Background: Candida auris is an emerging multidrug-resistant yeast that is transmitted in healthcare facilities and is associated with substantial morbidity and mortality. Environmental contamination is suspected to play an important role in transmission but additional information is needed to inform environmental cleaning recommendations to prevent spread. Methods: We conducted a multiregional (Chicago, IL; Irvine, CA) prospective study of environmental contamination associated with C. auris colonization of patients and residents of 4 long-term care facilities and 1 acute-care hospital. Participants were identified by screening or clinical cultures. Samples were collected from participants’ body sites (eg, nares, axillae, inguinal creases, palms and fingertips, and perianal skin) and their environment before room cleaning. Daily room cleaning and disinfection by facility environmental service workers was followed by targeted cleaning of high-touch surfaces by research staff using hydrogen peroxide wipes (see EPA-approved product for C. auris, List P). Samples were collected immediately after cleaning from high-touch surfaces and repeated at 4-hour intervals up to 12 hours. A pilot phase (n = 12 patients) was conducted to identify the value of testing specific high-touch surfaces to assess environmental contamination. High-yield surfaces were included in the full evaluation phase (n = 20 patients) (Fig. 1). Samples were submitted for semiquantitative culture of C. auris and other multidrug-resistant organisms (MDROs) including methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococcus (VRE), extended-spectrum β-lactamase–producing Enterobacterales (ESBLs), and carbapenem-resistant Enterobacterales (CRE). Times to room surface contamination with C. auris and other MDROs after effective cleaning were analyzed. Results: Candida auris colonization was most frequently detected in the nares (72%) and palms and fingertips (72%). Cocolonization of body sites with other MDROs was common (Fig. 2). Surfaces located close to the patient were commonly recontaminated with C. auris by 4 hours after cleaning, including the overbed table (24%), bed handrail (24%), and TV remote or call button (19%). Environmental cocontamination was more common with resistant gram-positive organisms (MRSA and, VRE) than resistant gram-negative organisms (Fig. 3). C. auris was rarely detected on surfaces located outside a patient’s room (1 of 120 swabs; <1%). Conclusions: Environmental surfaces near C. auris–colonized patients were rapidly recontaminated after cleaning and disinfection. Cocolonization of skin and environment with other MDROs was common, with resistant gram-positive organisms predominating over gram-negative organisms on environmental surfaces. Limitations include lack of organism sequencing or typing to confirm environmental contamination was from the room resident. Rapid recontamination of environmental surfaces after manual cleaning and disinfection suggests that alternate mitigation strategies should be evaluated.

Funding: None

Disclosures: None

Background: Bathing ICU patients with chlorhexidine gluconate (CHG) decreases bloodstream infections and multidrug-resistant organism transmission. The efficacy of CHG bathing on skin microorganism reduction may be influenced by patient-level clinical factors. We assessed the impact of clinical factors on the recovery of microorganisms from the skin of patients admitted to an ICU who were receiving routine CHG bathing. Methods: We analyzed data obtained from 6 single-day point-prevalence surveys of adult ICU patients between January and October 2018 at 1 medical ICU, in the context of a CHG bathing quality initiative. Demographics and covariates were collected at the bedside and by chart review. Skin swabs were collected from neck, axilla, and inguinal regions and were plated to selective and nonselective media. Standard microbiologic methods were used for species identification and susceptibilities. Multivariable models included patients who received a CHG bath and accounted for clustering of body sites within patients. Results: Across all time points, 144 patients participated, yielding 429 skin swab samples. Mean age was 57 years (SD, 17); 49% were male; 44% had a central venous catheter; and 15% had a tracheostomy Also, 140 patients (97%) had >1 CHG bath prior to skin swab collection, with a median of 9 hours since their last CHG bath (IQR, 6–13 hours). Gram-positive bacteria were more commonly recovered than gram-negative or Candida spp across all skin sites (Table 1). Variation by body site was detected only for gram-positive bacteria, with recovery more common from the neck compared to axilla or groin sites. On multivariate logistic regression (Table 2), presence of central venous catheter was associated with lower odds of gram-positive bacteria recovery among those who received a CHG bath. Presence of tracheostomy was associated with a significantly higher odds of gram-negative bacteria detection on skin. No clinical factors were independently associated with recovery of Candida spp. Conclusions: Central venous catheter presence was associated with lower odds of gram-positive bacteria detection on skin, suggesting the possibility of higher quality CHG bathing among such patients. Tracheostomy presence was associated with greater odds of gram-negative bacteria detection, suggesting that it may be a potential reservoir for skin contamination or colonization. Indwelling medical devices may influence CHG bathing effectiveness in reducing microorganism burden on skin.

Funding: None

Disclosures: None

Despite global deterioration of coral reef health, not all reef-associated organisms are in decline. Bioeroding sponges are thought to be largely resistant to the factors that stress and kill corals, and are increasing in abundance on many reefs. However, there is a paucity of information on how environmental factors influence spatial variation in the distribution of these sponges, and how they might be affected by different stressors. We aimed to identify the factors that explained differences in bioeroding sponge abundance and assemblage composition, and to determine whether bioeroding sponges benefit from the same environmental conditions that can contribute towards coral mortality. Abundance surveys were conducted in the Wakatobi region of Indonesia on reefs characterized by different biotic and abiotic conditions. Bioeroding sponges occupied an average of 8.9% of available dead substrate and variation in abundance and assemblage composition was primarily attributed to differences in the availability of dead substrate. Our results imply that if dead substrate availability increases as a consequence of coral mortality, bioeroding sponge abundance is also likely to increase. However, bioeroding sponge abundance was lowest on a sedimented reef, despite abundant dead substrate. This suggests that not all forms of coral mortality will benefit all bioeroding sponge species, and sediment-degraded reefs are likely to be dominated by a few resilient bioeroding sponge species. Overall, we demonstrate the importance of understanding the drivers of bioeroding sponge abundance and assemblage composition in order to predict possible impacts of different stressors on reefs communities.

This article considers the relationship between constitutions and political settlements and locates the special issue articles within this wider discussion. The article points to the apparently paradoxical connection between disillusionment with internationalised state-building techniques on one hand, and increased international faith in constitution-making as a state-building tool on the other. Using understandings of the relationship of the constitution to political settlement which draws on conventional constitutional theory, it argues that the current context of negotiated transitions requires constitution-making to be approached with an eye to the distinctive dilemmas of statecraft that pertain in contemporary transitions. The most central dilemma concerns how power-balances between political/military elites can be broadened to ensure the constitution’s capacity to fulfil its normative role in restraining power and delivering broader social inclusion. The pieces which make up this special issue draw together development and legal discourses. This article suggests how constitutional theory provides a resource for those seeking to promote constitutionalism as a tool for reaching political settlements capable of resolving conflict. It also argues that those who seek to rely on constitutions for conflict resolution need to understand this enterprise as just as political and fraught as all other institution-building efforts.

In this short piece, I open a conversation over how the Colombian Final Peace Accord provides evidence of, and a contribution to, a more general lex pacificatoria or “law of the peacemakers” (lex pax for short). In light of the Accord’s recent ballot defeat, I integrate into this assessment the merits of using a referendum to approve (in Colombia’s case “affirm or deny”) the Agreement as a whole. Throughout, I draw on a peace agreement database which has coded over one thousand four hundred peace agreements since 1990 for comparative insight.

Twin pairs discordant for disease may help elucidate the epigenetic mechanisms and causal environmental factors in disease development and progression. To obtain the numbers of pairs, especially monozygotic (MZ) twin pairs, necessary for in-depth studies while also allowing for replication, twin studies worldwide need to pool their resources. The Discordant Twin (DISCOTWIN) consortium was established for this goal. Here, we describe the DISCOTWIN Consortium and present an analysis of type 2 diabetes (T2D) data in nearly 35,000 twin pairs. Seven twin cohorts from Europe (Denmark, Finland, Norway, the Netherlands, Spain, Sweden, and the United Kingdom) and one from Australia investigated the rate of discordance for T2D in same-sex twin pairs aged 45 years and older. Data were available for 34,166 same-sex twin pairs, of which 13,970 were MZ, with T2D diagnosis based on self-reported diagnosis and medication use, fasting glucose and insulin measures, or medical records. The prevalence of T2D ranged from 2.6% to 12.3% across the cohorts depending on age, body mass index (BMI), and national diabetes prevalence. T2D discordance rate was lower for MZ (5.1%, range 2.9–11.2%) than for same-sex dizygotic (DZ) (8.0%, range 4.9–13.5%) pairs. Across DISCOTWIN, 720 discordant MZ pairs were identified. Except for the oldest of the Danish cohorts (mean age 79), heritability estimates based on contingency tables were moderate to high (0.47–0.77). From a meta-analysis of all data, the heritability was estimated at 72% (95% confidence interval 61–78%). This study demonstrated high T2D prevalence and high heritability for T2D liability across twin cohorts. Therefore, the number of discordant MZ pairs for T2D is limited. By combining national resources, the DISCOTWIN Consortium maximizes the number of discordant MZ pairs needed for in-depth genotyping, multi-omics, and phenotyping studies, which may provide unique insights into the pathways linking genes to the development of many diseases.

The present study compared the effects of feeding uncooked pea fractions (embryo v. seed coat) on glucose homeostasis in glucose-intolerant rats and examined potential mechanisms influencing glucose homeostasis. Rats were made glucose intolerant by high-fat feeding, after which diets containing both high-fat and pea fractions were fed for 4 weeks. Rats fed diets containing uncooked pea seed coats low (non-coloured seed coat; NSC) or high (coloured seed coat; CSC) in proanthocyanidins but not embryos had improved oral glucose tolerance (P < 0·05). NSC also lowered fasting and glucose-stimulated insulin secretion (P < 0·05), decreased β-cell mass by 50 % (P < 0·05) and lowered levels of malondialdehyde, a marker of oxidative stress. Furthermore, NSC decreased the mucosal thickness of the colon by 25 % (P < 0·05), which might affect fibre fermentation and other gut functions. Small but statistically significant (P < 0·05) effects consistent with enhanced glucose transport or metabolism were observed in the skeletal muscle of rats fed NSC or CSC, for example, increased levels of AMP-dependent kinase or akt. We conclude that pea seed coats are the fraction exerting beneficial effects on glucose tolerance. Most of the changes were small in amplitude, suggesting that additive effects on multiple tissues may be important. NSC content appeared to have the most beneficial effects in improving glucose homeostasis but our ability to detect the effect of flavonoids may have been limited by their low concentration in the diet.