Impact of care bundle audit on compliance to device care bundles and device associated infections in the Critical Care Unit of a tertiary care hospital, Southern India - A before-after interventional study.

BACKGROUND: A care bundle comprises a set of evidence-based practices in patient care that are grouped together with the assumption that these practices when performed together will result in better clinical outcomes than when these practices are performed separately. Care bundles for devices when implemented effectively can bring about a reduction in device associated infection rates. METHODS: The study was conducted in three phases, 1 month pre-interventional and interventional phases and 11 months of post-interventional phase in a critical care unit. Compliance to care bundles were recorded by direct observation during daily audit rounds. An educational intervention addressing the healthcare workers regarding bundle care approach was conducted and supplemented with bedside "audit and feedback" during the interventional phase. Audit was conducted in the post-interventional period to study the trend of device associated infections and compliance rates. RESULTS: An increasing trend of month-wise compliance rates to the device care bundles were observed. The month-wise Ventilator Associated Events rates showed a decreasing trend. In the post-interventional phase, the average Catheter-associated Urinary Tract Infection, Central Line Associated Bloodstream Infection and Ventilator Associated Events rates showed a reduction from their respective baseline rates for the study setting. CONCLUSIONS: An educational intervention targeted at the healthcare workers along with daily audit of care bundle practices in the critical care setting led to an increase in the compliance to device care bundles and a reduction in the incidence of Catheter-associated Urinary Tract Infection, Central Line Associated Bloodstream Infection and Ventilator Associated Events rates in the critical care setting.

Feasibility of Using Ceftazidime-Avibactam as a Therapeutic Option for Bloodstream Infections Caused by Multidrug-Resistant Enterobacterales and Pseudomonas aeruginosa Based on Its Susceptibility Profile.

Background In the era of increased antimicrobial resistance, there are limited therapeutic options available for the treatment of bacteremia caused by multidrug-resistant organisms (MDROs). This study aims to find out the feasibility of using ceftazidime/avibactam (CZA) as a therapeutic option for bloodstream infections caused by multidrug-resistant (MDR) Enterobacterales and Pseudomonas aeruginosa based on its susceptibility profile. Materials and methods The isolates were routinely subjected to antimicrobial susceptibility testing (AST) by an automated AST system (VITEK-2). Those isolates found as MDR (resistant to at least one drug for ≥3 antimicrobial classes) were tested against CZA by Kirby-Bauer's disk diffusion (kb-DD) method. Results A total number of 293 MDR Enterobacterales and 31 MDR P. aeruginosa isolates were included. Of these, 87.3% of isolates were found as carbapenem-resistant (CR), whereas 12.7% of isolates were found as carbapenem susceptible. About 30.6% of MDROs were susceptible to CZA. Among carbapenem-resistant organisms (CROs), CR Klebsiella pneumoniae(33.5%) is most susceptible to CZA, compared to CR P. aeruginosa(0%)and CREscherichia coli(3.2%). Among the MDR isolates that were susceptible to CZA (30.6%), the majority had poor susceptibility against other ß-lactam-ß-lactamase inhibitor (BL-BLI) agents. Among all antimicrobial agents tested against CROs, colistin (96%) was found to have the best susceptibility profile. Conclusion It is observed that CZA is an acceptable therapeutic option for the treatment of bacteremia caused by MDROs, especially CROs. Therefore, it is important for the laboratories to perform the AST for CZA if the healthcare settings intend to use CZA for the management of such "difficult-to-treat" bloodstream infections.

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.

In-vitro synergistic activity of colistin and meropenem against clinical isolates of carbapenem resistant E.coli and Klebsiella pneumoniae by checkerboard method.

CONTEXT: The emergence of drug resistant pathogens pose major threat to hospitalized patients as well as to the community associated with increased mortality and morbidity. The treatment of carbapenem resistant enterobacteriaceae, one of the top WHO priority pathogen remains a global issue. Combination therapy with different classes of antibiotics have been tried with the aim to reduce toxicity, to increase the efficacy of the drugs and to reduce resistance. The in-vitro synergy methods have to be carried out to determine whether the combination of those antibiotics are synergistic, antagonistic or additive. AIMS: We have performed in-vitro synergy testing by checkerboard method for colistin -meropenem combination to determine whether the combination of the two antibiotics were synergistic or antagonistic. METHODS AND MATERIAL: All the consecutive twenty five blood isolates of Escherichia coli and twenty five blood isolates of Klebsiella pneumoniae which were showing resistance to carbapenems by either disc diffusion or vitek 2 were collected over a period of 6 months and checkerboard method was performed. STATISTICAL ANALYSIS USED: The reduction of MIC of colisin on combination with meropenem compared to MIC of colistin alone is analyzed by McNemar's chisquare test with the help of software Stata version 14 and p value < 0.05 is considered as significant. RESULTS: 56% of K. pneumoniae showed synergy and 44% showed additive/indifference results. For E. coli 40% showed synergy and 60% showed additive/indifference. None of the isolates of E. coli and K. pneumoniae showed antagonism. There was more than two fold reduction in MIC of colistin (significant) on combining withmeropenem. CONCLUSIONS: The study results support the combination therapy to treat infections by multi-drug-resistant Klebsiela pneumoniae and Escherichia coli by in-vitro checkerboard testing method which inturn will be helpful for clinicians for judicious use of antimicrobials.

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.

Bacteriological Profile of Diabetic Foot Ulcers and Detection of Methicillin-Resistant Staphylococcus aureus and Extended-Spectrum ß-Lactamase Producers in a Tertiary Care Hospital.

Introduction Diabetic foot infection is the most dreaded complication of diabetes mellitus and the commonest cause of hospitalization and limb amputation. Identification of the causative agent responsible for diabetic foot infection and the earliest initiation of appropriate antimicrobial therapy are vital for the control and prevention of the complication of diabetic foot ulcers. Therefore, we conducted this study to determine the bacteriological profile of diabetic foot ulcers and to detect methicillin-resistant Staphylococcus aureus (MRSA) and extended-spectrum ß-lactamase (ESBL) producers in our institute. Methodology During the study period, samples were collected from the foot ulcers of 100 patients at the Diabetic Outpatient Department. The samples were processed according to the standard laboratory protocol, and bacterial isolates were identified. Antibiotic susceptibility testing was performed using the modified Kirby-Bauer disk diffusion technique, and results were interpreted according to the Clinical and Laboratory Standards Institute guidelines (CLSI 2016). A phenotypic test for MRSA detection was performed using cefoxitin (30 µg) disk.  Results The highest incidence of diabetic foot ulcers was observed in patients aged 41-50 years. There were 83 men and 17 women, with a male to female ratio of 4.882. Of the 100 collected samples, 73 were positive for microbial growth, and 27 samples showed no growth. Of the 73 positive cultures, monomicrobial infection was found in 48 patients, and polymicrobial infection was found in 25 patients. Gram-positive pathogens were isolated from 34 patients, and gram-negative microbes were isolated from 64 patients. Among all collected isolates (n=100), Staphylococcus aureus was the most predominant organism and Acinetobacter species was the least common (only two isolates). Among the gram-negative bacteria, Pseudomonas aeruginosa was predominant. All the isolated gram-positive bacteria were susceptible to vancomycin. Gram-negative bacteria were highly susceptible to colistin with the exception of Proteus species which is intrinsically resistant to colistin and it is not reported for Proteus species. ESBL producers were primarily found among Klebsiella species isolates (22.22%). Among 29 S. aureus isolates, 8 (27.5%) were found to be MRSA producers. Conclusion Based on the bacteriological profile of diabetic foot ulcers, S. aureus among the gram-positive isolates and P. aeruginosa among the gram-negative isolates were the predominant pathogens. Infections caused by multidrug-resistant bacteria such as MRSA and ESBL producers have been reported with increasing frequency. According to the antibiotic susceptibility pattern, treatment can be initiated, continued, or altered, thereby reducing morbidity in patients with diabetic foot ulcers.