Epidemiology and management Vancomycin resistant Enterococci and carbapenem resistant Enterobacteriaceae in low resource hospital in Thailand

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Abstracts of the 7th International Congress of the Asia Pacific Society of Infection Control, Taipei, Taiwan, March 26-29, 2015

Results: Overall there were 126 patients with CRKB BSIs in the study period. According to the latest minimum inhibitory concentration (MIC) interpretive breakpoints for Enterobacteriaceae issued by the Clinical and Laboratory Standards Institute (CLSI), 64 (50.8%) CRKP isolates were susceptible to cefepime (total 126 isolates showed MIC range: 0.5-128; MIC90: 64 mg/L). Of 22 (17.5%) patients with cefepime-susceptible CRKP BSI, cefepime definitive therapy showed a significantly lower mortality than other antibiotics (2/ 22, 9.1% vs. 40/104, 38.5%, P Z 0.007). In logistic regression analysis, 30day mortality was independently associated with critical illness (odds ratio [OR]: 14.6; 95% confidence interval [CI]: 4.2-50.9; P < 0.001); pneumonia (OR: 7.3; 95% CI: 1.8-30.4; P Z 0.006); a rapidly fatal underlying disease (OR 9.5; 95% CI 1.5-58.9; P Z 0.015), and definitive cefepime therapy (OR: 0.1; 95% CI: 0.01-0.8; P Z 0.028). Conclusions: Cefepime may be useful for the treatment of BSIs due to carbapenem-resistant but cefepime-susceptible K. pneumoniae, particularly if source control is achieved.

OS 5-1 CARBAPENEM-RESISTANT VERSUS CARBAPENEM-SUSCEPTIBLE ACINETOBACTER BAUMANNII BACTEREMIA IN A TEACHING HOSPITAL IN CHINA: RISK FACTORS AND OUTCOMES Fu Qiao, Wenzhi Huang. Infection Control Department, West China Hospital, S.C.U., Chengdu, China

Purpose: The objective of this study was to compare the mortality associated with Carbapenem- resistant Acinetobacter baumannii (CRAB) versus Carbapenem-susceptible Acinetobacter baumannii (CSAB) bacteremia, and to determine specific risk factors for CRAB isolates in a 4300-bed teaching hospital in China. Methods: We performed a retrospective case-control study between January 1, 2010 and December 30, 2013. One hundred and sixty three patients with CRAB bacteremia cases were compared to sixty eight unmatched patients with CSAB bacteremia controls during the study period. Results: The mortality rate was 32.5% and 4.4% in CRAB and CSAB cases respectively (P Z 0.000). The risk factors for mortality were got bacteremia with CRAB (hazard ratio [HR], 15.55; 95% confidence interval [CI], 3.2774.08; P Z 0.001), hematologic malignancy (HR, 13.77; 95%CI, 4.49-42.19; P Z 0.000), cardiovascular disease (HR, 4.53; 95%CI, 1.34-15.26; P Z 0.015) and increasing of age (HR, 1.03; 95%CI, 1.01-1.05; P Z 0.000). By multivariate analysis, the independent risk factors for CRAB bacteremia compared to CSAB bacteremia were emergency visit (odds ratio [OR], 2.58; 95% CI, 1.10-6.06; P Z 0.029) and ICU stay (OR, 6.64; 95%CI, 2.2619.54; P Z 0.001) before infection. Conclusions: The mortality rate was much higher among patients with CRAB bacteremia. Led to emergency and stay in ICU were found to be independent risk factors for bacteremia with CRAB.

OS 5-2 EFFICACY OF APPROPRIATE ANTIMICROBIAL THERAPY ON THE SURVIVAL OF PATIENTS WITH CARBAPENEM NON-SUSCEPTIBLE KLEBSIELLA PNEUMONIAE INFECTION: A MULTICENTER STUDY IN TAIWAN Yi-Tsung Lin 1,2, Chien Chuang 1, Chin-Fang Su 1, Yin-Ching Chuang 3, L. Kristopher Siu 4, Chang-Phone Fung 1,2. 1Division of Infectious Diseases, Department of Medicine, Taipei Veterans General Hospital, Taiwan, Taiwan; 2School of Medicine, National Yang-Ming University, Taipei, Taiwan; 3 Department of Internal Medicine and Medical Research, Chi Mei Medical Center, Tainan, Taiwan; 4Institute of Infectious Diseases and Vaccinology, National Health Research Institutes, Miaoli, Taiwan

Purpose: The impact of antimicrobial treatment on the outcome of carbapenem non-susceptible K. pneumoniae (CnsKP) infections needs to be elucidated. This nationwide, multicenter study was conducted to evaluate the impact of appropriate antimicrobial therapy on 14-day mortality among patients with CnsKP infection in Taiwan. Particular attention was focused on the outcome related to different levels of disease severity. Methods: Patients with CnsKP infections from 11 medical centers and four regional hospitals in Taiwan were enrolled in 2013. Carbapenem non-susceptibility was defined as a minimum inhibitory concentration of 2 mg/L for

imipenem or meropenem. Predictors of 14-day mortality were determined using the Cox proportional regression model. The influence of infection severity on the impact of appropriate use of antimicrobials on 14-day mortality was determined using the Acute Physiology and Chronic Health Evaluation (APACHE) II score. Results: Overall 14-day mortality was 31.8% (49/154 patients). Unadjusted mortality for appropriate antimicrobial therapy was 23.1% (18/78 patients). Appropriate therapy was independently associated with reduced mortality (hazard ratio [HR], 0.44; 95% confidence interval [CI], 0.24 to 0.80; P Z 0.007). A subgroup analysis revealed that the benefit of appropriate therapy was limited to patients with higher APACHE II scores (HR for patients with scores >15 and 35, 0.46 [95% CI, 0.23 e 0.92]; HR for those with scores >35, 0.14; 95% CI, 0.02 e 0.99). Conclusions: In conclusion, appropriate antimicrobial therapy significantly reduces 14-day mortality for CnsKP infections. Survival benefit is more notable among more severely ill patients.

OS 5-3 EPIDEMIOLOGY AND MANAGEMENT VANCOMYCIN RESISTANT ENTEROCOCCI AND CARBAPENEM RESISTANT ENTEROBACTERIACEAE IN LOW RESOURCE HOSPITAL IN THAILAND Aree Goonna, Prapaipan wongkrue, Sawalak Fupinwong, Nantana NunNgam, Chuleewan Yamrubboon. Infection Control Unit, Chiangmai University Hospital, Chiangmai, Thailand

Background: Hospitals in central part of Thailand has recently emerged Vancomycin Resistant Enterococci(VRE) and Carbapenem Resistant Enterobacteriaceae (CRE) for 3 years ago. These organisms associated with high mortality and high cost of treatment and care. January 2014 we found the first case of VRE in Maharaj Nakorn Chiangmai hospital, 1400 bed facility, a university hospital, we concerned about the spread of the organism and cost of treatment and care. Objectives: 1. To study epidemiology of VRE and CRE 2. To implementation infection control and prevention for new emerging organisms in hospital. Methods: Prospective surveillance study in all of patients visit our hospital was done from January to June 2014. The data source for surveillance was laboratory base system, collected using surveillance methodology and definition of Center for Disease Control. Data were analysis by using descriptive statistics. Implementing infection control strategies concurrent with the surveillance data. Strategies were; set up the special policy for VRE and CRE , announce of policy and share the guidelines. Developing manual for health care personnel, patients and family. Support of some disposable equipment. Set up a fast tract to notifying laboratory result report and rapid implementation, strict contact precautions . Environmental control was arranged for proper strict isolations, in general ward we created isolation chamber with plastic semi-hard partitions. Active surveillance of close contact patients for 2 weeks and when consequence negative clinical specimens and stool culture. Strict contact precautions was stopped. Set up one stop service for out patients.. For referral cases, notification system was performed to infection control team of other hospitals. Results: From January to June 2014, we found VRE and CRE of 27 and 25 cases consecutively. The incidence rate of VRE and CRE was 0.198/1000 and 0.184/1000 patient days, Most incident cases found in the medical department (53.84%). For the VRE incident infected patients were 44.4 % , and 54.6 % were colonized patients, HAI were 44.4 % . For CRE infected patients and colonization were 52.0% and 48.0% . HAI were 40.0 %. About 33% VRE had received Vancomycin before developed infection and colonization. For CRE incident 56 % and 36 % had received Cephalosporin, and Carbapenem before developed CRE. Close contact VRE patient developed colonization 22.2%, and 12.1% for CRE. Compliance of personnel, patients and relatives were at good level. However, sometimes we encountered shortage of PPE equipment. The major defect of practice was the thorough cleaning of environmental surrounding surface of the patient unit which spot checked by ATP test. Conclusion: The incidence of VRE and CRE in Maharaj nakorn chiangmai hospital is similar to incidence of hospitals those of European countries. Patient close contact VRE index cases developed infection and colonization with VRE

Abstracts of the 7th International Congress of the Asia Pacific Society of Infection Control, Taipei, Taiwan, March 26-29, 2015 more than patients close contact with CRE. The patients who have exposure with cephalosporin are high risk to developed infection and colonization with CRE.

OS 5-4 IMPLEMENTATION OF BUNDLE CARE TO DECREASE HEALTHCARE ASSOCIATED INFECTIONS CAUSED BY MULTIDRUG RESISTANT BACTERIA AT A MEDICAL CENTER Wang-Huei Sheng 1,2, Jann-Tay Wang 1,2, Ying-Ying Chang 2, I-Chen Hung 2, Mei-Ling Chen 2, An-Chi Chen 2, Yee-Chun Chen 1,2, Shan-Chwen Chang 1,2. 1 Center for Infection Control, National Taiwan University Hospital, Taipei, Taiwan; 2Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan

Purpose: Health care-associated infections (HAIs) are associated with significant morbidity, mortality, and cost. Growing rates of HAIs alongside evidence suggesting that active surveillance and infection control practices can prevent HAIs led to the development of hospital epidemiology and infection control programs. We aims to provide the successful experience of vigorous infection control program to decreasing HAIs caused by multidrug resistant microorganisms (MDRO) at a medical center in Taiwan. Methods: National Taiwan University Hospital (NTUH) is a 2500-bed medical center located in northern Taiwan which provides primary and tertiary medical care.The infection control team has implemented active surveillance, hand hygiene promotion, isolation cohort of MDRO, bundle care at intensive care units with special focus on catheter associated bloodstream infection prevention, urinary tract infection and ventilator associated pneumonia since 2010. MDRO related hospital infection density was used to evaluate its efficacy on decreasing HAI during implementation of these interventions. Results: The infection density have been decreased from 5.1 per 1000 patient-days in 2011, 4.9 in 2012, 4.2 in 2013 and 3.0 in 2014 (data update to Octorber 2014), respectively. Infection density of methicillin-resistant Staphylococcus aureus had decreased from 0.18 per 1000 patient-days (&) in 2011, 0.16 in 2012, 0.15 in 2013 and 0.11 in 2014 (P Z 0.003). Infection density of carbapenem-resistant Acinetobacter baumannii had had decreased from 0.15 per 1000 patient-days (&) in 2011, 0.18 in 2012, 0.09 in 2013 and 0.07 in 2014 (P < 0.001). However, infection density of vancomycin-resistant Enterococcus remains stationary, 0.14 per 1000 patient-days (&) in 2011 and 0.13 in 2014 (P Z 0.83). Conclusions: Well-structured infection control programs, with the expertise of a hospital epidemiologist and fully support of infection control practitioners, as well as a good cooperative network among microbiology laboratory, clinical staff, and infection control practitioners, are imperative to the prevention of HAIs. Trends of HAI caused by MRSA and CRAB, but not VRE, had been decreased under the implementation of bundle.

OS 5-5 CONTAINMENT OF KLEBSIELLA PNEUMONIAE CARBAPENEMASE IN THE ACUTE STROKE ICU OF MANILA DOCTORS HOSPITAL: AN OUTBREAK INVESTIGATION CASE STUDY Aisa Jensen Lee, RN , Melecia Velmonte, MD , Danna Mae Rodriguez. Manila Doctors Hospital, Manila, Philippines

Purpose: From January to October 2014, there have been 16 recorded Klebsiella pneumoniae carbapenemase (KPC) cases isolated from patients admitted in the Acute Stroke ICU. The highest incidence of KPC was noted in the month of August and September which has three (KPC rate: 30%) and six (60%) cases respectively. (See Figure 1) The 2013 prevalence rate was 25%. After establishing the existence of a KPC outbreak, Infection Prevention and Control (IPC) Office spearheaded an investigation to determine causes and control the transmission of the multi-drug organism. Methods: Following the CDC methodology of outbreak investigation, first a case definition was established for the verification of the outbreak. Thus the definition was formulated: “A case is a patient admitted in the Acute Stroke ICU with a growth of KPC within 48 hours admission.” Secondly, analysis of the epidemic curve revealed person-to-person transmission as characterized by the multiple peaks as wave after wave of infection occurs.

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Thirdly, the environmental culture was done pre-intervention. Environmental culture showed KPC isolated from two healthcare workers’ hands and patient care items (eg: stethoscope, infusion pumps, bedside / medication table, and alcohol handrub dispenser).The hypothesis established was transmission among patients was caused healthcare workers’ hand transmission to patients and their immediate environment. Implementation of IPC measures was done; the thorough cleaning of the patient immediate environment every shift by environmental service worker specifically trained and increase compliance on hand hygiene by all healthcare workers through a “buddy” system. Results: Post-intervention environmental cultures done showed that KPC was no longer present in the Acute Stroke ICU. There has been 40% decrease in KPC rates in October and further decrease of 50% reduction in November 2014. Findings were discussed in the ICU Committee meeting and cleaning policies/procedures were modified based on the results.

Conclusions: Klebsiella pneumoniae carbapenemase (KPC) producing bacteria is infections associated with significant morbidity and mortality but it can be eradicated through effective cleaning/disinfection of hospital environment and high hand hygiene compliance of healthcare workers.

OS 5-6 EMERGENCE OF COMMUNITY-ACQUIRED EXTENDED-SPECTRUM-BETALACTAMASE-PRODUCING ESCHERICHIA COLI UROPATHOGEN IN CHILDREN: PREVALENCE OF CTX-M 14 IN E. COLI O25B-ST131 Yun-Wen Chen 1,3, Jiun-Ling Wang 4,6, Wan-Yu Hung 5, I-Fei Huang 1,3, WanLing Chen 1,3,7, Yee-Hsuan Chiou 1,3, Yao-Shen Chen 2,3, Susan Shin-Jung Lee 2,3, Chih-Hsin Hung 5,*, Ming-Fang Cheng 1,3,*. 1Department of Pediatrics, Veterans General Hospital-Kaohsiung, Kaohsiung, Taiwan; 2 Department of Internal Medicine, Veterans General Hospital-Kaohsiung, Kaohsiung, Taiwan; 3School of Medicine, National Yang-Ming University, Taipei, Taiwan; 4School of Chinese Medicine for Post Baccalaureate I-Shou University, Kaohsiung, Taiwan; 5Department of Chemical Engineering and Institute of Biotechnology and Chemical Engineering, I-Shou University, Kaohsiung, Taiwan; 6Department of Internal Medicine, E-Da Hospital, Kaohsiung, Taiwan; 7Department of Pediatrics, Pingtung Branch of Veterans General Hospital-Kaohsiung, Pingtung, Taiwan

Purpose: Escherichia coli sero-group O25b-sequence type 131 (O25b-ST131), a multi-drug-resistant clonal group, is a significant pathogen in adults and children. This study investigated the genotyping and role of extended-spectrum b-lactamase (ESBL)-producing E. coli O25b-ST131 and non-O25b-ST131 in urinary tract infections (UTI) in children. Methods: We randomly enrolled one third of all the children (n Z 363) under 18 years of age who were hospitalized for UTI caused by ESBL-producing E. coli between 2009 and 2012. Clinical and laboratory data from the enrolled 121 children were collected. Polymerase chain reactions and multi-locus sequence typing were used to identify E. coli O25-ST131 clones. The gene blaCTX-M groups 1, 2, and 9, a specific PCR reaction of CTX-M 14 and 15, were also determined in ESBL-producing E. coli isolates. Results: O25b-ST131 accounted for 57 (47%) of the 121 isolates, while 54 isolates belonged to the blaCTX-M group 9, of which most were CTX-M-14. Among the 64 non-O25b-ST131 isolates, 10 isolates belonged to the blaCTX-M group 1, of which seven were CTX-M-14; three isolates belonged to the blaCTX-M group 2 and fourteen isolates belonged to the blaCTX-M group 9, of which ten were CTX-M-14. Those with O25b-ST131 clones had similar risk factors, clinical features, and outcomes as those with nonO25b-ST131. The O25b-ST131 isolates were more resistant to ciprofloxacin