scholarly journals Six Years of Admission Screening for Carbapenemase-Producing Organisms at the NIH Clinical Center

2020 ◽  
Vol 41 (S1) ◽  
pp. s79-s80
Author(s):  
Robin T. Odom ◽  
Michele E. Woolbert ◽  
Anna F. Lau ◽  
John P. Dekker ◽  
Angela V. Michelin ◽  
...  
Keyword(s):  
High Risk ◽  
Patient Population ◽  
The United States ◽  
Point Prevalence ◽  
Safety Measures ◽  
Healthcare Facilities ◽  
Admission Screening ◽  
Clinical Center ◽  
Risk Patients ◽  
Vulnerable Patient

Background: Transmission of carbapenemase-producing organisms (CPO) threatens patient safety in healthcare facilities. As a result of a 2011 outbreak of blaKPC+ Klebsiella pneumoniae, the NIH Clinical Center (NIHCC) has prioritized early detection and isolation of CPO carriers, using point-prevalence surveys and targeted high-risk ward surveillance since 2011 and admission surveillance since 2013. We describe our experience over 6 years of admission surveillance. Methods: The NIHCC is a 200-bed research hospital that provides care for a highly immunocompromised patient population. From September 2013 to September 2019, perirectal swabs were ordered automatically for all patients on admission to nonbehavioral health wards. Swabs were ordered twice weekly for ICU patients, weekly in other high-risk wards, and monthly for hospital-wide point prevalence (excluding behavioral health). Patients hospitalized in the United States in the previous week or abroad in the previous 6 months were considered high risk for carriage and isolated pending results from 2 swabs. Most swabs (n = 37,526) were cultured onto HardyCHROM CRE. If gram-negative bacilli (GNB) were present, a molecular screen for carbapenemases was performed on a sweep of cultured material (day 1) pending organism isolation. GNB were identified by MALDI-TOF MS. Prior to June 2019, isolates were screened by blaKPC/blaNDM PCR. Starting in June 2019, Enterobacteriaceae and Pseudomonas aeruginosa were screened using the phenotypic modified carbapenem inactivation method (mCIM), reflexing to the GeneXpert CARBA-R molecular assay if positive; other GNB were tested directly with CARBA-R. Selected GNB underwent susceptibility testing (Sensititre). Whole-genome sequencing was used to assess relatedness among CPO isolates. Swabs from high-risk patients were tested directly by blaKPC PCR (n = 699) until August 2019 (most in parallel with culture) and thereafter by CARBA-R (n = 13). Results: Among 54,188 orders for perirectal swabs, 38,238 were collected from 14,497 patients (compliance 71%). Among 33 CPO-colonized patients identified from September 2013 through September 2019, 15 were identified on admission, 6 were identified in point-prevalence surveys, 8 were identified from high-risk ward surveillance, and 4 were identified from clinical cultures. Sequencing demonstrated no relatedness among CPO isolates. Although only 1.4% of patients sampled on admission were colonized with CPO, those meeting high-risk criteria were 21 times as likely to be colonized. Conclusion: Admission surveillance for CPO identified a low rate of colonization, but it detected nearly half of known CPO-colonized NIHCC patients over the past 6 years. Modest compliance with swab collection leaves room for improvement and likely results in missed instances of colonization. Although we cannot determine its effectiveness, we view our strategy as one of several key safety measures for our highly vulnerable patient population.Funding: NoneDisclosures: None

scholarly journals Admission Screening for Candida auris Among High-Risk Patient Populations

2020 ◽  
Vol 41 (S1) ◽  
pp. s112-s113
Author(s):  
Christine D. Spalding ◽  
Zelazny Adrian ◽  
Christina M. Kenosky ◽  
Shamira J. Shallom ◽  
Seyedmojtaba Syedmoussavi ◽  
...  
Keyword(s):  
High Risk ◽  
High Risk Patient ◽  
The United States ◽  
Risk Patient ◽  
Molecular Testing ◽  
Candida Auris ◽  
Admission Screening ◽  
Clinical Center ◽  
Its Sequence Analysis ◽  
Healthcare Associated

Background:Candida auris is a highly transmissible healthcare-associated pathogen that can cause severe infection as well as long-lasting colonization. C. auris is often resistant to the antifungals that are commonly used to treat Candida infections, which may lead to clinical failure. Therefore, healthcare facilities must identify the organism quickly and implement strict precautions to prevent its spread. In 2019, the NIH Clinical Center instituted C. auris admission screening among its high-risk patient populations. Methods: Patients admitted to the NIH Clinical Center, a 200-bed research hospital, were identified on admission as having been hospitalized outside the United States in the prior 6 months. Admission screening began in August 2019. In September 2019, due to evolving regional epidemiology, we expanded surveillance criteria to include patients housed in any healthcare facility in the District of Columbia, Maryland, and Virginia metro area in the previous 6 months. Screening was performed as routine clinical care, and therefore did not require written informed consent. Swabs were obtained from nares, axilla and groin, with subsequent addition of mouth and toe web (BD ESwabs). Patients were placed on empiric contact isolation for at least 48 hours and concurrently screened for carbapenemase-producing organisms. Swabs were cultured on CHROMagar Candida and in Sabouraud dextrose broth with 10% NaCL and 50 mg/L chloramphenicol and gentamicin, and incubated for 14 days at 30°C and 40°C, respectively. Positive broth tubes were subcultured onto CHROMagar Candida. C. auris was identified by MALDI-TOF MS and ITS sequence analysis. Susceptibility testing was performed using Sensititre YeastOne Colorimetric assay. Whole-genome sequencing was used to identify clonal designations and genetic relatedness of isolates. Results: Since August 2019, 1 to 2 patients per week have been screened for C. auris. As of November 2019, 1 of 15 patients screened on admission grew C. auris from a groin swab. The patient, who had been hospitalized abroad, was found to be cocolonized with blaNDM-1+ E. coli and K. pneumoniae. Subsequent screening of other patients on the same ward identified no evidence of spread. Admission surveillance is ongoing. Conclusions: Healthcare-associated outbreaks can originate from C. auris–colonized patients. Admission surveillance of high-risk patients is intended to prevent transmission from undetected reservoirs. Our sampling of multiple sites, though laborious, may add to the data on C. auris colonization. Future plans include incorporating molecular testing and streamlining geographic criteria. C. auris admission screening has already identified one colonized patient, and will continue as a new and important patient safety measure at our hospital.Funding: NoneDisclosures: None

Guidelines for the Management of Pediatric and Adult Tumor Lysis Syndrome: An Evidence-Based Review

2008 ◽  
Vol 26 (16) ◽  
pp. 2767-2778 ◽  
Author(s):  
Bertrand Coiffier ◽  
Arnold Altman ◽  
Ching-Hon Pui ◽  
Anas Younes ◽  
Mitchell S. Cairo
Keyword(s):  
At Risk ◽  
High Risk ◽  
Tumor Lysis Syndrome ◽  
The United States ◽  
Standards Of Care ◽  
Close Monitoring ◽  
Tumor Lysis ◽  
High Risk Patients ◽  
Patients At Risk ◽  
Risk Patients

PurposeTumor lysis syndrome (TLS) has recently been subclassified into either laboratory TLS or clinical TLS, and a grading system has been established. Standardized guidelines, however, are needed to aid in the stratification of patients according to risk and to establish prophylaxis and treatment recommendations for patients at risk or with established TLS.MethodsA panel of experts in pediatric and adult hematologic malignancies and TLS was assembled to develop recommendations and guidelines for TLS based on clinical evidence and standards of care. A review of relevant literature was also used.ResultsNew guidelines are presented regarding the prevention and management of patients at risk of developing TLS. The best management of TLS is prevention. Prevention strategies include hydration and prophylactic rasburicase in high-risk patients, hydration plus allopurinol or rasburicase for intermediate-risk patients, and close monitoring for low-risk patients. Primary management of established TLS involves similar recommendations, with the addition of aggressive hydration and diuresis, plus allopurinol or rasburicase for hyperuricemia. Alkalinization is not recommended. Although guidelines for rasburicase use in adults are provided, this agent is currently only approved for use in pediatric patients in the United States.ConclusionThe potential severity of complications resulting from TLS requires measures for prevention in high-risk patients and prompts treatment in the event that symptoms arise. Recognition of risk factors, monitoring of at-risk patients, and appropriate interventions are the key to preventing or managing TLS. These guidelines should assist in the prevention of TLS and improve the management of patients with established TLS.

Syndrome of Inappropriate Antidiuretic Hormone Associated with Escitalopram Therapy

CNS Spectrums ◽  
2006 ◽  
Vol 11 (6) ◽  
pp. 429-432 ◽  
Author(s):  
Anjali Nirmalani ◽  
Saundra L. Stock ◽  
Glenn Catalano
Keyword(s):  
United States ◽  
Side Effects ◽  
High Risk ◽  
Antidiuretic Hormone ◽  
Side Effect ◽  
Parent Compound ◽  
The United States ◽  
Side Effect Profile ◽  
Significant Side Effect ◽  
Risk Patients

ABSTRACTEscitalopram is the selective serotonin reuptake inhibitor (SSRI) most recently approved for use in the United States. It is structurally related to citalopram, but is felt to have a more tolerable side-effect profile than its parent compound. Side effects are not generally serious and include headache, diarrhea, and nausea. While hyponatremia and the syndrome of inappropriate antidiuretic hormone (SIADH) have been associated with treatment with other SSRIs, there has only been one case of escitalopram-induced SIADH reported in the literature to date. We now report another case of a patient who developed SIADH after being treated with escitalopram for 4 weeks. The patient's hyponatremia improved following the discontinuation of escitalopram. Clinicians should be aware of this uncommon but significant side effect of SSRIs and monitor high-risk patients for the development of SIADH.

scholarly journals Assessment of statin therapy, LDL-C levels, and cardiovascular events among high-risk patients in the United States

2016 ◽  
Vol 10 (1) ◽  
pp. 63-71.e3 ◽  
Author(s):  
Sudhir K. Unni ◽  
Ruben G.W. Quek ◽  
Joseph Biskupiak ◽  
Vinson C. Lee ◽  
Xiangyang Ye ◽  
...  
Keyword(s):  
United States ◽  
High Risk ◽  
Statin Therapy ◽  
Cardiovascular Events ◽  
The United States ◽  
High Risk Patients ◽  
Risk Patients

scholarly journals A systematic review of outbreaks of bloodborne infections (hepatitis B and C, HIV) transmitted from patient to patient in healthcare settings

2021 ◽  
Vol 98 (3) ◽  
pp. 319-330
Author(s):  
A. V. Sacuk ◽  
G. G. Solopova ◽  
A. A. Ploskireva
Keyword(s):  
Hepatitis C ◽  
High Risk ◽  
Hepatitis B ◽  
Healthcare Workers ◽  
Risk Groups ◽  
The United States ◽  
Hepatitis B Vaccination ◽  
Diabetes Diagnosis ◽  
Healthcare Facilities ◽  
Bloodborne Infections

Healthcare facilities have always played an important role in transmission of bloodborne infections. Procedures involving blood and blood fluids pose a risk of transmitting hepatitis B, hepatitis C and HIV not only to healthcare workers, but also to patients. To assess the role of healthcare facilities in transmission of bloodborne infections and to identify risk groups among patients as well as transmission factors, a total of 75 outbreaks of hepatitis B, hepatitis C and HIV have been analyzed with reference to the data published in different countries in 2008–2020. The comparative analysis was conducted for the outbreaks in the United States during 1992–2008 and 2008–2019. Most of the outbreaks of bloodborne infections at healthcare facilities were caused by non-adherence to standard precautions among healthcare workers: Reusing disposable items; improper handwashing; reusing gloves; non-disinfecting surfaces, reusable equipment and devices; non-sterilizing reusable instruments. In terms of bloodborne infections, high-risk facilities include hemodialysis centers, oncohematology clinics, outpatient clinics, nursing homes, residential care facilities, and diabetes treatment centers. High-risk groups include patients undergoing hemodialysis, oncohematological patients, and patients with diabetes. Diagnosis of bloodborne infections on a regular basis, hepatitis B vaccination among high-risk patients, investigation of outbreaks, adoption of rules and procedures combined with training and compliance control of healthcare workers contribute to solution of the problem associated with nosocomial transmission of bloodborne infections.

scholarly journals Optimizing antiviral treatment for seasonal influenza in the United States: A Mathematical Modeling Analysis

2020 ◽  
Author(s):  
Matan Yechezkel ◽  
Martial Ndeffo-Mba ◽  
Dan Yamin
Keyword(s):  
United States ◽  
High Risk ◽  
Seasonal Influenza ◽  
Antiviral Treatment ◽  
Social Contact ◽  
Population Level ◽  
The United States ◽  
Transmission Model ◽  
High Risk Patients ◽  
Risk Patients

Seasonal influenza remains a major health burden in the United States. Despite recommendations of early antiviral treatment of high-risk patients, the effective treatment coverage remains very low. We developed an influenza transmission model that incorporates data on infectious viral load, social contact, and healthcare-seeking behavior, to evaluate the population-level impact of increasing antiviral treatment timeliness and coverage among high-risk patients in the US. We found that increasing the rate of early treatment among high-risk patients who received treatment more than 48 hours after symptoms onset, would substantially avert infections and influenza-induced hospitalizations. We found that treatment of the elderly has the highest impact on reducing hospitalizations, whereas treating high-risk individuals aged 5-19 years old has the highest impact on transmission. The population-level impact of increased timeliness and coverage of treatment among high-risk patients was observed regardless of seasonal influenza vaccination coverage and the severity of the influenza season.

Comparison of ColoPrint risk classification with clinical risk in the prospective PARSC trial.

2014 ◽  
Vol 32 (3_suppl) ◽  
pp. 465-465 ◽  
Author(s):  
Ramon Salazar ◽  
Jaume Capdevila ◽  
Robert Rosenberg ◽  
Jan Willem de Waard ◽  
Bengt Glimelius ◽  
...  
Keyword(s):  
High Risk ◽  
Adjuvant Chemotherapy ◽  
Prospective Study ◽  
The United States ◽  
Risk Classification ◽  
Low Risk ◽  
Stage Ii ◽  
High Risk Patients ◽  
Clinical Risk ◽  
Risk Patients

465 Background: The 18-gene expression profile, ColoPrint, has been developed and validated for identifying risk of recurrence in patients with early-stage colon cancer (CC). In a pooled stage II validation study ColoPrint identified 63% of patients as Low Risk with a 3-yr recurrence-free survival (RFS) of 93% while High Risk patients had a 3-yr RFS of 82% with a HR of 2.7 (p=0.001). PARSC is a prospective study for the assessment of recurrence risk in stage II CC patients using ColoPrint. ColoPrint classification is compared to NCCN risk classification. Methods: The study enrolled 468 patients with histologically proven stage II CC from 31 institutes in Europe, the United States, and Asia between October 2008 and May 2013. Synchronous tumors were excluded. ColoPrint results were not disclosed to the physician and patient. Treatment was at the discretion of the physician, adhering to NCCN approved regimens or a recognized alternative. A McNemars test is performed to compare ColoPrint with NCCN risk classification. A p value ≤ 0.05 indicates the two tests differ significantly. Results: ColoPrint classified 320 (68%) patients as Low Risk and 148 (32%) as High Risk. 89 patients (19%) received adjuvant chemotherapy. In the ColoPrint Low Risk group, 57 (18%) patients received adjuvant chemotherapy while 32 (22%) of ColoPrint High Risk patients received chemotherapy. According to NCCN high risk factors (T4, high grade (exclusive of MSI-H), lymphovascular/perineural invasion, perforation/obstruction, <12 nodes examined, positive margins) 234 (50%) patients were NCCN Low Risk and 234 were NCCN High Risk. 72 (31%) of the NCCN Low Risk patients are ColoPrint High Risk. 158 (68%) of the NCCN High Risk patients are ColoPrint Low Risk. MSI-status was assessed in 86 (18%) patients of which 29 were MSI high and 57 were MSS. All MSI high were classified as ColoPrint Low Risk. Conclusions: The PARSC study is the first prospective study to compare genomic and clinical risk assessment and we observed marked differences between NCCN risk classification and ColoPrint. The clinical validity of these methods will be based on the outcomes at 3 and 5 years. Clinical trial information: NCT00903565. [Table: see text]

Patterns of care in treating childhood neuroblastoma: Evidence from a population level study (SEER) in the United States.

2017 ◽  
Vol 35 (15_suppl) ◽  
pp. e22011-e22011
Author(s):  
Diarmuid Coughlan ◽  
Charles Lynch ◽  
Matthew Gianferante ◽  
Jennifer Stevens ◽  
Linda C Harlan
Keyword(s):  
United States ◽  
Clinical Trial ◽  
High Risk ◽  
Cancer Registries ◽  
The United States ◽  
Patterns Of Care ◽  
Treatment Modalities ◽  
High Dose ◽  
High Risk Patients ◽  
Risk Patients

e22011 Background: Childhood neuroblastoma describes a heterogeneous group of extracranial solid tumors. This heterogeneity is reflected in the sequence and variety of treatment modalities administered. We describe the treatment pattern and survival of childhood neuroblastoma patients using population-based data in the United States. Methods: Using the National Cancer Institute’s (NCI) Patterns of Care data, we examined treatment provided to childhood neuroblastoma patients newly diagnosed in 2010 and 2011 and registered to one of 14 Surveillance, Epidemiology, and End Results (SEER) cancer registries. Data were re-abstracted from hospital records and treating physicians were contacted to verify the treatment given. Stratifying by the Children’s Oncology Group (COG)’s 3-level (low, intermediate and high) neuroblastoma risk classification system for therapeutic decision-making, gave a snapshot of community-based treatment patterns. Kaplan-Meier survival analyses were also performed. Results: The majority of 250 patients (76%) were enrolled on an open/active clinical trial. All low-risk patients received surgery with/without chemotherapy. The majority of intermediate-risk patients (77%) received chemotherapy regimen that included carboplatin, etoposide, cyclophosphamide and doxorubicin. High-risk patients received extensive, multimodal treatment consisting of chemotherapy, surgery, high dose chemotherapy with stem cell rescue (transplant), radiation, immunotherapy (dinutuximab), and isotretinoin therapy. Cyclophosphamide was the most utilized chemotherapy agent (94%) in high-risk patients. Survival with a maximum follow-up of 48 months, was lowest (68%) for patients diagnosed with high-risk disease. Conclusions: The majority of childhood neuroblastoma patients are registered on a risk-based open/active clinical trial. Variation in modality, systemic agents and sequence of treatment reflects the heterogeneity of therapy for childhood neuroblastoma patients.

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