To save content items to your account,
please confirm that you agree to abide by our usage policies.
If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your account.
Find out more about saving content to .
To save content items to your Kindle, first ensure email@example.com
is added to your Approved Personal Document E-mail List under your Personal Document Settings
on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part
of your Kindle email address below.
Find out more about saving to your Kindle.
Note you can select to save to either the @free.kindle.com or @kindle.com variations.
‘@free.kindle.com’ emails are free but can only be saved to your device when it is connected to wi-fi.
‘@kindle.com’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.
We evaluated the appropriateness of antibiotic prescriptions at discharge from a tertiary-care hospital in India. Of the 790 adult patients included, 84.4% received antibiotics. Microbiological specimens were taken from 67.3% of these patients, and pathogens were identified in 28.8% of cases. Overuse of antimicrobials at hospital discharge should be curtailed.
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.
Health-care personnel (HCPs) are predisposed to infection during direct or indirect patient care as well as due to the community spread of the disease.
We observed the clinical presentation and course of severe acute respiratory syndrome coronavirus disease 2 (SARS-CoV-2) infection in HCPs working in a dedicated coronavirus disease 2019 (COVID-19) care hospital during the first and the second wave.
A total of 100 and 223 HCPs were enrolled for the first wave and the second wave, respectively. Cough, shortness of breath, sore throat, runny nose, and headache was seen in 40 (40%) and 152 (68%) (P < 0.01), 15 (15%) and 64 (29%) (P = 0.006), 40 (40%) and 119 (53.3%) (P = 0.03), 9 (9%) and 66 (30%) (P < 0.01), 20 (20%) and 125 (56%) (P < 0.01), respectively. Persistent symptoms at the time of joining back to work were seen in 31 (31%) HCPs and 152 (68%) HCPs, respectively (P ≤ 0.01). Reinfection was reported in 10 HCPs.
Most of the HCPs had mild to moderate infections. Symptoms persist after joining back to work. Upgradation of home-based care and teleconsultation facilities for active disease and redressal of residual symptoms will be helpful.
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: Globally, surgical site infections (SSIs) not only complicate the surgeries but also lead to $5–10 billion excess health expenditures, along with the increased length of hospital stay. SSI rates have become a universal measure of quality in hospital-based surgical practice because they are probably the most preventable of all healthcare-associated infections. Although, many national regulatory bodies have made it mandatory to report SSI rates, the burden of SSI is still likely to be significant underestimated due to truncated SSI surveillance as well as underestimated postdischarge SSIs. A WHO survey found that in low- to middle-income countries, the incidence of SSIs ranged from 1.2 to 23.6 per 100 surgical procedures. This contrasted with rates between 1.2% and 5.2% in high-income countries. Objectives: We aimed to leverage the existing surveillance capacities at our tertiary-care hospital to estimate the incidence of SSIs in a cohort of trauma patients and to develop and validate an indigenously developed, electronic SSI surveillance system. Methods: A prospective cohort study was conducted at a 248-bed apex trauma center for 18 months. This project was a part of an ongoing multicenter study. The demographic details were recorded, and all the patients who underwent surgery (n = 770) were followed up until 90 days after discharge. The associations of occurrence of SSI and various clinico-microbiological variables were studied. Results: In total, 32 (4.2%) patients developed SSI. S. aureus (28.6%) were the predominant pathogen causing SSI, followed by E. coli (14.3%) and K. pneumoniae (14.3%). Among the patients who had SSI, higher SSI rates were associated in patients who were referred from other facilities (P = .03), had wound class-CC (P < .001), were on HBOT (P = .001), were not administered surgical antibiotics (P = .04), were not given antimicrobial coated sutures (P = .03) or advanced dressings (P = .02), had a resurgery (P < .001), had a higher duration of stay in hospital from admission to discharge (P = .002), as well as from procedure to discharge (P = .002). SSI was cured in only 16 patients (50%) by 90 days. SSI data collection, validation, and analyses are essential in developing countries like India. Thus, it is very crucial to implement a surveillance system and a system for reporting SSI rates to surgeons and conduct a robust postdischarge surveillance using trained and committed personnel to generate, apply, and report accurate SSI data.
Background: Candidiasis caused by Candida auris is one of the most serious hospital-acquired infection. Initially, Candida auris was reported to cause local infections; later, invasive candidasis was also reported in which the bloodstream, the central nervous system, kidneys, liver eyes, etc, are invaded. In this study, we evaluated the clinical epidemiology and risk factors in patients hospitalized to trauma center. Methods: This study was conducted at JPN Apex Trauma Centre of All India Institute of Medical Sciences, New Delhi, which is a 169-bed hospital. All patients who were identiﬁed to have candidemia due to C. auris over a period of 5 years from January 2012 to December 2016 were included. Blood samples were collected in BAC-T-Alert bottles (Bio Merieux, Durham, NC) and isolates were identiﬁed up to the species level by the VITEK 2 (version 8.01, BioMerieux). Conventional identiﬁcation was performed by observing color development on CHROMagar (Becton Dickinson, Franklin Lakes, NJ). The demographic and clinical data of patients were collected from the hospital information system. Results: Over a period of 5 years, 20 patients admitted to our trauma hospital developed candidemia due to Candida auris. Among them, men were predominant (95%), and the mean (SD) age of the patients was 33 (+15) years. Among these patients, 80% were in hospitalized and 20% were follow-up patients. The median of the total length of stay in the hospital was 34 days (range, 7–122). All of the patients were on mechanical ventilation; 65% patients were catheterized and 75% patients had central line placed. Head injury was the major cause of trauma followed by abdomen, chest, and spine. The overall mortality rate was 40%. Most of the patients (65%) who developed Candida auris infection were immunocompromised. The different comorbidities present were hypertension (35%), diabetes (15%), renal disease (10%), and hepatitis C (5%). Broad-spectrum antibiotics were given: amoxicillin-clavulanate was given to 65% of patients; cefoperazone sulbactam was given to 30% of patients; chloroamphenicol, amicillin-sulbactam, or clindamycin was given to 10% of patients. Antifungal agents like fluconazole or caspofungin were given to 5% of patients. Major surgeries like cranioplasty were performed in 58% of patients. Pancreatectomy, laparotomy, and endoscopic necrosectomy were performed in 42% of patients. Conclusions:Candida auris is one of the dreaded and most commonly spread hospital-acquired fungal infections, especially in immunocompromised patients. Broad-spectrum antibiotics use, major surgery, and invasive devices were the most common risk factors for acquiring Candida auris infection.
Resistance to colistin, a last resort antibiotic, has emerged in India. We investigated colistin-resistant Klebsiella pneumoniae(ColR-KP) in a hospital in India to describe infections, characterize resistance of isolates, compare concordance of detection methods, and identify transmission events.
Retrospective observational study.
Case-patients were defined as individuals from whom ColR-KP was isolated from a clinical specimen between January 2016 and October 2017. Isolates resistant to colistin by Vitek 2 were confirmed by broth microdilution (BMD). Isolates underwent colistin susceptibility testing by disk diffusion and whole-genome sequencing. Medical records were reviewed.
Of 846 K. pneumoniae isolates, 34 (4%) were colistin resistant. In total, 22 case-patients were identified. Most (90%) were male; their median age was 33 years. Half were transferred from another hospital; 45% died. Case-patients were admitted for a median of 14 days before detection of ColR-KP. Also, 7 case-patients (32%) received colistin before detection of ColR-KP. All isolates were resistant to carbapenems and susceptible to tigecycline. Isolates resistant to colistin by Vitek 2 were also resistant by BMD; 2 ColR-KP isolates were resistant by disk diffusion. Moreover, 8 multilocus sequence types were identified. Isolates were negative for mobile colistin resistance (mcr) genes. Based on sequencing analysis, in-hospital transmission may have occurred with 8 case-patients (38%).
Multiple infections caused by highly resistant, mcr-negative ColR-KP with substantial mortality were identified. Disk diffusion correlated poorly with Vitek 2 and BMD for detection of ColR-KP. Sequencing indicated multiple importation and in-hospital transmission events. Enhanced detection for ColR-KP may be warranted in India.
To report the International Nosocomial Infection Control Consortium surveillance data from 40 hospitals (20 cities) in India 2004–2013.
Surveillance using US National Healthcare Safety Network’s criteria and definitions, and International Nosocomial Infection Control Consortium methodology.
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.
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.
Infect. Control Hosp. Epidemiol. 2016;37(2):172–181
Email your librarian or administrator to recommend adding this to your organisation's collection.