Trend of methicillin-resistant Staphylococcus aureus (MRSA) bacteremia in an institution with a high rate of MRSA after the reinforcement of antibiotic stewardship and hand hygiene

Impact of the COVID-19 pandemic on the incidence of surgical site infection after orthopaedic surgery: an interrupted time series analysis of the nationwide surveillance database in Japan

BACKGROUND

During the COVID-19 pandemic, hygiene awareness was increased in communities and hospitals. However, there is controversy regarding whether such circumstances affected the incidence of surgical site infections (SSIs) in the orthopaedic surgical field.

AIM

To examine the impact of the COVID-19 pandemic on the incidence of SSIs after orthopaedic surgery.

METHODS

The medical records of patients having undergone orthopaedic surgery were extracted from the nationwide surveillance database in Japan. The primary outcomes were the monthly incidences of total SSIs, deep or organ/space SSIs, and SSIs due to meticillin-resistant Staphylococcus aureus (MRSA). Interrupted time series analysis was conducted between pre-pandemic (January 2017 to March 2020) and pandemic (April 2020 to June 2021) periods.

RESULTS

A total of 309,341 operations were included. Interrupted time series analysis adjusted for seasonality showed no significant changes in the incidence of total SSIs (rate ratio 0.94 and 95% confidence interval 0.98-1.02), deep or organ/space SSIs (0.91, 0.72-1.15), or SSIs due to MRSA (1.07, 0.68-1.68) along with no remarkable slope changes in any parameter (1.00, 0.98-1.02; 1.00, 0.97-1.02; and 0.98, 0.93-1.03, respectively).

CONCLUSIONS

Awareness and measures against the COVID-19 pandemic did not markedly influence the incidence of total SSIs, deep or organ/space SSIs, or SSIs due to MRSA following orthopaedic surgery in Japan.

Prescriptions patterns and appropriateness of usage of antibiotics in non-teaching community hospitals in South Korea: a multicentre retrospective study

Background

Although non-teaching community hospitals form the majority of healthcare providers in South Korea, there is limited data on antibiotic usage in them. To evaluate the pattern of antibiotic usage and its appropriateness in hospitals with < 400 beds in South Korea.

Methods

A multicentre retrospective study was conducted in 10 hospitals (six long-term care hospitals, three acute care hospitals, and one orthopaedic hospital), with < 400 beds in South Korea. We analysed patterns of antibiotic prescription in 2019, and their appropriateness in the participating hospitals. For the evaluation of the appropriateness of the prescription, 25 patients under antibiotic therapy were randomly selected at each hospital, over two separate periods. Due to the heterogeneity of their characteristics, the orthopaedics hospital was excluded from the analysis.

Results

The most commonly prescribed antibiotics in long-term care hospitals was fluoroquinolone, followed by beta-lactam/beta-lactamase inhibitor (anti-pseudomonal). In acute care hospitals, these were third generation cephalosporin, followed by first generation cephalosporin, and second generation cephalosporin. The major antibiotics that were prescribed in the orthopedics hospital was first generation cephalosporin Only 2.3% of the antibiotics were administered inappropriately. In comparison, 15.3% of patients were prescribed an inappropriate dose. The proportion of inappropriate antibiotic prescriptions was 30.6% of the total antibiotic prescriptions.

Conclusions

The antibiotic usage patterns vary between non-teaching community hospitals in South Korea. The proportion of inappropriate prescriptions exceeded 30% of the total antibiotic prescriptions.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13756-022-01082-2.

A Strategy for Hospital Pharmacists to Control Antimicrobial Resistance (AMR) in Japan

In Japan, there is concern regarding the relation between the inappropriate use of antibiotics and antibiotic resistance (AMR). Increased bacterial resistance is due in part to the inappropriate use of antimicrobial agents. The support of the pharmacist becomes important, and there is growing interest in antimicrobial stewardship to promote the appropriate and safe use of antimicrobials needed for the optimal selection of drugs, doses, durations of therapy, therapeutic drug monitoring (TDM), and implementations of cost containment strategies in Japan. Pharmacists should strive to disseminate the concept of "choosing wisely" in relation to all medicines, implement further interventions, and put them into practice. In this article, we present data for antimicrobial stewardship and Japan's AMR action plan, focusing on how pharmacists should be involved in enabling physicians to choose antimicrobials wisely.

Epidemiology and Clinical Characteristics of Bloodstream Infection in Patients Under Extracorporeal Membranous Oxygenation

BACKGROUND

Bloodstream infection (BSI) is an important complication of extracorporeal membranous oxygenation (ECMO) and a major cause of mortality. This study evaluated the epidemiological and clinical characteristics of BSI that occur during ECMO application according to microbial etiology.

METHODS

Adult patients who underwent ECMO from January 2009 to December 2016 were retrospectively analyzed for BSI episodes at a 2,700-bed, tertiary center. Epidemiological and clinical characteristics and outcomes of BSI were evaluated and were compared for etiologic groups (gram-positive cocci, gram-negative rods, and fungi groups). Risk factors for 14-day mortality were analyzed.

RESULTS

A total of 1,100 patients underwent ECMO during the study period, and 65 BSI episodes occurred in 61 patients. The BSI incidence was 8.3 episodes/1,000 ECMO days, which significantly decreased over time (P = 0.03), primarily in gram-positive cocci BSI. Gram-positive cocci, gram-negative rods, and fungi accounted for 38%, 40%, and 22% of the 73 blood isolates, respectively. Baseline characteristics were comparable between groups. Catheter-related infection (CRI) and pneumonia were the most common sources of BSI; 52% of gram-positive cocci BSIs and 79% of fungi BSIs were caused by CRI, and 75% of gram-negative BSIs by pneumonia. Patients with gram-negative rods BSI died more frequently and earlier than those with other BSIs. Independent risk factors for 14-day mortality were older age and gram-negative rods BSI.

CONCLUSIONS

The decreased BSI incidence during ECMO was mainly because of the decrease of gram-positive cocci BSI. The high early mortality of gram-negative rods BSI makes prevention and adequate treatment necessary.

Australian Group on Antimicrobial Resistance (AGAR) Australian Staphylococcus aureus Sepsis Outcome Programme (ASSOP) Annual Report 2019

From 1 January to 31 December 2019, 39 institutions around Australia participated in the Australian Staphylococcus aureus Sepsis Outcome Programme (ASSOP). The aim of ASSOP 2019 was to determine the proportion of Staphylococcus aureus bacteraemia (SAB) isolates in Australia that are antimicrobial resistant, with particular emphasis on susceptibility to methicillin and on characterising the molecular epidemiology of the methicillin-resistant isolates. A total of 3,157 S. aureus bacteraemia episodes were reported, of which 79.8% were community-onset. 18.5% of S. aureus were methicillin resistant. The 30-day all-cause mortality associated with methicillin-resistant SAB was 14.0%, which was not significantly different from the 14.3% mortality associated with methicillin-susceptible SAB (p = 0.9). With the exception of the β-lactams and erythromycin, antimicrobial resistance in methicillin-susceptible S. aureus was rare. However, in addition to the β-lactams, approximately 36% of methicillin-resistant S. aureus (MRSA) were resistant to ciprofloxacin, 34% to erythromycin, 13% to tetracycline, 9% to gentamicin and 4% to co-trimoxazole. When applying the EUCAST breakpoints, teicoplanin resistance was detected in two S. aureus isolates. Resistance was not detected for vancomycin and linezolid. Resistance to non-beta-lactam antimicrobials was largely attributable to two healthcare-associated MRSA clones: ST22-IV [2B] (EMRSA-15) and ST239-III [3A] (Aus-2/3 EMRSA). ST22-IV [2B] (EMRSA-15) is the predominant healthcare-associated clone in Australia. Eighty percent of methicillin-resistant SAB, however, were due to community-associated clones. Although polyclonal, approximately 71.4% of community-associated clones were variously characterised as ST93-IV [2B] (Queensland CA-MRSA), ST5-IV [2B], ST45-V_T [5C2&5], ST1-IV [2B], ST30-IV [2B], ST78-IV [2B] and ST8-IV [2B]. Community-associated MRSA (CA-MRSA), in particular the ST45-V_T [5C2&5] clone, have acquired multiple antimicrobial resistance determinants including ciprofloxacin, erythromycin, clindamycin, gentamicin and tetracycline. The multiresistant ST45-V_T [5C2&5] clone accounted for 12.7% of CA-MRSA. As CA-MRSA is well established in the Australian community, it is important that antimicrobial resistance patterns in community- and healthcare-associated SAB are monitored, as this information will guide therapeutic practices in treating S. aureus sepsis.

Discontinuation of Glycopeptides in Patients with Culture Negative Severe Sepsis or Septic Shock: A Propensity-Matched Retrospective Cohort Study

Implementation of antibiotic stewardship is difficult in patients with sepsis because of severity of disease. We evaluated the impact of glycopeptide discontinuation (GD) in patients with culture negative severe sepsis or septic shock who received glycopeptides as initial empiric antibiotic therapy at admission. We conducted a single center retrospective cohort study between January 2010 and March 2018. GD was defined as discontinuation of initial empiric glycopeptides on availability of culture results, revealing the absence of identified pathogens. In 92 included patients, the leading causes of sepsis were pneumonia (34.8%) and intra-abdominal infection (23.9%); 28-day mortality and overall mortality were 14% and 21%, respectively. Glycopeptides were discontinued in 42/92 patients. After propensity score matching, baseline characteristics were not significantly different between the GD and non-GD (GND) groups. GND was associated with development of acute kidney injury (OR 5.54, 95% CI 1.49–20.6, P = 0.011). GD did not increase the 7-day, 14-day, and 28-day mortality compared with GND. The length of hospital stay was shorter in the GD group than in GND group (16.33 ± 17.11 vs. 25.05 ± 14.37, P = 0.082), though not statistically significant. GD may be safe and reduce adverse events of prolonged antibiotic use in patients with culture negative severe sepsis or septic shock receiving glycopeptides as initial empiric antibiotic therapy.

Australian Group on Antimicrobial Resistance (AGAR) Australian Staphylococcus aureus Sepsis Outcome Programme (ASSOP) Annual Report 2018

From 1 January to 31 December 2018, thirty-six institutions around Australia participated in the Australian Staphylococcus aureus Sepsis Outcome Programme (ASSOP). The aim of ASSOP 2018 was to determine the proportion of Staphylococcus aureus bacteraemia (SAB) isolates in Australia that are antimicrobial resistant, with particular emphasis on susceptibility to methicillin, and to characterise the molecular epidemiology of the methicillin-resistant isolates. A total of 2,673 S. aureus bacteraemia episodes were reported, of which 78.9% were community-onset. A total of 17.4% of S. aureus isolates were methicillin resistant. The 30-day all-cause mortality associated with methicillin-resistant SAB was 17.1% which was not significantly higher than the 13.6% mortality associated with methicillin-susceptible SAB (p = 0.1). With the exception of the β-lactams and erythromycin, antimicrobial resistance in methicillin-susceptible S. aureus was rare. However in addition to the β-lactams approximately 42% of methicillin-resistant S. aureus (MRSA) were resistant to erythromycin, 36% to ciprofloxacin and approximately 13% resistant to co-trimoxazole, tetracycline and gentamicin. When applying the EUCAST breakpoints teicoplanin resistance was detected in two S. aureus isolates. Resistance was not detected for vancomycin and linezolid. Resistance to non-beta-lactam antimicrobials was largely attributable to two healthcare-associated MRSA clones: ST22-IV [2B] (EMRSA-15) and ST239-III [3A] (Aus-2/3 EMRSA). The ST22-IV [2B] (EMRSA-15) clone is the predominant healthcare-associated clone in Australia. Seventy-eight percent of methicillin-resistant SAB episodes in 2018 were due to community-associated clones. Although polyclonal, approximately 76.3% of community-associated clones were characterised as ST93-IV [2B] (Queensland CA-MRSA), ST5-IV [2B], ST45-VT [5C2&5], ST1-IV [2B], ST30-IV [2B], ST78-IV [2B] and ST97-IV [2B]. Community-associated MRSA, in particular the ST45-VT [5C2&5] clone, has acquired multiple antimicrobial resistance determinants including ciprofloxacin, erythromycin, clindamycin, gentamicin and tetracycline. The ST45-VT [5C2&5] clone accounted for 11.7% of CA-MRSA. As CA-MRSA is well established in the Australian community, it is important that antimicrobial resistance patterns in community- and healthcare-associated SAB are monitored, as this information will guide therapeutic practices in treating S. aureus sepsis.

Ten-year surveillance of central line-associated bloodstream infections in South Korea: Surveillance not enough, action needed

BACKGROUND

Central line-associated bloodstream infections (CLABSIs) are preventable health care-associated infections that can lead to increased mortality. Therefore, we investigated trends in CLABSI rates, and the factors associated with changing trends over a 10-year period using the Korean National Healthcare-associated Infections Surveillance System (KONIS).

METHODS

We investigated annual CLABSI rates from 2006 to 2015 in 190 KONIS-participating intensive care units (ICUs) from 107 participating hospitals. We collected data associated with hospital and ICU characteristics and analyzed trends using generalized autoregressive moving average models.

RESULTS

The CLABSI pooled mean rate decreased from 3.40 in 2006 to 2.20 in 2015 (per 1,000 catheter-days). The trend analysis also showed a significant decreasing trend in CLABSI rates in unadjusted models (annual increase, -0.137; P < .001). After adjusting for hospital and ICU characteristics, significant decreasing trends were identified (annual increase, -0.109; P < .001). However, there were no significant changes in subgroups with non-university-affiliated hospitals, hospitals in metropolitan areas near Seoul, small hospitals (300-699 beds), or surgical ICUs.

CONCLUSIONS

In South Korea, CLABSI rates have shown significant reductions in the past 10 years with participation in the KONIS. However, CLABSI rates may be reduced by encouraging more hospitals to participate in the KONIS and by improved policy support for hospitals lacking infection control resources.

Association between statewide adoption of the CDC's Core Elements of Hospital Antimicrobial Stewardship Programs and rates of methicillin-resistant Staphylococcus aureus bacteremia and Clostridioides difficile infection in the United States

OBJECTIVE

To measure the association between statewide adoption of the Centers for Disease Control and Prevention's (CDC's) Core Elements for Hospital Antimicrobial Stewardship Programs (Core Elements) and hospital-associated methicillin-resistant Staphylococcus aureus bacteremia (MRSA) and Clostridioides difficile infection (CDI) rates in the United States. We hypothesized that states with a higher percentage of reported compliance with the Core Elements have significantly lower MRSA and CDI rates.

PARTICIPANTS

All US states.

DESIGN

Observational longitudinal study.

METHODS

We used 2014-2016 data from Hospital Compare, Provider of Service files, Medicare cost reports, and the CDC's Patient Safety Atlas website. Outcomes were MRSA standardized infection ratio (SIR) and CDI SIR. The key explanatory variable was the percentage of hospitals that meet the Core Elements in each state. We estimated state and time fixed-effects models with time-variant controls, and we weighted our analyses for the number of hospitals in the state.

RESULTS

The percentage of hospitals reporting compliance with the Core Elements between 2014 and 2016 increased in all states. A 1% increase in reported ASP compliance was associated with a 0.3% decrease (P < .01) in CDIs in 2016 relative to 2014. We did not find an association for MRSA infections.

CONCLUSIONS

Increasing documentation of the Core Elements may be associated with decreases in the CDI SIR. We did not find evidence of such an association for the MRSA SIR, probably due to the short length of the study and variety of stewardship strategies that ASPs may encompass.

Australian Group on Antimicrobial Resistance (AGAR) Australian Staphylococcus aureus Sepsis Outcome Programme (ASSOP) Annual Report 2017

From 1 January to 31 December 2017, 36 institutions around Australia participated in the Australian Staphylococcus aureus Sepsis Outcome Programme (ASSOP). The aim of ASSOP 2017 was to determine the proportion of Staphylococcus aureus bacteraemia (SAB) isolates in Australia that are antimicrobial resistant, with particular emphasis on susceptibility to methicillin and to characterise the molecular epidemiology of the methicillin-resistant isolates. A total of 2,515 S. aureus bacteraemia episodes were reported, of which 77% were community-onset. Approximately one in five S. aureus (19.0%) were methicillin resistant. The 30-day all-cause mortality associated with methicillin-resistant SAB was 18.7% which was significantly higher than the 14.0% mortality associated with methicillin-susceptible SAB. With the exception of the β-lactams and erythromycin, antimicrobial resistance in methicillin-susceptible S. aureus was rare. However in addition to the β-lactams approximately 42% of methicillin-resistant S. aureus (MRSA) were resistant to erythromycin and ciprofloxacin and approximately 14% resistant to co-trimoxazole, tetracycline and gentamicin. When applying the EUCAST breakpoints teicoplanin resistance was detected in five S. aureus isolates. Resistance was not detected for vancomycin and linezolid. Resistance to non-beta-lactam antimicrobials was largely attributable to two healthcare-associated MRSA clones: ST22-IV [2B] (EMRSA-15) and ST239-III [3A] (Aus-2/3 EMRSA). ST22-IV [2B] (EMRSA-15) is the predominant healthcare-associated clone in Australia. Seventy-five percent of methicillin-resistant SAB were due to community-associated clones. Although polyclonal approximately 74% of community-associated clones were characterised as ST93-IV [2B] (Queensland CA-MRSA), ST5-IV [2B], ST45-V_T [5C2&5] and ST1-IV [2B]. CA-MRSA, in particular the ST45-V_T [5C2&5] clone has acquired multiple antimicrobial resistance determinants including ciprofloxacin, erythromycin, clindamycin, gentamicin and tetracycline. ST45-V_T [5C2&5] accounted for 12.8% of CA-MRSA. As CA-MRSA is well established in the Australian community it is important antimicrobial resistance patterns in community- and healthcare-associated SAB is monitored as this information will guide therapeutic practices in treating S. aureus sepsis.

Impact of an Infectious Disease Specialist on an Antimicrobial Stewardship Program at a Resource-Limited, Non-Academic Community Hospital in Korea

BACKGROUND

Implementing a successful antimicrobial stewardship program (ASP) is difficult for non-academic community (NAC) hospitals due to insufficient infrastructure.

AIM

We evaluated the impact of an infectious disease specialist (IDS) on implementing an ASP in a resource-limited setting in Korea.

METHODS

A retrospective study was performed at a NAC hospital between June 2015 and August 2018. An IDS has led an ASP at the hospital since June 2017. We used an interrupted time series analysis to evaluate longitudinal effects of the IDS-led ASP on the amount of antibiotic use and incidence of multidrug-resistant organism (MDRO) acquisition.

FINDINGS

Total antibiotic use changed from 698.82 ± 74.41 to 602.09 ± 69.94 defined daily dose/1000 patient-days (PDs) after intervention. An immediate reduction in the use of carbapenems, glycopeptides, penicillins, and other antibiotics followed the IDS-led ASP. The 3rd/4th generation cephalosporins and carbapenems prescription rates decreased in slope after the intervention. Incidence of MDRO acquisition changed from 1.38, 0.78, and 0.21/1000 PDs to 1.06, 0.15, and 0.32/1000 PDs in methicillin-resistant Staphylococcus aureus, multidrug-resistant Acinetobacter baumannii, and multidrug-resistant Pseudomonas aeruginosa, respectively. The incidence of methicillin-resistant Staphylococcus aureus and multidrug-resistant Acinetobacter baumannii acquisition immediately decreased following intervention.

CONCLUSION

An IDS can implement a successful ASP by reducing antibiotic consumption and MDRO acquisition at resource-limited NAC hospitals.

Impact of MRSA Transmission and Infection in a Neonatal Intensive Care Unit in China: A Bundle Intervention Study during 2014-2017

Objective. To evaluate the efficacy of bundle intervention on healthcare-associated (HA) methicillin-resistant Staphylococcus Aureus (MRSA) infection in the neonatal intensive care unit (NICU). Methods. In this study, 11,277 infants having undergone treatment at the NICU in Xiamen, China, from January 2014 to February 2017 were recruited. We retrospectively reviewed patients' demographic and clinical information. Patients from 2014 to 2015 were treated as the control group and those from 2016 to 2017 were classified as the experimental group. Bundle intervention measures were performed, including screening for MRSA, isolation precautions, training of hand hygiene, cleaning protocols, and decontamination of isolation ward. The HA-MRSA data and compliance of infection control measures between both groups were analyzed. Results. Through bundle interventions, the compliance with the isolation of MRSA raised from 55.88% to 92.86% and hand hygiene compliance increased from 90.07% to 93.23% (P < 0.05). The HA infection decreased from 1.87% to 1.71% (P > 0.05) and HA detection rate of MRSA declined from 2.63‰ to 1.00‰, respectively (P < 0.05). Conclusion. Multifaceted interventions can effectively prevent MRSA infection and transmission; this includes active surveillance, isolation precautions, increased hand hygiene compliance, environmental cleaning, and decontamination.

An outbreak of severe infectious diseases caused by methicillin-resistant Staphylococcus aureus USA300 clone among hospitalized patients and nursing staff in a tertiary care university hospital

The USA300 clone, which produces Panton-Valentine leukocidin (PVL), is a major highly pathogenic community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) clone that is spreading throughout the world. Although the prevalence of the USA300 clone in Japan was very limited a decade ago, its incidence has been increasing in both community and hospital settings in recent years. There is great concern that the USA300 clone will cause more complicated diseases and become a serious threat to immunocompromised patients in hospital settings. Here, we report an outbreak of severe infectious diseases in a tertiary care university hospital involving the incidence of deep infections, including bacteremia, and continuous and frequent isolation of MRSA strains for five months from six patients and a healthy nursing staff member in the same ward. The genotype of all MRSA isolates was identical to that of the USA300 clone. Furthermore, pulsed-field gel electrophoresis analysis indicated that all MRSA had the same patterns. These data demonstrate that a USA300 clone outbreak had occurred in the hospital. Fortunately, this outbreak was terminated subsequent to the interventions of the infection control team and all patients recovered following the appropriate therapies. Our report demonstrates that patients carrying highly pathogenic CA-MRSA have the potential to become a source of nosocomial outbreaks that can spread to healthy healthcare workers. Therefore, stricter standard precautions should be applied for all patients at the time of admission to prevent such nosocomial outbreaks.

Prevalence, trend and antimicrobial susceptibility of Methicillin Resistant Staphylococcus aureus in Nigeria: a systematic review

BACKGROUND

Evidence to demonstrate the prevalence and trend of Methicillin Resistant Staphylococcus aureus (MRSA) infection in Nigeria is scarce. This review evaluates the prevalence, trend and antimicrobial susceptibility of clinical MRSA isolates reported in published studies.

METHOD

Electronic search (PubMed, Scopus and Google scholar) was conducted using the following search terms: "MRSA OR Methicillin Resistant Staphylococcus aureus AND Nigeria." Reference list of selected studies was scanned to identify more studies. Studies published between 2007 and 2017 that tested at least 30 non-duplicate S. aureus isolates were selected. An independent reviewer extracted data from the studies using a standardized form.

RESULTS

Twelve studies were included in this review. Overall, prevalence of MRSA infection increased from 18.3% (2009) to 42.3% (2013). The prevalence of MRSA infection was less than 50% in all the regions during the period under review. There was a decline in the prevalence of MRSA infection in the North-East (from 12.5% to 8.0%) between 2007 and 2012, and an increase in the South-West (from 20.2% to 47.4%) between 2006 and 2010. Wound, blood and urine specimens had the highest proportion of MRSA isolates. Non-susceptibility of MRSA strains to cotrimoxazole and tetracycline was greater than 85%.

CONCLUSION

Prevalence of MRSA infection in Nigeria is rising, albeit regional variations. Non-susceptibility to commonly prescribed, orally available and inexpensive antibiotics was high. Antimicrobial resistance surveillance system, infection control, and antimicrobial stewardship interventions are recommended.

Are antimicrobial stewardship programs effective strategies for preventing antibiotic resistance? A systematic review

BACKGROUND

Antimicrobial stewardship programs (ASPs) have been proposed as a solution for the global burden of antibiotic resistance, despite the lack of evidence on the subject.

OBJECTIVE

To analyze the role of ASPs in reducing bacterial resistance to antibiotics in hospital settings.

DATA SOURCES

A review in PubMed, Scopus, LILACS, and SciELO databases was performed. The period analyzed was January 1, 2012-January 4, 2017.

ELIGIBILITY CRITERIA

Studies that related ASPs to bacterial resistance.

DATA EXTRACTION

All studies that did not focus on ASPs were removed. Antifungal and antiviral programs were excluded.

RESULTS

Only 8 studies had quasi-experimental designs, and none were controlled trials. ASP strategies and microorganism-antibiotic pairs evaluated varied widely. Seven studies were classified as presenting clearly positive results, 3 had limited positive results, 7 had doubtful results, 4 had negative results, and 5 had noninterpretable results. The implementation of new infection control practices occurred in 7 studies.

LIMITATIONS

There are yet few studies on this matter, and most of them have inadequate study designs. Great heterogeneity between study features was detrimental to drawing evidence-based conclusions.

CONCLUSIONS

There is no solid evidence that ASPs are effective in reducing antibiotic resistance in hospital settings. We uphold the need for more studies with appropriate study designs, standardized ASP interventions targeting common microorganism-antibiotic pairs, and avoiding simultaneous implementation of infection control practices.

Changes in Antimicrobial Susceptibility Pattern of Blood Isolates at a University Hospital in the Kyungnam area during 2005-2014

Objectives Blood culture is a one of the most important procedure for diagnosis and treatment of infectious disease, but distribution of pathogenic species and the antimicrobial susceptibility can be vary from pathogen, individual trait, regional or environmental features. In this study, we investigated the changes in frequency of occurrence and antimicrobial susceptibility pattern of blood isolates from 2005 to 2014. Methods Data of blood isolates from Kosin Gospel Hospital during 2005 to 2014 were analyzed retrospectively. Blood isolates were cultured for 5 days using BACTEC Plus Aerobic/F and BACTEC lytic/10 Anaerobic/F. Identification and antimicrobial susceptibility test was performed using VITEK 1 system, VITEK 2 XL, PHOENIX 100 and conventional method. Results 9,847 isolates were identified during 10 years. Among the isolates aerobic or falcutative anaerobic bacteria were isolated in 99.5% specimens, anaerobic were 0.1%, and fugi were 0.4%. Most commonly isolated bacteria were coagulase-negative Staphylococcus (CoNS) followed by Escherichia coli, Staphylococcus aureus and Klebsiella pneumoniae. Candida parapsilosis were most frequently isolated among fungi. The proportion of S. aureus, A. baumannii and E. faecium were increased, while Pseudomonas aeruginosa and Streptococcus pneumoniae decreased over decennium. Imipenem resistant K. pneumoniae were identified. Vancomycin resistant E. faecium and imipenem resistant A. baumannii were increased (7.1% in 2005 to 12.3% in 2014, 0% in 2005 to 55.6% in 2014, respectively). Conclusions Over the last 10 year, CoNS were the most frequently isolated pathogen. Imipenem resistant K. pneumoniae was emerged. Vancomycin resistant E. faecium and imipenem resistant A. baumannii increased during this period.

Methicillin Resistant Staphylococcus aureus Transmission in a Ghanaian Burn Unit: The Importance of Active Surveillance in Resource-Limited Settings

Objectives:Staphylococcus aureus infections in burn patients can lead to serious complications and death. The frequency of S. aureus infection is high in low- and middle-income countries presumably due to limited resources, misuse of antibiotics and poor infection control. The objective of the present study was to apply population genomics to precisely define, for the first time, the transmission of antibiotic resistant S. aureus in a resource-limited setting in sub-Saharan Africa.

Methods:Staphylococcus aureus surveillance was performed amongst burn patients and healthcare workers during a 7-months survey within the burn unit of the Korle Bu Teaching Hospital in Ghana.

Results: Sixty-six S. aureus isolates (59 colonizing and 7 clinical) were obtained from 31 patients and 10 healthcare workers. Twenty-one of these isolates were ST250-IV methicillin-resistant S. aureus (MRSA). Notably, 25 (81%) of the 31 patients carried or were infected with S. aureus within 24 h of admission. Genome comparisons revealed six distinct S. aureus clones circulating in the burn unit, and demonstrated multiple transmission events between patients and healthcare workers. Further, the collected S. aureus isolates exhibited a wide range of genotypic resistances to antibiotics, including trimethoprim (21%), aminoglycosides (33%), oxacillin (33%), chloramphenicol (50%), tetracycline (59%) and fluoroquinolones (100%).

Conclusion: Population genomics uncovered multiple transmission events of S. aureus, especially MRSA, within the investigated burn unit. Our findings highlight lapses in infection control and prevention, and underscore the great importance of active surveillance to protect burn victims against multi-drug resistant pathogens in resource-limited settings.

Drug-resistance dynamics of Staphylococcus aureus between 2008 and 2014 at a tertiary teaching hospital, Jiangxi Province, China

Background

To understand the relationship between the Staphylococcus aureus infection rate and the reasonable usage of antibiotics, which will help in the effective control of MRSA infection.

Methods

All data were obtained by the application of the nosocomial infection surveillance network. Drug resistance, departmental sources, and isolated sites as well as infection rate variations of S. aureus were analyzed in the 7-year period in key departments.

Results

Between 2008 and 2014, 2525 strains of S. aureus isolates, mainly from sputum, skin/soft tissue, bloodstreams were collected from several hospital departments including respiratory, burn, brain surgery, orthopedics, ICU, and emergency. During these periods, the resistance rate of S. aureus to most drugs, including oxacillin, tetracycline, erythromycin, clindamycin, gentamicin, and ciprofloxacin, showed a tendency to decrease. The resistance to sulphamethoxazole/trimethoprim showed the opposite trend (P = 0.075) and there were no S. aureus strains resistant to linezolid and vancomycin. The MRSA infection rate was different across crucial hospital departments, with the burns department and ICU maintaining a high infection level. Over the 7-year period, both the brain surgery and the emergency departments had an expected upward trend (P < 0.05), while the orthopedic department showed a clear downward trend (P < 0.05) in MRSA infection rate.

Conclusion

Hospitals should continue to maintain the current pattern of antibiotic administration, while more effective measures should be taken to reduce the high MRSA infection rate in some important hospital departments.

Impact of a hand hygiene campaign in a tertiary hospital in South Korea on the rate of hospital-onset methicillin-resistant Staphylococcus aureus bacteremia and economic evaluation of the campaign

BACKGROUND

Hand hygiene (HH) is the most important factor affecting health care-associated infections.

METHODS

We introduced a World Health Organization HH campaign in October 2010. The monthly procurement of hand sanitizers per 1,000 patient days was calculated, and the monthly incidence of methicillin-resistant Staphylococcus aureus bacteremia (MRSAB), classified into community- and hospital-onset (HO), was measured from a microbiologic laboratory database. Trends of MRSAB incidence were assessed using Bayesian structural time series models. A cost-benefit analysis was also performed based on the economic burden of HO MRSAB in Korea.

RESULTS

Procurement of hand sanitizers increased 134% after the intervention (95% confidence interval [CI], 120%-149%), compared with the preintervention period (January 2008-September 2010). In the same manner, HH compliance improved from 33.2% in September 2010 to 92.2% after the intervention. The incidence of HO MRSAB per 100,000 patient days decreased 33% (95% CI, -57% to -7.8%) after the intervention. Because there was a calculated reduction of 65 HO MRSAB cases during the intervention period, the benefit outweighed the cost (total benefit [$851,565]/total cost [$167,495] = 5.08).

CONCLUSIONS

Implementation of the HH campaign led to increased compliance and significantly reduced HO MRSAB incidence; it was also cost saving.

Systematic Review and Meta-analysis of Clinical and Economic Outcomes from the Implementation of Hospital-Based Antimicrobial Stewardship Programs

The implementation of antimicrobial stewardship programs (ASPs) is a promising strategy to help address the problem of antimicrobial resistance. We sought to determine the efficacy of ASPs and their effect on clinical and economic parameters. We searched PubMed, EMBASE, and Google Scholar looking for studies on the efficacy of ASPs in hospitals. Based on 26 studies (extracted from 24,917 citations) with pre- and postimplementation periods from 6 months to 3 years, the pooled percentage change of total antimicrobial consumption after the implementation of ASPs was -19.1% (95% confidence interval [CI] = -30.1 to -7.5), and the use of restricted antimicrobial agents decreased by -26.6% (95% CI = -52.3 to -0.8). Interestingly, in intensive care units, the decrease in antimicrobial consumption was -39.5% (95% CI = -72.5 to -6.4). The use of broad-spectrum antibiotics (-18.5% [95% CI = -32 to -5.0] for carbapenems and -14.7% [95% CI = -27.7 to -1.7] for glycopeptides), the overall antimicrobial cost (-33.9% [95% CI = -42.0 to -25.9]), and the hospital length of stay (-8.9% [95% CI = -12.8 to -5]) decreased. Among hospital pathogens, the implementation of ASPs was associated with a decrease in infections due to methicillin-resistant Staphylococcus aureus (risk difference [RD] = -0.017 [95% CI = -0.029 to -0.005]), imipenem-resistant Pseudomonas aeruginosa (RD = -0.079 [95% CI = -0.114 to -0.040]), and extended-spectrum beta-lactamase Klebsiella spp. (RD = -0.104 [95% CI = -0.153 to -0.055]). Notably, these improvements were not associated with adverse outcomes, since the all-cause, infection-related 30-day mortality and infection rates were not significantly different after implementation of an ASP (RD = -0.001 [95% CI = -0.009 to 0.006], RD = -0.005 [95% CI = -0.016 to 0.007], and RD = -0.045% [95% CI = -0.241 to 0.150], respectively). Hospital ASPs result in significant decreases in antimicrobial consumption and cost, and the benefit is higher in the critical care setting. Infections due to specific antimicrobial-resistant pathogens and the overall hospital length of stay are improved as well. Future studies should focus on the sustainability of these outcomes and evaluate potential beneficial long-term effects of ASPs in mortality and infection rates.

Evidence-based practices to increase hand hygiene compliance in health care facilities: An integrated review

BACKGROUND

Hand hygiene (HH) in health care facilities is a key component to reduce pathogen transmission and nosocomial infections. However, most HH interventions (HHI) have not been sustainable.

AIMS

This review aims to provide a comprehensive summary of recently published evidence-based HHI designed to improve HH compliance (HHC) that will enable health care providers to make informed choices when allocating limited resources to improve HHC and patient safety.

METHODS

The Medline electronic database (using PubMed) was used to identify relevant studies. English language articles that included hand hygiene interventions and related terms combined with health care environments or related terms were included.

RESULTS

Seventy-three studies that met the inclusion criteria were summarized. Interventions were categorized as improving awareness with education, facility design, and planning, unit-level protocols and procedures, hospital-wide programs, and multimodal interventions. Past successful HHIs may not be as effective when applied to other health care environments. HH education should be interactive and engaging. Electronic monitoring and reminders should be implemented in phases to ensure cost-effectiveness. To create hospitalwide programs that engage end users, policy makers should draw expertise from interdisciplinary fields. Before implementing the various components of multimodal interventions, health care practitioners should identify and examine HH difficulties unique to their organizations.

CONCLUSIONS

Future research should seek to achieve the following: replicate successful HHI in other health care environments, develop reliable HHC monitoring tools, understand caregiver-patient-family interactions, examine ways (eg, hospital leadership, financial support, and strategies from public health and infection prevention initiatives) to sustain HHC, and use simulated lab environments to refine study designs.

New epidemiology of Staphylococcus aureus infection in Asia

Not only is Asia the most populous region in the world, but inappropriate therapy, including self-medication with over-the-counter antimicrobial agents, is a common response to infectious diseases. The high antibiotic selective pressure among the overcrowded inhabitants creates an environment that is suitable for the rapid development and efficient spread of numerous multidrug-resistant pathogens. Indeed, Asia is among the regions with the highest prevalence rates of healthcare-associated methicillin-resistant Staphylococcus aureus (HA-MRSA) and community-associated methicillin-resistant S. aureus (CA-MRSA) in the world. Most hospitals in Asia are endemic for multidrug-resistant methicillin-resistant S. aureus (MRSA), with an estimated proportion from 28% (in Hong Kong and Indonesia) to >70% (in Korea) among all clinical S. aureus isolates in the early 2010s. Isolates with reduced susceptibility or a high level of resistance to glycopeptides have also been increasingly identified in the past few years. In contrast, the proportion of MRSA among community-associated S. aureus infections in Asian countries varies markedly, from <5% to >35%. Two pandemic HA-MRSA clones, namely multilocus sequence type (ST) 239 and ST5, are disseminated internationally in Asia, whereas the molecular epidemiology of CA-MRSA in Asia is characterized by clonal heterogeneity, similar to that in Europe. In this review, the epidemiology of S. aureus in both healthcare facilities and communities in Asia is addressed, with an emphasis on the prevalence, clonal structure and antibiotic resistant profiles of the MRSA strains. The novel MRSA strains from livestock animals have been considered to constitute a public health threat in western countries. The emerging livestock-associated MRSA strains in Asia are also included in this review.

The burden of nosocomial staphylococcus aureus bloodstream infection in South Korea: a prospective hospital-based nationwide study

Background

We estimated the nationwide burden of nosocomial S. aureus bloodstream infection (SA-BSI), a major cause of nosocomial infection, in South Korea.

Methods

To evaluate the nationwide incidence of nosocomial SA-BSI, cases of SA-BSI were prospectively collected from 22 hospitals with over 500 beds over 4?months. Data on patient-days were obtained from a national health insurance database containing the claims data for all healthcare facilities in South Korea. The additional cost of SA-BSI was estimated through a matched case?control study. The economic burden was calculated from the sum of the medical costs, the costs of caregiving and loss of productivity.

Results

Three hundred and thirty nine cases of nosocomial SA-BSI were included in the study: 254 cases of methicillin-resistant SA-BSI (MRSA-BSI) and 85 cases of methicillin-susceptible SA-BSI (MSSA-BSI). Death related to BSI occurred in 81 cases (31.9%) of MRSA-BSI and 12 cases (14.1%) of MSSA-BSI. The estimated incidence of nosocomial MRSA-BSI was 0.12/1,000 patient-days and that of nosocomial MSSA-BSI, 0.04/1,000 patient-days. The estimated annual cases of nosocomial BSI were 2,946 for MRSA and 986 for MSSA in South Korea. The additional economic burden per case of nosocomial SA-BSI was US $20,494 for MRSA-BSI and $6,914 for MSSA-BSI. Total additional annual cost of nosocomial SA-BSI was $67,192,559.

Conclusion

In view of the burden of nosocomial SA-BSI, a national strategy for reducing nosocomial SA-BSI is urgently needed in South Korea.

Electronic supplementary material

The online version of this article (doi:10.1186/s12879-014-0590-4) contains supplementary material, which is available to authorized users.

Improved Hand Hygiene Compliance is Associated with the Change of Perception toward Hand Hygiene among Medical Personnel

Background

Hand hygiene compliance has improved significantly through hand hygiene promotion programs that have included poster campaign, monitoring and performance feedback, and education with special attentions to perceived subjective norms. We investigated factors associated with improved hand hygiene compliance, focusing on whether the improvement of hand hygiene compliance is associated with changed perception toward hand hygiene among medical personnel.

Materials and Methods

Hand hygiene compliance and perceptions toward hand hygiene among medical personnel were compared between the second quarter of 2009 (before the start of a hand hygiene promotion program) and the second quarter of 2012. We assessed adherence to hand hygiene among medical personnel quarterly according to the WHO recommended method for direct observation. Also, we used a modified self-report questionnaire to collect perception data.

Results

Hand hygiene compliance among physicians and nurses improved significantly from 19.0% in 2009 to 74.5% in 2012 (P < 0001), and from 52.3% to 91.2% (P < 0.001), respectively. These improvements were observed in all professional status or all medical specialties that were compared between two periods, regardless of the level of the risk for cross-transmission. Hand hygiene compliance among the medical personnel continued to improve, with a slight decline in 2013. Perceptions toward hand hygiene improved significantly between 2009 and 2012. Specifically, improvements were evident in intention to adhere to hand hygiene, knowledge about hand hygiene methods, knowledge about hand hygiene indications including care of a dirty and a clean body site on the same patient, perceived behavioral and subjective norms, positive attitude toward hand hygiene promotion campaign, perception of difficulty in adhering to hand hygiene, and motivation to improve adherence to hand hygiene.

Conclusions

The examined hand hygiene promotion program resulted in improved hand hygiene compliance and perception toward hand hygiene among medical personnel. The improved perception increased hand hygiene compliance. Especially, the perception of being a role model for other colleagues is very important to improve hand hygiene compliance among clinicians.

Infection control link nurse program: an interdisciplinary approach in targeting health care-acquired infection

BACKGROUND

We describe a successful interdisciplinary liaison program that effectively reduced health care-acquired (HCA), methicillin-resistant Staphylococcus aureus (MRSA) in a university hospital setting.

METHODS

Baseline was from January 2006 to March 2008, and intervention period was April 2008 to September 2009. Staff nurses were trained to be liaisons (link nurses) to infection prevention (IP) personnel with clearly defined goals assigned and with ongoing monthly education. HCA-MRSA incidence per 1,000 patient-days (PD) was compared between baseline and intervention period along with total and non-HCA-MRSA, HCA and non-HCA-MRSA bacteremia, and hand soap/sanitizer usage. Hand hygiene compliance was assessed.

RESULTS

A reduction in MRSA rates was as follows in intervention period compared with baseline: HCA-MRSA decreased by 28% from 0.92 to 0.67 cases per 1,000 PD (incidence rate ratio, 0.72; 95% confidence interval: 0.62-0.83, P < .001), and HCA-MRSA bacteremia rate was reduced by 41% from 0.18 to 0.10 per 1,000 PD (incidence rate ratio, 0.59; 95% confidence interval: 0.42-0.84, P = .003). Total MRSA rate and MRSA bacteremia rate also showed significant reduction with nonsignificant reductions in overall non-HCA-MRSA and non-HCA-MRSA bacteremia. Hand soap/sanitizer usage and compliance with hand hygiene also increased significantly during IP.

CONCLUSION

Link nurse program effectively reduced HCA-MRSA. Goal-defined metrics with ongoing re-education for the nurses by IP personnel helped drive these results.

High burden of antimicrobial drug resistance in Asia

The rapid development of antimicrobial resistance among micro-organisms is a serious public health concern. Moreover, the dissemination of antibiotic-resistant bacteria makes this issue a global problem, and Asia is no exception. For example, since New Delhi metallo-β-lactamase (NDM)-producing Enterobacteriaceae were identified in India, further spread of NDM has become a worldwide threat. However, the epidemiology of antibiotic-resistant bacteria in Asia may be different to other regions, and clinical condition may be worse than in western countries. Antibiotic-resistant bacteria, including community-acquired and hospital-acquired meticillin-resistant Staphylococcus aureus (MRSA), vancomycin-intermediate S. aureus (VISA), vancomycin-resistant enterococci, macrolide- and penicillin-resistant Streptococcus pneumoniae, extend-spectrum β-lactamase (ESBL)-producing Escherichia coli and Klebsiella pneumoniae, carbapenem-resistant Enterobacteriaceae, and multidrug-resistant Pseudomonas aeruginosa and Acinetobacter spp., are becoming prevalent in many countries in Asia. Moreover, the prevalence of each antibiotic-resistant bacterium in each country is not identical. This review provides useful information regarding the critical condition of antibiotic resistance in Asia and emphasises the importance of continuous surveillance of resistance data.

Antimicrobial stewardship in hospitals: Does it work and can we do it?

Selection of resistant pathogens by antimicrobial use is probably the most important cause of antimicrobial resistance. Antimicrobial stewardship (AMS) refers to a multifaceted approach to optimise prescribing. The benefits of AMS programmes have been widely demonstrated in terms of reductions in antimicrobial use, mortality, Clostridium difficile and other healthcare-associated infections, hospital length of stay and bacterial resistance. Several kinds of interventions (i.e. restriction of drugs, pre-authorisation of certain antimicrobials, joint clinical rounds with prescribers, implementation of guidelines and education) have shown positive results. Regrettably, in most hospitals in Latin America, Asia and Africa as well as in a significant proportion of institutions in Europe and North America, essential human and material resources are scarce or absent, and teams are neither developed nor well functioning. Despite current or potential barriers, we should start or improve our already ongoing initiatives on AMS by considering the main specific problems and act accordingly with the available human and material resources. From supervising the use of specific classes of drugs to implementing more sophisticated decision support programmes, there is a wide range of possible useful interventions.