infections are difficult to diagnose and treat; environmental exposures occur in both healthcare and community settings. Few population-based studies describe NTM disease epidemiology. Current data indicate PNTM disease and ENTM skin and soft tissue infections are increasing. We describe findings from a multi-site pilot of population-based NTM surveillance.

Methods

CDC’s Emerging Infections Program conducted active, laboratory- and population-based surveillance for NTM cases occurring in 4 sites (Colorado [5 counties], Minnesota [2 counties], New York [2 counties], and Oregon [3 counties PNTM; statewide ENTM]) during October 1, 2019–March 31, 2020. PNTM cases were defined according to current published microbiologic criteria, based on isolation of NTM in respiratory cultures or tissue. ENTM cases required NTM isolation from a non-pulmonary specimen, excluding stool or rectal swabs. Demographic, clinical, exposure, and laboratory data were collected via medical record review. We calculated overall incidence per 100,000 population using census data and performed descriptive analyses of medical record data.

Results

Overall, 299 NTM cases were reported (231 [77%] PNTM); M. avium was the most commonly isolated species (Table). NTM incidence was 3.8 per 100,000 (PNTM 3.1/100,000; ENTM 0.7/100,000). Most patients with available data had ≥1 sign or symptom in the 14 days before culture (63 [97%] ENTM, 203 [92%] PNTM). During the surveillance period, 187 (63%) had their first infection-defining culture collected in an outpatient setting (33 [49%] ENTM, 154 [67%] PNTM). Of PNTM cases, 145 (64%) were female, and 154 (67%) had underlying pulmonary disease. Among ENTM cases, 29 (43%) were female, 9 (13%) had diabetes, 8 (12%) had HIV and 27 (40%) had infection at the site of a medical device or healthcare procedure. Common ENTM infection types were lymphadenitis (16 [24%]) and skin abscess (12 [18%]).

Table. Characteristics of persons with NTM infection identified in population-based surveillance, October 1, 2019–March 31, 2020.

Conclusion

Characterizing disease burden and affected populations with population-based NTM surveillance will provide data to inform potential interventions and monitor prevention strategy impact.

Disclosures

Christopher A. Czaja, MD, DrPH, Centers for Disease Control and Prevention (Grant/Research Support) Ruth Lynfield, MD, Nothing to disclose Ghinwa Dumyati, MD, Pfizer (Grant/Research Support)Roche Diagnostics (Advisor or Review Panel member) Emily Henkle, PhD, MPH, AN2 (Consultant, Advisor or Review Panel member)Zambon (Advisor or Review Panel member) Kevin L. Winthrop, MD, MPH, Insmed (Consultant, Grant/Research Support)Paratek (Consultant)RedHill (Consultant)Spero (Consultant) Kevin L. Winthrop, MD, MPH, Insmed (Consultant, Research Grant or Support)Paratek (Consultant)RedHill Biopharma (Consultant)Spero (Consultant)

Adult Population Coverage With Influenza Vaccine and Influenza Hospitalization Rates-Is There a Role for Active Outreach to Immunize At-Risk Neighborhoods?

We evaluated whether Denver neighborhoods with elevated rates of adult hospitalizations for laboratory-confirmed influenza had lower adult coverage with influenza vaccine. Overall vaccine coverage was low. Hospitalization rates were associated with demographic and socioeconomic characteristics. Active immunization of at-risk neighborhoods may be necessary to address disparities in influenza hospitalization rates.

The landscape of candidemia during the COVID-19 pandemic

BACKGROUND

The COVID-19 pandemic has resulted in unprecedented healthcare challenges, and COVID-19 has been linked to secondary infections. Candidemia, a fungal healthcare-associated infection, has been described in patients hospitalized with severe COVID-19. However, studies of candidemia and COVID-19 co-infection have been limited in sample size and geographic scope. We assessed differences in patients with candidemia with and without a COVID-19 diagnosis.

METHODS

We conducted a case-level analysis using population-based candidemia surveillance data collected through the Centers for Disease Control and Prevention's Emerging Infections Program during April-August 2020 to compare characteristics of candidemia patients with and without a positive test for COVID-19 in the 30 days before their Candida culture using chi-square or Fisher exact tests.

RESULTS

Of the 251 candidemia patients included, 64 (25.5%) were positive for SARS-CoV-2. Liver disease, solid organ malignancies, and prior surgeries were each >3 times more common in patients without COVID-19 co-infection, whereas intensive care unit-level care, mechanical ventilation, having a central venous catheter, and receipt of corticosteroids and immunosuppressants were each >1.3 times more common in patients with COVID-19. All cause in-hospital fatality was two times higher among those with COVID-19 (62.5%) than without (32.1%).

CONCLUSIONS

One quarter of candidemia patients had COVID-19. These patients were less likely to have certain underlying conditions and recent surgery commonly associated with candidemia and more likely to have acute risk factors linked to COVID-19 care, including immunosuppressive medications. Given the high mortality, it is important for clinicians to remain vigilant and take proactive measures to prevent candidemia in patients with COVID-19.

Treatment Practices for Adults with Candidemia at Nine Active Surveillance Sites - United States, 2017-2018

BACKGROUND

Candidemia is a common opportunistic infection causing substantial morbidity and mortality. Because of an increasing proportion of non-albicans Candida species and rising antifungal drug resistance, the Infectious Diseases Society of America (IDSA) changed treatment guidelines in 2016 to recommend echinocandins over fluconazole as first-line treatment for adults with candidemia. We describe candidemia treatment practices and adherence to the updated guidelines.

METHODS

During 2017-2018, the Emerging Infections Program conducted active population-based candidemia surveillance at nine U.S. sites using a standardized case definition. We assessed factors associated with initial antifungal treatment for the first candidemia case among adults using multivariable logistic regression models. To identify instances of potentially inappropriate treatment, we compared the first antifungal drug received with species and antifungal susceptibility testing (AFST) results from initial blood cultures.

RESULTS

Among 1,835 patients who received antifungal treatment, 1,258 (68.6%) received an echinocandin and 543 (29.6%) received fluconazole as initial treatment. Cirrhosis (adjusted odds ratio = 2.06, 95% confidence interval: 1.29-3.29) was the only underlying medical condition significantly associated with initial receipt of an echinocandin (versus fluconazole). Over half (n = 304, 56.0%) of patients initially treated with fluconazole grew a non-albicans species. Among 265 patients initially treated with fluconazole and with fluconazole AFST results, 28 (10.6%) had a fluconazole-resistant isolate.

CONCLUSIONS

A substantial proportion of patients with candidemia were initially treated with fluconazole, resulting in potentially inappropriate treatment for those involving non-albicans or fluconazole-resistant species. Reasons for non-adherence to IDSA guidelines should be evaluated, and clinician education is needed.

Improving Delayed Antibiotic Prescribing for Acute Otitis Media

OBJECTIVES

Acute otitis media (AOM) is the most-common indication for antibiotics in children. Delayed antibiotic prescribing for AOM can significantly reduce unnecessary antibiotic use and is recommended by the American Academy of Pediatrics for select children. We sought to improve delayed prescribing for AOM across 8 outpatient pediatric practices in Colorado.

METHODS

Through a collaborative initiative with American Academy of Pediatrics and the Centers for Disease Control and Prevention, we implemented an economical 6-month antimicrobial stewardship intervention that included education, audit and feedback, online resources, and content expertise. Practices used The Model for Improvement and plan-do-study-act cycles to improve delayed antibiotic prescribing. Generalized estimating equations were used to generate relative risk ratios (RRRs) for outcomes at the intervention end and 3- and 6-months postintervention. Practice surveys were evaluated.

RESULTS

In total, 69 clinicians at 8 practice sites implemented 27 plan-do-study-act cycles. Practices varied by size (range: 6-37 providers), payer type, and geographic setting. The rate of delayed antibiotic prescribing increased from 2% at baseline to 21% at intervention end (RRR: 8.96; 95% confidence interval [CI]: 4.68-17.17). Five practices submitted postintervention data. The rate of delayed prescribing at 3 months and 6 months postintervention remained significantly higher than baseline (3 months postintervention, RRR: 8.46; 95% CI: 4.18-17.11; 6 months postintervention, RRR: 6.69; 95% CI: 3.53-12.65) and did not differ from intervention end (3 months postintervention, RRR: 1.12; 95% CI: 0.62-2.05; 6-months postintervention, RRR: 0.89; 95% CI: 0.53-1.49).

CONCLUSIONS

Baseline rate of delayed prescribing was low. A low-cost intervention resulted in a significant and sustained increase in delayed antibiotic prescribing across a diversity of settings.

Evaluation of rates of laboratory-confirmed influenza hospitalization in rural and urban census tracts over eight influenza seasons

The burden of influenza in rural areas is largely unstudied. Rural populations may be vulnerable yet isolated from circulating virus. Laboratory-confirmed influenza hospitalizations in rural Colorado census tracts over eight influenza seasons were inconsistently distributed across seasons. Rural rates were, on average, lower than urban rates. Race, ethnicity, poverty, health insurance coverage, and distance from a hospital accounted for rate differences. Our interpretation is: 1) influenza regularly circulates in urban areas and inconsistently spreads to rural areas, 2) demographic and socioeconomic factors drive morbidity in exposed populations, and 3) public health interventions targeting high-risk urban census tracts may be beneficial.

State-level estimates of excess hospitalizations and deaths associated with influenza

Background

National estimates of influenza burden may not reflect state‐level influenza activity, and local surveillance may not capture the full burden of influenza.

Methods

To provide state‐level information about influenza burden, we estimated excess pneumonia and influenza (P&I) and respiratory and circulatory (R&C) hospitalizations and deaths in Colorado from local hospital discharge records, death certificates, and influenza virus surveillance using negative binomial models.

Results

From July 2007 to June 2016, influenza was associated with an excess of 17 911 P&I hospitalizations (95%CI: 15 227, 20 354), 30 811 R&C hospitalizations (95%CI: 24 344, 37 176), 1,064 P&I deaths (95%CI: 757, 1298), and 3828 R&C deaths (95%CI: 2060, 5433). There was a large burden of influenza A(H1N1) among persons aged 0‐64 years, with high median seasonal rates of excess hospitalization among persons aged 0‐4 years. Persons aged ≥65 years experienced the largest numbers and highest median seasonal rates of excess hospitalization and death associated with influenza A (H3N2). The burden of influenza B was generally lower, with elevated median seasonal rates of excess hospitalization among persons aged 0‐4 years and ≥65 years.

Conclusions

These findings complement existing influenza surveillance. Periodic state‐level estimates of influenza disease burden may be useful for setting state public health priorities and planning prevention and control initiatives.

Age-Related Differences in Hospitalization Rates, Clinical Presentation, and Outcomes Among Older Adults Hospitalized With Influenza-U.S. Influenza Hospitalization Surveillance Network (FluSurv-NET)

BACKGROUND

Rates of influenza hospitalizations differ by age, but few data are available regarding differences in laboratory-confirmed rates among adults aged ≥65 years.

METHODS

We evaluated age-related differences in influenza-associated hospitalization rates, clinical presentation, and outcomes among 19 760 older adults with laboratory-confirmed influenza at 14 FluSurv-NET sites during the 2011-2012 through 2014-2015 influenza seasons using 10-year age groups.

RESULTS

There were large stepwise increases in the population rates of influenza hospitalization with each 10-year increase in age. Rates ranged from 101-417, 209-1264, and 562-2651 per 100 000 persons over 4 influenza seasons in patients aged 65-74 years, 75-84 years, and ≥85 years, respectively. Hospitalization rates among adults aged 75-84 years and ≥85 years were 1.4-3.0 and 2.2-6.4 times greater, respectively, than rates for adults aged 65-74 years. Among patients hospitalized with laboratory-confirmed influenza, there were age-related differences in demographics, medical histories, and symptoms and signs at presentation. Compared to hospitalized patients aged 65-74 years, patients aged ≥85 years had higher odds of pneumonia (aOR, 1.2; 95% CI, 1.0-1.3; P = .01) and in-hospital death or transfer to hospice (aOR, 2.1; 95% CI, 1.7-2.6; P < .01).

CONCLUSIONS

Age-related differences in the incidence and severity of influenza hospitalizations among adults aged ≥65 years can inform prevention and treatment efforts, and data should be analyzed and reported using additional age strata.

Identifying gaps in research prioritization: The global burden of neglected tropical diseases as reflected in the Cochrane database of systematic reviews

Background:

Neglected tropical diseases (NTDs) impact disadvantaged populations in resource-scarce settings. Availability of synthesized evidence is paramount to end this disparity. The aim of the study was to determine whether NTD systematic reviews or protocols in the Cochrane Database of Systematic Reviews (CDSR) reflect disease burden.

Methods:

Two authors independently searched the CDSR for reviews/protocols regarding the NTDs diseases. Each review or protocol was classified to a single NTD category. Any discrepancy was solved by consensus with third author. NTD systematic review or protocol from CDSR were matched with disability-adjusted life year (DALY) metrics from the Global Burden of Disease 2010 Study. Spearman's rank correlation coefficient and associated P values were used to assess for correlation between the number of systematic reviews and protocols and the %2010 DALY associated with each NTD.

Results:

Overall, there was poor correlation between CDSR representation and DALYs. Yellow fever, echinococcus, onchocerciasis, and schistosomiasis representation was well-aligned with DALY. Leprosy, trachoma, dengue, leishmaniasis, and Chagas disease representation was greater, while cysticercosis, human African trypanosomiasis, ascariasis, lymphatic filariasis, and hookworm representation was lower than DALY. Three of the 18 NTDs had reviews/protocols of diagnostic test accuracy.

Conclusions:

Our results indicate the need for increased prioritization of systematic reviews on NTDs, particularly diagnostic test accuracy reviews.

Rituximab as successful adjunct treatment in a patient with disseminated nontuberculous mycobacterial infection due to acquired anti-interferon-γ autoantibody

An acquired immune deficiency due to interferon gamma (IFN-γ) autoantibodies was diagnosed in a 78-year-old Japanese man with treatment-refractory disseminated nontuberculous mycobacterial infection. In addition to standard antimycobacterial therapy, he was successfully treated with rituximab to eliminate B cells and thereby the autoantibody. Subsequently, he obtained a sustained remission from infection.

Randomized, placebo-controlled phase 2 trial of a Lactobacillus crispatus probiotic given intravaginally for prevention of recurrent urinary tract infection

BACKGROUND

Urinary tract infections (UTIs) are common among women and frequently recur. Depletion of vaginal lactobacilli is associated with UTI risk, which suggests that repletion may be beneficial. We conducted a double-blind placebo-controlled trial of a Lactobacillus crispatus intravaginal suppository probiotic (Lactin-V; Osel) for prevention of recurrent UTI in premenopausal women.

METHODS

One hundred young women with a history of recurrent UTI received antimicrobials for acute UTI and then were randomized to receive either Lactin-V or placebo daily for 5 d, then once weekly for 10 weeks. Participants were followed up at 1 week and 10 weeks after intervention and for UTIs; urine samples for culture and vaginal swabs for real-time quantitative 16S ribosomal RNA gene polymerase chain reaction for L. crispatus were collected.

RESULTS

Recurrent UTI occurred in 7/48 15% of women receiving Lactin-V compared with 13/48 27% of women receiving placebo (relative risk [RR], .5; 95% confidence interval, .2-1.2). High-level vaginal colonization with L. crispatus (≥10(6) 16S RNA gene copies per swab) throughout follow-up was associated with a significant reduction in recurrent UTI only for Lactin-V (RR for Lactin-V, .07; RR for placebo, 1.1; P < .01).

CONCLUSIONS

Lactin-V after treatment for cystitis is associated with a reduction in recurrent UTI. Larger efficacy trials of this novel preventive method for recurrent UTI are warranted. CLINICAL TRIALS REGISTRATION. NCT00305227.

Prospective cohort study of microbial and inflammatory events immediately preceding Escherichia coli recurrent urinary tract infection in women

BACKGROUND

A prospective cohort study was conducted to characterize the temporal sequence of microbial and inflammatory events immediately preceding Escherichia coli recurrent urinary tract infection (rUTI).

METHODS

Women with acute cystitis and a history of UTI within the previous year self-collected periurethral and urine samples daily and recorded measurements of urine leukocyte esterase, symptoms, and sexual intercourse daily for 3 months. rUTI strains were characterized by pulsed-field gel electrophoresis and genomic virulence profiling. Urinary cytokine levels were measured.

RESULTS

There were 38 E. coli rUTIs in 29 of 104 women. The prevalence of periurethral rUTI strain carriage increased from 46% to 90% during the 14 days immediately preceding rUTI, with similar increases in same-strain bacteriuria (from 7% to 69%), leukocyte esterase (from 31% to 64%), and symptoms (from 3% to 43%), most notably 2-3 days before rUTI (P<.05 for all comparisons). Intercourse with periurethral carriage of the rUTI strain also increased before rUTI (P=.008). Recurrent UTIs preceded by bacteriuria, pyuria, and symptoms were caused by strains less likely to have P fimbriae than other rUTI strains (P=.002).

CONCLUSIONS

Among women with frequent rUTIs, the prevalences of periurethral rUTI strain carriage, bacteriuria, pyuria, and intercourse dramatically increase over the days preceding rUTI. A better understanding of the pathogenesis of rUTI will lead to better prevention strategies.

Urinary tract infections in women with type 1 diabetes mellitus: survey of female participants in the epidemiology of diabetes interventions and complications study cohort

PURPOSE

We determined the prevalence of and risk factors for urinary tract infection in women with type 1 diabetes, and compared the prevalence of cystitis to that in nondiabetic women.

MATERIALS AND METHODS

Women enrolled in the Epidemiology of Diabetes Interventions and Complications study were surveyed at year 10 as part of the Uro-EDIC study to assess the prevalence of cystitis and pyelonephritis in the preceding 12 months. Multivariate logistic regression models including measures of glycemic control and vascular complications of type 1 diabetes were used for risk factor analyses. The prevalence of cystitis in Uro-EDIC women was compared to that in a nondiabetic subset of women participants in the National Health and Nutrition Examination Survey III (NHANES III).

RESULTS

A total of 550 women participated in the Uro-EDIC survey. The prevalence of cystitis and pyelonephritis in the preceding 12 months was 15% and 3%, respectively. Duration of diabetes, hemoglobin A1C, retinopathy, neuropathy, nephropathy, composite vascular complication score and intensive glycemic therapy during the Diabetes Control and Complications Trial, and Diabetes Control and Complications Trial cohort were not associated with cystitis or pyelonephritis. Sexual activity was associated with increased cystitis risk (adjusted OR 8.28; 95% CI 1.45, 158.32; p = 0.01). The adjusted prevalence of cystitis was 19.1% in Uro-EDIC women and 23.1% in NHANES III participants (adjusted OR 0.78; 95% CI 0.51, 1.22; p = 0.28).

CONCLUSIONS

In Uro-EDIC women sexual activity rather than measures of diabetes control and complications was the main risk factor for urinary tract infection. The prevalence of cystitis was similar to that in nondiabetic women participants in NHANES III.

Population-based epidemiologic analysis of acute pyelonephritis

BACKGROUND

Acute pyelonephritis is a potentially severe disease for which there are few population-based studies. We performed a population-based analysis of trends in the incidence, microbial etiology, antimicrobial resistance, and antimicrobial therapy of outpatient and inpatient pyelonephritis.

METHODS

A total of 4887 enrollees of Group Health Cooperative, based in Seattle, Washington, who received an International Classification of Diseases, Ninth Revision, Clinical Modification, diagnosis of acute pyelonephritis from 1997 through 2001 were identified using computerized records. Diagnoses were linked to urine culture and antibiotic prescription data. Case patients (n=3236) included subjects who had received an inpatient or culture-confirmed outpatient diagnosis of acute pyelonephritis.

RESULTS

Among the female population, annual rates of outpatient and inpatient pyelonephritis were 12-13 cases per 10,000 population and 3-4 cases per 10,000 population, respectively; among the male population, the rates were 2-3 cases per 10,000 population and 1-2 cases per 10,000 population, respectively. Rates were relatively stable from year to year. Incidence was highest among young women, followed by infants and the elderly population. The ratio of outpatient to inpatient cases was highest among young women (ranging from 5 : 1 to 6 : 1). Escherichia coli caused 80% of cases of acute pyelonephritis in women and 70% of cases in men and was less dominant in older age groups. Among E. coli strains, the rate of ciprofloxacin resistance increased from 0.2% of isolates to 1.5% of isolates (P=.03), and the rate of trimethoprim-sulfamethoxazole resistance decreased from 25% of isolates to 13% of isolates (P<.01) from 1997 to 2001. Among outpatient cases, the rate of fluoroquinolone use increased from 35% to 61%, whereas the rate of trimethoprim-sulfamethoxazole use decreased from 53% to 32% over the 5-year period (P<.01).

CONCLUSIONS

This comprehensive, population-based analysis adds to our limited knowledge of the epidemiology of acute pyelonephritis, especially among outpatients, in whom the majority of cases now occur.

Update on acute uncomplicated urinary tract infection in women

UTI continues to be a common problem for otherwise healthy adult women. Treatment of UTI has become more difficult because of the rising levels of resistance to commonly used antibiotics. Further research is needed to develop new antibiotic therapies and nonantibiotic prevention measures.