Author Interviews, Breast Cancer, Cancer Research, JAMA, MRSA, Radiation Therapy / 06.05.2023

MedicalResearch.com Interview with: Beth McLellan, M.D. Chief, Division of Dermatology Montefiore Medical Center Albert Einstein College of Medicine MedicalResearch.com: What is the background for this study? How is the decolonization initiated and maintained? Response: We were interested in exploring whether bacteria on the skin plays a role in radiation dermatitis like it does in other skin diseases that cause a breakdown in the skin barrier. We used a bacterial decolonization regimen that includes chlorhexidine 2% cleanser for the body and mupirocin 2% ointment to the inside of the nose for 5 consecutive days before starting radiation therapy and repeated for an additional 5 days every other week for the duration of radiation. (more…)
Author Interviews, Lancet, MRSA, NIH / 18.01.2023

MedicalResearch.com Interview with: Michael Otto PhD Senior Investigator Laboratory of Bacteriology Chief of the Pathogen Molecular Genetics Section NIAID, NIH Bethesda, MD 20814 MedicalResearch.com: What is the background for this study? Response:  Staphylococcus aureus is one the of the most important causes of infectious diseases worldwide. It is known mostly for causing skin infections in the community and as a hospital-associated pathogen. It is in fact the most frequent cause of infections patients acquire in the hospital when they are weakened by underlying diseases or immune-suppressing therapy. The type of infections Staph can cause in these situations are diverse – comprising bone, lung, and blood infections (sepsis) - and can be quite severe and often fatal. Except for moderately severe skin infections that may not require antibiotic treatment, treatment of Staph infections is by antibiotics. S. aureus has naturally been very responsive to penicillin-type antibiotics, but already in the mid of the last century, resistance to penicillin spread worldwide. Then, methicillin was invented to overcome this resistance, but nowadays there also is considerable spread of methicillin-resistant strains (MRSA). The current situation is difficult for two reasons:
  • First, S. aureus has become increasingly resistant to many antibiotics, and
  • Second, the alternatives to methicillin are often by far not as efficient as penicillin/methicillin against Staph.
Researchers have therefore been searching for alternatives to antibiotics to treat Staph infections. Unfortunately, vaccines that work against Staph have not yet been produced despite intensive efforts for decades. Other modern approaches of treatment, like virulence-targeted drugs or phages are still only at the early investigational level. As with many diseases, an alternative to treatment is prevention. In the case of S. aureus, a type of preventative strategy that has often been proposed and tested is decolonization. This is based on the fact that ~ 1/3 of the population is naturally colonized with S. aureus (asymptomatically), and these colonized people have an increased risk of being infected. In other words, Staph infections stem from the Staph you carry on your body and which only under certain conditions causes infection. Thus, eliminating the colonizing Staph would reduce the risk for infection, which is the basis for Staph decolonization-based infection prevention strategies. (more…)
Author Interviews, Infections, MRSA, NIH, Probiotics / 12.10.2018

MedicalResearch.com Interview with: "staph aureus on blood agar" by Iqbal Osman is licensed under CC BY 2.0Pipat Piewngam Postdoctorol fellow Pathogen Molecular Genetics Section, Laboratory of Bacteriology, NIAID/NIH Bethesda, MD, USA 20892  MedicalResearch.com: What is the background for this study? What are the main findings?  Response: Our team at National Institutes of health, Mahidol University and Rajamangala University of Technology in Thailand has reported that the consumption of probiotic Bacillus bacteria comprehensively abolishes colonization with the dangerous pathogen, Staphylococcus aureus. We hypothesized that the composition of the human gut microbiota affects intestinal colonization with S. aureus. We collected fecal samples from 200 healthy individuals from rural populations in Thailand and analyzed the composition of the gut microbiome by 16S rRNA sequencing. Surprisingly, we did not detect significant differences in the composition of the microbiome between S. aureus carriers and non-carriers. We then sampled the same 200 people for S. aureus in the gut (25 positive) and nose (26 positive). Strikingly, we found no S. aureus in any of the samples where Bacillus were present. In mouse studies, we discovered S. aureus Agr quorum-sensing signaling system that must function for the bacteria to grow in the gut. Intriguingly, all of the more than 100 Bacillus isolates we had recovered from the human feces efficiently inhibited that system. Then, we discovered that the fengycin class of Bacillus lipopeptides achieves colonization resistance by inhibiting that system. To further validate their findings, we colonized the gut of mice with S. aureus and fed them B. subtilis spores to mimic probiotic intake. Probiotic Bacillus given every two days eliminated S. aureus in the guts of the mice. The same test using Bacillus where fengycin production had been removed had no effect, and S. aureus grew as expected. This is one of the first study that provide human evidence supporting the biological significance of probiotic bacterial interference and show that such interference can be achieved by blocking a pathogen’s signaling system. (more…)
Author Interviews, MRSA / 05.10.2018

MedicalResearch.com Interview with: Kathryn Dalton, VMD MPH AKC CHF Fellow PhD Student, Davis Lab Environmental Health and Engineering Johns Hopkins Bloomberg School of Public Health MedicalResearch.com: What is the background for this study? What are the main findings? Response: Animal-assisted interventions (or AAI for short) have become increasing popular in hospitals for the emotional and physical benefits they bring to patients. But there is a risk that these therapy dogs could potential spread infectious germs, including MRSA (methicillin-resistantStaphylococcus aureus), to patients. Our study found that therapy dogs can spread MRSA to patients, and children who had more contact with the therapy dog were at higher risk of getting MRSA. But, we used a new cleaning protocol on the dog with an anti-septic shampoo before the visit and anti-septic wipes during the visit. Patients who had more contact with the dog did not have a higher risk of MRSA when the dog was giving this new cleaning protocol, which made the AAI therapy visits safer for the patients. In addition, the patients’ emotional and physical benefits we observed were not changed by using this dog cleaning protocol.       (more…)
Author Interviews, Hand Washing, Infections, MRSA, Pediatrics / 15.06.2018

MedicalResearch.com Interview with: “Bart Infant” by Bart Everson is licensed under CC BY 2.0Gwen M. Westerling, BSN, RN, CIC Infection Preventionist Helen DeVos Children's Hospital MedicalResearch.com: What is the background for this study? Response: The setting of this study is a Level III Neonatal Intensive Care Unit (NICU) with 106 beds. In 2016, an increase in Hospital Acquired Infections (HAI) was noted in the Neonatal Intensive Care Unit (NICU) caused by Staphylococcus aureus (SA) through diligent Infection Prevention Surveillance. When we reviewed the literature we found the SA is a common skin colonizer and can be a problem for neonates with immature skin and immune systems. Staphylococcus aureus is easily transmitted through direct contact with skin, the contaminated hands of health care workers, the environment and equipment. We also found one study that listed skin to skin care as a risk factor for acquisition of SA. Before we saw the increase in infections some process changes occurred in our NICU that included increased skin to skin care, meaningful touch between neonates and parents, and two person staff care. We hypothesized that the process changes were exposing neonates to increased amounts of Staphylococcus aureus and contributing to the increase in infections. (more…)
Author Interviews, Infections, MRSA / 04.10.2017

MedicalResearch.com Interview with: Mr. Jonathan Shahbazian, MPH Johns Hopkins Bloomberg School of Public Health Baltimore MedicalResearch.com: What is the background for this study? What are the main findings? Response: Our study was designed to investigate risk factors for drug resistance in MRSA found in dust on surfaces in the home. We undertook this investigation because we were concerned first that people living in the home could pick up MRSA from these surfaces, and second, that if they picked up drug-resistant MRSA, it would be more difficult to treat them. Our main finding was that use of antibiotics by either people or pets in the home, as well as use of biocidal cleaning products, was associated with multidrug resistance (MDR) in home MRSA. This study is the first to report that use clindamycin in either humans or domestic animals was not associated with risk of MDR in the home environment. We also found that mupirocin treatment was associated with a slight increase in mupirocin resistance in the household environment, which could complicate decolonization efforts that rely on use of nasal mupirocin ointment. We found that 100% of our MRSA isolates from rural homes were MDR, suggesting living in a rural household may be a risk factor. We also found the presence of domestic pets was associated with MDR MRSA in the home environment while the presence of unwanted pests, such as mice or cockroaches, was associated with non-MDR MRSA strains at the three-month visit. (more…)
Author Interviews, Infections, MRSA, Nature / 03.12.2016

MedicalResearch.com Interview with: Ferric C. Fang, M.D. Professor of Laboratory Medicine and Microbiology Adjunct Professor of Medicine (Infectious Diseases) Director, Harborview Medical Center Clinical Microbiology Laboratory University of Washington School of Medicine Seattle, WA MedicalResearch.com: What is the background for this study? What are the main findings? Response: The Fang lab has a longstanding interest in the interaction between nitric oxide (NO·) and pathogenic bacteria. NO· is an important mediator of the host innate immune response that restricts the growth of invading bacterial pathogens. One of the known actions of NO· is the reversible inhibition of aerobic respiration that results from NO· binding to the heme centers of terminal oxidases. Like mammalian hosts, many bacteria also possess the ability to enzymatically synthesize NO·. Our latest research investigated the physiological role of the Staphylococcus aureus nitric oxide synthase (saNOS). We discovered that endogenously produced NO· is able to target bacterial terminal oxidases under microaerobic conditions, allowing the bacteria to transition to nitrate respiration when oxygen concentrations are limited and helping to maintain the membrane potential. This process was found to be essential for S. aureus nasal colonization in a mouse model. Thus, a conserved mechanism is involved in both the antimicrobial actions of NO· and the physiological role of NO· in regulating bacterial electron transfer reactions. Interestingly, NO·-heme interactions have been shown to control mitochondrial respiration during hypoxia in mammalian cells. (more…)
Author Interviews, Infections, MRSA, NIH, Science / 01.12.2016

MedicalResearch.com Interview with: Warren Leonard, M.D. NIH Distinguished Investigator Laboratory of Molecular Immunology NHLBI, NIH MedicalResearch.com: What is the background for this study? Response: TSLP is a cytokine that has been well studied in the context of T cell helper type 2 (TH2) responses and the promotion of atopic diseases. TSLP is naturally expressed at barrier surfaces, such as the skin; however, its role in skin infections was not previously explored. In our study, we investigated whether TSLP plays a role in host defense to Staphylococcus aureus skin infections, using the most common strain of methicillin-resistant S. aureus (MRSA) present in the United States. (more…)
Author Interviews, CDC, MRSA / 15.09.2015

MedicalResearch.com Interview with: Dr. Lauren Epstein M.D., M.S. Division of Healthcare Quality Promotion Epidemic Intelligence Service Centers for Disease Control and Prevention Atlanta, GA, USA  Medical Research: What is the background for this study? What are the main findings? Dr. Epstein: Nearly 80% of methicillin resistant Staphylococcus aureus (MRSA) infections occurs outside of the hospitals and mostly among individuals with a recent hospitalization.  However, risk factors for MRSA infections among patients recently discharged from an acute care hospital have not been well explored.   The goal of this study was to identify modifiable risk factors associated with MRSA infections among recently discharged patients to target future prevention efforts.  We found that patients with a history of MRSA colonization, chronic wounds, invasive devices at discharge such as central lines and surgical drains, and those discharged from a hospital to a nursing home are at increased risk of invasive MRSA infections within 12 weeks after hospital discharge. Medical Research: What should clinicians and patients take away from your report? Dr. Epstein: MRSA infections are a significant public health concern and patients remain at risk for MRSA infections following acute care hospitalizations, especially in the 3 months following discharge from an acute care facility. Patients with a prior history of MRSA colonization are at increased risk for MRSA infections following an acute care hospitalization.  In addition, patients who have an invasive device (such as a central line or surgical drain) or a chronic wound at the time of discharge from a hospitalization are at increased risk of MRSA infection following discharge.  Finally, patients who are discharged to a long term care facility, regardless of other risk factors, are at increased risk of MRSA infection. (more…)
Author Interviews, MRSA, NEJM / 20.03.2015

Loren G. Miller, M.D., M.P.H. Los Angeles Biomedical Research Institute (LA BioMed) Infectious Disease SpecialistMedicalResearch.com Interview with: Loren G. Miller, M.D., M.P.H. Los Angeles Biomedical Research Institute (LA BioMed) Infectious Disease Specialist   Medical Research: What is the background for this study? Dr. Miller: Skin and skin structure infections are extremely common reasons for persons to seek medical care in the U.S., accounting for approximately 14.2 million outpatient visits in 2005, the latest year for which statistics are available, and 850,000 hospital admissions. Until this study was completed, the most effective approach to outpatient antibiotic treatment of uncomplicated skin infections in the era of community-acquired methicillin-resistant Staphylococcus aureus (MRSA) was unclear. Prior to this research, there were no data on which antibiotics were best for treatment of these common skin infections. Medical Research: What are the main findings? Dr. Miller: Two antibiotics frequently prescribed to treat serious skin infections - clindamycin and trimethoprim sulfamethoxazole (TMP-SMX) - had similar rates of success in curing uncomplicated infections in outpatients. They also had similar rates of side effects. To conduct the study, we recruited outpatients from emergency departments, clinics and other healthcare facilities associated with Los Angeles County's Harbor-UCLA Medical Center, University of Chicago Medical Center, San Francisco General Hospital and Vanderbilt University Medical Center from May 2009 to August 2011. We studied 524 adults and children with uncomplicated skin infections who had cellulitis, abscesses of 5 centimeters or more or both. In the multicenter, double blind, randomized clinical trial, 264 received clindamycin and 260 received TMP-SMX. We followed the outpatients for a month after their treatment. We found similar outcomes for both groups - 80.3% of the outpatients who received clindamycin and 77.7% of the outpatients in the group that received TMP-SMX were cured within seven to 10 days after the end of their treatment. These are not considered significant differences, so our evaluation is that these two commonly prescribed antibiotics for serious skin infections are similarly effective in treating uncomplicated skin infections in children and adults who have few or no major co-existing conditions. (more…)
Author Interviews, MRSA, University of Pennsylvania / 17.02.2015

MedicalResearch.com Interview with: Valerie Cluzet, MD Hospital of the University of Pennsylvania Division of Infectious Diseases Philadelphia, PA 19104 MedicalResearch: What is the background for this study? What are the main findings? Dr. Cluzet: MRSA is a major cause of skin and soft tissue infection (SSTI) in the community and we know that colonization is an important risk factor for subsequent infection. Past studies have calculated duration of colonization based on colonization at hospital admission or focused on populations not representative of the typical community-dwelling patient. We wanted to identify the factors associated with duration of colonization in a typical patient that clinicians would see (i.e. adults and children presenting to ambulatory setting with a MRSA SSTI), so that the findings would be generalizable and relevant to their practice. In addition, there has been an increasing focus on the role of the household in transmission of MRSA, so wanted to specifically examine that in a longitudinal, systematic way. There are a few major points that emerged from our study. 1) The first is that the duration of colonization after treatment for a methicillin-resistant Staphylococcus aureus (MRSA) skin and soft tissue infection (SSTI) is relatively short, but there is a significant subset of patients (approximately 20%) who will have persistent colonization. 2) We also found that treatment of the MRSA SSTI with clindamycin was associated with shorter duration of colonization, an association we did not see with other MRSA-active agents. 3) Finally, this study highlights the potential role of MRSA colonization among household members as a contributing factor in duration of colonization in patients. (more…)
Author Interviews, MRSA, PNAS, UCLA, Vaccine Studies / 14.12.2014

Dr. Michael Yeaman Ph.D. Professor of Medicine, Infectious Disease Specialist Chief, Division of Molecular Medicine David Geffen School of Medicine at UCLA Los Angeles Biomedical Research Institute at Harbor-UCLA Medical CenterMedicalResearch.com Interview with: Dr. Michael Yeaman Ph.D. Professor of Medicine, Infectious Disease Specialist Chief, Division of Molecular Medicine David Geffen School of Medicine at UCLA Los Angeles Biomedical Research Institute Harbor-UCLA Medical Center Medical Research: What is the background for this study? What are the main findings? Dr. Yeaman: In the U.S. and around the globe, skin and soft tissue infections caused by methicillin-resistant Staphylococcus aureus (MRSA) continue to endanger the health and lives of patients and otherwise healthy individuals. Treatment is difficult because MRSA is resistant to many antibiotics, and the infections can recur, placing family members and other close contacts at risk of infection. Infectious disease specialists at the Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center (LA BioMed) tested a new investigational vaccine, NDV-3, and found it holds new hope for preventing or reducing the severity of infections caused by the "superbug" MRSA. In the study, which was published Dec. 8 in the Proceedings of the National Academy of Sciences USA, the researchers reported that NDV-3, employing the recombinant protein Als3, can mobilize the immune system to fight off MRSA skin infections in an experimental model. The researchers found the vaccine works by enhancing molecular and cellular immune defenses of the skin in response to MRSA and other S. aureus bacteria in disease models. This is the first published study to demonstrate the effectiveness of a cross-kingdom recombinant vaccine against MRSA skin infections. NDV-3 is unique as it is the first vaccine to demonstrate it can be effective in protecting against infections caused by both S. aureus and the fungus Candida albicans. NDV-3 represents a novel approach to vaccine design that pioneers an approach termed convergent immunity. (more…)
Author Interviews, MRSA / 05.11.2014

Melissa Ward PhD CIIE Research Fellow Centre for Immunity, Infection and Evolution University of EdinburghMedicalResearch.com Interview with: Melissa Ward PhD CIIE Research Fellow Centre for Immunity, Infection and Evolution University of Edinburgh   Medical Research: What is the background for this study? What are the main findings? Dr. Ward: We studied a strain of the bacterium Staphylococcus aureus known as CC398, which can colonise and cause MRSA infection in humans and livestock. People and animals generally harbour genetically distinct variants of CC398, but we found human isolates, including a small number from Scottish hospitals, which were more similar to the livestock strains. Such isolates were resistant to a larger number of antibiotics than the CC398 strain which typically circulates in humans. By looking at the genetic sequences of strains from across the globe, we also inferred that CC398 has entered Scotland on multiple occasions. (more…)
Cost of Health Care, MRSA / 08.10.2014

https://medicalresearch.com/cost-of-health-care/id_week_14_universal_mrsa_screening_may_be_too_expensive_to_implement/8166/Medical Research’s Interview with: James A. McKinnell, MD Los Angeles Biomedical Research Institute   Medical Research: What are the main findings of the study? Dr. McKinnell: Numerous experts and policy makers have called for hospitals to screen patients for methicillin-resistant Staphylococcus aureus (MRSA) infections and isolate anyone testing positive to prevent the spread of these so-called “Superbugs” in healthcare settings. Several states have enacted laws requiring patients be screened for MRSA upon admission. We conducted two studies, both of which were presented as abstracts at IDWeek, the annual scientific meeting for infectious disease specialists, which found universal MRSA screening and isolation of high-risk patients will help prevent MRSA infections but may be too economically burdensome for an individual hospital to adopt. Researchers at Los Angeles Biomedical Research Institute, the University of California, Irvine and John Hopkins University examined the cost of a hospital infection prevention strategy that tested all patients for MRSA and then took precautions to avoid contact with potential carriers. We found that using the traditional method of testing for MRSA in the nose, or nares surveillance, and then isolating MRSA carriers prevented nearly three MRSA infections. But it cost the hospital $103,000 per 10,000 hospital admissions. More extensive screening, through the use of other testing methods, which included PCR-based screening, prevented more infections, but increased the cost. In the second study, we also evaluated the cost of a hospital infection prevention strategy that targeted high-risk patients. Again, we found the costs of the program exceeded the potential savings to the hospital that would be generated by preventing MRSA infections. We found nares screening and isolation of high-risk patients prevented fewer than one infection (0.6) per 1,000 high-risk admissions to the hospital and created a financial loss of $36,899 for the hospitals. Using more extensive MRSA screening – which included nares, pharynx and inguinal folds screening – prevented slightly more infections (0.8 infections per 1,000 high-risk admissions), according to the study. But our abstract reported an even larger financial loss of $51,478 with the more extensive screening. (more…)
Author Interviews, MRSA / 15.08.2014

dr_kyle_popovichMedicalResearch.com Interview with: Kyle J. Popovich, MD, MS Rush University Medical Center Stroger Hospital of Cook County, Chicago, Illinois   Medical Research: What are the main findings of the study? Dr. Popovich: Colonization with methicillin-resistant Staphylococcus aureus (MRSA) at body sites outside the nares was common, with more than half of all colonized individuals having MRSA colonization in the rectal or groin areas.  Resistance to mupirocin was uncommon and molecular testing showed no signs of resistance to chlorhexidine gluconate. (more…)
Author Interviews, MRSA / 05.06.2014

Dr. Brad Spellberg MD Associate Program Director, Internal Medicine Training Program Professor of Medicine, David Geffen School of Medicine at UCLA Division of General Internal MedicineMedicalResearch.com Interview with: Dr. Brad Spellberg MD Associate Program Director Internal Medicine Training Program Professor of Medicine, David Geffen School of Medicine at UCLA, Division of General Internal Medicine MedicalResearch: What are the main findings of the study? Dr. Spellberg:  The rates of community-onset methicillin-resistant Staphylococcus aureus (CO-MRSA) varied dramatically among academic medical centers in California, New York, Illinois and North Carolina, suggesting there is not a uniform change in the "national epidemic" of the "superbug" that has generated extensive public health concern over the past decade, according to a new study.The study surveyed hospital records of 4,171 cases of MRSA and MRSA-related infections between 2008 and 2011 in five medical centers located in Los Angeles, San Francisco, Chicago, New York City and Raleigh-Durham, NC.The rates of MRSA acquired in the community declined 57% from 2008-2011 in the Los Angeles medical center. In contrast, CO-MRSA rates tripled at the New York medical center, while the rates remained stable in San Francisco, Chicago and Raleigh-Durham. (more…)
Author Interviews, Geriatrics, MRSA / 11.01.2014

Courtney Reynolds, PhD Medical Scientist Training Program University of California Irvine, School of MedicineMedicalResearch.com Interview with: Courtney Reynolds, PhD Medical Scientist Training Program University of California Irvine, School of Medicine MedicalResearch.com: What are the main findings of the study? Dr. Reynolds: Our survey of factors influencing admission to 13 nursing homes in Orange County, California showed that MRSA carriers are denied admission more often than non-carriers, even after accounting for other important factors such as insurance status, required level of care and previous experience at the facility. In 80% of cases where MRSA carriage was responsible for denial of admission, nursing home administrators cited a lack of available single or cohort (MRSA only) rooms to accommodate these potential residents. (more…)
Author Interviews, MRSA, OBGYNE / 10.01.2014

MedicalResearch.com Interview with: Dr. Andrea Parriott MPH, PhD Department of Epidemiology Fielding School of Public Health University of California Los Angeles

MedicalResearch.com: What are the main findings of the study? Dr. Parriott:  We wanted to know whether hospital and provider volume (i.e. the number of deliveries performed by each hospital and provider per quarter) and cesarean section rates were predictors of the risk of methicillin-resistant Staphylococcus aureus (MRSA) infection before discharge from the hospital (after delivering a baby). We did not find an association between any of these variables and risk of MRSA infection. (more…)
Author Interviews, Hand Washing, JAMA, MRSA / 07.10.2013

Anthony Harris, MD, MPH Department of Epidemiology and Public Health Professor University of Maryland School of Medicine Acting Medical Director of Infection Control University of Maryland Medical CenterMedicalResearch.com Interview with: Anthony Harris, MD, MPH Department of Epidemiology and Public Health Professor University of Maryland School of Medicine Acting Medical Director of Infection Control University of Maryland Medical Center     MedicalResearch.com: What are the main findings of the study? Dr. Harris: The aim of the study was to understand if wearing disposable gowns and gloves for all patient contact in the ICU could help prevent the spread of MRSA and similar antibiotic-resistant bacteria. Secondarily we wanted to make sure this type of patient isolation did not result in any harm to patients. The results of the study were that gowns and gloves worn by healthcare workers for contact with all patients in the ICU did not decrease the number of patients who acquired VRE but did decrease MRSA about 40 percent.  Also, wearing gloves and gowns did not adversely impact patient care.  For our goal of studying all types of infection, we did not find a benefit to universal gown and glove use. However, for transmission of MRSA alone, the intervention decreased transmission by about 40 percent. Although previous studies have showed isolation is associated with falls, bed sores and other adverse events, we found gowns and gloves did not produce more of these negative events. (more…)
Author Interviews, MRSA, Pediatrics / 23.09.2013

MedicalResearch.com Interview with: Dr. Martha Iwamoto, MD, MPH Centers for Disease Control and Prevention, Atlanta, Georgia; MedicalResearch.com: What are the main findings of the study? Dr. Iwamoto: We have been successful in decreasing invasive MRSA infections among infants younger than 3 months, mostly due to declines in hospital –onset infections in NICUs. However, more needs to be done among pediatric patients older than 3 months, especially those in the community settings and without recent healthcare exposures. (more…)