The association of adherence to Antimicrobial Prophylactic Recommendations for Clean Neurosurgeries with post-operative surgical site infection

Objective@#The use of antimicrobial prophylaxis to prevent surgical site infections (SSI) is well established. This study examined the association of adherence to antimicrobial prophylaxis for clean neurosurgeries with post-operative surgical site infection (SSI) rates. @*Methods@#A retrospective descriptive study was conducted at the Philippine General Hospital (PGH) among pediatric patients who underwent clean neurosurgical procedures between January 1, 2018 – December 31, 2019. The outcome measured was the development of SSI. Univariate and multivariate analysis was performed to show the association of risk factors with SSI. Compliance to existing antibiotic prophylaxis recommendation was assessed.@*Results@#One hundred eighty-nine (189) medical charts were reviewed. Overall prevalence of SSI was 9.5% and fever was the most common initial symptom of SSI. Staphylococcus species was identified from cultures of surgical sites, consistent with existing literature, however gram-negative organisms including multidrug-resistant organisms (MDRO) were noted. All cases received prophylactic antibiotics, but adherence to all parameters (antimicrobial choice, dose, timing, route, re-dosing and duration of prophylaxis) was low at 7.9%. Appropriate antibiotics were prescribed in only 15.9% and antibiotics were discontinued beyond 24 hours post-surgery in 45.5% of cases. Patients who received a regimen fully compliant with antimicrobial prophylaxis recommendations did not develop SSI. @*Conclusion@#Adherence to existing antimicrobial prophylaxis protocol for neurosurgeries is low at 7.9%. Patients who received a regimen fully compliant with the recommendations did not develop SSI. Interventions to improve compliance to antimicrobial prophylaxis guidelines are needed.

Antimicrobial Stewardship (AMS) program in private hospitals in the Philippines: Its acceptability, barriers, and enablers

Background@#Antimicrobials are drugs that are often misused and inappropriate antimicrobial prescribing often results in poor clinical outcome and drug resistance. Monitoring and regulation of antimicrobial use is currently being done by the Department of Health through the Antimicrobial Stewardship (AMS) Program. There is a need to determine the factors that affect successful implementation of an AMS program in private hospitals in the Philippines. This study was conducted to identify the enablers and potential barriers in implementing an AMS program in nine (9) private hospitals. @*Methodology@#A concurrent mixed methods design was used to assess various stakeholders’ (physicians, administrators, other AMS members) perceptions of existing or proposed AMS programs, and to identify barriers and enablers in their implementation. Quantitative data were collected using self-administered survey questionnaire to assess clinician’s acceptance of AMS programs. Qualitative data were collected through semi-structured one-on-one interviews of clinicians and other AMS personnel and focus group discussions (FGD) of selected clinician groups. Data were gathered from October 2018 to October 2019. @*Results@#409 clinicians were surveyed, 52 were interviewed and 46 sat for 13 sessions of FGDs. Overall, the survey established that physicians were well aware of antimicrobial resistance problem. Majority of the clinicians indicated general agreement with the currently practiced antimicrobial protocols in their hospitals and with the AMS program. However, there were disagreements in perceptions with how antimicrobial restrictions impair prescribing practices and overuse of the same. These responses were strong points of discussion during the Key Informant Interviews (KII) and FGDs. All respondents were amenable with the institutionalization of an AMS program in their hospitals. The hospital leadership’s commitment was determined to be the key enabler of a successful AMS program’s implementation. Barriers identified for hospitals with existing AMS programs were: lack of dedicated staff, resistance and/or non-cooperation of physicians, lack of support from non-medical departments, and inadequate cooperation between hospital personnel. Barriers identified, regardless of the status of the AMS programs were: deficiency in knowledge with developing and implementing an AMS program, inadequate information dissemination, unavailability of an IT-based monitoring for antibiotic use, and the influence of pharmaceutical companies on stakeholders with regards to antimicrobial use. @*Conclusion@#Similar enablers and barriers to a successful implementation of an AMS program were seen in the different hospitals. A hospital leadership’s commitment was determined to be the key enabler. The success or failure of any AMS program appears to depend on physician understanding, commitment and support for such a program. By involving the main players in an AMS program- the hospital administrators, clinicians and other key members, perceived barriers will be better identified and overcome, and enablers will help allow a successful implementation of an AMS program. This multi-center study was funded by Philippine Council on Health Research and Development ( PCHRD) and Pediatric Infectious Disease Society of the Philippines ( PIDSP) and was conducted by the PIDSP Research Committee.

Clinico-Epidemiologic profile and outcome of pediatric patients with Multi Drug Resistant Gram-Negative healthcare associated infections at the Philippine General Hospital

Introduction@#Multi Drug Resistant Organisms (MDRO) are microorganisms that are resistant to one or more classes of antimicrobial agents, and these have become significant pathogens to contend with in the treatment of Healthcare Associated Infections.@*Objectives@#This study aimed to determine the clinico-epidemiologic profile and outcome of pediatric patients with healthcare-associated multi-drug resistant gram-negative infections, and its antimicrobial susceptibility patterns. @*Methodology@#This was a retrospective study done on pediatric patients with gram negative healthcare associated MDRO sepsis compared to non-MDRO sepsis admitted at the ICU and pediatric wards of a tertiary government hospital from July 2015 to June 2016. Descriptive statistics was used to summarize the clinical characteristics of patients. Odds ratio and the corresponding 95% confidence interval from binary logistic regression was computed to determine significant predictors for the development of multi drug resistance. Outcome of patients with MDRO gram-negative infection was noted, as well as its antimicrobial susceptibility patterns. @*Results@#A total of 199 patients developed HAI, and 41% were identified to be gram negative MDR cases. Pediatric patients with healthcare associated infections due to MDR gram negative organisms had shorter hospital stay and a higher mortality rate of 78% compared to 41% among non MDR patients.The most commonly isolated gram negative organisms were Burkholderia cepacia, 38%; Klebsiella pneumoniae, 31%; and Acinetobacter baumanii, 18%; while the most common MDR gram negative isolates were Klebsiella pneumoniae, 65%; Acinetobacter aumanii, 22%; and Pseudomonas aeruginosa, 7%. Significant predictors for MDRO were age (0-28 days old), ICU admission, intravascular catheterization and use of total parenteral nutrition. @*Conclusion@#Profile of pediatric patients with healthcare-associated multidrug resistant gram-negative infections were neonates admitted in the ICU with a shorter hospital stay and a high mortality rate. The identified risk factors for developing Multi Drug Resistant Gram Negative sepsis were age of 0-28 days, admission to ICU, intravascular catheterization and parenteral nutrition. Patients with gram-negative MDR infections have a high mortality rate and isolates are susceptible mostly to Colistin.

Validation of the modified Faine’s Criteria in the diagnosis of leptospirosis in children using the Microscopic Agglutination Test as the gold standard

Objective@#This study aimed to validate the modified Faine’s criteria (Parts A and B) proposed by Brato in the early diagnosis of leptospirosis in children using the microscopic agglutination test (MAT) as gold standard. @*Methodology@#This diagnostic validity study was conducted at the Philippine General Hospital. It included all pediatric patients who were admitted between September 2009 to December 2010 and who satisfied the presumptive and suggestive criteria in the diagnosis of leptospirosis based on the modified Faine’s criteria. A fourfold or greater rise in paired MAT titers was used as the gold standard. Calculations for sensitivity, specificity, positive and negative predictive values, and likelihood ratios of positive and negative tests were computed. Results Thirty-three patients satisfied the diagnosis of leptospirosis based on the criteria; however, only 20 of these had paired MAT titers and were included. The modified Faine’s criteria had a sensitivity of 60%, specificity of 73%, positive predictive value (PPV) of 43%, negative predictive value (NPV) of 85%, positive likelihood ratio of 2 and negative likelihood ratio of 0.4 . Modifying the clinical criteria by revision of the point allocation to create a “Pediatric Locally Modified Criteria” increased the sensitivity to 80%, PPV to 50%, NPV to 92%, positive likelihood ratio to 3 and negative likelihood ratio to 0.3. @*Conclusion@#The Modified Faine’s criteria had poor sensitivity and low positive predictive value and cannot be recommended as a screening test for the early diagnosis of leptospirosis in children. A proposed modification of the clinical criteria for local application increased diagnostic accuracy but must be further validated in a larger number of pediatric patients in the Philippines.