Background: Candida auris is a globally emerging, multidrug-resistant fungal pathogen that causes serious, difficult-to-treat infections in hospitalized patients. C. auris cases in the United States have been linked to receipt of healthcare overseas. Outbreaks have also occurred in New York City, New Jersey, Illinois, Nevada, and California. We provide care to patients from all 50 states and 138 countries and are therefore, at risk for encountering C.auris within our facility. Methods: A case-finding tool was created by Infection Prevention and Control (IPAC) within the electronic medical record (EMR) to identify patients for screening. Inclusion criteria was centric to patients who were admitted in the previous 24 hours with a primary address in a foreign country or in areas of the United States with known C. auris transmission. Patients who are positive for Carbapenamase-producing organisms (CPO) are also included in screening criteria. In 2020, Clinical Microbiology validated a polymerase chain reaction (PCR) test in partnership with the State Health Department and IPAC. In January 2022, IPAC created a protocol that allows IPAC staff to order C. auris screening directly in the EMR utilizing the validated PCR test. The order is paired with communication from IPAC alerting the patient care team that C.auris screening is indicated. Instructions on test collection and information on C. auris are also included in messaging. The patient’s primary nurse then obtains verbal consent from the patient to collect a composite axilla–groin skin swab. Swabs are sent to Clinical Microbiology for testing, and results are reported directly into the EMR. Results: Since the introduction of the nursing protocol in January 2022, 2,660 patients have been identified for C. auris screening through November 2025. Of the 2,660 patients identified for testing, 1,111 patients had screening completed. Two patients tested positive for C. auris on screening. Both patients had prolonged travel to regions with known C. auris transmission. Conclusion: The EMR can be leveraged for early identification and screening of patients at risk of C.auris colonization. Case finding tools, combined with nursing protocols and communication strategies within the EMR can be effectively replicated and modified to respond to emerging infections.

Background: We describe an investigation of a cluster of eight Corynebacterium amycolatum sternal surgical site infections (SSIs) that occurred among cardiac surgery patients from February to October 2025. Although C. amycolatum is a member of the skin microbiota, clinically significant infections caused by this organism may occur in cardiac surgery patients. Methods: The investigation included retrospective reviews of SSIs, clinical cultures and medical records, surgical observations, and operating room (OR) assessment. Line lists of surgical case criteria and infection prevention practices were created to assess common factors among cases (e.g., staffing, instrumentation, equipment, skin preparation and antisepsis, nasal decolonization, antibiotic protocols, and closure). Whole genome sequencing of isolates was performed and analyzed using SNIPPY for single-nucleotide polymorphism (SNP)-based phylogenetic analysis. Results: Phylogenetic analysis indicated isolates from five of eight case patients who had cardiac surgeries occurring over a six-week period from February to April 2025 were genetically related (?7 SNPs across the genome), suggesting a common source of infection. These five isolates were ceftriaxone, meropenem, and penicillin resistant. The other three case patient isolates were unrelated (<3181 to <15,000 SNPs); two were ceftriaxone, meropenem and penicillin resistant (one also doxycycline intermediate resistant), and the third penicillin resistant. Use of sternal tape for closure was identified as a recent practice change. Four of five genetically related cases involved the same surgeons and suture tape for sternal closure (wire for all other cases). Sternal tape was discontinued with three cases occurring afterwards. Seven patients completed chlorhexidine gluconate bathing and nasal decolonization. Hair was removed in the OR with reusable surgical clippers. All received the same skin antiseptic, and antibiotic prophylaxis was appropriate. No trends were identified in instrument or equipment use. Broad infection control measures were implemented, including surgical clipper replacement, OR cleaning and ultraviolet light disinfection, headlamp cleaning, and environmental repairs. Leadership was engaged through frequent meetings and audits. Infection control practices such as minimizing OR traffic, double gloving, glove changes, and strict adherence to hand hygiene and attire were reinforced. Two of eight cases occurred after these recommendations were completed but were not genetically related to the primary cluster. Conclusion: We describe a cluster of invasive C. amycolatum sternotomy SSIs. Only two genetically unrelated cases of C. amycolatum occurred following infection control investigation and interventions, underscoring the effectiveness of a comprehensive, multidisciplinary approach. This organism has rarely been reported as a cause of SSIs and may be an emerging pathogen.

NEJM Catalyst Insights Council members have high confidence in vaccine efficacy and safety. Direct counseling is the top means of overcoming patient hesitancy about vaccines, and many Council members have had personal discussions with patients or parents that changed their vaccine decisions.

Background: In 2025, 50 measles outbreaks drove 87% of confirmed cases reported in the United States. As a highly infectious virus with an estimated R ranging from 12-18, we sought rapidly scalable and implementable measles preparedness measures for our facilities. Methods: The electronic health record (EHR) has flags that can be placed on patient records to denote the presence of, or concern for, active, transmissible infections. These flags are highly visible in the EHR and represent a good usability heuristic as front line providers are already trained to look for this information. Infection Prevention and Control (IPAC) worked with nursing informatics to develop measles-specific flags for suspected, confirmed and exposed patients in the EHR, expanding flagging functionality in preparation for potential measles cases and exposures. The flagging was tied to registry functionality to allow for tracking of exposed and confirmed cases longitudinally for supporting IPAC investigations in addition to clinical operations. Results: Three different flags were developed in the EHR to address measles. Specific criteria were created for each flag, as shown in Table 1. Table 1: Attached as Image Conclusion: As a highly contagious virus, measles presents unique challenges to healthcare facilities managing both cases and exposures. Measles flags within the EHR can be leveraged to assist facilities with case tracking, exposure management, and infection prevention and control.

Background: Measles is a highly transmissible virus. A single case can result in significant exposures within a healthcare facility and prompt action is needed to prevent secondary cases. In October 2025, Infection Prevention and Control (IPAC) was notified of a patient being admitted to our facility with recent international travel and symptoms consistent with measles. The patient was unvaccinated and had five healthcare facility visits prior to measles being suspected and subsequently confirmed. Objective: To describe our facility’s effective identification, prioritization, and prophylaxis of individuals exposed to measles. Methods: IPAC leveraged the electronic medical record to identify potentially exposed patients. Patients were quickly assessed for age and immune status, then prioritized and assigned to primary care teams. These teams promptly contacted patients and coordinated PEP administration. Results: Across five encounters, the index patient exposed 539 other patients. Due to delayed notification, our teams had less than four days to administer PEP for those exposed and still within PEP window. PEP administration began within hours of the index case’s positive test and patients received PEP within three days (Table 1). No secondary measles cases occurred within our facility. Conclusion: Timely and coordinated multidisciplinary effort enabled us to rapidly respond to our first measles case and control secondary transmission. Although the index case resulted in a large exposure, patients that were exposed and eligible for PEP were quickly prioritized to prevent secondary transmission.

Background: Carbapenemase-producing organisms (CPO) are a serious public health threat. The Centers for Disease Control and Prevention (CDC) guidelines for combating CPO includes a recommendation to screen selected high risk patients. We describe a program to identify and screen patients at risk for CPO. Setting: An academic, tertiary care center with 2,059 licensed beds and 74,359 admissions a year. Methods: A report was created in the electronic medical record (EMR) to identify adult patients admitted in the previous 24 hours who were from countries and states with known CPO transmission based on address and zip code. A nursing protocol was subsequently developed in the EMR to facilitate CPO screening for eligible patients at admission. After the CPO order is placed, an electronic communication is sent via the EMR alerting the patient care team of the order, the rationale for screening, details on swab collection, and links to a toolkit with resources to help answer patient questions. A single perirectal swab is obtained by the patient’s primary nurse and is tested for Klebsiella pneumoniae Carbapenemase (KPC), New Delhi metallo-β-lactamase (NDM), oxacillinase-48 (OXA-48), and Verona integron-encoded metallo-β-lactamase (VIM) by polymerase chain reaction (PCR). Patients may refuse testing. Results: From May 2018 through November 2025, 6,039 patients were identified for CPO screening using case-finding report. Of these patients, 2,424 had CPO swabs completed. Eighteen patients with CPO were identified with an overall yield of 0.75% on admission screening. There was one patient who tested positive for KPC, 10 patients who tested positive for NDM, and 5 patients who tested positive for OXA-48. Two patients were identified to have both NDM and OXA-48. Conclusions: The EMR can be leveraged for early identification and screening of patients with epidemiologically significant pathogens. Use of the nursing protocol has enabled IPAC to complete timely CPO surveillance and prevent transmission to other patients. Protocols within the EMR can be effectively replicated for a timely response to emerging infections.

Blood culture contamination can lead to false-positive blood culture results, potentially contributing to increased costs and unneeded antibiotic utilization. Initial specimen diversion devices (ISDD) have been proposed to reduce blood culture contamination rates. A single-center, observational study conducted at Mayo Clinic Rochester compared blood culture contamination rates using Steripath or Kurin ISDDs versus standard blood culture collection protocols. Over 255 phlebotomists were trained in the use of the ISDDs, with 31,215 blood cultures, 410 of which were contaminated, collected from adults in the emergency department and inpatient wards. Baseline contamination rates were 1.29%-2.53% with standard collection methods. The Steripath ISDD with direct-to-media inoculation of blood culture bottles (Steripath-DTM) reduced blood culture contamination compared to standard practice (0.34% vs. 1.43%, respectively, P < 0.001). Follow-up studies with the alternative Steripath configuration with an integrated syringe (Steripath-syringe), and then the Kurin ISDD with syringe collection (Kurin-syringe), did not meet the primary endpoint of <0.5% contamination (Steripath-syringe: 1.28%; Kurin-syringe: 1.76%). All three ISDD configurations failed to meet our goal of >75% utilization, with an average measured utilization of 26% for the Steripath-DTM, 26.4% for the Steripath ISDD (combined DTM and syringe) in a follow-up study, and 41.5% in the Kurin study. Additionally, a survey of phlebotomists revealed low staff satisfaction with both Steripath ISDD configurations. Staff reported multiple ergonomic barriers limiting the Steripath ISDD's utility, which precluded implementation of the Steripath-DTM in routine clinical practice. IMPORTANCE:We conducted a very large, real-world study of two blood diversion devices to determine whether either would meet goals for reduced blood culture contamination and a high rate of utilization by phlebotomists.

Background: Carbapenemase-producing organisms (CPO) are a serious public health threat. The Centers for Disease Control and Prevention (CDC) guidelines for combating CPO includes a recommendation to screen selected high risk patients. We describe a program to identify and screen patients at risk for CPO. Setting: An academic, tertiary care center with 2,059 licensed beds and 74,359 admissions a year. Methods: A report was created in the electronic medical record (EMR) to identify adult patients admitted in the previous 24 hours who were from countries and states with known CPO transmission based on address and zip code. A nursing protocol was subsequently developed in the EMR to facilitate CPO screening for eligible patients at admission. After the CPO order is placed, an electronic communication is sent via the EMR alerting the patient care team of the order, the rationale for screening, details on swab collection, and links to a toolkit with resources to help answer patient questions. A single perirectal swab is obtained by the patient’s primary nurse and is tested for Klebsiella pneumoniae Carbapenemase (KPC), New Delhi metallo-β-lactamase (NDM), oxacillinase-48 (OXA-48), and Verona integron-encoded metallo-β-lactamase (VIM) by polymerase chain reaction (PCR). Patients may refuse testing. Results: From May 2018 through November 2025, 6,039 patients were identified for CPO screening using case-finding report. Of these patients, 2,424 had CPO swabs completed. Eighteen patients with CPO were identified with an overall yield of 0.75% on admission screening. There was one patient who tested positive for KPC, 10 patients who tested positive for NDM, and 5 patients who tested positive for OXA-48. Two patients were identified to have both NDM and OXA-48. Conclusions: The EMR can be leveraged for early identification and screening of patients with epidemiologically significant pathogens. Use of the nursing protocol has enabled IPAC to complete timely CPO surveillance and prevent transmission to other patients. Protocols within the EMR can be effectively replicated for a timely response to emerging infections.

Background: Advanced planning and adaptable response strategies are essential for preventing measles transmission in healthcare facilities. Objective: To describe a measles management plan and subsequent modifications in response to a cluster of measles cases. Methods: Drawing on previously published work (doi:10.1017/ice.2025.49), the Infection Prevention and Control (IPAC) team initiated a multi-disciplinary team and developed a measles preparedness plan with the following domains: Guidance and education; early detection and testing; isolation and patient movement; contact tracing and exposure management (Table 1). In October 2025, a patient was admitted during their fifth healthcare encounter and was diagnosed with measles. Two family members were later hospitalized with measles. Delayed recognition of the first case prompted enhancements to our preparedness framework (Table 1). Results: The first case resulted in 539 exposed patients. The second resulted in 87 exposures, and the third resulted in no exposure. Despite the extensive exposure, zero secondary measles were reported. Conclusion: Proactive planning enabled rapid response to our first case and controlled secondary transmission. Despite extensive planning, delayed identification of the first case caused significant exposures. As the cluster unfolded, we refined our plan, resulting in zero exposures from the last patient and zero secondary cases, despite over 850 exposures. These efforts may guide other healthcare facilities in improving their measles preparedness and response.

This multisociety infection prevention guidance document was developed for individuals and organizations that engage in sterilization or high-level disinfection (HLD). It was endorsed by SHEA, APIC, ASGE, IDSA, and SGNA. This guidance is based on a synthesis of published scientific evidence, theoretical rationale, current practices, practical considerations, writing group consensus, and consideration of potential harm when applicable. The supplementary material includes a summary of recommendations. The guidance provides an overview of the Spaulding Classification and considerations around manufacturers' instructions for use (MIFUs). Its recommendations address: point-of-use treatment prior to sterilization or HLD, preparation of reusable medical devices at the location of processing, sterilization, and immediate use steam sterilization (IUSS), HLD of lumened and non-lumened devices, processing of reusable medical devices used with lubricating or defoaming agents, monitoring for effectiveness of processing, handling of devices after HLD, augments and alternatives to HLD, processing of investigational devices, tracking of reusable medical devices, and approaches to implementation.

INTRODUCTION:Vaccination is crucial to the thoracic solid organ transplant (SOT) population to reduce vaccine-preventable infection. However, data on posttransplant hepatitis B virus (HBV) vaccination compliance and vaccine-induced seroprotection are lacking. METHODS:We conducted a retrospective study of adult thoracic organ (heart and lung) transplant recipients at Mayo Clinic sites in Minnesota, Arizona, and Florida between January 2018 and August 2023. Recombivax HB was used before 2020, and Heplisav-B was preferred after 2020. Recipients with posttransplant hepatitis B surface antibody (HBsAb) < 10 IU/L were eligible for the HBV vaccine. HBV seroprotection was defined as an HBsAb ≥ 10 IU/L. RESULTS:A total of 1116 recipients were evaluated, all of whom underwent posttransplant HBsAb testing. Of these, 751 (67%) had an HBsAb level < 10 IU/L and were eligible for posttransplant HBV vaccination. Of the eligible recipients, 117 (16%) completed the HBV vaccine series during the study period. Among these 117 recipients, 40 (34%) had their HBsAb levels rechecked after completing the vaccine series, with a seroprotection rate of 37.5% (15/40). There was no statistically significant difference in the seroprotection rates between Heplisav-B and Recombivax HB vaccines (39% [13/33] vs. 29% [2/7]; p = 0.691). In addition, HBsAb levels were lowest at week 2 but rebounded at week 4 posttransplant and pretransplant HBsAb levels of ≥100 IU/L ensured 5-year seroprotection. CONCLUSION:Suboptimal compliance with HBV vaccination and poor vaccine-induced seroprotection occur in thoracic organ transplant recipients, regardless of the vaccine used. These findings underscore the necessity of enhancing vaccination strategies for SOT recipients.

Introduction Heplisav-B, a CpG-adjuvanted recombinant hepatitis B virus (HBV) vaccine, has a higher seroprotection rate and immunogenicity than the conventional HBV vaccine. This study aimed to identify the predictors of HBV seroprotection post-transplantation in thoracic organ transplant recipients who received Heplisav-B. Methods We conducted a retrospective study of adult thoracic organ (heart and lung) transplant recipients at Mayo Clinic sites in Minnesota, Arizona, and Florida between January 2020 and August 2023. Patients who completed Heplisav-B series were classified into three strategies: strategy A (completed 2 doses of Heplisav-B pre-transplantation with achieved seroprotection pre-transplantation), strategy B (received first dose of Heplisav-B pre-transplantation and second dose of Heplisav-B post-transplantation), and strategy C (completed 2 doses of Heplisav-B post-transplantation). HBV seroprotection was defined as HBsAb ≥10 IU/L. Results A total of 154 thoracic organ transplant recipients completed Heplisav-B vaccine series. Post-transplant seroprotection was highest in strategy A, followed by strategy B and strategy C (54/76 [71 %] vs. 18/39 [46 %] vs. 14/39 [36 %]; p < 0.001). Multivariate logistic regression analysis identified two independent factors predicting lack of HBV seroprotection post-transplantation; both were related to Heplisav-B schedule: strategy B (adjusted odds ratio [aOR], 2.482; 95 % confidence interval [CI] 1.085 5.679; p = 0.031), and strategy C (aOR 4.963; 95 % CI 2.106 11.697; p < 0.001). Conclusion The vaccine schedule significantly predicts HBV seroprotection in adult thoracic organ transplant recipients. Our data supports the recommendation that pre-transplantation Heplisav-B to achieve HBsAb ≥10 IU/L is the optimal vaccination schedule to maintain an HBsAb level of ≥10 IU/L post-transplantation. Further studies are needed to determine whether this observation can be replicated in non-thoracic organ transplant recipients or pediatric populations.

Introduction: Hepatitis B virus (HBV) vaccination is recommended for solid organ transplant (SOT) candidates. However, there is a lack of data on the HBV vaccine compliance, serologic response, and durability of HBV seroprotection in thoracic organ transplantation recipients. Methods: We conducted a retrospective study of adult thoracic organ (heart and lung) transplant candidates who received HBV vaccination at Mayo Clinic sites in Minnesota, Arizona, and Florida between January 2018 and August 2023. Conventional recombinant hepatitis B vaccine (Recombivax HB) was used before 2020, and Heplisav-B was preferred after 2020. HBV seroprotection was defined as hepatitis B surface antibody (HBsAb) >= 10 IU/L. Furthermore, we compared characteristics between recipients who maintained HBV seroprotection and those who lost HBV seroprotection (HBsAb < 10 IU/L) at 30 days posttransplantation (D30). Results: Among 922 candidates who were eligible for HBV vaccination, 430 (47%) completed the HBV vaccine series. Patients receiving Heplisav-B were more likely to complete the series than Recombivax HB (81% vs. 60%, p < 0.001) and Heplisav-B had a higher seroprotection rate than Recombivax HB (75% vs. 64%, p = 0.023). Multivariate logistic regression analysis identified receiving Heplisav-B as an independent predictor for HBV seroprotection (adjusted odds ratio [aOR] 1.723; 95% confidence interval [CI] 1.056-2.810; p = 0.029). A total of 145 thoracic organ transplant recipients achieved HBV seroprotection at the date of transplantation. Loss of HBV seroprotection occurred in 38 (26%) patients at D30. Multivariate logistic regression analysis identified two predictors for HBV seroprotection loss at D30: age >= 60 years (aOR, 2.503; 95% CI 1.026-6.107; p = 0.044), and pretransplant HBsAb level between 10 and 100 IU/L (aOR, 18.575; 95% CI 5.211-66.209; p < 0.001). Conclusions: Although less than half of thoracic organ transplant candidates completed HBV vaccine series pretransplant, Heplisav-B provided a higher vaccine completion rate and seroprotection than the 3-dose Recombivax HB. Clinicians should also be aware of the increased loss of HBV seroprotection in thoracic organ transplant recipients with age >= 60 years and pretransplant HBsAb between 10 and 100 IU/L. Assessment of seroprotection after HBV vaccination should be prioritized during the pretransplant period.

Traditionally, public health surveillance relied on individual-level data but recently wastewater-based epidemiology (WBE) for the detection of infectious diseases including COVID-19 became a valuable tool in the public health arsenal. Here, we use WBE to follow the course of the COVID-19 pandemic in Rochester, Minnesota (population 121,395 at the 2020 census), from February 2021 to December 2022. We monitored the impact of SARS-CoV-2 infections on public health by comparing three sets of data: quantitative measurements of viral RNA in wastewater as an unbiased reporter of virus level in the community, positive results of viral RNA or antigen tests from nasal swabs reflecting community reporting, and hospitalization data. From February 2021 to August 2022 viral RNA levels in wastewater were closely correlated with the oscillating course of COVID-19 case and hospitalization numbers. However, from September 2022 cases remained low and hospitalization numbers dropped, whereas viral RNA levels in wastewater continued to oscillate. The low reported cases may reflect virulence reduction combined with abated inclination to report, and the divergence of virus levels in wastewater from reported cases may reflect COVID-19 shifting from pandemic to endemic. WBE, which also detects asymptomatic infections, can provide an early warning of impending cases, and offers crucial insights during pandemic waves and in the transition to the endemic phase.

A 51-year-old woman presented to the emergency department (ED) during the summertime with a 2-day history of fever up to 39.2 °C, nonproductive cough, myalgias, and nausea without associated diarrhea or vomiting. Her medical comorbidities included nicotine dependence with a 20-pack-year smoking history, common variable immune deficiency, quiescent multiple sclerosis not receiving immunomodulatory therapy, heart failure with preserved ejection fraction, hypertension, and fibromyalgia. Medications at the time of presentation were nortriptyline, cyclobenzaprine, aspirin, and duloxetine. She endorsed use of e-cigarette or vaping products that contained marijuana; other drug use was denied. Because of a plumbing issue at home, the patient and her partner had been staying in a hotel for 4 days before presentation, where they had been using the swimming pool and hot tub. The patient had received multiple cat bites on her forearms 1 week earlier; she had no other animal exposures. She lived in Minnesota and reported no travel outside the region. The patient had not received a vaccine for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The patient’s partner was experiencing similar symptoms, and she denied other sick contacts. In the ED, the patient was alert and oriented but appeared tired and diaphoretic. At the time of presentation, the respiratory rate was 17 breaths/min; blood pressure, 165/82 mm Hg; heart rate, 97 beats/min; oxygen saturation, 97% on room air; and temperature, 36.0 °C. Heart rhythm was regular with no murmur appreciated; there was no lower extremity edema. Vesicular breathing was appreciated bilaterally with no adventitious breath sounds. There was no appreciable supraclavicular or axillary lymphadenopathy. Abdomen was soft and nontender. There was no joint swelling or tenderness and no motor or sensory abnormalities. Healing excoriations were noted on the forearms bilaterally with no surrounding erythema. A complete blood count was notable for the following (normal ranges shown parenthetically): leukocytosis of 22.5×109/L ((3.4 to 9.6)×109/L) and a neutrophilia of 19.12×109/L ((1.6 to 6.5)×109/L). A basic metabolic profile was notable only for a mild hypokalemia of 3.3 mmol/L (3.6 to 5.2 mmol/L). Nasopharyngeal polymerase chain reaction (PCR) testing was negative for SARS-CoV-2. A chest radiograph revealed subtle interstitial opacities in the mid and lower lung fields bilaterally without evidence of consolidation.1.Which one of the following is the best next step in the management of this patient?a.Retest for SARS-CoV-2 infectionb.Prescribe a corticosteroid for suspected e-cigarette or vaping use–associated lung injuryc.Prescribe a 5-day course of levofloxacin with close outpatient follow-upd.Conservative treatment with close outpatient follow-upe.Admit patient for further evaluation Although a negative nasopharyngeal PCR test for SARS-CoV-2 does not rule out coronavirus disease 2019, it has a high sensitivity. Although laboratory and radiographic findings associated with coronavirus disease 2019 pneumonia can vary substantially, profound neutrophilia without lymphopenia is unusual and peripheral opacities are a more common pattern on chest radiography. E-cigarette or vaping use–associated lung injury is a possibility, but corticosteroids should be reserved for severe cases and withheld until community-acquired pneumonia has been ruled out. The salient features in this case include fever, cough, interstitial opacities on chest imaging, possible environmental exposures, and a close contact with similar symptoms, concerning for pneumonia as the infectious syndrome. Levofloxacin would be an appropriate choice in this instance, providing coverage for both typical and atypical respiratory pathogens. Although viral pneumonia is a possibility, neutrophilia and imaging changes raise concern for bacterial infection and antibiotic therapy is indicated. Inpatient care should be reserved for patients with increased work of breathing, evidence of hemodynamic instability, or altered mental status; and scoring tools such as the pneumonia severity index or CURB-65 can guide the initial site of treatment. On the basis of the data provided, the CURB-65 score is zero and inpatient treatment is not indicated at this time. The patient was diagnosed as having a viral infection and discharged from the ED without antibiotics, with recommendations to follow up with her primary care provider. Six days later, she was found unresponsive at home and brought to the ED by family for further assessment. During this time frame, her partner had died of respiratory illness. At this presentation, her initial blood pressure was 87/34 mm Hg; heart rate, 90 beats/min; respiratory rate, 37 breaths/min; oxygen saturation, 70% on room air; and temperature, 35.1 °C. Laboratory evaluation was notable for a hemoglobin level of 12.1 mg/dL (11.6 to 15 mg/dL); platelet count, 539×109/L ((157 to 371)×109/L); and leukocyte count, 34.0×109/L ((3.4 to 9.6)×109/L) with neutrophilia. The metabolic panel revealed a sodium level of 129 mmol/L (135 to 145 mmol/L); potassium level, 3.4 mmol/L (3.6 to 5.2 mmol/L); chloride level, 90 mmol/L (98 to 107 mmol/L); bicarbonate level, 12 mmol/L (22 to 29 mmol/L); and creatinine level, 3.80 mg/dL (0.74 to 1.35 mg/dL). The hepatic function panel revealed a total bilirubin level of 1.8 mg/dL (<1.2 mg/dL); alanine aminotransferase level, 384 U/L (7-25 U/L); and aspartate aminotransferase level, 466 U/L (8 to 33 U/L). Repeat SARS-CoV-2 testing was negative. Computed tomography of the chest revealed diffuse bilateral nodular pulmonary opacities.2.Which one of the following is the most likely diagnosis?a.Cat scratch diseaseb.Influenza virusc.Coronavirus disease 2019 pneumoniad.Fungal pneumoniae.Legionnaires disease The patient has returned to the ED with a clinical syndrome of septic shock secondary to a lower respiratory tract infection. Cat scratch disease due to infection by Bartonella henselae typically presents as localized cutaneous erythema near the site of a scratch. Visceral organ involvement is generally limited to the liver and spleen. Although there is a positive exposure history with evidence of bite marks on physical examination, this diagnosis does not fit with her current clinical presentation. The 4 alternative diagnoses may all present as pneumonia. Influenza is very unlikely, given the patient presented during the summertime and has no documented history of travel to the southern hemisphere. Coronavirus disease 2019 pneumonia should be considered in the differential, but the patient now has had 2 negative PCR tests. Both Legionnaires disease and pneumonia caused by endemic fungi (Histoplasma sp and Blastomyces sp) may have similar radiologic features. In this case, the rapid progression to septic shock, supportive laboratory features (hyponatremia and elevated transaminase levels), and a family member with similar symptoms and environmental exposures (hot tub and swimming pool) are most suggestive of Legionnaires disease. The patient was emergently intubated and admitted to the medical intensive care unit.3.Which one of the following is the best approach to confirm the diagnosis in this patient?a.Obtain 2 sets of blood culturesb.Obtain urine for antigen testingc.Obtain upper respiratory samples for cultured.Obtain upper respiratory samples for PCR testinge.Perform bronchoalveolar lavage with PCR testing The yield of blood cultures for the detection of Legionella sp is low, with growth of the organism often failing to exceed the threshold for detection using routine methods.1Murdoch D.R. Diagnosis of Legionella infection.Clin Infect Dis. 2003; 36: 64-69https://doi.org/10.1086/345529Crossref PubMed Scopus (219) Google Scholar Urinary antigen testing (UAT) is widely available, and results can be obtained rapidly. However, it detects only L pneumophilia serogroup 1, which accounts for around 84% of cases.2Yu V.L. Plouffe J.F. Pastoris M.C. et al.Distribution of Legionella species and serogroups isolated by culture in patients with sporadic community-acquired legionellosis: an international collaborative survey.J Infect Dis. 2002; 186: 127-128https://doi.org/10.1086/341087Crossref PubMed Scopus (527) Google Scholar Although isolation of Legionella sp on a culture medium or via PCR is confirmatory, the sensitivity of upper airway specimens is low. In this patient, the diagnosis should be confirmed with bronchoalveolar lavage and PCR testing. Polymerase chain reaction testing is rapid and more sensitive than both culture and urinary antigen testing.3Peci A. Winter A.L. Gubbay J.B. Evaluation and comparison of multiple test methods, including real-time PCR, for Legionella detection in clinical specimens.Front Public Health. 2016; 4: 175https://doi.org/10.3389/fpubh.2016.00175Crossref PubMed Scopus (31) Google Scholar Testing for other causes of bacterial, fungal, and atypical pneumonia, including Histoplasmosis sp and Blastomycosis sp may be performed at the time of bronchoalveolar lavage. A bronchoalveolar lavage was performed. PCR testing returned positive for Legionella within 24 hours. Cultures of bronchoalveolar lavage also exhibited growth of Legionella. Fungal and other infectious studies obtained returned negative.4.After diagnostic confirmation, which one of the following is the most appropriate antimicrobial regimen for this patient’s condition?a.Ceftriaxone 1 g intravenous (IV) every 24 hours and azithromycin 500 mg IV every 24 hoursb.Doxycycline 100 mg orally twice a dayc.Levofloxacin 750 mg IV every 24 hoursd.Levofloxacin 500 mg IV every 24 hours and azithromycin 500 mg IV every 24 hourse.Azithromycin 500 mg IV every 24 hours and rifampin 600 mg IV every 24 hours Ceftriaxone along with azithromycin is an appropriate empirical regimen for patients presenting with severe community-acquired pneumonia without risk factors for methicillin-resistant Staphylococcus aureus or Pseudomonas aeruginosa. When a pathogen is identified, treatment should be narrowed. Doxycycline and the tetracycline class of antibiotics are effective against Legionella sp, but their use is limited to mild infection and is generally not considered first line because of increased levels of resistance among Legionella species longbeachae.4Roig J. Rello J. Legionnaires’ disease: a rational approach to therapy.J Antimicrob Chemother. 2003; 51: 1119-1129https://doi.org/10.1093/jac/dkg191Crossref PubMed Scopus (100) Google Scholar The correct answer is levofloxacin 750 mg IV every 24 hours. The first-line treatment of severe Legionnaires disease is a respiratory fluoroquinolone or a macrolide. However, there is no evidence that combination therapy improves outcomes.5Cecchini J. Tuffet S. Sonneville R. et al.Antimicrobial strategy for severe community-acquired Legionnaires’ disease: a multicentre retrospective observational study.J Antimicrob Chemother. 2017; 72: 1502-1509https://doi.org/10.1093/jac/dkx007Crossref PubMed Scopus (12) Google Scholar Legionella is a facultative intracellular pathogen, and its virulence may be enhanced by biofilm formation.6Abdel-Nour M. Duncan C. Low D.E. Guyard C. Biofilms: the stronghold of Legionella pneumophila.Int J Mol Sci. 2013; 14: 21660-21675https://doi.org/10.3390/ijms141121660Crossref PubMed Scopus (106) Google Scholar Rifampin can attain high intracellular concentrations and penetrate biofilms; however, research has not reported the efficacy of rifampin as an adjunctive therapy for Legionnaires disease.7Grau S. Antonio J.M. Ribes E. Salvadó M. Garcés J.M. Garau J. Impact of rifampicin addition to clarithromycin in Legionella pneumophila pneumonia.Int J Antimicrob Agents. 2006; 28: 249-252https://doi.org/10.1016/j.ijantimicag.2006.03.029Crossref PubMed Scopus (27) Google Scholar In patients with severe pneumonia, a minimum of 7 days of therapy is warranted, and to reduce the risk of relapse in this patient with common variable immune deficiency, a 14-day course would be reasonable. Ultimately, duration can be adjusted on the basis of clinical response to therapy. In this case, the patient received a 15-day course of levofloxacin, which was dose adjusted for dialysis after the patient had sepsis-associated renal failure. The patient responded well to directed therapy with resolution of hypoxia and renal failure, and after a prolonged hospitalization, she was discharged to the community.5.Which one of the following is the most appropriate step that the medical facility should take once this patient’s diagnosis is confirmed?a.Place the patient on airborne precautionsb.Place the patient on droplet precautionsc.Report diagnosis to the state department of healthd.Perform contact tracing of exposed personse.Conduct an environmental study to determine the source of the case Legionnaires disease is spread through aerosolized water particles, and person-to-person transmission has not been convincingly reported. Given this, neither airborne nor droplet precautions are warranted once the diagnosis has been established. It is the responsibility of the treating medical facility to report the diagnosis to the relevant state authority, and this should be done expeditiously, both to identify the source of the outbreak and to alert local practitioners to the possibility of additional cases. Tracing of close contacts or other persons exposed to the source of the outbreak and undertaking an environmental study is the responsibility of the state department of health. State authorities were alerted, and the source of the outbreak was identified. Pneumonia caused by Legionella infection is referred to as Legionnaires disease, stemming from its discovery after an outbreak associated with a meeting of the American Legion in Philadelphia, Pennsylvania, in 1976. Legionnaires disease is caused by Legionella sp, an aerobic gram-negative bacillus. The most common species L pneumophilia accounts for more than 90% of cases in the United States,2Yu V.L. Plouffe J.F. Pastoris M.C. et al.Distribution of Legionella species and serogroups isolated by culture in patients with sporadic community-acquired legionellosis: an international collaborative survey.J Infect Dis. 2002; 186: 127-128https://doi.org/10.1086/341087Crossref PubMed Scopus (527) Google Scholar and to date, 15 serogroups of L pneumophilia have been identified, with serogroup 1 accounting for 84% of reported cases. Legionella bacteria live and grow in water systems at temperatures of 20 to 50 °C. The most common form of transmission of Legionella is inhalation of contaminated aerosols. Sources of aerosols that have been linked to transmission of Legionella include air conditioning cooling towers, hot and cold water systems, humidifiers, and whirlpool spas.8Legionellosis. World Health Organization. Updated February 16, 2018. Accessed March 28, 2022.https://www.who.int/news-room/fact-sheets/detail/legionellosisGoogle Scholar The Centers for Disease Control and Prevention recommends that health care facilities routinely test for Legionella in water sources and develop a comprehensive water management plan to reduce the risk of outbreaks. Legionnaires disease presents, similar to other bacterial pneumonias, with signs and symptoms including fever, cough, headache, and myalgias developing 2 to 10 days after the initial exposure. Interestingly, more than half of patients do not produce sputum9Dias A. Cysneiros A. Lopes F.T. et al.The typical presentation of an atypical pathogen during an outbreak of Legionnaires’ disease in Vila Franca de Xira, Portugal, 2014.Rev Port Pneumol (2006). 2017; 23: 117-123https://doi.org/10.1016/j.rppnen.2017.01.007Crossref PubMed Scopus (5) Google Scholar and also had sphygmothermic dissociation, through which patients do not develop tachycardia in the presence of fever.10Ostergaard L. Huniche B. Andersen P.L. Relative bradycardia in infectious diseases.J Infect. 1996; 33: 185-191https://doi.org/10.1016/s0163-4453(96)92225-2Abstract Full Text PDF PubMed Scopus (0) Google Scholar The laboratory profile is notable for hyponatremia in more than half of patients.9Dias A. Cysneiros A. Lopes F.T. et al.The typical presentation of an atypical pathogen during an outbreak of Legionnaires’ disease in Vila Franca de Xira, Portugal, 2014.Rev Port Pneumol (2006). 2017; 23: 117-123https://doi.org/10.1016/j.rppnen.2017.01.007Crossref PubMed Scopus (5) Google Scholar The precise mechanism for hyponatremia has not been elucidated, and the often-cited hypothesis that it is secondary to the syndrome of inappropriate antidiuretic hormone secretion is not borne out.11Schuetz P. Haubitz S. Christ-Crain M. Albrich W.C. Zimmerli W. Mueller B. ProHOSP Study GroupHyponatremia and anti-diuretic hormone in Legionnaires’ disease.BMC Infect Dis. 2013; 13: 585https://doi.org/10.1186/1471-2334-13-585Crossref PubMed Scopus (27) Google Scholar Patients with hyponatremia and evidence of sepsis secondary to Legionnaires disease should not be deprived of appropriate fluid resuscitation for this reason. Radiographic manifestations are nonspecific; unilobar and multilobar infiltrates are almost equally as common, and pleural effusion may also be frequently observed.12Tan M.J. Tan J.S. Hamor R.H. File Jr., T.M. Breiman R.F. The Ohio Community-Based Pneumonia Incidence Study Group. The radiologic manifestations of Legionnaire’s disease.Chest. 2000; 117: 398-403https://doi.org/10.1378/chest.117.2.398Abstract Full Text Full Text PDF PubMed Scopus (100) Google Scholar As previously noted, monotherapy with a fluoroquinolone or a macrolide is the recommended first-line therapy for Legionnaires disease.

Abstract Background Peripherally inserted central catheters (PICCs) and midlines are commonly used devices for reliable vascular access. Infection and thrombosis are the main adverse effects of these catheters. We aimed to evaluate the relative risk of complications from midlines and PICCs. Methods We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) and observational studies. The primary outcomes were catheter-related bloodstream infection (CRBSI) and thrombosis. Secondary outcomes evaluated included mortality, failure to complete therapy, catheter occlusion, phlebitis, and catheter fracture. The certainty of evidence was assessed using the GRADE approach. Results Of 8368 citations identified, 20 studies met the eligibility criteria, including 1 RCT and 19 observational studies. Midline use was associated with fewer patients with CRBSI compared with PICCs (odds ratio [OR], 0.24; 95% CI, 0.15–0.38). This association was not observed when we evaluated risk per catheter. No significant association was found between catheters when evaluating risk of localized thrombosis and pulmonary embolism. A subgroup analysis based on location of thrombosis showed higher rates of superficial venous thrombosis in patients using midlines (OR, 2.30; 95% CI, 1.48–3.57). We did not identify any significant difference between midlines and PICCs for the secondary outcomes. Conclusions Our findings suggest that patients who use midlines might experience fewer CRBSIs than those who use PICCs. However, the use of midline catheters was associated with greater risk of superficial vein thrombosis. These findings can help guide future cost-benefit analyses and direct comparative RCTs to further characterize the efficacy and risks of PICCs vs midline catheters.

In this retrospective cohort of adult hematology-oncology and transplant patients, discontinuation of universal gloving did not result in significant changes in rates of central line-associated bloodstream infection, Clostridioides difficile infection, or vancomycin-resistant Enterococcus colonization. Active surveillance and subsequent isolation may be a viable alternative strategy to universal precautions.