Anurag N Malani

St Joseph Mercy Oakland, Pontiac, Michigan, United States

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Publications (41)311.6 Total impact

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    ABSTRACT: Objectives: The study objective was to determine whether there was an improvement in compliance with recommended Clostridium difficile infection (CDI) treatment after introduction of an institutional CDI bundle with daily antimicrobial stewardship assessment. Patients and methods: This was a single-centre, quasi-experimental study evaluating compliance with an antimicrobial stewardship team-implemented care bundle in patients with CDI compared with historical controls. The primary outcome, compliance with overall bundle elements, was achieved when the following measures were accomplished: (i) appropriate CDI antimicrobial therapy based on the institutional treatment algorithm; (ii) discontinuation of acid-suppressant therapy in the absence of a pre-specified indication; and (iii) discontinuation of unnecessary antimicrobials. Secondary objectives were to evaluate the extent to which antimicrobial stewardship involvement affected treatment compliance and to assess trends in CDI clinical outcomes, such as mortality and readmission. Results: One-hundred-and-sixty-nine patients were evaluated; 83 after implementation of the care bundle (bundle group) and 89 prior to bundle implementation (historical control group). Compliance with overall bundle endpoints was significantly higher in the bundle group versus the control group (81% versus 45%, P < 0.001). Individual bundle components that were significantly improved in the bundle group were discontinuation of non-essential acid suppressants (90% versus 18%, P < 0.001) and administration of appropriate CDI therapy (82% versus 64%, P < 0.009). No significant differences were observed in overall or CDI-related mortality or readmissions, durations of therapy or reduction of non-essential concomitant antimicrobials. Conclusions: Introduction of an antimicrobial stewardship bundle for CDI significantly improved adherence to institutional treatment recommendations and overall management of patients with CDI.
    No preview · Article · Dec 2015 · Journal of Antimicrobial Chemotherapy

  • No preview · Article · Nov 2015 · Infection Control and Hospital Epidemiology

  • No preview · Article · Oct 2015 · MMWR. Morbidity and mortality weekly report
  • Anurag N Malani · Lisa E Kerr · Carol A Kauffman
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    ABSTRACT: Voriconazole is an important agent in the antifungal armamentarium. It is the treatment of choice for invasive aspergillosis, other hyaline molds, and many brown-black molds. It is also effective for infections caused by Candida species, including those that are fluconazole resistant, and for infections caused by the endemic mycoses, including those that occur in the central nervous system. It has the advantage of being available in both an intravenous and an oral formulation that is well absorbed. Drawbacks to the use of voriconazole are that it has unpredictable, nonlinear pharmacokinetics with extensive interpatient and intrapatient variation in serum levels. Some of the adverse effects seen with voriconazole are related to high serum concentrations, and, as a result, therapeutic drug monitoring is essential when using this agent. Drug-drug interactions are common, and possible interactions must be sought before voriconazole is prescribed. With prolonged use, newly described adverse effects, including periostitis, alopecia, and development of skin cancers, have been noted.
    No preview · Article · Sep 2015 · Seminars in Respiratory and Critical Care Medicine
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    ABSTRACT: Treatment of asymptomatic bacteriuria contributes to antimicrobial overuse in hospitalized patients. Indications for urine culture, treatment, and targets for improvement were evaluated in 153 patients. Drivers of antimicrobial overuse included fever with an alternative source, altered mental status, and leukocytosis, which led 435 excess days of antimicrobial therapy.
    No preview · Article · Mar 2015 · Infection Control and Hospital Epidemiology
  • April C Pettit · Anurag N Malani
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    ABSTRACT: In September 2012, an unprecedented outbreak of fungal infections due to preservative-free, injectable methylprednisolone acetate (MPA) was identified. Exserohilum rostratum was quickly identified as the predominant organism involved in disease cases. Prior to this outbreak, little was known about the pathogenesis, treatment, and prognosis of infections due to this unusual brown-black mold. Almost 2 years after the onset of this outbreak, numerous epidemiologic and basic science studies have provided some guidance in understanding the epidemiology, clinical findings, diagnosis, and treatment of patients exposed to the contaminated medication. Additionally, this outbreak has directly led to the passage of legislation supporting increased regulation in the industry of pharmaceutical compounding. Many unanswered questions, particularly surrounding the long-term prognosis and outcomes for affected patients remain. However, it is clear that a strong relationship between clinicians caring for patients and public health as well as a rapid, effective public health response was critical in preventing additional cases of disease.
    No preview · Article · Jan 2015 · Current Infectious Disease Reports
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    ABSTRACT: Prompt diagnosis and treatment of fungal meningitis are critical, but culture is insensitive. (1,3)-β-d-Glucan (BDG) testing is FDA approved for serological diagnosis of invasive fungal disease; however, BDG testing is not approved for cerebrospinal fluid (CSF), and the appropriate cutoff value is unknown. We aimed to validate the diagnostic accuracy of CSF BDG measurements for fungal meningitis among patients exposed to contaminated methylprednisolone acetate (MPA). A retrospective observational study was conducted at St. Joseph Mercy Hospital and Vanderbilt University from November 2013 to February 2014. Patients were included if they had received a contaminated MPA injection. Cases were classified as probable or proven meningitis according to Centers for Disease Control and Prevention guidelines. CSF BDG testing was performed according to the package insert instructions for serum samples, and results were validated using Clinical and Laboratory Standards Institute procedures (MiraVista Diagnostics). Of 233 patients, 45 had meningitis (28 proven cases), 53 had spinal/paraspinal infections (19 proven cases), and 135 did not develop disease. Using the manufacturer's cutoff value (≥80 pg/ml), the sensitivity and specificity were 96% and 95%, respectively, for proven meningitis and 84% and 95% for probable or proven meningitis. Receiver operating characteristic analysis identified the optimal cutoff value for proven meningitis to be 66 pg/ml (sensitivity, 100%; specificity, 94%) and that for probable or proven meningitis to be 66 pg/ml (sensitivity, 91%; specificity, 92%). Our results suggest that CSF BDG measurements are highly sensitive and specific for the diagnosis of fungal meningitis associated with contaminated MPA injections. Further study on the utility of CSF BDG testing for other types of fungal meningitis is needed.
    Full-text · Conference Paper · Oct 2014
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    ABSTRACT: Background: Voriconazole is a triazole antifungal medication used for prophylaxis or to treat invasive fungal infections. Inflammation of the periosteum resulting in skeletal pain, known as periostitis, is a reported side effect of long-term voriconazole therapy. The trifluorinated molecular structure of voriconazole suggests a possible link between excess fluoride and periostitis, as elevated blood fluoride has been reported among patients with periostitis who received voriconazole. Methods: Two hundred sixty-four patients from Michigan were impacted by the multistate outbreak of fungal infections as a result of contaminated methylprednisolone injections. A retrospective study was conducted among 195 patients who received voriconazole therapy at St Joseph Mercy Hospital during this outbreak. Twenty-eight patients who received both bone scan and plasma fluoride measurements for skeletal pain were included in the statistical analyses. Increased tracer uptake on bone scan was considered positive for periostitis. The primary outcome measure was the correlation between plasma fluoride and bone scan results. Results: Blood fluoride (P < .001), alkaline phosphatase (P = .020), daily voriconazole dose (P < .001), and cumulative voriconazole dose (P = .027) were significantly elevated in patients who had periostitis compared with those who did not. Discontinuation or dose reduction of voriconazole resulted in improvement of pain in 89% of patients. Conclusions: High plasma fluoride levels coupled with skeletal pain among patients who are on long-term voriconazole therapy is highly suggestive of periostitis. Initial measurement of fluoride may be considered when bone scan is not readily available. Early detection should be sought, as discontinuation of voriconazole is effective at reversing the disease.
    Full-text · Article · Jul 2014 · Clinical Infectious Diseases
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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.
    No preview · Conference Paper · Jun 2014

  • No preview · Article · Jun 2014 · American Journal of Infection Control
  • Anurag N Malani · Lisa Kerr · Janet Obear · Bonita Singal · Carol A Kauffman
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    ABSTRACT: Background: Voriconazole was 1 of 2 antifungal agents recommended for treatment of fungal infections associated with injection of contaminated methylprednisolone. Alopecia and nail changes are not commonly reported side effects of voriconazole. Having noted increasing hair loss among our patients treated with voriconazole, we sought to determine the prevalence and characteristics of alopecia associated with this agent. Methods: Patients who received voriconazole for at least 1 month for probable or confirmed fungal infection were eligible to complete a survey regarding alopecia and nail changes. For those patients who reported alopecia, additional questions about reversal of hair loss were asked after voriconazole had been stopped for at least 3 months. Results: A total of 152 of 175 eligible patients (87%) completed the survey. One hundred twenty-five (82%) reported alopecia. Hair loss on the scalp was noted in 120 (96%), arms and legs in 52 (42%), and eyebrows and eyelashes in 47 each (38%). Nineteen patients (15%) reported wearing a wig or hat because of extensive hair loss. Alopecia developed a mean (standard deviation) of 75 (54) days after initiation of voriconazole. Of 114 patients who were off voriconazole for at least 3 months, hair loss had stopped in 94 (82%) and regrowth had begun in 79 (69%), including those who were changed to either itraconazole or posaconazole. Nail changes or loss occurred in 106 (70%) patients. Conclusions: Alopecia and nail changes were common adverse effects associated with voriconazole therapy during the multistate fungal outbreak.
    No preview · Article · May 2014 · Clinical Infectious Diseases
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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.
    No preview · Article · Apr 2014 · Infection Control and Hospital Epidemiology
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    ABSTRACT: Tigecycline is one of the few remaining therapeutic options for extensively drug-resistant (XDR) Gram-negative bacilli (GNB). MICs of tigecycline to Acinetobacter baumannii have been reported to be elevated when determined by the Etest compared to determinations by the broth microdilution (BMD) method. The study aim was to compare the susceptibility of GNB to tigecycline by four different testing methods. GNB were collected from six health care systems (25 hospitals) in southeast Michigan from January 2010 to September 2011. Tigecycline MICs among A. baumannii, carbapenem-resistant Enterobacteriaceae (CRE), extended-spectrum β-lactamase (ESBL)-producing Enterobacteriaceae, and susceptible Enterobacteriaceae isolates were determined by Etest, BMD, Vitek-2, and MicroScan. Nonsusceptibility was categorized as a tigecycline MIC of ≥4 μg/ml for both A. baumannii and Enterobacteriaceae. The study included 4,427 isolates: 2,065 ESBL-producing Enterobacteriaceae, 1,105 A. baumannii, 888 susceptible Enterobacteriaceae, and 369 CRE isolates. Tigecycline nonsusceptibility among A. baumannii isolates was significantly more common as determined by Etest compared to that determined by BMD (odds ratio [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. Tigecycline MICs varied greatly according to the in vitro testing methods among A. baumannii isolates. Etest should probably not be used by laboratories for tigecycline MIC testing of A. baumannii isolates, since MICs are significantly elevated with Etest compared to those determined by the three other methods.
    Full-text · Article · Mar 2014 · Journal of clinical microbiology
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    ABSTRACT: A nationwide outbreak of fungal infections was traced to injection of Exserohilum-contaminated methylprednisolone. We describe our experience with patients who developed spinal or paraspinal infection after injection of contaminated methylprednisolone. Data were assembled from the Michigan Department of Community Health, electronic medical records, and magnetic resonance imaging (MRI) reports. Of 544 patients who received an epidural injection from a contaminated lot of methylprednisolone at a pain clinic in southeastern Michigan, 153 (28%) were diagnosed at our institution with probable or confirmed spinal or paraspinal fungal infection at the injection site. Forty-one patients had both meningitis and spinal or paraspinal infection, and 112 had only spinal or paraspinal infection. Magnetic resonance imaging abnormalities included abscess, phlegmon, arachnoiditis, and osteomyelitis. Surgical debridement in 116 patients revealed epidural phlegmon and epidural abscess most often. Among 26 patients with an abnormal MRI but with no increase or change in chronic pain, 19 (73%) had infection identified at surgery. Fungal infection was confirmed in 78 patients (51%) by finding hyphae in tissues, positive polymerase chain reaction, or culture. Initial therapy was voriconazole plus liposomal amphotericin B in 115 patients (75%) and voriconazole alone in 38 patients (25%). As of January 31, 2014, 20 patients remained on an azole agent. Five patients died of infection. We report on 153 patients who had spinal or paraspinal fungal infection at the site of epidural injection of contaminated methylprednisolone. One hundred sixteen (76%) underwent operative debridement in addition to treatment with antifungal agents.
    Full-text · Article · Mar 2014 · Open Forum Infectious Diseases
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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.
    No preview · Article · Nov 2013 · Infection Control and Hospital Epidemiology
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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.)
    Preview · Article · Oct 2013 · New England Journal of Medicine
  • Anurag N Malani · Bonita Singal · Carol A Kauffman

    No preview · Article · Oct 2013 · JAMA The Journal of the American Medical Association
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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.
    No preview · Conference Paper · Oct 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.
    No preview · Article · Jun 2013 · JAMA The Journal of the American Medical Association
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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 .
    No preview · Article · Jan 2013 · Infection Control and Hospital Epidemiology

Publication Stats

578 Citations
311.60 Total Impact Points


  • 2014-2015
    • St Joseph Mercy Oakland
      Pontiac, Michigan, United States
    • Wayne State University
      • Division of Infectious Diseases
      Detroit, Michigan, United States
  • 2009-2014
    • Saint Joseph Mercy Health System
      Canton, Michigan, United States
  • 2007-2014
    • Concordia University–Ann Arbor
      Ann Arbor, Michigan, United States
  • 2007-2008
    • University of Michigan
      • Division of Infectious Diseases
      Ann Arbor, Michigan, United States