A healthy 34-year-old man exhibited progressive lower-extremity numbness and weakness. Computed tomography revealed a mass compressing the thoracic spine with associated pathologic fracture. Biopsy showed findings compatible with giant cell tumor of the bone, and H3F3A gene mutation testing confirmed the diagnosis present in the axial skeleton. He was successfully managed with T3–T7 fusion, T5 corpectomy, and physical therapy. This case highlights an atypical presentation of an uncommon neoplasm with associated neurologic deficits.

Background Antibiotic treatment decisions in severely ill patients must often be made in the absence of microbiologic results. The recently Food and Drug Administration-cleared BioFire FilmArray Pneumonia Panel (PN) detects 15 bacteria semiquantitatively, 3 atypical pneumonia bacteria, 8 viruses, and 7 antimicrobial resistance markers by multiplex PCR in ~1 hour in the laboratory. Previous reports have shown that the PN Panel bacterial detections are highly accurate, even when routine culture had no growth. Methods Consecutive bronchoalveolar lavage and endotracheal specimens submitted for culture between June and September 2018 from 270 patients with sufficient clinical and laboratory data were tested with the PN Panel. Patients were divided into 3 groups: (1) both culture and PN Panel positive, (2) PN Panel positive but culture uninformative (no growth or normal flora), and (3) patients with no PN Panel detections. Results Groups 1 and 2 had significantly higher maximum temperatures on the day of culture (P = .00036, analysis of variance [ANOVA] with Bonferroni correction), higher levels of an inflammatory response as measured by percent polymorphonuclear leukocytes in bronchoalveolar lavage (P = .00025, ANOVA with Bonferroni correction), and gram stain report of white blood cells, as previously reported [1]. Conclusions Both group 1 (culture and PN Panel positive), and group 2 (PN Panel positive but culture uninformative) had higher levels of host response inflammatory responses compared with group 3, which had no targets detected, suggesting that PN Panel detections need to be interpreted in the clinical context, even if cultures are discordant. Depending on laboratory turnaround time, there could be opportunities for improved diagnosis and antibiotic stewardship.

BACKGROUND:Until recently, there has been a lack of viable alternative to an indwelling urinary catheter for female patients that require precise urine output measurements. With the introduction of external female urinary catheters, we can now substitute this type of device for an indwelling urinary catheter in many patients, decreasing their risk of catheter-associated urinary tract infections.METHODS:In this retrospective study, we analyzed the impact of a hospital-wide implementation of an external female urinary catheter at a large academic medical center. The study included female patients, greater than 18 years of age. We compared a 12-month period before and after device implementation to assess the impact on indwelling urinary catheter utilization and catheter-associated urinary tract infections rate.RESULTS:Data included over 220,000 patient days, over 10,000 external urinary catheter days and 33,000 indwelling urinary catheter days. We found a statistically significant decrease in indwelling urinary catheter utilization following the implementation of the external female urinary catheter, but only in intensive care units.CONCLUSIONS:It is our recommendation that facilities first implement the device in ICUs as this level of care was where we observed the most significant impact.

The following fictional case is intended as a learning tool within the Pathology Competencies for Medical Education (PCME), a set of national standards for teaching pathology. These are divided into three basic competencies: Disease Mechanisms and Processes, Organ System Pathology, and Diagnostic Medicine and Therapeutic Pathology. For additional information, and a full list of learning objectives for all three competencies, see http://journals.sagepub.com/doi/10.1177/2374289517715040.1.

Abstract Background Microbiologic results are critical to optimal management of patients with lower respiratory tract infection, but standard methods may take several days. The multiplex polymerase chain reaction BioFire Pneumonia (PN) panel detects 15 common bacterial species semiquantitatively as copy number/mL, 8 viral species, and 7 resistance genes in about an hour within the clinical laboratory. Methods We tested 396 unique endotracheal or bronchoalveolar lavage specimens with the BioFire Pneumonia panel and compared the bacterial detections to conventional gram stain and culture results. Results Of the 396 patients, 138 grew at least 1 bacterium that had a target on the PN panel, and 136/138 (98.6%) were detected by the panel. A total of 177 isolates were recovered in culture and the PN panel detected 174/177 (98.3%). A further 20% of patients had additional targets detected that were not found on standard culture (specificity 69%, positive predictive value 63%, and negative predictive value 98.9%). Copy number was strongly related to standard semiquantitative growth on plates reported by the laboratory (eg, 1+, 2+, 3+ growths) and was significantly higher in those specimens that grew a potential pathogen. Both higher copy number and bacterial detections found by the PN panel, but not found in culture, were strongly positively related to the level of white blood cells reported in the initial gram stain. Conclusions Higher copy number and bacterial detections by the PN panel are related to the host respiratory tract inflammatory response. If laboratories can achieve a rapid turnaround time, the PN panel should have a significant impact both on patient management and on antibiotic stewardship.

BACKGROUND:To evaluate risk factors for infection or colonization with carbapenem-resistant Enterobacteriaceae (CRE) to develop an algorithm for targeted CRE screening.METHODS:We conducted a case-control study of 50 CRE-positive cases and 100 CRE-negative controls to identify risk factors that were significant for CRE infection or colonization. The setting was at an acute care academic hospital. Patients who tested positive for CRE or other microbiological laboratory tests during the study period were included. We reviewed medical records of 50 patients who were CRE-positive and 100 matched controls who had a non-CRE culture at a similar anatomic site within the closest time period to the case's culture date. Risk factors were assessed using logistic regression with SAS 9.4, observing the 95% confidence interval (CI) to determine significance.RESULTS:Significant risk factors for CRE infection or colonization included the use of fluoroquinolones (odds ratio [OR], 3.75; 95% CI, 1.35, 10.38) and cephalosporins (OR, 2.37; 95% CI, 1.17, 4.86). In addition, undergoing an invasive procedure with a scope device was also a significant risk factor for our participants (OR, 4.57; 95% CI, 1.31, 16.02). Significance of these risk factors varied within the community-acquired and hospital-acquired cases.CONCLUSIONS:Our results suggest that exposure to certain antimicrobials and invasive procedures with a scope device (endoscopic retrograde cholangiopancreatography, duodenal endoscope) are risk factors for CRE. The findings of significant differences in antimicrobials received highlight the necessity to understand antimicrobial stewardship in the development of CRE colonization and infection. Along with antibiotics, inaccessibility to components within scope devices may be increasing the risk of CRE spread.

ABSTRACT Objective: Gastrointestinal (GI) panels have allowed for faster and accurate detection, treatment, and control of pathogens. Because of the large number of potential pathogens included in the panel the clinical significance and manifestations of some organisms, such as Enteroaggregative Escherichia coli (EAEC) and Enteropathogenic E. coli (EPEC), remains undetermined. Methodology: We performed a single-institution retrospective chart review for 222 patients with a stool sample tested on BioFire FilmArray Gastrointestinal Panel (GI Panel) between June 1, 2016 and March 9, 2017. Results: Of the 222 patients, four had EAEC and 17 and EPEC. Patients who tested positive for EAEC and EPEC were younger (26.3 years and 33.9 years, respectively) than patients that did not test positive for a GI pathogen (47.7 years). In cases where multiple organisms were detected, EPEC was present 56.3% of the time. Analysis of symptoms showed that EPEC patients had a high prevalence of abdominal pain (p=0.0425) and vomiting (p=0.0045), but not diarrhea, when compared to the presence of these symptoms in patients with no targets detected. With only four patients positive for EAEC in this study, the results of symptoms in EAEC patients were inconclusive. Cases involving EPEC and EAEC were treated similarly to other cases of diarrhea with no significant difference in the number of imaging studies and medication changes. Conclusions: While further studies are required to determine the specific clinical significance of EAEC or EPEC, it is evident that patients positive for EPEC often experience abdominal pain and diarrhea, suggesting EPEC may be more pathogenic than previously thought.  J Microbiol Infect Dis 2019; 9(1):1-9.

Abstract Background The Pneumonia Panel (PP) (BioFire Diagnostics, Salt Lake City, UT) detects 15 potentially pathogenic bacteria semiquantitatively (copy #/mL), 8 viruses and 7 resistance genes from the lower respiratory tract in ≈1 hour in the laboratory. Since identification and susceptibility take ≈ 2 days, this rapid result time is very attractive; however, the clinical significance of the PP copy #/mL as well as a predictable group of PP positive but culture negative patients is unknown. We retrospectively studied the relationship of 270 PP results to culture results, clinical data and outcomes. Methods Bronchoalveolar lavage fluid (N = 197) and endotracheal aspirates (N = 73) submitted to the UF Health Shands Hospital microbiology laboratory from June-September 2018 were frozen at −70°C, until tested on the PP. Patient data were extracted from the inpatient electronic medical record (Epic). Results Of 270 patients tested, 111/270 (41.1%) were PP bacteria negative/culture no growth or normal flora (Group 1), 59/270 (21.9%) were PP positive/culture negative (Group 2), and 100/270 (37.0%) were PP positive/culture positive (Group 3) for at least 1 concordant bacterial potential pathogen. Hospital length of stay (LOS), P = 0.0274, ANOVA; ICU LOS P = 0.0007 and BAL % Polys P < 0.0001 were significantly longer/higher in Group 3 than in Groups 1 and 2 (Table 1). Max daily temp on the day of culture in PP-positive groups 2 and 3 was significantly higher than the PP-negative group 1, P = 0.0260, ANOVA, (Table 1). Age, daily WBC, lowest paO2, max FiO2, % on antibiotics ( ≥80% for all groups), and % with viruses in the PP were not significantly different across groups. When all PP pathogens were grouped by copy # /mL, ICU LOS was significantly longer for 10(7) copies/mL (P = 0.0088), as was BAL % polys (P = 0.0006). Max daily temp was almost significantly higher for PP-positive groups 10(5), 10(6), and 10(7) combined compared with the PP-negative group (Table 2, P = 0.0608). Conclusion Hospital LOS was significantly longer and BAL %Polys higher in the bacterial pathogen culture-positive/PP-positive group vs. not positive groups. ICU LOS and BAL %Polys were significantly higher for the PP-positive groups vs. PP negative regardless of culture results. PP results (copy #/mL) independently correlated with outcome and clinical measures. Disclosures All authors: No reported disclosures.

Background: Currently, very little data exists that compare the features of pulmonary nontuberculous mycobacteria (NTM) and Mycobacterium tuberculosis (TB). Both have similar symptomology and analogous preliminary laboratory results, as both present with positive acid-fast bacilli stains. The objective of this study was to provide data that would help guide clinicians in their decision making regarding isolation precautions for patients, with a preliminary positive result for mycobacteria, prior to species identification. Methods: We conducted queries for patients who had positive respiratory cultures for mycobacteria via our electronic medical record system, between January 1, 2011, and December 31, 2017. Additionally, we collected demographic and medical history, clinical presentation, and radiographic findings. The 2-sample unpaired Student t test, the X-2 test, and logistic regression were used to compare each group. Results: Through logistic regression, 8 variables were significantly associated with patients who grew either TB or NTM. History of incarceration, born outside of the United States, cavitation, and lymphadenopathy were associated with TB; tobacco smoke exposure, pre-existing lung disease, immunosuppression, and bronchiectasis were associated with NTM. Incidence of HIV and hemoptysis was not significantly different between the 2 groups. Conclusions: Through the use of our study findings, improper use of airborne isolation precautions may be reduced or avoided. (C) 2019 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.

Background: Methicillin-resistant Staphylococcus aureus (MRSA) is responsible for many hospital-associated infections. Both MRSA-colonized and MRSA-infected patients must be isolated on contact precautions per the Centers for Disease Control and Prevention guidelines. This study evaluates the current practice for removing MRSA-colonized patients from contact precautions and proposes a new protocol to decrease inconsistencies with screening methodologies. Methods: This was a retrospective chart review of MRSA screening swabs collected at an academic medical center between January 1, 2010 and December 31, 2017. Of those patients with MRSA screening swabs, extra-nasal cultures were also evaluated for MRSA infection. Screening swabs were analyzed for appropriateness of order and timing between swabs and active infections. Analysis of variance and the chi(2) tests were used to determine significance between groups. Results: This study included 8,310 patients with a combined total of 11,601 nasal swabs. Significantly more (P = .0159) patients with 2 negative nasal swabs returned with a recurrent MRSA infection or colonization than those who had 3 consecutive negative nasal swabs (27.8% vs 17.0%, respectively). Additionally, 47.8% of patients only had 1 appropriately ordered negative nasal swab, indicating that a nurse-driven protocol may be more effective in obtaining the full series of samples required to remove contact precautions. Conclusions: The current practice for removing a patient from contact precautions for MRSA is insufficient. The number of negative nasal swabs required should be increased from 2 to 3 and a decolonization protocol should be implemented. (C) 2019 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.

Objectives: Hematopoietic stem cell transplantation (HSCT) patients are at higher risk of infection compared to their healthy counterparts.Aims were identity type and incidence of skin infections, describe the use of diagnostic tests, and identify the role of dermatology consults. Methods:In this single institution retrospective chart review, data were extracted from the medical record.A clinically diagnosed skin infection was defined as any skin pathology treated with antibiotics, antivirals, antifungals, or antiparasitics.The diagnostic tests data such as cultures, polymerase chain reactions (PCR), and direct fluorescent antibody (DFA) tests, and dermatology consultations were also collected.Results: A total of 92 patients and 143 skin infections were identified in the 5-year study period.The majority of infections occurred while the patient was not neutropenic.The infectious agents responsible for infections varied depending on a patient's age, neutropenia status, graft-versus-host disease (GVHD) diagnosis, and transplant type.Only 25 infections (17%) received a dermatology consultation.On average, infections associated with dermatology consultation received a higher number of diagnostic tests compared to those that did not receive a dermatology consultation. Conclusions:The etiologies and severities of clinically identified skin infections in HSCT patients are varied and require continuous vigilance of dermatological health.Dermatologists are not necessarily the physician's ordering more diagnostic.Therefore, earlier assessment by dermatologists might prevent excessive laboratory testing and earlier management of severe clinically identified infections.

ABSTRACT Conventional methods for the identification of gastrointestinal pathogens are time-consuming and expensive and have limited sensitivity. The aim of this study was to determine the clinical impact of a comprehensive molecular test, the BioFire FilmArray gastrointestinal (GI) panel, which tests for many of the most common agents of infectious diarrhea in approximately 1 h. Patients with stool cultures submitted were tested on the GI panel ( n = 241) and were compared with control patients ( n = 594) from the year prior. The most common organisms detected by the GI panel were enteropathogenic Escherichia coli (EPEC, n = 21), norovirus ( n = 21), rotavirus ( n = 15), sapovirus ( n = 9), and Salmonella ( n = 8). Patients tested on the GI panel had an average of 0.58 other infectious stool tests compared with 3.02 in the control group ( P = 0.0001). The numbers of days on antibiotic(s) per patient were 1.73 in the cases and 2.12 in the controls ( P = 0.06). Patients with the GI panel had 0.18 abdomen and/or pelvic imaging studies per patient compared with 0.39 ( P = 0.0002) in the controls. The average length of time from stool culture collection to discharge was 3.4 days in the GI panel group versus 3.9 days in the controls ( P = 0.04). The overall health care cost could have decreased by $293.61 per patient tested. The GI panel improved patient care by rapidly identifying a broad range of pathogens which may not have otherwise been detected, reducing the need for other diagnostic tests, reducing unnecessary use of antibiotics, and leading to a reduction in hospital length of stay.

Background Sternal wound infection continues to be the leading complication after median sternotomy. With the growing concern of multidrug-resistant and extensively drug-resistant (XDR) bacterial infections, sternal wound reconstruction is a critical step in successfully healing these patients. The use of a rectus abdominis muscle flap for coverage of the lower one third of sternal wounds as well as objectively optimizing antimicrobial therapy has revolutionized the field of sternal wound reconstruction, yet both practices are not well documented within the literature. Clinical Scenario A 72-year-old man developed an XDR Pseudomonas aeruginosa infection of his sternum after median sternotomy. The sternal wound was successfully reconstructed using a dual flap approach of bilateral pectoralis major myocutaneous flaps and a rectus abdominis muscle flap. Because of the antibiotic susceptibility profile and patient allergy profile, parental tobramycin and high-dose continuous-infusion meropenem were used to treat the osteomyelitis; meropenem serum concentrations were obtained via mass spectroscopy to optimize bactericidal activity. Conclusions Osteomyelitis secondary to XDR P. aeruginosa is exceedingly rare in the literature. Individuals with this type of infection can be successfully treated with aggressive surgical debridement, subsequent reconstruction using bilateral pectoralis major myocutaneous flaps and a rectus abdominis muscle flap for coverage of the sternal wound, and both guided and targeted parental antibiotics. Lastly, the innovative use of antibiotic concentrations was instrumental in targeting the appropriate dose of antimicrobials in this patient.

Objective: Patients ' with cystic fibrosis respiratory systems become colonized with pathogens as early as the first year of life. Some organisms are associated with a decline in pulmonary function and shortened survival, such as a mucoid strain of Pseudomonas aeruginosa (PA).Methods: We conducted a four year retrospective chart review study examining 158 pediatric and adult cystic fibrosis patients treated at an academic, tertiary care institution to compare patients treated by different antimicrobial regimens.Results: A higher proportion of mucoid PA study patients received alternate-monthly tobramycin therapy (83.3%), compared to those with non-mucoid PA (62.5%); although a large percentage of patients who had never had a mucoid PA infection were also receiving alternate-monthly tobramycin. Patients who had a mucoid PA infection had more hospitalizations and for longer periods of time than patients who had a non-mucoid PA infection; both mucoid and non-mucoid PA patients were hospitalized more often than patients who had never had a PA infection. We additionally found patients with mucoid PA infections to have strains that were either resistant or had intermediate resistance to tobramycin. Similar trends in resistance were not seen in patients who only received intermittent treatments with tobramycin.Conclusions Our findings on increased rates of infection with both Aspergillus (in the alternate-monthly inhaled tobramycin group) and NTM (in the overall patient population) comparative to international averages were also interesting, and open the doors to future research regarding CF patients with these infections. J Microbiol Infect Dis 2017; 7(4):178-185 [J Microbiol Infect Dis 2017; 7(4.000): 178-185]

BACKGROUND:Antibody tests for Borrelia burgdorferi (agent of Lyme disease), Toxoplasma gondii, and cytomegalovirus in cerebrospinal fluid (CSF) are rarely useful. One reason for misutilization of laboratory tests is simply the convenience offered by a computerized physician order entry (CPOE) system.METHODS:The cytomegalovirus (CMV) antibodies-CSF, B. burgdorferi antibodies-CSF, and T. gondii antibodies-CSF orders were removed from the test menu. A provider could still order these tests using a miscellaneous order. We collected monthly volumes of test orders before and after the tests were removed from the CPOE.RESULTS:Orders for CSF antibody testing for B. burgdorferi, T. gondii, and CMV decreased by 91%, 93%, and 98%, respectively (P < 0.01), after they were removed from the CPOE test menu. This result correlates to a savings of $50053.44 per year. Additionally, we did not see a paradoxical increase in CMV PCR or T. gondii PCR orders after the intervention.CONCLUSIONS:Removal of test orders from the CPOE dramatically decreased test order volume, which led to substantial cost savings and availability of CSF for more useful tests. There was no compensatory increase in order volume for related tests, indicating that providers were not looking for alternate tests.

In the acute care hospital inpatient setting, there is a wide variety of causes for both infectious and noninfectious diarrhea. However, without molecular assays for the wide range of agents causing gastroenteritis, there is no reliable way to determine which individuals should be placed in contact precautions, as recommended by CDC. We tested 158 inpatient diarrheal stool specimens with the FilmArray GI Panel (BioFire Diagnostics, Salt Lake City, UT, USA) that had been stored at -70°C after testing negative by conventional methods for Clostridium difficile and/or rotavirus. We found that 22.2% had at least 1 other infectious agent detected, and 60% of these patients were never placed in appropriate isolation for a total of 109 patient-days. In addition, 20.3% of patients with negative GI panel results could have been removed from isolation. Use of multiplex gastrointestinal panels may improve decisions regarding patient isolation and reduce nosocomial transmission.