APSIC Abstracts on Hospital Epidemiology and Surveillance

The following abstracts on the topic of hospital epidemiology and surveillance are from the meeting of the eighth International Congress of the Asia Pacific Society of Infection Control (APSIC), held in Bangkok, Thailand, Feb. 12-15, 2017.

Reference: Antimicrobial Resistance & Infection Control. Abstracts from the 8th International Congress of the Asia Pacific Society of Infection Control (APSIC) Volume 6, Supplement 2. February 2017.

HE1: Cardiac surgery infection prevention monitoring (CSIPM) tool-results of pilot study

Dorairajan Sureshkumar, Roopa Durairaj, Anusha Rohit, Saujanya Saravanakumar, Jothymani Hemalatha

Background
Post-operative infections are the leading cause of non-cardiac complications after cardiac surgeries in the developing world. Most of these infections are preventable, if the prevention measures were strictly followed. However, monitoring of these parameters is difficult in resource-limited settings. Here we reported initial results of infection prevention monitoring using CSIPM tool.

Materials and methods
This cross sectional study was carried out to pilot test the usage of CSIPM tool by infection prevention professionals in five cardiac centers in Chennai among patients undergoing cardiac surgeries. This CSIPM tool was created based on the Association for Professionals in Infection Control and Epidemiology (APIC) guidelines that included parameters such as antibiotic timing, antibiotic choice, hair removal technique, skin preparation, and pre-operative MRSA screening and intranasal mupirocin application.

Results
51 patients who underwent cardiac surgeries in 5 centers were assessed using CCSIPM tool. The results are as follows. Infection Prevention parameter Centre 1 (13 patients) Centre 2 (9 patients) Centre 3 (10 patients) Centre 4 (7 patients) Centre 5 (12 patients) were participated. First dose of antibiotic prophylaxis (within 1 hour of incision) was 40/51 (78.43%). Choice of prophylactic antibiotics (as per guidelines) was 45/51 (88.23%). Hair removal methods (clippers use) was 30/51 (58.82%) Surgical site skin preparation (cholrhexidine based methods) was 23/51 (45.09%). Pre-op MRSA screening was 0/51 (0%) Universal mupriocin administration was 21/51 (41.17%).

Conclusions
The CSIPM tool was easy to monitor infection prevention measured in cardiac surgery patients in Chennai. There was wide variability in implementing infection prevention measured among hospitals. There was an urgent need to test CSIPM tool in large multicenter studies before universal recommendation.

HE2: Retrospective study of mortality and species distribution among patients with Candida bloodstream infection: a single hospital experience in Japan

Ryuichi Hirano1, Yuichi Sakamoto, Shoji Yamamoto, Naoki Tachibana

Background
The mortality rate among patients with bloodstream infection caused by Candida species is relatively high. However, prognostic factors and species distribution of this disease have not yet been elucidated in detail. The aim of this study was to examine prognostic factors for candidemia using the mortality rate and Candida distribution among patients with candidemia.

Materials and methods
Seventy-five patients diagnosed with candidemia in Aomori Prefectural Central Hospital between January 2007 and December 2013 were enrolled in this study. Mycological data were collected from the records of each patient’s blood culture tests. Odds ratios (ORs) for death were analyzed using a multivariate stepwise logistic regression analysis.

Results
Twenty (26.6%) patients died within 30 days of being diagnosed with candidemia. Advanced age (OR = 1.1, 95% confidence interval = 1.01-1.23, P = 0.04) was a significant risk factor for a high mortality, whereas removal of a central venous catheter (OR = 0.03, 95% confidence interval = 0.002-0.3, P = 0.01) was associated with a lower mortality rate. Seventy-six Candida species were isolated from blood cultures; Candida albicans 28 (36.8%), Candida parapsilosis 23 (30.2%), Candida guilliermondii 16 (21.0%), Candida glabrata four (5.2%), Candida tropicalis two (2.6%), and Candida species three (3.9%) that could not be identified. The 30-day mortality rates for Candida albicans was 42% (12/28), which was significantly higher than that of Candida parapsilosis (4.3%, 1/23).

Conclusions
This study indicated that persistent of central venous catheter was detrimental to patients with candidemia. Close attention may be required in cases of elderly patients.

HE3: Post-quake infection control intervention on nursing homes for seniors

Miho Miura, Fumiyo Hieda, Yoshiro Sakai, Hiroshi Watanabe

Background
After the earthquake in Kumamoto on April 14, 2016, Disaster Medical Assistance Team (DMAT) and Japan Medical Association Team (JMAT) immediately supported the shelters and medical facilities in the disaster area. However, the arrivals of DMAT and JMAT to nursing homes were delayed due to lack of information and no transportation by landslides. We started supporting nursing homes as JMAT members 16 days after the quake. This study aimed to report about our infection control intervention in the disaster area.

Materials and methods
We conducted a survey on the occurrences of infectious gastroenteritis and influenza at nursing homes, and interviewed the healthcare workers about problems on infection control. Then, we offered guidance on infection control necessary to each facility.

Results
We visited eleven nursing homes between April 30th and May 2th, 2016 to find two residents with symptoms of influenza and one with symptoms of infectious gastroenteritis. The most frequent questions from the healthcare workers at nursing homes were how to clean and sterilize medical devices, and how to clean their hands appropriately.

Conclusions
It is important to educate health care workers at nursing homes on a regular basis regarding infection control, while the occurrence time of infection varies depending on the disaster’s type and scale.

HE4: Microbiological profile of device-related healthcare infections

Melecia Velmonte, Silverose Ann Bacolcol, Allan Alde, Keitleen Chavez, Arlene Joy Esteban, Aisa Jensen Lee

Background
The Manila Doctors Hospital – Infection Prevention and Control Office (IPCO) reviewed the surveillance data of device-related healthcare infections in Intensive Care Unit (ICU). This study aimed to determine the prevalence of device-related healthcare infections in ICU, identify most frequently isolated organisms and its antibiotic susceptibility.

Materials and methods
Profile of pathogens isolated from patients with device-related infections (DRI) was analyzed from surveillance data collected by Infection Prevention and Control nurse from 2014 to 2016.

Results
Three years surveillance data of DRI revealed 32 DRI developed among patients, nineteen (19) ventilator-associated pneumonia (VAP), seven (7) central line-associated blood stream infection (CLABSI), and six (6) catheter-associated urinary tract infection (CAUTI). Klebsiella pneumoniae Carbapenemase (+) KPC (8), Serratia marcescens (3), and Stenotrophomonas maltophilia (3), were the pathogens isolated from VAP, MRSA (4) and Acinetobacter baumannii (2) from CLABSI. E. coli and Klebsiella pneumoniae both ESBL (+) and Enterococcus faecalis were isolated from patients with CAUTI. Klebsiella pneumoniae carbapenemase positive was sensitive only to three antibiotics: amikacin, gentamicin and colistin. The carbapenems, aminoglycocides, extended spectrum penicillin, ciprofloxacin, levofloxacin were still effective against most of the gram negative bacteria isolated. MRSA was sensitive only to linezolid, daptomycin and vancomycin.

Conclusions
The most antibiotic-resistant pathogen KPC was isolated in patients with VAP on prolonged mechanical ventilation and MRSA in patients with central line of more than two weeks. It is recommended that devices be removed when no longer required to reduce risk of DRI, overuse of antibiotics, and emergence of antibiotic resistant strains. Strict implementation of infection prevention and control practices should be enforced.

HE5: A 3-year comparison of methicillin-resistant Staphylococcus aureus (MRSA) epidemiology in an acute-care hospital and affiliated intermediate-and long-term care facilities

Angela Chow, Jia-Wei Lim, Pei-Yun Hon, Aung-Aung Hein, Grace Tin, Vanessa Lim, Brenda Ang

Methicillin-resistant Staphylococcus aureus (MRSA) is the most common healthcare-associated multidrug resistant organism. Despite the interconnectedness between acute hospitals and intermediate- and long-term care facilities (ILTCs), the comparative epidemiology of MRSA between the institutions is not well understood. This study aimed to compare the epidemiology of MRSA in an acute hospital with its affiliated ILTCs longitudinally.

Materials and methods
We conducted period prevalence surveys screening for MRSA in June-July 2014-2016, in an acute hospital (AH) and affiliated intermediate-care (ITC) and long-term care (LTC) facilities in Singapore. Nasal, axilla, and groin swabs were cultured on selective chromogenic agar. Multivariable logistic regression models were constructed for comparison of MRSA prevalence.

Results
A total of 5458 patients were screened. MRSA prevalence was higher in ITCs (36.6%) than LTCs (22.2%) and AH (12.4%) (P < 0.001). In ITCs, MRSA prevalence increased significantly from 29.9% (2014) to 45.7% (2015) (P < 0.001) and decreased to 32.4% (2016) (P < 0.001). In LTCs, MRSA prevalence was similar in 2014 (20.4%) and 2015 (19.8%), but increased to 25.6% in 2016 (P = 0.049). MRSA prevalence in AH remained stable (2014: 11.8%, 2015: 13.5%, 2016: 11.9%, P = 0.44). Median length of stay (LOS) in LTCs (439 days) was significantly higher than in ITCs (22 days, P < 0.001) and AH (9 days, P < 0.001). After adjusting for age, gender, LOS, and year of screening, MRSA colonization was significantly higher in ITCs (OR 4.28, 95%CI 3.65-5.03) and LTCs (OR 2.21, 95%CI 1.80-2.71) than the AH.

Conclusions
MRSA prevalence is higher in ILTCs than the AH. Active surveillance and infection control strategies at acute hospitals should also be instituted at ILTCs.

HE6: Comparative epidemiology of vancomycin-resistant enterococcus (VRE) in an acute-care hospital and its affiliated intermediate- and long-term care facilities: a 3-year longitudinal study

Angela Chow, Aung-Aung Hein, Jia-Wei Lim, Pei-Yun Hon, Vanessa Lim, Grace Tin, Brenda Ang

Background
Vancomycin-resistant Enterococcus (VRE) infections in acute hospitals are increasing, but little is known about VRE colonization in intermediate- and long-term care facilities (ILTC). This study aimed to make longitudinal comparisons on the epidemiology of VRE in an acute hospital and its closely-affiliated ILTCs.

Materials and methods
We conducted period prevalence surveys screening for VRE in June-July 2014-2016, in an adult acute tertiary-care hospital (AH) and 6 of its affiliated ILTCs, in Singapore. Stool or rectal swabs were obtained and cultured using selective chromogenic agar. Epidemiologic data was obtained from electronic medical records. To compare differences in VRE prevalence, multivariable logistic regression models were constructed.

Results
Of 5359 patients screened, 9.8% were VRE colonized. VRE prevalence was significantly higher in the AH (14.2%) than in intermediate-care (ITC) (7.6%) and long-term care (LTC) (0.8%) facilities (P < 0.001). In the AH, VRE prevalence decreased from 19.8% in 2014 to 14.0% in 2015 to 8.9% in 2016 (P < 0.001). In ITCs, VRE prevalence increased from 5.1% in 2014 to 9.9% in 2015 (P = 0.012) and was 7.4% in 2016 (P = 0.19). VRE prevalence remained low in LTCs (2014: 0.3%, 2015: 0.8%, 2016: 1.1%, P = 0.45). After adjusting for age, gender, length of stay, and year of screening, VRE colonization was significantly higher in the AH than ITCs (OR 1.96, 95%CI 1.55-2.48, P < 0.001) and LTCs (OR 22.52, 95%CI 9.95-50.97, P < 0.001).

Conclusions
VRE prevalence was highest in the AH but has declined over the years. Prevention and control efforts in acute hospitals should be enhanced to further reduce VRE colonization and prevent transmission to ILTCS.

HE7: How different is the epidemiology of carbapenem-resistant enterobacteriaceae (CRE) in an acute-care hospital from its affiliated intermediate- and long-term care facilities?

Angela Chow, Grace Tin, Aung-Aung Hein, Vanessa Lim, Jia-Wei Lim, Pei-Yun Hon, Brenda Ang

Background
Carbapenem-resistant Enterobacteriaceae (CRE) colonization in acute hospitals is increasing, but little is known about CRE colonization in intermediate- and long-term care facilities (ILTC). This study aimed to compare the epidemiology of CRE longitudinally in an acute hospital and affiliated ILTCs.

Materials and methods
Cross-sectional studies were conducted with CRE screening in June-July 2014-2016, in an adult acute tertiary-care hospital (AH) and its 6 closely-affiliated ILTCs in Singapore. Stool or rectal swabs were cultured using selective chromogenic agar. Epidemiologic data were obtained from electronic medical records. Multivariable logistic regression models were then constructed for independent comparison of CRE prevalence between healthcare facilities.

Results
A total of 5359 patients were screened (2014: 1675, 2015: 1794, 2016: 1890). CRE prevalence was significantly higher in the AH (2.13%) than in intermediate-care (ITC) (1.29%) and long-term care (LTC) (0.35%) facilities (P < 0.001). CRE prevalence remained low In the AH (2014: 2.25%, 2015: 2.06%, 2016: 2.08%, P = 0.96) and ITCs (2014: 1.13%, 2015: 0.44%, 2016: 2.30% P = 0.045). Only 4 patients (all in 2015, 1.1%) were colonized with CRE in LTCs. Median length of stay (LOS) in LTCs (439 days) was higher than in ITCs (22 days, P < 0.001) and AH (9 days, P < 0.001). After adjusting for age, gender, LOS, and year of screening, CRE colonization was higher in the AH (OR 4.11, 95%CI 1.16-14.53) and ITCs (OR 2.49, 95%CI 0.66-9.32) than LTCs.

Conclusions
CRE colonization has remained low in the AH and ITCs, and negligible in LTCs. However, further studies are required to identify high-risk patients for targeted surveillance, to prevent CRE from becoming endemic.

HE8: Risk factors and causes of death in dengue fever– a retrospective study at one medical center in south Taiwan

Huwi-chun Chao, Chiu-Yin Yeh

Background
As Taiwan is situated in the high risk subtropical region, dengue fever has virtually become a seasonal infectious disease. This study aimed to determine risk factors and causes of death in dengue fever.

Materials and methods
Analysis was conducted on the 93 confirmed severe cases of dengue fever or dengue hemorrhagic fever reported to this hospital over the period between July 20 and September 30, 2015 in terms of gender, age, history of chronic diseases, warning signs and diagnostic criteria for severe conditions. Retrospective case study was also conducted to identify risk factors in dengue fever and dengue hemorrhagic fever as well as predictors of death among dengue fever cases for statistical analysis.

Results
Those susceptible to infection concentrated on older people aged over 65 (with an average age of 68); in total 73 cases had chronic diseases (with an average rate of 78.5%), among which hypertension and diabetes constituted the majorities; and based on symptoms, fever accounted for 83.51% while gastrointestinal bleeding was the most common at 38.7%. Of the 93 cases, there were 18 deaths.

Conclusions
It’s suggested that older people aged over 65 and with chronic diseases who are infected with dengue hemorrhagic fever must be closely monitored. To sum up, effective use of knowledge about risk factors and prognostic factors in dengue hemorrhagic fever can help epidemic prevention organizations to focus their limited resources on high risk groups and increase the effectiveness of prevention.

HE9: The exploration of risk factors for patients with severe influenza infection

Mei-feng Lo, Huwi-chun Chao

Background
The importance of influenza is its rapid spreading of the epidemic in a wide range and serious complications, especially bacterial and viral pneumonia. Taiwan medical and public health system experienced huge impacts of such epidemics. Our study integrated epidemiological results to improve the effectiveness of influenza surveillance and assess the effectiveness of health policies for influenza prevention.

Materials and methods
We retrospectively reviewed recorded data of patients admitted in the intensive care unit who were diagnosed as severe influenza with respiratory failure during January 1, 2015 to December 31, 2015. We also recorded their clinical outcomes and history of influenza vaccine administration. We analyzed their prognosis, predictors of death and their possible correlations.

Results
Sensitivity analysis was performed to assess the severity of patients admitted in the ICU. Mechanical ventilation was estimated for epidemiological week of hospitalization. These patients had low proportion of treatment with antiviral medication in the first period of the study.

Conclusions
Influenza deaths were increased. It may contributed from aging of the population, underestimated the needs for better prevention modalities, including more effective vaccines and vaccination programs for elderly persons.

HE10: Incidence of carbapenem–resistant Enterobacteriaceae in Suratthani Hospital

Chonlada Piwpong

Background
Carbapenem–resistant Enterobacteriaceae (CRE) infection in the hospital is a major problem that has a direct impact to patients, health personnel and hospital. This study aimed to study the incidence rate of CRE and to investigate factors associated with CRE in the hospital.

Materials and methods
Data were collected by CRE from October, 1 2013 to September, 30 2015, analyzed by descriptive statistics, Chi-square test, Fisher’s exact test and Mann-Whitney U test.

Results
The results revealed that in 2015 the total of patient days was 281,622 days or 60,961 discharged patients. CRE infection was diagnosed 35 times. The nosocomial infection rate was 0.12 times/1000 patient days and 0.57 times/1000 discharged patient. The majority of infections were ventilator-associated pneumonia (34.80%); catheter-related urinary tract infection (30.40%). Pathogens were Klebsiella pneumoniae (60.70%), Escherichia coli (26.80%) and Enterobacter cloacae (8.93%). Most of the patients were immunocompromised host (92.70%), received catheter insertion (80.00%). Admitted in medical ward (46.30%), followed by surgical ward (42.00%). Patients with CRE infection had a higher cost of antibiotic and a longer length of stay than those who were not infected (111,864.00 and 115,23.25 baht; 67.00 and 26.70 days, respectively). Moreover, the length of stay in the hospital of the study group was significantly higher than those in the control group (p < .05).

Conclusions
Controlling and preventing CRE infection in medical ward and surgical ward were important and necessary. Especially among patients who were admitted in the hospital for longer than 4 weeks.

HE11: Changing antibiotic prophylaxis from fosfomycin to cefazolin did not change the trend of postcraniotomy surgical site infections

Songyos Rajborirug, Ploypailin Preechawetchakul, Yada Pruekrattananapa, Tharntip Sangsuwan, Silom Jamulitrat

Background
Routine use antimicrobial prophylaxis is an essential part of brain surgery due to the potential devastating consequences of postcraniotomy surgical site infection (PC-SSI). In the late of year 2014, after the decreasing rates of PC-SSI in Songklanagarind Hospital from vigorous control measures, we decided to change the antibiotic prophylaxis from fosfomycin (FOS) to cefazolin (CZO). This study aimed to evaluate the trend of PC-SSIs after changing antibiotic prophylaxis.

Materials and methods
The surveillance data were reviewed together with patient medical records to access the trend of PC-SSIs and identify the factors needed for risk adjustment.

Results
Information of 3250 craniotomies or craniectomies were reviewed and 157 PC-SSIs were documented in the patients underwent the operations during January 2005 through June 2016. Since the late of year 2007, FOS prophylaxis were used more frequently due to the recognition of methicillin-resistant Staphylococcus aureus outbreak. After the downward trend of PC-SSIs began in year 2012, prophylaxis was changed from FOS to CZO and the trend of PC-SSIs did not change after that.

Conclusions
Changing surgical prophylaxis from FOS to CZO did not increase the risk of PC-SSI.

HE12: Analysis of vancomycin-resistant enterococci (VRE) at a tertiary care hospital in northern Thailand: assessing epidemiology, cost and length of stay

Ratchanee Wongsaen, Sungwan Paengta, Napatnun Nilchon, Sutthipun Thanompan, Samattanet Tariyo

Background

After the first identified at a tertiary care hospital in northern Thailand since 2014, VRE have spread rapidly and become a problem implicated in health care associated infections (HAIs). Our study aimed to analyze epidemiology, cost and length of stay among patients having VRE at a tertiary care hospital in northern part of Thailand.

Materials and methods
We conducted a one-year prospective study in 82 patients admitted in Inpatient Department from October 2015 to September 2016 who were colonized or infected with VRE. The data source for surveillance was laboratory-based system. Data were analyzed by using descriptive statistics.

Results
From October 2015 to September 2016, we found VRE in 82 cases (59.7% in female and 40.3% in male). The incidence rate of VRE was 0.03:1000 patient-days. Most cases were found in medical department (87.8%). Incidence of VRE-infected patients was 59.7% (49/82 cases). Majority of these cases (43/82 cases, 52.4%) were HAIs. Incidence of patients colonized with VRE was 40.3% (33/82 cases). The most common sites of the infections were catheter-associated urinary tract infections. The average of hospitalization cost and the cost of antibiotic therapy for each patient were 96,844 Baht and 30,721 Baht respectively. The average length of stay in hospital for each patient was 26.2 days.

Conclusions
As a result of this study, most of VRE-infected patients were HAIs. The impacts of the infection increased both in cost and length of hospital stay.

HE13: Incidence and risk factors of ventilator associated pneumonia in newborn at the national children’s hospital, Vietnam

Ngai Le, Dung Khu

Background
Newborn could be seen as patients who are potentially exposed to ventilator associated pneumonia (VAP) at high risk. Identify the incidence as well as risk factors for VAP in newborn would be much necessary for prevention application. This study aimed to identify incidence and risk factors of VAP in NICU at the National Children’s Hospital (NCH) in Vietnam.

Materials and methods
This cohort prospective study was conducted between January and December in 2012. After univariate analysis, multivariate regression analysis was used to handle all statistically significant risk factors.

Results
602 neonates with mechanical ventilation (MV) were enrolled in our study. Among them, 151 neonates with VAP were determined with 159 episodes. Incidence rate (IR) was 25.1% (151/602); incidence density rate (IDR) was 31.7/1000 ventilator days (159/5018 ventilator days). With univariate analysis, these risk factors of VAP in newborn were: very low birth weight (<1500 gr) (OR: 1.9;95%CI: 1.2-2.8), transfusion during MV (OR:4.51; 95%CI:1.35-3.10), Use of corticosteroids during MV (OR:2.23; 95%CI:1.2-4.13), use of vasopressor during MV (OR: 2.05;95%CI:1.35 -3.10), reintubation before occurrence of VAP (OR: 1.6; 95%CI:1.04 – 2.46), duration of MV > 10 days (OR: 2.3; 95%CI:1.4 – 3.6). With multivariate regression analysis, “blood transfusion during MV” and “duration of MV for > 10 days” were the risk factors of VAP in newborn (OR: 2.91 & 3.29; 95%CI: 1.06-8.02 & 1.004-10.8).

Conclusions
IR & IDR of VAP in newborn at the NCH in Vietnam still was high (25.1% & 31.7/1000 ventilator days); main risk factors for VAP in newborn were “blood transfusion during MV” and “duration of MV for > 10 days”