Sweta Shah

Impact of an International Nosocomial Infection Control Consortium multidimensional approach on central line-associated bloodstream infection rates in adult intensive care units in eight cities in India

OBJECTIVE To evaluate the impact of the International Nosocomial Infection Control Consortium (INICC) multidimensional infection control approach on central line-associated bloodstream infection (CLABSI) rates in eight cities of India. METHODS This was a prospective, before-and-after cohort study of 35650 patients hospitalized in 16 adult intensive care units of 11 hospitals. During the baseline period, outcome surveillance of CLABSI was performed, applying the definitions of the CDC/NHSN (US Centers for Disease Control and Prevention/National Healthcare Safety Network). During the intervention, the INICC approach was implemented, which included a bundle of interventions, education, outcome surveillance, process surveillance, feedback on CLABSI rates and consequences, and performance feedback. Random effects Poisson regression was used for clustering of CLABSI rates across time periods. RESULTS During the baseline period, 9472 central line (CL)-days and 61 CLABSIs were recorded; during the intervention period, 80898 CL-days and 404 CLABSIs were recorded. The baseline rate was 6.4 CLABSIs per 1000 CL-days, which was reduced to 3.9 CLABSIs per 1000 CL-days in the second year and maintained for 36 months of follow-up, accounting for a 53% CLABSI rate reduction (incidence rate ratio 0.47, 95% confidence interval 0.31-0.70; p=0.0001). CONCLUSIONS Implementing the six components of the INICC approach simultaneously was associated with a significant reduction in the CLABSI rate in India, which remained stable during 36 months of follow-up.

Device-Associated Infection Rates in 20 Cities of India, Data Summary for 2004-2013: Findings of the International Nosocomial Infection Control Consortium.

OBJECTIVE To report the International Nosocomial Infection Control Consortium surveillance data from 40 hospitals (20 cities) in India 2004-2013. METHODS Surveillance using US National Healthcare Safety Networks criteria and definitions, and International Nosocomial Infection Control Consortium methodology. RESULTS We collected data from 236,700 ICU patients for 970,713 bed-days Pooled device-associated healthcare-associated infection rates for adult and pediatric ICUs were 5.1 central line-associated bloodstream infections (CLABSIs)/1,000 central line-days, 9.4 cases of ventilator-associated pneumonia (VAPs)/1,000 mechanical ventilator-days, and 2.1 catheter-associated urinary tract infections/1,000 urinary catheter-days In neonatal ICUs (NICUs) pooled rates were 36.2 CLABSIs/1,000 central line-days and 1.9 VAPs/1,000 mechanical ventilator-days Extra length of stay in adult and pediatric ICUs was 9.5 for CLABSI, 9.1 for VAP, and 10.0 for catheter-associated urinary tract infections. Extra length of stay in NICUs was 14.7 for CLABSI and 38.7 for VAP Crude extra mortality was 16.3% for CLABSI, 22.7% for VAP, and 6.6% for catheter-associated urinary tract infections in adult and pediatric ICUs, and 1.2% for CLABSI and 8.3% for VAP in NICUs Pooled device use ratios were 0.21 for mechanical ventilator, 0.39 for central line, and 0.53 for urinary catheter in adult and pediatric ICUs; and 0.07 for mechanical ventilator and 0.06 for central line in NICUs. CONCLUSIONS Despite a lower device use ratio in our ICUs, our device-associated healthcare-associated infection rates are higher than National Healthcare Safety Network, but lower than International Nosocomial Infection Control Consortium Report.

Clostridium septicum Gas Gangrene in Colon Cancer: Importance of Early Diagnosis.

The Clostridia species are responsible for some of the deadliest diseases including gas gangrene, tetanus, and botulism. Clostridium septicum is a rare subgroup known to cause atraumatic myonecrosis and is associated with colonic malignancy or immunosuppression. It is a Gram-positive, anaerobic, spore-forming bacillus found in the gastrointestinal tract and can lead to direct, spontaneous infections of the bowel and peritoneal cavity. The anaerobic glycolysis of the tumor produces an acidic, hypoxic environment favoring germination of clostridial spores. Tumor-induced mucosal ulceration allows for translocation of sporulated bacteria from the bowel into the bloodstream, leading to fulminant sepsis. C. septicum bacteremia can have a variable presentation and is associated with greater than 60% mortality rate. The majority of deaths occur within the first 24 hours if diagnosis and appropriate treatment measures are not promptly started. We report a case of abdominal myonecrosis in a patient with newly diagnosed colon cancer. The aim of this study is to stress the importance of maintaining a high suspicion of C. septicum infection in patients with underlying colonic malignancy.

Outbreak of Burkholderia cepacia complex bacteremia in a chemotherapy day care unit due to intrinsic contamination of an antiemetic drug

Background: In the end of 2009, a large number of patients with cancer undergoing chemotherapy at the day care unit of a private hospital in Mumbai, India developed Burkholderia cepacia complex (BCC) blood stream infection (BSI). Objective: The objectives were to identify the source of the outbreak and terminate the outbreak as rapidly as possible. Materials and Methods: All infection control protocols and processes were reviewed. Intensive training was started for all nursing staff involved in patient care. Cultures were sent from the environment (surfaces, water, air), intravenous fluids, disinfectants and antiseptics and opened/unopened medication. Results: A total of 13 patients with cancer with tunneled catheters were affected with BCC BSI. The isolates were of similar antimicrobial sensitivity. No significant breach of infection control protocols could be identified. Cultures from the prepared intravenous medication bags grew BCC. Subsequently, culture from unused vials of the antiemetic granisetron grew BCC, whereas those from the unopened IV fluid bag and chemotherapy medication were negative. On review, it was discovered that the outbreak started when a new brand of granisetron was introduced. The result was communicated to the manufacturer and the brand was withdrawn. There were no further cases. Conclusions: This outbreak was thus linked to intrinsic contamination of medication vials. We acknowledge a delay in identifying the source as we were concentrating more on human errors in medication preparation and less on intrinsic contamination. We recommend that in an event of an outbreak, unopened vials be cultured at the outset.

A 4-year prospective study to determine the incidence and microbial etiology of surgical site infections at a private tertiary care hospital in Mumbai, India

BACKGROUND There is limited single-center data on the incidence and microbial etiology of surgical site infections (SSIs) from developing countries. METHODS This is a prospective observational study over 4-year period (April 2009-March 2013) at a 750-bed private multispecialty hospital in Mumbai, India, among patients undergoing clean and clean-contaminated surgeries. Standard guidelines for preventing, classifying, and diagnosing SSI were followed. RESULTS A total of 24,355 patients underwent clean and clean-contaminated surgeries during the study period. The overall SSI rate was 1.6% (389 cases). The SSI rate in clean surgeries was 1.57%, and the SSI rate in clean-contaminated surgeries was 1.64%. Of the SSIs, 66% were caused by gram-negative bacilli (GNB) (Escherichia coli [22.9%], Klebsiella [18.2%], Pseudomonas [12.7%], and Acinetobacter [6.0%] were the top 4), 31.7% were caused by gram-positive bacilli (Staphylococcus: 70.5%, Enterococcus: 23.8%, Streptococcus: 1.8%), and 2.1% were caused by Candida. A total of 64% of the E coli and Klebsiella isolates were extended spectrum β-lactamase producing, 6% of the GNB were carbapenem resistant, and only 17.3% of S aureus isolates were methicillin resistant. CONCLUSION Although the SSI rate is comparable with established international benchmarks, increasing prevalence of antimicrobial resistance in GNB is a matter of serious concern.

Pharmacy Report: Megestrol Acetate-Induced Adrenal Insufficiency.

A man aged 65 years with metastatic renal cell carcinoma presented for evaluation after a recent fall. A thorough workup of the case was performed and secondary adrenal insufficiency induced by the administration of megestrol acetate was determined to be the cause. Adrenal insufficiency is a serious disorder that is a potential adverse event of megestrol acetate, a medication used to help patients with cancer cachexia increase their appetite and gain weight. This association is not well recognized in clinical practice, so this case highlights the importance of distinguishing possible endocrine complications induced by the long-term administration or sudden discontinuation of megestrol acetate.

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.

Clostridium septicum Case Series: A 5-Year Experience at a Cancer Center

AbstractThe clostridia species are opportunistic pathogens responsible for some of the deadliest diseases including gas gangrene, tetanus, and botulism. Clostridium septicum is a rare subgroup found to cause atraumatic myonecrosis. It is a Gram-positive, anaerobic, spore-forming bacilli found in the gastrointestinal tract. Although rare, in the setting of malignancy or immunosuppression, it is associated with direct, spontaneous infections of the bowel and peritoneal cavity. The anaerobic glycolysis of the tumor produces an acidic, hypoxic environment favoring germination of clostridial spores. Tumor-induced mucosal ulceration allows for translocation of sporulated bacteria from the bowel into the bloodstream, leading to fulminant sepsis. Over 80% of C. septicum cases are associated with underlying malignancy, and it is associated with greater than 60% mortality rate. The majority of deaths occur within the first 24 hours if diagnosis and appropriate treatment measures are not promptly started. Therefore, in patients whom a C. septicum infection is diagnosed without a clear underlying etiology, there should be a strong suspicion for an associated malignancy. We report a case series of C. septicum bacteremia in patients with underlying malignancy, a 5-year experience at a cancer institute, as a reminder of the importance of early diagnosis.

Successful treatment of C. auris shunt infection with intraventricular caspofungin

C. auris is an emerging fungal pathogen with high prevalence of resistance to current antifungal agents. Central nervous system infection with C. auris has been infrequently described. We describe here an adult with nosocomial CSF shunt infection due to multi drug resistant C. auris. Systemic therapy with echinocandin and flucytosine failed. Fortunately, administration of daily intraventricular caspofungin 10 mg for 10 days in conjunction with systemic voriconazole resulted in both clinical and microbiological cure.

494Excellent Safety and Tolerability of Colistin in Septic Neonates. A Retrospective Study from a Neonatal and a Pediatric Cardiac Surgical Unit in India

Retrospective Study from a Neonatal and a Pediatric Cardiac Surgical Unit in India Tanu Singhal, MD, MSc; Sheetal Shetty, MD; Sweta Shah; Reshma Naik, GNM, MBA; Infectious Disease and Pediatrics, Kokilaben Dhirubhai Ambani Hospital and Medical Research Institute, Mumbai, India; Paediatrics, Kokilaben Dhirubhai Ambani Hospital, Mumbai, India; Microbiology, Kokilaben Dhirubhai Ambani Hospital and Medical Research Institute, Mumbai, India; Kokilaben Dhirubhai Ambani Hospital and Medical Research Institute, Mumbai, India