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Ghanta is an inpatient pharmacist at St Christopher’s Hospital for Children in Philadelphia, Pennsylvania.

Here is a novel use of ceftaroline to treat methicillin-resistant Staphylococcus epidermidis ventriculitis in a preterm infant with a ventriculosubgaleal shunt.

Addressing Neonatal CNS Infections: Case Report of Ceftaroline Therapy in Preterm Infant With Ventriculosubgaleal Shunt

Along with a 1 reported case in Massachusetts, the

New Hampshire Department of Health and Human Services (DHHS) has confirmed a person infected with eastern equine encephalitis (EEE) has died. The public health agency said the person was hospitalized due to severe central nervous system disease. The last reported human EEEV infection in New Hampshire was in 2014, when DHHS identified 3 human infections, including 2 fatalities. In the same statement, DHHS mentions there has been 1 confirmed case in Vermont this summer.

On August 16, the Massachusetts Department of Public Health (MDPH) released a statement discussing the confirmation of the first human case of EEE in the state this year. The confirmed case was discovered in an 80 year old man who was exposed to the vector borne disease in Worcester County. As a result, the risk level in the local communities of Douglas, Oxford, Sutton, and Webster has been raised to critical, and in Dudley, Northbridge, and Uxbridge the risk is increased to high.

Additionally, the neighboring communities of Auburn, Charlton, Grafton, Leicester, Mendon, Millbury, Millville, Southbridge, and Upton are now considered at moderate risk according to MDPH.

“This is the first time we have seen a person infected with EEE in Massachusetts since 2020,” Public Health Commissioner Robbie Goldstein, MD, PhD, said in a statement. “EEE is a rare but serious disease and a public health concern. We want to remind residents of the need to protect themselves from mosquito bites, especially in areas of the state where we are seeing EEE activity.

Though very rare, EEE is serious and a potentially fatal disease that can affect people of all ages. EEE is generally spread to humans through the bite of an infected mosquito. There were 12 human cases of EEE in Massachusetts in 2019 with 6 deaths, and 5 human cases with 1 death in 2020. There were no human cases of EEE in Massachusetts in 2021, 2022, or 2023.

EEE has a fatality rate of 33% to 70%, with most deaths occurring 2–10 days after the onset of symptoms.

In addition to a high mortality rate, long-term physical and mental complications, including permanent neurological deficits have been identified in many people who survive EEE.

Plymouth is approximately 40 miles south of Boston along the coast, and Worcester County is in the middle of the state, so the 2 areas are not in close proximity, but due to the elevated risk locally, the town of Plymouth decided to take action in response to outdoor parks. As of last Friday, all town public parks and fields are close daily from dusk until dawn.

“As Mass DPH has now elevated Plymouth’s EEE risk status to high, it is important to take extra precautions when outdoors and follow state and local health guidelines to avoid unnecessary risk to exposure to EEE. The health and safety of our community, residents, and visitors remain our priority,” Plymouth’s Commissioner of Health and Human Services, Michelle Bratti, said in a statement.

According to the Centers for Disease Control and Prevention (CDC) most people who are infected with the virus do not develop symptoms; however, for those that do, the date from the bite to the onset of the illness is 4 to 10 days. EEE can also result in fever or neurologic disease. The type of illness will depend on the age of the person and other factors. Those who are infected can develop meningitis.

There are no FDA-approved treatments for EEE and for patients who develop severe cases, they can be hospitalized to receive supportive treatment.

Over the weekend, MDPH detailed plans of spraying for mosquitos including aerially in areas of Plymouth County, and truck-mounted spraying in parts of Worcester County. As of Saturday, 10 communities in Massachusetts were raised to high or critical risk for EEE virus.

“The risk from EEE is high in parts of Plymouth County and critical in parts of Worcester County,” State Epidemiologist Catherine M. Brown, DVM, said in a statement. “In addition to recommending that people use mosquito repellent with an EPA-registered active ingredient and clothing to reduce exposed skin, we also recommend that evening outdoor events be rescheduled to avoid the hours between dusk and dawn. The mosquitoes most likely to spread EEE are most active during the dusk to dawn hours.”

There are preventative strategies to avoid EEE, and the MDPH has listed such measures 

For those who live in Massachusetts and want more information on EEE, it can be found 

 or by calling the DPH Division of Epidemiology at 617-983-6800.

1.NH DHHS Identifies Person Infected with Eastern Equine Encephalitis Virus in New Hampshire.The New Hampshire Department of Health and Human Services. August 27, 2024. Accessed August 28, 2024.
https://www.dhhs.nh.gov/news-and-media/nh-dhhs-identifies-person-infected-eastern-equine-encephalitis-virus-new-hampshire
2. State health officials announce season’s first human case of Eastern Equine Encephalitis in Massachusetts. MDPH. August 16, 2024. Accessed August 27, 2024.
https://www.mass.gov/news/state-health-officials-announce-seasons-first-human-case-of-eastern-equine-encephalitis-in-massachusetts
3.Plymouth to Close all Public Parks and Fields from Dusk to Dawn. Town of Plymouth. August 23, 2024. Accessed August 27, 2024. PDF.
4. Eastern Equine Encephalitis: Symptoms, Diagnosis, and Treatment. CDC. May 15, 2024. Accessed August 27, 2024.
https://www.cdc.gov/eastern-equine-encephalitis/symptoms-diagnosis-treatment/index.html
5. State officials announce plans to spray for mosquitoes in sections of Worcester and Plymouth counties due to EEE. MDPH. August 24, 2024. Accessed August 27, 2024. 
https://www.mass.gov/news/state-officials-announce-plans-to-spray-for-mosquitoes-in-sections-of-worcester-and-plymouth-counties-due-to-eee



The town of Plymouth decided to prohibit people from using the parks from dusk to dawn due to concerns over eastern equine encephalitis after a man contracted the rare disease in the state.

Concerns Over Mosquito-Borne Illness Causes Massachusetts Town to Create Curfew for Parks, Spraying in Counties

Clinical Decision Support (CDS) tools play a crucial role in healthcare, particularly in optimizing antibiotic prescribing and reducing infections. These tools are essential to Antimicrobial Stewardship (ASP) and Infection Prevention (IP) programs. A recent study highlights the application of established CDS evaluation frameworks, such as the "Five Rights" and "Ten Commandments," to real-world tools like the Vancomycin Best Practice Advisory and Clostridioides difficile (C. difficile) order panel. The findings emphasize the importance of user engagement and efficiency in designing and implementing these tools to improve antibiotic use and diagnostic stewardship. The results suggest that with a structured approach, these tools can significantly enhance quality improvement initiatives in ASP and IP programs. CDS tools contribute to better patient outcomes and more efficient healthcare delivery by focusing on effective implementation and user-centered design.

In an exclusive email interview, Mary Rochelle Smith, MD, MPH, Julie J Lee, MD, MPH, and Amy Chang, MD, PharmD, from Stanford University School of Medicine, shared valuable insights on the development and implementation of CDS tools in ASP and IP programs. They discussed the challenges of maintaining tool adaptability as clinical guidelines evolve, strategies for engaging clinicians in high-pressure environments, and how to evaluate the impact of CDS interventions on patient outcomes.

Contagion: How do you ensure CDS tools remain adaptable as clinical guidelines evolve, especially for conditions like antimicrobial resistance?

"Routine maintenance by CDS tool creators/owners of any CDS intervention/tool is vital to ensuring that it remains up to date and in line with recent national and institutional guidelines and local resistance patterns. This includes scheduled structured evaluation of the tool using a framework such as the ‘5 Rights’ of CDS or ’10 Commandments” that we outlined in our article to optimize the functionality of the intervention."

Agreed with the above. It’s critical to 1) maintain a comprehensive database of active AMR CDS tools, supported by a multidisciplinary team, including a physician who stays up-to-date with infectious disease guidelines and local/regional trends, 2) establish clear standards for updating tools, such as clinical content, intervention formats, or order options, and retiring those that are no longer necessary or aligned with current guidelines, with all changes documented in a detailed changelog, and 3) implement a methodical process to update all stakeholders when tools are updated or retired, ensuring consistent use and adherence to evolving guidelines."

: "Yes, agreed with the above. One additional note to add: Our CDS committee at Stanford frequently encounters alerts that are out of date. Because there are hundreds of different alerts operating at any given time, you cannot rely on a governing body like a CDS committee to point out where guidelines need to be updated; nor would this necessarily be their area of expertise. As such, we really rely on the requesting operational team, in this case the ASP or IPC team, to keep their own inventory of alerts they own and periodically re-examine alerts when local/national guidance changes."

Contagion: In your experience, what factors help maintain clinician engagement with CDS tools, particularly in high-pressure environments like ICUs or emergency departments?

: "Clinician engagement is maintained through a longitudinal collaborative process with most successful interventions. Some factors that can help are: Designing the CDS tool in a way that it is no longer an obstacle added to their workflow, but rather a tool to ultimately optimize their workflow."

: "User-centered design, or in other words, involving the end users at every stage of development, is a valuable approach that can help to improve not only the user interface, but also the overall perception of an alert and engagement with the process you are trying to improve."

: "Facilitating easy access and feedback to CDS tools is also important as this approach allows clinicians to feel supported and ensures the tools are refined based on their input. I would strongly recommend assigning a dedicated team to the feedback process and respond to feedback."

: "Building relationships with clinicians and finding a champion within those targeted units to support the CDS tool. Also building trust and goodwill by being receptive to removing other CDS interventions in their units that are ineffective or cumbersome for providers."

: "Adapting CDS intervention formats to the needs and realities of high-pressure environments will be critical for seamless workflow and adoption."

: "Incentivizing the use of the CDS tool by tracking metrics that can be tied to quality improvement measures can also maintain clinician engagement."

: "Sharing these improvements in metrics and quality outcomes with end users is important to highlight how these tools are truly driving better decisions and outcomes, as it fosters trust and aligns clinicians with the greater purpose of using CDS tools effectively."

Contagion: How do you incorporate patient outcomes into evaluating the effectiveness of CDS interventions in antimicrobial stewardship?

This would likely vary significantly and be specific for each stewardship CDS intervention and the goal outcome of the intervention. For example, if there is a CDS intervention such as an alert for IV to PO conversion, then an outcome measure such as Length of Stay (LOS) could be a helpful outcome metric to track. If your intervention is revising a C. difficile order panel to appropriate ordering on high-risk patients and discouraging inappropriate ordering on low-risk patients, then an outcome metric such as hospital acquired C. difficile infections could be tracked."

: "That is the question of the day. With all the complexities involved in patient care, it can be difficult to incorporate patient outcomes and pinpoint the effectiveness of CDS interventions for antimicrobial stewardship in isolation. For instance, comparing hospital-acquired C. difficile rates before and after an intervention might help, but it’s essential to acknowledge confounding variables, such as temporal factors, that can influence outcomes."

: "The key lies in approaching this like a well-thought-out study design. First, identify the key patient outcomes you want to measure, such as reductions in CLABSIs, along with the composite metrics or process measures that contribute to those outcomes. Then, design the CDS tool to address these specific goals and ensure you have the means to track the necessary data. Finally, it’s crucial to define and confirm your success metrics before launching the intervention; otherwise, you may risk chasing data that may not even exist or is difficult to capture."

: "‘Success’ is overall a difficult to define concept within CDS in general. Similar to any QI intervention, you will have some outcome measures that will establish your final ‘goal’, like the metrics mentioned above. However, on the way to that goal, there will likely be several process metrics that help you iterate upon your CDS tool and improve engagement over time. As an example, we have the vancomycin interruptive alert mentioned in our article. How would you define success of this pop-up alert? Should it be every time vancomycin is discontinued? Probably not, given that it may be perfectly reasonable for front-line providers to see the alert, and upon reviewing criteria, realize the patient still requires vancomycin. Instead, perhaps an initial process measure would be to attempt to measure each time the provider ‘appropriately’ interacted with the OPA by either discontinuing the order or identifying criteria that suggests vancomycin should continue. Meanwhile, you would also want to measure your outcome metric – in this case vancomycin DOT - which you would expect to decrease overall, but may take longer time to show meaningful effect. Lastly, but often forgotten -- in order to iterate upon the process, teams should obtain end-user feedback through surveys, focus groups, or feedback tools provided by the electronic medical record system. This process may reveal some design issues that may lead to decreased engagement and/or errors in design. It is important to recognize the unintended consequences of interruptive pop-up alerts leading to alert fatigue and increased medical errors. Unfortunately, because there is no gold standard metric to evaluate for this, we really rely on optimized design that takes into account the end-users workflow and has maximal engagement (e.g. high ‘acceptance’ rates)."

Overall, CDS tools play a key role in ASP and IP programs by improving antibiotic use, reducing infections, and supporting diagnostic decisions. A structured approach to the development and evaluation of CDS tools ensures alignment with clinical guidelines and enhances tool effectiveness. Regular updates, clinician engagement, and feedback are essential for maintaining the utility of these tools. As CDS tools evolve, they can improve patient outcomes, support decision-making, and contribute to more efficient healthcare delivery.

Smith MR, Lee JJ, Holubar M, et al. Clinical decision support in the electronic health record: a primer for antimicrobial stewards and infection preventionists: work smarter so end users don't work harder. Antimicrob Steward Healthc Epidemiol. 2024;4(1):e204. Published 2024 Nov 14. Accessed January 16, 2024. doi:10.1017/ash.2024.448

Mary Rochelle Smith, MD, Julie J Lee, MD, and Amy Chang, MD, PharmD, share expert strategies for implementing effective clinical decision support tools in practice.

Advice for Clinicians from Clinicians: Improving Antibiotic Stewardship and Infection Control

Robert H. Hopkins, Jr, MD, medical director, National Foundation for Infectious Diseases (NFID) provides an update on incidence rates and virus patterns across different regions of the US.

Seasonal Respiratory Virus Season: How Are We Doing Right Now?

The seasonal respiratory virus season in the northern hemisphere runs from October through April. As we are at about the halfway point of the season, we wanted to identify incidence rates and get some guidance from Robert H. Hopkins, Jr, MD, medical director, NFID, on the current state of the virus season focusing on COVID-19, influenza, and RSV.

The latest surveillance report from the Centers for Disease Control and Prevention (CDC) states the infection positivity rate of the 3 viruses remains stable or increased. “Nationally, influenza test positivity is stable at 18.6%. COVID-19 test positivity has remained stable at 6.9%. RSV test positivity increased to 11.6%,” CDC reported on its site.

And the federal agency said the amount of respiratory illness causing people to seek healthcare was characterized as high in the US.

“Nationally, emergency department visits are high for diagnosed influenza and very high for diagnosed RSV. Emergency department visits for COVID-19 are elevated,” CDC reported.

CDC sees the possibility of decline in COVID-19 and influenza based on emergency department visits. 

“As we think about trends, influenza seems to be, maybe peaking out, and starting to decline a little bit. Although, we have to remember this is data that's coming out for the holiday season, so it may be under reporting, but hopefully we see a decline in influenza across most of the US,” Hopkins said.

He also points out that not all the seasonal viruses run in concert.

“You'll often see an increase in influenza and or COVID, kind of in parallel,” Hopkins said. “RSV tends to have a bit of its own pattern. RSV really typically starts in the southeast and spreads rapidly across the country. We're kind of right in the middle of the mix right now, and hopefully we're going to see a decline over the next few weeks. But we don't want to predict that yet. We need to see a little more data.”

This is the first part of a 3-part interview with Hopkins. Next week he will offer his insights on avian influenza and our preparedness around the virus.

Reference
1. Respiratory Virus Activity Levels. CDC. January 13, 2025. Accessed January 17, 2025. https://www.cdc.gov/respiratory-viruses/data/activity-levels.html

The “skip phenomenon” (SP) refers to a clinical pattern in which blood cultures intermittently test positive before eventually clearing. A recent study sheds light on the fact that one-third of patients with Staphylococcus lugdunensis infective endocarditis (

 IE) experience the SP, and these patients tend to face prolonged bacteremia, extended hospital stays, and a higher 1-year mortality rate. In an exclusive email interview, Patrick D Crowley, DO, from the Mayo Clinic’s Division of Public Health, Infectious Disease, and Occupational Medicine, discussed the significance of this phenomenon, its impact on clinical practice, and the implications for patient care.

Contagion: Could you explain the "skip phenomenon" (SP) in simple terms and why it’s significant in the context of 

"'Skip Phenomenon' occurs in patients with positive blood cultures who are receiving antibiotics. One set of their blood cultures are negative for 24 hours, but the blood cultures turn positive the next day. This one day of negative cultures is the “skip”. This SP has only been described in 

, until now with Staphylococcus lugdunensis infective endocarditis."

Contagion: How can clinicians identify and interpret the skip phenomenon in patients, and what implications does this have for treatment and monitoring?

: "The first step to identifying SP is to know that it can occur. Previously, if a set of blood cultures had no bacterial growth, the team would not repeat cultures and would treat the patient like there was not bacteria in their blood anymore. If SP happens and the bacteremia recurs in the blood the next day, that puts patients at risk for an infection in central lines or surgically implanted material. Thus, if a patient has bacteremia with 

, we suggest waiting until there are two consecutive days of negative blood cultures prior to placing central lines or surgically implanted material to reduce risk."

Contagion: Your study found that patients with the SP had a longer duration of bacteremia and hospital stay. What factors do you think contribute to these longer durations, and how can they be managed more effectively?

: "Skip phenomenon may indicate either that patients are more vulnerable - sicker, frailer, older - or that 

 infection is more severe or has spread to a location not identified - such as the spine, large muscles, joints, or brain. If SP occurs, clinicians should consider whether the patient has an infection somewhere else. They should ask about new joint pain, back pain, check for confusion, and consider whether other imaging - such as a brain or spinal MRI or PET-CT is needed. Infective endocarditis is a difficult disease to diagnose and treat, and should be managed by an Infectious Diseases specialist."

Contagion: Given the higher 1-year mortality rate in patients with the SP, what do you believe are the key drivers of this increased mortality, and how can early detection and intervention impact long-term outcomes?

: "I think the mortality is higher in the patients with SP due to patient and disease factors outlined above. 

 infective endocarditis is a disease with high mortality. Over one fourth of patients without SP died as well. However, it is worth noting that we had a small study sample and it would be helpful to look into a larger number of cases to describe mortality rates and whether there are other contributing factors that we can address."

 IE presents unique challenges for clinicians, with implications for treatment, monitoring, and patient outcomes. Crowley’s insights underscore the importance of awareness in managing these patients, particularly as they are at greater risk for prolonged infection and higher mortality rates. The findings also highlight the need for further research to understand these dynamics better and improve clinical interventions.

Crowley P, Gasca L, Katragadda S, et. al. Identification of the Skip Phenomenon Among Patients with Staphylococcus lugdunensis Infective Endocarditis: A Retrospective Review, Open Forum Infectious Diseases, 2025;, ofaf015, https://doi.org/10.1093/ofid/ofaf015

Patrick D Crowley, DO explains the impact of the "skip phenomenon" in Staphylococcus lugdunensis infective endocarditis, linking it to longer hospital stays and higher mortality rates.





The "Skip Phenomenon" in Blood Infections

There are high infection rates in this population, but limited opportunities to bring about awareness has been a difficult factor to overcome. 

Black Women and HIV: Breaking Down Barriers

In 2024, the Centers for Disease Control and Prevention released its surveillance report that showed that despite Black women in the United States making up just 13% of the overall female population, they accounted for 50% of HIV diagnoses among women.

Barriers for Black women getting HIV prevention and care include access, economic, and cultural, which contribute to the disparity, and underscore an urgent need that demands focused action.

In trying to overcome these barriers and limited educational opportunities, ViiV Healthcare has been looking to meet women where they are. For example, last fall they sponsored a panel session at the Beautycon conference titled, “State of Beauty: Real Talk on the Intersection of Beauty, Self-Care and Sexual Health.” One of the featured panelists was Alftan Dyson, PharmD, AAHIVP, FNPhA, regional medical Lead & US DEI medical engagement lead at ViiV Healthcare.

“I think that's a key," Dyson said. "Showing up in nontraditional spaces to have this conversation, because that really breaks down the stigma, right?”

Dyson explains this is all part of a community-focused approach. One specific initiative involved in the approach is the 

 program, which was developed by ViiV Healthcare, and aims to increase awareness and access to HIV prevention and care for Black women by changing the conversation.

“How do we shift the conversation from talking about risk? So, reframing risk to talk about reasons, particularly motivating reasons for prevention and care,” Dyson said. “And so Risk to Reasons is one of those initiatives where you bring in community, you listen to and work with community to create this initiative. And it's really the first multimillion dollar philanthropic investment that was dedicated to black women's needs.”

Reference
1. HIV Surveillance Report: Diagnoses, Deaths, and Prevalence of HIV in the United States and 6 Territories and Freely Associated States, 2022. May 21, 2024. Accessed January 15, 2025.
https://stacks.cdc.gov/view/cdc/156509

There are high infection rates in this population, but limited opportunities to bring about awareness and education. However, a newer program sponsored by ViiV Healthcare looks to engage these women and bring about a better understanding behind transmission and care.   

Black Women and HIV: Breaking Down Barriers, Having Conversations in the Communities

In the second part of our conversation, Abdulwhab Shremo Msdi, PharmD, discusses using this methodology for this dosing technique and if he has a preference. 

Estimating the AUC for Vancomycin Using Non Trapezoidal Equations 

In the first part of the interview with Msdi, he discussed AUC-based monitoring for vancomycin and its adoption by institutions and its value in dosing. 

Looking at the Slow Adoption of AUC-Based Monitoring for Vancomycin

In this segment, Msdi talks about using a unique approach that estimates the AUC for vancomycin using non trapezoidal equations. He says the equations are not novel but rather uncommon and he discovered them during his fellowship. 

“I think it's an attention issue—not complexity—because they are not very complex to do, but there is just not much published for us pharmacists to see how to use them," Msdi said. 

He also likes this approach as it helps describe drug kinetics.

Back in the fall, Msdi coauthored an article on the topic and provided information on this approach. 

Optimizing Vancomycin Therapy: A Review of AUC Calculation Techniques

In the second part of our conversation, Abdulwhab Shremo Msdi, PharmD, discusses using this methodology. 

Teja Ghanta, PharmD

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