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Carbapenem-resistant Enterobacterales bacteriuria and subsequent bacteremia: A population-based study
- Jessica R. Howard-Anderson, Chris W. Bower, Gillian Smith, Mary Elizabeth Sexton, Monica M. Farley, Sarah W. Satola, Jesse T. Jacob
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- Journal:
- Infection Control & Hospital Epidemiology / Volume 42 / Issue 8 / August 2021
- Published online by Cambridge University Press:
- 10 December 2020, pp. 962-967
- Print publication:
- August 2021
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Objective:
To describe the epidemiology of carbapenem-resistant Enterobacterales (CRE) bacteriuria and to determine whether urinary catheters increase the risk of subsequent CRE bacteremia.
Design:Using active population- and laboratory-based surveillance we described a cohort of patients with incident CRE bacteriuria and identified risk factors for developing CRE bacteremia within 1 year.
Setting:The study was conducted among the 8 counties of Georgia Health District 3 (HD3) in Atlanta, Georgia.
Patients:Residents of HD3 with CRE first identified in urine between 2012 and 2017.
Results:We identified 464 patients with CRE bacteriuria (mean yearly incidence, 1.96 cases per 100,000 population). Of 425 with chart review, most had a urinary catheter (56%), and many resided in long-term care facilities (48%), had a Charlson comorbidity index >3 (38%) or a decubitus ulcer (37%). 21 patients (5%) developed CRE bacteremia with the same organism within 1 year. Risk factors for subsequent bacteremia included presence of a urinary catheter (odds ratio [OR], 8.0; 95% confidence interval [CI], 1.8–34.9), central venous catheter (OR, 4.3; 95% CI, 1.7–10.6) or another indwelling device (OR, 4.3; 95% CI, 1.6–11.4), urine culture obtained as an inpatient (OR, 5.7; 95% CI, 1.3–25.9), and being in the ICU in the week prior to urine culture (OR, 2.9; 95% CI, 1.1–7.8). In a multivariable analysis, urinary catheter increased the risk of CRE bacteremia (OR, 5.3; 95% CI, 1.2–23.6).
Conclusions:In patients with CRE bacteriuria, urinary catheters increase the risk of CRE bacteremia. Future interventions should aim to reduce inappropriate insertion and early removal of urinary catheters.
Evaluation of Discrepancies in Carbapenem Minimum Inhibitory Concentrations Obtained at Clinical Laboratories Compared to a Public Health Laboratory
- Julian E. Grass, Shelley S. Magill, Isaac See, Uzma Ansari, Lucy E. Wilson, Elisabeth Vaeth, Paula Snippes Vagnone, Brittany Pattee, Jesse T. Jacob, Georgia Emerging Infections Program, Chris Bower, Atlanta Veterans Affairs Medical Center, Foundation for Atlanta Veterans Education and Research, Sarah W. Satola, Sarah J. Janelle, Kyle Schutz, Rebecca Tsay, Marion A. Kainer, Daniel Muleta, P. Maureen Cassidy, Vivian H. Leung, Meghan Maloney, Erin C. Phipps, New Mexico Emerging Infections Program, Kristina G. Flores, New Mexico Emerging Infections Program, Erin Epson, Joelle Nadle, Maria Karlsson, Joseph D. Lutgring
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- Journal:
- Infection Control & Hospital Epidemiology / Volume 41 / Issue S1 / October 2020
- Published online by Cambridge University Press:
- 02 November 2020, pp. s474-s476
- Print publication:
- October 2020
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Background: Automated testing instruments (ATIs) are commonly used by clinical microbiology laboratories to perform antimicrobial susceptibility testing (AST), whereas public health laboratories may use established reference methods such as broth microdilution (BMD). We investigated discrepancies in carbapenem minimum inhibitory concentrations (MICs) among Enterobacteriaceae tested by clinical laboratory ATIs and by reference BMD at the CDC. Methods: During 2016–2018, we conducted laboratory- and population-based surveillance for carbapenem-resistant Enterobacteriaceae (CRE) through the CDC Emerging Infections Program (EIP) sites (10 sites by 2018). We defined an incident case as the first isolation of Enterobacter spp (E. cloacae complex or E. aerogenes), Escherichia coli, Klebsiella pneumoniae, K. oxytoca, or K. variicola resistant to doripenem, ertapenem, imipenem, or meropenem from normally sterile sites or urine identified from a resident of the EIP catchment area in a 30-day period. Cases had isolates that were determined to be carbapenem-resistant by clinical laboratory ATI MICs (MicroScan, BD Phoenix, or VITEK 2) or by other methods, using current Clinical and Laboratory Standards Institute (CLSI) criteria. A convenience sample of these isolates was tested by reference BMD at the CDC according to CLSI guidelines. Results: Overall, 1,787 isolates from 112 clinical laboratories were tested by BMD at the CDC. Of these, clinical laboratory ATI MIC results were available for 1,638 (91.7%); 855 (52.2%) from 71 clinical laboratories did not confirm as CRE at the CDC. Nonconfirming isolates were tested on either a MicroScan (235 of 462; 50.9%), BD Phoenix (249 of 411; 60.6%), or VITEK 2 (371 of 765; 48.5%). Lack of confirmation was most common among E. coli (62.2% of E. coli isolates tested) and Enterobacter spp (61.4% of Enterobacter isolates tested) (Fig. 1A), and among isolates testing resistant to ertapenem by the clinical laboratory ATI (52.1%, Fig. 1B). Of the 1,388 isolates resistant to ertapenem in the clinical laboratory, 1,006 (72.5%) were resistant only to ertapenem. Of the 855 nonconfirming isolates, 638 (74.6%) were resistant only to ertapenem based on clinical laboratory ATI MICs. Conclusions: Nonconfirming isolates were widespread across laboratories and ATIs. Lack of confirmation was most common among E. coli and Enterobacter spp. Among nonconfirming isolates, most were resistant only to ertapenem. These findings may suggest that ATIs overcall resistance to ertapenem or that isolate transport and storage conditions affect ertapenem resistance. Further investigation into this lack of confirmation is needed, and CRE case identification in public health surveillance may need to account for this phenomenon.
Funding: None
Disclosures: None
Challenges in Integrating the High-K Gate Dielectric Film to the Conventional Cmos Process Flow
- Avinash Agarwal, Michael Freiler, Pat Lysaght, Loyd Perrymore, Renate Bergmann, Chris Sparks, Bill Bowers, Joel Barnett, Deborah Riley, Yudong Kim, Billy Nguyen, Gennadi Bersuker, Eric Shero, Jae E. Lim, Steven Lin, Jerry Chen, Robert W. Murto, Howard R. Huff
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- Journal:
- MRS Online Proceedings Library Archive / Volume 670 / 2001
- Published online by Cambridge University Press:
- 21 March 2011, K2.1
- Print publication:
- 2001
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ZrO2 and HfO2 and their alloys with SiO2 are currently among the leading high-k materials for replacing SiOxNy as the gate dielectric for the sub-100 nm technology nodes. International SEMATECH (ISMT) is currently investigating integration issues associated with this required change in materials. Our work has focused on the integration of ALCVD deposited ZrO2 and HfO2 with an industry standard conventional MOSFET process flow with poly-Si electrode. Since the impact of contamination by these new high-k materials introduced in a production fab has not yet been established, it becomes very critical to prevent cross- contamination through the process tools in the fab. A baseline study was completed within ISMT's fab and appropriate protocols for handling high-k materials have been established. The integrated high-k gate stack in a conventional transistor flow should not only meet all the performance requirements of scaled transistors, but the gate dielectric film should be able withstand high-temperature anneal steps. Reactions between ZrO2 and Si have been observed at temperatures as low as 560°C (during the amorphous Si deposition process). Various wet chemistries were also evaluated for removing the high-k film inadvertently deposited on wafer backside, and it was found that ZrO2 etches at extremely slow rates in the majority of the common wet etch chemistries available in a fab. A new hot HF based process was found to be successful in lowering Zr contamination on the wafer backside to as low as 1.8 E10 atoms/cm2. The patterning of a high-k gate stack with poly-Si electrode is another area that required considerable focus. Various dry (plasma) etch and wet etch chemistries were evaluated for etching ZrO2 using both blanket films as well as wafers with patterned poly-Si gate over the high-k films. On the full CMOS flow device wafers, most of these wet chemistries resulted in severe pitting in the ZrO2 film remaining over the source/drain (S/D) areas, as well as in the Si substrate and the field oxide. A poly-Si gate over ZrO2 gate dielectric film was successfully patterned using the standard poly-Si gate etch (Cl2/HBr) for the main etch, followed by a combination of HF and H2SO4 clean for removing all of the ZrO2 remaining over the S/D area. This allowed the fabrication of low-resistance contacts to transistor S/D areas, which ultimately resulted in demonstration of functional transistors with high-k gate dielectric films.