Sally C. Y. Wong

Zika virus infection-the next wave after dengue?

Zika virus was initially discovered in east Africa about 70xa0years ago and remained a neglected arboviral disease in Africa and Southeast Asia. The virus first came into the limelight in 2007 when it caused an outbreak in Micronesia. In the ensuing decade, it spread widely in other Pacific islands, after which its incursion into Brazil in 2015 led to a widespread epidemic in Latin America. In most infected patients the disease is relatively benign. Serious complications include Guillain-Barré syndrome and congenital infection which may lead to microcephaly and maculopathy. Aedes mosquitoes are the main vectors, in particular, Ae. aegypti. Ae. albopictus is another potential vector. Since the competent mosquito vectors are highly prevalent in most tropical and subtropical countries, introduction of the virus to these areas could readily result in endemic transmission of the disease. The priorities of control include reinforcing education of travellers to and residents of endemic areas, preventing further local transmission by vectors, and an integrated vector management programme. The container habitats of Ae. aegypti and Ae. albopictus means engagement of the community and citizens is of utmost importance to the success of vector control.

Clinical evaluation of the new high-throughput Luminex NxTAG Respiratory Pathogen Panel assay for multiplex respiratory pathogen detection

ABSTRACT A broad range of viral and bacterial pathogens can cause acute respiratory tract infection. For rapid detection of a broad respiratory pathogen spectrum, multiplex real-time PCR is ideal. This study evaluated the performance of the new Luminex NxTAG Respiratory Pathogen Panel (NxTAG-RPP) in comparison with the BioFire FilmArray Respiratory Panel (FA-RP) or singleplex real-time PCR as reference. A total of 284 clinical respiratory specimens and 3 influenza A/H7N9 viral culture samples were tested. All clinical specimens were processed and analyzed in parallel using NxTAG-RPP and the reference standard method. The H7N9 viral culture samples were tested using NxTAG-RPP only. Overall, the NxTAG-RPP demonstrated ≥93% sensitivity and specificity for all respiratory targets except human coronavirus OC43 (HCoV-OC43) and HCoV-HKU1. The H7N9 virus was detected by the influenza A virus matrix gene target, while other influenza A virus subtyping gene targets in the panel remained negative. Complete concordance between NxTAG-RPP and FA-RP was observed in 98.8% (318/322) of positive results (kappa = 0.92). Substantial agreement was found for most respiratory targets, but significant differences were observed in human metapneumovirus (P = 0.001) and parainfluenza virus type 3 (P = 0.031). NxTAG-RPP has a higher sample throughput than FA-RP (96 samples versus 1 sample per run) while the turnaround times for NxTAG-RPP and FA-RP were 5 h (up to 96 samples) and 1 h (for one sample), respectively. Overall, NxTAG-RPP demonstrated good diagnostic performance for most respiratory pathogens. The high sample throughput with reasonable turnaround time of this new assay makes it a suitable multiplex platform for routine screening of respiratory specimens in hospital-based laboratories.

Proactive infection control measures to prevent nosocomial transmission of vancomycin-resistant enterococci in Hong Kong

BACKGROUND/PURPOSEnThe study describes a proactive infection control approach to prevent nosocomial transmission of vancomycin-resistant enterococci (VRE) and tests if this approach is effective for controlling multiple-drug resistant organisms in a nonendemic setting.nnnMETHODSnIn response to the increasing prevalence of VRE in Hong Kong since 2011, we adopted a multifaceted assertive approach in our health care network. This included active surveillance culture, extensive contact tracing, directly observed hand hygiene in conscious patients before they received meals and medications, stringent hand hygiene and environmental cleanliness, and an immediate feedback antimicrobial stewardship program. We report the occurrence of VRE outbreaks in our hospital after institution of these measures and compared with the concurrent occurrence in other public hospitals in Hong Kong.nnnRESULTSnBetween July 1, 2011 and November 13, 2013, VRE was identified in 0.32% (50/15,851) of admission episodes by active surveillance culture. The risk of VRE carriage was three times higher in patients with a history of hospitalization outside our hospital networks in the past 3 months (0.56% vs. 0.17%; p = 0.001) compared with those who were not. Extensive contact tracing involving 3277 patient episodes was performed in the investigation for the 25 VRE index patients upon whom implementation of contact precautions was delayed (more than 48 hours of hospitalization). One episode of VRE outbreak was identified in our hospital network, compared with the 77 VRE outbreaks reported in the other hospital networks (controls) without these proactive infection control measures.nnnCONCLUSIONnOur multifaceted assertive proactive infection control approach can minimize the nosocomial transmission and outbreak of VRE in a nonendemic area.

Hospital Outbreak of Pulmonary and Cutaneous Zygomycosis due to Contaminated Linen Items From Substandard Laundry

BACKGROUNDnHealthcare laundry-related infection is rare, and pulmonary zygomycosis due to contaminated hospital linens has never been reported.nnnMETHODSnWe reported an outbreak investigation of zygomycosis in a university-affiliated teaching hospital. Air samplers, sponge swabs and Replicate Organism Detection and Counting (RODAC) contact plates were used for environmental sampling. The fungal isolates from clinical and environmental samples were identified by morphology, MALDI-TOF MS, and ITS1-5.8S-ITS2 rRNA gene cluster sequencing.nnnRESULTSnFrom 2 June 2015 to 18 July 2015, 6 immunosuppressed patients developed pulmonary (n = 4) and/or cutaneous (n = 3) infection by a spore-forming mold, Rhizopus microsporus, through direct inhalation and skin contact of contaminated linen items supplied by a designated laundry. Seventy (27.8%) of 252 freshly laundered clothing and 15 (3.4%) of 443 nonclothing laundered linen items (pillow case, bed sheet, draw sheet) were contaminated by R. microsporus, which was significantly higher than those from other hospital laundries (0%, n = 451; P < .001) supplying linen to hospitals with no cases of zygomycosis reported during the same period. The fungal isolates from patients and linens were phylogenetically related. In sum, 61% of environmental samples and 100% of air samples at the designated laundry were also positive for zygomycetes, suggesting heavy environmental contamination. RODAC contact plates revealed mean total viable bacteria counts of freshly laundered items (1028 ± 611 CFU/100 cm(2)) far exceeded the hygienically clean standard of 20 CFU/100 cm(2) set by the US healthcare textile certification requirement.nnnCONCLUSIONSnSuboptimal conditions of washing, drying, and storage contributed to the massive linen contamination and the outbreak of zygomycosis.

Implementation of directly observed patient hand hygiene for hospitalized patients by hand hygiene ambassadors in Hong Kong

BACKGROUNDnThe importance of compliance with hand hygiene by patients is increasingly recognized to prevent health care-associated infections.nnnMETHODSnThis descriptive study observed the effects of an education campaign, targeted to increase patients self-initiated hand hygiene, and a hand hygiene ambassador-initiated directly observed hand hygiene program on patients hand hygiene compliance in a university-affiliated hospital.nnnRESULTSnThe overall audited compliance of patients self-initiated hand hygiene was only 37.5%, with a rate of 26.9% (112/416 episodes) before meals and medications, 27.5% (19/69 episodes) after using a urinal or bedpan, and 89.7% (87/97 episodes) after attending toilet facilities. Patients referred from a residential care home for older adults had significantly lower hand hygiene compliance (Pu2009=u2009.007). Comparatively, the overall audited compliance of ambassador-initiated directly observed hand hygiene was 97.3% (428/440 episodes), which was significantly higher than patients self-initiated hand hygiene via a patient education program (37.5%, 218/582 episodes, Pu2009<u2009.001).nnnCONCLUSIONSnDirectly observed hand hygiene can play an important role in improving compliance with hand hygiene by hospitalized patients.

Fatal empyema thoracis caused by Schizophyllum commune with cross-reactive cryptococcal antigenemia.

ABSTRACT We report a fatal case of Schizophyllum commune empyema thoracis with cross-reactive cryptococcal antigenemia. In vitro testing confirmed the ability of the fungus to cause a positive cryptococcal antigen latex agglutination system (CALAS) test result. Such a result may lead to delay in diagnosis and treatment, as most strains of S. commune are resistant to fluconazole.

Infection Control Preparedness for Human Infection With Influenza A H7N9 in Hong Kong

OBJECTIVE To assess the effectiveness of infection control preparedness for human infection with influenza A H7N9 in Hong Kong. DESIGN A descriptive study of responses to the emergence of influenza A H7N9. SETTING A university-affiliated teaching hospital. PARTICIPANTS Healthcare workers (HCWs) with unprotected exposure (not wearing N95 respirator during aerosol-generating procedure) to a patient with influenza A H7N9. METHODS A bundle approach including active and enhanced surveillance, early airborne infection isolation, rapid molecular diagnostic testing, and extensive contact tracing for HCWs with unprotected exposure was implemented. Seventy HCWs with unprotected exposure to an index case were interviewed especially regarding their patient care activities. RESULTS From April 1, 2013, through May 31, 2014, a total of 126 (0.08%) of 163,456 admitted patients were tested for the H7 gene by reverse transcription-polymerase chain reaction per protocol. Two confirmed cases were identified. Seventy (53.8%) of 130 HCWs had unprotected exposure to an index case, whereas 41 (58.6%) and 58 (82.9%) of 70 HCWs wore surgical masks and practiced hand hygiene after patient care, respectively. Sixteen (22.9%) of 70 HCWs were involved in high-risk patient contacts. More HCWs with high-risk patient contacts received oseltamivir prophylaxis (P=0.088) and significantly more had paired sera collected for H7 antibody testing (P<0.001). Ten (14.3%) of 70 HCWs developed influenza-like illness during medical surveillance, but none had positive results by reverse transcription-polymerase chain reaction. Paired sera was available from 33 of 70 HCWs with unprotected exposure, and none showed seroconversion against H7N9. CONCLUSIONS Despite the delay in airborne precautions implementation, no patient-to-HCW transmission of influenza A H7N9 was demonstrated.

Minimal Intervention for Controlling Nosocomial Transmission of Methicillin-Resistant Staphylococcus aureus in Resource Limited Setting with High Endemicity

Objective To control nosocomial transmission of methicillin-resistant Staphylococcus aureus (MRSA) in resource-limited healthcare setting with high endemicity. Methods Three phases of infection control interventions were implemented in a University-affiliated hospital between 1-January-2004 and 31-December-2012. The first phase of baseline period, defined as the first 48-months of the study period, when all MRSA patients were managed with standard precautions, followed by a second phase of 24-months, when a hospital-wide hand hygiene campaign was launched. In the third phase of 36-months, contact precautions in open cubicle, use of dedicated medical items, and 2% chlorhexidine gluconate daily bathing for MRSA-positive patients were implemented while hand hygiene campaign was continued. The changes in the incidence rates of hospital-acquired MRSA-per-1000-patient admissions, per-1000-patient-days, and per-1000-MRSA-positive-days were analyzed using segmented Poisson regression (an interrupted time series model). Usage density of broad-spectrum antibiotics was monitored. Results During the study period, 4256 MRSA-positive patients were newly diagnosed, of which 1589 (37.3%) were hospital-acquired. The reduction of hospital-acquired MRSA per 1000-patient admissions, per 1000-patient-days, and per 1000-MRSA-positive-days from phase 1 to 2 was 36.3% (p<0.001), 30.4% (p<0.001), and 19.6% (pu200a=u200a0.040), while the reduction of hospital-acquired MRSA per 1000-patient admissions, per 1000-patient-days, and per 1000-MRSA-positive-days from phase 2 to 3 was 27.4% (p<0.001), 24.1% (p<0.001), and 21.9% (pu200a=u200a0.041) respectively. This reduction is sustained despite that the usage density of broad-spectrum antibiotics has increased from 132.02 (phase 1) to 168.99 per 1000 patient-days (phase 3). Conclusions Nosocomial transmission of MRSA can be reduced with hand hygiene campaign, contact precautions in open cubicle, and 2% chlorhexidine gluconate daily bathing for MRSA-positive despite an increasing consumption of broad-spectrum antibiotics.

Infections associated with body modification

Although exact statistics are lacking, body modifications for cosmetic purposes are performed in many countries. The commonest forms include tattooing, body piercing, and breast and facial augmentation using implants or injectable fillers. Liposuction and, to a lesser extent, mesotherapy are also practiced in many countries. Infective complications of these procedures include local infections, transmission of bloodborne pathogens (viral hepatitis and human immunodeficiency virus), and distant infections such as infective endocarditis. Presence of foreign bodies, long healing time of piercing wounds, and poor compliance with infection control practices of some practitioners all predispose the recipients to infections. Apart from the endogenous microbial flora of the skin and mucosae, atypical mycobacteria, especially the rapid growers, have emerged as some of the most important pathogens in such settings. Outbreaks of infection are commonly reported. We hereby review the current knowledge of the topic with specific focus on infections associated with tattooing, body piercing, breast augmentation, mesotherapy, liposuction, and tissue filler injections. Greater awareness among consumers and health-care professionals, as well as more stringent regulations by the health authorities, is essential to minimize the health risks arising from these procedures.

Disseminated fusarium infection after ibrutinib therapy in chronic lymphocytic leukaemia

Dear Editor, A 46-year-old man presented in 2007 with generalized lymphadenopathy. A diagnosis of small lymphocytic lymphoma/ chronic lymphocytic leukaemia (CLL) with marrow involvement was made. He was treated with 6 cycles of fludarabine, mitoxantrone and dexamethasone and achieved a complete remission (CR). The disease relapsed in 2010, and he was treated with 6 cycles of rituximab, cyclophosphamide, epirubicin, vincristine and prednisolone, followed by consolidation with ibritumomab tiuxetin. In 2014, there was disease recurrence, presenting as generalized lymphadenopathy and marrow infiltration with anaemia and thrombocytopenia. Fluorescence in situ hybridization (FISH) showed a deletion of 11q23. Six cycles of obinutuzumab and bendamustine were given. However, pancytopenia due to marrow infiltration persisted. Because of neutropenia, he was put on maintenance itraconazole (200 mg twice daily) and regular injections of granulocyte colony stimulating factor to increase the neutropil count. After a brief period of stable disease, progressive lymphadenopathy then developed. He was started on the Bruton tyrosine kinase inhibitor ibrutinib at 420 mg daily. Itraconazole had to be stopped because of liver function derangement. Patient gave informed consent to treatment. Six weeks after commencement of ibrutinib, he developed unremitting fever. Full blood count showed haemoglobin: 7.4 g/dL; white cell count: 37.7 × 10/L (neutrophil: 0.5 × 10/L, lymphocyte 36.9 × 10/L); and platelet count: 24 × 10/L. There was also profound hypogammaglobulinaemia (immunoglobulin A, IgA: 9 mg/dL; IgG: 483 mg/dL; IgM: 15 mg/dL). Physical examination showed multiple skin lesions, including a plaque with a necrotic centre in the right calf (Fig. 1a), and ulcerated nodules in the right submandibular region, left shoulder and left knee (Fig. 1b). Biopsy of the left knee skin lesion showed infiltration of inflammatory cells (Fig. 1c), and Grocott stain showed the presence of fungal elements (Fig. 1d). Culture from blood and the biopsied tissue was negative. Polymerase chain reaction followed by sequencing of the internal transcribed spacer region confirmed that the fungus belonged to the Fusarium solani species complex. He was treated with oral voriconazole (400 mg twice daily for 1 day then 200 mg twice daily). Defervescence was achieved a week after voriconazole therapy and he was discharged. Six weeks later, the neutrophil count started to rise and skin lesions gradually subsided. Voriconazole has since been continued as secondary prophylaxis. Sixteen months after commencement of ibrutinib, he has normal blood counts and complete regression of all nodal lesions. Fusarium spp. are important hyaline moulds that can cause serious infections in immunocompromised hosts. They are ubiquitous in the environment, distributed widely in soil, plants and water systems [1]. The infection ranges from superficial (fungal keratitis, onychomycosis) to invasive (sinusitis, pneumonia) and disseminated. In patients with haematological malignancies, infection is typically invasive and disseminated [2]. Neutropenia and defects in T cell immunity are the important underlying risks. In a recent study from three countries over a 66-month period, 76 cases of fusariosis were * Yok-Lam Kwong ylkwong@hkucc.hku.hk