The novel application and effect of an ultraviolet light decontamination strategy on the healthcare acquisition of carbapenem-resistant Enterobacterales in a hospital setting.

BACKGROUND: The role of the hospital environment as contributory to healthcare acquisition of multidrug-resistant organisms (MDROs) is increasingly recognized. Ultraviolet light decontamination can minimize the environmental bioburden, thereby potentially reducing healthcare acquisition. This effect has been demonstrated for typical environmental MDROs, e.g. meticillin-resistant Staphylococcus aureus, vancomycin-resistant entero-cocci, and Clostridioides difficile; however, its role in reducing carbapenem-resistant Enterobacterales (CRE) incidence rates is unclear. AIM: To evaluate the impact of continuous ultraviolet light (C-UV) on healthcare acquisition rates of CRE. METHODS: A 26-month pragmatic, prospective interventional study with addition of C-UV decontamination to standard cleaning was conducted in units at high risk for CRE acquisition. Introduction of C-UV followed a 12 month baseline period, with a two-month wash-in period. Implementation included terminal decontamination at discharge and a novel in-use protocol, whereby rooms occupied for ≥48 h were decontaminated during the course of the patients' in-hospital stay. Incidence density rates of CRE during the intervention period were compared to the baseline period using interrupted time series regression. Rates were adjusted for ward/admission prevalence and analysed according to C-UV protocol. FINDINGS: The in-use C-UV protocol demonstrated a significant negative association with the incidence density rate of CRE when adjusting for CRE admission rate (P = 0.0069). CRE incidence density rates decreased significantly during the intervention period (P = 0.042). Non-intervention units demonstrated no change in incidence density rates when adjusting for ward and/or admission prevalence. CONCLUSION: C-UV decontamination can potentially reduce healthcare acquisition of CRE when implemented with an in-use protocol.

Procalcitonin-guided antibiotic therapy for suspected and confirmed sepsis of patients in a surgical trauma ICU: a prospective, two period cross-over, interventional study.

BACKGROUND: Biomarkers like procalcitonin (PCT) are an important antimicrobial stewardship tool for critically ill patients. There is little evidence regarding the use of PCT-guided antibiotic algorithms in developing countries. Evidence is also lacking for PCT-based antibiotic algorithms in surgical trauma patients admitted to the intensive care unit (ICU). METHODS: A prospective, two period cross-over study was conducted in a surgical trauma intensive care unit in South Africa. In the first period, 40 patients were recruited into the control group and antibiotics were discontinued as per standard of care. In the second period, 40 patients were recruited into the procalcitonin group and antibiotics were discontinued if the PCT decreased by ≥ 80% from the peak PCT level, or to an absolute value of less than 0.5 µg/L. Antibiotic duration of treatment was the primary outcome. Patients were followed up for 28 days from the first sepsis event. RESULTS: For the first sepsis event the PCT group had a mean antibiotic duration of 9.3 days while the control group had a mean duration of 10.9 days (p = 0.10). Patients in the intervention group had higher mean (SD) antibiotic free days alive of 7.7 (6.57) days compared to the control group mean (SD) of 3.8 (5.22) days, (p = 0.004). In-hospital mortality rate was lower in the intervention group (15%) compared to the control group (30%) and was statistically significant (p = 0.045). CONCLUSION: There was no significant difference in duration of antibiotic treatment between the two groups. However, the PCT group had more antibiotic free days alive and lower in-hospital mortality compared to the control group.

Surveillance and comparison of antimicrobial susceptibility patterns of ESKAPE organisms isolated from patients with bacteraemia in South Africa, 2016 - 2017.

BACKGROUND: In South Africa (SA), the National Department of Health has developed an Antimicrobial Resistance National Strategy Framework document to manage antimicrobial resistance (AMR). One of the strategic objectives is to optimise surveillance and early detection of AMR. At the National Institute for Communicable Diseases (NICD), an analysis of selected organisms and antimicrobial agents from both the public and the private sectors was conducted. OBJECTIVES: The relevance of surveillance for AMR is increasingly recognised in the light of global action plans to combat resistance. In this report, we present an overview of ESKAPE (Enterococcus faecium, Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa, Enterobacter spp.) organisms and Escherichia coli reported from public and private sector laboratories in SA for the period 2016 - 2017. METHODS: Antimicrobial susceptibility testing (AST) profiles on selected ESKAPE organisms and E. coli isolated from blood cultures from the public and private sectors in 2016 and 2017 were analysed. AST data were extracted from a web-based electronic platform created by the NICD. Drug-bug combinations following the World Health Organization's Global Antimicrobial Surveillance System guidelines were included in the analysis. RESULTS: A total of 28 920 ESKAPE organisms and E. coli were reported in 2016 and 32 293 in 2017 across the two health sectors. Proportions of some organisms differed between the two health sectors, such as E. coli (19% in the public sector and 36% in the private sector), A. baumannii (14% public and 4% private), P. aeruginosa (7% public and 11% private) and S. aureus (27% public and 17% private). Susceptibility data indicated changing patterns in both sectors towards an increase in non-susceptibility to carbapenems in K. pneumoniae (p<0.01). However, we demonstrated an increase in susceptibility to cloxacillin in S. aureus (p<0.01) in both sectors. CONCLUSIONS: The key clinically important finding is the rapidly decreasing carbapenem susceptibility among Enterobacteriaceae reported in SA, irrespective of sector. In addition, the analysis provides information that could be used to monitor the effectiveness of interventions implemented at a national level under the guidance and direction of the national AMR framework.

Minimum inhibitory concentration-guided antimicrobial therapy - the Achilles heel in the antimicrobial stewardship agenda.

The global problem of resistance to antimicrobials has resulted in a co-ordinated drive to use antimicrobial agents more responsibly. At a clinical level this is promoted through antimicrobial stewardship which demands appropriate use through optimal drug selection. Many factors play a role in this process of selection, antimicrobial susceptibility and the pharmacodynamics of the drug being two key determinants. Yet the detail provided by current diagnostic antimicrobial susceptibility testing is suboptimal and does not allow for adequate dose optimisation. The minimum inhibitory concentration (MIC) which underlies all antimicrobial susceptibility testing is largely ignored in the decision-making process of optimal drug selection. Understanding and application of MIC-guided antimicrobial therapy is desperately needed if antimicrobial stewardship is to truly fulfil its mandate.

Predictors of outcome in patients with severe sepsis or septic shock due to extended-spectrum ß-lactamase-producing Enterobacteriaceae.

PURPOSE: There are few data in the literature regarding sepsis or septic shock due to extended-spectrum ß-lactamases (ESBL)-producing Enterobacteriaceae (E). The aim of this study was to assess predictors of outcome in septic patients with bloodstream infection (BSI) caused by ESBL-E. METHODS: Patients with severe sepsis or septic shock and BSI due to ESBL-E were selected from the INCREMENT database. The primary endpoint of the study was the evaluation of predictors of outcome after 30 days from development of severe sepsis or septic shock due to ESBL-E infection. Three cohorts were created for analysis: global, empirical-therapy and targeted-therapy cohorts. RESULTS: 367 septic patients were analysed. Overall mortality was 43.9% at 30 days. Escherichia coli (62.4%) and Klebsiella pneumoniae (27.2%) were the most frequent isolates. ß-lactam/ß-lactamase inhibitor (BLBLI) combinations were the most empirically used drug (43.6%), followed by carbapenems (29.4%). Empirical therapy was active in vitro in 249 (67.8%) patients, and escalation of antibiotic therapy was reported in 287 (78.2%) patients. Cox regression analysis showed that age, Charlson Comorbidity Index, McCabe classification, Pitt bacteremia score, abdominal source of infection and escalation of antibiotic therapy were independently associated with 30-day mortality. No differences in survival were reported in patients treated with BLBLI combinations or carbapenems in empirical or definitive therapy. CONCLUSIONS: BSI due to ESBL-E in patients who developed severe sepsis or septic shock was associated with high 30-day mortality. Comorbidities, severity scores, source of infection and antibiotic therapy escalation were important determinants of unfavorable outcome.

The 'ins and outs' of faecal microbiota transplant for recurrent Clostridium difficile diarrhoea at Wits Donald Gordon Medical Centre, Johannesburg, South Africa.

BACKGROUND: Clostridium difficile-associated diarrhoea (CDAD) is a potentially life-threatening condition that is becoming increasingly common. A persistent burden of this infectious illness has been demonstrated over the past 4 years at Wits Donald Gordon Medical Centre (WDGMC), Johannesburg, South Africa, through implementation of active surveillance of hospital-acquired infections as part of the infection prevention and control programme. Oral treatment with metronidazole or vancomycin is recommended, but there is a major problem with symptomatic recurrence after treatment. Replacement of normal flora by the administration of donor stool through colonoscopy or nasogastric/duodenal routes is becoming increasingly popular. OBJECTIVES: To identify risk factors for the development of CDAD in patients referred for faecal microbiota transplant (FMT) and evaluate the safety of administration of donor stool as an outpatient procedure, including via the nasogastric route. METHODS: A retrospective record review of patients with recurrent CDAD referred for FMT at WDGMC between 1 January 2012 and 31 December 2016 was conducted. RESULTS: Twenty-seven patients were identified, all of whom fulfilled the criteria for recurrent CDAD. One-third were aged >65 years, and the majority were female. The most common risk factors were prior exposure to antibiotics or proton-pump inhibitors and underlying inflammatory bowel disease. Three procedures were carried out as inpatients and 24 in the outpatient gastroenterology unit. At 4-week follow-up, all patients reported clinical resolution of their diarrhoea after a single treatment and there were no recurrences. The FMT procedure was associated with no morbidity (with particular reference to the risk of aspiration when administered via the nasogastric route) or mortality. CONCLUSIONS: This case series confirms that FMT is a safe and effective therapy for recurrent CDAD. In most cases it can be administered via the nasogastric route in the outpatient department. We propose that the recently published South African Gastroenterology Society guidelines be reviewed with regard to recommendations for the route of administration of FMT and hospital admission. Meticulous prescription practice by clinicians practising in hospitals and outpatient settings, with particular attention to antimicrobials and chronic medication, is urgently required to prevent this debilitating and potentially life-threatening condition.

Erratum to: Antimicrobials: a global alliance for optimizing their rational use in intra-abdominal infections (AGORA).

[This corrects the article DOI: 10.1186/s13017-016-0089-y.].

Active Surveillance of Hospital-Acquired Infections in South Africa: Implementation; Impact and Challenges

BACKGROUND:Hospital-acquired infections (HAIs) are a significant although unquantified burden in South Africa. Lack of adequate surveillance compounds this problem.OBJECTIVE:To report on the establishment and outcomes of a unit-specific surveillance system for hospital-acquired infections; based on international standards; in a private academic hospital. METHODS: Active unit-specific surveillance of device-associated infections (DAIs) was introduced over a 2-year period. The surveillance system was based on the US National Healthcare Safety Network (NHSN) utilising standardised definitions. Analysis of DAI rates and device utilisation was done according to Centers for Disease Control and Prevention methods. Comparative analysis using study-derived annualised data and existing NHSN data was done.RESULTS:Surveillance results of DAI rates showed significant reductions in intensive care unit-related ventilator-associated pneumonia (42%) and central line-associated bloodstream infections (100%) over a 3-year period. Substantial variations in DAI rates and utilisation ratios between wards highlight the importance of unit-specific surveillance.CONCLUSIONS:Active surveillance requires a significant investment in resources and is a sustained operational challenge; although equally significant benefits are derived from a better understanding of HAIs with more targeted interventions and efficient use of resources. A robust surveillance system is an essential component of any healthcare infection prevention and control programme and is a prerequisite to contextualising the HAI burden of hospitals

Routine active surveillance for carbapenemase-producing Enterobacteriaceae from rectal swabs: diagnostic implications of multiplex polymerase chain reaction.

BACKGROUND: Screening for carriage of carbapenemase-producing Enterobacteriaceae (CPE) is considered an important infection prevention and control strategy. To date, screening has relied primarily on culture although polymerase chain reaction (PCR)-based screening is gaining momentum. Currently there is no gold standard screening method and consequently it is important to consider the implications of different diagnostic strategies used in active surveillance. AIM: To assess the utility of a multiplex PCR screening strategy, as a component of active surveillance, for detection of CPE in patients admitted to various hospitals. METHODS: A single rectal swab was collected from patients at various hospitals, considered to be at risk of colonization with CPE. Comparison of a modified US Centers for Disease Control and Prevention culture protocol with a PCR-based assay for the detection of the blaNDM, blaKPC, blaOxA-48-like, blaVIM, blaIMP, and blaGES genes was performed. FINDINGS: Of the 251 consecutive rectal swabs collected, 30 were PCR positive for one or more carbapenemase genes. Fifteen (50%) were culture positive and CPE only accounted for six isolates. PCR demonstrated excellent sensitivity (100%), specificity (89.8%), and negative predictive value (100%) for detection of CPE, but a positive predictive value of only 46.6% and 16.6% for detection of carbapenemase-producing Gram-negatives and CPE, respectively. CONCLUSION: The apparent excellent performance characteristics of PCR for detection of CPE from rectal swabs must be tempered by knowledge of CPE prevalence and be interpreted within a defined epidemiological context. Further comparative research with culture, evaluating the clinical utility of PCR-based assays as a screening tool, is needed.

NDM-1 has arrived: first report of a carbapenem resistance mechanism in South Africa.

The New Delhi Metallo-ß-lactamase (NDM) resistance mechanism in Enterobacteriaceae threatens to render serious Gram-negative infections untreatable. The NDM-1 enzyme hydrolyses all available penicillin, cephalosporin and carbapenem antibiotics, and is commonly accompanied by additional resistance mechanisms to multiple antibiotic classes. Initially identified as a significant healthcare risk on the Indian sub-continent, it has rapidly become a global problem, posing significant diagnostic and management challenges. Here we report the first laboratory-confirmed case of NDM-1 in South Africa.