Oral vs Intravenous Antibiotics for Patients With Klebsiella pneumoniae Liver Abscess: A Randomized, Controlled Noninferiority Study

BACKGROUND

Klebsiella pneumoniae liver abscess (KLA) is emerging worldwide due to hypermucoviscous strains with a propensity for metastatic infection. Treatment includes drainage and prolonged intravenous antibiotics. We aimed to determine whether oral antibiotics were noninferior to continued intravenous antibiotics for KLA.

METHODS

This noninferiority, parallel group, randomized, clinical trial recruited hospitalized adults with liver abscess and K. pneumoniae isolated from blood or abscess fluid who had received ≤7 days of effective antibiotics at 3 sites in Singapore. Patients were randomized 1:1 to oral (ciprofloxacin) or intravenous (ceftriaxone) antibiotics for 28 days. If day 28 clinical response criteria were not met, further oral antibiotics were prescribed until clinical response was met. The primary endpoint was clinical cure assessed at week 12 and included a composite of absence of fever in the preceding week, C-reactive protein <20 mg/L, and reduction in abscess size. A noninferiority margin of 12% was used.

RESULTS

Between November 2013 and October 2017, 152 patients (mean age, 58.7 years; 25.7% women) were recruited, following a median 5 days of effective intravenous antibiotics. A total of 106 (69.7%) underwent abscess drainage; 71/74 (95.9%) randomized to oral antibiotics met the primary endpoint compared with 72/78 (92.3%) randomized to intravenous antibiotics (risk difference, 3.6%; 2-sided 95% confidence interval, -4.9% to 12.8%). Effects were consistent in the per-protocol population. Nonfatal serious adverse events occurred in 12/72 (16.7%) in the oral group and 13/77 (16.9%) in the intravenous group.

CONCLUSIONS

Oral antibiotics were noninferior to intravenous antibiotics for the early treatment of KLA.

CLINICAL TRIALS REGISTRATION

NCT01723150.

Establishing a New Normal for Hospital Care: A Whole of Hospital Approach to COVID-19

Singapore’s hospitals had prepared operations to receive patients (potentially) infected with SARS-CoV-2, planning various scenarios and levels of surge with a policy of isolating all confirmed cases as inpatients. The National University Hospital, adopted a whole of hospital approach to COVID-19 with three primary goals: zero hospital-acquired COVID-19, all patients receive timely necessary care, and maintenance of staff morale. These goals to date have been met. A large influx of COVID-19 cases emerged requiring a significant transformation of clinical and operational processes. Isolation room numbers almost tripled and dedicated COVID-19 cohort wards were established, elective care was postponed and Intensive Care Units were augmented with equipment and manpower. In the wake of the surge establishing a new normal for hospital care requires a considered balance of maintaining vigilance to detect endemic COVID-19, establishing contingency plans to ramp up in case of another surge, while returning to business as usual.

Scenarios to Manage the Demand for N95 Respirators for Healthcare Workers During the COVID-19 Pandemic

Background

By estimating N95 respirator demand based on simulated epidemics, we aim to assist planning efforts requiring estimations of respirator demand for the healthcare system to continue operating safely in the coming months.

Methods

We assess respiratory needs over the course of mild, moderate and severe epidemic scenarios within Singapore as a case study using a transmission dynamic model. The number of respirators required within the respiratory isolation wards and intensive care units was estimated over the course of the epidemic. We also considered single-use, extended-use and prolonged-use strategies for N95 respirators for use by healthcare workers treating suspected but negative (misclassified) or confirmed COVID-19 patients.

Results

Depending on the confirmed to misclassified case ratio, from 1:0 to 1:10, a range of 117.1 million to 1.1 billion masks are required for single-use. This decreases to 71.6–784.4 million for extended-use and 12.8–148.2 million for prolonged-use, representing a 31.8–38.9% and 86.5–89.1% reduction, respectively.

Conclusion

An extended-use policy should be considered when short-term supply chains are strained but planning measures are in place to ensure long-term availability. With severe shortage expectations from a severe epidemic, as some European countries have experienced, prolonged use is necessary to prolong supply.

Responding to COVID-19: how an academic infectious diseases division mobilized in Singapore

BACKGROUND

On January 30, COVID-19 was declared a Public Health Emergency of International Concern-a week after Singapore's first imported case and 5 days before local transmission. The National University Hospital (NUH) is Singapore's third largest hospital with 1200 beds, heavy clinical workloads, and major roles in research and teaching.

MAIN BODY

With memories of SARS still vivid, there was an urgent requirement for the NUH Division of Infectious Diseases to adapt-undergoing major reorganization to face rapidly changing priorities while ensuring usual essential services and standards. Leveraging on individual strengths, our division mobilized to meet the demands of COVID-19 while engaging in high-level coordination, strategy, and advocacy. We present our experience of the 60 days since the nation's first case. During this time, our hospital has managed 3030 suspect cases, including 1300 inpatients, 37 confirmed cases, and overseen 4384 samples tested for COVID-19.

CONCLUSION

Complex hospital adaptations were supported by an unprecedented number of workflows and coordination channels essential to safe and effective operations. The actions we describe, aligned with international recommendations and emerging evidence-based best practices, may serve as a framework for other divisions and institutions facing the spread of COVID-19 globally.

Development of third-generation immunochemiluminometric assays of follitropin and lutropin and clinical application in determining pediatric reference ranges

We developed dioxatane-based immunochemiluminometric assays (ICMAs) for lutropin (LH) and follitropin (FSH), using monoclonal antibodies. These ICMAs have a minimal detectable dose (analytical sensitivity) of 0.01 IU/L, extending the lower limit of sensitivity 10-fold (from 0.10 IU/L) when compared with immunoradiometric assays (IRMA) (second generation), and thus provide a true third-generation assay. Daytime FSH and LH concentrations were measured in 236 boys and 195 girls. Unlike the previous assays, all the samples had detectable concentrations of LH and FSH. In agreement with results from earlier methods, the present results indicate that for both sexes mean FSH and LH concentrations are relatively high during the early months of life, fall to baseline prepubertal concentrations by 12-18 months, and remain low until the onset of puberty. During puberty, the mean concentrations of FSH and LH increase significantly in both girls and boys with each stage of puberty, but there is considerable overlap between stages. These third-generation FSH and LH ICMAs reliably separate daytime plasma FSH and LH concentrations of prepubertal children from those of sexually mature children, and therefore can more reliably distinguish between the major causes of precocious puberty (e.g., gonadotropin dependent and independent). Our LH assay is also useful in monitoring the gonadotropin-releasing hormone therapy of patients with gonadotropin-dependent precocious puberty.

High Yield of HIV Testing in Dengue-Like Febrile Illness in Singapore

Where dengue virus infections are endemic, acute febrile illness is often managed as dengue fever (DF) without diagnostic testing. In a prospective study of 140 patients with clinical features of DF, 3 (2.1%) had acute HIV infection (AHI). We recommend testing for AHI in dengue-like febrile illness.

Prevalence of Healthcare-Associated Infections and Antimicrobial Use Among Adult Inpatients in Singapore Acute-Care Hospitals: Results From the First National Point Prevalence Survey

Background

We conducted a national point prevalence survey (PPS) to determine the prevalence of healthcare-associated infections (HAIs) and antimicrobial use (AMU) in Singapore acute-care hospitals.

Methods

Trained personnel collected HAI, AMU, and baseline hospital- and patient-level data of adult inpatients from 13 private and public acute-care hospitals between July 2015 and February 2016, using the PPS methodology developed by the European Centre for Disease Prevention and Control. Factors independently associated with HAIs were determined using multivariable regression.

Results

Of the 5415 patients surveyed, there were 646 patients (11.9%; 95% confidence interval [CI], 11.1%-12.8%) with 727 distinct HAIs, of which 331 (45.5%) were culture positive. The most common HAIs were unspecified clinical sepsis (25.5%) and pneumonia (24.8%). Staphylococcus aureus (12.9%) and Pseudomonas aeruginosa (11.5%) were the most common pathogens implicated in HAIs. Carbapenem nonsusceptibility rates were highest in Acinetobacter species (71.9%) and P. aeruginosa (23.6%). Male sex, increasing age, surgery during current hospitalization, and presence of central venous or urinary catheters were independently associated with HAIs. A total of 2762 (51.0%; 95% CI, 49.7%-52.3%) patients were on 3611 systemic antimicrobial agents; 462 (12.8%) were prescribed for surgical prophylaxis and 2997 (83.0%) were prescribed for treatment. Amoxicillin/clavulanate was the most frequently prescribed (24.6%) antimicrobial agent.

Conclusions

This survey suggested a high prevalence of HAIs and AMU in Singapore's acute-care hospitals. While further research is necessary to understand the causes and costs of HAIs and AMU in Singapore, repeated PPSs over the next decade will be useful to gauge progress at controlling HAIs and AMU.

Association between neoadjuvant chemoradiation and survival for patients with locally advanced rectal cancer

AIM

To examine the overall survival differences for the following neoadjuvant therapy modalities - no therapy, chemotherapy alone, radiation alone and chemoradiation - in a large cohort of patients with locally advanced rectal cancer.

METHOD

Adults with clinical Stage II and III rectal adenocarcinoma were selected from the National Cancer Database and grouped by type of neoadjuvant therapy received: no therapy, chemotherapy only, radiotherapy only or chemoradiation. Multivariable regression methods were used to compare adjusted differences in perioperative outcomes and overall survival.

RESULTS

Among 32 978 patients included, 9714 (29.5%) received no neoadjuvant therapy, 890 (2.7%) chemotherapy only, 1170 (3.5%) radiotherapy only and 21 204 (64.3%) chemoradiation. Compared with no therapy, chemotherapy or radiotherapy alone were not associated with any adjusted differences in surgical margin positivity, permanent colostomy rate or overall survival (all P > 0.05). With adjustment, neoadjuvant chemoradiation vs no therapy was associated with a lower likelihood of surgical margin positivity (OR 0.74, P < 0.001), decreased rate of permanent colostomy (OR 0.77, P < 0.001) and overall survival [hazard ratio (HR) 0.79, P < 0.001]. When compared with chemotherapy or radiotherapy alone, chemoradiation remained associated with improved overall survival (vs chemotherapy alone HR 0.83, P = 0.04; vs radiotherapy alone HR 0.83, P < 0.019).

CONCLUSION

Neoadjuvant chemoradiation, not chemotherapy or radiotherapy alone, is important for sphincter preservation, R0 resection and survival for patients with locally advanced rectal cancer. Despite this finding, one-third of patients in the United States with locally advanced rectal cancer fail to receive stage-appropriate chemoradiation.

Ebola virus disease: An update on current prevention and management strategies

Ebola virus disease (EVD) is characterised by systemic viral replication, immuno-suppression, abnormal inflammatory responses, large volume fluid and electrolyte losses, and high mortality in under-resourced settings. There are various therapeutic strategies targeting EVD including vaccines utilizing different antigen delivery methods, antibody-based therapies and antiviral drugs. These therapies remain experimental, but received attention following their use particularly in cases treated outside West Africa during the 2014-15 outbreak, in which 20 (80%) out of 25 patients survived. Emerging data from current trials look promising and are undergoing further study, however optimised supportive care remains the key to reducing mortality from EVD.

Ertapenem in outpatient parenteral antimicrobial therapy for complicated urinary tract infections

BACKGROUND

Ertapenem is a broad-spectrum antibiotic that is increasingly being utilized. Its dosing convenience renders it suitable for outpatient therapy, and its pharmacokinetic characteristics favour its use against complicated urinary tract infections (cUTIs). Despite this, sufficient clinical data are lacking for its use against cUTIs in the outpatient setting. We assessed the microbiological and clinical cure rates associated with ertapenem treatment for cUTIs in two outpatient parenteral antimicrobial therapy (OPAT) departments.

METHODS

We undertook a prospective observational study of adult patients who received ertapenem for cUTIs between August 2010 and August 2014. Data on patient characteristics, clinical progress and microbiological results were collected and analysed.

RESULTS

Sixty-one patients were enrolled. The median age was 59 years (range 24, 83) and 61% were male. The most common diagnoses were pyelonephritis (39%) and prostatitis (15%). The most common causative organism was Escherichia coli (67%). Extended-spectrum β-lactamase (ESBL)-producing organisms were detected in 72% of infections. Microbiological cure was achieved in 67% overall, and was less likely in those with Klebsiella pneumoniae infection (OR = 0.21 [95%CI: 0.05 to 0.85] p = 0.029). Clinical cure was observed in 92% of patients.

CONCLUSION

In this study of treating cUTIs with ertapenem, we have demonstrated good clinical outcomes. A lower than expected microbiological cure rate was observed in those with Klebsiella pneumoniae infection.

Antiseptic Body Washes for Reducing the Transmission of Methicillin-Resistant Staphylococcus aureus: A Cluster Crossover Study

In a cluster cross-over trial, targeted decolonization with octenidine body washes was not associated with reduction in MRSA transmission or infection

Background. Limiting the spread of methicillin-resistant Staphylococcus aureus (MRSA) within healthcare facilities where the organism is highly endemic is a challenge. The use of topical antiseptic agents may help interrupt the transmission of MRSA and reduce the risk of clinical infection. Octenidine dihydrochloride is a topical antiseptic that exhibits in vitro efficacy against a wide variety of bacteria, including S aureus.

Methods. We conducted a prospective cluster crossover study to compare the use of daily octenidine body washes with soap and water in patients identified by active surveillance cultures to be MRSA-colonized, to prevent the acquisition of MRSA in patients with negative screening swabs. Five adult medical and surgical wards and 2 intensive care units were selected. The study involved an initial 6-month phase using octenidine or soap washes followed by a crossover in each ward to the alternative product. The primary and secondary outcomes were the rates of new MRSA acquisitions and MRSA clinical infections, respectively.

Results. A total of 10 936 patients admitted for ≥48 hours was included in the analysis. There was a small reduction in MRSA acquisition in the intervention group compared with controls (3.0% vs 3.3%), but this reduction was not significant (odds ratio, 0.89; 95% confidence interval, .72–1.11; P = .31). There were also no significant differences in clinical MRSA infection or incidence of MRSA bacteremia.

Conclusions. This study suggests that the targeted use of routine antiseptic washes may not in itself be adequate to reduce the transmission of MRSA in an endemic hospital setting.

A comparison of paediatric and adult infectious diseases consultations in Australia and New Zealand

The objective of this paper is to describe paediatric infectious diseases consultations across Australia and New Zealand. We surveyed infectious diseases physicians at 51 hospitals over a period of 2 weeks in 2012. Compared with adult consults, paediatric consults were more frequently received from general paediatricians/physicians and intensive care, yet less frequently from surgeons and emergency. Respiratory, skin/soft tissue and bone/joint infections were the most frequent consultations in children. These data demonstrate the breadth of formal infectious diseases consults in children. Differences between paediatric and infectious diseases consultations need to be considered when planning both paediatric and adult physician training and future curriculum development.

Type I IFNs and IL-18 regulate the antiviral response of primary human γδ T cells against dendritic cells infected with Dengue virus

Little is known about the cellular mechanisms of innate immunity against dengue virus (DV) infection. Specifically, the γδ T cell response to DV has not been characterized in detail. In this article, we demonstrate that markers of activation, proliferation, and degranulation are upregulated on γδ T cells in PBMC isolated from individuals with acute dengue fever. Primary γδ T cells responded rapidly in vitro to autologous DV-infected dendritic cells by secreting IFN-γ and upregulating CD107a. The anti-DV IFN-γ response is regulated by type I IFN and IL-18 in a TCR-independent manner, and IFN-γ secreting γδ T cells predominantly expressed IL-18Rα. Antagonizing the ATP-dependent P2X7 receptor pathway of inflammasome activation significantly inhibited the anti-DV IFN-γ response of γδ T cells. Overnight priming with IL-18 produced effector γδ T cells with significantly increased ability to lyse autologous DV-infected dendritic cells. Monocytes were identified as accessory cells that augmented the anti-DV IFN-γ response of γδ T cells. Lack of monocytes in culture is associated with lower IL-18 levels in culture supernatant and diminished production of IFN-γ by γδ T cells, whereas addition of exogenous IL-18 restored the IFN-γ response of γδ T cells in monocyte-depleted cocultures with DV-infected DC. Our results indicate that primary γδ T cells contribute to the immune response during DV infection by providing an early source of IFN-γ, as well as by killing DV-infected cells, and suggest that monocytes participate as accessory cells that sense DV infection and amplify the cellular immune response against this virus in an IL-18-dependent manner.

Progression from new methicillin-resistant Staphylococcus aureus colonisation to infection: an observational study in a hospital cohort

BACKGROUND

Patients newly colonised with methicillin-resistant Staphylococcus aureus (MRSA) are at higher risk of clinical MRSA infection. At present, there are limited data on the duration or magnitude of this risk in a hospital population with a known time of MRSA acquisition.

METHODS

A retrospective cohort study of 909 adult patients known to have newly identified MRSA colonisation during admission to National University Hospital, Singapore between 1 July 2007 and 30 June 2011 was undertaken. Patients were excluded if they had history of previous MRSA colonisation or infection, or if they had been a hospital inpatient in the preceding 12 months. Data were collected on the development of MRSA infection requiring hospitalisation up to 30 June 2012.

RESULTS

Of 840 patients newly colonised with MRSA as identified on active surveillance and not clinical specimens, 546 were men (65.0%) and the median age was 65 years (range 18-103 years). Median follow up was 24 months (range 0 -64 months, 85.1% followed >6 months). Clinical infection occurred in 121 patients (14.4%) with median time to infection of 22 days (95% CI 14-31). Overall 71.9% (87/121) of infected patients developed infection within 60 days of the date MRSA colonisation was detected. However, 17/121 patients (14.0%) developed clinical infection more than six months after documented MRSA acquisition. The most common sites of clinical infection were skin and soft tissue (49/121, 40.5%, 95% CI 31.7-49.8), respiratory tract (37/121, 30.6%, 95% CI 22.5-39.6) and bone and joint infections (14/121, 11.6%, 95% CI 6.5-18.7). Thirteen patients (13/121, 10.7%, 95% CI 5.8-17.7) had bacteraemias, of which six (5.0% 95% CI 1.8-10.5) were primary and seven (5.7%, 95% CI 2.3-11.6) were secondary to infection at other sites. Crude mortality at 30 days and six months was higher in patients with MRSA infection than colonisation alone (aOR 5.49, 95% CI 2.75-10.95, p<0.001 and aOR 2.94, 95% CI 1.78-4.85, p<0.001 respectively).

CONCLUSION

Risk of clinical infection is highest soon after MRSA acquisition. Prevention of MRSA acquisition in hospital will have significant impact on morbidity and mortality for patients.

Bad design, bad practices, bad bugs: frustrations in controlling an outbreak of Elizabethkingia meningoseptica in intensive care units

BACKGROUND

Elizabethkingia meningoseptica is a nosocomial-adapted Gram-negative bacillus intrinsically resistant to antibiotics commonly used in the intensive care setting. An outbreak investigation commenced when five patients developed E. meningoseptica infection in two intensive care units (ICUs).

METHODS

Analysis of laboratory data, case reviews, ICU workflows and extensive environmental sampling were undertaken. Molecular typing was performed using repetitive element palindromic polymerase chain reaction. Follow-up studies after interventions included environmental monitoring and a survey of staff compliance with interventions.

FINDINGS

Laboratory data revealed increasing incidence of E. meningoseptica colonization or infection in ICU patients compared with preceding years. E. meningoseptica was cultured from 44% (35/79) of taps, but not from other sources. Hand hygiene sinks were used for disposal of patient secretions and rinsing re-usable patient care items. Sinks misused in this way were contaminated more often than sinks that were not misused (odds ratio 4.38, 95% confidence interval 1.68-11.39; P = 0.004). Molecular typing revealed that patient isolates had identical patterns to several isolates from hand hygiene taps. An urgent education programme was instituted to change these practices. Taps were cleaned systematically and aerators were changed. A temporary reduction in case numbers was achieved. Recolonization of taps was demonstrated on follow-up environmental screening, and cases recurred after two months. A survey revealed that 77.3% (163/213) of nursing staff still misused sinks due to time constraints or other problems adhering to the interventions.

CONCLUSION

Introduction of non-sanctioned practices due to suboptimal unit design may have unintentional consequences for ICU patients. Room design and staff workflows must be optimized for patient safety as lapses in procedure can inadvertently put patients at risk.

Automated measures of hand hygiene compliance among healthcare workers using ultrasound: validation and a randomized controlled trial

OBJECTIVE

The primary objective of this study was to validate a novel method of assessing hand hygiene compliance using ultrasound transmitters in patient zones and staff tagged with receivers. The secondary objective was to assess the impact of audio reminders and quantified individual feedback.

DESIGN

An observational comparison against manual assessment followed by assessment using an open-label randomized control method.

SETTING

Patient zones were established in 3 wards of 2 large teaching hospitals, including 88 general and 18 intensive care unit ward beds.

PARTICIPANTS

Consented regular ward nursing, medical, and allied health staff.

METHODS

Concordance between 40 hours of manual observation using trained hand hygiene auditors and automated measures of opportunities and compliance. Subsequent measured interventions were reminder beeps and written individual feedback.

RESULTS

When compared with manual observations, ultrasound monitoring underestimated percentage compliances by a nonsignificant mean (95% confidence interval [CI]) difference of 5.2% (-20.1% to 9.8%; [Formula: see text]). After the intervention, adjusted multivariate analysis showed mean (95% CI) overall compliance in the intervention arm was 6.8% (2.5%-11.1%; [Formula: see text]) higher than in the control arm. Results stratified by compliance at entry and exit showed that the effect of intervention was stronger for compliance at exit than at entry.

CONCLUSIONS

Our automated measure of hand hygiene compliance is valid when compared with the traditional gold standard of manual observations. As an interventional tool, ultrasound-based automated hand hygiene audits have significant benefit that can be built upon with enhancements and find increasing acceptance with time.

A novel approach to improve hand hygiene compliance of student nurses

Background

The National University Hospital, Singapore routinely undertakes standardized Hand Hygiene auditing with results produced by ward and by staff type. In 2010 concern was raised over consistently low compliance by nursing students averaging 45% (95% CI 42%–48%) prompting us to explore novel approaches to educating our next generation of nurses to improve their hand hygiene practice.

We introduced an experiential learning assignment to final year student nurses on attachment to NUH inclusive of hand hygiene auditor training followed by a period of hand hygiene observation. The training was based on the World Health Organisation (WHO) “My 5 moments for hand hygiene” approach. Upon completion students completed an anonymous questionnaire to evaluate their learning experience.

Findings

By 2012, nursing students were 40% (RR: 1.4, 95% CI 1.3–1.5, p<0.001) more likely to comply with hand hygiene practices. 97.5% (359/368) of nursing students felt that the experience would enhance their own hand hygiene practice and would recommend participating in audits as a learning instrument.

Conclusions

With consideration of all stakeholders a sustainable, flexible, programme was implemented. Experiential learning of hand hygiene was a highly valued educational tool and in our project was directly associated with improved hand hygiene compliance. Feedback demonstrated popularity amongst participants and success in achieving its program objectives. While this does not guarantee long term behavioural change it is intuitive that instilling good habits and messages at the early stages of a career will potentially have significant long-term impact.

The global spread of healthcare-associated multidrug-resistant bacteria: a perspective from Asia

Since antibiotics were first used, each new introduced class has been followed by a global wave of emergent resistance, largely originating in Europe and North America where they were first used. Methicillin-resistant Staphylococcus aureus spread from the United Kingdom and North America across Europe and then Asia over more than a decade. Vancomycin-resistant enterococci and Klebsiella pneumoniae carbapenemase-producing K. pneumoniae followed a similar path some 20 years later. Recently however, metallo-β-lactamases have originated in Asia. New Delhi metallo-β-lactamase-1 was found in almost every continent within a year of its emergence in India. Metallo-β-lactamase enzymes are encoded on highly transmissible plasmids that spread rapidly between bacteria, rather than relying on clonal proliferation. Global air travel may have helped facilitate rapid dissemination. As the antibiotic pipeline offers little in the short term, our most important tools against the spread of antibiotic resistant organisms are intensified infection control, surveillance, and antimicrobial stewardship.

Late relapse of non-typhoidal salmonella vascular graft infection after 5 years

Salmonella bacteremia can be complicated by mycotic aneurysm with the potential for a catastrophic presentation. Treatment involves prompt surgery with debridement, extraanatomic bypass, and prolonged antibiotic therapy. Any relapse tends to occur within the 1st year after surgery. We describe a case of Salmonella enteritidis mycotic aneurysm in a 56-year-old man 5 years after the initial presentation, emphasizing the importance of aggressive initial therapy and long-term surveillance.

Confirmed adult dengue deaths in Singapore: 5-year multi-center retrospective study

Background

Dengue re-emerges in Singapore despite decades of effective vector control; the infection predominantly afflicts adults. Severe dengue not fulfilling dengue hemorrhagic fever (DHF) criteria according to World Health Organization (WHO) 1997 guideline was increasingly reported. A new WHO 2009 guideline emphasized warning signs and a wider range of severe dengue manifestations. We aim to evaluate the utility of these two guidelines in confirmed adult dengue fatalities.

Methods

We conducted a multi-center retrospective chart review of all confirmed adult dengue deaths in Singapore from 1 January 2004 to 31 December 2008.

Results

Of 28 adult dengue deaths, median age was 59 years. Male gender comprised 67.9% and co-morbidities existed in 75%. From illness onset, patients presented for admission at a median of 4 days and death occurred at a median of 12 days. Intensive care admission was required in 71.4%. Probable dengue was diagnosed in 32.1% by WHO 1997 criteria and 78.6% by WHO 2009. The earliest warning sign was persistent vomiting at a median of 1.5 days. Hematocrit change ≥20% concurrent with platelet count <20 × 10^9/L was associated with the shortest interval to death at a median of 3 days. Only 35.7% of death cases fulfilled DHF criteria by WHO 1997 versus severe dengue in 100.0% by WHO 2009 criteria. Deaths were due to shock and organ failure. Acute renal impairment occurred in 71.4%, impaired consciousness 57.1% and severe hepatitis 53.6%.

Conclusions

In our adult fatal dengue cohort, WHO 2009 criteria had higher sensitivity in diagnosing probable dengue and severe dengue compared with WHO 1997. As warning signs, persistent vomiting occurred early and hematocrit change ≥20% concurrent with platelet count <20 × 10^9/L preceded death most closely.

Barrett's esophagus, esophageal and esophagogastric junction adenocarcinomas: the role of diet

Identification of modifiable risk factors is an attractive approach to primary prevention of esophageal adenocarcinoma (EAC) and esophagogastric junction adenocarcinoma (EGJAC). We conducted a review of the literature to investigate the association between specific dietary components and the risk of Barrett’s esophagus (BE), EAC and EGJAC, supposing diet might be a risk factor for these tumors. Consumption of meat and high-fat meals has been found positively associated with EAC and EGJAC. An inverse association with increased intake of fruit, vegetables and antioxidants has been reported but this association was not consistent across all studies reviewed. Few studies have examined the association between diet and BE. Additional research is needed to confirm the aforementioned association and clarify the mechanisms by which dietary components affect the risk of developing EAC and EGJAC. Future studies could advance our knowledge by emphasizing prospective designs to reduce recall bias, by using validated dietary intake questionnaires and biological measures and by considering important confounders such as gastro-esophageal reflux disease (GERD) symptoms, tobacco and alcohol use, biometrics, physical activity, and socioeconomic factors.

High-dose cefazolin on consecutive hemodialysis in anuric patients with Staphylococcal bacteremia

Methicillin-sensitive Staphylococcus aureus (MSSA) bacteremia is a leading cause of infection in hemodialysis (HD) patients. Cloxacillin, cefazolin, and vancomycin are the mainstay antimicrobials. Cloxacillin administration leads to frequent drug dosing, longer length of stay (LOS), and higher cost, while resistance and poorer outcomes are associated with vancomycin use. Dosing cefazolin during HD allows for prolonged blood therapeutic levels. We assessed the outcomes and safety of a strategy of treating MSSA bacteremia with 2-3 g cefazolin on HD only. All HD patients with MSSA bacteremia admitted in June-December 2009 at our center and receiving this regime were compared with historical controls who received cloxacillin. Demographic characteristics and outcome measures like mortality, LOS, cost, recrudescence, and adverse drug reactions were assessed. Of 27 consecutive episodes reviewed, 14 and 13 patients received cefazolin and cloxacillin, respectively. Baseline demographics were comparable between the 2 treatment groups. More than one-third of the bacteremia was related to tunneled catheter infection. The 30-day mortality of cloxacillin- and cefazolin-treated patients was 15% and 7%, respectively (P=0.14). Two of the 11 survivors treated with cloxacillin (18%) had recrudescent bacteremia while none was observed in cefazolin-treated survivors. Cefazolin was associated with shorter LOS (10 vs. 20 days, P<0.05) and lower cost (US$8262.00 vs. US$15,367.00, P<0.05). Cefazolin use resulted in 3 idiosyncratic adverse drug reactions. Cefazolin dosed on each HD in MSSA bacteremia leads to earlier discharge and less cost. Larger prospective studies are, however, warranted to fully assess its safety and efficacy.

Cap-assisted endoscopic mucosal resection of large polyps involving the ileocecal valve

Standard endoscopic mucosal resection (EMR) is limited with regard to lesions below or involving the ileocecal valve. We describe the treatment and outcomes when using cap-assisted EMR (EMR-C) to remove large laterally spreading tumors (LSTs) with ileal infiltration in seven patients (median age 74 years). Each LST (median size 40 mm) was successfully resected in one session (median procedure time 50 minutes). Intraprocedural and early bleeding occurred in two patients, and delayed hemorrhage in one. Circumferential resection of the ileum caused asymptomatic strictures in six patients, with regression during follow-up for five. We conclude that the novel EMR-C method is a potentially effective treatment for cecal LST involving the distal ileum. Serious complications such as perforation or symptomatic strictures of the ileocecal valve were not observed and any procedure-related bleeding was easily controlled.

Cost-effectiveness analysis of hospital infection control response to an epidemic respiratory virus threat

Pandemic (H1N1) 2009 can be contained with less expensive measures than some other viruses.

The outbreak of influenza A pandemic (H1N1) 2009 prompted many countries in Asia, previously strongly affected by severe acute respiratory syndrome (SARS), to respond with stringent measures, particularly in preventing outbreaks in hospitals. We studied actual direct costs and cost-effectiveness of different response measures from a hospital perspective in tertiary hospitals in Singapore by simulating outbreaks of SARS, pandemic (H1N1) 2009, and 1918 Spanish influenza. Protection measures targeting only infected patients yielded lowest incremental cost/death averted of $23,000 (US$) for pandemic (H1N1) 2009. Enforced protection in high-risk areas (Yellow Alert) and full protection throughout the hospital (Orange Alert) averted deaths but came at an incremental cost of up to $2.5 million/death averted. SARS and Spanish influenza favored more stringent measures. High case-fatality rates, virulence, and high proportion of atypical manifestations impacted cost-effectiveness the most. A calibrated approach in accordance with viral characteristics and community risks may help refine responses to future epidemics.

Carbapenems and subsequent multiresistant bloodstream infection: does treatment duration matter?

It has been proposed that initial empirical broad-spectrum antibiotic therapy will result in better clinical outcomes and that shorter courses will reduce the 'collateral damage' of promoting antibiotic resistance. There are few data from Intensive Care Units (ICUs) that support this latter conclusion. A prospective observational study was undertaken at the National University Hospital, Singapore, to examine the relationship between duration of carbapenem therapy and subsequent nosocomial multidrug-resistant (MDR) bloodstream infection (BSI). Over a 2-year period, 415 ICU patients receiving empirical carbapenem therapy were prospectively followed. MDR BSI occurred on 35 occasions in 31 patients, comprising 21 carbapenem-resistant Acinetobacter baumannii, 3 carbapenem-resistant Pseudomonas aeruginosa and 11 meticillin-resistant Staphylococcus aureus (MRSA). There was no difference in the duration of carbapenems for those who developed MDR BSI compared with those who did not [median duration 8 days (range 3-23 days) vs. 9 days (range 3-59 days); P=0.78]. On multivariate analysis using the Cox proportional hazard model the hazard ratio was 0.935 (P=0.070). In this cohort of critically ill patients, a shorter duration of carbapenem therapy was not shown to protect against subsequent development of MDR BSI. Strategies that depend primarily on reducing broad-spectrum antibiotic duration may be inadequate in preventing the emergence of MDR organisms.

Adrenal Epinephrine and the Regulation of Pulmonary Surfactant Release in Neonatal Rabbits

Adrenergic mechanisms influence surfactant metabolism; however the nature and importance of catechol-mediated regulation is unclear. We designed experiments to assess the role of endogenous adrenal epinephrine (E) synthesis in neonatal alveolar surfactant release. We administered the experimental adrenal epinephrine synthesis inhibitor SKF 29661 to pregnant rabbits to reduce fetal adrenal E content. Surfactant release was measured as total alveolar phosphatidylcholine (PC) content recovered by a thorough alveolar wash performed on animals sacrificed at birth and at 1 h of age. At a maternal dose of 100 mg/kg/day, SKF 29661 caused a 57% reduction in fetal adrenal E content (p less than .01), which was associated with a 40% reduction in alveolar PC at birth and a 23% reduction in alveolar PC at 1 h of age (p less than .01). Moreover, adrenal E correlated positively with total alveolar PC content (p less than .001). These results suggest that in the neonatal period, the ability of the fetal adrenal gland to synthesize E for secretion plays a role in the regulation of pulmonary surfactant release.

Readiness exercise to combat avian influenza

AIM

To examine the readiness of our hospital for the potential pandemic threat of avian influenza, we developed and implemented simulation case scenarios in our hospital.

METHODS

Two volunteers, who assumed the identity of 'actual' patients, were trained to simulate acute respiratory symptoms following a visit to an avian influenza-affected area, and their identities and locations were kept confidential prior to the readiness exercise. A team of auditors was stationed at high-risk areas to assess adherence to the use of personal protective equipment (PPE) and infection control procedures.

RESULTS

A total of 324 healthcare workers and 84 administrators participated in this hospital-wide exercise. Following disclosure of their symptoms, the 'patients' were masked and isolated in negative-pressure rooms. A quarantine order was enforced on 38 inpatients and 45 healthcare workers who were present in the affected wards at the time of the exercise, which mandated the use of PPE. Although all affected healthcare workers were competent in the use of PPE, we observed breaches in PPE and isolation procedures in eight medical and nursing students, and 10 healthcare attendants. The exercise concluded after H5N1 tests returned negative.

CONCLUSION

We recommend the use of case simulation as an effective means of assessing potential breaches in infection control procedures.

Methicillin-resistant Staphylococcus aureus Control at the National University Hospital, Singapore: A Historical Perspective

Singapore has a sophisticated healthcare system and is an important referral centre for Asia. Like much of the world, methicillin-resistant Staphylococcus aureus (MRSA) is now endemic across its health system. MRSA infection has been associated with considerable attributable mortality, morbidity plus personal and public cost. Nosocomial infections are potentially preventable and need to be considered an unacceptable complication rather than a tolerable byproduct of healthcare. Failure to introduce long-term sustainable infection control initiatives is not an option for responsible clinical leaders and managers. Control of MRSA transmission in Singapore is achievable but we need to accept the challenge and acknowledge that it will take perhaps a decade. It requires implementation of many varied infection control measures to be rolled out sequentially and across all health services. Our ambition, in Singapore, should be for hospitals to achieve an inpatient prevalence of <1% MRSA colonised patients. Identified transmission of MRSA should be regarded as a serious breech. Successful control will require extraordinary collaboration, support, resources, accountability and consistency of effort. Currently, efforts are evolving significantly and today, we have a good opportunity to embark on this difficult journey. Implementing infection control initiatives successfully over the next few years will save lives in the future. Key words: Colonisation, Infection, Infection control

Methicillin-resistant Staphylococcus aureus Control in Singapore – Moving Forward

Singapore has a sophisticated healthcare system and is an important referral centre for Asia. Like much of the world, methicillin-resistant Staphylococcus aureus (MRSA) is now endemic across its health system. MRSA infection has been associated with considerable attributable mortality, morbidity plus personal and public cost. Nosocomial infections are potentially preventable and need to be considered an unacceptable complication rather than a tolerable byproduct of healthcare. Failure to introduce long-term sustainable infection control initiatives is not an option for responsible clinical leaders and managers. Control of MRSA transmission in Singapore is achievable but we need to accept the challenge and acknowledge that it will take perhaps a decade. It requires implementation of many varied infection control measures to be rolled out sequentially and across all health services. Our ambition, in Singapore, should be for hospitals to achieve an inpatient prevalence of <1% MRSA colonised patients. Identified transmission of MRSA should be regarded as a serious breech. Successful control will require extraordinary collaboration, support, resources, accountability and consistency of effort. Currently, efforts are evolving significantly and today, we have a good opportunity to embark on this difficult journey. Implementing infection control initiatives successfully over the next few years will save lives in the future. Key words: Colonisation, Infection, Infection control

Methicillin-resistant Staphylococcus aureus control in Singapore: moving forward

Singapore has a sophisticated healthcare system and is an important referral centre for Asia. Like much of the world, methicillin-resistant Staphylococcus aureus (MRSA) is now endemic across its health system. MRSA infection has been associated with considerable attributable mortality, morbidity plus personal and public cost. Nosocomial infections are potentially preventable and need to be considered an unacceptable complication rather than a tolerable byproduct of healthcare. Failure to introduce long-term sustainable infection control initiatives is not an option for responsible clinical leaders and managers. Control of MRSA transmission in Singapore is achievable but we need to accept the challenge and acknowledge that it will take perhaps a decade. It requires implementation of many varied infection control measures to be rolled out sequentially and across all health services. Our ambition, in Singapore, should be for hospitals to achieve an inpatient prevalence of <1% MRSA colonised patients. Identified transmission of MRSA should be regarded as a serious breech. Successful control will require extraordinary collaboration, support, resources, accountability and consistency of effort. Currently, efforts are evolving significantly and today, we have a good opportunity to embark on this difficult journey. Implementing infection control initiatives successfully over the next few years will save lives in the future.

Dengue management: practical and safe hospital-based outpatient care

Service provision for a population with endemic dengue is difficult because of its variable incidence and its unpredictable clinical course in individuals. We describe a novel hospital-based outpatient dengue management clinic that is sustainable both during and outside epidemic periods. Pre-defined selection criteria based on demographic, clinical and laboratory prognostic factors were applied. In the first five months, this predominantly nurse-operated, protocol-based clinic enrolled 118 adults, or 35% of patients who would have ordinarily received inpatient care. This resulted in 207 bed-days saved without adverse events.

Screening for Vancomycin-resistant Enterococci Using Stools Sent for Clostridium difficile Cytotoxin Assay is Effective: Results of a Survey of 300 Patients in a Large Singapore Teaching Hospital

Introduction: To assess the efficacy of screening stools sent for Clostridium difficile cytotoxin assay (CDTA) for surveillance of vancomycin-resistant enterococci (VRE). Materials and Methods: From April to May 2005, all stools submitted for CDTA were also cultured for VRE using vancomycin containing culture media. Isolates were identified to species level and vancomycin resistance confirmed, followed by polymerase chain reaction (PCR) for detection of vancomycin resistance genes and DNA fingerprinting. Over 2 consecutive days during that period, stool specimens or rectal swabs were also obtained from all patients in high-risk units (haematology, oncology, renal and intensive care). Fifty-one patients in each group were compared in terms of VRE risk factors previously identified. Results and Discussion: The prevalence of VRE in both groups was similar [3/204 (1.5%) in the CDTA arm and 1/97 (1.0%) in the high-risk arm; P = 1.0, Fisher’s exact test]. Prevalence of risk factors for VRE colonisation, including age, duration of hospitalisation, exposure to antibiotics, exposure to surgical procedures, presence of malignancy and diabetes mellitus was similar in both groups (P > 0.05). Only renal failure (P < 0.05) was more common in the high-risk group. All 4 isolates of VRE identified were genetically distinct by variable number tandem repeat (VNTR) typing; 3 were Enterococcus faecium (2 with the vanB gene, 1 with vanA) and one E. faecalis. Conclusion: Less than 2% of our high-risk patients are VRE carriers. In-hospital VRE screening using stools sent for CDTA is a simple, reasonable surrogate for screening individual high-risk patients as the patient risk profile is similar and the yield comparable in a low-prevalence setting. Key words: Antibiotic resistance, Surveillance, Vancomycin-resistant enterococci

Screening for vancomycin-resistant enterococci using stools sent for Clostridium difficile cytotoxin assay is effective: results of a survey of 300 Patients in a large Singapore Teaching Hospital

INTRODUCTION

To assess the efficacy of screening stools sent for Clostridium difficile cytotoxin assay (CDTA) for surveillance of vancomycin-resistant enterococci (VRE).

MATERIALS AND METHODS

From April to May 2005, all stools submitted for CDTA were also cultured for VRE using vancomycin containing culture media. Isolates were identified to species level and vancomycin resistance confirmed, followed by polymerase chain reaction (PCR) for detection of vancomycin resistance genes and DNA fingerprinting. Over 2 consecutive days during that period, stool specimens or rectal swabs were also obtained from all patients in high-risk units (haematology, oncology, renal and intensive care). Fifty-one patients in each group were compared in terms of VRE risk factors previously identified.

RESULTS AND DISCUSSION

The prevalence of VRE in both groups was similar [3/204 (1.5%) in the CDTA arm and 1/97 (1.0%) in the high-risk arm; P = 1.0, Fisher's exact test]. Prevalence of risk factors for VRE colonisation, including age, duration of hospitalisation, exposure to antibiotics, exposure to surgical procedures, presence of malignancy and diabetes mellitus was similar in both groups (P > 0.05). Only renal failure (P < 0.05) was more common in the high-risk group. All 4 isolates of VRE identified were genetically distinct by variable number tandem repeat (VNTR) typing; 3 were Enterococcus faecium (2 with the vanB gene, 1 with vanA) and one E. faecalis.

CONCLUSION

Less than 2% of our high-risk patients are VRE carriers. In-hospital VRE screening using stools sent for CDTA is a simple, reasonable surrogate for screening individual high-risk patients as the patient risk profile is similar and the yield comparable in a low-prevalence setting.

The relationship of 16 underage drinking laws to reductions in underage drinking drivers in fatal crashes in the United States

The minimum legal drinking age 21 (MLDA 21) legislation in the United States (U.S.) has been documented as one of the most effective public health measures adopted in recent times. This study reports on an effort to evaluate and interrelate a basic set of 16 laws directed at younger than age 21 youth that are designed to (a) control the sales of alcohol to youth, (b) prevent possession and consumption of alcohol by youth, and (c) prevent alcohol impaired driving by those younger than age 21. The first objective of this study was to determine whether there was any relationship between the existence and strength of the various underage drinking laws in a State and the percentage of younger than age 21 drivers involved in fatal crashes who were drinking. After controlling for various factors, the only significant finding that emerged was for the existence and strength of the law making it illegal for an underage person to use fake identification ( p <0.016). The second objective was to determine if the enactment of two of the sixteen provisions (possession and purchase laws) was associated with a reduction in the rate of underage drinking driver involvements in fatal crashes. Analysis of variance (ANOVA) showed that there was a national 11.2% reduction ( p <0.05) in the ratio of underage drinking drivers to underage non-drinking drivers in fatal crashes after the possession and purchase laws were adopted in 36 States and the District of Columbia (DC). This suggests that the two mandatory elements of the Federal MLDA 21 law are having the desired effect of reducing underage alcohol-related highway deaths.

Outpatient parenteral antibiotic therapy in Singapore

Outpatient parenteral antibiotic therapy (OPAT) remains in its infancy in Singapore, with the first patients enrolled 4 years ago. Singapore's three largest hospitals, with over 3000 inpatient beds, now have designated and approved OPAT services. This study reviews the demographic, clinical and cost data of all patients enrolled in 2005 to facilitate benchmarking between services in Singapore and abroad and also to identify common needs for further development. In 2005, 225 OPAT enrollments in 208 different patients resulted in 4050 days of OPAT care. Orthopaedic diagnoses constituted 40% of admissions. Vancomycin was the most frequently used antibiotic (34%). The re-admission rate was 8.9%, but complications of OPAT care were only occasionally implicated. An estimated $207,200 was saved by patients despite there being significant financial disincentives to subsidised patients. OPAT is a safe, cost-efficient system that is becoming increasingly accepted in Singapore by patients, clinicians and management. Our three services have evolved independently into very similar practices. There is potential for further innovation, including outreach and carer-delivered dosing. However, major financial disincentives require review.