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Background: Understanding the epidemiology and risk factors for nosocomial infections with vancomycin-resistant enterococci (VRE) is necessary for the prevention and control of VRE infections in the hospital setting. We sought to determine the incidence of nosocomial infections of VRE and to ascertain predictors associated with nosocomial infection. Methods: In this retrospective cohort study, data were collected from patients with VRE infection from January 2019 to December 2020 at a tertiary-care center in northern California. VRE infections were designated as hospital onset (HO) if the specimen was collected >3 days after hospital admission or community onset (CO) if the specimen was collected ≤3 days after admission. Associations between HO infections with time, unit, and specimen were identified. Results: Over the 2-year period, 214 unique VRE infections were identified in hospitalized patients; 115 infections were CO and 99 were HO. HO-VRE were associated most frequently with stay in medical/telemetry units (68%), followed by oncology–transplant units (15%) and ICUs (12%). There were ~4.7 and ~3.6 HO-VRE infections per month in 2019 and 2020, respectively. No differences were identified between HO-VRE infections in 2 medical units regarding glycopeptide and cephalosporin use in those units. The sources of VRE infections were urinary 45%, bloodstream 15%, stool 10%, and other 30%. Of the 45 infections in urine, 51% were identified from catheters (Foley and straight) and 27% were identified from clean-catch urine. Interestingly, 71% of patients with VRE identified from urine did not report urinary tract infection (UTI) symptoms at the time of collection. Urine was most often collected for urinalysis and culture from patients with nonspecific symptoms such as fever, leukocytosis, hypotension, tachycardia, or altered mental status. All urine collected from patients who reported UTI symptoms grew >100,000 CFU/mL in culture, while only 75% of cultures from patients without symptoms grew >100,000 CFU/mL. The most common antibiogram was resistance to ampicillin, cefazolin, levofloxacin, minocycline, penicillin, tetracycline, and/or vancomycin (42% of cases) and susceptibility to both daptomycin and linezolid (60% of cases). Conclusions: HO-VRE infections were frequently identified with urinary sources and were often associated with catheter use. However, the frequent lack of concurrent UTI symptoms suggests VRE colonization rather than infection in many cases. Understanding the epidemiology and risk factors for HO-VRE infections is essential for developing infection prevention protocols to reduce the incidence of those infections.
Coronavirus disease 2019 (COVID-19) vaccination effectiveness in healthcare personnel (HCP) has been established. However, questions remain regarding its performance in high-risk healthcare occupations and work locations. We describe the effect of a COVID-19 HCP vaccination campaign on SARS-CoV-2 infection by timing of vaccination, job type, and work location.
Methods:
We conducted a retrospective review of COVID-19 vaccination acceptance, incidence of postvaccination COVID-19, hospitalization, and mortality among 16,156 faculty, students, and staff at a large academic medical center. Data were collected 8 weeks prior to the start of phase 1a vaccination of frontline employees and ended 11 weeks after campaign onset.
Results:
The COVID-19 incidence rate among HCP at our institution decreased from 3.2% during the 8 weeks prior to the start of vaccinations to 0.38% by 4 weeks after campaign initiation. COVID-19 risk was reduced among individuals who received a single vaccination (hazard ratio [HR], 0.52; 95% confidence interval [CI], 0.40–0.68; P < .0001) and was further reduced with 2 doses of vaccine (HR, 0.17; 95% CI, 0.09–0.32; P < .0001). By 2 weeks after the second dose, the observed case positivity rate was 0.04%. Among phase 1a HCP, we observed a lower risk of COVID-19 among physicians and a trend toward higher risk for respiratory therapists independent of vaccination status. Rates of infection were similar in a subgroup of nurses when examined by work location.
Conclusions:
Our findings show the real-world effectiveness of COVID-19 vaccination in HCP. Despite these encouraging results, unvaccinated HCP remain at an elevated risk of infection, highlighting the need for targeted outreach to combat vaccine hesitancy.
To describe the pattern of transmission of severe acute respiratory coronavirus virus 2 (SARS-CoV-2) during 2 nosocomial outbreaks of coronavirus disease 2019 (COVID-19) with regard to the possibility of airborne transmission.
Design:
Contact investigations with active case finding were used to assess the pattern of spread from 2 COVID-19 index patients.
Setting:
A community hospital and university medical center in the United States, in February and March, 2020, early in the COVID-19 pandemic.
Patients:
Two index patients and 421 exposed healthcare workers.
Methods:
Exposed healthcare workers (HCWs) were identified by analyzing the electronic medical record (EMR) and conducting active case finding in combination with structured interviews. Healthcare coworkers (HCWs) were tested for COVID-19 by obtaining oropharyngeal/nasopharyngeal specimens, and RT-PCR testing was used to detect SARS-CoV-2.
Results:
Two separate index patients were admitted in February and March 2020, without initial suspicion for COVID-19 and without contact or droplet precautions in place; both patients underwent several aerosol-generating procedures in this context. In total, 421 HCWs were exposed in total, and the results of the case contact investigations identified 8 secondary infections in HCWs. In all 8 cases, the HCWs had close contact with the index patients without sufficient personal protective equipment. Importantly, despite multiple aerosol-generating procedures, there was no evidence of airborne transmission.
Conclusion:
These observations suggest that, at least in a healthcare setting, most SARS-CoV-2 transmission is likely to take place during close contact with infected patients through respiratory droplets, rather than by long-distance airborne transmission.
At some point during the 1070s the archbishop of Canterbury, Lanfranc, wrote to Herfast (bishop of East Anglia 1070–84/5) in trenchant terms. Much of his letter criticized the bishop's lifestyle – ‘Give up the dicing (to mention nothing worse) and the world's amusements in which you are said to idle away the entire day’ – and the company he kept: ‘Banish the monk Hermann, whose life is notorious for its many faults, from your society and your household completely.’ Instead, Lanfranc told his bishop to read Scripture and above all to master the decrees of the Roman pontiffs and the canons of the holy councils, to ‘discover what you do not know’ and ‘ensure that you hold no opinion that is at variance with your mother church’. The significance of that advice finds context in the opening of the letter, which relates to the affairs of the abbey of Bury St Edmunds. After a conventional greeting, where Lanfranc wished Bishop Herfast might be humble in wisdom and of sober understanding, the archbishop began by observing that Berard, a cleric of Abbot Baldwin of Bury, had delivered a previous letter from the Archbishop to Bishop Herfast. He went on:
As [Berard] himself affirmed to me later, you made a coarse joke about it; you uttered cheap and unworthy remarks about me in the hearing of many; and you declared on oath that you would give me no assistance in that matter. There will be another time and another place to speak of those things. But my immediate instructions are these: that you lay no claim to the property of St Edmund unless you can give indisputable proof that it was claimed by your predecessors and that you discharge the aforesaid Berard without any fine or threat of punishment, until the case comes into our own court and can be rightly concluded according to canon law and our own ruling as judge.
There are three types of epilepsy: analempsia, epilempsia, and catalempsia. Analempsia has that name because it deprives the sacred parts of the head of sensation, and it arises either from neglect of the stomach, or from an excess of food or drink, or from drinking cold things, or from luxury … Epilempsia has that name from seizure of the mind and senses, and when they are besieged the body is also possessed, for it is a serious and slow affliction. Some call this sickness comitialis, others the holy affliction, and the Greeks call it geronoson … Catalempsia is epilepsy accompanied by fever … the sickness of cataleptics starts with the feet or lower legs. When they feel the advancing pain and catarrh, it comes from an excess of blood, or rather, choler ferments in the confines of the stomach, with no natural exit, whence it burdens the head and injures the senses.
This explanation of the causes and effects working within the human body is found in an eleventh-century medical text from Salerno, the Passionarius (‘Book of Diseases’) attributed to the physician Gariopontus. This medical text survives in sixty-five medieval manuscripts, one of which is now London, British Library, MS Royal 12. C. xxiv. Michael Gullick has identified the script of this manuscript as that of an early twelfth-century scribe of Bury St Edmunds, demonstrating that this text was known at Bury in the generation after the physician-abbot Baldwin.
The notion that the history of the abbey of Bury St Edmunds after the Norman Conquest was unusual is not new. William of Malmesbury in his Gesta pontificum described St Edmund as ‘the first of the saints of the country’. And in the Gesta regum he wrote that the saint's abbey was remarkable both for its capacity to attract patronage and to repulse tax-collectors:
By these arts he has so engaged the loyalty of all the inhabitants of Britain that anyone thinks it a privilege to enrich his monastery by even a penny. Even kings, the lords of other men, rejoice to call themselves his servants, and place their royal crown at his service, redeeming it at a great price if they wish to use it. The tax-collectors who run riot in other places, making no distinction between right and wrong, are on their knees before St Edmund, and stay their legal processes at his boundary-ditch, knowing from experience how many have suffered who have thought fit to persist.
A monk of the great Ile-de-France abbey of Saint-Denis, Abbot Baldwin of Bury St Edmunds (1065–97) was the one non-Englishman to be an abbot in England on the day that Harold lost the Battle of Hastings. He had first visited England well before his appointment to Bury in 1065 and been treated with great favour by King Edward.
The medieval persona of St Edmund, as far as it can be recovered, is generally recognised to have resided in Abbo of Fleury's Passio sancti Eadmundi. Written at the request of the monks of Ramsey at the end of the tenth century, this text was swiftly adopted by the Benedictine community at Bury, where it appears to have been recorded in a booklist from the 1040s, and from whose scribes three eleventh-century copies survive. The Passio was undoubtedly a creative stimulus for the local community, for it gave rise both to the famous cycle of illuminations in the twelfth-century illustrated libellus, now New York, Pierpont Morgan Library, MS M. 736, and to an important collection of eleventh-century chants for St Edmund's feast, which forms the basis of this chapter. Even Bury's late eleventh-century hagiographer Herman owed a debt to Abbo: in alluding to the story of the Passio, commenting on the general shortage of other available accounts, and apparently fashioning his own Miracula as a continuation of that narrative. One might be forgiven for assuming, therefore, that the St Edmund portrayed by Abbo's Passio – the humble, peace-loving figure characterised by Antonia Gransden as a model of Christian kingship – was the very same St Edmund known to the monks of Bury.
In comparison with the large number of manuscripts at Saint-Denis from the Carolingian period and the twelfth century, the sources for the eleventh century, the time of Abbot Baldwin of Bury St Edmunds, are meagre. This is one indication that the abbey suffered severe losses in the tenth century at the hands of the Normans. It lost many of its domains, the fabric of the church seems to have deteriorated greatly, and the performance of the liturgy seems to have become lax.
Abbot Suger, writing in the 1140s, saw the division of the Carolingian empire under the sons of the son of Louis the Pious, that is, Charles the Bald, as the major reason for Saint-Denis's losses. In addition to the problem the monks faced in recovering their illustrious past, the monastery encountered two major challenges to its prestige in the first half of the eleventh century. First of all, the monks at Saint Emmeram, Regensburg, claimed that they had the relics of St Denis. In response to this, the saint's body was exhumed in 1053, and a new feast, the Detection of Saint Denis, was celebrated on 9 June to commemorate this event. Secondly, the bishop of Paris challenged Saint-Denis's claims of exemption from episcopal control. So it is perhaps not surprising that the extant manuscripts and charters from the eleventh century reflect both of these topics: charters were forged to prove the monastery's independence from episcopal control, and manuscripts were created for its new liturgical celebrations.
An accurate picture of the architectural history of Abbot Baldwin's church began to emerge already in the middle of the nineteenth century, as for example with Graham Hills's study of 1865. The first person to make sense of the remains on the site as a whole was Arthur Whittingham, with the research he published in the early 1950s, and many aspects of the subject were investigated further at the conference of the British Archaeological Association of 1994, organized by Antonia Gransden. In the present essay I want to examine three things: the contrast between the Norman church and its Anglo-Saxon predecessors; how relations between the abbey and the diocese in the late eleventh century may be reflected in changes in the plan of the church; and the relationship between the plans of the abbey and the town.
The Contrast between the Norman Church and its Anglo-Saxon Predecessors
According to Abbo of Fleury, when St Edmund's body arrived in Beodricesworth (before c. 950), the faithful of the vill built a very large wooden church to receive it. Nothing is recorded of its shape. Cnut and Emma supported the building of a church which was begun about 1020 and consecrated in 1031 or 1032, the new work, according to Herman, being carried out in stone.
O Mars god of war, who curbs kingdoms by the sword,
who demands bloodied corpses of young men,
and men's blood poured out in mass slaughter,
what was your intent; how great your thirst for evil,
when in their midst you ordered savage troops to battle?
In the late 1060s, a cleric, possibly the bishop of Amiens, wrote a poem on the Norman Conquest. It represented William the Conqueror as a hero worthy of Troy, rightfully claiming a kingdom; but it also depicted him as a warrior revelling in gore, enthralled to the god Mars. The poet told of how venerable age and beautiful youth lay mingled in death on the battlefield and how William camped at Dover where the vanquished came to seek terms and kiss his feet, ‘just as flies … throng in swarms to sores full of blood’. Blood was impure in the eyes of the religious. A drop of blood was enough to desecrate a sanctuary. The taint of blood from intercourse rendered a priest unfit to say Mass, and to shed the blood of a Christian was to shed the blood of Christ. The mordant analogy of those sores full of blood – the Normans – marching upon Westminster, where their leader would be sacramentally anointed, should have troubled the conscience of the king the poet pretended to flatter. His subtext betrays horror and the expectation of penance. Comparable pressure came from the Norman bishops who imposed penance on William and his troops.
Some ten years ago I identified an eleventh-century Continental medical manuscript in the British Library (Sloane 1621) as a hitherto unrecognised Bury book. It is a small book of several contemporary parts that is interesting for its content, its many contemporary, near-contemporary, and early twelfth-century additions by Continental and English scribes, and the likelihood that it should be linked to Baldwin, abbot of Bury between 1065 and 1097. Its content is discussed by Debby Banham in the following chapter, and therefore what follows is concerned mostly with the physical and scribal features of the manuscript, and the conclusions concerning its origin and provenance that can be drawn from them.
At the beginning of Sloane 1621 is a preliminary quire, formerly of four leaves but now with its first leaf lost (fols 2–4), of slightly later date than what follows. The quire contains medical prayers and three short texts concerning the monochord in two Anglo-Continental hands, probably of the early twelfth century, the second of which also made an addition on the last leaf of the manuscript proper (fol. 111r). There is little reason to doubt that the quire was an early addition to the manuscript, for its format (arrangement and number of lines) suggests that it was made with the intention to put it before what follows. At the top of what is now the opening page (fol. 2r) is a one-word twelfth-century title repeated by the same scribe (antidotarius), and this is an adequate description of the content of the manuscript proper, suggesting that the preliminary quire was in its present position by at least 1200, if not before.
Bury St Edmunds is noteworthy in so many ways: in preserving the cult and memory of the last East Anglian king, in the richness of its archives, and not least in its role as a mediator of medical texts and studies. All these aspects, and more, are amply illustrated in this collection, by specialists in their fields. The balance of the whole work, and the care taken to place the individual topics in context, has resulted in a satisfying whole, which places Abbot Baldwin and his abbey squarely in the forefront of eleventh-century politics and society. Professor Ann Williams. The abbey of Bury St Edmunds, by 1100, was an international centre of learning, outstanding for its culting of St Edmund, England's patron saint, who was known through France and Italy as a miracle worker principally, but also as a survivor, who had resisted the Vikings and the invading king Swein and gained strength after 1066. Here we journey into the concerns of his community as it negotiated survival in the Anglo-Norman empire, examining, on the one hand, the roles of leading monks, such as the French physician-abbot Baldwin, and, on the other, the part played by ordinary women of the vill. The abbey of Bury provides an exceptionally rich archive, including annals, historical texts, wills, charters, and medical recipes. The chapters in this volume, written by leading experts, present differing perspectives on Bury's responses to conquest; reflecting the interests of the monks, they cover literature, music, medicine, palaeography, and the history of the region itself. Dr Tom Licence is Senior Lecturer in Medieval History and Director of the Centre of East Anglian Studies at the University of East Anglia. Contributors: Debbie Banham, David Bates, Eric Fernie, Sarah Foot, Michael Gullick, Tom Licence, Henry Parkes, Véronique Thouroude, Elizabeth van Houts, Thomas Waldman, Teresa Webber