Mucosal Barrier Injury Laboratory-Confirmed Bloodstream Infection: Results from a Field Test of a New National Healthcare Safety Network Definition
(See the commentary by Steinberg and Coffin, on pages 777–779.)
Objective. To assess challenges to implementation of a new National Healthcare Safety Network (NHSN) surveillance definition, mucosal barrier injury laboratory-confirmed bloodstream infection (MBI-LCBI).
Design. Multicenter field test.
Setting. Selected locations of acute care hospitals participating in NHSN central line–associated bloodstream infection (CLABSI) surveillance.
Methods. Hospital staff augmented their CLABSI surveillance for 2 months to incorporate MBI-LCBI: a primary bloodstream infection due to a selected group of organisms in patients with either neutropenia or an allogeneic hematopoietic stem cell transplant with gastrointestinal graft-versus-host disease or diarrhea. Centers for Disease Control and Prevention (CDC) staff reviewed submitted data to verify whether CLABSIs met MBI-LCBI criteria and summarized the descriptive epidemiology of cases reported.
Results. Eight cancer, 2 pediatric, and 28 general acute care hospitals including 193 inpatient units (49% oncology/bone marrow transplant [BMT], 21% adult ward, 20% adult critical care, 6% pediatric, 4% step-down) conducted field testing. Among 906 positive blood cultures reviewed, 282 CLABSIs were identified. Of the 103 CLABSIs that also met MBI-LCBI criteria, 100 (97%) were reported from oncology/BMT locations. Agreement between hospital staff and CDC classification of reported CLABSIs as meeting the MBI-LCBI definition was high (90%; ). Most MBI-LCBIs (91%) occurred in patients meeting neutropenia criteria. Some hospitals indicated that their laboratories’ methods of reporting cell counts prevented application of neutropenia criteria; revised neutropenia criteria were created using data from field testing.
Conclusions. Hospital staff applied the MBI-LCBI definition accurately. Field testing informed modifications for the January 2013 implementation of MBI-LCBI in the NHSN.
The National Healthcare Safety Network (NHSN) currently receives reports of central line–associated bloodstream infections (CLABSIs) from more than 4,000 acute care hospitals across the United States. Because these data are now publicly reported as a measure of healthcare quality and are being used to determine reimbursement through the Centers for Medicare and Medicaid Services’ Hospital Inpatient Quality Reporting Program,1 some clinicians have illustrated that the NHSN CLABSI surveillance definition lacks specificity in certain patient populations.2,3 For example, concern has been raised that in certain oncology patient populations some bloodstream infections (BSIs) classified as CLABSIs do not result from the presence of the central line but instead from other mechanisms,4-8 such as translocation of bacteria through nonintact mucosa. Distinguishing BSIs related to central lines from those that occur through other mechanisms might facilitate BSI prevention efforts and improve reliability of interfacility comparisons of CLABSI rates.
Improving the specificity and reliability of the NHSN BSI surveillance definition requires making adjustments to current criteria that are both objective and better aligned with clinical judgment. On the basis of literature review and expert opinion from the fields of surveillance, public reporting, infection control, infectious diseases, and oncology, the Centers for Disease Control and Prevention (CDC) developed a modification of the NHSN BSI definition, termed “mucosal barrier injury laboratory-confirmed bloodstream infection” (MBI-LCBI). This definition was recently integrated into NHSN methods for primary BSI surveillance to aid in identifying a subset of BSIs reported as CLABSIs that are likely related to mucosal barrier injury,9 not the presence of a central line.
We field-tested the MBI-LCBI definition in selected hospitals to gain practical experience and assess challenges to implementation before integration into the NHSN.
In the NHSN, a positive blood culture satisfies the laboratory-confirmed bloodstream infection (LCBI) surveillance definition for a primary BSI if (1) it is determined to be healthcare associated, (2) it is not related to another type of healthcare-associated infection meeting NHSN criteria (ie, not a secondary BSI), and (3) either a common commensal organism (eg, coagulase-negative Staphylococcus species, viridans group Streptococcus species) is isolated from a blood culture on 2 occasions in a patient with specified signs/symptoms of BSI or a recognized pathogen (eg, Staphylococcus aureus, Escherichia coli) is isolated from at least 1 blood culture. If the criteria for LCBI are met and the patient has a central line in place during a specified time frame, then the LCBI is further classified as a CLABSI.10
A healthcare-associated primary BSI (ie, meeting the NHSN LCBI definition) was defined as an MBI-LCBI if it (1) resulted from 1 or more of a group of selected organisms known to be commensals of the oral cavity or gastrointestinal tract and (2) occurred in a patient with certain signs or symptoms compatible with the presence of mucosal barrier injury. For a BSI to be classified as MBI-LCBI, both the organism criteria and the patient criteria must be met. Eligible organisms included Candida species, Enterococcus species, Enterobacteriaceae, viridans group Streptococcus species, and certain anaerobes (Bacteroides, Clostridium, Fusobacterium, Prevotella, Peptostreptococcus, Veillonella) without isolation of additional recognized pathogens or common commensal organisms. Additionally, the BSI was required to occur in a patient with either of the following:
An allogeneic hematopoietic stem cell transplant (allo-SCT) in the past year and one of the following documented during the same admission as the positive blood culture:
Grade 3–4 gastrointestinal graft-versus-host disease (GI GVHD)
Diarrhea of 1 L or more in a 24-hour period documented within 7 days prior to or on the day of collection of the positive blood culture
Neutropenia meeting one of the following criteria during the 7 days prior to collection of the positive blood culture:
Absolute neutrophil count (ANC) or total white blood cell count (WBC) less than 500 on at least 2 occasions without an ANC of 500 of greater
At least 1 ANC or WBC less than 100
Participating Hospitals and Locations
A convenience sample of hospitals already performing CLABSI surveillance and reporting to the NHSN was recruited from the Comprehensive Cancer Center–Infection Control group (12 facilities) and 7 of the CDC Emerging Infections Program sites (26 facilities). Hospital staff participating in field testing attended two 1-hour webinars that explained the MBI-LCBI definition and data collection procedures. Staff at participating hospitals selected inpatient locations for field testing, which were defined using existing NHSN guidance.11 In all participating locations, CLABSI surveillance was already being performed using NHSN methods, but at the time of field testing not all locations reported CLABSI surveillance data to the NHSN.
Hospital staff applied the MBI-LCBI definition over a 2-month period during March–May 2012 while performing CLABSI surveillance according to their usual routine. The definition was operationalized using the following surveillance algorithm. First, hospital staff evaluated all positive blood cultures from participating locations using a standardized worksheet. Using the NHSN criteria, hospital staff reported to the CDC the classification of blood cultures as healthcare-associated, primary, or secondary BSI and whether they were central line associated. When a CLABSI was identified, additional data were collected: whether the patient received an allo-SCT within the past year and the presence or absence of GI GVHD (including grade) and diarrhea (including quantity), daily ANC or WBC ranges for 10 days around the time of the positive blood culture(s), up to 3 organisms isolated, and whether hospital staff determined that the CLABSI also met the MBI-LCBI definition. Biweekly conference calls were conducted between the CDC and participants to answer questions and provide clarification when needed. In locations reporting to the NHSN, CLABSI events identified were entered into the NHSN system per the hospitals’ usual routines.
Submitted worksheets and case report forms were reviewed by CDC staff for completeness and errors and entered into an Access 2007 database (Microsoft Corporation). To assess whether hospital staff were correctly applying the MBI-LCBI definition, CDC staff also determined whether CLABSIs reported satisfied the MBI-LCBI definition using the information submitted on worksheets. Cohen’s κ statistic was used to assess the level of concurrence between the classification of CLABSIs as MBI-LCBIs by hospital staff and by CDC staff.
The distribution of organisms reported for all CLABSIs and those meeting the MBI-LCBI definition were examined. To evaluate whether the organisms included in the MBI-LCBI definition were appropriate, we assessed the frequency of all organisms among patients who met the MBI-LCBI patient criteria (irrespective of whether the MBI-LCBI organism criteria were met), compared with those who did not. Descriptive analysis was performed using SAS, version 9.2 (SAS Institute).
Human Subjects Review
No facility or patient identifiers were submitted to the CDC as part of this field test. The project was determined to be a nonresearch quality improvement project by the CDC. Determination of nonresearch status was made or institutional review board approval granted at participating hospitals and Emerging Infections Program sites as appropriate.
Participating Hospital and Location Characteristics
Thirty-eight acute care hospitals (8 cancer hospitals, 28 general hospitals, and 2 children’s hospitals) field-tested MBI-LCBI at 193 inpatient locations. Oncology and bone marrow transplant were the most common location types reporting data, representing 94 (49%) of the 193 locations (Table 1).
|No. (%) of CLABSIs|
|NHSN location type||No. (%) of locations (n = 193)||Meeting MBI-LCBI definition||Not meeting MBI-LCBI definition||Total|
|Oncology or bone marrow transplant||94 (49)||100 (45)||121 (55)||221|
|Adult ward||41 (21)||2 (8)||22 (92)||24|
|Adult critical care||38 (20)||0 (0)||24 (100)||24|
|Pediatrica||12 (6)||1 (12)||7 (88)||8|
|Step-down||8 (4)||0 (0)||5 (100)||5|
Classification of BSIs and MBI-LCBIs
During the field-testing period, hospital staff reviewed 906 positive blood culture episodes and reported 282 CLABSIs (Figure 1). For 278 (98.6%) of the CLABSIs, hospital staff reported whether the MBI-LCBI definition was met; hospital staff and CDC reviewers agreed on this classification for 251 CLABSIs (90.3% agreement; ). Among the 27 CLABSIs with discordant classifications, no consistent causes for disagreement were identified.
Of all 282 CLABSIs identified, 103 fulfilled the MBI-LCBI definition. The highest proportion of MBI-LCBI (100 [45%] of 221 CLABSIs) was reported from oncology and bone marrow transplant locations (Table 1). In comparison, few CLABSIs (5%) reported from other locations also fulfilled the MBI-LCBI definition.
CLABSI Organisms and MBI-LCBI Organism Criteria
A total of 313 organisms were reported in association with the 282 CLABSIs identified. Among all CLABSIs, coagulase-negative Staphylococcus species were the most commonly reported organisms (15.0% of organisms), followed by Enterococcus faecium (12.1%) and E. coli (11.5%). The most common organisms among MBI-LCBI cases were E. faecium (16.0%), E. coli (14.9%), and Klebsiella species and viridans group streptococci (7.4% each).
MBI-LCBI Patient Criteria
Of the 103 MBI-LCBI cases identified, only 9 (9%) occurred in patients with an allo-SCT in the past year and either grade 3–4 GI GVHD or 1 L or more of diarrhea in a 24-hour period (Table 2). In contrast, 94 (91%) of MBI-LCBIs occurred in patients who met one of the 2 neutropenia criteria; most (79 [77%] of the 103 MBI-LCBIs) occurred in patients with a single ANC or WBC value less than 100 cells/mm3 within 7 days prior to the collection date of the positive blood culture.
|Patient criteria||No. (%) of cases satisfying criteria (n = 103)|
|Allo-SCT criteriaa only||9 (9)|
|Grade 3–4 GI GVHD only||4 (4)|
|Diarrhea ≥1 L in a 24-hour period only||3 (3)|
|Both GI GVHD and diarrhea criteria||2 (2)|
|Neutropenia criteriab||94 (91)c|
|Single ANC or WBC value <100 only||31 (30)|
|Two ANC or WBC values <500 only||13 (13)|
|Both single ANC or WBC value <100 and 2 ANC or WBC values <500||48 (47)|
Evaluating MBI-LCBI Organisms
Among 168 CLABSIs from patients who met one of the 2 patient criteria of the MBI-LCBI definition (irrespective of whether the MBI-LCBI organism criteria were met), E. faecium and E. coli (16.0% and 12.6% of organisms, respectively) were the organisms most commonly reported for CLABSI (Table 3). In comparison, among 121 CLABSIs from patients who did not meet the MBI-LCBI definition’s patient criteria, these 2 organisms were less commonly reported, with a joint rank of sixth (7.2% of organisms). Conversely, among patients who met one of the 2 patient criteria of the MBI-LCBI definition, S. aureus and non-albicans Candida species ranked sixth and eighth (5.1% and 4.0% of organisms, respectively), but among those who did not meet the MBI-LCBI definition’s patient criteria, these organisms were more common and ranked second and third (10.1% and 9.4% of organisms, respectively).
|CLABSIs, % of organisms reported (rank)|
|Organism||Mucosal barrier injury patient criteria meta (n = 175 organisms among 168 CLABSIs)||Mucosal barrier injury patient criteria not meta (n = 138 organisms among 121 CLABSIs)|
|Enterococcus faecium||16.0 (1)||7.2 (6)|
|Escherichia coli||14.9 (2)||7.2 (6)|
|Coagulase-negative staphylococci||12.6 (3)||18.1 (1)|
|Klebsiella species||7.4 (4)||9.4 (3)|
|Viridans group streptococci||7.4 (4)||2.2 (11)|
|Staphylococcus aureus||5.1 (6)||10.1 (2)|
|Enterobacter species||4.6 (7)||2.9 (10)|
|Candida species, non-albicans||4.0 (8)||9.4 (3)|
|Pseudomonas aeruginosa||4.0 (8)||7.2 (6)|
|Enterococcus speciesb||4.0 (8)||2.2 (12)|
|Enterococcus faecalis||2.9 (11)||5.8 (9)|
|Candida albicans||NR||9.4 (5)|
Evaluating Documentation of MBI-LCBI Patient Criteria
Among patients with documentation of an allo-SCT in the past year, 59 CLABSIs occurred (Table 4). Of these, 19 occurred in patients documented to have GI GVHD, but for 9 (47%) of these patients the GVHD grade was not documented in the medical record. Among patients documented to have diarrhea 33 CLABSIs occurred, but the quantity of diarrhea was not documented in 18 (55%) of these cases.
|Characteristic||No. of cases with characteristic (n = 59)|
|Grade not documentedb||9|
|Quantity not documented||18|
|<1 L in a 24-hour period||6|
|≥1 L in a 24-hour period||9|
|Neither GI GVHD nor diarrhea||25|
During field testing, limitations regarding reporting of total WBC or ANC values by hospital laboratories were reported from some participating hospitals: (1) when the total WBC was below a critical value, the differential for the WBC was not reported, so the exact ANC was also not known, and (2) when the WBC was below a critical value, the exact WBC value itself was not reported (eg, if the WBC was less than 300 cells/mm3, the laboratory would report the WBC as “WBC less than 300 cells/mm3”).
In light of the above limitations with reporting of blood cell counts (and, consequently, use of the field-tested neutropenia criteria), the sensitivity and specificity of 15 alternative criteria (Figure 2) for identifying the desired neutropenic patient population were compared with the neutropenia criteria field-tested (used as the referent standard). Among all the alternative criteria evaluated, the best combination of sensitivity (95%) and specificity (95%) was found when using the following alternative criteria: 2 separate days with ANC or WBC less than 500 cells/mm3 during a 4-day period ending on the date the positive blood culture was collected.
MBI-LCBI was successfully field-tested in a variety of hospital types and locations, with hospital staff applying the MBI-LCBI definition correctly to more than 90% of reported CLABSI cases. These results demonstrate that despite adding complexity to surveillance, the MBI-LCBI definition can be accurately applied by staff performing CLABSI surveillance. Additionally, through field testing we identified important issues with MBI-LCBI surveillance criteria that were addressed prior to NHSN implementation.
Only a small proportion of reported MBI-LCBI cases occurred in patients fulfilling criteria related to allo-SCT. However, this might be falsely low. Among CLABSIs occurring in patients with an allo-SCT and with any GI GVHD or diarrhea documented, 56% did not have documentation of the GVHD grade or the quantity of diarrhea; therefore, hospital staff were unable to apply allo-SCT criteria to these cases. The inclusion of these clinical characteristics in the allo-SCT criteria is important to ensure that there is objective evidence of mucosal barrier injury. For example, a GVHD severity grade of 1–2 can be assigned to a patient with no gastrointestinal symptoms or only nausea.12 Reevaluation of these criteria might be needed as additional experience with the MBI-LCBI definition is gained.
Field testing also highlighted the need to modify the neutropenia criteria to improve the usability of the MBI-LCBI definition. Feedback from sites indicated that criteria based on an ANC or WBC cut point of 100 could not be applied consistently across facilities due to variation in methods for reporting low ANC or WBC values. Secondary analysis of the WBC and ANC values reported during field testing indicated that the modification of the field-tested neutropenia criteria to require 2 values of WBC or ANC less than 500 during the 3 days before or on the day the blood culture was collected had a high sensitivity (95%) and specificity (95%) for identifying the target population (Figure 2). Additionally, this modification decreases the burden of data collection, requiring review of blood cell counts over a 4-day instead of an 8-day period.
The organisms most commonly reported for CLABSI appeared to differ among patients who did and did not meet the MBI-LCBI patient criteria. For example, S. aureus, not included in the MBI-LCBI organism criteria, ranked second among patients who did not meet the MBI-LCBI patient criteria but was infrequent in patients who did. Organisms included in the MBI-LCBI organism criteria, such as E. faecium and E. coli, were the most common in patients who met the MBI-LCBI patient criteria and less common in patients who did not. However, Candida species, included in the MBI-LCBI organism criteria, were rarely reported in patients who met the MBI-LCBI patient criteria. This could be due to recommendations for antifungal prophylaxis in some of these patients.8,13,14 Thus, although our sample size is small, many of the organisms included in the MBI-LCBI definition appear to be more common among patients meeting the MBI-LCBI patient criteria. Larger-scale evaluation is needed to assess whether the differences observed during field testing are representative of larger trends and whether the MBI-LCBI organism criteria will require further modification.
Limitations of this field test should be noted. First, to gain maximal experience with the MBI-LCBI definition in the target population, field testing was performed in a convenience sample of hospitals and locations heavily biased toward inclusion of hematology/oncology and bone marrow transplant units. Therefore, these results are likely not generalizable to the NHSN or to hospitals and locations in the United States in general. For instance, although none of the 38 adult critical care units reported any cases of CLABSI fulfilling the MBI-LCBI definition, suggesting that the occurrence of mucosal barrier injury–related BSI may be rare in these locations, it is very possible that in hospitals other than those in the field test these infections do occur in patients cared for in critical care units. Second, data to calculate central line–associated MBI-LCBI rates were not collected, and thus the potential impact of excluding MBI-LCBI cases from CLABSI rates remains unknown. Third, this field test was not designed to assess how accurately the MBI-LCBI definition identifies BSIs that do not result from central lines; future study to assess this could be beneficial.
The results from field testing informed revisions to the MBI-LCBI definition that were incorporated into NHSN CLABSI surveillance in January 2013 (Box 1). During the first year of implementation, central line–associated MBI-LCBI cases will still be reported to the NHSN and included in calculations of CLABSI rates. Reported MBI-LCBI data will be useful for several purposes. For local use and quality improvement, facilities will be able to view overall CLABSI rates in addition to how many of their CLABSIs met the MBI-LCBI definition. In the future, facilities will be able to track their CLABSI rates including and excluding MBI-LCBI cases. Additionally, MBI-LCBI data reported to the NHSN during 2013 will also be used to evaluate the impact that excluding MBI-LCBIs from CLABSI surveillance data might have on CLABSI rates nationally. These data will be used to inform discussions with the Centers for Medicare and Medicaid Services and the National Quality Forum to determine the role of MBI-LCBI in the context of CLABSI quality measurement and public reporting as part of Centers for Medicare and Medicaid Services’ Hospital Inpatient Quality Reporting Program. Finally, as attention moves toward prevention of all healthcare-associated BSIs (not only those related to central line use), MBI-LCBI itself might become a future target for BSI prevention. Future work will be needed to identify strategies for supportive care and prevention of mucosal barrier injury that can reduce the incidence of MBI-LCBI.
An MBI-LCBI must meet the following criteria in a patient already determined to have an NHSN-defined LCBI:
Pathogen eligible for MBI-LCBI. At least one of the following criteria must be met:
At least 1 blood culture growing Bacteroides species, Candida species, Clostridium species, Enterococcus species, Fusobacterium species, Peptostreptococcus species, Prevotella species, Veillonella species, or Enterobacteriaceae
Blood cultures on at least 2 separate occasions growing viridans group streptococci no more than 2 days apart and
At least one of following signs and symptoms: fever (temperature more than 38°C), chills, or hypotension
Patient less than or equal to 1 year of age with at least one of the following signs or symptoms: fever (temperature more than 38°C, core), hypothermia (temperature less than 36°C, core), apnea, or bradycardia
No other organism isolated meeting the criteria for an NHSN-defined LCBI
Patient eligible for MBI-LCBI. At least one of the following criteria must be met:
Allogeneic hematopoietic stem cell transplant recipient within the past year with one of the following documented during same hospitalization as the positive blood culture:
Grade 3–4 gastrointestinal graft-versus-host disease
One liter of diarrhea or more in a 24-hour period (or 20 mL/kg or more in a 24-hour period for patients less than 18 years of age) with onset on or within 7 calendar days before the positive blood culture is collected
Neutropenia meeting the following criteria:
At least 2 separate days with absolute neutrophil count or total white blood cell count less than 500 cells/mm3 within 3 calendar days before or on the day of collection of the positive blood culture
In the current era of public reporting of healthcare-associated infections as quality measures, the implementation of MBI-LCBI represents an important step toward ensuring the reliability and clinical relevance of CLABSI surveillance data.
We thank the members of the MBI-LCBI Field Test Working Group for their instrumental roles in collecting data (Twyla Anderson, RN, COHNS, CIC, Memorial Medical Center; Art Ashby, RN, CIC, Legacy Good Samaritan Medical Center; Natalie Bell, RN, MSN, OCN, Memorial Sloan Kettering Cancer Center; Connie Bryant, RN, BSN, CIC, Emory Healthcare; Alicia P. Budd, MPH, CIC, Johns Hopkins Medical Institutions; Laura Bunner, RN, CIC, Howard County General Hospital; David P. Calfee, MD, MS, Weill Cornell Medical College; Susan Cali, MSN, RN, MHA, Emory University Hospital Midtown; Jean-Marie Cannon, BSN, RN, CIC, New York Presbyterian Hospital, Weill Cornell Medical Center; Roy Chemaly, MD, M. D. Anderson Cancer Center; Teresa Childers, MPH, Memorial Sloan Kettering Cancer Center; Gretchen Copeland, EdD, RN, OCN, Memorial Sloan Kettering Cancer Center; Louise M. Dembry, MD, MS, MBA, Yale–New Haven Hospital; Jeanne A. Dickman, BS, MT(ASCP), CIC, James Cancer Hospital at the Ohio State University Wexner Medical Center; Susan Diskin, RN, BSN, Legacy Good Samaritan Medical Center; Janet Eagan, RN, MPH, CIC, Memorial Sloan Kettering Cancer Center; Mala B. Filippell, RN, BSN, CIC, University of Maryland Medical Center; Annemarie Flood, RN, BSN, CIC, City of Hope; Jacqueline A. Galluzo, RN, BSN, CIC, the Johns Hopkins Hospital; Mary Anne Giannini, MT, CIC, St. Jude Children’s Research Hospital; Joelle L. Glass, BS, CPhT, Sinai Hospital of Baltimore; Kimberly M. Hinckley, RN, BSN, CIC, Roswell Park Cancer Institute; Darci E. Hodge, RN, BSHA, CIC, East Tennessee Children’s Hospital; Candace Hsieh, RN, CIC, Dana Farber Cancer Institute; Jesse T. Jacob, MD, Emory University School of Medicine; Theresa Lafferty, RN, MSHA, Fox Chase Cancer Center; Surbhi Leekha, MBBS, MPH, University of Maryland School of Medicine; Gale M. Liddell, BS, MT, CIC, Roswell Park Cancer Institute; Christina T. Liscynesky, MD, Ohio State University Wexner Medical Center; Julie E. Mangino, MD, Ohio State University Wexner Medical Center; Vanessa A. Makarewicz, RN, MN, University of Washington Medical Center; Jennie L. Mayfield, BSN, MPH, CIC, Siteman Cancer Center, Barnes–Jewish Hospital/Washington University School of Medicine; Patsy McFadden, RN, BSN, MPA, CIC, Centennial Medical Center; James Meek, MPH, Connecticut Emerging Infections Program, Yale School of Public Health; Kim U. Nguyen, MT(ASCP), CIC, M. D. Anderson Cancer Center; Barbara O’Connor, RN, MSN, CIC, Howard County General Hospital; Susan O’Rourke, RN, CIC, Dana Farber Cancer Institute; Janett A. Pike, RN, BSN, CIC, New York Presbyterian Hospital, Weill Cornell; Katherine M. Roberts, BA, Memorial Sloan Kettering Cancer Center; Chad J. Robichaux, Emory Healthcare; Karin S. Rogers, RN, BSN, Seattle Children’s Hospital; Mary M. Shanks, RN, MSN, CIC, Providence St. Vincent Medical Center; Gloria N. Sliemers, BS, MT, James Cancer Hospital at the Ohio State University Wexner Medical Center; Crystal Son, MPH, Memorial Sloan Kettering Cancer Center; Madhuri M. Sopirala, MD, MPH, University of Cincinnati College of Medicine; Janet M. Sullivan, RN, BSN, CIC, Sacred Heart Medical Center at Riverbend; Linda K. Sullivan, RN, MBA, CIC, Yale–New Haven Hospital; Elise Tamplin, M(ASCP), MPH, CIC, Brigham and Women’s Hospital; Dana Trocino, RN, CIC, Kaiser Permanente Northwest; Shauna Usiak, MPH, Memorial Sloan Kettering Cancer Center; Jay B. Varkey, MD, Emory University School of Medicine; Nancy P. Whittington, RN, CIC, University of Washington Medical Center; Cindy York, RN, CIC, Baptist Memorial Hospital; Teresa E. Zaroda, RN, Ronald Reagan UCLA Medical Center) and recruiting facilities for participation (Adebola O. Ajao, PhD, Tennessee Department of Health; Zintars G. Beldavs, MS, Oregon Health Authority; Ghinwa Dumyati, MD, Center for Community Health, University of Rochester; Marion A. Kainer, MBBS, MPH, Tennessee Department of Health; Richard Melchreit, MD, Connecticut Department of Public Health; Gail A. Quinlan, RN, MS, CIC, University of Rochester, Center for Community Health, Emerging Infections Program; Susan M. Ray, MD, Emory University School of Medicine; Katherine M. Richards, MPH, Maryland Department of Health and Mental Hygiene; Deborah L. Thompson, MD, MSPH, FACPM, New Mexico Department of Health; and the Yale–New Haven Hospital epidemiology staff).
Financial support. This study was supported through a cooperative agreement with the Emerging Infections Program of the Centers for Disease Control and Prevention.
Potential conflicts of interest. All authors report no conflicts of interest relevant to this article. All authors submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest, and the conflicts that the editors consider relevant to this article are disclosed here.
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