Vision for Transformation Strengths: The SHSIP describes a holistic transformation plan and ensures connections between various plan components. The State’s Plan seeks to reward health care providers for better care, smarter spending, and healthier people through higher quality, instead of quantity of services by utilizing valuebased purchasing across public and private payers. The SHSIP provides a well-detailed description of the proposed value-based models of care through the Patient-Centered Medical Home (PCMH) model, resulting in the statewide implementation of Accountable Health Communities (AHCs). The SHSIP outlines a long-term vision of building and expanding the PCMH model into a Community Centered Health Homes (CCHHs) model, which will focus on prevention and collaboration with other communitybased organizations. Another strength identified is the amount of existing PCMHs operating within the State. The SHSIP provides a course of action to assist non-PCMH practices to become nationally certified, as well as, goals for a single, statewide PCMH model to be used by all providers and payers within the state. The implementation of the AHCs will be key in addressing social determinants of health within various communities and seems to align well with the PCMH goals. This focus on population and community health will enable the State to make a broader impact and support the long-term goal of moving towards a CCHH model. The focus on the improvement of clinical, behavioral, and oral health care within the urban, rural, and frontier communities is well aligned and consistent with the SIM goals and the overall Triple Aim initiative. Figure 18: Driver Diagram clearly shows how the State plans to achieve the Triple Aim by 2020.

Department of health & human services

of antibiotics, whether there was an explicit note in the medical chart in which the physician diagnosed a true bacteremia, and the Centers for Disease Control surveillance criteria for primary bloodstream infection. Agreement between same-strain bacteremia and each definition was examined, based on the assumption that most true infections should be the result of a single strain. The study sample consisted of 42 patients and 106 isolates. Nineteen of the 42 bacteremias (45%) were the same strain. Classification of bacteremias as same-strain correlated poorly with all three clinical assessments (range of percentage agreement, 50%-57%; range of kappa statistic, 0.01-0.15). There were both false-positive and false-negative errors. Patients with three or more positive blood cultures were more likely to have same-strain bacteremia than those with only two positive cultures (11/15 [73%] vs 8/27 [30%], P=.006). Pulsed-field gel electrophoresis was more discriminating than AP PCR (percentage agreement, 83%; kappa, 0.67). The authors concluded that molecular typing correlated poorly with clinical criteria for true bacteremia, suggesting either that true bacteremias are frequently the result of multiple strains or that the commonly used clinical criteria are not accurate for distinguishing contamination from true bacteremia. Vancomycin treatment of clinically defined coagulase-negative staphylococcal bacteremia may frequently be unnecessary. FROM: Seo SK, Venkataraman L, DeGirolami PC, Samore MH. Molecular typing of coagulase-negative staphylococci from blood cultures does not correlate with clinical criteria for true bacteremia. Am J Med 2000;109:697-704.

/pdf/nasal-carriage-as-a-source-of-staphylococcus-aureus-40zkf0m446.pdf

Nasal Carriage as a Source of Staphylococcus aureus Bacteremia

Campylobacter jejuni infection is one of the most widespread infectious diseases of the last century. The incidence and prevalence of campylobacteriosis have increased in both developed and developing countries over the last 10 years. The dramatic increase in North America, Europe, and Australia is alarming, and data from parts of Africa, Asia, and the Middle East indicate that campylobacteriosis is endemic in these areas, especially in children. In addition to C. jejuni, there is increasing recognition of the clinical importance of emerging Campylobacter species, including Campylobacter concisus and Campylobacter ureolyticus. Poultry is a major reservoir and source of transmission of campylobacteriosis to humans. Other risk factors include consumption of animal products and water, contact with animals, and international travel. Strategic implementation of multifaceted biocontrol measures to reduce the transmission of this group of pathogens is paramount for public health. Overall, campylobacteriosis is still one of the most important infectious diseases that is likely to challenge global health in the years to come. This review provides a comprehensive overview of the global epidemiology, transmission, and clinical relevance of Campylobacter infection.

Global Epidemiology of Campylobacter Infection

Greater use of antibiotics during the past 50 years has exerted selective pressure on susceptible bacteria and may have favoured the survival of resistant strains. Existing information on antibiotic resistance patterns from pathogens circulating among community-based patients is substantially less than from hospitalized patients on whom guidelines are often based. We therefore chose to assess the relationship between the antibiotic resistance pattern of bacteria circulating in the community and the consumption of antibiotics in the community. Both gray literature and published scientific literature in English and other European languages was examined. Multiple regression analysis was used to analyse whether studies found a positive relationship between antibiotic consumption and resistance. A subsequent meta-analysis and meta-regression was conducted for studies for which a common effect size measure (odds ratio) could be calculated. Electronic searches identified 974 studies but only 243 studies were considered eligible for inclusion by the two independent reviewers who extracted the data. A binomial test revealed a positive relationship between antibiotic consumption and resistance (p < .001) but multiple regression modelling did not produce any significant predictors of study outcome. The meta-analysis generated a significant pooled odds ratio of 2.3 (95% confidence interval 2.2 to 2.5) with a meta-regression producing several significant predictors (F(10,77) = 5.82, p < .01). Countries in southern Europe produced a stronger link between consumption and resistance than other regions. Using a large set of studies we found that antibiotic consumption is associated with the development of antibiotic resistance. A subsequent meta-analysis, with a subsample of the studies, generated several significant predictors. Countries in southern Europe produced a stronger link between consumption and resistance than other regions so efforts at reducing antibiotic consumption may need to be strengthened in this area. Increased consumption of antibiotics may not only produce greater resistance at the individual patient level but may also produce greater resistance at the community, country, and regional levels, which can harm individual patients.

/pdf/a-systematic-review-and-meta-analysis-of-the-effects-of-3zoewkkpg5.pdf

A systematic review and meta-analysis of the effects of antibiotic consumption on antibiotic resistance

Escherichia coli sequence type 131 (ST131) is a worldwide pandemic clone, causing predominantly community-onset antimicrobial-resistant infection. Its pandemic spread was identified in 2008 by utilizing multilocus sequence typing (MLST) of CTX-M-15 extended-spectrum β-lactamase-producing E. coli from three continents. Subsequent research has confirmed the worldwide prevalence of ST131 harbouring a broad range of virulence and resistance genes on a transferable plasmid. A high prevalence of the clone (∼30%-60%) has been identified amongst fluoroquinolone-resistant E. coli. In addition, it potentially harbours a variety of β-lactamase genes; most often, these include CTX-M family β-lactamases, and, less frequently, TEM, SHV and CMY β-lactamases. Our knowledge of ST131's geographical distribution is incomplete. A broad distribution has been demonstrated amongst antimicrobial-resistant E. coli from human infection in Europe (particularly the UK), North America, Canada, Japan and Korea. High rates are suggested from limited data in Asia, the Middle East and Africa. The clone has also been detected in companion animals, non-companion animals and foods. The clinical spectrum of disease described is similar to that for other E. coli, with urinary tract infection predominant. This can range from cystitis to life-threatening sepsis. Infection occurs in humans of all ages. Therapy must be tailored to the antimicrobial resistance phenotype of the infecting isolate and the site of infection. Phenotypic detection of the ST131 clone is not possible and DNA-based techniques, including MLST and PCR, are described.

/pdf/escherichia-coli-o25b-st131-a-pandemic-multiresistant-3nlpt9213v.pdf

Escherichia coli O25b-ST131: a pandemic, multiresistant, community-associated strain

We thank Saliou and Baron for their comments. They state that microbial surveillance of endoscopes by antegrade sampling with a sterile 0.9 % saline solution might be insufficient to reveal the microbial contamination. They also suggest the additional use of thiosulfate during sampling. Unfortunately, in the outbreak we described, the use of a thiosulfate-containing buffer would not have been able to detect the microbial contamination. As the manufacturer states, the elevator wire channel of the TJF-Q180V is sealed by an O-ring, which means that separate cleaning is no longer necessary. Moreover, this scope is also designed with a unique distal cap that is fixed, which impairs cleaning and disinfection in the spaces within this cap. Sampling of these spaces is only possible when using an ultrathin swab, as demonstrated in our study, which thereby revealed the VIM-2 producing Pseudomonas aeruginosa. 

However, we do agree with Saliou and Baron that the optimal sampling method for endoscopes is still under debate. At present, the use of sterile 0.9 % saline solution is recommended by the European Society of Gastrointestinal Endoscopy and the European Society of Gastroenterology and Endoscopy Nurses and Associates. Although the French guideline recommends the use of a tensioactive solution (e. g. Tween 80) to increase the detection of microorganisms, the use of sodium thiosulfate is not mentioned in this guideline. 

The combination of the narrow lumina of the endoscope and heavy contamination with blood, secretions, and microorganisms during its use, might promote the growth of biofilms in cases of insufficient (pre)cleaning. Once these biofilms occur, they are very resilient to physical removal by regular cleaning and are less susceptible to biocides. In a recent review, it was concluded that by ensuring prompt device cleaning and reprocessing, either by high-level disinfection or sterilization, and proper drying, biofilms will not have a chance to form [8]. Unfortunately, at present there is no evidence in the literature that a consensus on this matter has been reached. 

However, in light of recent reports of microbiological outbreaks after endoscopy, a reliable method of investigating microbial safety following high-level disinfection is urgently needed. The utility of sodium thiosulfate or another biofilm dissolver should be investigated in studies, led, ideally, by an international working group consisting of microbiologists and endoscopists. In addition, a consensus statement concerning the interpretation and action required from the data collected should become available and updated regularly. 

Saliou and Baron also stress the importance of endoscope drying in order to prevent bacterial proliferation. The importance of drying has been emphasized previously by Muscarella. As stated in our manuscript, at the Erasmus MC all endoscopes are dried and stored in a storage cabinet (WASSENBURG DRY 300; Wassenburg Medical Devices BV, Dodewaard, The Netherlands), unless immediate re-use (within 4 hours) is required. Therefore, bacterial proliferation during storage was not considered to be a possible cause of the VIM-2 producing P. aeruginosa outbreak.

Juliëtte A. Severin

Papers

Reply to Saliou et al