Burden, risk factors, and outcomes of multidrug-resistant bacterial colonisation at multiple sites in patients with cirrhosis.

Background & Aims: The reported burden of multidrug-resistant organism (MDRO) infections is highest in patients with cirrhosis from India. We evaluated whether colonisation at multiple barriers predisposes to such infections and poor outcomes in patients with cirrhosis. Methods: We prospectively performed swab cultures, antimicrobial susceptibility testing (AST), and genotype testing for MDROs from various sites (rectum, nose, composite-skin, and central-line) in patients with cirrhosis (2020-2021) on admission and follow-up at a tertiary institute. We analysed clinical data, risk factors for MDROs, and patient outcomes. Results: Of 125 patients aged 49 years, 85.6% males, 60.8% with acute-on-chronic liver failure, 99 (79.2%) were identified as 'colonisers'. MDRO-colonisation at rectum, nose, skin, or central line was observed in 72.7% (88/121), 30.0% (36/120), 14.9% (18/121), and 3.3% (4/121) patients, respectively. Patients were colonised with the following types of bacteria: extended-spectrum beta-lactamase (71/125), carbapenem-resistant Enterobacterales (67/125), MDR-Enterococcus (48/125), MDR-Acinetobacter (21/125), or methicillin-resistant Staphylococcus aureus (4/125). Multiple precipitants of acute-decompensation (odds ratio [OR]: 3.4, p = 0.042), norfloxacin prophylaxis (OR: 3.9, p = 0.008), and MDRO infection at admission (OR: 8.9, p = 0.041) were the independent predictors of colonisation. Colonisation increased the risk of infection by MDROs at admission (OR: 8.5, p = 0.017) and follow up (OR: 7.5, p <0.001). Although any-site colonisers were at greater risk of cerebral failure and poorer Child-Pugh scores, the nasal and skin colonisers were at higher risk of cerebral and circulatory failures than non-colonisers (p <0.05).Patients with more than one site colonisation (prevalence: 30%) developed multi-organ failure (p <0.05), MDRO infection (OR: 7.9, p <0.001), and poorer 30-day survival (hazard ratio: 2.0, p = 0.005). Conclusions: A strikingly high burden of MDRO colonisation among patients with cirrhosis in India necessitates urgent control measures. Multiple-site colonisation increases the risk of MDR-infections, multi-organ failure, and mortality in patients with cirrhosis. Impact and Implications: Infections by bacteria resistant to multiple antibiotics are an emerging cause of death in cirrhosis. We showed that ∼70-80% of critically ill hospitalised patients with cirrhosis carry such bacteria with the highest rate in the rectum, nose, skin, and central line port. Carbapenem-resistant and vancomycin-resistant bacteria were amongst the most common colonising bacteria. The presence of these bacteria at multiple sites increased the risk of multidrug-resistant infections, multiple organ failures, and death in patients with cirrhosis.

Bacterial diversity of hospital water tanks and the efficacy of hydrogen peroxide based cleaning: Experience in a tertiary care center in India.

BACKGROUND: Hospital water is often an overlooked yet preventable source of hospital-acquired infections. CDC recommends annual cleaning of water reservoirs in health care settings. In our tertiary care hospital, periodic disinfection and microbiological surveillance of all the water tanks in hospital premises is carried out. The aim of this paper is to report the diversity of bacterial flora noted and the role of cleaning method adopted in our hospital. METHODS: This retrospective study was carried out from July 2015 to September 2020. Tanks were cleaned using hydrogen peroxide based method and swabs were collected, pre- and post-cleaning. Any growth noted was identified using MALDI-TOF MS. RESULTS: A total of 398 swabs were collected during this period. In pre-cleaning samples, 144 (72%) showed growth of 219 microorganisms. Gram-negative organisms (53.7%, 116/216) were more frequently isolated than Gram-positive organisms (46.3%, 100/216). Although the overwhelming majority is generally regarded as non-pathogenic, a few pathogenic bacteria were also recovered. No bacteria were isolated in any of the post-cleaning samples. CONCLUSIONS: Diverse bacteria colonize water tanks over time, some of which are known to cause infections. Hydrogen peroxide is a simple and highly efficacious method of water tank disinfection. More such studies are required with other disinfectants to generate evidence with the ultimate aim of increasing safety of water supplied in hospitals.

Colonization of the central venous catheter by Stenotrophomonas maltophilia in an ICU setting: An impending outbreak managed in time.

BACKGROUND: Stenotrophomonas maltophiliacauses opportunistic infections in immunocompromised and patients in intensive care units (ICUs). An outbreak of S. maltophilia in ICU is described which highlights the importance of the risk of infection from contaminated medical devices and suction fluids in ventilated patients. METHODS: The investigation of the outbreak was carried out. Environmental sampling was done. This was followed by MALDI-TOF MS typing and recA gene-based-phylogeny. RESULTS: In February, S. maltophilia was reported from the central line blood of six patients from ICU within a span of two weeks. The peripheral line blood cultures were sterile in all patients. Relevant environmental sampling of the high-touch surface and fluids revealed S. maltophilia strains in normal saline used for suction and in the inspiratory circuit of two patients. The isolated strains from patients and environment (inspiratory fluid) showed a minimum of 95.41% recA gene sequence identity between each other. Strict cleaning and disinfection procedures were followed. Continuous surveillance was done and no further case of S. maltophilia was detected. Timely diagnosis and removal of central line prevented development of central-line associated blood stream infection. CONCLUSION: This outbreak report illustrates that environmental sources like suction fluid and normal saline could be the source of S. maltophilia in ICU patients.

Molecular confirmation & characterization of Rickettsia conorii in north India: A report of three cases.

Background & objectives: In India, spotted fever group rickettsiae (SFGR) are an underdiagnosed cause of acute febrile illness (AFI). The non-specific Weil-Felix test is the first diagnostic modality for the diagnosis of SFGR in many laboratories due to the lack of advanced diagnostic facilities in developing countries. The aim of this study was to detect SFGR using molecular methods in the patients, presenting with AFI in a tertiary care centre in north India. Methods: Consecutive patients (>14 yr of age) with AFI were enrolled over a six month period. Standard investigations for common pathogens causing AFI in India (malaria, dengue, scrub typhus, leptospirosis and enteric fever) were carried out. In patients who were negative for all of the above investigations, blood was subjected to polymerase chain reaction (PCR) targeting outer membrane protein A (ompA) gene of Rickettsia. Results: Of the 51 patients with an undiagnosed aetiology, three were positive by ompA PCR. Two of the PCR products produced good sequences and BLAST identification confirmed them as Rickettsia conorii. The sequences of R. conorii reported from south India clustered with two previously reported novel rickettsial genotypes. The study sequences clustered in a group different from that of Rickettsia spp. of the south Indian sequences reported earlier. Interpretation & conclusions: This study showed the existence of R. conorii in north India. Testing for SFGR may be included in the diagnostic workup of AFI for better disease management.

Effectiveness of hand hygiene promotional program based on the WHO multimodal hand hygiene improvement strategy, in terms of compliance and decontamination efficacy in an indian tertiary level neonatal surgical intensive care unit.

Background: The WHO Multimodal Hand Hygiene Improvement Strategy (MHHIS) has been proposed to improve the Hand Hygiene (HH) compliance of the WHO recommendations on HH.Therefore, the current study was planned in our neonatal unit with the objective of evaluating the effectiveness of a Hand Hygiene Promotional Program (HHPP) based on the WHO MHHIS, in terms of compliance and decontamination efficacy among the health-care workers (HCWs) in the unit. Objective: The objective of the study was to evaluate the effectiveness of the WHO MHHIS on HH compliance and decontamination efficacy. Methods: The HHPP was carried out in our neonatal surgical intensive care unit from July to August 2013. A pre-intervention phase consisted of assessment of ward infrastructure, HH knowledge and perception, determination of HH compliance and collection of hand rinse samples from the HCWs before and after handwashing. Intervention phase consisted of changing traditional to elbow-operated taps, display of posters and reminders, placement of soaps in water draining trays, autoclaved single-use paper towels for hand drying, availability of hand rubs and training sessions for health-care providers. In the post-intervention phase, all the assessments and observations of pre-intervention phase were repeated. Results: HHPP resulted in a significant increase in overall HH compliance from 26.6% (95% confidence interval [CI] 23.9-29.3) to 65.3% (95% CI 62.4-68.2) (P < 0.001) and reduction in load of microorganisms (P = 0.013). There was a significant improvement in HH knowledge (P < 0.001), and perception surveys revealed high appreciation of each strategy component by the participants. Conclusion: To the best of our knowledge, this is the first study about the effect of implementation of the WHO MHHIS from an Indian hospital. HHPP was found to be effective in terms of HH compliance and decontamination efficacy. Its implementation is highly recommended to promote HH in a developing country like India.