August 7, 2018
In This Issue
VOTE today for your 2019 SHEA Board of Trustees
"Zero-tolerance" Border Policy Poses Individual and Public Health Threats
Looking for a Job? Looking to Hire? Check out the SHEA Career Center
Save the Date - SHEA Spring 2019
IDWeek 2018 Registration Open to All
Pre-Meeting Workshops at IDWeek 2018
IDWeek Late Breaker Abstracts Now Being Accepted!
New on LearningCE: SHEA Spring 2018 Full Conference and Workshop Recordings
AHRQ Shutters National Guidelines Clearinghouse, National Quality Measures Clearinghouse
Do you want to save AHRQ from devastating cuts? Become a SHEA Advocate.
CDC's Antibiotic Stewardship Training Series
AHRQ Funding Available SHEA Submits Comments to the FY2019 Inpatient Prospective Payment System Proposed Rule SHEA Submits Comments to the FY2019 Inpatient Prospective Payment System Proposed Rule
NEW Emergency Department and Urgent Care Stewardship Toolkit
AHRQ National Advisory Council
AHRQ Funding Available
Funding Applications Due Sept. 25 and Oct. 5 for Research Projects on Healthcare-Associated Infections and Antibiotic Resistance
Order A Copy of Practical Implementation of an Antibiotic Stewardship Program Textbook
W(h)ither Vancomycin?
Systems Level Solutions to Challenges with Transmission Based Precautions
Leveraging Electronic Medical Record Tools to Reduce Unnecessary Antibiotic Use: Two Examples.
CRE or not CRE: A Question of Risky Business and Notes from the Field
Recent Articles of Note
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November 14 - 15, 2018
2018 Antimicrobial Stewardship Research Workshop
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October 3 - 7, 2018
IDWeek 2018
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Dear Colleagues,

It is already August and officially we are past the midpoint of my year as president – I can’t believe the year is going by so quickly!  I wanted to take time to recognize all the amazing volunteers that make SHEA the strong and collegial organization that it is today.   SHEA volunteers offer countless hours in support of the SHEA Board of Trustees, committees, task forces, working groups, writing groups, program planning committees, liaison efforts and many other endeavors. It is this collective effort that allows SHEA, despite its relatively small size, to be an extremely influential organization. I’d also like to thank in advance everyone who recently expressed interest in serving as a volunteer for the next leadership cycle. We are working hard to engage everyone who expresses interest in becoming a SHEA volunteer and look forward to filling many positions on committees, task forces, and writing groups.  We also recognize the incredible time and effort that SHEA mentors offer.  Every volunteer contribution is valued and helps to make SHEA that much stronger and more meaningful as an organization.    

Although the SHEA/CDC Outbreak Response Training Program (ORTP) recently wrapped up, I encourage you to explore the ORTP Website and all it has to offer.  This website offers multifaceted, FREE educational resources for preparing for, responding to, and recovering from outbreaks, including online simulation exercises, workshop recordings, and interactive implementation toolkits.

I am also pleased to announce the creation of the “Outbreak Prevention and Response Week” which will launch on September 17 through 21, 2018. During this week, SHEA and our partners will raise awareness regarding ways to prevent the spread of infectious diseases in healthcare settings.  A variety of resources will be highlighted to assist healthcare professionals, the infection prevention community, and patients and families prevent infection.  Outbreak Prevention and Response Week will highlight the important work SHEA members do to make healthcare delivery safer and promote the unique and critical expertise of the profession of infection prevention and healthcare epidemiology.  You can read about the daily themes and activities here and more information and materials will be available soon. We are excited to collaborate with a variety of members within the infection prevention stakeholder community to help spread the important message of infection prevention.   Thanks in advance for your support.

If you have not yet registered for IDWeek 2018 in San Francisco, October 3-7, 2018, there is still time. Many of the educational sessions offered are geared towards the Healthcare Epidemiologist and Antibiotic Steward. There is also great science being presented.  A record number of abstracts were submitted this year, many of which have an infection prevention or antibiotic stewardship focus. I look forward to seeing you there.

Of note, SHEA just opened registration for our Antibiotic Stewardship Research Workshop scheduled for November 14-15, 2018, in Baltimore, Maryland. This conference is for healthcare providers and professionals interested in all facets of antibiotic stewardship research including national strategies and goals for stewardship research and prevention of antimicrobial resistance through stewardship.  Visit www.asresearchworkshop.org for more information. 

I hope to see you at one of these great events, or to connect with you at one of our SHEA Connection Tour Stops planned for New York, Michigan, and Virginia in the fall.  Email info@shea-online.org for more information!

Sincerely,

Keith Kaye, MD, MPH, FSHEA
SHEA President 

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VOTE today for your 2019 SHEA Board of Trustees
The election is open for voting on the 2019 SHEA Board of Trustees.  
 
Everyone eligible to vote, which includes SHEA Members and Fellows of SHEA, should have received instructions via email about the candidates.  If you have any questions about the election, please email info@shea-online.orgVotes are due September 17, 2018, at Noon ET.   
 
We appreciate your participation in this important process and look forward to working with the 2019 Board of Trustees.
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"Zero-tolerance" Border Policy Poses Individual and Public Health Threats
In a recent joint statement, the leaders of IDSA, HIVMA, SHEA, and PIDS warned of the consequences to individual and public health of continuing "zero-tolerance" border policies and of large-scale detention of thousands of weakened and vulnerable individuals. 
 
The statement outlined concerns about prioritizing individual and public health at the border to prevent an outbreak situation.  Please read the full statement online HERE.
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Looking for a Job? Looking to Hire? Check out the SHEA Career Center

Whether you are an epidemiology professional or are looking to fill a position in your organization, the SHEA Career Center should be your first stop. It has tools and knowledge to help job seekers be well positioned to find a new job in 2014. The SHEA Career Center is the official online career center for SHEA and provides a diverse listing of opportunities for job seekers and places employers' jobs directly in front of our talented members. Visit www.healthecareers.com/shea to check out this career resource.

Click on Glasses to learn more. 

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Save the Date - SHEA Spring 2019
SHEA is pleased to announce the SHEA Spring 2019 Conference: Science Guiding Prevention will take place in Boston, MA at the Westin Boston Waterfront from Wednesday, April 24– Friday, April 26, 2019
 
This year's conference will build on the success of past SHEA Spring Conferences and 
focus on innovative and cutting-edge topics addressing unanswered issues in healthcare epidemiology and antibiotic stewardship.
 
SHEA Spring 2019 highlights include: 
  • Focused scientific abstracts related to healthcare epidemiology, surveillance, implementation science and patient safety, and prevention strategies with poster and abstract awards
  • Cutting-edge healthcare-associated infection prevention and antibiotic stewardship education delivered by experts in the field
  • Education focused on multi-disciplinary and integrated approaches involving implementation science and prevention across the healthcare continuum
  • SHEA Mentorship Program 
  • Women in Epi Networking Event
  • SHEA Epi Competition 
  • SHEA Education & Research Foundation Dinner (Ticket Purchase Required)
Who should come to SHEA Spring 2019?  
 
This conference is designed for physicians, infection preventionists, healthcare epidemiologists, infectious disease specialists, microbiologists, nurses, pharmacists, and other healthcare professionals 
interested in healthcare epidemiology, infection prevention, surveillance, research methods, patient safety, environmental issues, and quality improvement.
 
The SHEA 2019 Planning Committee recently met and are planning many great sessions that span the spectrum of antibiotic stewardship and infection prevention.  Make plans to join us in Spring 2019 in Boston.
 
Registration and Abstract Submission sites will open in early October 2018.
 
More information coming soon! 
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IDWeek 2018 Registration Open to All
IDWeek boasts a comprehensive array of CME, CPE and MOC offerings. Review the Program Primer to see the cutting-edge science presentations. View the schedule-at-a-glance to help plan your travel. The ten premeeting workshops start on Tuesday, Oct. 2. Register for workshops during the online registration process. The trivia showdown ID BugBowl will return on Saturday, Oct. 6 at 4:45 p.m. Watch teams of medical students, residents, and fellows duke it out for bragging rights and the BugBowl trophy. Stay through Sunday for the Closing Plenary, From Science Fiction to Clinical Trial: The use of Phage to Treat Antibiotic-Resistant Infections, to hear a firsthand account from the epidemiologist who championed cutting-edge phage therapy to save her husband’s life, as reported in Time Magazine.

Important Dates and Deadlines:

Discounted Early Registration Deadline 
June 29
 
IDWeek 2018, San Francisco, CA 
October 3-7
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Pre-Meeting Workshops at IDWeek 2018
SHEA would like to direct members attention to two pre-meeting workshops that SHEA is involved in helping to plan for IDWeek - Best Practices for Antimicrobial Stewardship Programs and A Sociobehavorial Approach to Infection Prevention and Antimicrobial Stewardship.
 
Attending either pre-conference workshop requires an additional fee.  Check out the details on each below and sign up at www.idweek.org. 
 
Best Practices for Antimicrobial Stewardship Programs
Tuesday, October 2
8 a.m. – 5 p.m.
 
Learning objectives for attendees of this workshop are to: 
 
  • evaluate components of effective antimicrobial stewardship programs and implement interventions in their healthcare setting
  • describe the strategies for the implementation process and the outcome measures
  • apply antimicrobial stewardship interventions for unique populations and across healthcare settings
  • critically assess available data, including pharmacy and microbiology data, needed to support antimicrobial stewardship in their institution
The full agenda with speakers can be found HERE
 
A Sociobehavioural Approach to Infection Prevention and Antimicrobial Stewardship
Wednesday, October 3
8 a.m. – Noon
 
Learning objectives for attendees of this workshop are to: 
 
  • describe a conceptual framework informed by the social sciences that can be applied to the work of improving patient safety and quality
  • discuss an overview of the fields of medical sociology, behavioral economics and implementation science as they apply to antimicrobial stewardship and infection prevention
  • describe a practical example of an antimicrobial stewardship intervention that utilizes evidence-based communication training
  • explain what a social driver diagram is and how it can be practically applied to the everyday work of managing social barriers to change in implementing antimicrobial stewardship and infection prevention interventions
 
The full agenda for this workshop with speakers is available HERE
 
We hope you will consider adding one of these workshops to your IDWeek registration. 
 
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IDWeek Late Breaker Abstracts Now Being Accepted!
Did you have an abstract with data that wasn't quite ready before the May 1st IDWeek abstract deadline? It’s not too late! Submit it now to be considered as a late breaker abstract.
 
Late breaker abstracts are highly competitive – IDWeek will accept less than 10 percent of submissions and only abstracts containing new, novel, cutting-edge information will be considered. Retrospective studies will not be considered. Please note, authors of late breaker abstracts are not eligible to apply for IDWeek travel grants or awards.
 
All late breaker abstracts must be submitted online by 5 p.m. EDT on Thursday, August 16th.
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New on LearningCE: SHEA Spring 2018 Full Conference and Workshop Recordings
We at SHEA are pleased to inform you that the SHEA Spring 2018 Full Conference and Pre-Conference Workshop video recordings are now available for purchase on SHEA's Online Education Center. Watch the video recordings and then take the online evaluation to earn your CME credit. 
 
Click HERE for a free preview!
 
*Members of APIC: Click HERE to receive a discounted rate for the APIC sponsored session
 
Access the Online Recordings:
First time accessing LearningCE? Login or register at learningce.shea-online.org.
 
Instructions: 
• Members - login with your SHEA email and password      
• Non-members - click register new user and fill out the information fields. Register with the same email used for SHEA Spring.
 
If you are having trouble accessing the course, please email LearningCE@shea-online.org.
 
The Society for Healthcare Epidemiology of America is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.
Physicians: The Society for Healthcare Epidemiology of America designates this enduring material for a maximum of 34.50 AMA PRA Category 1 Credit(s)™, the core Full Conference Recordings are designated for 31.00 credit hours and the pre-meeting workshop is an additional 3.50 credit hours. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
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AHRQ Shutters National Guidelines Clearinghouse, National Quality Measures Clearinghouse
On July 16, the National Guidelines Clearinghouse and the National Quality Measures Clearinghouse, both under the purview of the Agency for Healthcare Research and Quality (AHRQ), were shut down as a result of federal funding cuts. The data housed within these databases will no longer be publicly available.
 
This loss is a direct result of years of AHRQ budget stagnation and cuts. In FY 2016, the agency sustained a $30 million cut after a successful grassroots campaign to save AHRQ from termination, which was proposed in the House’s appropriations legislation. Shortly after the appropriations bill was signed into law, AHRQ officials announced in February 2016 that it would be forced to eliminate key programs because of the way the appropriations legislation was written. With lawmakers providing targeted funding for different projects, the $30 million cut was concentrated in the “crosscutting” project line where the NGC and NQMC were funded, an equivalent of a 40 percent cut to that budget line.  Those cuts forced AHRQ to terminate several programs including its multiple chronic conditions portfolio, the HIV Research Network, and other initiatives. 
Following the recent public outcry from the stakeholder community over the NGC “going dark,” AHRQ is exploring options to sustain the NGC and will continue to do so even though this site is offline. AHRQ Director Gopal Khanna recently posted a message on Twitter acknowledging stakeholders’ frustration and committed to keeping the healthcare community apprised of any updates and new information. 
 
There is a grassroots effort that has launched on Twitter to save the NGC, and a number of organizations have sent letters and comments to AHRQ. Any efforts to save the NGC must include a call to increase funding for AHRQ. The agency cannot save the NGC without new funding. And, if Congress provides AHRQ an unfunded mandate to keep the NGC going in its FY 2019 appropriations legislation, that just means the agency will be forced to cut something else of value.  
 
SHEA has and continues to collaborate with multiple stakeholder organizations through grassroots efforts to increase funding for AHRQ. The Friends of AHRQ is the primary convener for AHRQ stakeholders and continues to advocate for a significant funding increase to restore the NGC and other programs and opportunities lost after a decade of cuts and stagnant funding. This trend continues through to the FY 2018 budget which is essentially $120 million below FY 2010 levels, adjusted for inflation. Additionally, both the House and Senate Appropriations Committees have provided flat funding of $334 million in discretionary budget authority for the AHRQ in FY 2019.
 
The agency also faces a significant funding cliff of 20 percent of its program level budget if the Patient-Centered Outcomes Research Institute (PCORI) and Trust Fund are not reauthorized at the end of FY 2019. The Friends of AHRQ coalition has asked Congress to provide the agency $454 million in FY 2019 to avoid going over the funding cliff should PCORI and the Trust Fund not be reauthorized, and to get back to 2010 levels so the agency can restore the NGC and other activities. 
 
SHEA will join a Friends of AHRQ sign-on letter that reiterates our funding request and highlights the NGC and other cuts as justification in the coming weeks.  In the meantime, SHEA will continue to keep you apprised of any new information.
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Do you want to save AHRQ from devastating cuts? Become a SHEA Advocate.
In order to successfully reach policy goals, organizations rely on their members to actively participate in advocacy initiatives. SHEA recently launched a new Grassroots Network Action Center that utilizes technology to make it easier to contact your federal legislators. Our new platform offers multiple options for contacting congressional representatives using your mobile device or computer. 
 
All new and existing SHEA advocates are asked to sign up in our new Action Center by texting PREVENTION to 52886. Once you’ve sent your text, you will be asked to provide your email address, name, and your 5-digit zip code. You’ll only have to complete this step one time. After that, our advocacy tool will remember you. You can also opt out of text messaging later if you don’t think it will be right for you. But please don’t! This advocacy platform works seamlessly with mobile devices and you will only receive text alerts during active campaigns.
IMPORTANT: SHEA’s Grassroots Network is for anyone interested in supporting our policy agenda. So please pass this information on to anyone (in the U.S.) interested in taking action on our policy priorities.
 
News and policy updates will continue to be sent via email from grassroots@shea-online.orgg and our monthly newsletter which will always be accessible to anyone not subscribed to our Action Center. Please keep grassroots@shea-online.org on your whitelist to make sure you continue to receive our timely updates. 
 
We are still in the process of building out our Action Center, so please stay tuned for more. And let us know what you think.
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CDC's Antibiotic Stewardship Training Series
CDC just released section two of the "CDC Training on Antibiotic Stewardship".
 
The recently released section 2  is comprised of 4 modules all available at no cost.  Module 4a will cover what we know about outpatient antibiotic use in the United States.  Additionally, inappropriate antibiotic usages will be discussed and the opportunities for improvement.  Module 4b will discuss the barriers to appropriate outpatient antibiotic prescribing to identify methods to help clinicians overcome those barriers. Module 5 will discuss the importance of antibiotic stewardship in outpatient settings, the Core Elements of Outpatient Antibiotic Stewardship, and evidenced-based strategies to implement the Core Elements. Finally, Module 6 will provide training for clinicians about communicating with patients when antibiotics are not warranted. Each individual module has continuing education.
 
You can check out the entire course, including the prior released module HERE.
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AHRQ Funding Available SHEA Submits Comments to the FY2019 Inpatient Prospective Payment System Proposed Rule SHEA Submits Comments to the FY2019 Inpatient Prospective Payment System Proposed Rule
The Centers for Medicare and Medicaid Services (CMS) solicited public comments in April on its annual update of the Inpatient Prospective Payment System (IPPS) for acute care settings.  The IPPS rule determines payment for the operating costs of acute care hospital inpatient and long-term care hospital stays under Medicare Part A based on prospectively set rates. The rule is the vehicle for which policy changes associated with acute inpatient and long-term care hospitals are made, including requirements for quality reporting. The Hospital Value-Based Purchasing Program (VBP), Hospital Readmissions Reduction Program, and the Hospital-Acquired Condition (HAC) Reduction Program are all subject to annual review and updates under the IPPS rule. SHEA reviews annually all proposed policy changes associated with IPPS quality reporting requirements and submits comments on all proposed changes that impact reporting requirements measuring healthcare-associated infection rates and outcomes.
 
This year, SHEA submitted extensive comments [LINK:TBD] for the FY 2019 IPPS proposed rule. The most notable proposal seeks to minimize duplicative reporting of certain HAI quality metrics by consolidating them into a single program under the VBP program. If finalized, the following HAI quality reporting measures will be reported by CMS under the HAC program only:
 
•  National Healthcare Safety Network (NHSN) Catheter-Associated Urinary Tract Infection (CAUTI) Outcome Measure (NQF #0138) (CAUTI)
•  National Healthcare Safety Network (NHSN) Central Line-Associated Bloodstream Infection (CLABSI) Outcome Measure (NQF #0139) (CLABSI)
•  American College of Surgeons-Centers for Disease Control and Prevention (ACS–CDC) Harmonized Procedure Specific Surgical Site Infection (SSI) Outcome Measure (NQF #0753) (Colon and Abdominal Hysterectomy SSI)
•  National Healthcare Safety Network (NHSN) Facility-wide Inpatient Hospital-onset Methicillin-resistant Staphylococcus aureus (MRSA) Bacteremia Outcome Measure (NQF #1716) (MRSA Bacteremia)
•  National Healthcare Safety Network (NHSN) Facility-wide Inpatient Hospital-onset Clostridium difficile Infection (CDI) Outcome Measure (NQF #1717) (CDI)
•  Patient Safety and Adverse Events (Composite) (NQF #0531) (PSI 90) 
 
In previous rulemaking comment periods, SHEA has advocated for the elimination of duplicative reporting requirements that may impose multiple penalties for the same metric in the same reporting period. Therefore, SHEA supports CMS’ proposal.
 
However, SHEA recognizes that these proposed changes are not without shortcomings. SHEA expressed concern that removal of HAI metrics from the VBP Program will remove the incentive for hospitals to strive toward zero infections. We recommended CMS retain the HAI measures in the VBP Program rather than the HAC program, or alternatively take steps to incorporate incentives in the HAC Reduction Program before removing HAI measures from the VBP Program.
 
SHEA is also aware that many patient advocacy groups issued a strong rebuke of this proposal believing that CMS’ proposed policy changes would result in no HAI quality reporting requirements, and that data regarding hospitals’ infection rates would not be published on Hospital Compare. Their assessment was picked up by multiple media outlets and spurred multiple grassroots calls to action to reject CMS’ proposal. 
 
In our comments, SHEA laid out the society’s guiding principles for measuring quality through reporting of HAI metrics: 
 
1) SHEA believes HAI public reporting provides transparency and is beneficial, 
2) SHEA believes both incentives AND penalties are equally important to motivate hospitals to improve infection prevention practices, and 
3) SHEA believes redundancy and the burden of reporting should be minimized.
 
We disagree with some patient advocacy groups’ assessment that the FY 2019 IPPS proposed rule would eliminate the availability of hospital infections rates on Hospital Compare. SHEA’s analysis of the proposed rule reveals that CMS states multiple times throughout the proposal the importance of making these data available to the public, and its intent to continue to make infection rates available on Hospital Compare. Our analysis is further supported by consultation with CDC representatives who provided an overview of the proposed rule to multiple stakeholder groups including patient advocacy organizations.
 
While we do not share some organizations’ assessment of the proposed rule, SHEA agrees with them in that hospital infection rates should continue to be made available on Hospital Compare, and that data should continue to be easily accessible by the public. 
 
We will report on CMS’ final decision on this proposal when the rule is published in the fall.
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NEW Emergency Department and Urgent Care Stewardship Toolkit

The MITIGATE (A Multifaceted Intervention to Improve Prescribing for Acute Respiratory Infection for Adults and Children in the Emergency Department and Urgent Care Settings) Toolkit is intended as a “gold standard,” step-by-step implementation guide for healthcare providers and administrators interested in designing quality improvement programs in antimicrobial stewardship in emergency department (ED) and urgent care settings. When implemented as written, the toolkit will fulfill the CDC Core Elements of Outpatient Antibiotic Stewardship. 

The MITIGATE Toolkit is a systematically adapted antibiotic stewardship program developed for use in the emergency department and urgent care settings in collaboration with physicians, administrators, nurses, and patients. MITIGATE also includes specific strategies for pediatric settings.  The recommendations in this toolkit were based on a multicenter randomized comparative effectiveness trial using an implementation science approach to adapt existing evidence on behavioral economics approaches in outpatient settings to the ED and urgent care setting. It was developed as a complete step-by-step guide, as requested by focus groups of those working in episodic acute care settings.  The authors include experts in emergency medicine, pediatric emergency medicine, antibiotic stewardship, implementation science, and behavioral economics.

Effective stewardship strategies need to be adapted to ED and urgent care settings in order to be feasible. Providers in these settings are faced with unique challenges to rational decision making such as frequent interruptions, high-volume care, a need for rapid decisions with limited information, variation in staff over different shifts, and concerns with immediate patient satisfaction. This tool kit's implementation strategies are built on research into how to create effective programs amid these challenges.

The authors recognize the full implementation guide may not be immediately feasible for all sites and settings. Facilities may choose to implement portions of the toolkit incrementally based on resources and capabilities. 

For questions or comments pertaining to this toolkit, please contact Dr. Larissa May (larissa.may@gmail.com).
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AHRQ National Advisory Council
U.S. Department of Health and Human Services' Agency for Healthcare Research and Quality (AHRQ) is seeking Nominations to National Advisory Council before the August 8, 2018 deadline
 
AHRQ is seeking nominations for seven new members of its National Advisory Council. The panel, which represents health plans, providers, purchasers, consumers, and researchers, advises the agency director and the Secretary of HHS on AHRQ activities and priorities for a national health services research agenda. Seven individuals will be selected to serve to begin in spring 2019. Members generally serve three-year terms. Among other attributes, nominees should be distinguished in the conduct of healthcare research and demonstration projects, the fields of health care quality research or health care improvement and the practice of medicine. The deadline for nominations is August 8th. Access the Federal Register notice for more information. 
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AHRQ Funding Available
AHRQ is funding innovative ideas for combating antibiotic resistance and healthcare-associated infections. Find out more at by clicking here

AHRQ Has several research funding opportunities available that may be of interest to SHEA members.  Dissemination & implementation applications are due by September 25th and large research projects are due by October 5, 2018.  
 
There are links to funding opportunities listed on this page.
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Funding Applications Due Sept. 25 and Oct. 5 for Research Projects on Healthcare-Associated Infections and Antibiotic Resistance
AHRQ is seeking innovative research proposals for preventing healthcare-associated infections (HAI) and combating antibiotic-resistant bacteria (CARB). Funding applications are due by Sept. 25 for demonstration and dissemination projects (R18). Applications are due by Oct. 5 for large research projects (R01). HAI projects in both grant categories should demonstrate new ways to detect, prevent and reduce HAIs. CARB projects should address ways to promote appropriate antibiotic use, reduce the transmission of resistant bacteria or prevent HAIs. 
 
To learn more, access the "Research Funding Available" section at the top of AHRQ's Healthcare-Associated Infections Program Page, click HERE
 
 
Healthcare-associated infections (HAIs) are among the leading threats to patient safety, affecting one out of every 25 hospital patients at any one time. Over a million HAIs occur across the U.S. health care system every year, leading to the loss of tens of thousands of lives and adding billions of dollars in health care costs.
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Order A Copy of Practical Implementation of an Antibiotic Stewardship Program Textbook
Practical Implementation of an Antibiotic Stewardship Program provides an essential resource for healthcare providers in acute care, long-term care, and ambulatory care settings looking either to begin or to strengthen
existing antibiotic stewardship programs. 
 
Each chapter is written by both physician and pharmacist leaders in the stewardship field and incorporates both practical knowledge as well as evidence-based guidance. This book will also serve as a useful resource for medical
students, pharmacy students, residents, and infectious diseases fellows looking to learn more about the field of antibiotic stewardship. 

The textbook includes: 
 
• A practical guide for the implementation of antibiotic stewardship programs
• Real-life experience from experts in developing and sustaining antibiotic stewardship programs
• Practical experience and evidence-based guidance to implement effective antibiotic stewardship programs 
 
SHEA would like to thank the dedicated efforts of the editors who made this textbook possible:
Tamar F. Barlam, Boston Medical Center
Melinda M. Neuhauser, Centers for Disease Control and Prevention
Pranita D. Tamma, The Johns Hopkins University School of Medicine
Kavita K. Trivedi, Trivedi Consults, LLC.
 
Copies of the textbook can be purchased online here.

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W(h)ither Vancomycin?
Reviewed by: John A. Sellick, DO, MS, University at Buffalo Jacobs School of Medicine and Biomedical Sciences

Vancomycin gained a second life in the 1990s with the growth of methicillin-resistant Staphylococcus aureus (MRSA) infections. The initially sanguine view that the updated product was much less nephrotoxic than the original preparation has progressively been shown to be incorrect.

Adding to the chorus of concern is a recent study by Rutter and Burgess at the University of Kentucky. This retrospective data analysis compared the occurrence of acute kidney injury (AKI) with a combination of vancomycin plus piperacillin/tazobactam vs the combination of vancomycin plus meropenem. Multiple factors including patient factors, pre-existing kidney disease and concomitant nephrotoxic agent use were controlled in a multivariable analysis. The end result was that the vancomycin plus piperacillin-tazobactam combination was associated with significant increases in AKI incidence compared to the vancomycin plus meropenem combination therapy. This should not prompt a wholesale change to meropenem for routine use since this will generate other resistance problems, however, there may be circumstances where avoiding the current favorite of vancomycin plus piperacillin/tazobactam (“vancosyn”) needs to be reconsidered.

Decreasing vancomycin use is the most appropriate method of reducing its toxicity, though this can be problematic in settings where MRSA infection is prevalent or problematic. One such setting is the empiric therapy of nosocomial pneumonia. Parente et al did a review and meta-analysis of studies that utilized MRSA nasal carriage as a predictor of nosocomial MRSA pneumonia. As expected, there was variability in testing and detection methods. However, a positive MRSA nasal swab had poor predictive value for the occurrence of MRSA pneumonia but a negative MRSA nasal swab had a very high negative predictive value (96.5%) for the same outcome. Particularly in hospitals that use molecular testing for detection of MRSA nasal carriage, this could be an important method to decrease the potential toxicity of vancomycin combination therapy.

Specific recommendations by antibiotic stewardship programs (ASP) may raise concerns of legal liability given that the stewards are not generally the primary providers. Tebano et al used a survey of primarily European ASP program members to assess the perceived risk of legal liability and the response to it. The large majority reported perceiving some legal risk associated with their interventions, though only a small minority had ever been sued, and this translated into a high frequency of “defensive behaviors” such as using broader spectrum agents and prolonged courses of antibiotics. While the legal landscape varies by country, best evidence and appropriately referenced guidelines should direct our practices.

Citations:

Rutter WC, Burgess DS. Incidence of Acute Kidney Injury among Patients Treated with Piperacillin-Tazobactam or Meropenem in Combination with Vancomycin. Antimicrob Agents Chemother. 2018 Jun 26;62(7). pii: e00264-18.

https://www.ncbi.nlm.nih.gov/pubmed/?term=29712661

Parente D, Cunha C, Mylonakis E, Timbrook T. The Clinical Utility of Methicillin-Resistant Staphylococcus aureus (MRSA) Nasal Screening to Rule Out MRSA Pneumonia: A Diagnostic Meta-analysis With Antimicrobial Stewardship Implications. Clin Infect Dis. 2018;67:1-7.

https://www.ncbi.nlm.nih.gov/pubmed/?term=29340593

Tebano G, Dyar OJ, Beovic B, Be ́raud G, Thilly N, Pulcini C on behalf of the ESCMID Study Group for Antimicrobial stewardshiP (ESGAP). Defensive medicine among antibiotic stewards: the international ESCMID AntibioLegalMap survey. J Antimicrob Chemother 2018; 73: 1989–96.

https://www.ncbi.nlm.nih.gov/pubmed/?term=29635515

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Systems Level Solutions to Challenges with Transmission Based Precautions
Reviewed by: Sonali Advani, MBBS, MPH, Yale School of Medicine

Healthcare-associated infections are a persistent and growing problem aggravated by the development of microbial resistance to antibiotics and disinfectants. Using personal protective equipment (PPE) and transmission-based precautions are primary strategies for reducing the transmission of infectious agents. Two articles this month discuss errors with transmission based precautions as well as surface modifications to enhance antimicrobial activity in the healthcare setting.

Health care personnel in hospitals often make active errors in PPE use and infectious agent transmission precaution practices that could potentially result in self-contamination, according to a recent study by Krein et al. in JAMA Internal Medicine. Observations of 325 encounters in patient rooms at 2 medical centers over 9 months revealed several lapses and errors in donning and doffing PPE. The authors focused on the sharp end (individual end) and divided these into violations (deviations from policy), mistakes (errors when attempting to follow policy) and slips (automatic behaviors). The context of these errors suggests that a variety of systems-level solutions (blunt end) will be necessary. Given the broad array of circumstances contributing to active failures in precaution practices that were identified and categorized; behavioral, organizational, and environmental strategies may be needed to reduce the risk of infection transmission and self-contamination.

As we explore different systems-level approaches to this problem, a recent comprehensive review by Adlhart et al. in Journal of Hospital Infection focuses on the risk of nosocomial transmission from adhesion of microbes to external solid-gas interfaces (e.g. door knobs, keyboards etc.). This review discusses well-established and novel methodologies to functionally modify surfaces to reduce microbial contamination, as well as the potential risks associated with the implementation of such decontamination measures. The authors explain chemical approaches like anti-adhesive surfaces (e.g. superhydrophobic, zwitterions), contact-killing surfaces (e.g. polymer brushes, phages), and biocide-releasing surfaces (e.g. triggered release, quorum sensing-based systems) as well as topographical modifications at distinct dimensions (nano-sized features may create difficult topographic conditions for attachment). Additionally, the authors discuss the importance of applying safe-by-design criteria (e.g. toxicity, contribution for the unwanted acquisition of antimicrobial resistance, long-term stability) when developing and implementing antimicrobial surfaces.

Citations:

Krein SL, Mayer J, Harrod M, et al. Identification and Characterization of Failures in Infectious Agent Transmission Precaution Practices in Hospitals A Qualitative Study. JAMA Intern Med. Published online June 11, 2018. doi:10.1001/jamainternmed.2018.1898 https://www.ncbi.nlm.nih.gov/pubmed/29889934

Adlhart, C. et al. Surface modifications for antimicrobial effects in the healthcare setting: a critical overview. Journal of Hospital Infection , Volume 99 , Issue 3 , 239 – 249 OI: 10.1016/j.jhin.2018.01.018 https://www.ncbi.nlm.nih.gov/pubmed/29410096

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Leveraging Electronic Medical Record Tools to Reduce Unnecessary Antibiotic Use: Two Examples.
Reviewed by: Valeria Fabre, MD, Johns Hopkins University School of Medicine
Inappropriate treatment of asymptomatic bacteriuria (ASB) in acute care hospitals is common and a major driver of inappropriate antibiotic use. In a Canadian study published in ICHE, the authors evaluated the impact of a change in urine laboratory reporting on the treatment of ASB through a randomized, parallel, superiority trial comparing 2 different methods of reporting positive urine cultures. Exclusion criteria: pregnancy, neutropenia, indwelling urinary catheters, admission to ICU, antibiotics at the time of urine collection, age <18 years. Modified reporting consisted of blinding the urine culture result and prompting the physician to call the microbiology lab for results if urinary tract infection was clinically suspected. The intervention resulted in a significantly higher proportion of appropriate treatment (80% in the modified arm compared to 52% in the standard arm). The number needed to report for the benefit was 3.7. There was no increase in adverse events (deaths, SIRS or any new urinary symptoms within 7 days after urine collection), although the study was not powered to assess safety outcomes. 

Chen et al. developed an electronic clinical decision support tool that prompted a penicillin allergy skin testing by pharmacists for patients receiving aztreonam.  An allergy-trained pharmacist performed skin testing and oral challenges to determine whether patients could safely obtain penicillin. Exclusion criteria: the history of cutaneous adverse reactions, anaphylaxis within last 4 weeks and severe cardiac or pulmonary conditions. The intervention led to an increase in penicillin allergy testing among patients receiving aztreonam (85% vs 24%) and reduction in delay between hospital admission and skin testing from 3.31 to 1.05 days. Penicillin exposure increase by 58% and aztreonam use declined from 2.54 to 1.47 doses per 1000 patient-days.

In summary, electronic-based interventions offer an opportunity to antimicrobial stewardship programs to quickly implement changes and impact a larger number of patients.

Citations:

First article: Modified Reporting of Positive Urine Cultures to Reduce Inappropriate Treatment of Asymptomatic Bacteriuria Among Nonpregnant, noncatheterized Inpatients: A Randomized Controlled Trial, https://doi.org/10.1017/ice.2018.100
 
Second article: Improving Aztreonam Stewardship and Cost Through a Penicillin Allergy Testing Clinical Guideline, doi: 10.1093/ofid/ofy106 
 
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CRE or not CRE: A Question of Risky Business and Notes from the Field
Reviewed by: Jasmine R Marcelin, MD, Assistant Professor, Division of Infectious Diseases, Associate Medical Director, Antimicrobial Stewardship, University of Nebraska Medical Center

Carbapenem-resistant Enterobacteriaceae (CRE) are not as prevalent in the United States as they are in the Eastern Hemisphere; however, travel within our global village creates an opportunity for the rapid spread of these antibiotic-resistant organisms.  Additionally, identifying risk factors aside from international travel are important for infection prevention efforts as well as empiric antibiotic decisions. The following is a review of two studies on risk predictors for CRE and carbapenemase-producing (CP) CRE, and three “Notes from the field” investigations from the CDC.

Sullivan T, Ichikawa O, Dudley J, Li L, Aberg J. The Rapid Prediction of Carbapenem Resistance in Patients With Klebsiella pneumoniae Bacteremia Using Electronic Medical Record Data. Open Forum Infect Dis. 2018 Apr 28;5(5):ofy091.

https://www.ncbi.nlm.nih.gov/pubmed/29876366

Sullivan and colleagues created a model to predict the likelihood of carbapenem resistance (as defined by imipenem MIC ≥2μg/mL) in Klebsiella pneumoniae bacteremia. 613 individual cases of K. pneumoniae bacteremia occurred over a 4 year period, with a 10% imipenem-resistance rate. Logistic regression was used for the initial model development, which was subsequently validated using additional statistical methods.  The model included the following; colonization with imipenem-resistant Klebsiella pneumoniae, hospital location (ICU/med-surg vs low-risk units), age (>60yrs), total oral or intravenous antibiotic days of therapy (in the past 2 years) and inpatient days (in the past 5 years). The model correctly predicted imipenem resistance in 73% of cases, with a specificity of 59%; the positive predictive value of 16% and negative predictive value of 95%. All culture data present in the EMR were available to the model, eliminating manual searches when making decisions about empiric therapy. The negative predictive value is high, but lack of generalizability could limit clinical utility.

Simner, PJ, Goodman KE, Carroll KC, Harris AD, Han JH, Tamma PD. Using Patient Risk Factors to Identify Whether Carbapenem-Resistant Enterobacteriaceae Infections Are Caused by Carbapenemase-Producing Organisms. Open Forum Infect Dis. 2018 May 17;5(5):ofy094.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5961169/

In this brief report, the authors identified risk factors for CP-CRE (as compared to non-CP-CRE). Their retrospective, single-institution cohort included 96 hospitalized individuals who had CRE over a one-year period. CP-CRE isolates (predominantly K. pneumoniae) were identified in 47% of the patients. CP-CRE isolates were more commonly identified in patients with recent international healthcare exposure within six months (27% vs 2%; odds ratio [OR], 18.18; 95% confidence interval [CI], 2.26–46.53); and patients who were recently transferred from a post-acute care facility (31% vs 12%; OR, 3.39; 95% CI, 1.17–9.78). Considering the prevalence of CP-CRE in regions outside the United States, should we be more intentional about travel histories when patients are being admitted to the hospital?

The following snippets are Notes from the Field published in MMWR with new information about CRE organisms:

Danielle Rankin, Luz Caicedo, Nychie Dotson, Paige Gable, Alvina Chu. Verona Integron-Encoded Metallo-Beta-Lactamase–Producing Pseudomonas aeruginosa Outbreak in a Long-Term Acute Care Hospital — Orange County, Florida, 2017. MMWR Morb Mortal Wkly Rep. 2018 Jun 1; 67(21): 611–612.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6038905/

The first VIM-producing Pseudomonas aeruginosa in Florida was detected in an outbreak of colonized patients at a long-term acute care hospital in Orange County. One patient was first identified in July 2017, followed by six additional patients identified in the subsequent months at the same facility. Only 2 isolates were closely related.

Maroya S. Walters, Medora Witwer, Yeon-Kyeng Lee, et al. Carbapenemase-Producing Carbapenem-Resistant Enterobacteriaceae from Less Common Enterobacteriaceae Genera — United States, 2014–2017/MMWR. MMWR Morb Mortal Wkly Rep. 2018 Jun 15; 67(23): 668–669.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6002034/

CRE Surveillance by the Minnesota Department of Health revealed 20 CP-CRE from less common Enterobacteriaceae genera (i.e. not Klebsiella spp., Enterobacter spp. or E. coli). 7 IMP-producing Providencia rettgeri and 6 KPC-producing Citrobacter freundii predominated. Most patients with these isolates were hospitalized; two were previously hospitalized internationally in the preceding year.

D.J. Shannon, Sara Blosser, Maroya Walters, Alex Kallen, Christine Feaster. Notes from the Field: Domestically Acquired Verona Integron-Mediated Metallo-β-Lactamase-Producing Enterobacteriaceae — Indiana, 2016–2017. MMWR Morb Mortal Wkly Rep. 2018 Jun 29; 67(25): 727–728.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6023186/

This report highlights possible regional emergence of VIM-producing CRE, with 7 patients & 9 isolates reported in Indiana between 2016-2017. One patient had three different VIM-CRE organisms isolated. All patients had recent hospitalizations and none had prior international travel within the past 6 months. 

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Recent Articles of Note
Reviewed by: SHEA's Journal Club
Each month the SHEA Journal Club Committee reviews numerous excellent articles that are of interest, but may not be of broad enough scope, or maybe so well known, that a full review is not warranted. A few articles that J-Club readers may wish to note are as follows:

The Consequences of Contamination
Reviewed by: Lauren M. DiBiase, MS, University of North Carolina Hospitals

Glowicz et al. summarize the epidemiologic and laboratory investigation of reported clusters of Burkholderia cepacia complex (Bcc) healthcare-associated infections that occurred among critically ill, hospitalized, adult and pediatric patients across 12 states.  The investigation was performed between January 2016 and October 2016 and in total, 108 case patients (63 confirmed and 45 suspect cases) with Bcc infections at a variety of body sites were identified. Two distinct strains of Bcc were obtained from patient clinical cultures and found by PFGE to be indistinguishable or closely related to 2 strains of Bcc obtained from cultures of water used in production of liquid docusate, and product released to the market by manufacturer X.  
Once Bcc was found in prefilled syringes containing liquid docusate, the CDC recommended healthcare personnel not use any liquid docusate products on critically ill, ventilated or immunosuppressed patients. A few weeks later, FDA announced that manufacturer X was voluntarily recalling liquid docusate sodium.  The manufacturer ultimately expanded the recall to production of all their liquid products made at the site, since they used the same water system in production of all liquid products.
This investigation and other recent outbreaks highlight Bcc as a frequent and problematic pathogen in healthcare and underscore the importance of manufacturers’ responsibility to establish strict specifications for nonsterile drugs that ensure the safety of the population using the product. Lapses in good manufacturing practices and quality control can result in serious consequences.
 
Citations: 

Glowicz J, Crist M, Gould C, et al. B. cepacia Investigation Workgroup. A multistate investigation of health care-associated Burkholderia cepacia complex infections related to liquid docusate sodium contamination, January-October 2016. Am J Infect Control. 2018 Jun;46(6):649-655. 
 
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Taking Toll of the Influenza 2017-2018 Season
Reviewed by: Rossana Rosa, MD UnityPoint Health, Des Moines, Iowa

The 2017-2018 influenza season was a high severity season, characterized by nationwide high volume and intensity of influenza cases, record hospitalization rates and high-numbers of pediatric deaths. 
The Centers for Disease Control and Prevention (CDC) reported the summary of influenza activity during the most recent season (October 1, 2017 to May 19, 2018). Clinical laboratories tested 1,210,053 specimens and 224,113 (18.5%) tested positive. Influenza A was identified in 67.6% of cases, and influenza B in 32.4%. Among seasonal influenza, A viruses subtyped, 84.9% were influenza A(H3N2). 
 
Resistance to oseltamivir and peramivir was detected in 11 out of 1147 (1%) of influenza
A(H1N1)pdm09 viruses tested; no resistance to zanamivir was identified. All influenza A(H3N2) and influenza B viruses were susceptible to all three antivirals tested. 
Peak clinical activity varied regionally, ranging from the week ending December 30 to the week ending February 17. The cumulative hospitalization incidence rate was 106.6 per 100,000 population. The proportion of deaths attributed to pneumonia and influenza was above the epidemic threshold, exceeding 10% for 4 consecutive weeks. A total of 171 laboratory-confirmed influenza pediatric deaths were reported to CDC. Compared to previous influenza seasons, the 2017-2018 season was classified as high-severity.    
The effectiveness of the 2017-2018 vaccines were 36% overall, 25% against influenza A(H3N2) viruses, 67% against influenza A(H1N1)pdm09, and 42% against influenza B viruses. The 2018-2019 vaccine will have updated influenza B and influenza A(H3N2) components. 
       
Citations: 

Garten R, Blanton L, Elal AIA, et al. Update: Influenza Activity in the United States During the 2017-18 Season and Composition of the 2018-19 Influenza Vaccine. MMWR Morb Mortal Wkly Rep. 2018 Jun 8;67(22):634-642.
 
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Candida duobushaemulonii masquerading as Candida auris: A warning from Panama
Reviewed by: Sara C.Keller, MD, MPH, MSPH, Johns Hopkins University School of Medicine

VITEK 2 is unable to distinguish between closely related Candida auris (famously associated with healthcare setting outbreaks), C. duobushaemulonii, C. haemulonii, and C. pseudohaemulonii and instead all of these may be called C. haemulonii. In this study, Panamanian clinical laboratories forwarded Candida isolates suspected of being C. auris to a central lab for additional identification by MALDI-TOF MS and sequence analysis of internal transcribed spacer region of rDNA. The central lab received 36 isolates initially identified as C. haemulonii by VITEK 2 but where there was a clinical concern for C. auris. MALDI-TOF MS identified 47% of these as C. duobushaemulonii, including 16/20 blood or central venous catheter isolates. Most were resistant to fluconazole and amphotericin B, and half were resistant to voriconazole. This report highlights that C. duobushaemulonii may cause more invasive infections than previously reported with significant antifungal resistance. 

Citations: 
 
Ramos R, Caceres DH, Perez M, et al. Emerging multi-drug resistant Candida duobushaemulonii infections in Panama hospitals: importance of laboratory surveillance and accurate identification. J Clin Microbiol 2018; 56:e00371-18. https://www.ncbi.nlm.nih.gov/pubmed/29695521
 
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The Consequences of Contamination
Reviewed by: Lauren M. DiBiase, MS, University of North Carolina Hospitals

Glowicz et al. summarize the epidemiologic and laboratory investigation of reported clusters of Burkholderia cepacia complex (Bcc) healthcare-associated infections that occurred among critically ill, hospitalized, adult and pediatric patients across 12 states.  The investigation was performed between January 2016 and October 2016 and in total, 108 case-patients (63 confirmed and 45 suspect cases) with Bcc infections at a variety of body sites were identified. Two distinct strains of Bcc were obtained from patient clinical cultures and found by PFGE to be indistinguishable or closely related to 2 strains of Bcc obtained from cultures of water used in the production of liquid docusate, and product released to the market by manufacturer X. 

Once Bcc was initially found in prefilled syringes containing liquid docusate, the CDC recommended that healthcare personnel not use any liquid docusate products on critically ill, ventilated or immunosuppressed patients; a few weeks later, FDA announced that manufacturer X was voluntarily recalling liquid docusate sodium.  The manufacturer ultimately expanded the recall to the production of all of their liquid products made at the site, since they used the same water system in the production of all their liquid products.

This investigation and other recent outbreaks highlight Bcc as a frequent and problematic pathogen in healthcare and underscore the importance of manufacturer's responsibility to establish strict specifications for nonsterile drugs that ensure the safety of the population using the product. Lapses in good manufacturing practices and quality control can result in serious consequences.

Citations:

Glowicz J, Crist M, Gould C, Moulton-Meissner H, Noble-Wang J, de Man TJB, Perry KA, Miller Z, Yang WC, Langille S, Ross J, Garcia B, Kim J, Epson E, Black S, Pacilli M, LiPuma JJ, Fagan R; B. cepacia Investigation Workgroup. A multistate investigation of healthcare-associated Burkholderia cepacia complex infections related to liquid docusate sodium contamination, January-October 2016. Am J Infect Control. 2018 Jun;46(6):649-655. doi: 10.1016/j.ajic.2017.11.018. Epub 2018 Jan 9.

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