Ban Hock Tan

Pandemic (H1N1) 2009 infection in adult solid organ transplant recipients in Singapore.

Background. Influenza can produce significant complications in immunocompromised persons. Methods. We studied the effects of the pandemic (H1N1) 2009 (pH1N1) infection on solid organ transplant recipients in our hospital, with emphasis on clinical information, duration of viral culture positivity, polymerase chain reaction positivity, effects of oseltamivir therapy, and graft status at 6 months of follow-up. Results. Twenty-two cases of pH1N1 infection involving 18 renal, two lung, one heart, and one liver transplant recipients were seen from July 14 to September 8, 2009. Their median age was 50.5 years (range 20-70 years); 64% were women, and median time posttransplant was 40 months (range 6-204 months). Common symptoms were fever (86%), cough (77%), sore throat (55%), phlegm (32%), and myalgia (27%). The median duration of symptoms (n=21) and duration of polymerase chain reaction positivity (n=15) were 7 (range 4-13 days) and 8 days (range 4-16 days), respectively. Mean (±SD) duration of symptom resolution (7.4±3.0 vs. 7.8±3.0 days, P=0.76) and viral culture positivity (5.3±2.8 vs. 4.3±3.2 days, P=0.65) did not differ between those who received a 5-day (n=9) or 10-day (n=12) course of oseltamivir. Five patients (22.7%) developed pneumonia with three needing intensive care. Mortality rate was 4.5% (1/22). At 6 months, three graft rejections involving two renal and one lung developed. Conclusions. Our findings indicate that the pH1N1 infection in solid organ transplant recipients is associated with some degree of morbidity and may affect the function of the transplanted organ. In this nonrandomized comparison, patients treated with 5 days of oseltamivir did not fare worse compared with those who received 10 days.

Atypical SARS and Escherichia coli Bacteremia

We describe a patient with severe acute respiratory syndrome (SARS) whose clinical symptoms were masked by Escherichia coli bacteremia. SARS developed in a cluster of healthcare workers who had contact with this patient. SARS was diagnosed when a chest infiltrate developed and when the patient’s brother was hospitalized with acute respiratory failure. We highlight problems in atypical cases and offer infection control suggestions.

First outbreak of colonization and infection with vancomycin-resistant Enterococcus faecium in a tertiary care hospital in Singapore.

We report the first outbreak of vancomycin-resistant Enterococcus faecium colonization and infection among inpatients in the hematology ward of an acute tertiary care public hospital in Singapore. Two cases of bacteremia and 4 cases of gastrointestinal carriage were uncovered before implementation of strict infection control measures resulted in control of the outbreak.

Invasive Mould Disease â Predictive Risk Factors in Acute Leukemia Patients Receiving Intensive Chemotherapy and its Impact on Survival

Background: Invasive mould disease (IMD) after chemotherapy in patients with acute leukemia has traditionally caused much morbidity and mortality. Methods: We conducted a retrospective, matched case-control study of IMD in patients with acute leukemia managed in our institution from January 2004 to March 2007 to determine the incidence and clinical outcomes of IMD, including its impact on 1-year survival. Results: During this period, 172 patients with acute leukemia underwent chemotherapy with curative intent. A probable or proven IMD developed in 19 patients (cases), giving an incidence of 11%. Aspergillus was the commonest mould. Cases were more likely than controls to have prolonged neutropenia, fever that did not respond to carbapenems, a bacteremia and a longer length of stay. Three-month survival was 93.3% among both cases and controls, but one-year survival was 46.7% among cases and 93.3% among controls. Having an IMD appears to impart a higher risk of mortality at one year. Conclusion: The incidence of invasive mould disease in acute leukemia patients receiving chemotherapy is 11%. Absolute neutropenia more than 14 days is a risk factor for IMD. Itraconazole prophylaxis did not reduce the likelihood of an IMD and a change should be considered. Having an IMD appeared to predict mortality at 12 months.

A Report of Adult Human Adenovirus Infections in a Tertiary Hospital

Abstract We describe a review of human adenovirus (HAdV) infections occurring among adults in a tertiary hospital in Singapore from February to May 2013. A similar increase in cases was observed among children and military personnel during the same time period. The majority of isolates were identified as HAdV-7, likely an emerging pathogen in Asia.

A dedicated fungal culture medium is useful in the diagnosis of fungemia: a retrospective cross-sectional study.

Background Mortality for candidemia ranges from 15% to 35%. Current guidelines recommend inoculating blood into three aerobic and three anaerobic blood culture bottles when candidemia is suspected, without mention of a fungal blood culture bottle. Objective To determine the value of the BACTEC Myco/F Lytic blood culture media in the diagnosis of fungemia. Methods A two-year retrospective cross-sectional study was performed for patients who had fungemia with submitted BACTEC Plus Aerobic/F (Aer), BACTEC Plus Anaerobic/F (Anaer) or Myco/F Lytic (Myco) blood culture bottles. Results The detection rate of fungemia was 77.4% in 93 patients with contemporaneously submitted blood culture bottles when limited to only Aer/Anaer culture results. The detection rate improved significantly with the addition of the Myco culture bottle results (p<0.0001). A logistic regression model showed that Myco culture bottle submissions were less useful for patients with appropriate anti-fungal therapy administered within 48 hours [OR = 0.18, 95% CI = (0.06, 0.49), p = 0.001] and those with fungal growth detected within 48 hours [OR = 0.33, 95% CI = (0.12, 0.89), p = 0.001]. Among a subset of patients with concordant blood culture results, those with Myco culture bottles submission allowed earlier fungal detection and speciation by at least one day in 27.5% and 25.0% of the cases respectively. Conclusion Our study highlights the importance of a dedicated fungal blood culture when fungemia is clinically suspected. Nearly a quarter of fungemias may be missed if a fungal blood culture is not performed.

A retrospective review of a tertiary Hospital’s isolation and de-isolation policy for suspected pulmonary tuberculosis

BackgroundEffective protocols for the isolation and de-isolation of patients with suspected pulmonary tuberculosis (PTB) are essential determinants of health-care costs. Early de-isolation needs to be balanced with the need to prevent nosocomial transmission of PTB. The aim of our study was to evaluate the efficiency of our hospital’s current protocol for isolating and de-isolating patients with suspected PTB, in particular assessing the timeliness to de-isolation of patients with AFB smear negative respiratory samples.MethodsWe retrospectively reviewed 121 patients with suspected PTB who were admitted to our hospital’s isolation ward. We analyzed the time spent in isolation, the total number of respiratory samples that were collected for each patient and the time taken from collection of the first respiratory sample to release of the result of third respiratory sample for acid-fast bacilli (AFB) smear. We also calculated the direct cost of isolation for each patient.ResultsThe mean and median number of AFB smears for each patient was three. Thirty percent of patients had four or more AFB smears taken and 20% were de-isolated before the results of three negative AFB smears were obtained. The mean duration of isolation was significantly shorter in patients who had fewer than three negative AFB smears compared to those who had three or more negative AFB smears (three days vs. five days, p <0.01). The mean cost in patients who were de-isolated before three negative smears were obtained was USD 947 compared to USD 1,636 in those were only de-isolated after three negative AFB smears (p <0.01).ConclusionsOur study suggests that our institution’s current infection control policy for the isolation of patients with suspected PTB is fairly satisfactory, but may need to be tightened further to prevent true cases of PTB being de-isolated prematurely. However, there may be instances when patients could potentially be de-isolated more quickly without risk to others, thus saving on the use of limited resources and costs to patients.

Antimicrobial stewardship for acute-care hospitals: An Asian perspective.

Inappropriate use of antibiotics is contributing to a serious antimicrobial resistance problem in Asian hospitals. Despite resource constraints in the region, all Asian hospitals should implement antimicrobial stewardship (AMS) programs to optimize antibiotic treatment, improve patient outcomes, and minimize antimicrobial resistance. This document describes a consensus statement from a panel of regional experts to help multidisciplinary AMS teams design programs that suit the needs and resources of their hospitals. In general, AMS teams must decide on appropriate interventions (eg, prospective audit and/or formulary restriction) for their hospital, focusing on the most misused antibiotics and problematic multidrug-resistant organisms. This focus is likely to include carbapenem use with the goal to reduce carbapenem-resistant gram-negative bacteria. Rather than initially trying to introduce a comprehensive, hospital-wide AMS program, it would be practical to begin by pilot testing a simple program based on 1 achievable core intervention for the hospital. AMS team members must work together to determine the most suitable AMS interventions to implement in their hospitals and how best to put them into practice. Continuous monitoring and feedback of outcomes to the AMS teams, hospital administration, and prescribers will enhance sustainability of the AMS programs.

Utility of Serial β-D-Glucan Levels in Patients with High Risk for Invasive Candidiasis – A Potential Tool for Antifungal Stewardship

Abstract Background Invasive candidiasis (IC) is a severe infection in which diagnosis is challenging and often made late in the course of infection. Patients with delayed initiation of antifungals have high mortality risk; physicians tend to start empiric therapy at earliest clinical suspicion of IC. Excessive use of antifungals worsens selection pressure for resistance. Thus, alternative ways to aid antifungal stewardship are highly relevant. We aimed to evaluate performance of (1–3)-β-d-glucan (BDG) serial testing for antifungal stewardship to improve antifungal prescribing and to stop unnecessary use without compromising care. Methods This was a prospective observational study on patients at high risk of IC. Adults with recent intra-abdominal surgery, admitted to surgical intensive care unit (ICU), and prescribed an antifungal for suspected IC were included. Blood samples were taken at start of and days 3, 7, 10, 14, and weekly thereafter until antifungal is stopped, for BDG quantification with Fungitell assay. Medical records were reviewed for patient characteristics, antifungal regimen and outcomes. BDG was evaluated against clinical and microbiological outcomes. Sensitivity, specificity, positive and negative predictive values of BDG and Candida score were evaluated. Results We included 15 patients and 74 BDG levels. Patients with confirmed IC from cultures had a median BGD of >500 pg/mL and candida score of 3, compared with 55.5 pg/mL and score of 2 in those without confirmed IC. BGD assay anticipated diagnosis of IC with a sensitivity and specificity of 100% and 66.7%, with a positive and negative predictive value of 62.5% and 100% respectively. Of the five patients with confirmed IC, two had declining BDG, corresponding to clinical response to therapy. Their BDG were <80 pg/mL on day 7 and 14 of therapy, respectively, and were disharged from ICU, but one later had septic shock with Klebsiella pneumoniae bacteremia and demised. Repeat fungal cultures were negative. The remaining three had persistently high BGD of >500 pg/mL and eventually demised. No obvious trend was observed in those without confirmed IC. Conclusion We were able to characterise BDG levels in patients at high risk of IC. There is utility in BGD serial testing as a tool for antifungal stewardship, however more data is required to confirm findings. Disclosures All authors: No reported disclosures.

What We Learned From Plasma BK-Virus Monitoring in Allogeneic Hematopoietic Transplant Recipients.

Diagnosis Acute leukemia 149 (66.5) Myelodysplastic syndrome 26 (11.6) Myeloproliferative disorders 19 (8.5) Lymphoproliferative disease 24 (10.7) Aplastic anemia 6 (2.7) Conditioning regimen Myeloablative 103 (46) Reduced intensity 107 (47.8) Nonmyeloablative 14 (6.3) Graft source Sibling 118 (52.7) Unrelated donor 74 (33) Cord blood (2 units) 26 (11.6) Haploidentical donor 6 (2.7) B virus (BKV)-related hemorrhagic cystitis (HC) (BKHC) causes significant morbidity after allogeneic hematopoietic stem cell transplant (HSCT). The immunosuppressive state allows for BKV reactivation and active viral replication which destroys infected uroepithelial cells. The prevalence of this problem as reported in the literature is based mostly on retrospective analyses of patients presenting with HC as well as monitoring using urine samples for BKV, which we have previously found to have poor correlation with clinically significant HC in post-HSCT recipients. We initiated a BKV monitoring protocol that assumed that early detection or rising plasma BKV levels predicts for BKHC. A positive outcome would be the starting point for development of strategies aimed at halting progression to overt HC. The primary objective was to determine the predictive values of positive and/or incremental plasma BKV levels for clinically significant (grade ≥ 2) HC postallogeneic HSCT. Secondary objectives were to define BKHC prevalence and identify high-risk patients. Plasma BKV monitoring started before HSCT then continued weekly from days 14 to 56 using quantitative PCR targeting the VP1 protein gene paired with urine microscopy samples. Transplant conditioning intensity was as follows: myeloablative (busulfan-cyclophosphamide; cyclophosphamide-total body irradiation [TBI], 12 Gy; fludarabine-cyclophosphamide-TBI, 12 Gy), nonmyeloablative (fludarabine-TBI, 2 Gy; cyclophosphamide-antithymocyte globulin [ATG]; fludarabine-cyclophosphamide-TBI, 2 Gy), and reduced intensity (all others). The ATG and posttransplantation cyclophosphamide were used as in vivo T cell