Computerized clinical decision support (CCDS) significantly reduced Clostridioides difficile testing at 3 hospitals; from 12.6 to 9.5, from 10.1 to 6.4, and from 14.0 to 9.6 average weekly tests per 1000 inpatient days. There were no related adverse events. Senior providers were more likely than interns or residents to follow CCDS.

No abstract

f This case series highlights our experience with use of the Fungitell assay for quantifying (1,3)-␤-D-glucan in cerebrospinal fluid during the current U.S. outbreak of fungal meningitis related to contaminated methylprednisolone acetate. This test may prove a useful adjunct in diagnosis and management of exposed patients.(1,3)-␤-D-glucan (BG) is found in cell walls of multiple fungi. Its detection in serum assists in diagnosis of invasive fungal infections (1). Recently, diagnostic challenge has arisen in the fungal meningitis outbreak associated with exposure to contaminated epidural steroid injections (2). Diagnosis in this setting has been established by culture of cerebrospinal fluid (CSF) and/or detection using a pan-fungal PCR assay performed by the Centers for Disease Control (CDC). However, these tests have not always been positive in suspected cases (3). One early study has demonstrated the proof of concept of using CSF BG detection in diagnosis of fungal central nervous system infection in an experimental hematogenous Candida meningoencephalitis model (4). Here we report our experience with CSF BG measurement in 5 individuals from Johns Hopkins Hospital and Indiana University Hospital who were exposed to potentially contaminated drugs. Cases were diagnosed and managed according to CDC guidelines. BG was tested at Beacon Diagnostics Laboratory (East Falmouth, MA) using the Fungitell assay. Information was obtained by chart review with approval from the Johns Hopkins Institutional Review Board.The first case was a 55-year-old woman who developed headaches, blurred vision, and injection site pain 1 week after lumbar epidural injection with potentially contaminated methylprednisolone and was admitted 35 days after symptom onset when the outbreak was recognized. CSF showed 30 white blood cells (WBCs)/mm 3 and normal glucose and protein; no opening pressure was recorded. Intravenous voriconazole was initiated, but symptoms continued despite troughs of 2 to 3 g/ml. Repeat lumbar puncture (LP) showed opening pressure of 42 cm H 2 O, 974 WBC/mm 3 (56% neutrophils, 16% lymphocytes, 21% monocytes), 1,000 red blood cells (RBCs)/mm 3 , normal glucose, and 93 mg/dl protein, with a negative culture. CSF PCR performed by the CDC was negative. With serial LPs for persistent headache and elevated opening pressures and voriconazole increase to maintain troughs of 3 to 5 g/ml, her symptoms resolved. CSF fungal cultures from postinjection days 57, 69, and 73 were negative. CSF BG samples sent on postinjection days 57 and 73 were positive at 2,396 and 701 pg/ml, respectively (Table 1).The second case was a 37-year-old man who underwent lumbar epidural injection with potentially contaminated methylprednisolone and developed a headache several days later. Thirteen days after the injection he started oral voriconazole. His symptoms did not improve, and LP 2 weeks later showed 5 WBCs/mm 3 ( Table 1). PCR performed by the CDC and fungal cultures were negative. Magnetic resonance imaging (MRI) of the brain showed a small intrapa...