Rohini Kelkar

Surgical site infection rates in six cities of India: findings of the International Nosocomial Infection Control Consortium (INICC).

BACKGROUND Surgical site infections are a threat to patient safety. However, in India, data on their rates stratified by surgical procedure are not available. METHODS From January 2005 to December 2011, the International Nosocomial Infection Control Consortium (INICC) conducted a cohort prospective surveillance study on surgical site infections in 10 hospitals in 6 Indian cities. CDC National Healthcare Safety Network (CDC-NHSN) methods were applied and surgical procedures were classified into 11 types, according to the ninth edition of the International Classification of Diseases. RESULTS We documented 1189 surgical site infections, associated with 28 340 surgical procedures (4.2%; 95% CI: 4.0-4.4). Surgical site infections rates were compared with INICC and CDC-NHSN reports, respectively: 4.3% for coronary bypass with chest and donor incision (4.5% vs 2.9%); 8.3% for breast surgery (1.7% vs 2.3%); 6.5% for cardiac surgery (5.6% vs 1.3%); 6.0% for exploratory abdominal surgery (4.1% vs 2.0%), among others. CONCLUSIONS In most types of surgical procedures, surgical site infections rates were higher than those reported by the CDC-NHSN, but similar to INICC. This study is an important advancement towards the knowledge of surgical site infections epidemiology in the participating Indian hospitals that will allow us to introduce targeted interventions.

Scalp flora in Indian patients undergoing craniotomy for brain tumors - Implications for pre-surgical site preparation and surgical site infection

Causation of surgical site infection (SSI) following craniotomy is multifactorial. Most preventive strategies (including site preparation and antibiotic prophylaxis) revolve around reducing preoperative contamination of the local site. There is little evidence, however, linking site contamination with postoperative infections. This is important given the preference for performing non-shaved cranial surgery. We undertook a prospective study to document the scalp flora in neurosurgical patients in an Indian setting and to assess possible association with SSI. A prospective study recruited 45 patients undergoing non-shaved clean craniotomies for various brain tumors. Standard perioperative procedures and antibiotic policy were employed. Prior to and immediately following the pre-surgical scrubbing, we collected swabs and evaluated their growth qualitatively. SSI was documented adhering to CDC guidelines. The association of swab-positivity with various parameters (including SSI) was evaluated. Pre-scrub positivity was seen in 18 of 44 patients, three of them developed subsequent SSI. Most were known skin contaminants. Five patients had swab positivity after scrubbing, though none of these developed any SSI. Four of these five had pre-scrub positivity. In three the same organisms persisted (two being Staphylococcus aureus) , and one had different growth post-scrub, whereas one patient developed new growth (contaminant mycelial fungus) in the post-scrub swab. We did not find any association between swab positivity and SSI. Swab positivity was also not related to hair-length or hygiene. Scalp flora in Indian patients is similar to that described. Pre-surgical preparation does not always eliminate this contamination (especially staphylococcus). However, this does not necessarily translate into increased SSI. Moreover, the results also provide objective evidence to support the performance of non-shaved cranial surgery without an undue risk of SSI.

Bacteriological profile and antibiotic susceptibility patterns of clinical isolates in a tertiary care cancer center.

Introduction: This increased risk of bacterial infections in the cancer patient is further compounded by the rising trends of antibiotic resistance in commonly implicated organisms. In the Indian setting this is particularly true in case of Gram negative bacilli such as Escherichia coli, Klebsiella pneumoniae and Acinetobacter spp. Increasing resistance among Gram positive organisms is also a matter of concern. The aim of this study was to document the common organisms isolated from bacterial infections in cancer patients and describe their antibiotic susceptibilities. Methods: We conducted a 6 month study of all isolates from blood, urine, skin/soft tissue and respiratory samples of patients received from medical and surgical oncology units in our hospital. All samples were processed as per standard microbiology laboratory operating procedures. Isolates were identified to species level and susceptibility tests were performed as per Clinical Laboratory Standards Institute (CLSI) guidelines -2012. Results: A total of 285 specimens from medical oncology (114) and surgical oncology services (171) were cultured. Escherichia coli, Klebsiella pneumoniae, Pseudomonas aeruginosa, Staphylococcus aureus and Acinetobacter spp. were most commonly encountered. More than half of the Acinetobacter strains were resistant to carbapenems. Resistance in Klebsiella pneumoniae to cephalosporins, fluoroquinolones and carbapenems was >50%. Of the Staphylococcus aureus isolates 41.67% were methicillin resistant. Conclusion: There is, in general, a high level of antibiotic resistance among gram negative bacilli, particularly E. coli, Klebsiella pneumoniae and Acinetobacter spp. Resistance among Gram positives is not as acute, although the MRSA incidence is increasing.

Correlation of HPV DNA result with cervical cancer in a tertiary care cancer centre

T long natural history of HPV diseases (e.g., CIN) provides an opportunity for potentially effective non-surgical management of these conditions before they become frank cancer. Traditional surgical treatment modalities have potential complications like bleeding, cervical stenosis, adverse pregnancy outcomes, infections, pain and most concerning, a high overall recurrence rate. Up to one in five women treated with local destructive surgical techniques will recur within two years thus potentially requiring another traumatic locally destructive therapy. Since surgical treatments are not ideal, there has long been interest in less invasive modalities for management of HPV diseases including vulvar and cervical dysplasias. We will attempt to briefly discuss these non-invasive management options that could be considered alternatives to local destructive surgical techniques in certain situations. Specific topics covered will include condom use, smoking, nutrients, retinoids, indoles, interferons, antimetabolites, immune therapies and more.

Ventilator-associated pneumonia: Survey of infection control practices in intensive care units of 15 tertiary care hospitals in Mumbai

Ventilator-associated pneumonia (VAP) is an important cause of morbidity and mortality in patients hospitalized in intensive care units (ICUs). Meticulous implementation of infection control measures is a key component for reducing the incidence of VAP. The Society for Healthcare Epidemiology of America, Infectious Diseases Society of America, Association for the Profession of Infection Control and Epidemiology, and Centers for Disease Control and Prevention provide guidelines1-3 that comprehensively review the infection control measures for VAP prevention and provide evidence-based recommendations. Studies have shown that the efficient implementation of VAP care bundles decreases the incidence of VAP4,5 and significantly improves outcomes. But although clear recommendations are now available for many components of these bundles (eg, semirecumbent patient positioning), there remain controversies over certain issues (eg, selective digestive tract decontamination). We conducted a survey to determine the VAP policies and practices in various Mumbai hospital ICUs and to compare them for uniformity and differences. A prestructured questionnaire designed to cover the important VAP prevention practices and procedures were circulated to participating hospitals in Mumbai. Respondents included 15 multispecialty tertiary care hospitals. The results of the survey are shown in Figure 1. Other relevant findings included the following. Closed suction systems were used by two-thirds of the respondents; 53.3% reported changing the suction system when it was soiled, 26.67% reported changing the system every 48 hours, and 13.3% reported changing the system every 24 hours. Sixty percent of respondents reported changing the ventilator circuit when it was soiled, 20% reported changing it at 48 hours, and 13.3% reported changing it at 7 days. Heat moisture exchanger humidifiers were used by all respondents; approximately 20% of respondents changed the humidifier at 24 hours, 53.33% did so at 48 hours and 13.33% did so after 72 hours. The important components of ventilator patient care aimed at reducing infection include preventing inspiration of oropharyngeal secretions, preventing contamination of equipment, preventing