Control of hospital endemicity of multiple-drug-resistant Acinetobacter baumannii ST457 with directly observed hand hygiene.

An increasing endemicity of multiple-drug-resistant Acinetobacter baumannii (MRAB) ST457 was noted in Hong Kong. The epidemiology, risk factors, and infection control measures to prevent nosocomial transmission of this epidemic clone were analyzed. A total of 5,058 patients cultured positive with A. baumannii between 1 January 2004 and 30 June 2014 were included, of which 297 (5.9 %) had bacteremia. The first case of MRAB bacteremia emerged in 2009, with an incidence that increased from 0.27 (one case) in 2009 to 1.86 (14 cases) per 100,000 patient-days in 2013 (p < 0.001). With the implementation of strict contact precautions and directly observed hand hygiene in conscious patients immediately before receiving meals and medications in July 2013, the incidence of MRAB bacteremia reduced from its peak to 0.77 (one case) per 100,000 patient-days in the first 6 months of 2014 (p < 0.001). Patients from long-term care facilities for the elderly [odds ratio (OR) 18.6, confidence interval (CI) 2.1-162.4, p = 0.008] and history of carbapenem (OR 7.0, CI 1.7-28.0, p = 0.006) and beta-lactam/beta-lactamase use (OR 5.6, CI 1.1-28.7, p = 0.038) 90 days prior to admission were independent risk factors for MRAB bacteremia by logistic regression when compared with carbapenem-susceptible A. baumannii bacteremia.

Use of fluoroquinolones is the single most important risk factor for the high bacterial load in patients with nasal and gastrointestinal colonization by multidrug-resistant Acinetobacter baumannii.

Gastrointestinal colonization by carbapenem-resistant Acinetobacter baumannii (CRAB) and multidrug-resistant Acinetobacter baumannii (MRAB) provides an important reservoir for clinical infections and hospital outbreaks. We conducted a 7-month study in a 3200-bed healthcare network to investigate the prevalence of gastrointestinal colonization of CRAB and MRAB in Hong Kong. Between 1 June and 31 December 2014, a total of 17,760 fecal specimens from 9469 patients were screened. Testing showed that 340 (1.9%) specimens from 224 (2.6%) patients were CRAB-positive, which included 70 (0.39%) MRAB-positive specimens from 54 (0.57%) patients. The presence of wound or ulcer, use of broad-spectrum antibiotics in the preceding 6 months, and residence in elderly homes are independent risk factors for gastrointestinal colonization of CRAB. Quantitative bacterial counts in various body sites (rectal, nasal, axilla, wound, catheterized urine, if available) were performed in 33 (61.1%) of 54 MRAB patients. Ten (30.3%) and 8 (24.2%) patients had high bacterial load (defined as over 3 log10) in rectal and nasal swabs, with a median of 5.04 log10 cfu/ml of rectal swab and 4.89 log10 cfu/ml of nasal swab in saline diluent, respectively. Nine (81.8%) of 11 patients with wounds had high bacterial load in wound swabs, with a median of 5.62 log10 cfu/ml. Use of fluoroquinolones 6 months before admission was the only significant factor associated with high bacterial load in nasal and rectal swabs. With the implementation of directly observed hand hygiene before meals and medications to all conscious hospitalized patients, no hospital outbreaks were observed during our study period.

Containment of Clostridium difficile infection without reduction in antimicrobial use in Hong Kong.

Clostridium difficile ribotype 002 with hypersporulating capacity has been increasingly identified in Hong Kong. Proactive infection control measures are important to prevent the establishment of endemicity of C. difficile ribotype 002. A total of 329 patients with healthcare-associated C. difficile infection (CDI) were recruited in our healthcare network between 1 January 2008 and 30 June 2012 in this study. The incidence rates of healthcare-associated CDI per 10,000 admissions and 10,000 patient-days increased significantly by 15.3 and 17.0%, respectively, per quarter (p < 0.001) from 2008 1Q to 2010 1Q by segmented Poisson regression. With the full implementation of enhanced infection control interventions, there was an immediate significant reduction in both healthcare-associated CDI rates per 10,000 admissions and per 10,000 patient-days by 47% (p < 0.001) in 2010 2Q, followed by a further decline of CDI per 10,000 admissions and CDI per 10,000 patient-days by -19.4 and -19.8% from 2010 2Q to 2012 2Q, respectively (p < 0.001), despite a replacement of hand washing with soap and water by alcohol-based hand rub in the healthcare network. The proportion of C. difficile ribotype 002 was not statistically different (34/177, 19.2% vs. 25/152, 16.4%, p = 0.515), and the consumption of broad-spectrum antibiotics presented as divided daily dose per 1,000 acute bed-day occupancy per quarter remained unchanged (140.9 vs. 152.3) before and after infection control interventions. Our results suggested that the reduction of healthcare-associated CDI was attributable to infection control interventions instead of replacement of ribotypes or reduction in antimicrobial selective pressure.

Air dispersal of multi-drug-resistant organisms including meticillin-resistant Staphylococcus aureus, carbapenem-resistant Acinetobacter baumannii and carbapenemase-producing Enterobacterales in general wards: surveillance culture of air grilles.

BACKGROUND: The environmental surveillance of air grilles in clinical areas has not been systematically analysed. METHODS: Samples were collected from frequently touched items (N = 529), air supply (N = 295) and exhaust (N = 184) grilles in six medical and 11 surgical wards for the cultures of multi-drug-resistant organisms (MDROs): meticillin-resistant Staphylococcus aureus (MRSA), carbapenem-resistant Acinetobacter baumannii (CRAB) and carbapenemase-producing Enterobacterales (CPE), and isolates were selected for whole-genome sequencing (WGS). The contamination rates were correlated with the colonization pressures of the respective MDROs. RESULTS: From 3rd October to 21st November 2023, 9.8% (99/1008) of the samples tested positive, with MRSA (24.2%, 24/99), CRAB (59.6%, 59/99) and CPE (2.0%, 2/99), being the only detected MDROs. The contamination rate in air exhaust grilles (26.6%, 49/184) was significantly higher than in air supply grilles (5.8%, 17/295; P<0.001). The contamination rate of air exhaust grilles with any MDRO in acute medical wards (73.7%, 14/19) was significantly higher than in surgical wards (12.5%, 4/32; P<0.001). However, there was no difference in the contamination rate of air exhaust grilles between those located inside and outside the cohort cubicles for MDROs (27.1%, 13/48 vs 28.8%, 30/104; P=0.823). Nevertheless, the weekly CRAB colonization pressure showed a significant correlation with the overall environmental contamination rate (r = 0.878; 95% confidence interval (CI): 0.136-0.986; P=0.004), as well as with the contamination rate in air supply grilles (r = 0.960; 95% CI: 0.375-0.999; P<0.001) and air exhaust grilles (r = 0.850; 95% CI: 0.401-0.980; P=0.008). WGS demonstrated clonal relatedness of isolates collected from patients and air exhaust grilles. CONCLUSIONS: Air grilles may serve as MDRO reservoirs. Cohort nursing in open cubicles may not completely prevent MDRO transmission through air dispersal, prompting the consideration of future hospital design.

Gut microbiome and symptoms in females with irritable bowel syndrome: a cross-sectional analysis.

Irritable bowel syndrome (IBS), a disorder of gut-brain interaction, is associated with abdominal pain and stool frequency/character alterations that are linked to changes in microbiome composition. We tested whether taxa differentially abundant between females with IBS vs healthy control females (HC) are associated with daily gastrointestinal and psychological symptom severity. Participants (age 18-50 year) completed a 3-day food record and collected a stool sample during the follicular phase. They also completed a 28-day diary rating symptom intensity; analysis focused on the three days after the stool sample collection. 16S rRNA gene sequencing was used for bacterial identification. Taxon abundance was compared between IBS and HC using zero-inflated quantile analysis (ZINQ). We found that females with IBS (n = 67) had greater Bacteroides abundance (q = 0.003) and lower odds of Bifidobacterium presence (q = 0.036) compared to HC (n = 46) after adjusting for age, race, body mass index, fibre intake, and hormonal contraception use. Intestimonas, Oscillibacter, and Phascolarctobacterium were more often present and Christensenellaceae R-7 group, Collinsella, Coprococcus 2, Moryella, Prevotella 9, Ruminococcaceae UCG-002, Ruminococcaceae UCG-005, and Ruminococcaceae UCG-014 were less commonly present in IBS compared to HC. Despite multiple taxon differences in IBS vs HC, we found no significant associations between taxon presence or abundance and average daily symptom severity within the IBS group. This may indicate the need to account for interactions between microbiome, dietary intake, metabolites, and host factors.

Gastrointestinal colonization of meticillin-resistant Staphylococcus aureus: an unrecognized burden upon hospital infection control.

BACKGROUND: Meticillin-resistant Staphylococcus aureus (MRSA) has become endemic in many healthcare settings. AIM: To analyse the incidence, risk factors, outcomes, and genomic relatedness of patients with newly diagnosed gastrointestinal colonization of MRSA. METHODS: Epidemiology and genetic analysis by whole-genome sequencing (WGS) in a hospital network in Hong Kong. FINDINGS: Between October 1st, 2015 and December 31st, 2018, a total of 919 (2.7%) of 34,667 patients had newly diagnosed gastrointestinal MRSA colonization by admission screening. The incidence was 0.67 ± 0.32 per 1000 patient-days per quarter. Including patients with gastrointestinal MRSA colonization, the overall burden of MRSA increased by 59.2%, with an addition of 4727 MRSA patient-days during the study period. Patients referred from residential care home for the elderly, with history of hospitalization in the past six months, and consumption of fluoroquinolones, cephalosporins, and proton-pump inhibitors in the preceding six months were found to be independent risk factors by multivariate analysis in the case-control analysis. The median survival of cases was significantly shorter than that of controls (860 vs 1507 days, P < 0.001). Of 919 patients, 127 (13.8%) developed symptomatic MRSA infection in a median of 112 days. Of 19 patients with paired MRSA faecal and blood culture isolates subjected to WGS, clonality was found in 16 (84.2%) pairs of MRSA isolates. MRSA ST45 constituted 44.7% (17/38) of MRSA isolates. CONCLUSION: Gastrointestinal MRSA colonization may contribute to adverse clinical outcomes and pose an unrecognized burden upon hospital infection control.

Air dispersal of meticillin-resistant Staphylococcus aureus in residential care homes for the elderly: implications for transmission during the COVID-19 pandemic.

BACKGROUND: Meticillin-resistant Staphylococcus aureus (MRSA) infections are rampant in hospitals and residential care homes for the elderly (RCHEs). AIM: To analyse the prevalence of MRSA colonization among residents and staff, and degree of environmental contamination and air dispersal of MRSA in RCHEs. METHODS: Epidemiological and genetic analysis by whole-genome sequencing (WGS) in 12 RCHEs in Hong Kong. FINDINGS: During the COVID-19 pandemic (from September to October 2021), 48.7% (380/781) of RCHE residents were found to harbour MRSA at any body site, and 8.5% (8/213) of staff were nasal MRSA carriers. Among 239 environmental samples, MRSA was found in 39.0% (16/41) of randomly selected resident rooms and 31.3% (62/198) of common areas. The common areas accessible by residents had significantly higher MRSA contamination rates than those that were not accessible by residents (37.2%, 46/121 vs. 22.1%, 17/177, P=0.028). Of 124 air samples, nine (7.3%) were MRSA-positive from four RCHEs. Air dispersal of MRSA was significantly associated with operating indoor fans in RCHEs (100%, 4/4 vs. 0%, 0/8, P=0.002). WGS of MRSA isolates collected from residents, staff and environmental and air samples showed that ST 1047 (CC1) lineage 1 constituted 43.1% (66/153) of all MRSA isolates. A distinctive predominant genetic lineage of MRSA in each RCHE was observed, suggestive of intra-RCHE transmission rather than clonal acquisition from the catchment hospital. CONCLUSION: MRSA control in RCHEs is no less important than in hospitals. Air dispersal of MRSA may be an important mechanism of dissemination in RCHEs with operating indoor fans.

Air dispersal of multidrug-resistant Acinetobacter baumannii: implications for nosocomial transmission during the COVID-19 pandemic.

AIM: To describe the nosocomial transmission of Air, multidrug-resistant, Acinetobacter baumannii, nosocomial, COVID-19 Acinetobacter baumannii (MRAB) in an open-cubicle neurology ward with low ceiling height, where MRAB isolates collected from air, commonly shared items, non-reachable high-level surfaces and patients were analysed epidemiologically and genetically by whole-genome sequencing. This is the first study to understand the genetic relatedness of air, environmental and clinical isolates of MRAB in the outbreak setting. FINDINGS: Of 11 highly care-dependent patients with 363 MRAB colonization days during COVID-19 pandemic, 10 (90.9%) and nine (81.8%) had cutaneous and gastrointestinal colonization, respectively. Of 160 environmental and air samples, 31 (19.4%) were MRAB-positive. The proportion of MRAB-contaminated commonly shared items was significantly lower in cohort than in non-cohort patient care (0/10, 0% vs 12/18, 66.7%; P<0.001). Air dispersal of MRAB was consistently detected during but not before diaper change in the cohort cubicle by 25-min air sampling (4/4,100% vs 0/4, 0%; P=0.029). The settle plate method revealed MRAB in two samples during diaper change. The proportion of MRAB-contaminated exhaust air grills was significantly higher when the cohort cubicle was occupied by six MRAB patients than when fewer than six patients were cared for in the cubicle (5/9, 55.6% vs 0/18, 0%; P=0.002). The proportion of MRAB-contaminated non-reachable high-level surfaces was also significantly higher when there were three or more MRAB patients in the cohort cubicle (8/31, 25.8% vs 0/24, 0%; P=0.016). Whole-genome sequencing revealed clonality of air, environment, and patients' isolates, suggestive of air dispersal of MRAB. CONCLUSIONS: Our findings support the view that patient cohorting in enclosed cubicles with partitions and a closed door is preferred if single rooms are not available.

Methimazole-induced antineutrophil cytoplasmic antibody-associated diffuse alveolar haemorrhage in a Chinese woman with Graves' disease.

We report on a case of diffuse alveolar haemorrhage in a Chinese woman due to methimazole-induced antineutrophil cytoplasmic antibodies. A literature search for anti-thyroid drugs associated with antineutrophil cytoplasmic antibody-induced diffuse alveolar haemorrhages is reviewed. Diffuse alveolar haemorrhage is a rare complication of thiourea agents and the treatment often requires corticosteroids or other immunosuppressants, together with withdrawal of the causative agent.

Hand-touch contact assessment of high-touch and mutual-touch surfaces among healthcare workers, patients, and visitors.

BACKGROUND: Unlike direct contact with patients' body, hand hygiene practice is often neglected by healthcare workers (HCWs) and visitors after contact with patients' environment. Contact with hospital environmental items may increase risk of pathogen transmission. AIM: To enumerate the number of hand-touch contacts by patients, HCWs and visitors with any hospital environmental items. METHODS: All contact-episodes between person and item were recorded by direct observation in a six-bed cubicle of acute wards for 33 working days. High-touch and mutual-touch items with high contact frequencies by HCWs, patients, and visitors were analysed. FINDINGS: In total, 1107 person-episodes with 6144 contact-episodes were observed in 66 observation hours (average: 16.8 person-episodes and 93.1 contact-episodes per hour). Eight of the top 10 high-touch items, including bedside rails, bedside tables, patients' bodies, patients' files, linen, bed curtains, bed frames, and lockers were mutually touched by HCWs, patients, and visitors. Bedside rails topped the list with 13.6 contact-episodes per hour (mean), followed by bedside tables (12.3 contact-episodes per hour). Using patients' body contacts as a reference, it was found that medical staff and nursing staff contacted bedside tables [rate ratio (RR): 1.741, 1.427, respectively] and patients' files (RR: 1.358, 1.324, respectively) more than patients' bodies, and nursing staff also contacted bedside rails (RR: 1.490) more than patients' bodies. CONCLUSION: Patients' surroundings may be links in the transmission of nosocomial infections because many are frequently touched and mutually contacted by HCWs, patients, and visitors. Therefore, the focus of hand hygiene education, environmental disinfection, and other system changes should be enhanced with respect to high-touch and mutual-touch items.

Pulmonary scar cancer. A pathologic reappraisal.

A total of 49 consecutive specimens of lung cancer were collected prospectively at surgical resection or autopsy from 40 men and nine women, aged 40-74 years. Of the 49 tumors, the gross appearance of 22 fitted the description of a scar cancer, i.e., a tumor with pleural puckering and central pigmentation. Nineteen of the "scar cancers" were peripheral (17 adenocarcinomas and two squamous cell carcinomas); three were central (one squamous cell carcinoma and two adenocarcinomas). In the 19 peripheral "scar cancers," elastic stains demonstrated the presence of collapsed, unfibrosed lung tissue at the center with traction of the overlying pleura toward it. Elsewhere in the tumor, the elastic framework was either destroyed or expanded by tumor filling the alveolar spaces. None of the "scar cancers" had a significant desmoplastic reaction that might otherwise explain the scarred appearance. It appeared that local atelectasis was solely responsible for the pleural puckering and central pigmentation. On the other hand, atelectatic lung tissue was not seen in the 27 cancers that did not have the appearance of a scar cancer. Tuberculosis was found in 10 of the 49 lung specimens. In only one specimen was the tuberculous lesion anatomically associated with the tumor. There was no evidence of pulmonary infarct in any of the specimens. The term "scar cancer" was considered inappropriate as there was no preformed fibrous tissue. The scarred appearance was thought to be the result of localized pulmonary atelectasis owing to small airways obstruction by tumor. Association with tuberculosis was considered incidental.

Bronchorrhea. A presenting feature of active endobronchial tuberculosis.

A 32-year-old woman presented with a one-month history of bronchorrhea (500 ml daily). She had normal findings on chest roentgenogram, and negative results for malignant cells and acid-fast bacilli in the sputum. Fiberoptic bronchoscopic examination, however, showed subtotal obliteration of left main bronchus due to active tuberculosis. The protean manifestations of endobronchial tuberculosis and its association with bronchorrhea are stressed.

Endobronchial tuberculosis revisited.

Analysis was made of 20 patients with endobronchial tuberculosis proven by fiberoptic bronchoscopy and bronchial biopsy. Unlike prechemotherapy reports, the disease affects the older age group and more men. Only one half of the patients had fever, and the characteristic localized wheeze was found in 15 percent of cases. Chest roentgenogram showed typical collapse-consolidation in most cases; however, it was clear in 20 percent of patients. Sputum/smear was negative for AFB in 85 percent of patients. When the gelatinous granulation tissue was not found during bronchoscopy, a diagnosis of bronchogenic carcinoma was made incorrectly in 30 percent of patients. At a mean period of 27 months postchemotherapy, all 12 patients recalled for study developed bronchostenosis proven by bronchoscopy/bronchography except one. Noninvasive methods such as chest roentgenogram and flow-volume loops were insensitive for detection of stenosis. Steroid therapy probably did not influence outcome of tuberculous endobronchitis.

Unusual rib destruction in pleuropulmonary tuberculosis.

Two cases of pleuropulmonary tuberculosis had local rib destruction simulating malignancy. There was no superficial abscess formation which was the usual clinical feature of rib tuberculosis. Computerized tomography was valuable in demonstrating and assessing the extent of skeletal involvement.

High incidence of pulmonary tuberculosis in the non-HIV infected immunocompromised patients in Hong Kong.

In areas where tuberculosis is endemic, clinicians managing immunocompromised patients (ICP) are confronted with the possibility of Mycobacterium tuberculosis as a pathogen. To determine the incidence and clinical pattern of, the diagnostic approach to, and potential therapeutic implications of pulmonary tuberculosis in this patient population, we reviewed 62 non-HIV infected ICP in Hong Kong who had bronchoscopy because of pulmonary infiltrates. Pulmonary tuberculosis was the second most common cause after bacterial infections. Clinical and radiographic presentations of 12 patients with tuberculosis were nonspecific. Flexible bronchoscopy for tuberculosis carried a diagnostic sensitivity of 91.7 percent. We conclude that for the non-HIV infected ICP from areas where tuberculosis is endemic: M tuberculosis should be suspected as the pathogen; radiographic findings are diagnostically not helpful; FB is a sensitive diagnostic test for tuberculosis and in smear-negative cases where tuberculosis is suspected, initiation of empiric anti-tuberculosis therapy should be considered while awaiting culture results.

Blue bodies in cytology specimens in a case of pulmonary talcosis.

Unusual extracellular birefringent laminated ovoid structures are seen in bronchial brushing, aspiration, and washing specimens in a 28-year-old woman who had histologic evidence of pulmonary talcosis. Energy dispersive x-ray analysis and microchemical studies have identified them to be calcium carbonate. These structures are known as pulmonary blue bodies and are seen mainly in histologic paraffin sections. Their occurrence in cytologic preparations and association with talcosis have not been reported.

Cyclic combination chemotherapy in advanced adenocarcinoma of the lung: comparison of two FAM schedules.

Forty patients with advanced adenocarcinoma of the lung were treated by two FAM chemotherapy schedules. Group A (20 patients) received Futraful, adriamycin, and mitomycin C, and group B (20 patients) received 5-fluorouracil, adriamycin, and mitomycin C. The response/stabilization rate was greater for group B (4 partial responses + 4 cases of stable disease) than for group A (no responders + 5 cases of stable disease), and the median survival was longer for group B (32 weeks) than for group A (22 weeks), although the differences did not reach statistical significance in either case (P greater than 0.05). Myelotoxicity was mild in both schedules. Further studies of the two FAM schemes at an escalated dose would be worthwhile.

5-fluorouracil, adriamycin, and mitomycin-C (FAM) chemotherapy in advanced adenocarcinoma of the lung: comparison of two dosage schedules.

Fifty patients with inoperable adenocarcinoma of the lung were randomized in a prospective study to receive either standard doses or high doses of 5-fluorouracil, adriamycin, and mitomycin-C (FAM versus Hi-FAM). The response/stabilization rate was 32% for FAM and 34% for Hi-FAM (P greater than 0.05), and the median survival was 27 weeks for FAM group and 24 weeks for Hi-FAM group (P greater than 0.05). Myelotoxicity was mild in FAM, but moderate to severe in Hi-FAM. It is concluded that Hi-FAM did not yield a higher response rate or median survival compared with FAM, but caused significantly more severe myelotoxicity.

Chronic sinopulmonary disease in Chinese patients with obstructive azoospermia.

The prevalence of chronic infections of the nasal sinuses and the lung (chronic sinopulmonary disease) was investigated in 33 Chinese patients with obstructive azoospermia who were compared with 32 patients with azoospermia due to failure of the germinal epithelium. Ten out of the group of 33 patients with obstructive azoospermia had congenital absence of the vas and/or epididymis and were excluded from that group. The patients with obstructive azoospermia had normal testis size, normal levels of serum FSH and LH, lower seminal fluid fructose, and a higher incidence of serum sperm agglutinating and immobilizing antibodies when compared with the group with damage to the germinal epithelium. The number of patients with symptoms of chronic sinopulmonary infections were similar in all groups. One patient with obstructive azoospermia had bronchiectasis. All other patients had normal chest x-ray studies. About 40% of the patients in all three groups had abnormal sinus X-rays. However, the nonsmoking patients with obstructive azoospermia had a statistically significant (P less than 0.05) lower mid-expiratory flow rate than the nonsmoking patients with nonobstructive azoospermia. Only three additional patients with obstructive azoospermia had both abnormal sinus x-ray and a reduced mid-expiratory flow rate, suggestive of Young's syndrome. It was concluded that Young's syndrome (sinopulmonary infections associated with acquired obstructive azoospermia) is much less common in Chinese men (four out of 23, 17%) and their sinopulmonary problems are less severe than in Caucasians.

Melioidosis: a serological survey in a tuberculosis sanatorium in Hong Kong.

A serological survey of 275 Chinese patients with underlying pulmonary diseases in a tuberculosis sanatorium in Hong Kong showed that 39 (14%) had haemagglutinating antibody (HA) against Pseudomonas pseudomallei in a titre of 1: 80 or above. Only 9 of these 39 patients had travelled to endemic areas, suggesting that at least 30 patients (11%) had been exposed to Ps. pseudomallei locally. Females are affected as often as males, and the seropositive rate is the same whether patients are immunosuppressed or not. Because subclinical melioidosis is prevalent and HA may persist for a long time, even at a high titre, after infection, determination of HA alone cannot differentiate between active melioidosis and its masquerade--active tuberculosis.