Outbreaks Of Multidrug-resistant Organisms Research Articles

A cross-sectional study in critically ill patients affected by COVID-19 in an intensive care unit: would Acinetobacter baumannii resistant to carbapenems be the biggest villain?

to describe cases of infection of Acinetobacter baumannii (A. baumannii) in critically ill patients affected by COVID-19, admitted to an intensive care unit (ICU), using dexamethasone. cross-sectional study conducted on patients admitted to the intensive care unit COVID-19 survey among hospitalized patients from November 2020 to March 2021. large hospital, reference for caring for patients with COVID-19 in Bahia (Brazil). a convenience sample of 22 patients admitted to the COVID ICU signed the consent form agreeing to participate in the study. Three patients were excluded for having decided to participate without signing the form. of the 22 patients listed, 45 % (10) had blood infection or mechanical ventilation-associated pneumonia by A. baumannii in blood cultures and/or tracheal aspirate secretion. We observed that there is a moderate correlation between the length of stay and infection by A. baumannii (Spearman's ρ; 0.592; p-value<0.005) and a strong correlation between the number of days on mechanical ventilation and infection by these bacteria (Spearman's ρ; 0.740; p-value<0.001). This percentage is higher than the value of 0.62 % of infection by A. baumannii in this ICU in the same period of the year before COVID-19 (p-value<0.0001). hospitals that receive patients with COVID-19 may be vulnerable to outbreaks of multi-drug resistant organisms, such as A. baumannii . It is worth reflecting on the care and operational practices in handling these patients, especially in isolation and restriction measures for those from other nosocomial areas.

Acinetobacter cavitations in COVID-19 interstitial pneumonia: a case report and review of the literature

Acinetobacter baumannii is commonly known to cause infection in immunocompromised patients. During COVID-19 pandemic, outbreaks of multidrug-resistant organisms, including Acinetobacter, have been well documented in acute care hospitals, particularly among critically ill patients. In the case reported, a woman was admitted to our ICU because of a severe COVID-19 pneumonia. During her stay, she worsened due to Acinetobacterrelated lung cavitations and only after proper antibiotic treatment she eventually recovered. To our knowledge, very few cases have been reported pointing to Acinetobacter as a causal agent for the acute development of lung cavities, especially in COVID-19 patients.

Genomic Characterization of Carbapenem-Resistant Acinetobacter baumannii (CRAB) in Mechanically Ventilated COVID-19 Patients and Impact of Infection Control Measures on Reducing CRAB Circulation during the Second Wave of the SARS-CoV-2 Pandemic in Milan, Italy.

COVID-19 has significantly affected hospital infection prevention and control (IPC) practices, especially in intensive care units (ICUs). This frequently caused dissemination of multidrug-resistant organisms (MDROs), including carbapenem-resistant Acinetobacter baumannii (CRAB). Here, we report the management of a CRAB outbreak in a large ICU COVID-19 hub Hospital in Italy, together with retrospective genotypic analysis by whole-genome sequencing (WGS). Bacterial strains obtained from severe COVID-19 mechanically ventilated patients diagnosed with CRAB infection or colonization between October 2020 and May 2021 were analyzed by WGS to assess antimicrobial resistance and virulence genes, along with mobile genetic elements. Phylogenetic analysis in combination with epidemiological data was used to identify putative transmission chains. CRAB infections and colonization were diagnosed in 14/40 (35%) and 26/40 (65%) cases, respectively, with isolation within 48 h from admission in 7 cases (17.5%). All CRAB strains belonged to Pasteur sequence type 2 (ST2) and 5 different Oxford STs and presented blaOXA-23 gene-carrying Tn2006 transposons. Phylogenetic analysis revealed the existence of four transmission chains inside and among ICUs, circulating mainly between November and January 2021. A tailored IPC strategy was composed of a 5-point bundle, including ICU modules' temporary conversion to CRAB-ICUs and dynamic reopening, with limited impact on ICU admission rate. After its implementation, no CRAB transmission chains were detected. Our study underlies the potentiality of integrating classical epidemiological studies with genomic investigation to identify transmission routes during outbreaks, which could represent a valuable tool to ensure IPC strategies and prevent the spread of MDROs. IMPORTANCE Infection prevention and control (IPC) practices are of paramount importance for preventing the spread of multidrug-resistant organisms (MDROs) in hospitals, especially in the intensive care unit (ICU). Whole-genome sequencing (WGS) is seen as a promising tool for IPC, but its employment is currently still limited. COVID-19 pandemics have posed dramatic challenges in IPC practices, causing worldwide several outbreaks of MDROs, including carbapenem-resistant Acinetobacter baumannii (CRAB). We present the management of a CRAB outbreak in a large ICU COVID-19 hub hospital in Italy using a tailored IPC strategy that allowed us to contain CRAB transmission while preventing ICU closure during a critical pandemic period. The analysis of clinical and epidemiological data coupled with retrospective genotypic analysis by WGS identified different putative transmission chains and confirmed the effectiveness of the IPC strategy implemented. This could be a promising approach for future IPC strategies.

Evaluation of multiple fixed in-room air cleaners with ultraviolet germicidal irradiation, in high-occupancy areas of selected commercial indoor environments

The use of ultraviolet germicidal irradiation (UVGI) to combat disease transmission has come into the international spotlight again because of the recent SARS-CoV-2 pandemic and ongoing outbreaks of multidrug resistant organisms in hospitals. Although the implementation of ultraviolet disinfection technology is widely employed in healthcare facilities and its effectiveness has been repeatedly demonstrated, the use of such technology in the commercial sector has been limited. Considering that most disease transmission occurs in commercial, public, and residential indoor environments as opposed to healthcare facilities, there is a need to understand whether ultraviolet (UV) disinfection technology can be effective for mitigating disease transmission in these environments. The results presented here demonstrate that the installation of fixed in-room UVGI air cleaners in commercial buildings, including restaurants and offices, can produce significant reductions in both airborne and surface-borne bacterial contamination. Total airborne reductions after UV implementation at six separate commercial sites averaged 73% (p < 0.0001) with a range of 71–88%. Total non-high touch surface reductions after implementation averaged 55% (p < 0.0001) with a range of 28–88%. All reductions at the mitigated sites were statistically significant. The mean value of indoor airborne bacteria was 320 CFU/m3 before intervention and 76 CFU/m3 after. The mean value of indoor non-high touch surface borne bacteria was 131 CFU/plate before intervention and 47 CFU/plate after. All test locations and controls had their required pandemic cleaning procedures in place for pre- and post-sampling events. Outdoor levels of airborne bacteria were monitored and there was no significant correlation between the levels of airborne bacteria in the outside air as opposed to the indoor air. Rooms with fixed in-room UVGI air cleaners installed had significant CFU reductions on local surface contamination, which is a novel and important finding. Installation of fixed in-room UVGI air cleaners in commercial buildings will decontaminate the indoor environment and reduce hazardous exposure to human pathogens.

S970 New Automated Cleaning System Is More Effective in Reducing Bioburden vs Standard Manual Clean in Duodenoscopes

Introduction: Multiple recent outbreaks of multidrug resistant organisms (MDRO) related to contaminated duodenoscopes have led to increased scrutiny of duodenoscope standard reprocessing methods. A key component of duodenoscope reprocessing is the cleaning step that occurs before high-level disinfection (HLD) or sterilization. Perfect adherence to manufacturer Instructions for Use (IFU) for manual cleaning can be difficult to achieve due to technical complexity and is open to human factor error. Adequate cleaning is measured against FDA and industry maximum allowed contaminants post cleaning of protein < 6.4 ug/cm^2 and carbohydrates < 2.2 ug/cm^2. Inadequate cleaning increases the risk for inadequate high-level disinfection and the possibility of procedures being performed with contaminated duodenoscopes. A new cleaning process has been developed to fully automate the cleaning step using turbulent flow technology. Methods: A total of 48 therapeutic ERCP procedures were performed utilizing Olympus TJF-Q180V duodenoscopes. After bedside point of use cleaning, 21 duodenoscopes were manually cleaned by trained technicians following the manufacturer IFU. 27 duodenoscopes were cleaned using the automated cleaning system. Duodenoscope instrument channels and distal elevator areas were sampled for residual protein and carbohydrates after cleaning. Results: The automated cleaning process resulted in a lower average level of residual protein and carbohydrate compared to standard manual cleaning (Table 1). Using FDA and industry standards as a benchmark, the automated cleaning process reduced levels of protein and carbohydrate below safety threshold levels on all study duodenoscopes, while manual cleaning resulted in 4/21 (19%) duodenoscopes having protein or carbohydrate levels above FDA standards (p = 0.03). Conclusion: Recent outbreaks of MDRO organisms transmitted after ERCP have brought to light the risk to patients when reusable duodenoscopes are not sufficiently reprocessed. The complex design of the device – involving multiple channels and an elevator mechanism at the distal tip – makes proper cleaning difficult. Without sufficient cleaning, subsequent HLD or sterilization can fail to adequately remove contaminants. As seen in this study, manual cleaning can be prone to error. With no incidents of elevated bioburden post cleaning, a fully automated cleaning technology appears to be a viable alternative for replacement of manual cleaning of duodenoscopes.Table 1.: Residual Protein and Carbohydrate Post Manual Versus Automated Clean *One manually cleaned duodenoscope had levels of both protein and carbohydrate above FDA threshold.

MDRO transmission in acute hospitals during the COVID-19 pandemic.

The coronavirus disease (COVID-19) pandemic has resulted in necessary modifications of infection control policies and practices in acute healthcare facilities globally. This is often accompanied by infrastructure modifications, ward redesignations, as well as healthcare staff redeployments and changes to infection prevention and control (IPC) practices. We review the potential for both negative and positive impacts these major changes can have on nosocomial transmission of multidrug-resistant organisms (MDROs). Healthcare facilities around the world have reported outbreaks of MDROs during the COVID-19 pandemic. In contrast some centres have reported a decrease in baseline rates due to a number of possible factors. While implementing crucial preventive measures for COVID-19, is it important to consider any collateral effects of changes in IPC and antimicrobial stewardship program (ASP) practices. The disruption caused to IPC and ASP practices during the pandemic are likely to see a counter intuitive increase in transmission of MDROs.

Efficacy of Infection Control Measures in Managing Outbreaks of Multidrug-Resistant Organisms in Burn Units.

Multidrug-resistant organisms (MDROs) pose a significant threat to severe burn victims and represents a clear epidemic hazard in burn units. Several infection control measures have been implemented to control and manage the outbreaks of MDRO. The efficiency of those measures, however, remains controversial and an area of debate. A systematic review was conducted to evaluate the efficacy of infection control measures and the necessity of closing burn units in dealing with MDRO outbreaks. Peer-reviewed articles were identified using PubMed, EMBASE, and Cochrane Central Register of Controlled Trials databases, focusing on infection control measures to manage MDRO outbreaks in burn units. Twenty-one studies that reported MDRO outbreaks in burn units met the inclusion criteria. The outbreaks were successfully controlled with interventions in 17 units (81%), partially controlled in 1 unit (4.7%), and uncontrolled in 3 units (14.3%). Infection control measures were implemented by screening patient (19 units), screening health care worker (17 units), obtaining environmental cultures (16 units), providing ongoing staff education (13 units), cohort or isolation (17 units), preemptive barrier precautions (10 units), improving hand hygiene (15 units), and enhanced cleaning and environmental disinfection (17 units). Closure of burn units occurred in 8 units, with outbreaks controlled in 6 of the units (75%). The reasons for unit closure include decontamination (4 units; 50%), outbreak investigation (1 unit; 12.5%), and uncontrolled outbreaks (3 units; 37.5%). The incidence of infection was significantly decreased in 4 units after the closure but rose again after reopening in 1 of the units. In 3 units, the spread was halted by other control measures, including change of hydrotherapy facilities, identification of staff transmission, and unit structure remodeling. Proper infection control measures play an important role in managing MDRO outbreaks in burn units. Temporary closure of burn units may be necessary to control the spread of nosocomial, and this option should be considered when other measures are ineffective.

The tripartite insurance model (TIM): a financial incentive to prevent outbreaks of infections due to multidrug-resistant microorganisms in hospitals

Healthcare-associated infections caused by multidrug-resistant organisms (MDROs) constitute a major challenge worldwide, but care providers are often not sufficiently incentivized to implement recommended infection prevention measures to prevent the spread of such infections. We propose a new approach which creates incentives for hospitals, external laboratories and insurers to collaborate on preventing MDRO outbreaks by testing more and implementing infection prevention measures. This tripartite insurance model (TIM) redistributes the costs of preventing and combating MDRO outbreaks in a way that all parties benefit from reducing the number of outbreaks.

Burkholderia cepacia complex bacteremia outbreaks among non-cystic fibrosis patients in the pediatric unit of a university hospital.

Burkholderia cepacia complex (Bcc) comprises multi-drug resistant, Gram-negative, motile, and aerobic bacteria. Bcc causes severe nosocomial infections particularly in patients with intravascular catheters and in those with cystic fibrosis. We studied a Bcc outbreak in non-cystic fibrosis patients. We analyzed data from six patients hospitalized at our center. Blood cultures identified as infectious were incubated onto 5% blood sheep agar, chocolate agar, and eosin methylene blue (EMB) agar. We examined possible sites that could be sources of infection at the clinic. We confirmed isolations with pulsed-field gel electrophoresis (PFGE) tests. The first patient was hospitalized due to left renal agenesis, urinary tract infection, and renal failure. Bcc was isolated in blood cultures obtained due to high fever on the third day of hospitalization. We stopped new patient hospitalizations after detecting Bcc in blood cultures of other five patients. We did not detect further positive specimens obtained from other clinic and the patient rooms. PFGE patterns were similar in all clinical isolates of Bcc indicating that the outbreak had originated from the source. Bcc infection should be considered in cases of nosocomial outbreaks of multi-drug resistant organisms that require hospitalization at intensive care units. Control measures should be taken for prevention of nosocomial infections and required investigations should be done to detect the source of infection.

Duodenoscope-associated infection prevention: A call for evidence-based decision making.

Background Recent outbreaks of duodenoscope-associated multidrug-resistant organisms (MDROs) have brought attention to the infection risk from procedures performed with duodenoscopes. Prior to these MDRO outbreaks, procedures with duodenoscopes were considered safe and low risk for exogenous infection transmission, provided they were performed in strict accordance with manufacturer instructions for use and multisociety reprocessing guidelines. The attention and efforts of the scientific community, regulatory agencies, and the device industry have deepened our understanding of factors responsible for suboptimal outcomes. These include instrument design, reprocessing practices, and surveillance strategies for detecting patient and instrument colonization. Various investigations have made it clear that current reprocessing methods fail to consistently deliver a pathogen-free instrument. The magnitude of infection transmission has been underreported due to several factors. These include the types of organisms responsible for infection, clinical signs presenting in sites distant from ERCP inoculation, and long latency from the time of acquisition to infection. Healthcare providers remain hampered by the ill-defined infectious risk innate to the current instrument design, contradictory information and guidance, and limited evidence-based interventions or reprocessing modifications that reduce risk. Therefore, the objectives of this narrative review included identifying outbreaks described in the peer-reviewed literature and comparing the findings with infections reported elsewhere. Search strategies included accessing peer-reviewed articles, governmental databases, abstracts for scientific conferences, and media reports describing outbreaks. This review summarizes current knowledge, highlights gaps in traditional sources of evidence, and explores opportunities to improve our understanding of actual risk and evidence-based approaches to mitigate risk.

Social Network Analysis of Patient Movement Across Health Care Entities in Orange County, Florida.

Multidrug-resistant organisms (MDROs) are continually emerging and threatening health care systems. Little attention has been paid to the effect of patient transfers on MDRO dissemination among health care entities in health care systems. In this study, the Florida Department of Health in Orange County (DOH-Orange) developed a baseline social network analysis of patient movement across health care entities in Orange County, Florida, and regionally, within 6 surrounding counties in Central Florida. DOH-Orange constructed 2 directed network sociograms-graphic visualizations that show the direction of relationships (ie, county and regional)-by using 2016 health insurance data from the Centers for Medicare & Medicaid Services, which include metrics that could be useful for local public health interventions, such as MDRO outbreaks. We found that both our county and regional networks were sparse and centralized. The county-level network showed that acute-care hospitals had the highest influence on controlling the flow of patients between health care entities that would otherwise not be connected. The regional-level network showed that post-acute-care hospitals and other facilities (behavioral hospitals and mental health/substance abuse facilities) served as the primary controls for flow of patients between health care entities. The most prominent health care entities in both networks were the same 2 acute-care hospitals. Social network analysis can help local public health officials respond to MDRO outbreak investigations by determining which health care facilities are the main contributors of dissemination of MDROs or are at high risk of receiving patients with MDROs. This information can help epidemiologists prioritize prevention efforts and develop county- or regional-specific interventions to control and halt MDRO transmission across a health care network.

Genomic Investigation Reveals Contaminated Detergent as the Source of an Extended-Spectrum-β-Lactamase-Producing Klebsiella michiganensis Outbreak in a Neonatal Unit.

Klebsiella species are problematic pathogens in neonatal units and may cause outbreaks, for which the sources of transmission may be challenging to elucidate. We describe the use of whole-genome sequencing (WGS) to investigate environmental sources of transmission during an outbreak of extended-spectrum-β-lactamase (ESBL)-producing Klebsiella michiganensis colonizing neonates. Ceftriaxone-resistant Klebsiella spp. isolated from neonates (or their mothers) and the hospital environment were included. Short-read sequencing (Illumina) and long-read sequencing (MinION; Oxford Nanopore Technologies) were used to confirm species taxonomy, to identify antimicrobial resistance genes, and to determine phylogenetic relationships using single-nucleotide polymorphism profiling. A total of 21 organisms (10 patient-derived isolates and 11 environmental isolates) were sequenced. Standard laboratory methods identified the outbreak strain as an ESBL-producing Klebsiella oxytoca, but taxonomic assignment from WGS data suggested closer identity to Klebsiella michiganensis Strains isolated from multiple detergent-dispensing bottles were either identical or closely related by single-nucleotide polymorphism comparison. Detergent bottles contaminated by K. michiganensis had been used for washing milk expression equipment. No new cases were identified once the detergent bottles were removed. Environmental reservoirs may be an important source in outbreaks of multidrug-resistant organisms. WGS, in conjunction with traditional epidemiological investigation, can be instrumental in revealing routes of transmission and guiding infection control responses.

Electrochemical Sensors to Monitor Multi-Drug Resistant Organisms in the Gut Microbiome

Infections caused by multi-drug resistant organisms (MDROs) are responsible for over 2 million of hospitalization and 23,000 deaths annually in the United States, with direct financial impact of $20 billion a year. Microbiome dysbiosis (imbalance) is considered to be the main cause for MDRO colonization and the resulting infections. MDRO outbreaks need to be quickly detected and monitored for effective intervention to provide relief to the stressed patient community and healthcare facility. Unfortunately, current diagnostic methods for MDRO detection are slow and costly. Polymerase chain reaction (PCR) and enzyme immunoassay (EIA) techniques or the next generation sequencing (NGS) methods do not provide the low cost and rapid platform necessary for such MDRO pathology for a patient care facility. These methods often require several days to complete, use many reagents, and need skilled technicians in a resource intensive laboratory. In this work, we report a rapid, accurate and cost-effective electrochemical sensor capable of MDRO detection down to 104 colony forming units (CFU)/g in mice and human stool samples. To achieve this, we utilize disposable screen printed electrodes (SPEs) modified with highly specific oligonucleotide probes capable of hybridizing (duplex formation) select target gene sequences associated with MDROs. In the presence of a redox mediator, the hybridized probe/target complex generates an electrochemical current signal that differs from a non-hybridized probe molecule. The signal is highly sensitive and selective of target gene sequences and can detect as little as 3.5 picomols of target DNA. Furthermore, the SPEs can be pre-functionalized, stored, and used when needed, reducing individual sample analysis time to less than an hour. Several target sequences from two exemplary genes (AmpC and AcrB found in MDRO E. coli) have been identified and successfully detected in clinical stool samples with results comparable to the standard quantitative PCR method. Additional target genes associated with drug resistance (TEM-1, VanA, and SHV) have also been successfully detected in vitro and are ready to be tested in clinical samples. Our gut microbiome sensor is currently being developed for multiplexed operation to simultaneously detect up to eight MDROs genes, including the ones that are responsible for breaking down b-lactam containing antibiotics. This novel sensor platform will be an economical point-of-care device with little requirement of reagent handling or technical training. Figure 1

Collaborative emergency preparedness and response to cross-institutional outbreaks of multidrug-resistant organisms: a scenario-based approach in two regions of the Netherlands

BackgroundThe likelihood of large-scale outbreaks of multidrug-resistant organisms (MDRO) is growing. MDRO outbreaks can affect a wide range of healthcare institutions. Control of such outbreaks requires structured collaboration between professionals from all involved healthcare institutions, but guidelines for cross-institutional procedures are, however, often missing. Literature indicates that such multi-actor collaboration is most promising when effective network brokers are present, and when the collaborative actors have clarity about the different roles and responsibilities in the outbreak response network, including collaborative structures and coordination roles. Studying these factors in an imaginary MDRO outbreak scenario, we gained insights into the expectations that health professionals in the Netherlands have in regard to the procedures required to best respond to any future cross-institutional MDRO outbreaks.MethodsFor exploration purpose, a focus group discussion with ten healthcare professionals was held. Subsequently, an online-survey was conducted among 56 healthcare professionals in two Dutch regions. The survey data was analysed using social network analyses (clique analysis and centrality analysis), which provided insights into the collaborative structures and potential brokers in the outbreak response networks. Additionally, respondents were asked which healthcare institutions and which professions they would prefer as coordinating actors in the collaborative network.ResultsOur results show a relatively high level of perceived clarity about the roles and responsibilities that healthcare professionals have during a joint outbreak response. The regional outbreak response networks which were studied appeared inclusive and integrated, with many overlapping groups of fully-connected healthcare actors. Social network analyses resulted in the identification of several central actors from different healthcare institutions with the potential to take on a brokerage role in the collaboration. Actors in the outbreak response networks also showed to prefer several healthcare professionals to take on the coordination roles.ConclusionExpected collaborative structures during an imaginary regional MDRO outbreak response are relatively dense and integrated. In regard to the coordination of an MDRO outbreak response, based on both the network analysis results and the preferred coordination roles, our findings support a governance structure with several healthcare institutions involved in responding to future cross-institutional MDRO outbreaks.

Duodenoscope reprocessing practice patterns in U.S. endoscopy centers: a survey study

After recent outbreaks of duodenoscope-related infections from multidrug-resistant organisms (MDRO), the United States Food and Drug Administration (FDA) recommended implementing 1 or more of 4 enhanced reprocessing measures in addition to updated manual cleaning methods and high-level disinfection (HLD). The implementation of these techniques in endoscopy facilities and provider opinions regarding reprocessing priorities remain unknown. Physicians, nurse managers, nurses, and infection control staff at endoscopy units performing ERCP in the United States were surveyed to assess current institutional practices and individual opinions regarding future reprocessing solutions. A total of 249 distinct institutions participated in the survey. Of these, 223 (89.6%) implemented at least 1 of the 4 supplemental reprocessing methods after MDRO outbreaks. Overall, 63% of centers used repeat HLD, 53% performed surveillance microbiological culturing, 35% used liquid chemical sterilization, and 12% used ethylene oxide sterilization. Thirty-seven centers (15%) routinely screened patients for MDRO. Forced-air drying after reprocessing was used by 47.8% of centers. Fifty percent of individual respondents, including 58.6% of physicians, believed that redesign of the duodenoscope is the best long-term reprocessing solution. The majority (55.1%) identified efficacy to be the single most important factor in selecting a reprocessing technique. Although most endoscopy centers have implemented enhanced duodenoscope reprocessing techniques, there is a large variation in practice. Most providers believe that duodenoscope redesign and identifying reprocessing techniques with maximal efficacy are the long-term priorities. Improved adherence to forced-air drying in duodenoscope reprocessing is needed.

Anesthesia in patients with infectious disease caused by multi-drug resistant bacteria.

Up to 50% of specific bacterial strains in healthcare admission facilities are multi-drug resistant organisms (MDROs). Involvement of anesthesiologists in management of patients carrying/at risk of carrying MDROs may decrease transmission in the Operating Room (OR). Anesthesiologists, their work area and tools have all been implicated in MDRO outbreaks. Causes include contamination of external ventilation circuits and noncontribution of filters to prevention, inappropriate decontamination procedures for nondisposable equipment (e.g. laryngoscopes, bronchoscopes and stethoscopes) and the anesthesia workplace (e.g. external surfaces of cart and anesthesia machine, telephones and computer keyboards) during OR cleaning and lack of training in sterile drug management. Discussions regarding the management of potential MDRO carriers must include anesthesia providers to optimize infection control interventions as well as the anesthesia method, the location of surgery and recovery and the details of patient transport. Anesthesia staff must learn to identify patients at risk for MDRO infection. Antibiotic prophylaxis, although not evidence based, should adhere to known best practices. Adjuvant therapies (e.g. intranasal Mupirocin and bathing with antiseptics) should be considered. Addition of nonmanual OR cleaning methods such as ultraviolet irradiation or gaseous decontamination is encouraged. Anesthesiologists must undergo formal training in sterile drug preparation and administration.

209 Risk of Infection Transmission in Curvilinear Array Echoendoscopes: Results of a Prospective Reprocessing and Culture Registry

Outbreaks of multi-drug resistant organisms leading to occasional fatal infections have been attributed to transmission from reprocessed duodenoscopes. The complex design of the elevator mechanism is a recognized challenge for disinfection and has been implicated as the potential source of persistent contamination. Linear echoendoscopes also have an elevator mechanism, however there are no data or recommendations regarding the risk of persistent bacterial contamination of echoendoscopes.

Utility of whole-cell repetitive extragenic palindromic sequence-based PCR (REP-PCR) for the rapid detection of nosocomial outbreaks of multidrug resistant organisms: Experience at a tertiary care center in North India

There is a huge need to develop molecular typing methods which are simple to perform, rapid and cost effective to confirm clonality of nosocomial isolates in outbreak situations. The aim of the study was to investigate a hospital outbreak of multi-drug resistant (MDR) Klebsiellapneumoniae septicemia in a paediatric surgery intensive care unit (PSICU) using a repetitive extragenic palindromic polymerase chain reaction (REP-PCR). MDR Klebsiella pneumoniae isolates from an outbreak of nosocomial sepsis were typed byREP-PCR using consensus primers. Isolates from different intensive care units (ICUs) but with similar antibiogram were also genotyped for comparison. A cluster of twelve MDR K Pneumoniae septicemia cases was identified at the PSICU by genotyping using REP-PCR. Surveillance cultures failed to pick up any source of infection. REP-PCR was found to be a rapid and simple tool for investigation outbreaks in hospitals. Due to early detection we could initiate infection control practices with focus on hand washing and prevent the further transmission of the organism.

A Web-Based Multidrug-Resistant Organisms Surveillance and Outbreak Detection System with Rule-Based Classification and Clustering

BackgroundThe emergence and spread of multidrug-resistant organisms (MDROs) are causing a global crisis. Combating antimicrobial resistance requires prevention of transmission of resistant organisms and improved use of antimicrobials.ObjectivesTo develop a Web-based information system for automatic integration, analysis, and interpretation of the antimicrobial susceptibility of all clinical isolates that incorporates rule-based classification and cluster analysis of MDROs and implements control chart analysis to facilitate outbreak detection.MethodsElectronic microbiological data from a 2200-bed teaching hospital in Taiwan were classified according to predefined criteria of MDROs. The numbers of organisms, patients, and incident patients in each MDRO pattern were presented graphically to describe spatial and time information in a Web-based user interface. Hierarchical clustering with 7 upper control limits (UCL) was used to detect suspicious outbreaks. The system’s performance in outbreak detection was evaluated based on vancomycin-resistant enterococcal outbreaks determined by a hospital-wide prospective active surveillance database compiled by infection control personnel.ResultsThe optimal UCL for MDRO outbreak detection was the upper 90% confidence interval (CI) using germ criterion with clustering (area under ROC curve (AUC) 0.93, 95% CI 0.91 to 0.95), upper 85% CI using patient criterion (AUC 0.87, 95% CI 0.80 to 0.93), and one standard deviation using incident patient criterion (AUC 0.84, 95% CI 0.75 to 0.92). The performance indicators of each UCL were statistically significantly higher with clustering than those without clustering in germ criterion (P < .001), patient criterion (P = .04), and incident patient criterion (P < .001). ConclusionThis system automatically identifies MDROs and accurately detects suspicious outbreaks of MDROs based on the antimicrobial susceptibility of all clinical isolates.

A Clinical Syndrome-Based Antibiotic Drug Use Evaluation: Impact on Antibiotic Use in a Large Teaching Hospital

The traditional drug use evaluation (DUE) process fails to integrate well with the way patients are treated by physicians. In order to address the shortcomings of the traditional DUE process, a clinical syndrome-based antibiotic drug use evaluation was developed. The steps involved in the development and implementation of this process are described, with an emphasis on physician involvement in each step of the development process. Feedback loops to Medical Staff Quality Management Committees are an integral part of this program. Results of this program have been encouraging, with final physician compliance with the established guidelines occurring for 91% to 96% of the antibiotic orders written. This program has also resulted in a 10% decline in per day antibiotic expenditures, and has been instrumental in enabling the institution to tightly restrict antibiotic usage in response to outbreaks of multidrug-resistant organisms.