Surendra Karki

Impact of chlorhexidine-impregnated washcloths on reducing incidence of vancomycin-resistant enterococci colonization in hematology-oncology patients.

BACKGROUND Daily skin cleansing with washcloths impregnated with chlorhexidine gluconate (CHG) of patients in intensive care unit is associated with reduction in incidence of vancomycin-resistant Enterococci (VRE) acquisition. This study describes the impact on incidence of VRE colonization after the implementation of daily skin cleansing with 2% CHG-impregnated washcloths in hematology-oncology patients. METHODS In this before-and-after study, we compared the incidence rate of VRE colonization during the baseline period (where routine soap-and-water bathing was used) with the intervention period where patients were cleansed with 2% CHG-impregnated washcloths. RESULTS Acquisition of VRE decreased from 7.8% in the baseline to 3.8% in the intervention period (relative risk, 0.48, 95% confidence interval [CI], 0.21-1.09; P = .07). The crude relative rate of acquisition during the intervention period compared with the baseline period was 0.53 (95% CI, 0.23-1.23; P = .13). Patients who had been a roommate of a patient subsequently found to have VRE were at a significantly increased risk for acquiring VRE (hazard ratio, 18.8, 95% CI, 5.37-66.15; P < .001). However, patients admitted to the same bed number of previously known VRE-colonized patient were not at increased risk of VRE acquisition (hazard ratio, 0.37, 95% CI, 0.11-1.22; P = .10). CONCLUSION We did not observe a statistically significant reduction in the rate of VRE colonization in association with the use of 2% CHG-impregnated washcloths among hematology-oncology patients.

Patients under contact precautions have an increased risk of injuries and medication errors: a retrospective cohort study.

Contact precautions (CPs) may lead to adverse psychological effects, delays in access to services, and compromises in the quality of care and patient safety. These need to be balanced with the benefits in preventing transmission of resistant microorganisms. In this study, we aimed to quantify the effect of CPs on reported patient safety incidents. The Alfred hospital is a tertiary referral hospital in Melbourne, Australia. Previous studies have shown that colonization with vancomycin-resistant enterococcus (VRE) is endemic in our hospital. Patients found to be colonized with VRE are placed in CPs immediately and during each subsequent admission. At our facility, modified CPs practiced during the study period include isolation in single rooms with a dedicated toilet, use of gloves when entering the room, and gloves and gown if contact with body fluids is anticipated. The hospital has a computerized risk management system where relevant patient safety incidents are reported to facilitate institutional review and response. We conducted a retrospective cohort study using these routinely collected data, comparing the incidence rate of documented adverse events in patients prior and subsequent to initiation of CPs among patients colonized or infected with VRE. Patients with incident VRE detection between January 2009 and October 2010 were included.

Trends of Etiology and Drug Resistance in Enteric Fever in the Last Two Decades in Nepal: A Systematic Review and Meta-analysis

Prospective time-trend analyses on shifting etiology and trends of drug resistance in enteric fever are scarce. Using published and unpublished datasets from Nepal, we performed a systematic review and meta-analysis to understand the trends in etiology and resistance to antimicrobials that have occurred since 1993. Thirty-two studies involving 21 067 Salmonella enterica serotype Typhi (ST) and S. enterica serotype Paratyphi A (SPA) isolates were included. There was an increasing trend in enteric fever caused by SPA during the last 2 decades (P < .01). We observed sharply increasing trends in resistance to nalidixic acid and ciprofloxacin for both ST and SPA. In contrast, multi-drug resistance (MDR), resistance to traditional first-line antibiotics such as chloramphenicol and co-trimoxazole have significantly decreased for both organisms. The resistance to ceftriaxone has remained low, suggesting it is likely to remain useful as a reserve antibiotic for treatment. Trends in decreasing resistance to traditional first-line antibiotics and decreasing MDR provide an opportunity to reconsider these first-line antimicrobials as therapeutic options.

Prevalence and risk factors for VRE colonisation in a tertiary hospital in Melbourne, Australia: a cross sectional study

BackgroundVancomycin-resistant Enterococcus (VRE) has been established as a significant health-care associated problem since its first isolation in Australia in 1994. In this study, we measured the point prevalence and identified risk factors associated with vanB VRE colonisation in a tertiary care hospital in Melbourne, Australia where VRE has been endemic for 15 years.MethodsA hospital-wide point prevalence survey was conducted on October 13, 2008 with colonisation detected using rectal swab culture. Patient’s demographic and medical information was collected through a review of medical records. Factors associated with VRE colonisation in univariate analysis were included in multivariate logistic regression model to adjust for confounding.ResultsThe prevalence of VRE colonisation on the day of screening was 17.5% (95% CI, 13.7 to 21.9). VRE was detected from patients in each ward with the prevalence ranging from 3% to 29%. Univariate analysis showed the use of any antibiotic, meropenem, ciprofloxacin, diarrhoea and longer length of hospital stay were associated with increased risk of VRE colonisation (p<0.05). However, age, sex, proximity to VRE positive cases, use of other antibiotics including cephalosporins, vancomycin were not associated with increased risk (P>0.05). Multivariate analysis showed the exposure to meropenem (p=0.004), age (≥65 years) (p=0.036) and length of stay ≥7 days (p<0.001) as independent predictors of VRE colonisation.ConclusionOur study suggests that exposure to antibiotics may have been more important than recent cross transmission for a high prevalence of vanB VRE colonisation at our hospital.

Long-Term Carriage of Vancomycin-Resistant Enterococci in Patients Discharged from Hospitals: a 12-Year Retrospective Cohort Study

ABSTRACT Contact precautions are recommended in hospitals to prevent the transmission of vancomycin-resistant enterococci (VRE); however, there is no clear policy for how long patients should be under contact precautions due to a lack of information on the duration of carriage of these organisms. We conducted a retrospective cohort study to understand the duration of carriage of VRE (by screening of a single stool culture) and associated factors among patients who had been identified with VRE infection and/or colonization since the year 2000 at our health facilities. Of the 345 eligible participants, 136 did not respond, 90 declined to participate, and 16 did not send in the required specimens. Of the 103 remaining participants, 13 were found to have current VRE fecal carriage. The proportion of colonized patients fell from 40% (2/5) in the first year to 23.3% (7/30) in year 4. None of the 40 patients who had VRE detected >4 years prior were found to be colonized at the time of the study. The longest duration of detected VRE positivity was 46.5 months. Univariate analysis revealed that recent exposure to any antibiotics (P = 0.016), multiple antibiotics (P = 0.001), amoxicillin-clavulanic acid (P = 0.021), piperacillin-tazobactam (P = 0.007), glycopeptides (P < 0.001), meropenem (P = 0.007), aminoglycosides (P = 0.021), or fluoroquinolones (P = 0.021), being the index case in a clinical specimen (P = 0.016), and recent hospitalization (P < 0.001) were significantly associated with continued carriage on follow-up. In the surviving outpatients, a significant proportion appeared to clear VRE carriage. Our results suggest that in the absence of recent risk factors, such as hospitalization or antibiotic use, patients with a remote history of colonization (>4 years) may no longer require contact isolation precautions.

Seroprevalence of human immunodeficiency virus in Nepalese blood donors: A study from three regional blood transfusion services

Background and Objective: The likelihood of human immunodeficiency virus (HIV) infection occurring in recipients of HIV seropositive blood is close to 100%. Transmission during window period is still possible even each unit of blood is tested for anti-HIV 1 and 2 antibodies. The possibility of window period transmission would be minimized if blood is collected from low risk targeted general public. A continuous surveillance data might prove valuable for concerned authorities to assess their service and plan for further improvements in transfusion safety. Our aim was to determine the seroprevalence of HIV in regional blood transfusion services located at three developmental regions of Nepal and compare the results. Materials and Methods: A total of 16,557 blood donors were screened for anti-HIV 1 and 2 antibodies in three blood transfusion services viz. 5,351 donors in Morang, 5,211 in Banke, 5,995 in Kaski by using rapid anti HIV 1 and 2 Test. The statistical significance of difference in seroprevalence was tested by Fisher’s Exact Test using the statistical software ‘Winpepi ver 3.8’. Results: The overall seroprevalence of HIV among blood donors in the regional blood transfusion services was 0.054% (9/16557) and 100% seropositivity was among male donors. The individual seroprevalence in Morang was 0.019%, in Banke was 0.095% and in Kaski was 0.05%. The HIV seroprevalence was not significantly different in regional blood transfusion services of Nepal (Fisher Exact Test, P = 0.2096). Conclusion: The seroprevalence in the regional blood transfusion service of Nepal was quite low and the seroprevalence rate was not significantly different.

Drug resistance mutations in HIV type 1 isolates from naive patients eligible for first line antiretroviral therapy in JJ Hospital, Mumbai, India.

More than 50 HIV-1-infected patients, naive of antiretroviral therapy (ART) but eligible for first line ART in JJ Hospital, Mumbai, India were investigated for surveillance drug resistance mutations (SDRMs); all but one virus belonged to subtype C; we could observe SDRMs to nonnucleoside reverse transcriptase inhibitors and protease inhibitors in 9.6% of the patients.

HBsAg serosurveillance among Nepalese blood donors

Context: Hepatitis B virus (HBV) is highly infectious and can be transmitted covertly by percutaneous routes and overtly by blood transfusion. Earlier studies among Nepalese blood donors have shown a high seroprevalence of HBV. Regarding this problem Blood Transfusion Service in Nepal has focused seriously for improving its service by various motivation and education programs. Aims: The study was aimed to reveal the seroprevalence of HBV among different category of blood donors, in relation to their sex and age. Settings and Design: Descriptive cross-sectional Study. Materials and Methods: A total of 33,255 blood samples were screened from donors using enzyme-linked immunosorbent assay kits from December 1, 2006 to September 1, 2007 in Central Blood Transfusion Service, Nepal Red Cross Society, Exhibition Road, Kathmandu. Statistical Analysis: Chi-square test was used for significance testing by using the software SPSS ver. 11.5. Results: The seroprevalence of HBsAg among total blood donors was 0.53% (95% confidence interval [CI] = 0.46-0.62%). Significantly, higher seroprevalence was observed among male donors than in females (0.58% vs. 0.18%, respectively) ( P 0.05). The hepatitis C virus coinfection rate among HBV-infected donors was 1.67%. Conclusions: On the basis of this study, we concluded that the seroprevalence of HBV among Nepalese blood donors in Kathmandu Valley, is decreasing compared to recent past years and is relatively lower than as described for most of the major cities in South Asia. However, similar seroprevalence rate among first time and repeat donors suggests that further improvements are essential.

Epidemiology, Impact and Control of Rabies in Nepal: A Systematic Review

Background Rabies is a vaccine-preventable viral zoonosis belonging to the group of neglected tropical diseases. Exposure to a rabid animal may result in a fatal acute encephalitis if effective post-exposure prophylaxis is not provided. Rabies occurs worldwide, but its burden is disproportionately high in developing countries, including Nepal. We aimed to summarize current knowledge on the epidemiology, impact and control of rabies in Nepal. Methods We performed a systematic review of international and national scientific literature and searched grey literature through the World Health Organization Digital Library and the library of the National Zoonoses and Food Hygiene Research Centre, Nepal, and through searching Google and Google Scholar. Further data on animal and human rabies were obtained from the relevant Nepalese government agencies. Finally, we surveyed the archives of a Nepalese daily to obtain qualitative information on rabies in Nepal. Findings So far, only little original research has been conducted on the epidemiology and impact of rabies in Nepal. Per year, rabies is reported to kill about 100 livestock and 10–100 humans, while about 1,000 livestock and 35,000 humans are reported to receive rabies post-exposure prophylaxis. However, these estimates are very likely to be serious underestimations of the true rabies burden. Significant progress has been made in the production of cell culture-based anti-rabies vaccine and rabies immunoglobulin, but availability and supply remain a matter of concern, especially in remote areas. Different state and non-state actors have initiated rabies control activities over the years, but efforts typically remained focalized, of short duration and not harmonized. Communication and coordination between veterinary and human health authorities is limited at present, further complicating rabies control in Nepal. Important research gaps include the reporting biases for both human and animal rabies, the ecology of stray dog populations and the true contribution of the sylvatic cycle. Interpretation Better data are needed to unravel the true burden of animal and human rabies. More collaboration, both within the country and within the region, is needed to control rabies. To achieve these goals, high level political commitment is essential. We therefore propose to make rabies the model zoonosis for successful control in Nepal.

Should we continue to isolate patients with vancomycin-resistant enterococci in hospitals?

During outbreaks, VRE is assumed to spread between patients mainly via the hands of health care workers or in the hospital environment. Widely recommended strategies for minimising the risk of VRE transmission include screening to identify colonised patients, and subsequent contact precautions to minimise crosstransmission. Many hospitals use contact precautions for patients colonised or infected with VRE on current and each subsequent hospital admission, assuming VRE colonisation is lifelong. These recommendations for contact precautions are based on observational studies conducted primarily during outbreaks, inductive reasoning based on the known transmission potential, and expert opinion. However, dissent has been expressed against the routine use of contact precautions, particularly in hospitals where VRE is endemic.2