Clostridioides difficile
infection is a major cause of nosocomial and community illness. In this report from the Emerging Infections Program, associated with the U.S. CDC, the national burden of
C. ...difficile
infection is estimated from 2011 through 2017. In 2017, an estimated 462,100 cases of
C. difficile
infection occurred.
Recently, Tennessee, USA, has seen an increase in the use of commonly injected drugs, such as heroin and fentanyl. Injection drug use (IDU) practices can lead to life-threatening ...methicillin-resistant Staphylococcus aureus (MRSA) bloodstream infections (BSIs) and other serious diseases. We matched MRSA BSIs identified through the National Healthcare Safety Network to the Tennessee Hospital Discharge Data System to characterize the prevalence, demographics, and clinical characteristics associated with IDU in this disease population. Of the 7,646 MRSA BSIs identified during 2015-2017, we found that 1,839 (24.1%) were IDU-related. IDU-related BSIs increased by 118.9%; the greatest rise occurred among emergency department-onset infections (197.4%). IDU was more often associated with white, female, 18-49-year-old, and uninsured persons (p<0.001). We found >1 additional IDU-related diagnoses in 84.2% of IDU-related BSIs. Targeted harm reduction strategies for persons at high risk of IDU are necessary to reduce MRSA BSIs in acute care settings.
IMPORTANCE: Inappropriate antimicrobial drug use is associated with adverse events in hospitalized patients and contributes to the emergence and spread of resistant pathogens. Targeting effective ...interventions to improve antimicrobial use in the acute care setting requires understanding hospital prescribing practices. OBJECTIVE: To determine the prevalence of and describe the rationale for antimicrobial use in participating hospitals. DESIGN, SETTING, AND PARTICIPANTS: One-day prevalence surveys were conducted in acute care hospitals in 10 states between May and September 2011. Patients were randomly selected from each hospital’s morning census on the survey date. Data collectors reviewed medical records retrospectively to gather data on antimicrobial drugs administered to patients on the survey date and the day prior to the survey date, including reasons for administration, infection sites treated, and whether treated infections began in community or health care settings. MAIN OUTCOMES AND MEASURES: Antimicrobial use prevalence, defined as the number of patients receiving antimicrobial drugs at the time of the survey divided by the total number of surveyed patients. RESULTS: Of 11 282 patients in 183 hospitals, 5635 (49.9%; 95% CI, 49.0%-50.9%) were administered at least 1 antimicrobial drug; 77.5% (95% CI, 76.6%-78.3%) of antimicrobial drugs were used to treat infections, most commonly involving the lower respiratory tract, urinary tract, or skin and soft tissues, whereas 12.2% (95% CI, 11.5%-12.8%) were given for surgical and 5.9% (95% CI, 5.5%-6.4%) for medical prophylaxis. Of 7641 drugs to treat infections, the most common were parenteral vancomycin (1103, 14.4%; 95% CI, 13.7%-15.2%), ceftriaxone (825, 10.8%; 95% CI, 10.1%-11.5%), piperacillin-tazobactam (788, 10.3%; 95% CI, 9.6%-11.0%), and levofloxacin (694, 9.1%; 95% CI, 8.5%-9.7%). Most drugs administered to treat infections were given for community-onset infections (69.0%; 95% CI, 68.0%-70.1%) and to patients outside critical care units (81.6%; 95% CI, 80.4%-82.7%). The 4 most common treatment antimicrobial drugs overall were also the most common drugs used for both community-onset and health care facility–onset infections and for infections in patients in critical care and noncritical care locations. CONCLUSIONS AND RELEVANCE: In this cross-sectional evaluation of antimicrobial use in US hospitals, use of broad-spectrum antimicrobial drugs such as piperacillin-tazobactam and drugs such as vancomycin for resistant pathogens was common, including for treatment of community-onset infections and among patients outside critical care units. Further work is needed to understand the settings and indications for which reducing antimicrobial use can be most effectively and safely accomplished.
Our research explores local perspectives of a recent and controversial shift in conservation and development strategies in the Brazilian Amazon whereby legal timber commercialization is being ...pioneered in select extractive reserves, which are a type of comanaged sustainable-use protected area. To understand how this initiative might affect well-being, we documented perceptions of reserve residents about a legal logging project and factors that influenced their decision to participate or not participate. Semistructured interviews (N = 64) were conducted with both male and female heads of household from June to August 2014. We tested the effect of household-level livelihood assets associated with material and relational well-being on project participation. Participating households were significantly less economically well-off and were more educated than nonparticipating households. Individual perceptions indicated that project supporters were motivated by income, whereas nonsupporters most frequently criticized the low price of timber. Both groups expressed concern about the potential environmental impacts of logging. By gender, supportive men were more motivated by financial aspects, whereas supportive women pointed to improved physical assets. Men opposed to the logging project highlighted governance issues, whereas nonsupportive women tended to express environmental concerns. Our study corroborates previously documented interests (and needs) of residents to develop alternative income-generating livelihood opportunities. Further, most interviewed residents expressed support for a more locally customized logging project, indicating that a lack of resident inclusion in project development generated much of the project controversy. Our study highlights both economic development and comanagement governance challenges of sustainable-use protected areas and how project interventions relate to well-being of forest residents
To identify prescriber characteristics that predict antibiotic high-prescribing behavior to inform statewide antimicrobial stewardship interventions.
Retrospective analysis of 2016 IQVIA Xponent, ...formerly QuintilesIMS, outpatient retail pharmacy oral antibiotic prescriptions in Tennessee.
Statewide retail pharmacies filling outpatient antibiotic prescriptions.
Prescribers who wrote at least 1 antibiotic prescription filled at a retail pharmacy in Tennessee in 2016.
Multivariable logistic regression, including prescriber gender, birth decade, specialty, and practice location, and patient gender and age group, to determine the association with high prescribing.
In 2016, 7,949,816 outpatient oral antibiotic prescriptions were filled in Tennessee: 1,195 prescriptions per 1,000 total population. Moreover, 50% of Tennessee's outpatient oral antibiotic prescriptions were written by 9.3% of prescribers. Specific specialties and prescriber types were associated with high prescribing: urology (odds ratio OR, 3.249; 95% confidence interval CI, 3.208-3.289), nurse practitioners (OR, 2.675; 95% CI, 2.658-2.692), dermatologists (OR, 2.396; 95% CI, 2.365-2.428), physician assistants (OR, 2.382; 95% CI, 2.364-2.400), and pediatric physicians (OR, 2.340; 95% CI, 2.320-2.361). Prescribers born in the 1960s were most likely to be high prescribers (OR, 2.574; 95% CI, 2.532-2.618). Prescribers in rural areas were more likely than prescribers in all other practice locations to be high prescribers. High prescribers were more likely to prescribe broader-spectrum antibiotics (P < .001).
Targeting high prescribers, independent of specialty, degree, practice location, age, or gender, may be the best strategy for implementing cost-conscious, effective outpatient antimicrobial stewardship interventions. More information about high prescribers, such as patient volumes, clinical scope, and specific barriers to intervention, is needed.
Trees in the upper canopy contribute disproportionately to forest ecosystem productivity. The large, canopy-emergent Bertholletia excelsa also supports a multimillion-dollar commodity crop (Brazil ...nut), harvested almost exclusively from Amazonian forests. B. excelsa fruit production, however is extremely variable within populations and years, destabilizing local harvester livelihoods and the extractive economy. To understand this variability, data were collected in Acre, Brazil over 10 years at two sites with similar climate and forest types, but different fruit production levels, despite their proximity (~ 30 km). One site consistently produced more fruit, showed less individual- and population-level variability, and had significantly higher soil P and K levels. The strongest predictor of fruit production was crown area. Elevation and sapwood area also significantly impacted fruit production, but effects differed by site. While number of wet days and dry season vapor pressure prior to flowering were significant production predictors, no climatic variables completely captured annual observed variation. Trees on the site with higher available P and K produced nearly three times more fruits, and appeared more resilient to prolonged drought and drier atmospheric conditions. Management activities, such as targeted fertilization, may shield income-dependent harvesters from expected climate changes and production swings, ultimately contributing to conservation of old growth forests where this species thrives.
To identify facilities at risk of receiving patients colonized or infected with multidrug-resistant organisms (MDROs), we developed an interactive web-based interface for visualization of ...patient-sharing networks among healthcare facilities in Tennessee, USA. Using hospital discharge data and the Centers for Medicare and Medicaid Services' claims and Minimum Data Set, we constructed networks among hospitals and skilled nursing facilities. Networks included direct and indirect transfers, which accounted for <365 days in the community outside of facility admissions. Authorized users can visualize a facility of interest and tailor visualizations by year, network dataset, length of time in the community, and minimum number of transfers. The interface visualizes the facility of interest with its connected facilities that receive or send patients, the number of interfacility transfers, and facilities at risk of receiving transfers from the facility of interest. This tool will help other health departments enhance their MDRO outbreak responses.
Heteroresistance is a form of antibiotic resistance where a bacterial strain is comprised of a minor resistant subpopulation and a majority susceptible subpopulation. We showed previously that ...colistin heteroresistance can mediate the failure of colistin therapy in an
infection model, even for isolates designated susceptible by clinical diagnostics. We sought to characterize the extent of colistin heteroresistance among the highly drug-resistant carbapenem-resistant
(CRE). We screened 408 isolates for colistin heteroresistance. These isolates were collected between 2012 and 2015 in eight U.S. states as part of active surveillance for CRE. Colistin heteroresistance was detected in 10.1% (41/408) of isolates, and it was more common than conventional homogenous resistance (7.1%, 29/408). Most (93.2%, 38/41) of these heteroresistant isolates were classified as colistin susceptible by standard clinical diagnostic testing. The frequency of colistin heteroresistance was greatest in 2015, the last year of the study. This was especially true among
isolates, of which specific species had the highest rates of heteroresistance. Among
isolates, which were the majority of isolates tested, there was a closely related cluster of colistin-heteroresistant ST-258 isolates found mostly in Georgia. However, cladistic analysis revealed that, overall, there was significant diversity in the genetic backgrounds of heteroresistant
isolates. These findings suggest that due to being largely undetected in the clinic, colistin heteroresistance among CRE is underappreciated in the United States.
Heteroresistance is an underappreciated phenomenon that may be the cause of some unexplained antibiotic treatment failures. Misclassification of heteroresistant isolates as susceptible may lead to inappropriate therapy. Heteroresistance to colistin was more common than conventional resistance and was overwhelmingly misclassified as susceptibility by clinical diagnostic testing. Higher proportions of colistin heteroresistance observed in certain
species and clustering among heteroresistant
strains may inform colistin treatment recommendations. Overall, the rate of colistin nonsusceptibility was more than double the level detected by clinical diagnostics, suggesting that the prevalence of colistin nonsusceptibility among CRE may be higher than currently appreciated in the United States.
Extractive reserves are conservation units that are concurrently expected to sustain subsistence and cash economies of reserve residents, often through use of non-timber forest products (NTFPs). ...Brazil nut (Bertholletia excelsa) has been central to many Amazonian reserves and resident livelihoods therein, due to its basin-wide distribution, significance in global markets, and potential for sustainable use and forest conservation. Yet, do the benefits of this and other NTFPs extend to all extractive reserve residents? A livelihood survey, structured interviews, and Brazil nut inventories from 2008 to 2010, randomly sampling the widely dispersed households and corresponding forests across the three regions of Riozinho do Anfrísio Extractive Reserve (RDAER), revealed significant social and ecological heterogeneity among RDAER regions. There were differences in Brazil nut stand access, individual tree characteristics (including crown form and marginally, and fruit production), stand and tree management, multiple household characteristics that shape resident investment and dependence on NTFPs, and the contribution of Brazil nut to forest-based income. If Brazil nut and other NTFPs are to reconcile conservation and development in forest communities, then policies to regulate and promote NTFP use must integrate the socioecological heterogeneity inherent in these forest products and within reserve polygons.
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