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The burden of healthcare-associated infections (HAIs) is higher in low- and middle-income countries, but HAIs are often missed because surveillance is not conducted. Here, we describe the identification of and response to a cluster of Burkholderia cepacia complex (BCC) bloodstream infections (BSIs) associated with high mortality in a surgical ICU (SICU) that joined an HAI surveillance network.
A 780-bed, tertiary-level, public teaching hospital in northern India.
After detecting a cluster of BCC in the SICU, cases were identified by reviewing laboratory registers and automated identification and susceptibility testing outputs. Sociodemographic details, clinical records, and potential exposure histories were collected, and a self-appraisal of infection prevention and control (IPC) practices using assessment tools from the World Health Organization and the US Centers for Disease Control and Prevention was conducted. Training and feedback were provided to hospital staff. Environmental samples were collected from high-touch surfaces, intravenous medications, saline, and mouthwash.
Between October 2017 and October 2018, 183 BCC BSI cases were identified. Case records were available for 121 case patients. Of these 121 cases, 91 (75%) were male, the median age was 35 years, and 57 (47%) died. IPC scores were low in the areas of technical guidelines, human resources, and monitoring and evaluation. Of the 30 environmental samples, 4 grew BCC. A single source of the outbreak was not identified.
Implementing standardized HAI surveillance in a low-resource setting detected an ongoing Burkholderia cepacia outbreak. The outbreak investigation and use of a multimodal approach reduced incident cases and informed changes in IPC practices.
Background: Antimicrobial decision making in the ICU is challenging. Injudicious use of antimicrobials contributes to the development of resistant pathogens and drug-related adverse events. However, inadequate antimicrobial therapy is associated with mortality in critically ill patients. Antimicrobial stewardship programs are increasingly being implemented to improve prescribing. Methods: This prospective study was conducted over 11 months, during which the pharmacist used a standardized survey form to collect data on antibiotic use. Evaluation of antimicrobial use and stewardship practices in a 12-bed polytrauma ICU and a 20-bed neurosurgery ICU of the 248-bed AIIMS Trauma Center in Delhi, India. Antimicrobial consumption was measured using WHO-recommended defined daily dose (DDD) of given antimicrobials and days of therapy (DOT). Results: Antibiotics were ranked by frequency of use over the 11-month period based on empirical therapy and culture-based therapy. The 11-month DDD and DOT averages when empiric antibiotics were used were 532 of 1,000 patient days and 484 per 1,000 patient days, respectively (Figure 1). When cultures were available, DDD was 486 per 1,000 patient days and DOT was 442 per 1,000 patient days (Figure). Conclusions: The quantity and frequency of antibiotics used in the ICUs allowed the AMSP to identify areas to optimize antibiotic use such as educational initiatives, early specimen collection, and audit and feedback opportunities.
Background: Healthcare-associated infections (HAIs) are a major global threat to patient safety. Systematic surveillance is crucial for understanding HAI rates and antimicrobial resistance trends and to guide infection prevention and control (IPC) activities based on local epidemiology. In India, no standardized national HAI surveillance system was in place before 2017. Methods: Public and private hospitals from across 21 states in India were recruited to participate in an HAI surveillance network. Baseline assessments followed by trainings ensured that basic microbiology and IPC implementation capacity existed at all sites. Standardized surveillance protocols for central-line–associated bloodstream infections (CLABSIs) and catheter-associated urinary tract infections (CAUTIs) were modified from the NHSN for the Indian context. IPC nurses were trained to implement surveillance protocols. Data were reported through a locally developed web portal. Standardized external data quality checks were performed to assure data quality. Results: Between May 2017 and April 2019, 109 ICUs from 37 hospitals (29 public and 8 private) enrolled in the network, of which 33 were teaching hospitals with >500 beds. The network recorded 679,109 patient days, 212,081 central-line days, and 387,092 urinary catheter days. Overall, 4,301 bloodstream infection (BSI) events and 1,402 urinary tract infection (UTI) events were reported. The network CLABSI rate was 9.4 per 1,000 central-line days and the CAUTI rate was 3.4 per 1,000 catheter days. The central-line utilization ratio was 0.31 and the urinary catheter utilization ratio was 0.57. Moreover, 3,542 (73%) of 4,742 pathogens reported from BSIs and 868 (53%) of 1,644 pathogens reported from UTIs were gram negative. Also, 1,680 (26.3%) of all 6,386 pathogens reported were Enterobacteriaceae. Of 1,486 Enterobacteriaceae with complete antibiotic susceptibility testing data reported, 832 (57%) were carbapenem resistant. Of 951 Enterobacteriaceae subjected to colistin broth microdilution testing, 62 (7%) were colistin resistant. The surveillance platform identified 2 separate hospital-level HAI outbreaks; one caused by colistin-resistant K. pneumoniae and another due to Burkholderia cepacia. Phased expansion of surveillance to additional hospitals continues. Conclusions: HAI surveillance was successfully implemented across a national network of diverse hospitals using modified NHSN protocols. Surveillance data are being used to understand HAI burden and trends at the facility and national levels, to inform public policy, and to direct efforts to implement effective hospital IPC activities. This network approach to HAI surveillance may provide lessons to other countries or contexts with limited surveillance capacity.
Background: The multidrug-resistant fungus Candida auris is emerging as a major cause of healthcare-associated infection globally. Understanding the epidemiology of these infections in vulnerable groups such as cancer patients is important for hospital infection control and their effective management. In this report we present diagnostic, clinical, antifungal resistance and outcome data of 11 cases of C. auris infection from an oncology center in India. Methods:C. auris strains were identified by Sanger-based DNA sequencing of the internal transcriber spacer (ITS) gene. Antifungal susceptibility testing (AFST) was performed using the broth dilution method. Identification and AFST were checked by the WHO Collaborating Center for Reference & Research on Fungi of Medical Importance. Patients had both empirical as well as directed therapy with antifungal agents based on AFST results and clinical assessment. Results: Between November 2018 and March 2019, 11 cases of C. auris (8 from patients with solid-organ tumors and 3 from hematological malignancy) were detected. Two distinct genetic clusters were identified by ITS gene sequencing; one of these clusters showed 100% homology with a previously unknown C. auris isolate (GenBank accession no. MK881076) and the other cluster had a 100% identity score with isolates from Japan and South Korea (GenBank accession nos. MH071441, KY657027, and EU884189). All 11 strains were resistant to fluconazole. With voriconazole, 1 isolate was susceptible, 3 were resistant, and 7 showed dose-dependent susceptibility. Two isolates were resistant to amphotericin B. Resistance to caspofungin or anidulafungin was noted in 1 of 11 isolates (9%); most showed intermediate susceptibility (63% to caspofungin). Among all of the patients, 72% were from the intensive care unit (ICU) or the high-dependency unit. The 30-day all-cause mortality was 5 of 11 (45%) in the C. auris group and 4 of 11 (36%) the control group (ie, infections with other Candida spp during same period). Duration of ICU stay in the C. auris group was 12 days and in the control group it was 6 days. The median cost (in terms of hospital bill at the time of discharge or death) for management of Candida auris infection and the primary medical condition was US$10,121 for the C. auris groups and US$8,608 for the control group. Most cases (10 of 11) were detected in wards without isolation rooms, and 8 of the 11 C. auris cases (73%) were detected in patients in the intensive care unit. Conclusions: Morbidity, mortality, ICU stay, and healthcare costs are significant in C. auris infection.