Anurag N Malani

Trinity Health, Livonia, Michigan, United States

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Publications (27)210.92 Total impact

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    ABSTRACT: Background: The prompt diagnosis and treatment of fungal meningitis is critical, but culture is insensitive. (1,3)-beta-D-glucan (BDG) is FDA-cleared for serologic diagnosis of invasive fungal disease. (Fungitell assay, Associates of Cape Cod Incorporated). However, BDG is not cleared for testing cerebrospinal fluid (CSF) and the appropriate cutoff is unknown. We aim to validate the accuracy of CSF BDG for the diagnosis of fungal meningitis among patients exposed to contaminated methylprednisolone acetate (MPA). Methods: A case-control study was conducted at St. Joseph Mercy Hospital and Vanderbilt University from November, 2013 February, 2014. Patients were included if they received a contaminated MPA injection. Cases were classified as probable or confirmed meningitis according to Centers for Disease Control and Prevention guidelines. Controls were defined as persons exposed but not diagnosed with disease. CSF BDG testing was performed according to the package insert for serum and validated using Clinical Laboratory Standards Institute procedures (MiraVista Diagnostics). Results: Of 233 patients, 45 had meningitis (28 confirmed), 53 had spinal/paraspinal infection (19 confirmed), and 135 did not develop disease. The figure depicts CSF BDG results from those with confirmed meningitis, probable meningitis, and controls. Using the manufacturer's cutoff (BDG ≥ 80 pg/mL), the sensitivity and specificity were 96% (95% CI 80-100%) and 93% (95% CI 87-97%) for confirmed meningitis and 84% (95% CI 70-93%) and 93% (95% CI 87-97%) for probable meningitis. The Receiver Operating Characteristic analysis identified the optimal cutoff for confirmed meningitis to be ≥ 500 pg/mL (sensitivity 93% [95% CI 76-99%], specificity 100% [95% CI 97-100%]); for probable meningitis to be 66 pg/mL (sensitivity 91% [95% CI 79-98%],specificity 92% [95% CI 87-96%]). Conclusion: Our results suggest that CSF BDG is both a highly sensitive and specific test for diagnosis of fungal meningitis associated with contaminated MPA injections. Further study is needed on the diagnostic utility of CSF BDG for other types of fungal meningitis.
    IDWeek 2014 Meeting of the Infectious Diseases Society of America; 10/2014
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    Clinical infectious diseases : an official publication of the Infectious Diseases Society of America. 07/2014;
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    ABSTRACT: BACKGROUND: Fungal infection from a contaminated injection is rare (~4/10,000 injections) and can result in permanent joint damage if untreated. Infection associated with the 2012 nationwide fungal meningitis outbreak caused by contaminated methylprednisolone acetate (CMPA) injections continue to be reported. Michigan has reported 25/33 of U.S.-reported peripheral joint infections (PJIs). We describe the epidemiologic and clinical characteristics of affected Michigan patients. METHODS: A probable case was defined as osteomyelitis or worsening inflammatory arthritis of a peripheral joint after CMPA injection after May 21, 2012. Confirmed cases also had a fungal pathogen detected through direct microscopy, culture, or polymerase chain reaction of synovial fluid, or histopathology of joint tissue. Cases were identified through active surveillance or patients self-reporting symptoms; clinical information was obtained through medical record review. All patients had magnetic resonance imaging (MRI). RESULTS: Among the 22 probable and 3 confirmed cases, all presented with joint pain; however, 15 (60%) were among patients with symptoms unchanged from before their infection. Twenty-three patients had ≥1 underlying chronic condition, including renal insufficiency, diabetes, cardiovascular disease, and immunosuppression. Twenty-four had surgical treatment for infection, including incision and drainage, arthroscopic debridement, clavicle resection, and hip arthroplasty. Median joint aspirate white blood cell count at diagnosis was 717 cells/µL (range: 9–24,000). Median days from last injection to first MRI joint infection evidence was 70 (range: 22–171). Patients had received a median of 1 (range: 1–3) CMPA injection. CONCLUSIONS: Approximately half of Michigan PJIs occurred among patients without new symptoms who later required surgical treatment. A higher index of suspicion should be maintained for patients who received PJIs in the absence of a gold standard for case identification.
    2014 Council of State and Territorial Epidemiologists Annual Conference; 06/2014
  • Clinical Infectious Diseases 05/2014; · 9.37 Impact Factor
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    ABSTRACT: Background. Carbapenem-resistant Enterobacteriaceae (CRE) are clinically challenging, threaten patient safety, and represent an emerging public health issue. CRE reporting is not mandated in Michigan. Methods. The Michigan Department of Community Health-led CRE Surveillance and Prevention Initiative enrolled 21 facilities (17 acute care and 4 long-term acute care facilities) across the state. Baseline data collection began September 1, 2012, and ended February 28, 2013 (duration, 6 months). Enrolled facilities voluntarily reported cases of Klebsiella pneumoniae and Escherichia coli according to the surveillance algorithm. Patient demographic characteristics, laboratory testing, microbiology, clinical, and antimicrobial information were captured via standardized data collection forms. Facilities reported admissions and patient-days each month. Results. One-hundred two cases over 957,220 patient-days were reported, resulting in a crude incidence rate of 1.07 cases per 10,000 patient-days. Eighty-nine case patients had test results positive for K. pneumoniae, whereas 13 had results positive for E. coli. CRE case patients had a mean age of 63 years, and 51% were male. Urine cultures (61%) were the most frequently reported specimen source. Thirty-five percent of cases were hospital onset; sixty-five percent were community onset (CO), although 75% of CO case patients reported healthcare exposure within the previous 90 days. Cardiovascular disease, renal failure, and diabetes mellitus were the most frequently reported comorbid conditions. Common ris k factors included surgery within the previous 90 days, recent infection or colonization with a multidrug-resistant organism, and recent exposures to antimicrobials, especially third- or fourth-generation cephalosporins. Conclusions. CRE are found throughout Michigan healthcare facilities. Implementing a regional, coordinated surveillance and prevention initiative may prevent CRE from becoming hyperendemic in Michigan.
    Infection Control and Hospital Epidemiology 04/2014; 35(4):342-9. · 4.02 Impact Factor
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    ABSTRACT: Background: Tigecycline is one of few remaining therapeutic options for extensively drug resistant (XDR) Gram-negative bacilli (GNB). Minimal inhibitory concentrations (MICs) of tigecycline to Acinetobacter baumannii have been reported to be elevated when determined by E-test compared to broth microdilution (BMD). Study aims were to compare the susceptibility of GNBs to tigecycline by four different testing methods.Methods: GNBs were collected from six different healthcare systems (25 hospitals) in Southeast Michigan from 01/2010 - 09/2011. Tigecycline MICs among A. baumannii, carbapenem-resistant enterobacteriaceae (CRE), extended-spectrum β-lactamase producing enterobacteriaceae (ESBL) and susceptible enterobacteriaceae isolates were determined by E-test, BMD, Vitek-2, and MicroScan. Non-susceptibility was categorized as tigecycline MIC≥4 μg/mL for both A. baumannii and enterobacteriaceae.Results: The study included 4,427 isolates: 2,065 ESBLs, 1,105 A. baumannii, 888 susceptible enterobacteriaceae, and 369 CREs. Tigecycline resistance among A. baumannii isolates was significantly more common as determined by E-test compared to BMD (OR=10.3, p<0.001), MicroScan (OR=12.4, p<0.001), or Vitek-2 (OR=9.4, p<0.001). These differences were not evident with the other pathogens.Conclusion: Tigecycline MICs varied greatly according to in-vitro testing methods among A. baumannii isolates. E-test should probably not be used by laboratories for tigecycline MIC testing of A. baumannii, since MICs are significantly elevated compared to three other methods.
    Journal of clinical microbiology 03/2014; · 4.16 Impact Factor
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    ABSTRACT: Urine cultures are frequently obtained for hospitalized patients. We reviewed documented indications for culture and compared these with professional society guidelines. Lack of documentation and important clinical scenarios (before orthopedic procedures and when the patient has altered mental status without a urinary catheter) are highlighted as areas of use outside of current guidelines.
    Infection Control and Hospital Epidemiology 11/2013; 34(11):1204-1207. · 4.02 Impact Factor
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    ABSTRACT: BACKGROUND Since September 18, 2012, public health officials have been investigating a large outbreak of fungal meningitis and other infections in patients who received epidural, paraspinal, or joint injections with contaminated lots of methylprednisolone acetate. Little is known about infections caused by Exserohilum rostratum, the predominant outbreak-associated pathogen. We describe the early clinical course of outbreak-associated infections. METHODS We reviewed medical records for outbreak cases reported to the Centers for Disease Control and Prevention before November 19, 2012, from the six states with the most reported cases (Florida, Indiana, Michigan, New Jersey, Tennessee, and Virginia). Polymerase-chain-reaction assays and immunohistochemical testing were performed on clinical isolates and tissue specimens for pathogen identification. RESULTS Of 328 patients without peripheral-joint infection who were included in this investigation, 265 (81%) had central nervous system (CNS) infection and 63 (19%) had non-CNS infections only. Laboratory evidence of E. rostratum was found in 96 of 268 patients (36%) for whom samples were available. Among patients with CNS infections, strokes were associated with an increased severity of abnormalities in cerebrospinal fluid (P<0.001). Non-CNS infections were more frequent later in the course of the outbreak (median interval from last injection to diagnosis, 39 days for epidural abscess and 21 days for stroke; P<0.001), and such infections developed in patients with and in those without meningitis. CONCLUSIONS The initial clinical findings from this outbreak suggest that fungal infections caused by epidural and paraspinal injection of a contaminated glucocorticoid product can result in a broad spectrum of clinical disease, reflecting possible variations in the pathogenic mechanism and in host and exposure risk factors. (Funded by the Centers for Disease Control and Prevention.)
    New England Journal of Medicine 10/2013; 369:1610. · 54.42 Impact Factor
  • Anurag N Malani, Bonita Singal, Carol A Kauffman
    JAMA The Journal of the American Medical Association 10/2013; 310(16):1735-6. · 29.98 Impact Factor
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    ABSTRACT: Background: The emergence of hospital acquired infections (HAIs) and antimicrobial resistance has resulted in considerable morbidity, mortality, and increased expenditures. Urinary tract infection (UTI) accounts for 40% of all HAIs. However, recent studies have shown that over half of urine cultures in acute care facilities are ordered inappropriately, leading to unnecessary antibiotic therapy and contributing to the development of antimicrobial resistance. This phenomenon has not been studied in long term acute care hospitals (LTACHs), facilities that admit complex patients with acute care needs. We sought to evaluate the appropriateness of testing and antimicrobial treatment for UTI in an LTACH. Methods: Medical records were retrospectively reviewed from adult patients who had a urine culture collected from February-July 2012 at Select Specialty Hospital Ann Arbor, a 36-bed LTACH. Only the first urine culture was reviewed for those with multiple urine cultures. Data collected included culture results, urinary catheter presence, signs and symptoms of UTI, reasons for ordering a urine culture, antimicrobial therapy, and reasons for/duration of treatment. Appropriateness criteria for testing and antimicrobial therapy were defined according to Infectious Diseases Society of America (IDSA) and Centers for Disease Control and Prevention (CDC) guidelines. Results: Urine cultures were reviewed in 77 patients. Of the 77 patients, 62 (81%) had a urinary catheter present at the time of culture or removed within 48 hours, 50 (65%) had presence of wounds and 39 (51%) required mechanical ventilation on admission. The most common reasons for ordering a urine culture were fever (31%), change in character of urine (21%), and leukocytosis (18%). Based on national guidelines, 40 cultures (52%) were ordered inappropriately, with no documented reasons in 18 (23%) patients. Of these 40 patients who did not meet appropriateness criteria, 11 (28%) received antibiotics for UTI, resulting in 96 days of antimicrobial therapy. Conclusion: At our LTACH, over half of urine cultures were obtained outside of accepted criteria – leading to a significant excess of antimicrobial use. As the number of LTACHs continues to increase, testing guidelines for urine cultures in these facilities is urgently needed.
    IDWeek 2013 Meeting of the Infectious Diseases Society of America; 10/2013
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    ABSTRACT: Injection of contaminated methylprednisolone has resulted in an unprecedented nationwide outbreak of Exserohilum rostratum fungal infections, manifested initially as meningitis and/or basilar stroke. Insidious onset of spinal or paraspinal infection at the injection site has been increasingly reported and is occurring months after receipt of injection with the contaminated drug. The clinical findings are often subtle and similar to those that led the patient to undergo the methylprednisolone injection. To determine if patients who had not presented for medical care but who had received contaminated methylprednisolone developed spinal or paraspinal infection at the injection site using contrast-enhanced magnetic resonance imaging (MRI) screening. There were 172 patients who had received an injection of contaminated methylprednisolone from a highly contaminated lot (No. 06292012@26) at a pain facility but had not presented for medical care related to adverse effects after the injection. Screening MRI was performed between November 9, 2012, and April 30, 2013. MAIN OUTCOMES AND MEASURES: Number of persons identified with previously undiagnosed spinal or paraspinal infection. Of the 172 patients screened, MRI was abnormal in 36 (21%), showing epidural or paraspinal abscess or phlegmon, arachnoiditis, spinal osteomyelitis or diskitis, or moderate to severe epidural, paraspinal, or intradural enhancement. Of the 115 patients asked about new or worsening back or neck pain, lower extremity weakness, or radiculopathy symptoms, 35 (30%) had at least 1 symptom. Thirty-five of the 36 patients with abnormal MRIs met the Centers for Disease Control and Prevention (CDC) case definition for probable (17 patients) or confirmed (18 patients) fungal spinal or paraspinal infection. All 35 patients were treated with antifungal agents (voriconazole, with or without liposomal amphotericin B), and 24 required surgical debridement. At the time of surgery, 17 of 24 patients (71%), including 5 patients who denied having symptoms, had laboratory evidence of fungal infection. Among patients who underwent screening MRI to look for infection at the site of injection of contaminated methylprednisolone, 21% had an abnormal MRI, and all but one met CDC criteria for probable or confirmed fungal spinal or paraspinal infection. Screening MRI led to identification of patients who had minimal or no symptoms of spinal or paraspinal infection and allowed early initiation of medical and surgical treatment.
    JAMA The Journal of the American Medical Association 06/2013; 309(23):2465-72. · 29.98 Impact Factor
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    ABSTRACT: (See the commentary by Gilligan, on pages 22-23 .) Objective. To determine relative rates of blood culture contamination for 3 skin antisepsis interventions-10% povidone iodine aqueous solution (PI), 2% iodine tincture (IT), and 2% chlorhexidine gluconate in 70% isopropyl alcohol (CHG)-when used by dedicated phlebotomy teams to obtain peripheral blood cultures. Design. Randomized crossover trial with hospital floor as the unit of randomization. Setting. Teaching hospital with 885 beds. Patients. All adult patients undergoing peripheral blood culture collection on 3 medical-surgical floors from May 2009 through September 2009. Intervention. Each antisepsis intervention was used for 5 months on each study floor, with random crossover after a 1-month washout period. Phlebotomy teams collected all peripheral blood cultures. Each positive blood culture was adjudicated by physicians blinded to the intervention and scored as a true positive or contaminated blood culture. The primary outcome was the rate of blood culture contamination for each antisepsis agent. Results. In total, 12,904 peripheral blood culture sets were evaluated, of which 735 (5.7%) were positive. There were 98 contaminated cultures, representing 13.3% of all positive cultures. The overall blood culture contamination rate for the study population was 0.76%. Intent-to-treat rates of contaminated blood cultures were not significantly different among the 3 antiseptics ([Formula: see text]), yielding 0.58% with PI (95% confidence interval [CI], 0.38%-0.86%), 0.76% with IT (95% CI, 0.52%-1.07%), and 0.93% with CHG (95% CI, 0.67%-1.27%). Conclusion. Choice of antiseptic agent does not impact contamination rates when blood cultures are obtained by a phlebotomy team and should, therefore, be based on costs or preference. Trial registration. identifier: NCT01216761 .
    Infection Control and Hospital Epidemiology 01/2013; 34(1):15-21. · 4.02 Impact Factor
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    ABSTRACT: BACKGROUND: Data from community antimicrobial stewardship programs (ASPs) are limited. We describe clinical and economic outcomes from the first year of our hospital's ASP. METHODS: The ASP team comprised 2 infectious disease physicians and 3 intensive care unit pharmacists. The team prospectively audited the new starts and weekly use of 8 target antimicrobials: aztreonam, caspofungin, daptomycin, ertapenem, linezolid, meropenem, tigecycline, and voriconazole. Using administrative data, outcomes from the first year of the program, including death within 30 days of hospitalization, readmission within 30 days of discharge, and development of Clostridium difficile infection (CDI), were compared with outcomes from a similar period before institution of the program. RESULTS: A total of 510 antimicrobial orders were reviewed, of which 323 (63%) were appropriate, 94 (18%) prompted deescalation, 61 (12%) were denied, and 27 (5%) led to formal consultation with an infectious disease physician. On multivariate analysis, implementation of the ASP was associated with an approximate 50% reduction in the odds of developing CDI (odds ratio, 0.46; 95% confidence interval, 0.25-0.82). The ASP was not associated with decreased mortality at 30 days after discharge or readmission rate. The antimicrobial cost per patient-day decreased by 13.3%, from $10.16 to $8.81. The antimicrobial budget decreased by 15.2%, resulting in a total savings of $228,911. There was a 25.4% decrease in defined daily doses of the target antimicrobials. CONCLUSIONS: Implementation of the ASP was associated with significant reductions in CDI rate, antimicrobial use, and pharmacy costs.
    American journal of infection control 05/2012; · 3.01 Impact Factor
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    ABSTRACT: Long-term acute care (LTAC) facilities admit patients with complex, advanced disease states. Study aims were to determine the burden posed on hospitals associated with LTAC exposure and analyze the differences between "present on admission" (POA) multidrug-resistant (MDR), gram-negative organisms (GNO) and POA MDR gram-positive organisms (GPO). A multicenter retrospective study was conducted in 13 hospitals from southeast Michigan, from September 1, 2008, to August 31, 2009. Cultures obtained in the first 72 hours of hospitalization (ie, POA) of MDR-GPO and MDR-GNO were reviewed. LTAC exposures in the previous 6 months and direct admission from a LTAC were recorded. Overall, 5,297 patients with 7,147 MDR POA cultures were analyzed: 2,619 (36.6%) were MDR-GNO, and 4,528 (63.4%) were MDR-GPO. LTAC exposure in the past 6 months was present in 251 (5.2%) infectious episodes and was significantly more common among POA MDR-GNO than MDR-GPO (158 [8.6%] and 94 [3.1%], respectively, odds ratio, 2.87; P < .001). Recent LTAC exposure was strongly associated with both carbapenem-resistant Enterobacteriaceae (CRE) (31.6% of all CRE cases, P < .001) and Acinetobacter baumannii (14.9% of all A baumannii cases, P < .001). Nearly 10% of MDR-GNO POA had recent LTAC exposure. Hospital efforts to control the spread of MDR-GNO should focus on collaborations and communications with referring LTACs and interventions targeted towards patients with recent LTAC exposure.
    American journal of infection control 01/2012; 40(8):760-5. · 3.01 Impact Factor
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    ABSTRACT: Studies have reported that Candida glabrata infections are more common in older adults. We sought to determine colonisation rates of C. glabrata in the oral cavity and its relationship with age, comorbid illnesses and hospital or extended care facility stay. Samples were obtained from four sites in the oral cavity and from dentures, when available, from 408 subjects from the community (136), hospital (126) or an extended care facility (146). Overall, 219 (53.7%) subjects were colonised with yeast; the predominant species was Candida albicans. Sixty-two patients (15.2%) were colonised with C. glabrata. None of the subjects <40 years was colonised with C. glabrata; in those from the community, only nine persons, all of whom were >60 years, were colonised with C. glabrata. By multivariate analysis, increasing age, dentures and use of psychotropic medications were independently associated with C. glabrata colonisation; residing in the community, rather than hospital or extended care, was strongly protective against colonisation. Candida glabrata colonisation is multifactorial; age, and hospitalisation/extended care stay contribute to colonisation. Dentures are strongly associated with colonisation with any yeast and with C. glabrata. Further study is needed to evaluate the relationship of these findings to increasing C. glabrata infections in older adults.
    Mycoses 11/2011; 54(6):531-7. · 1.28 Impact Factor
  • Anurag N. Malani
    Infectious Diseases in Clinical Practice - INFECT DIS CLIN PRAC. 01/2010; 18(4):271-272.
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    Emerging Infectious Diseases 08/2009; 15(8):1328-30. · 6.79 Impact Factor
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    Anurag N Malani, David M Aronoff
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    ABSTRACT: Voriconazole is a broad-spectrum triazole antifungal agent indicated for invasive aspergillosis, refractory Candida infections, and other emerging invasive fungal infections. Adverse cutaneous reactions associated with voriconazole therapy occur in fewer than 10% of treated patients and range from mild erythematous eruptions to life-threatening reactions such as the Stevens-Johnson syndrome and toxic epidermal necrolysis. Photosensitivity reactions are an uncommon but characteristic dermatitis in voriconazole recipients, particularly following chronic administration. We report a case of voriconazole-induced phototoxicity in a 50-year-old male with Candida parapsilosis endocarditis that reversed on discontinuation of the drug.
    Clinical Medicine &amp Research 10/2008; 6(2):83-5.
  • Carol A Kauffman, Anurag N Malani
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    ABSTRACT: Zygomycosis occurs primarily in immunosuppressed patients and those with diabetes mellitus. Diabetes remains the most common risk factor; however, zygomycosis has increased among transplant recipients and patients with hematologic malignancy. Treatment or prophylaxis with voriconazole seems to be associated with the development of zygomycosis among severely immunosuppressed patients in these latter risk groups. Rhino-orbital-cerebral zygomycosis is the most common manifestation in patients with diabetes mellitus, but transplant recipients and patients with hematologic malignancy are more likely to develop pulmonary infection. Zygomycosis remains difficult to treat and requires a multifaceted approach involving elimination of predisposing factors, surgical debridement, and antifungal therapy. Lipid formulations of amphotericin B are the treatments of choice. The use of posaconazole has been successful in salvage trials but should not be used as first-line therapy until an effective intravenous formulation is available.
    Current Infectious Disease Reports 12/2007; 9(6):435-40.
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    ABSTRACT: False-positive blood culture results may lead to prolonged hospitalization, inappropriate antibiotic administration, and increased healthcare costs. We conducted a review of the literature to assess the effect of skin antiseptic agents on the rate of false-positive blood culture results. We found no clear evidence to suggest which antiseptic should be used to prevent false-positive results. Studies suggest, however, a possible benefit from the use of prepackaged skin antiseptic kits and alcohol-containing antiseptics.
    Infection Control and Hospital Epidemiology 08/2007; 28(7):892-5. · 4.02 Impact Factor

Publication Stats

308 Citations
210.92 Total Impact Points


  • 2013
    • Trinity Health
      Livonia, Michigan, United States
  • 2012
    • Detroit Medical Center
      Detroit, Michigan, United States
    • Saint Joseph Mercy Health System
      Canton, Michigan, United States
  • 2005–2008
    • University of Michigan
      • • Division of Infectious Diseases
      • • Department of Internal Medicine
      Ann Arbor, Michigan, United States