Moi Lin Ling

The Global Spread of Healthcare-Associated Multidrug-Resistant Bacteria: A Perspective From Asia

Since antibiotics were first used, each new introduced class has been followed by a global wave of emergent resistance, largely originating in Europe and North America where they were first used. Methicillin-resistant Staphylococcus aureus spread from the United Kingdom and North America across Europe and then Asia over more than a decade. Vancomycin-resistant enterococci and Klebsiella pneumoniae carbapenemase-producing K. pneumoniae followed a similar path some 20 years later. Recently however, metallo-β-lactamases have originated in Asia. New Delhi metallo-β-lactamase-1 was found in almost every continent within a year of its emergence in India. Metallo-β-lactamase enzymes are encoded on highly transmissible plasmids that spread rapidly between bacteria, rather than relying on clonal proliferation. Global air travel may have helped facilitate rapid dissemination. As the antibiotic pipeline offers little in the short term, our most important tools against the spread of antibiotic resistant organisms are intensified infection control, surveillance, and antimicrobial stewardship.

The impact of multidrug resistance in healthcare-associated and nosocomial Gram-negative bacteraemia on mortality and length of stay: cohort study

Multidrug-resistant Gram-negative bacteria (MDR-GNB) are an emerging public health threat. Accurate estimates of their clinical impact are vital for justifying interventions directed towards preventing or managing infections caused by these pathogens. A retrospective observational cohort study was conducted between 1 January 2007 and 31 July 2009, involving subjects with healthcare-associated and nosocomial Gram-negative bacteraemia at two large Singaporean hospitals. Outcomes studied were mortality and length of stay post-onset of bacteraemia in survivors (LOS). There were 675 subjects (301 with MDR-GNB) matching study inclusion criteria. On multivariate analysis, multidrug resistance was not associated with 30-day mortality, but it was independently associated with longer LOS in survivors (coefficient, 0.34; 95% CI, 0.21-0.48; p < 0.001). The excess LOS attributable to multidrug resistance after adjustment for confounders was 6.1 days. Other independent risk factors for higher mortality included male gender, higher APACHE II score, higher Charlson comorbidity index, intensive care unit stay and presence of concomitant pneumonia. Concomitant urinary tract infection and admission to a surgical discipline were associated with lower risk of mortality. Appropriate empirical antibiotic therapy was neither associated with 30-day mortality nor LOS, although the study was not powered to assess this covariate adequately. Our study adds to existing evidence that multidrug resistance per se is not associated with higher mortality when effective antibiotics are used for definitive therapy. However, its association with longer hospitalization justifies the use of control efforts.

The Burden of Healthcare-Associated Infections in Southeast Asia: A Systematic Literature Review and Meta-analysis

A systematic literature review and meta-analysis of the burden of healthcare-associated infections (HAIs) in Southeast Asia was performed on 41 studies out of the initially identified 14 089 records. The pooled prevalence of overall HAIs was 9.0% (95% confidence interval [CI], 7.2%-10.8%), whereas the pooled incidence density of HAI was 20 cases per 1000 intensive care unit-days. The pooled incidence density of ventilator-associated pneumonia, central line-associated bloodstream infection, and catheter-associated urinary tract infection was 14.7 per 1000 ventilator-days (95% CI, 11.7-17.7), 4.7 per 1000 catheter-days (95% CI, 2.9-6.5), and 8.9 per 1000 catheter-days (95% CI, 6.2-11.7), respectively. The pooled incidence of surgical site infection was 7.8% (95% CI, 6.3%-9.3%). The attributed mortality and excess length of stay in hospitals of infected patients ranged from 7% to 46% and 5 to 21 days, respectively.

Control of a hospital-wide vancomycin-resistant Enterococci outbreak

Background To analyze control measures used to eradicate a large vancomycin-resistant Enterococci (VRE) outbreak in a nonendemic 1600-bed tertiary care institution. Methods In mid-March 2005, VRE Van B was isolated from 2 clinical samples from different wards. Despite such measures as screening patients sharing rooms with index cases and isolating VRE patients, 43 isolates from different wards were detected by the end of March 2005. To eradicate a hospital-wide outbreak, a coordinated strategy between March and June 2005 comprised (1) formation of a VRE task force, (2) hospital-wide screening, (3) isolation of carriers, (4) physical segregation of contacts, (5) surveillance of high-risk groups, (6) increased cleaning, (7) electronic tagging of VRE status, and (8) education and audits. This is a retrospective study of this multipronged approach to containing VRE. The adequacy of rectal swab sampling for VRE was assessed in a substudy of 111 patients. The prevalence of methicillin-resistant Staphylococcus aureus (MRSA)/VRE co-colonization or co-infection also was determined. Results A total of 19,574 contacts were identified. Between April and June 2005, 5095 patients were screened, yielding 104 VRE carriers, 54 of whom (52%) were detected in the first 2 weeks of hospital-wide screening. The initial positive yield of 11.4% of persons actively screened declined to 4.2% by the end of June 2005. Pulsed-field typing revealed 1 major clone and several minor clones among the 151 total VRE cases, including 4 clinical cases. Hospital-wide physical segregation of contacts from other patients was difficult to achieve in communal wards. Co-colonization or co-infection with MRSA, which was present in 52 of 151 cases (34%) and the indefinite electronic tagging of positive VRE status strained limited isolation beds. Analysis of 2 fecal or rectal specimens collected 1 day apart may detect at least 83% of VRE carriers. Conclusion A multipronged strategy orchestrated by a central task force curbed but could not eradicate VRE. Control measures were confounded by hospital infrastructure and high MRSA endemicity.

APSIC guide for prevention of Central Line Associated Bloodstream Infections (CLABSI)

This document is an executive summary of the APSIC Guide for Prevention of Central Line Associated Bloodstream Infections (CLABSI). It describes key evidence-based care components of the Central Line Insertion and Maintenance Bundles and its implementation using the quality improvement methodology, namely the Plan-Do-Study-Act (PDSA) methodology involving multidisciplinary process and stakeholders. Monitoring of improvement over time with timely feedback to stakeholders is a key component to ensure the success of implementing best practices. A surveillance program is recommended to monitor outcomes and adherence to evidence-based central line insertion and maintenance practices (compliance rate) and identify quality improvement opportunities and strategically targeting interventions for the reduction of CLABSI.

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.

APSIC Guidelines for environmental cleaning and decontamination

This document is an executive summary of APSIC Guidelines for Environmental Cleaning and Decontamination. It describes best practices in routine cleaning and decontamination in healthcare facilities as well as in specific settings e.g. management of patients with isolation precautions, food preparation areas, construction and renovation, and following a flood. It recommends the implementation of environmental hygiene program to keep the environment safe for patients, staff and visitors visiting a healthcare facility. Objective assessment of cleanliness and quality is an essential component of this program as a method for identifying quality improvement opportunities. Recommendations for safe handling of linen and bedding; as well as occupational health and safety issues are included in the guidelines. A training program is vital to ensure consistent adherence to best practices.

Prevalence of Healthcare-Associated Infections and Antimicrobial Use Among Adult Inpatients in Singapore Acute-Care Hospitals: Results From the First National Point Prevalence Survey.

Background We conducted a national point prevalence survey (PPS) to determine the prevalence of healthcare-associated infections (HAIs) and antimicrobial use (AMU) in Singapore acute-care hospitals. Methods Trained personnel collected HAI, AMU, and baseline hospital- and patient-level data of adult inpatients from 13 private and public acute-care hospitals between July 2015 and February 2016, using the PPS methodology developed by the European Centre for Disease Prevention and Control. Factors independently associated with HAIs were determined using multivariable regression. Results Of the 5415 patients surveyed, there were 646 patients (11.9%; 95% confidence interval [CI], 11.1%-12.8%) with 727 distinct HAIs, of which 331 (45.5%) were culture positive. The most common HAIs were unspecified clinical sepsis (25.5%) and pneumonia (24.8%). Staphylococcus aureus (12.9%) and Pseudomonas aeruginosa (11.5%) were the most common pathogens implicated in HAIs. Carbapenem nonsusceptibility rates were highest in Acinetobacter species (71.9%) and P. aeruginosa (23.6%). Male sex, increasing age, surgery during current hospitalization, and presence of central venous or urinary catheters were independently associated with HAIs. A total of 2762 (51.0%; 95% CI, 49.7%-52.3%) patients were on 3611 systemic antimicrobial agents; 462 (12.8%) were prescribed for surgical prophylaxis and 2997 (83.0%) were prescribed for treatment. Amoxicillin/clavulanate was the most frequently prescribed (24.6%) antimicrobial agent. Conclusions This survey suggested a high prevalence of HAIs and AMU in Singapores acute-care hospitals. While further research is necessary to understand the causes and costs of HAIs and AMU in Singapore, repeated PPSs over the next decade will be useful to gauge progress at controlling HAIs and AMU.

APSIC guidelines for disinfection and sterilization of instruments in health care facilities

BackgroundThe Asia Pacific Society of Infection Control launched its revised Guidelines for Disinfection and Sterilization of Instruments in Health Care Facilities in February 2017. This document describes the guidelines and recommendations for the reprocessing of instruments in healthcare setting. It aims to highlight practical recommendations in a concise format designed to assist healthcare facilities at Asia Pacific region in achieving high standards in sterilization and disinfection.MethodThe guidelines were revised by an appointed workgroup comprising experts in the Asia Pacific region, following reviews of previously published guidelines and recommendations relevant to each section.ResultsIt recommends the centralization of reprocessing, training of all staff with annual competency assessment, verification of cleaning, continual monitoring of reprocessing procedures to ensure their quality and a corporate strategy for dealing with single-use and single-patient use medical equipment/devices. Detailed recommendations are also given with respect to reprocessing of endoscopes. Close working with the Infection Prevention & Control department is also recommended where decisions related to reprocessing medical equipment/devices are to be made.ConclusionsSterilization facilities should aim for excellence in practices as this is part of patient safety. The guidelines that come with a checklist help service providers identify gaps for improvement to reach this goal.

Reply to Wang et al

TO THE EDITOR—We thank Wang et al for their interest in our systematic review and meta-analysis of healthcare-associated infections (HAIs) in Southeast Asia. Welldesigned systematic reviews and metaanalyses can clarify important questions in public health and medicine, which can be utilized to support health policy and health promotion activities. Wang et al made several significant comments on our systematic reviewandmeta-analysis, which we believe are valuable for academic discussion. These include comments on quality assessment, heterogeneity, and Egger test for funnel plot asymmetry. The methodological quality of studies included in our systematic review was assessed using the STrengthening the Reporting of OBservational studies in Epidemiology (STROBE) checklist mainly because it covers 3 major types of observational research: cohort, case-control, and cross-sectional studies [1]. Several systematic reviews had previously used STROBE as a quality assessment tool, including published systematic reviews related to infectious diseases [2, 3]. The Newcastle-Ottawa scale [4]and theDowns and Black [5] methodological assessment quality checklist, as suggested by Wang et al, may be helpful to assess nonrandomized controlled trials, such as prospective cohort studies or retrospective case-control studies. Our systematic review included prevalence and incidence studies, which are classified as crosssectional studies. Another option that we consideredwas the quality assessment used by Allegranzi et al [6].However, Allegranzi et al’s predetermined criteria—prospective study design, use of standardized definitions of HAI, detection of ≥4 major infections within each study, and publication in a peer-reviewed journal [6]—did not meet our eligibility criteria. Even though studies of moderate (n = 9) to low (n = 3) quality were identified, they were included in the pooled data to minimize the reduction of statistical power. We agree withWang et al that there is significant heterogeneity of the pooled data and we thank them for conducting the sensitivity analysis via the leave-one-out method. However, we prefer to perform sensitivity analysis by pooling data from subsets of studies based on high-quality vs moderateto low-quality studies, as we find this more useful to interpret by choosing a decision node rather than invoking the leave-one-out method. We concur with Abdel-Aleem and Nasr [7] that a good sensitivity analysis will explore the effect on pooled outcomes when various categories of studies are excluded. Other sensitivity analysis methods also offer benefits over the leave-one-out approach, as discussed by Higgins [8] and Patsopoulos et al [9]. Sensitivity analyses were done for each pooled data set to retain high-quality studies only (Table 1). Egger test has been used to test for funnel plot asymmetry to determine if there is possible bias in meta-analysis. This test for funnel asymmetry has been recommended to be used only if there are ≥10 studies [10, 11, 12]. This is the primary reason why we only used Egger test for studies related to surgical site infections. Egger et al cautioned the users of this test when there are limited studies, as its capacity to detect bias will be limited [13]. Furthermore, the results of Egger test for funnel plot asymmetry will be seriously prone to false-positive findings if statistical power is low [11, 12].