Control of Acinetobacter baumannii outbreak in the neonatal intensive care unit in Latvia: whole-genome sequencing powered investigation and closure of the ward.

Background: Acinetobacter baumannii is an emerging pathogen capable of causing hospital-acquired infections (HAIs). It has the ability to survive on environmental surfaces for months, making transmission difficult to control. Our report describes the investigation and restriction of an outbreak of A.baumannii in the Neonatal Intensive Care Unit (NICU) using whole-genome sequencing (WGS) and multi-modal infection control measures. Methods: A prospective surveillance of HAIs was initiated in the NICU at the Pauls Stradins Clinical University Hospital (PSCUH) in Latvia on 1/9/2012 and identified an outbreak of A.baumannii. Case definitions for A.baumannii bloodstream infection (BSI) and colonization were implemented; surveillance cultures were obtained from all admitted patients to monitor the rate of colonization; an infection prevention and control team was formed and infection control interventions implemented. Environmental sampling of the NICU and Labour ward was performed. We employed WGS to differentiate phenotypically identical multidrug-resistant A.baumannii (MDRAB) strains from simultaneous intrahospital outbreaks in the adult Intensive Care Unit and NICU. Results: Between 1/9/2012 and 31/12/2017 the surveillance included 2157 neonates. A total of 17 neonates had A.baumannii BSI, with the highest rate of 30.0 cases per 1000 bed-days in November 2012. Rectal screening samples were positive for A.baumannii-complex in 182 neonates reaching 119.6 per 1000 bed-days in July 2015. All 298 environmental cultures were negative. Two phenotypically identical MDRAB isolates from the simultaneous intrahospital outbreaks were differentiated using WGS, ruling out an inter-ward transmission. Adherence to stringent infection control measures decreased BSI cases but colonization remained persistent. With several relapses, the outbreak was ongoing for four years. No new A.baumannii BSI cases were registered after total environmental decontamination in the NICU in July 2015. Colonization reappeared and persisted until in November 2016 when the ward was temporarily closed, relocated and renovated. No A.baumannii cases were registered after the renovation. Conclusion: The HAI surveillance system successfully detected and facilitated the control of the A.baumannii outbreak. Whole-genome sequencing was found to be a useful method for differentiation of phenotypically identical A.baumannii strains from the intrahospital outbreak. Only multi-modal infection control program, including closure, temporary relocation, and renovation of the ward, restricted the outbreak.

Infection prevention and control measures and tools for the prevention of entry of carbapenem-resistant Enterobacteriaceae into healthcare settings: guidance from the European Centre for Disease Prevention and Control.

BACKGROUND: Infections with carbapenem-resistant Enterobacteriaceae (CRE) are increasingly being reported from patients in healthcare settings. They are associated with high patient morbidity, attributable mortality and hospital costs. Patients who are "at-risk" may be carriers of these multidrug-resistant Enterobacteriaceae (MDR-E).The purpose of this guidance is to raise awareness and identify the "at-risk" patient when admitted to a healthcare setting and to outline effective infection prevention and control measures to halt the entry and spread of CRE. METHODS: The guidance was created by a group of experts who were functioning independently of their organisations, during two meetings hosted by the European Centre for Disease Prevention and Control. A list of epidemiological risk factors placing patients "at-risk" for carriage with CRE was created by the experts. The conclusions of a systematic review on the prevention of spread of CRE, with the addition of expert opinion, were used to construct lists of core and supplemental infection prevention and control measures to be implemented for "at-risk" patients upon admission to healthcare settings. RESULTS: Individuals with the following profile are "at-risk" for carriage of CRE: a) a history of an overnight stay in a healthcare setting in the last 12 months, b) dialysis-dependent or cancer chemotherapy in the last 12 months, c) known previous carriage of CRE in the last 12 months and d) epidemiological linkage to a known carrier of a CRE.Core infection prevention and control measures that should be considered for all patients in healthcare settings were compiled. Preliminary supplemental measures to be implemented for "at-risk" patients on admission are: pre-emptive isolation, active screening for CRE, and contact precautions. Patients who are confirmed positive for CRE will need additional supplemental measures. CONCLUSIONS: Strengthening the microbiological capacity, surveillance and reporting of new cases of CRE in healthcare settings and countries is necessary to monitor the epidemiological situation so that, if necessary, the implemented CRE prevention strategies can be refined in a timely manner. Creating a large communication network to exchange this information would be helpful to understand the extent of the CRE reservoir and to prevent infections in healthcare settings, by applying the principles outlined here.This guidance document offers suggestions for best practices, but is in no way prescriptive for all healthcare settings and all countries. Successful implementation will result if there is local commitment and accountability. The options for intervention can be adopted or adapted to local needs, depending on the availability of financial and structural resources.

Burden of antimicrobial resistance in European hospitals: excess mortality and length of hospital stay associated with bloodstream infections due to Escherichia coli resistant to third-generation cephalosporins.

OBJECTIVES: This study determined excess mortality and length of hospital stay (LOS) attributable to bloodstream infection (BSI) caused by third-generation-cephalosporin-resistant Escherichia coli in Europe. METHODS: A prospective parallel matched cohort design was used. Cohort I consisted of patients with third-generation-cephalosporin-resistant E. coli BSI (REC) and cohort II consisted of patients with third-generation-cephalosporin-susceptible E. coli BSI (SEC). Patients in both cohorts were matched for LOS before infection with patients free of the respective BSI. Thirteen European tertiary care centres participated between July 2007 and June 2008. RESULTS: Cohort I consisted of 111 REC patients and 204 controls and cohort II consisted of 1110 SEC patients and 2084 controls. REC patients had a higher mortality at 30 days (adjusted odds ratio = 4.6) and a higher hospital mortality (adjusted hazard ratio = 5.7) than their controls. LOS was increased by 8 days. For SEC patients, these figures were adjusted odds ratio = 1.9, adjusted hazard ratio = 2.0 and excess LOS = 3 days. A 2.5 times [95% confidence interval (95% CI) 0.9-6.8] increase in all-cause mortality at 30 days and a 2.9 times (95% CI 1.2-6.9) increase in mortality during entire hospital stay as well as an excess LOS of 5 days (95% CI 0.4-10.2) could be attributed to resistance to third-generation cephalosporins in E. coli BSI. CONCLUSIONS: Morbidity and mortality attributable to third-generation-cephalosporin-resistant E. coli BSI is significant. If prevailing resistance trends continue, high societal and economic costs can be expected. Better management of infections caused by resistant E. coli is becoming essential.

Repeated prevalence studies on antibiotic use in Latvia, 2003-2007.

Antibiotic resistance and nosocomial infections have recently been recognised as a growing threat in Latvian hospitals. We used a modified point prevalence study design to gain accurate information on the antibiotic prescription pattern and the prevalence of nosocomial infections in different hospital departments. A given department was observed on a given day in a given month (May) five years in a row. All antibiotic treatments, dose and route of administration were recorded, in addition to demographic data. The most commonly used antibiotic groups were first generation cephalosporins (35.6-38.9%), broad-spectrum penicillins (17.5-23.0%), fluoroquinolones (8.4-14.5%) and aminoglycosides (7.7-12.6%). Cefazolin was the most commonly used antibiotic. Antibiotics were predominantly used intravenously. The proportion of oral administration varied from 15.1% to 21.8%. A large proportion (13.3%) of the antibiotics was administered without clear reason. The crude prevalence rate of infection treated with antibiotics was 19.3%. The average prevalence of nosocomial infections was found to be 3.6%. These prevalence studies provided an opportunity to compare hospitals and outline variations and problem areas. They indicated the main problems in antibiotic prescription: large interhospital variations in the choice of an antibiotic for the most common infections, frequent antibiotic use without clear reason, and predominant intravenous administration.

National hand hygiene campaigns in Europe, 2000-2009.

Hand hygiene represents the single most effective way to prevent healthcare-associated infections. The World Health Organization, as part of its First Global Patient Safety Challenge, recommends implementation of multi-faceted strategies to increase compliance with hand hygiene. A questionnaire was sent by the European Centre for Disease Prevention and Control to 30 European countries, regarding the availability and organisation of their national hand hygiene campaigns. All countries responded. Thirteen countries had organised at least one national campaign during the period 2000-2009 and three countries were in the process of organising a national campaign. Although the remaining countries did not have a national campaign, several reported regional and local hand hygiene activities or educational resources on national websites.

Differences in antibiotic prescribing in three university hospitals in the Baltic region revealed by a simple protocol for quality assessment of therapeutic indications.

OBJECTIVE: To identify inexpensive and simple quality parameters for the surveillance of antibiotic use in hospital settings. METHODS: A modified point-prevalence study was conducted in three university hospitals in Huddinge, Sweden, Riga, Latvia, and Vilnius, Lithuania. Each ward was visited once during May in the year 2002. All patients receiving antibiotics were identified and their medical records were reviewed by the authors according to the same protocol. Only data from corresponding departments were evaluated and compared. RESULTS: The prevalence of antibiotic use was 35%, 25% and 24% in Huddinge, Riga and Vilnius, respectively. Almost 2/3 of antibiotics were prescribed for treatment and 1/3 for either surgical or medical prophylaxis. Parenteral administration was significantly more common in Riga and Vilnius than in Huddinge. The most commonly prescribed antibiotics were cephalosporins and fluoroquinolones. Prescription of antibiotics for different diagnoses showed large variation between and within hospitals. The first or second generation cephalosporins were prescribed in most cases of surgical prophylaxis. The duration of surgical prophylaxis exceeded one day in 57%, 63% and 87% of cases in Huddinge, Riga and Vilnius, respectively. All antibiotics in Huddinge, and all except five in Riga were supplied by the hospital pharmacy. Antibiotics bought by patients and donated made up 41% of prescribed antibiotics in Vilnius. CONCLUSION: This point-prevalence survey using a simple and inexpensive method for benchmarking demonstrated quantitative and qualitative differences in the use of antibiotics between three university hospitals in the Baltic region, differences that now calls for explanations to their rationality. We suggest that the choice of an antibiotic, rates of intravenously administered treatment and duration of surgical prophylaxis are examples of suitable indicators of rational antibiotic use within a hospital but that comparison of such rates between hospitals is less meaningful.

Benchmarking antimicrobial drug use at university hospitals in five European countries.

A point-prevalence survey of five European university hospitals was performed to benchmark antimicrobial drug use in order to identify potential problem areas in prescribing practice and to aid in establishing appropriate and attainable goals. All inpatients at the university hospitals of Rijeka (Croatia), Tartu (Estonia), Riga (Latvia), Vilnius (Lithuania) and Karolinska-Huddinge (Sweden) were surveyed for antimicrobial drug use during a single day. The frequency of antimicrobial drug use was 24% in Rijeka, 30% in Tartu, 26% in Riga, 14% in Vilnius and 32% in Huddinge. Surgical patients were treated with antimicrobial agents more often than medical patients in Riga (53% vs. 31%), Tartu (39% vs. 26%) and Vilnius (54% vs. 25%). Two-thirds of patients in Rijeka, Tartu, Riga and Vilnius, and fewer than half of the patients in Huddinge, received antimicrobial agents intravenously. Broad-spectrum antimicrobial agents were used most commonly in Rijeka. The prevalence of nosocomial infections treated with antibiotics was 9% at Huddinge, and 3-5% at the other centres. Benchmarking antimicrobial drug use at five university hospitals identified differences and problem areas. The high rates of intravenous administration, poor compliance with guidelines, and prolonged surgical prophylaxis were general problems that deserved specific attention at all centres. A change in prescription practices may reduce unnecessary drug use and decrease antimicrobial resistance.

Healthcare associated infections in university hospitals in Latvia, Lithuania and Sweden: a simple protocol for quality assessment.

Surveillance of healthcare associated infections is an overlooked parameter of good clinical practice in most healthcare institutions, due to the workload demanded in the absence of adequate IT-systems. The aim of the present study was to investigate whether a simple protocol could be used to estimate the burden of healthcare associated infections in three university hospitals in Huddinge in Sweden, Riga in Latvia and Vilnius in Lithuania and form the basis for initiating a long term follow up system. The medical records of all patients receiving antibiotics were reviewed according to a standardised protocol, focusing on the indications for the drugs and on the frequency of hospital acquired infection (HAI) in a point-prevalence survey. Only comparable specialties were included. The proportion of patients treated with antibiotics (prophylaxis not included) were 63/280 (22%) in Huddinge, 73/649 (11%) in Riga and 99/682 (15%) in Vilnius. The proportion of admitted patients treated for a HAI were 15%, 3% and 4%, respectively, (both comparisons Huddinge versus other centres P <0.001). Surgical site infections were most common, followed by infections with an onset more than 2 days after admission without any of the other registered risk factors present. Our inexpensive and simple method showed that healthcare associated infections were a significant problem among patients admitted to Huddinge. The figures obtained can be used for further discussion and form a baseline for follow up at the local level. The comparison of figures between centres was far less relevant than the process the study created.

Healthcare associated infections in university hospitals in Latvia, Lithuania and Sweden: a simple protocol for quality assessment.

Surveillance of healthcare associated infections is an overlooked parameter of good clinical practice in most healthcare institutions, due to the workload demanded in the absence of adequate IT-systems. The aim of the present study was to investigate whether a simple protocol could be used to estimate the burden of healthcare associated infections in three university hospitals in Huddinge in Sweden, Riga in Latvia and Vilnius in Lithuania and form the basis for initiating a long term follow up system. The medical records of all patients receiving antibiotics were reviewed according to a standardised protocol, focusing on the indications for the drugs and on the frequency of hospital acquired infection (HAI) in a point-prevalence survey. Only comparable specialities were included. The proportion of patients treated with antibiotics (prophylaxis not included) were 63/280 (22%) in Huddinge, 73/649 (11%) in Riga and 99/682 (15%) in Vilnius. The proportion of admitted patients treated for a HAI were 15%, 3% and 4%, respectively, (both comparisons Huddinge versus other centres P<0.001). Surgical site infections were most common, followed by infections with an onset more than 2 days after admission without any of the other registered risk factors present. Our inexpensive and simple method showed that healthcare associated infections were a significant problem among patients admitted to Huddinge. The figures obtained can be used for further discussion and form a baseline for follow up at the local level. The comparison of figures between centres was far less relevant than the process the study created.

Report on the first PVL-positive community acquired MRSA strain in Latvia.

Infections by community-acquired methicillin resistant Staphylococcus aureus (CA-MRSA) have been reported worldwide. Here we present characterisation of the first CA-MRSA isolated in Latvia. A PVL-positive ST30-MRSA-IV strain was isolated from a nasal swab and the central venous catheter of a patient with fever and multiple organ failure. The PFGE pattern of this strain was identical to pattern SE00-3 of MRSA isolated in Sweden from 29 patients during 2000-2003. This strain is related to the South Pacific area, and its appearance in Sweden and Latvia demonstrates its global spread.

Report on the first PVL-positive community acquired MRSA strain in Latvia.

Infections by community-acquired methicillin resistant Staphylococcus aureus (CA-MRSA) have been reported worldwide. Here we present characterisation of the first CA-MRSA isolated in Latvia. A PVL-positive ST30-MRSA-IV strain was isolated from a nasal swab and the central venous catheter of a patient with fever and multiple organ failure. The PFGE pattern of this strain was identical to pattern SE00-3 of MRSA isolated in Sweden from 29 patients during 2000-2003. This strain is related to the South Pacific area, and its appearance in Sweden and Latvia demonstrates its global spread.

Prevalence of nosocomial infections in two Latvian hospitals.

The first point prevalence survey of the nosocomial infection (NI) rate was conducted in two Latvian hospitals. At the time of the survey 17.5% (226/1291) patients had symptoms or were being treated for infection. The overall prevalence rate was 5.6% (72/1291) for NI and 12.7% for community acquired infections (164/1291). Surgical site infection (SSI) was the most common NI (62%) followed by respiratory tract infection (RTI) (7.5%), and urinary tract infection (UTI) (6.4%). NI rate was higher with increasing age of patients, in intensive care units and surgical wards, and among those who had an intravenous device or urinary catheter. Microbiological investigation yielded positive results in 29% (21/72) of patients with NIs. Antibacterial treatment was given to 22.3% (288/1291) of hospitalised patients and in 62% (182/288) of these, cefazolin was prescribed. Results from this study will be used to plan a national prevalence survey.

Prevalence of HBV core promoter/precore/core mutations in Gambian chronic carriers.

One hundred forty-two precore/core sequences were obtained from Gambian chronic hepatitis B virus (HBV) carriers and the predominant variants defined. The two point mutations, from A to T and G to A at nt positions 1762 and 1764 in the basic core promoter region, were found in only 7/99 (7%) of the samples where this region was sequenced. These mutations were found in both HBeAg-positive and -negative patients. The precore stop-codon mutation at nt position 1896 was found in 14/51 (27%) of HBeAg-negative samples, which is a lower prevalence rate in comparison with other parts of the world with high carrier rates. In HBeAg-positive patients the core amino acid sequences were conserved, but after seroconversion to anti-HBe significantly more changes were apparent. Several of the amino acid substitutions found have been described previously been in wild-type viruses of other genotypes.

Transmission of hepatitis B virus infection in Gambian families revealed by phylogenetic analysis.

BACKGROUND/AIMS: Transmission of hepatitis B virus (HBV) in Africa occurs horizontally, with most people becoming infected between the ages of 1 and 5 years. The index cases in such events have been assumed to come from within the family unit or from sources outside the immediate family, such as other families or inhabitants of the same compound or village. Here, we define these routes of transmission by phylogenetic tree analysis of sequences from the entire pre-core/core region of the virus, in Gambian chronic carriers. METHODS: Amplification by polymerase chain reaction of serum extracted HBV-DNA was followed by direct sequencing of the target region. Following editing and alignment of these sequences, phylogenetic tree analysis was performed using the neighbour-joining and maximum-likelihood methods. RESULTS: Despite the overall conserved nature of the sequences of the pre-core/core region from 142 chronic carriers, distinct clusters were easily defined at the family and village level, but not on a wider geographical separation. CONCLUSIONS: Phylogenetic tree analysis of sequences obtained from family members provided strong evidence of intrafamilial transmission of HBV in at least two-thirds of the families studied from Gambia.

Tick-borne encephalitis.

Tick-borne encephalitis (TBE) is a zoonotic arbovirus infection endemic to Russia and Eastern and Central Europe. Despite being a common and serious life-threatening disease for which a mass vaccination program was implemented in Austria, there is only limited reference to this disease in the English-language literature. TBE is transmitted to humans usually by the bite of a tick (either Ixodes persulcatus or Ixodes ricinus); occasionally, cases occur following consumption of infected unpasteurized milk. Transmission is seasonal and occurs in spring and summer, particularly in rural areas favored by the vector. TBE is a serious cause of acute central nervous system disease, which may result in death or long-term neurological sequelae. Effective vaccines are available in a few countries. The risk for travelers of acquiring TBE is increasing with the recent rise in tourism to areas of endemicity during spring and summer.