Withdrawal of Staphylococcus aureus from intensive care units in Turkey

Beta-Lactamase-Producing Gram-Negative Bacterial Isolates Among the Patients Attending a Tertiary Care Hospital, Kathmandu, Nepal

Over the times, carbapenems have been the choice of drug for treating multidrug-resistant (MDR) and extended spectrum beta-lactamase (ESBL)-producing organisms. The current study aimed at determining the occurrence of metallo beta-lactamase (MBL) and AmpC beta-lactamase (ABL) in gram negative bacteria isolated from clinical samples. A cross-sectional study was conducted amongst the patients visiting Manmohan Memorial Medical College and Teaching Hospital (MMTH), Kathmandu, Nepal from August 2017 to January 2018. A total of 4351 samples including urine, pus, wound swab, endotracheal tip, catheter tip, and blood were collected from the patients and processed by standard conventional microbiological methods. Antibiotic susceptibility testing (AST) of the isolates was performed by Kirby-Bauer disk diffusion method. Double disc synergy test was performed on carbapenem resistant organisms to detect production of MBL and inhibitor-based test was used for the detection of ABL production. Of the 4351 samples, 421 bacterial isolates belonging to 16 different genera were recovered, of which 303 (71.97%) were Gram negative bacilli (GNB). E. coli (189/303) and S. aureus (80/118) were the most prevalent among gram negatives and gram positives, respectively. Bacterial incidence was found significantly associated with gender, specimen type, and the department where the patients were enrolled. Colistin-sulfate and polymycin-B were the most effective drug against GNB, whereas imipenem against gram positives. Prevalence of MDR and methicillin-resistant S. aureus (MRSA) was 35.15% and 60%, respectively. The prevalence of MBL and ABL-producing isolate was 11(3.6%) and 13(4.3%), respectively. Pseudomonas aeruginosa (5/11) and E. coli (9/13) were the major MBL and ABL producers, respectively. MBL and ABL production was found to be significantly associated with the age of the patient and the specimen type. A regular antibiotic surveillance activity with screening for MBL and ABL-producing bacterial isolates in the hospital settings to curb the incidence and transmission of such difficult-to-treat pathogens.

Analyzing central-line associated bloodstream infection prevention bundles in 22 countries: The results of ID-IRI survey

BACKGROUND

Because central line-associated bloodstream infections (CLABSIs) are a significant complication of central venous access, it is critical to prevent CLABSIs through the use of central line bundles. The purpose of this study was to take a snapshot of central venous access bundles in various countries.

METHODS

The participants in intensive care units (ICUs) completed a questionnaire that included information about the health center, infection control procedures, and central line maintenance. The countries were divided into 2 groups: those with a low or low-middle income and those with an upper-middle or high income.

RESULTS

Forty-three participants from 22 countries (46 hospitals, 85 ICUs) responded to the survey. Eight (17.4%) hospitals had no surveillance system for CLABSI. Approximately 7.1 % (n = 6) ICUs had no CLABSI bundle. Twenty ICUs (23.5%) had no dedicated checklist. The percentage of using ultrasonography during catheter insertion, transparent semi-permeable dressings, needleless connectors and single-use sterile pre-filled ready to use 0.9% NaCl were significantly higher in countries with higher and middle-higher income (P < .05).

CONCLUSIONS

Our study demonstrated that there are significant differences in the central line bundles between low/low-middle income countries and upper-middle/high-income countries. Additional measures should be taken to address inequity in the management of vascular access in resource-limited countries.

Treatment of ventilator-associated pneumonia (VAP) caused by Acinetobacter: results of prospective and multicenter ID-IRI study

Ventilator-associated pneumonia (VAP) due to Acinetobacter spp. is one of the most common infections in the intensive care unit. Hence, we performed this prospective-observational multicenter study, and described the course and outcome of the disease. This study was performed in 24 centers between January 06, 2014, and December 02, 2016. The patients were evaluated at time of pneumonia diagnosis, when culture results were available, and at 72 h, at the 7th day, and finally at the 28th day of follow-up. Patients with coexistent infections were excluded and only those with a first VAP episode were enrolled. Logistic regression analysis was performed. A total of 177 patients were included; empiric antimicrobial therapy was appropriate (when the patient received at least one antibiotic that the infecting strain was ultimately shown to be susceptible) in only 69 (39%) patients. During the 28-day period, antibiotics were modified for side effects in 27 (15.2%) patients and renal dose adjustment was made in 38 (21.5%). Ultimately, 89 (50.3%) patients died. Predictors of mortality were creatinine level (OR, 1.84 (95% CI 1.279-2.657); p = 0.001), fever (OR, 0.663 (95% CI 0.454-0.967); p = 0.033), malignancy (OR, 7.095 (95% CI 2.142-23.500); p = 0.001), congestive heart failure (OR, 2.341 (95% CI 1.046-5.239); p = 0.038), appropriate empiric antimicrobial treatment (OR, 0.445 (95% CI 0.216-0.914); p = 0.027), and surgery in the last month (OR, 0.137 (95% CI 0.037-0.499); p = 0.003). Appropriate empiric antimicrobial treatment in VAP due to Acinetobacter spp. was associated with survival while renal injury and comorbid conditions increased mortality. Hence, early diagnosis and appropriate antibiotic therapy remain crucial to improve outcomes.

Antibacterial resistance patterns and incidence of hospital-acquired Staphylococcus aureus bacteremia in a tertiary care educational hospital in Turkey: a perspective from 2001 to 2013

Background/aim: Staphylococcus aureus is an important nosocomial pathogen and a successful antimicrobial-resistance developer. In this study we retrospectively evaluated the resistance patterns and incidence of microbiologically confirmed nosocomial bacteremia (MCNB) related S. aureus strains between 2001 and 2013. Materials and methods: Any patient in whom S. aureus was isolated in at least one set of blood cultures (sent to the bacteriology laboratory 72 h after hospital admission) was considered to have MCNB. Results: The methicillin-resistant S. aureus (MRSA) rate in 2001 was 73.8% whereas it was 36.2% in 2013. When the 2001-2003 and 2011?2013 periods were compared, resistance to oxacillin, levofloxacin, gentamicin, erythromycin, and clindamycin decreased significantly (P < 0.05). When we evaluated the total S. aureus, MRSA, and methicillin-sensitive S. aureus (MSSA) bacteremia rates per 1000 days and 1000 patients, there was an increase in the 2004?2005 period, which was followed by a slight decrease until 2013 (P < 0.05). There was a plateau in MCNB-related S. aureus rates between 2008 and 2011. Conclusion: There was a decrease in overall S. aureus and MRSA bacteremia incidence as well as MRSA rates except for a plateau between 2008 and 2011. This steady decrease in the resistance rates is most probably due to the 2003 budget application and application of antimicrobial stewardship.

Molecular Characterization of Methicillin-Resistant Staphylococcus aureus Bloodstream Isolates in a Turkish University Hospital Between 2002 and 2012

AIMS

Methicillin-resistant Staphylococcus aureus (MRSA) is one of the most important pathogens in the hospital environment. Monitoring of this pathogen by molecular characterization and phenotypic methods is important for the development of suitable infection control measures and proper therapy design. In this study, our aim was to investigate the molecular epidemiological characteristics of MRSA bloodstream isolates obtained from patients hospitalized at Ankara University Ibn-i Sina Hospital in a 10-year period (2002-2012) and monitor the possible changes. A total of 134 isolates were characterized according to their antimicrobial susceptibility profiles, biofilm formation capabilities, accessory gene regulator (agr) locus types, presence of genes encoding Panton-Valentine leukocidin (PVL), staphylococcal enterotoxins A-J (SEs A-J), toxic shock syndrome toxin, sasX, and genes associated with biofilm formation (icaD, icaA, IS256) by polymerase chain reaction. The staphylococcal cassette chromosome mec (SCCmec) types of isolates were also defined and their clonal relationships were investigated by pulsed-field gel electrophoresis (PFGE) analysis and multilocus sequence typing was performed for representative isolates obtained by PFGE.

RESULTS

The majority of the isolates were resistant to rifampin (100%), ciprofloxacin (97%), tetracycline (97.7%), and gentamicin (94.7%); 100% carried type-III SCCmec and 89.5% were agr type-1. All the isolates were negative for PVL, and sasX genes while all of them carried the icaD, icaA, and IS256 genes. The most common SE was enterotoxin A (97%). Four major PFGE patterns with the dominance of one pattern and seven unique patterns were obtained. All the representative PFGE isolates (n = 11) belonged to sequence type 239.

CONCLUSION

We have documented the characteristics of the dominant MRSA clone in our hospital, which was a PVL (-), sasX (-) ST239 clone carrying sea (+) with type-III SCCmec, and type-1 agr locus.

Determining the Independent Risk Factors and Mortality Rate of Nosocomial Infections in Pediatric Patients

The objective of this study was to determine the rate, independent risk factors, and outcomes of healthcare-associated infections in pediatric patients. This study was performed between 2011 and 2014 in pediatric clinic and intensive care unit. 86 patients and 86 control subjects were included in the study. Of 86 patients with nosocomial infections (NIs), there were 100 NIs episodes and 90 culture growths. The median age was 32.0 months. The median duration of hospital stay of the patients was 30.0 days. The most frequent pathogens were Coagulase-negative Staphylococcus, Acinetobacter spp., Klebsiella spp., and Candida spp. Unconsciousness, prolonged hospitalization, transfusion, mechanical ventilation, use of central venous catheter, enteral feeding via a nasogastric tube, urinary catheter, and receiving carbapenems and glycopeptides were found to be significantly higher in NIs patients. Multivariate logistic regression analysis showed prolonged hospitalization, neutropenia, and use of central venous catheter and carbapenems as the independent risk factors for NIs. In the univariate analysis, unconsciousness, mechanical ventilation, enteral feeding, use of enteral feeding via a nasogastric tube, H₂ receptor blockers, and port and urinary catheter were significantly associated with mortality. In the multiple logistic regression analysis, only mechanical ventilation was found as an independent predictor of mortality in patients with NIs.

Mortality predictors of Staphylococcus aureus bacteremia: a prospective multicenter study

Background

Staphylococcus aureus is one of the causes of both community and healthcare-associated bacteremia. The attributable mortality of S. aureus bacteremia (SAB) is still higher and predictors for mortality and clinical outcomes of this condition are need to be clarified. In this prospective observational study, we aimed to examine the predictive factors for mortality in patients with SAB in eight Turkish tertiary care hospitals.

Methods

Adult patients with signs and symptoms of bacteremia with positive blood cultures for S. aureus were included. All data for episodes of SAB including demographics, clinical and laboratory findings, antibiotics, and outcome were recorded for a 3-year (2010–2012) period. Cox proportional hazard model with forward selection was used to assess the independent effect of risk factors on mortality. A 28-day mortality was the dependent variable in the Cox regression analysis.

Results

A total of 255 episodes of SAB were enrolled. The median age of the patients was 59 years. Fifty-five percent of the episodes were considered as primary SAB and vascular catheter was the source of 42.1 %. Healthcare associated SAB was defined in 55.7 %. Blood cultures yielded methicillin-resistant S. aureus (MRSA) as a cause of SAB in 39.2 %. Initial empirical therapy was inappropriate in 28.2 %. Although overall mortality was observed in 52 (20.4 %), 28-day mortality rate was 15.3 %. Both the numbers of initial inappropriate empirical antibiotic treatment and the median hours to start an appropriate antibiotic between the cases of fatal outcome and survivors after fever onset were found to be similar (12/39 vs 60/216 and 6 vs 12 h, respectively; p > 0.05). High Charlson comorbidity index (CCI) score (p = 0.002), MRSA (p = 0.017), intensive care unit (ICU) admission (p < 0.001) and prior exposure to antibiotics (p = 0.002) all were significantly associated with mortality. The Cox analysis defined age [Hazard Ratio (HR) 1.03; p = 0.023], ICU admission (HR 6.9; p = 0.002), and high CCI score (HR 1.32; p = 0.002) as the independent predictive factors mortality.

Conclusions

The results of this prospective study showed that age, ICU stay and high CCI score of a patient were the independent predictors of mortality and MRSA was also significantly associated with mortality in SAB.

Evaluation of the effectiveness of an infection control program in adult intensive care units: a report from a middle-income country

BACKGROUND

The rates of hand hygiene improvement and health care-associated infections (HAIs) were evaluated after the introduction in 2004 of an infection surveillance and prevention program at a university teaching hospital in a low- to middle-income country.

METHODS

Data on hand hygiene compliance, HAI rate, multiresistant organisms, and antibiotic consumption in 4 adult intensive care units (ICUs; medical, general surgery, anesthesiology and reanimation, and neurosurgery) were collected retrospectively for each year from 2004 to 2012. Negative binomial regression modeling with a log link was used to adjust for overdispersion in observations, and the first year of observations served as the baseline for comparing changes in incidence rate ratio (IRR) over the subsequent years.

RESULTS

Total hand hygiene compliance improved from 30.5% in 2004 to 43.5% by 2010 (IRR, 1.3; P <.0001) and reached 63.8% by 2012 (IRR, 1.9; P < .0001). The HAI rate was 42.6/1,000 patient-days at baseline and increased significantly thereafter until 2012, when it decreased by 20% to 33.6/1,000 patient-days (IRR, 0.8; P = .001). The rate of central line-associated bloodstream infection was 7.85 (95% confidence interval [CI], 5.89-10.26)/1,000 catheter-days in 2004 and increased to 12.4 (95% CI, 9.98-14.39)/1,000 catheter-days in 2012 (IRR, 1.5; P = .024). The rate of ventilator-associated pneumonia remained stable from the 2004 baseline rate of 31.66/1,000 ventilator-days to the 2012 rate of 24.04/ 1,000 ventilator-days (IRR, 0.88; P = .574). The rate of catheter-associated urinary tract infection remained relatively stable between 2004 and 2012 (from 7.92/1,000 catheter-days to 4.97/1,000 catheter-days; P = .101). The rate of methicillin-resistant Staphylococcus aureus infection was 6.24/1,000 patient-days at baseline and decreased significantly to 0.73/1,000 patient-days by 2007 (IRR, 0.13; P <.001) and continued to remain below 2/1,000 patient-days for the next 5 years. The rate of Pseudomonas aeruginosa infection decreased significantly from 8.66/1,000 patient-days in 2004 to 6.09/1,000 patient-days in 2010 (IRR, 0.72; P = .026) and to 5.44/1,000 patient-days by 2012 (IRR, 0.63; P = .002). The rate of Acinetobacter baumannii infection was 14.3/1,000 patient-days at baseline, decreased significantly by 2005 (IRR, 0.73; P = .012), fluctuated between 2006 and 2010, and then decreased significantly to 10.44/1,000 patient-days in 2011 (IRR, 0.74; P = .007) and then to 7.6/1,000 patient-days in 2012 (IRR, 0.53; P < .001). Antibiotic consumption did not decrease noticeably over the 9-year study period.

CONCLUSIONS

Hand hygiene improved in all of the ICUs evaluated. Measuring changes in HAI rates in a single health care setting can be statistically challenging, and a bias in the detection rates is not uncommon in the early years of a new infection prevention program. Here, for the first time, implementation of an infection surveillance and prevention program was associated with a reduction in HAI rate.

The features of infectious diseases departments and anti-infective practices in France and Turkey: a cross-sectional study

The aim of this study was to assess the infectious diseases (ID) wards of tertiary hospitals in France and Turkey for technical capacity, infection control, characteristics of patients, infections, infecting organisms, and therapeutic approaches. This cross-sectional study was carried out on a single day on one of the weekdays of June 17-21, 2013. Overall, 36 ID departments from Turkey (n = 21) and France (n = 15) were involved. On the study day, 273 patients were hospitalized in Turkish and 324 patients were followed in French ID departments. The numbers of patients and beds in the hospitals, and presence of an intensive care unit (ICU) room in the ID ward was not different in both France and Turkey. Bed occupancy in the ID ward, single rooms, and negative pressure rooms were significantly higher in France. The presence of a laboratory inside the ID ward was more common in Turkish ID wards. The configuration of infection control committees, and their qualifications and surveillance types were quite similar in both countries. Although differences existed based on epidemiology, the distribution of infections were uniform on both sides. In Turkey, anti-Gram-positive agents, carbapenems, and tigecycline, and in France, cephalosporins, penicillins, aminoglycosides, and metronidazole were more frequently preferred. Enteric Gram-negatives and hepatitis B and C were more frequent in Turkey, while human immunodeficiency virus (HIV) and streptococci were more common in France (p < 0.05 for all significances). Various differences and similarities existed in France and Turkey in the ID wards. However, the current scene is that ID are managed with high standards in both countries.

Evaluation of risk factors affecting hospital-acquired infections in the neurosurgery intensive care unit

The aim of the present study was to identify nosocomial infections (NIs), and their associated risk factors, in patients treated in the neurosurgery intensive care unit (NICU) of our hospital. Patients determined to have NIs between January 2008 and December 2012 were included in the study. Each patient's age, gender, microbiological culture results, underlying conditions, type of NIs, device utilization, total parenteral nutrition, reason for hospitalization, Glasgow score, and treatment were recorded and evaluated using statistical analysis. Risk factors for NIs were analyzed with a logistic regression model. During the five-year period, 60 NI episodes were detected in 56 out of 1643 patients. The mean age of the patient population was 33.3 (1-79) years. Of the patients, 22 were female and 34 were male. The overall incidence rate (NIs/100) and incidence density (NIs /1000 days of stay) of NIs were 3.65% and 6.5/1000 patient days, respectively. Regardless of the year of surveillance, the three most commonly detected NIs were bloodstream infection, shunt infection, and ventilator-associated pneumonia. No statistically significant difference was detected between infected and uninfected patients in terms of sex, age, blood transfusions, or mannitol and steroid use (p ≥ 0.05). In the present study, Glasgow scores, the frequency of prior usage of broad-spectrum antibiotics, and NICU stay durations were significantly higher among patients with infections (p < 0.001). Univariate analysis demonstrated that a low Glasgow score, re-operation, and use of mechanical ventilation were risk factors for NIs. We identified low Glasgow coma scores, long hospital stay duration, use of wide spectrum antibiotics, mechanical ventilation, total parenteral nutrition, and re-operation as risk factors for NIs.

Surveillance, control and management of infections in intensive care units in Southern Europe, Turkey and Iran--a prospective multicenter point prevalence study

OBJECTIVE

We aimed to compare the features of intensive care units (ICUs), their antimicrobial resistance patterns, infection control policies, and distribution of infectious diseases from central Europe to Mid-West Asia.

METHODS

A cross-sectional point prevalence study was performed in 88 ICUs from 12 countries. Characteristics of ICUs, patient and antibiotic therapy data were collected with a standard form by infectious diseases specialists.

RESULTS

Out of 749, 305 patients at least with one infectious disease were assessed and 254 patients were reported to have coexistent medical problems. When primary infectious diseases diagnoses of the patients were evaluated, 69 had community-acquired, 61 had healthcare-associated, and 176 had hospital-acquired infections. Pneumonia was the most frequent ICU infection seen in half of the patients. Distribution of frequent pathogens was as follows: Enteric Gram-negatives (n = 62, 28.8%), Acinetobacter spp. (n = 47, 21.9%), Pseudomonas aeruginosa (n = 29, 13.5%). Multidrug resistance profiles of the infecting microorganisms seem to have a uniform pattern throughout Southern Europe and Turkey. On the other hand, active and device-associated infection surveillance was performed in Turkey more than Iran and Southeastern Europe (p < 0.05). However, designing antibiotic treatment according to culture results was highest in Southeastern Europe (p < 0.05). The most frequently used antibiotics were carbapenems (n = 92, 30.2%), followed by anti-gram positive agents (vancomycin, teicoplanin, linezolid, daptomycin, and tigecycline; n = 79, 25.9%), beta-lactam/beta lactamase inhibitors (n = 78, 25.6%), and extended-spectrum cephalosporins (n = 73, 23.9%).

CONCLUSION

ICU features appears to have similar characteristics from the infectious diseases perspective, although variability seems to exist in this large geographical area.