No abstract

Background Outsourcing of microbiology laboratory services is a growing trend in US medical centers. Data on the actual impact of outsourcing on patient care, safety, and medical education, including costs, are limited. The objective of this study was to examine the published literature on the potential benefits and harms when medical centers outsource common microbiology services. Methods We conducted a 16-step literature search of PubMed and Embase. Articles were selected for full-text review if their content matched our key questions: (1) What are the potential benefits of outsourcing core microbiology laboratory testing? (2) What are the potential harms to patient care and medical education when medical centers outsource essential microbiology services? Results The initial search yielded 6111 unique published articles; 36 were selected for full-text review, which resulted in the identification of 8 articles that addressed our key questions (2 editorials, 3 editorials with observational data, 1 survey, 1 case series, and 1 study of blood culture transport). These articles described a variety of issues, including longer turnaround times for blood cultures that resulted in delays in diagnosis and treatment, errors that resulted in patient morbidity, limited cost savings, and communication barriers. Conclusions In this study, with the exception of the blood culture transport study, we found no published prospective studies that quantified the effects of outsourcing microbiology services on patient care, patient safety, or medical education. However, these largely anecdotal reports suggest that outsourcing microbiology services may have a detrimental impact on medical education, especially infectious disease training programs.

BackgroundCMV is the most common non-hereditary cause of sensorineural hearing loss (SNHL) in children in the United States. SNHL may be the only presenting symptom in otherwise asymptomatic infants. Several states are making CMV testing mandatory for newborn infants who have a hearing deficit. Testing should be performed before 21 days of life to diagnose congenital CMV infection and provide effective therapy. However, the results of a retrospective 1 year audit of all newborn patients in the nursery of University Hospital of Brooklyn (UHB) who failed their hearing screen found that none were tested for CMV and approximately half failed to follow-up with audiology. Therefor we developed a new protocol to ensure testing and follow-up.MethodsUnder the new protocol, newborns who fail an initial and repeat hearing screen are tested for CMV in urine by culture and the audiology appointment is scheduled before discharge. Patients are tracked by a pediatric infectious disease fellow to ensure adherence to protocol.ResultsThe pre-intervention audit conducted from November 1, 2017 to October 31, 2018 found 37/923 (4%) infants failed their hearing screening tests. Although 34/37 (92%) of these children had audiology appointments made before discharge, only 19 (56%) actually attended. Two (11%) children failed an otoacoustic emissions hearing test. One infant also went on to fail an auditory brainstem response test; both were lost to follow-up. None of these infants was tested for CMV. The new protocol was initiated November 1, 2018, 11/372 (3%) infants failed initial and repeat hearing screening tests. All 11 (100%) of these children had audiology appointments made before discharge, of which 9 (82%) attended. 2 (18%) of these children failed the otoacoustic emissions hearing test at that visit, 1 infant was lost to follow-up; 9 infants who failed hearing test were tested for CMV; 1 (9%) was positive.ConclusionAlthough it has only been in place for 5 months, the new protocol has increased adherence to audiology appointments. CMV testing has increased from 0% to 82% and 1 patient has tested positive for congenital CMV infection. The ongoing success of this protocol could facilitate timely and appropriate treatment of CMV with valgancyclovir. Disclosures All authors: No reported disclosures.

Chlamydia pneumoniae is an obligate intracellular bacterium that causes respiratory infection in adults and children. There may exist an association between atypical bacterial pathogens (C. pneumoniae, Mycoplasma pneumoniae) and asthma, as well as production of immunoglobulin (Ig) E responses in vitro. Previous studies in our laboratory demonstrated that doxycycline suppresses C. pneumoniae-induced production of IgE in peripheral blood mononuclear cells (PBMC) from IgE+ allergic asthmatic subjects. Whereas macrolides have anti-chlamydial activity, their effect on anti-inflammatory (IgE) responses to C. pneumoniae has not been studied. METHODS: Total serum IgE levels were assayed (ELISA). PBMC (1.5 x 10 6) from IgE negative adult atopic subjects (N55) were infected +/-C. pneumoniae BAL69 (multiplicity of infection of 0.1), +/-azithromycin (0.1, 1.0 ug/mL) for 10 days. IgE levels were determined in supernatants by ELISA. A single unequivocally positive skin test, or history of atopic dermatitis or allergic rhinitis defined atopy. RESULTS: Total serum IgE levels were low in all subjects (<100 IU/mL). IgE was detected in supernatants of PBMC on day 10. When azithromycin (0.1 ug/ml) was added to cultures, IgE levels increased (50%), but when azithromycin (1.0 ug/mL) was added IgE levels decreased (38%). When PBMC were infected with C. pneumoniae, IgE levels decreased (63%). Addition of azithromycin (0.1, 1.0 ug/mL) had no effect on IgE levels (0-3%). CONCLUSIONS: These findings indicate that azithromycin had a bimodal affect on IgE responses in PBMC from atopic patients in vitro and may have immunomodulatory properties. However, azithromycin doesn't modulate C. pneumoniae-induced production of IgE.

RATIONALE: Expression of both co-inhibitory and co-stimulatory molecules is a key feature of antigen-presenting cells which allow initiation or suppression of T-cell activation. Excessive expression of coinhibitory molecules may be associated with tolerogenic properties of dendritic cells (DC). Expression of B7-family of co-inhibitory molecules by DC was assessed. METHODS: Blood samples from 14 patients with stage II-III pancreatic cancer were studied. Monocyte-derived dendritic cells were obtained. Expression of CD273 (B7-DC), CD274 (B7-H1), CD275 (B7-H2), CD276 (B7-H3), B7-H4, B7-H5 and B7-H6 molecules was assessed by FCM. CaCo-2 cell line served as a positive expression control. RESULTS: Expression of CD276 molecule was approximately 100% (99.1; range 98.6 to 99.7) with high MFI (53.6; range 42.5 to 92.7). CD274 expression was 60.5 % (range 53.6 to 66.9 %). Only 23.6% (range 20.6 to 38.3 %) of DC expressed CD273 and CD275 + DC varied from 11.8% to 30.0% (median 14.8%). The expression of B7-H4, B7-H5 and B7-H6 was absent in the majority of DC. Only 2 DC samples expressed B7-H4 (2.6% and 3.1%), and 2 other samples of DC had noticeable B7-H5 expression (3.0% and 4.2%). B7-H6 was seen only in one DC sample at 9.6%. CONCLUSIONS: CD274 and CD276 are constitutive for DC while expression of CD273 and CD275 is present in relatively low numbers of DC. Expression of B7-H4, B7-H5 and B7-H6 is also present in some of the DC samples in pancreatic cancer. The expression of these molecules by dendritic cells in pancreatic cancer patients may impact disease course.