The effectiveness of a dedicated central venous access care team to prevent catheter-related bloodstream infection in a private hospital.

Objective: We hypothesized a dedicated team would decrease catheter-related bloodstream infection (CRBSI) rates. Method: We implemented a before-after study. Results: CRBSI frequency (39/103 vs. 28/105, P=0.084) and incidence (36.61/1000 vs. 26.1/1000 catheter-days, P=0.175) were lower in the intervention arm. Conclusion: The intervention delayed median time to CRBSI, but was insufficient to decrease overall rates.

Bacterial coinfection and antimicrobial use among patients with COVID-19 infection in a referral center in the Philippines: A retrospective cohort study.

Objective: This study aimed to describe community-acquired bacterial coinfection (CAI) and antimicrobial use among COVID-19 patients. Methods: Electronic records were retrospectively reviewed, and clinical data, laboratory data, antibiotic use, and outcomes of patients with and without CAI were compared. Results: Of 1116 patients, 55.1% received antibiotics within 48 hours, but only 66 (5.9%) had documented CAI, mainly respiratory (40/66, 60.6%). Patients with CAI were more likely to present with myalgia (p = 0.02), nausea/vomiting (p = 0.014), altered sensorium (p = 0.007), have a qSOFA ≥ 2 (p = 0.016), or require vasopressor support (p < 0.0001). Patients with CAI also had higher median WBC count (10 vs 7.6 cells/mm3), and higher levels of procalcitonin (0.55 vs 0.13, p = 0.0003) and ferritin (872 vs 550, p = 0.028). Blood cultures were drawn for almost half of the patients (519, 46.5%) but were positive in only a few cases (30/519, 5.8%). Prescribing frequency was highest at the start and declined only slightly over time. The mortality of those with CAI (48.5%) was higher compared with those without CAI (14.3%). Conclusion: Overall CAI rate was low (5.9%) and antimicrobial use disproportionately high (55.0%), varying little over time. The mortality rate of coinfected patients was high. Certain parameters can be used to better identify those with CAI and those who need blood cultures.

A retrospective review of infections and outcomes within 100 days of hematopoietic stem cell transplantation: insights from a new transplant program in the Philippines.

Background: Few hematopoietic stem cell transplantations (HSCT) are performed in lower-middle income countries. Only four institutions in the Philippines are able to perform transplants. This study describes the experience of a newly established program. Methods: The charts of all adult patients who underwent HSCT at The Medical City from May 1, 2016 to December 31, 2019 were reviewed retrospectively. Results: A total of 33 patients were included in the cohort, of whom 31 (93.9%) underwent autologous HSCT and only two (6.1%) underwent allogeneic HSCT. Most were female (21/33, 63%), and median age was 51 years (range 21-67 years). The primary indication for transplantation was multiple myeloma (n = 21), followed by diffuse B-cell lymphoma (n = 6). Fifteen of the 33 patients had a history of treated tuberculosis (TB) disease (n = 4) or latent TB infection (n = 11). The median time for neutrophil recovery was 7.4 days (range 4-13 days). Transplant complications included neutropenic fever (n = 33, 100%) and mucositis (n = 14, 42.4%). Bacterial infection was documented in 12 (36.4%) patients, with nine (24.2%) developing a bacterial blood stream infection of which seven were related to a central line. The overall mortality rate was at 6.1% (2/33) in the first 30 days post-transplant, with no additional mortality in the succeeding days until day 100. Conclusions: This cohort with mostly autologous HSCT had favorable outcomes in the first 100 days. Rates of bacterial infection were high in the early post-transplant period. Latent TB infection was common, but no reactivation was observed. Longer-term follow-up of patients is needed to determine late post-transplant complications and outcomes.

Prevalent subtypes and one-year outcomes of an HIV-cohort from an urban Philippine center.

ABSTRACT: Circulating HIV subtypes in the Philippines have increasingly diversified, potentially affecting treatment. We monitored outcomes of a treatment-naïve cohort and their virus subtype prevalence.Retrospective/prospective study cohort.HIV-I-REACT clinic patients co-enrolled in the Virology Quality Assurance Program (RUSH-VQA) from 7/2017-6/2019 were included. Relevant demographic and laboratory information were collected. The ViroSeq HIV-1 Genotyping System v.3 and HIV-1 Integrase Genotyping Kit identified protease-reverse transcriptase and integrase drug resistance mutations (DRM). Sequence subtyping followed using the Stanford University Drug Resistance Database and the REGA HIV-1 Subtyping Tool v.3. The jpHMM HIV-1 Tool and REGA HIV-1 Subtyping Tool provided additional subtype analysis of this cohort's 5'LTR-VIF regions after Sanger sequencing. One-year outcomes included virologic suppression, mortality, and follow-up.86/88 patients were males. Median age was 30 (range 19-65) years; 61/88 were MSM. 15/85 carried baseline DRM. ViroSeq-generated sequences included subtypes CRF01_AE (66/85), B (14/85), and newer recombinants (4/85). Extensive sequencing (n = 71) of the 5'-LTR-GAG-Pol genes showed CRF01_AE (n = 50), subtype B (n = 7), and other recombinants (n = 13). Bootstrap analysis identified 7 pairs of highly related strains. Discordant DRM appeared in 2/7 pairs, where 1/2 strains displayed DRM. After 1 year, 87 individuals were alive, with 19 lost to care. Viral load (VL) was repeated for only 31/77 (40.2%). Follow-up CD4 testing for 39/77 (50.6%) showed an increase to a median of 327 cells/mm3.Our cohort currently carries subtype CRF01_AE (∼68%-70%), followed by subtype B and CRF01_AE/B recombinants. Outcomes were favorable, regardless of subtype after 1 year on cART.

Early experience with COVID-19 patients in a private tertiary hospital in the Philippines: Implications on surge capacity, healthcare systems response, and clinical care.

BACKGROUND: Our healthcare institution was one of the first to see SARS CoV-2 cases in the country. We describe the early COVID-19 experience of a private hospital in the Philippines and discuss the healthcare system response in the setting of surge capacity. METHODS: We reviewed the medical records of adult COVID-19 hospitalized patients admitted in March 2020. We reported their demographic and clinical characteristics using descriptive statistics. RESULTS: Of 40 patients admitted, 23 (57.5%) were male and 19 (47.5%) were aged <60 years. Most (n = 27, 67.5%) had moderate-risk, 9 (22.5%) had high-risk, and 4 (10%) had low-risk COVID-19. SARS-CoV-2 testing took 5.5 (range 1-10) days. Overall mortality rate was 6/40 (15.0%). Clinical cure was documented in all low-risk patients, 25 (92.6%) moderate-risk patients, and only 1 (11.1%) high-risk patient. In response to the surge, the hospital rapidly introduced one-way traffic systems, dedicated screening, triage and Emergency Department areas for COVID-19, a clinical pathway, engineering controls, patient cohorting, and strict infection prevention and control measures. CONCLUSION: Majority of patients recovered from COVID-19. Older age and high-risk pneumonia were associated with poor outcomes. Adaptations to hospital structure and staff were quickly made in response to surge capacity, although our response was hampered by prolonged time to COVID-19 confirmation. Our study underscores the urgent need for rapid adaptive response by the healthcare system to address the surge of cases.

A systematic review of the effectiveness of cohorting to reduce transmission of healthcare-associated C. difficile and multidrug-resistant organisms.

BACKGROUND: Cohorting of patients and staff is a control strategy often used to prevent the spread of infection in healthcare institutions. However, a comprehensive evaluation of cohorting as a prevention approach is lacking. METHODS: We performed a systematic review of studies that used cohorting as part of an infection control strategy to reduce hospital-acquired infections. We included studies published between 1966 and November 30, 2019, on adult populations hospitalized in acute-care hospitals. RESULTS: In total, 87 studies met inclusion criteria. Study types were quasi-experimental "before and after" (n = 35), retrospective (n = 49), and prospective (n = 3). Case-control analysis was performed in 7 studies. Cohorting was performed with other infection control strategies in the setting of methicillin-resistant Staphylococcus aureus (MRSA, n = 22), Clostridioides difficile infection (CDI, n = 6), vancomycin-resistant Enterococcus (VRE, n = 17), carbapenem-resistant Enterobacteriaceae infections (CRE, n = 22), A. baumannii (n = 15), and other gram-negative infections (n = 5). Cohorting was performed either simultaneously (56 of 87, 64.4%) or in phases (31 of 87, 35.6%) to help contain transmission. In 60 studies, both patients and staff were cohorted. Most studies (77 of 87, 88.5%) showed a decline in infection or colonization rates after a multifaceted approach that included cohorting as part of the intervention bundle. Hand hygiene compliance improved in approximately half of the studies (8 of 15) during the respective intervention. CONCLUSION: Cohorting of staff, patients, or both is a frequently used and reasonable component of an enhanced infection control strategy. However, determining the effectiveness of cohorting as a strategy to reduce transmission of MDRO and C. difficile infections is difficult, particularly in endemic situations.

Prevention and treatment of tuberculosis in solid organ transplant recipients.

Introduction: Tuberculosis (TB) in solid organ transplant (SOT) recipients is associated with significant morbidity and mortality. Its management in transplant recipients is difficult and highly complex, given the underlying immunosuppression and the risks of drug-drug interactions imposed by immunosuppressive drugs that are needed to maintain the transplant allograft.Areas covered: We provide a brief review of TB in SOT and discuss the clinical indications, mechanisms of action and drug resistance, drug-drug interactions, and adverse effects of anti-TB drugs. We provide a summary of recent clinical trials, which serve as the foundation for current recommendations. We further include relevant updates on new agents being evaluated for clinical use in TB management.Expert commentary: TB causes significant morbidity in SOT recipients. The drugs used in the treatment for latent TB and active disease in SOT are similar to the regimens used in the general population. However, TB disease in transplant recipients is more difficult to manage because of the potential for hepatotoxicity and the complex drug-drug interactions with immunosuppressive drugs. We believe that alternative regimens suited for the vulnerable transplant population, and more therapeutic drug options are needed given the adverse toxicities associated with currently approved anti-TB drugs.

Evaluating carbapenem restriction practices at a private hospital in Manila, Philippines as a strategy for antimicrobial stewardship.

BACKGROUND: Hospital antimicrobial stewardship programs are especially critical in countries such as the Philippines, where antibiotic resistant infections are highly prevalent. At the study institution in Manila, Philippines, a Prior Approval for Restricted Antimicrobials (PARA) is required for non-infectious disease specialists to prescribe certain antimicrobials, including carbapenems. PARA request forms include specification of empiric or definitive therapy based on diagnostic tests. Recommended duration of therapy is typically 3 days for empiric use and 7 days for definitive, with possible extension upon specialist approval. METHODS: The study took place at an 800-bed tertiary hospital. We performed a retrospective review of patient medical records and laboratory reports dating from January 1 to December 31, 2016. Information related to patient demographics, carbapenem prescription, laboratory diagnosis, and therapy were compiled. Carbapenem prescriptions were classified as 'adherent' or 'non-adherent' according to clinical guidelines related to infection diagnosis, treatment duration, and de-escalation. RESULTS: Of the 185 patients on carbapenem therapy, Prescriptions of carbapenems were either definitive (n = 56), empiric (n = 127), or prophylactic (n = 2) as defined by the ordering provider. 69 out of 185 (37%) prescriptions were deemed non-adherent to guidelines, despite receiving approvals for their respective requests. Of these, 72% were non-adherent due to failure to de-escalate the carbapenem and 28% were non-adherent due to an incomplete course of therapy. CONCLUSION: Despite initial PARA approval for carbapenem therapy, 37% of prescriptions were non-guideline-adherent, highlighting the ongoing challenges in implementing this type of stewardship strategy. In order to increase the effectiveness of PARA, additional approaches may be warranted, including the application of strict policies which reinforce follow-up of available culture results, justification of therapy extension, or referral to an infectious disease specialist.

Donor derived Mycobacterium tuberculosis infection after solid-organ transplantation: A comprehensive review.

BACKGROUND: Mycobacterium tuberculosis may be transmitted via the allograft to cause a morbid and potentially fatal infection after solid organ transplantation (SOT). We reviewed all reported cases of donor-derived tuberculosis (DDTB) to provide an update on its epidemiology, clinical course, and outcome after SOT. METHODS: MEDLINE, OVID, and EMBASE were reviewed from its inception until December 31, 2016 using key words donor-derived infection, tuberculosis and solid organ transplant or transplantation. RESULTS: We retrieved 36 cases of proven (n = 17), probable (n = 8), and possible (n = 11) DDTB among 16 lung, 13 kidney, 6 liver, and 1 heart recipients. Most patients were male (21/35, 60%) with median age of 48 (range 23-68) years. Median time to clinical presentation or diagnosis was 2.7 months (range 0.2-29). The most common donor risk factor was residence in a TB-endemic area (13/28, 46.4%). Fever was the most frequent presenting symptom (20/36, 56.5%). Diagnosis of tuberculosis was mostly made via AFB smear or mycobacterial culture (30/36, 83.3%). Allograft involvement was expectedly common; there were almost equal proportions of pulmonary (36%), extra-pulmonary (28%) and disseminated (36%) cases. All cases of pulmonary TB were identified only among lung transplant recipients. The median duration of TB treatment was 10.5 (range 3-24) months. Graft loss occurred in four (4/22, 18.2%) patients. All-cause mortality was 25% (9/36); four of nine deaths were attributed to TB. CONCLUSIONS: Donor-derived TB presents early after SOT, most commonly as fever, and carries a high mortality risk. Donors should be screened, with particular attention to TB risk factors. Fever during the early post-operative period should prompt a thorough evaluation for DDTB in endemic regions and among patients with "at-risk" donors.

Infection control at an urban hospital in Manila, Philippines: a systems engineering assessment of barriers and facilitators.

BACKGROUND: Healthcare facilities in low- and middle-income countries, including the Philippines, face substantial challenges in achieving effective infection control. Early stages of interventions should include efforts to understand perceptions held by healthcare workers who participate in infection control programs. METHODS: We performed a qualitative study to examine facilitators and barriers to infection control at an 800-bed, private, tertiary hospital in Manila, Philippines. Semi-structured interviews were conducted with 22 nurses, physicians, and clinical pharmacists using a guide based on the Systems Engineering Initiative for Patient Safety (SEIPS). Major facilitators and barriers to infection control were reported for each SEIPS factor: person, organization, tasks, physical environment, and technology and tools. RESULTS: Primary facilitators included a robust, long-standing infection control committee, a dedicated infection control nursing staff, and innovative electronic hand hygiene surveillance technology. Barriers included suboptimal dissemination of hand hygiene compliance data, high nursing turnover, clinical time constraints, and resource limitations that restricted equipment purchasing. CONCLUSIONS: The identified facilitators and barriers may be used to prioritize possible opportunities for infection control interventions. A systems engineering approach is useful for conducting a comprehensive work system analysis, and maximizing resources to overcome known barriers to infection control in heavily resource-constrained settings.

Probiotics for Treatment and Prevention of Urogenital Infections in Women: A Systematic Review.

INTRODUCTION: Probiotics are a complementary and integrative therapy useful in the treatment and prevention of urogenital infections in women. This study extends the work of researchers who systematically investigated the scientific literature on probiotics to prevent or treat urogenital infections. METHODS: A systematic review was conducted to determine the efficacy of probiotics for prevention and/or treatment of urogenital infections in adult women from January 1, 2008, through June 30, 2015. We searched in CINAHL, MEDLINE, Cochrane Central Register of Controlled Trials, Web of Science, Dissertations and Theses, and Alt-HealthWatch. After removing duplicates and studies that did not meet inclusion criteria, 20 studies were reviewed. All included at least one species of Lactobacillus probiotic as an intervention for treatment or prevention of urogenital infections. Data extracted included samples, settings, study designs, intervention types, reported outcomes, follow-up periods, and results. We evaluated all randomized controlled trials for risk of bias and made quality appraisals on all studies. RESULTS: Fourteen of the studies focused on bacterial vaginosis (BV), 3 on urinary tract infections (UTIs), 2 on vulvovaginal candidiasis, and one on human papillomavirus (HPV) as identified on Papanicolaou test. Studies were heterogeneous in terms of design, intervention, and outcomes. Four studies were of good quality, 9 of fair, and 7 poor. Probiotic interventions were effective for treatment and prevention of BV, prevention of recurrences of candidiasis and UTIs, and clearing HPV lesions. No study reported significant adverse events related to the probiotic intervention. DISCUSSION: The quality of the studies in this systematic review varied. Although clinical practice recommendations were limited by the strength of evidence, probiotic interventions were effective in treatment and prevention of urogenital infections as alternatives or co-treatments. More good quality research is needed to strengthen the body of evidence needed for application by clinicians.

Non-tuberculous mycobacterial infections in solid organ transplant recipients: An update.

Non-tuberculous mycobacteria are ubiquitous environmental organisms that are now increasingly recognized as important causes of clinical disease in solid organ transplant recipients. Risk factors of non-tuberculous mycobacteria infection are severe immunologic defects and structural abnormalities. Lung transplant recipients are at higher risk for non-tuberculous mycobacterial disease compared to recipients of other solid organs. The clinical presentation could be skin and soft tissue infection, osteoarticular disease, pleuropulmonary infection, bloodstream (including catheter-associated) infection, lymphadenitis, and disseminated or multi-organ disease. Management of non-tuberculous mycobacteria infection is complex due to the prolonged treatment course with multi-drug regimens that are anticipated to interact with immunosuppressive medications. This review article provides an update on infections due to non-tuberculous mycobacteria after solid organ transplantation, and discusses the epidemiology, risk factors, clinical presentation, and management.

Antimicrobial therapy of sepsis and septic shock--when are two drugs better than one?

In clinical practice, physicians frequently use combination therapy despite the conflicting evidence for its effectiveness. The results of recent studies have contributed to our understanding of this important issue. In this article, we examine the evidence for, or against, the use of combination drug therapy compared with monotherapy in the management of serious infections, sepsis, and septic shock.

Diagnostic accuracy of the physical examination and imaging tests for osteomyelitis underlying diabetic foot ulcers: meta-analysis.

Accurate diagnosis of osteomyelitis underlying diabetic foot ulcers is essential to optimize outcomes. We undertook a meta-analysis of the accuracy of diagnostic tests for osteomyelitis in diabetic patients with foot ulcers. Pooled sensitivity and specificity, the summary measure of accuracy (Q*), and diagnostic odds ratio were calculated. Exposed bone or probe-to-bone test had a sensitivity of 0.60 and a specificity of 0.91. Plain radiography had a sensitivity of 0.54 and a specificity of 0.68. MRI had a sensitivity of 0.90 and a specificity of 0.79. Bone scan was found to have a sensitivity of 0.81 and a specificity of 0.28. Leukocyte scan was found to have a sensitivity of 0.74 and a specificity of 0.68. The diagnostic odds ratios for clinical examination, radiography, MRI, bone scan, and leukocyte scan were 49.45, 2.84, 24.36, 2.10, and 10.07, respectively. The presence of exposed bone or a positive probe-to-bone test result is moderately predictive of osteomyelitis. MRI is the most accurate imaging test for diagnosis of osteomyelitis.