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A four-year study of candidaemia (2011–2014) from a single center in southern India
journal of patient safety & infection control 3 ( 2 0 1 5 ) 50–69
Introduction: The rate of infection following total knee replacement (TKR) is between 2% and 5%. Attempts to curb this have included the use of antibiotic-loaded bone cement (ALBC) at the time of primary surgery. Prophylactic use of ALBC in addition to intravenous antibiotic for primary arthroplasty has been suggested to reduce the risk of infection along with monitoring of other infection control practices. Method: We conducted a retrospective cohort study to estimate the TKR infection rates and to compare infection rates during two periods. First phase was between 1 September 2013 to 31 May 2014 in which Gentamicin LBC was used followed by Vancomycin LBC between June to September 2014. Identification of deep surgical site infection was based on CDC/NHSN criteria. Each patient was followed for three months after surgery. Infections were identified with use of a validated surveillance tools. Chi-square was used to determine the statistical significance. Result: 577 and 445 knee replacements were done in 424 and 324 patients during first and second period. Of these knee replacements, 9 knees became infected (0.8%). The incidence rate was 3.5 per 100 knee years after follow-up duration of 252 years TKR infection rates with GLBC and VLBC were 1.4% (8/577) and 0.2% (1/445) knees respectively. There was no statistical difference between the use of Gentamycin and introduction of Vancomycin (p > 0.05). Conclusions: Use of prophylactic ALBC in addition to intravenous antibiotic along with other standard recommended practices could have possibly contributed for lower incidence of post-TKR infections. Funding: The present study was funded from institutional/research funds of the authors. No pharmaceutical grants were used for this study. http://dx.doi.org/10.1016/j.jpsic.2015.10.014
C008 Central line bundle implementation in intensive care units and its impact on Central Line Associated Blood Stream Infection (CLABSI) in a tertiary care centre I. Bora 1,∗ , V. Dutta 1 , V. Lyngdoh 1 , C. Lyngdoh 1 , D. Pradhan 2 1
Department of Microbiology, NEIGRIHMS, Shillong, India 2 Department of Anaesthesiology, NEIGRIHMS, Shillong, India Introduction: Bloodstream infections associated with the insertion and maintenance of central venous catheters (CVC) are the most common cause of health care-associated infections in intensive-care units (ICU). Mortality for central line-associated bloodstream infections (CLABSIs) is 12–25%, making them among the most deadly of healthcare-associated infections (HAIs). There was no clear cut evidence as to whether any specific guidelines were followed in our ICU as far as the prevention and control of CLABSI was concerned. Hence the study was planned with the objective to determine the effect of implementation of appropriate CLABSI Bundle to prevent Catheter-associated Blood Stream infection in ICU.
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Method: The study was conducted on 153 patients with central lines in Anaesthesiology ICU for a period of six months from July to December 2014.Blood samples, drawn simultaneously through the central catheter as well as peripherally prior to starting antibiotics, were processed in the Microbiology Department using standard protocols. CLABSI control and prevention plan with CLABSI insertion and maintenance bundles was prepared and implemented according to standard guidelines. Result: The Central Line Utilization Rate was 91.6% and out of 153 patients with CVC placed, 29 developed CLABSI. Acinetobacter baumannii was the commonest organism isolated. The rate of CLABSI in the post intervention period was 15.6 per 1000 device days, which was apparently decreased by 31% from the pre-intervention rate of 22 (per 1000 device days). Conclusions: The implementation of CLABSI Bundle is associated with lower infection rates only when compliance is high. For implementation of these bundles various local factors like good leadership support from ICU staff, patients and patients family are required. http://dx.doi.org/10.1016/j.jpsic.2015.10.015
C009 A four-year study of candidaemia (2011–2014) from a single center in southern India R. Adhikary ∗ , S. Joshi, M. Bhavana, H. Beena Manipal Hospital, Bangalore, India Introduction: Candida is one of the important causes of blood stream infections with significant mortality and morbidity. There are reports of shift in the relative frequency of Candida spp. isolated from blood. Method: We performed a retrospective laboratory-based study from January 2011 to December 2014. This study was conducted to determine the frequency of various Candida spp. with associated risk factors and its mortality rate. The species distribution of Candida was compared with our previous published study of data from January 2009 to December 2010. All consecutive patients who developed candidaemia were included during this four-year period. Result: During the study period, there had been 228 Candida isolates detected from blood of 168 patients. Seven patients had dual infections with 2 different Candida spp. The most frequent isolates were C. tropicalis (25.1%), C. haemulonii (19.4%), C. albicans (17.7%), C. parapsilosis (17.7%) and C. glabrata (5.7%). We identified 23 infants, 15 children and 130 adults with candidaemia. Mortality rate was 39.3%. Probable risk factors determined were antibiotic therapy (78.6%), intensive care stay (55.95%), ventilator (30.4%), abdominal surgery (27.97%) and malignancy (26.2%). When compared with our previous study, C. haemulonii has shown a steady rise from 0 cases in 2011 to 23 cases in 2014 and thereby replacing C. tropicalis as the most frequent isolate. Conclusions: Close monitoring of infection control practices and good antibiotic stewardship program could possibly reduce the emergence of resistant Candida spp. like C.
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journal of patient safety & infection control 3 ( 2 0 1 5 ) 50–69
haemulonii which has been reported to be less susceptible to commonly used antifungal agents.
C011 Profile of Candidiasis from a tertiary care hospital of North India: A 5 year study
http://dx.doi.org/10.1016/j.jpsic.2015.10.016 S. Riyaz Department of Microbiology, JNMC, AMU, Aligarh, India
C010 Outbreak of carbapenemase producing Klebsiella pneumoniae in pediatric intensive care unit and pediatric wards of a tertiary care hospital: Control measures H. Paul ∗ , J. Michael, V. Balaji, S. Selvan, V. Verghese, K. Ebenezar CMC Vellore, India Introduction: Emergence of carbapenem-resistant enterobacteriaceae is of concern as the treatment options are restricted, increased cost of treatment and increasing mortality. Between 24th July to 20th September 2014 eight pediatric patients from the same pediatric ward and pediatric intensive care unit developed septicemia. Blood cultures drawn showed the growth of Klebsiella pneumoniae with identical antibiogram. We initiated an investigation to identify the source of the pathogen and control measures to eradicate the pathogen from the unit. Method: Patient demographic details and relevant information were gathered from the medical records. Culture results were obtained from the clinical microbiology laboratory. A number of swabs were collected from the suspected environmental surfaces including hand impressions from healthcare workers. All the samples were processed using standard microbiological techniques. Result: Carbapenem resistant Klebsiella pneumoniae strains, with identical antibiotic sensitivity pattern were isolated from all the eight patients. Four isolates selected randomly were tested for NDM, KPC, OXA48, VIM, IMP and found to be positive for NDM. Further sequencing revealed that all belonged to NDM belongs to subset1. Susceptible strain of Klebsiella spp. was isolated from swabs taken from oxygen flow meter. All other cultures demonstrated the presence of non-fermenting Gram negative bacilli (NFGNB), but no carbapenem resistant enterobacteriaceae were detected. Standard precaution including, patient isolation, hand hygiene and handling of IV lines were re-emphasized. Terminal disinfection with standard disinfectants was done. Regular audits on hand hygiene and intravenous line care were implemented. Conclusions: K. pneumoniae producing NDM1 carbapenemase was probably responsible for an outbreak that affected eight patients in pediatric ward and pediatric ICU. Rapid spread of multidrug resistant pathogens is a concern in clinical areas, therefore surveillance and strict adherence to standard precautions in high risk areas can prevent such infections. Though we were unable to detect the point source, appropriate control measures helped to eradicate the pathogen. http://dx.doi.org/10.1016/j.jpsic.2015.10.017
Introduction: Pathogenic yeasts from genus Candida can cause serious infections in humans and are now recognized as a major agent of hospital acquired (nosocomial) infections. However, the invasive fungal infections are often life threatening, probably due to inefficient diagnostic methods, inappropriate initial antifungal therapy and emergence of drug resistance. We undertook the present work to study the associated risk factors, species distribution and antifungal susceptibility pattern of Candida isolates from various clinical samples. Method: The study was conducted at the Dept. of Microbiology, JNMC, Aligarh over a 5 year period. Risk factors were identified and clinical outcome described. Various clinical samples from the patients suspected of having fungal infection were cultured in accordance with the standard methods. Antifungal susceptibility testing of the isolated yeasts was done in accordance with the proposed guidelines for disk diffusion susceptibility methods based on CLSI document M44-A and Micro Broth dilution method based on CLSI document M27-A. Result: A total of 256 isolates of Candida species were recovered from various clinical samples like blood, urine, CSF, pus, BAL, oral swab, nail scrapings etc. Broad spectrum antibiotic or steroid therapy, presence of peripheral catheter, low birth weight, duration of hospital stay (>7 days) were the significantly associated risk factors. C. albicans 169 (66%) was most common isolated species followed by C. parapsilosis 27 (10.5%), C. krusei 20 (7.8%), C. tropicalis 19 (7.4%), C. guilliermondii 9(3.5%), C. dubliniensis 7 (2.7%), C. glabrata 5 (1.9%). Fluconazole resistance was detected in 32 (12.5%) Candida isolates followed by resistance to ketoconazole in 3 (1.1%), Amphotericin B in 2 (0.7%), Clotrimazole in 12 (4.6%) isolates, while no resistance was detected against Itraconazole and Nystatin. Conclusions: The presence of drug resistant Candida isolates in our region stresses an urgent need for clinicians to go for early diagnosis and antifungal susceptibility testing before initiating antifungal prophylactic treatment. http://dx.doi.org/10.1016/j.jpsic.2015.10.018
C012 Microbiological assessment of human milk from a milk bank at a tertiary care hospital in Mumbai D. D’Souza ∗ , A. De, S. Baveja, R. Chavan LTMM College, India Introduction: Breast milk enhances optimum growth and development and protects infants from infections. However, in some cases mothers have problems in lactation. Banking of human milk will thus reduce infection rates and help improve survival rates in hospitalized babies. Sometimes milk
Introduction: The rate of infection following total knee replacement (TKR) is between 2% and 5%. Attempts to curb this have included the use of antibiotic-loaded bone cement (ALBC) at the time of primary surgery. Prophylactic use of ALBC in addition to intravenous antibiotic for primary arthroplasty has been suggested to reduce the risk of infection along with monitoring of other infection control practices. Method: We conducted a retrospective cohort study to estimate the TKR infection rates and to compare infection rates during two periods. First phase was between 1 September 2013 to 31 May 2014 in which Gentamicin LBC was used followed by Vancomycin LBC between June to September 2014. Identification of deep surgical site infection was based on CDC/NHSN criteria. Each patient was followed for three months after surgery. Infections were identified with use of a validated surveillance tools. Chi-square was used to determine the statistical significance. Result: 577 and 445 knee replacements were done in 424 and 324 patients during first and second period. Of these knee replacements, 9 knees became infected (0.8%). The incidence rate was 3.5 per 100 knee years after follow-up duration of 252 years TKR infection rates with GLBC and VLBC were 1.4% (8/577) and 0.2% (1/445) knees respectively. There was no statistical difference between the use of Gentamycin and introduction of Vancomycin (p > 0.05). Conclusions: Use of prophylactic ALBC in addition to intravenous antibiotic along with other standard recommended practices could have possibly contributed for lower incidence of post-TKR infections. Funding: The present study was funded from institutional/research funds of the authors. No pharmaceutical grants were used for this study. http://dx.doi.org/10.1016/j.jpsic.2015.10.014
C008 Central line bundle implementation in intensive care units and its impact on Central Line Associated Blood Stream Infection (CLABSI) in a tertiary care centre I. Bora 1,∗ , V. Dutta 1 , V. Lyngdoh 1 , C. Lyngdoh 1 , D. Pradhan 2 1
Department of Microbiology, NEIGRIHMS, Shillong, India 2 Department of Anaesthesiology, NEIGRIHMS, Shillong, India Introduction: Bloodstream infections associated with the insertion and maintenance of central venous catheters (CVC) are the most common cause of health care-associated infections in intensive-care units (ICU). Mortality for central line-associated bloodstream infections (CLABSIs) is 12–25%, making them among the most deadly of healthcare-associated infections (HAIs). There was no clear cut evidence as to whether any specific guidelines were followed in our ICU as far as the prevention and control of CLABSI was concerned. Hence the study was planned with the objective to determine the effect of implementation of appropriate CLABSI Bundle to prevent Catheter-associated Blood Stream infection in ICU.
53
Method: The study was conducted on 153 patients with central lines in Anaesthesiology ICU for a period of six months from July to December 2014.Blood samples, drawn simultaneously through the central catheter as well as peripherally prior to starting antibiotics, were processed in the Microbiology Department using standard protocols. CLABSI control and prevention plan with CLABSI insertion and maintenance bundles was prepared and implemented according to standard guidelines. Result: The Central Line Utilization Rate was 91.6% and out of 153 patients with CVC placed, 29 developed CLABSI. Acinetobacter baumannii was the commonest organism isolated. The rate of CLABSI in the post intervention period was 15.6 per 1000 device days, which was apparently decreased by 31% from the pre-intervention rate of 22 (per 1000 device days). Conclusions: The implementation of CLABSI Bundle is associated with lower infection rates only when compliance is high. For implementation of these bundles various local factors like good leadership support from ICU staff, patients and patients family are required. http://dx.doi.org/10.1016/j.jpsic.2015.10.015
C009 A four-year study of candidaemia (2011–2014) from a single center in southern India R. Adhikary ∗ , S. Joshi, M. Bhavana, H. Beena Manipal Hospital, Bangalore, India Introduction: Candida is one of the important causes of blood stream infections with significant mortality and morbidity. There are reports of shift in the relative frequency of Candida spp. isolated from blood. Method: We performed a retrospective laboratory-based study from January 2011 to December 2014. This study was conducted to determine the frequency of various Candida spp. with associated risk factors and its mortality rate. The species distribution of Candida was compared with our previous published study of data from January 2009 to December 2010. All consecutive patients who developed candidaemia were included during this four-year period. Result: During the study period, there had been 228 Candida isolates detected from blood of 168 patients. Seven patients had dual infections with 2 different Candida spp. The most frequent isolates were C. tropicalis (25.1%), C. haemulonii (19.4%), C. albicans (17.7%), C. parapsilosis (17.7%) and C. glabrata (5.7%). We identified 23 infants, 15 children and 130 adults with candidaemia. Mortality rate was 39.3%. Probable risk factors determined were antibiotic therapy (78.6%), intensive care stay (55.95%), ventilator (30.4%), abdominal surgery (27.97%) and malignancy (26.2%). When compared with our previous study, C. haemulonii has shown a steady rise from 0 cases in 2011 to 23 cases in 2014 and thereby replacing C. tropicalis as the most frequent isolate. Conclusions: Close monitoring of infection control practices and good antibiotic stewardship program could possibly reduce the emergence of resistant Candida spp. like C.
54
journal of patient safety & infection control 3 ( 2 0 1 5 ) 50–69
haemulonii which has been reported to be less susceptible to commonly used antifungal agents.
C011 Profile of Candidiasis from a tertiary care hospital of North India: A 5 year study
http://dx.doi.org/10.1016/j.jpsic.2015.10.016 S. Riyaz Department of Microbiology, JNMC, AMU, Aligarh, India
C010 Outbreak of carbapenemase producing Klebsiella pneumoniae in pediatric intensive care unit and pediatric wards of a tertiary care hospital: Control measures H. Paul ∗ , J. Michael, V. Balaji, S. Selvan, V. Verghese, K. Ebenezar CMC Vellore, India Introduction: Emergence of carbapenem-resistant enterobacteriaceae is of concern as the treatment options are restricted, increased cost of treatment and increasing mortality. Between 24th July to 20th September 2014 eight pediatric patients from the same pediatric ward and pediatric intensive care unit developed septicemia. Blood cultures drawn showed the growth of Klebsiella pneumoniae with identical antibiogram. We initiated an investigation to identify the source of the pathogen and control measures to eradicate the pathogen from the unit. Method: Patient demographic details and relevant information were gathered from the medical records. Culture results were obtained from the clinical microbiology laboratory. A number of swabs were collected from the suspected environmental surfaces including hand impressions from healthcare workers. All the samples were processed using standard microbiological techniques. Result: Carbapenem resistant Klebsiella pneumoniae strains, with identical antibiotic sensitivity pattern were isolated from all the eight patients. Four isolates selected randomly were tested for NDM, KPC, OXA48, VIM, IMP and found to be positive for NDM. Further sequencing revealed that all belonged to NDM belongs to subset1. Susceptible strain of Klebsiella spp. was isolated from swabs taken from oxygen flow meter. All other cultures demonstrated the presence of non-fermenting Gram negative bacilli (NFGNB), but no carbapenem resistant enterobacteriaceae were detected. Standard precaution including, patient isolation, hand hygiene and handling of IV lines were re-emphasized. Terminal disinfection with standard disinfectants was done. Regular audits on hand hygiene and intravenous line care were implemented. Conclusions: K. pneumoniae producing NDM1 carbapenemase was probably responsible for an outbreak that affected eight patients in pediatric ward and pediatric ICU. Rapid spread of multidrug resistant pathogens is a concern in clinical areas, therefore surveillance and strict adherence to standard precautions in high risk areas can prevent such infections. Though we were unable to detect the point source, appropriate control measures helped to eradicate the pathogen. http://dx.doi.org/10.1016/j.jpsic.2015.10.017
Introduction: Pathogenic yeasts from genus Candida can cause serious infections in humans and are now recognized as a major agent of hospital acquired (nosocomial) infections. However, the invasive fungal infections are often life threatening, probably due to inefficient diagnostic methods, inappropriate initial antifungal therapy and emergence of drug resistance. We undertook the present work to study the associated risk factors, species distribution and antifungal susceptibility pattern of Candida isolates from various clinical samples. Method: The study was conducted at the Dept. of Microbiology, JNMC, Aligarh over a 5 year period. Risk factors were identified and clinical outcome described. Various clinical samples from the patients suspected of having fungal infection were cultured in accordance with the standard methods. Antifungal susceptibility testing of the isolated yeasts was done in accordance with the proposed guidelines for disk diffusion susceptibility methods based on CLSI document M44-A and Micro Broth dilution method based on CLSI document M27-A. Result: A total of 256 isolates of Candida species were recovered from various clinical samples like blood, urine, CSF, pus, BAL, oral swab, nail scrapings etc. Broad spectrum antibiotic or steroid therapy, presence of peripheral catheter, low birth weight, duration of hospital stay (>7 days) were the significantly associated risk factors. C. albicans 169 (66%) was most common isolated species followed by C. parapsilosis 27 (10.5%), C. krusei 20 (7.8%), C. tropicalis 19 (7.4%), C. guilliermondii 9(3.5%), C. dubliniensis 7 (2.7%), C. glabrata 5 (1.9%). Fluconazole resistance was detected in 32 (12.5%) Candida isolates followed by resistance to ketoconazole in 3 (1.1%), Amphotericin B in 2 (0.7%), Clotrimazole in 12 (4.6%) isolates, while no resistance was detected against Itraconazole and Nystatin. Conclusions: The presence of drug resistant Candida isolates in our region stresses an urgent need for clinicians to go for early diagnosis and antifungal susceptibility testing before initiating antifungal prophylactic treatment. http://dx.doi.org/10.1016/j.jpsic.2015.10.018
C012 Microbiological assessment of human milk from a milk bank at a tertiary care hospital in Mumbai D. D’Souza ∗ , A. De, S. Baveja, R. Chavan LTMM College, India Introduction: Breast milk enhances optimum growth and development and protects infants from infections. However, in some cases mothers have problems in lactation. Banking of human milk will thus reduce infection rates and help improve survival rates in hospitalized babies. Sometimes milk