[Show abstract][Hide abstract] ABSTRACT: Limited knowledge of the local molecular epidemiology and the paucity of new effective antibiotics has resulted in an immense challenge in the control and treatment of extensively drug-resistant (XDR) Acinetobacter baumannii infections in Thailand. Antimicrobial combination regimens may be the only feasible treatment option in such cases. We sought to characterize the local molecular epidemiology and assess the bactericidal activity of various antibiotics individually and in combination against XDR A. baumannii in a Thai hospital.
All XDR A. baumannii isolates from Thammasat University Hospital were collected between October 2010 and May 2011. Susceptibility testing was conducted according to reference broth dilution methods. Pulse-field gel electrophoresis was used to genotype the isolates. Carbapenemase genes were detected using polymerase chain reaction. In vitro testing of clinically-relevant concentrations of imipenem, meropenem, doripenem, rifampicin and tigecycline alone and in combination with polymyxin B was conducted using multiple combination bactericidal testing.
Forty-nine polymyxin B-susceptible XDR A. baumannii isolates were identified. bla OXA-23 and bla OXA-51 genes were detected in all isolates. Eight clonally related clusters were identified, resulting in the initiation of several infection control measures. Imipenem, meropenem, doripenem, rifampicin, and tigecycline in combination with PB respectively, exhibited bactericidal killing in 100%, 100%, 98.0%, 100% and 87.8% isolates respectively at 24 hours.
Molecular epidemiologic analysis can aid the early detection of infection outbreak within the institution, resulting in the rapid containment of the outbreak. Imipenem/meropenem/rifampicin in combination with polymyxin B demonstrated consistent bactericidal effect against 49 bla OXA-23-harbouring XDR A. baumannii clinical isolates, suggesting a role of combination therapy in the treatment of these infections.
[Show abstract][Hide abstract] ABSTRACT: OBJECTIVE To evaluate the expected and treatment outcomes of Thai infectious disease physicians (IDPs) regarding carbapenem-resistant Acinetobacter baumannii (CRAB) ventilator-associated pneumonia (VAP) METHODS From June 1, 2014, to March 1, 2015, survey data regarding the expected and clinical success rates of CRAB VAP treatment were collected from all Thai IDPs. The expected success rate was defined as the expectation of clinical response after CRAB VAP treatment for the given case scenario. Clinical success rate was defined as the overall reported success rate of CRAB VAP treatment based on the clinical practice of each IDP. The expected and clinical success rates were divided into low (80%) categories and were then compared with standard clinical response rates archived in the existing literature. RESULTS Of 183 total Thai IDPs, 111 (60%) were enrolled in this study. The median expected and clinical success rates were 68% and 58%, respectively. Using multivariate analysis, we determined that working in a hospital that implemented the standard intervention combined with an intensified infection control (IC) intervention for CRAB (adjusted odds ratio [aOR], 3.01; 95% confidence interval [CI], 1.17-7.73; P=.02) was associated with standard and high expected rates (>60%). Being a board-certified IDP (aOR, 5.76; 95% CI, 2.16-15.37; P60%). We identified a significant correlation between expected and clinical success rates (r=0.58; P<.001). CONCLUSIONS Awareness of IC among IDPs can improve physicians' expected and clinical success rates for CRAB VAP treatment, and treatment experience impacts overall treatment success. Infect. Control Hosp. Epidemiol. 2015;00(0):1-9.
Infection Control and Hospital Epidemiology 10/2015; DOI:10.1017/ice.2015.240 · 4.18 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: A cross-sectional study was conducted on the performance of tuberculin skin test (TST) and QuantiFERON®-TB Gold In-tube test (QFT-IT) for detecting latent tuberculosis infection among Thai healthcare workers (HCWs). Each HCW underwent simultaneous TST and QFT-IT during the annual health screening. Among 260 HCWs enrolled, the median age was 30 (range 19-60 years), 92% were female, 64% were nurses and nurse assistants, 78% were BCG-vaccinated, and 37% had previous TST. Correlation between TST reaction size and level of interferon- γ (IFN-γ) was weak (r = 0.29; P<0.001). Thirty-eight percent and 20% of HCWs had reactive TST and positive QFT-IT, respectively. Using QFT-IT positivity as standard for latent tuberculosis diagnosis, the cut-off for TST reactivity with the best performance was ≥ 13 mm with sensitivity, specificity, false positivity and false negativity of 71%, 70%, 30% and 29%, respectively (area under the curve 0.73; P<0.001). Independent factor associated with false reactive TST was previous TST (adjusted odds ratio 1.83; P=0.04). Our findings suggest that QFT-IT may be a preferred test among HCWs with previous TST. In settings where QFT-IT is not available, appropriate cut-offs for TST reactivity should be evaluated for use among HCWs.
[Show abstract][Hide abstract] ABSTRACT: Several viral diseases have emerged and impacted healthcare systems worldwide. Healthcare personnels (HCPs) are at high risk of acquiring some emerging infections while caring for patients. We provide a review of risk factors, evidence of infection in HCPs, and prevention strategies with Middle East respiratory syndrome coronavirus, Ebola virus disease (Ebola), severe acute respiratory syndrome (SARS), and avian influenza.
HCP-related infections with Middle East respiratory syndrome coronavirus, Ebola, and SARS have been reported among 1-27%, 2.5-12%, and 11-57% of total cases, respectively. The case fatality rate of Ebola in HCPs has been reported up to 73%. The WHO guidelines for the global surveillance of SARS were developed in 2004 and used as a template for other emerging diseases preparedness. Risks to HCPs with emerging diseases are related to inappropriate and insufficient infection control measures during an initial encounter, at the beginning of outbreak and with an overwhelming number of patient cases. To date, there are no reports of avian influenza transmission to HCPs from affected cases.
Early and rapid detection of suspected infected patients with communicable diseases along with appropriate infection control practice, education, national and global preparedness guidelines would help to prevent disease transmission to HCPs.
Current Opinion in Infectious Diseases 06/2015; 28(4). DOI:10.1097/QCO.0000000000000183 · 5.01 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Objective:
To evaluate behavioral-based interventions to improve hand hygiene (HH) among healthcare workers (HCWs) at a Thai tertiary care center.
A quasi-experimental study was performed in 6 intensive care units with computer-generated allocation. Baseline demographic characteristics, self-reported stage of HH behavioral commitment, and observed HH adherence were examined from January 1, 2012, through December 31, 2012 (preintervention), and from January 1, 2013, through December 31, 2013 (postintervention). Self-reported HH was categorized by the stages construct from the Transtheoretical Model of Health Behavior Change. The intensive care unit group randomization was to either standard-of-care HH education every 3 months (S1), intensified HH interventions (S2), or intensified HH interventions plus increased availability of alcohol-based handrub throughout the unit (S3).
Among 125 HCWs from 6 intensive care units (42 in S1, 41 in S2, 42 in S3) there were 1,936 total HH observations; most HCWs (100 [ 80%]) were nurses or nurse assistants. Compared with preintervention, overall postintervention HH adherence improved in HCWs assigned to S2 (65% vs 85%; P=.02) and S3 (66% vs 95%; P=.005) but not S1 (68% vs 71%; P=.84). Improvement in HH adherence was demonstrated among HCWs who reported lower stages of HH commitment in S2 (21% vs 84%; P<.001) and S3 (24% vs 89%; P<.001) and in HCWs who self-reported higher stages of commitment in S3 (78% vs 96%; P<.001).
HCW HH programs may benefit from stage-based tailored strategies to promote sustained HH adherence.
Infection Control and Hospital Epidemiology 02/2015; 36(05):1-5. DOI:10.1017/ice.2015.1 · 4.18 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: OBJECTIVE To analyze available evidence on the effectiveness of triclosan-coated sutures (TCSs) in reducing the risk of surgical site infection (SSI). DESIGN Systematic review and meta-analysis. METHODS A systematic search of both randomized (RCTs) and nonrandomized (non-RCT) studies was performed on PubMed Medline, OVID, EMBASE, and SCOPUS, without restrictions in language and publication type. Random-effects models were utilized and pooled estimates were reported as the relative risk (RR) ratio with 95% confidence interval (CI). Tests for heterogeneity as well as meta-regression, subgroup, and sensitivity analyses were performed. RESULTS A total of 29 studies (22 RCTs, 7 non-RCTs) were included in the meta-analysis. The overall RR of acquiring an SSI was 0.65 (95% CI: 0.55-0.77; I2=42.4%, P=.01) in favor of TCS use. The pooled RR was particularly lower for the abdominal surgery group (RR: 0.56; 95% CI: 0.41-0.77) and was robust to sensitivity analysis. Meta-regression analysis revealed that study design, in part, may explain heterogeneity (P=.03). The pooled RR subgroup meta-analyses for randomized controlled trials (RCTs) and non-RCTs were 0.74 (95% CI: 0.61-0.89) and 0.53 (95% CI: 0.42-0.66), respectively, both of which favored the use of TCSs. CONCLUSION The random-effects meta-analysis based on RCTs suggests that TCSs reduced the risk of SSI by 26% among patients undergoing surgery. This effect was particularly evident among those who underwent abdominal surgery. Infect Control Hosp Epidemiol 2015;36(2): 1-11.
Infection Control and Hospital Epidemiology 02/2015; 36(2):169-79. DOI:10.1017/ice.2014.22 · 4.18 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background and objectiveLimited data exist for the performance of QuantiFERON-TB Gold In-tube Test (QFT-IT) in comparison to tuberculin skin test (TST) for detecting latent tuberculosis (LTB) in patients with human immunodeficiency virus (HIV) infection from tuberculosis (TB)-endemic Asia-Pacific countries.MethodsA cohort study of Thai HIV-infected patients without history of TB or LTB treatment was conducted from March 2012 through March 2013. Each patient underwent simultaneous TST and QFT-IT.ResultsAmong the 150 enrolled subjects, the median age was 40 years (range 17–65), 53% were male, and the median CD4 count was 367 cells/μL (range 8–1290). Reactive TST and positive QFT-IT were 16% and 13%, respectively, with low concordance between tests (kappa = 0.26); correlation between TST reaction size and level of interferon-γ was moderate (r = 0.34). Independent factors associated with discordant results were long-term smoking (adjusted odds ratio (aOR) 5.74; P = 0.002) for TST-reactive, QFT-IT-negative subjects, and age greater than 52 years (aOR 5.56; P = 0.02) and female gender (aOR 4.40; P = 0.04) for TST non-reactive, QFT-IT-positive subjects. The level of agreement between both tests improved when using a TST cut-off of ≥10 mm (kappa = 0.39).Conclusions
In our setting where QFT-IT is available but has limited use due to cost, TST with a cut-off of 10 mm for reactivity should be the initial LTB test. HIV-infected women and persons older than 52 years with non-reactive TST and long-term smokers with reactive TST may benefit from subsequent QFT-IT.
[Show abstract][Hide abstract] ABSTRACT: Background: Clinical Pharmacist (CP) is an emerging career in Thailand. We evaluated the efficacy of antimicrobial stewardship programs (ASP) featuring CP with or without infectious diseases consultation (IDC) in Thailand.
Methods: From 1/1/12-9/30/12, all patients with infections admitted to 4 medicine units were prospectively followed until hospital discharge for the impact of ASP with or without IDC for outcomes: inappropriate antibiotic use, antibiotic de-escalation, duration of antibiotic use, hospital length of stay (LOS), and mortality. Patients were retrospectively categorized as patients who had CP input without IDC (Group 1), CP input and IDC (Group 2), and no CP input or IDC (Group 3). All groups received basic ASP supervised by hospital pharmacy during the study period. CP was responsible for making daily rounds, alert treating physicians on antibiotic use, and reminders on antibiotic de-escalation. Appropriate antibiotic use was retrospectively evaluated for prehoc prescribing criteria.
Results: The cohort was comprised of 574 patients (G1 = 104; G2 = 320; G3 = 150), with no difference in demographics in G1 and G2. Compared to G3, G1 and G2 patients were more likely to have comorbidities and advanced age. Most antibiotic prescriptions were for empirical therapy (373/574; 65%) while antibiotic prescriptions were most often prescribed for respiratory tract infection (287/574; 50%). By multivariate analysis, G1 was associated with <7days duration of antibiotic use (adjusted Odds Ratio 19.6; P<0.001), while G2 was associated with less inappropriate antibiotic use (aOR = 0.03; P<0.001), antibiotic de-escalation (aOR = 3.7; P<0.001), and <7 days duration of antibiotic use (aOR = 6.81; P<0.001). Compared to G3 (as reference), G1 and G2 were less likely to be prescribed inappropriate antibiotic use (P<0.001), have de-escalation of antibiotics (P<0.001), receive antibiotics <7 days (P<0.001) and have subjects with shorter hospital LOS (P<0.001). There were no group differences in mortality.
Conclusion: This study suggests the feasibility and efficacy of ASP featuring CP, with or without IDC, among hospitalized patients in Thailand. Appropriate antibiotic use, antibiotic de-escalation, <7 day antibiotic regimens, and shorter hospital LOS was associated with CP participation on medical teams.
IDWeek 2014 Meeting of the Infectious Diseases Society of America; 10/2014
[Show abstract][Hide abstract] ABSTRACT: We report the results of an International Nosocomial Infection Control Consortium (INICC) surveillance study from January 2007-December 2012 in 503 intensive care units (ICUs) in Latin America, Asia, Africa, and Europe. During the 6-year study using the Centers for Disease Control and Prevention's (CDC) U.S. National Healthcare Safety Network (NHSN) definitions for device-associated health care-associated infection (DA-HAI), we collected prospective data from 605,310 patients hospitalized in the INICC's ICUs for an aggregate of 3,338,396 days. Although device utilization in the INICC's ICUs was similar to that reported from ICUs in the U.S. in the CDC's NHSN, rates of device-associated nosocomial infection were higher in the ICUs of the INICC hospitals: the pooled rate of central line-associated bloodstream infection in the INICC's ICUs, 4.9 per 1,000 central line days, is nearly 5-fold higher than the 0.9 per 1,000 central line days reported from comparable U.S. ICUs. The overall rate of ventilator-associated pneumonia was also higher (16.8 vs 1.1 per 1,000 ventilator days) as was the rate of catheter-associated urinary tract infection (5.5 vs 1.3 per 1,000 catheter days). Frequencies of resistance of Pseudomonas isolates to amikacin (42.8% vs 10%) and imipenem (42.4% vs 26.1%) and Klebsiella pneumoniae isolates to ceftazidime (71.2% vs 28.8%) and imipenem (19.6% vs 12.8%) were also higher in the INICC's ICUs compared with the ICUs of the CDC's NHSN.
American Journal of Infection Control 09/2014; 42(9):942-56. DOI:10.1016/j.ajic.2014.05.029 · 2.21 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Alexander Fleming's discovery of penicillin heralded an age of antibiotic development and healthcare advances that are premised on the ability to prevent and treat bacterial infections both safely and effectively. The resultant evolution of antimicrobial resistant mechanisms and spread of bacteria bearing these genetic determinants of resistance is acknowledged to be one of the major public health challenges globally, and threatens to unravel the gains of the past decades. We describe the major mechanisms of resistance to β-lactam antibiotics - the most widely used and effective antibiotics currently - in both Gram-positive and Gram-negative bacteria, and also briefly detail the existing and emergent pharmacological strategies to overcome such resistance. The global epidemiology of the four major types of bacteria that are responsible for the bulk of antimicrobial-resistant infections in the healthcare setting - methicillin-resistant Staphylococcus aureus, vancomycin-resistant enterococci, Enterobactericeae, and Acinetobacter baumannii - are also briefly described.