Implementation of central venouscatheter bundle in an intensive care unitin Kuwait: Effect on centralline-associated bloodstream infections

Central line-associated bloodstream infection [CLABSIs] is an importanthealthcare-associated infection in the critical care units. It causes substantial mor-bidity, mortality and incurs high costs. The use of central venous line [CVL] insertionbundle has been shown to decrease the incidence of CLABSIs.Our aim was to study the impact of CVL insertion bundle on incidence of CLABSIand study the causative microbial agents in an intensive care unit in Kuwait.Surveillance for CLABSI was conducted by trained infection control team usingNational Health Safety Network [NHSN] case definitions and device days measure-ment methods. During the intervention period, nursing staff used central line carebundle consisting of [1] hand hygiene by inserter [2] maximal barrier precautionsupon insertion by the physician inserting the catheter and sterile drape from headto toe to the patient [3] use of a 2% chlorohexidine gluconate [CHG] in 70% ethanolscrub for the insertion site [4] optimum catheter site selection. [5] Examination ofthe daily necessity of the central line.During the pre-intervention period, there were 5367 documented catheter-daysand 80 CLABSIs, for an incidence density of 14.9 CLABSIs per 1000 catheter-days. After implementation of the interventions, there were 5052 catheter-days and 56CLABSIs, for an incidence density of 11.08 per 1000 catheter-days. The reduction inthe CLABSI/1000 catheter days was not statistically significant [P = 0.0859].This study demonstrates that implementation of a central venous catheter post-insertion care bundle was associated with a reduction in CLABSI in an intensive carearea setting

Occupational injuries prone to infectious risks amongst healthcare personnel in Kuwait: a retrospective study

The study aimed at determining the prevalence of incident occupational exposure to blood and other potentially infectious materials [OPIM] among healthcare personnel [HCP] during 2010 and at evaluating the factors associated with these incidents. Subjects and an epidemiological, retrospective, record-based study was conducted. All self-reported incidents of occupational exposure to blood and OPIM among HCP from all healthcare settings of the Kuwait Ministry of Health during 2010 were included. The total number of the exposed HCP was 249. The prevalence of incident exposure was 0.7% of the HCP at risk. Their mean age was 32.31 +/- 6.98 years. The majority were nurses: 166 [66.7%], followed by doctors: 35 [14.1%], technicians: 26 [10.4%] and housekeeping personnel: 22 [8.8%]. Needle stick injury was the most common type of exposure, in 189 [75.9%], followed by sharp-object injury, mucous-membrane exposure and contact with nonintact skin. The majority of needle stick exposures, i.e. 177 [93.7%], were caused by hollow-bore needles. Exposure to blood represented 96.8%, mostly during drawing blood and the insertion or removal of needles from patients [88 [35.4%]] and when performing surgical interventions [56 [22.6%]]. Easily preventable exposures such as injuries related to 2-handed recapping of needles [24 [9.6%]] and garbage collection [21 [8.4%]] were reported. Exposures mainly occurred in the inpatient wards [75 [30.1%]] and operating theaters [56 [22.6%]]. Among the exposed HCP, 130 [52.2%] had been fully vaccinated against hepatitis B virus [HBV]. Needle stick injuries are the most common exposure among HCP in Kuwait, and nurses are the most frequently involved HCP category. A good proportion of exposures could be easily prevented. HBV vaccination coverage is incomplete

Risk Factors of catheter related blood stream infection in neonatal intensive care unit: experience from a developing country

Objective: The aim of this study was to detect the rate of catheter-related bloodstream infection [CRBSI] in NICU of Mansoura University Children's Hospital and to focus on possible predictors of infection. Study

Design: A cross sectional comparative study to detect rate of CRBSI among neonates with central vascular catheters during the period between January 2009 and April 2012. Then, a nested case control study done among CRBSI cases and central vascular catheters none infected as a control group to detect predictors associated with their occurrence

Patients and Methods: Blood samples were collected from III neonates clinically suspected ofsepticemia and had inserted venous line. Central, peripheral blood and catheter tip cultures were done for each case

Results: CRBSI was confirmed in 69 cases as central blood culture count was > 3 folds of peripheral blood culture count. Catheter tip culture showed > 103 CFV/ ml per catheter of the same organisms. Low birth weight, age below 7 days, prematurity, mechanical ventilation, TPN administration and prolonged hospital stay were predictors of CRBSI. Logistic regression of the studied predictors showed that birth weight, TPN administration and length of central venous catheter stay were significant predictors of CRBSI

Conclusion: CRBSI is a common problem in NICU. Predictors of CRBSI included low birth weight, prematurity and mechanical ventilation. Potential use of TPN, prolonged catheter stay and low birth weight are independent predictors for CRBSI

effect of hand hygiene compliance on hospital-acquired infections in an ICU setting in a Kuwaiti teaching hospital

Hand washing is widely accepted as the cornerstone of infection control in the intensive care unit [ICU]. Nosocomial infections are frequently viewed as indicating poor compliance with hand washing guidelines. To determine the hand hygiene [HH] compliance rate among healthcare workers [HCWs] and its effect on the nosocomial infection rates in the ICU of our hospital, we conducted an interventional study. The study spanned a period of 7 months [February 2011-August 2011] and consisted of education about HH indications and techniques, workplace reminder posters, focused group sessions, and feedback on the HH compliance and infection rates. The WHO HH observation protocol was used both before and after a hospital-wide HH campaign directed at all staff members, particularly those in the ICU. Compliance was measured by direct observation of the HCWs, using observation record forms in a patient-directed manner, with no more than two patients observed simultaneously. The overall HH compliance rate was calculated by dividing the number of HH actions by the total number of HH opportunities. The nosocomial infection rates for the pre- and post-interventional periods were also compared to establish the effect of the intervention on rate of infections acquired within the unit. The overall rate of HH compliance by all the HCWs increased from 42.9% pre-intervention to 61.4% post-intervention, P < 0.001. Individually, the compliance was highest among the nurses, 49.9 vs. 82.5%, respectively [P < 0.001] and lowest among the doctors, 38.6 vs. 43.2%, respectively [P = 0.24]. The effect of the increase in the HH compliance rate on the nosocomial infection rate was remarkable. There were significant reductions in the following: the rate of overall health care-associated infections/1000 patient-days, which fell from 37.2 pre-intervention to 15.1 post-intervention [P < 0.001]; the rate of bloodstream infections, which fell from 18.6 to 3.4/1000 central-line-days [P < 0.001]; and the rate of lower respiratory tract infections, which fell from 17.6 to 5.2/1000 ventilator-days [P < 0.001]. Similarly, there were significant reductions in the isolation rates of 4 major hospital pathogens [P < 0.001 and P = 0.03]. These findings suggest that although cross-infection in the ICU is a complex process, its frequency can be affected by meticulous adherence to hand hygiene recommendations

Atypical pharyngitis in suppurative otitis media cases

Unexplained persistent or recurrent bacterial pharyngitis in some patients who are suffering from infected middle ear cleft. Bacteriological swabs were obtained from both ears and pharynx of thirty-seven cases with chronic otorrhea and perforation, who are complaining of recurrent or persistent sore throat. isolation and identification of the microorganisms were done. This included examination by direct Gram stained films and cultures. Isolated Gram-negative bacilli were subjected to further identification by biochemical reactions and antimicrobial susceptibility testing using modified Kirby Bauer disk diffusion method. Identical isolates from the same patient [ear and pharyngeal swabs] were subjected to further identification by genotyping using the pulsed field gel electrophoresis technique [PFGE]. Six cases [16%] showed identity in both phenotypes and genotypes for ear and pharyngeal samples from the same patient. Four of the isolates were Pseudomonas aeruginosa, one was Proteus mirabilis, and one was Escherichia coli. None of these three species is known to be among the primary organisms that may cause pharyngitis. Bacterial pharyngitis in patients with chronically infected middle ear cleft may be attributed to the same organism invading the middle ear mucosa. In addition, this study highlights some organisms as pharyngeal invaders although they are not among the previously documented causatives of bacterial pharyngitis. However, the study did not confirm the method of spread of these organisms between the middle ear cleft and the pharynx and did not prove whether the spread was directly via the eustachian tube or not. The study correlates the causative organism of the middle ear infection and that infected the pharyngeal mucosa by using phenotypic and genotypic bacteriological identification and typing methods

Detection of bordetella pertussis by PCR in infants with respiratory failure

Despite being under-reported, Bordetella pertussis injection remains a severe disease of high incidence world-wide. No cases were reported in Egypt since 2001. Different immunization protocols exist in different countries with variable vaccination coverage ratios. This prospective investigation study was conducted in the PICU of Mansoura University Children Hospital. Mansoura, Egypt identifying cases of B. pertussis infection among mechanically ventilated infants presenting with respiratory failure and features compatible with pertussis [bronchopneumonia, apnoea, acute life threatening event]. Infants less than one year of age were enrolled over a period of 12 months. Sixty one specimens of endotracheal secretions were examined by PCR for the presence of a 262-bp target sequence from IS481 specific for B. pertussis. Nine specimens were positive for B. pertussis, five infants in this group did not survive. All non survivors were younger than 6 months of age. Infants in the PCR-positive group had a younger age [p = 0.038], a longer duration of illness prior to PICU admission [p < 0.01] and a higher mortality rate [p = 0.045] compared to the PCR - negative infants. It is crucial to raise awareness, among medical professionals, of clinical picture, complications and treatment of pertussis, If immunization program of Egypt was to be reviewed, there may be a need for a more accelerated primary immunization program against pertussis with booster doses for young adults

Listeria monocytogenes bloodstream infection in the main ICU of a general hospital in Kuwait- a case report

Invasive listeriosis is rarely reported in adult hospitalized patients in Kuwait. A case of Listeria monocytogenes bloodstream infection in an adult in the main ICU of A Kuwaiti general hospital is presented. A possible explanation for its occurrence is discussed

Comparative molecular analysis of community or health care associated methicillin-resistant staphylococcus aureus

Methicillin-resistant Staphylococcus aureus [MRSA] is no longer only hospital acquired. Community acquisition was defined as growth of the isolates within 48 hours after hospital admission in patients who had no risk factors for nosocomial acquisition, including no hospitalizations or nursing home residence in the year before admission. Community-acquired methicillin-resistant Staphylococcus aureus [CA-MRSA] is a growing public health Concern It is hypothesized that the evolution of CA-MRSA is a recent event due to the acquisition of mec DNA by previously methicillin-susceptible strains that circulated in the community. This study investigated the genetic relatedness between CA-MRSA and hospital-associated MRSA [HAMRSA]. Isolates were typed by resistance pattern, plasmid analysis, pulsed field gel electrophoresis, bacteriophage pattern, coagulase gene restriction fragment length polymorphism and SCC mec. Thirty out of the 32 CA-MRSA isolates were closely related as determined by pulsed field gel electrophoresis and yet were unrelated to the 32 HCA-MRSA strains. All CA-MRSA isolates tested contained a type IV staphylococcal cassette chromosome mec [SCCmec] element. Antibiotic susceptibility patterns showed difference between the CA-MRSA and HA-MRSA isolates; Thirty of the CA-MRSA isolates were typically resistant only to beta-lactam antibiotics. Non of the CA-MRSA were typeable by the international set of phages

Characterization of multiresistant acinetobacter baumannii strain causing a large and sustained hospital outbreak in ICU

Thirty two Acinetobacter baumanni samples isolated from patients and the environment in an intensive care unit [ICU] during an outbreak investigation were tested for antimicrobial resistance and typed by pulsed-field gel electrophoresis. Three pulsed-field patterns were observed. Twenty four isolates showed identical pulsed-field pattern. Seven isolates showed same but different pattern and a third pattern was showed by the remaining isolate. The results suggested that Acinetobacter baumanni clone had contaminated the environment and spread among patients. This study demonstrates the application of infection control surveillance combined with strain typing in detecting Acinetobacter baumanni colonization in the ICU where it was not known to exist

Bacterial DNA and its consequences in patients with cirrhosis and culture negative, non neutrocytic ascites

The detection of bacterial DNA [BactDNA] in serum and ascitic fluid [AF] from patients with liver cirrhosis and ascites is interpreted as molecular evidence of intestinal bacterial translocation [BT] and considered sufficient to activate the cellular immune response leading to greater cytokine synthesis. In the present work we study whether BactDNA and Tumor necrosis factor-alpha [TNF- alpha] in cirrhotic patients with culture negative, non neutrocytic ascites have been implicated in various complications of cirrhosis such as hepatorenal syndrome [HRS], spontaneous bacterial peritonitis [SBP] and mortality. We studied 34 patients with liver cirrhosis and culture negative, non neutrocytic ascites [22 patients without BactDNA [group I] aged [48.3 +/- 7.85y] and 12 patients with BactDNA [group II], aged [49.7 +/- 6.5y]]. Full history and complete clinical examination were done with the following investigations in the first admission and subsequent admissions during follow up for 24 weeks: complete blood picture, S. creatinine, S. bilirubin, S. albumin, S. transaminases [AIT and AST], AF and plasma TNF-alpha, AF protein and polymorphnuclear leucocytes [PMNL], both blood culture and AF aerobic and anaerobic cultivation, and detection of blood and ascitic fluid BactDNA using PCR. Plasma and ascitic TNF-alpha were significantly higher in cirrhotic patients with compared to those without BactDNA during first admission [54.5 +/- 22.56 vs 35.2 +/- 17.97; 123.2 +/- 49.32 vs 82.6 +/- 29.58 pg/ml respectively, P<0.05]. These changes became highly significant at the end of follow up of both groups [119.3 +/- 27.19 vs 40.2 +/- 16.08; 518.8 +/- 91.11 vs 97.6 +/- 17.81 pg/ml respectively, P<0.001]. There is non significant change of plasma and ascitic TNF-alpha in group I at first admission compared to those at the end of follow up [P>0.05]. However, in group II, there is highly significant increase in both plasma and ascitic TNF-alpha at the end of follow up compared to those at the first admission [P<0.001]. The relative risk of deaths, HRS and SBP were higher in patients with compared to those without BactDNA after follow up for 24 weeks [2.73, 27.37 and 18.18 respectively]. There were significant positive correlation between both plasma and ascitic TNF-alpha and each of serum creatinine and PMNL in the studied patients at the end of follow up. [r= 0.590, p= 0.002 ; r= 0.535, p= 0.005 ; r=0.499, p=0.009 ; r= 0.589, p= 0.002, respectively]. -Patients with BactDNA had more advanced liver disease after 24 weeks follow up compared to patients without BactDNA. We conclude that cirrhotic patients with culture negative, non neutrocytic ascites and BactDNA have significant higher level of AF and plasma TNF-alpha and higher risk of HRS, SBP and morality compared to those without BactDNA during follow up for 24 weeks which could suggest that both BactDNA and TNF-alpha have been implicated in these complications of liver cirrhosis

Nosocomial infections caused by klebsiellae species with plasmids carrying bla shv-5 extended-spectrum beta-lactamase gene in Mansoura university hospitals

SHV-5 is a variant of SHV-1 and it is considered now one of the most important ESBL enzymes produced by Klebsiellae species. In this study we aimed to detect the prevalence of plasmid encoded SHV-5 among Klebsiellae strains causing nosocomial infections in Mansoura University Hospitals [MUH]. One hundred and seventy four Klebsiellae strains were isolated from overall 680 cases of nosocomial infections [25.59%] acquired within MUH over 4 months period from July to November 2004. One hundred and thirty six isolates [78.16%] of them were K. pneumoniae and 38 isolates [21.84%] were K. oxytoca. MICs [micro g/ml] of the isolated strains was done for augmentin, cefoperazone and ceftazidime using E test. One hundred and forty one [81.03%] of them were beta- lactamase producer as detected by nitrocefin discs, where 77 isolates from ?-lactamase producing strains were ESBL producers constituting 44.25% of Klebsiellae isolates. Sixty six ESBL producing strains of total 77 were isolated from cases of blood stream infections [85.71%]. Sixty five ESBL producing strains were isolated from neonatal intensive care unit [NICU] [84.42%]. All ESBL producing strains [n=77] posses at least one large plasmid > 23 kbp. SHV-5 gene was amplified by PCR after plasmid isolation from ESBL producing Klebsiellae isolates, reveal that 68 isolates [88.31%] were harbored SHV-5 gene on their large plasmids. In conclusion we found that the SHV-5-producing K. pneumoniae isolates were recovered from different wards of Mansoura University Hospital during the studied period. Thus, it was hypothesized that one clone may have persisted in that hospital. We recommend that infection control measure of endemic ESBL producers should include : the consumption of the broad-spectrum cephalosporins needs to be restricted to reduce the selection pressure which enables the proliferation of ESBL producers in hospital, continuous application of infection control program as; surveillance, hand washing and contact isolation procedure