Comparison of hand hygiene compliance among healthcare workers in Intensive care units and wards of COVID-19: A large scale multicentric study in India.

BACKGROUND: Hand hygiene is a significant component involved in preventing transmission of health care associated infections including COVID-19. Compliance to hand hygiene among the health care workers (HCWs) requires evaluation and timely feedback. "You can't improve what you can't measure" is a famous saying and this multicentric study was designed to measure hand hygiene compliance and have birds eye view on hand hygiene compliance in COVID Intensive care units (ICUs) and wards across India. METHODS: A prospective multicentric observational study was conducted for a period of 6 months in 92 health care facility across India which included varied type of public and private hospitals. Hand hygiene audit was conducted in COVID ICU and COVID non-ICU wards in all these facilities by their HCWs using the IBHAR mobile application based on WHO's hand hygiene audit tool. Hand hygiene total adherence rate (HHTAR) and hand hygiene complete adherence rate (HHCAR) were analyzed and compared between 2 locations. Adherence rates were analyzed based on the zones, institute type, profession and for each WHO moments. RESULTS: A total of 1,61,056 hand hygiene opportunities were documented and adherence rates were recorded higher in COVID wards (HHTAR-61.4%; HHCAR-28.8%) than COVID ICUs (HHTAR-57.8%; HHCAR-25.6%). Overall, the adherence rates were observed higher in COVID wards (HHTAR- 68.1%; HHCAR-38.3%) of private hospitals, COVID wards of the west zone (HHTAR- 70.2%; HHCAR-36.8%), cleaning staffs of the COVID ward scores better compliance than all other professions in COVID ICUs and COVID wards. HHTAR was found to be the higher in moment 3 (After body fluid exposure-76.3%) followed by moment 4 (after touching patient-73.7%) done in COVID wards compared to moments done in ICUs. CONCLUSIONS: This study highlights the practice of hand hygiene in COVID care locations across India. Effective strategies need to be implemented in COVID ICUs across the facilities to improve the compliance.

Impact of conducting hand hygiene audit in COVID-19 care locations of India-A large scale national multicentric study - HHAC study.

PURPOSE: Hand hygiene (HH), the core element in infection prevention in healthcare, especially for multidrug resistant organism's transmission. The role of HH audits and HH adherence rates in the COVID-19 pandemic, especially in resource limited settings, are yet to be established. METHODS: A nationwide multicenter study was conducted in India, involving public, private, teaching and non-teaching COVID healthcare facilities (COVID-HCFs) using the IBhar mobile application based on WHO's hand hygiene audit tool. The HH adherence rates (HHAR) such as complete HHAR (HHCAR), total HHAR (HHTAR), profession specific HHAR, WHO's 5 HH moment specific HHAR and associated variables were measured over 6 month duration (June-December 2021). RESULTS: A total of 2,01,829 HH opportunities were available and the HHCAR and HHTAR were 27.3% and 59.7%. The HHTAR was significantly higher in the west zone (72.2%), private institutes (65.6%), non-teaching institutes (67.7%), nurses (61.6%), HH moments 2 (71.8%) and 3 (72.1%), and morning shift (61.4%). The HHTAR was better in non-COVID HCFs (65.4%) than COVID-HCFs (57.8%) as well as non-COVID ICUs (68.1%) than COVID ICUs (58.7%). The HHTAR was increased from month 1 to month 6 except a small decrease in the month of December. CONCLUSIONS: The hand hygiene adherence is comparable with adherence rate during COVID-19 pandemic in western countries as well as the resource limited settings. The use of gloves during the pandemic and simplified HH techniques and their influence over the HH adherence to be studied further. The sustainable adherence rate over long duration needs to be ensured by continuing the HH audit using multimodal interventions.

Increasing Trend of Vancomycin-resistant Enterococci Bacteremia in a Tertiary Care Hospital of South India: A Three-year Prospective Study.

Introduction: Vancomycin-resistant enterococci (VRE) are emerging as an important multidrug-resistant pathogen causing nosocomial infections, predominantly bacteremia and urinary tract infections. VRE bacteremia has caused a significant increase in the duration of the hospital stay and mortality and had caused high public health threat due to limited treatment options. Materials and methods: Between October 2017 and September 2020, all consecutive patients with culture-proven bloodstream infection with Enterococcus species, isolated for the first time, were included in the study. A total of 427 Enterococcus species were identified, and antimicrobial susceptibility tests were performed and interpreted using Clinical and Laboratory Standard Institute guidelines. Results: Of the total 427 Enterococcus species isolated, 63 (45.6%) were VRE. Among them, 51/63 (81%) were Enterococcus faecium (E. faecium) and 5/63 (8%) were Enterococcus faecalis. There was an increased trend of VRE rate in the bloodstream infections of 6.12% (2018), 13.2% (2019), and 19.2% (2020). The majority of the VRE patients [43/63 (68%)] were admitted to the intensive care units (ICUs). Vancomycin A (VanA) is the most common phenotype isolated from 51/63(81%) patients. Conclusion: This increasing trend of VRE bacteremia is a red alert to the clinicians and the infection control practitioners, so that strict antibiotic policies and proper adherence to the infection control practices can be initiated to reduce the VRE rate. How to cite this article: Sivaradjy M, Gunalan A, Priyadarshi K, Madigubba H, Rajshekar D, Sastry AS. Increasing Trend of Vancomycin-resistant Enterococci Bacteremia in a Tertiary Care Hospital of South India: A Three-year Prospective Study. Indian J Crit Care Med 2021;25(8):881-885.

Evaluation of the Performance of Direct Susceptibility Test by VITEK-2 from Positively Flagged Blood Culture Broth for Gram-Negative Bacilli.

Background Timely initiation of antimicrobial therapy in patients with blood stream infection is absolutely necessary to reduce mortality and morbidity. Most clinical microbiology laboratories use conventional methods for identification and antimicrobial susceptibility testing (AST) that involve biochemical methods for identification followed by AST by disk diffusion. The aim of the current study is to assess the various errors associated with direct susceptibility testing done from blood culture broth using automated AST system-Vitek-2 compact compared with the reference method of AST done from bacterial colonies. Materials and Methods The study was conducted in a tertiary care public sector 2,200-bedded hospital in South India for a period of 6 months. The study involved positively flagged blood culture bottles that yielded single morphotype of Gram-negative organism by Gram stain. A total of 120 bacterial isolates were collected that consisted of consecutively obtained first 60 isolates of Enterobacteriaceae family (30 Escherichia coli and 30 Klebsiella pneumoniae ) and consecutively obtained first 60 nonfermenters (30 Pseudomonas aeruginosa and 30 Acinetobacter baumannii). Vitek-2 AST was done from these 120 blood culture broth, following the protocol by Biomerieux, and results were obtained. Then, Vitek-2 was done from colonies (reference method) using appropriate panel for Enterobacteriaceae and nonfermenters, and results were obtained. Both the results were compared. Results Nonfermenters showed a better categorical agreement of 97.6%, as compared to Enterobacteriaceae, which showed 97%. Among Enterobacteriaceae, both E. coli and K. pneumoniae showed categorical agreement of 97% each. Conclusion The procedure of AST directly from blood culture broth represents a simple and effective technique that can reduce the turnaround time by 24 hours, which in turn benefits the clinician in appropriate utilization of antimicrobials for better patient care.

Evaluation of performance of direct disk diffusion test from positively flagged blood culture broth: A large scale study from South India.

BACKGROUND: Rapid turnaround time of blood culture reports should be the main motive for a clinical microbiologist for optimal patient care. Categorical agreement (CA) between direct disk diffusion (dDD) and reference disk diffusion (rDD) may vary between laboratories. AIMS AND OBJECTIVES: This study was designed to determine the CA and understand various types of errors associated with antibiotic organism combination, so that caution can be derived while interpreting and reporting dDD results in the earliest meaningful time frame. MATERIALS AND METHODS: In the present study, dDD results were compared to the rDD results from the positive blood culture bottles. CA and various types of errors were evaluated. RESULTS: A total of 965 pathogens and 7106 organism antibiotic combinations were evaluated in this study. Overall, there was a CA of 96% which was extremely satisfactory. The categorical disagreement was found only in 4% of organism antibiotic combinations; majority of which were major error (ME, 2.1%) followed by very ME (1%) and minor error (0.9%). The errors were marginally high for Enterobacteriaceae testing against ß lactam- ß lactamase inhibitor combinations, for Pseudomonas species against aminoglycosides and ciprofloxacin and Staphylococcus species against cefoxitin, one should be vigilant while reporting dDD result of these antibiotic organism combinations. CONCLUSION: dDD is of paramount importance for early institution of targeted therapy and is considered as one of the key stewardship intervention. Our study gives an insight that every laboratory must perform dDD for positively flagged blood culture specimens; the result of which should be confirmed later by performing rDD. One should be vigilant while reporting dDD result of BL BLI for Enterobacteriaceae; aminoglycosides and CF for Pseudomonas species; cefoxitin for Staphylococcus species and HLG for Enterococcus species. Supplementary tests such as MRSA latex should be included when necessary.

Care bundle approach to reduce device-associated infections in a tertiary care teaching hospital, South India.

CONTEXT: The care bundle approach is a set of evidence-based practices that when performed collectively and reliably have been shown to improve the patient outcome. AIMS: To evaluate the impact of the bundle care approach on reducing device-associated infections (DAIs). SETTINGS AND DESIGN: The study was conducted at a tertiary care hospital, South India. The study period was from January 2016 to September 2016 which was divided into three phases, each comprising 3 months. SUBJECTS AND METHODS: During the implementation phase, bundle care forms were implemented in all Intensive Care Units (ICUs) and the ICU staff were given a basic education on the importance of bundle care approach. The DAI rates (ventilator-associated pneumonia [VAP] rates, central line-associated bloodstream infection [CLABSI] rate, and catheter-associated urinary tract infection [CAUTI] rate) were calculated throughout the study period. STATISTICAL ANALYSIS USED: Statistical analysis was performed using SPSS 19 software. RESULTS: During preimplementation phase, the VAP rate, CLABSI rate, and CAUTI rate were 14.79, 4.98, and 4.86 per 1000 device days, respectively. Rates were reduced to 13.03, 3.98, and 3.39 per 1000 device days, respectively, during the implementation phase and further reduced into 11.91, 3.49, and 2.36 per 1000 device days during the postimplementation phase. The month-wise decreasing trend of DAI rates was significant for medical ICUs as compared to surgical and pediatric ICUs. CONCLUSIONS: The month-wise decreasing trend of VAP rate, CLABSI rate, and CAUTI rate was noted, which signifies that the use of care bundle approach has a great impact on reducing DAIs.