APSIC Abstracts on MDRO Prevention

The following abstracts on the topic of MDRO prevention 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.

PM1: Successful control of carbapenem-resistant Enterobacteriaceae outbreaks

Terrence Rohan Chinniah, Kavitha Prabu, Rashidah Ahmad, Susylawathi Magon, Jauharatud DiniSuhaimi, Aizzuddin Mirasin, Nurul Morni, Boon Chu, Azizah Samsuddin, Aliyah Ahmad, Amalina Sidek, Noraini Ajis, Amalina AbuBakar, Amanie Shafiee, Julaini Safar

Background
Infection with Carbapenem-resistant Enterobacteriaceae (CRE) is increasing worldwide leading to high morbidity and mortality. No CRE cases were detected in Brunei till April 2013. This study aimed to control the outbreak as soon as it’s detected by microbiology laboratory.

Materials and methods
All specimens at microbiology laboratory are cultured according to routine laboratory methods and identified by VITEK 2, VITEK MS, API 20E and API 20NE. Antibiotic susceptibility test is performed according to Clinical Laboratory Standard Institute (CLSI) guidelines. Enterobacteriaceae showing resistant to carbepenems, namely ertapenem, imipenem and meropenem, were rechecked by VITEK 2 XL, Kirby-bauer method and Minimum Inhibitory Concentration by E-strips. If it still remain resistance to carbapenem, clinicians and infection control team was alerted immediately by email and phone. All these were found to be carbapenemase producing CRE, by Modified-Hodge test recommended by CLSI.

Results
One case of CRE was identified in April 2013. No case was detected during the year of 2014. From March 2015 till October 2015, sixteen cases of CRE were confirmed. Another small outbreak of four cases was noted from January 2016 till March 2016. No cases were identified since then.

Conclusions
Following identification of one case in April 2013 barrier nursing and isolation were re-visited to seal spread from this case. Outbreak of 15 cases in 2015 was mainly among critical care patients. Due to vigorous infection control measures this outbreak was control. Similarly the smaller outbreak of 5 cases in 2016 was also controlled by vigorous infection control practices. This experience of ours underlines the importance of early detection of CRE and strict infection control measures.

PM2: A continuous quality improvement (CQI) program of prevention and control of multiple drugs resistant organisms (MDROs) infections in a respiratory medical ward

Ng Po Yan, Leung Annie, Fung Yuk Ling, Lau Edna, Luk Kristine

Background
There was methicillin-resistant Staphylococcus aureus (MRSA) endemic and multidrug resistant Acinetobacter baumannii (MDRAB) increased in a male respiratory medical ward since 2014. This program aimed to control the spread of MDROs by bundle of infection control enhancement.

Materials and methods
A pilot CQI program was conducted in the respiratory ward since December 2015 by enhancing the quality care for 5 basic care procedures: hand hygiene, catheter care, nasogastric tube care, incontinence care and perianal care, promoting hand hygiene by training senior nurses in the ward as advocators to monitor the compliance of different disciplinary staff and improving the decontamination of respiratory equipment by standardizing as high level disinfection or replaced by disposable equipment.

Results
All ward staffs had been audited on 5 basic care procedures in 1Q 2016. Total 19 senior nurses in the ward were trained to be the hand hygiene auditor. Hand hygiene compliance rate was improved to over 90%. Respiratory equipment was either disposable or undergone high level disinfection at the end of program. Disinfection of respiratory equipment in ward was eliminated. Both MDRAB and MRSA has been decreased. MRSA hospital acquired infection (HAI) rate decreased from 1.3 in September 2015 to 0.6 in March 2016. There had no new MDRAB clinical cases from November 2015 to March 2016. The successful CQI program had been implemented to other medical wards in our hospital.

Conclusions
MDROs increase the mortality of patients and it is a great challenge to patient’s safety and prolonged hospital stay. Good compliance in basic infection control measures is a key factor to battle with MDROs in hospital.

PM3: Comprehensive strategy to reduce MRSA by dedicated certified nurse in infection control (CNIC) involvement at community hospital in Japan

Satoshi Shinomiya, Kumiko Yamamoto, Kayoko Kjiwara, Mitsuhiro Yamaguchi

Background
In Japan the government has decided to pay incentives for infection control (IC) interventions from 2012. Detection of methicillin-resistant Staphylococcus aureus (MRSA) is useful for evaluating efficacy of IC interventions in healthcare facilities. Our study would like to evaluate if comprehensive strategy of IC interventions are effective via monitoring MRSA rates.

Materials and methods
We investigated MRSA incidence per 1,000 patient-days from April 2007 to March 2016. Comprehensive strategy of IC interventions we’ve taken during study period were 1) full-time dedicated CNIC involvement since 2009, 2) routine reporting of multidrug-resistant organisms (MDROs) to CNIC, and 3) Personnel Protective Equipment (PPE) holder and portable hand sanitizer introduction.

Results
The mean detection rate of 1.29 was statistically decreased to 0.71 after the implementation of the IC interventions.

Conclusions
The detection of healthcare-associated MRSA has reduced after implementing comprehensive strategy. Key element of comprehensive strategy is an intervention by dedicated CNIC.

PM5 Are topical nasal antiseptics effective in reducing methicillin-resistant Staphylococcus aureus (MRSA) colonization?

Angela Chow, Grace Tin, Wei Zhang, Pei-Yun Hon, Bee-Fong Poh, Kalisvar Marimuthu, Brenda Ang

Background
Methicillin-resistant Staphylococcus aureus (MRSA) is a growing clinical problem in intermediate-care facilities. Nasal carriage could be a source of nosocomial transmission, and decolonization could reduce institutional MRSA prevalence. We evaluated the effect of octenidine nasal gel, coupled with universal chlorhexidine baths, in reducing MRSA prevalence.

Materials and methods
We conducted a quasi-experimental before-after study, screening all inpatients for MRSA in a rehabilitation facility in Singapore, in June-2014, July-2015, and July-2016. Nasal, axilla, and groin swabs were cultured on selective chromogenic agar. Universal chlorhexidine baths were implemented in 2014-2015. Octenidine nasal gel for MRSA-colonizers was added in 2016. Multivariable logistic regression models were constructed to assess for differences in MRSA prevalence.

Results
A total of 257 patients (97 in 2014, 77 in 2015, 83 in 2016) were screened. MRSA prevalence was 33.0% in 2014, 39.0% in 2015, and 19.3% in 2016 (P = 0.020). Groin colonization decreased from 21.7% (2014) and 28.6% (2015), to 14.5% (2016) (P = 0.094). Nasal colonization decreased from 17.5% (2014) and 21.8% (2015), to 6.0% (2016) (P = 0.020). Median length of stay (LOS) was longer in 2016 (20 days) compared to 2014 (14 days, P = 0.043) and 2015 (13 days, P = 0.012), although age and gender distributions were similar. After adjusting for age, gender, and LOS, MRSA colonization was significantly higher in 2014 (OR 2.69, 95%CI 1.23-5.89) and 2015 (OR 4.00, 95%CI 1.77-9.02) than 2016.

Conclusions
Topical nasal octenidine, coupled with universal chlorhexidine baths, can reduce MRSA colonization prevalence in intermediate-care facilities. Larger studies should be conducted to validate the findings and assess for applicability in other settings.

PM6: The influence of disease burden for patients infected with multidrug-resistant pathogens

Ming-Chin Chan1, Chih-Chien Wang2

Background
Since the use of antibiotics, drug-resistant pathogens were inevitably appeared. It is undoubtedly a huge challenge to clinical practices. Infections with multidrug-resistant Pathogens would result in higher mortality rate and extra medical expenses.

Materials and methods
This research collected and analyzed healthcare-associated bloodstream infection by multi-drug resistant pathogens including Acinetobacter baumannii, Pseudomonas aeruginosa, Vancomycin-resistant enterococci (VRE), Staphylococcus aureus and E. coli in Tri-Service General Hospital between 2011 and 2014. The cases were collected by infection control nurses. All the information and the expenditure of ICUs or wards were analyzed and compared.

Results
The results showed the highest mortality was VRE, about 80% and 57% of mortality rate in ICUs and wards, respectively. The longest days from admission to infection was Staphylococcus aureus, about 55.4 and 74.5 days in ICU and ward, respectively. Moreover, pathogen that has the longest days from infection to outpatient or expired was E. coli, with the average of 59.6 and 41.6 days in ICUs and wards, respectively. As for the expenditure, patients infected with E. coli in ICUs, and patients infected with VRE in wards cost the most expenses, which was about 15,333 and 5,000 US dollars, respectively.

Conclusions
The expenditure for nosocomial infections with multi-drug resistant pathogens in ICUs is higher than in wards, especially infected with E. coli, the other four pathogens caused about 6,333-10,000 US dollars in ICUs. In wards, it is about 3,667-4,667 US dollars infected with VRE, Staphylococcus aureus and E. coli. The antibiotics cost is the highest when infected with VRE.

PM7: The effectiveness of body wash employing 2% chlorhexidine to reduce healthcare-associated infections in a medical ICU of a medical center

Shu-Ju Huang, Huey-Jen Huang, Su-Fang Yu, Huan-Yu Huang, Pei-Chen Cheng, Jian-Feng Li1, Yuan-Ti Lee1, Chiung-Ling Lai, Min-Chi Lu

Background
In recent literature, the use of 2% chlorhexidine gluconate (2% CHG) for skin disinfection via bathing could reduce bacterial colonization. Thereby, healthcare-associated infection (HAI) and multidrug resistant organisms (MDROs) were successfully reduced. In the Medical Intensive Care Unit (ICU) of a Medical Center in Central Taiwan, the density of HAI was 6.6% in 2013 and 28.6% of the isolated pathogens were MDRO. Therefore, 2% CHG body wipe was employed since Apr 2014.

Materials and methods
The periods of Apr 2013 - Mar 2014 and Apr 2014 - Mar 2015 were designated as stages of pre-implementation (pIMP) and bundle implementation (bIMP), respectively. For pIMP, daily shower gel bath was used. For bIMP, (1) 2% CHG towel was used to wipe whole body after routine soap bath. Besides, (2) infection control measures, including hand hygiene, sterile techniques, isolation, environmental cleaning and disinfection, and (3) antibiotic stewardship were strictly applied.

Results
At bIMP, the HAI density was down to 3.6% from 6.1% of pIMP. Similarly, MDROs rate decreased from 32.1% to 10.3%, Carbapenem-resistant Acinetobacter baumannii from 66.9% to 44.2%, Carbapenem-resistant Pseudomonas aeruginosa from 14.9% to 13.9%, MRSA from 34.9% to 15.1%, and VRE from 47.7% to 30.0%. However, carbapenem-resistant Klebsiella pneumoniae (CRE) increasing from 1.4% to 4.1%. The rise in CRE rate was attributed to the active surveillance of VRE and CRE for patients from long-term care facilities (LTCF) and respiratory wards since Aug 2013.

Conclusions
MDROs are prevalent in ICU and LTCF, and contribute a lot to HAI, infection control measures should be implemented cautiously. In this study, 2% CHG wipe was effective in reducing HAI and MDRO rates, and provided a simple strategy and resulted in the improved quality of daily ICU care.

PM8: SHIP BE Program for multidrug-resistant Acinetobacter baumannii control in a crowded tertiary care hospital in southern Thailand

Sajeerat Kosol, Wantana Sakolwirat, Patchanee Paepong, Sawalee Jansanga, Pattarin Jaisamoot, Nuttha Thongnuanual, Chittima Srithong

Background
Suratthani Hospital is a tertiary care center providing care to patients in Southern Thailand with 880 beds and nearly 100% bed occupancy year round. The most common multidrug-resistant (MDR) bacteria causing infections in the hospital is Acinetobacter baumannii. Carbapenem-resistant Enterobacteriaceae have also been detected more frequently.

Materials and methods
The SHIP BE (S = Staff education, H = Hand Hygiene, I = Isolation/ Information, P = Personal Protective Equipment, B = Bathing with chlorhexidine gluconate (CHG), E = Environment) program was implemented between December 2015 and May 2016 as an effort to control such organisms among patients in general medical wards and medical intensive care units.

Results
Seventy nurses were enrolled in the educational program. After education, healthcare workers significantly gained more knowledge (Pre-intervention score 8.9/15 vs. Post-intervention score 10.4/15; p < .001). Compliance to isolation precautions increased significantly from 51.6 to95.5% (p < .001). For examples, hand hygiene compliance increased from 49.7% to 85.9%, wearing protective barriers increased from 58.6% to 91.9% and dedicated patient care items increased from 54.9% to 98.8%. Correctly performed environmental cleaning increased from 54.9 to 99%. We also use 2% chlorhexidine gluconate bathing frequently for patients (0% to 91.7%). The prevalence of MDROs decreased from 10.4% to 6.8%.

Conclusions
The SHIP BE program was effective in reducing the prevalence of MDROs although our hospital was very crowded.

PM9: Successful control of XDR-Acinetobacter baumannii in a critical care unit

Somporn Somsakul, Kumthorn Malathum, Sutima Plongpunth

Background
Extensively drug-resistant Acinetobacter baumannii (XDR-Ab) is a growing problem in acute care medical facilities worldwide. The Intermediate Medical Intensive Care Unit (IMU) was one of the areas with highest prevalence of infection caused by this organism in our hospital, 16.47 episodes/1,000 patient-days during October-December 2015. This study aimed to reduce the incidence of XDR-Ab in IMU.

Materials and methods
This study was performed between October 1st, 2015 and March 31st, 2016. The IMU had 20 beds, 2 were single-bed isolation room but the remaining was in a common hallway divided into three 6-bed sections. Space between each bed was only 90 cm. A total of 396 patients were observed. After the first three months to determine the baseline prevalence, we implemented the control measures including cohorting patients with XDR-Ab in the same area, encouraging hand hygiene by providing alcohol hand rub solution at each bed and common areas in the ward, mandatory isolation gown and gloves for caring of patient with XDR-Ab, improving environmental cleaning technique and frequency.

Results
The prevalence of XDR-Ab was gradually decreased, from 16.47 episodes /1,000 patient-days in the first phase to 3.98 episodes /1,000 patient-days in the second phase.

Conclusions
This study suggests that cohorting along with stringent infection prevention technique was effective in controlling spread of drug-resistant organisms and it might be an option for the crowded patient care areas.

PM10: Adherence of healthcare workers to guidelines for contact precautions in a tertiary care hospital

Mukkapon Punpop, Porntip Malathum, Kumthorn Malathum

Background
The Medical Semi-intensive Care Unit (MSCU) at Ramathibodi Hospital provides care for 20 patients who shared a common hall with 0.9 meter space between beds. The prevalence of multidrug-resistant organisms is highest in the hospital. Contact precautions have been implemented in the past five years to control such organisms. This study aimed to explore adherence of health care workers (HCWs) and their opinions toward guidelines for contact precautions.

Materials and methods
Survey using questionnaires and direct, blinded, random observation was performed during regular work shifts from April to May 2015. Descriptive statistics were used to analyze the data.

Results
The adherence rate to gloving was highest, followed by gowning and hand hygiene (81%, 56% and 51% respectively). Hand hygiene was performed more after than before giving care to patients. Although they wore gowns and gloves before patient care, HCWs immediately removed gown and gloves infrequently afterward. Forty percent of the HCWs adhered to the guidelines in every step, whereas 14% did not adhere at all. Nurses adhered most to the guidelines (72%). HCWs agreed with the guidelines but were unable to adhere to the guidelines at every step because of the crowded environment and perceived work overload. Results of this study suggested that adherence to the guidelines for contact precautions needs more cooperation among HCWs and barriers to the adherence should be minimized to prevent widespread multi-drug resistant organisms, and thereby improving the quality of care.

Conclusions
The gloves compliance rate was highest than gown and hand hygiene. Overall compliance rate 40%. The study finding needs to be concerned by healthcare workers for improving the quality of care.

PM11: Using the development and empowerment program followed role and competency of advanced practice nurse in extreme drug resistance organisms-infected patients caring in medical and surgical departments of Nakornping Hospital

Sutthiphan Thanomphan, Ratchanee Wongsaen, Kulada Peautiwat

Background
An Extreme Drug Resistance organisms (XDR) outbreak investigation at NKP Hospital in 2014 revealed that the hospital had 2 risk factors, which were inappropriate number of nurses and substandard infection prevention and control (IC) practices. The purpose of this developmental research was to develop a patient care model for XDR in medical and surgical departments, and to reduce the XDR infection rate.

Materials and methods
The methods of study were used Development and Empowerment Program (DEP), which followed role and competency of Advanced Practice Nurse (APN). Data were gathered from medical and surgical departments from 1 January to 30 September 2015. There were 3 purposive selected groups: 1) Case Manager Team, 2) Medical and Surgical Nursing Teams and 3) XDR infected cases. The research tools were: 1) DEP, 2) Data questionnaires, 3) The XDR IC practice observational forms and 4) The evaluation quality of XDR cases forms. Data were analyzed using descriptive statistics and t-test.

Results
The results of study suggested that a model for nursing care should consisted of 3 components: 1) providing XDR infection control activities in process of care, 2) developed and empowered case managers in role and competency of APN and 3) feedback outcomes of caring and supporting system. After using DEP, the XDR infection rate significantly decreased from 4.1 to 1.6 per 100 patient-days (p < 0.05).

Conclusions
This study showed that using DEP in case managers and nurses promoted participants learning in teams. The DEP also aligned XDR caring processes with IC standard practices that resulted in decreased XDR infection rate in hospital efficiency.

PM12: Development of clinical pathway for prevention and control of multidrug-resistant organisms transmission in hospital

Nattawipa boon kirdram, Wilawan Picheansathian, Pimpaporn Klunklin

Background
Transmission of multidrug-resistant organisms in hospitals has a direct impact on patients, health care personnel, the hospital, community, and the nation. This developmental research aimed to develop a clinical pathway for prevention and control of multidrug-resistant organism transmission in the medical department at a regional hospital.

Materials and methods
Study samples included 131 health care personnel who worked in the medical department and related including: hemodialysis, echocardiogram, radiology and ultrasound, CT scan, MRI, and stretcher. Ten patients infected or suspected of multidrug-resistant organism infection at the medical department were included in the test. The process for developing was based on Cheah’s (2000) framework. Three development steps were thus included: assessment and situation analysis, designing, and testing the implementation. The data collection instruments consisted of a demographic data record form and questionnaire assessing the opinions of health care personnel towards. The content validity of the questionnaire was examined by 5 experts and the content validity index was 0.90. Data were analyzed using descriptive statistics and data categorization.

Results
The results included: screening for multidrug-resistant organisms, using contact precautions, using masks when performing splash-generating procedures, cleaning patients’ bodies, cleaning the immediate environment, reminding health care personnel of best practices and proper transfer between units, active surveillance, and limiting medical errors and adverse events. Most health care personnel agreed that this clinical pathway was clear, convenient, feasible, practical and appropriate for implementation in their units.

Conclusions
This research suggests that should be routinely implemented in the hospital.